Grady Health System "Updated April 15,2023" Procedure Code Type Code NDC Procedure Description IP/OP Charge Cash Discount (74%) Payor Rate Min Payor Rate Max Aetna Exp Reimbursement Coventry Exp Reimbursement Aetna Advantage Coventry Advantage Ambetter Exp Reimbursement Amerigroup Exp Reimbursement Anthem BCBS HMO Exp Reimbursement Anthem BCBS POS Exp Reimbursement BCBS PPO Exp Reimbursement BCBS Advantage CareSource CMO Exp Reimbursement CareSource Advantage Exp Reimbursement Cigna Exp Reimbursement Cigna Advantage Eon Health Exp Reimbursement Humana Exp Reimbursement Kaiser Exp Reimbursement Multiplan Exp Reimbursement NaphCare Exp Reimbursement Oscar Exp Reimbursement USP Exp Reimbursement Peachstate Exp Reimbursement Tricare Choice Exp Reimbursement Veteran's Choice Exp Reimbursement Wellcare Medicaid Exp Reimbursement Wellcare Medicare Exp Reimbusrement CIGNA CLOVER MEDICAID SONDER MS003 DRG MS003 "ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES" INPATIENT ONLY "$846,619.47" "$626,498.41" $0.00 "$633,310.40" "$545,963.96" "$545,963.96" "$246,500.86" "$246,500.86" "$226,063.68" $0.00 $0.00 $0.00 "$633,310.40" "$169,544.23" $0.00 "$200,521.93" "$552,556.41" "$552,556.41" "$136,503.65" "$413,995.33" "$504,437.36" "$573,019.79" "$182,532.67" "$552,556.41" "$182,532.67" "$185,417.02" "$167,931.68" "$167,931.68" "$136,503.65" "$194,687.78" $0.00 $0.00 $0.00 $0.00 MS004 DRG MS004 "TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES" INPATIENT ONLY "$560,790.65" "$414,985.08" $0.00 "$500,611.30" "$303,701.56" "$303,701.56" "$102,651.23" "$102,651.23" "$117,598.72" "$139,546.44" $0.00 $0.00 $0.00 "$93,123.67" "$139,546.44" "$106,877.24" "$307,479.91" "$307,479.91" "$112,641.38" "$410,855.25" "$500,611.30" $0.00 "$134,386.24" "$307,479.91" "$134,386.24" "$32,473.86" "$147,233.83" "$147,233.83" "$107,277.50" "$34,561.30" $0.00 $0.00 $0.00 $0.00 MS011 DRG MS011 "TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC" INPATIENT ONLY "$341,624.34" "$252,802.01" $0.00 "$53,518.70" $0.00 $0.00 "$45,708.66" "$45,708.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$45,618.98" $0.00 "$46,622.83" $0.00 $0.00 "$47,587.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$53,518.70" "$53,518.70" "$45,321.23" $0.00 $0.00 $0.00 $0.00 $0.00 MS012 DRG MS012 "TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC" INPATIENT ONLY "$435,854.28" "$322,532.17" $0.00 "$527,844.11" $0.00 $0.00 "$64,752.45" "$64,752.45" $0.00 $0.00 $0.00 $0.00 "$527,844.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$112,717.74" "$124,172.81" "$124,172.81" $0.00 "$40,861.37" $0.00 $0.00 $0.00 $0.00 MS013 DRG MS013 "TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC" INPATIENT ONLY "$427,041.11" "$316,010.42" $0.00 "$28,929.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,929.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,929.99" $0.00 $0.00 $0.00 $0.00 $0.00 MS020 DRG MS020 INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC INPATIENT ONLY "$640,592.00" "$474,038.08" $0.00 "$461,392.05" $0.00 $0.00 "$117,892.75" "$117,892.75" "$130,119.32" $0.00 $0.00 $0.00 "$445,362.06" "$82,209.64" $0.00 "$84,042.11" "$354,069.74" "$354,069.74" "$87,750.60" "$378,667.73" "$461,392.05" $0.00 "$121,357.54" "$354,069.74" "$121,357.54" $0.00 "$101,514.63" "$101,514.63" "$83,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 MS021 DRG MS021 INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC INPATIENT ONLY "$829,388.27" "$613,747.32" $0.00 "$583,001.67" "$432,052.38" "$432,052.38" $0.00 $0.00 "$185,501.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$538,738.80" "$538,738.80" $0.00 "$478,473.59" "$583,001.67" $0.00 "$152,156.12" "$538,738.80" "$152,156.12" $0.00 "$91,625.03" "$91,625.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS022 DRG MS022 INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC INPATIENT ONLY "$262,016.11" "$193,891.92" $0.00 "$95,010.54" $0.00 $0.00 "$44,476.05" "$44,476.05" $0.00 $0.00 $0.00 $0.00 $0.00 "$88,779.12" $0.00 $0.00 $0.00 $0.00 "$95,010.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$38,549.28" $0.00 $0.00 "$90,486.22" "$40,476.72" $0.00 $0.00 $0.00 $0.00 MS023 DRG MS023 CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR INPATIENT ONLY "$218,569.58" "$161,741.49" $0.00 "$201,607.59" "$122,687.67" "$122,687.67" "$50,198.05" "$50,198.05" "$63,817.39" $0.00 $0.00 $0.00 "$44,292.45" "$50,096.77" $0.00 "$67,359.13" "$201,607.59" "$201,607.59" "$52,188.44" "$105,398.91" "$128,424.52" "$123,922.26" "$56,307.53" "$201,607.59" "$56,307.53" "$53,114.71" "$59,017.16" "$59,017.16" "$49,703.28" "$55,770.42" $0.00 $0.00 $0.00 $0.00 MS024 DRG MS024 CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC INPATIENT ONLY "$157,585.04" "$116,612.93" $0.00 "$101,279.86" "$101,279.86" "$101,279.86" "$38,238.47" "$38,238.47" $0.00 $0.00 $0.00 $0.00 "$76,208.16" "$38,168.13" $0.00 "$39,003.24" $0.00 $0.00 "$41,250.33" "$33,522.62" "$79,948.14" "$86,190.36" "$40,262.62" $0.00 "$40,262.62" $0.00 "$45,945.91" "$45,945.91" "$39,286.03" $0.00 $0.00 $0.00 $0.00 $0.00 MS025 DRG MS025 CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC INPATIENT ONLY "$478,309.25" "$353,948.85" $0.00 "$226,592.28" "$226,592.28" "$226,592.28" "$54,020.48" "$54,020.48" $0.00 "$111,176.48" $0.00 $0.00 "$124,468.05" "$42,011.95" "$140,855.50" "$55,104.90" $0.00 $0.00 "$43,833.50" "$153,273.67" "$186,758.08" "$99,788.97" "$44,051.81" $0.00 "$44,051.81" $0.00 "$49,032.85" "$49,032.85" "$41,746.19" $0.00 $0.00 $0.00 $0.00 $0.00 MS026 DRG MS026 CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC INPATIENT ONLY "$270,390.78" "$200,089.18" $0.00 "$374,897.72" "$363,866.18" "$363,866.18" "$32,699.36" "$32,699.36" "$115,593.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$33,354.58" "$374,897.72" "$374,897.72" $0.00 $0.00 $0.00 $0.00 $0.00 "$374,897.72" $0.00 $0.00 "$38,018.73" "$38,018.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS027 DRG MS027 CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$150,043.04" "$111,031.85" $0.00 "$232,805.15" $0.00 $0.00 "$28,405.90" "$28,405.90" $0.00 "$54,890.22" $0.00 $0.00 $0.00 $0.00 "$69,843.08" "$28,974.02" $0.00 $0.00 "$30,181.04" "$191,064.82" "$232,805.15" "$82,819.30" "$36,977.13" $0.00 "$36,977.13" $0.00 "$32,717.89" "$32,717.89" "$28,743.85" $0.00 $0.00 $0.00 $0.00 $0.00 MS028 DRG MS028 SPINAL PROCEDURES WITH MCC INPATIENT ONLY "$378,830.18" "$280,334.33" $0.00 "$240,380.32" $0.00 $0.00 "$50,062.96" "$50,062.96" "$77,466.83" $0.00 $0.00 $0.00 "$238,773.51" $0.00 $0.00 $0.00 "$240,380.32" "$240,380.32" "$52,005.99" "$141,041.44" "$171,853.56" $0.00 "$56,039.87" "$240,380.32" "$56,039.87" $0.00 "$58,799.12" "$58,799.12" "$49,529.51" $0.00 $0.00 $0.00 $0.00 $0.00 MS029 DRG MS029 SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS INPATIENT ONLY "$255,521.10" "$189,085.61" $0.00 "$229,583.19" $0.00 $0.00 "$33,806.33" "$33,806.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$34,482.46" $0.00 $0.00 "$35,718.41" $0.00 $0.00 "$229,583.19" $0.00 $0.00 $0.00 $0.00 "$39,335.16" "$39,335.16" "$34,017.53" $0.00 $0.00 $0.00 $0.00 $0.00 MS030 DRG MS030 SPINAL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$247,560.24" "$183,194.58" $0.00 "$29,329.56" $0.00 $0.00 $0.00 $0.00 $0.00 "$19,797.75" $0.00 $0.00 $0.00 $0.00 "$19,797.75" $0.00 $0.00 $0.00 "$29,329.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,932.91" $0.00 $0.00 $0.00 $0.00 $0.00 MS031 DRG MS031 VENTRICULAR SHUNT PROCEDURES WITH MCC INPATIENT ONLY "$411,152.28" "$304,252.69" $0.00 "$59,024.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,834.72" "$59,024.65" "$59,024.65" $0.00 "$23,976.45" $0.00 $0.00 $0.00 $0.00 MS032 DRG MS032 VENTRICULAR SHUNT PROCEDURES WITH CC INPATIENT ONLY "$213,869.28" "$158,263.27" $0.00 "$14,380.55" "$14,380.55" "$14,380.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS033 DRG MS033 VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$184,494.76" "$136,526.12" $0.00 "$12,635.25" "$9,990.32" "$9,990.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$12,033.57" $0.00 $0.00 $0.00 "$12,635.25" $0.00 $0.00 $0.00 $0.00 MS034 DRG MS034 CAROTID ARTERY STENT PROCEDURES WITH MCC INPATIENT ONLY "$284,867.36" "$210,801.85" $0.00 "$160,900.01" "$160,900.01" "$160,900.01" "$38,508.31" "$38,508.31" $0.00 $0.00 $0.00 $0.00 $0.00 "$38,437.26" $0.00 "$39,278.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$43,799.77" "$43,799.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS035 DRG MS035 CAROTID ARTERY STENT PROCEDURES WITH CC INPATIENT ONLY "$129,223.20" "$95,625.17" $0.00 "$31,946.16" $0.00 $0.00 "$27,200.91" "$27,200.91" $0.00 $0.00 $0.00 $0.00 $0.00 "$27,159.12" $0.00 "$27,744.93" $0.00 $0.00 "$29,535.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,946.16" "$31,946.16" "$28,128.81" $0.00 $0.00 $0.00 $0.00 $0.00 MS036 DRG MS036 CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$63,272.72" "$46,821.81" $0.00 "$9,048.30" "$9,048.30" "$9,048.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS037 DRG MS037 EXTRACRANIAL PROCEDURES WITH MCC INPATIENT ONLY "$179,064.31" "$132,507.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS038 DRG MS038 EXTRACRANIAL PROCEDURES WITH CC INPATIENT ONLY "$162,863.49" "$120,518.98" $0.00 "$26,825.78" $0.00 $0.00 "$22,501.67" "$22,501.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,951.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,825.78" "$26,825.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS039 DRG MS039 EXTRACRANIAL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$99,295.23" "$73,478.47" $0.00 "$53,458.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,293.26" $0.00 $0.00 $0.00 "$43,873.91" "$53,458.66" $0.00 "$11,340.50" $0.00 "$11,340.50" $0.00 "$22,384.03" "$22,384.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS040 DRG MS040 "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC" INPATIENT ONLY "$181,156.10" "$134,055.51" $0.00 "$120,959.00" "$114,037.71" "$114,037.71" "$37,726.38" "$37,726.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$38,480.91" $0.00 $0.00 "$40,730.30" "$99,271.90" "$120,959.00" $0.00 "$39,499.78" $0.00 "$39,499.78" "$26,844.41" "$45,324.46" "$45,324.46" "$38,790.76" "$28,186.61" $0.00 $0.00 $0.00 $0.00 MS041 DRG MS041 "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR" INPATIENT ONLY "$127,537.44" "$94,377.71" $0.00 "$72,242.00" "$37,578.12" "$37,578.12" "$27,269.91" "$27,269.91" $0.00 "$27,327.64" $0.00 $0.00 $0.00 "$27,227.95" "$27,327.64" "$27,815.31" $0.00 $0.00 "$30,008.81" "$6,724.57" "$72,242.00" $0.00 "$23,772.63" $0.00 "$23,772.63" "$26,156.21" "$32,512.09" "$32,512.09" "$28,579.82" "$27,464.00" $0.00 $0.00 $0.00 $0.00 MS042 DRG MS042 "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$105,060.67" "$77,744.90" $0.00 "$125,934.52" "$18,514.80" "$18,514.80" "$24,174.58" "$24,174.58" "$16,589.36" "$107,683.75" $0.00 $0.00 $0.00 $0.00 "$107,684.43" "$24,658.07" "$67,315.38" "$67,315.38" $0.00 $0.00 $0.00 "$125,934.52" $0.00 "$67,315.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS052 DRG MS052 SPINAL DISORDERS AND INJURIES WITH CC/MCC INPATIENT ONLY "$156,658.67" "$115,927.42" $0.00 "$83,265.35" $0.00 $0.00 "$23,845.39" "$23,845.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,322.30" $0.00 $0.00 "$24,934.09" "$68,336.46" "$83,265.35" $0.00 "$16,328.58" $0.00 "$16,328.58" $0.00 "$26,447.68" "$26,447.68" "$23,746.75" $0.00 $0.00 $0.00 $0.00 $0.00 MS053 DRG MS053 SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC INPATIENT ONLY "$178,803.45" "$132,314.55" $0.00 "$18,896.33" $0.00 $0.00 "$18,896.33" "$18,896.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS054 DRG MS054 NERVOUS SYSTEM NEOPLASMS WITH MCC INPATIENT ONLY "$57,218.00" "$42,341.32" $0.00 "$32,180.45" "$28,652.18" "$28,652.18" "$20,496.79" "$20,496.79" "$11,646.29" $0.00 $0.00 $0.00 $0.00 "$20,472.36" $0.00 "$20,906.73" "$20,524.50" "$20,524.50" "$22,960.49" "$15,497.86" "$32,180.45" $0.00 "$13,433.57" "$20,524.50" "$13,433.57" "$16,209.33" "$24,089.19" "$24,089.19" "$21,867.13" "$16,209.33" $0.00 $0.00 $0.00 $0.00 MS055 DRG MS055 NERVOUS SYSTEM NEOPLASMS WITHOUT MCC INPATIENT ONLY "$29,991.33" "$22,193.58" $0.00 "$20,540.66" "$12,259.80" "$12,259.80" "$18,262.77" "$18,262.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,628.03" $0.00 $0.00 "$20,540.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$12,303.42" $0.00 $0.00 "$19,562.53" "$12,918.59" $0.00 $0.00 $0.00 $0.00 MS056 DRG MS056 DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC INPATIENT ONLY "$74,193.16" "$54,902.94" $0.00 "$32,929.50" "$12,532.35" "$12,532.35" "$26,204.32" "$26,204.32" "$15,722.67" "$27,637.01" $0.00 $0.00 "$16,742.05" "$26,165.12" "$27,637.01" "$26,728.41" "$32,929.50" "$32,929.50" "$28,784.91" $0.00 $0.00 $0.00 $0.00 "$32,929.50" $0.00 "$3,891.53" "$31,049.49" "$31,049.49" "$27,414.20" "$4,141.69" $0.00 $0.00 $0.00 $0.00 MS057 DRG MS057 DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC INPATIENT ONLY "$48,700.14" "$36,038.10" $0.00 "$24,142.42" "$24,142.42" "$24,142.42" "$19,801.12" "$19,801.12" "$9,014.09" $0.00 $0.00 $0.00 $0.00 "$19,778.49" $0.00 "$20,197.14" "$19,012.50" "$19,012.50" "$20,335.16" "$9,564.24" "$17,411.42" $0.00 "$12,137.42" "$19,012.50" "$12,137.42" $0.00 "$18,349.35" "$18,349.35" "$19,366.82" $0.00 $0.00 $0.00 $0.00 $0.00 MS058 DRG MS058 MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC INPATIENT ONLY "$57,255.06" "$42,368.74" $0.00 "$35,850.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,006.13" "$27,593.07" $0.00 "$19,594.52" $0.00 "$19,594.52" $0.00 "$35,850.39" "$35,850.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS059 DRG MS059 MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC INPATIENT ONLY "$42,378.53" "$31,360.11" $0.00 "$63,687.23" "$63,687.23" "$63,687.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,348.41" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,254.77" "$16,079.42" "$33,948.36" $0.00 "$10,931.50" $0.00 "$10,931.50" $0.00 "$22,050.83" "$22,050.83" "$20,242.64" $0.00 $0.00 $0.00 $0.00 $0.00 MS060 DRG MS060 MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC INPATIENT ONLY "$17,859.37" "$13,215.93" $0.00 "$17,386.96" $0.00 $0.00 "$17,386.96" "$17,386.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS061 DRG MS061 "ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC" INPATIENT ONLY "$95,693.84" "$70,813.44" $0.00 "$215,011.32" "$92,084.48" "$92,084.48" "$31,007.07" "$31,007.07" $0.00 $0.00 $0.00 $0.00 $0.00 "$30,955.43" $0.00 "$31,627.21" $0.00 $0.00 "$32,892.67" "$176,461.31" "$215,011.32" $0.00 "$32,518.99" $0.00 "$32,518.99" $0.00 "$35,958.33" "$35,958.33" "$31,326.35" $0.00 $0.00 $0.00 $0.00 $0.00 MS062 DRG MS062 "ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC" INPATIENT ONLY "$103,906.20" "$76,890.59" $0.00 "$73,869.50" "$19,584.47" "$19,584.47" "$24,775.73" "$24,775.73" "$16,561.69" $0.00 $0.00 $0.00 $0.00 "$24,740.22" $0.00 "$25,271.24" "$29,824.50" "$29,824.50" "$27,546.62" "$15,607.97" "$73,869.50" $0.00 "$20,160.87" "$29,824.50" "$20,160.87" $0.00 "$29,569.72" "$29,569.72" "$26,234.88" $0.00 $0.00 $0.00 $0.00 $0.00 MS063 DRG MS063 "ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC" INPATIENT ONLY "$95,685.66" "$70,807.39" $0.00 "$50,374.27" "$8,398.95" "$8,398.95" "$22,852.96" "$22,852.96" "$13,476.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,310.02" "$25,645.50" "$25,645.50" $0.00 "$18,358.07" "$50,374.27" $0.00 "$16,848.86" "$25,645.50" "$16,848.86" $0.00 "$26,871.51" "$26,871.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS064 DRG MS064 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC INPATIENT ONLY "$123,857.52" "$91,654.56" $0.00 "$110,327.78" "$110,327.78" "$110,327.78" "$25,320.78" "$25,320.78" "$15,513.81" "$25,409.92" $0.00 $0.00 "$17,959.97" "$25,286.52" "$25,409.92" "$24,782.69" "$28,783.50" "$28,783.50" "$26,614.49" "$27,643.93" "$64,405.47" $0.00 "$18,793.56" "$28,783.50" "$18,793.56" "$44,500.15" "$28,455.79" "$28,455.79" "$25,347.13" "$25,793.36" $0.00 $0.00 $0.00 $0.00 MS065 DRG MS065 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS INPATIENT ONLY "$79,103.20" "$58,536.37" $0.00 "$60,123.35" "$27,569.45" "$27,569.45" "$18,093.01" "$18,093.01" "$9,499.65" "$13,734.30" $0.00 $0.00 "$6,993.69" "$18,074.80" "$13,734.30" "$18,454.87" "$15,300.00" "$15,300.00" "$20,825.64" "$15,153.44" "$60,123.35" "$54,112.55" "$10,301.98" "$15,300.00" "$10,301.98" $0.00 "$21,537.99" "$21,537.99" "$19,833.94" $0.00 $0.00 $0.00 $0.00 $0.00 MS066 DRG MS066 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC INPATIENT ONLY "$41,730.17" "$30,880.33" $0.00 "$30,837.84" $0.00 $0.00 "$15,964.58" "$15,964.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,283.87" $0.00 $0.00 "$18,702.38" "$8,810.14" "$30,837.84" $0.00 "$7,187.44" $0.00 "$7,187.44" $0.00 "$19,000.67" "$19,000.67" "$17,811.79" $0.00 $0.00 $0.00 $0.00 $0.00 MS067 DRG MS067 NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC INPATIENT ONLY "$113,443.89" "$83,948.48" $0.00 "$25,105.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,105.11" "$25,105.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS068 DRG MS068 NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC INPATIENT ONLY "$68,653.56" "$50,803.63" $0.00 "$20,522.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,976.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,522.91" "$20,522.91" "$19,024.95" $0.00 $0.00 $0.00 $0.00 $0.00 MS069 DRG MS069 TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC INPATIENT ONLY "$52,701.73" "$38,999.28" $0.00 "$19,517.62" "$4,165.08" "$4,165.08" "$16,485.64" "$16,485.64" $0.00 $0.00 $0.00 $0.00 "$3,348.41" "$16,471.58" $0.00 "$16,815.35" $0.00 $0.00 "$19,134.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,517.62" "$19,517.62" "$18,223.78" $0.00 $0.00 $0.00 $0.00 $0.00 MS070 DRG MS070 NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC INPATIENT ONLY "$118,539.35" "$87,719.12" $0.00 "$36,315.50" "$16,579.68" "$16,579.68" "$22,645.22" "$22,645.22" "$14,672.11" $0.00 $0.00 $0.00 $0.00 "$36,315.50" $0.00 "$23,098.12" "$25,194.00" "$25,194.00" "$25,234.77" $0.00 $0.00 $0.00 $0.00 "$25,194.00" $0.00 $0.00 "$32,577.11" "$32,577.11" "$28,582.72" $0.00 $0.00 $0.00 $0.00 $0.00 MS071 DRG MS071 NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC INPATIENT ONLY "$54,131.74" "$40,057.49" $0.00 "$35,678.57" "$4,086.60" "$4,086.60" "$18,036.40" "$18,036.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,018.34" $0.00 "$18,397.13" $0.00 $0.00 "$20,600.14" $0.00 $0.00 "$35,678.57" $0.00 $0.00 $0.00 $0.00 "$21,268.52" "$21,268.52" "$19,619.18" $0.00 $0.00 $0.00 $0.00 $0.00 MS072 DRG MS072 NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$61,347.12" "$45,396.87" $0.00 "$18,849.31" $0.00 $0.00 "$16,379.34" "$16,379.34" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,365.57" $0.00 "$16,706.93" $0.00 $0.00 "$18,849.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,951.72" $0.00 $0.00 $0.00 $0.00 $0.00 MS073 DRG MS073 CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC INPATIENT ONLY "$41,000.17" "$30,340.13" $0.00 "$24,705.77" $0.00 $0.00 "$21,080.64" "$21,080.64" $0.00 "$14,136.39" $0.00 $0.00 $0.00 $0.00 "$14,136.39" "$21,502.25" $0.00 $0.00 "$23,476.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,705.77" "$24,705.77" "$22,358.52" $0.00 $0.00 $0.00 $0.00 $0.00 MS074 DRG MS074 CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC INPATIENT ONLY "$33,436.38" "$24,742.92" $0.00 "$36,882.23" "$25,719.00" "$25,719.00" $0.00 $0.00 $0.00 "$8,974.55" $0.00 $0.00 "$6,696.82" "$18,067.90" "$8,974.55" $0.00 $0.00 $0.00 "$20,555.00" "$14,569.53" "$36,882.23" $0.00 "$9,905.01" $0.00 "$9,905.01" "$8,589.85" "$21,214.59" "$21,214.59" "$19,576.19" "$9,019.34" $0.00 $0.00 $0.00 $0.00 MS075 DRG MS075 VIRAL MENINGITIS WITH CC/MCC INPATIENT ONLY "$63,854.38" "$47,252.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS077 DRG MS077 HYPERTENSIVE ENCEPHALOPATHY WITH MCC INPATIENT ONLY "$29,147.98" "$21,569.51" $0.00 "$25,742.09" "$13,255.89" "$13,255.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,065.43" $0.00 $0.00 "$24,343.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,742.09" "$25,742.09" "$23,184.42" $0.00 $0.00 $0.00 $0.00 $0.00 MS078 DRG MS078 HYPERTENSIVE ENCEPHALOPATHY WITH CC INPATIENT ONLY "$59,520.47" "$44,045.15" $0.00 "$20,376.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,376.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,406.35" $0.00 $0.00 $0.00 $0.00 $0.00 MS080 DRG MS080 NONTRAUMATIC STUPOR AND COMA WITH MCC INPATIENT ONLY "$109,992.22" "$81,394.24" $0.00 "$29,003.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,003.98" "$29,003.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS081 DRG MS081 NONTRAUMATIC STUPOR AND COMA WITHOUT MCC INPATIENT ONLY "$65,998.93" "$48,839.21" $0.00 "$20,324.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,324.45" "$20,324.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS082 DRG MS082 TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC INPATIENT ONLY "$109,243.85" "$80,840.45" $0.00 "$73,345.89" "$12,231.51" "$12,231.51" "$26,677.77" "$26,677.77" "$17,085.63" $0.00 $0.00 $0.00 "$16,934.46" "$26,637.35" $0.00 "$33,757.89" "$33,958.50" "$33,958.50" "$29,190.82" "$60,195.49" "$73,345.89" $0.00 "$22,572.74" "$33,958.50" "$22,572.74" $0.00 "$31,534.56" "$31,534.56" "$27,800.78" $0.00 $0.00 $0.00 $0.00 $0.00 MS083 DRG MS083 TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC INPATIENT ONLY "$91,871.44" "$67,984.87" $0.00 "$83,592.12" "$19,781.66" "$19,781.66" "$20,329.09" "$20,329.09" "$11,068.80" $0.00 $0.00 $0.00 "$16,307.27" "$20,305.08" $0.00 "$20,735.67" "$20,160.00" "$20,160.00" "$22,759.59" "$68,604.63" "$83,592.12" $0.00 "$13,138.85" "$20,160.00" "$13,138.85" $0.00 "$23,849.11" "$23,849.11" "$21,675.80" $0.00 $0.00 $0.00 $0.00 $0.00 MS084 DRG MS084 TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC INPATIENT ONLY "$60,065.16" "$44,448.22" $0.00 "$105,860.74" "$105,860.74" "$105,860.74" "$17,303.46" "$17,303.46" $0.00 $0.00 $0.00 $0.00 "$21,552.95" "$17,287.29" $0.00 "$17,649.53" $0.00 $0.00 "$18,985.24" "$74,022.47" "$90,193.56" $0.00 "$8,994.81" $0.00 "$8,994.81" $0.00 "$20,473.08" "$20,473.08" "$18,985.24" $0.00 $0.00 $0.00 $0.00 $0.00 MS085 DRG MS085 TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC INPATIENT ONLY "$133,066.60" "$98,469.28" $0.00 "$189,335.99" "$129,464.98" "$129,464.98" "$27,007.67" "$27,007.67" $0.00 $0.00 $0.00 $0.00 "$46,184.90" "$26,966.37" $0.00 "$27,547.82" $0.00 $0.00 "$29,149.82" "$155,389.38" "$189,335.99" $0.00 "$23,840.21" $0.00 "$23,840.21" "$6,719.03" "$39,231.69" "$39,231.69" "$27,761.73" "$7,054.97" $0.00 $0.00 $0.00 $0.00 MS086 DRG MS086 TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC INPATIENT ONLY "$91,005.46" "$67,344.04" $0.00 "$156,793.36" "$16,054.95" "$16,054.95" "$19,849.42" "$19,849.42" "$9,979.86" $0.00 $0.00 $0.00 "$39,612.08" "$19,826.66" $0.00 "$20,246.41" "$66,216.14" "$66,216.14" "$22,261.41" "$21,878.17" "$26,657.70" "$156,793.36" "$12,408.08" "$66,216.14" "$12,408.08" $0.00 "$23,253.77" "$23,253.77" "$21,201.34" $0.00 $0.00 $0.00 $0.00 $0.00 MS087 DRG MS087 TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC INPATIENT ONLY "$54,038.57" "$39,988.54" $0.00 "$54,184.31" "$10,442.68" "$10,442.68" "$17,013.59" "$17,013.59" "$6,658.59" "$6,337.82" $0.00 $0.00 "$4,618.49" $0.00 "$6,337.82" "$17,353.86" "$12,954.00" "$12,954.00" "$19,537.48" "$44,469.44" "$54,184.31" $0.00 "$8,412.39" "$12,954.00" "$8,412.39" "$6,066.14" "$19,998.62" "$19,998.62" "$18,607.12" "$6,369.44" $0.00 $0.00 $0.00 $0.00 MS088 DRG MS088 CONCUSSION WITH MCC INPATIENT ONLY "$61,942.49" "$45,837.44" $0.00 "$12,687.93" $0.00 $0.00 $0.00 $0.00 $0.00 "$12,687.93" $0.00 $0.00 $0.00 $0.00 "$12,687.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS089 DRG MS089 CONCUSSION WITH CC INPATIENT ONLY "$82,992.64" "$61,414.55" $0.00 "$74,998.20" "$74,998.20" "$74,998.20" "$18,393.22" "$18,393.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,761.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS090 DRG MS090 CONCUSSION WITHOUT CC/MCC INPATIENT ONLY "$63,676.92" "$47,120.92" $0.00 "$19,599.65" $0.00 $0.00 $0.00 $0.00 "$6,563.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$12,819.00" "$12,819.00" "$19,599.65" $0.00 $0.00 $0.00 $0.00 "$12,819.00" $0.00 $0.00 $0.00 $0.00 "$18,666.33" $0.00 $0.00 $0.00 $0.00 $0.00 MS091 DRG MS091 OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC INPATIENT ONLY "$52,693.58" "$38,993.25" $0.00 "$26,373.98" $0.00 $0.00 "$26,373.98" "$26,373.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,895.40" $0.00 $0.00 "$24,498.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,926.64" "$25,926.64" "$23,331.51" $0.00 $0.00 $0.00 $0.00 $0.00 MS092 DRG MS092 OTHER DISORDERS OF NERVOUS SYSTEM WITH CC INPATIENT ONLY "$112,379.69" "$83,160.97" $0.00 "$60,857.94" "$4,119.13" "$4,119.13" "$17,878.35" "$17,878.35" $0.00 $0.00 $0.00 $0.00 $0.00 "$17,860.69" $0.00 "$18,235.92" $0.00 $0.00 "$20,404.67" "$3,652.60" "$60,857.94" $0.00 "$9,684.47" $0.00 "$9,684.47" $0.00 "$21,034.94" "$21,034.94" "$19,433.02" $0.00 $0.00 $0.00 $0.00 $0.00 MS093 DRG MS093 OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC INPATIENT ONLY "$23,227.89" "$17,188.64" $0.00 "$21,343.61" "$5,791.65" "$5,791.65" "$16,451.82" "$16,451.82" $0.00 "$7,940.48" $0.00 $0.00 $0.00 "$16,437.85" "$7,940.48" "$16,780.86" $0.00 $0.00 "$19,004.44" "$4,008.53" "$21,343.61" $0.00 "$7,630.49" $0.00 "$7,630.49" $0.00 "$19,361.64" "$19,361.64" "$18,099.47" $0.00 $0.00 $0.00 $0.00 $0.00 MS094 DRG MS094 BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC INPATIENT ONLY "$208,527.33" "$154,310.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS095 DRG MS095 BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC INPATIENT ONLY "$128,295.60" "$94,938.74" $0.00 "$28,357.59" $0.00 $0.00 "$28,357.59" "$28,357.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS097 DRG MS097 NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC INPATIENT ONLY "$40,298.97" "$29,821.24" $0.00 "$141,271.31" "$13,337.55" "$13,337.55" "$37,005.85" "$37,005.85" $0.00 $0.00 $0.00 $0.00 "$141,271.31" "$36,938.70" $0.00 "$37,745.97" $0.00 $0.00 "$38,239.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$46,143.44" $0.00 $0.00 $0.00 $0.00 $0.00 MS098 DRG MS098 NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC INPATIENT ONLY "$81,880.42" "$60,591.51" $0.00 "$27,162.57" $0.00 $0.00 "$25,632.89" "$25,632.89" $0.00 $0.00 $0.00 $0.00 "$6,696.82" $0.00 $0.00 "$26,145.55" $0.00 $0.00 "$27,162.57" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,869.11" $0.00 $0.00 $0.00 $0.00 $0.00 MS099 DRG MS099 NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC INPATIENT ONLY "$174,672.76" "$129,257.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS100 DRG MS100 SEIZURES WITH MCC INPATIENT ONLY "$113,408.24" "$83,922.10" $0.00 "$127,077.03" "$41,317.50" "$41,317.50" "$28,871.11" "$28,871.11" "$13,659.94" "$16,066.40" $0.00 $0.00 "$16,742.05" "$23,969.93" "$16,066.40" "$24,483.50" "$28,146.00" "$28,146.00" "$26,241.38" "$104,293.01" "$127,077.03" $0.00 "$18,246.24" "$28,146.00" "$18,246.24" $0.00 "$28,009.92" "$28,009.92" "$24,991.79" $0.00 $0.00 $0.00 $0.00 $0.00 MS101 DRG MS101 SEIZURES WITHOUT MCC INPATIENT ONLY "$40,436.43" "$29,922.96" $0.00 "$30,456.31" "$20,980.25" "$20,980.25" "$17,184.76" "$17,184.76" $0.00 "$7,244.17" $0.00 $0.00 $0.00 "$17,168.90" "$7,244.17" "$17,528.46" $0.00 $0.00 "$19,836.12" "$3,828.93" "$30,456.31" "$28,419.72" "$8,850.46" $0.00 "$8,850.46" "$6,933.64" "$20,355.50" "$20,355.50" "$18,891.54" "$7,280.31" $0.00 $0.00 $0.00 $0.00 MS102 DRG MS102 HEADACHES WITH MCC INPATIENT ONLY "$29,362.26" "$21,728.07" $0.00 "$19,391.81" "$8,589.34" "$8,589.34" "$19,011.58" "$19,011.58" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,990.99" $0.00 "$19,391.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS103 DRG MS103 HEADACHES WITHOUT MCC INPATIENT ONLY "$49,370.41" "$36,534.10" $0.00 "$19,674.42" "$15,663.02" "$15,663.02" "$16,778.24" "$16,778.24" "$6,172.14" $0.00 $0.00 $0.00 "$6,696.82" "$16,763.43" $0.00 "$17,113.80" "$12,442.50" "$12,442.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$12,442.50" $0.00 "$6,384.88" "$19,674.42" "$19,674.42" $0.00 "$6,704.13" $0.00 $0.00 $0.00 $0.00 MS113 DRG MS113 ORBITAL PROCEDURES WITH CC/MCC INPATIENT ONLY "$138,306.42" "$102,346.75" $0.00 "$276,386.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$134,305.87" $0.00 $0.00 "$28,372.83" "$191,344.73" "$233,146.18" "$276,386.52" "$36,547.34" $0.00 "$36,547.34" $0.00 "$30,557.04" "$30,557.04" "$27,021.74" $0.00 $0.00 $0.00 $0.00 $0.00 MS114 DRG MS114 ORBITAL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$87,408.31" "$64,682.15" $0.00 "$22,869.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,940.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,869.95" "$22,869.95" "$20,895.44" $0.00 $0.00 $0.00 $0.00 $0.00 MS115 DRG MS115 EXTRAOCULAR PROCEDURES EXCEPT ORBIT INPATIENT ONLY "$67,898.23" "$50,244.69" $0.00 "$105,509.24" "$105,509.24" "$105,509.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS116 DRG MS116 INTRAOCULAR PROCEDURES WITH CC/MCC INPATIENT ONLY "$82,320.88" "$60,917.45" $0.00 "$30,595.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,725.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$30,595.31" $0.00 $0.00 $0.00 $0.00 $0.00 MS117 DRG MS117 INTRAOCULAR PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$367,970.92" "$272,298.48" $0.00 "$239,144.21" $0.00 $0.00 $0.00 $0.00 "$61,633.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$239,144.21" "$239,144.21" $0.00 $0.00 $0.00 $0.00 $0.00 "$239,144.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS121 DRG MS121 ACUTE MAJOR EYE INFECTIONS WITH CC/MCC INPATIENT ONLY "$15,973.21" "$11,820.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS123 DRG MS123 NEUROLOGICAL EYE DISORDERS INPATIENT ONLY "$44,663.68" "$33,051.12" $0.00 "$16,672.44" $0.00 $0.00 "$16,345.53" "$16,345.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,672.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS124 DRG MS124 OTHER DISORDERS OF THE EYE WITH MCC INPATIENT ONLY "$29,314.17" "$21,692.49" $0.00 "$26,180.77" "$26,180.77" "$26,180.77" "$20,729.36" "$20,729.36" "$10,203.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,143.95" "$21,030.00" "$21,030.00" $0.00 "$3,939.75" "$21,706.29" $0.00 "$13,927.76" "$21,030.00" "$13,927.76" $0.00 "$24,491.81" "$24,491.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS125 DRG MS125 OTHER DISORDERS OF THE EYE WITHOUT MCC INPATIENT ONLY "$41,942.08" "$31,037.14" $0.00 "$19,591.92" $0.00 $0.00 "$16,830.03" "$16,830.03" $0.00 $0.00 $0.00 $0.00 "$6,552.22" $0.00 $0.00 "$17,166.63" $0.00 $0.00 "$19,197.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,591.92" "$19,591.92" "$18,282.99" $0.00 $0.00 $0.00 $0.00 $0.00 MS137 DRG MS137 MOUTH PROCEDURES WITH CC/MCC INPATIENT ONLY "$21,396.53" "$15,833.43" $0.00 "$22,914.03" "$13,358.33" "$13,358.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,914.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,380.67" $0.00 $0.00 "$21,822.89" "$8,799.70" $0.00 $0.00 $0.00 $0.00 MS138 DRG MS138 MOUTH PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$106,064.54" "$78,487.76" $0.00 "$17,303.89" "$8,601.10" "$8,601.10" "$16,964.60" "$16,964.60" $0.00 $0.00 $0.00 $0.00 "$17,079.99" "$16,949.30" $0.00 "$17,303.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS139 DRG MS139 SALIVARY GLAND PROCEDURES INPATIENT ONLY $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS140 DRG MS140 MAJOR HEAD AND NECK PROCEDURES WITH MCC INPATIENT ONLY "$309,670.31" "$229,156.03" $0.00 "$213,352.18" "$194,628.71" "$194,628.71" "$60,708.75" "$60,708.75" "$194,363.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$213,352.18" "$213,352.18" "$213,352.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS141 DRG MS141 MAJOR HEAD AND NECK PROCEDURES WITH CC INPATIENT ONLY "$205,684.54" "$152,206.56" $0.00 "$93,559.19" $0.00 $0.00 "$26,278.86" "$26,278.86" $0.00 $0.00 $0.00 $0.00 "$93,559.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS142 DRG MS142 MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$165,428.82" "$122,417.33" $0.00 "$124,242.12" "$91,709.28" "$91,709.28" $0.00 $0.00 "$24,814.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$124,242.12" "$124,242.12" "$124,242.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS143 DRG MS143 "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC" INPATIENT ONLY "$304,173.95" "$225,088.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS144 DRG MS144 "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" INPATIENT ONLY "$18,109.68" "$13,401.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS145 DRG MS145 "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$93,894.95" "$69,482.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS146 DRG MS146 "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC" INPATIENT ONLY "$179,849.11" "$133,088.34" $0.00 "$28,926.04" $0.00 $0.00 "$25,140.12" "$25,140.12" $0.00 $0.00 $0.00 $0.00 $0.00 "$25,103.67" $0.00 "$25,642.92" $0.00 $0.00 "$26,982.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,926.04" "$28,926.04" "$25,697.29" $0.00 $0.00 $0.00 $0.00 $0.00 MS147 DRG MS147 "EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC" INPATIENT ONLY "$66,379.23" "$49,120.63" $0.00 "$97,982.21" "$97,982.21" "$97,982.21" "$20,033.00" "$20,033.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$20,009.77" $0.00 "$20,433.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS149 DRG MS149 DYSEQUILIBRIUM INPATIENT ONLY "$20,824.61" "$15,410.21" $0.00 "$19,110.92" $0.00 $0.00 "$16,139.87" "$16,139.87" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,126.71" $0.00 "$16,462.67" $0.00 $0.00 "$18,794.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,110.92" "$19,110.92" "$17,899.66" $0.00 $0.00 $0.00 $0.00 $0.00 MS150 DRG MS150 EPISTAXIS WITH MCC INPATIENT ONLY "$39,367.10" "$29,131.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS152 DRG MS152 OTITIS MEDIA AND URI WITH MCC INPATIENT ONLY "$24,484.17" "$18,118.29" $0.00 "$20,902.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$13,393.64" $0.00 $0.00 $0.00 $0.00 $0.00 "$20,902.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,907.48" $0.00 $0.00 $0.00 $0.00 $0.00 MS153 DRG MS153 OTITIS MEDIA AND URI WITHOUT MCC INPATIENT ONLY "$23,118.21" "$17,107.48" $0.00 "$18,914.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$10,415.87" "$16,796.75" $0.00 "$7,081.17" $0.00 "$7,081.17" $0.00 "$18,914.10" "$18,914.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS154 DRG MS154 "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC" INPATIENT ONLY "$93,847.35" "$69,447.04" $0.00 "$22,163.26" $0.00 $0.00 "$21,728.69" "$21,728.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,163.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS155 DRG MS155 "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" INPATIENT ONLY "$43,876.11" "$32,468.32" $0.00 "$20,504.12" $0.00 $0.00 "$17,330.38" "$17,330.38" $0.00 $0.00 $0.00 $0.00 $0.00 "$17,314.14" $0.00 "$17,676.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,166.65" "$20,504.12" "$20,504.12" $0.00 "$6,474.98" $0.00 $0.00 $0.00 $0.00 MS156 DRG MS156 "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" INPATIENT ONLY "$23,686.23" "$17,527.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS157 DRG MS157 DENTAL AND ORAL DISEASES WITH MCC INPATIENT ONLY "$74,941.49" "$55,456.70" $0.00 "$25,908.70" $0.00 $0.00 "$21,931.61" "$21,931.61" $0.00 $0.00 $0.00 $0.00 "$21,981.73" "$21,903.46" $0.00 "$22,370.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,908.70" "$25,908.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS158 DRG MS158 DENTAL AND ORAL DISEASES WITH CC INPATIENT ONLY "$78,110.53" "$57,801.79" $0.00 "$20,222.38" $0.00 $0.00 "$17,266.18" "$17,266.18" $0.00 $0.00 $0.00 $0.00 $0.00 "$17,250.11" $0.00 "$17,611.50" $0.00 $0.00 "$19,724.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,376.14" "$20,222.38" "$20,222.38" "$18,785.45" "$8,794.95" $0.00 $0.00 $0.00 $0.00 MS159 DRG MS159 DENTAL AND ORAL DISEASES WITHOUT CC/MCC INPATIENT ONLY "$77,636.24" "$57,450.82" $0.00 "$49,192.35" "$17,283.48" "$17,283.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,401.02" "$7,632.24" "$49,192.35" $0.00 "$6,745.36" $0.00 "$6,745.36" $0.00 "$18,640.54" "$18,640.54" "$17,524.78" $0.00 $0.00 $0.00 $0.00 $0.00 MS163 DRG MS163 MAJOR CHEST PROCEDURES WITH MCC INPATIENT ONLY "$279,043.80" "$206,492.41" $0.00 "$296,439.13" "$137,000.36" "$137,000.36" $0.00 $0.00 $0.00 "$51,285.84" $0.00 $0.00 "$112,921.68" $0.00 "$53,850.16" "$48,524.14" $0.00 $0.00 $0.00 "$243,289.68" "$296,439.13" $0.00 "$60,731.26" $0.00 "$60,731.26" $0.00 "$52,946.21" "$52,946.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS164 DRG MS164 MAJOR CHEST PROCEDURES WITH CC INPATIENT ONLY "$282,327.09" "$208,922.05" $0.00 "$223,039.12" "$220,306.22" "$220,306.22" $0.00 $0.00 "$62,096.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$223,039.12" "$223,039.12" "$31,102.90" "$182,933.69" "$222,897.67" $0.00 "$34,322.38" "$223,039.12" "$34,322.38" $0.00 "$33,819.53" "$33,819.53" "$29,621.81" $0.00 $0.00 $0.00 $0.00 $0.00 MS165 DRG MS165 MAJOR CHEST PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$65,007.56" "$48,105.59" $0.00 "$28,246.73" $0.00 $0.00 "$24,280.88" "$24,280.88" $0.00 $0.00 $0.00 $0.00 $0.00 "$24,246.64" $0.00 "$24,766.50" $0.00 $0.00 "$26,439.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,246.73" "$28,246.73" "$25,180.51" $0.00 $0.00 $0.00 $0.00 $0.00 MS166 DRG MS166 OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC INPATIENT ONLY "$178,026.71" "$131,739.77" $0.00 "$55,255.73" $0.00 $0.00 "$36,751.19" "$36,751.19" $0.00 $0.00 $0.00 $0.00 $0.00 "$36,684.69" $0.00 "$37,486.21" $0.00 $0.00 "$39,297.27" "$16,179.17" "$55,255.73" $0.00 "$37,397.68" $0.00 "$37,397.68" $0.00 "$43,611.96" "$43,611.96" "$47,571.93" $0.00 $0.00 $0.00 $0.00 $0.00 MS167 DRG MS167 OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC INPATIENT ONLY "$133,062.87" "$98,466.52" $0.00 "$32,510.42" $0.00 $0.00 "$23,605.22" "$23,605.22" $0.00 $0.00 $0.00 $0.00 $0.00 "$23,572.75" $0.00 "$24,077.32" $0.00 $0.00 "$26,885.12" "$16,604.60" "$32,510.42" $0.00 "$19,190.53" $0.00 "$19,190.53" "$17,468.56" "$28,779.21" "$28,779.21" "$25,604.88" "$18,341.98" $0.00 $0.00 $0.00 $0.00 MS168 DRG MS168 OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$296,531.05" "$219,432.98" $0.00 "$22,868.93" $0.00 $0.00 "$20,400.85" "$20,400.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,511.55" $0.00 $0.00 "$22,868.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,779.93" $0.00 $0.00 $0.00 $0.00 $0.00 MS175 DRG MS175 PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE INPATIENT ONLY "$46,945.21" "$34,739.46" $0.00 "$38,070.00" "$26,408.34" "$26,408.34" "$21,723.17" "$21,723.17" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,695.56" $0.00 "$22,157.63" $0.00 $0.00 "$23,432.41" "$16,704.06" "$38,070.00" $0.00 "$14,479.10" $0.00 "$14,479.10" $0.00 "$24,940.97" "$24,940.97" "$22,316.58" $0.00 $0.00 $0.00 $0.00 $0.00 MS176 DRG MS176 PULMONARY EMBOLISM WITHOUT MCC INPATIENT ONLY "$35,673.42" "$26,398.33" $0.00 "$18,666.99" $0.00 $0.00 "$17,180.62" "$17,180.62" $0.00 $0.00 $0.00 $0.00 "$3,348.41" "$16,508.75" $0.00 "$17,524.23" $0.00 $0.00 "$18,666.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,736.43" "$18,474.68" "$18,474.68" "$18,666.99" "$8,233.74" $0.00 $0.00 $0.00 $0.00 MS177 DRG MS177 RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC INPATIENT ONLY "$54,920.67" "$40,641.30" $0.00 "$35,112.81" "$24,674.54" "$24,674.54" "$29,566.11" "$29,566.11" "$17,398.03" "$18,110.89" $0.00 $0.00 "$24,142.73" "$29,518.11" "$18,110.89" "$30,157.43" "$27,736.50" "$27,736.50" "$26,726.58" "$8,082.82" "$21,757.37" "$11,693.56" "$18,957.97" "$27,736.50" "$18,957.97" "$2,527.77" "$35,112.81" "$35,112.81" "$30,597.17" "$2,690.25" $0.00 $0.00 $0.00 $0.00 MS178 DRG MS178 RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC INPATIENT ONLY "$41,304.99" "$30,565.69" $0.00 "$31,014.33" "$4,086.60" "$4,086.60" "$23,653.50" "$23,653.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$19,367.53" $0.00 "$30,157.43" $0.00 $0.00 "$22,298.99" "$10,783.80" "$31,014.33" "$27,319.11" "$12,463.21" $0.00 "$12,463.21" "$3,578.23" "$27,587.02" "$27,587.02" "$24,618.39" "$3,808.24" $0.00 $0.00 $0.00 $0.00 MS179 DRG MS179 RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC INPATIENT ONLY "$14,995.29" "$11,096.51" $0.00 "$27,548.37" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,204.24" $0.00 $0.00 $0.00 $0.00 "$6,880.87" $858.97 $0.00 $0.00 "$19,721.29" "$12,770.64" "$27,548.37" "$11,997.43" "$8,682.05" $0.00 "$8,682.05" $0.00 "$23,205.61" "$23,205.61" "$21,137.62" $0.00 $0.00 $0.00 $0.00 $0.00 MS180 DRG MS180 RESPIRATORY NEOPLASMS WITH MCC INPATIENT ONLY "$96,534.84" "$71,435.78" $0.00 "$27,231.65" $0.00 $0.00 "$23,061.38" "$23,061.38" $0.00 $0.00 $0.00 $0.00 "$23,438.87" "$23,030.30" $0.00 "$23,522.61" $0.00 $0.00 "$25,590.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,231.65" "$27,231.65" "$24,371.54" $0.00 $0.00 $0.00 $0.00 $0.00 MS181 DRG MS181 RESPIRATORY NEOPLASMS WITH CC INPATIENT ONLY "$48,052.18" "$35,558.61" $0.00 "$22,553.09" "$4,515.45" "$4,515.45" "$18,783.83" "$18,783.83" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,763.84" $0.00 "$19,159.51" $0.00 $0.00 "$21,675.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,553.09" "$22,553.09" "$20,642.93" $0.00 $0.00 $0.00 $0.00 $0.00 MS182 DRG MS182 RESPIRATORY NEOPLASMS WITHOUT CC/MCC INPATIENT ONLY "$48,193.46" "$35,663.16" $0.00 "$19,562.08" "$16,511.68" "$16,511.68" $0.00 $0.00 "$7,219.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$11,880.00" "$11,880.00" "$19,562.08" $0.00 $0.00 $0.00 $0.00 "$11,880.00" $0.00 $0.00 $0.00 $0.00 "$18,630.55" $0.00 $0.00 $0.00 $0.00 $0.00 MS183 DRG MS183 MAJOR CHEST TRAUMA WITH MCC INPATIENT ONLY "$71,723.96" "$53,075.73" $0.00 "$24,116.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,601.98" $0.00 $0.00 "$24,116.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,967.71" $0.00 $0.00 $0.00 $0.00 $0.00 MS184 DRG MS184 MAJOR CHEST TRAUMA WITH CC INPATIENT ONLY "$80,313.41" "$59,431.92" $0.00 "$68,413.61" "$22,437.76" "$22,437.76" "$18,237.24" "$18,237.24" $0.00 $0.00 $0.00 $0.00 "$68,413.61" "$18,218.65" $0.00 "$18,601.98" $0.00 $0.00 "$20,760.71" "$52,951.87" "$64,519.81" $0.00 "$10,206.75" $0.00 "$10,206.75" $0.00 "$21,460.41" "$21,460.41" "$19,772.10" $0.00 $0.00 $0.00 $0.00 $0.00 MS185 DRG MS185 MAJOR CHEST TRAUMA WITHOUT CC/MCC INPATIENT ONLY "$50,595.65" "$37,440.78" $0.00 "$19,139.50" "$12,596.89" "$12,596.89" "$16,401.44" "$16,401.44" "$5,915.97" $0.00 $0.00 $0.00 "$16,934.46" "$16,387.60" $0.00 "$16,729.47" "$11,623.50" "$11,623.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$11,623.50" $0.00 $0.00 "$19,139.50" "$19,139.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS186 DRG MS186 PLEURAL EFFUSION WITH MCC INPATIENT ONLY "$30,155.37" "$22,314.97" $0.00 "$39,070.27" $0.00 $0.00 "$18,487.14" "$18,487.14" $0.00 $0.00 $0.00 $0.00 $0.00 "$39,070.27" $0.00 "$18,856.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,067.06" "$31,067.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS187 DRG MS187 PLEURAL EFFUSION WITH CC INPATIENT ONLY "$66,163.36" "$48,960.89" $0.00 "$20,826.98" $0.00 $0.00 "$18,182.03" "$18,182.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,545.67" $0.00 $0.00 "$20,826.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,835.22" $0.00 $0.00 $0.00 $0.00 $0.00 MS188 DRG MS188 PLEURAL EFFUSION WITHOUT CC/MCC INPATIENT ONLY "$23,754.99" "$17,578.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS189 DRG MS189 PULMONARY EDEMA AND RESPIRATORY FAILURE INPATIENT ONLY "$40,618.71" "$30,057.85" $0.00 "$36,477.30" "$25,196.85" "$25,196.85" "$19,549.83" "$19,549.83" "$9,782.23" "$12,640.58" $0.00 $0.00 "$3,348.41" "$19,493.51" "$13,272.61" "$19,905.70" "$9,782.23" "$9,782.23" "$22,110.38" "$15,587.39" "$36,477.30" "$26,164.57" "$12,186.54" "$9,782.23" "$12,186.54" $0.00 "$23,073.29" "$23,073.29" "$21,057.50" $0.00 $0.00 $0.00 $0.00 $0.00 MS190 DRG MS190 CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC INPATIENT ONLY "$22,075.42" "$16,335.81" $0.00 "$22,487.76" "$8,385.55" "$8,385.55" "$17,727.21" "$17,727.21" $0.00 "$10,092.46" $0.00 $0.00 $0.00 "$18,798.25" "$10,597.09" "$19,194.71" $0.00 $0.00 "$21,620.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,487.76" "$22,487.76" "$20,590.86" $0.00 $0.00 $0.00 $0.00 $0.00 MS191 DRG MS191 CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC INPATIENT ONLY "$27,212.46" "$20,137.22" $0.00 "$20,436.33" $0.00 $0.00 "$17,156.46" "$17,156.46" $0.00 "$14,254.34" $0.00 $0.00 $0.00 "$17,140.67" "$8,483.54" "$17,499.59" $0.00 $0.00 "$19,903.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,436.33" "$20,436.33" "$18,955.96" $0.00 $0.00 $0.00 $0.00 $0.00 MS192 DRG MS192 CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC INPATIENT ONLY "$39,809.35" "$29,458.92" $0.00 "$18,936.98" "$8,173.20" "$8,173.20" "$15,854.15" "$15,854.15" $0.00 $0.00 $0.00 $0.00 "$3,348.41" $0.00 $0.00 "$16,171.23" $0.00 $0.00 "$18,649.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,936.98" "$18,936.98" "$17,761.04" $0.00 $0.00 $0.00 $0.00 $0.00 MS193 DRG MS193 SIMPLE PNEUMONIA AND PLEURISY WITH MCC INPATIENT ONLY "$53,920.15" "$39,900.91" $0.00 "$43,491.25" "$24,519.60" "$24,519.60" "$20,108.24" "$20,108.24" $0.00 $0.00 $0.00 $0.00 $0.00 "$20,084.80" $0.00 "$20,510.40" $0.00 $0.00 "$22,915.39" "$3,781.24" "$33,085.28" "$43,491.25" "$13,367.42" $0.00 "$13,367.42" "$12,168.50" "$24,035.30" "$24,035.30" "$21,824.18" "$12,776.92" $0.00 $0.00 $0.00 $0.00 MS194 DRG MS194 SIMPLE PNEUMONIA AND PLEURISY WITH CC INPATIENT ONLY "$23,780.48" "$17,597.56" $0.00 "$20,557.21" $0.00 $0.00 "$17,015.67" "$17,015.67" $0.00 $0.00 $0.00 $0.00 $0.00 "$17,000.25" $0.00 "$17,355.98" $0.00 $0.00 "$19,875.06" "$6,896.00" "$20,557.21" $0.00 "$8,907.60" $0.00 "$8,907.60" "$2,899.29" "$20,402.05" "$20,402.05" "$18,928.63" "$3,085.65" $0.00 $0.00 $0.00 $0.00 MS195 DRG MS195 SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC INPATIENT ONLY "$27,752.98" "$20,537.21" $0.00 "$18,715.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$10,045.23" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,463.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,926.47" "$18,715.67" "$18,715.67" "$17,584.66" "$3,114.59" $0.00 $0.00 $0.00 $0.00 MS196 DRG MS196 INTERSTITIAL LUNG DISEASE WITH MCC INPATIENT ONLY "$62,019.94" "$45,894.76" $0.00 "$50,112.69" "$4,298.95" "$4,298.95" "$23,052.43" "$23,052.43" $0.00 $0.00 $0.00 $0.00 $0.00 "$23,021.37" $0.00 "$23,513.48" $0.00 $0.00 "$25,251.85" "$24,703.77" "$50,112.69" $0.00 "$16,794.73" $0.00 "$16,794.73" $0.00 "$26,827.41" "$26,827.41" "$24,049.38" $0.00 $0.00 $0.00 $0.00 $0.00 MS197 DRG MS197 INTERSTITIAL LUNG DISEASE WITH CC INPATIENT ONLY "$33,882.40" "$25,072.98" $0.00 "$21,487.37" $0.00 $0.00 "$18,003.28" "$18,003.28" $0.00 $0.00 $0.00 $0.00 $0.00 "$17,985.30" $0.00 "$18,363.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,487.37" "$21,487.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS198 DRG MS198 INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC INPATIENT ONLY "$58,135.75" "$43,020.46" $0.00 "$6,417.29" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,111.70" $0.00 $0.00 $0.00 $0.00 "$6,417.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS199 DRG MS199 PNEUMOTHORAX WITH MCC INPATIENT ONLY "$87,933.44" "$65,070.75" $0.00 "$71,834.87" "$22,271.35" "$22,271.35" "$28,615.62" "$28,615.62" "$16,374.25" "$20,990.30" $0.00 $0.00 $0.00 "$33,369.82" "$20,995.35" "$29,187.93" "$26,850.00" "$26,850.00" $0.00 "$19,741.79" "$71,834.87" $0.00 "$17,984.61" "$26,850.00" "$17,984.61" "$13,711.52" "$27,796.78" "$27,796.78" $0.00 "$14,397.09" $0.00 $0.00 $0.00 $0.00 MS200 DRG MS200 PNEUMOTHORAX WITH CC INPATIENT ONLY "$88,938.55" "$65,814.53" $0.00 "$41,863.22" "$26,577.44" "$26,577.44" "$18,482.92" "$18,482.92" "$9,000.71" "$7,212.00" $0.00 $0.00 "$7,290.56" $0.00 "$7,212.00" "$18,852.58" "$16,147.50" "$16,147.50" "$21,197.39" "$7,597.89" "$33,230.54" "$41,863.22" "$10,847.31" "$16,147.50" "$10,847.31" "$6,902.85" "$21,982.26" "$21,982.26" "$20,187.99" "$7,247.99" $0.00 $0.00 $0.00 $0.00 MS201 DRG MS201 PNEUMOTHORAX WITHOUT CC/MCC INPATIENT ONLY "$18,226.67" "$13,487.74" $0.00 "$28,659.30" "$28,659.30" "$28,659.30" $0.00 $0.00 $0.00 "$5,832.61" $0.00 $0.00 $0.00 $0.00 "$5,832.61" "$16,269.80" $0.00 $0.00 "$18,709.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,818.31" $0.00 $0.00 $0.00 $0.00 $0.00 MS202 DRG MS202 BRONCHITIS AND ASTHMA WITH CC/MCC INPATIENT ONLY "$27,125.85" "$20,073.13" $0.00 "$20,887.13" "$8,642.61" "$8,642.61" "$17,727.21" "$17,727.21" $0.00 "$7,793.93" $0.00 $0.00 $0.00 $0.00 "$8,183.63" "$18,081.75" $0.00 $0.00 "$20,280.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,887.13" "$20,887.13" "$19,315.22" $0.00 $0.00 $0.00 $0.00 $0.00 MS203 DRG MS203 BRONCHITIS AND ASTHMA WITHOUT CC/MCC INPATIENT ONLY "$17,147.67" "$12,689.28" $0.00 "$18,811.21" $0.00 $0.00 "$15,932.82" "$15,932.82" $0.00 "$3,735.21" $0.00 $0.00 "$3,348.41" "$15,920.20" "$5,866.67" "$16,251.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,811.21" "$18,811.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS204 DRG MS204 RESPIRATORY SIGNS AND SYMPTOMS INPATIENT ONLY "$12,787.21" "$9,462.54" $0.00 "$116,821.39" "$114,402.61" "$114,402.61" "$16,530.50" "$16,530.50" "$19,192.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,861.11" "$116,821.39" "$116,821.39" "$19,354.99" $0.00 $0.00 $0.00 $0.00 "$116,821.39" $0.00 $0.00 "$19,780.56" "$19,780.56" "$18,433.32" $0.00 $0.00 $0.00 $0.00 $0.00 MS205 DRG MS205 OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC INPATIENT ONLY "$71,391.42" "$52,829.65" $0.00 "$46,642.66" "$16,664.62" "$16,664.62" "$27,050.39" "$27,050.39" "$12,495.13" $0.00 $0.00 $0.00 $0.00 "$22,651.02" $0.00 "$27,591.40" "$25,272.00" "$25,272.00" "$24,970.31" "$12,908.72" "$46,642.66" $0.00 "$16,381.71" "$25,272.00" "$16,381.71" $0.00 "$26,490.96" "$26,490.96" "$23,781.25" $0.00 $0.00 $0.00 $0.00 $0.00 MS206 DRG MS206 OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC INPATIENT ONLY "$30,695.99" "$22,715.03" $0.00 "$34,911.74" $0.00 $0.00 "$17,168.19" "$17,168.19" $0.00 "$6,502.44" $0.00 $0.00 "$10,045.23" "$17,152.37" "$6,502.44" $0.00 $0.00 $0.00 "$19,765.04" "$4,150.00" "$34,911.74" $0.00 "$8,746.21" $0.00 "$8,746.21" $0.00 "$20,270.57" "$20,270.57" "$18,823.85" $0.00 $0.00 $0.00 $0.00 $0.00 MS207 DRG MS207 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS INPATIENT ONLY "$381,382.83" "$282,223.29" $0.00 "$350,029.12" "$136,076.60" "$136,076.60" "$50,641.13" "$50,641.13" $0.00 "$62,949.70" $0.00 $0.00 "$7,290.56" "$50,538.71" "$66,097.21" "$51,653.95" $0.00 $0.00 "$50,474.52" "$287,271.37" "$350,029.12" $0.00 "$78,281.84" $0.00 "$78,281.84" $0.00 "$59,984.89" "$59,984.89" "$50,474.52" $0.00 $0.00 $0.00 $0.00 $0.00 MS208 DRG MS208 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS INPATIENT ONLY "$129,996.22" "$96,197.20" $0.00 "$33,431.63" "$26,856.98" "$26,856.98" "$28,616.41" "$28,616.41" $0.00 $0.00 $0.00 $0.00 $0.00 "$28,570.95" $0.00 "$29,188.74" $0.00 $0.00 "$30,778.29" "$5,386.48" "$22,287.15" $0.00 "$24,901.37" $0.00 "$24,901.37" $0.00 "$33,431.63" "$33,431.63" "$29,312.66" $0.00 $0.00 $0.00 $0.00 $0.00 MS215 DRG MS215 OTHER HEART ASSIST SYSTEM IMPLANT INPATIENT ONLY "$302,673.62" "$223,978.48" $0.00 "$426,802.21" "$177,689.39" "$177,689.39" "$83,922.24" "$83,922.24" $0.00 $0.00 $0.00 $0.00 "$3,645.28" $0.00 $0.00 "$85,600.68" $0.00 $0.00 "$101,862.99" "$350,279.60" "$426,802.21" $0.00 "$129,174.20" $0.00 "$129,174.20" $0.00 "$118,379.20" "$118,379.20" "$97,012.37" $0.00 $0.00 $0.00 $0.00 $0.00 MS216 DRG MS216 CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC INPATIENT ONLY "$844,071.58" "$624,612.97" $0.00 "$363,816.68" "$363,816.68" "$363,816.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$95,156.23" "$95,156.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS219 DRG MS219 CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC INPATIENT ONLY "$652,285.78" "$482,691.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS220 DRG MS220 CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC INPATIENT ONLY "$834,118.48" "$617,247.68" $0.00 "$314,960.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$258,490.53" "$314,960.76" $0.00 "$67,066.33" $0.00 "$67,066.33" $0.00 "$56,475.77" "$56,475.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS222 DRG MS222 "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI, HF OR SHOCK WITH MCC" INPATIENT ONLY "$557,934.66" "$412,871.65" $0.00 "$652,154.79" "$652,154.79" "$652,154.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$81,291.22" "$81,291.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS224 DRG MS224 "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI, HF OR SHOCK WITH MCC" INPATIENT ONLY "$224,109.48" "$165,841.02" $0.00 "$66,349.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$66,349.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$63,190.05" $0.00 $0.00 $0.00 $0.00 $0.00 MS225 DRG MS225 "CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI, HF OR SHOCK WITHOUT MCC" INPATIENT ONLY "$304,647.12" "$225,438.87" $0.00 "$59,276.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$49,909.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$59,276.04" "$59,276.04" "$49,909.59" $0.00 $0.00 $0.00 $0.00 $0.00 MS226 DRG MS226 CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC INPATIENT ONLY "$262,894.89" "$194,542.22" $0.00 "$59,504.66" $0.00 $0.00 "$56,361.78" "$56,361.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$57,489.02" $0.00 $0.00 "$59,504.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$56,671.10" $0.00 $0.00 $0.00 $0.00 $0.00 MS227 DRG MS227 CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC INPATIENT ONLY "$237,743.92" "$175,930.50" $0.00 "$47,965.26" $0.00 $0.00 "$47,024.76" "$47,024.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$47,965.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS228 DRG MS228 OTHER CARDIOTHORACIC PROCEDURES WITH MCC INPATIENT ONLY "$357,913.50" "$264,855.99" $0.00 "$66,076.66" $0.00 $0.00 "$47,840.51" "$47,840.51" $0.00 $0.00 $0.00 $0.00 $0.00 "$47,745.32" $0.00 "$48,797.32" $0.00 $0.00 "$66,076.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$64,482.16" "$64,482.16" "$66,076.66" $0.00 $0.00 $0.00 $0.00 $0.00 MS233 DRG MS233 CORONARY BYPASS WITH CARDIAC CATHETERIZATION WITH MCC INPATIENT ONLY "$709,784.74" "$525,240.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS234 DRG MS234 CORONARY BYPASS WITH CARDIAC CATHETERIZATION WITHOUT MCC INPATIENT ONLY "$480,271.74" "$355,401.09" $0.00 "$55,662.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$55,662.39" "$55,662.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS235 DRG MS235 CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC INPATIENT ONLY "$433,659.48" "$320,908.02" $0.00 "$82,191.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$46,536.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$82,191.24" "$82,191.24" "$44,320.66" $0.00 $0.00 $0.00 $0.00 $0.00 MS236 DRG MS236 CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC INPATIENT ONLY "$407,163.36" "$301,300.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS239 DRG MS239 AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC INPATIENT ONLY "$309,142.02" "$228,765.09" $0.00 "$520,828.58" $0.00 $0.00 "$40,051.71" "$40,051.71" $0.00 $0.00 $0.00 $0.00 $0.00 "$40,042.67" $0.00 "$30,906.38" $0.00 $0.00 "$45,984.42" "$427,447.72" "$520,828.58" $0.00 "$126,573.84" $0.00 "$126,573.84" $0.00 "$51,280.25" "$51,280.25" "$43,794.69" $0.00 $0.00 $0.00 $0.00 $0.00 MS240 DRG MS240 AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC INPATIENT ONLY "$156,536.31" "$115,836.87" $0.00 "$197,317.38" $0.00 $0.00 "$30,300.37" "$30,300.37" $0.00 $0.00 $0.00 $0.00 "$197,317.38" "$30,250.57" $0.00 "$30,906.38" $0.00 $0.00 "$32,140.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$35,684.78" "$35,684.78" "$32,140.33" $0.00 $0.00 $0.00 $0.00 $0.00 MS241 DRG MS241 AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC INPATIENT ONLY "$120,662.24" "$89,290.06" $0.00 "$25,528.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,528.14" "$25,528.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS242 DRG MS242 PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC INPATIENT ONLY "$265,067.17" "$196,149.71" $0.00 "$43,451.88" $0.00 $0.00 "$36,779.50" "$36,779.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$43,451.88" "$43,451.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS243 DRG MS243 PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC INPATIENT ONLY "$158,068.54" "$116,970.72" $0.00 "$29,003.59" $0.00 $0.00 "$28,434.89" "$28,434.89" $0.00 $0.00 $0.00 $0.00 $0.00 "$28,389.92" $0.00 "$29,003.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS244 DRG MS244 PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC INPATIENT ONLY "$95,847.00" "$70,926.78" $0.00 "$30,094.00" $0.00 $0.00 "$25,293.32" "$25,293.32" $0.00 $0.00 $0.00 $0.00 $0.00 "$25,256.47" $0.00 "$25,799.19" $0.00 $0.00 "$27,985.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$30,094.00" "$30,094.00" "$26,652.72" $0.00 $0.00 $0.00 $0.00 $0.00 MS245 DRG MS245 AICD GENERATOR PROCEDURES INPATIENT ONLY "$152,256.14" "$112,669.54" $0.00 "$49,413.28" $0.00 $0.00 "$48,444.39" "$48,444.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$49,413.28" $0.00 $0.00 "$49,391.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$47,039.42" $0.00 $0.00 $0.00 $0.00 $0.00 MS246 DRG MS246 PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS INPATIENT ONLY "$209,787.55" "$155,242.79" $0.00 "$121,561.11" "$24,732.19" "$24,732.19" "$32,615.82" "$32,615.82" $0.00 $0.00 $0.00 $0.00 "$121,561.11" "$32,560.02" $0.00 "$33,268.14" $0.00 $0.00 "$35,484.73" "$17,653.94" "$81,055.22" $0.00 "$31,805.11" $0.00 "$31,805.11" $0.00 "$39,055.90" "$39,055.90" "$33,794.98" $0.00 $0.00 $0.00 $0.00 $0.00 MS247 DRG MS247 PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC INPATIENT ONLY "$113,312.93" "$83,851.57" $0.00 "$74,539.79" "$15,580.11" "$15,580.11" "$24,671.50" "$24,671.50" $0.00 $0.00 $0.00 $0.00 "$3,348.41" "$24,636.27" $0.00 "$25,164.93" $0.00 $0.00 "$27,707.22" "$30,001.65" "$74,539.79" "$58,858.96" "$20,396.45" $0.00 "$20,396.45" $0.00 "$29,761.63" "$29,761.63" "$26,387.83" $0.00 $0.00 $0.00 $0.00 $0.00 MS248 DRG MS248 PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS INPATIENT ONLY "$176,079.18" "$130,298.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS249 DRG MS249 PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC INPATIENT ONLY "$68,186.12" "$50,457.73" $0.00 "$26,900.15" $0.00 $0.00 "$23,984.81" "$23,984.81" $0.00 $0.00 $0.00 $0.00 $0.00 "$23,951.35" $0.00 "$24,464.51" $0.00 $0.00 "$26,900.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,619.19" $0.00 $0.00 $0.00 $0.00 $0.00 MS250 DRG MS250 PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC INPATIENT ONLY "$159,798.37" "$118,250.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS251 DRG MS251 PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITHOUT MCC INPATIENT ONLY "$72,880.41" "$53,931.50" $0.00 "$14,906.70" $0.00 $0.00 $0.00 $0.00 $0.00 "$14,894.34" $0.00 $0.00 $0.00 $0.00 "$14,906.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS252 DRG MS252 OTHER VASCULAR PROCEDURES WITH MCC INPATIENT ONLY "$145,151.23" "$107,411.91" $0.00 "$169,852.02" "$12,259.80" "$12,259.80" "$34,005.79" "$34,005.79" $0.00 $0.00 $0.00 $0.00 "$169,852.02" "$33,946.40" $0.00 "$34,685.91" $0.00 $0.00 "$36,220.00" $0.00 $0.00 "$100,414.90" $0.00 $0.00 $0.00 $0.00 "$39,934.57" "$39,934.57" "$34,495.24" $0.00 $0.00 $0.00 $0.00 $0.00 MS253 DRG MS253 OTHER VASCULAR PROCEDURES WITH CC INPATIENT ONLY "$129,099.23" "$95,533.43" $0.00 "$34,432.01" $0.00 $0.00 "$29,367.29" "$29,367.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,954.64" $0.00 $0.00 "$31,615.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$34,432.01" "$34,432.01" "$30,109.93" $0.00 $0.00 $0.00 $0.00 $0.00 MS254 DRG MS254 OTHER VASCULAR PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$209,675.21" "$155,159.66" $0.00 "$27,238.50" "$7,561.44" "$7,561.44" "$23,585.90" "$23,585.90" "$15,445.08" $0.00 $0.00 $0.00 $0.00 "$23,553.48" $0.00 "$24,057.62" "$27,238.50" "$27,238.50" "$26,240.69" $0.00 $0.00 $0.00 $0.00 "$27,238.50" $0.00 "$17,128.08" $0.00 $0.00 "$24,991.13" "$17,984.48" $0.00 $0.00 $0.00 $0.00 MS255 DRG MS255 UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC INPATIENT ONLY "$101,664.29" "$75,231.57" $0.00 "$85,925.68" "$85,925.68" "$85,925.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,909.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$30,389.81" $0.00 $0.00 $0.00 $0.00 $0.00 MS256 DRG MS256 UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC INPATIENT ONLY "$55,860.77" "$41,336.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS258 DRG MS258 CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC INPATIENT ONLY "$237,539.00" "$175,778.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS259 DRG MS259 CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC INPATIENT ONLY "$113,151.42" "$83,732.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS260 DRG MS260 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC INPATIENT ONLY "$163,381.24" "$120,902.12" $0.00 "$43,357.97" $0.00 $0.00 "$18,747.12" "$18,747.12" $0.00 $0.00 $0.00 $0.00 $0.00 "$35,609.47" $0.00 "$19,122.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$43,357.97" "$43,357.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS261 DRG MS261 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC INPATIENT ONLY "$51,477.15" "$38,093.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS262 DRG MS262 CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC INPATIENT ONLY "$57,243.02" "$42,359.83" $0.00 "$11,542.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$11,542.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS264 DRG MS264 OTHER CIRCULATORY SYSTEM O.R. PROCEDURES INPATIENT ONLY $0.00 $0.00 $0.00 "$39,670.80" $0.00 $0.00 "$33,508.18" "$33,508.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$34,178.34" $0.00 $0.00 "$35,999.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$39,670.80" "$39,670.80" "$34,285.03" $0.00 $0.00 $0.00 $0.00 $0.00 MS265 DRG MS265 AICD LEAD PROCEDURES INPATIENT ONLY "$281,375.98" "$208,218.23" $0.00 "$35,132.77" $0.00 $0.00 "$34,280.46" "$34,280.46" $0.00 $0.00 $0.00 $0.00 $0.00 "$34,220.36" $0.00 $0.00 $0.00 $0.00 "$35,132.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$33,459.78" $0.00 $0.00 $0.00 $0.00 $0.00 MS269 DRG MS269 AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC INPATIENT ONLY "$295,971.85" "$219,019.17" $0.00 "$42,958.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$42,958.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$40,912.47" $0.00 $0.00 $0.00 $0.00 $0.00 MS270 DRG MS270 OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC INPATIENT ONLY "$509,550.86" "$377,067.64" $0.00 "$340,524.80" "$340,524.80" "$340,524.80" "$46,851.53" "$46,851.53" $0.00 $0.00 $0.00 $0.00 $0.00 "$54,034.64" $0.00 $0.00 $0.00 $0.00 "$48,724.42" "$160,865.70" "$196,008.66" $0.00 "$51,226.20" $0.00 "$51,226.20" $0.00 "$54,877.59" "$54,877.59" "$46,404.21" $0.00 $0.00 $0.00 $0.00 $0.00 MS271 DRG MS271 OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC INPATIENT ONLY "$275,679.20" "$204,002.61" $0.00 "$188,211.42" "$185,320.36" "$185,320.36" "$35,698.21" "$35,698.21" "$185,320.36" "$5,081.42" $0.00 $0.00 $0.00 $0.00 "$5,081.42" $0.00 "$188,211.42" "$188,211.42" "$38,048.73" $0.00 $0.00 "$161,466.25" $0.00 "$188,211.42" $0.00 $0.00 "$42,119.94" "$42,119.94" "$36,236.89" $0.00 $0.00 $0.00 $0.00 $0.00 MS272 DRG MS272 OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$163,285.34" "$120,831.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS273 DRG MS273 PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC INPATIENT ONLY "$346,813.41" "$256,641.92" $0.00 "$91,804.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$39,157.85" "$44,119.66" "$91,804.70" $0.00 "$37,193.18" $0.00 "$37,193.18" $0.00 "$43,445.35" "$43,445.35" "$37,293.19" $0.00 $0.00 $0.00 $0.00 $0.00 MS274 DRG MS274 PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC INPATIENT ONLY "$132,117.47" "$97,766.93" $0.00 "$35,395.88" $0.00 $0.00 "$33,735.93" "$33,735.93" $0.00 $0.00 $0.00 $0.00 $0.00 "$33,677.24" $0.00 "$34,410.65" $0.00 $0.00 "$35,395.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$33,710.36" $0.00 $0.00 $0.00 $0.00 $0.00 MS280 DRG MS280 "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" INPATIENT ONLY "$61,063.46" "$45,186.96" $0.00 "$306,336.59" "$306,336.59" "$306,336.59" "$22,143.49" "$22,143.49" $0.00 $0.00 $0.00 $0.00 $0.00 "$22,114.79" $0.00 "$22,586.36" $0.00 $0.00 "$24,947.74" "$17,813.05" "$20,968.38" $0.00 "$16,348.64" $0.00 "$16,348.64" $0.00 "$32,089.26" "$32,089.26" "$23,759.75" $0.00 $0.00 $0.00 $0.00 $0.00 MS281 DRG MS281 "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" INPATIENT ONLY "$26,455.86" "$19,577.34" $0.00 "$42,566.21" "$12,468.89" "$12,468.89" "$17,475.99" "$17,475.99" "$9,146.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,825.51" "$13,959.00" "$13,959.00" "$20,422.44" "$13,390.76" "$42,566.21" $0.00 "$9,710.54" "$13,959.00" "$9,710.54" $0.00 "$21,056.17" "$21,056.17" "$19,449.94" $0.00 $0.00 $0.00 $0.00 $0.00 MS282 DRG MS282 "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" INPATIENT ONLY "$93,190.71" "$68,961.13" $0.00 "$19,171.35" $0.00 $0.00 "$16,064.63" "$16,064.63" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,051.66" $0.00 "$16,385.92" $0.00 $0.00 "$18,845.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,171.35" "$19,171.35" "$17,947.82" $0.00 $0.00 $0.00 $0.00 $0.00 MS283 DRG MS283 "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC" INPATIENT ONLY "$189,098.49" "$139,932.88" $0.00 "$96,797.90" $0.00 $0.00 "$23,922.70" "$23,922.70" $0.00 $0.00 $0.00 $0.00 $0.00 "$23,889.39" $0.00 "$24,401.15" $0.00 $0.00 "$28,357.09" "$11,537.64" "$96,797.90" $0.00 "$18,040.74" $0.00 "$18,040.74" $0.00 "$27,842.50" "$27,842.50" "$27,006.75" $0.00 $0.00 $0.00 $0.00 $0.00 MS286 DRG MS286 "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC" INPATIENT ONLY "$170,797.89" "$126,390.44" $0.00 "$146,910.87" "$145,102.74" "$145,102.74" "$25,797.14" "$25,797.14" "$34,337.57" $0.00 $0.00 $0.00 $0.00 "$25,758.99" $0.00 "$26,313.08" "$146,910.87" "$146,910.87" "$28,819.07" $0.00 $0.00 $0.00 $0.00 "$146,910.87" $0.00 $0.00 "$31,090.31" "$31,090.31" "$27,446.73" $0.00 $0.00 $0.00 $0.00 $0.00 MS287 DRG MS287 "CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC" INPATIENT ONLY "$67,028.40" "$49,601.02" $0.00 "$29,646.46" $0.00 $0.00 "$18,749.32" "$18,749.32" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,729.41" $0.00 "$19,124.31" $0.00 $0.00 "$21,676.42" "$5,663.06" "$29,646.46" $0.00 "$11,550.01" $0.00 "$11,550.01" $0.00 "$22,554.71" "$22,554.71" "$20,644.21" $0.00 $0.00 $0.00 $0.00 $0.00 MS288 DRG MS288 ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC INPATIENT ONLY "$106,406.72" "$78,740.97" $0.00 "$35,135.48" $0.00 $0.00 "$34,446.55" "$34,446.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$35,135.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$34,846.87" "$34,846.87" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS291 DRG MS291 HEART FAILURE AND SHOCK WITH MCC INPATIENT ONLY "$40,413.15" "$29,905.73" $0.00 "$59,590.83" "$19,939.50" "$19,939.50" "$19,806.64" "$19,806.64" "$13,475.17" "$13,083.40" $0.00 $0.00 "$13,855.47" "$19,783.99" "$13,083.40" "$20,202.77" "$19,024.50" "$19,024.50" "$21,904.23" "$19,843.82" "$59,590.83" $0.00 "$13,490.72" "$19,024.50" "$13,490.72" "$12,522.56" "$24,135.73" "$24,135.73" "$21,904.23" "$13,148.68" $0.00 $0.00 $0.00 $0.00 MS292 DRG MS292 HEART FAILURE AND SHOCK WITH CC INPATIENT ONLY "$31,089.32" "$23,006.10" $0.00 "$83,990.57" "$16,088.88" "$16,088.88" "$17,012.91" "$17,012.91" "$8,768.64" $0.00 $0.00 $0.00 "$23,092.45" "$16,997.50" $0.00 "$17,353.17" "$83,990.57" "$83,990.57" "$19,990.54" "$3,423.49" "$22,244.34" "$25,542.17" "$9,077.01" "$83,990.57" "$9,077.01" $0.00 "$20,540.04" "$20,540.04" "$19,038.61" $0.00 $0.00 $0.00 $0.00 $0.00 MS293 DRG MS293 HEART FAILURE AND SHOCK WITHOUT CC/MCC INPATIENT ONLY "$25,091.99" "$18,568.07" $0.00 "$19,670.90" "$15,852.90" "$15,852.90" "$15,124.67" "$15,124.67" $0.00 $0.00 $0.00 $0.00 "$3,348.41" "$15,114.12" $0.00 "$15,427.16" $0.00 $0.00 "$18,280.74" $0.00 $0.00 "$19,670.90" $0.00 $0.00 $0.00 $0.00 "$18,496.80" "$18,496.80" "$17,410.23" $0.00 $0.00 $0.00 $0.00 $0.00 MS294 DRG MS294 DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC INPATIENT ONLY "$51,250.50" "$37,925.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS296 DRG MS296 "CARDIAC ARREST, UNEXPLAINED WITH MCC" INPATIENT ONLY "$60,132.19" "$44,497.82" $0.00 "$55,644.87" $0.00 $0.00 "$22,062.74" "$22,062.74" $0.00 $0.00 $0.00 $0.00 $0.00 "$22,034.25" $0.00 "$22,503.99" $0.00 $0.00 "$24,534.30" $0.00 $0.00 "$55,644.87" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 MS299 DRG MS299 PERIPHERAL VASCULAR DISORDERS WITH MCC INPATIENT ONLY "$61,640.61" "$45,614.05" $0.00 "$24,984.23" $0.00 $0.00 "$16,477.47" "$16,477.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,603.33" $0.00 "$22,063.32" $0.00 $0.00 "$23,709.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,984.23" "$24,984.23" "$22,580.44" $0.00 $0.00 $0.00 $0.00 $0.00 MS300 DRG MS300 PERIPHERAL VASCULAR DISORDERS WITH CC INPATIENT ONLY "$33,127.53" "$24,514.37" $0.00 "$48,648.19" "$48,648.19" "$48,648.19" "$18,257.24" "$18,257.24" "$8,720.44" $0.00 $0.00 $0.00 "$6,696.82" "$18,238.60" $0.00 "$18,622.38" "$15,657.00" "$15,657.00" "$20,824.93" $0.00 $0.00 $0.00 $0.00 "$15,657.00" $0.00 "$9,354.11" "$21,537.17" "$21,537.17" "$19,833.27" "$9,821.82" $0.00 $0.00 $0.00 $0.00 MS301 DRG MS301 PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$26,808.70" "$19,838.44" $0.00 "$18,762.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,762.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,869.07" $0.00 $0.00 $0.00 $0.00 $0.00 MS302 DRG MS302 ATHEROSCLEROSIS WITH MCC INPATIENT ONLY "$27,989.74" "$20,712.41" $0.00 "$22,147.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,981.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,147.21" "$22,147.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS303 DRG MS303 ATHEROSCLEROSIS WITHOUT MCC INPATIENT ONLY "$9,872.00" "$7,305.28" $0.00 "$18,663.40" "$8,245.79" "$8,245.79" $0.00 $0.00 "$5,445.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$10,164.00" "$10,164.00" "$18,420.15" $0.00 $0.00 $0.00 $0.00 "$10,164.00" $0.00 $0.00 "$18,663.40" "$18,663.40" "$17,543.00" $0.00 $0.00 $0.00 $0.00 $0.00 MS304 DRG MS304 HYPERTENSION WITH MCC INPATIENT ONLY "$53,951.20" "$39,923.89" $0.00 "$22,059.01" $0.00 $0.00 "$18,624.42" "$18,624.42" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,604.83" $0.00 "$18,996.91" $0.00 $0.00 "$21,261.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,059.01" "$22,059.01" "$20,249.16" $0.00 $0.00 $0.00 $0.00 $0.00 MS305 DRG MS305 HYPERTENSION WITHOUT MCC INPATIENT ONLY "$25,501.90" "$18,871.41" $0.00 "$19,723.81" "$16,899.41" "$16,899.41" "$16,589.44" "$16,589.44" "$5,598.22" $0.00 $0.00 $0.00 "$3,348.41" "$16,146.66" $0.00 "$16,765.12" "$11,098.50" "$11,098.50" "$12,322.90" "$3,994.80" "$19,723.81" $0.00 "$7,332.77" "$11,098.50" "$7,332.77" $0.00 "$19,119.10" "$19,119.10" "$12,322.90" $0.00 $0.00 $0.00 $0.00 $0.00 MS306 DRG MS306 CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC INPATIENT ONLY "$21,558.58" "$15,953.35" $0.00 "$21,885.92" $0.00 $0.00 "$21,456.78" "$21,456.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,458.56" $0.00 "$21,885.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS307 DRG MS307 CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC INPATIENT ONLY "$33,309.85" "$24,649.29" $0.00 "$20,349.78" "$4,312.35" "$4,312.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,349.78" "$20,349.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS308 DRG MS308 CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC INPATIENT ONLY "$49,289.07" "$36,473.91" $0.00 "$23,133.27" "$4,086.60" "$4,086.60" "$19,341.47" "$19,341.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,133.27" $0.00 $0.00 "$21,919.03" "$3,891.70" "$14,418.05" $0.00 "$11,905.86" $0.00 "$11,905.86" $0.00 "$22,844.63" "$22,844.63" "$20,875.27" $0.00 $0.00 $0.00 $0.00 $0.00 MS309 DRG MS309 CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC INPATIENT ONLY "$32,971.70" "$24,399.06" $0.00 "$19,321.62" $0.00 $0.00 "$16,233.04" "$16,233.04" $0.00 $0.00 $0.00 $0.00 "$7,290.56" $0.00 $0.00 "$16,557.70" $0.00 $0.00 "$18,970.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,321.62" "$19,321.62" "$18,067.58" $0.00 $0.00 $0.00 $0.00 $0.00 MS310 DRG MS310 CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$26,112.51" "$19,323.26" $0.00 "$22,828.20" "$4,086.60" "$4,086.60" "$14,912.79" "$14,912.79" "$4,902.90" "$5,253.92" $0.00 $0.00 "$6,255.35" "$14,902.81" "$5,516.62" "$15,211.05" "$8,388.00" "$8,388.00" "$17,624.69" "$3,748.58" "$22,828.20" $0.00 "$5,606.59" "$8,388.00" "$5,606.59" "$3,051.09" "$17,712.81" "$17,712.81" "$16,785.42" "$3,247.21" $0.00 $0.00 $0.00 $0.00 MS311 DRG MS311 ANGINA PECTORIS INPATIENT ONLY "$52,330.57" "$38,724.62" $0.00 "$16,191.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,191.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS312 DRG MS312 SYNCOPE AND COLLAPSE INPATIENT ONLY "$61,214.52" "$45,298.74" $0.00 "$21,765.49" "$8,863.70" "$8,863.70" "$16,841.76" "$16,841.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,826.78" $0.00 "$17,178.60" $0.00 $0.00 "$19,383.03" $0.00 $0.00 "$21,765.49" $0.00 $0.00 $0.00 "$6,911.00" "$19,814.06" "$19,814.06" "$18,460.03" "$7,256.54" $0.00 $0.00 $0.00 $0.00 MS313 DRG MS313 CHEST PAIN INPATIENT ONLY "$33,212.42" "$24,577.19" $0.00 "$18,986.78" $0.00 $0.00 "$16,032.21" "$16,032.21" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,019.33" $0.00 "$16,352.85" $0.00 $0.00 "$18,707.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,986.78" "$18,986.78" "$17,816.56" $0.00 $0.00 $0.00 $0.00 $0.00 MS314 DRG MS314 OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC INPATIENT ONLY "$76,851.46" "$56,870.08" $0.00 "$90,518.61" $0.00 $0.00 "$25,441.03" "$25,441.03" $0.00 $0.00 $0.00 $0.00 $0.00 "$25,403.80" $0.00 "$25,949.85" $0.00 $0.00 "$27,671.68" "$27,623.06" "$90,518.61" $0.00 "$20,344.32" $0.00 "$20,344.32" $0.00 "$29,719.16" "$29,719.16" "$26,353.98" $0.00 $0.00 $0.00 $0.00 $0.00 MS315 DRG MS315 OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC INPATIENT ONLY "$25,527.92" "$18,890.66" $0.00 "$54,485.36" "$54,485.36" "$54,485.36" "$17,791.75" "$17,791.75" "$8,580.30" $0.00 $0.00 $0.00 "$10,045.23" $0.00 $0.00 "$18,126.81" "$14,601.00" "$14,601.00" "$20,434.06" $0.00 $0.00 $0.00 $0.00 "$14,601.00" $0.00 "$9,679.17" "$21,070.06" "$21,070.06" "$19,461.01" "$10,301.36" $0.00 $0.00 $0.00 $0.00 MS316 DRG MS316 OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC INPATIENT ONLY "$10,452.75" "$7,735.04" $0.00 "$56,774.44" $0.00 $0.00 "$16,046.01" "$16,046.01" $0.00 $0.00 $0.00 $0.00 "$10,604.42" $0.00 $0.00 "$16,366.93" $0.00 $0.00 $0.00 "$10,943.74" "$56,774.44" $0.00 "$7,440.03" $0.00 "$7,440.03" $0.00 "$19,206.47" "$19,206.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS326 DRG MS326 "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC" INPATIENT ONLY "$251,818.24" "$186,345.50" $0.00 "$291,990.40" "$291,990.40" "$291,990.40" "$47,743.90" "$47,743.90" $0.00 $0.00 $0.00 $0.00 "$112,752.12" "$47,648.96" $0.00 "$48,698.78" $0.00 $0.00 "$49,819.86" "$125,184.57" "$152,532.58" $0.00 "$52,833.10" $0.00 "$52,833.10" $0.00 "$74,365.49" "$74,365.49" "$47,447.49" $0.00 $0.00 $0.00 $0.00 $0.00 MS327 DRG MS327 "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC" INPATIENT ONLY "$345,047.66" "$255,335.27" $0.00 "$181,704.09" "$181,704.09" "$181,704.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,385.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$34,156.81" "$34,156.81" "$29,890.60" $0.00 $0.00 $0.00 $0.00 $0.00 MS328 DRG MS328 "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$223,193.30" "$165,163.04" $0.00 "$94,605.75" $0.00 $0.00 "$22,557.58" "$22,557.58" $0.00 $0.00 $0.00 $0.00 "$33,357.43" "$22,527.81" $0.00 "$23,008.73" $0.00 $0.00 $0.00 $0.00 $0.00 "$94,605.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS329 DRG MS329 MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC INPATIENT ONLY "$274,008.89" "$202,766.58" $0.00 "$350,555.03" "$136,237.60" "$136,237.60" "$44,775.57" "$44,775.57" "$114,248.26" "$46,129.16" $0.00 $0.00 "$88,406.87" "$44,688.31" "$46,129.16" "$45,671.08" "$350,555.03" "$350,555.03" "$47,337.16" "$119,188.76" "$145,226.91" $0.00 "$49,191.26" "$350,555.03" "$49,191.26" "$44,151.78" "$53,219.79" "$53,219.79" "$45,083.01" "$46,359.35" $0.00 $0.00 $0.00 $0.00 MS330 DRG MS330 MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC INPATIENT ONLY "$213,414.08" "$157,926.42" $0.00 "$229,756.74" "$229,756.74" "$229,756.74" "$28,647.46" "$28,647.46" $0.00 $0.00 $0.00 $0.00 "$96,654.18" "$28,601.93" $0.00 "$29,220.41" $0.00 $0.00 "$31,070.11" "$108,768.24" "$132,529.93" $0.00 "$25,329.40" $0.00 "$25,329.40" $0.00 "$33,780.33" "$33,780.33" "$29,590.58" $0.00 $0.00 $0.00 $0.00 $0.00 MS331 DRG MS331 MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$192,463.33" "$142,422.86" $0.00 "$148,688.87" "$107,640.79" "$107,640.79" "$30,696.66" "$30,696.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,315.65" $0.00 $0.00 "$25,346.16" "$122,030.00" "$148,688.87" $0.00 "$16,933.05" $0.00 "$16,933.05" "$15,266.31" "$26,940.12" "$26,940.12" "$24,139.20" "$16,029.62" $0.00 $0.00 $0.00 $0.00 MS332 DRG MS332 RECTAL RESECTION WITH MCC INPATIENT ONLY "$887,584.06" "$656,812.20" $0.00 "$103,355.68" $0.00 $0.00 "$103,349.75" "$103,349.75" $0.00 $0.00 $0.00 $0.00 $0.00 "$103,355.68" $0.00 "$64,185.57" $0.00 $0.00 "$90,845.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$86,519.75" $0.00 $0.00 $0.00 $0.00 $0.00 MS333 DRG MS333 RECTAL RESECTION WITH CC INPATIENT ONLY "$620,492.87" "$459,164.72" $0.00 "$65,011.79" $0.00 $0.00 "$65,011.79" "$65,011.79" $0.00 $0.00 $0.00 $0.00 $0.00 "$65,006.35" $0.00 $0.00 $0.00 $0.00 "$56,104.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$53,432.55" $0.00 $0.00 $0.00 $0.00 $0.00 MS335 DRG MS335 PERITONEAL ADHESIOLYSIS WITH MCC INPATIENT ONLY "$532,766.31" "$394,247.07" $0.00 "$110,895.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$91,012.77" "$110,895.56" $0.00 "$40,549.32" $0.00 "$40,549.32" $0.00 "$46,179.48" "$46,179.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS336 DRG MS336 PERITONEAL ADHESIOLYSIS WITH CC INPATIENT ONLY "$219,777.95" "$162,635.68" $0.00 "$31,652.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,289.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,652.16" "$31,652.16" "$27,894.51" $0.00 $0.00 $0.00 $0.00 $0.00 MS337 DRG MS337 PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC INPATIENT ONLY "$186,895.48" "$138,302.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS338 DRG MS338 APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC INPATIENT ONLY "$181,523.85" "$134,327.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS339 DRG MS339 APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC INPATIENT ONLY "$125,577.54" "$92,927.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS340 DRG MS340 APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC INPATIENT ONLY "$100,873.09" "$74,646.09" $0.00 "$86,067.33" "$86,067.33" "$86,067.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$48,704.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS341 DRG MS341 APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC INPATIENT ONLY "$126,465.33" "$93,584.34" $0.00 "$36,751.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,284.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$36,751.27" $0.00 $0.00 $0.00 $0.00 $0.00 MS342 DRG MS342 APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC INPATIENT ONLY "$99,896.38" "$73,923.32" $0.00 "$75,672.75" "$4,542.21" "$4,542.21" $0.00 $0.00 "$11,703.42" $0.00 $0.00 $0.00 "$3,348.41" $0.00 $0.00 $0.00 "$75,672.75" "$75,672.75" $0.00 "$5,521.83" "$60,127.78" $0.00 "$16,142.14" "$75,672.75" "$16,142.14" $0.00 "$26,295.79" "$26,295.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS343 DRG MS343 APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC INPATIENT ONLY "$99,694.46" "$73,773.90" $0.00 "$70,753.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,348.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,075.14" "$70,753.35" "$58,511.81" "$11,543.98" $0.00 "$11,543.98" $0.00 "$22,549.80" "$22,549.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS344 DRG MS344 MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC INPATIENT ONLY "$63,631.33" "$47,087.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS345 DRG MS345 MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC INPATIENT ONLY "$164,994.22" "$122,095.72" $0.00 "$22,388.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,388.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS346 DRG MS346 MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$74,406.10" "$55,060.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS347 DRG MS347 ANAL AND STOMAL PROCEDURES WITH MCC INPATIENT ONLY "$26,552.02" "$19,648.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS348 DRG MS348 ANAL AND STOMAL PROCEDURES WITH CC INPATIENT ONLY "$83,349.83" "$61,678.87" $0.00 "$24,654.33" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,830.84" $0.00 $0.00 $0.00 $0.00 "$23,744.82" $0.00 $0.00 $0.00 "$23,433.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,654.33" "$24,654.33" "$22,317.52" $0.00 $0.00 $0.00 $0.00 $0.00 MS349 DRG MS349 ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$65,922.10" "$48,782.35" $0.00 "$40,375.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,168.36" $0.00 $0.00 $0.00 "$6,026.40" "$40,375.68" $0.00 "$9,832.84" $0.00 "$9,832.84" $0.00 "$21,155.80" "$21,155.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS350 DRG MS350 INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC INPATIENT ONLY "$281,616.81" "$208,396.44" $0.00 "$30,472.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$30,472.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,021.10" $0.00 $0.00 $0.00 $0.00 $0.00 MS351 DRG MS351 INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC INPATIENT ONLY "$141,041.73" "$104,370.88" $0.00 "$114,048.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$93,600.21" "$114,048.28" $0.00 "$14,618.44" $0.00 "$14,618.44" $0.00 "$25,054.47" "$25,054.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS352 DRG MS352 INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$80,949.32" "$59,902.50" $0.00 "$120,426.90" "$120,426.90" "$120,426.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,938.97" "$21,938.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS353 DRG MS353 HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC INPATIENT ONLY "$250,528.06" "$185,390.76" $0.00 "$77,604.07" $0.00 $0.00 "$31,929.81" "$31,929.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$34,077.63" "$5,681.42" "$77,604.07" $0.00 "$29,741.12" $0.00 "$29,741.12" $0.00 "$37,374.40" "$37,374.40" "$32,454.89" $0.00 $0.00 $0.00 $0.00 $0.00 MS354 DRG MS354 HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC INPATIENT ONLY "$283,035.02" "$209,445.91" $0.00 "$101,424.28" "$101,424.28" "$101,424.28" "$23,371.27" "$23,371.27" $0.00 $0.00 $0.00 $0.00 "$53,576.10" "$23,339.39" $0.00 "$23,838.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,208.78" "$27,208.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS355 DRG MS355 HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC INPATIENT ONLY "$131,335.21" "$97,188.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS356 DRG MS356 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC INPATIENT ONLY "$231,882.30" "$171,592.90" $0.00 "$46,441.63" $0.00 $0.00 "$40,783.74" "$40,783.74" $0.00 $0.00 $0.00 $0.00 $0.00 "$40,706.81" $0.00 "$41,599.41" $0.00 $0.00 "$39,681.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$46,441.63" "$46,441.63" "$39,681.10" $0.00 $0.00 $0.00 $0.00 $0.00 MS357 DRG MS357 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC INPATIENT ONLY "$246,036.70" "$182,067.16" $0.00 "$27,791.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,669.02" $0.00 $0.00 $0.00 $0.00 "$27,791.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,791.66" $0.00 $0.00 $0.00 $0.00 $0.00 MS358 DRG MS358 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$305,696.80" "$226,215.63" $0.00 "$66,333.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,778.35" "$66,333.91" $0.00 "$13,749.33" $0.00 "$13,749.33" $0.00 "$24,346.43" "$24,346.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS368 DRG MS368 MAJOR ESOPHAGEAL DISORDERS WITH MCC INPATIENT ONLY "$44,626.39" "$33,023.53" $0.00 "$28,691.00" "$17,417.13" "$17,417.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,857.51" $0.00 $0.00 $0.00 "$4,678.10" "$21,077.61" $0.00 "$19,082.27" $0.00 "$19,082.27" $0.00 "$28,691.00" "$28,691.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS369 DRG MS369 MAJOR ESOPHAGEAL DISORDERS WITH CC INPATIENT ONLY "$33,210.98" "$24,576.13" $0.00 "$21,827.08" $0.00 $0.00 "$18,487.75" "$18,487.75" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,468.52" $0.00 "$18,857.51" $0.00 $0.00 $0.00 "$8,473.19" "$17,181.21" $0.00 "$10,656.83" $0.00 "$10,656.83" $0.00 "$21,827.08" "$21,827.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS370 DRG MS370 MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$70,028.29" "$51,820.93" $0.00 "$9,760.80" "$9,760.80" "$9,760.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS371 DRG MS371 MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC INPATIENT ONLY "$90,719.83" "$67,132.67" $0.00 "$27,236.55" $0.00 $0.00 "$23,001.33" "$23,001.33" $0.00 $0.00 $0.00 $0.00 $0.00 "$22,970.42" $0.00 "$23,461.36" $0.00 $0.00 "$25,594.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,236.55" "$27,236.55" "$24,375.45" $0.00 $0.00 $0.00 $0.00 $0.00 MS372 DRG MS372 MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC INPATIENT ONLY "$41,041.65" "$30,370.82" $0.00 "$21,495.52" $0.00 $0.00 "$18,157.17" "$18,157.17" $0.00 "$3,697.23" $0.00 $0.00 $0.00 "$18,138.79" "$9,522.34" "$18,520.31" $0.00 $0.00 "$20,790.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,495.52" "$21,495.52" "$19,800.09" $0.00 $0.00 $0.00 $0.00 $0.00 MS373 DRG MS373 MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC INPATIENT ONLY "$25,826.81" "$19,111.84" $0.00 "$18,871.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,871.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,973.20" $0.00 $0.00 $0.00 $0.00 $0.00 MS374 DRG MS374 DIGESTIVE MALIGNANCY WITH MCC INPATIENT ONLY "$130,953.52" "$96,905.60" $0.00 "$103,204.32" "$8,173.20" "$8,173.20" "$25,365.10" "$25,365.10" $0.00 $0.00 $0.00 $0.00 $0.00 "$25,328.06" $0.00 "$25,872.40" $0.00 $0.00 "$27,453.01" $0.00 $0.00 "$103,204.32" $0.00 $0.00 $0.00 $0.00 "$25,228.00" "$25,228.00" "$26,145.72" $0.00 $0.00 $0.00 $0.00 $0.00 MS375 DRG MS375 DIGESTIVE MALIGNANCY WITH CC INPATIENT ONLY "$43,263.16" "$32,014.74" $0.00 "$23,004.69" $0.00 $0.00 "$19,387.71" "$19,387.71" $0.00 $0.00 $0.00 $0.00 $0.00 "$19,366.15" $0.00 "$19,775.46" $0.00 $0.00 "$22,052.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,004.69" "$23,004.69" "$21,002.83" $0.00 $0.00 $0.00 $0.00 $0.00 MS376 DRG MS376 DIGESTIVE MALIGNANCY WITHOUT CC/MCC INPATIENT ONLY "$50,921.70" "$37,682.06" $0.00 "$20,645.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,241.18" $0.00 "$17,602.37" $0.00 $0.00 "$20,645.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,662.12" $0.00 $0.00 $0.00 $0.00 $0.00 MS377 DRG MS377 GASTROINTESTINAL HEMORRHAGE WITH MCC INPATIENT ONLY "$78,283.67" "$57,929.92" $0.00 "$56,749.25" "$20,646.76" "$20,646.76" "$23,484.44" "$23,484.44" $0.00 "$15,384.27" $0.00 $0.00 $0.00 "$23,452.27" "$15,384.27" "$23,954.13" $0.00 $0.00 "$25,897.63" $0.00 $0.00 "$56,749.25" $0.00 $0.00 $0.00 $0.00 "$27,599.14" "$27,599.14" "$24,664.41" $0.00 $0.00 $0.00 $0.00 $0.00 MS378 DRG MS378 GASTROINTESTINAL HEMORRHAGE WITH CC INPATIENT ONLY "$34,470.23" "$25,507.97" $0.00 "$34,384.78" "$17,023.65" "$17,023.65" "$17,910.11" "$17,910.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$17,892.36" $0.00 "$18,268.31" $0.00 $0.00 "$19,576.19" "$14,569.53" "$34,384.78" $0.00 "$9,905.01" $0.00 "$9,905.01" "$8,932.14" "$21,214.59" "$21,214.59" "$19,576.19" "$9,378.74" $0.00 $0.00 $0.00 $0.00 MS379 DRG MS379 GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC INPATIENT ONLY "$37,486.96" "$27,740.35" $0.00 "$18,418.41" "$8,963.57" "$8,963.57" "$15,451.11" "$15,451.11" "$6,048.07" $0.00 $0.00 $0.00 "$10,935.84" "$15,439.72" $0.00 "$15,760.13" "$9,558.00" "$9,558.00" "$18,215.14" $0.00 $0.00 $0.00 $0.00 "$9,558.00" $0.00 $0.00 "$18,418.41" "$18,418.41" "$17,347.75" $0.00 $0.00 $0.00 $0.00 $0.00 MS380 DRG MS380 COMPLICATED PEPTIC ULCER WITH MCC INPATIENT ONLY "$26,794.24" "$19,827.74" $0.00 "$194,237.98" $0.00 $0.00 "$29,530.88" "$29,530.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,555.31" $0.00 $0.00 $0.00 "$159,412.49" "$194,237.98" $0.00 "$24,569.41" $0.00 "$24,569.41" $0.00 "$28,560.33" "$28,560.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS381 DRG MS381 COMPLICATED PEPTIC ULCER WITH CC INPATIENT ONLY "$46,100.59" "$34,114.44" $0.00 "$21,938.15" "$8,173.20" "$8,173.20" "$18,364.22" "$18,364.22" $0.00 $0.00 $0.00 $0.00 "$13,393.64" $0.00 $0.00 "$18,731.50" $0.00 $0.00 "$21,160.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,938.15" "$21,938.15" "$20,152.85" $0.00 $0.00 $0.00 $0.00 $0.00 MS382 DRG MS382 COMPLICATED PEPTIC ULCER WITHOUT CC/MCC INPATIENT ONLY "$31,452.30" "$23,274.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS383 DRG MS383 UNCOMPLICATED PEPTIC ULCER WITH MCC INPATIENT ONLY "$24,431.24" "$18,079.12" $0.00 "$23,976.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,976.51" "$23,976.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS384 DRG MS384 UNCOMPLICATED PEPTIC ULCER WITHOUT MCC INPATIENT ONLY "$33,274.53" "$24,623.15" $0.00 "$26,787.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,787.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS385 DRG MS385 INFLAMMATORY BOWEL DISEASE WITH MCC INPATIENT ONLY "$67,760.04" "$50,142.43" $0.00 "$24,806.99" $0.00 $0.00 "$22,249.76" "$22,249.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$22,220.79" $0.00 "$22,694.76" $0.00 $0.00 "$24,806.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,625.70" $0.00 $0.00 $0.00 $0.00 $0.00 MS386 DRG MS386 INFLAMMATORY BOWEL DISEASE WITH CC INPATIENT ONLY "$56,023.07" "$41,457.07" $0.00 "$21,190.92" "$20,433.00" "$20,433.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,696.82" $0.00 $0.00 $0.00 $0.00 $0.00 "$20,535.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,190.92" "$21,190.92" "$19,557.33" $0.00 $0.00 $0.00 $0.00 $0.00 MS387 DRG MS387 INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC INPATIENT ONLY "$23,208.03" "$17,173.94" $0.00 "$16,305.69" $0.00 $0.00 "$15,985.97" "$15,985.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,305.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS388 DRG MS388 GASTROINTESTINAL OBSTRUCTION WITH MCC INPATIENT ONLY "$77,758.35" "$57,541.18" $0.00 "$25,918.43" "$25,918.43" "$25,918.43" "$21,506.47" "$21,506.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,479.43" $0.00 "$21,936.60" $0.00 $0.00 "$24,224.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,599.99" "$25,599.99" "$23,071.18" $0.00 $0.00 $0.00 $0.00 $0.00 MS389 DRG MS389 GASTROINTESTINAL OBSTRUCTION WITH CC INPATIENT ONLY "$39,413.46" "$29,165.96" $0.00 "$20,002.70" $0.00 $0.00 "$16,734.77" "$16,734.77" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,720.07" $0.00 "$17,069.47" $0.00 $0.00 "$19,540.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,002.70" "$20,002.70" "$18,610.37" $0.00 $0.00 $0.00 $0.00 $0.00 MS390 DRG MS390 GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC INPATIENT ONLY "$29,912.81" "$22,135.48" $0.00 "$95,740.02" "$95,740.02" "$95,740.02" "$15,077.74" "$15,077.74" $0.00 "$5,565.81" $0.00 $0.00 "$3,348.41" "$15,067.32" "$5,565.81" "$15,379.29" $0.00 $0.00 "$17,763.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,327.23" $0.00 $0.00 "$16,917.55" "$5,593.59" $0.00 $0.00 $0.00 $0.00 MS391 DRG MS391 "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" INPATIENT ONLY "$41,863.55" "$30,979.03" $0.00 "$23,230.90" $0.00 $0.00 "$19,674.82" "$19,674.82" $0.00 $0.00 $0.00 $0.00 $0.00 "$19,652.52" $0.00 "$20,068.32" $0.00 $0.00 "$22,242.27" "$7,432.68" "$17,525.21" $0.00 "$12,380.02" $0.00 "$12,380.02" $0.00 "$23,230.90" "$23,230.90" "$21,183.11" $0.00 $0.00 $0.00 $0.00 $0.00 MS392 DRG MS392 "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" INPATIENT ONLY "$33,170.14" "$24,545.90" $0.00 "$41,242.74" "$12,630.39" "$12,630.39" "$16,338.64" "$16,338.64" $0.00 "$2,286.70" $0.00 $0.00 "$6,696.82" $0.00 "$7,045.49" "$16,665.41" $0.00 $0.00 "$19,006.49" "$11,228.32" "$41,242.74" "$23,420.75" "$7,633.51" $0.00 "$7,633.51" "$4,002.23" "$19,364.08" "$19,364.08" "$18,101.42" "$4,259.49" $0.00 $0.00 $0.00 $0.00 MS393 DRG MS393 OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC INPATIENT ONLY "$50,282.24" "$37,208.86" $0.00 "$26,411.73" "$16,829.88" "$16,829.88" "$22,518.23" "$22,518.23" "$15,078.24" $0.00 $0.00 $0.00 $0.00 "$22,488.57" $0.00 "$22,968.59" "$20,121.93" "$20,121.93" "$24,904.01" $0.00 $0.00 $0.00 $0.00 "$20,121.93" $0.00 $0.00 "$26,411.73" "$26,411.73" "$23,718.10" $0.00 $0.00 $0.00 $0.00 $0.00 MS394 DRG MS394 OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC INPATIENT ONLY "$43,731.97" "$32,361.66" $0.00 "$21,956.06" $0.00 $0.00 "$17,547.08" "$17,547.08" $0.00 $0.00 $0.00 $0.00 "$13,393.64" "$17,530.28" $0.00 "$17,898.02" $0.00 $0.00 "$20,213.34" "$7,280.15" "$21,956.06" $0.00 "$9,403.81" $0.00 "$9,403.81" "$5,243.56" "$20,806.29" "$20,806.29" "$19,250.80" "$5,580.62" $0.00 $0.00 $0.00 $0.00 MS395 DRG MS395 OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC INPATIENT ONLY "$22,243.70" "$16,460.34" $0.00 "$24,982.77" "$24,982.77" "$24,982.77" "$15,549.79" "$15,549.79" "$5,867.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,327.28" "$9,772.50" "$9,772.50" $0.00 "$7,147.50" "$12,116.27" $0.00 "$6,559.90" "$9,772.50" "$6,559.90" "$4,462.69" "$18,489.46" "$18,489.46" $0.00 "$4,749.55" $0.00 $0.00 $0.00 $0.00 MS405 DRG MS405 "PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC" INPATIENT ONLY "$200,263.23" "$148,194.79" $0.00 "$50,890.72" $0.00 $0.00 "$50,651.50" "$50,651.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$50,890.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$48,467.35" $0.00 $0.00 $0.00 $0.00 $0.00 MS406 DRG MS406 "PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC" INPATIENT ONLY "$83,962.91" "$62,132.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS407 DRG MS407 "PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$379,474.22" "$280,810.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS408 DRG MS408 BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC INPATIENT ONLY "$436,154.41" "$322,754.26" $0.00 "$50,500.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$50,500.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS410 DRG MS410 BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC INPATIENT ONLY "$300,972.34" "$222,719.53" $0.00 "$201,119.77" "$193,135.50" "$193,135.50" $0.00 $0.00 "$49,341.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$195,549.45" "$195,549.45" $0.00 "$165,060.42" "$201,119.77" $0.00 "$26,144.96" "$195,549.45" "$26,144.96" $0.00 "$26,701.64" "$26,701.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS414 DRG MS414 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC INPATIENT ONLY "$156,040.59" "$115,470.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS415 DRG MS415 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC INPATIENT ONLY "$136,109.70" "$100,721.18" $0.00 "$120,290.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$98,722.88" "$120,290.03" $0.00 "$20,566.86" $0.00 "$20,566.86" $0.00 "$29,900.46" "$29,900.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS416 DRG MS416 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC INPATIENT ONLY "$292,085.37" "$216,143.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS417 DRG MS417 LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC INPATIENT ONLY "$137,676.65" "$101,880.72" $0.00 "$146,623.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,096.73" $0.00 $0.00 "$44,529.93" $0.00 "$21,096.73" $0.00 $0.00 $0.00 "$30,276.71" "$120,335.03" "$146,623.60" $0.00 "$24,165.59" $0.00 "$24,165.59" $0.00 "$32,832.21" "$32,832.21" "$28,834.96" $0.00 $0.00 $0.00 $0.00 $0.00 MS418 DRG MS418 LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC INPATIENT ONLY "$146,973.04" "$108,760.05" $0.00 "$84,039.69" "$84,039.69" "$84,039.69" "$22,710.10" "$22,710.10" $0.00 "$28,650.88" $0.00 $0.00 $0.00 $0.00 "$28,651.56" "$23,164.30" $0.00 $0.00 "$25,207.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,007.06" $0.00 $0.00 $0.00 $0.00 $0.00 MS419 DRG MS419 LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC INPATIENT ONLY "$132,793.00" "$98,266.82" $0.00 "$104,723.37" "$91,322.65" "$91,322.65" $0.00 $0.00 "$12,698.94" "$10,708.77" $0.00 $0.00 $0.00 $0.00 "$11,244.21" $0.00 "$92,670.16" "$92,670.16" "$22,732.94" "$85,947.21" "$104,723.37" "$67,774.35" "$13,099.76" "$92,670.16" "$13,099.76" "$10,762.21" "$23,817.26" "$23,817.26" "$21,650.42" "$11,300.32" $0.00 $0.00 $0.00 $0.00 MS420 DRG MS420 HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC INPATIENT ONLY "$138,545.38" "$102,523.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS423 DRG MS423 OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC INPATIENT ONLY "$287,776.74" "$212,954.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS432 DRG MS432 CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC INPATIENT ONLY "$71,759.88" "$53,102.31" $0.00 "$28,036.05" "$8,624.70" "$8,624.70" "$24,159.76" "$24,159.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$24,000.21" $0.00 $784.10 $0.00 $0.00 "$26,263.25" "$17,070.50" "$27,475.36" $0.00 "$18,278.31" $0.00 "$18,278.31" $0.00 "$28,036.05" "$28,036.05" "$25,012.62" $0.00 $0.00 $0.00 $0.00 $0.00 MS433 DRG MS433 CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC INPATIENT ONLY "$45,714.27" "$33,828.56" $0.00 "$29,212.66" "$4,086.60" "$4,086.60" "$18,161.31" "$18,161.31" "$8,187.57" $0.00 $0.00 $0.00 "$13,393.64" "$18,142.93" $0.00 "$18,524.54" "$15,448.50" "$15,448.50" "$20,855.02" "$14,492.23" "$29,212.66" $0.00 "$10,345.09" "$15,448.50" "$10,345.09" $0.00 "$21,573.12" "$21,573.12" "$19,861.92" $0.00 $0.00 $0.00 $0.00 $0.00 MS434 DRG MS434 CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC INPATIENT ONLY "$20,195.51" "$14,944.68" $0.00 "$18,175.50" "$4,086.60" "$4,086.60" $0.00 $0.00 $0.00 "$6,206.31" $0.00 $0.00 $0.00 "$15,326.14" "$6,206.31" $0.00 $0.00 $0.00 "$18,175.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,310.00" $0.00 $0.00 $0.00 $0.00 $0.00 MS435 DRG MS435 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC INPATIENT ONLY "$95,710.06" "$70,825.44" $0.00 "$27,004.64" "$13,847.40" "$13,847.40" "$23,154.55" "$23,154.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,617.64" $0.00 $0.00 "$25,400.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,004.64" "$27,004.64" "$24,190.62" $0.00 $0.00 $0.00 $0.00 $0.00 MS436 DRG MS436 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC INPATIENT ONLY "$52,499.34" "$38,849.51" $0.00 "$21,514.22" $0.00 $0.00 "$18,793.50" "$18,793.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,773.47" $0.00 $0.00 $0.00 $0.00 "$21,514.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,489.83" $0.00 $0.00 $0.00 $0.00 $0.00 MS437 DRG MS437 MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC INPATIENT ONLY "$67,843.68" "$50,204.32" $0.00 "$19,475.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,475.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,475.99" $0.00 $0.00 $0.00 $0.00 $0.00 MS438 DRG MS438 DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC INPATIENT ONLY "$45,592.09" "$33,738.15" $0.00 "$26,524.44" $0.00 $0.00 "$22,080.67" "$22,080.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,522.28" $0.00 $0.00 "$24,998.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,524.44" "$26,524.44" "$23,807.93" $0.00 $0.00 $0.00 $0.00 $0.00 MS439 DRG MS439 DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC INPATIENT ONLY "$35,242.46" "$26,079.42" $0.00 "$27,105.60" "$27,105.60" "$27,105.60" "$16,886.61" "$16,886.61" $0.00 "$8,501.51" $0.00 $0.00 $0.00 "$16,871.51" "$8,501.51" "$17,224.34" $0.00 $0.00 "$19,592.13" "$3,287.36" "$18,691.33" $0.00 "$8,492.59" $0.00 "$8,492.59" "$8,137.08" "$20,063.94" "$20,063.94" "$18,659.17" "$8,543.93" $0.00 $0.00 $0.00 $0.00 MS440 DRG MS440 DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC INPATIENT ONLY "$36,890.80" "$27,299.19" $0.00 "$8,173.20" "$8,173.20" "$8,173.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS441 DRG MS441 "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" INPATIENT ONLY "$49,349.00" "$36,518.26" $0.00 "$236,480.96" $0.00 $0.00 "$24,024.82" "$24,024.82" $0.00 $0.00 $0.00 $0.00 "$236,480.96" $0.00 $0.00 "$29,751.07" $0.00 $0.00 "$26,532.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,575.49" "$19,575.49" "$26,532.44" $0.00 $0.00 $0.00 $0.00 $0.00 MS442 DRG MS442 "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" INPATIENT ONLY "$39,164.06" "$28,981.40" $0.00 "$20,767.89" "$16,346.40" "$16,346.40" "$17,471.86" "$17,471.86" $0.00 $0.00 $0.00 $0.00 "$16,742.05" "$17,455.25" $0.00 $171.72 $0.00 $0.00 "$20,181.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,767.89" "$20,767.89" "$19,220.20" $0.00 $0.00 $0.00 $0.00 $0.00 MS443 DRG MS443 "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC" INPATIENT ONLY "$37,763.49" "$27,944.98" $0.00 "$38,930.80" "$12,711.30" "$12,711.30" "$15,630.55" "$15,630.55" "$5,812.44" $0.00 $0.00 $0.00 $0.00 "$15,618.70" $0.00 "$15,943.16" "$9,948.00" "$9,948.00" $0.00 "$10,031.02" "$38,930.80" $0.00 "$6,819.53" "$9,948.00" "$6,819.53" "$6,169.37" "$18,700.96" "$18,700.96" $0.00 "$6,477.83" $0.00 $0.00 $0.00 $0.00 MS444 DRG MS444 DISORDERS OF THE BILIARY TRACT WITH MCC INPATIENT ONLY "$40,567.37" "$30,019.85" $0.00 "$24,914.95" "$16,346.40" "$16,346.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,041.82" $0.00 $0.00 "$24,914.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,728.52" $0.00 $0.00 $0.00 $0.00 $0.00 MS445 DRG MS445 DISORDERS OF THE BILIARY TRACT WITH CC INPATIENT ONLY "$39,233.35" "$29,032.68" $0.00 "$21,920.18" $0.00 $0.00 "$18,489.83" "$18,489.83" $0.00 "$10,502.48" $0.00 $0.00 $0.00 $0.00 "$10,502.48" "$18,859.63" $0.00 $0.00 "$21,145.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,920.18" "$21,920.18" "$20,138.52" $0.00 $0.00 $0.00 $0.00 $0.00 MS446 DRG MS446 DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC INPATIENT ONLY "$46,325.27" "$34,280.70" $0.00 "$13,393.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$13,393.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS453 DRG MS453 COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC INPATIENT ONLY "$438,917.25" "$324,798.77" $0.00 "$236,554.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$236,554.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS454 DRG MS454 COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC INPATIENT ONLY "$407,718.97" "$301,712.04" $0.00 "$271,075.74" $0.00 $0.00 $0.00 $0.00 $0.00 "$104,673.75" $0.00 $0.00 "$271,075.74" $0.00 "$104,674.30" $0.00 $0.00 $0.00 "$55,659.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$63,264.79" "$63,164.90" "$63,164.90" "$53,008.86" "$50,919.68" $0.00 $0.00 $0.00 $0.00 MS455 DRG MS455 COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC INPATIENT ONLY "$334,789.12" "$247,743.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS456 DRG MS456 "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC" INPATIENT ONLY "$340,429.20" "$251,917.61" $0.00 "$71,814.47" $0.00 $0.00 "$70,406.34" "$70,406.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$71,814.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS457 DRG MS457 "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC" INPATIENT ONLY "$334,299.43" "$247,381.58" $0.00 "$69,502.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$69,502.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS459 DRG MS459 SPINAL FUSION EXCEPT CERVICAL WITH MCC INPATIENT ONLY "$590,788.39" "$437,183.41" $0.00 "$294,344.86" "$294,344.86" "$294,344.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$259,255.92" $0.00 $0.00 $0.00 $0.00 $0.00 "$60,627.44" "$173,392.23" "$211,271.76" $0.00 "$68,686.54" $0.00 "$68,686.54" $0.00 "$69,101.93" "$69,101.93" "$57,740.42" $0.00 $0.00 $0.00 $0.00 $0.00 MS460 DRG MS460 SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC INPATIENT ONLY "$243,368.62" "$180,092.78" $0.00 "$66,414.60" $0.00 $0.00 "$38,181.18" "$38,181.18" $0.00 "$49,968.85" $0.00 $0.00 $0.00 $0.00 "$66,414.60" "$38,944.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS463 DRG MS463 WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC INPATIENT ONLY "$340,239.14" "$251,776.96" $0.00 "$407,660.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$55,832.33" "$334,570.22" "$407,660.93" $0.00 "$94,279.70" $0.00 "$94,279.70" $0.00 "$55,837.96" "$55,837.96" "$53,173.65" $0.00 $0.00 $0.00 $0.00 $0.00 MS464 DRG MS464 WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC INPATIENT ONLY "$323,690.26" "$239,530.79" $0.00 "$146,335.63" "$115,976.76" "$115,976.76" "$31,591.63" "$31,591.63" $0.00 "$88,498.29" $0.00 $0.00 $0.00 $0.00 "$88,498.29" "$32,223.46" $0.00 $0.00 $0.00 "$120,098.69" "$146,335.63" $0.00 "$29,598.76" $0.00 "$29,598.76" "$27,265.48" "$37,258.44" "$37,258.44" $0.00 "$28,628.74" $0.00 $0.00 $0.00 $0.00 MS465 DRG MS465 WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$180,920.22" "$133,880.96" $0.00 "$117,446.30" "$101,350.92" "$101,350.92" $0.00 $0.00 "$23,618.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$117,446.30" "$117,446.30" $0.00 "$28,239.62" "$77,963.23" $0.00 "$19,198.54" "$117,446.30" "$19,198.54" "$13,287.73" "$28,785.73" "$28,785.73" $0.00 "$13,952.11" $0.00 $0.00 $0.00 $0.00 MS466 DRG MS466 REVISION OF HIP OR KNEE REPLACEMENT WITH MCC INPATIENT ONLY "$222,148.64" "$164,389.99" $0.00 "$54,786.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$54,786.94" "$54,786.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS467 DRG MS467 REVISION OF HIP OR KNEE REPLACEMENT WITH CC INPATIENT ONLY "$270,187.14" "$199,938.48" $0.00 "$41,826.76" $0.00 $0.00 "$35,743.58" "$35,743.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$36,458.45" $0.00 $0.00 "$37,803.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$41,826.76" "$41,826.76" "$36,003.24" $0.00 $0.00 $0.00 $0.00 $0.00 MS468 DRG MS468 REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC INPATIENT ONLY "$240,260.62" "$177,792.86" $0.00 "$36,110.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$36,110.24" "$36,110.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS469 DRG MS469 MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT INPATIENT ONLY "$181,244.35" "$134,120.82" $0.00 "$38,787.20" $0.00 $0.00 "$32,350.79" "$32,350.79" $0.00 $0.00 $0.00 $0.00 $0.00 "$32,295.68" $0.00 "$32,859.14" $0.00 $0.00 "$35,259.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$38,787.20" "$38,787.20" "$33,580.84" $0.00 $0.00 $0.00 $0.00 $0.00 MS470 DRG MS470 MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC INPATIENT ONLY "$140,929.21" "$104,287.62" $0.00 "$90,107.90" "$90,107.90" "$90,107.90" "$24,168.39" "$24,168.39" $0.00 $0.00 $0.00 $0.00 $0.00 "$24,134.45" $0.00 "$26,686.88" $0.00 $0.00 "$27,254.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,220.19" "$29,220.19" "$25,956.32" $0.00 $0.00 $0.00 $0.00 $0.00 MS471 DRG MS471 CERVICAL SPINAL FUSION WITH MCC INPATIENT ONLY "$357,681.21" "$264,684.10" $0.00 "$46,610.85" $0.00 $0.00 "$45,696.91" "$45,696.91" $0.00 $0.00 $0.00 $0.00 $0.00 "$45,607.28" $0.00 "$46,610.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS472 DRG MS472 CERVICAL SPINAL FUSION WITH CC INPATIENT ONLY "$261,184.95" "$193,276.86" $0.00 "$160,311.29" $0.00 $0.00 "$32,128.57" "$32,128.57" $0.00 "$97,395.39" $0.00 $0.00 $0.00 "$32,074.03" "$97,407.75" "$32,771.14" $0.00 $0.00 "$34,587.43" "$131,568.61" "$160,311.29" $0.00 "$30,488.93" $0.00 "$30,488.93" $0.00 "$37,983.62" "$37,983.62" "$32,940.41" $0.00 $0.00 $0.00 $0.00 $0.00 MS473 DRG MS473 CERVICAL SPINAL FUSION WITHOUT CC/MCC INPATIENT ONLY "$239,665.96" "$177,352.81" $0.00 "$107,627.95" "$99,766.44" "$99,766.44" "$28,576.36" "$28,576.36" $0.00 "$40,046.68" $0.00 $0.00 "$107,627.95" "$28,531.02" "$40,046.68" "$29,147.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS474 DRG MS474 AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC INPATIENT ONLY "$201,974.02" "$149,460.77" $0.00 "$40,282.68" $0.00 $0.00 "$39,184.68" "$39,184.68" $0.00 $0.00 $0.00 $0.00 $0.00 "$39,111.88" $0.00 "$39,968.37" $0.00 $0.00 "$40,282.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$38,364.46" $0.00 $0.00 $0.00 $0.00 $0.00 MS475 DRG MS475 AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC INPATIENT ONLY "$105,803.89" "$78,294.88" $0.00 "$326,501.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,160.30" "$267,962.31" "$326,501.77" $0.00 "$64,048.46" $0.00 "$64,048.46" $0.00 "$30,303.06" "$30,303.06" "$26,819.33" $0.00 $0.00 $0.00 $0.00 $0.00 MS476 DRG MS476 AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$108,051.26" "$79,957.93" $0.00 "$9,120.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,685.83" $0.00 $0.00 $0.00 "$9,120.12" $0.00 $0.00 $0.00 $0.00 MS477 DRG MS477 BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC INPATIENT ONLY "$61,538.76" "$45,538.68" $0.00 "$39,729.61" $0.00 $0.00 "$34,234.90" "$34,234.90" $0.00 $0.00 $0.00 $0.00 $0.00 "$34,174.93" $0.00 "$34,919.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$39,729.61" "$39,729.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS478 DRG MS478 BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC INPATIENT ONLY "$39,367.17" "$29,131.71" $0.00 "$224,555.14" "$217,556.76" "$217,556.76" $0.00 $0.00 "$61,408.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$224,555.14" "$224,555.14" "$29,637.06" $0.00 $0.00 $0.00 $0.00 "$224,555.14" $0.00 "$20,384.36" "$32,067.82" "$32,067.82" "$28,225.77" "$21,403.57" $0.00 $0.00 $0.00 $0.00 MS479 DRG MS479 BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC INPATIENT ONLY "$106,309.92" "$78,669.34" $0.00 "$71,699.35" $0.00 $0.00 $0.00 $0.00 "$15,452.22" "$15,243.66" $0.00 $0.00 $0.00 $0.00 "$20,028.55" $0.00 "$69,077.11" "$69,077.11" $0.00 "$18,769.33" "$71,699.35" $0.00 "$17,864.32" "$69,077.11" "$17,864.32" $0.00 "$27,698.78" "$27,698.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS480 DRG MS480 HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC INPATIENT ONLY "$243,911.55" "$180,494.55" $0.00 "$155,993.30" "$155,993.30" "$155,993.30" "$31,936.01" "$31,936.01" $0.00 "$68,695.36" $0.00 $0.00 "$113,747.24" "$31,881.99" "$68,695.36" "$32,574.73" $0.00 $0.00 "$34,430.27" "$117,923.11" "$143,684.76" $0.00 "$30,258.36" $0.00 "$30,258.36" $0.00 "$37,795.79" "$37,795.79" "$32,790.73" $0.00 $0.00 $0.00 $0.00 $0.00 MS481 DRG MS481 HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC INPATIENT ONLY "$187,285.44" "$138,591.23" $0.00 "$103,487.69" "$103,487.69" "$103,487.69" "$25,519.71" "$25,519.71" $0.00 "$34,406.15" $0.00 $0.00 "$69,006.41" "$25,482.27" "$44,024.27" "$26,030.10" $0.00 $0.00 "$28,070.09" "$19,240.38" "$68,283.40" "$91,568.13" "$20,928.74" $0.00 "$20,928.74" "$16,097.59" "$30,195.26" "$30,195.26" "$26,733.42" "$16,920.75" $0.00 $0.00 $0.00 $0.00 MS482 DRG MS482 HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC INPATIENT ONLY "$152,211.21" "$112,636.30" $0.00 "$106,385.28" "$106,385.28" "$106,385.28" "$22,411.96" "$22,411.96" "$94,795.46" "$28,317.96" $0.00 $0.00 "$10,396.95" "$22,382.56" "$21,211.70" "$22,860.20" "$94,795.46" "$94,795.46" "$25,046.15" "$20,216.62" "$82,311.01" "$82,947.32" "$16,492.99" "$94,795.46" "$16,492.99" "$15,016.39" "$26,581.60" "$26,581.60" "$23,853.48" "$15,767.20" $0.00 $0.00 $0.00 $0.00 MS483 DRG MS483 MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES INPATIENT ONLY "$217,236.63" "$160,755.11" $0.00 "$32,680.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,475.77" $0.00 $0.00 $0.00 $0.00 "$30,149.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$32,680.33" "$32,680.33" "$28,713.91" $0.00 $0.00 $0.00 $0.00 $0.00 MS485 DRG MS485 KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC INPATIENT ONLY "$181,169.09" "$134,065.13" $0.00 "$34,584.81" $0.00 $0.00 "$34,584.81" "$34,584.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS486 DRG MS486 KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC INPATIENT ONLY "$132,640.30" "$98,153.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS487 DRG MS487 KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC INPATIENT ONLY "$66,172.30" "$48,967.50" $0.00 "$24,785.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,344.01" $0.00 $0.00 $0.00 $0.00 "$24,785.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,605.52" $0.00 $0.00 $0.00 $0.00 $0.00 MS488 DRG MS488 KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC INPATIENT ONLY "$194,584.23" "$143,992.33" $0.00 "$263,384.75" "$137,696.34" "$137,696.34" "$24,688.76" "$24,688.76" $0.00 "$31,065.50" $0.00 $0.00 $0.00 $0.00 "$37,012.28" "$25,182.54" $0.00 $0.00 "$27,259.61" "$135,883.23" "$165,568.51" "$263,384.75" "$19,739.85" $0.00 "$19,739.85" "$13,685.26" "$29,226.72" "$29,226.72" "$25,961.53" "$14,369.52" $0.00 $0.00 $0.00 $0.00 MS489 DRG MS489 KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC INPATIENT ONLY "$85,707.36" "$63,423.45" $0.00 "$242,647.77" "$199,162.73" "$199,162.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,406.27" "$101,383.95" "$123,532.45" "$242,647.77" "$12,620.61" $0.00 "$12,620.61" $0.00 "$23,426.88" "$23,426.88" "$21,339.30" $0.00 $0.00 $0.00 $0.00 $0.00 MS492 DRG MS492 "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC" INPATIENT ONLY "$180,446.20" "$133,530.19" $0.00 "$167,518.79" "$137,567.97" "$137,567.97" "$35,001.66" "$35,001.66" $0.00 "$28,627.59" $0.00 $0.00 "$132,023.09" "$34,939.69" "$30,058.98" "$27,647.07" $0.00 $0.00 "$37,346.90" "$137,483.85" "$167,518.79" "$97,394.98" "$42,010.85" $0.00 "$42,010.85" $0.00 "$41,281.24" "$41,281.24" "$35,568.48" $0.00 $0.00 $0.00 $0.00 $0.00 MS493 DRG MS493 "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" INPATIENT ONLY "$173,538.94" "$128,418.82" $0.00 "$136,591.07" "$118,634.14" "$118,634.14" "$27,104.97" "$27,104.97" "$30,494.41" "$20,250.93" $0.00 $0.00 "$22,271.98" "$27,063.44" "$20,250.93" "$27,647.07" "$136,591.07" "$136,591.07" "$28,127.50" "$89,392.64" "$108,921.50" "$67,758.80" "$23,075.96" "$136,591.07" "$23,075.96" "$12,466.42" "$31,944.52" "$31,944.52" "$28,127.50" "$13,089.73" $0.00 $0.00 $0.00 $0.00 MS494 DRG MS494 "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" INPATIENT ONLY "$138,260.52" "$102,312.78" $0.00 "$95,441.38" "$26,344.79" "$26,344.79" "$23,832.96" "$23,832.96" "$13,742.95" "$16,007.13" $0.00 $0.00 "$10,821.20" "$23,799.89" "$16,007.13" "$24,309.62" "$81,035.66" "$81,035.66" "$26,181.24" "$8,346.59" "$77,751.89" "$95,441.38" "$18,158.03" "$81,035.66" "$18,158.03" "$12,466.42" "$27,938.05" "$27,938.05" "$24,934.51" "$13,089.73" $0.00 $0.00 $0.00 $0.00 MS495 DRG MS495 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC INPATIENT ONLY "$91,782.64" "$67,919.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS496 DRG MS496 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC INPATIENT ONLY "$169,241.03" "$125,238.36" $0.00 "$29,808.99" "$19,806.91" "$19,806.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$13,025.13" "$29,808.99" "$29,808.99" $0.00 "$13,676.38" $0.00 $0.00 $0.00 $0.00 MS497 DRG MS497 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC INPATIENT ONLY "$75,872.17" "$56,145.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS498 DRG MS498 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC INPATIENT ONLY "$117,318.76" "$86,815.88" $0.00 "$146,260.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,838.72" $0.00 $0.00 $0.00 $0.00 "$30,532.28" "$120,037.39" "$146,260.94" $0.00 "$24,540.49" $0.00 "$24,540.49" $0.00 "$33,137.63" "$33,137.63" "$29,078.36" $0.00 $0.00 $0.00 $0.00 $0.00 MS499 DRG MS499 LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC INPATIENT ONLY "$81,325.84" "$60,181.12" $0.00 "$11,045.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$11,045.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS500 DRG MS500 SOFT TISSUE PROCEDURES WITH MCC INPATIENT ONLY "$578,168.03" "$427,844.34" $0.00 "$311,174.26" "$102,731.36" "$102,731.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$311,174.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$80,884.60" "$80,884.60" $0.00 "$80,884.60" $0.00 "$80,884.60" $0.00 "$37,768.84" "$37,768.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS501 DRG MS501 SOFT TISSUE PROCEDURES WITH CC INPATIENT ONLY "$72,783.50" "$53,859.79" $0.00 "$116,069.81" "$4,437.05" "$4,437.05" "$23,011.70" "$23,011.70" $0.00 $0.00 $0.00 $0.00 $0.00 "$22,980.75" $0.00 "$23,471.93" $0.00 $0.00 "$25,269.62" "$95,259.31" "$116,069.81" "$62,879.13" "$16,820.79" $0.00 "$16,820.79" $0.00 "$26,848.64" "$26,848.64" "$24,066.30" $0.00 $0.00 $0.00 $0.00 $0.00 MS502 DRG MS502 SOFT TISSUE PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$101,560.84" "$75,155.02" $0.00 "$164,767.02" "$98,313.18" "$98,313.18" "$20,251.78" "$20,251.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,656.82" $0.00 $0.00 "$22,827.91" "$135,225.45" "$164,767.02" $0.00 "$14,731.48" $0.00 "$14,731.48" $0.00 "$23,930.76" "$23,930.76" "$21,740.87" $0.00 $0.00 $0.00 $0.00 $0.00 MS503 DRG MS503 FOOT PROCEDURES WITH MCC INPATIENT ONLY "$73,724.81" "$54,556.36" $0.00 "$187,255.41" $0.00 $0.00 "$29,277.56" "$29,277.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,863.11" $0.00 $0.00 "$32,367.16" "$187,255.41" "$148,306.29" $0.00 "$187,255.41" $0.00 "$187,255.41" $0.00 "$35,330.35" "$35,330.35" "$30,825.87" $0.00 $0.00 $0.00 $0.00 $0.00 MS504 DRG MS504 FOOT PROCEDURES WITH CC INPATIENT ONLY "$113,617.68" "$84,077.08" $0.00 "$148,692.35" "$142,601.36" "$142,601.36" "$23,303.62" "$23,303.62" "$33,045.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,769.69" "$148,692.35" "$148,692.35" $0.00 "$94,993.22" "$115,745.60" $0.00 "$17,407.21" "$148,692.35" "$17,407.21" $0.00 "$27,326.39" "$27,326.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS505 DRG MS505 FOOT PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$141,271.98" "$104,541.27" $0.00 "$133,223.81" "$14,075.15" "$14,075.15" "$23,303.62" "$23,303.62" $0.00 $0.00 $0.00 $0.00 $0.00 "$23,271.93" $0.00 "$23,769.69" $0.00 $0.00 $0.00 "$109,337.71" "$133,223.81" $0.00 "$16,855.87" $0.00 "$16,855.87" $0.00 "$26,878.91" "$26,878.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS506 DRG MS506 MAJOR THUMB OR JOINT PROCEDURES INPATIENT ONLY "$77,651.23" "$57,461.91" $0.00 "$21,718.38" $0.00 $0.00 "$21,292.53" "$21,292.53" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,266.04" $0.00 "$21,718.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS507 DRG MS507 MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC INPATIENT ONLY "$147,482.67" "$109,137.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS508 DRG MS508 MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$152,347.28" "$112,736.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS510 DRG MS510 "SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC" INPATIENT ONLY "$272,856.35" "$201,913.70" $0.00 "$179,649.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$142,790.15" $0.00 $0.00 "$30,588.88" $0.00 $0.00 $0.00 "$147,439.34" "$179,649.18" $0.00 "$27,947.77" $0.00 "$27,947.77" $0.00 "$35,913.41" "$35,913.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS511 DRG MS511 "SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC" INPATIENT ONLY "$155,199.53" "$114,847.65" $0.00 "$119,097.38" "$119,097.38" "$119,097.38" "$24,631.47" "$24,631.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$24,596.33" $0.00 "$25,124.10" $0.00 $0.00 "$26,678.75" "$83,340.79" "$101,547.55" $0.00 "$18,887.80" $0.00 "$18,887.80" "$14,202.32" "$28,532.58" "$28,532.58" "$25,408.33" "$14,912.43" $0.00 $0.00 $0.00 $0.00 MS512 DRG MS512 "SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$130,533.10" "$96,594.49" $0.00 "$69,039.85" "$4,526.08" "$4,526.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$43,076.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,928.39" "$69,039.85" "$47,895.51" "$15,174.79" $0.00 "$15,174.79" "$9,356.83" "$25,507.72" "$25,507.72" $0.00 "$9,824.67" $0.00 $0.00 $0.00 $0.00 MS513 DRG MS513 "HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC" INPATIENT ONLY "$82,233.47" "$60,852.77" $0.00 "$95,133.80" $0.00 $0.00 "$21,902.63" "$21,902.63" $0.00 $0.00 $0.00 $0.00 "$9,665.56" "$21,874.54" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,775.22" "$34,223.36" "$95,133.80" "$15,809.32" $0.00 "$15,809.32" $0.00 "$26,024.64" "$26,024.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS514 DRG MS514 "HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$65,501.95" "$48,471.44" $0.00 "$38,957.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,109.64" "$5,825.91" "$38,957.44" $0.00 "$10,693.93" $0.00 "$10,693.93" $0.00 "$21,857.31" "$21,857.31" "$20,104.47" $0.00 $0.00 $0.00 $0.00 $0.00 MS515 DRG MS515 OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC INPATIENT ONLY "$247,874.96" "$183,427.47" $0.00 "$265,646.77" "$265,646.77" "$265,646.77" "$32,728.31" "$32,728.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$33,382.88" $0.00 $0.00 "$35,356.23" "$171,828.87" "$209,366.89" $0.00 "$31,616.65" $0.00 "$31,616.65" $0.00 "$38,902.35" "$38,902.35" "$33,672.60" $0.00 $0.00 $0.00 $0.00 $0.00 MS516 DRG MS516 OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC INPATIENT ONLY "$202,001.98" "$149,481.47" $0.00 "$192,718.78" "$6,477.57" "$6,477.57" "$24,599.75" "$24,599.75" "$18,238.84" "$59,746.59" $0.00 $0.00 "$40,231.44" $0.00 "$59,758.95" "$25,091.75" "$82,828.31" "$82,828.31" "$27,053.91" "$6,215.66" "$41,578.09" "$192,718.78" "$19,438.14" "$82,828.31" "$19,438.14" $0.00 "$28,980.91" "$28,980.91" "$25,765.63" $0.00 $0.00 $0.00 $0.00 $0.00 MS517 DRG MS517 OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$105,666.11" "$78,192.92" $0.00 "$260,109.45" "$260,109.45" "$260,109.45" "$20,703.15" "$20,703.15" $0.00 $0.00 $0.00 $0.00 "$44,163.99" "$20,678.18" $0.00 "$21,117.21" $0.00 $0.00 $0.00 "$100,967.39" "$123,024.86" "$194,960.94" "$14,187.39" $0.00 "$14,187.39" $0.00 "$24,703.31" "$24,703.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS518 DRG MS518 BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR INPATIENT ONLY "$305,899.54" "$226,365.66" $0.00 "$53,149.12" $0.00 $0.00 "$35,808.45" "$35,808.45" $0.00 "$34,583.75" $0.00 $0.00 $0.00 "$35,744.40" "$53,149.12" "$36,524.62" $0.00 $0.00 "$35,329.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$35,329.63" $0.00 $0.00 $0.00 $0.00 $0.00 MS519 DRG MS519 BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC INPATIENT ONLY "$247,143.59" "$182,886.26" $0.00 "$259,633.24" "$259,633.24" "$259,633.24" "$24,580.40" "$24,580.40" $0.00 $0.00 $0.00 $0.00 "$153,503.88" $0.00 $0.00 "$25,072.01" $0.00 $0.00 $0.00 "$120,293.25" "$146,572.73" "$101,333.30" "$19,133.38" $0.00 "$19,133.38" $0.00 "$28,732.65" "$28,732.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS520 DRG MS520 BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC INPATIENT ONLY "$263,064.66" "$194,667.85" $0.00 "$195,326.87" $0.00 $0.00 "$20,841.86" "$20,841.86" $0.00 $0.00 $0.00 $0.00 "$195,326.87" "$20,816.53" $0.00 "$21,258.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS522 DRG MS522 HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC INPATIENT ONLY "$164,480.28" "$121,715.41" $0.00 "$110,446.07" "$110,446.07" "$110,446.07" "$26,163.61" "$26,163.61" $0.00 $0.00 $0.00 $0.00 $0.00 "$26,124.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS533 DRG MS533 FRACTURES OF FEMUR WITH MCC INPATIENT ONLY "$19,588.32" "$14,495.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS534 DRG MS534 FRACTURES OF FEMUR WITHOUT MCC INPATIENT ONLY "$31,460.66" "$23,280.89" $0.00 "$19,117.88" $0.00 $0.00 "$16,507.02" "$16,507.02" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,492.92" $0.00 $0.00 $0.00 $0.00 "$19,117.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,207.50" $0.00 $0.00 $0.00 $0.00 $0.00 MS535 DRG MS535 FRACTURES OF HIP AND PELVIS WITH MCC INPATIENT ONLY "$54,105.68" "$40,038.20" $0.00 "$55,410.08" $0.00 $0.00 "$19,561.65" "$19,561.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,952.88" $0.00 $0.00 "$22,188.27" "$45,475.45" "$55,410.08" $0.00 "$12,300.82" $0.00 "$12,300.82" $0.00 "$23,166.38" "$23,166.38" "$21,131.69" $0.00 $0.00 $0.00 $0.00 $0.00 MS536 DRG MS536 FRACTURES OF HIP AND PELVIS WITHOUT MCC INPATIENT ONLY "$55,004.91" "$40,703.63" $0.00 "$51,105.97" "$10,159.55" "$10,159.55" "$16,379.34" "$16,379.34" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,365.57" $0.00 "$16,706.93" $0.00 $0.00 "$18,985.98" "$41,943.03" "$51,105.97" $0.00 "$7,603.43" $0.00 "$7,603.43" $0.00 "$19,339.59" "$19,339.59" "$18,081.89" $0.00 $0.00 $0.00 $0.00 $0.00 MS539 DRG MS539 OSTEOMYELITIS WITH MCC INPATIENT ONLY $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS540 DRG MS540 OSTEOMYELITIS WITH CC INPATIENT ONLY "$56,790.13" "$42,024.70" $0.00 "$23,761.72" $0.00 $0.00 "$20,036.46" "$20,036.46" $0.00 "$12,280.17" $0.00 $0.00 $0.00 "$20,013.22" "$12,280.17" "$20,437.19" $0.00 $0.00 "$22,686.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,761.72" "$23,761.72" "$21,606.16" $0.00 $0.00 $0.00 $0.00 $0.00 MS541 DRG MS541 OSTEOMYELITIS WITHOUT CC/MCC INPATIENT ONLY "$16,708.96" "$12,364.63" $0.00 "$20,549.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$10,045.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,521.61" "$13,050.54" $0.00 "$9,089.03" $0.00 "$9,089.03" $0.00 "$20,549.86" "$20,549.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS542 DRG MS542 PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC INPATIENT ONLY "$48,347.24" "$35,776.96" $0.00 "$28,047.49" "$20,433.00" "$20,433.00" "$23,539.66" "$23,539.66" "$17,380.18" $0.00 $0.00 $0.00 $0.00 "$23,507.35" $0.00 "$24,010.45" "$27,138.00" "$27,138.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$27,138.00" $0.00 $0.00 "$28,047.49" "$28,047.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS543 DRG MS543 PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC INPATIENT ONLY "$138,113.94" "$102,204.32" $0.00 "$57,212.40" "$57,212.40" "$57,212.40" "$18,266.92" "$18,266.92" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,248.25" $0.00 "$19,775.46" $0.00 $0.00 "$21,021.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,020.07" $0.00 $0.00 $0.00 $0.00 $0.00 MS544 DRG MS544 PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC INPATIENT ONLY "$34,792.01" "$25,746.09" $0.00 "$20,893.70" "$20,893.70" "$20,893.70" $0.00 $0.00 "$7,083.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$11,665.50" "$11,665.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$11,665.50" $0.00 $0.00 "$19,338.77" "$19,338.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS545 DRG MS545 CONNECTIVE TISSUE DISORDERS WITH MCC INPATIENT ONLY "$64,829.08" "$47,973.52" $0.00 "$55,923.33" "$26,284.20" "$26,284.20" $0.00 $0.00 "$22,618.69" "$41,824.02" $0.00 $0.00 $0.00 $0.00 "$55,923.33" $0.00 "$37,546.50" "$37,546.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$37,546.50" $0.00 "$20,564.56" "$33,790.14" "$33,790.14" $0.00 "$21,592.78" $0.00 $0.00 $0.00 $0.00 MS546 DRG MS546 CONNECTIVE TISSUE DISORDERS WITH CC INPATIENT ONLY "$55,499.36" "$41,069.53" $0.00 "$39,074.00" "$20,716.21" "$20,716.21" "$19,390.49" "$19,390.49" $0.00 "$11,246.10" $0.00 $0.00 $0.00 "$19,368.91" "$11,246.10" "$19,778.30" $0.00 $0.00 $0.00 "$17,744.13" "$39,074.00" "$23,690.09" "$12,063.24" $0.00 "$12,063.24" "$10,764.02" "$22,972.84" "$22,972.84" $0.00 "$11,302.22" $0.00 $0.00 $0.00 $0.00 MS547 DRG MS547 CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$25,917.84" "$19,179.20" $0.00 "$21,983.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,338.61" "$3,981.64" "$21,983.21" $0.00 "$8,120.69" $0.00 "$8,120.69" $0.00 "$19,760.97" "$19,760.97" "$18,417.72" $0.00 $0.00 $0.00 $0.00 $0.00 MS548 DRG MS548 SEPTIC ARTHRITIS WITH MCC INPATIENT ONLY "$413,977.48" "$306,343.34" $0.00 "$33,605.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$33,605.39" "$33,605.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS549 DRG MS549 SEPTIC ARTHRITIS WITH CC INPATIENT ONLY "$59,228.85" "$43,829.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS550 DRG MS550 SEPTIC ARTHRITIS WITHOUT CC/MCC INPATIENT ONLY "$68,433.98" "$50,641.15" $0.00 "$20,201.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,746.96" "$9,998.30" $0.00 "$8,661.00" $0.00 "$8,661.00" $0.00 "$20,201.14" "$20,201.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS551 DRG MS551 MEDICAL BACK PROBLEMS WITH MCC INPATIENT ONLY "$114,513.50" "$84,739.99" $0.00 "$26,358.23" "$26,358.23" "$26,358.23" "$22,284.97" "$22,284.97" $0.00 $0.00 $0.00 $0.00 "$11,045.89" "$22,255.91" $0.00 "$22,730.67" $0.00 $0.00 "$24,664.14" $0.00 $0.00 "$25,317.60" $0.00 $0.00 $0.00 "$10,043.22" "$26,125.09" "$26,125.09" "$23,489.66" "$10,545.38" $0.00 $0.00 $0.00 $0.00 MS552 DRG MS552 MEDICAL BACK PROBLEMS WITHOUT MCC INPATIENT ONLY "$72,301.05" "$53,502.78" $0.00 "$46,583.09" "$42,175.25" "$42,175.25" "$17,564.33" "$17,564.33" "$7,763.60" "$8,531.79" $0.00 $0.00 "$23,389.21" "$17,547.49" "$8,531.79" "$17,915.62" "$14,151.00" "$14,151.00" "$20,034.27" "$3,841.70" "$46,583.09" "$46,274.32" "$9,141.16" "$14,151.00" "$9,141.16" "$8,166.06" "$41,185.53" "$41,185.53" "$19,080.26" "$8,574.36" $0.00 $0.00 $0.00 $0.00 MS553 DRG MS553 BONE DISEASES AND ARTHROPATHIES WITH MCC INPATIENT ONLY "$51,045.58" "$37,773.73" $0.00 "$28,077.22" $0.00 $0.00 "$19,860.48" "$19,860.48" $0.00 $0.00 $0.00 $0.00 $0.00 "$19,806.02" $0.00 "$20,225.30" $0.00 $0.00 "$22,587.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,077.22" "$28,077.22" "$21,511.79" $0.00 $0.00 $0.00 $0.00 $0.00 MS554 DRG MS554 BONE DISEASES AND ARTHROPATHIES WITHOUT MCC INPATIENT ONLY "$34,943.63" "$25,858.29" $0.00 "$19,573.95" "$8,173.20" "$8,173.20" "$16,522.90" "$16,522.90" "$6,492.58" $0.00 $0.00 $0.00 $0.00 "$16,508.75" $0.00 "$16,853.36" "$11,887.50" "$11,887.50" "$19,182.11" $0.00 $0.00 $0.00 $0.00 "$11,887.50" $0.00 "$7,215.26" "$19,573.95" "$19,573.95" "$18,268.68" "$7,576.01" $0.00 $0.00 $0.00 $0.00 MS555 DRG MS555 SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC INPATIENT ONLY "$55,014.70" "$40,710.88" $0.00 "$25,282.80" $0.00 $0.00 "$20,498.16" "$20,498.16" $0.00 "$10,813.74" $0.00 $0.00 $0.00 "$20,473.72" "$10,813.74" "$20,908.12" $0.00 $0.00 "$22,791.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,282.80" $0.00 $0.00 $0.00 $0.00 $0.00 MS556 DRG MS556 SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC INPATIENT ONLY "$15,857.45" "$11,734.51" $0.00 "$19,611.52" $0.00 $0.00 "$16,634.69" "$16,634.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,967.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,611.52" "$19,611.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS557 DRG MS557 "TENDONITIS, MYOSITIS AND BURSITIS WITH MCC" INPATIENT ONLY "$24,976.66" "$18,482.73" $0.00 "$25,053.66" $0.00 $0.00 "$20,709.35" "$20,709.35" $0.00 $0.00 $0.00 $0.00 $0.00 "$20,684.37" $0.00 "$17,338.39" $0.00 $0.00 $0.00 "$7,288.53" "$23,483.23" $0.00 "$14,617.44" $0.00 "$14,617.44" "$8,981.94" "$25,053.66" "$25,053.66" $0.00 "$9,431.03" $0.00 $0.00 $0.00 $0.00 MS558 DRG MS558 "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" INPATIENT ONLY "$29,084.09" "$21,522.23" $0.00 "$20,179.91" $0.00 $0.00 "$16,998.42" "$16,998.42" $0.00 "$7,373.78" $0.00 $0.00 "$3,348.41" "$16,983.03" "$7,373.78" "$17,338.39" $0.00 $0.00 "$19,689.18" "$6,684.92" "$14,709.82" $0.00 "$8,634.93" $0.00 "$8,634.93" "$7,057.69" "$20,179.91" "$20,179.91" "$18,751.60" "$7,410.57" $0.00 $0.00 $0.00 $0.00 MS559 DRG MS559 "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC" INPATIENT ONLY "$71,553.76" "$52,949.78" $0.00 "$26,115.65" $0.00 $0.00 "$23,926.84" "$23,926.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,405.38" $0.00 $0.00 "$26,115.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,872.05" $0.00 $0.00 $0.00 $0.00 $0.00 MS560 DRG MS560 "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" INPATIENT ONLY "$37,994.06" "$28,115.60" $0.00 "$19,176.18" $0.00 $0.00 "$18,479.48" "$18,479.48" $0.00 "$4,841.55" $0.00 $0.00 $0.00 "$18,460.26" "$19,176.18" "$18,849.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS561 DRG MS561 "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC" INPATIENT ONLY "$13,202.24" "$9,769.66" $0.00 "$16,852.65" $0.00 $0.00 "$16,522.21" "$16,522.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,852.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS562 DRG MS562 "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" INPATIENT ONLY "$19,338.11" "$14,310.20" $0.00 "$29,572.12" "$21,147.88" "$21,147.88" "$20,797.00" "$20,797.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,212.94" $0.00 $0.00 "$23,008.32" "$24,270.04" "$29,572.12" $0.00 "$13,503.74" $0.00 "$13,503.74" $0.00 "$24,146.36" "$24,146.36" "$21,912.69" $0.00 $0.00 $0.00 $0.00 $0.00 MS563 DRG MS563 "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" INPATIENT ONLY "$45,179.03" "$33,432.48" $0.00 "$30,007.85" "$8,550.54" "$8,550.54" "$17,072.96" "$17,072.96" "$6,922.80" "$10,446.77" $0.00 $0.00 "$11,045.89" $0.00 "$8,103.21" "$17,414.42" "$13,083.00" "$13,083.00" "$19,638.62" "$24,627.66" "$30,007.85" "$29,566.02" "$8,560.76" "$13,083.00" "$8,560.76" "$7,755.86" "$20,119.49" "$20,119.49" "$18,703.45" "$8,143.64" $0.00 $0.00 $0.00 $0.00 MS564 DRG MS564 OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC INPATIENT ONLY "$28,508.20" "$21,096.07" $0.00 "$33,697.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$33,697.98" $0.00 $0.00 "$24,135.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$10,269.60" "$25,493.02" "$25,493.02" "$22,985.93" "$10,783.08" $0.00 $0.00 $0.00 $0.00 MS565 DRG MS565 OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC INPATIENT ONLY "$58,776.46" "$43,494.58" $0.00 "$58,773.78" $0.00 $0.00 "$18,019.16" "$18,019.16" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,001.13" $0.00 "$18,379.54" $0.00 $0.00 $0.00 "$42,888.55" "$52,258.04" "$58,773.78" "$9,828.83" $0.00 "$9,828.83" "$10,269.60" "$21,152.55" "$21,152.55" $0.00 "$10,783.08" $0.00 $0.00 $0.00 $0.00 MS566 DRG MS566 OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC INPATIENT ONLY "$52,050.86" "$38,517.64" $0.00 "$19,333.07" "$14,242.21" "$14,242.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,333.07" "$19,333.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS570 DRG MS570 SKIN DEBRIDEMENT WITH MCC INPATIENT ONLY "$176,422.47" "$130,552.63" $0.00 "$37,352.79" $0.00 $0.00 "$30,665.46" "$30,665.46" $0.00 $0.00 $0.00 $0.00 $0.00 "$30,614.70" $0.00 "$31,278.77" $0.00 $0.00 "$29,679.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$37,352.79" "$37,352.79" "$29,679.42" $0.00 $0.00 $0.00 $0.00 $0.00 MS571 DRG MS571 SKIN DEBRIDEMENT WITH CC INPATIENT ONLY "$85,212.35" "$63,057.14" $0.00 "$92,480.47" $0.00 $0.00 "$59,862.87" "$59,862.87" $0.00 "$14,515.09" $0.00 $0.00 "$11,045.89" "$59,924.61" "$14,515.09" "$61,129.05" $0.00 $0.00 "$25,230.67" "$7,827.96" "$92,480.47" $0.00 "$16,763.65" $0.00 "$16,763.65" $0.00 "$26,802.10" "$26,802.10" "$24,029.21" $0.00 $0.00 $0.00 $0.00 $0.00 MS572 DRG MS572 SKIN DEBRIDEMENT WITHOUT CC/MCC INPATIENT ONLY "$94,703.95" "$70,080.92" $0.00 "$187,600.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$11,045.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$187,600.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS574 DRG MS574 SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC INPATIENT ONLY "$148,433.14" "$109,840.52" $0.00 "$96,481.54" "$94,618.60" "$94,618.60" $0.00 $0.00 "$23,472.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$96,481.54" "$96,481.54" "$96,481.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS575 DRG MS575 SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC INPATIENT ONLY "$159,802.59" "$118,253.92" $0.00 "$106,610.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$106,610.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS576 DRG MS576 SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC INPATIENT ONLY "$201,124.76" "$148,832.32" $0.00 "$191,834.21" $0.00 $0.00 "$187,666.77" "$187,666.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$191,834.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$52,745.32" "$52,745.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS577 DRG MS577 SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC INPATIENT ONLY "$326,238.97" "$241,416.84" $0.00 "$210,439.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,509.22" $0.00 $0.00 "$152,022.01" $0.00 "$21,509.22" $0.00 $0.00 $0.00 "$30,310.19" "$172,709.30" "$210,439.66" $0.00 "$30,411.56" $0.00 "$30,411.56" "$20,587.20" "$32,872.23" "$32,872.23" "$28,866.85" "$21,616.55" $0.00 $0.00 $0.00 $0.00 MS578 DRG MS578 SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC INPATIENT ONLY "$195,675.49" "$144,799.86" $0.00 "$89,151.39" $0.00 $0.00 $0.00 $0.00 $0.00 "$15,734.20" $0.00 $0.00 $0.00 $0.00 "$15,734.20" $0.00 $0.00 $0.00 $0.00 "$6,314.74" "$89,151.39" $0.00 "$16,313.56" $0.00 "$16,313.56" $0.00 "$26,435.44" "$26,435.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS579 DRG MS579 "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" INPATIENT ONLY "$204,580.32" "$151,389.44" $0.00 "$37,531.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,506.89" $0.00 $0.00 "$34,208.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$37,531.20" "$37,531.20" "$32,579.85" $0.00 $0.00 $0.00 $0.00 $0.00 MS580 DRG MS580 "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" INPATIENT ONLY "$135,202.42" "$100,049.79" $0.00 "$103,996.14" "$103,996.14" "$103,996.14" "$22,984.77" "$22,984.77" $0.00 "$17,934.78" $0.00 $0.00 $0.00 "$22,953.89" "$17,934.78" "$23,444.47" $0.00 $0.00 "$24,796.03" "$13,426.57" "$96,657.78" $0.00 "$16,126.10" $0.00 "$16,126.10" "$13,096.07" "$26,282.71" "$26,282.71" "$23,615.27" "$13,137.34" $0.00 $0.00 $0.00 $0.00 MS581 DRG MS581 "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$103,131.58" "$76,317.37" $0.00 "$289,721.02" "$98,764.64" "$98,764.64" $0.00 $0.00 $0.00 "$34,620.26" $0.00 $0.00 $0.00 $0.00 "$44,809.25" "$17,283.48" $0.00 $0.00 "$22,377.58" "$237,776.11" "$289,721.02" $0.00 "$51,492.35" $0.00 "$51,492.35" "$8,905.88" "$23,392.60" "$23,392.60" "$21,311.98" "$9,351.17" $0.00 $0.00 $0.00 $0.00 MS582 DRG MS582 MASTECTOMY FOR MALIGNANCY WITH CC/MCC INPATIENT ONLY "$129,566.31" "$95,879.07" $0.00 "$22,841.19" $0.00 $0.00 "$22,393.32" "$22,393.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,841.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS583 DRG MS583 MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC INPATIENT ONLY "$162,444.59" "$120,209.00" $0.00 "$29,509.94" $0.00 $0.00 $0.00 $0.00 $0.00 "$22,037.12" $0.00 $0.00 $0.00 $0.00 "$29,509.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS584 DRG MS584 "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC" INPATIENT ONLY "$94,531.64" "$69,953.41" $0.00 "$474,664.05" "$474,664.05" "$474,664.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$15,496.32" $0.00 $0.00 $0.00 "$16,271.13" $0.00 $0.00 $0.00 $0.00 MS585 DRG MS585 "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$165,756.69" "$122,659.95" $0.00 "$66,928.30" $0.00 $0.00 $0.00 $0.00 $0.00 "$32,770.74" $0.00 $0.00 $0.00 $0.00 "$32,770.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$66,928.30" $0.00 $0.00 $0.00 "$15,175.67" $0.00 $0.00 $0.00 $0.00 MS592 DRG MS592 SKIN ULCERS WITH MCC INPATIENT ONLY "$22,209.32" "$16,434.90" $0.00 "$23,226.65" $0.00 $0.00 "$22,784.82" "$22,784.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,226.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,094.03" "$21,094.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS593 DRG MS593 SKIN ULCERS WITH CC INPATIENT ONLY "$15,697.87" "$11,616.42" $0.00 "$22,518.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,646.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,518.78" "$22,518.78" "$20,615.57" $0.00 $0.00 $0.00 $0.00 $0.00 MS594 DRG MS594 SKIN ULCERS WITHOUT CC/MCC INPATIENT ONLY "$24,390.66" "$18,049.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS595 DRG MS595 MAJOR SKIN DISORDERS WITH MCC INPATIENT ONLY "$29,157.59" "$21,576.62" $0.00 "$525,887.27" "$525,887.27" "$525,887.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS596 DRG MS596 MAJOR SKIN DISORDERS WITHOUT MCC INPATIENT ONLY "$18,558.10" "$13,732.99" $0.00 "$21,100.29" $0.00 $0.00 "$17,918.39" "$17,918.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,276.76" $0.00 $0.00 "$20,459.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,100.29" "$21,100.29" "$19,485.10" $0.00 $0.00 $0.00 $0.00 $0.00 MS597 DRG MS597 MALIGNANT BREAST DISORDERS WITH MCC INPATIENT ONLY "$151,439.02" "$112,064.87" $0.00 "$26,970.32" $0.00 $0.00 "$22,399.52" "$22,399.52" $0.00 $0.00 $0.00 $0.00 $0.00 "$22,370.18" $0.00 "$22,847.51" $0.00 $0.00 "$25,371.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$11,123.52" "$26,970.32" "$26,970.32" "$24,163.28" "$11,679.69" $0.00 $0.00 $0.00 $0.00 MS598 DRG MS598 MALIGNANT BREAST DISORDERS WITH CC INPATIENT ONLY "$10,043.51" "$7,432.20" $0.00 "$35,696.67" $0.00 $0.00 "$18,765.23" "$18,765.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.31 $0.00 $0.00 "$21,241.80" "$10,944.14" "$35,696.67" $0.00 "$10,912.47" $0.00 "$10,912.47" $0.00 "$22,035.33" "$22,035.33" "$20,230.29" $0.00 $0.00 $0.00 $0.00 $0.00 MS600 DRG MS600 NON-MALIGNANT BREAST DISORDERS WITH CC/MCC INPATIENT ONLY "$24,329.27" "$18,003.66" $0.00 "$18,292.24" $0.00 $0.00 "$17,933.57" "$17,933.57" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,292.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS601 DRG MS601 NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$11,235.84" "$8,314.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS602 DRG MS602 CELLULITIS WITH MCC INPATIENT ONLY "$39,242.55" "$29,039.49" $0.00 "$24,821.74" "$4,323.53" "$4,323.53" "$21,060.64" "$21,060.64" "$12,993.19" $0.00 $0.00 $0.00 $0.00 "$21,073.09" $0.00 "$17,283.48" "$21,750.00" "$21,750.00" "$23,573.49" $0.00 $0.00 "$18,754.05" $0.00 "$21,750.00" $0.00 $0.00 "$24,821.74" "$24,821.74" "$22,450.94" $0.00 $0.00 $0.00 $0.00 $0.00 MS603 DRG MS603 CELLULITIS WITHOUT MCC INPATIENT ONLY "$33,623.54" "$24,881.42" $0.00 "$20,033.73" "$16,457.97" "$16,457.97" "$16,944.59" "$16,944.59" "$7,539.56" $0.00 $0.00 $0.00 "$16,809.02" "$16,929.35" $0.00 "$17,283.48" "$12,804.00" "$12,804.00" "$19,566.86" "$6,546.00" "$17,835.13" $0.00 "$8,455.50" "$12,804.00" "$8,455.50" "$8,000.35" "$20,033.73" "$20,033.73" "$18,635.10" "$8,400.36" $0.00 $0.00 $0.00 $0.00 MS604 DRG MS604 "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC" INPATIENT ONLY "$58,470.55" "$43,268.21" $0.00 "$101,032.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,678.25" $0.00 $0.00 "$23,810.62" "$82,918.27" "$101,032.73" $0.00 "$14,680.60" $0.00 "$14,680.60" $0.00 "$25,105.11" "$25,105.11" "$22,676.78" $0.00 $0.00 $0.00 $0.00 $0.00 MS605 DRG MS605 "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" INPATIENT ONLY "$44,177.90" "$32,691.65" $0.00 "$33,846.48" "$11,723.60" "$11,723.60" "$17,291.74" "$17,291.74" $0.00 "$6,598.94" $0.00 $0.00 "$9,236.98" "$17,275.60" "$6,598.94" "$17,637.57" $0.00 $0.00 "$19,786.89" "$27,778.04" "$33,846.48" $0.00 "$8,778.29" $0.00 "$8,778.29" "$6,316.06" "$20,354.44" "$20,354.44" "$18,844.66" "$6,631.86" $0.00 $0.00 $0.00 $0.00 MS606 DRG MS606 MINOR SKIN DISORDERS WITH MCC INPATIENT ONLY "$38,821.50" "$28,727.91" $0.00 "$25,358.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,358.28" "$25,358.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS607 DRG MS607 MINOR SKIN DISORDERS WITHOUT MCC INPATIENT ONLY "$24,146.53" "$17,868.43" $0.00 "$19,891.64" "$4,312.35" "$4,312.35" "$16,769.28" "$16,769.28" $0.00 "$6,557.31" $0.00 $0.00 "$6,696.82" "$16,754.48" "$6,557.31" "$17,104.67" $0.00 $0.00 "$19,447.95" "$6,767.14" "$9,573.60" $0.00 "$8,281.08" $0.00 "$8,281.08" $0.00 "$19,891.64" "$19,891.64" "$18,521.86" $0.00 $0.00 $0.00 $0.00 $0.00 MS614 DRG MS614 ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC INPATIENT ONLY "$332,589.59" "$246,116.30" $0.00 "$187,016.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$39,122.95" $0.00 $0.00 "$187,016.76" $0.00 "$50,125.70" $0.00 $0.00 $0.00 "$30,431.14" "$137,820.12" "$167,928.51" $0.00 "$24,392.14" $0.00 "$24,392.14" $0.00 "$33,016.77" "$33,016.77" "$28,982.04" $0.00 $0.00 $0.00 $0.00 $0.00 MS615 DRG MS615 ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$152,983.56" "$113,207.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS616 DRG MS616 "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" INPATIENT ONLY "$192,155.28" "$142,194.91" $0.00 "$45,817.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$41,143.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$45,817.70" "$45,817.70" "$39,183.85" $0.00 $0.00 $0.00 $0.00 $0.00 MS617 DRG MS617 "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" INPATIENT ONLY "$70,219.82" "$51,962.67" $0.00 "$78,850.16" $0.00 $0.00 "$25,062.13" "$25,062.13" $0.00 $0.00 $0.00 $0.00 "$3,348.41" "$25,025.87" $0.00 "$25,563.37" $0.00 $0.00 "$27,820.65" "$30,246.42" "$78,850.16" $0.00 "$20,562.86" $0.00 "$20,562.86" $0.00 "$29,897.18" "$29,897.18" "$26,495.86" $0.00 $0.00 $0.00 $0.00 $0.00 MS622 DRG MS622 "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" INPATIENT ONLY "$231,450.41" "$171,273.30" $0.00 "$150,442.75" $0.00 $0.00 $0.00 $0.00 "$41,216.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$150,442.75" "$150,442.75" "$150,442.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS623 DRG MS623 "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" INPATIENT ONLY "$112,314.61" "$83,112.81" $0.00 "$25,933.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,933.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,698.30" $0.00 $0.00 $0.00 $0.00 $0.00 MS626 DRG MS626 "THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC" INPATIENT ONLY "$190,024.42" "$140,618.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS627 DRG MS627 "THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$133,664.81" "$98,911.96" $0.00 "$29,066.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,066.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS628 DRG MS628 "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" INPATIENT ONLY "$110,871.85" "$82,045.17" $0.00 "$39,014.36" $0.00 $0.00 "$36,446.84" "$36,446.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$37,175.78" $0.00 $0.00 "$39,014.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$37,156.53" $0.00 $0.00 $0.00 $0.00 $0.00 MS629 DRG MS629 "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" INPATIENT ONLY "$112,509.13" "$83,256.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS630 DRG MS630 "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC" INPATIENT ONLY "$158,798.79" "$117,511.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS637 DRG MS637 DIABETES WITH MCC INPATIENT ONLY "$36,108.73" "$26,720.46" $0.00 "$40,133.70" "$16,572.15" "$16,572.15" "$20,554.07" "$20,554.07" "$12,446.04" "$23,792.53" $0.00 $0.00 $0.00 "$20,529.49" "$23,792.53" "$20,965.15" "$20,649.00" "$20,649.00" "$23,272.11" "$20,432.15" "$40,133.70" $0.00 "$13,890.67" "$20,649.00" "$13,890.67" "$12,230.98" "$24,461.58" "$24,461.58" "$22,163.91" "$12,842.52" $0.00 $0.00 $0.00 $0.00 MS638 DRG MS638 DIABETES WITH CC INPATIENT ONLY "$34,793.06" "$25,746.86" $0.00 "$22,063.63" "$12,998.32" "$12,998.32" "$17,122.64" "$17,122.64" $0.00 "$7,457.98" $0.00 $0.00 "$12,069.23" "$17,106.93" "$7,457.98" "$17,465.09" $0.00 $0.00 "$19,844.30" "$3,621.13" "$22,063.63" $0.00 "$8,862.48" $0.00 "$8,862.48" "$2,865.07" "$20,365.28" "$20,365.28" "$18,899.33" "$3,049.24" $0.00 $0.00 $0.00 $0.00 MS639 DRG MS639 DIABETES WITHOUT CC/MCC INPATIENT ONLY "$23,626.99" "$17,483.97" $0.00 "$31,516.95" $0.00 $0.00 "$15,260.63" "$15,260.63" $0.00 "$4,826.72" $0.00 $0.00 "$3,348.41" $0.00 "$5,194.00" "$15,565.84" $0.00 $0.00 "$17,993.04" "$7,233.31" "$31,516.95" $0.00 "$6,146.90" $0.00 "$6,146.90" "$4,971.35" "$18,153.00" "$18,153.00" "$17,136.23" "$5,219.92" $0.00 $0.00 $0.00 $0.00 MS640 DRG MS640 "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" INPATIENT ONLY "$49,024.53" "$36,278.15" $0.00 "$79,244.98" "$8,356.69" "$8,356.69" "$19,547.83" "$19,547.83" $0.00 "$9,176.07" $0.00 $0.00 $0.00 "$19,525.85" "$9,176.07" "$19,963.83" $0.00 $0.00 "$22,100.13" "$17,903.38" "$79,244.98" $0.00 "$12,171.50" $0.00 "$12,171.50" "$8,782.73" "$23,061.04" "$23,061.04" "$21,047.74" "$9,221.86" $0.00 $0.00 $0.00 $0.00 MS641 DRG MS641 "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" INPATIENT ONLY "$51,782.41" "$38,318.98" $0.00 "$120,359.68" "$12,711.30" "$12,711.30" "$16,258.58" "$16,258.58" "$6,293.53" $0.00 $0.00 $0.00 "$6,696.82" "$16,245.11" $0.00 "$16,583.75" "$11,313.00" "$11,313.00" "$17,809.69" "$98,780.05" "$120,359.68" $0.00 "$7,584.39" "$11,313.00" "$7,584.39" "$6,726.27" "$19,324.07" "$19,324.07" "$16,961.90" "$7,062.58" $0.00 $0.00 $0.00 $0.00 MS642 DRG MS642 INBORN AND OTHER DISORDERS OF METABOLISM INPATIENT ONLY "$38,588.82" "$28,555.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS643 DRG MS643 ENDOCRINE DISORDERS WITH MCC INPATIENT ONLY "$53,294.85" "$39,438.19" $0.00 "$82,100.01" $0.00 $0.00 "$22,563.09" "$22,563.09" $0.00 $0.00 $0.00 $0.00 "$10,045.23" "$22,533.31" $0.00 "$23,014.35" $0.00 $0.00 "$24,910.85" "$22,826.66" "$82,100.01" $0.00 "$16,294.50" $0.00 "$16,294.50" $0.00 "$26,419.91" "$26,419.91" "$23,724.62" $0.00 $0.00 $0.00 $0.00 $0.00 MS644 DRG MS644 ENDOCRINE DISORDERS WITH CC INPATIENT ONLY "$30,234.31" "$22,373.39" $0.00 "$21,541.26" $0.00 $0.00 "$18,091.62" "$18,091.62" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,073.40" $0.00 "$18,453.45" $0.00 $0.00 "$20,828.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,541.26" "$21,541.26" "$19,836.54" $0.00 $0.00 $0.00 $0.00 $0.00 MS645 DRG MS645 ENDOCRINE DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$20,021.98" "$14,816.27" $0.00 "$19,394.31" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,885.00" $0.00 $0.00 $0.00 $0.00 "$6,576.23" $0.00 $0.00 $0.00 "$19,031.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,394.31" "$19,394.31" "$18,125.50" $0.00 $0.00 $0.00 $0.00 $0.00 MS653 DRG MS653 MAJOR BLADDER PROCEDURES WITH MCC INPATIENT ONLY "$422,791.72" "$312,865.87" $0.00 "$120,632.51" "$120,632.51" "$120,632.51" "$87,387.01" "$87,387.01" $0.00 "$45,216.19" $0.00 $0.00 $0.00 $0.00 "$45,216.19" "$89,154.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$58,358.97" "$58,358.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS654 DRG MS654 MAJOR BLADDER PROCEDURES WITH CC INPATIENT ONLY "$254,371.61" "$188,234.99" $0.00 "$398,005.53" $0.00 $0.00 "$31,087.15" "$31,087.15" $0.00 $0.00 $0.00 $0.00 $0.00 "$31,035.30" $0.00 "$31,708.89" $0.00 $0.00 "$33,020.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$398,005.53" "$38,871.58" "$38,871.58" "$31,448.06" "$398,005.53" $0.00 $0.00 $0.00 $0.00 MS655 DRG MS655 MAJOR BLADDER PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$248,905.14" "$184,189.80" $0.00 "$27,896.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,896.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,568.11" $0.00 $0.00 $0.00 $0.00 $0.00 MS656 DRG MS656 KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC INPATIENT ONLY "$508,652.91" "$376,403.15" $0.00 "$322,334.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$322,334.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS657 DRG MS657 KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC INPATIENT ONLY "$225,332.95" "$166,746.38" $0.00 "$25,489.18" $0.00 $0.00 "$24,986.36" "$24,986.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,489.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS658 DRG MS658 KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC INPATIENT ONLY "$296,090.66" "$219,107.09" $0.00 "$24,530.88" $0.00 $0.00 "$21,943.35" "$21,943.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,382.22" $0.00 $0.00 "$24,530.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,362.74" $0.00 $0.00 $0.00 $0.00 $0.00 MS659 DRG MS659 KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC INPATIENT ONLY "$74,221.21" "$54,923.70" $0.00 "$66,773.39" $0.00 $0.00 "$29,455.62" "$29,455.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$66,773.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,657.76" "$35,029.80" "$35,029.80" $0.00 "$9,090.65" $0.00 $0.00 $0.00 $0.00 MS660 DRG MS660 KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC INPATIENT ONLY "$15,538.14" "$11,498.22" $0.00 "$175,248.02" "$175,248.02" "$175,248.02" "$21,013.02" "$21,013.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,511.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$75,856.50" "$75,856.50" "$22,391.71" $0.00 $0.00 $0.00 $0.00 $0.00 MS661 DRG MS661 KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC INPATIENT ONLY "$84,694.84" "$62,674.18" $0.00 "$160,446.31" "$115,839.73" "$115,839.73" "$19,282.45" "$19,282.45" "$21,549.38" "$40,633.76" $0.00 $0.00 $0.00 $0.00 "$40,633.76" "$19,668.10" "$117,270.70" "$117,270.70" $0.00 "$131,679.42" "$160,446.31" $0.00 "$12,993.46" "$117,270.70" "$12,993.46" $0.00 "$44,096.27" "$44,096.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS663 DRG MS663 MINOR BLADDER PROCEDURES WITH CC INPATIENT ONLY "$199,962.84" "$147,972.50" $0.00 "$132,197.62" $0.00 $0.00 "$22,092.41" "$22,092.41" "$26,512.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,534.26" "$129,949.73" "$129,949.73" $0.00 "$108,495.52" "$132,197.62" $0.00 "$15,271.03" "$129,949.73" "$15,271.03" $0.00 "$25,586.10" "$25,586.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS664 DRG MS664 MINOR BLADDER PROCEDURES WITHOUT CC/MCC INPATIENT ONLY $0.00 $0.00 $0.00 "$88,508.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$88,508.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS667 DRG MS667 PROSTATECTOMY WITHOUT CC/MCC INPATIENT ONLY "$77,902.65" "$57,647.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS668 DRG MS668 TRANSURETHRAL PROCEDURES WITH MCC INPATIENT ONLY "$158,833.08" "$117,536.48" $0.00 "$35,915.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,029.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$35,915.88" "$35,915.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS669 DRG MS669 TRANSURETHRAL PROCEDURES WITH CC INPATIENT ONLY "$91,302.59" "$67,563.92" $0.00 "$22,280.82" $0.00 $0.00 "$21,843.94" "$21,843.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,280.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS670 DRG MS670 TRANSURETHRAL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$139,074.86" "$102,915.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS671 DRG MS671 URETHRAL PROCEDURES WITH CC/MCC INPATIENT ONLY "$232,859.23" "$172,315.83" $0.00 "$156,574.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,291.95" "$128,501.69" "$156,574.35" $0.00 "$18,320.42" $0.00 "$18,320.42" $0.00 "$28,070.35" "$28,070.35" "$25,039.95" $0.00 $0.00 $0.00 $0.00 $0.00 MS672 DRG MS672 URETHRAL PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$137,707.44" "$101,903.51" $0.00 "$177,791.94" "$177,791.94" "$177,791.94" $0.00 $0.00 "$36,697.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$166,277.84" "$166,277.84" $0.00 "$112,067.60" "$136,550.05" $0.00 "$10,357.11" "$166,277.84" "$10,357.11" $0.00 "$21,582.93" "$21,582.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS673 DRG MS673 OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC INPATIENT ONLY "$110,049.20" "$81,436.41" $0.00 "$71,089.21" "$34,498.80" "$34,498.80" "$34,989.93" "$34,989.93" "$31,260.58" "$25,130.83" $0.00 $0.00 "$26,787.28" "$34,927.98" "$25,130.83" "$35,689.73" "$71,089.21" "$71,089.21" "$36,410.02" $0.00 $0.00 $0.00 $0.00 "$71,089.21" $0.00 $0.00 "$42,337.17" "$42,337.17" "$36,410.02" $0.00 $0.00 $0.00 $0.00 $0.00 MS674 DRG MS674 OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC INPATIENT ONLY "$131,367.95" "$97,212.28" $0.00 "$27,501.12" $0.00 $0.00 "$27,501.12" "$27,501.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS675 DRG MS675 OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$139,199.75" "$103,007.82" $0.00 "$26,473.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,473.00" "$26,473.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS682 DRG MS682 RENAL FAILURE WITH MCC INPATIENT ONLY "$43,843.12" "$32,443.91" $0.00 "$45,225.20" "$45,225.20" "$45,225.20" "$21,217.30" "$21,217.30" "$13,561.75" $0.00 $0.00 $0.00 $0.00 "$21,191.00" $0.00 "$21,641.65" "$22,090.50" "$22,090.50" "$23,902.86" "$21,793.11" "$26,628.42" $0.00 "$14,815.93" "$22,090.50" "$14,815.93" "$11,998.26" "$25,215.35" "$25,215.35" "$22,764.63" "$12,616.02" $0.00 $0.00 $0.00 $0.00 MS683 DRG MS683 RENAL FAILURE WITH CC INPATIENT ONLY "$43,023.52" "$31,837.40" $0.00 "$31,160.10" "$16,589.21" "$16,589.21" "$17,121.96" "$17,121.96" $0.00 $0.00 $0.00 $0.00 "$13,393.64" "$17,106.27" $0.00 "$17,464.40" $0.00 $0.00 "$19,934.50" "$10,177.45" "$31,160.10" $0.00 "$8,994.81" $0.00 "$8,994.81" $0.00 "$20,236.40" "$20,236.40" "$18,985.24" $0.00 $0.00 $0.00 $0.00 $0.00 MS684 DRG MS684 RENAL FAILURE WITHOUT CC/MCC INPATIENT ONLY "$10,087.95" "$7,465.08" $0.00 "$18,170.14" $0.00 $0.00 "$15,248.89" "$15,248.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$15,553.87" $0.00 $0.00 $0.00 "$3,360.22" "$8,379.35" $0.00 "$6,167.96" $0.00 "$6,167.96" $0.00 "$18,170.14" "$18,170.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS686 DRG MS686 KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC INPATIENT ONLY "$27,117.25" "$20,066.77" $0.00 "$24,475.76" $0.00 $0.00 "$23,995.84" "$23,995.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,475.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS687 DRG MS687 KIDNEY AND URINARY TRACT NEOPLASMS WITH CC INPATIENT ONLY "$34,699.96" "$25,677.97" $0.00 "$21,741.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,741.34" "$21,741.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS689 DRG MS689 KIDNEY AND URINARY TRACT INFECTIONS WITH MCC INPATIENT ONLY "$52,264.96" "$38,676.07" $0.00 "$22,280.33" "$12,330.23" "$12,330.23" "$18,743.11" "$18,743.11" $0.00 $0.00 $0.00 $0.00 "$3,348.41" "$18,723.22" $0.00 "$19,117.97" $0.00 $0.00 "$21,446.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,280.33" "$22,280.33" "$20,425.54" $0.00 $0.00 $0.00 $0.00 $0.00 MS690 DRG MS690 KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC INPATIENT ONLY "$34,630.42" "$25,626.51" $0.00 "$38,475.04" "$4,086.60" "$4,086.60" "$16,533.26" "$16,533.26" $0.00 $0.00 $0.00 $0.00 "$20,090.46" "$16,519.08" $0.00 "$16,863.93" $0.00 $0.00 "$19,206.72" "$6,663.05" "$38,475.04" $0.00 "$7,927.21" $0.00 "$7,927.21" $0.00 "$17,599.41" "$17,599.41" "$18,292.11" $0.00 $0.00 $0.00 $0.00 $0.00 MS693 DRG MS693 URINARY STONES WITH MCC INPATIENT ONLY "$37,763.02" "$27,944.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS694 DRG MS694 URINARY STONES WITHOUT MCC INPATIENT ONLY "$27,812.82" "$20,581.49" $0.00 "$22,027.43" "$4,116.30" "$4,116.30" "$16,375.91" "$16,375.91" $0.00 $0.00 $0.00 $0.00 $0.00 "$16,362.14" $0.00 "$16,703.43" $0.00 $0.00 "$18,862.29" "$8,086.81" "$22,027.43" $0.00 "$7,422.00" $0.00 "$7,422.00" $0.00 "$19,191.77" "$19,191.77" "$17,964.09" $0.00 $0.00 $0.00 $0.00 $0.00 MS695 DRG MS695 KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC INPATIENT ONLY "$30,389.68" "$22,488.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS696 DRG MS696 KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC INPATIENT ONLY "$8,697.46" "$6,436.12" $0.00 "$15,828.61" $0.00 $0.00 "$15,828.61" "$15,828.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS698 DRG MS698 OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC INPATIENT ONLY "$62,273.78" "$46,082.60" $0.00 "$26,856.59" $0.00 $0.00 "$22,169.02" "$22,169.02" $0.00 $0.00 $0.00 $0.00 "$16,742.05" "$26,856.59" $0.00 "$22,612.40" $0.00 $0.00 "$24,863.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,363.55" "$26,363.55" "$23,679.70" $0.00 $0.00 $0.00 $0.00 $0.00 MS699 DRG MS699 OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC INPATIENT ONLY "$34,407.79" "$25,461.76" $0.00 "$21,922.34" "$8,173.20" "$8,173.20" "$18,141.30" "$18,141.30" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,122.96" $0.00 "$18,504.13" $0.00 $0.00 "$20,859.81" "$10,876.54" "$19,704.17" $0.00 "$10,352.10" $0.00 "$10,352.10" "$3,969.84" "$21,922.34" "$21,922.34" "$19,866.49" "$4,225.02" $0.00 $0.00 $0.00 $0.00 MS700 DRG MS700 OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC INPATIENT ONLY "$33,843.09" "$25,043.89" $0.00 "$35,130.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,871.19" "$7,542.32" "$35,130.91" $0.00 "$7,435.02" $0.00 "$7,435.02" $0.00 "$19,202.40" "$19,202.40" "$17,972.56" $0.00 $0.00 $0.00 $0.00 $0.00 MS707 DRG MS707 MAJOR MALE PELVIC PROCEDURES WITH CC/MCC INPATIENT ONLY "$245,462.36" "$181,642.15" $0.00 "$26,581.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.04 $0.00 $0.00 $0.00 $0.00 "$26,581.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,315.26" $0.00 $0.00 $0.00 $0.00 $0.00 MS708 DRG MS708 MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$191,309.76" "$141,569.22" $0.00 "$25,003.02" $0.00 $0.00 "$21,344.99" "$21,344.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,771.89" $0.00 $0.00 "$23,725.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,003.02" "$25,003.02" "$22,595.42" $0.00 $0.00 $0.00 $0.00 $0.00 MS709 DRG MS709 PENIS PROCEDURES WITH CC/MCC INPATIENT ONLY "$184,084.60" "$136,222.60" $0.00 "$32,790.56" $0.00 $0.00 "$27,036.64" "$27,036.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,577.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$32,790.56" "$32,790.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS710 DRG MS710 PENIS PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$64,254.48" "$47,548.32" $0.00 "$120,205.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,549.05" $0.00 $0.00 $0.00 $0.00 $0.00 "$120,205.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS711 DRG MS711 TESTES PROCEDURES WITH CC/MCC INPATIENT ONLY "$99,610.22" "$73,711.56" $0.00 "$85,899.31" $0.00 $0.00 $0.00 $0.00 $0.00 "$17,621.76" $0.00 $0.00 $0.00 $0.00 "$17,621.76" $0.00 $0.00 $0.00 $0.00 "$4,158.09" "$85,899.31" $0.00 "$21,484.09" $0.00 "$21,484.09" $0.00 "$30,647.69" "$30,647.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS713 DRG MS713 TRANSURETHRAL PROSTATECTOMY WITH CC/MCC INPATIENT ONLY "$82,750.61" "$61,235.45" $0.00 "$25,084.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$12,211.96" "$25,084.68" "$25,084.68" $0.00 "$12,822.56" $0.00 $0.00 $0.00 $0.00 MS714 DRG MS714 TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC INPATIENT ONLY "$112,034.77" "$82,905.73" $0.00 "$20,620.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,620.89" "$20,620.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS715 DRG MS715 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC INPATIENT ONLY "$40,796.73" "$30,189.58" $0.00 "$148,588.40" $0.00 $0.00 "$25,005.54" "$25,005.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$121,947.55" "$148,588.40" $0.00 "$21,416.93" $0.00 "$21,416.93" $0.00 "$30,592.97" "$30,592.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS717 DRG MS717 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC INPATIENT ONLY "$2,327,046.38" "$1,722,014.32" $0.00 "$326,740.55" "$178,318.50" "$178,318.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,674.83" $0.00 $0.00 "$326,740.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,674.83" $0.00 $0.00 $0.00 $0.00 $0.00 MS718 DRG MS718 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC INPATIENT ONLY "$158,309.83" "$117,149.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS722 DRG MS722 "MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC" INPATIENT ONLY "$13,710.93" "$10,146.09" $0.00 "$26,136.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,136.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,892.20" $0.00 $0.00 $0.00 $0.00 $0.00 MS723 DRG MS723 "MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC" INPATIENT ONLY "$21,568.66" "$15,960.81" $0.00 "$22,188.86" $0.00 $0.00 "$18,589.21" "$18,589.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,960.99" $0.00 $0.00 "$21,370.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,188.86" "$22,188.86" "$20,352.65" $0.00 $0.00 $0.00 $0.00 $0.00 MS725 DRG MS725 BENIGN PROSTATIC HYPERTROPHY WITH MCC INPATIENT ONLY "$120,705.19" "$89,321.84" $0.00 "$23,861.50" $0.00 $0.00 "$19,925.34" "$19,925.34" $0.00 $0.00 $0.00 $0.00 $0.00 "$19,902.39" $0.00 $0.00 $0.00 $0.00 "$22,381.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,861.50" "$23,861.50" "$21,315.89" $0.00 $0.00 $0.00 $0.00 $0.00 MS727 DRG MS727 INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC INPATIENT ONLY "$19,627.88" "$14,524.63" $0.00 "$23,556.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,556.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,434.67" $0.00 $0.00 $0.00 $0.00 $0.00 MS728 DRG MS728 INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC INPATIENT ONLY "$17,324.91" "$12,820.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS729 DRG MS729 OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC INPATIENT ONLY "$53,996.15" "$39,957.15" $0.00 "$21,997.01" $0.00 $0.00 "$21,565.70" "$21,565.70" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,538.45" $0.00 "$21,997.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS730 DRG MS730 OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC INPATIENT ONLY "$55,239.20" "$40,877.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS736 DRG MS736 UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC INPATIENT ONLY "$342,516.71" "$253,462.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS737 DRG MS737 UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC INPATIENT ONLY "$149,825.85" "$110,871.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS738 DRG MS738 UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC INPATIENT ONLY "$190,239.02" "$140,776.87" $0.00 "$23,225.63" $0.00 $0.00 "$21,239.38" "$21,239.38" $0.00 $0.00 $0.00 $0.00 $0.00 "$21,213.03" $0.00 $0.00 $0.00 $0.00 "$23,225.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,119.65" $0.00 $0.00 $0.00 $0.00 $0.00 MS739 DRG MS739 UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC INPATIENT ONLY "$345,645.71" "$255,777.83" $0.00 "$76,002.23" $0.00 $0.00 "$37,444.79" "$37,444.79" $0.00 $0.00 $0.00 $0.00 $0.00 "$37,376.50" $0.00 $0.00 $0.00 $0.00 "$39,391.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$76,002.23" "$76,002.23" "$37,515.77" $0.00 $0.00 $0.00 $0.00 $0.00 MS740 DRG MS740 UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC INPATIENT ONLY "$289,589.03" "$214,295.88" $0.00 "$27,721.64" $0.00 $0.00 "$23,487.20" "$23,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$23,455.02" $0.00 "$23,956.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,721.64" "$27,721.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS741 DRG MS741 UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC INPATIENT ONLY "$220,233.64" "$162,972.89" $0.00 "$156,113.16" "$141,373.62" "$141,373.62" $0.00 $0.00 "$29,872.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$143,113.04" "$143,113.04" $0.00 "$128,123.16" "$156,113.16" $0.00 "$13,327.31" "$143,113.04" "$13,327.31" $0.00 "$24,002.64" "$24,002.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS742 DRG MS742 UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC INPATIENT ONLY "$178,499.01" "$132,089.27" $0.00 "$144,571.35" "$4,086.60" "$4,086.60" "$22,910.93" "$22,910.93" $0.00 "$14,751.72" $0.00 $0.00 $0.00 "$22,880.25" "$21,251.43" "$23,369.15" $0.00 $0.00 "$25,364.14" "$118,650.74" "$144,571.35" "$135,777.03" "$16,936.07" $0.00 "$16,936.07" $0.00 "$26,942.56" "$26,942.56" "$24,156.36" $0.00 $0.00 $0.00 $0.00 $0.00 MS743 DRG MS743 UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC INPATIENT ONLY "$215,798.10" "$159,690.59" $0.00 "$113,095.63" "$113,095.63" "$113,095.63" "$27,072.03" "$27,072.03" $0.00 "$22,501.93" $0.00 $0.00 $0.00 "$27,069.04" "$22,968.22" "$27,614.54" $0.00 $0.00 $0.00 "$16,934.63" "$94,504.91" $0.00 "$11,512.92" $0.00 "$11,512.92" "$8,031.14" "$22,524.51" "$22,524.51" $0.00 "$8,432.69" $0.00 $0.00 $0.00 $0.00 MS744 DRG MS744 "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC" INPATIENT ONLY "$235,639.36" "$174,373.13" $0.00 "$10,045.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$10,045.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS745 DRG MS745 "D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC" INPATIENT ONLY "$91,531.43" "$67,733.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS746 DRG MS746 "VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC" INPATIENT ONLY $0.00 $0.00 $0.00 "$75,281.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,948.45" $0.00 $0.00 "$75,281.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,760.43" $0.00 $0.00 $0.00 $0.00 $0.00 MS748 DRG MS748 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES INPATIENT ONLY "$154,956.04" "$114,667.47" $0.00 "$101,307.70" $0.00 $0.00 $0.00 $0.00 "$14,571.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$99,574.54" "$99,574.54" $0.00 "$83,143.95" "$101,307.70" $0.00 "$13,249.13" "$99,574.54" "$13,249.13" $0.00 "$23,938.94" "$23,938.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS749 DRG MS749 OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC INPATIENT ONLY "$113,765.76" "$84,186.66" $0.00 "$104,733.83" "$104,733.83" "$104,733.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,516.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$30,015.58" $0.00 $0.00 $0.00 $0.00 $0.00 MS754 DRG MS754 "MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC" INPATIENT ONLY "$172,896.37" "$127,943.31" $0.00 "$27,533.80" $0.00 $0.00 "$23,656.98" "$23,656.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$11,631.52" "$27,533.80" "$27,533.80" $0.00 "$12,213.09" $0.00 $0.00 $0.00 $0.00 MS755 DRG MS755 "MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC" INPATIENT ONLY "$31,589.96" "$23,376.57" $0.00 "$20,798.98" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,164.57" $0.00 $0.00 $0.00 "$18,827.17" "$10,971.74" $0.00 $0.00 $0.00 "$20,798.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,808.55" $0.00 $0.00 $0.00 $0.00 $0.00 MS756 DRG MS756 "MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" INPATIENT ONLY "$13,121.56" "$9,709.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS757 DRG MS757 "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" INPATIENT ONLY "$32,053.15" "$23,719.33" $0.00 "$29,643.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,508.57" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,643.01" "$29,643.01" "$22,389.11" $0.00 $0.00 $0.00 $0.00 $0.00 MS758 DRG MS758 "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" INPATIENT ONLY "$32,039.33" "$23,709.10" $0.00 "$20,399.89" "$12,259.80" "$12,259.80" $0.00 $0.00 "$9,388.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$14,545.50" "$14,545.50" "$20,399.89" $0.00 $0.00 $0.00 $0.00 "$14,545.50" $0.00 $0.00 $0.00 $0.00 "$19,428.47" $0.00 $0.00 $0.00 $0.00 $0.00 MS759 DRG MS759 "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" INPATIENT ONLY "$31,529.67" "$23,331.96" $0.00 "$5,834.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,556.33" $0.00 $0.00 $0.00 "$5,834.14" $0.00 $0.00 $0.00 $0.00 MS760 DRG MS760 MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC INPATIENT ONLY "$22,036.45" "$16,306.97" $0.00 "$12,958.36" "$12,958.36" "$12,958.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS761 DRG MS761 MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$26,444.46" "$19,568.90" $0.00 "$12,489.77" "$12,489.77" "$12,489.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS768 DRG MS768 VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C INPATIENT ONLY "$40,711.25" "$30,126.33" $0.00 "$21,373.04" "$19,822.68" "$19,822.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,061.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$14,855.59" "$20,902.18" $0.00 "$10,099.48" $0.00 "$10,099.48" "$5,802.63" "$21,373.04" "$21,373.04" $0.00 "$6,092.76" $0.00 $0.00 $0.00 $0.00 MS769 DRG MS769 POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES INPATIENT ONLY "$269,978.86" "$199,784.36" $0.00 "$175,470.46" "$172,148.03" "$172,148.03" $0.00 $0.00 "$43,372.20" "$12,300.04" $0.00 $0.00 $0.00 $0.00 "$12,300.04" $0.00 "$175,470.46" "$175,470.46" $0.00 $0.00 $0.00 $0.00 $0.00 "$175,470.46" $0.00 "$11,772.78" $0.00 $0.00 $0.00 "$12,361.42" $0.00 $0.00 $0.00 $0.00 MS770 DRG MS770 "ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY" INPATIENT ONLY "$31,584.85" "$23,372.79" $0.00 "$6,160.27" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,129.68" $0.00 $0.00 $0.00 $0.00 "$6,129.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,866.92" $0.00 $0.00 $0.00 "$6,160.27" $0.00 $0.00 $0.00 $0.00 MS776 DRG MS776 POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES INPATIENT ONLY "$15,568.58" "$11,520.75" $0.00 "$18,942.70" "$8,173.20" "$8,173.20" $0.00 $0.00 $0.00 "$2,725.88" $0.00 $0.00 "$3,348.41" $0.00 "$6,136.30" $0.00 $0.00 $0.00 $0.00 "$3,376.61" "$3,044.04" "$13,481.20" "$3,843.48" $0.00 "$3,843.48" "$5,873.26" "$18,942.70" "$18,942.70" $0.00 "$6,166.92" $0.00 $0.00 $0.00 $0.00 MS779 DRG MS779 ABORTION WITHOUT D&C INPATIENT ONLY "$16,003.04" "$11,842.25" $0.00 "$23,300.47" "$4,106.40" "$4,106.40" $0.00 $0.00 $0.00 "$5,080.47" $0.00 $0.00 $0.00 $0.00 "$5,080.47" $0.00 $0.00 $0.00 $0.00 "$16,835.84" "$23,300.47" $0.00 "$11,445.75" $0.00 "$11,445.75" "$1,430.21" "$22,469.79" "$22,469.79" $0.00 "$1,522.14" $0.00 $0.00 $0.00 $0.00 MS783 DRG MS783 CESAREAN SECTION WITH STERILIZATION WITH MCC INPATIENT ONLY "$71,796.43" "$53,129.36" $0.00 "$13,830.75" "$13,830.75" "$13,830.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,087.89" $0.00 $0.00 $0.00 "$9,542.28" $0.00 $0.00 $0.00 $0.00 MS784 DRG MS784 CESAREAN SECTION WITH STERILIZATION WITH CC INPATIENT ONLY "$69,676.31" "$51,560.47" $0.00 "$37,137.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,288.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,705.74" "$37,137.03" "$12,460.97" "$10,477.40" $0.00 "$10,477.40" "$9,087.89" "$21,680.91" "$21,680.91" $0.00 "$9,542.28" $0.00 $0.00 $0.00 $0.00 MS785 DRG MS785 CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC INPATIENT ONLY "$66,138.83" "$48,942.73" $0.00 "$52,378.97" "$14,254.51" "$14,254.51" $0.00 $0.00 "$52,378.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$13,752.00" "$13,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$13,752.00" $0.00 "$9,087.89" $0.00 $0.00 $0.00 "$9,542.28" $0.00 $0.00 $0.00 $0.00 MS786 DRG MS786 CESAREAN SECTION WITHOUT STERILIZATION WITH MCC INPATIENT ONLY "$64,226.23" "$47,527.41" $0.00 "$51,796.52" "$13,929.31" "$13,929.31" "$22,095.35" "$22,095.35" "$7,050.47" $0.00 $0.00 $0.00 "$13,985.42" "$22,067.08" $0.00 $0.00 "$23,916.00" "$23,916.00" $0.00 "$24,076.48" "$51,796.52" "$27,565.16" "$17,186.67" "$23,916.00" "$17,186.67" "$9,087.89" "$27,146.72" "$27,146.72" $0.00 "$9,542.28" $0.00 $0.00 $0.00 $0.00 MS787 DRG MS787 CESAREAN SECTION WITHOUT STERILIZATION WITH CC INPATIENT ONLY "$60,021.02" "$44,415.55" $0.00 "$38,858.99" "$13,908.48" "$13,908.48" "$18,399.43" "$18,399.43" "$9,500.59" $0.00 $0.00 $0.00 "$7,288.60" $0.00 $0.00 $0.00 "$15,966.00" "$15,966.00" "$20,947.28" "$7,707.95" "$38,858.99" $0.00 "$10,480.42" "$15,966.00" "$10,480.42" "$9,087.89" "$21,683.37" "$21,683.37" "$19,949.79" "$9,542.28" $0.00 $0.00 $0.00 $0.00 MS788 DRG MS788 CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC INPATIENT ONLY "$53,940.94" "$39,916.30" $0.00 "$37,750.88" "$13,582.80" "$13,582.80" $0.00 $0.00 "$7,920.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$13,311.00" "$13,311.00" $0.00 "$13,361.92" "$37,750.88" $0.00 "$9,084.02" "$13,311.00" "$9,084.02" "$7,405.42" "$20,545.77" "$20,545.77" $0.00 "$7,775.68" $0.00 $0.00 $0.00 $0.00 MS789 DRG MS789 "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" INPATIENT ONLY "$12,236.12" "$9,054.73" $0.00 "$20,596.05" "$4,334.40" "$4,334.40" $0.00 $0.00 $0.00 "$18,997.58" $0.00 $0.00 "$14,581.12" $0.00 "$18,997.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,596.05" $0.00 $0.00 $0.00 $219.20 $0.00 $0.00 $0.00 $0.00 MS790 DRG MS790 "EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE" INPATIENT ONLY "$47,484.99" "$35,138.89" $0.00 "$345,528.12" "$227,852.34" "$227,852.34" $0.00 $0.00 $0.00 "$6,824.32" $0.00 $0.00 $0.00 $0.00 "$6,824.32" $0.00 $0.00 $0.00 $0.00 "$283,577.38" "$345,528.12" $0.00 "$76,626.93" $0.00 "$76,626.93" "$24,017.10" "$58,657.03" "$58,657.03" $0.00 "$25,214.25" $0.00 $0.00 $0.00 $0.00 MS791 DRG MS791 PREMATURITY WITH MAJOR PROBLEMS INPATIENT ONLY "$106,775.51" "$79,013.88" $0.00 "$131,833.16" "$86,741.10" "$86,741.10" $0.00 $0.00 $0.00 "$3,625.61" $0.00 $0.00 $0.00 $0.00 "$3,625.61" $0.00 $0.00 $0.00 $0.00 "$16,878.92" "$15,649.71" "$131,833.16" "$19,759.75" $0.00 "$19,759.75" "$21,244.37" "$44,228.51" "$44,228.51" $0.00 "$22,302.88" $0.00 $0.00 $0.00 $0.00 MS792 DRG MS792 PREMATURITY WITHOUT MAJOR PROBLEMS INPATIENT ONLY "$9,474.02" "$7,010.77" $0.00 "$31,899.59" "$5,534.55" "$5,534.55" $0.00 $0.00 $0.00 "$2,752.37" $0.00 $0.00 $0.00 $0.00 "$2,752.37" $0.00 $0.00 $0.00 $0.00 "$5,340.18" "$4,229.42" $0.00 "$5,340.18" $0.00 "$5,340.18" "$3,473.37" "$31,899.59" "$31,899.59" $0.00 "$3,643.33" $0.00 $0.00 $0.00 $0.00 MS793 DRG MS793 FULL TERM NEONATE WITH MAJOR PROBLEMS INPATIENT ONLY "$31,960.27" "$23,650.60" $0.00 "$73,489.93" "$32,199.00" "$32,199.00" $0.00 $0.00 "$16,677.00" $0.00 $0.00 $0.00 "$48,678.47" $0.00 $0.00 $0.00 "$73,489.93" "$73,489.93" $0.00 "$4,386.25" "$3,473.91" "$19,810.22" "$4,386.25" "$73,489.93" "$4,386.25" "$21,244.37" "$45,073.74" "$45,073.74" $0.00 "$22,302.88" $0.00 $0.00 $0.00 $0.00 MS794 DRG MS794 NEONATE WITH OTHER SIGNIFICANT PROBLEMS INPATIENT ONLY "$6,506.03" "$4,814.46" $0.00 "$24,446.07" "$3,699.60" "$3,699.60" $0.00 $0.00 "$4,761.00" $0.00 $0.00 $0.00 "$2,023.02" $0.00 $0.00 $0.00 "$21,126.00" "$21,126.00" $0.00 "$5,394.25" "$4,272.25" $0.00 "$5,394.25" "$21,126.00" "$5,394.25" "$2,637.56" "$24,446.07" "$24,446.07" $0.00 "$2,765.74" $0.00 $0.00 $0.00 $0.00 MS795 DRG MS795 NORMAL NEWBORN INPATIENT ONLY "$4,674.03" "$3,458.78" $0.00 "$14,674.90" "$3,689.70" "$3,689.70" $0.00 $0.00 "$1,012.00" "$1,296.58" $0.00 $0.00 "$2,023.02" $0.00 "$2,139.31" $0.00 "$2,860.50" "$2,860.50" $0.00 "$1,781.77" "$3,743.93" "$2,259.28" "$1,877.55" "$2,860.50" "$1,877.55" "$2,050.78" "$14,674.90" "$14,674.90" $0.00 "$2,149.62" $0.00 $0.00 $0.00 $0.00 MS796 DRG MS796 VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC INPATIENT ONLY "$54,907.25" "$40,631.37" $0.00 "$8,366.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,061.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,967.75" $0.00 $0.00 $0.00 "$8,366.13" $0.00 $0.00 $0.00 $0.00 MS797 DRG MS797 VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC INPATIENT ONLY "$45,318.16" "$33,535.44" $0.00 "$8,366.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,967.75" $0.00 $0.00 $0.00 "$8,366.13" $0.00 $0.00 $0.00 $0.00 MS798 DRG MS798 VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC INPATIENT ONLY "$52,110.07" "$38,561.45" $0.00 "$8,366.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,061.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,967.75" $0.00 $0.00 $0.00 "$8,366.13" $0.00 $0.00 $0.00 $0.00 MS799 DRG MS799 SPLENECTOMY WITH MCC INPATIENT ONLY "$327,183.49" "$242,115.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS801 DRG MS801 SPLENECTOMY WITHOUT CC/MCC INPATIENT ONLY "$172,895.48" "$127,942.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS802 DRG MS802 OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC INPATIENT ONLY "$596,528.35" "$441,430.98" $0.00 "$96,469.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$96,469.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS803 DRG MS803 OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC INPATIENT ONLY "$251,863.58" "$186,379.05" $0.00 "$27,694.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,694.69" "$27,694.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS805 DRG MS805 VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC INPATIENT ONLY "$30,983.57" "$22,927.84" $0.00 "$29,462.16" "$11,805.47" "$11,805.47" $0.00 $0.00 "$29,462.16" $0.00 $0.00 $0.00 "$7,076.75" $0.00 $0.00 $0.00 "$15,448.50" "$15,448.50" $0.00 "$7,672.56" "$14,281.34" $0.00 "$10,432.30" "$15,448.50" "$10,432.30" "$6,630.28" "$25,233.70" "$25,233.70" $0.00 "$6,961.79" $0.00 $0.00 $0.00 $0.00 MS806 DRG MS806 VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC INPATIENT ONLY "$25,294.22" "$18,717.72" $0.00 "$21,350.23" "$8,052.96" "$8,052.96" $0.00 $0.00 "$6,550.61" $0.00 $0.00 $0.00 "$5,061.36" $0.00 $0.00 $0.00 "$11,019.00" "$11,019.00" "$18,649.09" "$7,746.04" "$13,604.81" "$21,350.23" "$7,109.24" "$11,019.00" "$7,109.24" "$5,802.63" "$18,936.98" "$18,936.98" "$17,761.04" "$6,092.76" $0.00 $0.00 $0.00 $0.00 MS807 DRG MS807 VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC INPATIENT ONLY "$22,303.67" "$16,504.72" $0.00 "$18,264.05" "$8,254.49" "$8,254.49" $0.00 $0.00 "$5,733.00" $0.00 $0.00 $0.00 "$5,061.36" $0.00 $0.00 $0.00 "$9,634.50" "$9,634.50" $0.00 "$8,401.97" "$11,615.99" "$17,521.13" "$6,283.23" "$9,634.50" "$6,283.23" "$5,802.63" "$18,264.05" "$18,264.05" $0.00 "$6,092.76" $0.00 $0.00 $0.00 $0.00 MS808 DRG MS808 MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC INPATIENT ONLY "$34,593.18" "$25,598.95" $0.00 "$30,536.62" $0.00 $0.00 "$26,138.77" "$26,138.77" $0.00 $0.00 $0.00 $0.00 $0.00 "$26,099.74" $0.00 "$26,661.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$30,536.62" "$30,536.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS809 DRG MS809 MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC INPATIENT ONLY "$75,870.07" "$56,143.85" $0.00 "$22,111.75" $0.00 $0.00 "$19,496.75" "$19,496.75" $0.00 "$12,843.09" $0.00 $0.00 $0.00 "$19,474.91" "$12,843.09" "$19,886.69" $0.00 $0.00 "$22,111.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,058.81" $0.00 $0.00 $0.00 $0.00 $0.00 MS810 DRG MS810 MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$26,038.35" "$19,268.38" $0.00 "$20,194.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,194.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,233.22" $0.00 $0.00 $0.00 $0.00 $0.00 MS811 DRG MS811 RED BLOOD CELL DISORDERS WITH MCC INPATIENT ONLY "$37,057.02" "$27,422.19" $0.00 "$78,735.41" "$23,615.76" "$23,615.76" "$20,572.70" "$20,572.70" "$11,450.82" "$3,403.76" $0.00 $0.00 "$10,045.23" "$20,548.08" "$14,177.07" "$20,984.15" "$20,689.50" "$20,689.50" "$22,961.85" "$19,762.72" "$78,735.41" $0.00 "$13,435.57" "$20,689.50" "$13,435.57" "$30,963.95" "$24,090.82" "$24,090.82" "$21,868.43" "$30,963.95" $0.00 $0.00 $0.00 $0.00 MS812 DRG MS812 RED BLOOD CELL DISORDERS WITHOUT MCC INPATIENT ONLY "$30,116.25" "$22,286.03" $0.00 "$24,519.60" "$24,519.60" "$24,519.60" "$17,128.85" "$17,128.85" "$7,285.18" "$8,031.31" $0.00 $0.00 "$13,393.64" "$17,113.13" "$8,031.31" "$17,471.43" "$13,204.50" "$13,204.50" "$19,752.74" "$3,776.02" "$13,151.79" $0.00 "$8,728.17" "$13,204.50" "$8,728.17" "$7,687.04" "$20,255.87" "$20,255.87" "$18,812.13" "$8,071.38" $0.00 $0.00 $0.00 $0.00 MS813 DRG MS813 COAGULATION DISORDERS INPATIENT ONLY "$130,887.07" "$96,856.43" $0.00 "$87,448.69" $0.00 $0.00 "$21,716.98" "$21,716.98" $0.00 "$11,549.79" $0.00 $0.00 $0.00 "$21,689.39" "$11,549.79" "$22,151.32" $0.00 $0.00 $0.00 "$23,373.77" "$87,448.69" $0.00 "$15,890.52" $0.00 "$15,890.52" $0.00 "$52,183.21" "$52,183.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS814 DRG MS814 RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC INPATIENT ONLY "$30,605.13" "$22,647.80" $0.00 "$27,429.29" $0.00 $0.00 "$24,109.04" "$24,109.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,591.22" $0.00 $0.00 "$25,755.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,429.29" "$27,429.29" "$24,529.05" $0.00 $0.00 $0.00 $0.00 $0.00 MS815 DRG MS815 RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC INPATIENT ONLY "$62,708.27" "$46,404.12" $0.00 "$21,416.31" $0.00 $0.00 $0.00 $0.00 $0.00 "$11,825.34" $0.00 $0.00 "$16,742.05" $0.00 "$18,141.81" $0.00 $0.00 $0.00 "$20,723.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,416.31" "$21,416.31" "$19,736.96" $0.00 $0.00 $0.00 $0.00 $0.00 MS816 DRG MS816 RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC INPATIENT ONLY "$36,966.21" "$27,355.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS817 DRG MS817 OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC INPATIENT ONLY "$331,165.41" "$245,062.40" $0.00 "$196,880.15" "$12,259.80" "$12,259.80" $0.00 $0.00 "$196,880.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$196,880.15" "$196,880.15" $0.00 "$32,736.50" "$78,339.09" $0.00 "$25,223.16" "$196,880.15" "$25,223.16" "$11,253.79" "$33,693.78" "$33,693.78" $0.00 "$7,558.26" $0.00 $0.00 $0.00 $0.00 MS818 DRG MS818 OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC INPATIENT ONLY "$97,432.35" "$72,099.94" $0.00 "$86,024.42" $0.00 $0.00 $0.00 $0.00 "$86,024.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,397.00" "$20,397.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$20,397.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS819 DRG MS819 OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$70,909.67" "$52,473.16" $0.00 "$7,495.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,138.29" $0.00 $0.00 $0.00 "$7,495.20" $0.00 $0.00 $0.00 $0.00 MS821 DRG MS821 LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC INPATIENT ONLY "$162,576.13" "$120,306.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS823 DRG MS823 LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC INPATIENT ONLY "$630,888.82" "$466,857.73" $0.00 "$65,586.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$65,586.69" "$65,586.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS824 DRG MS824 LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC INPATIENT ONLY "$51,601.70" "$38,185.26" $0.00 "$28,418.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,418.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS826 DRG MS826 MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC INPATIENT ONLY "$379,947.04" "$281,160.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS827 DRG MS827 MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC INPATIENT ONLY "$423,291.52" "$313,235.72" $0.00 "$32,906.05" $0.00 $0.00 "$32,906.05" "$32,906.05" $0.00 $0.00 $0.00 $0.00 $0.00 "$32,906.05" $0.00 $0.00 $0.00 $0.00 "$32,906.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$32,906.05" $0.00 $0.00 $0.00 $0.00 $0.00 MS828 DRG MS828 MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$247,026.79" "$182,799.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS829 DRG MS829 MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC INPATIENT ONLY "$279,328.65" "$206,703.20" $0.00 "$38,787.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$38,787.20" "$38,787.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS830 DRG MS830 MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$211,300.46" "$156,362.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS831 DRG MS831 OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC INPATIENT ONLY "$29,160.39" "$21,578.69" $0.00 "$21,952.85" "$20,552.75" "$20,552.75" $0.00 $0.00 "$10,012.94" $0.00 $0.00 $0.00 "$14,394.30" $0.00 $0.00 $0.00 "$16,827.00" "$16,827.00" $0.00 "$9,939.05" "$19,151.15" $0.00 "$10,811.22" "$16,827.00" "$10,811.22" "$7,138.29" "$21,952.85" "$21,952.85" $0.00 "$7,495.20" $0.00 $0.00 $0.00 $0.00 MS832 DRG MS832 OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC INPATIENT ONLY "$20,347.40" "$15,057.08" $0.00 "$18,988.42" "$12,259.80" "$12,259.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,696.82" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,692.12" "$2,930.57" "$10,159.89" $0.00 "$7,172.39" $0.00 "$7,172.39" "$7,138.29" "$18,988.42" "$18,988.42" "$17,802.02" "$7,495.20" $0.00 $0.00 $0.00 $0.00 MS833 DRG MS833 OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$14,743.82" "$10,910.43" $0.00 "$10,045.23" "$8,272.70" "$8,272.70" $0.00 $0.00 "$2,152.00" $0.00 $0.00 $0.00 "$10,045.23" $0.00 $0.00 $0.00 "$4,723.00" "$4,723.00" $0.00 "$7,048.80" "$7,048.80" "$6,068.80" "$7,048.80" "$4,723.00" "$7,048.80" "$5,802.63" "$7,048.80" "$7,048.80" $0.00 "$6,092.76" $0.00 $0.00 $0.00 $0.00 MS834 DRG MS834 ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC INPATIENT ONLY "$507,748.30" "$375,733.74" $0.00 "$56,196.91" $0.00 $0.00 "$55,070.71" "$55,070.71" $0.00 $0.00 $0.00 $0.00 $0.00 "$55,066.67" $0.00 "$56,196.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS835 DRG MS835 ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC INPATIENT ONLY "$40,262.10" "$29,793.95" $0.00 "$10,045.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$10,045.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS836 DRG MS836 ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$18,640.57" "$13,794.02" $0.00 "$23,905.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,905.45" "$23,905.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS837 DRG MS837 CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC INPATIENT ONLY "$51,339.82" "$37,991.47" $0.00 "$62,068.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$62,068.97" "$62,068.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS838 DRG MS838 CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT INPATIENT ONLY "$48,284.50" "$35,730.53" $0.00 "$31,012.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$31,012.72" "$31,012.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS839 DRG MS839 CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC INPATIENT ONLY "$46,940.94" "$34,736.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS840 DRG MS840 LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC INPATIENT ONLY "$189,074.54" "$139,915.16" $0.00 "$34,299.15" $0.00 $0.00 "$33,279.73" "$33,279.73" $0.00 $0.00 $0.00 $0.00 $0.00 "$33,222.22" $0.00 "$22,689.83" $0.00 $0.00 "$34,299.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,807.13" "$28,807.13" "$34,299.15" $0.00 $0.00 $0.00 $0.00 $0.00 MS841 DRG MS841 LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC INPATIENT ONLY "$15,184.92" "$11,236.84" $0.00 "$22,689.83" $0.00 $0.00 "$22,244.93" "$22,244.93" $0.00 "$13,446.69" $0.00 $0.00 $0.00 $0.00 "$13,446.69" "$22,689.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,565.68" "$19,565.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS842 DRG MS842 LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC INPATIENT ONLY "$38,523.96" "$28,507.73" $0.00 "$21,645.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,645.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,614.66" $0.00 $0.00 $0.00 $0.00 $0.00 MS843 DRG MS843 OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC INPATIENT ONLY "$90,251.16" "$66,785.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS844 DRG MS844 OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC INPATIENT ONLY "$25,954.84" "$19,206.58" $0.00 "$22,057.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,057.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$21,007.37" $0.00 $0.00 $0.00 $0.00 $0.00 MS846 DRG MS846 CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC INPATIENT ONLY "$30,411.91" "$22,504.81" $0.00 "$30,090.51" $0.00 $0.00 "$29,500.50" "$29,500.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$30,090.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS847 DRG MS847 CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC INPATIENT ONLY "$31,407.44" "$23,241.51" $0.00 "$45,264.16" "$8,173.20" "$8,173.20" $0.00 $0.00 "$5,107.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,107.14" "$5,107.14" $0.00 "$19,402.95" "$45,264.16" "$34,827.46" "$13,190.98" "$5,107.14" "$13,190.98" $0.00 "$23,891.56" "$23,891.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS848 DRG MS848 CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC INPATIENT ONLY "$30,134.29" "$22,299.37" $0.00 "$22,966.96" "$12,259.80" "$12,259.80" $0.00 $0.00 "$7,545.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$15,484.50" "$15,484.50" $0.00 "$12,768.30" "$22,966.96" $0.00 "$9,837.86" "$15,484.50" "$9,837.86" $0.00 "$21,159.88" "$21,159.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS853 DRG MS853 INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC INPATIENT ONLY "$349,119.20" "$258,348.21" $0.00 "$565,069.81" "$17,269.35" "$17,269.35" "$45,338.71" "$45,338.71" $0.00 "$50,464.10" $0.00 $0.00 $0.00 "$45,250.00" "$52,987.33" "$46,245.48" $0.00 $0.00 "$48,645.14" "$463,756.79" "$565,069.81" "$228,902.42" "$140,496.05" $0.00 "$140,496.05" $0.00 "$54,782.85" "$54,782.85" "$46,328.70" $0.00 $0.00 $0.00 $0.00 $0.00 MS854 DRG MS854 INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC INPATIENT ONLY "$172,549.34" "$127,686.51" $0.00 "$28,571.70" $0.00 $0.00 "$25,699.83" "$25,699.83" $0.00 $0.00 $0.00 $0.00 $0.00 "$25,661.94" $0.00 "$26,213.83" $0.00 $0.00 "$28,571.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,211.14" $0.00 $0.00 $0.00 $0.00 $0.00 MS856 DRG MS856 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC INPATIENT ONLY "$469,903.79" "$347,728.80" $0.00 "$49,287.63" "$21,079.29" "$21,079.29" "$43,241.35" "$43,241.35" $0.00 "$37,955.94" $0.00 $0.00 $0.00 $0.00 "$37,955.94" "$44,106.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$49,287.63" "$49,287.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS857 DRG MS857 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC INPATIENT ONLY "$110,455.26" "$81,736.89" $0.00 "$409,840.86" "$90,864.72" "$90,864.72" "$25,563.20" "$25,563.20" $0.00 $0.00 $0.00 $0.00 "$30,135.69" "$26,369.16" $0.00 "$26,074.46" $0.00 $0.00 "$27,697.65" "$336,359.28" "$409,840.86" $0.00 "$88,518.80" $0.00 "$88,518.80" $0.00 "$53,140.71" "$53,140.71" "$26,378.71" $0.00 $0.00 $0.00 $0.00 $0.00 MS858 DRG MS858 POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC INPATIENT ONLY "$300,169.86" "$222,125.70" $0.00 "$206,438.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,090.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$206,438.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS862 DRG MS862 POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC INPATIENT ONLY "$41,178.47" "$30,472.07" $0.00 "$28,258.17" $0.00 $0.00 "$24,143.55" "$24,143.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$28,258.17" "$28,258.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS863 DRG MS863 POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC INPATIENT ONLY "$26,750.77" "$19,795.57" $0.00 "$20,554.34" $0.00 $0.00 "$18,033.63" "$18,033.63" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,015.57" $0.00 "$18,394.30" $0.00 $0.00 "$20,554.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,575.56" $0.00 $0.00 $0.00 $0.00 $0.00 MS864 DRG MS864 FEVER AND INFLAMMATORY CONDITIONS INPATIENT ONLY "$19,333.68" "$14,306.92" $0.00 "$47,628.02" $0.00 $0.00 "$17,102.64" "$17,102.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,444.69" $0.00 $0.00 "$47,628.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,690.76" $0.00 $0.00 $0.00 $0.00 $0.00 MS865 DRG MS865 VIRAL ILLNESS WITH MCC INPATIENT ONLY "$14,496.05" "$10,727.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS866 DRG MS866 VIRAL ILLNESS WITHOUT MCC INPATIENT ONLY "$34,717.88" "$25,691.23" $0.00 "$26,124.06" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,802.34" $0.00 $0.00 $0.00 $0.00 "$6,802.34" $0.00 $0.00 $0.00 $0.00 "$10,651.53" "$26,124.06" $0.00 "$8,206.90" $0.00 "$8,206.90" $0.00 "$19,831.20" "$19,831.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS867 DRG MS867 OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC INPATIENT ONLY "$63,136.42" "$46,720.95" $0.00 "$112,359.77" "$112,359.77" "$112,359.77" "$26,492.82" "$26,492.82" $0.00 "$16,751.36" $0.00 $0.00 $0.00 $0.00 "$16,751.36" "$27,022.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS868 DRG MS868 OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC INPATIENT ONLY "$30,779.69" "$22,776.97" $0.00 "$69,508.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,175.27" "$69,508.29" $0.00 "$10,996.66" $0.00 "$10,996.66" $0.00 "$22,103.93" "$22,103.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS869 DRG MS869 OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC INPATIENT ONLY "$15,619.28" "$11,558.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS870 DRG MS870 SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS INPATIENT ONLY "$342,603.24" "$253,526.40" $0.00 "$437,462.32" "$222,926.65" "$222,926.65" "$55,492.21" "$55,492.21" $0.00 "$53,865.50" $0.00 $0.00 "$387,832.33" "$55,377.23" "$56,558.79" "$56,602.05" $0.00 $0.00 "$57,021.26" "$359,028.42" "$437,462.32" $0.00 "$105,276.97" $0.00 "$105,276.97" $0.00 "$64,792.48" "$64,792.48" "$71,505.46" $0.00 $0.00 $0.00 $0.00 $0.00 MS871 DRG MS871 SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC INPATIENT ONLY "$99,302.62" "$73,483.94" $0.00 "$69,468.99" "$49,039.20" "$49,039.20" "$23,974.45" "$23,974.45" "$16,130.58" "$17,521.48" $0.00 $0.00 "$16,742.05" "$23,941.03" "$17,521.48" "$24,453.94" "$28,083.00" "$28,083.00" "$26,556.42" "$27,518.59" "$69,468.99" "$47,721.33" "$18,708.37" "$28,083.00" "$18,708.37" "$16,770.40" "$28,386.40" "$28,386.40" "$30,367.39" "$17,608.91" $0.00 $0.00 $0.00 $0.00 MS872 DRG MS872 SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC INPATIENT ONLY "$39,146.17" "$28,968.17" $0.00 "$25,653.18" "$12,923.98" "$12,923.98" "$18,136.48" "$18,136.48" "$9,397.01" "$9,417.32" $0.00 $0.00 $0.00 "$18,118.16" "$9,417.32" "$18,499.21" "$15,394.50" "$15,394.50" "$20,904.90" "$7,127.66" "$25,653.18" $0.00 "$10,418.26" "$15,394.50" "$10,418.26" "$6,963.04" "$21,632.73" "$21,632.73" "$19,909.43" "$7,410.63" $0.00 $0.00 $0.00 $0.00 MS876 DRG MS876 O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS INPATIENT ONLY "$147,401.50" "$109,077.11" $0.00 "$46,127.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$46,127.21" "$46,127.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS880 DRG MS880 ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION INPATIENT ONLY "$37,752.98" "$27,937.21" $0.00 "$50,316.83" "$4,100.18" "$4,100.18" "$17,019.80" "$17,019.80" $0.00 "$5,575.59" $0.00 $0.00 "$10,045.23" $0.00 "$5,854.37" "$17,360.20" $0.00 $0.00 "$50,316.83" "$7,019.44" "$50,065.60" "$33,004.93" "$8,589.83" $0.00 "$8,589.83" "$5,603.41" "$20,143.15" "$20,143.15" "$49,378.27" "$5,883.58" $0.00 $0.00 $0.00 $0.00 MS881 DRG MS881 DEPRESSIVE NEUROSES INPATIENT ONLY "$19,663.24" "$14,550.80" $0.00 "$19,401.50" "$12,913.95" "$12,913.95" $0.00 $0.00 "$5,769.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$12,030.00" "$12,030.00" "$19,401.50" $0.00 $0.00 "$5,860.95" $0.00 "$12,030.00" $0.00 "$4,833.71" $0.00 $0.00 "$18,477.62" "$5,075.40" $0.00 $0.00 $0.00 $0.00 MS882 DRG MS882 NEUROSES EXCEPT DEPRESSIVE INPATIENT ONLY "$20,130.12" "$14,896.29" $0.00 "$12,620.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$12,620.55" "$12,620.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS883 DRG MS883 DISORDERS OF PERSONALITY AND IMPULSE CONTROL INPATIENT ONLY "$21,248.40" "$15,723.82" $0.00 "$22,936.59" "$16,782.35" "$16,782.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,936.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,140.10" "$7,183.84" "$7,183.84" "$21,844.37" "$7,497.10" $0.00 $0.00 $0.00 $0.00 MS884 DRG MS884 ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY INPATIENT ONLY "$38,142.56" "$28,225.49" $0.00 "$69,644.94" "$69,644.94" "$69,644.94" "$21,042.01" "$21,042.01" "$9,624.61" "$10,098.77" $0.00 $0.00 $0.00 "$21,016.17" "$10,603.71" "$21,462.85" "$25,969.50" "$25,969.50" "$23,629.52" $0.00 $0.00 $0.00 $0.00 "$25,969.50" $0.00 $0.00 "$24,888.70" "$24,888.70" "$22,504.30" $0.00 $0.00 $0.00 $0.00 $0.00 MS885 DRG MS885 PSYCHOSES INPATIENT ONLY "$27,249.99" "$20,164.99" $0.00 "$19,607.18" "$5,534.55" "$5,534.55" "$19,607.18" "$19,607.18" "$9,119.42" "$6,833.56" $0.00 $0.00 "$6,556.06" "$15,565.31" "$6,833.56" "$8,019.25" "$18,591.00" "$18,591.00" "$9,222.35" "$12,800.77" "$14,261.38" "$11,383.39" "$9,000.00" "$18,591.00" "$9,000.00" "$6,540.64" "$4,851.36" "$4,851.36" "$8,783.19" "$6,867.66" $0.00 $0.00 $0.00 $0.00 MS886 DRG MS886 BEHAVIORAL AND DEVELOPMENTAL DISORDERS INPATIENT ONLY "$18,427.83" "$13,636.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS887 DRG MS887 OTHER MENTAL DISORDER DIAGNOSES INPATIENT ONLY "$41,241.49" "$30,518.70" $0.00 "$57,514.90" $0.00 $0.00 $0.00 $0.00 "$8,326.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,197.00" "$16,197.00" $0.00 "$16,044.03" "$57,514.90" $0.00 "$10,907.45" "$16,197.00" "$10,907.45" $0.00 "$22,031.26" "$22,031.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS894 DRG MS894 "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" INPATIENT ONLY "$21,543.05" "$15,941.86" $0.00 "$17,768.90" "$4,086.60" "$4,086.60" "$16,734.90" "$16,734.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,069.60" $0.00 $0.00 "$17,768.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$12,658.39" $0.00 $0.00 "$16,922.76" "$13,291.30" $0.00 $0.00 $0.00 $0.00 MS896 DRG MS896 "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" INPATIENT ONLY "$49,326.69" "$36,501.75" $0.00 "$40,932.53" "$4,136.10" "$4,136.10" "$23,340.19" "$23,340.19" "$13,606.38" $0.00 $0.00 $0.00 $0.00 "$23,308.40" $0.00 "$23,806.99" "$25,043.92" "$25,043.92" "$25,554.59" "$15,138.49" "$40,932.53" $0.00 "$17,238.80" "$25,043.92" "$17,238.80" $0.00 "$27,189.19" "$27,189.19" "$24,337.70" $0.00 $0.00 $0.00 $0.00 $0.00 MS897 DRG MS897 "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" INPATIENT ONLY "$30,584.36" "$22,632.43" $0.00 "$41,618.80" "$12,711.30" "$12,711.30" "$16,782.58" "$16,782.58" "$6,163.22" $0.00 $0.00 $0.00 "$10,638.97" "$16,746.23" $0.00 $0.00 "$12,405.00" "$12,405.00" "$19,418.55" "$41,618.80" "$32,962.09" "$14,261.88" "$41,618.80" "$12,405.00" "$41,618.80" "$6,496.27" "$4,824.19" "$4,824.19" "$18,493.86" "$6,821.08" $0.00 $0.00 $0.00 $0.00 MS901 DRG MS901 WOUND DEBRIDEMENTS FOR INJURIES WITH MCC INPATIENT ONLY "$368,092.68" "$272,388.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS902 DRG MS902 WOUND DEBRIDEMENTS FOR INJURIES WITH CC INPATIENT ONLY "$122,560.83" "$90,695.01" $0.00 "$116,932.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$116,932.68" $0.00 $0.00 $0.00 $0.00 $0.00 "$27,243.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$29,207.95" "$29,207.95" "$25,946.57" $0.00 $0.00 $0.00 $0.00 $0.00 MS903 DRG MS903 WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC INPATIENT ONLY "$69,084.55" "$51,122.57" $0.00 "$342,304.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$280,931.70" "$342,304.46" $0.00 "$66,795.60" $0.00 "$66,795.60" $0.00 "$40,627.42" "$40,627.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS904 DRG MS904 SKIN GRAFTS FOR INJURIES WITH CC/MCC INPATIENT ONLY "$587,248.63" "$434,563.99" $0.00 "$136,934.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$112,383.02" "$136,934.37" $0.00 "$35,459.97" $0.00 "$35,459.97" "$23,848.01" "$42,033.36" "$42,033.36" $0.00 "$25,040.40" $0.00 $0.00 $0.00 $0.00 MS905 DRG MS905 SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC INPATIENT ONLY "$130,398.68" "$96,495.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS906 DRG MS906 HAND PROCEDURES FOR INJURIES INPATIENT ONLY "$173,990.59" "$128,753.04" $0.00 "$201,237.38" "$184,096.43" "$184,096.43" "$23,502.39" "$23,502.39" "$49,807.27" $0.00 $0.00 $0.00 "$13,855.47" $0.00 $0.00 "$23,972.44" "$201,237.38" "$201,237.38" $0.00 "$128,086.32" "$156,068.25" $0.00 "$17,451.31" "$201,237.38" "$17,451.31" $0.00 "$27,362.32" "$27,362.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS907 DRG MS907 OTHER O.R. PROCEDURES FOR INJURIES WITH MCC INPATIENT ONLY "$314,976.43" "$233,082.56" $0.00 "$388,246.60" "$217,751.34" "$217,751.34" "$38,301.96" "$38,301.96" $0.00 "$30,419.81" $0.00 $0.00 "$98,592.46" "$38,231.45" "$41,160.33" "$39,068.00" $0.00 $0.00 $0.00 "$205,770.40" "$250,723.31" $0.00 "$45,461.07" $0.00 "$45,461.07" "$39,395.94" "$388,246.60" "$388,246.60" $0.00 "$41,365.72" $0.00 $0.00 $0.00 $0.00 MS908 DRG MS908 OTHER O.R. PROCEDURES FOR INJURIES WITH CC INPATIENT ONLY "$152,656.61" "$112,965.89" $0.00 "$182,669.21" $0.00 $0.00 "$25,204.31" "$25,204.31" $0.00 "$34,521.96" $0.00 $0.00 "$71,256.39" $0.00 "$34,521.96" "$25,708.40" $0.00 $0.00 "$27,901.30" "$97,496.00" "$118,795.12" "$182,669.21" "$20,681.15" $0.00 "$20,681.15" "$15,861.25" "$29,993.55" "$29,993.55" "$26,572.67" "$16,654.30" $0.00 $0.00 $0.00 $0.00 MS909 DRG MS909 OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC INPATIENT ONLY "$15,837.75" "$11,719.94" $0.00 "$58,188.52" $0.00 $0.00 $0.00 $0.00 $0.00 "$11,600.88" $0.00 $0.00 $0.00 $0.00 "$11,600.88" $0.00 $0.00 $0.00 "$22,814.25" "$47,755.73" "$58,188.52" $0.00 "$13,219.05" $0.00 "$13,219.05" "$15,861.25" "$23,914.43" "$23,914.43" "$21,727.86" "$16,654.30" $0.00 $0.00 $0.00 $0.00 MS913 DRG MS913 TRAUMATIC INJURY WITH MCC INPATIENT ONLY "$58,527.66" "$43,310.47" $0.00 "$35,408.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$35,408.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,201.47" "$25,201.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS914 DRG MS914 TRAUMATIC INJURY WITHOUT MCC INPATIENT ONLY "$50,070.45" "$37,052.13" $0.00 "$42,063.45" "$19,477.40" "$19,477.40" "$17,174.42" "$17,174.42" $0.00 $0.00 $0.00 $0.00 "$12,315.97" "$17,158.58" $0.00 "$17,517.91" $0.00 $0.00 $0.00 "$34,521.77" "$42,063.45" $0.00 "$8,637.95" $0.00 "$8,637.95" $0.00 "$20,182.36" "$20,182.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS915 DRG MS915 ALLERGIC REACTIONS WITH MCC INPATIENT ONLY "$13,523.90" "$10,007.69" $0.00 "$27,685.69" $0.00 $0.00 "$27,685.69" "$27,685.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,782.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS916 DRG MS916 ALLERGIC REACTIONS WITHOUT MCC INPATIENT ONLY "$18,896.57" "$13,983.46" $0.00 "$18,988.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,129.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,316.33" "$18,316.33" "$18,988.45" $0.00 $0.00 $0.00 $0.00 $0.00 MS917 DRG MS917 POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC INPATIENT ONLY "$41,023.80" "$30,357.61" $0.00 "$51,372.18" "$17,715.70" "$17,715.70" "$21,257.33" "$21,257.33" "$12,541.54" "$6,253.67" $0.00 $0.00 "$20,090.46" "$21,230.93" "$11,939.58" "$21,682.48" "$22,177.50" "$22,177.50" "$23,801.74" "$17,979.07" "$51,372.18" $0.00 "$14,667.56" "$22,177.50" "$14,667.56" "$11,427.78" "$25,094.49" "$25,094.49" "$22,668.32" "$11,999.16" $0.00 $0.00 $0.00 $0.00 MS918 DRG MS918 POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC INPATIENT ONLY "$26,175.61" "$19,369.95" $0.00 "$24,709.73" "$4,453.30" "$4,453.30" "$24,709.73" "$24,709.73" "$2,488.34" "$6,225.23" $0.00 $0.00 "$3,348.41" "$24,675.25" "$6,225.23" "$23,946.92" "$11,044.46" "$11,044.46" "$19,160.25" "$3,729.06" "$12,112.06" "$13,648.19" "$6,834.23" "$11,044.46" "$6,834.23" "$5,958.38" "$19,547.84" "$19,547.84" "$18,247.86" "$6,256.30" $0.00 $0.00 $0.00 $0.00 MS919 DRG MS919 COMPLICATIONS OF TREATMENT WITH MCC INPATIENT ONLY "$64,348.49" "$47,617.88" $0.00 "$69,950.28" "$5,749.93" "$5,749.93" "$23,780.51" "$23,780.51" $0.00 "$11,257.45" $0.00 $0.00 $0.00 "$23,747.59" "$11,257.45" "$24,256.12" $0.00 $0.00 "$26,276.23" "$26,914.05" "$69,950.28" $0.00 "$18,297.37" $0.00 "$18,297.37" $0.00 "$28,051.57" "$28,051.57" "$25,024.98" $0.00 $0.00 $0.00 $0.00 $0.00 MS920 DRG MS920 COMPLICATIONS OF TREATMENT WITH CC INPATIENT ONLY "$24,394.92" "$18,052.24" $0.00 "$28,277.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,687.60" "$14,855.59" "$28,277.30" $0.00 "$10,099.48" $0.00 "$10,099.48" $0.00 "$21,373.04" "$21,373.04" "$19,702.48" $0.00 $0.00 $0.00 $0.00 $0.00 MS921 DRG MS921 COMPLICATIONS OF TREATMENT WITHOUT CC/MCC INPATIENT ONLY "$34,245.21" "$25,341.46" $0.00 "$18,521.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$10,898.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,521.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,639.98" $0.00 $0.00 $0.00 $0.00 $0.00 MS922 DRG MS922 "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC" INPATIENT ONLY "$72,838.99" "$53,900.85" $0.00 "$61,719.57" $0.00 $0.00 "$22,014.43" "$22,014.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$22,454.72" $0.00 $0.00 $0.00 "$3,753.19" "$61,719.57" $0.00 "$16,074.98" $0.00 "$16,074.98" "$1,335.32" "$26,241.08" "$26,241.08" $0.00 "$1,421.16" $0.00 $0.00 $0.00 $0.00 MS923 DRG MS923 "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" INPATIENT ONLY "$20,532.46" "$15,194.02" $0.00 "$17,890.29" $0.00 $0.00 "$17,539.50" "$17,539.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,890.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS927 DRG MS927 EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT INPATIENT ONLY "$756,935.58" "$560,132.33" $0.00 "$636,813.54" "$636,813.54" "$636,813.54" $0.00 $0.00 $0.00 "$122,178.14" $0.00 $0.00 $0.00 $0.00 "$128,287.10" $0.00 $0.00 $0.00 $0.00 "$300,908.95" "$366,645.98" $0.00 "$199,919.71" $0.00 "$199,919.71" "$122,787.92" "$176,013.20" "$176,013.20" $0.00 "$128,927.26" $0.00 $0.00 $0.00 $0.00 MS928 DRG MS928 FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC INPATIENT ONLY "$201,318.93" "$148,976.01" $0.00 "$242,850.15" "$242,850.15" "$242,850.15" "$56,131.28" "$56,131.28" "$48,038.28" "$21,161.06" $0.00 $0.00 "$198,393.73" "$56,014.65" "$21,161.06" "$57,253.91" "$81,797.38" "$81,797.38" "$56,136.99" "$103,838.89" "$126,523.70" $0.00 "$62,099.56" "$81,797.38" "$62,099.56" "$20,253.97" "$63,735.75" "$63,735.75" "$53,463.80" "$21,266.66" $0.00 $0.00 $0.00 $0.00 MS929 DRG MS929 FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC INPATIENT ONLY "$110,995.12" "$82,136.39" $0.00 "$94,527.37" "$67,878.36" "$67,878.36" "$31,853.89" "$31,853.89" "$20,836.22" "$9,637.44" $0.00 $0.00 "$94,527.37" $0.00 "$10,119.31" "$32,490.97" "$68,724.23" "$68,724.23" "$33,904.08" "$52,200.82" "$63,604.70" "$60,897.37" "$62,099.56" "$68,724.23" "$62,099.56" "$9,685.54" "$63,735.75" "$63,735.75" "$32,289.60" "$10,169.81" $0.00 $0.00 $0.00 $0.00 MS933 DRG MS933 EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT INPATIENT ONLY "$239,425.50" "$177,174.87" $0.00 "$35,261.93" $0.00 $0.00 "$26,670.86" "$26,670.86" $0.00 "$34,672.09" $0.00 $0.00 $0.00 $0.00 "$34,672.09" "$27,204.28" $0.00 $0.00 "$35,261.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$33,582.79" $0.00 $0.00 $0.00 $0.00 $0.00 MS934 DRG MS934 FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY INPATIENT ONLY "$21,519.08" "$15,924.12" $0.00 "$32,060.98" "$32,060.98" "$32,060.98" "$28,769.31" "$28,769.31" $0.00 "$9,096.60" $0.00 $0.00 "$24,196.92" "$24,413.93" "$9,096.60" $516.01 $0.00 $0.00 "$26,170.31" "$4,043.26" "$16,532.51" $0.00 "$18,141.99" $0.00 "$18,141.99" "$2,220.06" "$27,924.99" "$27,924.99" "$24,924.10" "$2,362.77" $0.00 $0.00 $0.00 $0.00 MS935 DRG MS935 NON-EXTENSIVE BURNS INPATIENT ONLY "$41,960.79" "$31,050.98" $0.00 "$28,925.37" "$15,650.93" "$15,650.93" "$24,393.38" "$24,393.38" $0.00 "$8,178.90" $0.00 $0.00 "$8,531.60" "$24,358.86" "$8,178.90" "$24,881.25" $0.00 $0.00 "$27,007.44" "$15,169.68" "$18,483.67" "$7,817.30" "$19,369.96" $0.00 "$19,369.96" "$2,410.65" "$28,925.37" "$28,925.37" "$25,721.37" "$2,565.61" $0.00 $0.00 $0.00 $0.00 MS940 DRG MS940 O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC INPATIENT ONLY "$94,350.10" "$69,819.07" $0.00 "$27,930.95" "$20,433.00" "$20,433.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,930.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,930.95" $0.00 $0.00 $0.00 $0.00 $0.00 MS941 DRG MS941 O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC INPATIENT ONLY "$142,894.44" "$105,741.89" $0.00 "$26,996.52" $0.00 $0.00 "$24,325.75" "$24,325.75" $0.00 $0.00 $0.00 $0.00 $0.00 "$24,291.39" $0.00 $0.00 $0.00 $0.00 "$26,996.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,710.97" $0.00 $0.00 $0.00 $0.00 $0.00 MS947 DRG MS947 SIGNS AND SYMPTOMS WITH MCC INPATIENT ONLY "$47,907.15" "$35,451.29" $0.00 "$22,923.01" $0.00 $0.00 "$19,293.84" "$19,293.84" $0.00 $0.00 $0.00 $0.00 $0.00 "$19,272.53" $0.00 "$19,679.72" $0.00 $0.00 "$21,984.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$13,833.77" "$22,923.01" "$22,923.01" "$20,937.74" "$14,525.45" $0.00 $0.00 $0.00 $0.00 MS948 DRG MS948 SIGNS AND SYMPTOMS WITHOUT MCC INPATIENT ONLY "$17,563.09" "$12,996.69" $0.00 "$31,248.40" "$20,433.00" "$20,433.00" "$16,485.64" "$16,485.64" $0.00 "$7,783.43" $0.00 $0.00 $0.00 $0.00 "$7,783.43" "$16,815.35" $0.00 $0.00 "$19,130.18" "$3,483.39" "$31,248.40" "$17,149.01" "$6,011.26" $0.00 "$6,011.26" $0.00 "$19,511.90" "$19,511.90" "$18,219.22" $0.00 $0.00 $0.00 $0.00 $0.00 MS950 DRG MS950 AFTERCARE WITHOUT CC/MCC INPATIENT ONLY "$41,083.74" "$30,401.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS951 DRG MS951 OTHER FACTORS INFLUENCING HEALTH STATUS INPATIENT ONLY "$55,607.65" "$41,149.66" $0.00 "$20,033.73" $0.00 $0.00 "$17,291.74" "$17,291.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,033.73" "$20,033.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS955 DRG MS955 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA INPATIENT ONLY "$622,062.28" "$460,326.09" $0.00 "$646,654.77" "$646,654.77" "$646,654.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$74,994.21" $0.00 $0.00 "$74,415.79" "$361,311.27" "$440,243.88" "$303,884.19" "$105,609.45" $0.00 "$105,609.45" "$53,840.04" "$62,801.51" "$62,801.51" "$70,872.18" "$56,532.01" $0.00 $0.00 $0.00 $0.00 MS956 DRG MS956 "LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA" INPATIENT ONLY "$228,564.82" "$169,137.97" $0.00 "$294,666.51" "$147,277.43" "$147,277.43" "$37,624.23" "$37,624.23" $0.00 "$117,843.05" $0.00 $0.00 "$294,666.51" $0.00 "$116,900.81" "$38,376.71" $0.00 $0.00 "$40,613.44" "$174,522.63" "$212,649.13" "$278,577.75" "$39,328.35" $0.00 "$39,328.35" "$84,114.71" "$45,184.81" "$45,184.81" "$38,679.47" "$53,545.64" $0.00 $0.00 $0.00 $0.00 MS957 DRG MS957 OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC INPATIENT ONLY "$302,297.61" "$223,700.23" $0.00 "$661,644.95" "$303,164.25" "$303,164.25" "$62,268.78" "$62,268.78" "$144,907.91" "$80,138.05" $0.00 $0.00 "$432,660.03" $0.00 "$80,138.05" "$63,514.16" "$422,490.48" "$422,490.48" "$65,286.01" "$278,370.30" "$339,183.51" "$661,644.95" "$78,684.59" "$422,490.48" "$78,684.59" "$76,702.83" "$74,669.01" "$74,669.01" "$62,177.15" "$80,537.94" $0.00 $0.00 $0.00 $0.00 MS958 DRG MS958 OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC INPATIENT ONLY "$285,394.08" "$211,191.62" $0.00 "$243,925.14" "$243,925.14" "$243,925.14" "$40,437.04" "$40,437.04" $0.00 "$33,019.28" $0.00 $0.00 "$171,009.88" "$40,424.16" "$33,019.28" "$41,247.95" $0.00 $0.00 "$42,442.17" "$130,622.58" "$159,158.58" "$179,708.38" "$42,010.85" $0.00 "$42,010.85" "$31,603.87" "$47,370.16" "$47,370.16" "$40,421.11" "$33,184.05" $0.00 $0.00 $0.00 $0.00 MS959 DRG MS959 OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC INPATIENT ONLY "$198,587.32" "$146,954.62" $0.00 "$121,673.30" "$117,245.71" "$117,245.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$99,858.13" "$121,673.30" $0.00 "$28,073.07" $0.00 "$28,073.07" "$19,466.16" "$36,015.52" "$36,015.52" $0.00 "$20,439.46" $0.00 $0.00 $0.00 $0.00 MS963 DRG MS963 OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC INPATIENT ONLY "$102,608.59" "$75,930.36" $0.00 "$206,519.43" "$29,282.40" "$29,282.40" "$29,893.87" "$29,893.87" "$24,162.84" $0.00 $0.00 $0.00 "$206,519.43" "$37,659.87" $0.00 "$30,491.75" "$40,948.50" "$40,948.50" "$32,425.24" "$64,598.93" "$78,711.32" "$113,231.89" "$27,317.23" "$40,948.50" "$27,317.23" "$29,432.41" "$35,399.75" "$35,399.75" "$30,881.18" "$30,904.01" $0.00 $0.00 $0.00 $0.00 MS964 DRG MS964 OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC INPATIENT ONLY "$102,198.77" "$75,627.09" $0.00 "$62,293.64" "$19,477.40" "$19,477.40" "$21,349.12" "$21,349.12" "$13,182.41" "$17,222.51" $0.00 $0.00 "$13,855.47" "$21,322.49" "$17,222.51" "$21,776.10" "$22,377.00" "$22,377.00" $0.00 "$51,124.83" "$62,293.64" "$33,880.61" "$14,971.29" "$22,377.00" "$14,971.29" "$4,058.08" "$25,341.92" "$25,341.92" $0.00 "$4,318.93" $0.00 $0.00 $0.00 $0.00 MS965 DRG MS965 OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC INPATIENT ONLY "$110,685.47" "$81,907.25" $0.00 "$46,222.92" "$15,656.33" "$15,656.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,618.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$37,935.50" "$46,222.92" $0.00 "$9,193.30" $0.00 "$9,193.30" "$8,185.98" "$20,634.78" "$20,634.78" $0.00 "$8,595.28" $0.00 $0.00 $0.00 $0.00 MS969 DRG MS969 HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC INPATIENT ONLY "$353,828.86" "$261,833.36" $0.00 "$67,855.17" $0.00 $0.00 "$67,855.17" "$67,855.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS970 DRG MS970 HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC INPATIENT ONLY "$159,032.74" "$117,684.23" $0.00 "$36,966.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$36,966.90" "$36,966.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS974 DRG MS974 HIV WITH MAJOR RELATED CONDITION WITH MCC INPATIENT ONLY "$73,178.08" "$54,151.78" $0.00 "$583,583.70" "$35,613.99" "$35,613.99" "$37,227.84" "$37,227.84" $0.00 $0.00 $0.00 $0.00 "$583,583.70" "$29,573.90" $0.00 "$30,214.39" $0.00 $0.00 "$27,554.25" "$13,595.40" "$64,425.98" $0.00 "$26,803.98" $0.00 "$26,803.98" $0.00 "$44,204.35" "$44,204.35" "$27,554.25" $0.00 $0.00 $0.00 $0.00 $0.00 MS975 DRG MS975 HIV WITH MAJOR RELATED CONDITION WITH CC INPATIENT ONLY "$51,952.99" "$38,445.21" $0.00 "$25,529.20" "$16,572.15" "$16,572.15" "$19,901.89" "$19,901.89" $0.00 "$11,270.70" $0.00 $0.00 $0.00 $0.00 "$11,270.70" "$20,299.93" $0.00 $0.00 "$22,973.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$24,104.72" "$24,104.72" "$25,529.20" $0.00 $0.00 $0.00 $0.00 $0.00 MS976 DRG MS976 HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC INPATIENT ONLY "$22,299.59" "$16,501.70" $0.00 "$36,779.40" "$36,779.40" "$36,779.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,764.33" "$23,764.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS977 DRG MS977 HIV WITH OR WITHOUT OTHER RELATED CONDITION INPATIENT ONLY "$39,015.42" "$28,871.41" $0.00 "$23,765.79" "$8,399.10" "$8,399.10" "$20,193.12" "$20,193.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,596.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,765.79" "$23,765.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS981 DRG MS981 EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC INPATIENT ONLY "$206,905.41" "$153,110.00" $0.00 "$389,857.92" "$389,857.92" "$389,857.92" "$47,995.46" "$47,995.46" $0.00 "$47,997.68" $0.00 $0.00 $0.00 "$42,818.02" "$47,997.68" "$56,112.45" $0.00 $0.00 "$44,568.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$47,748.94" "$47,748.94" "$42,445.83" $0.00 $0.00 $0.00 $0.00 $0.00 MS982 DRG MS982 EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC INPATIENT ONLY "$141,904.77" "$105,009.53" $0.00 "$52,490.00" $0.00 $0.00 "$28,559.81" "$28,559.81" $0.00 $0.00 $0.00 $0.00 "$52,490.00" "$28,514.50" $0.00 "$26,802.53" $0.00 $0.00 "$30,463.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$20,815.40" "$33,055.16" "$33,055.16" "$29,012.63" "$21,856.15" $0.00 $0.00 $0.00 $0.00 MS983 DRG MS983 EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC INPATIENT ONLY "$191,096.52" "$141,411.42" $0.00 "$84,648.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,786.79" "$84,648.54" $0.00 "$16,410.80" $0.00 "$16,410.80" $0.00 "$26,514.63" "$26,514.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS987 DRG MS987 NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC INPATIENT ONLY "$116,755.62" "$86,399.16" $0.00 "$130,780.00" "$111,671.84" "$111,671.84" "$33,662.08" "$33,662.08" $0.00 $0.00 $0.00 $0.00 "$130,780.00" $0.00 $0.00 "$83,339.54" $0.00 $0.00 "$62,005.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$129,871.79" "$129,871.79" "$59,052.55" $0.00 $0.00 $0.00 $0.00 $0.00 MS988 DRG MS988 NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC INPATIENT ONLY "$301,856.57" "$223,373.86" $0.00 "$101,160.63" $0.00 $0.00 "$22,830.18" "$22,830.18" $0.00 $0.00 $0.00 $0.00 $0.00 "$22,799.71" $0.00 "$23,286.78" $0.00 $0.00 "$24,328.59" "$83,023.25" "$101,160.63" $0.00 "$17,224.76" $0.00 "$17,224.76" $0.00 "$27,177.75" "$27,177.75" "$24,328.59" $0.00 $0.00 $0.00 $0.00 $0.00 MS989 DRG MS989 NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC INPATIENT ONLY "$35,912.44" "$26,575.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS998 DRG MS998 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS INPATIENT ONLY "$72,064.04" "$53,327.39" $0.00 "$6,092.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,802.63" $0.00 $0.00 $0.00 "$6,092.76" $0.00 $0.00 $0.00 $0.00 MS999 DRG MS999 UNGROUPABLE INPATIENT ONLY "$30,544.21" "$22,602.72" $0.00 "$62,801.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$62,801.51" "$62,801.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 812 EAP CPT® 00812 ANESTHESIA LOWER INTST ENDOSCOPIC PX SCR COLSC BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $446.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $97.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 813 EAP CPT® 00813 ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $446.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $97.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11200 EAP CPT®11200 "PR DEBRIDEMENT OF NAILS, 6 OR MORE" BOTH IP/OP $255.00 $188.70 $0.00 $255.00 255 $255.00 $174.88 $174.88 175.86 53.15 255 $255.00 $255.00 $172.08 53.14 $111.85 $113.00 $113.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11976 EAP CPT®11976 CHEM CAUTERY GRANULATN TISSUE BOTH IP/OP $408.00 $301.92 $0.00 $606.01 $408.00 $408.00 $606.01 $606.01 $408.00 $0.00 $408.00 $408.00 $408.00 $596.11 $85.03 $387.47 $408.00 $408.00 $175.24 $305.00 $241.56 $244.00 $243.48 $408.00 $243.48 $37.05 $38.57 $38.57 $48.56 $166.90 $0.00 $0.00 $0.00 $0.00 11981 EAP CPT®11981 PR REMOVAL OF BREAST LESION BOTH IP/OP $286.00 $211.64 $0.00 $286.00 286 $286.00 $109.81 $109.81 110.43 59.61 $0.00 $0.00 $0.00 $107.30 59.6 $69.74 $113.00 $113.00 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11983 EAP CPT®11983 INJECT CARPAL TUNNEL BOTH IP/OP $402.00 $297.48 $0.00 $402.00 $402.00 $402.00 $264.30 $264.30 $265.79 $83.79 $0.00 $0.00 $0.00 $258.98 $83.78 $168.34 $113.00 $113.00 $262.54 $284.00 $224.93 $227.20 $284.00 $402.00 $284.00 $44.45 $59.49 $59.49 $45.21 $250.04 $0.00 $0.00 $0.00 $0.00 17250 EAP CPT® 17250 INJECT TENDON ORIGIN/INSERT BOTH IP/OP $256.00 $189.44 $0.00 $262.54 $256.00 $256.00 $174.88 $174.88 $175.86 $53.36 $0.00 $0.00 $0.00 $172.08 $53.35 $111.85 $113.00 $113.00 $262.54 $202.00 $159.98 $161.60 $202.00 $0.00 $202.00 $0.00 $41.47 $41.47 $32.16 $250.04 $0.00 $0.00 $0.00 $0.00 20526 EAP CPT® 20526 "INJECT TRIGGER POINTS, > 3" BOTH IP/OP $232.00 $171.68 $0.00 $262.54 $232.00 $232.00 $254.43 $254.43 $232.00 $48.35 $0.00 $0.00 $0.00 $250.31 $48.35 $162.70 $232.00 $232.00 $262.54 $230.00 $182.16 $184.00 $230.00 $0.00 $230.00 $66.56 $45.07 $45.07 $36.62 $250.04 $0.00 $0.00 $0.00 $0.00 20550 EAP CPT® 20550 ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US BOTH IP/OP $162.00 $119.88 $28.97 $262.54 $162.00 $162.00 $254.43 $254.43 $162.00 $33.76 $162.00 $162.00 $162.00 $250.31 $33.76 $162.70 $162.00 $162.00 $262.54 $182.00 $144.14 $145.60 $182.00 $162.00 $182.00 $54.79 $37.50 $37.50 $28.97 $250.04 $0.00 $0.00 $0.00 $0.00 20551 EAP CPT® 20551 ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT BOTH IP/OP $164.00 $121.36 $0.00 $274.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.54 $274.00 $217.01 $219.20 $274.00 $0.00 $274.00 $69.40 $47.60 $47.60 $43.62 $250.04 $0.00 $0.00 $0.00 $0.00 20552 EAP CPT® 20552 ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US BOTH IP/OP $152.00 $112.48 $0.00 $626.89 $0.00 $0.00 $0.00 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $250.31 $31.68 $162.70 $152.00 $152.00 $626.89 $303.00 $239.98 $242.40 $303.00 $152.00 $303.00 $76.82 $54.81 $54.81 $48.24 $597.04 $0.00 $0.00 $0.00 $0.00 20553 EAP CPT® 20553 PR ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US BOTH IP/OP $175.00 $129.50 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20600 EAP CPT® 20600 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US BOTH IP/OP $150.00 $111.00 $31.26 $262.54 $150.00 $150.00 $254.43 $254.43 $150.00 $31.26 $150.00 $150.00 $150.00 $250.31 $31.26 $162.70 $150.00 $150.00 $262.54 $223.00 $176.62 $178.40 $223.00 $150.00 $223.00 $70.76 $47.59 $47.59 $35.50 $250.04 $0.00 $0.00 $0.00 $0.00 20604 EAP CPT® 20604 ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US BOTH IP/OP $232.00 $171.68 $0.00 $338.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.31 $48.35 $162.70 $113.00 $113.00 $262.54 $338.00 $267.70 $270.40 $338.00 $0.00 $338.00 $88.61 $62.38 $62.38 $53.81 $250.04 $0.00 $0.00 $0.00 $0.00 20606 EAP CPT® 20606 CLOSED RX METATARSAL FX BOTH IP/OP $252.00 $186.48 $0.00 $790.00 $252.00 $252.00 $618.38 $618.38 $252.00 $52.52 $0.00 $0.00 $0.00 $608.20 $52.52 $395.33 $113.00 $113.00 $216.27 $790.00 $625.68 $632.00 $300.48 $0.00 $300.48 $214.80 $210.83 $210.83 $125.77 $205.98 $0.00 $0.00 $0.00 $0.00 20610 EAP CPT® 20610 PR SHOULDER SCOPE BONE SHAVING BOTH IP/OP $183.00 $135.42 $0.00 $254.43 183 $183.00 $254.43 $254.43 183 38.14 183 $183.00 $183.00 $250.31 38.14 $162.70 $183.00 $183.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20610 EAP CPT®20610 CLOSED RX TOE FX BOTH IP/OP $183.00 $135.42 $0.00 $346.90 $183.00 $183.00 $254.43 $254.43 $183.00 $38.14 $183.00 $183.00 $183.00 $250.31 $38.14 $162.70 $183.00 $183.00 $0.00 $0.00 $346.90 $0.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20611 EAP CPT® 20611 PR ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG BOTH IP/OP $281.00 $207.94 $0.00 $281.00 281 $281.00 $254.43 $254.43 255.86 58.57 $0.00 $0.00 $0.00 $250.31 58.56 $162.70 $113.00 $113.00 $281.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20612 EAP CPT®20612 "PR CATHETER ASPIRATN,NASOTRACH" BOTH IP/OP $181.00 $133.94 $0.00 $254.43 181 $181.00 $254.43 $254.43 181 0 $0.00 $0.00 $0.00 $250.31 37.72 $162.70 $181.00 $181.00 $181.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25600 EAP CPT®25600 "PHLEB, VENIPUNCTURE" BOTH IP/OP $970.00 $717.80 $0.00 $202.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.62 $202.15 $128.45 $113.00 $113.00 $3.15 $5.50 $8.71 $8.80 $4.35 $0.00 $4.35 $1.72 $3.00 $3.00 $1.75 $3.00 $0.00 $0.00 $0.00 $0.00 28470 EAP CPT® 28470 PR INSERT NON-TUNNEL CV CATH BOTH IP/OP $620.00 $458.80 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28490 EAP CPT®28490 "REMOVE TONSILS/ADENOIDS,<12 Y/O" BOTH IP/OP $401.00 $296.74 $0.00 $401.00 401 $401.00 $200.72 $200.72 201.85 0 $0.00 $0.00 $0.00 $0.00 83.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28510 EAP CPT® 28510 PR ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC BOTH IP/OP $340.00 $251.60 $0.00 $340.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 70.86 $0.00 $0.00 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36415 EAP CPT® 36415 PR COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD BOTH IP/OP $11.00 $8.14 $0.00 $7.15 5.97 $5.97 $3.00 $3.00 1.5 1.35 3.12 $3.12 $3.24 $3.00 2.29 $1.95 $6.51 $6.51 $7.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43235 EAP CPT®43235 COLONOSCOPY W/BIOPSY SINGLE/MULTIPLE BOTH IP/OP $867.00 $641.58 $0.00 "$1,530.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.94 $180.68 $504.36 $867.00 $867.00 "$1,007.17" "$1,530.00" "$1,211.76" "$1,224.00" "$1,399.33" $0.00 "$1,399.33" $353.17 $208.77 $208.77 $243.58 $959.21 $0.00 $0.00 $0.00 $0.00 43239 EAP CPT® 43239 COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ BOTH IP/OP "$1,110.00 " $821.40 $0.00 "$1,598.00" "$1,110.00" "$1,110.00" $787.99 $787.99 $792.43 $0.00 "$1,110.00" "$1,110.00" "$1,110.00" $775.94 $231.32 $504.36 "$1,110.00" "$1,110.00" "$1,007.17" "$1,598.00" "$1,265.62" "$1,278.40" "$1,399.33" $0.00 "$1,399.33" $450.95 $265.02 $265.02 $254.40 $959.21 $0.00 $0.00 $0.00 $0.00 43239 EAP CPT®43239 PR COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ BOTH IP/OP "$1,110.00 " $821.40 $0.00 "$1,110.00" 1110 "$1,110.00" $787.99 $787.99 792.43 0 1110 "$1,110.00" "$1,110.00" $775.94 231.32 $504.36 "$1,110.00" "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43246 EAP CPT®43246 PR COLSC FLX W/NDSC US XM RCTM ET AL LMTD&ADJ STRUX BOTH IP/OP $557.00 $412.18 $0.00 "$1,581.72" 557 $557.00 "$1,581.72" "$1,581.72" 557 0 557 $557.00 $557.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45330 EAP CPT® 45330 "PR LAP,CHOLECYSTECTOMY" BOTH IP/OP $542.00 $401.08 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45331 EAP CPT®45331 "PR REPAIR ING HERNIA,5+Y/O,REDUCIBL" BOTH IP/OP $844.00 $624.56 $0.00 $175.89 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 175.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45335 EAP CPT®45335 "PR BIOPSY OF PROSTATE,NEEDLE/PUNCH" BOTH IP/OP $860.00 $636.40 $0.00 $179.22 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 179.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45378 EAP CPT® 45378 "BIOPSY VULVA/PERINEUM,ONE LESN" BOTH IP/OP $984.00 $728.16 $0.00 $984.00 $984.00 $984.00 $772.82 $772.82 $777.17 $0.00 $984.00 $984.00 $984.00 $760.65 $205.07 $494.42 $984.00 $984.00 $640.34 $328.00 $259.78 $262.40 $328.00 $0.00 $328.00 $84.36 $63.10 $63.10 $52.22 $609.84 $0.00 $0.00 $0.00 $0.00 45378 EAP CPT®45378 "PR LAP,PROSTATECTOMY,RADICAL,W/NERVE SPARE,INCL ROBOTIC" BOTH IP/OP $984.00 $728.16 $0.00 $984.00 984 $984.00 $772.82 $772.82 777.17 0 984 $984.00 $984.00 $760.65 205.07 $494.42 $984.00 $984.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45380 EAP CPT® 45380 "COLPOSCOPY,CERVIX W/ADJ VAGINA,W/BX" BOTH IP/OP "$1,268.00 " $938.32 $0.00 "$1,268.00" "$1,268.00" "$1,268.00" "$1,009.84" "$1,009.84" "$1,015.53" $0.00 "$1,268.00" "$1,268.00" "$1,268.00" $993.84 $264.25 $646.00 "$1,268.00" "$1,268.00" $271.52 $560.00 $443.52 $448.00 $377.23 $0.00 $377.23 $145.54 $115.02 $115.02 $89.15 $258.59 $0.00 $0.00 $0.00 $0.00 45380 EAP CPT®45380 "COLPOSC,CERVIX W/ADJ VAG,W/BX & CURRETAG" BOTH IP/OP "$1,268.00 " $938.32 $0.00 "$1,268.00" "$1,268.00" "$1,268.00" "$1,009.84" "$1,009.84" "$1,015.53" $0.00 "$1,268.00" "$1,268.00" "$1,268.00" $993.84 $264.25 $646.00 "$1,268.00" "$1,268.00" $271.52 $594.00 $470.45 $475.20 $377.23 $0.00 $377.23 $99.94 $140.25 $140.25 $94.56 $258.59 $0.00 $0.00 $0.00 $0.00 45381 EAP CPT®45381 "COLPOSCOPY,CERVIX W/ADJ VAGINA, CURETTAG" BOTH IP/OP "$1,294.00 " $957.56 $0.00 "$1,294.00" "$1,294.00" "$1,294.00" "$1,009.84" "$1,009.84" "$1,015.53" $0.00 "$1,294.00" "$1,294.00" "$1,294.00" $993.84 $269.67 $646.00 "$1,294.00" "$1,294.00" $271.52 $526.00 $416.59 $420.80 $377.23 $0.00 $377.23 $137.69 $106.36 $106.36 $83.74 $258.59 $0.00 $0.00 $0.00 $0.00 45385 EAP CPT® 45385 BIOPSY OF UTERUS LINING BOTH IP/OP "$1,318.00 " $975.32 $0.00 "$1,318.00" "$1,318.00" "$1,318.00" "$1,009.84" "$1,009.84" "$1,015.53" $0.00 "$1,318.00" "$1,318.00" "$1,318.00" $993.84 $274.67 $646.00 "$1,318.00" "$1,318.00" $166.54 $353.00 $279.58 $282.40 $231.38 $0.00 $231.38 $59.72 $67.07 $67.07 $56.20 $158.61 $0.00 $0.00 $0.00 $0.00 45385 EAP CPT®45385 BIOPSY/EXCIS CERVICAL LESN BOTH IP/OP "$1,318.00 " $975.32 $0.00 "$1,318.00" "$1,318.00" "$1,318.00" "$1,009.84" "$1,009.84" "$1,015.53" $0.00 "$1,318.00" "$1,318.00" "$1,318.00" $993.84 $274.67 $646.00 "$1,318.00" "$1,318.00" $640.34 $518.00 $410.26 $414.40 $518.00 $0.00 $518.00 $71.26 $78.23 $78.23 $82.47 $609.84 $0.00 $0.00 $0.00 $0.00 56605 EAP CPT® 56605 "PR OBSTETRICAL CARE,VAG DELIV ONLY" BOTH IP/OP $276.00 $204.24 $0.00 $617.38 276 $276.00 $617.38 $617.38 276 57.53 276 $276.00 $276.00 $607.07 57.52 $394.60 $276.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 57454 EAP CPT® 57454 "PR FULL ROUT OBSTE CARE,CESAREAN DELIV" BOTH IP/OP $482.00 $356.68 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 57455 EAP CPT® 57455 "PR ROUT OB CARE,VAG DELIV,PREV C-SEC" BOTH IP/OP $461.00 $341.14 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 57456 EAP CPT® 57456 PR NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN BOTH IP/OP $432.00 $319.68 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 57500 EAP CPT® 57500 PR NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN BOTH IP/OP $448.00 $331.52 $0.00 $617.38 448 $448.00 $617.38 $617.38 448 93.37 448 $448.00 $448.00 $607.07 93.36 $394.60 $448.00 $448.00 $448.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 57505 EAP CPT®57505 INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH BOTH IP/OP $449.00 $332.26 $0.00 $626.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $626.89 $275.00 $217.80 $220.00 $275.00 $0.00 $275.00 $85.27 $44.35 $44.35 $43.78 $597.04 $0.00 $0.00 $0.00 $0.00 58100 EAP CPT® 58100 "PR INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL" BOTH IP/OP $292.00 $216.08 $0.00 $292.00 292 $292.00 $165.90 $165.90 166.84 60.86 292 $292.00 $292.00 $163.24 60.85 $106.10 $113.00 $113.00 $292.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 58110 EAP CPT® 58110 "PR DISCISSION,2ND CATARACT,LASER" BOTH IP/OP $141.00 $104.34 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 58300 EAP CPT® 58300 PR XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/O ECP BOTH IP/OP $265.00 $196.10 $0.00 $265.00 265 $265.00 $0.00 $0.00 51.66 55.23 $0.00 $0.00 $0.00 $0.00 55.23 $0.00 $113.00 $113.00 $265.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 58301 EAP CPT® 58301 PR INJECT INTRAVITREAL PHARMCOLOGIC BOTH IP/OP $316.00 $233.84 $0.00 $316.00 316 $316.00 $274.65 $274.65 276.2 65.86 $0.00 $0.00 $0.00 $269.78 65.85 $175.35 $316.00 $316.00 $316.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 64450 EAP CPT® 64450 "PR CT ANGIO,HEAD COMBO,INCL IMAGE PROCESS" BOTH IP/OP $216.00 $159.84 $0.00 $618.38 216 $216.00 $618.38 $618.38 216 45.02 216 $216.00 $216.00 $608.20 45.01 $395.33 $216.00 $216.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69210 EAP CPT® 69210 CHG RADIOLOGIC EXAM CHEST 2 VIEWS BOTH IP/OP $134.00 $99.16 $0.00 $134.00 134 $134.00 $54.21 $54.21 54.51 27.93 $0.00 $0.00 $0.00 $53.35 27.93 $34.67 $113.00 $113.00 $134.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70360 EAP CPT® 70360 "X-RAY RIBS, CHEST 4+ VW" BOTH IP/OP $90.00 $66.60 $18.76 $137.87 $63.70 $63.70 $78.77 $78.77 $79.21 $18.76 $45.06 $45.06 $46.80 $77.54 $18.76 $50.40 $53.24 $53.24 $112.41 $29.76 $98.21 $99.20 $124.00 $137.87 $124.00 $50.44 $35.30 $35.30 $19.74 $107.06 $0.00 $0.00 $0.00 $0.00 70450 EAP CPT® 70450 "CT SCAN,THORAX,W/O CONTRAST" BOTH IP/OP $313.00 $231.62 $55.40 $313.00 $313.00 $313.00 $106.02 $106.02 $106.62 $65.24 $313.00 $313.00 $313.00 $104.44 $65.23 $67.89 $313.00 $313.00 $112.41 $84.96 $280.37 $283.20 $156.18 $313.00 $156.18 $55.40 $101.21 $101.21 $56.36 $107.06 $0.00 $0.00 $0.00 $0.00 70450 EAP CPT®70450 "PR CT SCAN,THORAX,W/O CONTRAST" BOTH IP/OP $313.00 $231.62 $0.00 $313.00 313 $313.00 $106.02 $106.02 106.62 65.24 313 $313.00 $313.00 $104.44 65.23 $67.89 $313.00 $313.00 $313.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70487 EAP CPT®70487 CAT SCAN OF CHEST CONTRAST BOTH IP/OP $451.00 $333.74 $0.00 $451.00 $451.00 $451.00 $173.95 $173.95 $174.93 $94.00 $451.00 $451.00 $451.00 $171.13 $93.99 $111.23 $451.00 $451.00 $202.33 $113.52 $374.62 $378.40 $281.11 $0.00 $281.11 $74.02 $135.06 $135.06 $75.30 $192.70 $0.00 $0.00 $0.00 $0.00 70491 EAP CPT®70491 "PR CT ANGIO, CHEST (NON-CORON), COMBO, INCL IMG PROC" BOTH IP/OP $550.00 $407.00 $0.00 $550.00 550 $550.00 $173.95 $173.95 174.93 114.63 550 $550.00 $550.00 $171.13 114.62 $111.23 $550.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70492 EAP CPT® 70492 "CT ANGIO, CHEST, COMBO, INCL IMAGE PROC" BOTH IP/OP $661.00 $489.14 $0.00 $509.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.33 $152.88 $504.50 $509.60 $281.11 $0.00 $281.11 $99.69 $214.30 $214.30 $101.41 $192.70 $0.00 $0.00 $0.00 $0.00 71045 EAP CPT®71045 CHG X-RAY THORACIC SPINE 2 VW BOTH IP/OP $74.00 $54.76 $0.00 $78.77 45.3 $45.30 $78.77 $78.77 74 15.42 26.8 $26.80 $27.83 $77.54 15.42 $50.40 $43.77 $43.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71046 EAP CPT® 71046 X-RAY THOR-LUMB SP 2 VW BOTH IP/OP $96.00 $71.04 $13.05 $137.87 $69.46 $69.46 $78.77 $78.77 $79.21 $20.01 $49.06 $49.06 $50.94 $77.54 $20.01 $50.40 $56.78 $56.78 $80.04 $19.68 $64.94 $65.60 $82.00 $137.87 $82.00 $36.61 $23.41 $23.41 $13.05 $76.23 $0.00 $0.00 $0.00 $0.00 71046 EAP CPT®71046 X-RAY THORACIC SPINE 2 VW BOTH IP/OP $96.00 $71.04 $12.10 $137.87 $69.46 $69.46 $78.77 $78.77 $79.21 $20.01 $49.06 $49.06 $50.94 $77.54 $20.01 $50.40 $56.78 $56.78 $112.41 $18.24 $60.19 $60.80 $76.00 $137.87 $76.00 $35.88 $21.61 $21.61 $12.10 $107.06 $0.00 $0.00 $0.00 $0.00 71110 EAP CPT®71110 CHG X-RAY LUMBAR SPINE 2/3 VW BOTH IP/OP $126.00 $93.24 $0.00 $169.61 85.46 $85.46 $106.02 $106.02 106.62 26.26 67.28 $67.28 $69.87 $104.44 26.26 $67.89 $74.53 $74.53 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71111 EAP CPT® 71111 X-RAY LUMBAR SPINE 2/3 VW BOTH IP/OP $150.00 $111.00 $0.00 $112.41 $109.64 $109.64 $106.02 $106.02 $106.62 $31.26 $88.90 $88.90 $92.32 $104.44 $31.26 $67.89 $88.73 $88.73 $112.41 $22.80 $75.24 $76.00 $95.00 $0.00 $95.00 $36.61 $27.01 $27.01 $15.12 $107.06 $0.00 $0.00 $0.00 $0.00 71250 EAP CPT® 71250 X-RAY LUMBAR SPINE 4 VW BOTH IP/OP $393.00 $290.82 $19.90 $393.00 $393.00 $393.00 $106.02 $106.02 $106.62 $81.91 $393.00 $393.00 $393.00 $104.44 $81.90 $67.89 $393.00 $393.00 $112.41 $30.00 $99.00 $100.00 $125.00 $393.00 $125.00 $50.44 $35.66 $35.66 $19.90 $107.06 $0.00 $0.00 $0.00 $0.00 71250 EAP CPT®71250 CHG X-RAY LUMBAR SPINE 4 VW BOTH IP/OP $393.00 $290.82 $0.00 $393.00 393 $393.00 $106.02 $106.02 106.62 81.91 393 $393.00 $393.00 $104.44 81.9 $67.89 $393.00 $393.00 $393.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71260 EAP CPT® 71260 "CT SCAN,LUMBAR SPINE,W/O CONTRAST" BOTH IP/OP $494.00 $365.56 $0.00 $494.00 $494.00 $494.00 $173.95 $173.95 $174.93 $102.96 $494.00 $494.00 $494.00 $171.13 $102.95 $111.23 $494.00 $494.00 $112.41 $371.00 $293.83 $296.80 $156.18 $0.00 $156.18 $58.06 $105.89 $105.89 $59.06 $107.06 $0.00 $0.00 $0.00 $0.00 71260 EAP CPT®71260 "PR CT SCAN,CERVICAL SPINE,W/O CONTRAST" BOTH IP/OP $494.00 $365.56 $0.00 $494.00 494 $494.00 $173.95 $173.95 174.93 102.96 494 $494.00 $494.00 $171.13 102.95 $111.23 $494.00 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71275 EAP CPT®71275 "PR MRI, CERV SPINE" BOTH IP/OP $763.00 $564.62 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72040 EAP CPT®72040 CHG X-RAY PELVIS 1/2 VW BOTH IP/OP $113.00 $83.62 $0.00 $137.87 74.98 $74.98 $78.77 $78.77 79.21 23.55 62.89 $62.89 $65.31 $77.54 23.55 $50.40 $66.84 $66.84 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72050 EAP CPT® 72050 PR CT SCAN OF PELVIS CONTRAST BOTH IP/OP $152.00 $112.48 $0.00 $106.62 103.2 $103.20 $106.02 $106.02 106.62 31.68 89.81 $89.81 $93.27 $104.44 31.68 $67.89 $89.91 $89.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72052 EAP CPT® 72052 X-RAY SACRUM/COCCYX 2+ VW BOTH IP/OP $177.00 $130.98 $0.00 $104.70 $0.00 $0.00 $0.00 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $104.44 $36.89 $67.89 $104.70 $104.70 $80.04 $18.96 $62.57 $63.20 $79.00 $0.00 $79.00 $30.55 $22.69 $22.69 $12.58 $76.23 $0.00 $0.00 $0.00 $0.00 72070 EAP CPT® 72070 CHG X-RAY SHOULDER 2+ VW BOTH IP/OP $94.00 $69.56 $0.00 $169.61 77.4 $77.40 $106.02 $106.02 94 19.59 55.63 $55.63 $57.77 $104.44 19.59 $67.89 $55.60 $55.60 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72070 EAP CPT®72070 X-RAY CLAVICLE BOTH IP/OP $94.00 $69.56 $12.90 $169.61 $77.40 $77.40 $106.02 $106.02 $94.00 $19.59 $55.63 $55.63 $57.77 $104.44 $19.59 $67.89 $55.60 $55.60 $80.04 $19.44 $64.15 $64.80 $81.00 $169.61 $81.00 $27.72 $23.05 $23.05 $12.90 $76.23 $0.00 $0.00 $0.00 $0.00 72080 EAP CPT® 72080 X-RAY SHOULDER 2+ VW BOTH IP/OP $100.00 $74.00 $0.00 $83.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.04 $19.92 $65.74 $66.40 $83.00 $0.00 $83.00 $30.90 $23.77 $23.77 $13.21 $76.23 $0.00 $0.00 $0.00 $0.00 72100 EAP CPT® 72100 X-RAY HUMERUS BOTH IP/OP $114.00 $84.36 $12.90 $169.61 $79.81 $79.81 $106.02 $106.02 $106.62 $23.76 $67.44 $67.44 $70.04 $104.44 $23.76 $67.89 $67.43 $67.43 $80.04 $19.44 $64.15 $64.80 $81.00 $169.61 $81.00 $30.55 $23.05 $23.05 $12.90 $76.23 $0.00 $0.00 $0.00 $0.00 72100 EAP CPT®72100 CHG X-RAY HUMERUS BOTH IP/OP $114.00 $84.36 $0.00 $169.61 79.81 $79.81 $106.02 $106.02 106.62 23.76 67.44 $67.44 $70.04 $104.44 23.76 $67.89 $67.43 $67.43 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72110 EAP CPT® 72110 X-RAY ELBOW 2 VW BOTH IP/OP $147.00 $108.78 $0.00 $169.61 $111.25 $111.25 $106.02 $106.02 $106.62 $0.00 $94.35 $94.35 $97.98 $0.00 $0.00 $0.00 $0.00 $0.00 $80.04 $17.04 $56.23 $56.80 $71.00 $169.61 $71.00 $27.38 $20.17 $20.17 $11.30 $76.23 $0.00 $0.00 $0.00 $0.00 72110 EAP CPT®72110 CHG X-RAY ELBOW 2 VW BOTH IP/OP $147.00 $108.78 $0.00 $169.61 111.25 $111.25 $106.02 $106.02 106.62 0 94.35 $94.35 $97.98 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72114 EAP CPT®72114 X-RAY ELBOW 3+ VW BOTH IP/OP $177.00 $130.98 $12.42 $169.61 $141.08 $141.08 $106.02 $106.02 $106.62 $36.89 $127.92 $127.92 $132.84 $104.44 $36.89 $67.89 $104.70 $104.70 $80.04 $18.72 $61.78 $62.40 $78.00 $169.61 $78.00 $30.55 $22.33 $22.33 $12.42 $76.23 $0.00 $0.00 $0.00 $0.00 72125 EAP CPT®72125 CHG X-RAY FOREARM 2 VW BOTH IP/OP $385.00 $284.90 $0.00 $385.00 385 $385.00 $106.02 $106.02 106.62 80.24 385 $385.00 $385.00 $104.44 80.23 $67.89 $385.00 $385.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72131 EAP CPT® 72131 X-RAY FOREARM 2 VW BOTH IP/OP $383.00 $283.42 $0.00 $383.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.04 $17.28 $57.02 $57.60 $72.00 $383.00 $72.00 $27.72 $20.53 $20.53 $11.46 $76.23 $0.00 $0.00 $0.00 $0.00 72170 EAP CPT®72170 X-RAY WRIST 3+ VW BOTH IP/OP $80.00 $59.20 $0.00 $169.61 $72.57 $72.57 $106.02 $106.02 $80.00 $0.00 $42.34 $42.34 $43.97 $0.00 $0.00 $0.00 $0.00 $0.00 $80.04 $25.44 $83.95 $84.80 $106.00 $169.61 $106.00 $28.79 $30.25 $30.25 $16.88 $76.23 $0.00 $0.00 $0.00 $0.00 72190 EAP CPT®72190 X-RAY HAND 2 VW BOTH IP/OP $121.00 $89.54 $0.00 $112.41 $86.28 $86.28 $106.02 $106.02 $106.62 $25.22 $70.16 $70.16 $72.86 $104.44 $25.22 $67.89 $71.57 $71.57 $112.41 $18.48 $60.98 $61.60 $77.00 $0.00 $77.00 $27.37 $21.97 $21.97 $12.26 $107.06 $0.00 $0.00 $0.00 $0.00 72220 EAP CPT® 72220 X-RAY HAND 3+ VW BOTH IP/OP $93.00 $68.82 $0.00 $137.87 $63.70 $63.70 $78.77 $78.77 $79.21 $0.00 $51.11 $51.11 $53.07 $0.00 $0.00 $0.00 $0.00 $0.00 $80.04 $22.08 $72.86 $73.60 $92.00 $137.87 $92.00 $28.79 $26.29 $26.29 $14.65 $76.23 $0.00 $0.00 $0.00 $0.00 73000 EAP CPT® 73000 CHG RADEX HIP UNILATERAL WITH PELVIS 1 VIEW BOTH IP/OP $92.00 $68.08 $0.00 $137.87 62.88 $62.88 $78.77 $78.77 79.21 19.18 46.88 $46.88 $48.69 $77.54 19.17 $50.40 $54.42 $54.42 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73030 EAP CPT® 73030 RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS BOTH IP/OP $99.00 $73.26 $19.10 $137.87 $66.11 $66.11 $78.77 $78.77 $79.21 $20.63 $50.19 $50.19 $52.12 $77.54 $20.63 $50.40 $58.56 $58.56 $80.04 $28.80 $95.04 $96.00 $111.21 $137.87 $111.21 $39.45 $34.22 $34.22 $19.10 $76.23 $0.00 $0.00 $0.00 $0.00 73030 EAP CPT®73030 CHG RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS BOTH IP/OP $99.00 $73.26 $0.00 $137.87 66.11 $66.11 $78.77 $78.77 79.21 20.63 50.19 $50.19 $52.12 $77.54 20.63 $50.40 $58.56 $58.56 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73060 EAP CPT® 73060 RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS BOTH IP/OP $91.00 $67.34 $18.96 $137.87 $66.11 $66.11 $78.77 $78.77 $79.21 $18.97 $50.19 $50.19 $52.12 $77.54 $18.96 $50.40 $53.83 $53.83 $112.41 $31.44 $103.75 $104.80 $131.00 $137.87 $131.00 $46.58 $37.46 $37.46 $20.86 $107.06 $0.00 $0.00 $0.00 $0.00 73060 EAP CPT®73060 RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS BOTH IP/OP $91.00 $67.34 $16.08 $137.87 $66.11 $66.11 $78.77 $78.77 $79.21 $18.97 $50.19 $50.19 $52.12 $77.54 $18.96 $50.40 $53.83 $53.83 $112.41 $24.24 $79.99 $80.80 $101.00 $137.87 $101.00 $37.75 $28.81 $28.81 $16.08 $107.06 $0.00 $0.00 $0.00 $0.00 73070 EAP CPT® 73070 RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS BOTH IP/OP $83.00 $61.42 $14.17 $137.87 $62.09 $62.09 $78.77 $78.77 $79.21 $17.30 $46.88 $46.88 $48.69 $77.54 $17.30 $50.40 $49.09 $49.09 $80.04 $21.36 $70.49 $71.20 $89.00 $137.87 $89.00 $30.93 $25.57 $25.57 $14.17 $76.23 $0.00 $0.00 $0.00 $0.00 73070 EAP CPT®73070 CHG RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS BOTH IP/OP $83.00 $61.42 $0.00 $137.87 62.09 $62.09 $78.77 $78.77 79.21 17.3 46.88 $46.88 $48.69 $77.54 17.3 $50.40 $49.09 $49.09 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73080 EAP CPT® 73080 CHG X-RAY KNEE 1 OR 2 VIEW BOTH IP/OP $93.00 $68.82 $0.00 $137.87 70.96 $70.96 $78.77 $78.77 79.21 19.38 62.89 $62.89 $65.31 $77.54 19.38 $50.40 $55.01 $55.01 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73090 EAP CPT® 73090 X-RAY KNEE 3 VIEW BOTH IP/OP $83.00 $61.42 $16.72 $137.87 $58.87 $58.87 $78.77 $78.77 $79.21 $17.30 $46.88 $46.88 $48.69 $77.54 $17.30 $50.40 $49.09 $49.09 $80.04 $25.20 $83.16 $84.00 $105.00 $137.87 $105.00 $31.26 $29.89 $29.89 $16.72 $76.23 $0.00 $0.00 $0.00 $0.00 73090 EAP CPT®73090 X-RAY KNEE 1 OR 2 VIEW BOTH IP/OP $83.00 $61.42 $17.30 $137.87 $58.87 $58.87 $78.77 $78.77 $79.21 $17.30 $46.88 $46.88 $48.69 $77.54 $17.30 $50.40 $49.09 $49.09 $80.04 $31.68 $69.70 $105.60 $111.21 $137.87 $111.21 $28.43 $25.21 $25.21 $21.01 $76.23 $0.00 $0.00 $0.00 $0.00 73100 EAP CPT® 73100 X-RAY KNEE 4+ VIEW BOTH IP/OP $97.00 $71.78 $18.31 $137.87 $66.11 $66.11 $78.77 $78.77 $79.21 $20.22 $48.68 $48.68 $50.55 $77.54 $20.21 $50.40 $57.38 $57.38 $112.41 $27.60 $91.08 $92.00 $115.00 $137.87 $115.00 $34.81 $32.78 $32.78 $18.31 $107.06 $0.00 $0.00 $0.00 $0.00 73110 EAP CPT® 73110 "X-RAY TIB + FIB, 2VW" BOTH IP/OP $117.00 $86.58 $12.58 $137.87 $80.63 $80.63 $78.77 $78.77 $79.21 $24.39 $61.39 $61.39 $63.75 $77.54 $24.38 $50.40 $69.21 $69.21 $80.04 $18.96 $62.57 $63.20 $79.00 $137.87 $79.00 $28.43 $22.69 $22.69 $12.58 $76.23 $0.00 $0.00 $0.00 $0.00 73110 EAP CPT®73110 "CHG X-RAY TIB + FIB, 2VW" BOTH IP/OP $117.00 $86.58 $0.00 $137.87 80.63 $80.63 $78.77 $78.77 79.21 24.39 61.39 $61.39 $63.75 $77.54 24.38 $50.40 $69.21 $69.21 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73120 EAP CPT® 73120 CHG X-RAY ANKLE 2 VW BOTH IP/OP $89.00 $65.86 $0.00 $169.61 59.66 $59.66 $106.02 $106.02 89 18.55 45.96 $45.96 $47.73 $104.44 18.55 $67.89 $52.64 $52.64 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73130 EAP CPT® 73130 CHG X-RAY ANKLE 3+ VW BOTH IP/OP $105.00 $77.70 $0.00 $137.87 70.14 $70.14 $78.77 $78.77 79.21 21.88 54.14 $54.14 $56.22 $77.54 21.88 $50.40 $62.11 $62.11 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73130 EAP CPT®73130 X-RAY ANKLE 2 VW BOTH IP/OP $105.00 $77.70 $13.05 $137.87 $70.14 $70.14 $78.77 $78.77 $79.21 $21.88 $54.14 $54.14 $56.22 $77.54 $21.88 $50.40 $62.11 $62.11 $80.04 $19.68 $64.94 $65.60 $82.00 $137.87 $82.00 $27.37 $23.41 $23.41 $13.05 $76.23 $0.00 $0.00 $0.00 $0.00 73140 EAP CPT®73140 X-RAY ANKLE 3+ VW BOTH IP/OP $107.00 $79.18 $14.65 $137.87 $71.76 $71.76 $78.77 $78.77 $79.21 $22.30 $53.24 $53.24 $55.29 $77.54 $22.30 $50.40 $63.29 $63.29 $80.04 $22.08 $72.86 $73.60 $92.00 $137.87 $92.00 $28.79 $26.29 $26.29 $14.65 $76.23 $0.00 $0.00 $0.00 $0.00 73200 EAP CPT®73200 CHG X-RAY FOOT 2 VW BOTH IP/OP $451.00 $333.74 $0.00 $815.94 451 $451.00 $106.02 $106.02 106.62 0 785.72 $785.72 $815.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73501 EAP CPT®73501 X-RAY FOOT 2 VW BOTH IP/OP $93.00 $68.82 $11.30 $137.87 $67.72 $67.72 $78.77 $78.77 $79.21 $19.38 $50.89 $50.89 $52.84 $77.54 $19.38 $50.40 $55.01 $55.01 $80.04 $17.04 $56.23 $56.80 $71.00 $137.87 $71.00 $27.37 $20.17 $20.17 $11.30 $76.23 $0.00 $0.00 $0.00 $0.00 73502 EAP CPT® 73502 X-RAY FOOT 3+ VW BOTH IP/OP $134.00 $99.16 $13.69 $137.87 $94.33 $94.33 $78.77 $78.77 $79.21 $27.93 $75.00 $75.00 $77.89 $77.54 $27.93 $50.40 $79.26 $79.26 $80.04 $20.64 $68.11 $68.80 $86.00 $137.87 $86.00 $28.79 $24.49 $24.49 $13.69 $76.23 $0.00 $0.00 $0.00 $0.00 73502 EAP CPT®73502 CHG X-RAY FOOT 3+ VW BOTH IP/OP $134.00 $99.16 $0.00 $137.87 94.33 $94.33 $78.77 $78.77 79.21 27.93 75 $75.00 $77.89 $77.54 27.93 $50.40 $79.26 $79.26 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73521 EAP CPT® 73521 X-RAY TOE(S) BOTH IP/OP $118.00 $87.32 $12.10 $169.61 $90.29 $90.29 $106.02 $106.02 $106.62 $24.59 $70.54 $70.54 $73.26 $104.44 $24.59 $67.89 $69.80 $69.80 $80.04 $18.24 $60.19 $60.80 $76.00 $169.61 $76.00 $23.09 $21.61 $21.61 $12.10 $76.23 $0.00 $0.00 $0.00 $0.00 73522 EAP CPT® 73522 "CT SCAN,LOWER EXTREMITY,W/O CONTRAST" BOTH IP/OP $153.00 $113.22 $31.89 $371.00 $111.25 $111.25 $106.02 $106.02 $106.62 $31.89 $83.92 $83.92 $87.15 $104.44 $31.89 $67.89 $90.50 $90.50 $112.41 $371.00 $293.83 $296.80 $156.18 $169.61 $156.18 $58.06 $105.89 $105.89 $59.06 $107.06 $0.00 $0.00 $0.00 $0.00 73552 EAP CPT®73552 "PR MRI LOWER EXTREM JT, W/O CONTRAST" BOTH IP/OP $101.00 $74.74 $0.00 $137.87 74.18 $74.18 $78.77 $78.77 79.21 21.05 57.14 $57.14 $59.34 $77.54 21.05 $50.40 $59.74 $59.74 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73560 EAP CPT® 73560 RADIOLOGIC EXAM COMPLETE ACUTE ABDOMEN SERIES BOTH IP/OP $98.00 $72.52 $0.00 $137.87 $70.14 $70.14 $78.77 $78.77 $79.21 $20.43 $47.79 $47.79 $49.63 $77.54 $20.42 $50.40 $57.97 $57.97 $112.41 $27.60 $91.08 $92.00 $115.00 $137.87 $115.00 $44.36 $32.78 $32.78 $0.00 $107.06 $0.00 $0.00 $0.00 $0.00 73560 EAP CPT®73560 CHG RADIOLOGIC EXAM COMPLETE ACUTE ABDOMEN SERIES BOTH IP/OP $98.00 $72.52 $0.00 $137.87 70.14 $70.14 $78.77 $78.77 79.21 20.43 47.79 $47.79 $49.63 $77.54 20.42 $50.40 $57.97 $57.97 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73562 EAP CPT® 73562 "CT SCAN,ABDOMEN,W/O CONTRAST" BOTH IP/OP $117.00 $86.58 $24.38 $316.00 $81.42 $81.42 $78.77 $78.77 $79.21 $24.39 $60.18 $60.18 $62.50 $77.54 $24.38 $50.40 $69.21 $69.21 $112.41 $316.00 $250.27 $252.80 $156.18 $137.87 $156.18 $49.45 $90.40 $90.40 $50.31 $107.06 $0.00 $0.00 $0.00 $0.00 73564 EAP CPT® 73564 CT SCAN OF ABDOMEN CONTRAST BOTH IP/OP $132.00 $97.68 $27.51 $637.00 $90.29 $90.29 $106.02 $106.02 $106.62 $27.51 $69.25 $69.25 $71.92 $104.44 $27.51 $67.89 $78.08 $78.08 $202.33 $637.00 $504.50 $509.60 $281.11 $169.61 $281.11 $99.69 $185.49 $185.49 $101.41 $192.70 $0.00 $0.00 $0.00 $0.00 73590 EAP CPT® 73590 PR CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMGES BOTH IP/OP $90.00 $66.60 $0.00 $137.87 65.31 $65.31 $78.77 $78.77 79.21 18.76 45.06 $45.06 $46.80 $77.54 18.76 $50.40 $53.24 $53.24 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73590 EAP CPT®73590 CT SCAN OF ABDOMEN COMBO BOTH IP/OP $90.00 $66.60 $18.76 $637.00 $65.31 $65.31 $78.77 $78.77 $79.21 $18.76 $45.06 $45.06 $46.80 $77.54 $18.76 $50.40 $53.24 $53.24 $202.33 $637.00 $504.50 $509.60 $281.11 $137.87 $281.11 $99.69 $211.06 $211.06 $101.41 $192.70 $0.00 $0.00 $0.00 $0.00 73600 EAP CPT® 73600 "CHG CT SCAN,ABDOMENT AND PELVIS,W/O CONTRAST" BOTH IP/OP $92.00 $68.08 $0.00 $137.87 67.72 $67.72 $78.77 $78.77 79.21 19.18 45.96 $45.96 $47.73 $77.54 19.17 $50.40 $54.42 $54.42 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73600 EAP CPT®73600 CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMGES BOTH IP/OP $92.00 $68.08 $19.17 $836.80 $67.72 $67.72 $78.77 $78.77 $79.21 $19.18 $45.96 $45.96 $47.73 $77.54 $19.17 $50.40 $54.42 $54.42 $387.01 $251.04 $828.43 $836.80 $537.70 $137.87 $537.70 $163.70 $298.94 $298.94 $166.52 $368.58 $0.00 $0.00 $0.00 $0.00 73610 EAP CPT® 73610 "CHG CT SCAN,ABDOMENT AND PELVIS,W CONTRAST" BOTH IP/OP $105.00 $77.70 $0.00 $137.87 71.76 $71.76 $78.77 $78.77 79.21 21.88 54.14 $54.14 $56.22 $77.54 21.88 $50.40 $62.11 $62.11 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73610 EAP CPT®73610 "CT SCAN,ABDOMENT AND PELVIS,W/O CONTRAST" BOTH IP/OP $105.00 $77.70 $0.00 $315.22 $71.76 $71.76 $78.77 $78.77 $79.21 $21.88 $54.14 $54.14 $56.22 $77.54 $21.88 $50.40 $62.11 $62.11 $0.00 $95.52 $315.22 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73620 EAP CPT® 73620 "PR MRI, ABDOMEN, COMBO" BOTH IP/OP $81.00 $59.94 $0.00 $137.87 58.87 $58.87 $78.77 $78.77 79.21 16.88 44.15 $44.15 $45.85 $77.54 16.88 $50.40 $47.91 $47.91 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73620 EAP CPT®73620 "CT SCAN,ABDOMENT AND PELVIS,W CONTRAST" BOTH IP/OP $81.00 $59.94 $0.00 $661.32 $58.87 $58.87 $78.77 $78.77 $79.21 $16.88 $44.15 $44.15 $45.85 $77.54 $16.88 $50.40 $47.91 $47.91 $0.00 $200.40 $661.32 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73630 EAP CPT® 73630 "US,HEAD/NECK TISSUES,B-SCAN/REAL TIME" BOTH IP/OP $99.00 $73.26 $20.63 $248.80 $66.11 $66.11 $78.77 $78.77 $79.21 $20.63 $53.24 $53.24 $55.29 $77.54 $20.63 $50.40 $58.56 $58.56 $112.41 $74.64 $246.31 $248.80 $156.18 $137.87 $156.18 $82.37 $88.96 $88.96 $49.51 $107.06 $0.00 $0.00 $0.00 $0.00 73630 EAP CPT®73630 "US, HEAD/NECK TISSUES,REAL TIME" BOTH IP/OP $99.00 $73.26 $0.00 $137.87 66.11 $66.11 $78.77 $78.77 79.21 20.63 53.24 $53.24 $55.29 $77.54 20.63 $50.40 $58.56 $58.56 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73660 EAP CPT® 73660 CHG US BREAST UNI REAL TIME WITH IMAGE LIMITED BOTH IP/OP $83.00 $61.42 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73700 EAP CPT® 73700 "PR US, ABDOM,B-SCAN &/OR REAL TIME,COMPLETE" BOTH IP/OP $383.00 $283.42 $0.00 $383.00 383 $383.00 $106.02 $106.02 106.62 79.83 383 $383.00 $383.00 $104.44 79.82 $67.89 $383.00 $383.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74018 EAP CPT®74018 "PR US, ABDOMEN LIMITED" BOTH IP/OP $86.00 $63.64 $0.00 $137.87 62.2 $62.20 $78.77 $78.77 79.21 17.92 45.51 $45.51 $47.26 $77.54 17.92 $50.40 $50.87 $50.87 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74022 EAP CPT® 74022 US ABDOMINAL AORTA REAL TIME SCREEN STUDY AAA BOTH IP/OP $143.00 $105.82 $29.80 $244.80 $101.59 $101.59 $106.02 $106.02 $106.62 $29.80 $79.08 $79.08 $82.12 $104.44 $29.80 $67.89 $84.58 $84.58 $112.41 $73.44 $242.35 $244.80 $156.18 $169.61 $156.18 $90.50 $87.52 $87.52 $48.72 $107.06 $0.00 $0.00 $0.00 $0.00 74022 EAP CPT®74022 SONO ABDOMEN LIMITED BOTH IP/OP $143.00 $105.82 $29.80 $175.20 $101.59 $101.59 $106.02 $106.02 $106.62 $29.80 $79.08 $79.08 $82.12 $104.44 $29.80 $67.89 $84.58 $84.58 $112.41 $52.56 $173.45 $175.20 $156.18 $169.61 $156.18 $83.78 $62.67 $62.67 $34.86 $107.06 $0.00 $0.00 $0.00 $0.00 74150 EAP CPT® 74150 "PR US,RETROPERIT,REAL TIME,COMPLETE" BOTH IP/OP $406.00 $300.44 $0.00 $406.00 406 $406.00 $106.02 $106.02 106.62 84.62 406 $406.00 $406.00 $104.44 84.61 $67.89 $406.00 $406.00 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74160 EAP CPT® 74160 "US,RETROPERIT, B-SCAN/REAL TIME,COMPLETE" BOTH IP/OP $691.00 $511.34 $0.00 $691.00 $691.00 $691.00 $173.95 $173.95 $174.93 $0.00 $691.00 $691.00 $691.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.41 $65.04 $214.63 $216.80 $156.18 $540.00 $156.18 $112.23 $77.44 $77.44 $43.14 $107.06 $0.00 $0.00 $0.00 $0.00 74170 EAP CPT® 74170 SONO ABD RETROPERITNL LTD BOTH IP/OP $708.00 $523.92 $0.00 $112.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.41 $25.44 $83.95 $84.80 $106.00 $0.00 $106.00 $83.43 $30.25 $30.25 $16.88 $107.06 $0.00 $0.00 $0.00 $0.00 74174 EAP CPT®74174 "CHG US, OB >/= 14 WKS, SNGL FETUS" BOTH IP/OP "$1,140.00 " $843.60 $0.00 "$1,140.00" 1140 "$1,140.00" $358.61 $358.61 360.63 237.6 785.72 $785.72 $815.94 $352.81 237.58 $229.33 "$1,106.00" "$1,106.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74176 EAP CPT®74176 "CHG US,PREGNANT UTERUS,F/U,TRANSABD APP" BOTH IP/OP $242.00 $179.08 $0.00 $370.58 242 $242.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74177 EAP CPT®74177 "CHG FETAL BIOPHYS PROF,W/O NST" BOTH IP/OP $920.00 $680.80 $0.00 $920.00 920 $920.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74178 EAP CPT®74178 "CHG ECHOGRAPHY,TRANSVAGINAL" BOTH IP/OP "$1,030.00 " $762.20 $0.00 "$1,030.00" 1030 "$1,030.00" $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76536 EAP CPT® 76536 "ECHO,PELVIC (NONOBSTETRIC)" BOTH IP/OP $322.00 $238.28 $42.51 $266.85 $266.85 $266.85 $106.02 $106.02 $106.62 $67.11 $204.76 $204.76 $212.63 $104.44 $67.10 $67.89 $190.46 $190.46 $112.41 $64.08 $211.46 $213.60 $156.18 $183.00 $156.18 $92.96 $76.36 $76.36 $42.51 $107.06 $0.00 $0.00 $0.00 $0.00 76536 EAP CPT®76536 "PR US,PELVIC (NONOBSTETRIC),REAL TIME,COMPLETE" BOTH IP/OP $322.00 $238.28 $0.00 $266.85 266.85 $266.85 $106.02 $106.02 106.62 67.11 204.76 $204.76 $212.63 $104.44 67.1 $67.89 $190.46 $190.46 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76700 EAP CPT® 76700 "CHG US GUIDE, VASCULAR ACCESS" BOTH IP/OP $338.00 $250.12 $0.00 $280.53 280.53 $280.53 $106.02 $106.02 106.62 70.45 236.95 $236.95 $246.07 $104.44 70.44 $67.89 $199.93 $199.93 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76700 EAP CPT®76700 "US,EXTREMITY,NONVASCULAR,REAL-TIME IMAGE,LIMITED" BOTH IP/OP $338.00 $250.12 $0.00 $280.53 $280.53 $280.53 $106.02 $106.02 $106.62 $70.45 $236.95 $236.95 $246.07 $104.44 $70.44 $67.89 $199.93 $199.93 $0.00 $27.84 $91.87 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76705 EAP CPT® 76705 SCREENING DIGITAL BREAST TOMOSYNTHESIS BI BOTH IP/OP $252.00 $186.48 $14.01 $209.59 $209.59 $209.59 $106.02 $106.02 $106.62 $52.52 $182.05 $182.05 $189.05 $104.44 $52.52 $67.89 $149.06 $149.06 $26.75 $21.12 $69.70 $70.40 $25.21 $183.00 $25.21 $53.24 $25.21 $25.21 $14.01 $25.21 $0.00 $0.00 $0.00 $0.00 76705 EAP CPT®76705 SONO GUIDE NEEDLE BIOPSY BOTH IP/OP $252.00 $186.48 $0.00 $209.59 $209.59 $209.59 $106.02 $106.02 $106.62 $52.52 $182.05 $182.05 $189.05 $104.44 $52.52 $67.89 $149.06 $149.06 $0.00 $21.84 $72.07 $72.80 $0.00 $183.00 $0.00 $92.25 $25.93 $25.93 $14.49 $0.00 $0.00 $0.00 $0.00 $0.00 76706 EAP CPT® 76706 CHG SCREENING DIGITAL BREAST TOMOSYNTHESIS BI BOTH IP/OP $307.00 $227.18 $0.00 $214.45 214.45 $214.45 $106.02 $106.02 106.62 63.99 166.71 $166.71 $173.12 $104.44 63.98 $67.89 $181.59 $181.59 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76770 EAP CPT®76770 CHG DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI BOTH IP/OP $313.00 $231.62 $0.00 $259.59 259.59 $259.59 $106.02 $106.02 106.62 65.24 231.49 $231.49 $240.40 $104.44 65.23 $67.89 $185.14 $185.14 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76775 EAP CPT® 76775 CHG SCREENING MAMMOGRAPHY BI 2-VIEW BREAST INC CAD BOTH IP/OP $165.00 $122.10 $0.00 $209.79 133.82 $133.82 $106.02 $106.02 106.62 34.39 202.02 $202.02 $209.79 $104.44 34.39 $67.89 $97.60 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76830 EAP CPT®76830 CHG DRUG SCREEN QUANT DIPROPYLACETIC ACID TOTAL BOTH IP/OP $345.00 $255.30 $0.00 $280.55 280.55 $280.55 $106.02 $106.02 106.62 71.91 211.68 $211.68 $219.82 $104.44 71.9 $67.89 $204.07 $204.07 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76856 EAP CPT®76856 ASSAY OF VANCOMYCIN BOTH IP/OP $305.00 $225.70 $0.00 $253.12 253.12 $253.12 $106.02 $106.02 106.62 63.57 212.59 $212.59 $220.76 $104.44 63.56 $67.89 $180.41 $180.41 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76857 EAP CPT®76857 URINALYSIS WITH MICROSCOPY BOTH IP/OP $136.00 $100.64 $3.17 $208.22 $110.46 $110.46 $106.02 $106.02 $106.62 $28.35 $200.51 $200.51 $208.22 $104.44 $28.34 $67.89 $80.44 $80.44 $3.33 $8.86 $8.71 $8.80 $4.60 $169.61 $4.60 $4.99 $3.17 $3.17 $3.49 $3.17 $0.00 $0.00 $0.00 $0.00 76870 EAP CPT® 76870 CHG URINALYSIS NONAUTO W/O SCOPE BOTH IP/OP $291.00 $215.34 $0.00 $223.60 156.39 $156.39 $106.02 $106.02 106.62 60.65 215.32 $215.32 $223.60 $104.44 60.64 $67.89 $172.13 $172.13 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76882 EAP CPT® 76882 URINALYSIS BOTH IP/OP $160.00 $118.40 $0.00 $106.62 $82.24 $82.24 $106.02 $106.02 $106.62 $10.15 $0.00 $0.00 $0.00 $104.44 $0.00 $67.89 $0.00 $0.00 $2.36 $6.28 $6.34 $6.40 $3.26 $104.00 $3.26 $3.55 $2.25 $2.25 $2.48 $2.25 $0.00 $0.00 $0.00 $0.00 76942 EAP CPT® 76942 URINE PREGNANCY TEST BOTH IP/OP $165.00 $122.10 $0.00 $389.47 137.83 $137.83 $0.00 $0.00 0 34.39 375.04 $375.04 $389.47 $0.00 34.39 $0.00 $97.60 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77063 EAP CPT® 77063 PREGNANCY TEST-URINE BOTH IP/OP $149.00 $110.26 $6.98 $149.00 $126.56 $126.56 $25.21 $25.21 $46.99 $31.06 $64.15 $64.15 $66.61 $25.21 $31.05 $16.39 $88.13 $88.13 $9.04 $17.68 $23.76 $24.00 $12.48 $149.00 $12.48 $9.97 $8.61 $8.61 $6.98 $8.61 $0.00 $0.00 $0.00 $0.00 77063 EAP CPT®77063 URINALYSIS VOLUME MEASURE BOTH IP/OP $149.00 $110.26 $0.00 $149.00 126.56 $126.56 $25.21 $25.21 46.99 31.06 64.15 $64.15 $66.61 $25.21 31.05 $16.39 $88.13 $88.13 $149.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77067 EAP CPT®77067 "INSERT,IMPLANT CONTRACEPTIVE" BOTH IP/OP $366.00 $270.84 $0.00 $366.00 310.36 $310.36 $99.77 $99.77 113.86 76.28 249.62 $249.62 $259.22 $99.77 76.27 $64.85 $216.49 $216.49 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77080 EAP CPT® 77080 "ASPIRATION/INJ.,GANGION CYST" BOTH IP/OP $105.00 $77.70 $0.00 $169.61 93.51 $93.51 $106.02 $106.02 105 21.88 152.48 $152.48 $158.35 $104.44 21.88 $67.89 $62.11 $62.11 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77081 EAP CPT® 77081 TREAT FRACTURE RADIUS/ULNA BOTH IP/OP $88.00 $65.12 $0.00 $137.87 63.7 $63.70 $78.77 $78.77 79.21 0 48.21 $48.21 $50.07 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80048 EAP CPT®80048 G-TUBE INSERTION BOTH IP/OP $26.00 $19.24 $0.00 $17.45 17.45 $17.45 $8.46 $8.46 4.23 4.23 12.85 $12.85 $13.35 $8.46 12.52 $5.50 $15.38 $15.38 $13.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80053 EAP CPT®80053 #N/A BOTH IP/OP $32.00 $23.68 $0.00 $21.81 21.81 $21.81 $10.56 $10.56 5.28 5.28 16.06 $16.06 $16.68 $10.56 15.61 $6.86 $18.93 $18.93 $17.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80061 EAP CPT®80061 SIGMOIDOSCOPY W/SUBMUC INJ BOTH IP/OP $41.00 $30.34 $0.00 $27.64 27.64 $27.64 $13.39 $13.39 6.7 6.7 20.35 $20.35 $21.14 $13.39 19.79 $8.70 $24.25 $24.25 $22.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80069 EAP CPT®80069 #N/A BOTH IP/OP $27.00 $19.98 $0.00 $17.93 17.93 $17.93 $8.68 $8.68 4.34 4.34 13.19 $13.19 $13.69 $8.68 12.83 $5.64 $15.97 $15.97 $14.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80076 EAP CPT®80076 ECC CERVICAL SCRAPE BOTH IP/OP $25.00 $18.50 $0.00 $16.87 16.87 $16.87 $8.17 $8.17 4.09 4.09 12.41 $12.41 $12.88 $8.17 12.08 $5.31 $14.79 $14.79 $13.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81001 EAP CPT® 81001 FINGER 3 VIEWS BOTH IP/OP $10.00 $7.40 $0.00 $6.55 6.55 $6.55 $3.17 $3.17 1.59 1.58 4.82 $4.82 $5.00 $3.17 4.68 $2.06 $5.92 $5.92 $5.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81003 EAP CPT®81003 US PELVIS LTD/FU NON-OB BOTH IP/OP $7.00 $5.18 $0.00 $4.65 4.65 $4.65 $2.25 $2.25 1.13 1.12 3.41 $3.41 $3.54 $2.25 3.33 $1.46 $4.14 $4.14 $3.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81025 EAP CPT®81025 BASIC METABOLIC PANEL BOTH IP/OP $26.00 $19.24 $0.00 $15.38 13.04 $13.04 $8.61 $8.61 4.31 3.87 9.61 $9.61 $9.98 $8.61 9.36 $5.60 $15.38 $15.38 $14.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82150 EAP CPT®82150 "RETICULOCYTES, AUTOMATED" BOTH IP/OP $20.00 $14.80 $0.00 $13.38 13.38 $13.38 $6.48 $6.48 3.24 3.24 9.84 $9.84 $10.22 $6.48 9.58 $4.21 $11.83 $11.83 $10.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82274 EAP CPT® 82274 VFC FLU. VAC. 3-21 YRS BOTH IP/OP $48.00 $35.52 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82565 EAP CPT®82565 "NICU/PED/DEVELOP.TESTING,LIMI" BOTH IP/OP $16.00 $11.84 $0.00 $10.59 10.59 $10.59 $5.12 $5.12 2.56 2.56 7.78 $7.78 $8.08 $5.12 7.46 $3.33 $9.46 $9.46 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82947 EAP CPT®82947 "BLOOD,OCCULT,FECAL HGB,FECES,1-3 SIMULT" BOTH IP/OP $12.00 $8.88 $0.00 $44.80 $8.10 $8.10 $3.93 $3.93 $1.97 $0.00 $5.96 $5.96 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 $16.72 $44.44 $44.35 $44.80 $23.08 $0.00 $23.08 $27.15 $15.92 $15.92 $19.01 $15.92 $0.00 $0.00 $0.00 $0.00 82977 EAP CPT®82977 ASSAY OF IONIZED CALCIUM BOTH IP/OP $22.00 $16.28 $0.00 $14.86 14.86 $14.86 $7.20 $7.20 3.6 3.6 10.93 $10.93 $11.35 $7.20 7.46 $4.68 $13.01 $13.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83036 EAP CPT®83036 ASSAY OF CK (CPK) BOTH IP/OP $30.00 $22.20 $0.00 $20.04 20.04 $20.04 $9.71 $9.71 4.86 4.86 14.74 $14.74 $15.30 $9.71 14.33 $6.31 $17.75 $17.75 $16.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83540 EAP CPT®83540 CREATINE MB FRACTION BOTH IP/OP $20.00 $14.80 $0.00 $13.36 13.36 $13.36 $6.47 $6.47 3.24 3.24 9.84 $9.84 $10.22 $6.47 9.58 $4.21 $11.83 $11.83 $10.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83615 EAP CPT®83615 ASSAY OF URINE CREATININE BOTH IP/OP $19.00 $14.06 $0.00 $12.46 12.46 $12.46 $6.04 $6.04 3.02 3.02 9.16 $9.16 $9.51 $6.04 7.46 $3.93 $11.24 $11.24 $9.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83690 EAP CPT®83690 ASSAY OF FERRITIN BOTH IP/OP $21.00 $15.54 $0.00 $14.23 14.23 $14.23 $6.89 $6.89 3.45 3.44 10.46 $10.46 $10.86 $6.89 10.17 $4.48 $12.42 $12.42 $11.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83721 EAP CPT®83721 ASSAY OF FOLIC ACID SERUM BOTH IP/OP $32.00 $23.68 $0.00 $19.69 19.69 $19.69 $10.50 $10.50 5.25 4.77 14.49 $14.49 $15.04 $10.50 14.1 $6.83 $18.93 $18.93 $17.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83735 EAP CPT®83735 BLOOD PH BOTH IP/OP $21.00 $15.54 $0.00 $13.83 13.83 $13.83 $6.70 $6.70 3.35 3.35 10.17 $10.17 $10.56 $6.70 9.89 $4.36 $12.42 $12.42 $11.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84100 EAP CPT®84100 ASSAY OF HAPTOGLOBIN QUANT BOTH IP/OP $15.00 $11.10 $0.00 $9.79 9.79 $9.79 $4.74 $4.74 2.37 2.37 7.21 $7.21 $7.48 $4.74 7.01 $3.08 $8.87 $8.87 $7.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84132 EAP CPT®84132 HEMOGLOBIN ELECTROPHORESIS BOTH IP/OP $15.00 $11.10 $0.00 $9.50 9.5 $9.50 $4.76 $4.76 2.38 2.3 6.97 $6.97 $7.24 $4.76 6.79 $3.09 $8.87 $8.87 $7.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84155 EAP CPT®84155 LACTATE (LD) (LDH) ENZYME BOTH IP/OP $12.00 $8.88 $0.00 $7.58 7.58 $7.58 $3.67 $3.67 1.84 0 5.56 $5.56 $5.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84550 EAP CPT®84550 ASSAY OF SERUM POTASSIUM BOTH IP/OP $14.00 $10.36 $0.00 $9.32 9.32 $9.32 $4.52 $4.52 2.26 2.26 6.85 $6.85 $7.12 $4.52 6.67 $2.94 $8.28 $8.28 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 85018 EAP CPT®85018 PROTEIN ELECTROPHORESIS SERUM BOTH IP/OP $8.00 $5.92 $0.00 $4.88 4.88 $4.88 $2.37 $2.37 1.19 1.18 3.6 $3.60 $3.74 $2.37 3.5 $1.54 $4.73 $4.73 $3.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 85025 EAP CPT®85025 ASSAY OF URINE SODIUM BOTH IP/OP $24.00 $17.76 $0.00 $16.05 16.05 $16.05 $7.77 $7.77 3.89 3.88 9.97 $9.97 $10.36 $7.77 11.48 $5.05 $14.20 $14.20 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 85027 EAP CPT®85027 ASSAY OF FREE THYROXINE BOTH IP/OP $20.00 $14.80 $0.00 $13.36 13.36 $13.36 $6.47 $6.47 3.24 3.23 9.83 $9.83 $10.21 $6.47 9.57 $4.21 $11.83 $11.83 $10.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 85046 EAP CPT®85046 ASSAY THYROID STIM HORMONE BOTH IP/OP $17.00 $12.58 $0.00 $11.48 11.48 $11.48 $5.57 $5.57 2.79 2.79 8.48 $8.48 $8.80 $5.57 8.24 $3.62 $10.06 $10.06 $9.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 85610 EAP CPT®85610 ASSAY OF BLOOD/URIC ACID BOTH IP/OP $13.00 $9.62 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87070 EAP CPT® 87070 THROMBOPLASTIN TIME PARTIAL BOTH IP/OP $26.00 $19.24 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87210 EAP CPT®87210 VIRUS ANTIBODY NOS BOTH IP/OP $18.00 $13.32 $0.00 $10.65 8.82 $8.82 $5.82 $5.82 2.91 2.62 6.48 $6.48 $6.73 $5.82 6.3 $3.78 $10.65 $10.65 $9.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87430 EAP CPT® 87430 Culture Other Specimen Aerobic BOTH IP/OP $51.00 $37.74 $0.00 $24.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.05 $24.06 $23.76 $24.00 $12.50 $0.00 $12.50 $13.56 $8.62 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90460 EAP CPT® 90460 TISSUE HOMOGENIZATION CULTURE BOTH IP/OP $47.00 $34.78 $0.00 $17.04 0 $0.00 $14.42 $14.42 17.04 0 16.28 $16.28 $16.90 $14.42 9.79 $9.37 $0.00 $0.00 $14.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90461 EAP CPT® 90461 MICROBE SUSCEPTIBLE MIC BOTH IP/OP $36.00 $26.64 $0.00 $16.90 0 $0.00 $12.98 $12.98 12.86 0 16.28 $16.28 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90471 EAP CPT®90471 SMEAR GRAM STAIN BOTH IP/OP $47.00 $34.78 $0.00 $39.19 25.52 $25.52 $38.97 $38.97 39.19 9.8 34.88 $34.88 $36.23 $38.34 9.79 $24.92 $27.80 $27.80 $30.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90472 EAP CPT®90472 SMEAR WET MOUNT SALINE/INK BOTH IP/OP $36.00 $26.64 $0.00 $27.75 19.55 $19.55 $0.00 $0.00 0 7.5 26.72 $26.72 $27.75 $0.00 7.5 $0.00 $21.29 $21.29 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90620 EAP CPT® 90620 CHG IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE BOTH IP/OP $30.00 $22.20 $0.00 $171.96 13.5 $13.50 $0.00 $0.00 171.96 6.25 22.27 $22.27 $23.12 $0.00 30 $0.00 $17.75 $17.75 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90621 EAP CPT® 90621 IAAD IA STREPTOCOCCUS GROUP A BOTH IP/OP $30.00 $22.20 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $30.00 $0.00 $0.00 $0.00 $17.65 $33.52 $46.73 $47.20 $24.37 $13.50 $24.37 $18.87 $16.81 $16.81 $13.21 $16.81 $0.00 $0.00 $0.00 $0.00 90632 EAP CPT® 90632 "CHG CYTOPATH FLUIDS,SMEAR,INTERP" BOTH IP/OP $30.00 $22.20 $0.00 $56.67 13.5 $13.50 $0.00 $0.00 0 56.67 22.27 $22.27 $23.12 $0.00 30 $0.00 $17.75 $17.75 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90633 EAP CPT® 90633 "CHG CYTOPATH, CELL ENHANCE TECH" BOTH IP/OP $30.00 $22.20 $0.00 $23.12 13.5 $13.50 $0.00 $0.00 0 9.4 22.27 $22.27 $23.12 $0.00 6.25 $0.00 $17.75 $17.75 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90636 EAP CPT® 90636 CYTOPATH C/V THIN LAYER BOTH IP/OP $30.00 $22.20 $0.00 $13.50 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90647 EAP CPT® 90647 CYTOPATH FNA MISC BOTH IP/OP $30.00 $22.20 $0.00 $23.12 13.5 $13.50 $0.00 $0.00 0 0 22.27 $22.27 $23.12 $0.00 6.25 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90648 EAP CPT® 90648 BODY FLUID CELL COUNT BOTH IP/OP $30.00 $22.20 $0.00 $23.12 13.5 $13.50 $0.00 $0.00 0 6.25 22.27 $22.27 $23.12 $0.00 6.25 $0.00 $17.75 $17.75 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90651 EAP CPT® 90651 IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX BOTH IP/OP $30.00 $22.20 $0.00 $229.60 $13.50 $13.50 $0.00 $0.00 $229.60 $6.25 $22.27 $22.27 $23.12 $0.00 $30.00 $0.00 $17.75 $17.75 $21.90 $10.97 $17.37 $17.54 $14.42 $13.50 $14.42 $7.83 $14.42 $14.42 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 90658 EAP CPT®90658 IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT BOTH IP/OP $30.00 $22.20 $0.00 $23.12 $13.50 $13.50 $0.00 $0.00 $15.36 $0.00 $22.27 $22.27 $23.12 $0.00 $0.00 $0.00 $0.00 $0.00 $13.61 $10.97 $17.37 $17.54 $12.98 $0.00 $12.98 $0.00 $12.98 $12.98 $0.00 $12.98 $0.00 $0.00 $0.00 $0.00 90670 EAP CPT® 90670 "PR IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOXOID" BOTH IP/OP $30.00 $22.20 $0.00 $230.14 13.5 $13.50 $7.80 $7.80 230.14 6.25 22.27 $22.27 $23.12 $7.80 30 $5.07 $17.75 $17.75 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90674 EAP CPT® 90674 "IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOXOID" BOTH IP/OP $30.00 $22.20 $5.07 $50.00 $13.50 $13.50 $7.80 $7.80 $29.23 $6.25 $22.27 $22.27 $23.12 $7.80 $30.00 $5.07 $17.75 $17.75 $38.22 $25.00 $39.60 $40.00 $50.00 $13.50 $50.00 $7.83 $14.42 $14.42 $7.96 $36.40 $0.00 $0.00 $0.00 $0.00 90680 EAP CPT® 90680 "PR IMMUNIZ,ADMIN,EACH ADDL" BOTH IP/OP $30.00 $22.20 $0.00 $23.12 13.5 $13.50 $0.00 $0.00 0 6.25 22.27 $22.27 $23.12 $0.00 6.25 $0.00 $17.75 $17.75 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90681 EAP CPT® 90681 "IMMUNIZ,ADMIN,EACH ADDL" BOTH IP/OP $30.00 $22.20 $0.00 $119.46 $13.50 $13.50 $0.00 $0.00 $119.46 $6.25 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $7.04 $12.98 $12.98 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 90685 EAP CPT® 90685 MENB RECOMBINANT PROT W/OUT MEMBR VESIC VACC IM BOTH IP/OP $30.00 $22.20 $0.00 $200.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $18.00 $0.00 $18.00 $200.63 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 90686 EAP CPT® 90686 MENB RECOMBINANT LIPOPROTEIN VACCINE IM BOTH IP/OP $25.00 $18.50 $0.00 $163.94 $11.25 $11.25 $6.50 $6.50 $19.58 $5.21 $18.56 $18.56 $19.27 $6.50 $24.12 $4.23 $14.79 $14.79 $0.00 $15.00 $23.76 $24.00 $18.00 $11.25 $18.00 $163.94 $0.00 $0.00 $156.09 $0.00 $0.00 $0.00 $0.00 $0.00 90696 EAP CPT® 90696 HEPA VACCINE ADULT IM BOTH IP/OP $30.00 $22.20 $0.00 $70.39 $13.50 $13.50 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $13.50 $0.00 $70.39 $0.00 $0.00 $67.03 $0.00 $0.00 $0.00 $0.00 $0.00 90698 EAP CPT® 90698 HEPA VACCINE PED/ADOL-2 DOSE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90700 EAP CPT® 90700 HEPA/HEPB VACCINE ADULT IM BOTH IP/OP $30.00 $22.20 $0.00 $122.20 $13.50 $13.50 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $13.50 $0.00 $122.20 $0.00 $0.00 $116.36 $0.00 $0.00 $0.00 $0.00 $0.00 90707 EAP CPT® 90707 "HIB VACCINE, PRP-OMP, IM" BOTH IP/OP $30.00 $22.20 $0.00 $30.00 $13.50 $13.50 $0.00 $0.00 $0.00 $11.75 $22.27 $22.27 $23.12 $0.00 $30.00 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $13.50 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90710 EAP CPT® 90710 "HIB VACCINE, PRP-T, IM" BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $13.50 $13.50 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $13.50 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90713 EAP CPT® 90713 HUMAN PAPILLOMA VIRUS NONAVALENT HPV 3 DOSE IM BOTH IP/OP $30.00 $22.20 $0.00 $267.82 $13.50 $13.50 $0.00 $0.00 $0.00 $9.40 $22.27 $22.27 $23.12 $0.00 $30.00 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $18.00 $13.50 $18.00 $267.82 $0.00 $0.00 $255.01 $0.00 $0.00 $0.00 $0.00 $0.00 90715 EAP CPT® 90715 PNEUMOCOCCAL CONJ VACCINE 13 VALENT IM BOTH IP/OP $30.00 $22.20 $0.00 $252.18 $13.50 $13.50 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $23.12 $0.00 $30.00 $0.00 $17.75 $17.75 $4.38 $15.00 $23.76 $24.00 $4.38 $13.50 $4.38 $252.18 $7.80 $7.80 $240.12 $7.80 $0.00 $0.00 $0.00 $0.00 90716 EAP CPT® 90716 CCIIV4 VACCINE PRESERVATIVE FREE 0.5 ML IM USE BOTH IP/OP $30.00 $22.20 $0.00 $136.66 $13.50 $13.50 $0.00 $0.00 $136.66 $9.40 $22.27 $22.27 $23.12 $0.00 $30.00 $0.00 $17.75 $17.75 $4.38 $15.00 $23.76 $24.00 $4.38 $13.50 $4.38 $33.05 $7.80 $7.80 $31.47 $7.80 $0.00 $0.00 $0.00 $0.00 90723 EAP CPT® 90723 "ROTOVIRUS VACCINE, ORAL" BOTH IP/OP $30.00 $22.20 $0.00 $79.00 $13.50 $13.50 $0.00 $0.00 $79.00 $6.25 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $13.50 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90732 EAP CPT® 90732 "ROTOVIRUS VACCINE, HUMAN ATTENUATED, 2 DOSE, ORAL" BOTH IP/OP $30.00 $22.20 $0.00 $119.92 $13.50 $13.50 $7.80 $7.80 $119.92 $9.40 $22.27 $22.27 $23.12 $7.80 $30.00 $5.07 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $18.00 $13.50 $18.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90734 EAP CPT® 90734 IIV4 VACC PRSRV FREE 0.25 ML DOS FOR IM USE BOTH IP/OP $30.00 $22.20 $0.00 $129.14 $13.50 $13.50 $0.00 $0.00 $129.14 $9.40 $22.27 $22.27 $23.12 $0.00 $30.00 $0.00 $17.75 $17.75 $0.00 $0.00 $23.76 $0.00 $0.00 $13.50 $0.00 $4.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90744 EAP CPT® 90744 IIV4 VACC PRESRV FREE 0.5 ML DOS FOR IM USE BOTH IP/OP $30.00 $22.20 $0.00 $28.21 $13.50 $13.50 $7.80 $7.80 $28.21 $0.00 $22.27 $22.27 $23.12 $0.00 $0.00 $0.00 $0.00 $0.00 $3.65 $12.50 $19.80 $20.00 $3.65 $13.50 $3.65 $22.36 $6.50 $6.50 $21.29 $6.50 $0.00 $0.00 $0.00 $0.00 90746 EAP CPT® 90746 "DTAP-IPV, IM, AGE 4-6 YEAR" BOTH IP/OP $227.00 $167.98 $0.00 $174.97 $102.15 $102.15 $59.02 $59.02 $69.65 $70.16 $168.48 $168.48 $174.97 $59.02 $81.84 $38.36 $134.27 $134.27 $0.00 $15.00 $23.76 $24.00 $0.00 $102.15 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90791 EAP CPT® 90791 "DTAP-HIB-IP VACCINE, IM" BOTH IP/OP $494.00 $365.56 $0.00 $380.78 $268.24 $268.24 $130.30 $130.30 $131.03 $102.96 $366.65 $366.65 $380.78 $128.07 $0.00 $83.25 $292.20 $292.20 $0.00 $15.00 $23.76 $24.00 $0.00 $321.10 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90792 EAP CPT®90792 "DTAP IMMUNIZATION, IM" BOTH IP/OP $553.00 $409.22 $0.00 $426.25 $300.28 $300.28 $130.30 $130.30 $131.03 $115.26 $410.44 $410.44 $426.25 $128.07 $0.00 $83.25 $327.10 $327.10 $0.00 $15.00 $23.76 $24.00 $0.00 $359.45 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90832 EAP CPT® 90832 "COMBINED VACCINE,MMR+VARICELLA,SQ" BOTH IP/OP $215.00 $159.10 $0.00 $165.72 $116.75 $116.75 $130.30 $130.30 $131.03 $44.81 $159.57 $159.57 $165.72 $128.07 $0.00 $83.25 $127.17 $127.17 $0.00 $15.00 $23.76 $24.00 $0.00 $139.75 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 90832 EAP CPT®90832 "MMR VIRUS IMMUNIZATION, SUBCUT" BOTH IP/OP $215.00 $159.10 $0.00 $165.72 $116.75 $116.75 $130.30 $130.30 $131.03 $44.81 $159.57 $159.57 $165.72 $128.07 $0.00 $83.25 $127.17 $127.17 $0.00 $15.00 $23.76 $24.00 $0.00 $139.75 $0.00 $92.45 $0.00 $0.00 $88.03 $0.00 $0.00 $0.00 $0.00 $0.00 90834 EAP CPT®90834 "POLIOMYELITIS IMMUNIZATN,INACTV,SQ" BOTH IP/OP $284.00 $210.16 $0.00 $218.91 $154.21 $154.21 $130.30 $130.30 $131.03 $59.19 $210.78 $210.78 $218.91 $128.07 $0.00 $83.25 $167.99 $167.99 $0.00 $15.00 $23.76 $24.00 $0.00 $184.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90837 EAP CPT®90837 TDAP VACCINE >7 IM BOTH IP/OP $417.00 $308.58 $0.00 $321.42 $226.43 $226.43 $130.30 $130.30 $131.03 $86.91 $309.50 $309.50 $321.42 $128.07 $0.00 $83.25 $246.66 $246.66 $0.00 $15.00 $23.76 $24.00 $0.00 $271.05 $0.00 $39.53 $0.00 $0.00 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 91111 EAP CPT® 91111 "HEP B VACCINE,PED/ADOL,IM" BOTH IP/OP "$2,479.00 " "$1,834.46" $0.00 "$2,479.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $18.00 "$2,479.00" $18.00 $4.70 $7.80 $7.80 $0.00 $7.80 $0.00 $0.00 $0.00 $0.00 92250 EAP CPT®92250 PR PSYCHOTHERAPY W/PATIENT 45 MINUTES BOTH IP/OP $105.00 $77.70 $0.00 $109.81 57.02 $57.02 $109.81 $109.81 105 21.88 77.93 $77.93 $80.93 $107.30 21.88 $69.74 $62.11 $62.11 $68.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92551 EAP CPT® 92551 PR FAMILY PSYCHOTHERAPY W/O PATIENT PRESENT 50 MINS BOTH IP/OP $40.00 $29.60 $0.00 $30.83 21.72 $21.72 $0.00 $0.00 11.81 8.34 29.69 $29.69 $30.83 $0.00 8.34 $0.00 $23.66 $23.66 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92552 EAP CPT® 92552 PR FAMILY PSYCHOTHERAPY W/PATIENT PRESENT 50 MINS BOTH IP/OP $95.00 $70.30 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93000 EAP CPT® 93000 "PR EYE EXAM, EST PATIENT,COMPREHESV" BOTH IP/OP $40.00 $29.60 $0.00 $37.57 37.57 $37.57 $17.30 $17.30 14.92 0 29.69 $29.69 $30.83 $17.30 8.34 $11.25 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93015 EAP CPT® 93015 PR COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE BOTH IP/OP $200.00 $148.00 $0.00 $169.04 169.04 $169.04 $72.09 $72.09 71.62 0 148.44 $148.44 $154.16 $72.09 41.68 $46.86 $0.00 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93225 EAP CPT®93225 PR FUNDAL PHOTOGRAPHY BOTH IP/OP $59.00 $43.66 $0.00 $109.81 58.71 $58.71 $109.81 $109.81 59 12.3 43.79 $43.79 $45.48 $107.30 12.3 $69.74 $34.90 $34.90 $38.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93227 EAP CPT®93227 FUNDAL PHOTOGRAPHY BOTH IP/OP $56.00 $41.44 $0.00 $151.93 $56.00 $56.00 $27.05 $27.05 $18.80 $0.00 $0.00 $0.00 $0.00 $0.00 $11.67 $0.00 $0.00 $0.00 $109.35 $80.00 $126.72 $128.00 $151.93 $36.40 $151.93 $59.03 $23.77 $23.77 $25.47 $104.14 $0.00 $0.00 $0.00 $0.00 93242 EAP CPT®93242 PR SPEECH/HEARING THERAPY BOTH IP/OP $43.00 $31.82 $0.00 $33.14 0 $0.00 $0.00 $0.00 0 0 31.91 $31.91 $33.14 $0.00 8.96 $0.00 $0.00 $0.00 $27.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93244 EAP CPT®93244 "PURE TONE HEARING TEST, AIR" BOTH IP/OP $73.00 $54.02 $0.00 $47.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.21 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $26.40 $47.45 $26.40 $9.01 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 93246 EAP CPT®93246 "PURE TONE AUDIOMETRY, AIR" BOTH IP/OP $43.00 $31.82 $0.00 $112.00 $0.00 $0.00 $54.21 $54.21 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $109.35 $56.00 $88.70 $89.60 $112.00 $27.95 $112.00 $17.48 $32.05 $32.05 $17.83 $104.14 $0.00 $0.00 $0.00 $0.00 93248 EAP CPT®93248 PR TYMPANOMETRY BOTH IP/OP $81.00 $59.94 $0.00 $52.65 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 16.88 $0.00 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93306 EAP CPT®93306 "PR AUDITORY EVOKED POTENTIAL, LIMITED" BOTH IP/OP $566.00 $418.84 $0.00 $504.77 504.77 $504.77 $470.55 $470.55 473.2 117.97 420.09 $420.09 $436.27 $462.81 117.95 $300.83 $334.79 $334.79 $367.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93880 EAP CPT® 93880 CV STRS TST XERS&/OR RX CONT ECG W/SI&R BOTH IP/OP $116.00 $85.84 $0.00 $562.53 $116.00 $116.00 $224.08 $224.08 $116.00 $24.18 $541.69 $541.69 $562.53 $220.56 $24.17 $143.36 $68.61 $68.61 $76.29 $126.00 $199.58 $201.60 $72.09 $75.40 $72.09 $110.83 $72.09 $72.09 $0.00 $72.09 $0.00 $0.00 $0.00 $0.00 93926 EAP CPT® 93926 "PR CARDIAC STRESS TST,TRACING ONLY" BOTH IP/OP $381.00 $281.94 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93970 EAP CPT®93970 "PR ECHO HEART XTHORACIC,COMPLETE W DOPPLER" BOTH IP/OP $102.00 $75.48 $0.00 $565.47 102 $102.00 $224.08 $224.08 102 21.26 544.52 $544.52 $565.47 $220.56 21.26 $143.36 $60.33 $60.33 $66.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93971 EAP CPT®93971 "PR ECHO HEART XTHORACIC,LIMITED" BOTH IP/OP $343.00 $253.82 $0.00 $374.41 266.11 $266.11 $106.02 $106.02 106.62 71.49 360.55 $360.55 $374.41 $104.44 71.48 $67.89 $202.88 $202.88 $222.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94640 EAP CPT® 94640 DUPLEX LO EXTREM ART UNILAT/LTD BOTH IP/OP $32.00 $23.68 $0.00 $383.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.41 $239.50 $379.37 $383.20 $156.18 $0.00 $156.18 $120.13 $127.86 $127.86 $76.26 $107.06 $0.00 $0.00 $0.00 $0.00 94664 EAP CPT®94664 "DUPLEX EXTREM VENOUS,BILAT" BOTH IP/OP $48.00 $35.52 $0.00 $556.00 $26.06 $26.06 $183.05 $183.05 $48.00 $10.00 $35.63 $35.63 $37.00 $180.07 $10.00 $117.04 $28.39 $28.39 $233.72 $347.50 $550.44 $556.00 $324.73 $0.00 $324.73 $199.35 $163.16 $163.16 $110.64 $222.60 $0.00 $0.00 $0.00 $0.00 96110 EAP CPT®96110 "PR POS AIRWAY PRESSURE, CPAP" BOTH IP/OP $35.00 $25.90 $0.00 $26.98 0 $0.00 $0.00 $0.00 10.07 0 25.98 $25.98 $26.98 $0.00 7.29 $0.00 $0.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96127 EAP CPT®96127 "PR EXHALED AIR ANALYSIS: O2, CO2" BOTH IP/OP $14.00 $10.36 $0.00 $32.96 0 $0.00 $32.96 $32.96 14 0 $0.00 $0.00 $0.00 $32.43 $0.00 $21.08 $0.00 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96161 EAP CPT® 96161 PR PLETHYSMOGRAPHY LUNG VOLUMES W/WO AIRWAY RESIST BOTH IP/OP $8.00 $5.92 $0.00 $25.59 0 $0.00 $25.59 $25.59 8 0 5.94 $5.94 $6.17 $25.14 1.67 $16.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96361 EAP CPT® 96361 PR DIFFUSING CAPACITY BOTH IP/OP $37.00 $27.38 $0.00 $38.34 0 $0.00 $0.00 $0.00 0 7.71 $0.00 $0.00 $0.00 $38.34 7.71 $24.92 $21.89 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96372 EAP CPT® 96372 PR POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND BOTH IP/OP $41.00 $30.34 $0.00 $60.38 22.26 $22.26 $60.38 $60.38 41 8.55 30.43 $30.43 $31.60 $59.39 $0.00 $38.61 $24.25 $24.25 $26.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97802 EAP CPT® 97802 PR DEBRIDEMENT OPEN WOUND 20 SQ CM< BOTH IP/OP $104.00 $76.96 $0.00 $80.16 56.47 $56.47 $34.61 $34.61 33.05 21.68 77.19 $77.19 $80.16 $34.61 21.67 $22.50 $61.52 $61.52 $67.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97803 EAP CPT® 97803 "PR ORTHOTIC MGMT AND TRAINING, EACH 15 MIN" BOTH IP/OP $90.00 $66.60 $0.00 $69.37 48.87 $48.87 $29.21 $29.21 28.17 18.76 66.8 $66.80 $69.37 $29.21 18.76 $18.99 $53.24 $53.24 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98966 EAP CPT® 98966 PR ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN BOTH IP/OP $37.00 $27.38 $0.00 $24.05 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98967 EAP CPT® 98967 "MED NUTR THER, 1ST, INDIV, EA 15 MIN" BOTH IP/OP $67.00 $49.58 $0.00 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.55 $67.00 $106.13 $107.20 $34.61 $43.55 $34.61 $20.97 $34.61 $34.61 $21.33 $34.61 $0.00 $0.00 $0.00 $0.00 98968 EAP CPT® 98968 "MED NUTR THER, SUBSQ, INDIV, EA 15 MIN" BOTH IP/OP $95.00 $70.30 $0.00 $92.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.06 $58.00 $91.87 $92.80 $29.21 $61.75 $29.21 $18.15 $29.21 $29.21 $18.47 $29.21 $0.00 $0.00 $0.00 $0.00 99024 EAP CPT® 99024 NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 MIN BOTH IP/OP $0.01 $0.01 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99173 EAP CPT® 99173 NONPHYSICIAN TELEPHONE ASSESSMENT 11-20 MIN BOTH IP/OP $11.00 $8.14 $0.00 $212.80 $0.00 $0.00 $0.00 $0.00 $3.10 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $159.60 $7.15 $159.60 $41.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99202 EAP CPT® 99202 "VISUAL SCREENING TEST, BILAT" BOTH IP/OP $204.00 $150.96 $0.00 $323.29 $0.00 $0.00 $51.57 $51.57 $49.57 $67.13 $311.31 $311.31 $323.29 $51.57 $0.00 $33.52 $120.67 $120.67 $0.00 $5.50 $8.71 $8.80 $6.60 $204.00 $6.60 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99202 EAP CPT®99202 POST-OP FOLLOW-UP VISIT BOTH IP/OP $204.00 $150.96 $0.00 $323.29 $0.00 $0.00 $51.57 $51.57 $49.57 $67.13 $311.31 $311.31 $323.29 $51.57 $0.00 $33.52 $120.67 $120.67 $0.00 $0.00 $0.01 $0.00 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99203 EAP CPT®99203 OFFICE OUTPATIENT NEW 10 MINUTES BOTH IP/OP $314.00 $232.36 $0.00 $323.29 $0.00 $0.00 $77.17 $77.17 $83.89 $67.13 $311.31 $311.31 $323.29 $77.17 $0.00 $50.16 $185.73 $185.73 $28.83 $164.50 $260.57 $263.20 $27.04 $314.00 $27.04 $108.52 $27.04 $27.04 $99.16 $27.04 $0.00 $0.00 $0.00 $0.00 99204 EAP CPT®99204 OFFICE OUTPATIENT NEW 20 MINUTES BOTH IP/OP $467.00 $345.58 $0.00 $467.00 $0.00 $0.00 $131.98 $131.98 $136.63 $67.13 $311.31 $311.31 $323.29 $131.98 $0.00 $85.79 $276.23 $276.23 $54.20 $189.00 $299.38 $302.40 $51.57 $467.00 $51.57 $108.52 $51.57 $51.57 $99.16 $51.57 $0.00 $0.00 $0.00 $0.00 99205 EAP CPT®99205 OFFICE OUTPATIENT NEW 30 MINUTES BOTH IP/OP $618.00 $457.32 $0.00 $618.00 $0.00 $0.00 $172.37 $172.37 $185.53 $67.13 $311.31 $311.31 $323.29 $172.37 $0.00 $112.04 $365.55 $365.55 $82.35 $221.00 $350.06 $353.60 $77.17 $618.00 $77.17 $108.52 $77.17 $77.17 $99.16 $77.17 $0.00 $0.00 $0.00 $0.00 99211 EAP CPT®99211 OFFICE OUTPATIENT NEW 45 MINUTES BOTH IP/OP $65.00 $48.10 $0.00 $455.20 $0.00 $0.00 $9.38 $9.38 $9.03 $67.13 $311.31 $311.31 $323.29 $9.38 $0.00 $6.10 $38.45 $38.45 $138.78 $284.50 $450.65 $455.20 $131.98 $65.00 $131.98 $108.52 $131.98 $131.98 $99.16 $131.98 $0.00 $0.00 $0.00 $0.00 99212 EAP CPT®99212 OFFICE OUTPATIENT NEW 60 MINUTES BOTH IP/OP $159.00 $117.66 $0.00 $548.80 $0.00 $0.00 $26.32 $26.32 $36.10 $67.13 $311.31 $311.31 $323.29 $26.32 $0.00 $17.11 $94.05 $94.05 $181.26 $343.00 $543.31 $548.80 $172.37 $159.00 $172.37 $108.52 $172.37 $172.37 $99.16 $172.37 $0.00 $0.00 $0.00 $0.00 99213 EAP CPT®99213 OFFICE OUTPATIENT VISIT 5 MINUTES BOTH IP/OP $254.00 $187.96 $0.00 $323.29 $0.00 $0.00 $52.29 $52.29 $67.67 $67.13 $311.31 $311.31 $323.29 $52.29 $0.00 $33.99 $150.24 $150.24 $9.84 $145.00 $229.68 $232.00 $9.38 $254.00 $9.38 $108.52 $9.38 $9.38 $99.16 $9.38 $0.00 $0.00 $0.00 $0.00 99214 EAP CPT®99214 OFFICE OUTPATIENT VISIT 10 MINUTES BOTH IP/OP $358.00 $264.92 $0.00 $358.00 $0.00 $0.00 $80.42 $80.42 $99.97 $67.13 $311.31 $311.31 $323.29 $80.42 $0.00 $52.27 $211.76 $211.76 $27.29 $156.50 $247.90 $250.40 $26.32 $358.00 $26.32 $108.52 $26.32 $26.32 $99.16 $26.32 $0.00 $0.00 $0.00 $0.00 99215 EAP CPT®99215 OFFICE OUTPATIENT VISIT 15 MINUTES BOTH IP/OP $505.00 $373.70 $0.00 $505.00 $0.00 $0.00 $113.60 $113.60 $147.16 $67.13 $311.31 $311.31 $323.29 $113.60 $0.00 $73.84 $298.71 $298.71 $54.93 $199.50 $316.01 $319.20 $52.29 $505.00 $52.29 $108.52 $52.29 $52.29 $99.16 $52.29 $0.00 $0.00 $0.00 $0.00 99242 EAP CPT®99242 OFFICE OUTPATIENT VISIT 25 MINUTES BOTH IP/OP $288.00 $213.12 $0.00 $392.80 $0.00 $0.00 $0.00 $0.00 $67.99 $0.00 $311.31 $311.31 $323.29 $0.00 $60.02 $0.00 $0.00 $0.00 $84.06 $245.50 $388.87 $392.80 $80.42 $187.20 $80.42 $108.52 $80.42 $80.42 $99.16 $80.42 $0.00 $0.00 $0.00 $0.00 99243 EAP CPT®99243 PR OFFICE OUTPATIENT VISIT 40 MINUTES BOTH IP/OP $436.00 $322.64 $0.00 $0.00 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99244 EAP CPT® 99244 OFFICE CONSULTATION NEW/ESTAB PATIENT 40 MIN BOTH IP/OP $652.00 $482.48 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $152.96 $0.00 $311.31 $311.31 $323.29 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $218.00 $345.31 $348.80 $261.60 $423.80 $261.60 $112.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99381 EAP CPT® 99381 PR OFFICE CONSULTATION NEW/ESTAB PATIENT 60 MIN BOTH IP/OP $395.00 $292.30 $0.00 $323.29 0 $0.00 $0.00 $0.00 76.64 0 311.31 $311.31 $323.29 $0.00 82.32 $0.00 $0.00 $0.00 $256.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99382 EAP CPT® 99382 OFFICE CONSULTATION NEW/ESTAB PATIENT 60 MIN BOTH IP/OP $413.00 $305.62 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $81.52 $0.00 $311.31 $311.31 $323.29 $0.00 $86.07 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $391.20 $268.45 $391.20 $155.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99383 EAP CPT® 99383 "PREVENTIVE VISIT,NEW,INFANT < 1 YR" BOTH IP/OP $429.00 $317.46 $0.00 $323.29 $0.00 $0.00 $0.00 $0.00 $86.72 $0.00 $311.31 $311.31 $323.29 $0.00 $89.40 $0.00 $0.00 $0.00 $0.00 $197.50 $312.84 $316.00 $237.00 $278.85 $237.00 $61.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99384 EAP CPT® 99384 "PREVENTIVE VISIT,NEW,AGE 1-4" BOTH IP/OP $485.00 $358.90 $0.00 $330.40 $0.00 $0.00 $0.00 $0.00 $101.65 $0.00 $311.31 $311.31 $323.29 $0.00 $101.07 $0.00 $0.00 $0.00 $0.00 $206.50 $327.10 $330.40 $247.80 $315.25 $247.80 $64.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99385 EAP CPT®99385 "PREVENTIVE VISIT,NEW,AGE5-11" BOTH IP/OP $469.00 $347.06 $0.00 $343.20 $0.00 $0.00 $0.00 $0.00 $97.50 $0.00 $311.31 $311.31 $323.29 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $214.50 $339.77 $343.20 $257.40 $304.85 $257.40 $67.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99386 EAP CPT®99386 "PR PREVENTIVE VISIT,NEW,18-39" BOTH IP/OP $545.00 $403.30 $0.00 $354.25 0 $0.00 $0.00 $0.00 118.64 0 311.31 $311.31 $323.29 $0.00 113.58 $0.00 $0.00 $0.00 $354.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99387 EAP CPT® 99387 "PR PREVENTIVE VISIT,NEW,40-64" BOTH IP/OP $591.00 $437.34 $0.00 $123.16 0 $0.00 $0.00 $0.00 0 0 $0.00 $0.00 $0.00 $0.00 123.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99391 EAP CPT® 99391 "PREVENTIVE VISIT,NEW,40-64" BOTH IP/OP $354.00 $261.96 $0.00 $436.00 $0.00 $0.00 $0.00 $0.00 $69.73 $0.00 $311.31 $311.31 $323.29 $0.00 $73.77 $0.00 $0.00 $0.00 $0.00 $272.50 $431.64 $436.00 $327.00 $230.10 $327.00 $84.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99392 EAP CPT® 99392 "PREVENTIVE VISIT,NEW,65 & OVER" BOTH IP/OP $378.00 $279.72 $0.00 $472.80 $0.00 $0.00 $0.00 $0.00 $76.64 $0.00 $311.31 $311.31 $323.29 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $295.50 $468.07 $472.80 $0.00 $245.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99393 EAP CPT® 99393 "PREVENTIVE VISIT,EST, INFANT < 1 YR" BOTH IP/OP $377.00 $278.98 $0.00 $323.29 $0.00 $0.00 $0.00 $0.00 $76.64 $0.00 $311.31 $311.31 $323.29 $0.00 $78.57 $0.00 $0.00 $0.00 $0.00 $177.00 $280.37 $283.20 $212.40 $245.05 $212.40 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99394 EAP CPT® 99394 "PREVENTIVE VISIT,EST,AGE 1-4" BOTH IP/OP $414.00 $306.36 $0.00 $323.29 $0.00 $0.00 $0.00 $0.00 $86.72 $0.00 $311.31 $311.31 $323.29 $0.00 $86.28 $0.00 $0.00 $0.00 $0.00 $189.00 $299.38 $302.40 $226.80 $269.10 $226.80 $59.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99395 EAP CPT® 99395 "PREVENTIVE VISIT,EST,AGE5-11" BOTH IP/OP $423.00 $313.02 $0.00 $323.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.31 $311.31 $323.29 $0.00 $88.15 $0.00 $0.00 $0.00 $0.00 $188.50 $298.58 $301.60 $226.20 $274.95 $226.20 $59.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99396 EAP CPT® 99396 "PREVENTIVE VISIT,EST,12-17" BOTH IP/OP $450.00 $333.00 $0.00 $331.20 $0.00 $0.00 $0.00 $0.00 $96.80 $0.00 $311.31 $311.31 $323.29 $0.00 $93.78 $0.00 $0.00 $0.00 $0.00 $207.00 $327.89 $331.20 $248.40 $292.50 $248.40 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99397 EAP CPT®99397 "PREVENTIVE VISIT,EST,18-39" BOTH IP/OP $486.00 $359.64 $0.00 $338.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.31 $311.31 $323.29 $0.00 $101.28 $0.00 $0.00 $0.00 $0.00 $211.50 $335.02 $338.40 $253.80 $315.90 $253.80 $84.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99406 EAP CPT® 99406 "PREVENTIVE VISIT,EST,40-64" BOTH IP/OP $43.00 $31.82 $0.00 $360.00 $0.00 $0.00 $25.59 $25.59 $0.00 $0.00 $311.31 $311.31 $323.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.00 $356.40 $360.00 $270.00 $27.95 $270.00 $84.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99441 EAP CPT® 99441 TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES BOTH IP/OP $157.00 $116.18 $0.00 $102.05 $0.00 $0.00 $0.00 $0.00 $36.10 $0.00 $0.00 $0.00 $0.00 $0.00 $32.72 $0.00 $0.00 $0.00 $0.00 $27.00 $42.77 $43.20 $0.00 $102.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99442 EAP CPT® 99442 PHYS/QHP TELEPHONE EVALUATION 5-10 MIN BOTH IP/OP $253.00 $187.22 $0.00 $164.45 $0.00 $0.00 $0.00 $0.00 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $52.73 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $96.60 $164.45 $96.60 $25.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99443 EAP CPT® 99443 PHYS/QHP TELEPHONE EVALUATION 11-20 MIN BOTH IP/OP $358.00 $264.92 $0.00 $232.70 $0.00 $0.00 $0.00 $0.00 $100.28 $0.00 $0.00 $0.00 $0.00 $0.00 $74.61 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $159.60 $232.70 $159.60 $41.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99495 EAP CPT® 99495 PHYS/QHP TELEPHONE EVALUATION 21-30 MIN BOTH IP/OP $576.00 $426.24 $0.00 $576.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $120.04 $73.97 $340.70 $340.70 $0.00 $193.00 $305.71 $308.80 $231.60 $576.00 $231.60 $60.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99496 EAP CPT® 99496 TRANSITIONAL CARE MANAGE SERVICE 14 DAY DISCHRGE BOTH IP/OP $777.00 $574.98 $0.00 $777.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.27 $328.00 $519.55 $524.80 $161.54 $777.00 $161.54 $102.66 $125.50 $125.50 $104.44 $110.73 $0.00 $0.00 $0.00 $0.00 99497 EAP CPT®99497 TRANSITIONAL CARE MANAGE SERVICE 7 DAY DISCHARGE BOTH IP/OP $236.00 $174.64 $0.00 $693.60 $0.00 $0.00 $72.87 $72.87 $73.28 $67.13 $311.31 $311.31 $323.29 $71.76 $49.18 $46.64 $139.59 $139.59 $116.27 $433.50 $686.66 $693.60 $161.54 $236.00 $161.54 $135.69 $165.53 $165.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10932085 EAP HCPCS C1729 Catheter Urethral 8fr Foley 2 Way Latex Dover Silicone BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.50 $84.74 $85.60 $0.00 $0.00 $0.00 $16.75 $0.00 $0.00 $17.03 $0.00 $0.00 $0.00 $0.00 $0.00 10933190 EAP HCPCS C1729 Catheter Urethral 18fr Foley 2 Way Medium Olive Coude Tip 1 BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 10945160 EAP HCPCS C1751 Catheter Umb 3.5fr 15in .15ml Clr Strl Lf Arg 1 Lum Ll Hub BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $0.00 10945178 EAP HCPCS C1751 Cap Tube 13mm Blu Eztpr Dbl Flng Sl Thb Tab Pe BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $0.00 10945194 EAP HCPCS C1729 System Drn 35cm 700ml Blu Strl Lf Be2 Mntr Trndcr Atch Vntrc BOTH IP/OP $742.00 $549.08 $0.00 "$1,045.60" $402.91 $402.91 $0.00 $0.00 $0.00 $154.65 $550.71 $550.71 $571.93 $0.00 $154.63 $0.00 $438.89 $438.89 $0.00 $653.50 "$1,035.14" "$1,045.60" $0.00 $482.30 $0.00 $204.55 $0.00 $0.00 $208.07 $0.00 $0.00 $0.00 $0.00 $0.00 10961170 EAP HCPCS C1751 Kit Arterial Line .018in 20ga 22ga 1.75in Catheter Radiopq BOTH IP/OP $38.00 $28.12 $0.00 $45.60 $20.63 $20.63 $0.00 $0.00 $0.00 $7.92 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $22.48 $22.48 $0.00 $28.50 $45.14 $45.60 $0.00 $24.70 $0.00 $8.92 $0.00 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $0.00 11100001 EAP Custom 11100001 HB MED-SUR-GY/PVT BOTH IP/OP "$3,058.00 " "$2,262.92" $0.00 "$2,135.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11100003 EAP Custom 11100003 Tele Private Med Surg BOTH IP/OP "$3,378.00 " "$2,499.72" $0.00 "$2,358.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,358.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11100021 EAP Custom 11100021 HB PVT GYN BOTH IP/OP "$3,058.00 " "$2,262.92" $0.00 "$2,135.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11100023 EAP Custom 11100023 Tele Private Gyn BOTH IP/OP "$3,378.00 " "$2,499.72" $0.00 "$2,358.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,358.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11100501 EAP Custom 11100501 Trauma Private Med Surg BOTH IP/OP "$3,398.00 " "$2,514.52" $0.00 "$2,372.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,372.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11100503 EAP Custom 11100503 Trauma Tele Private Med Surg BOTH IP/OP "$3,718.00 " "$2,751.32" $0.00 "$2,596.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,596.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11100521 EAP Custom 11100521 Trauma Private Gyn BOTH IP/OP "$3,398.00 " "$2,514.52" $0.00 "$2,372.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,372.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11100523 EAP Custom 11100523 Trauma Tele Private Gyn BOTH IP/OP "$3,718.00 " "$2,751.32" $0.00 "$2,596.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,596.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11200001 EAP Custom 11200001 Private Ob BOTH IP/OP "$3,218.00 " "$2,381.32" $0.00 "$2,247.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11200002 EAP Custom 11200002 Tele Private Ob BOTH IP/OP "$3,533.00 " "$2,614.42" $0.00 "$2,467.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,467.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11200501 EAP Custom 11200501 Trauma Private Ob BOTH IP/OP "$3,559.00 " "$2,633.66" $0.00 "$2,485.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,485.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11200502 EAP Custom 11200502 Trauma Tele Private Ob BOTH IP/OP "$3,873.00 " "$2,866.02" $0.00 "$2,704.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,704.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11400002 EAP Custom 11400002 Private Psy BOTH IP/OP "$2,837.00 " "$2,099.38" $0.00 "$1,980.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,980.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11400502 EAP Custom 11400502 Trauma Private Psy BOTH IP/OP "$3,177.00 " "$2,350.98" $0.00 "$2,218.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,218.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11500001 EAP Custom 11500001 Inpatient Hospice BOTH IP/OP "$3,065.00 " "$2,268.10" $0.00 "$2,139.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,139.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11500501 EAP Custom 11500501 TRAUMA INPATIENT HOSPICE BOTH IP/OP "$3,176.00 " "$2,350.24" $0.00 "$2,217.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12100001 EAP Custom 12100001 Semiprivate Medsurg BOTH IP/OP "$2,166.00 " "$1,602.84" $0.00 "$1,512.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,512.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12100003 EAP Custom 12100003 Tele Semiprivate BOTH IP/OP "$2,550.00 " "$1,887.00" $0.00 "$1,780.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,780.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12100021 EAP Custom 12100021 Semiprivate Gyn BOTH IP/OP "$2,166.00 " "$1,602.84" $0.00 "$1,512.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,512.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12100023 EAP Custom 12100023 Tele Semiprivate Gyn BOTH IP/OP "$2,550.00 " "$1,887.00" $0.00 "$1,780.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,780.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12100501 EAP Custom 12100501 Trauma Semiprivate Medsurg BOTH IP/OP "$2,507.00 " "$1,855.18" $0.00 "$1,750.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,750.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12100503 EAP Custom 12100503 Trauma Tele Semiprivate BOTH IP/OP "$2,890.00 " "$2,138.60" $0.00 "$2,018.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12100521 EAP Custom 12100521 Trauma Semiprivate Gyn BOTH IP/OP "$2,507.00 " "$1,855.18" $0.00 "$1,750.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,750.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12100523 EAP Custom 12100523 Trauma Tele Semiprivate Gyn BOTH IP/OP "$2,890.00 " "$2,138.60" $0.00 "$2,018.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12200001 EAP Custom 12200001 Semiprivate Ob BOTH IP/OP "$2,359.00 " "$1,745.66" $0.00 "$1,647.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,647.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12200002 EAP Custom 12200002 Tele Semiprivate Ob BOTH IP/OP "$2,391.00 " "$1,769.34" $0.00 "$1,669.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12200501 EAP Custom 12200501 Trauma Semiprivate Ob BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$1,884.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,884.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12200502 EAP Custom 12200502 Trauma Tele Semiprivate Ob BOTH IP/OP "$2,732.00 " "$2,021.68" $0.00 "$1,907.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,907.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12400002 EAP Custom 12400002 Semiprivate Psych BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$1,833.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,833.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12400502 EAP Custom 12400502 Trauma Semiprivate Psych BOTH IP/OP "$2,966.00 " "$2,194.84" $0.00 "$2,071.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,071.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400001 EAP Custom 16400001 Tele.isolation BOTH IP/OP "$3,488.00 " "$2,581.12" $0.00 "$2,435.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,435.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400002 EAP Custom 16400002 Isolation Med Surg BOTH IP/OP "$3,362.00 " "$2,487.88" $0.00 "$2,347.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,347.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400004 EAP Custom 16400004 Isolation Med Surg BOTH IP/OP "$3,362.00 " "$2,487.88" $0.00 "$2,347.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,347.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400005 EAP Custom 16400005 Isolation Ob BOTH IP/OP "$3,563.00 " "$2,636.62" $0.00 "$2,488.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,488.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400006 EAP Custom 16400006 Tele.isolation Ob BOTH IP/OP "$3,581.00 " "$2,649.94" $0.00 "$2,500.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,500.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400007 EAP Custom 16400007 Isolation High-risk Scu BOTH IP/OP "$3,953.00 " "$2,925.22" $0.00 "$2,760.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,760.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400022 EAP Custom 16400022 Isolation Gyn BOTH IP/OP "$3,362.00 " "$2,487.88" $0.00 "$2,347.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,347.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400501 EAP Custom 16400501 Trauma Tele.isolation BOTH IP/OP "$3,828.00 " "$2,832.72" $0.00 "$2,673.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,673.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400502 EAP Custom 16400502 Trauma Isolation Med Surg BOTH IP/OP "$3,702.00 " "$2,739.48" $0.00 "$2,585.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400504 EAP Custom 16400504 Trauma Isolation Med Surg BOTH IP/OP "$3,702.00 " "$2,739.48" $0.00 "$2,585.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400505 EAP Custom 16400505 Trauma Isolation Ob BOTH IP/OP "$3,904.00 " "$2,888.96" $0.00 "$2,726.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,726.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400506 EAP Trauma Tele.isolation Ob BOTH IP/OP "$3,457.00 " "$2,558.18" $0.00 "$2,737.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,737.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400507 EAP Custom 16400507 Trauma Isolation High-risk Scu BOTH IP/OP "$4,293.00 " "$3,176.82" $0.00 "$2,997.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,997.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16400522 EAP Custom 16400522 Trauma Isolation Gyn BOTH IP/OP "$3,702.00 " "$2,739.48" $0.00 "$2,585.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17000001 EAP Custom 17000001 General Nursery BOTH IP/OP $849.00 $628.26 $0.00 $592.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $592.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17100001 EAP Custom 17100001 NURSERY/LEVEL I BOTH IP/OP "$1,331.00 " $984.94 $0.00 $812.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $812.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17100002 EAP Custom 17100002 Nursery Level I BOTH IP/OP "$1,331.00 " $984.94 $0.00 $812.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $812.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200002 EAP Custom 17200002 Nursery Level Ii BOTH IP/OP "$3,458.00 " "$2,558.92" $0.00 "$2,414.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,414.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17300001 EAP Custom 17300001 Nursery Level Iii BOTH IP/OP "$5,760.00 " "$4,262.40" $0.00 "$4,021.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,021.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17400001 EAP Custom 17400001 Nursery/level Iv BOTH IP/OP "$6,717.00 " "$4,970.58" $0.00 "$4,690.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,690.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18000010 EAP Custom 18000010 Leave Of Absence BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19818887 EAP HCPCS A6197 Dressing Wound Square 6x6in 2 Layer Absorbent Nonwoven Soft BOTH IP/OP $55.00 $40.70 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $42.39 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $35.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19979858 EAP HCPCS C1729 Kit Pressure Monitr Transducer Tipped Catheter Drill Bit BOTH IP/OP "$2,403.00 " "$1,778.22" $0.00 "$1,922.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,201.50" "$1,903.18" "$1,922.40" $0.00 $0.00 $0.00 $376.07 $0.00 $0.00 $382.56 $0.00 $0.00 $0.00 $0.00 $0.00 19988898 EAP Custom 19988898 Catheter Pressure 3.5mm 5mm 82cm 2cm Sensor Tip External BOTH IP/OP $58.00 $42.92 $0.00 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.05 $43.05 $44.71 $0.00 $12.09 $0.00 $0.00 $0.00 $0.00 $29.00 $45.94 $46.40 $0.00 $37.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19993849 EAP HCPCS C1751 Kit Arterial Line .018in 20ga 22ga 1.75in Catheter Radiopq BOTH IP/OP $29.00 $21.46 $0.00 $23.20 $15.75 $15.75 $0.00 $0.00 $0.00 $6.04 $21.52 $21.52 $22.35 $0.00 $6.04 $0.00 $17.15 $17.15 $0.00 $14.50 $22.97 $23.20 $0.00 $18.85 $0.00 $4.54 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 19993898 EAP HCPCS C1729 Tray Catheterization 16fr Foley Antireflux Evident Seal BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $14.12 $14.12 $0.00 $0.00 $0.00 $5.42 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $15.38 $15.38 $0.00 $13.00 $20.59 $20.80 $0.00 $16.90 $0.00 $4.07 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 19994800 EAP Custom 19994800 Kit Crntmy 25ga 5/8in Strl Rzr Ndl Drp BOTH IP/OP $701.00 $518.74 $0.00 "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $520.28 $520.28 $540.33 $0.00 $146.09 $0.00 $0.00 $0.00 $0.00 "$1,032.50" "$1,635.48" "$1,652.00" $0.00 $455.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20000001 EAP Custom 20000001 Intensive Care Icu Ob BOTH IP/OP "$6,502.00 " "$4,811.48" $0.00 "$4,539.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,539.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20000501 EAP Custom 20000501 Trauma Intensive Care Icu Ob BOTH IP/OP "$6,842.00 " "$5,063.08" $0.00 "$4,777.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,777.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20100001 EAP Custom 20100001 Intensive Care Icu Surgical BOTH IP/OP "$6,502.00 " "$4,811.48" $0.00 "$4,539.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,539.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20100501 EAP Custom 20100501 Trauma Intensive Care Icu Surgical BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$4,777.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,777.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20200001 EAP Custom 20200001 Intensive Care Icu Medical BOTH IP/OP "$6,502.00 " "$4,811.48" $0.00 "$4,539.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,539.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20200501 EAP Custom 20200501 Trauma Intensive Care Icu Medical BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$4,777.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,777.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20600001 EAP Custom 20600001 Intermediate Care BOTH IP/OP "$4,007.00 " "$2,965.18" $0.00 "$2,782.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,782.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20600002 EAP Custom 20600002 Intermediate Care Burn BOTH IP/OP "$9,266.00 " "$6,856.84" $0.00 "$6,450.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,450.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20600005 EAP Custom 20600005 Intermediate Care BOTH IP/OP "$4,007.00 " "$2,965.18" $0.00 "$2,782.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,782.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20600501 EAP Custom 20600501 Trauma Intermediate Care BOTH IP/OP "$4,708.00 " "$3,483.92" $0.00 "$3,019.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,019.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20600502 EAP Custom 20600502 Trauma Intermediate Care Burn BOTH IP/OP "$9,580.00 " "$7,089.20" $0.00 "$6,688.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,688.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20700001 EAP Custom 20700001 Intensive Care Icu Burn BOTH IP/OP "$10,118.00 " "$7,487.32" $0.00 "$7,036.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,036.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20700501 EAP Custom 20700501 Trauma Intensive Care Icu Burn BOTH IP/OP "$10,421.00 " "$7,711.54" $0.00 "$7,273.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,273.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21000001 EAP Custom 21000001 Intensive Care Icu Medical BOTH IP/OP "$6,502.00 " "$4,811.48" $0.00 "$4,539.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,539.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21400005 EAP Intermediate Coronary Care Unit BOTH IP/OP "$4,793.00 " "$3,546.82" $0.00 "$3,318.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,318.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21400505 EAP Custom 21400505 Trauma Intermediate Coronary Care Unit BOTH IP/OP "$5,219.00 " "$3,862.06" $0.00 "$3,556.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,556.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21900001 EAP Custom 21900001 Intermediate Care BOTH IP/OP "$3,741.00 " "$2,768.34" $0.00 "$2,782.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,782.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000134 EAP Custom 25000134 Rocephin 250mg BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000141 EAP Custom 25000141 Toradol 30 Mg BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $24.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000153 EAP Custom 25000153 "Rocephin 250mg, Im" BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000157 EAP Custom 25000157 Depoprovera 150mg BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $117.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000169 EAP Custom 25000169 Vit B 12 100mcg BOTH IP/OP $46.00 $34.04 $0.00 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.14 $34.14 $35.46 $0.00 $9.59 $0.00 $0.00 $0.00 $0.00 $23.00 $36.43 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000182 EAP Custom 25000182 Rocephin Injection BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000187 EAP Custom 25000187 Rocephin 250mg BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $15.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000189 EAP Custom 25000189 Bicillin Injection BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000224 EAP Custom 25000224 Rocephin 250mg (cef BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000226 EAP Custom 25000226 Depo Provera Inject BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $131.81 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $111.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000227 EAP Custom 25000227 Oral Contraceptives BOTH IP/OP $13.00 $9.62 $0.00 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.71 $0.00 $0.00 $0.00 $0.00 $6.50 $10.30 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000229 EAP Custom 25000229 Plan B BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000230 EAP Custom 25000230 Evra Transdermal Pa BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000327 EAP Custom 25000327 Oral Contraceptives BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000908 EAP Custom 25000908 Evra Trandermal Pat BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000960 EAP Custom 25000960 Hetastarch (hespan) BOTH IP/OP $435.00 $321.90 $0.00 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.86 $322.86 $335.30 $0.00 $90.65 $0.00 $0.00 $0.00 $0.00 $217.50 $344.52 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000961 EAP Custom 25000961 Hetastarch BOTH IP/OP $435.00 $321.90 $0.00 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.86 $322.86 $335.30 $0.00 $90.65 $0.00 $0.00 $0.00 $0.00 $217.50 $344.52 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000966 EAP Custom 25000966 "Rocephin 250mg, 1gm" BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25000990 EAP Custom 25000990 Nitric Oxide (per Hr) BOTH IP/OP $789.00 $583.86 $0.00 $631.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $585.60 $585.60 $608.16 $0.00 $164.43 $0.00 $0.00 $0.00 $0.00 $394.50 $624.89 $631.20 $0.00 $512.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25002130 EAP Custom 25002130 Zithromax BOTH IP/OP $24.00 $17.76 $0.00 $19.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $17.81 $18.50 $0.00 $5.00 $0.00 $0.00 $0.00 $0.00 $12.00 $19.01 $19.20 $0.00 $15.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25500016 EAP HCPCS Q9965 Locm 150-199mg/ml I BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $0.00 $0.00 $1.05 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25500039 EAP HCPCS Q9965 Locm 150-199mg/ml I BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $0.00 $0.00 $1.05 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800010 EAP Custom 25800010 Solutions Sodium Ch BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800013 EAP Custom 25800013 Solution Iv D 5% In BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800016 EAP Custom 25800016 Solution Iv Lactate BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800017 EAP Custom 25800017 Solution Iv Nacl 0. BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800018 EAP Custom 25800018 Solution Iv Nacl 0. BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800019 EAP Custom 25800019 Solution Iv Nacl 0. BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800020 EAP Custom 25800020 Solution Iv Nacl 0. BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800031 EAP Custom 25800031 Solution Iv D 5% In BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800033 EAP Custom 25800033 Solution Iv Lactate BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800034 EAP Custom 25800034 Solution Iv Nacl 0. BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800037 EAP Custom 25800037 Solution Iv Nacl 0. BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800038 EAP Custom 25800038 Solution Iv Nacl 0. BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800039 EAP Custom 25800039 Solution Iv Nacl 0. BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800060 EAP Custom 25800060 Iv Fluids BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $39.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800061 EAP Custom 25800061 Iv Fluids BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800062 EAP Custom 25800062 I.v. Fluids 500ml BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800063 EAP Custom 25800063 I.v. Fluid 100ml BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800080 EAP Custom 25800080 Iv Fluids 1000ml BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800095 EAP Custom 25800095 Solution Iv Water For Irr BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800260 EAP Custom 25800260 Iv Fluid 500ml BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800262 EAP Custom 25800262 Solutions Advantage Glou BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800263 EAP Custom 25800263 Solution Irrigation Water 150 BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800264 EAP Custom 25800264 Solutions Iv Water For Inject BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800265 EAP Custom 25800265 Solutions Sodium Chloride BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800267 EAP Custom 25800267 "Iv Fluids, 100cc" BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800268 EAP Custom 25800268 "Iv Fluids, 500cc" BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800269 EAP Custom 25800269 "Iv Fluids, 1000cc" BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800274 EAP Custom 25800274 Solution Iv Nacl 0.9% Gla BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800277 EAP Custom 25800277 Solution Iv Nacl 0.9% 50m BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800278 EAP Custom 25800278 "Iv Fluids, 50cc" BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800401 EAP Custom 25800401 I.v. Fluids BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800402 EAP Custom 25800402 I.v. Fluids 1000cc BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800403 EAP Custom 25800403 I.v. Fluids 500ml BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800404 EAP Custom 25800404 Iv Fluid 1000cc BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800405 EAP Custom 25800405 "Iv Fluid, # Bags" BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $39.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800406 EAP Custom 25800406 "Iv Fluid, #bags" BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800407 EAP Custom 25800407 Iv Fluids 1000ml BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800408 EAP Custom 25800408 Iv Fluids 500cc BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800409 EAP Custom 25800409 Iv Fluids 50cc BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800410 EAP Custom 25800410 Iv Fluids-500ml BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800411 EAP Custom 25800411 Solution Intravenous Viaflex Latex Free Plasma-lyte A BOTH IP/OP $29.00 $21.46 $0.00 $23.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.52 $21.52 $22.35 $0.00 $6.04 $0.00 $0.00 $0.00 $0.00 $14.50 $22.97 $23.20 $0.00 $18.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25800412 EAP Custom 25800412 Solution Irr 0.9% Na Chlor Urmtc 3l Strl Lf BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25900227 EAP Custom 25900227 Oral Contraceptives BOTH IP/OP $12.00 $8.88 $0.00 $9.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.91 $8.91 $9.25 $0.00 $2.50 $0.00 $0.00 $0.00 $0.00 $6.00 $9.50 $9.60 $0.00 $7.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25900255 EAP Custom 25900255 Insulin 5 Units BOTH IP/OP $4.00 $2.96 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.97 $2.97 $3.08 $0.00 $0.83 $0.00 $0.00 $0.00 $0.00 $2.00 $3.17 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26000001 EAP CPT® 96360 Iv Hydra Initial (31 Min To 1 Hr) BOTH IP/OP "$1,030.00 " $762.20 $34.59 $793.92 $559.29 $559.29 $199.22 $199.22 $200.34 $214.68 $764.47 $764.47 $793.92 $195.04 $214.65 $126.78 $609.25 $609.25 $184.28 $440.50 $697.75 $704.80 $256.03 $669.50 $256.03 $53.93 $34.59 $34.59 $140.26 $175.50 $0.00 $0.00 $0.00 $0.00 26000003 EAP CPT® 96361 Iv Hydra Add'l (31 Min To 1 Hr) BOTH IP/OP $347.00 $256.78 $13.69 $267.47 $188.42 $188.42 $38.97 $38.97 $39.19 $72.32 $257.54 $257.54 $267.47 $38.34 $72.31 $24.92 $205.25 $205.25 $38.22 $148.00 $234.43 $236.80 $53.10 $225.55 $53.10 $15.67 $13.69 $13.69 $47.12 $36.40 $0.00 $0.00 $0.00 $0.00 26000005 EAP CPT® 96365 "Iv Infus Ther,prophylax,dx Initial (16 Min To 1 Hr)" BOTH IP/OP "$1,796.00 " "$1,329.04" $65.68 "$1,384.36" $975.23 $975.23 $199.22 $199.22 $200.34 $374.33 "$1,332.99" "$1,332.99" "$1,384.36" $195.04 $374.29 $126.78 "$1,062.33" "$1,062.33" $184.28 $769.00 "$1,218.10" "$1,230.40" $256.03 "$1,167.40" $256.03 $65.68 $72.05 $72.05 $244.85 $175.50 $0.00 $0.00 $0.00 $0.00 26000006 EAP CPT® 96366 "Iv Infus Ther,prophylax,dx Add'l (31 Min To 1 Hr)" BOTH IP/OP $347.00 $256.78 $20.85 $267.47 $188.42 $188.42 $38.97 $38.97 $39.19 $72.32 $257.54 $257.54 $267.47 $38.34 $72.31 $24.92 $205.25 $205.25 $38.22 $148.00 $234.43 $236.80 $53.10 $225.55 $53.10 $20.85 $21.98 $21.98 $47.12 $36.40 $0.00 $0.00 $0.00 $0.00 26000007 EAP CPT® 96367 "Iv Infus Ther,prophylax,dx Add'l New Med (31 Min To 1 Hr)" BOTH IP/OP $523.00 $387.02 $31.35 $403.13 $283.99 $283.99 $60.38 $60.38 $60.72 $109.01 $388.17 $388.17 $403.13 $59.39 $108.99 $38.61 $309.35 $309.35 $60.65 $223.50 $354.02 $357.60 $84.26 $339.95 $84.26 $32.97 $31.35 $31.35 $71.16 $57.76 $0.00 $0.00 $0.00 $0.00 26000008 EAP CPT® 96368 "Iv Infus Ther,prophylax,dx Add'l Concur (31 Min To 1 Hr)" BOTH IP/OP $630.00 $466.20 $0.00 $485.60 $342.09 $342.09 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $485.60 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $245.00 $388.08 $392.00 $0.00 $480.35 $0.00 $19.47 $21.26 $21.26 $78.01 $0.00 $0.00 $0.00 $0.00 $0.00 26000111 EAP CPT® 96374 "Iv Push - Ther,prophylax,dx 1st Med" BOTH IP/OP $630.00 $466.20 $39.99 $485.60 $342.09 $342.09 $199.22 $199.22 $200.34 $131.31 $467.59 $467.59 $485.60 $195.04 $131.29 $126.78 $372.65 $372.65 $184.28 $245.00 $388.08 $392.00 $256.03 $409.50 $256.03 $52.02 $39.99 $39.99 $78.01 $175.50 $0.00 $0.00 $0.00 $0.00 26000112 EAP CPT® 96375 "Iv Push - Ther,prophylax,dx Add'l Med" BOTH IP/OP $523.00 $387.02 $16.57 $403.13 $283.99 $283.99 $38.97 $38.97 $39.19 $109.01 $388.17 $388.17 $403.13 $38.34 $108.99 $24.92 $309.35 $309.35 $38.22 $223.50 $354.02 $357.60 $53.10 $339.95 $53.10 $22.60 $16.57 $16.57 $71.16 $36.40 $0.00 $0.00 $0.00 $0.00 26000113 EAP CPT® 96376 "Iv Push - Ther,prophylax,dx Ea Push Same Med" BOTH IP/OP $349.00 $258.26 $0.00 $269.01 $189.51 $189.51 $0.00 $0.00 $0.00 $72.74 $259.03 $259.03 $269.01 $0.00 $72.73 $0.00 $206.43 $206.43 $0.00 $149.00 $236.02 $238.40 $0.00 $226.85 $0.00 $46.64 $0.00 $0.00 $47.44 $0.00 $0.00 $0.00 $0.00 $0.00 26000114 EAP CPT® 96523 Picc/portacath Line Flush BOTH IP/OP $282.00 $208.68 $27.46 $319.15 $73.05 $73.05 $54.21 $54.21 $54.51 $58.78 $209.30 $209.30 $217.37 $53.35 $58.77 $34.67 $166.80 $166.80 $55.17 $120.50 $190.87 $192.80 $76.65 $319.15 $76.65 $27.46 $28.10 $28.10 $38.37 $52.54 $0.00 $0.00 $0.00 $0.00 27000010 EAP Custom 27000010 Tube Salem Sump 48 Lengt BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000011 EAP Custom 27000011 Tube Salem Silicone Size BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000012 EAP Custom 27000012 Tubes Salem Sump 48 Leng BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000015 EAP Custom 27000015 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000016 EAP Custom 27000016 Scaple Surg W/handle Atta BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000019 EAP Custom 27000019 Kit L.f. Trach Care BOTH IP/OP $511.00 $378.14 $0.00 $408.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.26 $379.26 $393.88 $0.00 $106.49 $0.00 $0.00 $0.00 $0.00 $255.50 $404.71 $408.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000024 EAP Custom 27000024 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000026 EAP Custom 27000026 Kit Triple Lumen Catheter BOTH IP/OP $587.00 $434.38 $0.00 $469.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $435.67 $435.67 $452.46 $0.00 $122.33 $0.00 $0.00 $0.00 $0.00 $293.50 $464.90 $469.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000027 EAP Custom 27000027 Filter Set 0.22 Micron BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000029 EAP Custom 27000029 Set T-port Small Bore Ext BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000031 EAP Custom 27000031 Tray Douch Disposable BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000033 EAP Custom 27000033 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000034 EAP Custom 27000034 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000035 EAP Custom 27000035 Tray Thoracentesis Dispos BOTH IP/OP $134.00 $99.16 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.45 $99.45 $103.29 $0.00 $27.93 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000036 EAP Custom 27000036 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $30.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000045 EAP Custom 27000045 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000046 EAP Custom 27000046 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000047 EAP Custom 27000047 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000048 EAP Custom 27000048 Sleeve Thigh X-large Dvt BOTH IP/OP $663.00 $490.62 $0.00 $530.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.08 $492.08 $511.04 $0.00 $138.17 $0.00 $0.00 $0.00 $0.00 $331.50 $525.10 $530.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000066 EAP Custom 27000066 "Tray,instrumen 13-1/2x9/34x5/8" BOTH IP/OP $391.00 $289.34 $0.00 $312.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.20 $290.20 $301.38 $0.00 $81.48 $0.00 $0.00 $0.00 $0.00 $195.50 $309.67 $312.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000076 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $23.89 $23.89 $0.00 $0.00 $0.00 $9.17 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $26.03 $26.03 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $6.89 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000078 EAP Custom 27000078 Tubes Salem Sump 48 Leng BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000079 EAP Custom 27000079 Kit Tracheotomy Care Ster BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000081 EAP Custom 27000081 Scapel Surg W/ Handle Attached BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.97 $97.97 $101.75 $0.00 $27.51 $0.00 $0.00 $0.00 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000087 EAP Custom 27000087 Kit Thoracotomy BOTH IP/OP $203.00 $150.22 $0.00 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.67 $150.67 $156.47 $0.00 $42.31 $0.00 $0.00 $0.00 $0.00 $101.50 $160.78 $162.40 $0.00 $131.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000093 EAP Custom 27000093 Bag 1000ml Pump Set BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000094 EAP Custom 27000094 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000097 EAP Custom 27000097 Kit Triple Lumen Catheter BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.92 $221.92 $230.47 $0.00 $62.31 $0.00 $0.00 $0.00 $0.00 $149.50 $236.81 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000098 EAP Custom 27000098 Vest Econo Cotton Small BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000101 EAP Custom 27000101 Vest Econo Cotton X-large BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000103 EAP Custom 27000103 Filter Set 0.22 Micron BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000107 EAP Custom 27000107 Tray Foley Perconnected 1 BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000109 EAP Custom 27000109 Tray Thoracentesis Dispos BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $181.14 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000119 EAP Custom 27000119 3ml Posiflush Saline Syringe BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000125 EAP Custom 27000125 Sleeve Thigh Regular Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000127 EAP Custom 27000127 "Tray,catheter Instrument Dulmn" BOTH IP/OP $718.00 $531.32 $0.00 $574.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $532.90 $532.90 $553.43 $0.00 $149.63 $0.00 $0.00 $0.00 $0.00 $359.00 $568.66 $574.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000150 EAP Custom 27000150 Catheter Urethral Two-eye BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000151 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27000152 EAP HCPCS C1729 Catheter Coude 30cc 24fr BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $47.24 $47.24 $0.00 $0.00 $0.00 $18.13 $64.57 $64.57 $67.06 $0.00 $18.13 $0.00 $51.46 $51.46 $0.00 $43.50 $68.90 $69.60 $0.00 $0.00 $0.00 $13.62 $0.00 $0.00 $13.85 $0.00 $0.00 $0.00 $0.00 $0.00 27000153 EAP Custom 27000153 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000154 EAP Custom 27000154 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000155 EAP Custom 27000155 Kit Tracheotomy Care Ster BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000168 EAP Custom 27000168 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000169 EAP Custom 27000169 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000173 EAP Custom 27000173 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000174 EAP Custom 27000174 Kit Triple Lumen Catheter BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.92 $221.92 $230.47 $0.00 $62.31 $0.00 $0.00 $0.00 $0.00 $149.50 $236.81 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000179 EAP Custom 27000179 Filter Set 0.22 Micron BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000181 EAP Custom 27000181 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000182 EAP Custom 27000182 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000184 EAP Custom 27000184 Tray Thoracentesis Dispos BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $181.14 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000191 EAP Custom 27000191 "Suture,silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000197 EAP Custom 27000197 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000198 EAP Custom 27000198 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000199 EAP Custom 27000199 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000200 EAP Custom 27000200 Sleeve Thigh X-large Dvt BOTH IP/OP $663.00 $490.62 $0.00 $530.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.08 $492.08 $511.04 $0.00 $138.17 $0.00 $0.00 $0.00 $0.00 $331.50 $525.10 $530.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000222 EAP Custom 27000222 Catheter Urethral 14fr BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000223 EAP Custom 27000223 Catheter Urethral Two-eye BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000224 EAP Custom 27000224 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000225 EAP Custom 27000225 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000226 EAP Custom 27000226 Kit Tracheotomy Care Ster BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000228 EAP Custom 27000228 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000232 EAP Custom 27000232 Cream Baza 5oz BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000240 EAP Custom 27000240 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000241 EAP Custom 27000241 Needle Port-cath 20ga X 1 BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000242 EAP Custom 27000242 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000245 EAP Custom 27000245 Kit Triple Lumen Catheter BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $323.74 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000250 EAP Custom 27000250 Tray Foley Preconnected W BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000251 EAP Custom 27000251 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000252 EAP Custom 27000252 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000253 EAP Custom 27000253 Tray Thoracentesis/parace BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $0.00 $0.00 $0.00 $33.50 $53.06 $53.60 $0.00 $43.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000254 EAP Custom 27000254 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $30.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000259 EAP Custom 27000259 "Suture, Silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000265 EAP Custom 27000265 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000266 EAP Custom 27000266 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000267 EAP Custom 27000267 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000268 EAP Custom 27000268 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000293 EAP Custom 27000293 Catheter Urethral Two-eye BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000294 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27000295 EAP HCPCS C1729 Catheter Coude 30cc 24fr BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $47.24 $47.24 $0.00 $0.00 $0.00 $18.13 $64.57 $64.57 $67.06 $0.00 $18.13 $0.00 $51.46 $51.46 $0.00 $43.50 $68.90 $69.60 $0.00 $0.00 $0.00 $13.62 $0.00 $0.00 $13.85 $0.00 $0.00 $0.00 $0.00 $0.00 27000296 EAP Custom 27000296 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000297 EAP Custom 27000297 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000298 EAP Custom 27000298 Kit Tracheotomy Care Ster BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000300 EAP Custom 27000300 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000314 EAP Custom 27000314 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000315 EAP Custom 27000315 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000318 EAP Custom 27000318 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000319 EAP Custom 27000319 Kit Triple Lumen Catheter BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000323 EAP Custom 27000323 Vest Econo Cotton X-large BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000324 EAP Custom 27000324 Filter Set 0.22 Micron BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000326 EAP Custom 27000326 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000327 EAP Custom 27000327 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000330 EAP Custom 27000330 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000335 EAP Custom 27000335 "Suture, Silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000341 EAP Custom 27000341 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000342 EAP Custom 27000342 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000343 EAP Custom 27000343 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000344 EAP Custom 27000344 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000345 EAP Custom 27000345 Tubes Extension Plain Pla BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000358 EAP Custom 27000358 Catheter Thoracic 16f BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000359 EAP Custom 27000359 Catheter Thoracic 20fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000360 EAP Custom 27000360 Catheter Thoracic 36fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000361 EAP Custom 27000361 Catheter Ventricular 20cm BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $566.54 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000362 EAP Custom 27000362 Catheter Edm 11 Becker BOTH IP/OP "$1,339.00 " $990.86 $0.00 "$1,071.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $993.81 $993.81 "$1,032.10" $0.00 $279.05 $0.00 $0.00 $0.00 $0.00 $669.50 "$1,060.49" "$1,071.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000363 EAP Custom 27000363 Tube Feeding Plastic 8fr BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000364 EAP Custom 27000364 Artery Arterial Catheriza BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000365 EAP Custom 27000365 Artery Radial Catherizati BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000366 EAP Custom 27000366 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000367 EAP Custom 27000367 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000368 EAP Custom 27000368 Tubes Salem Sump 48 Leng BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000369 EAP Custom 27000369 Kit Tracheotomy Care Ster BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000371 EAP Custom 27000371 Bag Drainage Becker BOTH IP/OP $197.00 $145.78 $0.00 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.21 $146.21 $151.85 $0.00 $41.05 $0.00 $0.00 $0.00 $0.00 $98.50 $156.02 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000372 EAP Custom 27000372 Tray Catheter Insrtn Dulm BOTH IP/OP $377.00 $278.98 $0.00 $301.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.81 $279.81 $290.59 $0.00 $78.57 $0.00 $0.00 $0.00 $0.00 $188.50 $298.58 $301.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000373 EAP Custom 27000373 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000374 EAP Custom 27000374 Scaple Surg W/handle Atta BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000376 EAP Custom 27000376 Set Blood Administration BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000378 EAP Custom 27000378 Cream Baza 5oz BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000386 EAP Custom 27000386 Pouch Fecal Incontinence BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000387 EAP Custom 27000387 Kit Pressure Monitoring T BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000388 EAP Custom 27000388 Transducer Disp For Icp BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000389 EAP Custom 27000389 Bridge Kit Bifurated Resp BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.23 $97.23 $100.97 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000390 EAP Custom 27000390 Kit Transducer Monitoring BOTH IP/OP $339.00 $250.86 $0.00 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.61 $251.61 $261.30 $0.00 $70.65 $0.00 $0.00 $0.00 $0.00 $169.50 $268.49 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000392 EAP Custom 27000392 Kit Pressure Monitoring BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000394 EAP Custom 27000394 Bag 1000ml Pump Set BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000395 EAP Custom 27000395 Kit Pecutaneous Introduce BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $0.00 $0.00 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000396 EAP Custom 27000396 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000403 EAP Custom 27000403 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000404 EAP Custom 27000404 Kit Triple Lumen Catheter BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.92 $221.92 $230.47 $0.00 $62.31 $0.00 $0.00 $0.00 $0.00 $149.50 $236.81 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000405 EAP Custom 27000405 Catheter Swan Ganz BOTH IP/OP $674.00 $498.76 $0.00 $539.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.24 $500.24 $519.52 $0.00 $140.46 $0.00 $0.00 $0.00 $0.00 $337.00 $533.81 $539.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000406 EAP Custom 27000406 Delivery System Closed In BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $42.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000407 EAP Custom 27000407 Probe V-pacing BOTH IP/OP "$1,403.00 " "$1,038.22" $0.00 "$1,122.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,041.31" "$1,041.31" "$1,081.43" $0.00 $292.39 $0.00 $0.00 $0.00 $0.00 $701.50 "$1,111.18" "$1,122.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000410 EAP Custom 27000410 Filter Set 0.22 Micron BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000412 EAP Custom 27000412 Kit Ventriculostomy BOTH IP/OP "$1,652.00 " "$1,222.48" $0.00 "$1,321.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,226.11" "$1,226.11" "$1,273.36" $0.00 $344.28 $0.00 $0.00 $0.00 $0.00 $826.00 "$1,308.38" "$1,321.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000414 EAP Custom 27000414 "Suture, Silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000454 EAP Custom 27000454 Catheter Thoracic 28fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000455 EAP Custom 27000455 Catheter Thoracic 32fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000456 EAP Custom 27000456 Catheter Thoracic 36fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000457 EAP Custom 27000457 Catheter Urethral 14fr BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000458 EAP Custom 27000458 Catheter Urethral Two-eye BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000459 EAP Custom 27000459 Tube Salem Sump 48 Lengt BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000460 EAP Custom 27000460 Tube Salem Silicone Size BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000461 EAP Custom 27000461 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000462 EAP Custom 27000462 Kit Tracheotomy Care Ster BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000464 EAP Custom 27000464 Scaple Surg W/handle Atta BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000474 EAP Custom 27000474 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000475 EAP Custom 27000475 Needle Port-cath 20ga X 1 BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000476 EAP Custom 27000476 Chest Unit Drainage Pleur BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.73 $144.73 $150.31 $0.00 $40.64 $0.00 $0.00 $0.00 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000481 EAP Custom 27000481 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000482 EAP Custom 27000482 Kit Triple Lumen Catheter BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.92 $221.92 $230.47 $0.00 $62.31 $0.00 $0.00 $0.00 $0.00 $149.50 $236.81 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000483 EAP Custom 27000483 Filter Set 0.22 Micron BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000484 EAP Custom 27000484 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000487 EAP Custom 27000487 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000488 EAP Custom 27000488 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000489 EAP Custom 27000489 Tray Thoracentesis Dispos BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $181.14 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000491 EAP Custom 27000491 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000495 EAP Custom 27000495 "Suture, Silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000501 EAP Custom 27000501 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000502 EAP Custom 27000502 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000503 EAP Custom 27000503 Sleeve Thigh Regular Dvt BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.22 $169.22 $175.74 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.00 $180.58 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000504 EAP Custom 27000504 Sleeve Thigh X-large Dvt BOTH IP/OP $616.00 $455.84 $0.00 $492.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.20 $457.20 $474.81 $0.00 $128.37 $0.00 $0.00 $0.00 $0.00 $308.00 $487.87 $492.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000530 EAP Custom 27000530 Catheter Thoracic 28fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000531 EAP Custom 27000531 Catheter Thoracic 32fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000532 EAP Custom 27000532 Catheter Thoracic 36fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000533 EAP Custom 27000533 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000534 EAP Custom 27000534 Tubes Salem Sump 48 Leng BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000535 EAP Custom 27000535 Kit Tracheotomy Care Ster BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000538 EAP Custom 27000538 Scapel Surg W/ Handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000543 EAP Custom 27000543 Kit Thoracotomy BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000549 EAP Custom 27000549 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000551 EAP Custom 27000551 Chest Unit Drainage Pleur BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $44.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000556 EAP Custom 27000556 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000557 EAP Custom 27000557 Kit Triple Lumen Catheter BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.92 $221.92 $230.47 $0.00 $62.31 $0.00 $0.00 $0.00 $0.00 $149.50 $236.81 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000558 EAP Custom 27000558 Filter Set 0.22 Micron BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000559 EAP Custom 27000559 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000560 EAP Custom 27000560 Tray Douch Disposable BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000562 EAP Custom 27000562 Tray Foley Preconnected 1 BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $14.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000563 EAP Custom 27000563 Tray Foley Perconnected 1 BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000564 EAP Custom 27000564 Tray Thoracentesis Dispos BOTH IP/OP $261.00 $193.14 $0.00 $208.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.71 $193.71 $201.18 $0.00 $54.39 $0.00 $0.00 $0.00 $0.00 $130.50 $206.71 $208.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000570 EAP Custom 27000570 "Suture, Silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000577 EAP Custom 27000577 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $252.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000578 EAP Custom 27000578 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $304.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000579 EAP Custom 27000579 Sleeve Thigh Regular Dvt BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $154.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000580 EAP Custom 27000580 Sleeve Thigh X-large Dvt BOTH IP/OP $616.00 $455.84 $0.00 $492.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.20 $457.20 $474.81 $0.00 $128.37 $0.00 $0.00 $0.00 $0.00 $308.00 $487.87 $492.80 $0.00 $400.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000604 EAP Custom 27000604 Catheter Thoracic 28fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000605 EAP Custom 27000605 Catheter Thoracic 32fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000606 EAP Custom 27000606 Catheter Thoracic 36fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000607 EAP Custom 27000607 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000608 EAP Custom 27000608 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000612 EAP Custom 27000612 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000613 EAP Custom 27000613 Scaple Surg W/handle Atta BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000618 EAP Custom 27000618 Kit Thoracotomy BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $46.50 $73.66 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000624 EAP Custom 27000624 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000625 EAP Custom 27000625 Chest Unit Drainage Pleur BOTH IP/OP $332.00 $245.68 $0.00 $265.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $246.41 $246.41 $255.91 $0.00 $69.19 $0.00 $0.00 $0.00 $0.00 $166.00 $262.94 $265.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000630 EAP Custom 27000630 Dressing X-large BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000632 EAP Custom 27000632 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000633 EAP Custom 27000633 Kit Triple Lumen Catheter BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.92 $221.92 $230.47 $0.00 $62.31 $0.00 $0.00 $0.00 $0.00 $149.50 $236.81 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000637 EAP Custom 27000637 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000638 EAP Custom 27000638 Tray Douch Disposable BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000640 EAP Custom 27000640 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000641 EAP Custom 27000641 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000642 EAP Custom 27000642 Tray Thoracentesis Dispos BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $181.14 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000648 EAP Custom 27000648 "Suture, Silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000653 EAP Custom 27000653 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000654 EAP Custom 27000654 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000655 EAP Custom 27000655 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000656 EAP Custom 27000656 Sleeve Thigh X-large Dvt BOTH IP/OP $663.00 $490.62 $0.00 $530.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.08 $492.08 $511.04 $0.00 $138.17 $0.00 $0.00 $0.00 $0.00 $331.50 $525.10 $530.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000666 EAP Custom 27000666 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000667 EAP Custom 27000667 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000679 EAP Custom 27000679 Kit Triple Lumen Catheter BOTH IP/OP $646.00 $478.04 $0.00 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.46 $479.46 $497.94 $0.00 $134.63 $0.00 $0.00 $0.00 $0.00 $323.00 $511.63 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000680 EAP Custom 27000680 Filter Set 0.22 Micron BOTH IP/OP $7.00 $5.18 $0.00 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.20 $5.20 $5.40 $0.00 $1.46 $0.00 $0.00 $0.00 $0.00 $3.50 $5.54 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000683 EAP Custom 27000683 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000686 EAP Custom 27000686 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000687 EAP Custom 27000687 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000689 EAP Custom 27000689 Tray Thoracentesis Dispos BOTH IP/OP $216.00 $159.84 $0.00 $172.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.32 $160.32 $166.49 $0.00 $45.01 $0.00 $0.00 $0.00 $0.00 $108.00 $171.07 $172.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000691 EAP Custom 27000691 Bag Drainage Ureteral BOTH IP/OP $92.00 $68.08 $0.00 $73.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.28 $68.28 $70.91 $0.00 $19.17 $0.00 $0.00 $0.00 $0.00 $46.00 $72.86 $73.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000696 EAP Custom 27000696 "Suture, Silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000697 EAP Custom 27000697 10ml Posiflush Saline Syringe BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000701 EAP Custom 27000701 Sleeve Knee Regular Dvt BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.55 $280.55 $291.36 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000702 EAP Custom 27000702 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000703 EAP Custom 27000703 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000704 EAP Custom 27000704 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000705 EAP Custom 27000705 Sucrose Analgesia BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000709 EAP Custom 27000709 Tray Circumcision BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $30.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000710 EAP Custom 27000710 Needle Spinal 22g 25/bx BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000712 EAP Custom 27000712 Tubes Capillary Hepariniz BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000714 EAP Custom 27000714 Tube Feeding Plastic 8fr BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.23 $2.23 $2.31 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000715 EAP Custom 27000715 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000721 EAP Custom 27000721 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000723 EAP Custom 27000723 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000724 EAP Custom 27000724 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000725 EAP HCPCS C1751 Catheter Iv 26g 120/cs BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $4.38 $0.00 $0.00 $4.46 $0.00 $0.00 $0.00 $0.00 $0.00 27000726 EAP Custom 27000726 Sleeve Knee Regular Dvt BOTH IP/OP $166.00 $122.84 $0.00 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.21 $123.21 $127.95 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $83.00 $131.47 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000727 EAP Custom 27000727 Sleeve Knee X-large Dvt BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.18 $149.18 $154.93 $0.00 $41.89 $0.00 $0.00 $0.00 $0.00 $100.50 $159.19 $160.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000728 EAP Custom 27000728 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000741 EAP Custom 27000741 Catheter Thoracic 28fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000742 EAP Custom 27000742 Catheter Thoracic 32fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000743 EAP Custom 27000743 Catheter Thoracic 36fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000744 EAP Custom 27000744 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000745 EAP Custom 27000745 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000748 EAP Custom 27000748 Scapel Surg W/handle Att BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000760 EAP Custom 27000760 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000762 EAP Custom 27000762 Chest Unit Drainage Pleur BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $323.74 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000765 EAP Custom 27000765 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000766 EAP Custom 27000766 Kit Triple Lumen Catheter BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.92 $221.92 $230.47 $0.00 $62.31 $0.00 $0.00 $0.00 $0.00 $149.50 $236.81 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000770 EAP Custom 27000770 Filter Set 0.22 Micron BOTH IP/OP $7.00 $5.18 $0.00 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.20 $5.20 $5.40 $0.00 $1.46 $0.00 $0.00 $0.00 $0.00 $3.50 $5.54 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000771 EAP Custom 27000771 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000772 EAP Custom 27000772 Tray Douch Disposable BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000773 EAP Custom 27000773 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000774 EAP Custom 27000774 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000775 EAP Custom 27000775 Tray Thoracentesis Dispos BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $181.14 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000776 EAP Custom 27000776 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000781 EAP Custom 27000781 "Suture, Silk, 0" BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000784 EAP Custom 27000784 3ml Posiflush Saline Syringe BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000787 EAP Custom 27000787 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000788 EAP Custom 27000788 Sleeve Knee X-ray Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000789 EAP Custom 27000789 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000790 EAP Custom 27000790 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000791 EAP Custom 27000791 First Step Select Overlay BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.23 $97.23 $100.97 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000792 EAP Custom 27000792 Telemetry Med Supplies BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000793 EAP Custom 27000793 Med/surg Isolation Supplies BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.56 $208.56 $216.59 $0.00 $58.56 $0.00 $0.00 $0.00 $0.00 $140.50 $222.55 $224.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000803 EAP Custom 27000803 Dialysis Filter BOTH IP/OP $699.00 $517.26 $0.00 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $518.80 $518.80 $538.79 $0.00 $145.67 $0.00 $0.00 $0.00 $0.00 $349.50 $553.61 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000810 EAP Custom 27000810 Needle Spinal 18ga BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000811 EAP Custom 27000811 Needle Spinal Sterile 20g BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000815 EAP Custom 27000815 Catheter Thoracic 28fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000816 EAP Custom 27000816 Catheter Thoracic 32fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000817 EAP Custom 27000817 Catheter Thoracic 36fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000818 EAP HCPCS C1729 Catheter Foley 30cc 28fr BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $21.18 $21.18 $0.00 $0.00 $0.00 $8.13 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $6.10 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 27000819 EAP Custom 27000819 Artery Arterial Catheriza BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000820 EAP Custom 27000820 Artery Radial Catherizati BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000821 EAP Custom 27000821 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000822 EAP Custom 27000822 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000826 EAP Custom 27000826 Tray Catheter Insrtn Dulm BOTH IP/OP $434.00 $321.16 $0.00 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.11 $322.11 $334.53 $0.00 $90.45 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000828 EAP Custom 27000828 Catheter Peritoneal Adult BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.86 $155.86 $161.87 $0.00 $43.76 $0.00 $0.00 $0.00 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000829 EAP Custom 27000829 Triconnector With Valve BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000830 EAP Custom 27000830 Set Blood Administration BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000834 EAP Custom 27000834 Kit L.f. Trach Care BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $0.00 $0.00 $0.00 $118.50 $187.70 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000836 EAP Custom 27000836 Kit Thoracotomy BOTH IP/OP $217.00 $160.58 $0.00 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.06 $161.06 $167.26 $0.00 $45.22 $0.00 $0.00 $0.00 $0.00 $108.50 $171.86 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000841 EAP Custom 27000841 Pouch Fecal Incontinence BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000842 EAP Custom 27000842 Kit Pressure Monitoring T BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000843 EAP Custom 27000843 Kit Transducer Monitoring BOTH IP/OP $339.00 $250.86 $0.00 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.61 $251.61 $261.30 $0.00 $70.65 $0.00 $0.00 $0.00 $0.00 $169.50 $268.49 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000844 EAP Custom 27000844 Kit Pressure Monitoring BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000846 EAP Custom 27000846 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000847 EAP Custom 27000847 Kit Pecutaneous Introduce BOTH IP/OP $298.00 $220.52 $0.00 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.18 $221.18 $229.70 $0.00 $62.10 $0.00 $0.00 $0.00 $0.00 $149.00 $236.02 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000848 EAP Custom 27000848 Chest Unit Drainage Pleur BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $323.74 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000849 EAP Custom 27000849 Chest Unit Dry Suction Sy BOTH IP/OP $316.00 $233.84 $0.00 $252.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.54 $234.54 $243.57 $0.00 $65.85 $0.00 $0.00 $0.00 $0.00 $158.00 $250.27 $252.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000854 EAP Custom 27000854 Trac Dressing Xl BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $53.96 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000857 EAP Custom 27000857 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000858 EAP Custom 27000858 Kit Triple Lumen Catheter BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000859 EAP Custom 27000859 Catheter Swan Ganz BOTH IP/OP $726.00 $537.24 $0.00 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $538.84 $538.84 $559.60 $0.00 $151.30 $0.00 $0.00 $0.00 $0.00 $363.00 $574.99 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000860 EAP Custom 27000860 Delivery System Closed In BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000866 EAP Custom 27000866 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000868 EAP Custom 27000868 Tray Urine Meter 18fr BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000869 EAP Custom 27000869 Kit Ventriculostomy BOTH IP/OP $763.00 $564.62 $0.00 $610.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $566.30 $566.30 $588.12 $0.00 $159.01 $0.00 $0.00 $0.00 $0.00 $381.50 $604.30 $610.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000870 EAP Custom 27000870 Tray Thoracentesis Dispos BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $0.00 $0.00 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000872 EAP Custom 27000872 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000880 EAP Custom 27000880 Femoral Arterial Line Kit BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.11 $132.11 $137.20 $0.00 $37.10 $0.00 $0.00 $0.00 $0.00 $89.00 $140.98 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000881 EAP Custom 27000881 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000882 EAP Custom 27000882 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000883 EAP Custom 27000883 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000884 EAP Custom 27000884 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000886 EAP Custom 27000886 Med/surg Isolation Supplies BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.56 $208.56 $216.59 $0.00 $58.56 $0.00 $0.00 $0.00 $0.00 $140.50 $222.55 $224.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000887 EAP Custom 27000887 Med/pri Supplies BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000888 EAP Custom 27000888 Med/surg Semi-supplies BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000902 EAP Custom 27000902 Catheter Thoracic 28fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000903 EAP Custom 27000903 Catheter Thoracic 32fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000904 EAP Custom 27000904 Catheter Thoracic 36fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000905 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27000906 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27000907 EAP HCPCS C1729 Catheter Coude Size 16fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27000908 EAP Custom 27000908 Artery Arterial Catheriza BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000909 EAP Custom 27000909 Artery Radial Catherizati BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000910 EAP Custom 27000910 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000911 EAP Custom 27000911 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000912 EAP Custom 27000912 Tubes Salem Sump 48 Leng BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000915 EAP Custom 27000915 Tray Catheter Insrtn Dulm BOTH IP/OP $937.00 $693.38 $0.00 $749.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.44 $695.44 $722.24 $0.00 $195.27 $0.00 $0.00 $0.00 $0.00 $468.50 $742.10 $749.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000916 EAP Custom 27000916 Scaple Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000918 EAP Custom 27000918 Triconnector With Valve BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000922 EAP Custom 27000922 Pouch Active Life Squib Drain BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000926 EAP Custom 27000926 Kit Thoracotomy BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.86 $155.86 $161.87 $0.00 $43.76 $0.00 $0.00 $0.00 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000931 EAP Custom 27000931 Pouch Fecal Incontinence BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000932 EAP Custom 27000932 Kit Pressure Monitoring T BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000933 EAP Custom 27000933 Kit Pressure Monitoring BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000934 EAP Custom 27000934 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000935 EAP Custom 27000935 Needle Port-cath 20ga X 1 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000936 EAP Custom 27000936 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000941 EAP Custom 27000941 Dressing X-large BOTH IP/OP $321.00 $237.54 $0.00 $256.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.25 $238.25 $247.43 $0.00 $66.90 $0.00 $0.00 $0.00 $0.00 $160.50 $254.23 $256.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000942 EAP Custom 27000942 Trac Dressing Xl BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.53 $116.53 $121.02 $0.00 $32.72 $0.00 $0.00 $0.00 $0.00 $78.50 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000945 EAP Custom 27000945 Tube Feeding Ng 8fr 36in Entri BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000946 EAP Custom 27000946 Kit Triple Lumen Catheter BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000949 EAP Custom 27000949 Filter Set 0.22 Micron BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000951 EAP Custom 27000951 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000952 EAP Custom 27000952 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000953 EAP Custom 27000953 Tray Thoracentesis Dispos BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $181.14 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000955 EAP Custom 27000955 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000962 EAP Custom 27000962 Sleeve Knee Regular Dvt BOTH IP/OP $370.00 $273.80 $0.00 $296.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $274.61 $274.61 $285.20 $0.00 $77.11 $0.00 $0.00 $0.00 $0.00 $185.00 $293.04 $296.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000963 EAP Custom 27000963 Sleeve Knee X-large Dvt BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.99 $333.99 $346.86 $0.00 $93.78 $0.00 $0.00 $0.00 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000964 EAP Custom 27000964 Sleeve Thigh Regular Dvt BOTH IP/OP $529.00 $391.46 $0.00 $423.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $392.62 $392.62 $407.75 $0.00 $110.24 $0.00 $0.00 $0.00 $0.00 $264.50 $418.97 $423.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000965 EAP Custom 27000965 Sleeve Thigh X-large Dvt BOTH IP/OP $488.00 $361.12 $0.00 $390.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $362.19 $362.19 $376.15 $0.00 $101.70 $0.00 $0.00 $0.00 $0.00 $244.00 $386.50 $390.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000968 EAP Custom 27000968 Dialysis Fluid Bag BOTH IP/OP $166.00 $122.84 $0.00 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.21 $123.21 $127.95 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $83.00 $131.47 $132.80 $0.00 $107.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000969 EAP Custom 27000969 Dialysis Filter BOTH IP/OP $699.00 $517.26 $0.00 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $518.80 $518.80 $538.79 $0.00 $145.67 $0.00 $0.00 $0.00 $0.00 $349.50 $553.61 $559.20 $0.00 $454.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000975 EAP Custom 27000975 Ioban 2 Drape Incise Smal BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000977 EAP Custom 27000977 Ioban 2 Drape Incise Larg BOTH IP/OP $462.00 $341.88 $0.00 $369.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.90 $342.90 $356.11 $0.00 $96.28 $0.00 $0.00 $0.00 $0.00 $231.00 $365.90 $369.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000978 EAP Custom 27000978 Needle Spinal 18ga BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000982 EAP Custom 27000982 Catheter Thoracic 32fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000983 EAP Custom 27000983 Catheter Thoracic 36fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000984 EAP Custom 27000984 Catheter Urethral Two-eye BOTH IP/OP $7.00 $5.18 $0.00 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.20 $5.20 $5.40 $0.00 $1.46 $0.00 $0.00 $0.00 $0.00 $3.50 $5.54 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000985 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27000986 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $11.70 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27000987 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27000988 EAP HCPCS C1729 Catheter Foley 3-way 30cc BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $20.09 $20.09 $0.00 $0.00 $0.00 $7.71 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $21.89 $21.89 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 27000989 EAP Custom 27000989 Catheter Ventricular 20cm BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000990 EAP Custom 27000990 Catheter Edm Ii Becker BOTH IP/OP $617.00 $456.58 $0.00 $493.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.94 $457.94 $475.58 $0.00 $128.58 $0.00 $0.00 $0.00 $0.00 $308.50 $488.66 $493.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000991 EAP Custom 27000991 Artery Arterial Catheriza BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000992 EAP Custom 27000992 Artery Radial Catherizati BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000993 EAP Custom 27000993 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000994 EAP Custom 27000994 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000995 EAP Custom 27000995 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000996 EAP Custom 27000996 Kit Percuatane Trache 7fr BOTH IP/OP "$1,219.00 " $902.06 $0.00 $975.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $904.74 $904.74 $939.61 $0.00 $254.04 $0.00 $0.00 $0.00 $0.00 $609.50 $965.45 $975.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000997 EAP Custom 27000997 Kit Percuatane Trache 8fr BOTH IP/OP "$1,424.00 " "$1,053.76" $0.00 "$1,139.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,056.89" "$1,056.89" "$1,097.62" $0.00 $296.76 $0.00 $0.00 $0.00 $0.00 $712.00 "$1,127.81" "$1,139.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27000998 EAP Custom 27000998 Kit Tracheotomy Care Ster BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001001 EAP Custom 27001001 Bag Drainage Becker BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $0.00 $0.00 $0.00 $106.50 $168.70 $170.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001002 EAP Custom 27001002 Tray Catheter Insrtn Dulm BOTH IP/OP $937.00 $693.38 $0.00 $749.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.44 $695.44 $722.24 $0.00 $195.27 $0.00 $0.00 $0.00 $0.00 $468.50 $742.10 $749.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001006 EAP Custom 27001006 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001007 EAP Custom 27001007 Scaple Surg W/handle Atta BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001009 EAP Custom 27001009 Triconnector With Valve BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001012 EAP Custom 27001012 Cream Baza 5oz BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001016 EAP Custom 27001016 Valve Anti-reflux Salem S BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001017 EAP Custom 27001017 Kit L.f. Trach Care BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $0.00 $0.00 $0.00 $118.50 $187.70 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001019 EAP Custom 27001019 Kit Thoracotomy BOTH IP/OP $217.00 $160.58 $0.00 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.50 $171.86 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001025 EAP Custom 27001025 Pouch Fecal Incontinence BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001026 EAP Custom 27001026 Kit Pressure Monitoring T BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001027 EAP Custom 27001027 Transducer Disp For Icp BOTH IP/OP $79.00 $58.46 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.63 $58.63 $60.89 $0.00 $16.46 $0.00 $0.00 $0.00 $0.00 $39.50 $62.57 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001028 EAP Custom 27001028 Kit Transducer Monitoring BOTH IP/OP $339.00 $250.86 $0.00 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.61 $251.61 $261.30 $0.00 $70.65 $0.00 $0.00 $0.00 $0.00 $169.50 $268.49 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001029 EAP Custom 27001029 Kit Pressure Monitoring BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001031 EAP Custom 27001031 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001032 EAP Custom 27001032 Kit Pecutaneous Introduce BOTH IP/OP $298.00 $220.52 $0.00 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.18 $221.18 $229.70 $0.00 $62.10 $0.00 $0.00 $0.00 $0.00 $149.00 $236.02 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001033 EAP Custom 27001033 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001034 EAP Custom 27001034 Chest Unit Dry Suction Sy BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001035 EAP Custom 27001035 Bag Auto-transfusion Ple BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.84 $181.84 $188.85 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001040 EAP Custom 27001040 Dressing X-large BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001041 EAP Custom 27001041 Trac Dressing Xl BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.17 $126.17 $131.04 $0.00 $35.43 $0.00 $0.00 $0.00 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001044 EAP Custom 27001044 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001045 EAP Custom 27001045 Kit Triple Lumen Catheter BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001046 EAP Custom 27001046 Wire Guide Dual Purpose BOTH IP/OP $362.00 $267.88 $0.00 $289.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.68 $268.68 $279.03 $0.00 $75.44 $0.00 $0.00 $0.00 $0.00 $181.00 $286.70 $289.60 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001047 EAP Custom 27001047 Kit Monitoring Intracrani BOTH IP/OP $426.00 $315.24 $0.00 $340.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $316.18 $316.18 $328.36 $0.00 $88.78 $0.00 $0.00 $0.00 $0.00 $213.00 $337.39 $340.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001048 EAP Custom 27001048 Cath Trauma Ventricular BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001049 EAP Custom 27001049 Catheter Swan Ganz BOTH IP/OP $309.00 $228.66 $0.00 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.34 $229.34 $238.18 $0.00 $64.40 $0.00 $0.00 $0.00 $0.00 $154.50 $244.73 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001050 EAP Custom 27001050 Delivery System Closed In BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001051 EAP Custom 27001051 Probe V-pacing BOTH IP/OP "$1,277.00 " $944.98 $0.00 "$1,021.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $947.79 $947.79 $984.31 $0.00 $266.13 $0.00 $0.00 $0.00 $0.00 $638.50 "$1,011.38" "$1,021.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001055 EAP Custom 27001055 Filter Set 0.22 Micron BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001057 EAP Custom 27001057 Tray Foley Preconnected 1 BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001058 EAP Custom 27001058 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001060 EAP Custom 27001060 Tray Urine Meter 18fr BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001061 EAP Custom 27001061 Kit Ventriculostomy BOTH IP/OP "$1,782.00 " "$1,318.68" $0.00 "$1,425.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,322.60" "$1,322.60" "$1,373.57" $0.00 $371.37 $0.00 $0.00 $0.00 $0.00 $891.00 "$1,411.34" "$1,425.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001062 EAP Custom 27001062 Tray Thoracentesis Dispos BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $0.00 $0.00 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001063 EAP Custom 27001063 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001064 EAP Custom 27001064 Bag Drainage Ureteral BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001078 EAP Custom 27001078 Femoral Arterial Line Kit BOTH IP/OP $172.00 $127.28 $0.00 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.66 $127.66 $132.58 $0.00 $35.84 $0.00 $0.00 $0.00 $0.00 $86.00 $136.22 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001079 EAP Custom 27001079 Kit Percutane Trache 9fr BOTH IP/OP "$3,007.00 " "$2,225.18" $0.00 "$2,405.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,231.80" "$2,231.80" "$2,317.80" $0.00 $626.66 $0.00 $0.00 $0.00 $0.00 "$1,503.50" "$2,381.54" "$2,405.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001081 EAP Custom 27001081 Cath Cco Swan Ganz 8fr BOTH IP/OP "$2,182.00 " "$1,614.68" $0.00 "$1,745.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,091.00" "$1,728.14" "$1,745.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001082 EAP Custom 27001082 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001083 EAP Custom 27001083 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001084 EAP Custom 27001084 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001085 EAP Custom 27001085 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001086 EAP Custom 27001086 First Step Select Overlay BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001096 EAP Custom 27001096 Dialysis Filter BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001101 EAP Custom 27001101 Needle Spinal 22ga X 3-1/ BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001106 EAP Custom 27001106 Catheter Thoracic 28fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001107 EAP Custom 27001107 Catheter Thoracic 32fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001108 EAP Custom 27001108 Catheter Thoracic 36fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001109 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27001110 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27001111 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $12.35 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27001112 EAP HCPCS C1729 Catheter Foley 30cc 28fr BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $21.18 $21.18 $0.00 $0.00 $0.00 $8.13 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $6.10 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 27001113 EAP Custom 27001113 Catheter Ventricular 20cm BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $566.54 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001114 EAP Custom 27001114 Catheter Edm Ii Becker BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" "$1,109.95" $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001115 EAP Custom 27001115 Tube Feeding Ng 8fr 43in En BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $42.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001116 EAP Custom 27001116 Artery Arterial Catheriza BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001117 EAP Custom 27001117 Artery Radial Catherizati BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001118 EAP Custom 27001118 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001119 EAP Custom 27001119 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001120 EAP Custom 27001120 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001124 EAP Custom 27001124 Bag Drainage Becker BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $0.00 $0.00 $0.00 $106.50 $168.70 $170.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001125 EAP Custom 27001125 Blades Surgical #10 W/o H BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001126 EAP Custom 27001126 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001127 EAP Custom 27001127 Triconnector With Valve BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001129 EAP Custom 27001129 Set Blood Administration BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001135 EAP Custom 27001135 Valve Anti-reflux Salem S BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001137 EAP Custom 27001137 Kit Thoracotomy BOTH IP/OP $217.00 $160.58 $0.00 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.06 $161.06 $167.26 $0.00 $45.22 $0.00 $0.00 $0.00 $0.00 $108.50 $171.86 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001142 EAP Custom 27001142 Pouch Fecal Incontinence BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001143 EAP Custom 27001143 Kit Pressure Monitoring T BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001144 EAP Custom 27001144 Transducer Disp For Icp BOTH IP/OP $79.00 $58.46 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.63 $58.63 $60.89 $0.00 $16.46 $0.00 $0.00 $0.00 $0.00 $39.50 $62.57 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001145 EAP Custom 27001145 Bridge Kit Bifurated Resp BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $0.00 $0.00 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001146 EAP Custom 27001146 Kit Transducer Monitoring BOTH IP/OP $339.00 $250.86 $0.00 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.61 $251.61 $261.30 $0.00 $70.65 $0.00 $0.00 $0.00 $0.00 $169.50 $268.49 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001147 EAP Custom 27001147 Kit Pressure Monitoring BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001149 EAP Custom 27001149 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001150 EAP Custom 27001150 Kit Pecutaneous Introduce BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.85 $204.85 $212.74 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $138.00 $218.59 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001151 EAP Custom 27001151 Chest Unit Drainage Pleur BOTH IP/OP $401.00 $296.74 $0.00 $320.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.62 $297.62 $309.09 $0.00 $83.57 $0.00 $0.00 $0.00 $0.00 $200.50 $317.59 $320.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001152 EAP Custom 27001152 Chest Unit Dry Suction Sy BOTH IP/OP $316.00 $233.84 $0.00 $252.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.54 $234.54 $243.57 $0.00 $65.85 $0.00 $0.00 $0.00 $0.00 $158.00 $250.27 $252.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001157 EAP Custom 27001157 Dressing X-large BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001158 EAP Custom 27001158 Trac Dressing Xl BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.53 $116.53 $121.02 $0.00 $32.72 $0.00 $0.00 $0.00 $0.00 $78.50 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001161 EAP Custom 27001161 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001162 EAP Custom 27001162 Kit Triple Lumen Catheter BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.32 $255.32 $265.16 $0.00 $71.69 $0.00 $0.00 $0.00 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001163 EAP Custom 27001163 Wire Guide Dual Purpose BOTH IP/OP $392.00 $290.08 $0.00 $313.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.94 $290.94 $302.15 $0.00 $81.69 $0.00 $0.00 $0.00 $0.00 $196.00 $310.46 $313.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001164 EAP Custom 27001164 Kit Monitoring Intracrani BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $354.57 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001165 EAP Custom 27001165 Cath Trauma Ventricular BOTH IP/OP "$1,014.00 " $750.36 $0.00 $811.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.00 $803.09 $811.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001166 EAP Custom 27001166 Catheter Swan Ganz BOTH IP/OP $309.00 $228.66 $0.00 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.34 $229.34 $238.18 $0.00 $64.40 $0.00 $0.00 $0.00 $0.00 $154.50 $244.73 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001167 EAP Custom 27001167 Delivery System Closed In BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001173 EAP Custom 27001173 Filter Set 0.22 Micron BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001174 EAP Custom 27001174 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001176 EAP Custom 27001176 Kit Ventriculostomy BOTH IP/OP "$1,782.00 " "$1,318.68" $0.00 "$1,425.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,322.60" "$1,322.60" "$1,373.57" $0.00 $371.37 $0.00 $0.00 $0.00 $0.00 $891.00 "$1,411.34" "$1,425.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001178 EAP Custom 27001178 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $30.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001179 EAP Custom 27001179 Kit Lumbar Drainage Edm BOTH IP/OP $788.00 $583.12 $0.00 $630.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $584.85 $584.85 $607.39 $0.00 $164.22 $0.00 $0.00 $0.00 $0.00 $394.00 $624.10 $630.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001190 EAP Custom 27001190 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001191 EAP Custom 27001191 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001192 EAP Custom 27001192 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001193 EAP Custom 27001193 Sleeve Thigh X-large Dvt BOTH IP/OP $663.00 $490.62 $0.00 $530.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.08 $492.08 $511.04 $0.00 $138.17 $0.00 $0.00 $0.00 $0.00 $331.50 $525.10 $530.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001194 EAP Custom 27001194 First Step Select Overlay BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.23 $97.23 $100.97 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001205 EAP Custom 27001205 Dialysis Filter BOTH IP/OP $651.00 $481.74 $0.00 $520.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.17 $483.17 $501.79 $0.00 $135.67 $0.00 $0.00 $0.00 $0.00 $325.50 $515.59 $520.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001206 EAP Custom 27001206 Tubes Extension Plain Pla BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001218 EAP Custom 27001218 Catheter Thoracic 16f BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001219 EAP Custom 27001219 Catheter Thoracic 20fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001220 EAP Custom 27001220 Catheter Thoracic 24fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001221 EAP Custom 27001221 Catheter Thoracic 28fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001222 EAP Custom 27001222 Catheter Thoracic 32fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001223 EAP Custom 27001223 Catheter Urethral 8fr BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001224 EAP Custom 27001224 Entriflex BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001225 EAP Custom 27001225 Tube Feeding Nasogastric BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001226 EAP Custom 27001226 Artery Arterial Catheriza BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001227 EAP Custom 27001227 Artery Radial Catherizati BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001228 EAP Custom 27001228 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001229 EAP Custom 27001229 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001231 EAP Custom 27001231 Set Urinary Drain W/conta BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001232 EAP Custom 27001232 Tray Catheter Insrtn Dulm BOTH IP/OP $434.00 $321.16 $0.00 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.11 $322.11 $334.53 $0.00 $90.45 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001234 EAP Custom 27001234 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001235 EAP Custom 27001235 Stapler Skin Disposable 3 BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $24.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001236 EAP Custom 27001236 Triconnector With Valve BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001240 EAP Custom 27001240 Aquacel Ag 4x4 BOTH IP/OP $92.00 $68.08 $0.00 $73.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.28 $68.28 $70.91 $0.00 $19.17 $0.00 $0.00 $0.00 $0.00 $46.00 $72.86 $73.60 $0.00 $59.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001243 EAP Custom 27001243 Electrodes Operative BOTH IP/OP $289.00 $213.86 $0.00 $231.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.50 $214.50 $222.76 $0.00 $60.23 $0.00 $0.00 $0.00 $0.00 $144.50 $228.89 $231.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001249 EAP Custom 27001249 Kit Pressure Monitoring T BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001250 EAP Custom 27001250 Kit Transducer Monitoring BOTH IP/OP $339.00 $250.86 $0.00 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.61 $251.61 $261.30 $0.00 $70.65 $0.00 $0.00 $0.00 $0.00 $169.50 $268.49 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001252 EAP Custom 27001252 Kit Pressure Monitoring BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001254 EAP Custom 27001254 Bag 1000ml Pump Set BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001255 EAP Custom 27001255 Kit Pecutaneous Introduce BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.85 $204.85 $212.74 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $138.00 $218.59 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001256 EAP Custom 27001256 Chest Unit Drainage Pleur BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.73 $144.73 $150.31 $0.00 $40.64 $0.00 $0.00 $0.00 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001257 EAP Custom 27001257 Bag Pressure 500cc BOTH IP/OP $82.00 $60.68 $0.00 $65.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.86 $60.86 $63.21 $0.00 $17.09 $0.00 $0.00 $0.00 $0.00 $41.00 $64.94 $65.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001258 EAP Custom 27001258 Bag Pressure 1000cc BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001260 EAP Custom 27001260 Tube Feeding Ng 8fr 36in Entri BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001261 EAP Custom 27001261 Multi Lumen Cvc W/o Silver Su BOTH IP/OP $751.00 $555.74 $0.00 $600.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $557.39 $557.39 $578.87 $0.00 $156.51 $0.00 $0.00 $0.00 $0.00 $375.50 $594.79 $600.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001262 EAP Custom 27001262 Kit Triple Lumen Catheter BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001263 EAP Custom 27001263 Catheter Swan Ganz BOTH IP/OP $726.00 $537.24 $0.00 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $538.84 $538.84 $559.60 $0.00 $151.30 $0.00 $0.00 $0.00 $0.00 $363.00 $574.99 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001264 EAP Custom 27001264 Delivery System Closed In BOTH IP/OP $141.00 $104.34 $0.00 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.65 $104.65 $108.68 $0.00 $29.38 $0.00 $0.00 $0.00 $0.00 $70.50 $111.67 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001265 EAP Custom 27001265 Set T-port Small Bore Ext BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001268 EAP Custom 27001268 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001270 EAP Custom 27001270 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001271 EAP Custom 27001271 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001272 EAP Custom 27001272 Tray Thoracentesis Dispos BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001273 EAP Custom 27001273 Sponges Laparotomy 6522 BOTH IP/OP $119.00 $88.06 $0.00 $95.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.32 $88.32 $91.73 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $59.50 $94.25 $95.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001274 EAP Custom 27001274 Bovie Pencil Valleylab BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001283 EAP Custom 27001283 Dressing Acticoat 16x16 BOTH IP/OP $678.00 $501.72 $0.00 $542.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $503.21 $503.21 $522.60 $0.00 $141.30 $0.00 $0.00 $0.00 $0.00 $339.00 $536.98 $542.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001284 EAP Custom 27001284 Kit Vascular Conform BOTH IP/OP $108.00 $79.92 $0.00 $86.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $0.00 $0.00 $0.00 $54.00 $85.54 $86.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001285 EAP Custom 27001285 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001286 EAP Custom 27001286 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001287 EAP Custom 27001287 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001288 EAP Custom 27001288 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001289 EAP Custom 27001289 1st First Select Overlay BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.23 $97.23 $100.97 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001298 EAP Custom 27001298 Therapy For Cvvh/cvvhd 4 BOTH IP/OP $166.00 $122.84 $0.00 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.21 $123.21 $127.95 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $83.00 $131.47 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001299 EAP Custom 27001299 Dialysis Filter BOTH IP/OP $699.00 $517.26 $0.00 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $518.80 $518.80 $538.79 $0.00 $145.67 $0.00 $0.00 $0.00 $0.00 $349.50 $553.61 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001312 EAP Custom 27001312 Catheter Thoracic 20fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001313 EAP Custom 27001313 Catheter Thoracic 32fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001314 EAP Custom 27001314 Catheter Thoracic 36fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001315 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27001316 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27001317 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27001318 EAP Custom 27001318 Catheter Ventricular 20cm BOTH IP/OP $683.00 $505.42 $0.00 $546.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.92 $506.92 $526.46 $0.00 $142.34 $0.00 $0.00 $0.00 $0.00 $341.50 $540.94 $546.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001319 EAP Custom 27001319 Catheter Edm Ii Becker BOTH IP/OP "$1,339.00 " $990.86 $0.00 "$1,071.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $993.81 $993.81 "$1,032.10" $0.00 $279.05 $0.00 $0.00 $0.00 $0.00 $669.50 "$1,060.49" "$1,071.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001320 EAP Custom 27001320 Artery Arterial Catheriza BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001321 EAP Custom 27001321 Artery Radial Catherizati BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001322 EAP Custom 27001322 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001323 EAP Custom 27001323 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001324 EAP Custom 27001324 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001328 EAP Custom 27001328 Bag Drainage Becker BOTH IP/OP $202.00 $149.48 $0.00 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.92 $149.92 $155.70 $0.00 $42.10 $0.00 $0.00 $0.00 $0.00 $101.00 $159.98 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001329 EAP Custom 27001329 Tray Catheter Insrtn Dulm BOTH IP/OP $937.00 $693.38 $0.00 $749.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.44 $695.44 $722.24 $0.00 $195.27 $0.00 $0.00 $0.00 $0.00 $468.50 $742.10 $749.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001330 EAP Custom 27001330 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001331 EAP Custom 27001331 Triconnector With Valve BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001337 EAP Custom 27001337 Cable Patient 12 Pin #r53 BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001341 EAP Custom 27001341 Kit Thoracotomy BOTH IP/OP $217.00 $160.58 $0.00 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.06 $161.06 $167.26 $0.00 $45.22 $0.00 $0.00 $0.00 $0.00 $108.50 $171.86 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001347 EAP Custom 27001347 Pouch Fecal Incontinence BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001348 EAP Custom 27001348 Kit Pressure Monitoring T BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001349 EAP Custom 27001349 Transducer Disp For Icp BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001350 EAP Custom 27001350 Bridge Kit Bifurated Resp BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $0.00 $0.00 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001351 EAP Custom 27001351 Kit Transducer Monitoring BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $0.00 $0.00 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001352 EAP Custom 27001352 Kit Pressure Monitoring BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001354 EAP Custom 27001354 Bag Feeding Gavage 500ml BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001355 EAP Custom 27001355 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001356 EAP Custom 27001356 Kit Pecutaneous Introduce BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.74 $95.74 $99.43 $0.00 $26.88 $0.00 $0.00 $0.00 $0.00 $64.50 $102.17 $103.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001357 EAP Custom 27001357 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001358 EAP Custom 27001358 Chest Imot Dry Suction Sy BOTH IP/OP $316.00 $233.84 $0.00 $252.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.54 $234.54 $243.57 $0.00 $65.85 $0.00 $0.00 $0.00 $0.00 $158.00 $250.27 $252.80 $0.00 $205.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001363 EAP Custom 27001363 Trac Dressing Xl BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.53 $116.53 $121.02 $0.00 $32.72 $0.00 $0.00 $0.00 $0.00 $78.50 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001366 EAP Custom 27001366 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001367 EAP Custom 27001367 Kit Triple Lumen Catheter BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001369 EAP Custom 27001369 Kit Monitoring Intracrani BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $354.57 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001370 EAP Custom 27001370 Catheter Swan Ganz BOTH IP/OP $674.00 $498.76 $0.00 $539.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.24 $500.24 $519.52 $0.00 $140.46 $0.00 $0.00 $0.00 $0.00 $337.00 $533.81 $539.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001371 EAP Custom 27001371 Delivery System Closed In BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001372 EAP Custom 27001372 Probe V-pacing BOTH IP/OP "$1,403.00 " "$1,038.22" $0.00 "$1,122.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,041.31" "$1,041.31" "$1,081.43" $0.00 $292.39 $0.00 $0.00 $0.00 $0.00 $701.50 "$1,111.18" "$1,122.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001374 EAP Custom 27001374 Filter Set 0.22 Micron BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001376 EAP Custom 27001376 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001377 EAP Custom 27001377 Kit Ventriculostomy BOTH IP/OP "$1,782.00 " "$1,318.68" $0.00 "$1,425.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,322.60" "$1,322.60" "$1,373.57" $0.00 $371.37 $0.00 $0.00 $0.00 $0.00 $891.00 "$1,411.34" "$1,425.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001379 EAP Custom 27001379 Tray Pericardiocentesis BOTH IP/OP "$1,235.00 " $913.90 $0.00 $988.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $916.62 $916.62 $951.94 $0.00 $257.37 $0.00 $0.00 $0.00 $0.00 $617.50 $978.12 $988.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001380 EAP Custom 27001380 Central Line Dressing Tray With Biopatch BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001391 EAP Custom 27001391 .014 Nitrex Guidewire BOTH IP/OP "$2,554.00 " "$1,889.96" $0.00 "$2,043.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,895.58" "$1,895.58" "$1,968.62" $0.00 $532.25 $0.00 $0.00 $0.00 $0.00 "$1,277.00" "$2,022.77" "$2,043.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001392 EAP Custom 27001392 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001393 EAP Custom 27001393 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001394 EAP Custom 27001394 Sleeve Thigh Regular Dvt BOTH IP/OP $553.00 $409.22 $0.00 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.44 $410.44 $426.25 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001395 EAP Custom 27001395 Sleeve Thigh X-large Dvt BOTH IP/OP $616.00 $455.84 $0.00 $492.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.20 $457.20 $474.81 $0.00 $128.37 $0.00 $0.00 $0.00 $0.00 $308.00 $487.87 $492.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001399 EAP Custom 27001399 Tray Circumcision BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001400 EAP Custom 27001400 Needle Neo-natal Lumbar P BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001401 EAP Custom 27001401 Tubes Capillary Hepariniz BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001403 EAP Custom 27001403 Tube Feeding Plastic 8fr BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001408 EAP Custom 27001408 Bag Feeding Gavage 500ml BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001409 EAP Custom 27001409 Set Breast Pump Complete BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $35.50 $56.23 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001410 EAP Custom 27001410 Cassettes Imed #9260 20/c BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001411 EAP Custom 27001411 Catheter Quick Iv 22ga BOTH IP/OP $7.00 $5.18 $0.00 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.20 $5.20 $5.40 $0.00 $1.46 $0.00 $0.00 $0.00 $0.00 $3.50 $5.54 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001412 EAP Custom 27001412 Filter Set 0.22 Micron BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001413 EAP Custom 27001413 Set T-port Small Bore Ext BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001415 EAP Custom 27001415 Tube Sump Gastric 50/cs BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001418 EAP Custom 27001418 Precision Introd.26g(1.9f) BOTH IP/OP $149.00 $110.26 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $110.59 $110.59 $114.85 $0.00 $31.05 $0.00 $0.00 $0.00 $0.00 $74.50 $118.01 $119.20 $0.00 $96.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001419 EAP Custom 27001419 26g Catheter(1.9f 1st Picc Bd) BOTH IP/OP $260.00 $192.40 $0.00 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.97 $192.97 $200.41 $0.00 $54.18 $0.00 $0.00 $0.00 $0.00 $130.00 $205.92 $208.00 $0.00 $169.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001420 EAP Custom 27001420 Picc Tray (bd Procedure Tray) BOTH IP/OP $219.00 $162.06 $0.00 $175.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.54 $162.54 $168.81 $0.00 $45.64 $0.00 $0.00 $0.00 $0.00 $109.50 $173.45 $175.20 $0.00 $142.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001421 EAP Custom 27001421 Precision Introducer 22g(2.8f) BOTH IP/OP $183.00 $135.42 $0.00 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.82 $135.82 $141.06 $0.00 $38.14 $0.00 $0.00 $0.00 $0.00 $91.50 $144.94 $146.40 $0.00 $118.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001422 EAP Custom 27001422 22g Catheter(2.8f 1st Picc Bd) BOTH IP/OP $343.00 $253.82 $0.00 $274.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $264.38 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $171.50 $271.66 $274.40 $0.00 $222.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001423 EAP Custom 27001423 Argyle Picc 1.9frx39cm Dual Lu BOTH IP/OP $423.00 $313.02 $0.00 $338.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.95 $313.95 $326.05 $0.00 $88.15 $0.00 $0.00 $0.00 $0.00 $211.50 $335.02 $338.40 $0.00 $274.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001424 EAP Custom 27001424 20g(3fr)bdl Cath Picc Dual Lum BOTH IP/OP $154.00 $113.96 $0.00 $123.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.30 $114.30 $118.70 $0.00 $32.09 $0.00 $0.00 $0.00 $0.00 $77.00 $121.97 $123.20 $0.00 $100.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001428 EAP Custom 27001428 Tray Circumcision BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001429 EAP Custom 27001429 Needle Neo-natal Lumbar P BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001430 EAP Custom 27001430 Needle Spinal 22g 25/bx BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001431 EAP Custom 27001431 Tubes Capillary Hepariniz BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001432 EAP Custom 27001432 Tube Nasogastric Feeding BOTH IP/OP $91.00 $67.34 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.54 $67.54 $70.14 $0.00 $18.96 $0.00 $0.00 $0.00 $0.00 $45.50 $72.07 $72.80 $0.00 $59.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001435 EAP Custom 27001435 Catheter Urethral 8fr BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001436 EAP Custom 27001436 Catheter Umbilical 15 3- BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001437 EAP Custom 27001437 Catheter Umbilical 15 5f BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001438 EAP Custom 27001438 Tube Feeding Plastic 8fr BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001441 EAP Custom 27001441 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001443 EAP Custom 27001443 Pouch Little Ones Cut To BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001446 EAP Custom 27001446 Transducer With Interg 43 BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001447 EAP Custom 27001447 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001448 EAP Custom 27001448 Catheter Thoracic Trocar BOTH IP/OP $134.00 $99.16 $0.00 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.00 $106.13 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001449 EAP Custom 27001449 Catheter Thoracic Trocar 10 F BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001450 EAP Custom 27001450 Chest Unit Drainage Pleur BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001451 EAP Custom 27001451 Cassettes Imed #9260 20/c BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001452 EAP Custom 27001452 Catheter Quick Iv 22gax1- BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.23 $2.23 $2.31 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001453 EAP Custom 27001453 Catheter Introducer Steri BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.23 $2.23 $2.31 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001454 EAP Custom 27001454 Filter Set 0.22 Micron BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001455 EAP Custom 27001455 Set T-port Small Bore Ext BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001456 EAP Custom 27001456 Tray Transfusion Sterile BOTH IP/OP $597.00 $441.78 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.09 $443.09 $460.17 $0.00 $124.41 $0.00 $0.00 $0.00 $0.00 $298.50 $472.82 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001458 EAP Custom 27001458 Tube Sump Gastric 50/cs BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001459 EAP HCPCS C1751 Catheter Iv 26g 120/cs BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $4.38 $0.00 $0.00 $4.46 $0.00 $0.00 $0.00 $0.00 $0.00 27001466 EAP Custom 27001466 Catheter Suction 5fr Ster BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001468 EAP Custom 27001468 Catheter Suction Plastic 14 BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001469 EAP Custom 27001469 Catheter Urethral Two-eye BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001471 EAP Custom 27001471 Set Urinary Drain W/conta BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001473 EAP Custom 27001473 Scaple Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001475 EAP Custom 27001475 Stapler Skin Disposable 3 BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.57 $64.57 $67.06 $0.00 $18.13 $0.00 $0.00 $0.00 $0.00 $43.50 $68.90 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001486 EAP Custom 27001486 Speculum Pediatric BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001487 EAP Custom 27001487 Bag Hyperinflation BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $65.52 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001490 EAP Custom 27001490 Tray Catheter Urethral 14 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001492 EAP Custom 27001492 Tray Foley Preconnected 1 BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001494 EAP Custom 27001494 Sponges Laparotomy 6522 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001501 EAP Custom 27001501 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001502 EAP Custom 27001502 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001503 EAP Custom 27001503 Sleeve Thigh Regular Dvt BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001618 EAP Custom 27001618 Triadyne Ii (bed) BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.00 $547.00 $568.08 $0.00 $153.59 $0.00 $0.00 $0.00 $0.00 $368.50 $583.70 $589.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001620 EAP Custom 27001620 Fluidair Elite (bed) BOTH IP/OP $772.00 $571.28 $0.00 $617.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.98 $572.98 $595.06 $0.00 $160.88 $0.00 $0.00 $0.00 $0.00 $386.00 $611.42 $617.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001635 EAP Custom 27001635 Tube Salem Sump 48 Lengt BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001636 EAP Custom 27001636 Set Urinary Drain W/conta BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001641 EAP Custom 27001641 Tray Douch Disposable BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001644 EAP Custom 27001644 Tray Foley Preconnected 1 BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001645 EAP Custom 27001645 Tray Foley Perconnected 1 BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001647 EAP Custom 27001647 Arrow Super/extreme Cath Kit BOTH IP/OP $802.00 $593.48 $0.00 $641.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $595.24 $595.24 $618.18 $0.00 $167.14 $0.00 $0.00 $0.00 $0.00 $401.00 $635.18 $641.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001649 EAP Custom 27001649 Central Line Dressing Tray BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001650 EAP Custom 27001650 Continuous Cardiac O/put Swans BOTH IP/OP $604.00 $446.96 $0.00 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.29 $448.29 $465.56 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $302.00 $478.37 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001652 EAP Custom 27001652 Pressure Transclucer Kits BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001653 EAP Custom 27001653 Percutaneous Introducer Kits BOTH IP/OP "$2,364.00 " "$1,749.36" $0.00 "$1,891.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,754.56" "$1,754.56" "$1,822.17" $0.00 $492.66 $0.00 $0.00 $0.00 $0.00 "$1,182.00" "$1,872.29" "$1,891.20" $0.00 "$1,536.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001655 EAP Custom 27001655 Sutures BOTH IP/OP $211.00 $156.14 $0.00 $168.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.60 $156.60 $162.64 $0.00 $43.97 $0.00 $0.00 $0.00 $0.00 $105.50 $167.11 $168.80 $0.00 $137.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001657 EAP Custom 27001657 Swan Ganz Catheters BOTH IP/OP $604.00 $446.96 $0.00 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.29 $448.29 $465.56 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $302.00 $478.37 $483.20 $0.00 $392.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001658 EAP Custom 27001658 Guidewire .35x.68cm BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001660 EAP Custom 27001660 Huber Needle BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $11.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001665 EAP Custom 27001665 14fx15cm Schon Xl Dbl Lmn Vasc BOTH IP/OP "$6,497.00 " "$4,807.78" $0.00 "$5,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,007.89" $0.00 "$1,353.97" $0.00 $0.00 $0.00 $0.00 "$3,248.50" "$5,145.62" "$5,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001666 EAP Custom 27001666 14fx24cm Schon Xl Dbl Lmn Vasc BOTH IP/OP "$6,497.00 " "$4,807.78" $0.00 "$5,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,007.89" $0.00 "$1,353.97" $0.00 $0.00 $0.00 $0.00 "$3,248.50" "$5,145.62" "$5,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001667 EAP Custom 27001667 14fx20cm Schon Xl Dbl Lmn Vasc BOTH IP/OP "$6,497.00 " "$4,807.78" $0.00 "$5,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,007.89" $0.00 "$1,353.97" $0.00 $0.00 $0.00 $0.00 "$3,248.50" "$5,145.62" "$5,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001670 EAP Custom 27001670 Twist Lock Cath Gard Catheter BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $61.66 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001671 EAP Custom 27001671 Needles 18 Ga/7cm (cook) BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001672 EAP Custom 27001672 Cook Tlc Tray BOTH IP/OP $457.00 $338.18 $0.00 $365.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.19 $339.19 $352.26 $0.00 $95.24 $0.00 $0.00 $0.00 $0.00 $228.50 $361.94 $365.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001675 EAP Custom 27001675 Tubes Extension Plain Pla BOTH IP/OP $5.00 $3.70 $0.00 $4.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.71 $3.71 $3.85 $0.00 $1.04 $0.00 $0.00 $0.00 $0.00 $2.50 $3.96 $4.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001679 EAP Custom 27001679 Meter Astech Peak Flow BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001692 EAP Custom 27001692 Catheter Thoracic 28fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001693 EAP Custom 27001693 Catheter Thoracic 32fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001694 EAP Custom 27001694 Catheter Thoracic 36fr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001695 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27001696 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27001697 EAP HCPCS C1729 Catheter Coude Size 16fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27001698 EAP Custom 27001698 Artery Arterial Catheriza BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001699 EAP Custom 27001699 Artery Radial Catherizati BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001700 EAP Custom 27001700 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001701 EAP Custom 27001701 Tube Salem Silicone Size BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001702 EAP Custom 27001702 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001703 EAP Custom 27001703 Kit Tracheotomy Care Ster BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001706 EAP Custom 27001706 Tray Catheter Insrtn Dulm BOTH IP/OP "$1,009.00 " $746.66 $0.00 $807.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $748.88 $748.88 $777.74 $0.00 $210.28 $0.00 $0.00 $0.00 $0.00 $504.50 $799.13 $807.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001707 EAP Custom 27001707 Scapel Surg W/handle Attached BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001709 EAP Custom 27001709 Triconnector With Valve BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001713 EAP Custom 27001713 Pouch Active Life Squib Drain BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001715 EAP Custom 27001715 Cable Patient 12 Pin #r53 BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001716 EAP Custom 27001716 Electrodes Operative BOTH IP/OP $122.00 $90.28 $0.00 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.55 $90.55 $94.04 $0.00 $25.42 $0.00 $0.00 $0.00 $0.00 $61.00 $96.62 $97.60 $0.00 $79.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001721 EAP Custom 27001721 Pouch Fecal Incontinence BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001722 EAP Custom 27001722 Kit Pressure Monitoring T BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $136.43 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001723 EAP Custom 27001723 Kit Pressure Monitoring BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001725 EAP Custom 27001725 Bag 1000ml Pump Set BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001726 EAP Custom 27001726 Needle Port-cath 20ga X 1 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001727 EAP Custom 27001727 Chest Unit Drainage Pleur BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001732 EAP Custom 27001732 Dressing X-large BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001733 EAP Custom 27001733 Trac Dressing Xl BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.53 $116.53 $121.02 $0.00 $32.72 $0.00 $0.00 $0.00 $0.00 $78.50 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001735 EAP Custom 27001735 Tube Feeding Ng 8fr 36in Entri BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001736 EAP Custom 27001736 Kit Triple Lumen Catheter BOTH IP/OP $697.00 $515.78 $0.00 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.31 $517.31 $537.25 $0.00 $145.25 $0.00 $0.00 $0.00 $0.00 $348.50 $552.02 $557.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001740 EAP Custom 27001740 Tube Trach #8 Dct BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.64 $248.64 $258.22 $0.00 $69.81 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001741 EAP Custom 27001741 Tube Trach #6 Dct BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.64 $248.64 $258.22 $0.00 $69.81 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001742 EAP Custom 27001742 Tube Trach #10 Dct BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.64 $248.64 $258.22 $0.00 $69.81 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001743 EAP Custom 27001743 Tube Tracheostomy 4-dcfs BOTH IP/OP $326.00 $241.24 $0.00 $260.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.96 $241.96 $251.28 $0.00 $67.94 $0.00 $0.00 $0.00 $0.00 $163.00 $258.19 $260.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001744 EAP Custom 27001744 Filter Set 0.22 Micron BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001746 EAP Custom 27001746 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001747 EAP Custom 27001747 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001748 EAP Custom 27001748 Tray Thoracentesis Dispos BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $0.00 $0.00 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001763 EAP Custom 27001763 Sleeve Knee Regular Dvt BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $0.00 $0.00 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001764 EAP Custom 27001764 Sleeve Knee X-large Dvt BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001765 EAP Custom 27001765 Sleeve Thigh Regular Dvt BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001766 EAP Custom 27001766 Sleeve Thigh X-large Dvt BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.78 $210.78 $218.91 $0.00 $59.19 $0.00 $0.00 $0.00 $0.00 $142.00 $224.93 $227.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001768 EAP HCPCS A4300 Temporary Ven Cath Removal BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001769 EAP Custom 27001769 Tray Catheter Insrtn Dulm BOTH IP/OP "$1,048.00 " $775.52 $0.00 $838.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.83 $777.83 $807.80 $0.00 $218.40 $0.00 $0.00 $0.00 $0.00 $524.00 $830.02 $838.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001770 EAP Custom 27001770 Central Line Dressing Tray BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001771 EAP Custom 27001771 Catheter Repair Kit BOTH IP/OP $803.00 $594.22 $0.00 $642.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $595.99 $595.99 $618.95 $0.00 $167.35 $0.00 $0.00 $0.00 $0.00 $401.50 $635.98 $642.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001773 EAP Custom 27001773 Occult Blood Supply BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001778 EAP Custom 27001778 Needle Port-cath 20ga X 1 BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001779 EAP Custom 27001779 Tray Catheter Urethral 14 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001781 EAP Custom 27001781 Ace Wrap BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001782 EAP Custom 27001782 Splint BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001783 EAP Custom 27001783 Splint - Supply BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.43 $197.43 $205.03 $0.00 $55.43 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $0.00 $172.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001785 EAP Custom 27001785 Ace Wrap BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001786 EAP Custom 27001786 Ace Wrap Supply BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $20.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001788 EAP Custom 27001788 Wrist Brace BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27001789 EAP Custom 27001789 Sling/fig. 8 BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.60 $61.60 $63.98 $0.00 $17.30 $0.00 $0.00 $0.00 $0.00 $41.50 $65.74 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002257 EAP Custom 27002257 Cast Application Supply BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.83 $420.83 $437.04 $0.00 $118.16 $0.00 $0.00 $0.00 $0.00 $283.50 $449.06 $453.60 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002259 EAP Custom 27002259 Sling BOTH IP/OP $108.00 $79.92 $0.00 $86.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $0.00 $0.00 $0.00 $54.00 $85.54 $86.40 $0.00 $70.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002260 EAP Custom 27002260 Ace Bandage BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002261 EAP Custom 27002261 Urinary Drainage Bag BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $18.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002263 EAP Custom 27002263 Gastric Lavage Kit BOTH IP/OP $234.00 $173.16 $0.00 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.67 $173.67 $180.37 $0.00 $48.77 $0.00 $0.00 $0.00 $0.00 $117.00 $185.33 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002265 EAP Custom 27002265 Pelvic Tray BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $89.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002266 EAP Custom 27002266 Peak Flow Meter BOTH IP/OP $343.00 $253.82 $0.00 $274.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $264.38 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $171.50 $271.66 $274.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002267 EAP Custom 27002267 Ortho Traction Pins BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.82 $302.82 $314.49 $0.00 $85.03 $0.00 $0.00 $0.00 $0.00 $204.00 $323.14 $326.40 $0.00 $265.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002268 EAP Custom 27002268 Ace Bandage BOTH IP/OP $147.00 $108.78 $0.00 $117.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.10 $109.10 $113.31 $0.00 $30.63 $0.00 $0.00 $0.00 $0.00 $73.50 $116.42 $117.60 $0.00 $95.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002473 EAP Custom 27002473 Angiocath Iv Bb 18gx1.25in Nw BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002510 EAP Custom 27002510 Nuva Ring BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002515 EAP Custom 27002515 Clavical Straps BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002516 EAP Custom 27002516 Fiberglass Casting BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.74 $95.74 $99.43 $0.00 $26.88 $0.00 $0.00 $0.00 $0.00 $64.50 $102.17 $103.20 $0.00 $83.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002517 EAP Custom 27002517 Ankle Stirrup BOTH IP/OP $149.00 $110.26 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $110.59 $110.59 $114.85 $0.00 $31.05 $0.00 $0.00 $0.00 $0.00 $74.50 $118.01 $119.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002518 EAP Custom 27002518 Knee Immobilizer BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $116.00 $183.74 $185.60 $0.00 $150.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002519 EAP Custom 27002519 Philadephia Collar BOTH IP/OP $193.00 $142.82 $0.00 $154.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.24 $143.24 $148.76 $0.00 $40.22 $0.00 $0.00 $0.00 $0.00 $96.50 $152.86 $154.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002520 EAP Custom 27002520 Cervical Collar BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002521 EAP Custom 27002521 Pavlik Harness BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.11 $132.11 $137.20 $0.00 $37.10 $0.00 $0.00 $0.00 $0.00 $89.00 $140.98 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002522 EAP Custom 27002522 Cast Shoe BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002523 EAP Custom 27002523 Shoulder Immobilizer BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002524 EAP Custom 27002524 Post Op Shoe BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $24.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002525 EAP Custom 27002525 Hinged Knee Brace BOTH IP/OP $705.00 $521.70 $0.00 $564.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.25 $523.25 $543.41 $0.00 $146.92 $0.00 $0.00 $0.00 $0.00 $352.50 $558.36 $564.00 $0.00 $458.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002526 EAP Custom 27002526 Sling/fig. 8 BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $0.00 $0.00 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002527 EAP Custom 27002527 Hinged Knee Sleeve BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.74 $95.74 $99.43 $0.00 $26.88 $0.00 $0.00 $0.00 $0.00 $64.50 $102.17 $103.20 $0.00 $83.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002528 EAP Custom 27002528 Universal Knee Brace BOTH IP/OP $728.00 $538.72 $0.00 $582.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $540.32 $540.32 $561.14 $0.00 $151.72 $0.00 $0.00 $0.00 $0.00 $364.00 $576.58 $582.40 $0.00 $473.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002529 EAP Custom 27002529 Universal Knee Brace BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.36 $275.36 $285.97 $0.00 $77.32 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002530 EAP Custom 27002530 3d Walking Boot BOTH IP/OP $197.00 $145.78 $0.00 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.21 $146.21 $151.85 $0.00 $41.05 $0.00 $0.00 $0.00 $0.00 $98.50 $156.02 $157.60 $0.00 $128.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002531 EAP Custom 27002531 Knee Immobilizer BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $116.00 $183.74 $185.60 $0.00 $150.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002532 EAP Custom 27002532 Shoulder Immobilizer BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $116.00 $183.74 $185.60 $0.00 $150.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002533 EAP Custom 27002533 Philadelphia Collar BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002534 EAP Custom 27002534 Soft Collar BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $65.00 $102.96 $104.00 $0.00 $84.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002535 EAP Custom 27002535 Arm Sling BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $61.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002536 EAP Custom 27002536 Active Ankle Brace BOTH IP/OP $417.00 $308.58 $0.00 $333.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $309.50 $309.50 $321.42 $0.00 $86.90 $0.00 $0.00 $0.00 $0.00 $208.50 $330.26 $333.60 $0.00 $271.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002537 EAP Custom 27002537 Buck's Traction Splint BOTH IP/OP $172.00 $127.28 $0.00 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.66 $127.66 $132.58 $0.00 $35.84 $0.00 $0.00 $0.00 $0.00 $86.00 $136.22 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002538 EAP Custom 27002538 Knee Brace BOTH IP/OP $762.00 $563.88 $0.00 $609.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $565.56 $565.56 $587.35 $0.00 $158.80 $0.00 $0.00 $0.00 $0.00 $381.00 $603.50 $609.60 $0.00 $495.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002539 EAP Custom 27002539 Jacksonville Sling BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $0.00 $0.00 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002541 EAP Custom 27002541 Cast Over Wrap BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002542 EAP Custom 27002542 Cast Over Wrap-fiberglass BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.50 $92.66 $93.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002543 EAP Custom 27002543 Sandbag BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002544 EAP Custom 27002544 Aspen Collar BOTH IP/OP $154.00 $113.96 $0.00 $123.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.30 $114.30 $118.70 $0.00 $32.09 $0.00 $0.00 $0.00 $0.00 $77.00 $121.97 $123.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002545 EAP Custom 27002545 Miami J. Collar BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.73 $144.73 $150.31 $0.00 $40.64 $0.00 $0.00 $0.00 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002546 EAP Custom 27002546 Atlas Collar BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.99 $143.99 $149.54 $0.00 $40.43 $0.00 $0.00 $0.00 $0.00 $97.00 $153.65 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002547 EAP Custom 27002547 Pediatric Pmt Collar BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002548 EAP Custom 27002548 Abduction Pillow BOTH IP/OP $96.00 $71.04 $0.00 $76.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.25 $71.25 $74.00 $0.00 $20.01 $0.00 $0.00 $0.00 $0.00 $48.00 $76.03 $76.80 $0.00 $62.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002549 EAP Custom 27002549 Neoprene Knee Sleeve BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $0.00 $0.00 $0.00 $34.00 $53.86 $54.40 $0.00 $44.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002550 EAP Custom 27002550 Cuff And Collar BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $24.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002551 EAP Custom 27002551 Post Op Shoe BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $24.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002552 EAP Custom 27002552 Tlso Pre Fab BOTH IP/OP "$2,419.00 " "$1,790.06" $0.00 "$1,935.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,795.38" "$1,795.38" "$1,864.57" $0.00 $504.12 $0.00 $0.00 $0.00 $0.00 "$1,209.50" "$1,915.85" "$1,935.20" $0.00 "$1,572.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002564 EAP CPT® C1751 "Cvp Kit, Double Lumen" BOTH IP/OP $569.00 $421.06 $0.00 $455.20 $308.97 $308.97 $0.00 $0.00 $0.00 $118.59 $422.31 $422.31 $438.59 $0.00 $118.58 $0.00 $336.56 $336.56 $0.00 $284.50 $450.65 $455.20 $0.00 $369.85 $0.00 $89.05 $0.00 $0.00 $90.58 $0.00 $0.00 $0.00 $0.00 $0.00 27002565 EAP Custom 27002565 "Ett, Double-lumen" BOTH IP/OP $837.00 $619.38 $0.00 $669.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $621.22 $621.22 $645.16 $0.00 $174.43 $0.00 $0.00 $0.00 $0.00 $418.50 $662.90 $669.60 $0.00 $544.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002572 EAP Custom 27002572 Introducer Kit BOTH IP/OP $261.00 $193.14 $0.00 $208.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.71 $193.71 $201.18 $0.00 $54.39 $0.00 $0.00 $0.00 $0.00 $130.50 $206.71 $208.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002573 EAP Custom 27002573 Radial Artery Set (arrow) BOTH IP/OP $92.00 $68.08 $0.00 $73.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.28 $68.28 $70.91 $0.00 $19.17 $0.00 $0.00 $0.00 $0.00 $46.00 $72.86 $73.60 $0.00 $59.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002576 EAP Custom 27002576 Epidural Tray BOTH IP/OP $316.00 $233.84 $0.00 $252.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.54 $234.54 $243.57 $0.00 $65.85 $0.00 $0.00 $0.00 $0.00 $158.00 $250.27 $252.80 $0.00 $205.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002579 EAP Custom 27002579 Level One Inserts BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $0.00 $0.00 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002587 EAP HCPCS C1751 Kit Quad Lumen Cather BOTH IP/OP $148.00 $109.52 $0.00 $118.40 $80.36 $80.36 $0.00 $0.00 $0.00 $30.85 $109.85 $109.85 $114.08 $0.00 $30.84 $0.00 $87.54 $87.54 $0.00 $74.00 $117.22 $118.40 $0.00 $96.20 $0.00 $23.16 $0.00 $0.00 $23.56 $0.00 $0.00 $0.00 $0.00 $0.00 27002589 EAP Custom 27002589 Aintree Intubation Changer BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.60 $61.60 $63.98 $0.00 $17.30 $0.00 $0.00 $0.00 $0.00 $41.50 $65.74 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002590 EAP Custom 27002590 Kit Triple Lumen Catheter BOTH IP/OP $646.00 $478.04 $0.00 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.46 $479.46 $497.94 $0.00 $134.63 $0.00 $0.00 $0.00 $0.00 $323.00 $511.63 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002593 EAP Custom 27002593 "Cvp Kit, Double Lumen" BOTH IP/OP $307.00 $227.18 $0.00 $245.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.86 $227.86 $236.64 $0.00 $63.98 $0.00 $0.00 $0.00 $0.00 $153.50 $243.14 $245.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002594 EAP Custom 27002594 "Transducer And Tubing, Disp" BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002595 EAP Custom 27002595 Fiberoptic Intubation Scope BOTH IP/OP $321.00 $237.54 $0.00 $256.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.25 $238.25 $247.43 $0.00 $66.90 $0.00 $0.00 $0.00 $0.00 $160.50 $254.23 $256.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002598 EAP Custom 27002598 Air Embolism Detector BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002599 EAP Custom 27002599 Introducer Kit BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002600 EAP Custom 27002600 Radial Artery Set (arrow) BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002602 EAP Custom 27002602 Disp. Sao2 Probe BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002604 EAP Custom 27002604 Epidural Tray BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.97 $97.97 $101.75 $0.00 $27.51 $0.00 $0.00 $0.00 $0.00 $66.00 $104.54 $105.60 $0.00 $85.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002605 EAP Custom 27002605 Spinal Tray BOTH IP/OP $190.00 $140.60 $0.00 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.02 $141.02 $146.45 $0.00 $39.60 $0.00 $0.00 $0.00 $0.00 $95.00 $150.48 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002609 EAP Custom 27002609 Thoracotomy Tray BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.97 $97.97 $101.75 $0.00 $27.51 $0.00 $0.00 $0.00 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002610 EAP Custom 27002610 Tracheotomy Tray BOTH IP/OP $394.00 $291.56 $0.00 $315.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.43 $292.43 $303.70 $0.00 $82.11 $0.00 $0.00 $0.00 $0.00 $197.00 $312.05 $315.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002618 EAP Custom 27002618 Ioban 2 Drape Incise Smal BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002620 EAP Custom 27002620 Ioban 2 Drape Incise Larg BOTH IP/OP $434.00 $321.16 $0.00 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.11 $322.11 $334.53 $0.00 $90.45 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002621 EAP Custom 27002621 Needle Spinal 18ga BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002624 EAP Custom 27002624 Catheter Texas Large BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002625 EAP Custom 27002625 Catheter Thoracic 32fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002626 EAP Custom 27002626 Catheter Thoracic 36fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002627 EAP Custom 27002627 Catheter Urethral Two-eye BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002628 EAP Custom 27002628 Artery Arterial Catheriza BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002629 EAP Custom 27002629 Artery Radial Catherizati BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002630 EAP Custom 27002630 Tube Salem Sump 48 Lengt BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002631 EAP Custom 27002631 Tube Salem Silicone Size BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002632 EAP Custom 27002632 Tubes Salem Sump 48 Leng BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002636 EAP Custom 27002636 Bag Drainage Becker BOTH IP/OP $197.00 $145.78 $0.00 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.21 $146.21 $151.85 $0.00 $41.05 $0.00 $0.00 $0.00 $0.00 $98.50 $156.02 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002637 EAP Custom 27002637 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002640 EAP Custom 27002640 Set Blood Administration BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002643 EAP Custom 27002643 Cream Baza 5oz BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002646 EAP Custom 27002646 Electrodes Operative BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.43 $197.43 $205.03 $0.00 $55.43 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002647 EAP Custom 27002647 Valve Anti-reflux Salem S BOTH IP/OP $46.00 $34.04 $0.00 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.14 $34.14 $35.46 $0.00 $9.59 $0.00 $0.00 $0.00 $0.00 $23.00 $36.43 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002649 EAP Custom 27002649 Kit Thoracotomy BOTH IP/OP $203.00 $150.22 $0.00 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.67 $150.67 $156.47 $0.00 $42.31 $0.00 $0.00 $0.00 $0.00 $101.50 $160.78 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002653 EAP Custom 27002653 Set Pediatric Measured Fi BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002656 EAP Custom 27002656 Pouch Fecal Incontinence BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.11 $37.11 $38.54 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002657 EAP Custom 27002657 Kit Pressure Monitoring T BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002658 EAP Custom 27002658 Transducer Disp For Icp BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $53.96 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002659 EAP Custom 27002659 Kit Transducer Monitoring BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002660 EAP Custom 27002660 Kit Pressure Monitoring BOTH IP/OP $234.00 $173.16 $0.00 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.67 $173.67 $180.37 $0.00 $48.77 $0.00 $0.00 $0.00 $0.00 $117.00 $185.33 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002662 EAP Custom 27002662 Bag 1000ml Pump Set BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002663 EAP Custom 27002663 Kit Pecutaneous Introduce BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.85 $204.85 $212.74 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $138.00 $218.59 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002664 EAP Custom 27002664 Chest Unit Drainage Pleur BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $323.74 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002665 EAP Custom 27002665 Chest Unit Dry Suction Sy BOTH IP/OP $309.00 $228.66 $0.00 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.34 $229.34 $238.18 $0.00 $64.40 $0.00 $0.00 $0.00 $0.00 $154.50 $244.73 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002666 EAP Custom 27002666 Bag Auto-transfusion Ple BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.84 $181.84 $188.85 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002670 EAP Custom 27002670 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.27 $45.27 $47.02 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002671 EAP Custom 27002671 Kit Triple Lumen Catheter BOTH IP/OP $646.00 $478.04 $0.00 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.46 $479.46 $497.94 $0.00 $134.63 $0.00 $0.00 $0.00 $0.00 $323.00 $511.63 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002672 EAP Custom 27002672 Catheter Swan Ganz BOTH IP/OP $674.00 $498.76 $0.00 $539.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.24 $500.24 $519.52 $0.00 $140.46 $0.00 $0.00 $0.00 $0.00 $337.00 $533.81 $539.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002673 EAP Custom 27002673 Delivery System Closed In BOTH IP/OP $141.00 $104.34 $0.00 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.65 $104.65 $108.68 $0.00 $29.38 $0.00 $0.00 $0.00 $0.00 $70.50 $111.67 $112.80 $0.00 $91.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002676 EAP Custom 27002676 Filter Set 0.22 Micron BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002677 EAP Custom 27002677 Tray Catheter Urethral 14 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002678 EAP Custom 27002678 Tray Foley Preconnected W BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002679 EAP Custom 27002679 Tray Foley Perconnected 1 BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002681 EAP Custom 27002681 Tray Urine Meter 18fr BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $65.52 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002682 EAP Custom 27002682 Tray Thoracentesis Dispos BOTH IP/OP $216.00 $159.84 $0.00 $172.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.32 $160.32 $166.49 $0.00 $45.01 $0.00 $0.00 $0.00 $0.00 $108.00 $171.07 $172.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002684 EAP Custom 27002684 Bag Drainage Ureteral BOTH IP/OP $92.00 $68.08 $0.00 $73.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.28 $68.28 $70.91 $0.00 $19.17 $0.00 $0.00 $0.00 $0.00 $46.00 $72.86 $73.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002687 EAP Custom 27002687 Sleeve Knee Regular Dvt BOTH IP/OP $358.00 $264.92 $0.00 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $265.71 $265.71 $275.95 $0.00 $74.61 $0.00 $0.00 $0.00 $0.00 $179.00 $283.54 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002688 EAP Custom 27002688 Sleeve Knee X-large Dvt BOTH IP/OP $439.00 $324.86 $0.00 $351.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.83 $325.83 $338.38 $0.00 $91.49 $0.00 $0.00 $0.00 $0.00 $219.50 $347.69 $351.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002689 EAP Custom 27002689 Sleeve Thigh Regular Dvt BOTH IP/OP $512.00 $378.88 $0.00 $409.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.01 $380.01 $394.65 $0.00 $106.70 $0.00 $0.00 $0.00 $0.00 $256.00 $405.50 $409.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002697 EAP Custom 27002697 Catheter Suction Plastic 14 BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002701 EAP Custom 27002701 Set Pediatric Micro Drip BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002702 EAP Custom 27002702 Set Pediatric Measured Fi BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002703 EAP Custom 27002703 Stockings Antiembolism Thigh BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002704 EAP Custom 27002704 Stockings Antiembolism Thigh BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002705 EAP Custom 27002705 Stockings Antiembolism Thigh BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.11 $37.11 $38.54 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002706 EAP Custom 27002706 Stockings Antiembolish Ex BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002707 EAP Custom 27002707 Needle Port-cath 20ga X 1 BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002708 EAP Custom 27002708 Tray Catheter Urethral 14 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002709 EAP Custom 27002709 Tray Foley Preconnected 1 BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002710 EAP Custom 27002710 Bag Urine Leg BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $9.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002884 EAP Custom 27002884 Et/co2 Sensors BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002885 EAP Custom 27002885 Cpap Circuit BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 "$1,038.27" $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $875.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002886 EAP Custom 27002886 Flutter Valve BOTH IP/OP $167.00 $123.58 $0.00 $133.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.95 $123.95 $128.72 $0.00 $34.80 $0.00 $0.00 $0.00 $0.00 $83.50 $132.26 $133.60 $0.00 $108.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002892 EAP Custom 27002892 Fecal Occult Blood Supply BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002893 EAP Custom 27002893 Tubes Extension Plain Pla BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002908 EAP Custom 27002908 Kit Iv Start Custom BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002938 EAP Custom 27002938 Inflation Device BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002939 EAP Custom 27002939 "Catheter, Thrombectomy" BOTH IP/OP "$1,076.00 " $796.24 $0.00 $860.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $798.61 $798.61 $829.38 $0.00 $224.24 $0.00 $0.00 $0.00 $0.00 $538.00 $852.19 $860.80 $0.00 $699.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002940 EAP HCPCS C1751 Catheter Iv 180ga X 1x1/4 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $8.69 $8.69 $0.00 $0.00 $0.00 $3.33 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 27002941 EAP HCPCS C1751 Catheter Iv 20ga X 1 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 27002942 EAP HCPCS C1751 Catheter Iv 22ga X 1 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $8.69 $8.69 $0.00 $0.00 $0.00 $3.33 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 27002943 EAP Custom 27002943 Ioban 2 Drape Incise Medi BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002944 EAP Custom 27002944 Needle Spinal 18ga BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002945 EAP Custom 27002945 Lancet Grady Orange BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002946 EAP HCPCS C1751 Catheter Iv Cut-down 14g BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $23.89 $23.89 $0.00 $0.00 $0.00 $9.17 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $26.03 $26.03 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $6.89 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002947 EAP HCPCS C1751 Catheter Iv Cut-down 8 1 BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $23.89 $23.89 $0.00 $0.00 $0.00 $9.17 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $26.03 $26.03 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $6.89 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002951 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27002952 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27002953 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27002954 EAP Custom 27002954 Tube Salem Silicone Size BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002955 EAP Custom 27002955 Tubes Salem Sump 48 Leng BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002957 EAP Custom 27002957 Scaple Surg W/handle Atta BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.81 $112.81 $117.16 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002958 EAP Custom 27002958 Scaple Surg W/handle Attached BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002959 EAP Custom 27002959 Bore Y Extension Small BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002961 EAP Custom 27002961 Pad Defi BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.11 $37.11 $38.54 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $32.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002962 EAP Custom 27002962 Valve Reflux BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.23 $2.23 $2.31 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002963 EAP Custom 27002963 "Filter,micron .22 Fluid A" BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002964 EAP Custom 27002964 Set Scalp Vein Infusion 21 G BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.23 $2.23 $2.31 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002965 EAP Custom 27002965 Mask Sub-micron Small BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002966 EAP Custom 27002966 Kit Triple Lumen Catheter BOTH IP/OP $646.00 $478.04 $0.00 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.46 $479.46 $497.94 $0.00 $134.63 $0.00 $0.00 $0.00 $0.00 $323.00 $511.63 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002967 EAP Custom 27002967 Catheter Swan Ganz BOTH IP/OP $674.00 $498.76 $0.00 $539.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.24 $500.24 $519.52 $0.00 $140.46 $0.00 $0.00 $0.00 $0.00 $337.00 $533.81 $539.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002968 EAP Custom 27002968 Probe V-pacing BOTH IP/OP "$1,403.00 " "$1,038.22" $0.00 "$1,122.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,041.31" "$1,041.31" "$1,081.43" $0.00 $292.39 $0.00 $0.00 $0.00 $0.00 $701.50 "$1,111.18" "$1,122.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002969 EAP Custom 27002969 Filter Set 0.22 Micron BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002970 EAP Custom 27002970 Tray Foley Preconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002971 EAP Custom 27002971 Tray Foley Perconnected 1 BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002972 EAP Custom 27002972 Bag Urine Leg BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002973 EAP Custom 27002973 Pounches Sterilization 12 BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002974 EAP Custom 27002974 Bag Drainage Ureteral BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $0.00 $0.00 $0.00 $51.50 $81.58 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002975 EAP Custom 27002975 Needle Hypodermic Sterile BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002976 EAP Custom 27002976 Drape Half BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002978 EAP Custom 27002978 Jcd 5.0-38-20 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002979 EAP Custom 27002979 Jcd 7.0-38-20 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $11.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002980 EAP Custom 27002980 Jcd 8.0-38-20 BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002982 EAP Custom 27002982 Avantiplus Introducer 6fr 23cm BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $61.66 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002984 EAP Custom 27002984 Nail Cleaner Plastic Non-steri BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002985 EAP Custom 27002985 Super Arrow Flex Introducer-c BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002986 EAP Custom 27002986 6fr-24cm Flexsheath Introducer BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.31 $137.31 $142.60 $0.00 $38.55 $0.00 $0.00 $0.00 $0.00 $92.50 $146.52 $148.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002987 EAP Custom 27002987 8fr-35cm Flexsheath Introducer BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.31 $137.31 $142.60 $0.00 $38.55 $0.00 $0.00 $0.00 $0.00 $92.50 $146.52 $148.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002990 EAP Custom 27002990 Adapter Morse - Y BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $61.66 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002991 EAP Custom 27002991 Drape C-arm 42 X 64 BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002993 EAP Custom 27002993 Kit Catheter Suction 14fr BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $601.18 $601.18 $624.35 $0.00 $168.80 $0.00 $0.00 $0.00 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002994 EAP Custom 27002994 Kit Percutaneous Introducer BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $601.18 $601.18 $624.35 $0.00 $168.80 $0.00 $0.00 $0.00 $0.00 $405.00 $641.52 $648.00 $0.00 $526.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27002995 EAP Custom 27002995 Kanguru Web BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003005 EAP Custom 27003005 Filter Set 0.22 Micron BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003006 EAP Custom 27003006 Tray Foley Preconnected 1 BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003007 EAP Custom 27003007 Tray Foley Perconnected 1 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003008 EAP Custom 27003008 Central Line Dressing Tray BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $31.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003028 EAP Custom 27003028 Lumbo-sacral Support BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003040 EAP Custom 27003040 "Walker, For Platform Only" BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.35 $180.35 $187.30 $0.00 $50.64 $0.00 $0.00 $0.00 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003045 EAP Custom 27003045 Foot Plate-prefb BOTH IP/OP $577.00 $426.98 $0.00 $461.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $428.25 $428.25 $444.75 $0.00 $120.25 $0.00 $0.00 $0.00 $0.00 $288.50 $456.98 $461.60 $0.00 $375.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003049 EAP Custom 27003049 Dressing Stick BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $20.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003050 EAP Custom 27003050 Leg Lifter BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $33.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003051 EAP Custom 27003051 Reacher BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.84 $86.84 $90.18 $0.00 $24.38 $0.00 $0.00 $0.00 $0.00 $58.50 $92.66 $93.60 $0.00 $76.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003053 EAP Custom 27003053 Abduction Pillow BOTH IP/OP $404.00 $298.96 $0.00 $323.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.85 $299.85 $311.40 $0.00 $84.19 $0.00 $0.00 $0.00 $0.00 $202.00 $319.97 $323.20 $0.00 $262.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003054 EAP Custom 27003054 Compression Glove BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.13 $0.00 $0.00 $0.00 $0.00 $43.50 $68.90 $69.60 $0.00 $56.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003055 EAP Custom 27003055 Dowel BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $31.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003063 EAP Custom 27003063 Simple Hand-based Splint BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $33.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003065 EAP Custom 27003065 Custom Finger Splint BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003069 EAP Custom 27003069 Compression Glove BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.13 $0.00 $0.00 $0.00 $0.00 $43.50 $68.90 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003070 EAP Custom 27003070 Dowel BOTH IP/OP $46.00 $34.04 $0.00 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.14 $34.14 $35.46 $0.00 $9.59 $0.00 $0.00 $0.00 $0.00 $23.00 $36.43 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003073 EAP Custom 27003073 Foot Drop Splint BOTH IP/OP $233.00 $172.42 $0.00 $186.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.93 $172.93 $179.60 $0.00 $48.56 $0.00 $0.00 $0.00 $0.00 $116.50 $184.54 $186.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003080 EAP Custom 27003080 Custom Finger Splint BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003081 EAP Custom 27003081 Safe Position Splint BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $0.00 $0.00 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003084 EAP Custom 27003084 Compression Glove BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.13 $0.00 $0.00 $0.00 $0.00 $43.50 $68.90 $69.60 $0.00 $56.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003085 EAP Custom 27003085 Dowel BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $31.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003087 EAP Custom 27003087 "Tubigrip, Per Piece" BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003089 EAP Custom 27003089 Helsper Button BOTH IP/OP $710.00 $525.40 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.96 $526.96 $547.27 $0.00 $147.96 $0.00 $0.00 $0.00 $0.00 $355.00 $562.32 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003090 EAP Custom 27003090 Laryngectomy Tube BOTH IP/OP $667.00 $493.58 $0.00 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.05 $495.05 $514.12 $0.00 $139.00 $0.00 $0.00 $0.00 $0.00 $333.50 $528.26 $533.60 $0.00 $433.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003091 EAP Custom 27003091 Inhealth Advan.indwelling Pros BOTH IP/OP $859.00 $635.66 $0.00 $687.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $637.55 $637.55 $662.12 $0.00 $179.02 $0.00 $0.00 $0.00 $0.00 $429.50 $680.33 $687.20 $0.00 $558.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003092 EAP Custom 27003092 Inhealth Indwelling Prosthesis BOTH IP/OP $878.00 $649.72 $0.00 $702.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $651.65 $651.65 $676.76 $0.00 $182.98 $0.00 $0.00 $0.00 $0.00 $439.00 $695.38 $702.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003093 EAP Custom 27003093 Inhealth Low Pressure Prosthesis BOTH IP/OP $491.00 $363.34 $0.00 $392.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $364.42 $364.42 $378.46 $0.00 $102.32 $0.00 $0.00 $0.00 $0.00 $245.50 $388.87 $392.80 $0.00 $319.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003094 EAP Custom 27003094 Duckbill Prosthesis BOTH IP/OP $309.00 $228.66 $0.00 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.34 $229.34 $238.18 $0.00 $64.40 $0.00 $0.00 $0.00 $0.00 $154.50 $244.73 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003095 EAP Custom 27003095 Provox/atox Prosthesis BOTH IP/OP $893.00 $660.82 $0.00 $714.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.78 $662.78 $688.32 $0.00 $186.10 $0.00 $0.00 $0.00 $0.00 $446.50 $707.26 $714.40 $0.00 $580.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003096 EAP Custom 27003096 Insufflation Test Kit BOTH IP/OP $863.00 $638.62 $0.00 $690.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.52 $640.52 $665.20 $0.00 $179.85 $0.00 $0.00 $0.00 $0.00 $431.50 $683.50 $690.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003097 EAP Custom 27003097 Plug Insert BOTH IP/OP $339.00 $250.86 $0.00 $271.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.61 $251.61 $261.30 $0.00 $70.65 $0.00 $0.00 $0.00 $0.00 $169.50 $268.49 $271.20 $0.00 $220.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003098 EAP Custom 27003098 Catheters BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003100 EAP Custom 27003100 Barton-mayo Button BOTH IP/OP $849.00 $628.26 $0.00 $679.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $630.13 $630.13 $654.41 $0.00 $176.93 $0.00 $0.00 $0.00 $0.00 $424.50 $672.41 $679.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003101 EAP Custom 27003101 Oral Tubing BOTH IP/OP $5.00 $3.70 $0.00 $4.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.71 $3.71 $3.85 $0.00 $1.04 $0.00 $0.00 $0.00 $0.00 $2.50 $3.96 $4.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003103 EAP Custom 27003103 Occult Blood Supply BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003104 EAP Custom 27003104 Interceed Sup/admin BOTH IP/OP $424.00 $313.76 $0.00 $339.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $314.69 $314.69 $326.82 $0.00 $88.36 $0.00 $0.00 $0.00 $0.00 $212.00 $335.81 $339.20 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003105 EAP Custom 27003105 Pudendal Kit BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $66.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003108 EAP Custom 27003108 Dressing Hemostasis BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $327.31 $327.31 $339.92 $0.00 $91.90 $0.00 $0.00 $0.00 $0.00 $220.50 $349.27 $352.80 $0.00 $286.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003113 EAP Custom 27003113 Tegaderm Dressing BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003114 EAP Custom 27003114 Tegaderm Dressing BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003115 EAP Custom 27003115 "Wound Gel, Carrington" BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $0.00 $0.00 $0.00 $51.50 $81.58 $82.40 $0.00 $66.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003116 EAP Custom 27003116 "Kara Klenz, Wound Cleanser" BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003117 EAP Custom 27003117 "Little Ones, White Collar 4x4" BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003118 EAP Custom 27003118 "Pouch, Cut To Fit, Little Ones" BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003119 EAP Custom 27003119 "Pouch, Active Life" BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003120 EAP Custom 27003120 "Flange, Sur-fit" BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003121 EAP Custom 27003121 Pouch Drainable Opaque BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003124 EAP Custom 27003124 Barrier With Convexity BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003127 EAP Custom 27003127 High Flow Continuous BOTH IP/OP $406.00 $300.44 $0.00 $324.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.33 $301.33 $312.94 $0.00 $84.61 $0.00 $0.00 $0.00 $0.00 $203.00 $321.55 $324.80 $0.00 $263.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003128 EAP Custom 27003128 Low Flow Continous BOTH IP/OP $406.00 $300.44 $0.00 $324.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.33 $301.33 $312.94 $0.00 $84.61 $0.00 $0.00 $0.00 $0.00 $203.00 $321.55 $324.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003130 EAP Custom 27003130 Mdi Spacer Supply BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.73 $144.73 $150.31 $0.00 $40.64 $0.00 $0.00 $0.00 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003131 EAP Custom 27003131 Occult Blood Supply BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003132 EAP Custom 27003132 Wrist Brace BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003134 EAP HCPCS J2798 Mirena (iud) Kit BOTH IP/OP $994.00 $735.56 $0.00 $795.20 $0.00 $0.00 $0.00 $0.00 $0.00 $207.17 $0.00 $0.00 $0.00 $10.69 $12.56 $6.95 $587.95 $587.95 $0.00 $497.00 $787.25 $795.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27003153 EAP Custom 27003153 Nuva Ring Fp BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27004266 EAP Custom 27004266 13.5mm/3.2mm Wire Guide BOTH IP/OP "$1,747.00 " "$1,292.78" $0.00 "$1,397.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,296.62" "$1,296.62" "$1,346.59" $0.00 $364.07 $0.00 $0.00 $0.00 $0.00 $873.50 "$1,383.62" "$1,397.60" $0.00 "$1,135.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27004311 EAP Custom 27004311 Long Forceps 230mm BOTH IP/OP "$2,779.00 " "$2,056.46" $0.00 "$2,223.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,062.57" "$2,062.57" "$2,142.05" $0.00 $579.14 $0.00 $0.00 $0.00 $0.00 "$1,389.50" "$2,200.97" "$2,223.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27004327 EAP Custom 27004327 Medium Wire Cutter 160mm BOTH IP/OP "$4,148.00 " "$3,069.52" $0.00 "$3,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,078.65" "$3,078.65" "$3,197.28" $0.00 $864.44 $0.00 $0.00 $0.00 $0.00 "$2,074.00" "$3,285.22" "$3,318.40" $0.00 "$2,696.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27004640 EAP Custom 27004640 Large Anchoring Hook 30mm BOTH IP/OP $509.00 $376.66 $0.00 $407.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $377.78 $377.78 $392.34 $0.00 $106.08 $0.00 $0.00 $0.00 $0.00 $254.50 $403.13 $407.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007212 EAP Custom 27007212 10.0mm Circular Saw 28mm BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007213 EAP Custom 27007213 12.0mm Circular Saw 28mm BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007214 EAP Custom 27007214 15.0mm Circular Saw 28mm BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007219 EAP Custom 27007219 Tibial Nail Driving Adaptor BOTH IP/OP "$4,208.00 " "$3,113.92" $0.00 "$3,366.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,123.18" "$3,123.18" "$3,243.53" $0.00 $876.95 $0.00 $0.00 $0.00 $0.00 "$2,104.00" "$3,332.74" "$3,366.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007220 EAP Custom 27007220 Saw Blade 27mm Width 50mm/0.6m BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007221 EAP Custom 27007221 Saw Blade 10mm Width 25mm/0.6m BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007222 EAP Custom 27007222 Saw Blade 10mm Width 50mm/0.6m BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007223 EAP Custom 27007223 Saw Blade 20mm Width 50mm/0.6m BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007224 EAP Custom 27007224 Saw Blade 19mm Width 70mm/1.0m BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007225 EAP Custom 27007225 Saw Blade 19mm Width 95mm/0.9m BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007226 EAP Custom 27007226 Saw Blade 25mm Width 95mm/0.9 BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007227 EAP Custom 27007227 Saw Blade 25mm Width 60mm/0.9 BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007228 EAP Custom 27007228 Saw Blade 18mm Width 70mm/1.2 BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007229 EAP Custom 27007229 Saw Blade 19mm Width 95mm/1.25 BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007230 EAP Custom 27007230 Saw Blade 25mm Width 95mm/1.25 BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007231 EAP Custom 27007231 Saw Blade 19mm Width 95mm/1.4 BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007232 EAP Custom 27007232 Saw Blade 25mm Width 95mm/1.4 BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007233 EAP Custom 27007233 Saw Blade 12.5mm Wdth 90mm/0.9 BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007234 EAP Custom 27007234 Saw Blade 14mm Width 50mm/0.6 BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007235 EAP Custom 27007235 Saw Blade 27mm Width 70mm/0.8 BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007236 EAP Custom 27007236 Saw Blade 50mm Width 70mm/0.8 BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007237 EAP Custom 27007237 Saw Blade 27mm Width 70mm/1.0 BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007238 EAP Custom 27007238 Saw Blade 27mm Width 70mm/1.2 BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007239 EAP Custom 27007239 Saw Blade 6mm Width 25mm/0.6m BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007240 EAP Custom 27007240 Saw Blade 14mm Width 25mm/0.6m BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007241 EAP Custom 27007241 Saw Blade 6mm Width 10mm/0.4mm BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007242 EAP Custom 27007242 Saw Blade 6mm Width 10mm/0.4mm BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007243 EAP Custom 27007243 Saw Blade 10mm Width 10mm/0.4m BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007244 EAP Custom 27007244 Saw Blade 10mm Width 10mm/0.4m BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007245 EAP Custom 27007245 Saw Blade 16mm Width 10mm/0.4m BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007246 EAP Custom 27007246 Saw Blade 16mm Width 10mm/0.4m BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007247 EAP Custom 27007247 Saw Blade 4mm Width 15mm/0.4mm BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007248 EAP Custom 27007248 Saw Blade 4mm Width 15mm/0.4m BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007249 EAP Custom 27007249 Saw Blade 8mm Width 20mm/0.4mm BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007250 EAP Custom 27007250 Saw Blade 8mm Width 20mm/0.4 BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007251 EAP Custom 27007251 Saw Blade 12mm Width 20mm/0.4 BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007252 EAP Custom 27007252 Saw Blade 12mm Width 20mm/0.4 BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007253 EAP Custom 27007253 Saw Blade 6mm Width 30mm/0.4 BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007254 EAP Custom 27007254 Saw Blade 6mm Width 30mm/0.4 BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007255 EAP Custom 27007255 Saw Blade 10mm Width 30mm/0.4 BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007256 EAP Custom 27007256 Saw Blade 10mm Width 30mm/0.4 BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007257 EAP Custom 27007257 Saw Blade 6mm Width 25mm/0.6 BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007258 EAP Custom 27007258 Saw Blade 6mm Width 25mm/0.6 BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007259 EAP Custom 27007259 Saw Blade 10mm Width 25mm/0.6 BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007260 EAP Custom 27007260 Saw Blade 10mm Width 25mm/0.6 BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007261 EAP Custom 27007261 Saw Blade 14mm Width 25mm/0.6 BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007262 EAP Custom 27007262 Saw Blade 14mm Width 25mm/0.6 BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007263 EAP Custom 27007263 Saw Blade 10mm Width 50mm/0.6 BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007264 EAP Custom 27007264 Saw Bld 10 Wdth 50/0.6cut Thk BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007265 EAP Custom 27007265 Saw Bld 14 Wdth 50/0.6cut Thk BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007266 EAP Custom 27007266 Saw Bld 14 Wdth 50/0.6 Cut Thk BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007267 EAP Custom 27007267 Saw Bld 20 Wdth 50/0.6 Cut Thk BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007268 EAP Custom 27007268 Saw Bld 20 Wdth 50/0.6 Cut Thk BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007269 EAP Custom 27007269 Saw Bld 27 Wdth 50/0.6 Cut Thk BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007270 EAP Custom 27007270 Saw Bld 27 Wdth 50/0.6 Cut Thk BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007451 EAP Custom 27007451 "Peg Fully Thread 2.5mm, 24mm" BOTH IP/OP $398.00 $294.52 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.40 $295.40 $306.78 $0.00 $82.94 $0.00 $0.00 $0.00 $0.00 $199.00 $315.22 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007489 EAP Custom 27007489 Mini-clip Str 3mm BOTH IP/OP "$1,693.00 " "$1,252.82" $0.00 "$1,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.54" "$1,256.54" "$1,304.96" $0.00 $352.82 $0.00 $0.00 $0.00 $0.00 $846.50 "$1,340.86" "$1,354.40" $0.00 "$1,100.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007557 EAP Custom 27007557 Screwdriver Blade BOTH IP/OP "$1,268.00 " $938.32 $0.00 "$1,014.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $941.11 $941.11 $977.37 $0.00 $264.25 $0.00 $0.00 $0.00 $0.00 $634.00 "$1,004.26" "$1,014.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007632 EAP Custom 27007632 Rotary Mixer BOTH IP/OP "$8,539.00 " "$6,318.86" $0.00 "$6,831.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,581.86" $0.00 "$1,779.53" $0.00 $0.00 $0.00 $0.00 "$4,269.50" "$6,762.89" "$6,831.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007633 EAP Custom 27007633 Srs? Fast Set Putty 3cc Steril BOTH IP/OP "$3,760.00 " "$2,782.40" $0.00 "$3,008.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,790.67" "$2,790.67" "$2,898.21" $0.00 $783.58 $0.00 $0.00 $0.00 $0.00 "$1,880.00" "$2,977.92" "$3,008.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007634 EAP Custom 27007634 Nor? Srs? Bne Void Fill Ro 3cc BOTH IP/OP "$3,852.00 " "$2,850.48" $0.00 "$3,081.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,858.95" "$2,858.95" "$2,969.12" $0.00 $802.76 $0.00 $0.00 $0.00 $0.00 "$1,926.00" "$3,050.78" "$3,081.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007635 EAP Custom 27007635 Srs? Fast Set Putty 5cc Steril BOTH IP/OP "$6,218.00 " "$4,601.32" $0.00 "$4,974.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,792.83" $0.00 "$1,295.83" $0.00 $0.00 $0.00 $0.00 "$3,109.00" "$4,924.66" "$4,974.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007636 EAP Custom 27007636 Nor? Srs? Bne Void Fill Ro 5cc BOTH IP/OP "$6,310.00 " "$4,669.40" $0.00 "$5,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,863.75" $0.00 "$1,315.00" $0.00 $0.00 $0.00 $0.00 "$3,155.00" "$4,997.52" "$5,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007637 EAP Custom 27007637 Srs? Fast Set Putty 10cc Steri BOTH IP/OP "$12,321.00 " "$9,117.54" $0.00 "$9,856.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,497.03" $0.00 "$2,567.70" $0.00 $0.00 $0.00 $0.00 "$6,160.50" "$9,758.23" "$9,856.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007638 EAP Custom 27007638 Nor? Srs? Bne Vd Fill Ro Mx 10 BOTH IP/OP "$12,413.00 " "$9,185.62" $0.00 "$9,930.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,567.94" $0.00 "$2,586.87" $0.00 $0.00 $0.00 $0.00 "$6,206.50" "$9,831.10" "$9,930.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007639 EAP Custom 27007639 Srs? Fast Set Putty 15cc Ster BOTH IP/OP "$18,167.00 " "$13,443.58" $0.00 "$14,533.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,003.12" $0.00 "$3,786.00" $0.00 $0.00 $0.00 $0.00 "$9,083.50" "$14,388.26" "$14,533.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007640 EAP Custom 27007640 Pressure Measurement BOTH IP/OP $904.00 $668.96 $0.00 $723.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $670.95 $670.95 $696.80 $0.00 $188.39 $0.00 $0.00 $0.00 $0.00 $452.00 $715.97 $723.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007719 EAP Custom 27007719 Univ Lock Troch Stab Pl 131mm BOTH IP/OP "$2,620.00 " "$1,938.80" $0.00 "$2,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,944.56" "$1,944.56" "$2,019.50" $0.00 $546.01 $0.00 $0.00 $0.00 $0.00 "$1,310.00" "$2,075.04" "$2,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007749 EAP Custom 27007749 T15/2.5m Hex Cerclage But- Ste BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007795 EAP Custom 27007795 Swans Bur S?2.0m Hd Lgh 6.3mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007796 EAP Custom 27007796 Swans Bur M?2.0m Hd Lgh 6.3mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007797 EAP Custom 27007797 Swans Bur L?2.0m Hd Lgh 6.3mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007798 EAP Custom 27007798 Swans Bur S?3.0m Hd Lgh 9.7mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007799 EAP Custom 27007799 Swans Bur M?3.0m Hd Lgh 9.7mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007800 EAP Custom 27007800 Swans Bur L?3.0m Hd Lgh 9.7mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007801 EAP Custom 27007801 Swans Bur S?4.0m Hd Lgh 12.7mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007802 EAP Custom 27007802 Swans Bur M?4.0m Hd Lgh 12.7mm BOTH IP/OP $148.00 $109.52 $0.00 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.85 $109.85 $114.08 $0.00 $30.84 $0.00 $0.00 $0.00 $0.00 $74.00 $117.22 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007803 EAP Custom 27007803 Swans Bur L?4.0m Hd Lgh 12.7mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007810 EAP Custom 27007810 Swans Bur S?5.0m Hd Lgh 15.8mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007811 EAP Custom 27007811 Swans Bur M?5.0m Hd Lgh 15.8mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007812 EAP Custom 27007812 Swans Bur L?5.0m Hd Lgh 15.8mm BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007840 EAP Custom 27007840 Lindeman Rmer Lgh 45m ?2.3m BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007853 EAP Custom 27007853 Saw Blade F/sagittal Saw BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007854 EAP Custom 27007854 Saw Blde Cresc F/oscillat Saw BOTH IP/OP $366.00 $270.84 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007864 EAP Custom 27007864 Tibial Nail-ex Insertion Handl BOTH IP/OP "$5,201.00 " "$3,848.74" $0.00 "$4,160.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,860.18" "$3,860.18" "$4,008.93" $0.00 "$1,083.89" $0.00 $0.00 $0.00 $0.00 "$2,600.50" "$4,119.19" "$4,160.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007865 EAP Custom 27007865 Rad Ruler Ti Cannul Fem Nails BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007866 EAP Custom 27007866 Rad Ruler Ti Cannul Tib Nails BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007867 EAP Custom 27007867 Rad Ruler Ti Cannul Hum Nails BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007868 EAP Custom 27007868 Rad Canal Wdth Estimat Im Nail BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007869 EAP Custom 27007869 Hold Devic Gde Wire & Ream Rod BOTH IP/OP "$3,375.00 " "$2,497.50" $0.00 "$2,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,504.93" "$2,504.93" "$2,601.45" $0.00 $703.35 $0.00 $0.00 $0.00 $0.00 "$1,687.50" "$2,673.00" "$2,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007871 EAP Custom 27007871 15.0 Cannul Drl Bit Lg Qc/280m BOTH IP/OP "$1,969.00 " "$1,457.06" $0.00 "$1,575.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.39" "$1,461.39" "$1,517.71" $0.00 $410.34 $0.00 $0.00 $0.00 $0.00 $984.50 "$1,559.45" "$1,575.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007872 EAP Custom 27007872 17.0m Cannul Drl Bit Lg Qc/280 BOTH IP/OP "$2,461.00 " "$1,821.14" $0.00 "$1,968.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,826.55" "$1,826.55" "$1,896.94" $0.00 $512.87 $0.00 $0.00 $0.00 $0.00 "$1,230.50" "$1,949.11" "$1,968.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007873 EAP Custom 27007873 13.0mm Protection Sleeve BOTH IP/OP "$1,490.00 " "$1,102.60" $0.00 "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,105.88" "$1,105.88" "$1,148.49" $0.00 $310.52 $0.00 $0.00 $0.00 $0.00 $745.00 "$1,180.08" "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007874 EAP Custom 27007874 13.0/3.2 Wire Gude W/ Troc Tip BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $0.00 $0.00 $0.00 $295.50 $468.07 $472.80 $0.00 $384.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007875 EAP Custom 27007875 13 Flex Can Drl Bit Lg Qc/465 BOTH IP/OP "$2,762.00 " "$2,043.88" $0.00 "$2,209.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,049.96" "$2,049.96" "$2,128.95" $0.00 $575.60 $0.00 $0.00 $0.00 $0.00 "$1,381.00" "$2,187.50" "$2,209.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007876 EAP Custom 27007876 13 Flex Can Drl Bit Lg Qc/465 BOTH IP/OP "$2,891.00 " "$2,139.34" $0.00 "$2,312.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,145.70" "$2,145.70" "$2,228.38" $0.00 $602.48 $0.00 $0.00 $0.00 $0.00 "$1,445.50" "$2,289.67" "$2,312.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007877 EAP Custom 27007877 12.0mm Protection Sleeve BOTH IP/OP "$1,490.00 " "$1,102.60" $0.00 "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,105.88" "$1,105.88" "$1,148.49" $0.00 $310.52 $0.00 $0.00 $0.00 $0.00 $745.00 "$1,180.08" "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007878 EAP Custom 27007878 12.0 Cannul Drl Bit Lg Qc/190 BOTH IP/OP "$2,211.00 " "$1,636.14" $0.00 "$1,768.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,641.00" "$1,641.00" "$1,704.24" $0.00 $460.77 $0.00 $0.00 $0.00 $0.00 "$1,105.50" "$1,751.11" "$1,768.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007879 EAP Custom 27007879 10.0mm Protection Sleeve BOTH IP/OP "$1,490.00 " "$1,102.60" $0.00 "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,105.88" "$1,105.88" "$1,148.49" $0.00 $310.52 $0.00 $0.00 $0.00 $0.00 $745.00 "$1,180.08" "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007880 EAP Custom 27007880 10.0mm Cannulated Awl BOTH IP/OP "$1,747.00 " "$1,292.78" $0.00 "$1,397.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,296.62" "$1,296.62" "$1,346.59" $0.00 $364.07 $0.00 $0.00 $0.00 $0.00 $873.50 "$1,383.62" "$1,397.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007881 EAP Custom 27007881 12.0mm Cannulated Awl BOTH IP/OP "$1,778.00 " "$1,315.72" $0.00 "$1,422.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,319.63" "$1,319.63" "$1,370.48" $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $889.00 "$1,408.18" "$1,422.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007882 EAP Custom 27007882 14.0mm Cannulated Awl BOTH IP/OP "$1,855.00 " "$1,372.70" $0.00 "$1,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,376.78" "$1,376.78" "$1,429.83" $0.00 $386.58 $0.00 $0.00 $0.00 $0.00 $927.50 "$1,469.16" "$1,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007884 EAP Custom 27007884 Standard Insertion Handle BOTH IP/OP "$5,201.00 " "$3,848.74" $0.00 "$4,160.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,860.18" "$3,860.18" "$4,008.93" $0.00 "$1,083.89" $0.00 $0.00 $0.00 $0.00 "$2,600.50" "$4,119.19" "$4,160.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007885 EAP Custom 27007885 Percutaneous Insertion Handle BOTH IP/OP "$5,201.00 " "$3,848.74" $0.00 "$4,160.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,860.18" "$3,860.18" "$4,008.93" $0.00 "$1,083.89" $0.00 $0.00 $0.00 $0.00 "$2,600.50" "$4,119.19" "$4,160.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007887 EAP Custom 27007887 Rec Loc Aim Arm Lat Ent Fem Nl BOTH IP/OP "$4,071.00 " "$3,012.54" $0.00 "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,021.50" "$3,021.50" "$3,137.93" $0.00 $848.40 $0.00 $0.00 $0.00 $0.00 "$2,035.50" "$3,224.23" "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007893 EAP Custom 27007893 Insert Hdle Ti Cann Hum Nls-ex BOTH IP/OP "$4,522.00 " "$3,346.28" $0.00 "$3,617.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,356.23" "$3,356.23" "$3,485.56" $0.00 $942.38 $0.00 $0.00 $0.00 $0.00 "$2,261.00" "$3,581.42" "$3,617.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007894 EAP Custom 27007894 Sprl Blde Aim Arm Ti Can Hum N BOTH IP/OP "$4,071.00 " "$3,012.54" $0.00 "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,021.50" "$3,021.50" "$3,137.93" $0.00 $848.40 $0.00 $0.00 $0.00 $0.00 "$2,035.50" "$3,224.23" "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007900 EAP Custom 27007900 12.0mm/8.0mm Protectn Slve 188 BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $715.30 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007904 EAP Custom 27007904 11.5/8.5 Protectn Slve Rec Lck BOTH IP/OP $635.00 $469.90 $0.00 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.30 $471.30 $489.46 $0.00 $132.33 $0.00 $0.00 $0.00 $0.00 $317.50 $502.92 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007909 EAP Custom 27007909 Tap For 6.5mm Recon Screws BOTH IP/OP "$1,997.00 " "$1,477.78" $0.00 "$1,597.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,482.17" "$1,482.17" "$1,539.29" $0.00 $416.17 $0.00 $0.00 $0.00 $0.00 $998.50 "$1,581.62" "$1,597.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007910 EAP Custom 27007910 15.0/13.0 Pro Slve F/spir Bld BOTH IP/OP "$1,616.00 " "$1,195.84" $0.00 "$1,292.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,199.40" "$1,199.40" "$1,245.61" $0.00 $336.77 $0.00 $0.00 $0.00 $0.00 $808.00 "$1,279.87" "$1,292.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007911 EAP Custom 27007911 13.0/3.2 Wre Gde Spir Blde Aim BOTH IP/OP "$1,222.00 " $904.28 $0.00 $977.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $906.97 $906.97 $941.92 $0.00 $254.66 $0.00 $0.00 $0.00 $0.00 $611.00 $967.82 $977.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007912 EAP Custom 27007912 Spir Blde Insert Retrgrde Fem BOTH IP/OP "$3,061.00 " "$2,265.14" $0.00 "$2,448.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,271.87" "$2,271.87" "$2,359.42" $0.00 $637.91 $0.00 $0.00 $0.00 $0.00 "$1,530.50" "$2,424.31" "$2,448.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007913 EAP Custom 27007913 Speclty Lck Meas Dev Ti Fem Nl BOTH IP/OP $616.00 $455.84 $0.00 $492.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.20 $457.20 $474.81 $0.00 $128.37 $0.00 $0.00 $0.00 $0.00 $308.00 $487.87 $492.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007914 EAP Custom 27007914 14.0mm/8.0mm Drill Sleeve 130m BOTH IP/OP $679.00 $502.46 $0.00 $543.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $503.95 $503.95 $523.37 $0.00 $141.50 $0.00 $0.00 $0.00 $0.00 $339.50 $537.77 $543.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007919 EAP Custom 27007919 Spir Bld Mea Dev Ti Can Hum Nl BOTH IP/OP "$2,296.00 " "$1,699.04" $0.00 "$1,836.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,704.09" "$1,704.09" "$1,769.76" $0.00 $478.49 $0.00 $0.00 $0.00 $0.00 "$1,148.00" "$1,818.43" "$1,836.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007920 EAP Custom 27007920 Stan Aim Arm Ti Can Hum Nls-ex BOTH IP/OP "$4,071.00 " "$3,012.54" $0.00 "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,021.50" "$3,021.50" "$3,137.93" $0.00 $848.40 $0.00 $0.00 $0.00 $0.00 "$2,035.50" "$3,224.23" "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007921 EAP Custom 27007921 Ream Rod Push Rod Wth Ball Hdl BOTH IP/OP "$1,484.00 " "$1,098.16" $0.00 "$1,187.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,101.42" "$1,101.42" "$1,143.87" $0.00 $309.27 $0.00 $0.00 $0.00 $0.00 $742.00 "$1,175.33" "$1,187.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007932 EAP Custom 27007932 Hold Slve W/ Lcking Device BOTH IP/OP "$3,354.00 " "$2,481.96" $0.00 "$2,683.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,489.34" "$2,489.34" "$2,585.26" $0.00 $698.97 $0.00 $0.00 $0.00 $0.00 "$1,677.00" "$2,656.37" "$2,683.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007935 EAP Custom 27007935 Lrg Hexa Scwdrvr 3.5 Wdth Acrs BOTH IP/OP "$1,199.00 " $887.26 $0.00 $959.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $889.90 $889.90 $924.19 $0.00 $249.87 $0.00 $0.00 $0.00 $0.00 $599.50 $949.61 $959.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007937 EAP Custom 27007937 Shrt Compres Dev Ti Can Tib Nl BOTH IP/OP "$1,799.00 " "$1,331.26" $0.00 "$1,439.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,335.22" "$1,335.22" "$1,386.67" $0.00 $374.91 $0.00 $0.00 $0.00 $0.00 $899.50 "$1,424.81" "$1,439.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007938 EAP Custom 27007938 Lng Compres Dev Ti Can Tib Nl BOTH IP/OP "$1,799.00 " "$1,331.26" $0.00 "$1,439.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,335.22" "$1,335.22" "$1,386.67" $0.00 $374.91 $0.00 $0.00 $0.00 $0.00 $899.50 "$1,424.81" "$1,439.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007941 EAP Custom 27007941 15.0can Flex Dl Bit Lrg Qc/310 BOTH IP/OP "$2,711.00 " "$2,006.14" $0.00 "$2,168.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,012.10" "$2,012.10" "$2,089.64" $0.00 $564.97 $0.00 $0.00 $0.00 $0.00 "$1,355.50" "$2,147.11" "$2,168.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007942 EAP Custom 27007942 17 Can Flex Drl Bit Lrg Qc/310 BOTH IP/OP "$2,711.00 " "$2,006.14" $0.00 "$2,168.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,012.10" "$2,012.10" "$2,089.64" $0.00 $564.97 $0.00 $0.00 $0.00 $0.00 "$1,355.50" "$2,147.11" "$2,168.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007943 EAP Custom 27007943 11/8 Pro Slve 188mm For Asls BOTH IP/OP $889.00 $657.86 $0.00 $711.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.82 $659.82 $685.24 $0.00 $185.27 $0.00 $0.00 $0.00 $0.00 $444.50 $704.09 $711.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007945 EAP Custom 27007945 Insert Hndl F/4.5 Lcp Prox Tib BOTH IP/OP "$5,623.00 " "$4,161.02" $0.00 "$4,498.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,173.39" "$4,173.39" "$4,334.21" $0.00 "$1,171.83" $0.00 $0.00 $0.00 $0.00 "$2,811.50" "$4,453.42" "$4,498.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007947 EAP Custom 27007947 Strt Ball Spike Low Pro Pelvic BOTH IP/OP "$1,511.00 " "$1,118.14" $0.00 "$1,208.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,121.46" "$1,121.46" "$1,164.68" $0.00 $314.89 $0.00 $0.00 $0.00 $0.00 $755.50 "$1,196.71" "$1,208.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007948 EAP Custom 27007948 Strt Ball Spike Low Pro Pelvic BOTH IP/OP "$1,608.00 " "$1,189.92" $0.00 "$1,286.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,193.46" "$1,193.46" "$1,239.45" $0.00 $335.11 $0.00 $0.00 $0.00 $0.00 $804.00 "$1,273.54" "$1,286.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007949 EAP Custom 27007949 Strt Reduc Forceps Low Pro Pel BOTH IP/OP "$6,337.00 " "$4,689.38" $0.00 "$5,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,884.56" $0.00 "$1,320.63" $0.00 $0.00 $0.00 $0.00 "$3,168.50" "$5,018.90" "$5,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007952 EAP Custom 27007952 Reduct Forceps For Low Pro Pel BOTH IP/OP "$8,489.00 " "$6,281.86" $0.00 "$6,791.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,543.32" $0.00 "$1,769.11" $0.00 $0.00 $0.00 $0.00 "$4,244.50" "$6,723.29" "$6,791.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007954 EAP Custom 27007954 Lo Pro Pel Sys Rd Frcp 3.5 Scw BOTH IP/OP "$7,620.00 " "$5,638.80" $0.00 "$6,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,873.50" $0.00 "$1,588.01" $0.00 $0.00 $0.00 $0.00 "$3,810.00" "$6,035.04" "$6,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007955 EAP Custom 27007955 Round Disk BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007956 EAP Custom 27007956 Rectangular Disk BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007966 EAP Custom 27007966 Instn Hndl F/4.5 Lcp Prox Tib BOTH IP/OP "$5,623.00 " "$4,161.02" $0.00 "$4,498.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,173.39" "$4,173.39" "$4,334.21" $0.00 "$1,171.83" $0.00 $0.00 $0.00 $0.00 "$2,811.50" "$4,453.42" "$4,498.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007967 EAP Custom 27007967 Solid 4.0 Hex Scwdrvr Shft 200 BOTH IP/OP "$1,131.00 " $836.94 $0.00 $904.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $839.43 $839.43 $871.77 $0.00 $235.70 $0.00 $0.00 $0.00 $0.00 $565.50 $895.75 $904.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007969 EAP Custom 27007969 Spiked Round Disk BOTH IP/OP "$1,247.00 " $922.78 $0.00 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.52 $925.52 $961.19 $0.00 $259.87 $0.00 $0.00 $0.00 $0.00 $623.50 $987.62 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007970 EAP Custom 27007970 Spiked Rectangular Disk BOTH IP/OP "$1,247.00 " $922.78 $0.00 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.52 $925.52 $961.19 $0.00 $259.87 $0.00 $0.00 $0.00 $0.00 $623.50 $987.62 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007974 EAP Custom 27007974 Ped Lcp Hip Pl Gdng Blk 3.5scw BOTH IP/OP "$1,986.00 " "$1,469.64" $0.00 "$1,588.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,474.01" "$1,474.01" "$1,530.81" $0.00 $413.88 $0.00 $0.00 $0.00 $0.00 $993.00 "$1,572.91" "$1,588.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007975 EAP Custom 27007975 Ped Lcp Hip Pl Gdng Blck 5scw BOTH IP/OP "$1,986.00 " "$1,469.64" $0.00 "$1,588.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,474.01" "$1,474.01" "$1,530.81" $0.00 $413.88 $0.00 $0.00 $0.00 $0.00 $993.00 "$1,572.91" "$1,588.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007977 EAP Custom 27007977 Reduction Sleeve 4.3mm/2.8mm BOTH IP/OP $647.00 $478.78 $0.00 $517.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $480.20 $480.20 $498.71 $0.00 $134.83 $0.00 $0.00 $0.00 $0.00 $323.50 $512.42 $517.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007979 EAP Custom 27007979 Positioning Device Gdng Blck BOTH IP/OP "$1,727.00 " "$1,277.98" $0.00 "$1,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,281.78" "$1,281.78" "$1,331.17" $0.00 $359.91 $0.00 $0.00 $0.00 $0.00 $863.50 "$1,367.78" "$1,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007980 EAP Custom 27007980 Medialization Gde 3.5&5.0 Lcp BOTH IP/OP "$1,727.00 " "$1,277.98" $0.00 "$1,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,281.78" "$1,281.78" "$1,331.17" $0.00 $359.91 $0.00 $0.00 $0.00 $0.00 $863.50 "$1,367.78" "$1,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007981 EAP Custom 27007981 Osteotomy Measuring Device BOTH IP/OP "$1,061.00 " $785.14 $0.00 $848.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $787.47 $787.47 $817.82 $0.00 $221.11 $0.00 $0.00 $0.00 $0.00 $530.50 $840.31 $848.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007984 EAP Custom 27007984 Meas Dev 3.0 Hdles Compres Scw BOTH IP/OP $722.00 $534.28 $0.00 $577.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $535.87 $535.87 $556.52 $0.00 $150.46 $0.00 $0.00 $0.00 $0.00 $361.00 $571.82 $577.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007990 EAP Custom 27007990 Meas Dev F/drl Gde W/stp 3.0m BOTH IP/OP $642.00 $475.08 $0.00 $513.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $476.49 $476.49 $494.85 $0.00 $133.79 $0.00 $0.00 $0.00 $0.00 $321.00 $508.46 $513.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007991 EAP Custom 27007991 Medium Open Compressor BOTH IP/OP "$4,431.00 " "$3,278.94" $0.00 "$3,544.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,288.69" "$3,288.69" "$3,415.41" $0.00 $923.42 $0.00 $0.00 $0.00 $0.00 "$2,215.50" "$3,509.35" "$3,544.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007992 EAP Custom 27007992 Lo-pro Wrst Fxtr/schan Scr/200 BOTH IP/OP "$4,535.00 " "$3,355.90" $0.00 "$3,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,365.88" "$3,365.88" "$3,495.58" $0.00 $945.09 $0.00 $0.00 $0.00 $0.00 "$2,267.50" "$3,591.72" "$3,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007993 EAP Custom 27007993 Lo-pro Wrst Fxtr/schan Scr/220 BOTH IP/OP "$4,535.00 " "$3,355.90" $0.00 "$3,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,365.88" "$3,365.88" "$3,495.58" $0.00 $945.09 $0.00 $0.00 $0.00 $0.00 "$2,267.50" "$3,591.72" "$3,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007994 EAP Custom 27007994 Low-pro Wrst Fxtr/slf-drlg/200 BOTH IP/OP "$5,757.00 " "$4,260.18" $0.00 "$4,605.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,437.50" $0.00 "$1,199.76" $0.00 $0.00 $0.00 $0.00 "$2,878.50" "$4,559.54" "$4,605.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007995 EAP Custom 27007995 Low-pro Wrst Fxtr/slf-drlg/220 BOTH IP/OP "$5,757.00 " "$4,260.18" $0.00 "$4,605.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,437.50" $0.00 "$1,199.76" $0.00 $0.00 $0.00 $0.00 "$2,878.50" "$4,559.54" "$4,605.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007996 EAP Custom 27007996 Tensioner BOTH IP/OP "$16,191.00 " "$11,981.34" $0.00 "$12,952.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,480.02" $0.00 "$3,374.20" $0.00 $0.00 $0.00 $0.00 "$8,095.50" "$12,823.27" "$12,952.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007997 EAP Custom 27007997 Slotted Socket Wrench 11mm BOTH IP/OP "$2,314.00 " "$1,712.36" $0.00 "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,717.45" "$1,717.45" "$1,783.63" $0.00 $482.24 $0.00 $0.00 $0.00 $0.00 "$1,157.00" "$1,832.69" "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007998 EAP Custom 27007998 Patient Wrench 8mm/11mm BOTH IP/OP $604.00 $446.96 $0.00 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.29 $448.29 $465.56 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $302.00 $478.37 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27007999 EAP Custom 27007999 Ratchet Wrench 11mm BOTH IP/OP "$2,891.00 " "$2,139.34" $0.00 "$2,312.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,145.70" "$2,145.70" "$2,228.38" $0.00 $602.48 $0.00 $0.00 $0.00 $0.00 "$1,445.50" "$2,289.67" "$2,312.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008000 EAP Custom 27008000 Split Tissue Protect Slve 2.5m BOTH IP/OP "$2,314.00 " "$1,712.36" $0.00 "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,717.45" "$1,717.45" "$1,783.63" $0.00 $482.24 $0.00 $0.00 $0.00 $0.00 "$1,157.00" "$1,832.69" "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008001 EAP Custom 27008001 Split Tissue Protect Slve 5mm BOTH IP/OP "$2,314.00 " "$1,712.36" $0.00 "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,717.45" "$1,717.45" "$1,783.63" $0.00 $482.24 $0.00 $0.00 $0.00 $0.00 "$1,157.00" "$1,832.69" "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008004 EAP Custom 27008004 Schanz Screw Bolt Mr Safe BOTH IP/OP $906.00 $670.44 $0.00 $724.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $672.43 $672.43 $698.34 $0.00 $188.81 $0.00 $0.00 $0.00 $0.00 $453.00 $717.55 $724.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008005 EAP Custom 27008005 Pivot Schanz Screw Clamp Mr Sa BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,358.23" "$1,358.23" "$1,410.56" $0.00 $381.37 $0.00 $0.00 $0.00 $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008006 EAP Custom 27008006 Locking Hinge Mr Safe BOTH IP/OP $906.00 $670.44 $0.00 $724.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $672.43 $672.43 $698.34 $0.00 $188.81 $0.00 $0.00 $0.00 $0.00 $453.00 $717.55 $724.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008007 EAP Custom 27008007 Schanz Screw Bolt Post Mount M BOTH IP/OP "$1,045.00 " $773.30 $0.00 $836.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.60 $775.60 $805.49 $0.00 $217.78 $0.00 $0.00 $0.00 $0.00 $522.50 $827.64 $836.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008008 EAP Custom 27008008 Smth Wire/1.5mm Diameter 400m BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $228.60 $237.41 $0.00 $64.19 $0.00 $0.00 $0.00 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008009 EAP Custom 27008009 Smth Wire/1.8mm Diameter 400m BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $228.60 $237.41 $0.00 $64.19 $0.00 $0.00 $0.00 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008010 EAP Custom 27008010 Smth Wire/2.0mm Diameter 400m BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $228.60 $237.41 $0.00 $64.19 $0.00 $0.00 $0.00 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008011 EAP Custom 27008011 Smth Wire 1.5m Dia Hlf Pnt Tip BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $228.60 $237.41 $0.00 $64.19 $0.00 $0.00 $0.00 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008012 EAP Custom 27008012 Smth Wire 1.8m Dia Hlf Pnt Tip BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $228.60 $237.41 $0.00 $64.19 $0.00 $0.00 $0.00 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008013 EAP Custom 27008013 Smth Wire 2.0m Dia Hlf Pnt Tip BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $228.60 $237.41 $0.00 $64.19 $0.00 $0.00 $0.00 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008014 EAP Custom 27008014 Reductn Wre/1.5mm Diam 400m BOTH IP/OP $962.00 $711.88 $0.00 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $714.00 $714.00 $741.51 $0.00 $200.48 $0.00 $0.00 $0.00 $0.00 $481.00 $761.90 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008015 EAP Custom 27008015 Reductn Wre/1.8mm Diam 400m BOTH IP/OP $962.00 $711.88 $0.00 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $714.00 $714.00 $741.51 $0.00 $200.48 $0.00 $0.00 $0.00 $0.00 $481.00 $761.90 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008016 EAP Custom 27008016 Reductn Wire/2.0mm Diam 400m BOTH IP/OP $962.00 $711.88 $0.00 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $714.00 $714.00 $741.51 $0.00 $200.48 $0.00 $0.00 $0.00 $0.00 $481.00 $761.90 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008017 EAP Custom 27008017 Reductn Wre 1.5mm Dia Half Pnt BOTH IP/OP $962.00 $711.88 $0.00 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $714.00 $714.00 $741.51 $0.00 $200.48 $0.00 $0.00 $0.00 $0.00 $481.00 $761.90 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008018 EAP Custom 27008018 Reductn Wre 1.8mm Dia Hlf Pnt BOTH IP/OP $962.00 $711.88 $0.00 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $714.00 $714.00 $741.51 $0.00 $200.48 $0.00 $0.00 $0.00 $0.00 $481.00 $761.90 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008019 EAP Custom 27008019 Reductn Wre 2.0mm Dia Half Pnt BOTH IP/OP $962.00 $711.88 $0.00 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $714.00 $714.00 $741.51 $0.00 $200.48 $0.00 $0.00 $0.00 $0.00 $481.00 $761.90 $769.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008020 EAP Custom 27008020 Wire Bolt/slotted Mr Safe BOTH IP/OP $197.00 $145.78 $0.00 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.21 $146.21 $151.85 $0.00 $41.05 $0.00 $0.00 $0.00 $0.00 $98.50 $156.02 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008021 EAP Custom 27008021 Wire Bolt/offset Mr Safe BOTH IP/OP $183.00 $135.42 $0.00 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.82 $135.82 $141.06 $0.00 $38.14 $0.00 $0.00 $0.00 $0.00 $91.50 $144.94 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008024 EAP Custom 27008024 Schanz Scrw Bolt Can Rng Mnt BOTH IP/OP $906.00 $670.44 $0.00 $724.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $672.43 $672.43 $698.34 $0.00 $188.81 $0.00 $0.00 $0.00 $0.00 $453.00 $717.55 $724.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008025 EAP Custom 27008025 Schanz Scrw Bolt Can Post Mnt BOTH IP/OP "$1,045.00 " $773.30 $0.00 $836.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.60 $775.60 $805.49 $0.00 $217.78 $0.00 $0.00 $0.00 $0.00 $522.50 $827.64 $836.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008026 EAP Custom 27008026 Square Nut Mr Safe BOTH IP/OP $337.00 $249.38 $0.00 $269.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.12 $250.12 $259.76 $0.00 $70.23 $0.00 $0.00 $0.00 $0.00 $168.50 $266.90 $269.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008027 EAP Custom 27008027 Nut Mr Safe BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008028 EAP Custom 27008028 Nut 10 Pack Mr Safe BOTH IP/OP $154.00 $113.96 $0.00 $123.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.30 $114.30 $118.70 $0.00 $32.09 $0.00 $0.00 $0.00 $0.00 $77.00 $121.97 $123.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008029 EAP Custom 27008029 Speed Nut Mr Safe BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008030 EAP Custom 27008030 Wire Post-short Mr Safe BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008031 EAP Custom 27008031 Wire Post-tall Mr Safe BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $715.30 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008032 EAP Custom 27008032 Spacing Washer 1mm Mr Safe BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008033 EAP Custom 27008033 Spacing Washer 2mm Mr Safe BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008034 EAP Custom 27008034 Spacing Washer 4mm Mr Safe BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008035 EAP Custom 27008035 Spherical Washer Couple Mr Saf BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.62 $107.62 $111.77 $0.00 $30.22 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008036 EAP Custom 27008036 Oblique Support Mr Safe BOTH IP/OP "$2,314.00 " "$1,712.36" $0.00 "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,717.45" "$1,717.45" "$1,783.63" $0.00 $482.24 $0.00 $0.00 $0.00 $0.00 "$1,157.00" "$1,832.69" "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008038 EAP Custom 27008038 Thread Rod 80 Lng/slot Mr Safe BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.82 $207.82 $215.82 $0.00 $58.35 $0.00 $0.00 $0.00 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008039 EAP Custom 27008039 Thread Rod 100 Lng/slot Mr Sfe BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.82 $207.82 $215.82 $0.00 $58.35 $0.00 $0.00 $0.00 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008040 EAP Custom 27008040 Threaded Rod 120mm Lng Mr Safe BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.82 $207.82 $215.82 $0.00 $58.35 $0.00 $0.00 $0.00 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008041 EAP Custom 27008041 Threaded Rod 150mm Lng Mr Safe BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.82 $207.82 $215.82 $0.00 $58.35 $0.00 $0.00 $0.00 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008042 EAP Custom 27008042 Threaded Rod 200mm Lng Mr Safe BOTH IP/OP $301.00 $222.74 $0.00 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.40 $223.40 $232.01 $0.00 $62.73 $0.00 $0.00 $0.00 $0.00 $150.50 $238.39 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008043 EAP Custom 27008043 Threaded Rod 250mm Lng Mr Safe BOTH IP/OP $301.00 $222.74 $0.00 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.40 $223.40 $232.01 $0.00 $62.73 $0.00 $0.00 $0.00 $0.00 $150.50 $238.39 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008044 EAP Custom 27008044 Threaded Rod 300mm Lng Mr Safe BOTH IP/OP $347.00 $256.78 $0.00 $277.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.54 $257.54 $267.47 $0.00 $72.31 $0.00 $0.00 $0.00 $0.00 $173.50 $274.82 $277.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008045 EAP Custom 27008045 Threaded Rod 350mm Lng Mr Safe BOTH IP/OP $347.00 $256.78 $0.00 $277.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.54 $257.54 $267.47 $0.00 $72.31 $0.00 $0.00 $0.00 $0.00 $173.50 $274.82 $277.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008046 EAP Custom 27008046 Threaded Rod 400mm Lng Mr Safe BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $327.31 $327.31 $339.92 $0.00 $91.90 $0.00 $0.00 $0.00 $0.00 $220.50 $349.27 $352.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008051 EAP Custom 27008051 Standoff 20mm Long Mr Safe BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.31 $137.31 $142.60 $0.00 $38.55 $0.00 $0.00 $0.00 $0.00 $92.50 $146.52 $148.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008052 EAP Custom 27008052 Standoff 30mm Long Mr Safe BOTH IP/OP $208.00 $153.92 $0.00 $166.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.38 $154.38 $160.33 $0.00 $43.35 $0.00 $0.00 $0.00 $0.00 $104.00 $164.74 $166.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008053 EAP Custom 27008053 Standoff 40mm Long Mr Safe BOTH IP/OP $234.00 $173.16 $0.00 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.67 $173.67 $180.37 $0.00 $48.77 $0.00 $0.00 $0.00 $0.00 $117.00 $185.33 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008054 EAP Custom 27008054 Standoff 50mm Long Mr Safe BOTH IP/OP $301.00 $222.74 $0.00 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.40 $223.40 $232.01 $0.00 $62.73 $0.00 $0.00 $0.00 $0.00 $150.50 $238.39 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008055 EAP Custom 27008055 Ti Half Ring/80m Diam Mr Safe BOTH IP/OP "$1,505.00 " "$1,113.70" $0.00 "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,117.01" "$1,117.01" "$1,160.05" $0.00 $313.64 $0.00 $0.00 $0.00 $0.00 $752.50 "$1,191.96" "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008056 EAP Custom 27008056 Ti Half Ring/100m Diam Mr Safe BOTH IP/OP "$1,624.00 " "$1,201.76" $0.00 "$1,299.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,205.33" "$1,205.33" "$1,251.78" $0.00 $338.44 $0.00 $0.00 $0.00 $0.00 $812.00 "$1,286.21" "$1,299.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008057 EAP Custom 27008057 Ti Half Ring/110m Diam Mr Safe BOTH IP/OP "$1,667.00 " "$1,233.58" $0.00 "$1,333.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,237.25" "$1,237.25" "$1,284.92" $0.00 $347.40 $0.00 $0.00 $0.00 $0.00 $833.50 "$1,320.26" "$1,333.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008058 EAP Custom 27008058 Ti Half Ring/120m Diam Mr Safe BOTH IP/OP "$1,735.00 " "$1,283.90" $0.00 "$1,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,287.72" "$1,287.72" "$1,337.34" $0.00 $361.57 $0.00 $0.00 $0.00 $0.00 $867.50 "$1,374.12" "$1,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008059 EAP Custom 27008059 Ti Half Ring/130m Diam Mr Safe BOTH IP/OP "$1,783.00 " "$1,319.42" $0.00 "$1,426.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,323.34" "$1,323.34" "$1,374.34" $0.00 $371.58 $0.00 $0.00 $0.00 $0.00 $891.50 "$1,412.14" "$1,426.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008060 EAP Custom 27008060 Ti Half Ring/140m Diam Mr Safe BOTH IP/OP "$1,850.00 " "$1,369.00" $0.00 "$1,480.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,373.07" "$1,373.07" "$1,425.98" $0.00 $385.54 $0.00 $0.00 $0.00 $0.00 $925.00 "$1,465.20" "$1,480.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008061 EAP Custom 27008061 Ti Half Ring/150m Diam Mr Safe BOTH IP/OP "$1,969.00 " "$1,457.06" $0.00 "$1,575.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.39" "$1,461.39" "$1,517.71" $0.00 $410.34 $0.00 $0.00 $0.00 $0.00 $984.50 "$1,559.45" "$1,575.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008062 EAP Custom 27008062 Ti Half Ring/160m Diam Mr Safe BOTH IP/OP "$2,153.00 " "$1,593.22" $0.00 "$1,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.96" "$1,597.96" "$1,659.53" $0.00 $448.69 $0.00 $0.00 $0.00 $0.00 "$1,076.50" "$1,705.18" "$1,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008063 EAP Custom 27008063 Ti Half Ring/180m Diam Mr Safe BOTH IP/OP "$2,314.00 " "$1,712.36" $0.00 "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,717.45" "$1,717.45" "$1,783.63" $0.00 $482.24 $0.00 $0.00 $0.00 $0.00 "$1,157.00" "$1,832.69" "$1,851.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008064 EAP Custom 27008064 Ti Half Ring/200m Diam Mr Safe BOTH IP/OP "$2,498.00 " "$1,848.52" $0.00 "$1,998.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.02" "$1,854.02" "$1,925.46" $0.00 $520.58 $0.00 $0.00 $0.00 $0.00 "$1,249.00" "$1,978.42" "$1,998.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008065 EAP Custom 27008065 Ti Half Ring/220m Diam Mr Safe BOTH IP/OP "$2,663.00 " "$1,970.62" $0.00 "$2,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,976.48" "$1,976.48" "$2,052.64" $0.00 $554.97 $0.00 $0.00 $0.00 $0.00 "$1,331.50" "$2,109.10" "$2,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008066 EAP Custom 27008066 Ti Half Ring/240m Diam Mr Safe BOTH IP/OP "$2,779.00 " "$2,056.46" $0.00 "$2,223.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,062.57" "$2,062.57" "$2,142.05" $0.00 $579.14 $0.00 $0.00 $0.00 $0.00 "$1,389.50" "$2,200.97" "$2,223.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008067 EAP Custom 27008067 Ti Full Ring/140m Diam Mr Safe BOTH IP/OP "$3,704.00 " "$2,740.96" $0.00 "$2,963.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,749.11" "$2,749.11" "$2,855.04" $0.00 $771.91 $0.00 $0.00 $0.00 $0.00 "$1,852.00" "$2,933.57" "$2,963.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008068 EAP Custom 27008068 Ti Full Ring/160m Diam Mr Safe BOTH IP/OP "$4,303.00 " "$3,184.22" $0.00 "$3,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,193.69" "$3,193.69" "$3,316.75" $0.00 $896.75 $0.00 $0.00 $0.00 $0.00 "$2,151.50" "$3,407.98" "$3,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008069 EAP Custom 27008069 Ti Full Ring/180m Diam Mr Safe BOTH IP/OP "$4,627.00 " "$3,423.98" $0.00 "$3,701.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,434.16" "$3,434.16" "$3,566.49" $0.00 $964.27 $0.00 $0.00 $0.00 $0.00 "$2,313.50" "$3,664.58" "$3,701.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008070 EAP Custom 27008070 Ti Full Ring/200m Diam Mr Safe BOTH IP/OP "$5,022.00 " "$3,716.28" $0.00 "$4,017.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,727.33" "$3,727.33" "$3,870.96" $0.00 "$1,046.58" $0.00 $0.00 $0.00 $0.00 "$2,511.00" "$3,977.42" "$4,017.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008071 EAP Custom 27008071 Ti 5/8 Ring/130m Diam Mr Safe BOTH IP/OP "$2,430.00 " "$1,798.20" $0.00 "$1,944.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,803.55" "$1,803.55" "$1,873.04" $0.00 $506.41 $0.00 $0.00 $0.00 $0.00 "$1,215.00" "$1,924.56" "$1,944.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008072 EAP Custom 27008072 Ti 5/8 Ring/150mm Diam Mr Safe BOTH IP/OP "$2,663.00 " "$1,970.62" $0.00 "$2,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,976.48" "$1,976.48" "$2,052.64" $0.00 $554.97 $0.00 $0.00 $0.00 $0.00 "$1,331.50" "$2,109.10" "$2,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008073 EAP Custom 27008073 Ti 5/8 Ring/160mm Diam Mr Safe BOTH IP/OP "$2,891.00 " "$2,139.34" $0.00 "$2,312.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,145.70" "$2,145.70" "$2,228.38" $0.00 $602.48 $0.00 $0.00 $0.00 $0.00 "$1,445.50" "$2,289.67" "$2,312.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008074 EAP Custom 27008074 Ti 5/8 Ring/180mm Diam Mr Safe BOTH IP/OP "$3,358.00 " "$2,484.92" $0.00 "$2,686.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,492.31" "$2,492.31" "$2,588.35" $0.00 $699.81 $0.00 $0.00 $0.00 $0.00 "$1,679.00" "$2,659.54" "$2,686.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008075 EAP Custom 27008075 Ti 5/8 Ring/200mm Diam Mr Safe BOTH IP/OP "$3,470.00 " "$2,567.80" $0.00 "$2,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,575.43" "$2,575.43" "$2,674.68" $0.00 $723.15 $0.00 $0.00 $0.00 $0.00 "$1,735.00" "$2,748.24" "$2,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008076 EAP Custom 27008076 Ti Fem Arch Pl 180 Dia/90 Degr BOTH IP/OP "$4,165.00 " "$3,082.10" $0.00 "$3,332.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,091.26" "$3,091.26" "$3,210.38" $0.00 $867.99 $0.00 $0.00 $0.00 $0.00 "$2,082.50" "$3,298.68" "$3,332.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008077 EAP Custom 27008077 Ti Fem Arch Pl 180 Dia/120 Deg BOTH IP/OP "$4,281.00 " "$3,167.94" $0.00 "$3,424.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,177.36" "$3,177.36" "$3,299.79" $0.00 $892.16 $0.00 $0.00 $0.00 $0.00 "$2,140.50" "$3,390.55" "$3,424.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008078 EAP Custom 27008078 Ti Fem Arch Pl 240 Dia/90 Degr BOTH IP/OP "$4,515.00 " "$3,341.10" $0.00 "$3,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,351.03" "$3,351.03" "$3,480.16" $0.00 $940.93 $0.00 $0.00 $0.00 $0.00 "$2,257.50" "$3,575.88" "$3,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008079 EAP Custom 27008079 Ti Fem Arch Pl 240 Dia/120 Deg BOTH IP/OP "$4,627.00 " "$3,423.98" $0.00 "$3,701.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,434.16" "$3,434.16" "$3,566.49" $0.00 $964.27 $0.00 $0.00 $0.00 $0.00 "$2,313.50" "$3,664.58" "$3,701.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008080 EAP Custom 27008080 Linear Distrac 60 Lng 25mm Tr BOTH IP/OP "$2,663.00 " "$1,970.62" $0.00 "$2,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,976.48" "$1,976.48" "$2,052.64" $0.00 $554.97 $0.00 $0.00 $0.00 $0.00 "$1,331.50" "$2,109.10" "$2,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008081 EAP Custom 27008081 Linear Distrac 120lng 85mm Tra BOTH IP/OP "$2,891.00 " "$2,139.34" $0.00 "$2,312.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,145.70" "$2,145.70" "$2,228.38" $0.00 $602.48 $0.00 $0.00 $0.00 $0.00 "$1,445.50" "$2,289.67" "$2,312.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008082 EAP Custom 27008082 Linear Distrac 180 Lng 145 Tra BOTH IP/OP "$3,241.00 " "$2,398.34" $0.00 "$2,592.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,405.47" "$2,405.47" "$2,498.16" $0.00 $675.42 $0.00 $0.00 $0.00 $0.00 "$1,620.50" "$2,566.87" "$2,592.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008083 EAP Custom 27008083 Linear Distrac 250 Lng 215 Tra BOTH IP/OP "$3,934.00 " "$2,911.16" $0.00 "$3,147.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,919.81" "$2,919.81" "$3,032.33" $0.00 $819.85 $0.00 $0.00 $0.00 $0.00 "$1,967.00" "$3,115.73" "$3,147.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008118 EAP Custom 27008118 Sft Tissue Sprder Trocar 35mm BOTH IP/OP "$1,247.00 " $922.78 $0.00 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.52 $925.52 $961.19 $0.00 $259.87 $0.00 $0.00 $0.00 $0.00 $623.50 $987.62 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008119 EAP Custom 27008119 Sft Tissue Sprder Trocar 75 BOTH IP/OP "$1,247.00 " $922.78 $0.00 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.52 $925.52 $961.19 $0.00 $259.87 $0.00 $0.00 $0.00 $0.00 $623.50 $987.62 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008122 EAP Custom 27008122 Straight Sharp Hook BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $462.48 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008124 EAP Custom 27008124 Small Screw Removal Forceps BOTH IP/OP "$1,770.00 " "$1,309.80" $0.00 "$1,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,313.69" "$1,313.69" "$1,364.32" $0.00 $368.87 $0.00 $0.00 $0.00 $0.00 $885.00 "$1,401.84" "$1,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008125 EAP Custom 27008125 Large Screw Removal Forceps BOTH IP/OP "$2,123.00 " "$1,571.02" $0.00 "$1,698.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,575.69" "$1,575.69" "$1,636.41" $0.00 $442.43 $0.00 $0.00 $0.00 $0.00 "$1,061.50" "$1,681.42" "$1,698.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008126 EAP Custom 27008126 Ti End Cap T25 Strdr 0mext Hu BOTH IP/OP $631.00 $466.94 $0.00 $504.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.33 $468.33 $486.37 $0.00 $131.50 $0.00 $0.00 $0.00 $0.00 $315.50 $499.75 $504.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008127 EAP Custom 27008127 Ti End Cap T25 Strdrv 0mm Ext BOTH IP/OP $759.00 $561.66 $0.00 $607.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $563.33 $563.33 $585.04 $0.00 $158.18 $0.00 $0.00 $0.00 $0.00 $379.50 $601.13 $607.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008128 EAP Custom 27008128 Ti End Cap T25 Strdrv 5mm Ext BOTH IP/OP $631.00 $466.94 $0.00 $504.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.33 $468.33 $486.37 $0.00 $131.50 $0.00 $0.00 $0.00 $0.00 $315.50 $499.75 $504.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008129 EAP Custom 27008129 Ti End Cap T25 Strdrv 5mm Ext BOTH IP/OP $759.00 $561.66 $0.00 $607.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $563.33 $563.33 $585.04 $0.00 $158.18 $0.00 $0.00 $0.00 $0.00 $379.50 $601.13 $607.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008130 EAP Custom 27008130 Ti End Cap T25 Strdrv 10mm Ex BOTH IP/OP $631.00 $466.94 $0.00 $504.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.33 $468.33 $486.37 $0.00 $131.50 $0.00 $0.00 $0.00 $0.00 $315.50 $499.75 $504.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008131 EAP Custom 27008131 Ti End Cap T25 Strdrv 10mm Ex BOTH IP/OP $759.00 $561.66 $0.00 $607.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $563.33 $563.33 $585.04 $0.00 $158.18 $0.00 $0.00 $0.00 $0.00 $379.50 $601.13 $607.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008132 EAP Custom 27008132 Ti End Cap T25 Strdrv 15mm Ext BOTH IP/OP $631.00 $466.94 $0.00 $504.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.33 $468.33 $486.37 $0.00 $131.50 $0.00 $0.00 $0.00 $0.00 $315.50 $499.75 $504.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008133 EAP Custom 27008133 Ti End Cap T25 Strdrv 15mm Ex BOTH IP/OP $759.00 $561.66 $0.00 $607.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $563.33 $563.33 $585.04 $0.00 $158.18 $0.00 $0.00 $0.00 $0.00 $379.50 $601.13 $607.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008138 EAP Custom 27008138 11m Ti Can Prox Hum Nl-ex/150m BOTH IP/OP "$7,722.00 " "$5,714.28" $0.00 "$6,177.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,952.12" $0.00 "$1,609.26" $0.00 $0.00 $0.00 $0.00 "$3,861.00" "$6,115.82" "$6,177.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008139 EAP Custom 27008139 11m Ti Can Hum Nail-ex/190-320 BOTH IP/OP "$7,722.00 " "$5,714.28" $0.00 "$6,177.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,952.12" $0.00 "$1,609.26" $0.00 $0.00 $0.00 $0.00 "$3,861.00" "$6,115.82" "$6,177.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008140 EAP Custom 27008140 Ti End Cap T40 Sdrv 0mext Fem BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008141 EAP Custom 27008141 Ti End Cap T40 Sdrv 0mext Ste BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008142 EAP Custom 27008142 12 Ti End Cap T40 Sdrv 5m Ext BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008143 EAP Custom 27008143 12 Ti End Cap T40 Sdrv 5m Ext BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008144 EAP Custom 27008144 12 Ti End Cap T40 Sdrv 10mm Ex BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008145 EAP Custom 27008145 12 Ti End Cap T40 Sdrv 10mm Ex BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008146 EAP Custom 27008146 12 Ti End Cap T40 Sdrv 15mm Ex BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008147 EAP Custom 27008147 12 Ti End Cap T40 Sdrv 15mm Ex BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008148 EAP Custom 27008148 12 Ti End Cap T40 Sdrv 20mm Ex BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008149 EAP Custom 27008149 12 Ti End Cap T40 Sdrv 20mm Ex BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008150 EAP Custom 27008150 16 Ti End Cap T40 Sdrv 5m Ext BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008151 EAP Custom 27008151 16m Ti End Cap T40 Sdrv 5m Ext BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008152 EAP Custom 27008152 16m Ti End Cap T40 Sdrv 10mm BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008153 EAP Custom 27008153 16m Ti End Cap T40 Sdrv 10mm BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008154 EAP Custom 27008154 16m Ti End Cap T40 Sdrv 15mm BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008155 EAP Custom 27008155 16m Ti End Cap T40 Sdrv 15mm BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008156 EAP Custom 27008156 16 Ti End Cap T40 Sdrv 20mm Ex BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008157 EAP Custom 27008157 16 Ti End Cap T40 Sdrv 20mm Ex BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008185 EAP Custom 27008185 10ti Lat En Fem Nl-ex/300m-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008186 EAP Custom 27008186 11ti Lat En Fem Nl-ex/300m-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008187 EAP Custom 27008187 11ti Lat En Fem Nl-ex/300m-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008188 EAP Custom 27008188 12 Ti Lat En Fem Nl-ex/300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008189 EAP Custom 27008189 12 Ti Lat En Fem Nl-ex/300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008190 EAP Custom 27008190 13ti Lat Ent Fem Nl-ex/300m480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008191 EAP Custom 27008191 13ti Lat Ent Fem Nl-ex/300m480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008192 EAP Custom 27008192 14ti Lat Ent Fem Nl-ex/300m480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008193 EAP Custom 27008193 14ti Lat Ent Fem Nl-ex/300m480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008194 EAP Custom 27008194 15ti Lat Ent Fem Nl-ex/300m480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008195 EAP Custom 27008195 15ti Lat Ent Fem Nl-ex/300m480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008196 EAP Custom 27008196 16ti Lat Ent Fem Nl-ex/300m480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008197 EAP Custom 27008197 16ti Lat Ent Fem Nl-ex/300m480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008198 EAP Custom 27008198 Ti En Cp W/t40 Sdr 0m Ext F/t BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008199 EAP Custom 27008199 Ti En Cap W/t40 Sdr 0m Ext F/t BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008200 EAP Custom 27008200 Ti En Cap W/t40 Sdr 5m Ext F/t BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $0.00 $0.00 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008201 EAP Custom 27008201 Ti En Cap W/t40 Sdr 5m Ext-ste BOTH IP/OP "$1,010.00 " $747.40 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.62 $749.62 $778.51 $0.00 $210.48 $0.00 $0.00 $0.00 $0.00 $505.00 $799.92 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008202 EAP Custom 27008202 Ti En Cap W/ T40 Sdr Ext F/ti BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $0.00 $0.00 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008203 EAP Custom 27008203 Ti En Cap W/t40 Sdr 10m Ext-st BOTH IP/OP "$1,010.00 " $747.40 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.62 $749.62 $778.51 $0.00 $210.48 $0.00 $0.00 $0.00 $0.00 $505.00 $799.92 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008204 EAP Custom 27008204 Ti En Cap W/t40 Sdr 15m Ext BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $0.00 $0.00 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008205 EAP Custom 27008205 Ti En Cap W/t40 Sdr 15m Ext-st BOTH IP/OP "$1,010.00 " $747.40 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.62 $749.62 $778.51 $0.00 $210.48 $0.00 $0.00 $0.00 $0.00 $505.00 $799.92 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008206 EAP Custom 27008206 Ti En Cap Tib Nl-ex T40 Sdr 0m BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008207 EAP Custom 27008207 Ti En Cap Tib Nl-ex T40 Sdr 0 BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.67 $602.67 $625.89 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $406.00 $643.10 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008208 EAP Custom 27008208 Ti En Cap Tib Nl-ex T40 Sdr 5m BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $0.00 $0.00 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008209 EAP Custom 27008209 Ti En Cap Tib Nl-ex T40 Sdr 5m BOTH IP/OP "$1,010.00 " $747.40 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.62 $749.62 $778.51 $0.00 $210.48 $0.00 $0.00 $0.00 $0.00 $505.00 $799.92 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008210 EAP Custom 27008210 Ti En Cap Tib Nl-ex T40 Sdr 10 BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $0.00 $0.00 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008211 EAP Custom 27008211 Ti En Cap Tib Nl-ex T40 Sdr 10 BOTH IP/OP "$1,010.00 " $747.40 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.62 $749.62 $778.51 $0.00 $210.48 $0.00 $0.00 $0.00 $0.00 $505.00 $799.92 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008212 EAP Custom 27008212 Ti En Cap Tib Nl-ex T40 Sdr 15 BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $0.00 $0.00 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008213 EAP Custom 27008213 Ti En Cap Tib Nl-ex T40 Sdr 15 BOTH IP/OP "$1,010.00 " $747.40 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.62 $749.62 $778.51 $0.00 $210.48 $0.00 $0.00 $0.00 $0.00 $505.00 $799.92 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008216 EAP Custom 27008216 10m Ti Can Tib Nl-ex/255-435mm BOTH IP/OP "$6,110.00 " "$4,521.40" $0.00 "$4,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,709.59" $0.00 "$1,273.32" $0.00 $0.00 $0.00 $0.00 "$3,055.00" "$4,839.12" "$4,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008217 EAP Custom 27008217 12m Ti Can Tib Nl-ex/255-435mm BOTH IP/OP "$6,110.00 " "$4,521.40" $0.00 "$4,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,709.59" $0.00 "$1,273.32" $0.00 $0.00 $0.00 $0.00 "$3,055.00" "$4,839.12" "$4,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008219 EAP Custom 27008219 Ti En Cap T25 Sdr Hndft Art Nl BOTH IP/OP $712.00 $526.88 $0.00 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.45 $528.45 $548.81 $0.00 $148.38 $0.00 $0.00 $0.00 $0.00 $356.00 $563.90 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008220 EAP Custom 27008220 Ti En Cap T25 Sdr Hndft Art Nl BOTH IP/OP $842.00 $623.08 $0.00 $673.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $624.93 $624.93 $649.01 $0.00 $175.47 $0.00 $0.00 $0.00 $0.00 $421.00 $666.86 $673.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008221 EAP Custom 27008221 Ti En Cap T25 Sdr Hndft Art Nl BOTH IP/OP $712.00 $526.88 $0.00 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.45 $528.45 $548.81 $0.00 $148.38 $0.00 $0.00 $0.00 $0.00 $356.00 $563.90 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008222 EAP Custom 27008222 Ti En Cap T25 Sdr Hndft Art Nl BOTH IP/OP $842.00 $623.08 $0.00 $673.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $624.93 $624.93 $649.01 $0.00 $175.47 $0.00 $0.00 $0.00 $0.00 $421.00 $666.86 $673.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008223 EAP Custom 27008223 10ti Hft Art Can Nl-ex150-240m BOTH IP/OP "$6,453.00 " "$4,775.22" $0.00 "$5,162.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,973.97" $0.00 "$1,344.81" $0.00 $0.00 $0.00 $0.00 "$3,226.50" "$5,110.78" "$5,162.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008224 EAP Custom 27008224 Ti En Cap T40 Sdr 0m Ext Retr BOTH IP/OP $682.00 $504.68 $0.00 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.18 $506.18 $525.69 $0.00 $142.13 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008225 EAP Custom 27008225 Ti Spir Bld 45m Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008226 EAP Custom 27008226 Ti Spir Bld 50m Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008227 EAP Custom 27008227 Ti Spir Bld 50m-ster F/ti Retr BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008228 EAP Custom 27008228 Ti Spir Bld 55m Ti Retr Fem BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008229 EAP Custom 27008229 Ti Spir Bld 55m-ster F/ti Retr BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008230 EAP Custom 27008230 Ti Spir Bld 65m Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008231 EAP Custom 27008231 Ti Spir Bld 65f/ti Ret Fem Nls BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008232 EAP Custom 27008232 Ti Spir Bld 70m Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008233 EAP Custom 27008233 Ti Spir Bld 70m F/ti Retr Fem BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008234 EAP Custom 27008234 Ti Spir Bld 75m Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008235 EAP Custom 27008235 Ti Spir Bld 75 F/ti Ret Fem Nl BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008236 EAP Custom 27008236 Ti Spir Bld 80m Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008237 EAP Custom 27008237 Ti Spir Bld 80 F/ti Ret Fem Nl BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008238 EAP Custom 27008238 Ti Spir Bld 85 Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008239 EAP Custom 27008239 Ti Spir Bld 85m F/ti Retr Fem BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008240 EAP Custom 27008240 Ti Spir Bld 90m Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008241 EAP Custom 27008241 Ti Spir Bld 90m F/ti Retr Fem BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008242 EAP Custom 27008242 Ti Spir Bld 95m Ti Retr Fem Nl BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008243 EAP Custom 27008243 Ti Spir Bld 100m Ti Retr Fem BOTH IP/OP "$2,318.00 " "$1,715.32" $0.00 "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.42" "$1,720.42" "$1,786.71" $0.00 $483.07 $0.00 $0.00 $0.00 $0.00 "$1,159.00" "$1,835.86" "$1,854.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008244 EAP Custom 27008244 Ti Spir Bld 100m-st F/ti Ret BOTH IP/OP "$2,447.00 " "$1,810.78" $0.00 "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.16" "$1,816.16" "$1,886.15" $0.00 $509.95 $0.00 $0.00 $0.00 $0.00 "$1,223.50" "$1,938.02" "$1,957.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008247 EAP Custom 27008247 10ti Can Ret Fem Nl-ex/160-280 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008248 EAP Custom 27008248 10ti Can Ret/ant Fem Nl300-480 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008249 EAP Custom 27008249 11ti Can Ret Fem Nl-ex/160-280 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008250 EAP Custom 27008250 12mmti Can Retr Fem Nl 160-280 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008251 EAP Custom 27008251 13ti Can Retr Fem Nl-ex160-280 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008252 EAP Custom 27008252 13ti Can Ret/ant Fem Nl300-480 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008253 EAP Custom 27008253 14ti Can Retr Fem Nl-ex160-280 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008254 EAP Custom 27008254 14ti Can Ret/ant Fem Nl300-480 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008255 EAP Custom 27008255 15ti Can Retr Fem Nl-160-280mm BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008256 EAP Custom 27008256 15ti Can Ret/ant Fem Nl300-480 BOTH IP/OP "$6,897.00 " "$5,103.78" $0.00 "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,316.21" $0.00 "$1,437.33" $0.00 $0.00 $0.00 $0.00 "$3,448.50" "$5,462.42" "$5,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008258 EAP Custom 27008258 10ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008259 EAP Custom 27008259 10ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008260 EAP Custom 27008260 11ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008261 EAP Custom 27008261 12ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008262 EAP Custom 27008262 12ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008263 EAP Custom 27008263 13ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008264 EAP Custom 27008264 13ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008265 EAP Custom 27008265 14ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008266 EAP Custom 27008266 14ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008267 EAP Custom 27008267 15ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008268 EAP Custom 27008268 15ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008269 EAP Custom 27008269 16ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008270 EAP Custom 27008270 16ti Can Lat Ent Fem Nl300-480 BOTH IP/OP "$6,829.00 " "$5,053.46" $0.00 "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,263.79" $0.00 "$1,423.16" $0.00 $0.00 $0.00 $0.00 "$3,414.50" "$5,408.57" "$5,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008275 EAP Custom 27008275 T15/2.5m Hex Ti Cerclage Buttn BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008276 EAP Custom 27008276 T25/3.5m Hex Ti Cerclage Buttn BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008281 EAP Custom 27008281 Saw Bld 95x19 0.89m Cut Thknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008282 EAP Custom 27008282 Saw Bld 95x19 1.19m Cut Thknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008283 EAP Custom 27008283 Saw Bld 95x19 1.27m Cut Thknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008284 EAP Custom 27008284 Saw Bld 95x19 1.37m Cut Thknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008285 EAP Custom 27008285 Saw Bld 95x 19 1.47 Cut Thknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008286 EAP Custom 27008286 Saw Bld 80x19 0.89 Cut Thkness BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008287 EAP Custom 27008287 Saw Bld 95x19 1.00 Cut Thkness BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008288 EAP Custom 27008288 Saw Bld 95 X 19 1.07cut Thknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008289 EAP Custom 27008289 Saw Bld 95x25 0.89 Cut Thkness BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008290 EAP Custom 27008290 Saw Bld 95x25 1.19 Cut Thcknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008291 EAP Custom 27008291 Saw Bld 95x25 1.27 Cut Thcknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008292 EAP Custom 27008292 Saw Bld 95x25 1.37 Cut Thcknes BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008293 EAP Custom 27008293 Saw Bld 95x25 1.47cut Thckness BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008294 EAP Custom 27008294 Saw Blade 95mm X 25mm 1.00mm BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008295 EAP Custom 27008295 Saw Blade 95mm X 25mm 1.07mm BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008296 EAP Custom 27008296 Saw Blade 90mm X 12.5mm 0.89m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008297 EAP Custom 27008297 Saw Blade 90mm X 12.5mm 1.19m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008298 EAP Custom 27008298 Saw Blade 90mm X 12.5mm 1.27m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008299 EAP Custom 27008299 Saw Blade 90mm X 12.5mm 1.37m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008300 EAP Custom 27008300 Saw Blade 90mm X 12.5mm 1.47m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008301 EAP Custom 27008301 Saw Blade 90m X 19-12.5m 0.89m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008302 EAP Custom 27008302 Saw Blade 90m X19-12.5mm 1.19m BOTH IP/OP $328.00 $242.72 $0.00 $262.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $243.44 $243.44 $252.82 $0.00 $68.36 $0.00 $0.00 $0.00 $0.00 $164.00 $259.78 $262.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008303 EAP Custom 27008303 Saw Blade 90mx19-12.5mm 1.27m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008304 EAP Custom 27008304 Saw Blade 90m X19-12.5m 1.37m BOTH IP/OP $310.00 $229.40 $0.00 $248.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.08 $230.08 $238.95 $0.00 $64.60 $0.00 $0.00 $0.00 $0.00 $155.00 $245.52 $248.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008305 EAP Custom 27008305 Saw Blade 90mx19-12.5mm 1.47m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008306 EAP Custom 27008306 Saw Blade 90mx19-12.5mm 1.00m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008307 EAP Custom 27008307 Saw Blade 90mm X 12.5mm 1.00m BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008308 EAP Custom 27008308 Saw Blade 60mm X 25mm 0.89mm BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008309 EAP Custom 27008309 Plan&reduct Tech In Fx Surgery BOTH IP/OP $781.00 $577.94 $0.00 $624.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $579.66 $579.66 $601.99 $0.00 $162.76 $0.00 $0.00 $0.00 $0.00 $390.50 $618.55 $624.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008312 EAP Custom 27008312 The Rational Operative Fx Care BOTH IP/OP $781.00 $577.94 $0.00 $624.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $579.66 $579.66 $601.99 $0.00 $162.76 $0.00 $0.00 $0.00 $0.00 $390.50 $618.55 $624.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008316 EAP Custom 27008316 Minimax Fracture Fixation BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $467.59 $467.59 $485.60 $0.00 $131.29 $0.00 $0.00 $0.00 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008318 EAP Custom 27008318 Intern Fixatn Osteoporotic Bne BOTH IP/OP $538.00 $398.12 $0.00 $430.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $399.30 $399.30 $414.69 $0.00 $112.12 $0.00 $0.00 $0.00 $0.00 $269.00 $426.10 $430.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008321 EAP Custom 27008321 Oper Approach Orth Surg&trauma BOTH IP/OP $635.00 $469.90 $0.00 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.30 $471.30 $489.46 $0.00 $132.33 $0.00 $0.00 $0.00 $0.00 $317.50 $502.92 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008324 EAP Custom 27008324 1.5mm Cortex Scw 6-20mm BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.60 $61.60 $63.98 $0.00 $17.30 $0.00 $0.00 $0.00 $0.00 $41.50 $65.74 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008325 EAP Custom 27008325 1.0cor Scw Self-tapg 6-14mm BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.35 $252.35 $262.07 $0.00 $70.86 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008326 EAP Custom 27008326 1.3mm Cort Scw Slf-tapg 6-18 BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008327 EAP Custom 27008327 1.5mm Cort Scw Slf-tapg 6-24 BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $0.00 $0.00 $0.00 $48.50 $76.82 $77.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008335 EAP Custom 27008335 1.8mm Buttress Pin/12-30mm BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.17 $126.17 $131.04 $0.00 $35.43 $0.00 $0.00 $0.00 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008367 EAP Custom 27008367 Schuhli Assembly - 4.5 Cor Scw BOTH IP/OP "$1,039.00 " $768.86 $0.00 $831.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $771.15 $771.15 $800.86 $0.00 $216.53 $0.00 $0.00 $0.00 $0.00 $519.50 $822.89 $831.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008368 EAP Custom 27008368 Schuhli Assembly- 3.5 Cor Scw BOTH IP/OP "$1,039.00 " $768.86 $0.00 $831.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $771.15 $771.15 $800.86 $0.00 $216.53 $0.00 $0.00 $0.00 $0.00 $519.50 $822.89 $831.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008369 EAP Custom 27008369 Thrded Wash 3.0 Cannul Scw BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $415.63 $415.63 $431.65 $0.00 $116.70 $0.00 $0.00 $0.00 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008370 EAP Custom 27008370 Spiked Washer 8.0mm/3.2mm BOTH IP/OP $497.00 $367.78 $0.00 $397.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $368.87 $368.87 $383.09 $0.00 $103.57 $0.00 $0.00 $0.00 $0.00 $248.50 $393.62 $397.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008371 EAP Custom 27008371 Spiked Washer 13.5mm/4.0mm BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008372 EAP Custom 27008372 Spiked Washer 13.5mm/5.5mm BOTH IP/OP $492.00 $364.08 $0.00 $393.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.16 $365.16 $379.23 $0.00 $102.53 $0.00 $0.00 $0.00 $0.00 $246.00 $389.66 $393.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008373 EAP Custom 27008373 Spher Wash/sm Oval 6.5/ 0.3mm BOTH IP/OP $608.00 $449.92 $0.00 $486.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $451.26 $451.26 $468.65 $0.00 $126.71 $0.00 $0.00 $0.00 $0.00 $304.00 $481.54 $486.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008374 EAP Custom 27008374 Spher Washer/lrg Rnd 6.5/7.3 BOTH IP/OP $608.00 $449.92 $0.00 $486.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $451.26 $451.26 $468.65 $0.00 $126.71 $0.00 $0.00 $0.00 $0.00 $304.00 $481.54 $486.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008375 EAP Custom 27008375 Nut For 4.5mm Cortex Screws BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $0.00 $0.00 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008376 EAP Custom 27008376 Washer 6.5mm BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008377 EAP Custom 27008377 1.3mm Straight Plate 6 Holes BOTH IP/OP $789.00 $583.86 $0.00 $631.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $585.60 $585.60 $608.16 $0.00 $164.43 $0.00 $0.00 $0.00 $0.00 $394.50 $624.89 $631.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008378 EAP Custom 27008378 1.3mm Straight Plate 12 Holes BOTH IP/OP $996.00 $737.04 $0.00 $796.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $739.23 $739.23 $767.72 $0.00 $207.57 $0.00 $0.00 $0.00 $0.00 $498.00 $788.83 $796.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008379 EAP Custom 27008379 1.3mm Extended H-plate/right BOTH IP/OP $954.00 $705.96 $0.00 $763.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.06 $708.06 $735.34 $0.00 $198.81 $0.00 $0.00 $0.00 $0.00 $477.00 $755.57 $763.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008380 EAP Custom 27008380 1.3mm Extended H-plate/left BOTH IP/OP $954.00 $705.96 $0.00 $763.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.06 $708.06 $735.34 $0.00 $198.81 $0.00 $0.00 $0.00 $0.00 $477.00 $755.57 $763.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008381 EAP Custom 27008381 1.3mm T-plte 3 Hles Hd/ 8hles BOTH IP/OP $913.00 $675.62 $0.00 $730.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $677.63 $677.63 $703.74 $0.00 $190.27 $0.00 $0.00 $0.00 $0.00 $456.50 $723.10 $730.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008382 EAP Custom 27008382 1.3mm T-plte 4hles Head/8hles BOTH IP/OP $954.00 $705.96 $0.00 $763.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.06 $708.06 $735.34 $0.00 $198.81 $0.00 $0.00 $0.00 $0.00 $477.00 $755.57 $763.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008383 EAP Custom 27008383 1.3mm Y-plte 3 Hles Head/8hle BOTH IP/OP $913.00 $675.62 $0.00 $730.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $677.63 $677.63 $703.74 $0.00 $190.27 $0.00 $0.00 $0.00 $0.00 $456.50 $723.10 $730.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008384 EAP Custom 27008384 Semi-tubul Plate 2 Holes 39m BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.22 $169.22 $175.74 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.00 $180.58 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008385 EAP Custom 27008385 Semi-tubul Plate 3 Holes 55m BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $181.14 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008386 EAP Custom 27008386 Semi-tubul Plate 4 Holes 71m BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $196.55 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008387 EAP Custom 27008387 Semi-tubul Plate 5 Holes 87m BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008388 EAP Custom 27008388 Semi-tubulplate 6 Holes 103m BOTH IP/OP $283.00 $209.42 $0.00 $226.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.04 $210.04 $218.14 $0.00 $58.98 $0.00 $0.00 $0.00 $0.00 $141.50 $224.14 $226.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008389 EAP Custom 27008389 Semi-tubul Plate 7 Holes 119m BOTH IP/OP $307.00 $227.18 $0.00 $245.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.86 $227.86 $236.64 $0.00 $63.98 $0.00 $0.00 $0.00 $0.00 $153.50 $243.14 $245.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008390 EAP Custom 27008390 Semi-tubul Plate 8 Holes 135m BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008391 EAP Custom 27008391 Semi-tubul Plate 9 Holes 151m BOTH IP/OP $337.00 $249.38 $0.00 $269.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.12 $250.12 $259.76 $0.00 $70.23 $0.00 $0.00 $0.00 $0.00 $168.50 $266.90 $269.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008392 EAP Custom 27008392 Semi-tubul Plate 10 Holes 167m BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008393 EAP Custom 27008393 Semi-tubul Plate 11 Holes/183m BOTH IP/OP $356.00 $263.44 $0.00 $284.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.22 $264.22 $274.40 $0.00 $74.19 $0.00 $0.00 $0.00 $0.00 $178.00 $281.95 $284.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008394 EAP Custom 27008394 Semi-tubular Plate 12 Hles/199 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008662 EAP Custom 27008662 100deg Adoles Osteo Plt 50/10 BOTH IP/OP "$2,088.00 " "$1,545.12" $0.00 "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.71" "$1,549.71" "$1,609.43" $0.00 $435.14 $0.00 $0.00 $0.00 $0.00 "$1,044.00" "$1,653.70" "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008663 EAP Custom 27008663 100deg Adoles Osteo Plt 50/10 BOTH IP/OP "$2,219.00 " "$1,642.06" $0.00 "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,646.94" "$1,646.94" "$1,710.41" $0.00 $462.44 $0.00 $0.00 $0.00 $0.00 "$1,109.50" "$1,757.45" "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008666 EAP Custom 27008666 100deg Adoles Osteo Plt 40/10 BOTH IP/OP "$2,088.00 " "$1,545.12" $0.00 "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.71" "$1,549.71" "$1,609.43" $0.00 $435.14 $0.00 $0.00 $0.00 $0.00 "$1,044.00" "$1,653.70" "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008667 EAP Custom 27008667 100deg Adoles Osteo Plt 40/10 BOTH IP/OP "$2,219.00 " "$1,642.06" $0.00 "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,646.94" "$1,646.94" "$1,710.41" $0.00 $462.44 $0.00 $0.00 $0.00 $0.00 "$1,109.50" "$1,757.45" "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008670 EAP Custom 27008670 100deg Adoles Osteo Plt 50/15 BOTH IP/OP "$2,088.00 " "$1,545.12" $0.00 "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.71" "$1,549.71" "$1,609.43" $0.00 $435.14 $0.00 $0.00 $0.00 $0.00 "$1,044.00" "$1,653.70" "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008671 EAP Custom 27008671 100deg Adoles Osteo Plt 50/15 BOTH IP/OP "$2,219.00 " "$1,642.06" $0.00 "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,646.94" "$1,646.94" "$1,710.41" $0.00 $462.44 $0.00 $0.00 $0.00 $0.00 "$1,109.50" "$1,757.45" "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008674 EAP Custom 27008674 100deg Adoles Osteo Plt 60/15 BOTH IP/OP "$2,088.00 " "$1,545.12" $0.00 "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.71" "$1,549.71" "$1,609.43" $0.00 $435.14 $0.00 $0.00 $0.00 $0.00 "$1,044.00" "$1,653.70" "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008675 EAP Custom 27008675 100deg Adoles Osteo Plt 60/15 BOTH IP/OP "$2,219.00 " "$1,642.06" $0.00 "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,646.94" "$1,646.94" "$1,710.41" $0.00 $462.44 $0.00 $0.00 $0.00 $0.00 "$1,109.50" "$1,757.45" "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008678 EAP Custom 27008678 100deg Adoles Osteo Plt 40/15 BOTH IP/OP "$2,088.00 " "$1,545.12" $0.00 "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.71" "$1,549.71" "$1,609.43" $0.00 $435.14 $0.00 $0.00 $0.00 $0.00 "$1,044.00" "$1,653.70" "$1,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008679 EAP Custom 27008679 100deg Adoles Osteo Plt 40/15 BOTH IP/OP "$2,219.00 " "$1,642.06" $0.00 "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,646.94" "$1,646.94" "$1,710.41" $0.00 $462.44 $0.00 $0.00 $0.00 $0.00 "$1,109.50" "$1,757.45" "$1,775.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008680 EAP Custom 27008680 115 Deg Bifurcatd Plte 30/5 BOTH IP/OP "$1,187.00 " $878.38 $0.00 $949.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $880.99 $880.99 $914.94 $0.00 $247.37 $0.00 $0.00 $0.00 $0.00 $593.50 $940.10 $949.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008681 EAP Custom 27008681 115 Deg Bifurcatd Plte 30/5 BOTH IP/OP "$1,318.00 " $975.32 $0.00 "$1,054.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $978.22 $978.22 "$1,015.91" $0.00 $274.67 $0.00 $0.00 $0.00 $0.00 $659.00 "$1,043.86" "$1,054.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008682 EAP Custom 27008682 115 Deg Bifurcatd Plte 35/5 BOTH IP/OP "$1,187.00 " $878.38 $0.00 $949.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $880.99 $880.99 $914.94 $0.00 $247.37 $0.00 $0.00 $0.00 $0.00 $593.50 $940.10 $949.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27008683 EAP Custom 27008683 115 Deg Bifurcatd Plte 35/5 BOTH IP/OP "$1,318.00 " $975.32 $0.00 "$1,054.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $978.22 $978.22 "$1,015.91" $0.00 $274.67 $0.00 $0.00 $0.00 $0.00 $659.00 "$1,043.86" "$1,054.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010225 EAP Custom 27010225 0.8mm Guide Wire 100mm BOTH IP/OP $611.00 $452.14 $0.00 $488.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $453.48 $453.48 $470.96 $0.00 $127.33 $0.00 $0.00 $0.00 $0.00 $305.50 $483.91 $488.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010807 EAP Custom 27010807 "Bipolar Cord,disposable" BOTH IP/OP $683.00 $505.42 $0.00 $546.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.92 $506.92 $526.46 $0.00 $142.34 $0.00 $0.00 $0.00 $0.00 $341.50 $540.94 $546.40 $0.00 $443.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010828 EAP Custom 27010828 Cast App'l-spica Adult BOTH IP/OP $749.00 $554.26 $0.00 $599.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.50 $593.21 $599.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010880 EAP Custom 27010880 Colostomy Bag & Supplies BOTH IP/OP $509.00 $376.66 $0.00 $407.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $377.78 $377.78 $392.34 $0.00 $106.08 $0.00 $0.00 $0.00 $0.00 $254.50 $403.13 $407.20 $0.00 $330.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010881 EAP Custom 27010881 Gen-supp-guide Wire BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010943 EAP Custom 27010943 Endo Stitch* Polysorb* 3/0 7 V BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.96 $146.96 $152.62 $0.00 $41.26 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010987 EAP Custom 27010987 3.2mm Guide Wire 290mm BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010993 EAP Custom 27010993 Humeral Fracture Brace BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $127.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010994 EAP Custom 27010994 Wound Care Shoe BOTH IP/OP $309.00 $228.66 $0.00 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.34 $229.34 $238.18 $0.00 $64.40 $0.00 $0.00 $0.00 $0.00 $154.50 $244.73 $247.20 $0.00 $200.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010997 EAP Custom 27010997 3mmx20cm Tunneler BOTH IP/OP $656.00 $485.44 $0.00 $524.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $486.88 $486.88 $505.64 $0.00 $136.71 $0.00 $0.00 $0.00 $0.00 $328.00 $519.55 $524.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011002 EAP Custom 27011002 4fr Catheter Cobra 2 BOTH IP/OP $166.00 $122.84 $0.00 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.21 $123.21 $127.95 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $83.00 $131.47 $132.80 $0.00 $107.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011008 EAP Custom 27011008 5fr-100cm Sim 1 Cath BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011009 EAP Custom 27011009 5mmx19cmx90cm Monorail Bilary BOTH IP/OP "$4,654.00 " "$3,443.96" $0.00 "$3,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,454.20" "$3,454.20" "$3,587.30" $0.00 $969.89 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,685.97" "$3,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011010 EAP Custom 27011010 5x135x40cm Unifuse Kit BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.21 $408.21 $423.94 $0.00 $114.62 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011011 EAP Custom 27011011 5x135x50cm Unifuse Kit BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.21 $408.21 $423.94 $0.00 $114.62 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011013 EAP Custom 27011013 6fr Al1 Catheter BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011015 EAP Custom 27011015 6fr Ar1 Catheter BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011028 EAP Custom 27011028 7.1 Fr 100cm Pigtail Cath BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011029 EAP Custom 27011029 8fr X 40cm Skater Biliary Drai BOTH IP/OP $254.00 $187.96 $0.00 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.52 $188.52 $195.78 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $127.00 $201.17 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011032 EAP Custom 27011032 Air Guard Valved Introducer BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.64 $248.64 $258.22 $0.00 $69.81 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $217.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011033 EAP Custom 27011033 Bag Drainage Ureteral BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $0.00 $0.00 $0.00 $51.50 $81.58 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011037 EAP Custom 27011037 Balloon Dial Cath Xxl 12mmx4cm BOTH IP/OP $856.00 $633.44 $0.00 $684.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $635.32 $635.32 $659.80 $0.00 $178.39 $0.00 $0.00 $0.00 $0.00 $428.00 $677.95 $684.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011039 EAP Custom 27011039 Balloon Polar Cath 4x60x120 BOTH IP/OP "$2,002.00 " "$1,481.48" $0.00 "$1,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,485.88" "$1,485.88" "$1,543.14" $0.00 $417.22 $0.00 $0.00 $0.00 $0.00 "$1,001.00" "$1,585.58" "$1,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011040 EAP Custom 27011040 Balloon Polar Cath 5x40x120 BOTH IP/OP "$2,002.00 " "$1,481.48" $0.00 "$1,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,485.88" "$1,485.88" "$1,543.14" $0.00 $417.22 $0.00 $0.00 $0.00 $0.00 "$1,001.00" "$1,585.58" "$1,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011041 EAP Custom 27011041 Balloon Polar Cath 5x60x120 BOTH IP/OP "$2,002.00 " "$1,481.48" $0.00 "$1,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,485.88" "$1,485.88" "$1,543.14" $0.00 $417.22 $0.00 $0.00 $0.00 $0.00 "$1,001.00" "$1,585.58" "$1,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011051 EAP Custom 27011051 Basket Stone Removal 8-wire BOTH IP/OP $963.00 $712.62 $0.00 $770.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $714.74 $714.74 $742.28 $0.00 $200.69 $0.00 $0.00 $0.00 $0.00 $481.50 $762.70 $770.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011052 EAP Custom 27011052 Bead Block 100-300 BOTH IP/OP $667.00 $493.58 $0.00 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.05 $495.05 $514.12 $0.00 $139.00 $0.00 $0.00 $0.00 $0.00 $333.50 $528.26 $533.60 $0.00 $433.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011053 EAP Custom 27011053 Bead Block 300-500 BOTH IP/OP $667.00 $493.58 $0.00 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.05 $495.05 $514.12 $0.00 $139.00 $0.00 $0.00 $0.00 $0.00 $333.50 $528.26 $533.60 $0.00 $433.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011054 EAP Custom 27011054 Bead Block 500-700 BOTH IP/OP $667.00 $493.58 $0.00 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.05 $495.05 $514.12 $0.00 $139.00 $0.00 $0.00 $0.00 $0.00 $333.50 $528.26 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011055 EAP Custom 27011055 Bead Block 700-900 BOTH IP/OP $667.00 $493.58 $0.00 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.05 $495.05 $514.12 $0.00 $139.00 $0.00 $0.00 $0.00 $0.00 $333.50 $528.26 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011056 EAP Custom 27011056 Bead Block 900-1200 BOTH IP/OP $667.00 $493.58 $0.00 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.05 $495.05 $514.12 $0.00 $139.00 $0.00 $0.00 $0.00 $0.00 $333.50 $528.26 $533.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011058 EAP Custom 27011058 Cath 20fr 24cm Tenacath Hsg BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.50 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011061 EAP Custom 27011061 Cath 5fr 100cm Berenstein BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011062 EAP Custom 27011062 Cath 5fr 100cm Sim2 BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011063 EAP Custom 27011063 Cath 5fr 100cm Sim3 BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011065 EAP Custom 27011065 Cath 5fr 40cm Berenstein BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011067 EAP Custom 27011067 Cath 5fr 65cm Berenstein BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011068 EAP Custom 27011068 Cath 5fr 65cm Cobra1 BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011069 EAP Custom 27011069 Cath 5fr 65cm Cobra2 BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011070 EAP Custom 27011070 Cath 5fr 65cm Ns Straight BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011071 EAP Custom 27011071 Cath 5fr 65cm Pig BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011073 EAP Custom 27011073 Cath 5fr 80 Cm Mikalesson BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011074 EAP Custom 27011074 Cath 5fr 80cm Sos1 BOTH IP/OP $166.00 $122.84 $0.00 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.21 $123.21 $127.95 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $83.00 $131.47 $132.80 $0.00 $107.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011075 EAP Custom 27011075 Cath 5fr 80cm Sos2 BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011077 EAP Custom 27011077 Cath Polar Dilator Bal4x80x120 BOTH IP/OP "$2,335.00 " "$1,727.90" $0.00 "$1,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,167.50" "$1,849.32" "$1,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011078 EAP Custom 27011078 Cath Polar Dilator Bal5x80x120 BOTH IP/OP "$2,002.00 " "$1,481.48" $0.00 "$1,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,001.00" "$1,585.58" "$1,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011083 EAP Custom 27011083 Cath Triple Lumen 11fr BOTH IP/OP $413.00 $305.62 $0.00 $330.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.50 $327.10 $330.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011084 EAP Custom 27011084 Catheter Repair Kit BOTH IP/OP $349.00 $258.26 $0.00 $279.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.03 $259.03 $269.01 $0.00 $72.73 $0.00 $0.00 $0.00 $0.00 $174.50 $276.41 $279.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011086 EAP Custom 27011086 Chest Unit Drainage Pleur BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.09 $348.09 $361.51 $0.00 $97.74 $0.00 $0.00 $0.00 $0.00 $234.50 $371.45 $375.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011088 EAP Custom 27011088 Coil 15-250 Micron (2vl/bx) BOTH IP/OP $477.00 $352.98 $0.00 $381.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.03 $354.03 $367.67 $0.00 $99.41 $0.00 $0.00 $0.00 $0.00 $238.50 $377.78 $381.60 $0.00 $310.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011089 EAP Custom 27011089 Coil 250-355 Micron (5vl/bx) BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $0.00 $0.00 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011090 EAP Custom 27011090 Coil 355-500 Micron (5vl/bx) BOTH IP/OP $384.00 $284.16 $0.00 $307.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.00 $285.00 $295.99 $0.00 $80.03 $0.00 $0.00 $0.00 $0.00 $192.00 $304.13 $307.20 $0.00 $249.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011091 EAP Custom 27011091 Coil 500-710 Micron (2vl/bx) BOTH IP/OP $477.00 $352.98 $0.00 $381.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.50 $377.78 $381.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011092 EAP Custom 27011092 Coil 710-1000 Micron (2vl/bx) BOTH IP/OP $477.00 $352.98 $0.00 $381.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.50 $377.78 $381.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011093 EAP Custom 27011093 Coil Pusher 16 BOTH IP/OP $544.00 $402.56 $0.00 $435.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $403.76 $403.76 $419.32 $0.00 $113.37 $0.00 $0.00 $0.00 $0.00 $272.00 $430.85 $435.20 $0.00 $353.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011094 EAP Custom 27011094 Coil Pusher Trupush BOTH IP/OP "$1,228.00 " $908.72 $0.00 $982.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $911.42 $911.42 $946.54 $0.00 $255.92 $0.00 $0.00 $0.00 $0.00 $614.00 $972.58 $982.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011095 EAP Custom 27011095 Connector Ureteral Catheter BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011096 EAP Custom 27011096 Connectory Tuohy BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011097 EAP Custom 27011097 Contra 2 BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011098 EAP Custom 27011098 Contra Flush Catheter BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $0.00 $0.00 $0.00 $99.50 $157.61 $159.20 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011099 EAP Custom 27011099 Cope Suture Anchor Set BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $0.00 $0.00 $0.00 $99.50 $157.61 $159.20 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011105 EAP Custom 27011105 Embolization 38-4-3 BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.99 $143.99 $149.54 $0.00 $40.43 $0.00 $0.00 $0.00 $0.00 $97.00 $153.65 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011106 EAP Custom 27011106 Embolization 38-8-15 BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.99 $143.99 $149.54 $0.00 $40.43 $0.00 $0.00 $0.00 $0.00 $97.00 $153.65 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011107 EAP Custom 27011107 Embolization Coil 38-5-5 BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.99 $143.99 $149.54 $0.00 $40.43 $0.00 $0.00 $0.00 $0.00 $97.00 $153.65 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011108 EAP Custom 27011108 Embolization Coils 38-2-3 BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.99 $143.99 $149.54 $0.00 $40.43 $0.00 $0.00 $0.00 $0.00 $97.00 $153.65 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011109 EAP Custom 27011109 Embolization Coils 38-4-2 BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.99 $143.99 $149.54 $0.00 $40.43 $0.00 $0.00 $0.00 $0.00 $97.00 $153.65 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011110 EAP Custom 27011110 Embolization Coils 38-5-10 BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.99 $143.99 $149.54 $0.00 $40.43 $0.00 $0.00 $0.00 $0.00 $97.00 $153.65 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011111 EAP Custom 27011111 Face Shields BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011112 EAP Custom 27011112 Filling Station Plus (neuro) BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011113 EAP Custom 27011113 Filter Jugular G-2 BOTH IP/OP "$4,337.00 " "$3,209.38" $0.00 "$3,469.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,218.92" "$3,218.92" "$3,342.96" $0.00 $903.83 $0.00 $0.00 $0.00 $0.00 "$2,168.50" "$3,434.90" "$3,469.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011114 EAP Custom 27011114 Flo-switch Hp BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.04 $282.04 $292.90 $0.00 $79.19 $0.00 $0.00 $0.00 $0.00 $190.00 $300.96 $304.00 $0.00 $247.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011120 EAP Custom 27011120 Forearm Based Outrigger BOTH IP/OP $172.00 $127.28 $0.00 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.66 $127.66 $132.58 $0.00 $35.84 $0.00 $0.00 $0.00 $0.00 $86.00 $136.22 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011121 EAP Custom 27011121 Gtgw.180cm-45deg Angle BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $325.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011122 EAP Custom 27011122 Hemostasis V-pad BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011124 EAP Custom 27011124 Igtcfs-65-fem Celect Perm Cook BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 $0.00 $0.00 $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011125 EAP HCPCS C1880 Igtcfs-65-jugcelet Perm Cook BOTH IP/OP "$4,536.00 " "$3,356.64" $0.00 "$3,628.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,268.00" "$3,592.51" "$3,628.80" $0.00 $0.00 $0.00 $709.88 $0.00 $0.00 $722.13 $0.00 $0.00 $0.00 $0.00 $0.00 27011126 EAP Custom 27011126 Inflation Device Monarch-25 BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011127 EAP Custom 27011127 Introducer Mpis-401 BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011128 EAP Custom 27011128 Introducer Pinnacle 5fr 10cm BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $0.00 $0.00 $0.00 $33.50 $53.06 $53.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011129 EAP Custom 27011129 Jcd 10.0-38-20 BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011130 EAP Custom 27011130 Jcd 12.0-38-20 BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011131 EAP Custom 27011131 Jcd 14.0-38-20 BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011132 EAP Custom 27011132 Jcd 16.0-38-20 BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011133 EAP Custom 27011133 Jcd 4.0-25-20 BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011134 EAP Custom 27011134 Jcd 5.0-38-20 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011135 EAP Custom 27011135 Jcd 6.0-38-20 BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011136 EAP Custom 27011136 Jcd 7.0-38-20 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011137 EAP Custom 27011137 Jcd 8.0-38-20 BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011138 EAP Custom 27011138 Jcd 9.0-38-20 BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011139 EAP Custom 27011139 Jcd-20.0-38-20 Dilator BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011140 EAP Custom 27011140 Jcd-22.0-38-20 Dilator BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $34.69 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011141 EAP Custom 27011141 Jcd-24.0-38-20 Dilator BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $34.69 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011142 EAP Custom 27011142 Jcd-d18.0-38-20 Dilator BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011143 EAP Custom 27011143 Kinair Iii W/o Scale BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $142.50 $147.99 $0.00 $40.01 $0.00 $0.00 $0.00 $0.00 $96.00 $152.06 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011148 EAP Custom 27011148 Kit Angio Saftey With J Wire BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.11 $132.11 $137.20 $0.00 $37.10 $0.00 $0.00 $0.00 $0.00 $89.00 $140.98 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011149 EAP Custom 27011149 Kit Fallopian Tube BOTH IP/OP $349.00 $258.26 $0.00 $279.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.03 $259.03 $269.01 $0.00 $72.73 $0.00 $0.00 $0.00 $0.00 $174.50 $276.41 $279.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011150 EAP Custom 27011150 Kit Gastrostomy 18fr BOTH IP/OP $541.00 $400.34 $0.00 $432.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $401.53 $401.53 $417.00 $0.00 $112.74 $0.00 $0.00 $0.00 $0.00 $270.50 $428.47 $432.80 $0.00 $351.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011151 EAP Custom 27011151 Kit Mahurkar 12f Triple Lumen BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011152 EAP Custom 27011152 Kit Pressure Monitoring T BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $35.50 $56.23 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011153 EAP Custom 27011153 Kit Pressure Monitoring T BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011154 EAP Custom 27011154 Kit Triple Lumen Catheter BOTH IP/OP $726.00 $537.24 $0.00 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $538.84 $538.84 $559.60 $0.00 $151.30 $0.00 $0.00 $0.00 $0.00 $363.00 $574.99 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011156 EAP Custom 27011156 Lancet Grady Orange BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011157 EAP Custom 27011157 Line Connecting 36 Hp BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011158 EAP Custom 27011158 Line Connecting 48 Hp BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011160 EAP Custom 27011160 Mask Sub-micron Small BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011161 EAP Custom 27011161 Med/surg Semi Supplies BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011162 EAP Custom 27011162 Microsphere Embogold 500-700 BOTH IP/OP $734.00 $543.16 $0.00 $587.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $544.77 $544.77 $565.77 $0.00 $152.97 $0.00 $0.00 $0.00 $0.00 $367.00 $581.33 $587.20 $0.00 $477.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011163 EAP Custom 27011163 Microsphere Embogold 700-900 BOTH IP/OP $734.00 $543.16 $0.00 $587.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $544.77 $544.77 $565.77 $0.00 $152.97 $0.00 $0.00 $0.00 $0.00 $367.00 $581.33 $587.20 $0.00 $477.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011164 EAP Custom 27011164 Microsphere Embogold 900-1200 BOTH IP/OP "$3,669.00 " "$2,715.06" $0.00 "$2,935.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,834.50" "$2,905.85" "$2,935.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011165 EAP Custom 27011165 Needle Chiba 22ga X 15cm BOTH IP/OP $82.00 $60.68 $0.00 $65.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.86 $60.86 $63.21 $0.00 $17.09 $0.00 $0.00 $0.00 $0.00 $41.00 $64.94 $65.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011166 EAP Custom 27011166 Needle Hypodermic Sterile BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011167 EAP Custom 27011167 Needle Hypodermic Sterile BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011168 EAP Custom 27011168 Needle Port-cath 20ga X 1 BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011169 EAP Custom 27011169 Needle Port-cath 20ga X 1 BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011172 EAP Custom 27011172 Olcott Torque Device BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $42.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011176 EAP Custom 27011176 Perc Gastrostomy Set BOTH IP/OP "$1,079.00 " $798.46 $0.00 $863.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $800.83 $800.83 $831.69 $0.00 $224.86 $0.00 $0.00 $0.00 $0.00 $539.50 $854.57 $863.20 $0.00 $701.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011177 EAP Custom 27011177 Polar Cath Inflation Unit BOTH IP/OP "$7,912.00 " "$5,854.88" $0.00 "$6,329.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,098.57" $0.00 "$1,648.86" $0.00 $0.00 $0.00 $0.00 "$3,956.00" "$6,266.30" "$6,329.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011178 EAP Custom 27011178 Port Peritoneal/drain/ascites BOTH IP/OP "$1,070.00 " $791.80 $0.00 $856.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $794.15 $794.15 $824.76 $0.00 $222.99 $0.00 $0.00 $0.00 $0.00 $535.00 $847.44 $856.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011179 EAP Custom 27011179 Pressure Tubing BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.92 $411.92 $427.79 $0.00 $115.66 $0.00 $0.00 $0.00 $0.00 $277.50 $439.56 $444.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011181 EAP Custom 27011181 Rapad Shield BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011182 EAP Custom 27011182 Recovery Cone Removal System BOTH IP/OP "$1,985.00 " "$1,468.90" $0.00 "$1,588.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,473.27" "$1,473.27" "$1,530.04" $0.00 $413.67 $0.00 $0.00 $0.00 $0.00 $992.50 "$1,572.12" "$1,588.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011183 EAP Custom 27011183 Retention Device 10fr BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011184 EAP Custom 27011184 Retention Device 12fr BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011185 EAP Custom 27011185 Retention Device 8fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011190 EAP Custom 27011190 Ring Transjugular Set BOTH IP/OP "$1,404.00 " "$1,038.96" $0.00 "$1,123.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,042.05" "$1,042.05" "$1,082.20" $0.00 $292.59 $0.00 $0.00 $0.00 $0.00 $702.00 "$1,111.97" "$1,123.20" $0.00 $912.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011194 EAP Custom 27011194 Safety Angio Kit BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.26 $94.26 $97.89 $0.00 $26.47 $0.00 $0.00 $0.00 $0.00 $63.50 $100.58 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011195 EAP Custom 27011195 Safety Peg Kit Moni Bolster BOTH IP/OP "$1,497.00 " "$1,107.78" $0.00 "$1,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,111.07" "$1,111.07" "$1,153.89" $0.00 $311.97 $0.00 $0.00 $0.00 $0.00 $748.50 "$1,185.62" "$1,197.60" $0.00 $973.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011196 EAP Custom 27011196 Scaple Surg W/handle Attached BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011197 EAP Custom 27011197 Set Blood Administration BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011198 EAP Custom 27011198 Set Blood Adminstration BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011199 EAP Custom 27011199 Set Blood Adminstration BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011200 EAP Custom 27011200 Set Liver Biopsy Labs-100 BOTH IP/OP "$1,409.00 " "$1,042.66" $0.00 "$1,127.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,045.76" "$1,045.76" "$1,086.06" $0.00 $293.64 $0.00 $0.00 $0.00 $0.00 $704.50 "$1,115.93" "$1,127.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011201 EAP Custom 27011201 Set Mediport Infusion W/i BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011202 EAP Custom 27011202 Set Neff Perc Access BOTH IP/OP $244.00 $180.56 $0.00 $195.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.10 $181.10 $188.08 $0.00 $50.85 $0.00 $0.00 $0.00 $0.00 $122.00 $193.25 $195.20 $0.00 $158.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011203 EAP Custom 27011203 Set Pca Mini-bore W/int A BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011204 EAP Custom 27011204 Set Scalp Vein Infusion 21 G BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011207 EAP Custom 27011207 Set Scalp Vein Infusion 2 BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011208 EAP Custom 27011208 Set Secondary Piggy Back BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011209 EAP Custom 27011209 Set Urinary Drain W/conta BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011212 EAP Custom 27011212 Simon-nitinol Vena Cava Filte BOTH IP/OP "$3,605.00 " "$2,667.70" $0.00 "$2,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,675.63" "$2,675.63" "$2,778.73" $0.00 $751.28 $0.00 $0.00 $0.00 $0.00 "$1,802.50" "$2,855.16" "$2,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011213 EAP Custom 27011213 Simon-nitinol Vena Filter An BOTH IP/OP "$3,085.00 " "$2,282.90" $0.00 "$2,468.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,289.69" "$2,289.69" "$2,377.92" $0.00 $642.91 $0.00 $0.00 $0.00 $0.00 "$1,542.50" "$2,443.32" "$2,468.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011214 EAP Custom 27011214 Skater Introducer System BOTH IP/OP $254.00 $187.96 $0.00 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.52 $188.52 $195.78 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $127.00 $201.17 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011215 EAP HCPCS C1729 Skater Nephro Cath 8fr X 35cm BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $156.38 $156.38 $0.00 $0.00 $0.00 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $187.20 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 27011216 EAP Custom 27011216 Snare Amplatz 10mm BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $0.00 $0.00 $0.00 $458.00 $725.47 $732.80 $0.00 $595.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011217 EAP Custom 27011217 Snare Amplatz 5mm BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $0.00 $0.00 $0.00 $458.00 $725.47 $732.80 $0.00 $595.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011226 EAP Custom 27011226 Sponge Gelfoam Gelatin BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $65.52 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011227 EAP HCPCS C1876 Stent Vascular Covera Covered 10mm X 60mm 80cm Delivery BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 27011228 EAP Custom 27011228 Stent Luminex 12x60 BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 $0.00 $0.00 $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011229 EAP Custom 27011229 Stent Luminexx 7x30 BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 $0.00 $0.00 $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011230 EAP Custom 27011230 Stent Luminexx 7x40 BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 $0.00 $0.00 $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011231 EAP Custom 27011231 Stent Luminexx 8x40 BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 $0.00 $0.00 $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011232 EAP Custom 27011232 Stent Luminexx Stent 8x30 BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 $0.00 $0.00 $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011233 EAP Custom 27011233 Stiff Micropunture 5fr BOTH IP/OP $153.00 $113.22 $0.00 $122.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.50 $121.18 $122.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011234 EAP Custom 27011234 Stopcock 1-way Hp BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011236 EAP Custom 27011236 Stopcock 3-way Hp BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011237 EAP Custom 27011237 "Supplies, Non-sterile Penumbra" BOTH IP/OP $66.00 $48.84 $0.00 $52.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.99 $48.99 $50.87 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $33.00 $52.27 $52.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011241 EAP Custom 27011241 Threapulse Ii BOTH IP/OP $581.00 $429.94 $0.00 $464.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $431.22 $431.22 $447.83 $0.00 $121.08 $0.00 $0.00 $0.00 $0.00 $290.50 $460.15 $464.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011242 EAP Custom 27011242 Tray Catheter Urethral 14 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011243 EAP Custom 27011243 Tray Foley Perconnected 1 BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011244 EAP Custom 27011244 Tray Foley Perconnected 1 BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011245 EAP Custom 27011245 Tray Foley Preconnected 1 BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011246 EAP Custom 27011246 Tray Foley Preconnected 1 BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011252 EAP Custom 27011252 Triple Lumen Catheter Size 24 BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011253 EAP Custom 27011253 Tube Feeding Ng 8fr 43in En BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $0.00 $0.00 $0.00 $34.00 $53.86 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011254 EAP Custom 27011254 Tube Feeding Ng 8fr 36in Entr BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011255 EAP Custom 27011255 Tube Gastrostomy 18fr BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $61.66 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011256 EAP Custom 27011256 Tube Gastrostomy 22fr BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.41 $56.41 $58.58 $0.00 $15.84 $0.00 $0.00 $0.00 $0.00 $38.00 $60.19 $60.80 $0.00 $49.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011257 EAP Custom 27011257 Tube Jejunal Feeding 18 Fr O.d BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011258 EAP Custom 27011258 Tube Jejunostomy Feed 14 Fr BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011259 EAP Custom 27011259 Tube Salem Silicone Size BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011260 EAP Custom 27011260 Tube Salem Sump 48 Lengt BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011261 EAP Custom 27011261 Tube Tj Feeding 18 Fr 45cm End BOTH IP/OP $651.00 $481.74 $0.00 $520.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.17 $483.17 $501.79 $0.00 $135.67 $0.00 $0.00 $0.00 $0.00 $325.50 $515.59 $520.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011262 EAP Custom 27011262 Tube Tj Feeding 22 Fr 45cm End BOTH IP/OP $651.00 $481.74 $0.00 $520.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.17 $483.17 $501.79 $0.00 $135.67 $0.00 $0.00 $0.00 $0.00 $325.50 $515.59 $520.80 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011263 EAP Custom 27011263 Tubes Extension Plain Pla BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011265 EAP Custom 27011265 Tubes Extension Plain Pla BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011266 EAP Custom 27011266 Tubes Salem Sump 48 Leng BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011267 EAP Custom 27011267 Ultrasound Probe Covers BOTH IP/OP $46.00 $34.04 $0.00 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.14 $34.14 $35.46 $0.00 $9.59 $0.00 $0.00 $0.00 $0.00 $23.00 $36.43 $36.80 $0.00 $29.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011268 EAP Custom 27011268 Valve Reflux BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011269 EAP Custom 27011269 Valve Reflux BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011270 EAP Custom 27011270 .014 Nitrex Guidewire BOTH IP/OP "$1,219.00 " $902.06 $0.00 $975.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $904.74 $904.74 $939.61 $0.00 $254.04 $0.00 $0.00 $0.00 $0.00 $609.50 $965.45 $975.20 $0.00 $792.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011301 EAP Custom 27011301 Drsg Anti Sft Sil 8x20 20x50cm BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $0.00 $0.00 $0.00 $124.00 $196.42 $198.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011302 EAP Custom 27011302 Drsg Anti Sft Sil 8x20 20x50cm BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $0.00 $0.00 $0.00 $124.00 $196.42 $198.40 $0.00 $161.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011304 EAP Custom 27011304 Blood Administration Set BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $85.56 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011305 EAP Custom 27011305 Drsng Anti Sft Sil 6x6 15x15cm BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011306 EAP Custom 27011306 Drsng Anti Sft Sil 6x6 15x15cm BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011308 EAP Custom 27011308 Drsng Anti Sft Sil 4x4 10x10cm BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011309 EAP Custom 27011309 Drsng Anti Sft Sil 4x4 10x10cm BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $18.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011310 EAP HCPCS C1769 Volcano Combowire BOTH IP/OP "$3,669.00 " "$2,715.06" $0.00 "$2,935.20" "$1,992.27" "$1,992.27" $0.00 $0.00 $0.00 $764.71 "$2,723.13" "$2,723.13" "$2,828.07" $0.00 $764.62 $0.00 "$2,170.21" "$2,170.21" $0.00 "$1,834.50" "$2,905.85" "$2,935.20" $0.00 $0.00 $0.00 $574.20 $0.00 $0.00 $584.10 $0.00 $0.00 $0.00 $0.00 $0.00 27011320 EAP Custom 27011320 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011323 EAP Custom 27011323 Jcd 9.0-38-20 BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011324 EAP Custom 27011324 Jcd 6.0-38-20 BOTH IP/OP $167.00 $123.58 $0.00 $133.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $132.26 $133.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011325 EAP Custom 27011325 Tube Salem Sump 48 Lengt BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011326 EAP Custom 27011326 Tubes Salem Sump 48 Leng BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011327 EAP Custom 27011327 Jcd 9.0-38-20 BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011328 EAP Custom 27011328 Jcd 6.0-38-20 BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011401 EAP Custom 27011401 Super Arrow Flex Introducer - BOTH IP/OP $251.00 $185.74 $0.00 $200.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.29 $186.29 $193.47 $0.00 $52.31 $0.00 $0.00 $0.00 $0.00 $125.50 $198.79 $200.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011410 EAP Custom 27011410 Tube Trach #8 Dct BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.23 $97.23 $100.97 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011411 EAP Custom 27011411 Tube Trache 8-dcfs BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $97.12 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011413 EAP Custom 27011413 Bag Resusitator Adult BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011421 EAP Custom 27011421 Blade On Titanium Lopro S3 BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.51 $70.51 $73.23 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011422 EAP Custom 27011422 Blade On Titanium Lopro S4 BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.51 $70.51 $73.23 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011423 EAP Custom 27011423 Kit 135cm 2.7fr 20mm Img 1 Syr Rapex Tip Radiopq BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 $0.00 $0.00 $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011425 EAP Custom 27011425 Mic Transgastric Jejunal Feeding Kit 18f 45cm BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $325.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011426 EAP HCPCS C1729 Catheter Urethral 16fr Foley 2 BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.00 $177.41 $179.20 $0.00 $0.00 $0.00 $35.06 $0.00 $0.00 $35.66 $0.00 $0.00 $0.00 $0.00 $0.00 27011427 EAP HCPCS A4649 Medihoney Dressing 1.5oz Tube BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $4.38 $0.00 $0.00 $4.46 $0.00 $0.00 $0.00 $0.00 $0.00 27011428 EAP Tube Gstrm 12fr 10cm 5-7ml Entuit Bln Rtnt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011429 EAP Tube Fd Std 14fr 10cm 5ml Entuit Thrive Bln Rtnt Sm Gstrm BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011430 EAP Tube Fd Std 16fr 10cm 5ml Entuit Thrive Bln Rtnt Med Gstrm BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011431 EAP Tube Gstrm Std 18fr 10cm 5ml 60ml Entuit Thrive Bln Rtnt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011432 EAP Tube Fd Std 20fr 10cm 20ml Entuit Thrive Bln Rtnt Lg Gstrm BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011433 EAP Tube Fd Std 22fr 10cm 20ml Entuit Thrive Bln Rtnt Lg Gstrm BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011434 EAP Tube Fd Std 24fr 10cm 20ml Entuit Thrive Bln Rtnt Lg Gstrm BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011435 EAP Kit Tracheostomy 12.3mm 9mm Complete Set Inner Cannu BOTH IP/OP "$1,255.00 " $928.70 $0.00 "$1,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $931.46 $931.46 $967.35 $0.00 $261.54 $0.00 $0.00 $0.00 $0.00 $627.50 $993.96 "$1,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011436 EAP Kit Crntmy 25ga 5/8in Strl Rzr Ndl Drp BOTH IP/OP $701.00 $518.74 $0.00 $560.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.50 $555.19 $560.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27011437 EAP Custom 27011437 Blanket Wrm 84x36in Clr Strl Lf 24x48in 3m Br Hgr Full Acc BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27100021 EAP Custom 27100021 Pad Gel Hypo-hyperthermia Large BOTH IP/OP "$2,481.00 " "$1,835.94" $0.00 "$1,984.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,841.40" "$1,841.40" "$1,912.35" $0.00 $517.04 $0.00 $0.00 $0.00 $0.00 "$1,240.50" "$1,964.95" "$1,984.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27100022 EAP HCPCS A4467 POSTERIOR ELBOW SPLINT BOTH IP/OP $112.00 $82.88 $0.00 $89.60 $60.82 $60.82 $0.00 $0.00 $0.00 $0.00 $83.13 $83.13 $86.33 $0.00 $23.34 $0.00 $0.00 $0.00 $0.00 $56.00 $88.70 $89.60 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27100023 EAP Custom 27100023 Mölnlycke Z-flo Fluidized Positioner Pad BOTH IP/OP $122.00 $90.28 $0.00 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.55 $90.55 $94.04 $0.00 $25.42 $0.00 $0.00 $0.00 $0.00 $61.00 $96.62 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27100031 EAP Custom 27100031 Resuscitator Manual Medium 10f BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27100040 EAP Sup Ortho Universal Abd Binder Velcro Closure BOTH IP/OP $538.00 $398.12 $0.00 $430.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $399.30 $399.30 $414.69 $0.00 $112.12 $0.00 $0.00 $0.00 $0.00 $269.00 $426.10 $430.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200003 EAP Custom 27200003 Chest Unit Drainage Pleur BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.41 $56.41 $58.58 $0.00 $15.84 $0.00 $0.00 $0.00 $0.00 $38.00 $60.19 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200008 EAP HCPCS C1769 .014 Nitrex Guidewire BOTH IP/OP "$1,295.00 " $958.30 $0.00 "$1,036.00" $703.19 $703.19 $0.00 $0.00 $0.00 $269.91 $961.15 $961.15 $998.19 $0.00 $269.88 $0.00 $765.99 $765.99 $0.00 $647.50 "$1,025.64" "$1,036.00" $0.00 $0.00 $0.00 $202.67 $0.00 $0.00 $206.16 $0.00 $0.00 $0.00 $0.00 $0.00 27200011 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $11.70 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27200019 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $3.26 $3.26 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 27200021 EAP HCPCS C1729 Catheter Foley 30cc 28fr BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $19.55 $19.55 $0.00 $0.00 $0.00 $7.50 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $21.29 $21.29 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $5.63 $0.00 $0.00 $5.73 $0.00 $0.00 $0.00 $0.00 $0.00 27200024 EAP HCPCS C1729 Catheter Foley 3cc 10 Fr BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $18.46 $18.46 $0.00 $0.00 $0.00 $7.09 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $0.00 27200025 EAP HCPCS C1729 Catheter Foley 5cc 12fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27200026 EAP Custom 27200026 Dress Sofsorb Absorb Buttoc Sm BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200027 EAP Custom 27200027 Dress Sofsorb Absorb Butto Lg BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $0.00 $0.00 $0.00 $48.50 $76.82 $77.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200028 EAP Custom 27200028 Dress Sofsorb Absorb Chest Ssm BOTH IP/OP $41.00 $30.34 $0.00 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.43 $30.43 $31.60 $0.00 $8.54 $0.00 $0.00 $0.00 $0.00 $20.50 $32.47 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200029 EAP Custom 27200029 Dress Sofsorb Absors Chest Ilg BOTH IP/OP $41.00 $30.34 $0.00 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.43 $30.43 $31.60 $0.00 $8.54 $0.00 $0.00 $0.00 $0.00 $20.50 $32.47 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200030 EAP Custom 27200030 Dress Sofsorb Absorb Xl Chest BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200031 EAP Custom 27200031 Dressing Leg/hip Adult BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.57 $64.57 $67.06 $0.00 $18.13 $0.00 $0.00 $0.00 $0.00 $43.50 $68.90 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200032 EAP Custom 27200032 Dressing Burn Gauze 17 Ply 36' BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200033 EAP HCPCS C1751 Kit Cath Triple Lumen 5.5 Pedi BOTH IP/OP $159.00 $117.66 $0.00 $127.20 $86.34 $86.34 $0.00 $0.00 $0.00 $33.14 $118.01 $118.01 $122.56 $0.00 $33.14 $0.00 $94.05 $94.05 $0.00 $79.50 $125.93 $127.20 $0.00 $0.00 $0.00 $24.88 $0.00 $0.00 $25.31 $0.00 $0.00 $0.00 $0.00 $0.00 27200035 EAP HCPCS C1751 Femoral Arterial Line Cath Kit BOTH IP/OP $873.00 $646.02 $0.00 $698.40 $474.04 $474.04 $0.00 $0.00 $0.00 $181.96 $647.94 $647.94 $672.91 $0.00 $181.93 $0.00 $516.38 $516.38 $0.00 $436.50 $691.42 $698.40 $0.00 $0.00 $0.00 $136.62 $0.00 $0.00 $138.98 $0.00 $0.00 $0.00 $0.00 $0.00 27200040 EAP Custom 27200040 Kit Transducer Monitoring BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.62 $107.62 $111.77 $0.00 $30.22 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200041 EAP Custom 27200041 Kit Pressure Monitoring BOTH IP/OP $108.00 $79.92 $0.00 $86.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $0.00 $0.00 $0.00 $54.00 $85.54 $86.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200043 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $3.26 $3.26 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 27200045 EAP Custom 27200045 Paracentesis Tray BOTH IP/OP $214.00 $158.36 $0.00 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.83 $158.83 $164.95 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $107.00 $169.49 $171.20 $0.00 $139.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200047 EAP Custom 27200047 Biliary Plastic Stents BOTH IP/OP "$1,091.00 " $807.34 $0.00 $872.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $809.74 $809.74 $840.94 $0.00 $227.36 $0.00 $0.00 $0.00 $0.00 $545.50 $864.07 $872.80 $0.00 $709.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200048 EAP HCPCS C1769 Hydratomes Rx Cannulating Sphi BOTH IP/OP "$3,556.00 " "$2,631.44" $0.00 "$2,844.80" "$1,930.91" "$1,930.91" $0.00 $0.00 $0.00 $741.16 "$2,639.26" "$2,639.26" "$2,740.96" $0.00 $741.07 $0.00 "$2,103.37" "$2,103.37" $0.00 "$1,778.00" "$2,816.35" "$2,844.80" $0.00 $0.00 $0.00 $556.51 $0.00 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 27200049 EAP HCPCS C1769 Jagtomes Rx Cannulating Sphinc BOTH IP/OP "$1,255.00 " $928.70 $0.00 "$1,004.00" $681.47 $681.47 $0.00 $0.00 $0.00 $261.57 $931.46 $931.46 $967.35 $0.00 $261.54 $0.00 $742.33 $742.33 $0.00 $627.50 $993.96 "$1,004.00" $0.00 $815.75 $0.00 $196.41 $0.00 $0.00 $199.80 $0.00 $0.00 $0.00 $0.00 $0.00 27200050 EAP Custom 27200050 Extractor Balloon BOTH IP/OP "$1,388.00 " "$1,027.12" $0.00 "$1,110.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,030.17" "$1,030.17" "$1,069.87" $0.00 $289.26 $0.00 $0.00 $0.00 $0.00 $694.00 "$1,099.30" "$1,110.40" $0.00 $902.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200051 EAP Custom 27200051 Trapezoid Retrieval Baskets BOTH IP/OP "$2,263.00 " "$1,674.62" $0.00 "$1,810.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,679.60" "$1,679.60" "$1,744.32" $0.00 $471.61 $0.00 $0.00 $0.00 $0.00 "$1,131.50" "$1,792.30" "$1,810.40" $0.00 "$1,470.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200052 EAP Custom 27200052 Endoprosthesis Metal Stent BOTH IP/OP "$9,693.00 " "$7,172.82" $0.00 "$7,754.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,471.36" $0.00 "$2,020.02" $0.00 $0.00 $0.00 $0.00 "$4,846.50" "$7,676.86" "$7,754.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200053 EAP Custom 27200053 Esophageal Stent BOTH IP/OP "$11,672.00 " "$8,637.28" $0.00 "$9,337.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,996.78" $0.00 "$2,432.44" $0.00 $0.00 $0.00 $0.00 "$5,836.00" "$9,244.22" "$9,337.60" $0.00 "$7,586.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200054 EAP Custom 27200054 Colonic And Duodenal Stent BOTH IP/OP "$16,179.00 " "$11,972.46" $0.00 "$12,943.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,470.77" $0.00 "$3,371.70" $0.00 $0.00 $0.00 $0.00 "$8,089.50" "$12,813.77" "$12,943.20" $0.00 "$10,516.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200055 EAP HCPCS C1726 Cre Balloons BOTH IP/OP "$1,523.00 " "$1,127.02" $0.00 "$1,218.40" $826.99 $826.99 $0.00 $0.00 $0.00 $317.43 "$1,130.37" "$1,130.37" "$1,173.93" $0.00 $317.39 $0.00 $900.85 $900.85 $0.00 $761.50 "$1,206.22" "$1,218.40" $0.00 $989.95 $0.00 $238.35 $0.00 $0.00 $242.46 $0.00 $0.00 $0.00 $0.00 $0.00 27200056 EAP Custom 27200056 Esophageal/pyloric Balloon Dil BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 "$1,137.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200057 EAP Custom 27200057 Esophageal/pyloric/colonic Ba BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 "$1,137.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200058 EAP Custom 27200058 O2 Supply-each BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200060 EAP Custom 27200060 Venous Port - Maintenance BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.56 $136.56 $141.83 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $119.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200061 EAP Custom 27200061 Dressing BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200062 EAP Custom 27200062 "Dressing, Burn Supplies" BOTH IP/OP $206.00 $152.44 $0.00 $164.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.89 $152.89 $158.78 $0.00 $42.93 $0.00 $0.00 $0.00 $0.00 $103.00 $163.15 $164.80 $0.00 $133.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200063 EAP Custom 27200063 Iv Start Supply BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.22 $169.22 $175.74 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.00 $180.58 $182.40 $0.00 $148.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200064 EAP Custom 27200064 "Dressing, Burn Supplies" BOTH IP/OP $193.00 $142.82 $0.00 $154.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.24 $143.24 $148.76 $0.00 $40.22 $0.00 $0.00 $0.00 $0.00 $96.50 $152.86 $154.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200065 EAP Custom 27200065 Splint Supply BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200066 EAP Custom 27200066 Nephrostomy Bag BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.92 $221.92 $230.47 $0.00 $62.31 $0.00 $0.00 $0.00 $0.00 $149.50 $236.81 $239.20 $0.00 $194.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200067 EAP Custom 27200067 Dressing Change BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200068 EAP HCPCS C1729 Catheter Foley BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $18.46 $18.46 $0.00 $0.00 $0.00 $7.09 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $5.32 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $0.00 27200069 EAP Custom 27200069 Leg Bag BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200070 EAP Custom 27200070 Urinary Drainage Bag BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200074 EAP Custom 27200074 Acticoat Dressing BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $242.80 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $204.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200075 EAP Custom 27200075 Feeding/ng Tube BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200076 EAP Custom 27200076 Triple Lumen Cath BOTH IP/OP $222.00 $164.28 $0.00 $177.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.77 $164.77 $171.12 $0.00 $46.26 $0.00 $0.00 $0.00 $0.00 $111.00 $175.82 $177.60 $0.00 $144.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200077 EAP Custom 27200077 Transvenous Pacing Electrode BOTH IP/OP $389.00 $287.86 $0.00 $311.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $288.72 $288.72 $299.84 $0.00 $81.07 $0.00 $0.00 $0.00 $0.00 $194.50 $308.09 $311.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200080 EAP Custom 27200080 "Injection, Iv, Antibiotic" BOTH IP/OP $214.00 $158.36 $0.00 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.83 $158.83 $164.95 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $107.00 $169.49 $171.20 $0.00 $139.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200081 EAP Custom 27200081 "Steroid Injection, Iv Supply" BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $142.50 $147.99 $0.00 $40.01 $0.00 $0.00 $0.00 $0.00 $96.00 $152.06 $153.60 $0.00 $124.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200082 EAP Custom 27200082 "Iv Start, Supply" BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.00 $180.58 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200084 EAP Custom 27200084 Emerg Infus Catheter BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200085 EAP Custom 27200085 "Ett, Laser" BOTH IP/OP $897.00 $663.78 $0.00 $717.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $665.75 $665.75 $691.41 $0.00 $186.93 $0.00 $0.00 $0.00 $0.00 $448.50 $710.42 $717.60 $0.00 $583.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200086 EAP Custom 27200086 "Ett, Rae" BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $0.00 $0.00 $0.00 $59.00 $93.46 $94.40 $0.00 $76.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200087 EAP Custom 27200087 "Ett, Wire Reinf" BOTH IP/OP $362.00 $267.88 $0.00 $289.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.68 $268.68 $279.03 $0.00 $75.44 $0.00 $0.00 $0.00 $0.00 $181.00 $286.70 $289.60 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200088 EAP Custom 27200088 "Ett, Endotrol/mlt" BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $89.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200090 EAP Custom 27200090 "Cvp Kit, Single Lumen" BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $154.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200091 EAP HCPCS C1756 Swan Paceport Cath BOTH IP/OP $666.00 $492.84 $0.00 $532.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $494.31 $494.31 $513.35 $0.00 $138.79 $0.00 $0.00 $0.00 $0.00 $333.00 $527.47 $532.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200092 EAP HCPCS C1751 Cvp Kit Triple Lumen BOTH IP/OP $569.00 $421.06 $0.00 $455.20 $308.97 $308.97 $0.00 $0.00 $0.00 $118.59 $422.31 $422.31 $438.59 $0.00 $118.58 $0.00 $336.56 $336.56 $0.00 $284.50 $450.65 $455.20 $0.00 $369.85 $0.00 $89.05 $0.00 $0.00 $90.58 $0.00 $0.00 $0.00 $0.00 $0.00 27200093 EAP HCPCS C1756 Swan Ganz Cath-bipolar Pacing BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.20 $909.20 $944.23 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200094 EAP HCPCS C1756 Swan Pacing Td BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" "$1,856.86" $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200096 EAP Custom 27200096 Adult Iv Set-up BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200097 EAP Custom 27200097 "Ett, Endotrol/mlt" BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200098 EAP Custom 27200098 "Cvp Kit, Single Lumen" BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200099 EAP HCPCS C1756 Swan Paceport Cath BOTH IP/OP $634.00 $469.16 $0.00 $507.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $470.55 $470.55 $488.69 $0.00 $132.13 $0.00 $0.00 $0.00 $0.00 $317.00 $502.13 $507.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200100 EAP Custom 27200100 Cvp Kit Triple Lumen BOTH IP/OP $141.00 $104.34 $0.00 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.65 $104.65 $108.68 $0.00 $29.38 $0.00 $0.00 $0.00 $0.00 $70.50 $111.67 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200101 EAP HCPCS C1756 Swan Bipolar BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.20 $909.20 $944.23 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200102 EAP HCPCS C1756 Swan Pacing Td BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" "$1,856.86" $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200104 EAP HCPCS C1729 Catheter Foley 30cc 28fr BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $20.09 $20.09 $0.00 $0.00 $0.00 $7.71 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $21.89 $21.89 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 27200107 EAP HCPCS L8680 Implt Neurostim Elctr Each BOTH IP/OP "$1,605.00 " "$1,187.70" $0.00 "$1,284.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,191.23" "$1,191.23" "$1,237.13" $0.00 $334.48 $0.00 $0.00 $0.00 $0.00 $802.50 "$1,271.16" "$1,284.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200108 EAP Custom 27200108 Regional Nerve Block Tray BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $0.00 $0.00 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200109 EAP Custom 27200109 Epidural Tray BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200110 EAP Custom 27200110 Insulated Block Needle BOTH IP/OP $46.00 $34.04 $0.00 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.14 $34.14 $35.46 $0.00 $9.59 $0.00 $0.00 $0.00 $0.00 $23.00 $36.43 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200111 EAP Custom 27200111 O2 Therapy-ea 8 Hrs BOTH IP/OP $296.00 $219.04 $0.00 $236.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.69 $219.69 $228.16 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $148.00 $234.43 $236.80 $0.00 $192.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200113 EAP Custom 27200113 Peak Flow Meter BOTH IP/OP $487.00 $360.38 $0.00 $389.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.45 $361.45 $375.38 $0.00 $101.49 $0.00 $0.00 $0.00 $0.00 $243.50 $385.70 $389.60 $0.00 $316.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200114 EAP Custom 27200114 Heart Nebulizer BOTH IP/OP $440.00 $325.60 $0.00 $352.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.57 $326.57 $339.15 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $220.00 $348.48 $352.00 $0.00 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200115 EAP Custom 27200115 Mini Heart BOTH IP/OP $424.00 $313.76 $0.00 $339.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $314.69 $314.69 $326.82 $0.00 $88.36 $0.00 $0.00 $0.00 $0.00 $212.00 $335.81 $339.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200116 EAP Custom 27200116 Mdi Spacer BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $142.50 $147.99 $0.00 $40.01 $0.00 $0.00 $0.00 $0.00 $96.00 $152.06 $153.60 $0.00 $124.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200117 EAP Custom 27200117 Inc Spir-disposable BOTH IP/OP $319.00 $236.06 $0.00 $255.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.76 $236.76 $245.89 $0.00 $66.48 $0.00 $0.00 $0.00 $0.00 $159.50 $252.65 $255.20 $0.00 $207.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200118 EAP Custom 27200118 Inner Cannula BOTH IP/OP $134.00 $99.16 $0.00 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.45 $99.45 $103.29 $0.00 $27.93 $0.00 $0.00 $0.00 $0.00 $67.00 $106.13 $107.20 $0.00 $87.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200119 EAP Custom 27200119 Nasal Prongs BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200120 EAP Custom 27200120 Vent Kit Only BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $325.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200124 EAP Custom 27200124 Meter Astech Peak Flow BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200125 EAP Custom 27200125 Sleep Apnea Supply Kit BOTH IP/OP "$1,443.00 " "$1,067.82" $0.00 "$1,154.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,070.99" "$1,070.99" "$1,112.26" $0.00 $300.72 $0.00 $0.00 $0.00 $0.00 $721.50 "$1,142.86" "$1,154.40" $0.00 $937.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200126 EAP Custom 27200126 Tracheostomy-pipe Cleaner BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.34 $62.34 $64.75 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $42.00 $66.53 $67.20 $0.00 $54.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200128 EAP Custom 27200128 Tube Trach #8 Dct BOTH IP/OP $377.00 $278.98 $0.00 $301.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.81 $279.81 $290.59 $0.00 $78.57 $0.00 $0.00 $0.00 $0.00 $188.50 $298.58 $301.60 $0.00 $245.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200129 EAP Custom 27200129 Tube Trach #6 Dct BOTH IP/OP $377.00 $278.98 $0.00 $301.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.81 $279.81 $290.59 $0.00 $78.57 $0.00 $0.00 $0.00 $0.00 $188.50 $298.58 $301.60 $0.00 $245.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200130 EAP Custom 27200130 Tube Trach #10 Dct BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.64 $248.64 $258.22 $0.00 $69.81 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $217.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200131 EAP Custom 27200131 Tube Tracheostomy 4-dcfs BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $263.61 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $222.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200132 EAP Custom 27200132 Tube Tracheostomy 8-dcfs BOTH IP/OP $326.00 $241.24 $0.00 $260.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.96 $241.96 $251.28 $0.00 $67.94 $0.00 $0.00 $0.00 $0.00 $163.00 $258.19 $260.80 $0.00 $211.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200133 EAP Custom 27200133 Mini Bal-broncho-alveolar Lava BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200134 EAP Custom 27200134 Cont Oxy Hood-pediatrics BOTH IP/OP $866.00 $640.84 $0.00 $692.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $642.75 $642.75 $667.51 $0.00 $180.47 $0.00 $0.00 $0.00 $0.00 $433.00 $685.87 $692.80 $0.00 $562.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200135 EAP Custom 27200135 He-ox Rx Airway Obs + Supply BOTH IP/OP $947.00 $700.78 $0.00 $757.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $702.86 $702.86 $729.95 $0.00 $197.35 $0.00 $0.00 $0.00 $0.00 $473.50 $750.02 $757.60 $0.00 $615.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200136 EAP Custom 27200136 Trach Tube/passy Muir BOTH IP/OP $554.00 $409.96 $0.00 $443.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.18 $411.18 $427.02 $0.00 $115.45 $0.00 $0.00 $0.00 $0.00 $277.00 $438.77 $443.20 $0.00 $360.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200137 EAP Custom 27200137 Intubation Specialty Tube BOTH IP/OP "$1,545.00 " "$1,143.30" $0.00 "$1,236.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,146.70" "$1,146.70" "$1,190.89" $0.00 $321.98 $0.00 $0.00 $0.00 $0.00 $772.50 "$1,223.64" "$1,236.00" $0.00 "$1,004.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200138 EAP Custom 27200138 Pulse Oximetry Sensor BOTH IP/OP $292.00 $216.08 $0.00 $233.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.72 $216.72 $225.07 $0.00 $60.85 $0.00 $0.00 $0.00 $0.00 $146.00 $231.26 $233.60 $0.00 $189.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200139 EAP Custom 27200139 Vent Circuit Kit BOTH IP/OP $423.00 $313.02 $0.00 $338.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.95 $313.95 $326.05 $0.00 $88.15 $0.00 $0.00 $0.00 $0.00 $211.50 $335.02 $338.40 $0.00 $274.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200140 EAP Custom 27200140 Specialty Vent Circuit Kit BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $734.78 $734.78 $763.09 $0.00 $206.32 $0.00 $0.00 $0.00 $0.00 $495.00 $784.08 $792.00 $0.00 $643.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200143 EAP Custom 27200143 Blood Gas Kit BOTH IP/OP $112.00 $82.88 $0.00 $89.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.13 $83.13 $86.33 $0.00 $23.34 $0.00 $0.00 $0.00 $0.00 $56.00 $88.70 $89.60 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200144 EAP HCPCS C1729 Red Rubber Catheter BOTH IP/OP $54.00 $39.96 $0.00 $43.20 $29.32 $29.32 $0.00 $0.00 $0.00 $11.25 $40.08 $40.08 $41.62 $0.00 $11.25 $0.00 $31.94 $31.94 $0.00 $27.00 $42.77 $43.20 $0.00 $35.10 $0.00 $8.45 $0.00 $0.00 $8.60 $0.00 $0.00 $0.00 $0.00 $0.00 27200145 EAP Custom 27200145 Air Vest-disposable BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.99 $500.99 $520.29 $0.00 $140.67 $0.00 $0.00 $0.00 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200148 EAP Custom 27200148 "Iv Start, Supply" BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200149 EAP HCPCS C1769 Guidewire:pressurewire:radi BOTH IP/OP "$2,511.00 " "$1,858.14" $0.00 "$2,008.80" "$1,363.47" "$1,363.47" $0.00 $0.00 $0.00 $523.36 "$1,863.66" "$1,863.66" "$1,935.48" $0.00 $523.29 $0.00 "$1,485.26" "$1,485.26" $0.00 "$1,255.50" "$1,988.71" "$2,008.80" $0.00 $0.00 $0.00 $392.97 $0.00 $0.00 $399.75 $0.00 $0.00 $0.00 $0.00 $0.00 27200150 EAP Custom 27200150 Pericardiocentesis Kit BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $0.00 $0.00 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200151 EAP HCPCS C1769 Choice Pt X-support Guidewire BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $328.52 $328.52 $0.00 $0.00 $0.00 $126.10 $449.03 $449.03 $466.33 $0.00 $126.08 $0.00 $357.86 $357.86 $0.00 $302.50 $479.16 $484.00 $0.00 $393.25 $0.00 $94.68 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $0.00 27200152 EAP HCPCS C1769 Choice Pt Guidewire BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $328.52 $328.52 $0.00 $0.00 $0.00 $126.10 $449.03 $449.03 $466.33 $0.00 $126.08 $0.00 $357.86 $357.86 $0.00 $302.50 $479.16 $484.00 $0.00 $393.25 $0.00 $94.68 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $0.00 27200153 EAP HCPCS C1769 Glidewire .035 150cm Angled BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.00 $93.46 $94.40 $0.00 $0.00 $0.00 $18.47 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 27200154 EAP HCPCS C1892 Custom Left Heart Kit W/transd BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $37.47 $37.47 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $34.50 $54.65 $55.20 $0.00 $44.85 $0.00 $10.80 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $0.00 27200155 EAP HCPCS C1892 Custom Right Heart Kit W/trans BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $25.52 $25.52 $0.00 $0.00 $0.00 $9.80 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $27.80 $27.80 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $7.36 $0.00 $0.00 $7.48 $0.00 $0.00 $0.00 $0.00 $0.00 27200156 EAP HCPCS C2629 Micropuncture Set BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $60.33 $60.33 $0.00 $51.00 $80.78 $81.60 $0.00 $66.30 $0.00 $15.96 $0.00 $0.00 $16.24 $0.00 $0.00 $0.00 $0.00 $0.00 27200157 EAP HCPCS C1769 .025 X 260CM 7CM EMERALD GUIDEWIRE BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $11.40 $11.40 $0.00 $0.00 $0.00 $4.38 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $12.42 $12.42 $0.00 $10.50 $16.63 $16.80 $0.00 $13.65 $0.00 $3.29 $0.00 $0.00 $3.34 $0.00 $0.00 $0.00 $0.00 $0.00 27200158 EAP HCPCS C1887 6fr Al 1 St Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $129.35 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200159 EAP HCPCS C1887 6fr Ar 2 Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200160 EAP HCPCS C1894 6fr - 10cm Avanti + Sheath In BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $18.46 $18.46 $0.00 $0.00 $0.00 $7.09 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $0.00 27200161 EAP HCPCS C1887 6fr Jl4 St Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200162 EAP HCPCS C1887 6fr Mpa-1 Guiding Cath BOTH IP/OP $189.00 $139.86 $0.00 $151.20 $102.63 $102.63 $0.00 $0.00 $0.00 $39.39 $140.28 $140.28 $145.68 $0.00 $39.39 $0.00 $111.79 $111.79 $0.00 $94.50 $149.69 $151.20 $0.00 $122.85 $0.00 $29.58 $0.00 $0.00 $30.09 $0.00 $0.00 $0.00 $0.00 $0.00 27200163 EAP HCPCS C1887 6ft Jr 4 St Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $129.35 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200164 EAP HCPCS C1887 7fr Ar 1 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200165 EAP HCPCS C1887 7fr Jr 3.5 Guiding Cath BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200166 EAP HCPCS C1887 7fr H-stick Guiding Cath BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200167 EAP HCPCS C1887 7fr Jl5 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200168 EAP HCPCS C1887 7fr Jr 4 St Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200169 EAP HCPCS C1887 7fr Jr 5 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200170 EAP HCPCS C1887 7fr Mpa-1 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200171 EAP HCPCS C1887 7fr Xb 3.5 Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200172 EAP HCPCS C1887 7fr Xb 3.0 Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200173 EAP HCPCS C1887 7fr Al 1 St Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200174 EAP HCPCS C1887 7fr Al 2 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200175 EAP HCPCS C1887 7fr Jr 4 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200176 EAP HCPCS C1887 7fr Im Guiding Cath BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $117.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200177 EAP HCPCS C1887 6fr Ar 1 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200178 EAP HCPCS C1887 6fr Jl4 Sh Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200179 EAP HCPCS C1887 6fr Jr 4 Sh Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200180 EAP HCPCS C1769 .035 X 260CM 3CM EMERALD GUIDEWIRE BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $11.95 $11.95 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $14.30 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 27200181 EAP HCPCS C1887 6fr Xb 3 Sh Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200182 EAP HCPCS C1887 7fr Xb 3.5 Sh Guilding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200183 EAP HCPCS C1887 6fr Xb 3.5 Sh Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200184 EAP HCPCS C1769 .035 X 150CM 3CM EMERALD GUIDEWIRE BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $11.95 $11.95 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $14.30 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 27200185 EAP HCPCS C1887 7fr Jl4 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200186 EAP HCPCS C1887 7fr Jl4 Sh Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200187 EAP HCPCS C1887 7fr Xb 4.0 Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200188 EAP HCPCS C1887 7fr Jr 4 Sh Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200189 EAP HCPCS C1887 7fr Ar 1 Sh Guiding Cath BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200190 EAP HCPCS C1887 6fr Al 1 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200191 EAP HCPCS C1887 6fr Xb 4.0 Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200192 EAP HCPCS C1887 7fr Al 1 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200193 EAP HCPCS C1887 6fr Jl4 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200194 EAP HCPCS C1887 6fr Jr 4 Guiding Cath BOTH IP/OP $189.00 $139.86 $0.00 $151.20 $102.63 $102.63 $0.00 $0.00 $0.00 $39.39 $140.28 $140.28 $145.68 $0.00 $39.39 $0.00 $111.79 $111.79 $0.00 $94.50 $149.69 $151.20 $0.00 $122.85 $0.00 $29.58 $0.00 $0.00 $30.09 $0.00 $0.00 $0.00 $0.00 $0.00 27200195 EAP HCPCS C1887 6fr Xb 3 Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $129.35 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200196 EAP HCPCS C1887 6fr Xb 3.5 Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $129.35 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200197 EAP HCPCS C1887 6fr H-stick Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200198 EAP HCPCS C1887 6fr Jl3.5 Guiding Cath BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $117.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200199 EAP HCPCS C1887 6fr Jr 3.5 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200200 EAP HCPCS C1887 6fr Al .75 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200201 EAP HCPCS C1887 7fr Al .75 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200202 EAP HCPCS C1894 7fr - 10cm Avanti + Sheath Int BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $18.46 $18.46 $0.00 $0.00 $0.00 $7.09 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $0.00 27200203 EAP HCPCS C1894 8fr - 10cm Avanti + Sheath Int BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $18.46 $18.46 $0.00 $0.00 $0.00 $7.09 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $0.00 27200204 EAP HCPCS C1769 .025 X 150cm Emerald Guidewire BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $11.40 $11.40 $0.00 $0.00 $0.00 $4.38 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $12.42 $12.42 $0.00 $10.50 $16.63 $16.80 $0.00 $13.65 $0.00 $3.29 $0.00 $0.00 $3.34 $0.00 $0.00 $0.00 $0.00 $0.00 27200205 EAP HCPCS C1769 300cm Balanced Middleweight (b BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $156.38 $156.38 $0.00 $0.00 $0.00 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 27200206 EAP HCPCS C1769 Amplatz Guidewire Super Stiff BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $47.24 $47.24 $0.00 $0.00 $0.00 $18.13 $64.57 $64.57 $67.06 $0.00 $18.13 $0.00 $51.46 $51.46 $0.00 $43.50 $68.90 $69.60 $0.00 $0.00 $0.00 $13.62 $0.00 $0.00 $13.85 $0.00 $0.00 $0.00 $0.00 $0.00 27200207 EAP HCPCS C1751 7fr-100cm Swan-ganz Td Cathete BOTH IP/OP $189.00 $139.86 $0.00 $151.20 $102.63 $102.63 $0.00 $0.00 $0.00 $39.39 $140.28 $140.28 $145.68 $0.00 $39.39 $0.00 $111.79 $111.79 $0.00 $94.50 $149.69 $151.20 $0.00 $122.85 $0.00 $29.58 $0.00 $0.00 $30.09 $0.00 $0.00 $0.00 $0.00 $0.00 27200208 EAP HCPCS C1894 5fr - 10cm Avanti+sheath Intro BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $18.46 $18.46 $0.00 $0.00 $0.00 $7.09 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $0.00 27200209 EAP HCPCS C1887 7fr Jl4 St Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200214 EAP HCPCS C1884 Filter Wire Ex-300cm BOTH IP/OP "$5,361.00 " "$3,967.14" $0.00 "$4,288.80" "$2,911.02" "$2,911.02" $0.00 $0.00 $0.00 "$1,117.37" "$3,978.93" "$3,978.93" "$4,132.26" $0.00 "$1,117.23" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,680.50" "$4,245.91" "$4,288.80" $0.00 "$3,484.65" $0.00 $839.00 $0.00 $0.00 $853.47 $0.00 $0.00 $0.00 $0.00 $0.00 27200215 EAP HCPCS C1727 2.50 X 15mm Cutting Balloon BOTH IP/OP "$2,869.00 " "$2,123.06" $0.00 "$2,295.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,129.37" "$2,129.37" "$2,211.43" $0.00 $597.90 $0.00 $0.00 $0.00 $0.00 "$1,434.50" "$2,272.25" "$2,295.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200216 EAP HCPCS C1727 2.50 X 10cm Cutting Balloon BOTH IP/OP "$2,869.00 " "$2,123.06" $0.00 "$2,295.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,129.37" "$2,129.37" "$2,211.43" $0.00 $597.90 $0.00 $0.00 $0.00 $0.00 "$1,434.50" "$2,272.25" "$2,295.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200218 EAP HCPCS C1757 .014-145cm Export Catheter BOTH IP/OP "$1,865.00 " "$1,380.10" $0.00 "$1,492.00" "$1,012.70" "$1,012.70" $0.00 $0.00 $0.00 $388.71 "$1,384.20" "$1,384.20" "$1,437.54" $0.00 $388.67 $0.00 "$1,103.15" "$1,103.15" $0.00 $932.50 "$1,477.08" "$1,492.00" $0.00 "$1,212.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200219 EAP HCPCS C1756 Temporary Pace Eletrode Cathet BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $0.00 $0.00 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200220 EAP HCPCS C1727 "Balloon Cutting Ultra Tube, 2." BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" "$1,984.04" $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200226 EAP HCPCS C1725 4.00 X 15mm Voyager Rx Balloon BOTH IP/OP $699.00 $517.26 $0.00 $559.20 $379.56 $379.56 $0.00 $0.00 $0.00 $145.69 $518.80 $518.80 $538.79 $0.00 $145.67 $0.00 $413.46 $413.46 $0.00 $349.50 $553.61 $559.20 $0.00 $0.00 $0.00 $109.39 $0.00 $0.00 $111.28 $0.00 $0.00 $0.00 $0.00 $0.00 27200227 EAP HCPCS C1769 190cm All-star Guidewire BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $156.38 $156.38 $0.00 $0.00 $0.00 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 27200228 EAP HCPCS C1769 Choice X-support Guidewire BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $328.52 $328.52 $0.00 $0.00 $0.00 $126.10 $449.03 $449.03 $466.33 $0.00 $126.08 $0.00 $357.86 $357.86 $0.00 $302.50 $479.16 $484.00 $0.00 $0.00 $0.00 $94.68 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $0.00 27200229 EAP HCPCS C1769 Choice Standard Guidewire BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $328.52 $328.52 $0.00 $0.00 $0.00 $126.10 $449.03 $449.03 $466.33 $0.00 $126.08 $0.00 $357.86 $357.86 $0.00 $302.50 $479.16 $484.00 $0.00 $0.00 $0.00 $94.68 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $0.00 27200230 EAP HCPCS C1887 7fr Xb 3.0 Sh Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200231 EAP HCPCS C1887 6fr Al 2 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200238 EAP HCPCS C1887 7fr Ar 2 Guiding Cath BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200239 EAP HCPCS C1887 7fr Jl3.5 Guiding Cath BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200247 EAP HCPCS C1887 7fr Lcb Guiding Cath BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $108.06 $108.06 $0.00 $0.00 $0.00 $41.48 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $117.71 $117.71 $0.00 $99.50 $157.61 $159.20 $0.00 $129.35 $0.00 $31.14 $0.00 $0.00 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 27200248 EAP HCPCS C1887 7fr Jr 4 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200249 EAP HCPCS C1887 7fr Ar 1 Guiding Cath BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200250 EAP HCPCS C1769 "Glide Wire,.035 Straight" BOTH IP/OP $112.00 $82.88 $0.00 $89.60 $60.82 $60.82 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $86.33 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $56.00 $88.70 $89.60 $0.00 $72.80 $0.00 $17.53 $0.00 $0.00 $17.83 $0.00 $0.00 $0.00 $0.00 $0.00 27200251 EAP HCPCS C1887 6fr Mpa- 1 Guiding Cath BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200252 EAP HCPCS C1769 190cm J Tip Bmw Guidewire BOTH IP/OP $348.00 $257.52 $0.00 $278.40 $188.96 $188.96 $0.00 $0.00 $0.00 $72.53 $258.29 $258.29 $268.24 $0.00 $72.52 $0.00 $205.84 $205.84 $0.00 $174.00 $275.62 $278.40 $0.00 $226.20 $0.00 $54.46 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 27200253 EAP HCPCS C1726 12frx28mmx70cm Inoue Balloon BOTH IP/OP "$19,725.00 " "$14,596.50" $0.00 "$15,780.00" "$10,710.68" "$10,710.68" $0.00 $0.00 $0.00 "$4,111.18" "$4,181.12" "$4,181.12" "$15,204.03" $0.00 "$4,110.69" $0.00 "$3,094.73" "$3,094.73" $0.00 "$9,862.50" "$15,622.20" "$15,780.00" $0.00 $0.00 $0.00 "$3,086.96" $0.00 $0.00 "$3,140.22" $0.00 $0.00 $0.00 $0.00 $0.00 27200254 EAP HCPCS C1887 6fr H Stick Sh Guiding Cathete BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200255 EAP HCPCS C1887 6fr Al 1 Sh Guiding Catheter BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200256 EAP HCPCS C1887 6fr Al 2 Sh Guiding Catheter BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200257 EAP HCPCS C1725 2.0 X 9mm Maverick Monorail BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $497.39 $497.39 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $458.00 $725.47 $732.80 $0.00 $0.00 $0.00 $143.35 $0.00 $0.00 $145.83 $0.00 $0.00 $0.00 $0.00 $0.00 27200258 EAP HCPCS C1725 2.5 X 9mm Maverick Monorail BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $497.39 $497.39 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $458.00 $725.47 $732.80 $0.00 $0.00 $0.00 $143.35 $0.00 $0.00 $145.83 $0.00 $0.00 $0.00 $0.00 $0.00 27200259 EAP HCPCS C1725 3.0 X 9mm Maverick Monorail BOTH IP/OP $872.00 $645.28 $0.00 $697.60 $473.50 $473.50 $0.00 $0.00 $0.00 $181.75 $647.20 $647.20 $672.14 $0.00 $181.72 $0.00 $515.79 $515.79 $0.00 $436.00 $690.62 $697.60 $0.00 $0.00 $0.00 $136.47 $0.00 $0.00 $138.82 $0.00 $0.00 $0.00 $0.00 $0.00 27200283 EAP HCPCS C1769 Hi-torque Pilot 50 Guide Wire BOTH IP/OP $302.00 $223.48 $0.00 $241.60 $163.99 $163.99 $0.00 $0.00 $0.00 $62.94 $224.14 $224.14 $232.78 $0.00 $62.94 $0.00 $178.63 $178.63 $0.00 $151.00 $239.18 $241.60 $0.00 $196.30 $0.00 $47.26 $0.00 $0.00 $48.08 $0.00 $0.00 $0.00 $0.00 $0.00 27200285 EAP HCPCS C1769 Doc Guide Wire Extension BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $175.93 $175.93 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $210.60 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 27200292 EAP HCPCS C1725 1.5 X 6 Sprinter Balloon BOTH IP/OP $853.00 $631.22 $0.00 $682.40 $463.18 $463.18 $0.00 $0.00 $0.00 $177.79 $633.10 $633.10 $657.49 $0.00 $177.77 $0.00 $504.55 $504.55 $0.00 $426.50 $675.58 $682.40 $0.00 $0.00 $0.00 $133.49 $0.00 $0.00 $135.80 $0.00 $0.00 $0.00 $0.00 $0.00 27200294 EAP HCPCS C1751 7fr Wedge Pressure Cath BOTH IP/OP $153.00 $113.22 $0.00 $122.40 $83.08 $83.08 $0.00 $0.00 $0.00 $31.89 $113.56 $113.56 $117.93 $0.00 $31.89 $0.00 $90.50 $90.50 $0.00 $76.50 $121.18 $122.40 $0.00 $99.45 $0.00 $23.94 $0.00 $0.00 $24.36 $0.00 $0.00 $0.00 $0.00 $0.00 27200295 EAP Custom 27200295 Cardiac Cath Pack BOTH IP/OP $190.00 $140.60 $0.00 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.02 $141.02 $146.45 $0.00 $39.60 $0.00 $0.00 $0.00 $0.00 $95.00 $150.48 $152.00 $0.00 $123.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200296 EAP Custom 27200296 Contrast Inject Line-low Press BOTH IP/OP $7.00 $5.18 $0.00 $5.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.20 $5.20 $5.40 $0.00 $1.46 $0.00 $0.00 $0.00 $0.00 $3.50 $5.54 $5.60 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200297 EAP Custom 27200297 Implant Tray BOTH IP/OP $212.00 $156.88 $0.00 $169.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.00 $167.90 $169.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200298 EAP HCPCS C1893 5fr - 10cm Pinnacle Introducer BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $20.63 $20.63 $0.00 $0.00 $0.00 $7.92 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $22.48 $22.48 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $5.95 $0.00 $0.00 $6.05 $0.00 $0.00 $0.00 $0.00 $0.00 27200299 EAP HCPCS C1893 6fr - 10cm Pinnacle Introducer BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $21.72 $21.72 $0.00 $0.00 $0.00 $8.34 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $23.66 $23.66 $0.00 $20.00 $31.68 $32.00 $0.00 $26.00 $0.00 $6.26 $0.00 $0.00 $6.37 $0.00 $0.00 $0.00 $0.00 $0.00 27200300 EAP HCPCS C1893 7fr - 10cm Pinnacle Introducer BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $20.63 $20.63 $0.00 $0.00 $0.00 $7.92 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $22.48 $22.48 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $5.95 $0.00 $0.00 $6.05 $0.00 $0.00 $0.00 $0.00 $0.00 27200301 EAP HCPCS C1893 8fr - 10cm Pinnacle Introducer BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $20.63 $20.63 $0.00 $0.00 $0.00 $7.92 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $22.48 $22.48 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $5.95 $0.00 $0.00 $6.05 $0.00 $0.00 $0.00 $0.00 $0.00 27200302 EAP HCPCS C1893 6fr - 25cm Pinnacle Introducer BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $37.47 $37.47 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $10.80 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $0.00 27200303 EAP HCPCS C1893 7fr - 25cm Pinnacle Introducer BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $37.47 $37.47 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $10.80 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $0.00 27200304 EAP HCPCS C1893 8fr - 25cm Pinnacle Introducer BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $37.47 $37.47 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $10.80 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $0.00 27200305 EAP HCPCS C1887 6fr Ebu 3.0 Guiding Catheter BOTH IP/OP $189.00 $139.86 $0.00 $151.20 $102.63 $102.63 $0.00 $0.00 $0.00 $39.39 $140.28 $140.28 $145.68 $0.00 $39.39 $0.00 $111.79 $111.79 $0.00 $94.50 $149.69 $151.20 $0.00 $122.85 $0.00 $29.58 $0.00 $0.00 $30.09 $0.00 $0.00 $0.00 $0.00 $0.00 27200306 EAP HCPCS C1887 6fr Ebu 3.5 Guiding Catheter BOTH IP/OP $169.00 $125.06 $0.00 $135.20 $91.77 $91.77 $0.00 $0.00 $0.00 $35.22 $125.43 $125.43 $130.27 $0.00 $35.22 $0.00 $99.96 $99.96 $0.00 $84.50 $133.85 $135.20 $0.00 $109.85 $0.00 $26.45 $0.00 $0.00 $26.90 $0.00 $0.00 $0.00 $0.00 $0.00 27200307 EAP HCPCS C1887 6fr Ebu 4.0 Guiding Catheter BOTH IP/OP $169.00 $125.06 $0.00 $135.20 $91.77 $91.77 $0.00 $0.00 $0.00 $35.22 $125.43 $125.43 $130.27 $0.00 $35.22 $0.00 $99.96 $99.96 $0.00 $84.50 $133.85 $135.20 $0.00 $109.85 $0.00 $26.45 $0.00 $0.00 $26.90 $0.00 $0.00 $0.00 $0.00 $0.00 27200308 EAP HCPCS C1887 7fr Ebu 3.0 Guiding Catheter BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200309 EAP HCPCS C1887 7fr Ebu 3.5 Guiding Catheter BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200310 EAP HCPCS C1887 7fr Ebu 4.0 Guiding Catheter BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $104.65 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27200311 EAP HCPCS C1887 8fr Ebu 3.5 Guiding Catheter BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200312 EAP HCPCS C1887 8fr Ebu 4.0 Guiding Catheter BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200313 EAP HCPCS C1727 3.0 X 10cm Cutting Balloon Otw BOTH IP/OP $986.00 $729.64 $0.00 $788.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $731.81 $731.81 $760.01 $0.00 $205.48 $0.00 $0.00 $0.00 $0.00 $493.00 $780.91 $788.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200314 EAP HCPCS C1757 7fr Export Xt Catheter BOTH IP/OP "$2,850.00 " "$2,109.00" $0.00 "$2,280.00" "$1,547.55" "$1,547.55" $0.00 $0.00 $0.00 $594.01 "$2,115.27" "$2,115.27" "$2,196.78" $0.00 $593.94 $0.00 "$1,685.78" "$1,685.78" $0.00 "$1,425.00" "$2,257.20" "$2,280.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200315 EAP HCPCS C1769 .014 - 300cm Asahi Miraclebros BOTH IP/OP $691.00 $511.34 $0.00 $552.80 $375.21 $375.21 $0.00 $0.00 $0.00 $144.02 $512.86 $512.86 $532.62 $0.00 $144.00 $0.00 $408.73 $408.73 $0.00 $345.50 $547.27 $552.80 $0.00 $449.15 $0.00 $108.14 $0.00 $0.00 $110.01 $0.00 $0.00 $0.00 $0.00 $0.00 27200316 EAP HCPCS C1769 .014 - 300cm Asahi Soft Wire BOTH IP/OP $268.00 $198.32 $0.00 $214.40 $145.52 $145.52 $0.00 $0.00 $0.00 $55.86 $198.91 $198.91 $206.57 $0.00 $55.85 $0.00 $158.52 $158.52 $0.00 $134.00 $212.26 $214.40 $0.00 $0.00 $0.00 $41.94 $0.00 $0.00 $42.67 $0.00 $0.00 $0.00 $0.00 $0.00 27200317 EAP HCPCS C1769 .014 - 300cm Whisper Ms BOTH IP/OP $331.00 $244.94 $0.00 $264.80 $179.73 $179.73 $0.00 $0.00 $0.00 $68.99 $245.67 $245.67 $255.13 $0.00 $68.98 $0.00 $195.79 $195.79 $0.00 $165.50 $262.15 $264.80 $0.00 $0.00 $0.00 $51.80 $0.00 $0.00 $52.70 $0.00 $0.00 $0.00 $0.00 $0.00 27200318 EAP HCPCS C1769 .014 - 300cm All-star Wire BOTH IP/OP $307.00 $227.18 $0.00 $245.60 $166.70 $166.70 $0.00 $0.00 $0.00 $63.99 $227.86 $227.86 $236.64 $0.00 $63.98 $0.00 $181.59 $181.59 $0.00 $153.50 $243.14 $245.60 $0.00 $199.55 $0.00 $48.05 $0.00 $0.00 $48.87 $0.00 $0.00 $0.00 $0.00 $0.00 27200319 EAP HCPCS C1753 Eagle Eye Coronary Imaging Cat BOTH IP/OP "$2,449.00 " "$1,812.26" $0.00 "$1,959.20" "$1,329.81" "$1,329.81" $0.00 $0.00 $0.00 $510.43 "$1,817.65" "$1,817.65" "$1,887.69" $0.00 $510.37 $0.00 "$1,448.58" "$1,448.58" $0.00 "$1,224.50" "$1,939.61" "$1,959.20" $0.00 "$1,591.85" $0.00 $383.27 $0.00 $0.00 $389.88 $0.00 $0.00 $0.00 $0.00 $0.00 27200320 EAP Custom 27200320 Primewire BOTH IP/OP "$2,332.00 " "$1,725.68" $0.00 "$1,865.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,730.81" "$1,730.81" "$1,797.51" $0.00 $485.99 $0.00 $0.00 $0.00 $0.00 "$1,166.00" "$1,846.94" "$1,865.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200321 EAP HCPCS C1893 8fr-35cm Super Arrow Flex Intr BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $135.21 $135.21 $0.00 $0.00 $0.00 $51.90 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $147.28 $147.28 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $38.97 $0.00 $0.00 $39.64 $0.00 $0.00 $0.00 $0.00 $0.00 27200322 EAP Custom 27200322 Platinum Plus St .018 Guidewir BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $0.00 $0.00 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200323 EAP Custom 27200323 Platinum Plus St .014 Guidewir BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $0.00 $0.00 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200324 EAP Custom 27200324 V-18 Control Wire BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.35 $252.35 $262.07 $0.00 $70.86 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $221.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200325 EAP Custom 27200325 Steel Core 18 Guidewire BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200329 EAP Custom 27200329 14fr Sheath Introducer BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.57 $64.57 $67.06 $0.00 $18.13 $0.00 $0.00 $0.00 $0.00 $43.50 $68.90 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200338 EAP HCPCS C1725 Voyager Nc 2.5 X 15mm Balloon BOTH IP/OP $634.00 $469.16 $0.00 $507.20 $344.26 $344.26 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $488.69 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $317.00 $502.13 $507.20 $0.00 $412.10 $0.00 $99.22 $0.00 $0.00 $100.93 $0.00 $0.00 $0.00 $0.00 $0.00 27200373 EAP HCPCS C1726 Catheter Baldilat 12 Atm 1.5mm 142cm 12mm Rapex BOTH IP/OP $413.00 $305.62 $0.00 $330.40 $224.26 $224.26 $0.00 $0.00 $0.00 $86.08 $306.53 $306.53 $318.34 $0.00 $86.07 $0.00 $244.29 $244.29 $0.00 $206.50 $327.10 $330.40 $0.00 $268.45 $0.00 $64.63 $0.00 $0.00 $65.75 $0.00 $0.00 $0.00 $0.00 $0.00 27200376 EAP HCPCS C1726 Catheter Blndil 21cm .022in 2mm 142cm Lf 12mm Spntr Lgnd BOTH IP/OP $413.00 $305.62 $0.00 $330.40 $224.26 $224.26 $0.00 $0.00 $0.00 $86.08 $306.53 $306.53 $318.34 $0.00 $86.07 $0.00 $244.29 $244.29 $0.00 $206.50 $327.10 $330.40 $0.00 $268.45 $0.00 $64.63 $0.00 $0.00 $65.75 $0.00 $0.00 $0.00 $0.00 $0.00 27200382 EAP HCPCS C1726 Sprinter Legend Balloon Rx 3.0 BOTH IP/OP $569.00 $421.06 $0.00 $455.20 $308.97 $308.97 $0.00 $0.00 $0.00 $118.59 $422.31 $422.31 $438.59 $0.00 $118.58 $0.00 $336.56 $336.56 $0.00 $284.50 $450.65 $455.20 $0.00 $0.00 $0.00 $89.05 $0.00 $0.00 $90.58 $0.00 $0.00 $0.00 $0.00 $0.00 27200406 EAP HCPCS C1726 Sprinter Nc Balloon Rx 3.50x06 BOTH IP/OP $627.00 $463.98 $0.00 $501.60 $340.46 $340.46 $0.00 $0.00 $0.00 $130.68 $465.36 $465.36 $483.29 $0.00 $130.67 $0.00 $370.87 $370.87 $0.00 $313.50 $496.58 $501.60 $0.00 $0.00 $0.00 $98.13 $0.00 $0.00 $99.82 $0.00 $0.00 $0.00 $0.00 $0.00 27200408 EAP HCPCS C1726 Sprinter Nc Balloon Rx 3.50x12 BOTH IP/OP $627.00 $463.98 $0.00 $501.60 $340.46 $340.46 $0.00 $0.00 $0.00 $130.68 $465.36 $465.36 $483.29 $0.00 $130.67 $0.00 $370.87 $370.87 $0.00 $313.50 $496.58 $501.60 $0.00 $0.00 $0.00 $98.13 $0.00 $0.00 $99.82 $0.00 $0.00 $0.00 $0.00 $0.00 27200417 EAP HCPCS C1726 Sprinter Nc Balloon Rx 4.00x15 BOTH IP/OP $627.00 $463.98 $0.00 $501.60 $340.46 $340.46 $0.00 $0.00 $0.00 $130.68 $465.36 $465.36 $483.29 $0.00 $130.67 $0.00 $370.87 $370.87 $0.00 $313.50 $496.58 $501.60 $0.00 $0.00 $0.00 $98.13 $0.00 $0.00 $99.82 $0.00 $0.00 $0.00 $0.00 $0.00 27200422 EAP Custom 27200422 Spacer (mdi) BOTH IP/OP $215.00 $159.10 $0.00 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.57 $159.57 $165.72 $0.00 $44.81 $0.00 $0.00 $0.00 $0.00 $107.50 $170.28 $172.00 $0.00 $139.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200423 EAP Custom 27200423 FOOT DROP SPLINT-CUSTOM BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.35 $180.35 $187.30 $0.00 $50.64 $0.00 $0.00 $0.00 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200425 EAP Custom 27200425 "Catheterization Kit, Straight" BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200426 EAP Custom 27200426 Blood Administration Set Up BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.23 $2.23 $2.31 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200427 EAP Custom 27200427 Intra-uterine Press Cath BOTH IP/OP $92.00 $68.08 $0.00 $73.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.28 $68.28 $70.91 $0.00 $19.17 $0.00 $0.00 $0.00 $0.00 $46.00 $72.86 $73.60 $0.00 $59.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200428 EAP Custom 27200428 "Pack, C-section" BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.53 $116.53 $121.02 $0.00 $32.72 $0.00 $0.00 $0.00 $0.00 $78.50 $124.34 $125.60 $0.00 $102.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200430 EAP Custom 27200430 "Catheterization Kit, Foley" BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200431 EAP Custom 27200431 "Catheterization Kit, Straight" BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $138.74 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $117.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200432 EAP Custom 27200432 Blood Administration Set Up BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200433 EAP Custom 27200433 Karmen Cannula BOTH IP/OP "$1,131.00 " $836.94 $0.00 $904.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $839.43 $839.43 $871.77 $0.00 $235.70 $0.00 $0.00 $0.00 $0.00 $565.50 $895.75 $904.80 $0.00 $735.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200434 EAP HCPCS A4405 Stomahesive Paste 2 Oz Tube BOTH IP/OP $108.00 $79.92 $0.00 $86.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $0.00 $0.00 $0.00 $54.00 $85.54 $86.40 $0.00 $70.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200435 EAP Custom 27200435 "Little Ones, Pouch Flange" BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200436 EAP Custom 27200436 "Pouch, Urostomy Opaque" BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200437 EAP Custom 27200437 Flexible Flange BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200438 EAP Custom 27200438 "Irrigator, Visiflow W/cone" BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.18 $149.18 $154.93 $0.00 $41.89 $0.00 $0.00 $0.00 $0.00 $100.50 $159.19 $160.80 $0.00 $130.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200439 EAP Custom 27200439 Irrigation Sleeve BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200440 EAP HCPCS A4371 Stomahesive Powder BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $36.40 $0.00 $8.76 $0.00 $0.00 $8.92 $0.00 $0.00 $0.00 $0.00 $0.00 27200441 EAP Custom 27200441 Mini Pouch BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200442 EAP Custom 27200442 Wound Pouch Med. BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $0.00 $0.00 $0.00 $34.00 $53.86 $54.40 $0.00 $44.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200443 EAP HCPCS A4364 Medical Adhesive BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $36.92 $36.92 $0.00 $0.00 $0.00 $14.17 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $40.22 $40.22 $0.00 $34.00 $53.86 $54.40 $0.00 $44.20 $0.00 $10.64 $0.00 $0.00 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 27200444 EAP Custom 27200444 Drain Tube Attachment BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200446 EAP HCPCS A4364 "Skin Bond Cement, 4oz" BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $41.27 $41.27 $0.00 $0.00 $0.00 $15.84 $56.41 $56.41 $58.58 $0.00 $15.84 $0.00 $44.95 $44.95 $0.00 $38.00 $60.19 $60.80 $0.00 $0.00 $0.00 $11.89 $0.00 $0.00 $12.10 $0.00 $0.00 $0.00 $0.00 $0.00 27200447 EAP HCPCS A4455 "Uni-solve Wipes,adhes. Remover" BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $0.00 $0.00 $0.00 $51.50 $81.58 $82.40 $0.00 $66.95 $0.00 $16.12 $0.00 $0.00 $16.40 $0.00 $0.00 $0.00 $0.00 $0.00 27200448 EAP HCPCS A6197 Alginate Dressing>16<= 48 Sq In BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200449 EAP Custom 27200449 Ace Wrap Supply BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200450 EAP HCPCS C1728 "Catheter,brachytherapy Seed Ad" BOTH IP/OP "$10,554.00 " "$7,809.96" $0.00 "$8,443.20" "$5,730.82" "$5,730.82" $0.00 $0.00 $0.00 "$2,199.72" "$4,181.12" "$4,181.12" "$8,135.02" $0.00 "$2,199.45" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,277.00" "$8,358.77" "$8,443.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200452 EAP HCPCS C1757 Catheter 6fr X 65 Cm 9mm Cleaner Sterile BOTH IP/OP "$1,756.00 " "$1,299.44" $0.00 "$1,404.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $878.00 "$1,390.75" "$1,404.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200453 EAP HCPCS C1757 Catheter 6fr X 135 Cm 9mm Cleaner Sterile BOTH IP/OP "$2,351.00 " "$1,739.74" $0.00 "$1,880.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,175.50" "$1,861.99" "$1,880.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200454 EAP HCPCS C1757 Catheter 7 Fr X 65 Cm 9mm Cleaner Sterile BOTH IP/OP "$2,143.00 " "$1,585.82" $0.00 "$1,714.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,071.50" "$1,697.26" "$1,714.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200455 EAP HCPCS C1757 Catheter 7fr X 135 Cm 9mm Cleaner Sterile BOTH IP/OP "$2,660.00 " "$1,968.40" $0.00 "$2,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,330.00" "$2,106.72" "$2,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200456 EAP HCPCS C2629 Mic G-18 Introducer Kit BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.93 $434.19 $434.19 $450.92 $0.00 $121.91 $0.00 $346.03 $346.03 $0.00 $292.50 $463.32 $468.00 $0.00 $380.25 $0.00 $91.55 $0.00 $0.00 $93.13 $0.00 $0.00 $0.00 $0.00 $0.00 27200457 EAP HCPCS C1751 Cath Cen Ven 4fr 1 Lum Try 3cg Shrlk Sty Maximal Brr Pic BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $135.21 $135.21 $0.00 $0.00 $0.00 $51.90 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $147.28 $147.28 $0.00 $124.50 $197.21 $199.20 $0.00 $161.85 $0.00 $38.97 $0.00 $0.00 $39.64 $0.00 $0.00 $0.00 $0.00 $0.00 27200458 EAP HCPCS C1751 Cath 5fr 1lum Try 3cg Shrlk Sty Maximal Brr Picc P BOTH IP/OP $260.00 $192.40 $0.00 $208.00 $141.18 $141.18 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $200.41 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $130.00 $205.92 $208.00 $0.00 $169.00 $0.00 $40.69 $0.00 $0.00 $41.39 $0.00 $0.00 $0.00 $0.00 $0.00 27200459 EAP HCPCS C1751 Cath 6fr 1lum Try 3cg Shrlk Sty Maximal Brr Picc P BOTH IP/OP $260.00 $192.40 $0.00 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.00 $205.92 $208.00 $0.00 $0.00 $0.00 $40.69 $0.00 $0.00 $41.39 $0.00 $0.00 $0.00 $0.00 $0.00 27200460 EAP HCPCS C1894 Micro Microintruducer 7cm 5.0fr Flecura Guidewire BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $21.18 $21.18 $0.00 $0.00 $0.00 $8.13 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $0.00 $25.35 $0.00 $6.10 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 27200461 EAP HCPCS C1751 Tray Cath 5fr 12cm Cen Ven Spctrm 3 Lum Pu .025in Disp D BOTH IP/OP $320.00 $236.80 $0.00 $256.00 $173.76 $173.76 $0.00 $0.00 $0.00 $66.70 $237.50 $237.50 $246.66 $0.00 $66.69 $0.00 $189.28 $189.28 $0.00 $160.00 $253.44 $256.00 $0.00 $0.00 $0.00 $50.08 $0.00 $0.00 $50.94 $0.00 $0.00 $0.00 $0.00 $0.00 27200462 EAP HCPCS C1887 Sheath Guid 65cm 6fr Pn Dstn .038in Str Hydphi BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $121.63 $121.63 $0.00 $0.00 $0.00 $46.69 $166.25 $166.25 $172.66 $0.00 $46.68 $0.00 $132.50 $132.50 $0.00 $112.00 $177.41 $179.20 $0.00 $145.60 $0.00 $35.06 $0.00 $0.00 $35.66 $0.00 $0.00 $0.00 $0.00 $0.00 27200467 EAP HCPCS C1769 Guidewire Vascular Angle Standard .035in 180cm 3cm BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $21.47 $0.00 $0.00 $0.00 $0.00 $21.47 $0.00 $60.92 $60.92 $0.00 $51.50 $81.58 $82.40 $0.00 $0.00 $0.00 $16.12 $0.00 $0.00 $16.40 $0.00 $0.00 $0.00 $0.00 $0.00 27200470 EAP HCPCS C1884 Embosphere Pre-filled Syringe 300-500 Microns/2ml BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $339.38 $339.38 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $481.75 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $406.25 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 27200471 EAP HCPCS C1894 Introducer Sheath 7fr .1in 80cm Tuohy Borst Sidearm Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27200472 EAP HCPCS C1769 Guidewire Vascular 45d .016in 180cm 2mm Angled Flexible Tip BOTH IP/OP $725.00 $536.50 $0.00 $580.00 $393.68 $393.68 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $558.83 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $362.50 $574.20 $580.00 $0.00 $0.00 $0.00 $113.46 $0.00 $0.00 $115.42 $0.00 $0.00 $0.00 $0.00 $0.00 27200473 EAP HCPCS C1887 Catheter Guid Mpc Curve 5fr .056in 90cm Braid Radiopq Soft BOTH IP/OP $893.00 $660.82 $0.00 $714.40 $484.90 $484.90 $0.00 $0.00 $0.00 $186.12 $662.78 $662.78 $688.32 $0.00 $186.10 $0.00 $528.21 $528.21 $0.00 $446.50 $707.26 $714.40 $0.00 $580.45 $0.00 $139.75 $0.00 $0.00 $142.17 $0.00 $0.00 $0.00 $0.00 $0.00 27200474 EAP HCPCS C1725 Catheter Angiographic Motarjeme Curve 5fr .046in 100cm Braid BOTH IP/OP $310.00 $229.40 $0.00 $238.95 $168.33 $168.33 $0.00 $0.00 $0.00 $64.61 $230.08 $230.08 $238.95 $0.00 $64.60 $0.00 $183.37 $183.37 $0.00 $15.50 $24.55 $24.80 $0.00 $201.50 $0.00 $4.85 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 27200475 EAP HCPCS C1725 Catheter Angiographic .035in Pigtail 5fr .052in 90cm Ultra BOTH IP/OP $305.00 $225.70 $0.00 $244.00 $165.62 $165.62 $0.00 $0.00 $0.00 $63.57 $226.37 $226.37 $235.09 $0.00 $63.56 $0.00 $180.41 $180.41 $0.00 $152.50 $241.56 $244.00 $0.00 $198.25 $0.00 $47.73 $0.00 $0.00 $48.56 $0.00 $0.00 $0.00 $0.00 $0.00 27200476 EAP HCPCS C1769 Guidewire Vascular Str .018in 180cm 25cm Shapeable Shaft BOTH IP/OP $398.00 $294.52 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.00 $315.22 $318.40 $0.00 $0.00 $0.00 $62.29 $0.00 $0.00 $63.36 $0.00 $0.00 $0.00 $0.00 $0.00 27200477 EAP HCPCS C1769 Guidewire Vascular .014in 300cm 20cm Exchange Radiopq Distal BOTH IP/OP $896.00 $663.04 $0.00 $716.80 $486.53 $486.53 $0.00 $0.00 $0.00 $186.75 $665.01 $665.01 $690.64 $0.00 $186.73 $0.00 $529.98 $529.98 $0.00 $448.00 $709.63 $716.80 $0.00 $582.40 $0.00 $140.22 $0.00 $0.00 $142.64 $0.00 $0.00 $0.00 $0.00 $0.00 27200478 EAP HCPCS C1887 Catheter Infus 45d .014in Micro Str 1.9-2.4fr .017in 155cm BOTH IP/OP "$1,773.00 " "$1,312.02" $0.00 "$1,418.40" $962.74 $962.74 $0.00 $0.00 $0.00 $369.54 "$1,315.92" "$1,315.92" "$1,366.63" $0.00 $369.49 $0.00 "$1,048.73" "$1,048.73" $0.00 $886.50 "$1,404.22" "$1,418.40" $0.00 $0.00 $0.00 $277.47 $0.00 $0.00 $282.26 $0.00 $0.00 $0.00 $0.00 $0.00 27200479 EAP HCPCS C1887 Catheter Infus 90d .014in Micro Str 1.9-2.4fr .017in 155cm BOTH IP/OP "$1,688.00 " "$1,249.12" $0.00 "$1,350.40" $916.58 $916.58 $0.00 $0.00 $0.00 $351.82 "$1,252.83" "$1,252.83" "$1,301.11" $0.00 $351.78 $0.00 $998.45 $998.45 $0.00 $844.00 "$1,336.90" "$1,350.40" $0.00 "$1,097.20" $0.00 $264.17 $0.00 $0.00 $268.73 $0.00 $0.00 $0.00 $0.00 $0.00 27200481 EAP Custom 27200481 Catheter Vascular Occlusion 1028 Flocontrol Tn BOTH IP/OP "$6,988.00 " "$5,171.12" $0.00 "$5,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,386.35" $0.00 "$1,456.30" $0.00 $0.00 $0.00 $0.00 "$3,494.00" "$5,534.50" "$5,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200482 EAP HCPCS C1757 Catheter Reperfusion 4max BOTH IP/OP "$3,225.00 " "$2,386.50" $0.00 "$2,580.00" "$1,751.18" "$1,751.18" $0.00 $0.00 $0.00 $672.17 "$2,393.60" "$2,393.60" "$2,485.83" $0.00 $672.09 $0.00 "$1,907.59" "$1,907.59" $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 "$2,096.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200484 EAP Custom 27200484 Adhesive Ostomy Med Remain Flexible Silicone BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $34.69 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200485 EAP HCPCS C1887 Catheter Guid 9fr Balloon Cello BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27200496 EAP HCPCS C1894 Introducer Sheath .035in 7fr .1in 70cm Anl1 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27200714 EAP Custom 27200714 Compression Hose Lg/xlg Knee BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.23 $97.23 $100.97 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $85.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200751 EAP Custom 27200751 "Grasping Forceps, 10mm X 120cm" BOTH IP/OP $744.00 $550.56 $0.00 $595.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.20 $552.20 $573.48 $0.00 $155.05 $0.00 $0.00 $0.00 $0.00 $372.00 $589.25 $595.20 $0.00 $483.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200753 EAP Custom 27200753 "Grasping Forceps, 8mm X 120cm" BOTH IP/OP $708.00 $523.92 $0.00 $566.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.48 $525.48 $545.73 $0.00 $147.55 $0.00 $0.00 $0.00 $0.00 $354.00 $560.74 $566.40 $0.00 $460.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200755 EAP Custom 27200755 "Grasp Forceps, Stone Retrieval" BOTH IP/OP $705.00 $521.70 $0.00 $564.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.25 $523.25 $543.41 $0.00 $146.92 $0.00 $0.00 $0.00 $0.00 $352.50 $558.36 $564.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200766 EAP Custom 27200766 "Probe, Electrohydraulic Lithot" BOTH IP/OP $428.00 $316.72 $0.00 $342.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.66 $317.66 $329.90 $0.00 $89.20 $0.00 $0.00 $0.00 $0.00 $214.00 $338.98 $342.40 $0.00 $278.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200769 EAP Custom 27200769 Bipolar Forceps BOTH IP/OP $573.00 $424.02 $0.00 $458.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $425.28 $425.28 $441.67 $0.00 $119.41 $0.00 $0.00 $0.00 $0.00 $286.50 $453.82 $458.40 $0.00 $372.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27200834 EAP Custom 27200834 Wet Field Cautery BOTH IP/OP $136.00 $100.64 $0.00 $108.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.94 $100.94 $104.83 $0.00 $28.34 $0.00 $0.00 $0.00 $0.00 $68.00 $107.71 $108.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201077 EAP HCPCS C1769 "Guide Wire, 292.653" BOTH IP/OP $183.00 $135.42 $0.00 $146.40 $99.37 $99.37 $0.00 $0.00 $0.00 $38.14 $135.82 $135.82 $141.06 $0.00 $38.14 $0.00 $108.24 $108.24 $0.00 $91.50 $144.94 $146.40 $0.00 $0.00 $0.00 $28.64 $0.00 $0.00 $29.13 $0.00 $0.00 $0.00 $0.00 $0.00 27201301 EAP Custom 27201301 "Drill Bit, 357.047" BOTH IP/OP "$1,952.00 " "$1,444.48" $0.00 "$1,561.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,448.77" "$1,448.77" "$1,504.60" $0.00 $406.80 $0.00 $0.00 $0.00 $0.00 $976.00 "$1,545.98" "$1,561.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201369 EAP Custom 27201369 Endo Disposable Lap. Instr. BOTH IP/OP $977.00 $722.98 $0.00 $781.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $725.13 $725.13 $753.07 $0.00 $203.61 $0.00 $0.00 $0.00 $0.00 $488.50 $773.78 $781.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201377 EAP Custom 27201377 Ta Premium Dlu Staples BOTH IP/OP "$1,093.00 " $808.82 $0.00 $874.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $811.22 $811.22 $842.48 $0.00 $227.78 $0.00 $0.00 $0.00 $0.00 $546.50 $865.66 $874.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201399 EAP Custom 27201399 Bipolar Bovie BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $7.00 $11.09 $11.20 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201400 EAP Custom 27201400 Micro Clips BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201403 EAP Custom 27201403 Abd Binder BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201407 EAP Custom 27201407 Dermabond BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.57 $64.57 $67.06 $0.00 $18.13 $0.00 $0.00 $0.00 $0.00 $43.50 $68.90 $69.60 $0.00 $56.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201456 EAP Custom 27201456 "Grasping Forceps, 10mm X 120cm" BOTH IP/OP $744.00 $550.56 $0.00 $595.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.20 $552.20 $573.48 $0.00 $155.05 $0.00 $0.00 $0.00 $0.00 $372.00 $589.25 $595.20 $0.00 $483.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201458 EAP Custom 27201458 "Grasping Forceps, Stone Retrie" BOTH IP/OP $705.00 $521.70 $0.00 $564.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.25 $523.25 $543.41 $0.00 $146.92 $0.00 $0.00 $0.00 $0.00 $352.50 $558.36 $564.00 $0.00 $458.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201474 EAP Custom 27201474 "Grasping Forceps, 8mm X 120cm" BOTH IP/OP $707.00 $523.18 $0.00 $565.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $524.74 $524.74 $544.96 $0.00 $147.34 $0.00 $0.00 $0.00 $0.00 $353.50 $559.94 $565.60 $0.00 $459.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201489 EAP Custom 27201489 Irrigation Clip BOTH IP/OP $214.00 $158.36 $0.00 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.83 $158.83 $164.95 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $107.00 $169.49 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201492 EAP Custom 27201492 Jp Drain (hemaduct) BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201536 EAP Custom 27201536 Compression Hose Reg. Knee BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $0.00 $0.00 $0.00 $50.50 $79.99 $80.80 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201626 EAP Custom 27201626 "Cath,intra-aortic Balloon" BOTH IP/OP "$4,716.00 " "$3,489.84" $0.00 "$3,772.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,358.00" "$3,735.07" "$3,772.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201630 EAP Custom 27201630 "Cath,chest Tube Rt. Angled" BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $104.06 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $87.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201680 EAP Custom 27201680 Catheter Angio .038in Ka2 Crv 5fr .046in 40cm Impr BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201681 EAP Custom 27201681 Catheter Angio .038in Ka2 Crv 5fr .046in 65cm Prfm BOTH IP/OP $153.00 $113.22 $0.00 $122.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.56 $113.56 $117.93 $0.00 $31.89 $0.00 $0.00 $0.00 $0.00 $76.50 $121.18 $122.40 $0.00 $99.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201700 EAP Custom 27201700 Rbc Filter Unit BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.60 $61.60 $63.98 $0.00 $17.30 $0.00 $0.00 $0.00 $0.00 $41.50 $65.74 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201701 EAP Custom 27201701 Plat Filter Unit BOTH IP/OP $215.00 $159.10 $0.00 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.57 $159.57 $165.72 $0.00 $44.81 $0.00 $0.00 $0.00 $0.00 $107.50 $170.28 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201702 EAP Custom 27201702 Plf1 Filter Unit BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201800 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $3.26 $3.26 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 27201801 EAP HCPCS C1769 Guidewire .35x150cm Bentson BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $41.27 $41.27 $0.00 $0.00 $0.00 $15.84 $56.41 $56.41 $58.58 $0.00 $15.84 $0.00 $44.95 $44.95 $0.00 $38.00 $60.19 $60.80 $0.00 $49.40 $0.00 $11.89 $0.00 $0.00 $12.10 $0.00 $0.00 $0.00 $0.00 $0.00 27201802 EAP HCPCS C1750 24cm Duraflow Catheter BOTH IP/OP "$2,096.00 " "$1,551.04" $0.00 "$1,676.80" "$1,138.13" "$1,138.13" $0.00 $0.00 $0.00 $436.86 "$1,555.65" "$1,555.65" "$1,615.60" $0.00 $436.81 $0.00 "$1,239.78" "$1,239.78" $0.00 "$1,048.00" "$1,660.03" "$1,676.80" $0.00 $0.00 $0.00 $328.02 $0.00 $0.00 $333.68 $0.00 $0.00 $0.00 $0.00 $0.00 27201803 EAP HCPCS C1750 28cm Duraflow Catheter BOTH IP/OP "$1,720.00 " "$1,272.80" $0.00 "$1,376.00" $933.96 $933.96 $0.00 $0.00 $0.00 $358.49 "$1,276.58" "$1,276.58" "$1,325.78" $0.00 $358.45 $0.00 "$1,017.38" "$1,017.38" $0.00 $860.00 "$1,362.24" "$1,376.00" $0.00 $0.00 $0.00 $269.18 $0.00 $0.00 $273.82 $0.00 $0.00 $0.00 $0.00 $0.00 27201804 EAP HCPCS C1752 24cm Schon Xl Temp Cath BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $242.80 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201805 EAP HCPCS C1751 5x1235x20cm Unifuse Kit BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $298.65 $298.65 $0.00 $0.00 $0.00 $114.63 $408.21 $408.21 $423.94 $0.00 $114.62 $0.00 $325.33 $325.33 $0.00 $275.00 $435.60 $440.00 $0.00 $357.50 $0.00 $86.08 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 27201806 EAP HCPCS C1751 5x135x10cm Unifuse Kit BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $298.65 $298.65 $0.00 $0.00 $0.00 $114.63 $408.21 $408.21 $423.94 $0.00 $114.62 $0.00 $325.33 $325.33 $0.00 $275.00 $435.60 $440.00 $0.00 $357.50 $0.00 $86.08 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 27201807 EAP HCPCS C1725 8-4/5/75 Workhorse Pta BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201808 EAP HCPCS C1752 Temporary Dialysis Cath BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $242.80 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $204.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201809 EAP HCPCS C1752 Temporay Dialysis Cath BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.23 $549.23 $570.39 $0.00 $154.22 $0.00 $0.00 $0.00 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201810 EAP HCPCS C1725 Workhorse Pta Balloon BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201811 EAP HCPCS C1725 Workhorse Pta Balloon BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201812 EAP HCPCS C1725 Wrkhorse Balloon 5-2/5/75 BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201813 EAP HCPCS C1725 Wrkhrse Balloon 10-4/5/75 BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201814 EAP HCPCS C1725 Wrkhrse Balloon 5-2/5/100 BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201815 EAP HCPCS C1725 Wrkhrse Balloon 6-2/5/75 BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201816 EAP HCPCS C1751 5fr Dual Lumen Picc Line BOTH IP/OP $533.00 $394.42 $0.00 $426.40 $289.42 $289.42 $0.00 $0.00 $0.00 $111.09 $395.59 $395.59 $410.84 $0.00 $111.08 $0.00 $315.27 $315.27 $0.00 $266.50 $422.14 $426.40 $0.00 $0.00 $0.00 $83.41 $0.00 $0.00 $84.85 $0.00 $0.00 $0.00 $0.00 $0.00 27201817 EAP HCPCS C1751 5fr Sgle Lumen Pic Line BOTH IP/OP $419.00 $310.06 $0.00 $335.20 $227.52 $227.52 $0.00 $0.00 $0.00 $87.33 $310.98 $310.98 $322.97 $0.00 $87.32 $0.00 $247.84 $247.84 $0.00 $209.50 $331.85 $335.20 $0.00 $0.00 $0.00 $65.57 $0.00 $0.00 $66.70 $0.00 $0.00 $0.00 $0.00 $0.00 27201818 EAP HCPCS C1757 Thrombex Device BOTH IP/OP "$5,955.00 " "$4,406.70" $0.00 "$4,764.00" "$3,233.57" "$3,233.57" $0.00 $0.00 $0.00 "$1,241.17" "$4,181.12" "$4,181.12" "$4,590.11" $0.00 "$1,241.02" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,977.50" "$4,716.36" "$4,764.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201819 EAP HCPCS C1769 Guidewire .035/260m Exchange BOTH IP/OP $149.00 $110.26 $0.00 $119.20 $80.91 $80.91 $0.00 $0.00 $0.00 $31.06 $110.59 $110.59 $114.85 $0.00 $31.05 $0.00 $88.13 $88.13 $0.00 $74.50 $118.01 $119.20 $0.00 $96.85 $0.00 $23.32 $0.00 $0.00 $23.72 $0.00 $0.00 $0.00 $0.00 $0.00 27201820 EAP HCPCS C1769 Guidewire .035-150cm Angled Stiff BOTH IP/OP $167.00 $123.58 $0.00 $133.60 $90.68 $90.68 $0.00 $0.00 $0.00 $34.81 $123.95 $123.95 $128.72 $0.00 $34.80 $0.00 $98.78 $98.78 $0.00 $83.50 $132.26 $133.60 $0.00 $108.55 $0.00 $26.14 $0.00 $0.00 $26.59 $0.00 $0.00 $0.00 $0.00 $0.00 27201821 EAP HCPCS C1751 12cm Katzen Infusion Cath BOTH IP/OP "$1,506.00 " "$1,114.44" $0.00 "$1,204.80" $817.76 $817.76 $0.00 $0.00 $0.00 $313.89 "$1,117.75" "$1,117.75" "$1,160.82" $0.00 $313.85 $0.00 $890.80 $890.80 $0.00 $753.00 "$1,192.75" "$1,204.80" $0.00 $0.00 $0.00 $235.69 $0.00 $0.00 $239.76 $0.00 $0.00 $0.00 $0.00 $0.00 27201822 EAP HCPCS C1751 150/20 Tracker-18 Infusio BOTH IP/OP "$3,033.00 " "$2,244.42" $0.00 "$2,426.40" "$1,646.92" "$1,646.92" $0.00 $0.00 $0.00 $632.15 "$2,251.09" "$2,251.09" "$2,337.84" $0.00 $632.08 $0.00 "$1,794.02" "$1,794.02" $0.00 "$1,516.50" "$2,402.14" "$2,426.40" $0.00 $0.00 $0.00 $474.66 $0.00 $0.00 $482.85 $0.00 $0.00 $0.00 $0.00 $0.00 27201823 EAP HCPCS C1769 32-150 Angled Guidewire BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $155.84 $155.84 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $221.22 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 27201824 EAP HCPCS C1894 5fr Pinnacle Introducer BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $36.38 $36.38 $0.00 $0.00 $0.00 $13.96 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $39.63 $39.63 $0.00 $33.50 $53.06 $53.60 $0.00 $0.00 $0.00 $10.49 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 27201825 EAP HCPCS C1887 5fr-100cm At Catheter BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $20.09 $20.09 $0.00 $0.00 $0.00 $7.71 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $21.89 $21.89 $0.00 $18.50 $29.30 $29.60 $0.00 $24.05 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 27201826 EAP HCPCS C1751 A50/20 Fastracker-18 Infu BOTH IP/OP "$1,590.00 " "$1,176.60" $0.00 "$1,272.00" $863.37 $863.37 $0.00 $0.00 $0.00 $331.40 "$1,180.10" "$1,180.10" "$1,225.57" $0.00 $331.36 $0.00 $940.49 $940.49 $0.00 $795.00 "$1,259.28" "$1,272.00" $0.00 $0.00 $0.00 $248.84 $0.00 $0.00 $253.13 $0.00 $0.00 $0.00 $0.00 $0.00 27201827 EAP HCPCS C1769 Amplatz Guidewire 260cm BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $70.05 $70.05 $0.00 $0.00 $0.00 $26.89 $95.74 $95.74 $99.43 $0.00 $26.88 $0.00 $76.30 $76.30 $0.00 $64.50 $102.17 $103.20 $0.00 $83.85 $0.00 $20.19 $0.00 $0.00 $20.54 $0.00 $0.00 $0.00 $0.00 $0.00 27201828 EAP HCPCS C1725 Catheter Balloon 6-10/5 BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $106.58 $0.00 $0.00 $108.42 $0.00 $0.00 $0.00 $0.00 $0.00 27201829 EAP HCPCS C1887 Glidecath C2 Hydeophilic BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $95.03 $95.03 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $134.89 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $113.75 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 27201830 EAP HCPCS C1769 Glidewire .035 150cm Angled BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $54.84 $54.84 $0.00 $0.00 $0.00 $21.05 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $59.74 $59.74 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $15.81 $0.00 $0.00 $16.08 $0.00 $0.00 $0.00 $0.00 $0.00 27201831 EAP HCPCS C1769 Guidewire Amplatz Super BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 27201832 EAP HCPCS C1769 Guidewire-long Taper BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $169.96 $169.96 $0.00 $0.00 $0.00 $65.24 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $185.14 $185.14 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 27201833 EAP HCPCS C1769 Transcend Steerable BOTH IP/OP $546.00 $404.04 $0.00 $533.60 $296.48 $296.48 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $420.86 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $333.50 $528.26 $533.60 $0.00 $354.90 $0.00 $104.39 $0.00 $0.00 $106.19 $0.00 $0.00 $0.00 $0.00 $0.00 27201834 EAP HCPCS C1725 Xxl 14-4/5.8/120 BOTH IP/OP $856.00 $633.44 $0.00 $684.80 $464.81 $464.81 $0.00 $0.00 $0.00 $178.41 $635.32 $635.32 $659.80 $0.00 $178.39 $0.00 $506.32 $506.32 $0.00 $428.00 $677.95 $684.80 $0.00 $0.00 $0.00 $133.96 $0.00 $0.00 $136.28 $0.00 $0.00 $0.00 $0.00 $0.00 27201835 EAP HCPCS C1725 Xxl/12-5/5.8/120 Balloon BOTH IP/OP $856.00 $633.44 $0.00 $684.80 $464.81 $464.81 $0.00 $0.00 $0.00 $178.41 $635.32 $635.32 $659.80 $0.00 $178.39 $0.00 $506.32 $506.32 $0.00 $428.00 $677.95 $684.80 $0.00 $0.00 $0.00 $133.96 $0.00 $0.00 $136.28 $0.00 $0.00 $0.00 $0.00 $0.00 27201836 EAP HCPCS C1769 Guidewire .035-260cm Bentson E BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $47.78 $47.78 $0.00 $0.00 $0.00 $18.34 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $52.05 $52.05 $0.00 $44.00 $69.70 $70.40 $0.00 $57.20 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 27201837 EAP HCPCS C1729 10.2fr Mp Drain Catheter BOTH IP/OP $296.00 $219.04 $0.00 $236.80 $160.73 $160.73 $0.00 $0.00 $0.00 $61.69 $219.69 $219.69 $228.16 $0.00 $61.69 $0.00 $175.08 $175.08 $0.00 $148.00 $234.43 $236.80 $0.00 $192.40 $0.00 $46.32 $0.00 $0.00 $47.12 $0.00 $0.00 $0.00 $0.00 $0.00 27201838 EAP HCPCS C1894 11fr-70cm Introducer Set BOTH IP/OP $233.00 $172.42 $0.00 $186.40 $126.52 $126.52 $0.00 $0.00 $0.00 $48.56 $172.93 $172.93 $179.60 $0.00 $48.56 $0.00 $137.82 $137.82 $0.00 $116.50 $184.54 $186.40 $0.00 $151.45 $0.00 $36.46 $0.00 $0.00 $37.09 $0.00 $0.00 $0.00 $0.00 $0.00 27201839 EAP HCPCS C1729 14.0fr Mp Drain Catheter BOTH IP/OP $289.00 $213.86 $0.00 $231.20 $156.93 $156.93 $0.00 $0.00 $0.00 $60.23 $214.50 $214.50 $222.76 $0.00 $60.23 $0.00 $170.94 $170.94 $0.00 $144.50 $228.89 $231.20 $0.00 $0.00 $0.00 $45.23 $0.00 $0.00 $46.01 $0.00 $0.00 $0.00 $0.00 $0.00 27201840 EAP Custom 27201840 35-3-5 Embolization Coil BOTH IP/OP $172.00 $127.28 $0.00 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.66 $127.66 $132.58 $0.00 $35.84 $0.00 $0.00 $0.00 $0.00 $86.00 $136.22 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201841 EAP Custom 27201841 35-5-10 Embolization Coil BOTH IP/OP $279.00 $206.46 $0.00 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.07 $207.07 $215.05 $0.00 $58.14 $0.00 $0.00 $0.00 $0.00 $139.50 $220.97 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201842 EAP Custom 27201842 35-5-3 Embolization Coil BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.22 $169.22 $175.74 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.00 $180.58 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201843 EAP Custom 27201843 35-5-8 Embolization Coil BOTH IP/OP $167.00 $123.58 $0.00 $133.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.95 $123.95 $128.72 $0.00 $34.80 $0.00 $0.00 $0.00 $0.00 $83.50 $132.26 $133.60 $0.00 $75.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201844 EAP HCPCS C1893 5fr80cm Neff Catheter BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 27201845 EAP HCPCS C1894 6fr Balkan Introducer Set BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $32.58 $32.58 $0.00 $0.00 $0.00 $12.51 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $35.49 $35.49 $0.00 $30.00 $47.52 $48.00 $0.00 $39.00 $0.00 $9.39 $0.00 $0.00 $9.55 $0.00 $0.00 $0.00 $0.00 $0.00 27201846 EAP HCPCS C1894 7fr Balkan Introducer Set BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $92.31 $92.31 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $131.04 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 27201847 EAP HCPCS C1729 8.5fr Mp Drain Catheter BOTH IP/OP $311.00 $230.14 $0.00 $248.80 $168.87 $168.87 $0.00 $0.00 $0.00 $64.82 $230.82 $230.82 $239.72 $0.00 $64.81 $0.00 $183.96 $183.96 $0.00 $155.50 $246.31 $248.80 $0.00 $202.15 $0.00 $48.67 $0.00 $0.00 $49.51 $0.00 $0.00 $0.00 $0.00 $0.00 27201848 EAP HCPCS C1729 9.5fr Biliary Drain Cath. BOTH IP/OP $296.00 $219.04 $0.00 $236.80 $160.73 $160.73 $0.00 $0.00 $0.00 $61.69 $219.69 $219.69 $228.16 $0.00 $61.69 $0.00 $175.08 $175.08 $0.00 $148.00 $234.43 $236.80 $0.00 $192.40 $0.00 $46.32 $0.00 $0.00 $47.12 $0.00 $0.00 $0.00 $0.00 $0.00 27201849 EAP HCPCS C1757 Coil Embolization 35-4-3 BOTH IP/OP $172.00 $127.28 $0.00 $137.60 $93.40 $93.40 $0.00 $0.00 $0.00 $35.85 $127.66 $127.66 $132.58 $0.00 $35.84 $0.00 $101.74 $101.74 $0.00 $86.00 $136.22 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201850 EAP HCPCS C1769 Dtdw35-80-10 Deflecting BOTH IP/OP $520.00 $384.80 $0.00 $416.00 $282.36 $282.36 $0.00 $0.00 $0.00 $108.38 $385.94 $385.94 $400.82 $0.00 $108.37 $0.00 $307.58 $307.58 $0.00 $260.00 $411.84 $416.00 $0.00 $0.00 $0.00 $81.38 $0.00 $0.00 $82.78 $0.00 $0.00 $0.00 $0.00 $0.00 27201851 EAP HCPCS C1773 Filter Retrieval Set BOTH IP/OP $886.00 $655.64 $0.00 $708.80 $481.10 $481.10 $0.00 $0.00 $0.00 $184.66 $657.59 $657.59 $682.93 $0.00 $184.64 $0.00 $524.07 $524.07 $0.00 $443.00 $701.71 $708.80 $0.00 $575.90 $0.00 $138.66 $0.00 $0.00 $141.05 $0.00 $0.00 $0.00 $0.00 $0.00 27201852 EAP HCPCS C1769 Guidewire Cope Mandril BOTH IP/OP $116.00 $85.84 $0.00 $92.80 $62.99 $62.99 $0.00 $0.00 $0.00 $24.18 $86.10 $86.10 $89.41 $0.00 $24.17 $0.00 $68.61 $68.61 $0.00 $58.00 $91.87 $92.80 $0.00 $75.40 $0.00 $18.15 $0.00 $0.00 $18.47 $0.00 $0.00 $0.00 $0.00 $0.00 27201853 EAP HCPCS C1769 Lewis Micropunture Set BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $70.59 $70.59 $0.00 $0.00 $0.00 $27.10 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $76.90 $76.90 $0.00 $65.00 $102.96 $104.00 $0.00 $84.50 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 27201854 EAP HCPCS C2629 Micropuncture Set BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $60.33 $60.33 $0.00 $51.00 $80.78 $81.60 $0.00 $66.30 $0.00 $15.96 $0.00 $0.00 $16.24 $0.00 $0.00 $0.00 $0.00 $0.00 27201855 EAP HCPCS C1894 8fr-23cmavanti-introducer BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $5.43 $5.43 $0.00 $0.00 $0.00 $2.08 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $5.92 $5.92 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $1.57 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 27201856 EAP HCPCS C1894 9fr-23cm Avanti Introduce BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $5.43 $5.43 $0.00 $0.00 $0.00 $2.08 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $5.92 $5.92 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $1.57 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 27201857 EAP HCPCS C1773 12-20mmx120cm Std Snare BOTH IP/OP "$1,119.00 " $828.06 $0.00 $895.20 $607.62 $607.62 $0.00 $0.00 $0.00 $233.23 $830.52 $830.52 $862.53 $0.00 $233.20 $0.00 $661.89 $661.89 $0.00 $559.50 $886.25 $895.20 $0.00 $727.35 $0.00 $175.12 $0.00 $0.00 $178.14 $0.00 $0.00 $0.00 $0.00 $0.00 27201858 EAP HCPCS C1773 9-15mmx120cm Std Snare BOTH IP/OP "$1,119.00 " $828.06 $0.00 $895.20 $607.62 $607.62 $0.00 $0.00 $0.00 $233.23 $830.52 $830.52 $862.53 $0.00 $233.20 $0.00 $661.89 $661.89 $0.00 $559.50 $886.25 $895.20 $0.00 $727.35 $0.00 $175.12 $0.00 $0.00 $178.14 $0.00 $0.00 $0.00 $0.00 $0.00 27201859 EAP HCPCS C1725 Wrkhorse Balloon 10-4/5/100 BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201860 EAP HCPCS C1894 Pinnacle Introducer 5fr 10cm BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $43.44 $43.44 $0.00 $0.00 $0.00 $16.67 $59.38 $59.38 $61.66 $0.00 $16.67 $0.00 $47.32 $47.32 $0.00 $40.00 $63.36 $64.00 $0.00 $52.00 $0.00 $12.52 $0.00 $0.00 $12.74 $0.00 $0.00 $0.00 $0.00 $0.00 27201861 EAP HCPCS C1725 Conquest Pta Balloon Dilatatio BOTH IP/OP $753.00 $557.22 $0.00 $602.40 $408.88 $408.88 $0.00 $0.00 $0.00 $156.94 $558.88 $558.88 $580.41 $0.00 $156.93 $0.00 $445.40 $445.40 $0.00 $376.50 $596.38 $602.40 $0.00 $489.45 $0.00 $117.84 $0.00 $0.00 $119.88 $0.00 $0.00 $0.00 $0.00 $0.00 27201862 EAP HCPCS C1725 Opti-plast Balloon Dilatation BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $272.04 $272.04 $0.00 $0.00 $0.00 $104.42 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $296.34 $296.34 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $78.41 $0.00 $0.00 $79.76 $0.00 $0.00 $0.00 $0.00 $0.00 27201863 EAP HCPCS C1725 Workhorse Pta Workhorse Balloo BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27201864 EAP HCPCS C1769 Guidewire Straight Fixed Core BOTH IP/OP $86.00 $63.64 $0.00 $68.80 $46.70 $46.70 $0.00 $0.00 $0.00 $17.92 $63.83 $63.83 $66.29 $0.00 $17.92 $0.00 $50.87 $50.87 $0.00 $43.00 $68.11 $68.80 $0.00 $0.00 $0.00 $13.46 $0.00 $0.00 $13.69 $0.00 $0.00 $0.00 $0.00 $0.00 27201865 EAP HCPCS C1769 Guidewire 3mm J Fixed Core .03 BOTH IP/OP $46.00 $34.04 $0.00 $36.80 $24.98 $24.98 $0.00 $0.00 $0.00 $9.59 $34.14 $34.14 $35.46 $0.00 $9.59 $0.00 $27.21 $27.21 $0.00 $23.00 $36.43 $36.80 $0.00 $29.90 $0.00 $7.20 $0.00 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $0.00 27201866 EAP HCPCS C1894 Pinnacle Introducer 6fr 10cm BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $41.27 $41.27 $0.00 $0.00 $0.00 $15.84 $56.41 $56.41 $58.58 $0.00 $15.84 $0.00 $44.95 $44.95 $0.00 $38.00 $60.19 $60.80 $0.00 $0.00 $0.00 $11.89 $0.00 $0.00 $12.10 $0.00 $0.00 $0.00 $0.00 $0.00 27201867 EAP HCPCS C1894 8fr 10cm Pinnacle Introducer BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $39.10 $39.10 $0.00 $0.00 $0.00 $15.01 $53.44 $53.44 $55.50 $0.00 $15.00 $0.00 $42.59 $42.59 $0.00 $36.00 $57.02 $57.60 $0.00 $46.80 $0.00 $11.27 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $0.00 27201868 EAP HCPCS C1894 Pinnacle Introducer 8fr 10cm BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $36.38 $36.38 $0.00 $0.00 $0.00 $13.96 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $39.63 $39.63 $0.00 $33.50 $53.06 $53.60 $0.00 $0.00 $0.00 $10.49 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 27201869 EAP HCPCS C1894 Pinnacle Introducer 9fr 10cm BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $12.52 $0.00 $0.00 $12.74 $0.00 $0.00 $0.00 $0.00 $0.00 27201870 EAP HCPCS C1757 Fogarty 5.5-40cm BOTH IP/OP $352.00 $260.48 $0.00 $281.60 $191.14 $191.14 $0.00 $0.00 $0.00 $73.37 $261.25 $261.25 $271.32 $0.00 $73.36 $0.00 $208.21 $208.21 $0.00 $176.00 $278.78 $281.60 $0.00 $228.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201871 EAP HCPCS C1757 Fogarty 5.5 80cm BOTH IP/OP $352.00 $260.48 $0.00 $281.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.00 $278.78 $281.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201872 EAP HCPCS C1757 Arrow Trerotola Thromolytic De BOTH IP/OP "$1,805.00 " "$1,335.70" $0.00 "$1,444.00" $980.12 $980.12 $0.00 $0.00 $0.00 $376.21 "$1,339.67" "$1,339.67" "$1,391.29" $0.00 $376.16 $0.00 "$1,067.66" "$1,067.66" $0.00 $902.50 "$1,429.56" "$1,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201873 EAP HCPCS C1757 Complex Fiber Coil 18 X 3mm X BOTH IP/OP "$1,212.00 " $896.88 $0.00 $969.60 $658.12 $658.12 $0.00 $0.00 $0.00 $252.61 $899.55 $899.55 $934.21 $0.00 $252.58 $0.00 $716.90 $716.90 $0.00 $606.00 $959.90 $969.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201874 EAP HCPCS C1729 Skater 10fr BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $328.52 $328.52 $0.00 $0.00 $0.00 $126.10 $449.03 $449.03 $466.33 $0.00 $126.08 $0.00 $357.86 $357.86 $0.00 $302.50 $479.16 $484.00 $0.00 $0.00 $0.00 $94.68 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $0.00 27201875 EAP HCPCS C1887 Lima Guiding Catheter 7fr-55cm BOTH IP/OP $417.00 $308.58 $0.00 $333.60 $226.43 $226.43 $0.00 $0.00 $0.00 $86.91 $309.50 $309.50 $321.42 $0.00 $86.90 $0.00 $246.66 $246.66 $0.00 $208.50 $330.26 $333.60 $0.00 $0.00 $0.00 $65.26 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 27201876 EAP HCPCS C1892 Meditech Accustick Ii Introduc BOTH IP/OP $209.00 $154.66 $0.00 $167.20 $113.49 $113.49 $0.00 $0.00 $0.00 $43.56 $155.12 $155.12 $161.10 $0.00 $43.56 $0.00 $123.62 $123.62 $0.00 $104.50 $165.53 $167.20 $0.00 $135.85 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 27201877 EAP HCPCS C1769 22g X 10cm Chiba Needle BOTH IP/OP $27.00 $19.98 $0.00 $56.00 $14.66 $14.66 $0.00 $0.00 $0.00 $5.63 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $15.97 $15.97 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 27201878 EAP HCPCS C1769 .038-145 Amplatz Extra Stiff BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $41.27 $41.27 $0.00 $0.00 $0.00 $15.84 $56.41 $56.41 $58.58 $0.00 $15.84 $0.00 $44.95 $44.95 $0.00 $38.00 $60.19 $60.80 $0.00 $49.40 $0.00 $11.89 $0.00 $0.00 $12.10 $0.00 $0.00 $0.00 $0.00 $0.00 27201879 EAP HCPCS C1751 9fr Single Lumen Hickman BOTH IP/OP $241.00 $178.34 $0.00 $192.80 $130.86 $130.86 $0.00 $0.00 $0.00 $50.23 $178.87 $178.87 $185.76 $0.00 $50.22 $0.00 $142.55 $142.55 $0.00 $120.50 $190.87 $192.80 $0.00 $156.65 $0.00 $37.72 $0.00 $0.00 $38.37 $0.00 $0.00 $0.00 $0.00 $0.00 27201880 EAP HCPCS C1751 9fr Dual Lumen Hickman BOTH IP/OP $528.00 $390.72 $0.00 $422.40 $286.70 $286.70 $0.00 $0.00 $0.00 $110.05 $391.88 $391.88 $406.98 $0.00 $110.04 $0.00 $312.31 $312.31 $0.00 $264.00 $418.18 $422.40 $0.00 $0.00 $0.00 $82.63 $0.00 $0.00 $84.06 $0.00 $0.00 $0.00 $0.00 $0.00 27201881 EAP HCPCS C1769 .035-150cm 3mm J Guidewire BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $36.92 $36.92 $0.00 $0.00 $0.00 $14.17 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $40.22 $40.22 $0.00 $34.00 $53.86 $54.40 $0.00 $44.20 $0.00 $10.64 $0.00 $0.00 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 27201882 EAP HCPCS C1769 .035-150cm Rosen Guidewire BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 27201883 EAP HCPCS C1752 "12cm Niagra, Temp Dialysis Cat" BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201884 EAP HCPCS C1752 "15cm Niagra, Temp Dialysis Cat" BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201885 EAP HCPCS C1725 8-2/5/100 Workhorse Balloon BOTH IP/OP $427.00 $315.98 $0.00 $341.60 $231.86 $231.86 $0.00 $0.00 $0.00 $89.00 $316.92 $316.92 $329.13 $0.00 $88.99 $0.00 $252.57 $252.57 $0.00 $213.50 $338.18 $341.60 $0.00 $0.00 $0.00 $66.83 $0.00 $0.00 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 27201886 EAP HCPCS C1725 4-2/5/75 Opti-plast Balloon BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $272.04 $272.04 $0.00 $0.00 $0.00 $104.42 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $296.34 $296.34 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $78.41 $0.00 $0.00 $79.76 $0.00 $0.00 $0.00 $0.00 $0.00 27201887 EAP HCPCS C1725 3-way Hp Stopcock BOTH IP/OP $934.00 $691.16 $0.00 $747.20 $507.16 $507.16 $0.00 $0.00 $0.00 $194.67 $693.21 $693.21 $719.93 $0.00 $194.65 $0.00 $552.46 $552.46 $0.00 $467.00 $739.73 $747.20 $0.00 $0.00 $0.00 $146.17 $0.00 $0.00 $148.69 $0.00 $0.00 $0.00 $0.00 $0.00 27201888 EAP HCPCS C1894 7fr 10cm Pinnacle Introducer BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $38.55 $38.55 $0.00 $0.00 $0.00 $14.80 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $42.00 $42.00 $0.00 $35.50 $56.23 $56.80 $0.00 $46.15 $0.00 $11.11 $0.00 $0.00 $11.30 $0.00 $0.00 $0.00 $0.00 $0.00 27201889 EAP HCPCS C1894 7fr 10cm Pinnacle Introducer BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $73.31 $73.31 $0.00 $0.00 $0.00 $28.14 $100.20 $100.20 $104.06 $0.00 $28.13 $0.00 $79.85 $79.85 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $21.13 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $0.00 27201890 EAP HCPCS C1725 12-2/5.8/75 Udt Dilatation Bal BOTH IP/OP $889.00 $657.86 $0.00 $711.20 $482.73 $482.73 $0.00 $0.00 $0.00 $185.29 $659.82 $659.82 $685.24 $0.00 $185.27 $0.00 $525.84 $525.84 $0.00 $444.50 $704.09 $711.20 $0.00 $0.00 $0.00 $139.13 $0.00 $0.00 $141.53 $0.00 $0.00 $0.00 $0.00 $0.00 27201891 EAP HCPCS C1729 8fr Flexima Biliary Catheter BOTH IP/OP $271.00 $200.54 $0.00 $216.80 $147.15 $147.15 $0.00 $0.00 $0.00 $56.48 $201.14 $201.14 $208.89 $0.00 $56.48 $0.00 $160.30 $160.30 $0.00 $135.50 $214.63 $216.80 $0.00 $176.15 $0.00 $42.41 $0.00 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $0.00 27201892 EAP HCPCS C1729 Cx 18.0-38-40-p-32s-bcl BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27201893 EAP Custom 27201893 Tibia Fracture Brace BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.97 $359.97 $373.84 $0.00 $101.07 $0.00 $0.00 $0.00 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201905 EAP Custom 27201905 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201906 EAP HCPCS A6250 Wound Paste BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $24.59 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $69.80 $69.80 $0.00 $59.00 $93.46 $94.40 $0.00 $76.70 $0.00 $18.47 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 27201914 EAP Custom 27201914 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27201930 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27201931 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $11.70 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27201932 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27202362 EAP Custom 27202362 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202368 EAP Custom 27202368 Scapel Surg W/handle Att BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202375 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27202376 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27202377 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27202384 EAP HCPCS C1729 Catheter Foley 30cc 28fr BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $21.18 $21.18 $0.00 $0.00 $0.00 $8.13 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $6.10 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 27202388 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $12.35 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27202389 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27202390 EAP HCPCS C1729 Catheter Coude Size 16fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27202395 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27202396 EAP HCPCS C1729 Catheter Coude 30cc 24fr BOTH IP/OP $82.00 $60.68 $0.00 $65.60 $44.53 $44.53 $0.00 $0.00 $0.00 $17.09 $60.86 $60.86 $63.21 $0.00 $17.09 $0.00 $48.50 $48.50 $0.00 $41.00 $64.94 $65.60 $0.00 $0.00 $0.00 $12.83 $0.00 $0.00 $13.05 $0.00 $0.00 $0.00 $0.00 $0.00 27202397 EAP Custom 27202397 Scapel Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202403 EAP Custom 27202403 Scaple Surg W/handle Atta BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202406 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $25.52 $25.52 $0.00 $0.00 $0.00 $9.80 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $27.80 $27.80 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $7.36 $0.00 $0.00 $7.48 $0.00 $0.00 $0.00 $0.00 $0.00 27202407 EAP HCPCS C1729 Catheter Coude 30cc 24fr BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $47.24 $47.24 $0.00 $0.00 $0.00 $18.13 $64.57 $64.57 $67.06 $0.00 $18.13 $0.00 $51.46 $51.46 $0.00 $43.50 $68.90 $69.60 $0.00 $0.00 $0.00 $13.62 $0.00 $0.00 $13.85 $0.00 $0.00 $0.00 $0.00 $0.00 27202418 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27202419 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $11.70 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27202420 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27202421 EAP HCPCS C1729 Catheter Foley 3-way 30cc BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $20.09 $20.09 $0.00 $0.00 $0.00 $7.71 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $21.89 $21.89 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 27202432 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27202433 EAP HCPCS C1729 Catheter Coude Size 14fr BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $59.19 $59.19 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 27202434 EAP HCPCS C1729 Catheter Coude Size 16fr BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $55.39 $55.39 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $60.33 $60.33 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $15.96 $0.00 $0.00 $16.24 $0.00 $0.00 $0.00 $0.00 $0.00 27202435 EAP Custom 27202435 Scapel Surg W/handle Attached BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202446 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27202447 EAP HCPCS C1729 Catheter Foley 16fr BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $9.77 $9.77 $0.00 $0.00 $0.00 $3.75 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $10.65 $10.65 $0.00 $9.00 $14.26 $14.40 $0.00 $11.70 $0.00 $2.82 $0.00 $0.00 $2.87 $0.00 $0.00 $0.00 $0.00 $0.00 27202448 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27202449 EAP HCPCS C1729 Catheter Foley 30cc 28fr BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $21.18 $21.18 $0.00 $0.00 $0.00 $8.13 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $0.00 $6.10 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 27202462 EAP HCPCS C1729 Catheter Foley 5cc 14fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27202463 EAP HCPCS C1729 Catheter Foley 5cc 18fr BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $10.32 $10.32 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 27202470 EAP HCPCS C1751 Cragg-mcnamara 5-65-5 Infusion BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $401.82 $401.82 $0.00 $0.00 $0.00 $154.23 $549.23 $549.23 $570.39 $0.00 $154.22 $0.00 $437.71 $437.71 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $0.00 $115.81 $0.00 $0.00 $117.81 $0.00 $0.00 $0.00 $0.00 $0.00 27202471 EAP HCPCS C1751 Cragg-mcnamara 5-40-20 Infusio BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $171.05 $171.05 $0.00 $0.00 $0.00 $65.65 $233.79 $233.79 $242.80 $0.00 $65.65 $0.00 $186.32 $186.32 $0.00 $157.50 $249.48 $252.00 $0.00 $204.75 $0.00 $49.30 $0.00 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202472 EAP HCPCS C1751 Cragg-mcnamara 5-100-10 Infusi BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $171.05 $171.05 $0.00 $0.00 $0.00 $65.65 $233.79 $233.79 $242.80 $0.00 $65.65 $0.00 $186.32 $186.32 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $49.30 $0.00 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202473 EAP HCPCS C1773 15mm Amplatz Snare BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $497.39 $497.39 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $458.00 $725.47 $732.80 $0.00 $595.40 $0.00 $143.35 $0.00 $0.00 $145.83 $0.00 $0.00 $0.00 $0.00 $0.00 27202474 EAP HCPCS C1773 25mm Amplatz Snare BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $497.39 $497.39 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $458.00 $725.47 $732.80 $0.00 $595.40 $0.00 $143.35 $0.00 $0.00 $145.83 $0.00 $0.00 $0.00 $0.00 $0.00 27202475 EAP HCPCS C1729 10fr X 35cm Skater Nephrostomy BOTH IP/OP $254.00 $187.96 $0.00 $203.20 $137.92 $137.92 $0.00 $0.00 $0.00 $52.94 $188.52 $188.52 $195.78 $0.00 $52.93 $0.00 $150.24 $150.24 $0.00 $127.00 $201.17 $203.20 $0.00 $165.10 $0.00 $39.75 $0.00 $0.00 $40.44 $0.00 $0.00 $0.00 $0.00 $0.00 27202476 EAP HCPCS C1750 Chron Carbothane Cath 14.5f X 19cm BOTH IP/OP "$1,054.00 " $779.96 $0.00 $843.20 $572.32 $572.32 $0.00 $0.00 $0.00 $219.68 $782.28 $782.28 $812.42 $0.00 $219.65 $0.00 $623.44 $623.44 $0.00 $527.00 $834.77 $843.20 $0.00 $685.10 $0.00 $164.95 $0.00 $0.00 $167.80 $0.00 $0.00 $0.00 $0.00 $0.00 27202477 EAP HCPCS C1750 23cm Sport Pack Perm Dialysis BOTH IP/OP $921.00 $681.54 $0.00 $736.80 $500.10 $500.10 $0.00 $0.00 $0.00 $191.96 $683.57 $683.57 $709.91 $0.00 $191.94 $0.00 $544.77 $544.77 $0.00 $460.50 $729.43 $736.80 $0.00 $598.65 $0.00 $144.14 $0.00 $0.00 $146.62 $0.00 $0.00 $0.00 $0.00 $0.00 27202478 EAP HCPCS C1750 28cm Sport Pack Perm Dialysis BOTH IP/OP "$2,263.00 " "$1,674.62" $0.00 "$1,810.40" "$1,228.81" "$1,228.81" $0.00 $0.00 $0.00 $471.67 "$1,679.60" "$1,679.60" "$1,744.32" $0.00 $471.61 $0.00 "$1,338.56" "$1,338.56" $0.00 "$1,131.50" "$1,792.30" "$1,810.40" $0.00 $0.00 $0.00 $354.16 $0.00 $0.00 $360.27 $0.00 $0.00 $0.00 $0.00 $0.00 27202479 EAP HCPCS C1752 19cm Q-plus Temp Dialysis Kit BOTH IP/OP $254.00 $187.96 $0.00 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.52 $188.52 $195.78 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $127.00 $201.17 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202480 EAP HCPCS C1894 Sheath Flex 6fr 11cm BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $74.93 $74.93 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $21.60 $0.00 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 27202481 EAP HCPCS C1751 Hickman 10.0 French Triple Lum BOTH IP/OP "$1,357.00 " "$1,004.18" $0.00 "$1,085.60" $736.85 $736.85 $0.00 $0.00 $0.00 $282.83 "$1,007.17" "$1,007.17" "$1,045.98" $0.00 $282.80 $0.00 $802.67 $802.67 $0.00 $678.50 "$1,074.74" "$1,085.60" $0.00 $0.00 $0.00 $212.37 $0.00 $0.00 $216.03 $0.00 $0.00 $0.00 $0.00 $0.00 27202482 EAP HCPCS C1725 Balloon Udt 4-2/5/120 BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202483 EAP HCPCS C1725 Conquest Dialation Balloon 5mm BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202484 EAP HCPCS C1725 Conquest Dialation Balloon 5mm BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $466.05 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202485 EAP HCPCS C1725 Conquest Dialation Balloon 6mm BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $466.05 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202486 EAP HCPCS C1725 Conquest Dialation Balloon 6mm BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $0.00 $0.00 $0.00 $0.00 $0.00 $149.44 $0.00 $0.00 $0.00 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202487 EAP HCPCS C1725 Conquest Dialation Balloon 7mm BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202488 EAP HCPCS C1725 Conquest Dialation Balloon 7mm BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $466.05 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202489 EAP HCPCS C1725 Conquest Dialation Balloon 8mm BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $466.05 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202490 EAP HCPCS C1725 Conquest Dialation Balloon 8mm BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $466.05 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202491 EAP HCPCS C1725 Conquest Dialation Balloon 10m BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $466.05 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202492 EAP HCPCS C1725 Conquest Dialation Balloon 10m BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $466.05 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202493 EAP HCPCS C1725 Conquest Dialation Balloon 12m BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $466.05 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202494 EAP HCPCS C1725 Balloon Dial Cath 4mmx10cmx120 BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202495 EAP HCPCS C1751 Vaxcel Central Venous Cath BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $3.26 $3.26 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 27202496 EAP HCPCS C1725 4mmx2cmx90xm Monorail Balloon BOTH IP/OP "$1,407.00 " "$1,041.18" $0.00 "$1,125.60" $764.00 $764.00 $0.00 $0.00 $0.00 $293.25 "$1,044.28" "$1,044.28" "$1,084.52" $0.00 $293.22 $0.00 $832.24 $832.24 $0.00 $703.50 "$1,114.34" "$1,125.60" $0.00 $0.00 $0.00 $220.20 $0.00 $0.00 $223.99 $0.00 $0.00 $0.00 $0.00 $0.00 27202497 EAP HCPCS C1725 5mmx2cmx90cm Monorail Balloon BOTH IP/OP "$1,407.00 " "$1,041.18" $0.00 "$1,125.60" $764.00 $764.00 $0.00 $0.00 $0.00 $293.25 "$1,044.28" "$1,044.28" "$1,084.52" $0.00 $293.22 $0.00 $832.24 $832.24 $0.00 $703.50 "$1,114.34" "$1,125.60" $0.00 $0.00 $0.00 $220.20 $0.00 $0.00 $223.99 $0.00 $0.00 $0.00 $0.00 $0.00 27202498 EAP HCPCS C1725 5mmx15cmx90xcm Monorail Biliar BOTH IP/OP "$4,654.00 " "$3,443.96" $0.00 "$3,723.20" "$2,527.12" "$2,527.12" $0.00 $0.00 $0.00 $970.01 "$3,454.20" "$3,454.20" "$3,587.30" $0.00 $969.89 $0.00 "$2,752.84" "$2,752.84" $0.00 "$2,327.00" "$3,685.97" "$3,723.20" $0.00 $0.00 $0.00 $728.35 $0.00 $0.00 $740.92 $0.00 $0.00 $0.00 $0.00 $0.00 27202499 EAP HCPCS C1725 6mmx14cmx90cm Monorail Biliary BOTH IP/OP "$4,654.00 " "$3,443.96" $0.00 "$3,723.20" "$2,527.12" "$2,527.12" $0.00 $0.00 $0.00 $970.01 "$3,454.20" "$3,454.20" "$3,587.30" $0.00 $969.89 $0.00 "$2,752.84" "$2,752.84" $0.00 "$2,327.00" "$3,685.97" "$3,723.20" $0.00 $0.00 $0.00 $728.35 $0.00 $0.00 $740.92 $0.00 $0.00 $0.00 $0.00 $0.00 27202500 EAP HCPCS C1725 6mmx18cmx90cm Monorail Bilary BOTH IP/OP "$4,654.00 " "$3,443.96" $0.00 "$3,723.20" "$2,527.12" "$2,527.12" $0.00 $0.00 $0.00 $970.01 "$3,454.20" "$3,454.20" "$3,587.30" $0.00 $969.89 $0.00 "$2,752.84" "$2,752.84" $0.00 "$2,327.00" "$3,685.97" "$3,723.20" $0.00 $0.00 $0.00 $728.35 $0.00 $0.00 $740.92 $0.00 $0.00 $0.00 $0.00 $0.00 27202501 EAP HCPCS C1769 .018x190cm Thruway Guidewire BOTH IP/OP $291.00 $215.34 $0.00 $232.80 $158.01 $158.01 $0.00 $0.00 $0.00 $60.65 $215.98 $215.98 $224.30 $0.00 $60.64 $0.00 $172.13 $172.13 $0.00 $145.50 $230.47 $232.80 $0.00 $0.00 $0.00 $45.54 $0.00 $0.00 $46.33 $0.00 $0.00 $0.00 $0.00 $0.00 27202502 EAP HCPCS C1893 6frx45cm Renal Guiding Sheath BOTH IP/OP $260.00 $192.40 $0.00 $208.00 $141.18 $141.18 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $200.41 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $130.00 $205.92 $208.00 $0.00 $169.00 $0.00 $40.69 $0.00 $0.00 $41.39 $0.00 $0.00 $0.00 $0.00 $0.00 27202503 EAP HCPCS C1725 6x40x80 Polar Cath Balloon BOTH IP/OP "$4,496.00 " "$3,327.04" $0.00 "$3,596.80" "$2,441.33" "$2,441.33" $0.00 $0.00 $0.00 $937.08 "$3,336.93" "$3,336.93" "$3,465.52" $0.00 $936.97 $0.00 "$2,659.38" "$2,659.38" $0.00 "$2,248.00" "$3,560.83" "$3,596.80" $0.00 $0.00 $0.00 $703.62 $0.00 $0.00 $715.76 $0.00 $0.00 $0.00 $0.00 $0.00 27202504 EAP HCPCS C1725 7x60x80 Polar Cath Balloon BOTH IP/OP "$4,496.00 " "$3,327.04" $0.00 "$3,596.80" "$2,441.33" "$2,441.33" $0.00 $0.00 $0.00 $937.08 "$3,336.93" "$3,336.93" "$3,465.52" $0.00 $936.97 $0.00 "$2,659.38" "$2,659.38" $0.00 "$2,248.00" "$3,560.83" "$3,596.80" $0.00 $0.00 $0.00 $703.62 $0.00 $0.00 $715.76 $0.00 $0.00 $0.00 $0.00 $0.00 27202505 EAP HCPCS C2629 Banana Peel Sheath BOTH IP/OP $151.00 $111.74 $0.00 $120.80 $0.00 $0.00 $0.00 $0.00 $0.00 $31.47 $112.07 $112.07 $116.39 $0.00 $31.47 $0.00 $89.32 $89.32 $0.00 $75.50 $119.59 $120.80 $0.00 $0.00 $0.00 $23.63 $0.00 $0.00 $24.04 $0.00 $0.00 $0.00 $0.00 $0.00 27202506 EAP HCPCS C1769 Guidewite .014x180 Segway Gt BOTH IP/OP $417.00 $308.58 $0.00 $333.60 $226.43 $226.43 $0.00 $0.00 $0.00 $86.91 $309.50 $309.50 $321.42 $0.00 $86.90 $0.00 $246.66 $246.66 $0.00 $208.50 $330.26 $333.60 $0.00 $0.00 $0.00 $65.26 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 27202507 EAP HCPCS C1769 Guidewire .018x180cm Segway Gt BOTH IP/OP $417.00 $308.58 $0.00 $333.60 $226.43 $226.43 $0.00 $0.00 $0.00 $86.91 $309.50 $309.50 $321.42 $0.00 $86.90 $0.00 $246.66 $246.66 $0.00 $208.50 $330.26 $333.60 $0.00 $271.05 $0.00 $65.26 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 27202508 EAP HCPCS C1769 Str Guidewire .014x180 Segway BOTH IP/OP $417.00 $308.58 $0.00 $333.60 $226.43 $226.43 $0.00 $0.00 $0.00 $86.91 $309.50 $309.50 $321.42 $0.00 $86.90 $0.00 $246.66 $246.66 $0.00 $208.50 $330.26 $333.60 $0.00 $0.00 $0.00 $65.26 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 27202509 EAP HCPCS C1751 Infusion Embo Cath Segway BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $453.41 $453.41 $0.00 $0.00 $0.00 $174.03 $619.74 $619.74 $643.62 $0.00 $174.01 $0.00 $493.90 $493.90 $0.00 $417.50 $661.32 $668.00 $0.00 $0.00 $0.00 $130.68 $0.00 $0.00 $132.93 $0.00 $0.00 $0.00 $0.00 $0.00 27202510 EAP HCPCS C1757 Complex Helical Coil BOTH IP/OP $239.00 $176.86 $0.00 $191.20 $129.78 $129.78 $0.00 $0.00 $0.00 $49.81 $177.39 $177.39 $184.22 $0.00 $49.81 $0.00 $141.37 $141.37 $0.00 $119.50 $189.29 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202511 EAP HCPCS C1894 6fr Dial Ease Introducer Sheat BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $23.35 $23.35 $0.00 $0.00 $0.00 $8.96 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $25.43 $25.43 $0.00 $21.50 $34.06 $34.40 $0.00 $27.95 $0.00 $6.73 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 27202512 EAP HCPCS C1725 7-2/7/75 Workhorse Balloon BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27202513 EAP HCPCS C1725 7-4/5/75 Workhorse Balloon BOTH IP/OP $427.00 $315.98 $0.00 $341.60 $231.86 $231.86 $0.00 $0.00 $0.00 $89.00 $316.92 $316.92 $329.13 $0.00 $88.99 $0.00 $252.57 $252.57 $0.00 $213.50 $338.18 $341.60 $0.00 $0.00 $0.00 $66.83 $0.00 $0.00 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 27202514 EAP HCPCS C1894 10fr 25cm Pinnacle Sheath Intr BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $36.38 $36.38 $0.00 $0.00 $0.00 $13.96 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $39.63 $39.63 $0.00 $33.50 $53.06 $53.60 $0.00 $43.55 $0.00 $10.49 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 27202515 EAP HCPCS C1894 5fr 25cm Pinnacle Introducer S BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $32.04 $32.04 $0.00 $0.00 $0.00 $12.30 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $34.90 $34.90 $0.00 $29.50 $46.73 $47.20 $0.00 $38.35 $0.00 $9.23 $0.00 $0.00 $9.39 $0.00 $0.00 $0.00 $0.00 $0.00 27202516 EAP HCPCS C1894 9fr 25cm Pinnacle Introducer S BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $36.38 $36.38 $0.00 $0.00 $0.00 $13.96 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $39.63 $39.63 $0.00 $33.50 $53.06 $53.60 $0.00 $0.00 $0.00 $10.49 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 27202517 EAP HCPCS C1894 6fr 25cm Pinnacle Introducer S BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $36.38 $36.38 $0.00 $0.00 $0.00 $13.96 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $39.63 $39.63 $0.00 $33.50 $53.06 $53.60 $0.00 $0.00 $0.00 $10.49 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 27202518 EAP HCPCS C1894 7fr 25cm Pinnacle Introducer S BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $32.04 $32.04 $0.00 $0.00 $0.00 $12.30 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $34.90 $34.90 $0.00 $29.50 $46.73 $47.20 $0.00 $38.35 $0.00 $9.23 $0.00 $0.00 $9.39 $0.00 $0.00 $0.00 $0.00 $0.00 27202519 EAP HCPCS C1750 23cm Hemoglide Perm Cath BOTH IP/OP "$2,140.00 " "$1,583.60" $0.00 "$1,712.00" "$1,162.02" "$1,162.02" $0.00 $0.00 $0.00 $446.03 "$1,588.31" "$1,588.31" "$1,649.51" $0.00 $445.98 $0.00 "$1,265.81" "$1,265.81" $0.00 "$1,070.00" "$1,694.88" "$1,712.00" $0.00 $0.00 $0.00 $334.91 $0.00 $0.00 $340.69 $0.00 $0.00 $0.00 $0.00 $0.00 27202520 EAP HCPCS C1750 19cm Hemoglide Perm Cath BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $497.39 $497.39 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $458.00 $725.47 $732.80 $0.00 $0.00 $0.00 $143.35 $0.00 $0.00 $145.83 $0.00 $0.00 $0.00 $0.00 $0.00 27202521 EAP HCPCS C1769 Nitrex Guidewire BOTH IP/OP $728.00 $538.72 $0.00 $582.40 $395.30 $395.30 $0.00 $0.00 $0.00 $151.73 $540.32 $540.32 $561.14 $0.00 $151.72 $0.00 $430.61 $430.61 $0.00 $364.00 $576.58 $582.40 $0.00 $0.00 $0.00 $113.93 $0.00 $0.00 $115.90 $0.00 $0.00 $0.00 $0.00 $0.00 27202522 EAP HCPCS C1769 Disposable Tip Deflecting Wire BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $307.88 $307.88 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $437.04 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $368.55 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 27202523 EAP HCPCS C1894 10fr Pinnacle Introducer BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $41.27 $41.27 $0.00 $0.00 $0.00 $15.84 $56.41 $56.41 $58.58 $0.00 $15.84 $0.00 $44.95 $44.95 $0.00 $38.00 $60.19 $60.80 $0.00 $49.40 $0.00 $11.89 $0.00 $0.00 $12.10 $0.00 $0.00 $0.00 $0.00 $0.00 27202524 EAP HCPCS C1752 Niagra Dialysis Catheter BOTH IP/OP $203.00 $150.22 $0.00 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.67 $150.67 $156.47 $0.00 $42.31 $0.00 $0.00 $0.00 $0.00 $101.50 $160.78 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202525 EAP HCPCS C2629 5fr Tear-away Introducer BOTH IP/OP $81.00 $59.94 $0.00 $64.80 $0.00 $0.00 $0.00 $0.00 $0.00 $16.88 $60.12 $60.12 $62.43 $0.00 $16.88 $0.00 $47.91 $47.91 $0.00 $40.50 $64.15 $64.80 $0.00 $52.65 $0.00 $12.68 $0.00 $0.00 $12.90 $0.00 $0.00 $0.00 $0.00 $0.00 27202526 EAP HCPCS C2629 6fr Tear-away Introducer BOTH IP/OP $856.00 $633.44 $0.00 $684.80 $0.00 $0.00 $0.00 $0.00 $0.00 $178.41 $635.32 $635.32 $659.80 $0.00 $178.39 $0.00 $506.32 $506.32 $0.00 $428.00 $677.95 $684.80 $0.00 $556.40 $0.00 $133.96 $0.00 $0.00 $136.28 $0.00 $0.00 $0.00 $0.00 $0.00 27202527 EAP HCPCS C2629 8 Fr Tear Away Introducer BOTH IP/OP $397.00 $293.78 $0.00 $317.60 $0.00 $0.00 $0.00 $0.00 $0.00 $82.74 $294.65 $294.65 $306.01 $0.00 $82.73 $0.00 $234.83 $234.83 $0.00 $198.50 $314.42 $317.60 $0.00 $0.00 $0.00 $62.13 $0.00 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 27202528 EAP HCPCS C2629 9fr Tear-away Introducer BOTH IP/OP $81.00 $59.94 $0.00 $64.80 $0.00 $0.00 $0.00 $0.00 $0.00 $16.88 $60.12 $60.12 $62.43 $0.00 $16.88 $0.00 $47.91 $47.91 $0.00 $40.50 $64.15 $64.80 $0.00 $52.65 $0.00 $12.68 $0.00 $0.00 $12.90 $0.00 $0.00 $0.00 $0.00 $0.00 27202529 EAP HCPCS C2629 10fr-16cm Introducer BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.72 $63.09 $63.09 $65.52 $0.00 $17.71 $0.00 $50.28 $50.28 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $13.30 $0.00 $0.00 $13.53 $0.00 $0.00 $0.00 $0.00 $0.00 27202530 EAP Custom 27202530 18 Ga Needle Sterile Guide BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $42.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202531 EAP HCPCS C1729 12fr Flexima Biliary Cath BOTH IP/OP $291.00 $215.34 $0.00 $232.80 $158.01 $158.01 $0.00 $0.00 $0.00 $60.65 $215.98 $215.98 $224.30 $0.00 $60.64 $0.00 $172.13 $172.13 $0.00 $145.50 $230.47 $232.80 $0.00 $0.00 $0.00 $45.54 $0.00 $0.00 $46.33 $0.00 $0.00 $0.00 $0.00 $0.00 27202532 EAP HCPCS C1757 2mmx20mm Complex Helical BOTH IP/OP $257.00 $190.18 $0.00 $205.60 $139.55 $139.55 $0.00 $0.00 $0.00 $53.57 $190.75 $190.75 $198.10 $0.00 $53.56 $0.00 $152.02 $152.02 $0.00 $128.50 $203.54 $205.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202533 EAP HCPCS C1725 4-4/5/75 Balloon Catheter BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $369.78 $369.78 $0.00 $0.00 $0.00 $141.94 $505.44 $505.44 $524.91 $0.00 $141.92 $0.00 $402.81 $402.81 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $106.58 $0.00 $0.00 $108.42 $0.00 $0.00 $0.00 $0.00 $0.00 27202534 EAP HCPCS C1769 46fr-65cm C2 Glidecath BOTH IP/OP $167.00 $123.58 $0.00 $133.60 $90.68 $90.68 $0.00 $0.00 $0.00 $34.81 $123.95 $123.95 $128.72 $0.00 $34.80 $0.00 $98.78 $98.78 $0.00 $83.50 $132.26 $133.60 $0.00 $0.00 $0.00 $26.14 $0.00 $0.00 $26.59 $0.00 $0.00 $0.00 $0.00 $0.00 27202535 EAP HCPCS C1757 4mmx30mm Complex Helical BOTH IP/OP $265.00 $196.10 $0.00 $212.00 $143.90 $143.90 $0.00 $0.00 $0.00 $55.23 $196.68 $196.68 $204.26 $0.00 $55.23 $0.00 $156.75 $156.75 $0.00 $132.50 $209.88 $212.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202536 EAP HCPCS C1725 Bmx 8-3/5.8/75 Balloon Ca BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $497.39 $497.39 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $458.00 $725.47 $732.80 $0.00 $0.00 $0.00 $143.35 $0.00 $0.00 $145.83 $0.00 $0.00 $0.00 $0.00 $0.00 27202537 EAP HCPCS C1725 Bmx14-4/7/100 Ballon Gath BOTH IP/OP "$1,008.00 " $745.92 $0.00 $806.40 $547.34 $547.34 $0.00 $0.00 $0.00 $210.09 $748.14 $748.14 $776.97 $0.00 $210.07 $0.00 $596.23 $596.23 $0.00 $504.00 $798.34 $806.40 $0.00 $0.00 $0.00 $157.75 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $0.00 27202538 EAP HCPCS C1729 Catheter 10fr Flexima BOTH IP/OP $291.00 $215.34 $0.00 $232.80 $158.01 $158.01 $0.00 $0.00 $0.00 $60.65 $215.98 $215.98 $224.30 $0.00 $60.64 $0.00 $172.13 $172.13 $0.00 $145.50 $230.47 $232.80 $0.00 $189.15 $0.00 $45.54 $0.00 $0.00 $46.33 $0.00 $0.00 $0.00 $0.00 $0.00 27202539 EAP HCPCS C1729 Catheter 14fr Flexima BOTH IP/OP $282.00 $208.68 $0.00 $225.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.00 $223.34 $225.60 $0.00 $0.00 $0.00 $44.13 $0.00 $0.00 $44.89 $0.00 $0.00 $0.00 $0.00 $0.00 27202540 EAP HCPCS C1751 Catheter 9cm Katzen BOTH IP/OP "$1,506.00 " "$1,114.44" $0.00 "$1,204.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.00 "$1,192.75" "$1,204.80" $0.00 $0.00 $0.00 $235.69 $0.00 $0.00 $239.76 $0.00 $0.00 $0.00 $0.00 $0.00 27202541 EAP HCPCS C1725 Catheter Balloon Dc/20 BOTH IP/OP "$2,062.00 " "$1,525.88" $0.00 "$1,649.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,031.00" "$1,633.10" "$1,649.60" $0.00 $0.00 $0.00 $322.70 $0.00 $0.00 $328.27 $0.00 $0.00 $0.00 $0.00 $0.00 27202542 EAP HCPCS C1725 Catheter Balloon Ultra- BOTH IP/OP $718.00 $531.32 $0.00 $574.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.00 $568.66 $574.40 $0.00 $0.00 $0.00 $112.37 $0.00 $0.00 $114.31 $0.00 $0.00 $0.00 $0.00 $0.00 27202543 EAP HCPCS C1887 Glidecath: 100cm Straight BOTH IP/OP $838.00 $620.12 $0.00 $670.40 $455.03 $455.03 $0.00 $0.00 $0.00 $174.66 $621.96 $621.96 $645.93 $0.00 $174.64 $0.00 $495.68 $495.68 $0.00 $419.00 $663.70 $670.40 $0.00 $544.70 $0.00 $131.15 $0.00 $0.00 $133.41 $0.00 $0.00 $0.00 $0.00 $0.00 27202544 EAP HCPCS C1887 Guidecath 5fr-100cm BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $95.03 $95.03 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $134.89 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $113.75 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 27202545 EAP HCPCS C1769 Guidewire .035/150cm BOTH IP/OP "$1,424.00 " "$1,053.76" $0.00 "$1,139.20" $773.23 $773.23 $0.00 $0.00 $0.00 $296.80 "$1,056.89" "$1,056.89" "$1,097.62" $0.00 $296.76 $0.00 $842.30 $842.30 $0.00 $712.00 "$1,127.81" "$1,139.20" $0.00 $925.60 $0.00 $222.86 $0.00 $0.00 $226.70 $0.00 $0.00 $0.00 $0.00 $0.00 27202546 EAP HCPCS C1769 Transcend -ex Guidewire BOTH IP/OP "$1,759.00 " "$1,301.66" $0.00 "$1,407.20" $955.14 $955.14 $0.00 $0.00 $0.00 $366.62 "$1,305.53" "$1,305.53" "$1,355.84" $0.00 $366.58 $0.00 "$1,040.45" "$1,040.45" $0.00 $879.50 "$1,393.13" "$1,407.20" $0.00 $0.00 $0.00 $275.28 $0.00 $0.00 $280.03 $0.00 $0.00 $0.00 $0.00 $0.00 27202547 EAP HCPCS C1725 Udt6-10/5/120 Ballon Cath BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202548 EAP HCPCS C1769 V-18 Control Guidewires BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $169.96 $169.96 $0.00 $0.00 $0.00 $65.24 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $185.14 $185.14 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 27202549 EAP HCPCS C1725 Xxl 18-4/5.8/120e Ball Ga BOTH IP/OP $934.00 $691.16 $0.00 $747.20 $507.16 $507.16 $0.00 $0.00 $0.00 $194.67 $693.21 $693.21 $719.93 $0.00 $194.65 $0.00 $552.46 $552.46 $0.00 $467.00 $739.73 $747.20 $0.00 $0.00 $0.00 $146.17 $0.00 $0.00 $148.69 $0.00 $0.00 $0.00 $0.00 $0.00 27202550 EAP HCPCS C1769 Guidewire .035-260cm Rosen BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $36.92 $36.92 $0.00 $0.00 $0.00 $14.17 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $40.22 $40.22 $0.00 $34.00 $53.86 $54.40 $0.00 $44.20 $0.00 $10.64 $0.00 $0.00 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 27202551 EAP HCPCS C1729 10.2fr Biliary Drain Cath BOTH IP/OP $289.00 $213.86 $0.00 $231.20 $156.93 $156.93 $0.00 $0.00 $0.00 $60.23 $214.50 $214.50 $222.76 $0.00 $60.23 $0.00 $170.94 $170.94 $0.00 $144.50 $228.89 $231.20 $0.00 $187.85 $0.00 $45.23 $0.00 $0.00 $46.01 $0.00 $0.00 $0.00 $0.00 $0.00 27202552 EAP HCPCS C1729 12.0fr Biliary Drain Cath BOTH IP/OP $296.00 $219.04 $0.00 $236.80 $160.73 $160.73 $0.00 $0.00 $0.00 $61.69 $219.69 $219.69 $228.16 $0.00 $61.69 $0.00 $175.08 $175.08 $0.00 $148.00 $234.43 $236.80 $0.00 $192.40 $0.00 $46.32 $0.00 $0.00 $47.12 $0.00 $0.00 $0.00 $0.00 $0.00 27202553 EAP HCPCS C1729 12.0fr Mp Drain Catheter BOTH IP/OP $296.00 $219.04 $0.00 $236.80 $160.73 $160.73 $0.00 $0.00 $0.00 $61.69 $219.69 $219.69 $228.16 $0.00 $61.69 $0.00 $175.08 $175.08 $0.00 $148.00 $234.43 $236.80 $0.00 $192.40 $0.00 $46.32 $0.00 $0.00 $47.12 $0.00 $0.00 $0.00 $0.00 $0.00 27202554 EAP HCPCS C1729 14.0fr Biliary Drain BOTH IP/OP $296.00 $219.04 $0.00 $236.80 $160.73 $160.73 $0.00 $0.00 $0.00 $61.69 $219.69 $219.69 $228.16 $0.00 $61.69 $0.00 $175.08 $175.08 $0.00 $148.00 $234.43 $236.80 $0.00 $192.40 $0.00 $46.32 $0.00 $0.00 $47.12 $0.00 $0.00 $0.00 $0.00 $0.00 27202555 EAP HCPCS C1769 35-180 Coons Wire BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $104.26 $104.26 $0.00 $0.00 $0.00 $40.02 $142.50 $142.50 $147.99 $0.00 $40.01 $0.00 $113.57 $113.57 $0.00 $96.00 $152.06 $153.60 $0.00 $0.00 $0.00 $30.05 $0.00 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $0.00 27202556 EAP HCPCS C1757 35-2-3 Embolization Coil BOTH IP/OP $172.00 $127.28 $0.00 $137.60 $93.40 $93.40 $0.00 $0.00 $0.00 $35.85 $127.66 $127.66 $132.58 $0.00 $35.84 $0.00 $101.74 $101.74 $0.00 $86.00 $136.22 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202557 EAP HCPCS C1725 7fr-100cm Montef 10re Cat BOTH IP/OP $54.00 $39.96 $0.00 $43.20 $29.32 $29.32 $0.00 $0.00 $0.00 $11.25 $40.08 $40.08 $41.62 $0.00 $11.25 $0.00 $31.94 $31.94 $0.00 $27.00 $42.77 $43.20 $0.00 $35.10 $0.00 $8.45 $0.00 $0.00 $8.60 $0.00 $0.00 $0.00 $0.00 $0.00 27202558 EAP HCPCS C1894 8fr Balkanintroducer BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $92.31 $92.31 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $131.04 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 27202559 EAP HCPCS C1894 9fr Flexor Introducer BOTH IP/OP $159.00 $117.66 $0.00 $127.20 $86.34 $86.34 $0.00 $0.00 $0.00 $33.14 $118.01 $118.01 $122.56 $0.00 $33.14 $0.00 $94.05 $94.05 $0.00 $79.50 $125.93 $127.20 $0.00 $0.00 $0.00 $24.88 $0.00 $0.00 $25.31 $0.00 $0.00 $0.00 $0.00 $0.00 27202560 EAP HCPCS C1757 Coil Embolization 35-5-5 BOTH IP/OP $172.00 $127.28 $0.00 $137.60 $93.40 $93.40 $0.00 $0.00 $0.00 $35.85 $127.66 $127.66 $132.58 $0.00 $35.84 $0.00 $101.74 $101.74 $0.00 $86.00 $136.22 $137.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202561 EAP HCPCS C1751 135 Cm Mass Transit Max BOTH IP/OP "$2,960.00 " "$2,190.40" $0.00 "$2,368.00" "$1,607.28" "$1,607.28" $0.00 $0.00 $0.00 $616.94 "$2,196.91" "$2,196.91" "$2,281.57" $0.00 $616.86 $0.00 "$1,750.84" "$1,750.84" $0.00 "$1,480.00" "$2,344.32" "$2,368.00" $0.00 $0.00 $0.00 $463.24 $0.00 $0.00 $471.23 $0.00 $0.00 $0.00 $0.00 $0.00 27202562 EAP HCPCS C1894 Introducer Pinnacle 7fr 10cm BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $36.38 $36.38 $0.00 $0.00 $0.00 $13.96 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $39.63 $39.63 $0.00 $33.50 $53.06 $53.60 $0.00 $0.00 $0.00 $10.49 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 27202563 EAP HCPCS C1725 Balloon Udt 4-4/5/120 BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $389.33 $389.33 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202564 EAP HCPCS C1887 5fr.100cmhinck Headhunter BOTH IP/OP $167.00 $123.58 $0.00 $133.60 $90.68 $90.68 $0.00 $0.00 $0.00 $34.81 $123.95 $123.95 $128.72 $0.00 $34.80 $0.00 $98.78 $98.78 $0.00 $83.50 $132.26 $133.60 $0.00 $108.55 $0.00 $26.14 $0.00 $0.00 $26.59 $0.00 $0.00 $0.00 $0.00 $0.00 27202565 EAP HCPCS C1894 8fr 25cm Pinnacle Introducer S BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $32.04 $32.04 $0.00 $0.00 $0.00 $12.30 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $34.90 $34.90 $0.00 $29.50 $46.73 $47.20 $0.00 $38.35 $0.00 $9.23 $0.00 $0.00 $9.39 $0.00 $0.00 $0.00 $0.00 $0.00 27202566 EAP HCPCS C1887 5f-90cm Ruc Catheter BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $70.05 $70.05 $0.00 $0.00 $0.00 $26.89 $95.74 $95.74 $99.43 $0.00 $26.88 $0.00 $76.30 $76.30 $0.00 $64.50 $102.17 $103.20 $0.00 $0.00 $0.00 $20.19 $0.00 $0.00 $20.54 $0.00 $0.00 $0.00 $0.00 $0.00 27202567 EAP HCPCS C2629 Introducer Tear Away 120fx30cm BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $29.60 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $83.99 $83.99 $0.00 $71.00 $112.46 $113.60 $0.00 $0.00 $0.00 $22.22 $0.00 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $0.00 27202568 EAP HCPCS C2629 Introducer Tear Away 16f X15cm BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $14.17 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $40.22 $40.22 $0.00 $34.00 $53.86 $54.40 $0.00 $0.00 $0.00 $10.64 $0.00 $0.00 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 27202569 EAP HCPCS C2629 Introducer Tear Away 14f X15cm BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $14.17 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $40.22 $40.22 $0.00 $34.00 $53.86 $54.40 $0.00 $0.00 $0.00 $10.64 $0.00 $0.00 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 27202570 EAP HCPCS C2629 Introducer Tear Away12.5fx15cm BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $21.47 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $60.92 $60.92 $0.00 $51.50 $81.58 $82.40 $0.00 $0.00 $0.00 $16.12 $0.00 $0.00 $16.40 $0.00 $0.00 $0.00 $0.00 $0.00 27202571 EAP HCPCS C2629 Introducer Tear Away 6f X 10cm BOTH IP/OP $159.00 $117.66 $0.00 $127.20 $0.00 $0.00 $0.00 $0.00 $0.00 $33.14 $118.01 $118.01 $122.56 $0.00 $33.14 $0.00 $94.05 $94.05 $0.00 $79.50 $125.93 $127.20 $0.00 $0.00 $0.00 $24.88 $0.00 $0.00 $25.31 $0.00 $0.00 $0.00 $0.00 $0.00 27202572 EAP HCPCS C1769 "Amplatz Sup Guidewire,035/75gw" BOTH IP/OP $331.00 $244.94 $0.00 $255.13 $179.73 $179.73 $0.00 $0.00 $0.00 $68.99 $245.67 $245.67 $255.13 $0.00 $68.98 $0.00 $195.79 $195.79 $0.00 $33.00 $52.27 $52.80 $0.00 $215.15 $0.00 $10.33 $0.00 $0.00 $10.51 $0.00 $0.00 $0.00 $0.00 $0.00 27202573 EAP HCPCS C1726 Merci Balloon Guide Catheter BOTH IP/OP "$2,251.00 " "$1,665.74" $0.00 "$1,800.80" "$1,222.29" "$1,222.29" $0.00 $0.00 $0.00 $469.16 "$1,670.69" "$1,670.69" "$1,735.07" $0.00 $469.11 $0.00 "$1,331.47" "$1,331.47" $0.00 "$1,125.50" "$1,782.79" "$1,800.80" $0.00 $0.00 $0.00 $352.28 $0.00 $0.00 $358.36 $0.00 $0.00 $0.00 $0.00 $0.00 27202574 EAP HCPCS C1751 Merci Microcatheter BOTH IP/OP "$1,641.00 " "$1,214.34" $0.00 "$1,312.80" $891.06 $891.06 $0.00 $0.00 $0.00 $342.03 "$1,217.95" "$1,217.95" "$1,264.88" $0.00 $341.98 $0.00 $970.65 $970.65 $0.00 $820.50 "$1,299.67" "$1,312.80" $0.00 $0.00 $0.00 $256.82 $0.00 $0.00 $261.25 $0.00 $0.00 $0.00 $0.00 $0.00 27202575 EAP HCPCS C1757 Meri V-series Retrieval V2.0 BOTH IP/OP "$10,341.00 " "$7,652.34" $0.00 "$8,272.80" "$5,615.16" "$5,615.16" $0.00 $0.00 $0.00 "$2,155.32" "$4,181.12" "$4,181.12" "$7,970.84" $0.00 "$2,155.06" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,170.50" "$8,190.07" "$8,272.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202576 EAP HCPCS C1757 Meri V-series Retrieval V2.5 BOTH IP/OP "$10,708.00 " "$7,923.92" $0.00 "$8,566.40" "$5,814.44" "$5,814.44" $0.00 $0.00 $0.00 "$2,231.81" "$4,181.12" "$4,181.12" "$8,253.73" $0.00 "$2,231.55" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,354.00" "$8,480.74" "$8,566.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202577 EAP HCPCS C1757 Meri V-series Retrieval V3.0 BOTH IP/OP "$10,708.00 " "$7,923.92" $0.00 "$8,566.40" "$5,814.44" "$5,814.44" $0.00 $0.00 $0.00 "$2,231.81" "$4,181.12" "$4,181.12" "$8,253.73" $0.00 "$2,231.55" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,354.00" "$8,480.74" "$8,566.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202578 EAP HCPCS C1757 Meri V-series Retrieval V2.5 BOTH IP/OP "$10,341.00 " "$7,652.34" $0.00 "$8,272.80" "$5,615.16" "$5,615.16" $0.00 $0.00 $0.00 "$2,155.32" "$4,181.12" "$4,181.12" "$7,970.84" $0.00 "$2,155.06" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,170.50" "$8,190.07" "$8,272.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202579 EAP HCPCS C1751 Catheter Reperfusion 026 BOTH IP/OP "$3,767.00 " "$2,787.58" $0.00 "$3,013.60" "$2,045.48" "$2,045.48" $0.00 $0.00 $0.00 $785.14 "$2,795.87" "$2,795.87" "$2,903.60" $0.00 $785.04 $0.00 "$2,228.18" "$2,228.18" $0.00 "$1,883.50" "$2,983.46" "$3,013.60" $0.00 $0.00 $0.00 $589.54 $0.00 $0.00 $599.71 $0.00 $0.00 $0.00 $0.00 $0.00 27202580 EAP HCPCS C1751 Catheter Reperfusion 032 BOTH IP/OP "$3,635.00 " "$2,689.90" $0.00 "$2,908.00" "$1,973.81" "$1,973.81" $0.00 $0.00 $0.00 $757.62 "$2,697.90" "$2,697.90" "$2,801.86" $0.00 $757.53 $0.00 "$2,150.10" "$2,150.10" $0.00 "$1,817.50" "$2,878.92" "$2,908.00" $0.00 $0.00 $0.00 $568.88 $0.00 $0.00 $578.69 $0.00 $0.00 $0.00 $0.00 $0.00 27202581 EAP HCPCS C1751 Catheter Reperfusion 041 BOTH IP/OP "$3,635.00 " "$2,689.90" $0.00 "$2,908.00" "$1,973.81" "$1,973.81" $0.00 $0.00 $0.00 $757.62 "$2,697.90" "$2,697.90" "$2,801.86" $0.00 $757.53 $0.00 "$2,150.10" "$2,150.10" $0.00 "$1,817.50" "$2,878.92" "$2,908.00" $0.00 $0.00 $0.00 $568.88 $0.00 $0.00 $578.69 $0.00 $0.00 $0.00 $0.00 $0.00 27202582 EAP Custom 27202582 Separator 026 BOTH IP/OP "$7,910.00 " "$5,853.40" $0.00 "$6,328.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,097.03" $0.00 "$1,648.44" $0.00 $0.00 $0.00 $0.00 "$3,955.00" "$6,264.72" "$6,328.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202583 EAP Custom 27202583 Separator 032 BOTH IP/OP "$7,639.00 " "$5,652.86" $0.00 "$6,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,888.14" $0.00 "$1,591.97" $0.00 $0.00 $0.00 $0.00 "$3,819.50" "$6,050.09" "$6,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202584 EAP Custom 27202584 Separator 041 BOTH IP/OP "$7,639.00 " "$5,652.86" $0.00 "$6,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,888.14" $0.00 "$1,591.97" $0.00 $0.00 $0.00 $0.00 "$3,819.50" "$6,050.09" "$6,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202585 EAP Custom 27202585 "Tubing, Aspiration" BOTH IP/OP "$1,279.00 " $946.46 $0.00 "$1,023.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $949.27 $949.27 $985.85 $0.00 $266.54 $0.00 $0.00 $0.00 $0.00 $639.50 "$1,012.97" "$1,023.20" $0.00 $831.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202586 EAP Custom 27202586 "Pump, Penumbra Aspiration" BOTH IP/OP "$8,340.00 " "$6,171.60" $0.00 "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,428.47" $0.00 "$1,738.06" $0.00 $0.00 $0.00 $0.00 "$4,170.00" "$6,605.28" "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202587 EAP HCPCS C1751 "Microcatheter, Microvention" BOTH IP/OP "$2,353.00 " "$1,741.22" $0.00 "$1,882.40" "$1,277.68" "$1,277.68" $0.00 $0.00 $0.00 $490.42 "$1,746.40" "$1,746.40" "$1,813.69" $0.00 $490.37 $0.00 "$1,391.80" "$1,391.80" $0.00 "$1,176.50" "$1,863.58" "$1,882.40" $0.00 $0.00 $0.00 $368.24 $0.00 $0.00 $374.60 $0.00 $0.00 $0.00 $0.00 $0.00 27202588 EAP Custom 27202588 "Controller, V-grip Detachment" BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $415.63 $415.63 $431.65 $0.00 $116.70 $0.00 $0.00 $0.00 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202589 EAP HCPCS C1751 "Catheter, Echelon Micro" BOTH IP/OP "$2,072.00 " "$1,533.28" $0.00 "$1,657.60" "$1,125.10" "$1,125.10" $0.00 $0.00 $0.00 $431.86 "$1,537.84" "$1,537.84" "$1,597.10" $0.00 $431.80 $0.00 "$1,225.59" "$1,225.59" $0.00 "$1,036.00" "$1,641.02" "$1,657.60" $0.00 $0.00 $0.00 $324.27 $0.00 $0.00 $329.86 $0.00 $0.00 $0.00 $0.00 $0.00 27202590 EAP HCPCS C1726 "Balloon, Hyperform 4mm X 7mm" BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" "$2,174.72" "$2,174.72" $0.00 $0.00 $0.00 $834.74 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 "$2,368.96" "$2,368.96" $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $626.78 $0.00 $0.00 $637.60 $0.00 $0.00 $0.00 $0.00 $0.00 27202591 EAP HCPCS C1726 "Balloon, Hyperform 7mm X 7mm" BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" "$2,174.72" "$2,174.72" $0.00 $0.00 $0.00 $834.74 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 "$2,368.96" "$2,368.96" $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 "$2,603.25" $0.00 $626.78 $0.00 $0.00 $637.60 $0.00 $0.00 $0.00 $0.00 $0.00 27202592 EAP HCPCS C1726 "Balloon, Hyperglide 4mm X 15mm" BOTH IP/OP "$3,336.00 " "$2,468.64" $0.00 "$2,668.80" "$1,811.45" "$1,811.45" $0.00 $0.00 $0.00 $695.31 "$2,475.98" "$2,475.98" "$2,571.39" $0.00 $695.22 $0.00 "$1,973.24" "$1,973.24" $0.00 "$1,668.00" "$2,642.11" "$2,668.80" $0.00 $0.00 $0.00 $522.08 $0.00 $0.00 $531.09 $0.00 $0.00 $0.00 $0.00 $0.00 27202593 EAP HCPCS C1887 "Catheter, Envoy 6f Guiding" BOTH IP/OP $884.00 $654.16 $0.00 $707.20 $480.01 $480.01 $0.00 $0.00 $0.00 $184.25 $656.10 $656.10 $681.39 $0.00 $184.23 $0.00 $522.89 $522.89 $0.00 $442.00 $700.13 $707.20 $0.00 $574.60 $0.00 $138.35 $0.00 $0.00 $140.73 $0.00 $0.00 $0.00 $0.00 $0.00 27202594 EAP HCPCS C1751 "Microcatheter, Rapidtransit" BOTH IP/OP "$2,002.00 " "$1,481.48" $0.00 "$1,601.60" "$1,087.09" "$1,087.09" $0.00 $0.00 $0.00 $417.27 "$1,485.88" "$1,485.88" "$1,543.14" $0.00 $417.22 $0.00 "$1,184.18" "$1,184.18" $0.00 "$1,001.00" "$1,585.58" "$1,601.60" $0.00 $0.00 $0.00 $313.31 $0.00 $0.00 $318.72 $0.00 $0.00 $0.00 $0.00 $0.00 27202595 EAP Custom 27202595 "System,trufill N-bca Liquid Em" BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.56 $208.56 $216.59 $0.00 $58.56 $0.00 $0.00 $0.00 $0.00 $140.50 $222.55 $224.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202596 EAP HCPCS C1887 "Catheter, Envoy Xb Guiding" BOTH IP/OP $988.00 $731.12 $0.00 $790.40 $536.48 $536.48 $0.00 $0.00 $0.00 $205.92 $733.29 $733.29 $761.55 $0.00 $205.90 $0.00 $584.40 $584.40 $0.00 $494.00 $782.50 $790.40 $0.00 $0.00 $0.00 $154.62 $0.00 $0.00 $157.29 $0.00 $0.00 $0.00 $0.00 $0.00 27202597 EAP HCPCS C1751 "Microcatheter, Prowler" BOTH IP/OP "$2,169.00 " "$1,605.06" $0.00 "$1,735.20" "$1,177.77" "$1,177.77" $0.00 $0.00 $0.00 $452.07 "$1,609.83" "$1,609.83" "$1,671.87" $0.00 $452.02 $0.00 "$1,282.96" "$1,282.96" $0.00 "$1,084.50" "$1,717.85" "$1,735.20" $0.00 $0.00 $0.00 $339.45 $0.00 $0.00 $345.30 $0.00 $0.00 $0.00 $0.00 $0.00 27202598 EAP HCPCS C1751 "Microcatheter, Prowler" BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,236.41" "$1,236.41" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" "$1,755.11" $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 27202599 EAP HCPCS C1769 Guidewire Bentson .038 260 Exc BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $47.78 $47.78 $0.00 $0.00 $0.00 $18.34 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $52.05 $52.05 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 27202600 EAP HCPCS C1769 Guidwire Glide .038 150 Angle BOTH IP/OP $154.00 $113.96 $0.00 $123.20 $83.62 $83.62 $0.00 $0.00 $0.00 $32.10 $114.30 $114.30 $118.70 $0.00 $32.09 $0.00 $91.09 $91.09 $0.00 $77.00 $121.97 $123.20 $0.00 $100.10 $0.00 $24.10 $0.00 $0.00 $24.52 $0.00 $0.00 $0.00 $0.00 $0.00 27202601 EAP HCPCS C1769 Guidwire Glide .038 180 Angle BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $20.09 $20.09 $0.00 $0.00 $0.00 $7.71 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $21.89 $21.89 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 27202602 EAP HCPCS C1769 Guidewire Transend Ex .014 BOTH IP/OP "$1,036.00 " $766.64 $0.00 $828.80 $562.55 $562.55 $0.00 $0.00 $0.00 $215.93 $768.92 $768.92 $798.55 $0.00 $215.90 $0.00 $612.79 $612.79 $0.00 $518.00 $820.51 $828.80 $0.00 $0.00 $0.00 $162.13 $0.00 $0.00 $164.93 $0.00 $0.00 $0.00 $0.00 $0.00 27202603 EAP HCPCS C1769 Guidewire Transend Ex .014st BOTH IP/OP "$1,036.00 " $766.64 $0.00 $828.80 $562.55 $562.55 $0.00 $0.00 $0.00 $215.93 $768.92 $768.92 $798.55 $0.00 $215.90 $0.00 $612.79 $612.79 $0.00 $518.00 $820.51 $828.80 $0.00 $673.40 $0.00 $162.13 $0.00 $0.00 $164.93 $0.00 $0.00 $0.00 $0.00 $0.00 27202604 EAP HCPCS C1769 Guidewire Transend Es 300cm BOTH IP/OP "$1,320.00 " $976.80 $0.00 "$1,056.00" $716.76 $716.76 $0.00 $0.00 $0.00 $275.12 $979.70 $979.70 "$1,017.46" $0.00 $275.09 $0.00 $780.78 $780.78 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $0.00 $206.58 $0.00 $0.00 $210.14 $0.00 $0.00 $0.00 $0.00 $0.00 27202605 EAP HCPCS C1887 "Catheter, 7fr Guider Softip" BOTH IP/OP $667.00 $493.58 $0.00 $533.60 $362.18 $362.18 $0.00 $0.00 $0.00 $139.02 $495.05 $495.05 $514.12 $0.00 $139.00 $0.00 $394.53 $394.53 $0.00 $333.50 $528.26 $533.60 $0.00 $0.00 $0.00 $104.39 $0.00 $0.00 $106.19 $0.00 $0.00 $0.00 $0.00 $0.00 27202606 EAP HCPCS C1751 "Catheter, Renegade Micro" BOTH IP/OP "$1,202.00 " $889.48 $0.00 $961.60 $652.69 $652.69 $0.00 $0.00 $0.00 $250.53 $892.12 $892.12 $926.50 $0.00 $250.50 $0.00 $710.98 $710.98 $0.00 $601.00 $951.98 $961.60 $0.00 $0.00 $0.00 $188.11 $0.00 $0.00 $191.36 $0.00 $0.00 $0.00 $0.00 $0.00 27202607 EAP HCPCS C1751 "Microcatheter, Excelsior 1018" BOTH IP/OP "$2,169.00 " "$1,605.06" $0.00 "$1,735.20" "$1,177.77" "$1,177.77" $0.00 $0.00 $0.00 $452.07 "$1,609.83" "$1,609.83" "$1,671.87" $0.00 $452.02 $0.00 "$1,282.96" "$1,282.96" $0.00 "$1,084.50" "$1,717.85" "$1,735.20" $0.00 $0.00 $0.00 $339.45 $0.00 $0.00 $345.30 $0.00 $0.00 $0.00 $0.00 $0.00 27202608 EAP HCPCS C1769 "Guidewire, Synchro2" BOTH IP/OP "$1,251.00 " $925.74 $0.00 "$1,000.80" $679.29 $679.29 $0.00 $0.00 $0.00 $260.74 $928.49 $928.49 $964.27 $0.00 $260.71 $0.00 $739.97 $739.97 $0.00 $625.50 $990.79 "$1,000.80" $0.00 $813.15 $0.00 $195.78 $0.00 $0.00 $199.16 $0.00 $0.00 $0.00 $0.00 $0.00 27202609 EAP Custom 27202609 26x12x12cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202610 EAP Custom 27202610 26x12x14cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202611 EAP Custom 27202611 12x12x13.5cm Lliac Limb Aaa St BOTH IP/OP "$21,112.00 " "$15,622.88" $0.00 "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,273.13" $0.00 "$4,399.74" $0.00 $0.00 $0.00 $0.00 "$10,556.00" "$16,720.70" "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202612 EAP Custom 27202612 18x24x13.5cm Iliac Limb Aaa St BOTH IP/OP "$24,857.00 " "$18,394.18" $0.00 "$19,885.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,159.78" $0.00 "$5,180.20" $0.00 $0.00 $0.00 $0.00 "$12,428.50" "$19,686.74" "$19,885.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202613 EAP HCPCS C1751 Cath 6fr 1lum Try 3cg Shrlk Maximal Brr Picc P BOTH IP/OP "$1,010.00 " $747.40 $0.00 $808.00 $548.43 $548.43 $0.00 $0.00 $0.00 $210.51 $749.62 $749.62 $778.51 $0.00 $210.48 $0.00 $597.42 $597.42 $0.00 $505.00 $799.92 $808.00 $0.00 $656.50 $0.00 $158.07 $0.00 $0.00 $160.79 $0.00 $0.00 $0.00 $0.00 $0.00 27202614 EAP Custom 27202614 "Cather, Balloon, Ultra-thin Di" BOTH IP/OP "$1,580.00 " "$1,169.20" $0.00 "$1,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $790.00 "$1,251.36" "$1,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202615 EAP Custom 27202615 23x12x12cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202616 EAP Custom 27202616 23x12x14cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202617 EAP Custom 27202617 23x12x16cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202618 EAP Custom 27202618 23x12x18cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202619 EAP Custom 27202619 23x14.5x12cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202620 EAP Custom 27202620 23x14.5x14cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202621 EAP Custom 27202621 23x14.5x16cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202622 EAP Custom 27202622 23x14.5x18cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202623 EAP Custom 27202623 26x12x12cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202624 EAP Custom 27202624 26x12x14cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202625 EAP Custom 27202625 26x12x16cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202626 EAP Custom 27202626 26x12x18cm Aaa Endoprosthesis BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202627 EAP Custom 27202627 26x14.5x12cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202628 EAP Custom 27202628 26x14.5x14cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202629 EAP Custom 27202629 26x14.5x16cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202630 EAP Custom 27202630 26x14.4x18cm Aaa Endoprosthesi BOTH IP/OP "$25,581.00 " "$18,929.94" $0.00 "$20,464.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,717.83" $0.00 "$5,331.08" $0.00 $0.00 $0.00 $0.00 "$12,790.50" "$20,260.15" "$20,464.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202631 EAP Custom 27202631 28.5x12x12cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202632 EAP Custom 27202632 28.5x12x14cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202633 EAP Custom 27202633 28.5x12x16cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202634 EAP Custom 27202634 28.5x12x18cm Aaa Endoprosthesi BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202635 EAP Custom 27202635 28.5x14.5x12cm Aaa Endoprosthe BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202636 EAP Custom 27202636 28.5x14.5x14cm Aaa Endoprosthe BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202637 EAP Custom 27202637 28.5x14.5x16cm Aaa Endoprosthe BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202638 EAP Custom 27202638 28.5x14.4x18cm Aaa Endoprosthe BOTH IP/OP "$23,752.00 " "$17,576.48" $0.00 "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,308.04" $0.00 "$4,949.92" $0.00 $0.00 $0.00 $0.00 "$11,876.00" "$18,811.58" "$19,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202639 EAP Custom 27202639 12x10cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202640 EAP Custom 27202640 12x12cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202641 EAP Custom 27202641 12x14cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202642 EAP Custom 27202642 14.5x10cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202643 EAP Custom 27202643 14.4x12 Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202644 EAP Custom 27202644 14.5x14 Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202645 EAP Custom 27202645 16x9.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202646 EAP Custom 27202646 16x11.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202647 EAP Custom 27202647 16x13.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202648 EAP Custom 27202648 18x9.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202649 EAP Custom 27202649 18x11.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202650 EAP Custom 27202650 18x13.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202651 EAP Custom 27202651 20x9.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202652 EAP Custom 27202652 20x11.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202653 EAP Custom 27202653 20x13.5cm Aaa Endoprosthesis BOTH IP/OP "$22,940.00 " "$16,975.60" $0.00 "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,682.15" $0.00 "$4,780.70" $0.00 $0.00 $0.00 $0.00 "$11,470.00" "$18,168.48" "$18,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202654 EAP Custom 27202654 12x12x8.5cm Iliac Limb Aaa Ste BOTH IP/OP "$18,214.00 " "$13,478.36" $0.00 "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,039.35" $0.00 "$3,795.80" $0.00 $0.00 $0.00 $0.00 "$9,107.00" "$14,425.49" "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202655 EAP Custom 27202655 13x13x8.5cm Iliac Limb Aaa Ste BOTH IP/OP "$18,214.00 " "$13,478.36" $0.00 "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,039.35" $0.00 "$3,795.80" $0.00 $0.00 $0.00 $0.00 "$9,107.00" "$14,425.49" "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202656 EAP Custom 27202656 14x14x8.5cm Iliac Limb Aaa Ste BOTH IP/OP "$18,214.00 " "$13,478.36" $0.00 "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,039.35" $0.00 "$3,795.80" $0.00 $0.00 $0.00 $0.00 "$9,107.00" "$14,425.49" "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202657 EAP Custom 27202657 15x15x8.5cm Iliac Limb Aaa Ste BOTH IP/OP "$18,214.00 " "$13,478.36" $0.00 "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,039.35" $0.00 "$3,795.80" $0.00 $0.00 $0.00 $0.00 "$9,107.00" "$14,425.49" "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202658 EAP Custom 27202658 16x16x8.5cm Iliac Limb Aaa Ste BOTH IP/OP "$18,214.00 " "$13,478.36" $0.00 "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,039.35" $0.00 "$3,795.80" $0.00 $0.00 $0.00 $0.00 "$9,107.00" "$14,425.49" "$14,571.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202659 EAP Custom 27202659 18x18x8.5cm Iliac Limb Aaa Ste BOTH IP/OP "$18,898.00 " "$13,984.52" $0.00 "$15,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,566.58" $0.00 "$3,938.34" $0.00 $0.00 $0.00 $0.00 "$9,449.00" "$14,967.22" "$15,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202660 EAP Custom 27202660 20x20x8.5cm Iliac Limb Aaa Ste BOTH IP/OP "$18,898.00 " "$13,984.52" $0.00 "$15,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,566.58" $0.00 "$3,938.34" $0.00 $0.00 $0.00 $0.00 "$9,449.00" "$14,967.22" "$15,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202661 EAP Custom 27202661 12x12x11.5cm Iliac Limb Aaa St BOTH IP/OP "$19,236.00 " "$14,234.64" $0.00 "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,827.11" $0.00 "$4,008.78" $0.00 $0.00 $0.00 $0.00 "$9,618.00" "$15,234.91" "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202662 EAP Custom 27202662 13x13x11.5cmm Iliac Limb Aaa S BOTH IP/OP "$19,236.00 " "$14,234.64" $0.00 "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,827.11" $0.00 "$4,008.78" $0.00 $0.00 $0.00 $0.00 "$9,618.00" "$15,234.91" "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202663 EAP Custom 27202663 14x14x11.5cm Iliac Limb Aaa St BOTH IP/OP "$19,236.00 " "$14,234.64" $0.00 "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,827.11" $0.00 "$4,008.78" $0.00 $0.00 $0.00 $0.00 "$9,618.00" "$15,234.91" "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202664 EAP Custom 27202664 15x15x11.5cm Iliac Limb Aaa St BOTH IP/OP "$19,236.00 " "$14,234.64" $0.00 "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,827.11" $0.00 "$4,008.78" $0.00 $0.00 $0.00 $0.00 "$9,618.00" "$15,234.91" "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202665 EAP Custom 27202665 16x16x11.5cm Iliac Limb Aaa St BOTH IP/OP "$19,236.00 " "$14,234.64" $0.00 "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,827.11" $0.00 "$4,008.78" $0.00 $0.00 $0.00 $0.00 "$9,618.00" "$15,234.91" "$15,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202666 EAP Custom 27202666 18x18x11.5cm Iliac Limb Aaa St BOTH IP/OP "$19,916.00 " "$14,737.84" $0.00 "$15,932.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,351.25" $0.00 "$4,150.49" $0.00 $0.00 $0.00 $0.00 "$9,958.00" "$15,773.47" "$15,932.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202667 EAP Custom 27202667 20x20x11.5cm Iliac Limb Aaa St BOTH IP/OP "$19,916.00 " "$14,737.84" $0.00 "$15,932.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,351.25" $0.00 "$4,150.49" $0.00 $0.00 $0.00 $0.00 "$9,958.00" "$15,773.47" "$15,932.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202668 EAP Custom 27202668 13x13x13.5cm Iliac Limb Aaa St BOTH IP/OP "$21,112.00 " "$15,622.88" $0.00 "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,273.13" $0.00 "$4,399.74" $0.00 $0.00 $0.00 $0.00 "$10,556.00" "$16,720.70" "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202669 EAP Custom 27202669 14x14x13.5cm Iliac Limb Aaa St BOTH IP/OP "$21,112.00 " "$15,622.88" $0.00 "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,273.13" $0.00 "$4,399.74" $0.00 $0.00 $0.00 $0.00 "$10,556.00" "$16,720.70" "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202670 EAP Custom 27202670 15x15x13.5cm Iliac Limb Aaa St BOTH IP/OP "$21,112.00 " "$15,622.88" $0.00 "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,273.13" $0.00 "$4,399.74" $0.00 $0.00 $0.00 $0.00 "$10,556.00" "$16,720.70" "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202671 EAP Custom 27202671 16x16x13.5cm Iliac Limb Aaa St BOTH IP/OP "$21,112.00 " "$15,622.88" $0.00 "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,273.13" $0.00 "$4,399.74" $0.00 $0.00 $0.00 $0.00 "$10,556.00" "$16,720.70" "$16,889.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202672 EAP Custom 27202672 18x18x13.5cm Iliac Limb Aaa St BOTH IP/OP "$21,790.00 " "$16,124.60" $0.00 "$17,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,795.73" $0.00 "$4,541.04" $0.00 $0.00 $0.00 $0.00 "$10,895.00" "$17,257.68" "$17,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202673 EAP Custom 27202673 20x20x13.5cm Iliac Limb Aaa St BOTH IP/OP "$21,790.00 " "$16,124.60" $0.00 "$17,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,795.73" $0.00 "$4,541.04" $0.00 $0.00 $0.00 $0.00 "$10,895.00" "$17,257.68" "$17,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202674 EAP Custom 27202674 16x20x11.5cm Iliac Limb Aaa St BOTH IP/OP "$23,492.00 " "$17,384.08" $0.00 "$18,793.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,107.63" $0.00 "$4,895.73" $0.00 $0.00 $0.00 $0.00 "$11,746.00" "$18,605.66" "$18,793.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202675 EAP Custom 27202675 18x22x11.5cm Iliac Limb Aaa St BOTH IP/OP "$23,492.00 " "$17,384.08" $0.00 "$18,793.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,107.63" $0.00 "$4,895.73" $0.00 $0.00 $0.00 $0.00 "$11,746.00" "$18,605.66" "$18,793.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202676 EAP Custom 27202676 18x24x11.5cm Iliac Limb Aaa St BOTH IP/OP "$23,492.00 " "$17,384.08" $0.00 "$18,793.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,107.63" $0.00 "$4,895.73" $0.00 $0.00 $0.00 $0.00 "$11,746.00" "$18,605.66" "$18,793.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202677 EAP Custom 27202677 16x20x13.5cm Iliac Limb Aaa St BOTH IP/OP "$24,857.00 " "$18,394.18" $0.00 "$19,885.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,159.78" $0.00 "$5,180.20" $0.00 $0.00 $0.00 $0.00 "$12,428.50" "$19,686.74" "$19,885.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202678 EAP Custom 27202678 18x22x13.5cm Iliac Limb Aaa St BOTH IP/OP "$24,857.00 " "$18,394.18" $0.00 "$19,885.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,159.78" $0.00 "$5,180.20" $0.00 $0.00 $0.00 $0.00 "$12,428.50" "$19,686.74" "$19,885.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202679 EAP Custom 27202679 18x24x13.5cm Iliac Limb Aaa St BOTH IP/OP "$24,857.00 " "$18,394.18" $0.00 "$19,885.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,159.78" $0.00 "$5,180.20" $0.00 $0.00 $0.00 $0.00 "$12,428.50" "$19,686.74" "$19,885.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202680 EAP Custom 27202680 12x12x5.5cm Iliac Cuff Aaa Ste BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202681 EAP Custom 27202681 13x13x5.5cm Ilaic Cuff Aaa Ste BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202682 EAP Custom 27202682 14x14x5.5cm Iliac Cuff Aaa Ste BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202683 EAP Custom 27202683 15x15x5.5cm Iliac Cuff Aaa Ste BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202684 EAP Custom 27202684 16x15x5.5cm Iliac Cuff Aaa Ste BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202685 EAP Custom 27202685 18x18x5.5cm Iliac Cuff Aaa Ste BOTH IP/OP "$15,832.00 " "$11,715.68" $0.00 "$12,665.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,203.31" $0.00 "$3,299.39" $0.00 $0.00 $0.00 $0.00 "$7,916.00" "$12,538.94" "$12,665.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202686 EAP Custom 27202686 20x20x5.5cm Iliac Cuff Aaa Ste BOTH IP/OP "$15,832.00 " "$11,715.68" $0.00 "$12,665.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,203.31" $0.00 "$3,299.39" $0.00 $0.00 $0.00 $0.00 "$7,916.00" "$12,538.94" "$12,665.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202687 EAP HCPCS C1769 6mmx5cmx110cm 0.035 Guidewire BOTH IP/OP "$15,219.00 " "$11,262.06" $0.00 "$12,175.20" "$8,263.92" "$8,263.92" $0.00 $0.00 $0.00 "$3,172.02" "$4,181.12" "$4,181.12" "$11,730.81" $0.00 "$3,171.64" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,609.50" "$12,053.45" "$12,175.20" $0.00 $0.00 $0.00 "$2,381.77" $0.00 $0.00 "$2,422.86" $0.00 $0.00 $0.00 $0.00 $0.00 27202688 EAP HCPCS C1769 6mmx10cmx110cm 0.035 Guidewire BOTH IP/OP "$18,251.00 " "$13,505.74" $0.00 "$14,600.80" "$9,910.29" "$9,910.29" $0.00 $0.00 $0.00 "$3,803.96" "$4,181.12" "$4,181.12" "$14,067.87" $0.00 "$3,803.51" $0.00 "$3,094.73" "$3,094.73" $0.00 "$9,125.50" "$14,454.79" "$14,600.80" $0.00 $0.00 $0.00 "$2,856.28" $0.00 $0.00 "$2,905.56" $0.00 $0.00 $0.00 $0.00 $0.00 27202689 EAP HCPCS C1769 6mmx15cmx110cm 0.035 Guidewire BOTH IP/OP "$21,246.00 " "$15,722.04" $0.00 "$16,996.80" "$11,536.58" "$11,536.58" $0.00 $0.00 $0.00 "$4,428.20" "$4,181.12" "$4,181.12" "$16,376.42" $0.00 "$4,427.67" $0.00 "$3,094.73" "$3,094.73" $0.00 "$10,623.00" "$16,826.83" "$16,996.80" $0.00 $0.00 $0.00 "$3,325.00" $0.00 $0.00 "$3,382.36" $0.00 $0.00 $0.00 $0.00 $0.00 27202690 EAP HCPCS C1769 7mmx5cmx110cm 0.035 Guidewire BOTH IP/OP "$15,219.00 " "$11,262.06" $0.00 "$12,175.20" "$8,263.92" "$8,263.92" $0.00 $0.00 $0.00 "$3,172.02" "$4,181.12" "$4,181.12" "$11,730.81" $0.00 "$3,171.64" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,609.50" "$12,053.45" "$12,175.20" $0.00 $0.00 $0.00 "$2,381.77" $0.00 $0.00 "$2,422.86" $0.00 $0.00 $0.00 $0.00 $0.00 27202691 EAP HCPCS C1769 7mmx10cmx110cm 0.035 Guidewire BOTH IP/OP "$18,251.00 " "$13,505.74" $0.00 "$14,600.80" "$9,910.29" "$9,910.29" $0.00 $0.00 $0.00 "$3,803.96" "$4,181.12" "$4,181.12" "$14,067.87" $0.00 "$3,803.51" $0.00 "$3,094.73" "$3,094.73" $0.00 "$9,125.50" "$14,454.79" "$14,600.80" $0.00 $0.00 $0.00 "$2,856.28" $0.00 $0.00 "$2,905.56" $0.00 $0.00 $0.00 $0.00 $0.00 27202692 EAP HCPCS C1769 7mmx15cmx110cm 0.035 Guidewire BOTH IP/OP "$21,246.00 " "$15,722.04" $0.00 "$16,996.80" "$11,536.58" "$11,536.58" $0.00 $0.00 $0.00 "$4,428.20" "$4,181.12" "$4,181.12" "$16,376.42" $0.00 "$4,427.67" $0.00 "$3,094.73" "$3,094.73" $0.00 "$10,623.00" "$16,826.83" "$16,996.80" $0.00 $0.00 $0.00 "$3,325.00" $0.00 $0.00 "$3,382.36" $0.00 $0.00 $0.00 $0.00 $0.00 27202693 EAP HCPCS C1769 8mmx5cmx110cm 0.035 Guidewire BOTH IP/OP "$15,219.00 " "$11,262.06" $0.00 "$12,175.20" "$8,263.92" "$8,263.92" $0.00 $0.00 $0.00 "$3,172.02" "$4,181.12" "$4,181.12" "$11,730.81" $0.00 "$3,171.64" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,609.50" "$12,053.45" "$12,175.20" $0.00 $0.00 $0.00 "$2,381.77" $0.00 $0.00 "$2,422.86" $0.00 $0.00 $0.00 $0.00 $0.00 27202694 EAP HCPCS C1769 8mmx10cmx110cm 0.035 Guidewire BOTH IP/OP "$18,251.00 " "$13,505.74" $0.00 "$14,600.80" "$9,910.29" "$9,910.29" $0.00 $0.00 $0.00 "$3,803.96" "$4,181.12" "$4,181.12" "$14,067.87" $0.00 "$3,803.51" $0.00 "$3,094.73" "$3,094.73" $0.00 "$9,125.50" "$14,454.79" "$14,600.80" $0.00 $0.00 $0.00 "$2,856.28" $0.00 $0.00 "$2,905.56" $0.00 $0.00 $0.00 $0.00 $0.00 27202695 EAP HCPCS C1769 8mmx15cmx110cm 0.035 Guidewire BOTH IP/OP "$21,246.00 " "$15,722.04" $0.00 "$16,996.80" "$11,536.58" "$11,536.58" $0.00 $0.00 $0.00 "$4,428.20" "$4,181.12" "$4,181.12" "$16,376.42" $0.00 "$4,427.67" $0.00 "$3,094.73" "$3,094.73" $0.00 "$10,623.00" "$16,826.83" "$16,996.80" $0.00 $0.00 $0.00 "$3,325.00" $0.00 $0.00 "$3,382.36" $0.00 $0.00 $0.00 $0.00 $0.00 27202696 EAP HCPCS C1769 10mmx5cmx110cm 0.025 Guidewire BOTH IP/OP "$15,219.00 " "$11,262.06" $0.00 "$12,175.20" "$8,263.92" "$8,263.92" $0.00 $0.00 $0.00 "$3,172.02" "$4,181.12" "$4,181.12" "$11,730.81" $0.00 "$3,171.64" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,609.50" "$12,053.45" "$12,175.20" $0.00 "$9,892.35" $0.00 "$2,381.77" $0.00 $0.00 "$2,422.86" $0.00 $0.00 $0.00 $0.00 $0.00 27202697 EAP HCPCS C1769 10mmx10cmx110cm 0.025 Guidewir BOTH IP/OP "$18,251.00 " "$13,505.74" $0.00 "$14,600.80" "$9,910.29" "$9,910.29" $0.00 $0.00 $0.00 "$3,803.96" "$4,181.12" "$4,181.12" "$14,067.87" $0.00 "$3,803.51" $0.00 "$3,094.73" "$3,094.73" $0.00 "$9,125.50" "$14,454.79" "$14,600.80" $0.00 "$11,863.15" $0.00 "$2,856.28" $0.00 $0.00 "$2,905.56" $0.00 $0.00 $0.00 $0.00 $0.00 27202698 EAP HCPCS C1769 13mmx5cmx110cm 0.025 Guidewire BOTH IP/OP "$15,219.00 " "$11,262.06" $0.00 "$12,175.20" "$8,263.92" "$8,263.92" $0.00 $0.00 $0.00 "$3,172.02" "$4,181.12" "$4,181.12" "$11,730.81" $0.00 "$3,171.64" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,609.50" "$12,053.45" "$12,175.20" $0.00 "$9,892.35" $0.00 "$2,381.77" $0.00 $0.00 "$2,422.86" $0.00 $0.00 $0.00 $0.00 $0.00 27202699 EAP HCPCS C1769 13mmx2.5cmx110cm 0.025 Guidewi BOTH IP/OP "$15,219.00 " "$11,262.06" $0.00 "$12,175.20" "$8,263.92" "$8,263.92" $0.00 $0.00 $0.00 "$3,172.02" "$4,181.12" "$4,181.12" "$11,730.81" $0.00 "$3,171.64" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,609.50" "$12,053.45" "$12,175.20" $0.00 $0.00 $0.00 "$2,381.77" $0.00 $0.00 "$2,422.86" $0.00 $0.00 $0.00 $0.00 $0.00 27202700 EAP Custom 27202700 16mmx20mmx8.5cm Aaa Stent Graf BOTH IP/OP "$22,131.00 " "$16,376.94" $0.00 "$17,704.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,058.57" $0.00 "$4,612.10" $0.00 $0.00 $0.00 $0.00 "$11,065.50" "$17,527.75" "$17,704.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202701 EAP Custom 27202701 18mmx22mmx8.5cm Aaa Stent Graf BOTH IP/OP "$22,131.00 " "$16,376.94" $0.00 "$17,704.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,058.57" $0.00 "$4,612.10" $0.00 $0.00 $0.00 $0.00 "$11,065.50" "$17,527.75" "$17,704.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202702 EAP Custom 27202702 18mmx24mmx8.5cm Aaa Stent Graf BOTH IP/OP "$22,131.00 " "$16,376.94" $0.00 "$17,704.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,058.57" $0.00 "$4,612.10" $0.00 $0.00 $0.00 $0.00 "$11,065.50" "$17,527.75" "$17,704.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202703 EAP Custom 27202703 20mmx4.0cm Aaa Stent Graft BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202704 EAP Custom 27202704 22mmx4.0cm Aaa Stent Graft BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202705 EAP Custom 27202705 24mmx4.0cm Aaa Stent Graft BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202706 EAP Custom 27202706 26mmx4.0cm Aaa Stent Graft BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202707 EAP Custom 27202707 28mmx4.0cm Aaa Stent Graft BOTH IP/OP "$15,151.00 " "$11,211.74" $0.00 "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,678.39" $0.00 "$3,157.47" $0.00 $0.00 $0.00 $0.00 "$7,575.50" "$11,999.59" "$12,120.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202708 EAP Custom 27202708 23x3.3cm Aaa Endoprosthesis BOTH IP/OP "$17,322.00 " "$12,818.28" $0.00 "$13,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,351.80" $0.00 "$3,609.90" $0.00 $0.00 $0.00 $0.00 "$8,661.00" "$13,719.02" "$13,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202709 EAP Custom 27202709 26x3.3cm Aaa Endprosthesis BOTH IP/OP "$17,322.00 " "$12,818.28" $0.00 "$13,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,351.80" $0.00 "$3,609.90" $0.00 $0.00 $0.00 $0.00 "$8,661.00" "$13,719.02" "$13,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202710 EAP Custom 27202710 28.5x3.3cm Aaa Endoprosthesis BOTH IP/OP "$16,083.00 " "$11,901.42" $0.00 "$12,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,396.78" $0.00 "$3,351.70" $0.00 $0.00 $0.00 $0.00 "$8,041.50" "$12,737.74" "$12,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202711 EAP Custom 27202711 10x7cm Aaa Endoprosthesis BOTH IP/OP "$16,083.00 " "$11,901.42" $0.00 "$12,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,396.78" $0.00 "$3,351.70" $0.00 $0.00 $0.00 $0.00 "$8,041.50" "$12,737.74" "$12,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202712 EAP Custom 27202712 12x7cm Aaa Endoprosthesis BOTH IP/OP "$16,083.00 " "$11,901.42" $0.00 "$12,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,396.78" $0.00 "$3,351.70" $0.00 $0.00 $0.00 $0.00 "$8,041.50" "$12,737.74" "$12,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202713 EAP Custom 27202713 14.5x7cm Aaa Endoprosthesis BOTH IP/OP "$16,083.00 " "$11,901.42" $0.00 "$12,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,396.78" $0.00 "$3,351.70" $0.00 $0.00 $0.00 $0.00 "$8,041.50" "$12,737.74" "$12,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202714 EAP Custom 27202714 12frx30cm Introducer Sheath BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202715 EAP Custom 27202715 18frx30cm Intruder Sheath BOTH IP/OP $902.00 $667.48 $0.00 $721.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.46 $669.46 $695.26 $0.00 $187.98 $0.00 $0.00 $0.00 $0.00 $451.00 $714.38 $721.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202716 EAP Custom 27202716 26x10cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202717 EAP Custom 27202717 28x10cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202718 EAP Custom 27202718 28x15cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202719 EAP Custom 27202719 31x10cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202720 EAP Custom 27202720 31x15cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202721 EAP Custom 27202721 34x10cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202722 EAP Custom 27202722 34x15cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202723 EAP Custom 27202723 34x20cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202724 EAP Custom 27202724 37x10cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202725 EAP Custom 27202725 37x15cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202726 EAP Custom 27202726 37x20cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202727 EAP Custom 27202727 40x10cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202728 EAP Custom 27202728 40x15cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202729 EAP Custom 27202729 40x20cm Thoracic Endoprosthesi BOTH IP/OP "$23,023.00 " "$17,037.02" $0.00 "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,746.13" $0.00 "$4,797.99" $0.00 $0.00 $0.00 $0.00 "$11,511.50" "$18,234.22" "$18,418.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202730 EAP Custom 27202730 20frx30cm Introducer Sheath BOTH IP/OP "$2,043.00 " "$1,511.82" $0.00 "$1,634.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,516.31" "$1,516.31" "$1,574.74" $0.00 $425.76 $0.00 $0.00 $0.00 $0.00 "$1,021.50" "$1,618.06" "$1,634.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202731 EAP Custom 27202731 22frx30cm Introducer Sheath BOTH IP/OP "$2,043.00 " "$1,511.82" $0.00 "$1,634.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,516.31" "$1,516.31" "$1,574.74" $0.00 $425.76 $0.00 $0.00 $0.00 $0.00 "$1,021.50" "$1,618.06" "$1,634.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202732 EAP Custom 27202732 24frx30cm Introducer Sheath BOTH IP/OP "$2,043.00 " "$1,511.82" $0.00 "$1,634.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,516.31" "$1,516.31" "$1,574.74" $0.00 $425.76 $0.00 $0.00 $0.00 $0.00 "$1,021.50" "$1,618.06" "$1,634.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202733 EAP Custom 27202733 Gore Tri-lobe Ballon Catheter BOTH IP/OP "$3,391.00 " "$2,509.34" $0.00 "$2,712.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,516.80" "$2,516.80" "$2,613.78" $0.00 $706.68 $0.00 $0.00 $0.00 $0.00 "$1,695.50" "$2,685.67" "$2,712.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202734 EAP Custom 27202734 20x12x135mm Aaa Stent Graft BOTH IP/OP "$25,471.00 " "$18,848.54" $0.00 "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,633.05" $0.00 "$5,308.16" $0.00 $0.00 $0.00 $0.00 "$12,735.50" "$20,173.03" "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202735 EAP Custom 27202735 22x13x135mm Aaa Stent Graft BOTH IP/OP "$25,471.00 " "$18,848.54" $0.00 "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,633.05" $0.00 "$5,308.16" $0.00 $0.00 $0.00 $0.00 "$12,735.50" "$20,173.03" "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202736 EAP Custom 27202736 24x14x135mm Aaa Stent Graft BOTH IP/OP "$25,471.00 " "$18,848.54" $0.00 "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,633.05" $0.00 "$5,308.16" $0.00 $0.00 $0.00 $0.00 "$12,735.50" "$20,173.03" "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202737 EAP Custom 27202737 26x15x135mm Aaa Stent Graft BOTH IP/OP "$25,471.00 " "$18,848.54" $0.00 "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,633.05" $0.00 "$5,308.16" $0.00 $0.00 $0.00 $0.00 "$12,735.50" "$20,173.03" "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202738 EAP Custom 27202738 28x16x135mm Aaa Stent Graft BOTH IP/OP "$25,471.00 " "$18,848.54" $0.00 "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,633.05" $0.00 "$5,308.16" $0.00 $0.00 $0.00 $0.00 "$12,735.50" "$20,173.03" "$20,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202739 EAP Custom 27202739 20x12x165mm Aaa Stent Graft BOTH IP/OP "$1,232.00 " $911.68 $0.00 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.39 $914.39 $949.63 $0.00 $256.75 $0.00 $0.00 $0.00 $0.00 $616.00 $975.74 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202740 EAP Custom 27202740 22x13x165mm Aaa Stent Graft BOTH IP/OP "$1,232.00 " $911.68 $0.00 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.39 $914.39 $949.63 $0.00 $256.75 $0.00 $0.00 $0.00 $0.00 $616.00 $975.74 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202741 EAP Custom 27202741 24x14x165mm Aaa Stent Graft BOTH IP/OP "$1,232.00 " $911.68 $0.00 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.39 $914.39 $949.63 $0.00 $256.75 $0.00 $0.00 $0.00 $0.00 $616.00 $975.74 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202742 EAP Custom 27202742 26x15x165mm Aaa Stent Graft BOTH IP/OP "$1,232.00 " $911.68 $0.00 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.39 $914.39 $949.63 $0.00 $256.75 $0.00 $0.00 $0.00 $0.00 $616.00 $975.74 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202743 EAP Custom 27202743 28x16x165mm Aaa Stent Graft BOTH IP/OP "$1,232.00 " $911.68 $0.00 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.39 $914.39 $949.63 $0.00 $256.75 $0.00 $0.00 $0.00 $0.00 $616.00 $975.74 $985.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202744 EAP Custom 27202744 "Cath, Angioplasty Spv" BOTH IP/OP "$1,074.00 " $794.76 $0.00 $859.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $537.00 $850.61 $859.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202745 EAP HCPCS C1729 Catheter Drainage Spv BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 27202746 EAP Custom 27202746 "Cath, Hemodial, Long-term Spv" BOTH IP/OP "$1,131.00 " $836.94 $0.00 $904.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $565.50 $895.75 $904.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202747 EAP Custom 27202747 "Cath, Infusion Non-hemo Spv" BOTH IP/OP $431.00 $318.94 $0.00 $344.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.50 $341.35 $344.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202748 EAP Custom 27202748 "Cath, Hemodial, Short-term Spv" BOTH IP/OP $587.00 $434.38 $0.00 $469.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $293.50 $464.90 $469.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202749 EAP Custom 27202749 "Cath,thrombect/embolect Spv" BOTH IP/OP "$2,336.00 " "$1,728.64" $0.00 "$1,868.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.00" "$1,850.11" "$1,868.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202750 EAP Custom 27202750 Retrieval Device Spv BOTH IP/OP $391.00 $289.34 $0.00 $312.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.20 $290.20 $301.38 $0.00 $81.48 $0.00 $0.00 $0.00 $0.00 $195.50 $309.67 $312.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202751 EAP Custom 27202751 "Port, Implantable Spv" BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" "$1,487.64" $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202752 EAP Custom 27202752 "Stent, Covrd, W/delv Spv" BOTH IP/OP "$7,595.00 " "$5,620.30" $0.00 "$6,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,854.23" $0.00 "$1,582.80" $0.00 $0.00 $0.00 $0.00 "$3,797.50" "$6,015.24" "$6,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202753 EAP Custom 27202753 "Stent, Non-covrd W/delv Spv" BOTH IP/OP "$5,824.00 " "$4,309.76" $0.00 "$4,659.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,489.14" $0.00 "$1,213.72" $0.00 $0.00 $0.00 $0.00 "$2,912.00" "$4,612.61" "$4,659.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202754 EAP Custom 27202754 "Stent, Non-covrd W/o Delv Spv" BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 $0.00 $0.00 $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202755 EAP HCPCS C1887 "Catheter, Guiding Spv" BOTH IP/OP $431.00 $318.94 $0.00 $344.80 $234.03 $234.03 $0.00 $0.00 $0.00 $89.83 $319.89 $319.89 $332.21 $0.00 $89.82 $0.00 $254.94 $254.94 $0.00 $215.50 $341.35 $344.80 $0.00 $0.00 $0.00 $67.45 $0.00 $0.00 $68.62 $0.00 $0.00 $0.00 $0.00 $0.00 27202756 EAP Custom 27202756 Workhorse Balloon Catheter BOTH IP/OP "$1,462.00 " "$1,081.88" $0.00 "$1,169.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,085.10" "$1,085.10" "$1,126.91" $0.00 $304.68 $0.00 $0.00 $0.00 $0.00 $731.00 "$1,157.90" "$1,169.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202757 EAP Custom 27202757 Opta 5 Balloon Catheter BOTH IP/OP "$1,462.00 " "$1,081.88" $0.00 "$1,169.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,085.10" "$1,085.10" "$1,126.91" $0.00 $304.68 $0.00 $0.00 $0.00 $0.00 $731.00 "$1,157.90" "$1,169.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202758 EAP Custom 27202758 Arrow-trerotola Device BOTH IP/OP "$3,506.00 " "$2,594.44" $0.00 "$2,804.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,602.15" "$2,602.15" "$2,702.42" $0.00 $730.65 $0.00 $0.00 $0.00 $0.00 "$1,753.00" "$2,776.75" "$2,804.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202759 EAP Custom 27202759 Flexima Biliary Drain Cath W/l BOTH IP/OP $439.00 $324.86 $0.00 $351.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.83 $325.83 $338.38 $0.00 $91.49 $0.00 $0.00 $0.00 $0.00 $219.50 $347.69 $351.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202760 EAP Custom 27202760 "Catheter, Occlusion Spv" BOTH IP/OP "$2,336.00 " "$1,728.64" $0.00 "$1,868.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,733.78" "$1,733.78" "$1,800.59" $0.00 $486.82 $0.00 $0.00 $0.00 $0.00 "$1,168.00" "$1,850.11" "$1,868.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202761 EAP Custom 27202761 "G - Feeding Kit, 18fr, 2.5l" BOTH IP/OP "$1,090.00 " $806.60 $0.00 $872.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $809.00 $809.00 $840.17 $0.00 $227.16 $0.00 $0.00 $0.00 $0.00 $545.00 $863.28 $872.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202786 EAP HCPCS C1892 8fr-14cm Peel Away Sheath BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $54.84 $54.84 $0.00 $0.00 $0.00 $21.05 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $59.74 $59.74 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $15.81 $0.00 $0.00 $16.08 $0.00 $0.00 $0.00 $0.00 $0.00 27202790 EAP Custom 27202790 Alligator Retrieval BOTH IP/OP "$8,967.00 " "$6,635.58" $0.00 "$7,173.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,911.76" $0.00 "$1,868.72" $0.00 $0.00 $0.00 $0.00 "$4,483.50" "$7,101.86" "$7,173.60" $0.00 "$5,828.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202791 EAP HCPCS C1769 Cadence Precision BOTH IP/OP "$1,703.00 " "$1,260.22" $0.00 "$1,362.40" $924.73 $924.73 $0.00 $0.00 $0.00 $354.95 "$1,263.97" "$1,263.97" "$1,312.67" $0.00 $354.91 $0.00 "$1,007.32" "$1,007.32" $0.00 $851.50 "$1,348.78" "$1,362.40" $0.00 $0.00 $0.00 $266.52 $0.00 $0.00 $271.12 $0.00 $0.00 $0.00 $0.00 $0.00 27202792 EAP HCPCS C1751 Catheter Echelon 10 Micro BOTH IP/OP "$2,423.00 " "$1,793.02" $0.00 "$1,938.40" "$1,315.69" "$1,315.69" $0.00 $0.00 $0.00 $505.01 "$1,798.35" "$1,798.35" "$1,867.65" $0.00 $504.95 $0.00 "$1,433.20" "$1,433.20" $0.00 "$1,211.50" "$1,919.02" "$1,938.40" $0.00 $0.00 $0.00 $379.20 $0.00 $0.00 $385.74 $0.00 $0.00 $0.00 $0.00 $0.00 27202794 EAP Custom 27202794 Catheter Marathon BOTH IP/OP "$2,152.00 " "$1,592.48" $0.00 "$1,721.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.21" "$1,597.21" "$1,658.76" $0.00 $448.48 $0.00 $0.00 $0.00 $0.00 "$1,076.00" "$1,704.38" "$1,721.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202795 EAP HCPCS C2628 Catheter Marksman 105cm BOTH IP/OP "$3,587.00 " "$2,654.38" $0.00 "$2,869.60" "$1,947.74" "$1,947.74" $0.00 $0.00 $0.00 $747.62 "$2,662.27" "$2,662.27" "$2,764.86" $0.00 $747.53 $0.00 "$2,121.71" "$2,121.71" $0.00 "$1,793.50" "$2,840.90" "$2,869.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202796 EAP HCPCS C2628 Catheter Marksman 135cm BOTH IP/OP "$3,587.00 " "$2,654.38" $0.00 "$2,869.60" "$1,947.74" "$1,947.74" $0.00 $0.00 $0.00 $747.62 "$2,662.27" "$2,662.27" "$2,764.86" $0.00 $747.53 $0.00 "$2,121.71" "$2,121.71" $0.00 "$1,793.50" "$2,840.90" "$2,869.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202797 EAP Custom 27202797 Catheter Marksman 150cm BOTH IP/OP "$3,587.00 " "$2,654.38" $0.00 "$2,869.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,662.27" "$2,662.27" "$2,764.86" $0.00 $747.53 $0.00 $0.00 $0.00 $0.00 "$1,793.50" "$2,840.90" "$2,869.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202798 EAP HCPCS C1751 Catheter Rebar-027 130cm Micro BOTH IP/OP $989.00 $731.86 $0.00 $791.20 $537.03 $537.03 $0.00 $0.00 $0.00 $206.13 $734.04 $734.04 $762.32 $0.00 $206.11 $0.00 $584.99 $584.99 $0.00 $494.50 $783.29 $791.20 $0.00 $0.00 $0.00 $154.78 $0.00 $0.00 $157.45 $0.00 $0.00 $0.00 $0.00 $0.00 27202799 EAP HCPCS C1751 Catheter Rebar-027 145cm Micro BOTH IP/OP $989.00 $731.86 $0.00 $791.20 $537.03 $537.03 $0.00 $0.00 $0.00 $206.13 $734.04 $734.04 $762.32 $0.00 $206.11 $0.00 $584.99 $584.99 $0.00 $494.50 $783.29 $791.20 $0.00 $0.00 $0.00 $154.78 $0.00 $0.00 $157.45 $0.00 $0.00 $0.00 $0.00 $0.00 27202800 EAP HCPCS C1751 Catheter Rebar-10 153cm Micro BOTH IP/OP "$1,777.00 " "$1,314.98" $0.00 "$1,421.60" $964.91 $964.91 $0.00 $0.00 $0.00 $370.37 "$1,318.89" "$1,318.89" "$1,369.71" $0.00 $370.33 $0.00 "$1,051.10" "$1,051.10" $0.00 $888.50 "$1,407.38" "$1,421.60" $0.00 $0.00 $0.00 $278.10 $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $0.00 27202801 EAP HCPCS C1751 Catheter Rebar-14 153cm Micro BOTH IP/OP "$1,777.00 " "$1,314.98" $0.00 "$1,421.60" $964.91 $964.91 $0.00 $0.00 $0.00 $370.37 "$1,318.89" "$1,318.89" "$1,369.71" $0.00 $370.33 $0.00 "$1,051.10" "$1,051.10" $0.00 $888.50 "$1,407.38" "$1,421.60" $0.00 $0.00 $0.00 $278.10 $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $0.00 27202802 EAP HCPCS C1751 Catheter Rebar-18 130cm Micro BOTH IP/OP "$1,023.00 " $757.02 $0.00 $818.40 $555.49 $555.49 $0.00 $0.00 $0.00 $213.22 $759.27 $759.27 $788.53 $0.00 $213.19 $0.00 $605.10 $605.10 $0.00 $511.50 $810.22 $818.40 $0.00 $0.00 $0.00 $160.10 $0.00 $0.00 $162.86 $0.00 $0.00 $0.00 $0.00 $0.00 27202803 EAP HCPCS C1751 Catheter Rebar-18 153 Micro BOTH IP/OP "$1,292.00 " $956.08 $0.00 "$1,033.60" $701.56 $701.56 $0.00 $0.00 $0.00 $269.29 $958.92 $958.92 $995.87 $0.00 $269.25 $0.00 $764.22 $764.22 $0.00 $646.00 "$1,023.26" "$1,033.60" $0.00 $0.00 $0.00 $202.20 $0.00 $0.00 $205.69 $0.00 $0.00 $0.00 $0.00 $0.00 27202804 EAP HCPCS C1751 Catheter Rebar-18 153cm Micro BOTH IP/OP "$1,435.00 " "$1,061.90" $0.00 "$1,148.00" $779.21 $779.21 $0.00 $0.00 $0.00 $299.09 "$1,065.06" "$1,065.06" "$1,106.10" $0.00 $299.05 $0.00 $848.80 $848.80 $0.00 $717.50 "$1,136.52" "$1,148.00" $0.00 $0.00 $0.00 $224.58 $0.00 $0.00 $228.45 $0.00 $0.00 $0.00 $0.00 $0.00 27202806 EAP Custom 27202806 Dribath Onyx Heater Us BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 $0.00 $0.00 $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202808 EAP HCPCS C1751 Extended Ultraflow BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $973.60 $973.60 $0.00 $0.00 $0.00 $373.71 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 "$1,060.56" "$1,060.56" $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $280.60 $0.00 $0.00 $285.45 $0.00 $0.00 $0.00 $0.00 $0.00 27202809 EAP HCPCS C1769 Guidewire Silverspeed .010 BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $447.98 $447.98 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $635.91 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 27202810 EAP HCPCS C1769 Guidewire Silverspeed .014 BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $447.98 $447.98 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $635.91 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 27202811 EAP HCPCS C1769 Guidewire Silverspeed .016 BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $399.11 $399.11 $0.00 $0.00 $0.00 $153.19 $545.52 $545.52 $566.54 $0.00 $153.17 $0.00 $434.75 $434.75 $0.00 $367.50 $582.12 $588.00 $0.00 $477.75 $0.00 $115.03 $0.00 $0.00 $117.01 $0.00 $0.00 $0.00 $0.00 $0.00 27202812 EAP HCPCS C1769 Guidewire X-celerator .010r BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $643.46 $643.46 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $913.40 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $185.45 $0.00 $0.00 $188.65 $0.00 $0.00 $0.00 $0.00 $0.00 27202813 EAP HCPCS C1769 Guidewire X-celerator-14 Re BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $643.46 $643.46 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $913.40 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $185.45 $0.00 $0.00 $188.65 $0.00 $0.00 $0.00 $0.00 $0.00 27202814 EAP HCPCS C1769 Guidewire X-pedion 14 2 BOTH IP/OP $897.00 $663.78 $0.00 $717.60 $487.07 $487.07 $0.00 $0.00 $0.00 $186.96 $665.75 $665.75 $691.41 $0.00 $186.93 $0.00 $530.58 $530.58 $0.00 $448.50 $710.42 $717.60 $0.00 $0.00 $0.00 $140.38 $0.00 $0.00 $142.80 $0.00 $0.00 $0.00 $0.00 $0.00 27202815 EAP HCPCS C1769 Guidewire X-pedion-10 Re 2 BOTH IP/OP $897.00 $663.78 $0.00 $717.60 $487.07 $487.07 $0.00 $0.00 $0.00 $186.96 $665.75 $665.75 $691.41 $0.00 $186.93 $0.00 $530.58 $530.58 $0.00 $448.50 $710.42 $717.60 $0.00 $0.00 $0.00 $140.38 $0.00 $0.00 $142.80 $0.00 $0.00 $0.00 $0.00 $0.00 27202816 EAP HCPCS C1726 Hyperglide 3.0 X 10mm BOTH IP/OP "$3,837.00 " "$2,839.38" $0.00 "$3,069.60" "$2,083.49" "$2,083.49" $0.00 $0.00 $0.00 $799.73 "$2,847.82" "$2,847.82" "$2,957.56" $0.00 $799.63 $0.00 "$2,269.59" "$2,269.59" $0.00 "$1,918.50" "$3,038.90" "$3,069.60" $0.00 $0.00 $0.00 $600.49 $0.00 $0.00 $610.85 $0.00 $0.00 $0.00 $0.00 $0.00 27202817 EAP HCPCS C1726 Hyperglide 3.0 X 15mm BOTH IP/OP "$3,837.00 " "$2,839.38" $0.00 "$3,069.60" "$2,083.49" "$2,083.49" $0.00 $0.00 $0.00 $799.73 "$2,847.82" "$2,847.82" "$2,957.56" $0.00 $799.63 $0.00 "$2,269.59" "$2,269.59" $0.00 "$1,918.50" "$3,038.90" "$3,069.60" $0.00 $0.00 $0.00 $600.49 $0.00 $0.00 $610.85 $0.00 $0.00 $0.00 $0.00 $0.00 27202818 EAP HCPCS C1726 Hyperglide 4.0 X 10mm BOTH IP/OP "$3,837.00 " "$2,839.38" $0.00 "$3,069.60" "$2,083.49" "$2,083.49" $0.00 $0.00 $0.00 $799.73 "$2,847.82" "$2,847.82" "$2,957.56" $0.00 $799.63 $0.00 "$2,269.59" "$2,269.59" $0.00 "$1,918.50" "$3,038.90" "$3,069.60" $0.00 $0.00 $0.00 $600.49 $0.00 $0.00 $610.85 $0.00 $0.00 $0.00 $0.00 $0.00 27202819 EAP HCPCS C1726 Hyperglide 4.0 X 20mm BOTH IP/OP "$3,676.00 " "$2,720.24" $0.00 "$2,940.80" "$1,996.07" "$1,996.07" $0.00 $0.00 $0.00 $766.17 "$2,728.33" "$2,728.33" "$2,833.46" $0.00 $766.08 $0.00 "$2,174.35" "$2,174.35" $0.00 "$1,838.00" "$2,911.39" "$2,940.80" $0.00 $0.00 $0.00 $575.29 $0.00 $0.00 $585.22 $0.00 $0.00 $0.00 $0.00 $0.00 27202820 EAP HCPCS C1726 Hyperglide 5.0 X 15mm BOTH IP/OP "$3,837.00 " "$2,839.38" $0.00 "$3,069.60" "$2,083.49" "$2,083.49" $0.00 $0.00 $0.00 $799.73 "$2,847.82" "$2,847.82" "$2,957.56" $0.00 $799.63 $0.00 "$2,269.59" "$2,269.59" $0.00 "$1,918.50" "$3,038.90" "$3,069.60" $0.00 $0.00 $0.00 $600.49 $0.00 $0.00 $610.85 $0.00 $0.00 $0.00 $0.00 $0.00 27202821 EAP HCPCS C1726 Hyperglide 5.0 X 20mm BOTH IP/OP "$1,472.00 " "$1,089.28" $0.00 "$1,177.60" $799.30 $799.30 $0.00 $0.00 $0.00 $306.80 "$1,092.52" "$1,092.52" "$1,134.62" $0.00 $306.76 $0.00 $870.69 $870.69 $0.00 $736.00 "$1,165.82" "$1,177.60" $0.00 $0.00 $0.00 $230.37 $0.00 $0.00 $234.34 $0.00 $0.00 $0.00 $0.00 $0.00 27202822 EAP HCPCS C1751 Hyperglide 5.0 X 30 BOTH IP/OP "$4,627.00 " "$3,423.98" $0.00 "$3,701.60" "$2,512.46" "$2,512.46" $0.00 $0.00 $0.00 $964.38 "$3,434.16" "$3,434.16" "$3,566.49" $0.00 $964.27 $0.00 "$2,736.87" "$2,736.87" $0.00 "$2,313.50" "$3,664.58" "$3,701.60" $0.00 $0.00 $0.00 $724.13 $0.00 $0.00 $736.62 $0.00 $0.00 $0.00 $0.00 $0.00 27202823 EAP HCPCS C1726 Hyperglide System - 30mm BOTH IP/OP "$3,676.00 " "$2,720.24" $0.00 "$2,940.80" "$1,996.07" "$1,996.07" $0.00 $0.00 $0.00 $766.17 "$2,728.33" "$2,728.33" "$2,833.46" $0.00 $766.08 $0.00 "$2,174.35" "$2,174.35" $0.00 "$1,838.00" "$2,911.39" "$2,940.80" $0.00 $0.00 $0.00 $575.29 $0.00 $0.00 $585.22 $0.00 $0.00 $0.00 $0.00 $0.00 27202825 EAP HCPCS C1769 Meridian .014 Re BOTH IP/OP "$1,777.00 " "$1,314.98" $0.00 "$1,421.60" $964.91 $964.91 $0.00 $0.00 $0.00 $370.37 "$1,318.89" "$1,318.89" "$1,369.71" $0.00 $370.33 $0.00 "$1,051.10" "$1,051.10" $0.00 $888.50 "$1,407.38" "$1,421.60" $0.00 $0.00 $0.00 $278.10 $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $0.00 27202826 EAP HCPCS C1884 Microcatheter Nautica BOTH IP/OP "$1,882.00 " "$1,392.68" $0.00 "$1,505.60" "$1,021.93" "$1,021.93" $0.00 $0.00 $0.00 $392.26 "$1,396.82" "$1,396.82" "$1,450.65" $0.00 $392.21 $0.00 "$1,113.20" "$1,113.20" $0.00 $941.00 "$1,490.54" "$1,505.60" $0.00 $0.00 $0.00 $294.53 $0.00 $0.00 $299.61 $0.00 $0.00 $0.00 $0.00 $0.00 27202827 EAP HCPCS C1769 Mirage Re .008 BOTH IP/OP "$1,490.00 " "$1,102.60" $0.00 "$1,192.00" $809.07 $809.07 $0.00 $0.00 $0.00 $310.55 "$1,105.88" "$1,105.88" "$1,148.49" $0.00 $310.52 $0.00 $881.34 $881.34 $0.00 $745.00 "$1,180.08" "$1,192.00" $0.00 $0.00 $0.00 $233.19 $0.00 $0.00 $237.21 $0.00 $0.00 $0.00 $0.00 $0.00 27202828 EAP Custom 27202828 Mixer Us 15-17 Mm Vial BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 $0.00 $0.00 $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202829 EAP HCPCS C1884 Onyx 18 Kit Avm Us BOTH IP/OP "$8,071.00 " "$5,972.54" $0.00 "$6,456.80" "$4,382.55" "$4,382.55" $0.00 $0.00 $0.00 "$1,682.20" "$4,181.12" "$4,181.12" "$6,221.13" $0.00 "$1,682.00" $0.00 "$3,094.73" "$3,094.73" $0.00 "$4,035.50" "$6,392.23" "$6,456.80" $0.00 $0.00 $0.00 "$1,263.11" $0.00 $0.00 "$1,284.90" $0.00 $0.00 $0.00 $0.00 $0.00 27202830 EAP HCPCS C1884 Onyx 34 Kit Avm Us BOTH IP/OP "$3,227.00 " "$2,387.98" $0.00 "$2,581.60" "$1,752.26" "$1,752.26" $0.00 $0.00 $0.00 $672.59 "$2,395.08" "$2,395.08" "$2,487.37" $0.00 $672.51 $0.00 "$1,908.77" "$1,908.77" $0.00 "$1,613.50" "$2,555.78" "$2,581.60" $0.00 $0.00 $0.00 $505.03 $0.00 $0.00 $513.74 $0.00 $0.00 $0.00 $0.00 $0.00 27202831 EAP HCPCS C1751 Onyx Hd500 Kit Aneurys BOTH IP/OP "$9,325.00 " "$6,900.50" $0.00 "$7,460.00" "$5,063.48" "$5,063.48" $0.00 $0.00 $0.00 "$1,943.56" "$4,181.12" "$4,181.12" "$7,187.71" $0.00 "$1,943.33" $0.00 "$3,094.73" "$3,094.73" $0.00 "$4,662.50" "$7,385.40" "$7,460.00" $0.00 $0.00 $0.00 "$1,459.36" $0.00 $0.00 "$1,484.54" $0.00 $0.00 $0.00 $0.00 $0.00 27202833 EAP Custom 27202833 Syringe 1ml Single Pa BOTH IP/OP $268.00 $198.32 $0.00 $214.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.91 $198.91 $206.57 $0.00 $55.85 $0.00 $0.00 $0.00 $0.00 $134.00 $212.26 $214.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202834 EAP HCPCS C1726 Syringe Adapter-carton BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $973.60 $973.60 $0.00 $0.00 $0.00 $373.71 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 "$1,060.56" "$1,060.56" $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $280.60 $0.00 $0.00 $285.45 $0.00 $0.00 $0.00 $0.00 $0.00 27202835 EAP Custom 27202835 Ultraflow Hpc 1.5f Flow BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 $0.00 $0.00 $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202850 EAP Custom 27202850 Adjustable Outrigger(flex/ext) BOTH IP/OP $365.00 $270.10 $0.00 $292.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.90 $270.90 $281.34 $0.00 $76.07 $0.00 $0.00 $0.00 $0.00 $182.50 $289.08 $292.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202852 EAP Custom 27202852 Adjustable Wrist Hinge BOTH IP/OP $412.00 $304.88 $0.00 $329.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.79 $305.79 $317.57 $0.00 $85.86 $0.00 $0.00 $0.00 $0.00 $206.00 $326.30 $329.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202853 EAP Custom 27202853 Alumafoam Splint BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $11.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202854 EAP Custom 27202854 Aquacel Silver 4x4 BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202855 EAP Custom 27202855 Aquacel Silver 6x6 BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.84 $86.84 $90.18 $0.00 $24.38 $0.00 $0.00 $0.00 $0.00 $58.50 $92.66 $93.60 $0.00 $76.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202856 EAP Custom 27202856 Aquacel Silver 8x12 BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202857 EAP Custom 27202857 Aquacel Silver Rope BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202858 EAP Custom 27202858 Bioconcept Brief BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202859 EAP Custom 27202859 Bioconcept Sleeved Vest BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.62 $107.62 $111.77 $0.00 $30.22 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202860 EAP Custom 27202860 Bioconcepts Brief BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202861 EAP Custom 27202861 Bioconcepts Digi - Sleeve BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202862 EAP Custom 27202862 "Bioconcepts Digi Sleeves 3""" BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202863 EAP Custom 27202863 Bioconcepts Forearm Sleeve BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202865 EAP Custom 27202865 Bioconcepts Gloves BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202867 EAP Custom 27202867 Bioconcepts Sleeved Vest BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.62 $107.62 $111.77 $0.00 $30.22 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202868 EAP Custom 27202868 Bioconcepts Ue Sleeve BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202869 EAP Custom 27202869 Chin Strap BOTH IP/OP $54.00 $39.96 $0.00 $43.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.08 $40.08 $41.62 $0.00 $11.25 $0.00 $0.00 $0.00 $0.00 $27.00 $42.77 $43.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202870 EAP Custom 27202870 Clear Acrylic Cone BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $0.00 $0.00 $0.00 $33.50 $53.06 $53.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202871 EAP Custom 27202871 Desensitization Kits BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202872 EAP Custom 27202872 Digi Sleeve BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202874 EAP Custom 27202874 Double Finger Stall BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202875 EAP Custom 27202875 Dynamic Finger Flexion Strap BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202876 EAP Custom 27202876 Dynamic Mp Flexion Spring BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202877 EAP Custom 27202877 Elbow Pad BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202878 EAP Custom 27202878 External Fixator Splint BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.01 $213.01 $221.22 $0.00 $59.81 $0.00 $0.00 $0.00 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202879 EAP Custom 27202879 Ezy Wrap Tigger Splint BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202881 EAP Custom 27202881 Finger Cylinder Cast BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202882 EAP Custom 27202882 Finger Knuckle Bender Splint BOTH IP/OP $104.00 $76.96 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.19 $77.19 $80.16 $0.00 $21.67 $0.00 $0.00 $0.00 $0.00 $52.00 $82.37 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202883 EAP Custom 27202883 Green Stick Splint BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202884 EAP Custom 27202884 Individual Outigger-each Digit BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $35.50 $56.23 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202885 EAP Custom 27202885 Indivisual Outrigger BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $35.50 $56.23 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202886 EAP Custom 27202886 Joint Jack BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.63 $130.63 $135.66 $0.00 $36.68 $0.00 $0.00 $0.00 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202887 EAP Custom 27202887 Knee Hypercontrol Brace BOTH IP/OP $217.00 $160.58 $0.00 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.06 $161.06 $167.26 $0.00 $45.22 $0.00 $0.00 $0.00 $0.00 $108.50 $171.86 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202888 EAP Custom 27202888 Lmb Ulnar Deviation Splint BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.63 $130.63 $135.66 $0.00 $36.68 $0.00 $0.00 $0.00 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202889 EAP Custom 27202889 Merit Static Pro Component BOTH IP/OP $149.00 $110.26 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $110.59 $110.59 $114.85 $0.00 $31.05 $0.00 $0.00 $0.00 $0.00 $74.50 $118.01 $119.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202890 EAP Custom 27202890 Merit Static Progressive Comp BOTH IP/OP $149.00 $110.26 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $110.59 $110.59 $114.85 $0.00 $31.05 $0.00 $0.00 $0.00 $0.00 $74.50 $118.01 $119.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202891 EAP Custom 27202891 Neoprene Tennis Elbow Strap BOTH IP/OP $135.00 $99.90 $0.00 $104.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $104.06 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $27.00 $42.77 $43.20 $0.00 $87.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202892 EAP Custom 27202892 Preformed Elbow Hinge Splint BOTH IP/OP $515.00 $381.10 $0.00 $412.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.23 $382.23 $396.96 $0.00 $107.33 $0.00 $0.00 $0.00 $0.00 $257.50 $407.88 $412.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202893 EAP Custom 27202893 Profore BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202894 EAP Custom 27202894 Redi-fit Breifs BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202897 EAP Custom 27202897 Redi-fit Forearm Sleeves BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202898 EAP Custom 27202898 Redi-fit Sleeved Vest BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.62 $107.62 $111.77 $0.00 $30.22 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202899 EAP Custom 27202899 Redi-fit Ue Sleeves BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202900 EAP Custom 27202900 Reverse Knuckle Bender Splint BOTH IP/OP $104.00 $76.96 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.19 $77.19 $80.16 $0.00 $21.67 $0.00 $0.00 $0.00 $0.00 $52.00 $82.37 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202901 EAP Custom 27202901 Ring Splint BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.53 $116.53 $121.02 $0.00 $32.72 $0.00 $0.00 $0.00 $0.00 $78.50 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202902 EAP Custom 27202902 Soft Ulnar Deviation Support BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202903 EAP Custom 27202903 Supination / Pronation Kit BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.85 $204.85 $212.74 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $138.00 $218.59 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202905 EAP Custom 27202905 Tap Splint BOTH IP/OP $211.00 $156.14 $0.00 $168.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.60 $156.60 $162.64 $0.00 $43.97 $0.00 $0.00 $0.00 $0.00 $105.50 $167.11 $168.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202906 EAP Custom 27202906 Ulnar Deviation Slint BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.56 $136.56 $141.83 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202908 EAP Custom 27202908 Wrap Finger Hooks BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202909 EAP Custom 27202909 Wrap On Finger Hooks(each) BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202910 EAP Custom 27202910 Wrist Hinge W/ Dynamic Springs BOTH IP/OP $480.00 $355.20 $0.00 $384.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.26 $356.26 $369.98 $0.00 $100.03 $0.00 $0.00 $0.00 $0.00 $240.00 $380.16 $384.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202911 EAP HCPCS C1769 Gwire Vasc 185cm .014in Prss Clip Conctr Radiopq Tip Trq Dev BOTH IP/OP "$1,772.00 " "$1,311.28" $0.00 "$1,417.60" $962.20 $962.20 $0.00 $0.00 $0.00 $369.33 "$1,315.18" "$1,315.18" "$1,365.86" $0.00 $369.28 $0.00 "$1,048.14" "$1,048.14" $0.00 $886.00 "$1,403.42" "$1,417.60" $0.00 "$1,151.80" $0.00 $277.32 $0.00 $0.00 $282.10 $0.00 $0.00 $0.00 $0.00 $0.00 27202912 EAP HCPCS C1769 Abbott Vascular BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27202913 EAP HCPCS C1725 Cath Baldilat .035in 5fr 9mm 75cm 40mm Pta Lp Nc Mustang BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $285.08 $285.08 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $341.25 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27202914 EAP HCPCS C1725 Cath Baldilat .035in 5fr 8mm 75cm 40mm Pta Lp Nc Mustang BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $285.08 $285.08 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $341.25 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27202915 EAP HCPCS C1726 Catheter Baldilat Lp 5.3fr 4mm 75cm 40mm High Pressure BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $285.08 $285.08 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $341.25 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27202916 EAP HCPCS C1725 Cath Baldilat 2.5mm 150cm 80mm Otw Cyte BOTH IP/OP $720.00 $532.80 $0.00 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $360.00 $570.24 $576.00 $0.00 $0.00 $0.00 $112.68 $0.00 $0.00 $114.62 $0.00 $0.00 $0.00 $0.00 $0.00 27202917 EAP HCPCS C1725 Catheter Balloon Dilit Coyote 2 X 220 150cm Otw BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $488.70 $488.70 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $693.72 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $585.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 27202918 EAP HCPCS C1725 "Balloon Coyote 2.5 X 220, 150cm, Otw" BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $488.70 $488.70 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $693.72 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $585.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 27202919 EAP HCPCS C1725 Catheter Balloon Dilit Coyote 3 X 100 150cm Otw BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $488.70 $488.70 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $693.72 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $585.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 27202920 EAP HCPCS C1725 Cath Baldilat .035in 5fr 5mm 135cm 200mm Pta Lp Nc Mustang BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $285.08 $285.08 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $341.25 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27202921 EAP HCPCS C1725 Cath Baldilat .035in 5fr 6mm 135cm 100mm Pta Lp Nc Mustang BOTH IP/OP $486.00 $359.64 $0.00 $388.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $243.00 $384.91 $388.80 $0.00 $0.00 $0.00 $76.06 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $0.00 27202922 EAP HCPCS C1768 Set Introd 40cm 4fr Mpnch Psh+ .018in Ntnl Trnstls Stf Cannu BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $57.02 $57.02 $0.00 $0.00 $0.00 $21.88 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $62.11 $62.11 $0.00 $52.50 $83.16 $84.00 $0.00 $68.25 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 27202923 EAP HCPCS C1769 Gwire Vasc 1.5mm Rsn Curve .035in 180cm 1.5mm Cvd Cath Exch BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $24.44 $24.44 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $34.69 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $29.25 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 27202924 EAP Custom 27202924 Cath Angio .035in Vcf Curve 5fr 65cm 8 Spiraled Sdprt Hflo BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202925 EAP Custom 27202925 Cath Angio .038in Kmp Curve 5fr 65cm Ang Multpur Nyl Ss Trnb BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202926 EAP HCPCS C1894 Sheath Guid 45cm 6fr .087in Chk-flo Flxr .018/.038in Anl0 BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $96.35 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $81.25 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 27202927 EAP HCPCS C1894 Sheath Guid 45cm 5fr .074in Chk-flo Flxr .018/.038in Anl0 BOTH IP/OP $119.00 $88.06 $0.00 $95.20 $64.62 $64.62 $0.00 $0.00 $0.00 $24.80 $88.32 $88.32 $91.73 $0.00 $24.80 $0.00 $70.39 $70.39 $0.00 $59.50 $94.25 $95.20 $0.00 $0.00 $0.00 $18.62 $0.00 $0.00 $18.94 $0.00 $0.00 $0.00 $0.00 $0.00 27202928 EAP HCPCS C1769 Gwire Vasc .035in 145cm 20cm Str Flexibile Tip Flpy Bntsn Lg BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 27202929 EAP HCPCS C1894 Introd Shth 5fr .074in 70cm Anl1 Curve Multpur Tip Ansel BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $92.31 $92.31 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $131.04 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 27202930 EAP HCPCS C1887 Cath Guid .035in 5mm Spc 3.1fr 150cm Lp Tpr Tip Sprt Radiopq BOTH IP/OP "$2,257.00 " "$1,670.18" $0.00 "$1,805.60" "$1,225.55" "$1,225.55" $0.00 $0.00 $0.00 $470.42 "$1,675.15" "$1,675.15" "$1,739.70" $0.00 $470.36 $0.00 "$1,335.02" "$1,335.02" $0.00 "$1,128.50" "$1,787.54" "$1,805.60" $0.00 "$1,467.05" $0.00 $353.22 $0.00 $0.00 $359.31 $0.00 $0.00 $0.00 $0.00 $0.00 27202931 EAP HCPCS C1887 Cath Guid .014in 3-1.9fr 150cm 3 Radiopq Mrkr Low Cx Prfl BOTH IP/OP "$2,257.00 " "$1,670.18" $0.00 "$1,805.60" "$1,225.55" "$1,225.55" $0.00 $0.00 $0.00 $470.42 "$1,675.15" "$1,675.15" "$1,739.70" $0.00 $470.36 $0.00 "$1,335.02" "$1,335.02" $0.00 "$1,128.50" "$1,787.54" "$1,805.60" $0.00 "$1,467.05" $0.00 $353.22 $0.00 $0.00 $359.31 $0.00 $0.00 $0.00 $0.00 $0.00 27202932 EAP HCPCS C1769 Gwire Vasc Std .035in 150cm 3cm Ang Tip Kink Rst Gldwr BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $226.97 $226.97 $0.00 $0.00 $0.00 $87.12 $310.24 $310.24 $322.19 $0.00 $87.11 $0.00 $247.25 $247.25 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $65.42 $0.00 $0.00 $66.55 $0.00 $0.00 $0.00 $0.00 $0.00 27202933 EAP HCPCS C1769 Gwire Vasc Std .035in 260cm 3cm Ang Tip Stf Shft Gldwr BOTH IP/OP $699.00 $517.26 $0.00 $559.20 $379.56 $379.56 $0.00 $0.00 $0.00 $145.69 $518.80 $518.80 $538.79 $0.00 $145.67 $0.00 $413.46 $413.46 $0.00 $349.50 $553.61 $559.20 $0.00 $0.00 $0.00 $109.39 $0.00 $0.00 $111.28 $0.00 $0.00 $0.00 $0.00 $0.00 27202934 EAP HCPCS C1887 Cath Angio .038in 5fr 100cm 40cm Tpr Ang Tip Gwire Hydphi BOTH IP/OP $644.00 $476.56 $0.00 $515.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.00 $510.05 $515.20 $0.00 $0.00 $0.00 $100.79 $0.00 $0.00 $102.52 $0.00 $0.00 $0.00 $0.00 $0.00 27202935 EAP HCPCS C1769 Gwire Vasc Endoscopic Terumo L260 Cm Od.035 In Straight BOTH IP/OP $623.00 $461.02 $0.00 $498.40 $338.29 $338.29 $0.00 $0.00 $0.00 $129.85 $462.39 $462.39 $480.21 $0.00 $129.83 $0.00 $368.50 $368.50 $0.00 $311.50 $493.42 $498.40 $0.00 $0.00 $0.00 $97.50 $0.00 $0.00 $99.18 $0.00 $0.00 $0.00 $0.00 $0.00 27202936 EAP Custom 27202936 Burn Pad 36x24in Abs Drsg Slvr Strl BOTH IP/OP $221.00 $163.54 $0.00 $176.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $170.35 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $110.50 $175.03 $176.80 $0.00 $143.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202940 EAP Custom 27202940 "Bioconcepts Digi-sleeve (per Digit - 3"")." BOTH IP/OP $17.00 $12.58 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.62 $12.62 $13.10 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202941 EAP HCPCS C1769 Stdj-185-4076 BOTH IP/OP $223.00 $165.02 $0.00 $178.40 $121.09 $121.09 $0.00 $0.00 $0.00 $46.48 $165.51 $165.51 $171.89 $0.00 $46.47 $0.00 $131.90 $131.90 $0.00 $111.50 $176.62 $178.40 $0.00 $0.00 $0.00 $34.90 $0.00 $0.00 $35.50 $0.00 $0.00 $0.00 $0.00 $0.00 27202942 EAP HCPCS C1769 Stdj-300-4076 BOTH IP/OP $223.00 $165.02 $0.00 $178.40 $121.09 $121.09 $0.00 $0.00 $0.00 $46.48 $165.51 $165.51 $171.89 $0.00 $46.47 $0.00 $131.90 $131.90 $0.00 $111.50 $176.62 $178.40 $0.00 $0.00 $0.00 $34.90 $0.00 $0.00 $35.50 $0.00 $0.00 $0.00 $0.00 $0.00 27202943 EAP HCPCS C1769 Stdj-86-15 40785 BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $152.58 $152.58 $0.00 $0.00 $0.00 $58.57 $208.56 $208.56 $216.59 $0.00 $58.56 $0.00 $166.21 $166.21 $0.00 $140.50 $222.55 $224.80 $0.00 $0.00 $0.00 $43.98 $0.00 $0.00 $44.74 $0.00 $0.00 $0.00 $0.00 $0.00 27202944 EAP HCPCS C1769 Sdj-86-5 40785 BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $152.58 $152.58 $0.00 $0.00 $0.00 $58.57 $208.56 $208.56 $216.59 $0.00 $58.56 $0.00 $166.21 $166.21 $0.00 $140.50 $222.55 $224.80 $0.00 $0.00 $0.00 $43.98 $0.00 $0.00 $44.74 $0.00 $0.00 $0.00 $0.00 $0.00 27202945 EAP HCPCS C1725 Coronary Sinus Balloon Venography Catheter BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 27202950 EAP Custom 27202950 C-36-152 Coil Interlock Detach BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202951 EAP Custom 27202951 C-36-154 Coil Interlock Detach BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202952 EAP Custom 27202952 C-36-156 Coil Interlock Detach BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202953 EAP Custom 27202953 C-36-157 Coil Interlock Detach BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202954 EAP HCPCS C1887 Cg510 Glide Catheter Simmon1 BOTH IP/OP "$1,253.00 " $927.22 $0.00 "$1,002.40" $680.38 $680.38 $0.00 $0.00 $0.00 $261.16 $929.98 $929.98 $965.81 $0.00 $261.13 $0.00 $741.15 $741.15 $0.00 $626.50 $992.38 "$1,002.40" $0.00 $814.45 $0.00 $196.09 $0.00 $0.00 $199.48 $0.00 $0.00 $0.00 $0.00 $0.00 27202955 EAP HCPCS C1725 Cg514 Benson-hanafee 1 BOTH IP/OP "$1,193.00 " $882.82 $0.00 $954.40 $536.85 $536.85 $0.00 $0.00 $0.00 $248.65 $885.44 $885.44 $919.56 $0.00 $248.62 $0.00 $705.66 $705.66 $0.00 $596.50 $944.86 $954.40 $0.00 $0.00 $0.00 $186.70 $0.00 $0.00 $189.93 $0.00 $0.00 $0.00 $0.00 $0.00 27202956 EAP HCPCS C1880 Option Ivc Filter BOTH IP/OP "$1,429.00 " "$1,057.46" $0.00 "$1,143.20" $643.05 $643.05 $0.00 $0.00 $0.00 $297.84 "$1,060.60" "$1,060.60" "$1,101.47" $0.00 $297.80 $0.00 $845.25 $845.25 $0.00 $714.50 "$1,131.77" "$1,143.20" $0.00 $0.00 $0.00 $223.64 $0.00 $0.00 $227.50 $0.00 $0.00 $0.00 $0.00 $0.00 27202957 EAP HCPCS C1894 Introducer Sheath 5fr BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $5.63 $0.00 $0.00 $5.73 $0.00 $0.00 $0.00 $0.00 $0.00 27202958 EAP HCPCS C1894 Introducer Sheath 6fr BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $5.63 $0.00 $0.00 $5.73 $0.00 $0.00 $0.00 $0.00 $0.00 27202959 EAP HCPCS C1725 Catheter Glide Simmons 2 BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $131.81 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $76.95 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 27202960 EAP HCPCS C1725 Catheter Vertebral 5fr BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $18.00 $18.00 $0.00 $0.00 $0.00 $8.34 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $23.66 $23.66 $0.00 $20.00 $31.68 $32.00 $0.00 $18.00 $0.00 $6.26 $0.00 $0.00 $6.37 $0.00 $0.00 $0.00 $0.00 $0.00 27202961 EAP HCPCS C1751 Microcatheter Stc BOTH IP/OP "$1,264.00 " $935.36 $0.00 "$1,011.20" $686.35 $686.35 $0.00 $0.00 $0.00 $263.45 $938.14 $938.14 $974.29 $0.00 $263.42 $0.00 $747.66 $747.66 $0.00 $632.00 "$1,001.09" "$1,011.20" $0.00 $0.00 $0.00 $197.82 $0.00 $0.00 $201.23 $0.00 $0.00 $0.00 $0.00 $0.00 27202962 EAP HCPCS C1751 System Drg Dlv L106 Cm 30cm Ekosonic Intlgnt Cath Microsonic BOTH IP/OP "$7,074.00 " "$5,234.76" $0.00 "$5,659.20" "$3,841.18" "$3,841.18" $0.00 $0.00 $0.00 "$1,474.40" "$4,181.12" "$4,181.12" "$5,452.64" $0.00 "$1,474.22" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,537.00" "$5,602.61" "$5,659.20" $0.00 $0.00 $0.00 "$1,107.08" $0.00 $0.00 "$1,126.18" $0.00 $0.00 $0.00 $0.00 $0.00 27202963 EAP HCPCS C1751 System Drg Dlv L106 Cm 40cm Ekosonic Intlgnt Cath Microsonic BOTH IP/OP "$6,738.00 " "$4,986.12" $0.00 "$5,390.40" "$3,658.73" "$3,658.73" $0.00 $0.00 $0.00 "$1,404.37" "$4,181.12" "$4,181.12" "$5,193.65" $0.00 "$1,404.20" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,369.00" "$5,336.50" "$5,390.40" $0.00 $0.00 $0.00 "$1,054.50" $0.00 $0.00 "$1,072.69" $0.00 $0.00 $0.00 $0.00 $0.00 27202964 EAP HCPCS C1751 System Drg Dlv L106 Cm 50cm Ekosonic Mach 4 Intlgnt Cath BOTH IP/OP "$6,738.00 " "$4,986.12" $0.00 "$5,390.40" "$3,658.73" "$3,658.73" $0.00 $0.00 $0.00 "$1,404.37" "$4,181.12" "$4,181.12" "$5,193.65" $0.00 "$1,404.20" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,369.00" "$5,336.50" "$5,390.40" $0.00 $0.00 $0.00 "$1,054.50" $0.00 $0.00 "$1,072.69" $0.00 $0.00 $0.00 $0.00 $0.00 27202965 EAP HCPCS C1751 System Drg Dlv L135 Cm 12cm Ekosonic Mach 4 Intlgnt Cath BOTH IP/OP "$6,738.00 " "$4,986.12" $0.00 "$5,390.40" "$3,658.73" "$3,658.73" $0.00 $0.00 $0.00 "$1,404.37" "$4,181.12" "$4,181.12" "$5,193.65" $0.00 "$1,404.20" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,369.00" "$5,336.50" "$5,390.40" $0.00 "$4,379.70" $0.00 "$1,054.50" $0.00 $0.00 "$1,072.69" $0.00 $0.00 $0.00 $0.00 $0.00 27202966 EAP HCPCS C1751 System Drg Dlv L135 Cm 30cm Ekosonic Intlgnt Cath Microsonic BOTH IP/OP "$7,074.00 " "$5,234.76" $0.00 "$5,659.20" "$3,841.18" "$3,841.18" $0.00 $0.00 $0.00 "$1,474.40" "$4,181.12" "$4,181.12" "$5,452.64" $0.00 "$1,474.22" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,537.00" "$5,602.61" "$5,659.20" $0.00 $0.00 $0.00 "$1,107.08" $0.00 $0.00 "$1,126.18" $0.00 $0.00 $0.00 $0.00 $0.00 27202967 EAP HCPCS C1751 System Drg Dlv L135 Cm 40cm Ekosonic Intlgnt Cath Microsonic BOTH IP/OP "$7,074.00 " "$5,234.76" $0.00 "$5,659.20" "$3,841.18" "$3,841.18" $0.00 $0.00 $0.00 "$1,474.40" "$4,181.12" "$4,181.12" "$5,452.64" $0.00 "$1,474.22" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,537.00" "$5,602.61" "$5,659.20" $0.00 "$4,598.10" $0.00 "$1,107.08" $0.00 $0.00 "$1,126.18" $0.00 $0.00 $0.00 $0.00 $0.00 27202968 EAP HCPCS C1751 SYSTEM DRG DLV L135 CM 50CM EKOSONIC TX ZN EVAS DEV CATH GWI BOTH IP/OP "$7,074.00 " "$5,234.76" $0.00 "$5,659.20" "$3,841.18" "$3,841.18" $0.00 $0.00 $0.00 "$1,474.40" "$4,181.12" "$4,181.12" "$5,452.64" $0.00 "$1,474.22" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,537.00" "$5,602.61" "$5,659.20" $0.00 $0.00 $0.00 "$1,107.08" $0.00 $0.00 "$1,126.18" $0.00 $0.00 $0.00 $0.00 $0.00 27202969 EAP HCPCS C1751 System Drg Dlv L106 Cm 6cm Ekosonic Intlgnt Cath Microsonic BOTH IP/OP "$7,074.00 " "$5,234.76" $0.00 "$5,659.20" "$3,841.18" "$3,841.18" $0.00 $0.00 $0.00 "$1,474.40" "$4,181.12" "$4,181.12" "$5,452.64" $0.00 "$1,474.22" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,537.00" "$5,602.61" "$5,659.20" $0.00 "$4,598.10" $0.00 "$1,107.08" $0.00 $0.00 "$1,126.18" $0.00 $0.00 $0.00 $0.00 $0.00 27202970 EAP HCPCS C1751 System Drg Dlv L106 Cm 12cm Ekosonic Cath Us Thrmbs 106cm 12 BOTH IP/OP "$7,074.00 " "$5,234.76" $0.00 "$5,659.20" "$3,841.18" "$3,841.18" $0.00 $0.00 $0.00 "$1,474.40" "$4,181.12" "$4,181.12" "$5,452.64" $0.00 "$1,474.22" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,537.00" "$5,602.61" "$5,659.20" $0.00 "$4,598.10" $0.00 "$1,107.08" $0.00 $0.00 "$1,126.18" $0.00 $0.00 $0.00 $0.00 $0.00 27202971 EAP HCPCS C1751 System Drg Dlv L106 Cm 18cm Ekosonic Intlgnt Cath Microsonic BOTH IP/OP "$7,074.00 " "$5,234.76" $0.00 "$5,659.20" "$3,841.18" "$3,841.18" $0.00 $0.00 $0.00 "$1,474.40" "$4,181.12" "$4,181.12" "$5,452.64" $0.00 "$1,474.22" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,537.00" "$5,602.61" "$5,659.20" $0.00 $0.00 $0.00 "$1,107.08" $0.00 $0.00 "$1,126.18" $0.00 $0.00 $0.00 $0.00 $0.00 27202972 EAP HCPCS C1751 System Drg Dlv L106 Cm 24cm Ekosonic Intlgnt Cath Microsonic BOTH IP/OP "$7,074.00 " "$5,234.76" $0.00 "$5,659.20" "$3,841.18" "$3,841.18" $0.00 $0.00 $0.00 "$1,474.40" "$4,181.12" "$4,181.12" "$5,452.64" $0.00 "$1,474.22" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,537.00" "$5,602.61" "$5,659.20" $0.00 $0.00 $0.00 "$1,107.08" $0.00 $0.00 "$1,126.18" $0.00 $0.00 $0.00 $0.00 $0.00 27202973 EAP HCPCS C1729 Kit Cath Peritoneum Strt Pleurx 1000ml BOTH IP/OP "$2,226.00 " "$1,647.24" $0.00 "$1,780.80" "$1,208.72" "$1,208.72" $0.00 $0.00 $0.00 $463.95 "$1,652.14" "$1,652.14" "$1,715.80" $0.00 $463.90 $0.00 "$1,316.68" "$1,316.68" $0.00 "$1,113.00" "$1,762.99" "$1,780.80" $0.00 "$1,446.90" $0.00 $348.37 $0.00 $0.00 $354.38 $0.00 $0.00 $0.00 $0.00 $0.00 27202974 EAP Custom 27202974 Cable Pcng 6ft Pc Lc Trnvns Sf Dev Temp Conctr Clip Adpr BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202976 EAP Custom 27202976 Shld Rad16x16in Drp Armr Rdbrrier L Pstn Prtc Strl BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.44 $53.44 $55.50 $0.00 $15.00 $0.00 $0.00 $0.00 $0.00 $36.00 $57.02 $57.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202977 EAP Custom 27202977 Trvo Prvue 4x20mm Rtrvr Kit & Trvo Pro 18 Mc BOTH IP/OP "$13,399.00 " "$9,915.26" $0.00 "$10,719.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,327.95" $0.00 "$2,792.35" $0.00 $0.00 $0.00 $0.00 "$6,699.50" "$10,612.01" "$10,719.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202978 EAP Custom 27202978 Trvo Xp Prvue 4x20mm Rtrvr Kit & Trvo Pro 18 Mc BOTH IP/OP "$13,399.00 " "$9,915.26" $0.00 "$10,719.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,327.95" $0.00 "$2,792.35" $0.00 $0.00 $0.00 $0.00 "$6,699.50" "$10,612.01" "$10,719.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202979 EAP Custom 27202979 Trvo Xp Prvue 3x20mm Rtrvr Kit & Trvo Pro 14 Mc BOTH IP/OP "$13,399.00 " "$9,915.26" $0.00 "$10,719.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,327.95" $0.00 "$2,792.35" $0.00 $0.00 $0.00 $0.00 "$6,699.50" "$10,612.01" "$10,719.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202980 EAP HCPCS C1769 Guidewire Vasc 190cm .035in Strbl Str Htrq Scr BOTH IP/OP $197.00 $145.78 $0.00 $157.60 $106.97 $106.97 $0.00 $0.00 $0.00 $41.06 $146.21 $146.21 $151.85 $0.00 $41.05 $0.00 $116.53 $116.53 $0.00 $98.50 $156.02 $157.60 $0.00 $0.00 $0.00 $30.83 $0.00 $0.00 $31.36 $0.00 $0.00 $0.00 $0.00 $0.00 27202981 EAP HCPCS C1887 "Turnpike Catheter, Smooth Shaft, 135cm" BOTH IP/OP "$1,377.00 " "$1,018.98" $0.00 "$1,101.60" $747.71 $747.71 $0.00 $0.00 $0.00 $287.00 "$1,022.01" "$1,022.01" "$1,061.39" $0.00 $286.97 $0.00 $814.50 $814.50 $0.00 $688.50 "$1,090.58" "$1,101.60" $0.00 $895.05 $0.00 $215.50 $0.00 $0.00 $219.22 $0.00 $0.00 $0.00 $0.00 $0.00 27202982 EAP HCPCS C1887 "Turnpike Catheter, Smooth Shaft, 155cm" BOTH IP/OP "$1,561.00 " "$1,155.14" $0.00 "$1,248.80" $847.62 $847.62 $0.00 $0.00 $0.00 $325.35 "$1,158.57" "$1,158.57" "$1,203.22" $0.00 $325.31 $0.00 $923.33 $923.33 $0.00 $780.50 "$1,236.31" "$1,248.80" $0.00 "$1,014.65" $0.00 $244.30 $0.00 $0.00 $248.51 $0.00 $0.00 $0.00 $0.00 $0.00 27202983 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Hbrd Radiopq Str Tip BOTH IP/OP $394.00 $291.56 $0.00 $315.20 $213.94 $213.94 $0.00 $0.00 $0.00 $82.12 $292.43 $292.43 $303.70 $0.00 $82.11 $0.00 $233.05 $233.05 $0.00 $197.00 $312.05 $315.20 $0.00 $256.10 $0.00 $61.66 $0.00 $0.00 $62.72 $0.00 $0.00 $0.00 $0.00 $0.00 27202984 EAP Gdwire Vasc Strght; Sprg L200cm L9 Cm Od.008 In BOTH IP/OP "$1,238.00 " $916.12 $0.00 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.84 $918.84 $954.25 $0.00 $258.00 $0.00 $0.00 $0.00 $0.00 $619.00 $980.50 $990.40 $0.00 $804.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202985 EAP HCPCS C1769 Gdwire Vasc 25d L150 Cm Rnd Curve L200 Cm L170 BOTH IP/OP "$1,337.00 " $989.38 $0.00 "$1,069.60" $725.99 $725.99 $0.00 $0.00 $0.00 $278.66 $992.32 $992.32 "$1,030.56" $0.00 $278.63 $0.00 $790.84 $790.84 $0.00 $668.50 "$1,058.90" "$1,069.60" $0.00 $869.05 $0.00 $209.24 $0.00 $0.00 $212.85 $0.00 $0.00 $0.00 $0.00 $0.00 27202986 EAP HCPCS C1769 "Gdwire Vasc Slip Coat Stnlss Stl Polymer 25 D, L" BOTH IP/OP "$1,337.00 " $989.38 $0.00 "$1,069.60" $725.99 $725.99 $0.00 $0.00 $0.00 $278.66 $992.32 $992.32 "$1,030.56" $0.00 $278.63 $0.00 $790.84 $790.84 $0.00 $668.50 "$1,058.90" "$1,069.60" $0.00 $869.05 $0.00 $209.24 $0.00 $0.00 $212.85 $0.00 $0.00 $0.00 $0.00 $0.00 27202987 EAP HCPCS C1769 Gdwire Vasc Slip-coat; Stnlss Stl; Polymer 25 D; BOTH IP/OP $919.00 $680.06 $0.00 $735.20 $499.02 $499.02 $0.00 $0.00 $0.00 $191.54 $682.08 $682.08 $708.37 $0.00 $191.52 $0.00 $543.59 $543.59 $0.00 $459.50 $727.85 $735.20 $0.00 $597.35 $0.00 $143.82 $0.00 $0.00 $146.30 $0.00 $0.00 $0.00 $0.00 $0.00 27202988 EAP HCPCS C1887 Arc Catheter BOTH IP/OP "$4,712.00 " "$3,486.88" $0.00 "$3,769.60" "$2,558.62" "$2,558.62" $0.00 $0.00 $0.00 $982.10 "$3,497.25" "$3,497.25" "$3,632.01" $0.00 $981.98 $0.00 "$2,787.15" "$2,787.15" $0.00 "$2,356.00" "$3,731.90" "$3,769.60" $0.00 $0.00 $0.00 $737.43 $0.00 $0.00 $750.15 $0.00 $0.00 $0.00 $0.00 $0.00 27202989 EAP HCPCS C1887 Arc Mini Catheter BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,968.38" "$1,968.38" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$2,144.19" "$2,144.19" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27202990 EAP HCPCS C1887 Marksman Catheter BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" "$1,541.60" $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 "$1,300.00" $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 27202991 EAP HCPCS C1769 Guidewire Vasc 200cm .014in Str 3cm Traxcess Ntnl BOTH IP/OP $844.00 $624.56 $0.00 $675.20 $458.29 $458.29 $0.00 $0.00 $0.00 $175.91 $626.42 $626.42 $650.56 $0.00 $175.89 $0.00 $499.23 $499.23 $0.00 $422.00 $668.45 $675.20 $0.00 $548.60 $0.00 $132.09 $0.00 $0.00 $134.36 $0.00 $0.00 $0.00 $0.00 $0.00 27202992 EAP HCPCS C1769 Guidewire Vasc Traxcess 3x200 Ex BOTH IP/OP $878.00 $649.72 $0.00 $702.40 $476.75 $476.75 $0.00 $0.00 $0.00 $183.00 $651.65 $651.65 $676.76 $0.00 $182.98 $0.00 $519.34 $519.34 $0.00 $439.00 $695.38 $702.40 $0.00 $570.70 $0.00 $137.41 $0.00 $0.00 $139.78 $0.00 $0.00 $0.00 $0.00 $0.00 27202993 EAP HCPCS C1769 Guidewire Vasc Dck Traxcess BOTH IP/OP $338.00 $250.12 $0.00 $270.40 $183.53 $183.53 $0.00 $0.00 $0.00 $70.45 $250.86 $250.86 $260.53 $0.00 $70.44 $0.00 $199.93 $199.93 $0.00 $169.00 $267.70 $270.40 $0.00 $0.00 $0.00 $52.90 $0.00 $0.00 $53.81 $0.00 $0.00 $0.00 $0.00 $0.00 27202994 EAP HCPCS C1725 Catheter 3.4fr 2.4fr 135cm Crossboss Intvn Rnd BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27202995 EAP HCPCS C1725 Catheter Baldilat 3.7fr 2.9fr 135cm Coron Sdprt BOTH IP/OP "$4,738.00 " "$3,506.12" $0.00 "$3,790.40" "$2,572.73" "$2,572.73" $0.00 $0.00 $0.00 $987.52 "$3,516.54" "$3,516.54" "$3,652.05" $0.00 $987.40 $0.00 "$2,802.53" "$2,802.53" $0.00 "$2,369.00" "$3,752.50" "$3,790.40" $0.00 $0.00 $0.00 $741.50 $0.00 $0.00 $754.29 $0.00 $0.00 $0.00 $0.00 $0.00 27202996 EAP HCPCS C1769 Guidewire Vasc 185cm .014in True Lum Slf Ornt BOTH IP/OP "$1,013.00 " $749.62 $0.00 $810.40 $550.06 $550.06 $0.00 $0.00 $0.00 $211.13 $751.85 $751.85 $780.82 $0.00 $211.11 $0.00 $599.19 $599.19 $0.00 $506.50 $802.30 $810.40 $0.00 $0.00 $0.00 $158.53 $0.00 $0.00 $161.27 $0.00 $0.00 $0.00 $0.00 $0.00 27202997 EAP HCPCS C1769 Guidewire Vasc 300cm .014in True Lum Slf Ornt BOTH IP/OP "$1,013.00 " $749.62 $0.00 $810.40 $550.06 $550.06 $0.00 $0.00 $0.00 $211.13 $751.85 $751.85 $780.82 $0.00 $211.11 $0.00 $599.19 $599.19 $0.00 $506.50 $802.30 $810.40 $0.00 $0.00 $0.00 $158.53 $0.00 $0.00 $161.27 $0.00 $0.00 $0.00 $0.00 $0.00 27202998 EAP HCPCS C1769 Guidewire Vasc 20cm .014in Extn 28d Stingray BOTH IP/OP $305.00 $225.70 $0.00 $244.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.50 $241.56 $244.00 $0.00 $0.00 $0.00 $47.73 $0.00 $0.00 $48.56 $0.00 $0.00 $0.00 $0.00 $0.00 27202999 EAP HCPCS C1769 Coronary Intervention Wire. BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203000 EAP HCPCS C1887 Cath Angiogrphc .038in Pigtail 145d Cv 6fr 110cm 2 BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27203001 EAP Custom 27203001 Unit Therapeutic Incision Mngmnt Sys Peel Plc Kt BOTH IP/OP "$1,238.00 " $916.12 $0.00 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.84 $918.84 $954.25 $0.00 $258.00 $0.00 $0.00 $0.00 $0.00 $619.00 $980.50 $990.40 $0.00 $804.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203002 EAP HCPCS C1725 Catheter Baldilat Lp 5.3fr 3mm 75cm 60mm High Pressure BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27203003 EAP HCPCS C1725 Catheter Baldilat .035in 5mm 75cm 40mm High Pressure Lp BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $325.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27203004 EAP HCPCS C1725 Catheter Baldilat .035in 6mm 75cm 20mm High Pressure Lp BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27203005 EAP HCPCS C1725 Catheter Baldilat Lp 5.3fr 6mm 135cm 40mm High Pressure BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $325.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27203006 EAP HCPCS C1725 Catheter Baldilat Lp 5.3fr 8mm 75cm 20mm High Pressure BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $325.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27203050 EAP Custom 27203050 Chiba Needle 22g X 10cm BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203051 EAP Custom 27203051 Chiba Needle 18g X 10cm BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203052 EAP Custom 27203052 Chiba Needle 18g X 15cm BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203053 EAP Custom 27203053 Chiba Needle 18g X 20cm BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203054 EAP Custom 27203054 Chiba Needle 20g X 10cm BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203055 EAP Custom 27203055 Chiba Needle 20g X 15cm BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203056 EAP Custom 27203056 Chiba Needle 20g X 20cm BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203057 EAP Custom 27203057 6f Dilator BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.42 $7.42 $7.71 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $5.00 $7.92 $8.00 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203058 EAP Custom 27203058 7f Dilator BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203059 EAP Custom 27203059 8f Dilator BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $13.87 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203060 EAP Custom 27203060 10f Dilator BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $14.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203061 EAP Custom 27203061 12f Dilator BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203062 EAP Custom 27203062 14f Dilator BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $24.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203063 EAP Custom 27203063 Introducer Needle 17g X 10cm BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203064 EAP Custom 27203064 Introducer Needle 17g X 15cm BOTH IP/OP $115.00 $85.10 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.35 $85.35 $88.64 $0.00 $23.97 $0.00 $0.00 $0.00 $0.00 $57.50 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203065 EAP Custom 27203065 Introducer Needle 19g X 6cm BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $0.00 $0.00 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203066 EAP Custom 27203066 Introducer Needle 19g X 10cm BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203067 EAP Custom 27203067 Introducer Needle 19g X 15cm BOTH IP/OP $136.00 $100.64 $0.00 $108.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.94 $100.94 $104.83 $0.00 $28.34 $0.00 $0.00 $0.00 $0.00 $68.00 $107.71 $108.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203068 EAP Custom 27203068 Coaxial Sets 19x10x20x15 BOTH IP/OP $79.00 $58.46 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.63 $58.63 $60.89 $0.00 $16.46 $0.00 $0.00 $0.00 $0.00 $39.50 $62.57 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203069 EAP Custom 27203069 Coaxial Sets 19x15x20x20 BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $35.50 $56.23 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203070 EAP Custom 27203070 Achieve Gun 18g X 9cm BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $104.06 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203071 EAP Custom 27203071 Achieve Gun 18g X 11cm BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203072 EAP Custom 27203072 Achieve Gun 18g X 15cm BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203073 EAP Custom 27203073 Achieve Gun 18g X 20cm BOTH IP/OP $214.00 $158.36 $0.00 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.83 $158.83 $164.95 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $107.00 $169.49 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203074 EAP Custom 27203074 Achieve Gun 20g X 11cm BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $0.00 $0.00 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203075 EAP Custom 27203075 Achieve Gun 20g X 15cm BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $0.00 $0.00 $0.00 $118.50 $187.70 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203076 EAP Custom 27203076 Achieve Gun 20g X 20cm BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.84 $181.84 $188.85 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203077 EAP Custom 27203077 Franseen Lung Bx Needle BOTH IP/OP $122.00 $90.28 $0.00 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.55 $90.55 $94.04 $0.00 $25.42 $0.00 $0.00 $0.00 $0.00 $61.00 $96.62 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203078 EAP Custom 27203078 Vansonnenberg Needle Set BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.36 $108.36 $112.54 $0.00 $30.43 $0.00 $0.00 $0.00 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203079 EAP Custom 27203079 Bonopty Bx Set BOTH IP/OP "$1,154.00 " $853.96 $0.00 $923.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $856.50 $856.50 $889.50 $0.00 $240.49 $0.00 $0.00 $0.00 $0.00 $577.00 $913.97 $923.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203080 EAP Custom 27203080 Bonopty Bx Penetration Set BOTH IP/OP "$1,505.00 " "$1,113.70" $0.00 "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,117.01" "$1,117.01" "$1,160.05" $0.00 $313.64 $0.00 $0.00 $0.00 $0.00 $752.50 "$1,191.96" "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203081 EAP Custom 27203081 Soft Tissue Bx Tray BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203082 EAP Custom 27203082 Lumbar Puncture Tray BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $114.50 $181.37 $183.20 $0.00 $148.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203083 EAP Custom 27203083 Para/thoracentesis Tray BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203084 EAP Custom 27203084 Uresil Drainage Bag BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $85.56 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203085 EAP Custom 27203085 Gelfoam Sponge BOTH IP/OP $464.00 $343.36 $0.00 $371.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $344.38 $344.38 $357.65 $0.00 $96.70 $0.00 $0.00 $0.00 $0.00 $232.00 $367.49 $371.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203086 EAP Custom 27203086 Suture Silk 2-0 30in Black BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203087 EAP Custom 27203087 Steri-drape BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203088 EAP Custom 27203088 Drainge Catheters BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.22 $169.22 $175.74 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.00 $180.58 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203090 EAP Custom 27203090 Cre Wg 6-8mm Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $0.00 $0.00 $0.00 $162.00 $256.61 $259.20 $0.00 $210.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203091 EAP Custom 27203091 Cre Wg 8-10 Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $0.00 $0.00 $0.00 $162.00 $256.61 $259.20 $0.00 $210.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203092 EAP Custom 27203092 Cre Wg 10-12 Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $0.00 $0.00 $0.00 $162.00 $256.61 $259.20 $0.00 $210.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203093 EAP Custom 27203093 Cre 12-15mm Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $0.00 $0.00 $0.00 $162.00 $256.61 $259.20 $0.00 $210.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203094 EAP Custom 27203094 Cre 15-18 Mm Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $0.00 $0.00 $0.00 $162.00 $256.61 $259.20 $0.00 $210.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203095 EAP Custom 27203095 Cre 18-20 Mm Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $0.00 $0.00 $0.00 $162.00 $256.61 $259.20 $0.00 $210.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203096 EAP Custom 27203096 Alliance Inflation Syringe BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $33.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203097 EAP Custom 27203097 2.3mm Interject Inj Needle23g BOTH IP/OP $732.00 $541.68 $0.00 $585.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.29 $543.29 $564.23 $0.00 $152.55 $0.00 $0.00 $0.00 $0.00 $366.00 $579.74 $585.60 $0.00 $475.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203098 EAP Custom 27203098 Dreamwire .035 260str Stnd BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.56 $208.56 $216.59 $0.00 $58.56 $0.00 $0.00 $0.00 $0.00 $140.50 $222.55 $224.80 $0.00 $182.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203099 EAP Custom 27203099 Extractor Rx 9-12 Mm BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.13 $178.13 $184.99 $0.00 $50.02 $0.00 $0.00 $0.00 $0.00 $120.00 $190.08 $192.00 $0.00 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203100 EAP Custom 27203100 Extractor Rx 12-15 Mm BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $114.50 $181.37 $183.20 $0.00 $148.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203101 EAP Custom 27203101 Extractor Rx 15-18 Mm BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $114.50 $181.37 $183.20 $0.00 $148.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203102 EAP Custom 27203102 22g Blue Sheath (stiffer) BOTH IP/OP $386.00 $285.64 $0.00 $308.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.49 $286.49 $297.53 $0.00 $80.44 $0.00 $0.00 $0.00 $0.00 $193.00 $305.71 $308.80 $0.00 $250.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203103 EAP Custom 27203103 22g Green Spring Coil Sheath BOTH IP/OP $386.00 $285.64 $0.00 $308.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.49 $286.49 $297.53 $0.00 $80.44 $0.00 $0.00 $0.00 $0.00 $193.00 $305.71 $308.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203104 EAP Custom 27203104 Celiac Plexus Neurolysis Needl BOTH IP/OP $392.00 $290.08 $0.00 $313.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.94 $290.94 $302.15 $0.00 $81.69 $0.00 $0.00 $0.00 $0.00 $196.00 $310.46 $313.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203105 EAP Custom 27203105 19g Bx Needle BOTH IP/OP $515.00 $381.10 $0.00 $412.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.23 $382.23 $396.96 $0.00 $107.33 $0.00 $0.00 $0.00 $0.00 $257.50 $407.88 $412.00 $0.00 $334.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203106 EAP Custom 27203106 Cytology Brush Echo -19 BOTH IP/OP $244.00 $180.56 $0.00 $195.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.10 $181.10 $188.08 $0.00 $50.85 $0.00 $0.00 $0.00 $0.00 $122.00 $193.25 $195.20 $0.00 $158.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203108 EAP Custom 27203108 Olympus Endo Jaw(cold Forceps) BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $11.56 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $9.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203109 EAP Custom 27203109 Roth Net BOTH IP/OP "$1,278.00 " $945.72 $0.00 "$1,022.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $948.53 $948.53 $985.08 $0.00 $266.34 $0.00 $0.00 $0.00 $0.00 $639.00 "$1,012.18" "$1,022.40" $0.00 $830.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203110 EAP Custom 27203110 Erbe Probe BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $0.00 $0.00 $0.00 $144.00 $228.10 $230.40 $0.00 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203111 EAP Custom 27203111 Ercp Forcep BOTH IP/OP $691.00 $511.34 $0.00 $552.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $512.86 $512.86 $532.62 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $345.50 $547.27 $552.80 $0.00 $449.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203112 EAP Custom 27203112 Rx Dilatation Balloon 4-4/5.8 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $0.00 $0.00 $0.00 $207.00 $327.89 $331.20 $0.00 $269.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203113 EAP Custom 27203113 Rx Dilatation Balloon 6-4/5.8 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $0.00 $0.00 $0.00 $207.00 $327.89 $331.20 $0.00 $269.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203114 EAP Custom 27203114 Rx Dilatation Balloon 8-4/5.8 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $0.00 $0.00 $0.00 $207.00 $327.89 $331.20 $0.00 $269.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203115 EAP Custom 27203115 Rx Dilatation Balloon 10-4/5.8 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $0.00 $0.00 $0.00 $207.00 $327.89 $331.20 $0.00 $269.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203116 EAP Custom 27203116 Encore 26 Single BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203117 EAP Custom 27203117 Injection Probe 10fr BOTH IP/OP $431.00 $318.94 $0.00 $344.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.89 $319.89 $332.21 $0.00 $89.82 $0.00 $0.00 $0.00 $0.00 $215.50 $341.35 $344.80 $0.00 $280.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203118 EAP Custom 27203118 Injection Probe 7fr BOTH IP/OP $431.00 $318.94 $0.00 $344.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.89 $319.89 $332.21 $0.00 $89.82 $0.00 $0.00 $0.00 $0.00 $215.50 $341.35 $344.80 $0.00 $280.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203120 EAP HCPCS C1769 .014 Nitrex Guidewire BOTH IP/OP "$1,295.00 " $958.30 $0.00 "$1,036.00" $703.19 $703.19 $0.00 $0.00 $0.00 $269.91 $961.15 $961.15 $998.19 $0.00 $269.88 $0.00 $765.99 $765.99 $0.00 $647.50 "$1,025.64" "$1,036.00" $0.00 $0.00 $0.00 $202.67 $0.00 $0.00 $206.16 $0.00 $0.00 $0.00 $0.00 $0.00 27203121 EAP Custom 27203121 Coil Axium Helical Qc-1.5-2-helix BOTH IP/OP "$3,686.00 " "$2,727.64" $0.00 "$2,948.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,735.75" "$2,735.75" "$2,841.17" $0.00 $768.16 $0.00 $0.00 $0.00 $0.00 "$1,843.00" "$2,919.31" "$2,948.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203122 EAP Custom 27203122 Coil Axium Helical Qc-2-1-helix BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 $0.00 $0.00 $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203123 EAP Custom 27203123 Coil Axium Helical Qc-2-2-helix BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 $0.00 $0.00 $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203124 EAP Custom 27203124 Coil Axium Helical Qc-2-3-helix BOTH IP/OP "$3,770.00 " "$2,789.80" $0.00 "$3,016.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,798.09" "$2,798.09" "$2,905.92" $0.00 $785.67 $0.00 $0.00 $0.00 $0.00 "$1,885.00" "$2,985.84" "$3,016.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203125 EAP Custom 27203125 Coil Axium Helical Qc-2-4-helix BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 $0.00 $0.00 $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203126 EAP Custom 27203126 Coil Axium Helical Qc-2-6-helix BOTH IP/OP "$3,819.00 " "$2,826.06" $0.00 "$3,055.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,834.46" "$2,834.46" "$2,943.69" $0.00 $795.88 $0.00 $0.00 $0.00 $0.00 "$1,909.50" "$3,024.65" "$3,055.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203127 EAP Custom 27203127 Coil Axium Helical Qc-2-8-helix BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 $0.00 $0.00 $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203128 EAP Custom 27203128 Coil Axium Helical Qc-3-4-helix BOTH IP/OP "$3,854.00 " "$2,851.96" $0.00 "$3,083.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,860.44" "$2,860.44" "$2,970.66" $0.00 $803.17 $0.00 $0.00 $0.00 $0.00 "$1,927.00" "$3,052.37" "$3,083.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203129 EAP Custom 27203129 Coil Axium Helical Qc-3-6-helix BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 $0.00 $0.00 $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203130 EAP Custom 27203130 Coil Axium Helical Qc-3-8-helix BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 $0.00 $0.00 $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203131 EAP Custom 27203131 Coil Axium Helical Qc-4-8-helix BOTH IP/OP "$4,071.00 " "$3,012.54" $0.00 "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,021.50" "$3,021.50" "$3,137.93" $0.00 $848.40 $0.00 $0.00 $0.00 $0.00 "$2,035.50" "$3,224.23" "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203132 EAP Custom 27203132 Coil Axium Helical Qc-4-10-helix BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 $0.00 $0.00 $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203133 EAP Custom 27203133 Coil Axium Helical Qc-4-12-helix BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 $0.00 $0.00 $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203134 EAP Custom 27203134 Coil Axium Helical Qc-5-15-helix BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 $0.00 $0.00 $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203135 EAP Custom 27203135 Coil Axium Helical Qc-5-20-helix BOTH IP/OP "$3,955.00 " "$2,926.70" $0.00 "$3,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,935.40" "$2,935.40" "$3,048.51" $0.00 $824.22 $0.00 $0.00 $0.00 $0.00 "$1,977.50" "$3,132.36" "$3,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203136 EAP Custom 27203136 Coil Axium Helical Qc-6-20-helix BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 $0.00 $0.00 $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203137 EAP Custom 27203137 Coil Axium Helical Qc-7 -30-helix BOTH IP/OP "$4,020.00 " "$2,974.80" $0.00 "$3,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,983.64" "$2,983.64" "$3,098.62" $0.00 $837.77 $0.00 $0.00 $0.00 $0.00 "$2,010.00" "$3,183.84" "$3,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203138 EAP Custom 27203138 Coil Axium Helical Qc-8-30-helix BOTH IP/OP "$4,071.00 " "$3,012.54" $0.00 "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,021.50" "$3,021.50" "$3,137.93" $0.00 $848.40 $0.00 $0.00 $0.00 $0.00 "$2,035.50" "$3,224.23" "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203139 EAP Custom 27203139 Coil Axium Helical Qc-9-30-helix BOTH IP/OP "$4,071.00 " "$3,012.54" $0.00 "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,021.50" "$3,021.50" "$3,137.93" $0.00 $848.40 $0.00 $0.00 $0.00 $0.00 "$2,035.50" "$3,224.23" "$3,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203140 EAP Custom 27203140 Coil Axium Helical Qc-10-30-helix BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 $0.00 $0.00 $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203141 EAP Custom 27203141 Coil Axium Helical Qc-12-30-helix BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 $0.00 $0.00 $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203142 EAP Custom 27203142 Coil Axium Helical Qc-14-30-helix BOTH IP/OP "$3,903.00 " "$2,888.22" $0.00 "$3,122.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,896.81" "$2,896.81" "$3,008.43" $0.00 $813.39 $0.00 $0.00 $0.00 $0.00 "$1,951.50" "$3,091.18" "$3,122.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203143 EAP Custom 27203143 Coil Axium Helical Qc-16-30-helix BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 $0.00 $0.00 $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203144 EAP Custom 27203144 Coil Axium Helical Qc-16-40-helix BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 $0.00 $0.00 $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203145 EAP Custom 27203145 Coil Axium Helical Qc-18-40-helix BOTH IP/OP "$3,955.00 " "$2,926.70" $0.00 "$3,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,935.40" "$2,935.40" "$3,048.51" $0.00 $824.22 $0.00 $0.00 $0.00 $0.00 "$1,977.50" "$3,132.36" "$3,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203146 EAP Custom 27203146 Coil Axium Helical Qc-20-40-helix BOTH IP/OP "$3,936.00 " "$2,912.64" $0.00 "$3,148.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,921.30" "$2,921.30" "$3,033.87" $0.00 $820.26 $0.00 $0.00 $0.00 $0.00 "$1,968.00" "$3,117.31" "$3,148.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203147 EAP Custom 27203147 Coil Axium Helical Qc-20-50-helix BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 $0.00 $0.00 $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203148 EAP Custom 27203148 Coil Axium 3d Qc-2-2-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203149 EAP Custom 27203149 Coil Axium 3d Qc-2-4-3d BOTH IP/OP "$4,105.00 " "$3,037.70" $0.00 "$3,284.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,046.73" "$3,046.73" "$3,164.13" $0.00 $855.48 $0.00 $0.00 $0.00 $0.00 "$2,052.50" "$3,251.16" "$3,284.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203150 EAP Custom 27203150 Coil Axium 3d Qc-2-6-3d BOTH IP/OP "$4,020.00 " "$2,974.80" $0.00 "$3,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,983.64" "$2,983.64" "$3,098.62" $0.00 $837.77 $0.00 $0.00 $0.00 $0.00 "$2,010.00" "$3,183.84" "$3,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203151 EAP Custom 27203151 Coil Axium 3d Qc-3-4-3d BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 $0.00 $0.00 $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203152 EAP Custom 27203152 Coil Axium 3d Qc-3-6-3d BOTH IP/OP "$3,245.00 " "$2,401.30" $0.00 "$2,596.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,408.44" "$2,408.44" "$2,501.25" $0.00 $676.26 $0.00 $0.00 $0.00 $0.00 "$1,622.50" "$2,570.04" "$2,596.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203153 EAP Custom 27203153 Coil Axium 3d Qc-3-8-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203154 EAP Custom 27203154 Coil Axium 3d Qc-4-8-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203155 EAP Custom 27203155 Coil Axium 3d Qc-4-12-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203156 EAP Custom 27203156 Coil Axium 3d Qc-5-10-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203157 EAP Custom 27203157 Coil Axium 3d Qc-5-15-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203158 EAP Custom 27203158 Coil Axium 3d Qc-6-15-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203159 EAP Custom 27203159 Coil Axium 3d Qc-6-20-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203160 EAP Custom 27203160 Coil Axium 3d Qc-7-20-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203161 EAP Custom 27203161 Coil Axium 3d Qc-7-30-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203162 EAP Custom 27203162 Coil Axium 3d Qc-8-20-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203163 EAP Custom 27203163 Coil Axium 3d Qc-8-30-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203164 EAP Custom 27203164 Coil Axium 3d Qc-9-20-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203165 EAP Custom 27203165 Coil Axium 3d Qc-9-30-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203166 EAP Custom 27203166 Coil Axium 3d Qc-10-20-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203167 EAP Custom 27203167 Coil Axium 3d Qc-10-30-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203168 EAP Custom 27203168 Coil Axium 3d Qc-12-40-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203169 EAP Custom 27203169 Coil Axium 3d Qc-14-40-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203170 EAP Custom 27203170 Coil Axium 3d Qc-16-40-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203171 EAP Custom 27203171 Coil Axium 3d Qc-18-40-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203172 EAP Custom 27203172 Coil Axium 3d Qc-20-50-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203173 EAP Custom 27203173 Coil Axium 3d Qc-22-50-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203174 EAP Custom 27203174 Coil Axium 3d Qc-25-50-3d BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.37" "$1,035.37" "$1,075.27" $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203180 EAP HCPCS C1726 Roth Net BOTH IP/OP "$1,278.00 " $945.72 $0.00 "$1,022.40" $693.95 $693.95 $0.00 $0.00 $0.00 $266.37 $948.53 $948.53 $985.08 $0.00 $266.34 $0.00 $755.94 $755.94 $0.00 $639.00 "$1,012.18" "$1,022.40" $0.00 $830.70 $0.00 $200.01 $0.00 $0.00 $203.46 $0.00 $0.00 $0.00 $0.00 $0.00 27203181 EAP HCPCS C1726 2.3mm Interject Inj Needle23g BOTH IP/OP $732.00 $541.68 $0.00 $585.60 $397.48 $397.48 $0.00 $0.00 $0.00 $152.57 $543.29 $543.29 $564.23 $0.00 $152.55 $0.00 $432.98 $432.98 $0.00 $366.00 $579.74 $585.60 $0.00 $475.80 $0.00 $114.56 $0.00 $0.00 $116.53 $0.00 $0.00 $0.00 $0.00 $0.00 27203182 EAP HCPCS C1726 Ercp Forcep BOTH IP/OP $691.00 $511.34 $0.00 $552.80 $375.21 $375.21 $0.00 $0.00 $0.00 $144.02 $512.86 $512.86 $532.62 $0.00 $144.00 $0.00 $408.73 $408.73 $0.00 $345.50 $547.27 $552.80 $0.00 $0.00 $0.00 $108.14 $0.00 $0.00 $110.01 $0.00 $0.00 $0.00 $0.00 $0.00 27203183 EAP HCPCS C1726 19g Bx Needle BOTH IP/OP $515.00 $381.10 $0.00 $412.00 $279.65 $279.65 $0.00 $0.00 $0.00 $107.34 $382.23 $382.23 $396.96 $0.00 $107.33 $0.00 $304.62 $304.62 $0.00 $257.50 $407.88 $412.00 $0.00 $0.00 $0.00 $80.60 $0.00 $0.00 $81.99 $0.00 $0.00 $0.00 $0.00 $0.00 27203184 EAP HCPCS C1751 Cather Cco Swan-ganz Sv02 W/o BOTH IP/OP $479.00 $354.46 $0.00 $383.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.50 $379.37 $383.20 $0.00 $0.00 $0.00 $74.96 $0.00 $0.00 $76.26 $0.00 $0.00 $0.00 $0.00 $0.00 27203185 EAP HCPCS C1751 Injection Probe 10fr BOTH IP/OP $431.00 $318.94 $0.00 $344.80 $234.03 $234.03 $0.00 $0.00 $0.00 $89.83 $319.89 $319.89 $332.21 $0.00 $89.82 $0.00 $254.94 $254.94 $0.00 $215.50 $341.35 $344.80 $0.00 $0.00 $0.00 $67.45 $0.00 $0.00 $68.62 $0.00 $0.00 $0.00 $0.00 $0.00 27203186 EAP HCPCS C1751 Injection Probe 7fr BOTH IP/OP $431.00 $318.94 $0.00 $344.80 $234.03 $234.03 $0.00 $0.00 $0.00 $89.83 $319.89 $319.89 $332.21 $0.00 $89.82 $0.00 $254.94 $254.94 $0.00 $215.50 $341.35 $344.80 $0.00 $280.15 $0.00 $67.45 $0.00 $0.00 $68.62 $0.00 $0.00 $0.00 $0.00 $0.00 27203187 EAP HCPCS C1726 Rx Dilatation Balloon 4-4/5.8 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $224.80 $224.80 $0.00 $0.00 $0.00 $86.29 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $244.88 $244.88 $0.00 $207.00 $327.89 $331.20 $0.00 $0.00 $0.00 $64.79 $0.00 $0.00 $65.91 $0.00 $0.00 $0.00 $0.00 $0.00 27203188 EAP HCPCS C1726 Rx Dilatation Balloon 6-4/5.8 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $224.80 $224.80 $0.00 $0.00 $0.00 $86.29 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $244.88 $244.88 $0.00 $207.00 $327.89 $331.20 $0.00 $0.00 $0.00 $64.79 $0.00 $0.00 $65.91 $0.00 $0.00 $0.00 $0.00 $0.00 27203189 EAP HCPCS C1726 Rx Dilatation Balloon 8-4/5.8 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $224.80 $224.80 $0.00 $0.00 $0.00 $86.29 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $244.88 $244.88 $0.00 $207.00 $327.89 $331.20 $0.00 $0.00 $0.00 $64.79 $0.00 $0.00 $65.91 $0.00 $0.00 $0.00 $0.00 $0.00 27203190 EAP HCPCS C1726 Rx Dilatation Balloon 10-4/5.8 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $224.80 $224.80 $0.00 $0.00 $0.00 $86.29 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $244.88 $244.88 $0.00 $207.00 $327.89 $331.20 $0.00 $0.00 $0.00 $64.79 $0.00 $0.00 $65.91 $0.00 $0.00 $0.00 $0.00 $0.00 27203191 EAP HCPCS C1726 Celiac Plexus Neurolysis Needl BOTH IP/OP $392.00 $290.08 $0.00 $313.60 $212.86 $212.86 $0.00 $0.00 $0.00 $81.70 $290.94 $290.94 $302.15 $0.00 $81.69 $0.00 $231.87 $231.87 $0.00 $196.00 $310.46 $313.60 $0.00 $0.00 $0.00 $61.35 $0.00 $0.00 $62.41 $0.00 $0.00 $0.00 $0.00 $0.00 27203192 EAP HCPCS C1726 22g Blue Sheath (stiffer) BOTH IP/OP $386.00 $285.64 $0.00 $308.80 $209.60 $209.60 $0.00 $0.00 $0.00 $80.45 $286.49 $286.49 $297.53 $0.00 $80.44 $0.00 $228.32 $228.32 $0.00 $193.00 $305.71 $308.80 $0.00 $0.00 $0.00 $60.41 $0.00 $0.00 $61.45 $0.00 $0.00 $0.00 $0.00 $0.00 27203193 EAP HCPCS C1726 22g Green Spring Coil Sheath BOTH IP/OP $386.00 $285.64 $0.00 $308.80 $209.60 $209.60 $0.00 $0.00 $0.00 $80.45 $286.49 $286.49 $297.53 $0.00 $80.44 $0.00 $228.32 $228.32 $0.00 $193.00 $305.71 $308.80 $0.00 $0.00 $0.00 $60.41 $0.00 $0.00 $61.45 $0.00 $0.00 $0.00 $0.00 $0.00 27203194 EAP HCPCS C1726 Cre Wg 8-10 Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $175.93 $175.93 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 27203195 EAP HCPCS C1726 Cre Wg 10-12 Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $175.93 $175.93 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $210.60 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 27203196 EAP HCPCS C1726 Cre 12-15mm Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $175.93 $175.93 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 27203197 EAP HCPCS C1726 Cre 15-18 Mm Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $175.93 $175.93 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 27203198 EAP HCPCS C1726 Cre 18-20 Mm Dilation Balloon BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $175.93 $175.93 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $249.74 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 27203199 EAP HCPCS C1726 Erbe Probe BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $156.38 $156.38 $0.00 $0.00 $0.00 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 27203200 EAP HCPCS C1769 Dreamwire .035 260str Stnd BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $152.58 $152.58 $0.00 $0.00 $0.00 $58.57 $208.56 $208.56 $216.59 $0.00 $58.56 $0.00 $166.21 $166.21 $0.00 $140.50 $222.55 $224.80 $0.00 $0.00 $0.00 $43.98 $0.00 $0.00 $44.74 $0.00 $0.00 $0.00 $0.00 $0.00 27203201 EAP HCPCS C1726 Cytology Brush Echo -19 BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $125.98 $125.98 $0.00 $0.00 $0.00 $48.35 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $137.23 $137.23 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $0.00 $36.31 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 27203202 EAP HCPCS C1726 Extractor Rx 9-12 Mm BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $124.35 $124.35 $0.00 $0.00 $0.00 $47.73 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $135.45 $135.45 $0.00 $114.50 $181.37 $183.20 $0.00 $148.85 $0.00 $35.84 $0.00 $0.00 $36.46 $0.00 $0.00 $0.00 $0.00 $0.00 27203203 EAP HCPCS C1726 Extractor Rx 12-15 Mm BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $124.35 $124.35 $0.00 $0.00 $0.00 $47.73 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $135.45 $135.45 $0.00 $114.50 $181.37 $183.20 $0.00 $0.00 $0.00 $35.84 $0.00 $0.00 $36.46 $0.00 $0.00 $0.00 $0.00 $0.00 27203204 EAP HCPCS C1726 Extractor Rx 15-18 Mm BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $124.35 $124.35 $0.00 $0.00 $0.00 $47.73 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $135.45 $135.45 $0.00 $114.50 $181.37 $183.20 $0.00 $0.00 $0.00 $35.84 $0.00 $0.00 $36.46 $0.00 $0.00 $0.00 $0.00 $0.00 27203205 EAP HCPCS C1726 Alliance Inflation Syringe BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $28.24 $28.24 $0.00 $0.00 $0.00 $10.84 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $8.14 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 27203206 EAP HCPCS C1726 Encore 26 Single BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $19.01 $19.01 $0.00 $0.00 $0.00 $7.29 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $20.70 $20.70 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 27203207 EAP HCPCS C1726 Rx Lckng Dvce &bx Cap/olympus BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $8.69 $8.69 $0.00 $0.00 $0.00 $3.33 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 27203208 EAP HCPCS C1726 Olympus Endo Jaw(cold Forceps) BOTH IP/OP $14.00 $10.36 $0.00 $11.20 $7.60 $7.60 $0.00 $0.00 $0.00 $2.92 $10.39 $10.39 $10.79 $0.00 $2.92 $0.00 $8.28 $8.28 $0.00 $7.00 $11.09 $11.20 $0.00 $9.10 $0.00 $2.19 $0.00 $0.00 $2.23 $0.00 $0.00 $0.00 $0.00 $0.00 27203210 EAP HCPCS C1773 Kit Snr Agn 90d Mic 200cm 2.3-3fr 2mm Cath Loop BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 27203211 EAP HCPCS C1729 Cath Drain Edm (ventricular) L 26cm BOTH IP/OP $480.00 $355.20 $0.00 $384.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.00 $380.16 $384.00 $0.00 $0.00 $0.00 $75.12 $0.00 $0.00 $76.42 $0.00 $0.00 $0.00 $0.00 $0.00 27203212 EAP HCPCS C1729 "Catheter, Evd Bactiseal 82-1750" BOTH IP/OP "$1,924.00 " "$1,423.76" $0.00 "$1,539.20" "$1,044.73" "$1,044.73" $0.00 $0.00 $0.00 $401.01 "$1,427.99" "$1,427.99" "$1,483.02" $0.00 $400.96 $0.00 "$1,138.05" "$1,138.05" $0.00 $962.00 "$1,523.81" "$1,539.20" $0.00 $0.00 $0.00 $301.11 $0.00 $0.00 $306.30 $0.00 $0.00 $0.00 $0.00 $0.00 27203213 EAP HCPCS C1773 Kit Snr Agn 90d 200cm 2.3-3fr 4mm Mcth Loop Coil BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 27203214 EAP HCPCS C1773 Kit Snr Agn 90d 200cm 2.3-3fr 7mm Mcth Loop Coil BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 "$1,056.25" $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 27203215 EAP HCPCS C1887 Catheter Guid Sim2 Curve 6fr 90cm Env BOTH IP/OP $901.00 $666.74 $0.00 $720.80 $489.24 $489.24 $0.00 $0.00 $0.00 $187.79 $668.72 $668.72 $694.49 $0.00 $187.77 $0.00 $532.94 $532.94 $0.00 $450.50 $713.59 $720.80 $0.00 $585.65 $0.00 $141.01 $0.00 $0.00 $143.44 $0.00 $0.00 $0.00 $0.00 $0.00 27203216 EAP HCPCS C1887 Catheter Guid Sim2 Curve 6fr 100cm Env BOTH IP/OP $901.00 $666.74 $0.00 $720.80 $489.24 $489.24 $0.00 $0.00 $0.00 $187.79 $668.72 $668.72 $694.49 $0.00 $187.77 $0.00 $532.94 $532.94 $0.00 $450.50 $713.59 $720.80 $0.00 $585.65 $0.00 $141.01 $0.00 $0.00 $143.44 $0.00 $0.00 $0.00 $0.00 $0.00 27203217 EAP HCPCS C1769 Guidewire Vasc 175cm Rnd Prfl Agile Tip Smtr Rot BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $855.23 $855.23 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" "$1,214.01" $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 "$1,023.75" $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 27203220 EAP HCPCS C1894 Introducer Shth Lng 5fr 30cm Gry Lf Traw Hi Kink Rst Ulsmth BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $55.39 $55.39 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $60.33 $60.33 $0.00 $51.00 $80.78 $81.60 $0.00 $66.30 $0.00 $15.96 $0.00 $0.00 $16.24 $0.00 $0.00 $0.00 $0.00 $0.00 27203221 EAP HCPCS C1894 Introducer Shth Lng 6fr 30cm Lf Traw Unq Lck Hi Kink Rst BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $55.39 $55.39 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $60.33 $60.33 $0.00 $51.00 $80.78 $81.60 $0.00 $66.30 $0.00 $15.96 $0.00 $0.00 $16.24 $0.00 $0.00 $0.00 $0.00 $0.00 27203222 EAP HCPCS C1894 Sheath Intro Lng 7fr 30cm Traw Fnl Ulsmth Dil Tpr Ptfe BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $55.39 $55.39 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $60.33 $60.33 $0.00 $51.00 $80.78 $81.60 $0.00 $66.30 $0.00 $15.96 $0.00 $0.00 $16.24 $0.00 $0.00 $0.00 $0.00 $0.00 27203251 EAP Custom 27203251 Coil Axium Helical Qc-1.5-2-helix BOTH IP/OP "$1,034.00 " $765.16 $0.00 $827.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $767.43 $767.43 $797.01 $0.00 $215.49 $0.00 $0.00 $0.00 $0.00 $517.00 $818.93 $827.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203270 EAP Custom 27203270 Mpc Envoy Guiding Cath BOTH IP/OP $303.00 $224.22 $0.00 $242.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.89 $224.89 $233.55 $0.00 $63.15 $0.00 $0.00 $0.00 $0.00 $151.50 $239.98 $242.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203271 EAP Custom 27203271 Control Wire .018 V-18 BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $581.14 $581.14 $603.54 $0.00 $163.18 $0.00 $0.00 $0.00 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203290 EAP Custom 27203290 Foot Drop Splint-prefab BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203400 EAP Custom 27203400 Interlock Detach 36-156 Coil BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203401 EAP Custom 27203401 Dfs100406-20 Micrus Microcoil BOTH IP/OP $483.00 $357.42 $0.00 $386.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.48 $358.48 $372.30 $0.00 $100.66 $0.00 $0.00 $0.00 $0.00 $241.50 $382.54 $386.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203402 EAP Custom 27203402 Dfs100310-20 Micrus Microcoil BOTH IP/OP "$1,429.00 " "$1,057.46" $0.00 "$1,143.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,060.60" "$1,060.60" "$1,101.47" $0.00 $297.80 $0.00 $0.00 $0.00 $0.00 $714.50 "$1,131.77" "$1,143.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203403 EAP Custom 27203403 Dpl100151-20 Micrus Microcoil BOTH IP/OP "$1,571.00 " "$1,162.54" $0.00 "$1,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,166.00" "$1,166.00" "$1,210.93" $0.00 $327.40 $0.00 $0.00 $0.00 $0.00 $785.50 "$1,244.23" "$1,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203404 EAP Custom 27203404 Hel180620-2o Micrus Microcoil BOTH IP/OP $834.00 $617.16 $0.00 $667.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $618.99 $618.99 $642.85 $0.00 $173.81 $0.00 $0.00 $0.00 $0.00 $417.00 $660.53 $667.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203405 EAP Custom 27203405 Brs000609-00 Balloon Ascnt BOTH IP/OP "$1,900.00 " "$1,406.00" $0.00 "$1,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,410.18" "$1,410.18" "$1,464.52" $0.00 $395.96 $0.00 $0.00 $0.00 $0.00 $950.00 "$1,504.80" "$1,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203406 EAP Custom 27203406 4.5x20 4.5x20 Viatrac Balloon BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203407 EAP Custom 27203407 5x20 Viatrac Balloon BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203408 EAP Custom 27203408 6x20 Viatrac Balloon BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203409 EAP Custom 27203409 .038 150cm Stiff Angled Glide BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203410 EAP Custom 27203410 .038 150cm Guidewire Bntsn BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203411 EAP Custom 27203411 9fr-30 Tear-away Introducer BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203412 EAP Custom 27203412 10fr-30cm Tear-away Introducer BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203413 EAP Custom 27203413 16fr-30cm Tear-away Introducer BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $31.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203414 EAP Custom 27203414 2.0 Mm X9 Maverick Balloon Catheter BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $0.00 $0.00 $0.00 $458.00 $725.47 $732.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203415 EAP Custom 27203415 2.5 Mm X9 Maverick Balloon Catheter BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $0.00 $0.00 $0.00 $458.00 $725.47 $732.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203416 EAP Custom 27203416 Stent Microdelivery System Neurform2 System 3.5 X 30mm BOTH IP/OP "$8,535.00 " "$6,315.90" $0.00 "$6,828.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,578.78" $0.00 "$1,778.69" $0.00 $0.00 $0.00 $0.00 "$4,267.50" "$6,759.72" "$6,828.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203417 EAP Custom 27203417 3.0 Mm X9 Maverick Balloon Catheter BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $0.00 $0.00 $0.00 $458.00 $725.47 $732.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203418 EAP Custom 27203418 Stent Stabilizer Catheter Neurform BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 $0.00 $0.00 $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203419 EAP Custom 27203419 Mpc Envoy Guiding Cath BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.99 $333.99 $346.86 $0.00 $93.78 $0.00 $0.00 $0.00 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203420 EAP Custom 27203420 5.5 Accunet Distal Protection Device BOTH IP/OP "$5,171.00 " "$3,826.54" $0.00 "$4,136.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,837.92" "$3,837.92" "$3,985.81" $0.00 "$1,077.64" $0.00 $0.00 $0.00 $0.00 "$2,585.50" "$4,095.43" "$4,136.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203421 EAP Custom 27203421 2.25 Minivision Stent BOTH IP/OP "$1,256.00 " $929.44 $0.00 "$1,004.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.20 $932.20 $968.12 $0.00 $261.75 $0.00 $0.00 $0.00 $0.00 $628.00 $994.75 "$1,004.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203422 EAP Custom 27203422 4.0x20mm Viatrac Balloon BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203423 EAP Custom 27203423 125cm Vetebral Catheter BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $42.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203425 EAP HCPCS C1887 Catheter Intvn 5fr .056in .046in 150cm 25cm Rapex BOTH IP/OP "$1,023.00 " $757.02 $0.00 $818.40 $555.49 $555.49 $0.00 $0.00 $0.00 $213.22 $759.27 $759.27 $788.53 $0.00 $213.19 $0.00 $605.10 $605.10 $0.00 $511.50 $810.22 $818.40 $0.00 $664.95 $0.00 $160.10 $0.00 $0.00 $162.86 $0.00 $0.00 $0.00 $0.00 $0.00 27203426 EAP HCPCS C1887 Catheter Intvn 7fr .078in .062in 150cm 25cm Rapex BOTH IP/OP "$1,023.00 " $757.02 $0.00 $818.40 $555.49 $555.49 $0.00 $0.00 $0.00 $213.22 $759.27 $759.27 $788.53 $0.00 $213.19 $0.00 $605.10 $605.10 $0.00 $511.50 $810.22 $818.40 $0.00 $0.00 $0.00 $160.10 $0.00 $0.00 $162.86 $0.00 $0.00 $0.00 $0.00 $0.00 27203427 EAP HCPCS C1887 Catheter Intvn 8fr .088in .071in 150cm 25cm Rapex BOTH IP/OP "$1,023.00 " $757.02 $0.00 $818.40 $555.49 $555.49 $0.00 $0.00 $0.00 $213.22 $759.27 $759.27 $788.53 $0.00 $213.19 $0.00 $605.10 $605.10 $0.00 $511.50 $810.22 $818.40 $0.00 $664.95 $0.00 $160.10 $0.00 $0.00 $162.86 $0.00 $0.00 $0.00 $0.00 $0.00 27203428 EAP HCPCS C1887 Sheath Guid 90cm 3 Radiopq Xcut Vlv Pn Dstn 8fr BOTH IP/OP $239.00 $176.86 $0.00 $191.20 $129.78 $129.78 $0.00 $0.00 $0.00 $49.81 $177.39 $177.39 $184.22 $0.00 $49.81 $0.00 $141.37 $141.37 $0.00 $119.50 $189.29 $191.20 $0.00 $0.00 $0.00 $37.40 $0.00 $0.00 $38.05 $0.00 $0.00 $0.00 $0.00 $0.00 27203429 EAP HCPCS C1887 Sheath Guid 65cm 8fr Pn Dstn .038in Str Hydphi BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $121.63 $121.63 $0.00 $0.00 $0.00 $46.69 $166.25 $166.25 $172.66 $0.00 $46.68 $0.00 $132.50 $132.50 $0.00 $112.00 $177.41 $179.20 $0.00 $145.60 $0.00 $35.06 $0.00 $0.00 $35.66 $0.00 $0.00 $0.00 $0.00 $0.00 27203434 EAP HCPCS C1769 Moo326420 Guidewire Standard P BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $705.36 $705.36 $0.00 $0.00 $0.00 $270.74 $964.12 $964.12 "$1,001.27" $0.00 $270.71 $0.00 $768.36 $768.36 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $203.29 $0.00 $0.00 $206.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203450 EAP HCPCS C1751 105-5092-150 Echelon 14 Micro BOTH IP/OP "$1,751.00 " "$1,295.74" $0.00 "$1,400.80" $950.79 $950.79 $0.00 $0.00 $0.00 $364.95 "$1,299.59" "$1,299.59" "$1,349.67" $0.00 $364.91 $0.00 "$1,035.72" "$1,035.72" $0.00 $875.50 "$1,386.79" "$1,400.80" $0.00 "$1,138.15" $0.00 $274.03 $0.00 $0.00 $278.76 $0.00 $0.00 $0.00 $0.00 $0.00 27203467 EAP HCPCS C1884 Spd2-us-050-320 Device Protect BOTH IP/OP "$1,411.00 " "$1,044.14" $0.00 "$1,128.80" $766.17 $766.17 $0.00 $0.00 $0.00 $294.09 "$1,047.24" "$1,047.24" "$1,087.60" $0.00 $294.05 $0.00 $834.61 $834.61 $0.00 $705.50 "$1,117.51" "$1,128.80" $0.00 $0.00 $0.00 $220.82 $0.00 $0.00 $224.63 $0.00 $0.00 $0.00 $0.00 $0.00 27203477 EAP Custom 27203477 36-152 Coil Detachable Interlo BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $968.90 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203478 EAP Custom 27203478 36-154 Coil Detachable Interlo BOTH IP/OP "$1,320.00 " $976.80 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $979.70 $979.70 "$1,017.46" $0.00 $275.09 $0.00 $0.00 $0.00 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $594.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203479 EAP Custom 27203479 36-156 Coil Detachable Interlo BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $968.90 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203480 EAP Custom 27203480 36-157 Coil Detachable Interlo BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $968.90 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203481 EAP Custom 27203481 Marker Straight 2-tip 150cm/6c BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $843.88 $843.88 $876.40 $0.00 $236.95 $0.00 $0.00 $0.00 $0.00 $568.50 $900.50 $909.60 $0.00 $739.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203483 EAP HCPCS C1887 Mpc Envoy Guiding Wire BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $244.35 $244.35 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $346.86 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 27203484 EAP Custom 27203484 Starclose Se BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $519.54 $519.54 $539.56 $0.00 $145.88 $0.00 $0.00 $0.00 $0.00 $350.00 $554.40 $560.00 $0.00 $455.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203485 EAP Custom 27203485 Lc Bead 300-500 BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $990.84 $990.84 "$1,029.02" $0.00 $278.21 $0.00 $0.00 $0.00 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203487 EAP HCPCS C1769 Guidewire Silverspeed .014 BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $447.98 $447.98 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $635.91 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 27203488 EAP HCPCS C1769 Guidewire Silverspeed .014 BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $447.98 $447.98 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $635.91 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 27203489 EAP HCPCS C1751 Catheter Echelon 10 Micro BOTH IP/OP "$2,423.00 " "$1,793.02" $0.00 "$1,938.40" "$1,315.69" "$1,315.69" $0.00 $0.00 $0.00 $505.01 "$1,798.35" "$1,798.35" "$1,867.65" $0.00 $504.95 $0.00 "$1,433.20" "$1,433.20" $0.00 "$1,211.50" "$1,919.02" "$1,938.40" $0.00 $0.00 $0.00 $379.20 $0.00 $0.00 $385.74 $0.00 $0.00 $0.00 $0.00 $0.00 27203490 EAP HCPCS C1751 Catheter Echelon 10 Micro BOTH IP/OP "$2,423.00 " "$1,793.02" $0.00 "$1,938.40" "$1,315.69" "$1,315.69" $0.00 $0.00 $0.00 $505.01 "$1,798.35" "$1,798.35" "$1,867.65" $0.00 $504.95 $0.00 "$1,433.20" "$1,433.20" $0.00 "$1,211.50" "$1,919.02" "$1,938.40" $0.00 $0.00 $0.00 $379.20 $0.00 $0.00 $385.74 $0.00 $0.00 $0.00 $0.00 $0.00 27203491 EAP HCPCS C1751 Catheter Echelon 14 Micro BOTH IP/OP "$2,423.00 " "$1,793.02" $0.00 "$1,938.40" "$1,315.69" "$1,315.69" $0.00 $0.00 $0.00 $505.01 "$1,798.35" "$1,798.35" "$1,867.65" $0.00 $504.95 $0.00 "$1,433.20" "$1,433.20" $0.00 "$1,211.50" "$1,919.02" "$1,938.40" $0.00 $0.00 $0.00 $379.20 $0.00 $0.00 $385.74 $0.00 $0.00 $0.00 $0.00 $0.00 27203492 EAP HCPCS C1751 Catheter Echelon 10micro BOTH IP/OP "$2,423.00 " "$1,793.02" $0.00 "$1,938.40" "$1,315.69" "$1,315.69" $0.00 $0.00 $0.00 $505.01 "$1,798.35" "$1,798.35" "$1,867.65" $0.00 $504.95 $0.00 "$1,433.20" "$1,433.20" $0.00 "$1,211.50" "$1,919.02" "$1,938.40" $0.00 $0.00 $0.00 $379.20 $0.00 $0.00 $385.74 $0.00 $0.00 $0.00 $0.00 $0.00 27203493 EAP HCPCS C1751 Catheter Echelon 14 Micro BOTH IP/OP "$2,423.00 " "$1,793.02" $0.00 "$1,938.40" "$1,315.69" "$1,315.69" $0.00 $0.00 $0.00 $505.01 "$1,798.35" "$1,798.35" "$1,867.65" $0.00 $504.95 $0.00 "$1,433.20" "$1,433.20" $0.00 "$1,211.50" "$1,919.02" "$1,938.40" $0.00 $0.00 $0.00 $379.20 $0.00 $0.00 $385.74 $0.00 $0.00 $0.00 $0.00 $0.00 27203494 EAP Custom 27203494 Alligator Retrieval BOTH IP/OP "$8,340.00 " "$6,171.60" $0.00 "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,428.47" $0.00 "$1,738.06" $0.00 $0.00 $0.00 $0.00 "$4,170.00" "$6,605.28" "$6,672.00" $0.00 "$5,421.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203495 EAP Custom 27203495 Alligator Retrieval BOTH IP/OP "$8,340.00 " "$6,171.60" $0.00 "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,428.47" $0.00 "$1,738.06" $0.00 $0.00 $0.00 $0.00 "$4,170.00" "$6,605.28" "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203496 EAP Custom 27203496 Alligator Retrieval BOTH IP/OP "$8,340.00 " "$6,171.60" $0.00 "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,428.47" $0.00 "$1,738.06" $0.00 $0.00 $0.00 $0.00 "$4,170.00" "$6,605.28" "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203497 EAP Custom 27203497 Alligator Retrieval BOTH IP/OP "$8,340.00 " "$6,171.60" $0.00 "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,428.47" $0.00 "$1,738.06" $0.00 $0.00 $0.00 $0.00 "$4,170.00" "$6,605.28" "$6,672.00" $0.00 "$5,421.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203498 EAP HCPCS C1725 Catheter Balloon Pta 3.50 X 15 BOTH IP/OP "$3,387.00 " "$2,506.38" $0.00 "$2,709.60" "$1,839.14" "$1,839.14" $0.00 $0.00 $0.00 $705.94 "$2,513.83" "$2,513.83" "$2,610.70" $0.00 $705.85 $0.00 "$2,003.41" "$2,003.41" $0.00 "$1,693.50" "$2,682.50" "$2,709.60" $0.00 $0.00 $0.00 $530.07 $0.00 $0.00 $539.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203499 EAP HCPCS C1725 Catheter Balloon Pta 3.00 X 15 BOTH IP/OP "$3,387.00 " "$2,506.38" $0.00 "$2,709.60" "$1,839.14" "$1,839.14" $0.00 $0.00 $0.00 $705.94 "$2,513.83" "$2,513.83" "$2,610.70" $0.00 $705.85 $0.00 "$2,003.41" "$2,003.41" $0.00 "$1,693.50" "$2,682.50" "$2,709.60" $0.00 $0.00 $0.00 $530.07 $0.00 $0.00 $539.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203500 EAP HCPCS C1725 Catheter Balloon Pta 2.50 X 15 BOTH IP/OP "$3,387.00 " "$2,506.38" $0.00 "$2,709.60" "$1,839.14" "$1,839.14" $0.00 $0.00 $0.00 $705.94 "$2,513.83" "$2,513.83" "$2,610.70" $0.00 $705.85 $0.00 "$2,003.41" "$2,003.41" $0.00 "$1,693.50" "$2,682.50" "$2,709.60" $0.00 $0.00 $0.00 $530.07 $0.00 $0.00 $539.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203501 EAP HCPCS C1725 Catheter Balloon Pta 3.50 X 9. BOTH IP/OP "$3,387.00 " "$2,506.38" $0.00 "$2,709.60" "$1,839.14" "$1,839.14" $0.00 $0.00 $0.00 $705.94 "$2,513.83" "$2,513.83" "$2,610.70" $0.00 $705.85 $0.00 "$2,003.41" "$2,003.41" $0.00 "$1,693.50" "$2,682.50" "$2,709.60" $0.00 $0.00 $0.00 $530.07 $0.00 $0.00 $539.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203502 EAP HCPCS C1725 Catheter Balloon Pta 3.00 X 9. BOTH IP/OP "$3,387.00 " "$2,506.38" $0.00 "$2,709.60" "$1,839.14" "$1,839.14" $0.00 $0.00 $0.00 $705.94 "$2,513.83" "$2,513.83" "$2,610.70" $0.00 $705.85 $0.00 "$2,003.41" "$2,003.41" $0.00 "$1,693.50" "$2,682.50" "$2,709.60" $0.00 $0.00 $0.00 $530.07 $0.00 $0.00 $539.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203503 EAP HCPCS C1725 Catheter Balloon 2.50 X 9.0mm BOTH IP/OP "$3,387.00 " "$2,506.38" $0.00 "$2,709.60" "$1,839.14" "$1,839.14" $0.00 $0.00 $0.00 $705.94 "$2,513.83" "$2,513.83" "$2,610.70" $0.00 $705.85 $0.00 "$2,003.41" "$2,003.41" $0.00 "$1,693.50" "$2,682.50" "$2,709.60" $0.00 $0.00 $0.00 $530.07 $0.00 $0.00 $539.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203504 EAP HCPCS C1725 Catheter Balloon 2.00 X 9.0mm BOTH IP/OP "$3,387.00 " "$2,506.38" $0.00 "$2,709.60" "$1,839.14" "$1,839.14" $0.00 $0.00 $0.00 $705.94 "$2,513.83" "$2,513.83" "$2,610.70" $0.00 $705.85 $0.00 "$2,003.41" "$2,003.41" $0.00 "$1,693.50" "$2,682.50" "$2,709.60" $0.00 $0.00 $0.00 $530.07 $0.00 $0.00 $539.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203505 EAP HCPCS C1725 Catheter Balloon Pta 1.50 X 9. BOTH IP/OP "$3,387.00 " "$2,506.38" $0.00 "$2,709.60" "$1,839.14" "$1,839.14" $0.00 $0.00 $0.00 $705.94 "$2,513.83" "$2,513.83" "$2,610.70" $0.00 $705.85 $0.00 "$2,003.41" "$2,003.41" $0.00 "$1,693.50" "$2,682.50" "$2,709.60" $0.00 $0.00 $0.00 $530.07 $0.00 $0.00 $539.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203506 EAP HCPCS C1751 Microcatheter Hi-flo Distal Fl BOTH IP/OP "$2,270.00 " "$1,679.80" $0.00 "$1,816.00" "$1,232.61" "$1,232.61" $0.00 $0.00 $0.00 $473.12 "$1,684.79" "$1,684.79" "$1,749.72" $0.00 $473.07 $0.00 "$1,342.71" "$1,342.71" $0.00 "$1,135.00" "$1,797.84" "$1,816.00" $0.00 $0.00 $0.00 $355.26 $0.00 $0.00 $361.38 $0.00 $0.00 $0.00 $0.00 $0.00 27203507 EAP HCPCS C1751 Microcathter Hi-pro Distal Fl BOTH IP/OP "$2,270.00 " "$1,679.80" $0.00 "$1,816.00" "$1,232.61" "$1,232.61" $0.00 $0.00 $0.00 $473.12 "$1,684.79" "$1,684.79" "$1,749.72" $0.00 $473.07 $0.00 "$1,342.71" "$1,342.71" $0.00 "$1,135.00" "$1,797.84" "$1,816.00" $0.00 $0.00 $0.00 $355.26 $0.00 $0.00 $361.38 $0.00 $0.00 $0.00 $0.00 $0.00 27203508 EAP HCPCS C1751 Microcatheter Pre-shaped 45 2- BOTH IP/OP "$2,837.00 " "$2,099.38" $0.00 "$2,269.60" "$1,540.49" "$1,540.49" $0.00 $0.00 $0.00 $591.30 "$2,105.62" "$2,105.62" "$2,186.76" $0.00 $591.23 $0.00 "$1,678.09" "$1,678.09" $0.00 "$1,418.50" "$2,246.90" "$2,269.60" $0.00 "$1,844.05" $0.00 $443.99 $0.00 $0.00 $451.65 $0.00 $0.00 $0.00 $0.00 $0.00 27203509 EAP HCPCS C1769 Guidewire Standard Pre-shap 1 BOTH IP/OP "$2,151.00 " "$1,591.74" $0.00 "$1,720.80" "$1,167.99" "$1,167.99" $0.00 $0.00 $0.00 $448.32 "$1,596.47" "$1,596.47" "$1,657.99" $0.00 $448.27 $0.00 "$1,272.32" "$1,272.32" $0.00 "$1,075.50" "$1,703.59" "$1,720.80" $0.00 "$1,398.15" $0.00 $336.63 $0.00 $0.00 $342.44 $0.00 $0.00 $0.00 $0.00 $0.00 27203510 EAP HCPCS C1769 Guidewire Standard Pre-shap 2 BOTH IP/OP "$1,838.00 " "$1,360.12" $0.00 "$1,470.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $919.00 "$1,455.70" "$1,470.40" $0.00 $0.00 $0.00 $287.65 $0.00 $0.00 $292.61 $0.00 $0.00 $0.00 $0.00 $0.00 27203511 EAP HCPCS C1769 Guidewire Soft Pre-shaped 200c BOTH IP/OP "$1,838.00 " "$1,360.12" $0.00 "$1,470.40" $998.03 $998.03 $0.00 $0.00 $0.00 $383.09 "$1,364.16" "$1,364.16" "$1,416.73" $0.00 $383.04 $0.00 "$1,087.18" "$1,087.18" $0.00 $919.00 "$1,455.70" "$1,470.40" $0.00 "$1,194.70" $0.00 $287.65 $0.00 $0.00 $292.61 $0.00 $0.00 $0.00 $0.00 $0.00 27203512 EAP HCPCS C1887 Catheter Utk Slip 5f 125cm BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $401.82 $401.82 $0.00 $0.00 $0.00 $154.23 $549.23 $549.23 $570.39 $0.00 $154.22 $0.00 $437.71 $437.71 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $0.00 $115.81 $0.00 $0.00 $117.81 $0.00 $0.00 $0.00 $0.00 $0.00 27203513 EAP HCPCS C1887 Catheter Davis 5f .038 100cm BOTH IP/OP $328.00 $242.72 $0.00 $262.40 $178.10 $178.10 $0.00 $0.00 $0.00 $68.36 $243.44 $243.44 $252.82 $0.00 $68.36 $0.00 $194.01 $194.01 $0.00 $164.00 $259.78 $262.40 $0.00 $0.00 $0.00 $51.33 $0.00 $0.00 $52.22 $0.00 $0.00 $0.00 $0.00 $0.00 27203514 EAP HCPCS C1894 Sheath Shuttle 7f 90cm BOTH IP/OP $413.00 $305.62 $0.00 $330.40 $224.26 $224.26 $0.00 $0.00 $0.00 $86.08 $306.53 $306.53 $318.34 $0.00 $86.07 $0.00 $244.29 $244.29 $0.00 $206.50 $327.10 $330.40 $0.00 $268.45 $0.00 $64.63 $0.00 $0.00 $65.75 $0.00 $0.00 $0.00 $0.00 $0.00 27203515 EAP HCPCS C1894 Sheath Shuttle 6f 90cm BOTH IP/OP $483.00 $357.42 $0.00 $386.40 $262.27 $262.27 $0.00 $0.00 $0.00 $100.67 $358.48 $358.48 $372.30 $0.00 $100.66 $0.00 $285.69 $285.69 $0.00 $241.50 $382.54 $386.40 $0.00 $313.95 $0.00 $75.59 $0.00 $0.00 $76.89 $0.00 $0.00 $0.00 $0.00 $0.00 27203516 EAP HCPCS C1894 Sheath Shuttle 6fr 80cm. BOTH IP/OP $595.00 $440.30 $0.00 $476.00 $323.09 $323.09 $0.00 $0.00 $0.00 $124.01 $441.61 $441.61 $458.63 $0.00 $124.00 $0.00 $351.94 $351.94 $0.00 $297.50 $471.24 $476.00 $0.00 $386.75 $0.00 $93.12 $0.00 $0.00 $94.72 $0.00 $0.00 $0.00 $0.00 $0.00 27203517 EAP HCPCS C1884 Roadrunners Conners.035x260cm BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $86.88 $86.88 $0.00 $0.00 $0.00 $33.35 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $94.64 $94.64 $0.00 $80.00 $126.72 $128.00 $0.00 $104.00 $0.00 $25.04 $0.00 $0.00 $25.47 $0.00 $0.00 $0.00 $0.00 $0.00 27203518 EAP HCPCS C1887 Catheter Envoy 6fr X13-mp BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $244.35 $244.35 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $346.86 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 27203519 EAP HCPCS C1887 Catheter Envoy 5fr Mipd 9 BOTH IP/OP "$1,048.00 " $775.52 $0.00 $838.40 $569.06 $569.06 $0.00 $0.00 $0.00 $218.43 $777.83 $777.83 $807.80 $0.00 $218.40 $0.00 $619.89 $619.89 $0.00 $524.00 $830.02 $838.40 $0.00 $681.20 $0.00 $164.01 $0.00 $0.00 $166.84 $0.00 $0.00 $0.00 $0.00 $0.00 27203520 EAP HCPCS C1887 Catheter Envoy Straight 9 BOTH IP/OP "$1,048.00 " $775.52 $0.00 $838.40 $569.06 $569.06 $0.00 $0.00 $0.00 $218.43 $777.83 $777.83 $807.80 $0.00 $218.40 $0.00 $619.89 $619.89 $0.00 $524.00 $830.02 $838.40 $0.00 $681.20 $0.00 $164.01 $0.00 $0.00 $166.84 $0.00 $0.00 $0.00 $0.00 $0.00 27203521 EAP HCPCS C1751 Microcathter Prowler Select L BOTH IP/OP "$2,578.00 " "$1,907.72" $0.00 "$2,062.40" "$1,399.85" "$1,399.85" $0.00 $0.00 $0.00 $537.32 "$1,913.39" "$1,913.39" "$1,987.12" $0.00 $537.26 $0.00 "$1,524.89" "$1,524.89" $0.00 "$1,289.00" "$2,041.78" "$2,062.40" $0.00 $0.00 $0.00 $403.46 $0.00 $0.00 $410.42 $0.00 $0.00 $0.00 $0.00 $0.00 27203522 EAP HCPCS C1751 Microcatht.prowler Select L 2 BOTH IP/OP "$2,578.00 " "$1,907.72" $0.00 "$2,062.40" "$1,399.85" "$1,399.85" $0.00 $0.00 $0.00 $537.32 "$1,913.39" "$1,913.39" "$1,987.12" $0.00 $537.26 $0.00 "$1,524.89" "$1,524.89" $0.00 "$1,289.00" "$2,041.78" "$2,062.40" $0.00 $0.00 $0.00 $403.46 $0.00 $0.00 $410.42 $0.00 $0.00 $0.00 $0.00 $0.00 27203523 EAP HCPCS C1751 Microcatht.prowler Select L 3 BOTH IP/OP "$2,578.00 " "$1,907.72" $0.00 "$2,062.40" "$1,399.85" "$1,399.85" $0.00 $0.00 $0.00 $537.32 "$1,913.39" "$1,913.39" "$1,987.12" $0.00 $537.26 $0.00 "$1,524.89" "$1,524.89" $0.00 "$1,289.00" "$2,041.78" "$2,062.40" $0.00 $0.00 $0.00 $403.46 $0.00 $0.00 $410.42 $0.00 $0.00 $0.00 $0.00 $0.00 27203524 EAP HCPCS C1751 Microcatht.prowler Select L 4 BOTH IP/OP "$2,526.00 " "$1,869.24" $0.00 "$2,020.80" "$1,371.62" "$1,371.62" $0.00 $0.00 $0.00 $526.48 "$1,874.80" "$1,874.80" "$1,947.04" $0.00 $526.42 $0.00 "$1,494.13" "$1,494.13" $0.00 "$1,263.00" "$2,000.59" "$2,020.80" $0.00 $0.00 $0.00 $395.32 $0.00 $0.00 $402.14 $0.00 $0.00 $0.00 $0.00 $0.00 27203525 EAP HCPCS C1751 Microcathet.prowler Select P 1 BOTH IP/OP "$2,454.00 " "$1,815.96" $0.00 "$1,963.20" "$1,332.52" "$1,332.52" $0.00 $0.00 $0.00 $511.47 "$1,821.36" "$1,821.36" "$1,891.54" $0.00 $511.41 $0.00 "$1,451.54" "$1,451.54" $0.00 "$1,227.00" "$1,943.57" "$1,963.20" $0.00 $0.00 $0.00 $384.05 $0.00 $0.00 $390.68 $0.00 $0.00 $0.00 $0.00 $0.00 27203526 EAP HCPCS C1751 Microcath.prowler Select P 2 BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $572.87 $572.87 $0.00 $0.00 $0.00 $219.89 $783.02 $783.02 $813.19 $0.00 $219.86 $0.00 $624.03 $624.03 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 27203527 EAP HCPCS C1751 Catheter Echelon 14 Micro BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" "$1,151.16" "$1,151.16" $0.00 $0.00 $0.00 $441.86 "$1,573.46" "$1,573.46" "$1,634.10" $0.00 $441.81 $0.00 "$1,253.98" "$1,253.98" $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $331.78 $0.00 $0.00 $337.50 $0.00 $0.00 $0.00 $0.00 $0.00 27203528 EAP HCPCS C1751 Microcath.prowler Select P 3 BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $572.87 $572.87 $0.00 $0.00 $0.00 $219.89 $783.02 $783.02 $813.19 $0.00 $219.86 $0.00 $624.03 $624.03 $0.00 $527.50 $835.56 $844.00 $0.00 $685.75 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 27203529 EAP HCPCS C1751 Micrcathters Rapidtransit 17 BOTH IP/OP "$2,235.00 " "$1,653.90" $0.00 "$1,788.00" "$1,213.61" "$1,213.61" $0.00 $0.00 $0.00 $465.83 "$1,658.82" "$1,658.82" "$1,722.74" $0.00 $465.77 $0.00 "$1,322.00" "$1,322.00" $0.00 "$1,117.50" "$1,770.12" "$1,788.00" $0.00 $0.00 $0.00 $349.78 $0.00 $0.00 $355.81 $0.00 $0.00 $0.00 $0.00 $0.00 27203530 EAP HCPCS C1751 Micrcatheter Rapidtransit 150 BOTH IP/OP "$2,235.00 " "$1,653.90" $0.00 "$1,788.00" "$1,213.61" "$1,213.61" $0.00 $0.00 $0.00 $465.83 "$1,658.82" "$1,658.82" "$1,722.74" $0.00 $465.77 $0.00 "$1,322.00" "$1,322.00" $0.00 "$1,117.50" "$1,770.12" "$1,788.00" $0.00 $0.00 $0.00 $349.78 $0.00 $0.00 $355.81 $0.00 $0.00 $0.00 $0.00 $0.00 27203531 EAP HCPCS C1769 Guidewire Hydrophilic Coat S 1 BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 27203532 EAP HCPCS C1769 Guidewire Hydrophilic Coat S 2 BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $21.18 $21.18 $0.00 $0.00 $0.00 $8.13 $28.95 $28.95 $30.06 $0.00 $8.13 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $0.00 $25.35 $0.00 $6.10 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203533 EAP HCPCS C1769 Guidewire Hydrophilic Coated T BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $317.66 $317.66 $0.00 $0.00 $0.00 $121.93 $434.19 $434.19 $450.92 $0.00 $121.91 $0.00 $346.03 $346.03 $0.00 $292.50 $463.32 $468.00 $0.00 $380.25 $0.00 $91.55 $0.00 $0.00 $93.13 $0.00 $0.00 $0.00 $0.00 $0.00 27203534 EAP HCPCS C1769 Guidewire Hydrophilic Coat 0 1 BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 27203535 EAP HCPCS C1769 Guidewire Hydrophilic Coat 0 2 BOTH IP/OP $149.00 $110.26 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.50 $118.01 $119.20 $0.00 $0.00 $0.00 $23.32 $0.00 $0.00 $23.72 $0.00 $0.00 $0.00 $0.00 $0.00 27203536 EAP HCPCS C1769 Guidewire Hydrophilic Coat 3 BOTH IP/OP $29.00 $21.46 $0.00 $23.20 $15.75 $15.75 $0.00 $0.00 $0.00 $6.04 $21.52 $21.52 $22.35 $0.00 $6.04 $0.00 $17.15 $17.15 $0.00 $14.50 $22.97 $23.20 $0.00 $0.00 $0.00 $4.54 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 27203537 EAP Custom 27203537 Catheter Separator 054 BOTH IP/OP "$8,337.00 " "$6,169.38" $0.00 "$6,669.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,426.16" $0.00 "$1,737.43" $0.00 $0.00 $0.00 $0.00 "$4,168.50" "$6,602.90" "$6,669.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203538 EAP HCPCS C1757 Catheter Reperfilision 054 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$2,264.31" "$2,264.31" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,466.56" "$2,466.56" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203539 EAP HCPCS C1887 Cath.lumen Delivery Neuron 1 BOTH IP/OP "$1,719.00 " "$1,272.06" $0.00 "$1,375.20" $933.42 $933.42 $0.00 $0.00 $0.00 $358.28 "$1,275.84" "$1,275.84" "$1,325.01" $0.00 $358.24 $0.00 "$1,016.79" "$1,016.79" $0.00 $859.50 "$1,361.45" "$1,375.20" $0.00 "$1,117.35" $0.00 $269.02 $0.00 $0.00 $273.66 $0.00 $0.00 $0.00 $0.00 $0.00 27203540 EAP HCPCS C1887 Catheter Delivery Neuron 6f St BOTH IP/OP "$3,436.00 " "$2,542.64" $0.00 "$2,748.80" "$1,865.75" "$1,865.75" $0.00 $0.00 $0.00 $716.15 "$2,550.20" "$2,550.20" "$2,648.47" $0.00 $716.06 $0.00 "$2,032.39" "$2,032.39" $0.00 "$1,718.00" "$2,721.31" "$2,748.80" $0.00 $0.00 $0.00 $537.73 $0.00 $0.00 $547.01 $0.00 $0.00 $0.00 $0.00 $0.00 27203541 EAP HCPCS C1887 Cath.select Neuron 5f 120 1 BOTH IP/OP $417.00 $308.58 $0.00 $333.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.50 $330.26 $333.60 $0.00 $0.00 $0.00 $65.26 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 27203542 EAP HCPCS C1887 Cath.select Neuron 5f 120 2 BOTH IP/OP $417.00 $308.58 $0.00 $333.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.50 $330.26 $333.60 $0.00 $0.00 $0.00 $65.26 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 27203543 EAP HCPCS C1887 Cath.lumen Delivery Neuron 2 BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 27203544 EAP HCPCS C1887 Cath.lumen Delivery Neuron 3 BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 27203545 EAP HCPCS C1884 Device Protection Spider Fx 5. BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$2,264.31" "$2,264.31" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,466.56" "$2,466.56" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 "$2,710.50" $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27203546 EAP HCPCS C1884 Device Distal Protection Spide BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$2,264.31" "$2,264.31" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,466.56" "$2,466.56" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 "$2,710.50" $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27203547 EAP HCPCS C2628 Cath.balloon Guide Concent 1 BOTH IP/OP "$2,364.00 " "$1,749.36" $0.00 "$1,891.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,182.00" "$1,872.29" "$1,891.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203548 EAP HCPCS C2628 Catheter Balloon Guide 9f 80cm BOTH IP/OP "$2,364.00 " "$1,749.36" $0.00 "$1,891.20" "$1,283.65" "$1,283.65" $0.00 $0.00 $0.00 $492.72 "$1,754.56" "$1,754.56" "$1,822.17" $0.00 $492.66 $0.00 "$1,398.31" "$1,398.31" $0.00 "$1,182.00" "$1,872.29" "$1,891.20" $0.00 "$1,536.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203549 EAP HCPCS C2628 Cath.balloon Guide Concent 2 BOTH IP/OP "$2,251.00 " "$1,665.74" $0.00 "$1,800.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.50" "$1,782.79" "$1,800.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203550 EAP HCPCS C2628 Cath.balloon Guide Concent 3 BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203551 EAP HCPCS C1751 Cath.distal Access Dac 057 1 BOTH IP/OP "$3,321.00 " "$2,457.54" $0.00 "$2,656.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.50" "$2,630.23" "$2,656.80" $0.00 $0.00 $0.00 $519.74 $0.00 $0.00 $528.70 $0.00 $0.00 $0.00 $0.00 $0.00 27203552 EAP HCPCS C1751 Cath.distal Access Dac 057 2 BOTH IP/OP "$3,321.00 " "$2,457.54" $0.00 "$2,656.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.50" "$2,630.23" "$2,656.80" $0.00 $0.00 $0.00 $519.74 $0.00 $0.00 $528.70 $0.00 $0.00 $0.00 $0.00 $0.00 27203553 EAP HCPCS C1751 Catheter Dac 044 - 130cm BOTH IP/OP "$1,429.00 " "$1,057.46" $0.00 "$1,143.20" $775.95 $775.95 $0.00 $0.00 $0.00 $297.84 "$1,060.60" "$1,060.60" "$1,101.47" $0.00 $297.80 $0.00 $845.25 $845.25 $0.00 $714.50 "$1,131.77" "$1,143.20" $0.00 $0.00 $0.00 $223.64 $0.00 $0.00 $227.50 $0.00 $0.00 $0.00 $0.00 $0.00 27203554 EAP HCPCS C1751 Catheter Dac 038 - 136cm BOTH IP/OP "$3,321.00 " "$2,457.54" $0.00 "$2,656.80" "$1,803.30" "$1,803.30" $0.00 $0.00 $0.00 $692.18 "$2,464.85" "$2,464.85" "$2,559.83" $0.00 $692.10 $0.00 "$1,964.37" "$1,964.37" $0.00 "$1,660.50" "$2,630.23" "$2,656.80" $0.00 $0.00 $0.00 $519.74 $0.00 $0.00 $528.70 $0.00 $0.00 $0.00 $0.00 $0.00 27203555 EAP HCPCS C1884 Sph100200-20 Microcoil Platino BOTH IP/OP "$3,586.00 " "$2,653.64" $0.00 "$2,868.80" "$1,947.20" "$1,947.20" $0.00 $0.00 $0.00 $747.41 "$2,661.53" "$2,661.53" "$2,764.09" $0.00 $747.32 $0.00 "$2,121.12" "$2,121.12" $0.00 "$1,793.00" "$2,840.11" "$2,868.80" $0.00 $0.00 $0.00 $561.21 $0.00 $0.00 $570.89 $0.00 $0.00 $0.00 $0.00 $0.00 27203556 EAP Custom 27203556 Marker Strght 2-tip 150cm/6cm BOTH IP/OP "$2,518.00 " "$1,863.32" $0.00 "$2,014.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,868.86" "$1,868.86" "$1,940.87" $0.00 $524.75 $0.00 $0.00 $0.00 $0.00 "$1,259.00" "$1,994.26" "$2,014.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203557 EAP Custom 27203557 Axium Coil Detacher BOTH IP/OP $166.00 $122.84 $0.00 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.21 $123.21 $127.95 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $83.00 $131.47 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203558 EAP HCPCS C1887 Mpc Envoy Guiding Wire BOTH IP/OP "$1,048.00 " $775.52 $0.00 $838.40 $569.06 $569.06 $0.00 $0.00 $0.00 $218.43 $777.83 $777.83 $807.80 $0.00 $218.40 $0.00 $619.89 $619.89 $0.00 $524.00 $830.02 $838.40 $0.00 $0.00 $0.00 $164.01 $0.00 $0.00 $166.84 $0.00 $0.00 $0.00 $0.00 $0.00 27203559 EAP Custom 27203559 Starclose Se BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.43 $197.43 $205.03 $0.00 $55.43 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203560 EAP Custom 27203560 Wrap On Finger Hooks(each) BOTH IP/OP $21.00 $15.54 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $10.50 $16.63 $16.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203561 EAP HCPCS C1729 Shunt Prtnvn Dnvr Asct 25-40ml/min Ample Flowrate BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" "$3,054.38" "$3,054.38" $0.00 $0.00 $0.00 "$1,172.39" "$4,174.88" "$4,174.88" "$4,335.75" $0.00 "$1,172.25" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 "$3,656.25" $0.00 $880.31 $0.00 $0.00 $895.50 $0.00 $0.00 $0.00 $0.00 $0.00 27203562 EAP HCPCS C1729 "Cath, Drainage" BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 27203563 EAP HCPCS C1769 Tray Tracheostomy 24-26-28fr 2 Cannu Tube Shiley C BOTH IP/OP "$1,219.00 " $902.06 $0.00 $975.20 $661.92 $661.92 $0.00 $0.00 $0.00 $254.07 $904.74 $904.74 $939.61 $0.00 $254.04 $0.00 $721.04 $721.04 $0.00 $609.50 $965.45 $975.20 $0.00 $0.00 $0.00 $190.77 $0.00 $0.00 $194.06 $0.00 $0.00 $0.00 $0.00 $0.00 27203564 EAP Custom 27203564 Cannula Prfsn 22fr Vns 20d Dilat Crct Bbl Trp Fnl BOTH IP/OP "$32,500.00 " "$24,050.00" $0.00 "$26,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$25,051.00" $0.00 "$6,773.00" $0.00 $0.00 $0.00 $0.00 "$16,250.00" "$25,740.00" "$26,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203565 EAP HCPCS C1725 Catheter Angio Vtk Curve 5fr 125cm Cerebrum Trnb BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $17.92 $17.92 $0.00 $0.00 $0.00 $6.88 $24.49 $24.49 $25.44 $0.00 $6.88 $0.00 $19.52 $19.52 $0.00 $16.50 $26.14 $26.40 $0.00 $21.45 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 27203580 EAP Custom 27203580 Safeguard 24cm Pressure Devce BOTH IP/OP $66.00 $48.84 $0.00 $52.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.99 $48.99 $50.87 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $33.00 $52.27 $52.80 $0.00 $42.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203590 EAP Custom 27203590 Needle 25g BOTH IP/OP $119.00 $88.06 $0.00 $95.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.32 $88.32 $91.73 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $59.50 $94.25 $95.20 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203591 EAP Custom 27203591 Resolution235cm BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.22 $169.22 $175.74 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.00 $180.58 $182.40 $0.00 $148.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203592 EAP Custom 27203592 Rx Lithotripter Basket3 BOTH IP/OP $379.00 $280.46 $0.00 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.29 $281.29 $292.13 $0.00 $78.98 $0.00 $0.00 $0.00 $0.00 $189.50 $300.17 $303.20 $0.00 $246.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203593 EAP Custom 27203593 Rx Lithotripter Basket4 BOTH IP/OP $379.00 $280.46 $0.00 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.29 $281.29 $292.13 $0.00 $78.98 $0.00 $0.00 $0.00 $0.00 $189.50 $300.17 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203594 EAP Custom 27203594 Rx Lithotripter Basket5 BOTH IP/OP $379.00 $280.46 $0.00 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.29 $281.29 $292.13 $0.00 $78.98 $0.00 $0.00 $0.00 $0.00 $189.50 $300.17 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203595 EAP Custom 27203595 Rx Lithotripter Basket6 BOTH IP/OP $379.00 $280.46 $0.00 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.29 $281.29 $292.13 $0.00 $78.98 $0.00 $0.00 $0.00 $0.00 $189.50 $300.17 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203596 EAP Custom 27203596 Autotome Rx 44-20mm BOTH IP/OP $622.00 $460.28 $0.00 $497.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $461.65 $461.65 $479.44 $0.00 $129.62 $0.00 $0.00 $0.00 $0.00 $311.00 $492.62 $497.60 $0.00 $404.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203597 EAP Custom 27203597 Autotome Rx 44-20mm BOTH IP/OP $592.00 $438.08 $0.00 $473.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $439.38 $439.38 $456.31 $0.00 $123.37 $0.00 $0.00 $0.00 $0.00 $296.00 $468.86 $473.60 $0.00 $384.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203598 EAP Custom 27203598 Hydro Tome Rx 450cm BOTH IP/OP $592.00 $438.08 $0.00 $473.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $439.38 $439.38 $456.31 $0.00 $123.37 $0.00 $0.00 $0.00 $0.00 $296.00 $468.86 $473.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203599 EAP Custom 27203599 Needleknife Rx BOTH IP/OP $260.00 $192.40 $0.00 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.97 $192.97 $200.41 $0.00 $54.18 $0.00 $0.00 $0.00 $0.00 $130.00 $205.92 $208.00 $0.00 $169.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203621 EAP Custom 27203621 Laceration Tray BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203624 EAP Custom 27203624 Standard Peg Kit 20 BOTH IP/OP $517.00 $382.58 $0.00 $413.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $383.72 $383.72 $398.50 $0.00 $107.74 $0.00 $0.00 $0.00 $0.00 $258.50 $409.46 $413.60 $0.00 $336.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203680 EAP HCPCS C1769 Hydra-jag/.035/260cm/str BOTH IP/OP $647.00 $478.78 $0.00 $517.60 $351.32 $351.32 $0.00 $0.00 $0.00 $134.85 $480.20 $480.20 $498.71 $0.00 $134.83 $0.00 $382.70 $382.70 $0.00 $323.50 $512.42 $517.60 $0.00 $0.00 $0.00 $101.26 $0.00 $0.00 $103.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203681 EAP HCPCS C1769 Hydra-jag/.035/450cm/str BOTH IP/OP $749.00 $554.26 $0.00 $599.20 $406.71 $406.71 $0.00 $0.00 $0.00 $156.11 $555.91 $555.91 $577.33 $0.00 $156.09 $0.00 $443.03 $443.03 $0.00 $374.50 $593.21 $599.20 $0.00 $0.00 $0.00 $117.22 $0.00 $0.00 $119.24 $0.00 $0.00 $0.00 $0.00 $0.00 27203682 EAP HCPCS C1769 Jag Hini 025/260 St Bx2 BOTH IP/OP $352.00 $260.48 $0.00 $281.60 $191.14 $191.14 $0.00 $0.00 $0.00 $73.37 $261.25 $261.25 $271.32 $0.00 $73.36 $0.00 $208.21 $208.21 $0.00 $176.00 $278.78 $281.60 $0.00 $0.00 $0.00 $55.09 $0.00 $0.00 $56.04 $0.00 $0.00 $0.00 $0.00 $0.00 27203683 EAP HCPCS C1769 Jagwire/025/straight 450cm BOTH IP/OP $533.00 $394.42 $0.00 $426.40 $289.42 $289.42 $0.00 $0.00 $0.00 $111.09 $395.59 $395.59 $410.84 $0.00 $111.08 $0.00 $315.27 $315.27 $0.00 $266.50 $422.14 $426.40 $0.00 $346.45 $0.00 $83.41 $0.00 $0.00 $84.85 $0.00 $0.00 $0.00 $0.00 $0.00 27203684 EAP HCPCS C1769 Pathfinder 018/450 BOTH IP/OP $544.00 $402.56 $0.00 $435.20 $295.39 $295.39 $0.00 $0.00 $0.00 $113.38 $403.76 $403.76 $419.32 $0.00 $113.37 $0.00 $321.78 $321.78 $0.00 $272.00 $430.85 $435.20 $0.00 $0.00 $0.00 $85.14 $0.00 $0.00 $86.60 $0.00 $0.00 $0.00 $0.00 $0.00 27203701 EAP Custom 27203701 Barrier Adh Abs Plvs Intcd 4x3 BOTH IP/OP $745.00 $551.30 $0.00 $596.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.94 $552.94 $574.25 $0.00 $155.26 $0.00 $0.00 $0.00 $0.00 $372.50 $590.04 $596.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203702 EAP HCPCS C1877 Catheter Tr Renegade Hi Flo 13 BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $682.55 $682.55 $0.00 $0.00 $0.00 $261.99 $932.95 $932.95 $968.90 $0.00 $261.96 $0.00 $743.52 $743.52 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $817.05 $0.00 $196.72 $0.00 $0.00 $200.11 $0.00 $0.00 $0.00 $0.00 $0.00 27203703 EAP Custom 27203703 Catheter Embolic F-idc 2d 3mm BOTH IP/OP "$1,321.00 " $977.54 $0.00 "$1,056.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $980.45 $980.45 "$1,018.23" $0.00 $275.30 $0.00 $0.00 $0.00 $0.00 $660.50 "$1,046.23" "$1,056.80" $0.00 $858.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203704 EAP Custom 27203704 Catheter Embolic 2/5mm X 5.8cm BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $817.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203705 EAP Custom 27203705 Cm Catheter Embolic 2/5mm X 5.8 BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203706 EAP Custom 27203706 Coil Axium Helical Detachable Qc-3-8-helix BOTH IP/OP "$2,404.00 " "$1,778.96" $0.00 "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,784.25" "$1,784.25" "$1,853.00" $0.00 $500.99 $0.00 $0.00 $0.00 $0.00 "$1,202.00" "$1,903.97" "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203707 EAP Custom 27203707 Microcoil Platinum Deltaplush 2mmx4cm BOTH IP/OP "$3,217.00 " "$2,380.58" $0.00 "$2,573.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,387.66" "$2,387.66" "$2,479.66" $0.00 $670.42 $0.00 $0.00 $0.00 $0.00 "$1,608.50" "$2,547.86" "$2,573.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203708 EAP Custom 27203708 Microcoil Platinum Deltaplush 2mmx6cm BOTH IP/OP "$3,217.00 " "$2,380.58" $0.00 "$2,573.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,387.66" "$2,387.66" "$2,479.66" $0.00 $670.42 $0.00 $0.00 $0.00 $0.00 "$1,608.50" "$2,547.86" "$2,573.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203740 EAP HCPCS C1887 Catheter Renegade Stc-18 130/2 BOTH IP/OP "$1,664.00 " "$1,231.36" $0.00 "$1,331.20" $903.55 $903.55 $0.00 $0.00 $0.00 $346.82 "$1,235.02" "$1,235.02" "$1,282.61" $0.00 $346.78 $0.00 $984.26 $984.26 $0.00 $832.00 "$1,317.89" "$1,331.20" $0.00 "$1,081.60" $0.00 $260.42 $0.00 $0.00 $264.91 $0.00 $0.00 $0.00 $0.00 $0.00 27203741 EAP Custom 27203741 Catheter Embolic F-3mm X 12cm BOTH IP/OP "$1,321.00 " $977.54 $0.00 "$1,056.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $980.45 $980.45 "$1,018.23" $0.00 $275.30 $0.00 $0.00 $0.00 $0.00 $660.50 "$1,046.23" "$1,056.80" $0.00 $858.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203742 EAP Custom 27203742 Catheter Embolic F-4mm X 8cm BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $817.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203743 EAP Custom 27203743 4mm X 15cm Catheter Embolic F- BOTH IP/OP "$1,321.00 " $977.54 $0.00 "$1,056.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $980.45 $980.45 "$1,018.23" $0.00 $275.30 $0.00 $0.00 $0.00 $0.00 $660.50 "$1,046.23" "$1,056.80" $0.00 $858.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203744 EAP Custom 27203744 Catheter Embolic F-5mm X 8cm BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203745 EAP Custom 27203745 Coil Embolization 2d Helix 5mm 15cm 8 Coil Occlusion System BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $817.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203746 EAP Custom 27203746 Coil Embolization 2d Helix 6mm 10cm 18 Coil Occlusion System BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $817.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203747 EAP Custom 27203747 Coil Embolization 2d Helix 6mm 20cm 18 Coil Occlusion System BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $817.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203748 EAP Custom 27203748 8MM X 20CM CATHETER EMBOLIC F- BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $817.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203749 EAP Custom 27203749 10MM X 20CM CATHETER EMBOLIC F BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203750 EAP Custom 27203750 10MM X 30CM CATHETER EMBOLIC F BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203751 EAP Custom 27203751 CATHETER EMBOLIC F12M X 20CM BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203752 EAP Custom 27203752 Catheter Embolic F 12m X 30cm BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203753 EAP Custom 27203753 Catheter Embolic F 14mm X 20cm BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203754 EAP Custom 27203754 Catheter Embolic F 14mm X 30cm BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203755 EAP Custom 27203755 CATHETER EMBOLIC F-IDC VORTX DCM BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $817.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203756 EAP Custom 27203756 Catheter Embolic F-2/4mm X 4.1cm BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $969.67 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $817.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203766 EAP Custom 27203766 Catheter Swan Ganz BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203769 EAP Custom 27203769 Tray Thoracentesis/parace BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203770 EAP HCPCS C1769 Miraclebros Guiding Wire 14937-01 BOTH IP/OP "$2,251.00 " "$1,665.74" $0.00 "$1,800.80" "$1,222.29" "$1,222.29" $0.00 $0.00 $0.00 $469.16 "$1,670.69" "$1,670.69" "$1,735.07" $0.00 $469.11 $0.00 "$1,331.47" "$1,331.47" $0.00 "$1,125.50" "$1,782.79" "$1,800.80" $0.00 $0.00 $0.00 $352.28 $0.00 $0.00 $358.36 $0.00 $0.00 $0.00 $0.00 $0.00 27203773 EAP Custom 27203773 Catheter Guid 14fr Acty Pro 130d Cs-ic Curve Inr BOTH IP/OP $613.00 $453.62 $0.00 $490.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.97 $454.97 $472.50 $0.00 $127.75 $0.00 $0.00 $0.00 $0.00 $306.50 $485.50 $490.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203774 EAP Custom 27203774 Catheter Gd 16fr 1.5cm Bln Loprfl BOTH IP/OP "$1,238.00 " $916.12 $0.00 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.84 $918.84 $954.25 $0.00 $258.00 $0.00 $0.00 $0.00 $0.00 $619.00 $980.50 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203775 EAP Custom 27203775 Catheter Gd 16fr 3.5cm Bln Loprfl BOTH IP/OP "$1,238.00 " $916.12 $0.00 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.84 $918.84 $954.25 $0.00 $258.00 $0.00 $0.00 $0.00 $0.00 $619.00 $980.50 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203776 EAP HCPCS C1724 Catheter Athrcm 145cm Stlth 360 1.25mm Orbtl Cls BOTH IP/OP "$9,488.00 " "$7,021.12" $0.00 "$7,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,313.35" $0.00 "$1,977.30" $0.00 $0.00 $0.00 $0.00 "$4,744.00" "$7,514.50" "$7,590.40" $0.00 "$6,167.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203777 EAP HCPCS C1769 Guidewire Vasc 360 Orbtl BOTH IP/OP $488.00 $361.12 $0.00 $390.40 $264.98 $264.98 $0.00 $0.00 $0.00 $101.71 $362.19 $362.19 $376.15 $0.00 $101.70 $0.00 $288.65 $288.65 $0.00 $244.00 $386.50 $390.40 $0.00 $317.20 $0.00 $76.37 $0.00 $0.00 $77.69 $0.00 $0.00 $0.00 $0.00 $0.00 27203780 EAP HCPCS C1766 Sheath Flex 7fr 10cm BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $380.10 $380.10 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $539.56 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 27203790 EAP HCPCS C1751 Microcatheter Microvention BOTH IP/OP "$2,390.00 " "$1,768.60" $0.00 "$1,912.00" "$1,297.77" "$1,297.77" $0.00 $0.00 $0.00 $498.14 "$1,773.86" "$1,773.86" "$1,842.21" $0.00 $498.08 $0.00 "$1,413.69" "$1,413.69" $0.00 "$1,195.00" "$1,892.88" "$1,912.00" $0.00 "$1,553.50" $0.00 $374.04 $0.00 $0.00 $380.49 $0.00 $0.00 $0.00 $0.00 $0.00 27203795 EAP HCPCS C1751 Microcatheter Merci BOTH IP/OP "$1,585.00 " "$1,172.90" $0.00 "$1,268.00" $860.66 $860.66 $0.00 $0.00 $0.00 $330.35 "$1,176.39" "$1,176.39" "$1,221.72" $0.00 $330.31 $0.00 $937.53 $937.53 $0.00 $792.50 "$1,255.32" "$1,268.00" $0.00 $0.00 $0.00 $248.05 $0.00 $0.00 $252.33 $0.00 $0.00 $0.00 $0.00 $0.00 27203796 EAP HCPCS C1757 2.5 Meri V-series Retrieval Sy BOTH IP/OP "$10,341.00 " "$7,652.34" $0.00 "$8,272.80" "$5,615.16" "$5,615.16" $0.00 $0.00 $0.00 "$2,155.32" "$4,181.12" "$4,181.12" "$7,970.84" $0.00 "$2,155.06" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,170.50" "$8,190.07" "$8,272.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203797 EAP HCPCS C1757 3.0 Meri V-series Retrieval Sy BOTH IP/OP "$10,341.00 " "$7,652.34" $0.00 "$8,272.80" "$5,615.16" "$5,615.16" $0.00 $0.00 $0.00 "$2,155.32" "$4,181.12" "$4,181.12" "$7,970.84" $0.00 "$2,155.06" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,170.50" "$8,190.07" "$8,272.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203798 EAP HCPCS C1757 Meri V-series Retrieval System BOTH IP/OP "$10,341.00 " "$7,652.34" $0.00 "$8,272.80" "$5,615.16" "$5,615.16" $0.00 $0.00 $0.00 "$2,155.32" "$4,181.12" "$4,181.12" "$7,970.84" $0.00 "$2,155.06" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,170.50" "$8,190.07" "$8,272.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203799 EAP HCPCS C1751 026 Catheter Reperfusion BOTH IP/OP "$3,635.00 " "$2,689.90" $0.00 "$2,908.00" "$1,973.81" "$1,973.81" $0.00 $0.00 $0.00 $757.62 "$2,697.90" "$2,697.90" "$2,801.86" $0.00 $757.53 $0.00 "$2,150.10" "$2,150.10" $0.00 "$1,817.50" "$2,878.92" "$2,908.00" $0.00 $0.00 $0.00 $568.88 $0.00 $0.00 $578.69 $0.00 $0.00 $0.00 $0.00 $0.00 27203800 EAP HCPCS C1751 032 Catheter Reperfusion BOTH IP/OP "$3,817.00 " "$2,824.58" $0.00 "$3,053.60" "$2,072.63" "$2,072.63" $0.00 $0.00 $0.00 $795.56 "$2,832.98" "$2,832.98" "$2,942.14" $0.00 $795.46 $0.00 "$2,257.76" "$2,257.76" $0.00 "$1,908.50" "$3,023.06" "$3,053.60" $0.00 "$2,481.05" $0.00 $597.36 $0.00 $0.00 $607.67 $0.00 $0.00 $0.00 $0.00 $0.00 27203801 EAP HCPCS C1751 041 Catheter Reperfusion BOTH IP/OP "$3,635.00 " "$2,689.90" $0.00 "$2,908.00" "$1,973.81" "$1,973.81" $0.00 $0.00 $0.00 $757.62 "$2,697.90" "$2,697.90" "$2,801.86" $0.00 $757.53 $0.00 "$2,150.10" "$2,150.10" $0.00 "$1,817.50" "$2,878.92" "$2,908.00" $0.00 $0.00 $0.00 $568.88 $0.00 $0.00 $578.69 $0.00 $0.00 $0.00 $0.00 $0.00 27203802 EAP Custom 27203802 026 Separator BOTH IP/OP "$7,639.00 " "$5,652.86" $0.00 "$6,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,888.14" $0.00 "$1,591.97" $0.00 $0.00 $0.00 $0.00 "$3,819.50" "$6,050.09" "$6,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203803 EAP Custom 27203803 032 Separator BOTH IP/OP "$7,639.00 " "$5,652.86" $0.00 "$6,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,888.14" $0.00 "$1,591.97" $0.00 $0.00 $0.00 $0.00 "$3,819.50" "$6,050.09" "$6,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203804 EAP Custom 27203804 "Tubing, Aspiration" BOTH IP/OP "$1,297.00 " $959.78 $0.00 "$1,037.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $962.63 $962.63 $999.73 $0.00 $270.29 $0.00 $0.00 $0.00 $0.00 $648.50 "$1,027.22" "$1,037.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203805 EAP Custom 27203805 "Supplies, Non-sterile Penumbra" BOTH IP/OP $913.00 $675.62 $0.00 $730.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $677.63 $677.63 $703.74 $0.00 $190.27 $0.00 $0.00 $0.00 $0.00 $456.50 $723.10 $730.40 $0.00 $593.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203806 EAP Custom 27203806 "Pump, Penumbra Aspiration" BOTH IP/OP "$8,340.00 " "$6,171.60" $0.00 "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,428.47" $0.00 "$1,738.06" $0.00 $0.00 $0.00 $0.00 "$4,170.00" "$6,605.28" "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203807 EAP Custom 27203807 Device Accunet Distal Protecti BOTH IP/OP "$7,006.00 " "$5,184.44" $0.00 "$5,604.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,400.22" $0.00 "$1,460.05" $0.00 $0.00 $0.00 $0.00 "$3,503.00" "$5,548.75" "$5,604.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203808 EAP Custom 27203808 1008195-20 Balloon Viatrac BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203809 EAP Custom 27203809 Qc-2-1 Helix Coil Axium Helica BOTH IP/OP "$2,404.00 " "$1,778.96" $0.00 "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,784.25" "$1,784.25" "$1,853.00" $0.00 $500.99 $0.00 $0.00 $0.00 $0.00 "$1,202.00" "$1,903.97" "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203810 EAP Custom 27203810 Qc-3-4-helix Coil Axium Helica BOTH IP/OP "$2,404.00 " "$1,778.96" $0.00 "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,784.25" "$1,784.25" "$1,853.00" $0.00 $500.99 $0.00 $0.00 $0.00 $0.00 "$1,202.00" "$1,903.97" "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203815 EAP Custom 27203815 Ballon-trek Mini Rx 2.0mm X 12mm BOTH IP/OP $685.00 $506.90 $0.00 $548.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $508.41 $508.41 $528.00 $0.00 $142.75 $0.00 $0.00 $0.00 $0.00 $342.50 $542.52 $548.00 $0.00 $445.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203816 EAP Custom 27203816 Ballon-TREK MINI RX 2.0MM X 15MM BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203817 EAP Custom 27203817 Ballon-TREK RX 2.50MM X 12MM BOTH IP/OP $685.00 $506.90 $0.00 $548.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $508.41 $508.41 $528.00 $0.00 $142.75 $0.00 $0.00 $0.00 $0.00 $342.50 $542.52 $548.00 $0.00 $445.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203818 EAP Custom 27203818 Ballon-TREK RX 2.50MM X 15MM BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203819 EAP Custom 27203819 Ballon-TREK RX 3.0MM X 12MM BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203820 EAP HCPCS C1757 Set Thrombectomy Dvx BOTH IP/OP "$5,308.00 " "$3,927.92" $0.00 "$4,246.40" "$2,882.24" "$2,882.24" $0.00 $0.00 $0.00 "$1,106.32" "$3,939.60" "$3,939.60" "$4,091.41" $0.00 "$1,106.19" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,654.00" "$4,203.94" "$4,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203821 EAP HCPCS C1757 Set Thrombectomy Avx BOTH IP/OP "$2,452.00 " "$1,814.48" $0.00 "$1,961.60" "$1,331.44" "$1,331.44" $0.00 $0.00 $0.00 $511.06 "$1,819.87" "$1,819.87" "$1,890.00" $0.00 $511.00 $0.00 "$1,450.36" "$1,450.36" $0.00 "$1,226.00" "$1,941.98" "$1,961.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203822 EAP HCPCS C1757 Set Thrombectomy Spiroflex BOTH IP/OP "$6,464.00 " "$4,783.36" $0.00 "$5,171.20" "$3,509.95" "$3,509.95" $0.00 $0.00 $0.00 "$1,347.26" "$4,181.12" "$4,181.12" "$4,982.45" $0.00 "$1,347.10" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,232.00" "$5,119.49" "$5,171.20" $0.00 "$4,201.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203823 EAP HCPCS C1757 Set Thrombectomy Spiroflex Vg BOTH IP/OP "$6,156.00 " "$4,555.44" $0.00 "$4,924.80" "$3,342.71" "$3,342.71" $0.00 $0.00 $0.00 "$1,283.06" "$4,181.12" "$4,181.12" "$4,745.04" $0.00 "$1,282.91" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,078.00" "$4,875.55" "$4,924.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203824 EAP Custom 27203824 Ballon-TREK RX 3.0MM X 15MM BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203825 EAP HCPCS C1725 Balloon Nc Trek 2.0 X 6mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203826 EAP HCPCS C1725 Balloon Nc Trek 2.5 X 6mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203827 EAP HCPCS C1725 Balloon Nc Trek 2.5 X 8mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203828 EAP HCPCS C1725 Balloon Nc Trek 2.5 X 12mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203829 EAP HCPCS C1725 Balloon Nc Trek 2.5 X 20mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203830 EAP HCPCS C1725 Balloon Nc Trek 2.5 X 25mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203831 EAP HCPCS C1725 Balloon Nc Trek 2.75 X 6mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203832 EAP HCPCS C1725 Balloon Nc Trek 2.75 X 12mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203833 EAP HCPCS C1725 "Balloon, Mini Trek Otw 1.50 X" BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203834 EAP HCPCS C1725 "Balloon, Mini Trek Otw 1.50 X" BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203835 EAP HCPCS C1725 "Balloon, Mini Trek Otw 2.00 X" BOTH IP/OP $685.00 $506.90 $0.00 $548.00 $371.96 $371.96 $0.00 $0.00 $0.00 $142.77 $508.41 $508.41 $528.00 $0.00 $142.75 $0.00 $405.18 $405.18 $0.00 $342.50 $542.52 $548.00 $0.00 $0.00 $0.00 $107.20 $0.00 $0.00 $109.05 $0.00 $0.00 $0.00 $0.00 $0.00 27203836 EAP HCPCS C1725 "Balloon, Mini Trek Otw 2.00 X" BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203837 EAP HCPCS C1725 "Balloon, Mini Trek Otw 2.00 X" BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203838 EAP HCPCS C1725 Balloon Nc Trek 2.75 X 15mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203839 EAP HCPCS C1725 Balloon Nc Trek 2.75 X 20mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203840 EAP HCPCS C1725 Balloon Nc Trek 3.0 X 6mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203841 EAP HCPCS C1725 Balloon Nc Trek 3.0 X 8mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203842 EAP HCPCS C1725 Balloon Nc Trek 3.0 X 12mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203843 EAP HCPCS C1725 Balloon Nc Trek 3.0 X 15mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203844 EAP HCPCS C1725 Balloon Nc Trek 3.0 X 20mm BOTH IP/OP $685.00 $506.90 $0.00 $548.00 $371.96 $371.96 $0.00 $0.00 $0.00 $142.77 $508.41 $508.41 $528.00 $0.00 $142.75 $0.00 $405.18 $405.18 $0.00 $342.50 $542.52 $548.00 $0.00 $445.25 $0.00 $107.20 $0.00 $0.00 $109.05 $0.00 $0.00 $0.00 $0.00 $0.00 27203845 EAP HCPCS C1725 Balloon Nc Trek 3.0 X 25mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203846 EAP HCPCS C1725 Balloon Nc Trek 3.25 X 12mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203847 EAP HCPCS C1725 Balloon Nc Trek 3.25 X 15mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203848 EAP HCPCS C1725 Balloon Nc Trek 3.5 X 6mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203849 EAP HCPCS C1725 Balloon Nc Trek 3.5 X 8mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203850 EAP HCPCS C1725 Balloon Nc Trek 3.5 X 12mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203851 EAP HCPCS C1725 Balloon Nc Trek 3.5 X 15mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203852 EAP HCPCS C1725 Balloon Nc Trek 3.5 X 20mm BOTH IP/OP $685.00 $506.90 $0.00 $548.00 $371.96 $371.96 $0.00 $0.00 $0.00 $142.77 $508.41 $508.41 $528.00 $0.00 $142.75 $0.00 $405.18 $405.18 $0.00 $342.50 $542.52 $548.00 $0.00 $445.25 $0.00 $107.20 $0.00 $0.00 $109.05 $0.00 $0.00 $0.00 $0.00 $0.00 27203853 EAP HCPCS C1725 Balloon Nc Trek 3.5 X 25mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203854 EAP HCPCS C1725 Balloon Nc Trek 3.75 X 12mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203855 EAP HCPCS C1725 Balloon Nc Trek 3.75 X 15mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203856 EAP HCPCS C1725 Balloon Nc Trek 3.75 X 20mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203857 EAP HCPCS C1725 Balloon Nc Trek 4.0 X 8mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203858 EAP HCPCS C1725 Balloon Nc Trek 4.0 X 12mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203859 EAP HCPCS C1725 Balloon Nc Trek 4.0 X 15mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203860 EAP HCPCS C1725 Balloon Nc Trek 4.0 X 20mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203861 EAP HCPCS C1725 Balloon Nc Trek 5.0 X 8mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $0.00 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203862 EAP HCPCS C1725 Balloon Nc Trek 5.0 X 12mm BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $354.04 $354.04 $0.00 $0.00 $0.00 $135.89 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $385.66 $385.66 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $102.04 $0.00 $0.00 $103.80 $0.00 $0.00 $0.00 $0.00 $0.00 27203863 EAP HCPCS C1725 Stent Xcience 2.25 X 8mm BOTH IP/OP "$6,940.00 " "$5,135.60" $0.00 "$5,552.00" "$3,768.42" "$3,768.42" $0.00 $0.00 $0.00 "$1,446.47" "$4,181.12" "$4,181.12" "$5,349.35" $0.00 "$1,446.30" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,470.00" "$5,496.48" "$5,552.00" $0.00 $0.00 $0.00 "$1,086.11" $0.00 $0.00 "$1,104.85" $0.00 $0.00 $0.00 $0.00 $0.00 27203864 EAP HCPCS C1887 Catheter Guid Ebu3.75 Curve 8fr .09in 90cm Left BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27203865 EAP HCPCS C1887 Atheter Guid Xb3.5 Curve 8fr 90cm Coron Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27203867 EAP HCPCS C1887 Catheter Guid Jl4 Curve 8fr 90cm Coron Shr Nx Bal BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27203868 EAP HCPCS C1887 Catheter Guid Mb1 Curve 8fr .088in 90cm Coron Shr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27203869 EAP HCPCS C1887 Catheter Angio Jacky Radl 3.5 Curve 5fr 110cm BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $47.78 $47.78 $0.00 $0.00 $0.00 $18.34 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $52.05 $52.05 $0.00 $44.00 $69.70 $70.40 $0.00 $57.20 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 27203870 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 2.0x10 Mm 5f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203871 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 2.0x15 Mm 5f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203872 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 2.0x20 Mm 5f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203873 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 2.5x10 Mm 5f BOTH IP/OP $788.00 $583.12 $0.00 $630.40 $427.88 $427.88 $0.00 $0.00 $0.00 $164.24 $584.85 $584.85 $607.39 $0.00 $164.22 $0.00 $466.10 $466.10 $0.00 $394.00 $624.10 $630.40 $0.00 $512.20 $0.00 $123.32 $0.00 $0.00 $125.45 $0.00 $0.00 $0.00 $0.00 $0.00 27203874 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 2.5x15 Mm 5f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203875 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 2.5x20 Mm 5f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203876 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 3.0x10 Mm 6f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203878 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 3.0x20 Mm 6f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203879 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 3.5x10 Mm 6f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203880 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 3.5x15 Mm 6f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203881 EAP HCPCS C1725 Chocolate Ptca Balloon Catheter 3.5x20 Mm 6f BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $407.25 $407.25 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $578.10 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $487.50 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 27203882 EAP HCPCS C1887 Catheter Dlv Sys .062in 5max Max Trk Tch 125cm 129 BOTH IP/OP "$4,175.00 " "$3,089.50" $0.00 "$3,340.00" "$2,267.03" "$2,267.03" $0.00 $0.00 $0.00 $870.17 "$3,098.69" "$3,098.69" "$3,218.09" $0.00 $870.07 $0.00 "$2,469.51" "$2,469.51" $0.00 "$2,087.50" "$3,306.60" "$3,340.00" $0.00 "$2,713.75" $0.00 $653.39 $0.00 $0.00 $664.66 $0.00 $0.00 $0.00 $0.00 $0.00 27203890 EAP Custom 27203890 Kit Gel Pad Medium Arctic Sun BOTH IP/OP "$6,305.00 " "$4,665.70" $0.00 "$5,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,152.50" "$4,993.56" "$5,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203891 EAP Custom 27203891 Kit Gel Pad Large Arctic Sun BOTH IP/OP "$6,305.00 " "$4,665.70" $0.00 "$5,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,859.89" $0.00 "$1,313.96" $0.00 $0.00 $0.00 $0.00 "$3,152.50" "$4,993.56" "$5,044.00" $0.00 "$4,098.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203892 EAP Custom 27203892 Pad Gel Universal BOTH IP/OP "$6,005.00 " "$4,443.70" $0.00 "$4,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,002.50" "$4,755.96" "$4,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203895 EAP Custom 27203895 Ballon-TREK RX 3.50MM X 12MM BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203896 EAP Custom 27203896 Ballon-TREK RX 3.50MM X 15MM BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203897 EAP Custom 27203897 Ballon-TREK RX 4.0MM X 15MM BOTH IP/OP $652.00 $482.48 $0.00 $521.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.91 $483.91 $502.56 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $326.00 $516.38 $521.60 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203899 EAP Custom 27203899 "Catheter, Tiger 4.5 Radial Access" BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203900 EAP Custom 27203900 Device Spec Rtrvl Xtrt Pro Xl 7-6fr 12-15mm 200cm BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,855.50" "$1,855.50" "$1,927.00" $0.00 $521.00 $0.00 $0.00 $0.00 $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203901 EAP Custom 27203901 Tray Foley 16fr With Unrinemeter BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203902 EAP HCPCS C1751 Fa-55150-1030 Catheter Marksman BOTH IP/OP "$3,104.00 " "$2,296.96" $0.00 "$2,483.20" "$1,685.47" "$1,685.47" $0.00 $0.00 $0.00 $646.95 "$2,303.79" "$2,303.79" "$2,392.56" $0.00 $646.87 $0.00 "$1,836.02" "$1,836.02" $0.00 "$1,552.00" "$2,458.37" "$2,483.20" $0.00 $0.00 $0.00 $485.78 $0.00 $0.00 $494.16 $0.00 $0.00 $0.00 $0.00 $0.00 27203903 EAP HCPCS C1725 Catheter Balloon Udt 16-449 5-10/5/75 BOTH IP/OP $634.00 $469.16 $0.00 $507.20 $344.26 $344.26 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $488.69 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $317.00 $502.13 $507.20 $0.00 $0.00 $0.00 $99.22 $0.00 $0.00 $100.93 $0.00 $0.00 $0.00 $0.00 $0.00 27203904 EAP HCPCS C1894 Cl-07690 Sheath Set Super Arrow Flex 90cm BOTH IP/OP $347.00 $256.78 $0.00 $277.60 $188.42 $188.42 $0.00 $0.00 $0.00 $72.32 $257.54 $257.54 $267.47 $0.00 $72.31 $0.00 $205.25 $205.25 $0.00 $173.50 $274.82 $277.60 $0.00 $0.00 $0.00 $54.31 $0.00 $0.00 $55.24 $0.00 $0.00 $0.00 $0.00 $0.00 27203905 EAP HCPCS C1894 Cl - 07665 Sheath Set Super Arrow Flex 65cm BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $157.47 $157.47 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $188.50 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 27203906 EAP Custom 27203906 Catheter Tiger Radial Access 5fr 100cm 4.0 40-5011 BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203907 EAP Custom 27203907 Catheter Siteseer Al 1 5 Fr 5a0018 BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203908 EAP HCPCS C1769 Guidewire Asahi Grand Slam .014x300cm 14940 BOTH IP/OP $234.00 $173.16 $0.00 $187.20 $127.06 $127.06 $0.00 $0.00 $0.00 $48.77 $173.67 $173.67 $180.37 $0.00 $48.77 $0.00 $138.41 $138.41 $0.00 $117.00 $185.33 $187.20 $0.00 $152.10 $0.00 $36.62 $0.00 $0.00 $37.25 $0.00 $0.00 $0.00 $0.00 $0.00 27203909 EAP HCPCS C1887 La6ebu375 Catheter Guidingebu 3.75 BOTH IP/OP $464.00 $343.36 $0.00 $371.20 $251.95 $251.95 $0.00 $0.00 $0.00 $96.71 $344.38 $344.38 $357.65 $0.00 $96.70 $0.00 $274.46 $274.46 $0.00 $232.00 $367.49 $371.20 $0.00 $301.60 $0.00 $72.62 $0.00 $0.00 $73.87 $0.00 $0.00 $0.00 $0.00 $0.00 27203912 EAP HCPCS C1887 Catheter Guideliner 5571 BOTH IP/OP "$1,227.00 " $907.98 $0.00 $981.60 $666.26 $666.26 $0.00 $0.00 $0.00 $255.74 $910.68 $910.68 $945.77 $0.00 $255.71 $0.00 $725.77 $725.77 $0.00 $613.50 $971.78 $981.60 $0.00 $797.55 $0.00 $192.03 $0.00 $0.00 $195.34 $0.00 $0.00 $0.00 $0.00 $0.00 27203913 EAP HCPCS C1887 La7ebu375 Catheter Guiding Ebu 3.75 BOTH IP/OP $464.00 $343.36 $0.00 $371.20 $251.95 $251.95 $0.00 $0.00 $0.00 $96.71 $344.38 $344.38 $357.65 $0.00 $96.70 $0.00 $274.46 $274.46 $0.00 $232.00 $367.49 $371.20 $0.00 $0.00 $0.00 $72.62 $0.00 $0.00 $73.87 $0.00 $0.00 $0.00 $0.00 $0.00 27203914 EAP Custom 27203914 Catheter Siteseer Angled Pigtailed 5fr 5a0070 BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203916 EAP HCPCS C1892 French Large Peel Away Introducer 20 BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 27203917 EAP HCPCS C1892 French Large Peel Away Introducer 22 BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 27203918 EAP HCPCS C1892 French Large Peel Away Introducer 24 BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 27203919 EAP HCPCS C1892 French Large Peel Away Introducer 26 BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 27203920 EAP HCPCS C1894 Flexor Ceckflo Introducer BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $41.27 $41.27 $0.00 $0.00 $0.00 $15.84 $56.41 $56.41 $58.58 $0.00 $15.84 $0.00 $44.95 $44.95 $0.00 $38.00 $60.19 $60.80 $0.00 $49.40 $0.00 $11.89 $0.00 $0.00 $12.10 $0.00 $0.00 $0.00 $0.00 $0.00 27203921 EAP HCPCS C1750 French X 36 Cm Titan Hemodialysis Catheter BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $128.69 $128.69 $0.00 $0.00 $0.00 $49.40 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $140.19 $140.19 $0.00 $118.50 $187.70 $189.60 $0.00 $0.00 $0.00 $37.09 $0.00 $0.00 $37.73 $0.00 $0.00 $0.00 $0.00 $0.00 27203922 EAP HCPCS C1750 French X 40 Cm Titan Hemodialysis Catheter BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $128.69 $128.69 $0.00 $0.00 $0.00 $49.40 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $140.19 $140.19 $0.00 $118.50 $187.70 $189.60 $0.00 $0.00 $0.00 $37.09 $0.00 $0.00 $37.73 $0.00 $0.00 $0.00 $0.00 $0.00 27203923 EAP HCPCS C1750 Set Catheter 15.5fr 55cm 2 Lumen Titan Hd Long Term BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $366.13 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $213.75 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 27203925 EAP HCPCS C1752 French X 32 Cm Titan Hemodialysis Catheter T- 3 Triple 5 BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $0.00 $0.00 $0.00 $118.50 $187.70 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203926 EAP HCPCS C1752 Titan Hemodialysis Catheter 14f X 30 Cm BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $0.00 $0.00 $0.00 $118.50 $187.70 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203927 EAP HCPCS C1892 Tear Away Sheath Introducer BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $95.03 $95.03 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $134.89 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 27203928 EAP Custom 27203928 Dressing Adherent Mepilex Border 9.2 X 9.2 282400 BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $24.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203929 EAP HCPCS C1892 Large Peel Away Introducer BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 27203930 EAP HCPCS C1769 G131660 Introducer Tracheostomy Percutaneous Ciaglia Bm BOTH IP/OP "$1,124.00 " $831.76 $0.00 $899.20 $610.33 $610.33 $0.00 $0.00 $0.00 $234.27 $834.23 $834.23 $866.38 $0.00 $234.24 $0.00 $664.85 $664.85 $0.00 $562.00 $890.21 $899.20 $0.00 $0.00 $0.00 $175.91 $0.00 $0.00 $178.94 $0.00 $0.00 $0.00 $0.00 $0.00 27203931 EAP HCPCS C1769 G12565 Introducer Tracheostomy Percutaneous Ciaglia Blm BOTH IP/OP "$1,124.00 " $831.76 $0.00 $899.20 $610.33 $610.33 $0.00 $0.00 $0.00 $234.27 $834.23 $834.23 $866.38 $0.00 $234.24 $0.00 $664.85 $664.85 $0.00 $562.00 $890.21 $899.20 $0.00 $730.60 $0.00 $175.91 $0.00 $0.00 $178.94 $0.00 $0.00 $0.00 $0.00 $0.00 27203933 EAP HCPCS C1769 Um-04018 Femoral Arterial Line Kit BOTH IP/OP $91.00 $67.34 $0.00 $72.80 $49.41 $49.41 $0.00 $0.00 $0.00 $18.97 $67.54 $67.54 $70.14 $0.00 $18.96 $0.00 $53.83 $53.83 $0.00 $45.50 $72.07 $72.80 $0.00 $0.00 $0.00 $14.24 $0.00 $0.00 $14.49 $0.00 $0.00 $0.00 $0.00 $0.00 27203937 EAP Custom 27203937 M827057/10.s T.r.a.c. Pad BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203938 EAP HCPCS C1887 Fa-55150-1030 Catheter Marksman BOTH IP/OP "$3,259.00 " "$2,411.66" $0.00 "$2,607.20" "$1,769.64" "$1,769.64" $0.00 $0.00 $0.00 $679.26 "$2,418.83" "$2,418.83" "$2,512.04" $0.00 $679.18 $0.00 "$1,927.70" "$1,927.70" $0.00 "$1,629.50" "$2,581.13" "$2,607.20" $0.00 "$2,118.35" $0.00 $510.03 $0.00 $0.00 $518.83 $0.00 $0.00 $0.00 $0.00 $0.00 27203939 EAP HCPCS C1725 Baloon 2.5 X 15mm Raptor 573-125 BOTH IP/OP $743.00 $549.82 $0.00 $594.40 $403.45 $403.45 $0.00 $0.00 $0.00 $154.86 $551.45 $551.45 $572.70 $0.00 $154.84 $0.00 $439.48 $439.48 $0.00 $371.50 $588.46 $594.40 $0.00 $0.00 $0.00 $116.28 $0.00 $0.00 $118.29 $0.00 $0.00 $0.00 $0.00 $0.00 27203940 EAP Custom 27203940 Catheter Siteseer Al1 5fr 5a0018 BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203941 EAP Custom 27203941 Cl-07665 Sheath Set Super Arrow Flex 65cm BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203942 EAP Custom 27203942 Needle Guide Sterile 9001c0212 BOTH IP/OP $48.00 $35.52 $0.00 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.63 $35.63 $37.00 $0.00 $10.00 $0.00 $0.00 $0.00 $0.00 $24.00 $38.02 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203943 EAP HCPCS C1895 "Reliance Lead,aicd, Endo Dual Coil" BOTH IP/OP "$11,794.00 " "$8,727.56" $0.00 "$9,435.20" "$6,404.14" "$6,404.14" $0.00 $0.00 $0.00 "$2,458.16" "$4,181.12" "$4,181.12" "$9,090.82" $0.00 "$2,457.87" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,897.00" "$9,340.85" "$9,435.20" $0.00 $0.00 $0.00 "$1,845.76" $0.00 $0.00 "$1,877.60" $0.00 $0.00 $0.00 $0.00 $0.00 27203945 EAP HCPCS C1887 "6fr Acuity Cath, Guiding W Del Sys" BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $263.36 $263.36 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $373.84 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 27203946 EAP HCPCS C1887 "8fr Acuity Cath, Guiding W Del Sys" BOTH IP/OP "$1,104.00 " $816.96 $0.00 $883.20 $599.47 $599.47 $0.00 $0.00 $0.00 $230.10 $819.39 $819.39 $850.96 $0.00 $230.07 $0.00 $653.02 $653.02 $0.00 $552.00 $874.37 $883.20 $0.00 $0.00 $0.00 $172.78 $0.00 $0.00 $175.76 $0.00 $0.00 $0.00 $0.00 $0.00 27203947 EAP HCPCS C1887 "Ep Ds2c002 Slit/outer Cath, Guiding" BOTH IP/OP "$1,551.00 " "$1,147.74" $0.00 "$1,240.80" $842.19 $842.19 $0.00 $0.00 $0.00 $323.27 "$1,151.15" "$1,151.15" "$1,195.51" $0.00 $323.23 $0.00 $917.42 $917.42 $0.00 $775.50 "$1,228.39" "$1,240.80" $0.00 $0.00 $0.00 $242.73 $0.00 $0.00 $246.92 $0.00 $0.00 $0.00 $0.00 $0.00 27203950 EAP HCPCS C1769 Neuroscout 14 Standard 601314 BOTH IP/OP "$1,111.00 " $822.14 $0.00 $888.80 $603.27 $603.27 $0.00 $0.00 $0.00 $231.56 $824.58 $824.58 $856.36 $0.00 $231.53 $0.00 $657.16 $657.16 $0.00 $555.50 $879.91 $888.80 $0.00 $0.00 $0.00 $173.87 $0.00 $0.00 $176.87 $0.00 $0.00 $0.00 $0.00 $0.00 27203951 EAP HCPCS C1769 Neuroscout 14 Soft Xl 601414 BOTH IP/OP "$1,111.00 " $822.14 $0.00 $888.80 $499.95 $499.95 $0.00 $0.00 $0.00 $231.56 $824.58 $824.58 $856.36 $0.00 $231.53 $0.00 $657.16 $657.16 $0.00 $555.50 $879.91 $888.80 $0.00 $0.00 $0.00 $173.87 $0.00 $0.00 $176.87 $0.00 $0.00 $0.00 $0.00 $0.00 27203952 EAP HCPCS C1887 Prowler 27 Microcatheter BOTH IP/OP "$2,468.00 " "$1,826.32" $0.00 "$1,974.40" "$1,340.12" "$1,340.12" $0.00 $0.00 $0.00 $514.39 "$1,831.75" "$1,831.75" "$1,902.33" $0.00 $514.33 $0.00 "$1,459.82" "$1,459.82" $0.00 "$1,234.00" "$1,954.66" "$1,974.40" $0.00 $0.00 $0.00 $386.24 $0.00 $0.00 $392.91 $0.00 $0.00 $0.00 $0.00 $0.00 27203953 EAP HCPCS C1887 Catheter Delivery System Px Slim 130 D 0-.02 In Micro Lm BOTH IP/OP "$2,749.00 " "$2,034.26" $0.00 "$2,199.20" "$1,492.71" "$1,492.71" $0.00 $0.00 $0.00 $572.96 "$2,040.31" "$2,040.31" "$2,118.93" $0.00 $572.89 $0.00 "$1,626.03" "$1,626.03" $0.00 "$1,374.50" "$2,177.21" "$2,199.20" $0.00 $0.00 $0.00 $430.22 $0.00 $0.00 $437.64 $0.00 $0.00 $0.00 $0.00 $0.00 27203954 EAP HCPCS C1887 Catheter Delivery Sys Px Slim 45 D 0-.02 In Micro L150 M BOTH IP/OP "$2,749.00 " "$2,034.26" $0.00 "$2,199.20" "$1,492.71" "$1,492.71" $0.00 $0.00 $0.00 $572.96 "$2,040.31" "$2,040.31" "$2,118.93" $0.00 $572.89 $0.00 "$1,626.03" "$1,626.03" $0.00 "$1,374.50" "$2,177.21" "$2,199.20" $0.00 $0.00 $0.00 $430.22 $0.00 $0.00 $437.64 $0.00 $0.00 $0.00 $0.00 $0.00 27203955 EAP HCPCS C1887 Catheter Delivery Syspx Slim 90 D 0-.02 In Micro L150 Cm BOTH IP/OP "$2,749.00 " "$2,034.26" $0.00 "$2,199.20" "$1,492.71" "$1,492.71" $0.00 $0.00 $0.00 $572.96 "$2,040.31" "$2,040.31" "$2,118.93" $0.00 $572.89 $0.00 "$1,626.03" "$1,626.03" $0.00 "$1,374.50" "$2,177.21" "$2,199.20" $0.00 $0.00 $0.00 $430.22 $0.00 $0.00 $437.64 $0.00 $0.00 $0.00 $0.00 $0.00 27203956 EAP HCPCS C1887 Catheter Delivery Sys Px Slim 130 D 0-.02 In Micro L150m BOTH IP/OP "$2,749.00 " "$2,034.26" $0.00 "$2,199.20" "$1,492.71" "$1,492.71" $0.00 $0.00 $0.00 $572.96 "$2,040.31" "$2,040.31" "$2,118.93" $0.00 $572.89 $0.00 "$1,626.03" "$1,626.03" $0.00 "$1,374.50" "$2,177.21" "$2,199.20" $0.00 $0.00 $0.00 $430.22 $0.00 $0.00 $437.64 $0.00 $0.00 $0.00 $0.00 $0.00 27203957 EAP HCPCS C1887 Coil Detachment Handle BOTH IP/OP $739.00 $546.86 $0.00 $591.20 $401.28 $401.28 $0.00 $0.00 $0.00 $154.03 $548.49 $548.49 $569.62 $0.00 $154.01 $0.00 $437.12 $437.12 $0.00 $369.50 $585.29 $591.20 $0.00 $480.35 $0.00 $115.65 $0.00 $0.00 $117.65 $0.00 $0.00 $0.00 $0.00 $0.00 27203958 EAP HCPCS C1725 Catheter Delivery System .038in Sims Curve 5fr .04 BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $178.65 $178.65 $0.00 $0.00 $0.00 $68.57 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $194.60 $194.60 $0.00 $164.50 $260.57 $263.20 $0.00 $213.85 $0.00 $51.49 $0.00 $0.00 $52.38 $0.00 $0.00 $0.00 $0.00 $0.00 27203979 EAP HCPCS C1725 Catheter Baldilat 12mm 75cm 40mm High Pressure Lp BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27203980 EAP HCPCS C1725 Catheter Baldilat 10mm 75cm 40mm High Pressure Lp BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27203999 EAP Custom 27203999 Turnpike Catheter Lp 150cm BOTH IP/OP "$1,488.00 " "$1,101.12" $0.00 "$1,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,104.39" "$1,104.39" "$1,146.95" $0.00 $310.10 $0.00 $0.00 $0.00 $0.00 $744.00 "$1,178.50" "$1,190.40" $0.00 $967.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204010 EAP Custom 27204010 Camino Icp Catheter With Licox Bolt Fitting BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,745.65" "$1,745.65" "$1,812.92" $0.00 $490.16 $0.00 $0.00 $0.00 $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204011 EAP Custom 27204011 Brain Tissue Monitoring Kit BOTH IP/OP "$3,646.00 " "$2,698.04" $0.00 "$2,916.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,706.06" "$2,706.06" "$2,810.34" $0.00 $759.83 $0.00 $0.00 $0.00 $0.00 "$1,823.00" "$2,887.63" "$2,916.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204012 EAP Custom 27204012 Tube Blakemore Adult 20 Fr BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.65 $723.65 $751.53 $0.00 $203.19 $0.00 $0.00 $0.00 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204013 EAP Custom 27204013 "Retriever, Clot,trevo Pro 4 Kit, W Guidewire Tip" BOTH IP/OP "$15,192.00 " "$11,242.08" $0.00 "$12,153.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,709.99" $0.00 "$3,166.01" $0.00 $0.00 $0.00 $0.00 "$7,596.00" "$12,032.06" "$12,153.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204014 EAP HCPCS C1886 S-1304-cps-7-25-ls-bd Safire Blu BOTH IP/OP "$4,717.00 " "$3,490.58" $0.00 "$3,773.60" "$2,561.33" "$2,561.33" $0.00 $0.00 $0.00 $983.14 "$3,500.96" "$3,500.96" "$3,635.86" $0.00 $983.02 $0.00 "$2,790.11" "$2,790.11" $0.00 "$2,358.50" "$3,735.86" "$3,773.60" $0.00 $0.00 $0.00 $738.21 $0.00 $0.00 $750.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204015 EAP HCPCS C1886 S-1304-cps-7-25-ms-bd Safire Blu BOTH IP/OP "$4,717.00 " "$3,490.58" $0.00 "$3,773.60" "$2,561.33" "$2,561.33" $0.00 $0.00 $0.00 $983.14 "$3,500.96" "$3,500.96" "$3,635.86" $0.00 $983.02 $0.00 "$2,790.11" "$2,790.11" $0.00 "$2,358.50" "$3,735.86" "$3,773.60" $0.00 $0.00 $0.00 $738.21 $0.00 $0.00 $750.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204016 EAP HCPCS C1886 Medium Sweep Therapy Cool Path Bi-directional BOTH IP/OP "$4,717.00 " "$3,490.58" $0.00 "$3,773.60" "$2,561.33" "$2,561.33" $0.00 $0.00 $0.00 $983.14 "$3,500.96" "$3,500.96" "$3,635.86" $0.00 $983.02 $0.00 "$2,790.11" "$2,790.11" $0.00 "$2,358.50" "$3,735.86" "$3,773.60" $0.00 $0.00 $0.00 $738.21 $0.00 $0.00 $750.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204017 EAP HCPCS C1886 Large Sweep     Therapy Cool Path Bi-directional BOTH IP/OP "$4,717.00 " "$3,490.58" $0.00 "$3,773.60" "$2,561.33" "$2,561.33" $0.00 $0.00 $0.00 $983.14 "$3,500.96" "$3,500.96" "$3,635.86" $0.00 $983.02 $0.00 "$2,790.11" "$2,790.11" $0.00 "$2,358.50" "$3,735.86" "$3,773.60" $0.00 $0.00 $0.00 $738.21 $0.00 $0.00 $750.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204020 EAP HCPCS C1733 Safire Tx Catheter 8mm Large Curl BOTH IP/OP "$3,388.00 " "$2,507.12" $0.00 "$2,710.40" "$1,839.68" "$1,839.68" $0.00 $0.00 $0.00 $706.14 "$2,514.57" "$2,514.57" "$2,611.47" $0.00 $706.06 $0.00 "$2,004.00" "$2,004.00" $0.00 "$1,694.00" "$2,683.30" "$2,710.40" $0.00 "$2,202.20" $0.00 $530.22 $0.00 $0.00 $539.37 $0.00 $0.00 $0.00 $0.00 $0.00 27204021 EAP HCPCS C1733 Safire Cath 7f 4mm Lgcrl (us) BOTH IP/OP "$2,138.00 " "$1,582.12" $0.00 "$1,710.40" "$1,160.93" "$1,160.93" $0.00 $0.00 $0.00 $445.61 "$1,586.82" "$1,586.82" "$1,647.97" $0.00 $445.56 $0.00 "$1,264.63" "$1,264.63" $0.00 "$1,069.00" "$1,693.30" "$1,710.40" $0.00 "$1,389.70" $0.00 $334.60 $0.00 $0.00 $340.37 $0.00 $0.00 $0.00 $0.00 $0.00 27204022 EAP HCPCS C1733 Safire Tx Catheter 8mm Xlarge Curl BOTH IP/OP "$3,227.00 " "$2,387.98" $0.00 "$2,581.60" "$1,752.26" "$1,752.26" $0.00 $0.00 $0.00 $672.59 "$2,395.08" "$2,395.08" "$2,487.37" $0.00 $672.51 $0.00 "$1,908.77" "$1,908.77" $0.00 "$1,613.50" "$2,555.78" "$2,581.60" $0.00 $0.00 $0.00 $505.03 $0.00 $0.00 $513.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204023 EAP HCPCS C1733 Safire Cath 7f 5mm Lg Swp (us) BOTH IP/OP "$2,062.00 " "$1,525.88" $0.00 "$1,649.60" "$1,119.67" "$1,119.67" $0.00 $0.00 $0.00 $429.77 "$1,530.42" "$1,530.42" "$1,589.39" $0.00 $429.72 $0.00 "$1,219.67" "$1,219.67" $0.00 "$1,031.00" "$1,633.10" "$1,649.60" $0.00 $0.00 $0.00 $322.70 $0.00 $0.00 $328.27 $0.00 $0.00 $0.00 $0.00 $0.00 27204024 EAP HCPCS C1733 Safire Cath 7f 5mm Lg Crl (us) BOTH IP/OP "$2,165.00 " "$1,602.10" $0.00 "$1,732.00" "$1,175.60" "$1,175.60" $0.00 $0.00 $0.00 $451.24 "$1,606.86" "$1,606.86" "$1,668.78" $0.00 $451.19 $0.00 "$1,280.60" "$1,280.60" $0.00 "$1,082.50" "$1,714.68" "$1,732.00" $0.00 "$1,407.25" $0.00 $338.82 $0.00 $0.00 $344.67 $0.00 $0.00 $0.00 $0.00 $0.00 27204025 EAP HCPCS C1733 Safire Cath 7f 4mm Mdcrl (us) BOTH IP/OP "$2,036.00 " "$1,506.64" $0.00 "$1,628.80" "$1,105.55" "$1,105.55" $0.00 $0.00 $0.00 $424.35 "$1,511.12" "$1,511.12" "$1,569.35" $0.00 $424.30 $0.00 "$1,204.29" "$1,204.29" $0.00 "$1,018.00" "$1,612.51" "$1,628.80" $0.00 $0.00 $0.00 $318.63 $0.00 $0.00 $324.13 $0.00 $0.00 $0.00 $0.00 $0.00 27204026 EAP HCPCS C1733 Safire Cath 7f 4mm Sm Crl (us) BOTH IP/OP "$2,036.00 " "$1,506.64" $0.00 "$1,628.80" "$1,105.55" "$1,105.55" $0.00 $0.00 $0.00 $424.35 "$1,511.12" "$1,511.12" "$1,569.35" $0.00 $424.30 $0.00 "$1,204.29" "$1,204.29" $0.00 "$1,018.00" "$1,612.51" "$1,628.80" $0.00 $0.00 $0.00 $318.63 $0.00 $0.00 $324.13 $0.00 $0.00 $0.00 $0.00 $0.00 27204041 EAP HCPCS C1893 "Agilis Nxt 8.5f Steer Sm Crl,g2" BOTH IP/OP "$2,914.00 " "$2,156.36" $0.00 "$2,331.20" "$1,582.30" "$1,582.30" $0.00 $0.00 $0.00 $607.35 "$2,162.77" "$2,162.77" "$2,246.11" $0.00 $607.28 $0.00 "$1,723.63" "$1,723.63" $0.00 "$1,457.00" "$2,307.89" "$2,331.20" $0.00 "$1,894.10" $0.00 $456.04 $0.00 $0.00 $463.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204042 EAP HCPCS C1893 "Trns Intro 8.5f 63cm Sl1 032gw,g2" BOTH IP/OP $497.00 $367.78 $0.00 $397.60 $269.87 $269.87 $0.00 $0.00 $0.00 $103.59 $368.87 $368.87 $383.09 $0.00 $103.57 $0.00 $293.98 $293.98 $0.00 $248.50 $393.62 $397.60 $0.00 $0.00 $0.00 $77.78 $0.00 $0.00 $79.12 $0.00 $0.00 $0.00 $0.00 $0.00 27204043 EAP HCPCS C1893 "Trns Intro 8f 62 Cm Sl1 Tm,g2" BOTH IP/OP $397.00 $293.78 $0.00 $317.60 $215.57 $215.57 $0.00 $0.00 $0.00 $82.74 $294.65 $294.65 $306.01 $0.00 $82.73 $0.00 $234.83 $234.83 $0.00 $198.50 $314.42 $317.60 $0.00 $0.00 $0.00 $62.13 $0.00 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204044 EAP HCPCS C1893 "Trns Intro 8f 62cm Sl2 Tm,g2" BOTH IP/OP $397.00 $293.78 $0.00 $317.60 $215.57 $215.57 $0.00 $0.00 $0.00 $82.74 $294.65 $294.65 $306.01 $0.00 $82.73 $0.00 $234.83 $234.83 $0.00 $198.50 $314.42 $317.60 $0.00 $0.00 $0.00 $62.13 $0.00 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204045 EAP HCPCS C1766 "Trns Intro 8f 63cm Sl1 032gw,g2" BOTH IP/OP $497.00 $367.78 $0.00 $397.60 $269.87 $269.87 $0.00 $0.00 $0.00 $103.59 $368.87 $368.87 $383.09 $0.00 $103.57 $0.00 $293.98 $293.98 $0.00 $248.50 $393.62 $397.60 $0.00 $0.00 $0.00 $77.78 $0.00 $0.00 $79.12 $0.00 $0.00 $0.00 $0.00 $0.00 27204046 EAP HCPCS C1894 C-lock Hemo 8f 12cm 038gw-g2 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $32.04 $32.04 $0.00 $0.00 $0.00 $12.30 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $34.90 $34.90 $0.00 $29.50 $46.73 $47.20 $0.00 $38.35 $0.00 $9.23 $0.00 $0.00 $9.39 $0.00 $0.00 $0.00 $0.00 $0.00 27204047 EAP HCPCS C1894 C-lock Hemo 7f 12cm 038gw-g2 BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $30.41 $30.41 $0.00 $0.00 $0.00 $11.67 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $33.12 $33.12 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $8.76 $0.00 $0.00 $8.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204048 EAP HCPCS C1894 C-lock Hemo 6f 12cm 038gw-g2 BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $30.41 $30.41 $0.00 $0.00 $0.00 $11.67 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $33.12 $33.12 $0.00 $28.00 $44.35 $44.80 $0.00 $36.40 $0.00 $8.76 $0.00 $0.00 $8.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204049 EAP HCPCS C1894 "Duo Hemo 8f 12cm 038gw,g2" BOTH IP/OP $91.00 $67.34 $0.00 $72.80 $49.41 $49.41 $0.00 $0.00 $0.00 $18.97 $67.54 $67.54 $70.14 $0.00 $18.96 $0.00 $53.83 $53.83 $0.00 $45.50 $72.07 $72.80 $0.00 $0.00 $0.00 $14.24 $0.00 $0.00 $14.49 $0.00 $0.00 $0.00 $0.00 $0.00 27204050 EAP HCPCS C1893 "Hemo Intro 8f 60cm Sept Gw,g2" BOTH IP/OP $482.00 $356.68 $0.00 $385.60 $261.73 $261.73 $0.00 $0.00 $0.00 $100.46 $357.74 $357.74 $371.53 $0.00 $100.45 $0.00 $285.10 $285.10 $0.00 $241.00 $381.74 $385.60 $0.00 $0.00 $0.00 $75.43 $0.00 $0.00 $76.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204051 EAP HCPCS C1893 "Hemo Intro 8f 60cm Sr0 Tm,g2" BOTH IP/OP $397.00 $293.78 $0.00 $317.60 $215.57 $215.57 $0.00 $0.00 $0.00 $82.74 $294.65 $294.65 $306.01 $0.00 $82.73 $0.00 $234.83 $234.83 $0.00 $198.50 $314.42 $317.60 $0.00 $0.00 $0.00 $62.13 $0.00 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204052 EAP HCPCS C1893 "Hemo Intro 8f 60cm Ramp 038gw,g2" BOTH IP/OP $497.00 $367.78 $0.00 $397.60 $269.87 $269.87 $0.00 $0.00 $0.00 $103.59 $368.87 $368.87 $383.09 $0.00 $103.57 $0.00 $293.98 $293.98 $0.00 $248.50 $393.62 $397.60 $0.00 $0.00 $0.00 $77.78 $0.00 $0.00 $79.12 $0.00 $0.00 $0.00 $0.00 $0.00 27204053 EAP HCPCS C1893 "Hemo Intro 8.5f 60cm Sept Gw,g2" BOTH IP/OP $482.00 $356.68 $0.00 $385.60 $261.73 $261.73 $0.00 $0.00 $0.00 $100.46 $357.74 $357.74 $371.53 $0.00 $100.45 $0.00 $285.10 $285.10 $0.00 $241.00 $381.74 $385.60 $0.00 $0.00 $0.00 $75.43 $0.00 $0.00 $76.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204054 EAP HCPCS C1893 "Hemo Intro 8f 60cm Sr4 Tm,g2" BOTH IP/OP $397.00 $293.78 $0.00 $317.60 $215.57 $215.57 $0.00 $0.00 $0.00 $82.74 $294.65 $294.65 $306.01 $0.00 $82.73 $0.00 $234.83 $234.83 $0.00 $198.50 $314.42 $317.60 $0.00 $0.00 $0.00 $62.13 $0.00 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204055 EAP HCPCS C1893 "Hemo Intro 8.5f 63cm Sr0 038gw,g2" BOTH IP/OP $508.00 $375.92 $0.00 $406.40 $275.84 $275.84 $0.00 $0.00 $0.00 $105.88 $377.04 $377.04 $391.57 $0.00 $105.87 $0.00 $300.48 $300.48 $0.00 $254.00 $402.34 $406.40 $0.00 $0.00 $0.00 $79.50 $0.00 $0.00 $80.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204056 EAP HCPCS C1893 "Hemo Intro 8f 60cm Safl 038gw,g2" BOTH IP/OP $508.00 $375.92 $0.00 $406.40 $275.84 $275.84 $0.00 $0.00 $0.00 $105.88 $377.04 $377.04 $391.57 $0.00 $105.87 $0.00 $300.48 $300.48 $0.00 $254.00 $402.34 $406.40 $0.00 $0.00 $0.00 $79.50 $0.00 $0.00 $80.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204057 EAP HCPCS C1893 "Hemo Intro 8.5f 63cm Sr2 038gw,g2" BOTH IP/OP $508.00 $375.92 $0.00 $406.40 $275.84 $275.84 $0.00 $0.00 $0.00 $105.88 $377.04 $377.04 $391.57 $0.00 $105.87 $0.00 $300.48 $300.48 $0.00 $254.00 $402.34 $406.40 $0.00 $0.00 $0.00 $79.50 $0.00 $0.00 $80.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204058 EAP HCPCS C1893 "Hemo Intro 8.5f 60cm Csta Gw,g2" BOTH IP/OP $508.00 $375.92 $0.00 $406.40 $275.84 $275.84 $0.00 $0.00 $0.00 $105.88 $377.04 $377.04 $391.57 $0.00 $105.87 $0.00 $300.48 $300.48 $0.00 $254.00 $402.34 $406.40 $0.00 $330.20 $0.00 $79.50 $0.00 $0.00 $80.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204059 EAP HCPCS C1893 "Hemo Intro 8f 60cm Sr2 Tm,g2" BOTH IP/OP $397.00 $293.78 $0.00 $317.60 $215.57 $215.57 $0.00 $0.00 $0.00 $82.74 $294.65 $294.65 $306.01 $0.00 $82.73 $0.00 $234.83 $234.83 $0.00 $198.50 $314.42 $317.60 $0.00 $0.00 $0.00 $62.13 $0.00 $0.00 $63.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204060 EAP HCPCS C1766 Epicardial Catheter System BOTH IP/OP "$3,278.00 " "$2,425.72" $0.00 "$2,622.40" "$1,779.95" "$1,779.95" $0.00 $0.00 $0.00 $683.22 "$2,432.93" "$2,432.93" "$2,526.68" $0.00 $683.14 $0.00 "$1,938.94" "$1,938.94" $0.00 "$1,639.00" "$2,596.18" "$2,622.40" $0.00 $0.00 $0.00 $513.01 $0.00 $0.00 $521.86 $0.00 $0.00 $0.00 $0.00 $0.00 27204061 EAP HCPCS C1730 "Ep 5f Quad 5mm 120cm Crd,g2" BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $431.69 $431.69 $0.00 $0.00 $0.00 $165.70 $590.05 $590.05 $612.79 $0.00 $165.68 $0.00 $470.24 $470.24 $0.00 $397.50 $629.64 $636.00 $0.00 $516.75 $0.00 $124.42 $0.00 $0.00 $126.56 $0.00 $0.00 $0.00 $0.00 $0.00 27204062 EAP HCPCS C1730 "Ep 6f Dec 2/8mm 65cm Csl,g2" BOTH IP/OP "$1,087.00 " $804.38 $0.00 $869.60 $590.24 $590.24 $0.00 $0.00 $0.00 $226.56 $806.77 $806.77 $837.86 $0.00 $226.53 $0.00 $642.96 $642.96 $0.00 $543.50 $860.90 $869.60 $0.00 $0.00 $0.00 $170.12 $0.00 $0.00 $173.05 $0.00 $0.00 $0.00 $0.00 $0.00 27204063 EAP HCPCS C1730 "Ep 5f Quad 5mm 120cm Jsn,g2" BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $453.41 $453.41 $0.00 $0.00 $0.00 $174.03 $619.74 $619.74 $643.62 $0.00 $174.01 $0.00 $493.90 $493.90 $0.00 $417.50 $661.32 $668.00 $0.00 $542.75 $0.00 $130.68 $0.00 $0.00 $132.93 $0.00 $0.00 $0.00 $0.00 $0.00 27204064 EAP HCPCS C1730 "Eps 4f Quad 5mm Crd,g2" BOTH IP/OP "$1,031.00 " $762.94 $0.00 $824.80 $559.83 $559.83 $0.00 $0.00 $0.00 $214.89 $765.21 $765.21 $794.69 $0.00 $214.86 $0.00 $609.84 $609.84 $0.00 $515.50 $816.55 $824.80 $0.00 $0.00 $0.00 $161.35 $0.00 $0.00 $164.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204065 EAP HCPCS C1730 "Eps 4f Hex 5mm Crd-2,g2" BOTH IP/OP "$1,093.00 " $808.82 $0.00 $874.40 $593.50 $593.50 $0.00 $0.00 $0.00 $227.81 $811.22 $811.22 $842.48 $0.00 $227.78 $0.00 $646.51 $646.51 $0.00 $546.50 $865.66 $874.40 $0.00 $0.00 $0.00 $171.05 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $0.00 27204066 EAP HCPCS C1730 "Eps 5f Hex Uni 120cm Jsn X,g2" BOTH IP/OP $931.00 $688.94 $0.00 $744.80 $505.53 $505.53 $0.00 $0.00 $0.00 $194.04 $690.99 $690.99 $717.61 $0.00 $194.02 $0.00 $550.69 $550.69 $0.00 $465.50 $737.35 $744.80 $0.00 $0.00 $0.00 $145.70 $0.00 $0.00 $148.22 $0.00 $0.00 $0.00 $0.00 $0.00 27204067 EAP HCPCS C1730 "Eps 4f Quad 5mm Jsn,g2" BOTH IP/OP "$1,031.00 " $762.94 $0.00 $824.80 $559.83 $559.83 $0.00 $0.00 $0.00 $214.89 $765.21 $765.21 $794.69 $0.00 $214.86 $0.00 $609.84 $609.84 $0.00 $515.50 $816.55 $824.80 $0.00 $0.00 $0.00 $161.35 $0.00 $0.00 $164.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204068 EAP HCPCS C1730 "Eps 4f Quad 2mm Jsn,g2" BOTH IP/OP "$1,031.00 " $762.94 $0.00 $824.80 $559.83 $559.83 $0.00 $0.00 $0.00 $214.89 $765.21 $765.21 $794.69 $0.00 $214.86 $0.00 $609.84 $609.84 $0.00 $515.50 $816.55 $824.80 $0.00 $0.00 $0.00 $161.35 $0.00 $0.00 $164.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204069 EAP HCPCS C1730 "Ep 6f Dec 5/5mm 120cm Csl,g2" BOTH IP/OP "$1,087.00 " $804.38 $0.00 $869.60 $590.24 $590.24 $0.00 $0.00 $0.00 $226.56 $806.77 $806.77 $837.86 $0.00 $226.53 $0.00 $642.96 $642.96 $0.00 $543.50 $860.90 $869.60 $0.00 $0.00 $0.00 $170.12 $0.00 $0.00 $173.05 $0.00 $0.00 $0.00 $0.00 $0.00 27204070 EAP HCPCS C1730 "Eps 5f Quad 5mm Crd Superior,g2" BOTH IP/OP $844.00 $624.56 $0.00 $675.20 $458.29 $458.29 $0.00 $0.00 $0.00 $175.91 $626.42 $626.42 $650.56 $0.00 $175.89 $0.00 $499.23 $499.23 $0.00 $422.00 $668.45 $675.20 $0.00 $0.00 $0.00 $132.09 $0.00 $0.00 $134.36 $0.00 $0.00 $0.00 $0.00 $0.00 27204071 EAP HCPCS C1730 "Eps 6f Hex Uni 120cm Jsn X,g2" BOTH IP/OP $931.00 $688.94 $0.00 $744.80 $505.53 $505.53 $0.00 $0.00 $0.00 $194.04 $690.99 $690.99 $717.61 $0.00 $194.02 $0.00 $550.69 $550.69 $0.00 $465.50 $737.35 $744.80 $0.00 $0.00 $0.00 $145.70 $0.00 $0.00 $148.22 $0.00 $0.00 $0.00 $0.00 $0.00 27204072 EAP HCPCS C1730 "Eps 5f Dec 2/8mm 120cm Csl X,g2" BOTH IP/OP "$1,119.00 " $828.06 $0.00 $895.20 $607.62 $607.62 $0.00 $0.00 $0.00 $233.23 $830.52 $830.52 $862.53 $0.00 $233.20 $0.00 $661.89 $661.89 $0.00 $559.50 $886.25 $895.20 $0.00 $0.00 $0.00 $175.12 $0.00 $0.00 $178.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204080 EAP HCPCS C1731 "Epl 7f Duo 2/10 2m 95 S-lgcrl,g2" BOTH IP/OP "$2,932.00 " "$2,169.68" $0.00 "$2,345.60" "$1,592.08" "$1,592.08" $0.00 $0.00 $0.00 $611.10 "$2,176.13" "$2,176.13" "$2,259.99" $0.00 $611.03 $0.00 "$1,734.28" "$1,734.28" $0.00 "$1,466.00" "$2,322.14" "$2,345.60" $0.00 "$1,905.80" $0.00 $458.86 $0.00 $0.00 $466.77 $0.00 $0.00 $0.00 $0.00 $0.00 27204081 EAP Custom 27204081 "Eps Ext Cable B/t/q Blu 150 Us,g2 Supreme Quad Cable" BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204082 EAP HCPCS C1731 "Epl 7f Duo Dec 2/2 115cm Med,g2 ""caterpillar""" BOTH IP/OP "$2,792.00 " "$2,066.08" $0.00 "$2,233.60" "$1,516.06" "$1,516.06" $0.00 $0.00 $0.00 $581.92 "$2,072.22" "$2,072.22" "$2,152.07" $0.00 $581.85 $0.00 "$1,651.47" "$1,651.47" $0.00 "$1,396.00" "$2,211.26" "$2,233.60" $0.00 $0.00 $0.00 $436.95 $0.00 $0.00 $444.49 $0.00 $0.00 $0.00 $0.00 $0.00 27204083 EAP HCPCS C1731 Inquiry Afocusil Diagnostic Catheter 20 Pole With Double Loop BOTH IP/OP "$4,717.00 " "$3,490.58" $0.00 "$3,773.60" "$2,561.33" "$2,561.33" $0.00 $0.00 $0.00 $983.14 "$3,500.96" "$3,500.96" "$3,635.86" $0.00 $983.02 $0.00 "$2,790.11" "$2,790.11" $0.00 "$2,358.50" "$3,735.86" "$3,773.60" $0.00 $0.00 $0.00 $738.21 $0.00 $0.00 $750.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204084 EAP HCPCS C1731 Inquiry AFocus II EB Fixed Radius Loop Circular Mapping Catheter 20 POLE 20MM DIAMETER BOTH IP/OP "$2,979.00 " "$2,204.46" $0.00 "$2,383.20" "$1,617.60" "$1,617.60" $0.00 $0.00 $0.00 $620.90 "$2,211.01" "$2,211.01" "$2,296.21" $0.00 $620.82 $0.00 "$1,762.08" "$1,762.08" $0.00 "$1,489.50" "$2,359.37" "$2,383.20" $0.00 $0.00 $0.00 $466.21 $0.00 $0.00 $474.26 $0.00 $0.00 $0.00 $0.00 $0.00 27204085 EAP HCPCS C1730 Inquiry AFocus II EB Fixed Radius Loop Circular Mapping Catheter 10 POLE 20MM DIAMETER BOTH IP/OP "$2,979.00 " "$2,204.46" $0.00 "$2,383.20" "$1,617.60" "$1,617.60" $0.00 $0.00 $0.00 $620.90 "$2,211.01" "$2,211.01" "$2,296.21" $0.00 $620.82 $0.00 "$1,762.08" "$1,762.08" $0.00 "$1,489.50" "$2,359.37" "$2,383.20" $0.00 $0.00 $0.00 $466.21 $0.00 $0.00 $474.26 $0.00 $0.00 $0.00 $0.00 $0.00 27204086 EAP HCPCS C1730 Inquiry AFocus II EB Fixed Radius Loop Circular Mapping Catheter 10 POLE 15MM DIAMETER BOTH IP/OP "$2,979.00 " "$2,204.46" $0.00 "$2,383.20" "$1,617.60" "$1,617.60" $0.00 $0.00 $0.00 $620.90 "$2,211.01" "$2,211.01" "$2,296.21" $0.00 $620.82 $0.00 "$1,762.08" "$1,762.08" $0.00 "$1,489.50" "$2,359.37" "$2,383.20" $0.00 $0.00 $0.00 $466.21 $0.00 $0.00 $474.26 $0.00 $0.00 $0.00 $0.00 $0.00 27204087 EAP Custom 27204087 Ensite Navx Surface Electrode Kit BOTH IP/OP "$2,948.00 " "$2,181.52" $0.00 "$2,358.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,188.01" "$2,188.01" "$2,272.32" $0.00 $614.36 $0.00 $0.00 $0.00 $0.00 "$1,474.00" "$2,334.82" "$2,358.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204088 EAP Custom 27204088 "Velocity, Assembly, Navx Patch, Ensite" BOTH IP/OP "$2,948.00 " "$2,181.52" $0.00 "$2,358.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,188.01" "$2,188.01" "$2,272.32" $0.00 $614.36 $0.00 $0.00 $0.00 $0.00 "$1,474.00" "$2,334.82" "$2,358.40" $0.00 "$1,916.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204089 EAP Custom 27204089 EnSite Array Catheter - Domestic BOTH IP/OP "$10,553.00 " "$7,809.22" $0.00 "$8,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,134.25" $0.00 "$2,199.25" $0.00 $0.00 $0.00 $0.00 "$5,276.50" "$8,357.98" "$8,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204090 EAP HCPCS C1888 11403001 - KIT PROCEDURE NEVERTOUCLVET L45 CM BOTH IP/OP "$1,197.00 " $885.78 $0.00 $957.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $888.41 $888.41 $922.65 $0.00 $249.45 $0.00 $0.00 $0.00 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204091 EAP HCPCS C1888 11403002 - KIT PROCEDURE NEVERTOUC BOTH IP/OP "$1,197.00 " $885.78 $0.00 $957.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $888.41 $888.41 $922.65 $0.00 $249.45 $0.00 $0.00 $0.00 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204092 EAP Custom 27204092 Coil Detachment Handle BOTH IP/OP $739.00 $546.86 $0.00 $591.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $548.49 $548.49 $569.62 $0.00 $154.01 $0.00 $0.00 $0.00 $0.00 $369.50 $585.29 $591.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204093 EAP Custom 27204093 Quatro Cath Kit BOTH IP/OP "$2,341.00 " "$1,732.34" $0.00 "$1,872.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,737.49" "$1,737.49" "$1,804.44" $0.00 $487.86 $0.00 $0.00 $0.00 $0.00 "$1,170.50" "$1,854.07" "$1,872.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204095 EAP HCPCS C1887 Orion 21 Microcatheter BOTH IP/OP "$2,172.00 " "$1,607.28" $0.00 "$1,737.60" "$1,179.40" "$1,179.40" $0.00 $0.00 $0.00 $452.70 "$1,612.06" "$1,612.06" "$1,674.18" $0.00 $452.64 $0.00 "$1,284.74" "$1,284.74" $0.00 "$1,086.00" "$1,720.22" "$1,737.60" $0.00 "$1,411.80" $0.00 $339.92 $0.00 $0.00 $345.78 $0.00 $0.00 $0.00 $0.00 $0.00 27204096 EAP Custom 27204096 Mini Attachable Catheter 5f BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $0.00 $0.00 $0.00 $295.50 $468.07 $472.80 $0.00 $384.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204097 EAP Custom 27204097 Captivator Snare Large Oval Stiff BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204098 EAP HCPCS C1726 Cre Wg 8-10mm BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $144.44 $144.44 $0.00 $0.00 $0.00 $55.44 $197.43 $197.43 $205.03 $0.00 $55.43 $0.00 $157.34 $157.34 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $41.63 $0.00 $0.00 $42.35 $0.00 $0.00 $0.00 $0.00 $0.00 27204099 EAP HCPCS C1726 Cre Wg 10-12mm BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $144.44 $144.44 $0.00 $0.00 $0.00 $55.44 $197.43 $197.43 $205.03 $0.00 $55.43 $0.00 $157.34 $157.34 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $41.63 $0.00 $0.00 $42.35 $0.00 $0.00 $0.00 $0.00 $0.00 27204100 EAP HCPCS C1726 Cre Wg 12-15mm BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $144.44 $144.44 $0.00 $0.00 $0.00 $55.44 $197.43 $197.43 $205.03 $0.00 $55.43 $0.00 $157.34 $157.34 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $41.63 $0.00 $0.00 $42.35 $0.00 $0.00 $0.00 $0.00 $0.00 27204101 EAP HCPCS C1726 Cre Wf 15-18mm BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $144.44 $144.44 $0.00 $0.00 $0.00 $55.44 $197.43 $197.43 $205.03 $0.00 $55.43 $0.00 $157.34 $157.34 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $41.63 $0.00 $0.00 $42.35 $0.00 $0.00 $0.00 $0.00 $0.00 27204102 EAP HCPCS C1769 Dreamwire .035 260 Str Stnd BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $149.50 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27204103 EAP HCPCS C1769 Glidewire .035 260 Str BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $149.50 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27204105 EAP Custom 27404105 Extractor Rx 9-12 Mm BOTH IP/OP $189.00 $139.86 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $140.28 $140.28 $145.68 $0.00 $39.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $122.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204106 EAP Custom 27204106 Extractor Rx 12-15 Mm BOTH IP/OP $189.00 $139.86 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $140.28 $140.28 $145.68 $0.00 $39.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $122.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204107 EAP Custom 272040107 Cytology Brush BOTH IP/OP $134.00 $99.16 $0.00 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.45 $99.45 $103.29 $0.00 $27.93 $0.00 $0.00 $0.00 $0.00 $67.00 $106.13 $107.20 $0.00 $87.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204108 EAP Custom 27204108 Roth Net BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $68.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204109 EAP Custom 27204109 Fiapc Probe BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.84 $181.84 $188.85 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $122.50 $194.04 $196.00 $0.00 $159.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204110 EAP HCPCS C1757 Solitaire Fr 4x15 BOTH IP/OP "$11,643.00 " "$8,615.82" $0.00 "$9,314.40" "$6,322.15" "$6,322.15" $0.00 $0.00 $0.00 "$2,426.69" "$4,181.12" "$4,181.12" "$8,974.42" $0.00 "$2,426.40" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,821.50" "$9,221.26" "$9,314.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204111 EAP HCPCS C1757 Solitaire Fr 4x20 BOTH IP/OP "$12,225.00 " "$9,046.50" $0.00 "$9,780.00" "$6,638.18" "$6,638.18" $0.00 $0.00 $0.00 "$2,548.00" "$4,181.12" "$4,181.12" "$9,423.03" $0.00 "$2,547.69" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,112.50" "$9,682.20" "$9,780.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204112 EAP HCPCS C1757 Solitaire Fr 6x20 BOTH IP/OP "$11,643.00 " "$8,615.82" $0.00 "$9,314.40" "$6,322.15" "$6,322.15" $0.00 $0.00 $0.00 "$2,426.69" "$4,181.12" "$4,181.12" "$8,974.42" $0.00 "$2,426.40" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,821.50" "$9,221.26" "$9,314.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204113 EAP HCPCS C1757 Solitaire Fr 6x30 BOTH IP/OP "$12,225.00 " "$9,046.50" $0.00 "$9,780.00" "$6,638.18" "$6,638.18" $0.00 $0.00 $0.00 "$2,548.00" "$4,181.12" "$4,181.12" "$9,423.03" $0.00 "$2,547.69" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,112.50" "$9,682.20" "$9,780.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204114 EAP HCPCS C1887 NAVIEN INTRACRANIAL CATHETER 6FX 1 BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $369.24 $369.24 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $524.14 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $442.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 27204115 EAP HCPCS C1887 Navien Intracranial Catheter 6fx 115cm BOTH IP/OP $714.00 $528.36 $0.00 $571.20 $387.70 $387.70 $0.00 $0.00 $0.00 $148.82 $529.93 $529.93 $550.35 $0.00 $148.80 $0.00 $422.33 $422.33 $0.00 $357.00 $565.49 $571.20 $0.00 $464.10 $0.00 $111.74 $0.00 $0.00 $113.67 $0.00 $0.00 $0.00 $0.00 $0.00 27204116 EAP HCPCS C1887 Navien Intracranial Catheter 5fx 115cm BOTH IP/OP "$1,176.00 " $870.24 $0.00 $940.80 $638.57 $638.57 $0.00 $0.00 $0.00 $245.11 $872.83 $872.83 $906.46 $0.00 $245.08 $0.00 $695.60 $695.60 $0.00 $588.00 $931.39 $940.80 $0.00 $764.40 $0.00 $184.04 $0.00 $0.00 $187.22 $0.00 $0.00 $0.00 $0.00 $0.00 27204117 EAP HCPCS C1887 Navien Intracranial Catheter 5fx 125cm BOTH IP/OP "$1,235.00 " $913.90 $0.00 $988.00 $670.61 $670.61 $0.00 $0.00 $0.00 $257.40 $916.62 $916.62 $951.94 $0.00 $257.37 $0.00 $730.50 $730.50 $0.00 $617.50 $978.12 $988.00 $0.00 $802.75 $0.00 $193.28 $0.00 $0.00 $196.61 $0.00 $0.00 $0.00 $0.00 $0.00 27204118 EAP HCPCS C1887 Navien Intracranial Catheter 5fx 130cm BOTH IP/OP "$1,176.00 " $870.24 $0.00 $940.80 $638.57 $638.57 $0.00 $0.00 $0.00 $245.11 $872.83 $872.83 $906.46 $0.00 $245.08 $0.00 $695.60 $695.60 $0.00 $588.00 $931.39 $940.80 $0.00 $0.00 $0.00 $184.04 $0.00 $0.00 $187.22 $0.00 $0.00 $0.00 $0.00 $0.00 27204119 EAP HCPCS C2629 Pinnacle Rdc Sheath 6fr BOTH IP/OP "$2,374.00 " "$1,756.76" $0.00 "$1,899.20" $0.00 $0.00 $0.00 $0.00 $0.00 $494.80 "$1,761.98" "$1,761.98" "$1,829.88" $0.00 $494.74 $0.00 "$1,404.22" "$1,404.22" $0.00 "$1,187.00" "$1,880.21" "$1,899.20" $0.00 "$1,543.10" $0.00 $371.53 $0.00 $0.00 $377.94 $0.00 $0.00 $0.00 $0.00 $0.00 27204120 EAP Custom 27204120 Tc Catheter BOTH IP/OP $151.00 $111.74 $0.00 $120.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.07 $112.07 $116.39 $0.00 $31.47 $0.00 $0.00 $0.00 $0.00 $75.50 $119.59 $120.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204121 EAP HCPCS C1887 Van Aman Cathter BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $30.41 $30.41 $0.00 $0.00 $0.00 $11.67 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $33.12 $33.12 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $8.76 $0.00 $0.00 $8.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204122 EAP HCPCS C1894 Neuron Max 088 6f Sheath BOTH IP/OP "$1,226.00 " $907.24 $0.00 $980.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $613.00 $970.99 $980.80 $0.00 $0.00 $0.00 $191.87 $0.00 $0.00 $195.18 $0.00 $0.00 $0.00 $0.00 $0.00 27204124 EAP HCPCS C1788 Dignity Port 6.6f BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $325.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27204125 EAP Custom 27204125 Long Rodch Left Gastric Catheter 5fr 65cm BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204126 EAP Custom 27204126 Long Rodch Left Gastric Catheter 5fr 80cm BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204127 EAP HCPCS C1769 Avigo Guidewire BOTH IP/OP "$1,168.00 " $864.32 $0.00 $934.40 $634.22 $634.22 $0.00 $0.00 $0.00 $243.44 $866.89 $866.89 $900.29 $0.00 $243.41 $0.00 $690.87 $690.87 $0.00 $584.00 $925.06 $934.40 $0.00 $0.00 $0.00 $182.79 $0.00 $0.00 $185.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204128 EAP HCPCS C1887 Exceisior Xt-27 Microcatheter 135cm/6cm Straight BOTH IP/OP "$2,807.00 " "$2,077.18" $0.00 "$2,245.60" "$1,524.20" "$1,524.20" $0.00 $0.00 $0.00 $585.05 "$2,083.36" "$2,083.36" "$2,163.64" $0.00 $584.98 $0.00 "$1,660.34" "$1,660.34" $0.00 "$1,403.50" "$2,223.14" "$2,245.60" $0.00 $0.00 $0.00 $439.30 $0.00 $0.00 $446.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204129 EAP HCPCS C1887 Exceisior Xt-27 Microcatheter 135cm/6cm Pre-shaped BOTH IP/OP "$2,807.00 " "$2,077.18" $0.00 "$2,245.60" "$1,524.20" "$1,524.20" $0.00 $0.00 $0.00 $585.05 "$2,083.36" "$2,083.36" "$2,163.64" $0.00 $584.98 $0.00 "$1,660.34" "$1,660.34" $0.00 "$1,403.50" "$2,223.14" "$2,245.60" $0.00 $0.00 $0.00 $439.30 $0.00 $0.00 $446.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204130 EAP HCPCS C1887 Exceisior Xt-27 Microcatheter 150 Cm/80cm Straight BOTH IP/OP "$2,807.00 " "$2,077.18" $0.00 "$2,245.60" "$1,524.20" "$1,524.20" $0.00 $0.00 $0.00 $585.05 "$2,083.36" "$2,083.36" "$2,163.64" $0.00 $584.98 $0.00 "$1,660.34" "$1,660.34" $0.00 "$1,403.50" "$2,223.14" "$2,245.60" $0.00 "$1,824.55" $0.00 $439.30 $0.00 $0.00 $446.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204131 EAP HCPCS C1887 Exceisior Xt-27 Microcatheter 150cm/18cm Straight BOTH IP/OP "$2,807.00 " "$2,077.18" $0.00 "$2,245.60" "$1,524.20" "$1,524.20" $0.00 $0.00 $0.00 $585.05 "$2,083.36" "$2,083.36" "$2,163.64" $0.00 $584.98 $0.00 "$1,660.34" "$1,660.34" $0.00 "$1,403.50" "$2,223.14" "$2,245.60" $0.00 "$1,824.55" $0.00 $439.30 $0.00 $0.00 $446.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204132 EAP HCPCS C1887 Exceisior Xt-27 Microcatheter 135cm/6cm Pre-shaped BOTH IP/OP "$2,807.00 " "$2,077.18" $0.00 "$2,245.60" "$1,524.20" "$1,524.20" $0.00 $0.00 $0.00 $585.05 "$2,083.36" "$2,083.36" "$2,163.64" $0.00 $584.98 $0.00 "$1,660.34" "$1,660.34" $0.00 "$1,403.50" "$2,223.14" "$2,245.60" $0.00 $0.00 $0.00 $439.30 $0.00 $0.00 $446.87 $0.00 $0.00 $0.00 $0.00 $0.00 27204140 EAP Custom 27204140 Kit Catheter Presep Oligon Heparin L16 Cm Od8.5 Fr Centl BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204141 EAP Custom 27204141 Kit Catheter Presep Oligon L20 Cm Od8.5 Fr Arterial 3 Ln BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204142 EAP HCPCS C1894 Introd Shth 8fr 150cm 12cm 2 Distal Gwire Hmst Vlv Sdprt BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $30.41 $30.41 $0.00 $0.00 $0.00 $11.67 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $33.12 $33.12 $0.00 $28.00 $44.35 $44.80 $0.00 $0.00 $0.00 $8.76 $0.00 $0.00 $8.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204143 EAP HCPCS C1894 Introd Shth 9fr 150cm 12cm 2 Distal Gwire Hmst Vlv Sdprt BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $34.21 $34.21 $0.00 $0.00 $0.00 $13.13 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $37.26 $37.26 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $9.86 $0.00 $0.00 $10.03 $0.00 $0.00 $0.00 $0.00 $0.00 27204144 EAP HCPCS C1894 Introd Cath 12cm 10fr .038in Trnspt Fstcth Hmsts BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $38.01 $38.01 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $53.96 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204145 EAP HCPCS C1893 Introd Shth 8.5fr 180cm 63cm Superstiff Guiewire Guid Braid BOTH IP/OP $532.00 $393.68 $0.00 $425.60 $288.88 $288.88 $0.00 $0.00 $0.00 $110.88 $394.85 $394.85 $410.07 $0.00 $110.87 $0.00 $314.68 $314.68 $0.00 $266.00 $421.34 $425.60 $0.00 $0.00 $0.00 $83.26 $0.00 $0.00 $84.69 $0.00 $0.00 $0.00 $0.00 $0.00 27204146 EAP Custom 27204146 Needle 71cm 18ga Curve Prc Trnspt Brk-1 Adlt BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.51 $427.51 $443.98 $0.00 $120.04 $0.00 $0.00 $0.00 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204147 EAP HCPCS C1766 Introd Shth 8.5fr 91cm 71cm Dual Reach Bidir Erg Hndl Atrm BOTH IP/OP "$2,642.00 " "$1,955.08" $0.00 "$2,113.60" "$1,434.61" "$1,434.61" $0.00 $0.00 $0.00 $550.66 "$1,960.89" "$1,960.89" "$2,036.45" $0.00 $550.59 $0.00 "$1,562.74" "$1,562.74" $0.00 "$1,321.00" "$2,092.46" "$2,113.60" $0.00 "$1,717.30" $0.00 $413.47 $0.00 $0.00 $420.61 $0.00 $0.00 $0.00 $0.00 $0.00 27204148 EAP HCPCS C1766 Introd Shth 8.5fr 71cm 50mm Strbl Erg Hndl Atrm Tip Intgr BOTH IP/OP "$2,642.00 " "$1,955.08" $0.00 "$2,113.60" "$1,434.61" "$1,434.61" $0.00 $0.00 $0.00 $550.66 "$1,960.89" "$1,960.89" "$2,036.45" $0.00 $550.59 $0.00 "$1,562.74" "$1,562.74" $0.00 "$1,321.00" "$2,092.46" "$2,113.60" $0.00 "$1,717.30" $0.00 $413.47 $0.00 $0.00 $420.61 $0.00 $0.00 $0.00 $0.00 $0.00 27204149 EAP HCPCS C1730 Cable Cath Blue 150cm Rspn Ep Bipol Trplr Qdpl BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $106.50 $168.70 $170.40 $0.00 $0.00 $0.00 $33.33 $0.00 $0.00 $33.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204150 EAP Custom 27204150 Cable Cath Blk 150cm Rspn Ep Hexpl BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $146.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204151 EAP Custom 27204151 Cable Cath Blk 150cm Rspn Ep Hexpl Octpl Dcapl BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204152 EAP Custom 27204152 Cable Cath Red 150cm Rspn Ep Hexpl Octpl Dcapl Extn BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.43 $197.43 $205.03 $0.00 $55.43 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204153 EAP HCPCS C1730 Cath Ep 2-5-2mm Spc 1mm 6fr 115cm 4mm Qdpl Med Swp Strbl BOTH IP/OP "$1,490.00 " "$1,102.60" $0.00 "$1,192.00" $809.07 $809.07 $0.00 $0.00 $0.00 $310.55 "$1,105.88" "$1,105.88" "$1,148.49" $0.00 $310.52 $0.00 $881.34 $881.34 $0.00 $745.00 "$1,180.08" "$1,192.00" $0.00 $968.50 $0.00 $233.19 $0.00 $0.00 $237.21 $0.00 $0.00 $0.00 $0.00 $0.00 27204154 EAP HCPCS C1730 Cath Ep 5mm Spc 1mm 5fr 115cm 2mm Hexpl Med Swp Strbl Lvwr BOTH IP/OP "$1,608.00 " "$1,189.92" $0.00 "$1,286.40" $873.14 $873.14 $0.00 $0.00 $0.00 $335.15 "$1,193.46" "$1,193.46" "$1,239.45" $0.00 $335.11 $0.00 $951.13 $951.13 $0.00 $804.00 "$1,273.54" "$1,286.40" $0.00 "$1,045.20" $0.00 $251.65 $0.00 $0.00 $255.99 $0.00 $0.00 $0.00 $0.00 $0.00 27204155 EAP HCPCS C1730 Cath Ep 4mm Spc 7fr 20mm 110cm 20 Eltrd Mp Inq Afocus 2 BOTH IP/OP "$4,493.00 " "$3,324.82" $0.00 "$3,594.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,246.50" "$3,558.46" "$3,594.40" $0.00 $0.00 $0.00 $703.15 $0.00 $0.00 $715.29 $0.00 $0.00 $0.00 $0.00 $0.00 27204156 EAP HCPCS C1731 Cath Ep 99cm 7fr 15-25mm Reflexion Sprl 1-4-1mm Spc 1mm Smtr BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204157 EAP Custom 27204157 Cable Cath Safire Ep Gntr Intfc BOTH IP/OP $449.00 $332.26 $0.00 $359.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.25 $333.25 $346.09 $0.00 $93.57 $0.00 $0.00 $0.00 $0.00 $224.50 $355.61 $359.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204158 EAP Custom 27204158 Cable Cath Safire Ep Extn BOTH IP/OP $461.00 $341.14 $0.00 $368.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.15 $342.15 $355.34 $0.00 $96.07 $0.00 $0.00 $0.00 $0.00 $230.50 $365.11 $368.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204159 EAP HCPCS C2630 Cath Ablt 110cm 7fr 4mm 2-5-2mm Spc 2mm Med Curl Thrp Cl Pth BOTH IP/OP "$4,493.00 " "$3,324.82" $0.00 "$3,594.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,246.50" "$3,558.46" "$3,594.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204160 EAP HCPCS C2630 Cath Ablt 110cm 7fr 4mm 2-5-2mm Spc 2mm Lg Curl Thrp Cl Pth BOTH IP/OP "$4,493.00 " "$3,324.82" $0.00 "$3,594.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,246.50" "$3,558.46" "$3,594.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204161 EAP HCPCS C1759 Cath Us 120d Intrcrd Stab 1 Hnd Cntrl M Mode Pls Wv Dplr Ice BOTH IP/OP "$6,242.00 " "$4,619.08" $0.00 "$4,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,121.00" "$4,943.66" "$4,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204162 EAP HCPCS C1730 Cath Ep 2-5-2mm Spc Csl Curve 5fr 65cm Mp Dcapl Fix Curve BOTH IP/OP "$1,183.00 " $875.42 $0.00 $946.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.50 $936.94 $946.40 $0.00 $0.00 $0.00 $185.14 $0.00 $0.00 $188.33 $0.00 $0.00 $0.00 $0.00 $0.00 27204164 EAP HCPCS C1887 Catheter Reperfusion BOTH IP/OP "$6,176.00 " "$4,570.24" $0.00 "$4,940.80" "$3,353.57" "$3,353.57" $0.00 $0.00 $0.00 "$1,287.23" "$4,181.12" "$4,181.12" "$4,760.46" $0.00 "$1,287.08" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,088.00" "$4,891.39" "$4,940.80" $0.00 "$4,014.40" $0.00 $966.54 $0.00 $0.00 $983.22 $0.00 $0.00 $0.00 $0.00 $0.00 27204168 EAP HCPCS C1894 Flexor Ansel Guiding Sheath/ Str BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $161.20 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27204169 EAP HCPCS C1894 Flexor Ansel Guiding Sheath/ Mp BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $0.00 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27204170 EAP HCPCS C1894 Introducer Shth 10 Fr/ 40cm BOTH IP/OP $216.00 $159.84 $0.00 $172.80 $117.29 $117.29 $0.00 $0.00 $0.00 $45.02 $160.32 $160.32 $166.49 $0.00 $45.01 $0.00 $127.76 $127.76 $0.00 $108.00 $171.07 $172.80 $0.00 $0.00 $0.00 $33.80 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $0.00 27204171 EAP HCPCS C1887 Catheter Angio Sim 3 Crv 5fr BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $66.79 $66.79 $0.00 $0.00 $0.00 $25.64 $91.29 $91.29 $94.81 $0.00 $25.63 $0.00 $72.75 $72.75 $0.00 $61.50 $97.42 $98.40 $0.00 $79.95 $0.00 $19.25 $0.00 $0.00 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 27204210 EAP HCPCS C1769 Guidewire Vascular X-celer Hydro L300 Cm L10 Cm Od.01 BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $529.43 $529.43 $0.00 $0.00 $0.00 $203.21 $723.65 $723.65 $751.53 $0.00 $203.19 $0.00 $576.71 $576.71 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $0.00 $152.59 $0.00 $0.00 $155.22 $0.00 $0.00 $0.00 $0.00 $0.00 27204211 EAP HCPCS C2629 Set Introducer Aprima Hydrophilic L15 Cm Od6 Fr Odsec22a BOTH IP/OP $212.00 $156.88 $0.00 $169.60 $0.00 $0.00 $0.00 $0.00 $0.00 $44.19 $157.35 $157.35 $163.41 $0.00 $44.18 $0.00 $125.40 $125.40 $0.00 $106.00 $167.90 $169.60 $0.00 $0.00 $0.00 $33.18 $0.00 $0.00 $33.75 $0.00 $0.00 $0.00 $0.00 $0.00 27204212 EAP Custom 27204212 Biotronik Lead Delivery System BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $0.00 $0.00 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204213 EAP HCPCS C1751 Cath Cen Ven 4fr 1 Lum Try 3cg Shrlk Sty Maximal Brr Pip BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 27204214 EAP HCPCS C1769 Gwire Vasc .035in 15mm 260cm 4cm 2 Cvd Exch Xstif Lndrqs Ss BOTH IP/OP $620.00 $458.80 $0.00 $496.00 $336.66 $336.66 $0.00 $0.00 $0.00 $129.22 $460.16 $460.16 $477.90 $0.00 $129.21 $0.00 $366.73 $366.73 $0.00 $310.00 $491.04 $496.00 $0.00 $403.00 $0.00 $97.03 $0.00 $0.00 $98.70 $0.00 $0.00 $0.00 $0.00 $0.00 27204216 EAP Custom 27204216 Site-rite 6 Ultrasound System 21 Ga Needle Guide Kit BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204217 EAP HCPCS C1894 Micro Microintruducer 7cm 5.0fr Flecura Guidewire BOTH IP/OP $98.00 $72.52 $0.00 $78.40 $53.21 $53.21 $0.00 $0.00 $0.00 $20.43 $72.74 $72.74 $75.54 $0.00 $20.42 $0.00 $57.97 $57.97 $0.00 $49.00 $77.62 $78.40 $0.00 $0.00 $0.00 $15.34 $0.00 $0.00 $15.60 $0.00 $0.00 $0.00 $0.00 $0.00 27204218 EAP HCPCS C1726 Balloon Dilatation Catheter 6mmx40mmx135cm BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $298.65 $298.65 $0.00 $0.00 $0.00 $114.63 $408.21 $408.21 $423.94 $0.00 $114.62 $0.00 $325.33 $325.33 $0.00 $275.00 $435.60 $440.00 $0.00 $357.50 $0.00 $86.08 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 27204220 EAP HCPCS C1769 Sphntm 30mm 5mm 3.9fr Atme Bil Pncr Gwire Cann Chnl C Md BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$2,407.12" "$2,407.12" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,622.12" "$2,622.12" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204221 EAP HCPCS C1887 CATH GUID CS-A6 CURVE 8FR 49CM CORON SIN OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204222 EAP HCPCS C1887 CATH GUID CS-A6 CURVE 8FR 54CM CORON SIN OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204223 EAP HCPCS C1887 CATH GUID CS-EH CURVE 8FR 49CM OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204224 EAP HCPCS C1887 CATH GUID OUTR ACTY BRKWY CS-EH 61CM 8FR BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204225 EAP HCPCS C1887 CATH GUID CS-H CURVE 8FR 6.78FR 55CM 49CM IS-1 AND LV-1 LEAD BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204226 EAP HCPCS C1887 CATH GUID CS-H CURVE 8FR 54CM CORON SIN OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204227 EAP HCPCS C1887 CATH GUID 130D CS-IC CURVE 6FR 63CM INR ACTY BRKWY BOTH IP/OP $461.00 $341.14 $0.00 $368.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.50 $365.11 $368.80 $0.00 $0.00 $0.00 $72.15 $0.00 $0.00 $73.39 $0.00 $0.00 $0.00 $0.00 $0.00 27204228 EAP HCPCS C1894 INTROD LEAD BL CODE 9.7% HE 21% OZ 27% CO 42.35% N2 BOTH IP/OP "$2,660.00 " "$1,968.40" $0.00 "$2,128.00" "$1,444.38" "$1,444.38" $0.00 $0.00 $0.00 $554.41 "$1,974.25" "$1,974.25" "$2,050.33" $0.00 $554.34 $0.00 "$1,573.39" "$1,573.39" $0.00 "$1,330.00" "$2,106.72" "$2,128.00" $0.00 $0.00 $0.00 $416.29 $0.00 $0.00 $423.47 $0.00 $0.00 $0.00 $0.00 $0.00 27204229 EAP HCPCS C1769 CATH ENDSCP 8.5FR NSL BIL GWIRE STRL BOTH IP/OP "$1,463.00 " "$1,082.62" $0.00 "$1,170.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $731.50 "$1,158.70" "$1,170.40" $0.00 $0.00 $0.00 $228.96 $0.00 $0.00 $232.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204230 EAP HCPCS C1769 CATH ENDSCP 7.5FR NSL BIL GWIRE STRL BOTH IP/OP "$1,463.00 " "$1,082.62" $0.00 "$1,170.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $731.50 "$1,158.70" "$1,170.40" $0.00 $0.00 $0.00 $228.96 $0.00 $0.00 $232.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204231 EAP HCPCS C1887 CATH GUID CS-MP CURVE 8FR 49CM CORON SIN OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204232 EAP HCPCS C1887 CATH GUID CS-MP 8FR 54CM 61CM OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204233 EAP HCPCS C1887 CATH GUID STR 8FR 49CM CORON SIN OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204234 EAP HCPCS C1887 CATH GUID CS-ST CURVE 8FR 54CM CORON SIN OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204235 EAP HCPCS C1887 CATH GUID CS-EH ST R CURVE 8FR 49CM CORON SIN OUTR ACTY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204236 EAP HCPCS C1887 CATH GUID CS-EH ST R CURVE 8FR 54CM OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204237 EAP HCPCS C1887 CATH GUID CS-W CURVE 8FR 49CM CORON SIN OUTR ACTY BRKWY BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $164.79 $0.00 $0.00 $167.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204238 EAP HCPCS C1769 CATH ENDSCP 6FR NSL BIL GWIRE STRL BOTH IP/OP "$1,463.00 " "$1,082.62" $0.00 "$1,170.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $731.50 "$1,158.70" "$1,170.40" $0.00 $0.00 $0.00 $228.96 $0.00 $0.00 $232.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204239 EAP HCPCS C1887 ACUITY CUTAWAY LEAD DELIVERY SYSTEM - PERCUTANEOUS CATHETERS BOTH IP/OP "$5,010.00 " "$3,707.40" $0.00 "$4,008.00" "$2,720.43" "$2,720.43" $0.00 $0.00 $0.00 "$1,044.21" "$3,718.42" "$3,718.42" "$3,861.71" $0.00 "$1,044.08" $0.00 "$2,963.42" "$2,963.42" $0.00 "$2,505.00" "$3,967.92" "$4,008.00" $0.00 "$3,256.50" $0.00 $784.07 $0.00 $0.00 $797.59 $0.00 $0.00 $0.00 $0.00 $0.00 27204240 EAP HCPCS C1769 SPHNTM 20MM 7-5FR BIL PNCR GWIRE 3 LUM SHRT NOSE CANN RAPEX BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$2,407.12" "$2,407.12" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,622.12" "$2,622.12" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204241 EAP Custom 27204241 DEVICE LCK BIOP CAP RAPEX RX BL BIL PNTX ESCP BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 $0.00 $0.00 $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204242 EAP HCPCS C1725 CATH BIL 12 ATM 5.8FR 8MM 180CM 2CM RAPEX NVSC BALDILAT HRCN BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $941.03 $0.00 $0.00 $0.00 $0.00 $0.00 27204243 EAP HCPCS C1769 Sphntm 30mm 5mm 4.4fr Atme Rx BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$2,407.12" "$2,407.12" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,622.12" "$2,622.12" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204245 EAP HCPCS C1725 Mustang Balloon Catheter 3.0mm X 20mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204246 EAP HCPCS C1725 Mustang Balloon Catheter 3.0mm X 40mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204247 EAP HCPCS C1725 Mustang Balloon Catheter 4.0mm X 20mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204248 EAP HCPCS C1725 Mustang Balloon Catheter 4.0mm X 40mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204249 EAP HCPCS C1725 Mustang Balloon Catheter 4.0mm X 80mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204250 EAP HCPCS C1887 Cxi Support Catheter Str / 2.6fr-.018-150cm BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $272.04 $272.04 $0.00 $0.00 $0.00 $104.42 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $296.34 $296.34 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $78.41 $0.00 $0.00 $79.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204251 EAP HCPCS C1725 Cxi Support Catheter Ang/ 2.6fr-.018-150cm BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $272.04 $272.04 $0.00 $0.00 $0.00 $104.42 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $296.34 $296.34 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $78.41 $0.00 $0.00 $79.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204252 EAP HCPCS C1887 Cxi Support Catheter Str/ 4.0fr-.035-135cm BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $78.41 $0.00 $0.00 $79.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204253 EAP HCPCS C1725 Mustang Balloon Catheter 6.0mm X 80mm X 135cm BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $272.04 $272.04 $0.00 $0.00 $0.00 $104.42 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $296.34 $296.34 $0.00 $250.50 $396.79 $400.80 $0.00 $325.65 $0.00 $78.41 $0.00 $0.00 $79.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204254 EAP HCPCS C1725 Mustang Balloon Catheter 6.0mm X 100mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204255 EAP HCPCS C1725 Mustang Balloon Catheter 6.0mm X 120mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204256 EAP HCPCS C1725 Mustang Balloon Catheter 6.0mm X 150mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204257 EAP HCPCS C1725 Mustang Balloon Catheter 6.0mm X 220mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204258 EAP HCPCS C1725 Mustang Balloon Catheter 7.0mm X 40mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204259 EAP HCPCS C1725 Mustang Balloon Catheter 8.0mm X 40mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204260 EAP HCPCS C1725 Mustang Balloon Catheter 9.0mm X 40mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204261 EAP HCPCS C1725 Mustang Balloon Catheter 5.0mm X 40mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204262 EAP HCPCS C1725 Mustang Balloon Catheter 5.0mm X 100mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204263 EAP HCPCS C1725 Mustang Balloon Catheter 6.0mm X 40mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204270 EAP HCPCS C1725 Mustang Balloon Catheter 10.0mm X 40mm X 135cm BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $297.56 $297.56 $0.00 $0.00 $0.00 $114.22 $406.73 $406.73 $422.40 $0.00 $114.20 $0.00 $324.14 $324.14 $0.00 $274.00 $434.02 $438.40 $0.00 $356.20 $0.00 $85.76 $0.00 $0.00 $87.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204280 EAP HCPCS C1755 Kyphopast First Fracture Kit-kpe1003 BOTH IP/OP "$10,626.00 " "$7,863.24" $0.00 "$8,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,190.52" $0.00 "$2,214.46" $0.00 $0.00 $0.00 $0.00 "$5,313.00" "$8,415.79" "$8,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204281 EAP HCPCS C1755 Kyphopasty Additonal Fracture Kit-kpe1003 BOTH IP/OP "$7,079.00 " "$5,238.46" $0.00 "$5,663.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,456.49" $0.00 "$1,475.26" $0.00 $0.00 $0.00 $0.00 "$3,539.50" "$5,606.57" "$5,663.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204282 EAP HCPCS C1713 Kyphoplasty Cememnt Mixer-a07a BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $128.69 $128.69 $0.00 $0.00 $0.00 $49.40 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $140.19 $140.19 $0.00 $118.50 $187.70 $189.60 $0.00 $0.00 $0.00 $37.09 $0.00 $0.00 $37.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204283 EAP HCPCS C1713 Kyphoasty Activos Cement-c10a BOTH IP/OP $901.00 $666.74 $0.00 $720.80 $489.24 $489.24 $0.00 $0.00 $0.00 $187.79 $668.72 $668.72 $694.49 $0.00 $187.77 $0.00 $532.94 $532.94 $0.00 $450.50 $713.59 $720.80 $0.00 $0.00 $0.00 $141.01 $0.00 $0.00 $143.44 $0.00 $0.00 $0.00 $0.00 $0.00 27204284 EAP HCPCS C1884 Rx Emosheild Nav6 5.0 Mm BOTH IP/OP "$4,581.00 " "$3,389.94" $0.00 "$3,664.80" "$2,487.48" "$2,487.48" $0.00 $0.00 $0.00 $954.79 "$3,400.02" "$3,400.02" "$3,531.03" $0.00 $954.68 $0.00 "$2,709.66" "$2,709.66" $0.00 "$2,290.50" "$3,628.15" "$3,664.80" $0.00 $0.00 $0.00 $716.93 $0.00 $0.00 $729.30 $0.00 $0.00 $0.00 $0.00 $0.00 27204286 EAP HCPCS C1884 Rx Embosheild Nav6 7.2 Mm BOTH IP/OP "$4,581.00 " "$3,389.94" $0.00 "$3,664.80" "$2,487.48" "$2,487.48" $0.00 $0.00 $0.00 $954.79 "$3,400.02" "$3,400.02" "$3,531.03" $0.00 $954.68 $0.00 "$2,709.66" "$2,709.66" $0.00 "$2,290.50" "$3,628.15" "$3,664.80" $0.00 $0.00 $0.00 $716.93 $0.00 $0.00 $729.30 $0.00 $0.00 $0.00 $0.00 $0.00 27204292 EAP HCPCS C1769 Guidewire X-pedion-10 Re 2 BOTH IP/OP $778.00 $575.72 $0.00 $622.40 $422.45 $422.45 $0.00 $0.00 $0.00 $162.15 $577.43 $577.43 $599.68 $0.00 $162.14 $0.00 $460.19 $460.19 $0.00 $389.00 $616.18 $622.40 $0.00 $505.70 $0.00 $121.76 $0.00 $0.00 $123.86 $0.00 $0.00 $0.00 $0.00 $0.00 27204293 EAP HCPCS C1769 Mirage Re .008 BOTH IP/OP "$1,288.00 " $953.12 $0.00 "$1,030.40" $699.38 $699.38 $0.00 $0.00 $0.00 $268.45 $955.95 $955.95 $992.79 $0.00 $268.42 $0.00 $761.85 $761.85 $0.00 $644.00 "$1,020.10" "$1,030.40" $0.00 $837.20 $0.00 $201.57 $0.00 $0.00 $205.05 $0.00 $0.00 $0.00 $0.00 $0.00 27204294 EAP HCPCS C1887 Catheter Marathon BOTH IP/OP "$1,861.00 " "$1,377.14" $0.00 "$1,488.80" "$1,010.52" "$1,010.52" $0.00 $0.00 $0.00 $387.88 "$1,381.23" "$1,381.23" "$1,434.46" $0.00 $387.83 $0.00 "$1,100.78" "$1,100.78" $0.00 $930.50 "$1,473.91" "$1,488.80" $0.00 $0.00 $0.00 $291.25 $0.00 $0.00 $296.27 $0.00 $0.00 $0.00 $0.00 $0.00 27204295 EAP HCPCS C1757 Cath Thrmb 130cm 4.3fr .044in Dac Multitransition Radio Pq BOTH IP/OP "$2,941.00 " "$2,176.34" $0.00 "$2,352.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.50" "$2,329.27" "$2,352.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204298 EAP HCPCS C1894 Sheath Long Neuronmax 90/4 Mp 6f 088 BOTH IP/OP "$1,109.00 " $820.66 $0.00 $887.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.50 $878.33 $887.20 $0.00 $0.00 $0.00 $173.56 $0.00 $0.00 $176.55 $0.00 $0.00 $0.00 $0.00 $0.00 27204299 EAP Custom 27204299 Turnpike Catheter Lp 135cm BOTH IP/OP "$1,313.00 " $971.62 $0.00 "$1,050.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $974.51 $974.51 "$1,012.06" $0.00 $273.63 $0.00 $0.00 $0.00 $0.00 $656.50 "$1,039.90" "$1,050.40" $0.00 $853.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204300 EAP Custom 27204300 Torque Delivery System 10 Fr BOTH IP/OP "$1,797.00 " "$1,329.78" $0.00 "$1,437.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.73" "$1,333.73" "$1,385.13" $0.00 $374.49 $0.00 $0.00 $0.00 $0.00 $898.50 "$1,423.22" "$1,437.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204301 EAP Custom 27204301 Spider Standard Surgical Platform BOTH IP/OP "$1,034.00 " $765.16 $0.00 $827.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $767.43 $767.43 $797.01 $0.00 $215.49 $0.00 $0.00 $0.00 $0.00 $517.00 $818.93 $827.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204302 EAP HCPCS C1884 System Embolic Spiderfx.014 In L320 Cm BOTH IP/OP "$4,124.00 " "$3,051.76" $0.00 "$3,299.20" "$2,239.33" "$2,239.33" $0.00 $0.00 $0.00 $859.54 "$3,060.83" "$3,060.83" "$3,178.78" $0.00 $859.44 $0.00 "$2,439.35" "$2,439.35" $0.00 "$2,062.00" "$3,266.21" "$3,299.20" $0.00 $0.00 $0.00 $645.41 $0.00 $0.00 $656.54 $0.00 $0.00 $0.00 $0.00 $0.00 27204303 EAP HCPCS C1725 Cath Ball Dilatation Viatrac 14 Plus Xcelon .014 In L BOTH IP/OP $739.00 $546.86 $0.00 $591.20 $401.28 $401.28 $0.00 $0.00 $0.00 $154.03 $548.49 $548.49 $569.62 $0.00 $154.01 $0.00 $437.12 $437.12 $0.00 $369.50 $585.29 $591.20 $0.00 $480.35 $0.00 $115.65 $0.00 $0.00 $117.65 $0.00 $0.00 $0.00 $0.00 $0.00 27204304 EAP HCPCS C1894 Sheath Check-flo Flexor .035 In L55 Cm Od6 Fr Multi BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $36.92 $36.92 $0.00 $0.00 $0.00 $14.17 $50.47 $50.47 $52.41 $0.00 $14.17 $0.00 $40.22 $40.22 $0.00 $34.00 $53.86 $54.40 $0.00 $0.00 $0.00 $10.64 $0.00 $0.00 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 27204305 EAP HCPCS C1894 Sheath Check-flo Flexor .035 In L55 Cm Od6 Fr Curv Strat BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204306 EAP HCPCS C1887 Cath Cxi Stainless Steel Polymer L135 Cm Od4 Fr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204307 EAP HCPCS C1769 Guidewire Vas Pt Graph Hydro Poly Straight BOTH IP/OP "$2,572.00 " "$1,903.28" $0.00 "$2,057.60" "$1,396.60" "$1,396.60" $0.00 $0.00 $0.00 $536.07 "$1,908.94" "$1,908.94" "$1,982.50" $0.00 $536.00 $0.00 "$1,521.34" "$1,521.34" $0.00 "$1,286.00" "$2,037.02" "$2,057.60" $0.00 $0.00 $0.00 $402.52 $0.00 $0.00 $409.46 $0.00 $0.00 $0.00 $0.00 $0.00 27204308 EAP HCPCS C1769 Guidewire Vascular Pt Graphix Hydro Polymer J L300 Cm BOTH IP/OP "$2,572.00 " "$1,903.28" $0.00 "$2,057.60" "$1,396.60" "$1,396.60" $0.00 $0.00 $0.00 $536.07 "$1,908.94" "$1,908.94" "$1,982.50" $0.00 $536.00 $0.00 "$1,521.34" "$1,521.34" $0.00 "$1,286.00" "$2,037.02" "$2,057.60" $0.00 $0.00 $0.00 $402.52 $0.00 $0.00 $409.46 $0.00 $0.00 $0.00 $0.00 $0.00 27204309 EAP HCPCS C2628 Transform Compliant 3mm X 10mm BOTH IP/OP "$4,222.00 " "$3,124.28" $0.00 "$3,377.60" "$2,292.55" "$2,292.55" $0.00 $0.00 $0.00 $879.97 "$3,133.57" "$3,133.57" "$3,254.32" $0.00 $879.86 $0.00 "$2,497.31" "$2,497.31" $0.00 "$2,111.00" "$3,343.82" "$3,377.60" $0.00 "$2,744.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204310 EAP HCPCS C2628 Transform Compliant 3mm X 15mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 "$2,613.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204311 EAP HCPCS C2628 Transform Compliant 4mm X 10mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 "$2,613.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204312 EAP HCPCS C2628 Transform Compliant 4mm X 15mm BOTH IP/OP "$4,222.00 " "$3,124.28" $0.00 "$3,377.60" "$2,292.55" "$2,292.55" $0.00 $0.00 $0.00 $879.97 "$3,133.57" "$3,133.57" "$3,254.32" $0.00 $879.86 $0.00 "$2,497.31" "$2,497.31" $0.00 "$2,111.00" "$3,343.82" "$3,377.60" $0.00 "$2,744.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204313 EAP HCPCS C2628 Transform Compliant 4mm X 20mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204314 EAP HCPCS C2628 Transform Compliant 4mm X 30mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204315 EAP HCPCS C2628 Transform Compliant 5mm X 10mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204316 EAP HCPCS C2628 TransForm Compliant 5mm x 10mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204317 EAP HCPCS C2628 Transform Compliant 5mm X 20mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204318 EAP HCPCS C2628 Transform Compliant 5mm X 30mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204319 EAP HCPCS C2628 Transform Super Compliant 3mm X 5mm BOTH IP/OP "$4,222.00 " "$3,124.28" $0.00 "$3,377.60" "$2,292.55" "$2,292.55" $0.00 $0.00 $0.00 $879.97 "$3,133.57" "$3,133.57" "$3,254.32" $0.00 $879.86 $0.00 "$2,497.31" "$2,497.31" $0.00 "$2,111.00" "$3,343.82" "$3,377.60" $0.00 "$2,744.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204320 EAP HCPCS C2628 Transform Super Compliant 4mm X 10mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204321 EAP HCPCS C2628 Transform Super Compliant 4mm X 7mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 "$2,613.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204322 EAP HCPCS C2628 Transform Super Compliant 7mm X 10mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204323 EAP HCPCS C2628 Transform Super Compliant 7mm X 15mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204324 EAP HCPCS C2628 Transform Super Compliant 7mm X 7mm BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,183.40" "$2,183.40" $0.00 $0.00 $0.00 $838.08 "$2,984.39" "$2,984.39" "$3,099.39" $0.00 $837.98 $0.00 "$2,378.42" "$2,378.42" $0.00 "$2,010.50" "$3,184.63" "$3,216.80" $0.00 "$2,613.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204330 EAP Custom 27204330 Probe Stereo Mammo Revolve L9 Cm Od8 Ga BOTH IP/OP "$1,378.00 " "$1,019.72" $0.00 "$1,102.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,022.75" "$1,022.75" "$1,062.16" $0.00 $287.18 $0.00 $0.00 $0.00 $0.00 $689.00 "$1,091.38" "$1,102.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204332 EAP HCPCS C1887 Cath Cantata 2.5f Superselective Micro 135 Cm BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $138.03 $0.00 $0.00 $140.41 $0.00 $0.00 $0.00 $0.00 $0.00 27204333 EAP Custom 27204333 Cath Cantata 2.8f Superselective Micro 135 Cm BOTH IP/OP $897.00 $663.78 $0.00 $717.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.50 $710.42 $717.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204334 EAP Custom 27204334 Glidesheath Slender 6f BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204335 EAP Custom 27204335 Torque Delivery System 12 Fr BOTH IP/OP "$1,797.00 " "$1,329.78" $0.00 "$1,437.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.73" "$1,333.73" "$1,385.13" $0.00 $374.49 $0.00 $0.00 $0.00 $0.00 $898.50 "$1,423.22" "$1,437.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204336 EAP Custom 27204336 Amplatzer Sizing Balloons 34 Mm BOTH IP/OP $821.00 $607.54 $0.00 $656.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $609.35 $609.35 $632.83 $0.00 $171.10 $0.00 $0.00 $0.00 $0.00 $410.50 $650.23 $656.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204337 EAP HCPCS C1759 Viewflex Ice Plus Catheter BOTH IP/OP "$8,102.00 " "$5,995.48" $0.00 "$6,481.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,245.02" $0.00 "$1,688.46" $0.00 $0.00 $0.00 $0.00 "$4,051.00" "$6,416.78" "$6,481.60" $0.00 "$5,266.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204338 EAP Custom 27204338 System Fec Mgmt 60cc Ns Lf Dignishield Cath Syr Cl BOTH IP/OP $298.00 $220.52 $0.00 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.18 $221.18 $229.70 $0.00 $62.10 $0.00 $0.00 $0.00 $0.00 $149.00 $236.02 $238.40 $0.00 $193.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204351 EAP HCPCS C1725 Cath Baldilat .014in 5fr 2mm 8mm Coron Rapex Ult Lp Guid BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 27204352 EAP HCPCS C1725 Cath Baldilat .021in 5fr 2mm 20mm Coron Rapex Flxb Tung Mrkr BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204354 EAP HCPCS C1725 Cath Baldilat .014in 5fr 2.5mm 20mm Coron Rapex Ult Lp Guid BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $211.77 $211.77 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $300.61 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $253.50 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 27204356 EAP HCPCS C1725 Cath Baldilat .014in 5fr 3mm 8mm Coron Rapex Ult Lp Guid BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204358 EAP HCPCS C1725 Cath Baldilat .021in 5fr 3mm 25mm Coron Rapex Lp Flxb Tung BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $55.24 $0.00 $0.00 $56.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204359 EAP HCPCS C1725 Cath Baldilat .021in 5fr 3.5mm 8mm Coron Rapex Lp Flxb Tung BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $55.24 $0.00 $0.00 $56.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204360 EAP HCPCS C1725 Cath Baldilat .014in 5fr 3.5mm 20mm Coron Rapex Ult Lp Guid BOTH IP/OP $336.00 $248.64 $0.00 $268.80 $182.45 $182.45 $0.00 $0.00 $0.00 $70.03 $249.38 $249.38 $258.99 $0.00 $70.02 $0.00 $198.74 $198.74 $0.00 $168.00 $266.11 $268.80 $0.00 $218.40 $0.00 $52.58 $0.00 $0.00 $53.49 $0.00 $0.00 $0.00 $0.00 $0.00 27204361 EAP HCPCS C1725 Cath Baldilat .021in 5fr 3.5mm 25mm Coron Rapex Lp Flxb Tung BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $55.24 $0.00 $0.00 $56.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204362 EAP HCPCS C1725 Cath Baldilat .021in 5fr 4mm 8mm Coron Rapex Hypotube Slim BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $201.45 $201.45 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $285.97 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $185.50 $293.83 $296.80 $0.00 $241.15 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204363 EAP HCPCS C1725 Cath Baldilat .021in 5fr 4mm 12mm Coron Rapex Lp Flxb Tung BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $191.68 $191.68 $0.00 $0.00 $0.00 $73.57 $262.00 $262.00 $272.09 $0.00 $73.57 $0.00 $208.80 $208.80 $0.00 $176.50 $279.58 $282.40 $0.00 $229.45 $0.00 $55.24 $0.00 $0.00 $56.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204364 EAP HCPCS C1725 Cath Baldilat .021in 5fr 1.5mm 8mm Coron Otw Flxb Tung Mrkr BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204365 EAP HCPCS C1725 Cath Baldilat 2mm 8mm Coron Rapex Dual Tung Mrkr Flxb Smth BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204366 EAP HCPCS C1725 Cath Baldilat 2.25mm 8mm Coron Rapex Flxb Dual Tung Mrkr BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204367 EAP HCPCS C1725 Cath Baldilat 2.25mm 12mm Coron Rapex Flxb Dual Tung Mrkr BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204368 EAP HCPCS C1725 Cath Baldilat 2.25mm 15mm Coron Rapex Flxb Dual Tung Mrkr BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $201.45 $201.45 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $285.97 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $185.50 $293.83 $296.80 $0.00 $241.15 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204369 EAP HCPCS C1725 Cath Baldilat 2.25mm 20mm Coron Rapex Flxb Dual Tung Mrkr BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204370 EAP HCPCS C1725 Cath Baldilat 2.75mm 8mm Coron Rapex Flxb Dual Tung Mrkr BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204371 EAP HCPCS C1725 Cath Baldilat 3.25mm 8mm Coron Rapex Dual Tung Mrkr Flxb BOTH IP/OP $336.00 $248.64 $0.00 $268.80 $182.45 $182.45 $0.00 $0.00 $0.00 $70.03 $249.38 $249.38 $258.99 $0.00 $70.02 $0.00 $198.74 $198.74 $0.00 $168.00 $266.11 $268.80 $0.00 $218.40 $0.00 $52.58 $0.00 $0.00 $53.49 $0.00 $0.00 $0.00 $0.00 $0.00 27204372 EAP HCPCS C1725 Cath Baldilat 3.25mm 20mm Coron Rapex Dual Tung Mrkr Flxb BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $201.45 $201.45 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $285.97 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $185.50 $293.83 $296.80 $0.00 $241.15 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204374 EAP HCPCS C1725 Cath Baldilat 4.5mm 8mm Coron Rapex Flxb Dual Tung Mrkr Smth BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $191.68 $191.68 $0.00 $0.00 $0.00 $73.57 $262.00 $262.00 $272.09 $0.00 $73.57 $0.00 $208.80 $208.80 $0.00 $176.50 $279.58 $282.40 $0.00 $229.45 $0.00 $55.24 $0.00 $0.00 $56.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204375 EAP HCPCS C1725 Cath Baldilat 4.5mm 15mm Coron Rapex Dual Tung Mrkr Flxb BOTH IP/OP $336.00 $248.64 $0.00 $268.80 $182.45 $182.45 $0.00 $0.00 $0.00 $70.03 $249.38 $249.38 $258.99 $0.00 $70.02 $0.00 $198.74 $198.74 $0.00 $168.00 $266.11 $268.80 $0.00 $218.40 $0.00 $52.58 $0.00 $0.00 $53.49 $0.00 $0.00 $0.00 $0.00 $0.00 27204376 EAP HCPCS C1725 Cath Baldilat 5mm 15mm Coron Rapex Flxb Dual Tung Mrkr Smth BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $201.45 $201.45 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $285.97 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $185.50 $293.83 $296.80 $0.00 $241.15 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204390 EAP Custom 27204390 Cath Cantata Double Markers 2.5 Fr X 100 Cm BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204391 EAP Custom 27204391 Cath Cantata Double Markers 2.5 Fr X 110 Cm BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204392 EAP Custom 27204392 Cath Cantata Double Markers 2.5 X 135 Cm BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204393 EAP Custom 27204393 Cath Cantata Double Markers 2.5 X 150 Cm BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204394 EAP Custom 27204394 Cath Cantata Double Markers 2.8 Fr X 108 Cm BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204395 EAP Custom 27204395 Cath Cantata Double Markers 2.8 X 110 Cm BOTH IP/OP $358.00 $264.92 $0.00 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.00 $283.54 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204396 EAP Custom 27204396 Cath Cantata Double Markers 2.8 X 135 Cm BOTH IP/OP $358.00 $264.92 $0.00 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.00 $283.54 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204397 EAP Custom 27204397 Cath Cantata Double Markers 2.8 X 150 Cm BOTH IP/OP $358.00 $264.92 $0.00 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.00 $283.54 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204398 EAP Custom 27204398 Cath Cantata Markers. 2.5 X 100 Cm BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204399 EAP Custom 27204399 Cath Cantata Markers. 2.5 X 110 Cm BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204400 EAP Custom 27204400 Cath Cantata Markers. 2.5 X 150 Cm BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204401 EAP Custom 27204401 Cath Cantata Markers. 2.8 X100 Cm BOTH IP/OP $358.00 $264.92 $0.00 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.00 $283.54 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204402 EAP Custom 27204402 Cath Cantata Markers. 2.8 X 110 Cm BOTH IP/OP $358.00 $264.92 $0.00 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.00 $283.54 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204403 EAP Custom 27204403 Cath Cantata Markers. 2.8 X 150 Cm BOTH IP/OP $358.00 $264.92 $0.00 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.00 $283.54 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204404 EAP HCPCS C1892 Sheath Long Neuronmax 90/4 Straight 6f 088 BOTH IP/OP "$1,086.00 " $803.64 $0.00 $868.80 $589.70 $589.70 $0.00 $0.00 $0.00 $226.35 $806.03 $806.03 $837.09 $0.00 $226.32 $0.00 $642.37 $642.37 $0.00 $543.00 $860.11 $868.80 $0.00 $705.90 $0.00 $169.96 $0.00 $0.00 $172.89 $0.00 $0.00 $0.00 $0.00 $0.00 27204405 EAP HCPCS C1753 Catheter Ultrasound Eagle Eye Gold Od5 Fr Short Tip BOTH IP/OP "$1,999.00 " "$1,479.26" $0.00 "$1,599.20" "$1,085.46" "$1,085.46" $0.00 $0.00 $0.00 $416.64 "$1,483.66" "$1,483.66" "$1,540.83" $0.00 $416.59 $0.00 "$1,182.41" "$1,182.41" $0.00 $999.50 "$1,583.21" "$1,599.20" $0.00 "$1,299.35" $0.00 $312.84 $0.00 $0.00 $318.24 $0.00 $0.00 $0.00 $0.00 $0.00 27204406 EAP Custom 27204406 Catheter Steerable 3.2 Outer Diam 2mm Working Channel BOTH IP/OP "$1,653.00 " "$1,223.22" $0.00 "$1,322.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,226.86" "$1,226.86" "$1,274.13" $0.00 $344.49 $0.00 $0.00 $0.00 $0.00 $826.50 "$1,309.18" "$1,322.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204407 EAP HCPCS C1887 Trevo Microcatheter BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $622.82 $622.82 $0.00 $0.00 $0.00 $239.06 $851.30 $851.30 $884.11 $0.00 $239.03 $0.00 $678.45 $678.45 $0.00 $573.50 $908.42 $917.60 $0.00 $745.55 $0.00 $179.51 $0.00 $0.00 $182.60 $0.00 $0.00 $0.00 $0.00 $0.00 27204408 EAP HCPCS C1757 Retriever Stent Trevo Xp 4 X 20 BOTH IP/OP "$12,766.00 " "$9,446.84" $0.00 "$10,212.80" "$6,931.94" "$6,931.94" $0.00 $0.00 $0.00 "$2,660.75" "$4,181.12" "$4,181.12" "$9,840.03" $0.00 "$2,660.43" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,383.00" "$10,110.67" "$10,212.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204409 EAP HCPCS C1757 Retriever Stent Trevo Xp 3 X 20 BOTH IP/OP "$14,776.00 " "$10,934.24" $0.00 "$11,820.80" "$8,023.37" "$8,023.37" $0.00 $0.00 $0.00 "$3,079.69" "$4,181.12" "$4,181.12" "$11,389.34" $0.00 "$3,079.32" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,388.00" "$11,702.59" "$11,820.80" $0.00 "$9,604.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204416 EAP HCPCS C1757 Set Cath 135cm 5fr 3mm Spiroflex Vg Angjt .014in Thrmb Gwire BOTH IP/OP "$5,925.00 " "$4,384.50" $0.00 "$4,740.00" "$3,217.28" "$3,217.28" $0.00 $0.00 $0.00 "$1,234.92" "$4,181.12" "$4,181.12" "$4,566.99" $0.00 "$1,234.77" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,962.50" "$4,692.60" "$4,740.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204417 EAP HCPCS C1714 CATHETER TURBOHAWK High Efficiency Cutter- Large Vessel Standard Calcium BOTH IP/OP "$9,081.00 " "$6,719.94" $0.00 "$7,264.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,999.63" $0.00 "$1,892.48" $0.00 $0.00 $0.00 $0.00 "$4,540.50" "$7,192.15" "$7,264.80" $0.00 $0.00 $0.00 "$1,421.18" $0.00 $0.00 "$1,445.70" $0.00 $0.00 $0.00 $0.00 $0.00 27204418 EAP HCPCS C1714 Catheter Turbohawk  high Efficiency Cutter- Large Vessel Xtended Calcium Tip Lx-c BOTH IP/OP "$9,081.00 " "$6,719.94" $0.00 "$7,264.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,999.63" $0.00 "$1,892.48" $0.00 $0.00 $0.00 $0.00 "$4,540.50" "$7,192.15" "$7,264.80" $0.00 $0.00 $0.00 "$1,421.18" $0.00 $0.00 "$1,445.70" $0.00 $0.00 $0.00 $0.00 $0.00 27204419 EAP HCPCS C1714 Catheter Turbohawk Smooth Cutter- Large Vessel Xtended Tip  lx-m BOTH IP/OP "$9,081.00 " "$6,719.94" $0.00 "$7,264.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,999.63" $0.00 "$1,892.48" $0.00 $0.00 $0.00 $0.00 "$4,540.50" "$7,192.15" "$7,264.80" $0.00 $0.00 $0.00 "$1,421.18" $0.00 $0.00 "$1,445.70" $0.00 $0.00 $0.00 $0.00 $0.00 27204420 EAP HCPCS C1714 Catheter Turbohawk   High Efficiency Cutter- Small Vessel Xtended Calcium Tip Sx-c BOTH IP/OP "$9,081.00 " "$6,719.94" $0.00 "$7,264.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,999.63" $0.00 "$1,892.48" $0.00 $0.00 $0.00 $0.00 "$4,540.50" "$7,192.15" "$7,264.80" $0.00 $0.00 $0.00 "$1,421.18" $0.00 $0.00 "$1,445.70" $0.00 $0.00 $0.00 $0.00 $0.00 27204421 EAP HCPCS C1714 Catheter Turbohawk  High Efficiency Cutter Small Vessel Standard Calcium Tip Long Catheter  Ss-cl BOTH IP/OP "$9,081.00 " "$6,719.94" $0.00 "$7,264.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,999.63" $0.00 "$1,892.48" $0.00 $0.00 $0.00 $0.00 "$4,540.50" "$7,192.15" "$7,264.80" $0.00 $0.00 $0.00 "$1,421.18" $0.00 $0.00 "$1,445.70" $0.00 $0.00 $0.00 $0.00 $0.00 27204422 EAP HCPCS C1714 Catheter Turbohawk Smooth Cutter- Large Vessel Standard Tip   ls-m BOTH IP/OP "$9,081.00 " "$6,719.94" $0.00 "$7,264.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,999.63" $0.00 "$1,892.48" $0.00 $0.00 $0.00 $0.00 "$4,540.50" "$7,192.15" "$7,264.80" $0.00 $0.00 $0.00 "$1,421.18" $0.00 $0.00 "$1,445.70" $0.00 $0.00 $0.00 $0.00 $0.00 27204423 EAP HCPCS C1769 Gwire Vasc 190cm .014in Core To Tip Str 16cm A Fldr Xt BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $224.80 $224.80 $0.00 $0.00 $0.00 $86.29 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $244.88 $244.88 $0.00 $207.00 $327.89 $331.20 $0.00 $269.10 $0.00 $64.79 $0.00 $0.00 $65.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204424 EAP HCPCS C1769 Gwire Vasc 300cm .014in Core To Tip Str 16cm A Fldr Xt BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $224.80 $224.80 $0.00 $0.00 $0.00 $86.29 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $244.88 $244.88 $0.00 $207.00 $327.89 $331.20 $0.00 $269.10 $0.00 $64.79 $0.00 $0.00 $65.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204426 EAP Custom 27204426 Certus Lk Ablation 15cm-17 Gauge BOTH IP/OP "$6,063.00 " "$4,486.62" $0.00 "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,673.36" $0.00 "$1,263.53" $0.00 $0.00 $0.00 $0.00 "$3,031.50" "$4,801.90" "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204427 EAP Custom 27204427 Certus Lk Ablation 20cm-17 Gauge BOTH IP/OP "$6,063.00 " "$4,486.62" $0.00 "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,673.36" $0.00 "$1,263.53" $0.00 $0.00 $0.00 $0.00 "$3,031.50" "$4,801.90" "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204428 EAP Custom 27204428 Certus Ln Ablation 15cm-17 Gauge BOTH IP/OP "$6,063.00 " "$4,486.62" $0.00 "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,673.36" $0.00 "$1,263.53" $0.00 $0.00 $0.00 $0.00 "$3,031.50" "$4,801.90" "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204429 EAP Custom 27204429 Certus Ln Ablation 20cm-17 Gauge BOTH IP/OP "$6,063.00 " "$4,486.62" $0.00 "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,673.36" $0.00 "$1,263.53" $0.00 $0.00 $0.00 $0.00 "$3,031.50" "$4,801.90" "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204430 EAP HCPCS C1769 Gwire Vasc .035in 150cm 1.5mm Rsn Curve Jtp Fix Core Ptfe BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 27204431 EAP HCPCS C1769 Gwire Vasc Rsn Curve J Curve Lng .035in 260cm 1.5mm Exch BOTH IP/OP $82.00 $60.68 $0.00 $65.60 $44.53 $44.53 $0.00 $0.00 $0.00 $17.09 $60.86 $60.86 $63.21 $0.00 $17.09 $0.00 $48.50 $48.50 $0.00 $41.00 $64.94 $65.60 $0.00 $53.30 $0.00 $12.83 $0.00 $0.00 $13.05 $0.00 $0.00 $0.00 $0.00 $0.00 27204432 EAP HCPCS C1773 Kit Vasc 120cm 15mm 6fr Agn Ntnl Gold Tung Loop Cath Ntnl BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $478.93 $478.93 $0.00 $0.00 $0.00 $183.83 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $521.70 $521.70 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $138.03 $0.00 $0.00 $140.41 $0.00 $0.00 $0.00 $0.00 $0.00 27204433 EAP HCPCS C1773 Kit Vasc 120cm 25mm 6fr Agn Ntnl Gold Tung Loop Cath Ntnl BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $478.93 $478.93 $0.00 $0.00 $0.00 $183.83 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $521.70 $521.70 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $138.03 $0.00 $0.00 $140.41 $0.00 $0.00 $0.00 $0.00 $0.00 27204434 EAP HCPCS C1773 Kit Vasc 120cm 10mm 4fr Agn Ntnl Gold Tung Loop Cath Ntnl BOTH IP/OP $882.00 $652.68 $0.00 $705.60 $478.93 $478.93 $0.00 $0.00 $0.00 $183.83 $654.62 $654.62 $679.85 $0.00 $183.81 $0.00 $521.70 $521.70 $0.00 $441.00 $698.54 $705.60 $0.00 $0.00 $0.00 $138.03 $0.00 $0.00 $140.41 $0.00 $0.00 $0.00 $0.00 $0.00 27204436 EAP HCPCS C1757 Trevo Xp - 4mm X 20mm BOTH IP/OP "$14,072.00 " "$10,413.28" $0.00 "$11,257.60" "$7,641.10" "$7,641.10" $0.00 $0.00 $0.00 "$2,932.96" "$4,181.12" "$4,181.12" "$10,846.70" $0.00 "$2,932.60" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,036.00" "$11,145.02" "$11,257.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204437 EAP HCPCS C1887 Flowgate Balloon Guide Catheter 8f X 95cm BOTH IP/OP "$2,746.00 " "$2,032.04" $0.00 "$2,196.80" "$1,491.08" "$1,491.08" $0.00 $0.00 $0.00 $572.34 "$2,038.08" "$2,038.08" "$2,116.62" $0.00 $572.27 $0.00 "$1,624.26" "$1,624.26" $0.00 "$1,373.00" "$2,174.83" "$2,196.80" $0.00 "$1,784.90" $0.00 $429.75 $0.00 $0.00 $437.16 $0.00 $0.00 $0.00 $0.00 $0.00 27204438 EAP CPT® C1725 Bln Splxxx Sprinter Legend Xxxxxx BOTH IP/OP $456.00 $337.44 $0.00 $364.80 $247.61 $247.61 $0.00 $0.00 $0.00 $95.04 $338.44 $338.44 $351.48 $0.00 $95.03 $0.00 $269.72 $269.72 $0.00 $228.00 $361.15 $364.80 $0.00 $0.00 $0.00 $71.36 $0.00 $0.00 $72.60 $0.00 $0.00 $0.00 $0.00 $0.00 27204439 EAP HCPCS C1887 Flowgate Balloon Guide Catheter 8f X 85cm BOTH IP/OP "$2,746.00 " "$2,032.04" $0.00 "$2,196.80" "$1,491.08" "$1,491.08" $0.00 $0.00 $0.00 $572.34 "$2,038.08" "$2,038.08" "$2,116.62" $0.00 $572.27 $0.00 "$1,624.26" "$1,624.26" $0.00 "$1,373.00" "$2,174.83" "$2,196.80" $0.00 $0.00 $0.00 $429.75 $0.00 $0.00 $437.16 $0.00 $0.00 $0.00 $0.00 $0.00 27204440 EAP Custom 27204440 Certus Pr Ablation 15cm-17 Gauge BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" "$4,239.40" $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 "$3,575.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204441 EAP Custom 27204441 Certus Pr Ablation 20cm-17 Gauge BOTH IP/OP "$6,063.00 " "$4,486.62" $0.00 "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,673.36" $0.00 "$1,263.53" $0.00 $0.00 $0.00 $0.00 "$3,031.50" "$4,801.90" "$4,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204442 EAP HCPCS C1724 Cath Athrcm 135cm .58in Rtbl Rtl 1.25mm Ptfe Shth Precnct BOTH IP/OP "$1,364.00 " "$1,009.36" $0.00 "$1,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,012.36" "$1,012.36" "$1,051.37" $0.00 $284.26 $0.00 $0.00 $0.00 $0.00 $682.00 "$1,080.29" "$1,091.20" $0.00 $886.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204443 EAP HCPCS C1724 Cath Athrcm 135cm .58in Rtbl Rtl 1.5mm Ptfe Shth Precnct BOTH IP/OP "$1,364.00 " "$1,009.36" $0.00 "$1,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,012.36" "$1,012.36" "$1,051.37" $0.00 $284.26 $0.00 $0.00 $0.00 $0.00 $682.00 "$1,080.29" "$1,091.20" $0.00 $886.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204444 EAP HCPCS C1724 Cath Athrcm 135cm .58in Rtbl Rtl 1.75mm Precnct Exchgl Rot BOTH IP/OP "$1,364.00 " "$1,009.36" $0.00 "$1,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,012.36" "$1,012.36" "$1,051.37" $0.00 $284.26 $0.00 $0.00 $0.00 $0.00 $682.00 "$1,080.29" "$1,091.20" $0.00 $886.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204445 EAP Custom 27204445 Pcmkr Crd Thk6mm Sm 50x46mm Endurity 2 Chmbr Is-1 Conctr W Adapter BOTH IP/OP "$6,669.00 " "$4,935.06" $0.00 "$5,335.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,140.47" $0.00 "$1,389.82" $0.00 $0.00 $0.00 $0.00 "$3,334.50" "$5,281.85" "$5,335.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204446 EAP HCPCS C1887 Catheter Guid .035in 4.8-3.7fr 90cm Low Crossing P BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $226.97 $226.97 $0.00 $0.00 $0.00 $87.12 $310.24 $310.24 $322.19 $0.00 $87.11 $0.00 $247.25 $247.25 $0.00 $209.00 $331.06 $334.40 $0.00 $271.70 $0.00 $65.42 $0.00 $0.00 $66.55 $0.00 $0.00 $0.00 $0.00 $0.00 27204447 EAP HCPCS C1887 Catheter Gd .035in Mpb 9fr 7.2fr 45cm Atn Cmnd Sur BOTH IP/OP $588.00 $435.12 $0.00 $470.40 $319.28 $319.28 $0.00 $0.00 $0.00 $122.55 $436.41 $436.41 $453.23 $0.00 $122.54 $0.00 $347.80 $347.80 $0.00 $294.00 $465.70 $470.40 $0.00 $382.20 $0.00 $92.02 $0.00 $0.00 $93.61 $0.00 $0.00 $0.00 $0.00 $0.00 27204448 EAP HCPCS C1887 Catheter Gd 90d 2.4mm 1.9mm 65cm Strl Atn Slct Ii BOTH IP/OP $540.00 $399.60 $0.00 $432.00 $293.22 $293.22 $0.00 $0.00 $0.00 $112.55 $400.79 $400.79 $416.23 $0.00 $112.54 $0.00 $319.41 $319.41 $0.00 $270.00 $427.68 $432.00 $0.00 $0.00 $0.00 $84.51 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $0.00 27204449 EAP Custom 27204449 Catheter Gd 3drc Crv 6fr .070in 100cm Blu Ylw Strl BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $0.00 $0.00 $0.00 $60.00 $95.04 $96.00 $0.00 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204450 EAP HCPCS C1750 Pack Cath 28/45cm 14.5fr Carbothane Mh Mxd 2 Lum Sh Hmdial BOTH IP/OP $921.00 $681.54 $0.00 $736.80 $500.10 $500.10 $0.00 $0.00 $0.00 $191.96 $683.57 $683.57 $709.91 $0.00 $191.94 $0.00 $544.77 $544.77 $0.00 $460.50 $729.43 $736.80 $0.00 $598.65 $0.00 $144.14 $0.00 $0.00 $146.62 $0.00 $0.00 $0.00 $0.00 $0.00 27204451 EAP HCPCS C1750 Pack Cath 33/50cm 14.5fr Carbothane Mh Mxd 2 Lum Sh Hmdial BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $161.20 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27204452 EAP Custom 27204452 Obt Shth 10cm 5fr Flxb 5mm BOTH IP/OP "$4,675.00 " "$3,459.50" $0.00 "$3,740.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,337.50" "$3,702.60" "$3,740.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204453 EAP Custom 27204453 Obt Shth 10cm 6fr Flxb 5mm BOTH IP/OP "$4,908.00 " "$3,631.92" $0.00 "$3,926.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,642.72" "$3,642.72" "$3,783.09" $0.00 "$1,022.83" $0.00 $0.00 $0.00 $0.00 "$2,454.00" "$3,887.14" "$3,926.40" $0.00 "$3,190.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204454 EAP HCPCS C1769 Gwire Vasc 300cm .014in Shp Tip Str 3cm Runthrough Ns Ptfe BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $127.61 $127.61 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $181.14 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $152.75 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 27204455 EAP HCPCS C1887 Cath Ep .014in 2.6-1.8fr .021-.018in 130cm 90cm Coron Mic BOTH IP/OP "$1,621.00 " "$1,199.54" $0.00 "$1,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $810.50 "$1,283.83" "$1,296.80" $0.00 $0.00 $0.00 $253.69 $0.00 $0.00 $258.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204456 EAP HCPCS C1887 Cath Ep .014in 2.6-1.8fr .021-.018in 150cm 70cm Coron Mic BOTH IP/OP "$1,621.00 " "$1,199.54" $0.00 "$1,296.80" $880.20 $880.20 $0.00 $0.00 $0.00 $337.86 "$1,203.11" "$1,203.11" "$1,249.47" $0.00 $337.82 $0.00 $958.82 $958.82 $0.00 $810.50 "$1,283.83" "$1,296.80" $0.00 "$1,053.65" $0.00 $253.69 $0.00 $0.00 $258.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204457 EAP HCPCS C1769 Gwire Vasc .014in 180cm 3cm Str Shp Tip Runthrough Ns Coron BOTH IP/OP $247.00 $182.78 $0.00 $197.60 $134.12 $134.12 $0.00 $0.00 $0.00 $51.48 $183.32 $183.32 $190.39 $0.00 $51.47 $0.00 $146.10 $146.10 $0.00 $123.50 $195.62 $197.60 $0.00 $160.55 $0.00 $38.66 $0.00 $0.00 $39.32 $0.00 $0.00 $0.00 $0.00 $0.00 27204458 EAP HCPCS C1733 Arctic Front Advance Cryoablation Catheter 23mm BOTH IP/OP "$12,401.00 " "$9,176.74" $0.00 "$9,920.80" "$6,733.74" "$6,733.74" $0.00 $0.00 $0.00 "$2,584.68" "$4,181.12" "$4,181.12" "$9,558.69" $0.00 "$2,584.37" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,200.50" "$9,821.59" "$9,920.80" $0.00 $0.00 $0.00 "$1,940.76" $0.00 $0.00 "$1,974.24" $0.00 $0.00 $0.00 $0.00 $0.00 27204459 EAP HCPCS C1733 Arctic Front Advance Cryoablation Catheter 28mm BOTH IP/OP "$12,401.00 " "$9,176.74" $0.00 "$9,920.80" "$6,733.74" "$6,733.74" $0.00 $0.00 $0.00 "$2,584.68" "$4,181.12" "$4,181.12" "$9,558.69" $0.00 "$2,584.37" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,200.50" "$9,821.59" "$9,920.80" $0.00 "$8,060.65" $0.00 "$1,940.76" $0.00 $0.00 "$1,974.24" $0.00 $0.00 $0.00 $0.00 $0.00 27204460 EAP HCPCS C1733 Freezor Max Cardiac Cryoablation Catheter Med BOTH IP/OP "$5,236.00 " "$3,874.64" $0.00 "$4,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,618.00" "$4,146.91" "$4,188.80" $0.00 $0.00 $0.00 $819.43 $0.00 $0.00 $833.57 $0.00 $0.00 $0.00 $0.00 $0.00 27204461 EAP HCPCS C1733 Freezor Max Cardiac Cryoablation Catheter Lrg BOTH IP/OP "$5,236.00 " "$3,874.64" $0.00 "$4,188.80" "$2,843.15" "$2,843.15" $0.00 $0.00 $0.00 "$1,091.31" "$3,886.16" "$3,886.16" "$4,035.91" $0.00 "$1,091.18" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,618.00" "$4,146.91" "$4,188.80" $0.00 $0.00 $0.00 $819.43 $0.00 $0.00 $833.57 $0.00 $0.00 $0.00 $0.00 $0.00 27204462 EAP HCPCS C1733 Freezor Cardiac Cryoablation Catheter Sm BOTH IP/OP "$3,444.00 " "$2,548.56" $0.00 "$2,755.20" "$1,870.09" "$1,870.09" $0.00 $0.00 $0.00 $717.82 "$2,556.14" "$2,556.14" "$2,654.64" $0.00 $717.73 $0.00 "$2,037.13" "$2,037.13" $0.00 "$1,722.00" "$2,727.65" "$2,755.20" $0.00 $0.00 $0.00 $538.99 $0.00 $0.00 $548.28 $0.00 $0.00 $0.00 $0.00 $0.00 27204463 EAP HCPCS C1733 Freezor Cardiac Cryoablation Catheter Med BOTH IP/OP "$3,444.00 " "$2,548.56" $0.00 "$2,755.20" "$1,870.09" "$1,870.09" $0.00 $0.00 $0.00 $717.82 "$2,556.14" "$2,556.14" "$2,654.64" $0.00 $717.73 $0.00 "$2,037.13" "$2,037.13" $0.00 "$1,722.00" "$2,727.65" "$2,755.20" $0.00 $0.00 $0.00 $538.99 $0.00 $0.00 $548.28 $0.00 $0.00 $0.00 $0.00 $0.00 27204464 EAP HCPCS C1733 Freezor Cardiac Cryoablation Catheter Lrg BOTH IP/OP "$3,444.00 " "$2,548.56" $0.00 "$2,755.20" "$1,870.09" "$1,870.09" $0.00 $0.00 $0.00 $717.82 "$2,556.14" "$2,556.14" "$2,654.64" $0.00 $717.73 $0.00 "$2,037.13" "$2,037.13" $0.00 "$1,722.00" "$2,727.65" "$2,755.20" $0.00 $0.00 $0.00 $538.99 $0.00 $0.00 $548.28 $0.00 $0.00 $0.00 $0.00 $0.00 27204472 EAP HCPCS C1766 Flexcath Advance 12 Steerable Sheath - 12 Fr BOTH IP/OP "$3,307.00 " "$2,447.18" $0.00 "$2,645.60" "$1,795.70" "$1,795.70" $0.00 $0.00 $0.00 $689.26 "$2,454.46" "$2,454.46" "$2,549.04" $0.00 $689.18 $0.00 "$1,956.09" "$1,956.09" $0.00 "$1,653.50" "$2,619.14" "$2,645.60" $0.00 "$2,149.55" $0.00 $517.55 $0.00 $0.00 $526.47 $0.00 $0.00 $0.00 $0.00 $0.00 27204473 EAP HCPCS C1766 Flexcath 10 Steerable Sheath - 10 Fr BOTH IP/OP "$2,067.00 " "$1,529.58" $0.00 "$1,653.60" "$1,122.38" "$1,122.38" $0.00 $0.00 $0.00 $430.81 "$1,534.13" "$1,534.13" "$1,593.24" $0.00 $430.76 $0.00 "$1,222.63" "$1,222.63" $0.00 "$1,033.50" "$1,637.06" "$1,653.60" $0.00 $0.00 $0.00 $323.49 $0.00 $0.00 $329.07 $0.00 $0.00 $0.00 $0.00 $0.00 27204474 EAP HCPCS C1730 Achieve Mapping Catheter Sm BOTH IP/OP "$2,618.00 " "$1,937.32" $0.00 "$2,094.40" "$1,421.57" "$1,421.57" $0.00 $0.00 $0.00 $545.66 "$1,943.08" "$1,943.08" "$2,017.95" $0.00 $545.59 $0.00 "$1,548.55" "$1,548.55" $0.00 "$1,309.00" "$2,073.46" "$2,094.40" $0.00 "$1,701.70" $0.00 $409.72 $0.00 $0.00 $416.79 $0.00 $0.00 $0.00 $0.00 $0.00 27204475 EAP HCPCS C1730 Achieve Mapping Catheter Lrg BOTH IP/OP "$2,618.00 " "$1,937.32" $0.00 "$2,094.40" "$1,421.57" "$1,421.57" $0.00 $0.00 $0.00 $545.66 "$1,943.08" "$1,943.08" "$2,017.95" $0.00 $545.59 $0.00 "$1,548.55" "$1,548.55" $0.00 "$1,309.00" "$2,073.46" "$2,094.40" $0.00 $0.00 $0.00 $409.72 $0.00 $0.00 $416.79 $0.00 $0.00 $0.00 $0.00 $0.00 27204478 EAP HCPCS C1730 Cath Ep 5-5-5mm Spc Csl Curve 6fr 65cm Mp Dcapl Fix Curve BOTH IP/OP $965.00 $714.10 $0.00 $772.00 $524.00 $524.00 $0.00 $0.00 $0.00 $201.13 $716.22 $716.22 $743.82 $0.00 $201.11 $0.00 $570.80 $570.80 $0.00 $482.50 $764.28 $772.00 $0.00 $627.25 $0.00 $151.02 $0.00 $0.00 $153.63 $0.00 $0.00 $0.00 $0.00 $0.00 27204479 EAP HCPCS C1769 Gwire Vasc 325cm .009in Flpy Wrclp Trq Flxb Lng Tpr 2.8cm BOTH IP/OP $457.00 $338.18 $0.00 $365.60 $248.15 $248.15 $0.00 $0.00 $0.00 $95.25 $339.19 $339.19 $352.26 $0.00 $95.24 $0.00 $270.32 $270.32 $0.00 $228.50 $361.94 $365.60 $0.00 $297.05 $0.00 $71.52 $0.00 $0.00 $72.75 $0.00 $0.00 $0.00 $0.00 $0.00 27204480 EAP HCPCS C1769 Gwire Vasc 325cm .009in Flpy Wrclp Trq Flxb Lng Tpr 2.2cm BOTH IP/OP $457.00 $338.18 $0.00 $365.60 $248.15 $248.15 $0.00 $0.00 $0.00 $95.25 $339.19 $339.19 $352.26 $0.00 $95.24 $0.00 $270.32 $270.32 $0.00 $228.50 $361.94 $365.60 $0.00 $297.05 $0.00 $71.52 $0.00 $0.00 $72.75 $0.00 $0.00 $0.00 $0.00 $0.00 27204481 EAP Custom 27204481 Lubricant Rotaglide BOTH IP/OP $301.00 $222.74 $0.00 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.40 $223.40 $232.01 $0.00 $62.73 $0.00 $0.00 $0.00 $0.00 $150.50 $238.39 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204482 EAP HCPCS C1887 Cath Infus Mic 1.9fr 1.25mm .5mm 1.5cm Dlv Drblty Dtch Tip BOTH IP/OP "$5,498.00 " "$4,068.52" $0.00 "$4,398.40" "$2,985.41" "$2,985.41" $0.00 $0.00 $0.00 "$1,145.92" "$4,080.62" "$4,080.62" "$4,237.86" $0.00 "$1,145.78" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,749.00" "$4,354.42" "$4,398.40" $0.00 "$3,573.70" $0.00 $860.44 $0.00 $0.00 $875.28 $0.00 $0.00 $0.00 $0.00 $0.00 27204483 EAP HCPCS C1887 Cath Infus Mic 1.9fr 1.25mm .5mm 3cm Dlv Drblty Dtch Tip BOTH IP/OP "$5,498.00 " "$4,068.52" $0.00 "$4,398.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,749.00" "$4,354.42" "$4,398.40" $0.00 $0.00 $0.00 $860.44 $0.00 $0.00 $875.28 $0.00 $0.00 $0.00 $0.00 $0.00 27204484 EAP HCPCS C1769 Gwire Vasc 190cm .014in Radiopq Mrkr Core To Tip Str 3cm BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204485 EAP HCPCS C1769 Gwire Vasc 300cm .014in Radiopq Mrkr Core To Tip Str 3cm BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204486 EAP HCPCS C1769 Gwire Vasc 300cm .014in Strbl Core To Tip Radiopq Str 3cm BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204487 EAP HCPCS C1769 Gwire Vasc 180cm .014in Radiopq Mrkr Str 3cm A Fldr Fc BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204488 EAP HCPCS C1769 Gwire Vasc 300cm .014in Radiopq Mrkr Str 3cm A Fldr Fc BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204489 EAP HCPCS C1769 Gwire Vasc 190cm .014in Str 3cm Htorq Whspr Ms Ss Hydphi BOTH IP/OP $217.00 $160.58 $0.00 $173.60 $117.83 $117.83 $0.00 $0.00 $0.00 $45.23 $161.06 $161.06 $167.26 $0.00 $45.22 $0.00 $128.36 $128.36 $0.00 $108.50 $171.86 $173.60 $0.00 $141.05 $0.00 $33.96 $0.00 $0.00 $34.55 $0.00 $0.00 $0.00 $0.00 $0.00 27204490 EAP HCPCS C1757 Cath Guid .014in Rnd 6fr .07+ In 140cm 6mm S Tp Aspirat Cmpt BOTH IP/OP "$1,513.00 " "$1,119.62" $0.00 "$1,210.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $756.50 "$1,198.30" "$1,210.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204491 EAP HCPCS C1757 Cath Guid .014in 1mm 7fr 140cm 6mm Lg Xtrt Lum Rnd S Tp Shrt BOTH IP/OP "$1,441.00 " "$1,066.34" $0.00 "$1,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $720.50 "$1,141.27" "$1,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204492 EAP HCPCS C1769 Gwire Vasc 180cm .035in Jkt Core To Tip Atrm 1.5mm Rad Std J BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $63.53 $63.53 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $90.18 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $58.50 $92.66 $93.60 $0.00 $76.05 $0.00 $18.31 $0.00 $0.00 $18.63 $0.00 $0.00 $0.00 $0.00 $0.00 27204493 EAP HCPCS C1769 Gwire Vasc 260cm .035in Jkt Core To Tip Atrm 1.5mm Rad Std J BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $71.13 $71.13 $0.00 $0.00 $0.00 $27.30 $97.23 $97.23 $100.97 $0.00 $27.30 $0.00 $77.49 $77.49 $0.00 $65.50 $103.75 $104.80 $0.00 $85.15 $0.00 $20.50 $0.00 $0.00 $20.86 $0.00 $0.00 $0.00 $0.00 $0.00 27204494 EAP HCPCS C1769 Guidewire Vasc .014in 300cm 3cm Strg Med Sprt Htorq Whspr Ms BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204495 EAP HCPCS C1887 Microcatheter Headway 21 BOTH IP/OP "$2,288.00 " "$1,693.12" $0.00 "$1,830.40" "$1,242.38" "$1,242.38" $0.00 $0.00 $0.00 $476.88 "$1,698.15" "$1,698.15" "$1,763.59" $0.00 $476.82 $0.00 "$1,353.35" "$1,353.35" $0.00 "$1,144.00" "$1,812.10" "$1,830.40" $0.00 "$1,487.20" $0.00 $358.07 $0.00 $0.00 $364.25 $0.00 $0.00 $0.00 $0.00 $0.00 27204496 EAP HCPCS C1887 Microcatheter Headway Duo 17 BOTH IP/OP "$2,563.00 " "$1,896.62" $0.00 "$2,050.40" "$1,391.71" "$1,391.71" $0.00 $0.00 $0.00 $534.19 "$1,902.26" "$1,902.26" "$1,975.56" $0.00 $534.13 $0.00 "$1,516.01" "$1,516.01" $0.00 "$1,281.50" "$2,029.90" "$2,050.40" $0.00 "$1,665.95" $0.00 $401.11 $0.00 $0.00 $408.03 $0.00 $0.00 $0.00 $0.00 $0.00 27204497 EAP HCPCS C1887 6fr Jr 5 Guide Catheter BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $67.33 $67.33 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $80.60 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204498 EAP HCPCS C1887 6fr Lcb Guide Catheter BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $67.33 $67.33 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $80.60 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204499 EAP HCPCS C1887 7fr Al2 Guide Catheter BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $67.33 $67.33 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204500 EAP HCPCS C1887 7fr Al 1.5 Guide Catheter BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $67.33 $67.33 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204501 EAP HCPCS C1887 7fr Al 1.0 Guide Catheter BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $67.33 $67.33 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $80.60 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204502 EAP HCPCS C1887 6fr Mradial Guide Catheter BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $70.59 $70.59 $0.00 $0.00 $0.00 $27.10 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $76.90 $76.90 $0.00 $65.00 $102.96 $104.00 $0.00 $84.50 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 27204503 EAP HCPCS C1887 6fr Lara Curve Guide Catheter BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $67.33 $67.33 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204504 EAP HCPCS C1887 6fr Mac3030 Guide Catheter BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $67.33 $67.33 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $80.60 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204505 EAP HCPCS C1887 6fr Ima Guide Catheter BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $67.33 $67.33 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $80.60 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204506 EAP HCPCS C1887 5fr Jr4 Diagnostic Catheter 125cm BOTH IP/OP $193.00 $142.82 $0.00 $154.40 $104.80 $104.80 $0.00 $0.00 $0.00 $40.23 $143.24 $143.24 $148.76 $0.00 $40.22 $0.00 $114.16 $114.16 $0.00 $96.50 $152.86 $154.40 $0.00 $125.45 $0.00 $30.20 $0.00 $0.00 $30.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204507 EAP HCPCS C1887 5fr Jl4 Diagnostic Catheter 125cm BOTH IP/OP $193.00 $142.82 $0.00 $154.40 $104.80 $104.80 $0.00 $0.00 $0.00 $40.23 $143.24 $143.24 $148.76 $0.00 $40.22 $0.00 $114.16 $114.16 $0.00 $96.50 $152.86 $154.40 $0.00 $0.00 $0.00 $30.20 $0.00 $0.00 $30.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204508 EAP HCPCS C1724 Cath Athrcm 135cm .58in Rtbl Rtl+ 2mm Precnct Exchgl Rot BOTH IP/OP "$3,409.00 " "$2,522.66" $0.00 "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,704.50" "$2,699.93" "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204509 EAP HCPCS C1724 Cath Athrcm 135cm Rtbl Rtl+ 2.15mm Bur Precnct Exchgl Rot BOTH IP/OP "$3,409.00 " "$2,522.66" $0.00 "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,704.50" "$2,699.93" "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204510 EAP HCPCS C1724 Cath Athrcm 135cm Rtbl Rtl+ 2.25mm Bur Precnct Exchgl Rot BOTH IP/OP "$3,409.00 " "$2,522.66" $0.00 "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,530.16" "$2,530.16" "$2,627.66" $0.00 $710.44 $0.00 $0.00 $0.00 $0.00 "$1,704.50" "$2,699.93" "$2,727.20" $0.00 "$2,215.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204511 EAP HCPCS C1724 Cath Athrcm 135cm Rtbl Rtl+ 2.38mm Bur Precnct Exchgl Rot BOTH IP/OP "$3,409.00 " "$2,522.66" $0.00 "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,704.50" "$2,699.93" "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204512 EAP HCPCS C1724 Cath Athrcm 135cm Rtbl Rtl+ 2.5mm Bur Precnct Exchgl Rot Adv BOTH IP/OP "$3,409.00 " "$2,522.66" $0.00 "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,704.50" "$2,699.93" "$2,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204513 EAP HCPCS C1725 Otw Mini Trek Ii 1.20 X 6mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204514 EAP HCPCS C1725 Otw Mini Trek Ii 1.20 X 8mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $358.15 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204515 EAP HCPCS C1725 Otw Mini Trek Ii 1.20 X 12mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204516 EAP HCPCS C1725 Otw Mini Trek Ii 1.20 X 15mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204517 EAP HCPCS C1725 Otw Mini Trek Ii 1.20 X 20mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204518 EAP HCPCS C1725 Otw Mini Trek Ii 1.50 X 6mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $358.15 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204519 EAP HCPCS C1725 Otw Mini Trek Ii 1.50 X 20mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204520 EAP HCPCS C1725 Otw Mini Trek Ii 2.00 X 6mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204521 EAP HCPCS C1725 Otw Mini Trek Ii 2.00 X 20mm Bdc BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204522 EAP HCPCS C1725 Mini Trek Rx 1.20 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204523 EAP HCPCS C1725 Mini Trek Rx 1.20 X 8mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204524 EAP HCPCS C1725 Mini Trek Rx 1.20 X 12mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204525 EAP HCPCS C1725 Mini Trek Rx 1.20 X 15mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204526 EAP HCPCS C1725 Mini Trek Rx 1.20 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204527 EAP HCPCS C1725 Mini Trek Rx 1.50 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204528 EAP HCPCS C1725 Mini Trek Rx 1.50 X 8mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204529 EAP HCPCS C1725 Mini Trek Rx 1.50 X 12mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204530 EAP HCPCS C1725 Mini Trek Rx 1.50 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204531 EAP HCPCS C1725 Mini Trek Rx 2.00 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204532 EAP HCPCS C1725 Mini Trek Rx 2.00 X 25mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204533 EAP HCPCS C1725 Mini Trek Rx 2.00 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204534 EAP HCPCS C1725 Mini Trek Rx 2.25 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204535 EAP HCPCS C1725 Mini Trek Rx 2.25 X 8mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204536 EAP HCPCS C1725 Mini Trek Rx 2.25 X 12mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204537 EAP HCPCS C1725 Mini Trek Rx 2.25 X 15mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204538 EAP HCPCS C1725 Mini Trek Rx 2.25 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204539 EAP HCPCS C1725 Mini Trek Rx 2.25 X 25mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204540 EAP HCPCS C1725 Mini Trek Rx 2.25 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204541 EAP HCPCS C1725 Trek Rx 2.50 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204542 EAP HCPCS C1725 Trek Rx 2.50 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204543 EAP HCPCS C1725 Trek Rx 2.75 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204544 EAP HCPCS C1725 Trek Rx 2.75 X 8mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204545 EAP HCPCS C1725 Trek Rx 2.75 X 12mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204546 EAP HCPCS C1725 Trek Rx 2.75 X 15mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204547 EAP HCPCS C1725 Trek Rx 2.75 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204548 EAP HCPCS C1725 Trek Rx 2.75 X 25mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204549 EAP HCPCS C1725 Trek Rx 2.75 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204550 EAP HCPCS C1725 Trek Rx 3.00 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204551 EAP HCPCS C1725 Trek Rx 3.00 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204552 EAP HCPCS C1725 Trek Rx 3.25 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204553 EAP HCPCS C1725 Trek Rx 3.25 X 8mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204554 EAP HCPCS C1725 Trek Rx 3.25 X 12mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204555 EAP HCPCS C1725 Trek Rx 3.25 X 15mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204556 EAP HCPCS C1725 Trek Rx 3.25 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204557 EAP HCPCS C1725 Trek Rx 3.25 X 25mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204558 EAP HCPCS C1725 Trek Rx 3.25 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204559 EAP HCPCS C1725 Trek Rx 3.50 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204560 EAP HCPCS C1725 Trek Rx 3.50 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204561 EAP HCPCS C1725 Trek Rx 3.75 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204562 EAP HCPCS C1725 Trek Rx 3.75 X 8mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204563 EAP HCPCS C1725 Trek Rx 3.75 X 12mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204564 EAP HCPCS C1725 Trek Rx 3.75 X 15mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204565 EAP HCPCS C1725 Trek Rx 3.75 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204566 EAP HCPCS C1725 Trek Rx 3.75 X 25mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204567 EAP HCPCS C1725 Trek Rx 3.75 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204568 EAP HCPCS C1725 Trek Rx 4.00 X 06mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204569 EAP HCPCS C1725 Trek Rx 4.00 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204570 EAP HCPCS C1725 Trek Rx 4.00 X 25mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204571 EAP HCPCS C1725 Trek Rx 4.00 X 30mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204572 EAP HCPCS C1725 Nc Trek Rx 1.50 X 06mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204573 EAP HCPCS C1725 Nc Trek Rx 1.50 X 08mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204574 EAP HCPCS C1725 Nc Trek Rx 1.50 X 12mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204575 EAP HCPCS C1725 Nc Trek Rx 1.50 X 15mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204576 EAP HCPCS C1725 Nc Trek Rx 1.50 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204577 EAP HCPCS C1725 Nc Trek Rx 2.00 X 15mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204578 EAP HCPCS C1725 Nc Trek Rx 2.00 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204579 EAP HCPCS C1725 Nc Trek Rx 2.25 X 06mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204580 EAP HCPCS C1725 Nc Trek Rx 3.00 X 8mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204581 EAP HCPCS C1725 Nc Trek Rx 3.25 X 06mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204582 EAP HCPCS C1725 Nc Trek Rx 4.50 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204583 EAP HCPCS C1725 Nc Trek Rx 5.00 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204584 EAP HCPCS C1769 Asahi Prowater Ptca Guide Wire 180cm BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204585 EAP HCPCS C1769 Hi-torque Iron Man Guide Wire BOTH IP/OP $217.00 $160.58 $0.00 $173.60 $117.83 $117.83 $0.00 $0.00 $0.00 $45.23 $161.06 $161.06 $167.26 $0.00 $45.22 $0.00 $128.36 $128.36 $0.00 $108.50 $171.86 $173.60 $0.00 $141.05 $0.00 $33.96 $0.00 $0.00 $34.55 $0.00 $0.00 $0.00 $0.00 $0.00 27204586 EAP HCPCS C1769 Asahi Prowater Ptca Guide Wire 300cm BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204587 EAP Custom 27204587 Temporary Pacing Catheter 5fr BOTH IP/OP $509.00 $376.66 $0.00 $407.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $377.78 $377.78 $392.34 $0.00 $106.08 $0.00 $0.00 $0.00 $0.00 $254.50 $403.13 $407.20 $0.00 $330.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204588 EAP HCPCS C1757 Cath Dx 135cm 4.2fr Fetch 2 .014in Hydphi Rapex Aspirat BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $34.21 $34.21 $0.00 $0.00 $0.00 $13.13 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $37.26 $37.26 $0.00 $31.50 $49.90 $50.40 $0.00 $40.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204589 EAP HCPCS C1769 Hi Torque 150 Gide Wire 0.014 Straight Tip 3.0 X 190cm BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204590 EAP HCPCS C1725 Nc Trek Rx 2.00 X 06mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204591 EAP HCPCS C1725 Nc Trek Rx 2.50 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204592 EAP HCPCS C1725 Nc Trek Rx 2.75 X 06mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204593 EAP HCPCS C1725 Nc Trek Rx 3.00 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204594 EAP HCPCS C1725 Nc Trek Rx 3.50 X 6mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204595 EAP HCPCS C1725 Nc Trek Rx 3.50 X 25mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204596 EAP HCPCS C1725 Nc Trek Rx 3.75 X 20mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204597 EAP HCPCS C1725 Nc Trek Rx 5.00 X 08mm Bdc BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204598 EAP HCPCS C1769 Extn Gwire Vasc Asa BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204599 EAP HCPCS C1877 Headway Duo Microtheter BOTH IP/OP "$2,307.00 " "$1,707.18" $0.00 "$1,845.60" "$1,252.70" "$1,252.70" $0.00 $0.00 $0.00 $480.84 "$1,712.26" "$1,712.26" "$1,778.24" $0.00 $480.78 $0.00 "$1,364.59" "$1,364.59" $0.00 "$1,153.50" "$1,827.14" "$1,845.60" $0.00 "$1,499.55" $0.00 $361.05 $0.00 $0.00 $367.27 $0.00 $0.00 $0.00 $0.00 $0.00 27204600 EAP HCPCS C2628 Compliant Occlusion Balloon 4.0mm X 10mm BOTH IP/OP "$3,473.00 " "$2,570.02" $0.00 "$2,778.40" "$1,885.84" "$1,885.84" $0.00 $0.00 $0.00 $723.86 "$2,577.66" "$2,577.66" "$2,676.99" $0.00 $723.77 $0.00 "$2,054.28" "$2,054.28" $0.00 "$1,736.50" "$2,750.62" "$2,778.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204601 EAP HCPCS C2628 Compliant Occlusion Balloon 4.0mm X 15mm BOTH IP/OP "$3,473.00 " "$2,570.02" $0.00 "$2,778.40" "$1,885.84" "$1,885.84" $0.00 $0.00 $0.00 $723.86 "$2,577.66" "$2,577.66" "$2,676.99" $0.00 $723.77 $0.00 "$2,054.28" "$2,054.28" $0.00 "$1,736.50" "$2,750.62" "$2,778.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204602 EAP HCPCS C2628 Compliant Occlusion Balloon 4.0mm X 20mm BOTH IP/OP "$3,473.00 " "$2,570.02" $0.00 "$2,778.40" "$1,885.84" "$1,885.84" $0.00 $0.00 $0.00 $723.86 "$2,577.66" "$2,577.66" "$2,676.99" $0.00 $723.77 $0.00 "$2,054.28" "$2,054.28" $0.00 "$1,736.50" "$2,750.62" "$2,778.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204603 EAP HCPCS C2628 Occlusion Balloon Xc Catheter 4mm X 11mm BOTH IP/OP "$3,647.00 " "$2,698.78" $0.00 "$2,917.60" "$1,980.32" "$1,980.32" $0.00 $0.00 $0.00 $760.13 "$2,706.80" "$2,706.80" "$2,811.11" $0.00 $760.03 $0.00 "$2,157.20" "$2,157.20" $0.00 "$1,823.50" "$2,888.42" "$2,917.60" $0.00 "$2,370.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204604 EAP HCPCS C1725 Cath Baldilat 5fr 2mm 25mm Otw Flxb Tung Mrkr Trnstls Tip BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204605 EAP HCPCS C1725 Cath Baldilat 5fr 2mm 30mm Otw Flxb Tung Mrkr Trnstls Tip BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204606 EAP HCPCS C1725 Cath Baldilat Ult Lp 5fr 4.5mm 12mm Coron 2 Lum Rapex Flxb BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204607 EAP HCPCS C1725 Cath Baldilat Ult Lp 5fr 4.5mm 15mm Coron 2 Lum Rapex Flxb BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204608 EAP HCPCS C1725 Cath Baldilat Ult Lp 5fr 5mm 12mm Coron 2 Lum Rapex Flxb BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204609 EAP HCPCS C1725 Cath Baldilat Ult Lp 5fr 5mm 15mm Coron 2 Lum Rapex Flxb BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204610 EAP HCPCS C1725 Cath Baldilat Rnd 4.5mm 12mm 2 Mrkr Rapex Ml Lr Smth Flxb BOTH IP/OP $362.00 $267.88 $0.00 $289.60 $196.57 $196.57 $0.00 $0.00 $0.00 $75.45 $268.68 $268.68 $279.03 $0.00 $75.44 $0.00 $214.12 $214.12 $0.00 $181.00 $286.70 $289.60 $0.00 $235.30 $0.00 $56.65 $0.00 $0.00 $57.63 $0.00 $0.00 $0.00 $0.00 $0.00 27204611 EAP HCPCS C1769 Cath Baldilat Rnd 2mm 12mm 2 Mrkr Rapex Ml Lr Smth Flxb BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $224.25 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204612 EAP Custom 27204612 Valve Hmsts Coplt 1 Un Bldbck Cntrl Vlv BOTH IP/OP $137.00 $101.38 $0.00 $109.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.50 $108.50 $109.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204613 EAP HCPCS C1757 Solitaire Fr 4x40 BOTH IP/OP "$11,643.00 " "$8,615.82" $0.00 "$9,314.40" "$6,322.15" "$6,322.15" $0.00 $0.00 $0.00 "$2,426.69" "$4,181.12" "$4,181.12" "$8,974.42" $0.00 "$2,426.40" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,821.50" "$9,221.26" "$9,314.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204614 EAP Custom 27204614 Needle Biop 17ga 13.8cm Trgd Coax Disp Mnpty Mxcor BOTH IP/OP $153.00 $113.22 $0.00 $122.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.56 $113.56 $117.93 $0.00 $31.89 $0.00 $0.00 $0.00 $0.00 $76.50 $121.18 $122.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204615 EAP Custom 27204615 Needle Biop 18ga 16cm 22mm Mxcor Automate Strl Disp BOTH IP/OP $412.00 $304.88 $0.00 $329.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.79 $305.79 $317.57 $0.00 $85.86 $0.00 $0.00 $0.00 $0.00 $206.00 $326.30 $329.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204616 EAP HCPCS C1769 Gwire Vasc .012in 200cm 55cm Sft Pshp Acces Lgth Synchro2 BOTH IP/OP "$1,283.00 " $949.42 $0.00 "$1,026.40" $696.67 $696.67 $0.00 $0.00 $0.00 $267.41 $952.24 $952.24 $988.94 $0.00 $267.38 $0.00 $758.89 $758.89 $0.00 $641.50 "$1,016.14" "$1,026.40" $0.00 $833.95 $0.00 $200.79 $0.00 $0.00 $204.25 $0.00 $0.00 $0.00 $0.00 $0.00 27204617 EAP HCPCS C1769 Gwire Vasc .012in 300cm 55cm Sft Pshp Acces Lgth Synchro2 BOTH IP/OP "$1,593.00 " "$1,178.82" $0.00 "$1,274.40" $865.00 $865.00 $0.00 $0.00 $0.00 $332.02 "$1,182.32" "$1,182.32" "$1,227.88" $0.00 $331.98 $0.00 $942.26 $942.26 $0.00 $796.50 "$1,261.66" "$1,274.40" $0.00 "$1,035.45" $0.00 $249.30 $0.00 $0.00 $253.61 $0.00 $0.00 $0.00 $0.00 $0.00 27204618 EAP Custom 27204618 Drsg 6x3.5in Gntl Ps Strp Anmc Flxb Brthbl Ionic Slvr Sil BOTH IP/OP $53.00 $39.22 $0.00 $42.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.34 $39.34 $40.85 $0.00 $11.05 $0.00 $0.00 $0.00 $0.00 $26.50 $41.98 $42.40 $0.00 $34.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204619 EAP Custom 27204619 Drsg 10x3.5in Gntl Ps Strp Anmc Flxb Brthbl Ionic Slvr Sil BOTH IP/OP $62.00 $45.88 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.02 $46.02 $47.79 $0.00 $12.92 $0.00 $0.00 $0.00 $0.00 $31.00 $49.10 $49.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204620 EAP Custom 27204620 Drsg 14x3.5in Gntl Ps Nstn Adh Hi Abs Sil Latex Optfm Ag BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.44 $53.44 $55.50 $0.00 $15.00 $0.00 $0.00 $0.00 $0.00 $36.00 $57.02 $57.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204621 EAP Custom 27204621 Sensor Flw Microflow Bynt Hndl Flxb Neck 1.5mm Disp BOTH IP/OP "$2,612.00 " "$1,932.88" $0.00 "$2,089.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,938.63" "$1,938.63" "$2,013.33" $0.00 $544.34 $0.00 $0.00 $0.00 $0.00 "$1,306.00" "$2,068.70" "$2,089.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204622 EAP Custom 27204622 Probe Surg Microflow Bynt Hndl Flxb Neck Disp 2mm BOTH IP/OP "$2,612.00 " "$1,932.88" $0.00 "$2,089.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,938.63" "$1,938.63" "$2,013.33" $0.00 $544.34 $0.00 $0.00 $0.00 $0.00 "$1,306.00" "$2,068.70" "$2,089.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204623 EAP Custom 27204623 Probe Surg Microflow Bynt Hndl Flxb Neck Disp 3mm BOTH IP/OP "$2,612.00 " "$1,932.88" $0.00 "$2,089.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,938.63" "$1,938.63" "$2,013.33" $0.00 $544.34 $0.00 $0.00 $0.00 $0.00 "$1,306.00" "$2,068.70" "$2,089.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204624 EAP HCPCS C1769 "Gwire Vsc 190cm .014"" Mkr Tp Str 3cm Htrq Bl Mwt U" BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $134.55 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204625 EAP HCPCS C1788 Tray Infus Port Std 1 Lum Plflw Cath Introd Ndl BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27204626 EAP HCPCS C1788 Tray Infus Port Lp 1 Lum Introd Ndl Tnl Tl Cath 6 BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27204627 EAP HCPCS C1788 Tray Infus Port J Lp 1 Lum Cath Introd Ndl Gwire BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $285.08 $285.08 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27204628 EAP HCPCS C1757 Flow Restoration Catheter (6-10mm) X 155cm BOTH IP/OP "$11,238.00 " "$8,316.12" $0.00 "$8,990.40" "$6,102.23" "$6,102.23" $0.00 $0.00 $0.00 "$2,342.28" "$4,181.12" "$4,181.12" "$8,662.25" $0.00 "$2,342.00" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,619.00" "$8,900.50" "$8,990.40" $0.00 "$7,304.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204629 EAP HCPCS C1757 Flow Restoration Catheter (11-14mm) X 155cm BOTH IP/OP "$11,238.00 " "$8,316.12" $0.00 "$8,990.40" "$6,102.23" "$6,102.23" $0.00 $0.00 $0.00 "$2,342.28" "$4,181.12" "$4,181.12" "$8,662.25" $0.00 "$2,342.00" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,619.00" "$8,900.50" "$8,990.40" $0.00 "$7,304.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204630 EAP HCPCS C1757 Flow Restoration Catheter (15-18mm) X 155cm BOTH IP/OP "$11,238.00 " "$8,316.12" $0.00 "$8,990.40" "$6,102.23" "$6,102.23" $0.00 $0.00 $0.00 "$2,342.28" "$4,181.12" "$4,181.12" "$8,662.25" $0.00 "$2,342.00" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,619.00" "$8,900.50" "$8,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204631 EAP HCPCS C1757 Aspiration Guide Catheter 20f X 95cm BOTH IP/OP "$5,738.00 " "$4,246.12" $0.00 "$4,590.40" "$3,115.73" "$3,115.73" $0.00 $0.00 $0.00 "$1,195.94" "$4,181.12" "$4,181.12" "$4,422.85" $0.00 "$1,195.80" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,869.00" "$4,544.50" "$4,590.40" $0.00 "$3,729.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204632 EAP HCPCS C1773 Retraction Aspirator Device BOTH IP/OP $787.00 $582.38 $0.00 $629.60 $427.34 $427.34 $0.00 $0.00 $0.00 $164.03 $584.11 $584.11 $606.62 $0.00 $164.01 $0.00 $465.51 $465.51 $0.00 $393.50 $623.30 $629.60 $0.00 $0.00 $0.00 $123.17 $0.00 $0.00 $125.29 $0.00 $0.00 $0.00 $0.00 $0.00 27204633 EAP HCPCS C1757 Trevo Xp 6mm X 25mm BOTH IP/OP "$13,402.00 " "$9,917.48" $0.00 "$10,721.60" "$7,277.29" "$7,277.29" $0.00 $0.00 $0.00 "$2,793.31" "$4,181.12" "$4,181.12" "$10,330.26" $0.00 "$2,792.98" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,701.00" "$10,614.38" "$10,721.60" $0.00 "$8,711.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204634 EAP HCPCS C1757 Trevo Xp Provue Retriever 4.0 X 30mm BOTH IP/OP "$14,072.00 " "$10,413.28" $0.00 "$11,257.60" "$7,641.10" "$7,641.10" $0.00 $0.00 $0.00 "$2,932.96" "$4,181.12" "$4,181.12" "$10,846.70" $0.00 "$2,932.60" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,036.00" "$11,145.02" "$11,257.60" $0.00 "$9,146.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204635 EAP HCPCS C1887 "Micrcatheter Std Straight, 2 Tip-marker, 150cm-15cm" BOTH IP/OP "$2,324.00 " "$1,719.76" $0.00 "$1,859.20" "$1,261.93" "$1,261.93" $0.00 $0.00 $0.00 $484.38 "$1,724.87" "$1,724.87" "$1,791.34" $0.00 $484.32 $0.00 "$1,374.65" "$1,374.65" $0.00 "$1,162.00" "$1,840.61" "$1,859.20" $0.00 $0.00 $0.00 $363.71 $0.00 $0.00 $369.98 $0.00 $0.00 $0.00 $0.00 $0.00 27204636 EAP HCPCS C1887 "Microcatheter Standard Pre-shaped 45, 2-tip Mkr, 150cm/7.5cm" BOTH IP/OP "$2,381.00 " "$1,761.94" $0.00 "$1,904.80" "$1,292.88" "$1,292.88" $0.00 $0.00 $0.00 $496.26 "$1,767.18" "$1,767.18" "$1,835.27" $0.00 $496.20 $0.00 "$1,408.36" "$1,408.36" $0.00 "$1,190.50" "$1,885.75" "$1,904.80" $0.00 $0.00 $0.00 $372.63 $0.00 $0.00 $379.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204637 EAP HCPCS C1887 "Micrcatheter Std Pre-shp 90, 2-tip Mkr, 150cm/7.5cm" BOTH IP/OP "$2,381.00 " "$1,761.94" $0.00 "$1,904.80" "$1,292.88" "$1,292.88" $0.00 $0.00 $0.00 $496.26 "$1,767.18" "$1,767.18" "$1,835.27" $0.00 $496.20 $0.00 "$1,408.36" "$1,408.36" $0.00 "$1,190.50" "$1,885.75" "$1,904.80" $0.00 $0.00 $0.00 $372.63 $0.00 $0.00 $379.06 $0.00 $0.00 $0.00 $0.00 $0.00 27204639 EAP HCPCS C1769 Guidewire Vascular Str .035in 150cm Bentson Smooth BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $17.92 $17.92 $0.00 $0.00 $0.00 $6.88 $24.49 $24.49 $25.44 $0.00 $6.88 $0.00 $19.52 $19.52 $0.00 $16.50 $26.14 $26.40 $0.00 $21.45 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 27204640 EAP HCPCS C1725 Catheter Baldilat .035in 8fr 18mm 80cm 4cm Gold BOTH IP/OP $722.00 $534.28 $0.00 $577.60 $392.05 $392.05 $0.00 $0.00 $0.00 $150.48 $535.87 $535.87 $556.52 $0.00 $150.46 $0.00 $427.06 $427.06 $0.00 $361.00 $571.82 $577.60 $0.00 $469.30 $0.00 $112.99 $0.00 $0.00 $114.94 $0.00 $0.00 $0.00 $0.00 $0.00 27204641 EAP HCPCS C1725 Catheter Baldilat .035in 8fr 16mm 80cm 4cm Gold BOTH IP/OP $722.00 $534.28 $0.00 $577.60 $392.05 $392.05 $0.00 $0.00 $0.00 $150.48 $535.87 $535.87 $556.52 $0.00 $150.46 $0.00 $427.06 $427.06 $0.00 $361.00 $571.82 $577.60 $0.00 $469.30 $0.00 $112.99 $0.00 $0.00 $114.94 $0.00 $0.00 $0.00 $0.00 $0.00 27204642 EAP HCPCS C1725 Catheter Baldilat .035in 7fr 14mm 80cm 4cm Gold BOTH IP/OP $688.00 $509.12 $0.00 $550.40 $373.58 $373.58 $0.00 $0.00 $0.00 $143.40 $510.63 $510.63 $530.31 $0.00 $143.38 $0.00 $406.95 $406.95 $0.00 $344.00 $544.90 $550.40 $0.00 $447.20 $0.00 $107.67 $0.00 $0.00 $109.53 $0.00 $0.00 $0.00 $0.00 $0.00 27204643 EAP HCPCS C1725 Catheter Xtrt 120cm 14fr Xl .035in Str Tip Gwire BOTH IP/OP "$1,956.00 " "$1,447.44" $0.00 "$1,564.80" "$1,062.11" "$1,062.11" $0.00 $0.00 $0.00 $407.68 "$1,451.74" "$1,451.74" "$1,507.68" $0.00 $407.63 $0.00 "$1,156.97" "$1,156.97" $0.00 $978.00 "$1,549.15" "$1,564.80" $0.00 $0.00 $0.00 $306.11 $0.00 $0.00 $311.40 $0.00 $0.00 $0.00 $0.00 $0.00 27204644 EAP HCPCS C1757 Set Introd 70cm 14fr 15mm Ck-z Trchbr Gnt Rsch BOTH IP/OP $749.00 $554.26 $0.00 $599.20 $406.71 $406.71 $0.00 $0.00 $0.00 $156.11 $555.91 $555.91 $577.33 $0.00 $156.09 $0.00 $443.03 $443.03 $0.00 $374.50 $593.21 $599.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204645 EAP HCPCS C1757 Coil Embl 132cm .064mm Penumbra Ruby Ace 5max BOTH IP/OP "$5,484.00 " "$4,058.16" $0.00 "$4,387.20" "$2,977.81" "$2,977.81" $0.00 $0.00 $0.00 "$1,143.00" "$4,070.22" "$4,070.22" "$4,227.07" $0.00 "$1,142.87" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,742.00" "$4,343.33" "$4,387.20" $0.00 "$3,564.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204647 EAP HCPCS C1894 Introducer Shth Ped 5fr 21ga 40cm 7cm Gry Hub BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $55.93 $55.93 $0.00 $0.00 $0.00 $21.47 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $60.92 $60.92 $0.00 $51.50 $81.58 $82.40 $0.00 $66.95 $0.00 $16.12 $0.00 $0.00 $16.40 $0.00 $0.00 $0.00 $0.00 $0.00 27204648 EAP HCPCS C1894 Introducer Shth Ped 6fr 21ga 40cm 7cm Grn Hub BOTH IP/OP $108.00 $79.92 $0.00 $86.40 $58.64 $58.64 $0.00 $0.00 $0.00 $22.51 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $63.88 $63.88 $0.00 $54.00 $85.54 $86.40 $0.00 $70.20 $0.00 $16.90 $0.00 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $0.00 27204649 EAP HCPCS C1884 System Embl Prtc 190cm .014in 110um Crtd Gwire BOTH IP/OP "$4,397.00 " "$3,253.78" $0.00 "$3,517.60" "$2,387.57" "$2,387.57" $0.00 $0.00 $0.00 $916.44 "$3,263.45" "$3,263.45" "$3,389.21" $0.00 $916.33 $0.00 "$2,600.83" "$2,600.83" $0.00 "$2,198.50" "$3,482.42" "$3,517.60" $0.00 $0.00 $0.00 $688.13 $0.00 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204650 EAP HCPCS C1884 System Embl Prtc 190cm .014in 110um Sprg Crtd BOTH IP/OP "$4,397.00 " "$3,253.78" $0.00 "$3,517.60" "$2,387.57" "$2,387.57" $0.00 $0.00 $0.00 $916.44 "$3,263.45" "$3,263.45" "$3,389.21" $0.00 $916.33 $0.00 "$2,600.83" "$2,600.83" $0.00 "$2,198.50" "$3,482.42" "$3,517.60" $0.00 $0.00 $0.00 $688.13 $0.00 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204651 EAP HCPCS C2630 Catheter Ablt 115cm 7fr 3.5mm 75mm Curve 2-5-2mm BOTH IP/OP "$6,561.00 " "$4,855.14" $0.00 "$5,248.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,280.50" "$5,196.31" "$5,248.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204652 EAP HCPCS C2630 Catheter Ablt 115cm 7fr 3.5mm 65mm Curve 2-5-2mm BOTH IP/OP "$6,561.00 " "$4,855.14" $0.00 "$5,248.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,280.50" "$5,196.31" "$5,248.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204653 EAP HCPCS C2630 Catheter Ablt 115cm 8fr 4mm 1-4-1mm Spc D-d Curve BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204654 EAP HCPCS C2630 Catheter Ablt 115cm 8fr 4mm 1-4-1mm Spc D-f Curve BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204655 EAP HCPCS C2630 Catheter Ablt 115cm 8fr 4mm 1-4-1mm Spc F-f Curve BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204656 EAP HCPCS C2630 Catheter Ablt 115cm 8fr 4mm 1-4-1mm Spc F-j Curve BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204657 EAP HCPCS C2630 Catheter Ablt 115cm 8fr 4mm 1-4-1mm Spc J-j Curve BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204658 EAP HCPCS C2630 Catheter Ablt 115cm 8fr 4mm D Curve Flexability 4 BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,895.81" "$3,895.81" "$4,045.93" $0.00 "$1,093.89" $0.00 $0.00 $0.00 $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 "$3,411.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204659 EAP HCPCS C2630 Catheter Ablt 115cm 8fr 4mm 1-4-1mm Spc F Curve BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204660 EAP HCPCS C2630 Catheter Ablt 115cm 8fr 4mm 1-4-1mm Spc J Curve BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204661 EAP HCPCS C1885 Catheter Angio Jacky Radl Curve 5fr 3.5mm 100cm 2 BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204662 EAP HCPCS C1725 Coronary Balloon BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204663 EAP CPT® C1769 Guidewire Vasc 80cm .035in Jkt Core To Tip Atrm BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $43.44 $43.44 $0.00 $0.00 $0.00 $16.67 $59.38 $59.38 $61.66 $0.00 $16.67 $0.00 $47.32 $47.32 $0.00 $40.00 $63.36 $64.00 $0.00 $52.00 $0.00 $12.52 $0.00 $0.00 $12.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204664 EAP HCPCS C1769 035IN 150CM 7CM STANDARD TIP FIX BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $10.86 $10.86 $0.00 $0.00 $0.00 $4.17 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $11.83 $11.83 $0.00 $10.00 $15.84 $16.00 $0.00 $13.00 $0.00 $3.13 $0.00 $0.00 $3.18 $0.00 $0.00 $0.00 $0.00 $0.00 27204665 EAP HCPCS C1887 Cath Angio Jr3.5 Curve 6fr 100cm Stsr BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204666 EAP HCPCS C1887 Catheter Angiographic Jl3.5 Curve 6fr 100cm Siteseer BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.50 $102.17 $103.20 $0.00 $0.00 $0.00 $20.19 $0.00 $0.00 $20.54 $0.00 $0.00 $0.00 $0.00 $0.00 27204667 EAP HCPCS C1887 Catheter Angiographic Jl4 Curve 6fr 100cm Siteseer BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204668 EAP HCPCS C1887 Catheter Angiographic Jr5 Curve 5fr 100cm Siteseer BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 27204669 EAP Custom 27204669 Kit Pricrdcts 8.3fr Perivc Flxm Pgtl Curve 3w BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204670 EAP HCPCS C1887 Catheter 6a0083 Ss 6f Jl 5.0 100cm BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204671 EAP HCPCS C1887 Catheter Angiographic Mpa1 Curve 5fr 100cm Siteseer BOTH IP/OP $193.00 $142.82 $0.00 $154.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.50 $152.86 $154.40 $0.00 $0.00 $0.00 $30.20 $0.00 $0.00 $30.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204673 EAP HCPCS C1887 Catheter Guid Jr4 Curve 6fr 100cm Siteseer Stainless Steel BOTH IP/OP $294.00 $217.56 $0.00 $235.20 $159.64 $159.64 $0.00 $0.00 $0.00 $61.28 $218.21 $218.21 $226.62 $0.00 $61.27 $0.00 $173.90 $173.90 $0.00 $147.00 $232.85 $235.20 $0.00 $0.00 $0.00 $46.01 $0.00 $0.00 $46.80 $0.00 $0.00 $0.00 $0.00 $0.00 27204674 EAP HCPCS C1887 "Catheter,6fr Al2 Siteseer" BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $85.79 $85.79 $0.00 $0.00 $0.00 $32.93 $117.27 $117.27 $121.79 $0.00 $32.93 $0.00 $93.46 $93.46 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $24.73 $0.00 $0.00 $25.15 $0.00 $0.00 $0.00 $0.00 $0.00 27204675 EAP HCPCS C1894 Set Introd .018in 4fr 10cm 40c BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $66.79 $66.79 $0.00 $0.00 $0.00 $25.64 $91.29 $91.29 $94.81 $0.00 $25.63 $0.00 $72.75 $72.75 $0.00 $61.50 $97.42 $98.40 $0.00 $0.00 $0.00 $19.25 $0.00 $0.00 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 27204676 EAP HCPCS C1769 Set Introd 24-26-28fr Cgl Brhn BOTH IP/OP $905.00 $669.70 $0.00 $724.00 $491.42 $491.42 $0.00 $0.00 $0.00 $188.62 $671.69 $671.69 $697.57 $0.00 $188.60 $0.00 $535.31 $535.31 $0.00 $452.50 $716.76 $724.00 $0.00 $0.00 $0.00 $141.63 $0.00 $0.00 $144.08 $0.00 $0.00 $0.00 $0.00 $0.00 27204677 EAP HCPCS C1894 Set Introd .018in 4fr 21ga 40c BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $45.07 $45.07 $0.00 $0.00 $0.00 $17.30 $61.60 $61.60 $63.98 $0.00 $17.30 $0.00 $49.09 $49.09 $0.00 $41.50 $65.74 $66.40 $0.00 $0.00 $0.00 $12.99 $0.00 $0.00 $13.21 $0.00 $0.00 $0.00 $0.00 $0.00 27204678 EAP Custom 27204678 Set Introd .018in Long 5fr 21g BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.51 $70.51 $73.23 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204679 EAP Custom 27204679 Set Introd .018in Long 5fr 70c BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.51 $70.51 $73.23 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204680 EAP HCPCS C1894 Set Introd 6fr 13cm 20cm Sidea BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $21.72 $21.72 $0.00 $0.00 $0.00 $8.34 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $23.66 $23.66 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $6.26 $0.00 $0.00 $6.37 $0.00 $0.00 $0.00 $0.00 $0.00 27204681 EAP HCPCS C1894 Set Introd .038in 11fr 15.5cm BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $57.56 $57.56 $0.00 $0.00 $0.00 $22.09 $78.67 $78.67 $81.70 $0.00 $22.09 $0.00 $62.70 $62.70 $0.00 $53.00 $83.95 $84.80 $0.00 $0.00 $0.00 $16.59 $0.00 $0.00 $16.88 $0.00 $0.00 $0.00 $0.00 $0.00 27204682 EAP HCPCS C1894 Set Introd .038in 12fr 15.5cm BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $57.56 $57.56 $0.00 $0.00 $0.00 $22.09 $78.67 $78.67 $81.70 $0.00 $22.09 $0.00 $62.70 $62.70 $0.00 $53.00 $83.95 $84.80 $0.00 $0.00 $0.00 $16.59 $0.00 $0.00 $16.88 $0.00 $0.00 $0.00 $0.00 $0.00 27204683 EAP HCPCS C1894 Set Introd .038in 14fr 15.5cm BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $57.56 $57.56 $0.00 $0.00 $0.00 $22.09 $78.67 $78.67 $81.70 $0.00 $22.09 $0.00 $62.70 $62.70 $0.00 $53.00 $83.95 $84.80 $0.00 $0.00 $0.00 $16.59 $0.00 $0.00 $16.88 $0.00 $0.00 $0.00 $0.00 $0.00 27204684 EAP HCPCS C1894 Set Introd 18fr 15.5cm Peel-aw BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $57.56 $57.56 $0.00 $0.00 $0.00 $22.09 $78.67 $78.67 $81.70 $0.00 $22.09 $0.00 $62.70 $62.70 $0.00 $53.00 $83.95 $84.80 $0.00 $0.00 $0.00 $16.59 $0.00 $0.00 $16.88 $0.00 $0.00 $0.00 $0.00 $0.00 27204685 EAP HCPCS C1769 Set Introd 8fr J Tip Needle Gu BOTH IP/OP "$1,198.00 " $886.52 $0.00 $958.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.00 $948.82 $958.40 $0.00 $0.00 $0.00 $187.49 $0.00 $0.00 $190.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204686 EAP Custom 27204686 Set Introd .018in Micro Str 7f BOTH IP/OP $153.00 $113.22 $0.00 $122.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.56 $113.56 $117.93 $0.00 $31.89 $0.00 $0.00 $0.00 $0.00 $76.50 $121.18 $122.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204687 EAP HCPCS C1894 Set Introd 16fr 20-35mm 70cm G BOTH IP/OP $713.00 $527.62 $0.00 $570.40 $387.16 $387.16 $0.00 $0.00 $0.00 $148.61 $529.19 $529.19 $549.58 $0.00 $148.59 $0.00 $421.74 $421.74 $0.00 $356.50 $564.70 $570.40 $0.00 $463.45 $0.00 $111.58 $0.00 $0.00 $113.51 $0.00 $0.00 $0.00 $0.00 $0.00 27204688 EAP HCPCS C1894 Set Introd 6fr 8fr 13.75in 3 W BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $135.21 $135.21 $0.00 $0.00 $0.00 $51.90 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $147.28 $147.28 $0.00 $124.50 $197.21 $199.20 $0.00 $161.85 $0.00 $38.97 $0.00 $0.00 $39.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204689 EAP HCPCS C1894 Set Introd 6fr 8fr 17.75in 3 W BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $135.21 $135.21 $0.00 $0.00 $0.00 $51.90 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $147.28 $147.28 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $38.97 $0.00 $0.00 $39.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204690 EAP HCPCS C1887 "Catherer, Guiding" BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204691 EAP HCPCS C1887 Catheter Angiographic Cobra 2 Curve 4fr .041in 65c BOTH IP/OP $613.00 $453.62 $0.00 $490.40 $332.86 $332.86 $0.00 $0.00 $0.00 $127.76 $454.97 $454.97 $472.50 $0.00 $127.75 $0.00 $362.59 $362.59 $0.00 $306.50 $485.50 $490.40 $0.00 $398.45 $0.00 $95.93 $0.00 $0.00 $97.59 $0.00 $0.00 $0.00 $0.00 $0.00 27204694 EAP HCPCS C1769 Guidewire Vasc 300cm Rnd Prfl Agile Tip Smtr Rot BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $814.50 $814.50 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 27204695 EAP HCPCS C1757 "Indigo Catheter 8, Xtorq Tip 115cm" BOTH IP/OP "$7,255.00 " "$5,368.70" $0.00 "$5,804.00" "$3,939.47" "$3,939.47" $0.00 $0.00 $0.00 "$1,512.12" "$4,181.12" "$4,181.12" "$5,592.15" $0.00 "$1,511.94" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,627.50" "$5,745.96" "$5,804.00" $0.00 "$4,715.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204696 EAP Custom 27204696 Indigo Separator 8 BOTH IP/OP "$4,700.00 " "$3,478.00" $0.00 "$3,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,488.34" "$3,488.34" "$3,622.76" $0.00 $979.48 $0.00 $0.00 $0.00 $0.00 "$2,350.00" "$3,722.40" "$3,760.00" $0.00 "$3,055.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204697 EAP Custom 27204697 Max Aspiration Tubing 3 BOTH IP/OP "$1,095.00 " $810.30 $0.00 $876.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $812.71 $812.71 $844.03 $0.00 $228.20 $0.00 $0.00 $0.00 $0.00 $547.50 $867.24 $876.00 $0.00 $711.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204698 EAP Custom 27204698 Sealant Hemostatic Needle Free Adapter Floseal Matrix 10ml BOTH IP/OP $913.00 $675.62 $0.00 $730.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $677.63 $677.63 $703.74 $0.00 $190.27 $0.00 $0.00 $0.00 $0.00 $456.50 $723.10 $730.40 $0.00 $593.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204699 EAP Custom 27204699 Sealant Hemostatic Needle Free Adapter Floseal Matrix 5ml BOTH IP/OP $499.00 $369.26 $0.00 $399.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.36 $370.36 $384.63 $0.00 $103.99 $0.00 $0.00 $0.00 $0.00 $249.50 $395.21 $399.20 $0.00 $324.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204700 EAP HCPCS C1887 Catheter Interventional 6fr .07in .056in 145cm 20c BOTH IP/OP "$1,183.00 " $875.42 $0.00 $946.40 $642.37 $642.37 $0.00 $0.00 $0.00 $246.57 $878.02 $878.02 $911.86 $0.00 $246.54 $0.00 $699.74 $699.74 $0.00 $591.50 $936.94 $946.40 $0.00 $768.95 $0.00 $185.14 $0.00 $0.00 $188.33 $0.00 $0.00 $0.00 $0.00 $0.00 27204702 EAP HCPCS C1766 Introducer Shth 8.8fr 7fr 55cm Hi Flx Dilat BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $74.93 $74.93 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $21.60 $0.00 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 27204705 EAP Catheter Echelon 10 Micro BOTH IP/OP "$1,687.00 " "$1,248.38" $0.00 "$1,349.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.09" "$1,252.09" "$1,300.34" $0.00 $351.57 $0.00 $0.00 $0.00 $0.00 $843.50 "$1,336.10" "$1,349.60" $0.00 "$1,096.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204707 EAP Amplatz Super Stiff Exchange Guidewire .038x260 BOTH IP/OP $96.00 $71.04 $0.00 $76.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.00 $76.03 $76.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204708 EAP HCPCS C1769 Guidewire .016 Fathom BOTH IP/OP $893.00 $660.82 $0.00 $714.40 $484.90 $484.90 $0.00 $0.00 $0.00 $186.12 $662.78 $662.78 $688.32 $0.00 $186.10 $0.00 $528.21 $528.21 $0.00 $446.50 $707.26 $714.40 $0.00 $580.45 $0.00 $139.75 $0.00 $0.00 $142.17 $0.00 $0.00 $0.00 $0.00 $0.00 27204709 EAP Custom 27204709 Valve Rotating Hemostatic BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204710 EAP Custom 27204710 Manifold Kit BOTH IP/OP $58.00 $42.92 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.05 $43.05 $44.71 $0.00 $12.09 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $37.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204711 EAP HCPCS C1887 Axs Catalyst 5 Distal Access Catheter 0.058in X 11 BOTH IP/OP "$3,878.00 " "$2,869.72" $0.00 "$3,102.40" "$2,105.75" "$2,105.75" $0.00 $0.00 $0.00 $808.27 "$2,878.25" "$2,878.25" "$2,989.16" $0.00 $808.18 $0.00 "$2,293.84" "$2,293.84" $0.00 "$1,939.00" "$3,071.38" "$3,102.40" $0.00 "$2,520.70" $0.00 $606.91 $0.00 $0.00 $617.38 $0.00 $0.00 $0.00 $0.00 $0.00 27204712 EAP HCPCS C1769 Contol Wire 200cm .018 V-18 BOTH IP/OP $227.00 $167.98 $0.00 $181.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.50 $179.78 $181.60 $0.00 $0.00 $0.00 $35.53 $0.00 $0.00 $36.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204714 EAP HCPCS C1894 Introducer Shth 8fr 2.9mm 80cm Flxr Strl Acpt .038 BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $96.35 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 27204715 EAP HCPCS C1894 Introducer Shth 8fr 90cm Sm Vlv Asmbly Radiopq BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $78.74 $78.74 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $111.77 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 27204716 EAP Custom 27204716 Kit Pricrdcts 40cm 8fr Pgtl Curve Cath BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204717 EAP Custom 27204717 Catheter Angiographic Cobra 2 Curve 5fr 80cm Torcon Nb BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204718 EAP HCPCS C1887 Catheter Angiographic .046in Uac Curve 5fr .046in 90cm BOTH IP/OP $150.00 $111.00 $0.00 $115.62 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $17.50 $27.72 $28.00 $0.00 $97.50 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 27204719 EAP HCPCS C1725 Cath Baldilat 4mm 8mm Coron Rapex Nc Trek Angiopls BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204720 EAP HCPCS C1725 Cath Baldilat 4mm 15mm Coron Rapex Nc Trek Angiopl BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204721 EAP HCPCS C1725 Cath Baldilat 4mm 20mm Coron Rapex Nc Trek Angiopl BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204722 EAP HCPCS C1894 Introducer Sheath .035in 10fr .134in 45cm Anl0 Curve Str Tip BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $73.45 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 27204723 EAP HCPCS C1894 Introducer Sheath .035in 12fr .162in 45cm Anl0 Curve Str Tip BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $74.93 $74.93 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $69.00 $109.30 $110.40 $0.00 $89.70 $0.00 $21.60 $0.00 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 27204724 EAP Custom 27204724 Set Ndl 45mm 15ga Ezio Ss 1 Port Shrp Block Drsg BOTH IP/OP "$1,663.00 " "$1,230.62" $0.00 "$1,330.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,234.28" "$1,234.28" "$1,281.84" $0.00 $346.57 $0.00 $0.00 $0.00 $0.00 $831.50 "$1,317.10" "$1,330.40" $0.00 "$1,080.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204725 EAP HCPCS C1773 Snare Endscp .98in 47in 1 Loop Gold Plated Tungsten BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $488.70 $488.70 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $693.72 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $585.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 27204726 EAP HCPCS C1773 Separator Thrmb Indg 6 Latex Free BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$2,160.00" "$1,466.10" "$1,466.10" $0.00 $0.00 $0.00 $562.75 "$2,003.94" "$2,003.94" "$2,081.16" $0.00 $562.68 $0.00 "$1,597.05" "$1,597.05" $0.00 "$1,350.00" "$2,138.40" "$2,160.00" $0.00 "$1,755.00" $0.00 $422.55 $0.00 $0.00 $429.84 $0.00 $0.00 $0.00 $0.00 $0.00 27204729 EAP HCPCS C1757 Catheter Thrmb 6fr Indg Aspirat Latex Free BOTH IP/OP "$4,725.00 " "$3,496.50" $0.00 "$3,780.00" "$2,565.68" "$2,565.68" $0.00 $0.00 $0.00 $984.81 "$3,506.90" "$3,506.90" "$3,642.03" $0.00 $984.69 $0.00 "$2,794.84" "$2,794.84" $0.00 "$2,362.50" "$3,742.20" "$3,780.00" $0.00 "$3,071.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204730 EAP HCPCS C1757 Catheter Thrmb 132cm 5-6fr .064in .054in Peri Unq BOTH IP/OP "$2,908.00 " "$2,151.92" $0.00 "$2,326.40" "$1,579.04" "$1,579.04" $0.00 $0.00 $0.00 $606.10 "$2,158.32" "$2,158.32" "$2,241.49" $0.00 $606.03 $0.00 "$1,720.08" "$1,720.08" $0.00 "$1,454.00" "$2,303.14" "$2,326.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204731 EAP HCPCS C1757 Catheter Thrmb 150cm 3.4-4.1fr .041in .032in Peri BOTH IP/OP "$2,908.00 " "$2,151.92" $0.00 "$2,326.40" "$1,579.04" "$1,579.04" $0.00 $0.00 $0.00 $606.10 "$2,158.32" "$2,158.32" "$2,241.49" $0.00 $606.03 $0.00 "$1,720.08" "$1,720.08" $0.00 "$1,454.00" "$2,303.14" "$2,326.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204733 EAP HCPCS C1757 Catheter Thrmb 85cm 8fr Indg Aspirat Trq Tip Latex BOTH IP/OP "$7,225.00 " "$5,346.50" $0.00 "$5,780.00" "$3,923.18" "$3,923.18" $0.00 $0.00 $0.00 "$1,505.87" "$4,181.12" "$4,181.12" "$5,569.03" $0.00 "$1,505.69" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,612.50" "$5,722.20" "$5,780.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204736 EAP HCPCS C1887 Six Fr Asahi Fubuki Guide Catheter Dilator Kit/90cm/straight  BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204737 EAP HCPCS C1887 Six Fr Asahi Fubuki Guide Catheter Dilator Kit 80cm/straight BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27204738 EAP HCPCS C1894 Introducer Shth 7fr 2.5cm 10cm Dilat Radiopq Mrkr BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $30.41 $30.41 $0.00 $0.00 $0.00 $11.67 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $33.12 $33.12 $0.00 $28.00 $44.35 $44.80 $0.00 $36.40 $0.00 $8.76 $0.00 $0.00 $8.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204739 EAP HCPCS C1894 Introducer Shth 8fr 2.5cm 10cm Gwire Dilat Radiopq BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $30.41 $30.41 $0.00 $0.00 $0.00 $11.67 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $33.12 $33.12 $0.00 $28.00 $44.35 $44.80 $0.00 $36.40 $0.00 $8.76 $0.00 $0.00 $8.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204740 EAP HCPCS C1894 Introducer Shth 7fr 2.5cm 25cm Dilat Radiopq Mrkr BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.50 $56.23 $56.80 $0.00 $0.00 $0.00 $11.11 $0.00 $0.00 $11.30 $0.00 $0.00 $0.00 $0.00 $0.00 27204741 EAP HCPCS C1894 Introducer Shth 8fr 2.5cm 25cm Dilat Radiopq Mrkr BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $38.55 $38.55 $0.00 $0.00 $0.00 $14.80 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $42.00 $42.00 $0.00 $35.50 $56.23 $56.80 $0.00 $46.15 $0.00 $11.11 $0.00 $0.00 $11.30 $0.00 $0.00 $0.00 $0.00 $0.00 27204742 EAP HCPCS C1887 Catheter Angiographic Judkins Right 4 Curve 5fr 10 BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $60.27 $60.27 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $85.56 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $72.15 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 27204747 EAP Custom 27204747 Kit Pressure Monitr 14ga Basic Transducer Tuohy Needle BOTH IP/OP "$1,883.00 " "$1,393.42" $0.00 "$1,506.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,397.56" "$1,397.56" "$1,451.42" $0.00 $392.42 $0.00 $0.00 $0.00 $0.00 $941.50 "$1,491.34" "$1,506.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204748 EAP Custom 27204748 Kit Craniotomy Cranial Acces Codman BOTH IP/OP $635.00 $469.90 $0.00 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.30 $471.30 $489.46 $0.00 $132.33 $0.00 $0.00 $0.00 $0.00 $317.50 $502.92 $508.00 $0.00 $412.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204749 EAP Custom 27204749 System Drain Complete Nonvented Catheter Latex Free Eds Iii BOTH IP/OP $373.00 $276.02 $0.00 $298.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.50 $295.42 $298.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204750 EAP HCPCS C1751 Catheter Cen Ven .032in 9.3fr 38cm 75cm 3 Infus Lumen Extn BOTH IP/OP "$1,995.00 " "$1,476.30" $0.00 "$1,596.00" "$1,083.29" "$1,083.29" $0.00 $0.00 $0.00 $415.81 "$1,480.69" "$1,480.69" "$1,537.75" $0.00 $415.76 $0.00 "$1,180.04" "$1,180.04" $0.00 $997.50 "$1,580.04" "$1,596.00" $0.00 $0.00 $0.00 $312.22 $0.00 $0.00 $317.60 $0.00 $0.00 $0.00 $0.00 $0.00 27204751 EAP HCPCS C1751 Catheter Cen Ven 9.3fr 22cm 58mm Ods BOTH IP/OP "$1,228.00 " $908.72 $0.00 $982.40 $666.80 $666.80 $0.00 $0.00 $0.00 $255.95 $911.42 $911.42 $946.54 $0.00 $255.92 $0.00 $726.36 $726.36 $0.00 $614.00 $972.58 $982.40 $0.00 $0.00 $0.00 $192.18 $0.00 $0.00 $195.50 $0.00 $0.00 $0.00 $0.00 $0.00 27204752 EAP HCPCS C1757 "Dawn Ide, Trevo Xp 6x25 Kit" BOTH IP/OP "$12,766.00 " "$9,446.84" $0.00 "$10,212.80" "$6,931.94" "$6,931.94" $0.00 $0.00 $0.00 "$2,660.75" "$4,181.12" "$4,181.12" "$9,840.03" $0.00 "$2,660.43" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,383.00" "$10,110.67" "$10,212.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204753 EAP HCPCS C1757 "Dawn Ide, Trevo Xp 4x30 Kit" BOTH IP/OP "$12,766.00 " "$9,446.84" $0.00 "$10,212.80" "$6,931.94" "$6,931.94" $0.00 $0.00 $0.00 "$2,660.75" "$4,181.12" "$4,181.12" "$9,840.03" $0.00 "$2,660.43" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,383.00" "$10,110.67" "$10,212.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204754 EAP HCPCS C1769 Guidewire Vascular .014in 300cm 11cm Radiopq Str T BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $244.35 $244.35 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $346.86 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $292.50 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204755 EAP HCPCS C1769 Guidewire Vasc 180cm Asahi Ptca Sion Blue BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $243.75 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27204756 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Str 3cm Sion Asahi Ss BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $243.75 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27204757 EAP HCPCS C1769 Guidewire Vasc 300cm .014in 3 Radiopq Seg Str 3cm BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27204758 EAP HCPCS C1769 Guidewire Vasc Rg3 BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $312.23 $312.23 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $443.21 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 27204759 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Str Tip 11cm BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $244.35 $244.35 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $346.86 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 27204760 EAP HCPCS C1769 Catheter Guid Extra Backup 4.5 Left Curve 6fr .071 BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204761 EAP HCPCS C1769 Catheter Guid Xb 5 Left Curve 6fr .071in 100cm BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204762 EAP HCPCS C1769 Catheter Atherectomy .017in .018in 165cm Shapable BOTH IP/OP "$4,800.00 " "$3,552.00" $0.00 "$3,840.00" "$2,606.40" "$2,606.40" $0.00 $0.00 $0.00 "$1,000.44" "$3,562.56" "$3,562.56" "$3,699.84" $0.00 "$1,000.32" $0.00 "$2,839.20" "$2,839.20" $0.00 "$2,400.00" "$3,801.60" "$3,840.00" $0.00 $0.00 $0.00 $751.20 $0.00 $0.00 $764.16 $0.00 $0.00 $0.00 $0.00 $0.00 27204763 EAP HCPCS C1882 Catheter Angio .035in Vert Curve 5fr .046in 125cm BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $19.01 $19.01 $0.00 $0.00 $0.00 $7.29 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $20.70 $20.70 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 27204764 EAP HCPCS C1887 Catheter Guid Jr4 Curve 8fr 90cm Coron Sh Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204765 EAP HCPCS C1887 Catheter Guid Al1 Curve 8fr 90cm Coron Sh Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204766 EAP HCPCS C1887 Catheter Guid 3drc Curve 8fr 90cm Coron Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204767 EAP HCPCS C1887 Catheter Guid 3 Dmn Right Curve 8fr .09in 90cm BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204768 EAP HCPCS C1887 Catheter Guid Al1.5 Curve 8fr .09in 90cm Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204769 EAP HCPCS C1887 Catheter Guid Al1.5 Curve 8fr 90cm Coron Sh Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204770 EAP HCPCS C1887 Catheter Guid Al2 Curve 8fr 90cm Coron Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204771 EAP HCPCS C1887 Catheter Guid Al2 Curve 8fr .09in 90cm Coron Sh BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204772 EAP HCPCS C1887 Catheter Guid Xb4 Curve 8fr 90cm Coron Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204773 EAP HCPCS C1887 Catheter Guid Xb3.5 Curve 8fr 90cm Coron Sh Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204774 EAP HCPCS C1887 Catheter Guid Ebu3.75 Curve 8fr .09in 90cm Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204775 EAP HCPCS C1887 Catheter Guid Xb4 Curve 8fr 90cm Coron Sh Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204776 EAP HCPCS C1887 Catheter Guid Al1 Curve 8fr 90cm Coron Lnchr BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204777 EAP HCPCS C1725 Catheter Baldilat Lp Taper 4.8fr 6mm 135cm 80mm Ot BOTH IP/OP $686.00 $507.64 $0.00 $548.80 $372.50 $372.50 $0.00 $0.00 $0.00 $142.98 $509.15 $509.15 $528.77 $0.00 $142.96 $0.00 $405.77 $405.77 $0.00 $343.00 $543.31 $548.80 $0.00 $0.00 $0.00 $107.36 $0.00 $0.00 $109.21 $0.00 $0.00 $0.00 $0.00 $0.00 27204778 EAP Custom 27204778 Catheter Angio Bcn Sim2 Curve 5fr 125cm Ss Nyl BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204779 EAP HCPCS C1887 Catheter Thrmb 125cm 6fr Neuron Sim Curve Slct BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $169.96 $169.96 $0.00 $0.00 $0.00 $65.24 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $185.14 $185.14 $0.00 $156.50 $247.90 $250.40 $0.00 $203.45 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 27204782 EAP HCPCS C1725 Catheter Baldilat Lp Taper 3.8fr 4mm 135cm 80mm Otw Inflat BOTH IP/OP $686.00 $507.64 $0.00 $548.80 $372.50 $372.50 $0.00 $0.00 $0.00 $142.98 $509.15 $509.15 $528.77 $0.00 $142.96 $0.00 $405.77 $405.77 $0.00 $343.00 $543.31 $548.80 $0.00 $0.00 $0.00 $107.36 $0.00 $0.00 $109.21 $0.00 $0.00 $0.00 $0.00 $0.00 27204783 EAP HCPCS C1753 Catheter Ultrasound .035in 8.5fr 90cm 100cm Otw Radiopq BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,357.50" "$1,357.50" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" "$1,927.00" $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 "$1,625.00" $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204785 EAP HCPCS C1725 Catheter Baldilat Ultra Lp Taper 6fr 4mm 150cm 220mm Coyote BOTH IP/OP $857.00 $634.18 $0.00 $685.60 $465.35 $465.35 $0.00 $0.00 $0.00 $178.62 $636.07 $636.07 $660.58 $0.00 $178.60 $0.00 $506.92 $506.92 $0.00 $428.50 $678.74 $685.60 $0.00 $557.05 $0.00 $134.12 $0.00 $0.00 $136.43 $0.00 $0.00 $0.00 $0.00 $0.00 27204786 EAP HCPCS C1769 Guidewire Vascular Str Short Taper .014in 300cm 8cm Robust BOTH IP/OP $343.00 $253.82 $0.00 $274.40 $186.25 $186.25 $0.00 $0.00 $0.00 $71.49 $254.57 $254.57 $264.38 $0.00 $71.48 $0.00 $202.88 $202.88 $0.00 $171.50 $271.66 $274.40 $0.00 $222.95 $0.00 $53.68 $0.00 $0.00 $54.61 $0.00 $0.00 $0.00 $0.00 $0.00 27204787 EAP Custom 27204787 Omni Flush (vcf) 5fr 100cm BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204790 EAP HCPCS C1884 System Embl Prtc 104.5cm .035in Prox Crbrl Cath BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$2,172.00" "$2,172.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" "$3,083.20" $0.00 $833.60 $0.00 "$2,366.00" "$2,366.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 "$2,600.00" $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 27204791 EAP CPT® C1894 Set Introd .018in 5fr 21ga 40c BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204792 EAP Custom 27204792 Band Compression Regular 24cm 2 Balloon Air Injec Port BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204793 EAP Custom 27204793 Catheter Angiographic .038in 21ml/sec Radial Tiger Curve Str BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204795 EAP HCPCS C1894 Introducer Sheath .021in Str Thin Wall 6fr 20ga 10cm 45cm BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $74.93 $74.93 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $69.00 $109.30 $110.40 $0.00 $89.70 $0.00 $21.60 $0.00 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 27204796 EAP Custom 27204796 Tray Amniocentesis 20ga 3.5in BOTH IP/OP $32.00 $23.68 $0.00 $25.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.75 $23.75 $24.67 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $16.00 $25.34 $25.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204797 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Strbl Radiopq Kink Rst BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $20.63 $20.63 $0.00 $0.00 $0.00 $7.92 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $22.48 $22.48 $0.00 $19.00 $30.10 $30.40 $0.00 $24.70 $0.00 $5.95 $0.00 $0.00 $6.05 $0.00 $0.00 $0.00 $0.00 $0.00 27204798 EAP Custom 27204798 Tube Gastrostomy 20fr 14.25x11.25x9in Handrail Chr BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $34.69 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $29.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204799 EAP Custom 27204799 Needle Intraosseous 15ga 25mm Ez Connect Wrist Ban BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" "$1,059.85" $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $893.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204802 EAP HCPCS C1725 Catheter Baldilat 5fr 4mm 130cm 80mm Pcltxl BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,900.50" "$1,900.50" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 "$2,070.25" "$2,070.25" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204806 EAP HCPCS C1725 Catheter Baldilat 5fr 5mm 130cm 40mm Pcltxl BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,900.50" "$1,900.50" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 "$2,070.25" "$2,070.25" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204807 EAP HCPCS C1725 Catheter Baldilat 5fr 5mm 130cm 60mm Pcltxl BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,900.50" "$1,900.50" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 "$2,070.25" "$2,070.25" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204810 EAP HCPCS C1757 Solitaire Revascularization Device 4-20-10 BOTH IP/OP "$10,563.00 " "$7,816.62" $0.00 "$8,450.40" "$5,735.71" "$5,735.71" $0.00 $0.00 $0.00 "$2,201.59" "$4,181.12" "$4,181.12" "$8,141.96" $0.00 "$2,201.33" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,281.50" "$8,365.90" "$8,450.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204811 EAP HCPCS C1757 SOLITAIRE PLATINUM 6X20 BOTH IP/OP "$10,563.00 " "$7,816.62" $0.00 "$8,450.40" "$5,735.71" "$5,735.71" $0.00 $0.00 $0.00 "$2,201.59" "$4,181.12" "$4,181.12" "$8,141.96" $0.00 "$2,201.33" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,281.50" "$8,365.90" "$8,450.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204812 EAP HCPCS C1757 Solitaire Platinum Revascularization Device 4-40 BOTH IP/OP "$10,563.00 " "$7,816.62" $0.00 "$8,450.40" "$4,753.35" "$4,753.35" $0.00 $0.00 $0.00 "$2,201.59" "$4,181.12" "$4,181.12" "$8,141.96" $0.00 "$2,201.33" $0.00 "$5,207.56" "$5,207.56" $0.00 "$5,281.50" "$8,365.90" "$8,450.40" $0.00 "$4,753.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204813 EAP HCPCS C1758 Catheter Urethral 16fr Foley 2 Way Medium Olive Coude Tip 1 BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $14.12 $14.12 $0.00 $0.00 $0.00 $5.42 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $15.38 $15.38 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204814 EAP HCPCS C1887 Catheter Angiographic Cobra 2 Curve 4fr .041in 65cm 2 Braid BOTH IP/OP $613.00 $453.62 $0.00 $490.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.50 $485.50 $490.40 $0.00 $0.00 $0.00 $95.93 $0.00 $0.00 $97.59 $0.00 $0.00 $0.00 $0.00 $0.00 27204817 EAP HCPCS C1725 Catheter Baldilat 6mm 130cm 40mm Lutonix Acpt 6fr BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,900.50" "$1,900.50" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 "$2,070.25" "$2,070.25" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204818 EAP HCPCS C1725 Catheter Baldilat 6fr 6mm 130cm 60mm Pcltxl BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,900.50" "$1,900.50" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 "$2,070.25" "$2,070.25" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204819 EAP HCPCS C1725 Catheter Baldilat 6fr 6mm 130cm 80mm Pcltxl BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,900.50" "$1,900.50" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 "$2,070.25" "$2,070.25" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204822 EAP HCPCS C1725 Catheter Baldilat 6fr 6mm 130cm 150mm Pcltxl BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,900.50" "$1,900.50" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 "$2,070.25" "$2,070.25" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27204823 EAP HCPCS C1894 Introducer Sheath .038in Stand BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $24.44 $24.44 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $34.69 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $29.25 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 27204824 EAP Custom 27204824 Set Tubing 2.6mr 2 Way Communication Irrigation Pump BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204825 EAP HCPCS C1751 Axs Catalyst 6 Distal Access Catheter BOTH IP/OP "$4,875.00 " "$3,607.50" $0.00 "$3,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,437.50" "$3,861.00" "$3,900.00" $0.00 $0.00 $0.00 $762.94 $0.00 $0.00 $776.10 $0.00 $0.00 $0.00 $0.00 $0.00 27204826 EAP HCPCS C1751 Axs Catalyst 5 Distal Access Catheter BOTH IP/OP "$4,875.00 " "$3,607.50" $0.00 "$3,900.00" "$2,647.13" "$2,647.13" $0.00 $0.00 $0.00 "$1,016.07" "$3,618.23" "$3,618.23" "$3,757.65" $0.00 "$1,015.95" $0.00 "$2,883.56" "$2,883.56" $0.00 "$2,437.50" "$3,861.00" "$3,900.00" $0.00 "$3,168.75" $0.00 $762.94 $0.00 $0.00 $776.10 $0.00 $0.00 $0.00 $0.00 $0.00 27204827 EAP HCPCS C1885 Catheter Angio Kmp Curve Ang 4fr 65cm Radiopq BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204828 EAP Custom 27204828 Bit Drill 25mm 4mm Strl BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.13 $106.13 $110.22 $0.00 $29.80 $0.00 $0.00 $0.00 $0.00 $71.50 $113.26 $114.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204830 EAP Custom 27204830 Impella Rp Us Hde Pump Set BOTH IP/OP "$62,500.00 " "$46,250.00" $0.00 "$66,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$48,175.00" $0.00 "$13,025.00" $0.00 $0.00 $0.00 $0.00 "$31,250.00" "$49,500.00" "$50,000.00" $0.00 "$66,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204832 EAP HCPCS C1894 Sheath Introd 16fr 6.2mm 5.3mm 28cm Dryseal Dilat BOTH IP/OP $668.00 $494.32 $0.00 $534.40 $362.72 $362.72 $0.00 $0.00 $0.00 $139.23 $495.79 $495.79 $514.89 $0.00 $139.21 $0.00 $395.12 $395.12 $0.00 $334.00 $529.06 $534.40 $0.00 $434.20 $0.00 $104.54 $0.00 $0.00 $106.35 $0.00 $0.00 $0.00 $0.00 $0.00 27204833 EAP Custom 27204833 Catheter Baldilat Tpr 10-50mm 65cm Stent Gft Flx BOTH IP/OP "$1,213.00 " $897.62 $0.00 $970.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $900.29 $900.29 $934.98 $0.00 $252.79 $0.00 $0.00 $0.00 $0.00 $606.50 $960.70 $970.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204835 EAP HCPCS C1757 System Thrmb Zelantedvt BOTH IP/OP "$7,313.00 " "$5,411.62" $0.00 "$5,850.40" "$3,970.96" "$3,970.96" $0.00 $0.00 $0.00 "$1,524.21" "$4,181.12" "$4,181.12" "$5,636.86" $0.00 "$1,524.03" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,656.50" "$5,791.90" "$5,850.40" $0.00 "$4,753.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204840 EAP HCPCS C1884 Axs Infinity Ls .088 Long Guide Sheath 90cm BOTH IP/OP "$1,463.00 " "$1,082.62" $0.00 "$1,170.40" $794.41 $794.41 $0.00 $0.00 $0.00 $304.93 "$1,085.84" "$1,085.84" "$1,127.68" $0.00 $304.89 $0.00 $865.36 $865.36 $0.00 $731.50 "$1,158.70" "$1,170.40" $0.00 $950.95 $0.00 $228.96 $0.00 $0.00 $232.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204841 EAP HCPCS C1894 Axs Infinity Ls .088 Long Guide Sheath 80cm BOTH IP/OP "$1,463.00 " "$1,082.62" $0.00 "$1,170.40" $794.41 $794.41 $0.00 $0.00 $0.00 $304.93 "$1,085.84" "$1,085.84" "$1,127.68" $0.00 $304.89 $0.00 $865.36 $865.36 $0.00 $731.50 "$1,158.70" "$1,170.40" $0.00 $950.95 $0.00 $228.96 $0.00 $0.00 $232.91 $0.00 $0.00 $0.00 $0.00 $0.00 27204842 EAP HCPCS C1773 Snare Vasc 175cm .16-.32in 3.2fr Ensnr Mini Ntnl 3 BOTH IP/OP "$1,638.00 " "$1,212.12" $0.00 "$1,310.40" $889.43 $889.43 $0.00 $0.00 $0.00 $341.40 "$1,215.72" "$1,215.72" "$1,262.57" $0.00 $341.36 $0.00 $968.88 $968.88 $0.00 $819.00 "$1,297.30" "$1,310.40" $0.00 $0.00 $0.00 $256.35 $0.00 $0.00 $260.77 $0.00 $0.00 $0.00 $0.00 $0.00 27204843 EAP HCPCS C2628 Er-reboa Catheter BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,708.48" "$2,708.48" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,950.40" "$2,950.40" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 "$3,242.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204844 EAP HCPCS C1773 Snare Vasc 47in .71-1.18in .055in .074in Ensnr BOTH IP/OP $888.00 $657.12 $0.00 $710.40 $482.18 $482.18 $0.00 $0.00 $0.00 $185.08 $659.07 $659.07 $684.47 $0.00 $185.06 $0.00 $525.25 $525.25 $0.00 $444.00 $703.30 $710.40 $0.00 $0.00 $0.00 $138.97 $0.00 $0.00 $141.37 $0.00 $0.00 $0.00 $0.00 $0.00 27204845 EAP HCPCS C1894 Percutaneous Sheath Intro Kit 6f .035in X 10cm BOTH IP/OP $788.00 $583.12 $0.00 $630.40 $427.88 $427.88 $0.00 $0.00 $0.00 $164.24 $584.85 $584.85 $607.39 $0.00 $164.22 $0.00 $466.10 $466.10 $0.00 $394.00 $624.10 $630.40 $0.00 $0.00 $0.00 $123.32 $0.00 $0.00 $125.45 $0.00 $0.00 $0.00 $0.00 $0.00 27204846 EAP HCPCS C1769 Pericardio Set And Tray BOTH IP/OP $474.00 $350.76 $0.00 $379.20 $257.38 $257.38 $0.00 $0.00 $0.00 $98.79 $351.80 $351.80 $365.36 $0.00 $98.78 $0.00 $280.37 $280.37 $0.00 $237.00 $375.41 $379.20 $0.00 $308.10 $0.00 $74.18 $0.00 $0.00 $75.46 $0.00 $0.00 $0.00 $0.00 $0.00 27204847 EAP HCPCS C1894 Set Catheter .035in 15cm 70cm Sidehole Removable Stylet Tip BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27204848 EAP "Flexor Ansel Guiding Sheath W/hfd, Check-flo 8f 2.9mm X 70cm Mp" BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204849 EAP HCPCS C1894 Flexor Ansel Guiding Sheath W/check-flo 7f 2.5mm X 45cm Str BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $73.45 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 27204850 EAP HCPCS C1725 Viatrac 14 Plus Rx 5mm X 30mm X 135cm BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $339.38 $339.38 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $481.75 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $406.25 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 27204851 EAP HCPCS C1769 X-celerator .010 10cm X 300cm BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $447.98 $447.98 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $635.91 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 27204852 EAP HCPCS C1725 "Mustang 7fr 12.0mm X 60mm, 135cm" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $325.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27204853 EAP Custom 27204853 Sterling Otw 4mm X 60mm X 135cm BOTH IP/OP $685.00 $506.90 $0.00 $548.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $508.41 $508.41 $528.00 $0.00 $142.75 $0.00 $0.00 $0.00 $0.00 $342.50 $542.52 $548.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204854 EAP HCPCS C1725 Sterling Otw 5mm X 100mm X 135cm BOTH IP/OP $685.00 $506.90 $0.00 $548.00 $371.96 $371.96 $0.00 $0.00 $0.00 $142.77 $508.41 $508.41 $528.00 $0.00 $142.75 $0.00 $405.18 $405.18 $0.00 $342.50 $542.52 $548.00 $0.00 $445.25 $0.00 $107.20 $0.00 $0.00 $109.05 $0.00 $0.00 $0.00 $0.00 $0.00 27204855 EAP HCPCS C1725 Sterling Otw 6mm X 100mm X 135cm BOTH IP/OP $685.00 $506.90 $0.00 $548.00 $371.96 $371.96 $0.00 $0.00 $0.00 $142.77 $508.41 $508.41 $528.00 $0.00 $142.75 $0.00 $405.18 $405.18 $0.00 $342.50 $542.52 $548.00 $0.00 $445.25 $0.00 $107.20 $0.00 $0.00 $109.05 $0.00 $0.00 $0.00 $0.00 $0.00 27204856 EAP HCPCS C1725 Coyote 3.5mm X 220mm X 150cm BOTH IP/OP $856.00 $633.44 $0.00 $684.80 $464.81 $464.81 $0.00 $0.00 $0.00 $178.41 $635.32 $635.32 $659.80 $0.00 $178.39 $0.00 $506.32 $506.32 $0.00 $428.00 $677.95 $684.80 $0.00 $0.00 $0.00 $133.96 $0.00 $0.00 $136.28 $0.00 $0.00 $0.00 $0.00 $0.00 27204857 EAP HCPCS C1894 Tear-away Intro Sheath 8f 30cm BOTH IP/OP $477.00 $352.98 $0.00 $381.60 $259.01 $259.01 $0.00 $0.00 $0.00 $99.42 $354.03 $354.03 $367.67 $0.00 $99.41 $0.00 $282.15 $282.15 $0.00 $238.50 $377.78 $381.60 $0.00 $310.05 $0.00 $74.65 $0.00 $0.00 $75.94 $0.00 $0.00 $0.00 $0.00 $0.00 27204858 EAP Sterling Otw 4mm X 220mm X 135cm BOTH IP/OP $830.00 $614.20 $0.00 $664.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $616.03 $616.03 $639.76 $0.00 $172.97 $0.00 $0.00 $0.00 $0.00 $415.00 $657.36 $664.00 $0.00 $539.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204860 EAP HCPCS C1887 Catheter Guid 47cm Cps Dir 115d Upsize Latex Free BOTH IP/OP "$1,721.00 " "$1,273.54" $0.00 "$1,376.80" $934.50 $934.50 $0.00 $0.00 $0.00 $358.70 "$1,277.33" "$1,277.33" "$1,326.55" $0.00 $358.66 $0.00 "$1,017.97" "$1,017.97" $0.00 $860.50 "$1,363.03" "$1,376.80" $0.00 $0.00 $0.00 $269.34 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 27204863 EAP Custom 27204863 Needle Port 1in 20ga 5ml/sec Grpr Plus Deltec Pcth BOTH IP/OP $203.00 $150.22 $0.00 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.67 $150.67 $156.47 $0.00 $42.31 $0.00 $0.00 $0.00 $0.00 $101.50 $160.78 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204864 EAP Custom 27204864 Needle Port 1.25in 20ga 5ml/sec Grpr Plus Deltec BOTH IP/OP $203.00 $150.22 $0.00 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.67 $150.67 $156.47 $0.00 $42.31 $0.00 $0.00 $0.00 $0.00 $101.50 $160.78 $162.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204865 EAP Custom 27204865 Introd Shth 9fr 14cm Hmsts Gwire Plwy .038in Trnsp BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $0.00 $0.00 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204870 EAP HCPCS C1887 Catheter Delivery System 0-.02in Micro Str 2.6-2.95fr .025in BOTH IP/OP "$2,325.00 " "$1,720.50" $0.00 "$1,860.00" "$1,262.48" "$1,262.48" $0.00 $0.00 $0.00 $484.59 "$1,725.62" "$1,725.62" "$1,792.11" $0.00 $484.53 $0.00 "$1,375.24" "$1,375.24" $0.00 "$1,162.50" "$1,841.40" "$1,860.00" $0.00 "$1,511.25" $0.00 $363.86 $0.00 $0.00 $370.14 $0.00 $0.00 $0.00 $0.00 $0.00 27204871 EAP Custom 27204871 Axs Catalyst 5 Distal Access Catheter 0.058in X 115cm BOTH IP/OP "$3,878.00 " "$2,869.72" $0.00 "$3,102.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,878.25" "$2,878.25" "$2,989.16" $0.00 $808.18 $0.00 $0.00 $0.00 $0.00 "$1,939.00" "$3,071.38" "$3,102.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204873 EAP HCPCS C1887 Terumo Medical Corp- Div Terumo Group BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204874 EAP HCPCS C1887 Catheter Angio Radl Tiger 4.5 Curve 5fr 110cm BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204875 EAP HCPCS C1887 Catheter Angio Sarah Radl 4 Curve 5fr 110cm Coron BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204876 EAP HCPCS C1887 Catheter Angio Radialtiger Curve 6fr 4mm 110cm BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204879 EAP HCPCS C1887 Catheter Angio Sarah Radl Curve 6fr 4mm 110cm BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204880 EAP HCPCS C1769 Gui Vas St Str .035in 260cm Flexible Tip BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $54.30 $54.30 $0.00 $0.00 $0.00 $20.84 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $0.00 $65.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 27204881 EAP HCPCS C1725 Cat Baldi Lp 5.3fr 8mm 75cm 100mm High Pres BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.50 $366.70 $370.40 $0.00 $0.00 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204883 EAP HCPCS C1894 Int Sheath .035in 7fr .1in 70cm Anl0 Curve Str Tip BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204884 EAP HCPCS C1725 Cat Bald .018in 6fr 5mm 135mm 60mm Otw Lp Infl BOTH IP/OP $713.00 $527.62 $0.00 $570.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.50 $564.70 $570.40 $0.00 $0.00 $0.00 $111.58 $0.00 $0.00 $113.51 $0.00 $0.00 $0.00 $0.00 $0.00 27204885 EAP HCPCS C1725 Cat Bald 6mm 75cm 40mm High Pres Lp Infla Pt BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204886 EAP HCPCS C1887 Cat Guid Micro Str 3-2.4fr .021in 130cm 30cm Rad BOTH IP/OP $806.00 $596.44 $0.00 $644.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $403.00 $638.35 $644.80 $0.00 $0.00 $0.00 $126.14 $0.00 $0.00 $128.32 $0.00 $0.00 $0.00 $0.00 $0.00 27204887 EAP HCPCS C1725 Cat Bald 5fr 9mm 75cm 60mm High Pres Lp Infl BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204888 EAP HCPCS C1725 Cat Bald Lp 5.8fr 12mm 75cm 60mm High Pres BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204889 EAP HCPCS C1894 Sth Gui .018-.038in Anl2 Crve 6fr .087in 90cm Radi BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27204890 EAP HCPCS C1725 Cat Bald Ult Lp Tap 6fr 2.5mm 150cm 100mm Otw BOTH IP/OP $686.00 $507.64 $0.00 $548.80 $372.50 $372.50 $0.00 $0.00 $0.00 $142.98 $509.15 $509.15 $528.77 $0.00 $142.96 $0.00 $405.77 $405.77 $0.00 $343.00 $543.31 $548.80 $0.00 $445.90 $0.00 $107.36 $0.00 $0.00 $109.21 $0.00 $0.00 $0.00 $0.00 $0.00 27204891 EAP HCPCS C1725 Cat Bald Lp 5.3fr 7mm 135cm 150mm High Pres BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $86.08 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 27204892 EAP HCPCS C1725 Cat Bald Lp 5.3fr 5mm 75cm 20mm High Pres BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204893 EAP HCPCS C1725 Cat Bald Lp 5.3fr 9mm 75cm 20mm High Pres BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204894 EAP HCPCS C1725 Cat Bald 5.8fr 10mm 75cm 60mm High Pres Lp BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.50 $366.70 $370.40 $0.00 $0.00 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204896 EAP HCPCS C1725 Cat Bald Lp 5.3fr 7mm 135cm 100mm High Pres BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204898 EAP HCPCS C1725 Cat Bald 14 Atm Ult Lp 6fr 2.5mm 143cm 20mm BOTH IP/OP $713.00 $527.62 $0.00 $570.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.50 $564.70 $570.40 $0.00 $0.00 $0.00 $111.58 $0.00 $0.00 $113.51 $0.00 $0.00 $0.00 $0.00 $0.00 27204899 EAP HCPCS C1725 Cat Bald Lp 5.3fr 6mm 135cm 60mm High Pres BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204900 EAP HCPCS C1892 Introd Shth 7fr .092in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $14.09 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 27204901 EAP HCPCS C1892 Introd Shth 7fr .092in 25cm Rbst Vlv Splt Sdprt BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $57.02 $57.02 $0.00 $0.00 $0.00 $21.88 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $62.11 $62.11 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 27204902 EAP Custom 27204902 Starclose Se BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204903 EAP Custom 27204903 System Embolization Nonadhesive Delivery Syringe L BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" "$4,335.75" $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204910 EAP HCPCS C1894 Shth Gu .018/.038in Anl1 Cve 6fr .087in 45cm Rad BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $73.45 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 27204911 EAP HCPCS C1725 Cat Bald Ula Lp Tper 6fr 2mm 150cm 100mm BOTH IP/OP $686.00 $507.64 $0.00 $548.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.00 $543.31 $548.80 $0.00 $0.00 $0.00 $107.36 $0.00 $0.00 $109.21 $0.00 $0.00 $0.00 $0.00 $0.00 27204912 EAP HCPCS C1725 Catr Bald 14 Atm Lp Taer 7fr 5mm 150cm 150mm BOTH IP/OP $754.00 $557.96 $0.00 $603.20 $409.42 $409.42 $0.00 $0.00 $0.00 $157.15 $559.62 $559.62 $581.18 $0.00 $157.13 $0.00 $445.99 $445.99 $0.00 $377.00 $597.17 $603.20 $0.00 $490.10 $0.00 $118.00 $0.00 $0.00 $120.04 $0.00 $0.00 $0.00 $0.00 $0.00 27204913 EAP HCPCS C1725 Catbald Lp 5.3fr 7mm 135cm 60mm High Pres BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204914 EAP HCPCS C1725 Cat Bald .035in 7mm 75cm 60mm High Pres Lp BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204916 EAP HCPCS C1725 Cat Bald .035in 8mm 75cm 60mm High Pre Lp BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204917 EAP HCPCS C1725 Cat Bald Lp 5.8fr 9mm 135cm 60mm High Pres BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204918 EAP HCPCS C1725 Cat Guid Ebu3.75 Curve 7fr .081in 100cm Luch BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27204919 EAP HCPCS C1725 Cat Bald .035in 6mm 75cm 60mm High Pres Lp BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204920 EAP HCPCS C1830 Biopsy System Comprehensive Tray 102mm BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $269.78 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204921 EAP HCPCS C1830 Biopsy System Comprehensive Tray 152mm BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $269.78 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204923 EAP HCPCS C1830 Oncontrol Biopsy System Tray 152mm BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204924 EAP Custom 27204924 Oncontrol Coaxial Tray 6cm 11/13 Gauge BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $0.00 $0.00 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204925 EAP Custom 27204925 Oncontrol Coaxial Tray 10cm 11/13 Gauge BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $0.00 $0.00 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204926 EAP Custom 27204926 Oncontrol Coaxial Tray 15cm 11/13 Gauge BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $0.00 $0.00 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204927 EAP HCPCS C1769 Guidewire Vasc 185cm Strl Lf Verrata + Prss Disp BOTH IP/OP "$1,688.00 " "$1,249.12" $0.00 "$1,350.40" $916.58 $916.58 $0.00 $0.00 $0.00 $351.82 "$1,252.83" "$1,252.83" "$1,301.11" $0.00 $351.78 $0.00 $998.45 $998.45 $0.00 $844.00 "$1,336.90" "$1,350.40" $0.00 "$1,097.20" $0.00 $264.17 $0.00 $0.00 $268.73 $0.00 $0.00 $0.00 $0.00 $0.00 27204928 EAP HCPCS C2628 Catheter Baldilat 9fr 32mm 120cm 2 Lum Radiopq BOTH IP/OP "$1,430.00 " "$1,058.20" $0.00 "$1,144.00" $776.49 $776.49 $0.00 $0.00 $0.00 $298.05 "$1,061.35" "$1,061.35" "$1,102.24" $0.00 $298.01 $0.00 $845.85 $845.85 $0.00 $715.00 "$1,132.56" "$1,144.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204930 EAP HCPCS C1769 Gwire Vasc .038in 180cm Strl 3cm Merit Laurea BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $43.44 $43.44 $0.00 $0.00 $0.00 $16.67 $59.38 $59.38 $61.66 $0.00 $16.67 $0.00 $47.32 $47.32 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $12.52 $0.00 $0.00 $12.74 $0.00 $0.00 $0.00 $0.00 $0.00 27204932 EAP HCPCS C1769 Gdwre Vasc Tper .038in 145cm 6cm Str Tip Am BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.50 $48.31 $48.80 $0.00 $0.00 $0.00 $9.55 $0.00 $0.00 $9.71 $0.00 $0.00 $0.00 $0.00 $0.00 27204933 EAP HCPCS C1769 Set Cat 15.5fr 24cm 3 Lumen Bas Gwire Dil Scal BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $150.95 $150.95 $0.00 $0.00 $0.00 $57.94 $206.33 $206.33 $214.28 $0.00 $57.94 $0.00 $164.44 $164.44 $0.00 $139.00 $220.18 $222.40 $0.00 $180.70 $0.00 $43.51 $0.00 $0.00 $44.26 $0.00 $0.00 $0.00 $0.00 $0.00 27204941 EAP HCPCS C1769 Set Cath 20cm 15.5fr 3 Lum Basic Gwire Dilat Scpl BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $0.00 $0.00 $0.00 $0.00 $0.00 $60.03 $0.00 $0.00 $0.00 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 27204942 EAP HCPCS C1753 Catheter Us Kodama BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $814.50 $814.50 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 27204943 EAP Custom 27204943 Glove Compression Large Open Finger Seamless Latex Free Pr BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $27.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204944 EAP Custom 27204944 Glove Cmpr Xs 5-6in Lf Istnr F F Thrp Mach Wshbl 80% Nyl 20% Pr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204945 EAP Custom 27204945 Glove Cmpr Med Lf Istnr Anemb F F L/r Hnd Edema Cntrl Pr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204946 EAP Custom 27204946 Glove Cmpr Sm 23-32 Mmhg 6-7in Lf Istnr F F Thrp Nyl Spndx Pr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204947 EAP Custom 27204947 Glove Cmpr Lg 23-32 Mmhg 8-9in Lf Istnr F F Thrp Nyl Spndx Pr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204948 EAP Custom 27204948 Glove Cmpr Xs 5-6in Lf Istnr Opn Fngr Ltwt Blnd Smls Sprt Pr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204949 EAP Custom 27204949 Glove Cmpr Sm Lf Istnr Opn Fngr Smls 80% Nyl 20% Spndx 23-32 Pr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204950 EAP Custom 27204950 Glove Cmpr Md Lf Istnr Opn Fngr Smls 80% Nyl 20% Spndx 23-32 Pr BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204951 EAP Custom 27204951 Sphere Embl Ylw Embsph 100-300um Mcsph Ns Prefl BOTH IP/OP $608.00 $449.92 $0.00 $486.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $451.26 $451.26 $468.65 $0.00 $126.71 $0.00 $0.00 $0.00 $0.00 $304.00 $481.54 $486.40 $0.00 $395.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204952 EAP Custom 27204952 Sphere Embl Blue Embsph 300-500um Mcsph Ns Prefl BOTH IP/OP $608.00 $449.92 $0.00 $486.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $451.26 $451.26 $468.65 $0.00 $126.71 $0.00 $0.00 $0.00 $0.00 $304.00 $481.54 $486.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204953 EAP CPT® C1894 Set Intro 5fr Mcstk Ntnl Wre Radopq Tip Coax Stf BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $5.95 $0.00 $0.00 $6.05 $0.00 $0.00 $0.00 $0.00 $0.00 27204954 EAP CPT® C1894 Set Intro 5fr Mcstk Radopq Coax Stf Wre Ntnl BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $8.34 $0.00 $23.66 $23.66 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $6.26 $0.00 $0.00 $6.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205000 EAP HCPCS C1769 Guidewire Vasc 175cm .014in Radiopq Tip Snsr Elmt BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27205001 EAP Custom 27205001 Introd Shth 11fr .144in 25cm Rbst Vlv Splt Sdprt BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205003 EAP Custom 27205003 Introd Shth 10fr .131in 25cm Rbst Vlv Splt Sdprt BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205004 EAP Custom 27205004 Introd Shth 10.5fr .138in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205005 EAP Custom 27205005 Introd Shth 10fr .131in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205006 EAP Custom 27205006 Introd Shth 11fr .144in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205007 EAP Custom 27205007 Introd Shth 12.5fr .164in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205008 EAP Custom 27205008 Introd Shth 12fr .158in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205009 EAP Custom 27205009 Introd Shth 6fr .083in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205010 EAP Custom 27205010 Introd Shth 8.5fr .112in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205011 EAP Custom 27205011 Introd Shth 8fr .105in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $193.00 $142.82 $0.00 $148.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.24 $143.24 $148.76 $0.00 $40.22 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205012 EAP Custom 27205012 Introd Shth 9.5fr .125in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205013 EAP Custom 27205013 Introd Shth 9fr .118in 13cm Rbst Vlv Splt Sdprt BOTH IP/OP $191.00 $141.34 $0.00 $147.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.76 $141.76 $147.22 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205014 EAP Custom 27205014 Introd Shth 6fr .083in 25cm Rbst Vlv Splt Sdprt BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205015 EAP Custom 27205015 Introd Shth 9fr .118in 25cm Rbst Vlv Splt Sdprt BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205016 EAP Custom 27205016 Introd Shth 8fr .083in 25cm Rbst Vlv Splt Sdprt BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205017 EAP HCPCS C1894 Introd Shth 7fr 13cm 19.5cm 3w Stpck Traw Hmst Vlv BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $79.28 $79.28 $0.00 $0.00 $0.00 $30.43 $108.36 $108.36 $112.54 $0.00 $30.43 $0.00 $86.36 $86.36 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $0.00 $22.85 $0.00 $0.00 $23.24 $0.00 $0.00 $0.00 $0.00 $0.00 27205018 EAP HCPCS C1894 Introd Shth 9fr 13cm 19.5cm 3w Stpck Traw Hmst Vlv BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $79.28 $79.28 $0.00 $0.00 $0.00 $30.43 $108.36 $108.36 $112.54 $0.00 $30.43 $0.00 $86.36 $86.36 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $0.00 $22.85 $0.00 $0.00 $23.24 $0.00 $0.00 $0.00 $0.00 $0.00 27205019 EAP HCPCS C1894 Introd Lead 23cm 7fr Sfshth Ult Hmst Vlv Lp Traw BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $79.28 $79.28 $0.00 $0.00 $0.00 $30.43 $108.36 $108.36 $112.54 $0.00 $30.43 $0.00 $86.36 $86.36 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $0.00 $22.85 $0.00 $0.00 $23.24 $0.00 $0.00 $0.00 $0.00 $0.00 27205021 EAP HCPCS C1887 Catheter Infus Mic .027in Phenom BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" "$1,541.60" $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 "$1,300.00" $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205022 EAP HCPCS C1887 Catheter Infus 30cm .040in .036in .027in Phenom BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" "$1,541.60" $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205023 EAP HCPCS C1887 Catheter Infs Mic .17in Phenom BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" "$1,541.60" $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205024 EAP HCPCS C1887 Catheter Infus 105cm .061in .055in .044in Phenom BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" "$1,541.60" $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205025 EAP HCPCS C1887 Catheter Infs Mic .45in Phenom BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" "$1,541.60" $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 "$1,300.00" $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205026 EAP HCPCS C1769 Kit Cath 13.5fr 16cm Strl Mh Q+ Strg Xtn Pu Hmdial BOTH IP/OP $115.00 $85.10 $0.00 $92.00 $62.45 $62.45 $0.00 $0.00 $0.00 $23.97 $85.35 $85.35 $88.64 $0.00 $23.97 $0.00 $68.02 $68.02 $0.00 $57.50 $91.08 $92.00 $0.00 $0.00 $0.00 $18.00 $0.00 $0.00 $18.31 $0.00 $0.00 $0.00 $0.00 $0.00 27205027 EAP HCPCS C1769 Kit Cath 19.5cm 13.5fr Pu Mh Q+ Str Extn Hmdial BOTH IP/OP $115.00 $85.10 $0.00 $92.00 $62.45 $62.45 $0.00 $0.00 $0.00 $23.97 $85.35 $85.35 $88.64 $0.00 $23.97 $0.00 $68.02 $68.02 $0.00 $57.50 $91.08 $92.00 $0.00 $0.00 $0.00 $18.00 $0.00 $0.00 $18.31 $0.00 $0.00 $0.00 $0.00 $0.00 27205028 EAP HCPCS C1769 Kit Cath Strg 13.5fr 24cm 7cm Mh Q+ 2 Lum Xtn Pu Hmdial BOTH IP/OP $115.00 $85.10 $0.00 $92.00 $62.45 $62.45 $0.00 $0.00 $0.00 $23.97 $85.35 $85.35 $88.64 $0.00 $23.97 $0.00 $68.02 $68.02 $0.00 $57.50 $91.08 $92.00 $0.00 $0.00 $0.00 $18.00 $0.00 $0.00 $18.31 $0.00 $0.00 $0.00 $0.00 $0.00 27205029 EAP HCPCS C1769 Guidewire Vascular 15d .018in 180cm 5cm Intermedia BOTH IP/OP $216.00 $159.84 $0.00 $172.80 $117.29 $117.29 $0.00 $0.00 $0.00 $45.02 $160.32 $160.32 $166.49 $0.00 $45.01 $0.00 $127.76 $127.76 $0.00 $108.00 $171.07 $172.80 $0.00 $140.40 $0.00 $33.80 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205032 EAP Custom 27205032 Kit Biopsy Tlab Metal Straight Curve L60 Cm L65 Cm BOTH IP/OP "$1,350.00 " $999.00 $0.00 "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,001.97" "$1,001.97" "$1,040.58" $0.00 $281.34 $0.00 $0.00 $0.00 $0.00 $675.00 "$1,069.20" "$1,080.00" $0.00 $877.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205033 EAP HCPCS C1884 System Embolic Protection 3.2-4.2fr 6mm 320cm 190c BOTH IP/OP "$3,488.00 " "$2,581.12" $0.00 "$2,790.40" "$1,893.98" "$1,893.98" $0.00 $0.00 $0.00 $726.99 "$2,588.79" "$2,588.79" "$2,688.55" $0.00 $726.90 $0.00 "$2,063.15" "$2,063.15" $0.00 "$1,744.00" "$2,762.50" "$2,790.40" $0.00 "$2,267.20" $0.00 $545.87 $0.00 $0.00 $555.29 $0.00 $0.00 $0.00 $0.00 $0.00 27205035 EAP Custom 27205035 Catheter Intvn 180- D 2.4-2.9fr .021in 125cm Swift BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,624.80" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 "$3,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205036 EAP HCPCS C1725 Catheter Baldilat Ultra Lp 5fr 1.5mm 12mm 2 Lumen BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27205037 EAP HCPCS C1725 Catheter Baldilat Ultra Lp 5fr 1.5mm 15mm 2 Lumen BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27205038 EAP HCPCS C1725 Catheter Baldilat 2.25mm 10mm Rapex Legend Semicom BOTH IP/OP "$1,033.00 " $764.42 $0.00 $826.40 $560.92 $560.92 $0.00 $0.00 $0.00 $215.30 $766.69 $766.69 $796.24 $0.00 $215.28 $0.00 $611.02 $611.02 $0.00 $516.50 $818.14 $826.40 $0.00 $671.45 $0.00 $161.66 $0.00 $0.00 $164.45 $0.00 $0.00 $0.00 $0.00 $0.00 27205039 EAP HCPCS C1725 Catheter Baldilat Lp 5.3fr 4mm 75cm 20mm High Pres BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27205040 EAP HCPCS C1725 Catheter Baldilat Ultra Lp 5fr 1.5mm 20mm 2 Lumen BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27205041 EAP HCPCS C1725 Catheter Baldilat Ultra Lp 5fr 1.5mm 6mm 2 Lumen R BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27205042 EAP HCPCS C1725 Catheter Baldilat Ultra Lp 5fr 1.5mm 8mm 2 Lumen R BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27205051 EAP HCPCS C1769 Catheter Gd Strg 6fr 115cm Strl Lf Sofia Disp Strk BOTH IP/OP "$4,990.00 " "$3,692.60" $0.00 "$3,992.00" "$2,709.57" "$2,709.57" $0.00 $0.00 $0.00 "$1,040.04" "$3,703.58" "$3,703.58" "$3,846.29" $0.00 "$1,039.92" $0.00 "$2,951.59" "$2,951.59" $0.00 "$2,495.00" "$3,952.08" "$3,992.00" $0.00 "$3,243.50" $0.00 $780.94 $0.00 $0.00 $794.41 $0.00 $0.00 $0.00 $0.00 $0.00 27205052 EAP HCPCS C1887 Catheter Angio Sim 1 Crv 5fr .043in 100cm Gldcath Xp Gld Tch BOTH IP/OP $122.00 $90.28 $0.00 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.00 $96.62 $97.60 $0.00 $0.00 $0.00 $19.09 $0.00 $0.00 $19.42 $0.00 $0.00 $0.00 $0.00 $0.00 27205054 EAP HCPCS C1887 Catheter Angio Ang 5fr .043in 100cm Gldcath Xp Gld Tch 1 Brd BOTH IP/OP $122.00 $90.28 $0.00 $97.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.00 $96.62 $97.60 $0.00 $0.00 $0.00 $19.09 $0.00 $0.00 $19.42 $0.00 $0.00 $0.00 $0.00 $0.00 27205055 EAP HCPCS C1769 Guidewire Vasc 90d .018in 180cm 25cm Gldwr Gt Hdrph BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $331.44 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 27205056 EAP Custom 27205056 Catheter Balloon  6x100mm 135c BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $0.00 $0.00 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205057 EAP HCPCS C1887 Catheter Angio .035in 135cm Navicross Strg Tip BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205058 EAP HCPCS C1887 Catheter Angio .035in 65cm Navicross Strg Tip BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205059 EAP HCPCS C1887 Catheter Angio .038in 1 Crv 5fr 100cm 15cm Gldcath Xp 2 BOTH IP/OP $121.88 $90.19 $0.00 $97.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.94 $96.53 $97.50 $0.00 $0.00 $0.00 $19.07 $0.00 $0.00 $19.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205060 EAP HCPCS C1887 Catheter Angio .038in 5fr 100cm 15cm Gldcath Xp 2 Braid Pu BOTH IP/OP $121.88 $90.19 $0.00 $97.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.94 $96.53 $97.50 $0.00 $0.00 $0.00 $19.07 $0.00 $0.00 $19.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205061 EAP HCPCS C1887 Catheter Angio .038in 5fr 65cm 15cm Gldcath Xp 2 Braid Pu BOTH IP/OP $121.88 $90.19 $0.00 $97.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.94 $96.53 $97.50 $0.00 $0.00 $0.00 $19.07 $0.00 $0.00 $19.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205062 EAP HCPCS C1887 Catheter Angio .038in 5fr 70cm Gldcath Yashiro Tip BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $21.91 $0.00 $0.00 $22.29 $0.00 $0.00 $0.00 $0.00 $0.00 27205063 EAP HCPCS C1887 Catheter Angio .038in J Crv 4fr 65cm 15cm Gldcath Gw Hdrph BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205064 EAP HCPCS C1887 Catheter Angio .038in J Crv 5fr 65cm 25cm Gldcath Gw Hdrph BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205065 EAP HCPCS C1887 Catheter Angio .038in Jb2 Crv 4fr 100cm 15cm Gldcath Gw BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205066 EAP HCPCS C1887 Catheter Angio .038in Jb2 Crv 5fr 100cm 40cm Gldcath Tpr Gw BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205067 EAP HCPCS C1887 Catheter Angio .038in Mani Crv 4fr 100cm 15cm Gldcath Gw BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205068 EAP HCPCS C1887 Catheter Angio .038in Mani Crv 5fr 100cm 40cm Gldcath Gw BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205069 EAP HCPCS C1887 Catheter Angio .038in Sim1 Crv 4fr 100cm 15cm Gldcath Gw BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205070 EAP HCPCS C1887 Catheter Angio .038in Sim2 Crv 5fr 65cm Gldcath 1 Braid BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205071 EAP HCPCS C1887 Catheter Angio .038in Sim3 Crv 4fr 100cm 15cm Gldcath Gw BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205072 EAP HCPCS C1887 Catheter Angio 150cm Navicross Radopq Strg Tip Ss Hdrph BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205073 EAP HCPCS C1887 Catheter Angio 30d 12mm 135cm Navicross 3 Radopq Sprt Ss BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205074 EAP HCPCS C1887 Catheter Angio 30d 12mm 65cm Navicross 3 Radopq Sprt Ss BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205075 EAP HCPCS C1887 Catheter Angio 30d 150cm Navicross Sprt Radopq Ang Tip Hdrph BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205076 EAP HCPCS C1887 Catheter Angio 4fr BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $21.91 $0.00 $0.00 $22.29 $0.00 $0.00 $0.00 $0.00 $0.00 27205077 EAP HCPCS C1887 Catheter Angio 4fr .041in 150cm Gldcath Gld Tch Ang Tip 2 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205078 EAP HCPCS C1887 Catheter Angio Ang 4fr .041in 120cm Gldcath Gld Tch 2 Brd Ss BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205080 EAP HCPCS C1887 Catheter Angio Cbr 1 Crv 4fr .041in 65cm Gldcath Gld Tch 2 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205081 EAP HCPCS C1887 Catheter Angio Cbr 1 Crv 5fr .047in 65cm Gldcath Gld Tch 1 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205082 EAP HCPCS C1887 Catheter Angio Cbr 2 Crv 4fr .041in 100cm Gldcath Gld Tch 2 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205083 EAP HCPCS C1887 Catheter Angio Cbr 2 Crv 5fr .047in 100cm Gldcath Gld Tch 1 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205084 EAP HCPCS C1887 Catheter Angio Cbr 2 Crv 5fr 65cm 15cm Gldcath Xp 2 Brd Jkt BOTH IP/OP $121.88 $90.19 $0.00 $97.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.94 $96.53 $97.50 $0.00 $0.00 $0.00 $19.07 $0.00 $0.00 $19.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205085 EAP HCPCS C1887 Catheter Angio Hdhntr 1 Crv 4fr .041in 100cm Gldcath Gld Tch BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205086 EAP HCPCS C1887 Catheter Angio Mp Crv 4fr .041in 100cm Gldcath Gld Tch 2 Brd BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205088 EAP HCPCS C1887 Catheter Angio Pv Mc 4fr 150cm Gldcath 2 Braid Hdrph Ss BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205089 EAP Catheter Angio Rbt Crv 5fr 90cm Trnb Ad Acpt .035in Gw BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.12 $24.12 $25.05 $0.00 $6.77 $0.00 $0.00 $0.00 $0.00 $16.25 $25.74 $26.00 $0.00 $21.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205090 EAP HCPCS C1887 Catheter Angio Sim2 Crv 4fr 100cm 15cm Gldcath 2 Ss Braid Pu BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205091 EAP HCPCS C1887 Catheter Angio Strg 4fr 150cm Gldcath 2 Braid Hdrph Ss BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205092 EAP HCPCS C1887 Catheter Angio Strg 5fr 150cm Gldcath Xp 2 Braid Hdrph Ss BOTH IP/OP $121.88 $90.19 $0.00 $97.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.94 $96.53 $97.50 $0.00 $0.00 $0.00 $19.07 $0.00 $0.00 $19.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205093 EAP HCPCS C1887 Catheter Angio Strg Crv 4fr .041in 100cm Gldcath Gld Tch 2 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205094 EAP HCPCS C1887 Catheter Angio Strg Crv 4fr .041in 120cm Gldcath Gld Tch 2 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205095 EAP HCPCS C1887 Catheter Angio Strg Crv 4fr .041in 65cm Gldcath Gld Tch 2 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205096 EAP HCPCS C1887 Catheter Angio Strg Crv 5fr .043in 65cm Gldcath Xp Gld Tch 1 BOTH IP/OP $121.88 $90.19 $0.00 $97.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.94 $96.53 $97.50 $0.00 $0.00 $0.00 $19.07 $0.00 $0.00 $19.40 $0.00 $0.00 $0.00 $0.00 $0.00 27205097 EAP HCPCS C1887 Catheter Angio Strg Crv 5fr .047in 65cm Gldcath Gld Tch 1 BOTH IP/OP $121.38 $89.82 $0.00 $97.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 27205098 EAP HCPCS C1725 Catheter Blndil .035in 6fr 3mm 90cm 120mm Metacross Rx Peri BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205099 EAP HCPCS C1725 Catheter Blndil 2.5mm 150cm 200mm Crosperio Otw Pta BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205100 EAP HCPCS C1725 Catheter Blndil 3.5fr 1.5mm 150cm 20mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205101 EAP HCPCS C1725 Catheter Blndil 3.5fr 1.5mm 150cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205102 EAP HCPCS C1725 Catheter Blndil 3.5fr 1.5mm 150cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205103 EAP HCPCS C1725 Catheter Blndil 3.5fr 1.5mm 90cm 120mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205104 EAP HCPCS C1725 Catheter Blndil 3.5fr 1.5mm 90cm 20mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205105 EAP HCPCS C1725 Catheter Blndil 3.5fr 1.5mm 90cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205106 EAP HCPCS C1725 Catheter Blndil 3.5fr 1.5mm 90cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205107 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 150cm 120mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205108 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 150cm 200mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205109 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 150cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205110 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 150cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205111 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 90cm 120mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205112 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 90cm 150mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205113 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 90cm 200mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205114 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 90cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205115 EAP HCPCS C1725 Catheter Blndil 3.5fr 2.5mm 90cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205116 EAP HCPCS C1725 Catheter Blndil 3.5fr 2mm 150cm 150mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205117 EAP HCPCS C1725 Catheter Blndil 3.5fr 2mm 150cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205118 EAP HCPCS C1725 Catheter Blndil 3.5fr 2mm 150cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205119 EAP HCPCS C1725 Catheter Blndil 3.5fr 2mm 90cm 120mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205120 EAP HCPCS C1725 Catheter Blndil 3.5fr 2mm 90cm 150mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205121 EAP HCPCS C1725 Catheter Blndil 3.5fr 2mm 90cm 200mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205122 EAP HCPCS C1725 Catheter Blndil 3.5fr 2mm 90cm 40mm Crosperio Rx Tpr Cor Wre BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205123 EAP HCPCS C1725 Catheter Blndil 3.5fr 2mm 90cm 80mm Crosperio Rx Tpr Cor Wre BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205124 EAP HCPCS C1725 Catheter Blndil 3.5fr 3.5mm 150cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205125 EAP HCPCS C1725 Catheter Blndil 3.5fr 3.5mm 150cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205126 EAP HCPCS C1725 Catheter Blndil 3.5fr 3.5mm 90cm 120mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205127 EAP HCPCS C1725 Catheter Blndil 3.5fr 3.5mm 90cm 150mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205128 EAP HCPCS C1725 Catheter Blndil 3.5fr 3.5mm 90cm 200mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205129 EAP HCPCS C1725 Catheter Blndil 3.5fr 3.5mm 90cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205130 EAP HCPCS C1725 Catheter Blndil 3.5fr 3.5mm 90cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205131 EAP HCPCS C1725 Catheter Blndil 3.5fr 3mm 150cm 150mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205132 EAP HCPCS C1725 Catheter Blndil 3.5fr 3mm 150cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205133 EAP HCPCS C1725 Catheter Blndil 3.5fr 3mm 150cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205134 EAP HCPCS C1725 Catheter Blndil 3.5fr 3mm 90cm 120mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205135 EAP HCPCS C1725 Catheter Blndil 3.5fr 3mm 90cm 150mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205136 EAP HCPCS C1725 Catheter Blndil 3.5fr 3mm 90cm 200mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205138 EAP HCPCS C1725 Catheter Blndil 3.5fr 3mm 90cm 80mm Crosperio Rx Tpr Cor Wre BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205139 EAP HCPCS C1725 Catheter Blndil 3.5fr 4mm 150cm 40mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205140 EAP HCPCS C1725 Catheter Blndil 3.5fr 4mm 150cm 80mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205141 EAP HCPCS C1725 Catheter Blndil 3.5fr 4mm 90cm 120mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205142 EAP HCPCS C1725 Catheter Blndil 3.5fr 4mm 90cm 150mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205143 EAP HCPCS C1725 Catheter Blndil 3.5fr 4mm 90cm 40mm Crosperio Rx Tpr Cor Wre BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205144 EAP HCPCS C1725 Catheter Blndil 3.5fr 4mm 90cm 80mm Crosperio Rx Tpr Cor Wre BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205145 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 150cm 120mm Crosperio Otw Tpr BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205146 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 150cm 20mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205147 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 150cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205148 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 150cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205149 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 65cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205150 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 65cm 20mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205151 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 65cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205152 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 65cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205153 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 90cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205154 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 90cm 20mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205155 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 90cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205156 EAP HCPCS C1725 Catheter Blndil 3.8fr 1.5mm 90cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205157 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 150cm 120mm Crosperio Otw Tpr BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205158 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 150cm 150mm Crosperio Otw Tpr BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205159 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 150cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205161 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 65cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205162 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 65cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205163 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 65cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205164 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 65cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205165 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 65cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205166 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 90cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205167 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 90cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205168 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 90cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205169 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 90cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205170 EAP HCPCS C1725 Catheter Blndil 3.8fr 2.5mm 90cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205171 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 150cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205172 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 150cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205173 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 150cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205174 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 150cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205175 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 150cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205176 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 65cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205177 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 65cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205178 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 65cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205179 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 65cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205180 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 65cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205181 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 90cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205182 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 90cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205183 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 90cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205184 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 90cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205185 EAP HCPCS C1725 Catheter Blndil 3.8fr 2mm 90cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205186 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 150cm 120mm Crosperio Otw Tpr BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205187 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 150cm 150mm Crosperio Otw Tpr BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205188 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 150cm 200mm Crosperio Otw Tpr BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205189 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 150cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205190 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 150cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205191 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 65cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205192 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 65cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205193 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 65cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205194 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 65cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205195 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 65cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205196 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 90cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205197 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 90cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205198 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 90cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205199 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 90cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205200 EAP HCPCS C1725 Catheter Blndil 3.8fr 3.5mm 90cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205201 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 150cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205202 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 150cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205203 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 150cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205204 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 150cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205205 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 65cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205206 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 65cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205207 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 65cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205208 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 65cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205209 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 65cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205210 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 90cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205211 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 90cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205212 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 90cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205213 EAP HCPCS C1725 Catheter Blndil 3.8fr 3mm 90cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205214 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 150cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205215 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 150cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205216 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 150cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205217 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 150cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205218 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 65cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205219 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 65cm 150mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205220 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 65cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205221 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 65cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205222 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 65cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205223 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 90cm 120mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205224 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 90cm 200mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205225 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 90cm 40mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205226 EAP HCPCS C1725 Catheter Blndil 3.8fr 4mm 90cm 80mm Crosperio Otw Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205227 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 150cm 100mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205228 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 150cm 120mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205229 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 150cm 150mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205230 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 150cm 200mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205231 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 150cm 20mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205232 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 150cm 40mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205233 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 150cm 60mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205234 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 150cm 80mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205235 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 90cm 100mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205236 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 90cm 120mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205237 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 90cm 150mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205238 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 90cm 200mm Crosstella Otw Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205239 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 90cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205240 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 90cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205241 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 90cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205242 EAP HCPCS C1725 Catheter Blndil 3.9fr 2.5mm 90cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205243 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 150cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205244 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 150cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205245 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 150cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205246 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 150cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205247 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 150cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205248 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 150cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205249 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 150cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205250 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 150cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205251 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 90cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205252 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 90cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205253 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 90cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205254 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 90cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205255 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 90cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205256 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 90cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205257 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 90cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205258 EAP HCPCS C1725 Catheter Blndil 3.9fr 2mm 90cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205259 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 150cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205260 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 150cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205261 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 150cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205262 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 150cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205263 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 150cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205264 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 150cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205265 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 150cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205266 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 150cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205267 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 90cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205268 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 90cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205269 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 90cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205270 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 90cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205271 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 90cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205272 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 90cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205273 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 90cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205274 EAP HCPCS C1725 Catheter Blndil 3.9fr 3mm 90cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205275 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 150cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205276 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 150cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205277 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 150cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205278 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 150cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205279 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 150cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205280 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 150cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205281 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 150cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205282 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 150cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205283 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 90cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205284 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 90cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205285 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 90cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205286 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 90cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205287 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 90cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205288 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 90cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205289 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 90cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205290 EAP HCPCS C1725 Catheter Blndil 3.9fr 4mm 90cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205291 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205292 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205293 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205294 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205295 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205296 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205297 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205298 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205299 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205300 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 150cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205301 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205302 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205303 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205304 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205305 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205306 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205307 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 40mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205308 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205309 EAP HCPCS C1725 Catheter Blndil 4.3fr 5mm 90cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205310 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 150cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205311 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 150cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205312 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 150cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205313 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 150cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205314 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 150cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205315 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 150cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205316 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 90cm 100mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205317 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 90cm 120mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205318 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 90cm 150mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205319 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 90cm 200mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205320 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 90cm 20mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205321 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 90cm 60mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205322 EAP HCPCS C1725 Catheter Blndil 4.3fr 6mm 90cm 80mm Crosstella Otw Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205323 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 150cm 100mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205324 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 150cm 120mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205325 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 150cm 150mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205326 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 150cm 200mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205327 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 150cm 20mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205328 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 150cm 40mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205329 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 150cm 60mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205330 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 150cm 80mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205331 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 90cm 100mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205332 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 90cm 120mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205333 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 90cm 150mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205334 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 90cm 200mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205335 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 90cm 20mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205336 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 90cm 40mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205337 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 90cm 60mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205338 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2.5mm 90cm 80mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205339 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 100mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205340 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 120mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205341 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 150mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205342 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 200mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205343 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 200mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205344 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205345 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205346 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205347 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 150cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205348 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 100mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205349 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 120mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205350 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 150mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205351 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 200mm Crosperio Rx Tpr Cor BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205352 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 200mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205353 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205354 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205355 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205356 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 2mm 90cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205357 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 150cm 100mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205358 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 150cm 120mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205359 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 150cm 150mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205360 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 150cm 200mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205361 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 150cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205362 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 150cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205363 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 150cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205364 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 150cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205365 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 90cm 100mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205366 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 90cm 120mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205367 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 90cm 150mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205368 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 90cm 200mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205369 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 90cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205370 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 90cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205371 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 90cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205372 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 3mm 90cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205373 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 150cm 100mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205374 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 150cm 120mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205375 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 150cm 150mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205376 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 150cm 200mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205377 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 150cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205378 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 150cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205379 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 150cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205380 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 150cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205381 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 90cm 100mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205382 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 90cm 120mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205383 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 90cm 150mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205384 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 90cm 200mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205385 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 90cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205386 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 90cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205387 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 90cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205388 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 4mm 90cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205389 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 5mm 150cm 100mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205390 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 5mm 150cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205391 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 5mm 150cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205392 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 5mm 150cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205393 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 5mm 150cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205394 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 5mm 90cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205395 EAP HCPCS C1725 Catheter Blndil 4-3.4fr 5mm 90cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205396 EAP HCPCS C1725 Catheter Blndil 4-3.9fr 6mm 150cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205397 EAP HCPCS C1725 Catheter Blndil 4-3.9fr 6mm 150cm 40mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205398 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 5mm 150cm 120mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205399 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 5mm 150cm 150mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205401 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 5mm 90cm 100mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205402 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 5mm 90cm 120mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205403 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 5mm 90cm 150mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205404 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 5mm 90cm 200mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205405 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 5mm 90cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205406 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 5mm 90cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205407 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 150cm 100mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205408 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 150cm 120mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205409 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 150cm 150mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205410 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 150cm 200mm Crosstella Rx Tpr BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205411 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 150cm 60mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205412 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 150cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205413 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 90cm 100mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205414 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 90cm 120mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205415 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 90cm 150mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205416 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 90cm 200mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205417 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 90cm 20mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205419 EAP HCPCS C1725 Catheter Blndil 4-4.1fr 6mm 90cm 80mm Crosstella Rx Tpr Cor BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205420 EAP HCPCS C1725 Catheter Blndil 4fr 1.5mm 150cm 120mm Crosperio Rx Acpt .014 BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205421 EAP HCPCS C1725 Catheter Blndil 4fr 2.5mm 150cm 150mm Crosperio Rx Acpt .014 BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205422 EAP HCPCS C1725 Catheter Blndil 4fr 2mm 150cm 120mm Crosperio Rx Acpt .014in BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205423 EAP HCPCS C1725 Catheter Blndil 4fr 2mm 150cm 200mm Crosperio Rx Acpt .014in BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205424 EAP HCPCS C1725 Catheter Blndil 4fr 3.5mm 150cm 120mm Crosperio Rx Acpt .014 BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205425 EAP HCPCS C1725 Catheter Blndil 4fr 3.5mm 150cm 150mm Crosperio Rx Acpt .014 BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205427 EAP HCPCS C1725 Catheter Blndil 4fr 3mm 150cm 120mm Crosperio Rx Acpt .014in BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205428 EAP HCPCS C1725 Catheter Blndil 4fr 3mm 150cm 200mm Crosperio Rx Acpt .014in BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205429 EAP HCPCS C1725 Catheter Blndil 4fr 3mm 150cm 200mm Crosperio Rx Otw Acpt BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205430 EAP HCPCS C1725 Catheter Blndil 4fr 3mm 90cm 200mm Crosperio Rx Otw Acpt BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205431 EAP HCPCS C1725 Catheter Blndil 4fr 4mm 150cm 120mm Crosperio Rx Acpt .014in BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205432 EAP HCPCS C1725 Catheter Blndil 4fr 4mm 150cm 150mm Crosperio Rx Acpt .014in BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205433 EAP HCPCS C1725 Catheter Blndil 4fr 4mm 150cm 200mm Crosperio Rx Otw Acpt BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205434 EAP HCPCS C1725 Catheter Blndil 4mm 90cm 150mm Crosperio Otw Pta BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $414.31 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 27205435 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 135cm 100mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205436 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 135cm 120mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205437 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 135cm 150mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205438 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 135cm 200mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205439 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 135cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205440 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 135cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205441 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 135cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205442 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 65cm 100mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205443 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 65cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205444 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 65cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205445 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 65cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205446 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205447 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 65cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205448 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 65cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205449 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 65cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205450 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 100mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205451 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205452 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205453 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205454 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205455 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205456 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205457 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205458 EAP HCPCS C1725 Catheter Blndil 5.4fr 3mm 90cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205459 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 135cm 100mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205460 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 135cm 150mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205461 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 135cm 200mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205462 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 135cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205463 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 135cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205464 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 135cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205465 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 135cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205466 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 65cm 100mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205467 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 65cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205468 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 65cm 150mm Metacross Otw Tpr Cor BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205469 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 65cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205470 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205471 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 65cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205472 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 65cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205473 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 65cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205474 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 90cm 100mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205475 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 90cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205476 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 90cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205477 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 90cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205478 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 90cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205479 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 90cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205480 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 90cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205481 EAP HCPCS C1725 Catheter Blndil 5.4fr 4mm 90cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205482 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 135cm 100mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205483 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 135cm 120mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205484 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 135cm 150mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205485 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 135cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205486 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 135cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205487 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 135cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205488 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 65cm 100mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205489 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 65cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205490 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 65cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205491 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 65cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205492 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205493 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 65cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205494 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 65cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205495 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 65cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205496 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 90cm 100mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205497 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 90cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205498 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 90cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205499 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 90cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205500 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 90cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205501 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 90cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205502 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 90cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205503 EAP HCPCS C1725 Catheter Blndil 5.4fr 5mm 90cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205504 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 135cm 100mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205505 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 135cm 120mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205506 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 135cm 150mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205507 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 135cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205508 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 135cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205509 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 135cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205510 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 135cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205511 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 135cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205512 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 65cm 100mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205513 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 65cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205514 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205515 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 65cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205516 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 90cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205518 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 90cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205519 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 90cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205520 EAP HCPCS C1725 Catheter Blndil 5.4fr 6mm 90cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205521 EAP HCPCS C1725 Catheter Blndil 5.7-3.6-9fr 9mm 90cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205522 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 10mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205523 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 10mm 135cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205524 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 10mm 135cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205526 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 10mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205527 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 10mm 90cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205528 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 10mm 90cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205529 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 10mm 90cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205530 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 12mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205531 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 12mm 135cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205532 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 12mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205534 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 135cm 100mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205535 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 135cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205536 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 135cm 150mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205537 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 135cm 200mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205538 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205539 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 135cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205540 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 135cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205542 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 90cm 150mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205543 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 90cm 200mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205544 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205545 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 90cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205546 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 3mm 90cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205547 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 135cm 100mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205548 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 135cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205549 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 135cm 150mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205550 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 135cm 200mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205551 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205552 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 135cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205553 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 135cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205554 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 135cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205555 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 90cm 100mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205556 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 90cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205557 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 90cm 150mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205559 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205560 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 90cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205561 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 90cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205562 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 90cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205563 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 4mm 90cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205564 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 135cm 100mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205565 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 135cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205567 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 135cm 200mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205568 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205569 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 135cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205570 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 135cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205571 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 135cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205572 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 90cm 100mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205573 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 90cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205575 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 90cm 200mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205576 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205577 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 90cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205578 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 90cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205579 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 5mm 90cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205580 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 135cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205581 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 135cm 150mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205583 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205584 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 135cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205585 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 135cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205586 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 90cm 100mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205587 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 90cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205588 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 90cm 150mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205589 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 90cm 200mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205590 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205591 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 90cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205592 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 90cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205593 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 6mm 90cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205594 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 135cm 100mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205595 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 135cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205596 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 135cm 150mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205597 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 135cm 200mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205598 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205599 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 135cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205600 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 135cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205601 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 135cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205602 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 90cm 100mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205603 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 90cm 120mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205604 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 90cm 150mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205605 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 90cm 200mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205606 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205607 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 90cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205608 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 90cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205609 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 7mm 90cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205610 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 8mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205611 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 8mm 135cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205612 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 8mm 135cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205613 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 8mm 135cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205614 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 8mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205615 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 8mm 90cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205616 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 8mm 90cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205617 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 8mm 90cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205618 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 9mm 135cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205619 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 9mm 135cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205620 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 9mm 135cm 60mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205621 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 9mm 135cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205622 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 9mm 90cm 20mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205623 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 9mm 90cm 40mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205624 EAP HCPCS C1725 Catheter Blndil 5.7-3.9fr 9mm 90cm 80mm Metacross Rx Gw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205625 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 135cm 20mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205626 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 135cm 40mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205627 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 135cm 60mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205628 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 135cm 80mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205629 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205630 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 65cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205631 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 65cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205633 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 90cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205634 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 90cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205635 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 90cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205636 EAP HCPCS C1725 Catheter Blndil 5.7fr 10mm 90cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205637 EAP HCPCS C1725 Catheter Blndil 5.7fr 12mm 135cm 20mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205638 EAP HCPCS C1725 Catheter Blndil 5.7fr 12mm 135cm 40mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205639 EAP HCPCS C1725 Catheter Blndil 5.7fr 12mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205641 EAP HCPCS C1725 Catheter Blndil 5.7fr 12mm 90cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205642 EAP HCPCS C1725 Catheter Blndil 5.7fr 12mm 90cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205643 EAP HCPCS C1725 Catheter Blndil 5.7fr 6mm 135cm 200mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205644 EAP HCPCS C1725 Catheter Blndil 5.7fr 6mm 65cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205645 EAP HCPCS C1725 Catheter Blndil 5.7fr 6mm 65cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205646 EAP HCPCS C1725 Catheter Blndil 5.7fr 6mm 65cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205647 EAP HCPCS C1725 Catheter Blndil 5.7fr 6mm 90cm 100mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205648 EAP HCPCS C1725 Catheter Blndil 5.7fr 6mm 90cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205649 EAP HCPCS C1725 Catheter Blndil 5.7fr 6mm 90cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205650 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 135cm 100mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205651 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 135cm 120mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205652 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 135cm 150mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205653 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 135cm 200mm Metacross 2 Lum Otw BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205654 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 135cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205655 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 135cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205656 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 135cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205658 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 65cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205659 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 65cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205660 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 65cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205661 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205662 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 65cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205663 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 65cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205664 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 65cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205666 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 90cm 120mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205667 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 90cm 150mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205668 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 90cm 200mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205669 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 90cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205670 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 90cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205671 EAP HCPCS C1725 Catheter Blndil 5.7fr 7mm 90cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205672 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 135cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205673 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 135cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205674 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 135cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205675 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 135cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205676 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205677 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 65cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205678 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 65cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205679 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 65cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205680 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 90cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205682 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 90cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205683 EAP HCPCS C1725 Catheter Blndil 5.7fr 8mm 90cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205684 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 135cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205685 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 135cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205686 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 135cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205687 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 135cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205688 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 65cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205689 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 65cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205690 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 65cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205691 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 65cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205692 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 90cm 20mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205693 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 90cm 40mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205694 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 90cm 60mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205695 EAP HCPCS C1725 Catheter Blndil 5.7fr 9mm 90cm 80mm Metacross 2 Lum Otw Tpr BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205696 EAP HCPCS C1725 Catheter Blndil 5fr 4mm 135cm 120mm Metacross Otw 2 Lum Shft BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205697 EAP HCPCS C1725 Catheter Blndil 5fr 5mm 135cm 200mm Metacross Otw 2 Lum Shft BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205698 EAP HCPCS C1725 Catheter Blndil 5fr 5mm 135cm 20mm Metacross Otw 2 Lum Shft BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205700 EAP HCPCS C1725 Catheter Blndil 5fr 6mm 90cm 40mm Crosstella Rx Tpr Cor Wre BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $356.50 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 27205701 EAP HCPCS C1725 Catheter Blndil 5fr 6mm 90cm 40mm Metacross Otw 2 Lum Shft BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205702 EAP HCPCS C1725 Catheter Blndil 6fr 4mm 135cm 60mm Metacross Rx Loow Prfl BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205703 EAP HCPCS C1725 Catheter Blndil 6mm 135cm 40mm Metacross Rx Sm Prfl Acpt BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $154.76 $154.76 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $219.68 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 27205704 EAP HCPCS C1887 Catheter Intvn .021in 2.8fr 150cm 160cm Progreat Gldwr BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $705.90 $705.90 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 "$1,002.04" $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 27205705 EAP HCPCS C1887 Catheter Intvn .021in 750 Psi 2.4fr 150cm 90cm Progreat Mcth BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $420.83 $420.83 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $597.37 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $503.75 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 27205706 EAP HCPCS C1887 Catheter Intvn .021in Mic 2.4-2.9fr .022in 130cm Progreat BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $420.83 $420.83 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $597.37 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $503.75 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 27205708 EAP HCPCS C1887 Catheter Intvn 2.7-2.9fr .021in 130cm Progreat Mcth Coax BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $705.90 $705.90 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 "$1,002.04" $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 27205709 EAP HCPCS C1887 Catheter Intvn 2.7-2.9fr .025in 110cm Progreat Mcth Coax BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $705.90 $705.90 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 "$1,002.04" $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 27205710 EAP HCPCS C1887 Catheter Intvn 2.7fr .021in 110cm 50cm Progreat Mcth Shp Tip BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $420.83 $420.83 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $597.37 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 27205711 EAP HCPCS C1887 Catheter Intvn Mic 2.4-2.9fr .022in 110cm Progreat Coax BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $420.83 $420.83 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $597.37 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 27205712 EAP HCPCS C1887 Catheter Intvn Mic 2.8-3fr .027in 110cm 50cm Progreat Coax BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $705.90 $705.90 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 "$1,002.04" $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 27205713 EAP HCPCS C1887 Catheter Intvn Mic 2.8-3fr .027in 130cm 17cm Progreat Mrkr BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $420.83 $420.83 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $597.37 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 27205714 EAP HCPCS C1887 Catheter Intvn Mic 2.8fr .027in 150cm 90cm Progreat Hmst Vlv BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 27205715 EAP HCPCS C1887 Catheter Sprt 30d 12mm 90cm Strl Lf 40cm Navicross Radopq BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $232.13 $232.13 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $329.52 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205716 EAP Custom 27205716 Device Infl 25cc Strl Solopath Stpck BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.64 $81.64 $84.79 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205717 EAP Custom 27205717 Device Infl 30 Atm 25ml Strl Solopath Excel Stpck BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.64 $81.64 $84.79 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205718 EAP HCPCS C1769 Form Submission .018 Ang 300cm Gw Cert BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $86.08 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 27205719 EAP HCPCS C1769 Guidewire Srg 45d .018in 180cm 3cm Gldwr Gl Ang Flx Tp Hdrph BOTH IP/OP $301.25 $222.93 $0.00 $241.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.63 $238.59 $241.00 $0.00 $0.00 $0.00 $47.15 $0.00 $0.00 $47.96 $0.00 $0.00 $0.00 $0.00 $0.00 27205720 EAP HCPCS C1769 Guidewire Srg 45d .018in 180cm 5cm Gldwr Hdrph BOTH IP/OP $301.25 $222.93 $0.00 $241.00 $163.58 $163.58 $0.00 $0.00 $0.00 $62.79 $223.59 $223.59 $232.20 $0.00 $62.78 $0.00 $178.19 $178.19 $0.00 $150.63 $238.59 $241.00 $0.00 $0.00 $0.00 $47.15 $0.00 $0.00 $47.96 $0.00 $0.00 $0.00 $0.00 $0.00 27205721 EAP HCPCS C1769 Guidewire Srg 70d .018in 180cm 3cm Gldwr Au Tip Ang Hdrph BOTH IP/OP $301.25 $222.93 $0.00 $241.00 $163.58 $163.58 $0.00 $0.00 $0.00 $62.79 $223.59 $223.59 $232.20 $0.00 $62.78 $0.00 $178.19 $178.19 $0.00 $150.63 $238.59 $241.00 $0.00 $0.00 $0.00 $47.15 $0.00 $0.00 $47.96 $0.00 $0.00 $0.00 $0.00 $0.00 27205722 EAP HCPCS C1769 Guidewire Srg Ang .018in 180cm 5cm Gldwr Hdrph BOTH IP/OP $301.25 $222.93 $0.00 $241.00 $163.58 $163.58 $0.00 $0.00 $0.00 $62.79 $223.59 $223.59 $232.20 $0.00 $62.78 $0.00 $178.19 $178.19 $0.00 $150.63 $238.59 $241.00 $0.00 $0.00 $0.00 $47.15 $0.00 $0.00 $47.96 $0.00 $0.00 $0.00 $0.00 $0.00 27205723 EAP HCPCS C1769 Guidewire Vasc 3mm Std .035in 150cm 3cm Gldwr Jtp Ntnl Hdrph BOTH IP/OP $72.50 $53.65 $0.00 $58.00 $39.37 $39.37 $0.00 $0.00 $0.00 $15.11 $53.81 $53.81 $55.88 $0.00 $15.11 $0.00 $42.88 $42.88 $0.00 $36.25 $57.42 $58.00 $0.00 $0.00 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 27205724 EAP HCPCS C1769 Guidewire Vasc 3mm Std .038in 150cm 3cm Gldwr Jtp Ntnl Hdrph BOTH IP/OP $72.50 $53.65 $0.00 $58.00 $39.37 $39.37 $0.00 $0.00 $0.00 $15.11 $53.81 $53.81 $55.88 $0.00 $15.11 $0.00 $42.88 $42.88 $0.00 $36.25 $57.42 $58.00 $0.00 $0.00 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 27205725 EAP HCPCS C1769 Guidewire Vasc 45d .018in 300cm 3cm Gldwr Hdrph BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $232.13 $232.13 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $329.52 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205726 EAP HCPCS C1769 Guidewire Vasc 45d .018in 300cm 5cm Gldwr Hdrph BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $232.13 $232.13 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $329.52 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205727 EAP HCPCS C1769 Guidewire Vasc 45d Std .018in 180cm 25cm Grind Flxb BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $264.71 $264.71 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $375.77 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 27205728 EAP HCPCS C1769 Guidewire Vasc 70d .018in 300cm 3cm Gldwr Hdrph BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $232.13 $232.13 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $329.52 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205729 EAP HCPCS C1769 Guidewire Vasc 70d .018in 300cm 5cm Gldwr Hdrph BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $232.13 $232.13 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $329.52 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 27205730 EAP HCPCS C1769 Guidewire Vasc Ang .014in 180cm BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27205731 EAP HCPCS C1769 Guidewire Vasc Ang .014in 300cm BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $305.44 $305.44 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $433.58 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 27205732 EAP HCPCS C1769 Guidewire Vasc Ang .018in 150cm 3cm Gldwr Hdrph BOTH IP/OP $134.38 $99.44 $0.00 $107.50 $72.97 $72.97 $0.00 $0.00 $0.00 $28.01 $99.74 $99.74 $103.58 $0.00 $28.00 $0.00 $79.49 $79.49 $0.00 $67.19 $106.43 $107.50 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205733 EAP HCPCS C1769 Guidewire Vasc Ang .018in 80cm 3cm Gldwr Hdrph BOTH IP/OP $134.38 $99.44 $0.00 $107.50 $72.97 $72.97 $0.00 $0.00 $0.00 $28.01 $99.74 $99.74 $103.58 $0.00 $28.00 $0.00 $79.49 $79.49 $0.00 $67.19 $106.43 $107.50 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205734 EAP HCPCS C1769 Guidewire Vasc Ang .025in 150cm 3cm Gldwr Hdrph BOTH IP/OP $101.13 $74.84 $0.00 $80.90 $54.91 $54.91 $0.00 $0.00 $0.00 $21.08 $75.06 $75.06 $77.95 $0.00 $21.08 $0.00 $59.82 $59.82 $0.00 $50.57 $80.09 $80.90 $0.00 $65.73 $0.00 $15.83 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $0.00 27205735 EAP HCPCS C1769 Guidewire Vasc Ang .025in 180cm 3cm Gldwr Hdrph BOTH IP/OP $134.38 $99.44 $0.00 $107.50 $72.97 $72.97 $0.00 $0.00 $0.00 $28.01 $99.74 $99.74 $103.58 $0.00 $28.00 $0.00 $79.49 $79.49 $0.00 $67.19 $106.43 $107.50 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205736 EAP HCPCS C1769 Guidewire Vasc Ang .025in 260cm 3cm Gldwr Hdrph BOTH IP/OP $144.00 $106.56 $0.00 $115.20 $78.19 $78.19 $0.00 $0.00 $0.00 $30.01 $106.88 $106.88 $111.00 $0.00 $30.01 $0.00 $85.18 $85.18 $0.00 $72.00 $114.05 $115.20 $0.00 $93.60 $0.00 $22.54 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $0.00 27205737 EAP HCPCS C1769 Guidewire Vasc Ang .035in 80cm 3cm Gldwr Stf Shft Hdrph BOTH IP/OP $112.88 $83.53 $0.00 $90.30 $61.29 $61.29 $0.00 $0.00 $0.00 $23.53 $83.78 $83.78 $87.01 $0.00 $23.52 $0.00 $66.77 $66.77 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $0.00 $17.67 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 27205738 EAP HCPCS C1769 Guidewire Vasc Ang .038in 150cm 3cm Gldwr Hdrph BOTH IP/OP $72.50 $53.65 $0.00 $58.00 $39.37 $39.37 $0.00 $0.00 $0.00 $15.11 $53.81 $53.81 $55.88 $0.00 $15.11 $0.00 $42.88 $42.88 $0.00 $36.25 $57.42 $58.00 $0.00 $0.00 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 27205739 EAP HCPCS C1769 Guidewire Vasc Ang .038in 80cm 3cm Gldwr Hdrph BOTH IP/OP $72.50 $53.65 $0.00 $58.00 $39.37 $39.37 $0.00 $0.00 $0.00 $15.11 $53.81 $53.81 $55.88 $0.00 $15.11 $0.00 $42.88 $42.88 $0.00 $36.25 $57.42 $58.00 $0.00 $0.00 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 27205740 EAP HCPCS C1769 Guidewire Vasc Ang .038in 80cm 3cm Gldwr Stf Shft Hdrph BOTH IP/OP $112.88 $83.53 $0.00 $90.30 $61.29 $61.29 $0.00 $0.00 $0.00 $23.53 $83.78 $83.78 $87.01 $0.00 $23.52 $0.00 $66.77 $66.77 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $0.00 $17.67 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 27205741 EAP HCPCS C1769 Guidewire Vasc Ang Lng Tpr .035in 150cm 5cm Gldwr Stf Shft BOTH IP/OP $112.88 $83.53 $0.00 $90.30 $61.29 $61.29 $0.00 $0.00 $0.00 $23.53 $83.78 $83.78 $87.01 $0.00 $23.52 $0.00 $66.77 $66.77 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $0.00 $17.67 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 27205742 EAP HCPCS C1769 Guidewire Vasc Ang Lng Tpr .035in 260cm 5cm Gldwr Stf Shft BOTH IP/OP $124.63 $92.23 $0.00 $99.70 $67.67 $67.67 $0.00 $0.00 $0.00 $25.98 $92.50 $92.50 $96.06 $0.00 $25.97 $0.00 $73.72 $73.72 $0.00 $62.32 $98.71 $99.70 $0.00 $0.00 $0.00 $19.50 $0.00 $0.00 $19.84 $0.00 $0.00 $0.00 $0.00 $0.00 27205743 EAP HCPCS C1769 Guidewire Vasc Ang Lng Tpr .038in 150cm 5cm Gldwr Stf Shft BOTH IP/OP $112.88 $83.53 $0.00 $90.30 $61.29 $61.29 $0.00 $0.00 $0.00 $23.53 $83.78 $83.78 $87.01 $0.00 $23.52 $0.00 $66.77 $66.77 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $0.00 $17.67 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 27205744 EAP HCPCS C1769 Guidewire Vasc Ang Std .035in 120cm 3cm Gldwr Jkt Cor To Tip BOTH IP/OP $72.50 $53.65 $0.00 $58.00 $39.37 $39.37 $0.00 $0.00 $0.00 $15.11 $53.81 $53.81 $55.88 $0.00 $15.11 $0.00 $42.88 $42.88 $0.00 $36.25 $57.42 $58.00 $0.00 $0.00 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 27205745 EAP HCPCS C1769 Guidewire Vasc Ang Std .035in 150cm 1cm Gldwr Jkt Cor To Tip BOTH IP/OP $72.50 $53.65 $0.00 $58.00 $39.37 $39.37 $0.00 $0.00 $0.00 $15.11 $53.81 $53.81 $55.88 $0.00 $15.11 $0.00 $42.88 $42.88 $0.00 $36.25 $57.42 $58.00 $0.00 $0.00 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 27205746 EAP HCPCS C1769 Guidewire Vasc Ang Std .035in 180cm 1cm Gldwr Jkt Cor To Tip BOTH IP/OP $99.25 $73.45 $0.00 $79.40 $53.89 $53.89 $0.00 $0.00 $0.00 $20.69 $73.66 $73.66 $76.50 $0.00 $20.68 $0.00 $58.71 $58.71 $0.00 $49.63 $78.61 $79.40 $0.00 $0.00 $0.00 $15.53 $0.00 $0.00 $15.80 $0.00 $0.00 $0.00 $0.00 $0.00 27205747 EAP HCPCS C1769 Guidewire Vasc Ang Std .035in 260cm 1cm Gldwr Jkt Cor To Tip BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $60.27 $60.27 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $85.56 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 27205748 EAP HCPCS C1769 Guidewire Vasc Ang Tpr .035in 150cm 1cm Gldwr Hdrph BOTH IP/OP $112.88 $83.53 $0.00 $90.30 $61.29 $61.29 $0.00 $0.00 $0.00 $23.53 $83.78 $83.78 $87.01 $0.00 $23.52 $0.00 $66.77 $66.77 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $0.00 $17.67 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 27205749 EAP HCPCS C1769 Guidewire Vasc Bolia Crv Std .035in 180cm 5cm Gldwr Jkt Cor BOTH IP/OP $101.13 $74.84 $0.00 $80.90 $54.91 $54.91 $0.00 $0.00 $0.00 $21.08 $75.06 $75.06 $77.95 $0.00 $21.08 $0.00 $59.82 $59.82 $0.00 $50.57 $80.09 $80.90 $0.00 $0.00 $0.00 $15.83 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $0.00 27205750 EAP HCPCS C1769 Guidewire Vasc Bolia Crv Std .035in 180cm 8cm Gldwr Jkt Cor BOTH IP/OP $101.13 $74.84 $0.00 $80.90 $54.91 $54.91 $0.00 $0.00 $0.00 $21.08 $75.06 $75.06 $77.95 $0.00 $21.08 $0.00 $59.82 $59.82 $0.00 $50.57 $80.09 $80.90 $0.00 $0.00 $0.00 $15.83 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $0.00 27205751 EAP HCPCS C1769 Guidewire Vasc Std Ang .018in 180cm 3cm Gldwr Trmo Gld Tch BOTH IP/OP $134.38 $99.44 $0.00 $107.50 $72.97 $72.97 $0.00 $0.00 $0.00 $28.01 $99.74 $99.74 $103.58 $0.00 $28.00 $0.00 $79.49 $79.49 $0.00 $67.19 $106.43 $107.50 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205752 EAP HCPCS C1769 Guidewire Vasc Std Strg .035in 150cm 1cm Gldwr Jkt Cor To BOTH IP/OP $72.50 $53.65 $0.00 $58.00 $39.37 $39.37 $0.00 $0.00 $0.00 $15.11 $53.81 $53.81 $55.88 $0.00 $15.11 $0.00 $42.88 $42.88 $0.00 $36.25 $57.42 $58.00 $0.00 $47.13 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 27205753 EAP HCPCS C1769 Guidewire Vasc Std Strg .035in 180cm 1cm Gldwr Jkt Cor To BOTH IP/OP $99.25 $73.45 $0.00 $79.40 $53.89 $53.89 $0.00 $0.00 $0.00 $20.69 $73.66 $73.66 $76.50 $0.00 $20.68 $0.00 $58.71 $58.71 $0.00 $49.63 $78.61 $79.40 $0.00 $0.00 $0.00 $15.53 $0.00 $0.00 $15.80 $0.00 $0.00 $0.00 $0.00 $0.00 27205754 EAP HCPCS C1769 Guidewire Vasc Std Strg .035in 260cm 1cm Gldwr Jkt Cor To BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $60.27 $60.27 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $85.56 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 27205755 EAP HCPCS C1769 Guidewire Vasc Strg .018in 150cm 3cm Gldwr Hdrph BOTH IP/OP $134.38 $99.44 $0.00 $107.50 $72.97 $72.97 $0.00 $0.00 $0.00 $28.01 $99.74 $99.74 $103.58 $0.00 $28.00 $0.00 $79.49 $79.49 $0.00 $67.19 $106.43 $107.50 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205756 EAP HCPCS C1769 Guidewire Vasc Strg .018in 150cm 3cm Gldwr Shp Tip Hdrph BOTH IP/OP $137.38 $101.66 $0.00 $109.90 $74.60 $74.60 $0.00 $0.00 $0.00 $28.63 $101.96 $101.96 $105.89 $0.00 $28.63 $0.00 $81.26 $81.26 $0.00 $68.69 $108.80 $109.90 $0.00 $0.00 $0.00 $21.50 $0.00 $0.00 $21.87 $0.00 $0.00 $0.00 $0.00 $0.00 27205757 EAP HCPCS C1769 Guidewire Vasc Strg .018in 180cm 3cm Gldwr Hdrph BOTH IP/OP $134.38 $99.44 $0.00 $107.50 $72.97 $72.97 $0.00 $0.00 $0.00 $28.01 $99.74 $99.74 $103.58 $0.00 $28.00 $0.00 $79.49 $79.49 $0.00 $67.19 $106.43 $107.50 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205758 EAP HCPCS C1769 Guidewire Vasc Strg .018in 260cm 3cm Gldwr Hdrph BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $100.46 $100.46 $0.00 $0.00 $0.00 $38.56 $137.31 $137.31 $142.60 $0.00 $38.55 $0.00 $109.43 $109.43 $0.00 $92.50 $146.52 $148.00 $0.00 $0.00 $0.00 $28.95 $0.00 $0.00 $29.45 $0.00 $0.00 $0.00 $0.00 $0.00 27205759 EAP HCPCS C1769 Guidewire Vasc Strg .025in 150cm 3cm Gldwr Hdrph BOTH IP/OP $101.13 $74.84 $0.00 $80.90 $54.91 $54.91 $0.00 $0.00 $0.00 $21.08 $75.06 $75.06 $77.95 $0.00 $21.08 $0.00 $59.82 $59.82 $0.00 $50.57 $80.09 $80.90 $0.00 $0.00 $0.00 $15.83 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $0.00 27205760 EAP HCPCS C1769 Guidewire Vasc Strg .025in 180cm 3cm Gldwr Hdrph BOTH IP/OP $134.38 $99.44 $0.00 $107.50 $72.97 $72.97 $0.00 $0.00 $0.00 $28.01 $99.74 $99.74 $103.58 $0.00 $28.00 $0.00 $79.49 $79.49 $0.00 $67.19 $106.43 $107.50 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205761 EAP HCPCS C1769 Guidewire Vasc Strg .025in 260cm 3cm Gldwr Hdrph BOTH IP/OP $144.00 $106.56 $0.00 $115.20 $78.19 $78.19 $0.00 $0.00 $0.00 $30.01 $106.88 $106.88 $111.00 $0.00 $30.01 $0.00 $85.18 $85.18 $0.00 $72.00 $114.05 $115.20 $0.00 $0.00 $0.00 $22.54 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $0.00 27205762 EAP HCPCS C1769 Guidewire Vasc Strg .032in 150cm 3cm Gldwr Hdrph BOTH IP/OP $74.00 $54.76 $0.00 $59.20 $40.18 $40.18 $0.00 $0.00 $0.00 $15.42 $54.92 $54.92 $57.04 $0.00 $15.42 $0.00 $43.77 $43.77 $0.00 $37.00 $58.61 $59.20 $0.00 $0.00 $0.00 $11.58 $0.00 $0.00 $11.78 $0.00 $0.00 $0.00 $0.00 $0.00 27205763 EAP HCPCS C1769 Guidewire Vasc Strg .035in 150cm 3cm Gldwr Shp Tip Hdrph BOTH IP/OP $79.75 $59.02 $0.00 $63.80 $43.30 $43.30 $0.00 $0.00 $0.00 $16.62 $59.19 $59.19 $61.47 $0.00 $16.62 $0.00 $47.17 $47.17 $0.00 $39.88 $63.16 $63.80 $0.00 $0.00 $0.00 $12.48 $0.00 $0.00 $12.70 $0.00 $0.00 $0.00 $0.00 $0.00 27205764 EAP HCPCS C1769 Guidewire Vasc Strg .035in 180cm 3cm Gldwr Shp Tip Hdrph BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $58.10 $58.10 $0.00 $0.00 $0.00 $22.30 $79.42 $79.42 $82.48 $0.00 $22.30 $0.00 $63.29 $63.29 $0.00 $53.50 $84.74 $85.60 $0.00 $69.55 $0.00 $16.75 $0.00 $0.00 $17.03 $0.00 $0.00 $0.00 $0.00 $0.00 27205765 EAP HCPCS C1769 Guidewire Vasc Strg .038in 150cm 3cm Gldwr Hdrph BOTH IP/OP $72.50 $53.65 $0.00 $58.00 $39.37 $39.37 $0.00 $0.00 $0.00 $15.11 $53.81 $53.81 $55.88 $0.00 $15.11 $0.00 $42.88 $42.88 $0.00 $36.25 $57.42 $58.00 $0.00 $0.00 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 27205766 EAP HCPCS C1769 Guidewire Vasc Strg .038in 150cm 3cm Gldwr Shp Tip Hdrph BOTH IP/OP $79.75 $59.02 $0.00 $63.80 $43.30 $43.30 $0.00 $0.00 $0.00 $16.62 $59.19 $59.19 $61.47 $0.00 $16.62 $0.00 $47.17 $47.17 $0.00 $39.88 $63.16 $63.80 $0.00 $0.00 $0.00 $12.48 $0.00 $0.00 $12.70 $0.00 $0.00 $0.00 $0.00 $0.00 27205767 EAP HCPCS C1769 Guidewire Vasc Strg .038in 150cm 3cm Gldwr Stf Shft Hdrph BOTH IP/OP $112.88 $83.53 $0.00 $90.30 $61.29 $61.29 $0.00 $0.00 $0.00 $23.53 $83.78 $83.78 $87.01 $0.00 $23.52 $0.00 $66.77 $66.77 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $0.00 $17.67 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 27205768 EAP HCPCS C1769 Guidewire Vasc Strg .038in 180cm 3cm Gldwr Hdrph BOTH IP/OP $99.25 $73.45 $0.00 $79.40 $53.89 $53.89 $0.00 $0.00 $0.00 $20.69 $73.66 $73.66 $76.50 $0.00 $20.68 $0.00 $58.71 $58.71 $0.00 $49.63 $78.61 $79.40 $0.00 $0.00 $0.00 $15.53 $0.00 $0.00 $15.80 $0.00 $0.00 $0.00 $0.00 $0.00 27205769 EAP HCPCS C1769 Guidewire Vasc Strg .038in 180cm 3cm Gldwr Stf Shft Hdrph BOTH IP/OP $116.75 $86.40 $0.00 $93.40 $63.40 $63.40 $0.00 $0.00 $0.00 $24.33 $86.65 $86.65 $89.99 $0.00 $24.33 $0.00 $69.06 $69.06 $0.00 $58.38 $92.47 $93.40 $0.00 $0.00 $0.00 $18.27 $0.00 $0.00 $18.59 $0.00 $0.00 $0.00 $0.00 $0.00 27205770 EAP HCPCS C1769 Guidewire Vasc Strg .038in 260cm 3cm Gldwr Hdrph BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $60.27 $60.27 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $85.56 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 27205771 EAP HCPCS C1769 Guidewire Vasc Strg Lng Tpr .035in 150cm 5cm Gldwr Stf Shft BOTH IP/OP $112.88 $83.53 $0.00 $90.30 $61.29 $61.29 $0.00 $0.00 $0.00 $23.53 $83.78 $83.78 $87.01 $0.00 $23.52 $0.00 $66.77 $66.77 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $0.00 $17.67 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 27205772 EAP HCPCS C1769 Guidewire Vasc Strg Lng Tpr .035in 150cm 8cm Gldwr Jkt Cor BOTH IP/OP $81.75 $60.50 $0.00 $65.40 $44.39 $44.39 $0.00 $0.00 $0.00 $17.04 $60.67 $60.67 $63.01 $0.00 $17.04 $0.00 $48.36 $48.36 $0.00 $40.88 $64.75 $65.40 $0.00 $0.00 $0.00 $12.79 $0.00 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $0.00 27205773 EAP HCPCS C1769 Guidewire Vasc Strg Lng Tpr .038in 150cm 5cm Gldwr Stf Shft BOTH IP/OP $112.88 $83.53 $0.00 $90.30 $61.29 $61.29 $0.00 $0.00 $0.00 $23.53 $83.78 $83.78 $87.01 $0.00 $23.52 $0.00 $66.77 $66.77 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $0.00 $17.67 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 27205774 EAP HCPCS C1769 Guidewire Vasc Strg Tpr .038in 150cm 8cm Gldwr Hdrph BOTH IP/OP $81.75 $60.50 $0.00 $65.40 $44.39 $44.39 $0.00 $0.00 $0.00 $17.04 $60.67 $60.67 $63.01 $0.00 $17.04 $0.00 $48.36 $48.36 $0.00 $40.88 $64.75 $65.40 $0.00 $0.00 $0.00 $12.79 $0.00 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $0.00 27205775 EAP HCPCS C1894 Introducer Cath 17fr 5.3fr 14fr 25cm Solopath Bln Expandable BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205776 EAP HCPCS C1894 Introducer Cath 21fr 13fr 18fr 25cm Strl 20cm Solopath BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205777 EAP HCPCS C1894 Introducer Cath 21fr 5.3fr 18fr 35cm Strl 30cm Solopath Bln BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205778 EAP HCPCS C1894 Introducer Cath 22fr 14fr 19fr 35cm Strl 30cm Solopath BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205779 EAP HCPCS C1894 Introducer Cath 22fr 5.3fr 19fr 25cm 20cm Solopath Bln BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205780 EAP HCPCS C1894 Introducer Cath 23fr 5.3fr 20fr 35cm Strl 25cm Solopath Bln BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205781 EAP HCPCS C1894 Introducer Cath 24fr 14fr 21fr 35cm Strl 30cm Solopath BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205782 EAP HCPCS C1894 Introducer Cath 24fr 5.3fr 21fr 25cm 20cm Solopath Bln BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205783 EAP HCPCS C1894 Introducer Cath Loprfl 11.5-17fr 5.3fr 14fr 35cm 30cm BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205784 EAP HCPCS C1894 Introducer Cath Loprfl 15-19fr 5.3fr 16fr 25cm 20cm Solopath BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205785 EAP HCPCS C1894 Introducer Cath Loprfl 15-19fr 5.3fr 16fr 35cm 30cm Solopath BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205786 EAP HCPCS C1894 Introducer Cath Loprfl 15-23fr 5.3fr 20fr 25cm 20cm Solopath BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $719.48 $719.48 $0.00 $0.00 $0.00 $276.16 $983.42 $983.42 "$1,021.31" $0.00 $276.13 $0.00 $783.74 $783.74 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205787 EAP HCPCS C1894 Introducer Shth .035in 4fr 10cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $57.50 $42.55 $0.00 $46.00 $31.22 $31.22 $0.00 $0.00 $0.00 $11.98 $42.68 $42.68 $44.32 $0.00 $11.98 $0.00 $34.01 $34.01 $0.00 $28.75 $45.54 $46.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $9.15 $0.00 $0.00 $0.00 $0.00 $0.00 27205788 EAP HCPCS C1894 Introducer Shth .035in 4fr 6cm 2.5cm Pncl R/o Ii Gw Dil BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $28.51 $28.51 $0.00 $0.00 $0.00 $10.94 $38.97 $38.97 $40.47 $0.00 $10.94 $0.00 $31.05 $31.05 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $8.22 $0.00 $0.00 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 27205789 EAP HCPCS C1894 Introducer Shth .035in Shrt 7fr 4cm 40cm Pncl R/o Ii Hiflo BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $32.58 $32.58 $0.00 $0.00 $0.00 $12.51 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $35.49 $35.49 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $9.39 $0.00 $0.00 $9.55 $0.00 $0.00 $0.00 $0.00 $0.00 27205790 EAP HCPCS C1894 Introducer Shth .035in Shrt 8fr 4cm 2.5cm Pncl R/o Ii Hiflo BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $32.58 $32.58 $0.00 $0.00 $0.00 $12.51 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $35.49 $35.49 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $9.39 $0.00 $0.00 $9.55 $0.00 $0.00 $0.00 $0.00 $0.00 27205791 EAP HCPCS C1894 Introducer Shth .038in 5fr 10cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $57.50 $42.55 $0.00 $46.00 $31.22 $31.22 $0.00 $0.00 $0.00 $11.98 $42.68 $42.68 $44.32 $0.00 $11.98 $0.00 $34.01 $34.01 $0.00 $28.75 $45.54 $46.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $9.15 $0.00 $0.00 $0.00 $0.00 $0.00 27205792 EAP HCPCS C1894 Introducer Shth .038in 5fr 6cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $28.51 $28.51 $0.00 $0.00 $0.00 $10.94 $38.97 $38.97 $40.47 $0.00 $10.94 $0.00 $31.05 $31.05 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $8.22 $0.00 $0.00 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 27205793 EAP HCPCS C1894 Introducer Shth .038in 6fr 10cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $57.50 $42.55 $0.00 $46.00 $31.22 $31.22 $0.00 $0.00 $0.00 $11.98 $42.68 $42.68 $44.32 $0.00 $11.98 $0.00 $34.01 $34.01 $0.00 $28.75 $45.54 $46.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $9.15 $0.00 $0.00 $0.00 $0.00 $0.00 27205794 EAP HCPCS C1894 Introducer Shth .038in 6fr 4cm Pncl R/o Ii Hiflo Dil Radopq BOTH IP/OP $58.13 $43.02 $0.00 $46.50 $31.56 $31.56 $0.00 $0.00 $0.00 $12.12 $43.14 $43.14 $44.81 $0.00 $12.11 $0.00 $34.38 $34.38 $0.00 $29.07 $46.04 $46.50 $0.00 $0.00 $0.00 $9.10 $0.00 $0.00 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 27205795 EAP HCPCS C1894 Introducer Shth .038in 6fr 6cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $28.51 $28.51 $0.00 $0.00 $0.00 $10.94 $38.97 $38.97 $40.47 $0.00 $10.94 $0.00 $31.05 $31.05 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $8.22 $0.00 $0.00 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 27205796 EAP HCPCS C1894 Introducer Shth .038in 7fr 10cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $57.50 $42.55 $0.00 $46.00 $31.22 $31.22 $0.00 $0.00 $0.00 $11.98 $42.68 $42.68 $44.32 $0.00 $11.98 $0.00 $34.01 $34.01 $0.00 $28.75 $45.54 $46.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $9.15 $0.00 $0.00 $0.00 $0.00 $0.00 27205797 EAP HCPCS C1894 Introducer Shth .038in 7fr 6cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $28.51 $28.51 $0.00 $0.00 $0.00 $10.94 $38.97 $38.97 $40.47 $0.00 $10.94 $0.00 $31.05 $31.05 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $8.22 $0.00 $0.00 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 27205798 EAP HCPCS C1894 Introducer Shth .038in 8fr 10cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $57.50 $42.55 $0.00 $46.00 $31.22 $31.22 $0.00 $0.00 $0.00 $11.98 $42.68 $42.68 $44.32 $0.00 $11.98 $0.00 $34.01 $34.01 $0.00 $28.75 $45.54 $46.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $9.15 $0.00 $0.00 $0.00 $0.00 $0.00 27205799 EAP HCPCS C1894 Introducer Shth .038in 8fr 6cm 2.5cm Pncl R/o Ii Gw Dil BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $28.51 $28.51 $0.00 $0.00 $0.00 $10.94 $38.97 $38.97 $40.47 $0.00 $10.94 $0.00 $31.05 $31.05 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $8.22 $0.00 $0.00 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 27205800 EAP HCPCS C1894 Introducer Shth .038in 9fr 10cm 2.5cm Pn Ro2 Gw Dil Radopq BOTH IP/OP $57.50 $42.55 $0.00 $46.00 $31.22 $31.22 $0.00 $0.00 $0.00 $11.98 $42.68 $42.68 $44.32 $0.00 $11.98 $0.00 $34.01 $34.01 $0.00 $28.75 $45.54 $46.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $9.15 $0.00 $0.00 $0.00 $0.00 $0.00 27205801 EAP HCPCS C1894 Introducer Shth .038in 9fr 6cm 2.5cm Pncl R/o Ii Gw Dil BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $28.51 $28.51 $0.00 $0.00 $0.00 $10.94 $38.97 $38.97 $40.47 $0.00 $10.94 $0.00 $31.05 $31.05 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $8.22 $0.00 $0.00 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 27205802 EAP HCPCS C1894 Introducer Shth 11fr 25cm 2.5cm Pncl Dil Kink Rst Hdrph Ptfe BOTH IP/OP $49.88 $36.91 $0.00 $39.90 $27.08 $27.08 $0.00 $0.00 $0.00 $10.40 $37.02 $37.02 $38.45 $0.00 $10.39 $0.00 $29.50 $29.50 $0.00 $24.94 $39.50 $39.90 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $7.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205803 EAP HCPCS C1894 Introducer Shth 4fr 10cm 2.5cm Pncl R/o Ii Dil Radopq BOTH IP/OP $53.50 $39.59 $0.00 $42.80 $29.05 $29.05 $0.00 $0.00 $0.00 $11.15 $39.71 $39.71 $41.24 $0.00 $11.15 $0.00 $31.65 $31.65 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 27205804 EAP HCPCS C1894 Introducer Shth 4fr 25cm 2.5cm Pncl R/o Ii Dil Radopq BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $35.30 $35.30 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 27205805 EAP HCPCS C1894 Introducer Shth 4fr 6cm 2.5cm Pncl R/o Ii Dil Radopq BOTH IP/OP $46.88 $34.69 $0.00 $37.50 $25.46 $25.46 $0.00 $0.00 $0.00 $9.77 $34.79 $34.79 $36.14 $0.00 $9.77 $0.00 $27.73 $27.73 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 27205806 EAP HCPCS C1894 Introducer Shth 5fr 10cm 2.5cm Pncl Radopq Dil No Mn Gw BOTH IP/OP $53.50 $39.59 $0.00 $42.80 $29.05 $29.05 $0.00 $0.00 $0.00 $11.15 $39.71 $39.71 $41.24 $0.00 $11.15 $0.00 $31.65 $31.65 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 27205807 EAP HCPCS C1894 Introducer Shth 5fr 25cm 2.5cm Pn Ro2 Dil Radopq Kink Rst BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $35.30 $35.30 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 27205808 EAP HCPCS C1894 Introducer Shth 5fr 6cm 2.5cm Pncl Radopq Dil No Mn Gw BOTH IP/OP $46.88 $34.69 $0.00 $37.50 $25.46 $25.46 $0.00 $0.00 $0.00 $9.77 $34.79 $34.79 $36.14 $0.00 $9.77 $0.00 $27.73 $27.73 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 27205809 EAP HCPCS C1894 Introducer Shth 6fr 10cm 2.5cm Pn Ro2 Dil Radopq Kink Rst BOTH IP/OP $53.50 $39.59 $0.00 $42.80 $29.05 $29.05 $0.00 $0.00 $0.00 $11.15 $39.71 $39.71 $41.24 $0.00 $11.15 $0.00 $31.65 $31.65 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 27205810 EAP HCPCS C1894 Introducer Shth 6fr 25cm 2.5cm Pn Ro2 Dil Radopq Kink Rst BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $35.30 $35.30 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 27205811 EAP HCPCS C1894 Introducer Shth 6fr 45cm Destination Gd Hdrph Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205812 EAP HCPCS C1894 Introducer Shth 6fr 45cm Pn Dstn Gd Hdrph Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205813 EAP HCPCS C1894 Introducer Shth 6fr 45cm Pn Dstn Gd Lima Crv Xcut Vlv Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205814 EAP HCPCS C1894 Introducer Shth 6fr 45cm Pn Dstn Gd Mp Crv T-b Vlv Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205815 EAP HCPCS C1894 Introducer Shth 6fr 45cm Pn Dstn Gd Rdc Crv T-b Vlv Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205816 EAP HCPCS C1894 Introducer Shth 6fr 45cm Pn Dstn Hdrph Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205817 EAP HCPCS C1894 Introducer Shth 6fr 4cm 40cm Pncl Radopq Dil Gw BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $32.58 $32.58 $0.00 $0.00 $0.00 $12.51 $44.53 $44.53 $46.25 $0.00 $12.50 $0.00 $35.49 $35.49 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $9.39 $0.00 $0.00 $9.55 $0.00 $0.00 $0.00 $0.00 $0.00 27205818 EAP HCPCS C1894 Introducer Shth 6fr 65cm Pn Dstn Gd Strg T-b Vlv Hdrph Ptfe BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 27205819 EAP HCPCS C1894 Introducer Shth 6fr 6cm 2.5cm Pn Ro2 Dil Radopq Kink Rst BOTH IP/OP $46.88 $34.69 $0.00 $37.50 $25.46 $25.46 $0.00 $0.00 $0.00 $9.77 $34.79 $34.79 $36.14 $0.00 $9.77 $0.00 $27.73 $27.73 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 27205820 EAP HCPCS C1894 Introducer Shth 7fr 45cm Pn Dstn Gd Hs Crv T-b Vlv Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205821 EAP HCPCS C1894 Introducer Shth 7fr 45cm Pn Dstn Gd Lima Crv T-b Vlv Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205822 EAP HCPCS C1894 Introducer Shth 7fr 45cm Pn Dstn Gd Mp Crv T-b Vlv Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205823 EAP HCPCS C1894 Introducer Shth 7fr 45cm Pn Dstn Gd Rdc Crv T-b Vlv Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205824 EAP HCPCS C1894 Introducer Shth 7fr 45cm Pn Dstn Gd Strg T-b Vlv Hdrph Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205825 EAP HCPCS C1894 Introducer Shth 7fr 4cm Pncl R/o Ii Hiflo Dil Radopq BOTH IP/OP $58.13 $43.02 $0.00 $46.50 $31.56 $31.56 $0.00 $0.00 $0.00 $12.12 $43.14 $43.14 $44.81 $0.00 $12.11 $0.00 $34.38 $34.38 $0.00 $29.07 $46.04 $46.50 $0.00 $0.00 $0.00 $9.10 $0.00 $0.00 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 27205826 EAP HCPCS C1894 Introducer Shth 7fr 65cm Pn Dstn Gd Hdrph Ptfe BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 27205827 EAP HCPCS C1894 Introducer Shth 7fr 6cm 2.5cm Pncl Radopq Dil No Mn Gw BOTH IP/OP $46.88 $34.69 $0.00 $37.50 $25.46 $25.46 $0.00 $0.00 $0.00 $9.77 $34.79 $34.79 $36.14 $0.00 $9.77 $0.00 $27.73 $27.73 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 27205828 EAP HCPCS C1894 Introducer Shth 8fr 4cm 2.5cm Pncl R/o Ii Hiflo Dil Radopq BOTH IP/OP $58.13 $43.02 $0.00 $46.50 $31.56 $31.56 $0.00 $0.00 $0.00 $12.12 $43.14 $43.14 $44.81 $0.00 $12.11 $0.00 $34.38 $34.38 $0.00 $29.07 $46.04 $46.50 $0.00 $0.00 $0.00 $9.10 $0.00 $0.00 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 27205829 EAP HCPCS C1894 Introducer Shth 8fr 6cm 2.5cm Pn Ro2 Dil Radopq Kink Rst BOTH IP/OP $46.88 $34.69 $0.00 $37.50 $25.46 $25.46 $0.00 $0.00 $0.00 $9.77 $34.79 $34.79 $36.14 $0.00 $9.77 $0.00 $27.73 $27.73 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 27205830 EAP HCPCS C1894 Introducer Shth 9fr 10cm 2.5cm Pn Ro2 Dil Radopq Kink Rst BOTH IP/OP $53.50 $39.59 $0.00 $42.80 $29.05 $29.05 $0.00 $0.00 $0.00 $11.15 $39.71 $39.71 $41.24 $0.00 $11.15 $0.00 $31.65 $31.65 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 27205831 EAP HCPCS C1894 Introducer Shth 9fr 25cm 2.5cm Pn Ro2 Dil Radopq Kink Rst BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $35.30 $35.30 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 27205832 EAP HCPCS C1894 Introducer Shth 9fr 6cm 2.5cm Pncl R/o Ii Dil Radopq BOTH IP/OP $46.88 $34.69 $0.00 $37.50 $25.46 $25.46 $0.00 $0.00 $0.00 $9.77 $34.79 $34.79 $36.14 $0.00 $9.77 $0.00 $27.73 $27.73 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 27205833 EAP HCPCS C1894 Sheath Escp 7fr 45cm Pn Dstn Gd Destination Hdrph Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205834 EAP HCPCS C1887 Sheath Gd .038in 6fr 45cm 2cm Pn Dstn T-b Vlv Strg Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205835 EAP HCPCS C1887 Sheath Gd .038in 7fr 45cm 2cm Pn Dstn T-b Vlv Strg Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205836 EAP HCPCS C1894 Sheath Gd .038in Hs Crv 5fr 45cm 2cm Pn Dstn Xcut Vlv Hdrph BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205837 EAP HCPCS C1894 Sheath Gd .038in Lima Crv 5fr 45cm 2cm Pn Dstn Xcut Vlv BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205838 EAP HCPCS C1894 Sheath Gd .038in Mp Crv 5fr 45cm 2cm Pn Dstn Xcut Vlv Kink BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205839 EAP HCPCS C1894 Sheath Gd .038in Mp Crv 6fr 90cm 5cm Pn Dstn T-b Vlv Hdrph BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205840 EAP HCPCS C1894 Sheath Gd .038in Mp Crv 7fr 90cm 5cm Pn Dstn T-b Vlv Hdrph BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205841 EAP HCPCS C1894 Sheath Gd .038in Mp Crv 7fr 90cm 5cm Pn Dstn Xcut Vlv Hdrph BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205842 EAP HCPCS C1894 Sheath Gd 22fr X 35cm Solopath BOTH IP/OP "$1,525.00 " "$1,128.50" $0.00 "$1,220.00" $828.08 $828.08 $0.00 $0.00 $0.00 $317.85 "$1,131.86" "$1,131.86" "$1,175.47" $0.00 $317.81 $0.00 $902.04 $902.04 $0.00 $762.50 "$1,207.80" "$1,220.00" $0.00 $0.00 $0.00 $238.66 $0.00 $0.00 $242.78 $0.00 $0.00 $0.00 $0.00 $0.00 27205843 EAP HCPCS C1894 Sheath Gd 23fr 13.5fr 19fr 25cm 20cm Solopath Expandable BOTH IP/OP "$1,525.00 " "$1,128.50" $0.00 "$1,220.00" $828.08 $828.08 $0.00 $0.00 $0.00 $317.85 "$1,131.86" "$1,131.86" "$1,175.47" $0.00 $317.81 $0.00 $902.04 $902.04 $0.00 $762.50 "$1,207.80" "$1,220.00" $0.00 $0.00 $0.00 $238.66 $0.00 $0.00 $242.78 $0.00 $0.00 $0.00 $0.00 $0.00 27205844 EAP HCPCS C1894 Sheath Gd 23fr 13.5fr 19fr 35cm 30cm Solopath Expandable BOTH IP/OP "$1,525.00 " "$1,128.50" $0.00 "$1,220.00" $828.08 $828.08 $0.00 $0.00 $0.00 $317.85 "$1,131.86" "$1,131.86" "$1,175.47" $0.00 $317.81 $0.00 $902.04 $902.04 $0.00 $762.50 "$1,207.80" "$1,220.00" $0.00 $0.00 $0.00 $238.66 $0.00 $0.00 $242.78 $0.00 $0.00 $0.00 $0.00 $0.00 27205845 EAP HCPCS C1894 Sheath Gd 24fr X 35cm Solopath BOTH IP/OP "$1,525.00 " "$1,128.50" $0.00 "$1,220.00" $828.08 $828.08 $0.00 $0.00 $0.00 $317.85 "$1,131.86" "$1,131.86" "$1,175.47" $0.00 $317.81 $0.00 $902.04 $902.04 $0.00 $762.50 "$1,207.80" "$1,220.00" $0.00 $0.00 $0.00 $238.66 $0.00 $0.00 $242.78 $0.00 $0.00 $0.00 $0.00 $0.00 27205846 EAP HCPCS C1894 Sheath Gd 26fr 15fr 22fr 35cm 30cm Solopath Expandable BOTH IP/OP "$1,525.00 " "$1,128.50" $0.00 "$1,220.00" $828.08 $828.08 $0.00 $0.00 $0.00 $317.85 "$1,131.86" "$1,131.86" "$1,175.47" $0.00 $317.81 $0.00 $902.04 $902.04 $0.00 $762.50 "$1,207.80" "$1,220.00" $0.00 $0.00 $0.00 $238.66 $0.00 $0.00 $242.78 $0.00 $0.00 $0.00 $0.00 $0.00 27205847 EAP HCPCS C1894 Sheath Gd 28.5fr 15fr 24fr 25cm 20cm Solopath Expandable BOTH IP/OP "$1,525.00 " "$1,128.50" $0.00 "$1,220.00" $828.08 $828.08 $0.00 $0.00 $0.00 $317.85 "$1,131.86" "$1,131.86" "$1,175.47" $0.00 $317.81 $0.00 $902.04 $902.04 $0.00 $762.50 "$1,207.80" "$1,220.00" $0.00 $0.00 $0.00 $238.66 $0.00 $0.00 $242.78 $0.00 $0.00 $0.00 $0.00 $0.00 27205848 EAP HCPCS C1894 Sheath Gd 4fr Strl Pncl Prcs Acc Sys Tl Intgr Fit Echgn Tpr BOTH IP/OP $81.25 $60.13 $0.00 $65.00 $44.12 $44.12 $0.00 $0.00 $0.00 $16.93 $60.30 $60.30 $62.63 $0.00 $16.93 $0.00 $48.06 $48.06 $0.00 $40.63 $64.35 $65.00 $0.00 $0.00 $0.00 $12.72 $0.00 $0.00 $12.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205849 EAP HCPCS C1894 Sheath Gd Hs Crv 7fr 45cm 5cm Pn Dstn Radopq Xcut Vlv Ss BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205850 EAP HCPCS C1894 Sheath Gd Mp Crv 6fr 45cm 5cm Pn Dstn Radopq Xcut Vlv Ss BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205851 EAP HCPCS C1894 Sheath Gd Mp Crv 6fr 90cm 15cm Pn Dstn Radopq Xcut Vlv Ss BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205852 EAP HCPCS C1894 Sheath Gd Mp Crv 7fr 45cm 5cm Pn Dstn Radopq Xcut Vlv Ss BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205853 EAP HCPCS C1894 Sheath Gd Rnl 2 Crv 5fr 45cm 5cm Pn Dstn Radopq Xcut Vlv Ss BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205854 EAP HCPCS C1894 Sheath Gd Strg 5fr 45cm 35cm Pn Dstn Radopq Xcut Vlv Ss Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205855 EAP HCPCS C1894 Sheath Gd Strg 6fr 45cm 35cm Pn Dstn Radopq Xcut Vlv Ss Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205856 EAP HCPCS C1894 Sheath Gd Strg 6fr 90cm 15cm Pn Dstn Radopq Xcut Vlv Ss Ptfe BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205857 EAP HCPCS C1894 Sheath Gd Strg 6fr 90cm 15cm Pn Dstn T-b Radopq Vlv Ss Ptfe BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205858 EAP HCPCS C1894 Sheath Gd Strg 7fr 45cm 35cm Pn Dstn Radopq Xcut Vlv Ss Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205859 EAP HCPCS C1894 Sheath Gd Strg 7fr 45cm 5cm Pn Dstn Radopq Xcut Vlv Ss Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205860 EAP HCPCS C1894 Sheath Gd Strg 7fr 65cm 35cm Pn Dstn Radopq Xcut Vlv Ss Ptfe BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 27205861 EAP HCPCS C1894 Sheath Gd Strg 7fr 90cm 15cm Pn Dstn Radopq Xcut Vlv Ss Ptfe BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205862 EAP HCPCS C1894 Sheath Gd Strg 7fr 90cm 15cm Pn Dstn T-b Radopq Vlv Ss Ptfe BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205863 EAP HCPCS C1894 Sheath Gd Strg 8fr 45cm 35cm Pn Dstn T-b Radopq Vlv Ss Ptfe BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205864 EAP HCPCS C1894 Sheath Gd Strg 8fr 65cm 35cm Pn Dstn T-b Radopq Vlv Ss Ptfe BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 27205865 EAP HCPCS C1894 Sheath Gd Strg 8fr 90cm 60cm Pn Dstn T-b Radopq Vlv Ss Ptfe BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205866 EAP HCPCS C1894 System Intro .018in 4fr 21ga 40cm Glideaccess Echgn Ndl Gw BOTH IP/OP $66.25 $49.03 $0.00 $53.00 $35.97 $35.97 $0.00 $0.00 $0.00 $13.81 $49.17 $49.17 $51.07 $0.00 $13.81 $0.00 $39.19 $39.19 $0.00 $33.13 $52.47 $53.00 $0.00 $0.00 $0.00 $10.37 $0.00 $0.00 $10.55 $0.00 $0.00 $0.00 $0.00 $0.00 27205867 EAP HCPCS C1894 System Intro .018in 4fr 21ga 40cm Glideaccess Non Echgn Ndl BOTH IP/OP $76.88 $56.89 $0.00 $61.50 $41.75 $41.75 $0.00 $0.00 $0.00 $16.02 $57.06 $57.06 $59.26 $0.00 $16.02 $0.00 $45.47 $45.47 $0.00 $38.44 $60.89 $61.50 $0.00 $0.00 $0.00 $12.03 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $0.00 27205868 EAP HCPCS C1894 System Intro .018in 4fr 40cm Glideaccess Coax Gw Echgn Ndl BOTH IP/OP $79.38 $58.74 $0.00 $63.50 $43.10 $43.10 $0.00 $0.00 $0.00 $16.54 $58.92 $58.92 $61.19 $0.00 $16.54 $0.00 $46.95 $46.95 $0.00 $39.69 $62.87 $63.50 $0.00 $0.00 $0.00 $12.42 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205869 EAP HCPCS C1894 System Intro .018in 5fr 21ga 40cm Glideaccess Echgn Ndl Gw BOTH IP/OP $66.25 $49.03 $0.00 $53.00 $35.97 $35.97 $0.00 $0.00 $0.00 $13.81 $49.17 $49.17 $51.07 $0.00 $13.81 $0.00 $39.19 $39.19 $0.00 $33.13 $52.47 $53.00 $0.00 $0.00 $0.00 $10.37 $0.00 $0.00 $10.55 $0.00 $0.00 $0.00 $0.00 $0.00 27205870 EAP HCPCS C1894 System Intro .018in 5fr 21ga 40cm Glideaccess Non Echgn Ndl BOTH IP/OP $76.88 $56.89 $0.00 $61.50 $41.75 $41.75 $0.00 $0.00 $0.00 $16.02 $57.06 $57.06 $59.26 $0.00 $16.02 $0.00 $45.47 $45.47 $0.00 $38.44 $60.89 $61.50 $0.00 $0.00 $0.00 $12.03 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $0.00 27205871 EAP HCPCS C1894 System Intro .018in 5fr 40cm Glideaccess Coax Gw Echgn Ndl BOTH IP/OP $79.38 $58.74 $0.00 $63.50 $43.10 $43.10 $0.00 $0.00 $0.00 $16.54 $58.92 $58.92 $61.19 $0.00 $16.54 $0.00 $46.95 $46.95 $0.00 $39.69 $62.87 $63.50 $0.00 $0.00 $0.00 $12.42 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 27205872 EAP HCPCS C1894 System Intro 5fr 21-19ga 45cm 10cm Pncl Prcs Acc Sys Stf BOTH IP/OP $81.25 $60.13 $0.00 $65.00 $44.12 $44.12 $0.00 $0.00 $0.00 $16.93 $60.30 $60.30 $62.63 $0.00 $16.93 $0.00 $48.06 $48.06 $0.00 $40.63 $64.35 $65.00 $0.00 $0.00 $0.00 $12.72 $0.00 $0.00 $12.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205873 EAP HCPCS C1894 System Intro Reg 4fr Echgn Ndl Fxcr Gw Ninitol BOTH IP/OP $81.25 $60.13 $0.00 $65.00 $44.12 $44.12 $0.00 $0.00 $0.00 $16.93 $60.30 $60.30 $62.63 $0.00 $16.93 $0.00 $48.06 $48.06 $0.00 $40.63 $64.35 $65.00 $0.00 $0.00 $0.00 $12.72 $0.00 $0.00 $12.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205874 EAP HCPCS C1894 System Intro Reg 4fr Echgn Ndl Gw Ss BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205875 EAP HCPCS C1894 System Intro Reg 5fr Echgn Ndl Fxcr Gw Ninitol BOTH IP/OP $81.25 $60.13 $0.00 $65.00 $44.12 $44.12 $0.00 $0.00 $0.00 $16.93 $60.30 $60.30 $62.63 $0.00 $16.93 $0.00 $48.06 $48.06 $0.00 $40.63 $64.35 $65.00 $0.00 $0.00 $0.00 $12.72 $0.00 $0.00 $12.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205876 EAP HCPCS C1894 System Intro Reg 5fr Echgn Ndl Gw Ss BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205877 EAP HCPCS C1894 System Intro Reg 6fr Echgn Ndl Fxcr Gw Ninitol BOTH IP/OP $81.25 $60.13 $0.00 $65.00 $44.12 $44.12 $0.00 $0.00 $0.00 $16.93 $60.30 $60.30 $62.63 $0.00 $16.93 $0.00 $48.06 $48.06 $0.00 $40.63 $64.35 $65.00 $0.00 $0.00 $0.00 $12.72 $0.00 $0.00 $12.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205878 EAP HCPCS C1894 System Intro Reg 6fr Echgn Ndl Gw Ss BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205879 EAP HCPCS C1894 System Intro Reg 7fr Echgn Ndl Fxcr Gw Ninitol BOTH IP/OP $81.25 $60.13 $0.00 $65.00 $44.12 $44.12 $0.00 $0.00 $0.00 $16.93 $60.30 $60.30 $62.63 $0.00 $16.93 $0.00 $48.06 $48.06 $0.00 $40.63 $64.35 $65.00 $0.00 $0.00 $0.00 $12.72 $0.00 $0.00 $12.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205880 EAP HCPCS C1894 System Intro Reg 7fr Echgn Ndl Gw Ss BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205881 EAP HCPCS C1894 System Intro Reg 8fr Echgn Ndl Gw Ss BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205882 EAP HCPCS C1894 System Intro Strg 4fr Echgn Ndl Fxcr Gw Ss BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205883 EAP HCPCS C1894 System Intro Strg 5fr Echgn Ndl Fxcr Gw Ss BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.75 $33.75 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205884 EAP HCPCS C1894 System Intro Tpr 8fr 19-21ga 45cm 10cm Prcs Acc Sys Pncl BOTH IP/OP $81.25 $60.13 $0.00 $65.00 $36.56 $36.56 $0.00 $0.00 $0.00 $16.93 $60.30 $60.30 $62.63 $0.00 $16.93 $0.00 $48.06 $48.06 $0.00 $40.63 $64.35 $65.00 $0.00 $0.00 $0.00 $12.72 $0.00 $0.00 $12.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205908 EAP Stabilit Full Fracture Kit - 2 Level Kit BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" "$3,468.60" $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205910 EAP Custom 27205910 Set Ndl 15ga 15mm Strl Lf Arw BOTH IP/OP "$1,563.00 " "$1,156.62" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,160.06" "$1,160.06" "$1,204.76" $0.00 $325.73 $0.00 $0.00 $0.00 $0.00 $781.50 "$1,237.90" "$1,250.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205911 EAP Custom 27205911 Kit Peritoneal Lavage .035in 8 BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $65.52 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205912 EAP Custom 27205912 Lens Irrigation Therapeutic Tu BOTH IP/OP $780.00 $577.20 $0.00 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $578.92 $578.92 $601.22 $0.00 $162.55 $0.00 $0.00 $0.00 $0.00 $390.00 $617.76 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205913 EAP Custom 27205913 Dressing Nasal Standard 8cm Co BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.15 $319.15 $331.44 $0.00 $89.61 $0.00 $0.00 $0.00 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205914 EAP HCPCS C1769 Tray Surg 14fr 18ga 29cm 5cm 1 BOTH IP/OP $417.00 $308.58 $0.00 $333.60 $226.43 $226.43 $0.00 $0.00 $0.00 $86.91 $309.50 $309.50 $321.42 $0.00 $86.90 $0.00 $246.66 $246.66 $0.00 $208.50 $330.26 $333.60 $0.00 $0.00 $0.00 $65.26 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 27205915 EAP Custom 27205915 Kit Incision And Drainage Ecc BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205916 EAP HCPCS C1727 Balloon Catheter Introducer Ki BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205917 EAP Custom 27205917 Kit Introd .035in 9fr 18ga 10c BOTH IP/OP $309.00 $228.66 $0.00 $247.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.34 $229.34 $238.18 $0.00 $64.40 $0.00 $0.00 $0.00 $0.00 $154.50 $244.73 $247.20 $0.00 $200.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205918 EAP Custom 27205918 Kit Prss Monitr 1 Ln Trndcr 1 BOTH IP/OP $261.00 $193.14 $0.00 $208.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.71 $193.71 $201.18 $0.00 $54.39 $0.00 $0.00 $0.00 $0.00 $130.50 $206.71 $208.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205920 EAP HCPCS C1769 Guidewire Vasc .038in 180cm Strl 3cm Merit Laureat BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $43.44 $43.44 $0.00 $0.00 $0.00 $16.67 $59.38 $59.38 $61.66 $0.00 $16.67 $0.00 $47.32 $47.32 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $12.52 $0.00 $0.00 $12.74 $0.00 $0.00 $0.00 $0.00 $0.00 27205921 EAP HCPCS C1769 Guidewire Vasc Ang .035in 150cm 3cm Laureate Fxcr BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $48.75 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27205922 EAP HCPCS C1751 Catheter Cen Ven 9fr 3mm 1.3mm .7mm 90cm 2 Lumen T BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $192.77 $192.77 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $273.63 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $230.75 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 27205923 EAP HCPCS C1769 Guidewire Vascular Taper .038in 145cm 6cm Str Tip BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $9.39 $0.00 $0.00 $9.55 $0.00 $0.00 $0.00 $0.00 $0.00 27205930 EAP HCPCS C1729 Catheter Urethral Standard 24f BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $140.64 $140.64 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $199.64 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 27205931 EAP Custom 27205931 Needle Biop 13 1/16in 15ga 15/ BOTH IP/OP $214.00 $158.36 $0.00 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.83 $158.83 $164.95 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $107.00 $169.49 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205932 EAP Custom 27205932 Speculum Vag Med Grn Ns Lf Er- BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $129.49 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205933 EAP Custom 27205933 Needle Spinal Long Bevel Quinc BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205934 EAP HCPCS C1729 Tray Catheterization 16fr 2 Co BOTH IP/OP $73.00 $54.02 $0.00 $58.40 $39.64 $39.64 $0.00 $0.00 $0.00 $15.22 $54.18 $54.18 $56.27 $0.00 $15.21 $0.00 $43.18 $43.18 $0.00 $36.50 $57.82 $58.40 $0.00 $47.45 $0.00 $11.42 $0.00 $0.00 $11.62 $0.00 $0.00 $0.00 $0.00 $0.00 27205938 EAP Custom 27205938 Sensor Oximeter 18in Adhesive BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205939 EAP Custom 27205939 Kit Laceration BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205940 EAP HCPCS C1729 Catheter Urethral 12fr 2 Way 1 BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 27205941 EAP HCPCS C1729 Catheter Urethral 14fr Foley 2 BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $14.12 $14.12 $0.00 $0.00 $0.00 $5.42 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $15.38 $15.38 $0.00 $13.00 $20.59 $20.80 $0.00 $16.90 $0.00 $4.07 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 27205942 EAP Custom 27205942 Kit Arterial Line .018in 20ga BOTH IP/OP $25.00 $18.50 $0.00 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.50 $19.80 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205943 EAP Envelope Defibrillator 3.35x3in Resorb Aigisrx Mino BOTH IP/OP "$2,488.00 " "$1,841.12" $0.00 "$1,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,846.59" "$1,846.59" "$1,917.75" $0.00 $518.50 $0.00 $0.00 $0.00 $0.00 "$1,244.00" "$1,970.50" "$1,990.40" $0.00 "$1,617.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205944 EAP HCPCS c1769 Guidewire Vasc 190cm Mic J Asahi Gaia 1st Coron BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205945 EAP HCPCS c1769 Guidewire Vasc 300cm Jtp Mic Asahi Gaia 1st Coron BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27205946 EAP HCPCS C1769 Guidewire Vasc 190cm Gaia 2 Mctip J Asahi BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27205947 EAP HCPCS C1769 Guidewire Vasc 300cm Jtp Mic Asahi Gaia Sec Coron BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27205948 EAP HCPCS C1769 Guidewire Vasc 190cm Gaia 3 Mctip J Asahi BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27205949 EAP HCPCS C1769 Guidewire Vasc 300cm 3rd Mic J Asahi Gaia Coron BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27205950 EAP Catheter Angio Brnstn 1 Crv 5fr .046in 125cm Prfm Wng Hub BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $89.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27206307 EAP Custom 27206307 Sheath Guid Str 8fr 45cm 35cm 3 Radiopq Cross Cut BOTH IP/OP "$1,550.00 " "$1,147.00" $0.00 "$1,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,150.41" "$1,150.41" "$1,194.74" $0.00 $323.02 $0.00 $0.00 $0.00 $0.00 $775.00 "$1,227.60" "$1,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27206308 EAP HCPCS C1894 Introducer Shth 23fr 55.7cm 69.9cm Micra Stpck Radopq Dil BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $814.50 $814.50 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 27206309 EAP HCPCS C1769 "Guidewire Hi-torque Comm Es .014"" 300cm" BOTH IP/OP $988.00 $731.12 $0.00 $790.40 $536.48 $536.48 $0.00 $0.00 $0.00 $205.92 $733.29 $733.29 $761.55 $0.00 $205.90 $0.00 $584.40 $584.40 $0.00 $494.00 $782.50 $790.40 $0.00 $642.20 $0.00 $154.62 $0.00 $0.00 $157.29 $0.00 $0.00 $0.00 $0.00 $0.00 27219613 EAP HCPCS C1751 Tray Catheterization 16fr Urine Meter Foley Statlo BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $21.72 $21.72 $0.00 $0.00 $0.00 $8.34 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $23.66 $23.66 $0.00 $20.00 $31.68 $32.00 $0.00 $26.00 $0.00 $6.26 $0.00 $0.00 $6.37 $0.00 $0.00 $0.00 $0.00 $0.00 27219614 EAP Custom 27219614 5fr Micro Stick BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.11 $37.11 $38.54 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219615 EAP Tube Gstrm 18fr 10cm 5-10ml Entuit Enfit Bln Rtnt Fd BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219616 EAP Tube Fd 20fr 10cm 20ml Entuit Bln Rtnt Mr Conditional Lg BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219617 EAP Tube Fd 22fr 10cm 20ml Entuit Bln Rtnt Mr Conditional Lg BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219618 EAP HCPCS C1769 Set Gstrm Lg 20-24fr 22-26fr Strl Entuit Srt Coons Dil Plwy BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $106.50 $168.70 $170.40 $0.00 $138.45 $0.00 $33.33 $0.00 $0.00 $33.91 $0.00 $0.00 $0.00 $0.00 $0.00 27219620 EAP Inst Ablat Spinestar 5-10 Gen2 BOTH IP/OP "$7,250.00 " "$5,365.00" $0.00 "$5,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,588.30" $0.00 "$1,510.90" $0.00 $0.00 $0.00 $0.00 "$3,625.00" "$5,742.00" "$5,800.00" $0.00 "$4,712.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219621 EAP Kit Angio 65in Acist Cvi Angiotouch 3w Hi-prs Stpck Prm BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219622 EAP HCPCS C2623 Catheter Blndil 5mm 40cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219623 EAP HCPCS C2623 Catheter Blndil 5mm 40cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219624 EAP HCPCS C2623 Catheter Blndil 5mm 40cm 80mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219625 EAP HCPCS C2623 Catheter Blndil 5mm 40cm 100mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 "$2,275.00" $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219626 EAP HCPCS C2623 Catheter Blndil 6mm 40cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219627 EAP HCPCS C2623 Catheter Blndil 6mm 40cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219628 EAP HCPCS C2623 Catheter Blndil 6mm 40cm 80mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219629 EAP HCPCS C2623 Catheter Blndil 6mm 40cm 100mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219630 EAP HCPCS C2623 Catheter Blndil 7mm 40cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219631 EAP HCPCS C2623 Catheter Blndil 7mm 40cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 "$2,275.00" $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219632 EAP HCPCS C2623 Catheter Blndil 8mm 40cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219633 EAP HCPCS C2623 Catheter Blndil 7fr 8mm 40cm 60mm Lutonix Drg Coat Acpt .035 BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219634 EAP HCPCS C2623 Catheter Blndil 4mm 75cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219635 EAP HCPCS C2623 Catheter Blndil 4mm 75cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219636 EAP HCPCS C2623 Catheter Blndil 4mm 75cm 80mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219637 EAP HCPCS C2623 Catheter Blndil 4mm 75cm 100mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219638 EAP HCPCS C2623 Catheter Blndil 5mm 75cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219639 EAP HCPCS C2623 Catheter Blndil 5mm 75cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219640 EAP HCPCS C2623 Catheter Blndil 5mm 75cm 80mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219641 EAP HCPCS C2623 Catheter Blndil 5mm 75cm 100mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219642 EAP HCPCS C2623 Catheter Blndil 6mm 75cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219643 EAP HCPCS C2623 Catheter Blndil 6mm 75cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219644 EAP HCPCS C2623 Catheter Blndil 6mm 75cm 80mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219645 EAP HCPCS C2623 Catheter Blndil 6mm 75cm 100mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 "$2,275.00" $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219646 EAP HCPCS C2623 Catheter Blndil 7mm 75cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219647 EAP HCPCS C2623 Catheter Blndil 7mm 75cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 "$2,275.00" $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219648 EAP HCPCS C2623 Catheter Blndil 8mm 75cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219649 EAP HCPCS C2623 Catheter Blndil 8mm 75cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 "$2,275.00" $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219650 EAP HCPCS C2623 Catheter Blndil 9mm 75cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219651 EAP HCPCS C2623 Catheter Blndil 9mm 75cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219652 EAP HCPCS C2623 Catheter Blndil 10mm 75cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219653 EAP HCPCS C2623 Catheter Blndil 10mm 75cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219654 EAP HCPCS C2623 Catheter Blndil 12mm 75cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219655 EAP HCPCS C2623 Catheter Blndil 8mm 100cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219656 EAP HCPCS C2623 Catheter Blndil 8mm 100cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219657 EAP HCPCS C2623 Catheter Blndil 9mm 100cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219658 EAP HCPCS C2623 Catheter Blndil 9mm 100cm 60mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219659 EAP HCPCS C2623 Catheter Blndil 10mm 100cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219660 EAP HCPCS C2623 Catheter Blndil 8fr 10mm 100cm 60mm Lutonix Drg Coat Acpt BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219661 EAP HCPCS C2623 Catheter Blndil 12mm 100cm 40mm Lutonix Drg Coat Acpt .035in BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 27219662 EAP Tube Fd 24fr 10cm 20ml Entuit Bln Rtnt Mr Conditional Lg BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219663 EAP Catheter Infs 2 2/3fr 45cm Clarivein BOTH IP/OP "$1,250.00 " $925.00 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219664 EAP Catheter Infs 4 4/3fr 65cm Clarivein BOTH IP/OP "$1,250.00 " $925.00 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219665 EAP HCPCS C1729 Stent Intracranial Pulserider T L10 Mm Od4 Mm BOTH IP/OP "$31,250.00 " "$23,125.00" $0.00 "$25,000.00" "$16,968.75" "$16,968.75" $0.00 $0.00 $0.00 "$6,513.28" "$4,181.12" "$4,181.12" "$24,087.50" $0.00 "$6,512.50" $0.00 "$3,094.73" "$3,094.73" $0.00 "$15,625.00" "$24,750.00" "$25,000.00" $0.00 $0.00 $0.00 "$4,890.63" $0.00 $0.00 "$4,975.00" $0.00 $0.00 $0.00 $0.00 $0.00 27219667 EAP HCPCS C1769 Guidewire Vasc Strg .035in 260cm 6cm Hiwire Bntsn Atrm X BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $30.95 $30.95 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $37.05 $0.00 $8.92 $0.00 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $0.00 27219668 EAP HCPCS C1887 Catheter Gd 10d 2.1-3.5fr 135cm 7mm Twnps 2 Lum Otw Trq Brd BOTH IP/OP "$1,123.00 " $831.02 $0.00 $898.40 $609.79 $609.79 $0.00 $0.00 $0.00 $234.06 $833.49 $833.49 $865.61 $0.00 $234.03 $0.00 $664.25 $664.25 $0.00 $561.50 $889.42 $898.40 $0.00 $0.00 $0.00 $175.75 $0.00 $0.00 $178.78 $0.00 $0.00 $0.00 $0.00 $0.00 27219669 EAP Drill Srg Vertecor Bn BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.21 $408.21 $423.94 $0.00 $114.62 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219670 EAP Catheter Chlgm Spyscope Ds Acc Dlv Disp BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,299.25" $0.00 "$1,432.75" $0.00 $0.00 $0.00 $0.00 "$3,437.50" "$5,445.00" "$5,500.00" $0.00 "$4,468.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219671 EAP HCPCS C1887 Catheter Intvn 5.1fr 150cm 13cm Trapliner Rx Gd Xtn Radopq BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219672 EAP HCPCS C1887 Catheter Intvn 5.7fr 150cm 13cm Trapliner Rx Gd Xtn Radopq BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219673 EAP HCPCS C1887 Catheter Intvn 6.5fr 150cm 13cm Trapliner Rx Gd Xtn Radopq BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219674 EAP HCPCS C1750 Catheter Hmdial 14.5fr 19cm Mh Mxd Sportpack 2 Lum Kink Rst BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $146.25 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 27219675 EAP HCPCS C1894 Sheath Gd 8fr 2.9mm 40cm Strl Flxr Chfl Blkn Disp Acpt .038 BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219676 EAP HCPCS C1887 Microcatheter Crbrvasc Thnwl 2fr .019in 130cm 70cm Progreat BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 "$1,056.25" $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219677 EAP HCPCS C1887 Microcatheter Crbrvasc Thnwl 2fr .019in 150cm 90cm Progreat BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219678 EAP HCPCS C1769 Embrotrap Ii Revascularization Device (5x21) BOTH IP/OP "$9,500.00 " "$7,030.00" $0.00 "$7,600.00" "$5,158.50" "$5,158.50" $0.00 $0.00 $0.00 "$1,980.04" "$4,181.12" "$4,181.12" "$7,322.60" $0.00 "$1,979.80" $0.00 "$3,094.73" "$3,094.73" $0.00 "$4,750.00" "$7,524.00" "$7,600.00" $0.00 $0.00 $0.00 "$1,486.75" $0.00 $0.00 "$1,512.40" $0.00 $0.00 $0.00 $0.00 $0.00 27219679 EAP HCPCS C1769 Embrotrap Ii Revascularization Device (5x33) BOTH IP/OP "$9,500.00 " "$7,030.00" $0.00 "$7,600.00" "$5,158.50" "$5,158.50" $0.00 $0.00 $0.00 "$1,980.04" "$4,181.12" "$4,181.12" "$7,322.60" $0.00 "$1,979.80" $0.00 "$3,094.73" "$3,094.73" $0.00 "$4,750.00" "$7,524.00" "$7,600.00" $0.00 "$6,175.00" $0.00 "$1,486.75" $0.00 $0.00 "$1,512.40" $0.00 $0.00 $0.00 $0.00 $0.00 27219680 EAP Catheter Angio.038in Chgb Crv 5fr BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $203.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219681 EAP Catheter Angio Rosch Infr Mes Crv Tpr 5fr 65cm Strl 41 BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $203.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219682 EAP HCPCS C1725 Catheter Angiographic Angle 4fr.041in 65cm 15cm 2 Braid BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $66.79 $66.79 $0.00 $0.00 $0.00 $25.64 $91.29 $91.29 $94.81 $0.00 $25.63 $0.00 $72.75 $72.75 $0.00 $61.50 $97.42 $98.40 $0.00 $79.95 $0.00 $19.25 $0.00 $0.00 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 27219690 EAP Custom 27219690 Device Indfltr Plus 30 10ml Inflat 30 Atm Disp BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $134.89 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219691 EAP Custom 27219691 Kit Inflat Indfltr Plus 30 .096in Coron Rot Hmst BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219692 EAP Custom 27219692 Device Indfltr Plus 30 10ml Rot Hmst Vlv Gwire BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219693 EAP Custom 27219693 Kit Inflat Indfltr .096in Rot Hmst Vlv Gwire BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219694 EAP Custom 27219694 Device 20/30 Indfltr 20ml Rot Hmst Vlv Gwire BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219695 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Str Rbn 3cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219696 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq J Rbn 4.5cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219697 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Str Rbn 3cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219698 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Jtp Shaping Rbn BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219699 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Strbl Core To Tip BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219700 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Jtp Core To Tip BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219701 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Core To Tip Radiopq J BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219702 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Kink Rst J 3cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219703 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Kink Rst Str 3 BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219704 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htrq Bl Mwt BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219705 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Jtp Shaping Rbn BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219706 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Kink Rst Str 3 BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219707 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Jtp Shaping Rbn BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219708 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Jtp Shaping Rbn BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219709 EAP HCPCS C1769 Guidewire Vasc 190cm .014in .01in Radiopq Coil Str BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219710 EAP HCPCS C1769 Guidewire Vasc 190cm .014in .01in Radiopq Coil J BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219711 EAP HCPCS C1769 Guidewire Vasc 300cm .014in .01in Radiopq Coil Str BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219712 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Jtp Core To Tip BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219713 EAP Custom 27219713 Valve Hmsts .096- In Coplt 20 Atm Inflat Trq Dev BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $129.49 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219714 EAP Custom 27219714 Valve Hmsts .096- In Coplt Kit Bldbck Cntrl Vlv BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219715 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 3cm Htorq Whspr Ls BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219716 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htorq Whspr Ls BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219717 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 3cm Htorq Whspr Ls BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219718 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htorq Whspr Ms BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219719 EAP HCPCS C1769 Guidewire Vasc 300cm .014in J 3cm Htorq Whspr Ms BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219720 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htrq Bl Mwt U BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219721 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq J 3cm Htrq Bl BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219722 EAP HCPCS C1769 Guidewire Vasc 190cm .014in W/o Mrkr Shaping Rbn BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219723 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 3cm Htrq Bl Mwt U BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219724 EAP HCPCS C1769 Guidewire Vasc 300cm .014in J 3cm Htrq Bl Mwt U BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219725 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Cover Str Rbn BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219726 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq J 3cm Htrq Bl BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219727 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Str 3cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219728 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq J 3cm Htrq Bl BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219729 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Mrkr Tip Str 3cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219730 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htrq Bl Mwt U Ii BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219731 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 3cm Htrq Bl Mwt U BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219732 EAP HCPCS C1769 Guidewire Vasc 300cm .014in J 3cm Htrq Bl Mwt U Ii BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219733 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Mrkr Core To BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219734 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Mrkr Core To BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219735 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Jtp Core To Tip BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219736 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Core To Tip BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219737 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Core To BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219738 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Core To BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219739 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Core To BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219740 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Core To BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219741 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Mrkr Str 3cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219742 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Mrkr J 3cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219743 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Str 3cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219744 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr J 3cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219745 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Mrkr Str 3cm BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219746 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Str 3cm BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219747 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Mrkr Str 3cm BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219748 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Str 3cm BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219749 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Mrkr Str Tpr 3 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219750 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Str Tpr 3 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219751 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Str Tpr 3cm BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219752 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Str Tpr 3 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219753 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Mrkr Str 3cm BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219754 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Mrkr Str 3cm BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219755 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Mrkr Str 3cm Htrq Bl BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219756 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq J 3cm Htrq Bl BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219757 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Str 3cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219758 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq J 3cm Htrq Bl BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219759 EAP HCPCS C1769 Guidewire Vasc 190cm .014in W/o Mrkr Str 3cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219760 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htrq Bl Mwt Elt BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219761 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 3cm Htrq Bl Mwt BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219762 EAP HCPCS C1769 Guidewire Vasc 300cm .014in J 3cm Htrq Bl Mwt Elt BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219763 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 3cm Htorq Bal BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219764 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 3cm Htorq Bal BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219765 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htorq Bal BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219766 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htorq Bal BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219767 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 3cm Htorq Bal BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219768 EAP HCPCS C1769 Guidewire Vasc 175cm .014in Str 3cm Htorq Bal BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219769 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq Str 3cm Htorq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219770 EAP Custom 27219770 Valve Hmsts .115in Duostat Rot BOTH IP/OP $58.00 $42.92 $0.00 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.05 $43.05 $44.71 $0.00 $12.09 $0.00 $0.00 $0.00 $0.00 $29.00 $45.94 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219771 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 30cm Htrq Wg Ss BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219772 EAP HCPCS C1769 Guidewire Vasc 300cm .014in J Tpr 3cm Htrq Trns Ss BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219773 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str Tpr 3cm Htrq Trns BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219774 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str Tip Tpr 3cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219775 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Jtp Lght Sprt Shaping BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219776 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 2cm Htrq Wg Ss BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219777 EAP HCPCS C1769 Guidewire Vasc 300cm .014in X Sprt Str 2cm Htrq Fl BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219778 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str Tip Lght Sprt BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219779 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str Sprg Tpr 3cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219780 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str Sprg Tpr 3cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219781 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Jtp Lght Sprt Shaping BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219782 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Lght Sprt Str 30cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219783 EAP HCPCS C1769 Guidewire Vasc 190cm .018in Lght Sprt Str 2cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219784 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str Tip Str 2cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219785 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 2cm Htrq Fl2 Ss BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219786 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 2cm Htorq Std Ss BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219787 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 2cm Htorq Std Ss BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219788 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 2cm Htorq Std Ss BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219789 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Radiopq J 3cm Htrq Inm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219790 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 3cm Htrq Inm Mcgld BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219791 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htrq Inm Hdrct BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219792 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 3cm Htrq Inm Hdrct BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219793 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 3cm Htrq Inm Hdrct BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219794 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str Rbn 30cm Htrq Wg BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219795 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str Shaping Rbn 2cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219796 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Lght Sprt Str 30cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219797 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Lght Sprt Str Tip 2cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219798 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 2cm Htrq Fl2 Ss BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219799 EAP Custom 27219799 Kit Gwire .009-.018in .115in Introd Trq Dev Rot BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $0.00 $0.00 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219800 EAP Custom 27219800 Kit Gwire .01-.018in BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $0.00 $0.00 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219801 EAP HCPCS C1769 Guidewire Vasc 300cm .014in X Sprt J 3cm Htorq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219802 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str Tip Core To Tip BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219803 EAP HCPCS C1769 Guidewire Vasc 190cm .014in X Sprt J 3cm Htrq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219804 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str Tip Str 3cm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219805 EAP HCPCS C1725 Catheter Baldilat 1.5mm 143cm 6mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219806 EAP HCPCS C1725 Catheter Baldilat 1.5mm 143cm 8mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219807 EAP HCPCS C1725 Catheter Baldilat 1.5mm 143cm 12mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219808 EAP HCPCS C1725 Catheter Baldilat 1.5mm 143cm 15mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219809 EAP HCPCS C1725 Catheter Baldilat 1.5mm 143cm 20mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219810 EAP HCPCS C1725 Catheter Baldilat 2mm 143cm 6mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219811 EAP HCPCS C1725 Catheter Baldilat 2mm 143cm 12mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219812 EAP HCPCS C1725 Catheter Baldilat 2.25mm 143cm 6mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219813 EAP HCPCS C1725 Catheter Baldilat 2.25mm 143cm 20mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219814 EAP HCPCS C1725 Catheter Baldilat 2.5mm 143cm 15mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219815 EAP HCPCS C1725 Catheter Baldilat 2.5mm 143cm 20mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219816 EAP HCPCS C1725 Catheter Baldilat 2.5mm 143cm 25mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219817 EAP HCPCS C1725 Catheter Baldilat 2.75mm 143cm 6mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219818 EAP HCPCS C1725 Catheter Baldilat 2.75mm 143cm 8mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219819 EAP HCPCS C1725 Catheter Baldilat 2.75mm 143cm 12mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219820 EAP HCPCS C1725 Catheter Baldilat 2.75mm 143cm 20mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219821 EAP HCPCS C1725 Catheter Baldilat 3mm 143cm 6mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219822 EAP HCPCS C1725 Catheter Baldilat 3mm 143cm 12mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219823 EAP HCPCS C1725 Catheter Baldilat 3mm 143cm 15mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219824 EAP HCPCS C1725 Catheter Baldilat 3mm 143cm 20mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219825 EAP HCPCS C1725 Catheter Baldilat 3mm 143cm 25mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219826 EAP HCPCS C1725 Catheter Baldilat 3.25mm 143cm 8mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219827 EAP HCPCS C1725 Catheter Baldilat 3.25mm 143cm 12mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219828 EAP HCPCS C1725 Catheter Baldilat 3.25mm 143cm 15mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219829 EAP HCPCS C1725 Catheter Baldilat 3.25mm 143cm 20mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219830 EAP HCPCS C1725 Catheter Baldilat 3.5mm 143cm 6mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219831 EAP HCPCS C1725 Catheter Baldilat 3.5mm 143cm 12mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219832 EAP HCPCS C1725 Catheter Baldilat 3.5mm 143cm 15mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219833 EAP HCPCS C1725 Catheter Baldilat 3.5mm 143cm 20mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219834 EAP HCPCS C1725 Catheter Baldilat 3.5mm 143cm 25mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219835 EAP HCPCS C1725 Catheter Baldilat 3.75mm 143cm 12mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219836 EAP HCPCS C1725 Catheter Baldilat 3.75mm 143cm 15mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219837 EAP HCPCS C1725 Catheter Baldilat 3.75mm 143cm 20mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219838 EAP HCPCS C1725 Catheter Baldilat 4mm 143cm 8mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219839 EAP HCPCS C1725 Catheter Baldilat 4mm 143cm 12mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219840 EAP HCPCS C1725 Catheter Baldilat 4.5mm 143cm 8mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219841 EAP HCPCS C1725 Catheter Baldilat 4.5mm 143cm 12mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219842 EAP HCPCS C1725 Catheter Baldilat 4.5mm 143cm 15mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219843 EAP HCPCS C1725 Catheter Baldilat 4.5mm 143cm 20mm Otw Smth Rnd BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219844 EAP HCPCS C1725 Catheter Baldilat 5mm 143cm 8mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219845 EAP HCPCS C1725 Catheter Baldilat 5mm 143cm 20mm Otw Smth Rnd Tip BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 27219846 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 3cm Htorq Adv Lt BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219847 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Str 3cm Htorq Adv BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219848 EAP HCPCS C1769 Guidewire Vasc 190cm .014in J 3cm Htorq Adv BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219849 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Str 3cm Htorq Adv BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219850 EAP HCPCS C1769 Guidewire Vasc 300cm .014in J 3cm Htorq Adv BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 27219851 EAP HCPCS C1769 Guidewire Vasc 300cm Ptca Asahi Ultimatebros 3 BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219852 EAP HCPCS C1769 Guidewire Vasc 180cm Ptca Asahi Ultimatebros 3 BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219853 EAP HCPCS C1769 Guidewire Vasc 300cm 3cm Str Asahi Suoh Ptca BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219854 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Sion Asahi Ptca Blue BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219855 EAP HCPCS C1769 Guidewire Vasc 300cm Wire J Asahi Ptca Sion Blue BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219856 EAP HCPCS C1769 Guidewire Vasc 190cm Str 3cm Asahi Suoh Ptca BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219857 EAP HCPCS C1769 Guidewire Vasc 190cm Pshp Mini 3cm Asahi Suoh Ptca BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219858 EAP HCPCS C1769 Guidewire Vasc 180cm Wire J Asahi Ptca Sion Blue BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219859 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip J 3cm A BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219860 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Jtp 3cm A Fldr Fc Plmr BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219861 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Core To Tip BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219862 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Core To Tip Str 11cm A BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219863 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Hbrd Radiopq Str Tip BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219864 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip J 3cm A BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219865 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Core To Tip J 3cm A BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219866 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip Str 3cm A BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219867 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Core To Tip Str 3cm A BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219868 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip J 3cm BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219869 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Core To Tip J 3cm BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219870 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Hbrd Radiopq Str Tip 3 BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219871 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Hbrd Radiopq Str Tip 3 BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219872 EAP HCPCS C1769 Guidewire Vasc 300cm Ptca A Cfnz Pro BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219873 EAP HCPCS C1769 Guidewire Vasc 180cm .009in Radiopq Str Tip 20cm A BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219874 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Core To Tip J BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219875 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Str Tip 11cm BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219876 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Str Tip 11cm BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219877 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Str Tip 3cm BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219878 EAP HCPCS C1769 Guidewire Vasc 180cm J Asahi Sft Ptca BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219879 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Core To Tip BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219880 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Core To Tip J BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219881 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Str Tip 3cm BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219882 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Core To Tip BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219883 EAP HCPCS C1769 Guidewire Vasc 180cm .014in .009in Radiopq Str Tip BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219884 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Radiopq Str Tip 3cm BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219885 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Core To Tip J BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219886 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Core To Tip BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219887 EAP HCPCS C1769 Guidewire Vasc 300cm J Asahi Sft Ptca BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219888 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Core To Tip J BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219889 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Core To Tip BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219890 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Core To Tip BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219891 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Str Tpr Tip 3 BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 27219892 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Radiopq Core To Tip BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $509.33 $509.33 $0.00 $0.00 $0.00 $195.50 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $0.00 $0.00 $0.00 $146.80 $0.00 $0.00 $149.33 $0.00 $0.00 $0.00 $0.00 $0.00 27219893 EAP HCPCS C1769 Introd Gwire .009-.018in Coron BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $57.81 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 27219894 EAP Custom 27219894 Device Trq Gwire Acpt .009-.018 In Gwire BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $96.35 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219896 EAP HCPCS C1887 Catheter Infs Mic 2.1-1.7fr 5fr .017in 155cm .34ml 150cm BOTH IP/OP "$1,588.00 " "$1,175.12" $0.00 "$1,270.40" $862.28 $862.28 $0.00 $0.00 $0.00 $330.98 "$1,178.61" "$1,178.61" "$1,224.03" $0.00 $330.94 $0.00 $939.30 $939.30 $0.00 $794.00 "$1,257.70" "$1,270.40" $0.00 "$1,032.20" $0.00 $248.52 $0.00 $0.00 $252.81 $0.00 $0.00 $0.00 $0.00 $0.00 27219897 EAP HCPCS C1757 Retriever Escp Trevo Xp Provue BOTH IP/OP "$13,641.00 " "$10,094.34" $0.00 "$10,912.80" "$7,407.06" "$7,407.06" $0.00 $0.00 $0.00 "$2,843.13" "$4,181.12" "$4,181.12" "$10,514.48" $0.00 "$2,842.78" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,820.50" "$10,803.67" "$10,912.80" $0.00 "$8,866.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219898 EAP HCPCS C1725 Catheter Baldilat Lp 5.3fr 4mm 75cm 60mm High Pressure BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $300.95 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27219899 EAP HCPCS C1894 Introducer Sheath .035in Anl1 Curve 11.4fr 10fr 45cm High BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $130.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 27219900 EAP HCPCS C1751 Catheter Cv 9.3fr 22cm Strl Lf Cl Ln Heat Exch Kt BOTH IP/OP "$1,288.00 " $953.12 $0.00 "$1,030.40" $699.38 $699.38 $0.00 $0.00 $0.00 $268.45 $955.95 $955.95 $992.79 $0.00 $268.42 $0.00 $761.85 $761.85 $0.00 $644.00 "$1,020.10" "$1,030.40" $0.00 $0.00 $0.00 $201.57 $0.00 $0.00 $205.05 $0.00 $0.00 $0.00 $0.00 $0.00 27219901 EAP HCPCS C1751 Kit Cath 9.3fr 38cm Icy Cv BOTH IP/OP "$2,053.00 " "$1,519.22" $0.00 "$1,642.40" "$1,114.78" "$1,114.78" $0.00 $0.00 $0.00 $427.90 "$1,523.74" "$1,523.74" "$1,582.45" $0.00 $427.85 $0.00 "$1,214.35" "$1,214.35" $0.00 "$1,026.50" "$1,625.98" "$1,642.40" $0.00 $0.00 $0.00 $321.29 $0.00 $0.00 $326.84 $0.00 $0.00 $0.00 $0.00 $0.00 27219902 EAP HCPCS C1887 Kit Cath 9.3fr 45cm Quattro Heat Exch 3 Lum Ll Applause Hep BOTH IP/OP "$2,299.00 " "$1,701.26" $0.00 "$1,839.20" "$1,248.36" "$1,248.36" $0.00 $0.00 $0.00 $479.17 "$1,706.32" "$1,706.32" "$1,772.07" $0.00 $479.11 $0.00 "$1,359.86" "$1,359.86" $0.00 "$1,149.50" "$1,820.81" "$1,839.20" $0.00 $0.00 $0.00 $359.79 $0.00 $0.00 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219903 EAP Kit Iv Clgrd 3k Srt BOTH IP/OP $455.00 $336.70 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.70 $337.70 $350.71 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219904 EAP Tubing Xtn 9ft BOTH IP/OP $511.00 $378.14 $0.00 $408.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.26 $379.26 $393.88 $0.00 $106.49 $0.00 $0.00 $0.00 $0.00 $255.50 $404.71 $408.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219905 EAP Pack Srg 6ft Ivtm Cool Line Srt Up Disp BOTH IP/OP "$6,725.00 " "$4,976.50" $0.00 "$5,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,183.63" $0.00 "$1,401.49" $0.00 $0.00 $0.00 $0.00 "$3,362.50" "$5,326.20" "$5,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219906 EAP Pack Srg 6ft Ivtm Icy Srt Up Disp BOTH IP/OP "$9,640.00 " "$7,133.60" $0.00 "$7,712.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,430.51" $0.00 "$2,008.98" $0.00 $0.00 $0.00 $0.00 "$4,820.00" "$7,634.88" "$7,712.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219907 EAP Pack Srg 6ft Ivtm Quattro Srt Up Disp BOTH IP/OP "$10,579.00 " "$7,828.46" $0.00 "$8,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,154.29" $0.00 "$2,204.66" $0.00 $0.00 $0.00 $0.00 "$5,289.50" "$8,378.57" "$8,463.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219908 EAP HCPCS C1887 Catheter Advanced Support Guidewire Center Cross Ultra BOTH IP/OP $498.00 $368.52 $0.00 $398.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.00 $394.42 $398.40 $0.00 $0.00 $0.00 $77.94 $0.00 $0.00 $79.28 $0.00 $0.00 $0.00 $0.00 $0.00 27219909 EAP HCPCS C1887 Catheter Angioplasty Microcross 0.014 In BOTH IP/OP $988.00 $731.12 $0.00 $790.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $494.00 $782.50 $790.40 $0.00 $0.00 $0.00 $154.62 $0.00 $0.00 $157.29 $0.00 $0.00 $0.00 $0.00 $0.00 27219910 EAP HCPCS C1887 Catheter Angioplasty Microcross 0.018 In BOTH IP/OP $988.00 $731.12 $0.00 $790.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $494.00 $782.50 $790.40 $0.00 $0.00 $0.00 $154.62 $0.00 $0.00 $157.29 $0.00 $0.00 $0.00 $0.00 $0.00 27219911 EAP Drain Incs Strl Lf Oas Bld Rcvr Dry Sct Ats Cmpt 1 Pt Tube BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $46.50 $73.66 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219912 EAP Separator Thrmb Strl Lf Indg Sys 4 Disp BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" "$1,695.76" $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219913 EAP Catheter Sct 16mm 105cm Strl Lf Clottriever Disp BOTH IP/OP "$11,988.00 " "$8,871.12" $0.00 "$9,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,240.35" $0.00 "$2,498.30" $0.00 $0.00 $0.00 $0.00 "$5,994.00" "$9,494.50" "$9,590.40" $0.00 "$7,792.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219914 EAP Catheter Sct 4.6mm 15cm Strl Lf Clottriever Shth Disp BOTH IP/OP "$3,238.00 " "$2,396.12" $0.00 "$2,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,403.24" "$2,403.24" "$2,495.85" $0.00 $674.80 $0.00 $0.00 $0.00 $0.00 "$1,619.00" "$2,564.50" "$2,590.40" $0.00 "$2,104.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219915 EAP HCPCS C1757 Set Thrombectomy 6fr 3mm 120cm 15mm Otw Contrast Injec Port BOTH IP/OP "$5,013.00 " "$3,709.62" $0.00 "$4,010.40" "$2,722.06" "$2,722.06" $0.00 $0.00 $0.00 "$1,044.83" "$3,720.65" "$3,720.65" "$3,864.02" $0.00 "$1,044.71" $0.00 "$2,965.19" "$2,965.19" $0.00 "$2,506.50" "$3,970.30" "$4,010.40" $0.00 "$3,258.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219916 EAP HCPCS C1769 Guidewire Vasc Ang .035in 150cm Hiwire Radopq Flx Tp Stf BOTH IP/OP $423.00 $313.02 $0.00 $338.40 $229.69 $229.69 $0.00 $0.00 $0.00 $88.16 $313.95 $313.95 $326.05 $0.00 $88.15 $0.00 $250.20 $250.20 $0.00 $211.50 $335.02 $338.40 $0.00 $274.95 $0.00 $66.20 $0.00 $0.00 $67.34 $0.00 $0.00 $0.00 $0.00 $0.00 27219917 EAP Catheter Angiographic Kmp Curve 5fr 40cm Torcon Nb Advantage BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.99 $143.99 $149.54 $0.00 $40.43 $0.00 $0.00 $0.00 $0.00 $97.00 $153.65 $155.20 $0.00 $126.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219918 EAP HCPCS C1769 Guidewire Vasc 3cm Strg .014in 190cm 25cm Spectre 2 Cor Kink BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $25.52 $25.52 $0.00 $0.00 $0.00 $9.80 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $27.80 $27.80 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $7.36 $0.00 $0.00 $7.48 $0.00 $0.00 $0.00 $0.00 $0.00 27219919 EAP HCPCS C1769 Guidewire Vasc 3cm Strg .014in 300cm 25cm Spectre 2 Cor Kink BOTH IP/OP $48.00 $35.52 $0.00 $38.40 $26.06 $26.06 $0.00 $0.00 $0.00 $10.00 $35.63 $35.63 $37.00 $0.00 $10.00 $0.00 $28.39 $28.39 $0.00 $24.00 $38.02 $38.40 $0.00 $0.00 $0.00 $7.51 $0.00 $0.00 $7.64 $0.00 $0.00 $0.00 $0.00 $0.00 27219920 EAP HCPCS C1753 Catheter Ultrasound 20mhz 3.4fr 135cm Scanner Transducer BOTH IP/OP "$1,688.00 " "$1,249.12" $0.00 "$1,350.40" $916.58 $916.58 $0.00 $0.00 $0.00 $351.82 "$1,252.83" "$1,252.83" "$1,301.11" $0.00 $351.78 $0.00 $998.45 $998.45 $0.00 $844.00 "$1,336.90" "$1,350.40" $0.00 "$1,097.20" $0.00 $264.17 $0.00 $0.00 $268.73 $0.00 $0.00 $0.00 $0.00 $0.00 27219921 EAP HCPCS C1887 Catheter Gd Mpc Crv 6fr 100cm Env Lg Inr Lum Radopq Brd Sft BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $503.90 $503.90 $0.00 $0.00 $0.00 $193.42 $688.76 $688.76 $715.30 $0.00 $193.40 $0.00 $548.91 $548.91 $0.00 $464.00 $734.98 $742.40 $0.00 $603.20 $0.00 $145.23 $0.00 $0.00 $147.74 $0.00 $0.00 $0.00 $0.00 $0.00 27219922 EAP HCPCS C1725 Catheter Blndil 8mm 90cm 20mm Pr Ctbln Otw Tpr Tip Infl Port BOTH IP/OP "$1,759.00 " "$1,301.66" $0.00 "$1,407.20" $955.14 $955.14 $0.00 $0.00 $0.00 $366.62 "$1,305.53" "$1,305.53" "$1,355.84" $0.00 $366.58 $0.00 "$1,040.45" "$1,040.45" $0.00 $879.50 "$1,393.13" "$1,407.20" $0.00 $0.00 $0.00 $275.28 $0.00 $0.00 $280.03 $0.00 $0.00 $0.00 $0.00 $0.00 27219923 EAP Pad Thrp Unv Sm Ns Lf Arcticgel Inlt/otlt Cnct Ddrgl Disp BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.80 $161.80 $168.03 $0.00 $45.43 $0.00 $0.00 $0.00 $0.00 $109.00 $172.66 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219924 EAP HCPCS C1769 Guidewire Vasc .014in 180cm Strl Lf Cnfnz Pro 12 Disp BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $216.45 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 27219925 EAP HCPCS C1769 Guidewire Vasc .014in 300cm Strl Lf Fielder Fc Disp BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 27219926 EAP HCPCS C1769 Guidewire Vasc .014in 180cm Strl Lf Fielder Fc Disp BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $130.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 27219927 EAP HCPCS C1769 Guidewire Vasc .014in 300cm Strl Lf Grand Slam Disp BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $156.38 $156.38 $0.00 $0.00 $0.00 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $187.20 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 27219928 EAP HCPCS C1769 Guidewire Vasc .014in 180cm Strl Lf Mrclbrs 6 Disp BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $216.45 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 27219929 EAP HCPCS C1769 Guidewire Vasc .014in 300cm Strl Lf Mrclbrs 6 Disp BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 27219930 EAP HCPCS C1769 Guidewire Vasc .014in 300cm Strl Lf Mrclbrs 3 Disp BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 27219931 EAP HCPCS C1769 Guidewire Vasc .014in 180cm Strl Lf P-h2o Disp BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $130.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 27219932 EAP HCPCS C1769 Guidewire Vasc .014in 300cm Strl Lf P-h2o Disp BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $130.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 27219933 EAP HCPCS C1769 Guidewire Vasc .014in 300cm 45cm Snchr14 BOTH IP/OP "$1,798.00 " "$1,330.52" $0.00 "$1,438.40" $976.31 $976.31 $0.00 $0.00 $0.00 $374.75 "$1,334.48" "$1,334.48" "$1,385.90" $0.00 $374.70 $0.00 "$1,063.52" "$1,063.52" $0.00 $899.00 "$1,424.02" "$1,438.40" $0.00 $0.00 $0.00 $281.39 $0.00 $0.00 $286.24 $0.00 $0.00 $0.00 $0.00 $0.00 27219934 EAP Medtronic Aortic And Peripheral Vascular - Div Med BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" "$3,661.30" $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 "$3,087.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219935 EAP HCPCS C1894 Introducer Gw Grdn Ii Nc Hmsts Vlv BOTH IP/OP "$1,688.00 " "$1,249.12" $0.00 "$1,350.40" $916.58 $916.58 $0.00 $0.00 $0.00 $351.82 "$1,252.83" "$1,252.83" "$1,301.11" $0.00 $351.78 $0.00 $998.45 $998.45 $0.00 $844.00 "$1,336.90" "$1,350.40" $0.00 $0.00 $0.00 $264.17 $0.00 $0.00 $268.73 $0.00 $0.00 $0.00 $0.00 $0.00 27219936 EAP Bronchoscope Flxb 600mm 3.8mm 1.2mm Slim Ambu BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.43 $482.43 $501.02 $0.00 $135.46 $0.00 $0.00 $0.00 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219937 EAP Bronchoscope Flxb 600mm 5mm 2.2mm Ambu Ascope 3 BOTH IP/OP $985.00 $728.90 $0.00 $788.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $731.07 $731.07 $759.24 $0.00 $205.27 $0.00 $0.00 $0.00 $0.00 $492.50 $780.12 $788.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219938 EAP Blade Lrnscp Mac S3 Spctrm Ti Disp Glidescope BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219939 EAP Blade Lrnscp Mac S4 Spctrm Ti Disp Glidescope BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219940 EAP Introducer Tube 15fr 70cm Strl Lf Clbrt Cde Boug Ldpe Adlt BOTH IP/OP $322.00 $238.28 $0.00 $257.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.99 $238.99 $248.20 $0.00 $67.10 $0.00 $0.00 $0.00 $0.00 $161.00 $255.02 $257.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219941 EAP Catheter Primafit Sage BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $17.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219942 EAP HCPCS C1729 Drain Incision Small Stature 1 Chamber Suction Control BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $39.31 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $33.15 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 27219943 EAP HCPCS C1729 Catheter External Drain Large 1.9mm Latex Free Bactiseal Evd BOTH IP/OP "$1,229.00 " $909.46 $0.00 $983.20 $667.35 $667.35 $0.00 $0.00 $0.00 $256.15 $912.16 $912.16 $947.31 $0.00 $256.12 $0.00 $726.95 $726.95 $0.00 $614.50 $973.37 $983.20 $0.00 $798.85 $0.00 $192.34 $0.00 $0.00 $195.66 $0.00 $0.00 $0.00 $0.00 $0.00 27219945 EAP Custom 27219945 Tracheostomy Tray BOTH IP/OP $279.00 $206.46 $0.00 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.50 $220.97 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219946 EAP Custom 27219946 Canister Wound Drain C500ml Gel Tube Clmp Conctr Charcoal BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.34 $62.34 $64.75 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $42.00 $66.53 $67.20 $0.00 $54.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219947 EAP Custom 27219947 Pad Wound Drain Tube Clmp Conctr Sensatrac Vac Sterile BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $27.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219948 EAP Custom 27219948 Airway Esophageal 3 Standard Str Mask Latex Free Auraonce BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219949 EAP HCPCS C1769 Guidewire Vascular .035in 26 13/16in 1 End Mark Spring Str BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $23.89 $23.89 $0.00 $0.00 $0.00 $9.17 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $26.03 $26.03 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $6.89 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219950 EAP Custom 27219950 Kit Arterial Line .018in 20ga 22ga 1.75in Catheter Radiopq BOTH IP/OP $29.00 $21.46 $0.00 $23.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.52 $21.52 $22.35 $0.00 $6.04 $0.00 $0.00 $0.00 $0.00 $14.50 $22.97 $23.20 $0.00 $18.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219953 EAP Custom 27219953 Solution Dialysate 2 Compartment Bag Peel Seam Pureflow BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $96.35 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219954 EAP Custom 27219954 Device Securing 6fr Kit Blue Retrival Probe White Catheter BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219955 EAP Custom 27219955 Device Securing Standard 8fr Kit Retrieval Probe Catheter BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $116.00 $183.74 $185.60 $0.00 $150.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219956 EAP Custom 27219956 Device Securing Standard 10fr Kit Retrieval Probe Catheter BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219957 EAP Custom 27219957 Device Scr Std 14fr Ylw Ns Lf Amt Bridle Preattach Clip Sty BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.19 $172.19 $178.83 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219959 EAP Custom 27219959 Kit Cath .032in 8.5fr 18ga 16cm Lf 2.5in Blu Flxtp Arwg+ard BOTH IP/OP $327.00 $241.98 $0.00 $261.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.70 $242.70 $252.05 $0.00 $68.15 $0.00 $0.00 $0.00 $0.00 $163.50 $258.98 $261.60 $0.00 $212.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219960 EAP Custom 27219960 Kit Urostomy Cut To Fit 2.25- In 2.75in 9in 2 Piece Belt Tab BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219961 EAP Custom 27219961 Suture Absorbable 3-0 Sh-1 27in Braid Coated Vicryl Undyed BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.31 $137.31 $142.60 $0.00 $38.55 $0.00 $0.00 $0.00 $0.00 $92.50 $146.52 $148.00 $0.00 $120.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219962 EAP Custom 27219962 Kit Repr 21-18ga Pilt Tube Syr Reinflate Cuf 10ml BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219963 EAP Custom 27219963 Dressing Abthera Snsa Trc Foam Opn Abd Neg Prss BOTH IP/OP $920.00 $680.80 $0.00 $736.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $682.82 $682.82 $709.14 $0.00 $191.73 $0.00 $0.00 $0.00 $0.00 $460.00 $728.64 $736.00 $0.00 $598.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219964 EAP Custom 27219964 Dressing Hdrcld 8x8in Cmfl Plus Abs Wtprf Top Flm BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219967 EAP Custom 27219967 Device Securing 12fr Kit Dk Blue BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219968 EAP Custom 27219968 Device Securing 18fr Kit Lt Blue BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219969 EAP HCPCS C1752 Kit Cath Strg 13fr 30cm Strl Pwr-trialysis 3 Lum Kink Rst BOTH IP/OP $563.00 $416.62 $0.00 $450.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.86 $417.86 $433.96 $0.00 $117.33 $0.00 $0.00 $0.00 $0.00 $281.50 $445.90 $450.40 $0.00 $365.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219970 EAP HCPCS C1752 Kit Cath 13fr 20cm Strl Pwr-trialysis 3 Lum Shrt Term Dlys BOTH IP/OP $563.00 $416.62 $0.00 $450.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.50 $445.90 $450.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219971 EAP HCPCS C1752 Catheter Hmdial 15cm Schn Xl Kink Rst Tip Clip Sh Rem Sty BOTH IP/OP $119.00 $88.06 $0.00 $95.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.32 $88.32 $91.73 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $59.50 $94.25 $95.20 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219972 EAP HCPCS C1752 Set Cath 24cm Schn Xl Bsc Sil Acute Hmdial BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $154.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219974 EAP HCPCS C1755 Kit Epidural Catheterization BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.36 $108.36 $112.54 $0.00 $30.43 $0.00 $0.00 $0.00 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219975 EAP Custom 27219975 Kit Dressing Midline Custom Change Tray BOTH IP/OP $48.00 $35.52 $0.00 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.63 $35.63 $37.00 $0.00 $10.00 $0.00 $0.00 $0.00 $0.00 $24.00 $38.02 $38.40 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219976 EAP HCPCS C1725 Catheter Blndil 2.25mm 142cm 35mm Mozec Rx Nyl Ptca BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $0.00 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27219977 EAP HCPCS C1725 Catheter Blndil 2.5mm 142cm 35mm Mozec Rx Nyl Ptca BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $0.00 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27219978 EAP HCPCS C1725 Catheter Blndil 2.75mm 142cm 35mm Mozec Rx Nyl Ptca BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $0.00 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27219979 EAP HCPCS C1725 Catheter Blndil 3mm Lf Crds Mozec Rx Ptca BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $0.00 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27219980 EAP HCPCS C1725 Catheter Blndil 3.5mm 142cm 35mm Mozec Rx Nyl Ptca BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $0.00 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27219981 EAP HCPCS C1725 Catheter Blndil 4mm 142cm 35mm Mozec Rx Nyl Ptca BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $134.66 $134.66 $0.00 $0.00 $0.00 $51.69 $184.07 $184.07 $191.16 $0.00 $51.68 $0.00 $146.69 $146.69 $0.00 $124.00 $196.42 $198.40 $0.00 $0.00 $0.00 $38.81 $0.00 $0.00 $39.48 $0.00 $0.00 $0.00 $0.00 $0.00 27219982 EAP HCPCS C1894 Set Intro 8fr 80cm Lf S Arwflx 3w Stpck Shth Radopq Intgr BOTH IP/OP $331.00 $244.94 $0.00 $264.80 $179.73 $179.73 $0.00 $0.00 $0.00 $68.99 $245.67 $245.67 $255.13 $0.00 $68.98 $0.00 $195.79 $195.79 $0.00 $165.50 $262.15 $264.80 $0.00 $0.00 $0.00 $51.80 $0.00 $0.00 $52.70 $0.00 $0.00 $0.00 $0.00 $0.00 27219983 EAP Custom 27219983 Cath Umb 3.5f Pu 15in BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219984 EAP Custom 27219984 Cath Umb 5f Pu 15in BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $22.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219985 EAP Custom 27219985 "Catheter, 8f Thoracic" BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219986 EAP Custom 27219986 Cath Trocar Fnl 10f 9in BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219987 EAP Custom 27219987 Cath Trocar 12fr BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219988 EAP Custom 27219988 "Kit, Chest Tube" BOTH IP/OP $74.00 $54.76 $0.00 $59.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.92 $54.92 $57.04 $0.00 $15.42 $0.00 $0.00 $0.00 $0.00 $37.00 $58.61 $59.20 $0.00 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219989 EAP Custom 27219989 Umbilical Vessel Catheter Tray 88-160408 BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.26 $94.26 $97.89 $0.00 $26.47 $0.00 $0.00 $0.00 $0.00 $63.50 $100.58 $101.60 $0.00 $82.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219990 EAP HCPCS C1887 Catheter Gd Strg 5fr .068in .055in 115cm 17cm Sofia Dist Acc BOTH IP/OP "$3,040.00 " "$2,249.60" $0.00 "$2,432.00" "$1,650.72" "$1,650.72" $0.00 $0.00 $0.00 $633.61 "$2,256.29" "$2,256.29" "$2,343.23" $0.00 $633.54 $0.00 "$1,798.16" "$1,798.16" $0.00 "$1,520.00" "$2,407.68" "$2,432.00" $0.00 "$1,976.00" $0.00 $475.76 $0.00 $0.00 $483.97 $0.00 $0.00 $0.00 $0.00 $0.00 27219991 EAP HCPCS C1887 Catheter Gd Strg 5fr .068in .055in 125cm 17cm Sofia Dist Acc BOTH IP/OP "$3,230.00 " "$2,390.20" $0.00 "$2,584.00" "$1,753.89" "$1,753.89" $0.00 $0.00 $0.00 $673.21 "$2,397.31" "$2,397.31" "$2,489.68" $0.00 $673.13 $0.00 "$1,910.55" "$1,910.55" $0.00 "$1,615.00" "$2,558.16" "$2,584.00" $0.00 "$2,099.50" $0.00 $505.50 $0.00 $0.00 $514.22 $0.00 $0.00 $0.00 $0.00 $0.00 27219992 EAP HCPCS C1725 Catheter Blndil 1mm 5mm Strl Lf Sphr Ii Pro Perc Ptca BOTH IP/OP $563.00 $416.62 $0.00 $450.40 $305.71 $305.71 $0.00 $0.00 $0.00 $117.34 $417.86 $417.86 $433.96 $0.00 $117.33 $0.00 $333.01 $333.01 $0.00 $281.50 $445.90 $450.40 $0.00 $0.00 $0.00 $88.11 $0.00 $0.00 $89.63 $0.00 $0.00 $0.00 $0.00 $0.00 27219993 EAP HCPCS C1725 Catheter Blndil 1mm 8mm Strl Lf Sphr Ii Pro Perc Ptca BOTH IP/OP $563.00 $416.62 $0.00 $450.40 $305.71 $305.71 $0.00 $0.00 $0.00 $117.34 $417.86 $417.86 $433.96 $0.00 $117.33 $0.00 $333.01 $333.01 $0.00 $281.50 $445.90 $450.40 $0.00 $0.00 $0.00 $88.11 $0.00 $0.00 $89.63 $0.00 $0.00 $0.00 $0.00 $0.00 27219994 EAP HCPCS C1725 Catheter Blndil 1mm 10mm Strl Lf Sphr Ii Pro Perc Ptca BOTH IP/OP $563.00 $416.62 $0.00 $450.40 $305.71 $305.71 $0.00 $0.00 $0.00 $117.34 $417.86 $417.86 $433.96 $0.00 $117.33 $0.00 $333.01 $333.01 $0.00 $281.50 $445.90 $450.40 $0.00 $0.00 $0.00 $88.11 $0.00 $0.00 $89.63 $0.00 $0.00 $0.00 $0.00 $0.00 27219995 EAP HCPCS C1725 Catheter Blndil 1mm 15mm Strl Lf Sphr Ii Pro Perc Ptca BOTH IP/OP $563.00 $416.62 $0.00 $450.40 $305.71 $305.71 $0.00 $0.00 $0.00 $117.34 $417.86 $417.86 $433.96 $0.00 $117.33 $0.00 $333.01 $333.01 $0.00 $281.50 $445.90 $450.40 $0.00 $0.00 $0.00 $88.11 $0.00 $0.00 $89.63 $0.00 $0.00 $0.00 $0.00 $0.00 27219996 EAP HCPCS C1725 Catheter Blndil 1.25mm 5mm Sphr Ii Pro Cor BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27219997 EAP HCPCS C1725 Catheter Blndil 1.25mm 8mm Sphr Ii Pro Cor BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27219998 EAP HCPCS C1725 Catheter Blndil 1.25mm 10mm Sphr Ii Pro Cor BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27219999 EAP HCPCS C1725 Catheter Blndil 1.25mm 15mm Sphr Ii Pro Cor BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220000 EAP HCPCS C1725 Catheter Blndil 1.5mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220001 EAP HCPCS C1725 Catheter Blndil 1.5mm Strl Lf 12mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220002 EAP HCPCS C1725 Catheter Blndil 1.5mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220003 EAP HCPCS C1725 Catheter Blndil 1.5mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220004 EAP HCPCS C1725 Catheter Blndil 1.75mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220005 EAP HCPCS C1725 Catheter Blndil 1.75mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220006 EAP HCPCS C1725 Catheter Blndil 1.75mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220007 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220008 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 12mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220009 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220010 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220011 EAP HCPCS C1725 Catheter Blndil 2.25mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220012 EAP HCPCS C1725 Catheter Blndil 2.25mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220013 EAP HCPCS C1725 Catheter Blndil 2.25mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220014 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220015 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 12mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220016 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220017 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220018 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 30mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220019 EAP HCPCS C1725 Catheter Blndil 2.75mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220020 EAP HCPCS C1725 Catheter Blndil 2.75mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220021 EAP HCPCS C1725 Catheter Blndil 2.75mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220022 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220023 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 12mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220024 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220025 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220026 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 30mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220027 EAP HCPCS C1725 Catheter Blndil 3.25mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220028 EAP HCPCS C1725 Catheter Blndil 3.25mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220029 EAP HCPCS C1725 Catheter Blndil 3.25mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220030 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220031 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220032 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220033 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 30mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220034 EAP HCPCS C1725 Catheter Blndil 4mm Strl Lf 10mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220035 EAP HCPCS C1725 Catheter Blndil 4mm Strl Lf 15mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220036 EAP HCPCS C1725 Catheter Blndil 4mm Strl Lf 20mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220037 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220038 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220039 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 12mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220040 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 15mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220041 EAP HCPCS C1725 Catheter Blndil 2mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220042 EAP HCPCS C1725 Catheter Blndil 2.25mm Strl Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220043 EAP HCPCS C1725 Catheter Blndil 2.25mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220044 EAP HCPCS C1725 Catheter Blndil 2.25mm Strl Lf 12mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220045 EAP HCPCS C1725 Catheter Blndil 2.25mm Strl Lf 15mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220046 EAP HCPCS C1725 Catheter Blndil 2.25mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220047 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220048 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220049 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 12mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220050 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 16mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220051 EAP HCPCS C1725 Catheter Blndil 2.5mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220052 EAP HCPCS C1725 Catheter Blndil 2.75mm Strl Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220053 EAP HCPCS C1725 Catheter Blndil 2.75mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220054 EAP HCPCS C1725 Catheter Blndil 2.75mm Strl Lf 12mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220055 EAP HCPCS C1725 Catheter Blndil 2.75mm Strl Lf 15mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220056 EAP HCPCS C1725 Catheter Blndil 2.75mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220057 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220058 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220059 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 12mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220060 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 15mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220061 EAP HCPCS C1725 Catheter Blndil 3mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220062 EAP HCPCS C1725 Catheter Blndil 3.25mm Strl Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220063 EAP HCPCS C1725 Catheter Blndil 3.25mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220064 EAP HCPCS C1725 Catheter Blndil 3.25mm Strl Lf 12mm Sphr Ii Pro Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220065 EAP HCPCS C1725 Catheter Blndil 3.25mm Strl Lf 15mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220066 EAP HCPCS C1725 Catheter Blndil 3.25mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220067 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220068 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220069 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 12mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220070 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 15mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220071 EAP HCPCS C1725 Catheter Blndil 3.5mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220072 EAP HCPCS C1725 Catheter Blndil 3.75mm Ns Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220073 EAP HCPCS C1725 Catheter Blndil 3.75mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220074 EAP HCPCS C1725 Catheter Blndil 3.75mm Strl Lf 12mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220075 EAP HCPCS C1725 Catheter Blndil 3.75mm Strl Lf 15mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220076 EAP HCPCS C1725 Catheter Blndil 3.75mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220077 EAP HCPCS C1725 Catheter Blndil 4mm Strl Lf 8mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220078 EAP HCPCS C1725 Catheter Blndil 4mm Strl Lf 10mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220079 EAP HCPCS C1725 Catheter Blndil 4mm Strl Lf 12mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220080 EAP HCPCS C1725 Catheter Blndil 4mm Strl Lf 15mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220081 EAP HCPCS C1725 Catheter Blndil 4mm Strl Lf 18mm Sphr Nc + Ptca BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 27220082 EAP HCPCS C1757 Catheter Asp .082-.085in .071in 115cm Axs Vecta 71 Scout BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220083 EAP HCPCS C1757 Catheter Asp .082-.085in .071in 125cm Axs Vecta 71 Scout BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,665.25" "$3,665.25" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 "$4,387.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220084 EAP HCPCS C1757 Cath Thromb Axs Vecta 71 2-4 Mm L132 Cm L150 Cm Od.082-.085 BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,665.25" "$3,665.25" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 "$4,387.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220085 EAP HCPCS C1730 "Cath, Ep, 5-5-5mm Spc Cs Lt Crv 6fr 65cm Rspn Mp Dcapl Fx" BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 27220086 EAP HCPCS C1730 "Cath, Ep, 5-5-5-5-5mm Spc Crnnd 2 Crv 5fr 115cm Strbl 8" BOTH IP/OP $365.00 $270.10 $0.00 $292.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.50 $289.08 $292.00 $0.00 $0.00 $0.00 $57.12 $0.00 $0.00 $58.11 $0.00 $0.00 $0.00 $0.00 $0.00 27220087 EAP HCPCS C1730 "Cath, Ep, 2-10-2mm Spc Sup Lg Curl Crv 7fr 95cm 2mm Lvwr" BOTH IP/OP $804.00 $594.96 $0.00 $643.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $402.00 $636.77 $643.20 $0.00 $0.00 $0.00 $125.83 $0.00 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220088 EAP HCPCS C1730 Catheter Ep 5mm Spc Crnnd Crv 5fr 120cm Rspn Qdpl BOTH IP/OP $98.00 $72.52 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.00 $77.62 $78.40 $0.00 $0.00 $0.00 $15.34 $0.00 $0.00 $15.60 $0.00 $0.00 $0.00 $0.00 $0.00 27220089 EAP HCPCS C1730 "Cath, Ep, 5mm Spacing Jsn Curve 5fr 120cm" BOTH IP/OP $98.00 $72.52 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.00 $77.62 $78.40 $0.00 $0.00 $0.00 $15.34 $0.00 $0.00 $15.60 $0.00 $0.00 $0.00 $0.00 $0.00 27220090 EAP Cable Cath 150cm Blk Rspn Hexpl Octpl Dcapl Ep Repro BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $76.31 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220091 EAP Catheter Ep 150cm Rspn Lvwr Hexpl Octpl Dcapl BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $76.31 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220092 EAP Cable Cath Xtn Sjm Gntr BOTH IP/OP $222.00 $164.28 $0.00 $177.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.77 $164.77 $171.12 $0.00 $46.26 $0.00 $0.00 $0.00 $0.00 $111.00 $175.82 $177.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220093 EAP HCPCS C1894 Introducer Sheath .038in Large 18fr 30cm 42cm Radiopq Band BOTH IP/OP $318.00 $235.32 $0.00 $254.40 $172.67 $172.67 $0.00 $0.00 $0.00 $66.28 $236.02 $236.02 $245.11 $0.00 $66.27 $0.00 $188.10 $188.10 $0.00 $159.00 $251.86 $254.40 $0.00 $0.00 $0.00 $49.77 $0.00 $0.00 $50.63 $0.00 $0.00 $0.00 $0.00 $0.00 27220094 EAP Catheter Angio Chuang 2.5 Crv 5fr 80cm Trnb Ad Bcntp Mp Ss BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $203.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220095 EAP Ft Retraction Aspirator Device Se BOTH IP/OP "$3,238.00 " "$2,396.12" $0.00 "$2,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,403.24" "$2,403.24" "$2,495.85" $0.00 $674.80 $0.00 $0.00 $0.00 $0.00 "$1,619.00" "$2,564.50" "$2,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220096 EAP Flowtriever Bundle BOTH IP/OP "$22,500.00 " "$16,650.00" $0.00 "$18,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,343.00" $0.00 "$4,689.00" $0.00 $0.00 $0.00 $0.00 "$11,250.00" "$17,820.00" "$18,000.00" $0.00 "$14,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220097 EAP Tube Nasogastric 10fr 1.22mr 24 Port Vented Vinyl Pediatric BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $27.46 $28.52 $0.00 $7.71 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220098 EAP Tube Ng 8fr 36in Lf Entflx Fd Sty Y St BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $17.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220099 EAP Cuff Blood Pressure Clearsight Small Finger BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $481.75 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220100 EAP Cuff Blood Pressure Clearsight Medium Finger BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $481.75 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220101 EAP Cuff Blood Pressure Clearsight Large Finger BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $481.75 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220102 EAP Powermidline Catheter Max Barrier Tray 4f Sl BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220103 EAP Central Line 10cm 18g Basic BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.62 $107.62 $111.77 $0.00 $30.22 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220104 EAP Central Line 10cm 18g Full BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220105 EAP Central Line 8cm 18g Basic BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.62 $107.62 $111.77 $0.00 $30.22 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220106 EAP Central Line 8cm 18g Full BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220107 EAP Soehendra Biliary Dilation Catheter BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.96 $146.96 $152.62 $0.00 $41.26 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $128.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220108 EAP Spybite Biopsy Forceps BOTH IP/OP "$1,338.00 " $990.12 $0.00 "$1,070.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $993.06 $993.06 "$1,031.33" $0.00 $278.84 $0.00 $0.00 $0.00 $0.00 $669.00 "$1,059.70" "$1,070.40" $0.00 $869.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220109 EAP Pancreatic Stent 5fr BOTH IP/OP $115.00 $85.10 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.35 $85.35 $88.64 $0.00 $23.97 $0.00 $0.00 $0.00 $0.00 $57.50 $91.08 $92.00 $0.00 $74.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220110 EAP Ligating Device BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $169.58 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220111 EAP Echotip Procore Biopsy Needle BOTH IP/OP "$1,013.00 " $749.62 $0.00 $810.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $751.85 $751.85 $780.82 $0.00 $211.11 $0.00 $0.00 $0.00 $0.00 $506.50 $802.30 $810.40 $0.00 $658.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220112 EAP Misc Central Line Supply BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $169.58 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220113 EAP HCPCS C1726 Catheter Blndil 5mm 135cm 20mm Pr Ctbln Otw Tpr Tip Infl BOTH IP/OP "$1,759.00 " "$1,301.66" $0.00 "$1,407.20" $955.14 $955.14 $0.00 $0.00 $0.00 $366.62 "$1,305.53" "$1,305.53" "$1,355.84" $0.00 $366.58 $0.00 "$1,040.45" "$1,040.45" $0.00 $879.50 "$1,393.13" "$1,407.20" $0.00 $0.00 $0.00 $275.28 $0.00 $0.00 $280.03 $0.00 $0.00 $0.00 $0.00 $0.00 27220114 EAP HCPCS C1753 Catheter Baldilat Lp 5.3fr 4mm 135cm 60mm High Pressure BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $251.41 $251.41 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $356.88 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.70 $370.40 $0.00 $0.00 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 27220117 EAP HCPCS C1887 Catheter Axs Catalyst 7 .068 Id X132cm BOTH IP/OP "$5,288.00 " "$3,913.12" $0.00 "$4,230.40" "$2,871.38" "$2,871.38" $0.00 $0.00 $0.00 "$1,102.15" "$3,924.75" "$3,924.75" "$4,075.99" $0.00 "$1,102.02" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,644.00" "$4,188.10" "$4,230.40" $0.00 "$3,437.20" $0.00 $827.57 $0.00 $0.00 $841.85 $0.00 $0.00 $0.00 $0.00 $0.00 27220118 EAP HCPCS C1887 Catheter Axs Catalyst 7 .068 Id X125cm BOTH IP/OP "$5,288.00 " "$3,913.12" $0.00 "$4,230.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,644.00" "$4,188.10" "$4,230.40" $0.00 $0.00 $0.00 $827.57 $0.00 $0.00 $841.85 $0.00 $0.00 $0.00 $0.00 $0.00 27220119 EAP HCPCS C1887 Catheter Axs Catalyst 7 .068 Id X115cm BOTH IP/OP "$5,288.00 " "$3,913.12" $0.00 "$4,230.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,644.00" "$4,188.10" "$4,230.40" $0.00 $0.00 $0.00 $827.57 $0.00 $0.00 $841.85 $0.00 $0.00 $0.00 $0.00 $0.00 27220120 EAP HCPCS C1751 "Kit Triple Lumen Cvc, 7fr 20 Cm" BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $195.48 $195.48 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $277.49 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $234.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 27220121 EAP HCPCS C1751 Misc Swan Ganz Catheter BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $380.10 $380.10 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $539.56 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 27220122 EAP Custom 27220122 Catheter Urethral 8fr Foley 2 Way Latex Dover Silicone BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.42 $79.42 $82.48 $0.00 $22.30 $0.00 $0.00 $0.00 $0.00 $53.50 $84.74 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220123 EAP Custom 27220123 Dressing Wound Square 6x6in 2 Layer Absorbent Nonwoven Soft BOTH IP/OP $56.00 $41.44 $0.00 $44.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $41.56 $43.16 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $28.00 $44.35 $44.80 $0.00 $36.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220124 EAP Custom 27220124 Tray Spnl 20ga 3.5in Strl Lf 3 Spng Stk Prp Well Bndg Adlt BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $31.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220125 EAP Custom 27220125 Tray Spnl 22ga 1.5in 10ml Strl Spec Vl Prenumber Cap Pt Id BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220126 EAP Custom 27220126 Dressing Burn 36x36in 17 Ply Gauze BOTH IP/OP $824.00 $609.76 $0.00 $635.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.57 $611.57 $635.14 $0.00 $171.72 $0.00 $0.00 $0.00 $0.00 $20.50 $32.47 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220127 EAP Custom 27220127 Bandage Compression 10ydx4in 5ydx4in 1 Self Adherent Elast BOTH IP/OP $26.00 $19.24 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.30 $19.30 $20.04 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $13.00 $20.59 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220129 EAP Custom 27220129 Valve Drn Sm 30ml Pnmst Grad Grmnt Atch Mlt Chst Tube Cnct BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $53.96 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220130 EAP Custom 27220130 Dressing Prfy H2o Calcium Alg Na Cmc Gntl Dbrd BOTH IP/OP $31.00 $22.94 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.01 $23.01 $23.89 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.50 $24.55 $24.80 $0.00 $20.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220131 EAP Custom 27220131 Dressing Biatain Ag 4x4in 1 Pc Rem Abs Wnd Alg BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $17.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220132 EAP Custom 27220132 Dressing Brn 48x4in Strl Lf Actct Flx 3 Anmc Brr 1 Lyr Knit BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220133 EAP Custom 27220133 Dressing Wnd 8x8in Medihoney Abs Lght Ddrgl Clld Sht BOTH IP/OP $67.00 $49.58 $0.00 $53.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $0.00 $0.00 $0.00 $33.50 $53.06 $53.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220134 EAP Custom 27220134 Gel Drsg Lf Medihoney Tub 400gm BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220135 EAP Custom 27220135 Tray Dressing Cardinal Central Line Grady Custom BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $27.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220136 EAP Pack Srg Crd Cath Haz BOTH IP/OP $173.00 $128.02 $0.00 $138.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.50 $137.02 $138.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220137 EAP Device Inflat 12fr 3in Pressure Gauge Latex Free Encore 26 BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $61.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220138 EAP Device Cmpr Lg 29cm Tr Band 2 Bln Trns Adj Strap Air Trtn BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.60 $61.60 $63.98 $0.00 $17.30 $0.00 $0.00 $0.00 $0.00 $41.50 $65.74 $66.40 $0.00 $53.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220139 EAP Umbilical Catheter 3.5 BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $65.52 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $55.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220140 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 25mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220141 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 30mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220142 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 38mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220143 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 9mm Rapex Elongate Tip BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220144 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 14mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220145 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 17mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220146 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 20mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220147 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 30mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220148 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 9mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220149 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 14mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220150 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 17mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220151 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 20mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220152 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 6mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220153 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 6mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220154 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 6mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220155 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 6mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220156 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 6mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220157 EAP HCPCS C1725 Catheter Baldilat 3.25mm 139cm 6mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220158 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 6mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220159 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 6mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220160 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220161 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220162 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220163 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220164 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220165 EAP HCPCS C1725 Catheter Baldilat 3.25mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220166 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220167 EAP HCPCS C1725 Catheter Baldilat 3.75mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220168 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 10mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220169 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220170 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220171 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220172 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220173 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220174 EAP HCPCS C1725 Catheter Baldilat 3.25mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220175 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220176 EAP HCPCS C1725 Catheter Baldilat 3.75mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220177 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 12mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220178 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220179 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220180 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220181 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220182 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220183 EAP HCPCS C1725 Catheter Baldilat 3.25mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220184 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220185 EAP HCPCS C1725 Catheter Baldilat 3.75mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220186 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 15mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220187 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220188 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220189 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220190 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220191 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220192 EAP HCPCS C1725 Catheter Baldilat 3.25mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220193 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220194 EAP HCPCS C1725 Catheter Baldilat 3.75mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220195 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 20mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220196 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 25mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220197 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 25mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220198 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 25mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220199 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 25mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220200 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 25mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220201 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 30mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220202 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 30mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220203 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 30mm Rapex Post Dil BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220204 EAP HCPCS C1725 Catheter Baldilat 1.5mm 139cm 6mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220205 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 6mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220206 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 6mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220207 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 6mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220208 EAP HCPCS C1725 Catheter Baldilat 1.5mm 139cm 10mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220209 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 10mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220210 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 10mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220211 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 10mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220212 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 10mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220213 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 10mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220214 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 10mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220215 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 10mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220216 EAP HCPCS C1725 Catheter Baldilat 1.5mm 139cm 12mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220217 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 12mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220218 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 12mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220219 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 12mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220220 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 12mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220221 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 12mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220222 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 12mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220223 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 12mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220224 EAP HCPCS C1725 Catheter Baldilat 1.5mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220225 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220226 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220227 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220228 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220229 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220230 EAP HCPCS C1725 Catheter Baldilat 3.25mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220231 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220232 EAP HCPCS C1725 Catheter Baldilat 3.75mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220233 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 15mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220234 EAP HCPCS C1725 Catheter Baldilat 1.5mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220235 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220236 EAP HCPCS C1725 Catheter Baldilat 2.25mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220237 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220238 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220239 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220240 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220241 EAP HCPCS C1725 Catheter Baldilat 3.75mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220242 EAP HCPCS C1725 Catheter Baldilat 4mm 139cm 20mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220243 EAP HCPCS C1725 Catheter Baldilat 2mm 139cm 30mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220244 EAP HCPCS C1725 Catheter Baldilat 2.5mm 139cm 30mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220245 EAP HCPCS C1725 Catheter Baldilat 2.75mm 139cm 30mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220246 EAP HCPCS C1725 Catheter Baldilat 3mm 139cm 30mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220247 EAP HCPCS C1725 Catheter Baldilat 3.5mm 139cm 30mm Rapex BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 27220248 EAP HCPCS C1725 Catheter Baldilat 2mm 8mm Mozec Ptca BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220249 EAP HCPCS C1725 Catheter Baldilat 2mm 10mm Mozec Ptca BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220250 EAP HCPCS C1725 Catheter Baldilat 2mm 142cm 13mm Rapex Radiopq Nc BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220251 EAP HCPCS C1725 Catheter Baldilat 2mm 15mm Mozec Ptca BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220252 EAP HCPCS C1725 Catheter Baldilat 2mm 18mm Mozec Ptca BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220253 EAP HCPCS C1725 Catheter Baldilat 2mm 23mm Mozec Ptca BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220254 EAP HCPCS C1725 Catheter Baldilat 2mm 28mm Mozec Ptca BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220255 EAP HCPCS C1725 Catheter Baldilat 2mm 35mm Mozec Ptca BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220256 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 8mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220257 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 10mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220258 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 13mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220259 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 15mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220260 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 18mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220261 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 23mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220262 EAP HCPCS C1725 Catheter Baldilat 2.5mm Rapex Latex Free Crds BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220263 EAP HCPCS C1725 Catheter Baldilat 2.5mm Rapex Latex Free Crds BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220264 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 10mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220265 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 13mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220266 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 15mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220267 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 18mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220268 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 23mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220269 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 28mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220270 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 8mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220271 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 10mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220272 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 13mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220273 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 15mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220274 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 18mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220275 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 23mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220276 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 28mm Rapex Nyl BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220277 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 8mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220278 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 10mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220279 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 13mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220280 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 15mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220281 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 18mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220282 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 23mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220283 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 28mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220284 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 8mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220285 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 10mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220286 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 13mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220287 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 15mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220288 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 18mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220289 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 23mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220290 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 28mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220291 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 8mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220292 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 10mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220293 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 13mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220294 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 15mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220295 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 18mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220296 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 23mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220297 EAP HCPCS C1725 Catheter Baldilat 4mm 142cm 28mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220298 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 8mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220299 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 10mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220300 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 13mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220301 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 15mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220302 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 18mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220303 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 23mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220304 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 28mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220305 EAP HCPCS C1725 Catheter Baldilat 4.5mm 142cm 35mm Rapex Nyl Mozec BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220306 EAP HCPCS C1725 Catheter Baldilat 1.5mm 142cm 9mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220307 EAP HCPCS C1725 Catheter Baldilat 1.5mm 142cm 12mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220308 EAP HCPCS C1725 Catheter Baldilat 1.5mm 142cm 15mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220309 EAP HCPCS C1725 Catheter Baldilat 2mm 142cm 9mm Rapex Elongate Tip BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220310 EAP HCPCS C1725 Catheter Baldilat 2mm 142cm 12mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220311 EAP HCPCS C1725 Catheter Baldilat 2mm 142cm 15mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220312 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 9mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220313 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 14mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220314 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 17mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220315 EAP HCPCS C1725 Catheter Baldilat 2.25mm 142cm 20mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220316 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 9mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220317 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 14mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220318 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 17mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220319 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 20mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220320 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 25mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220321 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 30mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220322 EAP HCPCS C1725 Catheter Baldilat 2.2mm 38mm Mozec Ptca BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220323 EAP HCPCS C1725 Catheter Baldilat 2.5mm 142cm 41mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220324 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 9mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220325 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 14mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220326 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 17mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220327 EAP HCPCS C1725 Catheter Baldilat 2.75mm 142cm 20mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220328 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 9mm Rapex Elongate Tip BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220329 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 14mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220330 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 17mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220331 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 20mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220332 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 25mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220333 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 30mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220334 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 38mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220335 EAP HCPCS C1725 Catheter Baldilat 3mm 142cm 41mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220336 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 9mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220337 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 14mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220338 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 17mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220339 EAP HCPCS C1725 Catheter Baldilat 3.5mm 142cm 20mm Rapex Elongate BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 27220340 EAP HCPCS C1725 Catheter Angiographic Angle 5fr .047in 65cm 25cm 1 Braid BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $66.79 $66.79 $0.00 $0.00 $0.00 $25.64 $91.29 $91.29 $94.81 $0.00 $25.63 $0.00 $72.75 $72.75 $0.00 $61.50 $97.42 $98.40 $0.00 $79.95 $0.00 $19.25 $0.00 $0.00 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 27220341 EAP HCPCS C1887 Catheter Intvn 900- Psi 2.2-2.9fr 6- Mm .02in 110 BOTH IP/OP "$2,488.00 " "$1,841.12" $0.00 "$1,990.40" "$1,350.98" "$1,350.98" $0.00 $0.00 $0.00 $518.56 "$1,846.59" "$1,846.59" "$1,917.75" $0.00 $518.50 $0.00 "$1,471.65" "$1,471.65" $0.00 "$1,244.00" "$1,970.50" "$1,990.40" $0.00 $0.00 $0.00 $389.37 $0.00 $0.00 $396.09 $0.00 $0.00 $0.00 $0.00 $0.00 27220342 EAP HCPCS C1887 Catheter Blnocc 900- Psi 2.2-2.9fr 6- Mm .02in 130 BOTH IP/OP "$2,488.00 " "$1,841.12" $0.00 "$1,990.40" "$1,350.98" "$1,350.98" $0.00 $0.00 $0.00 $518.56 "$1,846.59" "$1,846.59" "$1,917.75" $0.00 $518.50 $0.00 "$1,471.65" "$1,471.65" $0.00 "$1,244.00" "$1,970.50" "$1,990.40" $0.00 "$1,617.20" $0.00 $389.37 $0.00 $0.00 $396.09 $0.00 $0.00 $0.00 $0.00 $0.00 27220343 EAP HCPCS C1887 Catheter Blnocc 900- Psi 2.2-2.9fr 6- Mm .02in 150 BOTH IP/OP "$2,488.00 " "$1,841.12" $0.00 "$1,990.40" "$1,350.98" "$1,350.98" $0.00 $0.00 $0.00 $518.56 "$1,846.59" "$1,846.59" "$1,917.75" $0.00 $518.50 $0.00 "$1,471.65" "$1,471.65" $0.00 "$1,244.00" "$1,970.50" "$1,990.40" $0.00 $0.00 $0.00 $389.37 $0.00 $0.00 $396.09 $0.00 $0.00 $0.00 $0.00 $0.00 27220344 EAP HCPCS C1887 Catheter Infus 110cm 2 Lum Ang Tip Radiopq Gwire BOTH IP/OP "$2,488.00 " "$1,841.12" $0.00 "$1,990.40" "$1,350.98" "$1,350.98" $0.00 $0.00 $0.00 $518.56 "$1,846.59" "$1,846.59" "$1,917.75" $0.00 $518.50 $0.00 "$1,471.65" "$1,471.65" $0.00 "$1,244.00" "$1,970.50" "$1,990.40" $0.00 $0.00 $0.00 $389.37 $0.00 $0.00 $396.09 $0.00 $0.00 $0.00 $0.00 $0.00 27220345 EAP HCPCS C1887 Catheter Infus 130cm 2 Lum Ang Tip Radiopq Gwire BOTH IP/OP "$2,488.00 " "$1,841.12" $0.00 "$1,990.40" "$1,350.98" "$1,350.98" $0.00 $0.00 $0.00 $518.56 "$1,846.59" "$1,846.59" "$1,917.75" $0.00 $518.50 $0.00 "$1,471.65" "$1,471.65" $0.00 "$1,244.00" "$1,970.50" "$1,990.40" $0.00 $0.00 $0.00 $389.37 $0.00 $0.00 $396.09 $0.00 $0.00 $0.00 $0.00 $0.00 27220346 EAP HCPCS C1887 Catheter Infus 150cm 2 Lum Ang Tip Radiopq Gwire BOTH IP/OP "$2,488.00 " "$1,841.12" $0.00 "$1,990.40" "$1,350.98" "$1,350.98" $0.00 $0.00 $0.00 $518.56 "$1,846.59" "$1,846.59" "$1,917.75" $0.00 $518.50 $0.00 "$1,471.65" "$1,471.65" $0.00 "$1,244.00" "$1,970.50" "$1,990.40" $0.00 $0.00 $0.00 $389.37 $0.00 $0.00 $396.09 $0.00 $0.00 $0.00 $0.00 $0.00 27220347 EAP HCPCS C1887 Catheter Angio Jl 4 Crv 5fr .047in 100cm Infnt Thrlmn Radopq BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $52.67 $52.67 $0.00 $0.00 $0.00 $20.22 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $57.38 $57.38 $0.00 $48.50 $76.82 $77.60 $0.00 $63.05 $0.00 $15.18 $0.00 $0.00 $15.44 $0.00 $0.00 $0.00 $0.00 $0.00 27220348 EAP HCPCS C1887 Catheter Angio Al 1 Crv 6fr 100cm Infnt Lt Cor BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $52.67 $52.67 $0.00 $0.00 $0.00 $20.22 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $57.38 $57.38 $0.00 $48.50 $76.82 $77.60 $0.00 $63.05 $0.00 $15.18 $0.00 $0.00 $15.44 $0.00 $0.00 $0.00 $0.00 $0.00 27220349 EAP Kit Picc Dressing Change Tray 215 BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $29.50 $46.73 $47.20 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27220352 EAP HCPCS C1769 Guidewire Vasc 90d 60d 2cm .018in 180cm 25cm Gldwr Gt Tip BOTH IP/OP $393.00 $290.82 $0.00 $314.40 $213.40 $213.40 $0.00 $0.00 $0.00 $81.91 $291.68 $291.68 $302.92 $0.00 $81.90 $0.00 $232.46 $232.46 $0.00 $196.50 $311.26 $314.40 $0.00 $255.45 $0.00 $61.50 $0.00 $0.00 $62.57 $0.00 $0.00 $0.00 $0.00 $0.00 27220353 EAP Device Inflat 12fr Pressure Gauge Encore 26 20ml BOTH IP/OP $367.00 $271.58 $0.00 $293.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.39 $272.39 $282.88 $0.00 $76.48 $0.00 $0.00 $0.00 $0.00 $183.50 $290.66 $293.60 $0.00 $238.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27300022 EAP Stocking Compression 20-30 Mmhg Large Bk Od15.5-18 BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $31.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27300023 EAP Stocking Compression 20-30 Mmhg X-large Bk Od17.5-20 BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $31.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400001 EAP HCPCS A5121 "Skin Barrier, Solid 6X6 or Equival" BOTH IP/OP $36.00 $26.64 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $16.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400002 EAP HCPCS A5122 "Skin Barrier, Solid 8x8 Or Equivalent" BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $104.06 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $60.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400003 EAP HCPCS L0170 Neck Ext. Splint BOTH IP/OP $94.00 $69.56 $0.00 $556.60 $42.30 $42.30 $0.00 $0.00 $530.92 $556.60 $69.77 $69.77 $72.46 $0.00 $19.59 $0.00 $55.60 $55.60 $0.00 $47.00 $74.45 $75.20 $56.40 $42.30 $56.40 $529.98 $0.00 $0.00 $540.87 $0.00 $0.00 $0.00 $0.00 $0.00 27400004 EAP HCPCS L0150 Cervical Collar BOTH IP/OP $202.00 $149.48 $0.00 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.92 $149.92 $155.70 $0.00 $42.10 $0.00 $0.00 $0.00 $0.00 $101.00 $159.98 $161.60 $121.20 $90.90 $121.20 $0.00 $0.00 $0.00 $89.77 $0.00 $0.00 $0.00 $0.00 $0.00 27400005 EAP HCPCS L0172 Aspen Collar BOTH IP/OP $524.00 $387.76 $0.00 $419.20 $235.80 $235.80 $0.00 $0.00 $0.00 $112.86 $388.91 $388.91 $403.90 $0.00 $109.20 $0.00 $309.95 $309.95 $0.00 $262.00 $415.01 $419.20 $314.40 $235.80 $314.40 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 27400006 EAP HCPCS L0174 Miami Collar BOTH IP/OP $938.00 $694.12 $0.00 $750.40 $0.00 $0.00 $0.00 $0.00 $0.00 $202.73 $696.18 $696.18 $723.01 $0.00 $195.48 $0.00 $554.83 $554.83 $0.00 $469.00 $742.90 $750.40 $562.80 $422.10 $562.80 $193.04 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 27400007 EAP HCPCS L0190 Somi Brace BOTH IP/OP "$1,827.00 " "$1,351.98" $0.00 "$1,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,356.00" "$1,356.00" "$1,408.25" $0.00 $380.75 $0.00 $0.00 $0.00 $0.00 $913.50 "$1,446.98" "$1,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400008 EAP HCPCS L0200 Cervical Thoracic Orthosis(cto BOTH IP/OP "$1,679.00 " "$1,242.46" $0.00 "$1,343.20" $755.55 $755.55 $0.00 $0.00 $363.53 $381.11 "$1,246.15" "$1,246.15" "$1,294.17" $0.00 $349.90 $0.00 $993.13 $993.13 $0.00 $839.50 "$1,329.77" "$1,343.20" "$1,007.40" $755.55 "$1,007.40" $0.00 $0.00 $0.00 $370.34 $0.00 $0.00 $0.00 $0.00 $0.00 27400009 EAP HCPCS L0450 Tlso Brace BOTH IP/OP $929.00 $687.46 $0.00 $743.20 $418.05 $418.05 $0.00 $0.00 $122.60 $149.21 $689.50 $689.50 $716.07 $0.00 $193.60 $0.00 $549.50 $549.50 $0.00 $464.50 $735.77 $743.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400010 EAP HCPCS L0472 Jewett Brace BOTH IP/OP "$1,496.00 " "$1,107.04" $0.00 "$1,196.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,110.33" "$1,110.33" "$1,153.12" $0.00 $311.77 $0.00 $0.00 $0.00 $0.00 $748.00 "$1,184.83" "$1,196.80" $0.00 $673.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400011 EAP HCPCS L0486 Custom To Fit Tlso BOTH IP/OP "$6,431.00 " "$4,758.94" $0.00 "$5,144.80" "$2,893.95" "$2,893.95" $0.00 $0.00 "$1,327.28" $0.00 "$4,181.12" "$4,181.12" "$4,957.01" $0.00 "$1,340.22" $0.00 $0.00 $0.00 $0.00 "$3,215.50" "$5,093.35" "$5,144.80" "$3,858.60" "$2,893.95" "$3,858.60" "$1,324.93" $0.00 $0.00 "$1,352.17" $0.00 $0.00 $0.00 $0.00 $0.00 27400012 EAP HCPCS L0637 Lso Cybertech BOTH IP/OP "$4,041.00 " "$2,990.34" $0.00 "$3,232.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,999.23" "$2,999.23" "$3,114.80" $0.00 $842.14 $0.00 $0.00 $0.00 $0.00 "$2,020.50" "$3,200.47" "$3,232.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400013 EAP HCPCS L0638 Lso Brace BOTH IP/OP "$3,917.00 " "$2,898.58" $0.00 "$3,133.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,907.20" "$2,907.20" "$3,019.22" $0.00 $816.30 $0.00 $0.00 $0.00 $0.00 "$1,958.50" "$3,102.26" "$3,133.60" $0.00 "$1,762.65" $0.00 $996.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400014 EAP HCPCS L0700 Ctlso Brace BOTH IP/OP "$6,393.00 " "$4,730.82" $0.00 "$5,114.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,927.72" $0.00 "$1,332.30" $0.00 $0.00 $0.00 $0.00 "$3,196.50" "$5,063.26" "$5,114.40" $0.00 "$2,876.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400015 EAP HCPCS L1686 Hip Abduction Brace BOTH IP/OP "$4,383.00 " "$3,243.42" $0.00 "$3,506.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,253.06" "$3,253.06" "$3,378.42" $0.00 $913.42 $0.00 $0.00 $0.00 $0.00 "$2,191.50" "$3,471.34" "$3,506.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400017 EAP HCPCS L1830 Knee Immobilizer BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.36 $275.36 $285.97 $0.00 $77.32 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $166.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400019 EAP HCPCS L1940 Ankle Foot Orthosis BOTH IP/OP $345.00 $255.30 $0.00 $394.54 $0.00 $0.00 $0.00 $0.00 $0.00 $394.54 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $207.00 $155.25 $207.00 $375.67 $0.00 $0.00 $383.39 $0.00 $0.00 $0.00 $0.00 $0.00 27400020 EAP HCPCS L1834 Knee Ext. Splint BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.35 $180.35 $187.30 $0.00 $50.64 $0.00 $0.00 $0.00 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400021 EAP HCPCS L3650 Shoulder Immobilizer BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.36 $275.36 $285.97 $0.00 $77.32 $0.00 $0.00 $0.00 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400022 EAP HCPCS L3670 Shoulder Abduction BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $103.47 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $229.50 $229.50 $0.00 $194.00 $307.30 $310.40 $0.00 $174.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400024 EAP HCPCS L3702 Custom Elbow BOTH IP/OP $97.00 $71.78 $0.00 $208.54 $43.65 $43.65 $0.00 $0.00 $198.92 $208.54 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $57.38 $57.38 $0.00 $48.50 $76.82 $77.60 $58.20 $43.65 $58.20 $198.56 $0.00 $0.00 $202.65 $0.00 $0.00 $0.00 $0.00 $0.00 27400025 EAP HCPCS L3967 Airplane Splint BOTH IP/OP $406.00 $300.44 $0.00 "$1,392.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.33 $301.33 $312.94 $0.00 $84.61 $0.00 $0.00 $0.00 $0.00 $203.00 $321.55 $324.80 $243.60 $182.70 $243.60 $0.00 $0.00 $0.00 "$1,392.15" $0.00 $0.00 $0.00 $0.00 $0.00 27400026 EAP HCPCS L3905 Dynamic Wrist Splint BOTH IP/OP $107.00 $79.18 $0.00 $681.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.42 $79.42 $82.48 $0.00 $22.30 $0.00 $0.00 $0.00 $0.00 $53.50 $84.74 $85.60 $0.00 $48.15 $0.00 $681.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400027 EAP HCPCS L3935 Any Finger Splint BOTH IP/OP $198.00 $146.52 $0.00 $159.57 $89.10 $89.10 $0.00 $0.00 $152.21 $159.57 $146.96 $146.96 $152.62 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $118.80 $89.10 $118.80 $151.93 $0.00 $0.00 $155.06 $0.00 $0.00 $0.00 $0.00 $0.00 27400028 EAP HCPCS L3808 Ulnar/radial Gutter BOTH IP/OP $69.00 $51.06 $0.00 $247.75 $31.05 $31.05 $0.00 $0.00 $230.09 $247.75 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $34.50 $54.65 $55.20 $41.40 $31.05 $41.40 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400029 EAP HCPCS L3906 Wrist Cockup Splint BOTH IP/OP $202.00 $149.48 $0.00 $304.68 $90.90 $90.90 $0.00 $0.00 $290.61 $304.68 $149.92 $149.92 $155.70 $0.00 $42.10 $0.00 $119.48 $119.48 $0.00 $101.00 $159.98 $161.60 $121.20 $90.90 $121.20 $290.10 $0.00 $0.00 $296.07 $0.00 $0.00 $0.00 $0.00 $0.00 27400030 EAP HCPCS L3925 SPRING WIRE ASSIST SPLINT PREFAB BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $36.39 $39.19 $144.73 $144.73 $150.31 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $117.00 $87.75 $117.00 $37.31 $0.00 $0.00 $38.08 $0.00 $0.00 $0.00 $0.00 $0.00 27400033 EAP HCPCS L3671 Custom Humerus BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $323.74 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400034 EAP HCPCS L3982 RESTING HAND SPLINT-CUSTOM BOTH IP/OP $214.00 $158.36 $0.00 $275.84 $0.00 $0.00 $0.00 $0.00 $263.10 $275.84 $158.83 $158.83 $164.95 $0.00 $44.60 $0.00 $126.58 $126.58 $0.00 $107.00 $169.49 $171.20 $0.00 $96.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400038 EAP HCPCS L3334 Heel Lift BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $57.15 $57.15 $0.00 $0.00 $28.88 $30.28 $94.26 $94.26 $97.89 $0.00 $26.47 $0.00 $75.12 $75.12 $0.00 $63.50 $100.58 $101.60 $0.00 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400039 EAP HCPCS L3710 Hinged Elbow Brace BOTH IP/OP $431.00 $318.94 $0.00 $344.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.89 $319.89 $332.21 $0.00 $89.82 $0.00 $0.00 $0.00 $0.00 $215.50 $341.35 $344.80 $258.60 $193.95 $258.60 $99.70 $0.00 $0.00 $101.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400040 EAP HCPCS L3806 Dorsal Block Splint W/kleine BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $21.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400050 EAP HCPCS L3913 Simple Hand Based Spl BOTH IP/OP $55.00 $40.70 $0.00 $195.60 $24.75 $24.75 $0.00 $0.00 $186.59 $195.60 $40.82 $40.82 $42.39 $0.00 $11.46 $0.00 $32.53 $32.53 $0.00 $27.50 $43.56 $44.00 $33.00 $24.75 $33.00 $186.25 $0.00 $0.00 $190.08 $0.00 $0.00 $0.00 $0.00 $0.00 27400051 EAP HCPCS L3808 Dorsal Block Splint BOTH IP/OP $34.00 $25.16 $0.00 $247.75 $15.30 $15.30 $0.00 $0.00 $230.09 $247.75 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $20.40 $15.30 $20.40 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400052 EAP HCPCS L3931 Whfo Finger Exten W/wrist Supp BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $97.12 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400053 EAP HCPCS L3807 Ball Splint/finger Abd Splint BOTH IP/OP $161.00 $119.14 $0.00 $180.59 $0.00 $0.00 $0.00 $0.00 $0.00 $180.59 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $96.60 $72.45 $96.60 $171.95 $0.00 $0.00 $175.48 $0.00 $0.00 $0.00 $0.00 $0.00 27400054 EAP HCPCS L3908 Canv/leath/ezy-on Wrist Splint BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $44.55 $44.55 $0.00 $0.00 $41.27 $43.26 $73.48 $73.48 $76.31 $0.00 $20.63 $0.00 $58.56 $58.56 $0.00 $49.50 $78.41 $79.20 $59.40 $44.55 $59.40 $41.19 $0.00 $0.00 $42.04 $0.00 $0.00 $0.00 $0.00 $0.00 27400055 EAP HCPCS L3808 Gauntlet With Thumb Spica BOTH IP/OP $91.00 $67.34 $0.00 $247.75 $40.95 $40.95 $0.00 $0.00 $230.09 $247.75 $67.54 $67.54 $70.14 $0.00 $18.96 $0.00 $53.83 $53.83 $0.00 $45.50 $72.07 $72.80 $54.60 $40.95 $54.60 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400056 EAP HCPCS L3807 Prefab Burn Splint BOTH IP/OP $349.00 $258.26 $0.00 $279.20 $0.00 $0.00 $0.00 $0.00 $0.00 $180.59 $259.03 $259.03 $269.01 $0.00 $72.73 $0.00 $206.43 $206.43 $0.00 $174.50 $276.41 $279.20 $209.40 $157.05 $209.40 $171.95 $0.00 $0.00 $175.48 $0.00 $0.00 $0.00 $0.00 $0.00 27400057 EAP HCPCS L3807 Spasticity Splint BOTH IP/OP $164.00 $121.36 $0.00 $175.48 $73.80 $73.80 $0.00 $0.00 $59.92 $0.00 $121.72 $121.72 $126.41 $0.00 $34.18 $0.00 $0.00 $0.00 $0.00 $82.00 $129.89 $131.20 $98.40 $73.80 $98.40 $171.95 $0.00 $0.00 $175.48 $0.00 $0.00 $0.00 $0.00 $0.00 27400058 EAP HCPCS L3763 Forearm Sarmiento BOTH IP/OP $195.00 $144.30 $0.00 $926.06 $0.00 $0.00 $0.00 $0.00 $0.00 $926.06 $144.73 $144.73 $150.31 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $117.00 $87.75 $117.00 $881.77 $0.00 $0.00 $899.90 $0.00 $0.00 $0.00 $0.00 $0.00 27400059 EAP HCPCS L3931 Whfo - Palmer BOTH IP/OP $312.00 $230.88 $0.00 $249.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.57 $231.57 $240.49 $0.00 $65.02 $0.00 $0.00 $0.00 $0.00 $156.00 $247.10 $249.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400060 EAP HCPCS L3808 Thumb Spica BOTH IP/OP $72.00 $53.28 $0.00 $247.75 $32.40 $32.40 $0.00 $0.00 $230.09 $247.75 $53.44 $53.44 $55.50 $0.00 $15.00 $0.00 $42.59 $42.59 $0.00 $36.00 $57.02 $57.60 $43.20 $32.40 $43.20 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400061 EAP HCPCS L3808 Whfo Wr Gaunlet/thumb Spica BOTH IP/OP $185.00 $136.90 $0.00 $247.75 $83.25 $83.25 $0.00 $0.00 $230.09 $247.75 $137.31 $137.31 $142.60 $0.00 $38.55 $0.00 $109.43 $109.43 $0.00 $92.50 $146.52 $148.00 $111.00 $83.25 $111.00 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400062 EAP HCPCS L3808 "Whfo,long Opponens No Attachme" BOTH IP/OP $65.00 $48.10 $0.00 $247.75 $29.25 $29.25 $0.00 $0.00 $230.09 $247.75 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $32.50 $51.48 $52.00 $39.00 $0.00 $39.00 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400066 EAP HCPCS L3808 Safe Position Splint BOTH IP/OP $107.00 $79.18 $0.00 $247.75 $48.15 $48.15 $0.00 $0.00 $230.09 $247.75 $79.42 $79.42 $82.48 $0.00 $22.30 $0.00 $63.29 $63.29 $0.00 $53.50 $84.74 $85.60 $64.20 $48.15 $64.20 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400067 EAP HCPCS L4398 Foam Foot Drop Stop-prefab BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.88 $34.88 $36.23 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $21.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400070 EAP HCPCS L3808 Canv/leath/ezy-on Wrist Splint BOTH IP/OP $19.00 $14.06 $0.00 $247.75 $8.55 $8.55 $0.00 $0.00 $230.09 $247.75 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $11.40 $0.00 $11.40 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400071 EAP HCPCS L3905 Forearm Based Outrigger BOTH IP/OP $160.00 $118.40 $0.00 $681.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $72.00 $0.00 $681.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400078 EAP HCPCS L1834 Knee Extension Splint(s/p Bka) BOTH IP/OP $215.00 $159.10 $0.00 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.57 $159.57 $165.72 $0.00 $44.81 $0.00 $0.00 $0.00 $0.00 $107.50 $170.28 $172.00 $0.00 $96.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400080 EAP HCPCS L3807 Resting Hand Splint-prefab BOTH IP/OP $328.00 $242.72 $0.00 $262.40 $0.00 $0.00 $0.00 $0.00 $0.00 $180.59 $243.44 $243.44 $252.82 $0.00 $68.36 $0.00 $194.01 $194.01 $0.00 $164.00 $259.78 $262.40 $196.80 $147.60 $196.80 $171.95 $0.00 $0.00 $175.48 $0.00 $0.00 $0.00 $0.00 $0.00 27400085 EAP HCPCS L3921 Hand Based Outrigger BOTH IP/OP $118.00 $87.32 $0.00 $231.97 $53.10 $53.10 $0.00 $0.00 $221.26 $231.97 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $69.80 $69.80 $0.00 $59.00 $93.46 $94.40 $70.80 $53.10 $70.80 $220.87 $0.00 $0.00 $225.41 $0.00 $0.00 $0.00 $0.00 $0.00 27400086 EAP HCPCS A4467 Posterior Elbow Splint-prefab BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $47.25 $47.25 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $47.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400087 EAP HCPCS L4396 Foot Drop Splint Prefab BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.33 $206.33 $214.28 $0.00 $57.94 $0.00 $0.00 $0.00 $0.00 $139.00 $220.18 $222.40 $166.80 $125.10 $166.80 $126.82 $0.00 $0.00 $129.42 $0.00 $0.00 $0.00 $0.00 $0.00 27400090 EAP HCPCS L1960 Foot Drop Splint-custom BOTH IP/OP $237.00 $175.38 $0.00 $389.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.90 $175.90 $182.68 $0.00 $49.39 $0.00 $0.00 $0.00 $0.00 $118.50 $187.70 $189.60 $0.00 $106.65 $0.00 $389.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400091 EAP HCPCS L3808 Resting Hand/volar Wrist Custom BOTH IP/OP $209.00 $154.66 $0.00 $247.75 $94.05 $94.05 $0.00 $0.00 $230.09 $247.75 $155.12 $155.12 $161.10 $0.00 $43.56 $0.00 $123.62 $123.62 $0.00 $104.50 $165.53 $167.20 $125.40 $94.05 $125.40 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400097 EAP HCPCS L3931 Resting Hand Prefab Hand Rehab BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.70 $147.70 $153.39 $0.00 $41.47 $0.00 $0.00 $0.00 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400098 EAP HCPCS L3808 CUSTOM RESTING HAND BOTH IP/OP $198.00 $146.52 $0.00 $247.75 $89.10 $89.10 $0.00 $0.00 $230.09 $247.75 $146.96 $146.96 $152.62 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $118.80 $89.10 $118.80 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400099 EAP HCPCS L0810 Halo And Vest BOTH IP/OP "$7,045.00 " "$5,213.30" $0.00 "$5,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,430.29" $0.00 "$1,468.18" $0.00 $0.00 $0.00 $0.00 "$3,522.50" "$5,579.64" "$5,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400105 EAP HCPCS L3808 Extensor Tendon Splint BOTH IP/OP $132.00 $97.68 $0.00 $247.75 $59.40 $59.40 $0.00 $0.00 $230.09 $247.75 $97.97 $97.97 $101.75 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $79.20 $59.40 $79.20 $235.90 $0.00 $0.00 $240.75 $0.00 $0.00 $0.00 $0.00 $0.00 27400108 EAP HCPCS L3980 Humeral Fx Brace BOTH IP/OP $179.00 $132.46 $0.00 $216.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.85 $132.85 $137.97 $0.00 $37.30 $0.00 $0.00 $0.00 $0.00 $89.50 $141.77 $143.20 $107.40 $80.55 $107.40 $212.58 $0.00 $0.00 $216.95 $0.00 $0.00 $0.00 $0.00 $0.00 27400109 EAP HCPCS L3760 Hinged Elbow Brace BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $953.73 $953.73 $990.48 $0.00 $267.79 $0.00 $0.00 $0.00 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $578.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400113 EAP HCPCS A4467 Posterior Elbow Splint-prefab BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $47.25 $47.25 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $80.93 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400114 EAP Splint Orthopedic 5ydx6in Fast BOTH IP/OP $46.00 $34.04 $0.00 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.14 $34.14 $35.46 $0.00 $9.59 $0.00 $0.00 $0.00 $0.00 $23.00 $36.43 $36.80 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400115 EAP HCPCS L1830 Immobilizer Orthopedic Univers BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $34.69 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $20.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400116 EAP HCPCS L0150 Collar Cerv 2-5yr Short 35-45in Chin Dot Tracheostomy Open BOTH IP/OP $108.00 $79.92 $0.00 $89.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $0.00 $0.00 $0.00 $54.00 $85.54 $86.40 $64.80 $0.00 $64.80 $0.00 $0.00 $0.00 $89.77 $0.00 $0.00 $0.00 $0.00 $0.00 27400117 EAP HCPCS L0150 Collar Cerv 3-6yr Regular 37-48in Chin Dot Tracheostomy Open BOTH IP/OP $109.00 $80.66 $0.00 $89.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $84.02 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $54.50 $86.33 $87.20 $65.40 $0.00 $65.40 $0.00 $0.00 $0.00 $89.77 $0.00 $0.00 $0.00 $0.00 $0.00 27400118 EAP HCPCS L0172 Collar Cerv Short Latex Free Adult BOTH IP/OP $103.00 $76.22 $0.00 $112.86 $46.35 $46.35 $0.00 $0.00 $0.00 $112.86 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $60.92 $60.92 $0.00 $51.50 $81.58 $82.40 $61.80 $0.00 $61.80 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 27400119 EAP HCPCS L0172 Collar Cerv Regular Chin Rest Tracheostomy Opening BOTH IP/OP $100.00 $74.00 $0.00 $112.86 $45.00 $45.00 $0.00 $0.00 $0.00 $112.86 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $60.00 $0.00 $60.00 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 27400120 EAP HCPCS L0172 Collar Cerv Tall Chin Rest Tracheostomy Opening Adjustable BOTH IP/OP $97.00 $71.78 $0.00 $112.86 $43.65 $43.65 $0.00 $0.00 $0.00 $112.86 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $57.38 $57.38 $0.00 $48.50 $76.82 $77.60 $58.20 $0.00 $58.20 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 27400121 EAP HCPCS L0113 Collar Cerv 1-3yr Tot 33-40in Chin Dot Tracheostomy Open BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.96 $74.96 $77.85 $0.00 $21.05 $0.00 $0.00 $0.00 $0.00 $50.50 $79.99 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27400122 EAP HCPCS L0172 Collar Cerv Short Chin Rest Tracheostomy Opening Adjustable BOTH IP/OP $115.00 $85.10 $0.00 $112.86 $51.75 $51.75 $0.00 $0.00 $0.00 $112.86 $85.35 $85.35 $88.64 $0.00 $23.97 $0.00 $68.02 $68.02 $0.00 $57.50 $91.08 $92.00 $69.00 $0.00 $69.00 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 27400123 EAP HCPCS L0172 Collar Cerv 9-24 Month Regular 29-37in Chin Dot Tracheostomy BOTH IP/OP $114.00 $84.36 $0.00 $112.86 $51.30 $51.30 $0.00 $0.00 $0.00 $112.86 $84.61 $84.61 $87.87 $0.00 $23.76 $0.00 $67.43 $67.43 $0.00 $57.00 $90.29 $91.20 $68.40 $0.00 $68.40 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 27400124 EAP HCPCS L0172 Collar Crv Unv Occian Bck Intuitech BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $84.60 $84.60 $0.00 $0.00 $0.00 $112.86 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $112.80 $0.00 $112.80 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 27500001 EAP HCPCS C1721 2207-36 Current Dr Icd BOTH IP/OP "$52,001.00 " "$38,480.74" $0.00 "$41,600.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$40,082.37" $0.00 "$10,837.01" $0.00 "$25,636.49" "$25,636.49" $0.00 "$26,000.50" "$41,184.79" "$41,600.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500003 EAP HCPCS C1722 1207-36 Current Vr Icd BOTH IP/OP "$43,036.00 " "$31,846.64" $0.00 "$34,428.80" "$19,366.20" "$19,366.20" $0.00 $0.00 $0.00 "$8,969.78" "$4,181.12" "$4,181.12" "$33,172.15" $0.00 "$8,968.70" $0.00 "$21,216.75" "$21,216.75" $0.00 "$21,518.00" "$34,084.51" "$34,428.80" $0.00 $0.00 $0.00 "$6,735.13" $0.00 $0.00 "$6,851.33" $0.00 $0.00 $0.00 $0.00 $0.00 27500004 EAP HCPCS C1722 "Aicd, Single Chamber" BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500006 EAP HCPCS C1779 Capsurenovusfix Lead BOTH IP/OP "$8,340.00 " "$6,171.60" $0.00 "$6,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,428.47" $0.00 "$1,738.06" $0.00 $0.00 $0.00 $0.00 "$4,170.00" "$6,605.28" "$6,672.00" $0.00 "$3,753.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500007 EAP HCPCS C1785 Philos Dr Pacemaker BOTH IP/OP "$10,400.00 " "$7,696.00" $0.00 "$8,320.00" "$4,680.00" "$4,680.00" $0.00 $0.00 $0.00 "$2,167.62" "$4,181.12" "$4,181.12" "$8,016.32" $0.00 "$2,167.36" $0.00 "$5,127.20" "$5,127.20" $0.00 "$5,200.00" "$8,236.80" "$8,320.00" $0.00 $0.00 $0.00 "$1,627.60" $0.00 $0.00 "$1,655.68" $0.00 $0.00 $0.00 $0.00 $0.00 27500008 EAP HCPCS C1785 Rhaspsody Dr 2530 Pacemaker BOTH IP/OP "$14,582.00 " "$10,790.68" $0.00 "$11,665.60" "$6,561.90" "$6,561.90" $0.00 $0.00 $0.00 "$3,039.25" "$4,181.12" "$4,181.12" "$11,239.81" $0.00 "$3,038.89" $0.00 "$7,188.93" "$7,188.93" $0.00 "$7,291.00" "$11,548.94" "$11,665.60" $0.00 $0.00 $0.00 "$2,282.08" $0.00 $0.00 "$2,321.45" $0.00 $0.00 $0.00 $0.00 $0.00 27500009 EAP HCPCS C1785 5386 Identity Adx Xlr Pcmkr BOTH IP/OP "$12,195.00 " "$9,024.30" $0.00 "$9,756.00" "$5,487.75" "$5,487.75" $0.00 $0.00 $0.00 "$2,541.74" "$4,181.12" "$4,181.12" "$9,399.91" $0.00 "$2,541.44" $0.00 "$6,012.14" "$6,012.14" $0.00 "$6,097.50" "$9,658.44" "$9,756.00" $0.00 $0.00 $0.00 "$1,908.52" $0.00 $0.00 "$1,941.44" $0.00 $0.00 $0.00 $0.00 $0.00 27500010 EAP HCPCS C1785 Philos Ii Dr System BOTH IP/OP "$14,735.00 " "$10,903.90" $0.00 "$11,788.00" "$6,630.75" "$6,630.75" $0.00 $0.00 $0.00 "$3,071.14" "$4,181.12" "$4,181.12" "$11,357.74" $0.00 "$3,070.77" $0.00 "$7,264.36" "$7,264.36" $0.00 "$7,367.50" "$11,670.12" "$11,788.00" $0.00 $0.00 $0.00 "$2,306.03" $0.00 $0.00 "$2,345.81" $0.00 $0.00 $0.00 $0.00 $0.00 27500011 EAP HCPCS C1785 Sensia Dr Pacemaker BOTH IP/OP "$12,195.00 " "$9,024.30" $0.00 "$9,756.00" "$5,487.75" "$5,487.75" $0.00 $0.00 $0.00 "$2,541.74" "$4,181.12" "$4,181.12" "$9,399.91" $0.00 "$2,541.44" $0.00 "$6,012.14" "$6,012.14" $0.00 "$6,097.50" "$9,658.44" "$9,756.00" $0.00 $0.00 $0.00 "$1,908.52" $0.00 $0.00 "$1,941.44" $0.00 $0.00 $0.00 $0.00 $0.00 27500012 EAP HCPCS C1785 Symphony Dr 2550 Pacemaker BOTH IP/OP "$15,349.00 " "$11,358.26" $0.00 "$12,279.20" "$6,907.05" "$6,907.05" $0.00 $0.00 $0.00 "$3,199.12" "$4,181.12" "$4,181.12" "$11,831.01" $0.00 "$3,198.73" $0.00 "$7,567.06" "$7,567.06" $0.00 "$7,674.50" "$12,156.41" "$12,279.20" $0.00 $0.00 $0.00 "$2,402.12" $0.00 $0.00 "$2,443.56" $0.00 $0.00 $0.00 $0.00 $0.00 27500013 EAP HCPCS C1785 Repy Dr Pacemaker BOTH IP/OP "$15,063.00 " "$11,146.62" $0.00 "$12,050.40" "$6,778.35" "$6,778.35" $0.00 $0.00 $0.00 "$3,139.51" "$4,181.12" "$4,181.12" "$11,610.56" $0.00 "$3,139.13" $0.00 "$7,426.06" "$7,426.06" $0.00 "$7,531.50" "$11,929.90" "$12,050.40" $0.00 $0.00 $0.00 "$2,357.36" $0.00 $0.00 "$2,398.03" $0.00 $0.00 $0.00 $0.00 $0.00 27500014 EAP HCPCS C1785 Cylos Dr/cls Pacemaker BOTH IP/OP "$12,195.00 " "$9,024.30" $0.00 "$9,756.00" "$5,487.75" "$5,487.75" $0.00 $0.00 $0.00 "$2,541.74" "$4,181.12" "$4,181.12" "$9,399.91" $0.00 "$2,541.44" $0.00 "$6,012.14" "$6,012.14" $0.00 "$6,097.50" "$9,658.44" "$9,756.00" $0.00 $0.00 $0.00 "$1,908.52" $0.00 $0.00 "$1,941.44" $0.00 $0.00 $0.00 $0.00 $0.00 27500015 EAP HCPCS C1785 Adapta Dr Pacemaker BOTH IP/OP "$16,139.00 " "$11,942.86" $0.00 "$12,911.20" "$7,262.55" "$7,262.55" $0.00 $0.00 $0.00 "$3,363.77" "$4,181.12" "$4,181.12" "$12,439.94" $0.00 "$3,363.37" $0.00 "$7,956.53" "$7,956.53" $0.00 "$8,069.50" "$12,782.09" "$12,911.20" $0.00 $0.00 $0.00 "$2,525.75" $0.00 $0.00 "$2,569.33" $0.00 $0.00 $0.00 $0.00 $0.00 27500016 EAP HCPCS C1785 Philos Dr System BOTH IP/OP "$12,195.00 " "$9,024.30" $0.00 "$9,756.00" "$5,487.75" "$5,487.75" $0.00 $0.00 $0.00 "$2,541.74" "$4,181.12" "$4,181.12" "$9,399.91" $0.00 "$2,541.44" $0.00 "$6,012.14" "$6,012.14" $0.00 "$6,097.50" "$9,658.44" "$9,756.00" $0.00 $0.00 $0.00 "$1,908.52" $0.00 $0.00 "$1,941.44" $0.00 $0.00 $0.00 $0.00 $0.00 27500017 EAP HCPCS C1785 Rhaspsody Dr 2530 System BOTH IP/OP "$16,497.00 " "$12,207.78" $0.00 "$13,197.60" "$7,423.65" "$7,423.65" $0.00 $0.00 $0.00 "$3,438.39" "$4,181.12" "$4,181.12" "$12,715.89" $0.00 "$3,437.97" $0.00 "$8,133.02" "$8,133.02" $0.00 "$8,248.50" "$13,065.62" "$13,197.60" $0.00 $0.00 $0.00 "$2,581.78" $0.00 $0.00 "$2,626.32" $0.00 $0.00 $0.00 $0.00 $0.00 27500018 EAP HCPCS C1785 Symphony Dr 2550 System BOTH IP/OP "$18,420.00 " "$13,630.80" $0.00 "$14,736.00" "$8,289.00" "$8,289.00" $0.00 $0.00 $0.00 "$3,839.19" "$4,181.12" "$4,181.12" "$14,198.14" $0.00 "$3,838.73" $0.00 "$9,081.06" "$9,081.06" $0.00 "$9,210.00" "$14,588.64" "$14,736.00" $0.00 $0.00 $0.00 "$2,882.73" $0.00 $0.00 "$2,932.46" $0.00 $0.00 $0.00 $0.00 $0.00 27500019 EAP HCPCS C1785 Reply Dr System BOTH IP/OP "$17,932.00 " "$13,269.68" $0.00 "$14,345.60" "$8,069.40" "$8,069.40" $0.00 $0.00 $0.00 "$3,737.48" "$4,181.12" "$4,181.12" "$13,821.99" $0.00 "$3,737.03" $0.00 "$8,840.48" "$8,840.48" $0.00 "$8,966.00" "$14,202.14" "$14,345.60" $0.00 $0.00 $0.00 "$2,806.36" $0.00 $0.00 "$2,854.77" $0.00 $0.00 $0.00 $0.00 $0.00 27500020 EAP HCPCS C1785 Cylos Dr/cls System BOTH IP/OP "$15,063.00 " "$11,146.62" $0.00 "$12,050.40" "$6,778.35" "$6,778.35" $0.00 $0.00 $0.00 "$3,139.51" "$4,181.12" "$4,181.12" "$11,610.56" $0.00 "$3,139.13" $0.00 "$7,426.06" "$7,426.06" $0.00 "$7,531.50" "$11,929.90" "$12,050.40" $0.00 $0.00 $0.00 "$2,357.36" $0.00 $0.00 "$2,398.03" $0.00 $0.00 $0.00 $0.00 $0.00 27500021 EAP HCPCS C1785 S403 Altrua Pacemaker BOTH IP/OP "$22,045.00 " "$16,313.30" $0.00 "$17,636.00" "$9,920.25" "$9,920.25" $0.00 $0.00 $0.00 "$4,594.73" "$4,181.12" "$4,181.12" "$16,992.29" $0.00 "$4,594.18" $0.00 "$10,868.19" "$10,868.19" $0.00 "$11,022.50" "$17,459.64" "$17,636.00" $0.00 $0.00 $0.00 "$3,450.04" $0.00 $0.00 "$3,509.56" $0.00 $0.00 $0.00 $0.00 $0.00 27500024 EAP HCPCS C1786 Sensia Sr Pacemaker BOTH IP/OP "$11,110.00 " "$8,221.40" $0.00 "$8,888.00" "$4,999.50" "$4,999.50" $0.00 $0.00 $0.00 "$2,315.60" "$4,181.12" "$4,181.12" "$8,563.59" $0.00 "$2,315.32" $0.00 "$5,477.23" "$5,477.23" $0.00 "$5,555.00" "$8,799.12" "$8,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500025 EAP HCPCS C1786 Rhapsody Sr 2210 Pacemaker BOTH IP/OP "$11,130.00 " "$8,236.20" $0.00 "$8,904.00" "$5,008.50" "$5,008.50" $0.00 $0.00 $0.00 "$2,319.77" "$4,181.12" "$4,181.12" "$8,579.00" $0.00 "$2,319.49" $0.00 "$5,487.09" "$5,487.09" $0.00 "$5,565.00" "$8,814.96" "$8,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500026 EAP HCPCS C1786 Philos Sr Pacemaker BOTH IP/OP "$11,130.00 " "$8,236.20" $0.00 "$8,904.00" "$5,008.50" "$5,008.50" $0.00 $0.00 $0.00 "$2,319.77" "$4,181.12" "$4,181.12" "$8,579.00" $0.00 "$2,319.49" $0.00 "$5,487.09" "$5,487.09" $0.00 "$5,565.00" "$8,814.96" "$8,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500027 EAP HCPCS C1786 Rhapsody Sr 2210 System BOTH IP/OP "$11,835.00 " "$8,757.90" $0.00 "$9,468.00" "$5,325.75" "$5,325.75" $0.00 $0.00 $0.00 "$2,466.71" "$4,181.12" "$4,181.12" "$9,122.42" $0.00 "$2,466.41" $0.00 "$5,834.66" "$5,834.66" $0.00 "$5,917.50" "$9,373.32" "$9,468.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500028 EAP HCPCS C1786 Philos Sr System BOTH IP/OP "$12,664.00 " "$9,371.36" $0.00 "$10,131.20" "$5,698.80" "$5,698.80" $0.00 $0.00 $0.00 "$2,639.49" "$4,181.12" "$4,181.12" "$9,761.41" $0.00 "$2,639.18" $0.00 "$6,243.35" "$6,243.35" $0.00 "$6,332.00" "$10,029.89" "$10,131.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500029 EAP HCPCS C1786 Philos Ii Sr Pacemaker BOTH IP/OP "$12,854.00 " "$9,511.96" $0.00 "$10,283.20" "$5,784.30" "$5,784.30" $0.00 $0.00 $0.00 "$2,679.09" "$4,181.12" "$4,181.12" "$9,907.86" $0.00 "$2,678.77" $0.00 "$6,337.02" "$6,337.02" $0.00 "$6,427.00" "$10,180.37" "$10,283.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500030 EAP HCPCS C1786 Sympnony Sr 2550 Pacemaker BOTH IP/OP "$13,047.00 " "$9,654.78" $0.00 "$10,437.60" "$5,871.15" "$5,871.15" $0.00 $0.00 $0.00 "$2,719.32" "$4,181.12" "$4,181.12" "$10,056.63" $0.00 "$2,718.99" $0.00 "$6,432.17" "$6,432.17" $0.00 "$6,523.50" "$10,333.22" "$10,437.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500031 EAP HCPCS C1786 Phillos Ii Sr Pcmkr Syst BOTH IP/OP "$13,813.00 " "$10,221.62" $0.00 "$11,050.40" "$6,215.85" "$6,215.85" $0.00 $0.00 $0.00 "$2,878.97" "$4,181.12" "$4,181.12" "$10,647.06" $0.00 "$2,878.63" $0.00 "$6,809.81" "$6,809.81" $0.00 "$6,906.50" "$10,939.90" "$11,050.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500032 EAP HCPCS C1786 Symphony Sr 2550 System BOTH IP/OP "$13,628.00 " "$10,084.72" $0.00 "$10,902.40" "$6,132.60" "$6,132.60" $0.00 $0.00 $0.00 "$2,840.42" "$4,181.12" "$4,181.12" "$10,504.46" $0.00 "$2,840.08" $0.00 "$6,718.60" "$6,718.60" $0.00 "$6,814.00" "$10,793.38" "$10,902.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500033 EAP HCPCS C1786 Cylos Vr/cls Pacemaker BOTH IP/OP "$12,195.00 " "$9,024.30" $0.00 "$9,756.00" "$5,487.75" "$5,487.75" $0.00 $0.00 $0.00 "$2,541.74" "$4,181.12" "$4,181.12" "$9,399.91" $0.00 "$2,541.44" $0.00 "$6,012.14" "$6,012.14" $0.00 "$6,097.50" "$9,658.44" "$9,756.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500034 EAP HCPCS C1786 Reply Sr System BOTH IP/OP "$16,497.00 " "$12,207.78" $0.00 "$13,197.60" "$7,423.65" "$7,423.65" $0.00 $0.00 $0.00 "$3,438.39" "$4,181.12" "$4,181.12" "$12,715.89" $0.00 "$3,437.97" $0.00 "$8,133.02" "$8,133.02" $0.00 "$8,248.50" "$13,065.62" "$13,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500035 EAP HCPCS C1786 Cylos Vr/cls System BOTH IP/OP "$13,628.00 " "$10,084.72" $0.00 "$10,902.40" "$6,132.60" "$6,132.60" $0.00 $0.00 $0.00 "$2,840.42" "$4,181.12" "$4,181.12" "$10,504.46" $0.00 "$2,840.08" $0.00 "$6,718.60" "$6,718.60" $0.00 "$6,814.00" "$10,793.38" "$10,902.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500036 EAP HCPCS C1786 Reply Sr System BOTH IP/OP "$16,497.00 " "$12,207.78" $0.00 "$13,197.60" "$7,423.65" "$7,423.65" $0.00 $0.00 $0.00 "$3,438.39" "$4,181.12" "$4,181.12" "$12,715.89" $0.00 "$3,437.97" $0.00 "$8,133.02" "$8,133.02" $0.00 "$8,248.50" "$13,065.62" "$13,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500039 EAP HCPCS C1898 1688tc Pacemaker Lead BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $806.85 $806.85 $0.00 $0.00 $0.00 $373.71 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 "$1,060.56" "$1,060.56" $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $280.60 $0.00 $0.00 $285.45 $0.00 $0.00 $0.00 $0.00 $0.00 27500040 EAP HCPCS C1898 Tendril St Pkg Lead BOTH IP/OP "$1,920.00 " "$1,420.80" $0.00 "$1,536.00" $864.00 $864.00 $0.00 $0.00 $0.00 $400.18 "$1,425.02" "$1,425.02" "$1,479.94" $0.00 $400.13 $0.00 "$1,135.68" "$1,135.68" $0.00 $960.00 "$1,520.64" "$1,536.00" $0.00 $864.00 $0.00 $300.48 $0.00 $0.00 $305.66 $0.00 $0.00 $0.00 $0.00 $0.00 27500041 EAP HCPCS C1898 Tendril 1688 Lead BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $806.85 $806.85 $0.00 $0.00 $0.00 $373.71 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 "$1,060.56" "$1,060.56" $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $280.60 $0.00 $0.00 $285.45 $0.00 $0.00 $0.00 $0.00 $0.00 27500042 EAP HCPCS C1898 Tendril Sdx Lead BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $806.85 $806.85 $0.00 $0.00 $0.00 $373.71 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 "$1,060.56" "$1,060.56" $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $280.60 $0.00 $0.00 $285.45 $0.00 $0.00 $0.00 $0.00 $0.00 27500043 EAP HCPCS C1898 Tendril St 1700 Lead BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $806.85 $806.85 $0.00 $0.00 $0.00 $373.71 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 "$1,060.56" "$1,060.56" $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $280.60 $0.00 $0.00 $285.45 $0.00 $0.00 $0.00 $0.00 $0.00 27500044 EAP HCPCS C1900 Coronary Sinus Lead System BOTH IP/OP "$1,920.00 " "$1,420.80" $0.00 "$1,536.00" $864.00 $864.00 $0.00 $0.00 $0.00 $400.18 "$1,425.02" "$1,425.02" "$1,479.94" $0.00 $400.13 $0.00 "$1,135.68" "$1,135.68" $0.00 $960.00 "$1,520.64" "$1,536.00" $0.00 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500045 EAP HCPCS C1900 Scout Pro Lead System BOTH IP/OP "$1,920.00 " "$1,420.80" $0.00 "$1,536.00" $864.00 $864.00 $0.00 $0.00 $0.00 $400.18 "$1,425.02" "$1,425.02" "$1,479.94" $0.00 $400.13 $0.00 "$1,135.68" "$1,135.68" $0.00 $960.00 "$1,520.64" "$1,536.00" $0.00 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500046 EAP HCPCS C1900 Corox Bipolar Lead BOTH IP/OP "$5,739.00 " "$4,246.86" $0.00 "$4,591.20" "$2,582.55" "$2,582.55" $0.00 $0.00 $0.00 "$1,196.15" "$4,181.12" "$4,181.12" "$4,423.62" $0.00 "$1,196.01" $0.00 "$2,829.33" "$2,829.33" $0.00 "$2,869.50" "$4,545.29" "$4,591.20" $0.00 "$2,582.55" $0.00 $898.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500047 EAP HCPCS C1900 Corox Unipolar Lead BOTH IP/OP "$5,739.00 " "$4,246.86" $0.00 "$4,591.20" "$2,582.55" "$2,582.55" $0.00 $0.00 $0.00 "$1,196.15" "$4,181.12" "$4,181.12" "$4,423.62" $0.00 "$1,196.01" $0.00 "$2,829.33" "$2,829.33" $0.00 "$2,869.50" "$4,545.29" "$4,591.20" $0.00 $0.00 $0.00 $898.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500055 EAP HCPCS C1882 Crt-d Dtba1qq Viva Quad Xt Us Is4 Df4 Crt BOTH IP/OP "$50,260.00 " "$37,192.40" $0.00 "$40,208.00" "$22,617.00" "$22,617.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,740.41" $0.00 "$10,474.18" $0.00 "$24,778.18" "$24,778.18" $0.00 "$25,130.00" "$39,805.92" "$40,208.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,001.39" $0.00 $0.00 $0.00 $0.00 $0.00 27500056 EAP HCPCS C1882 Dfbr Crd Viva Qd Xt Crt-d Icd Df-1 Biphasic Wvfrm 35ml 80gm BOTH IP/OP "$50,228.00 " "$37,168.72" $0.00 "$40,182.40" "$22,602.60" "$22,602.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,715.74" $0.00 "$10,467.52" $0.00 "$24,762.40" "$24,762.40" $0.00 "$25,114.00" "$39,780.58" "$40,182.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,996.30" $0.00 $0.00 $0.00 $0.00 $0.00 27500057 EAP HCPCS C1882 Dfbr Crd Viva Crt D Qd S Is-4 Df1 Us BOTH IP/OP "$47,766.00 " "$35,346.84" $0.00 "$38,212.80" "$21,494.70" "$21,494.70" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$36,818.03" $0.00 "$9,954.43" $0.00 "$23,548.64" "$23,548.64" $0.00 "$23,883.00" "$37,830.67" "$38,212.80" $0.00 $0.00 $0.00 "$7,475.38" $0.00 $0.00 "$7,604.35" $0.00 $0.00 $0.00 $0.00 $0.00 27500058 EAP HCPCS C1882 Dfbr Crd Viva Crt D Qd S Is-4 Df4 Us BOTH IP/OP "$47,766.00 " "$35,346.84" $0.00 "$38,212.80" "$21,494.70" "$21,494.70" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$36,818.03" $0.00 "$9,954.43" $0.00 "$23,548.64" "$23,548.64" $0.00 "$23,883.00" "$37,830.67" "$38,212.80" $0.00 $0.00 $0.00 "$7,475.38" $0.00 $0.00 "$7,604.35" $0.00 $0.00 $0.00 $0.00 $0.00 27500059 EAP HCPCS C1900 Lead Attain Performa Usa Crt BOTH IP/OP "$5,840.00 " "$4,321.60" $0.00 "$4,672.00" "$2,628.00" "$2,628.00" $0.00 $0.00 $0.00 "$1,217.20" "$4,181.12" "$4,181.12" "$4,501.47" $0.00 "$1,217.06" $0.00 "$2,879.12" "$2,879.12" $0.00 "$2,920.00" "$4,625.28" "$4,672.00" $0.00 "$2,628.00" $0.00 $913.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500060 EAP HCPCS C1900 Attain Bipoldr Lead BOTH IP/OP "$6,276.00 " "$4,644.24" $0.00 "$5,020.80" "$2,824.20" "$2,824.20" $0.00 $0.00 $0.00 "$1,308.08" "$4,181.12" "$4,181.12" "$4,837.54" $0.00 "$1,307.92" $0.00 "$3,094.07" "$3,094.07" $0.00 "$3,138.00" "$4,970.59" "$5,020.80" $0.00 $0.00 $0.00 $982.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500062 EAP HCPCS C1900 Lv Quickflex Lead BOTH IP/OP "$5,739.00 " "$4,246.86" $0.00 "$4,591.20" "$2,582.55" "$2,582.55" $0.00 $0.00 $0.00 "$1,196.15" "$4,181.12" "$4,181.12" "$4,423.62" $0.00 "$1,196.01" $0.00 "$2,829.33" "$2,829.33" $0.00 "$2,869.50" "$4,545.29" "$4,591.20" $0.00 "$2,582.55" $0.00 $898.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500063 EAP HCPCS C1900 Lv Quicksite Leads BOTH IP/OP "$5,739.00 " "$4,246.86" $0.00 "$4,591.20" "$2,582.55" "$2,582.55" $0.00 $0.00 $0.00 "$1,196.15" "$4,181.12" "$4,181.12" "$4,423.62" $0.00 "$1,196.01" $0.00 "$2,829.33" "$2,829.33" $0.00 "$2,869.50" "$4,545.29" "$4,591.20" $0.00 $0.00 $0.00 $898.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500070 EAP HCPCS C1786 Zepher Dr Pacemaker BOTH IP/OP "$14,346.00 " "$10,616.04" $0.00 "$11,476.80" "$6,455.70" "$6,455.70" $0.00 $0.00 $0.00 "$2,990.07" "$4,181.12" "$4,181.12" "$11,057.90" $0.00 "$2,989.71" $0.00 "$7,072.58" "$7,072.58" $0.00 "$7,173.00" "$11,362.03" "$11,476.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500078 EAP HCPCS C1721 Teligen Rf He Dr Dual Icd BOTH IP/OP "$50,042.00 " "$37,031.08" $0.00 "$40,033.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,572.37" $0.00 "$10,428.75" $0.00 "$24,670.71" "$24,670.71" $0.00 "$25,021.00" "$39,633.26" "$40,033.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,966.69" $0.00 $0.00 $0.00 $0.00 $0.00 27500079 EAP HCPCS C1721 Confient Rf He Dual Icd BOTH IP/OP "$41,702.00 " "$30,859.48" $0.00 "$33,361.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,691.74" "$4,181.12" "$4,181.12" "$32,143.90" $0.00 "$8,690.70" $0.00 "$20,559.09" "$20,559.09" $0.00 "$20,851.00" "$33,027.98" "$33,361.60" $0.00 $0.00 $0.00 "$6,526.36" $0.00 $0.00 "$6,638.96" $0.00 $0.00 $0.00 $0.00 $0.00 27500080 EAP HCPCS C1722 Teligen Rf He Vr Icd BOTH IP/OP "$41,702.00 " "$30,859.48" $0.00 "$33,361.60" "$18,765.90" "$18,765.90" $0.00 $0.00 $0.00 "$8,691.74" "$4,181.12" "$4,181.12" "$32,143.90" $0.00 "$8,690.70" $0.00 "$20,559.09" "$20,559.09" $0.00 "$20,851.00" "$33,027.98" "$33,361.60" $0.00 $0.00 $0.00 "$6,526.36" $0.00 $0.00 "$6,638.96" $0.00 $0.00 $0.00 $0.00 $0.00 27500081 EAP HCPCS C1722 Vitality 2 El Vr Icd BOTH IP/OP "$38,365.00 " "$28,390.10" $0.00 "$30,692.00" "$17,264.25" "$17,264.25" $0.00 $0.00 $0.00 "$7,996.23" "$4,181.12" "$4,181.12" "$29,571.74" $0.00 "$7,995.27" $0.00 "$18,913.95" "$18,913.95" $0.00 "$19,182.50" "$30,385.08" "$30,692.00" $0.00 $0.00 $0.00 "$6,004.12" $0.00 $0.00 "$6,107.71" $0.00 $0.00 $0.00 $0.00 $0.00 27500082 EAP HCPCS C1786 Altrua 40 Sr Pacemaker BOTH IP/OP "$11,343.00 " "$8,393.82" $0.00 "$9,074.40" "$5,104.35" "$5,104.35" $0.00 $0.00 $0.00 "$2,364.16" "$4,181.12" "$4,181.12" "$8,743.18" $0.00 "$2,363.88" $0.00 "$5,592.10" "$5,592.10" $0.00 "$5,671.50" "$8,983.66" "$9,074.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500083 EAP HCPCS C1785 Altrua 40 Dr El Dual Pacemaker BOTH IP/OP "$6,340.00 " "$4,691.60" $0.00 "$5,072.00" "$2,853.00" "$2,853.00" $0.00 $0.00 $0.00 "$1,321.41" "$4,181.12" "$4,181.12" "$4,886.87" $0.00 "$1,321.26" $0.00 "$3,125.62" "$3,125.62" $0.00 "$3,170.00" "$5,021.28" "$5,072.00" $0.00 $0.00 $0.00 $992.21 $0.00 $0.00 "$1,009.33" $0.00 $0.00 $0.00 $0.00 $0.00 27500084 EAP HCPCS C1785 Altrua 40 Dr Dual Pacemaker BOTH IP/OP "$6,340.00 " "$4,691.60" $0.00 "$5,072.00" "$2,853.00" "$2,853.00" $0.00 $0.00 $0.00 "$1,321.41" "$4,181.12" "$4,181.12" "$4,886.87" $0.00 "$1,321.26" $0.00 "$3,125.62" "$3,125.62" $0.00 "$3,170.00" "$5,021.28" "$5,072.00" $0.00 $0.00 $0.00 $992.21 $0.00 $0.00 "$1,009.33" $0.00 $0.00 $0.00 $0.00 $0.00 27500085 EAP HCPCS C1882 Cognis Rf He Crt-d BOTH IP/OP "$73,393.00 " "$54,310.82" $0.00 "$58,714.40" "$33,026.85" "$33,026.85" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$56,571.32" $0.00 "$15,295.10" $0.00 "$36,182.75" "$36,182.75" $0.00 "$36,696.50" "$58,127.26" "$58,714.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500086 EAP HCPCS C1882 Livian Rf He Crt-d BOTH IP/OP "$56,714.00 " "$41,968.36" $0.00 "$45,371.20" "$25,521.30" "$25,521.30" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$43,715.15" $0.00 "$11,819.20" $0.00 "$27,960.00" "$27,960.00" $0.00 "$28,357.00" "$44,917.49" "$45,371.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500087 EAP HCPCS C1882 Livian Rf Crt-d BOTH IP/OP "$56,714.00 " "$41,968.36" $0.00 "$45,371.20" "$25,521.30" "$25,521.30" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$43,715.15" $0.00 "$11,819.20" $0.00 "$27,960.00" "$27,960.00" $0.00 "$28,357.00" "$44,917.49" "$45,371.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500088 EAP HCPCS C1882 Contak Renewal Tr Crt-p BOTH IP/OP "$21,350.00 " "$15,799.00" $0.00 "$17,080.00" "$9,607.50" "$9,607.50" $0.00 $0.00 $0.00 "$4,449.87" "$4,181.12" "$4,181.12" "$16,456.58" $0.00 "$4,449.34" $0.00 "$10,525.55" "$10,525.55" $0.00 "$10,675.00" "$16,909.20" "$17,080.00" $0.00 $0.00 $0.00 "$3,341.28" $0.00 $0.00 "$3,398.92" $0.00 $0.00 $0.00 $0.00 $0.00 27500089 EAP HCPCS C1895 Reliance G Af Lead BOTH IP/OP "$15,012.00 " "$11,108.88" $0.00 "$12,009.60" "$6,755.40" "$6,755.40" $0.00 $0.00 $0.00 "$3,128.88" "$4,181.12" "$4,181.12" "$11,571.25" $0.00 "$3,128.50" $0.00 "$7,400.92" "$7,400.92" $0.00 "$7,506.00" "$11,889.50" "$12,009.60" $0.00 $0.00 $0.00 "$2,349.38" $0.00 $0.00 "$2,389.91" $0.00 $0.00 $0.00 $0.00 $0.00 27500090 EAP HCPCS C1895 Reliance G Pf Lead BOTH IP/OP "$15,012.00 " "$11,108.88" $0.00 "$12,009.60" "$6,755.40" "$6,755.40" $0.00 $0.00 $0.00 "$3,128.88" "$4,181.12" "$4,181.12" "$11,571.25" $0.00 "$3,128.50" $0.00 "$7,400.92" "$7,400.92" $0.00 "$7,506.00" "$11,889.50" "$12,009.60" $0.00 $0.00 $0.00 "$2,349.38" $0.00 $0.00 "$2,389.91" $0.00 $0.00 $0.00 $0.00 $0.00 27500091 EAP HCPCS C1895 Relaince Af Lead BOTH IP/OP "$12,676.00 " "$9,380.24" $0.00 "$10,140.80" "$5,704.20" "$5,704.20" $0.00 $0.00 $0.00 "$2,642.00" "$4,181.12" "$4,181.12" "$9,770.66" $0.00 "$2,641.68" $0.00 "$6,249.27" "$6,249.27" $0.00 "$6,338.00" "$10,039.39" "$10,140.80" $0.00 $0.00 $0.00 "$1,983.79" $0.00 $0.00 "$2,018.02" $0.00 $0.00 $0.00 $0.00 $0.00 27500092 EAP HCPCS C1895 Relaince Pf Lead BOTH IP/OP "$12,676.00 " "$9,380.24" $0.00 "$10,140.80" "$5,704.20" "$5,704.20" $0.00 $0.00 $0.00 "$2,642.00" "$4,181.12" "$4,181.12" "$9,770.66" $0.00 "$2,641.68" $0.00 "$6,249.27" "$6,249.27" $0.00 "$6,338.00" "$10,039.39" "$10,140.80" $0.00 $0.00 $0.00 "$1,983.79" $0.00 $0.00 "$2,018.02" $0.00 $0.00 $0.00 $0.00 $0.00 27500093 EAP HCPCS C1898 "Myocardial Lead,pmkr,other Than Trans" BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" "$1,271.82" $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 27500094 EAP HCPCS C1898 Flexion - Oscor Lead BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" "$1,271.82" $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 27500095 EAP HCPCS C1898 "Fineline Ii Sterox Lead,pmkr,other Than Trans" BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" "$1,271.82" $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 27500096 EAP HCPCS C1898 "Fineline Ii Sterox Ez Lead,pmkr,other Than Trans" BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" "$1,271.82" $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 27500097 EAP HCPCS C1898 "Flextend Lead,pmkr,other Than Trans" BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 27500098 EAP HCPCS C1898 "Dextrus Lead,pmkr,other Than Trans" BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 27500099 EAP HCPCS C1900 Acuity Steerable/spiral Lead BOTH IP/OP "$6,672.00 " "$4,937.28" $0.00 "$5,337.60" "$3,002.40" "$3,002.40" $0.00 $0.00 $0.00 "$1,390.61" "$4,181.12" "$4,181.12" "$5,142.78" $0.00 "$1,390.44" $0.00 "$3,289.30" "$3,289.30" $0.00 "$3,336.00" "$5,284.22" "$5,337.60" $0.00 $0.00 $0.00 "$1,044.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500100 EAP HCPCS C1900 Easytrack 3 BOTH IP/OP "$5,004.00 " "$3,702.96" $0.00 "$4,003.20" "$2,251.80" "$2,251.80" $0.00 $0.00 $0.00 "$1,042.96" "$3,713.97" "$3,713.97" "$3,857.08" $0.00 "$1,042.83" $0.00 "$2,466.97" "$2,466.97" $0.00 "$2,502.00" "$3,963.17" "$4,003.20" $0.00 $0.00 $0.00 $783.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500101 EAP HCPCS C1900 Easytrack 2 BOTH IP/OP "$5,004.00 " "$3,702.96" $0.00 "$4,003.20" "$2,251.80" "$2,251.80" $0.00 $0.00 $0.00 "$1,042.96" "$3,713.97" "$3,713.97" "$3,857.08" $0.00 "$1,042.83" $0.00 "$2,466.97" "$2,466.97" $0.00 "$2,502.00" "$3,963.17" "$4,003.20" $0.00 $0.00 $0.00 $783.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500102 EAP HCPCS C1721 Evera Mri Xt Dr Device- Single Chamber BOTH IP/OP "$41,500.00 " "$30,710.00" $0.00 "$33,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,649.64" "$4,181.12" "$4,181.12" "$31,988.20" $0.00 "$8,648.60" $0.00 "$20,459.50" "$20,459.50" $0.00 "$20,750.00" "$32,868.00" "$33,200.00" $0.00 $0.00 $0.00 "$6,494.75" $0.00 $0.00 "$6,606.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500103 EAP HCPCS C1722 Evera Mri Xt Vr Device - Dual Chamber BOTH IP/OP "$36,500.00 " "$27,010.00" $0.00 "$29,200.00" "$19,819.50" "$19,819.50" $0.00 $0.00 $0.00 "$7,607.51" "$4,181.12" "$4,181.12" "$28,134.20" $0.00 "$7,606.60" $0.00 "$3,094.73" "$3,094.73" $0.00 "$18,250.00" "$28,908.00" "$29,200.00" $0.00 $0.00 $0.00 "$5,712.25" $0.00 $0.00 "$5,810.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500105 EAP HCPCS C1721 Fortify Assura Dr 40 Df4 Con Icd/defib/resync BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500106 EAP HCPCS C1722 Drbr Crd Visia Af Mri Df4 Vr BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500150 EAP HCPCS C1785 "Pacemaker, Dual Accent Dr" BOTH IP/OP "$19,351.00 " "$14,319.74" $0.00 "$15,480.80" "$8,707.95" "$8,707.95" $0.00 $0.00 $0.00 "$4,033.23" "$4,181.12" "$4,181.12" "$14,915.75" $0.00 "$4,032.75" $0.00 "$9,540.04" "$9,540.04" $0.00 "$9,675.50" "$15,325.99" "$15,480.80" $0.00 $0.00 $0.00 "$3,028.43" $0.00 $0.00 "$3,080.68" $0.00 $0.00 $0.00 $0.00 $0.00 27500151 EAP HCPCS C1786 "Pacemaker, Single Accent Sr" BOTH IP/OP "$17,681.00 " "$13,083.94" $0.00 "$14,144.80" "$7,956.45" "$7,956.45" $0.00 $0.00 $0.00 "$3,685.16" "$4,181.12" "$4,181.12" "$13,628.51" $0.00 "$3,684.72" $0.00 "$8,716.73" "$8,716.73" $0.00 "$8,840.50" "$14,003.35" "$14,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500152 EAP HCPCS C2621 "Pacemaker, Bi-v Anthem Crt-p" BOTH IP/OP "$11,209.00 " "$8,294.66" $0.00 "$8,967.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,639.90" $0.00 "$2,335.96" $0.00 $0.00 $0.00 $0.00 "$5,604.50" "$8,877.53" "$8,967.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500153 EAP HCPCS C1898 Lead Pcng 45cm Bipol Act Fix Solia S Strd Elut BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27500154 EAP HCPCS C1898 Lead Pcng 53cm Solia S Ecrdl Strd Elute Bipol Act BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $506.25 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27500155 EAP HCPCS C1898 Lead Pcng 60cm Promri Solia S Strd Elut BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $506.25 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27500160 EAP HCPCS C1898 Myopore Epicardial Lead 35 Cm BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500162 EAP HCPCS C1882 Pacemaker Crd Viva Crt-p BOTH IP/OP "$28,585.00 " "$21,152.90" $0.00 "$22,868.00" "$12,863.25" "$12,863.25" $0.00 $0.00 $0.00 "$5,957.83" "$4,181.12" "$4,181.12" "$22,033.32" $0.00 "$5,957.11" $0.00 "$14,092.41" "$14,092.41" $0.00 "$14,292.50" "$22,639.32" "$22,868.00" $0.00 $0.00 $0.00 "$4,473.55" $0.00 $0.00 "$4,550.73" $0.00 $0.00 $0.00 $0.00 $0.00 27500163 EAP HCPCS C1786 Pacemaker Crd Advisa Sr Mr Surescan 1 Chmbr Unplr BOTH IP/OP "$11,000.00 " "$8,140.00" $0.00 "$8,800.00" "$4,950.00" "$4,950.00" $0.00 $0.00 $0.00 "$2,292.68" "$4,181.12" "$4,181.12" "$8,478.80" $0.00 "$2,292.40" $0.00 "$5,423.00" "$5,423.00" $0.00 "$5,500.00" "$8,712.00" "$8,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500200 EAP HCPCS C1786 Reply Sr System BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500201 EAP HCPCS C1786 Reply Sr BOTH IP/OP "$10,344.00 " "$7,654.56" $0.00 "$8,275.20" "$4,654.80" "$4,654.80" $0.00 $0.00 $0.00 "$2,155.95" "$4,181.12" "$4,181.12" "$7,973.16" $0.00 "$2,155.69" $0.00 "$5,099.59" "$5,099.59" $0.00 "$5,172.00" "$8,192.45" "$8,275.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500202 EAP HCPCS C1722 Paradym Rf Crt 9750 System BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500203 EAP HCPCS C1722 Paradym Rf Crt 9750 BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500204 EAP HCPCS C1722 Paradym 9250 Rf Vr BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500205 EAP HCPCS C1900 Quickflex+++pmm#:89271 BOTH IP/OP "$4,729.00 " "$3,499.46" $0.00 "$3,783.20" "$2,128.05" "$2,128.05" $0.00 $0.00 $0.00 $985.64 "$3,509.86" "$3,509.86" "$3,645.11" $0.00 $985.52 $0.00 "$2,331.40" "$2,331.40" $0.00 "$2,364.50" "$3,745.37" "$3,783.20" $0.00 $0.00 $0.00 $740.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500206 EAP HCPCS C1900 Quickflex+++pmm#:89272 BOTH IP/OP "$4,729.00 " "$3,499.46" $0.00 "$3,783.20" "$2,128.05" "$2,128.05" $0.00 $0.00 $0.00 $985.64 "$3,509.86" "$3,509.86" "$3,645.11" $0.00 $985.52 $0.00 "$2,331.40" "$2,331.40" $0.00 "$2,364.50" "$3,745.37" "$3,783.20" $0.00 $0.00 $0.00 $740.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500207 EAP HCPCS C1900 Quickflex+++pmm#:89273 BOTH IP/OP "$4,729.00 " "$3,499.46" $0.00 "$3,783.20" "$2,128.05" "$2,128.05" $0.00 $0.00 $0.00 $985.64 "$3,509.86" "$3,509.86" "$3,645.11" $0.00 $985.52 $0.00 "$2,331.40" "$2,331.40" $0.00 "$2,364.50" "$3,745.37" "$3,783.20" $0.00 $0.00 $0.00 $740.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500208 EAP HCPCS C1900 Quickflex Micro BOTH IP/OP "$5,202.00 " "$3,849.48" $0.00 "$4,161.60" "$2,340.90" "$2,340.90" $0.00 $0.00 $0.00 "$1,084.23" "$3,860.92" "$3,860.92" "$4,009.70" $0.00 "$1,084.10" $0.00 "$2,564.59" "$2,564.59" $0.00 "$2,601.00" "$4,119.98" "$4,161.60" $0.00 $0.00 $0.00 $814.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500209 EAP HCPCS C1900 Quickflex Micro BOTH IP/OP "$5,202.00 " "$3,849.48" $0.00 "$4,161.60" "$2,340.90" "$2,340.90" $0.00 $0.00 $0.00 "$1,084.23" "$3,860.92" "$3,860.92" "$4,009.70" $0.00 "$1,084.10" $0.00 "$2,564.59" "$2,564.59" $0.00 "$2,601.00" "$4,119.98" "$4,161.60" $0.00 $0.00 $0.00 $814.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500210 EAP HCPCS C1898 Optisense BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500211 EAP HCPCS C1898 Optisense BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500212 EAP HCPCS C1898 Optisense+++pmm#:89078 BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500213 EAP HCPCS C1898 Optisense BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500214 EAP HCPCS C1898 Optisense BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500215 EAP HCPCS C1898 Tendril St Optim BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500216 EAP HCPCS C1898 Tendril St Optim BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500217 EAP HCPCS C1898 Tendril St Optim BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500218 EAP HCPCS C1898 Isoflex Optim BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $598.50 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500219 EAP HCPCS C1898 Isoflex Optim BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500220 EAP HCPCS C1898 Isoflex Optim BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500221 EAP HCPCS C1898 Isoflex Optim BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500222 EAP HCPCS C1898 Isoflex Optim BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500223 EAP HCPCS C1786 5157m/s BOTH IP/OP "$10,344.00 " "$7,654.56" $0.00 "$8,275.20" "$4,654.80" "$4,654.80" $0.00 $0.00 $0.00 "$2,155.95" "$4,181.12" "$4,181.12" "$7,973.16" $0.00 "$2,155.69" $0.00 "$5,099.59" "$5,099.59" $0.00 "$5,172.00" "$8,192.45" "$8,275.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500224 EAP HCPCS C1785 5357m/s BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500225 EAP HCPCS C1895 Durata BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500226 EAP HCPCS C1895 Durata BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500227 EAP HCPCS C1895 Durata+++pmm#:87533 BOTH IP/OP "$12,413.00 " "$9,185.62" $0.00 "$9,930.40" "$5,585.85" "$5,585.85" $0.00 $0.00 $0.00 "$2,587.18" "$4,181.12" "$4,181.12" "$9,567.94" $0.00 "$2,586.87" $0.00 "$6,119.61" "$6,119.61" $0.00 "$6,206.50" "$9,831.10" "$9,930.40" $0.00 $0.00 $0.00 "$1,942.63" $0.00 $0.00 "$1,976.15" $0.00 $0.00 $0.00 $0.00 $0.00 27500228 EAP HCPCS C1895 Durata BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500229 EAP HCPCS C1895 Durata BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500230 EAP HCPCS C1895 Durata Df4 - Active Tbp Single Shock BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500231 EAP HCPCS C1895 Durata Df4 - Active Tbp Single Shock BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500232 EAP HCPCS C1895 Durata Df4 - Active Tbp Single Shock BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500233 EAP HCPCS C1895 Durata BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500234 EAP HCPCS C1895 Durata BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500235 EAP HCPCS C1895 Durata BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500236 EAP HCPCS C1895 Durata+++pmm#:96295 BOTH IP/OP "$12,413.00 " "$9,185.62" $0.00 "$9,930.40" "$5,585.85" "$5,585.85" $0.00 $0.00 $0.00 "$2,587.18" "$4,181.12" "$4,181.12" "$9,567.94" $0.00 "$2,586.87" $0.00 "$6,119.61" "$6,119.61" $0.00 "$6,206.50" "$9,831.10" "$9,930.40" $0.00 $0.00 $0.00 "$1,942.63" $0.00 $0.00 "$1,976.15" $0.00 $0.00 $0.00 $0.00 $0.00 27500237 EAP HCPCS C1895 Durata+++pmm#:96296 BOTH IP/OP "$12,413.00 " "$9,185.62" $0.00 "$9,930.40" "$5,585.85" "$5,585.85" $0.00 $0.00 $0.00 "$2,587.18" "$4,181.12" "$4,181.12" "$9,567.94" $0.00 "$2,586.87" $0.00 "$6,119.61" "$6,119.61" $0.00 "$6,206.50" "$9,831.10" "$9,930.40" $0.00 $0.00 $0.00 "$1,942.63" $0.00 $0.00 "$1,976.15" $0.00 $0.00 $0.00 $0.00 $0.00 27500238 EAP HCPCS C1895 Durata BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500239 EAP HCPCS C1895 Durata Sj4 - Passive BOTH IP/OP "$12,413.00 " "$9,185.62" $0.00 "$9,930.40" "$5,585.85" "$5,585.85" $0.00 $0.00 $0.00 "$2,587.18" "$4,181.12" "$4,181.12" "$9,567.94" $0.00 "$2,586.87" $0.00 "$6,119.61" "$6,119.61" $0.00 "$6,206.50" "$9,831.10" "$9,930.40" $0.00 $0.00 $0.00 "$1,942.63" $0.00 $0.00 "$1,976.15" $0.00 $0.00 $0.00 $0.00 $0.00 27500240 EAP HCPCS C1895 Durata Df4 - Passive Tbp Dual Shock BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500241 EAP HCPCS C1895 Durata Df4 - Passive Tbp Dual Shock BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500242 EAP HCPCS C1895 Durata Sj4 - Passive BOTH IP/OP "$12,413.00 " "$9,185.62" $0.00 "$9,930.40" "$5,585.85" "$5,585.85" $0.00 $0.00 $0.00 "$2,587.18" "$4,181.12" "$4,181.12" "$9,567.94" $0.00 "$2,586.87" $0.00 "$6,119.61" "$6,119.61" $0.00 "$6,206.50" "$9,831.10" "$9,930.40" $0.00 $0.00 $0.00 "$1,942.63" $0.00 $0.00 "$1,976.15" $0.00 $0.00 $0.00 $0.00 $0.00 27500243 EAP HCPCS C1895 Durata Df4 - Passive Tbp Dual Shock BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500244 EAP HCPCS C1895 Durata Df4 - Passive Tbp Dual Shock BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500245 EAP HCPCS C1893 Cps Direct? Sl Ii Straight 47cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500246 EAP HCPCS C1893 Cps Direct? Sl Ii 135 Degrees 47cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500247 EAP HCPCS C1893 Cps Direct? Sl Ii Wide 47cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500248 EAP HCPCS C1893 Cps Direct? Sl Ii X-wide 47cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500249 EAP HCPCS C1893 Cps Direct? Sl Ii Right Side 47cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500250 EAP HCPCS C1893 Cps Direct? Sl Ii Straight 54cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500251 EAP HCPCS C1893 Cps Direct? Sl Ii 115 Degrees 54cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500252 EAP HCPCS C1893 Cps Direct? Sl Ii 135 Degrees 54cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500253 EAP HCPCS C1893 Cps Direct? Sl Ii Wide 54cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500254 EAP HCPCS C1893 Cps Direct? Sl Ii X-wide 54cm BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500255 EAP HCPCS C1893 Cps Aim S BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $265.95 $265.95 $0.00 $0.00 $0.00 $123.18 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $349.58 $349.58 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $92.49 $0.00 $0.00 $94.09 $0.00 $0.00 $0.00 $0.00 $0.00 27500256 EAP HCPCS C1893 Cps Aim Sl BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $265.95 $265.95 $0.00 $0.00 $0.00 $123.18 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $349.58 $349.58 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $92.49 $0.00 $0.00 $94.09 $0.00 $0.00 $0.00 $0.00 $0.00 27500257 EAP HCPCS C1893 Cps Aim S BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $265.95 $265.95 $0.00 $0.00 $0.00 $123.18 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $349.58 $349.58 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $92.49 $0.00 $0.00 $94.09 $0.00 $0.00 $0.00 $0.00 $0.00 27500258 EAP HCPCS C1893 Cps Aim Sl BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $265.95 $265.95 $0.00 $0.00 $0.00 $123.18 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $349.58 $349.58 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $92.49 $0.00 $0.00 $94.09 $0.00 $0.00 $0.00 $0.00 $0.00 27500259 EAP HCPCS C1893 Cps Aim Sl BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $265.95 $265.95 $0.00 $0.00 $0.00 $123.18 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $349.58 $349.58 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $92.49 $0.00 $0.00 $94.09 $0.00 $0.00 $0.00 $0.00 $0.00 27500260 EAP HCPCS C1893 Cps Aim Sl BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $265.95 $265.95 $0.00 $0.00 $0.00 $123.18 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $349.58 $349.58 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $92.49 $0.00 $0.00 $94.09 $0.00 $0.00 $0.00 $0.00 $0.00 27500261 EAP HCPCS C1893 Cps Aim Sl BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $265.95 $265.95 $0.00 $0.00 $0.00 $123.18 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $349.58 $349.58 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $92.49 $0.00 $0.00 $94.09 $0.00 $0.00 $0.00 $0.00 $0.00 27500262 EAP HCPCS C1786 Pacemakers Single Accent Sr Rf BOTH IP/OP "$15,665.00 " "$11,592.10" $0.00 "$12,532.00" "$7,049.25" "$7,049.25" $0.00 $0.00 $0.00 "$3,264.98" "$4,181.12" "$4,181.12" "$12,074.58" $0.00 "$3,264.59" $0.00 "$7,722.85" "$7,722.85" $0.00 "$7,832.50" "$12,406.68" "$12,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500263 EAP HCPCS C1722 Atlas Plus C Header BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500264 EAP HCPCS C1898 Myopore Epicardial Lead 54 Cm BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27500265 EAP HCPCS C1898 Passive Fixation Pacing Lead J-shape Silicone Insulation BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500266 EAP HCPCS C1898 Passive Fixation Pacing Lead J-shape Silicone Insulation BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500267 EAP HCPCS C1898 Passive Fixation Pacing Lead Straight Silicone Insulation BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500268 EAP HCPCS C1898 Passive Fixation Pacing Lead Straight Silicone Insulation BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500269 EAP HCPCS C1898 Active Fixation Pacing Lead Electrically Active Helix Sili BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500270 EAP HCPCS C1898 Active Fixation Pacing Lead Electrically Active Helix Sili BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500271 EAP HCPCS C1898 Active Fixation Pacing Lead Electrically Active Helix Sili BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500272 EAP HCPCS C1898 Active Fixation Single Coil Silicone Insulation 65 Cm BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500273 EAP HCPCS C1898 Passive Fixation Dual Coil Silicone Insulation 65 Cm 18 BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500274 EAP HCPCS C1898 Active Fixation Dual Coil Silicone Insulation 60 Cm 16 C BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500275 EAP HCPCS C1898 Active Fixation Dual Coil Silicone Insulation 65 Cm 18 C BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500276 EAP HCPCS C1900 Left Ventricular Lead With 3d Pre-shaped Helix At Distal End BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500277 EAP HCPCS C1900 Left Ventricular Lead With Pre-shaped Bend And Thread Fixati BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500278 EAP HCPCS C1900 Left Ventricular Lead With 2d Pre-shaped Bend At Distal End BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500279 EAP HCPCS C1895 Is-1 Silicone 35cm V Placement BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500280 EAP HCPCS C1895 Is-1 Silicone 54cm V Placement BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500281 EAP HCPCS C1892 Is-1 Polyurethane 44cm 7f Introducer 11mm Electrode Spac BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500282 EAP HCPCS C1892 Is-1 Polyurethane 52cm 7f Introducer 11mm Electrode Spac BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500283 EAP HCPCS C1892 Is-1 Polyurethane 58cm 7f Introducer 11mm Electrode Spac BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500284 EAP HCPCS C1892 Is-1 Polyurethane 7f 11mm Electrode Spacing 48cm Prefor BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500285 EAP HCPCS C1892 Is-1 Polyurethane 7f 11mm Electrode Spacing 52cm Prefor BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500286 EAP HCPCS C1892 Is-1 Polyurethane 7f 11mm Electrode Spacing 52cm Straig BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500287 EAP HCPCS C1892 Is-1 Polyurethane 7f 11mm Electrode Spacing 58cm Straig BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500288 EAP HCPCS C1892 Is-1 Polyurethane 7f 11mm Electrode Spacing 44cm Prefor BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500289 EAP HCPCS C1892 Is-1 Polyurethane 7f 11mm Electrode Spacing 52cm Prefor BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27500290 EAP HCPCS C1785 Reply Dr V2 BOTH IP/OP "$12,413.00 " "$9,185.62" $0.00 "$9,930.40" "$5,585.85" "$5,585.85" $0.00 $0.00 $0.00 "$2,587.18" "$4,181.12" "$4,181.12" "$9,567.94" $0.00 "$2,586.87" $0.00 "$6,119.61" "$6,119.61" $0.00 "$6,206.50" "$9,831.10" "$9,930.40" $0.00 $0.00 $0.00 "$1,942.63" $0.00 $0.00 "$1,976.15" $0.00 $0.00 $0.00 $0.00 $0.00 27500291 EAP HCPCS C1785 Reply Dr V2 System BOTH IP/OP "$14,777.00 " "$10,934.98" $0.00 "$11,821.60" "$6,649.65" "$6,649.65" $0.00 $0.00 $0.00 "$3,079.90" "$4,181.12" "$4,181.12" "$11,390.11" $0.00 "$3,079.53" $0.00 "$7,285.06" "$7,285.06" $0.00 "$7,388.50" "$11,703.38" "$11,821.60" $0.00 $0.00 $0.00 "$2,312.60" $0.00 $0.00 "$2,352.50" $0.00 $0.00 $0.00 $0.00 $0.00 27500292 EAP HCPCS C1785 Esprit Dr BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500293 EAP HCPCS C1785 Esprit Dr System BOTH IP/OP "$14,777.00 " "$10,934.98" $0.00 "$11,821.60" "$6,649.65" "$6,649.65" $0.00 $0.00 $0.00 "$3,079.90" "$4,181.12" "$4,181.12" "$11,390.11" $0.00 "$3,079.53" $0.00 "$7,285.06" "$7,285.06" $0.00 "$7,388.50" "$11,703.38" "$11,821.60" $0.00 $0.00 $0.00 "$2,312.60" $0.00 $0.00 "$2,352.50" $0.00 $0.00 $0.00 $0.00 $0.00 27500294 EAP HCPCS C1786 Reply Sr V2 BOTH IP/OP "$9,753.00 " "$7,217.22" $0.00 "$7,802.40" "$4,388.85" "$4,388.85" $0.00 $0.00 $0.00 "$2,032.77" "$4,181.12" "$4,181.12" "$7,517.61" $0.00 "$2,032.53" $0.00 "$4,808.23" "$4,808.23" $0.00 "$4,876.50" "$7,724.38" "$7,802.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500295 EAP HCPCS C1786 Reply Sr V2 System BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500296 EAP HCPCS C1786 Esprit Sr BOTH IP/OP "$10,344.00 " "$7,654.56" $0.00 "$8,275.20" "$4,654.80" "$4,654.80" $0.00 $0.00 $0.00 "$2,155.95" "$4,181.12" "$4,181.12" "$7,973.16" $0.00 "$2,155.69" $0.00 "$5,099.59" "$5,099.59" $0.00 "$5,172.00" "$8,192.45" "$8,275.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500297 EAP HCPCS C1786 Esprit Sr System BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500298 EAP HCPCS C1882 Paradym Crt-d 8750 BOTH IP/OP "$55,268.00 " "$40,898.32" $0.00 "$44,214.40" "$24,870.60" "$24,870.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$42,600.57" $0.00 "$11,517.85" $0.00 "$27,247.12" "$27,247.12" $0.00 "$27,634.00" "$43,772.26" "$44,214.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500299 EAP HCPCS C1882 Paradym Crt-d 8750 System BOTH IP/OP "$65,318.00 " "$48,335.32" $0.00 "$52,254.40" "$29,393.10" "$29,393.10" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$50,347.11" $0.00 "$13,612.27" $0.00 "$32,201.77" "$32,201.77" $0.00 "$32,659.00" "$51,731.86" "$52,254.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500300 EAP HCPCS C1882 Paradym 8250 Vr BOTH IP/OP "$41,378.00 " "$30,619.72" $0.00 "$33,102.40" "$18,620.10" "$18,620.10" $0.00 $0.00 $0.00 "$8,624.21" "$4,181.12" "$4,181.12" "$31,894.16" $0.00 "$8,623.18" $0.00 "$20,399.35" "$20,399.35" $0.00 "$20,689.00" "$32,771.38" "$33,102.40" $0.00 $0.00 $0.00 "$6,475.66" $0.00 $0.00 "$6,587.38" $0.00 $0.00 $0.00 $0.00 $0.00 27500301 EAP HCPCS C1882 Paradym 8550 Dr BOTH IP/OP "$48,767.00 " "$36,087.58" $0.00 "$39,013.60" "$21,945.15" "$21,945.15" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$37,589.60" $0.00 "$10,163.04" $0.00 "$24,042.13" "$24,042.13" $0.00 "$24,383.50" "$38,623.46" "$39,013.60" $0.00 $0.00 $0.00 "$7,632.04" $0.00 $0.00 "$7,763.71" $0.00 $0.00 $0.00 $0.00 $0.00 27500302 EAP HCPCS C1785 Reply Dr BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27500303 EAP HCPCS C1785 Reply Dr System BOTH IP/OP "$14,777.00 " "$10,934.98" $0.00 "$11,821.60" "$6,649.65" "$6,649.65" $0.00 $0.00 $0.00 "$3,079.90" "$4,181.12" "$4,181.12" "$11,390.11" $0.00 "$3,079.53" $0.00 "$7,285.06" "$7,285.06" $0.00 "$7,388.50" "$11,703.38" "$11,821.60" $0.00 $0.00 $0.00 "$2,312.60" $0.00 $0.00 "$2,352.50" $0.00 $0.00 $0.00 $0.00 $0.00 27500304 EAP HCPCS C1883 Is-1/df-1 Silicone 58cm Integrated Bipolar Active Fixation BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 $0.00 $0.00 $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500305 EAP HCPCS C1722 Paradym 9550 Rf Dr BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" "$20,614.95" "$20,614.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27500310 EAP HCPCS C1722 Defib Cardiac Protecta Vr Implantable Cardioverter BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500311 EAP HCPCS C1882 Defibrillator Cardiac Consulta D.59 In W2.01 In X H2.72d BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" "$20,614.95" "$20,614.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27500312 EAP HCPCS C1786 Dfbr Crd Inventra 7 Vr-t Dx Impltable Home Monitr BOTH IP/OP "$49,688.00 " "$36,769.12" $0.00 "$39,750.40" "$22,359.60" "$22,359.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,299.51" $0.00 "$10,354.98" $0.00 "$24,496.18" "$24,496.18" $0.00 "$24,844.00" "$39,352.90" "$39,750.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500350 EAP HCPCS C1721 Evera Xt Dr System - Mmem BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500351 EAP HCPCS C1721 Evera Xt Dr System - Mmee BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500352 EAP HCPCS C1721 Evera S Dr System - Mmem BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500353 EAP HCPCS C1721 Evera S Dr System - Mmee BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500354 EAP HCPCS C1721 Protecta Xt Dr System - Mmem BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500355 EAP HCPCS C1721 Protecta Xt Dr System - Mmee BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500356 EAP HCPCS C1722 Evera Xt Vr System - Mmem BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500357 EAP HCPCS C1722 Evera Xt Vr System - Mmee BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500358 EAP HCPCS C1722 Evera S Vr System - Mmem BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500359 EAP HCPCS C1722 Evera S Vr System - Mmee BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500360 EAP HCPCS C1722 Protecta Xt Vr System - Emem BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500361 EAP HCPCS C1722 Protecta Xt Vr System - Emee BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500362 EAP HCPCS C1721 Icd-dr Ddbb1d1 Evera Xt Us Is1/df1 BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27500363 EAP HCPCS C1721 Icd-dr Ddbb1d4 Evera Xt Us Is1/df4 BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27500364 EAP HCPCS C1721 Icd-dr Ddbc3d1 Evera S Is1/df1 Glob BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27500365 EAP HCPCS C1721 Icd-dr Ddbc3d4 Evera S Is1/df4 Glob BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27500366 EAP HCPCS C1721 Icd D314drg Protecta Xt Dr Is-1/df-1 Us BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27500367 EAP HCPCS C1721 Icd D314drm Protecta Xt Dr Us Mr Df4 BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27500368 EAP HCPCS C1722 Icd-vr Dvbb1d1 Evera Xt Is1/df1 Us BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500369 EAP HCPCS C1722 Icd-vr Dvbb1d4 Evera Xt Us Is1/df4 BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500370 EAP HCPCS C1722 Icd-vr Dvbc3d1 Evera S Is1/df1 Glob BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500371 EAP HCPCS C1722 Icd-vr Dvbc3d4 Evera S Df4 Glob BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500372 EAP HCPCS C1722 Icd D314vrg Protecta Xt Vr Us Mr Bcp BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500373 EAP HCPCS C1722 Icd D314vrm Protecta Xt Vr Us Mr Df4 Bcp BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27500374 EAP HCPCS C1882 Crt D314trg Protecta Xt Crt-d Us Mr BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500375 EAP HCPCS C1882 Crt D314trm Protecta Xt Crt-d Us Mr Df4 BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500376 EAP HCPCS C1882 Protecta Xt Crtd Sys - Mmmm BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500377 EAP HCPCS C1882 Protecta Xt Crtd Sys - Mmme BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500378 EAP HCPCS C1882 Protecta Xt Crtd Sys - Mmpm BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500379 EAP HCPCS C1882 Protecta Xt Crtd Sys - Mmpe BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500380 EAP HCPCS C1882 Protecta Xt Crtd Sys - Mmam BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500381 EAP HCPCS C1882 Protecta Xt Crtd Sys - Mmae BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500382 EAP HCPCS C1779 Lead 5038s-58 Capsure Vdd Quad Av 11.5cm BOTH IP/OP "$2,069.00 " "$1,531.06" $0.00 "$1,655.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,535.61" "$1,535.61" "$1,594.79" $0.00 $431.18 $0.00 $0.00 $0.00 $0.00 "$1,034.50" "$1,638.65" "$1,655.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500383 EAP HCPCS C1779 Lead 5038-58 Lead-quad Sngl-p A/v 58cm BOTH IP/OP "$2,069.00 " "$1,531.06" $0.00 "$1,655.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,535.61" "$1,535.61" "$1,594.79" $0.00 $431.18 $0.00 $0.00 $0.00 $0.00 "$1,034.50" "$1,638.65" "$1,655.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500384 EAP HCPCS C1779 Lead 5038l-65 Capsure Vdd Lead 65cm BOTH IP/OP "$2,069.00 " "$1,531.06" $0.00 "$1,655.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,535.61" "$1,535.61" "$1,594.79" $0.00 $431.18 $0.00 $0.00 $0.00 $0.00 "$1,034.50" "$1,638.65" "$1,655.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500385 EAP HCPCS C1785 Ipg A2dr01 Advisa Mri Dr. BOTH IP/OP "$15,073.00 " "$11,154.02" $0.00 "$12,058.40" "$6,782.85" "$6,782.85" $0.00 $0.00 $0.00 "$3,141.59" "$4,181.12" "$4,181.12" "$11,618.27" $0.00 "$3,141.21" $0.00 "$7,430.99" "$7,430.99" $0.00 "$7,536.50" "$11,937.82" "$12,058.40" $0.00 $0.00 $0.00 "$2,358.92" $0.00 $0.00 "$2,399.62" $0.00 $0.00 $0.00 $0.00 $0.00 27500386 EAP HCPCS C1785 Ipg Rvdr01 Revo Mri 1.5t BOTH IP/OP "$14,187.00 " "$10,498.38" $0.00 "$11,349.60" "$6,384.15" "$6,384.15" $0.00 $0.00 $0.00 "$2,956.93" "$4,181.12" "$4,181.12" "$10,935.34" $0.00 "$2,956.57" $0.00 "$6,994.19" "$6,994.19" $0.00 "$7,093.50" "$11,236.10" "$11,349.60" $0.00 $0.00 $0.00 "$2,220.27" $0.00 $0.00 "$2,258.57" $0.00 $0.00 $0.00 $0.00 $0.00 27500387 EAP HCPCS C1785 Advisa Mri System - Peem BOTH IP/OP "$18,029.00 " "$13,341.46" $0.00 "$14,423.20" "$8,113.05" "$8,113.05" $0.00 $0.00 $0.00 "$3,757.69" "$4,181.12" "$4,181.12" "$13,896.75" $0.00 "$3,757.24" $0.00 "$8,888.30" "$8,888.30" $0.00 "$9,014.50" "$14,278.97" "$14,423.20" $0.00 $0.00 $0.00 "$2,821.54" $0.00 $0.00 "$2,870.22" $0.00 $0.00 $0.00 $0.00 $0.00 27500388 EAP HCPCS C1785 Revo Mri System - Peem BOTH IP/OP "$17,142.00 " "$12,685.08" $0.00 "$13,713.60" "$7,713.90" "$7,713.90" $0.00 $0.00 $0.00 "$3,572.82" "$4,181.12" "$4,181.12" "$13,213.05" $0.00 "$3,572.39" $0.00 "$8,451.01" "$8,451.01" $0.00 "$8,571.00" "$13,576.46" "$13,713.60" $0.00 $0.00 $0.00 "$2,682.72" $0.00 $0.00 "$2,729.01" $0.00 $0.00 $0.00 $0.00 $0.00 27500389 EAP HCPCS C1882 Crt-d Dtbb1d1 Viva Sis1/df1 Us BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500390 EAP HCPCS C1882 Crt-d Dtbb1d4 Viva Sis1/df4 Us BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500391 EAP HCPCS C1882 Viva S Crtd System - Mmmm BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500392 EAP HCPCS C1882 Viva S Crtd System - Mmpm BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500393 EAP HCPCS C1882 Viva S Crtd System - Mmam BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27500394 EAP HCPCS C1786 Pcmkr Crd Thk6mm Sm 50x41mm Endurity 1 Chmbr Is-1 Conctr BOTH IP/OP "$11,942.00 " "$8,837.08" $0.00 "$9,553.60" "$5,373.90" "$5,373.90" $0.00 $0.00 $0.00 "$2,489.01" "$4,181.12" "$4,181.12" "$9,204.89" $0.00 "$2,488.71" $0.00 "$5,887.41" "$5,887.41" $0.00 "$5,971.00" "$9,458.06" "$9,553.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500395 EAP HCPCS C1785 Pcmkr Crd Thk6mm Sm 50x47mm Assurity Dr 2 Chmbr Is-1 Conctr BOTH IP/OP "$18,765.00 " "$13,886.10" $0.00 "$15,012.00" "$8,444.25" "$8,444.25" $0.00 $0.00 $0.00 "$3,911.10" "$4,181.12" "$4,181.12" "$14,464.06" $0.00 "$3,910.63" $0.00 "$9,251.15" "$9,251.15" $0.00 "$9,382.50" "$14,861.88" "$15,012.00" $0.00 "$8,444.25" $0.00 "$2,936.72" $0.00 $0.00 "$2,987.39" $0.00 $0.00 $0.00 $0.00 $0.00 27500396 EAP HCPCS C1785 Pcmkr Crd Thk6mm Sm 46x50x6 Endurity Dr 2 Chmbr Is-1 Conctr BOTH IP/OP "$16,141.00 " "$11,944.34" $0.00 "$12,912.80" "$7,263.45" "$7,263.45" $0.00 $0.00 $0.00 "$3,364.19" "$4,181.12" "$4,181.12" "$12,441.48" $0.00 "$3,363.78" $0.00 "$7,957.51" "$7,957.51" $0.00 "$8,070.50" "$12,783.67" "$12,912.80" $0.00 $0.00 $0.00 "$2,526.07" $0.00 $0.00 "$2,569.65" $0.00 $0.00 $0.00 $0.00 $0.00 27500397 EAP HCPCS C1786 Pcmkr Crd Thk6mm Sm 50x47mm Assurity Sr 1 Chmbr Is-1 Conctr BOTH IP/OP "$14,960.00 " "$11,070.40" $0.00 "$11,968.00" "$6,732.00" "$6,732.00" $0.00 $0.00 $0.00 "$3,118.04" "$4,181.12" "$4,181.12" "$11,531.17" $0.00 "$3,117.66" $0.00 "$7,375.28" "$7,375.28" $0.00 "$7,480.00" "$11,848.32" "$11,968.00" $0.00 "$6,732.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500398 EAP HCPCS C1786 Pcmkr Crd Thk6mm Sm 41x50 X6 Endurity Sr 1 Chmbr Is-1 Conctr BOTH IP/OP "$12,335.00 " "$9,127.90" $0.00 "$9,868.00" "$5,550.75" "$5,550.75" $0.00 $0.00 $0.00 "$2,570.92" "$4,181.12" "$4,181.12" "$9,507.82" $0.00 "$2,570.61" $0.00 "$6,081.16" "$6,081.16" $0.00 "$6,167.50" "$9,769.32" "$9,868.00" $0.00 "$5,550.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500399 EAP HCPCS C1785 Pcmkr Crd Thk6mm Sm 50x47mm Assurity Dr Rf Chmbr Is-1 Conctr BOTH IP/OP "$19,946.00 " "$14,760.04" $0.00 "$15,956.80" "$8,975.70" "$8,975.70" $0.00 $0.00 $0.00 "$4,157.25" "$4,181.12" "$4,181.12" "$15,374.38" $0.00 "$4,156.75" $0.00 "$9,833.38" "$9,833.38" $0.00 "$9,973.00" "$15,797.23" "$15,956.80" $0.00 "$8,975.70" $0.00 "$3,121.55" $0.00 $0.00 "$3,175.40" $0.00 $0.00 $0.00 $0.00 $0.00 27500400 EAP HCPCS C1785 Pcmkr Crd Thk6mm Sm Endurity Dr Rf Chmbr Is-1 Conctr Atcpt BOTH IP/OP "$17,322.00 " "$12,818.28" $0.00 "$13,857.60" "$7,794.90" "$7,794.90" $0.00 $0.00 $0.00 "$3,610.34" "$4,181.12" "$4,181.12" "$13,351.80" $0.00 "$3,609.90" $0.00 "$8,539.75" "$8,539.75" $0.00 "$8,661.00" "$13,719.02" "$13,857.60" $0.00 "$7,794.90" $0.00 "$2,710.89" $0.00 $0.00 "$2,757.66" $0.00 $0.00 $0.00 $0.00 $0.00 27500401 EAP HCPCS C1786 Pcmkr Crd Thk6mm Sm 50x47mm Assurity 1 Chmbr Is-1 Conctr BOTH IP/OP "$16,141.00 " "$11,944.34" $0.00 "$12,912.80" "$7,263.45" "$7,263.45" $0.00 $0.00 $0.00 "$3,364.19" "$4,181.12" "$4,181.12" "$12,441.48" $0.00 "$3,363.78" $0.00 "$7,957.51" "$7,957.51" $0.00 "$8,070.50" "$12,783.67" "$12,912.80" $0.00 "$7,263.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500402 EAP HCPCS C1786 Pcmkr Crd Thk6mm Sm 50x47mm Endurity 1 Chmbr Is-1 Conctr BOTH IP/OP "$13,516.00 " "$10,001.84" $0.00 "$10,812.80" "$6,082.20" "$6,082.20" $0.00 $0.00 $0.00 "$2,817.07" "$4,181.12" "$4,181.12" "$10,418.13" $0.00 "$2,816.73" $0.00 "$6,663.39" "$6,663.39" $0.00 "$6,758.00" "$10,704.67" "$10,812.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500403 EAP HCPCS C2621 Pcmkr Crd Thk6mm 59x56mm Alr Qd Rf Is4-llll Conctr Is-1 BOTH IP/OP "$18,372.00 " "$13,595.28" $0.00 "$14,697.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,161.14" $0.00 "$3,828.72" $0.00 $0.00 $0.00 $0.00 "$9,186.00" "$14,550.62" "$14,697.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500404 EAP HCPCS C2621 Pcmkr Crd Thk6mm 59x55mm Alr Rf Is-1 Conctr Corvue Thor BOTH IP/OP "$15,747.00 " "$11,652.78" $0.00 "$12,597.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,137.79" $0.00 "$3,281.67" $0.00 $0.00 $0.00 $0.00 "$7,873.50" "$12,471.62" "$12,597.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500405 EAP HCPCS C2621 Pcmkr Crd Thk6mm 59x56mm Alr Qd Pkg Is4-llll Conctr Is-1 BOTH IP/OP "$19,553.00 " "$14,469.22" $0.00 "$15,642.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,071.45" $0.00 "$4,074.85" $0.00 $0.00 $0.00 $0.00 "$9,776.50" "$15,485.98" "$15,642.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500406 EAP HCPCS C2621 Pcmkr Crd Thk6mm 59x55mm Alr Pkg Is-1 Conctr Corvue Thor BOTH IP/OP "$16,928.00 " "$12,526.72" $0.00 "$13,542.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,048.10" $0.00 "$3,527.80" $0.00 $0.00 $0.00 $0.00 "$8,464.00" "$13,406.98" "$13,542.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500407 EAP HCPCS C2621 Pcmkr Crd Thk6mm 59x56mm Alr Qd Rf Sys Is4-llll Conctr Is-1 BOTH IP/OP "$29,001.00 " "$21,460.74" $0.00 "$23,200.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$22,353.97" $0.00 "$6,043.81" $0.00 $0.00 $0.00 $0.00 "$14,500.50" "$22,968.79" "$23,200.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500408 EAP HCPCS C2621 Pcmkr Crd Thk6mm 59x55mm Alr Rf Sys Is-1 Conctr Corvue Thor BOTH IP/OP "$26,377.00 " "$19,518.98" $0.00 "$21,101.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$20,331.39" $0.00 "$5,496.97" $0.00 $0.00 $0.00 $0.00 "$13,188.50" "$20,890.58" "$21,101.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500409 EAP HCPCS C2621 Pcmkr Crd Thk6mm 59x56mm Alr Crt-p Sys Is4-llll Conctr Is-1 BOTH IP/OP "$30,182.00 " "$22,334.68" $0.00 "$24,145.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$23,264.29" $0.00 "$6,289.93" $0.00 $0.00 $0.00 $0.00 "$15,091.00" "$23,904.14" "$24,145.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500410 EAP HCPCS C2621 Pcmkr Crd Thk6mm 59x55mm Alr Crt-p Sys Is-1 Con Corvue Thor BOTH IP/OP "$27,558.00 " "$20,392.92" $0.00 "$22,046.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,241.71" $0.00 "$5,743.09" $0.00 $0.00 $0.00 $0.00 "$13,779.00" "$21,825.94" "$22,046.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500411 EAP HCPCS C1785 Pcmkr Cd 7.5mm Md Ellipse 44.5x47mm Ing Rythmiq BOTH IP/OP "$10,498.00 " "$7,768.52" $0.00 "$8,398.40" "$4,724.10" "$4,724.10" $0.00 $0.00 $0.00 "$2,188.05" "$4,181.12" "$4,181.12" "$8,091.86" $0.00 "$2,187.78" $0.00 "$5,175.51" "$5,175.51" $0.00 "$5,249.00" "$8,314.42" "$8,398.40" $0.00 $0.00 $0.00 "$1,642.94" $0.00 $0.00 "$1,671.28" $0.00 $0.00 $0.00 $0.00 $0.00 27500412 EAP HCPCS C1786 Pcmkr Cd 7.5mm Md Ellipse 44.5x45.7mm Ing Rythmiq BOTH IP/OP "$9,186.00 " "$6,797.64" $0.00 "$7,348.80" "$4,133.70" "$4,133.70" $0.00 $0.00 $0.00 "$1,914.59" "$4,181.12" "$4,181.12" "$7,080.57" $0.00 "$1,914.36" $0.00 "$4,528.70" "$4,528.70" $0.00 "$4,593.00" "$7,275.31" "$7,348.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500413 EAP HCPCS C1896 Dual Chamber Adaptive Rate Ingenior Dr System 8n22 BOTH IP/OP "$13,123.00 " "$9,711.02" $0.00 "$10,498.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,735.16" "$4,181.12" "$4,181.12" "$10,115.21" $0.00 "$2,734.83" $0.00 "$6,469.64" "$6,469.64" $0.00 "$6,561.50" "$10,393.42" "$10,498.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500414 EAP HCPCS C1896 Single Chmbr Adptiv Rt Ingenio Sr System 8n32 BOTH IP/OP "$10,236.00 " "$7,574.64" $0.00 "$8,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,133.44" "$4,181.12" "$4,181.12" "$7,889.91" $0.00 "$2,133.18" $0.00 "$5,046.35" "$5,046.35" $0.00 "$5,118.00" "$8,106.91" "$8,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500415 EAP HCPCS C1722 Itrevia Vr-t Df-1 Hgh Eng W/ti W/hm Monitoring BOTH IP/OP "$34,906.00 " "$25,830.44" $0.00 "$27,924.80" "$15,707.70" "$15,707.70" $0.00 $0.00 $0.00 "$7,275.28" "$4,181.12" "$4,181.12" "$26,905.54" $0.00 "$7,274.41" $0.00 "$17,208.66" "$17,208.66" $0.00 "$17,453.00" "$27,645.55" "$27,924.80" $0.00 $0.00 $0.00 "$5,462.79" $0.00 $0.00 "$5,557.04" $0.00 $0.00 $0.00 $0.00 $0.00 27500416 EAP HCPCS C1721 Dfbr Crd Evera Mri Surescan Df-1 Pin Plg Xt Dr BOTH IP/OP "$41,500.00 " "$30,710.00" $0.00 "$33,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,649.64" "$4,181.12" "$4,181.12" "$31,988.20" $0.00 "$8,648.60" $0.00 "$20,459.50" "$20,459.50" $0.00 "$20,750.00" "$32,868.00" "$33,200.00" $0.00 "$18,675.00" $0.00 "$6,494.75" $0.00 $0.00 "$6,606.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500417 EAP HCPCS C1721 Evera Mri Xt Dr Icd (dual Chamber Icd) Df4 Header BOTH IP/OP "$41,500.00 " "$30,710.00" $0.00 "$33,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,649.64" "$4,181.12" "$4,181.12" "$31,988.20" $0.00 "$8,648.60" $0.00 "$20,459.50" "$20,459.50" $0.00 "$20,750.00" "$32,868.00" "$33,200.00" $0.00 "$18,675.00" $0.00 "$6,494.75" $0.00 $0.00 "$6,606.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500418 EAP HCPCS C1722 Dfbr Crd Visia Af Mri Df4 Vr BOTH IP/OP "$36,500.00 " "$27,010.00" $0.00 "$29,200.00" "$16,425.00" "$16,425.00" $0.00 $0.00 $0.00 "$7,607.51" "$4,181.12" "$4,181.12" "$28,134.20" $0.00 "$7,606.60" $0.00 "$17,994.50" "$17,994.50" $0.00 "$18,250.00" "$28,908.00" "$29,200.00" $0.00 "$16,425.00" $0.00 "$5,712.25" $0.00 $0.00 "$5,810.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500419 EAP HCPCS C1722 Visia Vr Icd (single Chamber Icd) Df 1 Header BOTH IP/OP "$36,500.00 " "$27,010.00" $0.00 "$29,200.00" "$16,425.00" "$16,425.00" $0.00 $0.00 $0.00 "$7,607.51" "$4,181.12" "$4,181.12" "$28,134.20" $0.00 "$7,606.60" $0.00 "$17,994.50" "$17,994.50" $0.00 "$18,250.00" "$28,908.00" "$29,200.00" $0.00 "$16,425.00" $0.00 "$5,712.25" $0.00 $0.00 "$5,810.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500420 EAP HCPCS C1786 Pacemaker Cardiac .75cm 4.45x4.81cm 1 Chamber Is1 Conctr BOTH IP/OP "$8,600.00 " "$6,364.00" $0.00 "$6,880.00" "$3,870.00" "$3,870.00" $0.00 $0.00 $0.00 "$1,792.46" "$4,181.12" "$4,181.12" "$6,628.88" $0.00 "$1,792.24" $0.00 "$4,239.80" "$4,239.80" $0.00 "$4,300.00" "$6,811.20" "$6,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500421 EAP HCPCS C1722 Defibrillator Cardiac .99cm 5.37x7.79cm 1 Chamber Is-1 Df-4 BOTH IP/OP "$33,750.00 " "$24,975.00" $0.00 "$27,000.00" "$15,187.50" "$15,187.50" $0.00 $0.00 $0.00 "$7,034.34" "$4,181.12" "$4,181.12" "$26,014.50" $0.00 "$7,033.50" $0.00 "$16,638.75" "$16,638.75" $0.00 "$16,875.00" "$26,730.00" "$27,000.00" $0.00 $0.00 $0.00 "$5,281.88" $0.00 $0.00 "$5,373.00" $0.00 $0.00 $0.00 $0.00 $0.00 27500422 EAP HCPCS C1721 Defibrillator Cardiac .99cm 5.37x7.68cm 2 Chamber Extend BOTH IP/OP "$37,500.00 " "$27,750.00" $0.00 "$30,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$7,815.94" "$4,181.12" "$4,181.12" "$28,905.00" $0.00 "$7,815.00" $0.00 "$18,487.50" "$18,487.50" $0.00 "$18,750.00" "$29,700.00" "$30,000.00" $0.00 "$16,875.00" $0.00 "$5,868.75" $0.00 $0.00 "$5,970.00" $0.00 $0.00 $0.00 $0.00 $0.00 27500423 EAP HCPCS C1721 Defibrillator Cardiac .99cm 5.37x7.79cm 2 Chamber Extend BOTH IP/OP "$37,500.00 " "$27,750.00" $0.00 "$30,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$7,815.94" "$4,181.12" "$4,181.12" "$28,905.00" $0.00 "$7,815.00" $0.00 "$18,487.50" "$18,487.50" $0.00 "$18,750.00" "$29,700.00" "$30,000.00" $0.00 $0.00 $0.00 "$5,868.75" $0.00 $0.00 "$5,970.00" $0.00 $0.00 $0.00 $0.00 $0.00 27500424 EAP HCPCS C1882 Defibrillator Cardiac .99cm 5.37x8.08cm Is-1 Df-1 Lv-1 BOTH IP/OP "$44,750.00 " "$33,115.00" $0.00 "$35,800.00" "$20,137.50" "$20,137.50" $0.00 $0.00 $0.00 "$9,327.02" "$4,181.12" "$4,181.12" "$34,493.30" $0.00 "$9,325.90" $0.00 "$22,061.75" "$22,061.75" $0.00 "$22,375.00" "$35,442.00" "$35,800.00" $0.00 $0.00 $0.00 "$7,003.38" $0.00 $0.00 "$7,124.20" $0.00 $0.00 $0.00 $0.00 $0.00 27500425 EAP HCPCS C1893 Acuity Pro Implant Tools/lead Delivery System BOTH IP/OP "$15,250.00 " "$11,285.00" $0.00 "$12,200.00" "$6,862.50" "$6,862.50" $0.00 $0.00 $0.00 "$3,178.48" "$4,181.12" "$4,181.12" "$11,754.70" $0.00 "$3,178.10" $0.00 "$7,518.25" "$7,518.25" $0.00 "$7,625.00" "$12,078.00" "$12,200.00" $0.00 $0.00 $0.00 "$2,386.63" $0.00 $0.00 "$2,427.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500426 EAP HCPCS C2621 Pacemaker Cardiac 3d .75cm 16.2cu Cm Spiral 2.6fr 4.45x6.13 BOTH IP/OP "$15,250.00 " "$11,285.00" $0.00 "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,754.70" $0.00 "$3,178.10" $0.00 $0.00 $0.00 $0.00 "$7,625.00" "$12,078.00" "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500427 EAP HCPCS C1882 Defibrillator Cardiac .99in Mini 5.37x8.18cm Is-1 Df-4 Is-4 BOTH IP/OP "$44,750.00 " "$33,115.00" $0.00 "$35,800.00" "$20,137.50" "$20,137.50" $0.00 $0.00 $0.00 "$9,327.02" "$4,181.12" "$4,181.12" "$34,493.30" $0.00 "$9,325.90" $0.00 "$22,061.75" "$22,061.75" $0.00 "$22,375.00" "$35,442.00" "$35,800.00" $0.00 $0.00 $0.00 "$7,003.38" $0.00 $0.00 "$7,124.20" $0.00 $0.00 $0.00 $0.00 $0.00 27500428 EAP HCPCS C1882 Defibrillator Cardiac .99in Mini 5.37x8.08cm Is-1 Df-1 Is-4 BOTH IP/OP "$44,750.00 " "$33,115.00" $0.00 "$35,800.00" "$20,137.50" "$20,137.50" $0.00 $0.00 $0.00 "$9,327.02" "$4,181.12" "$4,181.12" "$34,493.30" $0.00 "$9,325.90" $0.00 "$22,061.75" "$22,061.75" $0.00 "$22,375.00" "$35,442.00" "$35,800.00" $0.00 $0.00 $0.00 "$7,003.38" $0.00 $0.00 "$7,124.20" $0.00 $0.00 $0.00 $0.00 $0.00 27500429 EAP HCPCS C1900 Lead Pacing X4 95 Cmconctr Acuity Left Ventricle Spiral L BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 $0.00 "$1,056.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500430 EAP HCPCS C1900 Lead Pacing X4 86cm Conctr Acuity Left Ventricle Spiral L BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 $0.00 "$1,056.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500431 EAP HCPCS C1900 Lead Pacing X4 95cm Conctr Acuity Left Ventricle Straight BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 $0.00 "$1,056.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500432 EAP HCPCS C1900 Lead Pacing X4 86 Cm Conctr Acuity Left Ventricle Spiral S BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 "$3,037.50" $0.00 "$1,056.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500433 EAP HCPCS C1900 Lead Pacing X4 95 Cm Conctr Acuity Left Ventricle Spiral S BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 $0.00 "$1,056.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500434 EAP HCPCS C1900 Lead Pacing X4 86 Cm Conctr Acuity Left Ventricle Straight BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 $0.00 "$1,056.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500435 EAP HCPCS C1882 Inventra 7 Vr-t Dx BOTH IP/OP "$49,688.00 " "$36,769.12" $0.00 "$39,750.40" "$22,359.60" "$22,359.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,299.51" $0.00 "$10,354.98" $0.00 "$24,496.18" "$24,496.18" $0.00 "$24,844.00" "$39,352.90" "$39,750.40" $0.00 "$22,359.60" $0.00 "$7,751.33" $0.00 $0.00 "$7,910.33" $0.00 $0.00 $0.00 $0.00 $0.00 27500440 EAP HCPCS C1785 Pacemaker Crd Promri 2 Chmbr Eluna Dr-t BOTH IP/OP "$14,000.00 " "$10,360.00" $0.00 "$11,200.00" "$6,300.00" "$6,300.00" $0.00 $0.00 $0.00 "$2,917.95" "$4,181.12" "$4,181.12" "$10,791.20" $0.00 "$2,917.60" $0.00 "$6,902.00" "$6,902.00" $0.00 "$7,000.00" "$11,088.00" "$11,200.00" $0.00 $0.00 $0.00 "$2,191.00" $0.00 $0.00 "$2,228.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500441 EAP HCPCS C1785 Pacemaker Crd Promri Eluna Dr-t Lead Cllr Home BOTH IP/OP "$16,500.00 " "$12,210.00" $0.00 "$13,200.00" "$7,425.00" "$7,425.00" $0.00 $0.00 $0.00 "$3,439.01" "$4,181.12" "$4,181.12" "$12,718.20" $0.00 "$3,438.60" $0.00 "$8,134.50" "$8,134.50" $0.00 "$8,250.00" "$13,068.00" "$13,200.00" $0.00 $0.00 $0.00 "$2,582.25" $0.00 $0.00 "$2,626.80" $0.00 $0.00 $0.00 $0.00 $0.00 27500442 EAP HCPCS C1786 Pacemaker Crd Eluna Sr-t Promri BOTH IP/OP "$12,125.00 " "$8,972.50" $0.00 "$9,700.00" "$5,456.25" "$5,456.25" $0.00 $0.00 $0.00 "$2,527.15" "$4,181.12" "$4,181.12" "$9,345.95" $0.00 "$2,526.85" $0.00 "$5,977.63" "$5,977.63" $0.00 "$6,062.50" "$9,603.00" "$9,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27500443 EAP HCPCS C1786 Pacemaker Crd Promri Eluna Sr-t Lead Cllr Home BOTH IP/OP "$13,250.00 " "$9,805.00" $0.00 "$10,600.00" "$5,962.50" "$5,962.50" $0.00 $0.00 $0.00 "$2,761.63" "$4,181.12" "$4,181.12" "$10,213.10" $0.00 "$2,761.30" $0.00 "$6,532.25" "$6,532.25" $0.00 "$6,625.00" "$10,494.00" "$10,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503012 EAP HCPCS C1785 "Altrua 60 Pmkr, Dual, Rate-resp" BOTH IP/OP "$12,375.00 " "$9,157.50" $0.00 "$9,900.00" "$5,568.75" "$5,568.75" $0.00 $0.00 $0.00 "$2,579.26" "$4,181.12" "$4,181.12" "$9,538.65" $0.00 "$2,578.95" $0.00 "$6,100.88" "$6,100.88" $0.00 "$6,187.50" "$9,801.00" "$9,900.00" $0.00 $0.00 $0.00 "$1,936.69" $0.00 $0.00 "$1,970.10" $0.00 $0.00 $0.00 $0.00 $0.00 27503013 EAP HCPCS C1786 "Altrua Pmkr, Single, Rate-resp" BOTH IP/OP "$10,553.00 " "$7,809.22" $0.00 "$8,442.40" "$4,748.85" "$4,748.85" $0.00 $0.00 $0.00 "$2,199.51" "$4,181.12" "$4,181.12" "$8,134.25" $0.00 "$2,199.25" $0.00 "$5,202.63" "$5,202.63" $0.00 "$5,276.50" "$8,357.98" "$8,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503014 EAP HCPCS C1721 Energen Dr Aicd Dual Chamber BOTH IP/OP "$46,552.00 " "$34,448.48" $0.00 "$37,241.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,882.28" $0.00 "$9,701.44" $0.00 "$22,950.14" "$22,950.14" $0.00 "$23,276.00" "$36,869.18" "$37,241.60" $0.00 $0.00 $0.00 "$7,285.39" $0.00 $0.00 "$7,411.08" $0.00 $0.00 $0.00 $0.00 $0.00 27503015 EAP HCPCS C1722 Energen Vr Aicd Single Chamber BOTH IP/OP "$38,792.00 " "$28,706.08" $0.00 "$31,033.60" "$17,456.40" "$17,456.40" $0.00 $0.00 $0.00 "$8,085.22" "$4,181.12" "$4,181.12" "$29,900.87" $0.00 "$8,084.25" $0.00 "$19,124.46" "$19,124.46" $0.00 "$19,396.00" "$30,723.26" "$31,033.60" $0.00 $0.00 $0.00 "$6,070.95" $0.00 $0.00 "$6,175.69" $0.00 $0.00 $0.00 $0.00 $0.00 27503016 EAP HCPCS C1895 "Reliance Gore Lead,aicd, Endo Dual Coil" BOTH IP/OP "$13,964.00 " "$10,333.36" $0.00 "$11,171.20" "$6,283.80" "$6,283.80" $0.00 $0.00 $0.00 "$2,910.45" "$4,181.12" "$4,181.12" "$10,763.45" $0.00 "$2,910.10" $0.00 "$6,884.25" "$6,884.25" $0.00 "$6,982.00" "$11,059.49" "$11,171.20" $0.00 $0.00 $0.00 "$2,185.37" $0.00 $0.00 "$2,223.07" $0.00 $0.00 $0.00 $0.00 $0.00 27503017 EAP HCPCS C2621 Contak Renewal Tr Crt-p BOTH IP/OP "$19,861.00 " "$14,697.14" $0.00 "$15,888.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,308.86" $0.00 "$4,139.03" $0.00 $0.00 $0.00 $0.00 "$9,930.50" "$15,729.91" "$15,888.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503018 EAP HCPCS C1900 "Acuity Steerable Lead, Coronary Venous" BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503019 EAP HCPCS C1900 "Acuity Spiral Lead,coronary Venous" BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503020 EAP HCPCS C1900 "Easytrak 2 Lead,coronary Venous" BOTH IP/OP "$4,656.00 " "$3,445.44" $0.00 "$3,724.80" "$2,095.20" "$2,095.20" $0.00 $0.00 $0.00 $970.43 "$3,455.68" "$3,455.68" "$3,588.84" $0.00 $970.31 $0.00 "$2,295.41" "$2,295.41" $0.00 "$2,328.00" "$3,687.55" "$3,724.80" $0.00 $0.00 $0.00 $728.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503021 EAP HCPCS C1900 "Easytrak 3 Lead,coronary Venous" BOTH IP/OP "$4,656.00 " "$3,445.44" $0.00 "$3,724.80" "$2,095.20" "$2,095.20" $0.00 $0.00 $0.00 $970.43 "$3,455.68" "$3,455.68" "$3,588.84" $0.00 $970.31 $0.00 "$2,295.41" "$2,295.41" $0.00 "$2,328.00" "$3,687.55" "$3,724.80" $0.00 $0.00 $0.00 $728.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503022 EAP HCPCS C1721 Fortify Dr Aicd Dual Chamber BOTH IP/OP "$64,394.00 " "$47,651.56" $0.00 "$51,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$49,634.90" $0.00 "$13,419.71" $0.00 "$31,746.24" "$31,746.24" $0.00 "$32,197.00" "$51,000.05" "$51,515.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503023 EAP HCPCS C1785 Accent Dr BOTH IP/OP "$17,142.00 " "$12,685.08" $0.00 "$13,713.60" "$7,713.90" "$7,713.90" $0.00 $0.00 $0.00 "$3,572.82" "$4,181.12" "$4,181.12" "$13,213.05" $0.00 "$3,572.39" $0.00 "$8,451.01" "$8,451.01" $0.00 "$8,571.00" "$13,576.46" "$13,713.60" $0.00 $0.00 $0.00 "$2,682.72" $0.00 $0.00 "$2,729.01" $0.00 $0.00 $0.00 $0.00 $0.00 27503024 EAP HCPCS C1786 Accent Sr BOTH IP/OP "$1,566.00 " "$1,158.84" $0.00 "$1,252.80" $704.70 $704.70 $0.00 $0.00 $0.00 $326.39 "$1,162.29" "$1,162.29" "$1,207.07" $0.00 $326.35 $0.00 $926.29 $926.29 $0.00 $783.00 "$1,240.27" "$1,252.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503025 EAP HCPCS C1898 Tendril Sts 2088tc/46 BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $665.10 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503028 EAP HCPCS C1721 Fortify Assura Dr 40 BOTH IP/OP "$61,328.00 " "$45,382.72" $0.00 "$49,062.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,271.62" $0.00 "$12,780.76" $0.00 "$30,234.70" "$30,234.70" $0.00 "$30,664.00" "$48,571.78" "$49,062.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503029 EAP HCPCS C1721 Fortify Assura Dr 40 Df4 Connector BOTH IP/OP "$61,328.00 " "$45,382.72" $0.00 "$49,062.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,271.62" $0.00 "$12,780.76" $0.00 "$30,234.70" "$30,234.70" $0.00 "$30,664.00" "$48,571.78" "$49,062.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503030 EAP HCPCS C1721 Ellipse Dr 36 BOTH IP/OP "$61,328.00 " "$45,382.72" $0.00 "$49,062.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,271.62" $0.00 "$12,780.76" $0.00 "$30,234.70" "$30,234.70" $0.00 "$30,664.00" "$48,571.78" "$49,062.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503031 EAP HCPCS C1722 Ellipse Dr 36 Df4 Connector BOTH IP/OP "$61,328.00 " "$45,382.72" $0.00 "$49,062.40" "$27,597.60" "$27,597.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,271.62" $0.00 "$12,780.76" $0.00 "$30,234.70" "$30,234.70" $0.00 "$30,664.00" "$48,571.78" "$49,062.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503032 EAP HCPCS C1722 Fortify Assura Vr 40 BOTH IP/OP "$53,200.00 " "$39,368.00" $0.00 "$42,560.00" "$23,940.00" "$23,940.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,006.56" $0.00 "$11,086.88" $0.00 "$26,227.60" "$26,227.60" $0.00 "$26,600.00" "$42,134.40" "$42,560.00" $0.00 "$23,940.00" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503033 EAP HCPCS C1722 Fortify Assura Vr 40 Df4 Connector BOTH IP/OP "$53,200.00 " "$39,368.00" $0.00 "$42,560.00" "$23,940.00" "$23,940.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,006.56" $0.00 "$11,086.88" $0.00 "$26,227.60" "$26,227.60" $0.00 "$26,600.00" "$42,134.40" "$42,560.00" $0.00 "$23,940.00" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503034 EAP HCPCS C1722 Ellipse Vr 36 BOTH IP/OP "$53,200.00 " "$39,368.00" $0.00 "$42,560.00" "$23,940.00" "$23,940.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,006.56" $0.00 "$11,086.88" $0.00 "$26,227.60" "$26,227.60" $0.00 "$26,600.00" "$42,134.40" "$42,560.00" $0.00 "$23,940.00" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503035 EAP HCPCS C1722 Ellipse Vr 36 Df4 Connector BOTH IP/OP "$53,200.00 " "$39,368.00" $0.00 "$42,560.00" "$23,940.00" "$23,940.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,006.56" $0.00 "$11,086.88" $0.00 "$26,227.60" "$26,227.60" $0.00 "$26,600.00" "$42,134.40" "$42,560.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503036 EAP HCPCS C1882 Quadra Assura Crt-d 40 BOTH IP/OP "$8,512.00 " "$6,298.88" $0.00 "$6,809.60" "$3,830.40" "$3,830.40" $0.00 $0.00 $0.00 "$1,774.11" "$4,181.12" "$4,181.12" "$6,561.05" $0.00 "$1,773.90" $0.00 "$4,196.42" "$4,196.42" $0.00 "$4,256.00" "$6,741.50" "$6,809.60" $0.00 $0.00 $0.00 "$1,332.13" $0.00 $0.00 "$1,355.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503037 EAP HCPCS C1882 Quadra Assura Crt-d 40 Df4 Connector BOTH IP/OP "$85,120.00 " "$62,988.80" $0.00 "$68,096.00" "$38,304.00" "$38,304.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$65,610.50" $0.00 "$17,739.01" $0.00 "$41,964.16" "$41,964.16" $0.00 "$42,560.00" "$67,415.04" "$68,096.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503038 EAP HCPCS C1882 Unify Assura Crt-d 40 BOTH IP/OP "$85,120.00 " "$62,988.80" $0.00 "$68,096.00" "$38,304.00" "$38,304.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$65,610.50" $0.00 "$17,739.01" $0.00 "$41,964.16" "$41,964.16" $0.00 "$42,560.00" "$67,415.04" "$68,096.00" $0.00 "$38,304.00" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503039 EAP HCPCS C1882 Unify Assura Crt-d 40 Df4 Connector BOTH IP/OP "$85,120.00 " "$62,988.80" $0.00 "$68,096.00" "$38,304.00" "$38,304.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$65,610.50" $0.00 "$17,739.01" $0.00 "$41,964.16" "$41,964.16" $0.00 "$42,560.00" "$67,415.04" "$68,096.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503040 EAP HCPCS C1898 Tendril Sts 2088tc/65 BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503041 EAP HCPCS C1898 Tendril Sts 2088tc/100 BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503042 EAP HCPCS C1785 "Adapta Vdd, Is-i" BOTH IP/OP "$4,729.00 " "$3,499.46" $0.00 "$3,783.20" "$2,128.05" "$2,128.05" $0.00 $0.00 $0.00 $985.64 "$3,509.86" "$3,509.86" "$3,645.11" $0.00 $985.52 $0.00 "$2,331.40" "$2,331.40" $0.00 "$2,364.50" "$3,745.37" "$3,783.20" $0.00 $0.00 $0.00 $740.09 $0.00 $0.00 $752.86 $0.00 $0.00 $0.00 $0.00 $0.00 27503043 EAP HCPCS C1898 Capsure Vdd2 Lead 5038s-52 BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $372.60 $372.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $638.22 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $372.60 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 27503044 EAP HCPCS C1898 Capsure Vdd2 Lead 5032s-58 BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $372.60 $372.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $638.22 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 27503045 EAP HCPCS C1898 Capsure Vdd2 Lead 50038-58 BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $372.60 $372.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $638.22 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 27503046 EAP HCPCS C1898 Capsure Vdd2 Lead 5038-65 BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $372.60 $372.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $638.22 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 27503050 EAP HCPCS C1785 Accent Dr Pacemaker Generator BOTH IP/OP "$17,142.00 " "$12,685.08" $0.00 "$13,713.60" "$7,713.90" "$7,713.90" $0.00 $0.00 $0.00 "$3,572.82" "$4,181.12" "$4,181.12" "$13,213.05" $0.00 "$3,572.39" $0.00 "$8,451.01" "$8,451.01" $0.00 "$8,571.00" "$13,576.46" "$13,713.60" $0.00 "$7,713.90" $0.00 "$2,682.72" $0.00 $0.00 "$2,729.01" $0.00 $0.00 $0.00 $0.00 $0.00 27503051 EAP HCPCS C1786 Accent Sr Pacemaker Generator BOTH IP/OP "$15,665.00 " "$11,592.10" $0.00 "$12,532.00" "$7,049.25" "$7,049.25" $0.00 $0.00 $0.00 "$3,264.98" "$4,181.12" "$4,181.12" "$12,074.58" $0.00 "$3,264.59" $0.00 "$7,722.85" "$7,722.85" $0.00 "$7,832.50" "$12,406.68" "$12,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503052 EAP HCPCS C1898 Tendril Sts 2088tc/46 Lead/electrode/access BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $665.10 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503053 EAP HCPCS C1898 Tendril Sts 2088tc/52 Lead/electrode/access BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $665.10 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503055 EAP HCPCS C1721 Fortify Assura Dr 40 Df4 Connector Icd/defib/resync BOTH IP/OP "$61,328.00 " "$45,382.72" $0.00 "$49,062.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,271.62" $0.00 "$12,780.76" $0.00 "$30,234.70" "$30,234.70" $0.00 "$30,664.00" "$48,571.78" "$49,062.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503056 EAP HCPCS C1721 Fortify Assura Dr 40 Df4 Connector Icd/defib/resync BOTH IP/OP "$61,328.00 " "$45,382.72" $0.00 "$49,062.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,271.62" $0.00 "$12,780.76" $0.00 "$30,234.70" "$30,234.70" $0.00 "$30,664.00" "$48,571.78" "$49,062.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503057 EAP HCPCS C1721 Ellipse Dr 36 Df4 Connector Icd/defib/resync BOTH IP/OP "$61,328.00 " "$45,382.72" $0.00 "$49,062.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,271.62" $0.00 "$12,780.76" $0.00 "$30,234.70" "$30,234.70" $0.00 "$30,664.00" "$48,571.78" "$49,062.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503058 EAP HCPCS C1721 Ellipse Dr 36 Df4 Connector Icd/defib/resync BOTH IP/OP "$61,328.00 " "$45,382.72" $0.00 "$49,062.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,271.62" $0.00 "$12,780.76" $0.00 "$30,234.70" "$30,234.70" $0.00 "$30,664.00" "$48,571.78" "$49,062.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503059 EAP HCPCS C1722 Fortify Assura Vr 40 Df4 Connector Icd/defib/resync BOTH IP/OP "$53,200.00 " "$39,368.00" $0.00 "$42,560.00" "$23,940.00" "$23,940.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,006.56" $0.00 "$11,086.88" $0.00 "$26,227.60" "$26,227.60" $0.00 "$26,600.00" "$42,134.40" "$42,560.00" $0.00 "$23,940.00" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503060 EAP HCPCS C1722 Fortify Assura Vr 40 Df4 Connector Icd/defib/resync BOTH IP/OP "$53,200.00 " "$39,368.00" $0.00 "$42,560.00" "$23,940.00" "$23,940.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,006.56" $0.00 "$11,086.88" $0.00 "$26,227.60" "$26,227.60" $0.00 "$26,600.00" "$42,134.40" "$42,560.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503061 EAP HCPCS C1722 Ellipse Vr 36 Df4 Connector Icd/defib/resync BOTH IP/OP "$53,200.00 " "$39,368.00" $0.00 "$42,560.00" "$23,940.00" "$23,940.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,006.56" $0.00 "$11,086.88" $0.00 "$26,227.60" "$26,227.60" $0.00 "$26,600.00" "$42,134.40" "$42,560.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503062 EAP HCPCS C1722 Ellipse Vr 36 Df4 Connector Icd/defib/resync BOTH IP/OP "$53,200.00 " "$39,368.00" $0.00 "$42,560.00" "$23,940.00" "$23,940.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,006.56" $0.00 "$11,086.88" $0.00 "$26,227.60" "$26,227.60" $0.00 "$26,600.00" "$42,134.40" "$42,560.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503063 EAP HCPCS C1882 Quadra Assura Crt-d 40 Df4 Connector Icd/defib/resync BOTH IP/OP "$8,512.00 " "$6,298.88" $0.00 "$6,809.60" "$3,830.40" "$3,830.40" $0.00 $0.00 $0.00 "$1,774.11" "$4,181.12" "$4,181.12" "$6,561.05" $0.00 "$1,773.90" $0.00 "$4,196.42" "$4,196.42" $0.00 "$4,256.00" "$6,741.50" "$6,809.60" $0.00 $0.00 $0.00 "$1,332.13" $0.00 $0.00 "$1,355.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503064 EAP HCPCS C1882 Quadra Assura Crt-d 40 Df4 Connector Icd/defib/resync BOTH IP/OP "$85,120.00 " "$62,988.80" $0.00 "$68,096.00" "$38,304.00" "$38,304.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$65,610.50" $0.00 "$17,739.01" $0.00 "$41,964.16" "$41,964.16" $0.00 "$42,560.00" "$67,415.04" "$68,096.00" $0.00 "$38,304.00" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503065 EAP HCPCS C1882 Unify Assura Crt-d 40 Df4 Connector Icd/defib/resync BOTH IP/OP "$85,120.00 " "$62,988.80" $0.00 "$68,096.00" "$38,304.00" "$38,304.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$65,610.50" $0.00 "$17,739.01" $0.00 "$41,964.16" "$41,964.16" $0.00 "$42,560.00" "$67,415.04" "$68,096.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503066 EAP HCPCS C1882 Unify Assura Crt-d 40 Df4 Connector Icd/defib/resync BOTH IP/OP "$85,120.00 " "$62,988.80" $0.00 "$68,096.00" "$38,304.00" "$38,304.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$65,610.50" $0.00 "$17,739.01" $0.00 "$41,964.16" "$41,964.16" $0.00 "$42,560.00" "$67,415.04" "$68,096.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503067 EAP HCPCS C1898 Tendril Sts 2088tc/100 Lead/electrode/access BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503068 EAP HCPCS C1898 Tendril Sts 2088tc/65 Lead/electrode/access BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503070 EAP HCPCS C1898 Lead 4076110 Pkg Assy Lead 4076 Mdt Us BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503071 EAP HCPCS C1898 Lead 407625 Pkg Assy Lead 4076 Mdt Us M BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503072 EAP HCPCS C1898 Lead 407635 Capsurefix Novus BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503073 EAP HCPCS C1898 Lead 407645 Pkg Assy Lead 4076 Mdt Us M BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503074 EAP HCPCS C1898 Lead 407652 Pkg Assy Lead 4076 Mdt Us M BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503075 EAP HCPCS C1898 Lead 407658 Pkg Assy Lead 4076 Mdt Us M BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503076 EAP HCPCS C1898 Lead 407665 Capsurefix Novus BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $665.10 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503077 EAP HCPCS C1898 Lead 407685 Capsurefix Novus BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503081 EAP HCPCS C1898 Lead 5076-35 Lead-bipolar Sil Screw-in BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $665.10 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503082 EAP HCPCS C1898 Lead 5076-65 Lead-bipolar Sil Screw-in BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $665.10 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503083 EAP HCPCS C1898 Lead 5076-85 Lead-bipolar Sil Screw-in BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $665.10 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503084 EAP HCPCS C1898 Lead 5076110 Capsurefix Novus Pacing BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $665.10 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27503085 EAP HCPCS C1895 Lead 6947100 Lead-quadripolar Rv/svc 10 BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27503086 EAP HCPCS C1895 Lead 694758 Lead-quadripolar Rv/svc 58c BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27503087 EAP HCPCS C1895 Lead 694765 Sprint Quad Can Rv/svc BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27503088 EAP HCPCS C1895 Lead 694775 Lead-quadripolar Rv/svc 75c BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27503089 EAP HCPCS C1895 Lead 6947m55 Df4 Active Dc Sprint 55 Cm BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 "$5,319.90" $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27503090 EAP HCPCS C1895 Lead 6947m62 Df4 Active Dc Sprint 62 Cm BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 "$5,319.90" $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27503091 EAP HCPCS C1895 Lead 6947m72 Df4 Active Dc Sprint 72 Cm BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27503092 EAP HCPCS C1895 Lead 6947m97 Df4 Active Dc Sprint 97 Cm BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27503093 EAP HCPCS C1786 Pacemaker Single Chamber Adapta Sr BOTH IP/OP "$10,344.00 " "$7,654.56" $0.00 "$8,275.20" "$4,654.80" "$4,654.80" $0.00 $0.00 $0.00 "$2,155.95" "$4,181.12" "$4,181.12" "$7,973.16" $0.00 "$2,155.69" $0.00 "$5,099.59" "$5,099.59" $0.00 "$5,172.00" "$8,192.45" "$8,275.20" $0.00 "$4,654.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503094 EAP HCPCS C1882 Generator Crt-d Maximo Ii BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503095 EAP HCPCS C1721 Icd Dual Chamber Maximo Ii Dr BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503096 EAP HCPCS C1721 Dfbr Crd Mxmo 2 Vr Impltable Cardvrt Sys BOTH IP/OP "$38,422.00 " "$28,432.28" $0.00 "$30,737.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,008.11" "$4,181.12" "$4,181.12" "$29,615.68" $0.00 "$8,007.14" $0.00 "$18,942.05" "$18,942.05" $0.00 "$19,211.00" "$30,430.22" "$30,737.60" $0.00 $0.00 $0.00 "$6,013.04" $0.00 $0.00 "$6,116.78" $0.00 $0.00 $0.00 $0.00 $0.00 27503097 EAP HCPCS C1900 Philos Dr BOTH IP/OP "$8,572.00 " "$6,343.28" $0.00 "$6,857.60" "$3,857.40" "$3,857.40" $0.00 $0.00 $0.00 "$1,786.62" "$4,181.12" "$4,181.12" "$6,607.30" $0.00 "$1,786.40" $0.00 "$4,226.00" "$4,226.00" $0.00 "$4,286.00" "$6,789.02" "$6,857.60" $0.00 $0.00 $0.00 "$1,341.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503098 EAP HCPCS C1900 Philos Sr BOTH IP/OP "$8,276.00 " "$6,124.24" $0.00 "$6,620.80" "$3,724.20" "$3,724.20" $0.00 $0.00 $0.00 "$1,724.93" "$4,181.12" "$4,181.12" "$6,379.14" $0.00 "$1,724.72" $0.00 "$4,080.07" "$4,080.07" $0.00 "$4,138.00" "$6,554.59" "$6,620.80" $0.00 $0.00 $0.00 "$1,295.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503099 EAP HCPCS C1900 Philos Dr System BOTH IP/OP "$10,049.00 " "$7,436.26" $0.00 "$8,039.20" "$4,522.05" "$4,522.05" $0.00 $0.00 $0.00 "$2,094.46" "$4,181.12" "$4,181.12" "$7,745.77" $0.00 "$2,094.21" $0.00 "$4,954.16" "$4,954.16" $0.00 "$5,024.50" "$7,958.81" "$8,039.20" $0.00 $0.00 $0.00 "$1,572.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503100 EAP HCPCS C1900 Philos Sr System BOTH IP/OP "$9,458.00 " "$6,998.92" $0.00 "$7,566.40" "$4,256.10" "$4,256.10" $0.00 $0.00 $0.00 "$1,971.28" "$4,181.12" "$4,181.12" "$7,290.23" $0.00 "$1,971.05" $0.00 "$4,662.79" "$4,662.79" $0.00 "$4,729.00" "$7,490.74" "$7,566.40" $0.00 $0.00 $0.00 "$1,480.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503101 EAP HCPCS C1900 Arox 60 Bp Lead BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503102 EAP HCPCS C1900 Arox 53 Bp Lead BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503103 EAP HCPCS C1898 Selox St 53 Lead BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27503104 EAP HCPCS C1898 Selox St 60 Lead BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27503105 EAP HCPCS C1898 Selox Jt 53 Lead BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27503106 EAP HCPCS C1898 Selox Jt 45 Lead BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27503107 EAP HCPCS C1900 Philos Ii Dr System BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503108 EAP HCPCS C1900 Cylos Dr With Cls Autonomic Response BOTH IP/OP "$10,049.00 " "$7,436.26" $0.00 "$8,039.20" "$4,522.05" "$4,522.05" $0.00 $0.00 $0.00 "$2,094.46" "$4,181.12" "$4,181.12" "$7,745.77" $0.00 "$2,094.21" $0.00 "$4,954.16" "$4,954.16" $0.00 "$5,024.50" "$7,958.81" "$8,039.20" $0.00 $0.00 $0.00 "$1,572.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503109 EAP HCPCS C1900 Cylos Vr With Cls Autonomic Response BOTH IP/OP "$10,049.00 " "$7,436.26" $0.00 "$8,039.20" "$4,522.05" "$4,522.05" $0.00 $0.00 $0.00 "$2,094.46" "$4,181.12" "$4,181.12" "$7,745.77" $0.00 "$2,094.21" $0.00 "$4,954.16" "$4,954.16" $0.00 "$5,024.50" "$7,958.81" "$8,039.20" $0.00 $0.00 $0.00 "$1,572.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503110 EAP HCPCS C1895 Linox Sd Steroid 65/16 BOTH IP/OP "$8,867.00 " "$6,561.58" $0.00 "$7,093.60" "$3,990.15" "$3,990.15" $0.00 $0.00 $0.00 "$1,848.10" "$4,181.12" "$4,181.12" "$6,834.68" $0.00 "$1,847.88" $0.00 "$4,371.43" "$4,371.43" $0.00 "$4,433.50" "$7,022.66" "$7,093.60" $0.00 $0.00 $0.00 "$1,387.69" $0.00 $0.00 "$1,411.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503111 EAP HCPCS C1895 Linox Sd Steroid 75/18 BOTH IP/OP "$8,867.00 " "$6,561.58" $0.00 "$7,093.60" "$3,990.15" "$3,990.15" $0.00 $0.00 $0.00 "$1,848.10" "$4,181.12" "$4,181.12" "$6,834.68" $0.00 "$1,847.88" $0.00 "$4,371.43" "$4,371.43" $0.00 "$4,433.50" "$7,022.66" "$7,093.60" $0.00 $0.00 $0.00 "$1,387.69" $0.00 $0.00 "$1,411.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503112 EAP HCPCS C1898 Setrox S 53 Lead BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27503113 EAP HCPCS C1898 Setrox S 60 Lead BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27503114 EAP HCPCS C1777 Linox S 65 Steroid BOTH IP/OP "$8,867.00 " "$6,561.58" $0.00 "$7,093.60" "$3,990.15" "$3,990.15" $0.00 $0.00 $0.00 "$1,848.10" "$4,181.12" "$4,181.12" "$6,834.68" $0.00 "$1,847.88" $0.00 "$4,371.43" "$4,371.43" $0.00 "$4,433.50" "$7,022.66" "$7,093.60" $0.00 $0.00 $0.00 "$1,387.69" $0.00 $0.00 "$1,411.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503115 EAP HCPCS C1777 Linox S 75 Steroid BOTH IP/OP "$8,867.00 " "$6,561.58" $0.00 "$7,093.60" "$3,990.15" "$3,990.15" $0.00 $0.00 $0.00 "$1,848.10" "$4,181.12" "$4,181.12" "$6,834.68" $0.00 "$1,847.88" $0.00 "$4,371.43" "$4,371.43" $0.00 "$4,433.50" "$7,022.66" "$7,093.60" $0.00 $0.00 $0.00 "$1,387.69" $0.00 $0.00 "$1,411.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503116 EAP HCPCS C1895 Linox Td Steroid 65/16 Cm BOTH IP/OP "$8,867.00 " "$6,561.58" $0.00 "$7,093.60" "$3,990.15" "$3,990.15" $0.00 $0.00 $0.00 "$1,848.10" "$4,181.12" "$4,181.12" "$6,834.68" $0.00 "$1,847.88" $0.00 "$4,371.43" "$4,371.43" $0.00 "$4,433.50" "$7,022.66" "$7,093.60" $0.00 $0.00 $0.00 "$1,387.69" $0.00 $0.00 "$1,411.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503117 EAP HCPCS C1777 Linox T 65 Steroid BOTH IP/OP "$8,867.00 " "$6,561.58" $0.00 "$7,093.60" "$3,990.15" "$3,990.15" $0.00 $0.00 $0.00 "$1,848.10" "$4,181.12" "$4,181.12" "$6,834.68" $0.00 "$1,847.88" $0.00 "$4,371.43" "$4,371.43" $0.00 "$4,433.50" "$7,022.66" "$7,093.60" $0.00 $0.00 $0.00 "$1,387.69" $0.00 $0.00 "$1,411.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503118 EAP HCPCS C1900 Corox Otw 75 Bp Lead BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503119 EAP HCPCS C1900 Corox Otw 85 Bp Lead BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503120 EAP HCPCS C1900 Corox Otw 75 Bp-s Lead BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503121 EAP HCPCS C1900 Corox Otw 85 Bp-s Lead BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503122 EAP HCPCS C1882 Lumax 340 Hf-t High Energy With Hm Landline BOTH IP/OP "$52,461.00 " "$38,821.14" $0.00 "$41,968.80" "$23,607.45" "$23,607.45" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$40,436.94" $0.00 "$10,932.87" $0.00 "$25,863.27" "$25,863.27" $0.00 "$26,230.50" "$41,549.11" "$41,968.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503123 EAP HCPCS C1900 Cylos Vr System With Cls Autonomic Response BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503124 EAP HCPCS C1721 Lumax 340 Dr-t High Energy With Hm Mobile Gsm BOTH IP/OP "$42,855.00 " "$31,712.70" $0.00 "$34,284.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,932.05" "$4,181.12" "$4,181.12" "$33,032.63" $0.00 "$8,930.98" $0.00 "$21,127.52" "$21,127.52" $0.00 "$21,427.50" "$33,941.16" "$34,284.00" $0.00 $0.00 $0.00 "$6,706.81" $0.00 $0.00 "$6,822.52" $0.00 $0.00 $0.00 $0.00 $0.00 27503125 EAP HCPCS C1721 Lumax 340 Dr-t High Energy System With Hm Mobile Gsm BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503126 EAP HCPCS C1721 Lumax 340 Dr-t High Energy System With Hm Landline BOTH IP/OP "$48,767.00 " "$36,087.58" $0.00 "$39,013.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$37,589.60" $0.00 "$10,163.04" $0.00 "$24,042.13" "$24,042.13" $0.00 "$24,383.50" "$38,623.46" "$39,013.60" $0.00 $0.00 $0.00 "$7,632.04" $0.00 $0.00 "$7,763.71" $0.00 $0.00 $0.00 $0.00 $0.00 27503127 EAP HCPCS C1882 Lumax 340 Hf-t High Energy With Hm Mobile Gsm BOTH IP/OP "$56,895.00 " "$42,102.30" $0.00 "$45,516.00" "$25,602.75" "$25,602.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$43,854.67" $0.00 "$11,856.92" $0.00 "$28,049.24" "$28,049.24" $0.00 "$28,447.50" "$45,060.84" "$45,516.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503128 EAP HCPCS C1882 Lumax 340 Hf-t High Energy System With Hm Mobile Gsm BOTH IP/OP "$74,628.00 " "$55,224.72" $0.00 "$59,702.40" "$33,582.60" "$33,582.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$57,523.26" $0.00 "$15,552.48" $0.00 "$36,791.60" "$36,791.60" $0.00 "$37,314.00" "$59,105.38" "$59,702.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503130 EAP HCPCS C1882 Lumax 340 Hf-t High Energy System With Hm Landline BOTH IP/OP "$68,716.00 " "$50,849.84" $0.00 "$54,972.80" "$30,922.20" "$30,922.20" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$52,966.29" $0.00 "$14,320.41" $0.00 "$33,876.99" "$33,876.99" $0.00 "$34,358.00" "$54,423.07" "$54,972.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503131 EAP HCPCS C1722 Lumax 340 Vr-t High Energy With Hm Mobile Gsm BOTH IP/OP "$35,467.00 " "$26,245.58" $0.00 "$28,373.60" "$15,960.15" "$15,960.15" $0.00 $0.00 $0.00 "$7,392.21" "$4,181.12" "$4,181.12" "$27,337.96" $0.00 "$7,391.32" $0.00 "$17,485.23" "$17,485.23" $0.00 "$17,733.50" "$28,089.86" "$28,373.60" $0.00 $0.00 $0.00 "$5,550.59" $0.00 $0.00 "$5,646.35" $0.00 $0.00 $0.00 $0.00 $0.00 27503132 EAP HCPCS C1772 Lumax 340 Vr-t High Energy System With Hm Mobile Gsm BOTH IP/OP "$44,334.00 " "$32,807.16" $0.00 "$35,467.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$34,172.65" $0.00 "$9,239.21" $0.00 $0.00 $0.00 $0.00 "$22,167.00" "$35,112.53" "$35,467.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503133 EAP HCPCS C1900 Arox 45 Jbp Lead BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503135 EAP HCPCS C1882 DEFIBRILLATOR CARDIAC 2.43X3.13IN COGNIS THK.39IN VENTRICULA BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503136 EAP HCPCS C1722 DFBR CRD THK1.1CM 6.3X7.1CM VTL 2VR HE 1 CHMBR IMPLTABLE 35 BOTH IP/OP "$33,989.00 " "$25,151.86" $0.00 "$27,191.20" "$15,295.05" "$15,295.05" $0.00 $0.00 $0.00 "$7,084.16" "$4,181.12" "$4,181.12" "$26,198.72" $0.00 "$7,083.31" $0.00 "$16,756.58" "$16,756.58" $0.00 "$16,994.50" "$26,919.29" "$27,191.20" $0.00 $0.00 $0.00 "$5,319.28" $0.00 $0.00 "$5,411.05" $0.00 $0.00 $0.00 $0.00 $0.00 27503137 EAP HCPCS C1722 DFBR CRD .99CM 6.17X7.45CM TELIGEN VR DF-1 IS-1 BIPHASIC BOTH IP/OP "$36,945.00 " "$27,339.30" $0.00 "$29,556.00" "$16,625.25" "$16,625.25" $0.00 $0.00 $0.00 "$7,700.26" "$4,181.12" "$4,181.12" "$28,477.21" $0.00 "$7,699.34" $0.00 "$18,213.89" "$18,213.89" $0.00 "$18,472.50" "$29,260.44" "$29,556.00" $0.00 $0.00 $0.00 "$5,781.89" $0.00 $0.00 "$5,881.64" $0.00 $0.00 $0.00 $0.00 $0.00 27503138 EAP HCPCS C1721 DFBR CRD TELIGEN DR HE DF-1 CONCTR NONPROGRAMMBALE CARDVRT BOTH IP/OP "$44,334.00 " "$32,807.16" $0.00 "$35,467.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,240.31" "$4,181.12" "$4,181.12" "$34,172.65" $0.00 "$9,239.21" $0.00 "$21,856.66" "$21,856.66" $0.00 "$22,167.00" "$35,112.53" "$35,467.20" $0.00 $0.00 $0.00 "$6,938.27" $0.00 $0.00 "$7,057.97" $0.00 $0.00 $0.00 $0.00 $0.00 27503139 EAP HCPCS C1722 DFBR CRD PUNCTUA VR ICD 1 CHMBR IMPLTABLE CARDVRT BOTH IP/OP "$33,989.00 " "$25,151.86" $0.00 "$27,191.20" "$15,295.05" "$15,295.05" $0.00 $0.00 $0.00 "$7,084.16" "$4,181.12" "$4,181.12" "$26,198.72" $0.00 "$7,083.31" $0.00 "$16,756.58" "$16,756.58" $0.00 "$16,994.50" "$26,919.29" "$27,191.20" $0.00 $0.00 $0.00 "$5,319.28" $0.00 $0.00 "$5,411.05" $0.00 $0.00 $0.00 $0.00 $0.00 27503140 EAP HCPCS C1772 DFBR CRD THK9.9MM 61.7MMX32.5MM PUNCTUA AV IMPLTABLE 2CH BOTH IP/OP "$36,945.00 " "$27,339.30" $0.00 "$29,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,477.21" $0.00 "$7,699.34" $0.00 $0.00 $0.00 $0.00 "$18,472.50" "$29,260.44" "$29,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503141 EAP HCPCS C1882 DFBR CRD PUNCTUA CRT-D RSYN THRP HI ENRG IMPLTABLE CARDVRT BOTH IP/OP "$50,244.00 " "$37,180.56" $0.00 "$40,195.20" "$22,609.80" "$22,609.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,728.08" $0.00 "$10,470.85" $0.00 "$24,770.29" "$24,770.29" $0.00 "$25,122.00" "$39,793.25" "$40,195.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,998.84" $0.00 $0.00 $0.00 $0.00 $0.00 27503142 EAP HCPCS C1882 DFBR CRD INCEPTA CRT-D IMPLTABLE CARDVRT HI ENRG DF1 IS1 PLS BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503143 EAP HCPCS C1722 DFBR CRD THK14.5MM 63.5X77.5MM LIVIAN RF IS-1 DF-1 IMPLTABLE BOTH IP/OP "$50,244.00 " "$37,180.56" $0.00 "$40,195.20" "$22,609.80" "$22,609.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,728.08" $0.00 "$10,470.85" $0.00 "$24,770.29" "$24,770.29" $0.00 "$25,122.00" "$39,793.25" "$40,195.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,998.84" $0.00 $0.00 $0.00 $0.00 $0.00 27503144 EAP HCPCS C1722 DFBR CRD THK14.5MM 63.5X77.5MM LIVIAN RF IMPLTABLE CRD RSYN BOTH IP/OP "$50,244.00 " "$37,180.56" $0.00 "$40,195.20" "$22,609.80" "$22,609.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,728.08" $0.00 "$10,470.85" $0.00 "$24,770.29" "$24,770.29" $0.00 "$25,122.00" "$39,793.25" "$40,195.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,998.84" $0.00 $0.00 $0.00 $0.00 $0.00 27503145 EAP HCPCS C1722 DFBR CRD THK14.5MM 67X82.5MM LIVIAN RF HE IMPLTABLE RSYN BOTH IP/OP "$50,244.00 " "$37,180.56" $0.00 "$40,195.20" "$22,609.80" "$22,609.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,728.08" $0.00 "$10,470.85" $0.00 "$24,770.29" "$24,770.29" $0.00 "$25,122.00" "$39,793.25" "$40,195.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,998.84" $0.00 $0.00 $0.00 $0.00 $0.00 27503146 EAP HCPCS C1722 Dfbr Crd Livian Rf He Cardvrt BOTH IP/OP "$50,244.00 " "$37,180.56" $0.00 "$40,195.20" "$22,609.80" "$22,609.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,728.08" $0.00 "$10,470.85" $0.00 "$24,770.29" "$24,770.29" $0.00 "$25,122.00" "$39,793.25" "$40,195.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,998.84" $0.00 $0.00 $0.00 $0.00 $0.00 27503147 EAP HCPCS C2621 INVIVE / EASYTRAK or ACUITY: CARDIAC RESYNCHRONIZATION THERA BOTH IP/OP "$26,452.00 " "$19,574.48" $0.00 "$21,161.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$20,389.20" $0.00 "$5,512.60" $0.00 $0.00 $0.00 $0.00 "$13,226.00" "$20,949.98" "$21,161.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503148 EAP HCPCS C1785 PCMKR CRD THK7.5MM 61X44.5MM INVIVE SMRT DELAY BIVENTRICLE BOTH IP/OP "$18,324.00 " "$13,559.76" $0.00 "$14,659.20" "$8,245.80" "$8,245.80" $0.00 $0.00 $0.00 "$3,819.18" "$4,181.12" "$4,181.12" "$14,124.14" $0.00 "$3,818.72" $0.00 "$9,033.73" "$9,033.73" $0.00 "$9,162.00" "$14,512.61" "$14,659.20" $0.00 $0.00 $0.00 "$2,867.71" $0.00 $0.00 "$2,917.18" $0.00 $0.00 $0.00 $0.00 $0.00 27503149 EAP HCPCS C1785 PCMKR CRD THK7.5MM 61X44.5MM INVIVE SMRT DELAY BIVENTRICLE BOTH IP/OP "$18,324.00 " "$13,559.76" $0.00 "$14,659.20" "$8,245.80" "$8,245.80" $0.00 $0.00 $0.00 "$3,819.18" "$4,181.12" "$4,181.12" "$14,124.14" $0.00 "$3,818.72" $0.00 "$9,033.73" "$9,033.73" $0.00 "$9,162.00" "$14,512.61" "$14,659.20" $0.00 $0.00 $0.00 "$2,867.71" $0.00 $0.00 "$2,917.18" $0.00 $0.00 $0.00 $0.00 $0.00 27503150 EAP HCPCS C1722 DFBR CRD INCEPTA VR IMPLTABLE CARDVRT HI ENRG DF4 CONCTR BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503151 EAP HCPCS C1721 DFBR CRD INCEPTA VR IMPLTABLE CARDVRT HI ENRG DF4 CONCTR BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503152 EAP HCPCS C1722 DFBR CRD THK.39IN 2.43X2.93IN INCEPTA VR 1 CHMBR IMPLTABLE BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27503153 EAP HCPCS C1722 DFBR CRD THK.39IN 2.43X2.93IN INCEPTA VR 1 CHMBR DF-4 BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27503154 EAP HCPCS C1721 DFBR CRD INCEPTA VR IMPLTABLE CARDVRT HI ENRG BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503155 EAP HCPCS C1882 DFBR CRD INCEPTA VR IMPLTABLE CARDVRT HI ENRG BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503156 EAP HCPCS C1882 INCEPTA LV-1 / EASYTRAK or ACUITY / ENDOTAK: CARDIAC RESYNCH BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503157 EAP HCPCS C1721 DFBR CRD INCEPTA DR IMPLTABLE CARDVRT HI ENRG DF4 CONCTR BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503158 EAP HCPCS C1721 DFBR CRD INCEPTA DR IMPLTABLE CARDVRT HI ENRG DF4 CONCTR BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503159 EAP HCPCS C1721 DFBR CRD THK.39IN 2.43X2.69-2.89IN INCEPTA DR 2CH IMPLTABLE BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503160 EAP HCPCS C1779 PCMKR CRD 7.5IN MOD ELIP 44.5X47IN ADVANTIO 2CH IS-1 CONCTR BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 $0.00 $0.00 $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503161 EAP HCPCS C2619 ADVANTIO DR IMPLANTABLE PACEMAKER SYSTEM (INCLUDES 2 LEADS) BOTH IP/OP "$14,777.00 " "$10,934.98" $0.00 "$11,821.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,390.11" $0.00 "$3,079.53" $0.00 $0.00 $0.00 $0.00 "$7,388.50" "$11,703.38" "$11,821.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503162 EAP HCPCS C1785 PCMKR CRD THK7.5MM 44.5X45.7MM ADVANTIO RIGHTRATE ATR VNTRC BOTH IP/OP "$10,344.00 " "$7,654.56" $0.00 "$8,275.20" "$4,654.80" "$4,654.80" $0.00 $0.00 $0.00 "$2,155.95" "$4,181.12" "$4,181.12" "$7,973.16" $0.00 "$2,155.69" $0.00 "$5,099.59" "$5,099.59" $0.00 "$5,172.00" "$8,192.45" "$8,275.20" $0.00 $0.00 $0.00 "$1,618.84" $0.00 $0.00 "$1,646.76" $0.00 $0.00 $0.00 $0.00 $0.00 27503163 EAP HCPCS C1785 ADVANTIO SR IMPLANTABLE PACEMAKER SYSTEM (INCLUDES 1 LEAD) BOTH IP/OP "$11,527.00 " "$8,529.98" $0.00 "$9,221.60" "$5,187.15" "$5,187.15" $0.00 $0.00 $0.00 "$2,402.51" "$4,181.12" "$4,181.12" "$8,885.01" $0.00 "$2,402.23" $0.00 "$5,682.81" "$5,682.81" $0.00 "$5,763.50" "$9,129.38" "$9,221.60" $0.00 $0.00 $0.00 "$1,803.98" $0.00 $0.00 "$1,835.10" $0.00 $0.00 $0.00 $0.00 $0.00 27503164 EAP HCPCS C1721 DFBR CRD INCEPTA DR IMPLTABLE CARDVRT HI ENRG BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503165 EAP HCPCS C1721 DFBR CRD INCEPTA DR IMPLTABLE CARDVRT HI ENRG BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503166 EAP HCPCS C1721 DFBR CRD THK.39IN 2.43X2.69-2.89IN INCEPTA DR 2CH IMPLTABLE BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503167 EAP HCPCS C1722 DFBR CRD THK9.9MM 61.7MM X 79.5MM ENERGEN VR VNTRC IMPLTABLE BOTH IP/OP "$36,945.00 " "$27,339.30" $0.00 "$29,556.00" "$16,625.25" "$16,625.25" $0.00 $0.00 $0.00 "$7,700.26" "$4,181.12" "$4,181.12" "$28,477.21" $0.00 "$7,699.34" $0.00 "$18,213.89" "$18,213.89" $0.00 "$18,472.50" "$29,260.44" "$29,556.00" $0.00 $0.00 $0.00 "$5,781.89" $0.00 $0.00 "$5,881.64" $0.00 $0.00 $0.00 $0.00 $0.00 27503168 EAP HCPCS C1722 ENERGEN VR DF4 ICD SYSTEMS (1 RELIANCE NON-GORE LEAD) BOTH IP/OP "$49,062.00 " "$36,305.88" $0.00 "$39,249.60" "$22,077.90" "$22,077.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$37,816.99" $0.00 "$10,224.52" $0.00 "$24,187.57" "$24,187.57" $0.00 "$24,531.00" "$38,857.10" "$39,249.60" $0.00 $0.00 $0.00 "$7,678.20" $0.00 $0.00 "$7,810.67" $0.00 $0.00 $0.00 $0.00 $0.00 27503169 EAP HCPCS C1785 PCMKR CRD 2.8V 8MM MOD ELIP 43X49MM ALTRUA 60DR ATR VNTRC BOTH IP/OP "$11,527.00 " "$8,529.98" $0.00 "$9,221.60" "$5,187.15" "$5,187.15" $0.00 $0.00 $0.00 "$2,402.51" "$4,181.12" "$4,181.12" "$8,885.01" $0.00 "$2,402.23" $0.00 "$5,682.81" "$5,682.81" $0.00 "$5,763.50" "$9,129.38" "$9,221.60" $0.00 $0.00 $0.00 "$1,803.98" $0.00 $0.00 "$1,835.10" $0.00 $0.00 $0.00 $0.00 $0.00 27503170 EAP HCPCS C1785 PCMKR CRD ALTRUA 60 DDDR 2 CHMBR IS-1 MV BLND SNSR STOR EGMS BOTH IP/OP "$11,527.00 " "$8,529.98" $0.00 "$9,221.60" "$5,187.15" "$5,187.15" $0.00 $0.00 $0.00 "$2,402.51" "$4,181.12" "$4,181.12" "$8,885.01" $0.00 "$2,402.23" $0.00 "$5,682.81" "$5,682.81" $0.00 "$5,763.50" "$9,129.38" "$9,221.60" $0.00 $0.00 $0.00 "$1,803.98" $0.00 $0.00 "$1,835.10" $0.00 $0.00 $0.00 $0.00 $0.00 27503171 EAP HCPCS C1785 PCMKR CRD 8MM MOD ELLIPSE 43X49MM ALTRUA 60 ATR VNTRC 2 BOTH IP/OP "$11,527.00 " "$8,529.98" $0.00 "$9,221.60" "$5,187.15" "$5,187.15" $0.00 $0.00 $0.00 "$2,402.51" "$4,181.12" "$4,181.12" "$8,885.01" $0.00 "$2,402.23" $0.00 "$5,682.81" "$5,682.81" $0.00 "$5,763.50" "$9,129.38" "$9,221.60" $0.00 $0.00 $0.00 "$1,803.98" $0.00 $0.00 "$1,835.10" $0.00 $0.00 $0.00 $0.00 $0.00 27503172 EAP HCPCS C1785 PCMKR CRD THK8MM 49X43MM ALTRUA 60DR ATR VNTRC IMPLTABLE 2 BOTH IP/OP "$14,482.00 " "$10,716.68" $0.00 "$11,585.60" "$6,516.90" "$6,516.90" $0.00 $0.00 $0.00 "$3,018.41" "$4,181.12" "$4,181.12" "$11,162.73" $0.00 "$3,018.05" $0.00 "$7,139.63" "$7,139.63" $0.00 "$7,241.00" "$11,469.74" "$11,585.60" $0.00 $0.00 $0.00 "$2,266.43" $0.00 $0.00 "$2,305.53" $0.00 $0.00 $0.00 $0.00 $0.00 27503173 EAP HCPCS C1900 PCMKR CRD THK8MM 42X42MM ALTRUA 60SR ATR VNTRC IMPLTABLE 1 BOTH IP/OP "$10,049.00 " "$7,436.26" $0.00 "$8,039.20" "$4,522.05" "$4,522.05" $0.00 $0.00 $0.00 "$2,094.46" "$4,181.12" "$4,181.12" "$7,745.77" $0.00 "$2,094.21" $0.00 "$4,954.16" "$4,954.16" $0.00 "$5,024.50" "$7,958.81" "$8,039.20" $0.00 $0.00 $0.00 "$1,572.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503174 EAP HCPCS C1785 PCMKR CRD THK3MM 42MMX42MM ALTRUA 60SR IMPLTABLE 1 CHMBR RR BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27503175 EAP HCPCS C1722 DFBR CRD .99CM THK.39IN SM 2.43X3.13IN COGNIS ATR VNTRC IS-1 BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503176 EAP HCPCS C1772 DFBR CRD ENERGEN VR IMPLTABLE CARDVRT HI ENRG DF4 CONCTR BOTH IP/OP "$49,062.00 " "$36,305.88" $0.00 "$39,249.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$37,816.99" $0.00 "$10,224.52" $0.00 $0.00 $0.00 $0.00 "$24,531.00" "$38,857.10" "$39,249.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503177 EAP HCPCS C1882 DFBR CRD COGNIS CNTK RNWL 3 RF HI ENRG BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503178 EAP HCPCS C1882 DFBR CRD 1.45CM 6.7X8.25CM CONFIENT RF HE ATR VNTRC 2CH BOTH IP/OP "$36,945.00 " "$27,339.30" $0.00 "$29,556.00" "$16,625.25" "$16,625.25" $0.00 $0.00 $0.00 "$7,700.26" "$4,181.12" "$4,181.12" "$28,477.21" $0.00 "$7,699.34" $0.00 "$18,213.89" "$18,213.89" $0.00 "$18,472.50" "$29,260.44" "$29,556.00" $0.00 $0.00 $0.00 "$5,781.89" $0.00 $0.00 "$5,881.64" $0.00 $0.00 $0.00 $0.00 $0.00 27503179 EAP HCPCS C2621 PCMKR CRD CNTK RNWL TR ATR VNTRC 2 WRNCH IS-1 IMPLTABLE BOTH IP/OP "$18,916.00 " "$13,997.84" $0.00 "$15,132.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,580.45" $0.00 "$3,942.09" $0.00 $0.00 $0.00 $0.00 "$9,458.00" "$14,981.47" "$15,132.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503180 EAP HCPCS C2621 PCMKR CRD CNTK RNWL TR LV-1 IMPLTABLE BOTH IP/OP "$18,916.00 " "$13,997.84" $0.00 "$15,132.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,580.45" $0.00 "$3,942.09" $0.00 $0.00 $0.00 $0.00 "$9,458.00" "$14,981.47" "$15,132.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503181 EAP HCPCS C1722 DFBR CRD THK.39IN 2.43X2.69-2.89IN ENERGEN VR VNTRC 1 CHMBR BOTH IP/OP "$36,945.00 " "$27,339.30" $0.00 "$29,556.00" "$16,625.25" "$16,625.25" $0.00 $0.00 $0.00 "$7,700.26" "$4,181.12" "$4,181.12" "$28,477.21" $0.00 "$7,699.34" $0.00 "$18,213.89" "$18,213.89" $0.00 "$18,472.50" "$29,260.44" "$29,556.00" $0.00 $0.00 $0.00 "$5,781.89" $0.00 $0.00 "$5,881.64" $0.00 $0.00 $0.00 $0.00 $0.00 27503182 EAP HCPCS C1898 LEAD PCNG 53CM 6.7FR 10MM SPC RIGHT AV BIPOL XTD-RETRAC HLX BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27503183 EAP HCPCS C1722 ENERGEN VR ICD SYSTEM (1 RELIANCE NON-GORE LEAD) BOTH IP/OP "$49,062.00 " "$36,305.88" $0.00 "$39,249.60" "$22,077.90" "$22,077.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$37,816.99" $0.00 "$10,224.52" $0.00 "$24,187.57" "$24,187.57" $0.00 "$24,531.00" "$38,857.10" "$39,249.60" $0.00 $0.00 $0.00 "$7,678.20" $0.00 $0.00 "$7,810.67" $0.00 $0.00 $0.00 $0.00 $0.00 27503184 EAP HCPCS C1722 DFBR CRD ENERGEN VR IMPLTABLE CARDVRT HI ENRG BOTH IP/OP "$49,062.00 " "$36,305.88" $0.00 "$39,249.60" "$22,077.90" "$22,077.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$37,816.99" $0.00 "$10,224.52" $0.00 "$24,187.57" "$24,187.57" $0.00 "$24,531.00" "$38,857.10" "$39,249.60" $0.00 $0.00 $0.00 "$7,678.20" $0.00 $0.00 "$7,810.67" $0.00 $0.00 $0.00 $0.00 $0.00 27503185 EAP HCPCS C1721 DFBR CRD THK9.9MM 61.7X74.5MM ENERGEN DR ATR ENTRICULAR BOTH IP/OP "$44,334.00 " "$32,807.16" $0.00 "$35,467.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,240.31" "$4,181.12" "$4,181.12" "$34,172.65" $0.00 "$9,239.21" $0.00 "$21,856.66" "$21,856.66" $0.00 "$22,167.00" "$35,112.53" "$35,467.20" $0.00 $0.00 $0.00 "$6,938.27" $0.00 $0.00 "$7,057.97" $0.00 $0.00 $0.00 $0.00 $0.00 27503186 EAP HCPCS C1721 ENERGEN DR DF4 ICD SYSTEMS (2 RELIANCE NON-GORE LEADS) BOTH IP/OP "$57,781.00 " "$42,757.94" $0.00 "$46,224.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$44,537.59" $0.00 "$12,041.56" $0.00 "$28,486.03" "$28,486.03" $0.00 "$28,890.50" "$45,762.55" "$46,224.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503187 EAP HCPCS C1721 DFBR CRD ENERGEN DR IMPLTABLE CARDVRT HI ENRG DF4 CONCTR BOTH IP/OP "$57,781.00 " "$42,757.94" $0.00 "$46,224.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$44,537.59" $0.00 "$12,041.56" $0.00 "$28,486.03" "$28,486.03" $0.00 "$28,890.50" "$45,762.55" "$46,224.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503188 EAP HCPCS C1721 DFBR CRD SM ENERGEN DR DF-4 2CH IMPLTABLE CARDVRT BTR-PWR BOTH IP/OP "$44,334.00 " "$32,807.16" $0.00 "$35,467.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,240.31" "$4,181.12" "$4,181.12" "$34,172.65" $0.00 "$9,239.21" $0.00 "$21,856.66" "$21,856.66" $0.00 "$22,167.00" "$35,112.53" "$35,467.20" $0.00 $0.00 $0.00 "$6,938.27" $0.00 $0.00 "$7,057.97" $0.00 $0.00 $0.00 $0.00 $0.00 27503189 EAP HCPCS C1721 ENERGEN DR ICD SYSTEM (2 RELIANCE NON-GORE LEADS) BOTH IP/OP "$57,781.00 " "$42,757.94" $0.00 "$46,224.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$44,537.59" $0.00 "$12,041.56" $0.00 "$28,486.03" "$28,486.03" $0.00 "$28,890.50" "$45,762.55" "$46,224.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503190 EAP HCPCS C1722 DFBR CRD ENERGEN VR IMPLTABLE CARDVRT HI ENRG BOTH IP/OP "$57,781.00 " "$42,757.94" $0.00 "$46,224.80" "$26,001.45" "$26,001.45" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$44,537.59" $0.00 "$12,041.56" $0.00 "$28,486.03" "$28,486.03" $0.00 "$28,890.50" "$45,762.55" "$46,224.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503191 EAP HCPCS C1882 ENERGEN RF HE DF4 (with brady lead) BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503192 EAP HCPCS C1882 ENERGEN RF HE DF4 (without brady lead) BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503193 EAP HCPCS C1721 DFBR CRD THK9.9MM 79.5MMX61.7MM ENERGEN CRT-D VNTRC BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503194 EAP HCPCS C1721 DFBR CRD ENERGEN CRT-D IMPLTABLE CARDVRT BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503195 EAP HCPCS C1882 ENERGEN RF HE (with brady lead) BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503211 EAP HCPCS C1721 Fortify Assura Next Nene Dr 40 BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503212 EAP HCPCS C1721 Fortify Assura Next Gene Dr 40 Df4 Conn BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503213 EAP HCPCS C1722 Ellipse Next Gene Dr 36 BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" "$20,614.95" "$20,614.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503214 EAP HCPCS C1722 Ellipse Next Gene Dr 36 Df4 Conn BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" "$20,614.95" "$20,614.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 "$20,614.95" $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27503215 EAP HCPCS C1722 Fortify Assura Next Gene Vr 40 BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 "$17,955.00" $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27503216 EAP HCPCS C1722 Fortify Assura Next Gene Vr 40 Df4 Conn BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27503217 EAP HCPCS C1722 Ellipse Next Gene Vr 36 BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27503218 EAP HCPCS C1722 Ellipse Next Gene Vr 36 Df4 Conn BOTH IP/OP "$39,900.00 " "$29,526.00" $0.00 "$31,920.00" "$17,955.00" "$17,955.00" $0.00 $0.00 $0.00 "$8,316.16" "$4,181.12" "$4,181.12" "$30,754.92" $0.00 "$8,315.16" $0.00 "$19,670.70" "$19,670.70" $0.00 "$19,950.00" "$31,600.80" "$31,920.00" $0.00 $0.00 $0.00 "$6,244.35" $0.00 $0.00 "$6,352.08" $0.00 $0.00 $0.00 $0.00 $0.00 27503219 EAP HCPCS C1721 Fortify Assura Next Gene Dr 40 System BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503220 EAP HCPCS C1721 Fortify Assura Next Gene Dr 40 Df4 Conn System BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503221 EAP HCPCS C1722 Ellipse Next Gene Dr 36 System BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" "$26,500.05" "$26,500.05" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503222 EAP HCPCS C1722 Ellipse Next Gene Dr 36 Df4 Conn System BOTH IP/OP "$58,889.00 " "$43,577.86" $0.00 "$47,111.20" "$26,500.05" "$26,500.05" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,391.64" $0.00 "$12,272.47" $0.00 "$29,032.28" "$29,032.28" $0.00 "$29,444.50" "$46,640.09" "$47,111.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503223 EAP HCPCS C1722 Fortify Assura Next Gene Vr 40 System BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 "$23,274.90" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503224 EAP HCPCS C1722 Fortify Assura Next Gene Vr 40 Df4 Conn System BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 "$23,274.90" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503225 EAP HCPCS C1722 Ellipse Next Gene Vr 36 System BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 "$23,274.90" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503226 EAP HCPCS C1722 Ellipse Next Gene Vr 36 36 Df4 Conn System BOTH IP/OP "$51,722.00 " "$38,274.28" $0.00 "$41,377.60" "$23,274.90" "$23,274.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,867.32" $0.00 "$10,778.86" $0.00 "$25,498.95" "$25,498.95" $0.00 "$25,861.00" "$40,963.82" "$41,377.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503227 EAP HCPCS C1882 Quadra Assura Next Gene Crt-d 40 BOTH IP/OP "$59,111.00 " "$43,742.14" $0.00 "$47,288.80" "$26,599.95" "$26,599.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,562.76" $0.00 "$12,318.73" $0.00 "$29,141.72" "$29,141.72" $0.00 "$29,555.50" "$46,815.91" "$47,288.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503228 EAP HCPCS C1882 Quadra Assura Next Gene Crt-d 40 Df4 Cc BOTH IP/OP "$59,111.00 " "$43,742.14" $0.00 "$47,288.80" "$26,599.95" "$26,599.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,562.76" $0.00 "$12,318.73" $0.00 "$29,141.72" "$29,141.72" $0.00 "$29,555.50" "$46,815.91" "$47,288.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503229 EAP HCPCS C1882 Unify Assura Next Gene Crt-d 40 BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503230 EAP HCPCS C1882 Unify Assura Next Gene Crt-d 40 Df4 Conn BOTH IP/OP "$53,791.00 " "$39,805.34" $0.00 "$43,032.80" "$24,205.95" "$24,205.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,462.10" $0.00 "$11,210.04" $0.00 "$26,518.96" "$26,518.96" $0.00 "$26,895.50" "$42,602.47" "$43,032.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503231 EAP HCPCS C1882 Quadra Assura Next Gene Crt-d 40 System BOTH IP/OP "$78,677.00 " "$58,220.98" $0.00 "$62,941.60" "$35,404.65" "$35,404.65" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$60,644.23" $0.00 "$16,396.29" $0.00 "$38,787.76" "$38,787.76" $0.00 "$39,338.50" "$62,312.18" "$62,941.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503232 EAP HCPCS C1882 Quadra Assura Next Gene Crt-d Df4 Conn System BOTH IP/OP "$78,677.00 " "$58,220.98" $0.00 "$62,941.60" "$35,404.65" "$35,404.65" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$60,644.23" $0.00 "$16,396.29" $0.00 "$38,787.76" "$38,787.76" $0.00 "$39,338.50" "$62,312.18" "$62,941.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503233 EAP HCPCS C1882 Unify Assura Next Gene Crt-d 40 System BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503234 EAP HCPCS C1882 Unify Assura Next Gene Crt-d 40 Df4 Conn System BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503235 EAP HCPCS C1722 Generator Pulse Sq-rx And Q-trak Electrode BOTH IP/OP "$71,926.00 " "$53,225.24" $0.00 "$57,540.80" "$32,366.70" "$32,366.70" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,440.56" $0.00 "$14,989.38" $0.00 "$35,459.52" "$35,459.52" $0.00 "$35,963.00" "$56,965.39" "$57,540.80" $0.00 "$32,366.70" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503236 EAP CPT® C1722 Generator Pulse Sq-rx BOTH IP/OP "$59,249.00 " "$43,844.26" $0.00 "$47,399.20" "$26,662.05" "$26,662.05" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,669.13" $0.00 "$12,347.49" $0.00 "$29,209.76" "$29,209.76" $0.00 "$29,624.50" "$46,925.21" "$47,399.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27503237 EAP HCPCS C1785 Pcmkr Crd Thk6mm Sm 50x47mm Assurity 2 Chmbr Is-1 Conctr BOTH IP/OP "$19,566.00 " "$14,478.84" $0.00 "$15,652.80" "$8,804.70" "$8,804.70" $0.00 $0.00 $0.00 "$4,078.04" "$4,181.12" "$4,181.12" "$15,081.47" $0.00 "$4,077.55" $0.00 "$9,646.04" "$9,646.04" $0.00 "$9,783.00" "$15,496.27" "$15,652.80" $0.00 "$8,804.70" $0.00 "$3,062.08" $0.00 $0.00 "$3,114.91" $0.00 $0.00 $0.00 $0.00 $0.00 27503238 EAP HCPCS C1785 Pcmkr Crd Thk6mm Sm 50x46mm Endurity 2 Chmbr Is-1 Conctr BOTH IP/OP "$15,432.00 " "$11,419.68" $0.00 "$12,345.60" "$6,944.40" "$6,944.40" $0.00 $0.00 $0.00 "$3,216.41" "$4,181.12" "$4,181.12" "$11,894.99" $0.00 "$3,216.03" $0.00 "$7,607.98" "$7,607.98" $0.00 "$7,716.00" "$12,222.14" "$12,345.60" $0.00 $0.00 $0.00 "$2,415.11" $0.00 $0.00 "$2,456.77" $0.00 $0.00 $0.00 $0.00 $0.00 27503239 EAP HCPCS C1785 Pcmkr Crd Thk6mm Sm 50x47mm Assurity Chmbr Is-1 Conctr Atcpt BOTH IP/OP "$20,669.00 " "$15,295.06" $0.00 "$16,535.20" "$9,301.05" "$9,301.05" $0.00 $0.00 $0.00 "$4,307.94" "$4,181.12" "$4,181.12" "$15,931.67" $0.00 "$4,307.42" $0.00 "$10,189.82" "$10,189.82" $0.00 "$10,334.50" "$16,369.85" "$16,535.20" $0.00 $0.00 $0.00 "$3,234.70" $0.00 $0.00 "$3,290.50" $0.00 $0.00 $0.00 $0.00 $0.00 27503240 EAP HCPCS C1785 Pcmkr Crd Thk6mm Sm 50x47mm Assurity 1 Chmbr Is-1 Conctr BOTH IP/OP "$17,774.00 " "$13,152.76" $0.00 "$14,219.20" "$7,998.30" "$7,998.30" $0.00 $0.00 $0.00 "$3,704.55" "$4,181.12" "$4,181.12" "$13,700.20" $0.00 "$3,704.10" $0.00 "$8,762.58" "$8,762.58" $0.00 "$8,887.00" "$14,077.01" "$14,219.20" $0.00 "$7,998.30" $0.00 "$2,781.63" $0.00 $0.00 "$2,829.62" $0.00 $0.00 $0.00 $0.00 $0.00 27503241 EAP HCPCS C1785 Entovis Dr-t Promri With Landline Hm(r) Bradycardia BOTH IP/OP "$19,759.00 " "$14,621.66" $0.00 "$15,807.20" "$8,891.55" "$8,891.55" $0.00 $0.00 $0.00 "$4,118.27" "$4,181.12" "$4,181.12" "$15,230.24" $0.00 "$4,117.78" $0.00 "$9,741.19" "$9,741.19" $0.00 "$9,879.50" "$15,649.13" "$15,807.20" $0.00 $0.00 $0.00 "$3,092.28" $0.00 $0.00 "$3,145.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503242 EAP HCPCS C1785 Entovis Dr-t Promri System With Landline Hm(r) Bradycardia BOTH IP/OP "$22,460.00 " "$16,620.40" $0.00 "$17,968.00" "$10,107.00" "$10,107.00" $0.00 $0.00 $0.00 "$4,681.23" "$4,181.12" "$4,181.12" "$17,312.17" $0.00 "$4,680.66" $0.00 "$11,072.78" "$11,072.78" $0.00 "$11,230.00" "$17,788.32" "$17,968.00" $0.00 $0.00 $0.00 "$3,514.99" $0.00 $0.00 "$3,575.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503243 EAP HCPCS C1785 Entovis Dr-t Promri System With Cellular Hm(r) Bradycardia BOTH IP/OP "$22,460.00 " "$16,620.40" $0.00 "$17,968.00" "$10,107.00" "$10,107.00" $0.00 $0.00 $0.00 "$4,681.23" "$4,181.12" "$4,181.12" "$17,312.17" $0.00 "$4,680.66" $0.00 "$11,072.78" "$11,072.78" $0.00 "$11,230.00" "$17,788.32" "$17,968.00" $0.00 $0.00 $0.00 "$3,514.99" $0.00 $0.00 "$3,575.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503244 EAP HCPCS C1786 Entovis Sr-t Promri With Landline Hm(r) Bradycardia BOTH IP/OP "$18,408.00 " "$13,621.92" $0.00 "$14,726.40" "$8,283.60" "$8,283.60" $0.00 $0.00 $0.00 "$3,836.69" "$4,181.12" "$4,181.12" "$14,188.89" $0.00 "$3,836.23" $0.00 "$9,075.14" "$9,075.14" $0.00 "$9,204.00" "$14,579.14" "$14,726.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503245 EAP HCPCS C1786 Entovis Sr-t Promri With Cellular Hm(r) Bradycardia BOTH IP/OP "$18,408.00 " "$13,621.92" $0.00 "$14,726.40" "$8,283.60" "$8,283.60" $0.00 $0.00 $0.00 "$3,836.69" "$4,181.12" "$4,181.12" "$14,188.89" $0.00 "$3,836.23" $0.00 "$9,075.14" "$9,075.14" $0.00 "$9,204.00" "$14,579.14" "$14,726.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503246 EAP HCPCS C1786 Entovis Sr-t Promri System With Landline Hm(r) Bradycardia BOTH IP/OP "$19,759.00 " "$14,621.66" $0.00 "$15,807.20" "$8,891.55" "$8,891.55" $0.00 $0.00 $0.00 "$4,118.27" "$4,181.12" "$4,181.12" "$15,230.24" $0.00 "$4,117.78" $0.00 "$9,741.19" "$9,741.19" $0.00 "$9,879.50" "$15,649.13" "$15,807.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503247 EAP HCPCS C1786 Entovis Sr-t Promri System With Cellular Hm(r) Bradycardia BOTH IP/OP "$19,759.00 " "$14,621.66" $0.00 "$15,807.20" "$8,891.55" "$8,891.55" $0.00 $0.00 $0.00 "$4,118.27" "$4,181.12" "$4,181.12" "$15,230.24" $0.00 "$4,117.78" $0.00 "$9,741.19" "$9,741.19" $0.00 "$9,879.50" "$15,649.13" "$15,807.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503248 EAP HCPCS C1785 Evia Dr-t With Cls With Landline Hmbradycardiadual Chamber BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27503249 EAP HCPCS C1785 Evia Dr-t With Cls With Cellular Gsm Hmbradycardiadual Chamber BOTH IP/OP "$17,003.00 " "$12,582.22" $0.00 "$13,602.40" "$7,651.35" "$7,651.35" $0.00 $0.00 $0.00 "$3,543.85" "$4,181.12" "$4,181.12" "$13,105.91" $0.00 "$3,543.43" $0.00 "$8,382.48" "$8,382.48" $0.00 "$8,501.50" "$13,466.38" "$13,602.40" $0.00 $0.00 $0.00 "$2,660.97" $0.00 $0.00 "$2,706.88" $0.00 $0.00 $0.00 $0.00 $0.00 27503250 EAP HCPCS C1785 Evia Dr-t System With Cls With Landline Hmbradycardiadual Chamber Sys BOTH IP/OP "$13,779.00 " "$10,196.46" $0.00 "$11,023.20" "$6,200.55" "$6,200.55" $0.00 $0.00 $0.00 "$2,871.89" "$4,181.12" "$4,181.12" "$10,620.85" $0.00 "$2,871.54" $0.00 "$6,793.05" "$6,793.05" $0.00 "$6,889.50" "$10,912.97" "$11,023.20" $0.00 $0.00 $0.00 "$2,156.41" $0.00 $0.00 "$2,193.62" $0.00 $0.00 $0.00 $0.00 $0.00 27503251 EAP HCPCS C1785 Evia Dr-t System With Cls A With Cellular Gsm Hmbradycardiadual Cham BOTH IP/OP "$19,704.00 " "$14,580.96" $0.00 "$15,763.20" "$8,866.80" "$8,866.80" $0.00 $0.00 $0.00 "$4,106.81" "$4,181.12" "$4,181.12" "$15,187.84" $0.00 "$4,106.31" $0.00 "$9,714.07" "$9,714.07" $0.00 "$9,852.00" "$15,605.57" "$15,763.20" $0.00 $0.00 $0.00 "$3,083.68" $0.00 $0.00 "$3,136.88" $0.00 $0.00 $0.00 $0.00 $0.00 27503252 EAP HCPCS C1786 Evia Sr-t With Cls With Landline Hmbradycardiasingle Chamber BOTH IP/OP "$9,646.00 " "$7,138.04" $0.00 "$7,716.80" "$4,340.70" "$4,340.70" $0.00 $0.00 $0.00 "$2,010.47" "$4,181.12" "$4,181.12" "$7,435.14" $0.00 "$2,010.23" $0.00 "$4,755.48" "$4,755.48" $0.00 "$4,823.00" "$7,639.63" "$7,716.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503253 EAP HCPCS C1786 Evia Sr-t With Cls With Cellular Gsm Hmbradycardiasingle Chamber BOTH IP/OP "$15,653.00 " "$11,583.22" $0.00 "$12,522.40" "$7,043.85" "$7,043.85" $0.00 $0.00 $0.00 "$3,262.48" "$4,181.12" "$4,181.12" "$12,065.33" $0.00 "$3,262.09" $0.00 "$7,716.93" "$7,716.93" $0.00 "$7,826.50" "$12,397.18" "$12,522.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503254 EAP HCPCS C1786 Evia Sr-t System With Cls With Landline Hmbradycardiasingle Chamber S BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503255 EAP HCPCS C1786 Evia Sr-t System With Cls With Cellular Gsm Hmbradycardiasingle Chamb BOTH IP/OP "$17,003.00 " "$12,582.22" $0.00 "$13,602.40" "$7,651.35" "$7,651.35" $0.00 $0.00 $0.00 "$3,543.85" "$4,181.12" "$4,181.12" "$13,105.91" $0.00 "$3,543.43" $0.00 "$8,382.48" "$8,382.48" $0.00 "$8,501.50" "$13,466.38" "$13,602.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503256 EAP HCPCS C2621 Evia Hf-t With Landline Hmcrtdevice BOTH IP/OP "$21,771.00 " "$16,110.54" $0.00 "$17,416.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,781.09" $0.00 "$4,537.08" $0.00 $0.00 $0.00 $0.00 "$10,885.50" "$17,242.63" "$17,416.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503257 EAP HCPCS C2621 Evia Hf-t With Cellular Gsm Hmcrtdevice BOTH IP/OP "$22,597.00 " "$16,721.78" $0.00 "$18,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,417.77" $0.00 "$4,709.21" $0.00 $0.00 $0.00 $0.00 "$11,298.50" "$17,896.82" "$18,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503258 EAP HCPCS C2621 Evia Hf-t System With Landline Hmcrtsystem BOTH IP/OP "$31,141.00 " "$23,044.34" $0.00 "$24,912.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$24,003.48" $0.00 "$6,489.78" $0.00 $0.00 $0.00 $0.00 "$15,570.50" "$24,663.67" "$24,912.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503259 EAP HCPCS C2621 Evia Hf-t System With Cellular Gsm Hmcrtsystem BOTH IP/OP "$31,692.00 " "$23,452.08" $0.00 "$25,353.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$24,428.19" $0.00 "$6,604.61" $0.00 $0.00 $0.00 $0.00 "$15,846.00" "$25,100.06" "$25,353.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503260 EAP HCPCS C1900 Corox Otw-l 75-bp Leadcrtlead BOTH IP/OP "$5,512.00 " "$4,078.88" $0.00 "$4,409.60" "$2,480.40" "$2,480.40" $0.00 $0.00 $0.00 "$1,148.84" "$4,091.01" "$4,091.01" "$4,248.65" $0.00 "$1,148.70" $0.00 "$2,717.42" "$2,717.42" $0.00 "$2,756.00" "$4,365.50" "$4,409.60" $0.00 $0.00 $0.00 $862.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503261 EAP HCPCS C1900 Corox Otw-l 85-bp Leadcrtlead BOTH IP/OP "$5,512.00 " "$4,078.88" $0.00 "$4,409.60" "$2,480.40" "$2,480.40" $0.00 $0.00 $0.00 "$1,148.84" "$4,091.01" "$4,091.01" "$4,248.65" $0.00 "$1,148.70" $0.00 "$2,717.42" "$2,717.42" $0.00 "$2,756.00" "$4,365.50" "$4,409.60" $0.00 $0.00 $0.00 $862.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503262 EAP HCPCS C1898 Lead Pcng 45cm Ecrdl Bipol Act Fix Is 1 Conctr Ring Eltrd BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $247.95 $247.95 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 27503263 EAP HCPCS C1785 Gntr Pcmkr Entovis Dr-t Promri Crd BOTH IP/OP "$19,759.00 " "$14,621.66" $0.00 "$15,807.20" "$8,891.55" "$8,891.55" $0.00 $0.00 $0.00 "$4,118.27" "$4,181.12" "$4,181.12" "$15,230.24" $0.00 "$4,117.78" $0.00 "$9,741.19" "$9,741.19" $0.00 "$9,879.50" "$15,649.13" "$15,807.20" $0.00 $0.00 $0.00 "$3,092.28" $0.00 $0.00 "$3,145.63" $0.00 $0.00 $0.00 $0.00 $0.00 27503265 EAP HCPCS C1882 Dfbr Crd .99cm Thn 5.37x8.08cm Inogen Easyview Right Atr Rv BOTH IP/OP "$38,056.00 " "$28,161.44" $0.00 "$30,444.80" "$17,125.20" "$17,125.20" $0.00 $0.00 $0.00 "$7,931.82" "$4,181.12" "$4,181.12" "$29,333.56" $0.00 "$7,930.87" $0.00 "$18,761.61" "$18,761.61" $0.00 "$19,028.00" "$30,140.35" "$30,444.80" $0.00 $0.00 $0.00 "$5,955.76" $0.00 $0.00 "$6,058.52" $0.00 $0.00 $0.00 $0.00 $0.00 27503266 EAP HCPCS C1785 Pacemaker Crd .75cm 4.45x5.02cm Acld; Ltd Nxt; BOTH IP/OP "$10,213.00 " "$7,557.62" $0.00 "$8,170.40" "$4,595.85" "$4,595.85" $0.00 $0.00 $0.00 "$2,128.64" "$4,181.12" "$4,181.12" "$7,872.18" $0.00 "$2,128.39" $0.00 "$5,035.01" "$5,035.01" $0.00 "$5,106.50" "$8,088.70" "$8,170.40" $0.00 $0.00 $0.00 "$1,598.33" $0.00 $0.00 "$1,625.91" $0.00 $0.00 $0.00 $0.00 $0.00 27503267 EAP HCPCS C1721 Pacemaker Crd 7.5mm 42.9x43.3mm Adapta Sr Atr BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" "$6,744.50" $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 27503268 EAP Custom 27503268 Envelope Defibrillator Medium 2.5x2.75in Pacemaker BOTH IP/OP "$1,738.00 " "$1,286.12" $0.00 "$1,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.94" "$1,289.94" "$1,339.65" $0.00 $362.20 $0.00 $0.00 $0.00 $0.00 $869.00 "$1,376.50" "$1,390.40" $0.00 $782.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503269 EAP Custom 27503269 Catheter Balloon Occlusion .01in 2mm 2.5-2.8fr 4mm BOTH IP/OP "$3,312.00 " "$2,450.88" $0.00 "$2,649.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,458.17" "$2,458.17" "$2,552.89" $0.00 $690.22 $0.00 $0.00 $0.00 $0.00 "$1,656.00" "$2,623.10" "$2,649.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503270 EAP HCPCS C2621 Quadra Allure Mp Rf Crt-p BOTH IP/OP "$16,625.00 " "$12,302.50" $0.00 "$13,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,312.50" "$13,167.00" "$13,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503271 EAP HCPCS C2621 "Quadra Allure Mp Rf Crt-p, Merlinpkg" BOTH IP/OP "$17,625.00 " "$13,042.50" $0.00 "$14,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,585.35" $0.00 "$3,673.05" $0.00 $0.00 $0.00 $0.00 "$8,812.50" "$13,959.00" "$14,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503272 EAP HCPCS C2621 Quadra Allure Mp Rf Crt-p System BOTH IP/OP "$23,875.00 " "$17,667.50" $0.00 "$19,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,402.85" $0.00 "$4,975.55" $0.00 $0.00 $0.00 $0.00 "$11,937.50" "$18,909.00" "$19,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503273 EAP HCPCS C2621 "Quadra Allure Mp Crt-p System, Merlinpkg" BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,270.00" $0.00 "$5,210.00" $0.00 $0.00 $0.00 $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503274 EAP HCPCS C1898 Lead Pcng 45cm Solia S Bp Actfx Strd Elut BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27503275 EAP HCPCS C1898 Lead Pcng 53cm Solia S Strd Elute Bp Actfx Ecrdl BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27503300 EAP HCPCS C1785 Pacemaker Crd 2 Chmbr Dr-t Etrinsa BOTH IP/OP "$9,500.00 " "$7,030.00" $0.00 "$7,600.00" "$4,275.00" "$4,275.00" $0.00 $0.00 $0.00 "$1,980.04" "$4,181.12" "$4,181.12" "$7,322.60" $0.00 "$1,979.80" $0.00 "$4,683.50" "$4,683.50" $0.00 "$4,750.00" "$7,524.00" "$7,600.00" $0.00 $0.00 $0.00 "$1,486.75" $0.00 $0.00 "$1,512.40" $0.00 $0.00 $0.00 $0.00 $0.00 27503301 EAP HCPCS C1785 Etrinsa Dr-t System With Cls With Home Monitoring BOTH IP/OP "$12,000.00 " "$8,880.00" $0.00 "$9,600.00" "$5,400.00" "$5,400.00" $0.00 $0.00 $0.00 "$2,501.10" "$4,181.12" "$4,181.12" "$9,249.60" $0.00 "$2,500.80" $0.00 "$5,916.00" "$5,916.00" $0.00 "$6,000.00" "$9,504.00" "$9,600.00" $0.00 $0.00 $0.00 "$1,878.00" $0.00 $0.00 "$1,910.40" $0.00 $0.00 $0.00 $0.00 $0.00 27503302 EAP HCPCS C1786 Pacemaker Crd 1 Chmbr Etrinsa Sr-t BOTH IP/OP "$8,375.00 " "$6,197.50" $0.00 "$6,700.00" "$3,768.75" "$3,768.75" $0.00 $0.00 $0.00 "$1,745.56" "$4,181.12" "$4,181.12" "$6,455.45" $0.00 "$1,745.35" $0.00 "$4,128.88" "$4,128.88" $0.00 "$4,187.50" "$6,633.00" "$6,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503303 EAP HCPCS C1786 Etrinsa Sr-t System With Cls With Home Monitoring BOTH IP/OP "$9,500.00 " "$7,030.00" $0.00 "$7,600.00" "$4,275.00" "$4,275.00" $0.00 $0.00 $0.00 "$1,980.04" "$4,181.12" "$4,181.12" "$7,322.60" $0.00 "$1,979.80" $0.00 "$4,683.50" "$4,683.50" $0.00 "$4,750.00" "$7,524.00" "$7,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503305 EAP HCPCS C2621 Percepta Bipolar Crtp BOTH IP/OP "$29,835.00 " "$22,077.90" $0.00 "$23,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$22,996.82" $0.00 "$6,217.61" $0.00 $0.00 $0.00 $0.00 "$14,917.50" "$23,629.32" "$23,868.00" $0.00 "$13,425.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503320 EAP CPT® C1898 Lead Pcng Strg 52cm Ingevity Mri Psv Fx Rv BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27503321 EAP CPT® C1898 Lead Pcng J Crv 45cm Ingevity Mri Psv Fx Prefrm Atr BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $506.25 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27503322 EAP CPT® C1898 Lead Pcng J Crv 52cm Ingevity Mri Psv Fx Prefrm Atr BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27503323 EAP Lead Pcng Strg 45cm Ingevity Mri Act Bp Flx Tp Sty Av BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503324 EAP CPT® C1898 Lead Pcng Strg 52cm Ingevity Mri Act Bp Flx Tp Sty Av BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $506.25 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 27503326 EAP HCPCS C1785 Pacemaker Crd Azure Wirelessly BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" "$10,598.50" $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 "$6,187.50" $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 27503327 EAP HCPCS c1786 Pacemaker Crd Azure BOTH IP/OP "$12,000.00 " "$8,880.00" $0.00 "$9,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,249.60" $0.00 "$2,500.80" $0.00 $0.00 $0.00 $0.00 "$6,000.00" "$9,504.00" "$9,600.00" $0.00 "$5,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503329 EAP HCPCS C1898 Lead Pcng 10mm Spc Sm Strg 6.2fr 2mm 45cm Strl Cp Nv Bp Scr BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $963.50 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $562.50 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503330 EAP HCPCS C1786 Edora Promri Sr-t-sing Chmbr Pacemaker-rate-ad BOTH IP/OP "$13,375.00 " "$9,897.50" $0.00 "$10,700.00" "$6,018.75" "$6,018.75" $0.00 $0.00 $0.00 "$2,787.68" "$4,181.12" "$4,181.12" "$10,309.45" $0.00 "$2,787.35" $0.00 "$6,593.88" "$6,593.88" $0.00 "$6,687.50" "$10,593.00" "$10,700.00" $0.00 "$6,018.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27503331 EAP HCPCS C1785 Pm Cardiac Acld Lat Nxt Dr-el 4.45 X 5.88 X 0.75 BOTH IP/OP "$7,625.00 " "$5,642.50" $0.00 "$6,100.00" "$3,431.25" "$3,431.25" $0.00 $0.00 $0.00 "$1,589.24" "$4,181.12" "$4,181.12" "$5,877.35" $0.00 "$1,589.05" $0.00 "$3,759.13" "$3,759.13" $0.00 "$3,812.50" "$6,039.00" "$6,100.00" $0.00 "$3,431.25" $0.00 "$1,193.31" $0.00 $0.00 "$1,213.90" $0.00 $0.00 $0.00 $0.00 $0.00 27503332 EAP HCPCS C1722 Dfbr Crd .99cm 5.37x7.36cm Resonate Heartlogic BOTH IP/OP "$23,893.00 " "$17,680.82" $0.00 "$19,114.40" "$10,751.85" "$10,751.85" $0.00 $0.00 $0.00 "$4,979.90" "$4,181.12" "$4,181.12" "$18,416.72" $0.00 "$4,979.30" $0.00 "$11,779.25" "$11,779.25" $0.00 "$11,946.50" "$18,923.26" "$19,114.40" $0.00 "$10,751.85" $0.00 "$3,739.25" $0.00 $0.00 "$3,803.77" $0.00 $0.00 $0.00 $0.00 $0.00 27800001 EAP HCPCS V2790 Prokera BOTH IP/OP "$2,140.00 " "$1,583.60" $0.00 "$1,712.00" $963.00 $963.00 $0.00 $0.00 $0.00 $446.03 "$1,588.31" "$1,588.31" "$1,649.51" $0.00 $445.98 $0.00 "$1,265.81" "$1,265.81" $0.00 "$1,070.00" "$1,694.88" "$1,712.00" $0.00 $963.00 $0.00 $334.91 $0.00 $0.00 $340.69 $0.00 $0.00 $0.00 $0.00 $0.00 27800002 EAP Custom 27800002 Coil Embl 20mm .014in 3mm Trfl Psh Cmplx Pltn Nyl BOTH IP/OP $406.00 $300.44 $0.00 $324.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.33 $301.33 $312.94 $0.00 $84.61 $0.00 $0.00 $0.00 $0.00 $203.00 $321.55 $324.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800003 EAP Custom 27800003 Coil Embl 30mm .014in 4mm Trfl Psh Cmplx Pltn Nyl BOTH IP/OP $406.00 $300.44 $0.00 $324.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.33 $301.33 $312.94 $0.00 $84.61 $0.00 $0.00 $0.00 $0.00 $203.00 $321.55 $324.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800004 EAP Custom 27800004 Pusher Surg 195cm Trupush Embl Coil .016in BOTH IP/OP "$1,244.00 " $920.56 $0.00 $995.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $923.30 $923.30 $958.88 $0.00 $259.25 $0.00 $0.00 $0.00 $0.00 $622.00 $985.25 $995.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800005 EAP Custom 27800005 Coil Embl 30cm 20mm .038in Azur Frme Elc Dtch Loop BOTH IP/OP "$3,188.00 " "$2,359.12" $0.00 "$2,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,366.13" "$2,366.13" "$2,457.31" $0.00 $664.38 $0.00 $0.00 $0.00 $0.00 "$1,594.00" "$2,524.90" "$2,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800006 EAP Custom 27800006 Coil Embl 30cm 20mm Azur Dtch Ddrgl Peri 35 Sys BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800007 EAP Custom 27800007 Coil Embl 30cm 15mm Azur Dtch Ddrgl Peri 35 Sys BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800008 EAP Custom 27800008 Azur Cx 35 Detachable 20mm/39cm BOTH IP/OP "$2,800.00 " "$2,072.00" $0.00 "$2,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,078.16" "$2,078.16" "$2,158.24" $0.00 $583.52 $0.00 $0.00 $0.00 $0.00 "$1,400.00" "$2,217.60" "$2,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800010 EAP HCPCS C1882 Defibrillator Cardiac Icd Df-1 Biphasic Waveform V BOTH IP/OP "$47,875.00 " "$35,427.50" $0.00 "$38,300.00" "$21,543.75" "$21,543.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$36,902.05" $0.00 "$9,977.15" $0.00 "$23,602.38" "$23,602.38" $0.00 "$23,937.50" "$37,917.00" "$38,300.00" $0.00 $0.00 $0.00 "$7,492.44" $0.00 $0.00 "$7,621.70" $0.00 $0.00 $0.00 $0.00 $0.00 27800011 EAP HCPCS C1876 Stent Vasc 8mm 40mm 75cm Slf Xpd Ilc Art Ep Ntnl Acpt 6fr BOTH IP/OP "$2,887.00 " "$2,136.38" $0.00 "$2,309.60" "$1,299.15" "$1,299.15" $0.00 $0.00 $0.00 $601.72 "$2,142.73" "$2,142.73" "$2,225.30" $0.00 $601.65 $0.00 "$1,423.29" "$1,423.29" $0.00 "$1,443.50" "$2,286.50" "$2,309.60" $0.00 $0.00 $0.00 $451.82 $0.00 $0.00 $459.61 $0.00 $0.00 $0.00 $0.00 $0.00 27800012 EAP HCPCS C1876 Stent Bil 8mm 6fr 37mm 75cm Bln Expandable Prmnt Xpr Ld Mtl BOTH IP/OP "$2,955.00 " "$2,186.70" $0.00 "$2,364.00" "$1,329.75" "$1,329.75" $0.00 $0.00 $0.00 $615.90 "$2,193.20" "$2,193.20" "$2,277.71" $0.00 $615.82 $0.00 "$1,456.82" "$1,456.82" $0.00 "$1,477.50" "$2,340.36" "$2,364.00" $0.00 $0.00 $0.00 $462.46 $0.00 $0.00 $470.44 $0.00 $0.00 $0.00 $0.00 $0.00 27800013 EAP HCPCS C1876 Stent Bil 8mm 6fr 27mm 75cm Bln Expandable Prmnt Xpr Ld Mtl BOTH IP/OP "$2,955.00 " "$2,186.70" $0.00 "$2,364.00" "$1,329.75" "$1,329.75" $0.00 $0.00 $0.00 $615.90 "$2,193.20" "$2,193.20" "$2,277.71" $0.00 $615.82 $0.00 "$1,456.82" "$1,456.82" $0.00 "$1,477.50" "$2,340.36" "$2,364.00" $0.00 $0.00 $0.00 $462.46 $0.00 $0.00 $470.44 $0.00 $0.00 $0.00 $0.00 $0.00 27800014 EAP Custom 27800014 Dvc Embl 25mm 4.5mm Ppln Flx 55d 75% Cocr 25% Pltn BOTH IP/OP "$37,389.00 " "$27,667.86" $0.00 "$29,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,694.50" "$29,612.09" "$29,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800015 EAP HCPCS C1874 Stent Tracheobronchial 16mm Cover Icast 6mm 6fr BOTH IP/OP "$6,009.00 " "$4,446.66" $0.00 "$4,807.20" "$2,704.05" "$2,704.05" $0.00 $0.00 $0.00 "$1,252.43" "$4,181.12" "$4,181.12" "$4,631.74" $0.00 "$1,252.28" $0.00 "$2,962.44" "$2,962.44" $0.00 "$3,004.50" "$4,759.13" "$4,807.20" $0.00 $0.00 $0.00 $940.41 $0.00 $0.00 $956.63 $0.00 $0.00 $0.00 $0.00 $0.00 27800016 EAP Custom 27800016 Dvc Embl 20mm 4.75mm Ppln Flx 55d 75% Ccr 25% Pltn BOTH IP/OP "$34,230.00 " "$25,330.20" $0.00 "$27,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,384.48" $0.00 "$7,133.53" $0.00 $0.00 $0.00 $0.00 "$17,115.00" "$27,110.16" "$27,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800017 EAP HCPCS C1752 Mahurkar Elite Se Catheter Only 16cm BOTH IP/OP $121.00 $89.54 $0.00 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.81 $89.81 $93.27 $0.00 $25.22 $0.00 $0.00 $0.00 $0.00 $60.50 $95.83 $96.80 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800018 EAP HCPCS C1752 Mahurkar Elite Se Catheter Only 20cm BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.26 $94.26 $97.89 $0.00 $26.47 $0.00 $0.00 $0.00 $0.00 $63.50 $100.58 $101.60 $0.00 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800019 EAP HCPCS C1752 Mahurkar Elite Se Catheter Only 24cm BOTH IP/OP $121.00 $89.54 $0.00 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.81 $89.81 $93.27 $0.00 $25.22 $0.00 $0.00 $0.00 $0.00 $60.50 $95.83 $96.80 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800020 EAP HCPCS C1874 Stent Tracheobronchial 16mm Cvr Icast 120cm 7mm 7f BOTH IP/OP "$6,009.00 " "$4,446.66" $0.00 "$4,807.20" "$2,704.05" "$2,704.05" $0.00 $0.00 $0.00 "$1,252.43" "$4,181.12" "$4,181.12" "$4,631.74" $0.00 "$1,252.28" $0.00 "$2,962.44" "$2,962.44" $0.00 "$3,004.50" "$4,759.13" "$4,807.20" $0.00 $0.00 $0.00 $940.41 $0.00 $0.00 $956.63 $0.00 $0.00 $0.00 $0.00 $0.00 27800021 EAP HCPCS C2616 "Yttrium-90,per Source" BOTH IP/OP "$60,196.00 " "$44,545.04" $0.00 "$48,156.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$46,399.08" $0.00 "$12,544.85" $0.00 $0.00 $0.00 $0.00 "$30,098.00" "$47,675.23" "$48,156.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800022 EAP HCPCS C1874 Stent Endoprsth 5cm 5mm Hep Ntnl Eptfe Vbhn 120cm BOTH IP/OP "$8,123.00 " "$6,011.02" $0.00 "$6,498.40" "$3,655.35" "$3,655.35" $0.00 $0.00 $0.00 "$1,693.04" "$4,181.12" "$4,181.12" "$6,261.21" $0.00 "$1,692.83" $0.00 "$4,004.64" "$4,004.64" $0.00 "$4,061.50" "$6,433.42" "$6,498.40" $0.00 $0.00 $0.00 "$1,271.25" $0.00 $0.00 "$1,293.18" $0.00 $0.00 $0.00 $0.00 $0.00 27800023 EAP HCPCS C1874 Stent Endoprsth 10cm 5mm Hep Ntnl Eptfe Vbhn 120cm BOTH IP/OP "$8,123.00 " "$6,011.02" $0.00 "$6,498.40" "$3,655.35" "$3,655.35" $0.00 $0.00 $0.00 "$1,693.04" "$4,181.12" "$4,181.12" "$6,261.21" $0.00 "$1,692.83" $0.00 "$4,004.64" "$4,004.64" $0.00 "$4,061.50" "$6,433.42" "$6,498.40" $0.00 $0.00 $0.00 "$1,271.25" $0.00 $0.00 "$1,293.18" $0.00 $0.00 $0.00 $0.00 $0.00 27800024 EAP HCPCS C1874 Stent Endoprsth 5cm 7mm Hep Ntnl Eptfe Vbhn 120cm BOTH IP/OP "$8,123.00 " "$6,011.02" $0.00 "$6,498.40" "$3,655.35" "$3,655.35" $0.00 $0.00 $0.00 "$1,693.04" "$4,181.12" "$4,181.12" "$6,261.21" $0.00 "$1,692.83" $0.00 "$4,004.64" "$4,004.64" $0.00 "$4,061.50" "$6,433.42" "$6,498.40" $0.00 $0.00 $0.00 "$1,271.25" $0.00 $0.00 "$1,293.18" $0.00 $0.00 $0.00 $0.00 $0.00 27800025 EAP HCPCS C1874 Stent Endoprsth 10cm 7mm Hep Ntnl Eptfe Vbhn 120cm BOTH IP/OP "$8,123.00 " "$6,011.02" $0.00 "$6,498.40" "$3,655.35" "$3,655.35" $0.00 $0.00 $0.00 "$1,693.04" "$4,181.12" "$4,181.12" "$6,261.21" $0.00 "$1,692.83" $0.00 "$4,004.64" "$4,004.64" $0.00 "$4,061.50" "$6,433.42" "$6,498.40" $0.00 $0.00 $0.00 "$1,271.25" $0.00 $0.00 "$1,293.18" $0.00 $0.00 $0.00 $0.00 $0.00 27800026 EAP HCPCS C1757 Mindframe Capture Lp 3x2 Revascularization Device BOTH IP/OP "$11,643.00 " "$8,615.82" $0.00 "$9,314.40" "$5,239.35" "$5,239.35" $0.00 $0.00 $0.00 "$2,426.69" "$4,181.12" "$4,181.12" "$8,974.42" $0.00 "$2,426.40" $0.00 "$5,740.00" "$5,740.00" $0.00 "$5,821.50" "$9,221.26" "$9,314.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800029 EAP HCPCS C1876 Stent Vasc 13mm 2.5mm Lvis Jr Intrlum Ntnl 3 Flr BOTH IP/OP "$17,219.00 " "$12,742.06" $0.00 "$13,775.20" "$7,748.55" "$7,748.55" $0.00 $0.00 $0.00 "$3,588.87" "$4,181.12" "$4,181.12" "$13,272.41" $0.00 "$3,588.44" $0.00 "$8,488.97" "$8,488.97" $0.00 "$8,609.50" "$13,637.45" "$13,775.20" $0.00 $0.00 $0.00 "$2,694.77" $0.00 $0.00 "$2,741.26" $0.00 $0.00 $0.00 $0.00 $0.00 27800030 EAP HCPCS C1876 Stent Vasc 17mm 2.5mm Lvis Jr Intrlum Ntnl 3 Flr BOTH IP/OP "$17,219.00 " "$12,742.06" $0.00 "$13,775.20" "$7,748.55" "$7,748.55" $0.00 $0.00 $0.00 "$3,588.87" "$4,181.12" "$4,181.12" "$13,272.41" $0.00 "$3,588.44" $0.00 "$8,488.97" "$8,488.97" $0.00 "$8,609.50" "$13,637.45" "$13,775.20" $0.00 $0.00 $0.00 "$2,694.77" $0.00 $0.00 "$2,741.26" $0.00 $0.00 $0.00 $0.00 $0.00 27800031 EAP HCPCS C1876 Stent Vasc 23mm 2.5mm Lvis Jr Intrlum Ntnl 3 Flr BOTH IP/OP "$17,219.00 " "$12,742.06" $0.00 "$13,775.20" "$7,748.55" "$7,748.55" $0.00 $0.00 $0.00 "$3,588.87" "$4,181.12" "$4,181.12" "$13,272.41" $0.00 "$3,588.44" $0.00 "$8,488.97" "$8,488.97" $0.00 "$8,609.50" "$13,637.45" "$13,775.20" $0.00 $0.00 $0.00 "$2,694.77" $0.00 $0.00 "$2,741.26" $0.00 $0.00 $0.00 $0.00 $0.00 27800032 EAP HCPCS C1876 Stent Vasc 34mm 2.5mm Lvis Jr Intrlum Ntnl 3 Flr BOTH IP/OP "$17,219.00 " "$12,742.06" $0.00 "$13,775.20" "$7,748.55" "$7,748.55" $0.00 $0.00 $0.00 "$3,588.87" "$4,181.12" "$4,181.12" "$13,272.41" $0.00 "$3,588.44" $0.00 "$8,488.97" "$8,488.97" $0.00 "$8,609.50" "$13,637.45" "$13,775.20" $0.00 $0.00 $0.00 "$2,694.77" $0.00 $0.00 "$2,741.26" $0.00 $0.00 $0.00 $0.00 $0.00 27800033 EAP HCPCS C1764 System Crd Monitr Rvl Impltable Ins Loop BOTH IP/OP "$13,900.00 " "$10,286.00" $0.00 "$11,120.00" "$6,255.00" "$6,255.00" $0.00 $0.00 $0.00 "$2,897.11" "$4,181.12" "$4,181.12" "$10,714.12" $0.00 "$2,896.76" $0.00 "$6,852.70" "$6,852.70" $0.00 "$6,950.00" "$11,008.80" "$11,120.00" $0.00 "$6,255.00" $0.00 "$2,175.35" $0.00 $0.00 "$2,212.88" $0.00 $0.00 $0.00 $0.00 $0.00 27800035 EAP HCPCS C1778 Lead Nrstm 50cm Prcs .014in Trl Lnr Str Tip Preld BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $963.50 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800039 EAP HCPCS C1876 Stent Endo 100cm 12mm 8fr 60mm 75cm Flexible Deliv BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" "$2,023.35" $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 27800040 EAP HCPCS C1876 Stent Endo 100cm 14mm 40mm 75cm Unconstrain Flex BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" "$2,023.35" $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 "$1,181.25" $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 27800041 EAP HCPCS C1876 Stent Endo 100cm 14mm 9fr 60mm 75cm Cath BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" "$2,023.35" $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 27800042 EAP HCPCS C1874 Stent Endoprsth 8mm 7fr 5cm 120cm Delivery System BOTH IP/OP "$7,738.00 " "$5,726.12" $0.00 "$6,190.40" "$3,482.10" "$3,482.10" $0.00 $0.00 $0.00 "$1,612.79" "$4,181.12" "$4,181.12" "$5,964.45" $0.00 "$1,612.60" $0.00 "$3,814.83" "$3,814.83" $0.00 "$3,869.00" "$6,128.50" "$6,190.40" $0.00 $0.00 $0.00 "$1,211.00" $0.00 $0.00 "$1,231.89" $0.00 $0.00 $0.00 $0.00 $0.00 27800043 EAP HCPCS C1876 Stent Vasc 6.5mm 6fr 100mm 120cm Otw Slf BOTH IP/OP "$1,988.00 " "$1,471.12" $0.00 "$1,590.40" $894.60 $894.60 $0.00 $0.00 $0.00 $414.35 "$1,475.49" "$1,475.49" "$1,532.35" $0.00 $414.30 $0.00 "$1,175.90" "$1,175.90" $0.00 $994.00 "$1,574.50" "$1,590.40" $0.00 $0.00 $0.00 $311.12 $0.00 $0.00 $316.49 $0.00 $0.00 $0.00 $0.00 $0.00 27800044 EAP HCPCS C1874 Graft Evas 32mm 8.1mm 20fr 124mm Znth 2 Intnl Stnt BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27800045 EAP HCPCS C1874 Graft Evas 2 Brch 12mm 8.1mm 20fr 91mm 62mm Znth I BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27800046 EAP Space Oar Hydrogel BOTH IP/OP "$7,125.00 " "$5,272.50" $0.00 "$5,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,491.95" $0.00 "$1,484.85" $0.00 $0.00 $0.00 $0.00 "$3,562.50" "$5,643.00" "$5,700.00" $0.00 "$3,206.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800053 EAP HCPCS C1757 Ace68 Reperfusion Catheter Kit BOTH IP/OP "$6,988.00 " "$5,171.12" $0.00 "$5,590.40" "$3,144.60" "$3,144.60" $0.00 $0.00 $0.00 "$1,456.47" "$4,181.12" "$4,181.12" "$5,386.35" $0.00 "$1,456.30" $0.00 "$3,445.08" "$3,445.08" $0.00 "$3,494.00" "$5,534.50" "$5,590.40" $0.00 "$3,144.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800055 EAP HCPCS C1880 Option Elite Vena Cava Filter System BOTH IP/OP "$2,941.00 " "$2,176.34" $0.00 "$2,352.80" "$1,323.45" "$1,323.45" $0.00 $0.00 $0.00 $612.98 "$2,182.81" "$2,182.81" "$2,266.92" $0.00 $612.90 $0.00 "$1,449.91" "$1,449.91" $0.00 "$1,470.50" "$2,329.27" "$2,352.80" $0.00 "$1,323.45" $0.00 $460.27 $0.00 $0.00 $468.21 $0.00 $0.00 $0.00 $0.00 $0.00 27800056 EAP Custom 27800056 Coil Embl 3cm 2mm Nst 4.8 Loop Sft Enh Radopc Mciol .01n BOTH IP/OP $279.00 $206.46 $0.00 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.07 $207.07 $215.05 $0.00 $58.14 $0.00 $0.00 $0.00 $0.00 $139.50 $220.97 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800057 EAP Custom 27800057 Coil Embl 3cm 3mm Nst 3.2 Loop Sft Enh Radopc Mciol .01n BOTH IP/OP $279.00 $206.46 $0.00 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.07 $207.07 $215.05 $0.00 $58.14 $0.00 $0.00 $0.00 $0.00 $139.50 $220.97 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800058 EAP Custom 27800058 Coil Embl 5cm 3mm Nst 5.3 Loop Sft Enh Radopc Mciol .01n BOTH IP/OP $271.00 $200.54 $0.00 $216.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.14 $201.14 $208.89 $0.00 $56.48 $0.00 $0.00 $0.00 $0.00 $135.50 $214.63 $216.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800059 EAP Custom 27800059 Coil Embl 7cm 6mm Nst 3.7 Loop Sft Enh Radopc .035in Pln BOTH IP/OP $294.00 $217.56 $0.00 $235.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.21 $218.21 $226.62 $0.00 $61.27 $0.00 $0.00 $0.00 $0.00 $147.00 $232.85 $235.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800060 EAP Custom 27800060 Coil Embl 7cm 8mm Nst 2.8 Loop Sft Enh Radopc .035in Pln BOTH IP/OP $294.00 $217.56 $0.00 $235.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.21 $218.21 $226.62 $0.00 $61.27 $0.00 $0.00 $0.00 $0.00 $147.00 $232.85 $235.20 $0.00 $132.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800061 EAP Custom 27800061 Coil Embl 14cm 16mm Nst 2.8 Loop Sft Enh Radopc .035in N BOTH IP/OP $320.00 $236.80 $0.00 $256.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.50 $237.50 $246.66 $0.00 $66.69 $0.00 $0.00 $0.00 $0.00 $160.00 $253.44 $256.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800062 EAP HCPCS C1874 Drug Eluting Stent BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800063 EAP HCPCS C1876 Bare Metal Stent BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800064 EAP HCPCS C1894 Glidesheath Slender Ss (.021) 5fr 10cm BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $62.10 $62.10 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $69.00 $109.30 $110.40 $0.00 $62.10 $0.00 $21.60 $0.00 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 27800065 EAP HCPCS C1894 Glidesheath Slender Ss (.021) 7fr 10cm BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $62.10 $62.10 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $69.00 $109.30 $110.40 $0.00 $62.10 $0.00 $21.60 $0.00 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 27800066 EAP HCPCS A4648 Visicoil Lung Gold Seeds 0.50mm X 0.50cm Length BOTH IP/OP $338.00 $250.12 $0.00 $270.40 $152.10 $152.10 $0.00 $0.00 $0.00 $70.45 $250.86 $250.86 $260.53 $0.00 $70.44 $0.00 $199.93 $199.93 $0.00 $169.00 $267.70 $270.40 $0.00 $152.10 $0.00 $52.90 $0.00 $0.00 $53.81 $0.00 $0.00 $0.00 $0.00 $0.00 27800100 EAP Catheter Dlv Sys 130cm 5fr .04in Neuron .035in BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800101 EAP HCPCS C1817 Occluder Cardio 15mm Spt Sft Wire Frm Flrscp Img BOTH IP/OP "$17,493.00 " "$12,944.82" $0.00 "$13,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,483.60" $0.00 "$3,645.54" $0.00 $0.00 $0.00 $0.00 "$8,746.50" "$13,854.46" "$13,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800102 EAP HCPCS C1817 Occluder Cardio 20mm Spt Sft Wire Frm Flrscp Img BOTH IP/OP "$17,493.00 " "$12,944.82" $0.00 "$13,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,483.60" $0.00 "$3,645.54" $0.00 $0.00 $0.00 $0.00 "$8,746.50" "$13,854.46" "$13,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800103 EAP HCPCS C1817 Occluder Cardio 25mm Spt Sft Wire Frm Flrscp Img BOTH IP/OP "$17,493.00 " "$12,944.82" $0.00 "$13,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,483.60" $0.00 "$3,645.54" $0.00 $0.00 $0.00 $0.00 "$8,746.50" "$13,854.46" "$13,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800104 EAP HCPCS C1817 Occluder Cardio 30mm Spt Sft Wire Frm Flrscp Img BOTH IP/OP "$17,493.00 " "$12,944.82" $0.00 "$13,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,483.60" $0.00 "$3,645.54" $0.00 $0.00 $0.00 $0.00 "$8,746.50" "$13,854.46" "$13,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27800105 EAP CPT® C1887 Catheter Angiography Guiding Upsized Cps Direct 13 BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $114.25 $0.00 $0.00 $116.22 $0.00 $0.00 $0.00 $0.00 $0.00 27801001 EAP HCPCS C1721 Livian Dual Crt-d Device BOTH IP/OP "$102,209.00 " "$75,634.66" $0.00 "$81,767.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$78,782.70" $0.00 "$21,300.36" $0.00 "$50,389.04" "$50,389.04" $0.00 "$51,104.50" "$80,949.53" "$81,767.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801002 EAP HCPCS C1721 Entrust At Dual Icd BOTH IP/OP "$63,028.00 " "$46,640.72" $0.00 "$50,422.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$48,581.98" $0.00 "$13,135.04" $0.00 "$31,072.80" "$31,072.80" $0.00 "$31,514.00" "$49,918.18" "$50,422.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801003 EAP HCPCS C1721 Maximo Dr Dual Icd BOTH IP/OP "$48,414.00 " "$35,826.36" $0.00 "$38,731.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$37,317.51" $0.00 "$10,089.48" $0.00 "$23,868.10" "$23,868.10" $0.00 "$24,207.00" "$38,343.89" "$38,731.20" $0.00 $0.00 $0.00 "$7,576.79" $0.00 $0.00 "$7,707.51" $0.00 $0.00 $0.00 $0.00 $0.00 27801004 EAP HCPCS C1722 Entrust Vr Single Icd BOTH IP/OP "$51,104.00 " "$37,816.96" $0.00 "$40,883.20" "$22,996.80" "$22,996.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$39,390.96" $0.00 "$10,650.07" $0.00 "$25,194.27" "$25,194.27" $0.00 "$25,552.00" "$40,474.37" "$40,883.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,135.76" $0.00 $0.00 $0.00 $0.00 $0.00 27801005 EAP HCPCS C1722 Maximo Vr Sindle Icd BOTH IP/OP "$39,450.00 " "$29,193.00" $0.00 "$31,560.00" "$17,752.50" "$17,752.50" $0.00 $0.00 $0.00 "$8,222.37" "$4,181.12" "$4,181.12" "$30,408.06" $0.00 "$8,221.38" $0.00 "$19,448.85" "$19,448.85" $0.00 "$19,725.00" "$31,244.40" "$31,560.00" $0.00 $0.00 $0.00 "$6,173.93" $0.00 $0.00 "$6,280.44" $0.00 $0.00 $0.00 $0.00 $0.00 27801006 EAP HCPCS C1722 Virtuoso Single Icd BOTH IP/OP "$51,104.00 " "$37,816.96" $0.00 "$40,883.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$25,552.00" "$40,474.37" "$40,883.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,135.76" $0.00 $0.00 $0.00 $0.00 $0.00 27801007 EAP HCPCS C1721 Ventak Prizm Dr Icd BOTH IP/OP "$53,793.00 " "$39,806.82" $0.00 "$43,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,463.64" $0.00 "$11,210.46" $0.00 "$26,519.95" "$26,519.95" $0.00 "$26,896.50" "$42,604.06" "$43,034.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801008 EAP HCPCS C1895 Sprint 6947 Rv Lead BOTH IP/OP "$16,139.00 " "$11,942.86" $0.00 "$12,911.20" "$7,262.55" "$7,262.55" $0.00 $0.00 $0.00 "$3,363.77" "$4,181.12" "$4,181.12" "$12,439.94" $0.00 "$3,363.37" $0.00 "$7,956.53" "$7,956.53" $0.00 "$8,069.50" "$12,782.09" "$12,911.20" $0.00 "$7,262.55" $0.00 "$2,525.75" $0.00 $0.00 "$2,569.33" $0.00 $0.00 $0.00 $0.00 $0.00 27801009 EAP HCPCS C1895 Linox Sd Lead BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 $0.00 $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27801010 EAP HCPCS C1895 Isoline Passive Fix Lead BOTH IP/OP "$15,063.00 " "$11,146.62" $0.00 "$12,050.40" "$6,778.35" "$6,778.35" $0.00 $0.00 $0.00 "$3,139.51" "$4,181.12" "$4,181.12" "$11,610.56" $0.00 "$3,139.13" $0.00 "$7,426.06" "$7,426.06" $0.00 "$7,531.50" "$11,929.90" "$12,050.40" $0.00 $0.00 $0.00 "$2,357.36" $0.00 $0.00 "$2,398.03" $0.00 $0.00 $0.00 $0.00 $0.00 27801011 EAP HCPCS C1895 Tachycardia Lead BOTH IP/OP "$15,063.00 " "$11,146.62" $0.00 "$12,050.40" "$6,778.35" "$6,778.35" $0.00 $0.00 $0.00 "$3,139.51" "$4,181.12" "$4,181.12" "$11,610.56" $0.00 "$3,139.13" $0.00 "$7,426.06" "$7,426.06" $0.00 "$7,531.50" "$11,929.90" "$12,050.40" $0.00 $0.00 $0.00 "$2,357.36" $0.00 $0.00 "$2,398.03" $0.00 $0.00 $0.00 $0.00 $0.00 27801012 EAP HCPCS C1895 7120 Durata Pkg Lead BOTH IP/OP "$15,063.00 " "$11,146.62" $0.00 "$12,050.40" "$6,778.35" "$6,778.35" $0.00 $0.00 $0.00 "$3,139.51" "$4,181.12" "$4,181.12" "$11,610.56" $0.00 "$3,139.13" $0.00 "$7,426.06" "$7,426.06" $0.00 "$7,531.50" "$11,929.90" "$12,050.40" $0.00 $0.00 $0.00 "$2,357.36" $0.00 $0.00 "$2,398.03" $0.00 $0.00 $0.00 $0.00 $0.00 27801013 EAP HCPCS C1721 Atlas Plus Dr Dual Icd BOTH IP/OP "$50,207.00 " "$37,153.18" $0.00 "$40,165.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,699.56" $0.00 "$10,463.14" $0.00 "$24,752.05" "$24,752.05" $0.00 "$25,103.50" "$39,763.94" "$40,165.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,992.95" $0.00 $0.00 $0.00 $0.00 $0.00 27801014 EAP HCPCS C1722 Atlas Plus Vr Sngl Icd BOTH IP/OP "$39,450.00 " "$29,193.00" $0.00 "$31,560.00" "$17,752.50" "$17,752.50" $0.00 $0.00 $0.00 "$8,222.37" "$4,181.12" "$4,181.12" "$30,408.06" $0.00 "$8,221.38" $0.00 "$19,448.85" "$19,448.85" $0.00 "$19,725.00" "$31,244.40" "$31,560.00" $0.00 $0.00 $0.00 "$6,173.93" $0.00 $0.00 "$6,280.44" $0.00 $0.00 $0.00 $0.00 $0.00 27801015 EAP HCPCS C1722 Atlas Plus C Header Icd BOTH IP/OP "$39,450.00 " "$29,193.00" $0.00 "$31,560.00" "$17,752.50" "$17,752.50" $0.00 $0.00 $0.00 "$8,222.37" "$4,181.12" "$4,181.12" "$30,408.06" $0.00 "$8,221.38" $0.00 "$19,448.85" "$19,448.85" $0.00 "$19,725.00" "$31,244.40" "$31,560.00" $0.00 $0.00 $0.00 "$6,173.93" $0.00 $0.00 "$6,280.44" $0.00 $0.00 $0.00 $0.00 $0.00 27801016 EAP HCPCS C1722 Atlas Ii Vr Sngl Icd BOTH IP/OP "$39,450.00 " "$29,193.00" $0.00 "$31,560.00" "$17,752.50" "$17,752.50" $0.00 $0.00 $0.00 "$8,222.37" "$4,181.12" "$4,181.12" "$30,408.06" $0.00 "$8,221.38" $0.00 "$19,448.85" "$19,448.85" $0.00 "$19,725.00" "$31,244.40" "$31,560.00" $0.00 $0.00 $0.00 "$6,173.93" $0.00 $0.00 "$6,280.44" $0.00 $0.00 $0.00 $0.00 $0.00 27801017 EAP HCPCS C1722 Lumax 340 Vr-t Single Icd BOTH IP/OP "$39,450.00 " "$29,193.00" $0.00 "$31,560.00" "$17,752.50" "$17,752.50" $0.00 $0.00 $0.00 "$8,222.37" "$4,181.12" "$4,181.12" "$30,408.06" $0.00 "$8,221.38" $0.00 "$19,448.85" "$19,448.85" $0.00 "$19,725.00" "$31,244.40" "$31,560.00" $0.00 $0.00 $0.00 "$6,173.93" $0.00 $0.00 "$6,280.44" $0.00 $0.00 $0.00 $0.00 $0.00 27801018 EAP HCPCS C1721 Lumax 340 Dr-t Dual Icd BOTH IP/OP "$46,622.00 " "$34,500.28" $0.00 "$37,297.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,936.24" $0.00 "$9,716.02" $0.00 "$22,984.65" "$22,984.65" $0.00 "$23,311.00" "$36,924.62" "$37,297.60" $0.00 $0.00 $0.00 "$7,296.34" $0.00 $0.00 "$7,422.22" $0.00 $0.00 $0.00 $0.00 $0.00 27801019 EAP HCPCS C1721 Atlas Ii+ Dr Dual Icd BOTH IP/OP "$66,346.00 " "$49,096.04" $0.00 "$53,076.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$51,139.50" $0.00 "$13,826.51" $0.00 "$32,708.58" "$32,708.58" $0.00 "$33,173.00" "$52,546.03" "$53,076.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801020 EAP HCPCS C1898 Bradycardia Lead BOTH IP/OP "$1,920.00 " "$1,420.80" $0.00 "$1,536.00" $864.00 $864.00 $0.00 $0.00 $0.00 $400.18 "$1,425.02" "$1,425.02" "$1,479.94" $0.00 $400.13 $0.00 "$1,135.68" "$1,135.68" $0.00 $960.00 "$1,520.64" "$1,536.00" $0.00 $864.00 $0.00 $300.48 $0.00 $0.00 $305.66 $0.00 $0.00 $0.00 $0.00 $0.00 27801021 EAP HCPCS C1721 Ovatio Oh60u Dr 6550 Icd BOTH IP/OP "$53,793.00 " "$39,806.82" $0.00 "$43,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,463.64" $0.00 "$11,210.46" $0.00 "$26,519.95" "$26,519.95" $0.00 "$26,896.50" "$42,604.06" "$43,034.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801022 EAP HCPCS C1722 Ovatio Oh61u Vr Icd BOTH IP/OP "$43,036.00 " "$31,846.64" $0.00 "$34,428.80" "$19,366.20" "$19,366.20" $0.00 $0.00 $0.00 "$8,969.78" "$4,181.12" "$4,181.12" "$33,172.15" $0.00 "$8,968.70" $0.00 "$21,216.75" "$21,216.75" $0.00 "$21,518.00" "$34,084.51" "$34,428.80" $0.00 $0.00 $0.00 "$6,735.13" $0.00 $0.00 "$6,851.33" $0.00 $0.00 $0.00 $0.00 $0.00 27801023 EAP HCPCS C1882 Ovatio Crt 6750 Icd BOTH IP/OP "$69,035.00 " "$51,085.90" $0.00 "$55,228.00" "$31,065.75" "$31,065.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$53,212.18" $0.00 "$14,386.89" $0.00 "$34,034.26" "$34,034.26" $0.00 "$34,517.50" "$54,675.72" "$55,228.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801024 EAP HCPCS C1882 Lumax 340 Hf-t Crt BOTH IP/OP "$63,656.00 " "$47,105.44" $0.00 "$50,924.80" "$28,645.20" "$28,645.20" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$49,066.04" $0.00 "$13,265.91" $0.00 "$31,382.41" "$31,382.41" $0.00 "$31,828.00" "$50,415.55" "$50,924.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801025 EAP HCPCS C1882 Concerto Bi-v Icd BOTH IP/OP "$81,588.00 " "$60,375.12" $0.00 "$65,270.40" "$36,714.60" "$36,714.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$62,888.03" $0.00 "$17,002.94" $0.00 "$40,222.88" "$40,222.88" $0.00 "$40,794.00" "$64,617.70" "$65,270.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801026 EAP HCPCS C1895 Linox S 65 BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 $0.00 $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27801027 EAP HCPCS C1895 Kainox S 60 BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 $0.00 $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27801028 EAP HCPCS C1882 Promote Bi-v BOTH IP/OP "$73,870.00 " "$54,663.80" $0.00 "$59,096.00" "$33,241.50" "$33,241.50" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$56,939.00" $0.00 "$15,394.51" $0.00 "$36,417.91" "$36,417.91" $0.00 "$36,935.00" "$58,505.04" "$59,096.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801029 EAP HCPCS C1882 Maximo Ii Crt-d BOTH IP/OP "$77,107.00 " "$57,059.18" $0.00 "$61,685.60" "$34,698.15" "$34,698.15" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$59,434.08" $0.00 "$16,069.10" $0.00 "$38,013.75" "$38,013.75" $0.00 "$38,553.50" "$61,068.74" "$61,685.60" $0.00 "$34,698.15" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801030 EAP HCPCS C1895 Setrox S 45 Lead BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $806.85 $806.85 $0.00 $0.00 $0.00 $373.71 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 "$1,060.56" "$1,060.56" $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $806.85 $0.00 $280.60 $0.00 $0.00 $285.45 $0.00 $0.00 $0.00 $0.00 $0.00 27801031 EAP HCPCS C1895 Setrox S 53 Lead BOTH IP/OP "$1,793.00 " "$1,326.82" $0.00 "$1,434.40" $806.85 $806.85 $0.00 $0.00 $0.00 $373.71 "$1,330.76" "$1,330.76" "$1,382.04" $0.00 $373.66 $0.00 "$1,060.56" "$1,060.56" $0.00 $896.50 "$1,420.06" "$1,434.40" $0.00 $0.00 $0.00 $280.60 $0.00 $0.00 $285.45 $0.00 $0.00 $0.00 $0.00 $0.00 27801032 EAP HCPCS C1882 Paradym Crt-d 8750 BOTH IP/OP "$82,842.00 " "$61,303.08" $0.00 "$66,273.60" "$37,278.90" "$37,278.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$63,854.61" $0.00 "$17,264.27" $0.00 "$40,841.11" "$40,841.11" $0.00 "$41,421.00" "$65,610.86" "$66,273.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801033 EAP HCPCS C1721 Maximo Ii Dr Dual Icd BOTH IP/OP "$55,588.00 " "$41,135.12" $0.00 "$44,470.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$42,847.23" $0.00 "$11,584.54" $0.00 "$27,404.88" "$27,404.88" $0.00 "$27,794.00" "$44,025.70" "$44,470.40" $0.00 "$25,014.60" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801034 EAP HCPCS C1722 Maximo Ii Vr Single Icd BOTH IP/OP "$46,622.00 " "$34,500.28" $0.00 "$37,297.60" "$20,979.90" "$20,979.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,936.24" $0.00 "$9,716.02" $0.00 "$22,984.65" "$22,984.65" $0.00 "$23,311.00" "$36,924.62" "$37,297.60" $0.00 $0.00 $0.00 "$7,296.34" $0.00 $0.00 "$7,422.22" $0.00 $0.00 $0.00 $0.00 $0.00 27801035 EAP HCPCS C1722 1211-36 Current Vr Icd BOTH IP/OP "$59,175.00 " "$43,789.50" $0.00 "$47,340.00" "$26,628.75" "$26,628.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,612.09" $0.00 "$12,332.07" $0.00 "$29,173.28" "$29,173.28" $0.00 "$29,587.50" "$46,866.60" "$47,340.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801040 EAP HCPCS C1880 Vena Tech Lp Filter BOTH IP/OP "$3,618.00 " "$2,677.32" $0.00 "$2,894.40" "$1,628.10" "$1,628.10" $0.00 $0.00 $0.00 $754.08 "$2,685.28" "$2,685.28" "$2,788.75" $0.00 $753.99 $0.00 "$1,783.67" "$1,783.67" $0.00 "$1,809.00" "$2,865.46" "$2,894.40" $0.00 $0.00 $0.00 $566.22 $0.00 $0.00 $575.99 $0.00 $0.00 $0.00 $0.00 $0.00 27801041 EAP HCPCS C1876 6fr-75cm 10x49 Wall BOTH IP/OP "$3,307.00 " "$2,447.18" $0.00 "$2,645.60" "$1,488.15" "$1,488.15" $0.00 $0.00 $0.00 $689.26 "$2,454.46" "$2,454.46" "$2,549.04" $0.00 $689.18 $0.00 "$1,630.35" "$1,630.35" $0.00 "$1,653.50" "$2,619.14" "$2,645.60" $0.00 $0.00 $0.00 $517.55 $0.00 $0.00 $526.47 $0.00 $0.00 $0.00 $0.00 $0.00 27801042 EAP HCPCS C1876 6fr-8x80-75cmwallst BOTH IP/OP "$3,307.00 " "$2,447.18" $0.00 "$2,645.60" "$1,488.15" "$1,488.15" $0.00 $0.00 $0.00 $689.26 "$2,454.46" "$2,454.46" "$2,549.04" $0.00 $689.18 $0.00 "$1,630.35" "$1,630.35" $0.00 "$1,653.50" "$2,619.14" "$2,645.60" $0.00 $0.00 $0.00 $517.55 $0.00 $0.00 $526.47 $0.00 $0.00 $0.00 $0.00 $0.00 27801043 EAP HCPCS C1876 7fr-75cm 10x94 Wall BOTH IP/OP "$5,303.00 " "$3,924.22" $0.00 "$4,242.40" "$2,386.35" "$2,386.35" $0.00 $0.00 $0.00 "$1,105.28" "$3,935.89" "$3,935.89" "$4,087.55" $0.00 "$1,105.15" $0.00 "$2,614.38" "$2,614.38" $0.00 "$2,651.50" "$4,199.98" "$4,242.40" $0.00 $0.00 $0.00 $829.92 $0.00 $0.00 $844.24 $0.00 $0.00 $0.00 $0.00 $0.00 27801044 EAP HCPCS C2625 8fr-26cm Ureteral S BOTH IP/OP $404.00 $298.96 $0.00 $323.20 $181.80 $181.80 $0.00 $0.00 $0.00 $84.20 $299.85 $299.85 $311.40 $0.00 $84.19 $0.00 $238.97 $238.97 $0.00 $202.00 $319.97 $323.20 $0.00 $0.00 $0.00 $63.23 $0.00 $0.00 $64.32 $0.00 $0.00 $0.00 $0.00 $0.00 27801045 EAP HCPCS C1876 8mmx40mm Wallstent BOTH IP/OP "$5,303.00 " "$3,924.22" $0.00 "$4,242.40" "$2,386.35" "$2,386.35" $0.00 $0.00 $0.00 "$1,105.28" "$3,935.89" "$3,935.89" "$4,087.55" $0.00 "$1,105.15" $0.00 "$2,614.38" "$2,614.38" $0.00 "$2,651.50" "$4,199.98" "$4,242.40" $0.00 $0.00 $0.00 $829.92 $0.00 $0.00 $844.24 $0.00 $0.00 $0.00 $0.00 $0.00 27801046 EAP HCPCS C1874 9frx16x90-75cm Wall BOTH IP/OP "$5,303.00 " "$3,924.22" $0.00 "$4,242.40" "$2,386.35" "$2,386.35" $0.00 $0.00 $0.00 "$1,105.28" "$3,935.89" "$3,935.89" "$4,087.55" $0.00 "$1,105.15" $0.00 "$2,614.38" "$2,614.38" $0.00 "$2,651.50" "$4,199.98" "$4,242.40" $0.00 "$2,386.35" $0.00 $829.92 $0.00 $0.00 $844.24 $0.00 $0.00 $0.00 $0.00 $0.00 27801047 EAP HCPCS C1874 Wall Graft 7mm X 3 BOTH IP/OP "$6,506.00 " "$4,814.44" $0.00 "$5,204.80" "$2,927.70" "$2,927.70" $0.00 $0.00 $0.00 "$1,356.01" "$4,181.12" "$4,181.12" "$5,014.82" $0.00 "$1,355.85" $0.00 "$3,207.46" "$3,207.46" $0.00 "$3,253.00" "$5,152.75" "$5,204.80" $0.00 $0.00 $0.00 "$1,018.19" $0.00 $0.00 "$1,035.76" $0.00 $0.00 $0.00 $0.00 $0.00 27801048 EAP HCPCS C1874 Wallgraft 10 X 50m BOTH IP/OP "$6,506.00 " "$4,814.44" $0.00 "$5,204.80" "$2,927.70" "$2,927.70" $0.00 $0.00 $0.00 "$1,356.01" "$4,181.12" "$4,181.12" "$5,014.82" $0.00 "$1,355.85" $0.00 "$3,207.46" "$3,207.46" $0.00 "$3,253.00" "$5,152.75" "$5,204.80" $0.00 $0.00 $0.00 "$1,018.19" $0.00 $0.00 "$1,035.76" $0.00 $0.00 $0.00 $0.00 $0.00 27801049 EAP HCPCS C1874 Wallgraft 12 X 70m BOTH IP/OP "$7,505.00 " "$5,553.70" $0.00 "$6,004.00" "$3,377.25" "$3,377.25" $0.00 $0.00 $0.00 "$1,564.23" "$4,181.12" "$4,181.12" "$5,784.85" $0.00 "$1,564.04" $0.00 "$3,699.97" "$3,699.97" $0.00 "$3,752.50" "$5,943.96" "$6,004.00" $0.00 $0.00 $0.00 "$1,174.53" $0.00 $0.00 "$1,194.80" $0.00 $0.00 $0.00 $0.00 $0.00 27801050 EAP HCPCS C1876 21v7-7-80-8.0-30 St BOTH IP/OP "$5,245.00 " "$3,881.30" $0.00 "$4,196.00" "$2,360.25" "$2,360.25" $0.00 $0.00 $0.00 "$1,093.19" "$3,892.84" "$3,892.84" "$4,042.85" $0.00 "$1,093.06" $0.00 "$2,585.79" "$2,585.79" $0.00 "$2,622.50" "$4,154.04" "$4,196.00" $0.00 $0.00 $0.00 $820.84 $0.00 $0.00 $835.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801051 EAP HCPCS C2625 8.5fr-22cm Nephrour BOTH IP/OP $361.00 $267.14 $0.00 $288.80 $162.45 $162.45 $0.00 $0.00 $0.00 $75.24 $267.93 $267.93 $278.26 $0.00 $75.23 $0.00 $213.53 $213.53 $0.00 $180.50 $285.91 $288.80 $0.00 $162.45 $0.00 $56.50 $0.00 $0.00 $57.47 $0.00 $0.00 $0.00 $0.00 $0.00 27801052 EAP HCPCS C2625 8.5fr-24cm Nephrour BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $269.78 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $157.50 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 27801053 EAP HCPCS C2625 8.5fr-28cm Nephrour BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $269.78 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $157.50 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 27801054 EAP HCPCS C1876 Ziv7-80-8.0-60 Sten BOTH IP/OP "$5,245.00 " "$3,881.30" $0.00 "$4,196.00" "$2,360.25" "$2,360.25" $0.00 $0.00 $0.00 "$1,093.19" "$3,892.84" "$3,892.84" "$4,042.85" $0.00 "$1,093.06" $0.00 "$2,585.79" "$2,585.79" $0.00 "$2,622.50" "$4,154.04" "$4,196.00" $0.00 $0.00 $0.00 $820.84 $0.00 $0.00 $835.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801055 EAP HCPCS C1875 6x 40 Fluency Stent Graft Old BOTH IP/OP "$7,656.00 " "$5,665.44" $0.00 "$6,124.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,901.24" $0.00 "$1,595.51" $0.00 $0.00 $0.00 $0.00 "$3,828.00" "$6,063.55" "$6,124.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801056 EAP HCPCS C1876 10 X 40 Luminexx Stent BOTH IP/OP "$4,186.00 " "$3,097.64" $0.00 "$3,348.80" "$1,883.70" "$1,883.70" $0.00 $0.00 $0.00 $872.47 "$3,106.85" "$3,106.85" "$3,226.57" $0.00 $872.36 $0.00 "$2,063.70" "$2,063.70" $0.00 "$2,093.00" "$3,315.31" "$3,348.80" $0.00 $0.00 $0.00 $655.11 $0.00 $0.00 $666.41 $0.00 $0.00 $0.00 $0.00 $0.00 27801057 EAP HCPCS C1880 Simon Nitinol Filte BOTH IP/OP "$2,836.00 " "$2,098.64" $0.00 "$2,268.80" "$1,276.20" "$1,276.20" $0.00 $0.00 $0.00 $591.09 "$2,104.88" "$2,104.88" "$2,185.99" $0.00 $591.02 $0.00 "$1,398.15" "$1,398.15" $0.00 "$1,418.00" "$2,246.11" "$2,268.80" $0.00 $0.00 $0.00 $443.83 $0.00 $0.00 $451.49 $0.00 $0.00 $0.00 $0.00 $0.00 27801058 EAP HCPCS C1874 Wall Stent 8fr/ 12x BOTH IP/OP "$3,605.00 " "$2,667.70" $0.00 "$2,884.00" "$1,622.25" "$1,622.25" $0.00 $0.00 $0.00 $751.37 "$2,675.63" "$2,675.63" "$2,778.73" $0.00 $751.28 $0.00 "$1,777.27" "$1,777.27" $0.00 "$1,802.50" "$2,855.16" "$2,884.00" $0.00 "$1,622.25" $0.00 $564.18 $0.00 $0.00 $573.92 $0.00 $0.00 $0.00 $0.00 $0.00 27801059 EAP HCPCS C1874 Wall Stent 8fr/ 12x BOTH IP/OP "$5,778.00 " "$4,275.72" $0.00 "$4,622.40" "$2,600.10" "$2,600.10" $0.00 $0.00 $0.00 "$1,204.28" "$4,181.12" "$4,181.12" "$4,453.68" $0.00 "$1,204.14" $0.00 "$2,848.55" "$2,848.55" $0.00 "$2,889.00" "$4,576.18" "$4,622.40" $0.00 $0.00 $0.00 $904.26 $0.00 $0.00 $919.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801060 EAP HCPCS C1875 10x40 Luminexx Sten BOTH IP/OP "$7,321.00 " "$5,417.54" $0.00 "$5,856.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,643.03" $0.00 "$1,525.70" $0.00 $0.00 $0.00 $0.00 "$3,660.50" "$5,798.23" "$5,856.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801061 EAP HCPCS C2625 8.5fr-26cm Nephro-u BOTH IP/OP $361.00 $267.14 $0.00 $288.80 $162.45 $162.45 $0.00 $0.00 $0.00 $75.24 $267.93 $267.93 $278.26 $0.00 $75.23 $0.00 $213.53 $213.53 $0.00 $180.50 $285.91 $288.80 $0.00 $162.45 $0.00 $56.50 $0.00 $0.00 $57.47 $0.00 $0.00 $0.00 $0.00 $0.00 27801062 EAP HCPCS C1875 8 X 40 Fluency Sten BOTH IP/OP "$9,054.00 " "$6,699.96" $0.00 "$7,243.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,886.85" $0.00 $0.00 $0.00 $0.00 "$4,527.00" "$7,170.77" "$7,243.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801063 EAP HCPCS C1880 Filter Recovery Femoral BOTH IP/OP "$3,669.00 " "$2,715.06" $0.00 "$2,935.20" "$1,651.05" "$1,651.05" $0.00 $0.00 $0.00 $764.71 "$2,723.13" "$2,723.13" "$2,828.07" $0.00 $764.62 $0.00 "$1,808.82" "$1,808.82" $0.00 "$1,834.50" "$2,905.85" "$2,935.20" $0.00 $0.00 $0.00 $574.20 $0.00 $0.00 $584.10 $0.00 $0.00 $0.00 $0.00 $0.00 27801064 EAP HCPCS C2625 8fr-28cm Ureteral S BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $277.49 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 27801065 EAP HCPCS C1788 Low Profile Port BOTH IP/OP $751.00 $555.74 $0.00 $600.80 $337.95 $337.95 $0.00 $0.00 $0.00 $156.53 $557.39 $557.39 $578.87 $0.00 $156.51 $0.00 $444.22 $444.22 $0.00 $375.50 $594.79 $600.80 $0.00 $0.00 $0.00 $117.53 $0.00 $0.00 $119.56 $0.00 $0.00 $0.00 $0.00 $0.00 27801066 EAP HCPCS C1880 Filter-femoral BOTH IP/OP "$3,156.00 " "$2,335.44" $0.00 "$2,524.80" "$1,420.20" "$1,420.20" $0.00 $0.00 $0.00 $657.79 "$2,342.38" "$2,342.38" "$2,432.64" $0.00 $657.71 $0.00 "$1,555.91" "$1,555.91" $0.00 "$1,578.00" "$2,499.55" "$2,524.80" $0.00 $0.00 $0.00 $493.91 $0.00 $0.00 $502.44 $0.00 $0.00 $0.00 $0.00 $0.00 27801067 EAP HCPCS C1880 Greenfield Filter-j BOTH IP/OP "$3,156.00 " "$2,335.44" $0.00 "$2,524.80" "$1,420.20" "$1,420.20" $0.00 $0.00 $0.00 $657.79 "$2,342.38" "$2,342.38" "$2,432.64" $0.00 $657.71 $0.00 "$1,555.91" "$1,555.91" $0.00 "$1,578.00" "$2,499.55" "$2,524.80" $0.00 "$1,420.20" $0.00 $493.91 $0.00 $0.00 $502.44 $0.00 $0.00 $0.00 $0.00 $0.00 27801068 EAP HCPCS C2625 Stent Ureteral 8fr 24cm BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $188.10 $188.10 $0.00 $0.00 $0.00 $87.12 $310.24 $310.24 $322.19 $0.00 $87.11 $0.00 $247.25 $247.25 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $65.42 $0.00 $0.00 $66.55 $0.00 $0.00 $0.00 $0.00 $0.00 27801069 EAP HCPCS C2625 Stent Ureteral 8fr 22cm BOTH IP/OP $398.00 $294.52 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.00 $315.22 $318.40 $0.00 $0.00 $0.00 $62.29 $0.00 $0.00 $63.36 $0.00 $0.00 $0.00 $0.00 $0.00 27801070 EAP HCPCS C1876 80-6.0x40cm Stent BOTH IP/OP "$5,245.00 " "$3,881.30" $0.00 "$4,196.00" "$2,360.25" "$2,360.25" $0.00 $0.00 $0.00 "$1,093.19" "$3,892.84" "$3,892.84" "$4,042.85" $0.00 "$1,093.06" $0.00 "$2,585.79" "$2,585.79" $0.00 "$2,622.50" "$4,154.04" "$4,196.00" $0.00 $0.00 $0.00 $820.84 $0.00 $0.00 $835.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801071 EAP HCPCS C1880 Filter Birds Nest Vena Cava Fe BOTH IP/OP "$3,442.00 " "$2,547.08" $0.00 "$2,753.60" "$1,548.90" "$1,548.90" $0.00 $0.00 $0.00 $717.40 "$2,554.65" "$2,554.65" "$2,653.09" $0.00 $717.31 $0.00 "$1,696.91" "$1,696.91" $0.00 "$1,721.00" "$2,726.06" "$2,753.60" $0.00 $0.00 $0.00 $538.67 $0.00 $0.00 $547.97 $0.00 $0.00 $0.00 $0.00 $0.00 27801072 EAP HCPCS C1880 Filter Birds Nest Vena Cava Ju BOTH IP/OP "$3,442.00 " "$2,547.08" $0.00 "$2,753.60" "$1,548.90" "$1,548.90" $0.00 $0.00 $0.00 $717.40 "$2,554.65" "$2,554.65" "$2,653.09" $0.00 $717.31 $0.00 "$1,696.91" "$1,696.91" $0.00 "$1,721.00" "$2,726.06" "$2,753.60" $0.00 "$1,548.90" $0.00 $538.67 $0.00 $0.00 $547.97 $0.00 $0.00 $0.00 $0.00 $0.00 27801073 EAP HCPCS C1880 Filter Gunther-tulip Femoral BOTH IP/OP "$3,586.00 " "$2,653.64" $0.00 "$2,868.80" "$1,613.70" "$1,613.70" $0.00 $0.00 $0.00 $747.41 "$2,661.53" "$2,661.53" "$2,764.09" $0.00 $747.32 $0.00 "$1,767.90" "$1,767.90" $0.00 "$1,793.00" "$2,840.11" "$2,868.80" $0.00 $0.00 $0.00 $561.21 $0.00 $0.00 $570.89 $0.00 $0.00 $0.00 $0.00 $0.00 27801074 EAP HCPCS C1880 Filter Gunther-tulip Jugular BOTH IP/OP "$3,216.00 " "$2,379.84" $0.00 "$2,572.80" "$1,447.20" "$1,447.20" $0.00 $0.00 $0.00 $670.29 "$2,386.92" "$2,386.92" "$2,478.89" $0.00 $670.21 $0.00 "$1,585.49" "$1,585.49" $0.00 "$1,608.00" "$2,547.07" "$2,572.80" $0.00 $0.00 $0.00 $503.30 $0.00 $0.00 $511.99 $0.00 $0.00 $0.00 $0.00 $0.00 27801075 EAP HCPCS C1880 Trapeaze Femoralve BOTH IP/OP "$4,154.00 " "$3,073.96" $0.00 "$3,323.20" "$1,869.30" "$1,869.30" $0.00 $0.00 $0.00 $865.80 "$3,083.10" "$3,083.10" "$3,201.90" $0.00 $865.69 $0.00 "$2,047.92" "$2,047.92" $0.00 "$2,077.00" "$3,289.97" "$3,323.20" $0.00 $0.00 $0.00 $650.10 $0.00 $0.00 $661.32 $0.00 $0.00 $0.00 $0.00 $0.00 27801076 EAP HCPCS C1875 "Covered Stent, 5mmx" BOTH IP/OP "$8,174.00 " "$6,048.76" $0.00 "$6,539.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,300.52" $0.00 "$1,703.46" $0.00 $0.00 $0.00 $0.00 "$4,087.00" "$6,473.81" "$6,539.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801077 EAP HCPCS C1874 "Covered Stent, 6mmx" BOTH IP/OP "$8,174.00 " "$6,048.76" $0.00 "$6,539.20" "$3,678.30" "$3,678.30" $0.00 $0.00 $0.00 "$1,703.67" "$4,181.12" "$4,181.12" "$6,300.52" $0.00 "$1,703.46" $0.00 "$4,029.78" "$4,029.78" $0.00 "$4,087.00" "$6,473.81" "$6,539.20" $0.00 $0.00 $0.00 "$1,279.23" $0.00 $0.00 "$1,301.30" $0.00 $0.00 $0.00 $0.00 $0.00 27801078 EAP HCPCS C1874 "Covered Stent, 8mmx" BOTH IP/OP "$8,174.00 " "$6,048.76" $0.00 "$6,539.20" "$3,678.30" "$3,678.30" $0.00 $0.00 $0.00 "$1,703.67" "$4,181.12" "$4,181.12" "$6,300.52" $0.00 "$1,703.46" $0.00 "$4,029.78" "$4,029.78" $0.00 "$4,087.00" "$6,473.81" "$6,539.20" $0.00 $0.00 $0.00 "$1,279.23" $0.00 $0.00 "$1,301.30" $0.00 $0.00 $0.00 $0.00 $0.00 27801079 EAP HCPCS C1874 "Covered Stent, 9mmx" BOTH IP/OP "$8,174.00 " "$6,048.76" $0.00 "$6,539.20" "$3,678.30" "$3,678.30" $0.00 $0.00 $0.00 "$1,703.67" "$4,181.12" "$4,181.12" "$6,300.52" $0.00 "$1,703.46" $0.00 "$4,029.78" "$4,029.78" $0.00 "$4,087.00" "$6,473.81" "$6,539.20" $0.00 $0.00 $0.00 "$1,279.23" $0.00 $0.00 "$1,301.30" $0.00 $0.00 $0.00 $0.00 $0.00 27801080 EAP HCPCS C1874 "Covered Stent, 10mm" BOTH IP/OP "$8,174.00 " "$6,048.76" $0.00 "$6,539.20" "$3,678.30" "$3,678.30" $0.00 $0.00 $0.00 "$1,703.67" "$4,181.12" "$4,181.12" "$6,300.52" $0.00 "$1,703.46" $0.00 "$4,029.78" "$4,029.78" $0.00 "$4,087.00" "$6,473.81" "$6,539.20" $0.00 $0.00 $0.00 "$1,279.23" $0.00 $0.00 "$1,301.30" $0.00 $0.00 $0.00 $0.00 $0.00 27801081 EAP HCPCS C1874 "Covered Stent, 12mm" BOTH IP/OP "$18,351.00 " "$13,579.74" $0.00 "$14,680.80" "$8,257.95" "$8,257.95" $0.00 $0.00 $0.00 "$3,824.81" "$4,181.12" "$4,181.12" "$14,144.95" $0.00 "$3,824.35" $0.00 "$9,047.04" "$9,047.04" $0.00 "$9,175.50" "$14,533.99" "$14,680.80" $0.00 $0.00 $0.00 "$2,871.93" $0.00 $0.00 "$2,921.48" $0.00 $0.00 $0.00 $0.00 $0.00 27801082 EAP HCPCS C1874 Coil Complex Helica BOTH IP/OP "$1,287.00 " $952.38 $0.00 "$1,029.60" $579.15 $579.15 $0.00 $0.00 $0.00 $268.24 $955.21 $955.21 $992.02 $0.00 $268.21 $0.00 $761.26 $761.26 $0.00 $643.50 "$1,019.30" "$1,029.60" $0.00 $579.15 $0.00 $201.42 $0.00 $0.00 $204.89 $0.00 $0.00 $0.00 $0.00 $0.00 27801083 EAP HCPCS C1760 Closure Device Vasc BOTH IP/OP "$5,062.00 " "$3,745.88" $0.00 "$4,049.60" "$2,277.90" "$2,277.90" $0.00 $0.00 $0.00 "$1,055.05" "$3,757.02" "$3,757.02" "$3,901.79" $0.00 "$1,054.92" $0.00 "$2,495.57" "$2,495.57" $0.00 "$2,531.00" "$4,009.10" "$4,049.60" $0.00 $0.00 $0.00 $792.20 $0.00 $0.00 $805.87 $0.00 $0.00 $0.00 $0.00 $0.00 27801084 EAP HCPCS C1876 Zilver Stent 10x40 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801085 EAP HCPCS C1876 Zilver Stent 10x30 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801086 EAP HCPCS C1876 Zilver Stent 8x60 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801087 EAP HCPCS C1876 Zilver Stent 8x40 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801088 EAP HCPCS C1876 Zilver Stent 8x30 BOTH IP/OP "$3,113.00 " "$2,303.62" $0.00 "$2,490.40" $0.00 $0.00 $0.00 $0.00 $0.00 $648.83 $0.00 $0.00 $0.00 $0.00 $648.75 $0.00 "$1,534.71" "$1,534.71" $0.00 "$1,556.50" "$2,465.50" "$2,490.40" $0.00 $0.00 $0.00 $487.18 $0.00 $0.00 $495.59 $0.00 $0.00 $0.00 $0.00 $0.00 27801089 EAP HCPCS C1876 Zilver Stent 7x40 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 "$1,876.50" $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801090 EAP HCPCS C1876 Zilver Stent 7x30 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801091 EAP HCPCS C1876 Zilver Stent 6x40 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 "$1,876.50" $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801092 EAP HCPCS C1876 Zilver Stent 6x30 BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801093 EAP HCPCS C1760 Bmrang Cls Device5- BOTH IP/OP "$5,004.00 " "$3,702.96" $0.00 "$4,003.20" "$2,251.80" "$2,251.80" $0.00 $0.00 $0.00 "$1,042.96" "$3,713.97" "$3,713.97" "$3,857.08" $0.00 "$1,042.83" $0.00 "$2,466.97" "$2,466.97" $0.00 "$2,502.00" "$3,963.17" "$4,003.20" $0.00 $0.00 $0.00 $783.13 $0.00 $0.00 $796.64 $0.00 $0.00 $0.00 $0.00 $0.00 27801094 EAP HCPCS C1760 Bmrang Cls Dvice 6- BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $50.85 $50.85 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $0.00 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 27801095 EAP HCPCS C1760 6ft Proglide Closur BOTH IP/OP $863.00 $638.62 $0.00 $690.40 $388.35 $388.35 $0.00 $0.00 $0.00 $179.87 $640.52 $640.52 $665.20 $0.00 $179.85 $0.00 $510.46 $510.46 $0.00 $431.50 $683.50 $690.40 $0.00 $388.35 $0.00 $135.06 $0.00 $0.00 $137.39 $0.00 $0.00 $0.00 $0.00 $0.00 27801096 EAP Custom 27801096 Coil Microplex 18re BOTH IP/OP "$2,050.00 " "$1,517.00" $0.00 "$1,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,521.51" "$1,521.51" "$1,580.14" $0.00 $427.22 $0.00 $0.00 $0.00 $0.00 "$1,025.00" "$1,623.60" "$1,640.00" $0.00 $922.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801097 EAP Custom 27801097 Coil Microplex 18re BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801098 EAP Custom 27801098 Coil Microplex 18so BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801099 EAP Custom 27801099 Coil Microplex 18so BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801100 EAP Custom 27801100 Coil Microplex 18so BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801101 EAP Custom 27801101 Coil Microplex 18so BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801102 EAP Custom 27801102 Coil Microplex 18so BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801103 EAP Custom 27801103 Coil Microplex 18so BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801104 EAP Custom 27801104 "Coil, Trufill Pusha" BOTH IP/OP $466.00 $344.84 $0.00 $372.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.87 $345.87 $359.19 $0.00 $97.11 $0.00 $0.00 $0.00 $0.00 $233.00 $369.07 $372.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801105 EAP Custom 27801105 Coil Trufil Complx BOTH IP/OP $466.00 $344.84 $0.00 $372.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.87 $345.87 $359.19 $0.00 $97.11 $0.00 $0.00 $0.00 $0.00 $233.00 $369.07 $372.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801106 EAP Custom 27801106 Coil Trufil Complex BOTH IP/OP $466.00 $344.84 $0.00 $372.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.87 $345.87 $359.19 $0.00 $97.11 $0.00 $0.00 $0.00 $0.00 $233.00 $369.07 $372.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801107 EAP Custom 27801107 Coil Trufil Complex BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.71 $170.71 $177.28 $0.00 $47.93 $0.00 $0.00 $0.00 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801108 EAP Custom 27801108 Coil Trufil Embolic BOTH IP/OP "$7,924.00 " "$5,863.76" $0.00 "$6,339.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,107.82" $0.00 "$1,651.36" $0.00 $0.00 $0.00 $0.00 "$3,962.00" "$6,275.81" "$6,339.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801109 EAP HCPCS C1874 Wallstent Iliac Spv BOTH IP/OP "$8,767.00 " "$6,487.58" $0.00 "$7,013.60" "$3,945.15" "$3,945.15" $0.00 $0.00 $0.00 "$1,827.26" "$4,181.12" "$4,181.12" "$6,757.60" $0.00 "$1,827.04" $0.00 "$4,322.13" "$4,322.13" $0.00 "$4,383.50" "$6,943.46" "$7,013.60" $0.00 $0.00 $0.00 "$1,372.04" $0.00 $0.00 "$1,395.71" $0.00 $0.00 $0.00 $0.00 $0.00 27801110 EAP HCPCS C1874 "Stent, Biliary, Pal" BOTH IP/OP "$9,320.00 " "$6,896.80" $0.00 "$7,456.00" "$4,194.00" "$4,194.00" $0.00 $0.00 $0.00 "$1,942.52" "$4,181.12" "$4,181.12" "$7,183.86" $0.00 "$1,942.29" $0.00 "$4,594.76" "$4,594.76" $0.00 "$4,660.00" "$7,381.44" "$7,456.00" $0.00 "$4,194.00" $0.00 "$1,458.58" $0.00 $0.00 "$1,483.74" $0.00 $0.00 $0.00 $0.00 $0.00 27801111 EAP HCPCS C1874 "Wallstent, Tracheob" BOTH IP/OP "$8,767.00 " "$6,487.58" $0.00 "$7,013.60" "$3,945.15" "$3,945.15" $0.00 $0.00 $0.00 "$1,827.26" "$4,181.12" "$4,181.12" "$6,757.60" $0.00 "$1,827.04" $0.00 "$4,322.13" "$4,322.13" $0.00 "$4,383.50" "$6,943.46" "$7,013.60" $0.00 $0.00 $0.00 "$1,372.04" $0.00 $0.00 "$1,395.71" $0.00 $0.00 $0.00 $0.00 $0.00 27801112 EAP HCPCS C1874 "Wallstent, Enteral" BOTH IP/OP "$8,767.00 " "$6,487.58" $0.00 "$7,013.60" "$3,945.15" "$3,945.15" $0.00 $0.00 $0.00 "$1,827.26" "$4,181.12" "$4,181.12" "$6,757.60" $0.00 "$1,827.04" $0.00 "$4,322.13" "$4,322.13" $0.00 "$4,383.50" "$6,943.46" "$7,013.60" $0.00 $0.00 $0.00 "$1,372.04" $0.00 $0.00 "$1,395.71" $0.00 $0.00 $0.00 $0.00 $0.00 27801113 EAP HCPCS C1874 Viatorr Sents 8mmx6 BOTH IP/OP "$12,472.00 " "$9,229.28" $0.00 "$9,977.60" "$5,612.40" "$5,612.40" $0.00 $0.00 $0.00 "$2,599.48" "$4,181.12" "$4,181.12" "$9,613.42" $0.00 "$2,599.16" $0.00 "$6,148.70" "$6,148.70" $0.00 "$6,236.00" "$9,877.82" "$9,977.60" $0.00 $0.00 $0.00 "$1,951.87" $0.00 $0.00 "$1,985.54" $0.00 $0.00 $0.00 $0.00 $0.00 27801114 EAP HCPCS C1874 Viatorr Sents 8mmx7 BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801115 EAP HCPCS C1874 Viatorr Sents 8mmx8 BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801116 EAP HCPCS C1874 Viatorr Sents 10mmx BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801117 EAP HCPCS C1874 Viatorr Sents 10mmx BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801118 EAP HCPCS C1874 Viatorr Sents 10mmx BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801119 EAP HCPCS C1874 Viatorr Sents 10mmx BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801120 EAP HCPCS C1874 Viatorr Sents 10mmx BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801121 EAP HCPCS C1874 Viatorr Sents 12mmx BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801122 EAP HCPCS C1874 Viatorr Sents 12mmx BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801123 EAP HCPCS C1874 Viatorr Sents 12mmx BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801124 EAP HCPCS C1874 Viatorr Sents 8mmx4 BOTH IP/OP "$15,988.00 " "$11,831.12" $0.00 "$12,790.40" "$7,194.60" "$7,194.60" $0.00 $0.00 $0.00 "$3,332.30" "$4,181.12" "$4,181.12" "$12,323.55" $0.00 "$3,331.90" $0.00 "$7,882.08" "$7,882.08" $0.00 "$7,994.00" "$12,662.50" "$12,790.40" $0.00 $0.00 $0.00 "$2,502.12" $0.00 $0.00 "$2,545.29" $0.00 $0.00 $0.00 $0.00 $0.00 27801125 EAP HCPCS C1874 Viatorr Sents 8mmx5 BOTH IP/OP "$16,213.00 " "$11,997.62" $0.00 "$12,970.40" "$7,295.85" "$7,295.85" $0.00 $0.00 $0.00 "$3,379.19" "$4,181.12" "$4,181.12" "$12,496.98" $0.00 "$3,378.79" $0.00 "$7,993.01" "$7,993.01" $0.00 "$8,106.50" "$12,840.70" "$12,970.40" $0.00 $0.00 $0.00 "$2,537.33" $0.00 $0.00 "$2,581.11" $0.00 $0.00 $0.00 $0.00 $0.00 27801126 EAP HCPCS C1876 Wall Stent 18mmx40m BOTH IP/OP "$3,972.00 " "$2,939.28" $0.00 "$3,177.60" "$1,787.40" "$1,787.40" $0.00 $0.00 $0.00 $827.86 "$2,948.02" "$2,948.02" "$3,061.62" $0.00 $827.76 $0.00 "$1,958.20" "$1,958.20" $0.00 "$1,986.00" "$3,145.82" "$3,177.60" $0.00 $0.00 $0.00 $621.62 $0.00 $0.00 $632.34 $0.00 $0.00 $0.00 $0.00 $0.00 27801127 EAP HCPCS C1876 Wall Stent 16mmx20m BOTH IP/OP "$3,918.00 " "$2,899.32" $0.00 "$3,134.40" "$1,763.10" "$1,763.10" $0.00 $0.00 $0.00 $816.61 "$2,907.94" "$2,907.94" "$3,019.99" $0.00 $816.51 $0.00 "$1,931.57" "$1,931.57" $0.00 "$1,959.00" "$3,103.06" "$3,134.40" $0.00 $0.00 $0.00 $613.17 $0.00 $0.00 $623.75 $0.00 $0.00 $0.00 $0.00 $0.00 27801128 EAP HCPCS C1874 Viabhnend.cov.stent BOTH IP/OP "$15,609.00 " "$11,550.66" $0.00 "$12,487.20" "$7,024.05" "$7,024.05" $0.00 $0.00 $0.00 "$3,253.31" "$4,181.12" "$4,181.12" "$12,031.42" $0.00 "$3,252.92" $0.00 "$7,695.24" "$7,695.24" $0.00 "$7,804.50" "$12,362.33" "$12,487.20" $0.00 $0.00 $0.00 "$2,442.81" $0.00 $0.00 "$2,484.95" $0.00 $0.00 $0.00 $0.00 $0.00 27801129 EAP HCPCS C1874 Viabhnend.cov.stent BOTH IP/OP "$14,496.00 " "$10,727.04" $0.00 "$11,596.80" "$6,523.20" "$6,523.20" $0.00 $0.00 $0.00 "$3,021.33" "$4,181.12" "$4,181.12" "$11,173.52" $0.00 "$3,020.97" $0.00 "$7,146.53" "$7,146.53" $0.00 "$7,248.00" "$11,480.83" "$11,596.80" $0.00 $0.00 $0.00 "$2,268.62" $0.00 $0.00 "$2,307.76" $0.00 $0.00 $0.00 $0.00 $0.00 27801130 EAP HCPCS C1874 Viabhnend.cov.stent BOTH IP/OP "$17,381.00 " "$12,861.94" $0.00 "$13,904.80" "$7,821.45" "$7,821.45" $0.00 $0.00 $0.00 "$3,622.63" "$4,181.12" "$4,181.12" "$13,397.27" $0.00 "$3,622.20" $0.00 "$8,568.83" "$8,568.83" $0.00 "$8,690.50" "$13,765.75" "$13,904.80" $0.00 $0.00 $0.00 "$2,720.13" $0.00 $0.00 "$2,767.06" $0.00 $0.00 $0.00 $0.00 $0.00 27801131 EAP HCPCS C1874 Viabhnend.cov.stent BOTH IP/OP "$20,235.00 " "$14,973.90" $0.00 "$16,188.00" "$9,105.75" "$9,105.75" $0.00 $0.00 $0.00 "$4,217.48" "$4,181.12" "$4,181.12" "$15,597.14" $0.00 "$4,216.97" $0.00 "$9,975.86" "$9,975.86" $0.00 "$10,117.50" "$16,026.12" "$16,188.00" $0.00 $0.00 $0.00 "$3,166.78" $0.00 $0.00 "$3,221.41" $0.00 $0.00 $0.00 $0.00 $0.00 27801134 EAP HCPCS C1874 Percut(mmxcm)8x4cov BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801135 EAP HCPCS C1874 Percut(mmxcm)8x6cov BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801136 EAP HCPCS C1874 Percut(mmxcm)8x8cov BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801137 EAP HCPCS C1874 Percut(mmxcm)8x10co BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801138 EAP HCPCS C1874 Percut(mmxcm)10x4co BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801139 EAP HCPCS C1874 Percut(mmxcm)10x6 C BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801140 EAP HCPCS C1875 Percut(mmxcm)10x8 C BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 $0.00 $0.00 $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801141 EAP HCPCS C1874 Percut(mmxcm)10x10 BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 "$6,157.80" $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801142 EAP HCPCS C1874 Percut(mmxcm)8x6unc BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801143 EAP HCPCS C1874 Percut(mmxcm)8x10un BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801144 EAP HCPCS C1874 Percut(mmxcm)10x6un BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801145 EAP HCPCS C1874 Percut(mmxcm)10x8un BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801146 EAP HCPCS C1874 Percut(mmxcm)10x10u BOTH IP/OP "$13,684.00 " "$10,126.16" $0.00 "$10,947.20" "$6,157.80" "$6,157.80" $0.00 $0.00 $0.00 "$2,852.09" "$4,181.12" "$4,181.12" "$10,547.63" $0.00 "$2,851.75" $0.00 "$6,746.21" "$6,746.21" $0.00 "$6,842.00" "$10,837.73" "$10,947.20" $0.00 $0.00 $0.00 "$2,141.55" $0.00 $0.00 "$2,178.49" $0.00 $0.00 $0.00 $0.00 $0.00 27801147 EAP HCPCS C1874 Endsc(mmxcm) 8x4 Co BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801148 EAP HCPCS C1874 Endsc(mmxcm) 8x6 Co BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801149 EAP HCPCS C1874 Endsc(mmxcm) 8x8 Co BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801150 EAP HCPCS C1874 Endsc(mmxcm) 8x10 C BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801151 EAP HCPCS C1874 Endsc(mmxcm) 10x4 C BOTH IP/OP "$12,902.00 " "$9,547.48" $0.00 "$10,321.60" "$5,805.90" "$5,805.90" $0.00 $0.00 $0.00 "$2,689.10" "$4,181.12" "$4,181.12" "$9,944.86" $0.00 "$2,688.78" $0.00 "$6,360.69" "$6,360.69" $0.00 "$6,451.00" "$10,218.38" "$10,321.60" $0.00 $0.00 $0.00 "$2,019.16" $0.00 $0.00 "$2,054.00" $0.00 $0.00 $0.00 $0.00 $0.00 27801152 EAP HCPCS C1874 Endsc (mmxcm) 10x6 BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801153 EAP HCPCS C1874 Endsc(mmxcm) 10x8 C BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801154 EAP HCPCS C1874 Endsc(mmxcm)10x10 C BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801155 EAP HCPCS C1874 Endsc(mmxcm) 8x6 Un BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801156 EAP HCPCS C1874 Endsc(mmxcm) 8x8 Un BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801157 EAP HCPCS C1874 Endsc(mmxcm)8x10 Un BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801158 EAP HCPCS C1874 Endsc(mmxcm)10x6 Un BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801159 EAP HCPCS C1874 Endsc(mmxcm)10x8 Un BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801160 EAP HCPCS C1874 Endsc(mmxcm)10x10un BOTH IP/OP "$12,810.00 " "$9,479.40" $0.00 "$10,248.00" "$5,764.50" "$5,764.50" $0.00 $0.00 $0.00 "$2,669.92" "$4,181.12" "$4,181.12" "$9,873.95" $0.00 "$2,669.60" $0.00 "$6,315.33" "$6,315.33" $0.00 "$6,405.00" "$10,145.52" "$10,248.00" $0.00 $0.00 $0.00 "$2,004.77" $0.00 $0.00 "$2,039.35" $0.00 $0.00 $0.00 $0.00 $0.00 27801161 EAP HCPCS C1874 "Stent,iliac,wallste" BOTH IP/OP "$6,980.00 " "$5,165.20" $0.00 "$5,584.00" "$3,141.00" "$3,141.00" $0.00 $0.00 $0.00 "$1,454.81" "$4,181.12" "$4,181.12" "$5,380.18" $0.00 "$1,454.63" $0.00 "$3,441.14" "$3,441.14" $0.00 "$3,490.00" "$5,528.16" "$5,584.00" $0.00 $0.00 $0.00 "$1,092.37" $0.00 $0.00 "$1,111.22" $0.00 $0.00 $0.00 $0.00 $0.00 27801162 EAP HCPCS C1880 Vena Cava Filter BOTH IP/OP "$4,656.00 " "$3,445.44" $0.00 "$3,724.80" "$2,095.20" "$2,095.20" $0.00 $0.00 $0.00 $970.43 "$3,455.68" "$3,455.68" "$3,588.84" $0.00 $970.31 $0.00 "$2,295.41" "$2,295.41" $0.00 "$2,328.00" "$3,687.55" "$3,724.80" $0.00 $0.00 $0.00 $728.66 $0.00 $0.00 $741.24 $0.00 $0.00 $0.00 $0.00 $0.00 27801163 EAP HCPCS C1874 "Ste.,bil Memmotherm" BOTH IP/OP "$6,980.00 " "$5,165.20" $0.00 "$5,584.00" "$3,141.00" "$3,141.00" $0.00 $0.00 $0.00 "$1,454.81" "$4,181.12" "$4,181.12" "$5,380.18" $0.00 "$1,454.63" $0.00 "$3,441.14" "$3,441.14" $0.00 "$3,490.00" "$5,528.16" "$5,584.00" $0.00 $0.00 $0.00 "$1,092.37" $0.00 $0.00 "$1,111.22" $0.00 $0.00 $0.00 $0.00 $0.00 27801164 EAP HCPCS C1874 "Ste.,bil Wallstent," BOTH IP/OP "$5,991.00 " "$4,433.34" $0.00 "$4,792.80" "$2,695.95" "$2,695.95" $0.00 $0.00 $0.00 "$1,248.67" "$4,181.12" "$4,181.12" "$4,617.86" $0.00 "$1,248.52" $0.00 "$2,953.56" "$2,953.56" $0.00 "$2,995.50" "$4,744.87" "$4,792.80" $0.00 $0.00 $0.00 $937.59 $0.00 $0.00 $953.77 $0.00 $0.00 $0.00 $0.00 $0.00 27801165 EAP HCPCS C1874 "Ste,bil W/s Rp-20,4" BOTH IP/OP "$5,991.00 " "$4,433.34" $0.00 "$4,792.80" "$2,695.95" "$2,695.95" $0.00 $0.00 $0.00 "$1,248.67" "$4,181.12" "$4,181.12" "$4,617.86" $0.00 "$1,248.52" $0.00 "$2,953.56" "$2,953.56" $0.00 "$2,995.50" "$4,744.87" "$4,792.80" $0.00 $0.00 $0.00 $937.59 $0.00 $0.00 $953.77 $0.00 $0.00 $0.00 $0.00 $0.00 27801166 EAP HCPCS C1874 "Ste.,bil Wallstent" BOTH IP/OP "$10,078.00 " "$7,457.72" $0.00 "$8,062.40" "$4,535.10" "$4,535.10" $0.00 $0.00 $0.00 "$2,100.51" "$4,181.12" "$4,181.12" "$7,768.12" $0.00 "$2,100.26" $0.00 "$4,968.45" "$4,968.45" $0.00 "$5,039.00" "$7,981.78" "$8,062.40" $0.00 $0.00 $0.00 "$1,577.21" $0.00 $0.00 "$1,604.42" $0.00 $0.00 $0.00 $0.00 $0.00 27801167 EAP HCPCS C1874 "Ste.,ent W/stent,un" BOTH IP/OP "$10,078.00 " "$7,457.72" $0.00 "$8,062.40" "$4,535.10" "$4,535.10" $0.00 $0.00 $0.00 "$2,100.51" "$4,181.12" "$4,181.12" "$7,768.12" $0.00 "$2,100.26" $0.00 "$4,968.45" "$4,968.45" $0.00 "$5,039.00" "$7,981.78" "$8,062.40" $0.00 $0.00 $0.00 "$1,577.21" $0.00 $0.00 "$1,604.42" $0.00 $0.00 $0.00 $0.00 $0.00 27801168 EAP HCPCS C1874 "St.,wallgraft Unist" BOTH IP/OP "$11,656.00 " "$8,625.44" $0.00 "$9,324.80" "$5,245.20" "$5,245.20" $0.00 $0.00 $0.00 "$2,429.40" "$4,181.12" "$4,181.12" "$8,984.44" $0.00 "$2,429.11" $0.00 "$5,746.41" "$5,746.41" $0.00 "$5,828.00" "$9,231.55" "$9,324.80" $0.00 $0.00 $0.00 "$1,824.16" $0.00 $0.00 "$1,855.64" $0.00 $0.00 $0.00 $0.00 $0.00 27801169 EAP HCPCS C1874 "Ste., W/g Unistep-2" BOTH IP/OP "$11,656.00 " "$8,625.44" $0.00 "$9,324.80" "$5,245.20" "$5,245.20" $0.00 $0.00 $0.00 "$2,429.40" "$4,181.12" "$4,181.12" "$8,984.44" $0.00 "$2,429.11" $0.00 "$5,746.41" "$5,746.41" $0.00 "$5,828.00" "$9,231.55" "$9,324.80" $0.00 $0.00 $0.00 "$1,824.16" $0.00 $0.00 "$1,855.64" $0.00 $0.00 $0.00 $0.00 $0.00 27801170 EAP HCPCS L8670 Aortic Ext Endopros BOTH IP/OP "$10,150.00 " "$7,511.00" $0.00 "$8,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,823.62" $0.00 "$2,115.26" $0.00 $0.00 $0.00 $0.00 "$5,075.00" "$8,038.80" "$8,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801171 EAP Custom 27801171 Pfo Implant BOTH IP/OP "$24,270.00 " "$17,959.80" $0.00 "$19,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$18,707.32" $0.00 "$5,057.87" $0.00 $0.00 $0.00 $0.00 "$12,135.00" "$19,221.84" "$19,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801172 EAP Custom 27801172 Asd Implant BOTH IP/OP "$14,800.00 " "$10,952.00" $0.00 "$11,840.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,407.84" $0.00 "$3,084.32" $0.00 $0.00 $0.00 $0.00 "$7,400.00" "$11,721.60" "$11,840.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801173 EAP HCPCS C1760 "Closure Device, Vas" BOTH IP/OP "$1,363.00 " "$1,008.62" $0.00 "$1,090.40" $613.35 $613.35 $0.00 $0.00 $0.00 $284.08 "$1,011.62" "$1,011.62" "$1,050.60" $0.00 $284.05 $0.00 $806.21 $806.21 $0.00 $681.50 "$1,079.50" "$1,090.40" $0.00 $0.00 $0.00 $213.31 $0.00 $0.00 $216.99 $0.00 $0.00 $0.00 $0.00 $0.00 27801190 EAP HCPCS C1876 3.0x8mm Vision Rx S BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801191 EAP HCPCS C1876 3.5x8mm Vision Rx S BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801192 EAP HCPCS C1876 4.0x8mm Vision Rx S BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801193 EAP HCPCS C1876 3.0x12mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801194 EAP HCPCS C1876 3.5x12mm Vision Rx BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801195 EAP HCPCS C1876 4.0x12mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801196 EAP HCPCS C1876 3.0x15mm Vision Rx BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801197 EAP HCPCS C1876 3.5x15mm Vision Rx BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801198 EAP HCPCS C1876 4.0x15mm Vision Rx BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801199 EAP HCPCS C1876 3.0x18mm Vision Rx BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801200 EAP HCPCS C1876 3.5x18mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801201 EAP HCPCS C1876 4.0x18mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801202 EAP HCPCS C1874 3.0x23mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801203 EAP HCPCS C1876 3.5x23mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801204 EAP HCPCS C1876 4.0x23mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801205 EAP HCPCS C1876 3.0x28mm Vision Rx BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801206 EAP HCPCS C1876 3.5x28mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801207 EAP HCPCS C1876 4.0x28mm Vision Rx BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801214 EAP HCPCS C1874 3.0 X 12mm Graftmas BOTH IP/OP "$17,938.00 " "$13,274.12" $0.00 "$14,350.40" "$8,072.10" "$8,072.10" $0.00 $0.00 $0.00 "$3,738.73" "$4,181.12" "$4,181.12" "$13,826.61" $0.00 "$3,738.28" $0.00 "$8,843.43" "$8,843.43" $0.00 "$8,969.00" "$14,206.90" "$14,350.40" $0.00 $0.00 $0.00 "$2,807.30" $0.00 $0.00 "$2,855.73" $0.00 $0.00 $0.00 $0.00 $0.00 27801215 EAP HCPCS C1876 2.50 X 8mm Mini-vis BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801216 EAP HCPCS C1876 2.50 X 12 Mm Mini V BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801217 EAP HCPCS C1876 2.5 X 15mm Mini-vis BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801218 EAP HCPCS C1876 2.5 X 18mm Mini-vis BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801219 EAP HCPCS C1876 205 X 23mm Mini-vis BOTH IP/OP "$7,782.00 " "$5,758.68" $0.00 "$6,225.60" "$3,501.90" "$3,501.90" $0.00 $0.00 $0.00 "$1,621.96" "$4,181.12" "$4,181.12" "$5,998.37" $0.00 "$1,621.77" $0.00 "$3,836.53" "$3,836.53" $0.00 "$3,891.00" "$6,163.34" "$6,225.60" $0.00 $0.00 $0.00 "$1,217.88" $0.00 $0.00 "$1,238.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801220 EAP HCPCS C1876 2.5 X 28mm Mini-vis BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801221 EAP HCPCS C1874 3.0 X 12 Graftmaste BOTH IP/OP "$17,938.00 " "$13,274.12" $0.00 "$14,350.40" "$8,072.10" "$8,072.10" $0.00 $0.00 $0.00 "$3,738.73" "$4,181.12" "$4,181.12" "$13,826.61" $0.00 "$3,738.28" $0.00 "$8,843.43" "$8,843.43" $0.00 "$8,969.00" "$14,206.90" "$14,350.40" $0.00 $0.00 $0.00 "$2,807.30" $0.00 $0.00 "$2,855.73" $0.00 $0.00 $0.00 $0.00 $0.00 27801222 EAP HCPCS C1722 Lumax 340 Vr Icd Sy BOTH IP/OP "$49,886.00 " "$36,915.64" $0.00 "$39,908.80" "$22,448.70" "$22,448.70" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,452.13" $0.00 "$10,396.24" $0.00 "$24,593.80" "$24,593.80" $0.00 "$24,943.00" "$39,509.71" "$39,908.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,941.85" $0.00 $0.00 $0.00 $0.00 $0.00 27801223 EAP HCPCS C1721 Intrinsic Dr Dual I BOTH IP/OP "$10,215.00 " "$7,559.10" $0.00 "$8,172.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,129.06" "$4,181.12" "$4,181.12" "$7,873.72" $0.00 "$2,128.81" $0.00 "$5,036.00" "$5,036.00" $0.00 "$5,107.50" "$8,090.28" "$8,172.00" $0.00 $0.00 $0.00 "$1,598.65" $0.00 $0.00 "$1,626.23" $0.00 $0.00 $0.00 $0.00 $0.00 27801224 EAP HCPCS C1721 Gem Iii Dr Dual Icd BOTH IP/OP "$3,890.00 " "$2,878.60" $0.00 "$3,112.00" $0.00 $0.00 $0.00 $0.00 $0.00 $810.77 "$2,887.16" "$2,887.16" "$2,998.41" $0.00 $810.68 $0.00 "$1,917.77" "$1,917.77" $0.00 "$1,945.00" "$3,080.88" "$3,112.00" $0.00 $0.00 $0.00 $608.79 $0.00 $0.00 $619.29 $0.00 $0.00 $0.00 $0.00 $0.00 27801225 EAP HCPCS C1722 Gem Iii Vr Single I BOTH IP/OP "$11,351.00 " "$8,399.74" $0.00 "$9,080.80" "$5,107.95" "$5,107.95" $0.00 $0.00 $0.00 "$2,365.83" "$4,181.12" "$4,181.12" "$8,749.35" $0.00 "$2,365.55" $0.00 "$5,596.04" "$5,596.04" $0.00 "$5,675.50" "$8,989.99" "$9,080.80" $0.00 $0.00 $0.00 "$1,776.43" $0.00 $0.00 "$1,807.08" $0.00 $0.00 $0.00 $0.00 $0.00 27801226 EAP HCPCS C1721 Confient He Dual Ic BOTH IP/OP "$15,364.00 " "$11,369.36" $0.00 "$12,291.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,202.24" "$4,181.12" "$4,181.12" "$11,842.57" $0.00 "$3,201.86" $0.00 "$7,574.45" "$7,574.45" $0.00 "$7,682.00" "$12,168.29" "$12,291.20" $0.00 $0.00 $0.00 "$2,404.47" $0.00 $0.00 "$2,445.95" $0.00 $0.00 $0.00 $0.00 $0.00 27801227 EAP HCPCS C1760 Angioseal Vasc Clos BOTH IP/OP "$1,906.00 " "$1,410.44" $0.00 "$1,524.80" $857.70 $857.70 $0.00 $0.00 $0.00 $397.26 "$1,414.63" "$1,414.63" "$1,469.14" $0.00 $397.21 $0.00 "$1,127.40" "$1,127.40" $0.00 $953.00 "$1,509.55" "$1,524.80" $0.00 $0.00 $0.00 $298.29 $0.00 $0.00 $303.44 $0.00 $0.00 $0.00 $0.00 $0.00 27801228 EAP HCPCS C1898 Setrox S Lead BOTH IP/OP "$2,869.00 " "$2,123.06" $0.00 "$2,295.20" "$1,291.05" "$1,291.05" $0.00 $0.00 $0.00 $597.97 "$2,129.37" "$2,129.37" "$2,211.43" $0.00 $597.90 $0.00 "$1,414.42" "$1,414.42" $0.00 "$1,434.50" "$2,272.25" "$2,295.20" $0.00 $0.00 $0.00 $449.00 $0.00 $0.00 $456.74 $0.00 $0.00 $0.00 $0.00 $0.00 27801229 EAP HCPCS C1898 Selox Sr Lead BOTH IP/OP "$2,681.00 " "$1,983.94" $0.00 "$2,144.80" "$1,206.45" "$1,206.45" $0.00 $0.00 $0.00 $558.79 "$1,989.84" "$1,989.84" "$2,066.51" $0.00 $558.72 $0.00 "$1,321.73" "$1,321.73" $0.00 "$1,340.50" "$2,123.35" "$2,144.80" $0.00 $0.00 $0.00 $419.58 $0.00 $0.00 $426.82 $0.00 $0.00 $0.00 $0.00 $0.00 27801230 EAP HCPCS C1722 Ovatio Vr Single Ic BOTH IP/OP "$14,505.00 " "$10,733.70" $0.00 "$11,604.00" "$6,527.25" "$6,527.25" $0.00 $0.00 $0.00 "$3,023.20" "$4,181.12" "$4,181.12" "$11,180.45" $0.00 "$3,022.84" $0.00 "$7,150.97" "$7,150.97" $0.00 "$7,252.50" "$11,487.96" "$11,604.00" $0.00 $0.00 $0.00 "$2,270.03" $0.00 $0.00 "$2,309.20" $0.00 $0.00 $0.00 $0.00 $0.00 27801231 EAP HCPCS C1721 Ovatio Dr Dual Icd BOTH IP/OP "$61,398.00 " "$45,434.52" $0.00 "$49,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,325.58" $0.00 "$12,795.34" $0.00 "$30,269.21" "$30,269.21" $0.00 "$30,699.00" "$48,627.22" "$49,118.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801232 EAP HCPCS C1721 Vitality 2 El Dr Du BOTH IP/OP "$19,454.00 " "$14,395.96" $0.00 "$15,563.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,054.70" "$4,181.12" "$4,181.12" "$14,995.14" $0.00 "$4,054.21" $0.00 "$9,590.82" "$9,590.82" $0.00 "$9,727.00" "$15,407.57" "$15,563.20" $0.00 $0.00 $0.00 "$3,044.55" $0.00 $0.00 "$3,097.08" $0.00 $0.00 $0.00 $0.00 $0.00 27801233 EAP HCPCS C1721 Vitality 2 Dr Dual BOTH IP/OP "$12,969.00 " "$9,597.06" $0.00 "$10,375.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,703.06" "$4,181.12" "$4,181.12" "$9,996.51" $0.00 "$2,702.74" $0.00 "$6,393.72" "$6,393.72" $0.00 "$6,484.50" "$10,271.45" "$10,375.20" $0.00 $0.00 $0.00 "$2,029.65" $0.00 $0.00 "$2,064.66" $0.00 $0.00 $0.00 $0.00 $0.00 27801234 EAP HCPCS C1721 Vitality Avt Dr Dua BOTH IP/OP "$19,454.00 " "$14,395.96" $0.00 "$15,563.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,054.70" "$4,181.12" "$4,181.12" "$14,995.14" $0.00 "$4,054.21" $0.00 "$9,590.82" "$9,590.82" $0.00 "$9,727.00" "$15,407.57" "$15,563.20" $0.00 $0.00 $0.00 "$3,044.55" $0.00 $0.00 "$3,097.08" $0.00 $0.00 $0.00 $0.00 $0.00 27801235 EAP HCPCS C1721 Vitality He Dual Ic BOTH IP/OP "$3,369.00 " "$2,493.06" $0.00 "$2,695.20" $0.00 $0.00 $0.00 $0.00 $0.00 $702.18 "$2,500.47" "$2,500.47" "$2,596.83" $0.00 $702.10 $0.00 "$1,660.92" "$1,660.92" $0.00 "$1,684.50" "$2,668.25" "$2,695.20" $0.00 $0.00 $0.00 $527.25 $0.00 $0.00 $536.34 $0.00 $0.00 $0.00 $0.00 $0.00 27801236 EAP HCPCS C1721 Vitality El Dual Ic BOTH IP/OP "$3,243.00 " "$2,399.82" $0.00 "$2,594.40" $0.00 $0.00 $0.00 $0.00 $0.00 $675.92 "$2,406.95" "$2,406.95" "$2,499.70" $0.00 $675.84 $0.00 "$1,598.80" "$1,598.80" $0.00 "$1,621.50" "$2,568.46" "$2,594.40" $0.00 $0.00 $0.00 $507.53 $0.00 $0.00 $516.29 $0.00 $0.00 $0.00 $0.00 $0.00 27801237 EAP HCPCS C1721 Vitality Ds Dr Dual BOTH IP/OP "$79,815.00 " "$59,063.10" $0.00 "$63,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$61,521.40" $0.00 "$16,633.45" $0.00 "$39,348.80" "$39,348.80" $0.00 "$39,907.50" "$63,213.48" "$63,852.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801238 EAP HCPCS C1722 Vitality 2 El Vr Sn BOTH IP/OP "$3,243.00 " "$2,399.82" $0.00 "$2,594.40" "$1,459.35" "$1,459.35" $0.00 $0.00 $0.00 $675.92 "$2,406.95" "$2,406.95" "$2,499.70" $0.00 $675.84 $0.00 "$1,598.80" "$1,598.80" $0.00 "$1,621.50" "$2,568.46" "$2,594.40" $0.00 $0.00 $0.00 $507.53 $0.00 $0.00 $516.29 $0.00 $0.00 $0.00 $0.00 $0.00 27801239 EAP HCPCS C1722 Vitality 2 Vr Sngl BOTH IP/OP "$79,815.00 " "$59,063.10" $0.00 "$63,852.00" "$35,916.75" "$35,916.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$61,521.40" $0.00 "$16,633.45" $0.00 "$39,348.80" "$39,348.80" $0.00 "$39,907.50" "$63,213.48" "$63,852.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801240 EAP HCPCS C1722 Vitality Ds Vr Sngl BOTH IP/OP "$16,836.00 " "$12,458.64" $0.00 "$13,468.80" "$7,576.20" "$7,576.20" $0.00 $0.00 $0.00 "$3,509.04" "$4,181.12" "$4,181.12" "$12,977.19" $0.00 "$3,508.62" $0.00 "$8,300.15" "$8,300.15" $0.00 "$8,418.00" "$13,334.11" "$13,468.80" $0.00 $0.00 $0.00 "$2,634.83" $0.00 $0.00 "$2,680.29" $0.00 $0.00 $0.00 $0.00 $0.00 27801241 EAP HCPCS C1895 Reliance G Active F BOTH IP/OP "$9,730.00 " "$7,200.20" $0.00 "$7,784.00" "$4,378.50" "$4,378.50" $0.00 $0.00 $0.00 "$2,027.98" "$4,181.12" "$4,181.12" "$7,499.88" $0.00 "$2,027.73" $0.00 "$4,796.89" "$4,796.89" $0.00 "$4,865.00" "$7,706.16" "$7,784.00" $0.00 $0.00 $0.00 "$1,522.75" $0.00 $0.00 "$1,549.02" $0.00 $0.00 $0.00 $0.00 $0.00 27801242 EAP HCPCS C1895 Reliance G Active F BOTH IP/OP "$10,102.00 " "$7,475.48" $0.00 "$8,081.60" "$4,545.90" "$4,545.90" $0.00 $0.00 $0.00 "$2,105.51" "$4,181.12" "$4,181.12" "$7,786.62" $0.00 "$2,105.26" $0.00 "$4,980.29" "$4,980.29" $0.00 "$5,051.00" "$8,000.78" "$8,081.60" $0.00 $0.00 $0.00 "$1,580.96" $0.00 $0.00 "$1,608.24" $0.00 $0.00 $0.00 $0.00 $0.00 27801243 EAP HCPCS C1895 Reliance G Passive BOTH IP/OP "$9,730.00 " "$7,200.20" $0.00 "$7,784.00" "$4,378.50" "$4,378.50" $0.00 $0.00 $0.00 "$2,027.98" "$4,181.12" "$4,181.12" "$7,499.88" $0.00 "$2,027.73" $0.00 "$4,796.89" "$4,796.89" $0.00 "$4,865.00" "$7,706.16" "$7,784.00" $0.00 $0.00 $0.00 "$1,522.75" $0.00 $0.00 "$1,549.02" $0.00 $0.00 $0.00 $0.00 $0.00 27801244 EAP HCPCS C1895 Reliance G Passive BOTH IP/OP "$9,730.00 " "$7,200.20" $0.00 "$7,784.00" "$4,378.50" "$4,378.50" $0.00 $0.00 $0.00 "$2,027.98" "$4,181.12" "$4,181.12" "$7,499.88" $0.00 "$2,027.73" $0.00 "$4,796.89" "$4,796.89" $0.00 "$4,865.00" "$7,706.16" "$7,784.00" $0.00 $0.00 $0.00 "$1,522.75" $0.00 $0.00 "$1,549.02" $0.00 $0.00 $0.00 $0.00 $0.00 27801245 EAP HCPCS C1895 Reliance Active Fix BOTH IP/OP "$6,985.00 " "$5,168.90" $0.00 "$5,588.00" "$3,143.25" "$3,143.25" $0.00 $0.00 $0.00 "$1,455.85" "$4,181.12" "$4,181.12" "$5,384.04" $0.00 "$1,455.67" $0.00 "$3,443.61" "$3,443.61" $0.00 "$3,492.50" "$5,532.12" "$5,588.00" $0.00 $0.00 $0.00 "$1,093.15" $0.00 $0.00 "$1,112.01" $0.00 $0.00 $0.00 $0.00 $0.00 27801246 EAP HCPCS C1895 Reliance Active Fix BOTH IP/OP "$7,253.00 " "$5,367.22" $0.00 "$5,802.40" "$3,263.85" "$3,263.85" $0.00 $0.00 $0.00 "$1,511.71" "$4,181.12" "$4,181.12" "$5,590.61" $0.00 "$1,511.53" $0.00 "$3,575.73" "$3,575.73" $0.00 "$3,626.50" "$5,744.38" "$5,802.40" $0.00 $0.00 $0.00 "$1,135.09" $0.00 $0.00 "$1,154.68" $0.00 $0.00 $0.00 $0.00 $0.00 27801247 EAP HCPCS C1895 Reliance Passive Fi BOTH IP/OP "$9,730.00 " "$7,200.20" $0.00 "$7,784.00" "$4,378.50" "$4,378.50" $0.00 $0.00 $0.00 "$2,027.98" "$4,181.12" "$4,181.12" "$7,499.88" $0.00 "$2,027.73" $0.00 "$4,796.89" "$4,796.89" $0.00 "$4,865.00" "$7,706.16" "$7,784.00" $0.00 $0.00 $0.00 "$1,522.75" $0.00 $0.00 "$1,549.02" $0.00 $0.00 $0.00 $0.00 $0.00 27801248 EAP HCPCS C1895 Reliance Passive Fi BOTH IP/OP "$9,730.00 " "$7,200.20" $0.00 "$7,784.00" "$4,378.50" "$4,378.50" $0.00 $0.00 $0.00 "$2,027.98" "$4,181.12" "$4,181.12" "$7,499.88" $0.00 "$2,027.73" $0.00 "$4,796.89" "$4,796.89" $0.00 "$4,865.00" "$7,706.16" "$7,784.00" $0.00 $0.00 $0.00 "$1,522.75" $0.00 $0.00 "$1,549.02" $0.00 $0.00 $0.00 $0.00 $0.00 27801249 EAP HCPCS C1721 Atlas Dr Dual Icd BOTH IP/OP "$9,730.00 " "$7,200.20" $0.00 "$7,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,027.98" "$4,181.12" "$4,181.12" "$7,499.88" $0.00 "$2,027.73" $0.00 "$4,796.89" "$4,796.89" $0.00 "$4,865.00" "$7,706.16" "$7,784.00" $0.00 $0.00 $0.00 "$1,522.75" $0.00 $0.00 "$1,549.02" $0.00 $0.00 $0.00 $0.00 $0.00 27801250 EAP HCPCS C1895 Riata Dual Coil Lea BOTH IP/OP "$17,833.00 " "$13,196.42" $0.00 "$14,266.40" "$8,024.85" "$8,024.85" $0.00 $0.00 $0.00 "$3,716.84" "$4,181.12" "$4,181.12" "$13,745.68" $0.00 "$3,716.40" $0.00 "$8,791.67" "$8,791.67" $0.00 "$8,916.50" "$14,123.74" "$14,266.40" $0.00 $0.00 $0.00 "$2,790.86" $0.00 $0.00 "$2,839.01" $0.00 $0.00 $0.00 $0.00 $0.00 27801251 EAP HCPCS C1895 Riata Dual Coil Lea BOTH IP/OP "$17,833.00 " "$13,196.42" $0.00 "$14,266.40" "$8,024.85" "$8,024.85" $0.00 $0.00 $0.00 "$3,716.84" "$4,181.12" "$4,181.12" "$13,745.68" $0.00 "$3,716.40" $0.00 "$8,791.67" "$8,791.67" $0.00 "$8,916.50" "$14,123.74" "$14,266.40" $0.00 $0.00 $0.00 "$2,790.86" $0.00 $0.00 "$2,839.01" $0.00 $0.00 $0.00 $0.00 $0.00 27801252 EAP HCPCS C1895 Riata I Dual Coil L BOTH IP/OP "$17,833.00 " "$13,196.42" $0.00 "$14,266.40" "$8,024.85" "$8,024.85" $0.00 $0.00 $0.00 "$3,716.84" "$4,181.12" "$4,181.12" "$13,745.68" $0.00 "$3,716.40" $0.00 "$8,791.67" "$8,791.67" $0.00 "$8,916.50" "$14,123.74" "$14,266.40" $0.00 $0.00 $0.00 "$2,790.86" $0.00 $0.00 "$2,839.01" $0.00 $0.00 $0.00 $0.00 $0.00 27801253 EAP HCPCS C1895 Riata Single Coil L BOTH IP/OP "$17,833.00 " "$13,196.42" $0.00 "$14,266.40" "$8,024.85" "$8,024.85" $0.00 $0.00 $0.00 "$3,716.84" "$4,181.12" "$4,181.12" "$13,745.68" $0.00 "$3,716.40" $0.00 "$8,791.67" "$8,791.67" $0.00 "$8,916.50" "$14,123.74" "$14,266.40" $0.00 $0.00 $0.00 "$2,790.86" $0.00 $0.00 "$2,839.01" $0.00 $0.00 $0.00 $0.00 $0.00 27801254 EAP HCPCS C1895 Riata Single Coil L BOTH IP/OP "$17,833.00 " "$13,196.42" $0.00 "$14,266.40" "$8,024.85" "$8,024.85" $0.00 $0.00 $0.00 "$3,716.84" "$4,181.12" "$4,181.12" "$13,745.68" $0.00 "$3,716.40" $0.00 "$8,791.67" "$8,791.67" $0.00 "$8,916.50" "$14,123.74" "$14,266.40" $0.00 $0.00 $0.00 "$2,790.86" $0.00 $0.00 "$2,839.01" $0.00 $0.00 $0.00 $0.00 $0.00 27801255 EAP HCPCS C1895 Riata St Dual Coil BOTH IP/OP "$13,714.00 " "$10,148.36" $0.00 "$10,971.20" "$6,171.30" "$6,171.30" $0.00 $0.00 $0.00 "$2,858.34" "$4,181.12" "$4,181.12" "$10,570.75" $0.00 "$2,858.00" $0.00 "$6,761.00" "$6,761.00" $0.00 "$6,857.00" "$10,861.49" "$10,971.20" $0.00 $0.00 $0.00 "$2,146.24" $0.00 $0.00 "$2,183.27" $0.00 $0.00 $0.00 $0.00 $0.00 27801256 EAP HCPCS C1895 Riata St Sngl Coil BOTH IP/OP "$11,221.00 " "$8,303.54" $0.00 "$8,976.80" "$5,049.45" "$5,049.45" $0.00 $0.00 $0.00 "$2,338.74" "$4,181.12" "$4,181.12" "$8,649.15" $0.00 "$2,338.46" $0.00 "$5,531.95" "$5,531.95" $0.00 "$5,610.50" "$8,887.03" "$8,976.80" $0.00 $0.00 $0.00 "$1,756.09" $0.00 $0.00 "$1,786.38" $0.00 $0.00 $0.00 $0.00 $0.00 27801257 EAP HCPCS C1895 Spl Leads BOTH IP/OP "$5,189.00 " "$3,839.86" $0.00 "$4,151.20" "$2,335.05" "$2,335.05" $0.00 $0.00 $0.00 "$1,081.52" "$3,851.28" "$3,851.28" "$3,999.68" $0.00 "$1,081.39" $0.00 "$2,558.18" "$2,558.18" $0.00 "$2,594.50" "$4,109.69" "$4,151.20" $0.00 $0.00 $0.00 $812.08 $0.00 $0.00 $826.09 $0.00 $0.00 $0.00 $0.00 $0.00 27801258 EAP HCPCS C1895 Tvl-adx Leads BOTH IP/OP "$5,189.00 " "$3,839.86" $0.00 "$4,151.20" "$2,335.05" "$2,335.05" $0.00 $0.00 $0.00 "$1,081.52" "$3,851.28" "$3,851.28" "$3,999.68" $0.00 "$1,081.39" $0.00 "$2,558.18" "$2,558.18" $0.00 "$2,594.50" "$4,109.69" "$4,151.20" $0.00 $0.00 $0.00 $812.08 $0.00 $0.00 $826.09 $0.00 $0.00 $0.00 $0.00 $0.00 27801259 EAP HCPCS C1895 Bipolar Endocard Pa BOTH IP/OP "$2,792.00 " "$2,066.08" $0.00 "$2,233.60" "$1,256.40" "$1,256.40" $0.00 $0.00 $0.00 $581.92 "$2,072.22" "$2,072.22" "$2,152.07" $0.00 $581.85 $0.00 "$1,376.46" "$1,376.46" $0.00 "$1,396.00" "$2,211.26" "$2,233.60" $0.00 $0.00 $0.00 $436.95 $0.00 $0.00 $444.49 $0.00 $0.00 $0.00 $0.00 $0.00 27801260 EAP HCPCS C1721 Lumax 300 Dr-t Dual BOTH IP/OP "$3,243.00 " "$2,399.82" $0.00 "$2,594.40" $0.00 $0.00 $0.00 $0.00 $0.00 $675.92 "$2,406.95" "$2,406.95" "$2,499.70" $0.00 $675.84 $0.00 "$1,598.80" "$1,598.80" $0.00 "$1,621.50" "$2,568.46" "$2,594.40" $0.00 $0.00 $0.00 $507.53 $0.00 $0.00 $516.29 $0.00 $0.00 $0.00 $0.00 $0.00 27801261 EAP HCPCS C1722 Lumax 300 Vr-t Sing BOTH IP/OP "$15,437.00 " "$11,423.38" $0.00 "$12,349.60" "$6,946.65" "$6,946.65" $0.00 $0.00 $0.00 "$3,217.46" "$4,181.12" "$4,181.12" "$11,898.84" $0.00 "$3,217.07" $0.00 "$7,610.44" "$7,610.44" $0.00 "$7,718.50" "$12,226.10" "$12,349.60" $0.00 $0.00 $0.00 "$2,415.89" $0.00 $0.00 "$2,457.57" $0.00 $0.00 $0.00 $0.00 $0.00 27801262 EAP HCPCS C1895 Riata Lead BOTH IP/OP "$14,592.00 " "$10,798.08" $0.00 "$11,673.60" "$6,566.40" "$6,566.40" $0.00 $0.00 $0.00 "$3,041.34" "$4,181.12" "$4,181.12" "$11,247.51" $0.00 "$3,040.97" $0.00 "$7,193.86" "$7,193.86" $0.00 "$7,296.00" "$11,556.86" "$11,673.60" $0.00 $0.00 $0.00 "$2,283.65" $0.00 $0.00 "$2,323.05" $0.00 $0.00 $0.00 $0.00 $0.00 27801263 EAP HCPCS C1895 Riata St Lead BOTH IP/OP "$14,592.00 " "$10,798.08" $0.00 "$11,673.60" "$6,566.40" "$6,566.40" $0.00 $0.00 $0.00 "$3,041.34" "$4,181.12" "$4,181.12" "$11,247.51" $0.00 "$3,040.97" $0.00 "$7,193.86" "$7,193.86" $0.00 "$7,296.00" "$11,556.86" "$11,673.60" $0.00 $0.00 $0.00 "$2,283.65" $0.00 $0.00 "$2,323.05" $0.00 $0.00 $0.00 $0.00 $0.00 27801264 EAP HCPCS C1777 Riata St Pkg BOTH IP/OP "$14,592.00 " "$10,798.08" $0.00 "$11,673.60" "$6,566.40" "$6,566.40" $0.00 $0.00 $0.00 "$3,041.34" "$4,181.12" "$4,181.12" "$11,247.51" $0.00 "$3,040.97" $0.00 "$7,193.86" "$7,193.86" $0.00 "$7,296.00" "$11,556.86" "$11,673.60" $0.00 $0.00 $0.00 "$2,283.65" $0.00 $0.00 "$2,323.05" $0.00 $0.00 $0.00 $0.00 $0.00 27801265 EAP HCPCS C1721 Atlas Ii Dr Dual Ic BOTH IP/OP "$9,730.00 " "$7,200.20" $0.00 "$7,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,027.98" "$4,181.12" "$4,181.12" "$7,499.88" $0.00 "$2,027.73" $0.00 "$4,796.89" "$4,796.89" $0.00 "$4,865.00" "$7,706.16" "$7,784.00" $0.00 $0.00 $0.00 "$1,522.75" $0.00 $0.00 "$1,549.02" $0.00 $0.00 $0.00 $0.00 $0.00 27801266 EAP HCPCS C1779 4457 Fineline 11 Le BOTH IP/OP "$2,973.00 " "$2,200.02" $0.00 "$2,378.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,206.56" "$2,206.56" "$2,291.59" $0.00 $619.57 $0.00 $0.00 $0.00 $0.00 "$1,486.50" "$2,354.62" "$2,378.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801267 EAP HCPCS C1721 Teligen Is Vr Sngl BOTH IP/OP "$61,398.00 " "$45,434.52" $0.00 "$49,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,325.58" $0.00 "$12,795.34" $0.00 "$30,269.21" "$30,269.21" $0.00 "$30,699.00" "$48,627.22" "$49,118.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801268 EAP HCPCS C1882 Insync Maximo Dual BOTH IP/OP "$68,113.00 " "$50,403.62" $0.00 "$54,490.40" "$30,650.85" "$30,650.85" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$52,501.50" $0.00 "$14,194.75" $0.00 "$33,579.71" "$33,579.71" $0.00 "$34,056.50" "$53,945.50" "$54,490.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801269 EAP HCPCS C1721 Ovatio Oh60u Dr 655 BOTH IP/OP "$40,295.00 " "$29,818.30" $0.00 "$32,236.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,398.49" "$4,181.12" "$4,181.12" "$31,059.39" $0.00 "$8,397.48" $0.00 "$19,865.44" "$19,865.44" $0.00 "$20,147.50" "$31,913.64" "$32,236.00" $0.00 $0.00 $0.00 "$6,306.17" $0.00 $0.00 "$6,414.96" $0.00 $0.00 $0.00 $0.00 $0.00 27801270 EAP HCPCS C1722 Ovatio Oh61u Vr Sys BOTH IP/OP "$57,559.00 " "$42,593.66" $0.00 "$46,047.20" "$25,901.55" "$25,901.55" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$44,366.48" $0.00 "$11,995.30" $0.00 "$28,376.59" "$28,376.59" $0.00 "$28,779.50" "$45,586.73" "$46,047.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801271 EAP HCPCS C1882 Ovatio Crt 6750 Sys BOTH IP/OP "$46,048.00 " "$34,075.52" $0.00 "$36,838.40" "$20,721.60" "$20,721.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,493.80" $0.00 "$9,596.40" $0.00 "$22,701.66" "$22,701.66" $0.00 "$23,024.00" "$36,470.02" "$36,838.40" $0.00 $0.00 $0.00 "$7,206.51" $0.00 $0.00 "$7,330.84" $0.00 $0.00 $0.00 $0.00 $0.00 27801272 EAP HCPCS C1721 Lumax 340 Dr-t Syst BOTH IP/OP "$69,071.00 " "$51,112.54" $0.00 "$55,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$53,239.93" $0.00 "$14,394.40" $0.00 "$34,052.00" "$34,052.00" $0.00 "$34,535.50" "$54,704.23" "$55,256.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801273 EAP HCPCS C1721 Lumos Dr-t System BOTH IP/OP "$65,235.00 " "$48,273.90" $0.00 "$52,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$50,283.14" $0.00 "$13,594.97" $0.00 "$32,160.86" "$32,160.86" $0.00 "$32,617.50" "$51,666.12" "$52,188.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801274 EAP HCPCS C1722 Lumax 340 Vr-t Syst BOTH IP/OP "$61,398.00 " "$45,434.52" $0.00 "$49,118.40" "$27,629.10" "$27,629.10" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$47,325.58" $0.00 "$12,795.34" $0.00 "$30,269.21" "$30,269.21" $0.00 "$30,699.00" "$48,627.22" "$49,118.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801275 EAP HCPCS C1722 Lumos Vr-t System BOTH IP/OP "$57,559.00 " "$42,593.66" $0.00 "$46,047.20" "$25,901.55" "$25,901.55" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$44,366.48" $0.00 "$11,995.30" $0.00 "$28,376.59" "$28,376.59" $0.00 "$28,779.50" "$45,586.73" "$46,047.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801276 EAP HCPCS C1882 Lumax 340 Hf-t Syst BOTH IP/OP "$100,923.00 " "$74,683.02" $0.00 "$80,738.40" "$45,415.35" "$45,415.35" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$77,791.45" $0.00 "$21,032.35" $0.00 "$49,755.04" "$49,755.04" $0.00 "$50,461.50" "$79,931.02" "$80,738.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801277 EAP HCPCS C1876 2.25 X 12mm Mini-vi BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27801278 EAP HCPCS C1876 4.5 X 13mm Ultra Rx BOTH IP/OP "$2,586.00 " "$1,913.64" $0.00 "$2,068.80" "$1,163.70" "$1,163.70" $0.00 $0.00 $0.00 $538.99 "$1,919.33" "$1,919.33" "$1,993.29" $0.00 $538.92 $0.00 "$1,274.90" "$1,274.90" $0.00 "$1,293.00" "$2,048.11" "$2,068.80" $0.00 $0.00 $0.00 $404.71 $0.00 $0.00 $411.69 $0.00 $0.00 $0.00 $0.00 $0.00 27801279 EAP HCPCS C1876 4.5 X 18mm Ultra Rx BOTH IP/OP "$9,175.00 " "$6,789.50" $0.00 "$7,340.00" "$4,128.75" "$4,128.75" $0.00 $0.00 $0.00 "$1,912.30" "$4,181.12" "$4,181.12" "$7,072.09" $0.00 "$1,912.07" $0.00 "$4,523.28" "$4,523.28" $0.00 "$4,587.50" "$7,266.60" "$7,340.00" $0.00 $0.00 $0.00 "$1,435.89" $0.00 $0.00 "$1,460.66" $0.00 $0.00 $0.00 $0.00 $0.00 27801280 EAP HCPCS C1876 4.5 X 28mm Ultra Rx BOTH IP/OP "$9,175.00 " "$6,789.50" $0.00 "$7,340.00" "$4,128.75" "$4,128.75" $0.00 $0.00 $0.00 "$1,912.30" "$4,181.12" "$4,181.12" "$7,072.09" $0.00 "$1,912.07" $0.00 "$4,523.28" "$4,523.28" $0.00 "$4,587.50" "$7,266.60" "$7,340.00" $0.00 $0.00 $0.00 "$1,435.89" $0.00 $0.00 "$1,460.66" $0.00 $0.00 $0.00 $0.00 $0.00 27801282 EAP HCPCS C1874 3.0 X 16mm Graftmas BOTH IP/OP "$7,990.00 " "$5,912.60" $0.00 "$6,392.00" "$3,595.50" "$3,595.50" $0.00 $0.00 $0.00 "$1,665.32" "$4,181.12" "$4,181.12" "$6,158.69" $0.00 "$1,665.12" $0.00 "$3,939.07" "$3,939.07" $0.00 "$3,995.00" "$6,328.08" "$6,392.00" $0.00 $0.00 $0.00 "$1,250.44" $0.00 $0.00 "$1,272.01" $0.00 $0.00 $0.00 $0.00 $0.00 27801283 EAP HCPCS C1874 3.5 X 16mm Graftmas BOTH IP/OP "$7,990.00 " "$5,912.60" $0.00 "$6,392.00" "$3,595.50" "$3,595.50" $0.00 $0.00 $0.00 "$1,665.32" "$4,181.12" "$4,181.12" "$6,158.69" $0.00 "$1,665.12" $0.00 "$3,939.07" "$3,939.07" $0.00 "$3,995.00" "$6,328.08" "$6,392.00" $0.00 $0.00 $0.00 "$1,250.44" $0.00 $0.00 "$1,272.01" $0.00 $0.00 $0.00 $0.00 $0.00 27801284 EAP HCPCS C1776 2mm Mini Snare BOTH IP/OP "$1,870.00 " "$1,383.80" $0.00 "$1,496.00" $841.50 $841.50 $0.00 $0.00 $0.00 $389.75 "$1,387.91" "$1,387.91" "$1,441.40" $0.00 $389.71 $0.00 "$1,106.11" "$1,106.11" $0.00 $935.00 "$1,481.04" "$1,496.00" $0.00 $841.50 $0.00 $292.66 $0.00 $0.00 $297.70 $0.00 $0.00 $0.00 $0.00 $0.00 27801285 EAP HCPCS C1776 4mm Mini Snare BOTH IP/OP "$1,870.00 " "$1,383.80" $0.00 "$1,496.00" $841.50 $841.50 $0.00 $0.00 $0.00 $389.75 "$1,387.91" "$1,387.91" "$1,441.40" $0.00 $389.71 $0.00 "$1,106.11" "$1,106.11" $0.00 $935.00 "$1,481.04" "$1,496.00" $0.00 $0.00 $0.00 $292.66 $0.00 $0.00 $297.70 $0.00 $0.00 $0.00 $0.00 $0.00 27801357 EAP HCPCS C1874 Endeavor Sprint Des BOTH IP/OP "$5,755.00 " "$4,258.70" $0.00 "$4,604.00" "$2,589.75" "$2,589.75" $0.00 $0.00 $0.00 "$1,199.49" "$4,181.12" "$4,181.12" "$4,435.95" $0.00 "$1,199.34" $0.00 "$2,837.22" "$2,837.22" $0.00 "$2,877.50" "$4,557.96" "$4,604.00" $0.00 $0.00 $0.00 $900.66 $0.00 $0.00 $916.20 $0.00 $0.00 $0.00 $0.00 $0.00 27801367 EAP HCPCS C1760 Mynx Vascular Closu BOTH IP/OP "$5,839.00 " "$4,320.86" $0.00 "$4,671.20" "$2,627.55" "$2,627.55" $0.00 $0.00 $0.00 "$1,216.99" "$4,181.12" "$4,181.12" "$4,500.70" $0.00 "$1,216.85" $0.00 "$2,878.63" "$2,878.63" $0.00 "$2,919.50" "$4,624.49" "$4,671.20" $0.00 $0.00 $0.00 $913.80 $0.00 $0.00 $929.57 $0.00 $0.00 $0.00 $0.00 $0.00 27801369 EAP HCPCS C1785 Philos Ii Dr Pacema BOTH IP/OP "$11,477.00 " "$8,492.98" $0.00 "$9,181.60" "$5,164.65" "$5,164.65" $0.00 $0.00 $0.00 "$2,392.09" "$4,181.12" "$4,181.12" "$8,846.47" $0.00 "$2,391.81" $0.00 "$5,658.16" "$5,658.16" $0.00 "$5,738.50" "$9,089.78" "$9,181.60" $0.00 $0.00 $0.00 "$1,796.15" $0.00 $0.00 "$1,827.14" $0.00 $0.00 $0.00 $0.00 $0.00 27801370 EAP HCPCS C1882 Insync Maximo BOTH IP/OP "$63,656.00 " "$47,105.44" $0.00 "$50,924.80" "$28,645.20" "$28,645.20" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$49,066.04" $0.00 "$13,265.91" $0.00 "$31,382.41" "$31,382.41" $0.00 "$31,828.00" "$50,415.55" "$50,924.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801371 EAP Custom 27801371 Coil Embl 14cm 3mm .018in Nst 14.9 Loop Sft Radopc BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801372 EAP Custom 27801372 Coil Embl 14cm 4mm Nst 11.1 Loop Sft Radopc .018in BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801373 EAP Custom 27801373 Coil Embl 14cm 5mm Nst 8.9 Loop Sft Enh Radopc BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801374 EAP Custom 27801374 Coil Embl 5cm 2mm Nst 8 Loop Sft Enh Radopc Mciol BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $114.50 $181.37 $183.20 $0.00 $103.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801375 EAP Custom 27801375 Coil Embl 5cm 5mm Nst Pltn Synth Fbr Acpt .018in BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.50 $181.37 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801376 EAP Custom 27801376 Coil Embl 7cm 10mm Nst 2.2 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801377 EAP Custom 27801377 Coil Embl 7cm 2mm Nst 11.1 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801378 EAP Custom 27801378 Coil Embl 7cm 5mm Nst 4.5 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801379 EAP Custom 27801379 Coil Embl 7cm 6mm Nst 3.7 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801381 EAP Custom 27801381 3 CM VERSATILE RNG FILL ADV COILS 1MM-3MM BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801382 EAP Custom 27801382 6cm Versatile Rng Fill Adv Coils 3mm-6mm BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801383 EAP Custom 27801383 10cm Versatile Rng Fill Adv Coils 3mm-6mm BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801384 EAP Custom 27801384 15cm Versatile Rng Fill Adv Coils 3mm-6mm BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801385 EAP Custom 27801385 20cm Versatile Rng Fill Adv Coils 6mm-10mm BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801386 EAP Custom 27801386 30cm Versatile Rng Fill Adv Coils 6mm-10mm BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801387 EAP Custom 27801387 30cm Versatile Rng Fill Adv Coils 10mm-15mm BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801388 EAP Custom 27801388 30cm Versatile Rng Fill Adv Coils 10mm-15mm BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801389 EAP Custom 27801389 40cm Versatile Rng Fill Adv Coils 15mm-20mm BOTH IP/OP "$4,547.00 " "$3,364.78" $0.00 "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,374.78" "$3,374.78" "$3,504.83" $0.00 $947.59 $0.00 $0.00 $0.00 $0.00 "$2,273.50" "$3,601.22" "$3,637.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801392 EAP HCPCS C1757 Catheter Thrombectomy Solitaire 6mm 40mm BOTH IP/OP "$10,563.00 " "$7,816.62" $0.00 "$8,450.40" "$4,753.35" "$4,753.35" $0.00 $0.00 $0.00 "$2,201.59" "$4,181.12" "$4,181.12" "$8,141.96" $0.00 "$2,201.33" $0.00 "$5,207.56" "$5,207.56" $0.00 "$5,281.50" "$8,365.90" "$8,450.40" $0.00 "$4,753.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801400 EAP Custom 27801400 Coil Embl 7cm 8mm Nst 2.8 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801401 EAP Custom 27801401 Coil Embl 7cm 12mm Nst 1.9 Loop .035in Pltn Peri BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801403 EAP Custom 27801403 Coil Embl 7cm 14mm Nst 1.6 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801404 EAP Custom 27801404 Coil Embl 7cm 16mm Nst 1.4 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801405 EAP Custom 27801405 Coil Embl 7cm 18mm Nst 1.2 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801406 EAP Custom 27801406 Coil Embl 7cm 20mm Nst 1.1 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801407 EAP Custom 27801407 Coil Embl 7cm 5mm Nst Pltn Synth Fbr Acpt .035in BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801409 EAP Custom 27801409 Coil Embl 4cm 4-2mm Trnd Mcl Mlfrm Sft .018in Pltn BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801410 EAP Custom 27801410 Coil Embl 5cm 5-2mm Trnd Mcl Cath .018in Pltn Strl BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801411 EAP Custom 27801411 Coil Embl 9cm 7-3mm Trnd Mlfrm Sft Xsect Ideally BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801412 EAP HCPCS C1887 "Cath, Sofia 6fr 131cm" BOTH IP/OP "$5,302.00 " "$3,923.48" $0.00 "$4,241.60" "$2,385.90" "$2,385.90" $0.00 $0.00 $0.00 "$1,105.07" "$3,935.14" "$3,935.14" "$4,086.78" $0.00 "$1,104.94" $0.00 "$2,613.89" "$2,613.89" $0.00 "$2,651.00" "$4,199.18" "$4,241.60" $0.00 "$2,385.90" $0.00 $829.76 $0.00 $0.00 $844.08 $0.00 $0.00 $0.00 $0.00 $0.00 27801413 EAP HCPCS C1887 "Cath, Sofia 6fr 125cm" BOTH IP/OP "$5,302.00 " "$3,923.48" $0.00 "$4,241.60" "$2,385.90" "$2,385.90" $0.00 $0.00 $0.00 "$1,105.07" "$3,935.14" "$3,935.14" "$4,086.78" $0.00 "$1,104.94" $0.00 "$2,613.89" "$2,613.89" $0.00 "$2,651.00" "$4,199.18" "$4,241.60" $0.00 "$2,385.90" $0.00 $829.76 $0.00 $0.00 $844.08 $0.00 $0.00 $0.00 $0.00 $0.00 27801414 EAP Custom 27801414 Plug Cardio 7mm 10mm Amplzr Ntnl Type Ii Dlv Sys BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,543.78" "$1,543.78" "$1,603.26" $0.00 $433.47 $0.00 $0.00 $0.00 $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $936.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801415 EAP Custom 27801415 Plug Cardio 9mm 12mm Amplzr Ntnl Type Ii Dlv Sys BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,543.78" "$1,543.78" "$1,603.26" $0.00 $433.47 $0.00 $0.00 $0.00 $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801417 EAP Custom 27801417 Coil Embl 12.5cm 10-5mm Trnd Sm Std Pltn BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801418 EAP Custom 27801418 Coil Embl 5.8cm 6-3mm Trnd Sft .035in Std Sm Pltn BOTH IP/OP $275.00 $203.50 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $211.97 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801419 EAP Custom 27801419 Coil Embl 8cm 8-4mm Trnd .035in Std Sm Pltn BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801420 EAP Custom 27801420 Coil Embl 8.2cm 8-5mm Trnd Mlfrm Pltn BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801421 EAP Custom 27801421 Coil Embl 2cm 1mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801422 EAP Custom 27801422 Coil Embl 3cm 1mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801423 EAP Custom 27801423 Coil Embl 4cm 1mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801424 EAP Custom 27801424 Coil Embl 2cm 1.5mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801425 EAP Custom 27801425 Coil Embl 3cm 1.5mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801426 EAP Custom 27801426 Coil Embl 4cm 1.5mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801427 EAP Custom 27801427 Coil Embl 2cm 2mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801428 EAP Custom 27801428 Coil Embl 3cm 2mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801429 EAP Custom 27801429 Coil Embl 4cm 2mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801430 EAP Custom 27801430 Coil Embl 3cm 2.5mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801431 EAP Custom 27801431 Coil Embl 6cm 2.5mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801432 EAP Custom 27801432 Coil Embl 4cm 3mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801433 EAP Custom 27801433 Coil Embl 6cm 3mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801434 EAP Custom 27801434 Coil Embl 8cm 3mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801435 EAP Custom 27801435 Coil Embl 6cm 3.5mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801436 EAP Custom 27801436 Coil Embl 8cm 3.5mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801437 EAP Custom 27801437 Coil Embl 10cm 3.5mm Axium Prm X Sft 3d BOTH IP/OP "$3,988.00 " "$2,951.12" $0.00 "$3,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.89" "$2,959.89" "$3,073.95" $0.00 $831.10 $0.00 $0.00 $0.00 $0.00 "$1,994.00" "$3,158.50" "$3,190.40" $0.00 "$1,794.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801438 EAP Custom 27801438 Coil Embl 1cm 1mm Axium Prm X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801439 EAP Custom 27801439 Coil Embl 2cm 1mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801440 EAP Custom 27801440 Coil Embl 3cm 1mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801441 EAP Custom 27801441 Coil Embl 1cm 1.5mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801442 EAP Custom 27801442 Coil Embl 2cm 1.5mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 "$1,344.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801443 EAP Custom 27801443 Coil Embl 3cm 1.5mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 "$1,344.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801444 EAP Custom 27801444 Coil Embl 4cm 1.5mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801445 EAP Custom 27801445 Coil Embl 1cm 2mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801446 EAP Custom 27801446 Coil Embl 2cm 2mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801447 EAP Custom 27801447 Coil Embl 3cm 2mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 "$1,344.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801448 EAP Custom 27801448 Coil Embl 4cm 2mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801449 EAP Custom 27801449 Coil Embl 6cm 2mm Axium Prm X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 "$1,344.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801450 EAP HCPCS C1877 "Stent, Non-coat/cov W/o Del" BOTH IP/OP "$12,969.00 " "$9,597.06" $0.00 "$10,375.20" "$5,836.05" "$5,836.05" $0.00 $0.00 $0.00 "$2,703.06" "$4,181.12" "$4,181.12" "$9,996.51" $0.00 "$2,702.74" $0.00 "$6,393.72" "$6,393.72" $0.00 "$6,484.50" "$10,271.45" "$10,375.20" $0.00 "$5,836.05" $0.00 "$2,029.65" $0.00 $0.00 "$2,064.66" $0.00 $0.00 $0.00 $0.00 $0.00 27801451 EAP HCPCS C1876 Mini Vision Rx 2.75 X 08 Mm Us BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27801452 EAP HCPCS C1876 Mini Vision Rx 2.75 X 12 Mm Us BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27801453 EAP HCPCS C1876 Mini Vision Rx 2.75 X 15 Mm Us BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27801454 EAP HCPCS C1876 Mini Vision Rx 2.75 X 18 Mm Us BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27801455 EAP HCPCS C1876 Mini Vision Rx 2.75 X 23 Mm Us BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27801456 EAP HCPCS C1876 Mini Vision Rx 2.75 X 28 Mm Us BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $93.15 $93.15 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 27801457 EAP HCPCS C1721 Ilesto Dr-t High Energy With Ti With Landline Hmtachycardia BOTH IP/OP "$54,233.00 " "$40,132.42" $0.00 "$43,386.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,802.80" $0.00 "$11,302.16" $0.00 "$26,736.87" "$26,736.87" $0.00 "$27,116.50" "$42,952.54" "$43,386.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801458 EAP HCPCS C1721 Ilesto Dr-t High Energy With Ti With Cellular Gsm Hmtachycardia BOTH IP/OP "$56,934.00 " "$42,131.16" $0.00 "$45,547.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$43,884.73" $0.00 "$11,865.05" $0.00 "$28,068.46" "$28,068.46" $0.00 "$28,467.00" "$45,091.73" "$45,547.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801459 EAP HCPCS C1722 Ilesto Dx High Energy With Atrial Diagnostics & Ti With Landline Hmtac BOTH IP/OP "$54,233.00 " "$40,132.42" $0.00 "$43,386.40" "$24,404.85" "$24,404.85" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$41,802.80" $0.00 "$11,302.16" $0.00 "$26,736.87" "$26,736.87" $0.00 "$27,116.50" "$42,952.54" "$43,386.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801460 EAP HCPCS C1722 Ilesto Dx High Energy With Atrial Diagnostics & Ti With Cellular Gsm H BOTH IP/OP "$56,934.00 " "$42,131.16" $0.00 "$45,547.20" "$25,620.30" "$25,620.30" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$43,884.73" $0.00 "$11,865.05" $0.00 "$28,068.46" "$28,068.46" $0.00 "$28,467.00" "$45,091.73" "$45,547.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801461 EAP HCPCS C1722 Ilesto Vr-t High Energy With Ti With Landline Hmtachycardia BOTH IP/OP "$50,182.00 " "$37,134.68" $0.00 "$40,145.60" "$22,581.90" "$22,581.90" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$38,680.29" $0.00 "$10,457.93" $0.00 "$24,739.73" "$24,739.73" $0.00 "$25,091.00" "$39,744.14" "$40,145.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,988.97" $0.00 $0.00 $0.00 $0.00 $0.00 27801462 EAP HCPCS C1722 Ilesto Vr-t High Energy With Ti With Cellular Gsm Hmtachycardia BOTH IP/OP "$52,883.00 " "$39,133.42" $0.00 "$42,306.40" "$23,797.35" "$23,797.35" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$40,762.22" $0.00 "$11,020.82" $0.00 "$26,071.32" "$26,071.32" $0.00 "$26,441.50" "$41,883.34" "$42,306.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801463 EAP HCPCS C1895 Linoxsmart Sd Steroid 60/16tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801464 EAP HCPCS C1895 Linoxsmart Sd Steroid 65/16tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801465 EAP HCPCS C1895 Linoxsmart Sd Steroid 65/18tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801466 EAP HCPCS C1895 Linoxsmart Sd Steroid 75/18tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801467 EAP HCPCS C1777 Linoxsmart S Steroid 60tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801468 EAP HCPCS C1777 Linoxsmart S Steroid 65tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801469 EAP HCPCS C1777 Linoxsmart S Steroid 75tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801470 EAP HCPCS C1777 Linoxsmart S Dx 65/15tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801471 EAP HCPCS C1895 Linoxsmart Td Steroid 65/16 Cmtachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801472 EAP HCPCS C1895 Linoxsmart Td Steroid 65/18 Cmtachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801473 EAP HCPCS C1777 Linoxsmart T Steroid 65tachycardialead BOTH IP/OP "$11,023.00 " "$8,157.02" $0.00 "$8,818.40" "$4,960.35" "$4,960.35" $0.00 $0.00 $0.00 "$2,297.47" "$4,181.12" "$4,181.12" "$8,496.53" $0.00 "$2,297.19" $0.00 "$5,434.34" "$5,434.34" $0.00 "$5,511.50" "$8,730.22" "$8,818.40" $0.00 $0.00 $0.00 "$1,725.10" $0.00 $0.00 "$1,754.86" $0.00 $0.00 $0.00 $0.00 $0.00 27801474 EAP HCPCS C1882 Ilesto Hf-t High Energy With Ti With Landline Hmcrt Heart Failure BOTH IP/OP "$65,477.00 " "$48,452.98" $0.00 "$52,381.60" "$29,464.65" "$29,464.65" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$50,469.67" $0.00 "$13,645.41" $0.00 "$32,280.16" "$32,280.16" $0.00 "$32,738.50" "$51,857.78" "$52,381.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801475 EAP HCPCS C1882 Ilesto Hf-t High Energy With Ti With Cellular Gsm Hmcrt Heart Failure BOTH IP/OP "$68,178.00 " "$50,451.72" $0.00 "$54,542.40" "$30,680.10" "$30,680.10" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$52,551.60" $0.00 "$14,208.30" $0.00 "$33,611.75" "$33,611.75" $0.00 "$34,089.00" "$53,996.98" "$54,542.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27801476 EAP Custom 27801476 Coil Embl 8cm 2mm Axium Prm X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801478 EAP Custom 27801478 Coil Embl 4cm 2.5mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801479 EAP Custom 27801479 Coil Embl 6cm 2.5mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801480 EAP Custom 27801480 Coil Embl 8cm 2.5mm Axium Prm X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801481 EAP Custom 27801481 Coil Embl 4cm 3mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801482 EAP Custom 27801482 Coil Embl 6cm 3mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 "$1,344.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801483 EAP Custom 27801483 Coil Embl 8cm 3mm Axium Prm Dtch X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801484 EAP Custom 27801484 Coil Embl 10cm 3mm Axium Prm X Sft Hlx BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801486 EAP Custom 27801486 Coil Embl 2cm 3mm Mreye 2.1 Loop Pltn A/v Strl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801487 EAP Custom 27801487 Coil Embl 3cm 2mm Mreye 4.8 Loop .035in Pltn Strl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801488 EAP Custom 27801488 Coil Embl 3cm 3mm Mreye 3.1 Loop Pltn A/v Strl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801489 EAP Custom 27801489 Coil Embl 4cm 3mm Mreye 4.2 Loop Pltn A/v Strl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801490 EAP Custom 27801490 Coil Embl 5cm 6mm Mreye 2.7 Loop End Hole Grt Radl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801491 EAP Custom 27801491 Coil Embl 5cm 7mm Mreye 2.3 Loop .035in Pltn Strl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801492 EAP Custom 27801492 Coil Embl 5cm 10mm Mreye 1.6 Loop Pltn Acpt .035in BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801493 EAP Custom 27801493 Coil Embl 8cm 5mm Mreye 5.1 Loop .035in Pltn Strl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801494 EAP HCPCS C1752 Tray Catheter Power-trialysis Straight L30 Cm Od13 BOTH IP/OP $693.00 $512.82 $0.00 $554.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $514.34 $514.34 $534.16 $0.00 $144.42 $0.00 $0.00 $0.00 $0.00 $346.50 $548.86 $554.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801495 EAP Custom 27801495 Coil Embl 8cm 8mm Mreye 3.2 Loop .035in Pltn Strl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801496 EAP Custom 27801496 Coil Embl 8cm 10mm Mreye 2.5 Loop .035in Pltn Strl BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.47 $145.47 $151.08 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801497 EAP HCPCS C1788 Port Implinfn 11.4fr 12fr Vtx Peelpro 2 Dtch Cath BOTH IP/OP "$1,455.00 " "$1,076.70" $0.00 "$1,164.00" $654.75 $654.75 $0.00 $0.00 $0.00 $303.26 "$1,079.90" "$1,079.90" "$1,121.51" $0.00 $303.22 $0.00 $860.63 $860.63 $0.00 $727.50 "$1,152.36" "$1,164.00" $0.00 $654.75 $0.00 $227.71 $0.00 $0.00 $231.64 $0.00 $0.00 $0.00 $0.00 $0.00 27801498 EAP HCPCS C1757 Solitaire Catheter Thrombectomy 6x40 BOTH IP/OP "$10,563.00 " "$7,816.62" $0.00 "$8,450.40" "$4,753.35" "$4,753.35" $0.00 $0.00 $0.00 "$2,201.59" "$4,181.12" "$4,181.12" "$8,141.96" $0.00 "$2,201.33" $0.00 "$5,207.56" "$5,207.56" $0.00 "$5,281.50" "$8,365.90" "$8,450.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801499 EAP HCPCS C1777 Lead Pcng 62cm Rv Trplr Scr In Xtd-retrac Hlx BOTH IP/OP "$6,100.00 " "$4,514.00" $0.00 "$4,880.00" "$2,745.00" "$2,745.00" $0.00 $0.00 $0.00 "$1,271.39" "$4,181.12" "$4,181.12" "$4,701.88" $0.00 "$1,271.24" $0.00 "$3,007.30" "$3,007.30" $0.00 "$3,050.00" "$4,831.20" "$4,880.00" $0.00 "$2,745.00" $0.00 $954.65 $0.00 $0.00 $971.12 $0.00 $0.00 $0.00 $0.00 $0.00 27801500 EAP Custom 27801500 Coil Embl .018in 2mm 2cm Azur Cx Hdrcl Dtch Loop S BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801501 EAP Custom 27801501 Coil Embl .018in 2mm 4cm Azur Cx Hdrcl Dtch Loop S BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801502 EAP Custom 27801502 Coil Embl .018in 3mm 4cm Azur Cx Hdrcl Dtch Loop S BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801503 EAP Custom 27801503 Coil Embl .018in 3mm 8cm Azur Cx Hdrcl Dtch Loop S BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801504 EAP HCPCS C1752 Catheter Hmdial Lg 12.5fr 16cm Grn Mhrkr Elt Dbl-d BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.11 $132.11 $137.20 $0.00 $37.10 $0.00 $0.00 $0.00 $0.00 $89.00 $140.98 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801505 EAP HCPCS C1752 Catheter Hmdial Lg 12.5fr 20cm Grn Mhrkr Elt Dbl-d BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.11 $132.11 $137.20 $0.00 $37.10 $0.00 $0.00 $0.00 $0.00 $89.00 $140.98 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801507 EAP HCPCS C1764 System Crd Monitr Rvl Linq Ins BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.01 $0.01 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801508 EAP Custom 27801508 Device Perclose BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801509 EAP HCPCS C1760 Device Closure 8fr .038in 70cm Hemostatic Bioabsor BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27801510 EAP HCPCS C1876 Stent Vascular Taper 8-6mm 30mm Self Expandable Er BOTH IP/OP "$6,113.00 " "$4,523.62" $0.00 "$4,841.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,841.50" $0.00 $0.00 $0.00 $0.00 $956.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801520 EAP HCPCS C1874 Stent Eprsth 5mm 5cm Strl 120cm Vbhn Flxb Slf Xpd BOTH IP/OP "$8,188.00 " "$6,059.12" $0.00 "$6,550.40" "$3,684.60" "$3,684.60" $0.00 $0.00 $0.00 "$1,706.58" "$4,181.12" "$4,181.12" "$6,311.31" $0.00 "$1,706.38" $0.00 "$4,036.68" "$4,036.68" $0.00 "$4,094.00" "$6,484.90" "$6,550.40" $0.00 $0.00 $0.00 "$1,281.42" $0.00 $0.00 "$1,303.53" $0.00 $0.00 $0.00 $0.00 $0.00 27801521 EAP Custom 27801521 Implant Ep Pack BOTH IP/OP $162.00 $119.88 $0.00 $129.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.00 $128.30 $129.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801522 EAP Custom 27801522 Coil Embl 15cm 12mm .038in Azur Dtch .035in Pltn BOTH IP/OP "$2,975.00 " "$2,201.50" $0.00 "$2,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,208.05" "$2,208.05" "$2,293.13" $0.00 $619.99 $0.00 $0.00 $0.00 $0.00 "$1,487.50" "$2,356.20" "$2,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801523 EAP Custom 27801523 Coil Embl 20cm 10mm Azur Dtch Ddrgl Peri 35 Sys BOTH IP/OP "$3,188.00 " "$2,359.12" $0.00 "$2,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,366.13" "$2,366.13" "$2,457.31" $0.00 $664.38 $0.00 $0.00 $0.00 $0.00 "$1,594.00" "$2,524.90" "$2,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801524 EAP Custom 27801524 Coil Embl 15cm 15mm Azur Hdrcl 18 Coils Dtch BOTH IP/OP "$2,127.00 " "$1,573.98" $0.00 "$1,701.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,578.66" "$1,578.66" "$1,639.49" $0.00 $443.27 $0.00 $0.00 $0.00 $0.00 "$1,063.50" "$1,684.58" "$1,701.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801525 EAP Custom 27801525 Coil Embl 20cm 10mm Azur Hdrcl 18 Coils Dtch BOTH IP/OP "$2,249.00 " "$1,664.26" $0.00 "$1,799.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.21" "$1,669.21" "$1,733.53" $0.00 $468.69 $0.00 $0.00 $0.00 $0.00 "$1,124.50" "$1,781.21" "$1,799.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801526 EAP Custom 27801526 Coil Embl 20cm 8mm .022in Azur Hdrcl Frme 6 Loop BOTH IP/OP "$1,020.00 " $754.80 $0.00 $816.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $757.04 $757.04 $786.22 $0.00 $212.57 $0.00 $0.00 $0.00 $0.00 $510.00 $807.84 $816.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801527 EAP Custom 27801527 Coil Embl 34cm 14mm Azur Hdrcl Dtch Nonhydrogel BOTH IP/OP "$2,975.00 " "$2,201.50" $0.00 "$2,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,208.05" "$2,208.05" "$2,293.13" $0.00 $619.99 $0.00 $0.00 $0.00 $0.00 "$1,487.50" "$2,356.20" "$2,380.00" $0.00 "$1,338.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801528 EAP Custom 27801528 Coil Embl 4mm .018in 15cm Azur Dtch Pltn BOTH IP/OP "$2,127.00 " "$1,573.98" $0.00 "$1,701.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,578.66" "$1,578.66" "$1,639.49" $0.00 $443.27 $0.00 $0.00 $0.00 $0.00 "$1,063.50" "$1,684.58" "$1,701.60" $0.00 $957.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801529 EAP Custom 27801529 Coil Embl 3mm .018in 10cm Azur Dtch Pltn BOTH IP/OP "$1,987.00 " "$1,470.38" $0.00 "$1,589.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,474.75" "$1,474.75" "$1,531.58" $0.00 $414.09 $0.00 $0.00 $0.00 $0.00 $993.50 "$1,573.70" "$1,589.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801530 EAP Custom 27801530 Coil Embl 6mm .018in 20cm Azur Dtch Pltn BOTH IP/OP "$2,244.00 " "$1,660.56" $0.00 "$1,795.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,665.50" "$1,665.50" "$1,729.68" $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 "$1,122.00" "$1,777.25" "$1,795.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27801531 EAP Custom 27801531 Coil Embl 4mm .018in 20cm Azur Dtch Pltn BOTH IP/OP "$2,244.00 " "$1,660.56" $0.00 "$1,795.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,665.50" "$1,665.50" "$1,729.68" $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 "$1,122.00" "$1,777.25" "$1,795.20" $0.00 "$1,009.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802002 EAP Custom 27802002 Coil Embl 14cm 6mm Nst 7.4 Loop Sft Radopc .018in BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802003 EAP Custom 27802003 Coil Embl 14cm 8mm Nst 5.6 Loop Sft Radopc .018in BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802004 EAP Custom 27802004 Coil Embl 14cm 10mm Nst 4.5 Loop Sft Radopc .018in BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802005 EAP Custom 27802005 Coil Embl 14cm 8mm Nst 5.6 Loop Pltn Synth Fbr Art BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802006 EAP Custom 27802006 Coil Embl 14cm 10mm Nst 4.5 Loop Sft .035in Pltn BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802008 EAP Custom 27802008 Coil Embl 9.5cm 8-4mm Trnd Mcl Mciol Sft Spc Push BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802009 EAP Custom 27802009 Coil Embl 4.1cm 5-3mm Trnd Sft .035in Std Sm Pltn BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802010 EAP Custom 27802010 Coil Embl 8cm 7-3mm Trnd Pltn Arteriovenous Acpt BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802011 EAP Custom 27802011 Coil Embl 14cm 6mm Nst Sft Cath Xtd Embl Endhole BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802012 EAP Custom 27802012 Coil Embl 7cm 4mm Nst 5.6 Loop Sft Enh Radopc .035 BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802013 EAP Custom 27802013 Coil Embolization .035in 10mm 7cm 2.2 Loop Soft Enhanced BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802014 EAP Custom 27802014 Coil Embl 14cm 20mm Nst 2.2 Loop Sft Enh Radopc BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802015 EAP Custom 27802015 Coil Embl 3cm 2mm Nst 4.8 Loop Sft Enh Radopc BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $114.50 $181.37 $183.20 $0.00 $103.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802016 EAP Custom 27802016 Coil Embl 3cm 3mm Nst 3.2 Loop Sft Enh Radopc BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $114.50 $181.37 $183.20 $0.00 $103.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802017 EAP Custom 27802017 Coil Embl 5cm 3mm Nst 5.3 Loop Sft Enh Radopc BOTH IP/OP $229.00 $169.46 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.96 $169.96 $176.51 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $114.50 $181.37 $183.20 $0.00 $103.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802018 EAP Custom 27802018 Coil Embl 7cm 6mm Nst 3.7 Loop Sft Enh Radopc .035 BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802020 EAP Custom 27802020 Coil Embl 14cm 16mm Nst 2.8 Loop Sft Xtd Enh BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802021 EAP Custom 27802021 Coil Embl 7cm 3mm Nst 7.4 Loop Sft Enh Radopc BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802022 EAP Custom 27802022 Coil Embl 7cm 4mm .018in Nst Cath Loop Sft Str Wg BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802023 EAP Custom 27802023 Coil Embl 2cm 3-2mm Trnd Mciol Mlfrm Sft .018in BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $208.12 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802024 EAP Custom 27802024 Coil Embl 7cm 3mm Nst 7.4 Loop Pltn Synth Fbr Strl BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $0.00 $0.00 $0.00 $124.50 $197.21 $199.20 $0.00 $112.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802025 EAP HCPCS C1882 Quadra Assura Mp Crt-d BOTH IP/OP "$42,750.00 " "$31,635.00" $0.00 "$34,200.00" "$19,237.50" "$19,237.50" $0.00 $0.00 $0.00 "$8,910.17" "$4,181.12" "$4,181.12" "$32,951.70" $0.00 "$8,909.10" $0.00 "$21,075.75" "$21,075.75" $0.00 "$21,375.00" "$33,858.00" "$34,200.00" $0.00 "$19,237.50" $0.00 "$6,690.38" $0.00 $0.00 "$6,805.80" $0.00 $0.00 $0.00 $0.00 $0.00 27802026 EAP HCPCS C1882 Quadra Assura Mp Crt-d Df4 Connector BOTH IP/OP "$42,750.00 " "$31,635.00" $0.00 "$34,200.00" "$19,237.50" "$19,237.50" $0.00 $0.00 $0.00 "$8,910.17" "$4,181.12" "$4,181.12" "$32,951.70" $0.00 "$8,909.10" $0.00 "$21,075.75" "$21,075.75" $0.00 "$21,375.00" "$33,858.00" "$34,200.00" $0.00 "$19,237.50" $0.00 "$6,690.38" $0.00 $0.00 "$6,805.80" $0.00 $0.00 $0.00 $0.00 $0.00 27802027 EAP HCPCS C1882 "Quadra Assura Mp Crt-d, Merlinpkg" BOTH IP/OP "$43,875.00 " "$32,467.50" $0.00 "$35,100.00" "$19,743.75" "$19,743.75" $0.00 $0.00 $0.00 "$9,144.65" "$4,181.12" "$4,181.12" "$33,818.85" $0.00 "$9,143.55" $0.00 "$21,630.38" "$21,630.38" $0.00 "$21,937.50" "$34,749.00" "$35,100.00" $0.00 $0.00 $0.00 "$6,866.44" $0.00 $0.00 "$6,984.90" $0.00 $0.00 $0.00 $0.00 $0.00 27802028 EAP HCPCS C1882 "Quadra Assura Mp Crt-d Df4, Merlinpkg" BOTH IP/OP "$43,875.00 " "$32,467.50" $0.00 "$35,100.00" "$19,743.75" "$19,743.75" $0.00 $0.00 $0.00 "$9,144.65" "$4,181.12" "$4,181.12" "$33,818.85" $0.00 "$9,143.55" $0.00 "$21,630.38" "$21,630.38" $0.00 "$21,937.50" "$34,749.00" "$35,100.00" $0.00 $0.00 $0.00 "$6,866.44" $0.00 $0.00 "$6,984.90" $0.00 $0.00 $0.00 $0.00 $0.00 27802029 EAP HCPCS C1882 Quadra Assura Mp Crt-d System BOTH IP/OP "$56,250.00 " "$41,625.00" $0.00 "$45,000.00" "$25,312.50" "$25,312.50" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$43,357.50" $0.00 "$11,722.50" $0.00 "$27,731.25" "$27,731.25" $0.00 "$28,125.00" "$44,550.00" "$45,000.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27802030 EAP HCPCS C1882 Quadra Assura Mp Crt-d Df4 Connector System BOTH IP/OP "$56,250.00 " "$41,625.00" $0.00 "$45,000.00" "$25,312.50" "$25,312.50" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$43,357.50" $0.00 "$11,722.50" $0.00 "$27,731.25" "$27,731.25" $0.00 "$28,125.00" "$44,550.00" "$45,000.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27802031 EAP HCPCS C1882 "Quadra Assura Mp Crt-d System, Merlinpkg" BOTH IP/OP "$58,500.00 " "$43,290.00" $0.00 "$46,800.00" "$26,325.00" "$26,325.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,091.80" $0.00 "$12,191.40" $0.00 "$28,840.50" "$28,840.50" $0.00 "$29,250.00" "$46,332.00" "$46,800.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27802032 EAP HCPCS C1882 "Quadra Assura Mp Crt-d Df4 System, Merlinpkg" BOTH IP/OP "$58,500.00 " "$43,290.00" $0.00 "$46,800.00" "$26,325.00" "$26,325.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$45,091.80" $0.00 "$12,191.40" $0.00 "$28,840.50" "$28,840.50" $0.00 "$29,250.00" "$46,332.00" "$46,800.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27802033 EAP HCPCS C1900 "Quartet, Small-s 75cm" BOTH IP/OP "$5,375.00 " "$3,977.50" $0.00 "$4,300.00" "$2,418.75" "$2,418.75" $0.00 $0.00 $0.00 "$1,120.28" "$3,989.33" "$3,989.33" "$4,143.05" $0.00 "$1,120.15" $0.00 "$2,649.88" "$2,649.88" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 $0.00 $0.00 $841.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802034 EAP HCPCS C1900 "Quartet, Small-s 86cm" BOTH IP/OP "$5,375.00 " "$3,977.50" $0.00 "$4,300.00" "$2,418.75" "$2,418.75" $0.00 $0.00 $0.00 "$1,120.28" "$3,989.33" "$3,989.33" "$4,143.05" $0.00 "$1,120.15" $0.00 "$2,649.88" "$2,649.88" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 $0.00 $0.00 $841.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802035 EAP HCPCS C1900 "Quartet, Wide Spacing 75cm" BOTH IP/OP "$5,375.00 " "$3,977.50" $0.00 "$4,300.00" "$2,418.75" "$2,418.75" $0.00 $0.00 $0.00 "$1,120.28" "$3,989.33" "$3,989.33" "$4,143.05" $0.00 "$1,120.15" $0.00 "$2,649.88" "$2,649.88" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 $0.00 $0.00 $841.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802036 EAP HCPCS C1900 "Quartet, Wide Spacing 86cm" BOTH IP/OP "$5,375.00 " "$3,977.50" $0.00 "$4,300.00" "$2,418.75" "$2,418.75" $0.00 $0.00 $0.00 "$1,120.28" "$3,989.33" "$3,989.33" "$4,143.05" $0.00 "$1,120.15" $0.00 "$2,649.88" "$2,649.88" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 "$2,418.75" $0.00 $841.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27802040 EAP HCPCS C1874 Stent Vasc 80mm 6mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802041 EAP HCPCS C1874 Stent Vasc 60mm 5mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802042 EAP HCPCS C1874 Stent Vasc 80mm 5mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802044 EAP HCPCS C1874 Stent Vasc 40mm 6mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802045 EAP HCPCS C1874 Stent Vasc 60mm 6mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802046 EAP HCPCS C1874 Stent Coron 40mm 5mm Gore Tigris Vasc Cbas Ntnl BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802047 EAP HCPCS C1874 Stent Vasc 100mm 6mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802048 EAP HCPCS C1874 Stent Vasc 40mm 7mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802050 EAP HCPCS C1874 Stent Vasc 80mm 7mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27802051 EAP HCPCS C1874 Stent Vasc 100mm 7mm Gore Tigris Cbas Ntnl Flplmr BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 27803013 EAP HCPCS C1781 Mesh Implt BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $292.50 $292.50 $0.00 $0.00 $0.00 $135.48 $482.43 $482.43 $501.02 $0.00 $135.46 $0.00 $384.48 $384.48 $0.00 $325.00 $514.80 $520.00 $0.00 $292.50 $0.00 $101.73 $0.00 $0.00 $103.48 $0.00 $0.00 $0.00 $0.00 $0.00 27803015 EAP Custom 27803015 Coil Embolization .018in Standard Length 2d 2mm 4c BOTH IP/OP $943.00 $697.82 $0.00 $754.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.89 $699.89 $726.86 $0.00 $196.52 $0.00 $0.00 $0.00 $0.00 $471.50 $746.86 $754.40 $0.00 $424.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803030 EAP HCPCS C1897 Sjm Percutaneous Lead BOTH IP/OP "$2,869.00 " "$2,123.06" $0.00 "$2,295.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,129.37" "$2,129.37" "$2,211.43" $0.00 $597.90 $0.00 $0.00 $0.00 $0.00 "$1,434.50" "$2,272.25" "$2,295.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803050 EAP Custom 27803050 Biliary Metal Stents BOTH IP/OP "$5,087.00 " "$3,764.38" $0.00 "$4,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,775.57" "$3,775.57" "$3,921.06" $0.00 "$1,060.13" $0.00 $0.00 $0.00 $0.00 "$2,543.50" "$4,028.90" "$4,069.60" $0.00 "$2,289.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803051 EAP Custom 27803051 Ultraflex Diamond Metal Stent BOTH IP/OP "$9,045.00 " "$6,693.30" $0.00 "$7,236.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,971.89" $0.00 "$1,884.98" $0.00 $0.00 $0.00 $0.00 "$4,522.50" "$7,163.64" "$7,236.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803052 EAP Custom 27803052 Polyflex Esophageal Stent BOTH IP/OP "$13,618.00 " "$10,077.32" $0.00 "$10,894.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,496.75" $0.00 "$2,837.99" $0.00 $0.00 $0.00 $0.00 "$6,809.00" "$10,785.46" "$10,894.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803053 EAP Custom 27803053 Stent Coron 8mm 2.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 $0.00 $0.00 $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803055 EAP HCPCS C1874 Stent Coron 12mm 2.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803056 EAP HCPCS C1874 Stent Coron 18mm 2.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803057 EAP HCPCS C1874 Stent Coron 23mm 2.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803058 EAP HCPCS C1874 Stent Coron 28mm 2.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803059 EAP HCPCS C1874 Stent Coron 8mm 3mm Abs Gt1 Poly L Lactd Pld Lactd BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803061 EAP HCPCS C1874 Stent Coron 12mm 3mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803062 EAP HCPCS C1874 Stent Coron 18mm 3mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803063 EAP HCPCS C1874 Stent Coron 23mm 3mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803064 EAP HCPCS C1874 Stent Coron 28mm 3mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803065 EAP HCPCS C1874 Stent Coron 12mm 3.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803066 EAP HCPCS C1874 Stent Coron 18mm 3.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803067 EAP HCPCS C1874 Stent Coron 23mm 3.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803068 EAP HCPCS C1874 Stent Coron 28mm 3.5mm Abs Gt1 Poly L Lactd Pld BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" "$2,794.15" $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803070 EAP Custom 27803070 Rx Stent 7x5 Cm BOTH IP/OP $169.00 $125.06 $0.00 $135.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.43 $125.43 $130.27 $0.00 $35.22 $0.00 $0.00 $0.00 $0.00 $84.50 $133.85 $135.20 $0.00 $76.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803071 EAP Custom 27803071 Rx Stent 7x7 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $72.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803072 EAP Custom 27803072 Rx Stent 7x12 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $72.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803073 EAP Custom 27803073 Rx Stent 10x5 BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $72.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803074 EAP Custom 27803074 Rx Stent 10x7cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $72.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803075 EAP Custom 27803075 Rx Stent 10x10 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803076 EAP Custom 27803076 Rx Stent 10x12 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $72.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803077 EAP Custom 27803077 Rx Stent 8.5 X5 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803078 EAP Custom 27803078 Rx Stent 8.5 X7cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $72.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803079 EAP Custom 27803079 Rx Stent 8.5 X 10cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803080 EAP Custom 27803080 Rx Stent 8.5x12 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803081 EAP Custom 27803081 Rx Stent 7x10 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $72.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803082 EAP HCPCS C1874 Graft Evas 74mm 24mm 16fr Znth Sprlz Z-trk Abd BOTH IP/OP "$7,713.00 " "$5,707.62" $0.00 "$6,170.40" "$3,470.85" "$3,470.85" $0.00 $0.00 $0.00 "$1,607.58" "$4,181.12" "$4,181.12" "$5,945.18" $0.00 "$1,607.39" $0.00 "$3,802.51" "$3,802.51" $0.00 "$3,856.50" "$6,108.70" "$6,170.40" $0.00 $0.00 $0.00 "$1,207.08" $0.00 $0.00 "$1,227.91" $0.00 $0.00 $0.00 $0.00 $0.00 27803083 EAP HCPCS C1874 Graft Evas 56mm 24mm 6mm 5.3mm Znth Sprlz Aaa Ilc BOTH IP/OP "$7,713.00 " "$5,707.62" $0.00 "$6,170.40" "$3,470.85" "$3,470.85" $0.00 $0.00 $0.00 "$1,607.58" "$4,181.12" "$4,181.12" "$5,945.18" $0.00 "$1,607.39" $0.00 "$3,802.51" "$3,802.51" $0.00 "$3,856.50" "$6,108.70" "$6,170.40" $0.00 $0.00 $0.00 "$1,207.08" $0.00 $0.00 "$1,227.91" $0.00 $0.00 $0.00 $0.00 $0.00 27803090 EAP HCPCS C1777 7120 Durata Pkg Lead BOTH IP/OP "$15,063.00 " "$11,146.62" $0.00 "$12,050.40" "$6,778.35" "$6,778.35" $0.00 $0.00 $0.00 "$3,139.51" "$4,181.12" "$4,181.12" "$11,610.56" $0.00 "$3,139.13" $0.00 "$7,426.06" "$7,426.06" $0.00 "$7,531.50" "$11,929.90" "$12,050.40" $0.00 $0.00 $0.00 "$2,357.36" $0.00 $0.00 "$2,398.03" $0.00 $0.00 $0.00 $0.00 $0.00 27803091 EAP HCPCS C1777 7121 Durata Pkg Lead BOTH IP/OP "$15,063.00 " "$11,146.62" $0.00 "$12,050.40" "$6,778.35" "$6,778.35" $0.00 $0.00 $0.00 "$3,139.51" "$4,181.12" "$4,181.12" "$11,610.56" $0.00 "$3,139.13" $0.00 "$7,426.06" "$7,426.06" $0.00 "$7,531.50" "$11,929.90" "$12,050.40" $0.00 $0.00 $0.00 "$2,357.36" $0.00 $0.00 "$2,398.03" $0.00 $0.00 $0.00 $0.00 $0.00 27803092 EAP HCPCS C1874 Wallflex Esop Pcoverdstent Spv BOTH IP/OP "$9,055.00 " "$6,700.70" $0.00 "$7,244.00" "$4,074.75" "$4,074.75" $0.00 $0.00 $0.00 "$1,887.29" "$4,181.12" "$4,181.12" "$6,979.59" $0.00 "$1,887.06" $0.00 "$4,464.12" "$4,464.12" $0.00 "$4,527.50" "$7,171.56" "$7,244.00" $0.00 $0.00 $0.00 "$1,417.11" $0.00 $0.00 "$1,441.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803093 EAP HCPCS C1896 Subcutaneous Ld System 6996-sq BOTH IP/OP "$8,967.00 " "$6,635.58" $0.00 "$7,173.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,868.95" "$4,181.12" "$4,181.12" "$6,911.76" $0.00 "$1,868.72" $0.00 "$4,420.73" "$4,420.73" $0.00 "$4,483.50" "$7,101.86" "$7,173.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803094 EAP HCPCS C1877 Transhepatic Biliary Stent Spv BOTH IP/OP "$6,456.00 " "$4,777.44" $0.00 "$5,164.80" "$2,905.20" "$2,905.20" $0.00 $0.00 $0.00 "$1,345.59" "$4,181.12" "$4,181.12" "$4,976.28" $0.00 "$1,345.43" $0.00 "$3,182.81" "$3,182.81" $0.00 "$3,228.00" "$5,113.15" "$5,164.80" $0.00 "$2,905.20" $0.00 "$1,010.36" $0.00 $0.00 "$1,027.80" $0.00 $0.00 $0.00 $0.00 $0.00 27803095 EAP HCPCS C1897 "Lead, Neurostim Test Kit" BOTH IP/OP "$3,411.00 " "$2,524.14" $0.00 "$2,728.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,531.64" "$2,531.64" "$2,629.20" $0.00 $710.85 $0.00 $0.00 $0.00 $0.00 "$1,705.50" "$2,701.51" "$2,728.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803096 EAP HCPCS C1725 Pta Dilatation Catheter 18 Spv BOTH IP/OP "$1,435.00 " "$1,061.90" $0.00 "$1,148.00" $645.75 $645.75 $0.00 $0.00 $0.00 $299.09 "$1,065.06" "$1,065.06" "$1,106.10" $0.00 $299.05 $0.00 $848.80 $848.80 $0.00 $717.50 "$1,136.52" "$1,148.00" $0.00 $0.00 $0.00 $224.58 $0.00 $0.00 $228.45 $0.00 $0.00 $0.00 $0.00 $0.00 27803097 EAP HCPCS C1725 Pta Dilatation Catheter 16 Spv BOTH IP/OP "$1,435.00 " "$1,061.90" $0.00 "$1,148.00" $645.75 $645.75 $0.00 $0.00 $0.00 $299.09 "$1,065.06" "$1,065.06" "$1,106.10" $0.00 $299.05 $0.00 $848.80 $848.80 $0.00 $717.50 "$1,136.52" "$1,148.00" $0.00 $0.00 $0.00 $224.58 $0.00 $0.00 $228.45 $0.00 $0.00 $0.00 $0.00 $0.00 27803098 EAP HCPCS C1880 80078352 - Filter Option Ivc BOTH IP/OP "$1,429.00 " "$1,057.46" $0.00 "$1,143.20" $643.05 $643.05 $0.00 $0.00 $0.00 $297.84 "$1,060.60" "$1,060.60" "$1,101.47" $0.00 $297.80 $0.00 $845.25 $845.25 $0.00 $714.50 "$1,131.77" "$1,143.20" $0.00 $0.00 $0.00 $223.64 $0.00 $0.00 $227.50 $0.00 $0.00 $0.00 $0.00 $0.00 27803099 EAP HCPCS A4301 Femoral Arterial Line Kit BOTH IP/OP $972.00 $719.28 $0.00 $777.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $721.42 $721.42 $749.22 $0.00 $202.56 $0.00 $0.00 $0.00 $0.00 $486.00 $769.82 $777.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803100 EAP HCPCS C2625 Rx Stent 7x5 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803101 EAP HCPCS C2625 Rx Stent 7x7 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803102 EAP HCPCS C2625 Rx Stent 7x10 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803103 EAP HCPCS C2625 Rx Stent 7x12 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803104 EAP HCPCS C2625 Rx Stent 10x5 BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803105 EAP HCPCS C2625 Rx Stent 10x7cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803106 EAP HCPCS C2625 Rx Stent 10x10 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803107 EAP HCPCS C2625 Rx Stent 10x12 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803108 EAP HCPCS C2625 Rx Stent 8.5 X5 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803109 EAP HCPCS C2625 Rx Stent 8.5 X7cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803110 EAP HCPCS C2625 Rx Stent 8.5 X 10cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803111 EAP HCPCS C2625 Rx Stent 8.5x12 Cm BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $72.45 $72.45 $0.00 $0.00 $0.00 $33.56 $119.49 $119.49 $124.10 $0.00 $33.55 $0.00 $95.23 $95.23 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803152 EAP HCPCS C1760 Starclose Se BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $129.60 $129.60 $0.00 $0.00 $0.00 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 27803160 EAP HCPCS C2625 3.0 Xmm Vision Rx Stent BOTH IP/OP "$4,987.00 " "$3,690.38" $0.00 "$3,989.60" "$2,244.15" "$2,244.15" $0.00 $0.00 $0.00 "$1,039.42" "$3,701.35" "$3,701.35" "$3,843.98" $0.00 "$1,039.29" $0.00 "$2,458.59" "$2,458.59" $0.00 "$2,493.50" "$3,949.70" "$3,989.60" $0.00 $0.00 $0.00 $780.47 $0.00 $0.00 $793.93 $0.00 $0.00 $0.00 $0.00 $0.00 27803161 EAP HCPCS C2625 2.50 X 8mm Mini-vision Stent BOTH IP/OP "$4,987.00 " "$3,690.38" $0.00 "$3,989.60" "$2,244.15" "$2,244.15" $0.00 $0.00 $0.00 "$1,039.42" "$3,701.35" "$3,701.35" "$3,843.98" $0.00 "$1,039.29" $0.00 "$2,458.59" "$2,458.59" $0.00 "$2,493.50" "$3,949.70" "$3,989.60" $0.00 $0.00 $0.00 $780.47 $0.00 $0.00 $793.93 $0.00 $0.00 $0.00 $0.00 $0.00 27803162 EAP Custom 27803162 Lc Bead 500-700 BOTH IP/OP "$4,654.00 " "$3,443.96" $0.00 "$3,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,454.20" "$3,454.20" "$3,587.30" $0.00 $969.89 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,685.97" "$3,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803163 EAP Custom 27803163 Lc Bead 300-500 BOTH IP/OP "$4,654.00 " "$3,443.96" $0.00 "$3,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,454.20" "$3,454.20" "$3,587.30" $0.00 $969.89 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,685.97" "$3,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803164 EAP HCPCS C1880 80078352 - Filter Option Ivc BOTH IP/OP "$1,429.00 " "$1,057.46" $0.00 "$1,143.20" $643.05 $643.05 $0.00 $0.00 $0.00 $297.84 "$1,060.60" "$1,060.60" "$1,101.47" $0.00 $297.80 $0.00 $845.25 $845.25 $0.00 $714.50 "$1,131.77" "$1,143.20" $0.00 $0.00 $0.00 $223.64 $0.00 $0.00 $227.50 $0.00 $0.00 $0.00 $0.00 $0.00 27803172 EAP HCPCS C1874 Vbh081502 Catheter Viabahn 8mm BOTH IP/OP "$5,107.00 " "$3,779.18" $0.00 "$4,085.60" "$2,298.15" "$2,298.15" $0.00 $0.00 $0.00 "$1,064.43" "$3,790.42" "$3,790.42" "$3,936.48" $0.00 "$1,064.30" $0.00 "$2,517.75" "$2,517.75" $0.00 "$2,553.50" "$4,044.74" "$4,085.60" $0.00 $0.00 $0.00 $799.25 $0.00 $0.00 $813.03 $0.00 $0.00 $0.00 $0.00 $0.00 27803173 EAP HCPCS C1874 Vbh071502 Catheter Viabahn 8mm BOTH IP/OP "$5,107.00 " "$3,779.18" $0.00 "$4,085.60" "$2,298.15" "$2,298.15" $0.00 $0.00 $0.00 "$1,064.43" "$3,790.42" "$3,790.42" "$3,936.48" $0.00 "$1,064.30" $0.00 "$2,517.75" "$2,517.75" $0.00 "$2,553.50" "$4,044.74" "$4,085.60" $0.00 "$2,298.15" $0.00 $799.25 $0.00 $0.00 $813.03 $0.00 $0.00 $0.00 $0.00 $0.00 27803184 EAP HCPCS C1894 9fr-30 Tear-away Introducer BOTH IP/OP $579.00 $428.46 $0.00 $463.20 $260.55 $260.55 $0.00 $0.00 $0.00 $120.68 $429.73 $429.73 $446.29 $0.00 $120.66 $0.00 $342.48 $342.48 $0.00 $289.50 $458.57 $463.20 $0.00 $0.00 $0.00 $90.61 $0.00 $0.00 $92.18 $0.00 $0.00 $0.00 $0.00 $0.00 27803185 EAP HCPCS C1894 10fr-30cm Tear Away Introducer BOTH IP/OP $579.00 $428.46 $0.00 $463.20 $260.55 $260.55 $0.00 $0.00 $0.00 $120.68 $429.73 $429.73 $446.29 $0.00 $120.66 $0.00 $342.48 $342.48 $0.00 $289.50 $458.57 $463.20 $0.00 $260.55 $0.00 $90.61 $0.00 $0.00 $92.18 $0.00 $0.00 $0.00 $0.00 $0.00 27803186 EAP HCPCS C1894 16fr-3ocm Tear-away Introducer BOTH IP/OP $579.00 $428.46 $0.00 $463.20 $260.55 $260.55 $0.00 $0.00 $0.00 $120.68 $429.73 $429.73 $446.29 $0.00 $120.66 $0.00 $342.48 $342.48 $0.00 $289.50 $458.57 $463.20 $0.00 $0.00 $0.00 $90.61 $0.00 $0.00 $92.18 $0.00 $0.00 $0.00 $0.00 $0.00 27803187 EAP HCPCS C1769 Wire Guide Lunderquist Extra S BOTH IP/OP $347.00 $256.78 $0.00 $277.60 $156.15 $156.15 $0.00 $0.00 $0.00 $72.32 $257.54 $257.54 $267.47 $0.00 $72.31 $0.00 $205.25 $205.25 $0.00 $173.50 $274.82 $277.60 $0.00 $0.00 $0.00 $54.31 $0.00 $0.00 $55.24 $0.00 $0.00 $0.00 $0.00 $0.00 27803188 EAP HCPCS C1894 Sheath Prelude BOTH IP/OP $277.00 $204.98 $0.00 $221.60 $124.65 $124.65 $0.00 $0.00 $0.00 $57.73 $205.59 $205.59 $213.51 $0.00 $57.73 $0.00 $163.85 $163.85 $0.00 $138.50 $219.38 $221.60 $0.00 $0.00 $0.00 $43.35 $0.00 $0.00 $44.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803189 EAP HCPCS C2625 3.0 X 8mm Vision Rx Stent BOTH IP/OP "$2,920.00 " "$2,160.80" $0.00 "$2,336.00" "$1,314.00" "$1,314.00" $0.00 $0.00 $0.00 $608.60 "$2,167.22" "$2,167.22" "$2,250.74" $0.00 $608.53 $0.00 "$1,439.56" "$1,439.56" $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $456.98 $0.00 $0.00 $464.86 $0.00 $0.00 $0.00 $0.00 $0.00 27803190 EAP HCPCS C2625 2.50 X 8mm Mini-vision Stent BOTH IP/OP "$3,836.00 " "$2,838.64" $0.00 "$3,068.80" "$1,726.20" "$1,726.20" $0.00 $0.00 $0.00 $799.52 "$2,847.08" "$2,847.08" "$2,956.79" $0.00 $799.42 $0.00 "$1,891.15" "$1,891.15" $0.00 "$1,918.00" "$3,038.11" "$3,068.80" $0.00 $0.00 $0.00 $600.33 $0.00 $0.00 $610.69 $0.00 $0.00 $0.00 $0.00 $0.00 27803191 EAP Custom 27803191 Lc Bead 500-700 BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $990.84 $990.84 "$1,029.02" $0.00 $278.21 $0.00 $0.00 $0.00 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803192 EAP HCPCS C1876 Stent Microdelive Wingspan 4 1 BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" "$9,180.00" "$9,180.00" $0.00 $0.00 $0.00 "$4,251.87" "$4,181.12" "$4,181.12" "$15,724.32" $0.00 "$4,251.36" $0.00 "$10,057.20" "$10,057.20" $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 "$3,192.60" $0.00 $0.00 "$3,247.68" $0.00 $0.00 $0.00 $0.00 $0.00 27803193 EAP HCPCS C1876 Stent Microdelive Wingspan 4 2 BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" "$9,180.00" "$9,180.00" $0.00 $0.00 $0.00 "$4,251.87" "$4,181.12" "$4,181.12" "$15,724.32" $0.00 "$4,251.36" $0.00 "$10,057.20" "$10,057.20" $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 "$3,192.60" $0.00 $0.00 "$3,247.68" $0.00 $0.00 $0.00 $0.00 $0.00 27803194 EAP HCPCS C1876 Stent Microdelive Wingspan 3 1 BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" "$9,180.00" "$9,180.00" $0.00 $0.00 $0.00 "$4,251.87" "$4,181.12" "$4,181.12" "$15,724.32" $0.00 "$4,251.36" $0.00 "$10,057.20" "$10,057.20" $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 "$3,192.60" $0.00 $0.00 "$3,247.68" $0.00 $0.00 $0.00 $0.00 $0.00 27803195 EAP HCPCS C1876 Stent Microdelive Wingspan 3 2 BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" "$9,180.00" "$9,180.00" $0.00 $0.00 $0.00 "$4,251.87" "$4,181.12" "$4,181.12" "$15,724.32" $0.00 "$4,251.36" $0.00 "$10,057.20" "$10,057.20" $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 "$3,192.60" $0.00 $0.00 "$3,247.68" $0.00 $0.00 $0.00 $0.00 $0.00 27803196 EAP HCPCS C1876 Stent Microdelivery 3.0 X 15.0 BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" "$9,180.00" "$9,180.00" $0.00 $0.00 $0.00 "$4,251.87" "$4,181.12" "$4,181.12" "$15,724.32" $0.00 "$4,251.36" $0.00 "$10,057.20" "$10,057.20" $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 "$3,192.60" $0.00 $0.00 "$3,247.68" $0.00 $0.00 $0.00 $0.00 $0.00 27803197 EAP HCPCS C1876 Stent Microdelive Wingspan 3 3 BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" "$9,180.00" "$9,180.00" $0.00 $0.00 $0.00 "$4,251.87" "$4,181.12" "$4,181.12" "$15,724.32" $0.00 "$4,251.36" $0.00 "$10,057.20" "$10,057.20" $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 "$3,192.60" $0.00 $0.00 "$3,247.68" $0.00 $0.00 $0.00 $0.00 $0.00 27803198 EAP HCPCS C1876 Stent Microdelivery Wingspan BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" "$9,180.00" "$9,180.00" $0.00 $0.00 $0.00 "$4,251.87" "$4,181.12" "$4,181.12" "$15,724.32" $0.00 "$4,251.36" $0.00 "$10,057.20" "$10,057.20" $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 "$3,192.60" $0.00 $0.00 "$3,247.68" $0.00 $0.00 $0.00 $0.00 $0.00 27803199 EAP HCPCS C1876 Stent Mircrodelivery Wingspan2 BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" "$9,180.00" "$9,180.00" $0.00 $0.00 $0.00 "$4,251.87" "$4,181.12" "$4,181.12" "$15,724.32" $0.00 "$4,251.36" $0.00 "$10,057.20" "$10,057.20" $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 "$3,192.60" $0.00 $0.00 "$3,247.68" $0.00 $0.00 $0.00 $0.00 $0.00 27803200 EAP HCPCS C1876 Stent Microdelivery 4.5x30mm BOTH IP/OP "$19,181.00 " "$14,193.94" $0.00 "$15,344.80" "$8,631.45" "$8,631.45" $0.00 $0.00 $0.00 "$3,997.80" "$4,181.12" "$4,181.12" "$14,784.71" $0.00 "$3,997.32" $0.00 "$9,456.23" "$9,456.23" $0.00 "$9,590.50" "$15,191.35" "$15,344.80" $0.00 $0.00 $0.00 "$3,001.83" $0.00 $0.00 "$3,053.62" $0.00 $0.00 $0.00 $0.00 $0.00 27803201 EAP HCPCS C1876 Stent Microdelivery 4.5x20mm BOTH IP/OP "$19,181.00 " "$14,193.94" $0.00 "$15,344.80" "$8,631.45" "$8,631.45" $0.00 $0.00 $0.00 "$3,997.80" "$4,181.12" "$4,181.12" "$14,784.71" $0.00 "$3,997.32" $0.00 "$9,456.23" "$9,456.23" $0.00 "$9,590.50" "$15,191.35" "$15,344.80" $0.00 $0.00 $0.00 "$3,001.83" $0.00 $0.00 "$3,053.62" $0.00 $0.00 $0.00 $0.00 $0.00 27803202 EAP HCPCS C1876 Stent Micrdelivery 4.0 X20mm BOTH IP/OP "$19,181.00 " "$14,193.94" $0.00 "$15,344.80" "$8,631.45" "$8,631.45" $0.00 $0.00 $0.00 "$3,997.80" "$4,181.12" "$4,181.12" "$14,784.71" $0.00 "$3,997.32" $0.00 "$9,456.23" "$9,456.23" $0.00 "$9,590.50" "$15,191.35" "$15,344.80" $0.00 $0.00 $0.00 "$3,001.83" $0.00 $0.00 "$3,053.62" $0.00 $0.00 $0.00 $0.00 $0.00 27803203 EAP HCPCS C1876 Stent Microdelivery 3.5x20mm BOTH IP/OP "$19,181.00 " "$14,193.94" $0.00 "$15,344.80" "$8,631.45" "$8,631.45" $0.00 $0.00 $0.00 "$3,997.80" "$4,181.12" "$4,181.12" "$14,784.71" $0.00 "$3,997.32" $0.00 "$9,456.23" "$9,456.23" $0.00 "$9,590.50" "$15,191.35" "$15,344.80" $0.00 $0.00 $0.00 "$3,001.83" $0.00 $0.00 "$3,053.62" $0.00 $0.00 $0.00 $0.00 $0.00 27803204 EAP HCPCS C1876 Neuroform Atlas Stent System BOTH IP/OP "$17,038.00 " "$12,608.12" $0.00 "$13,630.40" "$7,667.10" "$7,667.10" $0.00 $0.00 $0.00 "$3,551.15" "$4,181.12" "$4,181.12" "$13,132.89" $0.00 "$3,550.72" $0.00 "$8,399.73" "$8,399.73" $0.00 "$8,519.00" "$13,494.10" "$13,630.40" $0.00 $0.00 $0.00 "$2,666.45" $0.00 $0.00 "$2,712.45" $0.00 $0.00 $0.00 $0.00 $0.00 27803205 EAP Custom 27803205 Coil Tornado 5/3 .036 BOTH IP/OP $298.00 $220.52 $0.00 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.18 $221.18 $229.70 $0.00 $62.10 $0.00 $0.00 $0.00 $0.00 $149.00 $236.02 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803206 EAP Custom 27803206 Coil Tornado 4/3 .035 BOTH IP/OP $298.00 $220.52 $0.00 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.18 $221.18 $229.70 $0.00 $62.10 $0.00 $0.00 $0.00 $0.00 $149.00 $236.02 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803207 EAP HCPCS C1874 Cath.viabahn 8mm X 15cm 1 BOTH IP/OP "$5,107.00 " "$3,779.18" $0.00 "$4,085.60" "$2,298.15" "$2,298.15" $0.00 $0.00 $0.00 "$1,064.43" "$3,790.42" "$3,790.42" "$3,936.48" $0.00 "$1,064.30" $0.00 "$2,517.75" "$2,517.75" $0.00 "$2,553.50" "$4,044.74" "$4,085.60" $0.00 "$2,298.15" $0.00 $799.25 $0.00 $0.00 $813.03 $0.00 $0.00 $0.00 $0.00 $0.00 27803208 EAP HCPCS C1874 Cath.viabahn 8mm X 15cm 2 BOTH IP/OP "$5,107.00 " "$3,779.18" $0.00 "$4,085.60" "$2,298.15" "$2,298.15" $0.00 $0.00 $0.00 "$1,064.43" "$3,790.42" "$3,790.42" "$3,936.48" $0.00 "$1,064.30" $0.00 "$2,517.75" "$2,517.75" $0.00 "$2,553.50" "$4,044.74" "$4,085.60" $0.00 "$2,298.15" $0.00 $799.25 $0.00 $0.00 $813.03 $0.00 $0.00 $0.00 $0.00 $0.00 27803209 EAP HCPCS C1876 Microcatheter Enterprise 4.5x3 BOTH IP/OP "$17,347.00 " "$12,836.78" $0.00 "$13,877.60" "$7,806.15" "$7,806.15" $0.00 $0.00 $0.00 "$3,615.55" "$4,181.12" "$4,181.12" "$13,371.07" $0.00 "$3,615.11" $0.00 "$8,552.07" "$8,552.07" $0.00 "$8,673.50" "$13,738.82" "$13,877.60" $0.00 $0.00 $0.00 "$2,714.81" $0.00 $0.00 "$2,761.64" $0.00 $0.00 $0.00 $0.00 $0.00 27803210 EAP HCPCS C1876 Microcath.enterprise 4.5x2 1 BOTH IP/OP "$17,347.00 " "$12,836.78" $0.00 "$13,877.60" "$7,806.15" "$7,806.15" $0.00 $0.00 $0.00 "$3,615.55" "$4,181.12" "$4,181.12" "$13,371.07" $0.00 "$3,615.11" $0.00 "$8,552.07" "$8,552.07" $0.00 "$8,673.50" "$13,738.82" "$13,877.60" $0.00 $0.00 $0.00 "$2,714.81" $0.00 $0.00 "$2,761.64" $0.00 $0.00 $0.00 $0.00 $0.00 27803211 EAP HCPCS C1876 Microcath.enterprise 4.5x2 2 BOTH IP/OP "$17,347.00 " "$12,836.78" $0.00 "$13,877.60" "$7,806.15" "$7,806.15" $0.00 $0.00 $0.00 "$3,615.55" "$4,181.12" "$4,181.12" "$13,371.07" $0.00 "$3,615.11" $0.00 "$8,552.07" "$8,552.07" $0.00 "$8,673.50" "$13,738.82" "$13,877.60" $0.00 $0.00 $0.00 "$2,714.81" $0.00 $0.00 "$2,761.64" $0.00 $0.00 $0.00 $0.00 $0.00 27803212 EAP HCPCS C1876 Stent Icast 6mm X 22mm BOTH IP/OP "$8,391.00 " "$6,209.34" $0.00 "$6,712.80" "$3,775.95" "$3,775.95" $0.00 $0.00 $0.00 "$1,748.89" "$4,181.12" "$4,181.12" "$6,467.78" $0.00 "$1,748.68" $0.00 "$4,136.76" "$4,136.76" $0.00 "$4,195.50" "$6,645.67" "$6,712.80" $0.00 $0.00 $0.00 "$1,313.19" $0.00 $0.00 "$1,335.85" $0.00 $0.00 $0.00 $0.00 $0.00 27803213 EAP HCPCS C1876 Stent Carot Protege Rx 40x13 1 BOTH IP/OP "$2,941.00 " "$2,176.34" $0.00 "$2,352.80" "$1,323.45" "$1,323.45" $0.00 $0.00 $0.00 $612.98 "$2,182.81" "$2,182.81" "$2,266.92" $0.00 $612.90 $0.00 "$1,449.91" "$1,449.91" $0.00 "$1,470.50" "$2,329.27" "$2,352.80" $0.00 $0.00 $0.00 $460.27 $0.00 $0.00 $468.21 $0.00 $0.00 $0.00 $0.00 $0.00 27803214 EAP HCPCS C1876 Stent Carotid Protege Rx 30x13 BOTH IP/OP "$6,843.00 " "$5,063.82" $0.00 "$5,474.40" "$3,079.35" "$3,079.35" $0.00 $0.00 $0.00 "$1,426.25" "$4,181.12" "$4,181.12" "$5,274.58" $0.00 "$1,426.08" $0.00 "$3,373.60" "$3,373.60" $0.00 "$3,421.50" "$5,419.66" "$5,474.40" $0.00 $0.00 $0.00 "$1,070.93" $0.00 $0.00 "$1,089.41" $0.00 $0.00 $0.00 $0.00 $0.00 27803215 EAP HCPCS C1876 Stent Carot Protege Rx 40x13 2 BOTH IP/OP "$2,941.00 " "$2,176.34" $0.00 "$2,352.80" "$1,323.45" "$1,323.45" $0.00 $0.00 $0.00 $612.98 "$2,182.81" "$2,182.81" "$2,266.92" $0.00 $612.90 $0.00 "$1,449.91" "$1,449.91" $0.00 "$1,470.50" "$2,329.27" "$2,352.80" $0.00 $0.00 $0.00 $460.27 $0.00 $0.00 $468.21 $0.00 $0.00 $0.00 $0.00 $0.00 27803216 EAP HCPCS C1876 Stent Carotid Protege Rx BOTH IP/OP "$6,843.00 " "$5,063.82" $0.00 "$5,474.40" "$3,079.35" "$3,079.35" $0.00 $0.00 $0.00 "$1,426.25" "$4,181.12" "$4,181.12" "$5,274.58" $0.00 "$1,426.08" $0.00 "$3,373.60" "$3,373.60" $0.00 "$3,421.50" "$5,419.66" "$5,474.40" $0.00 $0.00 $0.00 "$1,070.93" $0.00 $0.00 "$1,089.41" $0.00 $0.00 $0.00 $0.00 $0.00 27803217 EAP HCPCS C1760 Sph100250-20 Microcoil Platinu BOTH IP/OP "$3,169.00 " "$2,345.06" $0.00 "$2,535.20" "$1,426.05" "$1,426.05" $0.00 $0.00 $0.00 $660.50 "$2,352.03" "$2,352.03" "$2,442.67" $0.00 $660.42 $0.00 "$1,562.32" "$1,562.32" $0.00 "$1,584.50" "$2,509.85" "$2,535.20" $0.00 $0.00 $0.00 $495.95 $0.00 $0.00 $504.50 $0.00 $0.00 $0.00 $0.00 $0.00 27803218 EAP HCPCS C1726 Sph100300-20 Microcoil Platinu BOTH IP/OP "$3,186.00 " "$2,357.64" $0.00 "$2,548.80" "$1,433.70" "$1,433.70" $0.00 $0.00 $0.00 $664.04 "$2,364.65" "$2,364.65" "$2,455.77" $0.00 $663.96 $0.00 "$1,570.70" "$1,570.70" $0.00 "$1,593.00" "$2,523.31" "$2,548.80" $0.00 $0.00 $0.00 $498.61 $0.00 $0.00 $507.21 $0.00 $0.00 $0.00 $0.00 $0.00 27803219 EAP HCPCS C1894 Sph100350-20 Microcoil Platinu BOTH IP/OP "$3,198.00 " "$2,366.52" $0.00 "$2,558.40" "$1,439.10" "$1,439.10" $0.00 $0.00 $0.00 $666.54 "$2,373.56" "$2,373.56" "$2,465.02" $0.00 $666.46 $0.00 "$1,576.61" "$1,576.61" $0.00 "$1,599.00" "$2,532.82" "$2,558.40" $0.00 $0.00 $0.00 $500.49 $0.00 $0.00 $509.12 $0.00 $0.00 $0.00 $0.00 $0.00 27803220 EAP HCPCS C1769 Wire Guide Lunderquist Extra S BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $12.60 $12.60 $0.00 $0.00 $0.00 $5.84 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $16.56 $16.56 $0.00 $14.00 $22.18 $22.40 $0.00 $0.00 $0.00 $4.38 $0.00 $0.00 $4.46 $0.00 $0.00 $0.00 $0.00 $0.00 27803221 EAP HCPCS C1894 Prelude Sheath BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $23.35 $23.35 $0.00 $0.00 $0.00 $8.96 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $25.43 $25.43 $0.00 $21.50 $34.06 $34.40 $0.00 $27.95 $0.00 $6.73 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 27803230 EAP HCPCS C1729 10.2fr 22cm Nephroureterostom BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $269.78 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $157.50 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 27803231 EAP HCPCS C1729 10.2fr 24cm Nephroureterostomy BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 27803232 EAP HCPCS C1892 16fr Check-flo Sheath 30cm Rad BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $170.10 $170.10 $0.00 $0.00 $0.00 $78.78 $280.55 $280.55 $291.36 $0.00 $78.78 $0.00 $223.59 $223.59 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $0.00 $59.16 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 27803233 EAP HCPCS C1751 5fr/65cm Mpa Catheter BOTH IP/OP $312.00 $230.88 $0.00 $249.60 $140.40 $140.40 $0.00 $0.00 $0.00 $65.03 $231.57 $231.57 $240.49 $0.00 $65.02 $0.00 $184.55 $184.55 $0.00 $156.00 $247.10 $249.60 $0.00 $140.40 $0.00 $48.83 $0.00 $0.00 $49.67 $0.00 $0.00 $0.00 $0.00 $0.00 27803234 EAP HCPCS C1892 7fr Tear-away Introducer BOTH IP/OP $462.00 $341.88 $0.00 $369.60 $207.90 $207.90 $0.00 $0.00 $0.00 $96.29 $342.90 $342.90 $356.11 $0.00 $96.28 $0.00 $273.27 $273.27 $0.00 $231.00 $365.90 $369.60 $0.00 $207.90 $0.00 $72.30 $0.00 $0.00 $73.55 $0.00 $0.00 $0.00 $0.00 $0.00 27803235 EAP HCPCS C1874 8x60 Luminexx Stent BOTH IP/OP "$4,186.00 " "$3,097.64" $0.00 "$3,348.80" "$1,883.70" "$1,883.70" $0.00 $0.00 $0.00 $872.47 "$3,106.85" "$3,106.85" "$3,226.57" $0.00 $872.36 $0.00 "$2,063.70" "$2,063.70" $0.00 "$2,093.00" "$3,315.31" "$3,348.80" $0.00 $0.00 $0.00 $655.11 $0.00 $0.00 $666.41 $0.00 $0.00 $0.00 $0.00 $0.00 27803236 EAP HCPCS C1769 Amplatz Super Stiff Guidewire BOTH IP/OP $92.00 $68.08 $0.00 $73.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.00 $72.86 $73.60 $0.00 $0.00 $0.00 $14.40 $0.00 $0.00 $14.65 $0.00 $0.00 $0.00 $0.00 $0.00 27803237 EAP HCPCS C1726 Ballon Cather 4-2/5/75 BOTH IP/OP $916.00 $677.84 $0.00 $732.80 $412.20 $412.20 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $706.05 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $458.00 $725.47 $732.80 $0.00 $0.00 $0.00 $143.35 $0.00 $0.00 $145.83 $0.00 $0.00 $0.00 $0.00 $0.00 27803238 EAP HCPCS C1726 Balloon Bmq 10-4/5.8/75 BOTH IP/OP $884.00 $654.16 $0.00 $707.20 $397.80 $397.80 $0.00 $0.00 $0.00 $184.25 $656.10 $656.10 $681.39 $0.00 $184.23 $0.00 $522.89 $522.89 $0.00 $442.00 $700.13 $707.20 $0.00 $0.00 $0.00 $138.35 $0.00 $0.00 $140.73 $0.00 $0.00 $0.00 $0.00 $0.00 27803239 EAP HCPCS C1726 Balloon Udt 4-10/5/75 BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $306.45 $306.45 $0.00 $0.00 $0.00 $141.94 $505.44 $505.44 $524.91 $0.00 $141.92 $0.00 $402.81 $402.81 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $106.58 $0.00 $0.00 $108.42 $0.00 $0.00 $0.00 $0.00 $0.00 27803240 EAP HCPCS C1726 Balloon Udt 5-10/5/75 BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $306.45 $306.45 $0.00 $0.00 $0.00 $141.94 $505.44 $505.44 $524.91 $0.00 $141.92 $0.00 $402.81 $402.81 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $106.58 $0.00 $0.00 $108.42 $0.00 $0.00 $0.00 $0.00 $0.00 27803241 EAP HCPCS C1751 Cath 5fr 100cm Vertebral Curve BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 27803242 EAP HCPCS C1751 Cath Dbl Lumen 9fr BOTH IP/OP $517.00 $382.58 $0.00 $413.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.50 $409.46 $413.60 $0.00 $0.00 $0.00 $80.91 $0.00 $0.00 $82.31 $0.00 $0.00 $0.00 $0.00 $0.00 27803243 EAP HCPCS C1887 Cath Guiding 7fr Sh BOTH IP/OP $186.00 $137.64 $0.00 $148.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.00 $147.31 $148.80 $0.00 $0.00 $0.00 $29.11 $0.00 $0.00 $29.61 $0.00 $0.00 $0.00 $0.00 $0.00 27803244 EAP HCPCS C1751 Cath Micro Mc 2.8f 130cm BOTH IP/OP "$1,890.00 " "$1,398.60" $0.00 "$1,512.00" $850.50 $850.50 $0.00 $0.00 $0.00 $393.92 "$1,402.76" "$1,402.76" "$1,456.81" $0.00 $393.88 $0.00 "$1,117.94" "$1,117.94" $0.00 $945.00 "$1,496.88" "$1,512.00" $0.00 $850.50 $0.00 $295.79 $0.00 $0.00 $300.89 $0.00 $0.00 $0.00 $0.00 $0.00 27803245 EAP Custom 27803245 Cytology Brushes 3x120x1.7 BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803246 EAP HCPCS C1751 Dual Picc Line BOTH IP/OP $307.00 $227.18 $0.00 $245.60 $138.15 $138.15 $0.00 $0.00 $0.00 $63.99 $227.86 $227.86 $236.64 $0.00 $63.98 $0.00 $181.59 $181.59 $0.00 $153.50 $243.14 $245.60 $0.00 $138.15 $0.00 $48.05 $0.00 $0.00 $48.87 $0.00 $0.00 $0.00 $0.00 $0.00 27803247 EAP Custom 27803247 Gasttostomy (peg Kit) Pull Typ BOTH IP/OP $271.00 $200.54 $0.00 $216.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.14 $201.14 $208.89 $0.00 $56.48 $0.00 $0.00 $0.00 $0.00 $135.50 $214.63 $216.80 $0.00 $121.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803248 EAP Custom 27803248 "Gelfoam, Sponge" BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $0.00 $0.00 $0.00 $51.50 $81.58 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803249 EAP HCPCS C1874 Ic Ast Stent 5mm X 2mm BOTH IP/OP "$8,391.00 " "$6,209.34" $0.00 "$6,712.80" "$3,775.95" "$3,775.95" $0.00 $0.00 $0.00 "$1,748.89" "$4,181.12" "$4,181.12" "$6,467.78" $0.00 "$1,748.68" $0.00 "$4,136.76" "$4,136.76" $0.00 "$4,195.50" "$6,645.67" "$6,712.80" $0.00 $0.00 $0.00 "$1,313.19" $0.00 $0.00 "$1,335.85" $0.00 $0.00 $0.00 $0.00 $0.00 27803250 EAP HCPCS C1721 Paradym Dr Dual Icd BOTH IP/OP "$55,047.00 " "$40,734.78" $0.00 "$44,037.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$42,430.23" $0.00 "$11,471.79" $0.00 "$27,138.17" "$27,138.17" $0.00 "$27,523.50" "$43,597.22" "$44,037.60" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27803251 EAP HCPCS C1722 Paradym Vr Single Icd BOTH IP/OP "$46,706.00 " "$34,562.44" $0.00 "$37,364.80" "$21,017.70" "$21,017.70" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$36,000.98" $0.00 "$9,733.53" $0.00 "$23,026.06" "$23,026.06" $0.00 "$23,353.00" "$36,991.15" "$37,364.80" $0.00 $0.00 $0.00 "$7,309.49" $0.00 $0.00 "$7,435.60" $0.00 $0.00 $0.00 $0.00 $0.00 27803252 EAP Custom 27803252 "Lc Bead,100-300um" BOTH IP/OP "$4,887.00 " "$3,616.38" $0.00 "$3,909.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,627.13" "$3,627.13" "$3,766.90" $0.00 "$1,018.45" $0.00 $0.00 $0.00 $0.00 "$2,443.50" "$3,870.50" "$3,909.60" $0.00 "$2,199.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803253 EAP Picc Line Tray W/o Device BOTH IP/OP $134.00 $99.16 $0.00 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.45 $99.45 $103.29 $0.00 $27.93 $0.00 $0.00 $0.00 $0.00 $67.00 $106.13 $107.20 $0.00 $87.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803254 EAP HCPCS C1769 Pinnacle Guidewire 6fr Straigh BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $125.10 $125.10 $0.00 $0.00 $0.00 $57.94 $206.33 $206.33 $214.28 $0.00 $57.94 $0.00 $164.44 $164.44 $0.00 $139.00 $220.18 $222.40 $0.00 $125.10 $0.00 $43.51 $0.00 $0.00 $44.26 $0.00 $0.00 $0.00 $0.00 $0.00 27803255 EAP HCPCS C1894 Sheath Gd Lima Crv 6fr 45cm 5cm Pn Dstn Xcut Vlv Radopq Ss BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $133.25 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 27803256 EAP HCPCS A4300 Port-a-cath Ii Low Profile Dua BOTH IP/OP "$1,429.00 " "$1,057.46" $0.00 "$1,143.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,060.60" "$1,060.60" "$1,101.47" $0.00 $297.80 $0.00 $0.00 $0.00 $0.00 $714.50 "$1,131.77" "$1,143.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803257 EAP HCPCS C1752 Set Schon Xl Temp Dialysis 15c BOTH IP/OP "$1,635.00 " "$1,209.90" $0.00 "$1,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,213.50" "$1,213.50" "$1,260.26" $0.00 $340.73 $0.00 $0.00 $0.00 $0.00 $817.50 "$1,294.92" "$1,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803258 EAP HCPCS C1751 Single Picc Line BOTH IP/OP $216.00 $159.84 $0.00 $172.80 $97.20 $97.20 $0.00 $0.00 $0.00 $45.02 $160.32 $160.32 $166.49 $0.00 $45.01 $0.00 $127.76 $127.76 $0.00 $108.00 $171.07 $172.80 $0.00 $97.20 $0.00 $33.80 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $0.00 27803259 EAP HCPCS C1751 Triple Lumen Catheter Size 20 BOTH IP/OP $384.00 $284.16 $0.00 $307.20 $172.80 $172.80 $0.00 $0.00 $0.00 $80.04 $285.00 $285.00 $295.99 $0.00 $80.03 $0.00 $227.14 $227.14 $0.00 $192.00 $304.13 $307.20 $0.00 $0.00 $0.00 $60.10 $0.00 $0.00 $61.13 $0.00 $0.00 $0.00 $0.00 $0.00 27803260 EAP HCPCS C1729 Tube Gastrostomy 24fr BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $26.55 $26.55 $0.00 $0.00 $0.00 $12.30 $43.79 $43.79 $45.48 $0.00 $12.30 $0.00 $34.90 $34.90 $0.00 $29.50 $46.73 $47.20 $0.00 $26.55 $0.00 $9.23 $0.00 $0.00 $9.39 $0.00 $0.00 $0.00 $0.00 $0.00 27803261 EAP HCPCS C1751 "Uhf Pigtail Sizing Cath 5 Fr,1" BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $141.75 $141.75 $0.00 $0.00 $0.00 $65.65 $233.79 $233.79 $242.80 $0.00 $65.65 $0.00 $186.32 $186.32 $0.00 $157.50 $249.48 $252.00 $0.00 $141.75 $0.00 $49.30 $0.00 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $0.00 27803262 EAP HCPCS C1751 "Uhf Pigtail Sizing Cath 5fr,2" BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $31.95 $31.95 $0.00 $0.00 $0.00 $14.80 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $42.00 $42.00 $0.00 $35.50 $56.23 $56.80 $0.00 $31.95 $0.00 $11.11 $0.00 $0.00 $11.30 $0.00 $0.00 $0.00 $0.00 $0.00 27803263 EAP HCPCS C1751 Venous Access BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $127.18 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $74.25 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 27803264 EAP HCPCS A4300 Isp Port Plas Lumen BOTH IP/OP $734.00 $543.16 $0.00 $587.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $544.77 $544.77 $565.77 $0.00 $152.97 $0.00 $0.00 $0.00 $0.00 $367.00 $581.33 $587.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803265 EAP Custom 27803265 Jcd 12.0-38-20 BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $8.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803270 EAP Custom 27803270 Tray Central Line Dressing Without Biopatch BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803294 EAP HCPCS C1725 Band Tr 24cm BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $55.35 $55.35 $0.00 $0.00 $0.00 $25.64 $91.29 $91.29 $94.81 $0.00 $25.63 $0.00 $72.75 $72.75 $0.00 $61.50 $97.42 $98.40 $0.00 $55.35 $0.00 $19.25 $0.00 $0.00 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 27803295 EAP HCPCS C1725 Band Tr 29cm BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $55.35 $55.35 $0.00 $0.00 $0.00 $25.64 $91.29 $91.29 $94.81 $0.00 $25.63 $0.00 $72.75 $72.75 $0.00 $61.50 $97.42 $98.40 $0.00 $55.35 $0.00 $19.25 $0.00 $0.00 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 27803302 EAP Custom 27803302 Embolization Coil - Azur 35d System 10mm X 20cm BOTH IP/OP "$3,754.00 " "$2,777.96" $0.00 "$3,003.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,786.22" "$2,786.22" "$2,893.58" $0.00 $782.33 $0.00 $0.00 $0.00 $0.00 "$1,877.00" "$2,973.17" "$3,003.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803303 EAP Custom 27803303 Embolization Coil - Azur 35d System 12mm X 20cm BOTH IP/OP "$3,754.00 " "$2,777.96" $0.00 "$3,003.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,786.22" "$2,786.22" "$2,893.58" $0.00 $782.33 $0.00 $0.00 $0.00 $0.00 "$1,877.00" "$2,973.17" "$3,003.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803304 EAP Custom 27803304 Embolization Coil - Azur 35d System 15mm X 20cm BOTH IP/OP "$3,754.00 " "$2,777.96" $0.00 "$3,003.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,786.22" "$2,786.22" "$2,893.58" $0.00 $782.33 $0.00 $0.00 $0.00 $0.00 "$1,877.00" "$2,973.17" "$3,003.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803305 EAP Custom 27803305 Embolization Coil - Azur 35d System 12mm X 30cm BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 $0.00 $0.00 $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803306 EAP Custom 27803306 Embolization Coil -azur 35d System 15mm X 30cm BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 $0.00 $0.00 $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803307 EAP Custom 27803307 Embolization Coil - Azur 35d System 20mm X 30cm BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 $0.00 $0.00 $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803308 EAP HCPCS C1876 Stent Bilinary Xpert Otw 5x30x120 Cm BOTH IP/OP "$5,755.00 " "$4,258.70" $0.00 "$4,604.00" "$2,589.75" "$2,589.75" $0.00 $0.00 $0.00 "$1,199.49" "$4,181.12" "$4,181.12" "$4,435.95" $0.00 "$1,199.34" $0.00 "$2,837.22" "$2,837.22" $0.00 "$2,877.50" "$4,557.96" "$4,604.00" $0.00 $0.00 $0.00 $900.66 $0.00 $0.00 $916.20 $0.00 $0.00 $0.00 $0.00 $0.00 27803309 EAP HCPCS C1876 Stent Bilinary Xpert Otw 5x40x120 Cm BOTH IP/OP "$5,755.00 " "$4,258.70" $0.00 "$4,604.00" "$2,589.75" "$2,589.75" $0.00 $0.00 $0.00 "$1,199.49" "$4,181.12" "$4,181.12" "$4,435.95" $0.00 "$1,199.34" $0.00 "$2,837.22" "$2,837.22" $0.00 "$2,877.50" "$4,557.96" "$4,604.00" $0.00 $0.00 $0.00 $900.66 $0.00 $0.00 $916.20 $0.00 $0.00 $0.00 $0.00 $0.00 27803310 EAP HCPCS C1876 Stent Bilinary Xpert Otw 6x30x120 Cm BOTH IP/OP "$5,755.00 " "$4,258.70" $0.00 "$4,604.00" "$2,589.75" "$2,589.75" $0.00 $0.00 $0.00 "$1,199.49" "$4,181.12" "$4,181.12" "$4,435.95" $0.00 "$1,199.34" $0.00 "$2,837.22" "$2,837.22" $0.00 "$2,877.50" "$4,557.96" "$4,604.00" $0.00 $0.00 $0.00 $900.66 $0.00 $0.00 $916.20 $0.00 $0.00 $0.00 $0.00 $0.00 27803311 EAP HCPCS C1876 Stent Bilinary Xpert Otw 6x40x120 Cm BOTH IP/OP "$5,755.00 " "$4,258.70" $0.00 "$4,604.00" "$2,589.75" "$2,589.75" $0.00 $0.00 $0.00 "$1,199.49" "$4,181.12" "$4,181.12" "$4,435.95" $0.00 "$1,199.34" $0.00 "$2,837.22" "$2,837.22" $0.00 "$2,877.50" "$4,557.96" "$4,604.00" $0.00 $0.00 $0.00 $900.66 $0.00 $0.00 $916.20 $0.00 $0.00 $0.00 $0.00 $0.00 27803312 EAP HCPCS C1876 Stent Corotid Straight Rx Acculink 6x40 BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" "$2,965.50" "$2,965.50" $0.00 $0.00 $0.00 "$1,373.52" "$4,181.12" "$4,181.12" "$5,079.57" $0.00 "$1,373.36" $0.00 "$3,248.87" "$3,248.87" $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 "$2,965.50" $0.00 "$1,031.34" $0.00 $0.00 "$1,049.13" $0.00 $0.00 $0.00 $0.00 $0.00 27803313 EAP HCPCS C1876 Stent Corotid Straight Rx Acculink 7x40 BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" "$2,965.50" "$2,965.50" $0.00 $0.00 $0.00 "$1,373.52" "$4,181.12" "$4,181.12" "$5,079.57" $0.00 "$1,373.36" $0.00 "$3,248.87" "$3,248.87" $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 "$1,031.34" $0.00 $0.00 "$1,049.13" $0.00 $0.00 $0.00 $0.00 $0.00 27803314 EAP HCPCS C1876 Stent Corotid Straight Rx Acculink 8x40 BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" "$2,965.50" "$2,965.50" $0.00 $0.00 $0.00 "$1,373.52" "$4,181.12" "$4,181.12" "$5,079.57" $0.00 "$1,373.36" $0.00 "$3,248.87" "$3,248.87" $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 "$1,031.34" $0.00 $0.00 "$1,049.13" $0.00 $0.00 $0.00 $0.00 $0.00 27803315 EAP HCPCS C1876 Stent Corotid Straight Rx Acculink 9x40 BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" "$2,965.50" "$2,965.50" $0.00 $0.00 $0.00 "$1,373.52" "$4,181.12" "$4,181.12" "$5,079.57" $0.00 "$1,373.36" $0.00 "$3,248.87" "$3,248.87" $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 "$1,031.34" $0.00 $0.00 "$1,049.13" $0.00 $0.00 $0.00 $0.00 $0.00 27803316 EAP HCPCS C1876 Stent Corotid Straight Rx Acculink 10x40 BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 "$1,031.34" $0.00 $0.00 "$1,049.13" $0.00 $0.00 $0.00 $0.00 $0.00 27803317 EAP HCPCS C1876 Stent Corotid Tapped Rx Acculink 6-8x40 BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" "$2,965.50" "$2,965.50" $0.00 $0.00 $0.00 "$1,373.52" "$4,181.12" "$4,181.12" "$5,079.57" $0.00 "$1,373.36" $0.00 "$3,248.87" "$3,248.87" $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 "$2,965.50" $0.00 "$1,031.34" $0.00 $0.00 "$1,049.13" $0.00 $0.00 $0.00 $0.00 $0.00 27803318 EAP HCPCS C1876 Stent Corotid Tapped Rx Acculink 7-10x40 BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" "$2,965.50" "$2,965.50" $0.00 $0.00 $0.00 "$1,373.52" "$4,181.12" "$4,181.12" "$5,079.57" $0.00 "$1,373.36" $0.00 "$3,248.87" "$3,248.87" $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 "$1,031.34" $0.00 $0.00 "$1,049.13" $0.00 $0.00 $0.00 $0.00 $0.00 27803319 EAP HCPCS C1882 Defibrillator Crd Amplia Mri Crt-d Vntrc Left Df4 BOTH IP/OP "$52,375.00 " "$38,757.50" $0.00 "$41,900.00" "$23,568.75" "$23,568.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$40,370.65" $0.00 "$10,914.95" $0.00 "$25,820.88" "$25,820.88" $0.00 "$26,187.50" "$41,481.00" "$41,900.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27803320 EAP HCPCS C1882 Defibrillator Crd Amplia Mri Crt-d 2 Plr Left BOTH IP/OP "$52,375.00 " "$38,757.50" $0.00 "$41,900.00" "$23,568.75" "$23,568.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$40,370.65" $0.00 "$10,914.95" $0.00 "$25,820.88" "$25,820.88" $0.00 "$26,187.50" "$41,481.00" "$41,900.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27803420 EAP HCPCS C1769 Guidewire Amplatz Super Stiff 0.038 X 260 BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $22.50 $22.50 $0.00 $0.00 $0.00 $10.42 $37.11 $37.11 $38.54 $0.00 $10.42 $0.00 $29.58 $29.58 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $7.83 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $0.00 27803421 EAP HCPCS C1769 Guidewire Hydrophilic Nitinol BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $174.60 $174.60 $0.00 $0.00 $0.00 $80.87 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $229.50 $229.50 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $60.72 $0.00 $0.00 $61.77 $0.00 $0.00 $0.00 $0.00 $0.00 27803441 EAP Custom 27803441 Stent Metal Bare Int35012ux BOTH IP/OP "$2,422.00 " "$1,792.28" $0.00 "$1,937.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,797.61" "$1,797.61" "$1,866.88" $0.00 $504.74 $0.00 $0.00 $0.00 $0.00 "$1,211.00" "$1,918.22" "$1,937.60" $0.00 "$1,089.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803450 EAP Custom 27803450 Target Detachable Colis 360 Soft 4mm X 6cm BOTH IP/OP "$2,270.00 " "$1,679.80" $0.00 "$1,816.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,684.79" "$1,684.79" "$1,749.72" $0.00 $473.07 $0.00 $0.00 $0.00 $0.00 "$1,135.00" "$1,797.84" "$1,816.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803451 EAP Custom 27803451 Target Detachable Colis Ultra 3mmx8cm BOTH IP/OP "$2,401.00 " "$1,776.74" $0.00 "$1,920.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,782.02" "$1,782.02" "$1,850.69" $0.00 $500.37 $0.00 $0.00 $0.00 $0.00 "$1,200.50" "$1,901.59" "$1,920.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803452 EAP Custom 27803452 Inzone Detachment System BOTH IP/OP $260.00 $192.40 $0.00 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.97 $192.97 $200.41 $0.00 $54.18 $0.00 $0.00 $0.00 $0.00 $130.00 $205.92 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803490 EAP HCPCS C2625 Rx Stent/11.5 X 5 BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $28.80 $28.80 $0.00 $0.00 $0.00 $13.34 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $37.86 $37.86 $0.00 $32.00 $50.69 $51.20 $0.00 $28.80 $0.00 $10.02 $0.00 $0.00 $10.19 $0.00 $0.00 $0.00 $0.00 $0.00 27803491 EAP HCPCS C2625 Rx Stent/11.5 X 7 BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $28.80 $28.80 $0.00 $0.00 $0.00 $13.34 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $37.86 $37.86 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $10.02 $0.00 $0.00 $10.19 $0.00 $0.00 $0.00 $0.00 $0.00 27803492 EAP HCPCS C2625 Rx Stent/11.5 X 10 BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $28.80 $28.80 $0.00 $0.00 $0.00 $13.34 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $37.86 $37.86 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $10.02 $0.00 $0.00 $10.19 $0.00 $0.00 $0.00 $0.00 $0.00 27803493 EAP HCPCS C2625 Rx Stent/11.5 X 12 BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $28.80 $28.80 $0.00 $0.00 $0.00 $13.34 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $37.86 $37.86 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $10.02 $0.00 $0.00 $10.19 $0.00 $0.00 $0.00 $0.00 $0.00 27803494 EAP HCPCS C2625 Rx Stent/11.5 X 15 BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $28.80 $28.80 $0.00 $0.00 $0.00 $13.34 $47.50 $47.50 $49.33 $0.00 $13.34 $0.00 $37.86 $37.86 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $10.02 $0.00 $0.00 $10.19 $0.00 $0.00 $0.00 $0.00 $0.00 27803496 EAP HCPCS C1874 "Icast Covered Stent 6mm X16mm, 120 Cm Cath Length" BOTH IP/OP "$8,340.00 " "$6,171.60" $0.00 "$6,672.00" "$3,753.00" "$3,753.00" $0.00 $0.00 $0.00 "$1,738.26" "$4,181.12" "$4,181.12" "$6,428.47" $0.00 "$1,738.06" $0.00 "$4,111.62" "$4,111.62" $0.00 "$4,170.00" "$6,605.28" "$6,672.00" $0.00 $0.00 $0.00 "$1,305.21" $0.00 $0.00 "$1,327.73" $0.00 $0.00 $0.00 $0.00 $0.00 27803499 EAP Custom 27803499 Central Line Tray W /biopatch BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.94 $195.94 $203.49 $0.00 $55.02 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $171.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803510 EAP HCPCS C2628 Boston Scientific Occlusion Balloon Catheter 27mm X 100m BOTH IP/OP $885.00 $654.90 $0.00 $708.00 $398.25 $398.25 $0.00 $0.00 $0.00 $184.46 $656.85 $656.85 $682.16 $0.00 $184.43 $0.00 $523.48 $523.48 $0.00 $442.50 $700.92 $708.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803520 EAP HCPCS C1876 Wallflex Bil Uncovered 10x60 BOTH IP/OP "$6,005.00 " "$4,443.70" $0.00 "$4,804.00" "$2,702.25" "$2,702.25" $0.00 $0.00 $0.00 "$1,251.59" "$4,181.12" "$4,181.12" "$4,628.65" $0.00 "$1,251.44" $0.00 "$2,960.47" "$2,960.47" $0.00 "$3,002.50" "$4,755.96" "$4,804.00" $0.00 "$2,702.25" $0.00 $939.78 $0.00 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803521 EAP HCPCS C1876 Wallflex Bil Uncovered 10x80 BOTH IP/OP "$6,005.00 " "$4,443.70" $0.00 "$4,804.00" "$2,702.25" "$2,702.25" $0.00 $0.00 $0.00 "$1,251.59" "$4,181.12" "$4,181.12" "$4,628.65" $0.00 "$1,251.44" $0.00 "$2,960.47" "$2,960.47" $0.00 "$3,002.50" "$4,755.96" "$4,804.00" $0.00 $0.00 $0.00 $939.78 $0.00 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803522 EAP HCPCS C1876 Wallflex Bil Uncovered 10x100 BOTH IP/OP "$6,005.00 " "$4,443.70" $0.00 "$4,804.00" "$2,702.25" "$2,702.25" $0.00 $0.00 $0.00 "$1,251.59" "$4,181.12" "$4,181.12" "$4,628.65" $0.00 "$1,251.44" $0.00 "$2,960.47" "$2,960.47" $0.00 "$3,002.50" "$4,755.96" "$4,804.00" $0.00 "$2,702.25" $0.00 $939.78 $0.00 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803523 EAP HCPCS C1876 Wallflex Bil Uncovered 10x40 BOTH IP/OP "$6,005.00 " "$4,443.70" $0.00 "$4,804.00" "$2,702.25" "$2,702.25" $0.00 $0.00 $0.00 "$1,251.59" "$4,181.12" "$4,181.12" "$4,628.65" $0.00 "$1,251.44" $0.00 "$2,960.47" "$2,960.47" $0.00 "$3,002.50" "$4,755.96" "$4,804.00" $0.00 "$2,702.25" $0.00 $939.78 $0.00 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803524 EAP HCPCS C1874 Wallflex Bil Covered 10x40 BOTH IP/OP "$9,476.00 " "$7,012.24" $0.00 "$7,580.80" "$4,264.20" "$4,264.20" $0.00 $0.00 $0.00 "$1,975.04" "$4,181.12" "$4,181.12" "$7,304.10" $0.00 "$1,974.80" $0.00 "$4,671.67" "$4,671.67" $0.00 "$4,738.00" "$7,504.99" "$7,580.80" $0.00 "$4,264.20" $0.00 "$1,482.99" $0.00 $0.00 "$1,508.58" $0.00 $0.00 $0.00 $0.00 $0.00 27803525 EAP HCPCS C1874 Wallflex Bil Covered 10x60 BOTH IP/OP "$9,476.00 " "$7,012.24" $0.00 "$7,580.80" "$4,264.20" "$4,264.20" $0.00 $0.00 $0.00 "$1,975.04" "$4,181.12" "$4,181.12" "$7,304.10" $0.00 "$1,974.80" $0.00 "$4,671.67" "$4,671.67" $0.00 "$4,738.00" "$7,504.99" "$7,580.80" $0.00 "$4,264.20" $0.00 "$1,482.99" $0.00 $0.00 "$1,508.58" $0.00 $0.00 $0.00 $0.00 $0.00 27803526 EAP HCPCS C1874 Wallflex Bil Covered 10x80 BOTH IP/OP "$9,476.00 " "$7,012.24" $0.00 "$7,580.80" "$4,264.20" "$4,264.20" $0.00 $0.00 $0.00 "$1,975.04" "$4,181.12" "$4,181.12" "$7,304.10" $0.00 "$1,974.80" $0.00 "$4,671.67" "$4,671.67" $0.00 "$4,738.00" "$7,504.99" "$7,580.80" $0.00 $0.00 $0.00 "$1,482.99" $0.00 $0.00 "$1,508.58" $0.00 $0.00 $0.00 $0.00 $0.00 27803527 EAP HCPCS C1874 Wallflex Bil Pc Covered 10x40 BOTH IP/OP "$9,142.00 " "$6,765.08" $0.00 "$7,313.60" "$4,113.90" "$4,113.90" $0.00 $0.00 $0.00 "$1,905.42" "$4,181.12" "$4,181.12" "$7,046.65" $0.00 "$1,905.19" $0.00 "$4,507.01" "$4,507.01" $0.00 "$4,571.00" "$7,240.46" "$7,313.60" $0.00 "$4,113.90" $0.00 "$1,430.72" $0.00 $0.00 "$1,455.41" $0.00 $0.00 $0.00 $0.00 $0.00 27803528 EAP HCPCS C1874 Wallflex Bil Pc Covered 10x60 BOTH IP/OP "$9,142.00 " "$6,765.08" $0.00 "$7,313.60" "$4,113.90" "$4,113.90" $0.00 $0.00 $0.00 "$1,905.42" "$4,181.12" "$4,181.12" "$7,046.65" $0.00 "$1,905.19" $0.00 "$4,507.01" "$4,507.01" $0.00 "$4,571.00" "$7,240.46" "$7,313.60" $0.00 "$4,113.90" $0.00 "$1,430.72" $0.00 $0.00 "$1,455.41" $0.00 $0.00 $0.00 $0.00 $0.00 27803529 EAP HCPCS C1874 Wallflex Bil Pc Covered 10x80 BOTH IP/OP "$9,142.00 " "$6,765.08" $0.00 "$7,313.60" "$4,113.90" "$4,113.90" $0.00 $0.00 $0.00 "$1,905.42" "$4,181.12" "$4,181.12" "$7,046.65" $0.00 "$1,905.19" $0.00 "$4,507.01" "$4,507.01" $0.00 "$4,571.00" "$7,240.46" "$7,313.60" $0.00 $0.00 $0.00 "$1,430.72" $0.00 $0.00 "$1,455.41" $0.00 $0.00 $0.00 $0.00 $0.00 27803531 EAP HCPCS C1876 Wallflex Ent Duo 27/22x6 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 $0.00 $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803532 EAP HCPCS C1876 Wallflex Ent Duo 27/22x9 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 $0.00 $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803533 EAP HCPCS C1876 Wallflex Ent Duo 27/22x12 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 "$3,940.20" $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803534 EAP HCPCS C1876 Wallflex Ent Col 30/25x6 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 $0.00 $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803535 EAP HCPCS C1876 Wallflex Ent Col 30/25x9 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 $0.00 $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803536 EAP HCPCS C1876 Wallflex Ent Col 30/25x12 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 $0.00 $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803537 EAP HCPCS C1876 Wallflex Ent Col 27/22x6 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 $0.00 $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803538 EAP HCPCS C1876 Wallflex Ent Col 27/22x9 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 $0.00 $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803539 EAP HCPCS C1876 Wallflex Ent Col 27/22x12 230cm BOTH IP/OP "$8,756.00 " "$6,479.44" $0.00 "$7,004.80" "$3,940.20" "$3,940.20" $0.00 $0.00 $0.00 "$1,824.97" "$4,181.12" "$4,181.12" "$6,749.12" $0.00 "$1,824.75" $0.00 "$4,316.71" "$4,316.71" $0.00 "$4,378.00" "$6,934.75" "$7,004.80" $0.00 $0.00 $0.00 "$1,370.31" $0.00 $0.00 "$1,393.96" $0.00 $0.00 $0.00 $0.00 $0.00 27803541 EAP HCPCS C1874 Wallflex Esoph Full Cov 18/10 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803542 EAP HCPCS C1874 Wallflex Esoph Full Cov 18/12 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803543 EAP HCPCS C1874 Wallflex Esoph Full Cov 18/15 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 "$3,828.15" $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803544 EAP HCPCS C1874 Wallflex Esoph Full Cov 23/10 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803545 EAP HCPCS C1874 Wallflex Esoph Full Cov 23/12 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803546 EAP HCPCS C1874 Wallflex Esoph Full Cov 23/15 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803547 EAP HCPCS C1874 Wallflex Esoph Part Cov 18/10 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803548 EAP HCPCS C1874 Wallflex Esoph Part Cov 18/12 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 "$3,828.15" $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803549 EAP HCPCS C1874 Wallflex Esoph Part Cov 18/23x103 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803550 EAP HCPCS C1874 Wallflex Esoph Part Cov 23/128x105 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803551 EAP HCPCS C1874 Wallflex Esoph Part Cov 23/28x125 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803552 EAP HCPCS C1874 Wallflex Esoph Part Cov 23/28x155 BOTH IP/OP "$8,507.00 " "$6,295.18" $0.00 "$6,805.60" "$3,828.15" "$3,828.15" $0.00 $0.00 $0.00 "$1,773.07" "$4,181.12" "$4,181.12" "$6,557.20" $0.00 "$1,772.86" $0.00 "$4,193.95" "$4,193.95" $0.00 "$4,253.50" "$6,737.54" "$6,805.60" $0.00 $0.00 $0.00 "$1,331.35" $0.00 $0.00 "$1,354.31" $0.00 $0.00 $0.00 $0.00 $0.00 27803554 EAP HCPCS C1874 Polyflex Esoph 20/16mm X 90mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803555 EAP HCPCS C1874 Polyflex Esoph 20/16mm X 120mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803556 EAP HCPCS C1874 Polyflex Esoph 20/16mm X 150mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803557 EAP HCPCS C1874 Polyflex Esoph 23/18mm X 90mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803558 EAP HCPCS C1874 Polyflex Esoph 23/18mm X 120mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803559 EAP HCPCS C1874 Polyflex Esoph 23/18mm X 150mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803560 EAP HCPCS C1874 Polyflex Esoph 25/21mm X 90mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803561 EAP HCPCS C1874 Polyflex Esoph 25/21mm X 120mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803562 EAP HCPCS C1874 Polyflex Esoph 25/21mm X 150mm BOTH IP/OP "$6,756.00 " "$4,999.44" $0.00 "$5,404.80" "$3,040.20" "$3,040.20" $0.00 $0.00 $0.00 "$1,408.12" "$4,181.12" "$4,181.12" "$5,207.52" $0.00 "$1,407.95" $0.00 "$3,330.71" "$3,330.71" $0.00 "$3,378.00" "$5,350.75" "$5,404.80" $0.00 $0.00 $0.00 "$1,057.31" $0.00 $0.00 "$1,075.56" $0.00 $0.00 $0.00 $0.00 $0.00 27803576 EAP Custom 44697837 Stent Bare Metal Int30012ux BOTH IP/OP "$2,422.00 " "$1,792.28" $0.00 "$1,937.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,797.61" "$1,797.61" "$1,866.88" $0.00 $504.74 $0.00 $0.00 $0.00 $0.00 "$1,211.00" "$1,918.22" "$1,937.60" $0.00 "$1,089.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803585 EAP Custom 44697928 Stent Bare Metal Int40015ux BOTH IP/OP "$2,422.00 " "$1,792.28" $0.00 "$1,937.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,797.61" "$1,797.61" "$1,866.88" $0.00 $504.74 $0.00 $0.00 $0.00 $0.00 "$1,211.00" "$1,918.22" "$1,937.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803600 EAP HCPCS C1713 Plate Xlng 134mm Ss 2.7/3.5mm Scr 6 Hole Var Ang BOTH IP/OP $840.58 $622.03 $0.00 $672.46 $378.26 $378.26 $0.00 $0.00 $0.00 $175.20 $623.88 $623.88 $647.92 $0.00 $175.18 $0.00 $497.20 $497.20 $0.00 $420.29 $665.74 $672.46 $0.00 $0.00 $0.00 $131.55 $0.00 $0.00 $133.82 $0.00 $0.00 $0.00 $0.00 $0.00 27803601 EAP HCPCS C1713 Screw Bone 3.5mm 30mm Lineum Ti Oct Spn Smth Shnk BOTH IP/OP "$1,877.60 " "$1,389.42" $0.00 "$1,502.08" $844.92 $844.92 $0.00 $0.00 $0.00 $391.34 "$1,393.55" "$1,393.55" "$1,447.25" $0.00 $391.29 $0.00 "$1,110.60" "$1,110.60" $0.00 $938.80 "$1,487.06" "$1,502.08" $0.00 $0.00 $0.00 $293.84 $0.00 $0.00 $298.91 $0.00 $0.00 $0.00 $0.00 $0.00 27803602 EAP HCPCS C1713 Rod Spnl 90mm 4.75mm Str Perc Ccm Plus BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 27803603 EAP HCPCS C1713 Screw Bone 1.5mm 8mm Hexalobe Pthrd Hand Lag BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $58.05 $58.05 $0.00 $0.00 $0.00 $26.89 $95.74 $95.74 $99.43 $0.00 $26.88 $0.00 $76.30 $76.30 $0.00 $64.50 $102.17 $103.20 $0.00 $0.00 $0.00 $20.19 $0.00 $0.00 $20.54 $0.00 $0.00 $0.00 $0.00 $0.00 27803604 EAP HCPCS C1713 Screw Bone 1.5mm 11mm Ti Hand Mtcrpl Phalanges BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $58.05 $58.05 $0.00 $0.00 $0.00 $26.89 $95.74 $95.74 $99.43 $0.00 $26.88 $0.00 $76.30 $76.30 $0.00 $64.50 $102.17 $103.20 $0.00 $0.00 $0.00 $20.19 $0.00 $0.00 $20.54 $0.00 $0.00 $0.00 $0.00 $0.00 27803605 EAP HCPCS C1713 Spacer Spnl 22mmx10mm Cpstn Cntrl 12d Peek Intrbd BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 27803606 EAP HCPCS C1713 Screw Bone 4.5mm 45mm Solera Cd Hzn Cocr Spn BOTH IP/OP "$1,558.20 " "$1,153.07" $0.00 "$1,246.56" $701.19 $701.19 $0.00 $0.00 $0.00 $324.77 "$1,156.50" "$1,156.50" "$1,201.06" $0.00 $324.73 $0.00 $921.68 $921.68 $0.00 $779.10 "$1,234.09" "$1,246.56" $0.00 $0.00 $0.00 $243.86 $0.00 $0.00 $248.07 $0.00 $0.00 $0.00 $0.00 $0.00 27803607 EAP HCPCS C1713 Screw Bone 5.5mm 35mm Ats Spn Multiax 4.75mm Rod BOTH IP/OP "$1,558.20 " "$1,153.07" $0.00 "$1,246.56" $701.19 $701.19 $0.00 $0.00 $0.00 $324.77 "$1,156.50" "$1,156.50" "$1,201.06" $0.00 $324.73 $0.00 $921.68 $921.68 $0.00 $779.10 "$1,234.09" "$1,246.56" $0.00 $0.00 $0.00 $243.86 $0.00 $0.00 $248.07 $0.00 $0.00 $0.00 $0.00 $0.00 27803608 EAP HCPCS C1713 Screw Bone 6.5mm 35mm Ats Spn Multiax 4.75mm Rod BOTH IP/OP "$1,558.20 " "$1,153.07" $0.00 "$1,246.56" $701.19 $701.19 $0.00 $0.00 $0.00 $324.77 "$1,156.50" "$1,156.50" "$1,201.06" $0.00 $324.73 $0.00 $921.68 $921.68 $0.00 $779.10 "$1,234.09" "$1,246.56" $0.00 $0.00 $0.00 $243.86 $0.00 $0.00 $248.07 $0.00 $0.00 $0.00 $0.00 $0.00 27803609 EAP HCPCS C1713 Cage Spnl 15-20mm 12mm BOTH IP/OP "$4,498.00 " "$3,328.52" $0.00 "$3,598.40" "$2,442.41" "$2,442.41" $0.00 $0.00 $0.00 $937.50 "$3,338.42" "$3,338.42" "$3,467.06" $0.00 $937.38 $0.00 "$2,660.57" "$2,660.57" $0.00 "$2,249.00" "$3,562.42" "$3,598.40" $0.00 $0.00 $0.00 $703.94 $0.00 $0.00 $716.08 $0.00 $0.00 $0.00 $0.00 $0.00 27803610 EAP HCPCS C1713 Spacer Spnl 50x18x8mm Crnt Xl Peek Tlif Rdlcnt BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" "$3,468.60" $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 27803611 EAP HCPCS C1713 Cage Spnl 45x18x12mm Crnt Xl Peek-optm Lat Lmbr BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" "$3,468.60" $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 27803612 EAP HCPCS C1713 Spacer Spnl 38x16x28mm Brigade 12d Spn Ant BOTH IP/OP "$5,513.00 " "$4,079.62" $0.00 "$4,410.40" "$2,480.85" "$2,480.85" $0.00 $0.00 $0.00 "$1,149.05" "$4,091.75" "$4,091.75" "$4,249.42" $0.00 "$1,148.91" $0.00 "$2,717.91" "$2,717.91" $0.00 "$2,756.50" "$4,366.30" "$4,410.40" $0.00 $0.00 $0.00 $862.78 $0.00 $0.00 $877.67 $0.00 $0.00 $0.00 $0.00 $0.00 27803613 EAP HCPCS C1713 Screw Bone 5mm 62.5mm Trgn Fem Lp BOTH IP/OP $259.20 $191.81 $0.00 $207.36 $116.64 $116.64 $0.00 $0.00 $0.00 $54.02 $192.38 $192.38 $199.79 $0.00 $54.02 $0.00 $153.32 $153.32 $0.00 $129.60 $205.29 $207.36 $0.00 $0.00 $0.00 $40.56 $0.00 $0.00 $41.26 $0.00 $0.00 $0.00 $0.00 $0.00 27803614 EAP HCPCS C1713 Nail 10mm 38cm Right Troc Trgn Im 130d Set Antgrd BOTH IP/OP "$2,280.00 " "$1,687.20" $0.00 "$1,824.00" "$1,026.00" "$1,026.00" $0.00 $0.00 $0.00 $475.21 "$1,692.22" "$1,692.22" "$1,757.42" $0.00 $475.15 $0.00 "$1,348.62" "$1,348.62" $0.00 "$1,140.00" "$1,805.76" "$1,824.00" $0.00 $0.00 $0.00 $356.82 $0.00 $0.00 $362.98 $0.00 $0.00 $0.00 $0.00 $0.00 27803616 EAP HCPCS C1713 Nail 10mm 38cm Tib Mt-nail Im Ti BOTH IP/OP "$2,108.00 " "$1,559.92" $0.00 "$1,686.40" $948.60 $948.60 $0.00 $0.00 $0.00 $439.36 "$1,564.56" "$1,564.56" "$1,624.85" $0.00 $439.31 $0.00 "$1,246.88" "$1,246.88" $0.00 "$1,054.00" "$1,669.54" "$1,686.40" $0.00 $0.00 $0.00 $329.90 $0.00 $0.00 $335.59 $0.00 $0.00 $0.00 $0.00 $0.00 27803618 EAP HCPCS C1713 Screw Bone 11mm 30mm Intertan Troch Cmpr BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $174.60 $174.60 $0.00 $0.00 $0.00 $80.87 $287.97 $287.97 $299.07 $0.00 $80.86 $0.00 $229.50 $229.50 $0.00 $194.00 $307.30 $310.40 $0.00 $0.00 $0.00 $60.72 $0.00 $0.00 $61.77 $0.00 $0.00 $0.00 $0.00 $0.00 27803620 EAP HCPCS C1713 Kit Scr 90mm 4.5mm Intertan Troch Ti Lag Cmpr BOTH IP/OP $836.00 $618.64 $0.00 $668.80 $376.20 $376.20 $0.00 $0.00 $0.00 $174.24 $620.48 $620.48 $644.39 $0.00 $174.22 $0.00 $494.49 $494.49 $0.00 $418.00 $662.11 $668.80 $0.00 $0.00 $0.00 $130.83 $0.00 $0.00 $133.09 $0.00 $0.00 $0.00 $0.00 $0.00 27803621 EAP HCPCS C1713 Plate 2mm Str Frac Bone BOTH IP/OP "$1,416.00 " "$1,047.84" $0.00 "$1,132.80" $637.20 $637.20 $0.00 $0.00 $0.00 $295.13 "$1,050.96" "$1,050.96" "$1,091.45" $0.00 $295.09 $0.00 $837.56 $837.56 $0.00 $708.00 "$1,121.47" "$1,132.80" $0.00 $0.00 $0.00 $221.60 $0.00 $0.00 $225.43 $0.00 $0.00 $0.00 $0.00 $0.00 27803622 EAP HCPCS C1713 Nail 10mm 39cm Tib Mt-nail Im Ti BOTH IP/OP "$2,108.00 " "$1,559.92" $0.00 "$1,686.40" $948.60 $948.60 $0.00 $0.00 $0.00 $439.36 "$1,564.56" "$1,564.56" "$1,624.85" $0.00 $439.31 $0.00 "$1,246.88" "$1,246.88" $0.00 "$1,054.00" "$1,669.54" "$1,686.40" $0.00 $0.00 $0.00 $329.90 $0.00 $0.00 $335.59 $0.00 $0.00 $0.00 $0.00 $0.00 27803788 EAP HCPCS C1726 Dfs100410-20microcoil Platinum Deltapapaq4m BOTH IP/OP "$2,923.00 " "$2,163.02" $0.00 "$2,338.40" "$1,315.35" "$1,315.35" $0.00 $0.00 $0.00 $609.23 "$2,169.45" "$2,169.45" "$2,253.05" $0.00 $609.15 $0.00 "$1,441.04" "$1,441.04" $0.00 "$1,461.50" "$2,315.02" "$2,338.40" $0.00 $0.00 $0.00 $457.45 $0.00 $0.00 $465.34 $0.00 $0.00 $0.00 $0.00 $0.00 27803789 EAP HCPCS C1717 "Brachytx, Non-str,hdr Ir-192" BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $338.30 $338.30 $341.72 $145.90 $519.54 $519.54 $539.56 $334.69 $145.88 $217.55 $414.05 $414.05 $338.12 $350.00 $554.40 $560.00 $466.93 $315.00 $466.93 $109.55 $0.00 $0.00 $111.44 $322.02 $0.00 $0.00 $0.00 $0.00 27803795 EAP HCPCS C1757 Catheter Thrmb 6fr 65cm Cleanerxt Rot 2 Pwr Cell L BOTH IP/OP "$1,488.00 " "$1,101.12" $0.00 "$1,190.40" $669.60 $669.60 $0.00 $0.00 $0.00 $310.14 "$1,104.39" "$1,104.39" "$1,146.95" $0.00 $310.10 $0.00 $880.15 $880.15 $0.00 $744.00 "$1,178.50" "$1,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803803 EAP HCPCS C1726 Hel181830-20microcoil Platinum Helipaq18 BOTH IP/OP "$1,895.00 " "$1,402.30" $0.00 "$1,516.00" $852.75 $852.75 $0.00 $0.00 $0.00 $394.97 "$1,406.47" "$1,406.47" "$1,460.67" $0.00 $394.92 $0.00 "$1,120.89" "$1,120.89" $0.00 $947.50 "$1,500.84" "$1,516.00" $0.00 $0.00 $0.00 $296.57 $0.00 $0.00 $301.68 $0.00 $0.00 $0.00 $0.00 $0.00 27803857 EAP HCPCS C1726 Dfs100250-20microcoil Platinum Deltapaq2 BOTH IP/OP "$2,923.00 " "$2,163.02" $0.00 "$2,338.40" "$1,315.35" "$1,315.35" $0.00 $0.00 $0.00 $609.23 "$2,169.45" "$2,169.45" "$2,253.05" $0.00 $609.15 $0.00 "$1,441.04" "$1,441.04" $0.00 "$1,461.50" "$2,315.02" "$2,338.40" $0.00 $0.00 $0.00 $457.45 $0.00 $0.00 $465.34 $0.00 $0.00 $0.00 $0.00 $0.00 27803858 EAP HCPCS C1726 Dfs100408-20 Microcoil Platinum Deltapaq4m BOTH IP/OP "$2,923.00 " "$2,163.02" $0.00 "$2,338.40" "$1,315.35" "$1,315.35" $0.00 $0.00 $0.00 $609.23 "$2,169.45" "$2,169.45" "$2,253.05" $0.00 $609.15 $0.00 "$1,441.04" "$1,441.04" $0.00 "$1,461.50" "$2,315.02" "$2,338.40" $0.00 $0.00 $0.00 $457.45 $0.00 $0.00 $465.34 $0.00 $0.00 $0.00 $0.00 $0.00 27803860 EAP HCPCS C1726 Dfs100510-20microcoil Platinum Deltapaq5m BOTH IP/OP "$2,923.00 " "$2,163.02" $0.00 "$2,338.40" "$1,315.35" "$1,315.35" $0.00 $0.00 $0.00 $609.23 "$2,169.45" "$2,169.45" "$2,253.05" $0.00 $609.15 $0.00 "$1,441.04" "$1,441.04" $0.00 "$1,461.50" "$2,315.02" "$2,338.40" $0.00 $0.00 $0.00 $457.45 $0.00 $0.00 $465.34 $0.00 $0.00 $0.00 $0.00 $0.00 27803861 EAP HCPCS C1726 Dfs100515-20 Microcoil Platinum Deltapaq5m BOTH IP/OP "$2,923.00 " "$2,163.02" $0.00 "$2,338.40" "$1,315.35" "$1,315.35" $0.00 $0.00 $0.00 $609.23 "$2,169.45" "$2,169.45" "$2,253.05" $0.00 $609.15 $0.00 "$1,441.04" "$1,441.04" $0.00 "$1,461.50" "$2,315.02" "$2,338.40" $0.00 $0.00 $0.00 $457.45 $0.00 $0.00 $465.34 $0.00 $0.00 $0.00 $0.00 $0.00 27803863 EAP HCPCS C1726 Dpl 100153-20microcoil Platinum Deltaplush BOTH IP/OP "$3,217.00 " "$2,380.58" $0.00 "$2,573.60" "$1,447.65" "$1,447.65" $0.00 $0.00 $0.00 $670.50 "$2,387.66" "$2,387.66" "$2,479.66" $0.00 $670.42 $0.00 "$1,585.98" "$1,585.98" $0.00 "$1,608.50" "$2,547.86" "$2,573.60" $0.00 $0.00 $0.00 $503.46 $0.00 $0.00 $512.15 $0.00 $0.00 $0.00 $0.00 $0.00 27803864 EAP HCPCS C1726 Dpl 100201-20 Microcoil Platinum Deltaplush BOTH IP/OP "$3,654.00 " "$2,703.96" $0.00 "$2,923.20" "$1,644.30" "$1,644.30" $0.00 $0.00 $0.00 $761.58 "$2,712.00" "$2,712.00" "$2,816.50" $0.00 $761.49 $0.00 "$1,801.42" "$1,801.42" $0.00 "$1,827.00" "$2,893.97" "$2,923.20" $0.00 $0.00 $0.00 $571.85 $0.00 $0.00 $581.72 $0.00 $0.00 $0.00 $0.00 $0.00 27803865 EAP HCPCS C1726 Dpl100202-20 Microcoil Platinum Deltaplush BOTH IP/OP "$3,654.00 " "$2,703.96" $0.00 "$2,923.20" "$1,644.30" "$1,644.30" $0.00 $0.00 $0.00 $761.58 "$2,712.00" "$2,712.00" "$2,816.50" $0.00 $761.49 $0.00 "$1,801.42" "$1,801.42" $0.00 "$1,827.00" "$2,893.97" "$2,923.20" $0.00 $0.00 $0.00 $571.85 $0.00 $0.00 $581.72 $0.00 $0.00 $0.00 $0.00 $0.00 27803866 EAP HCPCS C1726 Dpl 100203-20 Microcoil Platinum Deliaplush BOTH IP/OP "$3,217.00 " "$2,380.58" $0.00 "$2,573.60" "$1,447.65" "$1,447.65" $0.00 $0.00 $0.00 $670.50 "$2,387.66" "$2,387.66" "$2,479.66" $0.00 $670.42 $0.00 "$1,585.98" "$1,585.98" $0.00 "$1,608.50" "$2,547.86" "$2,573.60" $0.00 $0.00 $0.00 $503.46 $0.00 $0.00 $512.15 $0.00 $0.00 $0.00 $0.00 $0.00 27803867 EAP HCPCS C1726 Dpl 100206-20micocoil Platinum Deltaplush BOTH IP/OP "$3,654.00 " "$2,703.96" $0.00 "$2,923.20" "$1,644.30" "$1,644.30" $0.00 $0.00 $0.00 $761.58 "$2,712.00" "$2,712.00" "$2,816.50" $0.00 $761.49 $0.00 "$1,801.42" "$1,801.42" $0.00 "$1,827.00" "$2,893.97" "$2,923.20" $0.00 $0.00 $0.00 $571.85 $0.00 $0.00 $581.72 $0.00 $0.00 $0.00 $0.00 $0.00 27803868 EAP HCPCS C1726 Hel 180730-20 Microcoil Platinum Helipaq 7m BOTH IP/OP "$1,701.00 " "$1,258.74" $0.00 "$1,360.80" $765.45 $765.45 $0.00 $0.00 $0.00 $354.53 "$1,262.48" "$1,262.48" "$1,311.13" $0.00 $354.49 $0.00 "$1,006.14" "$1,006.14" $0.00 $850.50 "$1,347.19" "$1,360.80" $0.00 $0.00 $0.00 $266.21 $0.00 $0.00 $270.80 $0.00 $0.00 $0.00 $0.00 $0.00 27803869 EAP HCPCS C1726 Hel180930-20microcoil Platinum Helipaq9m BOTH IP/OP "$1,701.00 " "$1,258.74" $0.00 "$1,360.80" $765.45 $765.45 $0.00 $0.00 $0.00 $354.53 "$1,262.48" "$1,262.48" "$1,311.13" $0.00 $354.49 $0.00 "$1,006.14" "$1,006.14" $0.00 $850.50 "$1,347.19" "$1,360.80" $0.00 $0.00 $0.00 $266.21 $0.00 $0.00 $270.80 $0.00 $0.00 $0.00 $0.00 $0.00 27803870 EAP HCPCS C1726 Hel181030-20 Microcoil Platinum Helipaq10 BOTH IP/OP "$1,701.00 " "$1,258.74" $0.00 "$1,360.80" $765.45 $765.45 $0.00 $0.00 $0.00 $354.53 "$1,262.48" "$1,262.48" "$1,311.13" $0.00 $354.49 $0.00 "$1,006.14" "$1,006.14" $0.00 $850.50 "$1,347.19" "$1,360.80" $0.00 $0.00 $0.00 $266.21 $0.00 $0.00 $270.80 $0.00 $0.00 $0.00 $0.00 $0.00 27803871 EAP HCPCS C1726 Hel181230-20 Microcoil Platinum Helipaq12 BOTH IP/OP "$2,051.00 " "$1,517.74" $0.00 "$1,640.80" $922.95 $922.95 $0.00 $0.00 $0.00 $427.48 "$1,522.25" "$1,522.25" "$1,580.91" $0.00 $427.43 $0.00 "$1,213.17" "$1,213.17" $0.00 "$1,025.50" "$1,624.39" "$1,640.80" $0.00 $0.00 $0.00 $320.98 $0.00 $0.00 $326.52 $0.00 $0.00 $0.00 $0.00 $0.00 27803872 EAP HCPCS C1726 Hel181430-20 Microcoil Platinum Helipaq14 BOTH IP/OP "$1,805.00 " "$1,335.70" $0.00 "$1,444.00" $812.25 $812.25 $0.00 $0.00 $0.00 $376.21 "$1,339.67" "$1,339.67" "$1,391.29" $0.00 $376.16 $0.00 "$1,067.66" "$1,067.66" $0.00 $902.50 "$1,429.56" "$1,444.00" $0.00 $0.00 $0.00 $282.48 $0.00 $0.00 $287.36 $0.00 $0.00 $0.00 $0.00 $0.00 27803873 EAP HCPCS C1726 Hel181630-20 Microcoil Platinum Helipaq16 BOTH IP/OP "$1,601.00 " "$1,184.74" $0.00 "$1,280.80" $720.45 $720.45 $0.00 $0.00 $0.00 $333.69 "$1,188.26" "$1,188.26" "$1,234.05" $0.00 $333.65 $0.00 $946.99 $946.99 $0.00 $800.50 "$1,267.99" "$1,280.80" $0.00 $0.00 $0.00 $250.56 $0.00 $0.00 $254.88 $0.00 $0.00 $0.00 $0.00 $0.00 27803875 EAP HCPCS C1726 Hel182030-20 Microcoil Platinum Helipaq 20 BOTH IP/OP "$1,895.00 " "$1,402.30" $0.00 "$1,516.00" $852.75 $852.75 $0.00 $0.00 $0.00 $394.97 "$1,406.47" "$1,406.47" "$1,460.67" $0.00 $394.92 $0.00 "$1,120.89" "$1,120.89" $0.00 $947.50 "$1,500.84" "$1,516.00" $0.00 $0.00 $0.00 $296.57 $0.00 $0.00 $301.68 $0.00 $0.00 $0.00 $0.00 $0.00 27803876 EAP HCPCS C1726 Dpl 100152-20 Microcoil Platinum Deltaplush BOTH IP/OP "$3,217.00 " "$2,380.58" $0.00 "$2,573.60" "$1,447.65" "$1,447.65" $0.00 $0.00 $0.00 $670.50 "$2,387.66" "$2,387.66" "$2,479.66" $0.00 $670.42 $0.00 "$1,585.98" "$1,585.98" $0.00 "$1,608.50" "$2,547.86" "$2,573.60" $0.00 $0.00 $0.00 $503.46 $0.00 $0.00 $512.15 $0.00 $0.00 $0.00 $0.00 $0.00 27803880 EAP Custom 27803880 Device Perclose BOTH IP/OP $789.00 $583.86 $0.00 $631.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $585.60 $585.60 $608.16 $0.00 $164.43 $0.00 $0.00 $0.00 $0.00 $394.50 $624.89 $631.20 $0.00 $355.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803881 EAP HCPCS C1760 Sph100500-20 Mircrocoil Platin BOTH IP/OP "$3,686.00 " "$2,727.64" $0.00 "$2,948.80" "$1,658.70" "$1,658.70" $0.00 $0.00 $0.00 $768.25 "$2,735.75" "$2,735.75" "$2,841.17" $0.00 $768.16 $0.00 "$1,817.20" "$1,817.20" $0.00 "$1,843.00" "$2,919.31" "$2,948.80" $0.00 $0.00 $0.00 $576.86 $0.00 $0.00 $586.81 $0.00 $0.00 $0.00 $0.00 $0.00 27803882 EAP HCPCS C1760 Sph100620-20 Microcoil Platinu BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" "$1,748.25" "$1,748.25" $0.00 $0.00 $0.00 $809.73 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 "$1,915.31" "$1,915.31" $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $608.00 $0.00 $0.00 $618.49 $0.00 $0.00 $0.00 $0.00 $0.00 27803883 EAP HCPCS C1760 Sph100700-20 Microcoil Platinu BOTH IP/OP "$3,770.00 " "$2,789.80" $0.00 "$3,016.00" "$1,696.50" "$1,696.50" $0.00 $0.00 $0.00 $785.76 "$2,798.09" "$2,798.09" "$2,905.92" $0.00 $785.67 $0.00 "$1,858.61" "$1,858.61" $0.00 "$1,885.00" "$2,985.84" "$3,016.00" $0.00 $0.00 $0.00 $590.01 $0.00 $0.00 $600.18 $0.00 $0.00 $0.00 $0.00 $0.00 27803884 EAP HCPCS C1760 Sph100720-20 Microcoil Platinu BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" "$1,748.25" "$1,748.25" $0.00 $0.00 $0.00 $809.73 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 "$1,915.31" "$1,915.31" $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $608.00 $0.00 $0.00 $618.49 $0.00 $0.00 $0.00 $0.00 $0.00 27803885 EAP HCPCS C1760 Sph100800-20 Microil Platinum BOTH IP/OP "$3,819.00 " "$2,826.06" $0.00 "$3,055.20" "$1,718.55" "$1,718.55" $0.00 $0.00 $0.00 $795.98 "$2,834.46" "$2,834.46" "$2,943.69" $0.00 $795.88 $0.00 "$1,882.77" "$1,882.77" $0.00 "$1,909.50" "$3,024.65" "$3,055.20" $0.00 $0.00 $0.00 $597.67 $0.00 $0.00 $607.98 $0.00 $0.00 $0.00 $0.00 $0.00 27803886 EAP HCPCS C1760 Sph100825-20 Microcoil Platinu BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" "$1,793.70" "$1,793.70" $0.00 $0.00 $0.00 $830.78 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 "$1,965.10" "$1,965.10" $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $623.81 $0.00 $0.00 $634.57 $0.00 $0.00 $0.00 $0.00 $0.00 27803887 EAP HCPCS C1760 Sph100925-20 Microcoil Platinu BOTH IP/OP "$3,986.00 " "$2,949.64" $0.00 "$3,188.80" "$1,793.70" "$1,793.70" $0.00 $0.00 $0.00 $830.78 "$2,958.41" "$2,958.41" "$3,072.41" $0.00 $830.68 $0.00 "$1,965.10" "$1,965.10" $0.00 "$1,993.00" "$3,156.91" "$3,188.80" $0.00 $0.00 $0.00 $623.81 $0.00 $0.00 $634.57 $0.00 $0.00 $0.00 $0.00 $0.00 27803888 EAP HCPCS C1760 Sph101000-20 Microcoil Platinu BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" "$1,748.25" "$1,748.25" $0.00 $0.00 $0.00 $809.73 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 "$1,915.31" "$1,915.31" $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $608.00 $0.00 $0.00 $618.49 $0.00 $0.00 $0.00 $0.00 $0.00 27803889 EAP HCPCS C1760 Sph181100-20 Microcoil Platinu BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" "$1,748.25" "$1,748.25" $0.00 $0.00 $0.00 $809.73 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 "$1,915.31" "$1,915.31" $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $608.00 $0.00 $0.00 $618.49 $0.00 $0.00 $0.00 $0.00 $0.00 27803890 EAP HCPCS C1760 Sph181200-20 Microcoil Platinu BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 27803891 EAP HCPCS C1760 Sph181300-20 Microcoil Platinu BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 27803892 EAP HCPCS C1760 Sph181400-20 Microcoil Platinu BOTH IP/OP "$3,955.00 " "$2,926.70" $0.00 "$3,164.00" "$1,779.75" "$1,779.75" $0.00 $0.00 $0.00 $824.32 "$2,935.40" "$2,935.40" "$3,048.51" $0.00 $824.22 $0.00 "$1,949.82" "$1,949.82" $0.00 "$1,977.50" "$3,132.36" "$3,164.00" $0.00 $0.00 $0.00 $618.96 $0.00 $0.00 $629.64 $0.00 $0.00 $0.00 $0.00 $0.00 27803893 EAP HCPCS C1760 Sph181500-20 Microcoil Platinu BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" "$1,802.25" "$1,802.25" $0.00 $0.00 $0.00 $834.74 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 "$1,974.47" "$1,974.47" $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $626.78 $0.00 $0.00 $637.60 $0.00 $0.00 $0.00 $0.00 $0.00 27803894 EAP HCPCS C1760 Sph181600-20 Microcoil Platinu BOTH IP/OP "$4,020.00 " "$2,974.80" $0.00 "$3,216.00" "$1,809.00" "$1,809.00" $0.00 $0.00 $0.00 $837.87 "$2,983.64" "$2,983.64" "$3,098.62" $0.00 $837.77 $0.00 "$1,981.86" "$1,981.86" $0.00 "$2,010.00" "$3,183.84" "$3,216.00" $0.00 $0.00 $0.00 $629.13 $0.00 $0.00 $639.98 $0.00 $0.00 $0.00 $0.00 $0.00 27803895 EAP HCPCS C1760 Sph181700-20 Microcoil Platinu BOTH IP/OP "$4,071.00 " "$3,012.54" $0.00 "$3,256.80" "$1,831.95" "$1,831.95" $0.00 $0.00 $0.00 $848.50 "$3,021.50" "$3,021.50" "$3,137.93" $0.00 $848.40 $0.00 "$2,007.00" "$2,007.00" $0.00 "$2,035.50" "$3,224.23" "$3,256.80" $0.00 $0.00 $0.00 $637.11 $0.00 $0.00 $648.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803896 EAP HCPCS C1760 Sph181800-20 Microcoil Platinu BOTH IP/OP "$4,071.00 " "$3,012.54" $0.00 "$3,256.80" "$1,831.95" "$1,831.95" $0.00 $0.00 $0.00 $848.50 "$3,021.50" "$3,021.50" "$3,137.93" $0.00 $848.40 $0.00 "$2,007.00" "$2,007.00" $0.00 "$2,035.50" "$3,224.23" "$3,256.80" $0.00 $0.00 $0.00 $637.11 $0.00 $0.00 $648.10 $0.00 $0.00 $0.00 $0.00 $0.00 27803897 EAP HCPCS C1760 Src140306-20 Microcoil Platinu BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" "$1,748.25" "$1,748.25" $0.00 $0.00 $0.00 $809.73 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 "$1,915.31" "$1,915.31" $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $608.00 $0.00 $0.00 $618.49 $0.00 $0.00 $0.00 $0.00 $0.00 27803898 EAP HCPCS C1760 Src140445-20microcoil Platinum BOTH IP/OP "$3,885.00 " "$2,874.90" $0.00 "$3,108.00" "$1,748.25" "$1,748.25" $0.00 $0.00 $0.00 $809.73 "$2,883.45" "$2,883.45" "$2,994.56" $0.00 $809.63 $0.00 "$1,915.31" "$1,915.31" $0.00 "$1,942.50" "$3,076.92" "$3,108.00" $0.00 $0.00 $0.00 $608.00 $0.00 $0.00 $618.49 $0.00 $0.00 $0.00 $0.00 $0.00 27803899 EAP HCPCS C1760 Src140406-20 Microcoil Platinu BOTH IP/OP "$3,903.00 " "$2,888.22" $0.00 "$3,122.40" "$1,756.35" "$1,756.35" $0.00 $0.00 $0.00 $813.48 "$2,896.81" "$2,896.81" "$3,008.43" $0.00 $813.39 $0.00 "$1,924.18" "$1,924.18" $0.00 "$1,951.50" "$3,091.18" "$3,122.40" $0.00 $0.00 $0.00 $610.82 $0.00 $0.00 $621.36 $0.00 $0.00 $0.00 $0.00 $0.00 27803900 EAP HCPCS C1760 Src140408-20 Microcoil Platinu BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 27803901 EAP HCPCS C1760 Src140507-20 Microcoil Micrusp BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 27803902 EAP HCPCS C1760 Src140512-20 Microcoil Platinu BOTH IP/OP "$3,955.00 " "$2,926.70" $0.00 "$3,164.00" "$1,779.75" "$1,779.75" $0.00 $0.00 $0.00 $824.32 "$2,935.40" "$2,935.40" "$3,048.51" $0.00 $824.22 $0.00 "$1,949.82" "$1,949.82" $0.00 "$1,977.50" "$3,132.36" "$3,164.00" $0.00 $0.00 $0.00 $618.96 $0.00 $0.00 $629.64 $0.00 $0.00 $0.00 $0.00 $0.00 27803903 EAP HCPCS C1760 Src140609-20 Microcoil Platinu BOTH IP/OP "$3,936.00 " "$2,912.64" $0.00 "$3,148.80" "$1,771.20" "$1,771.20" $0.00 $0.00 $0.00 $820.36 "$2,921.30" "$2,921.30" "$3,033.87" $0.00 $820.26 $0.00 "$1,940.45" "$1,940.45" $0.00 "$1,968.00" "$3,117.31" "$3,148.80" $0.00 $0.00 $0.00 $615.98 $0.00 $0.00 $626.61 $0.00 $0.00 $0.00 $0.00 $0.00 27803904 EAP HCPCS C1760 Src140615-20 Microcoil Plainum BOTH IP/OP "$4,005.00 " "$2,963.70" $0.00 "$3,204.00" "$1,802.25" "$1,802.25" $0.00 $0.00 $0.00 $834.74 "$2,972.51" "$2,972.51" "$3,087.05" $0.00 $834.64 $0.00 "$1,974.47" "$1,974.47" $0.00 "$2,002.50" "$3,171.96" "$3,204.00" $0.00 $0.00 $0.00 $626.78 $0.00 $0.00 $637.60 $0.00 $0.00 $0.00 $0.00 $0.00 27803905 EAP HCPCS C1760 Src140711-20 Microcoil Platinu BOTH IP/OP "$3,955.00 " "$2,926.70" $0.00 "$3,164.00" "$1,779.75" "$1,779.75" $0.00 $0.00 $0.00 $824.32 "$2,935.40" "$2,935.40" "$3,048.51" $0.00 $824.22 $0.00 "$1,949.82" "$1,949.82" $0.00 "$1,977.50" "$3,132.36" "$3,164.00" $0.00 $0.00 $0.00 $618.96 $0.00 $0.00 $629.64 $0.00 $0.00 $0.00 $0.00 $0.00 27803906 EAP HCPCS C1760 Src140717-20 Microcoil Platinu BOTH IP/OP "$4,105.00 " "$3,037.70" $0.00 "$3,284.00" "$1,847.25" "$1,847.25" $0.00 $0.00 $0.00 $855.58 "$3,046.73" "$3,046.73" "$3,164.13" $0.00 $855.48 $0.00 "$2,023.77" "$2,023.77" $0.00 "$2,052.50" "$3,251.16" "$3,284.00" $0.00 $0.00 $0.00 $642.43 $0.00 $0.00 $653.52 $0.00 $0.00 $0.00 $0.00 $0.00 27803907 EAP HCPCS C1760 Src140812-20 Microcoil Platinu BOTH IP/OP "$4,020.00 " "$2,974.80" $0.00 "$3,216.00" "$1,809.00" "$1,809.00" $0.00 $0.00 $0.00 $837.87 "$2,983.64" "$2,983.64" "$3,098.62" $0.00 $837.77 $0.00 "$1,981.86" "$1,981.86" $0.00 "$2,010.00" "$3,183.84" "$3,216.00" $0.00 $0.00 $0.00 $629.13 $0.00 $0.00 $639.98 $0.00 $0.00 $0.00 $0.00 $0.00 27803908 EAP HCPCS C1760 Src140820-20 Microcoil Platinu BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27803909 EAP HCPCS C1760 Src140922-20 Microcoil Platinu BOTH IP/OP "$4,204.00 " "$3,110.96" $0.00 "$3,363.20" "$1,891.80" "$1,891.80" $0.00 $0.00 $0.00 $876.22 "$3,120.21" "$3,120.21" "$3,240.44" $0.00 $876.11 $0.00 "$2,072.57" "$2,072.57" $0.00 "$2,102.00" "$3,329.57" "$3,363.20" $0.00 $0.00 $0.00 $657.93 $0.00 $0.00 $669.28 $0.00 $0.00 $0.00 $0.00 $0.00 27803910 EAP HCPCS C1760 Src141016-20 Microcoil Platinu BOTH IP/OP "$4,105.00 " "$3,037.70" $0.00 "$3,284.00" "$1,847.25" "$1,847.25" $0.00 $0.00 $0.00 $855.58 "$3,046.73" "$3,046.73" "$3,164.13" $0.00 $855.48 $0.00 "$2,023.77" "$2,023.77" $0.00 "$2,052.50" "$3,251.16" "$3,284.00" $0.00 $0.00 $0.00 $642.43 $0.00 $0.00 $653.52 $0.00 $0.00 $0.00 $0.00 $0.00 27803911 EAP HCPCS C1760 Src141025-20 Microcoil Platinu BOTH IP/OP "$4,255.00 " "$3,148.70" $0.00 "$3,404.00" "$1,914.75" "$1,914.75" $0.00 $0.00 $0.00 $886.85 "$3,158.06" "$3,158.06" "$3,279.75" $0.00 $886.74 $0.00 "$2,097.72" "$2,097.72" $0.00 "$2,127.50" "$3,369.96" "$3,404.00" $0.00 $0.00 $0.00 $665.91 $0.00 $0.00 $677.40 $0.00 $0.00 $0.00 $0.00 $0.00 27803912 EAP HCPCS C1760 Src141118-20 Microcoil Platinu BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,336.00" "$1,876.50" "$1,876.50" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,055.81" "$2,055.81" $0.00 "$2,085.00" "$3,302.64" "$3,336.00" $0.00 $0.00 $0.00 $652.61 $0.00 $0.00 $663.86 $0.00 $0.00 $0.00 $0.00 $0.00 27803913 EAP HCPCS C1760 Src141127-20 Microcoil Platinu BOTH IP/OP "$4,304.00 " "$3,184.96" $0.00 "$3,443.20" "$1,936.80" "$1,936.80" $0.00 $0.00 $0.00 $897.06 "$3,194.43" "$3,194.43" "$3,317.52" $0.00 $896.95 $0.00 "$2,121.87" "$2,121.87" $0.00 "$2,152.00" "$3,408.77" "$3,443.20" $0.00 $0.00 $0.00 $673.58 $0.00 $0.00 $685.20 $0.00 $0.00 $0.00 $0.00 $0.00 27803914 EAP HCPCS C1760 Src141219-20 Microcoil [platin BOTH IP/OP "$4,204.00 " "$3,110.96" $0.00 "$3,363.20" "$1,891.80" "$1,891.80" $0.00 $0.00 $0.00 $876.22 "$3,120.21" "$3,120.21" "$3,240.44" $0.00 $876.11 $0.00 "$2,072.57" "$2,072.57" $0.00 "$2,102.00" "$3,329.57" "$3,363.20" $0.00 $0.00 $0.00 $657.93 $0.00 $0.00 $669.28 $0.00 $0.00 $0.00 $0.00 $0.00 27803915 EAP HCPCS C1760 Src141230-20 Microcoil Platinu BOTH IP/OP "$4,355.00 " "$3,222.70" $0.00 "$3,484.00" "$1,959.75" "$1,959.75" $0.00 $0.00 $0.00 $907.69 "$3,232.28" "$3,232.28" "$3,356.83" $0.00 $907.58 $0.00 "$2,147.02" "$2,147.02" $0.00 "$2,177.50" "$3,449.16" "$3,484.00" $0.00 $0.00 $0.00 $681.56 $0.00 $0.00 $693.32 $0.00 $0.00 $0.00 $0.00 $0.00 27803916 EAP HCPCS C1760 Fsr100201-20 Microcoil Platinu BOTH IP/OP "$3,135.00 " "$2,319.90" $0.00 "$2,508.00" "$1,410.75" "$1,410.75" $0.00 $0.00 $0.00 $653.41 "$2,326.80" "$2,326.80" "$2,416.46" $0.00 $653.33 $0.00 "$1,545.56" "$1,545.56" $0.00 "$1,567.50" "$2,482.92" "$2,508.00" $0.00 $0.00 $0.00 $490.63 $0.00 $0.00 $499.09 $0.00 $0.00 $0.00 $0.00 $0.00 27803917 EAP HCPCS C1760 Fsr100202-20 Microcoil Platinu BOTH IP/OP "$3,169.00 " "$2,345.06" $0.00 "$2,535.20" "$1,426.05" "$1,426.05" $0.00 $0.00 $0.00 $660.50 "$2,352.03" "$2,352.03" "$2,442.67" $0.00 $660.42 $0.00 "$1,562.32" "$1,562.32" $0.00 "$1,584.50" "$2,509.85" "$2,535.20" $0.00 $0.00 $0.00 $495.95 $0.00 $0.00 $504.50 $0.00 $0.00 $0.00 $0.00 $0.00 27803918 EAP HCPCS C1760 Fsr100203-20 Microcoil Platinu BOTH IP/OP "$3,186.00 " "$2,357.64" $0.00 "$2,548.80" "$1,433.70" "$1,433.70" $0.00 $0.00 $0.00 $664.04 "$2,364.65" "$2,364.65" "$2,455.77" $0.00 $663.96 $0.00 "$1,570.70" "$1,570.70" $0.00 "$1,593.00" "$2,523.31" "$2,548.80" $0.00 $0.00 $0.00 $498.61 $0.00 $0.00 $507.21 $0.00 $0.00 $0.00 $0.00 $0.00 27803919 EAP HCPCS C1760 Frs100204-20 Microcoil Platinu BOTH IP/OP "$3,203.00 " "$2,370.22" $0.00 "$2,562.40" "$1,441.35" "$1,441.35" $0.00 $0.00 $0.00 $667.59 "$2,377.27" "$2,377.27" "$2,468.87" $0.00 $667.51 $0.00 "$1,579.08" "$1,579.08" $0.00 "$1,601.50" "$2,536.78" "$2,562.40" $0.00 $0.00 $0.00 $501.27 $0.00 $0.00 $509.92 $0.00 $0.00 $0.00 $0.00 $0.00 27803920 EAP HCPCS C1760 Fsr100206-20 Microcoil Platinu BOTH IP/OP "$3,236.00 " "$2,394.64" $0.00 "$2,588.80" "$1,456.20" "$1,456.20" $0.00 $0.00 $0.00 $674.46 "$2,401.76" "$2,401.76" "$2,494.31" $0.00 $674.38 $0.00 "$1,595.35" "$1,595.35" $0.00 "$1,618.00" "$2,562.91" "$2,588.80" $0.00 $0.00 $0.00 $506.43 $0.00 $0.00 $515.17 $0.00 $0.00 $0.00 $0.00 $0.00 27803921 EAP HCPCS C1760 Fsr100208-20 Microcoil Platinu BOTH IP/OP "$3,270.00 " "$2,419.80" $0.00 "$2,616.00" "$1,471.50" "$1,471.50" $0.00 $0.00 $0.00 $681.55 "$2,426.99" "$2,426.99" "$2,520.52" $0.00 $681.47 $0.00 "$1,612.11" "$1,612.11" $0.00 "$1,635.00" "$2,589.84" "$2,616.00" $0.00 $0.00 $0.00 $511.76 $0.00 $0.00 $520.58 $0.00 $0.00 $0.00 $0.00 $0.00 27803922 EAP HCPCS C1760 Fsr100252-20 Microcoil Platinu BOTH IP/OP "$3,169.00 " "$2,345.06" $0.00 "$2,535.20" "$1,426.05" "$1,426.05" $0.00 $0.00 $0.00 $660.50 "$2,352.03" "$2,352.03" "$2,442.67" $0.00 $660.42 $0.00 "$1,562.32" "$1,562.32" $0.00 "$1,584.50" "$2,509.85" "$2,535.20" $0.00 $0.00 $0.00 $495.95 $0.00 $0.00 $504.50 $0.00 $0.00 $0.00 $0.00 $0.00 27803923 EAP HCPCS C1760 Fsr100254-20 Microcoil Platinu BOTH IP/OP "$3,203.00 " "$2,370.22" $0.00 "$2,562.40" "$1,441.35" "$1,441.35" $0.00 $0.00 $0.00 $667.59 "$2,377.27" "$2,377.27" "$2,468.87" $0.00 $667.51 $0.00 "$1,579.08" "$1,579.08" $0.00 "$1,601.50" "$2,536.78" "$2,562.40" $0.00 $0.00 $0.00 $501.27 $0.00 $0.00 $509.92 $0.00 $0.00 $0.00 $0.00 $0.00 27803924 EAP HCPCS C1760 Fsr100256-20 Microcoil Platinu BOTH IP/OP "$3,236.00 " "$2,394.64" $0.00 "$2,588.80" "$1,456.20" "$1,456.20" $0.00 $0.00 $0.00 $674.46 "$2,401.76" "$2,401.76" "$2,494.31" $0.00 $674.38 $0.00 "$1,595.35" "$1,595.35" $0.00 "$1,618.00" "$2,562.91" "$2,588.80" $0.00 $0.00 $0.00 $506.43 $0.00 $0.00 $515.17 $0.00 $0.00 $0.00 $0.00 $0.00 27803925 EAP HCPCS C1760 Fsr100258-20 Microcoil Platinu BOTH IP/OP "$3,270.00 " "$2,419.80" $0.00 "$2,616.00" "$1,471.50" "$1,471.50" $0.00 $0.00 $0.00 $681.55 "$2,426.99" "$2,426.99" "$2,520.52" $0.00 $681.47 $0.00 "$1,612.11" "$1,612.11" $0.00 "$1,635.00" "$2,589.84" "$2,616.00" $0.00 $0.00 $0.00 $511.76 $0.00 $0.00 $520.58 $0.00 $0.00 $0.00 $0.00 $0.00 27803926 EAP HCPCS C1760 Fsr100306-20 Microcoil Platinu BOTH IP/OP "$3,236.00 " "$2,394.64" $0.00 "$2,588.80" "$1,456.20" "$1,456.20" $0.00 $0.00 $0.00 $674.46 "$2,401.76" "$2,401.76" "$2,494.31" $0.00 $674.38 $0.00 "$1,595.35" "$1,595.35" $0.00 "$1,618.00" "$2,562.91" "$2,588.80" $0.00 $0.00 $0.00 $506.43 $0.00 $0.00 $515.17 $0.00 $0.00 $0.00 $0.00 $0.00 27803927 EAP HCPCS C1760 Fsr100308-20 Microcoil Platinu BOTH IP/OP "$3,270.00 " "$2,419.80" $0.00 "$2,616.00" "$1,471.50" "$1,471.50" $0.00 $0.00 $0.00 $681.55 "$2,426.99" "$2,426.99" "$2,520.52" $0.00 $681.47 $0.00 "$1,612.11" "$1,612.11" $0.00 "$1,635.00" "$2,589.84" "$2,616.00" $0.00 $0.00 $0.00 $511.76 $0.00 $0.00 $520.58 $0.00 $0.00 $0.00 $0.00 $0.00 27803928 EAP HCPCS C1760 Fsr100406-20 Microcoil Platinu BOTH IP/OP "$3,236.00 " "$2,394.64" $0.00 "$2,588.80" "$1,456.20" "$1,456.20" $0.00 $0.00 $0.00 $674.46 "$2,401.76" "$2,401.76" "$2,494.31" $0.00 $674.38 $0.00 "$1,595.35" "$1,595.35" $0.00 "$1,618.00" "$2,562.91" "$2,588.80" $0.00 $0.00 $0.00 $506.43 $0.00 $0.00 $515.17 $0.00 $0.00 $0.00 $0.00 $0.00 27803929 EAP HCPCS C1760 Fsr100408-20 Microcoil Platinu BOTH IP/OP "$3,270.00 " "$2,419.80" $0.00 "$2,616.00" "$1,471.50" "$1,471.50" $0.00 $0.00 $0.00 $681.55 "$2,426.99" "$2,426.99" "$2,520.52" $0.00 $681.47 $0.00 "$1,612.11" "$1,612.11" $0.00 "$1,635.00" "$2,589.84" "$2,616.00" $0.00 $0.00 $0.00 $511.76 $0.00 $0.00 $520.58 $0.00 $0.00 $0.00 $0.00 $0.00 27803940 EAP HCPCS C1888 "Endovascular Laser Catheter, Abl" BOTH IP/OP "$1,226.00 " $907.24 $0.00 $980.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.94 $909.94 $945.00 $0.00 $255.50 $0.00 $0.00 $0.00 $0.00 $613.00 $970.99 $980.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27803941 EAP HCPCS C1874 Viator Stent 10 X 4 BOTH IP/OP "$11,885.00 " "$8,794.90" $0.00 "$9,508.00" "$5,348.25" "$5,348.25" $0.00 $0.00 $0.00 "$2,477.13" "$4,181.12" "$4,181.12" "$9,160.96" $0.00 "$2,476.83" $0.00 "$5,859.31" "$5,859.31" $0.00 "$5,942.50" "$9,412.92" "$9,508.00" $0.00 $0.00 $0.00 "$1,860.00" $0.00 $0.00 "$1,892.09" $0.00 $0.00 $0.00 $0.00 $0.00 27803942 EAP HCPCS C1874 Viator Stent 10 X 5 BOTH IP/OP "$11,885.00 " "$8,794.90" $0.00 "$9,508.00" "$5,348.25" "$5,348.25" $0.00 $0.00 $0.00 "$2,477.13" "$4,181.12" "$4,181.12" "$9,160.96" $0.00 "$2,476.83" $0.00 "$5,859.31" "$5,859.31" $0.00 "$5,942.50" "$9,412.92" "$9,508.00" $0.00 $0.00 $0.00 "$1,860.00" $0.00 $0.00 "$1,892.09" $0.00 $0.00 $0.00 $0.00 $0.00 27803943 EAP HCPCS C1874 Viator Stent 10 X 6 BOTH IP/OP "$11,885.00 " "$8,794.90" $0.00 "$9,508.00" "$5,348.25" "$5,348.25" $0.00 $0.00 $0.00 "$2,477.13" "$4,181.12" "$4,181.12" "$9,160.96" $0.00 "$2,476.83" $0.00 "$5,859.31" "$5,859.31" $0.00 "$5,942.50" "$9,412.92" "$9,508.00" $0.00 "$5,348.25" $0.00 "$1,860.00" $0.00 $0.00 "$1,892.09" $0.00 $0.00 $0.00 $0.00 $0.00 27803944 EAP HCPCS C1874 Viator Stent 10 X 7 BOTH IP/OP "$11,885.00 " "$8,794.90" $0.00 "$9,508.00" "$5,348.25" "$5,348.25" $0.00 $0.00 $0.00 "$2,477.13" "$4,181.12" "$4,181.12" "$9,160.96" $0.00 "$2,476.83" $0.00 "$5,859.31" "$5,859.31" $0.00 "$5,942.50" "$9,412.92" "$9,508.00" $0.00 $0.00 $0.00 "$1,860.00" $0.00 $0.00 "$1,892.09" $0.00 $0.00 $0.00 $0.00 $0.00 27803945 EAP HCPCS C1874 Viator Stent 10 X 8 BOTH IP/OP "$11,885.00 " "$8,794.90" $0.00 "$9,508.00" "$5,348.25" "$5,348.25" $0.00 $0.00 $0.00 "$2,477.13" "$4,181.12" "$4,181.12" "$9,160.96" $0.00 "$2,476.83" $0.00 "$5,859.31" "$5,859.31" $0.00 "$5,942.50" "$9,412.92" "$9,508.00" $0.00 "$5,348.25" $0.00 "$1,860.00" $0.00 $0.00 "$1,892.09" $0.00 $0.00 $0.00 $0.00 $0.00 27803950 EAP HCPCS V2790 Prokera (amniograft) Ring 16mm BOTH IP/OP "$3,167.00 " "$2,343.58" $0.00 "$2,533.60" "$1,425.15" "$1,425.15" $0.00 $0.00 $0.00 $660.08 "$2,350.55" "$2,350.55" "$2,441.12" $0.00 $660.00 $0.00 "$1,561.33" "$1,561.33" $0.00 "$1,583.50" "$2,508.26" "$2,533.60" $0.00 $0.00 $0.00 $495.64 $0.00 $0.00 $504.19 $0.00 $0.00 $0.00 $0.00 $0.00 27803951 EAP HCPCS C1882 Crt-d 40 Unify (icd) BOTH IP/OP "$89,408.00 " "$66,161.92" $0.00 "$71,526.40" "$40,233.60" "$40,233.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$68,915.69" $0.00 "$18,632.63" $0.00 "$44,078.14" "$44,078.14" $0.00 "$44,704.00" "$70,811.14" "$71,526.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27803952 EAP HCPCS C1722 Fortify Icd-vr40 BOTH IP/OP "$60,048.00 " "$44,435.52" $0.00 "$48,038.40" "$27,021.60" "$27,021.60" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$46,285.00" $0.00 "$12,514.00" $0.00 "$29,603.66" "$29,603.66" $0.00 "$30,024.00" "$47,558.02" "$48,038.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27803960 EAP HCPCS C1886 "Catheter, Ablation" BOTH IP/OP $310.00 $229.40 $0.00 $248.00 $139.50 $139.50 $0.00 $0.00 $0.00 $64.61 $230.08 $230.08 $238.95 $0.00 $64.60 $0.00 $183.37 $183.37 $0.00 $155.00 $245.52 $248.00 $0.00 $0.00 $0.00 $48.52 $0.00 $0.00 $49.35 $0.00 $0.00 $0.00 $0.00 $0.00 27803961 EAP HCPCS C2617 Gore Viatorr Tips Endoprosthesis 4cm X 2cm X12mm BOTH IP/OP "$4,843.00 " "$3,583.82" $0.00 "$3,874.40" "$2,179.35" "$2,179.35" $0.00 $0.00 $0.00 "$1,009.40" "$3,594.47" "$3,594.47" "$3,732.98" $0.00 "$1,009.28" $0.00 "$2,387.60" "$2,387.60" $0.00 "$2,421.50" "$3,835.66" "$3,874.40" $0.00 $0.00 $0.00 $757.93 $0.00 $0.00 $771.01 $0.00 $0.00 $0.00 $0.00 $0.00 27803962 EAP HCPCS C2617 Gore Viatorr Tips Endoprosthesis 6cm X 2cm X 12mm BOTH IP/OP "$4,843.00 " "$3,583.82" $0.00 "$3,874.40" "$2,179.35" "$2,179.35" $0.00 $0.00 $0.00 "$1,009.40" "$3,594.47" "$3,594.47" "$3,732.98" $0.00 "$1,009.28" $0.00 "$2,387.60" "$2,387.60" $0.00 "$2,421.50" "$3,835.66" "$3,874.40" $0.00 $0.00 $0.00 $757.93 $0.00 $0.00 $771.01 $0.00 $0.00 $0.00 $0.00 $0.00 27803963 EAP HCPCS C2617 Gore Viatorr Tips Endoprosthesis 8cm X 2cm X 12mm BOTH IP/OP "$4,843.00 " "$3,583.82" $0.00 "$3,874.40" "$2,179.35" "$2,179.35" $0.00 $0.00 $0.00 "$1,009.40" "$3,594.47" "$3,594.47" "$3,732.98" $0.00 "$1,009.28" $0.00 "$2,387.60" "$2,387.60" $0.00 "$2,421.50" "$3,835.66" "$3,874.40" $0.00 $0.00 $0.00 $757.93 $0.00 $0.00 $771.01 $0.00 $0.00 $0.00 $0.00 $0.00 27803964 EAP HCPCS C2617 Gore Viabil Endoprosthesis 10mm X 4cm X 40cm BOTH IP/OP "$3,216.00 " "$2,379.84" $0.00 "$2,572.80" "$1,447.20" "$1,447.20" $0.00 $0.00 $0.00 $670.29 "$2,386.92" "$2,386.92" "$2,478.89" $0.00 $670.21 $0.00 "$1,585.49" "$1,585.49" $0.00 "$1,608.00" "$2,547.07" "$2,572.80" $0.00 "$1,447.20" $0.00 $503.30 $0.00 $0.00 $511.99 $0.00 $0.00 $0.00 $0.00 $0.00 27803965 EAP HCPCS C2617 Gore Viabil Endoprosthesis 10mm X 6cm X 40cm BOTH IP/OP "$3,216.00 " "$2,379.84" $0.00 "$2,572.80" "$1,447.20" "$1,447.20" $0.00 $0.00 $0.00 $670.29 "$2,386.92" "$2,386.92" "$2,478.89" $0.00 $670.21 $0.00 "$1,585.49" "$1,585.49" $0.00 "$1,608.00" "$2,547.07" "$2,572.80" $0.00 $0.00 $0.00 $503.30 $0.00 $0.00 $511.99 $0.00 $0.00 $0.00 $0.00 $0.00 27803966 EAP HCPCS C2617 Gore Viabil Endoprosthesis 10mm X 8cm X 40cm BOTH IP/OP "$3,216.00 " "$2,379.84" $0.00 "$2,572.80" "$1,746.29" "$1,746.29" $0.00 $0.00 $0.00 $670.29 "$2,386.92" "$2,386.92" "$2,478.89" $0.00 $670.21 $0.00 "$1,902.26" "$1,902.26" $0.00 "$1,608.00" "$2,547.07" "$2,572.80" $0.00 "$2,090.40" $0.00 $503.30 $0.00 $0.00 $511.99 $0.00 $0.00 $0.00 $0.00 $0.00 27803967 EAP HCPCS C2617 Gore Viabil Endoprosthesis 10mm X 10cm X 40cm BOTH IP/OP "$3,216.00 " "$2,379.84" $0.00 "$2,572.80" "$1,447.20" "$1,447.20" $0.00 $0.00 $0.00 $670.29 "$2,386.92" "$2,386.92" "$2,478.89" $0.00 $670.21 $0.00 "$1,585.49" "$1,585.49" $0.00 "$1,608.00" "$2,547.07" "$2,572.80" $0.00 $0.00 $0.00 $503.30 $0.00 $0.00 $511.99 $0.00 $0.00 $0.00 $0.00 $0.00 27803968 EAP HCPCS C1713 Amplatz Anchor System 8 X 30 BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $52.65 $52.65 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $90.18 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $58.50 $92.66 $93.60 $0.00 $0.00 $0.00 $18.31 $0.00 $0.00 $18.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803969 EAP HCPCS C1713 Amplatz Anchor System 10 X 30 BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $52.65 $52.65 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $90.18 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $58.50 $92.66 $93.60 $0.00 $52.65 $0.00 $18.31 $0.00 $0.00 $18.63 $0.00 $0.00 $0.00 $0.00 $0.00 27803970 EAP HCPCS C1876 M001711300 Stent Wall 6fr 8/80/75cm BOTH IP/OP "$4,931.00 " "$3,648.94" $0.00 "$3,944.80" "$2,218.95" "$2,218.95" $0.00 $0.00 $0.00 "$1,027.74" "$3,659.79" "$3,659.79" "$3,800.81" $0.00 "$1,027.62" $0.00 "$2,430.98" "$2,430.98" $0.00 "$2,465.50" "$3,905.35" "$3,944.80" $0.00 $0.00 $0.00 $771.70 $0.00 $0.00 $785.02 $0.00 $0.00 $0.00 $0.00 $0.00 27803971 EAP HCPCS C1894 Retriever Merci L6 90060 BOTH IP/OP "$10,536.00 " "$7,796.64" $0.00 "$8,428.80" "$4,741.20" "$4,741.20" $0.00 $0.00 $0.00 "$2,195.97" "$4,181.12" "$4,181.12" "$8,121.15" $0.00 "$2,195.70" $0.00 "$5,194.25" "$5,194.25" $0.00 "$5,268.00" "$8,344.51" "$8,428.80" $0.00 $0.00 $0.00 "$1,648.88" $0.00 $0.00 "$1,677.33" $0.00 $0.00 $0.00 $0.00 $0.00 27804055 EAP HCPCS C1874 Test Name New BOTH IP/OP "$7,990.00 " "$5,912.60" $0.00 "$6,392.00" "$3,595.50" "$3,595.50" $0.00 $0.00 $0.00 "$1,665.32" "$4,181.12" "$4,181.12" "$6,158.69" $0.00 "$1,665.12" $0.00 "$3,939.07" "$3,939.07" $0.00 "$3,995.00" "$6,328.08" "$6,392.00" $0.00 $0.00 $0.00 "$1,250.44" $0.00 $0.00 "$1,272.01" $0.00 $0.00 $0.00 $0.00 $0.00 27804056 EAP Custom 27804056 "Retriever Mercl L6, 90060" BOTH IP/OP "$10,536.00 " "$7,796.64" $0.00 "$8,428.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,121.15" $0.00 "$2,195.70" $0.00 $0.00 $0.00 $0.00 "$5,268.00" "$8,344.51" "$8,428.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804060 EAP HCPCS C1764 "Implantable Cardiac Monitor, Confirm Ic" BOTH IP/OP "$11,676.00 " "$8,640.24" $0.00 "$9,340.80" "$5,254.20" "$5,254.20" $0.00 $0.00 $0.00 "$2,433.57" "$4,181.12" "$4,181.12" "$8,999.86" $0.00 "$2,433.28" $0.00 "$5,756.27" "$5,756.27" $0.00 "$5,838.00" "$9,247.39" "$9,340.80" $0.00 "$5,254.20" $0.00 "$1,827.29" $0.00 $0.00 "$1,858.82" $0.00 $0.00 $0.00 $0.00 $0.00 27804067 EAP HCPCS C1880 Md800f Filter Peripheral Vena Cava Femoral BOTH IP/OP "$2,933.00 " "$2,170.42" $0.00 "$2,346.40" "$1,319.85" "$1,319.85" $0.00 $0.00 $0.00 $611.31 "$2,176.87" "$2,176.87" "$2,260.76" $0.00 $611.24 $0.00 "$1,445.97" "$1,445.97" $0.00 "$1,466.50" "$2,322.94" "$2,346.40" $0.00 $0.00 $0.00 $459.01 $0.00 $0.00 $466.93 $0.00 $0.00 $0.00 $0.00 $0.00 27804068 EAP HCPCS C1880 Md800j Filter Peripheral Vena Cava Jugular BOTH IP/OP "$3,080.00 " "$2,279.20" $0.00 "$2,464.00" "$1,386.00" "$1,386.00" $0.00 $0.00 $0.00 $641.95 "$2,285.98" "$2,285.98" "$2,374.06" $0.00 $641.87 $0.00 "$1,518.44" "$1,518.44" $0.00 "$1,540.00" "$2,439.36" "$2,464.00" $0.00 $0.00 $0.00 $482.02 $0.00 $0.00 $490.34 $0.00 $0.00 $0.00 $0.00 $0.00 27804070 EAP HCPCS C1757 Sfr-4-15 Device Thrombectomy Solitaire Fr 4x15 BOTH IP/OP "$18,930.00 " "$14,008.20" $0.00 "$15,144.00" "$8,518.50" "$8,518.50" $0.00 $0.00 $0.00 "$3,945.49" "$4,181.12" "$4,181.12" "$14,591.24" $0.00 "$3,945.01" $0.00 "$9,332.49" "$9,332.49" $0.00 "$9,465.00" "$14,992.56" "$15,144.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804071 EAP HCPCS C1757 Sfr-4-20 Device Thrombectomy Solitaire Fr 4x20 BOTH IP/OP "$18,930.00 " "$14,008.20" $0.00 "$15,144.00" "$8,518.50" "$8,518.50" $0.00 $0.00 $0.00 "$3,945.49" "$4,181.12" "$4,181.12" "$14,591.24" $0.00 "$3,945.01" $0.00 "$9,332.49" "$9,332.49" $0.00 "$9,465.00" "$14,992.56" "$15,144.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804072 EAP HCPCS C1757 Sfr-6-20 Device Thrombectomy Solitaire Fr 6x20 BOTH IP/OP "$18,930.00 " "$14,008.20" $0.00 "$15,144.00" "$8,518.50" "$8,518.50" $0.00 $0.00 $0.00 "$3,945.49" "$4,181.12" "$4,181.12" "$14,591.24" $0.00 "$3,945.01" $0.00 "$9,332.49" "$9,332.49" $0.00 "$9,465.00" "$14,992.56" "$15,144.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804073 EAP HCPCS C1757 Sfr-6-30 Device Thrombectomy Solitaire Fr 6x30 BOTH IP/OP "$18,930.00 " "$14,008.20" $0.00 "$15,144.00" "$8,518.50" "$8,518.50" $0.00 $0.00 $0.00 "$3,945.49" "$4,181.12" "$4,181.12" "$14,591.24" $0.00 "$3,945.01" $0.00 "$9,332.49" "$9,332.49" $0.00 "$9,465.00" "$14,992.56" "$15,144.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804080 EAP Custom 27804080 G08261 Embolization Coil BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.33 $206.33 $214.28 $0.00 $57.94 $0.00 $0.00 $0.00 $0.00 $139.00 $220.18 $222.40 $0.00 $125.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804088 EAP HCPCS C1777 "Reliance Df4 Lead, Aicd, Endo Single Coil" BOTH IP/OP "$13,964.00 " "$10,333.36" $0.00 "$11,171.20" "$6,283.80" "$6,283.80" $0.00 $0.00 $0.00 "$2,910.45" "$4,181.12" "$4,181.12" "$10,763.45" $0.00 "$2,910.10" $0.00 "$6,884.25" "$6,884.25" $0.00 "$6,982.00" "$11,059.49" "$11,171.20" $0.00 "$6,283.80" $0.00 "$2,185.37" $0.00 $0.00 "$2,223.07" $0.00 $0.00 $0.00 $0.00 $0.00 27804089 EAP HCPCS C1777 "Reliance Gore Df4 Lead,aicd, Endo Single Coil" BOTH IP/OP "$13,964.00 " "$10,333.36" $0.00 "$11,171.20" "$6,283.80" "$6,283.80" $0.00 $0.00 $0.00 "$2,910.45" "$4,181.12" "$4,181.12" "$10,763.45" $0.00 "$2,910.10" $0.00 "$6,884.25" "$6,884.25" $0.00 "$6,982.00" "$11,059.49" "$11,171.20" $0.00 "$6,283.80" $0.00 "$2,185.37" $0.00 $0.00 "$2,223.07" $0.00 $0.00 $0.00 $0.00 $0.00 27804090 EAP HCPCS C1882 "Energen Df4 Crt-d Aicd, Other Than Sing/dual" BOTH IP/OP "$68,273.00 " "$50,522.02" $0.00 "$54,618.40" "$30,722.85" "$30,722.85" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$52,624.83" $0.00 "$14,228.09" $0.00 "$33,658.59" "$33,658.59" $0.00 "$34,136.50" "$54,072.22" "$54,618.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27804091 EAP HCPCS C1882 "Energen Crt-d Aicd, Other Than Sing/dual" BOTH IP/OP "$68,273.00 " "$50,522.02" $0.00 "$54,618.40" "$30,722.85" "$30,722.85" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$52,624.83" $0.00 "$14,228.09" $0.00 "$33,658.59" "$33,658.59" $0.00 "$34,136.50" "$54,072.22" "$54,618.40" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27804092 EAP HCPCS C1882 "Unify Quadra Aicd, Other Than Sing/dual" BOTH IP/OP "$89,376.00 " "$66,138.24" $0.00 "$71,500.80" "$40,219.20" "$40,219.20" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$68,891.02" $0.00 "$18,625.96" $0.00 "$44,062.37" "$44,062.37" $0.00 "$44,688.00" "$70,785.79" "$71,500.80" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27804093 EAP HCPCS C1898 "Tc-1888 Tendril Lead Pmkr, Other Than Trans" BOTH IP/OP "$1,551.00 " "$1,147.74" $0.00 "$1,240.80" $697.95 $697.95 $0.00 $0.00 $0.00 $323.27 "$1,151.15" "$1,151.15" "$1,195.51" $0.00 $323.23 $0.00 $917.42 $917.42 $0.00 $775.50 "$1,228.39" "$1,240.80" $0.00 $0.00 $0.00 $242.73 $0.00 $0.00 $246.92 $0.00 $0.00 $0.00 $0.00 $0.00 27804094 EAP HCPCS C1900 "Q-1458 Quartet Lead, Aicd, Endo Single Coil" BOTH IP/OP "$8,566.00 " "$6,338.84" $0.00 "$6,852.80" "$3,854.70" "$3,854.70" $0.00 $0.00 $0.00 "$1,785.37" "$4,181.12" "$4,181.12" "$6,602.67" $0.00 "$1,785.15" $0.00 "$4,223.04" "$4,223.04" $0.00 "$4,283.00" "$6,784.27" "$6,852.80" $0.00 "$3,854.70" $0.00 "$1,340.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804098 EAP HCPCS C1876 Enterprise 22mm Stent No-tip BOTH IP/OP "$16,138.00 " "$11,942.12" $0.00 "$12,910.40" "$7,262.10" "$7,262.10" $0.00 $0.00 $0.00 "$3,363.56" "$4,181.12" "$4,181.12" "$12,439.17" $0.00 "$3,363.16" $0.00 "$7,956.03" "$7,956.03" $0.00 "$8,069.00" "$12,781.30" "$12,910.40" $0.00 "$7,262.10" $0.00 "$2,525.60" $0.00 $0.00 "$2,569.17" $0.00 $0.00 $0.00 $0.00 $0.00 27804099 EAP HCPCS C1876 Enterprise 38mm Stent No-tip BOTH IP/OP "$16,138.00 " "$11,942.12" $0.00 "$12,910.40" "$7,262.10" "$7,262.10" $0.00 $0.00 $0.00 "$3,363.56" "$4,181.12" "$4,181.12" "$12,439.17" $0.00 "$3,363.16" $0.00 "$7,956.03" "$7,956.03" $0.00 "$8,069.00" "$12,781.30" "$12,910.40" $0.00 $0.00 $0.00 "$2,525.60" $0.00 $0.00 "$2,569.17" $0.00 $0.00 $0.00 $0.00 $0.00 27804100 EAP HCPCS C1876 Enterprise 37mm Stent No-tip BOTH IP/OP "$16,138.00 " "$11,942.12" $0.00 "$12,910.40" "$7,262.10" "$7,262.10" $0.00 $0.00 $0.00 "$3,363.56" "$4,181.12" "$4,181.12" "$12,439.17" $0.00 "$3,363.16" $0.00 "$7,956.03" "$7,956.03" $0.00 "$8,069.00" "$12,781.30" "$12,910.40" $0.00 $0.00 $0.00 "$2,525.60" $0.00 $0.00 "$2,569.17" $0.00 $0.00 $0.00 $0.00 $0.00 27804103 EAP Custom 27804103 "Px 400,straight" BOTH IP/OP "$2,749.00 " "$2,034.26" $0.00 "$2,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,040.31" "$2,040.31" "$2,118.93" $0.00 $572.89 $0.00 $0.00 $0.00 $0.00 "$1,374.50" "$2,177.21" "$2,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804104 EAP Custom 27804104 "Px 400, 45" BOTH IP/OP "$2,749.00 " "$2,034.26" $0.00 "$2,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,040.31" "$2,040.31" "$2,118.93" $0.00 $572.89 $0.00 $0.00 $0.00 $0.00 "$1,374.50" "$2,177.21" "$2,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804105 EAP Custom 27804105 "Px 400, J" BOTH IP/OP "$2,749.00 " "$2,034.26" $0.00 "$2,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,040.31" "$2,040.31" "$2,118.93" $0.00 $572.89 $0.00 $0.00 $0.00 $0.00 "$1,374.50" "$2,177.21" "$2,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804106 EAP Custom 27804106 Start Up Kit BOTH IP/OP $798.00 $590.52 $0.00 $638.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $592.28 $592.28 $615.10 $0.00 $166.30 $0.00 $0.00 $0.00 $0.00 $399.00 $632.02 $638.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804107 EAP Custom 27804107 Senor Flotrac BOTH IP/OP $993.00 $734.82 $0.00 $794.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $737.00 $737.00 $765.40 $0.00 $206.94 $0.00 $0.00 $0.00 $0.00 $496.50 $786.46 $794.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804108 EAP Custom 27804108 "Coil 400 Complex Standard, 15mm X 57cm" BOTH IP/OP "$7,642.00 " "$5,655.08" $0.00 "$6,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,890.45" $0.00 "$1,592.59" $0.00 $0.00 $0.00 $0.00 "$3,821.00" "$6,052.46" "$6,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804109 EAP Custom 27804109 "Coil 400 Complex Standard, 16mm X 60cm" BOTH IP/OP "$7,685.00 " "$5,686.90" $0.00 "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,923.60" $0.00 "$1,601.55" $0.00 $0.00 $0.00 $0.00 "$3,842.50" "$6,086.52" "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804110 EAP HCPCS C1752 Cath. Schon(5615200) Xl Sil. 035 In L20 Cm Guidewire Inr BOTH IP/OP $571.00 $422.54 $0.00 $456.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.50 $452.23 $456.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804111 EAP HCPCS C1752 Cath. Schon(5615150) Xl Silicone .035 In L15 Cm Guidewir BOTH IP/OP $544.00 $402.56 $0.00 $435.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.00 $430.85 $435.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804112 EAP HCPCS C1752 Cath. Schon(5605300) 30cm Full Hemo BOTH IP/OP $571.00 $422.54 $0.00 $456.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.50 $452.23 $456.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804113 EAP HCPCS A4648 Implantable Tissue Marker BOTH IP/OP $520.00 $384.80 $0.00 $416.00 $234.00 $234.00 $0.00 $0.00 $0.00 $108.38 $385.94 $385.94 $400.82 $0.00 $108.37 $0.00 $307.58 $307.58 $0.00 $260.00 $411.84 $416.00 $0.00 $234.00 $0.00 $81.38 $0.00 $0.00 $82.78 $0.00 $0.00 $0.00 $0.00 $0.00 27804116 EAP Custom 27804116 "Coil 400 Complex Standard, 18mm X 57cm" BOTH IP/OP "$7,642.00 " "$5,655.08" $0.00 "$6,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,890.45" $0.00 "$1,592.59" $0.00 $0.00 $0.00 $0.00 "$3,821.00" "$6,052.46" "$6,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804117 EAP Custom 27804117 "Coil 400 Complex Standard, 20mm X 60cm" BOTH IP/OP "$7,685.00 " "$5,686.90" $0.00 "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,923.60" $0.00 "$1,601.55" $0.00 $0.00 $0.00 $0.00 "$3,842.50" "$6,086.52" "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804118 EAP Custom 27804118 "Coil 400 Complex Standard, 22mm X 60cm" BOTH IP/OP "$7,685.00 " "$5,686.90" $0.00 "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,923.60" $0.00 "$1,601.55" $0.00 $0.00 $0.00 $0.00 "$3,842.50" "$6,086.52" "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804119 EAP Custom 27804119 "Coil 400 Complex Standard, 24mm X 57cm" BOTH IP/OP "$7,642.00 " "$5,655.08" $0.00 "$6,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,890.45" $0.00 "$1,592.59" $0.00 $0.00 $0.00 $0.00 "$3,821.00" "$6,052.46" "$6,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804120 EAP Custom 27804120 "Coil 400 Complex Standard, 28mm X 60 Cm" BOTH IP/OP "$8,572.00 " "$6,343.28" $0.00 "$6,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,607.30" $0.00 "$1,786.40" $0.00 $0.00 $0.00 $0.00 "$4,286.00" "$6,789.02" "$6,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804121 EAP Custom 27804121 Px 400 90 BOTH IP/OP "$2,749.00 " "$2,034.26" $0.00 "$2,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,040.31" "$2,040.31" "$2,118.93" $0.00 $572.89 $0.00 $0.00 $0.00 $0.00 "$1,374.50" "$2,177.21" "$2,199.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804122 EAP Custom 27804122 "Coil 400 Complex Standard, 32mm X 60 Cm" BOTH IP/OP "$8,572.00 " "$6,343.28" $0.00 "$6,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,607.30" $0.00 "$1,786.40" $0.00 $0.00 $0.00 $0.00 "$4,286.00" "$6,789.02" "$6,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804123 EAP Custom 27804123 "Coil 400 Complex Soft, 3 Mm X 3 Cm" BOTH IP/OP "$7,034.00 " "$5,205.16" $0.00 "$5,627.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,421.81" $0.00 "$1,465.89" $0.00 $0.00 $0.00 $0.00 "$3,517.00" "$5,570.93" "$5,627.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804124 EAP Custom 27804124 "Coil 400 Complex Extra Soft, 4mm X 10cm" BOTH IP/OP "$8,157.00 " "$6,036.18" $0.00 "$6,525.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,287.42" $0.00 "$1,699.92" $0.00 $0.00 $0.00 $0.00 "$4,078.50" "$6,460.34" "$6,525.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804125 EAP Custom 27804125 "Coil 400 Complex Soft, 13mm X 35cm" BOTH IP/OP "$7,980.00 " "$5,905.20" $0.00 "$6,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,150.98" $0.00 "$1,663.03" $0.00 $0.00 $0.00 $0.00 "$3,990.00" "$6,320.16" "$6,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804126 EAP Custom 27804126 "Coil 400 Complex Soft, 13mm X 48cm" BOTH IP/OP "$8,364.00 " "$6,189.36" $0.00 "$6,691.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,446.97" $0.00 "$1,743.06" $0.00 $0.00 $0.00 $0.00 "$4,182.00" "$6,624.29" "$6,691.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804127 EAP Custom 27804127 "Coil 400 Complex Soft, 14mm X 40cm" BOTH IP/OP "$8,128.00 " "$6,014.72" $0.00 "$6,502.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,265.06" $0.00 "$1,693.88" $0.00 $0.00 $0.00 $0.00 "$4,064.00" "$6,437.38" "$6,502.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804128 EAP Custom 27804128 "Coil 400 Complex Soft, 14mm X 50cm" BOTH IP/OP "$8,424.00 " "$6,233.76" $0.00 "$6,739.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,493.22" $0.00 "$1,755.56" $0.00 $0.00 $0.00 $0.00 "$4,212.00" "$6,671.81" "$6,739.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804129 EAP Custom 27804129 "Coil 400 Complex Soft, 16mm X 45cm" BOTH IP/OP "$8,276.00 " "$6,124.24" $0.00 "$6,620.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,379.14" $0.00 "$1,724.72" $0.00 $0.00 $0.00 $0.00 "$4,138.00" "$6,554.59" "$6,620.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804130 EAP Custom 27804130 "Coil 400 J, 7cm" BOTH IP/OP "$6,680.00 " "$4,943.20" $0.00 "$5,344.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,148.94" $0.00 "$1,392.11" $0.00 $0.00 $0.00 $0.00 "$3,340.00" "$5,290.56" "$5,344.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804131 EAP Custom 27804131 "Coil 400 J, 10cm" BOTH IP/OP "$7,448.00 " "$5,511.52" $0.00 "$5,958.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,740.92" $0.00 "$1,552.16" $0.00 $0.00 $0.00 $0.00 "$3,724.00" "$5,898.82" "$5,958.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804132 EAP Custom 27804132 "Coil 400 J, 15cm" BOTH IP/OP "$7,743.00 " "$5,729.82" $0.00 "$6,194.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,968.30" $0.00 "$1,613.64" $0.00 $0.00 $0.00 $0.00 "$3,871.50" "$6,132.46" "$6,194.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804133 EAP Custom 27804133 "Coil 400 J, 25cm" BOTH IP/OP "$8,334.00 " "$6,167.16" $0.00 "$6,667.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,423.85" $0.00 "$1,736.81" $0.00 $0.00 $0.00 $0.00 "$4,167.00" "$6,600.53" "$6,667.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804134 EAP Custom 27804134 "Coil 400 Complex Standard, 3 Mm X 6 Cm" BOTH IP/OP "$6,532.00 " "$4,833.68" $0.00 "$5,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,034.87" $0.00 "$1,361.27" $0.00 $0.00 $0.00 $0.00 "$3,266.00" "$5,173.34" "$5,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804135 EAP Custom 27804135 "Coil 400 Complex Standard, 3 Mm X 10 Cm" BOTH IP/OP "$6,651.00 " "$4,921.74" $0.00 "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,126.59" $0.00 "$1,386.07" $0.00 $0.00 $0.00 $0.00 "$3,325.50" "$5,267.59" "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804136 EAP Custom 27804136 "Coil 400 Complex Standard, 4 Mm X 8 Cm" BOTH IP/OP "$6,591.00 " "$4,877.34" $0.00 "$5,272.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,080.34" $0.00 "$1,373.56" $0.00 $0.00 $0.00 $0.00 "$3,295.50" "$5,220.07" "$5,272.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804137 EAP Custom 27804137 "Coil 400 Complex Standard, 4 Mm X 12 Cm" BOTH IP/OP "$6,708.00 " "$4,963.92" $0.00 "$5,366.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,170.53" $0.00 "$1,397.95" $0.00 $0.00 $0.00 $0.00 "$3,354.00" "$5,312.74" "$5,366.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804138 EAP Custom 27804138 "Coil 400 Complex Standard, 5 Mm X 6 Cm" BOTH IP/OP "$6,532.00 " "$4,833.68" $0.00 "$5,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,034.87" $0.00 "$1,361.27" $0.00 $0.00 $0.00 $0.00 "$3,266.00" "$5,173.34" "$5,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804139 EAP Custom 27804139 "Coil 400 Complex Standard, 5mm X 10cm" BOTH IP/OP "$6,651.00 " "$4,921.74" $0.00 "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,126.59" $0.00 "$1,386.07" $0.00 $0.00 $0.00 $0.00 "$3,325.50" "$5,267.59" "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804140 EAP Custom 27804140 "Coil 400 Complex Standard, 6mm X 10cm" BOTH IP/OP "$6,651.00 " "$4,921.74" $0.00 "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,126.59" $0.00 "$1,386.07" $0.00 $0.00 $0.00 $0.00 "$3,325.50" "$5,267.59" "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804141 EAP Custom 27804141 "Coil 400 Complex Standard, 6mm X 15cm" BOTH IP/OP "$6,798.00 " "$5,030.52" $0.00 "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,239.90" $0.00 "$1,416.70" $0.00 $0.00 $0.00 $0.00 "$3,399.00" "$5,384.02" "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804142 EAP Custom 27804142 "Coil 400 Complex Standard, 7mm X 10cm" BOTH IP/OP "$6,651.00 " "$4,921.74" $0.00 "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,126.59" $0.00 "$1,386.07" $0.00 $0.00 $0.00 $0.00 "$3,325.50" "$5,267.59" "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804143 EAP Custom 27804143 "Coil 400 Complex Soft, 3 Mm X 4 Cm" BOTH IP/OP "$7,063.00 " "$5,226.62" $0.00 "$5,650.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,444.16" $0.00 "$1,471.93" $0.00 $0.00 $0.00 $0.00 "$3,531.50" "$5,593.90" "$5,650.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804144 EAP Custom 27804144 "Coil 400 Complex Soft, 3 Mm X 6 Cm" BOTH IP/OP "$7,123.00 " "$5,271.02" $0.00 "$5,698.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,490.41" $0.00 "$1,484.43" $0.00 $0.00 $0.00 $0.00 "$3,561.50" "$5,641.42" "$5,698.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804145 EAP Custom 27804145 "Coil 400 Complex Soft, 3 Mm X 10 Cm" BOTH IP/OP "$7,241.00 " "$5,358.34" $0.00 "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,581.36" $0.00 "$1,509.02" $0.00 $0.00 $0.00 $0.00 "$3,620.50" "$5,734.87" "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804146 EAP Custom 27804146 "Coil 400 Complex Soft, 4 Mm X 4 Cm" BOTH IP/OP "$7,063.00 " "$5,226.62" $0.00 "$5,650.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,444.16" $0.00 "$1,471.93" $0.00 $0.00 $0.00 $0.00 "$3,531.50" "$5,593.90" "$5,650.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804147 EAP Custom 27804147 "Coil 400 Complex Soft, 4 Mm X 6 Cm" BOTH IP/OP "$7,123.00 " "$5,271.02" $0.00 "$5,698.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,490.41" $0.00 "$1,484.43" $0.00 $0.00 $0.00 $0.00 "$3,561.50" "$5,641.42" "$5,698.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804148 EAP Custom 27804148 "Coil 400 Complex Soft, 4 Mm X 8 Cm" BOTH IP/OP "$7,182.00 " "$5,314.68" $0.00 "$5,745.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,535.89" $0.00 "$1,496.73" $0.00 $0.00 $0.00 $0.00 "$3,591.00" "$5,688.14" "$5,745.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804149 EAP Custom 27804149 "Coil 400 Complex Soft, 4 Mm X 12 Cm" BOTH IP/OP "$7,300.00 " "$5,402.00" $0.00 "$5,840.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,626.84" $0.00 "$1,521.32" $0.00 $0.00 $0.00 $0.00 "$3,650.00" "$5,781.60" "$5,840.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804150 EAP Custom 27804150 "Coil 400 Complex Soft, 5mm X 9cm" BOTH IP/OP "$7,211.00 " "$5,336.14" $0.00 "$5,768.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,558.24" $0.00 "$1,502.77" $0.00 $0.00 $0.00 $0.00 "$3,605.50" "$5,711.11" "$5,768.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804151 EAP Custom 27804151 "Coil 400 Complex Soft, 5mm X 13cm" BOTH IP/OP "$7,331.00 " "$5,424.94" $0.00 "$5,864.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,650.73" $0.00 "$1,527.78" $0.00 $0.00 $0.00 $0.00 "$3,665.50" "$5,806.15" "$5,864.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804152 EAP Custom 27804152 "Coil 400 Complex Standard, 10mm X 30cm" BOTH IP/OP "$7,241.00 " "$5,358.34" $0.00 "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,581.36" $0.00 "$1,509.02" $0.00 $0.00 $0.00 $0.00 "$3,620.50" "$5,734.87" "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804153 EAP Custom 27804153 "Coil 400 Complex Standard, 10mm X 40cm" BOTH IP/OP "$7,389.00 " "$5,467.86" $0.00 "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,695.44" $0.00 "$1,539.87" $0.00 $0.00 $0.00 $0.00 "$3,694.50" "$5,852.09" "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804154 EAP Custom 27804154 "Coil 400 Complex Standard, 11mm X 35cm" BOTH IP/OP "$7,316.00 " "$5,413.84" $0.00 "$5,852.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,639.17" $0.00 "$1,524.65" $0.00 $0.00 $0.00 $0.00 "$3,658.00" "$5,794.27" "$5,852.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804155 EAP Custom 27804155 "Coil 400 Complex Standard, 11mm X 45cm" BOTH IP/OP "$7,464.00 " "$5,523.36" $0.00 "$5,971.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,753.25" $0.00 "$1,555.50" $0.00 $0.00 $0.00 $0.00 "$3,732.00" "$5,911.49" "$5,971.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804156 EAP Custom 27804156 "Coil 400 Complex Standard, 12mm X 35cm" BOTH IP/OP "$7,316.00 " "$5,413.84" $0.00 "$5,852.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,639.17" $0.00 "$1,524.65" $0.00 $0.00 $0.00 $0.00 "$3,658.00" "$5,794.27" "$5,852.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804157 EAP Custom 27804157 "Coil 400 Complex Standard, 12mm X 45cm" BOTH IP/OP "$7,464.00 " "$5,523.36" $0.00 "$5,971.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,753.25" $0.00 "$1,555.50" $0.00 $0.00 $0.00 $0.00 "$3,732.00" "$5,911.49" "$5,971.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804158 EAP Custom 27804158 "Coil 400 Complex Standard, 13mm X 35cm" BOTH IP/OP "$7,316.00 " "$5,413.84" $0.00 "$5,852.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,639.17" $0.00 "$1,524.65" $0.00 $0.00 $0.00 $0.00 "$3,658.00" "$5,794.27" "$5,852.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804159 EAP Custom 27804159 "Coil 400 Complex Standard, 13mm X 48cm" BOTH IP/OP "$7,507.00 " "$5,555.18" $0.00 "$6,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,786.40" $0.00 "$1,564.46" $0.00 $0.00 $0.00 $0.00 "$3,753.50" "$5,945.54" "$6,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804160 EAP Custom 27804160 "Coil 400 Complex Standard, 14mm X 50cm" BOTH IP/OP "$7,537.00 " "$5,577.38" $0.00 "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,809.52" $0.00 "$1,570.71" $0.00 $0.00 $0.00 $0.00 "$3,768.50" "$5,969.30" "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804161 EAP Custom 27804161 "Coil 400 Complex Soft, 6mm X 10cm" BOTH IP/OP "$7,241.00 " "$5,358.34" $0.00 "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,581.36" $0.00 "$1,509.02" $0.00 $0.00 $0.00 $0.00 "$3,620.50" "$5,734.87" "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804162 EAP Custom 27804162 "Coil 400 Complex Soft, 6mm X 15cm" BOTH IP/OP "$7,389.00 " "$5,467.86" $0.00 "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,695.44" $0.00 "$1,539.87" $0.00 $0.00 $0.00 $0.00 "$3,694.50" "$5,852.09" "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804163 EAP Custom 27804163 "Coil 400 Complex Soft, 6mm X 20cm" BOTH IP/OP "$7,537.00 " "$5,577.38" $0.00 "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,809.52" $0.00 "$1,570.71" $0.00 $0.00 $0.00 $0.00 "$3,768.50" "$5,969.30" "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804164 EAP Custom 27804164 "Coil 400 Complex Soft, 7 Mm X 10 Cm" BOTH IP/OP "$7,241.00 " "$5,358.34" $0.00 "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,581.36" $0.00 "$1,509.02" $0.00 $0.00 $0.00 $0.00 "$3,620.50" "$5,734.87" "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804165 EAP Custom 27804165 "Coil 400 Complex Soft, 7mm X 15cm" BOTH IP/OP "$7,389.00 " "$5,467.86" $0.00 "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,695.44" $0.00 "$1,539.87" $0.00 $0.00 $0.00 $0.00 "$3,694.50" "$5,852.09" "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804166 EAP Custom 27804166 "Coil 400 Complex Soft, 7mm X 20cm" BOTH IP/OP "$7,537.00 " "$5,577.38" $0.00 "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,809.52" $0.00 "$1,570.71" $0.00 $0.00 $0.00 $0.00 "$3,768.50" "$5,969.30" "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804167 EAP Custom 27804167 "Coil 400 Complex Soft, 8mm X 15cm" BOTH IP/OP "$7,389.00 " "$5,467.86" $0.00 "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,695.44" $0.00 "$1,539.87" $0.00 $0.00 $0.00 $0.00 "$3,694.50" "$5,852.09" "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804168 EAP Custom 27804168 "Coil 400 Complex Soft, 8mm X 20cm" BOTH IP/OP "$7,389.00 " "$5,467.86" $0.00 "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,695.44" $0.00 "$1,539.87" $0.00 $0.00 $0.00 $0.00 "$3,694.50" "$5,852.09" "$5,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804169 EAP Custom 27804169 "Coil 400 Complex Soft, 8mm X 30cm" BOTH IP/OP "$7,832.00 " "$5,795.68" $0.00 "$6,265.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,036.91" $0.00 "$1,632.19" $0.00 $0.00 $0.00 $0.00 "$3,916.00" "$6,202.94" "$6,265.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804170 EAP Custom 27804170 "Coil 400 Curve Extra Soft, 3mm X 8cm" BOTH IP/OP "$7,241.00 " "$5,358.34" $0.00 "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,581.36" $0.00 "$1,509.02" $0.00 $0.00 $0.00 $0.00 "$3,620.50" "$5,734.87" "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804171 EAP Custom 27804171 "Coil 400 Curve Extra Soft, 3mm X 10cm" BOTH IP/OP "$7,699.00 " "$5,697.26" $0.00 "$6,159.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,934.39" $0.00 "$1,604.47" $0.00 $0.00 $0.00 $0.00 "$3,849.50" "$6,097.61" "$6,159.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804172 EAP Custom 27804172 "Coil 400 Curve Extra Soft, 4mm X 4cm" BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,624.80" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804173 EAP Custom 27804173 "Coil 400 Curve Extra Soft, 4mm X 6cm" BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,624.80" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804174 EAP Custom 27804174 "Coil 400 Curve Extra Soft, 4mm X 8cm" BOTH IP/OP "$7,241.00 " "$5,358.34" $0.00 "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,581.36" $0.00 "$1,509.02" $0.00 $0.00 $0.00 $0.00 "$3,620.50" "$5,734.87" "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804175 EAP Custom 27804175 "Coil 400 Curve Extra Soft, 4mm X 10cm" BOTH IP/OP "$7,699.00 " "$5,697.26" $0.00 "$6,159.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,934.39" $0.00 "$1,604.47" $0.00 $0.00 $0.00 $0.00 "$3,849.50" "$6,097.61" "$6,159.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804176 EAP Custom 27804176 "Coil 400 Complex Extra Soft, 2mm X 2cm" BOTH IP/OP "$5,674.00 " "$4,198.76" $0.00 "$4,539.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,373.52" $0.00 "$1,182.46" $0.00 $0.00 $0.00 $0.00 "$2,837.00" "$4,493.81" "$4,539.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804177 EAP Custom 27804177 "Coil 400 Complex Extra Soft, 2mm X 3cm" BOTH IP/OP "$5,986.00 " "$4,429.64" $0.00 "$4,788.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,614.01" $0.00 "$1,247.48" $0.00 $0.00 $0.00 $0.00 "$2,993.00" "$4,740.91" "$4,788.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804178 EAP Custom 27804178 "Coil 400 Complex Extra Soft, 2mm X 4cm" BOTH IP/OP "$6,296.00 " "$4,659.04" $0.00 "$5,036.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,852.96" $0.00 "$1,312.09" $0.00 $0.00 $0.00 $0.00 "$3,148.00" "$4,986.43" "$5,036.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804179 EAP Custom 27804179 "Coil 400 Complex Soft, 9mm X 25cm" BOTH IP/OP "$7,685.00 " "$5,686.90" $0.00 "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,923.60" $0.00 "$1,601.55" $0.00 $0.00 $0.00 $0.00 "$3,842.50" "$6,086.52" "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804180 EAP Custom 27804180 "Coil 400 Complex Soft, 9mm X 35cm" BOTH IP/OP "$7,980.00 " "$5,905.20" $0.00 "$6,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,150.98" $0.00 "$1,663.03" $0.00 $0.00 $0.00 $0.00 "$3,990.00" "$6,320.16" "$6,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804181 EAP Custom 27804181 "Coil 400 Complex Soft, 10mm X 20cm" BOTH IP/OP "$7,537.00 " "$5,577.38" $0.00 "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,809.52" $0.00 "$1,570.71" $0.00 $0.00 $0.00 $0.00 "$3,768.50" "$5,969.30" "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804182 EAP Custom 27804182 "Coil 400 Complex Soft, 10mm X 30cm" BOTH IP/OP "$7,832.00 " "$5,795.68" $0.00 "$6,265.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,036.91" $0.00 "$1,632.19" $0.00 $0.00 $0.00 $0.00 "$3,916.00" "$6,202.94" "$6,265.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804183 EAP Custom 27804183 "Coil 400 Complex Soft, 10mm X 40cm" BOTH IP/OP "$8,128.00 " "$6,014.72" $0.00 "$6,502.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,265.06" $0.00 "$1,693.88" $0.00 $0.00 $0.00 $0.00 "$4,064.00" "$6,437.38" "$6,502.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804184 EAP Custom 27804184 "Coil 400 Complex Soft, 11mm X 35cm" BOTH IP/OP "$7,980.00 " "$5,905.20" $0.00 "$6,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,150.98" $0.00 "$1,663.03" $0.00 $0.00 $0.00 $0.00 "$3,990.00" "$6,320.16" "$6,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804185 EAP Custom 27804185 "Coil 400 Complex Soft, 11mm X 45cm" BOTH IP/OP "$8,276.00 " "$6,124.24" $0.00 "$6,620.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,379.14" $0.00 "$1,724.72" $0.00 $0.00 $0.00 $0.00 "$4,138.00" "$6,554.59" "$6,620.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804186 EAP Custom 27804186 "Coil 400 Complex Soft, 12mm X 35cm" BOTH IP/OP "$7,980.00 " "$5,905.20" $0.00 "$6,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,150.98" $0.00 "$1,663.03" $0.00 $0.00 $0.00 $0.00 "$3,990.00" "$6,320.16" "$6,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804187 EAP Custom 27804187 "Coil 400 Complex Soft, 12mm X 45cm" BOTH IP/OP "$8,276.00 " "$6,124.24" $0.00 "$6,620.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,379.14" $0.00 "$1,724.72" $0.00 $0.00 $0.00 $0.00 "$4,138.00" "$6,554.59" "$6,620.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804188 EAP Custom 27804188 "Coil 400 Curve Extra Soft, 2mm X 1cm" BOTH IP/OP "$5,070.00 " "$3,751.80" $0.00 "$4,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,762.95" "$3,762.95" "$3,907.96" $0.00 "$1,056.59" $0.00 $0.00 $0.00 $0.00 "$2,535.00" "$4,015.44" "$4,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804189 EAP Custom 27804189 "Coil 400 Curve Extra Soft, 2mm X 2cm" BOTH IP/OP "$5,379.00 " "$3,980.46" $0.00 "$4,303.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,992.29" "$3,992.29" "$4,146.13" $0.00 "$1,120.98" $0.00 $0.00 $0.00 $0.00 "$2,689.50" "$4,260.17" "$4,303.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804190 EAP Custom 27804190 "Coil 400 Curve Extra Soft, 2mm X 3cm" BOTH IP/OP "$5,690.00 " "$4,210.60" $0.00 "$4,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,385.85" $0.00 "$1,185.80" $0.00 $0.00 $0.00 $0.00 "$2,845.00" "$4,506.48" "$4,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804191 EAP Custom 27804191 "Coil 400 Curve Extra Soft, 2mm X 4cm" BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,624.80" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804192 EAP Custom 27804192 "Coil 400 Curve Extra Soft, 3mm X 2cm" BOTH IP/OP "$5,379.00 " "$3,980.46" $0.00 "$4,303.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,992.29" "$3,992.29" "$4,146.13" $0.00 "$1,120.98" $0.00 $0.00 $0.00 $0.00 "$2,689.50" "$4,260.17" "$4,303.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804193 EAP Custom 27804193 "Coil 400 Curve Extra Soft, 3mm X 3cm" BOTH IP/OP "$5,690.00 " "$4,210.60" $0.00 "$4,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,385.85" $0.00 "$1,185.80" $0.00 $0.00 $0.00 $0.00 "$2,845.00" "$4,506.48" "$4,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804194 EAP Custom 27804194 "Coil 400 Curve Extra Soft, 3mm X 4cm" BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,624.80" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804195 EAP Custom 27804195 "Coil 400 Curve Extra Soft, 3mm X 5cm" BOTH IP/OP "$6,310.00 " "$4,669.40" $0.00 "$5,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,863.75" $0.00 "$1,315.00" $0.00 $0.00 $0.00 $0.00 "$3,155.00" "$4,997.52" "$5,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804196 EAP Custom 27804196 "Coil 400 Curve Extra Soft, 3mm X 6cm" BOTH IP/OP "$6,620.00 " "$4,898.80" $0.00 "$5,296.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,102.70" $0.00 "$1,379.61" $0.00 $0.00 $0.00 $0.00 "$3,310.00" "$5,243.04" "$5,296.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804197 EAP Custom 27804197 "Coil 400 Complex Extra Soft, 3mm X 3cm" BOTH IP/OP "$5,986.00 " "$4,429.64" $0.00 "$4,788.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,614.01" $0.00 "$1,247.48" $0.00 $0.00 $0.00 $0.00 "$2,993.00" "$4,740.91" "$4,788.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804198 EAP Custom 27804198 "Coil 400 Complex Extra Soft, 3mm X 4cm" BOTH IP/OP "$6,296.00 " "$4,659.04" $0.00 "$5,036.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,852.96" $0.00 "$1,312.09" $0.00 $0.00 $0.00 $0.00 "$3,148.00" "$4,986.43" "$5,036.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804199 EAP Custom 27804199 "Coil 400 Complex Extra Soft, 3mm X 5cm" BOTH IP/OP "$6,606.00 " "$4,888.44" $0.00 "$5,284.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,091.90" $0.00 "$1,376.69" $0.00 $0.00 $0.00 $0.00 "$3,303.00" "$5,231.95" "$5,284.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804200 EAP Custom 27804200 "Coil 400 Complex Extra Soft, 3mm X 6cm" BOTH IP/OP "$6,916.00 " "$5,117.84" $0.00 "$5,532.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,330.85" $0.00 "$1,441.29" $0.00 $0.00 $0.00 $0.00 "$3,458.00" "$5,477.47" "$5,532.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804201 EAP Custom 27804201 "Coil 400 Complex Extra Soft, 3mm X 8cm" BOTH IP/OP "$7,537.00 " "$5,577.38" $0.00 "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,809.52" $0.00 "$1,570.71" $0.00 $0.00 $0.00 $0.00 "$3,768.50" "$5,969.30" "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804202 EAP Custom 27804202 "Coil 400 Complex Extra Soft, 3mm X 10cm" BOTH IP/OP "$8,157.00 " "$6,036.18" $0.00 "$6,525.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,287.42" $0.00 "$1,699.92" $0.00 $0.00 $0.00 $0.00 "$4,078.50" "$6,460.34" "$6,525.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804203 EAP Custom 27804203 "Coil 400 Complex Extra Soft, 4mm X 4cm" BOTH IP/OP "$6,296.00 " "$4,659.04" $0.00 "$5,036.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,852.96" $0.00 "$1,312.09" $0.00 $0.00 $0.00 $0.00 "$3,148.00" "$4,986.43" "$5,036.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804204 EAP Custom 27804204 "Coil 400 Complex Extra Soft, 4mm X 6cm" BOTH IP/OP "$6,916.00 " "$5,117.84" $0.00 "$5,532.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,330.85" $0.00 "$1,441.29" $0.00 $0.00 $0.00 $0.00 "$3,458.00" "$5,477.47" "$5,532.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804205 EAP Custom 27804205 "Coil 400 Complex Extra Soft, 4mm X 8cm" BOTH IP/OP "$7,537.00 " "$5,577.38" $0.00 "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,809.52" $0.00 "$1,570.71" $0.00 $0.00 $0.00 $0.00 "$3,768.50" "$5,969.30" "$6,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804206 EAP Custom 27804206 "Coil 400 Complex Standard, 7 Mm X 15 Cm" BOTH IP/OP "$6,798.00 " "$5,030.52" $0.00 "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,239.90" $0.00 "$1,416.70" $0.00 $0.00 $0.00 $0.00 "$3,399.00" "$5,384.02" "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804207 EAP Custom 27804207 "Coil 400 Complex Standard, 7mm X 20cm" BOTH IP/OP "$6,946.00 " "$5,140.04" $0.00 "$5,556.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,353.98" $0.00 "$1,447.55" $0.00 $0.00 $0.00 $0.00 "$3,473.00" "$5,501.23" "$5,556.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804208 EAP Custom 27804208 "Coil 400 Complex Standard, 8 Mm X 15 Cm" BOTH IP/OP "$6,798.00 " "$5,030.52" $0.00 "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,239.90" $0.00 "$1,416.70" $0.00 $0.00 $0.00 $0.00 "$3,399.00" "$5,384.02" "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804209 EAP Custom 27804209 "Coil 400 Complex Standard, 8mm X 20cm" BOTH IP/OP "$6,798.00 " "$5,030.52" $0.00 "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,239.90" $0.00 "$1,416.70" $0.00 $0.00 $0.00 $0.00 "$3,399.00" "$5,384.02" "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804210 EAP Custom 27804210 "Coil 400 Complex Standard, 8mm X 30cm" BOTH IP/OP "$7,241.00 " "$5,358.34" $0.00 "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,581.36" $0.00 "$1,509.02" $0.00 $0.00 $0.00 $0.00 "$3,620.50" "$5,734.87" "$5,792.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804211 EAP Custom 27804211 "Coil 400 Complex Standard, 9 Mm X 15 Cm" BOTH IP/OP "$6,798.00 " "$5,030.52" $0.00 "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,239.90" $0.00 "$1,416.70" $0.00 $0.00 $0.00 $0.00 "$3,399.00" "$5,384.02" "$5,438.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804212 EAP Custom 27804212 "Coil 400 Complex Standard, 9mm X 25cm" BOTH IP/OP "$7,094.00 " "$5,249.56" $0.00 "$5,675.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,468.06" $0.00 "$1,478.39" $0.00 $0.00 $0.00 $0.00 "$3,547.00" "$5,618.45" "$5,675.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804213 EAP Custom 27804213 "Coil 400 Complex Standard, 9mm X 35cm" BOTH IP/OP "$7,300.00 " "$5,402.00" $0.00 "$5,840.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,626.84" $0.00 "$1,521.32" $0.00 $0.00 $0.00 $0.00 "$3,650.00" "$5,781.60" "$5,840.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804214 EAP Custom 27804214 "Coil 400 Complex Standard, 10 Mm X 20 Cm" BOTH IP/OP "$6,946.00 " "$5,140.04" $0.00 "$5,556.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,353.98" $0.00 "$1,447.55" $0.00 $0.00 $0.00 $0.00 "$3,473.00" "$5,501.23" "$5,556.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804250 EAP HCPCS C1751 Catheter Central Venous Pro-fuse Triniflex Od8 Fr Attace BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $265.95 $265.95 $0.00 $0.00 $0.00 $123.18 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $349.58 $349.58 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $92.49 $0.00 $0.00 $94.09 $0.00 $0.00 $0.00 $0.00 $0.00 27804251 EAP CPT® C1751 Catheter Powerglide 20 G 8 Cm Full Kit BOTH IP/OP $356.00 $263.44 $0.00 $284.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.00 $281.95 $284.80 $0.00 $0.00 $0.00 $55.71 $0.00 $0.00 $56.68 $0.00 $0.00 $0.00 $0.00 $0.00 27804252 EAP CPT® C1751 Catheter Powerglide 20 G 10 Cm Full Kit BOTH IP/OP $356.00 $263.44 $0.00 $284.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.00 $281.95 $284.80 $0.00 $0.00 $0.00 $55.71 $0.00 $0.00 $56.68 $0.00 $0.00 $0.00 $0.00 $0.00 27804254 EAP HCPCS C1713 Screw Bone Mini Long Post 7.5mm 55mm Polyax Mpa Ts BOTH IP/OP "$1,550.00 " "$1,147.00" $0.00 "$1,240.00" $697.50 $697.50 $0.00 $0.00 $0.00 $323.06 "$1,150.41" "$1,150.41" "$1,194.74" $0.00 $323.02 $0.00 $916.83 $916.83 $0.00 $775.00 "$1,227.60" "$1,240.00" $0.00 $0.00 $0.00 $242.58 $0.00 $0.00 $246.76 $0.00 $0.00 $0.00 $0.00 $0.00 27804260 EAP HCPCS C1722 Defibrillator Crd 12.7mm 83.1x69.1mm Eblm Pls BOTH IP/OP "$53,750.00 " "$39,775.00" $0.00 "$43,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,875.00" "$42,570.00" "$43,000.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27804261 EAP HCPCS C1896 Electrode Dfbr 45cm 3 Plr S-icd Coil Conctr Pin BOTH IP/OP "$12,500.00 " "$9,250.00" $0.00 "$10,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,605.31" "$4,181.12" "$4,181.12" "$9,635.00" $0.00 "$2,605.00" $0.00 "$6,162.50" "$6,162.50" $0.00 "$6,250.00" "$9,900.00" "$10,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804870 EAP HCPCS C1760 Device Closure .035in 6fr 70cm Valuelink Gwire Insertion BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 27804871 EAP Custom 27804871 Coil Embolization .02in Complex 11mm 35cm Soft The Penumbra BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 $0.00 $0.00 $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804872 EAP Custom 27804872 Coil Embolization .02in Complex 5mm 13cm Soft The Penumbra BOTH IP/OP "$6,108.00 " "$4,519.92" $0.00 "$4,886.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,708.05" $0.00 "$1,272.91" $0.00 $0.00 $0.00 $0.00 "$3,054.00" "$4,837.54" "$4,886.40" $0.00 "$2,748.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804880 EAP Custom 27804880 Coil Embolization .02in Complex 6mm 15cm Soft The Penumbra BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,817.50" $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 "$2,812.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804881 EAP Custom 27804881 Coil Embolization .02in Complex 7mm 20cm Soft The Penumbra BOTH IP/OP "$6,375.00 " "$4,717.50" $0.00 "$5,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,913.85" $0.00 "$1,328.55" $0.00 $0.00 $0.00 $0.00 "$3,187.50" "$5,049.00" "$5,100.00" $0.00 "$2,868.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804882 EAP Custom 27804882 Coil Embolization .02in Complex 8mm 20cm Soft The Penumbra BOTH IP/OP "$6,375.00 " "$4,717.50" $0.00 "$5,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,913.85" $0.00 "$1,328.55" $0.00 $0.00 $0.00 $0.00 "$3,187.50" "$5,049.00" "$5,100.00" $0.00 "$2,868.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804883 EAP Custom 27804883 Coil Embolization .02in Complex 9mm 25cm Soft The Penumbra BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,010.20" $0.00 "$1,354.60" $0.00 $0.00 $0.00 $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 "$2,925.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804884 EAP Custom 27804884 Coil Embolization .02in Standard Complex 11mm 35cm Complex BOTH IP/OP "$6,188.00 " "$4,579.12" $0.00 "$4,950.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,769.71" $0.00 "$1,289.58" $0.00 $0.00 $0.00 $0.00 "$3,094.00" "$4,900.90" "$4,950.40" $0.00 "$2,784.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804885 EAP Custom 27804885 Coil Embolization .02in Standard Complex 6mm 15cm Complex BOTH IP/OP "$5,175.00 " "$3,829.50" $0.00 "$4,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,840.89" "$3,840.89" "$3,988.89" $0.00 "$1,078.47" $0.00 $0.00 $0.00 $0.00 "$2,587.50" "$4,098.60" "$4,140.00" $0.00 "$3,363.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27804886 EAP Custom 27804886 Coil Embolization .02in Standard Complex 7mm 20cm Complex BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,528.45" $0.00 "$1,224.35" $0.00 $0.00 $0.00 $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805011 EAP Custom 27805011 20 FR SAFETY PEG KIT PULL BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $63.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805012 EAP Custom 27805012 24 FR SAFETY PEG KIT PULL BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $71.00 $112.46 $113.60 $0.00 $63.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805013 EAP Custom 27805013 "18 FR Replacement G-Tube, Right An 18" BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.17 $31.17 $32.37 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $21.00 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805014 EAP Custom 27805014 "20 FR REPLACEMENT G-TUBE, RIGHT-AN 20" BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805015 EAP Custom 27805015 "22 FR REPLACEMENT G-TUBE, RIGHT-AN" BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805016 EAP HCPCS C2625 Rx Stent 7x7cm BOTH IP/OP $133.00 $98.42 $0.00 $106.40 $59.85 $59.85 $0.00 $0.00 $0.00 $27.72 $98.71 $98.71 $102.52 $0.00 $27.72 $0.00 $78.67 $78.67 $0.00 $66.50 $105.34 $106.40 $0.00 $0.00 $0.00 $20.81 $0.00 $0.00 $21.17 $0.00 $0.00 $0.00 $0.00 $0.00 27805017 EAP HCPCS C2625 Rx Stent 7x10cm BOTH IP/OP $133.00 $98.42 $0.00 $106.40 $59.85 $59.85 $0.00 $0.00 $0.00 $27.72 $98.71 $98.71 $102.52 $0.00 $27.72 $0.00 $78.67 $78.67 $0.00 $66.50 $105.34 $106.40 $0.00 $0.00 $0.00 $20.81 $0.00 $0.00 $21.17 $0.00 $0.00 $0.00 $0.00 $0.00 27805018 EAP HCPCS C2625 Rx Stent 10x5cm BOTH IP/OP $133.00 $98.42 $0.00 $106.40 $59.85 $59.85 $0.00 $0.00 $0.00 $27.72 $98.71 $98.71 $102.52 $0.00 $27.72 $0.00 $78.67 $78.67 $0.00 $66.50 $105.34 $106.40 $0.00 $0.00 $0.00 $20.81 $0.00 $0.00 $21.17 $0.00 $0.00 $0.00 $0.00 $0.00 27805019 EAP HCPCS C2625 Rx Stent 10x10cm BOTH IP/OP $133.00 $98.42 $0.00 $106.40 $59.85 $59.85 $0.00 $0.00 $0.00 $27.72 $98.71 $98.71 $102.52 $0.00 $27.72 $0.00 $78.67 $78.67 $0.00 $66.50 $105.34 $106.40 $0.00 $0.00 $0.00 $20.81 $0.00 $0.00 $21.17 $0.00 $0.00 $0.00 $0.00 $0.00 27805020 EAP Custom 27805020 Pill Cam Capsule BOTH IP/OP $532.00 $393.68 $0.00 $425.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $394.85 $394.85 $410.07 $0.00 $110.87 $0.00 $0.00 $0.00 $0.00 $266.00 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HCPCS C1751 Cath Infus .038in 5fr 100cm 10cm Peri Vlv Crgg-mcnam BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805048 EAP HCPCS C1874 Xience Xpedition Sv Des 2.25 Mm X 8 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805049 EAP HCPCS C1874 Xience Xpedition Sv Des 2.25 Mm X 12 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 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"$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805056 EAP HCPCS C1874 Xience Xpedition Des 2.50 Mm X 15 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805057 EAP HCPCS C1874 Xience Xpedition Des 2.50 Mm X 18 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805058 EAP HCPCS C1874 Xience Xpedition Des 2.50 Mm X 23 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805059 EAP HCPCS C1874 Xience Xpedition Des 2.50 Mm X 28 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805060 EAP HCPCS C1874 Xience Xpedition Ll Des 2.50 Mm X 33 Mm BOTH IP/OP "$6,429.00 " "$4,757.46" $0.00 "$5,143.20" "$2,893.05" "$2,893.05" $0.00 $0.00 $0.00 "$1,339.96" "$4,181.12" "$4,181.12" "$4,955.47" 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"$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805064 EAP HCPCS C1874 Xience Xpedition Des 2.75 Mm X 15 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805065 EAP HCPCS C1874 Xience Xpedition Des 2.75 Mm X 18 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805066 EAP HCPCS C1874 Xience Xpedition Des 2.75 Mm X 23 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805067 EAP HCPCS C1874 Xience Xpedition Des 2.75 Mm X 28 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805068 EAP HCPCS C1874 Xience Xpedition Ll Des 2.75 Mm X 33 Mm BOTH IP/OP "$6,429.00 " "$4,757.46" $0.00 "$5,143.20" "$2,893.05" "$2,893.05" $0.00 $0.00 $0.00 "$1,339.96" "$4,181.12" "$4,181.12" "$4,955.47" 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"$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805072 EAP HCPCS C1874 Xience Xpedition Des 3.00 Mm X 15 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805073 EAP HCPCS C1874 Xience Xpedition Des 3.00 Mm X 18 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805074 EAP HCPCS C1874 Xience Xpedition Des 3.00 Mm X 23 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805075 EAP HCPCS C1874 Xience Xpedition Des 3.00 Mm X 28 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805076 EAP HCPCS C1874 Xience Xpedition Ll Des 3.00 Mm X 33 Mm BOTH IP/OP "$6,429.00 " "$4,757.46" $0.00 "$5,143.20" "$2,893.05" "$2,893.05" $0.00 $0.00 $0.00 "$1,339.96" "$4,181.12" "$4,181.12" "$4,955.47" 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"$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805080 EAP HCPCS C1874 Xience Xpedition Des 3.25 Mm X 15 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805081 EAP HCPCS C1874 Xience Xpedition Des 3.25 Mm X 18 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805082 EAP HCPCS C1874 Xience Xpedition Des 3.25 Mm X 23 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805083 EAP HCPCS C1874 Xience Xpedition Des 3.25 Mm X 28 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805084 EAP HCPCS C1874 Xience Xpedition Ll Des 3.25 Mm X 33 Mm BOTH IP/OP "$6,429.00 " "$4,757.46" $0.00 "$5,143.20" "$2,893.05" "$2,893.05" $0.00 $0.00 $0.00 "$1,339.96" "$4,181.12" "$4,181.12" "$4,955.47" 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"$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805088 EAP HCPCS C1874 Xience Xpedition Des 3.50 Mm X 15 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805089 EAP HCPCS C1874 Xience Xpedition Des 3.50 Mm X 18 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 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Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805096 EAP HCPCS C1874 Xience Xpedition Des 4.00 Mm X 15 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 "$2,793.60" $0.00 $971.55 $0.00 $0.00 $988.31 $0.00 $0.00 $0.00 $0.00 $0.00 27805097 EAP HCPCS C1874 Xience Xpedition Des 4.00 Mm X 18 Mm BOTH IP/OP "$6,208.00 " "$4,593.92" $0.00 "$4,966.40" "$2,793.60" "$2,793.60" $0.00 $0.00 $0.00 "$1,293.90" "$4,181.12" "$4,181.12" "$4,785.13" $0.00 "$1,293.75" $0.00 "$3,060.54" "$3,060.54" $0.00 "$3,104.00" "$4,916.74" "$4,966.40" $0.00 $0.00 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$0.00 "$8,623.18" $0.00 $0.00 $0.00 $0.00 "$20,689.00" "$32,771.38" "$33,102.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805102 EAP HCPCS C1874 Xience Xpedition Ll Des 4.00 Mm X 33 Mm BOTH IP/OP "$6,429.00 " "$4,757.46" $0.00 "$5,143.20" "$2,893.05" "$2,893.05" $0.00 $0.00 $0.00 "$1,339.96" "$4,181.12" "$4,181.12" "$4,955.47" $0.00 "$1,339.80" $0.00 "$3,169.50" "$3,169.50" $0.00 "$3,214.50" "$5,091.77" "$5,143.20" $0.00 $0.00 $0.00 "$1,006.14" $0.00 $0.00 "$1,023.50" $0.00 $0.00 $0.00 $0.00 $0.00 27805103 EAP HCPCS C1874 Xience Xpedition Ll Des 4.00 Mm X 38 Mm BOTH IP/OP "$6,429.00 " "$4,757.46" $0.00 "$5,143.20" "$2,893.05" "$2,893.05" $0.00 $0.00 $0.00 "$1,339.96" "$4,181.12" "$4,181.12" "$4,955.47" $0.00 "$1,339.80" $0.00 "$3,169.50" "$3,169.50" $0.00 "$3,214.50" "$5,091.77" "$5,143.20" $0.00 $0.00 $0.00 "$1,006.14" $0.00 $0.00 "$1,023.50" $0.00 $0.00 $0.00 $0.00 $0.00 27805104 EAP Custom 27805104 Coil Embl 4.1cm 5-3mm Trnd .035in Std Sm Pltn Arterioves BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.94 $195.94 $203.49 $0.00 $55.02 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805106 EAP HCPCS C1876 Se Biliary Stent 6mmx40mmx120cm BOTH IP/OP "$4,138.00 " "$3,062.12" $0.00 "$3,310.40" "$1,862.10" "$1,862.10" $0.00 $0.00 $0.00 $862.46 "$3,071.22" "$3,071.22" "$3,189.57" $0.00 $862.36 $0.00 "$2,040.03" "$2,040.03" $0.00 "$2,069.00" "$3,277.30" "$3,310.40" $0.00 $0.00 $0.00 $647.60 $0.00 $0.00 $658.77 $0.00 $0.00 $0.00 $0.00 $0.00 27805107 EAP HCPCS C1876 Se Peripheral Stent 7mmx80mmx120cm BOTH IP/OP "$5,024.00 " "$3,717.76" $0.00 "$4,019.20" "$2,260.80" "$2,260.80" $0.00 $0.00 $0.00 "$1,047.13" "$3,728.81" "$3,728.81" "$3,872.50" $0.00 "$1,047.00" $0.00 "$2,476.83" "$2,476.83" $0.00 "$2,512.00" "$3,979.01" "$4,019.20" $0.00 $0.00 $0.00 $786.26 $0.00 $0.00 $799.82 $0.00 $0.00 $0.00 $0.00 $0.00 27805108 EAP Custom 27805108 "Coil 400 Complex Standard, 22 Mm X 60 Cm" BOTH IP/OP "$7,685.00 " "$5,686.90" $0.00 "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,923.60" $0.00 "$1,601.55" $0.00 $0.00 $0.00 $0.00 "$3,842.50" "$6,086.52" "$6,148.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805112 EAP HCPCS Q4107 Coil Embolization 7cm 3mm Nester 7.4 Loop Microcoil .018 BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.95 $218.95 $227.39 $0.00 $61.48 $0.00 $0.00 $0.00 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805113 EAP Custom 27805113 Coil Embolization 7cm 4mm Nester 5.6 Loop Microcoil .018 BOTH IP/OP "$3,403.00 " "$2,518.22" $0.00 "$2,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,525.71" "$2,525.71" "$2,623.03" $0.00 $709.19 $0.00 $0.00 $0.00 $0.00 "$1,701.50" "$2,695.18" "$2,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805115 EAP Custom 27805115 "Coil 400 Complex Standard, 24 Mm X 57 Cm" BOTH IP/OP "$7,642.00 " "$5,655.08" $0.00 "$6,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,890.45" $0.00 "$1,592.59" $0.00 $0.00 $0.00 $0.00 "$3,821.00" "$6,052.46" "$6,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805116 EAP Custom 27805116 "Coil 400 Complex Standard, 28 Mm X 60 Cm" BOTH IP/OP "$8,572.00 " "$6,343.28" $0.00 "$6,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,607.30" $0.00 "$1,786.40" $0.00 $0.00 $0.00 $0.00 "$4,286.00" "$6,789.02" "$6,857.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805118 EAP Custom 27805118 Coil Embl 2cm 1mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805119 EAP Custom 27805119 Coil Embl 3cm 1mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805120 EAP Custom 27805120 Coil Embl 2cm 1.5mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805121 EAP Custom 27805121 Coil Embl 3cm 1.5mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805122 EAP Custom 27805122 Coil Embl 4cm 1.5mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805123 EAP Custom 27805123 Coil Embl 3cm 2mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805124 EAP Custom 27805124 Coil Embl 4cm 2mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805125 EAP Custom 27805125 Coil Embl 6cm 2mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805126 EAP Custom 27805126 Coil Embl 4cm 2.5mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805127 EAP Custom 27805127 Coil Embl 4cm 3mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805128 EAP Custom 27805128 Coil Embl 6cm 3mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805129 EAP Custom 27805129 Coil Embl 8cm 3mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805130 EAP Custom 27805130 Coil Embl 10cm 3mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805131 EAP Custom 27805131 Coil Embl 6cm 4mm Trgt Dtch Ult 360d BOTH IP/OP "$5,352.00 " "$3,960.48" $0.00 "$4,281.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,972.25" "$3,972.25" "$4,125.32" $0.00 "$1,115.36" $0.00 $0.00 $0.00 $0.00 "$2,676.00" "$4,238.78" "$4,281.60" $0.00 "$2,408.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805132 EAP Custom 27805132 Coil Embl 8cm 4mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805133 EAP Custom 27805133 Coil Embl 10cm 5mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805134 EAP Custom 27805134 Coil Embl 15cm 5mm Trgt Dtch Ult 360d BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 "$2,293.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805135 EAP Custom CUSTOM System Embl Dtch Inzone BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805137 EAP HCPCS C1898 LEAD PCNG BRKWY DLV SYS IMPLTABLE HRT FAIL ACTY BOTH IP/OP "$5,010.00 " "$3,707.40" $0.00 "$4,008.00" "$2,254.50" "$2,254.50" $0.00 $0.00 $0.00 "$1,044.21" "$3,718.42" "$3,718.42" "$3,861.71" $0.00 "$1,044.08" $0.00 "$2,469.93" "$2,469.93" $0.00 "$2,505.00" "$3,967.92" "$4,008.00" $0.00 $0.00 $0.00 $784.07 $0.00 $0.00 $797.59 $0.00 $0.00 $0.00 $0.00 $0.00 27805138 EAP HCPCS C1900 LEAD PCNG 59CM 9FR ECRDL BIPOL ACT FIX 1 COIL RTRCT HLX TIP BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805139 EAP HCPCS C1777 LEAD PCNG 64CM 9FR ECRDM 1 COIL ACT FIX BIPOL CARDVRT DFBR BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805140 EAP HCPCS C1898 LEAD PCNG 54CM MYOCRD BIPOL SUTLS INNOMEDICA SIL BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805141 EAP HCPCS C1898 LEAD PCNG 52CM 3.2MM ECRDM ATR VNTRC PCMKR FLXTND BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805142 EAP HCPCS C1895 LEAD PCNG 90CM ECRDM DUAL COIL PSV FIX CARDVRT DFBR BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805143 EAP HCPCS C1898 LEAD PCNG 64CM 9FR 18CM SPC ECRDM IS-1 CONCTR DUAL COIL BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805144 EAP HCPCS C1898 LEAD PCNG 59CM 9FR 18CM SPC ECRDL BIPOL PSV FIX 2 COIL TN BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805145 EAP HCPCS C1876 STENT BIL 10MM 8FR 80MM 3.2MM .035IN RAPEX UNCVR GWIRE BOTH IP/OP $461.00 $341.14 $0.00 $368.80 $207.45 $207.45 $0.00 $0.00 $0.00 $96.08 $342.15 $342.15 $355.34 $0.00 $96.07 $0.00 $272.68 $272.68 $0.00 $230.50 $365.11 $368.80 $0.00 $0.00 $0.00 $72.15 $0.00 $0.00 $73.39 $0.00 $0.00 $0.00 $0.00 $0.00 27805146 EAP HCPCS C1876 STENT BIL 10MM 8FR 60MM .035IN RAPEX UNCVR GWIRE DLV SYS BOTH IP/OP $461.00 $341.14 $0.00 $368.80 $207.45 $207.45 $0.00 $0.00 $0.00 $96.08 $342.15 $342.15 $355.34 $0.00 $96.07 $0.00 $272.68 $272.68 $0.00 $230.50 $365.11 $368.80 $0.00 $0.00 $0.00 $72.15 $0.00 $0.00 $73.39 $0.00 $0.00 $0.00 $0.00 $0.00 27805147 EAP HCPCS C1876 STENT BIL 8MM 8FR 100MM .035IN RAPEX NCT UNCVR DLV SYS BOTH IP/OP $461.00 $341.14 $0.00 $368.80 $207.45 $207.45 $0.00 $0.00 $0.00 $96.08 $342.15 $342.15 $355.34 $0.00 $96.07 $0.00 $272.68 $272.68 $0.00 $230.50 $365.11 $368.80 $0.00 $0.00 $0.00 $72.15 $0.00 $0.00 $73.39 $0.00 $0.00 $0.00 $0.00 $0.00 27805148 EAP HCPCS C1777 LEAD PCNG 64CM 9FR ECRDM 1 COIL PSV FIX BIPOL CARDVRT DFBR BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805149 EAP HCPCS C1898 LEAD PCNG 59CM 9FR 18CM SPC ECRDM 1 COIL PSV FIX BIPOL BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805150 EAP HCPCS C1777 ENDOTAK RELIANCE PF (Passive Fixation) LEADS BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805151 EAP HCPCS C1777 ENDOTAK RELIANCE S PF (Passive Fixation) LEADS BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805152 EAP HCPCS C1898 LEAD PCNG 90CM 18CM SPC ECRDM BIPOL PSV FIX 2 COIL IS-1 DF-1 BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805153 EAP HCPCS C1895 LEAD PCNG ECRDM DUAL COIL ICD PSV FIX CARDVRT DFBR IMPLTABLE BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805154 EAP HCPCS C1898 LEAD PCNG 64CM 9FR 18CM SPC ECRDL BIPOL PSV FIX 2 COIL TN BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805155 EAP HCPCS C1875 STENT BIL 8MM 8.5FR 80MM 70MM .035IN RAPEX PRT RMLM COVERED BOTH IP/OP "$1,053.00 " $779.22 $0.00 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $781.54 $781.54 $811.65 $0.00 $219.45 $0.00 $0.00 $0.00 $0.00 $526.50 $833.98 $842.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805156 EAP HCPCS C1898 LEAD PCNG 59CM 9FR 18CM SPC ECRDM BIPOL PSV FIX 2 COIL IS-1 BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805157 EAP HCPCS C1900 LEAD PCNG 80CM 4.1-2.6FR SPRL LV CORON VNS ACTY BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805158 EAP HCPCS C1779 LEAD PCNG 90CM 4.1-2.6FR SPRL LV CORON VNS IMPLTABLE ACTY BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 $0.00 $0.00 $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805159 EAP HCPCS C1777 LEAD PCNG ECRDM 1 COIL ICD CARDVRT DFBR IMPLTABLE ETAK RLNC BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805160 EAP HCPCS C1900 LEAD PCNG 80CM CORON VNS STRBL BIPOL ACTY STRD ELUT BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805161 EAP HCPCS C2625 STENT BIL 7FR 5CM RAPEX NONCORONARY TEMP DLV SYS PLST DISP BOTH IP/OP "$5,911.00 " "$4,374.14" $0.00 "$4,728.80" "$2,659.95" "$2,659.95" $0.00 $0.00 $0.00 "$1,232.00" "$4,181.12" "$4,181.12" "$4,556.20" $0.00 "$1,231.85" $0.00 "$2,914.12" "$2,914.12" $0.00 "$2,955.50" "$4,681.51" "$4,728.80" $0.00 $0.00 $0.00 $925.07 $0.00 $0.00 $941.03 $0.00 $0.00 $0.00 $0.00 $0.00 27805162 EAP HCPCS C1777 LEAD PCNG ECRDM 1 COIL ICD CARDVRT DFBR IMPLTABLE ETAK RLNC BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805163 EAP HCPCS C1777 Lead Dfbr Etak Rlnc G Act Fix BOTH IP/OP "$13,300.00 " "$9,842.00" $0.00 "$10,640.00" "$5,985.00" "$5,985.00" $0.00 $0.00 $0.00 "$2,772.05" "$4,181.12" "$4,181.12" "$10,251.64" $0.00 "$2,771.72" $0.00 "$6,556.90" "$6,556.90" $0.00 "$6,650.00" "$10,533.60" "$10,640.00" $0.00 $0.00 $0.00 "$2,081.45" $0.00 $0.00 "$2,117.36" $0.00 $0.00 $0.00 $0.00 $0.00 27805164 EAP HCPCS C1777 Lead Dfbr Etak Rlnc G Psv Fix BOTH IP/OP "$13,300.00 " "$9,842.00" $0.00 "$10,640.00" "$5,985.00" "$5,985.00" $0.00 $0.00 $0.00 "$2,772.05" "$4,181.12" "$4,181.12" "$10,251.64" $0.00 "$2,771.72" $0.00 "$6,556.90" "$6,556.90" $0.00 "$6,650.00" "$10,533.60" "$10,640.00" $0.00 $0.00 $0.00 "$2,081.45" $0.00 $0.00 "$2,117.36" $0.00 $0.00 $0.00 $0.00 $0.00 27805165 EAP HCPCS C1898 LEAD PCNG 90CM 18CM SPC ECRDM DUAL COIL ACT DISTAL TIP ELTRD BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805166 EAP HCPCS C1785 PCMKR CRD THK8MM 49X43MM ALTRUA 40DR ATR VNTRC IMPLTABLE 2 BOTH IP/OP "$11,527.00 " "$8,529.98" $0.00 "$9,221.60" "$5,187.15" "$5,187.15" $0.00 $0.00 $0.00 "$2,402.51" "$4,181.12" "$4,181.12" "$8,885.01" $0.00 "$2,402.23" $0.00 "$5,682.81" "$5,682.81" $0.00 "$5,763.50" "$9,129.38" "$9,221.60" $0.00 $0.00 $0.00 "$1,803.98" $0.00 $0.00 "$1,835.10" $0.00 $0.00 $0.00 $0.00 $0.00 27805167 EAP HCPCS C1786 PCMKR CRD 8MM 43X49MM ALTRUA 40 IS-1 CONCTR BOTH IP/OP "$11,527.00 " "$8,529.98" $0.00 "$9,221.60" "$5,187.15" "$5,187.15" $0.00 $0.00 $0.00 "$2,402.51" "$4,181.12" "$4,181.12" "$8,885.01" $0.00 "$2,402.23" $0.00 "$5,682.81" "$5,682.81" $0.00 "$5,763.50" "$9,129.38" "$9,221.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805168 EAP HCPCS C1785 PCMKR CRD THK8MM 44X42MM ALTRUA 40DR ATR VNTRC IMPLTABLE 2 BOTH IP/OP "$11,527.00 " "$8,529.98" $0.00 "$9,221.60" "$5,187.15" "$5,187.15" $0.00 $0.00 $0.00 "$2,402.51" "$4,181.12" "$4,181.12" "$8,885.01" $0.00 "$2,402.23" $0.00 "$5,682.81" "$5,682.81" $0.00 "$5,763.50" "$9,129.38" "$9,221.60" $0.00 $0.00 $0.00 "$1,803.98" $0.00 $0.00 "$1,835.10" $0.00 $0.00 $0.00 $0.00 $0.00 27805169 EAP HCPCS C1786 PCMKR CRD THK8MM 42X42MM ALTRUA 40SR 1 CHMBR RT RSPN BOTH IP/OP "$10,049.00 " "$7,436.26" $0.00 "$8,039.20" "$4,522.05" "$4,522.05" $0.00 $0.00 $0.00 "$2,094.46" "$4,181.12" "$4,181.12" "$7,745.77" $0.00 "$2,094.21" $0.00 "$4,954.16" "$4,954.16" $0.00 "$5,024.50" "$7,958.81" "$8,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805170 EAP HCPCS C1785 Pcmkr Crd Altura 2 Lead Sys BOTH IP/OP "$14,482.00 " "$10,716.68" $0.00 "$11,585.60" "$6,516.90" "$6,516.90" $0.00 $0.00 $0.00 "$3,018.41" "$4,181.12" "$4,181.12" "$11,162.73" $0.00 "$3,018.05" $0.00 "$7,139.63" "$7,139.63" $0.00 "$7,241.00" "$11,469.74" "$11,585.60" $0.00 $0.00 $0.00 "$2,266.43" $0.00 $0.00 "$2,305.53" $0.00 $0.00 $0.00 $0.00 $0.00 27805171 EAP HCPCS C1898 LEAD PCNG 70CM 9FR 18CM SPC ECRDM DUALCOIL XTD-RETRAC DF-1 BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805172 EAP HCPCS C1898 LEAD PCNG 64CM 9FR ECRDM BIPOL ACT FIX DUAL COIL XTD-RETRAC BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805173 EAP HCPCS C1898 LEAD PCNG 59CM 18CM SPC ECRDM BIPOL ACT FIX XTD-RETRAC 2 BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805174 EAP HCPCS C1898 LEAD PCNG 64CM HLX ECRDM 1 COIL BIPOL ACT FIX XTD-RETRAC BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805175 EAP HCPCS C1777 ENDOTAK RELIANCE G AF (Active Fixation) LEADS BOTH IP/OP "$13,300.00 " "$9,842.00" $0.00 "$10,640.00" "$5,985.00" "$5,985.00" $0.00 $0.00 $0.00 "$2,772.05" "$4,181.12" "$4,181.12" "$10,251.64" $0.00 "$2,771.72" $0.00 "$6,556.90" "$6,556.90" $0.00 "$6,650.00" "$10,533.60" "$10,640.00" $0.00 "$5,985.00" $0.00 "$2,081.45" $0.00 $0.00 "$2,117.36" $0.00 $0.00 $0.00 $0.00 $0.00 27805176 EAP HCPCS C1777 Lead Dfbr Etak Rlnc G Act Fix BOTH IP/OP "$13,300.00 " "$9,842.00" $0.00 "$10,640.00" "$5,985.00" "$5,985.00" $0.00 $0.00 $0.00 "$2,772.05" "$4,181.12" "$4,181.12" "$10,251.64" $0.00 "$2,771.72" $0.00 "$6,556.90" "$6,556.90" $0.00 "$6,650.00" "$10,533.60" "$10,640.00" $0.00 $0.00 $0.00 "$2,081.45" $0.00 $0.00 "$2,117.36" $0.00 $0.00 $0.00 $0.00 $0.00 27805177 EAP HCPCS C1876 STENT TRCHBR 7MM 8MM 30MM SLF XPD ARWY DLV SYS PLFX SIL BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,182.40" $665.10 $665.10 $0.00 $0.00 $0.00 $308.05 "$1,096.97" "$1,096.97" "$1,139.24" $0.00 $308.02 $0.00 $874.24 $874.24 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $231.31 $0.00 $0.00 $235.30 $0.00 $0.00 $0.00 $0.00 $0.00 27805178 EAP HCPCS C1882 COGNIS / ACUITY/ ENDOTAK - CARDIAC RESYNCHRONIZATION THERAPY BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27805179 EAP HCPCS C1898 LEAD PCNG 90CM 9FR 18CM SPC ECRDM DUAL COIL ACT FIX BIPOL BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805180 EAP HCPCS C1898 LEAD PCNG 64CM 9FR 18CM SPC ECRDL DUAL COIL IMPLTABLE BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805181 EAP HCPCS C1898 LEAD PCNG 59CM 9FR 18CM SPC ECRDL BIPOL ACT FIX 2 COIL BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805182 EAP HCPCS C1896 LEAD PCNG ECRDL 1 COIL ACT FIX CARDVRT DFBR IMPLTABLE ETAK BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805183 EAP HCPCS C1898 LEAD PCNG 45CM 6.7FR 10MM SPC RIGHT AV XTD-RETRAC ACT FIX BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805184 EAP HCPCS C1777 ENDOTAK RELIANCE AF (Active Fixation) LEADS BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 "$5,053.95" $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805185 EAP HCPCS C1898 LEAD PCNG 60CM 6.7FR 10MM SPC RIGHT AV ECRDL IS-1 CONCTR BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805186 EAP HCPCS C1900 Easytrack 2 BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$1,994.85" "$1,994.85" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,185.47" "$2,185.47" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805187 EAP HCPCS C1898 Lead Pcng Sm Act Fix Rlnc BOTH IP/OP "$11,231.00 " "$8,310.94" $0.00 "$8,984.80" "$5,053.95" "$5,053.95" $0.00 $0.00 $0.00 "$2,340.82" "$4,181.12" "$4,181.12" "$8,656.85" $0.00 "$2,340.54" $0.00 "$5,536.88" "$5,536.88" $0.00 "$5,615.50" "$8,894.95" "$8,984.80" $0.00 $0.00 $0.00 "$1,757.65" $0.00 $0.00 "$1,787.98" $0.00 $0.00 $0.00 $0.00 $0.00 27805188 EAP HCPCS C1887 RAPIDO ADVANCE LEAD DELIVERY SYSTEM BOTH IP/OP "$2,941.00 " "$2,176.34" $0.00 "$2,352.80" "$1,323.45" "$1,323.45" $0.00 $0.00 $0.00 $612.98 "$2,182.81" "$2,182.81" "$2,266.92" $0.00 $612.90 $0.00 "$1,449.91" "$1,449.91" $0.00 "$1,470.50" "$2,329.27" "$2,352.80" $0.00 $0.00 $0.00 $460.27 $0.00 $0.00 $468.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805189 EAP HCPCS C1900 LEAD PCNG 80CM 5.4FR CORON VNS LV IS 1 BIPOL OTW EZTRK 2 BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$1,994.85" "$1,994.85" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,185.47" "$2,185.47" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805190 EAP HCPCS C1898 LEAD PCNG CORON VNS IS 1 EZTRK 2 BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$1,994.85" "$1,994.85" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,185.47" "$2,185.47" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27805191 EAP HCPCS C1898 LEAD PCNG 100CM 7-5FR 8.5MM .035IN CORON VNS LV IS-1 DUAL BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$1,994.85" "$1,994.85" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,185.47" "$2,185.47" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27805192 EAP HCPCS C1898 LEAD PCNG 80CM 8FR J ECRDL RIGHT ARTIAL BIPOL IS-1 LV-1 DUAL BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$1,994.85" "$1,994.85" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,185.47" "$2,185.47" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27805193 EAP HCPCS C1898 LEAD PCNG 90CM CORON VNS LV LV-1 DUAL ELTRD CONCTR BIPOL PSV BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$1,994.85" "$1,994.85" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,185.47" "$2,185.47" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27805194 EAP HCPCS C1779 LEAD PCNG 35CM MYOCARDIUM VNTRC IS-1 CONCTR SCR FIX UNPLR BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805195 EAP HCPCS C1898 LEAD PCNG 80CM 8FR CORON VNS BIPOL DUAL ELTRD SPRL FIX IS-1 BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$1,994.85" "$1,994.85" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,185.47" "$2,185.47" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27805196 EAP HCPCS C1898 LEAD PCNG 90CM CORON VNS LV IS-1 EZTRK 3IS-1 STRD ELUT SIL BOTH IP/OP "$4,433.00 " "$3,280.42" $0.00 "$3,546.40" "$1,994.85" "$1,994.85" $0.00 $0.00 $0.00 $923.95 "$3,290.17" "$3,290.17" "$3,416.96" $0.00 $923.84 $0.00 "$2,185.47" "$2,185.47" $0.00 "$2,216.50" "$3,510.94" "$3,546.40" $0.00 $0.00 $0.00 $693.76 $0.00 $0.00 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 27805197 EAP HCPCS C1779 LEAD PCNG 35CM MYOCARDIUM EPICARDIUM RV IS-1 CONCTR OTHR BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805198 EAP HCPCS C1899 LEAD PCNG 59CM ECRDL 4 ST DUAL COIL IMPLTABLE CARDVRT DFBR BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 $0.00 $0.00 $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805199 EAP HCPCS C1898 LEAD PCNG 64CM ECRDL 4 ST DUAL COIL ACT FIX IMPLTABLE BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805200 EAP HCPCS C1898 LEAD PCNG 59CM ECRDM 4-ST DUAL COIL ACT DF4 TRM CONCTR BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805201 EAP HCPCS C1898 LEAD PCNG 64CM ECRDM 4-ST DUAL COIL ACT DF4 TRM CONCTR BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805202 EAP HCPCS C1898 LEAD PCNG 59CM ECRDM 4-ST DUAL COIL PSV DF4 TRM CONCTR BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805203 EAP HCPCS C1898 LEAD PCNG 64CM ECRDL 4 ST DUAL COIL ACT FIX IMPLTABLE BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805204 EAP HCPCS C1898 LEAD PCNG 59CM ECRDL 4 ST DUAL COIL PSV FIX IMPLTABLE BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805205 EAP HCPCS C1898 LEAD PCNG 64CM ECRDL 4 ST DUAL COIL PSV FIX IMPLTABLE BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805206 EAP HCPCS C1777 LEAD PCNG 59CM ECRDM 4-ST 1 COIL ACT DF4 TRM CONCTR CARDVRT BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805207 EAP HCPCS C1777 LEAD PCNG 64CM ECRDL 4 ST 1 COIL PSV FIX IMPLTABLE CARDVRT BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805208 EAP HCPCS C1777 LEAD PCNG 59CM ECRDL 4 ST 1 COIL PSV FIX IMPLTABLE CARDVRT BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805209 EAP HCPCS C1777 LEAD PCNG 64CM ECRDL 4 ST 1 COIL PSV FIX IMPLTABLE CARDVRT BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805210 EAP HCPCS C1900 INVIVE / EASYTRAK or ACUITY / w RV or AV LEAD: CARDIAC RESYN BOTH IP/OP "$26,452.00 " "$19,574.48" $0.00 "$21,161.60" "$11,903.40" "$11,903.40" $0.00 $0.00 $0.00 "$5,513.26" "$4,181.12" "$4,181.12" "$20,389.20" $0.00 "$5,512.60" $0.00 "$13,040.84" "$13,040.84" $0.00 "$13,226.00" "$20,949.98" "$21,161.60" $0.00 $0.00 $0.00 "$4,139.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805211 EAP HCPCS C1900 INVIVE / EASYTRAK or ACUITY / w RV & AV LEAD: CARDIAC RESYNC BOTH IP/OP "$26,452.00 " "$19,574.48" $0.00 "$21,161.60" "$11,903.40" "$11,903.40" $0.00 $0.00 $0.00 "$5,513.26" "$4,181.12" "$4,181.12" "$20,389.20" $0.00 "$5,512.60" $0.00 "$13,040.84" "$13,040.84" $0.00 "$13,226.00" "$20,949.98" "$21,161.60" $0.00 $0.00 $0.00 "$4,139.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805212 EAP HCPCS C1722 INCEPTA LV-1 / EASYTRAK or ACUITY / ENDOTAK w ATRIAL LEAD: C BOTH IP/OP "$71,524.00 " "$52,927.76" $0.00 "$57,219.20" "$32,185.80" "$32,185.80" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$55,130.70" $0.00 "$14,905.60" $0.00 "$35,261.33" "$35,261.33" $0.00 "$35,762.00" "$56,647.01" "$57,219.20" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27805213 EAP HCPCS C1898 LEAD PCNG 59CM 2.4MM STR ATR VNTRC BIPOL ACT FIX RTRCT HLX BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805214 EAP HCPCS C1898 LEAD PCNG 45CM ECRDM ATR VNTRC IS-1 CONCTR ACT FIX BIPOL SIL BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805215 EAP HCPCS C1898 LEAD PCNG ECRDL RIGHT ATR RV IS-1 CONCTR BIPOL XTD-RETRAC BOTH IP/OP "$1,463.00 " "$1,082.62" $0.00 "$1,170.40" $658.35 $658.35 $0.00 $0.00 $0.00 $304.93 "$1,085.84" "$1,085.84" "$1,127.68" $0.00 $304.89 $0.00 $865.36 $865.36 $0.00 $731.50 "$1,158.70" "$1,170.40" $0.00 $0.00 $0.00 $228.96 $0.00 $0.00 $232.91 $0.00 $0.00 $0.00 $0.00 $0.00 27805216 EAP HCPCS C1898 LEAD PCNG ECRDM RIGHT ATR LV BIPOL IS-1 SCR FIX SIL INSL FLN BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805217 EAP HCPCS C1898 LEAD PCNG 52CM 7FR RIGHT ATR VNTRC ECRDM IS-1 CONCTR BIPOL BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805218 EAP HCPCS C1898 LEAD PCNG 45CM 6FR ECRDL OTHR THAN TRNVNS VDD 1 PASS BIPOL BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805219 EAP HCPCS C1898 LEAD PCNG 58CM 5FR ECRDM AV BIPOL ACT FIX SCR IN IS-1 FLN2 BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805220 EAP HCPCS C1898 LEAD PCNG 52CM 7FR STR ECRDM RIGHT ATR LV BIPOL IS-1 SCR FIX BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805221 EAP HCPCS C1779 LEAD PCNG 45CM 7FR THK1.7MM STR ATR VNTRC BIPOL ACT FIX FLN2 BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805222 EAP HCPCS C1898 LEAD PCNG 52CM OTHR THAN TRNVNS VDD 1 PASS IMPLTABLE FLN2 BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805223 EAP HCPCS C1898 LEAD PCNG 45CM 8FR J ECRDM RIGHT ATR BIPOL IS-1 PSV FIX POLY BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805224 EAP HCPCS C1900 LEAD PCNG 58CM 6FR ECRDM VNTRC BIPOL IS-1 PSV FIX FLN2 BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805225 EAP HCPCS C1779 LEAD PCNG 52CM 9FR RV ECRDM BIPOL IS-1 PSV FIX TRNVNS VDD 1 BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805226 EAP HCPCS C1898 LEAD PCNG RV ECRDM BIPOL PSV FIX IS-1 FLN2 STRX PU BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27805227 EAP HCPCS C1900 LEAD PCNG 52CM VNTRC ECRDL OTHR THAN TRNVNS VDD 1 PASS BIPOL BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 "$1,025.16" $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $208.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805228 EAP Custom 27805228 Sensor Flotrac Vamp Adult 60in 152cm Sterile BOTH IP/OP $961.00 $711.14 $0.00 $768.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $713.25 $713.25 $740.74 $0.00 $200.27 $0.00 $0.00 $0.00 $0.00 $480.50 $761.11 $768.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805229 EAP Custom 27805229 Sensor Monitor Flotrac Adlt L60 In Vamp Bifurcated Pres BOTH IP/OP $961.00 $711.14 $0.00 $768.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $713.25 $713.25 $740.74 $0.00 $200.27 $0.00 $0.00 $0.00 $0.00 $480.50 $761.11 $768.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805231 EAP HCPCS C1874 Stent Endoprsth 8mm 5cm 120cm .035in Dlv Sys Tip To Hubl BOTH IP/OP "$7,966.00 " "$5,894.84" $0.00 "$6,372.80" "$3,584.70" "$3,584.70" $0.00 $0.00 $0.00 "$1,660.31" "$4,181.12" "$4,181.12" "$6,140.19" $0.00 "$1,660.11" $0.00 "$3,927.24" "$3,927.24" $0.00 "$3,983.00" "$6,309.07" "$6,372.80" $0.00 $0.00 $0.00 "$1,246.68" $0.00 $0.00 "$1,268.19" $0.00 $0.00 $0.00 $0.00 $0.00 27805232 EAP HCPCS C1874 Stent Endoprsth 8mm 10cm 120cm .035in Dlv Sys Tip To Hul BOTH IP/OP "$9,148.00 " "$6,769.52" $0.00 "$7,318.40" "$4,116.60" "$4,116.60" $0.00 $0.00 $0.00 "$1,906.67" "$4,181.12" "$4,181.12" "$7,051.28" $0.00 "$1,906.44" $0.00 "$4,509.96" "$4,509.96" $0.00 "$4,574.00" "$7,245.22" "$7,318.40" $0.00 $0.00 $0.00 "$1,431.66" $0.00 $0.00 "$1,456.36" $0.00 $0.00 $0.00 $0.00 $0.00 27805233 EAP HCPCS C1874 Stent Endoprsth 10mm 5cm 120cm .035in Dlv Sys Tip To Hul BOTH IP/OP "$7,966.00 " "$5,894.84" $0.00 "$6,372.80" "$3,584.70" "$3,584.70" $0.00 $0.00 $0.00 "$1,660.31" "$4,181.12" "$4,181.12" "$6,140.19" $0.00 "$1,660.11" $0.00 "$3,927.24" "$3,927.24" $0.00 "$3,983.00" "$6,309.07" "$6,372.80" $0.00 $0.00 $0.00 "$1,246.68" $0.00 $0.00 "$1,268.19" $0.00 $0.00 $0.00 $0.00 $0.00 27805234 EAP HCPCS C1874 Stent Endoprsth 10mm 10cm 120cm .035in Dlv Sys Tip To Hb BOTH IP/OP "$9,148.00 " "$6,769.52" $0.00 "$7,318.40" "$4,116.60" "$4,116.60" $0.00 $0.00 $0.00 "$1,906.67" "$4,181.12" "$4,181.12" "$7,051.28" $0.00 "$1,906.44" $0.00 "$4,509.96" "$4,509.96" $0.00 "$4,574.00" "$7,245.22" "$7,318.40" $0.00 $0.00 $0.00 "$1,431.66" $0.00 $0.00 "$1,456.36" $0.00 $0.00 $0.00 $0.00 $0.00 27805235 EAP HCPCS C1874 Stent Endoprsth 6mm 7fr 5cm 120cm .035in Hep Bioactive C BOTH IP/OP "$7,061.00 " "$5,225.14" $0.00 "$5,648.80" "$3,177.45" "$3,177.45" $0.00 $0.00 $0.00 "$1,471.69" "$4,181.12" "$4,181.12" "$5,442.62" $0.00 "$1,471.51" $0.00 "$3,481.07" "$3,481.07" $0.00 "$3,530.50" "$5,592.31" "$5,648.80" $0.00 "$3,177.45" $0.00 "$1,105.05" $0.00 $0.00 "$1,124.11" $0.00 $0.00 $0.00 $0.00 $0.00 27805236 EAP HCPCS C1874 Stent Endoprsth 6mm 10cm 120cm .035in Dlv Sys Tip To Hul BOTH IP/OP "$9,604.00 " "$7,106.96" $0.00 "$7,683.20" "$4,321.80" "$4,321.80" $0.00 $0.00 $0.00 "$2,001.71" "$4,181.12" "$4,181.12" "$7,402.76" $0.00 "$2,001.47" $0.00 "$4,734.77" "$4,734.77" $0.00 "$4,802.00" "$7,606.37" "$7,683.20" $0.00 $0.00 $0.00 "$1,503.03" $0.00 $0.00 "$1,528.96" $0.00 $0.00 $0.00 $0.00 $0.00 27805240 EAP HCPCS V2790 Graft Crnl 16mm Prokera Amnio Membr Crprs Ring Set BOTH IP/OP "$2,646.00 " "$1,958.04" $0.00 "$2,116.80" "$1,190.70" "$1,190.70" $0.00 $0.00 $0.00 $551.49 "$1,963.86" "$1,963.86" "$2,039.54" $0.00 $551.43 $0.00 "$1,304.48" "$1,304.48" $0.00 "$1,323.00" "$2,095.63" "$2,116.80" $0.00 $0.00 $0.00 $414.10 $0.00 $0.00 $421.24 $0.00 $0.00 $0.00 $0.00 $0.00 27805252 EAP Custom 27805252 Pipeline Embolization Device 2.75 Cm 10mm BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805253 EAP Custom 27805253 Pipeline Embolization Device 2.75 Cm 12mm BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805254 EAP Custom 27805254 PIPELINE EMBOLIZATION DEVICE 2.75CM 16MM BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805255 EAP Custom 27805255 Pipeline Embolization Device 3.00cm 10mm BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805256 EAP Custom 27805256 Pipeline Embolization Device 3.00cm 12mm BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805257 EAP Custom 27805257 Pipeline Embolization Device 3.00cm 16mm BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805258 EAP Custom 27805258 Pipeline Embolization Device 3.50cm 10mm BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805259 EAP Custom 27805259 PIPELINE EMBOLIZATION DEVICE 3.5CM 12MM BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805260 EAP Custom 27805260 PIPELINE EMBOLIZATION DEVICE 3.5CM 16MM BOTH IP/OP "$38,126.00 " "$28,213.24" $0.00 "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,387.52" $0.00 "$7,945.46" $0.00 $0.00 $0.00 $0.00 "$19,063.00" "$30,195.79" "$30,500.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805265 EAP HCPCS C1777 Linox Smart Dx 65/17 BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805266 EAP HCPCS C1777 Linox Smart Dx 65/15 BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805267 EAP HCPCS C1777 Lumax 740 Vr-t Dx W/gsm Hm BOTH IP/OP "$45,811.00 " "$33,900.14" $0.00 "$36,648.80" "$20,614.95" "$20,614.95" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$35,311.12" $0.00 "$9,547.01" $0.00 "$22,584.82" "$22,584.82" $0.00 "$22,905.50" "$36,282.31" "$36,648.80" $0.00 $0.00 $0.00 "$7,169.42" $0.00 $0.00 "$7,293.11" $0.00 $0.00 $0.00 $0.00 $0.00 27805268 EAP HCPCS C1777 Lumax 740 Vr-t Dx System W/gsm Hm BOTH IP/OP "$57,560.00 " "$42,594.40" $0.00 "$46,048.00" "$25,902.00" "$25,902.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$44,367.25" $0.00 "$11,995.50" $0.00 "$28,377.08" "$28,377.08" $0.00 "$28,780.00" "$45,587.52" "$46,048.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27805269 EAP HCPCS C1781 "Mesh Surg Craniocurve .6mm Occptl Crnm Etch Lbl Antm, 01-9520" BOTH IP/OP "$11,822.00 " "$8,748.28" $0.00 "$9,457.60" "$5,319.90" "$5,319.90" $0.00 $0.00 $0.00 "$2,464.00" "$4,181.12" "$4,181.12" "$9,112.40" $0.00 "$2,463.70" $0.00 "$5,828.25" "$5,828.25" $0.00 "$5,911.00" "$9,363.02" "$9,457.60" $0.00 $0.00 $0.00 "$1,850.14" $0.00 $0.00 "$1,882.06" $0.00 $0.00 $0.00 $0.00 $0.00 27805270 EAP Custom 27805270 Target Coils 360 Standard 3mm X 6cm BOTH IP/OP "$4,559.00 " "$3,373.66" $0.00 "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.69" "$3,383.69" "$3,514.08" $0.00 $950.10 $0.00 $0.00 $0.00 $0.00 "$2,279.50" "$3,610.73" "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805271 EAP Custom 27805271 Target Coils 360 Standard 3mm X 8cm BOTH IP/OP "$4,559.00 " "$3,373.66" $0.00 "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.69" "$3,383.69" "$3,514.08" $0.00 $950.10 $0.00 $0.00 $0.00 $0.00 "$2,279.50" "$3,610.73" "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805272 EAP Custom 27805272 Target Coils 360 Standard 4mm X 8cm BOTH IP/OP "$4,559.00 " "$3,373.66" $0.00 "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.69" "$3,383.69" "$3,514.08" $0.00 $950.10 $0.00 $0.00 $0.00 $0.00 "$2,279.50" "$3,610.73" "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805273 EAP Custom 27805273 Target Coils 360 Standard 4mm X 10cm BOTH IP/OP "$4,559.00 " "$3,373.66" $0.00 "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.69" "$3,383.69" "$3,514.08" $0.00 $950.10 $0.00 $0.00 $0.00 $0.00 "$2,279.50" "$3,610.73" "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805274 EAP Custom 27805274 Target Coils 360 Standard 4mm X 15cm BOTH IP/OP "$4,559.00 " "$3,373.66" $0.00 "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.69" "$3,383.69" "$3,514.08" $0.00 $950.10 $0.00 $0.00 $0.00 $0.00 "$2,279.50" "$3,610.73" "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805275 EAP Custom 27805275 Target Coils 360 Standard 5mm X 15cm BOTH IP/OP "$4,559.00 " "$3,373.66" $0.00 "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.69" "$3,383.69" "$3,514.08" $0.00 $950.10 $0.00 $0.00 $0.00 $0.00 "$2,279.50" "$3,610.73" "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805276 EAP Custom 27805276 Target Coils 360 Standard 5mm X 20cm BOTH IP/OP "$4,559.00 " "$3,373.66" $0.00 "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.69" "$3,383.69" "$3,514.08" $0.00 $950.10 $0.00 $0.00 $0.00 $0.00 "$2,279.50" "$3,610.73" "$3,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805277 EAP Custom 27805277 Target Coils 360 Standard 6mm X 15cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805278 EAP Custom 27805278 Target Coils 360 Standard 6mm X 20cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805279 EAP Custom 27805279 Target Coils 360 Standard 6mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805280 EAP Custom 27805280 Target Coils 360 Standard 7mm X 15cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805281 EAP Custom 27805281 Target Coils 360 Standard 7mm X 20cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805282 EAP Custom 27805282 Target Coils 360 Standard 7mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805283 EAP Custom 27805283 Target Coils 360 Standard 8mm X 20cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805284 EAP Custom 27805284 Target Coils 360 Standard 8mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805285 EAP Custom 27805285 Target Coils 360 Standard 9mm X 20cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805286 EAP Custom 27805286 Target Coils 360 Standard 9mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805287 EAP Custom 27805287 Target Coils 360 Standard 10mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805288 EAP Custom 27805288 Target Coils 360 Standard 11mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805289 EAP Custom 27805289 Target Coils 360 Standard 12mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805290 EAP Custom 27805290 Target Coils 360 Standard 13mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805291 EAP Custom 27805291 Target Coils 360 Standard 14mm X 30cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805292 EAP Custom 27805292 Target Coils 360 Standard 15mm X 40cm BOTH IP/OP "$5,097.00 " "$3,771.78" $0.00 "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,782.99" "$3,782.99" "$3,928.77" $0.00 "$1,062.21" $0.00 $0.00 $0.00 $0.00 "$2,548.50" "$4,036.82" "$4,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805293 EAP Custom 27805293 Target Coils 360 Soft 2mm X 4cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805294 EAP Custom 27805294 Target Coils 360 Soft 3mm X 6cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805295 EAP Custom 27805295 Target Coils 360 Soft 3mm X 8cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805296 EAP Custom 27805296 Target Coils 360 Soft 3mm X 10cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805297 EAP Custom 27805297 Target Coils 360 Soft 4mm X 6cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805298 EAP Custom 27805298 Target Coils 360 Soft 4mm X 8cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 "$2,172.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805299 EAP Custom 27805299 Target Coils 360 Soft 4mm X 10cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805300 EAP Custom 27805300 Target Coils 360 Soft 4mm X 15cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805301 EAP Custom 27805301 Target Coils 360 Soft 5mm X 10cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805302 EAP Custom 27805302 Target Coils 360 Soft 5mm X 15cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805303 EAP Custom 27805303 Target Coils 360 Soft 5mm X 20cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805304 EAP Custom 27805304 Target Coils 360 Soft 6mm X 10cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805305 EAP Custom 27805305 Target Coils 360 Soft 6mm X 15cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 "$2,172.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805306 EAP Custom 27805306 Target Coils 360 Soft 6mm X 20cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805307 EAP Custom 27805307 Target Coils 360 Soft 6mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805308 EAP Custom 27805308 Target Coils 360 Soft 7mm X 15cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805309 EAP Custom 27805309 Target Coils 360 Soft 7mm X 20cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805310 EAP Custom 27805310 Target Coils 360 Soft 7mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805311 EAP Custom 27805311 Target Coils 360 Soft 8mm X 20cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805312 EAP Custom 27805312 Target Coils 360 Soft 8mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805313 EAP Custom 27805313 Target Coils 360 Soft 9mm X 20cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805314 EAP Custom 27805314 Target Coils 360 Soft 9mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805315 EAP Custom 27805315 Target Coils 360 Soft 10mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805316 EAP Custom 27805316 Target Coils 360 Soft 11mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805317 EAP Custom 27805317 Target Coils 360 Soft 12mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805318 EAP Custom 27805318 Target Coils 360 Soft 13mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805319 EAP Custom 27805319 Target Coils 360 Soft 14mm X 30cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805320 EAP Custom 27805320 Target Coils Helical Ultra 1mm X 1cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805321 EAP Custom 27805321 Target Coils Helical Ultra 1mm X 2cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805322 EAP Custom 27805322 Target Coils Helical Ultra 1mm X 3cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805323 EAP Custom 27805323 Target Coils Helical Ultra 1.5mm X 1cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805324 EAP Custom 27805324 Target Coils Helical Ultra 1.5mm X 2cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805325 EAP Custom 27805325 Target Coils Helical Ultra 1.5mm X 3cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805326 EAP Custom 27805326 Target Coils Helical Ultra 1.5mm X 4cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805327 EAP Custom 27805327 Target Coils Helical Ultra 2mm X 1cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805328 EAP Custom 27805328 Target Coils Helical Ultra 2mm X 2cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805329 EAP Custom 27805329 Target Coils Helical Ultra 2mm X 3cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805330 EAP Custom 27805330 Target Coils Helical Ultra 2mm X 4cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805331 EAP Custom 27805331 Target Coils Helical Ultra 2mm X 6cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805332 EAP Custom 27805332 Target Coils Helical Ultra 2mm X 8cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805333 EAP Custom 27805333 Target Coils Helical Ultra 2.5mm X 3cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805334 EAP Custom 27805334 Target Coils Helical Ultra 2.5mm X 4cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805335 EAP Custom 27805335 Target Coils Helical Ultra 2.5mm X 6cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805336 EAP Custom 27805336 Target Coils Helical Ultra 3mm X 4cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805337 EAP Custom 27805337 Target Coils Helical Ultra 3mm X 6cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805338 EAP Custom 27805338 Target Coils Helical Ultra 3mm X 8cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805339 EAP Custom 27805339 Target Coils Helical Ultra 3mm X 10cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805340 EAP Custom 27805340 Target Coils Helical Ultra 4mm X 6cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805341 EAP Custom 27805341 Target Coils Helical Ultra 4mm X 8cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805342 EAP Custom 27805342 Target Coils Helical Ultra 4mm X 15cm BOTH IP/OP "$3,483.00 " "$2,577.42" $0.00 "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,585.08" "$2,585.08" "$2,684.70" $0.00 $725.86 $0.00 $0.00 $0.00 $0.00 "$1,741.50" "$2,758.54" "$2,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805343 EAP Custom 27805343 Target Xl Detachable Coils 360 Soft 6 X 20cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 "$2,656.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805344 EAP Custom 27805344 Target Xl Detachable Coils 360 Soft 7 X 20cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 "$2,656.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805345 EAP Custom 27805345 Target Xl Detachable Coils 360 Soft 8 X 30cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 "$2,656.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805346 EAP Custom 27805346 Target Xl Detachable Coils 360 Soft 9 X 30cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805347 EAP Custom 27805347 Target Xl Detachable Coils 360 Soft 10 X 40cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805348 EAP Custom 27805348 Target Xl Detachable Coils 360 Soft 12 X 45cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805349 EAP Custom 27805349 Target Xl Detachable Coils 360 Soft 14 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,964.72" $0.00 "$1,342.30" $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805350 EAP Custom 27805350 Target Xl Detachable Coils 360 Soft 16 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,964.72" $0.00 "$1,342.30" $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805351 EAP Custom 27805351 Target Xl Detachable Coils 360 Soft 18 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805352 EAP Custom 27805352 Target Xl Detachable Coils 360 Soft 20 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805353 EAP Custom 27805353 Target Xl Detachable Coils 360 Standard 6 X 20cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805354 EAP Custom 27805354 Target Xl Detachable Coils 360 Standard 7 X 20cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805355 EAP Custom 27805355 Target Xl Detachable Coils 360 Standard 8 X 30cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805356 EAP Custom 27805356 Target Xl Detachable Coils 360 Standard 9 X 30cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805357 EAP Custom 27805357 Target Xl Detachable Coils 360 Standard 10 X 40cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.03" $0.00 "$1,230.19" $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 "$2,656.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805358 EAP Custom 27805358 Target Xl Detachable Coils 360 Standard 12 X 45cm BOTH IP/OP "$5,903.00 " "$4,368.22" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,951.50" "$4,675.18" "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805359 EAP Custom 27805359 Target Xl Detachable Coils 360 Standard 14 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,964.72" $0.00 "$1,342.30" $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805360 EAP Custom 27805360 Target Xl Detachable Coils 360 Standard 16 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,964.72" $0.00 "$1,342.30" $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805361 EAP Custom 27805361 Target Xl Detachable Coils 360 Standard 18 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,964.72" $0.00 "$1,342.30" $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805362 EAP Custom 27805362 Target Xl Detachable Coils 360 Standard 20 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,964.72" $0.00 "$1,342.30" $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805363 EAP Custom 27805363 Target Xl Detachable Coils 360 Standard 22 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,964.72" $0.00 "$1,342.30" $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805364 EAP Custom 27805364 Target Xl Detachable Coils 360 Standard 24 X 50cm BOTH IP/OP "$6,441.00 " "$4,766.34" $0.00 "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,964.72" $0.00 "$1,342.30" $0.00 $0.00 $0.00 $0.00 "$3,220.50" "$5,101.27" "$5,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805365 EAP Custom 27805365 Target Xl Detachable Coils Helical 10 X 40cm BOTH IP/OP "$4,290.00 " "$3,174.60" $0.00 "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,184.04" "$3,184.04" "$3,306.73" $0.00 $894.04 $0.00 $0.00 $0.00 $0.00 "$2,145.00" "$3,397.68" "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805366 EAP Custom 27805366 Target Xl Detachable Coils Helical 12 X 50cm BOTH IP/OP "$4,290.00 " "$3,174.60" $0.00 "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,184.04" "$3,184.04" "$3,306.73" $0.00 $894.04 $0.00 $0.00 $0.00 $0.00 "$2,145.00" "$3,397.68" "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805367 EAP Custom 27805367 Target Xl Detachable Coils Helical 14 X 50cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805368 EAP Custom 27805368 Target Xl Detachable Coils Helical 16 X 50cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805369 EAP Custom 27805369 Target Xl Detachable Coils Helical 18 X 50cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805370 EAP Custom 27805370 Target Xl Detachable Coils Helical 20 X 50cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805371 EAP Custom 27805371 Target Xl Detachable Coils Helical 22 X 50cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805372 EAP Custom 27805372 Target Xl Detachable Coils Helical 24 X 50cm BOTH IP/OP "$4,827.00 " "$3,571.98" $0.00 "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,582.60" "$3,582.60" "$3,720.65" $0.00 "$1,005.95" $0.00 $0.00 $0.00 $0.00 "$2,413.50" "$3,822.98" "$3,861.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805373 EAP Custom 27805373 Target Xl Detachable Coils Helical 5 X 15cm BOTH IP/OP "$4,290.00 " "$3,174.60" $0.00 "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,184.04" "$3,184.04" "$3,306.73" $0.00 $894.04 $0.00 $0.00 $0.00 $0.00 "$2,145.00" "$3,397.68" "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805374 EAP Custom 27805374 Target Xl Detachable Coils Helical 6 X 20cm BOTH IP/OP "$4,290.00 " "$3,174.60" $0.00 "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,184.04" "$3,184.04" "$3,306.73" $0.00 $894.04 $0.00 $0.00 $0.00 $0.00 "$2,145.00" "$3,397.68" "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805375 EAP Custom 27805375 Target Xl Detachable Coils Helical 7 X 20cm BOTH IP/OP "$4,290.00 " "$3,174.60" $0.00 "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,184.04" "$3,184.04" "$3,306.73" $0.00 $894.04 $0.00 $0.00 $0.00 $0.00 "$2,145.00" "$3,397.68" "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805376 EAP Custom 27805376 Target Xl Detachable Coils Helical 8 X 30cm BOTH IP/OP "$4,290.00 " "$3,174.60" $0.00 "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,184.04" "$3,184.04" "$3,306.73" $0.00 $894.04 $0.00 $0.00 $0.00 $0.00 "$2,145.00" "$3,397.68" "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805377 EAP Custom 27805377 Target Xl Detachable Coils Helical 9 X 30cm BOTH IP/OP "$4,290.00 " "$3,174.60" $0.00 "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,184.04" "$3,184.04" "$3,306.73" $0.00 $894.04 $0.00 $0.00 $0.00 $0.00 "$2,145.00" "$3,397.68" "$3,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805378 EAP HCPCS C1781 "Mesh Surg Craniocurve .6mm Left Prtl Sm Crnm Etch Lbl Antm, 01-9521" BOTH IP/OP "$13,300.00 " "$9,842.00" $0.00 "$10,640.00" "$5,985.00" "$5,985.00" $0.00 $0.00 $0.00 "$2,772.05" "$4,181.12" "$4,181.12" "$10,251.64" $0.00 "$2,771.72" $0.00 "$6,556.90" "$6,556.90" $0.00 "$6,650.00" "$10,533.60" "$10,640.00" $0.00 $0.00 $0.00 "$2,081.45" $0.00 $0.00 "$2,117.36" $0.00 $0.00 $0.00 $0.00 $0.00 27805379 EAP HCPCS C1781 "Mesh Surg Craniocurve .6mm Right Prtl Sm Crnm Etch Lbl Antm, 01-9522" BOTH IP/OP "$13,300.00 " "$9,842.00" $0.00 "$10,640.00" "$5,985.00" "$5,985.00" $0.00 $0.00 $0.00 "$2,772.05" "$4,181.12" "$4,181.12" "$10,251.64" $0.00 "$2,771.72" $0.00 "$6,556.90" "$6,556.90" $0.00 "$6,650.00" "$10,533.60" "$10,640.00" $0.00 $0.00 $0.00 "$2,081.45" $0.00 $0.00 "$2,117.36" $0.00 $0.00 $0.00 $0.00 $0.00 27805380 EAP HCPCS C1781 "Mesh Surg Craniocurve .6mm Left Prtl Lg Crnm Etch Lbl Antm, 01-9523" BOTH IP/OP "$14,777.00 " "$10,934.98" $0.00 "$11,821.60" "$6,649.65" "$6,649.65" $0.00 $0.00 $0.00 "$3,079.90" "$4,181.12" "$4,181.12" "$11,390.11" $0.00 "$3,079.53" $0.00 "$7,285.06" "$7,285.06" $0.00 "$7,388.50" "$11,703.38" "$11,821.60" $0.00 $0.00 $0.00 "$2,312.60" $0.00 $0.00 "$2,352.50" $0.00 $0.00 $0.00 $0.00 $0.00 27805381 EAP HCPCS C1781 "Mesh Surg Craniocurve .6mm Right Prtl Lg Crnm Etch Lbl Antm, 01-9524" BOTH IP/OP "$14,777.00 " "$10,934.98" $0.00 "$11,821.60" "$6,649.65" "$6,649.65" $0.00 $0.00 $0.00 "$3,079.90" "$4,181.12" "$4,181.12" "$11,390.11" $0.00 "$3,079.53" $0.00 "$7,285.06" "$7,285.06" $0.00 "$7,388.50" "$11,703.38" "$11,821.60" $0.00 $0.00 $0.00 "$2,312.60" $0.00 $0.00 "$2,352.50" $0.00 $0.00 $0.00 $0.00 $0.00 27805382 EAP HCPCS C1876 Protege Everflex Stent 6x40x120 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805383 EAP HCPCS C1876 Protege Everflex Stent 6x60x120 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805384 EAP HCPCS C1876 Protege Everflex Stent 6x80x120 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805385 EAP HCPCS C1876 Protege Everflex Stent 8x40x120 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805386 EAP HCPCS C1876 Protege Everflex Stent 8x60x120 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805387 EAP HCPCS C1876 Protege Everflex Stent 8x80x120 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805388 EAP HCPCS C1876 Protege Stent 10x40x120 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805389 EAP HCPCS C1876 Protege Stent 10x60x120 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805390 EAP HCPCS C1876 Protege Stent 12x40x80 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805391 EAP HCPCS C1876 Protege Stent 12x60x80 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805392 EAP HCPCS C1876 Protege Stent 14x40x80 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805393 EAP HCPCS C1876 Protege Stent 14x80x80 BOTH IP/OP "$3,990.00 " "$2,952.60" $0.00 "$3,192.00" "$1,795.50" "$1,795.50" $0.00 $0.00 $0.00 $831.62 "$2,961.38" "$2,961.38" "$3,075.49" $0.00 $831.52 $0.00 "$1,967.07" "$1,967.07" $0.00 "$1,995.00" "$3,160.08" "$3,192.00" $0.00 $0.00 $0.00 $624.44 $0.00 $0.00 $635.21 $0.00 $0.00 $0.00 $0.00 $0.00 27805394 EAP HCPCS C1876 Protege Everflex Stent 6x150x120 BOTH IP/OP "$5,319.00 " "$3,936.06" $0.00 "$4,255.20" "$2,393.55" "$2,393.55" $0.00 $0.00 $0.00 "$1,108.61" "$3,947.76" "$3,947.76" "$4,099.89" $0.00 "$1,108.48" $0.00 "$2,622.27" "$2,622.27" $0.00 "$2,659.50" "$4,212.65" "$4,255.20" $0.00 $0.00 $0.00 $832.42 $0.00 $0.00 $846.78 $0.00 $0.00 $0.00 $0.00 $0.00 27805395 EAP HCPCS C1751 Cath Art 8fr 110cm Td Co Sg Hep BOTH IP/OP "$1,013.00 " $749.62 $0.00 $810.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.50 $802.30 $810.40 $0.00 $0.00 $0.00 $158.53 $0.00 $0.00 $161.27 $0.00 $0.00 $0.00 $0.00 $0.00 27805407 EAP HCPCS C1876 Stent Duodenal Wallflex .035 In L9 Cm L230 Cm Od22-27 Mm BOTH IP/OP "$7,537.00 " "$5,577.38" $0.00 "$6,029.60" "$3,391.65" "$3,391.65" $0.00 $0.00 $0.00 "$1,570.90" "$4,181.12" "$4,181.12" "$5,809.52" $0.00 "$1,570.71" $0.00 "$3,715.74" "$3,715.74" $0.00 "$3,768.50" "$5,969.30" "$6,029.60" $0.00 "$3,391.65" $0.00 "$1,179.54" $0.00 $0.00 "$1,199.89" $0.00 $0.00 $0.00 $0.00 $0.00 27805409 EAP HCPCS L8699 Onyx 18 Kit Avm Us BOTH IP/OP "$6,984.00 " "$5,168.16" $0.00 "$5,587.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,383.27" $0.00 "$1,455.47" $0.00 $0.00 $0.00 $0.00 "$3,492.00" "$5,531.33" "$5,587.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805410 EAP HCPCS L8699 Onyx 34 Kit Avm Us BOTH IP/OP "$6,651.00 " "$4,921.74" $0.00 "$5,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,126.59" $0.00 "$1,386.07" $0.00 $0.00 $0.00 $0.00 "$3,325.50" "$5,267.59" "$5,320.80" $0.00 "$2,992.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805412 EAP HCPCS C1874 Stent Bil 8mm 8.5fr 60mm Flly Covered Trnshep Wallflex BOTH IP/OP "$7,978.00 " "$5,903.72" $0.00 "$6,382.40" "$3,590.10" "$3,590.10" $0.00 $0.00 $0.00 "$1,662.81" "$4,181.12" "$4,181.12" "$6,149.44" $0.00 "$1,662.62" $0.00 "$3,933.15" "$3,933.15" $0.00 "$3,989.00" "$6,318.58" "$6,382.40" $0.00 $0.00 $0.00 "$1,248.56" $0.00 $0.00 "$1,270.10" $0.00 $0.00 $0.00 $0.00 $0.00 27805413 EAP HCPCS C1874 Stent Bil 8mm 8.5fr 80mm Flly Covered Trnshep Wallflex BOTH IP/OP "$7,978.00 " "$5,903.72" $0.00 "$6,382.40" "$3,590.10" "$3,590.10" $0.00 $0.00 $0.00 "$1,662.81" "$4,181.12" "$4,181.12" "$6,149.44" $0.00 "$1,662.62" $0.00 "$3,933.15" "$3,933.15" $0.00 "$3,989.00" "$6,318.58" "$6,382.40" $0.00 $0.00 $0.00 "$1,248.56" $0.00 $0.00 "$1,270.10" $0.00 $0.00 $0.00 $0.00 $0.00 27805414 EAP HCPCS C1874 Stent Bil 10mm 8.5fr 40mm Flly Covered Trnshep Wallflex BOTH IP/OP "$7,978.00 " "$5,903.72" $0.00 "$6,382.40" "$3,590.10" "$3,590.10" $0.00 $0.00 $0.00 "$1,662.81" "$4,181.12" "$4,181.12" "$6,149.44" $0.00 "$1,662.62" $0.00 "$3,933.15" "$3,933.15" $0.00 "$3,989.00" "$6,318.58" "$6,382.40" $0.00 "$3,590.10" $0.00 "$1,248.56" $0.00 $0.00 "$1,270.10" $0.00 $0.00 $0.00 $0.00 $0.00 27805415 EAP HCPCS C1876 Stent Bil 10mm 8.5fr 60mm Flly Covered Trnshep Wallflex BOTH IP/OP "$7,978.00 " "$5,903.72" $0.00 "$6,382.40" "$3,590.10" "$3,590.10" $0.00 $0.00 $0.00 "$1,662.81" "$4,181.12" "$4,181.12" "$6,149.44" $0.00 "$1,662.62" $0.00 "$3,933.15" "$3,933.15" $0.00 "$3,989.00" "$6,318.58" "$6,382.40" $0.00 $0.00 $0.00 "$1,248.56" $0.00 $0.00 "$1,270.10" $0.00 $0.00 $0.00 $0.00 $0.00 27805416 EAP HCPCS C1876 Stent Bil 10mm 8.5fr 80mm Flly Covered Trnshep Wallflex BOTH IP/OP "$7,978.00 " "$5,903.72" $0.00 "$6,382.40" "$3,590.10" "$3,590.10" $0.00 $0.00 $0.00 "$1,662.81" "$4,181.12" "$4,181.12" "$6,149.44" $0.00 "$1,662.62" $0.00 "$3,933.15" "$3,933.15" $0.00 "$3,989.00" "$6,318.58" "$6,382.40" $0.00 $0.00 $0.00 "$1,248.56" $0.00 $0.00 "$1,270.10" $0.00 $0.00 $0.00 $0.00 $0.00 27805417 EAP HCPCS C1876 Stent Bil 10mm 80mm Uncvr Wallflex BOTH IP/OP "$5,395.00 " "$3,992.30" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 "$1,124.45" "$4,004.17" "$4,004.17" "$4,158.47" $0.00 "$1,124.32" $0.00 "$2,659.74" "$2,659.74" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 $0.00 $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 27805418 EAP HCPCS C1876 Stent Bil 80mm 60mm Uncvr Wallflex BOTH IP/OP "$5,395.00 " "$3,992.30" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 "$1,124.45" "$4,004.17" "$4,004.17" "$4,158.47" $0.00 "$1,124.32" $0.00 "$2,659.74" "$2,659.74" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 $0.00 $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 27805419 EAP HCPCS C1876 Stent Bil 80mm 80mm Uncvr Wallflex BOTH IP/OP "$5,395.00 " "$3,992.30" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 "$1,124.45" "$4,004.17" "$4,004.17" "$4,158.47" $0.00 "$1,124.32" $0.00 "$2,659.74" "$2,659.74" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 $0.00 $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 27805420 EAP HCPCS C1876 Stent Bil 80mm 10mm Uncvr Wallflex BOTH IP/OP "$5,395.00 " "$3,992.30" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 "$1,124.45" "$4,004.17" "$4,004.17" "$4,158.47" $0.00 "$1,124.32" $0.00 "$2,659.74" "$2,659.74" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 $0.00 $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 27805421 EAP HCPCS C1876 Stent Bil 10mm 80mm Uncvr Wallflex BOTH IP/OP "$5,395.00 " "$3,992.30" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 "$1,124.45" "$4,004.17" "$4,004.17" "$4,158.47" $0.00 "$1,124.32" $0.00 "$2,659.74" "$2,659.74" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 $0.00 $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 27805422 EAP HCPCS C1876 Stent Bil 10mm 10mm Uncvr Wallflex BOTH IP/OP "$5,395.00 " "$3,992.30" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 "$1,124.45" "$4,004.17" "$4,004.17" "$4,158.47" $0.00 "$1,124.32" $0.00 "$2,659.74" "$2,659.74" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 $0.00 $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 27805423 EAP HCPCS C1876 Stent Bil 10mm 40mm Uncvr Wallflex BOTH IP/OP "$5,395.00 " "$3,992.30" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 "$1,124.45" "$4,004.17" "$4,004.17" "$4,158.47" $0.00 "$1,124.32" $0.00 "$2,659.74" "$2,659.74" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 "$2,427.75" $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 27805424 EAP HCPCS C1876 Stent Bil 10mm 60mm Uncvr Wallflex BOTH IP/OP "$5,395.00 " "$3,992.30" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 "$1,124.45" "$4,004.17" "$4,004.17" "$4,158.47" $0.00 "$1,124.32" $0.00 "$2,659.74" "$2,659.74" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 "$2,427.75" $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 27805431 EAP Custom 27805431 Pipeline Embolization Device 3.00mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805432 EAP Custom 27805432 Bowtie Shape - 10g Mammomark - Biopsy Site Identtfier BOTH IP/OP $689.00 $509.86 $0.00 $551.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $511.38 $511.38 $531.08 $0.00 $143.59 $0.00 $0.00 $0.00 $0.00 $344.50 $545.69 $551.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805437 EAP C1817 Amplatzer Septal Occluder 20 Mm BOTH IP/OP "$16,714.00 " "$12,368.36" $0.00 "$13,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,883.15" $0.00 "$3,483.20" $0.00 $0.00 $0.00 $0.00 "$8,357.00" "$13,237.49" "$13,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805438 EAP C1817 Amplatzer Septal Occluder 22 Mm BOTH IP/OP "$16,714.00 " "$12,368.36" $0.00 "$13,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,883.15" $0.00 "$3,483.20" $0.00 $0.00 $0.00 $0.00 "$8,357.00" "$13,237.49" "$13,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805439 EAP HCPCS C1817 Amplatzer Septal Occluder 24 Mm BOTH IP/OP "$16,714.00 " "$12,368.36" $0.00 "$13,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,883.15" $0.00 "$3,483.20" $0.00 $0.00 $0.00 $0.00 "$8,357.00" "$13,237.49" "$13,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805440 EAP CPT® C1817 Amplatzer Septal Occluder 26 Mm BOTH IP/OP "$16,714.00 " "$12,368.36" $0.00 "$13,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,883.15" $0.00 "$3,483.20" $0.00 $0.00 $0.00 $0.00 "$8,357.00" "$13,237.49" "$13,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805441 EAP CPT® C1896 Q-trak Electrode BOTH IP/OP "$13,779.00 " "$10,196.46" $0.00 "$11,023.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,871.89" "$4,181.12" "$4,181.12" "$10,620.85" $0.00 "$2,871.54" $0.00 "$6,793.05" "$6,793.05" $0.00 "$6,889.50" "$10,912.97" "$11,023.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805442 EAP HCPCS C1781 Occluder Septal 15mm BOTH IP/OP "$18,552.00 " "$13,728.48" $0.00 "$14,841.60" "$8,348.40" "$8,348.40" $0.00 $0.00 $0.00 "$3,866.70" "$4,181.12" "$4,181.12" "$14,299.88" $0.00 "$3,866.24" $0.00 "$9,146.14" "$9,146.14" $0.00 "$9,276.00" "$14,693.18" "$14,841.60" $0.00 $0.00 $0.00 "$2,903.39" $0.00 $0.00 "$2,953.48" $0.00 $0.00 $0.00 $0.00 $0.00 27805443 EAP HCPCS C1781 Occluder Septal 20mm BOTH IP/OP "$18,552.00 " "$13,728.48" $0.00 "$14,841.60" "$8,348.40" "$8,348.40" $0.00 $0.00 $0.00 "$3,866.70" "$4,181.12" "$4,181.12" "$14,299.88" $0.00 "$3,866.24" $0.00 "$9,146.14" "$9,146.14" $0.00 "$9,276.00" "$14,693.18" "$14,841.60" $0.00 $0.00 $0.00 "$2,903.39" $0.00 $0.00 "$2,953.48" $0.00 $0.00 $0.00 $0.00 $0.00 27805444 EAP HCPCS C1781 Occluder Septal 25mm BOTH IP/OP "$18,552.00 " "$13,728.48" $0.00 "$14,841.60" "$8,348.40" "$8,348.40" $0.00 $0.00 $0.00 "$3,866.70" "$4,181.12" "$4,181.12" "$14,299.88" $0.00 "$3,866.24" $0.00 "$9,146.14" "$9,146.14" $0.00 "$9,276.00" "$14,693.18" "$14,841.60" $0.00 "$8,348.40" $0.00 "$2,903.39" $0.00 $0.00 "$2,953.48" $0.00 $0.00 $0.00 $0.00 $0.00 27805445 EAP HCPCS C1781 Occluder Septal 30mm BOTH IP/OP "$18,552.00 " "$13,728.48" $0.00 "$14,841.60" "$8,348.40" "$8,348.40" $0.00 $0.00 $0.00 "$3,866.70" "$4,181.12" "$4,181.12" "$14,299.88" $0.00 "$3,866.24" $0.00 "$9,146.14" "$9,146.14" $0.00 "$9,276.00" "$14,693.18" "$14,841.60" $0.00 $0.00 $0.00 "$2,903.39" $0.00 $0.00 "$2,953.48" $0.00 $0.00 $0.00 $0.00 $0.00 27805446 EAP HCPCS C1781 Occluder Septal 35mm BOTH IP/OP "$18,552.00 " "$13,728.48" $0.00 "$14,841.60" "$8,348.40" "$8,348.40" $0.00 $0.00 $0.00 "$3,866.70" "$4,181.12" "$4,181.12" "$14,299.88" $0.00 "$3,866.24" $0.00 "$9,146.14" "$9,146.14" $0.00 "$9,276.00" "$14,693.18" "$14,841.60" $0.00 $0.00 $0.00 "$2,903.39" $0.00 $0.00 "$2,953.48" $0.00 $0.00 $0.00 $0.00 $0.00 27805447 EAP Custom 27805447 Pipeline Embolization Device 3.00mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805448 EAP Custom 27805448 Pipeline Embolization Device 3.00mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805449 EAP Custom 27805449 Pipeline Embolization Device 3.25mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805450 EAP Custom 27805450 Pipeline Embolization Device 3.25mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805451 EAP Custom 27805451 Pipeline Embolization Device 3.25mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805452 EAP Custom 27805452 Pipeline Embolization Device 3.50mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805453 EAP Custom 27805453 Pipeline Embolization Device 3.50mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805454 EAP Custom 27805454 Pipeline Embolization Device 3.50mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805455 EAP Custom 27805455 Pipeline Embolization Device 3.75mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805456 EAP Custom 27805456 Pipeline Embolization Device 3.75mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805457 EAP Custom 27805457 Pipeline Embolization Device 3.75mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805458 EAP Custom 27805458 Pipeline Embolization Device 4.00mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805459 EAP Custom 27805459 Pipeline Embolization Device 4.00mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805460 EAP Custom 27805460 Pipeline Embolization Device 4.00mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805461 EAP Custom 27805461 Pipeline Embolization Device 4.25mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805462 EAP Custom 27805462 Pipeline Embolization Device 4.25mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805463 EAP Custom 27805463 Pipeline Embolization Device 4.25mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805464 EAP Custom 27805464 Pipeline Embolization Device 4.50mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805465 EAP Custom 27805465 Pipeline Embolization Device 4.50mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805466 EAP Custom 27805466 Pipeline Embolization Device 4.50mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805467 EAP Custom 27805467 Pipeline Embolization Device 4.75mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805468 EAP Custom 27805468 Pipeline Embolization Device 4.75mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805469 EAP Custom 27805469 Pipeline Embolization Device 4.75mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805470 EAP Custom 27805470 Pipeline Embolization Device 5.00mm X 25mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805471 EAP Custom 27805471 Pipeline Embolization Device 5.00mm X 30mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805472 EAP Custom 27805472 Pipeline Embolization Device 5.00mm X 35mm BOTH IP/OP "$38,029.00 " "$28,141.46" $0.00 "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$29,312.75" $0.00 "$7,925.24" $0.00 $0.00 $0.00 $0.00 "$19,014.50" "$30,118.97" "$30,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805473 EAP Custom 27805473 Pipeline Embolization Device 2.50mm X 10mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805474 EAP Custom 27805474 Pipeline Embolization Device 2.50mm X 12mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805475 EAP Custom 27805475 Pipeline Embolization Device 2.50mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805476 EAP Custom 27805476 Pipeline Embolization Device 2.50mm X 16mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805477 EAP Custom 27805477 Pipeline Embolization Device 2.50mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805478 EAP Custom 27805478 Pipeline Embolization Device 2.50mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805479 EAP Custom 27805479 Pipeline Embolization Device 2.75mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805480 EAP Custom 27805480 Pipeline Embolization Device 2.75mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805481 EAP Custom 27805481 Pipeline Embolization Device 2.75mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805482 EAP Custom 27805482 Pipeline Embolization Device 3.00mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805483 EAP Custom 27805483 Pipeline Embolization Device 3.00mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805484 EAP Custom 27805484 Pipeline Embolization Device 3.00mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805485 EAP Custom 27805485 Pipeline Embolization Device 3.25mm X 10mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805486 EAP Custom 27805486 Pipeline Embolization Device 3.25mm X 12mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805487 EAP Custom 27805487 Pipeline Embolization Device 3.25mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805488 EAP Custom 27805488 Pipeline Embolization Device 3.25mm X 16mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805489 EAP Custom 27805489 Pipeline Embolization Device 3.25mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805490 EAP Custom 27805490 Pipeline Embolization Device 3.25mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805491 EAP Custom 27805491 Pipeline Embolization Device 3.50mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 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$0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805495 EAP Custom 27805495 Pipeline Embolization Device 3.75mm X 12mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805496 EAP Custom 27805496 Pipeline Embolization Device 3.75mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805497 EAP Custom 27805497 Pipeline Embolization Device 3.75mm X 16mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805498 EAP Custom 27805498 Pipeline Embolization Device 3.75mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805499 EAP Custom 27805499 Pipeline Embolization Device 3.75mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805500 EAP Custom 27805500 Pipeline Embolization Device 4.00mm X 10mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805501 EAP Custom 27805501 Pipeline Embolization Device 4.00mm X 12mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805502 EAP Custom 27805502 Pipeline Embolization Device 4.00mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805503 EAP Custom 27805503 Pipeline Embolization Device 4.00mm X 16mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805504 EAP Custom 27805504 Pipeline Embolization Device 4.00mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805505 EAP Custom 27805505 Pipeline Embolization Device 4.00mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805506 EAP Custom 27805506 Pipeline Embolization Device 4.25mm X 10mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805507 EAP Custom 27805507 Pipeline Embolization Device 4.25mm X 12mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805508 EAP Custom 27805508 Pipeline Embolization Device 4.25mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 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"$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805512 EAP Custom 27805512 Pipeline Embolization Device 4.50mm X 10mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805513 EAP Custom 27805513 Pipeline Embolization Device 4.50mm X 12mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805514 EAP Custom 27805514 Pipeline Embolization Device 4.50mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805515 EAP Custom 27805515 Pipeline Embolization Device 4.50mm X 16mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805516 EAP Custom 27805516 Pipeline Embolization Device 4.50mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805517 EAP Custom 27805517 Pipeline Embolization Device 4.50mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805518 EAP Custom 27805518 Pipeline Embolization Device 4.75mm X 10mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805519 EAP Custom 27805519 Pipeline Embolization Device 4.75mm X 12mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805520 EAP Custom 27805520 Pipeline Embolization Device 4.75mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805521 EAP Custom 27805521 Pipeline Embolization Device 4.75mm X 16mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805522 EAP Custom 27805522 Pipeline Embolization Device 4.75mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805523 EAP Custom 27805523 Pipeline Embolization Device 4.75mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805524 EAP Custom 27805524 Pipeline Embolization Device 5.00mm X 10mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805525 EAP Custom 27805525 Pipeline Embolization Device 5.00mm X 12mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805526 EAP Custom 27805526 Pipeline Embolization Device 5.00mm X 14mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805527 EAP Custom 27805527 Pipeline Embolization Device 5.00mm X 16mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805528 EAP Custom 27805528 Pipeline Embolization Device 5.00mm X 18mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805529 EAP Custom 27805529 Pipeline Embolization Device 5.00mm X 20mm BOTH IP/OP "$35,550.00 " "$26,307.00" $0.00 "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,401.94" $0.00 "$7,408.62" $0.00 $0.00 $0.00 $0.00 "$17,775.00" "$28,155.60" "$28,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805530 EAP HCPCS C1876 Stent Coron 4mm 18mm .014in Rapex Flxb Lp Mtlnk Vsn Cocr BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $322.65 $322.65 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27805531 EAP HCPCS C1876 Stent Coron 4mm 28mm .014in Rapex Flxb Lp Mtlnk Vsn Cocr BOTH IP/OP $717.00 $530.58 $0.00 $573.60 $322.65 $322.65 $0.00 $0.00 $0.00 $149.44 $532.16 $532.16 $552.66 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $358.50 $567.86 $573.60 $0.00 $0.00 $0.00 $112.21 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 27805532 EAP HCPCS C1874 Stent Coron 3.5mm 24mm Drg Eluding Endvr Sprnt Zotarolimus BOTH IP/OP "$1,847.00 " "$1,366.78" $0.00 "$1,477.60" $831.15 $831.15 $0.00 $0.00 $0.00 $384.96 "$1,370.84" "$1,370.84" "$1,423.67" $0.00 $384.91 $0.00 "$1,092.50" "$1,092.50" $0.00 $923.50 "$1,462.82" "$1,477.60" $0.00 $0.00 $0.00 $289.06 $0.00 $0.00 $294.04 $0.00 $0.00 $0.00 $0.00 $0.00 27805533 EAP HCPCS C1874 Stent Coron 3.5mm 12mm Drg Eluding Endvr Sprnt Zotarolimus BOTH IP/OP "$1,847.00 " "$1,366.78" $0.00 "$1,477.60" $831.15 $831.15 $0.00 $0.00 $0.00 $384.96 "$1,370.84" "$1,370.84" "$1,423.67" $0.00 $384.91 $0.00 "$1,092.50" "$1,092.50" $0.00 $923.50 "$1,462.82" "$1,477.60" $0.00 $0.00 $0.00 $289.06 $0.00 $0.00 $294.04 $0.00 $0.00 $0.00 $0.00 $0.00 27805534 EAP HCPCS C1874 Stent Coron 3.5mm 18mm Drg Eluding Endvr Sprnt Zotarolimus BOTH IP/OP "$1,847.00 " "$1,366.78" $0.00 "$1,477.60" $831.15 $831.15 $0.00 $0.00 $0.00 $384.96 "$1,370.84" "$1,370.84" "$1,423.67" $0.00 $384.91 $0.00 "$1,092.50" "$1,092.50" $0.00 $923.50 "$1,462.82" "$1,477.60" $0.00 $0.00 $0.00 $289.06 $0.00 $0.00 $294.04 $0.00 $0.00 $0.00 $0.00 $0.00 27805535 EAP HCPCS C1874 Stent Coron 2.5mm 12mm Drg Eluding Endvr Sprnt Zotarolimus BOTH IP/OP "$1,847.00 " "$1,366.78" $0.00 "$1,477.60" $831.15 $831.15 $0.00 $0.00 $0.00 $384.96 "$1,370.84" "$1,370.84" "$1,423.67" $0.00 $384.91 $0.00 "$1,092.50" "$1,092.50" $0.00 $923.50 "$1,462.82" "$1,477.60" $0.00 $0.00 $0.00 $289.06 $0.00 $0.00 $294.04 $0.00 $0.00 $0.00 $0.00 $0.00 27805536 EAP Custom 27805536 Coil Target 3d 3mm X 6cm BOTH IP/OP "$4,502.00 " "$3,331.48" $0.00 "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,341.38" "$3,341.38" "$3,470.14" $0.00 $938.22 $0.00 $0.00 $0.00 $0.00 "$2,251.00" "$3,565.58" "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805537 EAP Custom 27805537 Coil Target 3d 4mm X 8cm BOTH IP/OP "$4,502.00 " "$3,331.48" $0.00 "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,341.38" "$3,341.38" "$3,470.14" $0.00 $938.22 $0.00 $0.00 $0.00 $0.00 "$2,251.00" "$3,565.58" "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805538 EAP Custom 27805538 Coil Target 3d 5mm X 10cm BOTH IP/OP "$4,502.00 " "$3,331.48" $0.00 "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,341.38" "$3,341.38" "$3,470.14" $0.00 $938.22 $0.00 $0.00 $0.00 $0.00 "$2,251.00" "$3,565.58" "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805539 EAP Custom 27805539 Coil Target 3d 6mm X 15cm BOTH IP/OP "$4,502.00 " "$3,331.48" $0.00 "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,341.38" "$3,341.38" "$3,470.14" $0.00 $938.22 $0.00 $0.00 $0.00 $0.00 "$2,251.00" "$3,565.58" "$3,601.60" $0.00 "$2,025.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805540 EAP Custom 27805540 Coil Target 3d 7mm X 15cm BOTH IP/OP "$4,502.00 " "$3,331.48" $0.00 "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,341.38" "$3,341.38" "$3,470.14" $0.00 $938.22 $0.00 $0.00 $0.00 $0.00 "$2,251.00" "$3,565.58" "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805541 EAP Custom 27805541 Coil Target 3d 8mm X 25cm BOTH IP/OP "$4,502.00 " "$3,331.48" $0.00 "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,341.38" "$3,341.38" "$3,470.14" $0.00 $938.22 $0.00 $0.00 $0.00 $0.00 "$2,251.00" "$3,565.58" "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805542 EAP Custom 27805542 Coil Target 3d 10mm X 30cm BOTH IP/OP "$4,502.00 " "$3,331.48" $0.00 "$3,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,341.38" "$3,341.38" "$3,470.14" $0.00 $938.22 $0.00 $0.00 $0.00 $0.00 "$2,251.00" "$3,565.58" "$3,601.60" $0.00 "$2,025.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805543 EAP Custom 27805543 Coil Embl 10cm 4mm Trgt Dtch Ult 360d BOTH IP/OP "$4,752.00 " "$3,516.48" $0.00 "$3,801.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,526.93" "$3,526.93" "$3,662.84" $0.00 $990.32 $0.00 $0.00 $0.00 $0.00 "$2,376.00" "$3,763.58" "$3,801.60" $0.00 "$2,138.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805544 EAP Custom 27805544 Coil Target 360 Ultra 3.5mm X 8cm BOTH IP/OP "$5,401.00 " "$3,996.74" $0.00 "$4,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,008.62" "$4,008.62" "$4,163.09" $0.00 "$1,125.57" $0.00 $0.00 $0.00 $0.00 "$2,700.50" "$4,277.59" "$4,320.80" $0.00 "$2,430.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805545 EAP Custom 27805545 Coil Target 360 Ultra 4.5mm X 10cm BOTH IP/OP "$5,671.00 " "$4,196.54" $0.00 "$4,536.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,371.21" $0.00 "$1,181.84" $0.00 $0.00 $0.00 $0.00 "$2,835.50" "$4,491.43" "$4,536.80" $0.00 "$2,551.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805546 EAP Custom 27805546 Coil Target 360 Nano 2mm X 3cm BOTH IP/OP "$5,671.00 " "$4,196.54" $0.00 "$4,536.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,371.21" $0.00 "$1,181.84" $0.00 $0.00 $0.00 $0.00 "$2,835.50" "$4,491.43" "$4,536.80" $0.00 "$2,551.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805547 EAP Custom 27805547 Coil Target 360 Nano 2mm X 4cm BOTH IP/OP "$5,671.00 " "$4,196.54" $0.00 "$4,536.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,371.21" $0.00 "$1,181.84" $0.00 $0.00 $0.00 $0.00 "$2,835.50" "$4,491.43" "$4,536.80" $0.00 "$2,551.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805548 EAP Custom 27805548 Coil Target 360 Nano 2.5mm X 4cm BOTH IP/OP "$5,401.00 " "$3,996.74" $0.00 "$4,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,008.62" "$4,008.62" "$4,163.09" $0.00 "$1,125.57" $0.00 $0.00 $0.00 $0.00 "$2,700.50" "$4,277.59" "$4,320.80" $0.00 "$2,430.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805549 EAP Custom 27805549 Coil Target 360 Nano 3mm X 4cm BOTH IP/OP "$5,671.00 " "$4,196.54" $0.00 "$4,536.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,371.21" $0.00 "$1,181.84" $0.00 $0.00 $0.00 $0.00 "$2,835.50" "$4,491.43" "$4,536.80" $0.00 "$2,551.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805550 EAP Custom 27805550 Coil Target 360 Nano 3mm X 6cm BOTH IP/OP "$5,401.00 " "$3,996.74" $0.00 "$4,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,008.62" "$4,008.62" "$4,163.09" $0.00 "$1,125.57" $0.00 $0.00 $0.00 $0.00 "$2,700.50" "$4,277.59" "$4,320.80" $0.00 "$2,430.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805551 EAP Custom 27805551 Coil Target 360 Nano 3.5mm X 6cm BOTH IP/OP "$5,671.00 " "$4,196.54" $0.00 "$4,536.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,371.21" $0.00 "$1,181.84" $0.00 $0.00 $0.00 $0.00 "$2,835.50" "$4,491.43" "$4,536.80" $0.00 "$2,551.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805552 EAP Custom 27805552 Sensation Plus 40cc Iab 7.5 BOTH IP/OP "$3,004.00 " "$2,222.96" $0.00 "$2,403.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,229.57" "$2,229.57" "$2,315.48" $0.00 $626.03 $0.00 $0.00 $0.00 $0.00 "$1,502.00" "$2,379.17" "$2,403.20" $0.00 "$1,351.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805553 EAP Custom 27805553 Sensation Plus 50cc Iab 8.0 BOTH IP/OP "$3,154.00 " "$2,333.96" $0.00 "$2,523.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,340.90" "$2,340.90" "$2,431.10" $0.00 $657.29 $0.00 $0.00 $0.00 $0.00 "$1,577.00" "$2,497.97" "$2,523.20" $0.00 "$1,419.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805554 EAP HCPCS C1760 Vascade Vascular Closure Device 5fr BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $247.50 $247.50 $0.00 $0.00 $0.00 $114.63 $408.21 $408.21 $423.94 $0.00 $114.62 $0.00 $325.33 $325.33 $0.00 $275.00 $435.60 $440.00 $0.00 $247.50 $0.00 $86.08 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 27805555 EAP HCPCS C1760 Vascade Vascular Closure Device 6/7fr BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $247.50 $247.50 $0.00 $0.00 $0.00 $114.63 $408.21 $408.21 $423.94 $0.00 $114.62 $0.00 $325.33 $325.33 $0.00 $275.00 $435.60 $440.00 $0.00 $247.50 $0.00 $86.08 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 27805556 EAP HCPCS C1876 Stent Bil 9mm 6fr 20mm 80cm .035in 7.5-8.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805557 EAP HCPCS C1876 Stent Bil 9mm 6fr 30mm 80cm .035in 7.5-8.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805558 EAP HCPCS C1876 Stent Bil 9mm 6fr 40mm 80cm .035in Slf Xpd Flxb Lp Tntlm BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805559 EAP HCPCS C1876 Stent Bil 9mm 6fr 60mm 80cm .35in 7.5-8.5mm Slf Expandable BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805560 EAP HCPCS C1876 Stent Bil 9mm 6fr 80mm 80cm .035in 7.5-8.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805561 EAP HCPCS C1876 Stent Bil 10mm 6fr 20mm 80cm .035in 8.5-9.5mm Slf Xpd Lp BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805562 EAP HCPCS C1876 Stent Bil 10mm 6fr 30mm 80cm .035in 8.5-9.5mm Slf Xpd Lp BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805563 EAP HCPCS C1876 Stent Bil 10mm 6fr 40mm 80cm 8.5-9.5mm .035in Slf Xpd Flxb BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805564 EAP HCPCS C1876 Stent Bil 10mm 6fr 60mm 80cm .035in 8.5-9.5mm Slf Xpd Dlv BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805565 EAP HCPCS C1876 Stent Bil 10mm 6fr 80mm 80cm .035in 8.5-9.5mm Slf Xpd Lp BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805566 EAP HCPCS C1876 Stent Bil 12mm 6fr 20mm 80cm .35in 9.5-11mm Slf Xpd Lp Prcs BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805567 EAP HCPCS C1876 Stent Bil 12mm 6fr 30mm 80cm .035in 9.5-11mm Slf Xpd Lp Prcs BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805568 EAP HCPCS C1876 Stent Bil 12mm 6fr 80mm 80cm .035in Otw Slf Xpd Lp Tntlm BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805569 EAP HCPCS C1876 Stent Bil 14mm 6fr 20mm 80cm .035in 11.5-13mm Slf Xpd Lp BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805570 EAP HCPCS C1876 Stent Bil 14mm 6fr 30mm 80cm .035in 11.5-13mm Slf Xpd Lp BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805571 EAP HCPCS C1876 Stent Bil 14mm 6fr 60mm 80cm .035in Slf Xpd Cmpt Flxb Lp BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805572 EAP HCPCS C1876 Stent Bil 9mm 6fr 20mm 120cm .035in Slf Xpd Flxb Lp Tntlm BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805573 EAP HCPCS C1876 Stent Bil 9mm 6fr 30mm 120cm Lg Dia Lp Slf Xpd Opn Ltc Dsgn BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805574 EAP HCPCS C1876 Stent Bil 9mm 6fr 40mm 120cm .035in 7.5-8.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805575 EAP HCPCS C1876 Stent Bil 9mm 6fr 60mm 120cm .035in 7.5-8.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805576 EAP HCPCS C1876 Stent Bil 9mm 6fr 80mm 120cm .035in 7.5-8.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805577 EAP HCPCS C1876 Stent Bil 10mm 6fr 20mm 120cm .035in 8.5-9.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805578 EAP HCPCS C1876 Stent Bil 10mm 6fr 30mm 120cm .018in 8.5-9.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805579 EAP HCPCS C1876 Stent Bil 10mm 6fr 80mm 120cm .035in 8.5-9.5mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805580 EAP HCPCS C1876 Stent Bil 12mm 6fr 20mm 120cm Lg Dia Lp Slf Xpd Opn Ltc Dsgn BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805581 EAP HCPCS C1876 Stent Bil 12mm 6fr 30mm 120cm .035in 9.5-11mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805582 EAP HCPCS C1876 Stent Bil 12mm 6fr 40mm 120cm .035in 9.5-11mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805583 EAP HCPCS C1876 Stent Bil 12mm 6fr 60mm 120cm Lp Slf Xpd Flxb Radl Strth Gps BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805584 EAP HCPCS C1876 Stent Bil 12mm 9.5-11fr 80mm 120cm .035in Slf Xpd Flxb Lp BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805585 EAP HCPCS C1876 Stent Bil 14mm 6fr 20mm 120cm .035in Slf Xpd Cmpt Flxb Lp BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805586 EAP HCPCS C1876 Stent Bil 14mm 6fr 30mm 120cm .035in 11.5-13mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805587 EAP HCPCS C1876 Stent Bil 14mm 6fr 40mm 120cm .035in 11.5-13mm Gwire Lum Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805588 EAP HCPCS C1876 Stent Bil 14mm 6fr 60mm 120cm .035in Slf Xpd Flxb Lp Tntlm BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805589 EAP HCPCS C1876 Stent Bil 14mm 6fr 80mm 120cm .035in Slf Xpd Flxb Lp Tntlm BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805590 EAP CPT® C1876 Integrity Rx Coronary Stent System Mm BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $868.50 $868.50 $0.00 $0.00 $0.00 $402.26 "$1,432.45" "$1,432.45" "$1,487.64" $0.00 $402.21 $0.00 "$1,141.60" "$1,141.60" $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $302.05 $0.00 $0.00 $307.26 $0.00 $0.00 $0.00 $0.00 $0.00 27805591 EAP HCPCS C1876 Stent Prtg Everflex 6mm 6fr 80cm 20mm .035in Peri Otw Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805592 EAP HCPCS C1876 Stent Everflex 6mm 6fr 80cm 30mm .035in Peri Otw Slf Xpd BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805593 EAP HCPCS C1876 Stent Everflex 6mm 6fr 80cm 40mm .035in Peri Slf Xpd Flxb BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805594 EAP HCPCS C1876 Stent Bil 6mm 6fr 60mm 80cm .035in Slf Xpd Flxb Drblty Sprl BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805595 EAP HCPCS C1876 Stent Bil 6mm 6fr 80mm 80cm .035in 3 Wv Peak Dsgn Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805596 EAP HCPCS C1876 Stent Bil 6mm 6fr 100mm 80cm .035in Otw Slf Xpd Flxb Drble BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805597 EAP HCPCS C1876 Stent Bil 6mm 6fr 120mm 80cm .035in 3 Wv Peak Dsgn Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805598 EAP HCPCS C1876 Stent Bil 6mm 6fr 150mm 80cm .035in Otw Slf Xpd Flxb Drble BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805599 EAP HCPCS C1876 Stent Bil 7mm 6fr 20mm 80cm .035in Sprl 3 Wv Peak Dsgn Gwire BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805600 EAP HCPCS C1876 Stent Everflex Prtg 7mm 6fr 80cm 30mm .035in Peri 3 Wv Peak BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805601 EAP HCPCS C1876 Stent Everflex 7mm 6fr 80cm 40mm .035in Peri 3 Wv Peak BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805602 EAP HCPCS C1876 Stent Prtg Everflex 7mm 6fr 80cm 60mm .035in Peri 3 Wv Peak BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805603 EAP HCPCS C1876 Stent Bil 7mm 6fr 80mm 80cm .035in 3 Wv Peak Introd Shth Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805604 EAP HCPCS C1876 Stent Bil 7mm 6fr 100mm 80cm .035in 3 Wv Peak Dsgn Slf Xpd BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805605 EAP HCPCS C1876 Stent Bil 7mm 6fr 120mm 80cm .035in 3 Wv Peak Dsgn Slf Xpd BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805606 EAP HCPCS C1876 Stent Bil 7mm 6fr 150mm 80cm .035in 3 Wv Peak Dsgn Slf Xpd BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805607 EAP HCPCS C1876 Stent Bil 8mm 6fr 20mm 80cm .035in 3 Wv Peak Dsgn Otw Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805608 EAP HCPCS C1876 Stent Prtg Everflex 8mm 6fr 80mm 30cm .035in Peri 3 Wv Peak BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805609 EAP HCPCS C1876 Stent Everflex 8mm 6fr 80cm 40mm .035in Peri Slf Xpd Flxb BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805610 EAP HCPCS C1876 Stent Vasc 8mm 6fr 60mm 80cm .035in Slf Xpd Gwire Drblty BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805611 EAP HCPCS C1876 Stent Prtg Everflex 8mm 6fr 80mm 80cm .035in Peri 3 Wv Peak BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805612 EAP HCPCS C1876 Stent Bil 8mm 6fr 100mm 80cm .035in 3 Wv Peak Dsgn Slf Xpd BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805613 EAP HCPCS C1876 Stent Bil 8mm 6fr 120mm 80cm .035in 3 Wv Peak Dsgn Slf Xpd BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805614 EAP HCPCS C1876 Stent Bil 8mm 6fr 150mm 80cm .035in 3 Wv Peak Dsgn Slf Xpd BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805615 EAP HCPCS C1876 Stent Everflex 6mm 6fr 120cm 20mm .035in Peri Slf Xpd Flxb BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805616 EAP HCPCS C1876 Stent Bil 6mm 6fr 30mm 120cm .035in Slf Xpd Flxb Drblty Sprl BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805617 EAP HCPCS C1876 Stent Everflex 6mm 6fr 120cm 100mm .035in Peri 3 Wv Peak BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805618 EAP HCPCS C1876 Stent Everflex 6mm 6fr 120cm 120mm .035in Peri 3 Wv Peak BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805619 EAP HCPCS C1876 Stent Vasc 6mm 6fr 200mm 120cm .035in Slf Expandable Flxb BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805620 EAP HCPCS C1876 Stent Vasc 7mm 6fr 20mm 120cm .035in 3 Wv Peak Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805621 EAP HCPCS C1876 Stent Everflex 7mm 6fr 120cm 30mm .035in Peri 3 Wv Peak Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805622 EAP HCPCS C1876 Stent Vasc 7mm 6fr 40mm 120cm .035in Slf Expandable Flxb BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805623 EAP HCPCS C1876 Stent Bil 7mm 6fr 60mm 120cm 3 Wv Peak Dsgn Slf Xpd Flxb BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805624 EAP HCPCS C1876 Stent Vasc 7mm 6fr 80mm 120cm .035in 3 Wv Peak Introd Shth BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805625 EAP HCPCS C1876 Stent Vasc 7mm 6fr 100mm 120cm .035in 3 Wv Peak Introd Shth BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805626 EAP HCPCS C1876 Stent Vasc 7mm 6fr 120mm 120cm .035in 3 Wv Peak Introd Shth BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805627 EAP HCPCS C1876 Stent Bil 7mm 6fr 150mm 120cm .035in 3 Wv Peak Dsgn Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805628 EAP HCPCS C1876 Stent Vasc 7mm 6fr 200mm 120cm .035in 5.5-6.5mm Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805629 EAP HCPCS C1876 Stent Prtg Everflex 8mm 6fr 120mm 20cm .035in Peri 3 Wv Peak BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805630 EAP HCPCS C1876 Stent Bil 8mm 6fr 30mm 120cm .035in Slf Xpd Flxb Drble Sprl BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805631 EAP HCPCS C1876 Stent Everflex Prtg 8mm 6fr 120cm 100mm .035in Peri 3 Wv BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805632 EAP HCPCS C1876 Stent Prtg Everflex 8mm 6fr 120cm 120mm .035in Peri Otw Slf BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805633 EAP HCPCS C1876 Stent Prtg Everflex 8mm 6fr 120cm 150mm .035in Peri 3 Wv BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805634 EAP HCPCS C1876 Stent Vasc 8mm 6fr 200mm 120cm .035in 6.5-7.5mm Slf Xpd Shth BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" "$1,674.45" "$1,674.45" $0.00 $0.00 $0.00 $775.55 "$2,761.73" "$2,761.73" "$2,868.15" $0.00 $775.46 $0.00 "$1,834.45" "$1,834.45" $0.00 "$1,860.50" "$2,947.03" "$2,976.80" $0.00 $0.00 $0.00 $582.34 $0.00 $0.00 $592.38 $0.00 $0.00 $0.00 $0.00 $0.00 27805635 EAP HCPCS C1876 Stent Vasc 10-8mm 40mm Tpr Slf Expandable Erg Hndl Flxb Crtd BOTH IP/OP "$6,739.00 " "$4,986.86" $0.00 "$5,391.20" "$3,032.55" "$3,032.55" $0.00 $0.00 $0.00 "$1,404.58" "$4,181.12" "$4,181.12" "$5,194.42" $0.00 "$1,404.41" $0.00 "$3,322.33" "$3,322.33" $0.00 "$3,369.50" "$5,337.29" "$5,391.20" $0.00 "$3,032.55" $0.00 "$1,054.65" $0.00 $0.00 "$1,072.85" $0.00 $0.00 $0.00 $0.00 $0.00 27805636 EAP HCPCS C1876 Stent Vasc 9-7mm 40mm Tpr Slf Expandable Erg Hndl Flxb Crtd BOTH IP/OP "$6,739.00 " "$4,986.86" $0.00 "$5,391.20" "$3,032.55" "$3,032.55" $0.00 $0.00 $0.00 "$1,404.58" "$4,181.12" "$4,181.12" "$5,194.42" $0.00 "$1,404.41" $0.00 "$3,322.33" "$3,322.33" $0.00 "$3,369.50" "$5,337.29" "$5,391.20" $0.00 "$3,032.55" $0.00 "$1,054.65" $0.00 $0.00 "$1,072.85" $0.00 $0.00 $0.00 $0.00 $0.00 27805637 EAP HCPCS C1876 Stent Vasc 8-6mm 40mm Tpr Slf Expandable Erg Hndl Flxb Crtd BOTH IP/OP "$6,739.00 " "$4,986.86" $0.00 "$5,391.20" "$3,032.55" "$3,032.55" $0.00 $0.00 $0.00 "$1,404.58" "$4,181.12" "$4,181.12" "$5,194.42" $0.00 "$1,404.41" $0.00 "$3,322.33" "$3,322.33" $0.00 "$3,369.50" "$5,337.29" "$5,391.20" $0.00 "$3,032.55" $0.00 "$1,054.65" $0.00 $0.00 "$1,072.85" $0.00 $0.00 $0.00 $0.00 $0.00 27805638 EAP Custom 27805638 Og Cmplx Fill Coil 2x1.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805639 EAP Custom 27805639 Og Cmplx Fill Coil 2x2 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805640 EAP Custom 27805640 Og Cmplx Fill Coil 3x4 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805641 EAP Custom 27805641 Og Cmplx Fill Coil 3x6 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805642 EAP Custom 27805642 Og Cmplx Fill Coil 3x8 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805643 EAP Custom 27805643 Og Tdl Cmplx Fill Coil 4x4 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805644 EAP Custom 27805644 Og Tdl Cmplx Fill Coil 4x7 BOTH IP/OP "$4,327.00 " "$3,201.98" $0.00 "$3,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,211.50" "$3,211.50" "$3,335.25" $0.00 $901.75 $0.00 $0.00 $0.00 $0.00 "$2,163.50" "$3,426.98" "$3,461.60" $0.00 "$1,947.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805645 EAP Custom 27805645 Og Tdl Cmplx Fill Coil 4x10 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805646 EAP Custom 27805646 Og Tdl Cmplx Fill Coil 4x12 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805647 EAP Custom 27805647 Og Tdl Cmplx Fill Coil 5x5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805648 EAP Custom 27805648 Og Tdl Cmplx Fill Coil 5x10 BOTH IP/OP "$4,327.00 " "$3,201.98" $0.00 "$3,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,211.50" "$3,211.50" "$3,335.25" $0.00 $901.75 $0.00 $0.00 $0.00 $0.00 "$2,163.50" "$3,426.98" "$3,461.60" $0.00 "$1,947.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805649 EAP Custom 27805649 Coil Embolization .012in 5mm 15cm Complex Fill Detachable BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805650 EAP Custom 27805650 Og Tdl Cmplx Fill Coil 6x10 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805651 EAP Custom 27805651 Og Tdl Cmplx Fill Coil 6x15 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805652 EAP Custom 27805652 Og Tdl Cmplx Fill Coil 6x20 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805653 EAP Custom 27805653 Og Tdl Cmplx Fill Coil 7x15 BOTH IP/OP "$4,327.00 " "$3,201.98" $0.00 "$3,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,211.50" "$3,211.50" "$3,335.25" $0.00 $901.75 $0.00 $0.00 $0.00 $0.00 "$2,163.50" "$3,426.98" "$3,461.60" $0.00 "$1,947.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805654 EAP Custom 27805654 Og Tdl Cmplx Fill Coil 7x21 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805655 EAP Custom 27805655 Og Tdl Cmplx Fill Coil 8x15 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805656 EAP Custom 27805656 Og Tdl Cmplx Fill Coil 8x24 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805657 EAP Custom 27805657 Og Tdl Cmplx Fill Coil 9x15 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805658 EAP Custom 27805658 Og Tdl Cmplx Fill Coil 9x25 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805659 EAP Custom 27805659 Og Tdl Cmplx Fill Coil 10x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805660 EAP Custom 27805660 Og Tdl Cmplx Fill Coil 12x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805661 EAP Custom 27805661 Og Cmplx Fill Coil 3.5x7.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805662 EAP Custom 27805662 Og Tdl Cmplx Frame Coil 6x20 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805663 EAP Custom 27805663 Og Tdl Cmplx Frame Coil 7x25 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805664 EAP Custom 27805664 Og Tdl Cmplx Frame Coil 8x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805665 EAP Custom 27805665 Og Tdl Cmplx Frame Coil 9x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805666 EAP Custom 27805666 Og Tdl Cmplx Frame Coil 10x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805667 EAP Custom 27805667 Og Tdl Cmplx Frame Coil 12x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805668 EAP Custom 27805668 Og Tdl Cmplx Frame Coil 14x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805669 EAP Custom 27805669 Og Tdl Cmplx Frame Coil 16x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805670 EAP Custom 27805670 Og Tdl Cmplx Frame Coil 18x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805671 EAP Custom 27805671 Og Tdl Cmplx Frame Coil 20x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805672 EAP Custom 27805672 G2 Complex Fill Coil 2x1.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805673 EAP Custom 27805673 G2 Complex Fill Coil 2x2 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805674 EAP Custom 27805674 G2 Complex Fill Coil 3x4 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805675 EAP Custom 27805675 G2 Complex Fill Coil 3x6 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805676 EAP Custom 27805676 G2 Complex Fill Coil 3x8 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805677 EAP Custom 27805677 G2 Tdl Complex Fill Coil 4x7 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805678 EAP Custom 27805678 G2 Tdl Complex Fill Coil 4x10 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805679 EAP Custom 27805679 G2 Tdl Complex Fill Coil 4x12 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805680 EAP Custom 27805680 G2 Tdl Complex Fill Coil 5x10 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805681 EAP Custom 27805681 G2 Tdl Complex Fill Coil 5x15 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805682 EAP Custom 27805682 G2 Tdl Complex Fill Coil 6x15 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805683 EAP Custom 27805683 G2 Tdl Complex Fill Coil 6x20 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805684 EAP Custom 27805684 G2 Tdl Complex Fill Coil 7x15 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805685 EAP Custom 27805685 G2 Tdl Complex Fill Coil 7x21 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805686 EAP Custom 27805686 G2 Tdl Complex Fill Coil 8x15 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805687 EAP Custom 27805687 G2 Tdl Complex Fill Coil 8x24 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805688 EAP Custom 27805688 G2 Tdl Complex Fill Coil 9x25 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805689 EAP Custom 27805689 G2 Tdl Complex Fill Coil 10x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805690 EAP Custom 27805690 G2 Tdl Complex Fill Coil 12x30 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805691 EAP Custom 27805691 G2 Complex Fill Coil 2.5x5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805692 EAP Custom 27805692 G2 Complex Fill Coil 2.5x3.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805693 EAP Custom 27805693 G2 Complex Fill Coil 3.5x9 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805694 EAP Custom 27805694 G2 Complex Fill Coil 3.5x7.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805695 EAP Custom 27805695 G2 Complex Xtrasoft Coil 2x1.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805696 EAP Custom 27805696 G2 Complex Xtrasoft Coil 2x2 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805697 EAP Custom 27805697 G2 Complex Xtrasoft Coil 3x4 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805698 EAP Custom 27805698 G2 Complex Xtrasoft Coil 3x6 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805700 EAP Custom 27805700 G2 Tdl Complex Xtrasoft Coil 4 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805701 EAP Custom 27805701 G2 Complex Xtrasoft Coil 2.5x5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805702 EAP Custom 27805702 G2 Complex Xtrasoft Coil 2.5x2 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805703 EAP Custom 27805703 G2 Complex Xtrasoft Coil 2.5x3 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805704 EAP Custom 27805704 G2 Complex Xtrasoft Coil 3.5x5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805705 EAP Custom 27805705 G2 Complex Xtrasoft Coil 3.5x9 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805706 EAP Custom 27805706 G2 Complex Xtrasoft Coil 3.5x7 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805707 EAP Custom 27805707 G2 Helical Xtrasoft Coil 2x4 BOTH IP/OP "$3,148.00 " "$2,329.52" $0.00 "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.45" "$2,336.45" "$2,426.48" $0.00 $656.04 $0.00 $0.00 $0.00 $0.00 "$1,574.00" "$2,493.22" "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805708 EAP Custom 27805708 G2 Helical Xtrasoft Coil 2x6 BOTH IP/OP "$3,148.00 " "$2,329.52" $0.00 "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.45" "$2,336.45" "$2,426.48" $0.00 $656.04 $0.00 $0.00 $0.00 $0.00 "$1,574.00" "$2,493.22" "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805709 EAP Custom 27805709 G2 Helical Xtrasoft Coil 2x8 BOTH IP/OP "$3,148.00 " "$2,329.52" $0.00 "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.45" "$2,336.45" "$2,426.48" $0.00 $656.04 $0.00 $0.00 $0.00 $0.00 "$1,574.00" "$2,493.22" "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805710 EAP Custom 27805710 Og Cmplx Xtrasoft Coil 2x1.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805711 EAP Custom 27805711 Og Cmplx Xtrasoft Coil 2x2 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805712 EAP Custom 27805712 Og Cmplx Xtrasoft Coil 3x3 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805713 EAP Custom 27805713 Og Cmplx Xtrasoft Coil 3x4 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805714 EAP Custom 27805714 Og Cmplx Xtrasoft Coil 3x6 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805715 EAP Custom 27805715 Og Cmplx Xtrasoft Coil 3x8 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805716 EAP Custom 27805716 Og Cmplx Xtrasoft Coil 4x4 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805717 EAP Custom 27805717 Og Cmplx Xtrasoft Coil 4x6 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805718 EAP Custom 27805718 Og Cmplx Xtrasoft Coil 4x8 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805719 EAP Custom 27805719 Og Cmplx Xtrasoft Coil 4x10 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805720 EAP Custom 27805720 Og Cmplx Xtrasoft Coil 2.5x5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805721 EAP Custom 27805721 Og Cmplx Xtrasoft Coil 2.5x2.5 BOTH IP/OP "$4,327.00 " "$3,201.98" $0.00 "$3,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,211.50" "$3,211.50" "$3,335.25" $0.00 $901.75 $0.00 $0.00 $0.00 $0.00 "$2,163.50" "$3,426.98" "$3,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805722 EAP Custom 27805722 Og Cmplx Xtrasoft Coil 2.5x3.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805723 EAP Custom 27805723 Og Cmplx Xtrasoft Coil 3.5x5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 "$1,854.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805724 EAP Custom 27805724 Og Cmplx Xtrasoft Coil 3.5x9 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805725 EAP Custom 27805725 Og Cmplx Xtrasoft Coil 3.5x7.5 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805726 EAP Custom 27805726 Og Helical Xtrsoft Coil 2x4 BOTH IP/OP "$3,148.00 " "$2,329.52" $0.00 "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.45" "$2,336.45" "$2,426.48" $0.00 $656.04 $0.00 $0.00 $0.00 $0.00 "$1,574.00" "$2,493.22" "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805727 EAP Custom 27805727 Og Helical Xtrsoft Coil 2x6 BOTH IP/OP "$3,148.00 " "$2,329.52" $0.00 "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.45" "$2,336.45" "$2,426.48" $0.00 $656.04 $0.00 $0.00 $0.00 $0.00 "$1,574.00" "$2,493.22" "$2,518.40" $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805728 EAP Custom 27805728 Og Helical Xtrsoft Coil 2x8 BOTH IP/OP "$3,148.00 " "$2,329.52" $0.00 "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.45" "$2,336.45" "$2,426.48" $0.00 $656.04 $0.00 $0.00 $0.00 $0.00 "$1,574.00" "$2,493.22" "$2,518.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805729 EAP Custom 27805729 G2 Tdl Complex Xtrasoft Coil 4x8 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805730 EAP Custom 27805730 G2 Tdl Complex Xtrasoft Coil 4x10 BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.61" "$3,058.61" "$3,176.47" $0.00 $858.82 $0.00 $0.00 $0.00 $0.00 "$2,060.50" "$3,263.83" "$3,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805731 EAP Custom 27805731 Kit Prss Monitr 14ga Cdmn Mcsnsr Basic Trndcr Tuo Ndl BOTH IP/OP "$2,074.00 " "$1,534.76" $0.00 "$1,659.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,539.32" "$1,539.32" "$1,598.64" $0.00 $432.22 $0.00 $0.00 $0.00 $0.00 "$1,037.00" "$1,642.61" "$1,659.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805732 EAP Custom 27805732 Kit Prss Monitr Mcsnsr .7mm Sbdrl Inprench Skl Bolt BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" "$1,654.91" $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805733 EAP Custom 27805733 Kit Prss Monitr 38cm Cdmn Intrcran Vntrc Trndcr Cath Tnl BOTH IP/OP "$2,235.00 " "$1,653.90" $0.00 "$1,788.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,658.82" "$1,658.82" "$1,722.74" $0.00 $465.77 $0.00 $0.00 $0.00 $0.00 "$1,117.50" "$1,770.12" "$1,788.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805734 EAP Custom 27805734 Stent Lvis 4.5 23mm BOTH IP/OP "$17,913.00 " "$13,255.62" $0.00 "$14,330.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,807.34" $0.00 "$3,733.07" $0.00 $0.00 $0.00 $0.00 "$8,956.50" "$14,187.10" "$14,330.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805735 EAP Custom 27805735 Device Cmpr Gold Fmstp Pneum Dome Intgr Dgt Mnmtr Adj Belt BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $223.53 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $130.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805736 EAP Custom 27805736 Prtcl Embl 2 Vl Lq Sys Trfl Nbca 1gm BOTH IP/OP "$11,437.00 " "$8,463.38" $0.00 "$9,149.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,815.64" $0.00 "$2,383.47" $0.00 $0.00 $0.00 $0.00 "$5,718.50" "$9,058.10" "$9,149.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805737 EAP Custom 27805737 Prtcl Embl 1 Vl Lq Sys Trfl Nbca 1gm BOTH IP/OP "$6,546.00 " "$4,844.04" $0.00 "$5,236.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,045.66" $0.00 "$1,364.19" $0.00 $0.00 $0.00 $0.00 "$3,273.00" "$5,184.43" "$5,236.80" $0.00 "$2,945.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805738 EAP HCPCS C1760 Device Clsr 8fr Angsl Vip Vasc Hmst Strl Latex Free Disp BOTH IP/OP $723.00 $535.02 $0.00 $578.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.50 $572.62 $578.40 $0.00 $0.00 $0.00 $113.15 $0.00 $0.00 $115.10 $0.00 $0.00 $0.00 $0.00 $0.00 27805739 EAP Custom 27805739 Stent 3.5 X 19 Coil Assist Headway 21 BOTH IP/OP "$16,121.00 " "$11,929.54" $0.00 "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,426.07" $0.00 "$3,359.62" $0.00 $0.00 $0.00 $0.00 "$8,060.50" "$12,767.83" "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805740 EAP Custom 27805740 Stent 3.5 X 24 Coil Assist Headway 21 BOTH IP/OP "$16,121.00 " "$11,929.54" $0.00 "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,426.07" $0.00 "$3,359.62" $0.00 $0.00 $0.00 $0.00 "$8,060.50" "$12,767.83" "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805741 EAP Custom 27805741 Stent 4.5 X 16 Coil Assist Headway 21 BOTH IP/OP "$16,121.00 " "$11,929.54" $0.00 "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,426.07" $0.00 "$3,359.62" $0.00 $0.00 $0.00 $0.00 "$8,060.50" "$12,767.83" "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805742 EAP Custom 27805742 Stent 4.5 X 34 Coil Assist Headway 21 BOTH IP/OP "$16,121.00 " "$11,929.54" $0.00 "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,426.07" $0.00 "$3,359.62" $0.00 $0.00 $0.00 $0.00 "$8,060.50" "$12,767.83" "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805743 EAP Custom 27805743 Stent 5.5 X 27 Coil Assist Headway 21 BOTH IP/OP "$16,121.00 " "$11,929.54" $0.00 "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,426.07" $0.00 "$3,359.62" $0.00 $0.00 $0.00 $0.00 "$8,060.50" "$12,767.83" "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805744 EAP Custom 27805744 Stent 5.5 X 34 Coil Assist Headway 21 BOTH IP/OP "$16,121.00 " "$11,929.54" $0.00 "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,426.07" $0.00 "$3,359.62" $0.00 $0.00 $0.00 $0.00 "$8,060.50" "$12,767.83" "$12,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805745 EAP Custom 27805745 Stent 3.5 X 18 Coil Assist Headway 17 BOTH IP/OP "$18,980.00 " "$14,045.20" $0.00 "$15,184.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,629.78" $0.00 "$3,955.43" $0.00 $0.00 $0.00 $0.00 "$9,490.00" "$15,032.16" "$15,184.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805746 EAP Custom 27805746 Stent 3.5 X 23 Coil Assist Headway 17 BOTH IP/OP "$18,980.00 " "$14,045.20" $0.00 "$15,184.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,629.78" $0.00 "$3,955.43" $0.00 $0.00 $0.00 $0.00 "$9,490.00" "$15,032.16" "$15,184.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805747 EAP Custom 27805747 Stent 3.5 X 28 Coil Assist Headway 17 BOTH IP/OP "$18,981.00 " "$14,045.94" $0.00 "$15,184.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,630.55" $0.00 "$3,955.64" $0.00 $0.00 $0.00 $0.00 "$9,490.50" "$15,032.95" "$15,184.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805748 EAP Custom 27805748 Stent 3.5 X 33 Coil Assist Headway 17 BOTH IP/OP "$18,981.00 " "$14,045.94" $0.00 "$15,184.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,630.55" $0.00 "$3,955.64" $0.00 $0.00 $0.00 $0.00 "$9,490.50" "$15,032.95" "$15,184.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805750 EAP HCPCS C1764 System Crd Monitr Rvl Linq Ins BOTH IP/OP "$14,592.00 " "$10,798.08" $0.00 "$11,673.60" "$6,566.40" "$6,566.40" $0.00 $0.00 $0.00 "$3,041.34" "$4,181.12" "$4,181.12" "$11,247.51" $0.00 "$3,040.97" $0.00 "$7,193.86" "$7,193.86" $0.00 "$7,296.00" "$11,556.86" "$11,673.60" $0.00 $0.00 $0.00 "$2,283.65" $0.00 $0.00 "$2,323.05" $0.00 $0.00 $0.00 $0.00 $0.00 27805751 EAP HCPCS C1880 Filter Embl Vc Femoral Navalign Dlv Set Strl Disp Pltn Celect BOTH IP/OP "$3,032.00 " "$2,243.68" $0.00 "$2,425.60" "$1,364.40" "$1,364.40" $0.00 $0.00 $0.00 $631.94 "$2,250.35" "$2,250.35" "$2,337.07" $0.00 $631.87 $0.00 "$1,494.78" "$1,494.78" $0.00 "$1,516.00" "$2,401.34" "$2,425.60" $0.00 "$1,364.40" $0.00 $474.51 $0.00 $0.00 $482.69 $0.00 $0.00 $0.00 $0.00 $0.00 27805752 EAP HCPCS C1880 Filter Embl Vc Jug Navalign Dlv Set Strl Disp Pltn Celect BOTH IP/OP "$3,032.00 " "$2,243.68" $0.00 "$2,425.60" "$1,364.40" "$1,364.40" $0.00 $0.00 $0.00 $631.94 "$2,250.35" "$2,250.35" "$2,337.07" $0.00 $631.87 $0.00 "$1,494.78" "$1,494.78" $0.00 "$1,516.00" "$2,401.34" "$2,425.60" $0.00 $0.00 $0.00 $474.51 $0.00 $0.00 $482.69 $0.00 $0.00 $0.00 $0.00 $0.00 27805753 EAP HCPCS C1880 Filter Embl Navalign Dlv Uniset Strl Disp Pltn Celect BOTH IP/OP "$3,032.00 " "$2,243.68" $0.00 "$2,425.60" "$1,364.40" "$1,364.40" $0.00 $0.00 $0.00 $631.94 "$2,250.35" "$2,250.35" "$2,337.07" $0.00 $631.87 $0.00 "$1,494.78" "$1,494.78" $0.00 "$1,516.00" "$2,401.34" "$2,425.60" $0.00 "$1,364.40" $0.00 $474.51 $0.00 $0.00 $482.69 $0.00 $0.00 $0.00 $0.00 $0.00 27805754 EAP Custom 27805754 Syr Inflat Dfl Indfltr Embl Coil Trf Dcs 2 Pltn BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $628.97 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $367.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805755 EAP HCPCS C1876 Stent Coron 8mm 2mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805756 EAP HCPCS C1876 Stent Coron 12mm 2mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805757 EAP HCPCS C1876 Stent Coron 15mm 2mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805758 EAP HCPCS C1876 Stent Coron 18mm 2mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805759 EAP HCPCS C1876 Stent Coron 23mm 2mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805760 EAP HCPCS C1876 Stent Coron 28mm 2mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805761 EAP HCPCS C1876 Stent Coron 15mm 2.25mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805762 EAP HCPCS C1876 Stent Coron 18mm 2.25mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805763 EAP HCPCS C1876 Stent Coron 23mm 2.25mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805764 EAP HCPCS C1876 Stent Coron 28mm 2.25mm Cocr Mtlnk Mvsn 2 Radiopq Mrkr Bln BOTH IP/OP "$1,791.00 " "$1,325.34" $0.00 "$1,432.80" $805.95 $805.95 $0.00 $0.00 $0.00 $373.29 "$1,329.28" "$1,329.28" "$1,380.50" $0.00 $373.24 $0.00 "$1,059.38" "$1,059.38" $0.00 $895.50 "$1,418.47" "$1,432.80" $0.00 $0.00 $0.00 $280.29 $0.00 $0.00 $285.13 $0.00 $0.00 $0.00 $0.00 $0.00 27805765 EAP Custom 27805765 Cath Angio 5fr 8mm 110cm 2 Lum Bln Syr Wdg Prss Strl Latex BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $62.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805766 EAP HCPCS V2790 Amniofix 16mm Disc BOTH IP/OP $971.00 $718.54 $0.00 $776.80 $436.95 $436.95 $0.00 $0.00 $0.00 $202.38 $720.68 $720.68 $748.45 $0.00 $202.36 $0.00 $574.35 $574.35 $0.00 $485.50 $769.03 $776.80 $0.00 $0.00 $0.00 $151.96 $0.00 $0.00 $154.58 $0.00 $0.00 $0.00 $0.00 $0.00 27805767 EAP HCPCS V2790 Amniofix 2x3cm BOTH IP/OP "$2,756.00 " "$2,039.44" $0.00 "$2,204.80" "$1,240.20" "$1,240.20" $0.00 $0.00 $0.00 $574.42 "$2,045.50" "$2,045.50" "$2,124.32" $0.00 $574.35 $0.00 "$1,358.71" "$1,358.71" $0.00 "$1,378.00" "$2,182.75" "$2,204.80" $0.00 $0.00 $0.00 $431.31 $0.00 $0.00 $438.76 $0.00 $0.00 $0.00 $0.00 $0.00 27805768 EAP HCPCS V2790 Amniofix 3x3cm BOTH IP/OP "$3,662.00 " "$2,709.88" $0.00 "$2,929.60" "$1,647.90" "$1,647.90" $0.00 $0.00 $0.00 $763.25 "$2,717.94" "$2,717.94" "$2,822.67" $0.00 $763.16 $0.00 "$1,805.37" "$1,805.37" $0.00 "$1,831.00" "$2,900.30" "$2,929.60" $0.00 $0.00 $0.00 $573.10 $0.00 $0.00 $582.99 $0.00 $0.00 $0.00 $0.00 $0.00 27805769 EAP HCPCS V2790 Amniofix 4x4cm BOTH IP/OP "$3,925.00 " "$2,904.50" $0.00 "$3,140.00" "$1,766.25" "$1,766.25" $0.00 $0.00 $0.00 $818.07 "$2,913.14" "$2,913.14" "$3,025.39" $0.00 $817.97 $0.00 "$1,935.03" "$1,935.03" $0.00 "$1,962.50" "$3,108.60" "$3,140.00" $0.00 $0.00 $0.00 $614.26 $0.00 $0.00 $624.86 $0.00 $0.00 $0.00 $0.00 $0.00 27805770 EAP HCPCS V2790 Amniofix 4x6cm BOTH IP/OP "$5,629.00 " "$4,165.46" $0.00 "$4,503.20" "$2,533.05" "$2,533.05" $0.00 $0.00 $0.00 "$1,173.22" "$4,177.84" "$4,177.84" "$4,338.83" $0.00 "$1,173.08" $0.00 "$2,775.10" "$2,775.10" $0.00 "$2,814.50" "$4,458.17" "$4,503.20" $0.00 $0.00 $0.00 $880.94 $0.00 $0.00 $896.14 $0.00 $0.00 $0.00 $0.00 $0.00 27805771 EAP HCPCS V2790 Amniofix 2x12cm BOTH IP/OP "$2,612.00 " "$1,932.88" $0.00 "$2,089.60" "$1,175.40" "$1,175.40" $0.00 $0.00 $0.00 $544.41 "$1,938.63" "$1,938.63" "$2,013.33" $0.00 $544.34 $0.00 "$1,287.72" "$1,287.72" $0.00 "$1,306.00" "$2,068.70" "$2,089.60" $0.00 $0.00 $0.00 $408.78 $0.00 $0.00 $415.83 $0.00 $0.00 $0.00 $0.00 $0.00 27805772 EAP HCPCS V2790 Amniofix 6x16cm BOTH IP/OP "$9,005.00 " "$6,663.70" $0.00 "$7,204.00" "$4,052.25" "$4,052.25" $0.00 $0.00 $0.00 "$1,876.87" "$4,181.12" "$4,181.12" "$6,941.05" $0.00 "$1,876.64" $0.00 "$4,439.47" "$4,439.47" $0.00 "$4,502.50" "$7,131.96" "$7,204.00" $0.00 $0.00 $0.00 "$1,409.28" $0.00 $0.00 "$1,433.60" $0.00 $0.00 $0.00 $0.00 $0.00 27805773 EAP HCPCS V2790 Amniofix 9x20cm BOTH IP/OP "$21,453.00 " "$15,875.22" $0.00 "$17,162.40" "$9,653.85" "$9,653.85" $0.00 $0.00 $0.00 "$4,471.34" "$4,181.12" "$4,181.12" "$16,535.97" $0.00 "$4,470.81" $0.00 "$10,576.33" "$10,576.33" $0.00 "$10,726.50" "$16,990.78" "$17,162.40" $0.00 $0.00 $0.00 "$3,357.39" $0.00 $0.00 "$3,415.32" $0.00 $0.00 $0.00 $0.00 $0.00 27805774 EAP HCPCS V2790 Amniofix Wrap 2x2 Cm BOTH IP/OP "$1,903.00 " "$1,408.22" $0.00 "$1,522.40" $856.35 $856.35 $0.00 $0.00 $0.00 $396.63 "$1,412.41" "$1,412.41" "$1,466.83" $0.00 $396.59 $0.00 "$1,125.62" "$1,125.62" $0.00 $951.50 "$1,507.18" "$1,522.40" $0.00 $0.00 $0.00 $297.82 $0.00 $0.00 $302.96 $0.00 $0.00 $0.00 $0.00 $0.00 27805775 EAP HCPCS V2790 Amniofix Wrap 2x4 Cm BOTH IP/OP "$3,399.00 " "$2,515.26" $0.00 "$2,719.20" "$1,529.55" "$1,529.55" $0.00 $0.00 $0.00 $708.44 "$2,522.74" "$2,522.74" "$2,619.95" $0.00 $708.35 $0.00 "$1,675.71" "$1,675.71" $0.00 "$1,699.50" "$2,692.01" "$2,719.20" $0.00 $0.00 $0.00 $531.94 $0.00 $0.00 $541.12 $0.00 $0.00 $0.00 $0.00 $0.00 27805776 EAP HCPCS V2790 Amniofix Wrap 4x6 Cm BOTH IP/OP "$5,772.00 " "$4,271.28" $0.00 "$4,617.60" "$2,597.40" "$2,597.40" $0.00 $0.00 $0.00 "$1,203.03" "$4,181.12" "$4,181.12" "$4,449.06" $0.00 "$1,202.88" $0.00 "$2,845.60" "$2,845.60" $0.00 "$2,886.00" "$4,571.42" "$4,617.60" $0.00 $0.00 $0.00 $903.32 $0.00 $0.00 $918.90 $0.00 $0.00 $0.00 $0.00 $0.00 27805777 EAP HCPCS C1777 Lead Dfbr 65cm 8fr Optisure Ecrdm Optim 1 Coil Df1is-1 BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 $0.00 $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805778 EAP HCPCS C1777 Lead Dfbr 52cm 8fr Optisure Ecrdm 1 Coil Df4 Conctr True BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 $0.00 $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805779 EAP HCPCS C1777 Lead Dfbr 58cm 8fr Optisure Ecrdm Optim 1 Coil Df4 Conctr BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 "$4,842.45" $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805780 EAP HCPCS C1777 Lead Dfbr 65cm 8fr Optisure Ecrdm 1 Coil Df4 Conctr True BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 "$4,842.45" $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805781 EAP HCPCS C1895 Lead Dfbr 65cm 8fr Optisure Ecrdm 2 Coil Df1 Df4 Conctr True BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 "$4,842.45" $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805782 EAP HCPCS C1895 Lead Dfbr 52cm 8fr Optisure Ecrdm 2 Coil Df4 Conctr True BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 $0.00 $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805783 EAP HCPCS C1895 Lead Dfbr 58cm 8fr Optisure Ecrdm 2 Coil Df4 Conctr True BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 "$4,842.45" $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805784 EAP HCPCS C1895 Lead Dfbr 65cm 8fr Optisure Ecrdm 2 Coil Df4 220 Dual Shock BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 "$4,842.45" $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805785 EAP HCPCS C1895 Lead Dfbr 65cm 8fr Optisure Ecrdm 2 Coil Df4 230 Dual Shock BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 "$4,842.45" $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805786 EAP HCPCS C1895 Lead Dfbr 65cm 8fr Optisure Ecrdm 2 Coil Df4 Pass Dual Shock BOTH IP/OP "$10,761.00 " "$7,963.14" $0.00 "$8,608.80" "$4,842.45" "$4,842.45" $0.00 $0.00 $0.00 "$2,242.86" "$4,181.12" "$4,181.12" "$8,294.58" $0.00 "$2,242.59" $0.00 "$5,305.17" "$5,305.17" $0.00 "$5,380.50" "$8,522.71" "$8,608.80" $0.00 $0.00 $0.00 "$1,684.10" $0.00 $0.00 "$1,713.15" $0.00 $0.00 $0.00 $0.00 $0.00 27805787 EAP HCPCS C1777 Lead Pcng 64cm 9fr Ecrdm 1 Coil Act Fix Bipol Cardvrt Dfbr BOTH IP/OP "$9,175.00 " "$6,789.50" $0.00 "$7,340.00" "$4,128.75" "$4,128.75" $0.00 $0.00 $0.00 "$1,912.30" "$4,181.12" "$4,181.12" "$7,072.09" $0.00 "$1,912.07" $0.00 "$4,523.28" "$4,523.28" $0.00 "$4,587.50" "$7,266.60" "$7,340.00" $0.00 $0.00 $0.00 "$1,435.89" $0.00 $0.00 "$1,460.66" $0.00 $0.00 $0.00 $0.00 $0.00 27805788 EAP HCPCS C1874 Stent Coron 8mm 2.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 "$1,712.70" $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805789 EAP HCPCS C1874 Stent Coron 12mm 2.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805790 EAP HCPCS C1874 Stent Coron 15mm 2.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805791 EAP HCPCS C1874 Stent Coron 18mm 2.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805792 EAP HCPCS C1874 Stent Coron 23mm 2.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805793 EAP HCPCS C1874 Stent Coron 28mm 2.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805794 EAP HCPCS C1874 Stent Coron 8mm 2.5mm .034-.029in 5fr Cocr BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805795 EAP HCPCS C1874 Stent Coron 12mm 2.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805796 EAP HCPCS C1874 Stent Coron 15mm 2.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805797 EAP HCPCS C1874 Stent Coron 18mm 2.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805798 EAP HCPCS C1874 Stent Coron 23mm 2.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 "$1,712.70" $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805799 EAP HCPCS C1874 Stent Coron 28mm 2.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 "$1,712.70" $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805800 EAP HCPCS C1874 Stent Coron 33mm 2.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 "$1,712.70" $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805801 EAP HCPCS C1874 Stent Coron 38mm 2.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,996.00 " "$2,957.04" $0.00 "$3,196.80" "$1,798.20" "$1,798.20" $0.00 $0.00 $0.00 $832.87 "$2,965.83" "$2,965.83" "$3,080.12" $0.00 $832.77 $0.00 "$1,970.03" "$1,970.03" $0.00 "$1,998.00" "$3,164.83" "$3,196.80" $0.00 "$1,798.20" $0.00 $625.37 $0.00 $0.00 $636.16 $0.00 $0.00 $0.00 $0.00 $0.00 27805802 EAP HCPCS C1874 Stent Coron 8mm 2.75mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805803 EAP HCPCS C1874 Stent Coron 12mm 2.75mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805804 EAP HCPCS C1874 Stent Coron 15mm 2.75mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805805 EAP HCPCS C1874 Stent Coron 18mm 2.75mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805806 EAP HCPCS C1874 Stent Coron 23mm 2.75mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805807 EAP HCPCS C1874 Stent Coron 28mm 2.75mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805808 EAP HCPCS C1874 Stent Coron 33mm 2.75mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805809 EAP HCPCS C1874 Stent Coron 38mm 2.75mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805810 EAP HCPCS C1874 Stent Coron 8mm 3mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805811 EAP HCPCS C1874 Stent Coron 12mm 3mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805812 EAP HCPCS C1874 Stent Coron 15mm 3mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805813 EAP HCPCS C1874 Stent Coron 18mm 3mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,996.00 " "$2,957.04" $0.00 "$3,196.80" "$1,798.20" "$1,798.20" $0.00 $0.00 $0.00 $832.87 "$2,965.83" "$2,965.83" "$3,080.12" $0.00 $832.77 $0.00 "$1,970.03" "$1,970.03" $0.00 "$1,998.00" "$3,164.83" "$3,196.80" $0.00 $0.00 $0.00 $625.37 $0.00 $0.00 $636.16 $0.00 $0.00 $0.00 $0.00 $0.00 27805814 EAP HCPCS C1874 Stent Coron 23mm 3mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,996.00 " "$2,957.04" $0.00 "$3,196.80" "$1,798.20" "$1,798.20" $0.00 $0.00 $0.00 $832.87 "$2,965.83" "$2,965.83" "$3,080.12" $0.00 $832.77 $0.00 "$1,970.03" "$1,970.03" $0.00 "$1,998.00" "$3,164.83" "$3,196.80" $0.00 $0.00 $0.00 $625.37 $0.00 $0.00 $636.16 $0.00 $0.00 $0.00 $0.00 $0.00 27805815 EAP HCPCS C1874 Stent Coron 28mm 3mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805816 EAP HCPCS C1874 Stent Coron 33mm 3mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805817 EAP HCPCS C1874 Stent Coron 38mm 3mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,996.00 " "$2,957.04" $0.00 "$3,196.80" "$1,798.20" "$1,798.20" $0.00 $0.00 $0.00 $832.87 "$2,965.83" "$2,965.83" "$3,080.12" $0.00 $832.77 $0.00 "$1,970.03" "$1,970.03" $0.00 "$1,998.00" "$3,164.83" "$3,196.80" $0.00 $0.00 $0.00 $625.37 $0.00 $0.00 $636.16 $0.00 $0.00 $0.00 $0.00 $0.00 27805818 EAP HCPCS C1874 Stent Coron 8mm 3.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805819 EAP HCPCS C1874 Stent Coron 12mm 3.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805820 EAP HCPCS C1874 Stent Coron 15mm 3.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805821 EAP HCPCS C1874 Stent Coron 18mm 3.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805822 EAP HCPCS C1874 Stent Coron 23mm 3.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 "$1,712.70" $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805823 EAP HCPCS C1874 Stent Coron 28mm 3.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805824 EAP HCPCS C1874 Stent Coron 33mm 3.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,996.00 " "$2,957.04" $0.00 "$3,196.80" "$1,798.20" "$1,798.20" $0.00 $0.00 $0.00 $832.87 "$2,965.83" "$2,965.83" "$3,080.12" $0.00 $832.77 $0.00 "$1,970.03" "$1,970.03" $0.00 "$1,998.00" "$3,164.83" "$3,196.80" $0.00 $0.00 $0.00 $625.37 $0.00 $0.00 $636.16 $0.00 $0.00 $0.00 $0.00 $0.00 27805825 EAP HCPCS C1874 Stent Coron 38mm 3.25mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805826 EAP HCPCS C1874 Stent Coron 8mm 3.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805827 EAP HCPCS C1874 Stent Coron 12mm 3.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,996.00 " "$2,957.04" $0.00 "$3,196.80" "$1,798.20" "$1,798.20" $0.00 $0.00 $0.00 $832.87 "$2,965.83" "$2,965.83" "$3,080.12" $0.00 $832.77 $0.00 "$1,970.03" "$1,970.03" $0.00 "$1,998.00" "$3,164.83" "$3,196.80" $0.00 $0.00 $0.00 $625.37 $0.00 $0.00 $636.16 $0.00 $0.00 $0.00 $0.00 $0.00 27805828 EAP HCPCS C1874 Stent Coron 15mm 3.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805829 EAP HCPCS C1874 Stent Coron 18mm 3.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805830 EAP HCPCS C1874 Stent Coron 23mm 3.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,996.00 " "$2,957.04" $0.00 "$3,196.80" "$1,798.20" "$1,798.20" $0.00 $0.00 $0.00 $832.87 "$2,965.83" "$2,965.83" "$3,080.12" $0.00 $832.77 $0.00 "$1,970.03" "$1,970.03" $0.00 "$1,998.00" "$3,164.83" "$3,196.80" $0.00 $0.00 $0.00 $625.37 $0.00 $0.00 $636.16 $0.00 $0.00 $0.00 $0.00 $0.00 27805831 EAP HCPCS C1874 Stent Coron 28mm 3.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805832 EAP HCPCS C1874 Stent Coron 33mm 3.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,806.00 " "$2,816.44" $0.00 "$3,044.80" "$1,712.70" "$1,712.70" $0.00 $0.00 $0.00 $793.27 "$2,824.81" "$2,824.81" "$2,933.66" $0.00 $793.17 $0.00 "$1,876.36" "$1,876.36" $0.00 "$1,903.00" "$3,014.35" "$3,044.80" $0.00 $0.00 $0.00 $595.64 $0.00 $0.00 $605.92 $0.00 $0.00 $0.00 $0.00 $0.00 27805833 EAP HCPCS C1874 Stent Coron 38mm 3.5mm .034-.029in 5fr Everolimus BOTH IP/OP "$3,996.00 " "$2,957.04" $0.00 "$3,196.80" "$1,798.20" "$1,798.20" $0.00 $0.00 $0.00 $832.87 "$2,965.83" "$2,965.83" "$3,080.12" $0.00 $832.77 $0.00 "$1,970.03" "$1,970.03" $0.00 "$1,998.00" "$3,164.83" "$3,196.80" $0.00 $0.00 $0.00 $625.37 $0.00 $0.00 $636.16 $0.00 $0.00 $0.00 $0.00 $0.00 27805834 EAP HCPCS C1877 Stent Trchbr 15mm 14fr 5cm Introd Slf Xpd Gnt Rsch BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" "$2,362.05" "$2,362.05" $0.00 $0.00 $0.00 "$1,094.02" "$3,895.81" "$3,895.81" "$4,045.93" $0.00 "$1,093.89" $0.00 "$2,587.76" "$2,587.76" $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $821.47 $0.00 $0.00 $835.64 $0.00 $0.00 $0.00 $0.00 $0.00 27805836 EAP HCPCS C1877 Stent Trchbr 20mm 16fr 5cm Introd Slf Xpd Gnt Rsch BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" "$2,362.05" "$2,362.05" $0.00 $0.00 $0.00 "$1,094.02" "$3,895.81" "$3,895.81" "$4,045.93" $0.00 "$1,093.89" $0.00 "$2,587.76" "$2,587.76" $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $821.47 $0.00 $0.00 $835.64 $0.00 $0.00 $0.00 $0.00 $0.00 27805837 EAP HCPCS C1877 Stent Trchbr 25mm 16fr 5cm Introd Slf Xpd Gnt Rsch BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" "$2,362.05" "$2,362.05" $0.00 $0.00 $0.00 "$1,094.02" "$3,895.81" "$3,895.81" "$4,045.93" $0.00 "$1,093.89" $0.00 "$2,587.76" "$2,587.76" $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 "$2,362.05" $0.00 $821.47 $0.00 $0.00 $835.64 $0.00 $0.00 $0.00 $0.00 $0.00 27805838 EAP HCPCS C1877 Stent Trchbr 30mm 16fr 5cm Introd Slf Xpd Gnt Rsch BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" "$2,362.05" "$2,362.05" $0.00 $0.00 $0.00 "$1,094.02" "$3,895.81" "$3,895.81" "$4,045.93" $0.00 "$1,093.89" $0.00 "$2,587.76" "$2,587.76" $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $821.47 $0.00 $0.00 $835.64 $0.00 $0.00 $0.00 $0.00 $0.00 27805839 EAP HCPCS C1877 Stent Trchbr 35mm 16fr 5cm Introd Slf Xpd Gnt Rsch BOTH IP/OP "$5,249.00 " "$3,884.26" $0.00 "$4,199.20" "$2,362.05" "$2,362.05" $0.00 $0.00 $0.00 "$1,094.02" "$3,895.81" "$3,895.81" "$4,045.93" $0.00 "$1,093.89" $0.00 "$2,587.76" "$2,587.76" $0.00 "$2,624.50" "$4,157.21" "$4,199.20" $0.00 $0.00 $0.00 $821.47 $0.00 $0.00 $835.64 $0.00 $0.00 $0.00 $0.00 $0.00 27805841 EAP HCPCS C1874 Stent Coron 8mm 4mm 2.3-2.7fr Everolimus Elut Pltn BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" "$1,535.40" "$1,535.40" $0.00 $0.00 $0.00 $711.15 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 "$1,682.12" "$1,682.12" $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27805842 EAP HCPCS C1874 Stent Coron 12mm 4mm 2.3-2.7fr Everolimus Elut BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" "$1,535.40" "$1,535.40" $0.00 $0.00 $0.00 $711.15 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 "$1,682.12" "$1,682.12" $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27805843 EAP HCPCS C1874 Stent Coron 16mm 4mm 2.3-2.7fr Everolimus Elut BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" "$1,535.40" "$1,535.40" $0.00 $0.00 $0.00 $711.15 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 "$1,682.12" "$1,682.12" $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27805844 EAP HCPCS C1874 Stent Coron 20mm 4mm 2.3-2.7fr Everolimus Elut BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" "$1,535.40" "$1,535.40" $0.00 $0.00 $0.00 $711.15 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 "$1,682.12" "$1,682.12" $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27805845 EAP HCPCS C1874 Stent Coron 24mm 4mm 2.3-2.7fr Everolimus Elut BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" "$1,535.40" "$1,535.40" $0.00 $0.00 $0.00 $711.15 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 "$1,682.12" "$1,682.12" $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27805846 EAP HCPCS C1874 Stent Coron 28mm 4mm 2.3-2.7fr Everolimus Elut BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" "$1,535.40" "$1,535.40" $0.00 $0.00 $0.00 $711.15 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 "$1,682.12" "$1,682.12" $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27805847 EAP HCPCS C1874 Stent Coron 32mm 4mm 2.3-2.7fr Everolimus Elut BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" "$1,535.40" "$1,535.40" $0.00 $0.00 $0.00 $711.15 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 "$1,682.12" "$1,682.12" $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27805848 EAP HCPCS C1874 Stent Coron 38mm 4mm 2.3-2.7fr Everolimus Elut BOTH IP/OP "$3,412.00 " "$2,524.88" $0.00 "$2,729.60" "$1,535.40" "$1,535.40" $0.00 $0.00 $0.00 $711.15 "$2,532.39" "$2,532.39" "$2,629.97" $0.00 $711.06 $0.00 "$1,682.12" "$1,682.12" $0.00 "$1,706.00" "$2,702.30" "$2,729.60" $0.00 $0.00 $0.00 $533.98 $0.00 $0.00 $543.19 $0.00 $0.00 $0.00 $0.00 $0.00 27805850 EAP HCPCS C1900 Lead Pcng 78cm 5.3fr 5.1fr .014-.018in Lv Qdpl BOTH IP/OP "$5,840.00 " "$4,321.60" $0.00 "$4,672.00" "$2,628.00" "$2,628.00" $0.00 $0.00 $0.00 "$1,217.20" "$4,181.12" "$4,181.12" "$4,501.47" $0.00 "$1,217.06" $0.00 "$2,879.12" "$2,879.12" $0.00 "$2,920.00" "$4,625.28" "$4,672.00" $0.00 $0.00 $0.00 $913.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805851 EAP HCPCS C1900 Lead Pcng Lv Atn Starfix BOTH IP/OP "$5,840.00 " "$4,321.60" $0.00 "$4,672.00" "$2,628.00" "$2,628.00" $0.00 $0.00 $0.00 "$1,217.20" "$4,181.12" "$4,181.12" "$4,501.47" $0.00 "$1,217.06" $0.00 "$2,879.12" "$2,879.12" $0.00 "$2,920.00" "$4,625.28" "$4,672.00" $0.00 $0.00 $0.00 $913.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805852 EAP HCPCS C1900 Lead Pcng 78cm 5.3fr 5.1fr .014-.018in Offst S Lv BOTH IP/OP "$5,840.00 " "$4,321.60" $0.00 "$4,672.00" "$2,628.00" "$2,628.00" $0.00 $0.00 $0.00 "$1,217.20" "$4,181.12" "$4,181.12" "$4,501.47" $0.00 "$1,217.06" $0.00 "$2,879.12" "$2,879.12" $0.00 "$2,920.00" "$4,625.28" "$4,672.00" $0.00 $0.00 $0.00 $913.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805853 EAP HCPCS C1900 Lead Pcng 88cm 5.3fr 5.1fr .014-.018in Offst S Lv BOTH IP/OP "$5,840.00 " "$4,321.60" $0.00 "$4,672.00" "$2,628.00" "$2,628.00" $0.00 $0.00 $0.00 "$1,217.20" "$4,181.12" "$4,181.12" "$4,501.47" $0.00 "$1,217.06" $0.00 "$2,879.12" "$2,879.12" $0.00 "$2,920.00" "$4,625.28" "$4,672.00" $0.00 "$2,628.00" $0.00 $913.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805856 EAP HCPCS C1874 Stent Coron 16mm 4mm 2.3-2.7fr Everolimus Elut BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" "$15,402.15" "$15,402.15" $0.00 $0.00 $0.00 "$7,133.76" "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 "$16,873.91" "$16,873.91" $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 "$5,356.53" $0.00 $0.00 "$5,448.94" $0.00 $0.00 $0.00 $0.00 $0.00 27805860 EAP HCPCS C1767 Generator Esurg Demipulse Ncp BOTH IP/OP "$57,141.00 " "$42,284.34" $0.00 "$45,712.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$44,044.28" $0.00 "$11,908.18" $0.00 $0.00 $0.00 $0.00 "$28,570.50" "$45,255.67" "$45,712.80" $0.00 "$25,713.45" $0.00 "$7,751.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805861 EAP HCPCS C1778 Lead Nrstm 43cm 3mm Perenniaflex Vagus Nrv Sil BOTH IP/OP "$17,920.00 " "$13,260.80" $0.00 "$14,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,812.74" $0.00 "$3,734.53" $0.00 $0.00 $0.00 $0.00 "$8,960.00" "$14,192.64" "$14,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805862 EAP HCPCS C1876 "Stnt Trchbr 9mm 7fr 59mm 120cm .035"" Cvd Ult Lw Cx" BOTH IP/OP "$6,591.00 " "$4,877.34" $0.00 "$5,272.80" "$2,965.95" "$2,965.95" $0.00 $0.00 $0.00 "$1,373.73" "$4,181.12" "$4,181.12" "$5,080.34" $0.00 "$1,373.56" $0.00 "$3,249.36" "$3,249.36" $0.00 "$3,295.50" "$5,220.07" "$5,272.80" $0.00 $0.00 $0.00 "$1,031.49" $0.00 $0.00 "$1,049.29" $0.00 $0.00 $0.00 $0.00 $0.00 27805863 EAP Custom 27805863 Pipeline Embol. Device 3.00mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805864 EAP Custom 27805864 Pipeline Embol. Device 3.00mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805865 EAP Custom 27805865 Pipeline Embol. Device 3.00mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805866 EAP Custom 27805866 Pipeline Embol. Device 3.25mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805867 EAP Custom 27805867 Pipeline Embol. Device 3.25mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805868 EAP Custom 27805868 Pipeline Embol. Device 3.25mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805869 EAP Custom 27805869 Pipeline Embol. Device 3.50mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805870 EAP Custom 27805870 Pipeline Embol. Device 3.50mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805871 EAP Custom 27805871 Pipeline Embol. Device 3.50mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805872 EAP Custom 27805872 Pipeline Embol. Device 3.75mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805873 EAP Custom 27805873 Pipeline Embol. Device 3.75mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805874 EAP Custom 27805874 Pipeline Embol. Device 3.75mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805875 EAP Custom 27805875 Pipeline Embol. Device 4.00mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805876 EAP Custom 27805876 Pipeline Embol. Device 4.00mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805877 EAP Custom 27805877 Pipeline Embol. Device 4.00mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805878 EAP Custom 27805878 Pipeline Embol. Device 4.25mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805879 EAP Custom 27805879 Pipeline Embol. Device 4.25mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805880 EAP Custom 27805880 Pipeline Embol. Device 4.25mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805881 EAP Custom 27805881 Pipeline Embol. Device 4.50mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805882 EAP Custom 27805882 Pipeline Embol. Device 4.50mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805883 EAP Custom 27805883 Pipeline Embol. Device 4.50mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805884 EAP Custom 27805884 Pipeline Embol. Device 4.75mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805885 EAP Custom 27805885 Pipeline Embol. Device 4.75mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805886 EAP Custom 27805886 Pipeline Embol. Device 4.75mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805887 EAP Custom 27805887 Pipeline Embol. Device 5.00mm X 25mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805888 EAP Custom 27805888 Pipeline Embol. Device 5.00mm X 30mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805889 EAP Custom 27805889 Pipeline Embol. Device 5.00mm X 35mm BOTH IP/OP "$36,219.00 " "$26,802.06" $0.00 "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,917.61" $0.00 "$7,548.04" $0.00 $0.00 $0.00 $0.00 "$18,109.50" "$28,685.45" "$28,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805890 EAP Custom 27805890 Pipeline Embol. Device 2.50mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805891 EAP Custom 27805891 Pipeline Embol. Device 2.50mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805892 EAP Custom 27805892 Pipeline Embol. Device 2.50mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805893 EAP Custom 27805893 Pipeline Embol. Device 2.50mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805894 EAP Custom 27805894 Pipeline Embol. Device 2.50mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805895 EAP Custom 27805895 Pipeline Embol. Device 2.50mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805896 EAP Custom 27805896 Pipeline Embol. Device 2.75mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805897 EAP Custom 27805897 Pipeline Embol. Device 2.75mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805898 EAP Custom 27805898 Pipeline Embol. Device 2.75mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805899 EAP Custom 27805899 Pipeline Embol. Device 2.75mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805900 EAP Custom 27805900 Pipeline Embol. Device 2.75mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805901 EAP Custom 27805901 Pipeline Embol. Device 2.75mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805902 EAP Custom 27805902 Pipeline Embol. Device 3.00mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805903 EAP Custom 27805903 Pipeline Embol. Device 3.00mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805904 EAP Custom 27805904 Pipeline Embol. Device 3.00mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805905 EAP Custom 27805905 Pipeline Embol. Device 3.00mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805906 EAP Custom 27805906 Pipeline Embol. Device 3.00mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805907 EAP Custom 27805907 Pipeline Embol. Device 3.00mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805908 EAP Custom 27805908 Pipeline Embol. Device 3.25mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805909 EAP Custom 27805909 Pipeline Embol. Device 3.25mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805910 EAP Custom 27805910 Pipeline Embol. Device 3.25mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805911 EAP Custom 27805911 Pipeline Embol. Device 3.25mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805912 EAP Custom 27805912 Pipeline Embol. Device 3.25mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805913 EAP Custom 27805913 Pipeline Embol. Device 3.25mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805914 EAP Custom 27805914 Pipeline Embol. Device 3.50mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805915 EAP Custom 27805915 Pipeline Embol. Device 3.50mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805916 EAP Custom 27805916 Pipeline Embol. Device 3.50mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805917 EAP Custom 27805917 Pipeline Embol. Device 3.50mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805918 EAP Custom 27805918 Pipeline Embol. Device 3.50mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805919 EAP Custom 27805919 Pipeline Embol. Device 3.50mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805920 EAP Custom 27805920 Pipeline Embol. Device 3.75mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805921 EAP Custom 27805921 Pipeline Embol. Device 3.75mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805922 EAP Custom 27805922 Pipeline Embol. Device 3.75mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805923 EAP Custom 27805923 Pipeline Embol. Device 3.75mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805924 EAP Custom 27805924 Pipeline Embol. Device 3.75mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805925 EAP Custom 27805925 Pipeline Embol. Device 3.75mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805926 EAP Custom 27805926 Pipeline Embol. Device 4.00mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805927 EAP Custom 27805927 Pipeline Embol. Device 4.00mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805928 EAP Custom 27805928 Pipeline Embol. Device 4.00mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805929 EAP Custom 27805929 Pipeline Embol. Device 4.00mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805930 EAP Custom 27805930 Pipeline Embol. Device 4.00mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805931 EAP Custom 27805931 Pipeline Embol. Device 4.00mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805932 EAP Custom 27805932 Pipeline Embol. Device 4.25mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805933 EAP Custom 27805933 Pipeline Embol. Device 4.25mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805934 EAP Custom 27805934 Pipeline Embol. Device 4.25mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805935 EAP Custom 27805935 Pipeline Embol. Device 4.25mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805936 EAP Custom 27805936 Pipeline Embol. Device 4.25mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805937 EAP Custom 27805937 Pipeline Embol. Device 4.25mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805938 EAP Custom 27805938 Pipeline Embol. Device 4.50mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805939 EAP Custom 27805939 Pipeline Embol. Device 4.50mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805940 EAP Custom 27805940 Pipeline Embol. Device 4.50mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805941 EAP Custom 27805941 Pipeline Embol. Device 4.50mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805942 EAP Custom 27805942 Pipeline Embol. Device 4.50mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805943 EAP Custom 27805943 Pipeline Embol. Device 4.50mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805944 EAP Custom 27805944 Pipeline Embol. Device 4.75mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805945 EAP Custom 27805945 Pipeline Embol. Device 4.75mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805946 EAP Custom 27805946 Pipeline Embol. Device 4.75mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805947 EAP Custom 27805947 Pipeline Embol. Device 4.75mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805948 EAP Custom 27805948 Pipeline Embol. Device 4.75mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805949 EAP Custom 27805949 Pipeline Embol. Device 4.75mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805950 EAP Custom 27805950 Pipeline Embol. Device 5.00mm X 10mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805951 EAP Custom 27805951 Pipeline Embol. Device 5.00mm X 12mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805952 EAP Custom 27805952 Pipeline Embol. Device 5.00mm X 14mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805953 EAP Custom 27805953 Pipeline Embol. Device 5.00mm X 16mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805954 EAP Custom 27805954 Pipeline Embol. Device 5.00mm X 18mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805955 EAP Custom 27805955 Pipeline Embol. Device 5.00mm X 20mm BOTH IP/OP "$33,856.00 " "$25,053.44" $0.00 "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,096.20" $0.00 "$7,055.59" $0.00 $0.00 $0.00 $0.00 "$16,928.00" "$26,813.95" "$27,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805956 EAP Custom 27805956 "Pipeline Flex, 3.00mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805957 EAP Custom 27805957 "Pipeline Flex, 3.00mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805958 EAP Custom 27805958 "Pipeline Flex, 3.00mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805959 EAP Custom 27805959 "Pipeline Flex, 3.25mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805960 EAP Custom 27805960 "Pipeline Flex, 3.25mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805961 EAP Custom 27805961 "Pipeline Flex, 3.25mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805962 EAP Custom 27805962 "Pipeline Flex, 3.50mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805963 EAP Custom 27805963 "Pipeline Flex, 3.50mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805964 EAP Custom 27805964 "Pipeline Flex, 3.50mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805965 EAP Custom 27805965 "Pipeline Flex, 3.75mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805966 EAP Custom 27805966 "Pipeline Flex, 3.75mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805967 EAP Custom 27805967 "Pipeline Flex, 3.75mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805968 EAP Custom 27805968 "Pipeline Flex, 4.00mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805969 EAP Custom 27805969 "Pipeline Flex, 4.00mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805970 EAP Custom 27805970 "Pipeline Flex, 4.00mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805971 EAP Custom 27805971 "Pipeline Flex, 4.25mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805972 EAP Custom 27805972 "Pipeline Flex, 4.25mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805973 EAP Custom 27805973 "Pipeline Flex, 4.25mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805974 EAP Custom 27805974 "Pipeline Flex, 4.50mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805975 EAP Custom 27805975 "Pipeline Flex, 4.50mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805976 EAP Custom 27805976 "Pipeline Flex, 4.50mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805977 EAP Custom 27805977 "Pipeline Flex, 4.75mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805978 EAP Custom 27805978 "Pipeline Flex, 4.75mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805979 EAP Custom 27805979 "Pipeline Flex, 4.75mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805980 EAP Custom 27805980 "Pipeline Flex, 5.00mm X 25mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805981 EAP Custom 27805981 "Pipeline Flex, 5.00mm X 30mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805982 EAP Custom 27805982 "Pipeline Flex, 5.00mm X 35mm" BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805983 EAP Custom 27805983 "Pipeline Flex, 2.50mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805984 EAP Custom 27805984 "Pipeline Flex, 2.50mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805985 EAP Custom 27805985 "Pipeline Flex, 2.50mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805986 EAP Custom 27805986 "Pipeline Flex, 2.50mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805987 EAP Custom 27805987 "Pipeline Flex, 2.50mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805988 EAP Custom 27805988 "Pipeline Flex, 2.50mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805989 EAP Custom 27805989 "Pipeline Flex, 2.75mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805990 EAP Custom 27805990 "Pipeline Flex, 2.75mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805991 EAP Custom 27805991 "Pipeline Flex, 2.75mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805992 EAP Custom 27805992 "Pipeline Flex, 2.75mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805993 EAP Custom 27805993 "Pipeline Flex, 2.75mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805994 EAP Custom 27805994 "Pipeline Flex, 2.75mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805995 EAP Custom 27805995 "Pipeline Flex, 3.00mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805996 EAP Custom 27805996 "Pipeline Flex, 3.00mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805997 EAP Custom 27805997 "Pipeline Flex, 3.00mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805998 EAP Custom 27805998 "Pipeline Flex, 3.00mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27805999 EAP Custom 27805999 "Pipeline Flex, 3.00mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806000 EAP Custom 27806000 "Pipeline Flex, 3.00mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806001 EAP Custom 27806001 "Pipeline Flex, 3.25mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806002 EAP Custom 27806002 "Pipeline Flex, 3.25mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806003 EAP Custom 27806003 "Pipeline Flex, 3.25mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806004 EAP Custom 27806004 "Pipeline Flex, 3.25mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806005 EAP Custom 27806005 "Pipeline Flex, 3.25mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806006 EAP Custom 27806006 "Pipeline Flex, 3.25mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806007 EAP Custom 27806007 "Pipeline Flex, 3.50mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806008 EAP Custom 27806008 "Pipeline Flex, 3.50mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806009 EAP Custom 27806009 "Pipeline Flex, 3.50mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806010 EAP Custom 27806010 "Pipeline Flex, 3.50mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806011 EAP Custom 27806011 "Pipeline Flex, 3.50mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806012 EAP Custom 27806012 "Pipeline Flex, 3.50mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806013 EAP Custom 27806013 "Pipeline Flex, 3.75mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806014 EAP Custom 27806014 "Pipeline Flex, 3.75mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806015 EAP Custom 27806015 "Pipeline Flex, 3.75mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806016 EAP Custom 27806016 "Pipeline Flex, 3.75mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806017 EAP Custom 27806017 "Pipeline Flex, 3.75mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806018 EAP Custom 27806018 "Pipeline Flex, 3.75mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806019 EAP Custom 27806019 "Pipeline Flex, 4.00mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806020 EAP Custom 27806020 "Pipeline Flex, 4.00mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806021 EAP Custom 27806021 "Pipeline Flex, 4.00mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806022 EAP Custom 27806022 "Pipeline Flex, 4.00mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806023 EAP Custom 27806023 "Pipeline Flex, 4.00mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806024 EAP Custom 27806024 "Pipeline Flex, 4.00mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806025 EAP Custom 27806025 "Pipeline Flex, 4.25mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806026 EAP Custom 27806026 "Pipeline Flex, 4.25mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806027 EAP Custom 27806027 "Pipeline Flex, 4.25mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806028 EAP Custom 27806028 "Pipeline Flex, 4.25mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806029 EAP Custom 27806029 "Pipeline Flex, 4.25mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806030 EAP Custom 27806030 "Pipeline Flex, 4.25mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806031 EAP Custom 27806031 "Pipeline Flex, 4.50mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806032 EAP Custom 27806032 "Pipeline Flex, 4.50mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806033 EAP Custom 27806033 "Pipeline Flex, 4.50mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806034 EAP Custom 27806034 "Pipeline Flex, 4.50mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806035 EAP Custom 27806035 "Pipeline Flex, 4.50mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806036 EAP Custom 27806036 "Pipeline Flex, 4.50mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806037 EAP Custom 27806037 "Pipeline Flex, 4.75mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806038 EAP Custom 27806038 "Pipeline Flex, 4.75mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806039 EAP Custom 27806039 "Pipeline Flex, 4.75mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806040 EAP Custom 27806040 "Pipeline Flex, 4.75mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806041 EAP Custom 27806041 "Pipeline Flex, 4.75mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806042 EAP Custom 27806042 "Pipeline Flex, 4.75mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806043 EAP Custom 27806043 "Pipeline Flex, 5.00mm X 10mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806044 EAP Custom 27806044 "Pipeline Flex, 5.00mm X 12mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806045 EAP Custom 27806045 "Pipeline Flex, 5.00mm X 14mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806046 EAP Custom 27806046 "Pipeline Flex, 5.00mm X 16mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806047 EAP Custom 27806047 "Pipeline Flex, 5.00mm X 18mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806048 EAP Custom 27806048 "Pipeline Flex, 5.00mm X 20mm" BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806050 EAP Custom 27806050 Device Embl 25mm 3mm Pipeline Flx 55d Nrvsc 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806051 EAP Custom 27806051 DEVICE EMBL 30MM 3MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806052 EAP Custom 27806052 DEVICE EMBL 35MM 3MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806053 EAP Custom 27806053 DEVICE EMBL 25MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806054 EAP Custom 27806054 DEVICE EMBL 30MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806055 EAP Custom 27806055 DEVICE EMBL 35MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806056 EAP Custom 27806056 DEVICE EMBL 25MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806057 EAP Custom 27806057 DEVICE EMBL 30MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806058 EAP Custom 27806058 DEVICE EMBL 35MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806059 EAP Custom 27806059 DEVICE EMBL 25MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806060 EAP Custom 27806060 DEVICE EMBL 30MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806061 EAP Custom 27806061 DEVICE EMBL 35MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806062 EAP Custom 27806062 DEVICE EMBL 25MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806063 EAP Custom 27806063 DEVICE EMBL 30MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806064 EAP Custom 27806064 DEVICE EMBL 35MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806065 EAP Custom 27806065 DEVICE EMBL 25MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806066 EAP Custom 27806066 DEVICE EMBL 30MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806067 EAP Custom 27806067 DEVICE EMBL 35MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806068 EAP Custom 27806068 DEVICE EMBL 30MM 4.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806069 EAP Custom 27806069 DEVICE EMBL 35MM 4.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806070 EAP Custom 27806070 DEVICE EMBL 25MM 4.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806071 EAP Custom 27806071 DEVICE EMBL 30MM 4.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806072 EAP Custom 27806072 DEVICE EMBL 35MM 4.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806073 EAP Custom 27806073 DEVICE EMBL 25MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806074 EAP Custom 27806074 DEVICE EMBL 30MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,279.88" $0.00 "$7,645.99" $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806075 EAP Custom 27806075 DEVICE EMBL 35MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$36,689.00 " "$27,149.86" $0.00 "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,344.50" "$29,057.69" "$29,351.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806076 EAP Custom 27806076 DEVICE EMBL 10MM 2.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806077 EAP Custom 27806077 DEVICE EMBL 12MM 2.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806078 EAP Custom 27806078 DEVICE EMBL 16MM 2.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806079 EAP Custom 27806079 DEVICE EMBL 18MM 2.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806080 EAP Custom 27806080 DEVICE EMBL 20MM 2.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806081 EAP Custom 27806081 DEVICE EMBL 10MM 2.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806082 EAP Custom 27806082 DEVICE EMBL 12MM 2.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806083 EAP Custom 27806083 DEVICE EMBL 14MM 2.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806084 EAP Custom 27806084 DEVICE EMBL 16MM 2.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$35,938.00 " "$26,594.12" $0.00 "$28,750.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,701.01" $0.00 "$7,489.48" $0.00 $0.00 $0.00 $0.00 "$17,969.00" "$28,462.90" "$28,750.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806085 EAP Custom 27806085 DEVICE EMBL 18MM 2.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806086 EAP Custom 27806086 DEVICE EMBL 20MM 2.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806087 EAP Custom 27806087 DEVICE EMBL 10MM 3MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806088 EAP Custom 27806088 DEVICE EMBL 12MM 3MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806089 EAP Custom 27806089 DEVICE EMBL 14MM 3MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806090 EAP Custom 27806090 DEVICE EMBL 16MM 3MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806091 EAP Custom 27806091 DEVICE EMBL 18MM 3MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806092 EAP Custom 27806092 DEVICE EMBL 20MM 3MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806093 EAP Custom 27806093 DEVICE EMBL 10MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806094 EAP Custom 27806094 DEVICE EMBL 12MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 "$15,402.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806095 EAP Custom 27806095 DEVICE EMBL 14MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806096 EAP Custom 27806096 DEVICE EMBL 16MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806097 EAP Custom 27806097 DEVICE EMBL 18MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806098 EAP Custom 27806098 DEVICE EMBL 20MM 3.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806099 EAP Custom 27806099 DEVICE EMBL 10MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806100 EAP Custom 27806100 DEVICE EMBL 12MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806101 EAP Custom 27806101 DEVICE EMBL 14MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806102 EAP Custom 27806102 DEVICE EMBL 16MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 "$15,402.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806103 EAP Custom 27806103 DEVICE EMBL 18MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806104 EAP Custom 27806104 DEVICE EMBL 20MM 3.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806105 EAP Custom 27806105 DEVICE EMBL 10MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806106 EAP Custom 27806106 DEVICE EMBL 12MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806107 EAP Custom 27806107 DEVICE EMBL 14MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 "$15,402.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806108 EAP Custom 27806108 DEVICE EMBL 16MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 "$15,402.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806109 EAP Custom 27806109 DEVICE EMBL 18MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806110 EAP Custom 27806110 DEVICE EMBL 20MM 3.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806111 EAP Custom 27806111 DEVICE EMBL 10MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806112 EAP Custom 27806112 DEVICE EMBL 12MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806113 EAP Custom 27806113 DEVICE EMBL 14MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806114 EAP Custom 27806114 DEVICE EMBL 16MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 "$15,402.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806115 EAP Custom 27806115 DEVICE EMBL 18MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806116 EAP Custom 27806116 DEVICE EMBL 20MM 4MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806117 EAP Custom 27806117 DEVICE EMBL 10MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806118 EAP Custom 27806118 DEVICE EMBL 12MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806119 EAP Custom 27806119 DEVICE EMBL 14MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806120 EAP Custom 27806120 DEVICE EMBL 16MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806121 EAP Custom 27806121 DEVICE EMBL 18MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806122 EAP Custom 27806122 DEVICE EMBL 20MM 4.25MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806123 EAP Custom 27806123 DEVICE EMBL 10MM 4.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806124 EAP Custom 27806124 DEVICE EMBL 12MM 4.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 "$15,402.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806125 EAP Custom 27806125 DEVICE EMBL 14MM 4.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,107.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$27,107.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806126 EAP Custom 27806126 DEVICE EMBL 16MM 4.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806127 EAP Custom 27806127 DEVICE EMBL 18MM 4.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806128 EAP Custom 27806128 DEVICE EMBL 20MM 4.5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806129 EAP Custom 27806129 DEVICE EMBL 10MM 4.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806130 EAP Custom 27806130 DEVICE EMBL 12MM 4.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$32,603.00 " "$24,126.22" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$25,130.39" $0.00 "$6,794.47" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806131 EAP Custom 27806131 DEVICE EMBL 14MM 4.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806132 EAP Custom 27806132 DEVICE EMBL 16MM 4.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806133 EAP Custom 27806133 DEVICE EMBL 18MM 4.75MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806134 EAP Custom 27806134 DEVICE EMBL 10MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806135 EAP Custom 27806135 DEVICE EMBL 12MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806136 EAP Custom 27806136 DEVICE EMBL 14MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806137 EAP Custom 27806137 DEVICE EMBL 16MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806138 EAP Custom 27806138 DEVICE EMBL 18MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806139 EAP Custom 27806139 DEVICE EMBL 20MM 5MM PIPELINE FLX 55D NRVSC 75% BOTH IP/OP "$34,227.00 " "$25,327.98" $0.00 "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,382.17" $0.00 "$7,132.91" $0.00 $0.00 $0.00 $0.00 "$17,113.50" "$27,107.78" "$27,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806156 EAP HCPCS C2625 Stent Uret 10.2fr 28cm Pgtl Curve Lp Radiopq Sdprt BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $126.45 $126.45 $0.00 $0.00 $0.00 $58.57 $208.56 $208.56 $216.59 $0.00 $58.56 $0.00 $166.21 $166.21 $0.00 $140.50 $222.55 $224.80 $0.00 $0.00 $0.00 $43.98 $0.00 $0.00 $44.74 $0.00 $0.00 $0.00 $0.00 $0.00 27806157 EAP HCPCS C1876 Stent Vasc 4.5mm 6fr 20mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806158 EAP HCPCS C1876 Stent Vasc 4.5mm 6fr 30mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806159 EAP HCPCS C1876 Stent Bil 4.5mm 6fr 40mm 120cm Brd Slf Xpd Rapex BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806165 EAP HCPCS C1769 Coil Embl 8cm 4mm .0125in Axium 1 Hand Op Dtch BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $258.75 $258.75 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $443.21 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 27806166 EAP HCPCS C1880 Coil Embl 30cm 8mm Helipaq 18 Mciol Hlcl Loop Dtch BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $770.80 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $450.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 27806167 EAP HCPCS C1887 Coil Embl 6cm 3mm .0115in Axium 1 Hand Op Dtch BOTH IP/OP "$1,668.00 " "$1,234.32" $0.00 "$1,334.40" $750.60 $750.60 $0.00 $0.00 $0.00 $347.65 "$1,237.99" "$1,237.99" "$1,285.69" $0.00 $347.61 $0.00 $986.62 $986.62 $0.00 $834.00 "$1,321.06" "$1,334.40" $0.00 $750.60 $0.00 $261.04 $0.00 $0.00 $265.55 $0.00 $0.00 $0.00 $0.00 $0.00 27806168 EAP HCPCS C1887 Coil Embl 50cm 25mm .0145in Axium 1 Hand Op Dtch BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" "$1,214.01" $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $708.75 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 27806169 EAP Custom 27806169 System Embolization Nonadhesive Delivery Syringe Lower BOTH IP/OP "$5,908.00 " "$4,371.92" $0.00 "$4,726.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,553.89" $0.00 "$1,231.23" $0.00 $0.00 $0.00 $0.00 "$2,954.00" "$4,679.14" "$4,726.40" $0.00 "$2,658.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806170 EAP Custom 27806170 Coil Embolization Sphere 10mm 30cm 10 Microcoil Spherical BOTH IP/OP "$2,830.00 " "$2,094.20" $0.00 "$2,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,100.43" "$2,100.43" "$2,181.36" $0.00 $589.77 $0.00 $0.00 $0.00 $0.00 "$1,415.00" "$2,241.36" "$2,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806171 EAP Custom 27806171 Coil Embolization 9mm 14cm 14 Microcoil 2 Helical Multiple BOTH IP/OP "$2,960.00 " "$2,190.40" $0.00 "$2,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,196.91" "$2,196.91" "$2,281.57" $0.00 $616.86 $0.00 $0.00 $0.00 $0.00 "$1,480.00" "$2,344.32" "$2,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806172 EAP Custom 27806172 Coil Embl 10cm 2mm Deltapaq 10 Mciol Loop Dtch Sft Rst Dflc BOTH IP/OP "$2,294.00 " "$1,697.56" $0.00 "$1,835.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.61" "$1,702.61" "$1,768.22" $0.00 $478.07 $0.00 $0.00 $0.00 $0.00 "$1,147.00" "$1,816.85" "$1,835.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806173 EAP Custom 27806173 Coil Embolization 4mm 6cm 10 Microcoil Stretch Resistant BOTH IP/OP "$2,294.00 " "$1,697.56" $0.00 "$1,835.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.61" "$1,702.61" "$1,768.22" $0.00 $478.07 $0.00 $0.00 $0.00 $0.00 "$1,147.00" "$1,816.85" "$1,835.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806174 EAP Custom 27806174 Coil Embolization 8mm 30cm 18 Microcoil Helical Loop BOTH IP/OP "$1,358.00 " "$1,004.92" $0.00 "$1,086.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.91" "$1,007.91" "$1,046.75" $0.00 $283.01 $0.00 $0.00 $0.00 $0.00 $679.00 "$1,075.54" "$1,086.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806175 EAP Custom 27806175 Coil Embolization Helix 4mm .0125in 8cm 1 Hand Operation BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,404.98" "$1,404.98" "$1,459.12" $0.00 $394.50 $0.00 $0.00 $0.00 $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806176 EAP Custom 27806176 Coil Embolization 3d 3mm .0115in 6cm 1 Hand Operation BOTH IP/OP "$2,555.00 " "$1,890.70" $0.00 "$2,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,896.32" "$1,896.32" "$1,969.39" $0.00 $532.46 $0.00 $0.00 $0.00 $0.00 "$1,277.50" "$2,023.56" "$2,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806177 EAP Custom 27806177 Coil Embolization 3d 25mm .0145in 50cm 1 Hand Operation BOTH IP/OP "$2,555.00 " "$1,890.70" $0.00 "$2,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,896.32" "$1,896.32" "$1,969.39" $0.00 $532.46 $0.00 $0.00 $0.00 $0.00 "$1,277.50" "$2,023.56" "$2,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806178 EAP HCPCS C1757 System Dlv Angjt Pwr Pls Y Spk Irr 1 Wy Stpck Thrmb Cath BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806179 EAP HCPCS C1874 Stent Vascular 4.5mm 28mm W/o Distal Tip Enterprise Nitinol BOTH IP/OP "$13,910.00 " "$10,293.40" $0.00 "$11,128.00" "$6,259.50" "$6,259.50" $0.00 $0.00 $0.00 "$2,899.19" "$4,181.12" "$4,181.12" "$10,721.83" $0.00 "$2,898.84" $0.00 "$6,857.63" "$6,857.63" $0.00 "$6,955.00" "$11,016.72" "$11,128.00" $0.00 "$6,259.50" $0.00 "$2,176.92" $0.00 $0.00 "$2,214.47" $0.00 $0.00 $0.00 $0.00 $0.00 27806180 EAP HCPCS C1874 Stent Vascular 4.5mm 37mm W/o Distal Tip Enterprise Nitinol BOTH IP/OP "$13,910.00 " "$10,293.40" $0.00 "$11,128.00" "$6,259.50" "$6,259.50" $0.00 $0.00 $0.00 "$2,899.19" "$4,181.12" "$4,181.12" "$10,721.83" $0.00 "$2,898.84" $0.00 "$6,857.63" "$6,857.63" $0.00 "$6,955.00" "$11,016.72" "$11,128.00" $0.00 "$6,259.50" $0.00 "$2,176.92" $0.00 $0.00 "$2,214.47" $0.00 $0.00 $0.00 $0.00 $0.00 27806181 EAP HCPCS C1769 Guidewire Vascular J .014in 205cm 42cm Soft Tip Steerable BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $517.50 $517.50 $0.00 $0.00 $0.00 $239.69 $853.53 $853.53 $886.42 $0.00 $239.66 $0.00 $680.23 $680.23 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $179.98 $0.00 $0.00 $183.08 $0.00 $0.00 $0.00 $0.00 $0.00 27806182 EAP HCPCS C1769 Guidewire Vascular J .014in 205cm 43cm Soft Tip Steerable BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $517.50 $517.50 $0.00 $0.00 $0.00 $239.69 $853.53 $853.53 $886.42 $0.00 $239.66 $0.00 $680.23 $680.23 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $179.98 $0.00 $0.00 $183.08 $0.00 $0.00 $0.00 $0.00 $0.00 27806183 EAP HCPCS C1722 Defibrillator Crd .99cm 5.37x7.36cm Dynagen BOTH IP/OP "$33,750.00 " "$24,975.00" $0.00 "$27,000.00" "$15,187.50" "$15,187.50" $0.00 $0.00 $0.00 "$7,034.34" "$4,181.12" "$4,181.12" "$26,014.50" $0.00 "$7,033.50" $0.00 "$16,638.75" "$16,638.75" $0.00 "$16,875.00" "$26,730.00" "$27,000.00" $0.00 "$15,187.50" $0.00 "$5,281.88" $0.00 $0.00 "$5,373.00" $0.00 $0.00 $0.00 $0.00 $0.00 27806184 EAP HCPCS C1788 Catheter Central Venous Pro-fuse Triniflex Od8 Fr Attachable BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $385.40 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $225.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 27806185 EAP Custom 27806185 Xpede Cement And Mixer With Size 2 Multi-tap BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806189 EAP Custom 27806189 Graft Evas 10cm 12mm Xcldr Cntrlt Leg Stent Xtd BOTH IP/OP "$11,275.00 " "$8,343.50" $0.00 "$9,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,690.77" $0.00 "$2,349.71" $0.00 $0.00 $0.00 $0.00 "$5,637.50" "$8,929.80" "$9,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806190 EAP Custom 27806190 Graft Evas 3.3cm 23mm 19-21mm Aorta BOTH IP/OP "$7,938.00 " "$5,874.12" $0.00 "$6,350.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,118.61" $0.00 "$1,654.28" $0.00 $0.00 $0.00 $0.00 "$3,969.00" "$6,286.90" "$6,350.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806195 EAP HCPCS C1882 Claria Mri Quad Crt-d Device BOTH IP/OP "$52,375.00 " "$38,757.50" $0.00 "$41,900.00" "$23,568.75" "$23,568.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$40,370.65" $0.00 "$10,914.95" $0.00 "$25,820.88" "$25,820.88" $0.00 "$26,187.50" "$41,481.00" "$41,900.00" $0.00 "$23,568.75" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27806196 EAP HCPCS C1882 Dfbr Crd 13mm 51x74mm Claria Mri Crt-d Surescan BOTH IP/OP "$52,375.00 " "$38,757.50" $0.00 "$41,900.00" "$23,568.75" "$23,568.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$40,370.65" $0.00 "$10,914.95" $0.00 "$25,820.88" "$25,820.88" $0.00 "$26,187.50" "$41,481.00" "$41,900.00" $0.00 "$23,568.75" $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27806197 EAP HCPCS C1882 Dfbr Crd 13mm 51x71mm Surescan Claria Mri BOTH IP/OP "$52,375.00 " "$38,757.50" $0.00 "$41,900.00" "$23,568.75" "$23,568.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$40,370.65" $0.00 "$10,914.95" $0.00 "$25,820.88" "$25,820.88" $0.00 "$26,187.50" "$41,481.00" "$41,900.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27806198 EAP HCPCS C1882 Dfbr Crd 13mm 51x73mm Claria Mri Crt-d Surescan BOTH IP/OP "$52,375.00 " "$38,757.50" $0.00 "$41,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$26,187.50" "$41,481.00" "$41,900.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27806199 EAP HCPCS C1882 Claria Mri Crt-d System Mmam BOTH IP/OP "$67,375.00 " "$49,857.50" $0.00 "$53,900.00" "$30,318.75" "$30,318.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$51,932.65" $0.00 "$14,040.95" $0.00 "$33,215.88" "$33,215.88" $0.00 "$33,687.50" "$53,361.00" "$53,900.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27806200 EAP Custom 27806200 Target Xl Soft 2mm X 3cm -coil BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806201 EAP Custom 27806201 Target Xl Soft 2mm X 6cm -coil BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 "$2,656.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806202 EAP Custom 27806202 Target Xl Soft 3mm X 6cm -coil BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 "$2,656.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806203 EAP Custom 27806203 Target Xl Soft 3mm X 9cm - Coil BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 "$2,656.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806204 EAP Custom 27806204 Target Xl Soft 4mm X 8cm - Coil BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 "$2,656.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806205 EAP Custom 27806205 Target Xl Soft 4mm X 12cm -coil BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806206 EAP Custom 27806206 Target Xl Soft 5mm X 10cm Coil BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 "$2,656.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806207 EAP Custom 27806207 Target Xl Soft 5mm X 15cm -coil BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 "$2,656.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806208 EAP Custom 27806208 Dev Emb 25mm 3mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806209 EAP HCPCS C1725 Pleurx Peritoneal Catheter Kit BOTH IP/OP "$2,916.00 " "$2,157.84" $0.00 "$2,332.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,458.00" "$2,309.47" "$2,332.80" $0.00 $0.00 $0.00 $456.35 $0.00 $0.00 $464.23 $0.00 $0.00 $0.00 $0.00 $0.00 27806210 EAP HCPCS C1882 Claria Mri Quad Crtd System Mmqm BOTH IP/OP "$67,375.00 " "$49,857.50" $0.00 "$53,900.00" "$30,318.75" "$30,318.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$51,932.65" $0.00 "$14,040.95" $0.00 "$33,215.88" "$33,215.88" $0.00 "$33,687.50" "$53,361.00" "$53,900.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27806211 EAP HCPCS C1876 Stent Vasc 4.5mm 6fr 60mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806212 EAP HCPCS C1876 Stent Vasc 4.5mm 6fr 80mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806213 EAP HCPCS C1876 Stent Vasc 4.5mm 6fr 100mm 120cm Otw Slf BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806214 EAP HCPCS C1876 Stent Vasc 4.5mm 6fr 120mm 120cm Otw Slf BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806215 EAP HCPCS C1876 Stent Vasc 5mm 6fr 20mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806216 EAP HCPCS C1876 Stent Vasc 5mm 6fr 30mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806217 EAP HCPCS C1876 Stent Vasc 5mm 6fr 40mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806218 EAP HCPCS C1876 Stent Vasc 5mm 6fr 60mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806219 EAP HCPCS C1876 Stent Vasc 5mm 6fr 80mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 "$2,418.75" $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806220 EAP HCPCS C1876 Stent Vasc 5mm 6fr 100mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806221 EAP HCPCS C1876 Stent Vasc 5mm 6fr 120mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806222 EAP HCPCS C1876 Stent Vasc 5.5mm 6fr 20mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806223 EAP HCPCS C1876 Stent Vasc 5.5mm 6fr 30mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806224 EAP HCPCS C1876 Stent Vasc 5.5mm 6fr 40mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806225 EAP HCPCS C1876 Stent Vasc 5.5mm 6fr 60mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806227 EAP HCPCS C1876 Stent Bil 5.5mm 6fr 100mm 120cm Mimetic Dsgn Flxb BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806228 EAP HCPCS C1876 Stent Bil 5.5mm 6fr 120mm 120cm Mimetic Dsgn Flxb BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806229 EAP HCPCS C1876 Stent Vasc 6mm 6fr 20mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806230 EAP HCPCS C1876 Stent Vasc 6mm 6fr 30mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806231 EAP HCPCS C1876 Stent Vasc 6mm 6fr 40mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806232 EAP HCPCS C1876 Stent Vasc 6mm 6fr 60mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806233 EAP HCPCS C1876 Stent Vasc 6mm 6fr 80mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806234 EAP HCPCS C1876 Stent Vasc 6mm 6fr 100mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806235 EAP HCPCS C1876 Stent Vasc 6mm 6fr 120mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806236 EAP HCPCS C1876 Stent Vasc 6mm 6fr 150mm 120cm Peri Supera BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806237 EAP HCPCS C1876 Stent Vasc 6.5mm 6fr 20mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806238 EAP HCPCS C1876 Stent Vasc 6.5mm 6fr 30mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806239 EAP HCPCS C1876 Stent Vasc 6.5mm 6fr 40mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806240 EAP HCPCS C1876 Stent Vasc 6.5mm 6fr 60mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806241 EAP HCPCS C1876 Stent Vasc 6.5mm 6fr 120mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806242 EAP HCPCS C1876 Stent Vasc 6.5mm 6fr 150mm 120cm Otw Slf Expandable BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806243 EAP HCPCS C1876 Stent Bil 5.5mm 6fr 150mm 120cm Mimetic Dsgn Flxb BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" "$2,244.60" "$2,244.60" $0.00 $0.00 $0.00 "$1,039.62" "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 "$2,459.08" "$2,459.08" $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $780.62 $0.00 $0.00 $794.09 $0.00 $0.00 $0.00 $0.00 $0.00 27806244 EAP Custom 27806244 STENT VASC 6.5MM 6FR 80MM 120CM OTW SLF EXPANDABLE BOTH IP/OP "$4,988.00 " "$3,691.12" $0.00 "$3,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,702.09" "$3,702.09" "$3,844.75" $0.00 "$1,039.50" $0.00 $0.00 $0.00 $0.00 "$2,494.00" "$3,950.50" "$3,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806245 EAP Custom 27806245 Dev Emb 30mm 3mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806246 EAP Custom 27806246 Dev Emb 25mm 3.25 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806247 EAP Custom 27806247 Dev Emb 35mm 3mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806248 EAP Custom 27806248 Dev Emb 30mm 3.25 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806249 EAP Custom 27806249 Dev Emb 35mm 3.25 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806250 EAP Custom 27806250 Dev Emb 25mm 3.5m BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806251 EAP Custom 27806251 Dev Emb 30mm 3.5m BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806252 EAP Custom 27806252 Dev Emb 55d 3.5mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806253 EAP Custom 27806253 Dev Emb 25mm 3.75 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806254 EAP Custom 27806254 Dev Emb 30mm 3.75 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806255 EAP Custom 27806255 Dev Emb 55d 3.75mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806256 EAP Custom 27806256 Dev Emb 25mm 4mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 "$6,290.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806257 EAP Custom 27806257 Dev Emb 30mm 4mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 "$6,290.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806258 EAP Custom 27806258 Dev Emb 55d 4mm 35 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806259 EAP Custom 27806259 Dev Emb 25mm 4.25 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806260 EAP Custom 27806260 Dev Emb 30mm 4.25 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806261 EAP Custom 27806261 Dev Emb 55d 4.25mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806262 EAP Custom 27806262 Dev Emb 30mm 4.5m BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806263 EAP Custom 27806263 Dev Emb 55d 4.5mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806264 EAP Custom 27806264 Dev Emb 25mm 4.75 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806265 EAP Custom 27806265 Dev Emb 30mm 4.75 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806266 EAP Custom 27806266 Dev Emb 55d 4.75mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806267 EAP Custom 27806267 Dev Emb 55d 5mm 25 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806268 EAP Custom 27806268 Dev Emb 30mm 5mm BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 "$6,290.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806269 EAP Custom 27806269 Dev Emb 55d 5mm 33 BOTH IP/OP "$13,979.00 " "$10,344.46" $0.00 "$11,183.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,775.01" $0.00 "$2,913.22" $0.00 $0.00 $0.00 $0.00 "$6,989.50" "$11,071.37" "$11,183.20" $0.00 "$6,290.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806270 EAP Custom 27806270 Dev Emb 55d 2.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806271 EAP Custom 27806271 Dev Emb 12mm 2.5m BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806272 EAP Custom 27806272 Dev Emb 16mm 2.5m BOTH IP/OP "$32,603.00 " "$24,126.22" $0.00 "$26,082.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$25,130.39" $0.00 "$6,794.47" $0.00 $0.00 $0.00 $0.00 "$16,301.50" "$25,821.58" "$26,082.40" $0.00 "$14,671.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806273 EAP Custom 27806273 Dev Emb 18mm 2.5m BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806274 EAP Custom 27806274 Dev Emb 55d 2.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806275 EAP Custom 27806275 Dev Emb 10mm 2.75 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806276 EAP Custom 27806276 Dev Emb 12mm 2.75 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806277 EAP Custom 27806277 Dev Emb 14mm 2.75 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806278 EAP Custom 27806278 Dev Emb 55d 2.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806279 EAP Custom 27806279 Dev Emb 18mm 2.75 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806280 EAP Custom 27806280 Dev Emb 55d 2.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806281 EAP Custom 27806281 Dev Emb 10mm 3mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806282 EAP Custom 27806282 Dev Emb 12mm 3mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806283 EAP Custom 27806283 Dev Emb 55d 3mm 14 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806284 EAP Custom 27806284 Dev Emb 16mm 3mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806285 EAP Custom 27806285 Dev Emb 55d 3mm 18 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806286 EAP Custom 27806286 Dev Emb 55d 3mm 20 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806287 EAP Custom 27806287 Dev Emb 10mm 3.25 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806288 EAP Custom 27806288 Dev Emb 12mm 3.25 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806289 EAP Custom 27806289 Dev Emb 55d 3.25mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806290 EAP Custom 27806290 Dev Emb 16mm 3.25 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806291 EAP Custom 27806291 Dev Emb 55d 3.25mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806292 EAP Custom 27806292 Dev Emb 55d 3.25mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806293 EAP Custom 27806293 Dev Emb 10mm 3.5m BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806294 EAP Custom 27806294 Dev Emb 55d 3.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806295 EAP Custom 27806295 Dev Emb 55d 3.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806296 EAP Custom 27806296 Dev Emb 55d 3.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806297 EAP Custom 27806297 Dev Emb 55d 3.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806298 EAP Custom 27806298 Dev Emb 55d 3.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806299 EAP Custom 27806299 Dev Emb 10mm 3.75 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806300 EAP Custom 27806300 Dev Emb 12mm 3.75 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806301 EAP Custom 27806301 Dev Emb 55d 3.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806302 EAP Custom 27806302 Dev Emb 16mm 3.75 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806303 EAP Custom 27806303 Dev Emb 55d 3.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806304 EAP Custom 27806304 Dev Emb 55d 3.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806305 EAP Custom 27806305 Dev Emb 55d 4mm 10 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806306 EAP Custom 27806306 Dev Emb 55d 4mm 12 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806307 EAP Custom 27806307 Dev Emb 55d 4mm 14 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806308 EAP Custom 27806308 Dev Emb 55d 4mm 16 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806309 EAP Custom 27806309 Dev Emb 55d 4mm 18 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806310 EAP Custom 27806310 Dev Emb 55d 4mm 20 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806311 EAP Custom 27806311 Dev Emb 10mm 4.25 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806312 EAP Custom 27806312 Dev Emb 55d 4.25mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806313 EAP Custom 27806313 Dev Emb 55d 4.25mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806314 EAP Custom 27806314 Dev Emb 55d 4.25mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806315 EAP Custom 27806315 Dev Emb 55d 4.25mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806316 EAP Custom 27806316 Dev Emb 55d 4.25mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806317 EAP Custom 27806317 Dev Emb 10mm 4.5m BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806318 EAP Custom 27806318 Dev Emb 55d 4.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806319 EAP Custom 27806319 Dev Emb 55d 4.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806320 EAP Custom 27806320 Dev Emb 55d 4.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806321 EAP Custom 27806321 Dev Emb 55d 4.5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806322 EAP Custom 27806322 Dev Emb 10mm 4.75 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806323 EAP Custom 27806323 Dev Emb 55d 4.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806324 EAP Custom 27806324 Dev Emb 55d 4.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806325 EAP Custom 27806325 Dev Emb 55d 4.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806326 EAP Custom 27806326 Dev Emb 55d 4.75mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806327 EAP Custom 27806327 Dev Emb 10mm 5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806328 EAP Custom 27806328 Dev Emb 12mm 5mm BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806329 EAP Custom 27806329 Dev Emb 55d 5mm 14 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 "$5,868.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806330 EAP Custom 27806330 Dev Emb 55d 5mm 16 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806331 EAP Custom 27806331 Dev Emb 55d 5mm 18 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806332 EAP Custom 27806332 Dev Emb 55d 5mm 20 BOTH IP/OP "$13,041.00 " "$9,650.34" $0.00 "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,052.00" $0.00 "$2,717.74" $0.00 $0.00 $0.00 $0.00 "$6,520.50" "$10,328.47" "$10,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806333 EAP Innova 5mm X 20mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806334 EAP HCPCS C1876 Innova 5mm X 40mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806335 EAP HCPCS C1876 Innova 5mm X 60mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806336 EAP HCPCS C1876 Innova 5mm X 80mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806337 EAP HCPCS C1876 Innova 5mm X 100mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806338 EAP HCPCS C1876 Innova 5mm X 120mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806339 EAP HCPCS C1876 Innova 6mm X 20mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806340 EAP HCPCS C1876 Stent Vasc Blue 40mm 6mm Innova Slf Xpd Radiopq BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806341 EAP HCPCS C1876 Stent Vasc Blue 60mm 6mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806342 EAP HCPCS C1876 Stent Vasc Blue 80mm 6mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806343 EAP HCPCS C1876 Stent Vasc Blue 100mm 6mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806344 EAP HCPCS C1876 Innova 6mm X 120mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806345 EAP HCPCS C1876 Innova 7mm X 20mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806346 EAP HCPCS C1876 Stent Vasc Blue 40mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806347 EAP HCPCS C1876 Stent Vasc Blue 60mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806348 EAP HCPCS C1876 Stent Vasc Blue 80mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806349 EAP HCPCS C1876 Stent Vasc Blue 100mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806350 EAP HCPCS C1876 Innova 7mm X 120mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806351 EAP HCPCS C1876 Stent Vasc Blue 20mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806352 EAP HCPCS C1876 Stent Vasc Blue 40mm 8mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806353 EAP HCPCS C1876 Stent Vasc Blue 60mm 8mm Innova Slf Xpd Radiopq BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806354 EAP HCPCS C1876 Stent Vasc Blue 80mm 8mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806355 EAP HCPCS C1876 Innova 8mm X 100mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806356 EAP HCPCS C1876 Innova 8mm X 120mm X 75cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806357 EAP HCPCS C1876 Innova 5mm X 20mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806358 EAP HCPCS C1876 Stent Vasc Blue 40mm 5mm Innova Slf Xpd Radiopq BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806359 EAP HCPCS C1876 Stent Vasc Blue 60mm 5mm Innova Slf Xpd Radiopq BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806360 EAP HCPCS C1876 Stent Vasc Blue 80mm 5mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806361 EAP HCPCS C1876 Stent Vasc Blue 100mm 5mm Innova Slf Xpd Radiopq BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806362 EAP HCPCS C1876 Stent Vasc Blue 120mm 5mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806363 EAP HCPCS C1876 Innova 6mm X 20mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806364 EAP HCPCS C1876 Stent Vasc Blue 40mm 6mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806365 EAP HCPCS C1876 Stent Vasc 60mm 6mm Innova Slf Xpd Radiopq BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806366 EAP HCPCS C1876 Stent Vasc Blue 80mm 6mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806367 EAP HCPCS C1876 Stent Vasc 100mm 6mm Innova Slf Xpd Radiopq BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806368 EAP HCPCS C1876 Stent Vasc Blue 120mm 6mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806369 EAP HCPCS C1876 Innova 7mm X 20mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806370 EAP HCPCS C1876 Stent Vasc Blue 40mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806371 EAP HCPCS C1876 Stent Vasc Blue 60mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806372 EAP HCPCS C1876 Stent Vasc Blue 80mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806373 EAP HCPCS C1876 Stent Vasc Blue 100mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806374 EAP HCPCS C1876 Stent Vasc Blue 120mm 7mm Innova Sprfc Fem Art Slf BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806375 EAP HCPCS C1876 Innova 8mm X 20mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806376 EAP HCPCS C1876 Innova 8mm X 40mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806377 EAP HCPCS C1876 Innova 8mm X 60mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806378 EAP HCPCS C1876 Innova 8mm X 80mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806379 EAP HCPCS C1876 Innova 8mm X 100mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806380 EAP HCPCS C1876 Innova 8mm X 120mm X 130cm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 27806381 EAP Custom 27806381 Coil Embl 18d .018in 2mm 2cm Azur Hdrcl Dtch Pltn Ddrgl Peri BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806382 EAP Custom 27806382 Coil Embl 18d .018in 2mm 4cm Azur Hdrcl Dtch Pltn Ddrgl Peri BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806383 EAP Custom 27806383 Coil Embl 3mm .018in 2cm Azur Hdrcl 18 Coil Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806384 EAP Custom 27806384 Coil Embl .018in 3mm .021in 5cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806385 EAP Custom 27806385 Coil Embl .018in 4mm 5cm Azur BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806386 EAP Custom 27806386 System Embl 5mm .018in 5cm Azur Hdrcl 18 Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806387 EAP HCPCS C1882 "Claria Mri Crt-d System, Mmae" BOTH IP/OP "$67,375.00 " "$49,857.50" $0.00 "$53,900.00" "$30,318.75" "$30,318.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$51,932.65" $0.00 "$14,040.95" $0.00 "$33,215.88" "$33,215.88" $0.00 "$33,687.50" "$53,361.00" "$53,900.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27806388 EAP HCPCS C1882 "Claria Mri Quad Crtd System, Mmqe" BOTH IP/OP "$67,375.00 " "$49,857.50" $0.00 "$53,900.00" "$30,318.75" "$30,318.75" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" "$51,932.65" $0.00 "$14,040.95" $0.00 "$33,215.88" "$33,215.88" $0.00 "$33,687.50" "$53,361.00" "$53,900.00" $0.00 $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 27806389 EAP Custom 27806389 System Embl 5mm .018in 10cm Azur Hdrcl 18 Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806390 EAP Custom 27806390 System Embl 5mm .018in 15cm Azur 18 Dtch Hdrcl Peri BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806391 EAP Custom 27806391 System Embl 5mm .018in 20cm Azur 18 Dtch Hdrcl Peri BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806392 EAP Custom 27806392 Coil Embl 4mm .018in 10cm 135cm Azur Dtch Pltn Ddrgl Peri BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806393 EAP Custom 27806393 Coil Embl .018in 6mm .021in 10cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806394 EAP Custom 27806394 Coil Embl .018in 8mm .021in 10cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806395 EAP Custom 27806395 Coil Embl .018in 10mm .021in 10cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806396 EAP Custom 27806396 Coil Embl 6mm .018in 15cm 135cm Azur 18 Coil Dtch Hdrcl Pltn BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806397 EAP Custom 27806397 Coil Embl .018in 8mm .021in 15cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806398 EAP Custom 27806398 Coil Embl .018in 10mm .021in 15cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806399 EAP Custom 27806399 Coil Embl .018in 12mm .021in 15cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806400 EAP HCPCS C2617 Set Stent 2 Pigtail Curve 8fr 26cm Radiopq Graduat BOTH IP/OP $269.00 $199.06 $0.00 $215.20 $121.05 $121.05 $0.00 $0.00 $0.00 $56.07 $199.65 $199.65 $207.35 $0.00 $56.06 $0.00 $159.11 $159.11 $0.00 $134.50 $213.05 $215.20 $0.00 $0.00 $0.00 $42.10 $0.00 $0.00 $42.82 $0.00 $0.00 $0.00 $0.00 $0.00 27806401 EAP HCPCS C1874 Graft Evas 106mm 12mm H&l-b 1-shot Znth Fenestrate BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27806405 EAP Custom 27806405 Coil Embl 8mm 20cm Azur Hdrcl 18 Coils Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806406 EAP Custom 27806406 Coil Embl .018in 12mm .021in 20cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806407 EAP Custom 27806407 Coil Embl 15mm 20cm Azur Hdrcl 18 Coils Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806408 EAP Custom 27806408 Coil Embl 20mm .018in 20cm Strl Azur Hdrcl Dtch Pltn Ddrgl BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806409 EAP Custom 27806409 Coil Embl 15mm .018in 30cm Strl Azur Hdrcl 18 Coil Dtch Pltn BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806410 EAP Custom 27806410 Coil Embl 20mm .018in 30cm Strl Azur 18 Coil Dtch Hdrcl Pltn BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806411 EAP Custom 27806411 Coil Embl .018in 4mm .021-.027in 13cm Strl Azur Cx Dtch Pltn BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806412 EAP Custom 27806412 Coil Embl .018in 5mm .021-.027in 16cm Azur Cx Dtch Sft Flxb BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806413 EAP Custom 27806413 Coil Embl .018in 6mm .021-.027in 20cm Azur Cx Dtch Sft Flxb BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806414 EAP Custom 27806414 Coil Embl .018in 7mm .021-.027in 24cm Azur Cx Dtch Sft Flxb BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806415 EAP Custom 27806415 Coil Embl .018in 8mm .021-.027in 28cm Azur Cx Hdrcl Dtch Sft BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806416 EAP Custom 27806416 Coil Embl .018in 9mm .021-.027in 28cm Azur Cx Hdrcl Dtch Sft BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806417 EAP Custom 27806417 Coil Embl .018in 10mm .021-.027in 32cm Azur Cx Hdrcl Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806418 EAP Custom 27806418 Coil Embl .018in 12mm .021-.027in 38cm Azur Cx Hdrcl Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806419 EAP Custom 27806419 Coil Embl .018in 14mm .021-.027in 34cm Azur Cx Hdrcl Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806420 EAP Custom 27806420 Coil Embl .018in 16mm .021-.027in 39cm Azur Cx Hdrcl Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806421 EAP Custom 27806421 Coil Embl .018in 18mm .021-.027in 36cm Azur Cx Hdrcl Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806422 EAP Custom 27806422 Coil Embl .018in 20mm .021-.027in 40cm Azur Cx Hdrcl Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806423 EAP Custom 27806423 Coil Embl .035in 4mm .038in 5cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806424 EAP Custom 27806424 Coil Embl 4mm 10cm Azur Dtch Ddrgl Peri 35 Sys BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806425 EAP Custom 27806425 Coil Embl .035in 6mm .038in 10cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806426 EAP Custom 27806426 Coil Embl .035in 4mm 15cm Azur Dtch Ddrgl Peri BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806427 EAP Custom 27806427 Coil Embl .035in 6mm .038in 15cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806428 EAP Custom 27806428 Coil Embl .035in 8mm .038in 15cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806429 EAP Custom 27806429 Coil Embl .035in 10mm .038in 15cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806430 EAP Custom 27806430 Coil Embl 6mm 20cm Azur Dtch Ddrgl Peri 35 Sys BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806431 EAP Custom 27806431 Coil Embl .035in 8mm .038in 20cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806432 EAP Custom 27806432 Coil Embl .035in 12mm .038in 20cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806433 EAP Custom 27806433 Coil Embl .035in 15mm .038in 20cm 135cm Azur Dtch Pltn Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806434 EAP Custom 27806434 Coil Embl 20mm 20cm Azur Dtch Ddrgl Peri 35 Sys BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806435 EAP Custom 27806435 Coil Embl 12mm 30cm Azur Dtch Ddrgl Peri 35 Sys BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806436 EAP Custom 27806436 Coil Embl .035in 4mm 7cm Azur Cx Dtch Sft Sld Cor Flxb Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 "$1,406.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806437 EAP Custom 27806437 Coil Embl .035in 5mm 11cm Azur Cx Dtch Sft Sld Cor Flxb BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 "$1,406.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806438 EAP Custom 27806438 Coil Embl .035in 6mm 9cm Azur Cx Dtch Sft Sld Cor Flxb Ddrgl BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806439 EAP Custom 27806439 Coil Embl .035in 6mm 17cm Azur Cx Dtch Cx Sect Cvrgls Flxb BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 "$1,406.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806440 EAP Custom 27806440 Coil Embl .035in 8mm 12cm Azur Cx Dtch Sft Sld Cor Flxb BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806441 EAP Custom 27806441 Coil Embl .035in 8mm 24cm Azur Cx Dtch Sft Sld Cor Flxb BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 "$1,406.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806442 EAP Custom 27806442 Coil Embl .035in 10mm 19cm Azur Cx Dtch Sft Sld Cor Flxb BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806443 EAP Custom 27806443 Coil Embl .035in 13mm 24cm Azur Cx Dtch Sft Sld Cor Flxb BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 "$1,406.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806444 EAP Custom 27806444 Coil Embl .035in 16mm 32cm Azur Cx Dtch Sft Sld Cor Flxb BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806445 EAP Custom 27806445 Coil Embl .035in 10mm .038in 26cm 150cm Azur Frme Elc Dtch BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 "$1,406.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806446 EAP Custom 27806446 Coil Embl 8mm 20cm Azur Frm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806447 EAP Custom 27806447 Coil Embl .018in 10mm .021in 26cm 150cm Azur Frme Elc Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806448 EAP Custom 27806448 Coil Embl .018in 14mm 34mm Azur Frme Nonhydrogel Dtch Loop BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806449 EAP Custom 27806449 Coil Embl .018in 20mm .021in 50cm 150cm Azur Frme Elc Dtch BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806450 EAP Custom 27806450 Coil Embl Azur Dtch Cntrlr BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $191.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27806451 EAP HCPCS C1880 "Kit Aln Removal And/or Repositioning, 2in1 Rs" BOTH IP/OP "$1,063.00 " $786.62 $0.00 $850.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $531.50 $841.90 $850.40 $0.00 $0.00 $0.00 $166.36 $0.00 $0.00 $169.23 $0.00 $0.00 $0.00 $0.00 $0.00 27806493 EAP HCPCS C1874 Graft Evas 91mm 12fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27806494 EAP HCPCS C1874 Graft Evas 124mm 32mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27806596 EAP HCPCS C1874 Graft Evas 121mm 12mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27806798 EAP HCPCS C1874 Graft Evas 76mm 16fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27806899 EAP HCPCS C1874 Graft Evas 76mm 20fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807101 EAP HCPCS C1874 Graft Evas 91mm 16fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807202 EAP HCPCS C1874 Graft Evas 91mm 20fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807303 EAP HCPCS C1874 Graft Evas 106mm 16fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807404 EAP HCPCS C1874 Graft Evas 106mm 20fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807505 EAP HCPCS C1874 Graft Evas 121mm 16fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807606 EAP HCPCS C1874 Graft Evas 121mm 20fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807707 EAP HCPCS C1874 Graft Evas 76mm 12fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807808 EAP HCPCS C1874 Graft Evas 76mm 16fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27807909 EAP HCPCS C1874 Graft Evas 76mm 20fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808010 EAP HCPCS C1874 Graft Evas 76mm 24fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808111 EAP HCPCS C1874 Graft Evas 91mm 12fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808212 EAP HCPCS C1874 Graft Evas 91mm 16fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808313 EAP HCPCS C1874 Graft Evas 91mm 20fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808414 EAP HCPCS C1874 Graft Evas 91mm 24fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808515 EAP HCPCS C1874 Graft Evas 106mm 12fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808616 EAP HCPCS C1874 Graft Evas 106mm 16fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808717 EAP HCPCS C1874 Graft Evas 106mm 20fr Znth H&l-b 1-shot Vscr Fen BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808818 EAP HCPCS C1874 Graft Evas 106mm 24fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27808919 EAP HCPCS C1874 Graft Evas 121mm 12fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809020 EAP HCPCS C1874 Graft Evas 121mm 16fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809021 EAP HCPCS C1876 Tent Vasc Strg 10mm 30mm Xact Slf Xpd Cls Cell Fl BOTH IP/OP "$4,938.00 " "$3,654.12" $0.00 "$3,950.40" "$2,222.10" "$2,222.10" $0.00 $0.00 $0.00 "$1,029.20" "$3,664.98" "$3,664.98" "$3,806.21" $0.00 "$1,029.08" $0.00 "$2,434.43" "$2,434.43" $0.00 "$2,469.00" "$3,910.90" "$3,950.40" $0.00 "$2,222.10" $0.00 $772.80 $0.00 $0.00 $786.13 $0.00 $0.00 $0.00 $0.00 $0.00 27809121 EAP HCPCS C1874 Graft Evas 121mm 20fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809222 EAP HCPCS C1874 Graft Evas 121mm 24fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809323 EAP HCPCS C1874 Graft Evas 76mm 12fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809424 EAP HCPCS C1874 Graft Evas 76mm 20mm 8.1mm 20fr Znth Aaa Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809525 EAP HCPCS C1874 Graft Evas 76mm 24fr Znth 1-shot Aaa 2 Brch Vscr BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809626 EAP HCPCS C1874 Graft Evas 91mm 12fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809727 EAP HCPCS C1874 Graft Evas 91mm 16fr Znth Aaa Fenst Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809828 EAP HCPCS C1874 Graft Evas 91mm 20fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809929 EAP HCPCS C1874 Graft Evas 91mm 24fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27809930 EAP HCPCS C1876 Stent Endoth 12mm 8fr 40mm 100cm Flex Recons BOTH IP/OP "$2,438.00 " "$1,804.12" $0.00 "$1,950.40" "$1,097.10" "$1,097.10" $0.00 $0.00 $0.00 $508.14 "$1,809.48" "$1,809.48" "$1,879.21" $0.00 $508.08 $0.00 "$1,442.08" "$1,442.08" $0.00 "$1,219.00" "$1,930.90" "$1,950.40" $0.00 "$1,097.10" $0.00 $381.55 $0.00 $0.00 $388.13 $0.00 $0.00 $0.00 $0.00 $0.00 27809931 EAP HCPCS C1788 Set Hmdial 33ml Lf Aqdx Bld Crct Uf-500 BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 "$1,012.50" $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 27810030 EAP HCPCS C1874 Graft Evas 106mm 12fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810131 EAP HCPCS C1874 Graft Evas 106mm 16fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810232 EAP HCPCS C1874 Graft Evas 106mm 20fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810333 EAP HCPCS C1874 Graft Evas 106mm 24fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810434 EAP HCPCS C1874 Graft Evas 121mm 12fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810535 EAP HCPCS C1874 Graft Evas 121mm 16fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810636 EAP HCPCS C1874 Graft Evas 121mm 20fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810737 EAP HCPCS C1874 Graft Evas 121mm 24fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810838 EAP HCPCS C1874 Graft Evas 76mm 16fr Znth Aaa Vscr Fen Distal Bfur BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27810939 EAP HCPCS C1874 Graft Evas 76mm 24mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27811040 EAP HCPCS C1874 Graft Evas 76mm 26mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811141 EAP HCPCS C1874 Graft Evas 76mm 28mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811242 EAP HCPCS C1874 Graft Evas 76mm 30mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811343 EAP HCPCS C1874 Graft Evas 76mm 32mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811444 EAP HCPCS C1874 Graft Evas 91mm 24mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811545 EAP HCPCS C1874 Graft Evas 91mm 26mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811646 EAP HCPCS C1874 Graft Evas 91mm 28mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811747 EAP HCPCS C1874 Graft Evas 91mm 30mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811848 EAP HCPCS C1874 Graft Evas 91mm 32mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27811949 EAP HCPCS C1874 Graft Evas 106mm 24mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812050 EAP HCPCS C1874 Graft Evas 106mm 26mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812151 EAP HCPCS C1874 Graft Evas 106mm 28mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812252 EAP HCPCS C1874 Graft Evas 106mm 30mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812353 EAP HCPCS C1874 Graft Evas 106mm 32mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812454 EAP HCPCS C1874 Graft Evas 121mm 24mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812555 EAP HCPCS C1874 Graft Evas 121mm 26mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812656 EAP HCPCS C1874 Graft Evas 121mm 28mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812757 EAP HCPCS C1874 Graft Evas 121mm 30mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812858 EAP HCPCS C1874 Graft Evas 121mm 32mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27812959 EAP HCPCS C1874 Graft Evas 84mm 34mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813060 EAP HCPCS C1874 Graft Evas 84mm 36mm 8.5mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813161 EAP HCPCS C1874 Graft Evas 99mm 34mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813262 EAP HCPCS C1874 Graft Evas 99mm 36mm 8.5mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813363 EAP HCPCS C1874 Graft Evas 114mm 34mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813464 EAP HCPCS C1874 Graft Evas 114mm 36mm 8.5mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813565 EAP HCPCS C1874 Graft Evas 129mm 34mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813666 EAP HCPCS C1874 Graft Evas 129mm 36mm 8.5mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813767 EAP HCPCS C1874 Graft Evas 94mm 24mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813868 EAP HCPCS C1874 Graft Evas 94mm 26mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27813969 EAP HCPCS C1874 Graft Evas 94mm 20fr Znth Aaa Vscr Fen Prox Bfur BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814070 EAP HCPCS C1874 Graft Evas 94mm 30mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814171 EAP HCPCS C1874 Graft Evas 94mm 32mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814272 EAP HCPCS C1874 Graft Evas 109mm 24mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814373 EAP HCPCS C1874 Graft Evas 109mm 26mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814474 EAP HCPCS C1874 Graft Evas 109mm 28mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814575 EAP HCPCS C1874 Graft Evas 109mm 30mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814676 EAP HCPCS C1874 Graft Evas 109mm 32mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814777 EAP HCPCS C1874 Graft Evas 124mm 24mm 7.7mm 20fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814878 EAP HCPCS C1874 Graft Evas 124mm 12fr Znth Aaa Vscr Fen Distal BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27814979 EAP HCPCS C1874 Graft Evas 124mm 2fr Znth Aaa Fenst Prox Body 28mm BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27815080 EAP HCPCS C1874 Graft Evas 124mm 30mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27815282 EAP HCPCS C1874 Graft Evas 107mm 34mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27815383 EAP HCPCS C1874 Graft Evas 107mm 36mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27815484 EAP HCPCS C1874 Graft Evas 122mm 34mm 20fr H L-b 1-shot Znth 2 BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27815585 EAP HCPCS C1874 Graft Evas 122mm 36mm 8.5mm 22fr Znth H&l-b 1-shot BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27815686 EAP HCPCS C1874 Graft Evas 137mm 34mm H&l-b 1-shot Znth 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27815787 EAP HCPCS C1874 Graft Evas 137mm 36mm Znth H&l-b 1-shot 2 Prox BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" "$21,197.00" $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 27815888 EAP HCPCS C1874 Graft Evas 109mm 20mm 7.7mm 20fr Znth Fenestrate 2 BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" "$7,145.32" $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 27815889 EAP HCPCS C1881 Catheter Intvn Mic 2.7fr L130c BOTH IP/OP $818.13 $605.42 $0.00 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.22 $607.22 $630.61 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $409.07 $647.96 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815890 EAP Custom 27815890 Coil Embol L14cm Loop Od5mm 0.018in Platinum Hydrogel Polyme BOTH IP/OP $818.13 $605.42 $0.00 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.22 $607.22 $630.61 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $409.07 $647.96 $654.50 $0.00 $368.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815891 EAP Custom 27815891 Coil Embol L20cm Od6mm 0.018in Hydrocoil Pushable Azur 18p BOTH IP/OP $818.13 $605.42 $0.00 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.22 $607.22 $630.61 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $409.07 $647.96 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815892 EAP Custom 27815892 Coil Embol L20cm Loop Od8mm 0.018in Platinum Hydrogel Polyme BOTH IP/OP $923.33 $683.26 $0.00 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.30 $685.30 $711.70 $0.00 $192.42 $0.00 $0.00 $0.00 $0.00 $461.67 $731.28 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815893 EAP Custom 27815893 Coil Embol L14cm Loop Od6mm 0.035in Platinum Hydrogel Polyme BOTH IP/OP $923.33 $683.26 $0.00 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.30 $685.30 $711.70 $0.00 $192.42 $0.00 $0.00 $0.00 $0.00 $461.67 $731.28 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815894 EAP Custom 27815894 Coil Embol L20cm Loop Od8mm 0.035in Platinum Hydrogel Polyme BOTH IP/OP $923.33 $683.26 $0.00 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.30 $685.30 $711.70 $0.00 $192.42 $0.00 $0.00 $0.00 $0.00 $461.67 $731.28 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815895 EAP Custom 27815895 Coil Embol L20cm Loop Od10mm 0.035in Platinum Hydrogel Polym BOTH IP/OP $923.33 $683.26 $0.00 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.30 $685.30 $711.70 $0.00 $192.42 $0.00 $0.00 $0.00 $0.00 $461.67 $731.28 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815896 EAP Custom 27815896 Coil Embol L20cm Loop Od15mm 0 BOTH IP/OP $923.33 $683.26 $0.00 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.30 $685.30 $711.70 $0.00 $192.42 $0.00 $0.00 $0.00 $0.00 $461.67 $731.28 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815897 EAP Custom 27815897 Coil Embol L20cm Loop Od16mm 0 BOTH IP/OP $818.13 $605.42 $0.00 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.22 $607.22 $630.61 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $409.07 $647.96 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815898 EAP Custom 27815898 Coil Embl .018in 10mm 14cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.24 $260.24 $270.27 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.32 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815899 EAP Custom 27815899 Coil Embl .018in 2mm 2cm Azur Hdrcl Psh Perm Mech Ocl Ddrgl BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.24 $260.24 $270.27 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.32 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815900 EAP Custom 27815900 Coil Embl .018in 3mm 2cm Azur Hdrcl Psh Loop Pltn Ddrgl Peri BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.98 $346.98 $360.35 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815901 EAP Custom 27815901 Coil Embl .018in 3mm 4cm Azur Hdrcl Psh Perm Mech Ocl Ddrgl BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.24 $260.24 $270.27 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.32 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815902 EAP Custom 27815902 Coil Embl .018in 4mm 2cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.98 $346.98 $360.35 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815903 EAP Custom 27815903 Coil Embl .018in 4mm 4cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $584.38 $432.44 $0.00 $467.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $433.73 $433.73 $450.44 $0.00 $121.78 $0.00 $0.00 $0.00 $0.00 $292.19 $462.83 $467.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815904 EAP Custom 27815904 Coil Embl .018in 4mm 6cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $689.58 $510.29 $0.00 $551.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $511.81 $511.81 $531.53 $0.00 $143.71 $0.00 $0.00 $0.00 $0.00 $344.79 $546.15 $551.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815905 EAP Custom 27815905 Coil Embl .018in 4mm 6cm Azur Hdrcl Psh Perm Mech Ocl Ddrgl BOTH IP/OP $701.25 $518.93 $0.00 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $520.47 $520.47 $540.52 $0.00 $146.14 $0.00 $0.00 $0.00 $0.00 $350.63 $555.39 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815906 EAP Custom 27815906 Coil Embl .018in 5mm 10cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.98 $346.98 $360.35 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815907 EAP Custom 27815907 Coil Embl .018in 5mm 4cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $584.38 $432.44 $0.00 $467.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $433.73 $433.73 $450.44 $0.00 $121.78 $0.00 $0.00 $0.00 $0.00 $292.19 $462.83 $467.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815908 EAP Custom 27815908 Coil Embl .018in 5mm 6cm Azur Hdrcl Psh 18 Sys BOTH IP/OP $689.58 $510.29 $0.00 $551.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $511.81 $511.81 $531.53 $0.00 $143.71 $0.00 $0.00 $0.00 $0.00 $344.79 $546.15 $551.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815909 EAP Custom 27815909 Coil Embl .018in 5mm 6cm Azur Hdrcl Psh Perm Mech Ocl Ddrgl BOTH IP/OP $701.25 $518.93 $0.00 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $520.47 $520.47 $540.52 $0.00 $146.14 $0.00 $0.00 $0.00 $0.00 $350.63 $555.39 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815910 EAP Custom 27815910 Coil Embl .018in 6mm 10cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $818.13 $605.42 $0.00 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.22 $607.22 $630.61 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $409.07 $647.96 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815911 EAP Custom 27815911 Coil Embl .018in 6mm 14cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $584.38 $432.44 $0.00 $467.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $433.73 $433.73 $450.44 $0.00 $121.78 $0.00 $0.00 $0.00 $0.00 $292.19 $462.83 $467.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815912 EAP Custom 27815912 Coil Embl .018in 6mm 6cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $701.25 $518.93 $0.00 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $520.47 $520.47 $540.52 $0.00 $146.14 $0.00 $0.00 $0.00 $0.00 $350.63 $555.39 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815913 EAP Custom 27815913 Coil Embl .018in 8mm 10cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $818.13 $605.42 $0.00 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.22 $607.22 $630.61 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $409.07 $647.96 $654.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815914 EAP Custom 27815914 Coil Embl .018in 8mm 14cm Azur Hdrcl Psh Peri 18 Sys BOTH IP/OP $923.33 $683.26 $0.00 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.30 $685.30 $711.70 $0.00 $192.42 $0.00 $0.00 $0.00 $0.00 $461.67 $731.28 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815915 EAP Custom 27815915 Coil Embl .035in 10mm 14cm Azur Hdrcl Psh Peri 35 Sys BOTH IP/OP $923.33 $683.26 $0.00 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.30 $685.30 $711.70 $0.00 $192.42 $0.00 $0.00 $0.00 $0.00 $461.67 $731.28 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815916 EAP Custom 27815916 Coil Embl .035in 15mm 14cm Azur Hdrcl Psh Loop Pltn Ddrgl BOTH IP/OP $572.70 $423.80 $0.00 $458.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $425.06 $425.06 $441.44 $0.00 $119.35 $0.00 $0.00 $0.00 $0.00 $286.35 $453.58 $458.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815917 EAP Custom 27815917 Coil Embl .035in 4mm 4cm Azur Hdrcl Psh Peri 35 Sys BOTH IP/OP $806.45 $596.77 $0.00 $645.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $598.55 $598.55 $621.61 $0.00 $168.06 $0.00 $0.00 $0.00 $0.00 $403.23 $638.71 $645.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815918 EAP Custom 27815918 Coil Embl .035in 5mm 10cm Azur Hdrcl Psh BOTH IP/OP $806.45 $596.77 $0.00 $645.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $598.55 $598.55 $621.61 $0.00 $168.06 $0.00 $0.00 $0.00 $0.00 $403.23 $638.71 $645.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815919 EAP Custom 27815919 Coil Embl .035in 6mm 10cm Azur Hdrcl Psh BOTH IP/OP $806.45 $596.77 $0.00 $645.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $598.55 $598.55 $621.61 $0.00 $168.06 $0.00 $0.00 $0.00 $0.00 $403.23 $638.71 $645.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815920 EAP Custom 27815920 Coil Embl .035in 8mm 10cm Azur Hdrcl Psh Peri 35 Sys BOTH IP/OP $923.33 $683.26 $0.00 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.30 $685.30 $711.70 $0.00 $192.42 $0.00 $0.00 $0.00 $0.00 $461.67 $731.28 $738.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815922 EAP Custom 27815922 Coil Embol L20cm Od10mm 0.018in Hydrocoil Pushable Azur 18p BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.21 $575.21 $597.37 $0.00 $161.51 $0.00 $0.00 $0.00 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815923 EAP HCPCS C1874 Stent Endoprsth 29mm 7mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$6,725.00 " "$4,976.50" $0.00 "$5,380.00" "$3,026.25" "$3,026.25" $0.00 $0.00 $0.00 "$1,401.66" "$4,181.12" "$4,181.12" "$5,183.63" $0.00 "$1,401.49" $0.00 "$3,315.43" "$3,315.43" $0.00 "$3,362.50" "$5,326.20" "$5,380.00" $0.00 $0.00 $0.00 "$1,052.46" $0.00 $0.00 "$1,070.62" $0.00 $0.00 $0.00 $0.00 $0.00 27815924 EAP HCPCS C1874 Stent Endoprsth 29mm 8mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$6,725.00 " "$4,976.50" $0.00 "$5,380.00" "$3,026.25" "$3,026.25" $0.00 $0.00 $0.00 "$1,401.66" "$4,181.12" "$4,181.12" "$5,183.63" $0.00 "$1,401.49" $0.00 "$3,315.43" "$3,315.43" $0.00 "$3,362.50" "$5,326.20" "$5,380.00" $0.00 $0.00 $0.00 "$1,052.46" $0.00 $0.00 "$1,070.62" $0.00 $0.00 $0.00 $0.00 $0.00 27815925 EAP HCPCS C1874 Stent Endoprsth 29mm 11mm 16sq Mm 8fr Gore Vbhn BOTH IP/OP "$8,138.00 " "$6,022.12" $0.00 "$6,510.40" "$3,662.10" "$3,662.10" $0.00 $0.00 $0.00 "$1,696.16" "$4,181.12" "$4,181.12" "$6,272.77" $0.00 "$1,695.96" $0.00 "$4,012.03" "$4,012.03" $0.00 "$4,069.00" "$6,445.30" "$6,510.40" $0.00 $0.00 $0.00 "$1,273.60" $0.00 $0.00 "$1,295.57" $0.00 $0.00 $0.00 $0.00 $0.00 27815926 EAP HCPCS C1874 Stent Endoprsth 39mm 7mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$8,138.00 " "$6,022.12" $0.00 "$6,510.40" "$3,662.10" "$3,662.10" $0.00 $0.00 $0.00 "$1,696.16" "$4,181.12" "$4,181.12" "$6,272.77" $0.00 "$1,695.96" $0.00 "$4,012.03" "$4,012.03" $0.00 "$4,069.00" "$6,445.30" "$6,510.40" $0.00 $0.00 $0.00 "$1,273.60" $0.00 $0.00 "$1,295.57" $0.00 $0.00 $0.00 $0.00 $0.00 27815927 EAP HCPCS C1874 Stent Endoprsth 39mm 8mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$8,138.00 " "$6,022.12" $0.00 "$6,510.40" "$3,662.10" "$3,662.10" $0.00 $0.00 $0.00 "$1,696.16" "$4,181.12" "$4,181.12" "$6,272.77" $0.00 "$1,695.96" $0.00 "$4,012.03" "$4,012.03" $0.00 "$4,069.00" "$6,445.30" "$6,510.40" $0.00 $0.00 $0.00 "$1,273.60" $0.00 $0.00 "$1,295.57" $0.00 $0.00 $0.00 $0.00 $0.00 27815928 EAP HCPCS c1874 Stent Endoprsth 39mm 11mm 16sq Mm 8fr Gore Vbhn BOTH IP/OP "$8,138.00 " "$6,022.12" $0.00 "$6,510.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,272.77" $0.00 "$1,695.96" $0.00 $0.00 $0.00 $0.00 "$4,069.00" "$6,445.30" "$6,510.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815929 EAP HCPCS C1874 Stent Endoprsth 59mm 7mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$8,138.00 " "$6,022.12" $0.00 "$6,510.40" "$3,662.10" "$3,662.10" $0.00 $0.00 $0.00 "$1,696.16" "$4,181.12" "$4,181.12" "$6,272.77" $0.00 "$1,695.96" $0.00 "$4,012.03" "$4,012.03" $0.00 "$4,069.00" "$6,445.30" "$6,510.40" $0.00 "$3,662.10" $0.00 "$1,273.60" $0.00 $0.00 "$1,295.57" $0.00 $0.00 $0.00 $0.00 $0.00 27815930 EAP HCPCS C1874 Stent Endoprsth 59mm 8mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$8,138.00 " "$6,022.12" $0.00 "$6,510.40" "$3,662.10" "$3,662.10" $0.00 $0.00 $0.00 "$1,696.16" "$4,181.12" "$4,181.12" "$6,272.77" $0.00 "$1,695.96" $0.00 "$4,012.03" "$4,012.03" $0.00 "$4,069.00" "$6,445.30" "$6,510.40" $0.00 $0.00 $0.00 "$1,273.60" $0.00 $0.00 "$1,295.57" $0.00 $0.00 $0.00 $0.00 $0.00 27815931 EAP HCPCS C1874 Stent Endoprsth 59mm 11mm 16sq Mm 8fr Gore Vbhn BOTH IP/OP "$8,138.00 " "$6,022.12" $0.00 "$6,510.40" "$3,662.10" "$3,662.10" $0.00 $0.00 $0.00 "$1,696.16" "$4,181.12" "$4,181.12" "$6,272.77" $0.00 "$1,695.96" $0.00 "$4,012.03" "$4,012.03" $0.00 "$4,069.00" "$6,445.30" "$6,510.40" $0.00 $0.00 $0.00 "$1,273.60" $0.00 $0.00 "$1,295.57" $0.00 $0.00 $0.00 $0.00 $0.00 27815932 EAP Catheter Infus 18fr Trevo Pro Mic Nrvsc BOTH IP/OP "$1,269.00 " $939.06 $0.00 "$1,015.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $941.85 $941.85 $978.15 $0.00 $264.46 $0.00 $0.00 $0.00 $0.00 $634.50 "$1,005.05" "$1,015.20" $0.00 $571.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815933 EAP HCPCS C1874 Stent Eprsth 8mm 7fr 10cm 120cm Vbhn Dlv Sys Hep Sprfc Fem BOTH IP/OP "$8,738.00 " "$6,466.12" $0.00 "$6,990.40" "$3,932.10" "$3,932.10" $0.00 $0.00 $0.00 "$1,821.22" "$4,181.12" "$4,181.12" "$6,735.25" $0.00 "$1,821.00" $0.00 "$4,307.83" "$4,307.83" $0.00 "$4,369.00" "$6,920.50" "$6,990.40" $0.00 $0.00 $0.00 "$1,367.50" $0.00 $0.00 "$1,391.09" $0.00 $0.00 $0.00 $0.00 $0.00 27815934 EAP Coil Embolization 4mm 12cm Complex Fill Trufill Dcs Orbit BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815935 EAP HCPCS C1876 Stent Cor .02in 2.5mm 19mm 140cm Tryton Rx Dlv Sys Radopq Sd BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 "$1,002.04" $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 27815936 EAP HCPCS C1876 Stent Cor .02in 2.5-3mm 19mm 140cm Tryton Rx Dlv Sys Radopq BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 "$1,002.04" $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 27815937 EAP HCPCS C1876 Stent Cor .02in 2.5-3.5mm 19mm 140cm Tryton Rx Dlv Sys BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 "$1,002.04" $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 27815939 EAP HCPCS C1876 Stent Cor .02in 3.5-4mm 15mm 140cm Tryton Rx Dlv Sys Radopq BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 "$1,002.04" $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 27815940 EAP Custom 27815940 Pin Half 5mm 4mm 300mm 50mm Tr BOTH IP/OP $256.00 $189.44 $0.00 $204.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.00 $190.00 $197.32 $0.00 $53.35 $0.00 $0.00 $0.00 $0.00 $128.00 $202.75 $204.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815941 EAP HCPCS C1874 System Cor Stnt 4.5mm 12mm 140cm Rslt Onyx Rx Dlv Sys Radopq BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27815942 EAP Custom 27815942 Coil Embl 3d 3mm 6cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815943 EAP Custom 27815943 Coil Embl 3d 3mm 8cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815944 EAP Custom 27815944 Coil Embl 3d 3mm 10cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815945 EAP Custom 27815945 Coil Embl 3d 3.5mm 6cm Axium Prm Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815946 EAP Custom 27815946 Coil Embl 3d 3.5mm 8cm Axium Frm Nrvsc V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815947 EAP Custom 27815947 Coil Embl 3d 3.5mm 10cm Axium Frm Nrvsc V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815948 EAP Custom 27815948 Coil Embl 3d 4mm 6cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815949 EAP Custom 27815949 Coil Embl 3d 4mm 8cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815950 EAP Custom 27815950 Coil Embl 3d 4mm 10cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815951 EAP Custom 27815951 Coil Embl 3d 4mm 12cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815952 EAP Custom 27815952 Coil Embl 3d 4mm 15cm Axium Frm Nrvsc V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815953 EAP Custom 27815953 Coil Embl 3d 5mm 8cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815954 EAP Custom 27815954 Coil Embl 3d 5mm 10cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815955 EAP Custom 27815955 Coil Embl 3d 5mm 15cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815956 EAP Custom 27815956 Coil Embl 3d 5mm 20cm Axium Frm Nrvsc V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815957 EAP Custom 27815957 Coil Embl 3d 6mm 10cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815958 EAP Custom 27815958 Coil Embl 3d 6mm 15cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815959 EAP Custom 27815959 Coil Embl 3d 6mm 20cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815960 EAP Custom 27815960 Coil Embl 3d 6mm 25cm Axium Frm Nrvsc V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815961 EAP Custom 27815961 Coil Embl 3d 7mm 12cm Axium Frm Nrvsc V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815962 EAP Custom 27815962 Coil Embl 3d 7mm 15cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815963 EAP Custom 27815963 Coil Embl 3d 7mm 20cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,019.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815964 EAP Custom 27815964 Coil Embl 3d 7mm 30cm Axium Frm V01 BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815965 EAP Custom 27815965 Coil Embl 3d 8mm 15cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815966 EAP Custom 27815966 Coil Embl 3d 8mm 20cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 "$2,357.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815967 EAP Custom 27815967 Coil Embl 3d 8mm 30cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815968 EAP Custom 27815968 Coil Embl 3d 9mm 20cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 "$2,357.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815969 EAP Custom 27815969 Coil Embl 3d 9mm 30cm Axium Prm Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815970 EAP Custom 27815970 Coil Embl 3d 10mm 20cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 "$2,357.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815971 EAP Custom 27815971 Coil Embl 3d 10mm 30cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815972 EAP Custom 27815972 Coil Embl 3d 10mm 40cm Axium Frm Nrvsc V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815973 EAP Custom 27815973 Coil Embl 3d 12mm 30cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815974 EAP Custom 27815974 Coil Embl 3d 12mm 40cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815975 EAP Custom 27815975 Coil Embl 3d 12mm 50cm Axium Frm Nrvsc V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815976 EAP Custom 27815976 Coil Embl 3d 14mm 30cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815977 EAP Custom 27815977 Coil Embl 3d 14mm 40cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815978 EAP Custom 27815978 Coil Embl 3d 14mm 50cm Axium Frm Nrvsc V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815979 EAP Custom 27815979 Coil Embl 3d 16mm 40cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815980 EAP Custom 27815980 Coil Embl 3d 16mm 50cm Axium Frm Nrvsc V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815981 EAP Custom 27815981 Coil Embl 3d 18mm 40cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815982 EAP Custom 27815982 Coil Embl 3d 18mm 50cm Axium Frm Nrvsc V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815983 EAP Custom 27815983 Coil Embl 3d 20mm 50cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815984 EAP Custom 27815984 Coil Embl 3d 22mm 50cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815985 EAP Custom 27815985 Coil Embl 3d 25mm 50cm Axium Frm V01 BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 $0.00 $0.00 $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815986 EAP HCPCS C1876 Stent 4.5mm 30mm 5.0mm Neuroform Atlas BOTH IP/OP "$18,125.00 " "$13,412.50" $0.00 "$14,500.00" "$8,156.25" "$8,156.25" $0.00 $0.00 $0.00 "$3,777.70" "$4,181.12" "$4,181.12" "$13,970.75" $0.00 "$3,777.25" $0.00 "$8,935.63" "$8,935.63" $0.00 "$9,062.50" "$14,355.00" "$14,500.00" $0.00 "$8,156.25" $0.00 "$2,836.56" $0.00 $0.00 "$2,885.50" $0.00 $0.00 $0.00 $0.00 $0.00 27815987 EAP HCPCS C1876 Neuroform Atlas 4.5x21mm BOTH IP/OP "$17,038.00 " "$12,608.12" $0.00 "$13,630.40" "$7,667.10" "$7,667.10" $0.00 $0.00 $0.00 "$3,551.15" "$4,181.12" "$4,181.12" "$13,132.89" $0.00 "$3,550.72" $0.00 "$8,399.73" "$8,399.73" $0.00 "$8,519.00" "$13,494.10" "$13,630.40" $0.00 "$7,667.10" $0.00 "$2,666.45" $0.00 $0.00 "$2,712.45" $0.00 $0.00 $0.00 $0.00 $0.00 27815988 EAP HCPCS C1876 Neuroform Atlas 4.0x24mm BOTH IP/OP "$17,038.00 " "$12,608.12" $0.00 "$13,630.40" "$7,667.10" "$7,667.10" $0.00 $0.00 $0.00 "$3,551.15" "$4,181.12" "$4,181.12" "$13,132.89" $0.00 "$3,550.72" $0.00 "$8,399.73" "$8,399.73" $0.00 "$8,519.00" "$13,494.10" "$13,630.40" $0.00 "$7,667.10" $0.00 "$2,666.45" $0.00 $0.00 "$2,712.45" $0.00 $0.00 $0.00 $0.00 $0.00 27815989 EAP HCPCS C1876 Neuroform Atlas 4.0x21mm BOTH IP/OP "$17,038.00 " "$12,608.12" $0.00 "$13,630.40" "$7,667.10" "$7,667.10" $0.00 $0.00 $0.00 "$3,551.15" "$4,181.12" "$4,181.12" "$13,132.89" $0.00 "$3,550.72" $0.00 "$8,399.73" "$8,399.73" $0.00 "$8,519.00" "$13,494.10" "$13,630.40" $0.00 "$7,667.10" $0.00 "$2,666.45" $0.00 $0.00 "$2,712.45" $0.00 $0.00 $0.00 $0.00 $0.00 27815990 EAP HCPCS C1876 Neuroform Atlas 3.0x24mm BOTH IP/OP "$17,038.00 " "$12,608.12" $0.00 "$13,630.40" "$7,667.10" "$7,667.10" $0.00 $0.00 $0.00 "$3,551.15" "$4,181.12" "$4,181.12" "$13,132.89" $0.00 "$3,550.72" $0.00 "$8,399.73" "$8,399.73" $0.00 "$8,519.00" "$13,494.10" "$13,630.40" $0.00 "$7,667.10" $0.00 "$2,666.45" $0.00 $0.00 "$2,712.45" $0.00 $0.00 $0.00 $0.00 $0.00 27815991 EAP HCPCS C1876 Neuroform Atlas 3.0x21mm BOTH IP/OP "$17,038.00 " "$12,608.12" $0.00 "$13,630.40" "$7,667.10" "$7,667.10" $0.00 $0.00 $0.00 "$3,551.15" "$4,181.12" "$4,181.12" "$13,132.89" $0.00 "$3,550.72" $0.00 "$8,399.73" "$8,399.73" $0.00 "$8,519.00" "$13,494.10" "$13,630.40" $0.00 "$7,667.10" $0.00 "$2,666.45" $0.00 $0.00 "$2,712.45" $0.00 $0.00 $0.00 $0.00 $0.00 27815992 EAP HCPCS C1876 Neuroform Atlas 3.0x15mm BOTH IP/OP "$17,038.00 " "$12,608.12" $0.00 "$13,630.40" "$7,667.10" "$7,667.10" $0.00 $0.00 $0.00 "$3,551.15" "$4,181.12" "$4,181.12" "$13,132.89" $0.00 "$3,550.72" $0.00 "$8,399.73" "$8,399.73" $0.00 "$8,519.00" "$13,494.10" "$13,630.40" $0.00 "$7,667.10" $0.00 "$2,666.45" $0.00 $0.00 "$2,712.45" $0.00 $0.00 $0.00 $0.00 $0.00 27815993 EAP HCPCS C1874 Stent Trchbr 16mm 22fr 40mm 61cm Gmtr Otw Flly BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27815994 EAP HCPCS C1874 Stent Trchbr 12mm 16fr 30mm 62cm Gmtr Otw Flly BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27815995 EAP HCPCS C1874 Stent Trchbr 14mm 16fr 20mm 63cm Gmtr Otw Flly BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27815996 EAP HCPCS C1874 Stent Trchbr 14mm 16fr 40mm 61cm Gmtr Otw Flly BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27815997 EAP HCPCS C1874 Stent Trchbr 20mm 22fr 40mm 61cm Gmtr Otw Flly BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27815998 EAP HCPCS C1874 Stent Trchbr 20mm 60mm Otw Flly Covered Aero BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27815999 EAP HCPCS C1874 Stent Trchbr 16mm 60mm Flly Covered Purse Stng Dir BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816000 EAP HCPCS C1874 Stent Trchbr 14mm 40mm Flly Covered Purse Stng Dir BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816001 EAP Custom 27816001 Sizer Surg Aerosizer Stent Msr Dev BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816002 EAP HCPCS C1874 Stent Esph 16fr 18mm 67cm 70mm Full Cover Prox BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816003 EAP HCPCS C1874 Stent Esph 18mm 22fr 100cm Rem Covered Radiopq BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 "$2,362.50" $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816004 EAP HCPCS C1874 Stent Esph 22fr 18mm 120cm Rem Covered Alimaxx-e BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816005 EAP HCPCS C1874 Stent Esph 22mm 22fr 70cm Rem Covered Radiopq BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816006 EAP HCPCS C1874 Stent Esph 22fr 100cm Sys Alimaxx-e Mtl BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816007 EAP HCPCS C1874 Stent Esph 22fr 120cm Slf Xpd Alimaxx-e Mtl Disp BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816008 EAP HCPCS C1874 Stent Esph 12mm 70cm Flly Covered Alimaxx-es BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816009 EAP HCPCS C1874 Stent Esph 22mm 100cm Pu Cover Antimigration Strut BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816010 EAP HCPCS C1874 Stent Esph 12mm 16fr 120mm 62cm Gmtr Flly Covered BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816011 EAP HCPCS C1874 Stent Esph 14mm 70cm Flly Covered Alimaxx-es BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816012 EAP HCPCS C1874 Stent Esph 14mm 16fr 100mm 64cm Flly Covered Smth BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816013 EAP HCPCS C1874 Stent Esph 14mm 16fr 62cm 120mm Flly Covered Gmtr BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816014 EAP HCPCS C1874 Stent Esph 16mm 70cm Gmtr Flly Covered Pu Cover BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816015 EAP HCPCS C1874 Stent Esph 16mm 16fr 100mm 64cm Flly Covered Smth BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816016 EAP HCPCS C1874 Stent Esph 16mm 62cm 120mm Flly Covered Gmtr Pu BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816017 EAP HCPCS C1874 Stent Trchbr 18mm 22fr 56mm Lp Otw Full Cover Flxb BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816018 EAP HCPCS C1874 Stent Trchbr 16mm 22fr 56mm Lp Otw Full Cover Flxb BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816019 EAP HCPCS C1874 Stent Trchbr 10mm 16fr 20mm 63cm Gmtr Otw Flly BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816020 EAP HCPCS C1874 Stent Trchbr 10mm 16fr 40mm 61cm Gmtr Otw Flly BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816021 EAP HCPCS C1874 Stent Trchbr 12mm 16fr 20mm 63cm Flly Cover BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816022 EAP HCPCS C1874 Stent Trchbr 14mm 16fr 30mm 62cm Gmtr Otw Flly BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816023 EAP HCPCS C1874 Stent Trch 20mm 80mm Flly Covered Aero BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816024 EAP HCPCS C1874 Stent Trchbr 18mm 40mm Flly Covered Dir Vis Sys BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816025 EAP HCPCS C1874 Stent Trchbr 18mm 60mm Flly Covered Dir Vis Sys BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816026 EAP HCPCS C1874 Stent Trchbr 18mm 80mm Flly Covered Dir Vsn Dlv BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816027 EAP HCPCS C1874 Stent Trchbr 16mm 30mm 40mm 39mm Otw Dir Vis Novel BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816028 EAP HCPCS C1874 Stent Trchbr 16mm 80mm Flly Covered Dir Vsn Dlv BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816029 EAP HCPCS C1874 Stent Trchbr 12mm 20mm Flly Covered Dir Vsn Dlv BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816030 EAP HCPCS C1874 Stent Trchbr 12mm 28fr 30mm 40cm Gmtr Lp Full BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816031 EAP HCPCS C1874 Stent Trchbr 28fr 12mm 40mm 39cm Gmtr Lp Full BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816032 EAP HCPCS C1874 Stent Trchbr 14mm 20mm Flly Covered Dir Vsn Dlv BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816033 EAP HCPCS C1874 Stent Trchbr 14mm 30mm Flly Covered Dir Vis Sys BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816034 EAP HCPCS C1874 Stent Trchbr 20mm 40mm Flly Covered Dir Vis Sys BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816036 EAP HCPCS C1874 Stent Trchbr 20mm 80mm Flly Covered Dir Vis Sys BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 27816037 EAP HCPCS C1874 Stent Esph 19mm 24mm 70mm Flly Covered BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816038 EAP Custom 27816038 Holder Tube 100mm Blue Tio Unq Oral Arwy Dsgn Cnv BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816039 EAP Custom 27816039 Block Bite Tio 110mm BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816040 EAP Custom 27816040 Holder Tube 90mm Ylw Tio Unq Oral Arwy Dsgn Cnv BOTH IP/OP $20.00 $14.80 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $10.00 $15.84 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816041 EAP Custom 27816041 Device Basixcompak 20ml Anlg Lmscnt Dspl Inflat BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $48.18 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816042 EAP HCPCS C1874 Stent Esph 19mm 24fr 150mm 90cm Otw Flly Covered BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816043 EAP HCPCS C1874 Stent Esph 23mm 24fr 70mm 90cm 28mm Otw Flly Cover BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" "$4,432.10" $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 27816050 EAP HCPCS C1876 System Coron Stent 38mm 4.5mm Mtlnk Ul Xcelon BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816051 EAP HCPCS C1876 System Coron Stent 18mm 5mm Mtlnk Ul Xcelon Mcgld BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816052 EAP HCPCS C1876 System Coron Stent 38mm 5mm Mtlnk Ul Xcelon Mcgld BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816053 EAP HCPCS C1876 System Coron Stent 8mm 2.75mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816054 EAP HCPCS C1876 System Coron Stent 12mm 2.75mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816055 EAP HCPCS C1876 System Coron Stent 15mm 2.75mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816056 EAP HCPCS C1876 System Coron Stent 18mm 2.75mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816057 EAP HCPCS C1876 System Coron Stent 23mm 2.75mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816058 EAP HCPCS C1876 System Coron Stent 28mm 2.75mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816059 EAP HCPCS C1876 System Coron Stent 8mm 3mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816060 EAP HCPCS C1876 System Coron Stent 12mm 3mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816061 EAP HCPCS C1876 System Coron Stent 15mm 3mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816062 EAP HCPCS C1876 System Coron Stent 18mm 3mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816063 EAP HCPCS C1876 System Coron Stent 23mm 3mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816064 EAP HCPCS C1876 System Coron Stent 28mm 3mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816065 EAP HCPCS C1876 System Coron Stent 8mm 3.5mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816066 EAP HCPCS C1876 System Coron Stent 12mm 3.5mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816067 EAP HCPCS C1876 System Coron Stent 15mm 3.5mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816068 EAP HCPCS C1876 System Coron Stent 18mm 3.5mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816069 EAP HCPCS C1876 System Coron Stent 23mm 3.5mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816070 EAP HCPCS C1876 System Coron Stent 28mm 3.5mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816071 EAP HCPCS C1876 System Coron Stent 8mm 4mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816072 EAP HCPCS C1876 System Coron Stent 12mm 4mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816073 EAP HCPCS C1876 System Coron Stent 15mm 4mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816074 EAP HCPCS C1876 System Coron Stent 18mm 4mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816075 EAP HCPCS C1876 System Coron Stent 23mm 4mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816076 EAP HCPCS C1876 System Coron Stent 28mm 4mm Mtlnk Mvsn Cocr Otw BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816077 EAP HCPCS C1874 System Coron Stent 38mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816078 EAP HCPCS C1874 System Coron Stent 33mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816079 EAP HCPCS C1874 System Coron Stent 28mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816080 EAP HCPCS C1874 System Coron Stent 23mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816081 EAP HCPCS C1874 System Coron Stent 18mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816082 EAP HCPCS C1874 System Coron Stent 15mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816083 EAP HCPCS C1874 System Coron Stent 12mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816084 EAP HCPCS C1874 System Coron Stent 8mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816085 EAP HCPCS C1874 System Coron Stent 38mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816086 EAP HCPCS C1874 System Coron Stent 33mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816087 EAP HCPCS C1874 System Coron Stent 28mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816088 EAP HCPCS C1874 System Coron Stent 23mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816089 EAP HCPCS C1874 System Coron Stent 18mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816090 EAP HCPCS C1874 System Coron Stent 15mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816091 EAP HCPCS C1874 System Coron Stent 12mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816092 EAP HCPCS C1874 System Coron Stent 8mm 3.5mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816093 EAP HCPCS C1874 System Coron Stent 38mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816094 EAP HCPCS C1874 System Coron Stent 33mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816095 EAP HCPCS C1874 System Coron Stent 28mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816096 EAP HCPCS C1874 System Coron Stent 23mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816097 EAP HCPCS C1874 System Coron Stent 18mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816098 EAP HCPCS C1874 System Coron Stent 15mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816099 EAP HCPCS C1874 System Coron Stent 12mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816100 EAP HCPCS C1874 System Coron Stent 8mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816101 EAP HCPCS C1874 System Coron Stent 38mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816102 EAP HCPCS C1874 System Coron Stent 33mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816103 EAP HCPCS C1874 System Coron Stent 28mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816104 EAP HCPCS C1874 System Coron Stent 23mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816105 EAP HCPCS C1874 System Coron Stent 18mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816106 EAP HCPCS C1874 System Coron Stent 15mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816107 EAP HCPCS C1874 System Coron Stent 12mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816108 EAP HCPCS C1874 System Coron Stent 8mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816109 EAP HCPCS C1874 System Coron Stent 38mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816110 EAP HCPCS C1874 System Coron Stent 33mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816111 EAP HCPCS C1874 System Coron Stent 28mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816112 EAP HCPCS C1874 System Coron Stent 23mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816113 EAP HCPCS C1874 System Coron Stent 18mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816114 EAP HCPCS C1874 System Coron Stent 15mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816115 EAP HCPCS C1874 System Coron Stent 12mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816116 EAP HCPCS C1874 System Coron Stent 8mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816117 EAP HCPCS C1874 System Coron Stent 38mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816118 EAP HCPCS C1874 System Coron Stent 33mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816119 EAP HCPCS C1874 System Coron Stent 28mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816120 EAP HCPCS C1874 System Coron Stent 23mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816121 EAP HCPCS C1874 System Coron Stent 18mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816122 EAP HCPCS C1874 System Coron Stent 15mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816123 EAP HCPCS C1874 System Coron Stent 8mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816124 EAP HCPCS C1874 System Coron Stent 15mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816125 EAP HCPCS C1874 System Coron Stent 23mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816126 EAP HCPCS C1874 System Coron Stent 28mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816127 EAP HCPCS C1874 System Coron Stent 33mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816128 EAP HCPCS C1874 System Coron Stent 8mm 2.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816129 EAP HCPCS C1874 System Coron Stent 12mm 2.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816130 EAP HCPCS C1874 System Coron Stent 15mm 2.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816131 EAP HCPCS C1874 System Coron Stent 18mm 2.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816132 EAP HCPCS C1874 System Coron Stent 23mm 2.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816133 EAP HCPCS C1874 System Coron Stent 28mm 2.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816134 EAP HCPCS C1874 System Coron Stent 8mm 2.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816135 EAP HCPCS C1874 System Coron Stent 12mm 2.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816136 EAP HCPCS C1874 System Coron Stent 15mm 2.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816137 EAP HCPCS C1874 System Coron Stent 18mm 2.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816138 EAP HCPCS C1874 System Coron Stent 23mm 2.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816139 EAP HCPCS C1874 System Coron Stent 28mm 2.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816140 EAP HCPCS C1874 System Coron Stent 33mm 2.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816141 EAP HCPCS C1874 System Coron Stent 38mm 2.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816142 EAP HCPCS C1874 System Coron Stent 8mm 2.75mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816143 EAP HCPCS C1874 System Coron Stent 12mm 2.75mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816144 EAP HCPCS C1874 System Coron Stent 15mm 2.75mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816145 EAP HCPCS C1874 System Coron Stent 18mm 2.75mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816146 EAP HCPCS C1874 System Coron Stent 23mm 2.75mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816147 EAP HCPCS C1874 System Coron Stent 28mm 2.75mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816148 EAP HCPCS C1874 System Coron Stent 33mm 2.75mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816149 EAP HCPCS C1874 System Coron Stent 38mm 2.75mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816150 EAP HCPCS C1874 System Coron Stent 8mm 3mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816151 EAP HCPCS C1874 System Coron Stent 12mm 3mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816152 EAP HCPCS C1874 System Coron Stent 15mm 3mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816153 EAP HCPCS C1874 System Coron Stent 18mm 3mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816154 EAP HCPCS C1874 System Coron Stent 23mm 3mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816155 EAP HCPCS C1874 System Coron Stent 28mm 3mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816156 EAP HCPCS C1874 System Coron Stent 33mm 3mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816157 EAP HCPCS C1874 System Coron Stent 38mm 3mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816158 EAP HCPCS C1874 System Coron Stent 8mm 3.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816159 EAP HCPCS C1874 System Coron Stent 12mm 3.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816160 EAP HCPCS C1874 System Coron Stent 15mm 3.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816161 EAP HCPCS C1874 System Coron Stent 18mm 3.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816162 EAP HCPCS C1874 System Coron Stent 23mm 3.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816163 EAP HCPCS C1874 System Coron Stent 28mm 3.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816164 EAP HCPCS C1874 System Coron Stent 33mm 3.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816165 EAP HCPCS C1874 System Coron Stent 38mm 3.25mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816166 EAP HCPCS C1874 System Coron Stent 8mm 3.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816167 EAP HCPCS C1874 System Coron Stent 12mm 3.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816168 EAP HCPCS C1874 System Coron Stent 15mm 3.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816169 EAP HCPCS C1874 System Coron Stent 18mm 3.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816170 EAP HCPCS C1874 System Coron Stent 23mm 3.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816171 EAP HCPCS C1874 System Coron Stent 28mm 3.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816172 EAP HCPCS C1874 System Coron Stent 33mm 3.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816173 EAP HCPCS C1874 System Coron Stent 38mm 3.5mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816174 EAP HCPCS C1874 System Coron Stent 8mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816175 EAP HCPCS C1874 System Coron Stent 12mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816176 EAP HCPCS C1874 System Coron Stent 15mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816177 EAP HCPCS C1874 System Coron Stent 18mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816178 EAP HCPCS C1874 System Coron Stent 23mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816179 EAP HCPCS C1874 System Coron Stent 28mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816180 EAP HCPCS C1874 System Coron Stent 33mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816181 EAP HCPCS C1874 System Coron Stent 38mm 4mm Xience Alpine BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816182 EAP HCPCS C1874 System Coron Stent 12mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816183 EAP HCPCS C1874 System Coron Stent 8mm 2.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816184 EAP HCPCS C1874 System Coron Stent 12mm 2.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816185 EAP HCPCS C1874 System Coron Stent 15mm 2.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816186 EAP HCPCS C1874 System Coron Stent 18mm 2.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816187 EAP Coil Embolization 360d 5mm 15cm Detachable Soft Target BOTH IP/OP "$4,539.00 " "$3,358.86" $0.00 "$3,631.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,368.85" "$3,368.85" "$3,498.66" $0.00 $945.93 $0.00 $0.00 $0.00 $0.00 "$2,269.50" "$3,594.89" "$3,631.20" $0.00 "$2,042.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816188 EAP Coil Embolization Standard Large 22mm 50cm Detachable Smooth BOTH IP/OP "$5,904.00 " "$4,368.96" $0.00 "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,550.80" $0.00 "$1,230.39" $0.00 $0.00 $0.00 $0.00 "$2,952.00" "$4,675.97" "$4,723.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816190 EAP Coil Embl .02in Cmplx 4mm 10cm The Penumbra Coil 400 Xsft BOTH IP/OP "$6,900.00 " "$5,106.00" $0.00 "$5,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,318.52" $0.00 "$1,437.96" $0.00 $0.00 $0.00 $0.00 "$3,450.00" "$5,464.80" "$5,520.00" $0.00 "$3,105.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816191 EAP Coil Embl .02in Cmplx 4mm 8cm The Penumbra Coil 400 Sft BOTH IP/OP "$6,075.00 " "$4,495.50" $0.00 "$4,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,682.61" $0.00 "$1,266.03" $0.00 $0.00 $0.00 $0.00 "$3,037.50" "$4,811.40" "$4,860.00" $0.00 "$2,733.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816192 EAP Coil Embl Crv 4mm 10cm The Penumbra Coil 400 Xsft BOTH IP/OP "$6,513.00 " "$4,819.62" $0.00 "$5,210.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,020.22" $0.00 "$1,357.31" $0.00 $0.00 $0.00 $0.00 "$3,256.50" "$5,158.30" "$5,210.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816193 EAP Coil Embolization Curve 4mm 8cm Xsoft The Penumbra Coil 400 BOTH IP/OP "$6,125.00 " "$4,532.50" $0.00 "$4,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,721.15" $0.00 "$1,276.45" $0.00 $0.00 $0.00 $0.00 "$3,062.50" "$4,851.00" "$4,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816194 EAP Coil Embolization 10cm J Soft Fill Coil 400 Nitinol BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,856.04" $0.00 "$1,312.92" $0.00 $0.00 $0.00 $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816195 EAP Coil Embolization 15cm J Coil 400 BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,048.74" $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 "$2,947.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816196 EAP Custom 27816196 Graft Evas 26mm 22-23mm 3.3cm Aorta BOTH IP/OP "$8,135.00 " "$6,019.90" $0.00 "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,270.46" $0.00 "$1,695.33" $0.00 $0.00 $0.00 $0.00 "$4,067.50" "$6,442.92" "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816197 EAP Custom 27816197 Graft Evas 28.5mm 24-26mm 3.3cm Aorta BOTH IP/OP "$8,135.00 " "$6,019.90" $0.00 "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,270.46" $0.00 "$1,695.33" $0.00 $0.00 $0.00 $0.00 "$4,067.50" "$6,442.92" "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816198 EAP Custom 27816198 Graft Evas 32mm 27-29mm 4.5cm Xcldr Stnt Xtd Abrsn Rst BOTH IP/OP "$8,135.00 " "$6,019.90" $0.00 "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,270.46" $0.00 "$1,695.33" $0.00 $0.00 $0.00 $0.00 "$4,067.50" "$6,442.92" "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816199 EAP Custom 27816199 Graft Evas 36mm 30-32mm 4.5cm Xcldr Sinusoidal Stnt Sl Cuf BOTH IP/OP "$8,135.00 " "$6,019.90" $0.00 "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,270.46" $0.00 "$1,695.33" $0.00 $0.00 $0.00 $0.00 "$4,067.50" "$6,442.92" "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816200 EAP Custom 27816200 Graft Evas 12mm 10cm Gore Xcldr Cntrlt Lg BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816201 EAP Custom 27816201 Graft Evas 12mm 12cm Gore Xcldr Cntrlt Lg BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816202 EAP Custom 27816202 Graft Evas 12mm 14cm Gore Xcldr Cntrlt Lg BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816203 EAP Custom 27816203 Graft Evas 14.5mm 10cm Gore Xcldr Cntrlt Lg BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816204 EAP Custom 27816204 Graft Evas 14.5mm 12cm Gore Xcldr Cntrlt Lg BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816205 EAP Custom 27816205 Graft Evas 14.5mm 12-13.5mm 14cm Gore Xcldr Cntrlt Lg Aaa BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816206 EAP Custom 27816206 Graft Evas 16mm 13.5-14.5mm 11.5cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816207 EAP Custom 27816207 Graft Evas 16mm 13.5-14.5mm 13.5cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816208 EAP Custom 27816208 Graft Evas 18mm 14.5-16.5mm 9.5cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816209 EAP Custom 27816209 Graft Evas 18mm 14.5-16.5mm 11.5cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816210 EAP Custom 27816210 Graft Evas 18mm 14.5-16.5mm 13.5cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816211 EAP Custom 27816211 Graft Evas 20mm 16.5-18.5mm 9.5cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816212 EAP Custom 27816212 Graft Evas 20mm 16.5-18.5mm 13.5cm Grtx Xcldr Sinusoidal BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816213 EAP Custom 27816213 Graft Evas 23mm 18.5-21.5mm 12cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816214 EAP Custom 27816214 Graft Evas 23mm 18.5-21.5mm 14cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816215 EAP Custom 27816215 Graft Evas 27mm 21.5-25mm 10cm Grtx Xcldr Sinusoidal Stnt Sl BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816216 EAP Custom 27816216 Graft Evas 27mm 21.5-25mm 12cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816217 EAP Custom 27816217 Graft Evas 27mm 21.5-25mm 14cm Xcldr Stnt Abrsn Rst BOTH IP/OP "$11,558.00 " "$8,552.92" $0.00 "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,908.91" $0.00 "$2,408.69" $0.00 $0.00 $0.00 $0.00 "$5,779.00" "$9,153.94" "$9,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816218 EAP Custom 27816218 Graft Stnt 10mm 7cm Gore Xcldr Xtd Ilc Aaa BOTH IP/OP "$8,135.00 " "$6,019.90" $0.00 "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,270.46" $0.00 "$1,695.33" $0.00 $0.00 $0.00 $0.00 "$4,067.50" "$6,442.92" "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816219 EAP Custom 27816219 Graft Evas 12mm 7cm Xcldr Stnt Xtd Sl Cuf Ntnl Eptfe Ilc Aaa BOTH IP/OP "$8,135.00 " "$6,019.90" $0.00 "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,270.46" $0.00 "$1,695.33" $0.00 $0.00 $0.00 $0.00 "$4,067.50" "$6,442.92" "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816220 EAP Custom 27816220 Graft Evas 14.5mm 12-13.5mm 7cm Gore Xcldr Xtd Ilc Art Acpt BOTH IP/OP "$8,135.00 " "$6,019.90" $0.00 "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,270.46" $0.00 "$1,695.33" $0.00 $0.00 $0.00 $0.00 "$4,067.50" "$6,442.92" "$6,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816221 EAP Custom 27816221 Graft Evas 23mm 12mm 19-21mm 10-11mm 12cm Gore Xcldr C3 Bond BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816222 EAP Custom 27816222 Graft Evas 23mm 12mm 19-21mm 10-11mm 14cm Gore Xcldr C3 Bond BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816223 EAP Custom 27816223 Graft Evas 23mm 12mm 19-21mm 10-11mm 16cm Gore Xcldr C3 Bond BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816224 EAP Custom 27816224 Graft Evas 23mm 12mm 19-21mm 10-11mm 18cm Gore Xcldr C3 Bond BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816225 EAP Custom 27816225 Graft Evas 23mm 14.5mm 19-21mm 12-13.5mm 12cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816226 EAP Custom 27816226 Graft Evas 23mm 14.5mm 19-21mm 12-13.5mm 14cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816227 EAP Custom 27816227 Graft Evas 23mm 14.5mm 19-21mm 12-13.5mm 16cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816228 EAP Custom 27816228 Graft Evas 23mm 14.5mm 19-21mm 12-13.5mm 18cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816229 EAP Custom 27816229 Graft Evas 26mm 12mm 22-23mm 10-11mm 12cm Gore Xcldr C3 Bond BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816230 EAP Custom 27816230 Graft Evas 26mm 12mm 22-23mm 10-11mm 14cm Gore Xcldr C3 Bond BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816231 EAP Custom 27816231 Graft Evas 26mm 12mm 22-23mm 10-11mm 16cm Gore Xcldr C3 Bond BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816232 EAP Custom 27816232 Graft Evas 26mm 12mm 22-23mm 10-11mm 18cm Gore Xcldr C3 Bond BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816233 EAP Custom 27816233 Graft Evas 26mm 14.5mm 22-23mm 12-13.5mm 12cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816234 EAP Custom 27816234 Graft Evas 26mm 14.5mm 14cm Gore Xcldr C3 Trnkipsl Lg Aaa BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816235 EAP Custom 27816235 Graft Evas 26mm 14.5mm 16cm Gore Xcldr C3 Trnkipsl Lg Aaa BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816236 EAP Custom 27816236 Graft Evas 26mm 14.5mm 22-23mm 12-13.5mm 18cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816237 EAP Custom 27816237 Graft Evas 28.5mm 12mm 24-26mm 10-11mm 12cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816238 EAP Custom 27816238 Graft Evas 28.5mm 12mm 24-26mm 10-11mm 14cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816239 EAP Custom 27816239 Graft Evas 28.5mm 12mm 24-26mm 10-11mm 16cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816240 EAP Custom 27816240 Graft Evas 28.5mm 12mm 24-26mm 10-11mm 18cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816241 EAP Custom 27816241 Graft Evas 28.5mm 14.5mm 24-26mm 12-13.5mm 14cm Gore Xcldr C BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816242 EAP Custom 27816242 Graft Evas 28.5mm 14.5mm 24-26mm 12-13.5mm 16cm Gore Xcldr C BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816243 EAP Custom 27816243 Graft Evas 28.5mm 14.5mm 24-26mm 12-13.5mm 18cm Gore Xcldr C BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816244 EAP Custom 27816244 Graft Evas 31mm 14.5mm 13cm Xcldr C3 Stnt Dlv Sys Grtx Ntnl BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816245 EAP Custom 27816245 Graft Evas 31mm 14.5mm 15cm Xcldr C3 Stnt Dlv Sys Grtx Ntnl BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816246 EAP Custom 27816246 Graft Evas 31mm 14.5mm 17cm Xcldr C3 Stnt Dlv Sys Grtx Ntnl BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816247 EAP Custom 27816247 Graft Evas 35mm 14.5mm 30-32mm 12-13.5mm 14cm Strl Gore BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816248 EAP Custom 27816248 Graft Evas 35mm 14.5mm 16cm Xcldr C3 Stnt Dlv Sys Grtx Ntnl BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816249 EAP Custom 27816249 Graft Evas 35mm 14.5mm 30-32mm 12-13.5mm 18cm Gore Xcldr C3 BOTH IP/OP "$28,188.00 " "$20,859.12" $0.00 "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,727.31" $0.00 "$5,874.38" $0.00 $0.00 $0.00 $0.00 "$14,094.00" "$22,324.90" "$22,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816250 EAP HCPCS C1752 Catheter Hmdial 20cm Schn Xl Kink Rst Tip Clip Sh Rem Sty BOTH IP/OP $119.00 $88.06 $0.00 $95.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.32 $88.32 $91.73 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $59.50 $94.25 $95.20 $0.00 $53.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816251 EAP HCPCS C1876 Stent Intrcran T 2.7-3.5mm 8mm Pulserider Arch BOTH IP/OP "$31,250.00 " "$23,125.00" $0.00 "$25,000.00" "$14,062.50" "$14,062.50" $0.00 $0.00 $0.00 "$6,513.28" "$4,181.12" "$4,181.12" "$24,087.50" $0.00 "$6,512.50" $0.00 "$15,406.25" "$15,406.25" $0.00 "$15,625.00" "$24,750.00" "$25,000.00" $0.00 $0.00 $0.00 "$4,890.63" $0.00 $0.00 "$4,975.00" $0.00 $0.00 $0.00 $0.00 $0.00 27816252 EAP HCPCS C1876 Stent Intrcran T 3.5-4.5mm 8mm Pulserider Arch BOTH IP/OP "$31,250.00 " "$23,125.00" $0.00 "$25,000.00" "$14,062.50" "$14,062.50" $0.00 $0.00 $0.00 "$6,513.28" "$4,181.12" "$4,181.12" "$24,087.50" $0.00 "$6,512.50" $0.00 "$15,406.25" "$15,406.25" $0.00 "$15,625.00" "$24,750.00" "$25,000.00" $0.00 $0.00 $0.00 "$4,890.63" $0.00 $0.00 "$4,975.00" $0.00 $0.00 $0.00 $0.00 $0.00 27816253 EAP HCPCS C1876 Stent Intrcran T 2.7-3.5mm 10mm Pulserider Arch BOTH IP/OP "$31,250.00 " "$23,125.00" $0.00 "$25,000.00" "$14,062.50" "$14,062.50" $0.00 $0.00 $0.00 "$6,513.28" "$4,181.12" "$4,181.12" "$24,087.50" $0.00 "$6,512.50" $0.00 "$15,406.25" "$15,406.25" $0.00 "$15,625.00" "$24,750.00" "$25,000.00" $0.00 $0.00 $0.00 "$4,890.63" $0.00 $0.00 "$4,975.00" $0.00 $0.00 $0.00 $0.00 $0.00 27816254 EAP HCPCS C1876 Stent Intrcran Y 2.7-3.5mm 8mm Pulserider Arch BOTH IP/OP "$31,250.00 " "$23,125.00" $0.00 "$25,000.00" "$14,062.50" "$14,062.50" $0.00 $0.00 $0.00 "$6,513.28" "$4,181.12" "$4,181.12" "$24,087.50" $0.00 "$6,512.50" $0.00 "$15,406.25" "$15,406.25" $0.00 "$15,625.00" "$24,750.00" "$25,000.00" $0.00 $0.00 $0.00 "$4,890.63" $0.00 $0.00 "$4,975.00" $0.00 $0.00 $0.00 $0.00 $0.00 27816255 EAP HCPCS C1876 Stent Intrcran Y 3.5-4.5mm 8mm Pulserider Arch BOTH IP/OP "$31,250.00 " "$23,125.00" $0.00 "$25,000.00" "$14,062.50" "$14,062.50" $0.00 $0.00 $0.00 "$6,513.28" "$4,181.12" "$4,181.12" "$24,087.50" $0.00 "$6,512.50" $0.00 "$15,406.25" "$15,406.25" $0.00 "$15,625.00" "$24,750.00" "$25,000.00" $0.00 $0.00 $0.00 "$4,890.63" $0.00 $0.00 "$4,975.00" $0.00 $0.00 $0.00 $0.00 $0.00 27816256 EAP HCPCS C1876 Stent Intrcran Y 2.7-3.5mm 10mm Pulserider Arch BOTH IP/OP "$31,250.00 " "$23,125.00" $0.00 "$25,000.00" "$14,062.50" "$14,062.50" $0.00 $0.00 $0.00 "$6,513.28" "$4,181.12" "$4,181.12" "$24,087.50" $0.00 "$6,512.50" $0.00 "$15,406.25" "$15,406.25" $0.00 "$15,625.00" "$24,750.00" "$25,000.00" $0.00 $0.00 $0.00 "$4,890.63" $0.00 $0.00 "$4,975.00" $0.00 $0.00 $0.00 $0.00 $0.00 27816257 EAP HCPCS C1876 Stent Intrcran Y 3.5-4.5mm 10mm Pulserider Arch BOTH IP/OP "$31,250.00 " "$23,125.00" $0.00 "$25,000.00" "$14,062.50" "$14,062.50" $0.00 $0.00 $0.00 "$6,513.28" "$4,181.12" "$4,181.12" "$24,087.50" $0.00 "$6,512.50" $0.00 "$15,406.25" "$15,406.25" $0.00 "$15,625.00" "$24,750.00" "$25,000.00" $0.00 $0.00 $0.00 "$4,890.63" $0.00 $0.00 "$4,975.00" $0.00 $0.00 $0.00 $0.00 $0.00 27816259 EAP HCPCS C1874 System Cor Stnt 4.5mm 15mm 140cm Rslt Onyx Rx Dlv Sys Radopq BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816260 EAP HCPCS C1874 System Cor Stnt 4.5mm 18mm 140cm Rslt Onyx Rx Dlv Sys Radopq BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816261 EAP HCPCS C1874 System Cor Stnt 4.5mm 22mm 140cm Rslt Onyx Rx Dlv Sys Radopq BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816262 EAP HCPCS C1874 System Cor Stnt 4.5mm 26mm 140cm Rslt Onyx Rx Dlv Sys Radopq BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816263 EAP HCPCS C1874 System Cor Stnt 4.5mm 30mm 140cm Rslt Onyx Rx Dlv Sys Radopq BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816264 EAP HCPCS C1874 System Cor Stnt 5mm 12mm 140cm Rslt Onyx Rx Dlv Sys Radopq 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816265 EAP HCPCS C1874 System Cor Stnt 5mm 15mm 140cm Rslt Onyx Rx Dlv Sys Radopq 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816266 EAP HCPCS C1874 System Cor Stnt 5mm 18mm 140cm Rslt Onyx Rx Dlv Sys Radopq 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816267 EAP HCPCS C1874 System Cor Stnt 5mm 22mm 140cm Rslt Onyx Rx Dlv Sys Radopq 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816268 EAP HCPCS C1874 System Cor Stnt 5mm 26mm 140cm Rslt Onyx Rx Dlv Sys Radopq 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816269 EAP HCPCS C1874 System Cor Stnt 5mm 30mm 140cm Rslt Onyx Rx Dlv Sys Radopq 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 27816270 EAP HCPCS C1757 Catheter Thrmb .044in 140cm Strl Lf Indg Sys Asp Kt Cor BOTH IP/OP "$4,850.00 " "$3,589.00" $0.00 "$3,880.00" "$2,182.50" "$2,182.50" $0.00 $0.00 $0.00 "$1,010.86" "$3,599.67" "$3,599.67" "$3,738.38" $0.00 "$1,010.74" $0.00 "$2,391.05" "$2,391.05" $0.00 "$2,425.00" "$3,841.20" "$3,880.00" $0.00 "$2,182.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816279 EAP HCPCS C1874 Stent Eprsth 8mm 10cm Strl 120cm Vbhn Flxb Slf Xpd Radopq BOTH IP/OP "$9,160.00 " "$6,778.40" $0.00 "$7,328.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,580.00" "$7,254.72" "$7,328.00" $0.00 $0.00 $0.00 "$1,433.54" $0.00 $0.00 "$1,458.27" $0.00 $0.00 $0.00 $0.00 $0.00 27816280 EAP Custom 27816280 Stent Eprsth 21mm 10cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816281 EAP Custom 27816281 Stent Eprsth 21-26mm 10cm Strl Gore Tag Cnfrm Flxb Radopq BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816282 EAP Custom 27816282 Stent Eprsth 26mm 10cm Strl Gore Tag Flxb Radopq Ntnl Fep BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816283 EAP Custom 27816283 Stent Eprsth 28mm 10cm Strl Gore Tag Flxb Radopq Ntnl Fep BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816284 EAP Custom 27816284 Stent Eprsth 28mm 15cm Strl Gore Tag Flxb Radopq Ntnl Fep BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816285 EAP Custom 27816285 Stent Eprsth 26-31mm 10cm Strl Gore Tag Cnfrm Flxb Radopq BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816286 EAP Custom 27816286 Stent Eprsth 31mm 10cm Strl Gore Tag Flxb Radopq Ntnl Fep BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816287 EAP Custom 27816287 Stent Eprsth 31mm 15cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816288 EAP Custom 27816288 Stent Eprsth 34mm 10cm Strl Gore Tag Flxb Radopq Ntnl Fep BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816289 EAP Custom 27816289 Stent Eprsth 34mm 15cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816290 EAP Custom 27816290 Stent Eprsth 34mm 20cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816291 EAP Custom 27816291 Stent Eprsth 37mm 10cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816292 EAP Custom 27816292 Stent Eprsth 37mm 15cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816293 EAP Custom 27816293 Stent Eprsth 37mm 20cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816294 EAP Custom 27816294 Stent Eprsth 40mm 10cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816295 EAP Custom 27816295 Stent Eprsth 40mm 15cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816296 EAP Custom 27816296 Stent Eprsth 40mm 20cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816297 EAP Custom 27816297 Stent Eprsth 45mm 10cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816298 EAP Custom 27816298 Stent Eprsth 45mm 15cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816299 EAP Custom 27816299 Stent Eprsth 45mm 20cm Strl Gore Tag Cnfrm Flxb Radopq Eptfe BOTH IP/OP "$41,640.00 " "$30,813.60" $0.00 "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$32,096.11" $0.00 "$8,677.78" $0.00 $0.00 $0.00 $0.00 "$20,820.00" "$32,978.88" "$33,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816300 EAP Plug Ocl 3mm 12x5.3mm Mvp Mech Dtch Full Resheathable Ntnl BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816301 EAP Plug Ocl 5mm 12x6.5mm Strl Lf Mvp Mech Dtch Full BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816302 EAP Plug Ocl Mic 7mm Strl Lf Mvp Mech Vasc Disp V03 BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816303 EAP Plug Ocl 9mm Strl Lf Mvp V03 BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816304 EAP Custom 27816304 Graft Evas 10mm 10cm Gore Xcldr Brch Cmpnt Ilc Aaa BOTH IP/OP "$27,548.00 " "$20,385.52" $0.00 "$22,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,234.00" $0.00 "$5,741.00" $0.00 $0.00 $0.00 $0.00 "$13,774.00" "$21,818.02" "$22,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816305 EAP Custom 27816305 Graft Evas 12mm 10cm Gore Xcldr Brch Cmpnt Ilc Aaa BOTH IP/OP "$27,548.00 " "$20,385.52" $0.00 "$22,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,234.00" $0.00 "$5,741.00" $0.00 $0.00 $0.00 $0.00 "$13,774.00" "$21,818.02" "$22,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816306 EAP Custom 27816306 Graft Evas 14.5mm 10cm Gore Xcldr Brch Cmpnt Ilc Aaa BOTH IP/OP "$27,548.00 " "$20,385.52" $0.00 "$22,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,234.00" $0.00 "$5,741.00" $0.00 $0.00 $0.00 $0.00 "$13,774.00" "$21,818.02" "$22,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816307 EAP Custom 27816307 Graft Evas 14.5mm 7cm Gore Xcldr Intnl Cmpnt Ilc Aaa BOTH IP/OP "$7,688.00 " "$5,689.12" $0.00 "$6,150.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,925.91" $0.00 "$1,602.18" $0.00 $0.00 $0.00 $0.00 "$3,844.00" "$6,088.90" "$6,150.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816308 EAP HCPCS C1783 Stent Opth 50um 230um 80um 360um Strl Istent Inj 2 Preld 1 BOTH IP/OP "$3,688.00 " "$2,729.12" $0.00 "$2,950.40" "$1,659.60" "$1,659.60" $0.00 $0.00 $0.00 $768.67 "$2,737.23" "$2,737.23" "$2,842.71" $0.00 $768.58 $0.00 "$1,818.18" "$1,818.18" $0.00 "$1,844.00" "$2,920.90" "$2,950.40" $0.00 "$1,659.60" $0.00 $577.17 $0.00 $0.00 $587.13 $0.00 $0.00 $0.00 $0.00 $0.00 27816309 EAP HCPCS C1874 Axios Stent And Electrocautery 15x10 BOTH IP/OP "$11,625.00 " "$8,602.50" $0.00 "$9,300.00" "$5,231.25" "$5,231.25" $0.00 $0.00 $0.00 "$2,422.94" "$4,181.12" "$4,181.12" "$8,960.55" $0.00 "$2,422.65" $0.00 "$5,731.13" "$5,731.13" $0.00 "$5,812.50" "$9,207.00" "$9,300.00" $0.00 "$5,231.25" $0.00 "$1,819.31" $0.00 $0.00 "$1,850.70" $0.00 $0.00 $0.00 $0.00 $0.00 27816310 EAP HCPCS C1874 Wallflex Biliary Stent BOTH IP/OP "$6,738.00 " "$4,986.12" $0.00 "$5,390.40" "$3,032.10" "$3,032.10" $0.00 $0.00 $0.00 "$1,404.37" "$4,181.12" "$4,181.12" "$5,193.65" $0.00 "$1,404.20" $0.00 "$3,321.83" "$3,321.83" $0.00 "$3,369.00" "$5,336.50" "$5,390.40" $0.00 "$3,032.10" $0.00 "$1,054.50" $0.00 $0.00 "$1,072.69" $0.00 $0.00 $0.00 $0.00 $0.00 27816311 EAP HCPCS C1768 Envelope Tiss 5x5.4cm Cormatrix Cangaroo Sm Sft BOTH IP/OP "$12,063.00 " "$8,926.62" $0.00 "$9,650.40" "$5,428.35" "$5,428.35" $0.00 $0.00 $0.00 "$2,514.23" "$4,181.12" "$4,181.12" "$9,298.16" $0.00 "$2,513.93" $0.00 "$5,947.06" "$5,947.06" $0.00 "$6,031.50" "$9,553.90" "$9,650.40" $0.00 $0.00 $0.00 "$1,887.86" $0.00 $0.00 "$1,920.43" $0.00 $0.00 $0.00 $0.00 $0.00 27816312 EAP HCPCS C1768 Envelope Tiss 6.9x6.5cm Cormatrix Cangaroo Med Sft BOTH IP/OP "$12,063.00 " "$8,926.62" $0.00 "$9,650.40" "$5,428.35" "$5,428.35" $0.00 $0.00 $0.00 "$2,514.23" "$4,181.12" "$4,181.12" "$9,298.16" $0.00 "$2,513.93" $0.00 "$5,947.06" "$5,947.06" $0.00 "$6,031.50" "$9,553.90" "$9,650.40" $0.00 $0.00 $0.00 "$1,887.86" $0.00 $0.00 "$1,920.43" $0.00 $0.00 $0.00 $0.00 $0.00 27816313 EAP HCPCS C1768 Envelope Tiss 8x6.9cm Cormatrix Cangaroo Lg Sft BOTH IP/OP "$12,063.00 " "$8,926.62" $0.00 "$9,650.40" "$5,428.35" "$5,428.35" $0.00 $0.00 $0.00 "$2,514.23" "$4,181.12" "$4,181.12" "$9,298.16" $0.00 "$2,513.93" $0.00 "$5,947.06" "$5,947.06" $0.00 "$6,031.50" "$9,553.90" "$9,650.40" $0.00 $0.00 $0.00 "$1,887.86" $0.00 $0.00 "$1,920.43" $0.00 $0.00 $0.00 $0.00 $0.00 27816314 EAP HCPCS C1768 Envelope Tiss 9.5x6.9cm Cormatrix Cangaroo Xl Sft BOTH IP/OP "$12,063.00 " "$8,926.62" $0.00 "$9,650.40" "$5,428.35" "$5,428.35" $0.00 $0.00 $0.00 "$2,514.23" "$4,181.12" "$4,181.12" "$9,298.16" $0.00 "$2,513.93" $0.00 "$5,947.06" "$5,947.06" $0.00 "$6,031.50" "$9,553.90" "$9,650.40" $0.00 $0.00 $0.00 "$1,887.86" $0.00 $0.00 "$1,920.43" $0.00 $0.00 $0.00 $0.00 $0.00 27816315 EAP HCPCS C1768 Envelope Tiss 10.8x8.9cm Cangaroo 2xl Sft Reinf BOTH IP/OP "$16,563.00 " "$12,256.62" $0.00 "$13,250.40" "$7,453.35" "$7,453.35" $0.00 $0.00 $0.00 "$3,452.14" "$4,181.12" "$4,181.12" "$12,766.76" $0.00 "$3,451.73" $0.00 "$8,165.56" "$8,165.56" $0.00 "$8,281.50" "$13,117.90" "$13,250.40" $0.00 $0.00 $0.00 "$2,592.11" $0.00 $0.00 "$2,636.83" $0.00 $0.00 $0.00 $0.00 $0.00 27816316 EAP HCPCS C1874 Stent Endoprsth 2.5cm 5mm Hep Ntnl Eptfe Vbhn 120 BOTH IP/OP "$8,808.00 " "$6,517.92" $0.00 "$7,046.40" "$3,963.60" "$3,963.60" $0.00 $0.00 $0.00 "$1,835.81" "$4,181.12" "$4,181.12" "$6,789.21" $0.00 "$1,835.59" $0.00 "$4,342.34" "$4,342.34" $0.00 "$4,404.00" "$6,975.94" "$7,046.40" $0.00 $0.00 $0.00 "$1,378.45" $0.00 $0.00 "$1,402.23" $0.00 $0.00 $0.00 $0.00 $0.00 27816317 EAP HCPCS C1874 Stent Endoprsth 2.5cm 6mm Hep Ntnl Eptfe Vbhn 120 BOTH IP/OP "$8,808.00 " "$6,517.92" $0.00 "$7,046.40" "$3,963.60" "$3,963.60" $0.00 $0.00 $0.00 "$1,835.81" "$4,181.12" "$4,181.12" "$6,789.21" $0.00 "$1,835.59" $0.00 "$4,342.34" "$4,342.34" $0.00 "$4,404.00" "$6,975.94" "$7,046.40" $0.00 $0.00 $0.00 "$1,378.45" $0.00 $0.00 "$1,402.23" $0.00 $0.00 $0.00 $0.00 $0.00 27816318 EAP HCPCS C1874 Stent Endoprsth 2.5cm 8mm Hep Ntnl Eptfe Vbhn 120 BOTH IP/OP "$8,808.00 " "$6,517.92" $0.00 "$7,046.40" "$3,963.60" "$3,963.60" $0.00 $0.00 $0.00 "$1,835.81" "$4,181.12" "$4,181.12" "$6,789.21" $0.00 "$1,835.59" $0.00 "$4,342.34" "$4,342.34" $0.00 "$4,404.00" "$6,975.94" "$7,046.40" $0.00 $0.00 $0.00 "$1,378.45" $0.00 $0.00 "$1,402.23" $0.00 $0.00 $0.00 $0.00 $0.00 27816320 EAP HCPCS C1874 System Coron Stent 8mm 2.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816321 EAP HCPCS C1874 System Coron Stent 12mm 2.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816322 EAP HCPCS C1874 System Coron Stent 15mm 2.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816323 EAP HCPCS C1874 System Coron Stent 17mm 2.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816324 EAP HCPCS C1874 System Coron Stent 20mm 2.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816325 EAP HCPCS C1874 System Coron Stent 24mm 2.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816326 EAP HCPCS C1874 System Coron Stent 28mm 2.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816327 EAP HCPCS C1874 System Coron Stent 33mm 2.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816328 EAP HCPCS C1874 System Coron Stent 8mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816329 EAP HCPCS C1874 System Coron Stent 12mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816330 EAP HCPCS C1874 System Coron Stent 15mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816331 EAP HCPCS C1874 System Coron Stent 17mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816332 EAP HCPCS C1874 System Coron Stent 20mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816333 EAP HCPCS C1874 Stent Coron 24mm 2.75mm Carbosil 20 55d BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816334 EAP HCPCS C1874 System Coron Stent 28mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816335 EAP HCPCS C1874 System Coron Stent 33mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816336 EAP HCPCS C1874 System Coron Stent 38mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816337 EAP HCPCS C1874 System Coron Stent 44mm 2.75mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816338 EAP HCPCS C1874 System Coron Stent 8mm 3mm Elunir Thk90um Carbosil BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816339 EAP HCPCS C1874 System Coron Stent 12mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816340 EAP HCPCS C1874 System Coron Stent 15mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816341 EAP HCPCS C1874 System Coron Stent 17mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816342 EAP HCPCS C1874 System Coron Stent 20mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816343 EAP HCPCS C1874 System Coron Stent 24mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816344 EAP HCPCS C1874 System Coron Stent 28mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816345 EAP HCPCS C1874 System Coron Stent 33mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816346 EAP HCPCS C1874 System Coron Stent 38mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816347 EAP HCPCS C1874 System Coron Stent 44mm 3mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816348 EAP HCPCS C1874 System Coron Stent 8mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816349 EAP HCPCS C1874 System Coron Stent 12mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816350 EAP HCPCS C1874 System Coron Stent 15mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816351 EAP HCPCS C1874 System Coron Stent 17mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816352 EAP HCPCS C1874 System Coron Stent 20mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816353 EAP HCPCS C1874 System Coron Stent 24mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816354 EAP HCPCS C1874 System Coron Stent 28mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816355 EAP HCPCS C1874 System Coron Stent 33mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816356 EAP HCPCS C1874 System Coron Stent 38mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816357 EAP HCPCS C1874 System Coron Stent 44mm 3.5mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816358 EAP HCPCS C1874 System Coron Stent 8mm 4mm Elunir Thk90um Carbosil BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816359 EAP HCPCS C1874 System Coron Stent 12mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816360 EAP HCPCS C1874 System Coron Stent 15mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816361 EAP HCPCS C1874 System Coron Stent 17mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816362 EAP HCPCS C1874 System Coron Stent 20mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816363 EAP HCPCS C1874 System Coron Stent 24mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816364 EAP HCPCS C1874 System Coron Stent 28mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816365 EAP HCPCS C1874 System Coron Stent 33mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816366 EAP HCPCS C1874 System Coron Stent 38mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816367 EAP HCPCS C1874 System Coron Stent 44mm 4mm Elunir Thk90um BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 27816371 EAP HCPCS C1874 Stent Endoprosthesis Viabahn Heparin Nitinol Eptfe L25 Cm L120 Cm Od6 Mm BOTH IP/OP "$15,988.00 " "$11,831.12" $0.00 "$12,790.40" "$7,194.60" "$7,194.60" $0.00 $0.00 $0.00 "$3,332.30" "$4,181.12" "$4,181.12" "$12,323.55" $0.00 "$3,331.90" $0.00 "$7,882.08" "$7,882.08" $0.00 "$7,994.00" "$12,662.50" "$12,790.40" $0.00 "$7,194.60" $0.00 "$2,502.12" $0.00 $0.00 "$2,545.29" $0.00 $0.00 $0.00 $0.00 $0.00 28000001 EAP CPT® 96522 Refill/maint Implant Pump BOTH IP/OP $497.00 $367.78 $0.00 $397.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.57 $0.00 $0.00 $0.00 $0.00 $248.50 $393.62 $397.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000001 EAP CPT® 36415 "PHLEBOTOMY,VEN-1OPC" BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.15 $21.50 $34.06 $34.40 $4.35 $0.00 $4.35 $6.73 $3.00 $3.00 $6.85 $3.00 $0.00 $0.00 $0.00 $0.00 30000002 EAP CPT® 80053 Comp Metabolic Panel BOTH IP/OP $472.00 $349.28 $0.00 $381.60 $21.81 $21.81 $10.56 $10.56 $5.28 $5.28 $16.06 $16.06 $16.68 $10.56 $15.61 $6.86 $279.19 $279.19 $11.09 $29.54 $377.78 $381.60 $15.31 $0.00 $15.31 $16.64 $10.56 $10.56 $11.65 $10.56 $0.00 $0.00 $0.00 $0.00 30000003 EAP CPT® 81340 "T Cell Receptor (tcr) Beta Gene Rearrang, Pcr (so)" BOTH IP/OP $690.00 $510.60 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.42 $296.42 $307.82 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000004 EAP CPT® 84999 Unlisted Chemistry Procedure (so)gene BOTH IP/OP $143.00 $105.82 $0.00 $112.80 $0.00 $0.00 $0.00 $0.00 $25.45 $0.00 $106.13 $106.13 $110.22 $0.00 $29.80 $0.00 $0.00 $0.00 $0.00 $0.00 $111.67 $112.80 $0.00 $92.95 $0.00 $22.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000005 EAP CPT® 81340 T -cell Antigen Receptor Beta (so) Clon BOTH IP/OP $690.00 $510.60 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.42 $296.42 $307.82 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $341.00 $540.14 $545.60 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000006 EAP CPT® 81342 T -cell Antigen Receptor Gamma (so) Clon BOTH IP/OP $954.00 $705.96 $0.00 $753.60 $415.93 $415.93 $201.50 $201.50 $100.75 $100.75 $285.90 $285.90 $296.89 $201.50 $192.65 $130.98 $564.29 $564.29 $0.00 $471.00 $746.06 $753.60 $0.00 $332.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000007 EAP CPT® 84999 Unlisted Chemistry Procedure (so) Clon BOTH IP/OP $143.00 $105.82 $0.00 $112.80 $0.00 $0.00 $0.00 $0.00 $25.45 $0.00 $106.13 $106.13 $110.22 $0.00 $29.80 $0.00 $0.00 $0.00 $0.00 $0.00 $111.67 $112.80 $0.00 $92.95 $0.00 $22.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000008 EAP CPT® 81381 HLA- B57:01 DETERMINATION-PCR (QUEST) BOTH IP/OP $370.00 $273.80 $0.00 $370.40 $195.23 $195.23 $169.90 $169.90 $84.95 $76.46 $134.19 $134.19 $139.35 $169.90 $46.99 $110.44 $218.86 $218.86 $178.40 $231.50 $366.70 $370.40 $246.36 $0.00 $246.36 $50.07 $169.90 $169.90 $35.05 $169.90 $0.00 $0.00 $0.00 $0.00 30000009 EAP CPT® 81380 HLA -B HIGH RESOLUTION- PCR (QUEST) BOTH IP/OP $573.00 $424.02 $0.00 $539.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.48 $251.48 $261.15 $0.00 $192.65 $0.00 $0.00 $0.00 $0.00 $289.50 $458.57 $463.20 $0.00 $539.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000010 EAP CPT® 87798 "Ebola -cdc,rt-pcr,evd" BOTH IP/OP $114.00 $84.36 $0.00 $109.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $67.43 $67.43 $36.84 $54.82 $108.50 $109.60 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30000018 EAP CPT® 80346 "Benzodiazpne,ur-eia" BOTH IP/OP $374.00 $276.76 $0.00 $288.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.58 $277.58 $288.28 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $206.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000019 EAP CPT® 80353 Cocain Metab.ur-eia BOTH IP/OP $374.00 $276.76 $0.00 $288.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.58 $277.58 $288.28 $0.00 $14.16 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $203.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000020 EAP CPT® 83992 "Phencyclidne,ur-eia" BOTH IP/OP $374.00 $276.76 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.32 $22.32 $23.18 $0.00 $21.72 $0.00 $0.00 $0.00 $0.00 $41.08 $269.28 $272.00 $0.00 $159.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000021 EAP CPT® 80361 "Opiates,ur-eia" BOTH IP/OP $495.00 $366.30 $0.00 $381.55 $0.03 $0.03 $0.00 $0.00 $12.01 $11.94 $367.39 $367.39 $381.55 $0.00 $30.51 $0.00 $292.79 $292.79 $0.00 $225.00 $356.40 $360.00 $270.00 $321.75 $270.00 $32.51 $0.00 $0.00 $22.76 $0.00 $0.00 $0.00 $0.00 $0.00 30000022 EAP CPT® 80349 "Thc, Ur-eia" BOTH IP/OP $374.00 $276.76 $0.00 $288.28 $0.03 $0.03 $0.00 $0.00 $12.01 $0.00 $277.58 $277.58 $288.28 $0.00 $77.94 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $164.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000023 EAP CPT® 80345 "Barbiturate,ur-eia" BOTH IP/OP $245.00 $181.30 $0.00 $251.20 $0.03 $0.03 $0.00 $0.00 $12.01 $7.03 $181.84 $181.84 $188.85 $0.00 $16.93 $0.00 $144.92 $144.92 $0.00 $157.00 $248.69 $251.20 $0.00 $159.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000024 EAP CPT® 80150 Amikacin-random BOTH IP/OP $265.00 $196.10 $0.00 $212.00 $31.13 $31.13 $15.08 $15.08 $7.54 $7.54 $22.89 $22.89 $23.77 $15.08 $22.26 $9.80 $156.75 $156.75 $0.00 $42.12 $209.88 $212.00 $0.00 $172.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000025 EAP CPT® 80335 Amitriptyline-random BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.02 $69.02 $71.68 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $46.50 $73.66 $74.40 $0.00 $60.45 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000026 EAP CPT® 80159 Clozapine (so) BOTH IP/OP $299.00 $221.26 $9.25 $239.20 $38.17 $38.17 $20.15 $20.15 $10.08 $9.25 $26.24 $26.24 $27.25 $20.15 $23.71 $13.10 $176.86 $176.86 $21.16 $149.50 $236.81 $239.20 $29.22 $194.35 $29.22 $25.26 $20.15 $20.15 $17.68 $20.15 $0.00 $0.00 $0.00 $0.00 30000027 EAP CPT® 80156 Carbamazpine-random BOTH IP/OP $279.00 $206.46 $7.28 $223.20 $30.07 $30.07 $14.57 $14.57 $7.29 $7.28 $22.11 $22.11 $22.96 $14.57 $21.51 $9.47 $165.03 $165.03 $15.30 $40.68 $220.97 $223.20 $21.13 $181.35 $21.13 $22.92 $14.57 $14.57 $16.05 $14.57 $0.00 $0.00 $0.00 $0.00 30000028 EAP CPT® 80158 Cyclosporine BOTH IP/OP $238.00 $176.12 $6.57 $190.40 $12.30 $12.30 $18.05 $18.05 $9.03 $9.03 $9.05 $9.05 $9.40 $18.05 $8.81 $11.73 $140.78 $140.78 $18.95 $16.66 $188.50 $190.40 $26.17 $154.70 $26.17 $9.39 $18.05 $18.05 $6.57 $18.05 $0.00 $0.00 $0.00 $0.00 30000029 EAP CPT® 80335 Desipramine-random BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.03 $92.03 $95.58 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $62.00 $98.21 $99.20 $0.00 $80.60 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000030 EAP CPT® 80162 "Digoxin, Total" BOTH IP/OP $281.00 $207.94 $0.00 $224.80 $27.40 $27.40 $13.28 $13.28 $6.64 $0.00 $20.17 $20.17 $20.94 $0.00 $19.61 $0.00 $0.00 $0.00 $13.94 $37.10 $222.55 $224.80 $19.26 $182.65 $19.26 $20.90 $13.28 $13.28 $14.63 $13.28 $0.00 $0.00 $0.00 $0.00 30000031 EAP CPT® 80164 "Valproic Acid, Total" BOTH IP/OP $319.00 $236.06 $6.77 $255.20 $23.44 $23.44 $13.54 $13.54 $6.77 $6.77 $17.23 $17.23 $17.90 $13.54 $16.77 $8.80 $188.69 $188.69 $14.22 $31.72 $252.65 $255.20 $19.63 $207.35 $19.63 $17.87 $13.54 $13.54 $12.51 $13.54 $0.00 $0.00 $0.00 $0.00 30000032 EAP CPT® 80335 Doxepin-random BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.29 $91.29 $94.81 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $61.50 $97.42 $98.40 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000033 EAP CPT® 80168 Ethosuximide-random BOTH IP/OP $86.00 $63.64 $0.00 $68.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.81 $24.81 $25.77 $0.00 $24.14 $0.00 $0.00 $0.00 $0.00 $45.66 $68.11 $68.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000034 EAP CPT® 80170 Gentamicin-random BOTH IP/OP $201.00 $148.74 $8.19 $160.80 $33.82 $33.82 $16.38 $16.38 $8.19 $8.19 $24.89 $24.89 $25.84 $16.38 $24.21 $10.65 $118.89 $118.89 $17.20 $45.80 $159.19 $160.80 $23.75 $130.65 $23.75 $25.80 $16.38 $16.38 $18.06 $16.38 $0.00 $0.00 $0.00 $0.00 30000035 EAP CPT® 80173 Haloperidol BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $30.07 $30.07 $15.78 $15.78 $7.89 $7.28 $22.11 $22.11 $22.96 $15.78 $21.51 $10.26 $70.98 $70.98 $0.00 $40.68 $95.04 $96.00 $0.00 $37.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000036 EAP CPT® 80335 Imipramine-random BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $104.06 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000037 EAP CPT® 80176 Lidocaine-random BOTH IP/OP $159.00 $117.66 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.31 $22.31 $23.17 $0.00 $21.69 $0.00 $0.00 $0.00 $0.00 $41.04 $126.72 $128.00 $0.00 $103.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000038 EAP CPT® 80178 Lithium-random BOTH IP/OP $225.00 $166.50 $3.31 $180.00 $13.65 $13.65 $6.61 $6.61 $3.31 $3.31 $10.04 $10.04 $10.42 $6.61 $9.78 $4.30 $133.09 $133.09 $6.94 $18.48 $178.20 $180.00 $9.58 $146.25 $9.58 $10.42 $6.61 $6.61 $7.29 $6.61 $0.00 $0.00 $0.00 $0.00 30000039 EAP CPT® 80335 Nortriptyline-random BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.84 $86.84 $90.18 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $58.50 $92.66 $93.60 $0.00 $76.05 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000040 EAP CPT® 80184 Phenobarb-random BOTH IP/OP $236.00 $174.64 $6.89 $188.80 $23.02 $23.02 $15.30 $15.30 $7.65 $6.89 $17.39 $17.39 $18.06 $15.30 $16.93 $9.95 $139.59 $139.59 $16.07 $32.02 $186.91 $188.80 $22.19 $149.50 $22.19 $18.04 $15.30 $15.30 $12.62 $15.30 $0.00 $0.00 $0.00 $0.00 30000041 EAP CPT® 80185 Dilantin-random BOTH IP/OP $287.00 $212.38 $6.63 $229.60 $27.35 $27.35 $13.25 $13.25 $6.63 $6.63 $20.13 $20.13 $20.91 $13.25 $19.58 $8.61 $169.76 $169.76 $13.91 $37.04 $227.30 $229.60 $19.21 $186.55 $19.21 $20.87 $13.25 $13.25 $14.61 $13.25 $0.00 $0.00 $0.00 $0.00 30000042 EAP CPT® 80186 Phenytoin Free (so) BOTH IP/OP $205.00 $151.70 $6.88 $164.00 $28.41 $28.41 $13.76 $13.76 $6.88 $6.88 $20.90 $20.90 $21.71 $13.76 $20.34 $8.94 $121.26 $121.26 $14.45 $38.46 $162.36 $164.00 $19.95 $133.25 $19.95 $21.67 $13.76 $13.76 $15.17 $13.76 $0.00 $0.00 $0.00 $0.00 30000043 EAP CPT® 80188 Primidone/myso-rand. BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.20 $25.20 $26.17 $0.00 $24.51 $0.00 $0.00 $0.00 $0.00 $46.36 $148.90 $150.40 $0.00 $122.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000044 EAP CPT® 80192 Procainamide-random BOTH IP/OP $191.00 $141.34 $0.00 $152.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.44 $25.44 $26.42 $0.00 $24.75 $0.00 $0.00 $0.00 $0.00 $46.82 $151.27 $152.80 $0.00 $124.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000045 EAP CPT® 80194 Quinidine-random BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.16 $22.16 $23.01 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $40.78 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000046 EAP CPT® 80307 Salicylate-quant BOTH IP/OP $388.00 $287.12 $0.00 $299.07 $0.00 $0.00 $38.57 $38.57 $19.29 $80.87 $287.97 $287.97 $299.07 $38.57 $36.26 $25.07 $229.50 $229.50 $65.25 $176.50 $279.58 $282.40 $90.10 $63.64 $90.10 $76.56 $62.14 $62.14 $53.59 $62.14 $0.00 $0.00 $0.00 $0.00 30000047 EAP CPT® 80198 Theophylline-random BOTH IP/OP $173.00 $128.02 $0.00 $138.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.49 $21.49 $22.31 $0.00 $20.90 $0.00 $0.00 $0.00 $14.85 $39.54 $137.02 $138.40 $20.50 $112.45 $20.50 $0.00 $14.14 $14.14 $15.58 $14.14 $0.00 $0.00 $0.00 $0.00 30000048 EAP CPT® 80200 Tobramycin-random BOTH IP/OP $263.00 $194.62 $0.00 $210.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.74 $22.74 $23.62 $0.00 $22.13 $0.00 $0.00 $0.00 $0.00 $41.86 $208.30 $210.40 $0.00 $170.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000049 EAP CPT® 80201 Topiramate/topamaz BOTH IP/OP $94.00 $69.56 $5.96 $75.20 $24.60 $24.60 $11.92 $11.92 $5.96 $5.96 $18.10 $18.10 $18.79 $11.92 $17.61 $7.75 $55.60 $55.60 $12.52 $33.32 $74.45 $75.20 $17.28 $61.10 $17.28 $18.76 $11.92 $11.92 $13.13 $11.92 $0.00 $0.00 $0.00 $0.00 30000050 EAP CPT® 80202 Vancomycin-random BOTH IP/OP $292.00 $216.08 $6.77 $233.60 $23.44 $23.44 $13.54 $13.54 $6.77 $6.77 $17.23 $17.23 $17.90 $13.54 $16.77 $8.80 $172.72 $172.72 $14.22 $31.72 $231.26 $233.60 $19.63 $189.80 $19.63 $17.87 $13.54 $13.54 $12.51 $13.54 $0.00 $0.00 $0.00 $0.00 30000051 EAP CPT® 80299 Methotrexate-random BOTH IP/OP $217.00 $160.58 $0.00 $217.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.06 $161.06 $167.26 $0.00 $17.51 $0.00 $0.00 $0.00 $19.57 $33.64 $172.66 $174.40 $27.03 $217.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30000052 EAP CPT® 80171 "Gabapentin, Whl Bld/ser/plasma" BOTH IP/OP $431.00 $318.94 $0.00 $346.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.81 $18.81 $19.54 $0.00 $17.00 $0.00 $0.00 $0.00 $0.00 $216.50 $342.94 $346.40 $0.00 $247.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000053 EAP CPT® 80299 Amiodarone/cordarone BOTH IP/OP $217.00 $160.58 $0.00 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.06 $161.06 $167.26 $0.00 $17.51 $0.00 $0.00 $0.00 $19.57 $33.64 $172.66 $174.40 $27.03 $48.75 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30000054 EAP CPT® 80175 Lamotrigine (so) BOTH IP/OP $431.00 $318.94 $6.63 $346.40 $27.35 $27.35 $13.25 $13.25 $6.63 $6.63 $18.81 $18.81 $19.54 $13.25 $17.00 $8.61 $254.94 $254.94 $13.91 $216.50 $342.94 $346.40 $19.21 $280.15 $19.21 $18.11 $13.25 $13.25 $12.68 $13.25 $0.00 $0.00 $0.00 $0.00 30000055 EAP CPT® 80299 Olanzapine/zyprexa BOTH IP/OP $217.00 $160.58 $8.39 $174.40 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $128.36 $128.36 $19.57 $33.64 $172.66 $174.40 $27.03 $141.05 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30000056 EAP CPT® 82013 Acetylcholinesterase-amnio BOTH IP/OP $37.00 $27.38 $0.00 $31.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.96 $16.96 $17.61 $0.00 $16.51 $0.00 $0.00 $0.00 $0.00 $31.22 $29.30 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000057 EAP CPT® 82017 "Carnitine, Ester" BOTH IP/OP $131.00 $96.94 $0.00 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $104.54 $105.60 $0.00 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000058 EAP CPT® 82270 Fecal Occult Blood Test BOTH IP/OP $57.00 $42.18 $0.00 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $4.88 $5.07 $0.00 $4.75 $0.00 $0.00 $0.00 $0.00 $8.98 $45.94 $46.40 $0.00 $37.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000060 EAP CPT® 82330 "Calcium, Ionized" BOTH IP/OP $375.00 $277.50 $6.84 $273.60 $28.22 $28.22 $13.68 $13.68 $6.84 $6.84 $20.75 $20.75 $21.55 $13.68 $20.18 $8.89 $221.81 $221.81 $14.36 $38.18 $270.86 $273.60 $19.84 $22.57 $19.84 $21.50 $13.68 $13.68 $15.05 $13.68 $0.00 $0.00 $0.00 $0.00 30000062 EAP CPT® 82948 "Glucose-2hr Pp,wb" BOTH IP/OP $251.00 $185.74 $0.00 $248.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.82 $4.82 $5.00 $0.00 $4.68 $0.00 $0.00 $0.00 $0.00 $8.86 $246.31 $248.80 $0.00 $48.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000063 EAP CPT® 82948 "Glucose-fbs,wb" BOTH IP/OP $251.00 $185.74 $0.00 $248.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.82 $4.82 $5.00 $0.00 $4.68 $0.00 $0.00 $0.00 $0.00 $8.86 $246.31 $248.80 $0.00 $48.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000064 EAP CPT® 82948 "Glucose-fbs,wb Micro" BOTH IP/OP $251.00 $185.74 $0.00 $248.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.82 $4.82 $5.00 $0.00 $4.68 $0.00 $0.00 $0.00 $0.00 $8.86 $246.31 $248.80 $0.00 $48.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000065 EAP CPT® 82948 "Glucose-random,wb" BOTH IP/OP $251.00 $185.74 $0.00 $248.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.82 $4.82 $5.00 $0.00 $4.68 $0.00 $0.00 $0.00 $0.00 $8.86 $246.31 $248.80 $0.00 $48.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000066 EAP CPT® 82948 "GLU-RANDOM,WB MICRO" BOTH IP/OP $251.00 $185.74 $0.00 $248.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.82 $4.82 $5.00 $0.00 $4.68 $0.00 $0.00 $0.00 $0.00 $8.86 $246.31 $248.80 $0.00 $48.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000067 EAP CPT® 83020 Newborn Screen BOTH IP/OP $204.00 $150.96 $6.44 $163.20 $20.17 $20.17 $12.87 $12.87 $6.44 $6.44 $14.84 $14.84 $15.41 $12.87 $14.44 $8.37 $120.67 $120.67 $13.51 $27.32 $161.57 $163.20 $18.66 $21.24 $18.66 $15.38 $12.87 $12.87 $10.77 $12.87 $0.00 $0.00 $0.00 $0.00 30000068 EAP CPT® 83516 T-transglutamin Igg BOTH IP/OP $181.00 $133.94 $5.76 $140.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $107.06 $107.06 $12.11 $29.88 $139.39 $140.80 $16.72 $117.65 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30000069 EAP CPT® 83520 Anti Gm1 Ab Titer BOTH IP/OP $477.00 $352.98 $7.77 $371.20 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $282.15 $282.15 $18.13 $36.18 $367.49 $371.20 $25.04 $204.75 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30000070 EAP CPT® 83520 Anti Asialo-gm-ab BOTH IP/OP $411.00 $304.14 $7.77 $371.20 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $243.11 $243.11 $18.13 $36.18 $367.49 $371.20 $25.04 $204.75 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30000071 EAP CPT® 83520 Anti Gq1b Ab Titer BOTH IP/OP $477.00 $352.98 $7.77 $371.20 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $282.15 $282.15 $18.13 $36.18 $367.49 $371.20 $25.04 $204.75 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30000072 EAP CPT® 83520 Anti Gd 1b Ab Titer BOTH IP/OP $411.00 $304.14 $7.77 $371.20 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $243.11 $243.11 $18.13 $36.18 $367.49 $371.20 $25.04 $204.75 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30000073 EAP CPT® 83520 Mitochondrial Ab BOTH IP/OP $477.00 $352.98 $7.77 $371.20 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $282.15 $282.15 $18.13 $36.18 $367.49 $371.20 $25.04 $248.30 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30000074 EAP CPT® 83605 "Lactate, Plasma" BOTH IP/OP $258.00 $190.92 $5.34 $248.80 $22.04 $22.04 $11.57 $11.57 $5.79 $5.34 $16.21 $16.21 $16.84 $11.57 $15.78 $7.52 $152.61 $152.61 $12.15 $29.84 $246.31 $248.80 $16.78 $19.09 $16.78 $16.82 $11.57 $11.57 $11.77 $11.57 $0.00 $0.00 $0.00 $0.00 30000083 EAP CPT® 84030 "Phenylalanine (pku), Blood" BOTH IP/OP $48.00 $35.52 $0.00 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.36 $8.36 $8.68 $0.00 $8.13 $0.00 $0.00 $0.00 $0.00 $15.38 $38.02 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000084 EAP CPT® 84066 Prostatic Acid Phosphatase BOTH IP/OP $100.00 $74.00 $4.83 $76.00 $19.93 $19.93 $9.66 $9.66 $4.83 $4.83 $14.66 $14.66 $15.23 $9.66 $14.27 $6.28 $59.15 $59.15 $10.14 $27.00 $75.24 $76.00 $14.01 $15.94 $14.01 $15.20 $9.66 $9.66 $10.64 $9.66 $0.00 $0.00 $0.00 $0.00 30000085 EAP CPT® 84100 "Phosphorus, Serum" BOTH IP/OP $128.00 $94.72 $2.37 $108.80 $9.79 $9.79 $4.74 $4.74 $2.37 $2.37 $7.21 $7.21 $7.48 $4.74 $7.01 $3.08 $75.71 $75.71 $4.98 $13.26 $107.71 $108.80 $6.87 $72.80 $6.87 $7.47 $4.74 $4.74 $5.23 $4.74 $0.00 $0.00 $0.00 $0.00 30000086 EAP CPT® 84152 "Psa, Total Screening" BOTH IP/OP $237.00 $175.38 $0.00 $189.60 $37.96 $37.96 $19.31 $19.31 $9.66 $9.20 $27.92 $27.92 $29.00 $19.31 $27.17 $12.55 $140.19 $140.19 $20.28 $51.40 $187.70 $189.60 $26.67 $154.05 $26.67 $0.00 $18.39 $18.39 $20.27 $19.31 $0.00 $0.00 $0.00 $0.00 30000087 EAP CPT® 84163 Preg Assoc Plasma Protein BOTH IP/OP $96.00 $71.04 $7.07 $75.20 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $56.78 $56.78 $15.80 $17.94 $74.45 $75.20 $21.82 $24.83 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30000089 EAP CPT® 84702 D-HCG FREE & INTACT BOTH IP/OP $419.00 $310.06 $7.07 $304.80 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $247.84 $247.84 $15.80 $17.94 $301.75 $304.80 $21.82 $215.80 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30000090 EAP CPT® 85461 Fetal Screen Rhig BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.08 $10.08 $10.47 $0.00 $9.79 $0.00 $0.00 $0.00 $0.00 $18.52 $118.80 $120.00 $0.00 $97.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000091 EAP CPT® 85557 "Osmotic Fragility,erythrocytes" BOTH IP/OP $264.00 $195.36 $0.00 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.28 $20.28 $21.06 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $37.32 $209.09 $211.20 $0.00 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000092 EAP CPT® 85660 Donor Hgb S (arc) BOTH IP/OP $201.00 $148.74 $2.75 $146.40 $11.38 $11.38 $5.51 $5.51 $2.76 $2.75 $8.38 $8.38 $8.70 $5.51 $8.15 $3.58 $118.89 $118.89 $5.79 $15.42 $144.94 $146.40 $7.99 $9.09 $7.99 $8.68 $5.51 $5.51 $6.08 $5.51 $0.00 $0.00 $0.00 $0.00 30000093 EAP CPT® 86003 Epicoccum Purpurascn BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30000095 EAP CPT® 86022 Platelet Ab Screen (arc) BOTH IP/OP $457.00 $338.18 $0.00 $336.00 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $270.32 $270.32 $0.00 $51.32 $332.64 $336.00 $0.00 $30.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000096 EAP CPT® 86147 Antiphospholipid Igg BOTH IP/OP $581.00 $429.94 $12.73 $580.80 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $343.66 $343.66 $26.72 $71.08 $574.99 $580.80 $36.90 $41.99 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30000097 EAP CPT® 86147 Antiphospholipid Igm BOTH IP/OP $581.00 $429.94 $12.73 $580.80 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $343.66 $343.66 $26.72 $71.08 $574.99 $580.80 $36.90 $41.99 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30000098 EAP CPT® 86235 Antihistone Ab BOTH IP/OP $344.00 $254.56 $8.97 $265.60 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $203.48 $203.48 $18.83 $50.12 $262.94 $265.60 $26.00 $223.60 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30000099 EAP CPT® 86255 Murine Typhus Igg BOTH IP/OP $59.00 $43.66 $6.03 $47.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $34.90 $34.90 $12.65 $33.68 $46.73 $47.20 $17.47 $38.35 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30000100 EAP CPT® 86331 Pigeon Serum BOTH IP/OP $38.00 $28.12 $0.00 $33.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.20 $18.20 $18.90 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.50 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000101 EAP CPT® 86331 T. Candidus BOTH IP/OP $38.00 $28.12 $0.00 $33.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.20 $18.20 $18.90 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.50 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000102 EAP CPT® 86331 T.vulgaris BOTH IP/OP $38.00 $28.12 $0.00 $33.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.20 $18.20 $18.90 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.50 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000103 EAP CPT® 86331 S. Viridis BOTH IP/OP $38.00 $28.12 $0.00 $33.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.20 $18.20 $18.90 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.50 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000104 EAP CPT® 86355 "Cd19,total B %" BOTH IP/OP $210.00 $155.40 $0.00 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $172.66 $174.40 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30000105 EAP CPT® 86357 "Natural Killer (nk)cells,total" BOTH IP/OP $210.00 $155.40 $0.00 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $172.66 $174.40 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30000106 EAP CPT® 86357 "Cd56+16,nk%" BOTH IP/OP $210.00 $155.40 $0.00 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $172.66 $174.40 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30000107 EAP CPT® 86485 Candida Skin Test BOTH IP/OP $262.00 $193.88 $0.00 $211.20 $29.73 $29.73 $24.06 $24.06 $24.19 $54.61 $13.03 $13.03 $13.53 $23.64 $18.61 $15.37 $154.97 $154.97 $23.06 $132.00 $209.09 $211.20 $32.04 $170.30 $32.04 $19.83 $0.00 $0.00 $13.88 $21.96 $0.00 $0.00 $0.00 $0.00 30000108 EAP CPT® 86603 Adenovirus Ab BOTH IP/OP $64.00 $47.36 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.54 $19.54 $20.29 $0.00 $19.01 $0.00 $0.00 $0.00 $13.51 $35.96 $51.48 $52.00 $18.66 $41.60 $18.66 $0.00 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30000109 EAP CPT® 86612 Blastomyces Ab BOTH IP/OP $101.00 $74.74 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.59 $19.59 $20.35 $0.00 $19.07 $0.00 $0.00 $0.00 $0.00 $36.06 $79.20 $80.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000110 EAP CPT® 86635 Coccidiodes Ab BOTH IP/OP $155.00 $114.70 $0.00 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.42 $17.42 $18.09 $0.00 $16.95 $0.00 $0.00 $0.00 $0.00 $32.06 $111.67 $112.80 $0.00 $100.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000113 EAP CPT® 86710 Influenza A Ab BOTH IP/OP $134.00 $99.16 $0.00 $108.00 $27.98 $27.98 $13.55 $13.55 $6.78 $6.78 $20.59 $20.59 $21.38 $13.55 $20.03 $8.81 $79.26 $79.26 $0.00 $37.88 $106.92 $108.00 $0.00 $87.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000114 EAP CPT® 86710 Influenza B Ab BOTH IP/OP $134.00 $99.16 $0.00 $108.00 $27.98 $27.98 $13.55 $13.55 $6.78 $6.78 $20.59 $20.59 $21.38 $13.55 $20.03 $8.81 $79.26 $79.26 $0.00 $37.88 $106.92 $108.00 $0.00 $87.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000115 EAP CPT® 86710 Parainfluenza-1 Ab BOTH IP/OP $133.00 $98.42 $0.00 $108.00 $27.98 $27.98 $13.55 $13.55 $6.78 $6.78 $20.59 $20.59 $21.38 $13.55 $20.03 $8.81 $78.67 $78.67 $0.00 $37.88 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000116 EAP CPT® 86710 Parainfluenza-2 Ab BOTH IP/OP $133.00 $98.42 $0.00 $108.00 $27.98 $27.98 $13.55 $13.55 $6.78 $6.78 $20.59 $20.59 $21.38 $13.55 $20.03 $8.81 $78.67 $78.67 $0.00 $37.88 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000117 EAP CPT® 86710 Parainfluenza-3 Ab BOTH IP/OP $133.00 $98.42 $0.00 $108.00 $27.98 $27.98 $13.55 $13.55 $6.78 $6.78 $20.59 $20.59 $21.38 $13.55 $20.03 $8.81 $78.67 $78.67 $0.00 $37.88 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000118 EAP CPT® 86735 Mumps Igm BOTH IP/OP $130.00 $96.20 $6.53 $104.80 $26.93 $26.93 $13.05 $13.05 $6.53 $6.53 $19.82 $19.82 $20.58 $13.05 $19.28 $8.48 $76.90 $76.90 $13.70 $36.46 $103.75 $104.80 $18.92 $84.50 $18.92 $20.54 $13.05 $13.05 $14.38 $13.05 $0.00 $0.00 $0.00 $0.00 30000119 EAP CPT® 86735 Mumps Igg BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $26.93 $26.93 $13.05 $13.05 $6.53 $6.53 $19.82 $19.82 $20.58 $13.05 $19.28 $8.48 $77.49 $77.49 $13.70 $36.46 $103.75 $104.80 $18.92 $0.00 $18.92 $20.54 $13.05 $13.05 $14.38 $13.05 $0.00 $0.00 $0.00 $0.00 30000120 EAP CPT® 86744 Micropolyspora Faeni BOTH IP/OP $40.00 $29.60 $0.00 $36.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000121 EAP CPT® 86756 Rsv Ab BOTH IP/OP $186.00 $137.64 $0.00 $148.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.57 $19.57 $20.33 $0.00 $19.05 $0.00 $0.00 $0.00 $0.00 $36.02 $147.31 $148.80 $0.00 $120.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000124 EAP CPT® 86850 Antibody Screen (arc) BOTH IP/OP $366.00 $270.84 $4.40 $267.20 $7.89 $7.89 $48.39 $48.39 $48.66 $4.40 $16.59 $16.59 $17.23 $47.69 $17.89 $31.00 $216.49 $216.49 $49.62 $37.22 $264.53 $267.20 $68.93 $237.90 $68.93 $19.06 $9.77 $9.77 $13.35 $47.25 $0.00 $0.00 $0.00 $0.00 30000126 EAP CPT® 86850 Antibody Screen BOTH IP/OP $366.00 $270.84 $4.40 $267.20 $7.89 $7.89 $48.39 $48.39 $48.66 $4.40 $16.59 $16.59 $17.23 $47.69 $17.89 $31.00 $216.49 $216.49 $49.62 $37.22 $264.53 $267.20 $68.93 $237.90 $68.93 $19.06 $9.77 $9.77 $13.35 $47.25 $0.00 $0.00 $0.00 $0.00 30000128 EAP CPT® 86860 Rbc Elution (arc) BOTH IP/OP $563.00 $416.62 $0.00 $411.20 $47.04 $47.04 $145.24 $145.24 $146.06 $117.34 $19.75 $19.75 $20.51 $142.96 $7.19 $92.92 $333.01 $333.01 $143.92 $44.66 $407.09 $411.20 $199.96 $336.70 $199.96 $7.66 $0.00 $0.00 $5.36 $137.07 $0.00 $0.00 $0.00 $0.00 30000129 EAP CPT® 86860 Rbc Elution BOTH IP/OP $563.00 $416.62 $0.00 $411.20 $47.04 $47.04 $145.24 $145.24 $146.06 $117.34 $19.75 $19.75 $20.51 $142.96 $7.19 $92.92 $333.01 $333.01 $143.92 $44.66 $407.09 $411.20 $199.96 $336.70 $199.96 $7.66 $0.00 $0.00 $5.36 $137.07 $0.00 $0.00 $0.00 $0.00 30000130 EAP CPT® 86870 Antibody Id BOTH IP/OP $634.00 $469.16 $0.00 $463.20 $64.34 $64.34 $283.63 $283.63 $285.22 $132.14 $30.41 $30.41 $31.58 $279.15 $7.19 $181.45 $375.01 $375.01 $284.24 $69.46 $458.57 $463.20 $394.92 $412.10 $394.92 $7.66 $0.00 $0.00 $5.36 $270.71 $0.00 $0.00 $0.00 $0.00 30000131 EAP CPT® 86870 Antibody Id (arc) BOTH IP/OP $634.00 $469.16 $0.00 $463.20 $64.34 $64.34 $283.63 $283.63 $285.22 $132.14 $30.41 $30.41 $31.58 $279.15 $7.19 $181.45 $375.01 $375.01 $284.24 $69.46 $458.57 $463.20 $394.92 $412.10 $394.92 $7.66 $0.00 $0.00 $5.36 $270.71 $0.00 $0.00 $0.00 $0.00 30000136 EAP CPT® 86880 Direct Coombs (arc) BOTH IP/OP $140.00 $103.60 $2.70 $112.80 $11.11 $11.11 $54.21 $54.21 $54.51 $2.70 $8.15 $8.15 $8.47 $53.35 $7.93 $34.67 $82.81 $82.81 $33.53 $15.00 $111.67 $112.80 $46.58 $91.00 $46.58 $8.45 $5.39 $5.39 $5.91 $31.93 $0.00 $0.00 $0.00 $0.00 30000146 EAP CPT® 86900 "Blood Typing, Serologic, Abo (arc)" BOTH IP/OP $165.00 $122.10 $1.49 $150.00 $6.18 $6.18 $109.81 $109.81 $110.43 $1.49 $4.52 $4.52 $4.70 $107.30 $4.41 $69.74 $97.60 $97.60 $109.35 $8.34 $118.80 $120.00 $150.00 $107.25 $150.00 $4.70 $2.99 $2.99 $3.29 $104.14 $0.00 $0.00 $0.00 $0.00 30000149 EAP CPT® 86901 "Blood Typing, Serologic, Rh (d) (arc)" BOTH IP/OP $165.00 $122.10 $1.49 $120.00 $6.18 $6.18 $32.96 $32.96 $33.15 $1.49 $4.52 $4.52 $4.70 $32.43 $17.04 $21.08 $97.60 $97.60 $33.53 $8.34 $118.80 $120.00 $46.58 $88.40 $46.58 $18.16 $2.99 $2.99 $12.71 $31.93 $0.00 $0.00 $0.00 $0.00 30000153 EAP CPT® 86902 Blood Type Ag Donor Ea BOTH IP/OP $828.00 $612.72 $2.86 $604.80 $7.89 $7.89 $283.63 $283.63 $285.22 $2.86 $5.60 $5.60 $5.81 $279.15 $5.05 $181.45 $489.76 $489.76 $284.24 $378.00 $598.75 $604.80 $394.92 $494.00 $394.92 $5.38 $6.35 $6.35 $3.77 $270.71 $0.00 $0.00 $0.00 $0.00 30000154 EAP CPT® 86902 Blood Type Ag Donor Ea (arc) BOTH IP/OP $828.00 $612.72 $2.86 $604.80 $7.89 $7.89 $283.63 $283.63 $285.22 $2.86 $5.60 $5.60 $5.81 $279.15 $5.05 $181.45 $489.76 $489.76 $284.24 $378.00 $598.75 $604.80 $394.92 $538.20 $394.92 $5.38 $6.35 $6.35 $3.77 $270.71 $0.00 $0.00 $0.00 $0.00 30000155 EAP CPT® 86904 Ag Screen Pt Serum Ea Unit (arc) BOTH IP/OP "$2,572.00 " "$1,903.28" $0.00 $167.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.44 $14.44 $14.99 $0.00 $14.04 $0.00 $0.00 $0.00 $0.00 $26.56 $115.63 $116.80 $0.00 $167.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000160 EAP CPT® 86905 Patient Ag Typing (arc) BOTH IP/OP $353.00 $261.22 $1.91 $322.00 $7.89 $7.89 $283.63 $283.63 $285.22 $1.91 $5.80 $5.80 $6.03 $279.15 $5.65 $181.45 $208.80 $208.80 $284.24 $10.68 $255.02 $257.60 $322.00 $229.45 $322.00 $6.02 $3.83 $3.83 $4.21 $270.71 $0.00 $0.00 $0.00 $0.00 30000161 EAP CPT® 86905 Patient Ag Typing BOTH IP/OP $353.00 $261.22 $1.91 $322.00 $7.89 $7.89 $283.63 $283.63 $285.22 $1.91 $5.80 $5.80 $6.03 $279.15 $5.65 $181.45 $208.80 $208.80 $284.24 $10.68 $255.02 $257.60 $322.00 $229.45 $322.00 $6.02 $3.83 $3.83 $4.21 $270.71 $0.00 $0.00 $0.00 $0.00 30000179 EAP CPT® 86906 Rh Phenotype (arc) BOTH IP/OP $786.00 $581.64 $0.00 $572.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.76 $11.76 $12.21 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $21.66 $566.28 $572.00 $0.00 $405.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000180 EAP CPT® 86920 Crossmatch Is Ea Unit BOTH IP/OP $314.00 $232.36 $0.00 $228.80 $51.90 $51.90 $145.24 $145.24 $146.06 $65.45 $27.25 $27.25 $28.30 $142.96 $65.44 $92.92 $185.73 $185.73 $143.92 $62.02 $226.51 $228.80 $199.96 $204.10 $199.96 $44.76 $0.00 $0.00 $45.53 $137.07 $0.00 $0.00 $0.00 $0.00 30000182 EAP CPT® 86920 COMPATIBILITY EA- MT BOTH IP/OP $263.00 $194.62 $0.00 $228.80 $51.90 $51.90 $145.24 $145.24 $146.06 $54.82 $27.25 $27.25 $28.30 $142.96 $54.81 $92.92 $155.56 $155.56 $143.92 $62.02 $226.51 $228.80 $199.96 $0.00 $199.96 $44.76 $0.00 $0.00 $45.53 $137.07 $0.00 $0.00 $0.00 $0.00 30000185 EAP CPT® 86921 Crossmatch Incub Ea Unit BOTH IP/OP $502.00 $371.48 $0.00 $365.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.12 $22.12 $22.97 $0.00 $104.62 $0.00 $0.00 $0.00 $143.92 $50.44 $361.94 $365.60 $199.96 $295.75 $199.96 $71.52 $0.00 $0.00 $72.75 $137.07 $0.00 $0.00 $0.00 $0.00 30000187 EAP CPT® 86921 Platelet Crossmatch (arc) BOTH IP/OP $502.00 $371.48 $0.00 $365.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.12 $22.12 $22.97 $0.00 $104.62 $0.00 $0.00 $0.00 $143.92 $50.44 $361.94 $365.60 $199.96 $295.75 $199.96 $71.52 $0.00 $0.00 $72.75 $137.07 $0.00 $0.00 $0.00 $0.00 30000190 EAP CPT® 86922 Crossmatch Ahg (arc) BOTH IP/OP $528.00 $390.72 $0.00 $384.00 $55.68 $55.68 $145.24 $145.24 $146.06 $110.05 $24.89 $24.89 $25.84 $142.96 $110.04 $92.92 $312.31 $312.31 $143.92 $56.24 $380.16 $384.00 $199.96 $308.75 $199.96 $75.12 $0.00 $0.00 $76.42 $137.07 $0.00 $0.00 $0.00 $0.00 30000191 EAP CPT® 86922 Crossmatch Ahg BOTH IP/OP $528.00 $390.72 $0.00 $384.00 $55.68 $55.68 $145.24 $145.24 $146.06 $110.05 $24.89 $24.89 $25.84 $142.96 $110.04 $92.92 $312.31 $312.31 $143.92 $56.24 $380.16 $384.00 $199.96 $343.20 $199.96 $75.12 $0.00 $0.00 $76.42 $137.07 $0.00 $0.00 $0.00 $0.00 30000192 EAP CPT® 86923 Crossmatch Electronic BOTH IP/OP $463.00 $342.62 $0.00 $336.80 $41.63 $41.63 $145.24 $145.24 $146.06 $96.50 $19.75 $19.75 $20.51 $142.96 $96.49 $92.92 $273.86 $273.86 $143.92 $44.66 $333.43 $336.80 $199.96 $300.95 $199.96 $65.89 $0.00 $0.00 $67.02 $137.07 $0.00 $0.00 $0.00 $0.00 30000195 EAP CPT® 86940 Hemolysins/agglutinins Auto Ea (arc) BOTH IP/OP $139.00 $102.86 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.45 $12.45 $12.93 $0.00 $12.11 $0.00 $0.00 $0.00 $0.00 $22.92 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000196 EAP CPT® 86941 Hemolysins/agglutinins Incubated (arc) BOTH IP/OP $139.00 $102.86 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.39 $18.39 $19.09 $0.00 $17.89 $0.00 $0.00 $0.00 $0.00 $33.84 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000198 EAP CPT® 86970 Rbc Pretx Chem (arc) BOTH IP/OP $810.00 $599.40 $0.00 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.59 $16.59 $17.23 $0.00 $168.80 $0.00 $0.00 $0.00 $0.00 $37.22 $586.08 $592.00 $0.00 $193.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000199 EAP CPT® 86971 Rbc Pretx Enz (arc) BOTH IP/OP $383.00 $283.42 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.59 $16.59 $17.23 $0.00 $79.82 $0.00 $0.00 $0.00 $0.00 $37.22 $277.20 $280.00 $0.00 $248.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000200 EAP CPT® 86972 Rbc Pretx Dens Grad (arc) BOTH IP/OP $827.00 $611.98 $0.00 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.47 $26.47 $27.49 $0.00 $172.35 $0.00 $0.00 $0.00 $0.00 $60.36 $703.30 $710.40 $0.00 $285.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000201 EAP CPT® 86975 Rbc Pretx Drug (arc) BOTH IP/OP $810.00 $599.40 $0.00 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.12 $22.12 $22.97 $0.00 $168.80 $0.00 $0.00 $0.00 $0.00 $50.44 $586.08 $592.00 $0.00 $215.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000202 EAP CPT® 86976 "Rbc Dilution Of Serum, Per Aliquot (arc)" BOTH IP/OP $264.00 $195.36 $0.00 $107.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.89 $24.89 $25.84 $0.00 $55.02 $0.00 $0.00 $0.00 $0.00 $56.24 $57.82 $58.40 $0.00 $107.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000203 EAP CPT® 86977 "Rbc Incubation With Inhibitors, Per Aliquot (arc)" BOTH IP/OP $751.00 $555.74 $0.00 $261.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.12 $22.12 $22.97 $0.00 $156.51 $0.00 $0.00 $0.00 $0.00 $50.44 $157.61 $159.20 $0.00 $261.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000204 EAP CPT® 86978 Rbc Pretx Ab Id Diff Ea Absorp (arc) BOTH IP/OP $640.00 $473.60 $0.00 $467.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.12 $22.12 $22.97 $0.00 $133.38 $0.00 $0.00 $0.00 $0.00 $50.44 $462.53 $467.20 $0.00 $259.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000205 EAP CPT® 86985 Aliquot Blood Products Ea BOTH IP/OP $376.00 $278.24 $0.00 $304.00 $38.39 $38.39 $145.24 $145.24 $146.06 $78.37 $16.59 $16.59 $17.23 $142.96 $78.36 $92.92 $222.40 $222.40 $143.92 $37.22 $300.96 $304.00 $199.96 $244.40 $199.96 $0.00 $0.00 $0.00 $60.50 $137.07 $0.00 $0.00 $0.00 $0.00 30000208 EAP CPT® 87015 Concentration BOTH IP/OP $132.00 $97.68 $3.34 $96.00 $13.78 $13.78 $6.68 $6.68 $3.34 $3.34 $10.14 $10.14 $10.53 $6.68 $9.87 $4.34 $78.08 $78.08 $7.01 $18.66 $95.04 $96.00 $9.69 $11.02 $9.69 $10.52 $6.68 $6.68 $7.36 $6.68 $0.00 $0.00 $0.00 $0.00 30000209 EAP CPT® 87046 "Stool Cult, Aerobic-campy" BOTH IP/OP $143.00 $105.82 $2.60 $115.20 $19.48 $19.48 $9.44 $9.44 $4.72 $4.72 $14.32 $14.32 $14.87 $9.44 $3.49 $6.14 $84.58 $84.58 $9.91 $26.36 $114.05 $115.20 $13.69 $15.58 $13.69 $3.71 $9.44 $9.44 $2.60 $9.44 $0.00 $0.00 $0.00 $0.00 30000210 EAP CPT® 87046 "Stool, Cult, Aerobic-yersinnia" BOTH IP/OP $143.00 $105.82 $2.60 $115.20 $19.48 $19.48 $9.44 $9.44 $4.72 $4.72 $14.32 $14.32 $14.87 $9.44 $3.49 $6.14 $84.58 $84.58 $9.91 $26.36 $114.05 $115.20 $13.69 $15.58 $13.69 $3.71 $9.44 $9.44 $2.60 $9.44 $0.00 $0.00 $0.00 $0.00 30000211 EAP CPT® 87176 "Homogenization, Tissue" BOTH IP/OP $101.00 $74.74 $2.94 $73.60 $12.14 $12.14 $5.88 $5.88 $2.94 $2.94 $8.93 $8.93 $9.28 $5.88 $8.69 $3.82 $59.74 $59.74 $6.17 $16.44 $72.86 $73.60 $8.53 $9.70 $8.53 $9.26 $5.88 $5.88 $6.48 $5.88 $0.00 $0.00 $0.00 $0.00 30000212 EAP CPT® 87177 Wet Prep BOTH IP/OP $112.00 $82.88 $4.45 $87.20 $18.37 $18.37 $8.90 $8.90 $4.45 $4.45 $13.51 $13.51 $14.03 $8.90 $13.15 $5.79 $66.25 $66.25 $9.35 $24.86 $86.33 $87.20 $12.91 $72.80 $12.91 $14.01 $8.90 $8.90 $9.81 $8.90 $0.00 $0.00 $0.00 $0.00 30000213 EAP CPT® 87220 Skin Prep: 10% Koh BOTH IP/OP $198.00 $146.52 $2.14 $147.20 $8.82 $8.82 $4.27 $4.27 $2.14 $2.14 $6.48 $6.48 $6.73 $4.27 $6.30 $2.78 $117.12 $117.12 $4.48 $11.92 $145.73 $147.20 $6.19 $128.70 $6.19 $6.71 $4.27 $4.27 $4.70 $4.27 $0.00 $0.00 $0.00 $0.00 30000214 EAP CPT® 87250 Herpes Viral Culture BOTH IP/OP $367.00 $271.58 $9.78 $296.00 $40.37 $40.37 $19.56 $19.56 $9.78 $9.78 $29.69 $29.69 $30.83 $19.56 $28.89 $12.71 $217.08 $217.08 $20.54 $54.64 $293.04 $296.00 $28.36 $32.27 $28.36 $30.78 $19.56 $19.56 $21.54 $19.56 $0.00 $0.00 $0.00 $0.00 30000215 EAP CPT® 87497 "Cytomegalovirus, Dna" BOTH IP/OP "$1,040.00 " $769.60 $21.42 $807.20 $88.41 $88.41 $42.84 $42.84 $21.42 $21.42 $65.04 $65.04 $67.54 $42.84 $63.28 $27.85 $615.16 $615.16 $44.98 $119.70 $799.13 $807.20 $62.12 $676.00 $62.12 $67.43 $42.84 $42.84 $47.20 $42.84 $0.00 $0.00 $0.00 $0.00 30000217 EAP CPT® 87536 Hiv /rna Pcr Quant BOTH IP/OP $842.00 $623.08 $42.55 $653.60 $107.10 $107.10 $85.10 $85.10 $42.55 $42.55 $78.80 $78.80 $81.83 $85.10 $66.37 $55.32 $498.04 $498.04 $89.36 $145.02 $647.06 $653.60 $123.40 $140.42 $123.40 $70.72 $85.10 $85.10 $49.50 $85.10 $0.00 $0.00 $0.00 $0.00 30000218 EAP CPT® 87536 "Hiv-1 Rna Ultra, Qnt" BOTH IP/OP $790.00 $584.60 $0.00 $653.60 $107.10 $107.10 $85.10 $85.10 $42.55 $42.55 $78.80 $78.80 $81.83 $85.10 $66.37 $55.32 $467.29 $467.29 $89.36 $145.02 $647.06 $653.60 $123.40 $0.00 $123.40 $70.72 $85.10 $85.10 $49.50 $85.10 $0.00 $0.00 $0.00 $0.00 30000220 EAP CPT® 87798 "Ebv Dna-pcr, Qual" BOTH IP/OP $900.00 $666.00 $17.55 $725.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $532.35 $532.35 $36.84 $54.82 $718.34 $725.60 $50.88 $410.80 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30000221 EAP CPT® 89050 Csf Exam-hematology BOTH IP/OP $227.00 $167.98 $2.36 $171.20 $9.74 $9.74 $4.72 $4.72 $2.36 $2.36 $7.18 $7.18 $7.45 $4.72 $6.99 $3.07 $134.27 $134.27 $4.96 $13.22 $169.49 $171.20 $6.84 $147.55 $6.84 $7.45 $4.72 $4.72 $5.22 $4.72 $0.00 $0.00 $0.00 $0.00 30000222 EAP CPT® 89050 Fluid Exam-heme BOTH IP/OP $227.00 $167.98 $2.36 $171.20 $9.74 $9.74 $4.72 $4.72 $2.36 $2.36 $7.18 $7.18 $7.45 $4.72 $6.99 $3.07 $134.27 $134.27 $4.96 $13.22 $169.49 $171.20 $6.84 $147.55 $6.84 $7.45 $4.72 $4.72 $5.22 $4.72 $0.00 $0.00 $0.00 $0.00 30000223 EAP CPT® 89060 Synovial Fluid Crystal Id BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $14.76 $14.76 $7.33 $7.33 $3.67 $3.58 $10.86 $10.86 $11.28 $7.33 $10.56 $4.76 $88.73 $88.73 $7.70 $19.98 $118.80 $120.00 $10.63 $0.00 $10.63 $11.26 $7.33 $7.33 $7.88 $7.33 $0.00 $0.00 $0.00 $0.00 30000225 EAP CPT® 87081 "Pertussis,state Lab" BOTH IP/OP $631.00 $466.94 $3.31 $463.20 $13.68 $13.68 $6.63 $6.63 $3.32 $3.31 $10.08 $10.08 $10.47 $6.63 $9.79 $4.31 $373.24 $373.24 $6.96 $18.52 $458.57 $463.20 $9.61 $10.94 $9.61 $10.43 $6.63 $6.63 $7.30 $6.63 $0.00 $0.00 $0.00 $0.00 30000228 EAP CPT® 88275 "Fish,aml, Aml1/eto,translocation8,21,probe" BOTH IP/OP $435.00 $321.90 $23.04 $345.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $257.30 $257.30 $53.75 $112.22 $342.14 $345.60 $74.23 $282.75 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000229 EAP CPT® 88271 "Fish,aml, Aml1/eto,translocation8,21,100-300 Cells" BOTH IP/OP $435.00 $321.90 $10.71 $345.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $257.30 $257.30 $22.49 $59.86 $342.14 $345.60 $31.06 $282.75 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000230 EAP CPT® 88275 "Fish,mll,11g23,gene Rearrang,probe" BOTH IP/OP $397.00 $293.78 $23.04 $315.20 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $234.83 $234.83 $53.75 $112.22 $312.05 $315.20 $74.23 $258.05 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000231 EAP CPT® 88271 "Fish,mll,11g23,gene Rearrang,100-300 Cells" BOTH IP/OP $397.00 $293.78 $10.71 $315.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $234.83 $234.83 $22.49 $59.86 $312.05 $315.20 $31.06 $258.05 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000232 EAP CPT® 88235 "Sc Anemia,dna Probe,fetus" BOTH IP/OP $258.00 $190.92 $0.00 $261.00 $258.00 $258.00 $150.30 $150.30 $75.15 $0.00 $223.60 $223.60 $232.20 $0.00 $217.53 $0.00 $0.00 $0.00 $157.82 $261.00 $206.71 $208.80 $217.94 $167.70 $217.94 $231.78 $150.30 $150.30 $162.25 $150.30 $0.00 $0.00 $0.00 $0.00 30000234 EAP HCPCS 88271 "Fish,dup 22q11.2, Probe" BOTH IP/OP $330.00 $244.20 $10.71 $262.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $195.20 $195.20 $22.49 $59.86 $259.78 $262.40 $31.06 $214.50 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000235 EAP CPT® 88271 "Fish,dup 22q11.2, 100-300 Cells" BOTH IP/OP $364.00 $269.36 $10.71 $289.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $215.31 $215.31 $22.49 $59.86 $286.70 $289.60 $31.06 $236.60 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000236 EAP CPT® 84432 Thyroglobulin Panel BOTH IP/OP $68.00 $50.32 $8.03 $54.40 $33.16 $33.16 $16.06 $16.06 $8.03 $8.03 $24.39 $24.39 $25.33 $16.06 $23.73 $10.44 $40.22 $40.22 $16.86 $44.88 $53.86 $54.40 $23.29 $44.20 $23.29 $25.28 $16.06 $16.06 $17.70 $16.06 $0.00 $0.00 $0.00 $0.00 30000237 EAP CPT® 86800 "Thyroglobulin Panel, Antibody" BOTH IP/OP $69.00 $51.06 $7.95 $55.20 $32.84 $32.84 $15.91 $15.91 $7.96 $7.95 $24.15 $24.15 $25.08 $15.91 $23.50 $10.34 $40.81 $40.81 $16.71 $44.44 $54.65 $55.20 $23.07 $44.85 $23.07 $25.04 $15.91 $15.91 $17.53 $15.91 $0.00 $0.00 $0.00 $0.00 30000240 EAP CPT® 83520 "Vasc Endothelial Gf,elisa" BOTH IP/OP $593.00 $438.82 $7.77 $461.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $350.76 $350.76 $18.13 $36.18 $456.98 $461.60 $25.04 $204.75 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30000241 EAP CPT® 83605 Poct Lactate Venous (meter) BOTH IP/OP $239.00 $176.86 $5.34 $174.40 $22.04 $22.04 $11.57 $11.57 $5.79 $5.34 $16.21 $16.21 $16.84 $11.57 $15.78 $7.52 $141.37 $141.37 $12.15 $29.84 $172.66 $174.40 $16.78 $155.35 $16.78 $16.82 $11.57 $11.57 $11.77 $11.57 $0.00 $0.00 $0.00 $0.00 30000242 EAP CPT® 84484 Poct Troponin Venous (meter) BOTH IP/OP $283.00 $209.42 $5.61 $228.80 $20.33 $20.33 $12.47 $12.47 $6.24 $5.61 $14.94 $14.94 $15.52 $12.47 $14.54 $8.11 $167.39 $167.39 $13.09 $27.50 $226.51 $228.80 $18.08 $183.95 $18.08 $15.50 $12.47 $12.47 $10.85 $12.47 $0.00 $0.00 $0.00 $0.00 30000251 EAP CPT® 86828 Hla I/ii Ab Scr Plt Trans (arc) BOTH IP/OP $587.00 $434.38 $0.00 $474.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.46 $57.46 $59.67 $0.00 $122.33 $0.00 $0.00 $0.00 $0.00 $296.50 $469.66 $474.40 $0.00 $381.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000300 EAP CPT® 80358 Methadone - Urine BOTH IP/OP $375.00 $277.50 $0.00 $289.05 $0.03 $0.03 $0.00 $0.00 $12.01 $10.03 $278.33 $278.33 $289.05 $0.00 $24.12 $0.00 $221.81 $221.81 $0.00 $170.50 $270.07 $272.80 $0.00 $203.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000302 EAP CPT® 86885 Abid Ea Selected Cell BOTH IP/OP $168.00 $124.32 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.68 $8.68 $9.02 $0.00 $8.44 $0.00 $0.00 $0.00 $143.92 $15.98 $134.64 $136.00 $170.00 $109.20 $170.00 $9.00 $5.72 $5.72 $6.30 $137.07 $0.00 $0.00 $0.00 $0.00 30000411 EAP CPT® 86927 Ffp Thawing Ea Unit BOTH IP/OP $318.00 $235.32 $0.00 $231.20 $0.00 $0.00 $0.00 $0.00 $0.00 $66.28 $10.66 $10.66 $11.07 $142.96 $66.27 $92.92 $188.10 $188.10 $143.92 $24.80 $228.89 $231.20 $199.96 $206.70 $199.96 $45.23 $0.00 $0.00 $46.01 $137.07 $0.00 $0.00 $0.00 $0.00 30000412 EAP CPT® 84702 D-hcg Free & Intact BOTH IP/OP $214.00 $158.36 $0.00 $174.40 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $126.58 $126.58 $15.80 $17.94 $172.66 $174.40 $21.82 $0.00 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30000413 EAP CPT® 86920 "Charge: Xmatch, Saline" BOTH IP/OP $263.00 $194.62 $0.00 $228.80 $51.90 $51.90 $145.24 $145.24 $146.06 $54.82 $27.25 $27.25 $28.30 $142.96 $54.81 $92.92 $155.56 $155.56 $143.92 $62.02 $226.51 $228.80 $199.96 $0.00 $199.96 $44.76 $0.00 $0.00 $45.53 $137.07 $0.00 $0.00 $0.00 $0.00 30000420 EAP CPT® 36415 Venipuncture BOTH IP/OP $43.00 $31.82 $1.35 $34.40 $23.35 $23.35 $3.00 $3.00 $1.50 $1.35 $3.12 $3.12 $3.24 $3.00 $8.96 $1.95 $25.43 $25.43 $3.15 $21.50 $34.06 $34.40 $4.35 $27.95 $4.35 $6.73 $3.00 $3.00 $6.85 $3.00 $0.00 $0.00 $0.00 $0.00 30000425 EAP CPT® 86923 Crossmatch - Mass Transfusion BOTH IP/OP $314.00 $232.36 $0.00 $228.80 $41.63 $41.63 $145.24 $145.24 $146.06 $65.45 $19.75 $19.75 $20.51 $142.96 $65.44 $92.92 $185.73 $185.73 $143.92 $44.66 $226.51 $228.80 $199.96 $204.10 $199.96 $44.76 $0.00 $0.00 $45.53 $137.07 $0.00 $0.00 $0.00 $0.00 30000426 EAP CPT® 86480 Quantiferon-tb Gold BOTH IP/OP $315.00 $233.10 $30.99 $254.40 $127.93 $127.93 $61.98 $61.98 $30.99 $30.99 $94.11 $94.11 $97.73 $61.98 $91.55 $40.29 $186.32 $186.32 $65.08 $173.18 $251.86 $254.40 $89.87 $204.75 $89.87 $97.55 $61.98 $61.98 $68.28 $61.98 $0.00 $0.00 $0.00 $0.00 30000427 EAP CPT® 86022 Serotonin Release Assay (sra) Unfractionated BOTH IP/OP $315.00 $233.10 $0.00 $232.00 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $186.32 $186.32 $0.00 $51.32 $229.68 $232.00 $0.00 $204.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000428 EAP CPT® 86022 Serotonin Release Assay (sra) Lmwh BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $171.54 $171.54 $0.00 $51.32 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000429 EAP CPT® 81599 MATERNI T21™ PLUS BOTH IP/OP "$1,153.00 " $853.22 $0.00 "$1,054.40" $0.00 $0.00 $0.00 $0.00 $205.23 $240.31 $855.76 $855.76 $888.73 $0.00 $240.29 $0.00 $682.00 $682.00 $0.00 $659.00 "$1,043.86" "$1,054.40" $790.80 $0.00 $790.80 $0.00 $0.00 $0.00 $209.83 $0.00 $0.00 $0.00 $0.00 $0.00 30000502 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP $68.00 $50.32 $0.00 $61.60 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $40.22 $40.22 $12.11 $29.88 $60.98 $61.60 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30000503 EAP CPT® 86235 Nuclear Antigen Antibody BOTH IP/OP $71.00 $52.54 $0.00 $69.60 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $42.00 $42.00 $18.83 $50.12 $68.90 $69.60 $26.00 $0.00 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30000504 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $32.00 $23.68 $0.00 $32.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $18.93 $18.93 $5.48 $14.60 $31.68 $32.00 $7.57 $0.00 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30000505 EAP CPT® 86735 Mumps Antibody BOTH IP/OP $32.00 $23.68 $6.53 $32.00 $26.93 $26.93 $13.05 $13.05 $6.53 $6.53 $19.82 $19.82 $20.58 $13.05 $19.28 $8.48 $18.93 $18.93 $13.70 $32.00 $25.34 $25.60 $18.92 $21.53 $18.92 $20.54 $13.05 $13.05 $14.38 $13.05 $0.00 $0.00 $0.00 $0.00 30000506 EAP CPT® 86644 Cmv Antibody BOTH IP/OP $24.00 $17.76 $0.00 $24.00 $24.00 $24.00 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $14.20 $14.20 $15.11 $24.00 $19.01 $19.20 $20.87 $0.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30000507 EAP CPT® 86710 Influenza Virus Antibody BOTH IP/OP $25.00 $18.50 $0.00 $25.00 $25.00 $25.00 $13.55 $13.55 $6.78 $6.78 $20.59 $20.59 $21.38 $13.55 $20.03 $8.81 $14.79 $14.79 $0.00 $25.00 $19.80 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000508 EAP CPT® 84702 Chorionic Gonadotropin Test BOTH IP/OP $162.00 $119.88 $7.07 $117.60 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $95.82 $95.82 $15.80 $17.94 $116.42 $117.60 $21.82 $24.83 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30000509 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $402.00 $297.48 $8.39 $323.20 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $237.78 $237.78 $19.57 $33.64 $319.97 $323.20 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30000510 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $118.89 $118.89 $19.57 $33.64 $159.19 $160.80 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30000515 EAP CPT® 86022 Platelet Antibodies BOTH IP/OP $347.00 $256.78 $0.00 $277.60 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $205.25 $205.25 $0.00 $51.32 $274.82 $277.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000519 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $378.00 $279.72 $2.61 $376.80 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $223.59 $223.59 $5.48 $14.60 $373.03 $376.80 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30000521 EAP CPT® 86235 Nuclear Antigen Antibody BOTH IP/OP $144.00 $106.56 $0.00 $140.80 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $85.18 $85.18 $18.83 $50.12 $139.39 $140.80 $26.00 $0.00 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30000525 EAP CPT® 82962 Blood Glucose Check BOTH IP/OP $58.00 $42.92 $1.48 $42.40 $4.83 $4.83 $3.28 $3.28 $1.64 $1.48 $3.56 $3.56 $3.69 $3.28 $3.45 $2.13 $34.31 $34.31 $3.44 $6.54 $41.98 $42.40 $4.76 $37.70 $4.76 $3.68 $3.28 $3.28 $2.58 $3.28 $0.00 $0.00 $0.00 $0.00 30000526 EAP CPT® 86003 Allegen - Mosquito Q BOTH IP/OP $96.00 $71.04 $0.00 $96.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $56.78 $56.78 $5.48 $14.60 $95.04 $96.00 $7.57 $0.00 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30000527 EAP CPT® 83916 "Oligoclonal Bands,csf(so)" BOTH IP/OP $56.00 $41.44 $12.33 $51.00 $41.53 $41.53 $27.39 $27.39 $13.70 $12.33 $30.53 $30.53 $31.71 $27.39 $29.69 $17.80 $33.12 $33.12 $28.76 $51.00 $40.39 $40.80 $39.72 $36.40 $39.72 $31.64 $27.39 $27.39 $22.15 $27.39 $0.00 $0.00 $0.00 $0.00 30000528 EAP CPT® 84157 "Protein,total And Electrophoresis,csf(so)" BOTH IP/OP $103.00 $76.22 $1.83 $80.80 $7.58 $7.58 $4.00 $4.00 $2.00 $1.83 $5.56 $5.56 $5.78 $4.00 $5.42 $2.60 $60.92 $60.92 $4.20 $10.24 $79.99 $80.80 $5.80 $66.95 $5.80 $5.77 $4.00 $4.00 $4.04 $4.00 $0.00 $0.00 $0.00 $0.00 30000529 EAP CPT® 84166 "Protein,total And Electrophoresis,qnt,csf(so)" BOTH IP/OP $89.00 $65.86 $8.91 $69.60 $36.80 $36.80 $17.83 $17.83 $8.92 $8.91 $27.08 $27.08 $28.12 $17.83 $26.34 $11.59 $52.64 $52.64 $18.72 $49.84 $68.90 $69.60 $25.85 $57.85 $25.85 $28.07 $17.83 $17.83 $19.65 $17.83 $0.00 $0.00 $0.00 $0.00 30000530 EAP CPT® 85810 "Viscosity, Serum(so)" BOTH IP/OP $76.00 $56.24 $0.00 $61.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.73 $17.73 $18.41 $0.00 $17.26 $0.00 $0.00 $0.00 $0.00 $32.64 $60.98 $61.60 $0.00 $49.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000570 EAP CPT® 86341 Ia-2 Islet Cell Ab (so) BOTH IP/OP $193.00 $142.82 $0.00 $154.40 $40.84 $40.84 $23.57 $23.57 $11.79 $10.61 $30.05 $30.05 $31.20 $23.57 $29.24 $15.32 $114.16 $114.16 $24.75 $55.30 $152.86 $154.40 $34.18 $0.00 $34.18 $31.16 $23.57 $23.57 $21.81 $23.57 $0.00 $0.00 $0.00 $0.00 30000571 EAP CPT® 86355 Lymph Sub 1 B Cells Tot (so) BOTH IP/OP $206.00 $152.44 $0.00 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $169.49 $171.20 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30000572 EAP CPT® 86357 Lymph Sub 1 Nk Cells Tot (so) BOTH IP/OP $196.00 $145.04 $0.00 $163.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $161.57 $163.20 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30000573 EAP CPT® 86359 Lymph Sub 1 T Cells Tot (so) BOTH IP/OP $210.00 $155.40 $0.00 $174.40 $48.63 $48.63 $37.73 $37.73 $18.87 $18.86 $35.77 $35.77 $37.14 $37.73 $34.80 $24.52 $124.22 $124.22 $39.62 $65.82 $172.66 $174.40 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30000574 EAP CPT® 86360 Lymph Sub 1 T Cell Ratio (so) BOTH IP/OP $311.00 $230.14 $0.00 $258.40 $96.99 $96.99 $46.98 $46.98 $23.49 $23.49 $71.34 $71.34 $74.09 $46.98 $69.42 $30.54 $183.96 $183.96 $49.33 $131.30 $255.82 $258.40 $68.12 $0.00 $68.12 $73.96 $46.98 $46.98 $51.77 $46.98 $0.00 $0.00 $0.00 $0.00 30000602 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $55.60 $55.60 $22.49 $59.86 $74.45 $75.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000604 EAP CPT® 86603 Adenovirus Antibody BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.54 $19.54 $20.29 $0.00 $19.01 $0.00 $0.00 $0.00 $13.51 $35.96 $69.70 $70.40 $18.66 $0.00 $18.66 $0.00 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30000605 EAP CPT® 84182 Protein Western Blot Test BOTH IP/OP $513.00 $379.62 $0.00 $410.40 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $303.44 $303.44 $30.67 $50.30 $406.30 $410.40 $42.35 $0.00 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30000610 EAP CPT® 86316 Immunoassay Tumor Other BOTH IP/OP $217.00 $160.58 $10.41 $175.20 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $128.36 $128.36 $21.85 $58.14 $173.45 $175.20 $30.17 $141.05 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30000611 EAP CPT® 88305 Tissue Exam By Pathologist BOTH IP/OP $624.00 $461.76 $31.00 $405.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $162.36 $164.00 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 30000612 EAP CPT® 88311 Decalcify Tissue BOTH IP/OP $103.00 $76.22 $0.00 $83.20 $34.06 $34.06 $0.00 $0.00 $0.00 $9.89 $6.40 $6.40 $6.64 $0.00 $18.15 $0.00 $60.92 $60.92 $0.00 $12.30 $82.37 $83.20 $0.00 $66.95 $0.00 $19.34 $9.00 $9.00 $13.54 $0.00 $0.00 $0.00 $0.00 $0.00 30000613 EAP CPT® 88313 Special Stains Group 2 BOTH IP/OP $146.00 $108.04 $21.08 $116.00 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $86.36 $86.36 $33.53 $110.70 $114.84 $116.00 $46.58 $94.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 30000614 EAP CPT® 85097 Bone Marrow Interpretation BOTH IP/OP $700.00 $518.00 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.62 $48.62 $50.49 $0.00 $75.35 $0.00 $0.00 $0.00 $630.05 $213.48 $554.40 $560.00 $700.00 $0.00 $700.00 $80.29 $51.21 $51.21 $56.20 $600.04 $0.00 $0.00 $0.00 $0.00 30000615 EAP CPT® 82507 Assay Of Citrate BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $13.90 $42.22 $42.22 $43.85 $27.80 $41.08 $18.07 $113.57 $113.57 $0.00 $77.70 $152.06 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000616 EAP CPT® 82131 Amino Acids Single Quant BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $34.82 $34.82 $22.98 $22.98 $11.49 $10.34 $25.62 $25.62 $26.60 $22.98 $24.92 $14.94 $40.22 $40.22 $24.13 $47.14 $53.86 $54.40 $33.32 $0.00 $33.32 $26.55 $22.98 $22.98 $18.58 $22.98 $0.00 $0.00 $0.00 $0.00 30000617 EAP CPT® 86480 Tb Test Cell Immun Measure BOTH IP/OP $500.00 $370.00 $30.99 $482.40 $127.93 $127.93 $61.98 $61.98 $30.99 $30.99 $94.11 $94.11 $97.73 $61.98 $91.55 $40.29 $295.75 $295.75 $65.08 $173.18 $477.58 $482.40 $89.87 $293.15 $89.87 $97.55 $61.98 $61.98 $68.28 $61.98 $0.00 $0.00 $0.00 $0.00 30000618 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP "$2,073.00 " "$1,534.02" $5.76 "$1,872.00" $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 "$1,226.18" "$1,226.18" $12.11 $29.88 "$1,853.28" "$1,872.00" $16.72 $195.65 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30000621 EAP CPT® 82943 Assay Of Glucagon BOTH IP/OP $82.00 $60.68 $0.00 $65.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.69 $21.69 $22.53 $0.00 $21.11 $0.00 $0.00 $0.00 $0.00 $39.94 $64.94 $65.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000622 EAP CPT® 82040 Assay Of Serum Albumin BOTH IP/OP $10.00 $7.40 $0.00 $8.04 $5.94 $5.94 $4.95 $4.95 $2.48 $2.48 $4.37 $4.37 $4.54 $4.95 $4.25 $3.22 $5.92 $5.92 $5.20 $8.04 $7.92 $8.00 $7.18 $0.00 $7.18 $4.53 $4.95 $4.95 $3.17 $4.95 $0.00 $0.00 $0.00 $0.00 30000623 EAP CPT® 84270 Assay Of Sex Hormone Globul BOTH IP/OP $35.00 $25.90 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.87 $33.00 $33.00 $34.27 $21.73 $32.10 $14.12 $20.70 $20.70 $0.00 $35.00 $27.72 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000624 EAP CPT® 84403 Assay Of Total Testosterone BOTH IP/OP $50.00 $37.00 $0.00 $50.00 $50.00 $50.00 $25.81 $25.81 $12.91 $12.91 $39.21 $39.21 $40.72 $25.81 $38.15 $16.78 $29.58 $29.58 $27.10 $50.00 $39.60 $40.00 $37.42 $0.00 $37.42 $40.65 $25.81 $25.81 $28.45 $25.81 $0.00 $0.00 $0.00 $0.00 30000625 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $996.00 $737.04 $7.77 $899.20 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $589.13 $589.13 $18.13 $36.18 $890.21 $899.20 $25.04 $204.75 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30000626 EAP CPT® 87906 Genotype Dna Hiv Reverse T BOTH IP/OP $159.00 $117.66 $0.00 $186.66 $90.02 $90.02 $128.73 $128.73 $64.37 $64.36 $63.81 $63.81 $66.27 $128.73 $57.67 $83.67 $94.05 $94.05 $135.17 $96.00 $152.06 $153.60 $186.66 $0.00 $186.66 $61.44 $128.73 $128.73 $43.01 $128.73 $0.00 $0.00 $0.00 $0.00 30000627 EAP CPT® 87903 Phenotype Dna Hiv W/culture BOTH IP/OP $855.00 $632.70 $0.00 $884.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $513.58 $513.58 $533.34 $0.00 $499.62 $0.00 $0.00 $0.00 $0.00 $884.00 $700.13 $707.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000628 EAP CPT® 87904 Phenotype Dna Hiv W/clt Add BOTH IP/OP $172.00 $127.28 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.57 $33.57 $34.86 $0.00 $32.66 $0.00 $0.00 $0.00 $0.00 $61.78 $140.98 $142.40 $0.00 $108.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000629 EAP CPT® 83785 Assay Of Manganese BOTH IP/OP $69.00 $51.06 $0.00 $68.72 $50.77 $50.77 $26.65 $26.65 $13.33 $12.30 $37.34 $37.34 $38.77 $26.65 $36.32 $17.32 $40.81 $40.81 $0.00 $68.72 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000630 EAP CPT® 82300 Assay Of Cadmium BOTH IP/OP $67.00 $49.58 $0.00 $64.66 $47.78 $47.78 $23.64 $23.64 $11.82 $11.57 $35.14 $35.14 $36.49 $23.64 $34.19 $15.37 $39.63 $39.63 $0.00 $64.66 $53.06 $53.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000631 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $77.00 $56.98 $0.00 $61.60 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $45.55 $45.55 $5.44 $14.46 $60.98 $61.60 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30000632 EAP CPT® 83885 Assay Of Nickel BOTH IP/OP $69.00 $51.06 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.20 $37.20 $38.63 $0.00 $36.19 $0.00 $0.00 $0.00 $0.00 $68.46 $54.65 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000633 EAP CPT® 83018 Quantitative Screen Metals BOTH IP/OP $114.00 $84.36 $0.00 $91.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.34 $33.34 $34.62 $0.00 $32.43 $0.00 $0.00 $0.00 $0.00 $61.36 $90.29 $91.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000634 EAP CPT® 83785 Assay Of Manganese BOTH IP/OP $79.00 $58.46 $0.00 $68.72 $50.77 $50.77 $26.65 $26.65 $13.33 $12.30 $37.34 $37.34 $38.77 $26.65 $36.32 $17.32 $46.73 $46.73 $0.00 $68.72 $62.57 $63.20 $0.00 $51.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000635 EAP CPT® 82525 Assay Of Copper BOTH IP/OP $61.00 $45.14 $6.21 $49.60 $25.61 $25.61 $12.41 $12.41 $6.21 $6.21 $18.84 $18.84 $19.57 $12.41 $18.33 $8.07 $36.08 $36.08 $13.03 $34.68 $49.10 $49.60 $17.99 $39.65 $17.99 $19.53 $12.41 $12.41 $13.67 $12.41 $0.00 $0.00 $0.00 $0.00 30000636 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $974.00 $720.76 $7.77 $757.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $576.12 $576.12 $18.13 $36.18 $750.02 $757.60 $25.04 $204.75 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30000637 EAP CPT® 80361 Assay Of Dihydrocodeinone BOTH IP/OP $257.00 $190.18 $0.00 $217.60 $0.03 $0.03 $0.00 $0.00 $12.01 $11.94 $190.75 $190.75 $198.10 $0.00 $30.51 $0.00 $152.02 $152.02 $0.00 $136.00 $215.42 $217.60 $163.20 $0.00 $163.20 $32.51 $0.00 $0.00 $22.76 $0.00 $0.00 $0.00 $0.00 $0.00 30000706 EAP CPT® 81479 Rhd Variant By Snp (arc) BOTH IP/OP "$1,150.00 " $851.00 $0.00 "$1,114.12" $0.00 $0.00 $0.00 $0.00 $204.70 $239.69 $853.53 $853.53 $886.42 $0.00 "$1,045.61" $0.00 $680.23 $680.23 $0.00 $568.00 $899.71 $908.80 $681.60 $747.50 $681.60 "$1,114.12" $0.00 $0.00 $779.89 $0.00 $0.00 $0.00 $0.00 $0.00 30000710 EAP CPT® 81479 Rhce Variant By Snp (arc) BOTH IP/OP $994.00 $735.56 $0.00 "$1,114.12" $0.00 $0.00 $0.00 $0.00 $176.93 $207.17 $737.75 $737.75 $766.18 $0.00 $994.00 $0.00 $587.95 $587.95 $0.00 $491.00 $777.74 $785.60 $589.20 $646.10 $589.20 "$1,114.12" $0.00 $0.00 $779.89 $0.00 $0.00 $0.00 $0.00 $0.00 30000715 EAP CPT® 86355 Cd19 B-cells (flow Cytometry) So BOTH IP/OP $81.00 $59.94 $0.00 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $66.53 $67.20 $54.71 $52.65 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30000716 EAP CPT® 81403 Xhea Licensed Rbc Panel (arc) BOTH IP/OP $831.00 $614.94 $83.34 $656.80 $264.00 $264.00 $185.20 $185.20 $92.60 $83.34 $616.77 $616.77 $640.53 $185.20 $220.85 $120.38 $491.54 $491.54 $194.46 $410.50 $650.23 $656.80 $268.54 $305.58 $268.54 $235.32 $185.20 $185.20 $164.72 $185.20 $0.00 $0.00 $0.00 $0.00 30000750 EAP CPT® 85335 Adamts 13 Inhibitor (so) BOTH IP/OP $375.00 $277.50 $0.00 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.55 $19.55 $20.30 $0.00 $19.02 $0.00 $0.00 $0.00 $0.00 $35.98 $300.17 $303.20 $0.00 $228.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000751 EAP CPT® 87900 Hiv Genotyping BOTH IP/OP "$1,201.00 " $888.74 $0.00 "$1,084.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.86 $167.86 $174.31 $0.00 $163.30 $0.00 $0.00 $0.00 $0.00 $308.90 "$1,073.16" "$1,084.00" $0.00 $692.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000753 EAP CPT® 86830 Hla Ab Id (arc) BOTH IP/OP $560.00 $414.40 $0.00 $452.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.08 $117.08 $121.59 $0.00 $116.70 $0.00 $0.00 $0.00 $0.00 $282.50 $447.48 $452.00 $0.00 $364.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000755 EAP CPT® 81310 "Npm (exon 12) Mutation,gene Analy(so)" BOTH IP/OP $612.00 $452.88 $0.00 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.03 $257.03 $266.91 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $349.50 $553.61 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000761 EAP CPT® 81245 "FLT3 ITD and TKD Mutation,Variants(SO)" BOTH IP/OP $445.00 $329.30 $0.00 $407.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.56 $172.56 $179.19 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $254.50 $403.13 $407.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000762 EAP CPT® 81246 CEBPA Mutation(SO) BOTH IP/OP $576.00 $426.24 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.51 $427.51 $443.98 $0.00 $120.04 $0.00 $0.00 $0.00 $0.00 $329.00 $521.14 $526.40 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000764 EAP CPT® 81450 Myeloproliferative Neoplasm Mut(SO) BOTH IP/OP "$1,655.00 " "$1,224.70" $0.00 "$1,512.80" $982.56 $982.56 $759.53 $759.53 $379.77 $0.00 "$1,228.34" "$1,228.34" "$1,275.67" $0.00 $344.90 $0.00 $0.00 $0.00 $0.00 $945.50 "$1,497.67" "$1,512.80" $0.00 $0.00 $0.00 $295.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000766 EAP CPT® 81261 "Lympho Clonal Panel, IGK,PCR(SO)" BOTH IP/OP $878.00 $649.72 $0.00 $802.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.91 $280.91 $291.72 $0.00 $286.64 $0.00 $0.00 $0.00 $0.00 $501.50 $794.38 $802.40 $0.00 $0.00 $0.00 $305.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000767 EAP CPT® 81264 "Lympho Clonal Panel,TRB PCR(SO)" BOTH IP/OP $913.00 $675.62 $0.00 $834.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.87 $211.87 $220.02 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $521.50 $826.06 $834.40 $0.00 $0.00 $0.00 $123.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000768 EAP CPT® 81340 "Lympho Clonal Panel,TRG PCR(SO)" BOTH IP/OP $526.00 $389.24 $0.00 $480.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.42 $296.42 $307.82 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $300.50 $475.99 $480.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000769 EAP CPT® 81342 "Lympho Clonal Panel, PCR,Unlisted Proc(SO)" BOTH IP/OP $624.00 $461.76 $0.00 $570.40 $415.93 $415.93 $201.50 $201.50 $100.75 $100.75 $285.90 $285.90 $296.89 $201.50 $192.65 $130.98 $369.10 $369.10 $0.00 $356.50 $564.70 $570.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000770 EAP CPT® 84999 B-Cell Clonality Panel (IGH)(SO) BOTH IP/OP $517.00 $382.58 $0.00 $440.80 $0.00 $0.00 $0.00 $0.00 $92.03 $0.00 $383.72 $383.72 $398.50 $0.00 $107.74 $0.00 $0.00 $0.00 $0.00 $0.00 $436.39 $440.80 $0.00 $120.90 $0.00 $86.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000771 EAP CPT® 81261 B-Cell Clonality Panel (IGK)(SO) BOTH IP/OP $755.00 $558.70 $0.00 $755.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.91 $280.91 $291.72 $0.00 $286.64 $0.00 $0.00 $0.00 $0.00 $373.00 $590.83 $596.80 $0.00 $755.00 $0.00 $305.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000772 EAP CPT® 81264 "B-Cell Clonality Panel,Unlisted Proc(SO)" BOTH IP/OP $636.00 $470.64 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.87 $211.87 $220.02 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $314.00 $497.38 $502.40 $0.00 $636.00 $0.00 $123.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000773 EAP CPT® 84999 "MYD88, Mutation Analysis(SO)" BOTH IP/OP $970.00 $717.80 $0.00 $766.40 $0.00 $0.00 $0.00 $0.00 $172.66 $0.00 $719.93 $719.93 $747.68 $0.00 $202.15 $0.00 $0.00 $0.00 $0.00 $0.00 $758.74 $766.40 $0.00 $120.90 $0.00 $149.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000774 EAP CPT® 81479 "KIT D816, Mutation Analysis(SO)" BOTH IP/OP "$1,437.00 " "$1,063.38" $0.00 "$1,136.00" $0.00 $0.00 $0.00 $0.00 $255.79 $299.51 "$1,066.54" "$1,066.54" "$1,107.64" $0.00 "$1,045.61" $0.00 $849.99 $849.99 $0.00 $710.00 "$1,124.64" "$1,136.00" $852.00 $934.05 $852.00 "$1,114.12" $0.00 $0.00 $779.89 $0.00 $0.00 $0.00 $0.00 $0.00 30000777 EAP CPT® 88271 "Fish, ALL, TEL/ AML1 Transl,100-300 Cells(SO)" BOTH IP/OP $357.00 $264.18 $0.00 $285.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $211.17 $211.17 $22.49 $59.86 $282.74 $285.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000778 EAP CPT® 88275 "Chromosome Analysis, Lymph Node,BM(SO)" BOTH IP/OP "$1,347.00 " $996.78 $23.04 "$1,077.60" $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $796.75 $796.75 $53.75 $112.22 "$1,066.82" "$1,077.60" $74.23 $426.40 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000779 EAP CPT® 88237 "ChromAnaly, Lymph Node,20-25 Cells(SO)" BOTH IP/OP "$1,567.00 " "$1,159.58" $64.69 "$1,388.80" $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $926.88 $926.88 $150.94 $246.70 "$1,374.91" "$1,388.80" $208.44 $884.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 30000780 EAP CPT® 88264 "Fish, B-Cell Malignancy, IGH, 14q32(SO)" BOTH IP/OP $460.00 $340.40 $0.00 $408.00 $257.29 $257.29 $144.61 $144.61 $72.31 $65.07 $189.26 $189.26 $196.54 $144.61 $184.12 $94.00 $272.09 $272.09 $151.84 $348.28 $403.92 $408.00 $209.68 $0.00 $209.68 $196.18 $144.61 $144.61 $137.33 $144.61 $0.00 $0.00 $0.00 $0.00 30000781 EAP CPT® 88271 "Fish, B-Cell Malig, IGH, 14q32,100-300 Cells(SO)" BOTH IP/OP $398.00 $294.52 $10.71 $316.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $235.42 $235.42 $22.49 $59.86 $312.84 $316.00 $31.06 $258.70 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000782 EAP CPT® 88275 ZAP -70(SO) BOTH IP/OP $233.00 $172.42 $23.04 $184.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $137.82 $137.82 $53.75 $112.22 $182.95 $184.80 $74.23 $151.45 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000783 EAP CPT® 88184 "ZAP -70,Add Marker(SO)" BOTH IP/OP $303.00 $224.22 $0.00 $303.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $179.22 $179.22 $284.24 $133.74 $239.98 $242.40 $303.00 $0.00 $303.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30000784 EAP CPT® 88185 "CLL Prognostic Panel,First Marker(SO)" BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $76.90 $76.90 $0.00 $71.72 $102.96 $104.00 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000785 EAP CPT® 88184 "CLL Prognostic Panel,Add Marker(SO)-1" BOTH IP/OP $303.00 $224.22 $0.00 $303.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $179.22 $179.22 $284.24 $133.74 $239.98 $242.40 $303.00 $0.00 $303.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30000786 EAP CPT® 88185 "CLL Prognostic Panel,Add Marker(SO)-2" BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $76.90 $76.90 $0.00 $71.72 $102.96 $104.00 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000787 EAP CPT® 88185 "CLL Prognostic Panel,IGH(SO)" BOTH IP/OP $463.00 $342.62 $0.00 $370.40 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $273.86 $273.86 $0.00 $71.72 $366.70 $370.40 $0.00 $131.95 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000788 EAP CPT® 81263 "CLL Prognostic Panel,Beta-2(SO)" BOTH IP/OP $559.00 $413.66 $0.00 $559.00 $559.00 $559.00 $294.52 $294.52 $147.26 $147.26 $417.86 $417.86 $433.93 $294.52 $115.59 $191.44 $330.65 $330.65 $309.25 $319.50 $506.09 $511.20 $427.05 $0.00 $427.05 $123.17 $294.52 $294.52 $86.22 $294.52 $0.00 $0.00 $0.00 $0.00 30000789 EAP CPT® 82232 "CLL Prognostic Panel,DNA Probe(SO)-1" BOTH IP/OP $327.00 $241.98 $0.00 $327.20 $33.40 $33.40 $16.18 $16.18 $8.09 $8.09 $24.56 $24.56 $25.51 $16.18 $23.91 $10.52 $193.42 $193.42 $16.99 $45.22 $323.93 $327.20 $23.46 $0.00 $23.46 $25.48 $16.18 $16.18 $17.83 $16.18 $0.00 $0.00 $0.00 $0.00 30000790 EAP CPT® 88271 "CLL Prognostic Panel,DNA Probe(SO)-2" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $128.95 $128.95 $22.49 $59.86 $172.66 $174.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000791 EAP CPT® 88271 "CLL Prognostic Panel,DNA Probe(SO)-3" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $128.95 $128.95 $22.49 $59.86 $172.66 $174.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000792 EAP CPT® 88271 "CLL Prognostic Panel,DNA Probe(SO)-4" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $128.95 $128.95 $22.49 $59.86 $172.66 $174.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000793 EAP CPT® 88271 "CLL Prognostic Panel,DNA Probe(SO)-5" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $128.95 $128.95 $22.49 $59.86 $172.66 $174.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000794 EAP CPT® 88271 "CLL Prognostic Panel,100-300 Cells(SO)-1" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $128.95 $128.95 $22.49 $59.86 $172.66 $174.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000795 EAP CPT® 88275 "CLL Prognostic Panel,100-300 Cells(SO)-2" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $128.95 $128.95 $53.75 $112.22 $172.66 $174.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000796 EAP CPT® 88275 "CLL Prognostic Panel,100-300 Cells(SO)-3" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $128.95 $128.95 $53.75 $112.22 $172.66 $174.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000797 EAP CPT® 88275 "CLL Prognostic Panel,100-300 Cells(SO)-4" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $128.95 $128.95 $53.75 $112.22 $172.66 $174.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000798 EAP CPT® 88275 "CLL Prognostic Panel,100-300 Cells(SO)-5" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $128.95 $128.95 $53.75 $112.22 $172.66 $174.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000799 EAP CPT® 88275 "CLL Prognostic Panel,BM(SO)" BOTH IP/OP $233.00 $172.42 $0.00 $186.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $137.82 $137.82 $53.75 $112.22 $184.54 $186.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000800 EAP CPT® 88237 "CLL Prognostic Panel,20-25 Cells(SO)" BOTH IP/OP $382.00 $282.68 $0.00 $338.40 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $225.95 $225.95 $150.94 $246.70 $335.02 $338.40 $208.44 $0.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 30000801 EAP CPT® 88264 "CHROM, CLL/LPD,BM(SO)" BOTH IP/OP $592.00 $438.08 $0.00 $524.80 $257.29 $257.29 $144.61 $144.61 $72.31 $65.07 $189.26 $189.26 $196.54 $144.61 $184.12 $94.00 $350.17 $350.17 $151.84 $348.28 $519.55 $524.80 $209.68 $0.00 $209.68 $196.18 $144.61 $144.61 $137.33 $144.61 $0.00 $0.00 $0.00 $0.00 30000802 EAP CPT® 88237 "CHROM, CLL/LPD, 20-25 Cells(SO)" BOTH IP/OP $592.00 $438.08 $0.00 $524.80 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $350.17 $350.17 $150.94 $246.70 $519.55 $524.80 $208.44 $0.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 30000803 EAP CPT® 88264 "CHROM, CLL/LPD,Interp(SO)" BOTH IP/OP $592.00 $438.08 $0.00 $524.80 $257.29 $257.29 $144.61 $144.61 $72.31 $65.07 $189.26 $189.26 $196.54 $144.61 $184.12 $94.00 $350.17 $350.17 $151.84 $348.28 $519.55 $524.80 $209.68 $0.00 $209.68 $196.18 $144.61 $144.61 $137.33 $144.61 $0.00 $0.00 $0.00 $0.00 30000805 EAP CPT® 88271 "Fish, ALL, Pre-B,100-300 Cells(SO)" BOTH IP/OP "$1,002.00 " $741.48 $10.71 $801.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $592.68 $592.68 $22.49 $59.86 $793.58 $801.60 $31.06 $380.25 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000806 EAP CPT® 88275 "Fish, MALT Lymph, rea18q21,DNA Probe(SO)-1" BOTH IP/OP $303.00 $224.22 $0.00 $242.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $179.22 $179.22 $53.75 $112.22 $239.98 $242.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000807 EAP CPT® 88271 "Fish, MALT Lymph, rea18q21,DNA Probe(SO)-2" BOTH IP/OP $303.00 $224.22 $0.00 $242.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $179.22 $179.22 $22.49 $59.86 $239.98 $242.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000808 EAP CPT® 88271 "Fish, MALT Lymph, rea18q21100-300 Cells(SO)" BOTH IP/OP $303.00 $224.22 $0.00 $242.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $179.22 $179.22 $22.49 $59.86 $239.98 $242.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000809 EAP CPT® 88275 "Fish, TCL1, 14q32.1,DNA Probe(SO)-1" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $136.64 $136.64 $53.75 $112.22 $182.95 $184.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000810 EAP CPT® 88271 "Fish, TCL1, 14q32.1,DNA Probe(SO)-2" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.64 $136.64 $22.49 $59.86 $182.95 $184.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000811 EAP CPT® 88271 "Fish, TCL1, 14q32.1,100-300 Cells(SO)" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.64 $136.64 $22.49 $59.86 $182.95 $184.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000812 EAP CPT® 88275 "Fish, T-Cell Receptor Alpha/ Delta,DNA Probe(SO)-1" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $136.64 $136.64 $53.75 $112.22 $182.95 $184.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000813 EAP CPT® 88271 "Fish, T-Cell Receptor Alpha/ Delta,DNA Probe(SO)-2" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.64 $136.64 $22.49 $59.86 $182.95 $184.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000814 EAP CPT® 88271 "Fish, T-Cell Receptor Alpha/ Delta,100-300 Cells(SO)" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.64 $136.64 $22.49 $59.86 $182.95 $184.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000815 EAP CPT® 88275 "Chrom. Microarray, Hematologic Malig.(SO)" BOTH IP/OP "$2,718.00 " "$2,011.32" $23.04 "$2,174.40" $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 "$1,607.70" "$1,607.70" $53.75 $112.22 "$2,152.66" "$2,174.40" $74.23 $426.40 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000816 EAP CPT® 81406 "Fish, Mult Myel, IGH/ MAFB,DNA Probe(SO)-1" BOTH IP/OP $283.00 $209.42 $0.00 $283.00 $237.60 $237.60 $282.88 $282.88 $141.44 $127.30 $210.04 $210.04 $218.14 $282.88 $283.00 $183.87 $167.39 $167.39 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30000817 EAP CPT® 88271 "Fish, Mult Myel, IGH/ MAFB,DNA Probe(SO)-2" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.64 $136.64 $22.49 $59.86 $182.95 $184.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000818 EAP CPT® 88271 "Fish, Mult Myel, IGH/ MAFB,100-300 Cells(SO)" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.64 $136.64 $22.49 $59.86 $182.95 $184.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000819 EAP CPT® 88275 "Fish, Mult Myel, 1q21,DNA Probe(SO)-1" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $136.64 $136.64 $53.75 $112.22 $182.95 $184.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000820 EAP CPT® 88271 "Fish, Mult Myel, 1q21,DNA Probe(SO)-2" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.64 $136.64 $22.49 $59.86 $182.95 $184.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000821 EAP CPT® 88271 "Fish, Mult Myel, 1q21,100-300 Cells(SO)" BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.64 $136.64 $22.49 $59.86 $182.95 $184.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000822 EAP CPT® 88275 "Fish, Myeloid Neopl, MECOM,DNA Probe(SO)-1" BOTH IP/OP $251.00 $185.74 $0.00 $200.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $148.47 $148.47 $53.75 $112.22 $198.79 $200.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000823 EAP CPT® 88271 "Fish, Myeloid Neopl, MECOM,DNA Probe(SO)-2" BOTH IP/OP $251.00 $185.74 $0.00 $200.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $148.47 $148.47 $22.49 $59.86 $198.79 $200.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000824 EAP CPT® 88271 "Fish, Myeloid Neopl, MECOM,DNA Probe(SO)-3" BOTH IP/OP $251.00 $185.74 $0.00 $200.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $148.47 $148.47 $22.49 $59.86 $198.79 $200.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000825 EAP CPT® 88271 "Fish, Myeloid Neoplasms, MECOM,100-300 Cells(SO)" BOTH IP/OP $251.00 $185.74 $0.00 $200.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $148.47 $148.47 $22.49 $59.86 $198.79 $200.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000826 EAP CPT® 88275 "Fish, High-Grade LymphPanel,DNA Probe(SO)-1" BOTH IP/OP $312.00 $230.88 $0.00 $249.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $184.55 $184.55 $53.75 $112.22 $247.10 $249.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000827 EAP CPT® 88271 "Fish, High-Grade LymphPanel,DNA Probe(SO)-2" BOTH IP/OP $314.00 $232.36 $10.71 $249.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $185.73 $185.73 $22.49 $59.86 $247.10 $249.60 $31.06 $204.10 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000828 EAP CPT® 88271 "Fish, High-Grade LymphPanel,DNA Probe(SO)-3" BOTH IP/OP $314.00 $232.36 $10.71 $249.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $185.73 $185.73 $22.49 $59.86 $247.10 $249.60 $31.06 $204.10 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000829 EAP CPT® 88271 "Fish, High-Grade LymphPanel,DNA Probe(SO)-4" BOTH IP/OP $314.00 $232.36 $10.71 $249.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $185.73 $185.73 $22.49 $59.86 $247.10 $249.60 $31.06 $204.10 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000830 EAP CPT® 88271 "Fish, High-Grade LymphPanel,DNA Probe(SO)-5" BOTH IP/OP $314.00 $232.36 $10.71 $249.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $185.73 $185.73 $22.49 $59.86 $247.10 $249.60 $31.06 $204.10 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000831 EAP CPT® 88271 "Fish, High-Grade LymphPanel,DNA Probe(SO)-6" BOTH IP/OP $314.00 $232.36 $10.71 $249.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $185.73 $185.73 $22.49 $59.86 $247.10 $249.60 $31.06 $204.10 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000832 EAP CPT® 88271 "Fish, High-Grade LymphPanel,100-300 Cells(SO)-1" BOTH IP/OP $314.00 $232.36 $10.71 $249.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $185.73 $185.73 $22.49 $59.86 $247.10 $249.60 $31.06 $204.10 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000833 EAP CPT® 88275 "Fish, High-Grade LymphPanel,100-300 Cells(SO)-2" BOTH IP/OP $314.00 $232.36 $23.04 $249.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $185.73 $185.73 $53.75 $112.22 $247.10 $249.60 $74.23 $204.10 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000834 EAP CPT® 88275 "Fish, High-Grade LymphPanel,100-300 Cells(SO)-3" BOTH IP/OP $314.00 $232.36 $23.04 $249.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $185.73 $185.73 $53.75 $112.22 $247.10 $249.60 $74.23 $204.10 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000835 EAP CPT® 88275 "CLL Prognostic Panel, Comp,First Marker(SO)" BOTH IP/OP $130.00 $96.20 $23.04 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $76.90 $76.90 $53.75 $112.22 $102.17 $103.20 $74.23 $84.50 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000836 EAP CPT® 88184 "CLL Prognostic Panel, Comp,Add Marker(SO)-1" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $295.75 $295.75 $284.24 $133.74 $396.00 $400.00 $394.92 $0.00 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30000837 EAP CPT® 88185 "CLL Prognostic Panel, Comp,Add Marker(SO)-2" BOTH IP/OP $77.00 $56.98 $0.00 $71.72 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $45.55 $45.55 $0.00 $71.72 $60.98 $61.60 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000838 EAP CPT® 88185 "CLL Prognostic Panel,Comp,Beta-2(SO)" BOTH IP/OP $77.00 $56.98 $0.00 $71.72 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $45.55 $45.55 $0.00 $71.72 $60.98 $61.60 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000839 EAP CPT® 82232 "CLL Prognostic Panel, Comp,DNA Probe(SO)-1" BOTH IP/OP $194.00 $143.56 $0.00 $193.60 $33.40 $33.40 $16.18 $16.18 $8.09 $8.09 $24.56 $24.56 $25.51 $16.18 $23.91 $10.52 $114.75 $114.75 $16.99 $45.22 $191.66 $193.60 $23.46 $0.00 $23.46 $25.48 $16.18 $16.18 $17.83 $16.18 $0.00 $0.00 $0.00 $0.00 30000840 EAP CPT® 88271 "CLL Prognostic Panel, Comp,DNA Probe(SO)-2" BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $76.30 $76.30 $22.49 $59.86 $102.17 $103.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000841 EAP CPT® 88271 "CLL Prognostic Panel, Comp,DNA Probe(SO)-3" BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $76.30 $76.30 $22.49 $59.86 $102.17 $103.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000842 EAP CPT® 88271 "CLL Prognostic Panel, Comp,DNA Probe(SO)-4" BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $76.30 $76.30 $22.49 $59.86 $102.17 $103.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000843 EAP CPT® 88271 "CLL Prognostic Panel, Comp,DNA Probe(SO)-5" BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $76.30 $76.30 $22.49 $59.86 $102.17 $103.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000844 EAP CPT® 88271 "CLL Prognostic Panel, Comp,100-300 Cells(SO)-1" BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $76.30 $76.30 $22.49 $59.86 $102.17 $103.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30000845 EAP CPT® 88275 "CLL Prognostic Panel, Comp,100-300 Cells(SO)-2" BOTH IP/OP $129.00 $95.46 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $76.30 $76.30 $53.75 $112.22 $102.17 $103.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000846 EAP CPT® 88275 "CLL Prognostic Panel, Comp,100-300 Cells(SO)-3" BOTH IP/OP $129.00 $95.46 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $76.30 $76.30 $53.75 $112.22 $102.17 $103.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000847 EAP CPT® 88275 "CLL Prognostic Panel, Comp,100-300 Cells(SO)-4" BOTH IP/OP $129.00 $95.46 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $76.30 $76.30 $53.75 $112.22 $102.17 $103.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000848 EAP CPT® 88275 "CLL Prognostic Panel, Comp,100-300 Cells(SO)-5" BOTH IP/OP $129.00 $95.46 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $76.30 $76.30 $53.75 $112.22 $102.17 $103.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000849 EAP CPT® 88275 "CLL Lymphoma Follow-up Panel,First Marker(SO)" BOTH IP/OP $119.00 $88.06 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $70.39 $70.39 $53.75 $112.22 $94.25 $95.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30000850 EAP CPT® 88184 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-1" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $295.75 $295.75 $284.24 $133.74 $396.00 $400.00 $394.92 $0.00 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30000851 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-2" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000852 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-3" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000853 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-4" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000854 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-5" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000855 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-6" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000856 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-7" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000857 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-8" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000858 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-9" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000859 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-10" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000860 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-11" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000861 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-12" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000862 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-13" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000863 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,Add Marker(SO)-14" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000864 EAP CPT® 88185 "CLL Lymphoma Follow-up Panel,9-15 Markers(SO)" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30000865 EAP CPT® 88188 "Cll Lymphoma Follow-up Panel,9-15 Markers(so)" BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.70 $52.70 $54.73 $0.00 $71.00 $0.00 $0.00 $0.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30005065 EAP CPT® 82948 "Glu-random,wb Micro" BOTH IP/OP $251.00 $185.74 $0.00 $248.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.82 $4.82 $5.00 $0.00 $4.68 $0.00 $0.00 $0.00 $0.00 $8.86 $246.31 $248.80 $0.00 $48.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30040001 EAP CPT® 86885 Abid Ea Selected Cell (arc) BOTH IP/OP $149.00 $110.26 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.68 $8.68 $9.02 $0.00 $8.44 $0.00 $0.00 $0.00 $143.92 $15.98 $118.80 $120.00 $150.00 $96.85 $150.00 $9.00 $5.72 $5.72 $6.30 $137.07 $0.00 $0.00 $0.00 $0.00 30050138 EAP CPT® 86880 Direct Coombs BOTH IP/OP $140.00 $103.60 $2.70 $112.80 $11.11 $11.11 $54.21 $54.21 $54.51 $2.70 $8.15 $8.15 $8.47 $53.35 $7.93 $34.67 $82.81 $82.81 $33.53 $15.00 $111.67 $112.80 $46.58 $91.00 $46.58 $8.45 $5.39 $5.39 $5.91 $31.93 $0.00 $0.00 $0.00 $0.00 30050139 EAP CPT® 86880 "Dct,anti-igg" BOTH IP/OP $140.00 $103.60 $2.70 $112.80 $11.11 $11.11 $54.21 $54.21 $54.51 $2.70 $8.15 $8.15 $8.47 $53.35 $7.93 $34.67 $82.81 $82.81 $33.53 $15.00 $111.67 $112.80 $46.58 $91.00 $46.58 $8.45 $5.39 $5.39 $5.91 $31.93 $0.00 $0.00 $0.00 $0.00 30050140 EAP CPT® 86880 "Dct,anti-c3d" BOTH IP/OP $140.00 $103.60 $2.70 $112.80 $11.11 $11.11 $54.21 $54.21 $54.51 $2.70 $8.15 $8.15 $8.47 $53.35 $7.93 $34.67 $82.81 $82.81 $33.53 $15.00 $111.67 $112.80 $46.58 $91.00 $46.58 $8.45 $5.39 $5.39 $5.91 $31.93 $0.00 $0.00 $0.00 $0.00 30050141 EAP CPT® 86886 Antibody Titer BOTH IP/OP $146.00 $108.04 $2.59 $147.00 $9.58 $9.58 $145.24 $145.24 $146.00 $2.59 $7.06 $7.06 $7.33 $142.96 $6.87 $92.92 $86.36 $86.36 $143.92 $13.00 $116.42 $117.60 $147.00 $94.90 $147.00 $7.32 $5.18 $5.18 $5.12 $137.07 $0.00 $0.00 $0.00 $0.00 30050148 EAP CPT® 86900 "Blood Typing, Serologic, Abo" BOTH IP/OP $165.00 $122.10 $1.49 $150.00 $6.18 $6.18 $109.81 $109.81 $110.43 $1.49 $4.52 $4.52 $4.70 $107.30 $4.41 $69.74 $97.60 $97.60 $109.35 $8.34 $118.80 $120.00 $150.00 $107.25 $150.00 $4.70 $2.99 $2.99 $3.29 $104.14 $0.00 $0.00 $0.00 $0.00 30050149 EAP CPT® 86901 "Blood Typing, Serologic, Rh (d)" BOTH IP/OP $165.00 $122.10 $1.49 $120.00 $6.18 $6.18 $32.96 $32.96 $33.15 $1.49 $4.52 $4.52 $4.70 $32.43 $17.04 $21.08 $97.60 $97.60 $33.53 $8.34 $118.80 $120.00 $46.58 $88.40 $46.58 $18.16 $2.99 $2.99 $12.71 $31.93 $0.00 $0.00 $0.00 $0.00 30050300 EAP CPT® 80354 Fentanyl - Urine BOTH IP/OP $260.00 $192.40 $0.00 $200.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.97 $192.97 $200.41 $0.00 $54.18 $0.00 $0.00 $0.00 $0.00 $118.00 $186.91 $188.80 $0.00 $169.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050301 EAP CPT® 80324 Amphetamine - Urine BOTH IP/OP $260.00 $192.40 $0.00 $200.41 $0.00 $0.00 $0.00 $0.00 $0.00 $9.54 $192.97 $192.97 $200.41 $0.00 $22.96 $0.00 $153.79 $153.79 $0.00 $118.00 $186.91 $188.80 $141.60 $169.00 $141.60 $24.47 $0.00 $0.00 $17.13 $0.00 $0.00 $0.00 $0.00 $0.00 30050302 EAP CPT® 80307 Methaqualone - Urine BOTH IP/OP $241.00 $178.34 $29.09 $175.20 $115.05 $115.05 $62.14 $62.14 $31.07 $29.09 $79.51 $79.51 $82.57 $62.14 $71.85 $40.39 $142.55 $142.55 $65.25 $109.50 $173.45 $175.20 $90.10 $102.53 $90.10 $76.56 $62.14 $62.14 $53.59 $62.14 $0.00 $0.00 $0.00 $0.00 30050303 EAP CPT® 80367 Propoxyphene - Urine BOTH IP/OP $260.00 $192.40 $0.00 $200.41 $0.03 $0.03 $0.00 $0.00 $12.01 $11.94 $192.97 $192.97 $200.41 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $118.00 $186.91 $188.80 $0.00 $87.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050420 EAP CPT® 85347 Act BOTH IP/OP $103.00 $76.22 $2.13 $75.20 $8.79 $8.79 $4.28 $4.28 $2.14 $2.13 $6.47 $6.47 $6.72 $4.28 $6.30 $2.78 $60.92 $60.92 $4.49 $11.90 $74.45 $75.20 $6.21 $66.95 $6.21 $6.71 $4.28 $4.28 $4.70 $4.28 $0.00 $0.00 $0.00 $0.00 30050421 EAP CPT® 83018 Quantitative Screen Metals BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.34 $33.34 $34.62 $0.00 $32.43 $0.00 $0.00 $0.00 $0.00 $61.36 $166.32 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050422 EAP CPT® 84311 Spectrophotometry BOTH IP/OP $210.00 $155.40 $0.00 $209.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $207.50 $209.60 $11.75 $101.40 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30050423 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP "$1,284.00 " $950.16 $8.28 "$1,159.20" $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $759.49 $759.49 $19.32 $37.76 "$1,147.61" "$1,159.20" $26.68 $388.05 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30050424 EAP CPT® 86765 Rubeola Antibody BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $59.15 $59.15 $13.52 $36.00 $79.20 $80.00 $18.68 $0.00 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30050425 EAP CPT® 86022 Platelet Antibodies BOTH IP/OP $112.00 $82.88 $0.00 $89.60 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $66.25 $66.25 $0.00 $51.32 $88.70 $89.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050426 EAP CPT® 82480 Assay Serum Cholinesterase BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.97 $11.97 $12.43 $0.00 $11.64 $0.00 $0.00 $0.00 $0.00 $22.02 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050427 EAP CPT® 82638 Assay Of Dibucaine Number BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.60 $18.60 $19.31 $0.00 $18.09 $0.00 $0.00 $0.00 $0.00 $34.22 $38.81 $39.20 $0.00 $31.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050428 EAP CPT® 88360 Tumor Immunohistochem/manual BOTH IP/OP $911.00 $674.14 $0.00 $728.80 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $538.86 $538.86 $143.92 $121.34 $721.51 $728.80 $199.96 $0.00 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 30050435 EAP CPT® 86790 Virus Antibody Nos BOTH IP/OP $368.00 $272.32 $6.44 $268.80 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $217.67 $217.67 $13.52 $36.00 $266.11 $268.80 $18.68 $194.35 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30050436 EAP CPT® 87380 Hepatitis Delta Ag Eia BOTH IP/OP $202.00 $149.48 $0.00 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.94 $24.94 $25.90 $0.00 $24.26 $0.00 $0.00 $0.00 $0.00 $45.88 $159.98 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050437 EAP CPT® 87502 Influenza Dna Amp Probe BOTH IP/OP $627.00 $463.98 $0.00 $508.80 $107.10 $107.10 $95.80 $95.80 $47.90 $43.11 $75.96 $75.96 $78.88 $95.80 $68.64 $62.27 $370.87 $370.87 $100.59 $318.00 $503.71 $508.80 $138.91 $0.00 $138.91 $73.14 $95.80 $95.80 $51.20 $95.80 $0.00 $0.00 $0.00 $0.00 30050438 EAP CPT® 83520 Immunoassay Auant Nos Nonab BOTH IP/OP "$2,216.00 " "$1,639.84" $7.77 "$2,000.80" $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 "$1,310.76" "$1,310.76" $18.13 $36.18 "$1,980.79" "$2,000.80" $25.04 $204.75 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30050439 EAP CPT® 84145 Procalcitonin - Serum BOTH IP/OP $205.00 $151.70 $13.40 $165.60 $55.31 $55.31 $27.22 $27.22 $13.61 $13.40 $28.87 $28.87 $29.98 $27.22 $28.27 $17.69 $121.26 $121.26 $28.58 $103.50 $163.94 $165.60 $39.47 $133.25 $39.47 $30.12 $27.22 $27.22 $21.08 $27.22 $0.00 $0.00 $0.00 $0.00 30050440 EAP CPT® 85999 "Eosinophil Smear, Urine" BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $0.00 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050441 EAP HCPCS 89055 Fecal Leukocyte Smear BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $3.57 $3.70 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $6.56 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050442 EAP CPT® 87498 "Enterovirus Rna, Qual, Rt-pcr So" BOTH IP/OP $114.00 $84.36 $0.00 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.79 $29.79 $30.93 $0.00 $28.98 $0.00 $0.00 $0.00 $0.00 $54.82 $87.91 $88.80 $0.00 $74.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050443 EAP CPT® 89055 Fecal Leukocyte Smear BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $3.57 $3.70 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $6.56 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050445 EAP CPT® 81403 "JAK2-EXONS-12,13 SEQ" BOTH IP/OP $846.00 $626.04 $0.00 $773.60 $0.00 $0.00 $185.20 $185.20 $92.60 $176.33 $627.90 $627.90 $652.10 $185.20 $174.05 $120.38 $500.41 $500.41 $194.46 $483.50 $765.86 $773.60 $268.54 $0.00 $268.54 $235.32 $185.20 $185.20 $164.72 $185.20 $0.00 $0.00 $0.00 $0.00 30050446 EAP CPT® 86021 Proteinase -3 Antibody (so) BOTH IP/OP $163.00 $120.62 $7.53 $120.00 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $96.41 $96.41 $15.80 $42.06 $118.80 $120.00 $21.82 $105.95 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30050447 EAP CPT® 81261 "B-cell Recep Igh Gene Rearrangement , Pcr (so)" BOTH IP/OP $607.00 $449.18 $0.00 $555.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.91 $280.91 $291.72 $0.00 $286.64 $0.00 $0.00 $0.00 $0.00 $347.00 $549.65 $555.20 $0.00 $0.00 $0.00 $305.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050448 EAP CPT® 81264 "B-cell Recep Igk Gene Rearrangement , Pcr (so)" BOTH IP/OP $607.00 $449.18 $0.00 $555.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.87 $211.87 $220.02 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $347.00 $549.65 $555.20 $0.00 $0.00 $0.00 $123.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050449 EAP CPT® 88271 MOLECULAR CYTOGENETICS; DNA PROBE( FISH) (SO) BOTH IP/OP "$1,071.00 " $792.54 $10.71 $851.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $633.50 $633.50 $22.49 $59.86 $842.69 $851.20 $31.06 $380.25 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30050450 EAP CPT® 88274 Interphase In Situ Hybridization (25-99) Cells (so) BOTH IP/OP $537.00 $397.38 $0.00 $426.40 $0.00 $0.00 $0.00 $0.00 $0.00 $19.07 $52.85 $52.85 $54.89 $42.38 $51.42 $27.55 $317.64 $317.64 $44.50 $97.26 $422.14 $426.40 $61.45 $349.05 $61.45 $54.79 $42.38 $42.38 $38.35 $42.38 $0.00 $0.00 $0.00 $0.00 30050451 EAP CPT® 81342 "T - Cell Receptor Gamma Gene Rearrangement, Pcr (so)" BOTH IP/OP "$1,177.00 " $870.98 $0.00 $930.40 $415.93 $415.93 $201.50 $201.50 $100.75 $100.75 $285.90 $285.90 $296.89 $201.50 $192.65 $130.98 $696.20 $696.20 $0.00 $581.50 $921.10 $930.40 $0.00 $332.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050452 EAP CPT® 88271 Molecular Cytogenetics; Dna Probe( Fish) (so) BOTH IP/OP $504.00 $372.96 $10.71 $400.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $298.12 $298.12 $22.49 $59.86 $396.79 $400.80 $31.06 $327.60 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30050454 EAP CPT® 88271 MOLECULAR CYTOGENETICS; DNA PROBE( FISH) (SO) BOTH IP/OP $559.00 $413.66 $10.71 $444.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $330.65 $330.65 $22.49 $59.86 $439.56 $444.00 $31.06 $363.35 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30050455 EAP CPT® 88275 INTERPHASE IN SITU HYBRIDIZATION (100-300) CELLS (SO) BOTH IP/OP $280.00 $207.20 $23.04 $222.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $165.62 $165.62 $53.75 $112.22 $220.18 $222.40 $74.23 $182.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30050456 EAP CPT® 81331 "Prader-willi/angelman Syndrome , Dna Methylation (so)" BOTH IP/OP $588.00 $435.12 $0.00 $537.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $436.41 $436.41 $453.23 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $336.00 $532.22 $537.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050457 EAP CPT® 88275 Interphase In Situ Hybridization (100-300) Cells (so) BOTH IP/OP $253.00 $187.22 $23.04 $200.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $149.65 $149.65 $53.75 $112.22 $198.79 $200.80 $74.23 $164.45 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30050458 EAP CPT® 88271 MOLECULAR CYTOGENETICS; DNA PROBE( FISH) (SO) BOTH IP/OP $481.00 $355.94 $10.71 $382.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $284.51 $284.51 $22.49 $59.86 $378.58 $382.40 $31.06 $312.65 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30050459 EAP CPT® 88275 INTERPHASE IN SITU HYBRIDIZATION (100-300) CELLS (SO) BOTH IP/OP $242.00 $179.08 $23.04 $192.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $143.14 $143.14 $53.75 $112.22 $190.08 $192.00 $74.23 $157.30 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30050460 EAP CPT® 88271 Molecular Cytogenetics; Dna Probe( Fish) (so)cml BOTH IP/OP $481.00 $355.94 $10.71 $382.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $284.51 $284.51 $22.49 $59.86 $378.58 $382.40 $31.06 $312.65 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30050461 EAP CPT® 88275 Interphase In Situ Hybridization (100-300) Cells (so)cml BOTH IP/OP $242.00 $179.08 $23.04 $192.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $143.14 $143.14 $53.75 $112.22 $190.08 $192.00 $74.23 $157.30 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30050462 EAP CPT® 81315 Pml/rara T(15;17) Quant (pcr) (so) BOTH IP/OP $771.00 $570.54 $0.00 $771.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $294.14 $294.14 $305.46 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $381.00 $603.50 $609.60 $0.00 $771.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050463 EAP CPT® 81210 Braf Mutation Analysis (so) BOTH IP/OP "$1,079.00 " $798.46 $78.93 $852.80 $271.21 $271.21 $175.40 $175.40 $87.70 $78.93 $186.42 $186.42 $193.59 $175.40 $115.59 $114.01 $638.23 $638.23 $184.17 $533.00 $844.27 $852.80 $254.33 $289.41 $254.33 $123.17 $175.40 $175.40 $86.22 $175.40 $0.00 $0.00 $0.00 $0.00 30050464 EAP CPT® 82172 Apoliprotein (so) BOTH IP/OP $57.00 $42.18 $9.49 $45.60 $32.00 $32.00 $21.09 $21.09 $10.55 $9.49 $23.52 $23.52 $24.43 $21.09 $22.90 $13.71 $33.72 $33.72 $22.14 $43.30 $45.14 $45.60 $30.58 $37.05 $30.58 $24.40 $21.09 $21.09 $17.08 $21.09 $0.00 $0.00 $0.00 $0.00 30050465 EAP CPT® 86738 "Mycoplasma Pneumoniae Antibody (igg), Ifa, Csf (so)" BOTH IP/OP $95.00 $70.30 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 $6.62 $20.11 $20.11 $20.89 $13.24 $19.57 $8.61 $56.19 $56.19 $13.90 $37.02 $77.62 $78.40 $19.20 $0.00 $19.20 $20.85 $13.24 $13.24 $14.60 $13.24 $0.00 $0.00 $0.00 $0.00 30050466 EAP CPT® 81401 Cbfb/myh11 Inv(16) Quant Pcr (so) BOTH IP/OP $648.00 $479.52 $61.65 $512.00 $64.94 $64.94 $137.00 $137.00 $68.50 $61.65 $480.95 $480.95 $499.48 $137.00 $131.58 $89.05 $383.29 $383.29 $143.85 $320.00 $506.88 $512.00 $198.65 $226.05 $198.65 $140.20 $137.00 $137.00 $98.14 $137.00 $0.00 $0.00 $0.00 $0.00 30050467 EAP CPT® 81404 C-kit Mutation Analysis (so) BOTH IP/OP "$2,106.00 " "$1,558.44" $123.67 "$1,664.00" $462.00 $462.00 $274.83 $274.83 $137.42 $123.67 "$1,563.07" "$1,563.07" "$1,623.30" $274.83 $286.64 $178.64 "$1,245.70" "$1,245.70" $288.57 "$1,040.00" "$1,647.36" "$1,664.00" $398.50 $453.47 $398.50 $305.42 $274.83 $274.83 $213.79 $274.83 $0.00 $0.00 $0.00 $0.00 30050468 EAP CPT® 87798 "Bordetella Pertussis/parapertussis Dna, Pcr (so)" BOTH IP/OP $470.00 $347.80 $0.00 $452.80 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $278.01 $278.01 $36.84 $54.82 $448.27 $452.80 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30050469 EAP CPT® 86255 "Nmda- Receptor Antibody , Csf(mayo)" BOTH IP/OP $371.00 $274.54 $6.03 $371.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $219.45 $219.45 $12.65 $33.68 $367.49 $371.20 $17.47 $167.70 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050470 EAP CPT® 87661 "Trichomonas Vaginalis Rna, Qualitative, Tma (so)" BOTH IP/OP $153.00 $113.22 $0.00 $122.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $27.84 $27.84 $28.91 $35.09 $25.16 $22.81 $90.50 $90.50 $36.84 $76.50 $121.18 $122.40 $50.88 $0.00 $50.88 $26.81 $35.09 $35.09 $18.76 $35.09 $0.00 $0.00 $0.00 $0.00 30050471 EAP CPT® 86256 Agna-1 (mayo) BOTH IP/OP $86.00 $63.64 $0.00 $86.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $50.87 $50.87 $12.65 $33.68 $85.54 $86.40 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050472 EAP CPT® 86256 Amphiphysin (mayo) BOTH IP/OP $56.00 $41.44 $0.00 $56.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $33.12 $33.12 $12.65 $33.68 $55.44 $56.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050473 EAP CPT® 86256 Anna-1 (mayo) BOTH IP/OP $56.00 $41.44 $0.00 $56.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $33.12 $33.12 $12.65 $33.68 $55.44 $56.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050474 EAP CPT® 86256 Anna-2 (mayo) BOTH IP/OP $56.00 $41.44 $0.00 $56.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $33.12 $33.12 $12.65 $33.68 $55.44 $56.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050475 EAP CPT® 86256 Anna-3 (mayo) BOTH IP/OP $56.00 $41.44 $0.00 $56.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $33.12 $33.12 $12.65 $33.68 $55.44 $56.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050476 EAP CPT® 86256 Crmp-5-igg BOTH IP/OP $56.00 $41.44 $0.00 $56.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $33.12 $33.12 $12.65 $33.68 $55.44 $56.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050477 EAP CPT® 86256 Pca-1 (mayo) BOTH IP/OP $56.00 $41.44 $0.00 $56.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $33.12 $33.12 $12.65 $33.68 $55.44 $56.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050478 EAP CPT® 86256 Pca-2 (mayo) BOTH IP/OP $56.00 $41.44 $0.00 $56.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $33.12 $33.12 $12.65 $33.68 $55.44 $56.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050479 EAP CPT® 86256 Pca-tr (mayo) BOTH IP/OP $56.00 $41.44 $0.00 $56.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $33.12 $33.12 $12.65 $33.68 $55.44 $56.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050481 EAP CPT® 87912 "Hepatitis B Virus Drug Resistance, Genotype (so)" BOTH IP/OP $600.00 $444.00 $0.00 $484.80 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $373.52 $373.52 $387.88 $257.45 $112.65 $167.34 $354.90 $354.90 $0.00 $303.00 $479.95 $484.80 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050482 EAP CPT® 81402 "Follicular Lymphoma, Pcr (so)" BOTH IP/OP "$1,042.00 " $771.08 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $773.37 $773.37 $803.17 $0.00 $192.65 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050483 EAP CPT® 81401 "Mantle Cell Lymphoma, Pcr (so)" BOTH IP/OP "$1,163.00 " $860.62 $61.65 "$1,063.20" $64.94 $64.94 $137.00 $137.00 $68.50 $61.65 $863.18 $863.18 $896.44 $137.00 $131.58 $89.05 $687.91 $687.91 $143.85 $664.50 "$1,052.57" "$1,063.20" $198.65 $226.05 $198.65 $140.20 $137.00 $137.00 $98.14 $137.00 $0.00 $0.00 $0.00 $0.00 30050484 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Nhl BOTH IP/OP $514.00 $380.36 $10.71 $408.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $304.03 $304.03 $22.49 $59.86 $404.71 $408.80 $31.06 $334.10 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30050485 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Nhl BOTH IP/OP $258.00 $190.92 $23.04 $204.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $152.61 $152.61 $53.75 $112.22 $202.75 $204.80 $74.23 $167.70 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30050486 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Fol BOTH IP/OP $617.00 $456.58 $10.71 $490.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $364.96 $364.96 $22.49 $59.86 $485.50 $490.40 $31.06 $380.25 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30050487 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Fol BOTH IP/OP $309.00 $228.66 $23.04 $245.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $182.77 $182.77 $53.75 $112.22 $243.14 $245.60 $74.23 $200.85 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30050488 EAP CPT® 83520 Ganglioside Gq1b Antibody (igg)(so) BOTH IP/OP $296.00 $219.04 $7.77 $230.40 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $175.08 $175.08 $18.13 $36.18 $228.10 $230.40 $25.04 $192.40 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30050489 EAP CPT® 81210 "Melanoma, Braf V600 Mutation (so)" BOTH IP/OP "$1,482.00 " "$1,096.68" $78.93 "$1,171.20" $271.21 $271.21 $175.40 $175.40 $87.70 $78.93 $186.42 $186.42 $193.59 $175.40 $115.59 $114.01 $876.60 $876.60 $184.17 $732.00 "$1,159.49" "$1,171.20" $254.33 $289.41 $254.33 $123.17 $175.40 $175.40 $86.22 $175.40 $0.00 $0.00 $0.00 $0.00 30050490 EAP CPT® 81404 "Nras, Mutation Analysis (so)" BOTH IP/OP $771.00 $570.54 $123.67 $609.60 $462.00 $462.00 $274.83 $274.83 $137.42 $123.67 $572.24 $572.24 $594.29 $274.83 $286.64 $178.64 $456.05 $456.05 $288.57 $381.00 $603.50 $609.60 $398.50 $453.47 $398.50 $305.42 $274.83 $274.83 $213.79 $274.83 $0.00 $0.00 $0.00 $0.00 30050491 EAP CPT® 83520 Interleukin -2 (il-2) (so) BOTH IP/OP $284.00 $210.16 $0.00 $256.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $167.99 $167.99 $18.13 $36.18 $254.23 $256.80 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30050492 EAP CPT® 86255 Nmo/aqp4-igg Cba (mayo) BOTH IP/OP $55.00 $40.70 $0.00 $55.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $32.53 $32.53 $12.65 $33.68 $54.65 $55.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050493 EAP CPT® 86341 Gad65 Abs (mayo) BOTH IP/OP $66.00 $48.84 $0.00 $55.30 $40.84 $40.84 $23.57 $23.57 $11.79 $10.61 $30.05 $30.05 $31.20 $23.57 $29.24 $15.32 $39.04 $39.04 $24.75 $55.30 $52.27 $52.80 $34.18 $0.00 $34.18 $31.16 $23.57 $23.57 $21.81 $23.57 $0.00 $0.00 $0.00 $0.00 30050495 EAP CPT® 86255 "Nmo/aqp4-igg Cba, Csf (mayo)" BOTH IP/OP $462.00 $341.88 $6.03 $462.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $273.27 $273.27 $12.65 $33.68 $457.78 $462.40 $17.47 $167.70 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050496 EAP CPT® 81170 Abl Kinase Domain Mutation In Cml (so) BOTH IP/OP "$1,150.00 " $851.00 $0.00 "$1,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $135.00 $342.69 $342.69 $355.87 $300.00 $309.68 $195.00 $680.23 $680.23 $315.00 $568.00 $899.71 $908.80 $435.00 "$1,150.00" $435.00 $329.97 $300.00 $300.00 $230.98 $300.00 $0.00 $0.00 $0.00 $0.00 30050497 EAP CPT® 86003 Allergen Specific (mold Group) BOTH IP/OP $247.00 $182.78 $2.61 $199.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $146.10 $146.10 $5.48 $14.60 $197.21 $199.20 $7.57 $64.35 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30050500 EAP CPT® 80361 Monacetylmorphine-free-6 BOTH IP/OP $516.00 $381.84 $0.00 $436.80 $0.03 $0.03 $0.00 $0.00 $12.01 $11.94 $382.98 $382.98 $397.73 $0.00 $30.51 $0.00 $305.21 $305.21 $0.00 $273.00 $432.43 $436.80 $327.60 $269.10 $327.60 $32.51 $0.00 $0.00 $22.76 $0.00 $0.00 $0.00 $0.00 $0.00 30050501 EAP CPT® 87902 Hepatits C Viral Rna Ns3 Genotype (so) BOTH IP/OP "$1,252.00 " $926.48 $0.00 "$1,035.20" $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $740.56 $740.56 $270.32 $243.70 "$1,024.85" "$1,035.20" $373.30 $0.00 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30050503 EAP CPT® 88342 Platelet Function Plavix( Clopidogrel) BOTH IP/OP $326.00 $241.24 $11.21 $236.80 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $192.83 $192.83 $143.92 $106.46 $234.43 $236.80 $199.96 $211.90 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 30050520 EAP CPT® 86361 T Cell; Absolute Cd4 Count BOTH IP/OP $114.00 $84.36 $13.39 $92.00 $53.91 $53.91 $26.78 $26.78 $13.39 $13.39 $39.63 $39.63 $41.16 $26.78 $38.56 $17.41 $67.43 $67.43 $28.12 $72.94 $91.08 $92.00 $38.83 $74.10 $38.83 $41.08 $26.78 $26.78 $28.76 $26.78 $0.00 $0.00 $0.00 $0.00 30050521 EAP CPT® 85004 Automated Differential Wbc Count BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.83 $9.83 $10.21 $0.00 $9.57 $0.00 $0.00 $0.00 $0.00 $18.08 $65.74 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30050550 EAP CPT® 83520 Phospholipase A2 Ab Quant (so) BOTH IP/OP $424.00 $313.76 $7.77 $329.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $250.80 $250.80 $18.13 $36.18 $326.30 $329.60 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30050560 EAP CPT® 86255 Phospholipase A2 Scrn (so) BOTH IP/OP $263.00 $194.62 $6.03 $210.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $155.56 $155.56 $12.65 $33.68 $208.30 $210.40 $17.47 $167.70 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30050561 EAP CPT® 81162 Brca1&2 Seq & Full Dup/del (so) BOTH IP/OP "$3,730.00 " "$2,760.20" $912.44 "$3,730.00" "$3,730.00" "$3,730.00" "$1,824.88" "$1,824.88" $912.44 $912.44 "$2,585.29" "$2,585.29" "$2,684.73" "$1,824.88" "$2,336.20" "$1,186.17" "$2,206.30" "$2,206.30" "$1,916.12" "$1,842.50" "$2,918.52" "$2,948.00" "$2,646.08" "$3,011.05" "$2,646.08" "$2,489.27" "$1,824.88" "$1,824.88" "$1,742.49" "$1,824.88" $0.00 $0.00 $0.00 $0.00 30050562 EAP HCPCS C9803 Op Specimen Collection For (sars-cov-2) Covid-19 BOTH IP/OP $57.00 $42.18 $0.00 $57.00 $30.95 $30.95 $24.06 $24.06 $24.19 $22.38 $42.31 $42.31 $41.31 $23.64 $22.38 $15.37 $33.72 $33.72 $23.06 $28.50 $45.14 $45.60 $32.04 $57.00 $32.04 $8.92 $0.00 $0.00 $9.07 $21.96 $0.00 $0.00 $0.00 $0.00 30100001 EAP CPT® 80299 Oxycarbazepine So BOTH IP/OP $122.00 $90.28 $8.39 $97.60 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $72.16 $72.16 $19.57 $33.64 $96.62 $97.60 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100003 EAP CPT® 80051 "Chem 4, Electrolyte Panel" BOTH IP/OP $228.00 $168.72 $3.51 $184.00 $14.47 $14.47 $7.01 $7.01 $3.51 $3.51 $10.65 $10.65 $11.06 $7.01 $10.36 $4.56 $134.86 $134.86 $7.36 $19.60 $182.16 $184.00 $10.16 $11.57 $10.16 $11.04 $7.01 $7.01 $7.73 $7.01 $0.00 $0.00 $0.00 $0.00 30100005 EAP CPT® 80053 "Comprehensive Metabolic Panel, Evd" BOTH IP/OP $472.00 $349.28 $0.00 $381.60 $21.81 $21.81 $10.56 $10.56 $5.28 $5.28 $16.06 $16.06 $16.68 $10.56 $15.61 $6.86 $279.19 $279.19 $11.09 $29.54 $377.78 $381.60 $15.31 $0.00 $15.31 $16.64 $10.56 $10.56 $11.65 $10.56 $0.00 $0.00 $0.00 $0.00 30100006 EAP CPT® 80047 "Basic Metabolic Panel, Evd" BOTH IP/OP $370.00 $273.80 $0.00 $299.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.85 $12.85 $13.35 $0.00 $32.26 $0.00 $0.00 $0.00 $0.00 $187.00 $296.21 $299.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100007 EAP CPT® 80061 "Chem 3, Lipid Panel" BOTH IP/OP $282.00 $208.68 $6.70 $228.00 $27.64 $27.64 $13.39 $13.39 $6.70 $6.70 $20.35 $20.35 $21.14 $13.39 $19.79 $8.70 $166.80 $166.80 $14.06 $37.44 $225.72 $228.00 $19.42 $22.09 $19.42 $21.09 $13.39 $13.39 $14.76 $13.39 $0.00 $0.00 $0.00 $0.00 30100008 EAP CPT® 80069 "RENAL FUNCTION PANEL, EVD" BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $17.93 $17.93 $8.68 $8.68 $4.34 $4.34 $13.19 $13.19 $13.69 $8.68 $12.83 $5.64 $136.05 $136.05 $9.11 $24.26 $182.16 $184.00 $12.59 $0.00 $12.59 $13.67 $8.68 $8.68 $9.57 $8.68 $0.00 $0.00 $0.00 $0.00 30100009 EAP CPT® 80069 Renal Panel BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $17.93 $17.93 $8.68 $8.68 $4.34 $4.34 $13.19 $13.19 $13.69 $8.68 $12.83 $5.64 $136.05 $136.05 $9.11 $24.26 $182.16 $184.00 $12.59 $0.00 $12.59 $13.67 $8.68 $8.68 $9.57 $8.68 $0.00 $0.00 $0.00 $0.00 30100010 EAP CPT® 83986 "Ph, Misc Fluids" BOTH IP/OP $70.00 $51.80 $0.00 $51.20 $7.39 $7.39 $3.58 $3.58 $1.79 $1.79 $5.43 $5.43 $5.64 $3.58 $5.28 $2.33 $41.41 $41.41 $3.76 $10.00 $50.69 $51.20 $5.19 $5.91 $5.19 $0.00 $3.58 $3.58 $3.94 $3.58 $0.00 $0.00 $0.00 $0.00 30100011 EAP CPT® 80076 HEPATIC PROFILE BOTH IP/OP $333.00 $246.42 $4.09 $266.40 $16.87 $16.87 $8.17 $8.17 $4.09 $4.09 $12.41 $12.41 $12.88 $8.17 $12.08 $5.31 $196.97 $196.97 $8.58 $22.84 $263.74 $266.40 $11.85 $13.48 $11.85 $12.87 $8.17 $8.17 $9.01 $8.17 $0.00 $0.00 $0.00 $0.00 30100013 EAP CPT® 80346 Clonazepam/klonopin BOTH IP/OP $238.00 $176.12 $0.00 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100014 EAP CPT® 80197 Tacrolimus BOTH IP/OP $393.00 $290.82 $0.00 $393.00 $28.35 $28.35 $13.73 $13.73 $6.87 $0.00 $20.84 $20.84 $21.64 $0.00 $20.27 $0.00 $0.00 $0.00 $14.42 $38.34 $311.26 $314.40 $19.91 $393.00 $19.91 $21.59 $13.73 $13.73 $15.11 $13.73 $0.00 $0.00 $0.00 $0.00 30100015 EAP CPT® 80299 "Digitoxin, Serum" BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $128.95 $128.95 $19.57 $33.64 $172.66 $174.40 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100016 EAP CPT® 80299 Felbamate-random BOTH IP/OP $217.00 $160.58 $0.00 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.06 $161.06 $167.26 $0.00 $17.51 $0.00 $0.00 $0.00 $19.57 $33.64 $172.66 $174.40 $27.03 $56.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100017 EAP CPT® 80299 Bupropion/wellbutrin BOTH IP/OP $217.00 $160.58 $8.39 $174.40 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $128.36 $128.36 $19.57 $33.64 $172.66 $174.40 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100018 EAP CPT® 80307 Acetaminophen BOTH IP/OP $585.00 $432.90 $29.09 $425.60 $115.05 $115.05 $62.14 $62.14 $31.07 $29.09 $79.51 $79.51 $82.57 $62.14 $71.85 $40.39 $346.03 $346.03 $65.25 $266.00 $421.34 $425.60 $90.10 $102.53 $90.10 $76.56 $62.14 $62.14 $53.59 $62.14 $0.00 $0.00 $0.00 $0.00 30100019 EAP CPT® 80076 "Hepatic Function Panel, Evd" BOTH IP/OP $333.00 $246.42 $4.09 $266.40 $16.87 $16.87 $8.17 $8.17 $4.09 $4.09 $12.41 $12.41 $12.88 $8.17 $12.08 $5.31 $196.97 $196.97 $8.58 $22.84 $263.74 $266.40 $11.85 $13.48 $11.85 $12.87 $8.17 $8.17 $9.01 $8.17 $0.00 $0.00 $0.00 $0.00 30100020 EAP CPT® 82009 ACETOACETATE-QUALITATIVE BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.99 $4.99 $5.18 $0.00 $4.85 $0.00 $0.00 $0.00 $0.00 $9.18 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100021 EAP CPT® 82010 B-oh Butyric Acid BOTH IP/OP $192.00 $142.08 $4.09 $155.20 $16.87 $16.87 $8.17 $8.17 $4.09 $4.09 $12.41 $12.41 $12.88 $8.17 $12.08 $5.31 $113.57 $113.57 $8.58 $22.84 $153.65 $155.20 $11.85 $13.48 $11.85 $12.87 $8.17 $8.17 $9.01 $8.17 $0.00 $0.00 $0.00 $0.00 30100022 EAP CPT® 82024 "Acth, Plasma" BOTH IP/OP $461.00 $341.14 $19.31 $372.80 $79.73 $79.73 $38.62 $38.62 $19.31 $19.31 $58.66 $58.66 $60.91 $38.62 $57.06 $25.10 $272.68 $272.68 $40.55 $107.94 $369.07 $372.80 $56.00 $63.72 $56.00 $60.80 $38.62 $38.62 $42.56 $38.62 $0.00 $0.00 $0.00 $0.00 30100023 EAP CPT® 82040 Albumin (bcg) BOTH IP/OP $75.00 $55.50 $2.48 $60.80 $5.94 $5.94 $4.95 $4.95 $2.48 $2.48 $4.37 $4.37 $4.54 $4.95 $4.25 $3.22 $44.36 $44.36 $5.20 $8.04 $60.19 $60.80 $7.18 $8.17 $7.18 $4.53 $4.95 $4.95 $3.17 $4.95 $0.00 $0.00 $0.00 $0.00 30100024 EAP CPT® 82042 "Albumin,fluid" BOTH IP/OP $128.00 $94.72 $3.50 $103.20 $10.69 $10.69 $7.78 $7.78 $3.89 $3.50 $7.86 $7.86 $8.16 $7.78 $7.64 $5.06 $75.71 $75.71 $8.17 $14.46 $102.17 $103.20 $11.28 $12.84 $11.28 $8.14 $7.78 $7.78 $5.70 $7.78 $0.00 $0.00 $0.00 $0.00 30100025 EAP CPT® 82043 "Microalbumin, Ur" BOTH IP/OP $222.00 $164.28 $2.89 $179.20 $11.93 $11.93 $5.78 $5.78 $2.89 $2.89 $8.79 $8.79 $9.13 $5.78 $8.55 $3.76 $131.31 $131.31 $6.07 $16.18 $177.41 $179.20 $8.38 $9.54 $8.38 $9.11 $5.78 $5.78 $6.37 $5.78 $0.00 $0.00 $0.00 $0.00 30100026 EAP CPT® 83615 "Lactate Dehydrogenase (ldh), Evd" BOTH IP/OP $139.00 $102.86 $0.00 $111.20 $12.46 $12.46 $6.04 $6.04 $3.02 $3.02 $9.16 $9.16 $9.51 $6.04 $7.46 $3.93 $82.22 $82.22 $6.34 $16.88 $110.09 $111.20 $8.76 $0.00 $8.76 $7.94 $6.04 $6.04 $5.56 $6.04 $0.00 $0.00 $0.00 $0.00 30100027 EAP CPT® 80320 Ethanol BOTH IP/OP $399.00 $295.26 $0.03 $307.55 $0.03 $0.03 $114.43 $114.43 $57.22 $6.63 $296.14 $296.14 $307.55 $114.43 $15.96 $74.38 $236.01 $236.01 $120.15 $181.50 $287.50 $290.40 $217.80 $188.81 $217.80 $17.01 $114.43 $114.43 $11.90 $114.43 $0.00 $0.00 $0.00 $0.00 30100028 EAP CPT® 82085 "Aldolase, Serum" BOTH IP/OP $122.00 $90.28 $4.86 $97.60 $20.04 $20.04 $9.71 $9.71 $4.86 $4.86 $14.74 $14.74 $15.30 $9.71 $14.33 $6.31 $72.16 $72.16 $10.20 $27.12 $96.62 $97.60 $14.08 $16.02 $14.08 $15.27 $9.71 $9.71 $10.69 $9.71 $0.00 $0.00 $0.00 $0.00 30100029 EAP CPT® 82088 "Aldosterone, Serum" BOTH IP/OP $177.00 $130.98 $20.38 $141.60 $84.11 $84.11 $40.75 $40.75 $20.38 $20.38 $61.88 $61.88 $64.26 $40.75 $60.21 $26.49 $104.70 $104.70 $42.79 $113.88 $140.18 $141.60 $59.09 $67.24 $59.09 $64.15 $40.75 $40.75 $44.91 $40.75 $0.00 $0.00 $0.00 $0.00 30100030 EAP CPT® 82088 "Aldosterone, Ur-24hr" BOTH IP/OP $177.00 $130.98 $20.38 $141.60 $84.11 $84.11 $40.75 $40.75 $20.38 $20.38 $61.88 $61.88 $64.26 $40.75 $60.21 $26.49 $104.70 $104.70 $42.79 $113.88 $140.18 $141.60 $59.09 $67.24 $59.09 $64.15 $40.75 $40.75 $44.91 $40.75 $0.00 $0.00 $0.00 $0.00 30100031 EAP CPT® 82103 Alpha-1-antitrypsin BOTH IP/OP $299.00 $221.26 $6.72 $240.80 $27.75 $27.75 $13.44 $13.44 $6.72 $6.72 $20.39 $20.39 $21.18 $13.44 $19.85 $8.74 $176.86 $176.86 $14.11 $37.54 $238.39 $240.80 $19.49 $22.18 $19.49 $21.15 $13.44 $13.44 $14.80 $13.44 $0.00 $0.00 $0.00 $0.00 30100032 EAP CPT® 82104 Alpha-1 At Phenotype BOTH IP/OP $137.00 $101.38 $0.00 $137.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.95 $21.95 $22.80 $0.00 $21.36 $0.00 $0.00 $0.00 $0.00 $40.40 $109.30 $110.40 $0.00 $137.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100033 EAP CPT® 82105 Alpha-fetoprotein BOTH IP/OP $258.00 $190.92 $0.00 $206.40 $34.64 $34.64 $16.77 $16.77 $8.39 $8.39 $25.47 $25.47 $26.45 $16.77 $24.79 $10.90 $152.61 $152.61 $17.61 $46.88 $204.34 $206.40 $24.32 $0.00 $24.32 $26.41 $16.77 $16.77 $18.49 $16.77 $0.00 $0.00 $0.00 $0.00 30100034 EAP CPT® 82105 "Afp,maternal Serum" BOTH IP/OP $239.00 $176.86 $0.00 $191.20 $34.64 $34.64 $16.77 $16.77 $8.39 $8.39 $25.47 $25.47 $26.45 $16.77 $24.79 $10.90 $141.37 $141.37 $17.61 $46.88 $189.29 $191.20 $24.32 $0.00 $24.32 $26.41 $16.77 $16.77 $18.49 $16.77 $0.00 $0.00 $0.00 $0.00 30100035 EAP CPT® 82105 Alpha-fetoprotein BOTH IP/OP $257.00 $190.18 $8.39 $206.40 $34.64 $34.64 $16.77 $16.77 $8.39 $8.39 $25.47 $25.47 $26.45 $16.77 $24.79 $10.90 $152.02 $152.02 $17.61 $46.88 $204.34 $206.40 $24.32 $27.67 $24.32 $26.41 $16.77 $16.77 $18.49 $16.77 $0.00 $0.00 $0.00 $0.00 30100036 EAP CPT® 82106 "Afp, Amniotic Fluid" BOTH IP/OP $238.00 $176.12 $0.00 $191.20 $34.64 $34.64 $17.00 $17.00 $8.50 $0.00 $25.47 $25.47 $26.45 $0.00 $24.79 $0.00 $0.00 $0.00 $17.85 $46.88 $189.29 $191.20 $24.65 $28.05 $24.65 $26.41 $17.00 $17.00 $18.49 $17.00 $0.00 $0.00 $0.00 $0.00 30100037 EAP CPT® 82108 Aluminum BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $34.80 $34.80 $25.48 $25.48 $12.74 $12.74 $25.59 $25.59 $26.58 $25.48 $24.91 $16.56 $52.05 $52.05 $26.75 $47.10 $69.70 $70.40 $36.95 $42.04 $36.95 $0.00 $25.48 $25.48 $18.58 $25.48 $0.00 $0.00 $0.00 $0.00 30100038 EAP CPT® 82128 "Metabolic Screen,ur" BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.05 $21.05 $21.86 $0.00 $20.48 $0.00 $0.00 $0.00 $0.00 $38.74 $220.18 $222.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100039 EAP CPT® 82128 "Amino Acid-scn,urine" BOTH IP/OP $278.00 $205.72 $0.00 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.05 $21.05 $21.86 $0.00 $20.48 $0.00 $0.00 $0.00 $0.00 $38.74 $220.18 $222.40 $0.00 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100040 EAP CPT® 82131 Homocysteine BOTH IP/OP $158.00 $116.92 $10.34 $126.40 $34.82 $34.82 $22.98 $22.98 $11.49 $10.34 $25.62 $25.62 $26.60 $22.98 $24.92 $14.94 $93.46 $93.46 $24.13 $47.14 $125.14 $126.40 $33.32 $37.92 $33.32 $26.55 $22.98 $22.98 $18.58 $22.98 $0.00 $0.00 $0.00 $0.00 30100041 EAP CPT® 82131 "Cystine, Urine-24hr" BOTH IP/OP $165.00 $122.10 $10.34 $132.00 $34.82 $34.82 $22.98 $22.98 $11.49 $10.34 $25.62 $25.62 $26.60 $22.98 $24.92 $14.94 $97.60 $97.60 $24.13 $47.14 $130.68 $132.00 $33.32 $37.92 $33.32 $26.55 $22.98 $22.98 $18.58 $22.98 $0.00 $0.00 $0.00 $0.00 30100042 EAP CPT® 82139 "Amino Acids-qnt,plas" BOTH IP/OP $490.00 $362.60 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $388.08 $392.00 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100043 EAP CPT® 82139 Amino Acids - Qnt BOTH IP/OP $490.00 $362.60 $0.00 $392.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $388.08 $392.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100044 EAP CPT® 82140 "Ammonia,blood" BOTH IP/OP $317.00 $234.58 $7.29 $253.60 $20.41 $20.41 $14.57 $14.57 $7.29 $7.29 $15.02 $15.02 $15.60 $14.57 $14.62 $9.47 $187.51 $187.51 $15.30 $27.64 $251.06 $253.60 $21.13 $24.04 $21.13 $15.57 $14.57 $14.57 $10.90 $14.57 $0.00 $0.00 $0.00 $0.00 30100045 EAP CPT® 83605 "Lactate ( Lactic Acid),evd" BOTH IP/OP $258.00 $190.92 $5.34 $248.80 $22.04 $22.04 $11.57 $11.57 $5.79 $5.34 $16.21 $16.21 $16.84 $11.57 $15.78 $7.52 $152.61 $152.61 $12.15 $29.84 $246.31 $248.80 $16.78 $19.09 $16.78 $16.82 $11.57 $11.57 $11.77 $11.57 $0.00 $0.00 $0.00 $0.00 30100046 EAP CPT® 82150 "Amylase,serum" BOTH IP/OP $301.00 $222.74 $3.24 $243.20 $13.38 $13.38 $6.48 $6.48 $3.24 $3.24 $9.84 $9.84 $10.22 $6.48 $9.58 $4.21 $178.04 $178.04 $6.80 $18.12 $240.77 $243.20 $9.40 $10.69 $9.40 $10.20 $6.48 $6.48 $7.14 $6.48 $0.00 $0.00 $0.00 $0.00 30100047 EAP CPT® 82150 "Amylase,fluid" BOTH IP/OP $301.00 $222.74 $3.24 $243.20 $13.38 $13.38 $6.48 $6.48 $3.24 $3.24 $9.84 $9.84 $10.22 $6.48 $9.58 $4.21 $178.04 $178.04 $6.80 $18.12 $240.77 $243.20 $9.40 $10.69 $9.40 $10.20 $6.48 $6.48 $7.14 $6.48 $0.00 $0.00 $0.00 $0.00 30100048 EAP CPT® 82150 "AMYLASE,URINE" BOTH IP/OP $283.00 $209.42 $3.24 $243.20 $13.38 $13.38 $6.48 $6.48 $3.24 $3.24 $9.84 $9.84 $10.22 $6.48 $9.58 $4.21 $167.39 $167.39 $6.80 $18.12 $240.77 $243.20 $9.40 $10.69 $9.40 $10.20 $6.48 $6.48 $7.14 $6.48 $0.00 $0.00 $0.00 $0.00 30100049 EAP CPT® 82157 Androstenedione BOTH IP/OP $251.00 $185.74 $0.00 $251.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.45 $44.45 $46.16 $0.00 $43.24 $0.00 $0.00 $0.00 $30.74 $81.80 $200.38 $202.40 $42.46 $251.00 $42.46 $46.07 $29.28 $29.28 $32.25 $29.28 $0.00 $0.00 $0.00 $0.00 30100050 EAP CPT® 82164 Angio-1 Convert Enz. BOTH IP/OP $325.00 $240.50 $7.30 $237.60 $30.15 $30.15 $14.60 $14.60 $7.30 $7.30 $22.16 $22.16 $23.01 $14.60 $21.56 $9.49 $192.24 $192.24 $15.33 $40.78 $235.22 $237.60 $21.17 $24.09 $21.17 $22.97 $14.60 $14.60 $16.08 $14.60 $0.00 $0.00 $0.00 $0.00 30100051 EAP CPT® 82164 Angio-1 Conv Enz-csf BOTH IP/OP $325.00 $240.50 $7.30 $237.60 $30.15 $30.15 $14.60 $14.60 $7.30 $7.30 $22.16 $22.16 $23.01 $14.60 $21.56 $9.49 $192.24 $192.24 $15.33 $40.78 $235.22 $237.60 $21.17 $24.09 $21.17 $22.97 $14.60 $14.60 $16.08 $14.60 $0.00 $0.00 $0.00 $0.00 30100052 EAP CPT® 82175 "Arsenic,urine-24hr" BOTH IP/OP $97.00 $71.78 $0.00 $97.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.49 $28.81 $28.81 $29.92 $18.97 $28.02 $12.33 $57.38 $57.38 $19.92 $53.02 $76.82 $77.60 $27.51 $97.00 $27.51 $0.00 $18.97 $18.97 $20.90 $18.97 $0.00 $0.00 $0.00 $0.00 30100053 EAP CPT® 82180 "Vitamin C, Serum" BOTH IP/OP $155.00 $114.70 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.42 $13.42 $13.93 $0.00 $13.05 $0.00 $0.00 $0.00 $10.38 $24.68 $124.34 $125.60 $14.34 $155.00 $14.34 $13.91 $9.89 $9.89 $9.73 $9.89 $0.00 $0.00 $0.00 $0.00 30100054 EAP CPT® 80345 Pentobarbital-quant BOTH IP/OP $245.00 $181.30 $0.00 $188.85 $0.03 $0.03 $0.00 $0.00 $12.01 $7.03 $181.84 $181.84 $188.85 $0.00 $16.93 $0.00 $144.92 $144.92 $0.00 $111.50 $176.62 $178.40 $0.00 $159.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100055 EAP CPT® 82232 Beta-2 Microglobulin BOTH IP/OP $219.00 $162.06 $8.09 $160.80 $33.40 $33.40 $16.18 $16.18 $8.09 $8.09 $24.56 $24.56 $25.51 $16.18 $23.91 $10.52 $129.54 $129.54 $16.99 $45.22 $159.19 $160.80 $23.46 $26.70 $23.46 $25.48 $16.18 $16.18 $17.83 $16.18 $0.00 $0.00 $0.00 $0.00 30100056 EAP CPT® 82239 "Bile Acids, Serum" BOTH IP/OP $261.00 $193.14 $8.56 $192.80 $35.35 $35.35 $17.12 $17.12 $8.56 $8.56 $26.01 $26.01 $27.01 $17.12 $25.32 $11.13 $154.38 $154.38 $17.98 $47.88 $190.87 $192.80 $24.82 $28.25 $24.82 $26.97 $17.12 $17.12 $18.88 $17.12 $0.00 $0.00 $0.00 $0.00 30100057 EAP CPT® 82247 "Bilirubin,total" BOTH IP/OP $117.00 $86.58 $2.51 $94.40 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $7.42 $3.26 $69.21 $69.21 $5.27 $14.04 $93.46 $94.40 $7.28 $8.28 $7.28 $7.91 $5.02 $5.02 $5.54 $5.02 $0.00 $0.00 $0.00 $0.00 30100058 EAP CPT® 82150 "Amylase, Evd" BOTH IP/OP $283.00 $209.42 $3.24 $243.20 $13.38 $13.38 $6.48 $6.48 $3.24 $3.24 $9.84 $9.84 $10.22 $6.48 $9.58 $4.21 $167.39 $167.39 $6.80 $18.12 $240.77 $243.20 $9.40 $10.69 $9.40 $10.20 $6.48 $6.48 $7.14 $6.48 $0.00 $0.00 $0.00 $0.00 30100059 EAP CPT® 82247 "BILI, TOTAL-FLUID" BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $7.42 $3.26 $69.80 $69.80 $5.27 $14.04 $93.46 $94.40 $7.28 $0.00 $7.28 $7.91 $5.02 $5.02 $5.54 $5.02 $0.00 $0.00 $0.00 $0.00 30100060 EAP CPT® 82248 "Bilirubin,direct" BOTH IP/OP $117.00 $86.58 $2.51 $94.40 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $7.42 $3.26 $69.21 $69.21 $5.27 $14.04 $93.46 $94.40 $7.28 $8.28 $7.28 $7.91 $5.02 $5.02 $5.54 $5.02 $0.00 $0.00 $0.00 $0.00 30100061 EAP CPT® 82248 "Bili, Direct - Fluid" BOTH IP/OP $117.00 $86.58 $2.51 $94.40 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $7.42 $3.26 $69.21 $69.21 $5.27 $14.04 $93.46 $94.40 $7.28 $8.28 $7.28 $7.91 $5.02 $5.02 $5.54 $5.02 $0.00 $0.00 $0.00 $0.00 30100062 EAP CPT® 84100 "Phosphorus, Evd" BOTH IP/OP $128.00 $94.72 $2.37 $108.80 $9.79 $9.79 $4.74 $4.74 $2.37 $2.37 $7.21 $7.21 $7.48 $4.74 $7.01 $3.08 $75.71 $75.71 $4.98 $13.26 $107.71 $108.80 $6.87 $7.82 $6.87 $7.47 $4.74 $4.74 $5.23 $4.74 $0.00 $0.00 $0.00 $0.00 30100063 EAP CPT® 83735 "Magnesium,evd" BOTH IP/OP $160.00 $118.40 $0.00 $136.80 $13.83 $13.83 $6.70 $6.70 $3.35 $3.35 $10.17 $10.17 $10.56 $6.70 $9.89 $4.36 $94.64 $94.64 $7.04 $18.72 $135.43 $136.80 $9.72 $0.00 $9.72 $10.54 $6.70 $6.70 $7.38 $6.70 $0.00 $0.00 $0.00 $0.00 30100064 EAP CPT® 87536 "Hiv -1 Rna, Quant,rt-pcr (quest)" BOTH IP/OP $269.00 $199.06 $0.00 $222.40 $107.10 $107.10 $85.10 $85.10 $42.55 $42.55 $78.80 $78.80 $81.83 $85.10 $66.37 $55.32 $159.11 $159.11 $89.36 $145.02 $220.18 $222.40 $123.40 $0.00 $123.40 $70.72 $85.10 $85.10 $49.50 $85.10 $0.00 $0.00 $0.00 $0.00 30100065 EAP CPT® 83519 Pth-realated Protein So BOTH IP/OP $434.00 $321.16 $8.28 $337.60 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $256.71 $256.71 $19.32 $37.76 $334.22 $337.60 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30100066 EAP CPT® 82270 "OCCULT BLOOD, STOOL" BOTH IP/OP $58.00 $42.92 $0.00 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $4.88 $5.07 $0.00 $4.75 $0.00 $0.00 $0.00 $0.00 $8.98 $45.94 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100067 EAP CPT® 82271 "Occult Blood, Gastric" BOTH IP/OP $57.00 $42.18 $0.00 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $4.88 $5.07 $0.00 $4.75 $0.00 $0.00 $0.00 $5.59 $8.98 $45.94 $46.40 $7.71 $57.00 $7.71 $0.00 $5.32 $5.32 $3.54 $5.32 $0.00 $0.00 $0.00 $0.00 30100068 EAP CPT® 82306 "Vitamin D, Serum" BOTH IP/OP $279.00 $206.46 $14.80 $225.60 $61.12 $61.12 $29.60 $29.60 $14.80 $14.80 $44.95 $44.95 $46.68 $29.60 $43.72 $19.24 $165.03 $165.03 $31.08 $82.72 $223.34 $225.60 $42.92 $48.84 $42.92 $46.59 $29.60 $29.60 $32.61 $29.60 $0.00 $0.00 $0.00 $0.00 30100069 EAP CPT® 82308 "Calcitonin, Serum" BOTH IP/OP $138.00 $102.12 $0.00 $111.20 $55.31 $55.31 $26.79 $26.79 $13.40 $13.40 $40.66 $40.66 $42.23 $26.79 $39.55 $17.41 $81.63 $81.63 $28.13 $74.82 $110.09 $111.20 $38.85 $44.20 $38.85 $0.00 $26.79 $26.79 $29.50 $26.79 $0.00 $0.00 $0.00 $0.00 30100070 EAP CPT® 82310 Calcium BOTH IP/OP $102.00 $75.48 $2.58 $74.40 $10.67 $10.67 $5.16 $5.16 $2.58 $2.58 $7.83 $7.83 $8.13 $5.16 $7.46 $3.35 $60.33 $60.33 $5.42 $14.40 $73.66 $74.40 $7.48 $8.51 $7.48 $7.94 $5.16 $5.16 $5.56 $5.16 $0.00 $0.00 $0.00 $0.00 30100071 EAP CPT® 82310 "Calcium,synvl Fluid" BOTH IP/OP $102.00 $75.48 $2.58 $74.40 $10.67 $10.67 $5.16 $5.16 $2.58 $2.58 $7.83 $7.83 $8.13 $5.16 $7.46 $3.35 $60.33 $60.33 $5.42 $14.40 $73.66 $74.40 $7.48 $8.51 $7.48 $7.94 $5.16 $5.16 $5.56 $5.16 $0.00 $0.00 $0.00 $0.00 30100072 EAP CPT® 82310 "CALCIUM, URINE" BOTH IP/OP $90.00 $66.60 $0.00 $74.40 $10.67 $10.67 $5.16 $5.16 $2.58 $2.58 $7.83 $7.83 $8.13 $5.16 $7.46 $3.35 $53.24 $53.24 $5.42 $14.40 $73.66 $74.40 $7.48 $0.00 $7.48 $7.94 $5.16 $5.16 $5.56 $5.16 $0.00 $0.00 $0.00 $0.00 30100073 EAP CPT® 82330 "Calcium,ionized,wb" BOTH IP/OP $375.00 $277.50 $6.84 $273.60 $28.22 $28.22 $13.68 $13.68 $6.84 $6.84 $20.75 $20.75 $21.55 $13.68 $20.18 $8.89 $221.81 $221.81 $14.36 $38.18 $270.86 $273.60 $19.84 $22.57 $19.84 $21.50 $13.68 $13.68 $15.05 $13.68 $0.00 $0.00 $0.00 $0.00 30100074 EAP CPT® 82365 Stone Analysis BOTH IP/OP $399.00 $295.26 $6.45 $291.20 $26.61 $26.61 $12.90 $12.90 $6.45 $6.45 $19.58 $19.58 $20.34 $12.90 $19.05 $8.39 $236.01 $236.01 $13.55 $36.02 $288.29 $291.20 $18.71 $21.29 $18.71 $20.30 $12.90 $12.90 $14.21 $12.90 $0.00 $0.00 $0.00 $0.00 30100075 EAP CPT® 82374 Co2 Content BOTH IP/OP $35.00 $25.90 $2.44 $28.00 $10.08 $10.08 $4.88 $4.88 $2.44 $2.44 $7.43 $7.43 $7.71 $4.88 $7.22 $3.17 $20.70 $20.70 $5.12 $13.66 $27.72 $28.00 $7.08 $8.05 $7.08 $7.70 $4.88 $4.88 $5.39 $4.88 $0.00 $0.00 $0.00 $0.00 30100076 EAP CPT® 82378 Cea BOTH IP/OP $302.00 $223.48 $9.48 $244.00 $39.15 $39.15 $18.96 $18.96 $9.48 $9.48 $28.81 $28.81 $29.92 $18.96 $28.02 $12.32 $178.63 $178.63 $19.91 $53.02 $241.56 $244.00 $27.49 $31.28 $27.49 $29.86 $18.96 $18.96 $20.90 $18.96 $0.00 $0.00 $0.00 $0.00 30100077 EAP CPT® 82379 "Carnitine, Total" BOTH IP/OP $157.00 $116.18 $0.00 $127.20 $34.82 $34.82 $16.87 $16.87 $8.44 $8.43 $25.62 $25.62 $26.60 $16.87 $24.92 $10.97 $92.87 $92.87 $0.00 $47.14 $125.93 $127.20 $0.00 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100078 EAP CPT® 82379 "Carnitine, Free" BOTH IP/OP $157.00 $116.18 $0.00 $127.20 $34.82 $34.82 $16.87 $16.87 $8.44 $8.43 $25.62 $25.62 $26.60 $16.87 $24.92 $10.97 $92.87 $92.87 $0.00 $47.14 $125.93 $127.20 $0.00 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100079 EAP CPT® 82380 "Carotene, Serum" BOTH IP/OP $120.00 $88.80 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.01 $14.01 $14.55 $0.00 $13.63 $0.00 $0.00 $0.00 $0.00 $25.78 $95.83 $96.80 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100080 EAP CPT® 82384 "Catecholamines,plasm" BOTH IP/OP $173.00 $128.02 $12.63 $138.40 $52.11 $52.11 $25.25 $25.25 $12.63 $12.63 $38.34 $38.34 $39.82 $25.25 $37.30 $16.41 $102.33 $102.33 $26.51 $70.56 $137.02 $138.40 $36.61 $41.66 $36.61 $39.74 $25.25 $25.25 $27.82 $25.25 $0.00 $0.00 $0.00 $0.00 30100081 EAP CPT® 82384 "Catecholam.,ur Frac" BOTH IP/OP $173.00 $128.02 $12.63 $138.40 $52.11 $52.11 $25.25 $25.25 $12.63 $12.63 $38.34 $38.34 $39.82 $25.25 $37.30 $16.41 $102.33 $102.33 $26.51 $70.56 $137.02 $138.40 $36.61 $41.66 $36.61 $39.74 $25.25 $25.25 $27.82 $25.25 $0.00 $0.00 $0.00 $0.00 30100082 EAP CPT® 82390 "Ceruloplasmin,serum" BOTH IP/OP $236.00 $174.64 $5.37 $188.80 $22.18 $22.18 $10.74 $10.74 $5.37 $5.37 $16.31 $16.31 $16.93 $10.74 $15.87 $6.98 $139.59 $139.59 $11.28 $30.02 $186.91 $188.80 $15.57 $17.72 $15.57 $16.91 $10.74 $10.74 $11.83 $10.74 $0.00 $0.00 $0.00 $0.00 30100083 EAP CPT® 82415 Chloramphen-peak BOTH IP/OP $145.00 $107.30 $0.00 $134.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.24 $19.24 $19.98 $0.00 $18.71 $0.00 $0.00 $0.00 $0.00 $35.40 $114.84 $116.00 $0.00 $134.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100084 EAP CPT® 82435 Chloride BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $9.50 $9.50 $4.60 $4.60 $2.30 $2.30 $6.97 $6.97 $7.24 $4.60 $6.79 $2.99 $69.21 $69.21 $0.00 $12.84 $92.66 $93.60 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100085 EAP CPT® 82436 "Chloride, Urine" BOTH IP/OP $123.00 $91.02 $2.59 $98.40 $10.38 $10.38 $5.75 $5.75 $2.88 $2.59 $7.63 $7.63 $7.93 $5.75 $7.42 $3.74 $72.75 $72.75 $6.04 $14.04 $97.42 $98.40 $8.34 $9.49 $8.34 $7.91 $5.75 $5.75 $5.54 $5.75 $0.00 $0.00 $0.00 $0.00 30100086 EAP CPT® 82438 "Chloride,fluid" BOTH IP/OP $105.00 $77.70 $0.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.43 $7.43 $7.71 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $13.66 $83.16 $84.00 $0.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100087 EAP CPT® 87798 "Toxoplasma Gondii Dna,qual,pcr So" BOTH IP/OP $422.00 $312.28 $17.55 $340.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $249.61 $249.61 $36.84 $54.82 $336.60 $340.00 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30100088 EAP CPT® 82465 Cholesterol BOTH IP/OP $91.00 $67.34 $2.18 $73.60 $8.98 $8.98 $4.35 $4.35 $2.18 $2.18 $6.61 $6.61 $6.87 $4.35 $6.43 $2.83 $53.83 $53.83 $4.57 $12.16 $72.86 $73.60 $6.31 $7.18 $6.31 $6.85 $4.35 $4.35 $4.79 $4.35 $0.00 $0.00 $0.00 $0.00 30100090 EAP CPT® 82384 "Catacholamines,frac,ur So" BOTH IP/OP $46.00 $34.04 $12.63 $46.00 $46.00 $46.00 $25.25 $25.25 $12.63 $12.63 $38.34 $38.34 $39.82 $25.25 $37.30 $16.41 $27.21 $27.21 $26.51 $46.00 $36.43 $36.80 $36.61 $41.66 $36.61 $39.74 $25.25 $25.25 $27.82 $25.25 $0.00 $0.00 $0.00 $0.00 30100096 EAP CPT® 82507 "Citric Acid, Ur-24hr" BOTH IP/OP $129.00 $95.46 $0.00 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.90 $42.22 $42.22 $43.85 $27.80 $41.08 $18.07 $76.30 $76.30 $0.00 $77.70 $102.17 $103.20 $0.00 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100097 EAP CPT® 82523 Pyridinoline BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $38.57 $38.57 $18.68 $18.68 $9.34 $9.34 $28.38 $28.38 $29.47 $18.68 $27.60 $12.14 $52.05 $52.05 $19.61 $52.22 $69.70 $70.40 $27.09 $0.00 $27.09 $29.41 $18.68 $18.68 $20.59 $18.68 $0.00 $0.00 $0.00 $0.00 30100098 EAP CPT® 82525 "Copper, Serum" BOTH IP/OP $127.00 $93.98 $6.21 $102.40 $25.61 $25.61 $12.41 $12.41 $6.21 $6.21 $18.84 $18.84 $19.57 $12.41 $18.33 $8.07 $75.12 $75.12 $13.03 $34.68 $101.38 $102.40 $17.99 $20.48 $17.99 $19.53 $12.41 $12.41 $13.67 $12.41 $0.00 $0.00 $0.00 $0.00 30100099 EAP CPT® 82525 "Copper, Urine-24hr" BOTH IP/OP $127.00 $93.98 $6.21 $102.40 $25.61 $25.61 $12.41 $12.41 $6.21 $6.21 $18.84 $18.84 $19.57 $12.41 $18.33 $8.07 $75.12 $75.12 $13.03 $34.68 $101.38 $102.40 $17.99 $20.48 $17.99 $19.53 $12.41 $12.41 $13.67 $12.41 $0.00 $0.00 $0.00 $0.00 30100100 EAP CPT® 82530 "Cortisol Free, Ur-24h" BOTH IP/OP $302.00 $223.48 $8.36 $244.00 $34.48 $34.48 $16.71 $16.71 $8.36 $8.36 $25.39 $25.39 $26.36 $16.71 $24.70 $10.86 $178.63 $178.63 $17.55 $46.70 $241.56 $244.00 $24.23 $27.57 $24.23 $26.31 $16.71 $16.71 $18.42 $16.71 $0.00 $0.00 $0.00 $0.00 30100101 EAP CPT® 82533 "Cortisol,serum" BOTH IP/OP $650.00 $481.00 $8.15 $525.60 $33.66 $33.66 $16.30 $16.30 $8.15 $8.15 $24.76 $24.76 $25.71 $16.30 $24.09 $10.60 $384.48 $384.48 $17.12 $45.56 $520.34 $525.60 $23.64 $26.90 $23.64 $25.67 $16.30 $16.30 $17.97 $16.30 $0.00 $0.00 $0.00 $0.00 30100102 EAP CPT® 82542 "Thiopurine Methyl Transferase, Qt" BOTH IP/OP $791.00 $585.34 $6.62 $625.60 $37.28 $37.28 $24.09 $24.09 $12.05 $10.84 $9.12 $9.12 $9.47 $24.09 $8.87 $15.66 $467.88 $467.88 $25.29 $16.78 $619.34 $625.60 $34.93 $39.75 $34.93 $9.45 $24.09 $24.09 $6.62 $24.09 $0.00 $0.00 $0.00 $0.00 30100103 EAP CPT® 82550 "Cpk,total-serum" BOTH IP/OP $176.00 $130.24 $0.00 $151.20 $13.44 $13.44 $6.51 $6.51 $3.26 $3.25 $9.89 $9.89 $10.27 $6.51 $7.46 $4.23 $104.10 $104.10 $6.84 $18.20 $149.69 $151.20 $9.44 $0.00 $9.44 $7.94 $6.51 $6.51 $5.56 $6.51 $0.00 $0.00 $0.00 $0.00 30100104 EAP CPT® 82656 Pancreatic Elastase-1 So BOTH IP/OP $226.00 $167.24 $5.76 $179.20 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $47.10 $7.49 $133.68 $133.68 $12.11 $29.88 $177.41 $179.20 $16.72 $19.02 $16.72 $35.06 $11.53 $11.53 $35.66 $11.53 $0.00 $0.00 $0.00 $0.00 30100105 EAP CPT® 82553 Ckmb-meia BOTH IP/OP $355.00 $262.70 $5.77 $258.40 $23.84 $23.84 $11.55 $11.55 $5.78 $5.77 $17.53 $17.53 $18.21 $11.55 $17.05 $7.51 $209.98 $209.98 $12.13 $32.26 $255.82 $258.40 $16.75 $19.06 $16.75 $18.17 $11.55 $11.55 $12.72 $11.55 $0.00 $0.00 $0.00 $0.00 30100106 EAP CPT® 82565 Creatinine BOTH IP/OP $139.00 $102.86 $2.56 $103.20 $10.59 $10.59 $5.12 $5.12 $2.56 $2.56 $7.78 $7.78 $8.08 $5.12 $7.46 $3.33 $82.22 $82.22 $5.38 $14.32 $102.17 $103.20 $7.42 $8.45 $7.42 $7.94 $5.12 $5.12 $5.56 $5.12 $0.00 $0.00 $0.00 $0.00 30100107 EAP CPT® 82570 "Creatinine,fluid" BOTH IP/OP $122.00 $90.28 $2.59 $97.60 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $72.16 $72.16 $5.44 $14.46 $96.62 $97.60 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30100108 EAP CPT® 82570 "Creat,amniotic Fld" BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $76.30 $76.30 $5.44 $14.46 $102.17 $103.20 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30100109 EAP CPT® 82570 "Creatinine, Urine" BOTH IP/OP $122.00 $90.28 $2.59 $97.60 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $72.16 $72.16 $5.44 $14.46 $96.62 $97.60 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30100110 EAP CPT® 82108 "Aluminum, 24hr Urine So" BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $34.80 $34.80 $25.48 $25.48 $12.74 $12.74 $25.59 $25.59 $26.58 $25.48 $24.91 $16.56 $40.81 $40.81 $26.75 $47.10 $54.65 $55.20 $36.95 $42.04 $36.95 $0.00 $25.48 $25.48 $18.58 $25.48 $0.00 $0.00 $0.00 $0.00 30100111 EAP CPT® 82575 Creatinine Clearance BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.34 $14.34 $14.89 $0.00 $13.95 $0.00 $0.00 $0.00 $0.00 $26.40 $196.42 $198.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100112 EAP CPT® 82595 "Cryoglobulin,serum" BOTH IP/OP $88.00 $65.12 $3.23 $71.20 $13.36 $13.36 $6.47 $6.47 $3.24 $3.23 $9.83 $9.83 $10.21 $6.47 $9.57 $4.21 $52.05 $52.05 $6.79 $18.08 $70.49 $71.20 $9.38 $10.68 $9.38 $10.19 $6.47 $6.47 $7.13 $6.47 $0.00 $0.00 $0.00 $0.00 30100113 EAP CPT® 82595 "Cryocrit,serum" BOTH IP/OP $88.00 $65.12 $3.23 $71.20 $13.36 $13.36 $6.47 $6.47 $3.24 $3.23 $9.83 $9.83 $10.21 $6.47 $9.57 $4.21 $52.05 $52.05 $6.79 $18.08 $70.49 $71.20 $9.38 $10.68 $9.38 $10.19 $6.47 $6.47 $7.13 $6.47 $0.00 $0.00 $0.00 $0.00 30100114 EAP CPT® 82600 Cyanide BOTH IP/OP $135.00 $99.90 $0.00 $135.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.46 $29.46 $30.60 $0.00 $28.67 $0.00 $0.00 $0.00 $0.00 $54.22 $107.71 $108.80 $0.00 $135.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100115 EAP CPT® 82607 "Vitamin B12,serum" BOTH IP/OP $398.00 $294.52 $7.54 $321.60 $31.13 $31.13 $15.08 $15.08 $7.54 $7.54 $22.89 $22.89 $23.77 $15.08 $22.26 $9.80 $235.42 $235.42 $15.83 $42.12 $318.38 $321.60 $21.87 $24.88 $21.87 $23.72 $15.08 $15.08 $16.60 $15.08 $0.00 $0.00 $0.00 $0.00 30100116 EAP CPT® 82627 "Dhea-so4, Serum" BOTH IP/OP $428.00 $316.72 $11.12 $345.60 $45.91 $45.91 $22.23 $22.23 $11.12 $11.12 $33.76 $33.76 $35.06 $22.23 $32.84 $14.45 $253.16 $253.16 $23.34 $62.14 $342.14 $345.60 $32.23 $36.68 $32.23 $35.00 $22.23 $22.23 $24.50 $22.23 $0.00 $0.00 $0.00 $0.00 30100117 EAP CPT® 82634 "Deoxycortisol,11-bld" BOTH IP/OP $129.00 $95.46 $0.00 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.45 $44.45 $46.16 $0.00 $43.24 $0.00 $0.00 $0.00 $0.00 $81.80 $102.17 $103.20 $0.00 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100118 EAP CPT® 80327 Dihydrotestosterone BOTH IP/OP $142.00 $105.08 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.39 $105.39 $109.45 $0.00 $38.14 $0.00 $0.00 $0.00 $0.00 $64.50 $102.17 $103.20 $0.00 $92.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100119 EAP CPT® 82652 "Vit D,1,25-dihydroxy" BOTH IP/OP $355.00 $262.70 $19.25 $286.40 $79.46 $79.46 $38.50 $38.50 $19.25 $19.25 $58.45 $58.45 $60.70 $38.50 $56.86 $25.03 $209.98 $209.98 $40.43 $107.56 $283.54 $286.40 $55.83 $63.53 $55.83 $60.58 $38.50 $38.50 $42.41 $38.50 $0.00 $0.00 $0.00 $0.00 30100120 EAP CPT® 82664 "Amylase, Isoenzymes" BOTH IP/OP $501.00 $370.74 $0.00 $404.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.17 $52.17 $54.17 $0.00 $50.75 $0.00 $0.00 $0.00 $64.58 $96.00 $400.75 $404.80 $89.18 $222.00 $89.18 $54.07 $61.50 $61.50 $37.85 $61.50 $0.00 $0.00 $0.00 $0.00 30100121 EAP CPT® 82668 "Erythropoietin,serum" BOTH IP/OP $246.00 $182.04 $9.40 $198.40 $38.78 $38.78 $18.79 $18.79 $9.40 $9.40 $28.55 $28.55 $29.65 $18.79 $27.76 $12.21 $145.51 $145.51 $19.73 $52.52 $196.42 $198.40 $27.25 $31.00 $27.25 $29.58 $18.79 $18.79 $20.71 $18.79 $0.00 $0.00 $0.00 $0.00 30100122 EAP CPT® 82670 Estradiol BOTH IP/OP $405.00 $299.70 $13.97 $324.00 $57.66 $57.66 $27.94 $27.94 $13.97 $13.97 $42.43 $42.43 $44.06 $27.94 $41.28 $18.16 $239.56 $239.56 $29.34 $78.08 $320.76 $324.00 $40.51 $46.10 $40.51 $43.98 $27.94 $27.94 $30.79 $27.94 $0.00 $0.00 $0.00 $0.00 30100123 EAP CPT® 82677 "Estriol(free),serum" BOTH IP/OP $139.00 $102.86 $0.00 $139.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.72 $36.72 $38.13 $0.00 $35.72 $0.00 $0.00 $0.00 $25.39 $67.58 $110.09 $111.20 $35.06 $139.00 $35.06 $38.06 $24.18 $24.18 $26.64 $24.18 $0.00 $0.00 $0.00 $0.00 30100124 EAP CPT® 82677 "Estriol, Urine-ref" BOTH IP/OP $139.00 $102.86 $0.00 $111.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.72 $36.72 $38.13 $0.00 $35.72 $0.00 $0.00 $0.00 $25.39 $67.58 $110.09 $111.20 $35.06 $0.00 $35.06 $38.06 $24.18 $24.18 $26.64 $24.18 $0.00 $0.00 $0.00 $0.00 30100125 EAP CPT® 82677 "Estriol, Maternal Serum" BOTH IP/OP $139.00 $102.86 $0.00 $111.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.72 $36.72 $38.13 $0.00 $35.72 $0.00 $0.00 $0.00 $25.39 $67.58 $110.09 $111.20 $35.06 $0.00 $35.06 $38.06 $24.18 $24.18 $26.64 $24.18 $0.00 $0.00 $0.00 $0.00 30100126 EAP CPT® 82679 "Estrone, Serum" BOTH IP/OP $118.00 $87.32 $12.48 $94.40 $51.51 $51.51 $24.95 $24.95 $12.48 $12.48 $37.91 $37.91 $39.37 $24.95 $36.88 $16.22 $69.80 $69.80 $26.20 $69.76 $93.46 $94.40 $36.18 $41.17 $36.18 $39.29 $24.95 $24.95 $27.50 $24.95 $0.00 $0.00 $0.00 $0.00 30100127 EAP CPT® 82693 "Ethylene Glycol,bld" BOTH IP/OP $364.00 $269.36 $0.00 $337.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.62 $22.62 $23.49 $0.00 $22.02 $0.00 $0.00 $0.00 $0.00 $41.64 $291.46 $294.40 $0.00 $337.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100128 EAP CPT® 82705 "Stool Fat, Qual" BOTH IP/OP $64.00 $47.36 $0.00 $52.00 $10.51 $10.51 $5.10 $5.10 $2.55 $2.55 $7.73 $7.73 $8.02 $5.10 $7.52 $3.32 $37.86 $37.86 $0.00 $14.22 $51.48 $52.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100129 EAP CPT® 82710 "Fecal Fat, Quant" BOTH IP/OP $89.00 $65.86 $8.40 $72.00 $34.69 $34.69 $16.80 $16.80 $8.40 $8.40 $25.51 $25.51 $26.49 $16.80 $24.81 $10.92 $52.64 $52.64 $17.64 $46.94 $71.28 $72.00 $24.36 $27.72 $24.36 $26.44 $16.80 $16.80 $18.51 $16.80 $0.00 $0.00 $0.00 $0.00 30100130 EAP CPT® 82725 "Fatty Acids,ess-ser" BOTH IP/OP $212.00 $156.88 $0.00 $175.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.22 $20.22 $21.00 $0.00 $19.67 $0.00 $0.00 $0.00 $0.00 $37.20 $166.32 $168.00 $0.00 $175.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100131 EAP CPT® 82728 "Ferritin,serum" BOTH IP/OP $247.00 $182.78 $6.82 $199.20 $28.14 $28.14 $13.63 $13.63 $6.82 $6.82 $20.69 $20.69 $21.48 $13.63 $20.13 $8.86 $146.10 $146.10 $14.31 $38.06 $197.21 $199.20 $19.76 $22.49 $19.76 $21.45 $13.63 $13.63 $15.01 $13.63 $0.00 $0.00 $0.00 $0.00 30100132 EAP CPT® 82731 Fetal Fibronectin BOTH IP/OP $614.00 $454.36 $32.21 $496.00 $132.98 $132.98 $64.41 $64.41 $32.21 $32.21 $97.80 $97.80 $101.56 $64.41 $95.14 $41.87 $363.18 $363.18 $67.63 $179.98 $491.04 $496.00 $93.39 $106.28 $93.39 $101.37 $64.41 $64.41 $70.96 $64.41 $0.00 $0.00 $0.00 $0.00 30100133 EAP CPT® 82746 "Folate,serum" BOTH IP/OP $292.00 $216.08 $7.35 $235.20 $30.36 $30.36 $14.70 $14.70 $7.35 $7.35 $22.33 $22.33 $23.19 $14.70 $21.72 $9.56 $172.72 $172.72 $15.44 $41.08 $232.85 $235.20 $21.32 $24.26 $21.32 $23.15 $14.70 $14.70 $16.20 $14.70 $0.00 $0.00 $0.00 $0.00 30100134 EAP CPT® 82747 "Folate, Rbc" BOTH IP/OP $434.00 $321.16 $8.66 $350.40 $35.75 $35.75 $17.65 $17.65 $8.83 $8.66 $26.30 $26.30 $27.31 $17.65 $25.59 $11.47 $256.71 $256.71 $18.53 $48.40 $346.90 $350.40 $25.59 $29.12 $25.59 $27.27 $17.65 $17.65 $19.09 $17.65 $0.00 $0.00 $0.00 $0.00 30100135 EAP CPT® 82775 Galactose-1-put BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.98 $31.98 $33.21 $0.00 $31.12 $0.00 $0.00 $0.00 $0.00 $58.86 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100136 EAP CPT® 82775 Galactose-1-phos BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.98 $31.98 $33.21 $0.00 $31.12 $0.00 $0.00 $0.00 $0.00 $58.86 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100137 EAP CPT® 82784 "Immunoglob-a,serum" BOTH IP/OP $273.00 $202.02 $4.65 $220.80 $19.19 $19.19 $9.30 $9.30 $4.65 $4.65 $14.12 $14.12 $14.67 $9.30 $13.73 $6.05 $161.48 $161.48 $9.77 $25.98 $218.59 $220.80 $13.49 $15.35 $13.49 $14.63 $9.30 $9.30 $10.24 $9.30 $0.00 $0.00 $0.00 $0.00 30100138 EAP CPT® 82784 "Immunoglob-g,serum" BOTH IP/OP $273.00 $202.02 $4.65 $220.80 $19.19 $19.19 $9.30 $9.30 $4.65 $4.65 $14.12 $14.12 $14.67 $9.30 $13.73 $6.05 $161.48 $161.48 $9.77 $25.98 $218.59 $220.80 $13.49 $15.35 $13.49 $14.63 $9.30 $9.30 $10.24 $9.30 $0.00 $0.00 $0.00 $0.00 30100139 EAP CPT® 82784 "Immunoglob-m,serum" BOTH IP/OP $273.00 $202.02 $4.65 $220.80 $19.19 $19.19 $9.30 $9.30 $4.65 $4.65 $14.12 $14.12 $14.67 $9.30 $13.73 $6.05 $161.48 $161.48 $9.77 $25.98 $218.59 $220.80 $13.49 $15.35 $13.49 $14.63 $9.30 $9.30 $10.24 $9.30 $0.00 $0.00 $0.00 $0.00 30100140 EAP CPT® 82784 "Immuno-igg,csf" BOTH IP/OP $165.00 $122.10 $4.65 $133.60 $19.19 $19.19 $9.30 $9.30 $4.65 $4.65 $14.12 $14.12 $14.67 $9.30 $13.73 $6.05 $97.60 $97.60 $9.77 $25.98 $132.26 $133.60 $13.49 $15.35 $13.49 $14.63 $9.30 $9.30 $10.24 $9.30 $0.00 $0.00 $0.00 $0.00 30100141 EAP CPT® 82784 "Immunoglob-igd,serum" BOTH IP/OP $251.00 $185.74 $4.65 $202.40 $19.19 $19.19 $9.30 $9.30 $4.65 $4.65 $14.12 $14.12 $14.67 $9.30 $13.73 $6.05 $148.47 $148.47 $9.77 $25.98 $200.38 $202.40 $13.49 $15.35 $13.49 $14.63 $9.30 $9.30 $10.24 $9.30 $0.00 $0.00 $0.00 $0.00 30100142 EAP CPT® 82785 "Immunoglob-ige,serum" BOTH IP/OP $202.00 $149.48 $8.23 $163.20 $33.98 $33.98 $16.46 $16.46 $8.23 $8.23 $25.01 $25.01 $25.97 $16.46 $24.33 $10.70 $119.48 $119.48 $17.28 $46.02 $161.57 $163.20 $23.87 $27.16 $23.87 $25.92 $16.46 $16.46 $18.15 $16.46 $0.00 $0.00 $0.00 $0.00 30100143 EAP CPT® 82800 "Ph, Ven." BOTH IP/OP $222.00 $164.28 $4.95 $222.00 $17.48 $17.48 $11.00 $11.00 $5.50 $4.95 $12.86 $12.86 $13.36 $11.00 $12.52 $7.15 $131.31 $131.31 $11.55 $23.66 $159.98 $161.60 $15.95 $222.00 $15.95 $13.34 $11.00 $11.00 $9.34 $11.00 $0.00 $0.00 $0.00 $0.00 30100144 EAP CPT® 82800 "Ph, Art." BOTH IP/OP $222.00 $164.28 $4.95 $222.00 $17.48 $17.48 $11.00 $11.00 $5.50 $4.95 $12.86 $12.86 $13.36 $11.00 $12.52 $7.15 $131.31 $131.31 $11.55 $23.66 $159.98 $161.60 $15.95 $222.00 $15.95 $13.34 $11.00 $11.00 $9.34 $11.00 $0.00 $0.00 $0.00 $0.00 30100145 EAP CPT® 82800 "Ph, Cord, Art." BOTH IP/OP $201.00 $148.74 $4.95 $222.00 $17.48 $17.48 $11.00 $11.00 $5.50 $4.95 $12.86 $12.86 $13.36 $11.00 $12.52 $7.15 $118.89 $118.89 $11.55 $23.66 $159.98 $161.60 $15.95 $222.00 $15.95 $13.34 $11.00 $11.00 $9.34 $11.00 $0.00 $0.00 $0.00 $0.00 30100148 EAP CPT® 82803 Blood Gas-venous BOTH IP/OP $510.00 $377.40 $11.73 $371.20 $39.94 $39.94 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $30.51 $26.07 $28.59 $16.95 $301.67 $301.67 $27.37 $54.08 $367.49 $371.20 $37.80 $43.02 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100149 EAP CPT® 82803 Blood Gas-arterial BOTH IP/OP $510.00 $377.40 $11.73 $371.20 $39.94 $39.94 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $30.51 $26.07 $28.59 $16.95 $301.67 $301.67 $27.37 $54.08 $367.49 $371.20 $37.80 $43.02 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100150 EAP CPT® 82803 Blood Gas-micro BOTH IP/OP $510.00 $377.40 $11.73 $371.20 $39.94 $39.94 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $30.51 $26.07 $28.59 $16.95 $301.67 $301.67 $27.37 $54.08 $367.49 $371.20 $37.80 $43.02 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100151 EAP CPT® 82803 Blood Gas-cord Art. BOTH IP/OP $510.00 $377.40 $11.73 $371.20 $39.94 $39.94 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $30.51 $26.07 $28.59 $16.95 $301.67 $301.67 $27.37 $54.08 $367.49 $371.20 $37.80 $43.02 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100152 EAP CPT® 82803 BLOOD GAS-CORD VEN. BOTH IP/OP $462.00 $341.88 $11.73 $371.20 $39.94 $39.94 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $30.51 $26.07 $28.59 $16.95 $273.27 $273.27 $27.37 $54.08 $367.49 $371.20 $37.80 $43.02 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100153 EAP CPT® 82172 Apolipoproteina 1 (so) BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $32.00 $32.00 $21.09 $21.09 $10.55 $9.49 $23.52 $23.52 $24.43 $21.09 $22.90 $13.71 $104.10 $104.10 $22.14 $43.30 $139.39 $140.80 $30.58 $0.00 $30.58 $24.40 $21.09 $21.09 $17.08 $21.09 $0.00 $0.00 $0.00 $0.00 30100158 EAP CPT® 82805 "Bld. Gas+sat. Prof, Art" BOTH IP/OP $533.00 $394.42 $31.27 $388.00 $58.56 $58.56 $78.77 $78.77 $39.39 $35.45 $43.09 $43.09 $44.74 $78.77 $41.93 $51.20 $315.27 $315.27 $82.71 $79.30 $384.12 $388.00 $114.22 $129.97 $114.22 $44.67 $78.77 $78.77 $31.27 $78.77 $0.00 $0.00 $0.00 $0.00 30100159 EAP CPT® 82805 "Bld. Gas+sat. Prof, Ven" BOTH IP/OP $533.00 $394.42 $31.27 $388.00 $58.56 $58.56 $78.77 $78.77 $39.39 $35.45 $43.09 $43.09 $44.74 $78.77 $41.93 $51.20 $315.27 $315.27 $82.71 $79.30 $384.12 $388.00 $114.22 $129.97 $114.22 $44.67 $78.77 $78.77 $31.27 $78.77 $0.00 $0.00 $0.00 $0.00 30100160 EAP CPT® 82805 "Bld. Gas+sat. Prof, Mcr" BOTH IP/OP $483.00 $357.42 $31.27 $388.00 $58.56 $58.56 $78.77 $78.77 $39.39 $35.45 $43.09 $43.09 $44.74 $78.77 $41.93 $51.20 $285.69 $285.69 $82.71 $79.30 $384.12 $388.00 $114.22 $129.97 $114.22 $44.67 $78.77 $78.77 $31.27 $78.77 $0.00 $0.00 $0.00 $0.00 30100161 EAP CPT® 82810 "Saturation Prof, Ven." BOTH IP/OP $113.00 $83.62 $4.40 $113.00 $18.00 $18.00 $9.77 $9.77 $4.89 $4.40 $13.25 $13.25 $13.76 $9.77 $12.89 $6.35 $66.84 $66.84 $10.26 $24.40 $81.58 $82.40 $14.17 $113.00 $14.17 $13.74 $9.77 $9.77 $9.62 $9.77 $0.00 $0.00 $0.00 $0.00 30100162 EAP CPT® 82810 "Saturation Prof, Art." BOTH IP/OP $113.00 $83.62 $4.40 $113.00 $18.00 $18.00 $9.77 $9.77 $4.89 $4.40 $13.25 $13.25 $13.76 $9.77 $12.89 $6.35 $66.84 $66.84 $10.26 $24.40 $81.58 $82.40 $14.17 $113.00 $14.17 $13.74 $9.77 $9.77 $9.62 $9.77 $0.00 $0.00 $0.00 $0.00 30100163 EAP CPT® 82810 "Saturation Prof, Micro" BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $18.00 $18.00 $9.77 $9.77 $4.89 $4.40 $13.25 $13.25 $13.76 $9.77 $12.89 $6.35 $60.92 $60.92 $10.26 $24.40 $81.58 $82.40 $14.17 $0.00 $14.17 $13.74 $9.77 $9.77 $9.62 $9.77 $0.00 $0.00 $0.00 $0.00 30100165 EAP CPT® 82941 "Gastrin,serum" BOTH IP/OP $281.00 $207.94 $0.00 $222.40 $36.41 $36.41 $17.63 $17.63 $8.82 $8.82 $26.78 $26.78 $27.81 $17.63 $26.05 $11.46 $166.21 $166.21 $18.51 $49.28 $220.18 $222.40 $25.56 $29.09 $25.56 $0.00 $17.63 $17.63 $19.43 $17.63 $0.00 $0.00 $0.00 $0.00 30100167 EAP CPT® 82945 "Glucose,fluid" BOTH IP/OP $341.00 $252.34 $1.97 $248.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $201.70 $201.70 $4.13 $10.96 $246.31 $248.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100168 EAP CPT® 82945 "Glucose,csf" BOTH IP/OP $341.00 $252.34 $1.97 $248.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $201.70 $201.70 $4.13 $10.96 $246.31 $248.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100169 EAP CPT® 82945 "GLUCOSE,URINE(QUANT)" BOTH IP/OP $251.00 $185.74 $1.97 $248.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $148.47 $148.47 $4.13 $10.96 $246.31 $248.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100171 EAP CPT® 82947 Glucose BOTH IP/OP $358.00 $264.92 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $211.76 $211.76 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100173 EAP CPT® 82947 "Glucose,fasting Bld" BOTH IP/OP $358.00 $264.92 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $211.76 $211.76 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100174 EAP CPT® 82947 Glucose-wb BOTH IP/OP $358.00 $264.92 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $211.76 $211.76 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100176 EAP CPT® 82947 "Gtt,oral-1hr Indiv" BOTH IP/OP $263.00 $194.62 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $155.56 $155.56 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100177 EAP CPT® 82947 "GTT,ORAL-2HR INDIV" BOTH IP/OP $263.00 $194.62 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $155.56 $155.56 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100178 EAP CPT® 82947 "Poct, Glucose (meter)" BOTH IP/OP $92.00 $68.08 $1.97 $67.20 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $54.42 $54.42 $4.13 $10.96 $66.53 $67.20 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100180 EAP HCPCS G0480 Drug Test Definitive 1-7 Classes BOTH IP/OP $293.00 $216.82 $0.00 $234.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.46 $217.46 $225.84 $0.00 $110.57 $0.00 $0.00 $0.00 $120.15 $146.50 $232.06 $234.40 $165.92 $0.00 $165.92 $117.81 $114.43 $114.43 $82.47 $114.43 $0.00 $0.00 $0.00 $0.00 30100181 EAP HCPCS G0481 Drug Test Definitive 8-14 Classes BOTH IP/OP $322.00 $238.28 $0.00 $257.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.99 $238.99 $248.20 $0.00 $151.29 $0.00 $0.00 $0.00 $0.00 $161.00 $255.02 $257.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100182 EAP HCPCS G0482 Drug Test Definitive 15-21 Classes BOTH IP/OP $354.00 $261.96 $0.00 $283.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.74 $262.74 $272.86 $0.00 $192.03 $0.00 $0.00 $0.00 $0.00 $177.00 $280.37 $283.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100183 EAP HCPCS G0483 Drug Test Definitive 22+ Classes BOTH IP/OP $389.00 $287.86 $0.00 $311.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $288.72 $288.72 $299.84 $0.00 $238.59 $0.00 $0.00 $0.00 $0.00 $194.50 $308.09 $311.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100186 EAP CPT® 82948 "Glu-2hr Pp, Wb-micro" BOTH IP/OP $251.00 $185.74 $0.00 $248.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.82 $4.82 $5.00 $0.00 $4.68 $0.00 $0.00 $0.00 $0.00 $8.86 $246.31 $248.80 $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100187 EAP CPT® 82950 "Glucose,bld-2hr Pp" BOTH IP/OP $341.00 $252.34 $2.37 $248.80 $9.79 $9.79 $4.75 $4.75 $2.38 $2.37 $7.21 $7.21 $7.48 $4.75 $7.02 $3.09 $201.70 $201.70 $4.99 $13.28 $246.31 $248.80 $6.89 $7.84 $6.89 $7.48 $4.75 $4.75 $5.24 $4.75 $0.00 $0.00 $0.00 $0.00 30100188 EAP CPT® 82950 "Glucose, 1hr (75gm)" BOTH IP/OP $251.00 $185.74 $2.37 $248.80 $9.79 $9.79 $4.75 $4.75 $2.38 $2.37 $7.21 $7.21 $7.48 $4.75 $7.02 $3.09 $148.47 $148.47 $4.99 $13.28 $246.31 $248.80 $6.89 $7.84 $6.89 $7.48 $4.75 $4.75 $5.24 $4.75 $0.00 $0.00 $0.00 $0.00 30100189 EAP CPT® 82950 "GLUCOSE,1HR (50GM)" BOTH IP/OP $251.00 $185.74 $2.37 $248.80 $9.79 $9.79 $4.75 $4.75 $2.38 $2.37 $7.21 $7.21 $7.48 $4.75 $7.02 $3.09 $148.47 $148.47 $4.99 $13.28 $246.31 $248.80 $6.89 $7.84 $6.89 $7.48 $4.75 $4.75 $5.24 $4.75 $0.00 $0.00 $0.00 $0.00 30100192 EAP CPT® 82951 "Gtt,prenatal(75 Gm)" BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $26.58 $26.58 $12.87 $12.87 $6.44 $6.44 $19.55 $19.55 $20.30 $12.87 $19.02 $8.37 $118.89 $118.89 $13.51 $35.98 $159.19 $160.80 $18.66 $0.00 $18.66 $20.26 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30100193 EAP CPT® 82951 "Gtt,oral-3hr Gtt" BOTH IP/OP $199.00 $147.26 $6.44 $160.80 $26.58 $26.58 $12.87 $12.87 $6.44 $6.44 $19.55 $19.55 $20.30 $12.87 $19.02 $8.37 $117.71 $117.71 $13.51 $35.98 $159.19 $160.80 $18.66 $21.24 $18.66 $20.26 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30100194 EAP CPT® 82951 "Gtt,oral-4hr Gtt" BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $26.58 $26.58 $12.87 $12.87 $6.44 $6.44 $19.55 $19.55 $20.30 $12.87 $19.02 $8.37 $118.89 $118.89 $13.51 $35.98 $159.19 $160.80 $18.66 $0.00 $18.66 $20.26 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30100195 EAP CPT® 82951 "Gtt,oral-5hr Gtt" BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $26.58 $26.58 $12.87 $12.87 $6.44 $6.44 $19.55 $19.55 $20.30 $12.87 $19.02 $8.37 $118.89 $118.89 $13.51 $35.98 $159.19 $160.80 $18.66 $0.00 $18.66 $20.26 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30100196 EAP CPT® 82951 "Gtt,oral-6hr Gtt" BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $26.58 $26.58 $12.87 $12.87 $6.44 $6.44 $19.55 $19.55 $20.30 $12.87 $19.02 $8.37 $118.89 $118.89 $13.51 $35.98 $159.19 $160.80 $18.66 $0.00 $18.66 $20.26 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30100197 EAP CPT® 82951 "GTT,PRENATAL(100GM)" BOTH IP/OP $199.00 $147.26 $6.44 $160.80 $26.58 $26.58 $12.87 $12.87 $6.44 $6.44 $19.55 $19.55 $20.30 $12.87 $19.02 $8.37 $117.71 $117.71 $13.51 $35.98 $159.19 $160.80 $18.66 $21.24 $18.66 $20.26 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30100200 EAP CPT® 82952 3rd Hour-gtt Specimen BOTH IP/OP $102.00 $75.48 $1.96 $82.40 $8.10 $8.10 $3.92 $3.92 $1.96 $1.96 $5.95 $5.95 $6.18 $3.92 $5.80 $2.55 $60.33 $60.33 $4.12 $10.96 $81.58 $82.40 $5.68 $6.47 $5.68 $6.18 $3.92 $3.92 $4.32 $3.92 $0.00 $0.00 $0.00 $0.00 30100201 EAP CPT® 82952 4th Hour-gtt Specimen BOTH IP/OP $103.00 $76.22 $1.96 $82.40 $8.10 $8.10 $3.92 $3.92 $1.96 $1.96 $5.95 $5.95 $6.18 $3.92 $5.80 $2.55 $60.92 $60.92 $4.12 $10.96 $81.58 $82.40 $5.68 $6.47 $5.68 $6.18 $3.92 $3.92 $4.32 $3.92 $0.00 $0.00 $0.00 $0.00 30100202 EAP CPT® 82952 5TH HOUR GTT SPECIMEN BOTH IP/OP $103.00 $76.22 $1.96 $82.40 $8.10 $8.10 $3.92 $3.92 $1.96 $1.96 $5.95 $5.95 $6.18 $3.92 $5.80 $2.55 $60.92 $60.92 $4.12 $10.96 $81.58 $82.40 $5.68 $6.47 $5.68 $6.18 $3.92 $3.92 $4.32 $3.92 $0.00 $0.00 $0.00 $0.00 30100203 EAP CPT® 82955 "G6pd, Rbc Quant" BOTH IP/OP $242.00 $179.08 $4.85 $195.20 $16.08 $16.08 $9.70 $9.70 $4.85 $4.85 $11.86 $11.86 $12.31 $9.70 $11.54 $6.31 $143.14 $143.14 $10.19 $21.82 $193.25 $195.20 $14.07 $16.01 $14.07 $12.30 $9.70 $9.70 $8.61 $9.70 $0.00 $0.00 $0.00 $0.00 30100205 EAP CPT® 82977 "GGTP,SERUM" BOTH IP/OP $162.00 $119.88 $3.60 $129.60 $14.86 $14.86 $7.20 $7.20 $3.60 $3.60 $10.93 $10.93 $11.35 $7.20 $7.46 $4.68 $95.82 $95.82 $7.56 $20.12 $128.30 $129.60 $10.44 $11.88 $10.44 $7.94 $7.20 $7.20 $5.56 $7.20 $0.00 $0.00 $0.00 $0.00 30100206 EAP CPT® 83001 "Fsh,serum" BOTH IP/OP $480.00 $355.20 $9.29 $372.00 $38.36 $38.36 $18.58 $18.58 $9.29 $9.29 $28.23 $28.23 $29.31 $18.58 $27.46 $12.08 $283.92 $283.92 $19.51 $51.94 $368.28 $372.00 $26.94 $30.66 $26.94 $29.26 $18.58 $18.58 $20.48 $18.58 $0.00 $0.00 $0.00 $0.00 30100207 EAP CPT® 83002 "Lh,serum" BOTH IP/OP $532.00 $393.68 $9.26 $412.00 $38.23 $38.23 $18.52 $18.52 $9.26 $9.26 $28.12 $28.12 $29.20 $18.52 $27.36 $12.04 $314.68 $314.68 $19.45 $51.76 $407.88 $412.00 $26.85 $30.56 $26.85 $29.16 $18.52 $18.52 $20.41 $18.52 $0.00 $0.00 $0.00 $0.00 30100208 EAP CPT® 83003 Growth Hormone BOTH IP/OP $133.00 $98.42 $0.00 $103.20 $29.38 $29.38 $16.67 $16.67 $8.34 $8.33 $21.62 $21.62 $22.45 $16.67 $21.03 $10.84 $78.67 $78.67 $0.00 $39.78 $102.17 $103.20 $0.00 $27.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100209 EAP CPT® 83010 "Haptoglobin,serum" BOTH IP/OP $333.00 $246.42 $4.11 $268.80 $7.71 $7.71 $12.58 $12.58 $6.29 $6.29 $5.66 $5.66 $5.88 $12.58 $5.51 $8.18 $196.97 $196.97 $13.21 $10.42 $266.11 $268.80 $18.24 $20.76 $18.24 $5.87 $12.58 $12.58 $4.11 $12.58 $0.00 $0.00 $0.00 $0.00 30100211 EAP CPT® 83020 Hgb Elect - Family BOTH IP/OP $218.00 $161.32 $6.44 $174.40 $20.17 $20.17 $12.87 $12.87 $6.44 $6.44 $14.84 $14.84 $15.41 $12.87 $14.44 $8.37 $128.95 $128.95 $13.51 $27.32 $172.66 $174.40 $18.66 $21.24 $18.66 $15.38 $12.87 $12.87 $10.77 $12.87 $0.00 $0.00 $0.00 $0.00 30100212 EAP CPT® 83020 Hgb Electrophoresis BOTH IP/OP $218.00 $161.32 $6.44 $174.40 $20.17 $20.17 $12.87 $12.87 $6.44 $6.44 $14.84 $14.84 $15.41 $12.87 $14.44 $8.37 $128.95 $128.95 $13.51 $27.32 $172.66 $174.40 $18.66 $21.24 $18.66 $15.38 $12.87 $12.87 $10.77 $12.87 $0.00 $0.00 $0.00 $0.00 30100213 EAP CPT® 83020 Citrate Agar Elect. BOTH IP/OP $217.00 $160.58 $0.00 $174.40 $20.17 $20.17 $12.87 $12.87 $6.44 $6.44 $14.84 $14.84 $15.41 $12.87 $14.44 $8.37 $128.36 $128.36 $13.51 $27.32 $172.66 $174.40 $18.66 $0.00 $18.66 $15.38 $12.87 $12.87 $10.77 $12.87 $0.00 $0.00 $0.00 $0.00 30100214 EAP CPT® 83020 Hgb Elect. Quant BOTH IP/OP $217.00 $160.58 $0.00 $174.40 $20.17 $20.17 $12.87 $12.87 $6.44 $6.44 $14.84 $14.84 $15.41 $12.87 $14.44 $8.37 $128.36 $128.36 $13.51 $27.32 $172.66 $174.40 $18.66 $0.00 $18.66 $15.38 $12.87 $12.87 $10.77 $12.87 $0.00 $0.00 $0.00 $0.00 30100215 EAP CPT® 83020 HGB ELECT. CORD BLD BOTH IP/OP $217.00 $160.58 $0.00 $174.40 $20.17 $20.17 $12.87 $12.87 $6.44 $6.44 $14.84 $14.84 $15.41 $12.87 $14.44 $8.37 $128.36 $128.36 $13.51 $27.32 $172.66 $174.40 $18.66 $0.00 $18.66 $15.38 $12.87 $12.87 $10.77 $12.87 $0.00 $0.00 $0.00 $0.00 30100216 EAP CPT® 83021 "Hgb Phenotyping, Family Member" BOTH IP/OP $218.00 $161.32 $6.62 $174.40 $12.41 $12.41 $18.06 $18.06 $9.03 $9.03 $9.12 $9.12 $9.47 $18.06 $8.87 $11.74 $128.95 $128.95 $18.96 $16.78 $172.66 $174.40 $26.19 $29.80 $26.19 $9.45 $18.06 $18.06 $6.62 $18.06 $0.00 $0.00 $0.00 $0.00 30100217 EAP CPT® 83021 "Hgb A, S, And C Quant, Hplc" BOTH IP/OP $217.00 $160.58 $0.00 $174.40 $12.41 $12.41 $18.06 $18.06 $9.03 $9.03 $9.12 $9.12 $9.47 $18.06 $8.87 $11.74 $128.36 $128.36 $18.96 $16.78 $172.66 $174.40 $26.19 $0.00 $26.19 $9.45 $18.06 $18.06 $6.62 $18.06 $0.00 $0.00 $0.00 $0.00 30100218 EAP CPT® 83021 "Hgb Phenotyping, Complete" BOTH IP/OP $218.00 $161.32 $6.62 $174.40 $12.41 $12.41 $18.06 $18.06 $9.03 $9.03 $9.12 $9.12 $9.47 $18.06 $8.87 $11.74 $128.95 $128.95 $18.96 $16.78 $172.66 $174.40 $26.19 $29.80 $26.19 $9.45 $18.06 $18.06 $6.62 $18.06 $0.00 $0.00 $0.00 $0.00 30100219 EAP CPT® 83021 "Fetal Hgb Quant, Hplc" BOTH IP/OP $217.00 $160.58 $0.00 $174.40 $12.41 $12.41 $18.06 $18.06 $9.03 $9.03 $9.12 $9.12 $9.47 $18.06 $8.87 $11.74 $128.36 $128.36 $18.96 $16.78 $172.66 $174.40 $26.19 $0.00 $26.19 $9.45 $18.06 $18.06 $6.62 $18.06 $0.00 $0.00 $0.00 $0.00 30100221 EAP CPT® 83036 HGB GLUCOSE A1C BOTH IP/OP $219.00 $162.06 $4.86 $175.20 $20.04 $20.04 $9.71 $9.71 $4.86 $4.86 $14.74 $14.74 $15.30 $9.71 $14.33 $6.31 $129.54 $129.54 $10.20 $27.12 $173.45 $175.20 $14.08 $16.02 $14.08 $15.27 $9.71 $9.71 $10.69 $9.71 $0.00 $0.00 $0.00 $0.00 30100222 EAP CPT® 83051 "Hgb,plasma-quant" BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.10 $11.10 $11.52 $0.00 $10.79 $0.00 $0.00 $0.00 $0.00 $20.42 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100223 EAP CPT® 83060 "Sulfhemoglobin,bld" BOTH IP/OP $164.00 $121.36 $0.00 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.56 $12.56 $13.05 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $23.12 $129.89 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100224 EAP CPT® 83065 "Hgb Denaturat.,heat" BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.46 $10.46 $10.86 $0.00 $10.17 $0.00 $0.00 $0.00 $0.00 $19.24 $115.63 $116.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100225 EAP CPT® 83068 "Hgb Pp't,isopropanol" BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.86 $12.86 $13.36 $0.00 $12.52 $0.00 $0.00 $0.00 $0.00 $23.66 $139.39 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100226 EAP CPT® 83069 "Hemoglobin,urine-qnt" BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.99 $5.99 $6.22 $0.00 $5.83 $0.00 $0.00 $0.00 $0.00 $11.02 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100227 EAP CPT® 83070 "Hemosiderin, Urine" BOTH IP/OP $58.00 $42.92 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.21 $7.21 $7.48 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $13.28 $46.73 $47.20 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100228 EAP CPT® 83080 Hexosaminidase-1 BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $415.80 $420.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100229 EAP CPT® 83150 Homovanillic Acid-24h BOTH IP/OP $94.00 $69.56 $0.00 $87.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.38 $29.38 $30.51 $0.00 $28.59 $0.00 $0.00 $0.00 $0.00 $54.08 $74.45 $75.20 $0.00 $87.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100230 EAP CPT® 83491 "Steroids-17oh,24h Ur" BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.59 $26.59 $27.62 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $48.94 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100231 EAP CPT® 83497 "Serotonin,urine-24" BOTH IP/OP $154.00 $113.96 $6.45 $123.20 $26.61 $26.61 $12.90 $12.90 $6.45 $6.45 $19.58 $19.58 $20.34 $12.90 $19.05 $8.39 $91.09 $91.09 $13.55 $36.02 $121.97 $123.20 $18.71 $21.29 $18.71 $20.30 $12.90 $12.90 $14.21 $12.90 $0.00 $0.00 $0.00 $0.00 30100232 EAP CPT® 83498 "Progesterone,17a-oh" BOTH IP/OP $286.00 $211.64 $13.59 $231.20 $56.07 $56.07 $27.17 $27.17 $13.59 $13.59 $41.25 $41.25 $42.83 $27.17 $40.13 $17.66 $169.17 $169.17 $28.53 $75.90 $228.89 $231.20 $39.40 $44.83 $39.40 $42.76 $27.17 $27.17 $29.93 $27.17 $0.00 $0.00 $0.00 $0.00 30100233 EAP CPT® 83516 T-transglutaminase Iga BOTH IP/OP $181.00 $133.94 $5.76 $140.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $107.06 $107.06 $12.11 $29.88 $139.39 $140.80 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30100234 EAP CPT® 83516 Gliadin Ab Igg BOTH IP/OP $313.00 $231.62 $5.76 $243.20 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $185.14 $185.14 $12.11 $29.88 $240.77 $243.20 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30100235 EAP CPT® 83516 Gliadin Ab Iga BOTH IP/OP $269.00 $199.06 $0.00 $243.20 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $159.11 $159.11 $12.11 $29.88 $240.77 $243.20 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30100236 EAP CPT® 83519 Igf Binding Protein-3 BOTH IP/OP $260.00 $192.40 $8.28 $202.40 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $153.79 $153.79 $19.32 $37.76 $200.38 $202.40 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30100237 EAP CPT® 83519 Gad-65 Autoantibody BOTH IP/OP $260.00 $192.40 $8.28 $202.40 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $153.79 $153.79 $19.32 $37.76 $200.38 $202.40 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30100238 EAP CPT® 84490 "Trypsin,fecal" BOTH IP/OP $119.00 $88.06 $0.00 $119.00 $15.71 $15.71 $9.93 $9.93 $4.97 $0.00 $11.55 $11.55 $12.00 $0.00 $11.25 $0.00 $0.00 $0.00 $0.00 $21.26 $91.87 $92.80 $0.00 $119.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100239 EAP CPT® 80155 Caffeine (so) BOTH IP/OP $570.00 $421.80 $0.00 $443.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.07 $20.07 $20.84 $0.00 $18.13 $0.00 $0.00 $0.00 $0.00 $277.00 $438.77 $443.20 $0.00 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100240 EAP CPT® 83525 "Insulin, Serum" BOTH IP/OP $324.00 $239.76 $5.72 $261.60 $23.60 $23.60 $11.43 $11.43 $5.72 $5.72 $17.36 $17.36 $18.03 $11.43 $16.89 $7.43 $191.65 $191.65 $12.00 $31.96 $258.98 $261.60 $16.57 $18.86 $16.57 $18.00 $11.43 $11.43 $12.60 $11.43 $0.00 $0.00 $0.00 $0.00 30100241 EAP CPT® 83540 "Iron-total,serum" BOTH IP/OP $202.00 $149.48 $3.24 $160.00 $13.36 $13.36 $6.47 $6.47 $3.24 $3.24 $9.84 $9.84 $10.22 $6.47 $9.58 $4.21 $119.48 $119.48 $6.79 $18.10 $158.40 $160.00 $9.38 $10.68 $9.38 $10.20 $6.47 $6.47 $7.14 $6.47 $0.00 $0.00 $0.00 $0.00 30100242 EAP CPT® 83540 "Iron, Liver Tissue" BOTH IP/OP $186.00 $137.64 $0.00 $148.80 $13.36 $13.36 $6.47 $6.47 $3.24 $3.24 $9.84 $9.84 $10.22 $6.47 $9.58 $4.21 $110.02 $110.02 $6.79 $18.10 $147.31 $148.80 $9.38 $0.00 $9.38 $10.20 $6.47 $6.47 $7.14 $6.47 $0.00 $0.00 $0.00 $0.00 30100243 EAP CPT® 83582 "Steroids-17kg,24h Ur" BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.52 $21.52 $22.35 $0.00 $20.94 $0.00 $0.00 $0.00 $0.00 $39.60 $73.66 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100244 EAP CPT® 83593 "Steroids-17keto,24hr" BOTH IP/OP $367.00 $271.58 $0.00 $367.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.94 $39.94 $41.47 $0.00 $38.86 $0.00 $0.00 $0.00 $0.00 $73.50 $290.66 $293.60 $0.00 $367.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100247 EAP CPT® 83605 "Lactic Acid, Blood" BOTH IP/OP $341.00 $252.34 $5.34 $248.80 $22.04 $22.04 $11.57 $11.57 $5.79 $5.34 $16.21 $16.21 $16.84 $11.57 $15.78 $7.52 $201.70 $201.70 $12.15 $29.84 $246.31 $248.80 $16.78 $19.09 $16.78 $16.82 $11.57 $11.57 $11.77 $11.57 $0.00 $0.00 $0.00 $0.00 30100248 EAP CPT® 83605 "Lactic Acid, Csf" BOTH IP/OP $341.00 $252.34 $5.34 $248.80 $22.04 $22.04 $11.57 $11.57 $5.79 $5.34 $16.21 $16.21 $16.84 $11.57 $15.78 $7.52 $201.70 $201.70 $12.15 $29.84 $246.31 $248.80 $16.78 $19.09 $16.78 $16.82 $11.57 $11.57 $11.77 $11.57 $0.00 $0.00 $0.00 $0.00 30100249 EAP CPT® 83605 "LACTIC ACID, FLUID" BOTH IP/OP $258.00 $190.92 $5.34 $248.80 $22.04 $22.04 $11.57 $11.57 $5.79 $5.34 $16.21 $16.21 $16.84 $11.57 $15.78 $7.52 $152.61 $152.61 $12.15 $29.84 $246.31 $248.80 $16.78 $19.09 $16.78 $16.82 $11.57 $11.57 $11.77 $11.57 $0.00 $0.00 $0.00 $0.00 30100251 EAP CPT® 83615 "Ldh,total-serum" BOTH IP/OP $153.00 $113.22 $3.02 $111.20 $12.46 $12.46 $6.04 $6.04 $3.02 $3.02 $9.16 $9.16 $9.51 $6.04 $7.46 $3.93 $90.50 $90.50 $6.34 $16.88 $110.09 $111.20 $8.76 $9.97 $8.76 $7.94 $6.04 $6.04 $5.56 $6.04 $0.00 $0.00 $0.00 $0.00 30100252 EAP CPT® 83615 "Ldh,fluid" BOTH IP/OP $153.00 $113.22 $3.02 $111.20 $12.46 $12.46 $6.04 $6.04 $3.02 $3.02 $9.16 $9.16 $9.51 $6.04 $7.46 $3.93 $90.50 $90.50 $6.34 $16.88 $110.09 $111.20 $8.76 $9.97 $8.76 $7.94 $6.04 $6.04 $5.56 $6.04 $0.00 $0.00 $0.00 $0.00 30100253 EAP CPT® 83615 "LDH,CSF" BOTH IP/OP $139.00 $102.86 $0.00 $111.20 $12.46 $12.46 $6.04 $6.04 $3.02 $3.02 $9.16 $9.16 $9.51 $6.04 $7.46 $3.93 $82.22 $82.22 $6.34 $16.88 $110.09 $111.20 $8.76 $0.00 $8.76 $7.94 $6.04 $6.04 $5.56 $6.04 $0.00 $0.00 $0.00 $0.00 30100254 EAP CPT® 83655 "Lead,blood" BOTH IP/OP $200.00 $148.00 $6.05 $160.00 $25.00 $25.00 $12.11 $12.11 $6.06 $6.05 $18.38 $18.38 $19.08 $12.11 $11.75 $7.87 $118.30 $118.30 $12.72 $33.82 $158.40 $160.00 $17.56 $19.98 $17.56 $12.52 $12.11 $12.11 $8.76 $12.11 $0.00 $0.00 $0.00 $0.00 30100255 EAP CPT® 83655 "Lead,urine-24hr" BOTH IP/OP $195.00 $144.30 $6.05 $156.00 $25.00 $25.00 $12.11 $12.11 $6.06 $6.05 $18.38 $18.38 $19.08 $12.11 $11.75 $7.87 $115.34 $115.34 $12.72 $33.82 $154.44 $156.00 $17.56 $19.98 $17.56 $12.52 $12.11 $12.11 $8.76 $12.11 $0.00 $0.00 $0.00 $0.00 30100256 EAP CPT® 83661 Fetal Lung Maturity BOTH IP/OP $262.00 $193.88 $0.00 $210.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.37 $33.37 $34.66 $0.00 $32.47 $0.00 $0.00 $0.00 $0.00 $61.42 $208.30 $210.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100258 EAP CPT® 83690 "LIPASE, SERUM" BOTH IP/OP $225.00 $166.50 $0.00 $200.80 $14.23 $14.23 $6.89 $6.89 $3.45 $3.44 $10.46 $10.46 $10.86 $6.89 $10.17 $4.48 $133.09 $133.09 $7.23 $19.24 $198.79 $200.80 $9.99 $0.00 $9.99 $10.84 $6.89 $6.89 $7.59 $6.89 $0.00 $0.00 $0.00 $0.00 30100259 EAP CPT® 83698 Plac (lp-pla2) Test BOTH IP/OP $453.00 $335.22 $0.00 $362.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.54 $51.54 $53.52 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $94.86 $358.78 $362.40 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100260 EAP CPT® 83718 "CHOL,HDL" BOTH IP/OP $118.00 $87.32 $0.00 $95.20 $16.92 $16.92 $8.19 $8.19 $4.10 $4.10 $12.44 $12.44 $12.92 $8.19 $12.10 $5.32 $69.80 $69.80 $8.60 $22.88 $94.25 $95.20 $11.88 $0.00 $11.88 $12.89 $8.19 $8.19 $9.02 $8.19 $0.00 $0.00 $0.00 $0.00 30100262 EAP CPT® 83721 "CHOL-LDL, DIRECT" BOTH IP/OP $147.00 $108.78 $0.00 $119.20 $19.69 $19.69 $10.50 $10.50 $5.25 $4.77 $14.49 $14.49 $15.04 $10.50 $14.10 $6.83 $86.95 $86.95 $11.03 $26.66 $118.01 $119.20 $15.23 $0.00 $15.23 $15.03 $10.50 $10.50 $10.52 $10.50 $0.00 $0.00 $0.00 $0.00 30100263 EAP CPT® 83735 Magnesium BOTH IP/OP $188.00 $139.12 $3.35 $136.80 $13.83 $13.83 $6.70 $6.70 $3.35 $3.35 $10.17 $10.17 $10.56 $6.70 $9.89 $4.36 $111.20 $111.20 $7.04 $18.72 $135.43 $136.80 $9.72 $11.06 $9.72 $10.54 $6.70 $6.70 $7.38 $6.70 $0.00 $0.00 $0.00 $0.00 30100264 EAP CPT® 83735 "MAGNESIUM, URINE" BOTH IP/OP $160.00 $118.40 $0.00 $136.80 $13.83 $13.83 $6.70 $6.70 $3.35 $3.35 $10.17 $10.17 $10.56 $6.70 $9.89 $4.36 $94.64 $94.64 $7.04 $18.72 $135.43 $136.80 $9.72 $0.00 $9.72 $10.54 $6.70 $6.70 $7.38 $6.70 $0.00 $0.00 $0.00 $0.00 30100266 EAP CPT® 83825 "Mercury,urine-24hr" BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $33.55 $33.55 $16.26 $16.26 $8.13 $8.13 $24.69 $24.69 $25.64 $16.26 $24.02 $10.57 $49.69 $49.69 $17.07 $45.44 $66.53 $67.20 $23.58 $26.83 $23.58 $0.00 $16.26 $16.26 $17.92 $16.26 $0.00 $0.00 $0.00 $0.00 30100267 EAP CPT® 83835 "Metaneph.tot,ur" BOTH IP/OP $508.00 $375.92 $8.47 $376.80 $34.98 $34.98 $16.94 $16.94 $8.47 $8.47 $25.73 $25.73 $26.72 $16.94 $25.02 $11.01 $300.48 $300.48 $17.79 $47.34 $373.03 $376.80 $24.56 $27.95 $24.56 $26.66 $16.94 $16.94 $18.66 $16.94 $0.00 $0.00 $0.00 $0.00 30100268 EAP CPT® 83835 "Metanephrines, Frac, Plasma" BOTH IP/OP $544.00 $402.56 $8.47 $403.20 $34.98 $34.98 $16.94 $16.94 $8.47 $8.47 $25.73 $25.73 $26.72 $16.94 $25.02 $11.01 $321.78 $321.78 $17.79 $47.34 $399.17 $403.20 $24.56 $27.95 $24.56 $26.66 $16.94 $16.94 $18.66 $16.94 $0.00 $0.00 $0.00 $0.00 30100269 EAP CPT® 83835 "Metanephrines, Urine, Random" BOTH IP/OP $504.00 $372.96 $8.47 $403.20 $34.98 $34.98 $16.94 $16.94 $8.47 $8.47 $25.73 $25.73 $26.72 $16.94 $25.02 $11.01 $298.12 $298.12 $17.79 $47.34 $399.17 $403.20 $24.56 $27.95 $24.56 $26.66 $16.94 $16.94 $18.66 $16.94 $0.00 $0.00 $0.00 $0.00 30100270 EAP CPT® 83864 Mucopolysaccha BOTH IP/OP $388.00 $287.12 $0.00 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.23 $30.23 $31.40 $0.00 $15.87 $0.00 $0.00 $0.00 $0.00 $55.64 $307.30 $310.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100271 EAP CPT® 83874 "Myoglobin-qual,urine" BOTH IP/OP $182.00 $134.68 $6.46 $145.60 $26.66 $26.66 $12.92 $12.92 $6.46 $6.46 $19.61 $19.61 $20.37 $12.92 $19.08 $8.40 $107.65 $107.65 $13.57 $36.08 $144.14 $145.60 $18.73 $21.32 $18.73 $20.33 $12.92 $12.92 $14.23 $12.92 $0.00 $0.00 $0.00 $0.00 30100272 EAP CPT® 83880 B-type Natriurtic Peptide BOTH IP/OP $368.00 $272.32 $17.67 $297.60 $70.07 $70.07 $39.26 $39.26 $19.63 $17.67 $51.54 $51.54 $53.52 $39.26 $50.15 $25.52 $217.67 $217.67 $41.22 $94.86 $294.62 $297.60 $56.93 $64.78 $56.93 $53.43 $39.26 $39.26 $37.40 $39.26 $0.00 $0.00 $0.00 $0.00 30100273 EAP CPT® 83883 Alpha2-macroglbulin BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $105.29 $105.29 $14.28 $38.00 $140.98 $142.40 $19.72 $0.00 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30100274 EAP CPT® 83883 "Albumin-immuno,ser" BOTH IP/OP $176.00 $130.24 $6.80 $142.40 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $104.10 $104.10 $14.28 $38.00 $140.98 $142.40 $19.72 $22.44 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30100275 EAP CPT® 83883 "Albumin,csf-immuno" BOTH IP/OP $176.00 $130.24 $6.80 $142.40 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $104.10 $104.10 $14.28 $38.00 $140.98 $142.40 $19.72 $22.44 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30100276 EAP CPT® 83883 "Albumin,urine-immuno" BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $105.29 $105.29 $14.28 $38.00 $140.98 $142.40 $19.72 $0.00 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30100277 EAP CPT® 83883 C-1 Esterase Inhib BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $99.37 $99.37 $14.28 $38.00 $133.06 $134.40 $19.72 $0.00 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30100278 EAP CPT® 83883 Free Kappa BOTH IP/OP $176.00 $130.24 $6.80 $142.40 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $104.10 $104.10 $14.28 $38.00 $140.98 $142.40 $19.72 $22.44 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30100279 EAP CPT® 83883 Free Lambda BOTH IP/OP $176.00 $130.24 $6.80 $142.40 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $104.10 $104.10 $14.28 $38.00 $140.98 $142.40 $19.72 $22.44 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30100280 EAP CPT® 80323 Nicotine BOTH IP/OP $422.00 $312.28 $0.00 $337.60 $0.03 $0.03 $0.00 $0.00 $12.01 $18.43 $313.21 $313.21 $325.28 $0.00 $44.34 $0.00 $249.61 $249.61 $0.00 $211.00 $334.22 $337.60 $253.20 $249.60 $253.20 $47.25 $0.00 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 30100296 EAP CPT® 83915 5'-nucleotidase BOTH IP/OP $63.00 $46.62 $0.00 $51.20 $23.02 $23.02 $11.15 $11.15 $5.58 $5.58 $16.94 $16.94 $17.59 $11.15 $16.47 $7.25 $37.26 $37.26 $0.00 $31.16 $50.69 $51.20 $0.00 $18.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100297 EAP CPT® 83921 Methylmalonic Acid BOTH IP/OP $241.00 $178.34 $9.54 $194.40 $33.95 $33.95 $21.21 $21.21 $10.61 $9.54 $25.00 $25.00 $25.96 $21.21 $24.32 $13.79 $142.55 $142.55 $22.27 $46.00 $192.46 $194.40 $30.75 $35.00 $30.75 $25.91 $21.21 $21.21 $18.14 $21.21 $0.00 $0.00 $0.00 $0.00 30100298 EAP CPT® 83921 Orotic Acid BOTH IP/OP $241.00 $178.34 $9.54 $194.40 $33.95 $33.95 $21.21 $21.21 $10.61 $9.54 $25.00 $25.00 $25.96 $21.21 $24.32 $13.79 $142.55 $142.55 $22.27 $46.00 $192.46 $194.40 $30.75 $35.00 $30.75 $25.91 $21.21 $21.21 $18.14 $21.21 $0.00 $0.00 $0.00 $0.00 30100299 EAP CPT® 83930 "Osmolality,crystal" BOTH IP/OP $230.00 $170.20 $3.31 $192.80 $13.65 $13.65 $6.61 $6.61 $3.31 $3.31 $10.04 $10.04 $10.42 $6.61 $9.78 $4.30 $136.05 $136.05 $6.94 $18.48 $190.87 $192.80 $9.58 $10.91 $9.58 $10.42 $6.61 $6.61 $7.29 $6.61 $0.00 $0.00 $0.00 $0.00 30100300 EAP CPT® 83930 Osmolality BOTH IP/OP $265.00 $196.10 $3.31 $192.80 $13.65 $13.65 $6.61 $6.61 $3.31 $3.31 $10.04 $10.04 $10.42 $6.61 $9.78 $4.30 $156.75 $156.75 $6.94 $18.48 $190.87 $192.80 $9.58 $10.91 $9.58 $10.42 $6.61 $6.61 $7.29 $6.61 $0.00 $0.00 $0.00 $0.00 30100301 EAP CPT® 83935 "Osmolality,fluid" BOTH IP/OP $272.00 $201.28 $3.41 $197.60 $14.07 $14.07 $6.82 $6.82 $3.41 $3.41 $10.35 $10.35 $10.75 $6.82 $10.07 $4.43 $160.89 $160.89 $7.16 $19.04 $195.62 $197.60 $9.89 $11.25 $9.89 $10.73 $6.82 $6.82 $7.51 $6.82 $0.00 $0.00 $0.00 $0.00 30100302 EAP CPT® 83935 "Osmolality,urine" BOTH IP/OP $272.00 $201.28 $3.41 $197.60 $14.07 $14.07 $6.82 $6.82 $3.41 $3.41 $10.35 $10.35 $10.75 $6.82 $10.07 $4.43 $160.89 $160.89 $7.16 $19.04 $195.62 $197.60 $9.89 $11.25 $9.89 $10.73 $6.82 $6.82 $7.51 $6.82 $0.00 $0.00 $0.00 $0.00 30100303 EAP CPT® 83945 "Oxalate, Urine-24hr" BOTH IP/OP $53.00 $39.22 $0.00 $42.40 $26.58 $26.58 $14.45 $14.45 $7.23 $6.50 $19.55 $19.55 $20.30 $14.45 $19.02 $9.39 $31.35 $31.35 $0.00 $35.98 $41.98 $42.40 $0.00 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100304 EAP CPT® 83970 Parathormone Intact BOTH IP/OP $502.00 $371.48 $20.64 $401.60 $85.19 $85.19 $41.28 $41.28 $20.64 $20.64 $62.68 $62.68 $65.09 $41.28 $60.97 $26.83 $296.93 $296.93 $43.34 $115.34 $397.58 $401.60 $59.86 $68.11 $59.86 $64.97 $41.28 $41.28 $45.48 $41.28 $0.00 $0.00 $0.00 $0.00 30100306 EAP CPT® 83986 "Ph, Stool" BOTH IP/OP $86.00 $63.64 $0.00 $62.40 $7.39 $7.39 $3.58 $3.58 $1.79 $1.79 $5.43 $5.43 $5.64 $3.58 $5.28 $2.33 $50.87 $50.87 $3.76 $10.00 $61.78 $62.40 $5.19 $5.91 $5.19 $0.00 $3.58 $3.58 $3.94 $3.58 $0.00 $0.00 $0.00 $0.00 30100307 EAP CPT® 84075 Alk Phosphatase BOTH IP/OP $110.00 $81.40 $2.59 $84.00 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.46 $3.37 $65.07 $65.07 $5.44 $14.46 $83.16 $84.00 $7.51 $8.55 $7.51 $7.94 $5.18 $5.18 $5.56 $5.18 $0.00 $0.00 $0.00 $0.00 30100308 EAP CPT® 84075 "Alk Phos,fluid" BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.46 $3.37 $65.07 $65.07 $5.44 $14.46 $87.12 $88.00 $7.51 $0.00 $7.51 $7.94 $5.18 $5.18 $5.56 $5.18 $0.00 $0.00 $0.00 $0.00 30100309 EAP CPT® 84080 Alk Phos Isoenzymes BOTH IP/OP $316.00 $233.84 $7.39 $240.80 $30.52 $30.52 $14.78 $14.78 $7.39 $7.39 $22.45 $22.45 $23.32 $14.78 $21.84 $9.61 $186.91 $186.91 $15.52 $41.32 $238.39 $240.80 $21.43 $24.39 $21.43 $23.27 $14.78 $14.78 $16.29 $14.78 $0.00 $0.00 $0.00 $0.00 30100310 EAP CPT® 84081 Pg Agglutinin Test BOTH IP/OP $194.00 $143.56 $0.00 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.08 $25.08 $26.05 $0.00 $24.41 $0.00 $0.00 $0.00 $0.00 $46.18 $153.65 $155.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100311 EAP CPT® 84100 Phosphorus BOTH IP/OP $150.00 $111.00 $2.37 $108.80 $9.79 $9.79 $4.74 $4.74 $2.37 $2.37 $7.21 $7.21 $7.48 $4.74 $7.01 $3.08 $88.73 $88.73 $4.98 $13.26 $107.71 $108.80 $6.87 $7.82 $6.87 $7.47 $4.74 $4.74 $5.23 $4.74 $0.00 $0.00 $0.00 $0.00 30100312 EAP CPT® 84100 "Phosporus, Serum" BOTH IP/OP $128.00 $94.72 $2.37 $108.80 $9.79 $9.79 $4.74 $4.74 $2.37 $2.37 $7.21 $7.21 $7.48 $4.74 $7.01 $3.08 $75.71 $75.71 $4.98 $13.26 $107.71 $108.80 $6.87 $7.82 $6.87 $7.47 $4.74 $4.74 $5.23 $4.74 $0.00 $0.00 $0.00 $0.00 30100313 EAP CPT® 84105 "Phosphorus, Urine" BOTH IP/OP $164.00 $121.36 $2.60 $119.20 $10.69 $10.69 $5.78 $5.78 $2.89 $2.60 $7.86 $7.86 $8.16 $5.78 $7.64 $3.76 $97.01 $97.01 $6.07 $14.46 $118.01 $119.20 $8.38 $9.54 $8.38 $8.14 $5.78 $5.78 $5.70 $5.78 $0.00 $0.00 $0.00 $0.00 30100314 EAP CPT® 84110 Porphobilinogen-24hr BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.83 $12.83 $13.33 $0.00 $12.47 $0.00 $0.00 $0.00 $8.86 $23.60 $59.40 $60.00 $12.24 $0.00 $12.24 $13.29 $8.44 $8.44 $9.30 $8.44 $0.00 $0.00 $0.00 $0.00 30100315 EAP CPT® 84120 "Porphyrins,ur-quant" BOTH IP/OP $109.00 $80.66 $0.00 $109.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.36 $22.33 $22.33 $23.19 $14.71 $21.74 $9.56 $64.47 $64.47 $0.00 $41.10 $86.33 $87.20 $0.00 $109.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100316 EAP CPT® 84132 "Potassium, Wb" BOTH IP/OP $141.00 $104.34 $2.30 $112.80 $9.50 $9.50 $4.76 $4.76 $2.38 $2.30 $6.97 $6.97 $7.24 $4.76 $6.79 $3.09 $83.40 $83.40 $5.00 $12.84 $111.67 $112.80 $6.90 $7.85 $6.90 $7.24 $4.76 $4.76 $5.07 $4.76 $0.00 $0.00 $0.00 $0.00 30100317 EAP CPT® 84132 Potassium BOTH IP/OP $141.00 $104.34 $2.30 $112.80 $9.50 $9.50 $4.76 $4.76 $2.38 $2.30 $6.97 $6.97 $7.24 $4.76 $6.79 $3.09 $83.40 $83.40 $5.00 $12.84 $111.67 $112.80 $6.90 $7.85 $6.90 $7.24 $4.76 $4.76 $5.07 $4.76 $0.00 $0.00 $0.00 $0.00 30100318 EAP CPT® 84132 "Potassium,plasma" BOTH IP/OP $141.00 $104.34 $2.30 $112.80 $9.50 $9.50 $4.76 $4.76 $2.38 $2.30 $6.97 $6.97 $7.24 $4.76 $6.79 $3.09 $83.40 $83.40 $5.00 $12.84 $111.67 $112.80 $6.90 $7.85 $6.90 $7.24 $4.76 $4.76 $5.07 $4.76 $0.00 $0.00 $0.00 $0.00 30100319 EAP CPT® 84133 "Potassium,fluid" BOTH IP/OP $106.00 $78.44 $2.16 $84.80 $8.90 $8.90 $4.73 $4.73 $2.37 $2.16 $6.53 $6.53 $6.78 $4.73 $6.35 $3.07 $62.70 $62.70 $4.97 $12.02 $83.95 $84.80 $6.86 $7.80 $6.86 $6.77 $4.73 $4.73 $4.74 $4.73 $0.00 $0.00 $0.00 $0.00 30100320 EAP CPT® 84133 "Potassium, Urine" BOTH IP/OP $106.00 $78.44 $2.16 $84.80 $8.90 $8.90 $4.73 $4.73 $2.37 $2.16 $6.53 $6.53 $6.78 $4.73 $6.35 $3.07 $62.70 $62.70 $4.97 $12.02 $83.95 $84.80 $6.86 $7.80 $6.86 $6.77 $4.73 $4.73 $4.74 $4.73 $0.00 $0.00 $0.00 $0.00 30100321 EAP CPT® 84134 Prealbumin BOTH IP/OP $282.00 $208.68 $7.29 $204.80 $30.12 $30.12 $14.59 $14.59 $7.30 $7.29 $22.15 $22.15 $23.00 $14.59 $21.55 $9.48 $166.80 $166.80 $15.32 $40.76 $202.75 $204.80 $21.16 $24.07 $21.16 $22.96 $14.59 $14.59 $16.07 $14.59 $0.00 $0.00 $0.00 $0.00 30100322 EAP CPT® 84135 "Pregnanediol,ur-24hr" BOTH IP/OP $210.00 $155.40 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.06 $29.06 $30.18 $0.00 $43.76 $0.00 $0.00 $0.00 $0.00 $53.46 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100323 EAP CPT® 84138 "Pregnanetriol,ur-24h" BOTH IP/OP $209.00 $154.66 $0.00 $178.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.76 $28.76 $29.86 $0.00 $27.97 $0.00 $0.00 $0.00 $0.00 $52.92 $176.62 $178.40 $0.00 $95.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100324 EAP CPT® 84144 "Progesterone, Serum" BOTH IP/OP $222.00 $164.28 $10.43 $179.20 $42.06 $42.06 $20.86 $20.86 $10.43 $10.43 $30.93 $30.93 $32.12 $20.86 $30.08 $13.56 $131.31 $131.31 $21.90 $56.92 $177.41 $179.20 $30.25 $34.42 $30.25 $32.05 $20.86 $20.86 $22.44 $20.86 $0.00 $0.00 $0.00 $0.00 30100325 EAP CPT® 84146 "Prolactin,serum" BOTH IP/OP $427.00 $315.98 $9.69 $341.60 $40.00 $40.00 $19.38 $19.38 $9.69 $9.69 $29.43 $29.43 $30.56 $19.38 $28.63 $12.60 $252.57 $252.57 $20.35 $54.16 $338.18 $341.60 $28.10 $31.98 $28.10 $30.51 $19.38 $19.38 $21.36 $19.38 $0.00 $0.00 $0.00 $0.00 30100326 EAP CPT® 84153 Prostatic Antigen BOTH IP/OP $335.00 $247.90 $9.20 $268.00 $37.96 $37.96 $18.39 $18.39 $9.20 $9.20 $27.92 $27.92 $29.00 $18.39 $27.17 $11.95 $198.15 $198.15 $19.31 $51.40 $265.32 $268.00 $26.67 $30.34 $26.67 $28.95 $18.39 $18.39 $20.27 $18.39 $0.00 $0.00 $0.00 $0.00 30100327 EAP CPT® 84155 "Protein,total" BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $7.58 $7.58 $3.67 $3.67 $1.84 $1.83 $5.56 $5.56 $5.78 $3.67 $5.42 $2.39 $78.08 $78.08 $0.00 $10.24 $104.54 $105.60 $0.00 $6.06 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100328 EAP CPT® 84155 "Protein, Csf" BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $7.58 $7.58 $3.67 $3.67 $1.84 $1.83 $5.56 $5.56 $5.78 $3.67 $5.42 $2.39 $78.08 $78.08 $0.00 $10.24 $104.54 $105.60 $0.00 $6.06 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100329 EAP CPT® 84155 "Protein,total" BOTH IP/OP $135.00 $99.90 $0.00 $105.60 $7.58 $7.58 $3.67 $3.67 $1.84 $1.83 $5.56 $5.56 $5.78 $3.67 $5.42 $2.39 $79.85 $79.85 $0.00 $10.24 $104.54 $105.60 $0.00 $6.06 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100330 EAP CPT® 84156 "Protein,ur (quant)" BOTH IP/OP $132.00 $97.68 $1.83 $103.20 $7.58 $7.58 $3.67 $3.67 $1.84 $1.83 $5.56 $5.56 $5.78 $3.67 $5.42 $2.39 $78.08 $78.08 $3.85 $10.24 $102.17 $103.20 $5.32 $6.06 $5.32 $5.77 $3.67 $3.67 $4.04 $3.67 $0.00 $0.00 $0.00 $0.00 30100331 EAP CPT® 84157 "Protein,fluid" BOTH IP/OP $155.00 $114.70 $1.83 $121.60 $7.58 $7.58 $4.00 $4.00 $2.00 $1.83 $5.56 $5.56 $5.78 $4.00 $5.42 $2.60 $91.68 $91.68 $4.20 $10.24 $120.38 $121.60 $5.80 $6.60 $5.80 $5.77 $4.00 $4.00 $4.04 $4.00 $0.00 $0.00 $0.00 $0.00 30100332 EAP CPT® 84157 "Protein, Csf" BOTH IP/OP $155.00 $114.70 $1.83 $121.60 $7.58 $7.58 $4.00 $4.00 $2.00 $1.83 $5.56 $5.56 $5.78 $4.00 $5.42 $2.60 $91.68 $91.68 $4.20 $10.24 $120.38 $121.60 $5.80 $6.60 $5.80 $5.77 $4.00 $4.00 $4.04 $4.00 $0.00 $0.00 $0.00 $0.00 30100333 EAP CPT® 84165 "Protein Elect, Serum" BOTH IP/OP $357.00 $264.18 $5.37 $280.00 $22.18 $22.18 $10.74 $10.74 $5.37 $5.37 $16.31 $16.31 $16.93 $10.74 $15.87 $6.98 $211.17 $211.17 $11.28 $30.02 $277.20 $280.00 $15.57 $17.72 $15.57 $16.91 $10.74 $10.74 $11.83 $10.74 $0.00 $0.00 $0.00 $0.00 30100334 EAP CPT® 84166 "Protein Electrophoresis, Csf" BOTH IP/OP $350.00 $259.00 $8.91 $280.00 $36.80 $36.80 $17.83 $17.83 $8.92 $8.91 $27.08 $27.08 $28.12 $17.83 $26.34 $11.59 $207.03 $207.03 $18.72 $49.84 $277.20 $280.00 $25.85 $29.42 $25.85 $28.07 $17.83 $17.83 $19.65 $17.83 $0.00 $0.00 $0.00 $0.00 30100335 EAP CPT® 84166 "Protein Elect, Urine" BOTH IP/OP $357.00 $264.18 $8.91 $280.00 $36.80 $36.80 $17.83 $17.83 $8.92 $8.91 $27.08 $27.08 $28.12 $17.83 $26.34 $11.59 $211.17 $211.17 $18.72 $49.84 $277.20 $280.00 $25.85 $29.42 $25.85 $28.07 $17.83 $17.83 $19.65 $17.83 $0.00 $0.00 $0.00 $0.00 30100336 EAP CPT® 84202 "Protoporphyrin,rbc" BOTH IP/OP $74.00 $54.76 $0.00 $59.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.79 $21.79 $22.63 $0.00 $21.20 $0.00 $0.00 $0.00 $0.00 $40.10 $58.61 $59.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100337 EAP CPT® 84207 Vitamine B6; Pyridoxine BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.66 $42.66 $44.30 $0.00 $41.51 $0.00 $0.00 $0.00 $0.00 $78.50 $633.60 $640.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100338 EAP CPT® 84210 "Pyruvic Acid, Blood" BOTH IP/OP $118.00 $87.32 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.48 $16.48 $17.12 $0.00 $16.03 $0.00 $0.00 $0.00 $15.20 $30.34 $93.46 $94.40 $21.00 $118.00 $21.00 $0.00 $14.48 $14.48 $11.96 $14.48 $0.00 $0.00 $0.00 $0.00 30100339 EAP CPT® 84238 Acetcholn Reptor Ad BOTH IP/OP $201.00 $148.74 $18.28 $162.40 $75.48 $75.48 $36.57 $36.57 $18.29 $18.28 $55.53 $55.53 $57.66 $36.57 $54.01 $23.77 $118.89 $118.89 $38.40 $102.18 $160.78 $162.40 $53.03 $60.34 $53.03 $57.55 $36.57 $36.57 $40.29 $36.57 $0.00 $0.00 $0.00 $0.00 30100340 EAP CPT® 84244 "Renin, Blood" BOTH IP/OP $322.00 $238.28 $11.00 $260.00 $45.41 $45.41 $21.99 $21.99 $11.00 $11.00 $33.40 $33.40 $34.69 $21.99 $32.50 $14.29 $190.46 $190.46 $23.09 $61.46 $257.40 $260.00 $31.89 $36.28 $31.89 $34.63 $21.99 $21.99 $24.24 $21.99 $0.00 $0.00 $0.00 $0.00 30100341 EAP CPT® 84295 "Sodium, Wb" BOTH IP/OP $220.00 $162.80 $2.41 $160.00 $9.93 $9.93 $4.81 $4.81 $2.41 $2.41 $7.30 $7.30 $7.58 $4.81 $7.11 $3.13 $130.13 $130.13 $5.05 $13.44 $158.40 $160.00 $6.97 $7.94 $6.97 $7.57 $4.81 $4.81 $5.30 $4.81 $0.00 $0.00 $0.00 $0.00 30100342 EAP CPT® 84295 Sodium BOTH IP/OP $220.00 $162.80 $2.41 $160.00 $9.93 $9.93 $4.81 $4.81 $2.41 $2.41 $7.30 $7.30 $7.58 $4.81 $7.11 $3.13 $130.13 $130.13 $5.05 $13.44 $158.40 $160.00 $6.97 $7.94 $6.97 $7.57 $4.81 $4.81 $5.30 $4.81 $0.00 $0.00 $0.00 $0.00 30100343 EAP CPT® 84295 Sodium-direct Ise BOTH IP/OP $190.00 $140.60 $2.41 $160.00 $9.93 $9.93 $4.81 $4.81 $2.41 $2.41 $7.30 $7.30 $7.58 $4.81 $7.11 $3.13 $112.39 $112.39 $5.05 $13.44 $158.40 $160.00 $6.97 $7.94 $6.97 $7.57 $4.81 $4.81 $5.30 $4.81 $0.00 $0.00 $0.00 $0.00 30100344 EAP CPT® 84300 "Sodium, Urine" BOTH IP/OP $144.00 $106.56 $2.43 $104.80 $7.13 $7.13 $5.06 $5.06 $2.53 $2.43 $5.25 $5.25 $5.45 $5.06 $5.11 $3.29 $85.18 $85.18 $5.31 $9.66 $103.75 $104.80 $7.34 $8.35 $7.34 $5.45 $5.06 $5.06 $3.81 $5.06 $0.00 $0.00 $0.00 $0.00 30100345 EAP CPT® 84302 "Sodium,fluid" BOTH IP/OP $144.00 $106.56 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $5.25 $5.45 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $9.66 $103.75 $104.80 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100346 EAP CPT® 84305 Igf-1(somatomedin C) BOTH IP/OP $283.00 $209.42 $10.63 $220.00 $43.90 $43.90 $21.26 $21.26 $10.63 $10.63 $32.28 $32.28 $33.52 $21.26 $31.41 $13.82 $167.39 $167.39 $22.32 $59.40 $217.80 $220.00 $30.83 $35.08 $30.83 $33.46 $21.26 $21.26 $23.42 $21.26 $0.00 $0.00 $0.00 $0.00 30100347 EAP CPT® 84375 Oligosaccharide BOTH IP/OP $134.00 $99.16 $0.00 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.76 $29.76 $30.91 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $54.78 $106.13 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100348 EAP CPT® 84402 "Testosterone, Free" BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $52.59 $52.59 $25.47 $25.47 $12.74 $12.74 $38.67 $38.67 $40.15 $25.47 $37.60 $16.56 $56.19 $56.19 $26.74 $71.14 $75.24 $76.00 $36.93 $0.00 $36.93 $40.06 $25.47 $25.47 $28.04 $25.47 $0.00 $0.00 $0.00 $0.00 30100349 EAP CPT® 84403 "Testosterone, Total" BOTH IP/OP $384.00 $284.16 $0.00 $307.20 $53.28 $53.28 $25.81 $25.81 $12.91 $12.91 $39.21 $39.21 $40.72 $25.81 $38.15 $16.78 $227.14 $227.14 $27.10 $72.16 $304.13 $307.20 $37.42 $0.00 $37.42 $40.65 $25.81 $25.81 $28.45 $25.81 $0.00 $0.00 $0.00 $0.00 30100350 EAP CPT® 84403 "Testosterone, Serum" BOTH IP/OP $384.00 $284.16 $12.91 $307.20 $53.28 $53.28 $25.81 $25.81 $12.91 $12.91 $39.21 $39.21 $40.72 $25.81 $38.15 $16.78 $227.14 $227.14 $27.10 $72.16 $304.13 $307.20 $37.42 $42.59 $37.42 $40.65 $25.81 $25.81 $28.45 $25.81 $0.00 $0.00 $0.00 $0.00 30100351 EAP CPT® 84425 Vitamine B1; Thyamin BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $43.82 $43.82 $21.23 $21.23 $10.62 $10.62 $32.25 $32.25 $33.49 $21.23 $31.36 $13.80 $163.25 $163.25 $22.29 $59.34 $218.59 $220.80 $30.78 $0.00 $30.78 $33.42 $21.23 $21.23 $23.39 $21.23 $0.00 $0.00 $0.00 $0.00 30100352 EAP CPT® 84430 Thiocyanate-quant BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.76 $8.76 $9.09 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $16.12 $157.61 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100353 EAP CPT® 84432 "Thyroglobulin, Quant" BOTH IP/OP $214.00 $158.36 $8.03 $171.20 $33.16 $33.16 $16.06 $16.06 $8.03 $8.03 $24.39 $24.39 $25.33 $16.06 $23.73 $10.44 $126.58 $126.58 $16.86 $44.88 $169.49 $171.20 $23.29 $26.50 $23.29 $25.28 $16.06 $16.06 $17.70 $16.06 $0.00 $0.00 $0.00 $0.00 30100354 EAP CPT® 84436 "Thyroxine,total(t4)" BOTH IP/OP $322.00 $238.28 $3.43 $258.40 $14.18 $14.18 $6.87 $6.87 $3.44 $3.43 $10.43 $10.43 $10.83 $6.87 $10.16 $4.47 $190.46 $190.46 $7.21 $19.22 $255.82 $258.40 $9.96 $11.34 $9.96 $10.83 $6.87 $6.87 $7.58 $6.87 $0.00 $0.00 $0.00 $0.00 30100355 EAP CPT® 84439 Free Thyroxine BOTH IP/OP $215.00 $159.10 $4.51 $172.00 $18.61 $18.61 $9.02 $9.02 $4.51 $4.51 $13.70 $13.70 $14.22 $9.02 $13.32 $5.86 $127.17 $127.17 $9.47 $25.20 $170.28 $172.00 $13.08 $14.88 $13.08 $14.20 $9.02 $9.02 $9.94 $9.02 $0.00 $0.00 $0.00 $0.00 30100356 EAP CPT® 84442 Thyroxine Bind.glob. BOTH IP/OP $63.00 $46.62 $0.00 $63.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $15.52 $32.52 $49.90 $50.40 $21.43 $63.00 $21.43 $18.31 $14.78 $14.78 $12.82 $14.78 $0.00 $0.00 $0.00 $0.00 30100357 EAP CPT® 84443 "Tsh,serum-irma" BOTH IP/OP $275.00 $203.50 $8.40 $220.00 $34.69 $34.69 $16.80 $16.80 $8.40 $8.40 $25.51 $25.51 $26.49 $16.80 $24.81 $10.92 $162.66 $162.66 $17.64 $46.94 $217.80 $220.00 $24.36 $27.72 $24.36 $26.44 $16.80 $16.80 $18.51 $16.80 $0.00 $0.00 $0.00 $0.00 30100358 EAP CPT® 84446 "Vitamin E, Serum" BOTH IP/OP $178.00 $131.72 $7.09 $178.00 $29.28 $29.28 $14.18 $14.18 $7.09 $7.09 $21.53 $21.53 $22.36 $14.18 $20.95 $9.22 $105.29 $105.29 $14.89 $39.62 $140.98 $142.40 $20.56 $178.00 $20.56 $22.32 $14.18 $14.18 $15.62 $14.18 $0.00 $0.00 $0.00 $0.00 30100359 EAP CPT® 84450 "Sgot(ast),serum" BOTH IP/OP $63.00 $46.62 $2.59 $51.20 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.85 $7.85 $8.15 $5.18 $7.46 $3.37 $37.26 $37.26 $5.44 $14.44 $50.69 $51.20 $7.51 $8.55 $7.51 $7.94 $5.18 $5.18 $5.56 $5.18 $0.00 $0.00 $0.00 $0.00 30100360 EAP CPT® 84460 Sgpt(alt)-rate BOTH IP/OP $63.00 $46.62 $2.65 $51.20 $10.93 $10.93 $5.30 $5.30 $2.65 $2.65 $8.04 $8.04 $8.35 $5.30 $7.46 $3.45 $37.26 $37.26 $5.57 $14.80 $50.69 $51.20 $7.69 $8.75 $7.69 $7.94 $5.30 $5.30 $5.56 $5.30 $0.00 $0.00 $0.00 $0.00 30100361 EAP CPT® 84466 Transferrin BOTH IP/OP $340.00 $251.60 $6.38 $274.40 $26.35 $26.35 $12.76 $12.76 $6.38 $6.38 $19.39 $19.39 $20.13 $12.76 $18.87 $8.29 $201.11 $201.11 $13.40 $35.68 $271.66 $274.40 $18.50 $21.05 $18.50 $20.10 $12.76 $12.76 $14.07 $12.76 $0.00 $0.00 $0.00 $0.00 30100362 EAP CPT® 84478 Triglyceride-serum BOTH IP/OP $131.00 $96.94 $0.00 $120.00 $11.85 $11.85 $5.74 $5.74 $2.87 $2.87 $8.74 $8.74 $9.07 $5.74 $7.46 $3.73 $77.49 $77.49 $6.03 $16.08 $118.80 $120.00 $8.32 $0.00 $8.32 $7.94 $5.74 $5.74 $5.56 $5.74 $0.00 $0.00 $0.00 $0.00 30100363 EAP CPT® 84478 Triglyceride BOTH IP/OP $152.00 $112.48 $2.87 $120.00 $11.85 $11.85 $5.74 $5.74 $2.87 $2.87 $8.74 $8.74 $9.07 $5.74 $7.46 $3.73 $89.91 $89.91 $6.03 $16.08 $118.80 $120.00 $8.32 $9.47 $8.32 $7.94 $5.74 $5.74 $5.56 $5.74 $0.00 $0.00 $0.00 $0.00 30100364 EAP CPT® 84478 "Triglyceride,fluid" BOTH IP/OP $152.00 $112.48 $2.87 $120.00 $11.85 $11.85 $5.74 $5.74 $2.87 $2.87 $8.74 $8.74 $9.07 $5.74 $7.46 $3.73 $89.91 $89.91 $6.03 $16.08 $118.80 $120.00 $8.32 $9.47 $8.32 $7.94 $5.74 $5.74 $5.56 $5.74 $0.00 $0.00 $0.00 $0.00 30100365 EAP CPT® 84478 Triglyceride BOTH IP/OP $114.00 $84.36 $0.00 $104.80 $11.85 $11.85 $5.74 $5.74 $2.87 $2.87 $8.74 $8.74 $9.07 $5.74 $7.46 $3.73 $67.43 $67.43 $6.03 $16.08 $103.75 $104.80 $8.32 $0.00 $8.32 $7.94 $5.74 $5.74 $5.56 $5.74 $0.00 $0.00 $0.00 $0.00 30100366 EAP CPT® 84480 T3-triiodothyronine BOTH IP/OP $302.00 $223.48 $7.09 $239.20 $26.35 $26.35 $14.18 $14.18 $7.09 $7.09 $19.35 $19.35 $20.10 $14.18 $18.83 $9.22 $178.63 $178.63 $14.89 $35.62 $236.81 $239.20 $20.56 $23.40 $20.56 $20.06 $14.18 $14.18 $14.04 $14.18 $0.00 $0.00 $0.00 $0.00 30100367 EAP CPT® 84484 Troponin-1 BOTH IP/OP $416.00 $307.84 $5.61 $336.00 $20.33 $20.33 $12.47 $12.47 $6.24 $5.61 $14.94 $14.94 $15.52 $12.47 $14.54 $8.11 $246.06 $246.06 $13.09 $27.50 $332.64 $336.00 $18.08 $20.58 $18.08 $15.50 $12.47 $12.47 $10.85 $12.47 $0.00 $0.00 $0.00 $0.00 30100368 EAP CPT® 84484 Troponin-t BOTH IP/OP $416.00 $307.84 $5.61 $336.00 $20.33 $20.33 $12.47 $12.47 $6.24 $5.61 $14.94 $14.94 $15.52 $12.47 $14.54 $8.11 $246.06 $246.06 $13.09 $27.50 $332.64 $336.00 $18.08 $20.58 $18.08 $15.50 $12.47 $12.47 $10.85 $12.47 $0.00 $0.00 $0.00 $0.00 30100369 EAP CPT® 84520 Urea Nitrogen BOTH IP/OP $147.00 $108.78 $0.00 $118.40 $8.16 $8.16 $3.95 $3.95 $1.98 $1.98 $5.99 $5.99 $6.22 $3.95 $5.83 $2.57 $86.95 $86.95 $0.00 $11.02 $117.22 $118.40 $0.00 $6.52 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100370 EAP CPT® 84540 "Urea Nitrogen,fluid" BOTH IP/OP $171.00 $126.54 $2.50 $138.40 $9.79 $9.79 $5.56 $5.56 $2.78 $2.50 $7.21 $7.21 $7.48 $5.56 $7.02 $3.61 $101.15 $101.15 $5.84 $13.28 $137.02 $138.40 $8.06 $9.17 $8.06 $7.48 $5.56 $5.56 $5.24 $5.56 $0.00 $0.00 $0.00 $0.00 30100371 EAP CPT® 84540 "Urea Nitrogen,urine" BOTH IP/OP $171.00 $126.54 $2.50 $138.40 $9.79 $9.79 $5.56 $5.56 $2.78 $2.50 $7.21 $7.21 $7.48 $5.56 $7.02 $3.61 $101.15 $101.15 $5.84 $13.28 $137.02 $138.40 $8.06 $9.17 $8.06 $7.48 $5.56 $5.56 $5.24 $5.56 $0.00 $0.00 $0.00 $0.00 30100372 EAP CPT® 84550 Uric Acid - Serum BOTH IP/OP $141.00 $104.34 $2.26 $112.80 $9.32 $9.32 $4.52 $4.52 $2.26 $2.26 $6.85 $6.85 $7.12 $4.52 $6.67 $2.94 $83.40 $83.40 $4.75 $12.62 $111.67 $112.80 $6.55 $7.46 $6.55 $7.10 $4.52 $4.52 $4.97 $4.52 $0.00 $0.00 $0.00 $0.00 30100373 EAP CPT® 84550 Uric Acid BOTH IP/OP $140.00 $103.60 $2.26 $112.80 $9.32 $9.32 $4.52 $4.52 $2.26 $2.26 $6.85 $6.85 $7.12 $4.52 $6.67 $2.94 $82.81 $82.81 $4.75 $12.62 $111.67 $112.80 $6.55 $7.46 $6.55 $7.10 $4.52 $4.52 $4.97 $4.52 $0.00 $0.00 $0.00 $0.00 30100374 EAP CPT® 84560 "Uric Acid,syn Fluid" BOTH IP/OP $140.00 $103.60 $2.37 $112.80 $9.79 $9.79 $5.08 $5.08 $2.54 $2.37 $7.21 $7.21 $7.48 $5.08 $7.02 $3.30 $82.81 $82.81 $5.33 $13.28 $111.67 $112.80 $7.37 $8.38 $7.37 $7.48 $5.08 $5.08 $5.24 $5.08 $0.00 $0.00 $0.00 $0.00 30100375 EAP CPT® 84560 "Uric Acid, Urine" BOTH IP/OP $140.00 $103.60 $2.37 $112.80 $9.79 $9.79 $5.08 $5.08 $2.54 $2.37 $7.21 $7.21 $7.48 $5.08 $7.02 $3.30 $82.81 $82.81 $5.33 $13.28 $111.67 $112.80 $7.37 $8.38 $7.37 $7.48 $5.08 $5.08 $5.24 $5.08 $0.00 $0.00 $0.00 $0.00 30100376 EAP CPT® 84585 "Vma, Urine-24hr" BOTH IP/OP $85.00 $62.90 $0.00 $85.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.55 $23.55 $24.45 $0.00 $22.90 $0.00 $0.00 $0.00 $0.00 $43.32 $67.32 $68.00 $0.00 $85.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100377 EAP CPT® 84586 Vasoac Intes Polypep BOTH IP/OP $156.00 $115.44 $0.00 $156.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $53.65 $53.65 $55.72 $35.33 $52.20 $22.96 $92.27 $92.27 $37.10 $98.74 $123.55 $124.80 $51.23 $156.00 $51.23 $0.00 $35.33 $35.33 $38.93 $35.33 $0.00 $0.00 $0.00 $0.00 30100378 EAP CPT® 84588 Adh Result BOTH IP/OP $263.00 $194.62 $0.00 $263.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.54 $51.54 $53.52 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $94.86 $208.30 $210.40 $0.00 $263.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100379 EAP CPT® 84590 "Vitamin A, Serum" BOTH IP/OP $243.00 $179.82 $0.00 $196.00 $23.94 $23.94 $11.61 $11.61 $5.81 $5.81 $17.61 $17.61 $18.28 $11.61 $17.13 $7.55 $143.73 $143.73 $12.19 $32.40 $194.04 $196.00 $16.83 $19.16 $16.83 $0.00 $11.61 $11.61 $12.77 $11.61 $0.00 $0.00 $0.00 $0.00 30100380 EAP CPT® 84600 "Volatile, Drug Screen" BOTH IP/OP $333.00 $246.42 $0.00 $333.00 $33.18 $33.18 $17.11 $17.11 $8.56 $8.04 $24.41 $24.41 $25.35 $17.11 $23.74 $11.12 $196.97 $196.97 $0.00 $44.90 $263.74 $266.40 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100381 EAP CPT® 84620 "D-xylose, Serum" BOTH IP/OP $131.00 $96.94 $0.00 $111.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.98 $17.98 $18.67 $0.00 $17.50 $0.00 $0.00 $0.00 $0.00 $33.10 $110.09 $111.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100382 EAP CPT® 84620 "D-xylose, Urine" BOTH IP/OP $131.00 $96.94 $0.00 $111.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.98 $17.98 $18.67 $0.00 $17.50 $0.00 $0.00 $0.00 $0.00 $33.10 $110.09 $111.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100383 EAP CPT® 84630 "Zinc, Serum" BOTH IP/OP $81.00 $59.94 $5.69 $65.60 $23.50 $23.50 $11.39 $11.39 $5.70 $5.69 $17.30 $17.30 $17.96 $11.39 $16.82 $7.40 $47.91 $47.91 $11.96 $31.82 $64.94 $65.60 $16.52 $18.79 $16.52 $17.92 $11.39 $11.39 $12.55 $11.39 $0.00 $0.00 $0.00 $0.00 30100384 EAP CPT® 84681 "C-peptide, Random" BOTH IP/OP $370.00 $273.80 $10.41 $299.20 $32.82 $32.82 $20.81 $20.81 $10.41 $10.41 $24.13 $24.13 $25.06 $20.81 $23.47 $13.53 $218.86 $218.86 $21.85 $44.40 $296.21 $299.20 $30.17 $34.34 $30.17 $25.01 $20.81 $20.81 $17.50 $20.81 $0.00 $0.00 $0.00 $0.00 30100385 EAP CPT® 84681 "C-peptide, Fasting" BOTH IP/OP $374.00 $276.76 $0.00 $299.20 $32.82 $32.82 $20.81 $20.81 $10.41 $10.41 $24.13 $24.13 $25.06 $20.81 $23.47 $13.53 $221.22 $221.22 $21.85 $44.40 $296.21 $299.20 $30.17 $0.00 $30.17 $25.01 $20.81 $20.81 $17.50 $20.81 $0.00 $0.00 $0.00 $0.00 30100386 EAP CPT® 84681 "C-peptide, Stimulat." BOTH IP/OP $374.00 $276.76 $0.00 $299.20 $32.82 $32.82 $20.81 $20.81 $10.41 $10.41 $24.13 $24.13 $25.06 $20.81 $23.47 $13.53 $221.22 $221.22 $21.85 $44.40 $296.21 $299.20 $30.17 $0.00 $30.17 $25.01 $20.81 $20.81 $17.50 $20.81 $0.00 $0.00 $0.00 $0.00 30100387 EAP CPT® 84702 "*hcg, Serum, Quant" BOTH IP/OP $419.00 $310.06 $7.07 $304.80 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $247.84 $247.84 $15.80 $17.94 $301.75 $304.80 $21.82 $24.83 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30100388 EAP CPT® 84702 "B-hcg,mat.serum" BOTH IP/OP $204.00 $150.96 $0.00 $166.40 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $120.67 $120.67 $15.80 $17.94 $164.74 $166.40 $21.82 $0.00 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30100389 EAP CPT® 84702 "Hcg,serum-quant" BOTH IP/OP $374.00 $276.76 $7.07 $304.80 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $221.22 $221.22 $15.80 $17.94 $301.75 $304.80 $21.82 $24.83 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30100390 EAP CPT® 84703 Pregnancy Test BOTH IP/OP $67.00 $49.58 $0.00 $67.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.74 $9.74 $10.12 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $17.94 $48.31 $48.80 $0.00 $67.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100392 EAP CPT® 84999 Lysosomal Enz.scrn BOTH IP/OP "$2,308.00 " "$1,707.92" $0.00 "$1,966.40" $0.00 $0.00 $0.00 $0.00 $410.82 $0.00 "$1,713.00" "$1,713.00" "$1,779.01" $0.00 $480.99 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,946.74" "$1,966.40" $0.00 $120.90 $0.00 $384.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100393 EAP CPT® 84466 "B-2 Transferrin, Fld" BOTH IP/OP $483.00 $357.42 $6.38 $389.60 $26.35 $26.35 $12.76 $12.76 $6.38 $6.38 $19.39 $19.39 $20.13 $12.76 $18.87 $8.29 $285.69 $285.69 $13.40 $35.68 $385.70 $389.60 $18.50 $21.05 $18.50 $20.10 $12.76 $12.76 $14.07 $12.76 $0.00 $0.00 $0.00 $0.00 30100395 EAP CPT® 80048 Basic Metabolic Panel BOTH IP/OP $383.00 $283.42 $4.23 $299.20 $17.45 $17.45 $8.46 $8.46 $4.23 $4.23 $12.85 $12.85 $13.35 $8.46 $12.52 $5.50 $226.54 $226.54 $8.88 $23.66 $296.21 $299.20 $12.27 $13.96 $12.27 $13.34 $8.46 $8.46 $9.34 $8.46 $0.00 $0.00 $0.00 $0.00 30100396 EAP CPT® 88720 "Bilirubin,total-transcutaneous" BOTH IP/OP $56.00 $41.44 $2.51 $45.60 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $11.67 $3.26 $33.12 $33.12 $5.27 $28.50 $45.14 $45.60 $7.28 $8.28 $7.28 $8.92 $5.02 $5.02 $9.07 $5.02 $0.00 $0.00 $0.00 $0.00 30100401 EAP CPT® 82274 "Fecal Occult Blood,fit" BOTH IP/OP $133.00 $98.42 $7.95 $107.20 $32.84 $32.84 $15.92 $15.92 $7.96 $7.95 $24.15 $24.15 $25.08 $15.92 $25.48 $10.35 $78.67 $78.67 $16.72 $44.44 $106.13 $107.20 $23.08 $26.27 $23.08 $27.15 $15.92 $15.92 $19.01 $15.92 $0.00 $0.00 $0.00 $0.00 30100403 EAP CPT® 82306 "25-hydroxyvit D (d2,d3)(so)" BOTH IP/OP $86.00 $63.64 $0.00 $82.72 $61.12 $61.12 $29.60 $29.60 $14.80 $14.80 $44.95 $44.95 $46.68 $29.60 $43.72 $19.24 $50.87 $50.87 $31.08 $82.72 $68.11 $68.80 $42.92 $0.00 $42.92 $46.59 $29.60 $29.60 $32.61 $29.60 $0.00 $0.00 $0.00 $0.00 30100410 EAP CPT® 82009 Acetoacetate-qualitative BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.99 $4.99 $5.18 $0.00 $4.85 $0.00 $0.00 $0.00 $0.00 $9.18 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100411 EAP CPT® 82043 Microalbumin BOTH IP/OP $223.00 $165.02 $0.00 $179.20 $11.93 $11.93 $5.78 $5.78 $2.89 $2.89 $8.79 $8.79 $9.13 $5.78 $8.55 $3.76 $131.90 $131.90 $6.07 $16.18 $177.41 $179.20 $8.38 $0.00 $8.38 $9.11 $5.78 $5.78 $6.37 $5.78 $0.00 $0.00 $0.00 $0.00 30100412 EAP CPT® 82270 "Occult Blood, Stool" BOTH IP/OP $57.00 $42.18 $0.00 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $4.88 $5.07 $0.00 $4.75 $0.00 $0.00 $0.00 $0.00 $8.98 $45.94 $46.40 $0.00 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100413 EAP CPT® 82465 Cholesterol BOTH IP/OP $91.00 $67.34 $0.00 $73.60 $8.98 $8.98 $4.35 $4.35 $2.18 $2.18 $6.61 $6.61 $6.87 $4.35 $6.43 $2.83 $53.83 $53.83 $4.57 $12.16 $72.86 $73.60 $6.31 $0.00 $6.31 $6.85 $4.35 $4.35 $4.79 $4.35 $0.00 $0.00 $0.00 $0.00 30100414 EAP CPT® 82550 "Cpk,total-serum" BOTH IP/OP $208.00 $153.92 $3.25 $151.20 $13.44 $13.44 $6.51 $6.51 $3.26 $3.25 $9.89 $9.89 $10.27 $6.51 $7.46 $4.23 $123.03 $123.03 $6.84 $18.20 $149.69 $151.20 $9.44 $10.74 $9.44 $7.94 $6.51 $6.51 $5.56 $6.51 $0.00 $0.00 $0.00 $0.00 30100415 EAP CPT® 82565 "Poct, Creatinine (meter)" BOTH IP/OP $139.00 $102.86 $2.56 $103.20 $10.59 $10.59 $5.12 $5.12 $2.56 $2.56 $7.78 $7.78 $8.08 $5.12 $7.46 $3.33 $82.22 $82.22 $5.38 $14.32 $102.17 $103.20 $7.42 $8.45 $7.42 $7.94 $5.12 $5.12 $5.56 $5.12 $0.00 $0.00 $0.00 $0.00 30100416 EAP CPT® 82570 Creatinine Urine BOTH IP/OP $122.00 $90.28 $0.00 $97.60 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $72.16 $72.16 $5.44 $14.46 $96.62 $97.60 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30100417 EAP CPT® 82947 "Gtt, Oral-2hr Indiv" BOTH IP/OP $263.00 $194.62 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $155.56 $155.56 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100420 EAP CPT® 82950 "Glucose, Bld-2hr Pp" BOTH IP/OP $251.00 $185.74 $2.37 $248.80 $9.79 $9.79 $4.75 $4.75 $2.38 $2.37 $7.21 $7.21 $7.48 $4.75 $7.02 $3.09 $148.47 $148.47 $4.99 $13.28 $246.31 $248.80 $6.89 $7.84 $6.89 $7.48 $4.75 $4.75 $5.24 $4.75 $0.00 $0.00 $0.00 $0.00 30100421 EAP CPT® 83036 Hgb Glycosy A1c-ddcl BOTH IP/OP $218.00 $161.32 $0.00 $175.20 $20.04 $20.04 $9.71 $9.71 $4.86 $4.86 $14.74 $14.74 $15.30 $9.71 $14.33 $6.31 $128.95 $128.95 $10.20 $27.12 $173.45 $175.20 $14.08 $0.00 $14.08 $15.27 $9.71 $9.71 $10.69 $9.71 $0.00 $0.00 $0.00 $0.00 30100422 EAP CPT® 83690 "Lipase, Serum" BOTH IP/OP $248.00 $183.52 $3.44 $200.80 $14.23 $14.23 $6.89 $6.89 $3.45 $3.44 $10.46 $10.46 $10.86 $6.89 $10.17 $4.48 $146.69 $146.69 $7.23 $19.24 $198.79 $200.80 $9.99 $11.37 $9.99 $10.84 $6.89 $6.89 $7.59 $6.89 $0.00 $0.00 $0.00 $0.00 30100423 EAP CPT® 83718 "Chol,hdl" BOTH IP/OP $118.00 $87.32 $4.10 $95.20 $16.92 $16.92 $8.19 $8.19 $4.10 $4.10 $12.44 $12.44 $12.92 $8.19 $12.10 $5.32 $69.80 $69.80 $8.60 $22.88 $94.25 $95.20 $11.88 $13.51 $11.88 $12.89 $8.19 $8.19 $9.02 $8.19 $0.00 $0.00 $0.00 $0.00 30100424 EAP CPT® 83718 "Chol, Hdl" BOTH IP/OP $118.00 $87.32 $0.00 $95.20 $16.92 $16.92 $8.19 $8.19 $4.10 $4.10 $12.44 $12.44 $12.92 $8.19 $12.10 $5.32 $69.80 $69.80 $8.60 $22.88 $94.25 $95.20 $11.88 $0.00 $11.88 $12.89 $8.19 $8.19 $9.02 $8.19 $0.00 $0.00 $0.00 $0.00 30100425 EAP CPT® 83721 "Chol-ldl, Direct" BOTH IP/OP $148.00 $109.52 $4.77 $119.20 $19.69 $19.69 $10.50 $10.50 $5.25 $4.77 $14.49 $14.49 $15.04 $10.50 $14.10 $6.83 $87.54 $87.54 $11.03 $26.66 $118.01 $119.20 $15.23 $17.33 $15.23 $15.03 $10.50 $10.50 $10.52 $10.50 $0.00 $0.00 $0.00 $0.00 30100426 EAP CPT® 83721 "Chol-ldl, Direct" BOTH IP/OP $147.00 $108.78 $0.00 $119.20 $19.69 $19.69 $10.50 $10.50 $5.25 $4.77 $14.49 $14.49 $15.04 $10.50 $14.10 $6.83 $86.95 $86.95 $11.03 $26.66 $118.01 $119.20 $15.23 $0.00 $15.23 $15.03 $10.50 $10.50 $10.52 $10.50 $0.00 $0.00 $0.00 $0.00 30100427 EAP CPT® 83735 "Magneseum, Serum" BOTH IP/OP $160.00 $118.40 $0.00 $136.80 $13.83 $13.83 $6.70 $6.70 $3.35 $3.35 $10.17 $10.17 $10.56 $6.70 $9.89 $4.36 $94.64 $94.64 $7.04 $18.72 $135.43 $136.80 $9.72 $0.00 $9.72 $10.54 $6.70 $6.70 $7.38 $6.70 $0.00 $0.00 $0.00 $0.00 30100430 EAP CPT® 80048 "Chem 8, Metabolic Panel" BOTH IP/OP $383.00 $283.42 $4.23 $299.20 $17.45 $17.45 $8.46 $8.46 $4.23 $4.23 $12.85 $12.85 $13.35 $8.46 $12.52 $5.50 $226.54 $226.54 $8.88 $23.66 $296.21 $299.20 $12.27 $13.96 $12.27 $13.34 $8.46 $8.46 $9.34 $8.46 $0.00 $0.00 $0.00 $0.00 30100431 EAP CPT® 82270 Occult Blood BOTH IP/OP $58.00 $42.92 $0.00 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $4.88 $5.07 $0.00 $4.75 $0.00 $0.00 $0.00 $0.00 $8.98 $45.94 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100432 EAP CPT® 82977 Ggt-serum BOTH IP/OP $162.00 $119.88 $3.60 $129.60 $14.86 $14.86 $7.20 $7.20 $3.60 $3.60 $10.93 $10.93 $11.35 $7.20 $7.46 $4.68 $95.82 $95.82 $7.56 $20.12 $128.30 $129.60 $10.44 $11.88 $10.44 $7.94 $7.20 $7.20 $5.56 $7.20 $0.00 $0.00 $0.00 $0.00 30100434 EAP CPT® 80069 Renal Panel BOTH IP/OP $228.00 $168.72 $4.34 $184.00 $17.93 $17.93 $8.68 $8.68 $4.34 $4.34 $13.19 $13.19 $13.69 $8.68 $12.83 $5.64 $134.86 $134.86 $9.11 $24.26 $182.16 $184.00 $12.59 $14.32 $12.59 $13.67 $8.68 $8.68 $9.57 $8.68 $0.00 $0.00 $0.00 $0.00 30100435 EAP CPT® 80076 Hepatic Profile BOTH IP/OP $330.00 $244.20 $4.09 $266.40 $16.87 $16.87 $8.17 $8.17 $4.09 $4.09 $12.41 $12.41 $12.88 $8.17 $12.08 $5.31 $195.20 $195.20 $8.58 $22.84 $263.74 $266.40 $11.85 $13.48 $11.85 $12.87 $8.17 $8.17 $9.01 $8.17 $0.00 $0.00 $0.00 $0.00 30100436 EAP CPT® 80076 Hepatic Profile BOTH IP/OP $333.00 $246.42 $4.09 $266.40 $16.87 $16.87 $8.17 $8.17 $4.09 $4.09 $12.41 $12.41 $12.88 $8.17 $12.08 $5.31 $196.97 $196.97 $8.58 $22.84 $263.74 $266.40 $11.85 $13.48 $11.85 $12.87 $8.17 $8.17 $9.01 $8.17 $0.00 $0.00 $0.00 $0.00 30100437 EAP CPT® 82465 "Cholesterol,fluid" BOTH IP/OP $91.00 $67.34 $2.18 $73.60 $8.98 $8.98 $4.35 $4.35 $2.18 $2.18 $6.61 $6.61 $6.87 $4.35 $6.43 $2.83 $53.83 $53.83 $4.57 $12.16 $72.86 $73.60 $6.31 $7.18 $6.31 $6.85 $4.35 $4.35 $4.79 $4.35 $0.00 $0.00 $0.00 $0.00 30100439 EAP CPT® 82947 "Glucose,fasting Bld" BOTH IP/OP $263.00 $194.62 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $155.56 $155.56 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30100441 EAP CPT® 82950 "Glucose,1hr (50gm)" BOTH IP/OP $341.00 $252.34 $2.37 $248.80 $9.79 $9.79 $4.75 $4.75 $2.38 $2.37 $7.21 $7.21 $7.48 $4.75 $7.02 $3.09 $201.70 $201.70 $4.99 $13.28 $246.31 $248.80 $6.89 $7.84 $6.89 $7.48 $4.75 $4.75 $5.24 $4.75 $0.00 $0.00 $0.00 $0.00 30100442 EAP CPT® 82977 "Ggtp,serum" BOTH IP/OP $160.00 $118.40 $3.60 $129.60 $14.86 $14.86 $7.20 $7.20 $3.60 $3.60 $10.93 $10.93 $11.35 $7.20 $7.46 $4.68 $94.64 $94.64 $7.56 $20.12 $128.30 $129.60 $10.44 $11.88 $10.44 $7.94 $7.20 $7.20 $5.56 $7.20 $0.00 $0.00 $0.00 $0.00 30100443 EAP CPT® 83735 "Magnesium, Urine" BOTH IP/OP $188.00 $139.12 $3.35 $136.80 $13.83 $13.83 $6.70 $6.70 $3.35 $3.35 $10.17 $10.17 $10.56 $6.70 $9.89 $4.36 $111.20 $111.20 $7.04 $18.72 $135.43 $136.80 $9.72 $11.06 $9.72 $10.54 $6.70 $6.70 $7.38 $6.70 $0.00 $0.00 $0.00 $0.00 30100444 EAP CPT® 80375 Thiopurine Metabolites Serum (so) BOTH IP/OP $355.00 $262.70 $0.00 $273.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.48 $263.48 $273.63 $0.00 $21.44 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $193.80 $143.65 $193.80 $22.85 $0.00 $0.00 $15.99 $0.00 $0.00 $0.00 $0.00 $0.00 30100450 EAP CPT® 82803 Hemodynamics BOTH IP/OP $510.00 $377.40 $11.73 $371.20 $39.94 $39.94 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $30.51 $26.07 $28.59 $16.95 $301.67 $301.67 $27.37 $54.08 $367.49 $371.20 $37.80 $43.02 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100451 EAP CPT® 82803 Abg Analysis BOTH IP/OP $510.00 $377.40 $11.73 $371.20 $39.94 $39.94 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $30.51 $26.07 $28.59 $16.95 $301.67 $301.67 $27.37 $54.08 $367.49 $371.20 $37.80 $43.02 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100455 EAP CPT® 82040 Albumin (bcg) BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $5.94 $5.94 $4.95 $4.95 $2.48 $2.48 $4.37 $4.37 $4.54 $4.95 $4.25 $3.22 $44.95 $44.95 $5.20 $8.04 $60.19 $60.80 $7.18 $0.00 $7.18 $4.53 $4.95 $4.95 $3.17 $4.95 $0.00 $0.00 $0.00 $0.00 30100456 EAP CPT® 81381 HLA B5701 BOTH IP/OP $458.00 $338.92 $35.05 $370.40 $195.23 $195.23 $169.90 $169.90 $84.95 $76.46 $134.19 $134.19 $139.35 $169.90 $46.99 $110.44 $270.91 $270.91 $178.40 $231.50 $366.70 $370.40 $246.36 $280.34 $246.36 $50.07 $169.90 $169.90 $35.05 $169.90 $0.00 $0.00 $0.00 $0.00 30100475 EAP CPT® 82172 Apolipoprotein (so) BOTH IP/OP $181.00 $133.94 $0.00 $144.80 $32.00 $32.00 $21.09 $21.09 $10.55 $9.49 $23.52 $23.52 $24.43 $21.09 $22.90 $13.71 $107.06 $107.06 $22.14 $43.30 $143.35 $144.80 $30.58 $0.00 $30.58 $24.40 $21.09 $21.09 $17.08 $21.09 $0.00 $0.00 $0.00 $0.00 30100476 EAP CPT® 82247 Total Bilirubin (so) BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $7.42 $3.26 $52.05 $52.05 $5.27 $14.04 $69.70 $70.40 $7.28 $0.00 $7.28 $7.91 $5.02 $5.02 $5.54 $5.02 $0.00 $0.00 $0.00 $0.00 30100477 EAP CPT® 82977 Ggt (so) BOTH IP/OP $187.00 $138.38 $3.60 $149.60 $14.86 $14.86 $7.20 $7.20 $3.60 $3.60 $10.93 $10.93 $11.35 $7.20 $7.46 $4.68 $110.61 $110.61 $7.56 $20.12 $148.10 $149.60 $10.44 $11.88 $10.44 $7.94 $7.20 $7.20 $5.56 $7.20 $0.00 $0.00 $0.00 $0.00 30100478 EAP CPT® 83010 Haptoglobin Quant (so) BOTH IP/OP $265.00 $196.10 $0.00 $212.00 $7.71 $7.71 $12.58 $12.58 $6.29 $6.29 $5.66 $5.66 $5.88 $12.58 $5.51 $8.18 $156.75 $156.75 $13.21 $10.42 $209.88 $212.00 $18.24 $0.00 $18.24 $5.87 $12.58 $12.58 $4.11 $12.58 $0.00 $0.00 $0.00 $0.00 30100479 EAP CPT® 83883 Nephelometry (so) BOTH IP/OP $222.00 $164.28 $0.00 $177.60 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $131.31 $131.31 $14.28 $38.00 $175.82 $177.60 $19.72 $0.00 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30100480 EAP CPT® 84460 Alt (s0) BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $10.93 $10.93 $5.30 $5.30 $2.65 $2.65 $8.04 $8.04 $8.35 $5.30 $7.46 $3.45 $53.24 $53.24 $5.57 $14.80 $71.28 $72.00 $7.69 $0.00 $7.69 $7.94 $5.30 $5.30 $5.56 $5.30 $0.00 $0.00 $0.00 $0.00 30100481 EAP CPT® 88360 Pd-l1 Ihc W/interp (s0) BOTH IP/OP $488.00 $361.12 $58.38 $388.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $288.65 $288.65 $143.92 $121.34 $384.12 $388.00 $199.96 $317.20 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 30100482 EAP CPT® 88341 Lynch Syn Pan Addl Slide (so) BOTH IP/OP $566.00 $418.84 $0.00 $457.60 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $334.79 $334.79 $0.00 $286.00 $453.02 $457.60 $0.00 $367.90 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 30100483 EAP CPT® 88342 Lynch Syn Pan 1st Slide (so) BOTH IP/OP $645.00 $477.30 $48.82 $520.80 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $381.52 $381.52 $143.92 $106.46 $515.59 $520.80 $199.96 $419.25 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 30100490 EAP CPT® 80177 Levetiracetam (so) BOTH IP/OP $333.00 $246.42 $6.63 $267.20 $27.35 $27.35 $13.25 $13.25 $6.63 $6.63 $18.81 $18.81 $19.54 $13.25 $17.00 $8.61 $196.97 $196.97 $13.91 $167.00 $264.53 $267.20 $19.21 $21.86 $19.21 $18.11 $13.25 $13.25 $12.68 $13.25 $0.00 $0.00 $0.00 $0.00 30100499 EAP CPT® 83520 Anti Mag Q BOTH IP/OP $68.00 $50.32 $0.00 $61.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $40.22 $40.22 $18.13 $36.18 $60.98 $61.60 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100500 EAP CPT® 80342 "Fluphenazine, Serum" BOTH IP/OP $140.00 $103.60 $0.00 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.91 $103.91 $107.91 $0.00 $23.01 $0.00 $0.00 $0.00 $0.00 $74.00 $117.22 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100501 EAP CPT® 82438 "Feces, Chloride (so)" BOTH IP/OP $96.00 $71.04 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.43 $7.43 $7.71 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $13.66 $76.03 $76.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100502 EAP CPT® 84302 "Feces, Sodium (so)" BOTH IP/OP $105.00 $77.70 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $5.25 $5.45 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $9.66 $75.24 $76.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100503 EAP CPT® 84311 "Feces,electrophoresis (so)" BOTH IP/OP $160.00 $118.40 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $158.40 $160.00 $11.75 $156.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30100505 EAP CPT® 84311 "Feces, Potassium (so)" BOTH IP/OP $198.00 $146.52 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $158.40 $160.00 $11.75 $156.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30100600 EAP CPT® 82248 "Bilirubin,direct" BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $7.42 $3.26 $69.80 $69.80 $5.27 $14.04 $93.46 $94.40 $7.28 $0.00 $7.28 $7.91 $5.02 $5.02 $5.54 $5.02 $0.00 $0.00 $0.00 $0.00 30100602 EAP CPT® 80299 Voriconazole Quant Assay (so) BOTH IP/OP $204.00 $150.96 $0.00 $163.20 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $120.67 $120.67 $19.57 $33.64 $161.57 $163.20 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100622 EAP CPT® 80203 Zonisamide (so) BOTH IP/OP $417.00 $308.58 $0.00 $417.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.81 $18.81 $19.54 $0.00 $17.00 $0.00 $0.00 $0.00 $13.91 $209.50 $331.85 $335.20 $19.21 $417.00 $19.21 $18.11 $13.25 $13.25 $12.68 $13.25 $0.00 $0.00 $0.00 $0.00 30100634 EAP CPT® 84181 Western Blot Test BOTH IP/OP "$1,387.00 " "$1,026.38" $0.00 "$1,109.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.86 $25.86 $26.86 $0.00 $25.16 $0.00 $0.00 $0.00 $0.00 $47.60 "$1,098.50" "$1,109.60" $0.00 $507.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100635 EAP CPT® 82530 Cortisol;free BOTH IP/OP $200.00 $148.00 $8.36 $161.60 $34.48 $34.48 $16.71 $16.71 $8.36 $8.36 $25.39 $25.39 $26.36 $16.71 $24.70 $10.86 $118.30 $118.30 $17.55 $46.70 $159.98 $161.60 $24.23 $27.57 $24.23 $26.31 $16.71 $16.71 $18.42 $16.71 $0.00 $0.00 $0.00 $0.00 30100636 EAP CPT® 82570 Other Source BOTH IP/OP $91.00 $67.34 $2.59 $72.80 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $53.83 $53.83 $5.44 $14.46 $72.07 $72.80 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30100637 EAP CPT® 83789 "Quantitative, Each Specimen" BOTH IP/OP $142.00 $105.08 $0.00 $142.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $113.26 $114.40 $0.00 $142.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100643 EAP CPT® 83789 "Quantitative, Each Specimen" BOTH IP/OP $241.00 $178.34 $0.00 $241.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $191.66 $193.60 $0.00 $241.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100644 EAP CPT® 83520 "Quantitative, Not Otherwise Specified" BOTH IP/OP $103.00 $76.22 $0.00 $92.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $60.92 $60.92 $18.13 $36.18 $91.87 $92.80 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100645 EAP CPT® 84999 Unlisted Chemistry Procedure BOTH IP/OP $58.00 $42.92 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $10.32 $0.00 $43.05 $43.05 $44.71 $0.00 $12.09 $0.00 $0.00 $0.00 $0.00 $0.00 $49.10 $49.60 $0.00 $0.00 $0.00 $9.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100652 EAP CPT® 82017 Acylcarnities Quant BOTH IP/OP $187.00 $138.38 $0.00 $149.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $148.10 $149.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100653 EAP CPT® 82139 "Amino Acids,6 Or More Amino Acids,quantitative,each" BOTH IP/OP $292.00 $216.08 $0.00 $233.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $231.26 $233.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100654 EAP CPT® 82379 "Carnitine(total And Free),quantitative,each Specimen" BOTH IP/OP $223.00 $165.02 $0.00 $180.00 $34.82 $34.82 $16.87 $16.87 $8.44 $8.43 $25.62 $25.62 $26.60 $16.87 $24.92 $10.97 $131.90 $131.90 $0.00 $47.14 $178.20 $180.00 $0.00 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100656 EAP CPT® 82542 "Quantitative,single Stationary & Mobile Phase, Qt" BOTH IP/OP $296.00 $219.04 $0.00 $236.80 $37.28 $37.28 $24.09 $24.09 $12.05 $10.84 $9.12 $9.12 $9.47 $24.09 $8.87 $15.66 $175.08 $175.08 $25.29 $16.78 $234.43 $236.80 $34.93 $0.00 $34.93 $9.45 $24.09 $24.09 $6.62 $24.09 $0.00 $0.00 $0.00 $0.00 30100660 EAP CPT® 82962 Poct Glucose Meter BOTH IP/OP $92.00 $68.08 $1.48 $67.20 $4.83 $4.83 $3.28 $3.28 $1.64 $1.48 $3.56 $3.56 $3.69 $3.28 $3.45 $2.13 $54.42 $54.42 $3.44 $6.54 $66.53 $67.20 $4.76 $5.41 $4.76 $3.68 $3.28 $3.28 $2.58 $3.28 $0.00 $0.00 $0.00 $0.00 30100662 EAP CPT® 84600 Propylene Glycol (nms) BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $33.18 $33.18 $17.11 $17.11 $8.56 $8.04 $24.41 $24.41 $25.35 $17.11 $23.74 $11.12 $143.73 $143.73 $0.00 $44.90 $192.46 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100665 EAP CPT® 83825 "Mercury,blood(q)" BOTH IP/OP $41.00 $30.34 $0.00 $41.00 $33.55 $33.55 $16.26 $16.26 $8.13 $8.13 $24.69 $24.69 $25.64 $16.26 $24.02 $10.57 $24.25 $24.25 $17.07 $41.00 $32.47 $32.80 $23.58 $0.00 $23.58 $0.00 $16.26 $16.26 $17.92 $16.26 $0.00 $0.00 $0.00 $0.00 30100666 EAP CPT® 80347 Quantitative Benzo Panel(q) BOTH IP/OP $398.00 $294.52 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.40 $295.40 $306.78 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $199.00 $315.22 $318.40 $0.00 $98.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100668 EAP CPT® 86161 "C1 Inhibitor , Functional (so)" BOTH IP/OP $169.00 $125.06 $6.00 $136.80 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $99.96 $99.96 $12.60 $33.56 $135.43 $136.80 $17.40 $19.80 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30100669 EAP CPT® 86774 Tetanus Antitoxoid (so) BOTH IP/OP $83.00 $61.42 $0.00 $83.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.47 $22.47 $23.34 $0.00 $21.86 $0.00 $0.00 $0.00 $15.54 $41.36 $65.74 $66.40 $21.46 $83.00 $21.46 $23.29 $14.80 $14.80 $16.31 $14.80 $0.00 $0.00 $0.00 $0.00 30100670 EAP CPT® 86343 Histamine Release -cu (so) BOTH IP/OP $234.00 $173.16 $0.00 $188.80 $25.71 $25.71 $12.46 $12.46 $6.23 $6.23 $18.93 $18.93 $19.66 $12.46 $18.41 $8.10 $138.41 $138.41 $0.00 $34.82 $186.91 $188.80 $0.00 $20.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100671 EAP CPT® 83520 Tryptase (so) BOTH IP/OP $217.00 $160.58 $7.77 $168.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $128.36 $128.36 $18.13 $36.18 $167.11 $168.80 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100672 EAP CPT® 82106 Alpha- Fetoprotein Af (so) BOTH IP/OP $41.00 $30.34 $0.00 $41.00 $34.64 $34.64 $17.00 $17.00 $8.50 $0.00 $25.47 $25.47 $26.45 $0.00 $24.79 $0.00 $0.00 $0.00 $17.85 $41.00 $32.47 $32.80 $24.65 $28.05 $24.65 $26.41 $17.00 $17.00 $18.49 $17.00 $0.00 $0.00 $0.00 $0.00 30100673 EAP CPT® 83033 Fetal Hemoglobin Af (so) BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.05 $9.05 $9.40 $0.00 $8.81 $0.00 $0.00 $0.00 $0.00 $16.66 $60.19 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100674 EAP CPT® 82664 Acetylcholinesterase Af (so) BOTH IP/OP $156.00 $115.44 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.17 $52.17 $54.17 $0.00 $50.75 $0.00 $0.00 $0.00 $64.58 $96.00 $133.06 $134.40 $89.18 $0.00 $89.18 $54.07 $61.50 $61.50 $37.85 $61.50 $0.00 $0.00 $0.00 $0.00 30100680 EAP CPT® 82105 Maternal Serum Afp (so) BOTH IP/OP $47.00 $34.78 $8.39 $46.88 $34.64 $34.64 $16.77 $16.77 $8.39 $8.39 $25.47 $25.47 $26.45 $16.77 $24.79 $10.90 $27.80 $27.80 $17.61 $46.88 $37.22 $37.60 $24.32 $27.67 $24.32 $26.41 $16.77 $16.77 $18.49 $16.77 $0.00 $0.00 $0.00 $0.00 30100681 EAP CPT® 86160 C1 Esterase Inhibitor Protein (so) BOTH IP/OP $85.00 $62.90 $6.00 $68.80 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $50.28 $50.28 $12.60 $33.56 $68.11 $68.80 $17.40 $19.80 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30100682 EAP CPT® 84591 Vitamin B-5( Pantothenic Acid) (so) BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.61 $17.61 $18.28 $0.00 $17.13 $0.00 $0.00 $0.00 $0.00 $32.40 $140.98 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100683 EAP CPT® 82397 Leptin (so) BOTH IP/OP $232.00 $171.68 $0.00 $209.60 $29.15 $29.15 $14.12 $14.12 $7.06 $7.06 $21.46 $21.46 $22.28 $14.12 $20.87 $9.18 $137.23 $137.23 $14.83 $39.48 $207.50 $209.60 $20.47 $0.00 $20.47 $22.24 $14.12 $14.12 $15.57 $14.12 $0.00 $0.00 $0.00 $0.00 30100684 EAP CPT® 85415 Plasminogen Activator Inhibitor-a (pai-1) (so) BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.10 $26.10 $27.11 $0.00 $25.40 $0.00 $0.00 $0.00 $0.00 $48.04 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100685 EAP CPT® 83516 "Ribosomal P Antibody , Csf (so)" BOTH IP/OP $240.00 $177.60 $0.00 $216.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $141.96 $141.96 $12.11 $29.88 $214.63 $216.80 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30100686 EAP CPT® 83516 Serine Protease 3 Antibody (so)arup BOTH IP/OP $302.00 $223.48 $5.76 $272.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $178.63 $178.63 $12.11 $29.88 $270.07 $272.80 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30100687 EAP CPT® 82610 Cystatin C (so) BOTH IP/OP $244.00 $180.56 $8.33 $196.80 $28.06 $28.06 $18.52 $18.52 $9.26 $8.33 $20.64 $20.64 $21.44 $18.52 $20.09 $12.04 $144.33 $144.33 $19.45 $123.00 $194.83 $196.80 $26.85 $30.56 $26.85 $21.40 $18.52 $18.52 $14.98 $18.52 $0.00 $0.00 $0.00 $0.00 30100688 EAP CPT® 80180 Mycophenolic Acid (so) BOTH IP/OP $169.00 $125.06 $0.00 $135.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.44 $8.44 $8.77 $0.00 $7.63 $0.00 $0.00 $0.00 $0.00 $84.50 $133.85 $135.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100689 EAP CPT® 83516 "Saccharmyces Cerevisiae Ab, Igg (arup)" BOTH IP/OP $174.00 $128.76 $0.00 $156.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $102.92 $102.92 $12.11 $29.88 $155.23 $156.80 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30100690 EAP CPT® 83516 "Laminaribioside Carbohydrate Ab, Igg (arup)" BOTH IP/OP $174.00 $128.76 $0.00 $156.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $102.92 $102.92 $12.11 $29.88 $155.23 $156.80 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30100691 EAP CPT® 83516 "Mannobioside Carbohydrate Ab, Igg (arup)" BOTH IP/OP $174.00 $128.76 $0.00 $156.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $102.92 $102.92 $12.11 $29.88 $155.23 $156.80 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30100692 EAP CPT® 86671 "Chitobioside Carbohydrate Ab, Iga (arup)" BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $63.36 $64.00 $17.76 $0.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30100693 EAP CPT® 83789 Levamisole (so) Nms BOTH IP/OP $298.00 $220.52 $0.00 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $236.02 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100702 EAP CPT® 84182 Zic4 Ab Protein West Blot (so) BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $260.85 $260.85 $30.67 $50.30 $349.27 $352.80 $42.35 $0.00 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30100703 EAP CPT® 83789 Diurectics Screen Urine (so) BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $180.58 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100704 EAP CPT® 82785 Abpa Ige (so) BOTH IP/OP $191.00 $141.34 $0.00 $152.80 $33.98 $33.98 $16.46 $16.46 $8.23 $8.23 $25.01 $25.01 $25.97 $16.46 $24.33 $10.70 $112.98 $112.98 $17.28 $46.02 $151.27 $152.80 $23.87 $0.00 $23.87 $25.92 $16.46 $16.46 $18.15 $16.46 $0.00 $0.00 $0.00 $0.00 30100705 EAP CPT® 84146 Macroprolactin (so) BOTH IP/OP $322.00 $238.28 $0.00 $257.60 $40.00 $40.00 $19.38 $19.38 $9.69 $9.69 $29.43 $29.43 $30.56 $19.38 $28.63 $12.60 $190.46 $190.46 $20.35 $54.16 $255.02 $257.60 $28.10 $0.00 $28.10 $30.51 $19.38 $19.38 $21.36 $19.38 $0.00 $0.00 $0.00 $0.00 30100706 EAP CPT® 82570 Thiosulfate Urine BOTH IP/OP $280.00 $207.20 $2.59 $224.00 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $165.62 $165.62 $5.44 $14.46 $221.76 $224.00 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30100708 EAP CPT® 83921 Succinlylacetone Urine (so) BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $33.95 $33.95 $21.21 $21.21 $10.61 $9.54 $25.00 $25.00 $25.96 $21.21 $24.32 $13.79 $147.88 $147.88 $22.27 $46.00 $198.00 $200.00 $30.75 $0.00 $30.75 $25.91 $21.21 $21.21 $18.14 $21.21 $0.00 $0.00 $0.00 $0.00 30100709 EAP CPT® 83520 Vwf Propeptide (so) BOTH IP/OP $365.00 $270.10 $7.77 $329.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $215.90 $215.90 $18.13 $36.18 $326.30 $329.60 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100710 EAP CPT® 80061 Nmr Lipoprofile Panel (so) BOTH IP/OP $239.00 $176.86 $0.00 $228.00 $27.64 $27.64 $13.39 $13.39 $6.70 $6.70 $20.35 $20.35 $21.14 $13.39 $19.79 $8.70 $141.37 $141.37 $14.06 $37.44 $225.72 $228.00 $19.42 $0.00 $19.42 $21.09 $13.39 $13.39 $14.76 $13.39 $0.00 $0.00 $0.00 $0.00 30100711 EAP CPT® 83704 Nmr Lipoprofile Bld (so) BOTH IP/OP $239.00 $176.86 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.91 $47.91 $49.76 $0.00 $46.60 $0.00 $0.00 $0.00 $0.00 $88.16 $225.72 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100712 EAP CPT® 83520 Factor H Comp (so) BOTH IP/OP $365.00 $270.10 $7.77 $329.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $215.90 $215.90 $18.13 $36.18 $326.30 $329.60 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100714 EAP CPT® 82542 Thiosulfate Chromotography BOTH IP/OP $221.00 $163.54 $0.00 $176.80 $37.28 $37.28 $24.09 $24.09 $12.05 $10.84 $9.12 $9.12 $9.47 $24.09 $8.87 $15.66 $130.72 $130.72 $25.29 $16.78 $175.03 $176.80 $34.93 $0.00 $34.93 $9.45 $24.09 $24.09 $6.62 $24.09 $0.00 $0.00 $0.00 $0.00 30100715 EAP CPT® 82656 Pancreatitic Elastase Serum (so) BOTH IP/OP $326.00 $241.24 $0.00 $260.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $67.94 $7.49 $192.83 $192.83 $12.11 $29.88 $258.19 $260.80 $16.72 $0.00 $16.72 $51.02 $11.53 $11.53 $51.90 $11.53 $0.00 $0.00 $0.00 $0.00 30100716 EAP CPT® 80299 Itraconazole (so) BOTH IP/OP $203.00 $150.22 $0.00 $163.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.67 $150.67 $156.47 $0.00 $25.48 $0.00 $0.00 $0.00 $19.57 $33.64 $161.57 $163.20 $27.03 $27.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100717 EAP CPT® 80365 "Oxycodone And Metabolite Total, Urine (so)" BOTH IP/OP $136.00 $100.64 $0.00 $188.81 $0.03 $0.03 $114.43 $114.43 $57.22 $11.94 $100.94 $100.94 $104.83 $114.43 $28.34 $74.38 $80.44 $80.44 $120.15 $62.00 $98.21 $99.20 $74.40 $188.81 $74.40 $19.41 $0.00 $0.00 $19.74 $114.43 $0.00 $0.00 $0.00 $0.00 30100718 EAP CPT® 80361 Hydromorphone Opi 1 Urine (so) BOTH IP/OP $484.00 $358.16 $0.00 $409.60 $0.03 $0.03 $0.00 $0.00 $12.01 $11.94 $359.22 $359.22 $373.07 $0.00 $30.51 $0.00 $286.29 $286.29 $0.00 $256.00 $405.50 $409.60 $307.20 $269.10 $307.20 $32.51 $0.00 $0.00 $22.76 $0.00 $0.00 $0.00 $0.00 $0.00 30100719 EAP CPT® 83520 Thrombin-antithrom Quant (so) BOTH IP/OP $421.00 $311.54 $7.77 $327.20 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $249.02 $249.02 $18.13 $36.18 $323.93 $327.20 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100720 EAP CPT® 84182 Redombx (antirecoverin Ab) (so) BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $260.85 $260.85 $30.67 $50.30 $349.27 $352.80 $42.35 $0.00 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30100721 EAP CPT® 80299 Baclofin Quant BOTH IP/OP $430.00 $318.20 $8.39 $344.00 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $254.35 $254.35 $19.57 $33.64 $340.56 $344.00 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100722 EAP CPT® 82726 Very Long Fatty Acids (so) BOTH IP/OP $411.00 $304.14 $0.00 $325.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $322.34 $325.60 $0.00 $319.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100723 EAP CPT® 83051 Hgb Free Plasma (so) BOTH IP/OP $181.00 $133.94 $0.00 $171.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.10 $11.10 $11.52 $0.00 $10.79 $0.00 $0.00 $0.00 $0.00 $20.42 $143.35 $144.80 $0.00 $171.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100724 EAP CPT® 83789 Levamisole BOTH IP/OP $297.00 $219.78 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $236.02 $238.40 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100725 EAP CPT® 83520 Interleuk 2 Rec Cd25 (so) BOTH IP/OP $424.00 $313.76 $7.77 $329.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $250.80 $250.80 $18.13 $36.18 $326.30 $329.60 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100726 EAP CPT® 82542 Cannabinoid Quant (so) BOTH IP/OP $221.00 $163.54 $0.00 $176.80 $37.28 $37.28 $24.09 $24.09 $12.05 $10.84 $9.12 $9.12 $9.47 $24.09 $8.87 $15.66 $130.72 $130.72 $25.29 $16.78 $175.03 $176.80 $34.93 $0.00 $34.93 $9.45 $24.09 $24.09 $6.62 $24.09 $0.00 $0.00 $0.00 $0.00 30100729 EAP CPT® 82378 Cea Cyst Fluid (so) BOTH IP/OP $283.00 $209.42 $9.48 $228.80 $39.15 $39.15 $18.96 $18.96 $9.48 $9.48 $28.81 $28.81 $29.92 $18.96 $28.02 $12.32 $167.39 $167.39 $19.91 $53.02 $226.51 $228.80 $27.49 $31.28 $27.49 $29.86 $18.96 $18.96 $20.90 $18.96 $0.00 $0.00 $0.00 $0.00 30100730 EAP CPT® 83520 Paraneo Autoab Quant Ria(so) BOTH IP/OP $124.00 $91.76 $7.77 $96.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $73.35 $73.35 $18.13 $36.18 $95.83 $96.80 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100731 EAP CPT® 82542 "Cc/ms Spec Anal-ghb, Ql (so)" BOTH IP/OP $239.00 $176.86 $0.00 $191.20 $37.28 $37.28 $24.09 $24.09 $12.05 $10.84 $9.12 $9.12 $9.47 $24.09 $8.87 $15.66 $141.37 $141.37 $25.29 $16.78 $189.29 $191.20 $34.93 $0.00 $34.93 $9.45 $24.09 $24.09 $6.62 $24.09 $0.00 $0.00 $0.00 $0.00 30100732 EAP CPT® 83880 Cardio Iq Nt Probnp (so) BOTH IP/OP $309.00 $228.66 $17.67 $249.60 $70.07 $70.07 $39.26 $39.26 $19.63 $17.67 $51.54 $51.54 $53.52 $39.26 $50.15 $25.52 $182.77 $182.77 $41.22 $94.86 $247.10 $249.60 $56.93 $64.78 $56.93 $53.43 $39.26 $39.26 $37.40 $39.26 $0.00 $0.00 $0.00 $0.00 30100740 EAP CPT® 80299 Adalimumab Quant (so) BOTH IP/OP $210.00 $155.40 $8.39 $168.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $124.22 $124.22 $19.57 $33.64 $167.11 $168.80 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100741 EAP CPT® 82397 Anti Adalimumab Ab (so) BOTH IP/OP $286.00 $211.64 $7.06 $222.40 $29.15 $29.15 $14.12 $14.12 $7.06 $7.06 $21.46 $21.46 $22.28 $14.12 $20.87 $9.18 $169.17 $169.17 $14.83 $39.48 $220.18 $222.40 $20.47 $23.30 $20.47 $22.24 $14.12 $14.12 $15.57 $14.12 $0.00 $0.00 $0.00 $0.00 30100742 EAP CPT® 80354 Acetyl Fentanyl Qual (so) BOTH IP/OP $125.00 $92.50 $0.00 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $96.35 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100750 EAP CPT® 83088 Histamine 24hr Urine (so) BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.84 $44.84 $46.57 $0.00 $43.62 $0.00 $0.00 $0.00 $0.00 $82.52 $192.46 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100751 EAP CPT® 80299 Metoprolol Quant (so) BOTH IP/OP $211.00 $156.14 $0.00 $168.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $124.81 $124.81 $19.57 $33.64 $167.11 $168.80 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30100752 EAP CPT® 80361 Morphine Glucuronide (so) BOTH IP/OP $133.00 $98.42 $0.00 $112.80 $0.03 $0.03 $0.00 $0.00 $12.01 $11.94 $98.71 $98.71 $102.52 $0.00 $30.51 $0.00 $78.67 $78.67 $0.00 $70.50 $111.67 $112.80 $84.60 $0.00 $84.60 $32.51 $0.00 $0.00 $22.76 $0.00 $0.00 $0.00 $0.00 $0.00 30100755 EAP CPT® 84182 Recombx Mata Autoab (so) BOTH IP/OP $468.00 $346.32 $0.00 $374.40 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $276.82 $276.82 $30.67 $50.30 $370.66 $374.40 $42.35 $0.00 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30100756 EAP CPT® 83789 Bile Acids Urine (so) BOTH IP/OP $236.00 $174.64 $0.00 $188.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $186.91 $188.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100757 EAP CPT® 84311 Fluvoxamine (so) BOTH IP/OP $158.00 $116.92 $0.00 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $156.02 $157.60 $11.75 $156.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30100758 EAP CPT® 84311 Fungitell Serum (so) BOTH IP/OP $158.00 $116.92 $0.00 $157.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $156.02 $157.60 $11.75 $156.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30100759 EAP CPT® 83520 Ganglioside Gd1b Ab (so) BOTH IP/OP $335.00 $247.90 $7.77 $260.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $198.15 $198.15 $18.13 $36.18 $258.19 $260.80 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100760 EAP CPT® 83520 Ganglioside Gm-1 Ab (so) BOTH IP/OP $289.00 $213.86 $0.00 $260.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $170.94 $170.94 $18.13 $36.18 $258.19 $260.80 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30100761 EAP CPT® 83051 Hemoglobin Free Plasma (so) BOTH IP/OP $104.00 $76.96 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.10 $11.10 $11.52 $0.00 $10.79 $0.00 $0.00 $0.00 $0.00 $20.42 $82.37 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100762 EAP CPT® 83520 Interleukin-6 Ruo BOTH IP/OP $228.00 $168.72 $7.77 $177.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $134.86 $134.86 $18.13 $36.18 $175.82 $177.60 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30105004 EAP CPT® 80053 Comprehensive Metabolic Panel BOTH IP/OP $472.00 $349.28 $0.00 $381.60 $21.81 $21.81 $10.56 $10.56 $5.28 $5.28 $16.06 $16.06 $16.68 $10.56 $15.61 $6.86 $279.19 $279.19 $11.09 $29.54 $377.78 $381.60 $15.31 $0.00 $15.31 $16.64 $10.56 $10.56 $11.65 $10.56 $0.00 $0.00 $0.00 $0.00 30105007 EAP CPT® 80061 Lipid Panel BOTH IP/OP $239.00 $176.86 $0.00 $228.00 $27.64 $27.64 $13.39 $13.39 $6.70 $6.70 $20.35 $20.35 $21.14 $13.39 $19.79 $8.70 $141.37 $141.37 $14.06 $37.44 $225.72 $228.00 $19.42 $0.00 $19.42 $21.09 $13.39 $13.39 $14.76 $13.39 $0.00 $0.00 $0.00 $0.00 30105047 EAP CPT® 82150 "Amylase,urine" BOTH IP/OP $301.00 $222.74 $3.24 $243.20 $13.38 $13.38 $6.48 $6.48 $3.24 $3.24 $9.84 $9.84 $10.22 $6.48 $9.58 $4.21 $178.04 $178.04 $6.80 $18.12 $240.77 $243.20 $9.40 $10.69 $9.40 $10.20 $6.48 $6.48 $7.14 $6.48 $0.00 $0.00 $0.00 $0.00 30105057 EAP CPT® 82247 "Bili, Total-fluid" BOTH IP/OP $117.00 $86.58 $2.51 $94.40 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $7.42 $3.26 $69.21 $69.21 $5.27 $14.04 $93.46 $94.40 $7.28 $8.28 $7.28 $7.91 $5.02 $5.02 $5.54 $5.02 $0.00 $0.00 $0.00 $0.00 30105071 EAP CPT® 82310 "Calcium, Urine" BOTH IP/OP $102.00 $75.48 $2.58 $74.40 $10.67 $10.67 $5.16 $5.16 $2.58 $2.58 $7.83 $7.83 $8.13 $5.16 $7.46 $3.35 $60.33 $60.33 $5.42 $14.40 $73.66 $74.40 $7.48 $8.51 $7.48 $7.94 $5.16 $5.16 $5.56 $5.16 $0.00 $0.00 $0.00 $0.00 30105151 EAP CPT® 82803 Blood Gas-cord Ven. BOTH IP/OP $510.00 $377.40 $11.73 $371.20 $39.94 $39.94 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $30.51 $26.07 $28.59 $16.95 $301.67 $301.67 $27.37 $54.08 $367.49 $371.20 $37.80 $43.02 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30105168 EAP CPT® 82945 "Glucose,urine(quant)" BOTH IP/OP $341.00 $252.34 $1.97 $248.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $201.70 $201.70 $4.13 $10.96 $246.31 $248.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30105171 EAP CPT® 82947 "Gtt,oral-2hr Indiv" BOTH IP/OP $263.00 $194.62 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $155.56 $155.56 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30105196 EAP CPT® 82951 "Gtt,prenatal(100gm)" BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $26.58 $26.58 $12.87 $12.87 $6.44 $6.44 $19.55 $19.55 $20.30 $12.87 $19.02 $8.37 $118.89 $118.89 $13.51 $35.98 $159.19 $160.80 $18.66 $0.00 $18.66 $20.26 $12.87 $12.87 $14.18 $12.87 $0.00 $0.00 $0.00 $0.00 30105201 EAP CPT® 82952 5th Hour Gtt Specimen BOTH IP/OP $103.00 $76.22 $1.96 $82.40 $8.10 $8.10 $3.92 $3.92 $1.96 $1.96 $5.95 $5.95 $6.18 $3.92 $5.80 $2.55 $60.92 $60.92 $4.12 $10.96 $81.58 $82.40 $5.68 $6.47 $5.68 $6.18 $3.92 $3.92 $4.32 $3.92 $0.00 $0.00 $0.00 $0.00 30105214 EAP CPT® 83020 Hgb Elect. Cord Bld BOTH IP/OP $217.00 $160.58 $0.00 $174.40 $20.17 $20.17 $12.87 $12.87 $6.44 $6.44 $14.84 $14.84 $15.41 $12.87 $14.44 $8.37 $128.36 $128.36 $13.51 $27.32 $172.66 $174.40 $18.66 $0.00 $18.66 $15.38 $12.87 $12.87 $10.77 $12.87 $0.00 $0.00 $0.00 $0.00 30105248 EAP CPT® 83605 "Lactic Acid, Fluid" BOTH IP/OP $341.00 $252.34 $5.34 $248.80 $22.04 $22.04 $11.57 $11.57 $5.79 $5.34 $16.21 $16.21 $16.84 $11.57 $15.78 $7.52 $201.70 $201.70 $12.15 $29.84 $246.31 $248.80 $16.78 $19.09 $16.78 $16.82 $11.57 $11.57 $11.77 $11.57 $0.00 $0.00 $0.00 $0.00 30105252 EAP CPT® 83615 "Ldh,csf" BOTH IP/OP $153.00 $113.22 $3.02 $111.20 $12.46 $12.46 $6.04 $6.04 $3.02 $3.02 $9.16 $9.16 $9.51 $6.04 $7.46 $3.93 $90.50 $90.50 $6.34 $16.88 $110.09 $111.20 $8.76 $9.97 $8.76 $7.94 $6.04 $6.04 $5.56 $6.04 $0.00 $0.00 $0.00 $0.00 30105255 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP "$1,127.00 " $833.98 $8.28 $876.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $666.62 $666.62 $19.32 $37.76 $868.03 $876.80 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30105256 EAP CPT® 84260 Assay Of Serotonin BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.04 $47.04 $48.85 $0.00 $45.76 $0.00 $0.00 $0.00 $0.00 $86.56 $157.61 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30105257 EAP CPT® 84252 Assay Of Vitamin B-12 BOTH IP/OP $284.00 $210.16 $0.00 $284.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.73 $30.73 $31.91 $0.00 $29.89 $0.00 $0.00 $0.00 $0.00 $56.56 $224.93 $227.20 $0.00 $284.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30105258 EAP CPT® 83018 "Quantitative, Each" BOTH IP/OP $182.00 $134.68 $0.00 $145.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.34 $33.34 $34.62 $0.00 $32.43 $0.00 $0.00 $0.00 $0.00 $61.36 $144.14 $145.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30105261 EAP CPT® 83519 "Quantitative, By Radioimmunoassay(eg:ria)" BOTH IP/OP $743.00 $549.82 $8.28 $578.40 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $439.48 $439.48 $19.32 $37.76 $572.62 $578.40 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30105262 EAP CPT® 83519 "Quantitative, By Radioimmunoassay(eg:ria)" BOTH IP/OP $716.00 $529.84 $8.28 $556.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $423.51 $423.51 $19.32 $37.76 $551.23 $556.80 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30105263 EAP CPT® 82378 Cea Pancreatic Cyst Fluid (so) BOTH IP/OP $152.00 $112.48 $0.00 $126.40 $39.15 $39.15 $18.96 $18.96 $9.48 $9.48 $28.81 $28.81 $29.92 $18.96 $28.02 $12.32 $89.91 $89.91 $19.91 $53.02 $125.14 $126.40 $27.49 $0.00 $27.49 $29.86 $18.96 $18.96 $20.90 $18.96 $0.00 $0.00 $0.00 $0.00 30105264 EAP CPT® 84432 Thyroglobulin (so) Th BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.16 $33.16 $16.06 $16.06 $8.03 $8.03 $24.39 $24.39 $25.33 $16.06 $23.73 $10.44 $44.36 $44.36 $16.86 $44.88 $59.40 $60.00 $23.29 $0.00 $23.29 $25.28 $16.06 $16.06 $17.70 $16.06 $0.00 $0.00 $0.00 $0.00 30105265 EAP CPT® 86800 Thyroglobulin Antibody (so) Th BOTH IP/OP $54.00 $39.96 $0.00 $44.44 $32.84 $32.84 $15.91 $15.91 $7.96 $7.95 $24.15 $24.15 $25.08 $15.91 $23.50 $10.34 $31.94 $31.94 $16.71 $44.44 $42.77 $43.20 $23.07 $0.00 $23.07 $25.04 $15.91 $15.91 $17.53 $15.91 $0.00 $0.00 $0.00 $0.00 30105268 EAP CPT® 82108 "Aluminum, 24- Hour Urine (so)" BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $34.80 $34.80 $25.48 $25.48 $12.74 $12.74 $25.59 $25.59 $26.58 $25.48 $24.91 $16.56 $40.81 $40.81 $26.75 $47.10 $54.65 $55.20 $36.95 $0.00 $36.95 $0.00 $25.48 $25.48 $18.58 $25.48 $0.00 $0.00 $0.00 $0.00 30105269 EAP CPT® 83789 "Ethambutol, Serum (nms)" BOTH IP/OP $210.00 $155.40 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $167.11 $168.80 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30105270 EAP CPT® 83789 "Pyrazinamide, Serum (nms)" BOTH IP/OP $505.00 $373.70 $0.00 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $401.54 $405.60 $0.00 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30105271 EAP CPT® 84999 Nephrocheck Acute Kidney Injury BOTH IP/OP $301.00 $222.74 $0.00 $237.60 $0.00 $0.00 $0.00 $0.00 $53.58 $0.00 $223.40 $223.40 $232.01 $0.00 $62.73 $0.00 $0.00 $0.00 $0.00 $0.00 $235.22 $237.60 $0.00 $156.65 $0.00 $46.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30105275 EAP CPT® 80186 Free Phenytoin BOTH IP/OP $157.00 $116.18 $6.88 $125.60 $28.41 $28.41 $13.76 $13.76 $6.88 $6.88 $20.90 $20.90 $21.71 $13.76 $20.34 $8.94 $92.87 $92.87 $14.45 $38.46 $124.34 $125.60 $19.95 $22.70 $19.95 $21.67 $13.76 $13.76 $15.17 $13.76 $0.00 $0.00 $0.00 $0.00 30150004 EAP CPT® 80053 "Comp, Metabolic Panel" BOTH IP/OP $489.00 $361.86 $5.28 $381.60 $21.81 $21.81 $10.56 $10.56 $5.28 $5.28 $16.06 $16.06 $16.68 $10.56 $15.61 $6.86 $289.24 $289.24 $11.09 $29.54 $377.78 $381.60 $15.31 $17.42 $15.31 $16.64 $10.56 $10.56 $11.65 $10.56 $0.00 $0.00 $0.00 $0.00 30150007 EAP CPT® 80061 Lipoprotein Profile BOTH IP/OP $239.00 $176.86 $0.00 $228.00 $27.64 $27.64 $13.39 $13.39 $6.70 $6.70 $20.35 $20.35 $21.14 $13.39 $19.79 $8.70 $141.37 $141.37 $14.06 $37.44 $225.72 $228.00 $19.42 $0.00 $19.42 $21.09 $13.39 $13.39 $14.76 $13.39 $0.00 $0.00 $0.00 $0.00 30150171 EAP CPT® 82947 Glucose BOTH IP/OP $263.00 $194.62 $1.97 $260.80 $8.10 $8.10 $3.93 $3.93 $1.97 $1.97 $5.96 $5.96 $6.19 $3.93 $5.80 $2.55 $155.56 $155.56 $4.13 $10.96 $258.19 $260.80 $5.70 $6.48 $5.70 $6.18 $3.93 $3.93 $4.32 $3.93 $0.00 $0.00 $0.00 $0.00 30150172 EAP CPT® 82480 Cholinesterase; Serum BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.97 $11.97 $12.43 $0.00 $11.64 $0.00 $0.00 $0.00 $0.00 $22.02 $30.89 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150173 EAP CPT® 82482 Rbc BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.67 $11.67 $12.12 $0.00 $11.36 $0.00 $0.00 $0.00 $0.00 $21.48 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150174 EAP CPT® 86255 "Fluor Noninfec Agnt Ab Scr,ea" BOTH IP/OP $51.00 $37.74 $0.00 $51.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $30.17 $30.17 $12.65 $33.68 $50.69 $51.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30150176 EAP CPT® 86628 Candida BOTH IP/OP $252.00 $186.48 $0.00 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.23 $18.23 $18.93 $0.00 $17.73 $0.00 $0.00 $0.00 $0.00 $33.56 $201.17 $203.20 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150177 EAP CPT® 83789 "Quantitative, Each Specimen" BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150178 EAP CPT® 86235 "Extractable Nuclear Antigen,antibody To, Any Method" BOTH IP/OP $130.00 $96.20 $0.00 $127.20 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $76.90 $76.90 $18.83 $50.12 $125.93 $127.20 $26.00 $0.00 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30150179 EAP CPT® 87798 "Amplified Probe Technique,each Organism" BOTH IP/OP $502.00 $371.48 $0.00 $484.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $296.93 $296.93 $36.84 $54.82 $479.16 $484.00 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30150180 EAP CPT® 86658 Enterovirus - A BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $30.17 $30.17 $13.68 $36.40 $40.39 $40.80 $18.89 $0.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30150181 EAP CPT® 86658 Enterovirus - B BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $30.17 $30.17 $13.68 $36.40 $40.39 $40.80 $18.89 $0.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30150182 EAP CPT® 86750 Plasmodium(malaria) BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150183 EAP CPT® 86750 Plasmodium(malaria) BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150184 EAP CPT® 83520 "Quantitative, Not Otherwise Specified" BOTH IP/OP $638.00 $472.12 $7.77 $576.00 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $377.38 $377.38 $18.13 $36.18 $570.24 $576.00 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30150185 EAP CPT® 86635 Coccidioides BOTH IP/OP $75.00 $55.50 $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.42 $17.42 $18.09 $0.00 $16.95 $0.00 $0.00 $0.00 $0.00 $32.06 $53.86 $54.40 $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150193 EAP CPT® 83519 "Quantitative, By Radioimmunoassay" BOTH IP/OP $609.00 $450.66 $8.28 $549.60 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $360.22 $360.22 $19.32 $37.76 $544.10 $549.60 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30150194 EAP CPT® 88271 "Molecular Cytogenetics; Dna Probe, Each" BOTH IP/OP $307.00 $227.18 $0.00 $245.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $181.59 $181.59 $22.49 $59.86 $243.14 $245.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30150195 EAP CPT® 88275 "Interphase Insitu Hybrid, Ana 10-30 Cells" BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $236.60 $236.60 $53.75 $112.22 $316.80 $320.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30150196 EAP CPT® 86255 "Fluor Noninfect Agent Ab Scr, Ea Ab" BOTH IP/OP $85.00 $62.90 $0.00 $84.80 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $50.28 $50.28 $12.65 $33.68 $83.95 $84.80 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30150197 EAP CPT® 83625 "Isoenzymes, Separation And Quantitation" BOTH IP/OP $48.00 $35.52 $0.00 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.58 $17.58 $18.25 $0.00 $17.09 $0.00 $0.00 $0.00 $0.00 $32.34 $38.02 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150202 EAP CPT® 82379 "Carnitine, Urine (quest 30338)" BOTH IP/OP $321.00 $237.54 $0.00 $259.20 $34.82 $34.82 $16.87 $16.87 $8.44 $8.43 $25.62 $25.62 $26.60 $16.87 $24.92 $10.97 $189.87 $189.87 $0.00 $47.14 $256.61 $259.20 $0.00 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150203 EAP CPT® 84143 C17-HYDROXYPREGNENOLONE(QUEST 8352) BOTH IP/OP $150.00 $111.00 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.65 $34.65 $35.99 $0.00 $33.72 $0.00 $0.00 $0.00 $0.00 $63.78 $118.80 $120.00 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150204 EAP CPT® 86332 IMMUNE COMPLEX DETECTION BY C1Q BINDING(Q 36735) BOTH IP/OP $34.00 $25.16 $12.19 $40.21 $34.00 $34.00 $24.37 $24.37 $12.19 $12.19 $37.01 $37.01 $38.44 $24.37 $34.00 $15.84 $20.11 $20.11 $25.59 $34.00 $26.93 $27.20 $34.00 $40.21 $34.00 $38.36 $24.37 $24.37 $26.85 $24.37 $0.00 $0.00 $0.00 $0.00 30150205 EAP CPT® 81229 "CHROMOSOMAL MICROARRAY, PRENATAL (QUEST 90927)" BOTH IP/OP "$3,929.00 " "$2,907.46" $0.00 "$3,104.80" $807.84 $807.84 "$1,160.00" "$1,160.00" $580.00 $0.00 "$2,916.10" "$2,916.10" "$3,028.47" $0.00 "$2,725.40" $0.00 $0.00 $0.00 "$1,218.00" "$1,940.50" "$3,073.75" "$3,104.80" "$1,682.00" "$1,914.00" "$1,682.00" "$2,903.98" "$1,160.00" "$1,160.00" "$2,032.79" "$1,160.00" $0.00 $0.00 $0.00 $0.00 30150206 EAP CPT® 86003 "ALLERGY PANEL,MOLD GROUP (QUEST 7911)" BOTH IP/OP $252.00 $186.48 $2.61 $203.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $149.06 $149.06 $5.48 $14.60 $201.17 $203.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30150207 EAP CPT® 88271 "FISH,PDGFRB,5q331.(QUEST 90510)DNA PROBE" BOTH IP/OP $511.00 $378.14 $0.00 $408.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $302.26 $302.26 $22.49 $59.86 $404.71 $408.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30150208 EAP CPT® 88275 "FISH,PDGFRB,5q331.(QUEST 90510)100-300cells" BOTH IP/OP $256.00 $189.44 $0.00 $204.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $151.42 $151.42 $53.75 $112.22 $202.75 $204.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30150209 EAP CPT® 86235 MYOSITIS ASSESS AUTOAB (Q10185)NUC AG AB BOTH IP/OP $429.00 $317.46 $8.97 $331.20 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $253.75 $253.75 $18.83 $50.12 $327.89 $331.20 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30150210 EAP CPT® 83516 MYOSITIS ASSESS AUTOAB (Q10185)Non AB BOTH IP/OP "$1,134.00 " $839.16 $5.76 $882.40 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $670.76 $670.76 $12.11 $29.88 $873.58 $882.40 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30150211 EAP CPT® 80356 MONOACETLYMORPNINE MAM (SO) BOTH IP/OP $166.00 $122.84 $0.00 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.21 $123.21 $127.95 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $88.00 $139.39 $140.80 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30150212 EAP CPT® 80377 Hypoglycemic Mass Spec (so) BOTH IP/OP $428.00 $316.72 $0.00 $329.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.66 $317.66 $329.90 $0.00 $89.20 $0.00 $0.00 $0.00 $0.00 $194.50 $308.09 $311.20 $0.00 $278.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159005 EAP CPT® 89055 Fecal Leukocyte Smear BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $3.57 $3.70 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $6.56 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159016 EAP CPT® 82570 Urine Creatinine (so) BOTH IP/OP $79.00 $58.46 $2.59 $63.20 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $46.73 $46.73 $5.44 $14.46 $62.57 $63.20 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30159017 EAP CPT® 83918 Organic Acids (so) BOTH IP/OP $660.00 $488.40 $0.00 $533.60 $33.95 $33.95 $23.60 $23.60 $11.80 $10.62 $25.00 $25.00 $25.96 $23.60 $24.32 $15.34 $390.39 $390.39 $24.78 $46.00 $528.26 $533.60 $34.22 $38.94 $34.22 $0.00 $23.60 $23.60 $18.14 $23.60 $0.00 $0.00 $0.00 $0.00 30159018 EAP CPT® 83018 "Cobalt, Plasma (so)" BOTH IP/OP $158.00 $116.92 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.34 $33.34 $34.62 $0.00 $32.43 $0.00 $0.00 $0.00 $0.00 $61.36 $125.93 $127.20 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159019 EAP CPT® 84999 Macroamylase BOTH IP/OP $71.00 $52.54 $0.00 $60.80 $0.00 $0.00 $0.00 $0.00 $12.64 $0.00 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 $60.19 $60.80 $0.00 $0.00 $0.00 $11.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159020 EAP CPT® 81511 Integrated Maternal Serum Screen (so) BOTH IP/OP "$1,246.00 " $922.04 $69.08 $984.80 $462.00 $462.00 $153.50 $153.50 $76.75 $69.08 $924.78 $924.78 $960.42 $153.50 $144.26 $99.78 $737.01 $737.01 $161.18 $615.50 $974.95 $984.80 $222.58 $253.28 $222.58 $153.71 $153.50 $153.50 $107.60 $153.50 $0.00 $0.00 $0.00 $0.00 30159021 EAP CPT® 84163 Pregnancy Associated Plasma Protein (so) BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $106.47 $106.47 $15.80 $17.94 $142.56 $144.00 $21.82 $0.00 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30159024 EAP CPT® 82172 Apolipoprotein (so) BOTH IP/OP $155.00 $114.70 $0.00 $124.00 $32.00 $32.00 $21.09 $21.09 $10.55 $9.49 $23.52 $23.52 $24.43 $21.09 $22.90 $13.71 $91.68 $91.68 $22.14 $43.30 $122.76 $124.00 $30.58 $0.00 $30.58 $24.40 $21.09 $21.09 $17.08 $21.09 $0.00 $0.00 $0.00 $0.00 30159025 EAP CPT® 82247 "Bilirubin, Total (so)" BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $10.35 $10.35 $5.02 $5.02 $2.51 $2.51 $7.62 $7.62 $7.92 $5.02 $7.42 $3.26 $47.32 $47.32 $5.27 $14.04 $63.36 $64.00 $7.28 $0.00 $7.28 $7.91 $5.02 $5.02 $5.54 $5.02 $0.00 $0.00 $0.00 $0.00 30159026 EAP CPT® 82977 Gamma - Ggt (so) BOTH IP/OP $144.00 $106.56 $3.60 $115.20 $14.86 $14.86 $7.20 $7.20 $3.60 $3.60 $10.93 $10.93 $11.35 $7.20 $7.46 $4.68 $85.18 $85.18 $7.56 $20.12 $114.05 $115.20 $10.44 $11.88 $10.44 $7.94 $7.20 $7.20 $5.56 $7.20 $0.00 $0.00 $0.00 $0.00 30159027 EAP CPT® 83010 "Haptoglobin, Quant (so)" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $7.71 $7.71 $12.58 $12.58 $6.29 $6.29 $5.66 $5.66 $5.88 $12.58 $5.51 $8.18 $73.94 $73.94 $13.21 $10.42 $99.00 $100.00 $18.24 $0.00 $18.24 $5.87 $12.58 $12.58 $4.11 $12.58 $0.00 $0.00 $0.00 $0.00 30159028 EAP CPT® 83883 "Nephelometry, Each Analyte (so)" BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $85.77 $85.77 $14.28 $38.00 $114.84 $116.00 $19.72 $0.00 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30159029 EAP CPT® 84460 Alt (alanine Aminotransferase) (so) BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $10.93 $10.93 $5.30 $5.30 $2.65 $2.65 $8.04 $8.04 $8.35 $5.30 $7.46 $3.45 $47.32 $47.32 $5.57 $14.80 $63.36 $64.00 $7.69 $0.00 $7.69 $7.94 $5.30 $5.30 $5.56 $5.30 $0.00 $0.00 $0.00 $0.00 30159062 EAP CPT® 84210 "Pyruvate, Csf (so)" BOTH IP/OP $254.00 $187.96 $0.00 $214.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.48 $16.48 $17.12 $0.00 $16.03 $0.00 $0.00 $0.00 $15.20 $30.34 $201.17 $203.20 $21.00 $214.00 $21.00 $0.00 $14.48 $14.48 $11.96 $14.48 $0.00 $0.00 $0.00 $0.00 30159063 EAP CPT® 86787 "Varicella - Zoster Virus Antibody , Csf (so)" BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $64.47 $64.47 $13.52 $36.00 $86.33 $87.20 $18.68 $0.00 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30159064 EAP CPT® 80350 "Cannabinoids, Synthetic, 1-3" BOTH IP/OP $140.00 $103.60 $0.00 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.91 $103.91 $107.91 $0.00 $29.18 $0.00 $0.00 $0.00 $0.00 $74.00 $117.22 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159065 EAP CPT® 80335 "Clomipramine, Serum (nms), Qt" BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.43 $197.43 $205.03 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159066 EAP CPT® 82657 "Alpha - Galactosidase, Leukocytes (mayo)" BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $304.92 $308.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159067 EAP CPT® 80307 "Hypoglycemic Agent Screen, Serum (mayo)" BOTH IP/OP $397.00 $293.78 $29.09 $288.80 $115.05 $115.05 $62.14 $62.14 $31.07 $29.09 $79.51 $79.51 $82.57 $62.14 $71.85 $40.39 $234.83 $234.83 $65.25 $180.50 $285.91 $288.80 $90.10 $102.53 $90.10 $76.56 $62.14 $62.14 $53.59 $62.14 $0.00 $0.00 $0.00 $0.00 30159068 EAP CPT® 80347 Benzodiazepines (so)nms BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $81.50 $129.10 $130.40 $0.00 $98.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159069 EAP CPT® 80320 "Alcohol( Ethanol), (so)nms" BOTH IP/OP $46.00 $34.04 $0.00 $120.15 $0.03 $0.03 $114.43 $114.43 $57.22 $6.63 $34.14 $34.14 $35.46 $114.43 $15.96 $74.38 $27.21 $27.21 $120.15 $24.50 $38.81 $39.20 $29.40 $0.00 $29.40 $17.01 $0.00 $0.00 $11.90 $114.43 $0.00 $0.00 $0.00 $0.00 30159070 EAP CPT® 80307 "Drug Screen, Qualitative,(so)nms" BOTH IP/OP $270.00 $199.80 $0.00 $228.80 $115.05 $115.05 $62.14 $62.14 $31.07 $29.09 $79.51 $79.51 $82.57 $62.14 $71.85 $40.39 $159.71 $159.71 $65.25 $143.00 $226.51 $228.80 $90.10 $0.00 $90.10 $76.56 $62.14 $62.14 $53.59 $62.14 $0.00 $0.00 $0.00 $0.00 30159071 EAP CPT® 80307 "Single Drug Class (elisa), (so)nms" BOTH IP/OP $204.00 $150.96 $0.00 $172.80 $115.05 $115.05 $62.14 $62.14 $31.07 $29.09 $79.51 $79.51 $82.57 $62.14 $71.85 $40.39 $120.67 $120.67 $65.25 $108.00 $171.07 $172.80 $90.10 $0.00 $90.10 $76.56 $62.14 $62.14 $53.59 $62.14 $0.00 $0.00 $0.00 $0.00 30159072 EAP CPT® 83519 Ach Receptor (muscle Binding Abs) Mayo BOTH IP/OP $145.00 $107.30 $8.28 $112.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $85.77 $85.77 $19.32 $37.76 $111.67 $112.80 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30159073 EAP CPT® 83519 Achr Ganglionic Neuronal Abs (mayo) BOTH IP/OP $125.00 $92.50 $0.00 $112.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $73.94 $73.94 $19.32 $37.76 $111.67 $112.80 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30159074 EAP CPT® 83519 Neuronal Vgkc Autoantibody (mayo) BOTH IP/OP $125.00 $92.50 $0.00 $112.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $73.94 $73.94 $19.32 $37.76 $111.67 $112.80 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30159075 EAP CPT® 83519 N-type Calcium Channel Abs (mayo) BOTH IP/OP $125.00 $92.50 $0.00 $112.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $73.94 $73.94 $19.32 $37.76 $111.67 $112.80 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30159076 EAP CPT® 83519 P/q -type Calcium Channel Abs (mayo) BOTH IP/OP $125.00 $92.50 $0.00 $112.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $73.94 $73.94 $19.32 $37.76 $111.67 $112.80 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30159077 EAP CPT® 83519 Ach Receptor (muscle) Modulating Abs (mayo) BOTH IP/OP $125.00 $92.50 $0.00 $112.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $73.94 $73.94 $19.32 $37.76 $111.67 $112.80 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30159078 EAP CPT® 83520 Striational (striated Muscle) Abs (mayo) BOTH IP/OP $125.00 $92.50 $0.00 $112.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $73.94 $73.94 $18.13 $36.18 $111.67 $112.80 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30159079 EAP CPT® 84182 Amphiphysin Western Blot (mayo) BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $37.26 $37.26 $30.67 $50.30 $49.90 $50.40 $42.35 $0.00 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30159080 EAP CPT® 84182 Crmp-5-igg Western Blot (mayo) BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $37.26 $37.26 $30.67 $50.30 $49.90 $50.40 $42.35 $0.00 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30159081 EAP CPT® 84182 Paraneoplastic Autoantibody Western Blot (mayo) BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $37.26 $37.26 $30.67 $50.30 $49.90 $50.40 $42.35 $0.00 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30159082 EAP CPT® 83519 Alpha Subunit (so) BOTH IP/OP $216.00 $159.84 $0.00 $195.20 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $127.76 $127.76 $19.32 $37.76 $193.25 $195.20 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30159083 EAP CPT® 80299 "Metformin Quantitative, Serum (arup)" BOTH IP/OP $308.00 $227.92 $8.39 $246.40 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $182.18 $182.18 $19.57 $33.64 $243.94 $246.40 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30159084 EAP CPT® 83872 "Mucin Clot, Synovial (so)" BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.90 $8.90 $9.24 $0.00 $14.54 $0.00 $0.00 $0.00 $0.00 $16.38 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159085 EAP CPT® 82379 "Carnitine, Urine (so)" BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $34.82 $34.82 $16.87 $16.87 $8.44 $8.43 $25.62 $25.62 $26.60 $16.87 $24.92 $10.97 $191.65 $191.65 $0.00 $47.14 $256.61 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159086 EAP CPT® 83519 "Musk Quantitative , Antibody (so)" BOTH IP/OP "$1,583.00 " "$1,171.42" $8.28 "$1,429.60" $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $936.34 $936.34 $19.32 $37.76 "$1,415.30" "$1,429.60" $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30159087 EAP CPT® 82542 "Cannabinoid Metabolite, Urine (nms), Qt" BOTH IP/OP $284.00 $210.16 $0.00 $227.20 $37.28 $37.28 $24.09 $24.09 $12.05 $10.84 $9.12 $9.12 $9.47 $24.09 $8.87 $15.66 $167.99 $167.99 $25.29 $16.78 $224.93 $227.20 $34.93 $0.00 $34.93 $9.45 $24.09 $24.09 $6.62 $24.09 $0.00 $0.00 $0.00 $0.00 30159088 EAP CPT® 83520 Tsh Receptor Binding Ab Trab (so) BOTH IP/OP $270.00 $199.80 $7.77 $210.40 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $159.71 $159.71 $18.13 $36.18 $208.30 $210.40 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30159089 EAP CPT® 84143 "Hydroxypregnenolone-17, Lc/ms/ms (so)" BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.65 $34.65 $35.99 $0.00 $33.72 $0.00 $0.00 $0.00 $0.00 $63.78 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30159090 EAP CPT® 80299 Infliximab Drug Concentration BOTH IP/OP $399.00 $295.26 $8.39 $320.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $236.01 $236.01 $19.57 $33.64 $317.59 $320.80 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30159091 EAP CPT® 82397 Anti-infliximab Ab BOTH IP/OP $738.00 $546.12 $7.06 $574.40 $29.15 $29.15 $14.12 $14.12 $7.06 $7.06 $21.46 $21.46 $22.28 $14.12 $20.87 $9.18 $436.53 $436.53 $14.83 $39.48 $568.66 $574.40 $20.47 $23.30 $20.47 $22.24 $14.12 $14.12 $15.57 $14.12 $0.00 $0.00 $0.00 $0.00 30160020 EAP CPT® 82172 Apolipoprotein A1 (so) BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $32.00 $32.00 $21.09 $21.09 $10.55 $9.49 $23.52 $23.52 $24.43 $21.09 $22.90 $13.71 $103.51 $103.51 $22.14 $43.30 $138.60 $140.00 $30.58 $0.00 $30.58 $24.40 $21.09 $21.09 $17.08 $21.09 $0.00 $0.00 $0.00 $0.00 30160023 EAP CPT® 84182 Redombx Car Antirecoverin (so) BOTH IP/OP $468.00 $346.32 $0.00 $374.40 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $276.82 $276.82 $30.67 $50.30 $370.66 $374.40 $42.35 $0.00 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30160024 EAP CPT® 83520 Prothrom Frag 1.2 (so) BOTH IP/OP $367.00 $271.58 $7.77 $331.20 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $217.08 $217.08 $18.13 $36.18 $327.89 $331.20 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30160025 EAP CPT® 80369 Baclofin (so) BOTH IP/OP $380.00 $281.20 $0.00 $321.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.04 $282.04 $292.90 $0.00 $26.04 $0.00 $0.00 $0.00 $0.00 $201.00 $318.38 $321.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30160027 EAP CPT® 82042 "Albumin, Csf (so)" BOTH IP/OP $18.00 $13.32 $3.50 $14.46 $10.69 $10.69 $7.78 $7.78 $3.89 $3.50 $7.86 $7.86 $8.16 $7.78 $7.64 $5.06 $10.65 $10.65 $8.17 $14.46 $14.26 $14.40 $11.28 $12.84 $11.28 $8.14 $7.78 $7.78 $5.70 $7.78 $0.00 $0.00 $0.00 $0.00 30160028 EAP CPT® 82272 "Occult Blood Guaiac, Fecal" BOTH IP/OP $64.00 $47.36 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $4.88 $5.07 $0.00 $4.75 $0.00 $0.00 $0.00 $0.00 $8.98 $51.48 $52.00 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30160029 EAP CPT® 80365 "Oxycodone And Metabolite, Quant Serum (so-quest)" BOTH IP/OP $333.00 $246.42 $0.00 $256.68 $0.03 $0.03 $114.43 $114.43 $57.22 $11.94 $247.15 $247.15 $256.68 $114.43 $69.40 $74.38 $196.97 $196.97 $120.15 $151.50 $239.98 $242.40 $181.80 $188.81 $181.80 $47.42 $0.00 $0.00 $48.24 $114.43 $0.00 $0.00 $0.00 $0.00 30160030 EAP CPT® 82397 "Anti-mullerian Hormone (amh), Male (so)" BOTH IP/OP $255.00 $188.70 $0.00 $230.40 $29.15 $29.15 $14.12 $14.12 $7.06 $7.06 $21.46 $21.46 $22.28 $14.12 $20.87 $9.18 $150.83 $150.83 $14.83 $39.48 $228.10 $230.40 $20.47 $0.00 $20.47 $22.24 $14.12 $14.12 $15.57 $14.12 $0.00 $0.00 $0.00 $0.00 30160031 EAP CPT® 82397 "Anti-mullerian Hormone (amh), Female (so)" BOTH IP/OP $296.00 $219.04 $7.06 $230.40 $29.15 $29.15 $14.12 $14.12 $7.06 $7.06 $21.46 $21.46 $22.28 $14.12 $20.87 $9.18 $175.08 $175.08 $14.83 $39.48 $228.10 $230.40 $20.47 $23.30 $20.47 $22.24 $14.12 $14.12 $15.57 $14.12 $0.00 $0.00 $0.00 $0.00 30160032 EAP CPT® 83520 Infliximab Ab - Rd (so) BOTH IP/OP $425.00 $314.50 $7.77 $384.00 $26.72 $26.72 $114.43 $114.43 $57.22 $7.77 $19.67 $19.67 $20.42 $114.43 $19.12 $74.38 $251.39 $251.39 $120.15 $36.18 $380.16 $384.00 $25.04 $188.81 $25.04 $20.37 $17.27 $17.27 $14.26 $114.43 $0.00 $0.00 $0.00 $0.00 30160033 EAP CPT® 80299 Infliximab Rd (so) BOTH IP/OP $423.00 $313.02 $8.39 $340.00 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $250.20 $250.20 $19.57 $33.64 $336.60 $340.00 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30160034 EAP CPT® 83520 Infliximab Ab Ibd (so) BOTH IP/OP $494.00 $365.56 $7.77 $384.00 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $292.20 $292.20 $18.13 $36.18 $380.16 $384.00 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30160035 EAP CPT® 80299 Infliximab Ibd (so) BOTH IP/OP $423.00 $313.02 $8.39 $340.00 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $250.20 $250.20 $19.57 $33.64 $336.60 $340.00 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30160036 EAP CPT® 80050 Champva General Health Panel BOTH IP/OP $836.00 $618.64 $0.00 $664.00 $70.80 $70.80 $0.00 $0.00 $22.64 $22.10 $44.24 $44.24 $45.94 $0.00 $174.22 $0.00 $494.49 $494.49 $0.00 $91.78 $657.36 $664.00 $0.00 $287.95 $0.00 $129.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30160040 EAP CPT® 82570 Urine Creatinine Qd (so) BOTH IP/OP $27.00 $19.98 $2.59 $21.60 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $15.97 $15.97 $5.44 $14.46 $21.38 $21.60 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30160041 EAP CPT® 84156 Urine Protein Qd (so BOTH IP/OP $28.00 $20.72 $1.83 $21.60 $7.58 $7.58 $3.67 $3.67 $1.84 $1.83 $5.56 $5.56 $5.78 $3.67 $5.42 $2.39 $16.56 $16.56 $3.85 $10.24 $21.38 $21.60 $5.32 $6.06 $5.32 $5.77 $3.67 $3.67 $4.04 $3.67 $0.00 $0.00 $0.00 $0.00 30160042 EAP CPT® 83001 Follicle Stimulating Hormone (so) BOTH IP/OP $56.00 $41.44 $9.29 $51.94 $38.36 $38.36 $18.58 $18.58 $9.29 $9.29 $28.23 $28.23 $29.31 $18.58 $27.46 $12.08 $33.12 $33.12 $19.51 $51.94 $42.77 $43.20 $26.94 $30.66 $26.94 $29.26 $18.58 $18.58 $20.48 $18.58 $0.00 $0.00 $0.00 $0.00 30160043 EAP CPT® 83002 Luteinizing Hormone (so) BOTH IP/OP $56.00 $41.44 $9.26 $51.76 $38.23 $38.23 $18.52 $18.52 $9.26 $9.26 $28.12 $28.12 $29.20 $18.52 $27.36 $12.04 $33.12 $33.12 $19.45 $51.76 $42.77 $43.20 $26.85 $30.56 $26.85 $29.16 $18.52 $18.52 $20.41 $18.52 $0.00 $0.00 $0.00 $0.00 30160044 EAP CPT® 84182 Myositis Specific 11 Ab Protein Western Blot (so) BOTH IP/OP $103.00 $76.22 $13.14 $82.40 $37.14 $37.14 $29.21 $29.21 $14.61 $13.14 $27.33 $27.33 $28.38 $29.21 $26.60 $18.99 $60.92 $60.92 $30.67 $50.30 $81.58 $82.40 $42.35 $48.20 $42.35 $28.34 $29.21 $29.21 $19.84 $29.21 $0.00 $0.00 $0.00 $0.00 30160050 EAP CPT® 83520 Interleukin-6 (il-6) (so) BOTH IP/OP $257.00 $190.18 $7.77 $200.00 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $152.02 $152.02 $18.13 $36.18 $198.00 $200.00 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30160055 EAP CPT® 82140 Stone Risk Profile - Ammonia (so) BOTH IP/OP $21.00 $15.54 $7.29 $24.04 $20.41 $20.41 $14.57 $14.57 $7.29 $7.29 $15.02 $15.02 $15.60 $14.57 $14.62 $9.47 $12.42 $12.42 $15.30 $21.00 $16.63 $16.80 $21.00 $24.04 $21.00 $15.57 $14.57 $14.57 $10.90 $14.57 $0.00 $0.00 $0.00 $0.00 30160056 EAP CPT® 82340 Stone Risk Profile - Calcium Urine Quant (so) BOTH IP/OP $23.00 $17.02 $0.00 $23.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.16 $9.16 $9.51 $0.00 $8.91 $0.00 $0.00 $0.00 $0.00 $16.86 $16.63 $16.80 $0.00 $23.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30160057 EAP CPT® 82507 Stone Risk Profile - Citrate (so) BOTH IP/OP $21.00 $15.54 $0.00 $43.85 $0.00 $0.00 $0.00 $0.00 $0.00 $13.90 $42.22 $42.22 $43.85 $27.80 $21.00 $18.07 $12.42 $12.42 $0.00 $21.00 $16.63 $16.80 $0.00 $21.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30160058 EAP CPT® 82570 Stone Risk Profile - Creatinine (so) BOTH IP/OP $21.00 $15.54 $2.59 $16.80 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $12.42 $12.42 $5.44 $14.46 $16.63 $16.80 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30160059 EAP CPT® 83735 Stone Risk Profile - Magnesium (so) BOTH IP/OP $23.00 $17.02 $3.35 $18.72 $13.83 $13.83 $6.70 $6.70 $3.35 $3.35 $10.17 $10.17 $10.56 $6.70 $9.89 $4.36 $13.60 $13.60 $7.04 $18.72 $16.63 $16.80 $9.72 $11.06 $9.72 $10.54 $6.70 $6.70 $7.38 $6.70 $0.00 $0.00 $0.00 $0.00 30160060 EAP CPT® 83945 Stone Risk Profile - Oxalate (so) BOTH IP/OP $21.00 $15.54 $0.00 $23.84 $21.00 $21.00 $14.45 $14.45 $7.23 $6.50 $19.55 $19.55 $20.30 $14.45 $19.02 $9.39 $12.42 $12.42 $0.00 $21.00 $16.63 $16.80 $0.00 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30160061 EAP CPT® 83986 Stone Risk Profile - Ph Body Fluid (so) BOTH IP/OP $23.00 $17.02 $0.00 $16.80 $7.39 $7.39 $3.58 $3.58 $1.79 $1.79 $5.43 $5.43 $5.64 $3.58 $5.28 $2.33 $13.60 $13.60 $3.76 $10.00 $16.63 $16.80 $5.19 $5.91 $5.19 $0.00 $3.58 $3.58 $3.94 $3.58 $0.00 $0.00 $0.00 $0.00 30160062 EAP CPT® 84105 Stone Risk Profile - Phosphate Urine (so) BOTH IP/OP $23.00 $17.02 $2.60 $16.80 $10.69 $10.69 $5.78 $5.78 $2.89 $2.60 $7.86 $7.86 $8.16 $5.78 $7.64 $3.76 $13.60 $13.60 $6.07 $14.46 $16.63 $16.80 $8.38 $9.54 $8.38 $8.14 $5.78 $5.78 $5.70 $5.78 $0.00 $0.00 $0.00 $0.00 30160063 EAP CPT® 84133 Stone Risk Profile - Potassium Urine (so) BOTH IP/OP $21.00 $15.54 $2.16 $16.80 $8.90 $8.90 $4.73 $4.73 $2.37 $2.16 $6.53 $6.53 $6.78 $4.73 $6.35 $3.07 $12.42 $12.42 $4.97 $12.02 $16.63 $16.80 $6.86 $7.80 $6.86 $6.77 $4.73 $4.73 $4.74 $4.73 $0.00 $0.00 $0.00 $0.00 30160064 EAP CPT® 84300 Stone Risk Profile - Sodium Urine (so) BOTH IP/OP $23.00 $17.02 $2.43 $16.80 $7.13 $7.13 $5.06 $5.06 $2.53 $2.43 $5.25 $5.25 $5.45 $5.06 $5.11 $3.29 $13.60 $13.60 $5.31 $9.66 $16.63 $16.80 $7.34 $8.35 $7.34 $5.45 $5.06 $5.06 $3.81 $5.06 $0.00 $0.00 $0.00 $0.00 30160065 EAP CPT® 84392 Stone Risk Profile - Sulfate Urine (so) BOTH IP/OP $21.00 $15.54 $0.00 $21.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.21 $7.21 $7.48 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $13.28 $16.63 $16.80 $0.00 $21.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30160066 EAP CPT® 84560 Stone Risk Profile - Uric Acid (so) BOTH IP/OP $21.00 $15.54 $2.37 $16.80 $9.79 $9.79 $5.08 $5.08 $2.54 $2.37 $7.21 $7.21 $7.48 $5.08 $7.02 $3.30 $12.42 $12.42 $5.33 $13.28 $16.63 $16.80 $7.37 $8.38 $7.37 $7.48 $5.08 $5.08 $5.24 $5.08 $0.00 $0.00 $0.00 $0.00 30160070 EAP CPT® 84155 "Assay Protein, Serum (so)" BOTH IP/OP $21.00 $15.54 $0.00 $25.60 $7.58 $7.58 $3.67 $3.67 $1.84 $1.83 $5.56 $5.56 $5.78 $3.67 $5.42 $2.39 $12.42 $12.42 $0.00 $10.24 $25.34 $25.60 $0.00 $6.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30160071 EAP CPT® 84165 Protein Electrophoresis Urine (so) BOTH IP/OP $21.00 $15.54 $0.00 $30.02 $21.00 $21.00 $10.74 $10.74 $5.37 $5.37 $16.31 $16.31 $16.93 $10.74 $15.87 $6.98 $12.42 $12.42 $11.28 $30.02 $25.34 $25.60 $15.57 $17.72 $15.57 $0.00 $10.74 $10.74 $11.83 $10.74 $0.00 $0.00 $0.00 $0.00 30160072 EAP CPT® 82570 Assay Creatinine Urine (so) BOTH IP/OP $32.00 $23.68 $0.00 $28.00 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $18.93 $18.93 $5.44 $14.46 $27.72 $28.00 $7.51 $8.55 $7.51 $0.00 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30160073 EAP CPT® 84156 Assay Protein Urine (so) BOTH IP/OP $36.00 $26.64 $0.00 $28.00 $7.58 $7.58 $3.67 $3.67 $1.84 $1.83 $5.56 $5.56 $5.78 $3.67 $5.42 $2.39 $21.29 $21.29 $3.85 $10.24 $27.72 $28.00 $5.32 $6.06 $5.32 $0.00 $3.67 $3.67 $4.04 $3.67 $0.00 $0.00 $0.00 $0.00 30160074 EAP CPT® 84166 "Protein Electrophoresis, Urine (so)" BOTH IP/OP $36.00 $26.64 $0.00 $36.00 $36.00 $36.00 $17.83 $17.83 $8.92 $8.91 $27.08 $27.08 $28.12 $17.83 $26.34 $11.59 $21.29 $21.29 $18.72 $35.00 $27.72 $28.00 $25.85 $29.42 $25.85 $0.00 $17.83 $17.83 $19.65 $17.83 $0.00 $0.00 $0.00 $0.00 30200001 EAP CPT® 86000 Proteus Ox-19 Ab BOTH IP/OP $320.00 $236.80 $0.00 $319.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.60 $10.60 $11.01 $0.00 $10.31 $0.00 $0.00 $0.00 $0.00 $19.50 $316.01 $319.20 $0.00 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200002 EAP CPT® 86000 Typhoid O Antibody BOTH IP/OP $320.00 $236.80 $0.00 $319.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.60 $10.60 $11.01 $0.00 $10.31 $0.00 $0.00 $0.00 $0.00 $19.50 $316.01 $319.20 $0.00 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200003 EAP CPT® 86000 Typhoid H Antibody BOTH IP/OP $320.00 $236.80 $0.00 $319.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.60 $10.60 $11.01 $0.00 $10.31 $0.00 $0.00 $0.00 $0.00 $19.50 $316.01 $319.20 $0.00 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200004 EAP CPT® 86003 *alternaria Alternata Ige BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200005 EAP CPT® 86003 *penicillium Notatum Ige BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200006 EAP CPT® 86003 *kentucky/june Bluegrass Ige BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200007 EAP CPT® 86003 *mouse Epithelia Ige BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200008 EAP CPT® 86003 *clam Ige BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200009 EAP CPT® 86003 *walnut (food) Ige BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200010 EAP CPT® 86003 *scallop Ige BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200011 EAP CPT® 86003 Ige Allergen Sesame Seed BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200012 EAP CPT® 86003 Ige Allergen Nettle BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200013 EAP CPT® 86003 Ige Allergen Sheep Sorrel BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200014 EAP CPT® 86003 Mk82 Latex-rst BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200015 EAP CPT® 86003 Curvularia Lunato BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200016 EAP CPT® 86003 Heluminthosporium I. BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200017 EAP CPT® 86003 "Egg, Chicken" BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200018 EAP CPT® 86003 "Milk, Cow's" BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200019 EAP CPT® 86003 Wheat BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200020 EAP CPT® 86003 Oat BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200021 EAP CPT® 86003 Corn BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200022 EAP CPT® 86003 Soybean BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200023 EAP CPT® 86003 Peanut BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200024 EAP CPT® 86003 Tuna BOTH IP/OP $180.00 $133.20 $2.61 $179.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $106.47 $106.47 $5.48 $14.60 $177.41 $179.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200025 EAP CPT® 86003 Codfish BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200026 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $180.00 $133.20 $2.61 $179.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $106.47 $106.47 $5.48 $14.60 $177.41 $179.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200027 EAP CPT® 86003 Shrimp BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200028 EAP CPT® 86003 Beef BOTH IP/OP $180.00 $133.20 $2.61 $179.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $106.47 $106.47 $5.48 $14.60 $177.41 $179.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200029 EAP CPT® 86003 Rice BOTH IP/OP $180.00 $133.20 $2.61 $179.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $106.47 $106.47 $5.48 $14.60 $177.41 $179.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200030 EAP CPT® 86003 White Potato BOTH IP/OP $180.00 $133.20 $2.61 $179.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $106.47 $106.47 $5.48 $14.60 $177.41 $179.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200031 EAP CPT® 86003 Yellow Onion BOTH IP/OP $180.00 $133.20 $2.61 $179.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $106.47 $106.47 $5.48 $14.60 $177.41 $179.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200032 EAP CPT® 86003 Honey Bee BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200033 EAP CPT® 86003 White Faced Hornet BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200034 EAP CPT® 86003 Yellow Jacket BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200035 EAP CPT® 86003 Paper Wasp BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200036 EAP CPT® 86003 Yellow Faced Hornet BOTH IP/OP $207.00 $153.18 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $122.44 $122.44 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200037 EAP CPT® 86003 Short Ragweed BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200038 EAP CPT® 86003 Yellow Dock BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200039 EAP CPT® 86003 Lamb's Quarters BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200040 EAP CPT® 86003 Pigweed BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200041 EAP CPT® 86003 Marsh Elder BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200042 EAP CPT® 86003 English Plantain BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200043 EAP CPT® 86003 Cocklebur BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200044 EAP CPT® 86003 Bermuda Grass BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200045 EAP CPT® 86003 Perennial Ryegrass BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200046 EAP CPT® 86003 Timothy BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200047 EAP CPT® 86003 Johnson Grass BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200048 EAP CPT® 86003 Bahia Grass BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200049 EAP CPT® 86003 White Oak BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200050 EAP CPT® 86003 Elm BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200051 EAP CPT® 86003 Black Walnut BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200052 EAP CPT® 86003 White Ash BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200053 EAP CPT® 86003 White Pine BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200054 EAP CPT® 86003 Pecan BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200055 EAP CPT® 86003 Cottonwood BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200056 EAP CPT® 86003 Sycamore BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200057 EAP CPT® 86003 Birch BOTH IP/OP $209.00 $154.66 $0.00 $167.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.48 $14.60 $165.53 $167.20 $7.57 $0.00 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200058 EAP CPT® 86003 Eucalyptus BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200059 EAP CPT® 86003 Red Cedar BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200060 EAP CPT® 86003 Red Maple BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200061 EAP CPT® 86003 Cat Hair BOTH IP/OP $209.00 $154.66 $0.00 $167.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.48 $14.60 $165.53 $167.20 $7.57 $0.00 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200062 EAP CPT® 86003 Dog Hair BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200063 EAP CPT® 86003 Horse Hair BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200064 EAP CPT® 86003 Feather Mix BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200065 EAP CPT® 86003 D.pteronyssinus BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200066 EAP CPT® 86003 D.farinae Mite BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200067 EAP CPT® 86003 Cockroach BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200068 EAP CPT® 86003 Pen. Brevicomp BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200069 EAP CPT® 86003 "Clado, Herbarium" BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200070 EAP CPT® 86003 Candida Albicans BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200071 EAP CPT® 86003 Alternaria Tenuis BOTH IP/OP $168.00 $124.32 $2.61 $167.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $99.37 $99.37 $5.48 $14.60 $165.53 $167.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200072 EAP CPT® 86021 Perinuclear Ab Scrn BOTH IP/OP $326.00 $241.24 $0.00 $260.80 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $192.83 $192.83 $15.80 $42.06 $258.19 $260.80 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200073 EAP CPT® 86021 Cytoplasmic Ab Scrn BOTH IP/OP $355.00 $262.70 $7.53 $260.80 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $209.98 $209.98 $15.80 $42.06 $258.19 $260.80 $21.82 $24.83 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200074 EAP CPT® 86022 Plt Ab: Hla Class 1 BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $248.43 $248.43 $0.00 $51.32 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200075 EAP CPT® 86022 Plt Ab: Gp Iib/iiia BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $248.43 $248.43 $0.00 $51.32 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200076 EAP CPT® 86022 Plt Ab: Gp Ib/ix BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $248.43 $248.43 $0.00 $51.32 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200077 EAP CPT® 86022 Plt Ab: Gp Ia/iib BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $248.43 $248.43 $0.00 $51.32 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200078 EAP CPT® 86022 Plt Ab: Gp Iv BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $248.43 $248.43 $0.00 $51.32 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200079 EAP CPT® 86038 Ana Screen BOTH IP/OP $291.00 $215.34 $6.04 $220.80 $24.95 $24.95 $12.09 $12.09 $6.05 $6.04 $18.36 $18.36 $19.06 $12.09 $17.86 $7.86 $172.13 $172.13 $12.69 $33.78 $218.59 $220.80 $17.53 $19.95 $17.53 $19.03 $12.09 $12.09 $13.32 $12.09 $0.00 $0.00 $0.00 $0.00 30200080 EAP CPT® 86060 Strep Aso BOTH IP/OP $79.00 $58.46 $3.65 $60.80 $14.44 $14.44 $7.30 $7.30 $3.65 $3.65 $10.62 $10.62 $11.03 $7.30 $10.32 $4.75 $46.73 $46.73 $7.67 $19.54 $60.19 $60.80 $10.59 $12.05 $10.59 $11.00 $7.30 $7.30 $7.70 $7.30 $0.00 $0.00 $0.00 $0.00 30200081 EAP CPT® 86140 C-reactive Protein BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.86 $7.86 $8.16 $0.00 $7.64 $0.00 $0.00 $0.00 $0.00 $14.46 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200082 EAP CPT® 86141 C-reactive Protein-hs BOTH IP/OP $248.00 $183.52 $6.48 $200.00 $26.72 $26.72 $12.95 $12.95 $6.48 $6.48 $19.67 $19.67 $20.42 $12.95 $19.12 $8.42 $146.69 $146.69 $13.60 $36.18 $198.00 $200.00 $18.78 $21.37 $18.78 $20.37 $12.95 $12.95 $14.26 $12.95 $0.00 $0.00 $0.00 $0.00 30200083 EAP CPT® 86141 "Crp-hs,micro" BOTH IP/OP $250.00 $185.00 $6.48 $200.00 $26.72 $26.72 $12.95 $12.95 $6.48 $6.48 $19.67 $19.67 $20.42 $12.95 $19.12 $8.42 $147.88 $147.88 $13.60 $36.18 $198.00 $200.00 $18.78 $21.37 $18.78 $20.37 $12.95 $12.95 $14.26 $12.95 $0.00 $0.00 $0.00 $0.00 30200084 EAP CPT® 86160 Complement-3c BOTH IP/OP $337.00 $249.38 $6.00 $272.00 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $199.34 $199.34 $12.60 $33.56 $269.28 $272.00 $17.40 $19.80 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30200085 EAP CPT® 86160 Complement-4 BOTH IP/OP $337.00 $249.38 $6.00 $272.00 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $199.34 $199.34 $12.60 $33.56 $269.28 $272.00 $17.40 $19.80 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30200086 EAP CPT® 86160 "Complement-c3,synvl" BOTH IP/OP $337.00 $249.38 $6.00 $272.00 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $199.34 $199.34 $12.60 $33.56 $269.28 $272.00 $17.40 $19.80 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30200087 EAP CPT® 86160 "Complement-c4,synvl" BOTH IP/OP $337.00 $249.38 $6.00 $272.00 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $199.34 $199.34 $12.60 $33.56 $269.28 $272.00 $17.40 $19.80 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30200088 EAP CPT® 86162 "Complement Tot,ch50" BOTH IP/OP $227.00 $167.98 $0.00 $227.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.86 $30.86 $32.04 $0.00 $30.02 $0.00 $0.00 $0.00 $21.34 $56.78 $181.37 $183.20 $29.46 $227.00 $29.46 $31.99 $20.32 $20.32 $22.39 $20.32 $0.00 $0.00 $0.00 $0.00 30200089 EAP CPT® 86162 "Complemnt Tot,ch100" BOTH IP/OP $199.00 $147.26 $0.00 $183.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.86 $30.86 $32.04 $0.00 $30.02 $0.00 $0.00 $0.00 $21.34 $56.78 $181.37 $183.20 $29.46 $0.00 $29.46 $31.99 $20.32 $20.32 $22.39 $20.32 $0.00 $0.00 $0.00 $0.00 30200090 EAP CPT® 86171 Fungal Serology BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.62 $10.62 $11.03 $0.00 $10.32 $0.00 $0.00 $0.00 $0.00 $19.54 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200091 EAP CPT® 86171 Parasitic Serology BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.62 $10.62 $11.03 $0.00 $10.32 $0.00 $0.00 $0.00 $0.00 $19.54 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200092 EAP CPT® 86171 Viral Serology BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.62 $10.62 $11.03 $0.00 $10.32 $0.00 $0.00 $0.00 $0.00 $19.54 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200093 EAP CPT® 86171 Misc. Serology BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.62 $10.62 $11.03 $0.00 $10.32 $0.00 $0.00 $0.00 $0.00 $19.54 $124.34 $125.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200094 EAP CPT® 86215 Strep Antid-nase B BOTH IP/OP $190.00 $140.60 $6.62 $190.00 $27.35 $27.35 $13.25 $13.25 $6.63 $6.62 $20.12 $20.12 $20.90 $13.25 $19.57 $8.61 $112.39 $112.39 $13.91 $37.02 $144.14 $145.60 $19.21 $190.00 $19.21 $20.85 $13.25 $13.25 $14.60 $13.25 $0.00 $0.00 $0.00 $0.00 30200095 EAP CPT® 86225 "Ds-dna Ab,crithidia" BOTH IP/OP $291.00 $215.34 $0.00 $242.40 $28.35 $28.35 $13.74 $13.74 $6.87 $6.87 $20.86 $20.86 $21.66 $13.74 $20.30 $8.93 $172.13 $172.13 $14.43 $38.40 $239.98 $242.40 $19.92 $0.00 $19.92 $21.63 $13.74 $13.74 $15.14 $13.74 $0.00 $0.00 $0.00 $0.00 30200096 EAP CPT® 86225 "Ds-dna Ab,eia" BOTH IP/OP $325.00 $240.50 $6.87 $262.40 $28.35 $28.35 $13.74 $13.74 $6.87 $6.87 $20.86 $20.86 $21.66 $13.74 $20.30 $8.93 $192.24 $192.24 $14.43 $38.40 $259.78 $262.40 $19.92 $22.67 $19.92 $21.63 $13.74 $13.74 $15.14 $13.74 $0.00 $0.00 $0.00 $0.00 30200097 EAP CPT® 86235 "Jo-1 Ab Screen, Eia" BOTH IP/OP $344.00 $254.56 $8.97 $265.60 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $203.48 $203.48 $18.83 $50.12 $262.94 $265.60 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30200098 EAP CPT® 86235 "Scl-70 Ab Screen, Eia" BOTH IP/OP $344.00 $254.56 $8.97 $265.60 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $203.48 $203.48 $18.83 $50.12 $262.94 $265.60 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30200099 EAP CPT® 86235 Anticentromere Scrn BOTH IP/OP $344.00 $254.56 $8.97 $265.60 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $203.48 $203.48 $18.83 $50.12 $262.94 $265.60 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30200100 EAP CPT® 86235 Smith (sm) Ab Screen BOTH IP/OP $325.00 $240.50 $8.97 $251.20 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $192.24 $192.24 $18.83 $50.12 $248.69 $251.20 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30200101 EAP CPT® 86235 Rnp Ab Screen BOTH IP/OP $325.00 $240.50 $8.97 $251.20 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $192.24 $192.24 $18.83 $50.12 $248.69 $251.20 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30200102 EAP CPT® 86235 Ssa (ro) Ab Screen BOTH IP/OP $325.00 $240.50 $8.97 $251.20 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $192.24 $192.24 $18.83 $50.12 $248.69 $251.20 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30200103 EAP CPT® 86235 Ssb (la) Ab Screen BOTH IP/OP $325.00 $240.50 $8.97 $251.20 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $192.24 $192.24 $18.83 $50.12 $248.69 $251.20 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30200104 EAP CPT® 86255 Perinuclear Ab BOTH IP/OP $50.00 $37.00 $0.00 $50.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $29.58 $29.58 $12.65 $33.68 $49.90 $50.40 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200105 EAP CPT® 86255 Smooth Muscle Ab BOTH IP/OP $59.00 $43.66 $6.03 $47.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $34.90 $34.90 $12.65 $33.68 $46.73 $47.20 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200106 EAP CPT® 86255 Parietal Cell Ab BOTH IP/OP $59.00 $43.66 $6.03 $47.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $34.90 $34.90 $12.65 $33.68 $46.73 $47.20 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200107 EAP CPT® 86256 Adrenal Ab Screen BOTH IP/OP $88.00 $65.12 $6.03 $70.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $52.05 $52.05 $12.65 $33.68 $69.70 $70.40 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200108 EAP CPT® 86256 Basement Mem Ab Scrn BOTH IP/OP $88.00 $65.12 $6.03 $70.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $52.05 $52.05 $12.65 $33.68 $69.70 $70.40 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200109 EAP CPT® 86256 Rmsf Antibody Igg BOTH IP/OP $88.00 $65.12 $6.03 $70.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $52.05 $52.05 $12.65 $33.68 $69.70 $70.40 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200110 EAP CPT® 86256 Rmsf Antibody Igm BOTH IP/OP $88.00 $65.12 $6.03 $70.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $52.05 $52.05 $12.65 $33.68 $69.70 $70.40 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200111 EAP CPT® 86300 Cancer Antigen 15-3 BOTH IP/OP $143.00 $105.82 $10.41 $115.20 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $84.58 $84.58 $21.85 $58.14 $114.05 $115.20 $30.17 $34.34 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30200112 EAP CPT® 86300 Cancer Ag 27-29 BOTH IP/OP $143.00 $105.82 $10.41 $115.20 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $84.58 $84.58 $21.85 $58.14 $114.05 $115.20 $30.17 $34.34 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30200113 EAP CPT® 86301 Carbohydrate Ag 19-9 BOTH IP/OP $206.00 $152.44 $10.41 $166.40 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $121.85 $121.85 $21.85 $58.14 $164.74 $166.40 $30.17 $34.34 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30200114 EAP CPT® 86308 Infect Mono Screen BOTH IP/OP $203.00 $150.22 $2.59 $164.00 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $120.07 $120.07 $5.44 $14.46 $162.36 $164.00 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30200115 EAP CPT® 86316 Cancer Antigen 125 BOTH IP/OP $529.00 $391.46 $10.41 $426.40 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $312.90 $312.90 $21.85 $58.14 $422.14 $426.40 $30.17 $34.34 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30200116 EAP CPT® 86317 Diphtheria Ab BOTH IP/OP $248.00 $183.52 $7.49 $180.00 $24.79 $24.79 $14.99 $14.99 $7.50 $7.49 $18.22 $18.22 $18.92 $14.99 $17.72 $9.74 $146.69 $146.69 $15.74 $33.54 $178.20 $180.00 $21.74 $24.73 $21.74 $18.89 $14.99 $14.99 $13.22 $14.99 $0.00 $0.00 $0.00 $0.00 30200117 EAP CPT® 86317 Dnp Antibody BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $24.79 $24.79 $14.99 $14.99 $7.50 $7.49 $18.22 $18.22 $18.92 $14.99 $17.72 $9.74 $133.09 $133.09 $15.74 $33.54 $178.20 $180.00 $21.74 $0.00 $21.74 $18.89 $14.99 $14.99 $13.22 $14.99 $0.00 $0.00 $0.00 $0.00 30200118 EAP CPT® 86329 Hypersens Pneumo Scr BOTH IP/OP $204.00 $150.96 $0.00 $164.80 $28.99 $28.99 $14.05 $14.05 $7.03 $0.00 $21.33 $21.33 $22.15 $0.00 $20.75 $0.00 $0.00 $0.00 $14.75 $39.24 $163.15 $164.80 $20.37 $23.18 $20.37 $22.11 $14.05 $14.05 $15.48 $14.05 $0.00 $0.00 $0.00 $0.00 30200119 EAP CPT® 86332 Immune Complex(c1q) BOTH IP/OP $116.00 $85.84 $12.19 $93.60 $50.32 $50.32 $24.37 $24.37 $12.19 $12.19 $37.01 $37.01 $38.44 $24.37 $36.00 $15.84 $68.61 $68.61 $25.59 $68.10 $92.66 $93.60 $35.34 $40.21 $35.34 $38.36 $24.37 $24.37 $26.85 $24.37 $0.00 $0.00 $0.00 $0.00 30200120 EAP CPT® 86334 "Immunofixation,ser" BOTH IP/OP $439.00 $324.86 $11.17 $333.60 $46.12 $46.12 $22.34 $22.34 $11.17 $11.17 $33.92 $33.92 $35.23 $22.34 $33.00 $14.52 $259.67 $259.67 $23.46 $62.42 $330.26 $333.60 $32.39 $36.86 $32.39 $35.16 $22.34 $22.34 $24.61 $22.34 $0.00 $0.00 $0.00 $0.00 30200121 EAP CPT® 86335 "Immunofixation,urine" BOTH IP/OP $462.00 $341.88 $14.67 $351.20 $60.59 $60.59 $29.35 $29.35 $14.68 $14.67 $44.56 $44.56 $46.28 $29.35 $43.34 $19.08 $273.27 $273.27 $30.82 $82.00 $347.69 $351.20 $42.56 $48.43 $42.56 $46.18 $29.35 $29.35 $32.33 $29.35 $0.00 $0.00 $0.00 $0.00 30200122 EAP CPT® 86336 Inhibin-a BOTH IP/OP $77.00 $56.98 $0.00 $61.60 $26.74 $26.74 $15.59 $15.59 $7.80 $7.79 $19.66 $19.66 $20.41 $15.59 $19.12 $10.13 $45.55 $45.55 $16.37 $36.18 $60.98 $61.60 $22.61 $0.00 $22.61 $20.37 $15.59 $15.59 $14.26 $15.59 $0.00 $0.00 $0.00 $0.00 30200123 EAP CPT® 86337 Insulin Auto Ab BOTH IP/OP $235.00 $173.90 $0.00 $189.60 $44.19 $44.19 $21.41 $21.41 $10.71 $10.71 $32.52 $32.52 $33.77 $21.41 $31.64 $13.92 $139.00 $139.00 $22.48 $59.84 $187.70 $189.60 $31.04 $35.33 $31.04 $0.00 $21.41 $21.41 $23.60 $21.41 $0.00 $0.00 $0.00 $0.00 30200124 EAP CPT® 86340 Intrinsic Factor Ab BOTH IP/OP $230.00 $170.20 $7.54 $182.40 $31.13 $31.13 $15.08 $15.08 $7.54 $7.54 $22.89 $22.89 $23.77 $15.08 $22.26 $9.80 $136.05 $136.05 $15.83 $42.12 $180.58 $182.40 $21.87 $24.88 $21.87 $23.72 $15.08 $15.08 $16.60 $15.08 $0.00 $0.00 $0.00 $0.00 30200125 EAP CPT® 86341 Pancreatic Islet Ab BOTH IP/OP $81.00 $59.94 $10.61 $64.00 $40.84 $40.84 $23.57 $23.57 $11.79 $10.61 $30.05 $30.05 $31.20 $23.57 $29.24 $15.32 $47.91 $47.91 $24.75 $55.30 $63.36 $64.00 $34.18 $38.89 $34.18 $31.16 $23.57 $23.57 $21.81 $23.57 $0.00 $0.00 $0.00 $0.00 30200126 EAP CPT® 86344 Phagocytic Charge BOTH IP/OP $517.00 $382.58 $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.13 $12.13 $12.59 $0.00 $11.79 $0.00 $0.00 $0.00 $0.00 $22.32 $413.42 $417.60 $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200127 EAP CPT® 86359 "Cd3, Total T%" BOTH IP/OP $230.00 $170.20 $18.86 $185.60 $48.63 $48.63 $37.73 $37.73 $18.87 $18.86 $35.77 $35.77 $37.14 $37.73 $34.80 $24.52 $136.05 $136.05 $39.62 $65.82 $183.74 $185.60 $54.71 $62.25 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30200128 EAP CPT® 86360 Lymph Subsets:cd4&cd8 BOTH IP/OP $495.00 $366.30 $23.49 $400.00 $96.99 $96.99 $46.98 $46.98 $23.49 $23.49 $71.34 $71.34 $74.09 $46.98 $69.42 $30.54 $292.79 $292.79 $49.33 $131.30 $396.00 $400.00 $68.12 $77.52 $68.12 $73.96 $46.98 $46.98 $51.77 $46.98 $0.00 $0.00 $0.00 $0.00 30200129 EAP CPT® 86376 L-k Microsomal Ab BOTH IP/OP $295.00 $218.30 $7.28 $238.40 $30.04 $30.04 $14.55 $14.55 $7.28 $7.28 $22.10 $22.10 $22.95 $14.55 $21.49 $9.46 $174.49 $174.49 $15.28 $40.66 $236.02 $238.40 $21.10 $24.01 $21.10 $22.90 $14.55 $14.55 $16.03 $14.55 $0.00 $0.00 $0.00 $0.00 30200130 EAP CPT® 86376 Microsomal Ab BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $30.04 $30.04 $14.55 $14.55 $7.28 $7.28 $22.10 $22.10 $22.95 $14.55 $21.49 $9.46 $186.32 $186.32 $15.28 $40.66 $249.48 $252.00 $21.10 $0.00 $21.10 $22.90 $14.55 $14.55 $16.03 $14.55 $0.00 $0.00 $0.00 $0.00 30200131 EAP CPT® 86403 Rapid Strep Test BOTH IP/OP $204.00 $150.96 $5.19 $156.80 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $120.67 $120.67 $12.12 $28.48 $155.23 $156.80 $16.73 $19.04 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30200132 EAP CPT® 86403 Crypto.antigen Scrn BOTH IP/OP $204.00 $150.96 $5.19 $156.80 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $120.67 $120.67 $12.12 $28.48 $155.23 $156.80 $16.73 $19.04 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30200133 EAP CPT® 86403 "Crypto.ag,csf-qual" BOTH IP/OP $204.00 $150.96 $5.19 $156.80 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $120.67 $120.67 $12.12 $28.48 $155.23 $156.80 $16.73 $19.04 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30200134 EAP CPT® 86403 "H.flu Ag,urine" BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $115.93 $115.93 $12.12 $28.48 $155.23 $156.80 $16.73 $0.00 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30200135 EAP CPT® 86403 "N.mening Ag,urine" BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $115.93 $115.93 $12.12 $28.48 $155.23 $156.80 $16.73 $0.00 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30200136 EAP CPT® 86403 "St.pneumo Ag,urine" BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $115.93 $115.93 $12.12 $28.48 $155.23 $156.80 $16.73 $0.00 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30200137 EAP CPT® 86403 "Strep-b Ag,urine" BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $115.93 $115.93 $12.12 $28.48 $155.23 $156.80 $16.73 $0.00 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30200138 EAP CPT® 86406 "Crypto.ag,csf-quant" BOTH IP/OP $244.00 $180.56 $0.00 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $5.32 $16.15 $16.15 $16.77 $10.64 $15.72 $6.92 $144.33 $144.33 $11.17 $29.74 $187.70 $189.60 $15.43 $189.00 $15.43 $16.75 $10.64 $10.64 $11.72 $10.64 $0.00 $0.00 $0.00 $0.00 30200139 EAP CPT® 86406 "Crypto.ag,bld-quant" BOTH IP/OP $244.00 $180.56 $0.00 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $5.32 $16.15 $16.15 $16.77 $10.64 $15.72 $6.92 $144.33 $144.33 $11.17 $29.74 $187.70 $189.60 $15.43 $189.00 $15.43 $16.75 $10.64 $10.64 $11.72 $10.64 $0.00 $0.00 $0.00 $0.00 30200140 EAP CPT® 86431 "Rheumatoid Factor, Bld" BOTH IP/OP $183.00 $135.42 $2.84 $132.80 $11.70 $11.70 $5.67 $5.67 $2.84 $2.84 $8.62 $8.62 $8.95 $5.67 $8.39 $3.69 $108.24 $108.24 $5.95 $15.86 $131.47 $132.80 $8.22 $9.36 $8.22 $8.94 $5.67 $5.67 $6.26 $5.67 $0.00 $0.00 $0.00 $0.00 30200141 EAP CPT® 86431 "Rheumatoid Factor, Syn Fld" BOTH IP/OP $183.00 $135.42 $2.84 $132.80 $11.70 $11.70 $5.67 $5.67 $2.84 $2.84 $8.62 $8.62 $8.95 $5.67 $8.39 $3.69 $108.24 $108.24 $5.95 $15.86 $131.47 $132.80 $8.22 $9.36 $8.22 $8.94 $5.67 $5.67 $6.26 $5.67 $0.00 $0.00 $0.00 $0.00 30200145 EAP CPT® 86357 Natural Killer Cellls So BOTH IP/OP $85.00 $62.90 $0.00 $85.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $68.11 $68.80 $54.71 $85.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30200146 EAP CPT® 86341 Ia-2 Ab (so) BOTH IP/OP $193.00 $142.82 $0.00 $154.40 $40.84 $40.84 $23.57 $23.57 $11.79 $10.61 $30.05 $30.05 $31.20 $23.57 $29.24 $15.32 $114.16 $114.16 $24.75 $55.30 $152.86 $154.40 $34.18 $0.00 $34.18 $31.16 $23.57 $23.57 $21.81 $23.57 $0.00 $0.00 $0.00 $0.00 30200147 EAP CPT® 86355 Lymph Subset B Cell Tot (so) BOTH IP/OP $206.00 $152.44 $0.00 $171.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $169.49 $171.20 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30200148 EAP CPT® 86357 Lymph Subset Nk Cell Tot (so) BOTH IP/OP $196.00 $145.04 $0.00 $163.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $161.57 $163.20 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30200149 EAP CPT® 86580 "PPD, TB SKIN" BOTH IP/OP $89.00 $65.86 $3.89 $72.00 $12.43 $12.43 $24.06 $24.06 $24.19 $3.89 $7.48 $7.48 $7.77 $23.64 $9.56 $15.37 $52.64 $52.64 $23.06 $20.46 $71.28 $72.00 $32.04 $57.85 $32.04 $10.18 $9.36 $9.36 $7.13 $21.96 $0.00 $0.00 $0.00 $0.00 30200150 EAP CPT® 86780 Fta - Abs BOTH IP/OP $215.00 $159.10 $6.62 $156.80 $27.32 $27.32 $13.24 $13.24 $6.62 $6.62 $19.73 $19.73 $20.49 $13.24 $44.81 $8.61 $127.17 $127.17 $13.90 $98.00 $155.23 $156.80 $19.20 $21.85 $19.20 $30.67 $13.24 $13.24 $31.20 $13.24 $0.00 $0.00 $0.00 $0.00 30200157 EAP CPT® 86592 Rpr (qual) BOTH IP/OP $153.00 $113.22 $2.14 $111.20 $8.82 $8.82 $4.27 $4.27 $2.14 $2.14 $6.48 $6.48 $6.73 $4.27 $5.46 $2.78 $90.50 $90.50 $4.48 $11.92 $110.09 $111.20 $6.19 $7.05 $6.19 $5.82 $4.27 $4.27 $4.07 $4.27 $0.00 $0.00 $0.00 $0.00 30200158 EAP CPT® 86592 "Rpr(qual),capillary" BOTH IP/OP $139.00 $102.86 $0.00 $111.20 $8.82 $8.82 $4.27 $4.27 $2.14 $2.14 $6.48 $6.48 $6.73 $4.27 $5.46 $2.78 $82.22 $82.22 $4.48 $11.92 $110.09 $111.20 $6.19 $0.00 $6.19 $5.82 $4.27 $4.27 $4.07 $4.27 $0.00 $0.00 $0.00 $0.00 30200159 EAP CPT® 86592 "Vdrl,csf" BOTH IP/OP $153.00 $113.22 $2.14 $111.20 $8.82 $8.82 $4.27 $4.27 $2.14 $2.14 $6.48 $6.48 $6.73 $4.27 $5.46 $2.78 $90.50 $90.50 $4.48 $11.92 $110.09 $111.20 $6.19 $7.05 $6.19 $5.82 $4.27 $4.27 $4.07 $4.27 $0.00 $0.00 $0.00 $0.00 30200160 EAP CPT® 86593 "Vdrl-csf,quant" BOTH IP/OP $153.00 $113.22 $2.20 $111.20 $9.08 $9.08 $4.40 $4.40 $2.20 $2.20 $6.69 $6.69 $6.94 $4.40 $31.89 $2.86 $90.50 $90.50 $4.62 $12.32 $110.09 $111.20 $6.38 $7.26 $6.38 $21.75 $4.40 $4.40 $22.13 $4.40 $0.00 $0.00 $0.00 $0.00 30200161 EAP CPT® 86593 Rpr (quant) BOTH IP/OP $153.00 $113.22 $2.20 $111.20 $9.08 $9.08 $4.40 $4.40 $2.20 $2.20 $6.69 $6.69 $6.94 $4.40 $31.89 $2.86 $90.50 $90.50 $4.62 $12.32 $110.09 $111.20 $6.38 $7.26 $6.38 $21.75 $4.40 $4.40 $22.13 $4.40 $0.00 $0.00 $0.00 $0.00 30200162 EAP CPT® 86606 Aspergillus Fumigatus BOTH IP/OP $47.00 $34.78 $7.53 $42.06 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $27.80 $27.80 $15.80 $42.06 $37.22 $37.60 $21.82 $24.83 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200163 EAP CPT® 86611 B.henselae Igg BOTH IP/OP $80.00 $59.20 $5.09 $63.20 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $47.32 $47.32 $10.69 $28.44 $62.57 $63.20 $14.76 $16.80 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30200164 EAP CPT® 86611 B.henselae Igm BOTH IP/OP $80.00 $59.20 $5.09 $63.20 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $47.32 $47.32 $10.69 $28.44 $62.57 $63.20 $14.76 $16.80 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30200165 EAP CPT® 86611 B.quintana Igg BOTH IP/OP $80.00 $59.20 $5.09 $63.20 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $47.32 $47.32 $10.69 $28.44 $62.57 $63.20 $14.76 $16.80 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30200166 EAP CPT® 86611 B.quintana Igm BOTH IP/OP $80.00 $59.20 $5.09 $63.20 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $47.32 $47.32 $10.69 $28.44 $62.57 $63.20 $14.76 $16.80 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30200167 EAP CPT® 86617 Lyme Ab Westernblot BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.51 $23.51 $24.42 $0.00 $22.88 $0.00 $0.00 $0.00 $0.00 $43.28 $81.58 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200168 EAP CPT® 86618 Lyme Ab Total BOTH IP/OP $357.00 $264.18 $8.51 $288.80 $35.16 $35.16 $17.03 $17.03 $8.52 $8.51 $25.86 $25.86 $26.86 $17.03 $25.16 $11.07 $211.17 $211.17 $17.88 $47.60 $285.91 $288.80 $24.69 $28.10 $24.69 $26.81 $17.03 $17.03 $18.76 $17.03 $0.00 $0.00 $0.00 $0.00 30200169 EAP CPT® 86618 Lyme Ab-igm BOTH IP/OP $361.00 $267.14 $8.51 $288.80 $35.16 $35.16 $17.03 $17.03 $8.52 $8.51 $25.86 $25.86 $26.86 $17.03 $25.16 $11.07 $213.53 $213.53 $17.88 $47.60 $285.91 $288.80 $24.69 $28.10 $24.69 $26.81 $17.03 $17.03 $18.76 $17.03 $0.00 $0.00 $0.00 $0.00 30200170 EAP CPT® 86622 B. Abortus Igg BOTH IP/OP $131.00 $96.94 $0.00 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.57 $13.57 $14.09 $0.00 $13.19 $0.00 $0.00 $0.00 $9.38 $24.96 $104.54 $105.60 $12.95 $131.00 $12.95 $14.05 $8.93 $8.93 $9.84 $8.93 $0.00 $0.00 $0.00 $0.00 30200171 EAP CPT® 86622 B. Abortus Igm BOTH IP/OP $131.00 $96.94 $0.00 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.57 $13.57 $14.09 $0.00 $13.19 $0.00 $0.00 $0.00 $9.38 $24.96 $104.54 $105.60 $12.95 $131.00 $12.95 $14.05 $8.93 $8.93 $9.84 $8.93 $0.00 $0.00 $0.00 $0.00 30200172 EAP CPT® 86631 Chlam Pnuemo Igg BOTH IP/OP $135.00 $99.90 $0.00 $135.00 $24.42 $24.42 $11.82 $11.82 $5.91 $5.91 $17.96 $17.96 $18.65 $11.82 $17.47 $7.68 $79.85 $79.85 $0.00 $33.04 $97.42 $98.40 $0.00 $135.00 $0.00 $18.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200173 EAP CPT® 86631 Chlam Pnuemo Iga BOTH IP/OP $135.00 $99.90 $0.00 $135.00 $24.42 $24.42 $11.82 $11.82 $5.91 $5.91 $17.96 $17.96 $18.65 $11.82 $17.47 $7.68 $79.85 $79.85 $0.00 $33.04 $97.42 $98.40 $0.00 $135.00 $0.00 $18.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200174 EAP CPT® 86631 Chlam Trach Igg BOTH IP/OP $135.00 $99.90 $0.00 $135.00 $24.42 $24.42 $11.82 $11.82 $5.91 $5.91 $17.96 $17.96 $18.65 $11.82 $17.47 $7.68 $79.85 $79.85 $0.00 $33.04 $97.42 $98.40 $0.00 $135.00 $0.00 $18.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200175 EAP CPT® 86631 Chlam Trach Iga BOTH IP/OP $135.00 $99.90 $0.00 $135.00 $24.42 $24.42 $11.82 $11.82 $5.91 $5.91 $17.96 $17.96 $18.65 $11.82 $17.47 $7.68 $79.85 $79.85 $0.00 $33.04 $97.42 $98.40 $0.00 $135.00 $0.00 $18.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200176 EAP CPT® 86631 Chlam Psittaci Icg BOTH IP/OP $135.00 $99.90 $0.00 $135.00 $24.42 $24.42 $11.82 $11.82 $5.91 $5.91 $17.96 $17.96 $18.65 $11.82 $17.47 $7.68 $79.85 $79.85 $0.00 $33.04 $97.42 $98.40 $0.00 $135.00 $0.00 $18.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200177 EAP CPT® 86631 Chlam Psittaci Iga BOTH IP/OP $135.00 $99.90 $0.00 $135.00 $24.42 $24.42 $11.82 $11.82 $5.91 $5.91 $17.96 $17.96 $18.65 $11.82 $17.47 $7.68 $79.85 $79.85 $0.00 $33.04 $97.42 $98.40 $0.00 $135.00 $0.00 $18.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200178 EAP CPT® 86632 Chlam Pnuemo Igm BOTH IP/OP $143.00 $105.82 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.27 $19.27 $20.01 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $35.48 $102.96 $104.00 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200179 EAP CPT® 86632 Chlam Trach Igm BOTH IP/OP $143.00 $105.82 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.27 $19.27 $20.01 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $35.48 $102.96 $104.00 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200180 EAP CPT® 86638 "Q Fever Igg, Acute" BOTH IP/OP $250.00 $185.00 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $200.38 $202.40 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200181 EAP CPT® 86638 "Q Fever Igg, Conval." BOTH IP/OP $250.00 $185.00 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $200.38 $202.40 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200182 EAP CPT® 86644 Cmv Igg BOTH IP/OP $209.00 $154.66 $7.20 $152.00 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $123.62 $123.62 $15.11 $32.52 $150.48 $152.00 $20.87 $23.74 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200183 EAP CPT® 86644 Cmv Igg Ab-eia BOTH IP/OP $222.00 $164.28 $7.20 $161.60 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $131.31 $131.31 $15.11 $32.52 $159.98 $161.60 $20.87 $23.74 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200184 EAP CPT® 86645 Cmv Igm BOTH IP/OP $141.00 $104.34 $8.42 $102.40 $34.77 $34.77 $16.85 $16.85 $8.43 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $83.40 $83.40 $17.69 $47.08 $101.38 $102.40 $24.43 $27.80 $24.43 $26.53 $16.85 $16.85 $18.57 $16.85 $0.00 $0.00 $0.00 $0.00 30200185 EAP CPT® 86645 Cmv Igm Ab-eia BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $34.77 $34.77 $16.85 $16.85 $8.43 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $81.63 $81.63 $17.69 $47.08 $109.30 $110.40 $24.43 $0.00 $24.43 $26.53 $16.85 $16.85 $18.57 $16.85 $0.00 $0.00 $0.00 $0.00 30200186 EAP CPT® 86651 "Encep, California, Csf, Igg" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200187 EAP CPT® 86651 "Encep, California, Csf, Igm" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200188 EAP CPT® 86651 Calfornia Equine Igm BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200189 EAP CPT® 86651 Calif. Equine Encephalitis BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200190 EAP CPT® 86652 "Encep, E. Equine, Csf,igg" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200191 EAP CPT® 86652 "Encep, E. Equine, Csf,igm" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200192 EAP CPT® 86652 Eastern Equine Igm BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200193 EAP CPT® 86652 Eastern Equine Encephalitis BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200194 EAP CPT® 86653 "Encep,st. Louis, Csf Igg" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200195 EAP CPT® 86653 "Encep,st. Louis, Csf Igm" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200196 EAP CPT® 86653 St. Louis Equine Igm BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200197 EAP CPT® 86653 St. Louis Equine Encephalitis BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200198 EAP CPT® 86654 "Encep, W. Equine, Csf,igg" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200199 EAP CPT® 86654 "Encep, W. Equine, Csf,igm" BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200200 EAP CPT® 86654 Western Equine Igm BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200201 EAP CPT® 86654 Western Equine Encephalitis BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200202 EAP CPT® 86658 Coxsackie B1 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200203 EAP CPT® 86658 Coxsackie B2 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200204 EAP CPT® 86658 Coxsackie B3 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200205 EAP CPT® 86658 Coxsackie B4 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200206 EAP CPT® 86658 Coxsackie B5 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200207 EAP CPT® 86658 Coxsackie B6 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200208 EAP CPT® 86658 Echovirus 4 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200209 EAP CPT® 86658 Echovirus 9 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200210 EAP CPT® 86658 Echovirus 11 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200211 EAP CPT® 86658 Coxsackie A2 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200212 EAP CPT® 86658 Coxsackie A4 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200213 EAP CPT® 86658 Coxsackie A10 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200214 EAP CPT® 86658 Coxsackie A16 Titer BOTH IP/OP $112.00 $82.88 $6.51 $112.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $66.25 $66.25 $13.68 $36.40 $89.50 $90.40 $18.89 $112.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200215 EAP CPT® 86664 Ebv Nuclear Ab BOTH IP/OP $204.00 $150.96 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.65 $23.23 $23.23 $24.13 $15.29 $22.61 $9.94 $120.67 $120.67 $16.05 $42.76 $163.15 $164.80 $22.17 $204.00 $22.17 $24.09 $15.29 $15.29 $16.86 $15.29 $0.00 $0.00 $0.00 $0.00 30200216 EAP CPT® 86665 Ebv Capsid Igg Ab BOTH IP/OP $229.00 $169.46 $0.00 $229.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.07 $27.54 $27.54 $28.60 $18.14 $26.81 $11.79 $135.45 $135.45 $19.05 $50.70 $182.95 $184.80 $26.30 $229.00 $26.30 $28.56 $18.14 $18.14 $19.99 $18.14 $0.00 $0.00 $0.00 $0.00 30200217 EAP CPT® 86665 Ebv Capsid Igm Ab BOTH IP/OP $229.00 $169.46 $0.00 $229.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.07 $27.54 $27.54 $28.60 $18.14 $26.81 $11.79 $135.45 $135.45 $19.05 $50.70 $182.95 $184.80 $26.30 $229.00 $26.30 $28.56 $18.14 $18.14 $19.99 $18.14 $0.00 $0.00 $0.00 $0.00 30200218 EAP CPT® 86666 Ehrlichia Igg BOTH IP/OP $155.00 $114.70 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.44 $15.44 $16.04 $0.00 $15.04 $0.00 $0.00 $0.00 $0.00 $28.44 $124.34 $125.60 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200219 EAP CPT® 86666 Ehrlichia Igm BOTH IP/OP $155.00 $114.70 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.44 $15.44 $16.04 $0.00 $15.04 $0.00 $0.00 $0.00 $0.00 $28.44 $124.34 $125.60 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200220 EAP CPT® 86668 Tularemia Antibody BOTH IP/OP $72.00 $53.28 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.79 $15.79 $16.39 $0.00 $15.36 $0.00 $0.00 $0.00 $0.00 $29.06 $57.02 $57.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200221 EAP CPT® 86671 S.cerevisiae Igg BOTH IP/OP $139.00 $102.86 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $110.09 $111.20 $17.76 $124.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30200222 EAP CPT® 86671 S.cerevisiae Iga BOTH IP/OP $139.00 $102.86 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $110.09 $111.20 $17.76 $124.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30200223 EAP CPT® 86671 Sporothrix Igg BOTH IP/OP $139.00 $102.86 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $110.09 $111.20 $17.76 $124.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30200224 EAP CPT® 86671 Sporothrix Igm BOTH IP/OP $139.00 $102.86 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $110.09 $111.20 $17.76 $124.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30200225 EAP CPT® 86671 Sporothrix Iga BOTH IP/OP $139.00 $102.86 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $110.09 $111.20 $17.76 $124.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30200226 EAP CPT® 86677 H. Pylori Igg BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $29.94 $29.94 $16.85 $16.85 $8.43 $7.58 $22.04 $22.04 $22.89 $16.85 $21.44 $10.95 $122.44 $122.44 $17.69 $40.56 $163.94 $165.60 $24.43 $0.00 $24.43 $22.85 $16.85 $16.85 $15.99 $16.85 $0.00 $0.00 $0.00 $0.00 30200227 EAP CPT® 86677 H.pylori Iga BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $29.94 $29.94 $16.85 $16.85 $8.43 $7.58 $22.04 $22.04 $22.89 $16.85 $21.44 $10.95 $122.44 $122.44 $17.69 $40.56 $163.94 $165.60 $24.43 $0.00 $24.43 $22.85 $16.85 $16.85 $15.99 $16.85 $0.00 $0.00 $0.00 $0.00 30200228 EAP CPT® 86677 H.pylori Igg Ab-eia BOTH IP/OP $220.00 $162.80 $7.58 $177.60 $29.94 $29.94 $16.85 $16.85 $8.43 $7.58 $22.04 $22.04 $22.89 $16.85 $21.44 $10.95 $130.13 $130.13 $17.69 $40.56 $175.82 $177.60 $24.43 $27.80 $24.43 $22.85 $16.85 $16.85 $15.99 $16.85 $0.00 $0.00 $0.00 $0.00 30200229 EAP CPT® 86682 Cysticercus Igg BOTH IP/OP $127.00 $93.98 $6.50 $102.40 $26.85 $26.85 $13.01 $13.01 $6.51 $6.50 $19.75 $19.75 $20.51 $13.01 $19.20 $8.46 $75.12 $75.12 $13.66 $36.34 $101.38 $102.40 $18.86 $21.47 $18.86 $20.46 $13.01 $13.01 $14.32 $13.01 $0.00 $0.00 $0.00 $0.00 30200230 EAP CPT® 86682 Echinococcus Igg BOTH IP/OP $127.00 $93.98 $6.50 $102.40 $26.85 $26.85 $13.01 $13.01 $6.51 $6.50 $19.75 $19.75 $20.51 $13.01 $19.20 $8.46 $75.12 $75.12 $13.66 $36.34 $101.38 $102.40 $18.86 $21.47 $18.86 $20.46 $13.01 $13.01 $14.32 $13.01 $0.00 $0.00 $0.00 $0.00 30200231 EAP CPT® 86682 Filaria Ab BOTH IP/OP $127.00 $93.98 $6.50 $102.40 $26.85 $26.85 $13.01 $13.01 $6.51 $6.50 $19.75 $19.75 $20.51 $13.01 $19.20 $8.46 $75.12 $75.12 $13.66 $36.34 $101.38 $102.40 $18.86 $21.47 $18.86 $20.46 $13.01 $13.01 $14.32 $13.01 $0.00 $0.00 $0.00 $0.00 30200232 EAP CPT® 86682 Strongyloides Igg BOTH IP/OP $127.00 $93.98 $6.50 $102.40 $26.85 $26.85 $13.01 $13.01 $6.51 $6.50 $19.75 $19.75 $20.51 $13.01 $19.20 $8.46 $75.12 $75.12 $13.66 $36.34 $101.38 $102.40 $18.86 $21.47 $18.86 $20.46 $13.01 $13.01 $14.32 $13.01 $0.00 $0.00 $0.00 $0.00 30200233 EAP CPT® 86682 Schistosoma Igg BOTH IP/OP $127.00 $93.98 $6.50 $102.40 $26.85 $26.85 $13.01 $13.01 $6.51 $6.50 $19.75 $19.75 $20.51 $13.01 $19.20 $8.46 $75.12 $75.12 $13.66 $36.34 $101.38 $102.40 $18.86 $21.47 $18.86 $20.46 $13.01 $13.01 $14.32 $13.01 $0.00 $0.00 $0.00 $0.00 30200235 EAP CPT® 86689 Hiv-ab Western Blot BOTH IP/OP $388.00 $287.12 $0.00 $320.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $24.81 $0.00 $0.00 $0.00 $0.00 $54.10 $317.59 $320.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200236 EAP CPT® 86692 Hepatitis Delta Ab BOTH IP/OP $196.00 $145.04 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.58 $26.06 $26.06 $27.06 $17.16 $25.35 $11.15 $115.93 $115.93 $18.02 $47.96 $156.82 $158.40 $24.88 $196.00 $24.88 $27.01 $17.16 $17.16 $18.91 $17.16 $0.00 $0.00 $0.00 $0.00 30200237 EAP CPT® 86694 Hsv 1/2 Igm BOTH IP/OP $185.00 $136.90 $0.00 $185.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $15.11 $32.52 $142.56 $144.00 $20.87 $185.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200238 EAP CPT® 86694 Hsv Igm Ab Titer BOTH IP/OP $187.00 $138.38 $0.00 $154.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $15.11 $32.52 $152.86 $154.40 $20.87 $0.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200239 EAP CPT® 86694 "Hsv2 Igg/igm Ab,csf" BOTH IP/OP $174.00 $128.76 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $15.11 $32.52 $142.56 $144.00 $20.87 $0.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200240 EAP CPT® 86694 "Hsv-2 Igm Ab,csf" BOTH IP/OP $174.00 $128.76 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $15.11 $32.52 $142.56 $144.00 $20.87 $0.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200241 EAP CPT® 86694 Hsv Igg BOTH IP/OP $174.00 $128.76 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $15.11 $32.52 $142.56 $144.00 $20.87 $0.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200244 EAP CPT® 86695 HSV-I IGG BOTH IP/OP $133.00 $98.42 $6.59 $103.20 $27.22 $27.22 $13.19 $13.19 $6.60 $6.59 $20.02 $20.02 $20.79 $13.19 $19.49 $8.57 $78.67 $78.67 $13.85 $36.86 $102.17 $103.20 $19.13 $21.76 $19.13 $20.76 $13.19 $13.19 $14.54 $13.19 $0.00 $0.00 $0.00 $0.00 30200245 EAP CPT® 86696 HSV - II IGG BOTH IP/OP $145.00 $107.30 $9.68 $112.80 $39.94 $39.94 $19.35 $19.35 $9.68 $9.68 $29.39 $29.39 $30.52 $19.35 $28.60 $12.58 $85.77 $85.77 $20.32 $54.10 $111.67 $112.80 $28.06 $31.93 $28.06 $30.48 $19.35 $19.35 $21.33 $19.35 $0.00 $0.00 $0.00 $0.00 30200246 EAP CPT® 86698 Histoplasma Ab (s) BOTH IP/OP $74.00 $54.76 $0.00 $74.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $18.98 $18.98 $19.71 $13.79 $18.46 $8.96 $43.77 $43.77 $14.48 $34.92 $59.40 $60.00 $20.00 $74.00 $20.00 $19.67 $13.79 $13.79 $13.77 $13.79 $0.00 $0.00 $0.00 $0.00 30200247 EAP CPT® 86703 Hiv-1/2 BOTH IP/OP $255.00 $188.70 $0.00 $213.60 $28.30 $28.30 $13.71 $13.71 $6.86 $6.85 $20.82 $20.82 $21.62 $13.71 $17.58 $8.91 $150.83 $150.83 $14.40 $38.34 $211.46 $213.60 $19.88 $0.00 $19.88 $18.73 $13.71 $13.71 $13.11 $13.71 $0.00 $0.00 $0.00 $0.00 30200248 EAP CPT® 86704 Hbv Core Ab BOTH IP/OP $285.00 $210.90 $6.03 $229.60 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $168.58 $168.58 $12.65 $33.68 $227.30 $229.60 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200249 EAP CPT® 86705 Hepatitis-b Core M BOTH IP/OP $285.00 $210.90 $5.89 $229.60 $24.31 $24.31 $11.77 $11.77 $5.89 $5.89 $17.87 $17.87 $18.55 $11.77 $17.39 $7.65 $168.58 $168.58 $12.36 $32.88 $227.30 $229.60 $17.07 $19.42 $17.07 $18.53 $11.77 $11.77 $12.97 $11.77 $0.00 $0.00 $0.00 $0.00 30200250 EAP CPT® 86706 Hbv Surface Ab BOTH IP/OP $257.00 $190.18 $5.37 $207.20 $22.18 $22.18 $10.74 $10.74 $5.37 $5.37 $16.31 $16.31 $16.93 $10.74 $15.87 $6.98 $152.02 $152.02 $11.28 $30.02 $205.13 $207.20 $15.57 $17.72 $15.57 $16.91 $10.74 $10.74 $11.83 $10.74 $0.00 $0.00 $0.00 $0.00 30200251 EAP CPT® 86707 Hbv E Ab BOTH IP/OP $134.00 $99.16 $5.78 $108.00 $23.89 $23.89 $11.57 $11.57 $5.79 $5.78 $17.57 $17.57 $18.24 $11.57 $17.08 $7.52 $79.26 $79.26 $12.15 $32.32 $106.92 $108.00 $16.78 $19.09 $16.78 $18.20 $11.57 $11.57 $12.74 $11.57 $0.00 $0.00 $0.00 $0.00 30200252 EAP CPT® 86708 "Hav Ab, Total" BOTH IP/OP $291.00 $215.34 $0.00 $243.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.81 $18.81 $19.54 $0.00 $18.30 $0.00 $0.00 $0.00 $0.00 $34.62 $240.77 $243.20 $0.00 $202.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200253 EAP CPT® 86709 Hav Igm Ab BOTH IP/OP $275.00 $203.50 $5.63 $221.60 $23.23 $23.23 $11.26 $11.26 $5.63 $5.63 $17.10 $17.10 $17.76 $11.26 $16.63 $7.32 $162.66 $162.66 $11.82 $31.46 $219.38 $221.60 $16.33 $18.58 $16.33 $17.72 $11.26 $11.26 $12.41 $11.26 $0.00 $0.00 $0.00 $0.00 30200254 EAP CPT® 86713 L. Pneumoph. Ab - Total BOTH IP/OP $146.00 $108.04 $0.00 $146.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.24 $23.24 $24.14 $0.00 $22.62 $0.00 $0.00 $0.00 $0.00 $42.78 $116.42 $117.60 $0.00 $146.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200255 EAP CPT® 86720 Leptospirosis Ab BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $27.22 $27.22 $16.20 $16.20 $8.10 $7.29 $20.02 $20.02 $20.79 $16.20 $19.49 $10.53 $47.32 $47.32 $17.01 $36.86 $63.36 $64.00 $23.49 $0.00 $23.49 $0.00 $16.20 $16.20 $14.54 $16.20 $0.00 $0.00 $0.00 $0.00 30200256 EAP CPT® 86631 Lgv Antibody Screen BOTH IP/OP $212.00 $156.88 $0.00 $207.00 $24.42 $24.42 $11.82 $11.82 $5.91 $5.91 $17.96 $17.96 $18.65 $11.82 $17.47 $7.68 $125.40 $125.40 $0.00 $33.04 $152.86 $154.40 $0.00 $207.00 $0.00 $18.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200257 EAP CPT® 86738 Mycoplasma Igg BOTH IP/OP $99.00 $73.26 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.62 $20.11 $20.11 $20.89 $13.24 $19.57 $8.61 $58.56 $58.56 $13.90 $37.02 $76.03 $76.80 $19.20 $99.00 $19.20 $20.85 $13.24 $13.24 $14.60 $13.24 $0.00 $0.00 $0.00 $0.00 30200258 EAP CPT® 86738 Mycoplasma Igm BOTH IP/OP $99.00 $73.26 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.62 $20.11 $20.11 $20.89 $13.24 $19.57 $8.61 $58.56 $58.56 $13.90 $37.02 $76.03 $76.80 $19.20 $99.00 $19.20 $20.85 $13.24 $13.24 $14.60 $13.24 $0.00 $0.00 $0.00 $0.00 30200259 EAP CPT® 86747 Parvovirus Igg BOTH IP/OP $124.00 $91.76 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.83 $22.83 $23.71 $0.00 $22.21 $0.00 $0.00 $0.00 $15.78 $42.00 $99.00 $100.00 $21.79 $124.00 $21.79 $0.00 $15.03 $15.03 $16.56 $15.03 $0.00 $0.00 $0.00 $0.00 30200260 EAP CPT® 86747 Parvovirus Igm BOTH IP/OP $124.00 $91.76 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.83 $22.83 $23.71 $0.00 $22.21 $0.00 $0.00 $0.00 $15.78 $42.00 $99.00 $100.00 $21.79 $124.00 $21.79 $0.00 $15.03 $15.03 $16.56 $15.03 $0.00 $0.00 $0.00 $0.00 30200261 EAP CPT® 86753 Ent. Histolytica Ab BOTH IP/OP $96.00 $71.04 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.81 $18.81 $19.54 $0.00 $18.31 $0.00 $0.00 $0.00 $0.00 $34.64 $76.82 $77.60 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200262 EAP CPT® 86762 Rubella Immune Scrn BOTH IP/OP $230.00 $170.20 $7.20 $185.60 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $136.05 $136.05 $15.11 $32.52 $183.74 $185.60 $20.87 $23.74 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200263 EAP CPT® 86762 Rubella Igg BOTH IP/OP $216.00 $159.84 $7.20 $174.40 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $127.76 $127.76 $15.11 $32.52 $172.66 $174.40 $20.87 $23.74 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200264 EAP CPT® 86762 Rubella Igm BOTH IP/OP $216.00 $159.84 $7.20 $174.40 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $127.76 $127.76 $15.11 $32.52 $172.66 $174.40 $20.87 $23.74 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200265 EAP CPT® 86765 Rubeola (measles) Igm BOTH IP/OP $130.00 $96.20 $6.44 $104.80 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $76.90 $76.90 $13.52 $36.00 $103.75 $104.80 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30200266 EAP CPT® 86765 Rubeola (measles) Igg BOTH IP/OP $130.00 $96.20 $6.44 $104.80 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $76.90 $76.90 $13.52 $36.00 $103.75 $104.80 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30200267 EAP CPT® 86777 Toxoplasma Igg BOTH IP/OP $248.00 $183.52 $7.20 $200.80 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $146.69 $146.69 $15.11 $32.52 $198.79 $200.80 $20.87 $23.74 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200268 EAP CPT® 86777 "Toxo Ab-igg,csf" BOTH IP/OP $248.00 $183.52 $7.20 $200.80 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $146.69 $146.69 $15.11 $32.52 $198.79 $200.80 $20.87 $23.74 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200269 EAP CPT® 86777 Toxo Igg Ab-eia BOTH IP/OP $216.00 $159.84 $0.00 $216.00 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $127.76 $127.76 $15.11 $32.52 $213.84 $216.00 $20.87 $0.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200270 EAP CPT® 86778 Toxoplasma Igm BOTH IP/OP $133.00 $98.42 $7.20 $107.20 $29.73 $29.73 $14.41 $14.41 $7.21 $7.20 $21.87 $21.87 $22.71 $14.41 $21.27 $9.37 $78.67 $78.67 $15.13 $40.24 $106.13 $107.20 $20.89 $23.78 $20.89 $22.67 $14.41 $14.41 $15.87 $14.41 $0.00 $0.00 $0.00 $0.00 30200271 EAP CPT® 86778 "Toxo Ab-igm,csf" BOTH IP/OP $133.00 $98.42 $7.20 $107.20 $29.73 $29.73 $14.41 $14.41 $7.21 $7.20 $21.87 $21.87 $22.71 $14.41 $21.27 $9.37 $78.67 $78.67 $15.13 $40.24 $106.13 $107.20 $20.89 $23.78 $20.89 $22.67 $14.41 $14.41 $15.87 $14.41 $0.00 $0.00 $0.00 $0.00 30200272 EAP CPT® 86780 "Treponemal Igg, Csf" BOTH IP/OP $215.00 $159.10 $6.62 $156.80 $27.32 $27.32 $13.24 $13.24 $6.62 $6.62 $19.73 $19.73 $20.49 $13.24 $44.81 $8.61 $127.17 $127.17 $13.90 $98.00 $155.23 $156.80 $19.20 $21.85 $19.20 $30.67 $13.24 $13.24 $31.20 $13.24 $0.00 $0.00 $0.00 $0.00 30200273 EAP CPT® 86780 Treponemal-igg-eia BOTH IP/OP $215.00 $159.10 $6.62 $156.80 $27.32 $27.32 $13.24 $13.24 $6.62 $6.62 $19.73 $19.73 $20.49 $13.24 $44.81 $8.61 $127.17 $127.17 $13.90 $98.00 $155.23 $156.80 $19.20 $21.85 $19.20 $30.67 $13.24 $13.24 $31.20 $13.24 $0.00 $0.00 $0.00 $0.00 30200274 EAP CPT® 86780 Treponemal -igm-eia BOTH IP/OP $158.00 $116.92 $0.00 $144.80 $27.32 $27.32 $13.24 $13.24 $6.62 $6.62 $19.73 $19.73 $20.49 $13.24 $32.93 $8.61 $93.46 $93.46 $13.90 $90.50 $143.35 $144.80 $19.20 $0.00 $19.20 $28.33 $13.24 $13.24 $28.82 $13.24 $0.00 $0.00 $0.00 $0.00 30200275 EAP CPT® 86787 Varicella Zoster Igm BOTH IP/OP $237.00 $175.38 $6.44 $191.20 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $140.19 $140.19 $13.52 $36.00 $189.29 $191.20 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30200276 EAP CPT® 86787 Varicella Zoster BOTH IP/OP $254.00 $187.96 $6.44 $205.60 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $150.24 $150.24 $13.52 $36.00 $203.54 $205.60 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30200277 EAP CPT® 86788 "W. Nile Ab, Igm" BOTH IP/OP $352.00 $260.48 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $208.21 $208.21 $0.00 $47.08 $278.78 $281.60 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200278 EAP CPT® 86788 "W. Nile Ab, Igm, Csf" BOTH IP/OP $352.00 $260.48 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $208.21 $208.21 $0.00 $47.08 $278.78 $281.60 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200279 EAP CPT® 86789 "W. Nile Ab, Igg" BOTH IP/OP $352.00 $260.48 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $32.52 $278.78 $281.60 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200280 EAP CPT® 86789 "W. Nile Ab, Igg, Csf" BOTH IP/OP $352.00 $260.48 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $32.52 $278.78 $281.60 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200281 EAP CPT® 86790 Htlv I/ii Ab BOTH IP/OP $328.00 $242.72 $6.44 $240.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $194.01 $194.01 $13.52 $36.00 $237.60 $240.00 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30200282 EAP CPT® 86800 "Thyroglob Ab, Quant" BOTH IP/OP $336.00 $248.64 $7.95 $269.60 $32.84 $32.84 $15.91 $15.91 $7.96 $7.95 $24.15 $24.15 $25.08 $15.91 $23.50 $10.34 $198.74 $198.74 $16.71 $44.44 $266.90 $269.60 $23.07 $26.25 $23.07 $25.04 $15.91 $15.91 $17.53 $15.91 $0.00 $0.00 $0.00 $0.00 30200283 EAP CPT® 86800 Thyroglobulin Ab BOTH IP/OP $359.00 $265.66 $7.95 $287.20 $32.84 $32.84 $15.91 $15.91 $7.96 $7.95 $24.15 $24.15 $25.08 $15.91 $23.50 $10.34 $212.35 $212.35 $16.71 $44.44 $284.33 $287.20 $23.07 $26.25 $23.07 $25.04 $15.91 $15.91 $17.53 $15.91 $0.00 $0.00 $0.00 $0.00 30200284 EAP CPT® 86803 Hcv Ab (2nd Gen) BOTH IP/OP $343.00 $253.82 $7.13 $276.80 $29.44 $29.44 $14.27 $14.27 $7.14 $7.13 $21.67 $21.67 $22.51 $14.27 $11.75 $9.28 $202.88 $202.88 $14.98 $39.88 $274.03 $276.80 $20.69 $23.55 $20.69 $12.52 $14.27 $14.27 $8.76 $14.27 $0.00 $0.00 $0.00 $0.00 30200285 EAP CPT® 86812 Hla-b27 BOTH IP/OP $582.00 $430.68 $12.90 $470.40 $53.28 $53.28 $25.81 $25.81 $12.91 $12.90 $39.19 $39.19 $40.69 $25.81 $38.13 $16.78 $344.25 $344.25 $27.10 $72.12 $465.70 $470.40 $37.42 $42.59 $37.42 $40.62 $25.81 $25.81 $28.44 $25.81 $0.00 $0.00 $0.00 $0.00 30200286 EAP CPT® 86922 "Charge: Xmatch, Coombs" BOTH IP/OP $187.00 $138.38 $0.00 $199.96 $55.68 $55.68 $145.24 $145.24 $146.06 $38.98 $24.89 $24.89 $25.84 $142.96 $38.97 $92.92 $110.61 $110.61 $143.92 $56.24 $161.57 $163.20 $199.96 $0.00 $199.96 $31.93 $0.00 $0.00 $32.48 $137.07 $0.00 $0.00 $0.00 $0.00 30200287 EAP CPT® 86922 "Charge: Xmatch, Coombs" BOTH IP/OP $187.00 $138.38 $0.00 $199.96 $55.68 $55.68 $145.24 $145.24 $146.06 $38.98 $24.89 $24.89 $25.84 $142.96 $38.97 $92.92 $110.61 $110.61 $143.92 $56.24 $161.57 $163.20 $199.96 $0.00 $199.96 $31.93 $0.00 $0.00 $32.48 $137.07 $0.00 $0.00 $0.00 $0.00 30200289 EAP CPT® 86359 Lymph Subset T Cel Tot (so) BOTH IP/OP $210.00 $155.40 $0.00 $174.40 $48.63 $48.63 $37.73 $37.73 $18.87 $18.86 $35.77 $35.77 $37.14 $37.73 $34.80 $24.52 $124.22 $124.22 $39.62 $65.82 $172.66 $174.40 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30200292 EAP CPT® 86360 Lymph Subset Abs Ct Ratio (so) BOTH IP/OP $310.00 $229.40 $0.00 $257.60 $96.99 $96.99 $46.98 $46.98 $23.49 $23.49 $71.34 $71.34 $74.09 $46.98 $69.42 $30.54 $183.37 $183.37 $49.33 $131.30 $255.02 $257.60 $68.12 $0.00 $68.12 $73.96 $46.98 $46.98 $51.77 $46.98 $0.00 $0.00 $0.00 $0.00 30200310 EAP CPT® 86256 Smooth Muscle Ab Titer BOTH IP/OP $70.00 $51.80 $0.00 $70.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $41.41 $41.41 $12.65 $33.68 $69.70 $70.40 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200315 EAP CPT® 85027 Cbc & Plat BOTH IP/OP $202.00 $149.48 $3.23 $147.20 $13.36 $13.36 $6.47 $6.47 $3.24 $3.23 $9.83 $9.83 $10.21 $6.47 $9.57 $4.21 $119.48 $119.48 $6.79 $18.08 $145.73 $147.20 $9.38 $10.68 $9.38 $10.19 $6.47 $6.47 $7.13 $6.47 $0.00 $0.00 $0.00 $0.00 30200330 EAP CPT® 86355 Lymphocyte Sub 6 B Cells (so) BOTH IP/OP $217.00 $160.58 $0.00 $180.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $178.99 $180.80 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30200331 EAP CPT® 86357 Lymphocyte Sub 6 Nk Total (so) BOTH IP/OP $211.00 $156.14 $0.00 $175.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $173.45 $175.20 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30200332 EAP CPT® 86359 Lymphocyte Sub 6 T Cell Total (so) BOTH IP/OP $220.00 $162.80 $0.00 $183.20 $48.63 $48.63 $37.73 $37.73 $18.87 $18.86 $35.77 $35.77 $37.14 $37.73 $34.80 $24.52 $130.13 $130.13 $39.62 $65.82 $181.37 $183.20 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30200333 EAP CPT® 86360 Lymphocyte Sub 6 T Cells Abs(so) BOTH IP/OP $312.00 $230.88 $0.00 $259.20 $96.99 $96.99 $46.98 $46.98 $23.49 $23.49 $71.34 $71.34 $74.09 $46.98 $69.42 $30.54 $184.55 $184.55 $49.33 $131.30 $256.61 $259.20 $68.12 $0.00 $68.12 $73.96 $46.98 $46.98 $51.77 $46.98 $0.00 $0.00 $0.00 $0.00 30200334 EAP CPT® 86356 Lymphocyte Sub 6 Ag (so) BOTH IP/OP $190.00 $140.60 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.63 $39.63 $41.16 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200335 EAP CPT® 86021 Neutraphil Ab Id (so) BOTH IP/OP $244.00 $180.56 $0.00 $195.20 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $144.33 $144.33 $15.80 $42.06 $193.25 $195.20 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200336 EAP CPT® 86828 Neutraphil Ab Id Hla I&ii (so) BOTH IP/OP $591.00 $437.34 $0.00 $472.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.46 $57.46 $59.67 $0.00 $123.16 $0.00 $0.00 $0.00 $0.00 $295.50 $468.07 $472.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200337 EAP CPT® 86658 Echovirus Ab Csf (so) BOTH IP/OP $183.00 $135.42 $6.51 $183.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $108.24 $108.24 $13.68 $36.40 $146.52 $148.00 $18.89 $183.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30200338 EAP CPT® 83519 Enceph Auto Eval Csf Ria (so) BOTH IP/OP $434.00 $321.16 $8.28 $337.60 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $256.71 $256.71 $19.32 $37.76 $334.22 $337.60 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30200339 EAP CPT® 86255 Enceph Ab Screen Csf (so) BOTH IP/OP $240.00 $177.60 $6.03 $192.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $141.96 $141.96 $12.65 $33.68 $190.08 $192.00 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200340 EAP CPT® 86341 Enceph Islet Cell Ab Csf (so) BOTH IP/OP $196.00 $145.04 $10.61 $155.20 $40.84 $40.84 $23.57 $23.57 $11.79 $10.61 $30.05 $30.05 $31.20 $23.57 $29.24 $15.32 $115.93 $115.93 $24.75 $55.30 $153.65 $155.20 $34.18 $38.89 $34.18 $31.16 $23.57 $23.57 $21.81 $23.57 $0.00 $0.00 $0.00 $0.00 30200341 EAP CPT® 86606 Aspergillus Ab (so) BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $70.98 $70.98 $15.80 $42.06 $95.04 $96.00 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200342 EAP CPT® 86612 Blastomyces Ab (so) BOTH IP/OP $120.00 $88.80 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.59 $19.59 $20.35 $0.00 $19.07 $0.00 $0.00 $0.00 $0.00 $36.06 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200343 EAP CPT® 86305 Human Epididymis Prot 4 (so) BOTH IP/OP $330.00 $244.20 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.00 $31.00 $32.19 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200344 EAP CPT® 86635 Coccidioides Ab (so) BOTH IP/OP $180.00 $133.20 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.42 $17.42 $18.09 $0.00 $16.95 $0.00 $0.00 $0.00 $0.00 $32.06 $129.89 $131.20 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200345 EAP CPT® 86698 Histoplasma Ab (so) BOTH IP/OP $116.00 $85.84 $0.00 $92.80 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $18.98 $18.98 $19.71 $13.79 $18.46 $8.96 $68.61 $68.61 $14.48 $34.92 $91.87 $92.80 $20.00 $0.00 $20.00 $19.67 $13.79 $13.79 $13.77 $13.79 $0.00 $0.00 $0.00 $0.00 30200346 EAP CPT® 87449 Fungitell Csf (so) BOTH IP/OP $182.00 $134.68 $0.00 $145.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $144.14 $145.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200347 EAP CPT® 86790 Chikungunya Ab (so) BOTH IP/OP $188.00 $139.12 $6.44 $137.60 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $111.20 $111.20 $13.52 $36.00 $136.22 $137.60 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30200349 EAP CPT® 86580 Tb Skin Test BOTH IP/OP $75.00 $55.50 $0.00 $72.00 $12.43 $12.43 $24.06 $24.06 $24.19 $3.89 $7.48 $7.48 $7.77 $23.64 $9.56 $15.37 $44.36 $44.36 $23.06 $20.46 $71.28 $72.00 $32.04 $0.00 $32.04 $10.18 $9.36 $9.36 $7.13 $21.96 $0.00 $0.00 $0.00 $0.00 30200350 EAP CPT® 86580 Step 2 Ppd #1 BOTH IP/OP $62.00 $45.88 $0.00 $60.00 $12.43 $12.43 $24.06 $24.06 $24.19 $3.89 $7.48 $7.48 $7.77 $23.64 $9.56 $15.37 $36.67 $36.67 $23.06 $20.46 $59.40 $60.00 $32.04 $0.00 $32.04 $10.18 $9.36 $9.36 $7.13 $21.96 $0.00 $0.00 $0.00 $0.00 30200370 EAP CPT® 86701 Focus Hiv-1 Confirmation BOTH IP/OP $197.00 $145.78 $4.44 $158.40 $18.35 $18.35 $8.89 $8.89 $4.45 $4.44 $13.48 $13.48 $14.00 $8.89 $11.39 $5.78 $116.53 $116.53 $9.33 $24.82 $156.82 $158.40 $12.89 $14.67 $12.89 $12.14 $8.89 $8.89 $8.50 $8.89 $0.00 $0.00 $0.00 $0.00 30200371 EAP CPT® 86702 Focus Hiv-2 Confirmation BOTH IP/OP $238.00 $176.12 $6.76 $192.00 $27.90 $27.90 $13.52 $13.52 $6.76 $6.76 $20.53 $20.53 $21.32 $13.52 $17.33 $8.79 $140.78 $140.78 $14.20 $37.76 $190.08 $192.00 $19.60 $22.31 $19.60 $18.46 $13.52 $13.52 $12.92 $13.52 $0.00 $0.00 $0.00 $0.00 30200372 EAP CPT® 83516 Aquaporin 4 Recep Ab (so) BOTH IP/OP $259.00 $191.66 $0.00 $233.60 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $153.20 $153.20 $12.11 $29.88 $231.26 $233.60 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30200373 EAP CPT® 86003 Abpa Allergen Spec Ige (so) BOTH IP/OP $110.00 $81.40 $2.61 $109.60 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $65.07 $65.07 $5.48 $14.60 $108.50 $109.60 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200374 EAP CPT® 86606 Aspergillus Ab (so) BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $66.84 $66.84 $15.80 $42.06 $89.50 $90.40 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200375 EAP CPT® 86161 C3 Nephritic Factor (so) BOTH IP/OP $231.00 $170.94 $0.00 $212.80 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $136.64 $136.64 $12.60 $33.56 $210.67 $212.80 $17.40 $0.00 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30200376 EAP CPT® 86406 Toxo Titr Pregnancy (so) BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $5.32 $16.15 $16.15 $16.77 $10.64 $15.72 $6.92 $89.91 $89.91 $11.17 $29.74 $120.38 $121.60 $15.43 $0.00 $15.43 $16.75 $10.64 $10.64 $11.72 $10.64 $0.00 $0.00 $0.00 $0.00 30200377 EAP CPT® 86777 Toxoplasma Ab (so) BOTH IP/OP $152.00 $112.48 $0.00 $152.00 $24.02 $24.02 $14.39 $14.39 $7.20 $7.20 $17.67 $17.67 $18.35 $14.39 $17.19 $9.35 $89.91 $89.91 $15.11 $32.52 $150.48 $152.00 $20.87 $0.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30200378 EAP CPT® 86778 Toxoplasma Ab Igm (so) BOTH IP/OP $155.00 $114.70 $0.00 $155.20 $29.73 $29.73 $14.41 $14.41 $7.21 $7.20 $21.87 $21.87 $22.71 $14.41 $21.27 $9.37 $91.68 $91.68 $15.13 $40.24 $153.65 $155.20 $20.89 $0.00 $20.89 $22.67 $14.41 $14.41 $15.87 $14.41 $0.00 $0.00 $0.00 $0.00 30200379 EAP CPT® 86038 Ana Ifa With Reflex (so) BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $24.95 $24.95 $12.09 $12.09 $6.05 $6.04 $18.36 $18.36 $19.06 $12.09 $17.86 $7.86 $118.89 $118.89 $12.69 $33.78 $159.19 $160.80 $17.53 $0.00 $17.53 $19.03 $12.09 $12.09 $13.32 $12.09 $0.00 $0.00 $0.00 $0.00 30200380 EAP CPT® 86021 Wbc Ab Id (neutrophil) (so) BOTH IP/OP $236.00 $174.64 $0.00 $188.80 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $139.59 $139.59 $15.80 $42.06 $186.91 $188.80 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200381 EAP CPT® 86828 Hla I & Ii Ab Qual (so) BOTH IP/OP $593.00 $438.82 $0.00 $474.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.46 $57.46 $59.67 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $296.50 $469.66 $474.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200382 EAP CPT® 86255 Ampa Recept Fluor Ab Screen (so) BOTH IP/OP $429.00 $317.46 $6.03 $428.80 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $253.75 $253.75 $12.65 $33.68 $424.51 $428.80 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200383 EAP CPT® 86833 Hla Ii Post Trans Dsa (so) BOTH IP/OP $326.00 $241.24 $0.00 $260.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.37 $167.37 $173.80 $0.00 $67.94 $0.00 $0.00 $0.00 $0.00 $163.00 $258.19 $260.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200384 EAP CPT® 86832 Hla I Post Trans Dsa (so) BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.25 $184.25 $191.33 $0.00 $67.52 $0.00 $0.00 $0.00 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200385 EAP CPT® 86829 Hla I/ii Post Trans Dsa (so) BOTH IP/OP $245.00 $181.30 $0.00 $197.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.10 $43.10 $44.76 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $122.50 $194.04 $196.00 $0.00 $197.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200386 EAP CPT® 86671 Crohns Prognostic Fung Ab (so) BOTH IP/OP $145.00 $107.30 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $114.84 $116.00 $17.76 $124.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30200387 EAP CPT® 83516 Crohns Prognostic Nonab (so) BOTH IP/OP $244.00 $180.56 $0.00 $220.00 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $144.33 $144.33 $12.11 $29.88 $217.80 $220.00 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30200388 EAP CPT® 83519 Paraneo Autoab Eval Ria(so) BOTH IP/OP $124.00 $91.76 $8.28 $96.80 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $73.35 $73.35 $19.32 $37.76 $95.83 $96.80 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30200389 EAP CPT® 86256 Paraneo Autoab Titer Ria(so) BOTH IP/OP $80.00 $59.20 $6.03 $64.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $47.32 $47.32 $12.65 $33.68 $63.36 $64.00 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200390 EAP CPT® 86255 Nmda Recep Ab Serum BOTH IP/OP $184.00 $136.16 $0.00 $184.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $108.84 $108.84 $12.65 $33.68 $182.16 $184.00 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200400 EAP CPT® 82963 Beta Glucosidase So BOTH IP/OP "$1,282.00 " $948.68 $0.00 "$1,282.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.62 $32.62 $33.88 $0.00 $31.73 $0.00 $0.00 $0.00 $0.00 $60.02 $925.06 $934.40 $0.00 "$1,282.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200401 EAP CPT® 87389 Hiv 1/2 Ag/ab 4th Generation So BOTH IP/OP $104.00 $76.96 $12.04 $80.80 $49.71 $49.71 $24.08 $24.08 $12.04 $12.04 $35.48 $35.48 $36.85 $24.08 $32.07 $15.65 $61.52 $61.52 $25.28 $50.50 $79.99 $80.80 $34.92 $39.73 $34.92 $34.17 $24.08 $24.08 $23.92 $24.08 $0.00 $0.00 $0.00 $0.00 30200449 EAP CPT® 86580 Tb Skin Test BOTH IP/OP $75.00 $55.50 $0.00 $72.00 $12.43 $12.43 $24.06 $24.06 $24.19 $3.89 $7.48 $7.48 $7.77 $23.64 $9.56 $15.37 $44.36 $44.36 $23.06 $20.46 $71.28 $72.00 $32.04 $0.00 $32.04 $10.18 $9.36 $9.36 $7.13 $21.96 $0.00 $0.00 $0.00 $0.00 30200450 EAP CPT® 86021 Proteinase-3 Antibody BOTH IP/OP $206.00 $152.44 $0.00 $164.80 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $121.85 $121.85 $15.80 $42.06 $163.15 $164.80 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200451 EAP CPT® 86021 Myeloperoxidase Antibody BOTH IP/OP $200.00 $148.00 $7.53 $147.20 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $118.30 $118.30 $15.80 $42.06 $145.73 $147.20 $21.82 $24.83 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200452 EAP CPT® 86022 "Platelet Igg Ab,indirect" BOTH IP/OP $301.00 $222.74 $0.00 $240.80 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $178.04 $178.04 $0.00 $51.32 $238.39 $240.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200453 EAP CPT® 86023 Platelet Glycoprot. Ab BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.92 $18.92 $19.65 $0.00 $18.40 $0.00 $0.00 $0.00 $0.00 $34.80 $346.90 $350.40 $0.00 $334.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200454 EAP CPT® 86200 Cyclic Citurullinate Antibody BOTH IP/OP $387.00 $286.38 $6.48 $312.80 $26.72 $26.72 $12.95 $12.95 $6.48 $6.48 $19.67 $19.67 $20.42 $12.95 $19.12 $8.42 $228.91 $228.91 $13.60 $36.18 $309.67 $312.80 $18.78 $21.37 $18.78 $20.37 $12.95 $12.95 $14.26 $12.95 $0.00 $0.00 $0.00 $0.00 30200455 EAP CPT® 86256 Parietal Antibody Titer BOTH IP/OP $88.00 $65.12 $6.03 $70.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $52.05 $52.05 $12.65 $33.68 $69.70 $70.40 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30200480 EAP CPT® 83789 Tpmt Activity BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $546.48 $552.00 $0.00 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200481 EAP CPT® 86689 Htlv Ab. Western Blot BOTH IP/OP $281.00 $207.94 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $24.81 $0.00 $0.00 $0.00 $0.00 $54.10 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200491 EAP CPT® 86316 "Immunoassay, Tumor Antigen, Quant" BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $186.32 $186.32 $21.85 $58.14 $249.48 $252.00 $30.17 $0.00 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30200492 EAP CPT® 86651 Encephal Antibody Calif BOTH IP/OP $36.00 $26.64 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200493 EAP CPT® 86652 Encephal Antibody East Equ BOTH IP/OP $36.00 $26.64 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200494 EAP CPT® 86653 Encephal Antibody St Louis BOTH IP/OP $36.00 $26.64 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200495 EAP CPT® 86654 Encephal Antibody West Equ BOTH IP/OP $36.00 $26.64 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200496 EAP CPT® 88360 Tumor Immunohistochem/manual BOTH IP/OP "$1,842.00 " "$1,363.08" $58.38 "$1,473.60" $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 "$1,089.54" "$1,089.54" $143.92 $121.34 "$1,458.86" "$1,473.60" $199.96 $740.35 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 30200498 EAP CPT® 82787 "Igg1, 2, 3 Or 4, Each" BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $16.55 $16.55 $8.02 $8.02 $4.01 $4.01 $12.18 $12.18 $12.65 $8.02 $11.84 $5.21 $49.69 $49.69 $8.42 $22.40 $66.53 $67.20 $11.63 $0.00 $11.63 $12.62 $8.02 $8.02 $8.83 $8.02 $0.00 $0.00 $0.00 $0.00 30200499 EAP CPT® 86343 Leukocyte Histamine Release BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $25.71 $25.71 $12.46 $12.46 $6.23 $6.23 $18.93 $18.93 $19.66 $12.46 $18.41 $8.10 $247.25 $247.25 $0.00 $34.82 $331.06 $334.40 $0.00 $20.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200500 EAP CPT® 86580 Tb Intradermal Test BOTH IP/OP $106.00 $78.44 $3.89 $102.40 $12.43 $12.43 $24.06 $24.06 $24.19 $3.89 $7.48 $7.48 $7.77 $23.64 $9.56 $15.37 $62.70 $62.70 $23.06 $20.46 $101.38 $102.40 $32.04 $66.95 $32.04 $10.18 $9.36 $9.36 $7.13 $21.96 $0.00 $0.00 $0.00 $0.00 30200501 EAP CPT® 83789 "Mass Spectrometry Quant,nonspec" BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200503 EAP CPT® 88189 "Flowcytometry/read, 16 & > Markers" BOTH IP/OP $248.00 $183.52 $0.00 $210.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.07 $184.07 $191.16 $0.00 $115.43 $0.00 $0.00 $0.00 $93.43 $210.82 $196.42 $198.40 $88.72 $0.00 $88.72 $122.99 $88.72 $88.72 $86.09 $88.72 $0.00 $0.00 $0.00 $0.00 30200504 EAP CPT® 88188 "Flowcytometry/read, 9-15 Markers" BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.33 $206.33 $214.28 $0.00 $87.63 $0.00 $0.00 $0.00 $0.00 $161.74 $220.18 $222.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200505 EAP CPT® 88187 "Flowcytometry/read, 2-8 Markers" BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $138.74 $0.00 $70.22 $0.00 $0.00 $0.00 $50.66 $130.50 $142.56 $144.00 $39.31 $0.00 $39.31 $74.83 $39.31 $39.31 $52.38 $39.31 $0.00 $0.00 $0.00 $0.00 30200506 EAP CPT® 88368 "Insitu Hybridization, Manual" BOTH IP/OP "$1,076.00 " $796.24 $0.00 $860.80 $178.36 $178.36 $283.63 $283.63 $285.22 $58.22 $151.36 $151.36 $157.18 $279.15 $199.20 $181.45 $636.45 $636.45 $284.24 $207.74 $852.19 $860.80 $394.92 $0.00 $394.92 $212.25 $90.40 $90.40 $148.57 $270.71 $0.00 $0.00 $0.00 $0.00 30200507 EAP CPT® 86480 "Tb Test,cell Immun Meas By Gamma Interfron" BOTH IP/OP $572.00 $423.28 $30.99 $552.00 $127.93 $127.93 $61.98 $61.98 $30.99 $30.99 $94.11 $94.11 $97.73 $61.98 $91.55 $40.29 $338.34 $338.34 $65.08 $173.18 $546.48 $552.00 $89.87 $102.27 $89.87 $97.55 $61.98 $61.98 $68.28 $61.98 $0.00 $0.00 $0.00 $0.00 30200508 EAP CPT® 87799 "Jc Virus Pcr, Urine (q)" BOTH IP/OP $743.00 $549.82 $0.00 $679.20 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $154.84 $27.85 $439.48 $439.48 $0.00 $119.70 $672.41 $679.20 $0.00 $0.00 $0.00 $132.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200509 EAP CPT® 87799 "Bk Virus Pcr, Urine (q)" BOTH IP/OP $635.00 $469.90 $0.00 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $132.33 $27.85 $375.60 $375.60 $0.00 $119.70 $574.99 $580.80 $0.00 $0.00 $0.00 $113.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200510 EAP CPT® 83519 Thyrotrpn Bndng Inhib Ab (q) BOTH IP/OP $225.00 $166.50 $0.00 $203.20 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $133.09 $133.09 $19.32 $37.76 $201.17 $203.20 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30200511 EAP CPT® 83520 Prothrombin Fragment (e) BOTH IP/OP $232.00 $171.68 $7.77 $180.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $137.23 $137.23 $18.13 $36.18 $178.99 $180.80 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30200512 EAP CPT® 87912 "Heptis B Resist, Geno (q)" BOTH IP/OP $606.00 $448.44 $0.00 $484.80 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $373.52 $373.52 $387.88 $257.45 $112.65 $167.34 $358.45 $358.45 $0.00 $303.00 $479.95 $484.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200600 EAP CPT® 88184 Flowcytometry/ Tc 1 Marker BOTH IP/OP $300.00 $222.00 $0.00 $300.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $177.45 $177.45 $284.24 $133.74 $237.60 $240.00 $300.00 $0.00 $300.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30200601 EAP CPT® 88185 Flowcytometry/tc Add-on BOTH IP/OP $28.00 $20.72 $0.00 $50.81 $28.00 $28.00 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $16.56 $16.56 $0.00 $28.00 $22.18 $22.40 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30200602 EAP CPT® 86813 Hla Typing A B Or C BOTH IP/OP $413.00 $305.62 $0.00 $330.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.05 $88.05 $91.43 $0.00 $85.66 $0.00 $0.00 $0.00 $0.00 $162.04 $327.10 $330.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200603 EAP CPT® 87252 Virus Inoculation Tissue - Acyclovir BOTH IP/OP $496.00 $367.04 $0.00 $396.80 $45.65 $45.65 $26.07 $26.07 $13.04 $13.04 $33.57 $33.57 $34.86 $26.07 $32.66 $16.95 $293.38 $293.38 $27.37 $61.78 $392.83 $396.80 $37.80 $0.00 $37.80 $34.79 $26.07 $26.07 $24.36 $26.07 $0.00 $0.00 $0.00 $0.00 30200604 EAP CPT® 87253 Virus Inoculate Tissue Addl - Acyclovir BOTH IP/OP $471.00 $348.54 $0.00 $376.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.73 $24.73 $25.68 $0.00 $24.06 $0.00 $0.00 $0.00 $0.00 $45.52 $373.03 $376.80 $0.00 $249.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200605 EAP CPT® 85246 Blood Clot Factor Viii Test BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $47.36 $47.36 $22.94 $22.94 $11.47 $11.47 $34.85 $34.85 $36.19 $22.94 $33.89 $14.91 $62.70 $62.70 $24.09 $64.12 $83.95 $84.80 $33.26 $0.00 $33.26 $36.11 $22.94 $22.94 $25.28 $22.94 $0.00 $0.00 $0.00 $0.00 30200606 EAP CPT® 83033 Fetal Hemoglobin Assay Qual BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.05 $9.05 $9.40 $0.00 $8.81 $0.00 $0.00 $0.00 $0.00 $16.66 $75.24 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200629 EAP CPT® 80347 Assay Of Benzodiazepines BOTH IP/OP $562.00 $415.88 $0.00 $449.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.12 $417.12 $433.19 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $281.00 $445.10 $449.60 $0.00 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200630 EAP CPT® 88237 Tissue Culture Bone Marrow BOTH IP/OP $507.00 $375.18 $0.00 $449.60 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $299.89 $299.89 $150.94 $246.70 $445.10 $449.60 $208.44 $0.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 30200631 EAP CPT® 88264 Chromosome Analysis 20-25 BOTH IP/OP $624.00 $461.76 $0.00 $552.80 $257.29 $257.29 $144.61 $144.61 $72.31 $65.07 $189.26 $189.26 $196.54 $144.61 $184.12 $94.00 $369.10 $369.10 $151.84 $348.28 $547.27 $552.80 $209.68 $0.00 $209.68 $196.18 $144.61 $144.61 $137.33 $144.61 $0.00 $0.00 $0.00 $0.00 30200633 EAP CPT® 88237 Tissue Culture Bone Marrow BOTH IP/OP $237.00 $175.38 $0.00 $246.70 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $140.19 $140.19 $150.94 $246.70 $208.30 $210.40 $208.44 $0.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 30200634 EAP CPT® 88262 Chromosome Analysis 15-20 BOTH IP/OP $199.00 $147.26 $0.00 $220.00 $199.00 $199.00 $125.49 $125.49 $62.75 $62.32 $189.26 $189.26 $196.54 $125.49 $184.12 $81.57 $117.71 $117.71 $131.76 $220.00 $174.24 $176.00 $181.96 $0.00 $181.96 $196.18 $125.49 $125.49 $137.33 $125.49 $0.00 $0.00 $0.00 $0.00 30200636 EAP CPT® 86343 Leukocyte Histamine Release BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $25.71 $25.71 $12.46 $12.46 $6.23 $6.23 $18.93 $18.93 $19.66 $12.46 $18.41 $8.10 $30.76 $30.76 $0.00 $34.82 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200637 EAP CPT® 83088 Assay Of Histamine BOTH IP/OP $50.00 $37.00 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.84 $44.84 $46.57 $0.00 $43.62 $0.00 $0.00 $0.00 $0.00 $50.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200638 EAP CPT® 86021 Wbc Antibody Identification BOTH IP/OP $31.00 $22.94 $0.00 $31.00 $31.00 $31.00 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $18.34 $18.34 $15.80 $31.00 $24.55 $24.80 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200639 EAP CPT® 86376 Microsomal Antibody BOTH IP/OP $29.00 $21.46 $0.00 $29.00 $29.00 $29.00 $14.55 $14.55 $7.28 $7.28 $22.10 $22.10 $22.95 $14.55 $21.49 $9.46 $17.15 $17.15 $15.28 $29.00 $22.97 $23.20 $21.10 $0.00 $21.10 $22.90 $14.55 $14.55 $16.03 $14.55 $0.00 $0.00 $0.00 $0.00 30200640 EAP CPT® 84443 Assay Thyroid Stim Hormone BOTH IP/OP $42.00 $31.08 $0.00 $42.00 $34.69 $34.69 $16.80 $16.80 $8.40 $8.40 $25.51 $25.51 $26.49 $16.80 $24.81 $10.92 $24.84 $24.84 $17.64 $42.00 $33.26 $33.60 $24.36 $0.00 $24.36 $26.44 $16.80 $16.80 $18.51 $16.80 $0.00 $0.00 $0.00 $0.00 30200641 EAP CPT® 86800 Thyroglobulin Antibody BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $32.84 $32.84 $15.91 $15.91 $7.96 $7.95 $24.15 $24.15 $25.08 $15.91 $23.50 $10.34 $44.36 $44.36 $16.71 $44.44 $59.40 $60.00 $23.07 $0.00 $23.07 $25.04 $15.91 $15.91 $17.53 $15.91 $0.00 $0.00 $0.00 $0.00 30200649 EAP CPT® 88321 Microslide Consultation BOTH IP/OP $364.00 $269.36 $0.00 $291.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.27 $82.27 $85.44 $0.00 $69.33 $0.00 $0.00 $0.00 $0.00 $180.64 $288.29 $291.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200650 EAP CPT® 86343 Leukocyte Histamine Release BOTH IP/OP $48.00 $35.52 $0.00 $38.40 $25.71 $25.71 $12.46 $12.46 $6.23 $6.23 $18.93 $18.93 $19.66 $12.46 $18.41 $8.10 $28.39 $28.39 $0.00 $34.82 $38.02 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200651 EAP CPT® 83088 Assay Of Histamine BOTH IP/OP $49.00 $36.26 $0.00 $49.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.84 $44.84 $46.57 $0.00 $43.62 $0.00 $0.00 $0.00 $0.00 $49.00 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200652 EAP CPT® 86021 Wbc Antibody Identification BOTH IP/OP $29.00 $21.46 $0.00 $29.00 $29.00 $29.00 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $17.15 $17.15 $15.80 $29.00 $22.97 $23.20 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30200653 EAP CPT® 86376 Microsomal Antibody BOTH IP/OP $27.00 $19.98 $0.00 $27.00 $27.00 $27.00 $14.55 $14.55 $7.28 $7.28 $22.10 $22.10 $22.95 $14.55 $21.49 $9.46 $15.97 $15.97 $15.28 $27.00 $21.38 $21.60 $21.10 $0.00 $21.10 $22.90 $14.55 $14.55 $16.03 $14.55 $0.00 $0.00 $0.00 $0.00 30200654 EAP CPT® 84443 Assay Thyroid Stim Hormone BOTH IP/OP $39.00 $28.86 $0.00 $39.00 $34.69 $34.69 $16.80 $16.80 $8.40 $8.40 $25.51 $25.51 $26.49 $16.80 $24.81 $10.92 $23.07 $23.07 $17.64 $39.00 $30.89 $31.20 $24.36 $0.00 $24.36 $26.44 $16.80 $16.80 $18.51 $16.80 $0.00 $0.00 $0.00 $0.00 30200655 EAP CPT® 86800 Thyroglobulin Antibody BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $32.84 $32.84 $15.91 $15.91 $7.96 $7.95 $24.15 $24.15 $25.08 $15.91 $23.50 $10.34 $40.81 $40.81 $16.71 $44.44 $54.65 $55.20 $23.07 $0.00 $23.07 $25.04 $15.91 $15.91 $17.53 $15.91 $0.00 $0.00 $0.00 $0.00 30200656 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $77.00 $56.98 $0.00 $61.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $45.55 $45.55 $22.49 $59.86 $60.98 $61.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200657 EAP CPT® 88273 Cytogenetics 10-30 BOTH IP/OP $107.00 $79.18 $0.00 $89.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.79 $48.79 $50.66 $0.00 $47.46 $0.00 $0.00 $0.00 $0.00 $89.78 $84.74 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200660 EAP CPT® 88182 Cell Marker Study BOTH IP/OP $93.00 $68.82 $0.00 $93.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.95 $68.95 $71.60 $0.00 $78.66 $0.00 $0.00 $0.00 $0.00 $93.00 $73.66 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200661 EAP CPT® 86817 Hla Typing Dr/dq BOTH IP/OP $743.00 $549.82 $0.00 $594.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.76 $97.76 $101.52 $0.00 $95.11 $0.00 $0.00 $0.00 $0.00 $179.90 $588.46 $594.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200671 EAP CPT® 88360 Tumor Immunohistochem/manual BOTH IP/OP $310.00 $229.40 $0.00 $248.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $183.37 $183.37 $143.92 $121.34 $245.52 $248.00 $199.96 $0.00 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 30200672 EAP CPT® 88321 Microslide Consultation BOTH IP/OP $84.00 $62.16 $0.00 $85.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.27 $82.27 $85.44 $0.00 $69.33 $0.00 $0.00 $0.00 $0.00 $84.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200673 EAP CPT® 84600 Assay Of Volatiles BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $33.18 $33.18 $17.11 $17.11 $8.56 $8.04 $24.41 $24.41 $25.35 $17.11 $23.74 $11.12 $191.65 $191.65 $0.00 $44.90 $256.61 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200674 EAP CPT® 84600 Assay Of Volatiles BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $33.18 $33.18 $17.11 $17.11 $8.56 $8.04 $24.41 $24.41 $25.35 $17.11 $23.74 $11.12 $191.65 $191.65 $0.00 $44.90 $256.61 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200675 EAP CPT® 85210 Blood Clot Factor Ii Test BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.72 $19.72 $20.48 $0.00 $19.18 $0.00 $0.00 $0.00 $0.00 $36.28 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200676 EAP CPT® 85210 Blood Clot Factor Ii Test BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.72 $19.72 $20.48 $0.00 $19.18 $0.00 $0.00 $0.00 $0.00 $36.28 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200677 EAP CPT® 85260 Blood Clot Factor X Test BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.19 $27.19 $28.23 $0.00 $26.46 $0.00 $0.00 $0.00 $0.00 $50.04 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200679 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $59.74 $59.74 $22.49 $59.86 $79.99 $80.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200680 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $117.00 $86.58 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $69.21 $69.21 $53.75 $112.22 $92.66 $93.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30200681 EAP CPT® 88184 Flowcytometry/ Tc 1 Marker BOTH IP/OP $561.00 $415.14 $30.49 $452.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $331.83 $331.83 $284.24 $133.74 $237.60 $452.00 $300.00 $364.65 $300.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30200682 EAP CPT® 88185 Flowcytometry/tc Add-on BOTH IP/OP $33.00 $24.42 $0.00 $50.81 $33.00 $33.00 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $19.52 $19.52 $0.00 $33.00 $23.76 $26.40 $0.00 $21.45 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30200683 EAP CPT® 88184 Flowcytometry/ Tc 1 Marker BOTH IP/OP $300.00 $222.00 $0.00 $300.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $177.45 $177.45 $284.24 $133.74 $237.60 $240.00 $300.00 $0.00 $300.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30200684 EAP CPT® 88185 Flowcytometry/tc Add-on BOTH IP/OP $14.00 $10.36 $0.00 $50.81 $14.00 $14.00 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $14.00 $0.00 $8.28 $8.28 $0.00 $14.00 $11.09 $11.20 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30200685 EAP CPT® 88182 Cell Marker Study BOTH IP/OP $93.00 $68.82 $0.00 $93.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.95 $68.95 $71.60 $0.00 $78.66 $0.00 $0.00 $0.00 $0.00 $93.00 $73.66 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200686 EAP CPT® 85520 Heparin Assay BOTH IP/OP $199.00 $147.26 $0.00 $168.00 $27.03 $27.03 $13.09 $13.09 $6.55 $6.55 $19.87 $19.87 $20.64 $13.09 $19.34 $8.51 $117.71 $117.71 $13.74 $36.58 $166.32 $168.00 $18.98 $0.00 $18.98 $20.61 $13.09 $13.09 $14.43 $13.09 $0.00 $0.00 $0.00 $0.00 30200687 EAP CPT® 87252 Virus Inoculation Tissue BOTH IP/OP $496.00 $367.04 $0.00 $396.80 $45.65 $45.65 $26.07 $26.07 $13.04 $13.04 $33.57 $33.57 $34.86 $26.07 $32.66 $16.95 $293.38 $293.38 $27.37 $61.78 $392.83 $396.80 $37.80 $0.00 $37.80 $34.79 $26.07 $26.07 $24.36 $26.07 $0.00 $0.00 $0.00 $0.00 30200688 EAP CPT® 87253 Virus Inoculate Tissue Addl BOTH IP/OP $476.00 $352.24 $0.00 $380.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.73 $24.73 $25.68 $0.00 $24.06 $0.00 $0.00 $0.00 $0.00 $45.52 $376.99 $380.80 $0.00 $249.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200693 EAP CPT® 87449 Ag Detect Nos Eia Mult BOTH IP/OP $317.00 $234.58 $0.00 $253.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $251.06 $253.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200694 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $165.00 $122.10 $2.59 $132.00 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $97.60 $97.60 $5.44 $14.46 $130.68 $132.00 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30200695 EAP CPT® 84378 Sugars Single Quant BOTH IP/OP $210.00 $155.40 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.50 $17.50 $18.18 $0.00 $17.02 $0.00 $0.00 $0.00 $0.00 $32.20 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200696 EAP CPT® 80500 Lab Pathology Consultation BOTH IP/OP $112.00 $82.88 $0.00 $89.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.18 $0.00 $0.00 $0.00 $0.00 $43.34 $88.70 $89.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200697 EAP CPT® 87252 Virus Inoculation Tissue BOTH IP/OP $496.00 $367.04 $0.00 $396.80 $45.65 $45.65 $26.07 $26.07 $13.04 $13.04 $33.57 $33.57 $34.86 $26.07 $32.66 $16.95 $293.38 $293.38 $27.37 $61.78 $392.83 $396.80 $37.80 $0.00 $37.80 $34.79 $26.07 $26.07 $24.36 $26.07 $0.00 $0.00 $0.00 $0.00 30200698 EAP CPT® 87253 Virus Inoculate Tissue Addl BOTH IP/OP $476.00 $352.24 $0.00 $380.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.73 $24.73 $25.68 $0.00 $24.06 $0.00 $0.00 $0.00 $0.00 $45.52 $376.99 $380.80 $0.00 $249.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200708 EAP CPT® 88368 Insitu Hybridization Manual BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $178.36 $178.36 $283.63 $283.63 $285.22 $58.22 $151.36 $151.36 $157.18 $279.15 $199.20 $181.45 $296.34 $296.34 $284.24 $207.74 $396.79 $400.80 $394.92 $0.00 $394.92 $212.25 $90.40 $90.40 $148.57 $270.71 $0.00 $0.00 $0.00 $0.00 30200711 EAP CPT® 80307 "Drug Screen, Any Number Drug Classes" BOTH IP/OP $451.00 $333.74 $29.09 $328.00 $115.05 $115.05 $62.14 $62.14 $31.07 $29.09 $79.51 $79.51 $82.57 $62.14 $71.85 $40.39 $266.77 $266.77 $65.25 $205.00 $324.72 $328.00 $90.10 $102.53 $90.10 $76.56 $62.14 $62.14 $53.59 $62.14 $0.00 $0.00 $0.00 $0.00 30200712 EAP CPT® 87252 Virus Inoculation Tissue BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $45.65 $45.65 $26.07 $26.07 $13.04 $13.04 $33.57 $33.57 $34.86 $26.07 $32.66 $16.95 $204.07 $204.07 $27.37 $61.78 $273.24 $276.00 $37.80 $0.00 $37.80 $34.79 $26.07 $26.07 $24.36 $26.07 $0.00 $0.00 $0.00 $0.00 30200713 EAP CPT® 88184 Flowcytometry/ Tc 1 Marker BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $295.75 $295.75 $284.24 $133.74 $396.00 $400.00 $394.92 $0.00 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30200714 EAP CPT® 88185 Flowcytometry/tc Add-on BOTH IP/OP $58.00 $42.92 $0.00 $58.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $34.31 $34.31 $0.00 $58.00 $45.94 $46.40 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30200719 EAP CPT® 88360 Tumor Immunohistochem/manual BOTH IP/OP $310.00 $229.40 $0.00 $248.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $183.37 $183.37 $143.92 $121.34 $245.52 $248.00 $199.96 $0.00 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 30200720 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $131.00 $96.94 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $77.49 $77.49 $53.75 $112.22 $103.75 $104.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30200721 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $44.36 $44.36 $22.49 $59.86 $59.40 $60.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200732 EAP CPT® 87530 Hsv Dna Quant BOTH IP/OP $74.00 $54.76 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.04 $65.04 $67.54 $0.00 $15.42 $0.00 $0.00 $0.00 $0.00 $76.00 $60.19 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200740 EAP CPT® 87556 M.tuberculo Dna Amp Probe BOTH IP/OP $220.00 $162.80 $0.00 $181.60 $40.50 $40.50 $41.68 $41.68 $20.84 $18.76 $29.79 $29.79 $30.93 $41.68 $45.85 $27.09 $130.13 $130.13 $43.76 $54.82 $179.78 $181.60 $60.44 $0.00 $60.44 $35.53 $41.68 $41.68 $36.14 $41.68 $0.00 $0.00 $0.00 $0.00 30200746 EAP CPT® 83018 Quantitative Screen Metals BOTH IP/OP $61.00 $45.14 $0.00 $61.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.34 $33.34 $34.62 $0.00 $32.43 $0.00 $0.00 $0.00 $0.00 $61.00 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200747 EAP CPT® 83655 Assay Of Lead BOTH IP/OP $46.00 $34.04 $0.00 $36.80 $25.00 $25.00 $12.11 $12.11 $6.06 $6.05 $18.38 $18.38 $19.08 $12.11 $11.75 $7.87 $27.21 $27.21 $12.72 $33.82 $36.43 $36.80 $17.56 $0.00 $17.56 $12.52 $12.11 $12.11 $8.76 $12.11 $0.00 $0.00 $0.00 $0.00 30200748 EAP CPT® 83825 Assay Of Mercury BOTH IP/OP $41.00 $30.34 $0.00 $41.00 $33.55 $33.55 $16.26 $16.26 $8.13 $8.13 $24.69 $24.69 $25.64 $16.26 $24.02 $10.57 $24.25 $24.25 $17.07 $41.00 $32.47 $32.80 $23.58 $0.00 $23.58 $0.00 $16.26 $16.26 $17.92 $16.26 $0.00 $0.00 $0.00 $0.00 30200749 EAP CPT® 84255 Assay Of Selenium BOTH IP/OP $55.00 $40.70 $0.00 $55.00 $52.69 $52.69 $25.53 $25.53 $12.77 $12.77 $38.76 $38.76 $40.25 $25.53 $37.71 $16.59 $32.53 $32.53 $0.00 $55.00 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200750 EAP CPT® 88182 Cell Marker Study BOTH IP/OP $87.00 $64.38 $0.00 $87.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.95 $68.95 $71.60 $0.00 $78.66 $0.00 $0.00 $0.00 $0.00 $87.00 $68.90 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200751 EAP CPT® 88342 Immunohistochemistry BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $164.44 $164.44 $143.92 $106.46 $220.18 $222.40 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 30200752 EAP CPT® 88230 Tissue Culture Lymphocyte BOTH IP/OP $186.00 $137.64 $0.00 $206.00 $186.00 $186.00 $116.49 $116.49 $58.25 $58.25 $176.90 $176.90 $183.71 $116.49 $172.08 $75.72 $110.02 $110.02 $122.31 $206.00 $163.15 $164.80 $168.91 $0.00 $168.91 $183.36 $116.49 $116.49 $128.35 $116.49 $0.00 $0.00 $0.00 $0.00 30200753 EAP CPT® 88263 Chromosome Analysis 45 BOTH IP/OP $241.00 $178.34 $0.00 $267.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.20 $228.20 $236.97 $0.00 $221.99 $0.00 $0.00 $0.00 $0.00 $267.00 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200754 EAP CPT® 88285 Chromosome Count Additional BOTH IP/OP $31.00 $22.94 $0.00 $34.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.85 $28.85 $29.96 $0.00 $28.07 $0.00 $0.00 $0.00 $0.00 $34.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200756 EAP CPT® 82441 Test For Chlorohydrocarbons BOTH IP/OP $183.00 $135.42 $0.00 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.11 $9.11 $9.46 $0.00 $8.86 $0.00 $0.00 $0.00 $0.00 $16.76 $144.94 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200757 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $49.09 $49.09 $5.44 $14.46 $65.74 $66.40 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30200758 EAP CPT® 84600 Assay Of Volatiles BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $33.18 $33.18 $17.11 $17.11 $8.56 $8.04 $24.41 $24.41 $25.35 $17.11 $23.74 $11.12 $59.15 $59.15 $0.00 $44.90 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200759 EAP CPT® 85576 Blood Platelet Aggregation BOTH IP/OP $122.00 $90.28 $0.00 $120.80 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $72.16 $72.16 $26.16 $60.02 $119.59 $120.80 $36.12 $0.00 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30200760 EAP CPT® 85049 Automated Platelet Count BOTH IP/OP $24.00 $17.76 $0.00 $19.20 $9.24 $9.24 $4.48 $4.48 $2.24 $2.24 $6.79 $6.79 $7.05 $4.48 $6.62 $2.91 $14.20 $14.20 $4.70 $12.50 $19.01 $19.20 $6.50 $0.00 $6.50 $7.05 $4.48 $4.48 $4.93 $4.48 $0.00 $0.00 $0.00 $0.00 30200776 EAP CPT® 88184 Flowcytometry/ Tc 1 Marker BOTH IP/OP $303.00 $224.22 $0.00 $303.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $179.22 $179.22 $284.24 $133.74 $239.98 $242.40 $303.00 $0.00 $303.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30200777 EAP CPT® 88185 Flowcytometry/tc Add-on BOTH IP/OP $26.00 $19.24 $0.00 $50.81 $26.00 $26.00 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.00 $0.00 $15.38 $15.38 $0.00 $26.00 $20.59 $20.80 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30200778 EAP CPT® 88187 Flowcytometry/read 2-8 BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $138.74 $0.00 $70.22 $0.00 $0.00 $0.00 $50.66 $130.50 $142.56 $144.00 $39.31 $0.00 $39.31 $74.83 $39.31 $39.31 $52.38 $39.31 $0.00 $0.00 $0.00 $0.00 30200784 EAP CPT® 80500 Lab Pathology Consultation BOTH IP/OP $53.00 $39.22 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.18 $0.00 $0.00 $0.00 $0.00 $43.34 $41.98 $42.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200785 EAP CPT® 82657 Enzyme Cell Activity BOTH IP/OP $20.00 $14.80 $0.00 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $19.80 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200790 EAP CPT® 86022 Platelet Antibodies BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $108.84 $108.84 $0.00 $51.32 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200791 EAP CPT® 86022 Platelet Antibodies BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $62.70 $62.70 $0.00 $51.32 $83.95 $84.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200792 EAP CPT® 88239 Tissue Culture Tumor BOTH IP/OP $276.00 $204.24 $0.00 $306.00 $276.00 $276.00 $147.52 $147.52 $73.76 $73.76 $224.01 $224.01 $232.62 $147.52 $217.93 $95.89 $163.25 $163.25 $154.90 $306.00 $242.35 $244.80 $213.90 $0.00 $213.90 $232.21 $147.52 $147.52 $162.54 $147.52 $0.00 $0.00 $0.00 $0.00 30200793 EAP CPT® 88237 Tissue Culture Bone Marrow BOTH IP/OP $237.00 $175.38 $0.00 $246.70 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $140.19 $140.19 $150.94 $246.70 $208.30 $210.40 $208.44 $0.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 30200804 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $82.00 $60.68 $0.00 $65.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $48.50 $48.50 $22.49 $59.86 $64.94 $65.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200805 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $86.36 $86.36 $53.75 $112.22 $115.63 $116.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30200806 EAP CPT® 86780 Treponema Pallidum BOTH IP/OP $179.00 $132.46 $6.62 $130.40 $27.32 $27.32 $13.24 $13.24 $6.62 $6.62 $19.73 $19.73 $20.49 $13.24 $37.30 $8.61 $105.88 $105.88 $13.90 $81.50 $129.10 $130.40 $19.20 $21.85 $19.20 $25.51 $13.24 $13.24 $25.95 $13.24 $0.00 $0.00 $0.00 $0.00 30200818 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $362.00 $267.88 $2.61 $360.80 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $214.12 $214.12 $5.48 $14.60 $357.19 $360.80 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200819 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $362.00 $267.88 $2.61 $360.80 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $214.12 $214.12 $5.48 $14.60 $357.19 $360.80 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200820 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $362.00 $267.88 $2.61 $360.80 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $214.12 $214.12 $5.48 $14.60 $357.19 $360.80 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200827 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $62.70 $62.70 $22.49 $59.86 $83.95 $84.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200828 EAP CPT® 88272 Cytogenetics 3-5 BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $55.28 $55.28 $40.70 $40.70 $20.35 $18.32 $40.65 $40.65 $42.22 $40.70 $39.55 $26.46 $74.53 $74.53 $0.00 $74.82 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200830 EAP CPT® 88237 Tissue Culture Bone Marrow BOTH IP/OP $376.00 $278.24 $0.00 $332.80 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $222.40 $222.40 $150.94 $246.70 $329.47 $332.80 $208.44 $0.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 30200831 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $202.29 $202.29 $22.49 $59.86 $270.86 $273.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200832 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $236.60 $236.60 $53.75 $112.22 $316.80 $320.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30200840 EAP CPT® 88237 Tissue Culture Bone Marrow BOTH IP/OP $262.00 $193.88 $0.00 $246.70 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $154.97 $154.97 $150.94 $246.70 $229.68 $232.00 $208.44 $0.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 30200841 EAP CPT® 88262 Chromosome Analysis 15-20 BOTH IP/OP $219.00 $162.06 $0.00 $243.00 $219.00 $219.00 $125.49 $125.49 $62.75 $62.32 $189.26 $189.26 $196.54 $125.49 $184.12 $81.57 $129.54 $129.54 $131.76 $243.00 $192.46 $194.40 $181.96 $0.00 $181.96 $196.18 $125.49 $125.49 $137.33 $125.49 $0.00 $0.00 $0.00 $0.00 30200843 EAP CPT® 87449 Ag Detect Nos Eia Mult BOTH IP/OP $250.00 $185.00 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $200.38 $202.40 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200844 EAP CPT® 87449 Ag Detect Nos Eia Mult BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $200.38 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200845 EAP CPT® 88291 Cyto/molecular Report BOTH IP/OP $29.00 $21.46 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.04 $0.00 $0.00 $0.00 $0.00 $29.00 $22.97 $23.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200846 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $63.29 $63.29 $22.49 $59.86 $84.74 $85.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200847 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $136.00 $100.64 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $80.44 $80.44 $53.75 $112.22 $107.71 $108.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30200848 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $47.32 $47.32 $22.49 $59.86 $63.36 $64.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200849 EAP CPT® 88272 Cytogenetics 3-5 BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $55.28 $55.28 $40.70 $40.70 $20.35 $18.32 $40.65 $40.65 $42.22 $40.70 $39.55 $26.46 $62.70 $62.70 $0.00 $74.82 $83.95 $84.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200856 EAP CPT® 87186 Microbe Susceptible Mic BOTH IP/OP $308.00 $227.92 $4.32 $246.40 $17.85 $17.85 $8.65 $8.65 $4.33 $4.32 $13.12 $13.12 $13.63 $8.65 $12.77 $5.62 $182.18 $182.18 $9.08 $24.16 $243.94 $246.40 $12.54 $14.27 $12.54 $13.60 $8.65 $8.65 $9.52 $8.65 $0.00 $0.00 $0.00 $0.00 30200863 EAP CPT® 82136 Amino Acids Quant 2-5 BOTH IP/OP $338.00 $250.12 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $267.70 $270.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200864 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $47.32 $47.32 $22.49 $59.86 $63.36 $64.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30200865 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $139.00 $102.86 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $82.22 $82.22 $53.75 $112.22 $110.09 $111.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30200867 EAP CPT® 87385 Histoplasma Capsul Ag Eia BOTH IP/OP $215.00 $159.10 $0.00 $172.00 $24.74 $24.74 $13.25 $13.25 $6.63 $5.99 $18.22 $18.22 $18.92 $13.25 $17.71 $8.61 $127.17 $127.17 $13.91 $33.52 $170.28 $172.00 $19.21 $0.00 $19.21 $18.87 $13.25 $13.25 $13.21 $13.25 $0.00 $0.00 $0.00 $0.00 30200868 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $386.00 $285.64 $17.55 $311.20 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $228.32 $228.32 $36.84 $54.82 $308.09 $311.20 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30200869 EAP CPT® 82175 Assay Of Arsenic BOTH IP/OP $34.00 $25.16 $0.00 $34.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.49 $28.81 $28.81 $29.92 $18.97 $28.02 $12.33 $20.11 $20.11 $19.92 $34.00 $26.93 $27.20 $27.51 $0.00 $27.51 $0.00 $18.97 $18.97 $20.90 $18.97 $0.00 $0.00 $0.00 $0.00 30200895 EAP CPT® 84481 "T3, Free" BOTH IP/OP $150.00 $111.00 $8.47 $118.40 $34.98 $34.98 $16.94 $16.94 $8.47 $8.47 $25.73 $25.73 $26.72 $16.94 $25.02 $11.01 $88.73 $88.73 $17.79 $47.34 $117.22 $118.40 $24.56 $27.95 $24.56 $26.66 $16.94 $16.94 $18.66 $16.94 $0.00 $0.00 $0.00 $0.00 30200896 EAP CPT® 84481 Free Assay(ft-3) BOTH IP/OP $137.00 $101.38 $0.00 $125.60 $34.98 $34.98 $16.94 $16.94 $8.47 $8.47 $25.73 $25.73 $26.72 $16.94 $25.02 $11.01 $81.04 $81.04 $17.79 $47.34 $124.34 $125.60 $24.56 $0.00 $24.56 $26.66 $16.94 $16.94 $18.66 $16.94 $0.00 $0.00 $0.00 $0.00 30200898 EAP CPT® 83789 Mass Spectrometry Quant BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $93.46 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200900 EAP CPT® 82154 Androstanediol Glucuronide BOTH IP/OP $437.00 $323.38 $0.00 $349.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.78 $43.78 $45.47 $0.00 $42.60 $0.00 $0.00 $0.00 $0.00 $80.58 $346.10 $349.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200908 EAP CPT® 82010 Acetone Assay BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $16.87 $16.87 $8.17 $8.17 $4.09 $4.09 $12.41 $12.41 $12.88 $8.17 $12.08 $5.31 $168.58 $168.58 $8.58 $22.84 $225.72 $228.00 $11.85 $0.00 $11.85 $12.87 $8.17 $8.17 $9.01 $8.17 $0.00 $0.00 $0.00 $0.00 30200910 EAP CPT® 82010 Acetone Assay BOTH IP/OP $153.00 $113.22 $0.00 $122.40 $16.87 $16.87 $8.17 $8.17 $4.09 $4.09 $12.41 $12.41 $12.88 $8.17 $12.08 $5.31 $90.50 $90.50 $8.58 $22.84 $121.18 $122.40 $11.85 $0.00 $11.85 $12.87 $8.17 $8.17 $9.01 $8.17 $0.00 $0.00 $0.00 $0.00 30200912 EAP CPT® 87252 Virus Inoculation Tissue BOTH IP/OP $488.00 $361.12 $0.00 $390.40 $45.65 $45.65 $26.07 $26.07 $13.04 $13.04 $33.57 $33.57 $34.86 $26.07 $32.66 $16.95 $288.65 $288.65 $27.37 $61.78 $386.50 $390.40 $37.80 $0.00 $37.80 $34.79 $26.07 $26.07 $24.36 $26.07 $0.00 $0.00 $0.00 $0.00 30200913 EAP CPT® 87253 Virus Inoculate Tissue Addl BOTH IP/OP $488.00 $361.12 $0.00 $390.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.73 $24.73 $25.68 $0.00 $24.06 $0.00 $0.00 $0.00 $0.00 $45.52 $386.50 $390.40 $0.00 $249.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200915 EAP CPT® 82017 Acylcarnities Quant BOTH IP/OP $247.00 $182.78 $0.00 $197.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $195.62 $197.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200919 EAP CPT® 84311 Spectrophotometry BOTH IP/OP $239.00 $176.86 $0.00 $192.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $190.87 $192.80 $11.75 $156.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30200921 EAP CPT® 84311 Spectrophotometry BOTH IP/OP $239.00 $176.86 $0.00 $192.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $190.87 $192.80 $11.75 $156.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30200923 EAP CPT® 87260 Adenovirus Ag If BOTH IP/OP $128.00 $94.72 $0.00 $102.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $101.38 $102.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200925 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $464.00 $343.36 $0.00 $447.20 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $274.46 $274.46 $36.84 $54.82 $442.73 $447.20 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30200927 EAP CPT® 86316 Immunoassay Tumor Other BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $105.29 $105.29 $21.85 $58.14 $140.98 $142.40 $30.17 $0.00 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30200929 EAP CPT® 82088 Assay Of Aldosterone BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $84.11 $84.11 $40.75 $40.75 $20.38 $20.38 $61.88 $61.88 $64.26 $40.75 $60.21 $26.49 $175.68 $175.68 $42.79 $113.88 $235.22 $237.60 $59.09 $0.00 $59.09 $64.15 $40.75 $40.75 $44.91 $40.75 $0.00 $0.00 $0.00 $0.00 30200937 EAP CPT® 82103 Alpha-1-antitrypsin Total BOTH IP/OP $137.00 $101.38 $0.00 $109.60 $27.75 $27.75 $13.44 $13.44 $6.72 $6.72 $20.39 $20.39 $21.18 $13.44 $19.85 $8.74 $81.04 $81.04 $14.11 $37.54 $108.50 $109.60 $19.49 $0.00 $19.49 $21.15 $13.44 $13.44 $14.80 $13.44 $0.00 $0.00 $0.00 $0.00 30200939 EAP CPT® 86316 Immunoassay Tumor Other BOTH IP/OP $177.00 $130.98 $10.41 $142.40 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $104.70 $104.70 $21.85 $58.14 $140.98 $142.40 $30.17 $34.34 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30200941 EAP CPT® 86147 Cardiolipin Antibody BOTH IP/OP $53.00 $39.22 $0.00 $66.00 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $31.35 $31.35 $26.72 $66.00 $52.27 $52.80 $36.90 $0.00 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30200943 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $293.00 $216.82 $0.00 $264.80 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $173.31 $173.31 $18.13 $36.18 $262.15 $264.80 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30200945 EAP CPT® 86146 Glycoprotein Antibody BOTH IP/OP $107.00 $79.18 $0.00 $107.20 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $63.29 $63.29 $26.72 $71.08 $106.13 $107.20 $36.90 $0.00 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30200946 EAP CPT® 86147 Cardiolipin Antibody BOTH IP/OP $147.00 $108.78 $12.73 $107.20 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $86.95 $86.95 $26.72 $71.08 $106.13 $107.20 $36.90 $41.99 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30200947 EAP CPT® 86148 Phospholipid Antibody BOTH IP/OP $83.00 $61.42 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.39 $24.39 $25.33 $0.00 $23.73 $0.00 $0.00 $0.00 $0.00 $44.88 $82.37 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200949 EAP CPT® 85300 "Antithrombin Iii Test,activity" BOTH IP/OP $588.00 $435.12 $5.93 $470.40 $24.47 $24.47 $11.85 $11.85 $5.93 $5.93 $17.99 $17.99 $18.68 $11.85 $17.50 $7.70 $347.80 $347.80 $12.44 $33.10 $465.70 $470.40 $17.18 $19.55 $17.18 $18.65 $11.85 $11.85 $13.06 $11.85 $0.00 $0.00 $0.00 $0.00 30200950 EAP CPT® 85301 "Antithrombin Iii Test,antigen Assay" BOTH IP/OP $588.00 $435.12 $0.00 $470.40 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $16.42 $16.42 $17.05 $10.81 $15.98 $7.03 $347.80 $347.80 $11.35 $30.22 $465.70 $470.40 $15.67 $459.00 $15.67 $17.03 $10.81 $10.81 $11.92 $10.81 $0.00 $0.00 $0.00 $0.00 30200952 EAP CPT® 82172 Assay Of Apolipoprotein BOTH IP/OP $41.00 $30.34 $0.00 $41.00 $32.00 $32.00 $21.09 $21.09 $10.55 $9.49 $23.52 $23.52 $24.43 $21.09 $22.90 $13.71 $24.25 $24.25 $22.14 $41.00 $32.47 $32.80 $30.58 $0.00 $30.58 $24.40 $21.09 $21.09 $17.08 $21.09 $0.00 $0.00 $0.00 $0.00 30200954 EAP CPT® 86651 "Antibody Encephalitis, California (la Crosse)" BOTH IP/OP $25.00 $18.50 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $25.00 $19.80 $20.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200955 EAP CPT® 86652 "Antibody Encephalitis, Eastern Equine" BOTH IP/OP $25.00 $18.50 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $25.00 $19.80 $20.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200956 EAP CPT® 86653 "Antibody Encephalitis, St. Louis" BOTH IP/OP $25.00 $18.50 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $25.00 $19.80 $20.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200957 EAP CPT® 86654 "Antibody Encephalitis, Western Equine" BOTH IP/OP $25.00 $18.50 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $25.00 $19.80 $20.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200959 EAP CPT® 82175 Assay Of Arsenic BOTH IP/OP $117.00 $86.58 $0.00 $93.60 $0.00 $0.00 $0.00 $0.00 $0.00 $9.49 $28.81 $28.81 $29.92 $18.97 $28.02 $12.33 $69.21 $69.21 $19.92 $53.02 $92.66 $93.60 $27.51 $0.00 $27.51 $0.00 $18.97 $18.97 $20.90 $18.97 $0.00 $0.00 $0.00 $0.00 30200961 EAP CPT® 84311 Spectrophotometry BOTH IP/OP $286.00 $211.64 $0.00 $285.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $282.74 $285.60 $11.75 $156.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30200963 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $124.00 $91.76 $2.61 $124.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $73.35 $73.35 $5.48 $14.60 $122.76 $124.00 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30200965 EAP CPT® 87305 Aspergillus Ag Eia BOTH IP/OP $139.00 $102.86 $0.00 $111.20 $24.74 $24.74 $11.98 $11.98 $5.99 $5.99 $18.22 $18.22 $18.92 $11.98 $17.71 $7.79 $82.22 $82.22 $12.58 $33.52 $110.09 $111.20 $17.37 $0.00 $17.37 $18.87 $11.98 $11.98 $13.21 $11.98 $0.00 $0.00 $0.00 $0.00 30200967 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $280.00 $207.20 $8.39 $224.00 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $165.62 $165.62 $19.57 $33.64 $221.76 $224.00 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30200969 EAP CPT® 86337 Insulin Antibodies BOTH IP/OP $411.00 $304.14 $0.00 $328.80 $44.19 $44.19 $21.41 $21.41 $10.71 $10.71 $32.52 $32.52 $33.77 $21.41 $31.64 $13.92 $243.11 $243.11 $22.48 $59.84 $325.51 $328.80 $31.04 $35.33 $31.04 $0.00 $21.41 $21.41 $23.60 $21.41 $0.00 $0.00 $0.00 $0.00 30200976 EAP CPT® 86753 Protozoa Antibody Nos BOTH IP/OP $54.00 $39.96 $0.00 $54.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.81 $18.81 $19.54 $0.00 $18.31 $0.00 $0.00 $0.00 $0.00 $34.64 $43.56 $44.00 $0.00 $54.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200978 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $526.00 $389.24 $17.55 $424.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $311.13 $311.13 $36.84 $54.82 $419.76 $424.00 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30200980 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $301.00 $222.74 $8.39 $240.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $178.04 $178.04 $19.57 $33.64 $238.39 $240.80 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30200982 EAP CPT® 87471 Bartonella Dna Amp Probe BOTH IP/OP $441.00 $326.34 $0.00 $441.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.79 $29.79 $30.93 $0.00 $28.98 $0.00 $0.00 $0.00 $0.00 $54.82 $344.52 $348.00 $0.00 $441.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30200997 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $189.00 $139.86 $0.00 $151.20 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $111.79 $111.79 $19.57 $33.64 $149.69 $151.20 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30200999 EAP CPT® 86146 Glycoprotein Antibody BOTH IP/OP $93.00 $68.82 $0.00 $92.80 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $55.01 $55.01 $26.72 $71.08 $91.87 $92.80 $36.90 $0.00 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30201001 EAP CPT® 82143 Amniotic Fluid Scan BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.43 $10.43 $10.83 $0.00 $10.16 $0.00 $0.00 $0.00 $0.00 $19.22 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201003 EAP CPT® 87799 Detect Agent Nos Dna Quant BOTH IP/OP "$1,125.00 " $832.50 $0.00 "$1,121.00" $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $234.45 $27.85 $665.44 $665.44 $0.00 $119.70 "$1,018.51" "$1,028.80" $0.00 "$1,121.00" $0.00 $201.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201005 EAP CPT® 86615 Bordetella Antibody BOTH IP/OP $76.00 $56.24 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $60.98 $61.60 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201007 EAP CPT® 82523 Collagen Crosslinks BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $38.57 $38.57 $18.68 $18.68 $9.34 $9.34 $28.38 $28.38 $29.47 $18.68 $27.60 $12.14 $106.47 $106.47 $19.61 $52.22 $142.56 $144.00 $27.09 $0.00 $27.09 $29.41 $18.68 $18.68 $20.59 $18.68 $0.00 $0.00 $0.00 $0.00 30201009 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $186.00 $137.64 $0.00 $168.00 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $110.02 $110.02 $18.13 $36.18 $166.32 $168.00 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30201011 EAP CPT® 86160 Complement Antigen BOTH IP/OP $224.00 $165.76 $0.00 $206.40 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $132.50 $132.50 $12.60 $33.56 $204.34 $206.40 $17.40 $0.00 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30201013 EAP CPT® 86329 Immunodiffusion BOTH IP/OP $122.00 $90.28 $0.00 $120.00 $28.99 $28.99 $14.05 $14.05 $7.03 $0.00 $21.33 $21.33 $22.15 $0.00 $20.75 $0.00 $0.00 $0.00 $14.75 $39.24 $118.80 $120.00 $20.37 $0.00 $20.37 $22.11 $14.05 $14.05 $15.48 $14.05 $0.00 $0.00 $0.00 $0.00 30201015 EAP CPT® 86301 Immunoassay Tumor Ca 19-9 BOTH IP/OP $91.00 $67.34 $10.41 $73.60 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $53.83 $53.83 $21.85 $58.14 $72.86 $73.60 $30.17 $34.34 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30201017 EAP CPT® 86403 Particle Agglutination Test BOTH IP/OP $216.00 $159.84 $0.00 $172.80 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $127.76 $127.76 $12.12 $28.48 $171.07 $172.80 $16.73 $0.00 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30201019 EAP CPT® 80157 Assay Of Carbamazepine Free BOTH IP/OP $155.00 $114.70 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.13 $20.13 $20.91 $0.00 $14.69 $0.00 $0.00 $0.00 $0.00 $37.04 $122.76 $124.00 $0.00 $91.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201021 EAP CPT® 82375 Assay Carboxyhb Quant BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.37 $4.37 $4.54 $0.00 $4.25 $0.00 $0.00 $0.00 $0.00 $8.04 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201023 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP $172.00 $127.28 $0.00 $155.20 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $101.74 $101.74 $12.11 $29.88 $153.65 $155.20 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30201025 EAP CPT® 86147 Cariolipin Antibody BOTH IP/OP $53.00 $39.22 $0.00 $66.00 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $31.35 $31.35 $26.72 $66.00 $52.27 $52.80 $36.90 $0.00 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30201027 EAP CPT® 82384 Assay Three Catecholamines BOTH IP/OP $86.00 $63.64 $0.00 $70.56 $52.11 $52.11 $25.25 $25.25 $12.63 $12.63 $38.34 $38.34 $39.82 $25.25 $37.30 $16.41 $50.87 $50.87 $26.51 $70.56 $68.11 $68.80 $36.61 $0.00 $36.61 $39.74 $25.25 $25.25 $27.82 $25.25 $0.00 $0.00 $0.00 $0.00 30201028 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $20.11 $20.11 $5.44 $14.46 $26.93 $27.20 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201030 EAP CPT® 88184 Flowcytometry/tc 1 Marker BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $295.75 $295.75 $284.24 $133.74 $396.00 $400.00 $394.92 $0.00 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 30201031 EAP CPT® 88185 Flowcytometry/tc Add-on BOTH IP/OP $48.00 $35.52 $0.00 $50.81 $48.00 $48.00 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $28.39 $28.39 $0.00 $48.00 $38.02 $38.40 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 30201032 EAP CPT® 88187 Flowcytometry/read 2-8 BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $138.74 $0.00 $70.22 $0.00 $0.00 $0.00 $50.66 $130.50 $142.56 $144.00 $39.31 $0.00 $39.31 $74.83 $39.31 $39.31 $52.38 $39.31 $0.00 $0.00 $0.00 $0.00 30201034 EAP CPT® 82378 Carcinoembryinic Antigen BOTH IP/OP $58.00 $42.92 $0.00 $53.02 $39.15 $39.15 $18.96 $18.96 $9.48 $9.48 $28.81 $28.81 $29.92 $18.96 $28.02 $12.32 $34.31 $34.31 $19.91 $53.02 $47.52 $48.00 $27.49 $0.00 $27.49 $29.86 $18.96 $18.96 $20.90 $18.96 $0.00 $0.00 $0.00 $0.00 30201036 EAP CPT® 82378 Carcinoembryinic Antigen BOTH IP/OP $58.00 $42.92 $0.00 $53.02 $39.15 $39.15 $18.96 $18.96 $9.48 $9.48 $28.81 $28.81 $29.92 $18.96 $28.02 $12.32 $34.31 $34.31 $19.91 $53.02 $47.52 $48.00 $27.49 $0.00 $27.49 $29.86 $18.96 $18.96 $20.90 $18.96 $0.00 $0.00 $0.00 $0.00 30201038 EAP CPT® 86631 Chlamydia Antibody BOTH IP/OP $87.00 $64.38 $0.00 $87.00 $24.42 $24.42 $11.82 $11.82 $5.91 $5.91 $17.96 $17.96 $18.65 $11.82 $17.47 $7.68 $51.46 $51.46 $0.00 $33.04 $62.57 $63.20 $0.00 $87.00 $0.00 $18.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201039 EAP CPT® 86632 Chlamydia Igm Antibody BOTH IP/OP $82.00 $60.68 $0.00 $65.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.27 $19.27 $20.01 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $35.48 $64.94 $65.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201041 EAP CPT® 82480 Assay Serum Cholinesterase BOTH IP/OP $58.00 $42.92 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.97 $11.97 $12.43 $0.00 $11.64 $0.00 $0.00 $0.00 $0.00 $22.02 $45.94 $46.40 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201043 EAP CPT® 82495 Assay Of Chromium BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.79 $30.79 $31.98 $0.00 $29.97 $0.00 $0.00 $0.00 $0.00 $56.68 $76.82 $77.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201045 EAP CPT® 86316 Immunoassay Tumor Other BOTH IP/OP $293.00 $216.82 $0.00 $234.40 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $173.31 $173.31 $21.85 $58.14 $232.06 $234.40 $30.17 $0.00 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30201049 EAP CPT® 86157 Cold Agglutinin Titer BOTH IP/OP $24.00 $17.76 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.24 $12.24 $12.71 $0.00 $11.91 $0.00 $0.00 $0.00 $0.00 $22.54 $19.01 $19.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201051 EAP CPT® 82523 Collagen Crosslinks BOTH IP/OP $99.00 $73.26 $9.34 $79.20 $38.57 $38.57 $18.68 $18.68 $9.34 $9.34 $28.38 $28.38 $29.47 $18.68 $27.60 $12.14 $58.56 $58.56 $19.61 $52.22 $78.41 $79.20 $27.09 $30.82 $27.09 $29.41 $18.68 $18.68 $20.59 $18.68 $0.00 $0.00 $0.00 $0.00 30201053 EAP CPT® 86160 Complement Antigen BOTH IP/OP $224.00 $165.76 $0.00 $206.40 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $132.50 $132.50 $12.60 $33.56 $204.34 $206.40 $17.40 $0.00 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30201055 EAP CPT® 86160 Complement Antigen BOTH IP/OP $200.00 $148.00 $0.00 $184.80 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $118.30 $118.30 $12.60 $33.56 $182.95 $184.80 $17.40 $0.00 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30201057 EAP CPT® 86160 Complement Antigen BOTH IP/OP $230.00 $170.20 $0.00 $212.00 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $136.05 $136.05 $12.60 $33.56 $209.88 $212.00 $17.40 $0.00 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30201059 EAP CPT® 86160 Complement Antigen BOTH IP/OP $230.00 $170.20 $0.00 $212.00 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $136.05 $136.05 $12.60 $33.56 $209.88 $212.00 $17.40 $0.00 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30201061 EAP CPT® 86160 Complement Antigen BOTH IP/OP $224.00 $165.76 $0.00 $206.40 $24.76 $24.76 $12.00 $12.00 $6.00 $6.00 $18.23 $18.23 $18.93 $12.00 $17.73 $7.80 $132.50 $132.50 $12.60 $33.56 $204.34 $206.40 $17.40 $0.00 $17.40 $18.90 $12.00 $12.00 $13.23 $12.00 $0.00 $0.00 $0.00 $0.00 30201063 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP $686.00 $507.64 $8.28 $533.60 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $405.77 $405.77 $19.32 $37.76 $528.26 $533.60 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30201065 EAP CPT® 82530 Cortisol Free BOTH IP/OP $180.00 $133.20 $8.36 $145.60 $34.48 $34.48 $16.71 $16.71 $8.36 $8.36 $25.39 $25.39 $26.36 $16.71 $24.70 $10.86 $106.47 $106.47 $17.55 $46.70 $144.14 $145.60 $24.23 $27.57 $24.23 $26.31 $16.71 $16.71 $18.42 $16.71 $0.00 $0.00 $0.00 $0.00 30201067 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $150.00 $111.00 $8.39 $120.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $88.73 $88.73 $19.57 $33.64 $119.59 $120.80 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201069 EAP CPT® 82552 Assay Of Cpk In Blood BOTH IP/OP $61.00 $45.14 $0.00 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.34 $20.34 $21.12 $0.00 $19.78 $0.00 $0.00 $0.00 $0.00 $37.42 $48.31 $48.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201071 EAP CPT® 86343 Leukocyte Histamine Release BOTH IP/OP $386.00 $285.64 $0.00 $308.80 $25.71 $25.71 $12.46 $12.46 $6.23 $6.23 $18.93 $18.93 $19.66 $12.46 $18.41 $8.10 $228.32 $228.32 $0.00 $34.82 $305.71 $308.80 $0.00 $20.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201073 EAP CPT® 84443 Assay Thyroid Stim Hormone BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $34.69 $34.69 $16.80 $16.80 $8.40 $8.40 $25.51 $25.51 $26.49 $16.80 $24.81 $10.92 $86.36 $86.36 $17.64 $46.94 $115.63 $116.80 $24.36 $0.00 $24.36 $26.44 $16.80 $16.80 $18.51 $16.80 $0.00 $0.00 $0.00 $0.00 30201074 EAP CPT® 86343 Leukocyte Histamine Release BOTH IP/OP $204.00 $150.96 $0.00 $163.20 $25.71 $25.71 $12.46 $12.46 $6.23 $6.23 $18.93 $18.93 $19.66 $12.46 $18.41 $8.10 $120.67 $120.67 $0.00 $34.82 $161.57 $163.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201075 EAP CPT® 86376 Microsomal Antibody BOTH IP/OP $108.00 $79.92 $0.00 $86.40 $30.04 $30.04 $14.55 $14.55 $7.28 $7.28 $22.10 $22.10 $22.95 $14.55 $21.49 $9.46 $63.88 $63.88 $15.28 $40.66 $85.54 $86.40 $21.10 $0.00 $21.10 $22.90 $14.55 $14.55 $16.03 $14.55 $0.00 $0.00 $0.00 $0.00 30201076 EAP CPT® 86800 Thyroglobulin Antibody BOTH IP/OP $272.00 $201.28 $0.00 $217.60 $32.84 $32.84 $15.91 $15.91 $7.96 $7.95 $24.15 $24.15 $25.08 $15.91 $23.50 $10.34 $160.89 $160.89 $16.71 $44.44 $215.42 $217.60 $23.07 $0.00 $23.07 $25.04 $15.91 $15.91 $17.53 $15.91 $0.00 $0.00 $0.00 $0.00 30201078 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $227.00 $167.98 $0.00 $181.60 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $134.27 $134.27 $19.57 $33.64 $179.78 $181.60 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201080 EAP CPT® 86682 Helminth Antibody BOTH IP/OP $179.00 $132.46 $6.50 $144.80 $26.85 $26.85 $13.01 $13.01 $6.51 $6.50 $19.75 $19.75 $20.51 $13.01 $19.20 $8.46 $105.88 $105.88 $13.66 $36.34 $143.35 $144.80 $18.86 $21.47 $18.86 $20.46 $13.01 $13.01 $14.32 $13.01 $0.00 $0.00 $0.00 $0.00 30201082 EAP CPT® 82135 Assay Aminolevulinic Acid BOTH IP/OP $164.00 $121.36 $0.00 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $25.00 $25.96 $0.00 $24.32 $0.00 $0.00 $0.00 $0.00 $46.00 $129.89 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201084 EAP CPT® 82135 Assay Aminolevulinic Acid BOTH IP/OP $164.00 $121.36 $0.00 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $25.00 $25.96 $0.00 $24.32 $0.00 $0.00 $0.00 $0.00 $46.00 $129.89 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201086 EAP CPT® 86790 Virus Antibody Nos BOTH IP/OP $267.00 $197.58 $6.44 $195.20 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $157.93 $157.93 $13.52 $36.00 $193.25 $195.20 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30201088 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $118.89 $118.89 $19.57 $33.64 $159.19 $160.80 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201090 EAP CPT® 82533 Total Cortisol BOTH IP/OP $367.00 $271.58 $0.00 $293.60 $33.66 $33.66 $16.30 $16.30 $8.15 $8.15 $24.76 $24.76 $25.71 $16.30 $24.09 $10.60 $217.08 $217.08 $17.12 $45.56 $290.66 $293.60 $23.64 $0.00 $23.64 $25.67 $16.30 $16.30 $17.97 $16.30 $0.00 $0.00 $0.00 $0.00 30201092 EAP CPT® 86648 Diptheria Antibody BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.10 $23.10 $23.99 $0.00 $22.47 $0.00 $0.00 $0.00 $0.00 $42.50 $76.82 $77.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201093 EAP CPT® 86774 Tetanus Antibody BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.47 $22.47 $23.34 $0.00 $21.86 $0.00 $0.00 $0.00 $15.54 $41.36 $68.90 $69.60 $21.46 $0.00 $21.46 $23.29 $14.80 $14.80 $16.31 $14.80 $0.00 $0.00 $0.00 $0.00 30201097 EAP CPT® 80307 Drug Screen Single BOTH IP/OP $35.00 $25.90 $0.00 $82.57 $35.00 $35.00 $0.00 $0.00 $6.23 $29.09 $79.51 $79.51 $82.57 $0.00 $7.29 $0.00 $20.70 $20.70 $0.00 $37.50 $59.40 $60.00 $75.00 $0.00 $75.00 $76.56 $62.14 $62.14 $53.59 $0.00 $0.00 $0.00 $0.00 $0.00 30201105 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $282.00 $208.68 $8.39 $225.60 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $166.80 $166.80 $19.57 $33.64 $223.34 $225.60 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201107 EAP CPT® 82438 Assay Other Fluid Chlorides BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.43 $7.43 $7.71 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $13.66 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201108 EAP CPT® 84302 Assay Of Sweat Sodium BOTH IP/OP $114.00 $84.36 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $5.25 $5.45 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $9.66 $95.04 $96.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201109 EAP CPT® 84311 Spectrophotometry BOTH IP/OP $72.00 $53.28 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $71.28 $72.00 $11.75 $0.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30201111 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $124.00 $91.76 $6.03 $124.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $73.35 $73.35 $12.65 $33.68 $122.76 $124.00 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201113 EAP CPT® 87337 Entamoeb Hist Group Ag Eia BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $24.74 $24.74 $11.98 $11.98 $5.99 $5.99 $18.22 $18.22 $18.92 $11.98 $17.71 $7.79 $52.64 $52.64 $12.58 $33.52 $70.49 $71.20 $17.37 $0.00 $17.37 $18.87 $11.98 $11.98 $13.21 $11.98 $0.00 $0.00 $0.00 $0.00 30201115 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $311.00 $230.14 $0.00 $300.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $183.96 $183.96 $36.84 $54.82 $297.00 $300.00 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201117 EAP CPT® 87799 Detect Agent Nos Dna Quant BOTH IP/OP $779.00 $576.46 $0.00 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $162.34 $27.85 $460.78 $460.78 $0.00 $119.70 $704.88 $712.00 $0.00 $0.00 $0.00 $139.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201119 EAP CPT® 84202 Assay Rbc Protoporphyrin BOTH IP/OP $24.00 $17.76 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.79 $21.79 $22.63 $0.00 $21.20 $0.00 $0.00 $0.00 $0.00 $24.00 $19.01 $19.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201121 EAP CPT® 82672 Assay Of Estrogen BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.29 $25.29 $26.27 $0.00 $24.60 $0.00 $0.00 $0.00 $0.00 $46.54 $103.75 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201129 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $105.29 $105.29 $22.49 $59.86 $140.98 $142.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201130 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $139.00 $139.00 $53.75 $112.22 $186.12 $188.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201133 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $136.05 $136.05 $22.49 $59.86 $182.16 $184.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201134 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $293.00 $216.82 $0.00 $234.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $173.31 $173.31 $53.75 $112.22 $232.06 $234.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201137 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $128.95 $128.95 $22.49 $59.86 $172.66 $174.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201138 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $282.00 $208.68 $0.00 $225.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $166.80 $166.80 $53.75 $112.22 $223.34 $225.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201147 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $279.00 $206.46 $8.39 $223.20 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $165.03 $165.03 $19.57 $33.64 $220.97 $223.20 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201151 EAP CPT® 83789 Mass Spectrometry Quant BOTH IP/OP $104.00 $76.96 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $82.37 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201153 EAP CPT® 86001 Allergen Specific Igg BOTH IP/OP $196.00 $145.04 $0.00 $195.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.92 $7.92 $8.23 $0.00 $7.72 $0.00 $0.00 $0.00 $0.00 $14.60 $193.25 $195.20 $0.00 $149.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201155 EAP CPT® 82679 Assay Of Estrone BOTH IP/OP $35.00 $25.90 $0.00 $39.37 $35.00 $35.00 $24.95 $24.95 $12.48 $12.48 $37.91 $37.91 $39.37 $24.95 $35.00 $16.22 $20.70 $20.70 $26.20 $35.00 $27.72 $28.00 $35.00 $0.00 $35.00 $39.29 $24.95 $24.95 $27.50 $24.95 $0.00 $0.00 $0.00 $0.00 30201156 EAP CPT® 82670 Assay Of Estradiol BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.96 $146.96 $152.62 $0.00 $26.26 $0.00 $0.00 $0.00 $29.34 $78.08 $156.82 $158.40 $40.51 $100.00 $40.51 $43.98 $27.94 $27.94 $30.79 $27.94 $0.00 $0.00 $0.00 $0.00 30201157 EAP CPT® 82677 Assay Of Estriol BOTH IP/OP $35.00 $25.90 $0.00 $38.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.72 $36.72 $38.13 $0.00 $35.00 $0.00 $0.00 $0.00 $25.39 $35.00 $27.72 $28.00 $35.00 $0.00 $35.00 $38.06 $24.18 $24.18 $26.64 $24.18 $0.00 $0.00 $0.00 $0.00 30201159 EAP CPT® 83883 Assay Nephelometry Not Spec BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $28.06 $28.06 $13.60 $13.60 $6.80 $6.80 $20.64 $20.64 $21.44 $13.60 $20.09 $8.84 $125.99 $125.99 $14.28 $38.00 $168.70 $170.40 $19.72 $0.00 $19.72 $21.40 $13.60 $13.60 $14.98 $13.60 $0.00 $0.00 $0.00 $0.00 30201165 EAP CPT® 83727 Assay Of Irh Hormone BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.10 $26.10 $27.11 $0.00 $25.40 $0.00 $0.00 $0.00 $0.00 $48.04 $997.92 "$1,008.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201167 EAP CPT® 87338 Hpylori Stool Eia BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.84 $21.84 $22.68 $0.00 $21.25 $0.00 $0.00 $0.00 $0.00 $40.20 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201169 EAP CPT® 86684 Hemophilus Influenza BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.06 $24.06 $24.98 $0.00 $23.42 $0.00 $0.00 $0.00 $0.00 $44.28 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201171 EAP CPT® 84702 Chorionic Gonadotropin Test BOTH IP/OP $162.00 $119.88 $7.07 $117.60 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $95.82 $95.82 $15.80 $17.94 $116.42 $117.60 $21.82 $24.83 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30201173 EAP CPT® 82175 Assay Of Arsenic BOTH IP/OP $43.00 $31.82 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.49 $28.81 $28.81 $29.92 $18.97 $28.02 $12.33 $25.43 $25.43 $19.92 $43.00 $34.06 $34.40 $27.51 $0.00 $27.51 $0.00 $18.97 $18.97 $20.90 $18.97 $0.00 $0.00 $0.00 $0.00 30201174 EAP CPT® 83655 Assay Of Lead BOTH IP/OP $54.00 $39.96 $0.00 $43.20 $25.00 $25.00 $12.11 $12.11 $6.06 $6.05 $18.38 $18.38 $19.08 $12.11 $11.75 $7.87 $31.94 $31.94 $12.72 $33.82 $42.77 $43.20 $17.56 $0.00 $17.56 $12.52 $12.11 $12.11 $8.76 $12.11 $0.00 $0.00 $0.00 $0.00 30201175 EAP CPT® 83825 Assay Of Mercury BOTH IP/OP $38.00 $28.12 $0.00 $38.00 $33.55 $33.55 $16.26 $16.26 $8.13 $8.13 $24.69 $24.69 $25.64 $16.26 $24.02 $10.57 $22.48 $22.48 $17.07 $38.00 $30.10 $30.40 $23.58 $0.00 $23.58 $0.00 $16.26 $16.26 $17.92 $16.26 $0.00 $0.00 $0.00 $0.00 30201177 EAP CPT® 82175 Assay Of Arsenic BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $0.00 $9.49 $28.81 $28.81 $29.92 $18.97 $28.02 $12.33 $40.81 $40.81 $19.92 $53.02 $54.65 $55.20 $27.51 $0.00 $27.51 $0.00 $18.97 $18.97 $20.90 $18.97 $0.00 $0.00 $0.00 $0.00 30201178 EAP CPT® 82300 Assay Of Cadmium BOTH IP/OP $75.00 $55.50 $0.00 $64.66 $47.78 $47.78 $23.64 $23.64 $11.82 $11.57 $35.14 $35.14 $36.49 $23.64 $34.19 $15.37 $44.36 $44.36 $0.00 $64.66 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201179 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $91.00 $67.34 $0.00 $72.80 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $53.83 $53.83 $5.44 $14.46 $72.07 $72.80 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201180 EAP CPT® 83655 Assay Of Lead BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $25.00 $25.00 $12.11 $12.11 $6.06 $6.05 $18.38 $18.38 $19.08 $12.11 $11.75 $7.87 $44.95 $44.95 $12.72 $33.82 $60.19 $60.80 $17.56 $0.00 $17.56 $12.52 $12.11 $12.11 $8.76 $12.11 $0.00 $0.00 $0.00 $0.00 30201181 EAP CPT® 83825 Assay Of Mercury BOTH IP/OP $62.00 $45.88 $0.00 $49.60 $33.55 $33.55 $16.26 $16.26 $8.13 $8.13 $24.69 $24.69 $25.64 $16.26 $24.02 $10.57 $36.67 $36.67 $17.07 $45.44 $49.10 $49.60 $23.58 $0.00 $23.58 $0.00 $16.26 $16.26 $17.92 $16.26 $0.00 $0.00 $0.00 $0.00 30201183 EAP CPT® 86804 Hep C Ab Test Confirm BOTH IP/OP $396.00 $293.04 $0.00 $330.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.51 $23.51 $24.42 $0.00 $22.88 $0.00 $0.00 $0.00 $0.00 $43.28 $327.10 $330.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201185 EAP CPT® 87299 Antibody Detection Nos If BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201187 EAP CPT® 86970 Rbc Pretreatment BOTH IP/OP $510.00 $377.40 $0.00 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.59 $16.59 $17.23 $0.00 $106.28 $0.00 $0.00 $0.00 $0.00 $37.22 $434.02 $438.40 $0.00 $193.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201189 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $436.00 $322.64 $0.00 $420.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $257.89 $257.89 $36.84 $54.82 $415.80 $420.00 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201191 EAP CPT® 86698 Histoplasma BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $18.98 $18.98 $19.71 $13.79 $18.46 $8.96 $42.59 $42.59 $14.48 $34.92 $57.02 $57.60 $20.00 $0.00 $20.00 $19.67 $13.79 $13.79 $13.77 $13.79 $0.00 $0.00 $0.00 $0.00 30201193 EAP CPT® 86689 Htlv/hiv Confirmatory Test BOTH IP/OP $143.00 $105.82 $0.00 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $24.81 $0.00 $0.00 $0.00 $0.00 $54.10 $117.22 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201195 EAP CPT® 86702 Hiv-2 BOTH IP/OP $135.00 $99.90 $0.00 $112.80 $27.90 $27.90 $13.52 $13.52 $6.76 $6.76 $20.53 $20.53 $21.32 $13.52 $17.33 $8.79 $79.85 $79.85 $14.20 $37.76 $111.67 $112.80 $19.60 $0.00 $19.60 $18.46 $13.52 $13.52 $12.92 $13.52 $0.00 $0.00 $0.00 $0.00 30201202 EAP CPT® 83090 Assay Of Homocystine BOTH IP/OP $231.00 $170.94 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $182.95 $184.80 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201204 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $54.00 $39.96 $0.00 $43.20 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $31.94 $31.94 $5.44 $14.46 $42.77 $43.20 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201205 EAP CPT® 82150 Assay Of Amylase BOTH IP/OP $101.00 $74.74 $0.00 $87.20 $13.38 $13.38 $6.48 $6.48 $3.24 $3.24 $9.84 $9.84 $10.22 $6.48 $9.58 $4.21 $59.74 $59.74 $6.80 $18.12 $86.33 $87.20 $9.40 $0.00 $9.40 $10.20 $6.48 $6.48 $7.14 $6.48 $0.00 $0.00 $0.00 $0.00 30201207 EAP CPT® 87529 Hsv Dna Amp Probe BOTH IP/OP $188.00 $139.12 $17.55 $155.20 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $111.20 $111.20 $36.84 $54.82 $153.65 $155.20 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201209 EAP CPT® 87530 Hsv Dna Quant BOTH IP/OP $248.00 $183.52 $0.00 $204.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.04 $65.04 $67.54 $0.00 $51.68 $0.00 $0.00 $0.00 $0.00 $119.70 $202.75 $204.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201211 EAP CPT® 87532 Hhv-6 Dna Amp Probe BOTH IP/OP $343.00 $253.82 $0.00 $343.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.79 $29.79 $30.93 $0.00 $28.98 $0.00 $0.00 $0.00 $0.00 $54.82 $263.74 $266.40 $0.00 $343.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201213 EAP CPT® 83632 Placental Lactogen BOTH IP/OP $484.00 $358.16 $0.00 $352.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.69 $30.69 $31.87 $0.00 $29.86 $0.00 $0.00 $0.00 $0.00 $56.48 $349.27 $352.80 $0.00 $321.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201220 EAP CPT® 86331 Immunodiffusion Ouchterlony BOTH IP/OP $19.00 $14.06 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.20 $18.20 $18.90 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $19.00 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201221 EAP CPT® 86606 Aspergillus Antibody BOTH IP/OP $27.00 $19.98 $0.00 $27.00 $27.00 $27.00 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $15.97 $15.97 $15.80 $27.00 $21.38 $21.60 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30201222 EAP CPT® 86744 Nocardia Antibody BOTH IP/OP $24.00 $17.76 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $24.00 $19.01 $19.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201224 EAP CPT® 86341 Islet Cell Antibody BOTH IP/OP $195.00 $144.30 $10.61 $154.40 $40.84 $40.84 $23.57 $23.57 $11.79 $10.61 $30.05 $30.05 $31.20 $23.57 $29.24 $15.32 $115.34 $115.34 $24.75 $55.30 $152.86 $154.40 $34.18 $38.89 $34.18 $31.16 $23.57 $23.57 $21.81 $23.57 $0.00 $0.00 $0.00 $0.00 30201226 EAP CPT® 82784 Assay Iga/igd/igg/igm Each BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $19.19 $19.19 $9.30 $9.30 $4.65 $4.65 $14.12 $14.12 $14.67 $9.30 $13.73 $6.05 $20.11 $20.11 $9.77 $25.98 $26.93 $27.20 $13.49 $0.00 $13.49 $14.63 $9.30 $9.30 $10.24 $9.30 $0.00 $0.00 $0.00 $0.00 30201227 EAP CPT® 82787 Igg 1 2 3 Or 4 Each BOTH IP/OP $28.00 $20.72 $4.01 $22.40 $16.55 $16.55 $8.02 $8.02 $4.01 $4.01 $12.18 $12.18 $12.65 $8.02 $11.84 $5.21 $16.56 $16.56 $8.42 $22.40 $22.18 $22.40 $11.63 $13.23 $11.63 $12.62 $8.02 $8.02 $8.83 $8.02 $0.00 $0.00 $0.00 $0.00 30201229 EAP CPT® 86336 Inhibin A BOTH IP/OP $128.00 $94.72 $0.00 $102.40 $26.74 $26.74 $15.59 $15.59 $7.80 $7.79 $19.66 $19.66 $20.41 $15.59 $19.12 $10.13 $75.71 $75.71 $16.37 $36.18 $101.38 $102.40 $22.61 $0.00 $22.61 $20.37 $15.59 $15.59 $14.26 $15.59 $0.00 $0.00 $0.00 $0.00 30201231 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $383.00 $283.42 $7.77 $345.60 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $226.54 $226.54 $18.13 $36.18 $342.14 $345.60 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30201233 EAP CPT® 83789 Mass Spectrometry Quant BOTH IP/OP $116.00 $85.84 $0.00 $92.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $91.87 $92.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201235 EAP CPT® 86886 Coombs Test Indirect Titer BOTH IP/OP $163.00 $120.62 $0.00 $163.00 $9.58 $9.58 $145.24 $145.24 $146.06 $2.59 $7.06 $7.06 $7.33 $142.96 $6.87 $92.92 $96.41 $96.41 $143.92 $13.00 $129.10 $130.40 $163.00 $0.00 $163.00 $7.32 $5.18 $5.18 $5.12 $137.07 $0.00 $0.00 $0.00 $0.00 30201236 EAP CPT® 86900 "Blood Typing, Serologic, Abo" BOTH IP/OP $312.00 $230.88 $1.49 $262.40 $6.18 $6.18 $109.81 $109.81 $110.43 $1.49 $4.52 $4.52 $4.70 $107.30 $4.41 $69.74 $184.55 $184.55 $109.35 $8.34 $259.78 $262.40 $151.93 $159.90 $151.93 $4.70 $2.99 $2.99 $3.29 $104.14 $0.00 $0.00 $0.00 $0.00 30201238 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $209.00 $154.66 $8.39 $168.00 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $123.62 $123.62 $19.57 $33.64 $166.32 $168.00 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201248 EAP CPT® 83630 Lactoferrin Fecal (qual) BOTH IP/OP $164.00 $121.36 $0.00 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.81 $29.81 $30.95 $0.00 $15.80 $0.00 $0.00 $0.00 $0.00 $54.84 $129.89 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201250 EAP CPT® 87278 Legion Pneumophilia Ag If BOTH IP/OP $148.00 $109.52 $0.00 $118.40 $24.74 $24.74 $15.60 $15.60 $7.80 $7.02 $18.22 $18.22 $18.92 $15.60 $17.71 $10.14 $87.54 $87.54 $0.00 $33.52 $117.22 $118.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201252 EAP CPT® 86717 Leishmania Antibody BOTH IP/OP $149.00 $110.26 $0.00 $120.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.61 $18.61 $19.32 $0.00 $18.10 $0.00 $0.00 $0.00 $0.00 $34.24 $119.59 $120.80 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201254 EAP CPT® 83690 Assay Of Lipase BOTH IP/OP $83.00 $61.42 $3.44 $67.20 $14.23 $14.23 $6.89 $6.89 $3.45 $3.44 $10.46 $10.46 $10.86 $6.89 $10.17 $4.48 $49.09 $49.09 $7.23 $19.24 $66.53 $67.20 $9.99 $11.37 $9.99 $10.84 $6.89 $6.89 $7.59 $6.89 $0.00 $0.00 $0.00 $0.00 30201256 EAP CPT® 83695 Assay Of Lipoprotein(a) BOTH IP/OP $109.00 $80.66 $6.48 $87.20 $26.72 $26.72 $14.32 $14.32 $7.16 $6.48 $19.67 $19.67 $20.42 $14.32 $19.12 $9.31 $64.47 $64.47 $15.04 $36.18 $86.33 $87.20 $20.76 $23.63 $20.76 $20.37 $14.32 $14.32 $14.26 $14.32 $0.00 $0.00 $0.00 $0.00 30201258 EAP CPT® 82465 Assay Bld/serum Cholesterol BOTH IP/OP $9.00 $6.66 $0.00 $9.00 $8.98 $8.98 $4.35 $4.35 $2.18 $2.18 $6.61 $6.61 $6.87 $4.35 $6.43 $2.83 $5.32 $5.32 $4.57 $9.00 $7.13 $7.20 $6.31 $0.00 $6.31 $6.85 $4.35 $4.35 $4.79 $4.35 $0.00 $0.00 $0.00 $0.00 30201259 EAP CPT® 82664 Electrophoretic Test BOTH IP/OP $176.00 $130.24 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.17 $52.17 $54.17 $0.00 $50.75 $0.00 $0.00 $0.00 $64.58 $96.00 $149.69 $151.20 $89.18 $0.00 $89.18 $54.07 $61.50 $61.50 $37.85 $61.50 $0.00 $0.00 $0.00 $0.00 30201260 EAP CPT® 84478 Assay Of Triglycerides BOTH IP/OP $16.00 $11.84 $0.00 $16.08 $11.85 $11.85 $5.74 $5.74 $2.87 $2.87 $8.74 $8.74 $9.07 $5.74 $7.46 $3.73 $9.46 $9.46 $6.03 $16.08 $14.26 $14.40 $8.32 $0.00 $8.32 $7.94 $5.74 $5.74 $5.56 $5.74 $0.00 $0.00 $0.00 $0.00 30201261 EAP CPT® 84999 Clinical Chemistry Test BOTH IP/OP $23.00 $17.02 $0.00 $19.20 $0.00 $0.00 $0.00 $0.00 $4.09 $0.00 $17.07 $17.07 $17.73 $0.00 $4.79 $0.00 $0.00 $0.00 $0.00 $0.00 $19.01 $19.20 $0.00 $0.00 $0.00 $3.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201263 EAP CPT® 86609 Bacterium Antibody BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $103.51 $103.51 $0.00 $36.00 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201265 EAP CPT® 86376 Microsomal Antibody BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $30.04 $30.04 $14.55 $14.55 $7.28 $7.28 $22.10 $22.10 $22.95 $14.55 $21.49 $9.46 $121.26 $121.26 $15.28 $40.66 $162.36 $164.00 $21.10 $0.00 $21.10 $22.90 $14.55 $14.55 $16.03 $14.55 $0.00 $0.00 $0.00 $0.00 30201267 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP $107.00 $79.18 $0.00 $96.80 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $63.29 $63.29 $12.11 $29.88 $95.83 $96.80 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30201268 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $118.00 $87.32 $0.00 $106.40 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $69.80 $69.80 $18.13 $36.18 $105.34 $106.40 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30201269 EAP CPT® 86038 Antinuclear Antibodies BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $24.95 $24.95 $12.09 $12.09 $6.05 $6.04 $18.36 $18.36 $19.06 $12.09 $17.86 $7.86 $42.59 $42.59 $12.69 $33.78 $57.02 $57.60 $17.53 $0.00 $17.53 $19.03 $12.09 $12.09 $13.32 $12.09 $0.00 $0.00 $0.00 $0.00 30201270 EAP CPT® 84160 Assay Of Protein Any Source BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.86 $7.86 $8.16 $0.00 $7.64 $0.00 $0.00 $0.00 $0.00 $14.46 $102.17 $103.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201271 EAP CPT® 86235 Nuclear Antigen Antibody BOTH IP/OP $76.00 $56.24 $0.00 $74.40 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $44.95 $44.95 $18.83 $50.12 $73.66 $74.40 $26.00 $0.00 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30201272 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $61.00 $45.14 $0.00 $60.80 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $36.08 $36.08 $12.65 $33.68 $60.19 $60.80 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201273 EAP CPT® 86376 Microsomal Antibody BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $30.04 $30.04 $14.55 $14.55 $7.28 $7.28 $22.10 $22.10 $22.95 $14.55 $21.49 $9.46 $33.72 $33.72 $15.28 $40.66 $45.14 $45.60 $21.10 $0.00 $21.10 $22.90 $14.55 $14.55 $16.03 $14.55 $0.00 $0.00 $0.00 $0.00 30201274 EAP CPT® 86431 Rheumatoid Factor Quant BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $11.70 $11.70 $5.67 $5.67 $2.84 $2.84 $8.62 $8.62 $8.95 $5.67 $8.39 $3.69 $57.38 $57.38 $5.95 $15.86 $76.82 $77.60 $8.22 $0.00 $8.22 $8.94 $5.67 $5.67 $6.26 $5.67 $0.00 $0.00 $0.00 $0.00 30201276 EAP CPT® 86618 Lyme Disease Antibody BOTH IP/OP $69.00 $51.06 $8.51 $56.00 $35.16 $35.16 $17.03 $17.03 $8.52 $8.51 $25.86 $25.86 $26.86 $17.03 $25.16 $11.07 $40.81 $40.81 $17.88 $47.60 $55.44 $56.00 $24.69 $28.10 $24.69 $26.81 $17.03 $17.03 $18.76 $17.03 $0.00 $0.00 $0.00 $0.00 30201278 EAP CPT® 87476 Lyme Dis Dna Amp Probe BOTH IP/OP $387.00 $286.38 $0.00 $309.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.79 $29.79 $30.93 $0.00 $28.98 $0.00 $0.00 $0.00 $0.00 $54.82 $306.50 $309.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201280 EAP CPT® 87476 Lyme Dis Dna Amp Probe BOTH IP/OP $387.00 $286.38 $0.00 $309.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.79 $29.79 $30.93 $0.00 $28.98 $0.00 $0.00 $0.00 $0.00 $54.82 $306.50 $309.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201282 EAP CPT® 86355 B Cells Total Count BOTH IP/OP $111.00 $82.14 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $91.08 $92.00 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30201283 EAP CPT® 86357 Nk Cells Total Count BOTH IP/OP $111.00 $82.14 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $91.08 $92.00 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30201284 EAP CPT® 86359 T Cells Total Count BOTH IP/OP $111.00 $82.14 $0.00 $92.00 $48.63 $48.63 $37.73 $37.73 $18.87 $18.86 $35.77 $35.77 $37.14 $37.73 $34.80 $24.52 $65.66 $65.66 $39.62 $65.82 $91.08 $92.00 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30201285 EAP CPT® 86360 T Cell Absolute Count/ratio BOTH IP/OP $152.00 $112.48 $0.00 $131.30 $96.99 $96.99 $46.98 $46.98 $23.49 $23.49 $71.34 $71.34 $74.09 $46.98 $69.42 $30.54 $89.91 $89.91 $49.33 $131.30 $125.14 $126.40 $68.12 $0.00 $68.12 $73.96 $46.98 $46.98 $51.77 $46.98 $0.00 $0.00 $0.00 $0.00 30201286 EAP Custom 30201286 Mac Sensitivity BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201287 EAP CPT® 87190 Microbe Suscept Mycobacteri BOTH IP/OP $35.00 $25.90 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.58 $8.58 $8.91 $0.00 $8.35 $0.00 $0.00 $0.00 $0.00 $15.80 $25.34 $25.60 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201289 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $266.00 $196.84 $0.00 $212.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $157.34 $157.34 $22.49 $59.86 $210.67 $212.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201290 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $192.24 $192.24 $53.75 $112.22 $257.40 $260.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201295 EAP CPT® 83825 Assay Of Mercury BOTH IP/OP $50.00 $37.00 $0.00 $45.44 $33.55 $33.55 $16.26 $16.26 $8.13 $8.13 $24.69 $24.69 $25.64 $16.26 $24.02 $10.57 $29.58 $29.58 $17.07 $45.44 $39.60 $40.00 $23.58 $0.00 $23.58 $0.00 $16.26 $16.26 $17.92 $16.26 $0.00 $0.00 $0.00 $0.00 30201297 EAP CPT® 83825 Assay Of Mercury BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.55 $33.55 $16.26 $16.26 $8.13 $8.13 $24.69 $24.69 $25.64 $16.26 $24.02 $10.57 $44.36 $44.36 $17.07 $45.44 $59.40 $60.00 $23.58 $0.00 $23.58 $0.00 $16.26 $16.26 $17.92 $16.26 $0.00 $0.00 $0.00 $0.00 30201299 EAP CPT® 83835 Assay Of Metanephrines BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $34.98 $34.98 $16.94 $16.94 $8.47 $8.47 $25.73 $25.73 $26.72 $16.94 $25.02 $11.01 $136.05 $136.05 $17.79 $47.34 $182.16 $184.00 $24.56 $0.00 $24.56 $26.66 $16.94 $16.94 $18.66 $16.94 $0.00 $0.00 $0.00 $0.00 30201300 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $30.76 $30.76 $5.44 $14.46 $41.18 $41.60 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201302 EAP CPT® 83835 Assay Of Metanephrines BOTH IP/OP $573.00 $424.02 $8.47 $458.40 $34.98 $34.98 $16.94 $16.94 $8.47 $8.47 $25.73 $25.73 $26.72 $16.94 $25.02 $11.01 $338.93 $338.93 $17.79 $47.34 $453.82 $458.40 $24.56 $27.95 $24.56 $26.66 $16.94 $16.94 $18.66 $16.94 $0.00 $0.00 $0.00 $0.00 30201304 EAP CPT® 80358 Assay Of Methadone BOTH IP/OP $187.00 $138.38 $0.00 $158.40 $0.03 $0.03 $0.00 $0.00 $12.01 $10.03 $138.79 $138.79 $144.14 $0.00 $24.12 $0.00 $110.61 $110.61 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201306 EAP CPT® 82542 Column Chromotography Quant BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $37.28 $37.28 $24.09 $24.09 $12.05 $10.84 $9.12 $9.12 $9.47 $24.09 $8.87 $15.66 $170.35 $170.35 $25.29 $16.78 $228.10 $230.40 $34.93 $0.00 $34.93 $9.45 $24.09 $24.09 $6.62 $24.09 $0.00 $0.00 $0.00 $0.00 30201310 EAP CPT® 83921 Organic Acid Single Quant BOTH IP/OP $289.00 $213.86 $0.00 $231.20 $33.95 $33.95 $21.21 $21.21 $10.61 $9.54 $25.00 $25.00 $25.96 $21.21 $24.32 $13.79 $170.94 $170.94 $22.27 $46.00 $228.89 $231.20 $30.75 $0.00 $30.75 $25.91 $21.21 $21.21 $18.14 $21.21 $0.00 $0.00 $0.00 $0.00 30201312 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP "$1,254.00 " $927.96 $8.28 "$1,132.00" $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $741.74 $741.74 $19.32 $37.76 "$1,120.68" "$1,132.00" $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30201314 EAP CPT® 87190 Microbe Suscept Mycobacteri BOTH IP/OP $41.00 $30.34 $0.00 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.58 $8.58 $8.91 $0.00 $8.35 $0.00 $0.00 $0.00 $0.00 $15.80 $32.47 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201316 EAP CPT® 87581 M.pneumon Dna Probe BOTH IP/OP $505.00 $373.70 $0.00 $417.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $298.71 $298.71 $0.00 $54.82 $413.42 $417.60 $0.00 $57.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201318 EAP CPT® 83873 Assay Of Csf Protein BOTH IP/OP $54.00 $39.96 $0.00 $48.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.12 $26.12 $27.13 $0.00 $25.42 $0.00 $0.00 $0.00 $0.00 $48.08 $42.77 $43.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201320 EAP CPT® 83874 Assay Of Myoglobin BOTH IP/OP $54.00 $39.96 $0.00 $43.20 $26.66 $26.66 $12.92 $12.92 $6.46 $6.46 $19.61 $19.61 $20.37 $12.92 $19.08 $8.40 $31.94 $31.94 $13.57 $36.08 $42.77 $43.20 $18.73 $0.00 $18.73 $20.33 $12.92 $12.92 $14.23 $12.92 $0.00 $0.00 $0.00 $0.00 30201322 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $367.00 $271.58 $6.03 $294.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $217.08 $217.08 $12.65 $33.68 $291.46 $294.40 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201324 EAP CPT® 80323 Assay Of Nicotine BOTH IP/OP $212.00 $156.88 $0.00 $169.60 $0.03 $0.03 $0.00 $0.00 $12.01 $18.43 $157.35 $157.35 $163.41 $0.00 $44.34 $0.00 $125.40 $125.40 $0.00 $106.00 $167.90 $169.60 $127.20 $137.80 $127.20 $47.25 $0.00 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 30201326 EAP CPT® 84999 Clinical Chemistry Test BOTH IP/OP $124.00 $91.76 $0.00 $105.60 $0.00 $0.00 $0.00 $0.00 $22.07 $0.00 $92.03 $92.03 $95.58 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $104.54 $105.60 $0.00 $0.00 $0.00 $20.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201328 EAP CPT® 83945 Assay Of Oxalate BOTH IP/OP $48.00 $35.52 $0.00 $38.40 $26.58 $26.58 $14.45 $14.45 $7.23 $6.50 $19.55 $19.55 $20.30 $14.45 $19.02 $9.39 $28.39 $28.39 $0.00 $35.98 $38.02 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201330 EAP CPT® 87279 Parainfluenza Ag If BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201334 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $241.00 $178.34 $0.00 $192.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.65 $33.68 $190.87 $192.80 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201335 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $171.00 $126.54 $0.00 $171.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $101.15 $101.15 $12.65 $33.68 $169.49 $171.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201336 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $133.00 $98.42 $0.00 $132.80 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $78.67 $78.67 $12.65 $33.68 $131.47 $132.80 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201338 EAP CPT® 87799 Detect Agent Nos Dna Quant BOTH IP/OP $634.00 $469.16 $0.00 $634.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $132.13 $27.85 $375.01 $375.01 $0.00 $119.70 $495.79 $500.80 $0.00 $634.00 $0.00 $97.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201340 EAP CPT® 82657 Enzyme Cell Activity BOTH IP/OP $228.00 $168.72 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.12 $9.12 $9.47 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $16.78 $180.58 $182.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201342 EAP CPT® 83992 Assay For Phencyclidine BOTH IP/OP $254.00 $187.96 $0.00 $215.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.32 $22.32 $23.18 $0.00 $21.72 $0.00 $0.00 $0.00 $0.00 $41.08 $213.05 $215.20 $0.00 $159.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201344 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $49.69 $49.69 $5.44 $14.46 $66.53 $67.20 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201345 EAP CPT® 84600 Assay Of Volatiles BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $33.18 $33.18 $17.11 $17.11 $8.56 $8.04 $24.41 $24.41 $25.35 $17.11 $23.74 $11.12 $59.74 $59.74 $0.00 $44.90 $79.99 $80.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201354 EAP CPT® 84110 Assay Of Porphobilinogen BOTH IP/OP $54.00 $39.96 $0.00 $54.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.83 $12.83 $13.33 $0.00 $12.47 $0.00 $0.00 $0.00 $8.86 $23.60 $42.77 $43.20 $12.24 $54.00 $12.24 $13.29 $8.44 $8.44 $9.30 $8.44 $0.00 $0.00 $0.00 $0.00 30201358 EAP CPT® 84120 Assay Of Urine Porphyrins BOTH IP/OP $55.00 $40.70 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.36 $22.33 $22.33 $23.19 $14.71 $21.74 $9.56 $32.53 $32.53 $0.00 $41.10 $43.56 $44.00 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201362 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $414.00 $306.36 $8.39 $331.20 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $244.88 $244.88 $19.57 $33.64 $327.89 $331.20 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201363 EAP CPT® 84206 Proinsulin So BOTH IP/OP $488.00 $361.12 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.05 $27.05 $28.09 $0.00 $26.31 $0.00 $0.00 $0.00 $28.02 $49.78 $386.50 $390.40 $38.70 $488.00 $38.70 $28.04 $26.69 $26.69 $19.63 $26.69 $0.00 $0.00 $0.00 $0.00 30201364 EAP CPT® 84206 Assay Of Proinsulin BOTH IP/OP $644.00 $476.56 $0.00 $515.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.05 $27.05 $28.09 $0.00 $26.31 $0.00 $0.00 $0.00 $28.02 $49.78 $510.05 $515.20 $38.70 $0.00 $38.70 $28.04 $26.69 $26.69 $19.63 $26.69 $0.00 $0.00 $0.00 $0.00 30201368 EAP CPT® 85303 "Blood Clot Inhibitor Test;protein C,activity" BOTH IP/OP $428.00 $316.72 $0.00 $342.40 $28.56 $28.56 $13.84 $13.84 $6.92 $6.92 $21.00 $21.00 $21.81 $13.84 $20.43 $9.00 $253.16 $253.16 $14.53 $38.64 $338.98 $342.40 $20.07 $0.00 $20.07 $21.77 $13.84 $13.84 $15.24 $13.84 $0.00 $0.00 $0.00 $0.00 30201369 EAP CPT® 85306 "Blood Clot Inhibitor Test;protein S,free" BOTH IP/OP $513.00 $379.62 $0.00 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.26 $23.26 $24.16 $0.00 $22.64 $0.00 $0.00 $0.00 $0.00 $42.82 $406.30 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201371 EAP CPT® 85305 "Blood Clot Inhibitor Assay;protein S,total" BOTH IP/OP $493.00 $364.82 $0.00 $394.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.61 $17.61 $18.28 $0.00 $17.13 $0.00 $0.00 $0.00 $0.00 $32.40 $390.46 $394.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201373 EAP CPT® 84153 Assay Of Psa Total BOTH IP/OP $41.00 $30.34 $0.00 $32.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.47 $0.00 $0.00 $0.00 $0.00 $28.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201374 EAP CPT® 84154 Assay Of Psa Free BOTH IP/OP $42.00 $31.08 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.92 $27.92 $29.00 $0.00 $27.17 $0.00 $0.00 $0.00 $0.00 $42.00 $33.26 $33.60 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201376 EAP CPT® 83970 Assay Of Parathormone BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $85.19 $85.19 $41.28 $41.28 $20.64 $20.64 $62.68 $62.68 $65.09 $41.28 $60.97 $26.83 $104.70 $104.70 $43.34 $115.34 $140.18 $141.60 $59.86 $0.00 $59.86 $64.97 $41.28 $41.28 $45.48 $41.28 $0.00 $0.00 $0.00 $0.00 30201378 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP $483.00 $357.42 $0.00 $436.00 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $285.69 $285.69 $19.32 $37.76 $431.64 $436.00 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30201380 EAP CPT® 84220 Assay Of Pyruvate Kinase BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.32 $14.32 $14.87 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $26.36 $183.74 $185.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201382 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $255.00 $188.70 $8.39 $204.00 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $150.83 $150.83 $19.57 $33.64 $201.96 $204.00 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201384 EAP CPT® 86317 Immunoassay Infectious Agent BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $24.79 $24.79 $14.99 $14.99 $7.50 $7.49 $18.22 $18.22 $18.92 $14.99 $17.72 $9.74 $84.58 $84.58 $15.74 $33.54 $113.26 $114.40 $21.74 $0.00 $21.74 $18.89 $14.99 $14.99 $13.22 $14.99 $0.00 $0.00 $0.00 $0.00 30201386 EAP CPT® 80195 Assay Of Sirolimus BOTH IP/OP $279.00 $206.46 $0.00 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.84 $20.84 $21.64 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $38.34 $220.97 $223.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201388 EAP CPT® 87299 Antibody Detection Nos If BOTH IP/OP $91.00 $67.34 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $72.07 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201390 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $96.00 $71.04 $0.00 $96.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $56.78 $56.78 $5.48 $14.60 $95.04 $96.00 $7.57 $0.00 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30201392 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $104.00 $76.96 $2.61 $104.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $61.52 $61.52 $5.48 $14.60 $102.96 $104.00 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30201478 EAP CPT® 82480 Assay Serum Cholinesterase BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.97 $11.97 $12.43 $0.00 $11.64 $0.00 $0.00 $0.00 $0.00 $22.02 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201479 EAP CPT® 82482 Assay Rbc Cholinesterase BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.67 $11.67 $12.12 $0.00 $11.36 $0.00 $0.00 $0.00 $0.00 $21.48 $33.26 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201481 EAP CPT® 85635 Reptilase Test BOTH IP/OP $178.00 $131.72 $0.00 $178.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.96 $14.96 $15.53 $0.00 $14.54 $0.00 $0.00 $0.00 $0.00 $27.52 $140.98 $142.40 $0.00 $178.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201483 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $309.00 $228.66 $0.00 $297.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $182.77 $182.77 $36.84 $54.82 $294.62 $297.60 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201485 EAP CPT® 84482 T3 Reverse BOTH IP/OP $129.00 $95.46 $0.00 $118.40 $32.52 $32.52 $15.76 $15.76 $7.88 $7.88 $23.93 $23.93 $24.85 $15.76 $23.28 $10.24 $76.30 $76.30 $16.55 $44.04 $117.22 $118.40 $22.85 $0.00 $22.85 $0.00 $15.76 $15.76 $17.36 $15.76 $0.00 $0.00 $0.00 $0.00 30201487 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP $199.00 $147.26 $5.76 $155.20 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $117.71 $117.71 $12.11 $29.88 $153.65 $155.20 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30201489 EAP CPT® 86757 Rickettsia Antibody BOTH IP/OP $78.00 $57.72 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $54.10 $77.62 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201493 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $171.00 $126.54 $8.39 $137.60 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $101.15 $101.15 $19.57 $33.64 $136.22 $137.60 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201495 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $211.00 $156.14 $7.77 $164.00 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $124.81 $124.81 $18.13 $36.18 $162.36 $164.00 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30201497 EAP CPT® 86671 Fungus Antibody BOTH IP/OP $99.00 $73.26 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $79.20 $80.00 $17.76 $99.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30201499 EAP CPT® 86671 Fungus Antibody BOTH IP/OP $47.00 $34.78 $0.00 $47.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $37.22 $37.60 $17.76 $47.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30201501 EAP CPT® 86682 Helminth Antibody BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $26.85 $26.85 $13.01 $13.01 $6.51 $6.50 $19.75 $19.75 $20.51 $13.01 $19.20 $8.46 $113.57 $113.57 $13.66 $36.34 $152.06 $153.60 $18.86 $0.00 $18.86 $20.46 $13.01 $13.01 $14.32 $13.01 $0.00 $0.00 $0.00 $0.00 30201503 EAP CPT® 84255 Assay Of Selenium BOTH IP/OP $98.00 $72.52 $0.00 $78.40 $52.69 $52.69 $25.53 $25.53 $12.77 $12.77 $38.76 $38.76 $40.25 $25.53 $37.71 $16.59 $57.97 $57.97 $0.00 $71.34 $77.62 $78.40 $0.00 $42.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201505 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $42.59 $42.59 $5.44 $14.46 $57.02 $57.60 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201506 EAP CPT® 84255 Assay Of Selenium BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $52.69 $52.69 $25.53 $25.53 $12.77 $12.77 $38.76 $38.76 $40.25 $25.53 $37.71 $16.59 $42.00 $42.00 $0.00 $71.00 $56.23 $56.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201508 EAP CPT® 84270 Assay Of Sex Hormone Globul BOTH IP/OP $42.00 $31.08 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.87 $33.00 $33.00 $34.27 $21.73 $32.10 $14.12 $24.84 $24.84 $0.00 $42.00 $33.26 $33.60 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201510 EAP CPT® 86609 Bacterium Antibody BOTH IP/OP $24.00 $17.76 $0.00 $24.00 $24.00 $24.00 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $14.20 $14.20 $0.00 $24.00 $19.01 $19.20 $0.00 $21.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201512 EAP CPT® 86403 Particle Agglutination Test BOTH IP/OP $203.00 $150.22 $0.00 $162.40 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $120.07 $120.07 $12.12 $28.48 $160.78 $162.40 $16.73 $0.00 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30201514 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $117.12 $117.12 $19.57 $33.64 $156.82 $158.40 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201516 EAP CPT® 87186 Microbe Susceptible Mic BOTH IP/OP $323.00 $239.02 $4.32 $258.40 $17.85 $17.85 $8.65 $8.65 $4.33 $4.32 $13.12 $13.12 $13.63 $8.65 $12.77 $5.62 $191.05 $191.05 $9.08 $24.16 $255.82 $258.40 $12.54 $14.27 $12.54 $13.60 $8.65 $8.65 $9.52 $8.65 $0.00 $0.00 $0.00 $0.00 30201522 EAP CPT® 86780 Treponema Pallidum BOTH IP/OP $93.00 $68.82 $0.00 $85.60 $27.32 $27.32 $13.24 $13.24 $6.62 $6.62 $19.73 $19.73 $20.49 $13.24 $19.38 $8.61 $55.01 $55.01 $13.90 $53.50 $84.74 $85.60 $19.20 $0.00 $19.20 $16.75 $13.24 $13.24 $17.03 $13.24 $0.00 $0.00 $0.00 $0.00 30201524 EAP CPT® 84482 T3 Reverse BOTH IP/OP $150.00 $111.00 $0.00 $118.40 $32.52 $32.52 $15.76 $15.76 $7.88 $7.88 $23.93 $23.93 $24.85 $15.76 $23.28 $10.24 $88.73 $88.73 $16.55 $44.04 $117.22 $118.40 $22.85 $26.00 $22.85 $0.00 $15.76 $15.76 $17.36 $15.76 $0.00 $0.00 $0.00 $0.00 30201531 EAP CPT® 82040 Assay Of Serum Albumin BOTH IP/OP $8.00 $5.92 $0.00 $8.00 $5.94 $5.94 $4.95 $4.95 $2.48 $2.48 $4.37 $4.37 $4.54 $4.95 $4.25 $3.22 $4.73 $4.73 $5.20 $8.00 $6.34 $6.40 $7.18 $0.00 $7.18 $4.53 $4.95 $4.95 $3.17 $4.95 $0.00 $0.00 $0.00 $0.00 30201532 EAP CPT® 84270 Assay Of Sex Hormone Globul BOTH IP/OP $38.00 $28.12 $0.00 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.87 $33.00 $33.00 $34.27 $21.73 $32.10 $14.12 $22.48 $22.48 $0.00 $38.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201533 EAP CPT® 84403 Assay Of Total Testosterone BOTH IP/OP $52.00 $38.48 $0.00 $52.00 $52.00 $52.00 $25.81 $25.81 $12.91 $12.91 $39.21 $39.21 $40.72 $25.81 $38.15 $16.78 $30.76 $30.76 $27.10 $52.00 $41.18 $41.60 $37.42 $0.00 $37.42 $40.65 $25.81 $25.81 $28.45 $25.81 $0.00 $0.00 $0.00 $0.00 30201535 EAP CPT® 84402 Assay Of Testosterone BOTH IP/OP $50.00 $37.00 $12.74 $50.00 $50.00 $50.00 $25.47 $25.47 $12.74 $12.74 $38.67 $38.67 $40.15 $25.47 $37.60 $16.56 $29.58 $29.58 $26.74 $50.00 $39.60 $40.00 $36.93 $42.03 $36.93 $40.06 $25.47 $25.47 $28.04 $25.47 $0.00 $0.00 $0.00 $0.00 30201536 EAP CPT® 84403 Assay Of Total Testosterone BOTH IP/OP $50.00 $37.00 $12.91 $50.00 $50.00 $50.00 $25.81 $25.81 $12.91 $12.91 $39.21 $39.21 $40.72 $25.81 $38.15 $16.78 $29.58 $29.58 $27.10 $50.00 $39.60 $40.00 $37.42 $42.59 $37.42 $40.65 $25.81 $25.81 $28.45 $25.81 $0.00 $0.00 $0.00 $0.00 30201538 EAP CPT® 84402 Assay Of Testosterone BOTH IP/OP $50.00 $37.00 $12.74 $50.00 $50.00 $50.00 $25.47 $25.47 $12.74 $12.74 $38.67 $38.67 $40.15 $25.47 $37.60 $16.56 $29.58 $29.58 $26.74 $50.00 $39.60 $40.00 $36.93 $42.03 $36.93 $40.06 $25.47 $25.47 $28.04 $25.47 $0.00 $0.00 $0.00 $0.00 30201540 EAP CPT® 86744 Nocardia Antibody BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $73.66 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201542 EAP CPT® 83018 Quantitative Screen Metals BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.34 $33.34 $34.62 $0.00 $32.43 $0.00 $0.00 $0.00 $0.00 $61.36 $205.13 $207.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201544 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $101.00 $74.74 $0.00 $80.80 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $59.74 $59.74 $5.44 $14.46 $79.99 $80.80 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201545 EAP CPT® 84430 Assay Of Thiocyanate BOTH IP/OP $133.00 $98.42 $0.00 $106.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.76 $8.76 $9.09 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $16.12 $105.34 $106.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201546 EAP CPT® 84445 Thyroid Stimulating Immunoglobulin So BOTH IP/OP $135.00 $99.90 $9.34 $108.00 $17.48 $17.48 $50.86 $50.86 $25.43 $25.43 $12.85 $12.85 $13.35 $50.86 $12.52 $33.06 $79.85 $79.85 $53.40 $23.66 $106.92 $108.00 $73.75 $83.92 $73.75 $13.34 $50.86 $50.86 $9.34 $50.86 $0.00 $0.00 $0.00 $0.00 30201547 EAP CPT® 84445 Assay Of Tsi BOTH IP/OP $172.00 $127.28 $0.00 $137.60 $17.48 $17.48 $50.86 $50.86 $25.43 $25.43 $12.85 $12.85 $13.35 $50.86 $12.52 $33.06 $101.74 $101.74 $53.40 $23.66 $136.22 $137.60 $73.75 $0.00 $73.75 $13.34 $50.86 $50.86 $9.34 $50.86 $0.00 $0.00 $0.00 $0.00 30201549 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP $416.00 $307.84 $8.28 $324.00 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $246.06 $246.06 $19.32 $37.76 $320.76 $324.00 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30201551 EAP CPT® 86682 Helminth Antibody BOTH IP/OP $69.00 $51.06 $6.50 $56.00 $26.85 $26.85 $13.01 $13.01 $6.51 $6.50 $19.75 $19.75 $20.51 $13.01 $19.20 $8.46 $40.81 $40.81 $13.66 $36.34 $55.44 $56.00 $18.86 $21.47 $18.86 $20.46 $13.01 $13.01 $14.32 $13.01 $0.00 $0.00 $0.00 $0.00 30201553 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $442.00 $327.08 $0.00 $426.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $261.44 $261.44 $36.84 $54.82 $422.14 $426.40 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201555 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $242.00 $179.08 $0.00 $193.60 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $143.14 $143.14 $19.57 $33.64 $191.66 $193.60 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201559 EAP CPT® 86753 Prorozoa Antibody Nos BOTH IP/OP $39.00 $28.86 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.81 $18.81 $19.54 $0.00 $18.31 $0.00 $0.00 $0.00 $0.00 $34.64 $30.89 $31.20 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201561 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $211.00 $156.14 $0.00 $190.40 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $124.81 $124.81 $18.13 $36.18 $188.50 $190.40 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30201563 EAP CPT® 87799 Detect Agent Nos Dna Quant BOTH IP/OP $968.00 $716.32 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $201.73 $27.85 $572.57 $572.57 $0.00 $119.70 $757.15 $764.80 $0.00 $968.00 $0.00 $149.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201565 EAP CPT® 84425 Assay Of Vitamin B-1 BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $43.82 $43.82 $21.23 $21.23 $10.62 $10.62 $32.25 $32.25 $33.49 $21.23 $31.36 $13.80 $60.33 $60.33 $22.29 $59.34 $80.78 $81.60 $30.78 $0.00 $30.78 $33.42 $21.23 $21.23 $23.39 $21.23 $0.00 $0.00 $0.00 $0.00 30201566 EAP CPT® 84425 Vitamin B1 Plasma (thiamine) So BOTH IP/OP $65.00 $48.10 $10.62 $59.34 $43.82 $43.82 $21.23 $21.23 $10.62 $10.62 $32.25 $32.25 $33.49 $21.23 $31.36 $13.80 $38.45 $38.45 $22.29 $59.34 $51.48 $52.00 $30.78 $35.03 $30.78 $33.42 $21.23 $21.23 $23.39 $21.23 $0.00 $0.00 $0.00 $0.00 30201567 EAP CPT® 84425 Assay Of Vitamin B-1 BOTH IP/OP $157.00 $116.18 $0.00 $125.60 $43.82 $43.82 $21.23 $21.23 $10.62 $10.62 $32.25 $32.25 $33.49 $21.23 $31.36 $13.80 $92.87 $92.87 $22.29 $59.34 $124.34 $125.60 $30.78 $0.00 $30.78 $33.42 $21.23 $21.23 $23.39 $21.23 $0.00 $0.00 $0.00 $0.00 30201569 EAP CPT® 84597 Assay Of Vitamin K BOTH IP/OP $566.00 $418.84 $0.00 $452.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.81 $20.81 $21.61 $0.00 $20.25 $0.00 $0.00 $0.00 $0.00 $38.30 $448.27 $452.80 $0.00 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201571 EAP CPT® 84591 Assay Of Nos Vitamin BOTH IP/OP $121.00 $89.54 $0.00 $121.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.61 $17.61 $18.28 $0.00 $17.13 $0.00 $0.00 $0.00 $0.00 $32.40 $95.83 $96.80 $0.00 $121.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201573 EAP CPT® 84207 Assay Of Vtamin B-6 BOTH IP/OP $452.00 $334.48 $0.00 $452.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.66 $42.66 $44.30 $0.00 $41.51 $0.00 $0.00 $0.00 $0.00 $78.50 $357.98 $361.60 $0.00 $452.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201575 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $24.00 $17.76 $0.00 $19.20 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $14.20 $14.20 $5.44 $14.46 $19.01 $19.20 $7.51 $0.00 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201576 EAP CPT® 84585 Assay Of Urine Vma BOTH IP/OP $30.00 $22.20 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.55 $23.55 $24.45 $0.00 $22.90 $0.00 $0.00 $0.00 $0.00 $30.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201578 EAP CPT® 85247 Blood Clot Factor Viii Test BOTH IP/OP $323.00 $239.02 $0.00 $323.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.85 $34.85 $36.19 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $64.12 $236.02 $238.40 $0.00 $323.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201580 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $402.00 $297.48 $8.39 $323.20 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $237.78 $237.78 $19.57 $33.64 $319.97 $323.20 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201581 EAP CPT® 86788 West Nile Ab Csf So BOTH IP/OP $193.00 $142.82 $0.00 $193.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $114.16 $114.16 $0.00 $47.08 $139.39 $140.80 $0.00 $193.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201582 EAP CPT® 86788 West Nile Virus Ag Igm BOTH IP/OP $300.00 $222.00 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $177.45 $177.45 $0.00 $47.08 $237.60 $240.00 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201583 EAP CPT® 86789 West Nile Virus Antibody BOTH IP/OP $300.00 $222.00 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $32.52 $237.60 $240.00 $0.00 $299.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201584 EAP CPT® 86788 West Nile Ab Serum So BOTH IP/OP $162.00 $119.88 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $95.82 $95.82 $0.00 $47.08 $117.22 $118.40 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201585 EAP CPT® 86788 West Nile Virus Ag Igm BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $70.98 $70.98 $0.00 $47.08 $95.04 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201586 EAP CPT® 86789 West Nile Virus Antibody BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $32.52 $95.04 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201588 EAP CPT® 84311 Spectrophotometry BOTH IP/OP $239.00 $176.86 $0.00 $192.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.61 $10.61 $11.02 $0.00 $10.32 $0.00 $0.00 $0.00 $8.51 $19.54 $190.87 $192.80 $11.75 $156.00 $11.75 $11.00 $8.10 $8.10 $7.70 $8.10 $0.00 $0.00 $0.00 $0.00 30201590 EAP CPT® 82570 Assay Of Urine Creatinine BOTH IP/OP $68.00 $50.32 $2.59 $54.40 $10.69 $10.69 $5.18 $5.18 $2.59 $2.59 $7.86 $7.86 $8.16 $5.18 $7.64 $3.37 $40.22 $40.22 $5.44 $14.46 $53.86 $54.40 $7.51 $8.55 $7.51 $8.14 $5.18 $5.18 $5.70 $5.18 $0.00 $0.00 $0.00 $0.00 30201591 EAP CPT® 83497 Assay Of 5-hiaa BOTH IP/OP $147.00 $108.78 $6.45 $117.60 $26.61 $26.61 $12.90 $12.90 $6.45 $6.45 $19.58 $19.58 $20.34 $12.90 $19.05 $8.39 $86.95 $86.95 $13.55 $36.02 $116.42 $117.60 $18.71 $21.29 $18.71 $20.30 $12.90 $12.90 $14.21 $12.90 $0.00 $0.00 $0.00 $0.00 30201593 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP $288.00 $213.12 $5.76 $224.00 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $170.35 $170.35 $12.11 $29.88 $221.76 $224.00 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30201601 EAP CPT® 88360 Tumor Immunohistochem/manual BOTH IP/OP $310.00 $229.40 $0.00 $248.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $183.37 $183.37 $143.92 $121.34 $245.52 $248.00 $199.96 $0.00 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 30201612 EAP CPT® 88381 Microdissection Manual BOTH IP/OP $29.00 $21.46 $0.00 $210.18 $29.00 $29.00 $0.00 $0.00 $0.00 $70.38 $161.51 $161.51 $167.72 $0.00 $29.00 $0.00 $17.15 $17.15 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $210.18 $156.67 $156.67 $147.12 $0.00 $0.00 $0.00 $0.00 $0.00 30201614 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP $272.00 $201.28 $5.76 $212.00 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $160.89 $160.89 $12.11 $29.88 $209.88 $212.00 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30201616 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP $408.00 $301.92 $5.76 $368.00 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $241.33 $241.33 $12.11 $29.88 $364.32 $368.00 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30201618 EAP CPT® 87538 Hiv-2 Dna Amp Probe BOTH IP/OP $521.00 $385.54 $17.55 $404.80 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $108.58 $22.81 $308.17 $308.17 $36.84 $54.82 $400.75 $404.80 $50.88 $57.90 $50.88 $79.19 $35.09 $35.09 $80.56 $35.09 $0.00 $0.00 $0.00 $0.00 30201620 EAP CPT® 84432 Assay Of Thyroglobulin BOTH IP/OP $213.00 $157.62 $8.03 $170.40 $33.16 $33.16 $16.06 $16.06 $8.03 $8.03 $24.39 $24.39 $25.33 $16.06 $23.73 $10.44 $125.99 $125.99 $16.86 $44.88 $168.70 $170.40 $23.29 $26.50 $23.29 $25.28 $16.06 $16.06 $17.70 $16.06 $0.00 $0.00 $0.00 $0.00 30201628 EAP CPT® 86317 Immunoassay Infectious Agent BOTH IP/OP $36.00 $26.64 $7.49 $33.00 $24.79 $24.79 $14.99 $14.99 $7.50 $7.49 $18.22 $18.22 $18.92 $14.99 $17.72 $9.74 $21.29 $21.29 $15.74 $33.00 $26.14 $26.40 $21.74 $24.73 $21.74 $18.89 $14.99 $14.99 $13.22 $14.99 $0.00 $0.00 $0.00 $0.00 30201630 EAP CPT® 86382 Neutralization Test Viral BOTH IP/OP $46.00 $34.04 $0.00 $46.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.68 $25.68 $26.67 $0.00 $24.98 $0.00 $0.00 $0.00 $0.00 $46.00 $36.43 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201632 EAP CPT® 83088 Assay Of Histamine BOTH IP/OP $76.00 $56.24 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.84 $44.84 $46.57 $0.00 $43.62 $0.00 $0.00 $0.00 $0.00 $76.00 $60.19 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201634 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $69.00 $51.06 $0.00 $59.86 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $40.81 $40.81 $22.49 $59.86 $54.65 $55.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201635 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $137.00 $101.38 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $81.04 $81.04 $53.75 $112.22 $108.50 $109.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201638 EAP CPT® 88272 Cytogenetics 3-5 BOTH IP/OP $508.00 $375.92 $0.00 $406.40 $55.28 $55.28 $40.70 $40.70 $20.35 $18.32 $40.65 $40.65 $42.22 $40.70 $39.55 $26.46 $300.48 $300.48 $0.00 $74.82 $402.34 $406.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201640 EAP CPT® 86787 Varicella-zoster Antibody BOTH IP/OP $183.00 $135.42 $6.44 $148.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $108.24 $108.24 $13.52 $36.00 $146.52 $148.00 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30201642 EAP CPT® 88360 Tumor Immunohistoche/manual BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $175.68 $175.68 $143.92 $121.34 $235.22 $237.60 $199.96 $0.00 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 30201650 EAP CPT® 86694 Herpes Simplex Test BOTH IP/OP $145.00 $107.30 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.67 $17.67 $18.35 $0.00 $17.19 $0.00 $0.00 $0.00 $15.11 $32.52 $118.80 $120.00 $20.87 $0.00 $20.87 $18.31 $14.39 $14.39 $12.82 $14.39 $0.00 $0.00 $0.00 $0.00 30201652 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $62.00 $45.88 $0.00 $59.86 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $36.67 $36.67 $22.49 $59.86 $49.10 $49.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201653 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $151.00 $111.74 $0.00 $120.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $89.32 $89.32 $53.75 $112.22 $119.59 $120.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201656 EAP CPT® 86382 Neutralization Test Viral BOTH IP/OP $47.00 $34.78 $0.00 $47.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.68 $25.68 $26.67 $0.00 $24.98 $0.00 $0.00 $0.00 $0.00 $47.00 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201658 EAP CPT® 86317 Immunoassay Infectious Agent BOTH IP/OP $33.00 $24.42 $0.00 $33.00 $24.79 $24.79 $14.99 $14.99 $7.50 $7.49 $18.22 $18.22 $18.92 $14.99 $17.72 $9.74 $19.52 $19.52 $15.74 $33.00 $26.14 $26.40 $21.74 $0.00 $21.74 $18.89 $14.99 $14.99 $13.22 $14.99 $0.00 $0.00 $0.00 $0.00 30201660 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $77.00 $56.98 $0.00 $61.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $45.55 $45.55 $22.49 $59.86 $60.98 $61.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201661 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $117.00 $86.58 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $69.21 $69.21 $53.75 $112.22 $92.66 $93.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201664 EAP CPT® 83516 Immunoassay Nonantibody BOTH IP/OP $256.00 $189.44 $0.00 $231.20 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $151.42 $151.42 $12.11 $29.88 $228.89 $231.20 $16.72 $0.00 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30201665 EAP CPT® 82784 Assay Iga/igd/igg/igm Each BOTH IP/OP $28.00 $20.72 $0.00 $25.98 $19.19 $19.19 $9.30 $9.30 $4.65 $4.65 $14.12 $14.12 $14.67 $9.30 $13.73 $6.05 $16.56 $16.56 $9.77 $25.98 $22.18 $22.40 $13.49 $0.00 $13.49 $14.63 $9.30 $9.30 $10.24 $9.30 $0.00 $0.00 $0.00 $0.00 30201667 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $50.28 $50.28 $22.49 $59.86 $67.32 $68.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201668 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $139.00 $102.86 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $82.22 $82.22 $53.75 $112.22 $110.09 $111.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201671 EAP CPT® 86817 Hla Typing Dr/dq BOTH IP/OP "$1,108.00 " $819.92 $0.00 $886.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.76 $97.76 $101.52 $0.00 $95.11 $0.00 $0.00 $0.00 $0.00 $179.90 $877.54 $886.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201672 EAP CPT® 86813 Hla Typing A B Or C BOTH IP/OP "$1,254.00 " $927.96 $0.00 "$1,005.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.05 $88.05 $91.43 $0.00 $85.66 $0.00 $0.00 $0.00 $0.00 $162.04 $993.17 "$1,003.20" $0.00 "$1,005.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201673 EAP CPT® 86808 Cytotoxic Antibody Screening BOTH IP/OP $349.00 $258.26 $0.00 $279.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.06 $45.06 $46.80 $0.00 $43.84 $0.00 $0.00 $0.00 $0.00 $82.94 $276.41 $279.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201687 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $60.33 $60.33 $22.49 $59.86 $80.78 $81.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201688 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $104.10 $104.10 $53.75 $112.22 $139.39 $140.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201691 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $659.00 $487.66 $6.03 $528.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $389.80 $389.80 $12.65 $33.68 $522.72 $528.00 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201693 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP "$1,170.00 " $865.80 $8.28 "$1,056.00" $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $692.06 $692.06 $19.32 $37.76 "$1,045.44" "$1,056.00" $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30201706 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $182.00 $134.68 $0.00 $164.00 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $107.65 $107.65 $18.13 $36.18 $162.36 $164.00 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30201707 EAP CPT® 86021 Wbc Antibody Identification BOTH IP/OP $92.00 $68.08 $0.00 $73.60 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $54.42 $54.42 $15.80 $42.06 $72.86 $73.60 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30201708 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $83.00 $61.42 $0.00 $83.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $49.09 $49.09 $12.65 $33.68 $82.37 $83.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201709 EAP CPT® 86609 Bacterium Antibody BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $49.69 $49.69 $0.00 $36.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201710 EAP CPT® 86671 Fungus Antibody BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $18.62 $19.33 $0.00 $18.11 $0.00 $0.00 $0.00 $12.86 $34.26 $65.74 $66.40 $17.76 $0.00 $17.76 $19.30 $12.25 $12.25 $13.51 $12.25 $0.00 $0.00 $0.00 $0.00 30201711 EAP CPT® 86689 Hiv-2 Wb BOTH IP/OP $213.00 $157.62 $0.00 $213.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $24.81 $0.00 $0.00 $0.00 $0.00 $54.10 $163.94 $165.60 $0.00 $213.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201712 EAP CPT® 86038 Antinuclear Antibodies BOTH IP/OP $24.00 $17.76 $0.00 $24.00 $24.00 $24.00 $12.09 $12.09 $6.05 $6.04 $18.36 $18.36 $19.06 $12.09 $17.86 $7.86 $14.20 $14.20 $12.69 $24.00 $19.01 $19.20 $17.53 $0.00 $17.53 $19.03 $12.09 $12.09 $13.32 $12.09 $0.00 $0.00 $0.00 $0.00 30201713 EAP CPT® 86376 Microsomal Antibody BOTH IP/OP $49.00 $36.26 $0.00 $40.66 $30.04 $30.04 $14.55 $14.55 $7.28 $7.28 $22.10 $22.10 $22.95 $14.55 $21.49 $9.46 $28.98 $28.98 $15.28 $40.66 $38.81 $39.20 $21.10 $0.00 $21.10 $22.90 $14.55 $14.55 $16.03 $14.55 $0.00 $0.00 $0.00 $0.00 30201714 EAP CPT® 86658 Enterovirus Antibody BOTH IP/OP $27.00 $19.98 $0.00 $27.00 $26.90 $26.90 $13.03 $13.03 $6.52 $6.51 $19.79 $19.79 $20.55 $13.03 $19.25 $8.47 $15.97 $15.97 $13.68 $27.00 $21.38 $21.60 $18.89 $0.00 $18.89 $20.51 $13.03 $13.03 $14.36 $13.03 $0.00 $0.00 $0.00 $0.00 30201715 EAP CPT® 86652 "Antibody Encephalitis, Eastern Equine" BOTH IP/OP $19.00 $14.06 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $25.00 $19.80 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201718 EAP CPT® 86765 Rubeola Antibody BOTH IP/OP $31.00 $22.94 $0.00 $31.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $18.34 $18.34 $13.52 $31.00 $24.55 $24.80 $18.68 $0.00 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30201719 EAP CPT® 86653 Encephalitis Antibody BOTH IP/OP $19.00 $14.06 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $25.00 $19.80 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201720 EAP CPT® 86787 Varicella-zoster Antibody BOTH IP/OP $29.00 $21.46 $0.00 $29.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $17.15 $17.15 $13.52 $29.00 $22.97 $23.20 $18.68 $0.00 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30201721 EAP CPT® 86654 Encephalitis Antibody BOTH IP/OP $19.00 $14.06 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $25.00 $19.80 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201722 EAP CPT® 86645 Cmv Antibody Igm BOTH IP/OP $35.00 $25.90 $0.00 $35.00 $34.77 $34.77 $16.85 $16.85 $8.43 $8.42 $25.58 $25.58 $26.57 $16.85 $24.90 $10.95 $20.70 $20.70 $17.69 $35.00 $27.72 $28.00 $24.43 $0.00 $24.43 $26.53 $16.85 $16.85 $18.57 $16.85 $0.00 $0.00 $0.00 $0.00 30201724 EAP CPT® 86403 Particle Agglutination Test BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $53.24 $53.24 $12.12 $28.48 $71.28 $72.00 $16.73 $0.00 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30201725 EAP CPT® 86406 Particle Agglutination Test BOTH IP/OP $136.00 $100.64 $0.00 $108.80 $0.00 $0.00 $0.00 $0.00 $0.00 $5.32 $16.15 $16.15 $16.77 $10.64 $15.72 $6.92 $80.44 $80.44 $11.17 $29.74 $107.71 $108.80 $15.43 $0.00 $15.43 $16.75 $10.64 $10.64 $11.72 $10.64 $0.00 $0.00 $0.00 $0.00 30201726 EAP CPT® 86403 Particle Agglutination Test BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $21.04 $21.04 $11.54 $11.54 $5.77 $5.19 $15.48 $15.48 $16.07 $11.54 $11.75 $7.50 $58.56 $58.56 $12.12 $28.48 $78.41 $79.20 $16.73 $0.00 $16.73 $12.52 $11.54 $11.54 $8.76 $11.54 $0.00 $0.00 $0.00 $0.00 30201727 EAP CPT® 88342 Immunohistochemistry BOTH IP/OP $275.00 $203.50 $48.82 $222.40 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $162.66 $162.66 $143.92 $106.46 $220.18 $222.40 $199.96 $178.75 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 30201728 EAP CPT® 88360 Tumor Immunohistochem/manual BOTH IP/OP $638.00 $472.12 $0.00 $510.40 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $377.38 $377.38 $143.92 $121.34 $505.30 $510.40 $199.96 $0.00 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 30201729 EAP CPT® 86256 Fluorescent Antibody Titer BOTH IP/OP $131.00 $96.94 $6.03 $104.80 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $77.49 $77.49 $12.65 $33.68 $103.75 $104.80 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201730 EAP CPT® 88368 Insitu Hybridization Manual BOTH IP/OP $454.00 $335.96 $0.00 $394.92 $178.36 $178.36 $283.63 $283.63 $285.22 $58.22 $151.36 $151.36 $157.18 $279.15 $199.20 $181.45 $268.54 $268.54 $284.24 $207.74 $359.57 $363.20 $394.92 $0.00 $394.92 $212.25 $90.40 $90.40 $148.57 $270.71 $0.00 $0.00 $0.00 $0.00 30201731 EAP CPT® 88342 Immunohistochemistry BOTH IP/OP $556.00 $411.44 $0.00 $444.80 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $328.87 $328.87 $143.92 $106.46 $440.35 $444.80 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 30201735 EAP CPT® 86022 Nait Platelet Ab (so) BOTH IP/OP $361.00 $267.14 $0.00 $288.80 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $213.53 $213.53 $0.00 $51.32 $285.91 $288.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201736 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $27.00 $19.98 $0.00 $33.68 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $15.97 $15.97 $12.65 $33.68 $26.93 $27.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201737 EAP CPT® 86727 Lymph Choriomeningitis Ab BOTH IP/OP $19.00 $14.06 $0.00 $20.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.54 $19.54 $20.29 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $19.00 $15.05 $15.20 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201738 EAP CPT® 84181 Western Blot Test BOTH IP/OP $316.00 $233.84 $0.00 $252.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.86 $25.86 $26.86 $0.00 $25.16 $0.00 $0.00 $0.00 $0.00 $47.60 $250.27 $252.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201750 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $337.00 $249.38 $8.39 $269.60 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $199.34 $199.34 $19.57 $33.64 $266.90 $269.60 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201754 EAP CPT® 82985 Glycated Protein BOTH IP/OP $148.00 $109.52 $7.54 $119.20 $31.13 $31.13 $16.76 $16.76 $8.38 $7.54 $22.89 $22.89 $23.77 $16.76 $22.26 $10.89 $87.54 $87.54 $17.60 $42.12 $118.01 $119.20 $24.30 $27.65 $24.30 $23.72 $16.76 $16.76 $16.60 $16.76 $0.00 $0.00 $0.00 $0.00 30201758 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP $82.00 $60.68 $0.00 $74.40 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $48.50 $48.50 $19.32 $37.76 $73.66 $74.40 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30201759 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $35.00 $25.90 $0.00 $35.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $20.70 $20.70 $12.65 $33.68 $34.85 $35.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201760 EAP CPT® 86256 Fluorescent Antibody Titer BOTH IP/OP $35.00 $25.90 $0.00 $35.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $20.70 $20.70 $12.65 $33.68 $34.85 $35.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201761 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $104.00 $76.96 $2.61 $104.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $61.52 $61.52 $5.48 $14.60 $102.96 $104.00 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30201762 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP $359.00 $265.66 $8.28 $279.20 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $212.35 $212.35 $19.32 $37.76 $276.41 $279.20 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30201766 EAP CPT® 87186 Microbe Susceptible Mic BOTH IP/OP $271.00 $200.54 $4.32 $216.80 $17.85 $17.85 $8.65 $8.65 $4.33 $4.32 $13.12 $13.12 $13.63 $8.65 $12.77 $5.62 $160.30 $160.30 $9.08 $24.16 $214.63 $216.80 $12.54 $14.27 $12.54 $13.60 $8.65 $8.65 $9.52 $8.65 $0.00 $0.00 $0.00 $0.00 30201767 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $504.00 $372.96 $7.77 $392.00 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $298.12 $298.12 $18.13 $36.18 $388.08 $392.00 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30201768 EAP CPT® 82107 Alpha-fetoprotein 13 BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.80 $97.80 $101.56 $0.00 $95.14 $0.00 $0.00 $0.00 $0.00 $179.98 $218.59 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201769 EAP CPT® 87496 Cytomeg Dna Amp Probe BOTH IP/OP $212.00 $156.88 $0.00 $212.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $125.40 $125.40 $36.84 $54.82 $163.15 $164.80 $50.88 $212.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201770 EAP CPT® 82374 Assay Blood Carbon Dioxide BOTH IP/OP $91.00 $67.34 $0.00 $72.80 $10.08 $10.08 $4.88 $4.88 $2.44 $2.44 $7.43 $7.43 $7.71 $4.88 $7.22 $3.17 $53.83 $53.83 $5.12 $13.66 $72.07 $72.80 $7.08 $0.00 $7.08 $7.70 $4.88 $4.88 $5.39 $4.88 $0.00 $0.00 $0.00 $0.00 30201771 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $55.00 $40.70 $0.00 $55.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $32.53 $32.53 $12.65 $33.68 $54.65 $55.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201772 EAP CPT® 86256 Fluorescent Antibody Titer BOTH IP/OP $55.00 $40.70 $0.00 $55.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $32.53 $32.53 $12.65 $33.68 $54.65 $55.20 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201773 EAP CPT® 82310 Assay Of Calcium BOTH IP/OP $35.00 $25.90 $0.00 $28.80 $10.67 $10.67 $5.16 $5.16 $2.58 $2.58 $7.83 $7.83 $8.13 $5.16 $7.46 $3.35 $20.70 $20.70 $5.42 $14.40 $28.51 $28.80 $7.48 $0.00 $7.48 $7.94 $5.16 $5.16 $5.56 $5.16 $0.00 $0.00 $0.00 $0.00 30201774 EAP CPT® 83970 Assay Of Parathormone BOTH IP/OP $71.00 $52.54 $0.00 $71.00 $71.00 $71.00 $41.28 $41.28 $20.64 $20.64 $62.68 $62.68 $65.09 $41.28 $60.97 $26.83 $42.00 $42.00 $43.34 $71.00 $56.23 $56.80 $59.86 $0.00 $59.86 $64.97 $41.28 $41.28 $45.48 $41.28 $0.00 $0.00 $0.00 $0.00 30201786 EAP CPT® 84146 Assay Of Prolactin BOTH IP/OP $73.00 $54.02 $0.00 $58.40 $40.00 $40.00 $19.38 $19.38 $9.69 $9.69 $29.43 $29.43 $30.56 $19.38 $28.63 $12.60 $43.18 $43.18 $20.35 $54.16 $57.82 $58.40 $28.10 $0.00 $28.10 $30.51 $19.38 $19.38 $21.36 $19.38 $0.00 $0.00 $0.00 $0.00 30201789 EAP CPT® 83520 Immunoassay Quant Nos Nonab BOTH IP/OP $346.00 $256.04 $7.77 $312.00 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $204.66 $204.66 $18.13 $36.18 $308.88 $312.00 $25.04 $28.50 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30201790 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $262.00 $193.88 $0.00 $252.80 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $154.97 $154.97 $36.84 $54.82 $250.27 $252.80 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201793 EAP CPT® 86698 Histoplasma BOTH IP/OP $26.00 $19.24 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $18.98 $18.98 $19.71 $13.79 $18.46 $8.96 $15.38 $15.38 $14.48 $26.00 $20.59 $20.80 $20.00 $0.00 $20.00 $19.67 $13.79 $13.79 $13.77 $13.79 $0.00 $0.00 $0.00 $0.00 30201797 EAP CPT® 86611 Bartonella Antibody BOTH IP/OP $78.00 $57.72 $0.00 $78.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $46.14 $46.14 $10.69 $28.44 $77.62 $78.40 $14.76 $0.00 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30201798 EAP CPT® 86768 Salmonella Antibody BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.79 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $36.86 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201801 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $212.00 $156.88 $0.00 $169.60 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $125.40 $125.40 $19.57 $33.64 $167.90 $169.60 $27.03 $0.00 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201802 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $438.00 $324.12 $17.55 $352.80 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $259.08 $259.08 $36.84 $54.82 $349.27 $352.80 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201816 EAP CPT® 83519 Ria Nonantibody BOTH IP/OP $496.00 $367.04 $0.00 $448.00 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $293.38 $293.38 $19.32 $37.76 $443.52 $448.00 $26.68 $0.00 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30201817 EAP CPT® 80299 Quantitative Assay Drug BOTH IP/OP $369.00 $273.06 $8.39 $296.00 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $218.26 $218.26 $19.57 $33.64 $293.04 $296.00 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30201818 EAP CPT® 87906 Genotype Dna Hiv Reverse T BOTH IP/OP $679.00 $502.46 $0.00 $654.40 $90.02 $90.02 $128.73 $128.73 $64.37 $64.36 $63.81 $63.81 $66.27 $128.73 $57.67 $83.67 $401.63 $401.63 $135.17 $409.00 $647.86 $654.40 $186.66 $0.00 $186.66 $61.44 $128.73 $128.73 $43.01 $128.73 $0.00 $0.00 $0.00 $0.00 30201819 EAP CPT® 86727 Lymph Choriomeningitis Ab BOTH IP/OP $96.00 $71.04 $0.00 $76.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.54 $19.54 $20.29 $0.00 $19.01 $0.00 $0.00 $0.00 $0.00 $35.96 $76.03 $76.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201820 EAP CPT® 87906 Genotype Dna Hiv Reverse T BOTH IP/OP "$1,376.00 " "$1,018.24" $43.01 "$1,326.40" $90.02 $90.02 $128.73 $128.73 $64.37 $64.36 $63.81 $63.81 $66.27 $128.73 $57.67 $83.67 $813.90 $813.90 $135.17 $829.00 "$1,313.14" "$1,326.40" $186.66 $212.40 $186.66 $61.44 $128.73 $128.73 $43.01 $128.73 $0.00 $0.00 $0.00 $0.00 30201821 EAP CPT® 88365 Ebv Ish W/interp (so) BOTH IP/OP $574.00 $424.76 $0.00 $459.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.18 $102.18 $106.11 $0.00 $103.59 $0.00 $0.00 $0.00 $143.92 $156.90 $454.61 $459.20 $199.96 $0.00 $199.96 $110.38 $137.95 $137.95 $77.27 $137.07 $0.00 $0.00 $0.00 $0.00 30201822 EAP CPT® 88365 Ebv Ish W/o Interp (so) BOTH IP/OP $574.00 $424.76 $0.00 $459.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.18 $102.18 $106.11 $0.00 $103.59 $0.00 $0.00 $0.00 $143.92 $156.90 $454.61 $459.20 $199.96 $0.00 $199.96 $110.38 $137.95 $137.95 $77.27 $137.07 $0.00 $0.00 $0.00 $0.00 30201823 EAP CPT® 88275 Fish Burkitt Nhl T(8;14)(so) BOTH IP/OP $620.00 $458.80 $0.00 $496.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $366.73 $366.73 $53.75 $112.22 $491.04 $496.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30201824 EAP CPT® 88271 Fish Burkitt Dna Probe (so) BOTH IP/OP $404.00 $298.96 $0.00 $323.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $238.97 $238.97 $22.49 $59.86 $319.97 $323.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30201825 EAP CPT® 87902 Hcv Rna Genotype 1 Ns5b (so) BOTH IP/OP "$1,200.00 " $888.00 $0.00 $992.80 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $709.80 $709.80 $270.32 $243.70 $982.87 $992.80 $373.30 $0.00 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30201834 EAP CPT® 82656 Pancreatic Elastase Fecal BOTH IP/OP $273.00 $202.02 $0.00 $218.40 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $56.89 $7.49 $161.48 $161.48 $12.11 $29.88 $216.22 $218.40 $16.72 $0.00 $16.72 $42.72 $11.53 $11.53 $43.46 $11.53 $0.00 $0.00 $0.00 $0.00 30201835 EAP CPT® 87798 Detect Agent Nos Dna Amp BOTH IP/OP $252.00 $186.48 $0.00 $243.20 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $149.06 $149.06 $36.84 $54.82 $240.77 $243.20 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30201836 EAP CPT® 86356 Mononuclear Cell Antigen BOTH IP/OP $146.00 $108.04 $0.00 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.63 $39.63 $41.16 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201837 EAP CPT® 86355 Cells Total Count BOTH IP/OP $49.00 $36.26 $0.00 $49.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $49.00 $38.81 $39.20 $49.00 $49.00 $49.00 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30201838 EAP CPT® 86359 Cells Total Count BOTH IP/OP $49.00 $36.26 $18.86 $62.25 $48.63 $48.63 $37.73 $37.73 $18.87 $18.86 $35.77 $35.77 $37.14 $37.73 $34.80 $24.52 $28.98 $28.98 $39.62 $49.00 $38.81 $39.20 $49.00 $62.25 $49.00 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30201839 EAP CPT® 88365 Institu Hybridization (fish) BOTH IP/OP $262.00 $193.88 $0.00 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.18 $102.18 $106.11 $0.00 $103.59 $0.00 $0.00 $0.00 $143.92 $156.90 $205.92 $208.00 $199.96 $170.30 $199.96 $110.38 $137.95 $137.95 $77.27 $137.07 $0.00 $0.00 $0.00 $0.00 30201840 EAP CPT® 86808 Cytotoxic Antibody Screening BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.06 $45.06 $46.80 $0.00 $43.84 $0.00 $0.00 $0.00 $0.00 $82.94 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201841 EAP CPT® 86816 Hla Typing Dr/dq BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.30 $42.30 $43.92 $0.00 $41.15 $0.00 $0.00 $0.00 $0.00 $77.84 $272.45 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201842 EAP CPT® 86255 Fluorescent Antibody Screen BOTH IP/OP $25.00 $18.50 $6.03 $25.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $14.79 $14.79 $12.65 $25.00 $19.80 $20.00 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201843 EAP CPT® 86256 Fluorescent Antibody Titer BOTH IP/OP $25.00 $18.50 $6.03 $25.00 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $14.79 $14.79 $12.65 $25.00 $19.80 $20.00 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201844 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $407.00 $301.18 $2.61 $328.80 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $240.74 $240.74 $5.48 $14.60 $325.51 $328.80 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30201845 EAP CPT® 86317 "Immunoassay For Infectious Agent,ab,quant" BOTH IP/OP $31.00 $22.94 $0.00 $31.00 $24.79 $24.79 $14.99 $14.99 $7.50 $7.49 $18.22 $18.22 $18.92 $14.99 $17.72 $9.74 $18.34 $18.34 $15.74 $31.00 $24.55 $24.80 $21.74 $0.00 $21.74 $18.89 $14.99 $14.99 $13.22 $14.99 $0.00 $0.00 $0.00 $0.00 30201846 EAP CPT® 86001 Allergen Specific Igg Quant BOTH IP/OP $140.00 $103.60 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.92 $7.92 $8.23 $0.00 $7.72 $0.00 $0.00 $0.00 $0.00 $14.60 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201847 EAP CPT® 86003 Allergen Specific Ige BOTH IP/OP $140.00 $103.60 $2.61 $140.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $82.81 $82.81 $5.48 $14.60 $138.60 $140.00 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30201848 EAP CPT® 86147 Anti-cardiolipin Igg BOTH IP/OP $581.00 $429.94 $12.73 $580.80 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $343.66 $343.66 $26.72 $71.08 $574.99 $580.80 $36.90 $41.99 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30201849 EAP CPT® 86147 Anti-cardiolipin Igm BOTH IP/OP $581.00 $429.94 $12.73 $580.80 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $343.66 $343.66 $26.72 $71.08 $574.99 $580.80 $36.90 $41.99 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30201850 EAP CPT® 86757 Rmsf Igm Titer BOTH IP/OP $131.00 $96.94 $0.00 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $54.10 $129.89 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201856 EAP CPT® 81342 T-CELL REARRANGEMENT- PCR (RQD) BOTH IP/OP $667.00 $493.58 $0.00 $609.60 $415.93 $415.93 $201.50 $201.50 $100.75 $100.75 $285.90 $285.90 $296.89 $201.50 $192.65 $130.98 $394.53 $394.53 $0.00 $381.00 $603.50 $609.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201865 EAP Custom 30201865 Bcr/abl T(9;22) Fish (gen) BOTH IP/OP $663.00 $490.62 $0.00 $606.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.08 $492.08 $511.04 $0.00 $138.17 $0.00 $0.00 $0.00 $0.00 $379.00 $600.34 $606.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201869 EAP CPT® 81275 KRAS Gene Mutation Detection (RQD) BOTH IP/OP $952.00 $704.48 $86.96 $752.00 $298.80 $298.80 $193.25 $193.25 $96.63 $86.96 $205.38 $205.38 $213.28 $193.25 $220.85 $125.61 $563.11 $563.11 $202.91 $470.00 $744.48 $752.00 $280.21 $318.86 $280.21 $235.32 $193.25 $193.25 $164.72 $193.25 $0.00 $0.00 $0.00 $0.00 30201879 EAP CPT® 87906 "Integrase, Quest" BOTH IP/OP $793.00 $586.82 $0.00 $764.80 $90.02 $90.02 $128.73 $128.73 $64.37 $64.36 $63.81 $63.81 $66.27 $128.73 $57.67 $83.67 $469.06 $469.06 $135.17 $478.00 $757.15 $764.80 $186.66 $0.00 $186.66 $61.44 $128.73 $128.73 $43.01 $128.73 $0.00 $0.00 $0.00 $0.00 30201900 EAP CPT® 87999 "Trofile, Dna Monogram -quest" BOTH IP/OP "$3,182.00 " "$2,354.68" $0.00 "$2,545.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,361.68" "$2,361.68" "$2,452.69" $0.00 $663.13 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,520.14" "$2,545.60" $0.00 $390.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201914 EAP CPT® 81342 T-CELL REARRANGEMENT-PCR QD BOTH IP/OP $667.00 $493.58 $0.00 $609.60 $415.93 $415.93 $201.50 $201.50 $100.75 $100.75 $285.90 $285.90 $296.89 $201.50 $192.65 $130.98 $394.53 $394.53 $0.00 $381.00 $603.50 $609.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201926 EAP CPT® 81275 KRAS Gene Mutation Detect(RQD) BOTH IP/OP $823.00 $609.02 $0.00 $752.00 $298.80 $298.80 $193.25 $193.25 $96.63 $86.96 $205.38 $205.38 $213.28 $193.25 $220.85 $125.61 $486.80 $486.80 $202.91 $470.00 $744.48 $752.00 $280.21 $0.00 $280.21 $235.32 $193.25 $193.25 $164.72 $193.25 $0.00 $0.00 $0.00 $0.00 30201933 EAP CPT® 81270 Jak2 V617f Mutation Quant (so) BOTH IP/OP $981.00 $725.94 $45.83 $775.20 $189.21 $189.21 $91.66 $91.66 $45.83 $45.83 $130.06 $130.06 $135.06 $91.66 $84.58 $59.58 $580.26 $580.26 $96.24 $484.50 $767.45 $775.20 $132.91 $151.24 $132.91 $90.12 $91.66 $91.66 $63.08 $91.66 $0.00 $0.00 $0.00 $0.00 30201934 EAP CPT® 87906 "INTEGRASE, QUEST" BOTH IP/OP $649.00 $480.26 $0.00 $625.60 $90.02 $90.02 $128.73 $128.73 $64.37 $64.36 $63.81 $63.81 $66.27 $128.73 $57.67 $83.67 $383.88 $383.88 $135.17 $391.00 $619.34 $625.60 $186.66 $0.00 $186.66 $61.44 $128.73 $128.73 $43.01 $128.73 $0.00 $0.00 $0.00 $0.00 30201936 EAP CPT® 81402 MPL ANAL Mutation Anal (RQD) BOTH IP/OP "$1,430.00 " "$1,058.20" $0.00 "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,061.35" "$1,061.35" "$1,102.24" $0.00 $192.65 $0.00 $0.00 $0.00 $0.00 $817.00 "$1,294.13" "$1,307.20" $0.00 "$1,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201955 EAP CPT® 87999 "TROFILE, DNA Monogram -Quest" BOTH IP/OP "$3,030.00 " "$2,242.20" $0.00 "$2,424.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,248.87" "$2,248.87" "$2,335.52" $0.00 $631.45 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,399.76" "$2,424.00" $0.00 $390.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201958 EAP CPT® 86703 Focus Hiv 1/2 Ab Scrn BOTH IP/OP $265.00 $196.10 $6.85 $213.60 $28.30 $28.30 $18.29 $18.29 $9.15 $6.85 $20.82 $20.82 $21.62 $18.29 $17.58 $11.89 $156.75 $156.75 $19.20 $38.34 $211.46 $213.60 $19.88 $30.18 $19.88 $18.73 $18.29 $18.29 $13.11 $18.29 $0.00 $0.00 $0.00 $0.00 30201959 EAP CPT® 86689 Focus Hiv Wb BOTH IP/OP $388.00 $287.12 $0.00 $320.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $24.81 $0.00 $0.00 $0.00 $0.00 $54.10 $317.59 $320.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201960 EAP CPT® 86360 Focus Lymphocyte Subsets BOTH IP/OP $495.00 $366.30 $23.49 $400.00 $96.99 $96.99 $46.98 $46.98 $23.49 $23.49 $71.34 $71.34 $74.09 $46.98 $69.42 $30.54 $292.79 $292.79 $49.33 $131.30 $396.00 $400.00 $68.12 $77.52 $68.12 $73.96 $46.98 $46.98 $51.77 $46.98 $0.00 $0.00 $0.00 $0.00 30201961 EAP CPT® 86317 Strep Pneumoniae Igg Ab Panel (so) BOTH IP/OP $308.00 $227.92 $7.49 $224.00 $24.79 $24.79 $14.99 $14.99 $7.50 $7.49 $18.22 $18.22 $18.92 $14.99 $17.72 $9.74 $182.18 $182.18 $15.74 $33.54 $221.76 $224.00 $21.74 $24.73 $21.74 $18.89 $14.99 $14.99 $13.22 $14.99 $0.00 $0.00 $0.00 $0.00 30201962 EAP Custom 30201962 Fragile X Southern Blot (so) BOTH IP/OP $208.00 $153.92 $0.00 $166.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.38 $154.38 $160.33 $0.00 $43.35 $0.00 $0.00 $0.00 $0.00 $104.00 $164.74 $166.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201965 EAP CPT® 81291 Mthfr Mutation Analysis (so) BOTH IP/OP $331.00 $244.94 $29.40 $261.60 $90.10 $90.10 $65.34 $65.34 $32.67 $29.40 $61.93 $61.93 $64.31 $65.34 $46.99 $42.47 $195.79 $195.79 $68.61 $163.50 $258.98 $261.60 $94.74 $107.81 $94.74 $50.07 $65.34 $65.34 $35.05 $65.34 $0.00 $0.00 $0.00 $0.00 30201966 EAP CPT® 81241 FACTOR V LEIDEN MUTATION BOTH IP/OP $331.00 $244.94 $33.02 $261.60 $126.14 $126.14 $73.37 $73.37 $36.69 $33.02 $86.70 $86.70 $90.04 $73.37 $46.99 $47.69 $195.79 $195.79 $77.04 $163.50 $258.98 $261.60 $106.39 $121.06 $106.39 $50.07 $73.37 $73.37 $35.05 $73.37 $0.00 $0.00 $0.00 $0.00 30201967 EAP CPT® 81240 FACTOR II (PT) GENE MUTATION BOTH IP/OP $331.00 $244.94 $29.56 $261.60 $101.59 $101.59 $65.69 $65.69 $32.85 $29.56 $69.82 $69.82 $72.50 $65.69 $46.99 $42.70 $195.79 $195.79 $68.97 $163.50 $258.98 $261.60 $95.25 $108.39 $95.25 $50.07 $65.69 $65.69 $35.05 $65.69 $0.00 $0.00 $0.00 $0.00 30201968 EAP CPT® 81220 CYSTIC FIB 97 MUTATION RQD BOTH IP/OP "$1,038.00 " $768.12 $250.47 "$1,201.65" $789.36 $789.36 $556.60 $556.60 $278.30 $250.47 $770.40 $770.40 $800.09 $556.60 "$1,038.00" $361.79 $613.98 $613.98 $584.43 $512.50 $811.80 $820.00 $807.07 $918.39 $807.07 "$1,201.65" $556.60 $556.60 $841.15 $556.60 $0.00 $0.00 $0.00 $0.00 30201974 EAP CPT® 81406 MEN2 (RET) DNA SEQ(ATHENA) BOTH IP/OP "$5,489.00 " "$4,061.86" $0.00 "$5,017.60" $237.60 $237.60 $282.88 $282.88 $141.44 $127.30 "$4,073.94" "$4,073.94" "$4,230.92" $282.88 $610.87 $183.87 "$3,246.74" "$3,246.74" $0.00 "$3,136.00" "$4,967.42" "$5,017.60" $0.00 $466.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201975 EAP CPT® 81401 Huntington's Dna (so) BOTH IP/OP "$1,288.00 " $953.12 $61.65 "$1,017.60" $64.94 $64.94 $137.00 $137.00 $68.50 $61.65 $955.95 $955.95 $992.79 $137.00 $131.58 $89.05 $761.85 $761.85 $143.85 $636.00 "$1,007.42" "$1,017.60" $198.65 $226.05 $198.65 $140.20 $137.00 $137.00 $98.14 $137.00 $0.00 $0.00 $0.00 $0.00 30201977 EAP CPT® 81256 HERED HEMOCHROM DNA ANAL RQD BOTH IP/OP $575.00 $425.50 $0.00 $575.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.74 $92.74 $96.30 $0.00 $46.99 $0.00 $0.00 $0.00 $68.63 $284.00 $449.86 $454.40 $94.77 $575.00 $94.77 $50.07 $65.36 $65.36 $35.05 $65.36 $0.00 $0.00 $0.00 $0.00 30201980 EAP CPT® 86003 Allergen Specific Ige (so) BOTH IP/OP $40.00 $29.60 $2.61 $32.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $23.66 $23.66 $5.48 $14.60 $31.68 $32.00 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30201983 EAP CPT® 86003 Allergen Specific (food) Ige (so) BOTH IP/OP $40.00 $29.60 $2.61 $32.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $23.66 $23.66 $5.48 $14.60 $31.68 $32.00 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30201984 EAP CPT® 86003 Allergen Specific (enviro) Ige (so) BOTH IP/OP $40.00 $29.60 $2.61 $32.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $23.66 $23.66 $5.48 $14.60 $31.68 $32.00 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30201985 EAP CPT® 80074 Acute Hepatitis Panel BOTH IP/OP $890.00 $658.60 $0.00 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.32 $72.32 $75.10 $0.00 $70.35 $0.00 $0.00 $0.00 $0.00 $133.08 $704.88 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201986 EAP CPT® 86790 "Hantavirus Antibody (igg, Igm) (so)" BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $165.62 $165.62 $13.52 $36.00 $221.76 $224.00 $18.68 $0.00 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30201987 EAP CPT® 86332 Immune Complex Detection By C1q Binding (so) BOTH IP/OP $34.00 $25.16 $0.00 $38.44 $34.00 $34.00 $24.37 $24.37 $12.19 $12.19 $37.01 $37.01 $38.44 $24.37 $34.00 $15.84 $20.11 $20.11 $25.59 $34.00 $26.93 $27.20 $34.00 $0.00 $34.00 $38.36 $24.37 $24.37 $26.85 $24.37 $0.00 $0.00 $0.00 $0.00 30201988 EAP CPT® 86255 Ampa -receptor Antibody (so) Mayo BOTH IP/OP $379.00 $280.46 $6.03 $379.20 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $224.18 $224.18 $12.65 $33.68 $375.41 $379.20 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201989 EAP CPT® 86255 "Nmda -receptor Antibody, Serum (mml)" BOTH IP/OP $358.00 $264.92 $6.03 $358.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $211.76 $211.76 $12.65 $33.68 $354.82 $358.40 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30201990 EAP CPT® 86790 "Chikungunya Antibodies (igg, Igm) (so)" BOTH IP/OP $380.00 $281.20 $6.44 $304.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $224.77 $224.77 $13.52 $36.00 $300.96 $304.00 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30201991 EAP CPT® 86790 "Chikungunya Antibodies (igg, Titration) (so)" BOTH IP/OP $380.00 $281.20 $6.44 $304.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $224.77 $224.77 $13.52 $36.00 $300.96 $304.00 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30201992 EAP CPT® 86790 Chikungunya Antibodies (igm Titration) (so) BOTH IP/OP $380.00 $281.20 $6.44 $304.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $224.77 $224.77 $13.52 $36.00 $300.96 $304.00 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30201993 EAP CPT® 86357 Natural Killer Cells (so) BOTH IP/OP $83.00 $61.42 $0.00 $68.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $68.11 $68.80 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30201994 EAP CPT® 83516 Myositis Antibody Panel (mml) BOTH IP/OP $707.00 $523.18 $5.76 $638.40 $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $418.19 $418.19 $12.11 $29.88 $632.02 $638.40 $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30201995 EAP CPT® 82017 "Acylcarnitine,plasma(so)" BOTH IP/OP $117.00 $86.58 $0.00 $117.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $25.62 $26.60 $0.00 $24.92 $0.00 $0.00 $0.00 $0.00 $47.14 $93.46 $94.40 $0.00 $117.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201996 EAP CPT® 87305 "Aspergillus Antigen, Eia, Serum(so)" BOTH IP/OP $114.00 $84.36 $5.99 $92.00 $24.74 $24.74 $11.98 $11.98 $5.99 $5.99 $18.22 $18.22 $18.92 $11.98 $17.71 $7.79 $67.43 $67.43 $12.58 $33.52 $91.08 $92.00 $17.37 $19.77 $17.37 $18.87 $11.98 $11.98 $13.21 $11.98 $0.00 $0.00 $0.00 $0.00 30201997 EAP CPT® 87254 "Viral Respiratory,rapid Culture With Reflex(so)" BOTH IP/OP $425.00 $314.50 $0.00 $342.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $54.64 $338.98 $342.40 $0.00 $250.00 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30201998 EAP CPT® 82397 Anti-mullerian Hormone Assessr™(so) BOTH IP/OP $296.00 $219.04 $7.06 $230.40 $29.15 $29.15 $14.12 $14.12 $7.06 $7.06 $21.46 $21.46 $22.28 $14.12 $20.87 $9.18 $175.08 $175.08 $14.83 $39.48 $228.10 $230.40 $20.47 $23.30 $20.47 $22.24 $14.12 $14.12 $15.57 $14.12 $0.00 $0.00 $0.00 $0.00 30201999 EAP CPT® 87906 Hiv-1 Integrase Genotype(so) BOTH IP/OP $225.00 $166.50 $43.01 $212.40 $90.02 $90.02 $128.73 $128.73 $64.37 $64.36 $63.81 $63.81 $66.27 $128.73 $57.67 $83.67 $133.09 $133.09 $135.17 $113.50 $179.78 $181.60 $186.66 $212.40 $186.66 $61.44 $128.73 $128.73 $43.01 $128.73 $0.00 $0.00 $0.00 $0.00 30202000 EAP CPT® 87798 "Hpv 8 Dna,qual(so)" BOTH IP/OP $418.00 $309.32 $17.55 $336.80 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $247.25 $247.25 $36.84 $54.82 $333.43 $336.80 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30202001 EAP CPT® 86316 "Chromgranin A,ecl" BOTH IP/OP $221.00 $163.54 $10.41 $178.40 $42.95 $42.95 $20.81 $20.81 $10.41 $10.41 $31.60 $31.60 $32.81 $20.81 $30.73 $13.53 $130.72 $130.72 $21.85 $58.14 $176.62 $178.40 $30.17 $34.34 $30.17 $32.75 $20.81 $20.81 $22.92 $20.81 $0.00 $0.00 $0.00 $0.00 30202002 EAP CPT® 83516 Euromyelitis Optica(so) BOTH IP/OP "$1,413.00 " "$1,045.62" $5.76 "$1,099.20" $22.04 $22.04 $11.53 $11.53 $5.77 $5.76 $16.23 $16.23 $16.86 $11.53 $15.80 $7.49 $835.79 $835.79 $12.11 $29.88 "$1,088.21" "$1,099.20" $16.72 $19.02 $16.72 $16.84 $11.53 $11.53 $11.79 $11.53 $0.00 $0.00 $0.00 $0.00 30202003 EAP CPT® 86336 Inhibin A(so) BOTH IP/OP $89.00 $65.86 $7.79 $72.00 $26.74 $26.74 $15.59 $15.59 $7.80 $7.79 $19.66 $19.66 $20.41 $15.59 $19.12 $10.13 $52.64 $52.64 $16.37 $36.18 $71.28 $72.00 $22.61 $25.72 $22.61 $20.37 $15.59 $15.59 $14.26 $15.59 $0.00 $0.00 $0.00 $0.00 30202004 EAP CPT® 82397 Inhibin B(so) BOTH IP/OP $427.00 $315.98 $7.06 $332.00 $29.15 $29.15 $14.12 $14.12 $7.06 $7.06 $21.46 $21.46 $22.28 $14.12 $20.87 $9.18 $252.57 $252.57 $14.83 $39.48 $328.68 $332.00 $20.47 $23.30 $20.47 $22.24 $14.12 $14.12 $15.57 $14.12 $0.00 $0.00 $0.00 $0.00 30202005 EAP CPT® 88271 "Fish, Myeloma Chrom Cep 9,11,15 Dna Probe (so)" BOTH IP/OP $638.00 $472.12 $10.71 $510.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $377.38 $377.38 $22.49 $59.86 $505.30 $510.40 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30202006 EAP CPT® 88275 "Fish, Myeloma Chrom Cep 9,11,15 Hybridization(so)" BOTH IP/OP $354.00 $261.96 $0.00 $283.20 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $209.39 $209.39 $53.75 $112.22 $280.37 $283.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30202007 EAP CPT® 88271 "Fish, Myeloma 17p-,rea14q32 (so) Dna Probe (so)" BOTH IP/OP "$4,290.00 " "$3,174.60" $10.71 "$3,408.80" $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 "$2,537.54" "$2,537.54" $22.49 $59.86 "$3,374.71" "$3,408.80" $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30202008 EAP CPT® 88275 "Fish, Myeloma 17p-,rea14q32(so) Hybridization(so)" BOTH IP/OP $601.00 $444.74 $23.04 $477.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $355.49 $355.49 $53.75 $112.22 $472.82 $477.60 $74.23 $84.46 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30202009 EAP CPT® 88271 "Fish, Myeloma Igh Panel(so) Dna Probe (so)" BOTH IP/OP "$2,092.00 " "$1,548.08" $10.71 "$1,662.40" $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 "$1,237.42" "$1,237.42" $22.49 $59.86 "$1,645.78" "$1,662.40" $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 30202010 EAP CPT® 88275 "Fish, Myeloma Igh Panel(so) Hybridization(so)" BOTH IP/OP "$1,046.00 " $774.04 $23.04 $831.20 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $618.71 $618.71 $53.75 $112.22 $822.89 $831.20 $74.23 $84.46 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 30202011 EAP CPT® 81596 "Liver Fibrosis, Fibro Test-actitest Panel (so)" BOTH IP/OP "$1,021.00 " $755.54 $32.49 $807.20 $108.64 $108.64 $72.19 $72.19 $36.10 $32.49 $75.08 $75.08 $77.97 $72.19 $67.84 $46.92 $603.92 $603.92 $75.80 $504.50 $799.13 $807.20 $104.68 $119.11 $104.68 $72.29 $72.19 $72.19 $50.60 $72.19 $0.00 $0.00 $0.00 $0.00 30202012 EAP CPT® 87535 "Hiv-1, Rna Qualitative Tma(so)" BOTH IP/OP $347.00 $256.78 $17.55 $269.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $205.25 $205.25 $36.84 $54.82 $266.90 $269.60 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30202013 EAP CPT® 87140 "Viral Id, Respiratory(so)" BOTH IP/OP $349.00 $258.26 $0.00 $349.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.47 $8.47 $8.79 $0.00 $8.23 $0.00 $0.00 $0.00 $0.00 $15.58 $276.41 $279.20 $0.00 $349.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30202015 EAP CPT® 81420 Qnatal Advanced(so) BOTH IP/OP "$2,554.00 " "$1,889.96" $341.57 "$2,018.40" "$1,207.35" "$1,207.35" $759.05 $759.05 $379.53 $341.57 "$1,895.58" "$1,895.58" "$1,968.62" $759.05 $754.02 $493.38 "$1,510.69" "$1,510.69" $797.00 "$1,261.50" "$1,998.22" "$2,018.40" "$1,100.62" "$1,252.43" "$1,100.62" $803.42 $759.05 $759.05 $562.40 $759.05 $0.00 $0.00 $0.00 $0.00 30202016 EAP CPT® 83835 "Metanephrines,frac,ur(so)" BOTH IP/OP $81.00 $59.94 $8.47 $60.00 $34.98 $34.98 $16.94 $16.94 $8.47 $8.47 $25.73 $25.73 $26.72 $16.94 $25.02 $11.01 $47.91 $47.91 $17.79 $47.34 $59.40 $60.00 $24.56 $27.95 $24.56 $26.66 $16.94 $16.94 $18.66 $16.94 $0.00 $0.00 $0.00 $0.00 30202017 EAP CPT® 87305 "Aspergillus Antigen,eia(so)" BOTH IP/OP $103.00 $76.22 $5.99 $83.20 $24.74 $24.74 $11.98 $11.98 $5.99 $5.99 $18.22 $18.22 $18.92 $11.98 $17.71 $7.79 $60.92 $60.92 $12.58 $33.52 $82.37 $83.20 $17.37 $19.77 $17.37 $18.87 $11.98 $11.98 $13.21 $11.98 $0.00 $0.00 $0.00 $0.00 30202018 EAP CPT® 86701 Hiv-1 Confirmation BOTH IP/OP $197.00 $145.78 $4.44 $158.40 $18.35 $18.35 $8.89 $8.89 $4.45 $4.44 $13.48 $13.48 $14.00 $8.89 $11.39 $5.78 $116.53 $116.53 $9.33 $24.82 $156.82 $158.40 $12.89 $14.67 $12.89 $12.14 $8.89 $8.89 $8.50 $8.89 $0.00 $0.00 $0.00 $0.00 30202019 EAP CPT® 86702 Hiv-2 Confirmation BOTH IP/OP $238.00 $176.12 $6.76 $192.00 $27.90 $27.90 $13.52 $13.52 $6.76 $6.76 $20.53 $20.53 $21.32 $13.52 $17.33 $8.79 $140.78 $140.78 $14.20 $37.76 $190.08 $192.00 $19.60 $22.31 $19.60 $18.46 $13.52 $13.52 $12.92 $13.52 $0.00 $0.00 $0.00 $0.00 30202020 EAP CPT® 86666 Anaplasma Phaggocytopilium Ab (so) BOTH IP/OP $398.00 $294.52 $0.00 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.44 $15.44 $16.04 $0.00 $15.04 $0.00 $0.00 $0.00 $0.00 $28.44 $392.04 $396.00 $0.00 $241.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30202021 EAP CPT® 87798 "Pneumocysttis Jirovecii, Qual Rt Pcr (so)" BOTH IP/OP $448.00 $331.52 $17.55 $361.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $264.99 $264.99 $36.84 $54.82 $357.98 $361.60 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30202022 EAP CPT® 86790 Chikungunya Ab Reflex To Titer (so) BOTH IP/OP $219.00 $162.06 $6.44 $160.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $129.54 $129.54 $13.52 $36.00 $158.40 $160.00 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30202024 EAP CPT® 81255 Tay-sachs Disease Mutation Anal (so) BOTH IP/OP $304.00 $224.96 $0.00 $277.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.63 $225.63 $234.32 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $173.50 $274.82 $277.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30202025 EAP CPT® 86738 Mycoplasma Pneumoniae Ab Cf Csf (so) BOTH IP/OP $117.00 $86.58 $0.00 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $6.62 $20.11 $20.11 $20.89 $13.24 $19.57 $8.61 $69.21 $69.21 $13.90 $37.02 $95.83 $96.80 $19.20 $0.00 $19.20 $20.85 $13.24 $13.24 $14.60 $13.24 $0.00 $0.00 $0.00 $0.00 30202026 EAP CPT® 87902 Hepatitis C Viral Rna Ns3 Genotype(so) BOTH IP/OP $339.00 $250.86 $96.09 $424.79 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $200.52 $200.52 $270.32 $243.70 $260.57 $263.20 $329.00 $424.79 $329.00 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30202027 EAP CPT® 87902 "Hepatitis C Viral Rna, (so)" BOTH IP/OP $671.00 $496.54 $96.09 $520.80 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $396.90 $396.90 $270.32 $243.70 $515.59 $520.80 $373.30 $424.79 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30250310 EAP CPT® 86256 Mitochondrial Ab Titer BOTH IP/OP $70.00 $51.80 $0.00 $70.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $41.41 $41.41 $12.65 $33.68 $69.70 $70.40 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30250311 EAP CPT® 83519 Alp Sub Pit Glycoprotein Horm BOTH IP/OP $850.00 $629.00 $8.28 $767.20 $27.88 $27.88 $18.40 $18.40 $9.20 $8.28 $20.52 $20.52 $21.31 $18.40 $19.96 $11.96 $502.78 $502.78 $19.32 $37.76 $759.53 $767.20 $26.68 $30.36 $26.68 $21.27 $18.40 $18.40 $14.89 $18.40 $0.00 $0.00 $0.00 $0.00 30250312 EAP CPT® 87624 mRNA BOTH IP/OP $101.00 $74.74 $15.99 $78.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $27.77 $27.77 $28.84 $35.09 $21.44 $22.81 $59.74 $59.74 $36.84 $49.00 $77.62 $78.40 $50.88 $57.90 $50.88 $22.85 $35.09 $35.09 $15.99 $35.09 $0.00 $0.00 $0.00 $0.00 30250313 EAP CPT® 86021 C-anca Titer BOTH IP/OP $34.00 $25.16 $0.00 $34.00 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $20.11 $20.11 $15.80 $34.00 $26.93 $27.20 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30250314 EAP CPT® 86021 P-anca Titer BOTH IP/OP $34.00 $25.16 $0.00 $34.00 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $20.11 $20.11 $15.80 $34.00 $26.93 $27.20 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30250315 EAP CPT® 86021 Atypical P-anca Titer BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $47.32 $47.32 $15.80 $42.06 $63.36 $64.00 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30250316 EAP CPT® 86638 Q Fever Igg Phase I Titer BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30250317 EAP CPT® 86638 Q Fever Igg Phase Ii Titer BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30250318 EAP CPT® 86638 Q Fever Igm Phase I Titer BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30250320 EAP CPT® 86611 B.henselae Igg Titer BOTH IP/OP $50.00 $37.00 $0.00 $50.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $29.58 $29.58 $10.69 $28.44 $49.90 $50.40 $14.76 $0.00 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30250321 EAP CPT® 86611 B.henselae Igm Titer BOTH IP/OP $50.00 $37.00 $0.00 $50.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $29.58 $29.58 $10.69 $28.44 $49.90 $50.40 $14.76 $0.00 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30250322 EAP CPT® 86611 B.quintana Igg Titer BOTH IP/OP $50.00 $37.00 $0.00 $50.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $29.58 $29.58 $10.69 $28.44 $49.90 $50.40 $14.76 $0.00 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30250323 EAP CPT® 86611 B.quintana Igm Titer BOTH IP/OP $50.00 $37.00 $0.00 $50.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $29.58 $29.58 $10.69 $28.44 $49.90 $50.40 $14.76 $0.00 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30250325 EAP CPT® 86003 Allergen Specific Ige Tilapia (so) BOTH IP/OP $200.00 $148.00 $2.61 $199.20 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $118.30 $118.30 $5.48 $14.60 $197.21 $199.20 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30250326 EAP CPT® 86003 Allergen Specific Ige Trout (so) BOTH IP/OP $136.00 $100.64 $2.61 $136.00 $10.77 $10.77 $5.22 $5.22 $2.61 $2.61 $7.92 $7.92 $8.23 $5.22 $7.72 $3.39 $80.44 $80.44 $5.48 $14.60 $134.64 $136.00 $7.57 $8.61 $7.57 $8.22 $5.22 $5.22 $5.76 $5.22 $0.00 $0.00 $0.00 $0.00 30250327 EAP CPT® 86790 Hepatitis A Igg BOTH IP/OP $328.00 $242.72 $6.44 $240.00 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $194.01 $194.01 $13.52 $36.00 $237.60 $240.00 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30250328 EAP CPT® 87389 Hiv-1 Ag With Hiv-1/2 Ab BOTH IP/OP $306.00 $226.44 $12.04 $237.60 $49.71 $49.71 $24.08 $24.08 $12.04 $12.04 $35.48 $35.48 $36.85 $24.08 $32.07 $15.65 $181.00 $181.00 $25.28 $148.50 $235.22 $237.60 $34.92 $39.73 $34.92 $34.17 $24.08 $24.08 $23.92 $24.08 $0.00 $0.00 $0.00 $0.00 30250329 EAP CPT® 86255 "Ds-dna An, Crithidia Titer" BOTH IP/OP $150.00 $111.00 $0.00 $150.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $88.73 $88.73 $12.65 $33.68 $148.90 $150.40 $17.47 $0.00 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30250340 EAP CPT® 86361 Absolute Cd4 Count BOTH IP/OP $117.00 $86.58 $0.00 $97.60 $53.91 $53.91 $26.78 $26.78 $13.39 $13.39 $39.63 $39.63 $41.16 $26.78 $38.56 $17.41 $69.21 $69.21 $28.12 $72.94 $96.62 $97.60 $38.83 $0.00 $38.83 $41.08 $26.78 $26.78 $28.76 $26.78 $0.00 $0.00 $0.00 $0.00 30250342 EAP CPT® 86038 Ana Ifa W/reflex (so) BOTH IP/OP $219.00 $162.06 $6.04 $166.40 $24.95 $24.95 $12.09 $12.09 $6.05 $6.04 $18.36 $18.36 $19.06 $12.09 $17.86 $7.86 $129.54 $129.54 $12.69 $33.78 $164.74 $166.40 $17.53 $19.95 $17.53 $19.03 $12.09 $12.09 $13.32 $12.09 $0.00 $0.00 $0.00 $0.00 30250380 EAP CPT® 86790 Chikungunya Igg Titer(so) BOTH IP/OP $210.00 $155.40 $6.44 $153.60 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $124.22 $124.22 $13.52 $36.00 $152.06 $153.60 $18.68 $21.25 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30250381 EAP CPT® 86790 Chikungunya Igm Titer(so) BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $26.58 $26.58 $12.88 $12.88 $6.44 $6.44 $19.56 $19.56 $20.31 $12.88 $19.03 $8.37 $113.57 $113.57 $13.52 $36.00 $152.06 $153.60 $18.68 $0.00 $18.68 $20.27 $12.88 $12.88 $14.19 $12.88 $0.00 $0.00 $0.00 $0.00 30250382 EAP CPT® 86039 "Ana Screen Ifa, W/titer And Pattern" BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.95 $16.95 $17.60 $0.00 $16.50 $0.00 $0.00 $0.00 $0.00 $31.20 $112.46 $113.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30250383 EAP CPT® 86713 "Legionella Pneumophila Ab (igg), Ifa (so)" BOTH IP/OP $104.00 $76.96 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.24 $23.24 $24.14 $0.00 $22.62 $0.00 $0.00 $0.00 $0.00 $42.78 $83.16 $84.00 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30250384 EAP CPT® 86255 Copeptin (so) BOTH IP/OP $43.00 $31.82 $6.03 $34.40 $24.87 $24.87 $12.05 $12.05 $6.03 $6.03 $18.30 $18.30 $19.01 $12.05 $17.81 $7.83 $25.43 $25.43 $12.65 $33.68 $34.06 $34.40 $17.47 $19.88 $17.47 $18.97 $12.05 $12.05 $13.28 $12.05 $0.00 $0.00 $0.00 $0.00 30250390 EAP CPT® 86695 Hsv 1 Igg (so) BOTH IP/OP $59.00 $43.66 $6.59 $45.60 $27.22 $27.22 $13.19 $13.19 $6.60 $6.59 $20.02 $20.02 $20.79 $13.19 $19.49 $8.57 $34.90 $34.90 $13.85 $36.86 $45.14 $45.60 $19.13 $21.76 $19.13 $20.76 $13.19 $13.19 $14.54 $13.19 $0.00 $0.00 $0.00 $0.00 30250391 EAP CPT® 86696 Hsv 2 Igg (so) BOTH IP/OP $59.00 $43.66 $9.68 $54.10 $39.94 $39.94 $19.35 $19.35 $9.68 $9.68 $29.39 $29.39 $30.52 $19.35 $28.60 $12.58 $34.90 $34.90 $20.32 $54.10 $45.14 $45.60 $28.06 $31.93 $28.06 $30.48 $19.35 $19.35 $21.33 $19.35 $0.00 $0.00 $0.00 $0.00 30250392 EAP CPT® 86696 Hsv 2 Igg Inhibition (so) BOTH IP/OP $400.00 $296.00 $9.68 $310.40 $39.94 $39.94 $19.35 $19.35 $9.68 $9.68 $29.39 $29.39 $30.52 $19.35 $28.60 $12.58 $236.60 $236.60 $20.32 $54.10 $307.30 $310.40 $28.06 $31.93 $28.06 $30.48 $19.35 $19.35 $21.33 $19.35 $0.00 $0.00 $0.00 $0.00 30250395 EAP CPT® 86235 Myositis Specific 11 Ab Nuclear Ag (so) BOTH IP/OP $107.00 $79.18 $8.97 $82.40 $37.01 $37.01 $17.93 $17.93 $8.97 $8.97 $27.23 $27.23 $28.27 $17.93 $26.49 $11.65 $63.29 $63.29 $18.83 $50.12 $81.58 $82.40 $26.00 $29.58 $26.00 $28.23 $17.93 $17.93 $19.76 $17.93 $0.00 $0.00 $0.00 $0.00 30250396 EAP CPT® 88365 KAPPA/LAMBDA ISH BOTH IP/OP $251.00 $185.74 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.18 $102.18 $106.11 $0.00 $103.59 $0.00 $0.00 $0.00 $143.92 $156.90 $198.00 $200.00 $199.96 $163.15 $199.96 $110.38 $137.95 $137.95 $77.27 $137.07 $0.00 $0.00 $0.00 $0.00 30250397 EAP CPT® 88366 KAPPA/LAMBDA ISH BOTH IP/OP $251.00 $185.74 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.94 $155.94 $161.94 $0.00 $52.31 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $163.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30250400 EAP CPT® 86328 Ia Infectious Ag Ab Sars-cov2 Covid 19 BOTH IP/OP $151.00 $111.74 $0.00 $120.00 $119.41 $119.41 $0.00 $0.00 $22.62 $57.41 $0.00 $0.00 $0.00 $0.00 $57.41 $0.00 $89.32 $89.32 $47.49 $75.00 $118.80 $120.00 $65.58 $74.71 $65.58 $23.48 $45.23 $45.23 $23.88 $45.23 $0.00 $0.00 $0.00 $0.00 30250401 EAP CPT® 86769 Sars-cov-2 Covid-19 Antibody BOTH IP/OP $55.00 $40.70 $0.00 $59.15 $0.00 $0.00 $0.00 $0.00 $0.00 $57.41 $0.00 $0.00 $0.00 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $59.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500001 EAP CPT® 85002 "Bleeding Time, Temp" BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.83 $6.83 $7.10 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $12.58 $86.33 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500002 EAP CPT® 85007 Misc. Smear BOTH IP/OP $102.00 $75.48 $1.72 $80.80 $7.08 $7.08 $3.80 $3.80 $1.90 $1.72 $5.22 $5.22 $5.42 $3.80 $5.08 $2.47 $60.33 $60.33 $3.99 $9.62 $79.99 $80.80 $5.51 $6.27 $5.51 $5.41 $3.80 $3.80 $3.79 $3.80 $0.00 $0.00 $0.00 $0.00 30500003 EAP CPT® 85576 Bld Plat Agg - Teg BOTH IP/OP $442.00 $327.08 $11.21 $321.60 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $261.44 $261.44 $26.16 $60.02 $318.38 $321.60 $36.12 $41.10 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30500004 EAP CPT® 85384 Fibrinogen Act - Teg BOTH IP/OP $207.00 $153.18 $4.37 $150.40 $17.53 $17.53 $9.72 $9.72 $4.86 $4.37 $12.90 $12.90 $13.39 $9.72 $12.55 $6.32 $122.44 $122.44 $10.21 $23.74 $148.90 $150.40 $14.09 $16.04 $14.09 $13.37 $9.72 $9.72 $9.36 $9.72 $0.00 $0.00 $0.00 $0.00 30500005 EAP CPT® 85008 Rbc Morphology Exam BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $7.08 $7.08 $3.43 $3.43 $1.72 $1.72 $5.22 $5.22 $5.42 $3.43 $5.08 $2.23 $49.09 $49.09 $3.60 $9.62 $65.74 $66.40 $4.97 $0.00 $4.97 $5.41 $3.43 $3.43 $3.79 $3.43 $0.00 $0.00 $0.00 $0.00 30500006 EAP CPT® 85008 "Rbc, Schistocyte Cnt" BOTH IP/OP $91.00 $67.34 $1.72 $66.40 $7.08 $7.08 $3.43 $3.43 $1.72 $1.72 $5.22 $5.22 $5.42 $3.43 $5.08 $2.23 $53.83 $53.83 $3.60 $9.62 $65.74 $66.40 $4.97 $5.66 $4.97 $5.41 $3.43 $3.43 $3.79 $3.43 $0.00 $0.00 $0.00 $0.00 30500007 EAP CPT® 85013 Hematocrit Count BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.60 $3.60 $3.74 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $6.62 $40.39 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500008 EAP CPT® 85013 "Hematocrit, Fld - Spun" BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.60 $3.60 $3.74 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $6.62 $40.39 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500009 EAP CPT® 85347 "Coag Time, Activated-teg" BOTH IP/OP $293.00 $216.82 $2.13 $212.80 $8.79 $8.79 $4.28 $4.28 $2.14 $2.13 $6.47 $6.47 $6.72 $4.28 $6.30 $2.78 $173.31 $173.31 $4.49 $11.90 $210.67 $212.80 $6.21 $7.06 $6.21 $6.71 $4.28 $4.28 $4.70 $4.28 $0.00 $0.00 $0.00 $0.00 30500010 EAP CPT® 85013 "Hematocrit, Spun Cap" BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.60 $3.60 $3.74 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $6.62 $40.39 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500011 EAP CPT® 85013 "Hematocrit,csf-spun" BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.60 $3.60 $3.74 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $6.62 $40.39 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500012 EAP CPT® 85014 Hematocrit BOTH IP/OP $58.00 $42.92 $0.00 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.60 $3.60 $3.74 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $6.62 $45.94 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500013 EAP CPT® 85390 Fibrinolysins Scrn -teg BOTH IP/OP $134.00 $99.16 $0.00 $134.00 $10.69 $10.69 $15.48 $15.48 $7.74 $6.97 $7.84 $7.84 $8.14 $15.48 $7.63 $10.06 $79.26 $79.26 $0.00 $14.44 $96.62 $97.60 $0.00 $134.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500015 EAP CPT® 85018 "Hemoglobin, Micro(meter)" BOTH IP/OP $51.00 $37.74 $1.18 $40.80 $4.88 $4.88 $2.37 $2.37 $1.19 $1.18 $3.60 $3.60 $3.74 $2.37 $3.50 $1.54 $30.17 $30.17 $2.49 $6.62 $40.39 $40.80 $3.44 $3.91 $3.44 $3.73 $2.37 $2.37 $2.61 $2.37 $0.00 $0.00 $0.00 $0.00 30500016 EAP CPT® 86022 Platelet Antibody Screen Indirect (so) BOTH IP/OP $362.00 $267.88 $0.00 $289.60 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $214.12 $214.12 $0.00 $51.32 $286.70 $289.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500017 EAP CPT® 85018 Hgb & Hct BOTH IP/OP $51.00 $37.74 $1.18 $40.80 $4.88 $4.88 $2.37 $2.37 $1.19 $1.18 $3.60 $3.60 $3.74 $2.37 $3.50 $1.54 $30.17 $30.17 $2.49 $6.62 $40.39 $40.80 $3.44 $3.91 $3.44 $3.73 $2.37 $2.37 $2.61 $2.37 $0.00 $0.00 $0.00 $0.00 30500018 EAP CPT® 85018 "Hgb, Venous (meter)" BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $4.88 $4.88 $2.37 $2.37 $1.19 $1.18 $3.60 $3.60 $3.74 $2.37 $3.50 $1.54 $30.17 $30.17 $2.49 $6.62 $40.39 $40.80 $3.44 $0.00 $3.44 $3.73 $2.37 $2.37 $2.61 $2.37 $0.00 $0.00 $0.00 $0.00 30500021 EAP CPT® 85025 "CBC, PLAT & DIFF" BOTH IP/OP $212.00 $156.88 $3.88 $177.60 $16.05 $16.05 $7.77 $7.77 $3.89 $3.88 $9.97 $9.97 $10.36 $7.77 $11.48 $5.05 $125.40 $125.40 $8.16 $21.72 $175.82 $177.60 $11.27 $12.82 $11.27 $12.23 $7.77 $7.77 $8.56 $7.77 $0.00 $0.00 $0.00 $0.00 30500022 EAP CPT® 85027 CBC & PLAT BOTH IP/OP $175.00 $129.50 $3.23 $147.20 $13.36 $13.36 $6.47 $6.47 $3.24 $3.23 $9.83 $9.83 $10.21 $6.47 $9.57 $4.21 $103.51 $103.51 $6.79 $18.08 $145.73 $147.20 $9.38 $10.68 $9.38 $10.19 $6.47 $6.47 $7.13 $6.47 $0.00 $0.00 $0.00 $0.00 30500024 EAP CPT® 85046 "Reticulocytes, Automated" BOTH IP/OP $154.00 $113.96 $2.79 $112.00 $11.48 $11.48 $5.57 $5.57 $2.79 $2.79 $8.48 $8.48 $8.80 $5.57 $8.24 $3.62 $91.09 $91.09 $5.85 $15.60 $110.88 $112.00 $8.08 $9.19 $8.08 $8.78 $5.57 $5.57 $6.15 $5.57 $0.00 $0.00 $0.00 $0.00 30500026 EAP CPT® 85048 "EOSINOPHIL COUNT, WB" BOTH IP/OP $68.00 $50.32 $0.00 $59.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.86 $3.86 $4.01 $0.00 $3.76 $0.00 $0.00 $0.00 $0.00 $7.10 $58.61 $59.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500027 EAP CPT® 85049 Platelet Count (wb) BOTH IP/OP $127.00 $93.98 $2.24 $93.60 $9.24 $9.24 $4.48 $4.48 $2.24 $2.24 $6.79 $6.79 $7.05 $4.48 $6.62 $2.91 $75.12 $75.12 $4.70 $12.50 $92.66 $93.60 $6.50 $7.39 $6.50 $7.05 $4.48 $4.48 $4.93 $4.48 $0.00 $0.00 $0.00 $0.00 30500028 EAP CPT® 85097 Bone Marrow Exam BOTH IP/OP $773.00 $572.02 $0.00 $781.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.62 $48.62 $50.49 $0.00 $75.35 $0.00 $0.00 $0.00 $630.05 $213.48 $618.55 $624.80 $781.00 $502.45 $781.00 $80.29 $51.21 $51.21 $56.20 $600.04 $0.00 $0.00 $0.00 $0.00 30500029 EAP CPT® 85210 Factor Ii Assay BOTH IP/OP $424.00 $313.76 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.72 $19.72 $20.48 $0.00 $19.18 $0.00 $0.00 $0.00 $0.00 $36.28 $309.67 $312.80 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500030 EAP CPT® 85220 Factor V Assay BOTH IP/OP $568.00 $420.32 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.82 $26.80 $26.80 $27.83 $17.65 $26.07 $11.47 $335.97 $335.97 $0.00 $49.32 $415.01 $419.20 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500031 EAP CPT® 85230 Factor Vii Assay BOTH IP/OP $584.00 $432.16 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.19 $27.19 $28.23 $0.00 $26.46 $0.00 $0.00 $0.00 $18.80 $50.04 $426.10 $430.40 $25.96 $584.00 $25.96 $28.19 $17.90 $17.90 $19.74 $17.90 $0.00 $0.00 $0.00 $0.00 30500032 EAP CPT® 85240 Factor Viii Assay BOTH IP/OP $584.00 $432.16 $8.95 $430.40 $36.96 $36.96 $17.90 $17.90 $8.95 $8.95 $27.19 $27.19 $28.23 $17.90 $26.46 $11.64 $345.44 $345.44 $18.80 $50.04 $426.10 $430.40 $25.96 $29.54 $25.96 $28.19 $17.90 $17.90 $19.74 $17.90 $0.00 $0.00 $0.00 $0.00 30500033 EAP CPT® 85245 Vw Factor Activity BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $47.36 $47.36 $22.94 $22.94 $11.47 $11.47 $34.85 $34.85 $36.19 $22.94 $33.89 $14.91 $402.22 $402.22 $24.09 $64.12 $538.56 $544.00 $33.26 $0.00 $33.26 $36.11 $22.94 $22.94 $25.28 $22.94 $0.00 $0.00 $0.00 $0.00 30500034 EAP CPT® 85245 Ristocetin Cofactor BOTH IP/OP $738.00 $546.12 $11.47 $544.00 $47.36 $47.36 $22.94 $22.94 $11.47 $11.47 $34.85 $34.85 $36.19 $22.94 $33.89 $14.91 $436.53 $436.53 $24.09 $64.12 $538.56 $544.00 $33.26 $37.85 $33.26 $36.11 $22.94 $22.94 $25.28 $22.94 $0.00 $0.00 $0.00 $0.00 30500035 EAP CPT® 85246 Von Willebrand Ag BOTH IP/OP $738.00 $546.12 $11.47 $544.00 $47.36 $47.36 $22.94 $22.94 $11.47 $11.47 $34.85 $34.85 $36.19 $22.94 $33.89 $14.91 $436.53 $436.53 $24.09 $64.12 $538.56 $544.00 $33.26 $37.85 $33.26 $36.11 $22.94 $22.94 $25.28 $22.94 $0.00 $0.00 $0.00 $0.00 30500036 EAP CPT® 85250 Factor Ix Assay BOTH IP/OP $613.00 $453.62 $0.00 $613.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.90 $28.90 $30.01 $0.00 $28.12 $0.00 $0.00 $0.00 $19.99 $53.20 $447.48 $452.00 $27.61 $613.00 $27.61 $29.96 $19.04 $19.04 $20.97 $19.04 $0.00 $0.00 $0.00 $0.00 30500037 EAP CPT® 85260 Factor X Assay BOTH IP/OP $584.00 $432.16 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.19 $27.19 $28.23 $0.00 $26.46 $0.00 $0.00 $0.00 $0.00 $50.04 $426.10 $430.40 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500038 EAP CPT® 85270 Factor Xi Assay BOTH IP/OP $584.00 $432.16 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.19 $27.19 $28.23 $0.00 $26.46 $0.00 $0.00 $0.00 $0.00 $50.04 $426.10 $430.40 $0.00 $584.00 $0.00 $28.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500039 EAP CPT® 85280 Factor Xii Assay BOTH IP/OP $621.00 $459.54 $0.00 $621.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.38 $29.38 $30.51 $0.00 $28.59 $0.00 $0.00 $0.00 $0.00 $54.08 $453.02 $457.60 $0.00 $621.00 $0.00 $30.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500040 EAP CPT® 85291 Factor Xiii Screen BOTH IP/OP $680.00 $503.20 $0.00 $501.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $13.50 $14.02 $0.00 $13.14 $0.00 $0.00 $0.00 $0.00 $24.84 $496.58 $501.60 $0.00 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500041 EAP CPT® 85300 Protein S Activity BOTH IP/OP $493.00 $364.82 $5.93 $386.40 $24.47 $24.47 $11.85 $11.85 $5.93 $5.93 $17.99 $17.99 $18.68 $11.85 $17.50 $7.70 $291.61 $291.61 $12.44 $33.10 $382.54 $386.40 $17.18 $19.55 $17.18 $18.65 $11.85 $11.85 $13.06 $11.85 $0.00 $0.00 $0.00 $0.00 30500042 EAP CPT® 85300 Factor At-iii Assay BOTH IP/OP $493.00 $364.82 $5.93 $386.40 $24.47 $24.47 $11.85 $11.85 $5.93 $5.93 $17.99 $17.99 $18.68 $11.85 $17.50 $7.70 $291.61 $291.61 $12.44 $33.10 $382.54 $386.40 $17.18 $19.55 $17.18 $18.65 $11.85 $11.85 $13.06 $11.85 $0.00 $0.00 $0.00 $0.00 30500043 EAP CPT® 85301 At-iii Antigen BOTH IP/OP $971.00 $718.54 $0.00 $784.80 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $16.42 $16.42 $17.05 $10.81 $15.98 $7.03 $574.35 $574.35 $11.35 $30.22 $776.95 $784.80 $15.67 $459.00 $15.67 $17.03 $10.81 $10.81 $11.92 $10.81 $0.00 $0.00 $0.00 $0.00 30500044 EAP CPT® 85303 Protein C Activity BOTH IP/OP $466.00 $344.84 $6.92 $364.80 $28.56 $28.56 $13.84 $13.84 $6.92 $6.92 $21.00 $21.00 $21.81 $13.84 $20.43 $9.00 $275.64 $275.64 $14.53 $38.64 $361.15 $364.80 $20.07 $22.84 $20.07 $21.77 $13.84 $13.84 $15.24 $13.84 $0.00 $0.00 $0.00 $0.00 30500045 EAP CPT® 85307 Act Prot-c Resist (fv-leiden) BOTH IP/OP $264.00 $195.36 $7.66 $207.20 $31.63 $31.63 $15.32 $15.32 $7.66 $7.66 $23.26 $23.26 $24.16 $15.32 $22.64 $9.96 $156.16 $156.16 $16.09 $42.82 $205.13 $207.20 $22.21 $25.28 $22.21 $24.12 $15.32 $15.32 $16.88 $15.32 $0.00 $0.00 $0.00 $0.00 30500046 EAP CPT® 85379 D-dimer BOTH IP/OP $335.00 $247.90 $5.09 $270.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $198.15 $198.15 $10.69 $28.44 $267.70 $270.40 $14.76 $16.80 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30500047 EAP CPT® 85384 Fibrinogen Quant. BOTH IP/OP $299.00 $221.26 $4.37 $217.60 $17.53 $17.53 $9.72 $9.72 $4.86 $4.37 $12.90 $12.90 $13.39 $9.72 $12.55 $6.32 $176.86 $176.86 $10.21 $23.74 $215.42 $217.60 $14.09 $16.04 $14.09 $13.37 $9.72 $9.72 $9.36 $9.72 $0.00 $0.00 $0.00 $0.00 30500048 EAP CPT® 85410 Alpha-2-antiplasmin BOTH IP/OP $183.00 $135.42 $0.00 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.71 $11.71 $12.16 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $21.54 $144.94 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500049 EAP CPT® 85420 Plasminogen Activ. BOTH IP/OP $145.00 $107.30 $0.00 $145.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.93 $9.93 $10.31 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $18.26 $115.63 $116.80 $0.00 $145.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500050 EAP CPT® 85441 Heinz Body Direct BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.39 $6.39 $6.63 $0.00 $6.22 $0.00 $0.00 $0.00 $0.00 $11.76 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500051 EAP CPT® 85445 Heinz Body Induced BOTH IP/OP $83.00 $61.42 $0.00 $82.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.35 $10.35 $10.75 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $19.04 $65.74 $66.40 $0.00 $82.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500052 EAP CPT® 85460 K-b Hgb Fetal Screen ** BOTH IP/OP $51.00 $37.74 $2.66 $40.80 $4.99 $4.99 $7.73 $7.73 $3.87 $3.87 $3.67 $3.67 $3.81 $7.73 $3.57 $5.02 $30.17 $30.17 $8.12 $6.76 $40.39 $40.80 $11.21 $12.75 $11.21 $3.80 $7.73 $7.73 $2.66 $7.73 $0.00 $0.00 $0.00 $0.00 30500053 EAP CPT® 85475 "Hemolysis,acid-ham's" BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.91 $7.91 $8.22 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $14.56 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500054 EAP CPT® 85475 "Hemolysis, Sucrose" BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.91 $7.91 $8.22 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $14.56 $46.73 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500055 EAP CPT® 85520 Heparin Assay BOTH IP/OP $400.00 $296.00 $6.55 $323.20 $27.03 $27.03 $13.09 $13.09 $6.55 $6.55 $19.87 $19.87 $20.64 $13.09 $19.34 $8.51 $236.60 $236.60 $13.74 $36.58 $319.97 $323.20 $18.98 $21.60 $18.98 $20.61 $13.09 $13.09 $14.43 $13.09 $0.00 $0.00 $0.00 $0.00 30500056 EAP CPT® 85536 Iron Stores-bm BOTH IP/OP $186.00 $137.64 $0.00 $148.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.83 $9.83 $10.21 $0.00 $9.57 $0.00 $0.00 $0.00 $0.00 $18.08 $147.31 $148.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500057 EAP CPT® 85540 Wbc Lap Stain BOTH IP/OP $154.00 $113.96 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.17 $9.17 $9.53 $0.00 $8.93 $0.00 $0.00 $0.00 $0.00 $16.88 $133.06 $134.40 $0.00 $87.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500058 EAP CPT® 85549 Lysozyme BOTH IP/OP $180.00 $133.20 $9.37 $145.60 $38.70 $38.70 $18.75 $18.75 $9.38 $9.37 $28.49 $28.49 $29.58 $18.75 $27.71 $12.19 $106.47 $106.47 $19.69 $52.42 $144.14 $145.60 $27.19 $30.94 $27.19 $29.53 $18.75 $18.75 $20.67 $18.75 $0.00 $0.00 $0.00 $0.00 30500059 EAP CPT® 85576 "Plt Agg, Thrombin" BOTH IP/OP $465.00 $344.10 $11.21 $461.60 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $275.05 $275.05 $26.16 $60.02 $456.98 $461.60 $36.12 $41.10 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30500060 EAP CPT® 85576 "Plt Agg, Adp" BOTH IP/OP $465.00 $344.10 $11.21 $461.60 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $275.05 $275.05 $26.16 $60.02 $456.98 $461.60 $36.12 $41.10 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30500061 EAP CPT® 85576 "Plt Agg, Collagen" BOTH IP/OP $465.00 $344.10 $11.21 $461.60 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $275.05 $275.05 $26.16 $60.02 $456.98 $461.60 $36.12 $41.10 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30500062 EAP CPT® 85576 "Plt Agg, Ristocetin" BOTH IP/OP $465.00 $344.10 $11.21 $461.60 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $275.05 $275.05 $26.16 $60.02 $456.98 $461.60 $36.12 $41.10 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30500063 EAP CPT® 85576 "Plt Agg, Aracdnc Acid" BOTH IP/OP $465.00 $344.10 $11.21 $461.60 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $275.05 $275.05 $26.16 $60.02 $456.98 $461.60 $36.12 $41.10 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30500064 EAP CPT® 85576 Pfa-collagen/epi BOTH IP/OP $676.00 $500.24 $11.21 $492.00 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $399.85 $399.85 $26.16 $60.02 $487.08 $492.00 $36.12 $41.10 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30500065 EAP CPT® 85576 Pfa-collagen/adp BOTH IP/OP $676.00 $500.24 $11.21 $492.00 $44.35 $44.35 $24.91 $24.91 $12.46 $11.21 $32.62 $32.62 $33.88 $24.91 $31.73 $16.19 $399.85 $399.85 $26.16 $60.02 $487.08 $492.00 $36.12 $41.10 $36.12 $33.81 $24.91 $24.91 $23.67 $24.91 $0.00 $0.00 $0.00 $0.00 30500066 EAP CPT® 86022 Platelet Agg-heprin BOTH IP/OP $536.00 $396.64 $0.00 $394.40 $37.91 $37.91 $18.37 $18.37 $9.19 $9.18 $27.89 $27.89 $28.97 $18.37 $27.12 $11.94 $317.04 $317.04 $0.00 $51.32 $390.46 $394.40 $0.00 $30.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500067 EAP CPT® 85597 Plat Neutralization BOTH IP/OP $420.00 $310.80 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.30 $27.30 $28.35 $0.00 $26.57 $0.00 $0.00 $0.00 $0.00 $50.24 $412.63 $416.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500068 EAP CPT® 85610 Pt(prothrombin Time) BOTH IP/OP $159.00 $117.66 $1.97 $116.80 $8.10 $8.10 $4.29 $4.29 $2.15 $1.97 $5.97 $5.97 $6.20 $4.29 $5.81 $2.79 $94.05 $94.05 $4.50 $10.98 $115.63 $116.80 $6.22 $7.08 $6.22 $6.19 $4.29 $4.29 $4.33 $4.29 $0.00 $0.00 $0.00 $0.00 30500069 EAP CPT® 85610 "Pt,coumadin Therapy" BOTH IP/OP $159.00 $117.66 $1.97 $116.80 $8.10 $8.10 $4.29 $4.29 $2.15 $1.97 $5.97 $5.97 $6.20 $4.29 $5.81 $2.79 $94.05 $94.05 $4.50 $10.98 $115.63 $116.80 $6.22 $7.08 $6.22 $6.19 $4.29 $4.29 $4.33 $4.29 $0.00 $0.00 $0.00 $0.00 30500070 EAP CPT® 85610 "Pt, Coumatrak" BOTH IP/OP $146.00 $108.04 $1.97 $116.80 $8.10 $8.10 $4.29 $4.29 $2.15 $1.97 $5.97 $5.97 $6.20 $4.29 $5.81 $2.79 $86.36 $86.36 $4.50 $10.98 $115.63 $116.80 $6.22 $7.08 $6.22 $6.19 $4.29 $4.29 $4.33 $4.29 $0.00 $0.00 $0.00 $0.00 30500071 EAP CPT® 85611 Pt+normal Plasma BOTH IP/OP $145.00 $107.30 $0.00 $145.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.98 $5.98 $6.21 $0.00 $5.83 $0.00 $0.00 $0.00 $0.00 $11.02 $105.34 $106.40 $0.00 $145.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500072 EAP CPT® 85611 "Pt, Hepzyme-treated" BOTH IP/OP $133.00 $98.42 $0.00 $106.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.98 $5.98 $6.21 $0.00 $5.83 $0.00 $0.00 $0.00 $0.00 $11.02 $105.34 $106.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500073 EAP CPT® 85613 Dilute Russell's Viper Venom BOTH IP/OP $302.00 $223.48 $4.79 $220.00 $19.77 $19.77 $9.58 $9.58 $4.79 $4.79 $14.53 $14.53 $15.09 $9.58 $14.13 $6.23 $178.63 $178.63 $10.06 $26.74 $217.80 $220.00 $13.89 $15.81 $13.89 $15.06 $9.58 $9.58 $10.54 $9.58 $0.00 $0.00 $0.00 $0.00 30500074 EAP CPT® 85651 Sed Rate Westergren BOTH IP/OP $99.00 $73.26 $0.00 $98.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.39 $5.39 $5.59 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $9.92 $97.42 $98.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500075 EAP CPT® 85660 DONOR HGB S-ARC BOTH IP/OP $166.00 $122.84 $0.00 $146.40 $11.38 $11.38 $5.51 $5.51 $2.76 $2.75 $8.38 $8.38 $8.70 $5.51 $8.15 $3.58 $98.19 $98.19 $5.79 $15.42 $144.94 $146.40 $7.99 $0.00 $7.99 $8.68 $5.51 $5.51 $6.08 $5.51 $0.00 $0.00 $0.00 $0.00 30500076 EAP CPT® 85660 Donor Hgb S-gmh BOTH IP/OP $166.00 $122.84 $0.00 $146.40 $11.38 $11.38 $5.51 $5.51 $2.76 $2.75 $8.38 $8.38 $8.70 $5.51 $8.15 $3.58 $98.19 $98.19 $5.79 $15.42 $144.94 $146.40 $7.99 $0.00 $7.99 $8.68 $5.51 $5.51 $6.08 $5.51 $0.00 $0.00 $0.00 $0.00 30500077 EAP CPT® 85660 Sickledex BOTH IP/OP $201.00 $148.74 $2.75 $146.40 $11.38 $11.38 $5.51 $5.51 $2.76 $2.75 $8.38 $8.38 $8.70 $5.51 $8.15 $3.58 $118.89 $118.89 $5.79 $15.42 $144.94 $146.40 $7.99 $9.09 $7.99 $8.68 $5.51 $5.51 $6.08 $5.51 $0.00 $0.00 $0.00 $0.00 30500078 EAP CPT® 85670 Thrombin Time BOTH IP/OP $145.00 $107.30 $2.88 $145.00 $11.91 $11.91 $5.77 $5.77 $2.89 $2.88 $8.78 $8.78 $9.12 $5.77 $8.53 $3.75 $85.77 $85.77 $6.06 $16.14 $104.54 $105.60 $8.37 $145.00 $8.37 $9.08 $5.77 $5.77 $6.36 $5.77 $0.00 $0.00 $0.00 $0.00 30500079 EAP CPT® 85730 "Appt, Hepzyme-treated" BOTH IP/OP $216.00 $159.84 $3.00 $156.80 $12.41 $12.41 $6.01 $6.01 $3.01 $3.00 $9.11 $9.11 $9.46 $6.01 $8.86 $3.91 $127.76 $127.76 $6.31 $16.76 $155.23 $156.80 $8.71 $9.92 $8.71 $9.44 $6.01 $6.01 $6.61 $6.01 $0.00 $0.00 $0.00 $0.00 30500080 EAP CPT® 85730 Aptt BOTH IP/OP $216.00 $159.84 $3.00 $156.80 $12.41 $12.41 $6.01 $6.01 $3.01 $3.00 $9.11 $9.11 $9.46 $6.01 $8.86 $3.91 $127.76 $127.76 $6.31 $16.76 $155.23 $156.80 $8.71 $9.92 $8.71 $9.44 $6.01 $6.01 $6.61 $6.01 $0.00 $0.00 $0.00 $0.00 30500082 EAP CPT® 85730 Aptt Heparin Therapy BOTH IP/OP $187.00 $138.38 $3.00 $156.80 $12.41 $12.41 $6.01 $6.01 $3.01 $3.00 $9.11 $9.11 $9.46 $6.01 $8.86 $3.91 $110.61 $110.61 $6.31 $16.76 $155.23 $156.80 $8.71 $9.92 $8.71 $9.44 $6.01 $6.01 $6.61 $6.01 $0.00 $0.00 $0.00 $0.00 30500083 EAP CPT® 85730 Ptt-saline BOTH IP/OP $187.00 $138.38 $3.00 $156.80 $12.41 $12.41 $6.01 $6.01 $3.01 $3.00 $9.11 $9.11 $9.46 $6.01 $8.86 $3.91 $110.61 $110.61 $6.31 $16.76 $155.23 $156.80 $8.71 $9.92 $8.71 $9.44 $6.01 $6.01 $6.61 $6.01 $0.00 $0.00 $0.00 $0.00 30500084 EAP CPT® 85732 Aptt + Apc BOTH IP/OP $225.00 $166.50 $0.00 $164.00 $13.36 $13.36 $6.47 $6.47 $3.24 $3.23 $9.83 $9.83 $10.21 $6.47 $9.57 $4.21 $133.09 $133.09 $0.00 $18.08 $162.36 $164.00 $0.00 $10.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500085 EAP CPT® 85732 Factor Def Scrn-coag BOTH IP/OP $225.00 $166.50 $0.00 $164.00 $13.36 $13.36 $6.47 $6.47 $3.24 $3.23 $9.83 $9.83 $10.21 $6.47 $9.57 $4.21 $133.09 $133.09 $0.00 $18.08 $162.36 $164.00 $0.00 $10.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500086 EAP CPT® 85732 Factor Inhib Screen BOTH IP/OP $196.00 $145.04 $0.00 $164.00 $13.36 $13.36 $6.47 $6.47 $3.24 $3.23 $9.83 $9.83 $10.21 $6.47 $9.57 $4.21 $115.93 $115.93 $0.00 $18.08 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500087 EAP CPT® 85810 "Viscosity, Serum" BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.73 $17.73 $18.41 $0.00 $17.26 $0.00 $0.00 $0.00 $0.00 $32.64 $192.46 $194.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500088 EAP CPT® 86078 Transfusion Reaction BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.69 $48.69 $50.57 $0.00 $52.87 $0.00 $0.00 $0.00 $0.00 $103.62 $372.24 $376.00 $0.00 $305.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500090 EAP CPT® 85048 "Eosinophil Count, Wb" BOTH IP/OP $68.00 $50.32 $0.00 $59.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.86 $3.86 $4.01 $0.00 $3.76 $0.00 $0.00 $0.00 $0.00 $7.10 $58.61 $59.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500091 EAP CPT® 85652 "Sed Rate, Capillary Photometry" BOTH IP/OP $105.00 $77.70 $1.35 $84.80 $5.57 $5.57 $2.70 $2.70 $1.35 $1.35 $4.10 $4.10 $4.26 $2.70 $3.98 $1.76 $62.11 $62.11 $2.84 $7.54 $83.95 $84.80 $3.92 $4.46 $3.92 $4.24 $2.70 $2.70 $2.97 $2.70 $0.00 $0.00 $0.00 $0.00 30500092 EAP CPT® 85415 Plasminogen Act Inhib (so) BOTH IP/OP $268.00 $198.32 $0.00 $254.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.10 $26.10 $27.11 $0.00 $25.40 $0.00 $0.00 $0.00 $0.00 $48.04 $212.26 $214.40 $0.00 $254.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500102 EAP CPT® 85008 Rbc Morphology Exam BOTH IP/OP $91.00 $67.34 $1.72 $66.40 $7.08 $7.08 $3.43 $3.43 $1.72 $1.72 $5.22 $5.22 $5.42 $3.43 $5.08 $2.23 $53.83 $53.83 $3.60 $9.62 $65.74 $66.40 $4.97 $5.66 $4.97 $5.41 $3.43 $3.43 $3.79 $3.43 $0.00 $0.00 $0.00 $0.00 30500103 EAP CPT® 85013 "Hematocrit, Spun Cap" BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.60 $3.60 $3.74 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $6.62 $40.39 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500104 EAP CPT® 85018 Hgb & Hct BOTH IP/OP $51.00 $37.74 $1.18 $40.80 $4.88 $4.88 $2.37 $2.37 $1.19 $1.18 $3.60 $3.60 $3.74 $2.37 $3.50 $1.54 $30.17 $30.17 $2.49 $6.62 $40.39 $40.80 $3.44 $3.91 $3.44 $3.73 $2.37 $2.37 $2.61 $2.37 $0.00 $0.00 $0.00 $0.00 30500105 EAP CPT® 85025 "Cbc, Plat & Diff" BOTH IP/OP $244.00 $180.56 $3.88 $177.60 $16.05 $16.05 $7.77 $7.77 $3.89 $3.88 $9.97 $9.97 $10.36 $7.77 $11.48 $5.05 $144.33 $144.33 $8.16 $21.72 $175.82 $177.60 $11.27 $12.82 $11.27 $12.23 $7.77 $7.77 $8.56 $7.77 $0.00 $0.00 $0.00 $0.00 30500106 EAP CPT® 85027 Cbc & Plat BOTH IP/OP $175.00 $129.50 $3.23 $147.20 $13.36 $13.36 $6.47 $6.47 $3.24 $3.23 $9.83 $9.83 $10.21 $6.47 $9.57 $4.21 $103.51 $103.51 $6.79 $18.08 $145.73 $147.20 $9.38 $10.68 $9.38 $10.19 $6.47 $6.47 $7.13 $6.47 $0.00 $0.00 $0.00 $0.00 30500108 EAP CPT® 85008 Rbc Morphology BOTH IP/OP $91.00 $67.34 $1.72 $66.40 $7.08 $7.08 $3.43 $3.43 $1.72 $1.72 $5.22 $5.22 $5.42 $3.43 $5.08 $2.23 $53.83 $53.83 $3.60 $9.62 $65.74 $66.40 $4.97 $5.66 $4.97 $5.41 $3.43 $3.43 $3.79 $3.43 $0.00 $0.00 $0.00 $0.00 30500109 EAP CPT® 85013 "Hematocrit, Spun" BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.60 $3.60 $3.74 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $6.62 $40.39 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500110 EAP CPT® 85660 Sickledex BOTH IP/OP $166.00 $122.84 $0.00 $146.40 $11.38 $11.38 $5.51 $5.51 $2.76 $2.75 $8.38 $8.38 $8.70 $5.51 $8.15 $3.58 $98.19 $98.19 $5.79 $15.42 $144.94 $146.40 $7.99 $0.00 $7.99 $8.68 $5.51 $5.51 $6.08 $5.51 $0.00 $0.00 $0.00 $0.00 30500112 EAP CPT® 85025 "Cbc, Plat & Diff, Idp" BOTH IP/OP $244.00 $180.56 $3.88 $177.60 $16.05 $16.05 $7.77 $7.77 $3.89 $3.88 $9.97 $9.97 $10.36 $7.77 $11.48 $5.05 $144.33 $144.33 $8.16 $21.72 $175.82 $177.60 $11.27 $12.82 $11.27 $12.23 $7.77 $7.77 $8.56 $7.77 $0.00 $0.00 $0.00 $0.00 30500113 EAP CPT® 86146 Beta-2 Glycoprotein Antibodies BOTH IP/OP $327.00 $241.98 $12.73 $240.00 $52.54 $52.54 $25.45 $25.45 $12.73 $12.73 $38.63 $38.63 $40.11 $25.45 $37.58 $16.54 $193.42 $193.42 $26.72 $71.08 $237.60 $240.00 $36.90 $41.99 $36.90 $40.04 $25.45 $25.45 $28.03 $25.45 $0.00 $0.00 $0.00 $0.00 30500114 EAP CPT® 85397 Von Willebran Protease Act Q BOTH IP/OP $471.00 $348.54 $13.89 $380.80 $47.36 $47.36 $30.86 $30.86 $15.43 $13.89 $34.85 $34.85 $36.19 $30.86 $31.50 $20.06 $278.60 $278.60 $32.40 $238.00 $376.99 $380.80 $44.75 $50.92 $44.75 $33.56 $30.86 $30.86 $23.49 $30.86 $0.00 $0.00 $0.00 $0.00 30500115 EAP CPT® 85730 Silica Clotting Time BOTH IP/OP $187.00 $138.38 $3.00 $156.80 $12.41 $12.41 $6.01 $6.01 $3.01 $3.00 $9.11 $9.11 $9.46 $6.01 $8.86 $3.91 $110.61 $110.61 $6.31 $16.76 $155.23 $156.80 $8.71 $9.92 $8.71 $9.44 $6.01 $6.01 $6.61 $6.01 $0.00 $0.00 $0.00 $0.00 30500117 EAP CPT® 83520 Thrombin Anti Thrmbon Complex (e) BOTH IP/OP $286.00 $211.64 $0.00 $258.40 $26.72 $26.72 $17.27 $17.27 $8.64 $7.77 $19.67 $19.67 $20.42 $17.27 $19.12 $11.23 $169.17 $169.17 $18.13 $36.18 $255.82 $258.40 $25.04 $0.00 $25.04 $20.37 $17.27 $17.27 $14.26 $17.27 $0.00 $0.00 $0.00 $0.00 30500118 EAP HCPCS 85999 "Eosinophil Smear, Urine" BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $0.00 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500119 EAP CPT® 85999 "Esoinophil Smear, Urine" BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $0.00 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500121 EAP CPT® 85362 Fibrin Monomer (so) BOTH IP/OP $320.00 $236.80 $3.44 $232.80 $14.23 $14.23 $6.89 $6.89 $3.45 $3.44 $10.46 $10.46 $10.86 $6.89 $10.17 $4.48 $189.28 $189.28 $7.23 $19.24 $230.47 $232.80 $9.99 $11.37 $9.99 $10.84 $6.89 $6.89 $7.59 $6.89 $0.00 $0.00 $0.00 $0.00 30500122 EAP CPT® 85307 Activated Protein C Resistance (so) BOTH IP/OP $125.00 $92.50 $7.66 $97.60 $31.63 $31.63 $15.32 $15.32 $7.66 $7.66 $23.26 $23.26 $24.16 $15.32 $22.64 $9.96 $73.94 $73.94 $16.09 $42.82 $96.62 $97.60 $22.21 $25.28 $22.21 $24.12 $15.32 $15.32 $16.88 $15.32 $0.00 $0.00 $0.00 $0.00 30500123 EAP CPT® 86355 Lymphocyte Subset Bal - B Cells Total (so) BOTH IP/OP $113.00 $83.62 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.77 $35.77 $37.14 $0.00 $34.80 $0.00 $0.00 $0.00 $39.62 $65.82 $93.46 $94.40 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30500124 EAP CPT® 86359 Lymphocyte Subset Bal - T Cells Total (so) BOTH IP/OP $113.00 $83.62 $0.00 $94.40 $48.63 $48.63 $37.73 $37.73 $18.87 $18.86 $35.77 $35.77 $37.14 $37.73 $34.80 $24.52 $66.84 $66.84 $39.62 $65.82 $93.46 $94.40 $54.71 $0.00 $54.71 $37.08 $37.73 $37.73 $25.95 $37.73 $0.00 $0.00 $0.00 $0.00 30500125 EAP CPT® 86360 Lymphocyte Subset Bal - Absolute Cd4/cd8 With Ratio (so) BOTH IP/OP $113.00 $83.62 $0.00 $118.00 $96.99 $96.99 $46.98 $46.98 $23.49 $23.49 $71.34 $71.34 $74.09 $46.98 $69.42 $30.54 $66.84 $66.84 $49.33 $118.00 $93.46 $94.40 $68.12 $0.00 $68.12 $73.96 $46.98 $46.98 $51.77 $46.98 $0.00 $0.00 $0.00 $0.00 30500126 EAP CPT® 85460 Hemoglobin Fetal Stain Family Member BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $4.99 $4.99 $7.73 $7.73 $3.87 $3.87 $3.67 $3.67 $3.81 $7.73 $3.57 $5.02 $30.17 $30.17 $8.12 $6.76 $40.39 $40.80 $11.21 $0.00 $11.21 $3.80 $7.73 $7.73 $2.66 $7.73 $0.00 $0.00 $0.00 $0.00 30500130 EAP CPT® 80299 Apixaban Quantitative Assay BOTH IP/OP $155.00 $114.70 $8.39 $124.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $91.68 $91.68 $19.57 $33.64 $123.55 $124.80 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30500131 EAP CPT® 80299 Rivaroxaban Quantitative Assay BOTH IP/OP $155.00 $114.70 $8.39 $124.80 $28.04 $28.04 $18.64 $18.64 $9.32 $8.39 $18.28 $18.28 $18.99 $18.64 $17.79 $12.12 $91.68 $91.68 $19.57 $33.64 $123.55 $124.80 $27.03 $30.76 $27.03 $18.95 $18.64 $18.64 $13.27 $18.64 $0.00 $0.00 $0.00 $0.00 30600001 EAP CPT® 87040 Blood Cult. Routine BOTH IP/OP $476.00 $352.24 $5.16 $346.40 $21.30 $21.30 $10.32 $10.32 $5.16 $5.16 $15.67 $15.67 $16.28 $10.32 $15.25 $6.71 $281.55 $281.55 $10.84 $28.84 $342.94 $346.40 $14.96 $17.03 $14.96 $16.24 $10.32 $10.32 $11.37 $10.32 $0.00 $0.00 $0.00 $0.00 30600002 EAP CPT® 87045 Stool Culture BOTH IP/OP $206.00 $152.44 $4.72 $166.40 $19.48 $19.48 $9.44 $9.44 $4.72 $4.72 $14.32 $14.32 $14.87 $9.44 $42.93 $6.14 $121.85 $121.85 $9.91 $26.36 $164.74 $166.40 $13.69 $15.58 $13.69 $32.55 $9.44 $9.44 $33.11 $9.44 $0.00 $0.00 $0.00 $0.00 30600003 EAP CPT® 87070 Bone Marrow Culture BOTH IP/OP $371.00 $274.54 $4.31 $277.60 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $219.45 $219.45 $9.05 $24.06 $274.82 $277.60 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30600004 EAP CPT® 87070 Csf Culture BOTH IP/OP $371.00 $274.54 $4.31 $277.60 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $219.45 $219.45 $9.05 $24.06 $274.82 $277.60 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30600005 EAP CPT® 87070 Exudate Culture BOTH IP/OP $371.00 $274.54 $4.31 $277.60 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $219.45 $219.45 $9.05 $24.06 $274.82 $277.60 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30600006 EAP CPT® 87070 Fluid/tissue Cult. BOTH IP/OP $371.00 $274.54 $4.31 $277.60 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $219.45 $219.45 $9.05 $24.06 $274.82 $277.60 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30600007 EAP CPT® 87070 Genital Culture BOTH IP/OP $371.00 $274.54 $4.31 $277.60 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $219.45 $219.45 $9.05 $24.06 $274.82 $277.60 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30600008 EAP CPT® 87070 "Misc Cult,referral" BOTH IP/OP $338.00 $250.12 $4.31 $252.80 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $199.93 $199.93 $9.05 $24.06 $250.27 $252.80 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30600009 EAP CPT® 87070 Misc. Culture BOTH IP/OP $371.00 $274.54 $4.31 $277.60 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $219.45 $219.45 $9.05 $24.06 $274.82 $277.60 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30600010 EAP CPT® 87070 SPUTUM CULTURE BOTH IP/OP $371.00 $274.54 $4.31 $277.60 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $219.45 $219.45 $9.05 $24.06 $274.82 $277.60 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30600011 EAP CPT® 87081 Throat Culture BOTH IP/OP $305.00 $225.70 $3.31 $224.00 $13.68 $13.68 $6.63 $6.63 $3.32 $3.31 $10.08 $10.08 $10.47 $6.63 $9.79 $4.31 $180.41 $180.41 $6.96 $18.52 $221.76 $224.00 $9.61 $10.94 $9.61 $10.43 $6.63 $6.63 $7.30 $6.63 $0.00 $0.00 $0.00 $0.00 30600012 EAP CPT® 87075 Anaerobe Culture BOTH IP/OP $318.00 $235.32 $4.73 $231.20 $19.54 $19.54 $9.47 $9.47 $4.74 $4.73 $14.36 $14.36 $14.91 $9.47 $13.98 $6.16 $188.10 $188.10 $9.94 $26.44 $228.89 $231.20 $13.73 $15.63 $13.73 $14.89 $9.47 $9.47 $10.42 $9.47 $0.00 $0.00 $0.00 $0.00 30600013 EAP CPT® 87899 "Malaria Rapid Antigen Test,evd" BOTH IP/OP $359.00 $265.66 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $320.76 $324.00 $0.00 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600014 EAP CPT® 87076 CULTURE I.D.-AEROBE BIOCHEM BOTH IP/OP $229.00 $169.46 $0.00 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.27 $12.27 $12.74 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $22.58 $187.70 $189.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600015 EAP CPT® 87801 "Ebola- Amplified Probe Technique, Evd" BOTH IP/OP $475.00 $351.50 $0.00 $457.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.13 $90.13 $93.59 $0.00 $57.96 $0.00 $0.00 $0.00 $0.00 $109.64 $453.02 $457.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600016 EAP CPT® 87081 "Gc Cult,vag/cervix" BOTH IP/OP $305.00 $225.70 $3.31 $224.00 $13.68 $13.68 $6.63 $6.63 $3.32 $3.31 $10.08 $10.08 $10.47 $6.63 $9.79 $4.31 $180.41 $180.41 $6.96 $18.52 $221.76 $224.00 $9.61 $10.94 $9.61 $10.43 $6.63 $6.63 $7.30 $6.63 $0.00 $0.00 $0.00 $0.00 30600017 EAP CPT® 87081 "Gc Cult,urethral" BOTH IP/OP $305.00 $225.70 $3.31 $224.00 $13.68 $13.68 $6.63 $6.63 $3.32 $3.31 $10.08 $10.08 $10.47 $6.63 $9.79 $4.31 $180.41 $180.41 $6.96 $18.52 $221.76 $224.00 $9.61 $10.94 $9.61 $10.43 $6.63 $6.63 $7.30 $6.63 $0.00 $0.00 $0.00 $0.00 30600018 EAP CPT® 87081 "Gc Cult,anal" BOTH IP/OP $305.00 $225.70 $3.31 $224.00 $13.68 $13.68 $6.63 $6.63 $3.32 $3.31 $10.08 $10.08 $10.47 $6.63 $9.79 $4.31 $180.41 $180.41 $6.96 $18.52 $221.76 $224.00 $9.61 $10.94 $9.61 $10.43 $6.63 $6.63 $7.30 $6.63 $0.00 $0.00 $0.00 $0.00 30600019 EAP CPT® 87081 "Gc Cult,throat" BOTH IP/OP $305.00 $225.70 $3.31 $224.00 $13.68 $13.68 $6.63 $6.63 $3.32 $3.31 $10.08 $10.08 $10.47 $6.63 $9.79 $4.31 $180.41 $180.41 $6.96 $18.52 $221.76 $224.00 $9.61 $10.94 $9.61 $10.43 $6.63 $6.63 $7.30 $6.63 $0.00 $0.00 $0.00 $0.00 30600020 EAP CPT® 87081 Gc Culture Eye BOTH IP/OP $305.00 $225.70 $3.31 $224.00 $13.68 $13.68 $6.63 $6.63 $3.32 $3.31 $10.08 $10.08 $10.47 $6.63 $9.79 $4.31 $180.41 $180.41 $6.96 $18.52 $221.76 $224.00 $9.61 $10.94 $9.61 $10.43 $6.63 $6.63 $7.30 $6.63 $0.00 $0.00 $0.00 $0.00 30600021 EAP CPT® 87086 Urine Culture BOTH IP/OP $299.00 $221.26 $4.04 $241.60 $16.66 $16.66 $8.07 $8.07 $4.04 $4.04 $12.26 $12.26 $12.73 $8.07 $11.93 $5.25 $176.86 $176.86 $8.47 $22.56 $239.18 $241.60 $11.70 $13.32 $11.70 $12.71 $8.07 $8.07 $8.90 $8.07 $0.00 $0.00 $0.00 $0.00 30600022 EAP CPT® 87088 Urine Culture-presump. Id BOTH IP/OP $302.00 $223.48 $0.00 $241.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.29 $12.29 $12.77 $0.00 $11.96 $0.00 $0.00 $0.00 $0.00 $22.62 $239.18 $241.60 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600023 EAP CPT® 87101 Fungus Cult. Derm. BOTH IP/OP $218.00 $161.32 $3.85 $159.20 $15.89 $15.89 $7.71 $7.71 $3.86 $3.85 $11.71 $11.71 $12.16 $7.71 $11.38 $5.01 $128.95 $128.95 $8.10 $21.54 $157.61 $159.20 $11.18 $12.72 $11.18 $12.13 $7.71 $7.71 $8.49 $7.71 $0.00 $0.00 $0.00 $0.00 30600024 EAP CPT® 87102 "Fungus Culture,misc." BOTH IP/OP $231.00 $170.94 $4.20 $168.80 $17.34 $17.34 $8.41 $8.41 $4.21 $4.20 $12.75 $12.75 $13.24 $8.41 $12.42 $5.47 $136.64 $136.64 $8.83 $23.48 $167.11 $168.80 $12.19 $13.88 $12.19 $13.24 $8.41 $8.41 $9.26 $8.41 $0.00 $0.00 $0.00 $0.00 30600025 EAP CPT® 87103 Fungus Cult. Blood BOTH IP/OP $251.00 $185.74 $0.00 $251.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.70 $13.70 $14.22 $0.00 $13.32 $0.00 $0.00 $0.00 $0.00 $25.20 $181.37 $183.20 $0.00 $251.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600026 EAP CPT® 87106 Culture I.d.-yeast Biochem BOTH IP/OP $261.00 $193.14 $0.00 $208.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.67 $15.67 $16.28 $0.00 $15.25 $0.00 $0.00 $0.00 $0.00 $28.84 $206.71 $208.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600027 EAP CPT® 87107 Culture I.d.- Mold Biochem BOTH IP/OP $261.00 $193.14 $0.00 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.67 $15.67 $16.28 $0.00 $15.25 $0.00 $0.00 $0.00 $0.00 $28.84 $206.71 $208.80 $0.00 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600028 EAP CPT® 87110 "Chlam Cult,referral" BOTH IP/OP $141.00 $104.34 $0.00 $141.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.74 $29.74 $30.89 $0.00 $28.94 $0.00 $0.00 $0.00 $0.00 $54.74 $101.38 $102.40 $0.00 $141.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600029 EAP CPT® 87116 Afb Culture-misc BOTH IP/OP $270.00 $199.80 $5.40 $199.20 $15.02 $15.02 $10.80 $10.80 $5.40 $5.40 $11.02 $11.02 $11.45 $10.80 $56.27 $7.02 $159.71 $159.71 $11.34 $20.28 $197.21 $199.20 $15.66 $17.82 $15.66 $38.97 $10.80 $10.80 $39.64 $10.80 $0.00 $0.00 $0.00 $0.00 30600030 EAP CPT® 87116 "Afb Culture, Blood" BOTH IP/OP $270.00 $199.80 $5.40 $199.20 $15.02 $15.02 $10.80 $10.80 $5.40 $5.40 $11.02 $11.02 $11.45 $10.80 $56.27 $7.02 $159.71 $159.71 $11.34 $20.28 $197.21 $199.20 $15.66 $17.82 $15.66 $38.97 $10.80 $10.80 $39.64 $10.80 $0.00 $0.00 $0.00 $0.00 30600031 EAP CPT® 87147 Culture I.d.-immunologic BOTH IP/OP $105.00 $77.70 $0.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.77 $6.77 $7.03 $0.00 $6.59 $0.00 $0.00 $0.00 $0.00 $12.46 $83.16 $84.00 $0.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600032 EAP CPT® 87149 Culture I.d.-probe Biochem BOTH IP/OP $468.00 $346.32 $10.03 $378.40 $40.71 $40.71 $20.05 $20.05 $10.03 $10.03 $29.94 $29.94 $31.09 $20.05 $29.14 $13.03 $276.82 $276.82 $21.05 $55.10 $374.62 $378.40 $29.07 $33.08 $29.07 $31.05 $20.05 $20.05 $21.73 $20.05 $0.00 $0.00 $0.00 $0.00 30600033 EAP CPT® 87172 Pinworm Exam BOTH IP/OP $134.00 $99.16 $0.00 $134.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.48 $6.48 $6.73 $0.00 $6.30 $0.00 $0.00 $0.00 $0.00 $11.92 $106.92 $108.00 $0.00 $134.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600034 EAP CPT® 87177 "Ova & Parasites, Urn" BOTH IP/OP $251.00 $185.74 $4.45 $195.20 $18.37 $18.37 $8.90 $8.90 $4.45 $4.45 $13.51 $13.51 $14.03 $8.90 $13.15 $5.79 $148.47 $148.47 $9.35 $24.86 $193.25 $195.20 $12.91 $14.69 $12.91 $14.01 $8.90 $8.90 $9.81 $8.90 $0.00 $0.00 $0.00 $0.00 30600035 EAP CPT® 87177 "O&p,ethylacetate" BOTH IP/OP $229.00 $169.46 $4.45 $178.40 $18.37 $18.37 $8.90 $8.90 $4.45 $4.45 $13.51 $13.51 $14.03 $8.90 $13.15 $5.79 $135.45 $135.45 $9.35 $24.86 $176.62 $178.40 $12.91 $14.69 $12.91 $14.01 $8.90 $8.90 $9.81 $8.90 $0.00 $0.00 $0.00 $0.00 30600036 EAP CPT® 87186 Sens.special Panel BOTH IP/OP $235.00 $173.90 $4.32 $171.20 $17.85 $17.85 $8.65 $8.65 $4.33 $4.32 $13.12 $13.12 $13.63 $8.65 $12.77 $5.62 $139.00 $139.00 $9.08 $24.16 $169.49 $171.20 $12.54 $14.27 $12.54 $13.60 $8.65 $8.65 $9.52 $8.65 $0.00 $0.00 $0.00 $0.00 30600037 EAP CPT® 87186 Sens.gram Pos Cocci BOTH IP/OP $214.00 $158.36 $0.00 $171.20 $17.85 $17.85 $8.65 $8.65 $4.33 $4.32 $13.12 $13.12 $13.63 $8.65 $12.77 $5.62 $126.58 $126.58 $9.08 $24.16 $169.49 $171.20 $12.54 $0.00 $12.54 $13.60 $8.65 $8.65 $9.52 $8.65 $0.00 $0.00 $0.00 $0.00 30600038 EAP CPT® 87205 Gram Stain BOTH IP/OP $61.00 $45.14 $0.00 $50.40 $4.83 $4.83 $4.27 $4.27 $2.14 $2.14 $3.57 $3.57 $3.70 $4.27 $3.47 $2.78 $36.08 $36.08 $4.48 $6.56 $49.90 $50.40 $6.19 $0.00 $6.19 $3.69 $4.27 $4.27 $2.58 $4.27 $0.00 $0.00 $0.00 $0.00 30600039 EAP CPT® 87502 Influenza Virus -a/b Amplified Probe BOTH IP/OP $272.00 $201.28 $43.11 $220.00 $107.10 $107.10 $95.80 $95.80 $47.90 $43.11 $75.96 $75.96 $78.88 $95.80 $68.64 $62.27 $160.89 $160.89 $100.59 $137.50 $217.80 $220.00 $138.91 $158.07 $138.91 $73.14 $95.80 $95.80 $51.20 $95.80 $0.00 $0.00 $0.00 $0.00 30600040 EAP CPT® 87150 Group B Strep - Amplified Probe BOTH IP/OP $384.00 $284.16 $0.00 $307.20 $40.50 $40.50 $35.09 $35.09 $17.55 $0.00 $29.22 $29.22 $30.35 $0.00 $80.03 $0.00 $0.00 $0.00 $0.00 $192.00 $304.13 $307.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600041 EAP CPT® 87503 Influenza Virus (h1n1) (amplified Probe) BOTH IP/OP $271.00 $200.54 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.39 $11.39 $11.83 $0.00 $10.29 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600042 EAP CPT® 87206 PAS/KOH PREP BOTH IP/OP $158.00 $116.92 $2.70 $123.20 $11.11 $11.11 $5.39 $5.39 $2.70 $2.70 $8.15 $8.15 $8.47 $5.39 $7.93 $3.50 $93.46 $93.46 $5.66 $15.00 $121.97 $123.20 $7.82 $8.89 $7.82 $8.45 $5.39 $5.39 $5.91 $5.39 $0.00 $0.00 $0.00 $0.00 30600044 EAP CPT® 87328 Cryptosporidium Scrn. BOTH IP/OP $195.00 $144.30 $6.22 $154.40 $24.74 $24.74 $13.82 $13.82 $6.91 $6.22 $18.22 $18.22 $18.92 $13.82 $17.71 $8.98 $115.34 $115.34 $14.51 $33.52 $152.86 $154.40 $20.04 $22.80 $20.04 $18.87 $13.82 $13.82 $13.21 $13.82 $0.00 $0.00 $0.00 $0.00 30600045 EAP CPT® 87207 Malaria/parasite Smr BOTH IP/OP $229.00 $169.46 $3.00 $178.40 $12.38 $12.38 $5.99 $5.99 $3.00 $3.00 $9.10 $9.10 $9.45 $5.99 $8.84 $3.89 $135.45 $135.45 $6.29 $16.74 $176.62 $178.40 $8.69 $9.88 $8.69 $9.42 $5.99 $5.99 $6.59 $5.99 $0.00 $0.00 $0.00 $0.00 30600046 EAP CPT® 87207 Rbc Inclusion Body BOTH IP/OP $216.00 $159.84 $0.00 $178.40 $12.38 $12.38 $5.99 $5.99 $3.00 $3.00 $9.10 $9.10 $9.45 $5.99 $8.84 $3.89 $127.76 $127.76 $6.29 $16.74 $176.62 $178.40 $8.69 $0.00 $8.69 $9.42 $5.99 $5.99 $6.59 $5.99 $0.00 $0.00 $0.00 $0.00 30600047 EAP CPT® 87209 Microsporidium BOTH IP/OP $391.00 $289.34 $8.99 $304.80 $37.12 $37.12 $17.98 $17.98 $8.99 $8.99 $27.29 $27.29 $28.34 $17.98 $26.54 $11.69 $231.28 $231.28 $18.88 $50.22 $301.75 $304.80 $26.07 $29.67 $26.07 $28.28 $17.98 $17.98 $19.80 $17.98 $0.00 $0.00 $0.00 $0.00 30600048 EAP CPT® 87209 "O&p,pva/trichrome" BOTH IP/OP $367.00 $271.58 $8.99 $285.60 $37.12 $37.12 $17.98 $17.98 $8.99 $8.99 $27.29 $27.29 $28.34 $17.98 $26.54 $11.69 $217.08 $217.08 $18.88 $50.22 $282.74 $285.60 $26.07 $29.67 $26.07 $28.28 $17.98 $17.98 $19.80 $17.98 $0.00 $0.00 $0.00 $0.00 30600049 EAP CPT® 87799 Eb Virus Dna Quant Pcr (so) BOTH IP/OP $796.00 $589.04 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $165.89 $27.85 $470.83 $470.83 $0.00 $119.70 $622.51 $628.80 $0.00 $796.00 $0.00 $123.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600050 EAP CPT® 87252 Cmv Culture Inoc Tissue (so) BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $45.65 $45.65 $26.07 $26.07 $13.04 $13.04 $33.57 $33.57 $34.86 $26.07 $32.66 $16.95 $230.69 $230.69 $27.37 $61.78 $308.88 $312.00 $37.80 $0.00 $37.80 $34.79 $26.07 $26.07 $24.36 $26.07 $0.00 $0.00 $0.00 $0.00 30600051 EAP CPT® 87254 Cmv Culture Inoc Shell (so) BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $54.64 $190.08 $192.00 $0.00 $0.00 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600052 EAP CPT® 87210 "O & P DIRECT, SMEAR" BOTH IP/OP $216.00 $159.84 $2.62 $168.00 $8.82 $8.82 $5.82 $5.82 $2.91 $2.62 $6.48 $6.48 $6.73 $5.82 $6.30 $3.78 $127.76 $127.76 $6.11 $11.92 $166.32 $168.00 $8.44 $9.60 $8.44 $6.71 $5.82 $5.82 $4.70 $5.82 $0.00 $0.00 $0.00 $0.00 30600053 EAP CPT® 87220 Koh Level BOTH IP/OP $198.00 $146.52 $2.14 $147.20 $8.82 $8.82 $4.27 $4.27 $2.14 $2.14 $6.48 $6.48 $6.73 $4.27 $6.30 $2.78 $117.12 $117.12 $4.48 $11.92 $145.73 $147.20 $6.19 $7.05 $6.19 $6.71 $4.27 $4.27 $4.70 $4.27 $0.00 $0.00 $0.00 $0.00 30600055 EAP CPT® 87252 "Viral Cult,referral" BOTH IP/OP $238.00 $176.12 $13.04 $192.00 $45.65 $45.65 $26.07 $26.07 $13.04 $13.04 $33.57 $33.57 $34.86 $26.07 $32.66 $16.95 $140.78 $140.78 $27.37 $61.78 $190.08 $192.00 $37.80 $43.02 $37.80 $34.79 $26.07 $26.07 $24.36 $26.07 $0.00 $0.00 $0.00 $0.00 30600056 EAP CPT® 87320 Chlamydia Screen BOTH IP/OP $718.00 $531.32 $0.00 $574.40 $24.74 $24.74 $15.00 $15.00 $7.50 $6.75 $18.22 $18.22 $18.92 $15.00 $17.71 $9.75 $424.70 $424.70 $0.00 $33.52 $568.66 $574.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600057 EAP CPT® 87324 "C.diff. Assay,stool" BOTH IP/OP $195.00 $144.30 $5.99 $154.40 $24.74 $24.74 $11.98 $11.98 $5.99 $5.99 $18.22 $18.22 $18.92 $11.98 $17.71 $7.79 $115.34 $115.34 $12.58 $33.52 $152.86 $154.40 $17.37 $19.77 $17.37 $18.87 $11.98 $11.98 $13.21 $11.98 $0.00 $0.00 $0.00 $0.00 30600059 EAP CPT® 87329 Eia Giardia Screen BOTH IP/OP $195.00 $144.30 $5.99 $154.40 $24.74 $24.74 $11.98 $11.98 $5.99 $5.99 $18.22 $18.22 $18.92 $11.98 $17.71 $7.79 $115.34 $115.34 $12.58 $33.52 $152.86 $154.40 $17.37 $19.77 $17.37 $18.87 $11.98 $11.98 $13.21 $11.98 $0.00 $0.00 $0.00 $0.00 30600060 EAP CPT® 87337 H.pylori Ag -stool BOTH IP/OP $334.00 $247.16 $5.99 $264.00 $24.74 $24.74 $11.98 $11.98 $5.99 $5.99 $18.22 $18.22 $18.92 $11.98 $17.71 $7.79 $197.56 $197.56 $12.58 $33.52 $261.36 $264.00 $17.37 $19.77 $17.37 $18.87 $11.98 $11.98 $13.21 $11.98 $0.00 $0.00 $0.00 $0.00 30600061 EAP CPT® 87340 Hbv Surface Ag BOTH IP/OP $255.00 $188.70 $5.17 $205.60 $21.33 $21.33 $10.33 $10.33 $5.17 $5.17 $15.68 $15.68 $16.29 $10.33 $15.26 $6.71 $150.83 $150.83 $10.85 $28.86 $203.54 $205.60 $14.98 $17.04 $14.98 $16.26 $10.33 $10.33 $11.38 $10.33 $0.00 $0.00 $0.00 $0.00 30600062 EAP CPT® 87340 Hbv Surf Ag-ob BOTH IP/OP $246.00 $182.04 $5.17 $205.60 $21.33 $21.33 $10.33 $10.33 $5.17 $5.17 $15.68 $15.68 $16.29 $10.33 $15.26 $6.71 $145.51 $145.51 $10.85 $28.86 $203.54 $205.60 $14.98 $17.04 $14.98 $16.26 $10.33 $10.33 $11.38 $10.33 $0.00 $0.00 $0.00 $0.00 30600063 EAP CPT® 87350 Hbv E Ag BOTH IP/OP $87.00 $64.38 $5.76 $70.40 $23.79 $23.79 $11.53 $11.53 $5.77 $5.76 $17.50 $17.50 $18.18 $11.53 $17.02 $7.49 $51.46 $51.46 $12.11 $32.20 $69.70 $70.40 $16.72 $19.02 $16.72 $18.14 $11.53 $11.53 $12.70 $11.53 $0.00 $0.00 $0.00 $0.00 30600064 EAP CPT® 87385 Histoplasma Ag BOTH IP/OP $318.00 $235.32 $5.99 $251.20 $24.74 $24.74 $13.25 $13.25 $6.63 $5.99 $18.22 $18.22 $18.92 $13.25 $17.71 $8.61 $188.10 $188.10 $13.91 $33.52 $248.69 $251.20 $19.21 $21.86 $19.21 $18.87 $13.25 $13.25 $13.21 $13.25 $0.00 $0.00 $0.00 $0.00 30600065 EAP CPT® 87390 Hiv-ag-p24 BOTH IP/OP $225.00 $166.50 $0.00 $186.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.79 $26.79 $27.82 $0.00 $22.62 $0.00 $0.00 $0.00 $0.00 $49.30 $184.54 $186.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600066 EAP CPT® 87425 "Rotavirus Ag, Stool" BOTH IP/OP $223.00 $165.02 $0.00 $223.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $178.20 $180.00 $0.00 $223.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600068 EAP CPT® 87430 STREP A AG-THROAT BOTH IP/OP $162.00 $119.88 $0.00 $129.60 $24.74 $24.74 $16.81 $16.81 $8.41 $7.56 $18.22 $18.22 $18.92 $16.81 $17.71 $10.93 $95.82 $95.82 $17.65 $33.52 $128.30 $129.60 $24.37 $0.00 $24.37 $18.87 $16.81 $16.81 $13.21 $16.81 $0.00 $0.00 $0.00 $0.00 30600070 EAP CPT® 87450 "L. Pneumo-1 Ag, Urine" BOTH IP/OP $271.00 $200.54 $7.02 $271.00 $24.74 $24.74 $15.60 $15.60 $7.80 $7.02 $18.22 $18.22 $18.92 $15.60 $17.71 $10.14 $160.30 $160.30 $10.07 $26.78 $217.01 $219.20 $13.91 $271.00 $13.91 $15.08 $9.59 $9.59 $10.56 $9.59 $0.00 $0.00 $0.00 $0.00 30600071 EAP CPT® 87491 Chlamydia Detection BOTH IP/OP $374.00 $276.76 $17.55 $272.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $221.22 $221.22 $36.84 $54.82 $269.28 $272.00 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600072 EAP CPT® 87496 Cmv Dna-pcr Fluids BOTH IP/OP $905.00 $669.70 $0.00 $905.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $535.31 $535.31 $36.84 $54.82 $695.38 $702.40 $50.88 $905.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600073 EAP CPT® 87516 Hbv Dna-pcr BOTH IP/OP $319.00 $236.06 $0.00 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.79 $29.79 $30.93 $0.00 $28.98 $0.00 $0.00 $0.00 $0.00 $54.82 $261.36 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600074 EAP CPT® 87177 Coccidia Smear BOTH IP/OP $229.00 $169.46 $4.45 $178.40 $18.37 $18.37 $8.90 $8.90 $4.45 $4.45 $13.51 $13.51 $14.03 $8.90 $13.15 $5.79 $135.45 $135.45 $9.35 $24.86 $176.62 $178.40 $12.91 $14.69 $12.91 $14.01 $8.90 $8.90 $9.81 $8.90 $0.00 $0.00 $0.00 $0.00 30600075 EAP CPT® 87521 Hcv Rna-pcr BOTH IP/OP $706.00 $522.44 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.79 $29.79 $30.93 $0.00 $28.98 $0.00 $0.00 $0.00 $0.00 $54.82 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600076 EAP CPT® 87522 "Hcv Rna-pcr, Quant" BOTH IP/OP "$1,023.00 " $757.02 $21.42 $794.40 $88.41 $88.41 $42.84 $42.84 $21.42 $21.42 $65.04 $65.04 $67.54 $42.84 $63.28 $27.85 $605.10 $605.10 $44.98 $119.70 $786.46 $794.40 $62.12 $70.69 $62.12 $67.43 $42.84 $42.84 $47.20 $42.84 $0.00 $0.00 $0.00 $0.00 30600077 EAP CPT® 87529 Hsv Dna-pcr BOTH IP/OP $901.00 $666.74 $17.55 $700.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $532.94 $532.94 $36.84 $54.82 $693.00 $700.00 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600078 EAP CPT® 87535 Hiv-1 Dna-pcr BOTH IP/OP $675.00 $499.50 $17.55 $524.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $399.26 $399.26 $36.84 $54.82 $518.76 $524.00 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600079 EAP CPT® 87536 "Hiv-1 Rna B Dna, Quant" BOTH IP/OP $742.00 $549.08 $0.00 $613.60 $107.10 $107.10 $85.10 $85.10 $42.55 $42.55 $78.80 $78.80 $81.83 $85.10 $66.37 $55.32 $438.89 $438.89 $89.36 $145.02 $607.46 $613.60 $123.40 $0.00 $123.40 $70.72 $85.10 $85.10 $49.50 $85.10 $0.00 $0.00 $0.00 $0.00 30600080 EAP CPT® 87556 Direct M. Tb Test BOTH IP/OP $317.00 $234.58 $18.76 $246.40 $40.50 $40.50 $41.68 $41.68 $20.84 $18.76 $29.79 $29.79 $30.93 $41.68 $66.06 $27.09 $187.51 $187.51 $43.76 $54.82 $243.94 $246.40 $60.44 $68.77 $60.44 $48.20 $41.68 $41.68 $49.03 $41.68 $0.00 $0.00 $0.00 $0.00 30600081 EAP CPT® 87591 Gc Detection BOTH IP/OP $374.00 $276.76 $17.55 $272.00 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $25.16 $22.81 $221.22 $221.22 $36.84 $54.82 $269.28 $272.00 $50.88 $57.90 $50.88 $26.81 $35.09 $35.09 $18.76 $35.09 $0.00 $0.00 $0.00 $0.00 30600082 EAP CPT® 87798 "Enterovirus Pcr, Csf" BOTH IP/OP $807.00 $597.18 $17.55 $777.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $477.34 $477.34 $36.84 $54.82 $769.82 $777.60 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600083 EAP CPT® 87798 Thyroid Perox Ab; Tpo BOTH IP/OP $964.00 $713.36 $17.55 $777.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $570.21 $570.21 $36.84 $54.82 $769.82 $777.60 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600084 EAP CPT® 87798 "Jcv Dna-pcr,csf" BOTH IP/OP $900.00 $666.00 $17.55 $725.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $532.35 $532.35 $36.84 $54.82 $718.34 $725.60 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600085 EAP CPT® 87798 "Vzv Dna-pcr,csf" BOTH IP/OP $900.00 $666.00 $17.55 $725.60 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $532.35 $532.35 $36.84 $54.82 $718.34 $725.60 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600086 EAP CPT® 87804 Influenza-a Ag BOTH IP/OP $359.00 $265.66 $7.45 $290.40 $24.74 $24.74 $16.55 $16.55 $8.28 $7.45 $18.22 $18.22 $18.92 $16.55 $17.71 $10.76 $212.35 $212.35 $17.38 $33.52 $287.50 $290.40 $24.00 $27.31 $24.00 $18.87 $16.55 $16.55 $13.21 $16.55 $0.00 $0.00 $0.00 $0.00 30600087 EAP CPT® 87804 Influenza-b Ag BOTH IP/OP $359.00 $265.66 $7.45 $290.40 $24.74 $24.74 $16.55 $16.55 $8.28 $7.45 $18.22 $18.22 $18.92 $16.55 $17.71 $10.76 $212.35 $212.35 $17.38 $33.52 $287.50 $290.40 $24.00 $27.31 $24.00 $18.87 $16.55 $16.55 $13.21 $16.55 $0.00 $0.00 $0.00 $0.00 30600088 EAP CPT® 87807 Rsv Assay BOTH IP/OP $656.00 $485.44 $0.00 $510.40 $24.74 $24.74 $13.10 $13.10 $6.55 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $13.76 $33.52 $505.30 $510.40 $19.00 $219.00 $19.00 $18.87 $13.10 $13.10 $13.21 $13.10 $0.00 $0.00 $0.00 $0.00 30600089 EAP CPT® 87901 Hiv Genotyping BOTH IP/OP "$1,830.00 " "$1,354.20" $96.09 "$1,420.80" $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 "$1,082.45" "$1,082.45" $270.32 $243.70 "$1,406.59" "$1,420.80" $373.30 $424.79 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30600090 EAP CPT® 87902 Hcv Genotyping BOTH IP/OP "$1,980.00 " "$1,465.20" $96.09 "$1,537.60" $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 "$1,171.17" "$1,171.17" $270.32 $243.70 "$1,522.22" "$1,537.60" $373.30 $424.79 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30600094 EAP CPT® 86757 Richettsia Antibody Igm BOTH IP/OP $48.00 $35.52 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $48.00 $38.02 $38.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600095 EAP CPT® 87798 "Parvovirus B19 Pcr, Qual" BOTH IP/OP $311.00 $230.14 $17.55 $250.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $183.96 $183.96 $36.84 $54.82 $247.90 $250.40 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600096 EAP CPT® 87517 "Hbv Dna-pcr,quant" BOTH IP/OP $355.00 $262.70 $21.42 $276.00 $88.41 $88.41 $42.84 $42.84 $21.42 $21.42 $65.04 $65.04 $67.54 $42.84 $63.28 $27.85 $209.98 $209.98 $44.98 $119.70 $273.24 $276.00 $62.12 $70.69 $62.12 $67.43 $42.84 $42.84 $47.20 $42.84 $0.00 $0.00 $0.00 $0.00 30600100 EAP CPT® 87046 "E.coli O157, Culture(so)" BOTH IP/OP $63.00 $46.62 $2.60 $51.20 $19.48 $19.48 $9.44 $9.44 $4.72 $4.72 $14.32 $14.32 $14.87 $9.44 $3.49 $6.14 $37.26 $37.26 $9.91 $26.36 $50.69 $51.20 $13.69 $15.58 $13.69 $3.71 $9.44 $9.44 $2.60 $9.44 $0.00 $0.00 $0.00 $0.00 30600105 EAP CPT® 87497 "Cmv,dna,pcr, Quant" BOTH IP/OP $659.00 $487.66 $0.00 $544.80 $88.41 $88.41 $42.84 $42.84 $21.42 $21.42 $65.04 $65.04 $67.54 $42.84 $63.28 $27.85 $389.80 $389.80 $44.98 $119.70 $539.35 $544.80 $62.12 $0.00 $62.12 $67.43 $42.84 $42.84 $47.20 $42.84 $0.00 $0.00 $0.00 $0.00 30600106 EAP CPT® 87252 Cmv Inoc Tissue (so) BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $45.65 $45.65 $26.07 $26.07 $13.04 $13.04 $33.57 $33.57 $34.86 $26.07 $32.66 $16.95 $230.69 $230.69 $27.37 $61.78 $308.88 $312.00 $37.80 $0.00 $37.80 $34.79 $26.07 $26.07 $24.36 $26.07 $0.00 $0.00 $0.00 $0.00 30600107 EAP CPT® 87254 Cmv Inoc Shell Via (so) BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $30.83 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $54.64 $190.08 $192.00 $0.00 $0.00 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600108 EAP CPT® 87902 Hep C Dna Geno Quant (so) BOTH IP/OP "$1,193.00 " $882.82 $0.00 $986.40 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $705.66 $705.66 $270.32 $243.70 $976.54 $986.40 $373.30 $0.00 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30600109 EAP CPT® 87799 Ebv Dna Detect Nos (so) BOTH IP/OP $688.00 $509.12 $0.00 $628.80 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $143.38 $27.85 $406.95 $406.95 $0.00 $119.70 $622.51 $628.80 $0.00 $0.00 $0.00 $123.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600200 EAP CPT® 87205 Gram Stain BOTH IP/OP $65.00 $48.10 $2.14 $50.40 $4.83 $4.83 $4.27 $4.27 $2.14 $2.14 $3.57 $3.57 $3.70 $4.27 $3.47 $2.78 $38.45 $38.45 $4.48 $6.56 $49.90 $50.40 $6.19 $7.05 $6.19 $3.69 $4.27 $4.27 $2.58 $4.27 $0.00 $0.00 $0.00 $0.00 30600201 EAP CPT® 87205 Sezary Cell Prep BOTH IP/OP $61.00 $45.14 $0.00 $50.40 $4.83 $4.83 $4.27 $4.27 $2.14 $2.14 $3.57 $3.57 $3.70 $4.27 $3.47 $2.78 $36.08 $36.08 $4.48 $6.56 $49.90 $50.40 $6.19 $0.00 $6.19 $3.69 $4.27 $4.27 $2.58 $4.27 $0.00 $0.00 $0.00 $0.00 30600202 EAP CPT® 87206 Pas/koh Prep BOTH IP/OP $158.00 $116.92 $2.70 $123.20 $11.11 $11.11 $5.39 $5.39 $2.70 $2.70 $8.15 $8.15 $8.47 $5.39 $7.93 $3.50 $93.46 $93.46 $5.66 $15.00 $121.97 $123.20 $7.82 $8.89 $7.82 $8.45 $5.39 $5.39 $5.91 $5.39 $0.00 $0.00 $0.00 $0.00 30600203 EAP CPT® 87206 Afb Stain BOTH IP/OP $158.00 $116.92 $2.70 $123.20 $11.11 $11.11 $5.39 $5.39 $2.70 $2.70 $8.15 $8.15 $8.47 $5.39 $7.93 $3.50 $93.46 $93.46 $5.66 $15.00 $121.97 $123.20 $7.82 $8.89 $7.82 $8.45 $5.39 $5.39 $5.91 $5.39 $0.00 $0.00 $0.00 $0.00 30600204 EAP CPT® 87210 "O & P Direct, Smear" BOTH IP/OP $210.00 $155.40 $2.62 $168.00 $8.82 $8.82 $5.82 $5.82 $2.91 $2.62 $6.48 $6.48 $6.73 $5.82 $6.30 $3.78 $124.22 $124.22 $6.11 $11.92 $166.32 $168.00 $8.44 $9.60 $8.44 $6.71 $5.82 $5.82 $4.70 $5.82 $0.00 $0.00 $0.00 $0.00 30600205 EAP CPT® 87210 India Ink Prep BOTH IP/OP $216.00 $159.84 $2.62 $168.00 $8.82 $8.82 $5.82 $5.82 $2.91 $2.62 $6.48 $6.48 $6.73 $5.82 $6.30 $3.78 $127.76 $127.76 $6.11 $11.92 $166.32 $168.00 $8.44 $9.60 $8.44 $6.71 $5.82 $5.82 $4.70 $5.82 $0.00 $0.00 $0.00 $0.00 30600206 EAP CPT® 87210 Vaginal Wet Prep BOTH IP/OP $216.00 $159.84 $2.62 $168.00 $8.82 $8.82 $5.82 $5.82 $2.91 $2.62 $6.48 $6.48 $6.73 $5.82 $6.30 $3.78 $127.76 $127.76 $6.11 $11.92 $166.32 $168.00 $8.44 $9.60 $8.44 $6.71 $5.82 $5.82 $4.70 $5.82 $0.00 $0.00 $0.00 $0.00 30600207 EAP CPT® 87430 Strep A Ag-throat BOTH IP/OP $169.00 $125.06 $7.56 $129.60 $24.74 $24.74 $16.81 $16.81 $8.41 $7.56 $18.22 $18.22 $18.92 $16.81 $17.71 $10.93 $99.96 $99.96 $17.65 $33.52 $128.30 $129.60 $24.37 $27.74 $24.37 $18.87 $16.81 $16.81 $13.21 $16.81 $0.00 $0.00 $0.00 $0.00 30600208 EAP CPT® 87205 Gram Stain For Gc BOTH IP/OP $65.00 $48.10 $2.14 $50.40 $4.83 $4.83 $4.27 $4.27 $2.14 $2.14 $3.57 $3.57 $3.70 $4.27 $3.47 $2.78 $38.45 $38.45 $4.48 $6.56 $49.90 $50.40 $6.19 $7.05 $6.19 $3.69 $4.27 $4.27 $2.58 $4.27 $0.00 $0.00 $0.00 $0.00 30600209 EAP CPT® 87206 Koh Prep BOTH IP/OP $158.00 $116.92 $2.70 $123.20 $11.11 $11.11 $5.39 $5.39 $2.70 $2.70 $8.15 $8.15 $8.47 $5.39 $7.93 $3.50 $93.46 $93.46 $5.66 $15.00 $121.97 $123.20 $7.82 $8.89 $7.82 $8.45 $5.39 $5.39 $5.91 $5.39 $0.00 $0.00 $0.00 $0.00 30600210 EAP CPT® 87210 Vaginal Wet Prep BOTH IP/OP $216.00 $159.84 $2.62 $168.00 $8.82 $8.82 $5.82 $5.82 $2.91 $2.62 $6.48 $6.48 $6.73 $5.82 $6.30 $3.78 $127.76 $127.76 $6.11 $11.92 $166.32 $168.00 $8.44 $9.60 $8.44 $6.71 $5.82 $5.82 $4.70 $5.82 $0.00 $0.00 $0.00 $0.00 30600211 EAP CPT® 87430 Rapid Strep BOTH IP/OP $162.00 $119.88 $0.00 $129.60 $24.74 $24.74 $16.81 $16.81 $8.41 $7.56 $18.22 $18.22 $18.92 $16.81 $17.71 $10.93 $95.82 $95.82 $17.65 $33.52 $128.30 $129.60 $24.37 $0.00 $24.37 $18.87 $16.81 $16.81 $13.21 $16.81 $0.00 $0.00 $0.00 $0.00 30600212 EAP CPT® 87205 Gram Stain BOTH IP/OP $61.00 $45.14 $0.00 $50.40 $4.83 $4.83 $4.27 $4.27 $2.14 $2.14 $3.57 $3.57 $3.70 $4.27 $3.47 $2.78 $36.08 $36.08 $4.48 $6.56 $49.90 $50.40 $6.19 $0.00 $6.19 $3.69 $4.27 $4.27 $2.58 $4.27 $0.00 $0.00 $0.00 $0.00 30600213 EAP CPT® 87188 Microbe Suscept Macrobroth BOTH IP/OP $41.00 $30.34 $0.00 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.08 $10.08 $10.47 $0.00 $9.80 $0.00 $0.00 $0.00 $0.00 $18.54 $32.47 $32.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600215 EAP CPT® 87290 Varicella Zoster Ag If BOTH IP/OP $66.00 $48.84 $0.00 $52.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $52.27 $52.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600216 EAP CPT® 87299 Antibody Detection Nos If BOTH IP/OP $83.00 $61.42 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $65.74 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600218 EAP CPT® 87015 Pneumocycstis Carni Dfa-concen BOTH IP/OP $91.00 $67.34 $0.00 $72.80 $13.78 $13.78 $6.68 $6.68 $3.34 $3.34 $10.14 $10.14 $10.53 $6.68 $9.87 $4.34 $53.83 $53.83 $7.01 $18.66 $72.07 $72.80 $9.69 $0.00 $9.69 $10.52 $6.68 $6.68 $7.36 $6.68 $0.00 $0.00 $0.00 $0.00 30600219 EAP CPT® 87281 Pneumocycstis Carni Dfa-id (q) BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.22 $18.22 $18.92 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $33.52 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600220 EAP CPT® 87799 "Toxoplasma Gondii Dna , Quant Pcr (so)" BOTH IP/OP $846.00 $626.04 $0.00 $773.60 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $176.31 $27.85 $500.41 $500.41 $0.00 $119.70 $765.86 $773.60 $0.00 $0.00 $0.00 $151.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600221 EAP CPT® 87798 Bordetella Pertussis/parapertussis Qual/pcr(so) BOTH IP/OP $547.00 $404.78 $17.55 $440.80 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $323.55 $323.55 $36.84 $54.82 $436.39 $440.80 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30600222 EAP CPT® 87912 Hepatitis B Virus Drug Resistance Genotype Bcp/precore (so) BOTH IP/OP $590.00 $436.60 $0.00 $472.00 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $373.52 $373.52 $387.88 $257.45 $112.65 $167.34 $348.99 $348.99 $0.00 $295.00 $467.28 $472.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600223 EAP CPT® 87902 "Hepatitis C Viral Genotype , Lipa (so)" BOTH IP/OP $339.00 $250.86 $0.00 $350.00 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $200.52 $200.52 $270.32 $243.70 $277.20 $280.00 $350.00 $0.00 $350.00 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30600224 EAP CPT® 87661 "Trichomonas Vaginalis Rna, Qual" BOTH IP/OP $253.00 $187.22 $17.55 $196.80 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $27.84 $27.84 $28.91 $35.09 $25.16 $22.81 $149.65 $149.65 $36.84 $123.00 $194.83 $196.80 $50.88 $57.90 $50.88 $26.81 $35.09 $35.09 $18.76 $35.09 $0.00 $0.00 $0.00 $0.00 30600225 EAP CPT® 87493 "Clostridium Difficile Toxin, Gene ,pcr" BOTH IP/OP $288.00 $213.12 $17.55 $209.60 $40.50 $40.50 $37.27 $37.27 $18.64 $17.55 $29.22 $29.22 $30.35 $37.27 $60.02 $24.23 $170.35 $170.35 $39.13 $131.00 $207.50 $209.60 $54.04 $61.50 $54.04 $41.00 $37.27 $37.27 $41.71 $37.27 $0.00 $0.00 $0.00 $0.00 30600227 EAP CPT® 87632 Respiratory Pcr Panel Iv (so) BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $309.59 $309.59 $321.49 $0.00 $127.33 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $655.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30600228 EAP CPT® 87530 Herpes Sim Pcr Quant (so) BOTH IP/OP $331.00 $244.94 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.04 $65.04 $67.54 $0.00 $68.98 $0.00 $0.00 $0.00 $0.00 $119.70 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30630620 EAP CPT® 87798 Jc Polyoma Quant Amp (so) BOTH IP/OP $326.00 $241.24 $0.00 $314.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $192.83 $192.83 $36.84 $54.82 $311.26 $314.40 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30630621 EAP CPT® 87799 Jc Polyoma Quant Pcr (so) BOTH IP/OP $589.00 $435.86 $0.00 $589.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $122.75 $27.85 $348.39 $348.39 $0.00 $119.70 $460.94 $465.60 $0.00 $589.00 $0.00 $91.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30630622 EAP CPT® 87798 Aspergillus Dna Qual Pcr (so) BOTH IP/OP $326.00 $241.24 $0.00 $314.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $192.83 $192.83 $36.84 $54.82 $311.26 $314.40 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30630623 EAP CPT® 87081 Brucella Screen (so) BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $13.68 $13.68 $6.63 $6.63 $3.32 $3.31 $10.08 $10.08 $10.47 $6.63 $9.79 $4.31 $84.58 $84.58 $6.96 $18.52 $113.26 $114.40 $9.61 $0.00 $9.61 $10.43 $6.63 $6.63 $7.30 $6.63 $0.00 $0.00 $0.00 $0.00 30630624 EAP CPT® 87799 Herpes Virus 8 Dna Pcr (so) BOTH IP/OP $509.00 $376.66 $0.00 $465.60 $0.00 $0.00 $0.00 $0.00 $0.00 $21.42 $65.04 $65.04 $67.54 $42.84 $106.08 $27.85 $301.07 $301.07 $0.00 $119.70 $460.94 $465.60 $0.00 $0.00 $0.00 $91.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650009 EAP CPT® 87070 Sputum Culture BOTH IP/OP $371.00 $274.54 $4.31 $277.60 $17.79 $17.79 $8.62 $8.62 $4.31 $4.31 $13.07 $13.07 $13.58 $8.62 $12.73 $5.60 $219.45 $219.45 $9.05 $24.06 $274.82 $277.60 $12.50 $14.22 $12.50 $13.56 $8.62 $8.62 $9.49 $8.62 $0.00 $0.00 $0.00 $0.00 30650014 EAP CPT® 87077 Culture I.d.-aerobe Biochem BOTH IP/OP $261.00 $193.14 $4.04 $189.60 $16.68 $16.68 $8.08 $8.08 $4.04 $4.04 $12.27 $12.27 $12.74 $8.08 $11.94 $5.25 $154.38 $154.38 $8.48 $22.58 $187.70 $189.60 $11.72 $13.33 $11.72 $12.72 $8.08 $8.08 $8.90 $8.08 $0.00 $0.00 $0.00 $0.00 30650094 EAP CPT® 86757 Richettsia Antibody Igg BOTH IP/OP $48.00 $35.52 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.39 $29.39 $30.52 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $48.00 $38.02 $38.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650206 EAP CPT® 87210 Trichomonas Prep BOTH IP/OP $204.00 $150.96 $2.62 $168.00 $8.82 $8.82 $5.82 $5.82 $2.91 $2.62 $6.48 $6.48 $6.73 $5.82 $6.30 $3.78 $120.67 $120.67 $6.11 $11.92 $166.32 $168.00 $8.44 $9.60 $8.44 $6.71 $5.82 $5.82 $4.70 $5.82 $0.00 $0.00 $0.00 $0.00 30650311 EAP CPT® 87530 Hsv Dna Quant BOTH IP/OP $445.00 $329.30 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.04 $65.04 $67.54 $0.00 $92.74 $0.00 $0.00 $0.00 $0.00 $119.70 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650312 EAP CPT® 87798 "T.pallidum Pcr Ql,csf Q" BOTH IP/OP $401.00 $296.74 $17.55 $323.20 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $237.19 $237.19 $36.84 $54.82 $319.97 $323.20 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30650313 EAP CPT® 87624 Papillomavirus Human BOTH IP/OP $90.00 $66.60 $0.00 $74.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $27.77 $27.77 $28.84 $35.09 $21.44 $22.81 $53.24 $53.24 $36.84 $46.50 $73.66 $74.40 $50.88 $0.00 $50.88 $22.85 $35.09 $35.09 $15.99 $35.09 $0.00 $0.00 $0.00 $0.00 30650315 EAP CPT® 87798 Ehrlichia Chaff Pcr (so) BOTH IP/OP $373.00 $276.02 $0.00 $359.20 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $220.63 $220.63 $36.84 $54.82 $355.61 $359.20 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30650316 EAP CPT® 87529 Hsv Pcr Qual Amino (so) BOTH IP/OP $340.00 $251.60 $0.00 $280.80 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $201.11 $201.11 $36.84 $54.82 $277.99 $280.80 $50.88 $0.00 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30650317 EAP CPT® 87900 Hcv Ns3/4 Pheno (so) BOTH IP/OP "$1,201.00 " $888.74 $0.00 "$1,084.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.86 $167.86 $174.31 $0.00 $163.30 $0.00 $0.00 $0.00 $0.00 $308.90 "$1,073.16" "$1,084.00" $0.00 "$1,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650318 EAP CPT® 87902 Hcv Ns3/4 Geno (so) BOTH IP/OP "$1,193.00 " $882.82 $0.00 $986.40 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $705.66 $705.66 $270.32 $243.70 $976.54 $986.40 $373.30 $0.00 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30650319 EAP CPT® 87798 Jc Poly Qual Pcr (so) BOTH IP/OP $445.00 $329.30 $17.55 $359.20 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $263.22 $263.22 $36.84 $54.82 $355.61 $359.20 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30650320 EAP CPT® 87906 Hiv Coreceptor Tropism Ultra (so) BOTH IP/OP $973.00 $720.02 $0.00 $937.60 $90.02 $90.02 $128.73 $128.73 $64.37 $64.36 $63.81 $63.81 $66.27 $128.73 $57.67 $83.67 $575.53 $575.53 $135.17 $586.00 $928.22 $937.60 $186.66 $0.00 $186.66 $61.44 $128.73 $128.73 $43.01 $128.73 $0.00 $0.00 $0.00 $0.00 30650321 EAP CPT® 87902 Hcv Rna Ns5a Drug (so) BOTH IP/OP "$1,270.00 " $939.80 $96.09 $986.40 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $751.21 $751.21 $270.32 $243.70 $976.54 $986.40 $373.30 $424.79 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30650322 EAP CPT® 87902 Hcv Rna Ns5b Resist (so) BOTH IP/OP "$1,193.00 " $882.82 $0.00 $986.40 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $705.66 $705.66 $270.32 $243.70 $976.54 $986.40 $373.30 $0.00 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30650323 EAP CPT® 87632 Resp Virus Pcr Iv (6-11) (so) BOTH IP/OP "$3,561.00 " "$2,635.14" $0.00 "$2,848.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $309.59 $309.59 $321.49 $0.00 $127.33 $0.00 $0.00 $0.00 $0.00 "$1,780.50" "$2,820.31" "$2,848.80" $0.00 $655.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650324 EAP CPT® 87530 Hsv Dna Pcr Quant (so) BOTH IP/OP $327.00 $241.98 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.04 $65.04 $67.54 $0.00 $68.15 $0.00 $0.00 $0.00 $0.00 $119.70 $267.70 $270.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650325 EAP CPT® 87902 Hcv Ns5a Drug Resist (so) BOTH IP/OP $747.00 $552.78 $0.00 $617.60 $180.02 $180.02 $257.45 $257.45 $128.73 $128.72 $132.42 $132.42 $137.52 $257.45 $128.84 $167.34 $441.85 $441.85 $270.32 $243.70 $611.42 $617.60 $373.30 $0.00 $373.30 $137.28 $257.45 $257.45 $96.09 $257.45 $0.00 $0.00 $0.00 $0.00 30650326 EAP CPT® 87625 Hpv Genotyping BOTH IP/OP $245.00 $181.30 $0.00 $245.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.77 $27.77 $28.84 $0.00 $21.44 $0.00 $0.00 $0.00 $0.00 $123.50 $195.62 $197.60 $0.00 $245.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650330 EAP CPT® 87015 Cyclospora & Isospora Concentration (so) BOTH IP/OP $77.00 $56.98 $3.34 $56.00 $13.78 $13.78 $6.68 $6.68 $3.34 $3.34 $10.14 $10.14 $10.53 $6.68 $9.87 $4.34 $45.55 $45.55 $7.01 $18.66 $55.44 $56.00 $9.69 $11.02 $9.69 $10.52 $6.68 $6.68 $7.36 $6.68 $0.00 $0.00 $0.00 $0.00 30650331 EAP CPT® 87207 Cyclospora & Isospora Stain (so) BOTH IP/OP $72.00 $53.28 $3.00 $56.00 $12.38 $12.38 $5.99 $5.99 $3.00 $3.00 $9.10 $9.10 $9.45 $5.99 $8.84 $3.89 $42.59 $42.59 $6.29 $16.74 $55.44 $56.00 $8.69 $9.88 $8.69 $9.42 $5.99 $5.99 $6.59 $5.99 $0.00 $0.00 $0.00 $0.00 30650340 EAP CPT® 87635 Covid-19 Lab Test Non-cdc BOTH IP/OP $242.00 $179.08 $48.75 $406.40 $131.41 $131.41 $75.00 $75.00 $75.00 $111.88 $186.11 $186.11 $193.28 $75.00 $111.88 $48.75 $143.14 $143.14 $105.00 $254.00 $402.34 $406.40 $74.40 $123.75 $74.40 $79.50 $51.31 $51.31 $80.87 $100.00 $0.00 $0.00 $0.00 $0.00 30650341 EAP CPT® 87635 Sars-cov-2 Covid-19 Amp Prb (so) BOTH IP/OP $174.00 $128.76 $0.00 $193.28 $94.48 $94.48 $0.00 $0.00 $25.66 $111.88 $186.11 $186.11 $193.28 $0.00 $111.88 $0.00 $102.92 $102.92 $53.88 $86.50 $137.02 $138.40 $74.40 $56.89 $74.40 $27.07 $51.31 $51.31 $27.54 $51.31 $0.00 $0.00 $0.00 $0.00 30650350 EAP CPT® 87633 Respiratory Virus Panel 12-25 Targets BOTH IP/OP "$1,033.00 " $764.42 $0.00 $834.40 $363.98 $363.98 $416.78 $416.78 $208.39 $208.39 $535.13 $535.13 $555.71 $416.78 $227.79 $270.91 $611.02 $611.02 $0.00 $521.50 $826.06 $834.40 $0.00 $687.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650351 EAP CPT® 87798 Bordetella Pertussis BOTH IP/OP $87.00 $64.38 $17.55 $70.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $51.46 $51.46 $36.84 $54.82 $69.70 $70.40 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30650352 EAP CPT® 87486 Chlamydophila/chlamydia Pneumoniae BOTH IP/OP $97.00 $71.78 $0.00 $70.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $57.38 $57.38 $0.00 $54.82 $69.70 $70.40 $0.00 $57.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650353 EAP CPT® 87581 Mycoplasma Pneumoniae BOTH IP/OP $91.00 $67.34 $0.00 $70.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $53.83 $53.83 $0.00 $54.82 $69.70 $70.40 $0.00 $57.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30650354 EAP CPT® 87798 Bordetella Parapertussis BOTH IP/OP $87.00 $64.38 $17.55 $70.40 $40.50 $40.50 $35.09 $35.09 $17.55 $17.55 $29.79 $29.79 $30.93 $35.09 $28.98 $22.81 $51.46 $51.46 $36.84 $54.82 $69.70 $70.40 $50.88 $57.90 $50.88 $30.88 $35.09 $35.09 $21.62 $35.09 $0.00 $0.00 $0.00 $0.00 30700001 EAP CPT® 81000 "PH, URINE-DIPSTICK" BOTH IP/OP $103.00 $76.22 $1.81 $88.00 $6.55 $6.55 $4.02 $4.02 $2.01 $1.81 $4.82 $4.82 $5.00 $4.02 $4.68 $2.61 $60.92 $60.92 $4.22 $8.86 $87.12 $88.00 $5.83 $6.63 $5.83 $4.99 $4.02 $4.02 $3.49 $4.02 $0.00 $0.00 $0.00 $0.00 30700002 EAP CPT® 85025 "Cbc, Plat, Wbcdiff, Evd" BOTH IP/OP $212.00 $156.88 $3.88 $177.60 $16.05 $16.05 $7.77 $7.77 $3.89 $3.88 $9.97 $9.97 $10.36 $7.77 $11.48 $5.05 $125.40 $125.40 $8.16 $21.72 $175.82 $177.60 $11.27 $12.82 $11.27 $12.23 $7.77 $7.77 $8.56 $7.77 $0.00 $0.00 $0.00 $0.00 30700004 EAP CPT® 81002 Urine Dip Stick BOTH IP/OP $103.00 $76.22 $0.00 $103.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.89 $3.89 $4.04 $0.00 $3.77 $0.00 $0.00 $0.00 $0.00 $7.14 $75.24 $76.00 $0.00 $103.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30700007 EAP CPT® 81001 Urinalysis Complete BOTH IP/OP $192.00 $142.08 $1.58 $164.00 $6.55 $6.55 $3.17 $3.17 $1.59 $1.58 $4.82 $4.82 $5.00 $3.17 $4.68 $2.06 $113.57 $113.57 $3.33 $8.86 $162.36 $164.00 $4.60 $5.23 $4.60 $4.99 $3.17 $3.17 $3.49 $3.17 $0.00 $0.00 $0.00 $0.00 30700019 EAP CPT® 81003 Urinalysis BOTH IP/OP $157.00 $116.18 $0.00 $134.40 $4.65 $4.65 $2.25 $2.25 $1.13 $1.12 $3.41 $3.41 $3.54 $2.25 $3.33 $1.46 $92.87 $92.87 $2.36 $6.28 $133.06 $134.40 $3.26 $0.00 $3.26 $3.55 $2.25 $2.25 $2.48 $2.25 $0.00 $0.00 $0.00 $0.00 30700027 EAP CPT® 81005 "Ph, Urine(quant)" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30700035 EAP CPT® 81015 Urinalysis-micro Only BOTH IP/OP $180.00 $133.20 $0.00 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.61 $4.61 $4.78 $0.00 $4.48 $0.00 $0.00 $0.00 $0.00 $8.48 $152.06 $153.60 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30700041 EAP CPT® 81025 PREGNANCY TEST-URINE BOTH IP/OP $33.00 $24.42 $0.00 $28.00 $13.04 $13.04 $8.61 $8.61 $4.31 $3.87 $9.61 $9.61 $9.98 $8.61 $9.36 $5.60 $19.52 $19.52 $9.04 $17.68 $27.72 $28.00 $12.48 $0.00 $12.48 $9.97 $8.61 $8.61 $6.98 $8.61 $0.00 $0.00 $0.00 $0.00 30700042 EAP CPT® 81050 "Urine, Timed Collect" BOTH IP/OP $129.00 $95.46 $1.64 $95.20 $6.20 $6.20 $3.64 $3.64 $1.82 $1.64 $4.54 $4.54 $4.72 $3.64 $4.43 $2.37 $76.30 $76.30 $3.82 $8.38 $94.25 $95.20 $5.28 $6.01 $5.28 $4.72 $3.64 $3.64 $3.30 $3.64 $0.00 $0.00 $0.00 $0.00 30700050 EAP CPT® 81003 Urinalysis-biochem BOTH IP/OP $157.00 $116.18 $0.00 $134.40 $4.65 $4.65 $2.25 $2.25 $1.13 $1.12 $3.41 $3.41 $3.54 $2.25 $3.33 $1.46 $92.87 $92.87 $2.36 $6.28 $133.06 $134.40 $3.26 $0.00 $3.26 $3.55 $2.25 $2.25 $2.48 $2.25 $0.00 $0.00 $0.00 $0.00 30700080 EAP CPT® 81000 "Ph, Urine-dipstick" BOTH IP/OP $119.00 $88.06 $1.81 $88.00 $6.55 $6.55 $4.02 $4.02 $2.01 $1.81 $4.82 $4.82 $5.00 $4.02 $4.68 $2.61 $70.39 $70.39 $4.22 $8.86 $87.12 $88.00 $5.83 $6.63 $5.83 $4.99 $4.02 $4.02 $3.49 $4.02 $0.00 $0.00 $0.00 $0.00 30700081 EAP CPT® 81001 Urinalysis With Microscopy BOTH IP/OP $222.00 $164.28 $1.58 $164.00 $6.55 $6.55 $3.17 $3.17 $1.59 $1.58 $4.82 $4.82 $5.00 $3.17 $4.68 $2.06 $131.31 $131.31 $3.33 $8.86 $162.36 $164.00 $4.60 $5.23 $4.60 $4.99 $3.17 $3.17 $3.49 $3.17 $0.00 $0.00 $0.00 $0.00 30700082 EAP CPT® 81003 Urinalysis BOTH IP/OP $182.00 $134.68 $1.12 $134.40 $4.65 $4.65 $2.25 $2.25 $1.13 $1.12 $3.41 $3.41 $3.54 $2.25 $3.33 $1.46 $107.65 $107.65 $2.36 $6.28 $133.06 $134.40 $3.26 $3.71 $3.26 $3.55 $2.25 $2.25 $2.48 $2.25 $0.00 $0.00 $0.00 $0.00 30700083 EAP CPT® 81003 "Urinalysis, Top" BOTH IP/OP $182.00 $134.68 $1.12 $134.40 $4.65 $4.65 $2.25 $2.25 $1.13 $1.12 $3.41 $3.41 $3.54 $2.25 $3.33 $1.46 $107.65 $107.65 $2.36 $6.28 $133.06 $134.40 $3.26 $3.71 $3.26 $3.55 $2.25 $2.25 $2.48 $2.25 $0.00 $0.00 $0.00 $0.00 30700084 EAP CPT® 81025 Pregnancy Test-urine BOTH IP/OP $38.00 $28.12 $3.87 $28.00 $13.04 $13.04 $8.61 $8.61 $4.31 $3.87 $9.61 $9.61 $9.98 $8.61 $9.36 $5.60 $22.48 $22.48 $9.04 $17.68 $27.72 $28.00 $12.48 $14.21 $12.48 $9.97 $8.61 $8.61 $6.98 $8.61 $0.00 $0.00 $0.00 $0.00 30700085 EAP CPT® 81025 "Preg Test,urine" BOTH IP/OP $38.00 $28.12 $3.87 $28.00 $13.04 $13.04 $8.61 $8.61 $4.31 $3.87 $9.61 $9.61 $9.98 $8.61 $9.36 $5.60 $22.48 $22.48 $9.04 $17.68 $27.72 $28.00 $12.48 $14.21 $12.48 $9.97 $8.61 $8.61 $6.98 $8.61 $0.00 $0.00 $0.00 $0.00 30700086 EAP CPT® 81050 "Urine, Timed Collect" BOTH IP/OP $117.00 $86.58 $1.64 $100.00 $6.20 $6.20 $3.64 $3.64 $1.82 $1.64 $4.54 $4.54 $4.72 $3.64 $4.43 $2.37 $69.21 $69.21 $3.82 $8.38 $99.00 $100.00 $5.28 $6.01 $5.28 $4.72 $3.64 $3.64 $3.30 $3.64 $0.00 $0.00 $0.00 $0.00 30700090 EAP CPT® 81000 "Urobilinogen, Qualitativ" BOTH IP/OP $103.00 $76.22 $1.81 $88.00 $6.55 $6.55 $4.02 $4.02 $2.01 $1.81 $4.82 $4.82 $5.00 $4.02 $4.68 $2.61 $60.92 $60.92 $4.22 $8.86 $87.12 $88.00 $5.83 $6.63 $5.83 $4.99 $4.02 $4.02 $3.49 $4.02 $0.00 $0.00 $0.00 $0.00 30700091 EAP CPT® 81001 Urinalysis Comp BOTH IP/OP $192.00 $142.08 $1.58 $164.00 $6.55 $6.55 $3.17 $3.17 $1.59 $1.58 $4.82 $4.82 $5.00 $3.17 $4.68 $2.06 $113.57 $113.57 $3.33 $8.86 $162.36 $164.00 $4.60 $5.23 $4.60 $4.99 $3.17 $3.17 $3.49 $3.17 $0.00 $0.00 $0.00 $0.00 30700092 EAP CPT® 81003 Urinalysis-biochem BOTH IP/OP $157.00 $116.18 $0.00 $134.40 $4.65 $4.65 $2.25 $2.25 $1.13 $1.12 $3.41 $3.41 $3.54 $2.25 $3.33 $1.46 $92.87 $92.87 $2.36 $6.28 $133.06 $134.40 $3.26 $0.00 $3.26 $3.55 $2.25 $2.25 $2.48 $2.25 $0.00 $0.00 $0.00 $0.00 30700093 EAP CPT® 81025 Urine Pregnancy Test BOTH IP/OP $33.00 $24.42 $0.00 $28.00 $13.04 $13.04 $8.61 $8.61 $4.31 $3.87 $9.61 $9.61 $9.98 $8.61 $9.36 $5.60 $19.52 $19.52 $9.04 $17.68 $27.72 $28.00 $12.48 $0.00 $12.48 $9.97 $8.61 $8.61 $6.98 $8.61 $0.00 $0.00 $0.00 $0.00 30700094 EAP CPT® 81000 "Sugar, Clinitest" BOTH IP/OP $103.00 $76.22 $1.81 $88.00 $6.55 $6.55 $4.02 $4.02 $2.01 $1.81 $4.82 $4.82 $5.00 $4.02 $4.68 $2.61 $60.92 $60.92 $4.22 $8.86 $87.12 $88.00 $5.83 $6.63 $5.83 $4.99 $4.02 $4.02 $3.49 $4.02 $0.00 $0.00 $0.00 $0.00 30700095 EAP CPT® 81000 "Bile, Urine" BOTH IP/OP $103.00 $76.22 $1.81 $88.00 $6.55 $6.55 $4.02 $4.02 $2.01 $1.81 $4.82 $4.82 $5.00 $4.02 $4.68 $2.61 $60.92 $60.92 $4.22 $8.86 $87.12 $88.00 $5.83 $6.63 $5.83 $4.99 $4.02 $4.02 $3.49 $4.02 $0.00 $0.00 $0.00 $0.00 30700096 EAP CPT® 81000 Specific Gravity BOTH IP/OP $119.00 $88.06 $1.81 $88.00 $6.55 $6.55 $4.02 $4.02 $2.01 $1.81 $4.82 $4.82 $5.00 $4.02 $4.68 $2.61 $70.39 $70.39 $4.22 $8.86 $87.12 $88.00 $5.83 $6.63 $5.83 $4.99 $4.02 $4.02 $3.49 $4.02 $0.00 $0.00 $0.00 $0.00 30700097 EAP CPT® 81000 "Urobilinogen, Qualitativ" BOTH IP/OP $103.00 $76.22 $1.81 $88.00 $6.55 $6.55 $4.02 $4.02 $2.01 $1.81 $4.82 $4.82 $5.00 $4.02 $4.68 $2.61 $60.92 $60.92 $4.22 $8.86 $87.12 $88.00 $5.83 $6.63 $5.83 $4.99 $4.02 $4.02 $3.49 $4.02 $0.00 $0.00 $0.00 $0.00 30700120 EAP CPT® 81025 Urine Pregnancy Test BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.87 $0.00 $0.00 $0.00 $8.61 $9.36 $5.60 $19.52 $19.52 $9.04 $17.68 $27.72 $28.00 $12.48 $0.00 $12.48 $9.97 $8.61 $8.61 $6.98 $8.61 $0.00 $0.00 $0.00 $0.00 30750027 EAP CPT® 81005 "Clinitest, Stool" BOTH IP/OP $124.00 $91.76 $0.00 $114.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $114.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750028 EAP CPT® 81005 "Spec.gravity,refrac" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750029 EAP CPT® 81005 "Clinitest,urine" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750030 EAP CPT® 81005 "Protein, Ur-qual" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750031 EAP CPT® 81005 "Glucose, Ur-qual" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750032 EAP CPT® 81005 "Ketones,ur" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750033 EAP CPT® 81005 "Urobilinogen,ur-ql" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750034 EAP CPT® 81005 "Glucose, Ur-qual" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750035 EAP CPT® 81005 "Protein, Ur-qual" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750036 EAP CPT® 81005 "Glucose, Ur-qual" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750037 EAP CPT® 81005 "Ketones,ur" BOTH IP/OP $108.00 $79.92 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $3.29 $3.41 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $6.06 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30750080 EAP CPT® 81000 "Ph, Urine-dipstick" BOTH IP/OP $103.00 $76.22 $1.81 $88.00 $6.55 $6.55 $4.02 $4.02 $2.01 $1.81 $4.82 $4.82 $5.00 $4.02 $4.68 $2.61 $60.92 $60.92 $4.22 $8.86 $87.12 $88.00 $5.83 $6.63 $5.83 $4.99 $4.02 $4.02 $3.49 $4.02 $0.00 $0.00 $0.00 $0.00 30900004 EAP CPT® 89060 "Crystals,fluid" BOTH IP/OP $165.00 $122.10 $3.58 $120.00 $14.76 $14.76 $7.33 $7.33 $3.67 $3.58 $10.86 $10.86 $11.28 $7.33 $10.56 $4.76 $97.60 $97.60 $7.70 $19.98 $118.80 $120.00 $10.63 $107.25 $10.63 $11.26 $7.33 $7.33 $7.88 $7.33 $0.00 $0.00 $0.00 $0.00 30900005 EAP CPT® 89190 Nasal Smear For Eos BOTH IP/OP $129.00 $95.46 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.21 $7.21 $7.48 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $13.28 $99.79 $100.80 $0.00 $83.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30900006 EAP CPT® 89320 Semen Examination BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.76 $8.76 $9.09 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $16.12 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30900009 EAP CPT® 81511 Mss Sequential Screen-2 (so) BOTH IP/OP $504.00 $372.96 $69.08 $462.00 $462.00 $462.00 $153.50 $153.50 $76.75 $69.08 $374.07 $374.07 $388.48 $153.50 $144.26 $99.78 $298.12 $298.12 $161.18 $249.00 $394.42 $398.40 $222.58 $253.28 $222.58 $153.71 $153.50 $153.50 $107.60 $153.50 $0.00 $0.00 $0.00 $0.00 30900011 EAP CPT® 84163 Pregnancy Associated Plasma Protein (so) BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $106.47 $106.47 $15.80 $17.94 $142.56 $144.00 $21.82 $0.00 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30900012 EAP CPT® 84702 "Hcg,quantitative" BOTH IP/OP $31.00 $22.94 $0.00 $25.60 $13.25 $13.25 $15.05 $15.05 $7.53 $7.53 $9.74 $9.74 $10.12 $15.05 $9.48 $9.78 $18.34 $18.34 $15.80 $17.94 $25.34 $25.60 $21.82 $0.00 $21.82 $10.10 $15.05 $15.05 $7.07 $15.05 $0.00 $0.00 $0.00 $0.00 30900013 EAP CPT® 86021 C-anca Titer (so) BOTH IP/OP $34.00 $25.16 $0.00 $34.00 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $20.11 $20.11 $15.80 $34.00 $26.93 $27.20 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30900014 EAP CPT® 86021 P-anca Titer (so) BOTH IP/OP $34.00 $25.16 $0.00 $34.00 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $20.11 $20.11 $15.80 $34.00 $26.93 $27.20 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30900015 EAP CPT® 86021 Atypical P-anca Titer (so) BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $31.07 $31.07 $15.05 $15.05 $7.53 $7.53 $22.86 $22.86 $23.74 $15.05 $22.24 $9.78 $47.32 $47.32 $15.80 $42.06 $63.36 $64.00 $21.82 $0.00 $21.82 $23.70 $15.05 $15.05 $16.59 $15.05 $0.00 $0.00 $0.00 $0.00 30900020 EAP CPT® 86638 Q Fever Igg Phase I Titer (so) BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30900021 EAP CPT® 86638 Q Fever Igg Phase Ii Titer (so) BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30900022 EAP CPT® 86638 Q Fever Igg Phase I Titer (so) BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30900023 EAP CPT® 86638 Q Fever Igg Phase Ii (so) BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.41 $18.41 $19.12 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $33.88 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30900024 EAP CPT® 86611 B.henselae Igg Titer (so) BOTH IP/OP $64.00 $47.36 $5.09 $50.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $37.86 $37.86 $10.69 $28.44 $49.90 $50.40 $14.76 $16.80 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30900025 EAP CPT® 86611 B.henselae Igm Titer (so) BOTH IP/OP $64.00 $47.36 $5.09 $50.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $37.86 $37.86 $10.69 $28.44 $49.90 $50.40 $14.76 $16.80 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30900026 EAP CPT® 86611 B.quintana Igg Titer (so) BOTH IP/OP $64.00 $47.36 $5.09 $50.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $37.86 $37.86 $10.69 $28.44 $49.90 $50.40 $14.76 $16.80 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 30900027 EAP CPT® 86611 B.quintana Igm Titer (so) BOTH IP/OP $50.00 $37.00 $0.00 $50.40 $21.01 $21.01 $10.18 $10.18 $5.09 $5.09 $15.44 $15.44 $16.04 $10.18 $15.04 $6.62 $29.58 $29.58 $10.69 $28.44 $49.90 $50.40 $14.76 $0.00 $14.76 $16.02 $10.18 $10.18 $11.21 $10.18 $0.00 $0.00 $0.00 $0.00 31000001 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $384.00 $284.16 $0.00 $307.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $227.14 $227.14 $22.49 $59.86 $304.13 $307.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000002 EAP CPT® 88305 Level Iv Surgical Path Exam BOTH IP/OP $771.00 $570.54 $0.00 $616.80 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $456.05 $456.05 $49.62 $140.98 $610.63 $616.80 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31000004 EAP CPT® 88331 Path Consult Inraop 1 Bloc BOTH IP/OP $160.00 $118.40 $0.00 $160.00 $148.63 $148.63 $145.24 $145.24 $146.06 $44.60 $30.54 $30.54 $31.72 $142.96 $87.82 $92.92 $94.64 $94.64 $143.92 $57.46 $126.72 $128.00 $160.00 $0.00 $160.00 $93.58 $34.94 $34.94 $65.50 $137.07 $0.00 $0.00 $0.00 $0.00 31000006 EAP CPT® 81314 PDGFRA MUTATION ANALYSIS (QUEST) BOTH IP/OP "$1,002.00 " $741.48 $0.00 "$1,002.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.69 $342.69 $355.87 $0.00 $309.68 $0.00 $0.00 $0.00 $0.00 $495.00 $784.08 $792.00 $0.00 "$1,002.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000007 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $447.00 $330.78 $0.00 $357.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $264.40 $264.40 $53.75 $112.22 $354.02 $357.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000010 EAP CPT® 88120 "Cytopath In Situ Hybridization,urinary Tract Spec W/mors" BOTH IP/OP $930.00 $688.20 $0.00 $930.00 $930.00 $930.00 $145.24 $145.24 $146.06 $0.00 $422.54 $422.54 $438.79 $0.00 $324.87 $0.00 $0.00 $0.00 $0.00 $465.00 $736.56 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000011 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $62.00 $45.88 $0.00 $59.86 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $36.67 $36.67 $22.49 $59.86 $49.10 $49.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000013 EAP CPT® 88230 Tissue Culture For Non-neoplastic Disorders;lymphocyte BOTH IP/OP $347.00 $256.78 $0.00 $325.54 $240.48 $240.48 $116.49 $116.49 $58.25 $58.25 $176.90 $176.90 $183.71 $116.49 $172.08 $75.72 $205.25 $205.25 $122.31 $325.54 $304.13 $307.20 $168.91 $0.00 $168.91 $183.36 $116.49 $116.49 $128.35 $116.49 $0.00 $0.00 $0.00 $0.00 31000015 EAP CPT® 88271 Cytogenetics Dna Probe BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $169.76 $169.76 $22.49 $59.86 $227.30 $229.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000016 EAP CPT® 88275 Cytogenetics 100-300 BOTH IP/OP $349.00 $258.26 $0.00 $279.20 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $206.43 $206.43 $53.75 $112.22 $276.41 $279.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000018 EAP CPT® 88360 Er/pr Her2 W/reflex To Her2 Fish (so) BOTH IP/OP $731.00 $540.94 $58.38 $581.60 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $432.39 $432.39 $143.92 $121.34 $575.78 $581.60 $199.96 $475.15 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31000019 EAP CPT® 88368 "Fish, Her-2/neu (so)" BOTH IP/OP $741.00 $548.34 $58.22 $589.60 $178.36 $178.36 $283.63 $283.63 $285.22 $58.22 $151.36 $151.36 $157.18 $279.15 $199.20 $181.45 $438.30 $438.30 $284.24 $207.74 $583.70 $589.60 $394.92 $481.65 $394.92 $212.25 $90.40 $90.40 $148.57 $270.71 $0.00 $0.00 $0.00 $0.00 31000020 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Pdgfrb BOTH IP/OP $511.00 $378.14 $0.00 $408.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $302.26 $302.26 $22.49 $59.86 $404.71 $408.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000021 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Pdgfrb BOTH IP/OP $256.00 $189.44 $0.00 $204.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $151.42 $151.42 $53.75 $112.22 $202.75 $204.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000022 EAP CPT® 88342 "Lynch Syndrome Tumor Panel, Ihc (so)" BOTH IP/OP $700.00 $518.00 $48.82 $565.60 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $414.05 $414.05 $143.92 $106.46 $559.94 $565.60 $199.96 $455.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31000025 EAP CPT® 88368 "Fish, Mdm2 Gene Amphlification (arup)" BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $178.36 $178.36 $283.63 $283.63 $285.22 $58.22 $151.36 $151.36 $157.18 $279.15 $199.20 $181.45 $783.74 $783.74 $284.24 $207.74 "$1,049.40" "$1,060.00" $394.92 $0.00 $394.92 $212.25 $90.40 $90.40 $148.57 $270.71 $0.00 $0.00 $0.00 $0.00 31000026 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Mn BOTH IP/OP $300.00 $222.00 $10.71 $238.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $177.45 $177.45 $22.49 $59.86 $236.02 $238.40 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000027 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Mn BOTH IP/OP $128.00 $94.72 $23.04 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $75.71 $75.71 $53.75 $112.22 $100.58 $101.60 $74.23 $84.46 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000028 EAP CPT® 88271 "Fish, Hes/leukemia, 4q12 Rea(fip1l-pdgfra" BOTH IP/OP $665.00 $492.10 $10.71 $532.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $393.35 $393.35 $22.49 $59.86 $526.68 $532.00 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000029 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Hes BOTH IP/OP $221.00 $163.54 $0.00 $176.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $130.72 $130.72 $53.75 $112.22 $175.03 $176.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000030 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Fg BOTH IP/OP $499.00 $369.26 $0.00 $399.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $295.16 $295.16 $22.49 $59.86 $395.21 $399.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000031 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Fg BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $146.69 $146.69 $53.75 $112.22 $196.42 $198.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000032 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Ne BOTH IP/OP $714.00 $528.36 $10.71 $571.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $422.33 $422.33 $22.49 $59.86 $565.49 $571.20 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000033 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Ne BOTH IP/OP $142.00 $105.08 $0.00 $113.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $83.99 $83.99 $53.75 $112.22 $112.46 $113.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000034 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Eto BOTH IP/OP $563.00 $416.62 $0.00 $450.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $333.01 $333.01 $22.49 $59.86 $445.90 $450.40 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000035 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Eto BOTH IP/OP $282.00 $208.68 $0.00 $225.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $166.80 $166.80 $53.75 $112.22 $223.34 $225.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000036 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Mll BOTH IP/OP $511.00 $378.14 $0.00 $408.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $302.26 $302.26 $22.49 $59.86 $404.71 $408.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000037 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Mll BOTH IP/OP $256.00 $189.44 $0.00 $204.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $151.42 $151.42 $53.75 $112.22 $202.75 $204.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000038 EAP CPT® 88184 Flow Cytometry; First Marker (so) Pcn BOTH IP/OP $303.00 $224.22 $0.00 $303.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $179.22 $179.22 $284.24 $133.74 $239.98 $242.40 $303.00 $0.00 $303.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31000039 EAP CPT® 88185 Flow Cytometry;each Add Marker (so) Pcn BOTH IP/OP $233.00 $172.42 $0.00 $186.40 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $137.82 $137.82 $0.00 $71.72 $184.54 $186.40 $0.00 $131.95 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 31000042 EAP CPT® 81200 Canavan Disease Mutation Analysis (so) BOTH IP/OP $568.00 $420.32 $0.00 $519.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.57 $421.57 $437.81 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $324.50 $514.01 $519.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000043 EAP CPT® 88235 Tissue Culture For Am-fld Or Cv-cells (so) Sc BOTH IP/OP $236.00 $174.64 $0.00 $261.00 $236.00 $236.00 $150.30 $150.30 $75.15 $0.00 $223.60 $223.60 $232.20 $0.00 $217.53 $0.00 $0.00 $0.00 $157.82 $261.00 $206.71 $208.80 $217.94 $0.00 $217.94 $231.78 $150.30 $150.30 $162.25 $150.30 $0.00 $0.00 $0.00 $0.00 31000045 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Dup BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $207.03 $207.03 $22.49 $59.86 $277.20 $280.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000046 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Dup BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $207.03 $207.03 $53.75 $112.22 $277.20 $280.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000051 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Mm BOTH IP/OP $499.00 $369.26 $0.00 $399.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $295.16 $295.16 $22.49 $59.86 $395.21 $399.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000052 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Mm BOTH IP/OP $248.00 $183.52 $0.00 $198.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $146.69 $146.69 $53.75 $112.22 $196.42 $198.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000055 EAP CPT® 81401 "Eml4 Alk Gene Fusion, Pcr (so)" BOTH IP/OP "$1,030.00 " $762.20 $0.00 $941.60 $64.94 $64.94 $137.00 $137.00 $68.50 $61.65 $764.47 $764.47 $793.92 $137.00 $131.58 $89.05 $609.25 $609.25 $143.85 $588.50 $932.18 $941.60 $198.65 $0.00 $198.65 $140.20 $137.00 $137.00 $98.14 $137.00 $0.00 $0.00 $0.00 $0.00 31000060 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so)rara BOTH IP/OP $751.00 $555.74 $10.71 $600.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $444.22 $444.22 $22.49 $59.86 $594.79 $600.80 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000061 EAP CPT® 88275 Interphase In Situ Hybridization(100-300) Cells (so) Rara BOTH IP/OP $374.00 $276.76 $0.00 $299.20 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $221.22 $221.22 $53.75 $112.22 $296.21 $299.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31000062 EAP CPT® 88271 Molecular Cytogenetics: Dna Probe (fish) (so) Ros1 BOTH IP/OP $687.00 $508.38 $10.71 $545.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $406.36 $406.36 $22.49 $59.86 $540.14 $545.60 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000063 EAP CPT® 88274 Interphase In Situ Hybridization (25-99 Cells (so) Ros1 BOTH IP/OP $344.00 $254.56 $0.00 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.07 $52.85 $52.85 $54.89 $42.38 $51.42 $27.55 $203.48 $203.48 $44.50 $97.26 $270.86 $273.60 $61.45 $344.00 $61.45 $54.79 $42.38 $42.38 $38.35 $42.38 $0.00 $0.00 $0.00 $0.00 31000066 EAP CPT® 88274 Fanconi Anemia Tissue Cx (so) BOTH IP/OP $384.00 $284.16 $0.00 $307.20 $0.00 $0.00 $0.00 $0.00 $0.00 $19.07 $52.85 $52.85 $54.89 $42.38 $51.42 $27.55 $227.14 $227.14 $44.50 $97.26 $304.13 $307.20 $61.45 $0.00 $61.45 $54.79 $42.38 $42.38 $38.35 $42.38 $0.00 $0.00 $0.00 $0.00 31000067 EAP CPT® 88271 Fanconi Anemia Chrom Anal (so) BOTH IP/OP $241.00 $178.34 $0.00 $192.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $142.55 $142.55 $22.49 $59.86 $190.87 $192.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000068 EAP CPT® 88271 Fish Sry/x Centromere Dna (so) BOTH IP/OP $241.00 $178.34 $0.00 $192.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $142.55 $142.55 $22.49 $59.86 $190.87 $192.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000069 EAP CPT® 88273 Fish Sry/x Centromere Ish (so) BOTH IP/OP $392.00 $290.08 $0.00 $313.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.79 $48.79 $50.66 $0.00 $47.46 $0.00 $0.00 $0.00 $0.00 $89.78 $310.46 $313.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000070 EAP CPT® 88291 Fish Sry/x Centro Interp (so) BOTH IP/OP $222.00 $164.28 $0.00 $177.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.77 $164.77 $171.12 $0.00 $29.83 $0.00 $0.00 $0.00 $0.00 $53.96 $175.82 $177.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000071 EAP CPT® 88274 Fish Conception Prod Ish (so) BOTH IP/OP $387.00 $286.38 $0.00 $387.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.07 $52.85 $52.85 $54.89 $42.38 $51.42 $27.55 $228.91 $228.91 $44.50 $97.26 $304.13 $307.20 $61.45 $387.00 $61.45 $54.79 $42.38 $42.38 $38.35 $42.38 $0.00 $0.00 $0.00 $0.00 31000072 EAP CPT® 88271 Fish Conception Prod Dna (so) BOTH IP/OP $243.00 $179.82 $10.71 $192.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $143.73 $143.73 $22.49 $59.86 $190.87 $192.80 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31000099 EAP CPT® 81275 COLORECTAL CAN. MUT. PANEL KRA SO BOTH IP/OP "$1,636.00 " "$1,210.64" $86.96 "$1,292.80" $298.80 $298.80 $193.25 $193.25 $96.63 $86.96 $205.38 $205.38 $213.28 $193.25 $220.85 $125.61 $967.69 $967.69 $202.91 $808.00 "$1,279.87" "$1,292.80" $280.21 $318.86 $280.21 $235.32 $193.25 $193.25 $164.72 $193.25 $0.00 $0.00 $0.00 $0.00 31000100 EAP CPT® 81210 COLORECTAL CAN. MUT. PANEL BRA SO BOTH IP/OP "$1,636.00 " "$1,210.64" $78.93 "$1,292.80" $271.21 $271.21 $175.40 $175.40 $87.70 $78.93 $186.42 $186.42 $193.59 $175.40 $115.59 $114.01 $967.69 $967.69 $184.17 $808.00 "$1,279.87" "$1,292.80" $254.33 $289.41 $254.33 $123.17 $175.40 $175.40 $86.22 $175.40 $0.00 $0.00 $0.00 $0.00 31000101 EAP CPT® 88304 Seminal Vesicle BOTH IP/OP $299.00 $221.26 $0.00 $239.20 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $176.86 $176.86 $49.62 $108.12 $236.81 $239.20 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31000102 EAP CPT® 81382 Hla Ii Typing 1 (so) BOTH IP/OP $935.00 $691.90 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.48 $175.48 $182.23 $0.00 $192.65 $0.00 $0.00 $0.00 $0.00 $472.00 $747.65 $755.20 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000103 EAP CPT® 81379 Hla I Typing Comp (so) BOTH IP/OP "$2,608.00 " "$1,929.92" $0.00 "$2,107.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $475.84 $475.84 $494.14 $0.00 $192.65 $0.00 $0.00 $0.00 $0.00 "$1,317.00" "$2,086.13" "$2,107.20" $0.00 "$1,087.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000118 EAP CPT® 81331 Congen Hyoptonia Ube3a (so) BOTH IP/OP $519.00 $384.06 $0.00 $474.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $385.20 $385.20 $400.05 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $296.50 $469.66 $474.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000119 EAP CPT® 81400 Congen Hypotonia L1 (so) BOTH IP/OP $744.00 $550.56 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.20 $552.20 $573.48 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000120 EAP CPT® 81404 Congen Hypotonia L5 (so) BOTH IP/OP "$1,519.00 " "$1,124.06" $0.00 "$1,388.80" $462.00 $462.00 $274.83 $274.83 $137.42 $123.67 "$1,127.40" "$1,127.40" "$1,170.85" $274.83 $286.64 $178.64 $898.49 $898.49 $288.57 $868.00 "$1,374.91" "$1,388.80" $398.50 $0.00 $398.50 $305.42 $274.83 $274.83 $213.79 $274.83 $0.00 $0.00 $0.00 $0.00 31000121 EAP CPT® 88365 Insitu Hybrid Fish (so) BOTH IP/OP $579.00 $428.46 $0.00 $463.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.18 $102.18 $106.11 $0.00 $103.59 $0.00 $0.00 $0.00 $143.92 $156.90 $458.57 $463.20 $199.96 $0.00 $199.96 $110.38 $137.95 $137.95 $77.27 $137.07 $0.00 $0.00 $0.00 $0.00 31000122 EAP CPT® 88381 Mgmt Microdissection Pcr (so) BOTH IP/OP $506.00 $374.44 $0.00 $404.80 $185.41 $185.41 $0.00 $0.00 $0.00 $70.38 $161.51 $161.51 $167.72 $0.00 $197.25 $0.00 $299.30 $299.30 $0.00 $253.00 $400.75 $404.80 $0.00 $328.90 $0.00 $210.18 $156.67 $156.67 $147.12 $0.00 $0.00 $0.00 $0.00 $0.00 31000123 EAP CPT® 81287 Mgmt Gene Analysis (so) BOTH IP/OP $591.00 $437.34 $0.00 $591.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $438.64 $438.64 $455.54 $0.00 $123.16 $0.00 $0.00 $0.00 $0.00 $292.00 $462.53 $467.20 $0.00 $591.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000124 EAP CPT® 81479 Calr Mutation Analysis (so) BOTH IP/OP $954.00 $705.96 $0.00 "$1,114.12" $0.00 $0.00 $0.00 $0.00 $169.81 $198.84 $708.06 $708.06 $735.34 $0.00 $954.00 $0.00 $564.29 $564.29 $0.00 $471.00 $746.06 $753.60 $565.20 $620.10 $565.20 "$1,114.12" $0.00 $0.00 $779.89 $0.00 $0.00 $0.00 $0.00 $0.00 31000126 EAP CPT® 81406 CADASIL BOTH IP/OP "$4,379.00 " "$3,240.46" $0.00 "$3,460.80" $237.60 $237.60 $282.88 $282.88 $141.44 $127.30 "$3,250.09" "$3,250.09" "$3,375.33" $282.88 $610.87 $183.87 "$2,590.18" "$2,590.18" $0.00 "$2,163.00" "$3,426.19" "$3,460.80" $0.00 $466.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000135 EAP CPT® 81218 Aml Prognostic Cebpa (so) BOTH IP/OP $529.00 $391.46 $0.00 $529.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.69 $342.69 $355.87 $0.00 $309.68 $0.00 $0.00 $0.00 $0.00 $261.50 $414.22 $418.40 $0.00 $529.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000136 EAP CPT® 81245 Aml Prognostic Flt3 (so) BOTH IP/OP $381.00 $281.94 $0.00 $381.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.56 $172.56 $179.19 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $188.00 $297.79 $300.80 $0.00 $381.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000137 EAP CPT® 81246 Aml Prognostic Flt3 Anal (so) BOTH IP/OP $275.00 $203.50 $0.00 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $211.97 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $136.00 $215.42 $217.60 $0.00 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000138 EAP CPT® 81310 Aml Prognostic Npm1 (so) BOTH IP/OP $708.00 $523.92 $0.00 $708.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.03 $257.03 $266.91 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $349.50 $553.61 $559.20 $0.00 $708.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000139 EAP CPT® 81450 Myeloid Neo Mutation (so) BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$2,148.00" $982.56 $982.56 $759.53 $759.53 $379.77 $0.00 "$1,744.17" "$1,744.17" "$1,811.38" $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,342.50" "$2,126.52" "$2,148.00" $0.00 $0.00 $0.00 $420.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000145 EAP CPT® 81275 "KRAS GENE ANALYSIS; VARIANTS IN EXON 2 (EG, CODONS 12 & 13)" BOTH IP/OP $463.00 $342.62 $86.96 $365.60 $298.80 $298.80 $193.25 $193.25 $96.63 $86.96 $205.38 $205.38 $213.28 $193.25 $220.85 $125.61 $273.86 $273.86 $202.91 $228.50 $361.94 $365.60 $280.21 $318.86 $280.21 $235.32 $193.25 $193.25 $164.72 $193.25 $0.00 $0.00 $0.00 $0.00 31000146 EAP CPT® 81276 "KRAS GENE ANALYSIS; ADD'L VARIANT(S) (EG, CODON 61, CODON 146)" BOTH IP/OP $463.00 $342.62 $0.00 $463.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.08 $205.08 $212.97 $0.00 $185.31 $0.00 $0.00 $0.00 $0.00 $228.50 $361.94 $365.60 $0.00 $463.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000147 EAP CPT® 81210 Thyroseq - Braf Analysis (so) BOTH IP/OP $305.00 $225.70 $78.93 $289.41 $271.21 $271.21 $175.40 $175.40 $87.70 $78.93 $186.42 $186.42 $193.59 $175.40 $115.59 $114.01 $180.41 $180.41 $184.17 $150.50 $238.39 $240.80 $254.33 $289.41 $254.33 $123.17 $175.40 $175.40 $86.22 $175.40 $0.00 $0.00 $0.00 $0.00 31000148 EAP CPT® 81275 Thyroseq - Kras Analysis (so) BOTH IP/OP $335.00 $247.90 $86.96 $318.86 $298.80 $298.80 $193.25 $193.25 $96.63 $86.96 $205.38 $205.38 $213.28 $193.25 $220.85 $125.61 $198.15 $198.15 $202.91 $165.50 $262.15 $264.80 $280.21 $318.86 $280.21 $235.32 $193.25 $193.25 $164.72 $193.25 $0.00 $0.00 $0.00 $0.00 31000149 EAP CPT® 81322 Thyroseq - Pten Analysis (so) BOTH IP/OP $91.00 $67.34 $21.40 $123.17 $88.36 $88.36 $46.60 $46.60 $23.30 $21.40 $60.74 $60.74 $63.07 $46.60 $91.00 $30.29 $53.83 $53.83 $48.93 $45.00 $71.28 $72.00 $67.57 $76.89 $67.57 $123.17 $46.60 $46.60 $86.22 $46.60 $0.00 $0.00 $0.00 $0.00 31000150 EAP CPT® 81401 Thryoseq - Mopath Level 2 (so) BOTH IP/OP $238.00 $176.12 $61.65 $226.05 $64.94 $64.94 $137.00 $137.00 $68.50 $61.65 $176.64 $176.64 $183.45 $137.00 $131.58 $89.05 $140.78 $140.78 $143.85 $117.50 $186.12 $188.00 $198.65 $226.05 $198.65 $140.20 $137.00 $137.00 $98.14 $137.00 $0.00 $0.00 $0.00 $0.00 31000151 EAP CPT® 81403 Thryoseq - Mopath Level 4 (so) BOTH IP/OP $322.00 $238.28 $83.34 $305.58 $264.00 $264.00 $185.20 $185.20 $92.60 $83.34 $238.99 $238.99 $248.20 $185.20 $220.85 $120.38 $190.46 $190.46 $194.46 $159.00 $251.86 $254.40 $268.54 $305.58 $268.54 $235.32 $185.20 $185.20 $164.72 $185.20 $0.00 $0.00 $0.00 $0.00 31000152 EAP CPT® 81404 Thryoseq - Mopath Level 5 (so) BOTH IP/OP $477.00 $352.98 $123.67 $462.00 $462.00 $462.00 $274.83 $274.83 $137.42 $123.67 $354.03 $354.03 $367.67 $274.83 $286.64 $178.64 $282.15 $282.15 $288.57 $235.50 $373.03 $376.80 $398.50 $453.47 $398.50 $305.42 $274.83 $274.83 $213.79 $274.83 $0.00 $0.00 $0.00 $0.00 31000153 EAP CPT® 81405 Thryoseq - Mopath Level 6 (so) BOTH IP/OP $523.00 $387.02 $135.61 $497.23 $462.00 $462.00 $301.35 $301.35 $150.68 $135.61 $388.17 $388.17 $403.13 $301.35 $422.91 $195.88 $309.35 $309.35 $316.42 $258.50 $409.46 $413.60 $436.96 $497.23 $436.96 $450.62 $301.35 $301.35 $315.43 $301.35 $0.00 $0.00 $0.00 $0.00 31000154 EAP CPT® 81479 Thryoseq - Unlisted Mopath (so) BOTH IP/OP $2.00 $1.48 $0.00 "$1,114.12" $0.00 $0.00 $0.00 $0.00 $0.36 $0.42 $1.48 $1.48 $1.54 $0.00 $2.00 $0.00 $1.18 $1.18 $0.00 $1.00 $1.58 $1.60 $1.20 $1.30 $1.20 "$1,114.12" $0.00 $0.00 $779.89 $0.00 $0.00 $0.00 $0.00 $0.00 31000155 EAP CPT® 81219 JAK2 R/X CALR (SO) BOTH IP/OP $436.00 $322.64 $0.00 $394.40 $251.06 $251.06 $121.63 $121.63 $60.82 $60.81 $172.31 $172.31 $178.93 $121.63 $155.70 $79.06 $257.89 $257.89 $0.00 $246.50 $390.46 $394.40 $0.00 $200.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000156 EAP CPT® 81270 Jak2 V617f (so) BOTH IP/OP $436.00 $322.64 $45.83 $394.40 $189.21 $189.21 $91.66 $91.66 $45.83 $45.83 $130.06 $130.06 $135.06 $91.66 $84.58 $59.58 $257.89 $257.89 $96.24 $246.50 $390.46 $394.40 $132.91 $151.24 $132.91 $90.12 $91.66 $91.66 $63.08 $91.66 $0.00 $0.00 $0.00 $0.00 31000157 EAP CPT® 81479 JAK2 R/X-CSF3R (SO) BOTH IP/OP $436.00 $322.64 $0.00 "$1,114.12" $0.00 $0.00 $0.00 $0.00 $77.61 $90.87 $323.60 $323.60 $336.07 $0.00 $436.00 $0.00 $257.89 $257.89 $0.00 $246.50 $390.46 $394.40 $295.80 $283.40 $295.80 "$1,114.12" $0.00 $0.00 $779.89 $0.00 $0.00 $0.00 $0.00 $0.00 31000158 EAP CPT® 81402 JAK2 R/X-MPL (SO) BOTH IP/OP $436.00 $322.64 $0.00 $394.40 $0.00 $0.00 $185.20 $185.20 $92.60 $90.87 $323.60 $323.60 $336.07 $185.20 $174.05 $120.38 $257.89 $257.89 $0.00 $246.50 $390.46 $394.40 $0.00 $305.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000159 EAP CPT® 81403 JAK2 R/X-EXON12 (SO) BOTH IP/OP $431.00 $318.94 $0.00 $394.40 $264.00 $264.00 $185.20 $185.20 $92.60 $83.34 $319.89 $319.89 $332.21 $185.20 $220.85 $120.38 $254.94 $254.94 $194.46 $246.50 $390.46 $394.40 $268.54 $0.00 $268.54 $235.32 $185.20 $185.20 $164.72 $185.20 $0.00 $0.00 $0.00 $0.00 31000160 EAP CPT® 81311 Nras Gene Analysis Variants Exon 2&3 (so) BOTH IP/OP $463.00 $342.62 $0.00 $463.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.62 $307.62 $319.45 $0.00 $277.98 $0.00 $0.00 $0.00 $0.00 $228.50 $361.94 $365.60 $0.00 $463.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000161 EAP CPT® 81403 Hras Gene Analysis (so) BOTH IP/OP $463.00 $342.62 $83.34 $365.60 $264.00 $264.00 $185.20 $185.20 $92.60 $83.34 $343.64 $343.64 $356.88 $185.20 $220.85 $120.38 $273.86 $273.86 $194.46 $228.50 $361.94 $365.60 $268.54 $305.58 $268.54 $235.32 $185.20 $185.20 $164.72 $185.20 $0.00 $0.00 $0.00 $0.00 31000162 EAP CPT® 81450 "Leukovantage, Myloproliferative Neoplasm (so)" BOTH IP/OP "$4,269.00 " "$3,159.06" $0.00 "$3,373.60" $982.56 $982.56 $759.53 $759.53 $379.77 $0.00 "$3,168.45" "$3,168.45" "$3,290.55" $0.00 $889.66 $0.00 $0.00 $0.00 $0.00 "$2,108.50" "$3,339.86" "$3,373.60" $0.00 "$1,253.22" $0.00 $659.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000163 EAP CPT® 81450 Leukovantage Acute Myeloid Leukemia (so) BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,556.00" $982.56 $982.56 $759.53 $759.53 $379.77 $0.00 "$3,339.90" "$3,339.90" "$3,468.60" $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,222.50" "$3,520.44" "$3,556.00" $0.00 "$1,253.22" $0.00 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000164 EAP CPT® 81450 Leukovantage Myelodysplastic Syndrome (so) BOTH IP/OP "$4,425.00 " "$3,274.50" $0.00 "$3,496.80" $982.56 $982.56 $759.53 $759.53 $379.77 $0.00 "$3,284.24" "$3,284.24" "$3,410.79" $0.00 $922.17 $0.00 $0.00 $0.00 $0.00 "$2,185.50" "$3,461.83" "$3,496.80" $0.00 "$1,253.22" $0.00 $684.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000165 EAP CPT® 81270 Jak2 V617f Mutation Analysis (so) BOTH IP/OP $520.00 $384.80 $0.00 $416.00 $189.21 $189.21 $91.66 $91.66 $45.83 $45.83 $130.06 $130.06 $135.06 $91.66 $84.58 $59.58 $307.58 $307.58 $96.24 $260.00 $411.84 $416.00 $132.91 $0.00 $132.91 $90.12 $91.66 $91.66 $63.08 $91.66 $0.00 $0.00 $0.00 $0.00 31000170 EAP CPT® 88360 "Pd-l1 Lung (pembrolizumab), Ihc (so)" BOTH IP/OP $855.00 $632.70 $58.38 $680.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $505.73 $505.73 $143.92 $121.34 $673.20 $680.00 $199.96 $555.75 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31000171 EAP CPT® 88360 "Pd-l1 Lung (nivolumab), Ihc (so)" BOTH IP/OP $855.00 $632.70 $58.38 $680.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $505.73 $505.73 $143.92 $121.34 $673.20 $680.00 $199.96 $555.75 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31000172 EAP CPT® 88360 "Pd-l1 Lung (atezolizumab), Ihc (so)" BOTH IP/OP $855.00 $632.70 $58.38 $680.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $505.73 $505.73 $143.92 $121.34 $673.20 $680.00 $199.96 $555.75 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31000173 EAP CPT® 88360 "Pd-l1 Bladder (atezolizumab), Ihc (so)" BOTH IP/OP $855.00 $632.70 $58.38 $680.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $505.73 $505.73 $143.92 $121.34 $673.20 $680.00 $199.96 $555.75 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31000174 EAP CPT® 88360 "Pd-l1 Non-lung (pembrolizumab), Ihc (so)" BOTH IP/OP $944.00 $698.56 $58.38 $750.40 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $558.38 $558.38 $143.92 $121.34 $742.90 $750.40 $199.96 $613.60 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31000175 EAP CPT® 88184 "Pd-l1 Monocyte Expression, Sle Flare, 1st Marker (so)" BOTH IP/OP $323.00 $239.02 $30.49 $325.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $191.05 $191.05 $284.24 $133.74 $257.40 $260.00 $325.00 $209.95 $325.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31000176 EAP CPT® 88185 "Pd-l1 Monocyte Expression, Sle Flare, Addl Marker (so)" BOTH IP/OP $323.00 $239.02 $0.00 $260.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $191.05 $191.05 $0.00 $71.72 $257.40 $260.00 $0.00 $131.95 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 31000180 EAP HCPCS 0225U Nfct Ds Dna&rna 21 Targets Sars-cov-2 Amp Probe BOTH IP/OP $466.00 $344.84 $0.00 $370.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.87 $345.87 $359.19 $0.00 $97.11 $0.00 $0.00 $0.00 $0.00 $231.50 $366.70 $370.40 $0.00 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000185 EAP CPT® 81225 CYP2C19 GENOTYPE BOTH IP/OP $744.00 $550.56 $0.00 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $303.47 $303.47 $315.14 $0.00 $286.64 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100001 EAP CPT® 88289 Add High Reso BOTH IP/OP $460.00 $340.40 $0.00 $408.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.29 $52.29 $54.30 $0.00 $50.86 $0.00 $0.00 $0.00 $0.00 $96.22 $403.92 $408.00 $0.00 $314.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100002 EAP CPT® 88283 Addition Band Charge BOTH IP/OP $455.00 $336.70 $0.00 $403.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.14 $54.14 $56.22 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $99.64 $399.17 $403.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100003 EAP CPT® 88285 Addition Cell Charge BOTH IP/OP $244.00 $180.56 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.85 $28.85 $29.96 $0.00 $28.07 $0.00 $0.00 $0.00 $0.00 $53.08 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100004 EAP CPT® 88280 Addition Karyo Charge BOTH IP/OP $297.00 $219.78 $0.00 $240.00 $51.80 $51.80 $33.47 $33.47 $16.74 $0.00 $38.11 $38.11 $39.57 $0.00 $37.08 $0.00 $0.00 $0.00 $35.14 $70.14 $237.60 $240.00 $48.53 $55.23 $48.53 $39.50 $33.47 $33.47 $27.65 $33.47 $0.00 $0.00 $0.00 $0.00 31100005 EAP CPT® 88267 Ca - 15 Cells Charge BOTH IP/OP "$2,037.00 " "$1,507.38" $0.00 "$1,646.40" $371.10 $371.10 $188.57 $188.57 $94.29 $0.00 $272.97 $272.97 $283.47 $0.00 $265.55 $0.00 $0.00 $0.00 $198.00 $502.34 "$1,629.94" "$1,646.40" $273.43 $311.14 $273.43 $282.94 $188.57 $188.57 $198.06 $188.57 $0.00 $0.00 $0.00 $0.00 31100006 EAP CPT® 88248 Ca - Fragile X Charge BOTH IP/OP "$2,617.00 " "$1,936.58" $0.00 "$2,114.40" $357.46 $357.46 $173.17 $173.17 $86.59 $86.59 $262.95 $262.95 $273.07 $173.17 $255.81 $112.56 "$1,547.96" "$1,547.96" $0.00 $483.92 "$2,093.26" "$2,114.40" $0.00 $285.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100007 EAP CPT® 88264 Cell Analysis Chrg BOTH IP/OP "$1,265.00 " $936.10 $0.00 "$1,120.80" $257.29 $257.29 $144.61 $144.61 $72.31 $65.07 $189.26 $189.26 $196.54 $144.61 $184.12 $94.00 $748.25 $748.25 $151.84 $348.28 "$1,109.59" "$1,120.80" $209.68 $0.00 $209.68 $196.18 $144.61 $144.61 $137.33 $144.61 $0.00 $0.00 $0.00 $0.00 31100008 EAP CPT® 88262 Cell Cnt/karyo Typ BOTH IP/OP "$1,886.00 " "$1,395.64" $62.32 "$1,524.00" $257.29 $257.29 $125.49 $125.49 $62.75 $62.32 $189.26 $189.26 $196.54 $125.49 $184.12 $81.57 "$1,115.57" "$1,115.57" $131.76 $348.28 "$1,508.76" "$1,524.00" $181.96 $207.06 $181.96 $196.18 $125.49 $125.49 $137.33 $125.49 $0.00 $0.00 $0.00 $0.00 31100009 EAP CPT® 88164 "Cytology, Female Gen" BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.04 $16.04 $16.65 $0.00 $15.60 $0.00 $0.00 $0.00 $0.00 $29.52 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100010 EAP CPT® 88142 "Cytology, Gyn Lbp" BOTH IP/OP $288.00 $213.12 $10.13 $232.80 $41.82 $41.82 $20.26 $20.26 $10.13 $10.13 $30.76 $30.76 $31.95 $20.26 $29.94 $13.17 $170.35 $170.35 $21.27 $56.62 $230.47 $232.80 $29.38 $33.43 $29.38 $31.90 $20.26 $20.26 $22.33 $20.26 $0.00 $0.00 $0.00 $0.00 31100011 EAP CPT® 88104 "Cytology,pulmonary" BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $208.80 $208.80 $33.53 $60.16 $279.58 $282.40 $46.58 $0.00 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31100017 EAP CPT® 88172 Cytopathology Eval Of Fina BOTH IP/OP $176.00 $130.24 $19.45 $178.00 $87.57 $87.57 $145.24 $145.24 $146.06 $25.95 $23.45 $23.45 $24.35 $142.96 $66.47 $92.92 $104.10 $104.10 $143.92 $44.44 $140.98 $142.40 $178.00 $114.40 $178.00 $70.82 $19.45 $19.45 $49.57 $137.07 $0.00 $0.00 $0.00 $0.00 31100018 EAP CPT® 88184 Cytoplasmic Charge BOTH IP/OP $421.00 $311.54 $30.49 $394.92 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $249.02 $249.02 $284.24 $133.74 $335.81 $339.20 $394.92 $273.65 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31100019 EAP CPT® 88172 Fine Needle Aspiration BOTH IP/OP $176.00 $130.24 $19.45 $178.00 $87.57 $87.57 $145.24 $145.24 $146.06 $25.95 $23.45 $23.45 $24.35 $142.96 $66.47 $92.92 $104.10 $104.10 $143.92 $44.44 $140.98 $142.40 $178.00 $114.40 $178.00 $70.82 $19.45 $19.45 $49.57 $137.07 $0.00 $0.00 $0.00 $0.00 31100020 EAP CPT® 88185 Flow Cytometry - Addt'l Marker BOTH IP/OP $169.00 $125.06 $0.00 $135.20 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $99.96 $99.96 $0.00 $71.72 $133.85 $135.20 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 31100021 EAP CPT® 88188 "Flow Cytometry, Interp." BOTH IP/OP $305.00 $225.70 $0.00 $244.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $226.37 $226.37 $235.09 $0.00 $87.63 $0.00 $0.00 $0.00 $0.00 $161.74 $241.56 $244.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100022 EAP CPT® 88161 "Fna-breast,cyto" BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $100.00 $100.00 $24.06 $24.06 $24.19 $30.33 $30.67 $30.67 $31.85 $23.64 $40.98 $15.37 $122.44 $122.44 $23.06 $66.78 $163.94 $165.60 $32.04 $0.00 $32.04 $43.67 $43.22 $43.22 $30.57 $21.96 $0.00 $0.00 $0.00 $0.00 31100023 EAP CPT® 88104 "Fna-cell Blk,,misc" BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $208.80 $208.80 $33.53 $60.16 $279.58 $282.40 $46.58 $0.00 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31100024 EAP CPT® 88104 "Fna-cell Blk,breast" BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $208.80 $208.80 $33.53 $60.16 $279.58 $282.40 $46.58 $0.00 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31100025 EAP CPT® 88161 "Fna-misc,cyto" BOTH IP/OP $205.00 $151.70 $15.37 $165.60 $100.00 $100.00 $24.06 $24.06 $24.19 $30.33 $30.67 $30.67 $31.85 $23.64 $40.98 $15.37 $121.26 $121.26 $23.06 $66.78 $163.94 $165.60 $32.04 $133.25 $32.04 $43.67 $43.22 $43.22 $30.57 $21.96 $0.00 $0.00 $0.00 $0.00 31100026 EAP CPT® 88104 "Fna-pulmonary,cyto" BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $208.80 $208.80 $33.53 $60.16 $279.58 $282.40 $46.58 $0.00 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31100027 EAP CPT® 88184 Hairy Cell Leukemia BOTH IP/OP $424.00 $313.76 $0.00 $394.92 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $250.80 $250.80 $284.24 $133.74 $335.81 $339.20 $394.92 $0.00 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31100029 EAP CPT® 88280 Karyo Typing Charge BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $51.80 $51.80 $33.47 $33.47 $16.74 $0.00 $38.11 $38.11 $39.57 $0.00 $37.08 $0.00 $0.00 $0.00 $35.14 $70.14 $237.60 $240.00 $48.53 $0.00 $48.53 $39.50 $33.47 $33.47 $27.65 $33.47 $0.00 $0.00 $0.00 $0.00 31100030 EAP CPT® 88184 Lymphoma Prof-basic BOTH IP/OP $424.00 $313.76 $0.00 $394.92 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $250.80 $250.80 $284.24 $133.74 $335.81 $339.20 $394.92 $0.00 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31100031 EAP CPT® 88184 Nuclear Charge BOTH IP/OP $424.00 $313.76 $0.00 $394.92 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $250.80 $250.80 $284.24 $133.74 $335.81 $339.20 $394.92 $0.00 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31100032 EAP CPT® 88142 Pap Smear BOTH IP/OP $291.00 $215.34 $0.00 $232.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.27 $56.62 $230.47 $232.80 $29.38 $0.00 $29.38 $31.90 $20.26 $20.26 $22.33 $20.26 $0.00 $0.00 $0.00 $0.00 31100033 EAP CPT® 88130 Sex Chromatin:buccal BOTH IP/OP $166.00 $122.84 $0.00 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.85 $22.85 $23.73 $0.00 $22.23 $0.00 $0.00 $0.00 $0.00 $42.04 $131.47 $132.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100034 EAP CPT® 88235 "Tis Cult, Amino Charg" BOTH IP/OP "$2,229.00 " "$1,649.46" $0.00 "$1,801.60" $304.00 $304.00 $150.30 $150.30 $75.15 $0.00 $223.60 $223.60 $232.20 $0.00 $217.53 $0.00 $0.00 $0.00 $157.82 $411.48 "$1,783.58" "$1,801.60" $217.94 $248.00 $217.94 $231.78 $150.30 $150.30 $162.25 $150.30 $0.00 $0.00 $0.00 $0.00 31100035 EAP CPT® 88230 "Tis Cult, Lymph Charge" BOTH IP/OP "$1,765.00 " "$1,306.10" $58.25 "$1,426.40" $240.48 $240.48 $116.49 $116.49 $58.25 $58.25 $176.90 $176.90 $183.71 $116.49 $172.08 $75.72 "$1,044.00" "$1,044.00" $122.31 $325.54 "$1,412.14" "$1,426.40" $168.91 $192.21 $168.91 $183.36 $116.49 $116.49 $128.35 $116.49 $0.00 $0.00 $0.00 $0.00 31100036 EAP CPT® 88239 "Tis Cult, Other Charge" BOTH IP/OP "$2,232.00 " "$1,651.68" $73.76 "$1,804.00" $304.52 $304.52 $147.52 $147.52 $73.76 $73.76 $224.01 $224.01 $232.62 $147.52 $217.93 $95.89 "$1,320.23" "$1,320.23" $154.90 $412.24 "$1,785.96" "$1,804.00" $213.90 $243.41 $213.90 $232.21 $147.52 $147.52 $162.54 $147.52 $0.00 $0.00 $0.00 $0.00 31100037 EAP CPT® 88237 "Tissue Culture, Chrg" BOTH IP/OP $655.00 $484.70 $0.00 $580.80 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $387.43 $387.43 $150.94 $246.70 $574.99 $580.80 $208.44 $0.00 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 31100038 EAP CPT® 88184 Plasma Cell Neo Flow Tc/marker 1 (so) BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $295.75 $295.75 $284.24 $133.74 $396.00 $400.00 $394.92 $0.00 $394.92 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31100039 EAP CPT® 88185 Plasma Cell Neo Flow Tc/add On (so) BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $53.24 $53.24 $0.00 $71.72 $71.28 $72.00 $0.00 $0.00 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 31100040 EAP CPT® 88187 Plasma Cell Neo Flow Read 2 - 8(so) BOTH IP/OP $90.00 $66.60 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $69.37 $0.00 $70.22 $0.00 $0.00 $0.00 $50.66 $90.00 $71.28 $72.00 $39.31 $0.00 $39.31 $74.83 $39.31 $39.31 $52.38 $39.31 $0.00 $0.00 $0.00 $0.00 31100042 EAP CPT® 88271 Fish Aml M3 Rara Dna (so) BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $240.74 $240.74 $22.49 $59.86 $322.34 $325.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100043 EAP CPT® 88275 Fish Aml M3 Rara 100-300 (so) BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $363.77 $363.77 $53.75 $112.22 $487.08 $492.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100044 EAP CPT® 88364 "Fish, Oligoden 1p/19q (so)" BOTH IP/OP $566.00 $418.84 $0.00 $452.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.50 $101.50 $105.41 $0.00 $97.04 $0.00 $0.00 $0.00 $0.00 $283.00 $448.27 $452.80 $0.00 $0.00 $0.00 $103.40 $104.09 $104.09 $72.38 $0.00 $0.00 $0.00 $0.00 $0.00 31100046 EAP CPT® 88299 Fshd Cytogenetic Study (so) BOTH IP/OP "$2,331.00 " "$1,724.94" $0.00 "$1,864.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,730.07" "$1,730.07" "$1,796.73" $0.00 $485.78 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,846.15" "$1,864.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100047 EAP CPT® 88275 Fish Hes 4qrea 100-300 (so) BOTH IP/OP $389.00 $287.86 $0.00 $311.20 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $230.09 $230.09 $53.75 $112.22 $308.09 $311.20 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100048 EAP CPT® 88271 Fish Hes 4qrea Leuk Dna (so) BOTH IP/OP $389.00 $287.86 $0.00 $311.20 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $230.09 $230.09 $22.49 $59.86 $308.09 $311.20 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100049 EAP CPT® 88271 Fish Fgfr1 8p11-12 Dna(so) BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $133.09 $133.09 $22.49 $59.86 $178.20 $180.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100050 EAP CPT® 88275 Fish Fgfr1 8p11-12 Dna(so) BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $133.09 $133.09 $53.75 $112.22 $178.20 $180.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100051 EAP CPT® 88271 Fish Neonatal Screen Dna (so) BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $74.53 $74.53 $22.49 $59.86 $99.79 $100.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100052 EAP CPT® 88275 Fish Neonatal Screen (so) BOTH IP/OP $126.00 $93.24 $0.00 $112.22 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $74.53 $74.53 $53.75 $112.22 $99.79 $100.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100053 EAP CPT® 88275 Fish Fgfr1 8p11-12 100-300 (so) BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $363.77 $363.77 $53.75 $112.22 $487.08 $492.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100095 EAP CPT® 88143 Cytopatah C/v Thin Layer Redo BOTH IP/OP $109.00 $80.66 $0.00 $109.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.76 $30.76 $31.95 $0.00 $29.94 $0.00 $0.00 $0.00 $0.00 $56.62 $87.12 $88.00 $0.00 $109.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100096 EAP CPT® 88173 Cytopath Eval Fna Report BOTH IP/OP $405.00 $299.70 $31.00 $327.20 $234.59 $234.59 $48.39 $48.39 $48.66 $70.06 $66.81 $66.81 $69.38 $47.69 $107.58 $31.00 $239.56 $239.56 $49.62 $137.06 $323.93 $327.20 $68.93 $263.25 $68.93 $114.63 $83.20 $83.20 $80.24 $47.25 $0.00 $0.00 $0.00 $0.00 31100097 EAP CPT® 88174 Cytopath C/v Auto In Fluid BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.44 $32.44 $33.69 $0.00 $31.56 $0.00 $0.00 $0.00 $0.00 $59.70 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100098 EAP CPT® 88175 Cytopath C/v Auto Fluid Redo BOTH IP/OP $116.00 $85.84 $0.00 $92.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.19 $40.19 $41.73 $0.00 $39.09 $0.00 $0.00 $0.00 $0.00 $73.96 $91.87 $92.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100110 EAP Custom 31100110 "Fish, B-cell Cll Panel (so)" BOTH IP/OP $369.00 $273.06 $0.00 $293.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.87 $273.87 $284.43 $0.00 $76.90 $0.00 $0.00 $0.00 $0.00 $183.50 $290.66 $293.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100111 EAP CPT® 88271 Molecular Cytogen; Dna Probe (so) BOTH IP/OP $369.00 $273.06 $10.71 $293.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $218.26 $218.26 $22.49 $59.86 $290.66 $293.60 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100112 EAP CPT® 88275 Interphase In Situ Hybird (so) BOTH IP/OP $369.00 $273.06 $23.04 $293.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $218.26 $218.26 $53.75 $112.22 $290.66 $293.60 $74.23 $84.46 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100113 EAP Custom 31100113 "Fish, Locus -specific Probe (x1) (so)" BOTH IP/OP $367.00 $271.58 $0.00 $293.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.39 $272.39 $282.88 $0.00 $76.48 $0.00 $0.00 $0.00 $0.00 $183.50 $290.66 $293.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100114 EAP CPT® 88271 Molecular Cytogentics; Dna Probe (so) BOTH IP/OP $367.00 $271.58 $0.00 $293.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $217.08 $217.08 $22.49 $59.86 $290.66 $293.60 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100115 EAP Custom 31100115 Chromosome Analysis Hem Malig (so) BOTH IP/OP $340.00 $251.60 $0.00 $274.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.35 $252.35 $262.07 $0.00 $70.86 $0.00 $0.00 $0.00 $0.00 $171.50 $271.66 $274.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100116 EAP CPT® 88237 Tissue Culture For Neoplastic Disorder (so) BOTH IP/OP $340.00 $251.60 $64.69 $274.40 $182.24 $182.24 $143.75 $143.75 $71.88 $64.69 $134.06 $134.06 $139.21 $143.75 $130.42 $93.44 $201.11 $201.11 $150.94 $246.70 $271.66 $274.40 $208.44 $237.19 $208.44 $138.97 $143.75 $143.75 $97.28 $143.75 $0.00 $0.00 $0.00 $0.00 31100117 EAP CPT® 88264 Chromosome Analysis 20-25 Cells (so) BOTH IP/OP $366.00 $270.84 $65.07 $348.28 $257.29 $257.29 $144.61 $144.61 $72.31 $65.07 $189.26 $189.26 $196.54 $144.61 $184.12 $94.00 $216.49 $216.49 $151.84 $348.28 $293.04 $296.00 $209.68 $238.61 $209.68 $196.18 $144.61 $144.61 $137.33 $144.61 $0.00 $0.00 $0.00 $0.00 31100118 EAP CPT® 88120 "Bladder Cancer,fish (so)" BOTH IP/OP $488.00 $361.12 $0.00 $488.00 $488.00 $488.00 $145.24 $145.24 $146.06 $0.00 $422.54 $422.54 $438.79 $0.00 $324.87 $0.00 $0.00 $0.00 $0.00 $246.50 $390.46 $394.40 $0.00 $317.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100119 EAP Custom 31100119 "Fish, Prenatal Screen (so)" BOTH IP/OP $369.00 $273.06 $0.00 $293.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.87 $273.87 $284.43 $0.00 $76.90 $0.00 $0.00 $0.00 $0.00 $183.50 $290.66 $293.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100120 EAP CPT® 88271 Molecular Cytogen; Dna Probe (so) BOTH IP/OP $369.00 $273.06 $10.71 $293.60 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $218.26 $218.26 $22.49 $59.86 $290.66 $293.60 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100121 EAP CPT® 88275 Interphase Insitu Hybird (so) BOTH IP/OP $369.00 $273.06 $23.04 $293.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $218.26 $218.26 $53.75 $112.22 $290.66 $293.60 $74.23 $84.46 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100122 EAP CPT® 88275 Interphase In Situ Hybirdization (so) BOTH IP/OP $367.00 $271.58 $0.00 $293.60 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $217.08 $217.08 $53.75 $112.22 $290.66 $293.60 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100123 EAP CPT® 88271 Molecular Cytogenetics;dna Probe (fish) (so) BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $192.24 $192.24 $22.49 $59.86 $257.40 $260.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100124 EAP CPT® 88275 Interphase In Situ Hybirdization (so) BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $192.24 $192.24 $53.75 $112.22 $257.40 $260.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100126 EAP CPT® 88184 "Pnh Flow Cytometry, 1st Mrk (so)" BOTH IP/OP $93.00 $68.82 $30.49 $284.24 $92.98 $92.98 $283.63 $283.63 $93.00 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $55.01 $55.01 $284.24 $94.00 $74.45 $75.20 $94.00 $60.45 $94.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31100127 EAP CPT® 88185 "Pnh Flow Cytometry, Ea Addl Mrk (so)" BOTH IP/OP $93.00 $68.82 $0.00 $75.20 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $55.01 $55.01 $0.00 $71.72 $74.45 $75.20 $0.00 $60.45 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 31100130 EAP CPT® 88184 Flow Cytometry; First Marker (so) BOTH IP/OP $303.00 $224.22 $0.00 $303.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $179.22 $179.22 $284.24 $133.74 $239.98 $242.40 $303.00 $0.00 $303.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31100132 EAP CPT® 88185 Flow Cytometry;16 Or More Markers (so) BOTH IP/OP $133.00 $98.42 $0.00 $107.20 $56.76 $56.76 $0.00 $0.00 $0.00 $11.19 $48.93 $48.93 $50.81 $0.00 $26.63 $0.00 $78.67 $78.67 $0.00 $71.72 $106.13 $107.20 $0.00 $86.45 $0.00 $28.37 $22.33 $22.33 $19.86 $0.00 $0.00 $0.00 $0.00 $0.00 31100133 EAP Custom 31100133 Fish Aml M3-pml/rara Trans 15 17 (so) BOTH IP/OP $345.00 $255.30 $0.00 $274.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $0.00 $0.00 $0.00 $171.50 $271.66 $274.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100134 EAP CPT® 88271 Molecular Cytogen Dna Probe (so) BOTH IP/OP $345.00 $255.30 $10.71 $274.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $204.07 $204.07 $22.49 $59.86 $271.66 $274.40 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31100135 EAP CPT® 88275 Interphase In Situ Hybrid (so) BOTH IP/OP $343.00 $253.82 $0.00 $274.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $202.88 $202.88 $53.75 $112.22 $271.66 $274.40 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31100136 EAP Custom 31100136 Cll - Lymphoma Diagnostic Panel (so) BOTH IP/OP $93.00 $68.82 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100137 EAP CPT® 88184 Flow Cytometry; First Marker (so) BOTH IP/OP $303.00 $224.22 $0.00 $303.00 $92.98 $92.98 $283.63 $283.63 $285.22 $30.49 $82.40 $82.40 $85.57 $279.15 $54.16 $181.45 $179.22 $179.22 $284.24 $133.74 $239.98 $242.40 $303.00 $0.00 $303.00 $57.71 $68.07 $68.07 $40.40 $270.71 $0.00 $0.00 $0.00 $0.00 31100141 EAP CPT® 88112 Enriched Prep Surepath BOTH IP/OP $545.00 $403.30 $30.81 $440.80 $103.78 $103.78 $48.39 $48.39 $48.66 $30.81 $47.03 $47.03 $48.84 $47.69 $124.75 $31.00 $322.37 $322.37 $49.62 $116.38 $436.39 $440.80 $68.93 $354.25 $68.93 $132.92 $39.62 $39.62 $93.05 $47.25 $0.00 $0.00 $0.00 $0.00 31100142 EAP CPT® 80356 6-mam Opiates (so) BOTH IP/OP $166.00 $122.84 $0.00 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.21 $123.21 $127.95 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $88.00 $139.39 $140.80 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31150011 EAP CPT® 88104 "Cytology, Urinary" BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $208.80 $208.80 $33.53 $60.16 $279.58 $282.40 $46.58 $0.00 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31150012 EAP CPT® 88104 "Cytology,fluid" BOTH IP/OP $349.00 $258.26 $21.08 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $206.43 $206.43 $33.53 $60.16 $279.58 $282.40 $46.58 $226.85 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31150013 EAP CPT® 88104 "Cytology,breast" BOTH IP/OP $349.00 $258.26 $21.08 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $206.43 $206.43 $33.53 $60.16 $279.58 $282.40 $46.58 $226.85 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31150014 EAP CPT® 88104 "Cytology,cns" BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $208.80 $208.80 $33.53 $60.16 $279.58 $282.40 $46.58 $0.00 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31150015 EAP CPT® 88104 "Cytology,misc" BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $113.52 $113.52 $32.96 $32.96 $33.15 $32.11 $34.86 $34.86 $36.20 $32.43 $50.14 $21.08 $208.80 $208.80 $33.53 $60.16 $279.58 $282.40 $46.58 $0.00 $46.58 $53.42 $40.34 $40.34 $37.40 $31.93 $0.00 $0.00 $0.00 $0.00 31200001 EAP CPT® 88300 Tooth BOTH IP/OP $291.00 $215.34 $7.30 $230.40 $24.87 $24.87 $24.06 $24.06 $24.19 $7.30 $19.71 $19.71 $20.47 $23.64 $16.80 $15.37 $172.13 $172.13 $23.06 $38.76 $228.10 $230.40 $32.04 $189.15 $32.04 $17.90 $11.16 $11.16 $12.53 $21.96 $0.00 $0.00 $0.00 $0.00 31200002 EAP CPT® 88300 Foreign Body BOTH IP/OP $291.00 $215.34 $7.30 $230.40 $24.87 $24.87 $24.06 $24.06 $24.19 $7.30 $19.71 $19.71 $20.47 $23.64 $16.80 $15.37 $172.13 $172.13 $23.06 $38.76 $228.10 $230.40 $32.04 $189.15 $32.04 $17.90 $11.16 $11.16 $12.53 $21.96 $0.00 $0.00 $0.00 $0.00 31200003 EAP CPT® 88300 "Cataract,os /od" BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.06 $38.76 $228.10 $230.40 $32.04 $0.00 $32.04 $17.90 $11.16 $11.16 $12.53 $21.96 $0.00 $0.00 $0.00 $0.00 31200004 EAP CPT® 88300 Intrauterine Device BOTH IP/OP $291.00 $215.34 $7.30 $230.40 $24.87 $24.87 $24.06 $24.06 $24.19 $7.30 $19.71 $19.71 $20.47 $23.64 $16.80 $15.37 $172.13 $172.13 $23.06 $38.76 $228.10 $230.40 $32.04 $189.15 $32.04 $17.90 $11.16 $11.16 $12.53 $21.96 $0.00 $0.00 $0.00 $0.00 31200005 EAP CPT® 88302 "Appendix,incidential" BOTH IP/OP $393.00 $290.82 $14.11 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $232.46 $232.46 $23.06 $87.44 $308.09 $311.20 $32.04 $255.45 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200006 EAP CPT® 88302 "Foreskin, Newborn" BOTH IP/OP $389.00 $287.86 $0.00 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $230.09 $230.09 $23.06 $87.44 $308.09 $311.20 $32.04 $0.00 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200007 EAP CPT® 88302 "Testis,castration" BOTH IP/OP $393.00 $290.82 $14.11 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $232.46 $232.46 $23.06 $87.44 $308.09 $311.20 $32.04 $255.45 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200008 EAP CPT® 88302 Nerve BOTH IP/OP $389.00 $287.86 $0.00 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $230.09 $230.09 $23.06 $87.44 $308.09 $311.20 $32.04 $0.00 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200009 EAP CPT® 88302 Skin Plastic Repair BOTH IP/OP $393.00 $290.82 $14.11 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $232.46 $232.46 $23.06 $87.44 $308.09 $311.20 $32.04 $255.45 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200010 EAP CPT® 88302 "Amput,digit-traumat." BOTH IP/OP $393.00 $290.82 $14.11 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $232.46 $232.46 $23.06 $87.44 $308.09 $311.20 $32.04 $255.45 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200011 EAP CPT® 88302 Hernia Sac BOTH IP/OP $393.00 $290.82 $14.11 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $232.46 $232.46 $23.06 $87.44 $308.09 $311.20 $32.04 $255.45 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200012 EAP CPT® 88302 Hydrocele BOTH IP/OP $393.00 $290.82 $14.11 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $232.46 $232.46 $23.06 $87.44 $308.09 $311.20 $32.04 $255.45 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200013 EAP CPT® 88302 "Vas Deferens, Steril." BOTH IP/OP $393.00 $290.82 $14.11 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $232.46 $232.46 $23.06 $87.44 $308.09 $311.20 $32.04 $255.45 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200014 EAP CPT® 88302 Vaginal Mucosa BOTH IP/OP $393.00 $290.82 $14.11 $311.20 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $232.46 $232.46 $23.06 $87.44 $308.09 $311.20 $32.04 $255.45 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200015 EAP CPT® 88304 Nasal Polyp BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200016 EAP CPT® 88304 Colostomy Stoma BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200017 EAP CPT® 88304 "Foreskin,non-newborn" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200018 EAP CPT® 88304 "Bone/frag,non-pathologic" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200019 EAP CPT® 88304 Cartilage Shavings BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200020 EAP CPT® 88304 Carpal Tunnel Tissue BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200021 EAP CPT® 88304 Dupuytren's Contrac. BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200022 EAP CPT® 88304 "Femoral Head,n-fract" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200023 EAP CPT® 88304 "Cyst,misc" BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $292.79 $292.79 $49.62 $108.12 $392.04 $396.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200024 EAP CPT® 88304 "Cyst,synovial" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200025 EAP CPT® 88304 "Cyst,ganglion" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200026 EAP CPT® 88304 Fissure / Fistula BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200027 EAP CPT® 88304 Intervertebral Disc BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200028 EAP CPT® 88304 "Joint, Loose Body" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200029 EAP CPT® 88304 Tendon Sheath BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $292.79 $292.79 $49.62 $108.12 $392.04 $396.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200030 EAP CPT® 88304 "Cyst,dental" BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $292.79 $292.79 $49.62 $108.12 $392.04 $396.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200031 EAP CPT® 88304 "Neuroma,traumatic" BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $292.79 $292.79 $49.62 $108.12 $392.04 $396.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200032 EAP CPT® 88304 "Skin Biopsy,punch" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200033 EAP CPT® 88304 "Skin Excision,debrid" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200034 EAP CPT® 88304 "Cyst,pilonidal" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200035 EAP CPT® 88304 "Soft Tissue,debrid" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200036 EAP CPT® 88304 "Soft Tissue,lipoma" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200037 EAP CPT® 88304 Aneurysm BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200038 EAP CPT® 88304 "Vein, Varicosity" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200039 EAP CPT® 88304 Embolis/thrombus BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200040 EAP CPT® 88304 Hematoma BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200041 EAP CPT® 88304 Hemorrhoids BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200042 EAP CPT® 88304 "Artery/vein, Plaque" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200043 EAP CPT® 88304 Cholesteatoma BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200044 EAP CPT® 88304 Conjunctiva Biopsy BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $292.79 $292.79 $49.62 $108.12 $392.04 $396.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200045 EAP CPT® 88304 Cornea BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200046 EAP CPT® 88304 Salivary Mucocele BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $292.79 $292.79 $49.62 $108.12 $392.04 $396.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200047 EAP CPT® 88304 Tonsil/adenoids BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200048 EAP CPT® 88304 Gall Blad./bile Duct BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200049 EAP CPT® 88304 Spermatocele BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200050 EAP CPT® 88304 Varicocele BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $292.79 $292.79 $49.62 $108.12 $392.04 $396.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200051 EAP CPT® 88304 Vas Deferens BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200052 EAP CPT® 88304 "Cyst,bartholin" BOTH IP/OP $500.00 $370.00 $18.49 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $295.75 $295.75 $49.62 $108.12 $392.04 $396.00 $68.93 $325.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200053 EAP CPT® 88304 "Cyst,hydat-morgagni" BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $292.79 $292.79 $49.62 $108.12 $392.04 $396.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200054 EAP CPT® 88305 "Breast Bx,core Img" BOTH IP/OP $617.00 $456.58 $0.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $364.96 $364.96 $49.62 $140.98 $488.66 $493.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200055 EAP CPT® 88305 Bronchus Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200056 EAP CPT® 88305 "Trachea, Biopsy" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200057 EAP CPT® 88305 "Larynx, Biopsy" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200058 EAP CPT® 88305 Nasopharynx BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200059 EAP CPT® 88305 Nasal Mucosa Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200060 EAP CPT® 88305 Stomach Polyp BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200061 EAP CPT® 88305 Duodenum Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200062 EAP CPT® 88305 Colorectal Polyp BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200063 EAP CPT® 88305 Peritoneum Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200064 EAP CPT® 88305 Ur Bladder Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200065 EAP CPT® 88305 Prostate Chips BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200066 EAP CPT® 88305 Cell Block BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200067 EAP CPT® 88305 "Femoral Head, Fract." BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200068 EAP CPT® 88305 Synovium BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200069 EAP CPT® 88305 Meninges Resection BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200070 EAP CPT® 88305 "Skin Biopsy,shave" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200071 EAP CPT® 88305 "Skin Excision,other" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200072 EAP CPT® 88305 "Soft Tissue,other" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200073 EAP CPT® 88305 Breast Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200074 EAP CPT® 88305 "Breast,reduction" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200075 EAP CPT® 88305 Artery/vein Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200076 EAP CPT® 88305 Lymph Node Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200077 EAP CPT® 88305 Bone Marrow Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200078 EAP CPT® 88305 Spleen BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200079 EAP CPT® 88305 "Amput,extrm-traumat." BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200080 EAP CPT® 88305 Joint Resection BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200081 EAP CPT® 88305 Muscle Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200082 EAP CPT® 88305 "Amput,digit-nontraum" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200083 EAP CPT® 88305 Heart Valve BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200084 EAP CPT® 88305 "Lip, Wedge Biopsy" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200085 EAP CPT® 88305 Tongue Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200086 EAP CPT® 88305 Tonsil Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200087 EAP CPT® 88305 Oral/gingiva Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200088 EAP CPT® 88305 Salivary Gland Bx BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200089 EAP CPT® 88305 Parathyroid Gland BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200090 EAP CPT® 88305 Pituitary Tumor BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200091 EAP CPT® 88305 Nerve Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200092 EAP CPT® 88305 Pleural Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200093 EAP CPT® 88305 Pericardium Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200094 EAP CPT® 88305 Thyroglossal Duct BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200095 EAP CPT® 88305 Esophagus Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200096 EAP CPT® 88305 Stomach Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200097 EAP CPT® 88305 Sm.intestine Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200098 EAP CPT® 88305 Colon Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200099 EAP CPT® 88305 Omentum Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200100 EAP CPT® 88305 Kidney Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200101 EAP CPT® 88305 Ureter Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200102 EAP CPT® 88305 Urethra Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200103 EAP CPT® 88305 Prostate Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200104 EAP CPT® 88305 Endocervical Scrape BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200105 EAP CPT® 88305 Endometrial Scrape BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200106 EAP CPT® 88305 Cervical Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200107 EAP CPT® 88305 "Vagina, Biopsy" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200108 EAP CPT® 88305 Vulva / Labia Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200109 EAP CPT® 88305 Ovary BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200110 EAP CPT® 88305 Endometrial Polyp BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200111 EAP CPT® 88305 "Uterus, Prolapse" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200112 EAP CPT® 88305 Fallopian Tube Biopsy BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200113 EAP CPT® 88305 "Fallop. Tube,ectopic" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200114 EAP CPT® 88305 "Ovary,wedge Biopsy" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200115 EAP CPT® 88305 "POC, SPONTANEOUS" BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200116 EAP CPT® 88305 "Placenta, N-3rd Trim." BOTH IP/OP $624.00 $461.76 $31.00 $493.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $369.10 $369.10 $49.62 $140.98 $488.66 $493.60 $68.93 $405.60 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200117 EAP CPT® 88307 Stomach Resection BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200118 EAP CPT® 88307 "Colon, Seg Resection" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200119 EAP CPT® 88307 "Pancreas, Biopsy" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200120 EAP CPT® 88307 Liver Resection BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200121 EAP CPT® 88307 Ureter Resection BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200122 EAP CPT® 88307 Testis Biopsy BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200123 EAP CPT® 88307 Prostate Resection BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200124 EAP CPT® 88307 Bone Biopsy BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200125 EAP CPT® 88307 "Tumor,dental" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200126 EAP CPT® 88307 "Meninges,tumor" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200127 EAP CPT® 88307 "Breast,simple Mast." BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200128 EAP CPT® 88307 Lymph Node Resectn BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200129 EAP CPT® 88307 Liver Biopsy BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200130 EAP CPT® 88307 "Amput,extrm-non Traum" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200131 EAP CPT® 88307 "Bone/frag,pathologic" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200132 EAP CPT® 88307 "Mediastinum,mass" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200133 EAP CPT® 88307 "Soft Tissue,bx/excis" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200134 EAP CPT® 88307 "Eye, Enucleation" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200135 EAP CPT® 88307 Thyroid Resection BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200136 EAP CPT® 88307 Adrenal Resection BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200137 EAP CPT® 88307 Brain Biopsy BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200138 EAP CPT® 88307 "Lung, Wedge Biopsy" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200139 EAP CPT® 88307 Myocardium Biopsy BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200140 EAP CPT® 88307 Thymus Tumor BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200141 EAP CPT® 88307 Small Intes. Resectn BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200142 EAP CPT® 88307 Nephrectomy BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200143 EAP CPT® 88307 Testis Resection BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200144 EAP CPT® 88307 Uterus BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200145 EAP CPT® 88307 Cervical Cone BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200146 EAP CPT® 88307 "Placenta, Third Trim." BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200147 EAP CPT® 88307 "Ovary,tumor" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200148 EAP CPT® 88309 Small Intes. Tumor BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200149 EAP CPT® 88309 "Colon, Seg Resec,tumor" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200150 EAP CPT® 88309 Ur Bladder Resection BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200151 EAP CPT® 88309 "Testis Resect,tumor" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200152 EAP CPT® 88309 Bone Resection BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200153 EAP CPT® 88309 "Soft Tissue,tumor" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200154 EAP CPT® 88309 "Breast,mast.w/nodes" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200155 EAP CPT® 88309 "Larynx, Resectn/node" BOTH IP/OP "$1,051.00 " $777.74 $0.00 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $621.67 $621.67 $630.05 $328.48 $832.39 $840.80 $875.37 $0.00 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200156 EAP CPT® 88309 "Tongue, Resectn,tumor" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200157 EAP CPT® 88309 "Tonsil Resectn,tumor" BOTH IP/OP "$1,051.00 " $777.74 $0.00 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $621.67 $621.67 $630.05 $328.48 $832.39 $840.80 $875.37 $0.00 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200158 EAP CPT® 88309 Lung Resection BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200159 EAP CPT® 88309 Esophagus Resection BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200160 EAP CPT® 88309 "Colon, Total Resectn" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200161 EAP CPT® 88309 Pancreas BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200162 EAP CPT® 88309 "Prostate,resectn Rad" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200163 EAP CPT® 88309 "Uterus, Tumor" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200164 EAP CPT® 88309 "Fetus, W/dissection" BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200165 EAP CPT® 88309 Vulva Resection BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200166 EAP CPT® 88312 STAIN GRP I - ACID FAST BACT BOTH IP/OP $419.00 $310.06 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $247.84 $247.84 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200167 EAP CPT® 88312 STAIN GRP I - BIELSCHOWSKY BOTH IP/OP $415.00 $307.10 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $245.47 $245.47 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200168 EAP CPT® 88312 STAIN GRP I - C E VIOLET BOTH IP/OP $415.00 $307.10 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $245.47 $245.47 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200169 EAP CPT® 88312 STAIN GRP I - FITE STAIN BOTH IP/OP $419.00 $310.06 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $247.84 $247.84 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200170 EAP CPT® 88312 STAIN GRP I - GRAM STAIN BOTH IP/OP $419.00 $310.06 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $247.84 $247.84 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200171 EAP CPT® 88312 STAIN GRP I - GR METH SILVER BOTH IP/OP $419.00 $310.06 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $247.84 $247.84 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200172 EAP CPT® 88312 SPECAL STAIN GROUP I BOTH IP/OP $415.00 $307.10 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $245.47 $245.47 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200173 EAP CPT® 88312 STAIN GRP I - RETICUL STAIN BOTH IP/OP $419.00 $310.06 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $247.84 $247.84 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200174 EAP CPT® 88312 STAIN GRP I - STEINER-SPIRO BOTH IP/OP $415.00 $307.10 $31.00 $332.00 $150.27 $150.27 $48.39 $48.39 $48.66 $45.90 $75.24 $75.24 $78.14 $47.69 $50.97 $31.00 $245.47 $245.47 $49.62 $128.88 $328.68 $332.00 $68.93 $256.10 $68.93 $54.31 $79.24 $79.24 $38.01 $47.25 $0.00 $0.00 $0.00 $0.00 31200175 EAP CPT® 88313 STAIN GRP II - ALCIAN BLUE BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200176 EAP CPT® 88313 STAIN GRP II - COLLO IRON BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200177 EAP CPT® 88313 STAIN GRP II - COLLO IRON W HY BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200178 EAP CPT® 88313 STAIN GRP II - DIFF QUCK BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200179 EAP CPT® 88313 STAIN GRP II - CONGO RED BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200180 EAP CPT® 88313 STAIN GRP II - CRYSTAL VIOLET BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200181 EAP CPT® 88313 STAIN GRP II - ELASTIC BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200182 EAP CPT® 88313 STAIN GRP II - GIEMSA BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200183 EAP CPT® 88313 STAIN GRP II - IRON BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200184 EAP CPT® 88313 STAIN GRP II - LUXOL BLUE BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200185 EAP CPT® 88313 STAIN GRP II - MASSON TRI BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200186 EAP CPT® 88313 STAIN GRP II - MUCICARMINE BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200187 EAP CPT® 88313 STAIN GRP II - OIL RED O BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200188 EAP CPT® 88313 STAIN GRP II - PAS BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200189 EAP CPT® 88313 STAIN GRP II - PAS ALC BLUE BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200190 EAP CPT® 88313 STAIN GRP II - PAS W / WO DIAD BOTH IP/OP $366.00 $270.84 $21.08 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $216.49 $216.49 $33.53 $110.70 $287.50 $290.40 $46.58 $237.90 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200191 EAP CPT® 88313 STAIN GRP II - SUDAN BLK B BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200192 EAP CPT® 88313 STAIN GRP II - TOLU BLUE BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200193 EAP CPT® 88313 Stain Grp Ii - Sudan Black BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200194 EAP CPT® 88313 Stain Grp Ii - Nasd Cl-ac-est BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200195 EAP CPT® 88313 Stain Grp Ii - Nafl Inhi Nasd BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200196 EAP CPT® 88313 Stain Grp Ii - Pas BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200197 EAP CPT® 88313 Stain Grp Ii - Naphth Ester BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200198 EAP CPT® 88313 Stain Grp Ii - T Resist Ap BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $214.71 $214.71 $33.53 $110.70 $287.50 $290.40 $46.58 $0.00 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200199 EAP CPT® 88313 Stain Grp Ii - Fontana Masson BOTH IP/OP $518.00 $383.32 $21.08 $410.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $306.40 $306.40 $33.53 $110.70 $406.30 $410.40 $46.58 $316.55 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200200 EAP CPT® 88313 Stain Grp Ii - Bile Stain BOTH IP/OP $513.00 $379.62 $21.08 $410.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $303.44 $303.44 $33.53 $110.70 $406.30 $410.40 $46.58 $316.55 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200201 EAP CPT® 88313 Stain Grp Ii - Calcium Stain BOTH IP/OP $518.00 $383.32 $21.08 $410.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $306.40 $306.40 $33.53 $110.70 $406.30 $410.40 $46.58 $316.55 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200202 EAP CPT® 88313 Stain Grp Ii - Melanin (bleach) BOTH IP/OP $513.00 $379.62 $21.08 $410.40 $106.50 $106.50 $32.96 $32.96 $33.15 $33.25 $63.07 $63.07 $65.49 $32.43 $52.76 $21.08 $303.44 $303.44 $33.53 $110.70 $406.30 $410.40 $46.58 $316.55 $46.58 $56.22 $64.47 $64.47 $39.35 $31.93 $0.00 $0.00 $0.00 $0.00 31200203 EAP CPT® 88342 A-1 Antitrypsin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200204 EAP CPT® 88342 "Actin,muscle Spec." BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200205 EAP CPT® 88342 Alpha-fetoprotein BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200206 EAP CPT® 88342 B72.3-breast BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200207 EAP CPT® 88342 Ca 125-ovarian Ca BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200208 EAP CPT® 88342 Ca-19-9-carbohydrat BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200209 EAP CPT® 88342 Calcitonin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200210 EAP CPT® 88342 Cea-p BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200211 EAP CPT® 88342 Chromogranin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200212 EAP CPT® 88342 Cytokeratin-ae1/ae3 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200213 EAP CPT® 88342 Cytokeratin-cam5.2 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200214 EAP CPT® 88342 Cytomegalovirus BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200215 EAP CPT® 88342 Desmin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200216 EAP CPT® 88342 Ema BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200217 EAP CPT® 88342 Factor Viii BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200219 EAP CPT® 88342 *stain: Oncoprotein (bcl2) BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200220 EAP CPT® 88342 *stain: Cd30/ber H2 (ki-1) BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200221 EAP CPT® 88342 *stain: B-1 Glyco BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200222 EAP CPT® 88342 *stain: Calponin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200223 EAP CPT® 88342 *stain: Calretinin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200224 EAP CPT® 88342 *stain: A-1 Antichymotryps BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200225 EAP CPT® 88342 *stain: Cytokeratin 20 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200226 EAP CPT® 88342 *stain: Cd10 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200227 EAP CPT® 88342 *stain: Cd138 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200228 EAP CPT® 88342 *stain: Cd23 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200229 EAP CPT® 88342 *stain: Cd3 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200230 EAP CPT® 88342 *stain: Cd31 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200231 EAP CPT® 88342 *stain: Cd34 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200232 EAP CPT® 88342 *stain: Cd43 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200233 EAP CPT® 88342 *stain: Cd5 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200234 EAP CPT® 88342 *stain: Cd79 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200235 EAP CPT® 88360 *stain: Ki-67 (mib-1) BOTH IP/OP $642.00 $475.08 $58.38 $492.80 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $379.74 $379.74 $143.92 $121.34 $487.87 $492.80 $199.96 $417.30 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31200236 EAP CPT® 88342 *stain: Cytokeratin 7 BOTH IP/OP $544.00 $402.56 $48.82 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $321.78 $321.78 $143.92 $106.46 $434.81 $439.20 $199.96 $353.60 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200237 EAP CPT® 88342 *stain: Hepatocyte BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200238 EAP CPT® 88342 *stain: Hi Mol Wt Keratin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200239 EAP CPT® 88342 *stain: Inhibin Alpha BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200240 EAP CPT® 88342 *stain: Myeloperoxidase BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200241 EAP CPT® 88342 *stain: P16 BOTH IP/OP $544.00 $402.56 $48.82 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $321.78 $321.78 $143.92 $106.46 $434.81 $439.20 $199.96 $353.60 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200242 EAP CPT® 88342 *stain: P53 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200243 EAP CPT® 88342 *stain: Tdt BOTH IP/OP $544.00 $402.56 $48.82 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $321.78 $321.78 $143.92 $106.46 $434.81 $439.20 $199.96 $353.60 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200244 EAP CPT® 88342 *stain: Ttf-1 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200245 EAP CPT® 88342 *stain: Villin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200246 EAP CPT® 88342 Immunoperoxidase BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200247 EAP CPT® 88360 Estrogen Receptor BOTH IP/OP $620.00 $458.80 $58.38 $492.80 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $366.73 $366.73 $143.92 $121.34 $487.87 $492.80 $199.96 $403.00 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31200248 EAP CPT® 88360 Progesterone Recep. BOTH IP/OP $620.00 $458.80 $58.38 $492.80 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $366.73 $366.73 $143.92 $121.34 $487.87 $492.80 $199.96 $403.00 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31200249 EAP CPT® 88342 Glial Fibrillary Ap BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200250 EAP CPT® 88342 Glucagon BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200251 EAP CPT® 88342 Hepatitis B Core BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200252 EAP CPT® 88342 Hepatitis B Surface BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200253 EAP CPT® 88342 Herpes Simplex Prob BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200254 EAP CPT® 88342 Human Chorionic Gon BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200255 EAP CPT® 88342 Human Growth Hormon BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200256 EAP CPT® 88342 Insulin BOTH IP/OP $544.00 $402.56 $48.82 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $321.78 $321.78 $143.92 $106.46 $434.81 $439.20 $199.96 $353.60 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200257 EAP CPT® 88342 Kappa BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200258 EAP CPT® 88342 L-26 B Cell Marker BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200259 EAP CPT® 88342 Lambda BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200260 EAP CPT® 88342 Leu M1 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200261 EAP CPT® 88342 Leukocyte Common Ag BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200262 EAP CPT® 88342 Leuteinizing Hormon BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200263 EAP CPT® 88342 Macrophage-ham-56 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200264 EAP CPT® 88342 Melanoma-hmb-45 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200265 EAP CPT® 88342 Neuron Spec Enolase BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200266 EAP CPT® 88342 Placental Alk Phos BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200267 EAP CPT® 88342 Placental Lactogen BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200268 EAP CPT® 88342 Prolactin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200269 EAP CPT® 88342 Prostate Acid Phos BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200270 EAP CPT® 88342 Prostate Spec Ag BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200271 EAP CPT® 88342 S-100 Neural Ag BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200272 EAP CPT® 88342 Serotonin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200273 EAP CPT® 88342 Synatophysin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200274 EAP CPT® 88342 Thyroglobulin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200275 EAP CPT® 88342 Uchl-1 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200276 EAP CPT® 88342 Vimentin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200277 EAP CPT® 88342 Em:kappa BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200278 EAP CPT® 88342 Em:lambda BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200279 EAP CPT® 88346 Em:igg BOTH IP/OP $764.00 $565.36 $0.00 $648.00 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $451.91 $451.91 $284.24 $112.24 $641.52 $648.00 $394.92 $0.00 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200280 EAP CPT® 88346 Em:iga BOTH IP/OP $764.00 $565.36 $0.00 $648.00 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $451.91 $451.91 $284.24 $112.24 $641.52 $648.00 $394.92 $0.00 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200281 EAP CPT® 88346 Em:igm BOTH IP/OP $764.00 $565.36 $0.00 $648.00 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $451.91 $451.91 $284.24 $112.24 $641.52 $648.00 $394.92 $0.00 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200282 EAP CPT® 88346 Em:c3 BOTH IP/OP $764.00 $565.36 $0.00 $648.00 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $451.91 $451.91 $284.24 $112.24 $641.52 $648.00 $394.92 $0.00 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200283 EAP CPT® 88346 Em:c4 BOTH IP/OP $764.00 $565.36 $0.00 $648.00 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $451.91 $451.91 $284.24 $112.24 $641.52 $648.00 $394.92 $0.00 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200284 EAP CPT® 88346 Em:c1q BOTH IP/OP $764.00 $565.36 $0.00 $648.00 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $451.91 $451.91 $284.24 $112.24 $641.52 $648.00 $394.92 $0.00 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200285 EAP CPT® 88346 Em:fibrogen BOTH IP/OP $764.00 $565.36 $0.00 $648.00 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $451.91 $451.91 $284.24 $112.24 $641.52 $648.00 $394.92 $0.00 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200286 EAP CPT® 88346 "Immunof,dir Charge" BOTH IP/OP $794.00 $587.56 $50.44 $604.00 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $469.65 $469.65 $284.24 $112.24 $597.96 $604.00 $394.92 $510.25 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200287 EAP CPT® 88346 "Immunof, Ind Charge" BOTH IP/OP $537.00 $397.38 $50.44 $408.80 $144.30 $144.30 $283.63 $283.63 $285.22 $50.44 $59.58 $59.58 $61.87 $279.15 $83.33 $181.45 $317.64 $317.64 $284.24 $112.24 $404.71 $408.80 $394.92 $349.05 $394.92 $88.79 $90.76 $90.76 $62.15 $270.71 $0.00 $0.00 $0.00 $0.00 31200288 EAP CPT® 88360 *stain: Her2neu BOTH IP/OP $642.00 $475.08 $58.38 $492.80 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $379.74 $379.74 $143.92 $121.34 $487.87 $492.80 $199.96 $417.30 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31200290 EAP CPT® 88342 *stain: Ber Ep4 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200291 EAP CPT® 88342 *stain: Cd117 (c-kit) BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200292 EAP CPT® 88342 *stain: Cdx2 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200293 EAP CPT® 88342 *stain: Cea (monoclonal) BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200294 EAP CPT® 88342 *stain: Cyclin D1 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200295 EAP CPT® 88342 *stain: Cytokeratin 19 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200296 EAP CPT® 88342 *stain: Cytokeratin 5 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200297 EAP CPT® 88342 *stain: Cytokeratin 5/6 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200298 EAP CPT® 88342 *stain: Cytokeratin 6 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200299 EAP CPT® 88342 *stain: E-cadherin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200300 EAP CPT® 88342 *stain: Egfr BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200301 EAP CPT® 88342 *stain: Galectin-3 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200302 EAP CPT® 88342 *stain: Gcdfp-15 BOTH IP/OP $544.00 $402.56 $48.82 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $321.78 $321.78 $143.92 $106.46 $434.81 $439.20 $199.96 $353.60 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200303 EAP CPT® 88342 *stain: Hbme-1 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200304 EAP CPT® 88342 *stain: Helicobacter Pylori BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200305 EAP CPT® 88342 *stain: Hhv-8 (human Herpes-8) BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200306 EAP CPT® 88342 *stain: Melan A (mart-1) BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200307 EAP CPT® 88342 *stain: P10 BOTH IP/OP $544.00 $402.56 $48.82 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $321.78 $321.78 $143.92 $106.46 $434.81 $439.20 $199.96 $353.60 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200308 EAP CPT® 88342 *stain: P63 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200309 EAP CPT® 88342 *stain: Treponema BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200310 EAP CPT® 88342 *stain: Wt-1 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200311 EAP CPT® 88342 *stain:pin Cocktail(p63=p504s) BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200312 EAP CPT® 88342 *stain:sma(smooth Muscle Actin BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200313 EAP CPT® 88342 Stain: Cd56 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200314 EAP CPT® 88342 Stain: Cd99 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200315 EAP CPT® 88342 Stain: Glypican-3 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200316 EAP CPT® 88342 Stain: Moc-1 BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200317 EAP CPT® 88342 Immunohisto Chemistry BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $164.44 $164.44 $143.92 $106.46 $220.18 $222.40 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200320 EAP CPT® 88342 Ihc Marker (stain Only) (so) BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $196.97 $196.97 $143.92 $106.46 $263.74 $266.40 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200321 EAP CPT® 88361 Inscape Er/pr/her Quant-ihc (so) BOTH IP/OP $736.00 $544.64 $0.00 $588.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.90 $96.90 $100.62 $0.00 $143.65 $0.00 $0.00 $0.00 $0.00 $212.60 $582.91 $588.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31200322 EAP CPT® 88361 Inscape Er/pr Quant -ihc (so) BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.90 $96.90 $100.62 $0.00 $143.65 $0.00 $0.00 $0.00 $0.00 $212.60 $403.92 $408.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31200323 EAP CPT® 88342 Ercc1 Ihc With Interp (so) BOTH IP/OP $278.00 $205.72 $0.00 $222.40 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $164.44 $164.44 $143.92 $106.46 $220.18 $222.40 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200330 EAP CPT® 88305 Accessort Digit Diagnostic BOTH IP/OP $367.00 $271.58 $0.00 $293.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $217.08 $217.08 $49.62 $140.98 $290.66 $293.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200331 EAP CPT® 88305 Acromioclavicular Joint BOTH IP/OP $367.00 $271.58 $0.00 $293.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $217.08 $217.08 $49.62 $140.98 $290.66 $293.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200332 EAP CPT® 88304 Adhesions Pelvic BOTH IP/OP $371.00 $274.54 $18.49 $293.60 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $219.45 $219.45 $49.62 $108.12 $290.66 $293.60 $68.93 $241.15 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200333 EAP CPT® 88304 Adipose Tissue (fat/fatty Tissue) BOTH IP/OP $367.00 $271.58 $0.00 $293.60 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $217.08 $217.08 $49.62 $108.12 $290.66 $293.60 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200334 EAP CPT® 88305 Ampulla Of Vater BOTH IP/OP $371.00 $274.54 $31.00 $293.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $219.45 $219.45 $49.62 $140.98 $290.66 $293.60 $68.93 $241.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200335 EAP CPT® 88307 Amputation-extremity Non-traumatic BOTH IP/OP $371.00 $274.54 $116.80 $371.00 $371.00 $371.00 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $219.45 $219.45 $284.24 $240.00 $290.66 $293.60 $367.00 $241.15 $367.00 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200336 EAP CPT® 88307 Arachnoid Mater-tumor Resection BOTH IP/OP $367.00 $271.58 $0.00 $367.00 $367.00 $367.00 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $217.08 $217.08 $284.24 $240.00 $290.66 $293.60 $367.00 $0.00 $367.00 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200337 EAP CPT® 88305 Arteriovenous Malformation (avm) BOTH IP/OP $474.00 $350.76 $31.00 $375.20 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $280.37 $280.37 $49.62 $140.98 $371.45 $375.20 $68.93 $308.10 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200338 EAP CPT® 88307 Arteriovenous Malformation (avm) Complex BOTH IP/OP $474.00 $350.76 $116.80 $406.48 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $280.37 $280.37 $284.24 $240.00 $371.45 $375.20 $394.92 $308.10 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200339 EAP CPT® 88307 Axillary Tail/axilla - Lymph Nodes Resection BOTH IP/OP $474.00 $350.76 $116.80 $406.48 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $280.37 $280.37 $284.24 $240.00 $371.45 $375.20 $394.92 $308.10 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200340 EAP CPT® 88305 Bone Marrow Particle Clot BOTH IP/OP $474.00 $350.76 $31.00 $375.20 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $280.37 $280.37 $49.62 $140.98 $371.45 $375.20 $68.93 $308.10 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200341 EAP CPT® 88305 Breast Excision Of Discrete Lesion BOTH IP/OP $474.00 $350.76 $31.00 $375.20 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $280.37 $280.37 $49.62 $140.98 $371.45 $375.20 $68.93 $308.10 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200342 EAP CPT® 88305 Breast Needle Core Tissue Biopsy BOTH IP/OP $474.00 $350.76 $31.00 $375.20 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $280.37 $280.37 $49.62 $140.98 $371.45 $375.20 $68.93 $308.10 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200343 EAP CPT® 88305 Breast Incisional Biopsy BOTH IP/OP $474.00 $350.76 $31.00 $375.20 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $280.37 $280.37 $49.62 $140.98 $371.45 $375.20 $68.93 $308.10 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200344 EAP CPT® 88307 Breast Quadrantectomy/partial Mastectomy/segmentectomy BOTH IP/OP $474.00 $350.76 $116.80 $406.48 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $280.37 $280.37 $284.24 $240.00 $371.45 $375.20 $394.92 $308.10 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200345 EAP CPT® 88307 Cervix Amputation Without Uterus BOTH IP/OP $474.00 $350.76 $116.80 $406.48 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $280.37 $280.37 $284.24 $240.00 $371.45 $375.20 $394.92 $308.10 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200346 EAP CPT® 88305 "Colon ""donut""" BOTH IP/OP $474.00 $350.76 $31.00 $375.20 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $280.37 $280.37 $49.62 $140.98 $371.45 $375.20 $68.93 $308.10 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200347 EAP CPT® 88304 Colon Donut BOTH IP/OP $474.00 $350.76 $18.49 $375.20 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $280.37 $280.37 $49.62 $108.12 $371.45 $375.20 $68.93 $308.10 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200348 EAP CPT® 88307 Cyst - Bone BOTH IP/OP $469.00 $347.06 $0.00 $406.48 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $277.41 $277.41 $284.24 $240.00 $371.45 $375.20 $394.92 $0.00 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200349 EAP CPT® 88305 Cyst - Cervix BOTH IP/OP $469.00 $347.06 $0.00 $375.20 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $277.41 $277.41 $49.62 $140.98 $371.45 $375.20 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200350 EAP CPT® 88307 Cyst - Dermoid Of Soft Tissue/ovary (eg Teratoma) BOTH IP/OP $474.00 $350.76 $116.80 $406.48 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $280.37 $280.37 $284.24 $240.00 $371.45 $375.20 $394.92 $308.10 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200351 EAP CPT® 88304 Cyst - Dermoid Skin BOTH IP/OP $469.00 $347.06 $18.49 $375.20 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $277.41 $277.41 $49.62 $108.12 $371.45 $375.20 $68.93 $304.85 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200352 EAP CPT® 88304 Cyst - Epidermoid BOTH IP/OP $591.00 $437.34 $18.49 $468.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $349.58 $349.58 $49.62 $108.12 $463.32 $468.00 $68.93 $384.15 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200353 EAP CPT® 88305 Cyst - Ovarian Non-neoplastic BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200354 EAP CPT® 88307 Cyst Nos Neoplastic BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200355 EAP CPT® 88305 Cyst Nos Nonneoplastic BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200356 EAP CPT® 88302 Cystocele BOTH IP/OP $585.00 $432.90 $14.11 $468.00 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $346.03 $346.03 $23.06 $87.44 $463.32 $468.00 $32.04 $291.20 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200357 EAP CPT® 88309 Diaphragm - Resection For Tumor BOTH IP/OP $585.00 $432.90 $0.00 $638.19 $585.00 $585.00 $638.19 $638.19 $585.00 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $346.03 $346.03 $630.05 $328.48 $463.32 $468.00 $585.00 $0.00 $585.00 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200358 EAP CPT® 88307 Diaphragm - Resection Other Than For Tumor BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $346.03 $346.03 $284.24 $240.00 $463.32 $468.00 $394.92 $0.00 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200359 EAP CPT® 88307 Dura Mater - Tumor Resection BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200360 EAP CPT® 88305 Endometrial Polyp BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200361 EAP CPT® 88309 Endoscopic Mucosal Resection (emr) BOTH IP/OP $591.00 $437.34 $164.53 $638.19 $591.00 $591.00 $638.19 $638.19 $591.00 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $349.58 $349.58 $630.05 $328.48 $463.32 $468.00 $585.00 $384.15 $585.00 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200362 EAP CPT® 88305 Epiglottis Biopsy/simple Excision BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200363 EAP CPT® 88305 Esophageal Polyp BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200364 EAP CPT® 88304 Fat/fatty Tissue Nos BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $346.03 $346.03 $49.62 $108.12 $463.32 $468.00 $68.93 $0.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200365 EAP CPT® 88305 Gastric Polyp BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200366 EAP CPT® 88305 Mucosa Biopsy - Gingiva BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200367 EAP CPT® 88305 Mucosa Biopsy - Nasal BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200368 EAP CPT® 88305 Mucosa Biopsy - Nos BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200369 EAP CPT® 88304 Nasal Septum BOTH IP/OP $591.00 $437.34 $18.49 $468.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $349.58 $349.58 $49.62 $108.12 $463.32 $468.00 $68.93 $384.15 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200370 EAP CPT® 88307 Omentum Resection BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200371 EAP CPT® 88309 Omentum Resection - For Tumor BOTH IP/OP $591.00 $437.34 $164.53 $638.19 $591.00 $591.00 $638.19 $638.19 $591.00 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $349.58 $349.58 $630.05 $328.48 $463.32 $468.00 $585.00 $384.15 $585.00 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200372 EAP CPT® 88305 Oral Cyst BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200373 EAP CPT® 88305 Panniculus BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200374 EAP CPT® 88305 Penis Biopsy BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200375 EAP CPT® 88309 Penis Resection For Tumor BOTH IP/OP $591.00 $437.34 $164.53 $638.19 $591.00 $591.00 $638.19 $638.19 $591.00 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $349.58 $349.58 $630.05 $328.48 $463.32 $468.00 $585.00 $384.15 $585.00 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200376 EAP CPT® 88305 Pericardiium Biopsy Or Tissue BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200377 EAP CPT® 88309 Pericardium Resection - For Tumor BOTH IP/OP $585.00 $432.90 $0.00 $638.19 $585.00 $585.00 $638.19 $638.19 $585.00 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $346.03 $346.03 $630.05 $328.48 $463.32 $468.00 $585.00 $0.00 $585.00 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200378 EAP CPT® 88309 Peritoneum Resection - For Tumor BOTH IP/OP $591.00 $437.34 $164.53 $638.19 $591.00 $591.00 $638.19 $638.19 $591.00 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $349.58 $349.58 $630.05 $328.48 $463.32 $468.00 $585.00 $384.15 $585.00 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200379 EAP CPT® 88305 Pia Mater - Other Than Tumor Resection BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $346.03 $346.03 $49.62 $140.98 $463.32 $468.00 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200380 EAP CPT® 88307 Pia Mater - Tumor Resection BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $346.03 $346.03 $284.24 $240.00 $463.32 $468.00 $394.92 $0.00 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200381 EAP CPT® 88307 Pleura Resection BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200382 EAP CPT® 88305 Retroperitoneal Biopsy BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $346.03 $346.03 $49.62 $140.98 $463.32 $468.00 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200383 EAP CPT® 88304 Scar - Soft Tissue BOTH IP/OP $591.00 $437.34 $18.49 $468.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $349.58 $349.58 $49.62 $108.12 $463.32 $468.00 $68.93 $384.15 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200384 EAP CPT® 88305 Skin Wart (eg Verruca Vulgaris) BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200385 EAP CPT® 88305 Spinal Cord Biopsy BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200386 EAP CPT® 88307 Spinal Cord Tumor Excision BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200387 EAP CPT® 88304 Stoma (any Site) BOTH IP/OP $591.00 $437.34 $18.49 $468.00 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $349.58 $349.58 $49.62 $108.12 $463.32 $468.00 $68.93 $384.15 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200388 EAP CPT® 88305 Stomach Polyp BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200389 EAP CPT® 88302 Supernumerary Digit BOTH IP/OP $591.00 $437.34 $14.11 $468.00 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $349.58 $349.58 $23.06 $87.44 $463.32 $468.00 $32.04 $291.20 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200390 EAP CPT® 88305 Supernumerary Digit Diagnostic BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $346.03 $346.03 $49.62 $140.98 $463.32 $468.00 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200391 EAP CPT® 88307 Surgical Margin Complicated Exam BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200392 EAP CPT® 88302 Thymus Incidential BOTH IP/OP $591.00 $437.34 $14.11 $468.00 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $349.58 $349.58 $23.06 $87.44 $463.32 $468.00 $32.04 $291.20 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200393 EAP CPT® 88302 Uvula - Incidental BOTH IP/OP $585.00 $432.90 $14.11 $468.00 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $346.03 $346.03 $23.06 $87.44 $463.32 $468.00 $32.04 $291.20 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200394 EAP CPT® 88305 Vocal Cord Biopsy BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200395 EAP CPT® 88307 Vocal Cord Resection BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200396 EAP CPT® 88307 Bone Cyst BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200397 EAP CPT® 88305 Breast Biopsy Without Margin Exam BOTH IP/OP $591.00 $437.34 $31.00 $468.00 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $349.58 $349.58 $49.62 $140.98 $463.32 $468.00 $68.93 $384.15 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200398 EAP CPT® 88307 Cyst - Ovarian Neoplastic BOTH IP/OP $591.00 $437.34 $116.80 $468.00 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $349.58 $349.58 $284.24 $240.00 $463.32 $468.00 $394.92 $384.15 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200399 EAP CPT® 88305 Cyst - Sinsus BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $435.94 $435.94 $49.62 $140.98 $583.70 $589.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200400 EAP CPT® 88305 Diaphragm Biopsy Or Tissue BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $435.94 $435.94 $49.62 $140.98 $583.70 $589.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200401 EAP CPT® 88304 Diverticulum - Bladder/urethra BOTH IP/OP $745.00 $551.30 $18.49 $589.60 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $440.67 $440.67 $49.62 $108.12 $583.70 $589.60 $68.93 $429.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200402 EAP CPT® 88305 Dura Mater BOTH IP/OP $745.00 $551.30 $31.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $440.67 $440.67 $49.62 $140.98 $583.70 $589.60 $68.93 $484.25 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200403 EAP CPT® 88302 Enterocele BOTH IP/OP $737.00 $545.38 $14.11 $589.60 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $435.94 $435.94 $23.06 $87.44 $583.70 $589.60 $32.04 $291.20 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200404 EAP CPT® 88305 Ethmoid Tissue BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $435.94 $435.94 $49.62 $140.98 $583.70 $589.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200405 EAP CPT® 88305 Fat Pad Biopsy BOTH IP/OP $745.00 $551.30 $31.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $440.67 $440.67 $49.62 $140.98 $583.70 $589.60 $68.93 $484.25 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200406 EAP CPT® 88305 Leep Biopsy BOTH IP/OP $745.00 $551.30 $31.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $440.67 $440.67 $49.62 $140.98 $583.70 $589.60 $68.93 $484.25 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200407 EAP CPT® 88304 Ligament BOTH IP/OP $745.00 $551.30 $18.49 $589.60 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $440.67 $440.67 $49.62 $108.12 $583.70 $589.60 $68.93 $484.25 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200408 EAP CPT® 88307 Lymph Node For Lymphoma Workup BOTH IP/OP $745.00 $551.30 $116.80 $589.60 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $440.67 $440.67 $284.24 $240.00 $583.70 $589.60 $394.92 $484.25 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200409 EAP CPT® 88304 Meningematoma/meninghematoma BOTH IP/OP $737.00 $545.38 $18.49 $589.60 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $435.94 $435.94 $49.62 $108.12 $583.70 $589.60 $68.93 $429.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200410 EAP CPT® 88305 Mucosa Biopsy - Oral BOTH IP/OP $745.00 $551.30 $31.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $440.67 $440.67 $49.62 $140.98 $583.70 $589.60 $68.93 $484.25 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200411 EAP CPT® 88304 Nail Nail Bed Or Scrapping For Fungus BOTH IP/OP $745.00 $551.30 $18.49 $589.60 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $440.67 $440.67 $49.62 $108.12 $583.70 $589.60 $68.93 $429.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200412 EAP CPT® 88307 Nerve Tumor BOTH IP/OP $745.00 $551.30 $116.80 $589.60 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $440.67 $440.67 $284.24 $240.00 $583.70 $589.60 $394.92 $484.25 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200413 EAP CPT® 88305 Neurofibroma/neuroma BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $435.94 $435.94 $49.62 $140.98 $583.70 $589.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200414 EAP CPT® 88305 Osteochondroma (exostosis) BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $435.94 $435.94 $49.62 $140.98 $583.70 $589.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200415 EAP CPT® 88307 Pericardium Resection BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $435.94 $435.94 $284.24 $240.00 $583.70 $589.60 $394.92 $0.00 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200416 EAP CPT® 88307 Peritoneum Resection BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $435.94 $435.94 $284.24 $240.00 $583.70 $589.60 $394.92 $0.00 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200417 EAP CPT® 88309 Pleura Resection - For Tumor BOTH IP/OP $745.00 $551.30 $164.53 $737.00 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $440.67 $440.67 $630.05 $328.48 $583.70 $589.60 $737.00 $484.25 $737.00 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200418 EAP CPT® 88307 Retroperitoneal Mass BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $435.94 $435.94 $284.24 $240.00 $583.70 $589.60 $394.92 $0.00 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200419 EAP CPT® 88305 Rib Marrow Squeeze BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $435.94 $435.94 $49.62 $140.98 $583.70 $589.60 $68.93 $0.00 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200420 EAP CPT® 88305 Scar - Keloid BOTH IP/OP $745.00 $551.30 $31.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $440.67 $440.67 $49.62 $140.98 $583.70 $589.60 $68.93 $484.25 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200421 EAP CPT® 88304 Scar - Skin (simple/cicatrix) BOTH IP/OP $745.00 $551.30 $18.49 $589.60 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $440.67 $440.67 $49.62 $108.12 $583.70 $589.60 $68.93 $429.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200422 EAP CPT® 88305 Scar - Skin (tumor Excision/re-excision BOTH IP/OP $745.00 $551.30 $31.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $440.67 $440.67 $49.62 $140.98 $583.70 $589.60 $68.93 $484.25 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200423 EAP CPT® 88302 Sinus Contents BOTH IP/OP "$1,012.00 " $748.88 $14.11 $800.80 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $598.60 $598.60 $23.06 $87.44 $792.79 $800.80 $32.04 $291.20 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200424 EAP CPT® 88305 Sinus Mucosa Stripping BOTH IP/OP "$1,001.00 " $740.74 $31.00 $800.80 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $592.09 $592.09 $49.62 $140.98 $792.79 $800.80 $68.93 $521.30 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200425 EAP CPT® 88305 Surgical Margin Uncomplicated Exam BOTH IP/OP "$1,012.00 " $748.88 $31.00 $800.80 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $598.60 $598.60 $49.62 $140.98 $792.79 $800.80 $68.93 $657.80 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200426 EAP CPT® 88305 Thyroid Biopsy BOTH IP/OP "$1,012.00 " $748.88 $31.00 $800.80 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $598.60 $598.60 $49.62 $140.98 $792.79 $800.80 $68.93 $521.30 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200427 EAP CPT® 88304 Turbinates (nasal Conchae) BOTH IP/OP "$1,012.00 " $748.88 $18.49 $800.80 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $598.60 $598.60 $49.62 $108.12 $792.79 $800.80 $68.93 $429.00 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200428 EAP CPT® 88302 Uvula Simple Excision BOTH IP/OP "$1,012.00 " $748.88 $14.11 $800.80 $47.04 $47.04 $24.06 $24.06 $24.19 $14.11 $43.98 $43.98 $45.67 $23.64 $41.19 $15.37 $598.60 $598.60 $23.06 $87.44 $792.79 $800.80 $32.04 $291.20 $32.04 $43.89 $24.13 $24.13 $30.72 $21.96 $0.00 $0.00 $0.00 $0.00 31200429 EAP CPT® 88305 Vein Biopsy/segment BOTH IP/OP "$1,012.00 " $748.88 $31.00 $800.80 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $598.60 $598.60 $49.62 $140.98 $792.79 $800.80 $68.93 $521.30 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200450 EAP CPT® 88342 "P40 Protein, Ihc" BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200455 EAP CPT® 88309 "Teratoma , Extensive Resection" BOTH IP/OP "$1,001.00 " $740.74 $0.00 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $592.09 $592.09 $630.05 $328.48 $792.79 $800.80 $875.37 $0.00 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200456 EAP CPT® 88342 "Napsin-a,ihc" BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200457 EAP CPT® 88304 "Appendix, Non-incidental" BOTH IP/OP $474.00 $350.76 $18.49 $375.20 $62.70 $62.70 $48.39 $48.39 $48.66 $18.49 $53.11 $53.11 $55.16 $47.69 $35.46 $31.00 $280.37 $280.37 $49.62 $108.12 $371.45 $375.20 $68.93 $308.10 $68.93 $37.78 $29.89 $29.89 $26.45 $47.25 $0.00 $0.00 $0.00 $0.00 31200458 EAP CPT® 88307 Sentinel Lymph Node(s) BOTH IP/OP $745.00 $551.30 $116.80 $589.60 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $440.67 $440.67 $284.24 $240.00 $583.70 $589.60 $394.92 $484.25 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200459 EAP CPT® 88305 Needle Core Biopsy BOTH IP/OP $745.00 $551.30 $31.00 $589.60 $104.86 $104.86 $48.39 $48.39 $48.66 $31.63 $70.10 $70.10 $72.79 $47.69 $77.40 $31.00 $440.67 $440.67 $49.62 $140.98 $583.70 $589.60 $68.93 $484.25 $68.93 $82.47 $32.05 $32.05 $57.73 $47.25 $0.00 $0.00 $0.00 $0.00 31200460 EAP CPT® 88300 "Tissue, Gross Only" BOTH IP/OP $266.00 $196.84 $7.30 $210.40 $24.87 $24.87 $24.06 $24.06 $24.19 $7.30 $19.71 $19.71 $20.47 $23.64 $16.80 $15.37 $157.34 $157.34 $23.06 $38.76 $208.30 $210.40 $32.04 $172.90 $32.04 $17.90 $11.16 $11.16 $12.53 $21.96 $0.00 $0.00 $0.00 $0.00 31200461 EAP CPT® 88329 Intra-operative Pathology Consult BOTH IP/OP $298.00 $220.52 $0.00 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.74 $34.74 $36.07 $0.00 $43.31 $0.00 $0.00 $0.00 $0.00 $101.94 $236.02 $238.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31200462 EAP CPT® 88331 First Tissue Block W Fs (single Spec) BOTH IP/OP $581.00 $429.94 $30.54 $426.40 $148.63 $148.63 $145.24 $145.24 $146.06 $44.60 $30.54 $30.54 $31.72 $142.96 $87.82 $92.92 $343.66 $343.66 $143.92 $57.46 $422.14 $426.40 $199.96 $377.65 $199.96 $93.58 $34.94 $34.94 $65.50 $137.07 $0.00 $0.00 $0.00 $0.00 31200463 EAP CPT® 88332 Each Add Tissue Block W Frozen Section(s) BOTH IP/OP $280.00 $207.20 $0.00 $205.60 $80.52 $80.52 $0.00 $0.00 $0.00 $24.49 $10.90 $10.90 $11.32 $0.00 $44.09 $0.00 $165.62 $165.62 $0.00 $20.46 $203.54 $205.60 $0.00 $182.00 $0.00 $46.98 $23.05 $23.05 $32.88 $0.00 $0.00 $0.00 $0.00 $0.00 31200464 EAP CPT® 88360 ER/PR QUANTITIATIVE IHC BOTH IP/OP "$1,001.00 " $740.74 $58.38 $796.00 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $592.09 $592.09 $143.92 $121.34 $788.04 $796.00 $199.96 $650.65 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31200466 EAP CPT® 88342 "Human Herpesvirus , Type 8(hhv-8)" BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $301.67 $301.67 $143.92 $106.46 $403.92 $408.00 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200467 EAP CPT® 88342 "Neuron Specific Enolase (nse), Ihc" BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200468 EAP CPT® 88342 "Cd20, L26, Ihc" BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200469 EAP CPT® 88307 Salivary Gland BOTH IP/OP $774.00 $572.76 $0.00 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $457.82 $457.82 $284.24 $240.00 $613.01 $619.20 $394.92 $0.00 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200470 EAP CPT® 88307 "Urinary Bladder, Tur" BOTH IP/OP $782.00 $578.68 $116.80 $619.20 $406.48 $406.48 $283.63 $283.63 $285.22 $123.09 $135.39 $135.39 $140.59 $279.15 $156.60 $181.45 $462.55 $462.55 $284.24 $240.00 $613.01 $619.20 $394.92 $508.30 $394.92 $166.86 $194.49 $194.49 $116.80 $270.71 $0.00 $0.00 $0.00 $0.00 31200471 EAP CPT® 88333 Intraoperative Cytologic Examination (touch Prep) Initial Site BOTH IP/OP $654.00 $483.96 $0.00 $641.78 $143.77 $143.77 $638.19 $638.19 $641.78 $41.03 $32.82 $32.82 $34.08 $628.87 $88.68 $408.76 $386.84 $386.84 $0.00 $57.46 $475.20 $480.00 $0.00 $425.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31200472 EAP CPT® 88334 Intraoperative Cytologic Examination (touch Prep) Add Site BOTH IP/OP $280.00 $207.20 $0.00 $205.60 $0.00 $0.00 $0.00 $0.00 $0.00 $25.62 $20.02 $20.02 $20.79 $0.00 $46.34 $0.00 $165.62 $165.62 $0.00 $34.52 $203.54 $205.60 $0.00 $182.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31200473 EAP CPT® 88341 Ihc Stain - Additional BOTH IP/OP $766.00 $566.84 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $453.09 $453.09 $0.00 $386.50 $612.22 $618.40 $0.00 $497.90 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200474 EAP CPT® 88341 *stain: Melan A (mart-1) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200475 EAP CPT® 88341 *stain: P10 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200476 EAP CPT® 88341 *stain: P63 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200477 EAP CPT® 88341 *stain: Treponema BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200478 EAP CPT® 88341 *stain: Wt-1 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200479 EAP CPT® 88341 *stain: Pin Cocktail(p63=p504s) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200480 EAP CPT® 88341 *stain: Sma(smooth Muscle Actin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200481 EAP CPT® 88341 Stain: Cd56 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200482 EAP CPT® 88341 Stain: Cd99 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200483 EAP CPT® 88341 Stain: Glypican-3 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200484 EAP CPT® 88341 Stain: Moc-1 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200485 EAP CPT® 88341 Immunohisto Chemistry BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200486 EAP CPT® 88341 Ihc Marker (stain Only) (so) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200487 EAP CPT® 88341 Ercc1 Ihc With Interp (so) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200488 EAP CPT® 88341 "P40 Protein, Ihc" BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200489 EAP CPT® 88341 "Napsin-a,ihc" BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200490 EAP CPT® 88341 "Neuron Specific Enolase (nse), Ihc" BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200491 EAP CPT® 88341 "Cd20, L26, Ihc" BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200492 EAP CPT® 88341 Placental Lactogen BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200493 EAP CPT® 88341 Prolactin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200494 EAP CPT® 88341 Prostate Acid Phos BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200495 EAP CPT® 88341 Prostate Spec Ag BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200496 EAP CPT® 88341 S-100 Neural Ag BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200497 EAP CPT® 88341 Serotonin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200498 EAP CPT® 88341 Synatophysin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200499 EAP CPT® 88341 Thyroglobulin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200500 EAP CPT® 88341 Uchl-1 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200501 EAP CPT® 88341 Vimentin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200502 EAP CPT® 88341 Em:kappa BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200503 EAP CPT® 88341 Em:lambda BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200504 EAP CPT® 88341 *stain: Ber Ep4 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200505 EAP CPT® 88341 *stain: Cd117 (c-kit) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200506 EAP CPT® 88341 *stain: Cdx2 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200507 EAP CPT® 88341 *stain: Cdx2 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200508 EAP CPT® 88341 *stain: Cea (monoclonal) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200509 EAP CPT® 88341 *stain: Cyclin D1 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200510 EAP CPT® 88341 *stain: Cyclin D1 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200511 EAP CPT® 88341 *stain: Cytokeratin 19 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200512 EAP CPT® 88341 *stain: Cytokeratin 5 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200513 EAP CPT® 88341 *stain: Cytokeratin 5/6 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200514 EAP CPT® 88341 *stain: Cytokeratin 6 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200515 EAP CPT® 88341 *stain: E-cadherin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200516 EAP CPT® 88341 *stain: Egfr BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200517 EAP CPT® 88341 *stain: Galectin-3 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200518 EAP CPT® 88341 *stain: Gcdfp-15 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200519 EAP CPT® 88341 *stain: Hbme-1 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200520 EAP CPT® 88341 *stain: Helicobacter Pylori BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200521 EAP CPT® 88341 *stain: Hhv-8 (human Herpes-8) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200522 EAP CPT® 88341 *stain: Cd79 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200523 EAP CPT® 88341 *stain: Cytokeratin 7 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200524 EAP CPT® 88341 *stain: Hepatocyte BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200525 EAP CPT® 88341 *stain: Hi Mol Wt Keratin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200526 EAP CPT® 88341 *stain: Inhibin Alpha BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200527 EAP CPT® 88341 *stain: Myeloperoxidase BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200528 EAP CPT® 88341 *stain: P16 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200529 EAP CPT® 88341 *stain: P53 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200530 EAP CPT® 88341 *stain: Tdt BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200531 EAP CPT® 88341 *stain: Ttf-1 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200532 EAP CPT® 88341 *stain: Villin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200533 EAP CPT® 88341 Immunoperoxidase BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200534 EAP CPT® 88341 Glial Fibrillary Ap BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200535 EAP CPT® 88341 Glucagon BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200536 EAP CPT® 88341 Hepatitis B Core BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200537 EAP CPT® 88341 Hepatitis B Surface BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200538 EAP CPT® 88341 Herpes Simplex Prob BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200539 EAP CPT® 88341 Human Chorionic Gon BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200540 EAP CPT® 88341 Human Growth Hormon BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200541 EAP CPT® 88341 Insulin BOTH IP/OP $766.00 $566.84 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $453.09 $453.09 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200542 EAP CPT® 88341 Kappa BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200543 EAP CPT® 88341 L-26 B Cell Marker BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200544 EAP CPT® 88341 Lambda BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200545 EAP CPT® 88341 Leu M1 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200546 EAP CPT® 88341 Leukocyte Common Ag BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200547 EAP CPT® 88341 Leuteinizing Hormon BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200548 EAP CPT® 88341 Macrophage-ham-56 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200549 EAP CPT® 88341 Melanoma-hmb-45 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200550 EAP CPT® 88341 Neuron Spec Enolase BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200551 EAP CPT® 88341 Placental Alk Phos BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200552 EAP CPT® 88341 A-1 Antitrypsin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200553 EAP CPT® 88341 "Actin,muscle Spec." BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200554 EAP CPT® 88341 Alpha-fetoprotein BOTH IP/OP $586.00 $433.64 $0.00 $468.80 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $346.62 $346.62 $0.00 $293.00 $464.11 $468.80 $0.00 $0.00 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200555 EAP CPT® 88341 B72.3-breast BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200556 EAP CPT® 88341 Ca 125-ovarian Ca BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200557 EAP CPT® 88341 Ca-19-9-carbohydrat BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200558 EAP CPT® 88341 Calcitonin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200559 EAP CPT® 88341 Cea-p BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200560 EAP CPT® 88341 Chromogranin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200561 EAP CPT® 88341 Cytokeratin-ae1/ae3 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200562 EAP CPT® 88341 Cytokeratin-cam5.2 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200563 EAP CPT® 88341 Cytomegalovirus BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200564 EAP CPT® 88341 Desmin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200565 EAP CPT® 88341 Ema BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200566 EAP CPT® 88341 Factor Viii BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200567 EAP CPT® 88341 *stain:oncoprotein (bcl2) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200568 EAP CPT® 88341 *stain: Cd30/ber H2 (ki-1) BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200569 EAP CPT® 88341 *stain: B-1 Glyco BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200570 EAP CPT® 88341 *stain: Calponin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200571 EAP CPT® 88341 *stain: Calretinin BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200572 EAP CPT® 88341 *stain: A-1 Antichymotryps BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200573 EAP CPT® 88341 *stain: Cytokeratin 20 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200574 EAP CPT® 88341 *stain: Cd10 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200575 EAP CPT® 88341 *stain: Cd138 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200576 EAP CPT® 88341 *stain: Cd23 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200577 EAP CPT® 88341 *stain: Cd3 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200578 EAP CPT® 88341 *stain: Cd31 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200579 EAP CPT® 88341 *stain: Cd34 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200580 EAP CPT® 88341 *stain: Cd43 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200581 EAP CPT® 88341 *stain: Cd5 BOTH IP/OP $773.00 $572.02 $0.00 $618.40 $138.92 $138.92 $0.00 $0.00 $0.00 $42.49 $70.50 $70.50 $73.21 $0.00 $67.41 $0.00 $457.23 $457.23 $0.00 $386.50 $612.22 $618.40 $0.00 $389.35 $0.00 $71.83 $64.47 $64.47 $50.28 $0.00 $0.00 $0.00 $0.00 $0.00 31200582 EAP CPT® 88342 Stain:cd45(lca) BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $324.73 $324.73 $143.92 $106.46 $434.81 $439.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200583 EAP CPT® 88342 Stain:cd15 BOTH IP/OP $369.00 $273.06 $0.00 $295.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $218.26 $218.26 $143.92 $106.46 $292.25 $295.20 $199.96 $0.00 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31200584 EAP CPT® 88360 Er/pr Paraffin (so) BOTH IP/OP $526.00 $389.24 $58.38 $418.40 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $311.13 $311.13 $143.92 $121.34 $414.22 $418.40 $199.96 $341.90 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31200585 EAP CPT® 88360 Her2 Ihc W/interpret (so) BOTH IP/OP $430.00 $318.20 $58.38 $341.60 $214.05 $214.05 $145.24 $145.24 $146.06 $58.38 $68.33 $68.33 $70.96 $142.96 $114.71 $92.92 $254.35 $254.35 $143.92 $121.34 $338.18 $341.60 $199.96 $279.50 $199.96 $122.23 $83.20 $83.20 $85.56 $137.07 $0.00 $0.00 $0.00 $0.00 31200586 EAP CPT® 88309 Surg Path Fetus And Placenta BOTH IP/OP "$1,062.00 " $785.88 $164.53 $875.37 $623.22 $623.22 $638.19 $638.19 $641.78 $186.99 $185.59 $185.59 $192.73 $628.87 $220.59 $408.76 $628.17 $628.17 $630.05 $328.48 $832.39 $840.80 $875.37 $690.30 $875.37 $235.05 $274.45 $274.45 $164.53 $600.04 $0.00 $0.00 $0.00 $0.00 31200600 EAP CPT® 88342 Ihc Stain - First BOTH IP/OP $544.00 $402.56 $48.82 $439.20 $163.26 $163.26 $145.24 $145.24 $146.06 $48.82 $59.96 $59.96 $62.26 $142.96 $84.08 $92.92 $321.78 $321.78 $143.92 $106.46 $434.81 $439.20 $199.96 $353.60 $199.96 $89.59 $70.23 $70.23 $62.72 $137.07 $0.00 $0.00 $0.00 $0.00 31900001 EAP CPT® 88348 Em Processing Only BOTH IP/OP "$3,624.00 " "$2,681.76" $0.00 "$3,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.71 $572.71 $594.73 $0.00 $328.30 $0.00 $0.00 $0.00 $0.00 $906.38 "$3,042.07" "$3,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31900002 EAP CPT® 88348 Em: Non Kidney BOTH IP/OP "$3,624.00 " "$2,681.76" $0.00 "$3,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.71 $572.71 $594.73 $0.00 $328.30 $0.00 $0.00 $0.00 $0.00 $906.38 "$3,042.07" "$3,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31900003 EAP CPT® 88348 Em:kidney BOTH IP/OP "$3,624.00 " "$2,681.76" $0.00 "$3,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.71 $572.71 $594.73 $0.00 $328.30 $0.00 $0.00 $0.00 $0.00 $906.38 "$3,042.07" "$3,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31900004 EAP CPT® 81229 Chromosomal Microarray Postnatal (so) BOTH IP/OP "$1,401.00 " "$1,036.74" $0.00 "$2,903.98" $807.84 $807.84 "$1,160.00" "$1,160.00" $580.00 $0.00 "$1,039.82" "$1,039.82" "$1,079.89" $0.00 "$1,401.00" $0.00 $0.00 $0.00 "$1,218.00" $692.00 "$1,096.13" "$1,107.20" "$1,384.00" "$1,914.00" "$1,384.00" "$2,903.98" "$1,160.00" "$1,160.00" "$2,032.79" "$1,160.00" $0.00 $0.00 $0.00 $0.00 31900005 EAP CPT® 81263 Cll-igvh Mutation Status (so) BOTH IP/OP "$1,310.00 " $969.40 $86.22 "$1,035.20" $607.94 $607.94 $294.52 $294.52 $147.26 $147.26 $417.86 $417.86 $433.93 $294.52 $115.59 $191.44 $774.87 $774.87 $309.25 $647.00 "$1,024.85" "$1,035.20" $427.05 $485.96 $427.05 $123.17 $294.52 $294.52 $86.22 $294.52 $0.00 $0.00 $0.00 $0.00 31900007 EAP CPT® 81301 Microsatelite Instability (msi) (so) BOTH IP/OP "$1,565.00 " "$1,158.10" $0.00 "$1,236.80" $597.70 $597.70 $348.56 $348.56 $174.28 $0.00 $410.84 $410.84 $426.64 $0.00 $220.85 $0.00 $0.00 $0.00 $0.00 $773.00 "$1,224.43" "$1,236.80" $0.00 $575.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31900009 EAP CPT® 81206 P210 Bcr-abl1 (so) BOTH IP/OP $630.00 $466.20 $81.98 $497.60 $338.45 $338.45 $163.96 $163.96 $81.98 $81.98 $232.64 $232.64 $241.59 $163.96 $115.59 $106.57 $372.65 $372.65 $172.16 $311.00 $492.62 $497.60 $237.74 $270.53 $237.74 $123.17 $163.96 $163.96 $86.22 $163.96 $0.00 $0.00 $0.00 $0.00 31900011 EAP CPT® 81235 Egfr Mutation Analysis (so) BOTH IP/OP "$1,354.00 " "$1,001.96" $0.00 "$1,354.00" $0.00 $0.00 $0.00 $0.00 $0.00 $146.06 $343.21 $343.21 $356.41 $324.58 $115.59 $210.98 $800.89 $800.89 $340.81 $669.00 "$1,059.70" "$1,070.40" $470.64 "$1,354.00" $470.64 $123.17 $324.58 $324.58 $86.22 $324.58 $0.00 $0.00 $0.00 $0.00 31900013 EAP Custom 31900013 Bcr-abl1 Gene Rear Quant Pcr (so) BOTH IP/OP $630.00 $466.20 $0.00 $497.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $467.59 $467.59 $485.60 $0.00 $131.29 $0.00 $0.00 $0.00 $0.00 $311.00 $492.62 $497.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31900014 EAP CPT® 81207 P190 Bcr-abl1 (so) BOTH IP/OP $556.00 $411.44 $72.42 $439.20 $298.98 $298.98 $144.84 $144.84 $72.42 $72.42 $205.49 $205.49 $213.40 $144.84 $115.59 $94.15 $328.87 $328.87 $152.08 $274.50 $434.81 $439.20 $210.02 $238.99 $210.02 $123.17 $144.84 $144.84 $86.22 $144.84 $0.00 $0.00 $0.00 $0.00 31900015 EAP CPT® 88271 "Fish Dna Probe, Each (so)" BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $328.28 $328.28 $22.49 $59.86 $439.56 $444.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31900016 EAP CPT® 88275 Interphase In Situ Hybridization (so) BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $328.28 $328.28 $53.75 $112.22 $439.56 $444.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31900017 EAP CPT® 88271 "Fish Dna Probe, Each (so)" BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $328.28 $328.28 $22.49 $59.86 $439.56 $444.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31900018 EAP CPT® 88275 Interphase In Situ Hybridization (so) BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $328.28 $328.28 $53.75 $112.22 $439.56 $444.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31900019 EAP CPT® 88271 "Fish Dna Probe, Each (so)" BOTH IP/OP $411.00 $304.14 $0.00 $328.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $243.11 $243.11 $22.49 $59.86 $325.51 $328.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31900020 EAP CPT® 88275 Interphase In Situ Hybridization (so) BOTH IP/OP $411.00 $304.14 $0.00 $328.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $243.11 $243.11 $53.75 $112.22 $325.51 $328.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31900021 EAP CPT® 88271 "Fish Dna Probe, Each (so)" BOTH IP/OP $411.00 $304.14 $0.00 $328.80 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $243.11 $243.11 $22.49 $59.86 $325.51 $328.80 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31900022 EAP CPT® 88275 Interphase In Situ Hybridization (so) BOTH IP/OP $411.00 $304.14 $0.00 $328.80 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $243.11 $243.11 $53.75 $112.22 $325.51 $328.80 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31900023 EAP CPT® 88271 "Fish Dna Probe, Each (so)" BOTH IP/OP "$1,105.00 " $817.70 $10.71 $878.40 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $653.61 $653.61 $22.49 $59.86 $869.62 $878.40 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31900024 EAP CPT® 88275 Interphase In Situ Hybridization (so) BOTH IP/OP "$1,105.00 " $817.70 $23.04 $878.40 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $653.61 $653.61 $53.75 $112.22 $869.62 $878.40 $74.23 $84.46 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31900025 EAP CPT® 88271 "Fish, Dna Probe Each (so)" BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $328.28 $328.28 $22.49 $59.86 $439.56 $444.00 $31.06 $0.00 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31900026 EAP CPT® 88275 Interphase In Situ Hybridization (so) BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $328.28 $328.28 $53.75 $112.22 $439.56 $444.00 $74.23 $0.00 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31900027 EAP CPT® 88271 "Fish, Dna Probe Each (so)" BOTH IP/OP $690.00 $510.60 $10.71 $552.00 $44.22 $44.22 $21.42 $21.42 $10.71 $10.71 $32.52 $32.52 $33.77 $21.42 $31.65 $13.92 $408.14 $408.14 $22.49 $59.86 $546.48 $552.00 $31.06 $35.34 $31.06 $33.72 $21.42 $21.42 $23.60 $21.42 $0.00 $0.00 $0.00 $0.00 31900028 EAP CPT® 88275 Interphase In Situ Hybridization (so) BOTH IP/OP $690.00 $510.60 $23.04 $552.00 $82.90 $82.90 $51.19 $51.19 $25.60 $23.04 $60.99 $60.99 $63.33 $51.19 $59.33 $33.27 $408.14 $408.14 $53.75 $112.22 $546.48 $552.00 $74.23 $84.46 $74.23 $63.21 $51.19 $51.19 $44.25 $51.19 $0.00 $0.00 $0.00 $0.00 31900030 EAP CPT® 81404 Pancreatitis Press (so) BOTH IP/OP "$1,757.00 " "$1,300.18" $123.67 "$1,388.80" $462.00 $462.00 $274.83 $274.83 $137.42 $123.67 "$1,304.05" "$1,304.05" "$1,354.30" $274.83 $286.64 $178.64 "$1,039.27" "$1,039.27" $288.57 $868.00 "$1,374.91" "$1,388.80" $398.50 $453.47 $398.50 $305.42 $274.83 $274.83 $213.79 $274.83 $0.00 $0.00 $0.00 $0.00 31900031 EAP CPT® 81404 Pancreatitis Spink-1 (so) BOTH IP/OP "$1,757.00 " "$1,300.18" $123.67 "$1,388.80" $462.00 $462.00 $274.83 $274.83 $137.42 $123.67 "$1,304.05" "$1,304.05" "$1,354.30" $274.83 $286.64 $178.64 "$1,039.27" "$1,039.27" $288.57 $868.00 "$1,374.91" "$1,388.80" $398.50 $453.47 $398.50 $305.42 $274.83 $274.83 $213.79 $274.83 $0.00 $0.00 $0.00 $0.00 31900032 EAP CPT® 81479 Pancreatitis Ctrc (so) BOTH IP/OP $906.00 $670.44 $0.00 "$1,114.12" $0.00 $0.00 $0.00 $0.00 $161.27 $188.83 $672.43 $672.43 $698.34 $0.00 $906.00 $0.00 $535.90 $535.90 $0.00 $447.50 $708.84 $716.00 $537.00 $588.90 $537.00 "$1,114.12" $0.00 $0.00 $779.89 $0.00 $0.00 $0.00 $0.00 $0.00 32000001 EAP CPT® 77085 "Dual-energy X-ray Absorptiometry(dxa),bone Density Study" BOTH IP/OP $668.00 $494.32 $0.00 $534.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.50 $102.50 $106.44 $0.00 $139.21 $0.00 $0.00 $0.00 $0.00 $160.32 $529.06 $534.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000003 EAP CPT® 70015 Cisternography BOTH IP/OP "$1,032.00 " $763.68 $0.00 $825.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.20 $200.20 $207.90 $0.00 $215.07 $0.00 $0.00 $0.00 $0.00 $247.68 $817.34 $825.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000005 EAP CPT® 70100 MANDIBLE 1-3 VIEW RDG BOTH IP/OP $259.00 $191.66 $0.00 $259.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.98 $52.31 $52.31 $54.32 $77.54 $53.98 $50.40 $153.20 $153.20 $0.00 $62.88 $207.50 $209.60 $0.00 $259.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000007 EAP CPT® 70110 MANDIBLE COMPL 4+ VIEW RDG BOTH IP/OP $303.00 $224.22 $0.00 $244.80 $86.25 $86.25 $106.02 $106.02 $106.62 $0.00 $65.61 $65.61 $68.14 $0.00 $63.15 $0.00 $0.00 $0.00 $112.41 $73.44 $242.35 $244.80 $156.18 $169.61 $156.18 $36.22 $29.89 $29.89 $48.72 $107.06 $0.00 $0.00 $0.00 $0.00 32000013 EAP CPT® 70160 NASAL BONES COMPL 3+VIEW RDG BOTH IP/OP $455.00 $336.70 $0.00 $455.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.83 $56.86 $56.86 $59.04 $77.54 $94.82 $50.40 $269.13 $269.13 $0.00 $110.40 $364.32 $368.00 $0.00 $455.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000020 EAP CPT® 70250 SKULL 1-3VIEW W/WO STEREO RDG BOTH IP/OP $799.00 $591.26 $25.57 $645.60 $82.24 $82.24 $106.02 $106.02 $106.62 $166.53 $59.27 $59.27 $61.55 $104.44 $166.51 $67.89 $472.61 $472.61 $112.41 $193.68 $639.14 $645.60 $156.18 $169.61 $156.18 $35.86 $25.57 $25.57 $128.47 $107.06 $0.00 $0.00 $0.00 $0.00 32000022 EAP CPT® 70300 Periapical X-ray BOTH IP/OP $307.00 $227.18 $0.00 $296.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.47 $21.47 $22.29 $0.00 $63.98 $0.00 $0.00 $0.00 $0.00 $89.04 $293.83 $296.80 $0.00 $235.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000023 EAP CPT® 70320 X-ray Complete BOTH IP/OP $430.00 $318.20 $0.00 $416.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.04 $89.04 $92.47 $0.00 $89.61 $0.00 $0.00 $0.00 $0.00 $124.80 $411.84 $416.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000024 EAP CPT® 70355 X-ray Panorex BOTH IP/OP $572.00 $423.28 $8.64 $416.00 $47.57 $47.57 $78.77 $78.77 $79.21 $119.22 $31.14 $31.14 $32.34 $77.54 $119.20 $50.40 $338.34 $338.34 $80.04 $124.80 $411.84 $416.00 $111.21 $137.87 $111.21 $31.96 $8.64 $8.64 $82.78 $76.23 $0.00 $0.00 $0.00 $0.00 32000026 EAP CPT® 70328 TMJ UNILAT OPEN & CLOSED RDG BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.51 $50.51 $52.46 $0.00 $52.52 $0.00 $0.00 $0.00 $0.00 $60.48 $199.58 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000028 EAP CPT® 70330 TMJ BILAT OPEN & CLOSED RDG BOTH IP/OP $660.00 $488.40 $0.00 $533.60 $109.64 $109.64 $78.77 $78.77 $79.21 $137.56 $85.43 $85.43 $88.71 $77.54 $137.54 $50.40 $390.39 $390.39 $0.00 $160.08 $528.26 $533.60 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000031 EAP CPT® 70360 NECK SOFT TISSUE RDG BOTH IP/OP $746.00 $552.04 $21.61 $544.80 $63.70 $63.70 $78.77 $78.77 $79.21 $155.49 $45.06 $45.06 $46.80 $77.54 $155.47 $50.40 $441.26 $441.26 $80.04 $163.44 $539.35 $544.80 $111.21 $137.87 $111.21 $24.86 $21.61 $21.61 $108.42 $76.23 $0.00 $0.00 $0.00 $0.00 32000033 EAP CPT® 70370 Pharyn/larynx Fluo &/magn Rdg BOTH IP/OP "$1,216.00 " $899.84 $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.21 $143.21 $148.72 $0.00 $253.41 $0.00 $0.00 $0.00 $0.00 $326.40 "$1,077.12" "$1,088.00" $0.00 $814.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000035 EAP CPT® 70390 SIALOGRAPHY S&I RDG BOTH IP/OP "$2,072.00 " "$1,533.28" $0.00 "$1,853.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.01 $197.01 $204.58 $0.00 $431.80 $0.00 $0.00 $0.00 $0.00 $556.08 "$1,835.06" "$1,853.60" $0.00 $707.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000051 EAP CPT® 71046 Employee Health 2 View Chest BOTH IP/OP $653.00 $483.22 $0.00 $532.00 $69.46 $69.46 $78.77 $78.77 $79.21 $136.10 $49.06 $49.06 $50.94 $77.54 $136.09 $50.40 $386.25 $386.25 $80.04 $159.60 $526.68 $532.00 $111.21 $0.00 $111.21 $29.30 $21.97 $21.97 $105.87 $76.23 $0.00 $0.00 $0.00 $0.00 32000058 EAP CPT® 71110 RIBS BILAT X-RAY 3VIEW RDG BOTH IP/OP $750.00 $555.00 $28.45 $579.20 $85.46 $85.46 $106.02 $106.02 $106.62 $156.32 $67.28 $67.28 $69.87 $104.44 $156.30 $67.89 $443.63 $443.63 $112.41 $173.76 $573.41 $579.20 $156.18 $169.61 $156.18 $43.70 $28.45 $28.45 $115.26 $107.06 $0.00 $0.00 $0.00 $0.00 32000060 EAP CPT® 71111 RIBS BILAT X-RAY 4+VIEW RDG BOTH IP/OP "$1,290.00 " $954.60 $35.30 $996.80 $109.64 $109.64 $106.02 $106.02 $106.62 $268.87 $88.90 $88.90 $92.32 $104.44 $268.84 $67.89 $763.04 $763.04 $112.41 $299.04 $986.83 $996.80 $156.18 $169.61 $156.18 $50.44 $35.30 $35.30 $198.36 $107.06 $0.00 $0.00 $0.00 $0.00 32000062 EAP CPT® 71120 STERNUM X-RAY 2+VIEW RDG BOTH IP/OP $508.00 $375.92 $22.69 $410.40 $66.92 $66.92 $78.77 $78.77 $79.21 $105.88 $55.63 $55.63 $57.77 $77.54 $105.87 $50.40 $300.48 $300.48 $80.04 $123.12 $406.30 $410.40 $111.21 $137.87 $111.21 $34.82 $22.69 $22.69 $81.67 $76.23 $0.00 $0.00 $0.00 $0.00 32000064 EAP CPT® 71130 STERNOCLAVICU JNTS 3+VIEW RDG BOTH IP/OP $371.00 $274.54 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.71 $64.71 $67.20 $0.00 $77.32 $0.00 $0.00 $0.00 $0.00 $90.00 $297.00 $300.00 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000065 EAP CPT® 73020 SHOULDER 1 VIEW RDG BOTH IP/OP "$1,417.00 " "$1,048.58" $13.69 "$1,036.00" $52.40 $52.40 $78.77 $78.77 $79.21 $295.34 $38.71 $38.71 $40.20 $77.54 $295.30 $50.40 $838.16 $838.16 $80.04 $310.80 "$1,025.64" "$1,036.00" $111.21 $137.87 $111.21 $25.94 $13.69 $13.69 $206.16 $76.23 $0.00 $0.00 $0.00 $0.00 32000071 EAP CPT® 72020 CERVICAL SPINE 1 VIEW RDG BOTH IP/OP "$1,075.00 " $795.50 $16.21 $793.60 $50.00 $50.00 $78.77 $78.77 $79.21 $224.06 $38.71 $38.71 $40.20 $77.54 $224.03 $50.40 $635.86 $635.86 $80.04 $238.08 $785.66 $793.60 $111.21 $137.87 $111.21 $23.80 $16.21 $16.21 $157.93 $76.23 $0.00 $0.00 $0.00 $0.00 32000073 EAP CPT® 72020 LUMBAR SPINE 1 VIEW RDG BOTH IP/OP "$1,075.00 " $795.50 $16.21 $793.60 $50.00 $50.00 $78.77 $78.77 $79.21 $224.06 $38.71 $38.71 $40.20 $77.54 $224.03 $50.40 $635.86 $635.86 $80.04 $238.08 $785.66 $793.60 $111.21 $137.87 $111.21 $23.80 $16.21 $16.21 $157.93 $76.23 $0.00 $0.00 $0.00 $0.00 32000075 EAP CPT® 72020 THORACIC SPINE 1 VIEW RDG BOTH IP/OP "$1,075.00 " $795.50 $16.21 $793.60 $50.00 $50.00 $78.77 $78.77 $79.21 $224.06 $38.71 $38.71 $40.20 $77.54 $224.03 $50.40 $635.86 $635.86 $80.04 $238.08 $785.66 $793.60 $111.21 $137.87 $111.21 $23.80 $16.21 $16.21 $157.93 $76.23 $0.00 $0.00 $0.00 $0.00 32000078 EAP CPT® 72040 Rad Exam Spine 2 Or 3 Views BOTH IP/OP "$1,040.00 " $769.60 $27.01 $768.00 $74.98 $74.98 $78.77 $78.77 $79.21 $216.76 $62.89 $62.89 $65.31 $77.54 $216.74 $50.40 $615.16 $615.16 $80.04 $230.40 $760.32 $768.00 $111.21 $137.87 $111.21 $34.09 $27.01 $27.01 $152.83 $76.23 $0.00 $0.00 $0.00 $0.00 32000080 EAP CPT® 72050 CERVICAL SPINE 4+VIEW RDG BOTH IP/OP "$1,826.00 " "$1,351.24" $37.10 "$1,348.00" $103.20 $103.20 $106.02 $106.02 $106.62 $380.58 $89.81 $89.81 $93.27 $104.44 $380.54 $67.89 "$1,080.08" "$1,080.08" $112.41 $404.40 "$1,334.52" "$1,348.00" $156.18 $169.61 $156.18 $49.72 $37.10 $37.10 $268.25 $107.06 $0.00 $0.00 $0.00 $0.00 32000081 EAP CPT® 72052 CERVICAL SPINE COMPLETE W/ FLEX/EXT RDG BOTH IP/OP "$1,837.00 " "$1,359.38" $44.66 "$1,356.80" $127.38 $127.38 $106.02 $106.02 $106.62 $382.88 $115.22 $115.22 $119.65 $104.44 $382.83 $67.89 "$1,086.59" "$1,086.59" $112.41 $407.04 "$1,343.23" "$1,356.80" $156.18 $169.61 $156.18 $61.14 $44.66 $44.66 $270.00 $107.06 $0.00 $0.00 $0.00 $0.00 32000084 EAP CPT® 72070 THORACIC SPINE 2 VIEW RDG BOTH IP/OP "$1,158.00 " $856.92 $21.61 $848.00 $77.40 $77.40 $106.02 $106.02 $106.62 $241.36 $55.63 $55.63 $57.77 $104.44 $241.33 $67.89 $684.96 $684.96 $112.41 $254.40 $839.52 $848.00 $156.18 $169.61 $156.18 $35.88 $21.61 $21.61 $168.75 $107.06 $0.00 $0.00 $0.00 $0.00 32000088 EAP CPT® 72080 THORACOLUMBAR 2VIEW RDG BOTH IP/OP "$1,173.00 " $868.02 $23.41 $858.40 $69.33 $69.33 $78.77 $78.77 $79.21 $244.48 $59.27 $59.27 $61.55 $77.54 $244.45 $50.40 $693.83 $693.83 $80.04 $257.52 $849.82 $858.40 $111.21 $137.87 $111.21 $36.61 $23.41 $23.41 $170.82 $76.23 $0.00 $0.00 $0.00 $0.00 32000092 EAP CPT® 72100 LUMBOSACRAL SPINE 2-3VIEW RDG BOTH IP/OP "$1,018.00 " $753.32 $27.01 $791.20 $79.81 $79.81 $106.02 $106.02 $106.62 $212.18 $67.44 $67.44 $70.04 $104.44 $212.15 $67.89 $602.15 $602.15 $112.41 $237.36 $783.29 $791.20 $156.18 $169.61 $156.18 $36.61 $27.01 $27.01 $157.45 $107.06 $0.00 $0.00 $0.00 $0.00 32000095 EAP CPT® 72110 LUMBOSACRAL SPINE 4+VIEW RDG BOTH IP/OP "$1,784.00 " "$1,320.16" $35.66 "$1,386.40" $111.25 $111.25 $106.02 $106.02 $106.62 $371.83 $94.35 $94.35 $97.98 $104.44 $371.79 $67.89 "$1,055.24" "$1,055.24" $112.41 $415.92 "$1,372.54" "$1,386.40" $156.18 $169.61 $156.18 $50.44 $35.66 $35.66 $275.89 $107.06 $0.00 $0.00 $0.00 $0.00 32000097 EAP CPT® 72114 Lumbosac Com + Bending 6 Views BOTH IP/OP "$1,524.00 " "$1,127.76" $44.66 "$1,184.00" $141.08 $141.08 $106.02 $106.02 $106.62 $317.64 $127.92 $127.92 $132.84 $104.44 $317.60 $67.89 $901.45 $901.45 $112.41 $355.20 "$1,172.16" "$1,184.00" $156.18 $169.61 $156.18 $63.63 $44.66 $44.66 $235.62 $107.06 $0.00 $0.00 $0.00 $0.00 32000099 EAP CPT® 72120 Lumbosac Bending 2 Or 3 Views BOTH IP/OP $763.00 $564.62 $0.00 $681.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.62 $91.62 $95.15 $0.00 $159.01 $0.00 $0.00 $0.00 $0.00 $204.48 $674.78 $681.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000109 EAP CPT® 72170 PELVIS X-RAY 1-2 VIEW RDG BOTH IP/OP $796.00 $589.04 $19.81 $579.20 $72.57 $72.57 $106.02 $106.02 $106.62 $165.91 $42.34 $42.34 $43.97 $104.44 $165.89 $67.89 $470.83 $470.83 $112.41 $173.76 $573.41 $579.20 $156.18 $169.61 $156.18 $28.43 $19.81 $19.81 $115.26 $107.06 $0.00 $0.00 $0.00 $0.00 32000111 EAP CPT® 72190 PELVIS X-RAY COMPL 3+VIEW RDG BOTH IP/OP $805.00 $595.70 $28.09 $585.60 $86.28 $86.28 $106.02 $106.02 $106.62 $167.78 $70.16 $70.16 $72.86 $104.44 $167.76 $67.89 $476.16 $476.16 $112.41 $175.68 $579.74 $585.60 $156.18 $169.61 $156.18 $36.26 $28.09 $28.09 $116.53 $107.06 $0.00 $0.00 $0.00 $0.00 32000117 EAP CPT® 72200 Sacroiliac Jnt 1-2 View Rdg BOTH IP/OP $300.00 $222.00 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.61 $49.61 $51.52 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $90.00 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000119 EAP CPT® 72202 SACROILIAC JNT 3+VIEW RDG BOTH IP/OP $317.00 $234.58 $26.65 $256.00 $74.98 $74.98 $106.02 $106.02 $106.62 $66.07 $61.97 $61.97 $64.36 $104.44 $66.06 $67.89 $187.51 $187.51 $112.41 $76.80 $253.44 $256.00 $156.18 $169.61 $156.18 $33.41 $26.65 $26.65 $50.94 $107.06 $0.00 $0.00 $0.00 $0.00 32000122 EAP CPT® 72220 SACRUM&COCCYX 2+VIEW RDG BOTH IP/OP $655.00 $484.70 $22.69 $488.00 $63.70 $63.70 $78.77 $78.77 $79.21 $136.52 $51.11 $51.11 $53.07 $77.54 $136.50 $50.40 $387.43 $387.43 $80.04 $146.40 $483.12 $488.00 $111.21 $137.87 $111.21 $30.55 $22.69 $22.69 $97.11 $76.23 $0.00 $0.00 $0.00 $0.00 32000123 EAP CPT® 72240 MYELOGRAPHY CERVICAL S&I RDG BOTH IP/OP "$1,372.00 " "$1,015.28" $0.00 "$1,372.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.28 $278.28 $288.99 $0.00 $285.92 $0.00 $0.00 $0.00 $0.00 $332.64 "$1,097.71" "$1,108.80" $0.00 "$1,372.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000124 EAP CPT® 72255 MYELOGRAPHY THORACIC S&I RDG BOTH IP/OP "$1,317.00 " $974.58 $0.00 "$1,317.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.00 $247.00 $256.50 $0.00 $274.46 $0.00 $0.00 $0.00 $0.00 $319.20 "$1,053.36" "$1,064.00" $0.00 "$1,317.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000125 EAP CPT® 72265 MYELOGRAPHY LUMBAR S&I RDG BOTH IP/OP "$1,372.00 " "$1,015.28" $0.00 "$1,372.00" $210.41 $210.41 $696.71 $696.71 $700.64 $0.00 $260.59 $260.59 $270.62 $0.00 $285.92 $0.00 $0.00 $0.00 $0.00 $332.64 "$1,097.71" "$1,108.80" $0.00 "$1,372.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000126 EAP CPT® 72270 MYELOGRAPHY COMPLETE S&I RDG BOTH IP/OP "$1,265.00 " $936.10 $0.00 "$1,265.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $401.35 $401.35 $416.78 $0.00 $263.63 $0.00 $0.00 $0.00 $693.78 $306.72 "$1,012.18" "$1,022.40" $963.92 "$1,265.00" $963.92 $298.54 $75.28 $75.28 $203.46 $660.75 $0.00 $0.00 $0.00 $0.00 32000127 EAP CPT® 72285 Diskography Cervicl/thorac Spn BOTH IP/OP "$3,367.00 " "$2,491.58" $0.00 "$2,693.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.81 $300.81 $312.38 $0.00 $701.68 $0.00 $0.00 $0.00 $0.00 $808.08 "$2,666.66" "$2,693.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000128 EAP CPT® 72295 Diskography Lumbar Spn BOTH IP/OP "$3,838.00 " "$2,840.12" $0.00 "$3,070.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.41 $290.41 $301.58 $0.00 $799.84 $0.00 $0.00 $0.00 $0.00 $921.12 "$3,039.70" "$3,070.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000129 EAP CPT® 73000 Clavicle Complete Rdg BOTH IP/OP $754.00 $557.96 $23.05 $672.00 $62.88 $62.88 $78.77 $78.77 $79.21 $157.15 $46.88 $46.88 $48.69 $77.54 $157.13 $50.40 $445.99 $445.99 $80.04 $201.60 $665.28 $672.00 $111.21 $137.87 $111.21 $27.72 $23.05 $23.05 $133.73 $76.23 $0.00 $0.00 $0.00 $0.00 32000131 EAP CPT® 73000 CLAVICLE COMPLETE LT RDG BOTH IP/OP $922.00 $682.28 $23.05 $672.00 $62.88 $62.88 $78.77 $78.77 $79.21 $192.17 $46.88 $46.88 $48.69 $77.54 $192.14 $50.40 $545.36 $545.36 $80.04 $201.60 $665.28 $672.00 $111.21 $137.87 $111.21 $27.72 $23.05 $23.05 $133.73 $76.23 $0.00 $0.00 $0.00 $0.00 32000133 EAP CPT® 73000 CLAVICLE COMPLETE RT RDG BOTH IP/OP $922.00 $682.28 $23.05 $672.00 $62.88 $62.88 $78.77 $78.77 $79.21 $192.17 $46.88 $46.88 $48.69 $77.54 $192.14 $50.40 $545.36 $545.36 $80.04 $201.60 $665.28 $672.00 $111.21 $137.87 $111.21 $27.72 $23.05 $23.05 $133.73 $76.23 $0.00 $0.00 $0.00 $0.00 32000135 EAP CPT® 73000 CLAVICLES COMPLETE BILAT RDG BOTH IP/OP "$1,513.00 " "$1,119.62" $23.05 "$1,348.80" $62.88 $62.88 $78.77 $78.77 $79.21 $315.35 $46.88 $46.88 $48.69 $77.54 $315.31 $50.40 $894.94 $894.94 $80.04 $404.64 "$1,335.31" "$1,348.80" $111.21 $137.87 $111.21 $27.72 $23.05 $23.05 $268.41 $76.23 $0.00 $0.00 $0.00 $0.00 32000137 EAP CPT® 73010 Scapula Complete Rdg BOTH IP/OP $648.00 $479.52 $18.73 $520.00 $68.53 $68.53 $106.02 $106.02 $106.62 $135.06 $47.79 $47.79 $49.63 $104.44 $135.04 $67.89 $383.29 $383.29 $112.41 $156.00 $514.80 $520.00 $156.18 $169.61 $156.18 $28.43 $18.73 $18.73 $103.48 $107.06 $0.00 $0.00 $0.00 $0.00 32000139 EAP CPT® 73010 SCAPULA COMPLETE LT RDG BOTH IP/OP $711.00 $526.14 $18.73 $520.00 $68.53 $68.53 $106.02 $106.02 $106.62 $148.19 $47.79 $47.79 $49.63 $104.44 $148.17 $67.89 $420.56 $420.56 $112.41 $156.00 $514.80 $520.00 $156.18 $169.61 $156.18 $28.43 $18.73 $18.73 $103.48 $107.06 $0.00 $0.00 $0.00 $0.00 32000141 EAP CPT® 73010 SCAPULA COMPLETE RT RDG BOTH IP/OP $711.00 $526.14 $18.73 $520.00 $68.53 $68.53 $106.02 $106.02 $106.62 $148.19 $47.79 $47.79 $49.63 $104.44 $148.17 $67.89 $420.56 $420.56 $112.41 $156.00 $514.80 $520.00 $156.18 $169.61 $156.18 $28.43 $18.73 $18.73 $103.48 $107.06 $0.00 $0.00 $0.00 $0.00 32000143 EAP CPT® 73010 SCAPULAS COMPLETE BILAT RDG BOTH IP/OP "$1,291.00 " $955.34 $18.73 "$1,036.00" $68.53 $68.53 $106.02 $106.02 $106.62 $269.08 $47.79 $47.79 $49.63 $104.44 $269.04 $67.89 $763.63 $763.63 $112.41 $310.80 "$1,025.64" "$1,036.00" $156.18 $169.61 $156.18 $28.43 $18.73 $18.73 $206.16 $107.06 $0.00 $0.00 $0.00 $0.00 32000153 EAP CPT® 73030 Shoulder 2+views Rdg BOTH IP/OP "$1,291.00 " $955.34 $23.77 "$1,036.00" $66.11 $66.11 $78.77 $78.77 $79.21 $269.08 $50.19 $50.19 $52.12 $77.54 $269.04 $50.40 $763.63 $763.63 $80.04 $310.80 "$1,025.64" "$1,036.00" $111.21 $137.87 $111.21 $30.90 $23.77 $23.77 $206.16 $76.23 $0.00 $0.00 $0.00 $0.00 32000154 EAP CPT® 73030 Shoulder Compl 2+view Exr BOTH IP/OP "$1,291.00 " $955.34 $23.77 "$1,036.00" $66.11 $66.11 $78.77 $78.77 $79.21 $269.08 $50.19 $50.19 $52.12 $77.54 $269.04 $50.40 $763.63 $763.63 $80.04 $310.80 "$1,025.64" "$1,036.00" $111.21 $137.87 $111.21 $30.90 $23.77 $23.77 $206.16 $76.23 $0.00 $0.00 $0.00 $0.00 32000156 EAP CPT® 73030 SHOULDER COMPL 2+VIEWS LT RDG BOTH IP/OP "$1,417.00 " "$1,048.58" $23.77 "$1,036.00" $66.11 $66.11 $78.77 $78.77 $79.21 $295.34 $50.19 $50.19 $52.12 $77.54 $295.30 $50.40 $838.16 $838.16 $80.04 $310.80 "$1,025.64" "$1,036.00" $111.21 $137.87 $111.21 $30.90 $23.77 $23.77 $206.16 $76.23 $0.00 $0.00 $0.00 $0.00 32000158 EAP CPT® 73030 SHOULDER COMPL 2+VIEWS RT RDG BOTH IP/OP "$1,417.00 " "$1,048.58" $23.77 "$1,036.00" $66.11 $66.11 $78.77 $78.77 $79.21 $295.34 $50.19 $50.19 $52.12 $77.54 $295.30 $50.40 $838.16 $838.16 $80.04 $310.80 "$1,025.64" "$1,036.00" $111.21 $137.87 $111.21 $30.90 $23.77 $23.77 $206.16 $76.23 $0.00 $0.00 $0.00 $0.00 32000161 EAP CPT® 73030 SHOULDERS 2+VIEW ECH BILAT RDG BOTH IP/OP "$1,430.00 " "$1,058.20" $23.77 "$1,045.60" $66.11 $66.11 $78.77 $78.77 $79.21 $298.05 $50.19 $50.19 $52.12 $77.54 $298.01 $50.40 $845.85 $845.85 $80.04 $313.68 "$1,035.14" "$1,045.60" $111.21 $137.87 $111.21 $30.90 $23.77 $23.77 $208.07 $76.23 $0.00 $0.00 $0.00 $0.00 32000163 EAP CPT® 73040 SHOULDER ARTHROGRAPHY RT RDG BOTH IP/OP "$1,335.00 " $987.90 $94.00 $976.00 $227.33 $227.33 $358.61 $358.61 $360.63 $278.25 $195.02 $195.02 $202.52 $352.81 $278.21 $229.33 $789.65 $789.65 $387.01 $292.80 $966.24 $976.00 $537.70 $584.68 $537.70 $107.06 $94.00 $94.00 $194.22 $368.58 $0.00 $0.00 $0.00 $0.00 32000164 EAP CPT® 73040 SHOULDER ARTHROGRAPHY LT RDG BOTH IP/OP "$1,335.00 " $987.90 $94.00 $976.00 $227.33 $227.33 $358.61 $358.61 $360.63 $278.25 $195.02 $195.02 $202.52 $352.81 $278.21 $229.33 $789.65 $789.65 $387.01 $292.80 $966.24 $976.00 $537.70 $584.68 $537.70 $107.06 $94.00 $94.00 $194.22 $368.58 $0.00 $0.00 $0.00 $0.00 32000165 EAP CPT® 73040 Shoulder Arthrograph Bi Rdg BOTH IP/OP "$2,432.00 " "$1,799.68" $94.00 "$1,952.00" $227.33 $227.33 $358.61 $358.61 $360.63 $506.89 $195.02 $195.02 $202.52 $352.81 $506.83 $229.33 "$1,438.53" "$1,438.53" $387.01 $585.60 "$1,932.48" "$1,952.00" $537.70 $584.68 $537.70 $107.06 $94.00 $94.00 $388.45 $368.58 $0.00 $0.00 $0.00 $0.00 32000167 EAP CPT® 73050 ACROMICLAVICULAR JNTS BI DRG BOTH IP/OP $864.00 $639.36 $0.00 $864.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.97 $61.97 $64.36 $0.00 $180.06 $0.00 $0.00 $0.00 $0.00 $209.52 $691.42 $698.40 $0.00 $864.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000169 EAP CPT® 73060 HUMERI 2+VIEW EACH BILAT RDG BOTH IP/OP "$2,462.00 " "$1,821.88" $23.05 "$1,792.00" $66.11 $66.11 $78.77 $78.77 $79.21 $513.14 $50.19 $50.19 $52.12 $77.54 $513.08 $50.40 "$1,456.27" "$1,456.27" $80.04 $537.60 "$1,774.08" "$1,792.00" $111.21 $137.87 $111.21 $30.55 $23.05 $23.05 $356.61 $76.23 $0.00 $0.00 $0.00 $0.00 32000171 EAP CPT® 73060 Humerus 2+view Rdg BOTH IP/OP "$1,122.00 " $830.28 $23.05 $897.60 $66.11 $66.11 $78.77 $78.77 $79.21 $233.85 $50.19 $50.19 $52.12 $77.54 $233.82 $50.40 $663.66 $663.66 $80.04 $269.28 $888.62 $897.60 $111.21 $137.87 $111.21 $30.55 $23.05 $23.05 $178.62 $76.23 $0.00 $0.00 $0.00 $0.00 32000173 EAP CPT® 73060 HUMERUS 2+VIEW LT RDG BOTH IP/OP "$1,233.00 " $912.42 $23.05 $897.60 $66.11 $66.11 $78.77 $78.77 $79.21 $256.99 $50.19 $50.19 $52.12 $77.54 $256.96 $50.40 $729.32 $729.32 $80.04 $269.28 $888.62 $897.60 $111.21 $137.87 $111.21 $30.55 $23.05 $23.05 $178.62 $76.23 $0.00 $0.00 $0.00 $0.00 32000175 EAP CPT® 73060 HUMERUS 2+VIEW RT RDG BOTH IP/OP "$1,233.00 " $912.42 $23.05 $897.60 $66.11 $66.11 $78.77 $78.77 $79.21 $256.99 $50.19 $50.19 $52.12 $77.54 $256.96 $50.40 $729.32 $729.32 $80.04 $269.28 $888.62 $897.60 $111.21 $137.87 $111.21 $30.55 $23.05 $23.05 $178.62 $76.23 $0.00 $0.00 $0.00 $0.00 32000177 EAP CPT® 73070 Elbow 2 View Rdg BOTH IP/OP $647.00 $478.78 $20.17 $581.60 $62.09 $62.09 $78.77 $78.77 $79.21 $134.85 $46.88 $46.88 $48.69 $77.54 $134.83 $50.40 $382.70 $382.70 $80.04 $174.48 $575.78 $581.60 $111.21 $137.87 $111.21 $27.38 $20.17 $20.17 $115.74 $76.23 $0.00 $0.00 $0.00 $0.00 32000179 EAP CPT® 73070 ELBOW 2 VIEW LT RDG BOTH IP/OP $798.00 $590.52 $20.17 $581.60 $62.09 $62.09 $78.77 $78.77 $79.21 $166.32 $46.88 $46.88 $48.69 $77.54 $166.30 $50.40 $472.02 $472.02 $80.04 $174.48 $575.78 $581.60 $111.21 $137.87 $111.21 $27.38 $20.17 $20.17 $115.74 $76.23 $0.00 $0.00 $0.00 $0.00 32000181 EAP CPT® 73070 ELBOW 2 VIEW RT RDG BOTH IP/OP $798.00 $590.52 $20.17 $581.60 $62.09 $62.09 $78.77 $78.77 $79.21 $166.32 $46.88 $46.88 $48.69 $77.54 $166.30 $50.40 $472.02 $472.02 $80.04 $174.48 $575.78 $581.60 $111.21 $137.87 $111.21 $27.38 $20.17 $20.17 $115.74 $76.23 $0.00 $0.00 $0.00 $0.00 32000183 EAP CPT® 73070 ELBOWS 2 VIEW EACH BILAT RDG BOTH IP/OP "$1,598.00 " "$1,182.52" $20.17 "$1,164.80" $62.09 $62.09 $78.77 $78.77 $79.21 $333.06 $46.88 $46.88 $48.69 $77.54 $333.02 $50.40 $945.22 $945.22 $80.04 $349.44 "$1,153.15" "$1,164.80" $111.21 $137.87 $111.21 $27.38 $20.17 $20.17 $231.80 $76.23 $0.00 $0.00 $0.00 $0.00 32000185 EAP CPT® 73080 Elbow 3+view Nwr BOTH IP/OP $689.00 $509.86 $22.33 $619.20 $70.96 $70.96 $78.77 $78.77 $79.21 $143.60 $62.89 $62.89 $65.31 $77.54 $143.59 $50.40 $407.54 $407.54 $80.04 $185.76 $613.01 $619.20 $111.21 $137.87 $111.21 $30.55 $22.33 $22.33 $123.22 $76.23 $0.00 $0.00 $0.00 $0.00 32000186 EAP CPT® 73080 Elbow Compl 3+view Rdg BOTH IP/OP $689.00 $509.86 $22.33 $619.20 $70.96 $70.96 $78.77 $78.77 $79.21 $143.60 $62.89 $62.89 $65.31 $77.54 $143.59 $50.40 $407.54 $407.54 $80.04 $185.76 $613.01 $619.20 $111.21 $137.87 $111.21 $30.55 $22.33 $22.33 $123.22 $76.23 $0.00 $0.00 $0.00 $0.00 32000188 EAP CPT® 73080 ELBOW COMPL 3+VIEW LT RDG BOTH IP/OP $850.00 $629.00 $22.33 $619.20 $70.96 $70.96 $78.77 $78.77 $79.21 $177.16 $62.89 $62.89 $65.31 $77.54 $177.14 $50.40 $502.78 $502.78 $80.04 $185.76 $613.01 $619.20 $111.21 $137.87 $111.21 $30.55 $22.33 $22.33 $123.22 $76.23 $0.00 $0.00 $0.00 $0.00 32000190 EAP CPT® 73080 ELBOW COMPL 3+VIEW RT RDG BOTH IP/OP $850.00 $629.00 $22.33 $619.20 $70.96 $70.96 $78.77 $78.77 $79.21 $177.16 $62.89 $62.89 $65.31 $77.54 $177.14 $50.40 $502.78 $502.78 $80.04 $185.76 $613.01 $619.20 $111.21 $137.87 $111.21 $30.55 $22.33 $22.33 $123.22 $76.23 $0.00 $0.00 $0.00 $0.00 32000192 EAP CPT® 73080 ELBOWS 3+VIEW EACH BILAT RDG BOTH IP/OP "$1,376.00 " "$1,018.24" $22.33 "$1,236.00" $70.96 $70.96 $78.77 $78.77 $79.21 $286.79 $62.89 $62.89 $65.31 $77.54 $286.76 $50.40 $813.90 $813.90 $80.04 $370.80 "$1,223.64" "$1,236.00" $111.21 $137.87 $111.21 $30.55 $22.33 $22.33 $245.96 $76.23 $0.00 $0.00 $0.00 $0.00 32000195 EAP CPT® 73085 ELBOW ARTHROGRAPHY RT RDG BOTH IP/OP "$2,432.00 " "$1,799.68" $0.00 "$2,184.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.52 $170.52 $177.08 $0.00 $506.83 $0.00 $0.00 $0.00 $0.00 $655.44 "$2,162.95" "$2,184.80" $0.00 $827.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000196 EAP CPT® 73085 ELBOW ARTHROGRAPHY LT RDG BOTH IP/OP "$2,432.00 " "$1,799.68" $0.00 "$2,184.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.52 $170.52 $177.08 $0.00 $506.83 $0.00 $0.00 $0.00 $0.00 $655.44 "$2,162.95" "$2,184.80" $0.00 $827.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000197 EAP CPT® 73085 Elbow Arthrography Bilat Rdg BOTH IP/OP "$4,867.00 " "$3,601.58" $0.00 "$4,372.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.52 $170.52 $177.08 $0.00 "$1,014.28" $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$4,329.07" "$4,372.80" $0.00 "$1,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000198 EAP CPT® 73090 FOREARM X-RAY 2 VIEW RDG BOTH IP/OP $739.00 $546.86 $20.53 $624.80 $58.87 $58.87 $78.77 $78.77 $79.21 $154.03 $46.88 $46.88 $48.69 $77.54 $154.01 $50.40 $437.12 $437.12 $80.04 $187.44 $618.55 $624.80 $111.21 $137.87 $111.21 $27.72 $20.53 $20.53 $124.34 $76.23 $0.00 $0.00 $0.00 $0.00 32000200 EAP CPT® 73090 FOREARM X-RAY 2 VIEW LT RDG BOTH IP/OP $859.00 $635.66 $20.53 $624.80 $58.87 $58.87 $78.77 $78.77 $79.21 $179.04 $46.88 $46.88 $48.69 $77.54 $179.02 $50.40 $508.10 $508.10 $80.04 $187.44 $618.55 $624.80 $111.21 $137.87 $111.21 $27.72 $20.53 $20.53 $124.34 $76.23 $0.00 $0.00 $0.00 $0.00 32000202 EAP CPT® 73090 FOREARM X-RAY 2 VIEW RT RDG BOTH IP/OP $859.00 $635.66 $20.53 $624.80 $58.87 $58.87 $78.77 $78.77 $79.21 $179.04 $46.88 $46.88 $48.69 $77.54 $179.02 $50.40 $508.10 $508.10 $80.04 $187.44 $618.55 $624.80 $111.21 $137.87 $111.21 $27.72 $20.53 $20.53 $124.34 $76.23 $0.00 $0.00 $0.00 $0.00 32000205 EAP CPT® 73090 FOREARMS 2 VIEW EACH BILAT RDG BOTH IP/OP "$1,721.00 " "$1,273.54" $20.53 "$1,252.00" $58.87 $58.87 $78.77 $78.77 $79.21 $358.70 $46.88 $46.88 $48.69 $77.54 $358.66 $50.40 "$1,017.97" "$1,017.97" $80.04 $375.60 "$1,239.48" "$1,252.00" $111.21 $137.87 $111.21 $27.72 $20.53 $20.53 $249.15 $76.23 $0.00 $0.00 $0.00 $0.00 32000206 EAP CPT® 73092 Upp Ext Infant 2+view Rdg BOTH IP/OP $495.00 $366.30 $0.00 $667.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.68 $48.68 $50.55 $0.00 $103.16 $0.00 $0.00 $0.00 $0.00 $125.52 $414.22 $418.40 $0.00 $667.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000207 EAP CPT® 73092 UPP EXT INFANT 2+VIEW BI RDG BOTH IP/OP $984.00 $728.16 $0.00 "$1,266.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.68 $48.68 $50.55 $0.00 $205.07 $0.00 $0.00 $0.00 $0.00 $249.60 $823.68 $832.00 $0.00 "$1,266.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000210 EAP CPT® 73092 UPP EXT INFANT 2+VIEW LT RDG BOTH IP/OP $575.00 $425.50 $0.00 $667.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.68 $48.68 $50.55 $0.00 $119.83 $0.00 $0.00 $0.00 $0.00 $125.52 $414.22 $418.40 $0.00 $667.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000212 EAP CPT® 73092 UPP EXT INFANT 2+VIEW RT RDG BOTH IP/OP $575.00 $425.50 $0.00 $667.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.68 $48.68 $50.55 $0.00 $119.83 $0.00 $0.00 $0.00 $0.00 $125.52 $414.22 $418.40 $0.00 $667.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000214 EAP CPT® 73100 Wrist 2 View Rdg BOTH IP/OP $628.00 $464.72 $24.49 $528.00 $66.11 $66.11 $78.77 $78.77 $79.21 $130.89 $48.68 $48.68 $50.55 $77.54 $130.88 $50.40 $371.46 $371.46 $80.04 $158.40 $522.72 $528.00 $111.21 $137.87 $111.21 $27.37 $24.49 $24.49 $105.07 $76.23 $0.00 $0.00 $0.00 $0.00 32000216 EAP CPT® 73100 WRIST 2 VIEW LT RDG BOTH IP/OP $725.00 $536.50 $24.49 $528.00 $66.11 $66.11 $78.77 $78.77 $79.21 $151.11 $48.68 $48.68 $50.55 $77.54 $151.09 $50.40 $428.84 $428.84 $80.04 $158.40 $522.72 $528.00 $111.21 $137.87 $111.21 $27.37 $24.49 $24.49 $105.07 $76.23 $0.00 $0.00 $0.00 $0.00 32000218 EAP CPT® 73100 WRIST 2 VIEW RT RDG BOTH IP/OP $725.00 $536.50 $24.49 $528.00 $66.11 $66.11 $78.77 $78.77 $79.21 $151.11 $48.68 $48.68 $50.55 $77.54 $151.09 $50.40 $428.84 $428.84 $80.04 $158.40 $522.72 $528.00 $111.21 $137.87 $111.21 $27.37 $24.49 $24.49 $105.07 $76.23 $0.00 $0.00 $0.00 $0.00 32000220 EAP CPT® 73100 WRISTS 2 VIEW BILAT RDG BOTH IP/OP "$1,252.00 " $926.48 $24.49 "$1,053.60" $66.11 $66.11 $78.77 $78.77 $79.21 $260.95 $48.68 $48.68 $50.55 $77.54 $260.92 $50.40 $740.56 $740.56 $80.04 $316.08 "$1,043.06" "$1,053.60" $111.21 $137.87 $111.21 $27.37 $24.49 $24.49 $209.67 $76.23 $0.00 $0.00 $0.00 $0.00 32000223 EAP CPT® 73110 WRIST 3+VIEW RDG BOTH IP/OP $675.00 $499.50 $28.79 $568.00 $80.63 $80.63 $78.77 $78.77 $79.21 $140.69 $61.39 $61.39 $63.75 $77.54 $140.67 $50.40 $399.26 $399.26 $80.04 $170.40 $562.32 $568.00 $111.21 $137.87 $111.21 $28.79 $30.25 $30.25 $113.03 $76.23 $0.00 $0.00 $0.00 $0.00 32000225 EAP CPT® 73110 WRIST 3+VIEW LT RDG BOTH IP/OP $780.00 $577.20 $28.79 $568.00 $80.63 $80.63 $78.77 $78.77 $79.21 $162.57 $61.39 $61.39 $63.75 $77.54 $162.55 $50.40 $461.37 $461.37 $80.04 $170.40 $562.32 $568.00 $111.21 $137.87 $111.21 $28.79 $30.25 $30.25 $113.03 $76.23 $0.00 $0.00 $0.00 $0.00 32000227 EAP CPT® 73110 WRIST 3+VIEW RT RDG BOTH IP/OP $780.00 $577.20 $28.79 $568.00 $80.63 $80.63 $78.77 $78.77 $79.21 $162.57 $61.39 $61.39 $63.75 $77.54 $162.55 $50.40 $461.37 $461.37 $80.04 $170.40 $562.32 $568.00 $111.21 $137.87 $111.21 $28.79 $30.25 $30.25 $113.03 $76.23 $0.00 $0.00 $0.00 $0.00 32000229 EAP CPT® 73110 WRISTS 3+VIEW EACH BILAT RDG BOTH IP/OP "$1,561.00 " "$1,155.14" $28.79 "$1,136.80" $80.63 $80.63 $78.77 $78.77 $79.21 $325.35 $61.39 $61.39 $63.75 $77.54 $325.31 $50.40 $923.33 $923.33 $80.04 $341.04 "$1,125.43" "$1,136.80" $111.21 $137.87 $111.21 $28.79 $30.25 $30.25 $226.22 $76.23 $0.00 $0.00 $0.00 $0.00 32000231 EAP CPT® 73115 Wrist Arthrography Bilat Rdg BOTH IP/OP "$4,442.00 " "$3,287.08" $0.00 "$3,736.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.57 $183.57 $190.63 $0.00 $925.71 $0.00 $0.00 $0.00 $0.00 "$1,121.04" "$3,699.43" "$3,736.80" $0.00 "$1,848.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000232 EAP CPT® 73115 WRIST ARTHROGRAPHY RT/LT RDG BOTH IP/OP "$2,563.00 " "$1,896.62" $0.00 "$1,866.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.57 $183.57 $190.63 $0.00 $534.13 $0.00 $0.00 $0.00 $0.00 $559.92 "$1,847.74" "$1,866.40" $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000233 EAP CPT® 73120 Hand 2 View Rdg BOTH IP/OP $646.00 $478.04 $21.97 $545.60 $59.66 $59.66 $106.02 $106.02 $106.62 $134.64 $45.96 $45.96 $47.73 $104.44 $134.63 $67.89 $382.11 $382.11 $112.41 $163.68 $540.14 $545.60 $156.18 $169.61 $156.18 $27.37 $21.97 $21.97 $108.57 $107.06 $0.00 $0.00 $0.00 $0.00 32000235 EAP CPT® 73120 HAND 2 VIEW LT RDG BOTH IP/OP $743.00 $549.82 $21.97 $545.60 $59.66 $59.66 $106.02 $106.02 $106.62 $154.86 $45.96 $45.96 $47.73 $104.44 $154.84 $67.89 $439.48 $439.48 $112.41 $163.68 $540.14 $545.60 $156.18 $169.61 $156.18 $27.37 $21.97 $21.97 $108.57 $107.06 $0.00 $0.00 $0.00 $0.00 32000237 EAP CPT® 73120 HAND 2 VIEW RT RDG BOTH IP/OP $743.00 $549.82 $21.97 $545.60 $59.66 $59.66 $106.02 $106.02 $106.62 $154.86 $45.96 $45.96 $47.73 $104.44 $154.84 $67.89 $439.48 $439.48 $112.41 $163.68 $540.14 $545.60 $156.18 $169.61 $156.18 $27.37 $21.97 $21.97 $108.57 $107.06 $0.00 $0.00 $0.00 $0.00 32000239 EAP CPT® 73130 HAND 3+VIEW RDG BOTH IP/OP $698.00 $516.52 $26.29 $589.60 $70.14 $70.14 $78.77 $78.77 $79.21 $145.48 $54.14 $54.14 $56.22 $77.54 $145.46 $50.40 $412.87 $412.87 $80.04 $176.88 $583.70 $589.60 $111.21 $137.87 $111.21 $28.79 $26.29 $26.29 $117.33 $76.23 $0.00 $0.00 $0.00 $0.00 32000241 EAP CPT® 73130 HAND 3+VIEW LT RDG BOTH IP/OP $802.00 $593.48 $26.29 $589.60 $70.14 $70.14 $78.77 $78.77 $79.21 $167.16 $54.14 $54.14 $56.22 $77.54 $167.14 $50.40 $474.38 $474.38 $80.04 $176.88 $583.70 $589.60 $111.21 $137.87 $111.21 $28.79 $26.29 $26.29 $117.33 $76.23 $0.00 $0.00 $0.00 $0.00 32000243 EAP CPT® 73130 HAND 3+VIEW RT RDG BOTH IP/OP $802.00 $593.48 $26.29 $589.60 $70.14 $70.14 $78.77 $78.77 $79.21 $167.16 $54.14 $54.14 $56.22 $77.54 $167.14 $50.40 $474.38 $474.38 $80.04 $176.88 $583.70 $589.60 $111.21 $137.87 $111.21 $28.79 $26.29 $26.29 $117.33 $76.23 $0.00 $0.00 $0.00 $0.00 32000244 EAP CPT® 73120 HANDS 2 VIEW EACH BILAT RDG BOTH IP/OP "$1,485.00 " "$1,098.90" $21.97 "$1,091.20" $59.66 $59.66 $106.02 $106.02 $106.62 $309.51 $45.96 $45.96 $47.73 $104.44 $309.47 $67.89 $878.38 $878.38 $112.41 $327.36 "$1,080.29" "$1,091.20" $156.18 $169.61 $156.18 $27.37 $21.97 $21.97 $217.15 $107.06 $0.00 $0.00 $0.00 $0.00 32000246 EAP CPT® 73130 HANDS 3+VIEW EACH BILAT RDG BOTH IP/OP "$1,609.00 " "$1,190.66" $26.29 "$1,182.40" $70.14 $70.14 $78.77 $78.77 $79.21 $335.36 $54.14 $54.14 $56.22 $77.54 $335.32 $50.40 $951.72 $951.72 $80.04 $354.72 "$1,170.58" "$1,182.40" $111.21 $137.87 $111.21 $28.79 $26.29 $26.29 $235.30 $76.23 $0.00 $0.00 $0.00 $0.00 32000248 EAP CPT® 73140 Finger 3 Views BOTH IP/OP $609.00 $450.66 $23.09 $551.20 $71.76 $71.76 $78.77 $78.77 $79.21 $126.93 $53.24 $53.24 $55.29 $77.54 $126.92 $50.40 $360.22 $360.22 $80.04 $165.36 $545.69 $551.20 $111.21 $137.87 $111.21 $23.09 $28.81 $28.81 $109.69 $76.23 $0.00 $0.00 $0.00 $0.00 32000249 EAP CPT® 73140 Finger X-ray BOTH IP/OP $609.00 $450.66 $23.09 $551.20 $71.76 $71.76 $78.77 $78.77 $79.21 $126.93 $53.24 $53.24 $55.29 $77.54 $126.92 $50.40 $360.22 $360.22 $80.04 $165.36 $545.69 $551.20 $111.21 $137.87 $111.21 $23.09 $28.81 $28.81 $109.69 $76.23 $0.00 $0.00 $0.00 $0.00 32000250 EAP CPT® 73140 FINGER(S) 2+VIEW RDG BOTH IP/OP $609.00 $450.66 $23.09 $551.20 $71.76 $71.76 $78.77 $78.77 $79.21 $126.93 $53.24 $53.24 $55.29 $77.54 $126.92 $50.40 $360.22 $360.22 $80.04 $165.36 $545.69 $551.20 $111.21 $137.87 $111.21 $23.09 $28.81 $28.81 $109.69 $76.23 $0.00 $0.00 $0.00 $0.00 32000252 EAP CPT® 73140 FINGER(S) 2+VIEW EACH BILAT RD BOTH IP/OP "$1,218.00 " $901.32 $23.09 "$1,102.40" $71.76 $71.76 $78.77 $78.77 $79.21 $253.86 $53.24 $53.24 $55.29 $77.54 $253.83 $50.40 $720.45 $720.45 $80.04 $330.72 "$1,091.38" "$1,102.40" $111.21 $137.87 $111.21 $23.09 $28.81 $28.81 $219.38 $76.23 $0.00 $0.00 $0.00 $0.00 32000254 EAP CPT® 73140 FINGER(S) 2+VIEW LT RDG BOTH IP/OP $718.00 $531.32 $23.09 $551.20 $71.76 $71.76 $78.77 $78.77 $79.21 $149.65 $53.24 $53.24 $55.29 $77.54 $149.63 $50.40 $424.70 $424.70 $80.04 $165.36 $545.69 $551.20 $111.21 $137.87 $111.21 $23.09 $28.81 $28.81 $109.69 $76.23 $0.00 $0.00 $0.00 $0.00 32000256 EAP CPT® 73140 FINGER(S) 2+VIEW RT RDG BOTH IP/OP $718.00 $531.32 $23.09 $551.20 $71.76 $71.76 $78.77 $78.77 $79.21 $149.65 $53.24 $53.24 $55.29 $77.54 $149.63 $50.40 $424.70 $424.70 $80.04 $165.36 $545.69 $551.20 $111.21 $137.87 $111.21 $23.09 $28.81 $28.81 $109.69 $76.23 $0.00 $0.00 $0.00 $0.00 32000258 EAP CPT® 36299 Inject Vascular Unlstd Proc BOTH IP/OP "$4,131.00 " "$3,056.94" $0.00 "$2,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $861.00 $0.00 $0.00 $0.00 $0.00 $860.90 $0.00 "$2,443.49" "$2,443.49" $0.00 "$2,255.00" "$2,754.58" "$2,782.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000285 EAP CPT® 73525 HIP ARTHROGRAPHY RT RDG BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,275.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.72 $168.72 $175.21 $0.00 $265.71 $0.00 $0.00 $0.00 $387.01 $283.44 $935.35 $944.80 $537.70 "$1,275.00" $537.70 $107.06 $94.73 $94.73 $188.02 $368.58 $0.00 $0.00 $0.00 $0.00 32000286 EAP CPT® 73525 HIP ARTHROGRAPHY LT RDG BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,275.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.72 $168.72 $175.21 $0.00 $265.71 $0.00 $0.00 $0.00 $387.01 $283.44 $935.35 $944.80 $537.70 "$1,275.00" $537.70 $107.06 $94.73 $94.73 $188.02 $368.58 $0.00 $0.00 $0.00 $0.00 32000287 EAP CPT® 73525 Hips Arthrography Bilat Rdg BOTH IP/OP "$1,891.00 " "$1,399.34" $0.00 "$1,888.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.72 $168.72 $175.21 $0.00 $394.08 $0.00 $0.00 $0.00 $387.01 $566.64 "$1,869.91" "$1,888.80" $537.70 $0.00 $537.70 $107.06 $94.73 $94.73 $375.87 $368.58 $0.00 $0.00 $0.00 $0.00 32000303 EAP CPT® 73560 KNEE 1-2 VIEW RDG BOTH IP/OP $694.00 $513.56 $25.21 $612.80 $70.14 $70.14 $78.77 $78.77 $79.21 $144.65 $47.79 $47.79 $49.63 $77.54 $144.63 $50.40 $410.50 $410.50 $80.04 $183.84 $606.67 $612.80 $111.21 $137.87 $111.21 $28.43 $25.21 $25.21 $121.95 $76.23 $0.00 $0.00 $0.00 $0.00 32000305 EAP CPT® 73560 KNEE 1-2 VIEW LT RDG BOTH IP/OP $835.00 $617.90 $25.21 $612.80 $70.14 $70.14 $78.77 $78.77 $79.21 $174.03 $47.79 $47.79 $49.63 $77.54 $174.01 $50.40 $493.90 $493.90 $80.04 $183.84 $606.67 $612.80 $111.21 $137.87 $111.21 $28.43 $25.21 $25.21 $121.95 $76.23 $0.00 $0.00 $0.00 $0.00 32000307 EAP CPT® 73560 KNEE 1-2 VIEW RT RDG BOTH IP/OP $835.00 $617.90 $25.21 $612.80 $70.14 $70.14 $78.77 $78.77 $79.21 $174.03 $47.79 $47.79 $49.63 $77.54 $174.01 $50.40 $493.90 $493.90 $80.04 $183.84 $606.67 $612.80 $111.21 $137.87 $111.21 $28.43 $25.21 $25.21 $121.95 $76.23 $0.00 $0.00 $0.00 $0.00 32000309 EAP CPT® 73560 KNEES 1-2 VIEW EACH BILAT RDG BOTH IP/OP "$1,666.00 " "$1,232.84" $25.21 "$1,222.40" $70.14 $70.14 $78.77 $78.77 $79.21 $347.24 $47.79 $47.79 $49.63 $77.54 $347.19 $50.40 $985.44 $985.44 $80.04 $366.72 "$1,210.18" "$1,222.40" $111.21 $137.87 $111.21 $28.43 $25.21 $25.21 $243.26 $76.23 $0.00 $0.00 $0.00 $0.00 32000311 EAP CPT® 73562 Knee 3 View Rdg BOTH IP/OP $749.00 $554.26 $29.89 $660.80 $81.42 $81.42 $78.77 $78.77 $79.21 $156.11 $60.18 $60.18 $62.50 $77.54 $156.09 $50.40 $443.03 $443.03 $80.04 $198.24 $654.19 $660.80 $111.21 $137.87 $111.21 $31.26 $29.89 $29.89 $131.50 $76.23 $0.00 $0.00 $0.00 $0.00 32000313 EAP CPT® 73562 KNEE 3 VIEW LT RDG BOTH IP/OP $901.00 $666.74 $29.89 $660.80 $81.42 $81.42 $78.77 $78.77 $79.21 $187.79 $60.18 $60.18 $62.50 $77.54 $187.77 $50.40 $532.94 $532.94 $80.04 $198.24 $654.19 $660.80 $111.21 $137.87 $111.21 $31.26 $29.89 $29.89 $131.50 $76.23 $0.00 $0.00 $0.00 $0.00 32000315 EAP CPT® 73562 KNEE 3 VIEW RT RDG BOTH IP/OP $901.00 $666.74 $29.89 $660.80 $81.42 $81.42 $78.77 $78.77 $79.21 $187.79 $60.18 $60.18 $62.50 $77.54 $187.77 $50.40 $532.94 $532.94 $80.04 $198.24 $654.19 $660.80 $111.21 $137.87 $111.21 $31.26 $29.89 $29.89 $131.50 $76.23 $0.00 $0.00 $0.00 $0.00 32000317 EAP CPT® 73562 KNEES 3 VIEW EACH BILAT RDG BOTH IP/OP "$1,495.00 " "$1,106.30" $29.89 "$1,319.20" $81.42 $81.42 $78.77 $78.77 $79.21 $311.60 $60.18 $60.18 $62.50 $77.54 $311.56 $50.40 $884.29 $884.29 $80.04 $395.76 "$1,306.01" "$1,319.20" $111.21 $137.87 $111.21 $31.26 $29.89 $29.89 $262.52 $76.23 $0.00 $0.00 $0.00 $0.00 32000319 EAP CPT® 73564 KNEE 4+VIEW EXR BOTH IP/OP $699.00 $517.26 $32.78 $616.80 $90.29 $90.29 $106.02 $106.02 $106.62 $145.69 $69.25 $69.25 $71.92 $104.44 $145.67 $67.89 $413.46 $413.46 $112.41 $185.04 $610.63 $616.80 $156.18 $169.61 $156.18 $34.81 $32.78 $32.78 $122.74 $107.06 $0.00 $0.00 $0.00 $0.00 32000320 EAP CPT® 73564 KNEE 4+VIEW LT RDG BOTH IP/OP $841.00 $622.34 $32.78 $616.80 $90.29 $90.29 $106.02 $106.02 $106.62 $175.29 $69.25 $69.25 $71.92 $104.44 $175.26 $67.89 $497.45 $497.45 $112.41 $185.04 $610.63 $616.80 $156.18 $169.61 $156.18 $34.81 $32.78 $32.78 $122.74 $107.06 $0.00 $0.00 $0.00 $0.00 32000322 EAP CPT® 73564 KNEE 4+VIEW RT RDG BOTH IP/OP $841.00 $622.34 $32.78 $616.80 $90.29 $90.29 $106.02 $106.02 $106.62 $175.29 $69.25 $69.25 $71.92 $104.44 $175.26 $67.89 $497.45 $497.45 $112.41 $185.04 $610.63 $616.80 $156.18 $169.61 $156.18 $34.81 $32.78 $32.78 $122.74 $107.06 $0.00 $0.00 $0.00 $0.00 32000324 EAP CPT® 73564 KNEES 4+VIEW BILAT RDG BOTH IP/OP "$1,395.00 " "$1,032.30" $32.78 "$1,231.20" $90.29 $90.29 $106.02 $106.02 $106.62 $290.75 $69.25 $69.25 $71.92 $104.44 $290.72 $67.89 $825.14 $825.14 $112.41 $369.36 "$1,218.89" "$1,231.20" $156.18 $169.61 $156.18 $34.81 $32.78 $32.78 $245.01 $107.06 $0.00 $0.00 $0.00 $0.00 32000327 EAP CPT® 73565 KNEES BOTH STANDING AP RDG BOTH IP/OP $826.00 $611.24 $0.00 $728.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.41 $51.41 $53.38 $0.00 $172.14 $0.00 $0.00 $0.00 $0.00 $218.64 $721.51 $728.80 $0.00 $577.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000329 EAP CPT® 73580 KNEE ARTHROGRAPHY RT RDG BOTH IP/OP "$2,466.00 " "$1,824.84" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.38 $227.38 $236.12 $0.00 $513.91 $0.00 $0.00 $0.00 $0.00 $652.80 "$2,154.24" "$2,176.00" $0.00 "$1,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000330 EAP CPT® 73580 KNEE ARTHROGRAPHY LT RDG BOTH IP/OP "$2,466.00 " "$1,824.84" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.38 $227.38 $236.12 $0.00 $513.91 $0.00 $0.00 $0.00 $0.00 $652.80 "$2,154.24" "$2,176.00" $0.00 "$1,044.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000331 EAP CPT® 73580 Knees Arthrography Bilat Rdg BOTH IP/OP "$2,466.00 " "$1,824.84" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.38 $227.38 $236.12 $0.00 $513.91 $0.00 $0.00 $0.00 $0.00 $652.80 "$2,154.24" "$2,176.00" $0.00 "$2,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000332 EAP CPT® 73590 TIBIA&FIBULA 2 VIEW RDG BOTH IP/OP $879.00 $650.46 $22.69 $639.20 $65.31 $65.31 $78.77 $78.77 $79.21 $183.21 $45.06 $45.06 $46.80 $77.54 $183.18 $50.40 $519.93 $519.93 $80.04 $191.76 $632.81 $639.20 $111.21 $137.87 $111.21 $28.43 $22.69 $22.69 $127.20 $76.23 $0.00 $0.00 $0.00 $0.00 32000334 EAP CPT® 73590 TIBIA&FIBULA 2 VIEW LT RDG BOTH IP/OP $879.00 $650.46 $22.69 $639.20 $65.31 $65.31 $78.77 $78.77 $79.21 $183.21 $45.06 $45.06 $46.80 $77.54 $183.18 $50.40 $519.93 $519.93 $80.04 $191.76 $632.81 $639.20 $111.21 $137.87 $111.21 $28.43 $22.69 $22.69 $127.20 $76.23 $0.00 $0.00 $0.00 $0.00 32000336 EAP CPT® 73590 TIBIA&FIBULA 2 VIEW RT RDG BOTH IP/OP $879.00 $650.46 $22.69 $639.20 $65.31 $65.31 $78.77 $78.77 $79.21 $183.21 $45.06 $45.06 $46.80 $77.54 $183.18 $50.40 $519.93 $519.93 $80.04 $191.76 $632.81 $639.20 $111.21 $137.87 $111.21 $28.43 $22.69 $22.69 $127.20 $76.23 $0.00 $0.00 $0.00 $0.00 32000338 EAP CPT® 73590 TIBIA&FIBULA 2VW ECH BILAT RDG BOTH IP/OP $790.00 $584.60 $22.69 $639.20 $65.31 $65.31 $78.77 $78.77 $79.21 $164.66 $45.06 $45.06 $46.80 $77.54 $164.64 $50.40 $467.29 $467.29 $80.04 $191.76 $632.81 $639.20 $111.21 $137.87 $111.21 $28.43 $22.69 $22.69 $127.20 $76.23 $0.00 $0.00 $0.00 $0.00 32000339 EAP CPT® 73592 Low Ext Infant 2+view Rdg BOTH IP/OP $372.00 $275.28 $0.00 $300.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.68 $48.68 $50.55 $0.00 $77.52 $0.00 $0.00 $0.00 $0.00 $90.24 $297.79 $300.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000340 EAP CPT® 73592 LOW EXT INFANT 2+VIEW BI RDG BOTH IP/OP $372.00 $275.28 $0.00 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.68 $48.68 $50.55 $0.00 $77.52 $0.00 $0.00 $0.00 $0.00 $90.24 $297.79 $300.80 $0.00 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000343 EAP CPT® 73592 LOW EXT INFANT 2+VIEW LT RDG BOTH IP/OP $372.00 $275.28 $0.00 $300.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.68 $48.68 $50.55 $0.00 $77.52 $0.00 $0.00 $0.00 $0.00 $90.24 $297.79 $300.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000345 EAP CPT® 73592 LOW EXT INFANT 2+VIEW RT RDG BOTH IP/OP $372.00 $275.28 $0.00 $300.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.68 $48.68 $50.55 $0.00 $77.52 $0.00 $0.00 $0.00 $0.00 $90.24 $297.79 $300.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000347 EAP CPT® 73600 Ankle 2 View Rdg BOTH IP/OP $734.00 $543.16 $23.41 $713.60 $67.72 $67.72 $78.77 $78.77 $79.21 $152.98 $45.96 $45.96 $47.73 $77.54 $152.97 $50.40 $434.16 $434.16 $80.04 $214.08 $706.46 $713.60 $111.21 $137.87 $111.21 $27.37 $23.41 $23.41 $142.01 $76.23 $0.00 $0.00 $0.00 $0.00 32000349 EAP CPT® 73600 ANKLE 2 VIEW LT RDG BOTH IP/OP $980.00 $725.20 $23.41 $713.60 $67.72 $67.72 $78.77 $78.77 $79.21 $204.26 $45.96 $45.96 $47.73 $77.54 $204.23 $50.40 $579.67 $579.67 $80.04 $214.08 $706.46 $713.60 $111.21 $137.87 $111.21 $27.37 $23.41 $23.41 $142.01 $76.23 $0.00 $0.00 $0.00 $0.00 32000351 EAP CPT® 73600 ANKLE 2 VIEW RT RDG BOTH IP/OP $980.00 $725.20 $23.41 $713.60 $67.72 $67.72 $78.77 $78.77 $79.21 $204.26 $45.96 $45.96 $47.73 $77.54 $204.23 $50.40 $579.67 $579.67 $80.04 $214.08 $706.46 $713.60 $111.21 $137.87 $111.21 $27.37 $23.41 $23.41 $142.01 $76.23 $0.00 $0.00 $0.00 $0.00 32000353 EAP CPT® 73600 ANKLES 2 VIEW EACH BILAT RDG BOTH IP/OP "$1,958.00 " "$1,448.92" $23.41 "$1,425.60" $67.72 $67.72 $78.77 $78.77 $79.21 $408.10 $45.96 $45.96 $47.73 $77.54 $408.05 $50.40 "$1,158.16" "$1,158.16" $80.04 $427.68 "$1,411.34" "$1,425.60" $111.21 $137.87 $111.21 $27.37 $23.41 $23.41 $283.69 $76.23 $0.00 $0.00 $0.00 $0.00 32000357 EAP CPT® 73610 ANKLE 3+VIEW LT RDG BOTH IP/OP "$1,060.00 " $784.40 $26.29 $772.00 $71.76 $71.76 $78.77 $78.77 $79.21 $220.93 $54.14 $54.14 $56.22 $77.54 $220.90 $50.40 $626.99 $626.99 $80.04 $231.60 $764.28 $772.00 $111.21 $137.87 $111.21 $28.79 $26.29 $26.29 $153.63 $76.23 $0.00 $0.00 $0.00 $0.00 32000359 EAP CPT® 73610 ANKLE 3+VIEW RT RDG BOTH IP/OP "$1,060.00 " $784.40 $26.29 $772.00 $71.76 $71.76 $78.77 $78.77 $79.21 $220.93 $54.14 $54.14 $56.22 $77.54 $220.90 $50.40 $626.99 $626.99 $80.04 $231.60 $764.28 $772.00 $111.21 $137.87 $111.21 $28.79 $26.29 $26.29 $153.63 $76.23 $0.00 $0.00 $0.00 $0.00 32000362 EAP CPT® 73615 ANKLE ARTHROGRAPHY LT RDG BOTH IP/OP "$2,593.00 " "$1,918.82" $0.00 "$2,522.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.98 $175.98 $182.75 $0.00 $540.38 $0.00 $0.00 $0.00 $0.00 $756.72 "$2,497.18" "$2,522.40" $0.00 $861.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000363 EAP CPT® 73615 ANKLE ARTHROGRAPHY RT RDG BOTH IP/OP "$2,593.00 " "$1,918.82" $0.00 "$2,522.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.98 $175.98 $182.75 $0.00 $540.38 $0.00 $0.00 $0.00 $0.00 $756.72 "$2,497.18" "$2,522.40" $0.00 $861.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000364 EAP CPT® 73610 ANKLES 3+VIEW EACH BILAT RDG BOTH IP/OP "$2,115.00 " "$1,565.10" $26.29 "$1,540.00" $71.76 $71.76 $78.77 $78.77 $79.21 $440.82 $54.14 $54.14 $56.22 $77.54 $440.77 $50.40 "$1,251.02" "$1,251.02" $80.04 $462.00 "$1,524.60" "$1,540.00" $111.21 $137.87 $111.21 $28.79 $26.29 $26.29 $306.46 $76.23 $0.00 $0.00 $0.00 $0.00 32000366 EAP CPT® 73615 Ankles Arthrography Bilat Rdg BOTH IP/OP "$5,189.00 " "$3,839.86" $0.00 "$5,047.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.98 $175.98 $182.75 $0.00 "$1,081.39" $0.00 $0.00 $0.00 $0.00 "$1,514.16" "$4,996.73" "$5,047.20" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000367 EAP CPT® 73620 FEET 2 VIEW EACH BILAT RDG BOTH IP/OP "$1,600.00 " "$1,184.00" $20.17 "$1,168.80" $58.87 $58.87 $78.77 $78.77 $79.21 $333.48 $44.15 $44.15 $45.85 $77.54 $333.44 $50.40 $946.40 $946.40 $80.04 $350.64 "$1,157.11" "$1,168.80" $111.21 $137.87 $111.21 $27.37 $20.17 $20.17 $232.59 $76.23 $0.00 $0.00 $0.00 $0.00 32000369 EAP CPT® 73620 FOOT 2 VIEW LT RDG BOTH IP/OP $801.00 $592.74 $20.17 $585.60 $58.87 $58.87 $78.77 $78.77 $79.21 $166.95 $44.15 $44.15 $45.85 $77.54 $166.93 $50.40 $473.79 $473.79 $80.04 $175.68 $579.74 $585.60 $111.21 $137.87 $111.21 $27.37 $20.17 $20.17 $116.53 $76.23 $0.00 $0.00 $0.00 $0.00 32000371 EAP CPT® 73620 FOOT 2 VIEW RT RDG BOTH IP/OP $801.00 $592.74 $20.17 $585.60 $58.87 $58.87 $78.77 $78.77 $79.21 $166.95 $44.15 $44.15 $45.85 $77.54 $166.93 $50.40 $473.79 $473.79 $80.04 $175.68 $579.74 $585.60 $111.21 $137.87 $111.21 $27.37 $20.17 $20.17 $116.53 $76.23 $0.00 $0.00 $0.00 $0.00 32000373 EAP CPT® 73620 Foot 2 Views Rdg BOTH IP/OP $669.00 $495.06 $20.17 $585.60 $58.87 $58.87 $78.77 $78.77 $79.21 $139.44 $44.15 $44.15 $45.85 $77.54 $139.42 $50.40 $395.71 $395.71 $80.04 $175.68 $579.74 $585.60 $111.21 $137.87 $111.21 $27.37 $20.17 $20.17 $116.53 $76.23 $0.00 $0.00 $0.00 $0.00 32000375 EAP CPT® 73630 FEET 3+VIEW EACH BILAT RDG BOTH IP/OP "$1,730.00 " "$1,280.20" $24.49 "$1,264.00" $66.11 $66.11 $78.77 $78.77 $79.21 $360.58 $53.24 $53.24 $55.29 $77.54 $360.53 $50.40 "$1,023.30" "$1,023.30" $80.04 $379.20 "$1,251.36" "$1,264.00" $111.21 $137.87 $111.21 $28.79 $24.49 $24.49 $251.54 $76.23 $0.00 $0.00 $0.00 $0.00 32000377 EAP CPT® 73630 FOOT 3+VIEW RDG BOTH IP/OP $863.00 $638.62 $24.49 $630.40 $66.11 $66.11 $78.77 $78.77 $79.21 $179.87 $53.24 $53.24 $55.29 $77.54 $179.85 $50.40 $510.46 $510.46 $80.04 $189.12 $624.10 $630.40 $111.21 $137.87 $111.21 $28.79 $24.49 $24.49 $125.45 $76.23 $0.00 $0.00 $0.00 $0.00 32000379 EAP CPT® 73630 FOOT 3+VIEW LT RDG BOTH IP/OP $863.00 $638.62 $24.49 $630.40 $66.11 $66.11 $78.77 $78.77 $79.21 $179.87 $53.24 $53.24 $55.29 $77.54 $179.85 $50.40 $510.46 $510.46 $80.04 $189.12 $624.10 $630.40 $111.21 $137.87 $111.21 $28.79 $24.49 $24.49 $125.45 $76.23 $0.00 $0.00 $0.00 $0.00 32000381 EAP CPT® 73630 FOOT 3+VIEW RT RDG BOTH IP/OP $720.00 $532.80 $24.49 $630.40 $66.11 $66.11 $78.77 $78.77 $79.21 $150.07 $53.24 $53.24 $55.29 $77.54 $150.05 $50.40 $425.88 $425.88 $80.04 $189.12 $624.10 $630.40 $111.21 $137.87 $111.21 $28.79 $24.49 $24.49 $125.45 $76.23 $0.00 $0.00 $0.00 $0.00 32000383 EAP CPT® 73650 CALCANEI 2+VIEW EACH BILAT RDG BOTH IP/OP "$1,538.00 " "$1,138.12" $20.17 "$1,166.40" $61.27 $61.27 $78.77 $78.77 $79.21 $320.56 $45.06 $45.06 $46.80 $77.54 $320.52 $50.40 $909.73 $909.73 $80.04 $349.92 "$1,154.74" "$1,166.40" $111.21 $137.87 $111.21 $26.66 $20.17 $20.17 $232.11 $76.23 $0.00 $0.00 $0.00 $0.00 32000385 EAP CPT® 73650 CALCANEUS 2+VIEW RDG BOTH IP/OP $638.00 $472.12 $20.17 $584.00 $61.27 $61.27 $78.77 $78.77 $79.21 $132.98 $45.06 $45.06 $46.80 $77.54 $132.96 $50.40 $377.38 $377.38 $80.04 $175.20 $578.16 $584.00 $111.21 $137.87 $111.21 $26.66 $20.17 $20.17 $116.22 $76.23 $0.00 $0.00 $0.00 $0.00 32000387 EAP CPT® 73650 CALCANEUS 2+VIEW LT RDG BOTH IP/OP $770.00 $569.80 $20.17 $584.00 $61.27 $61.27 $78.77 $78.77 $79.21 $160.49 $45.06 $45.06 $46.80 $77.54 $160.47 $50.40 $455.46 $455.46 $80.04 $175.20 $578.16 $584.00 $111.21 $137.87 $111.21 $26.66 $20.17 $20.17 $116.22 $76.23 $0.00 $0.00 $0.00 $0.00 32000389 EAP CPT® 73650 CALCANEUS 2+VIEW RT RDG BOTH IP/OP $770.00 $569.80 $20.17 $584.00 $61.27 $61.27 $78.77 $78.77 $79.21 $160.49 $45.06 $45.06 $46.80 $77.54 $160.47 $50.40 $455.46 $455.46 $80.04 $175.20 $578.16 $584.00 $111.21 $137.87 $111.21 $26.66 $20.17 $20.17 $116.22 $76.23 $0.00 $0.00 $0.00 $0.00 32000391 EAP CPT® 73660 Toe X-ray BOTH IP/OP $863.00 $638.62 $21.61 $690.40 $63.70 $63.70 $78.77 $78.77 $79.21 $179.87 $50.51 $50.51 $52.46 $77.54 $179.85 $50.40 $510.46 $510.46 $80.04 $207.12 $683.50 $690.40 $111.21 $137.87 $111.21 $23.09 $21.61 $21.61 $137.39 $76.23 $0.00 $0.00 $0.00 $0.00 32000392 EAP CPT® 73660 TOE(S) 2+VIEW EACH BILAT RDG BOTH IP/OP "$1,733.00 " "$1,282.42" $21.61 "$1,386.40" $63.70 $63.70 $78.77 $78.77 $79.21 $361.20 $50.51 $50.51 $52.46 $77.54 $361.16 $50.40 "$1,025.07" "$1,025.07" $80.04 $415.92 "$1,372.54" "$1,386.40" $111.21 $137.87 $111.21 $23.09 $21.61 $21.61 $275.89 $76.23 $0.00 $0.00 $0.00 $0.00 32000394 EAP CPT® 73660 TOE(S) X-RAY 2+VIEW RDG BOTH IP/OP $863.00 $638.62 $21.61 $690.40 $63.70 $63.70 $78.77 $78.77 $79.21 $179.87 $50.51 $50.51 $52.46 $77.54 $179.85 $50.40 $510.46 $510.46 $80.04 $207.12 $683.50 $690.40 $111.21 $137.87 $111.21 $23.09 $21.61 $21.61 $137.39 $76.23 $0.00 $0.00 $0.00 $0.00 32000396 EAP CPT® 73660 TOE(S) X-RAY 2+VIEW LT RDG BOTH IP/OP $878.00 $649.72 $21.61 $690.40 $63.70 $63.70 $78.77 $78.77 $79.21 $183.00 $50.51 $50.51 $52.46 $77.54 $182.98 $50.40 $519.34 $519.34 $80.04 $207.12 $683.50 $690.40 $111.21 $137.87 $111.21 $23.09 $21.61 $21.61 $137.39 $76.23 $0.00 $0.00 $0.00 $0.00 32000398 EAP CPT® 73660 TOE(S) X-RAY 2+VIEW RT RDG BOTH IP/OP $878.00 $649.72 $21.61 $690.40 $63.70 $63.70 $78.77 $78.77 $79.21 $183.00 $50.51 $50.51 $52.46 $77.54 $182.98 $50.40 $519.34 $519.34 $80.04 $207.12 $683.50 $690.40 $111.21 $137.87 $111.21 $23.09 $21.61 $21.61 $137.39 $76.23 $0.00 $0.00 $0.00 $0.00 32000412 EAP CPT® 74018 "KUB-KIDNEY,URETER,BLADDER RDG" BOTH IP/OP $797.00 $589.78 $20.17 $581.60 $62.20 $62.20 $78.77 $78.77 $79.21 $166.11 $45.51 $45.51 $47.26 $77.54 $166.09 $50.40 $471.43 $471.43 $80.04 $174.48 $575.78 $581.60 $111.21 $137.87 $111.21 $26.25 $20.17 $20.17 $115.74 $76.23 $0.00 $0.00 $0.00 $0.00 32000417 EAP CPT® 74019 ABDOMEN AP OBLIQ&CONE RDG BOTH IP/OP $704.00 $520.96 $24.49 $578.40 $75.90 $75.90 $106.02 $106.02 $106.62 $146.73 $54.42 $54.42 $56.52 $104.44 $146.71 $67.89 $416.42 $416.42 $112.41 $173.52 $572.62 $578.40 $156.18 $169.61 $156.18 $32.02 $24.49 $24.49 $115.10 $107.06 $0.00 $0.00 $0.00 $0.00 32000419 EAP CPT® 74019 ABDOMEN W/DECUB&/ERECT RDG BOTH IP/OP $813.00 $601.62 $24.49 $593.60 $75.90 $75.90 $106.02 $106.02 $106.62 $169.45 $54.42 $54.42 $56.52 $104.44 $169.43 $67.89 $480.89 $480.89 $112.41 $178.08 $587.66 $593.60 $156.18 $169.61 $156.18 $32.02 $24.49 $24.49 $118.13 $107.06 $0.00 $0.00 $0.00 $0.00 32000421 EAP CPT® 74022 Xr 2 Vw Abd W/ Single View Chest BOTH IP/OP "$1,195.00 " $884.30 $0.00 $872.00 $101.59 $101.59 $106.02 $106.02 $106.62 $249.07 $79.08 $79.08 $82.12 $104.44 $249.04 $67.89 $706.84 $706.84 $112.41 $261.60 $863.28 $872.00 $156.18 $169.61 $156.18 $44.36 $32.78 $32.78 $0.00 $107.06 $0.00 $0.00 $0.00 $0.00 32000430 EAP CPT® 74210 Xr Pharynx/cerv Esoph Single Contrast BOTH IP/OP $630.00 $466.20 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.45 $142.45 $147.93 $0.00 $131.29 $0.00 $0.00 $0.00 $0.00 $159.60 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000432 EAP CPT® 74220 Xr Esophagus Single Contrast BOTH IP/OP "$1,176.00 " $870.24 $66.99 $950.40 $200.75 $200.75 $173.95 $173.95 $174.93 $245.11 $156.06 $156.06 $162.06 $171.13 $245.08 $111.23 $695.60 $695.60 $202.33 $285.12 $940.90 $950.40 $281.11 $286.19 $281.11 $68.55 $66.99 $66.99 $189.13 $192.70 $0.00 $0.00 $0.00 $0.00 32000434 EAP CPT® 74230 Xr Swallow Function Single Contrast BOTH IP/OP $978.00 $723.72 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.16 $153.16 $159.05 $0.00 $203.82 $0.00 $0.00 $0.00 $0.00 $237.12 $782.50 $790.40 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000435 EAP CPT® 74230 Barium Swallow BOTH IP/OP $988.00 $731.12 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.16 $153.16 $159.05 $0.00 $205.90 $0.00 $0.00 $0.00 $0.00 $237.12 $782.50 $790.40 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000436 EAP CPT® 74235 ESOPHAGEAL FB REMOVAL S&I SPV BOTH IP/OP "$1,329.00 " $983.46 $0.00 "$5,322.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.34 $298.34 $309.82 $0.00 $276.96 $0.00 $0.00 $0.00 $0.00 $322.08 "$1,062.86" "$1,073.60" $0.00 "$5,322.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000437 EAP CPT® 74235 FB REMOVAL ESOPHAGEAL S&I EXR BOTH IP/OP "$1,342.00 " $993.08 $0.00 "$5,322.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.34 $298.34 $309.82 $0.00 $279.67 $0.00 $0.00 $0.00 $0.00 $322.08 "$1,062.86" "$1,073.60" $0.00 "$5,322.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000439 EAP CPT® 74235 Rem. F.b. Esoph Xray Super/int BOTH IP/OP "$1,329.00 " $983.46 $0.00 "$5,322.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.34 $298.34 $309.82 $0.00 $276.96 $0.00 $0.00 $0.00 $0.00 $322.08 "$1,062.86" "$1,073.60" $0.00 "$5,322.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000441 EAP CPT® 74240 UGI W/O KUB RDG BOTH IP/OP "$1,446.00 " "$1,070.04" $80.68 "$1,088.80" $256.37 $256.37 $173.95 $173.95 $174.93 $301.38 $177.54 $177.54 $184.37 $171.13 $301.35 $111.23 $855.31 $855.31 $202.33 $326.64 "$1,077.91" "$1,088.80" $281.11 $286.19 $281.11 $90.47 $80.68 $80.68 $216.67 $192.70 $0.00 $0.00 $0.00 $0.00 32000448 EAP CPT® 74246 UGI W/ AIR CON W/O KUB RDG BOTH IP/OP "$1,369.00 " "$1,013.06" $94.36 "$1,031.20" $288.60 $288.60 $173.95 $173.95 $174.93 $285.33 $216.23 $216.23 $224.54 $171.13 $285.30 $111.23 $809.76 $809.76 $202.33 $309.36 "$1,020.89" "$1,031.20" $281.11 $286.19 $281.11 $97.60 $94.36 $94.36 $205.21 $192.70 $0.00 $0.00 $0.00 $0.00 32000449 EAP CPT® 74246 Ugi W/air Contrast BOTH IP/OP "$1,369.00 " "$1,013.06" $94.36 "$1,031.20" $288.60 $288.60 $173.95 $173.95 $174.93 $285.33 $216.23 $216.23 $224.54 $171.13 $285.30 $111.23 $809.76 $809.76 $202.33 $309.36 "$1,020.89" "$1,031.20" $281.11 $286.19 $281.11 $97.60 $94.36 $94.36 $205.21 $192.70 $0.00 $0.00 $0.00 $0.00 32000457 EAP CPT® 74250 Xr Small Bowel Single Contrast BOTH IP/OP $656.00 $485.44 $0.00 $490.40 $236.20 $236.20 $173.95 $173.95 $174.93 $0.00 $190.37 $190.37 $197.69 $0.00 $136.71 $0.00 $0.00 $0.00 $0.00 $147.12 $485.50 $490.40 $0.00 $286.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000462 EAP CPT® 74270 Xr Colon Single Contrast BOTH IP/OP "$1,428.00 " "$1,056.72" $100.09 "$1,386.40" $332.96 $332.96 $173.95 $173.95 $174.93 $297.63 $270.52 $270.52 $280.93 $171.13 $297.60 $111.23 $844.66 $844.66 $202.33 $415.92 "$1,372.54" "$1,386.40" $281.11 $286.19 $281.11 $100.09 $103.37 $103.37 $275.89 $192.70 $0.00 $0.00 $0.00 $0.00 32000463 EAP CPT® 74270 Be (barium Enema) Routi BOTH IP/OP "$1,716.00 " "$1,269.84" $100.09 "$1,386.40" $332.96 $332.96 $173.95 $173.95 $174.93 $357.66 $270.52 $270.52 $280.93 $171.13 $357.61 $111.23 "$1,015.01" "$1,015.01" $202.33 $415.92 "$1,372.54" "$1,386.40" $281.11 $286.19 $281.11 $100.09 $103.37 $103.37 $275.89 $192.70 $0.00 $0.00 $0.00 $0.00 32000465 EAP CPT® 74280 Xr Colon Double Contrast BOTH IP/OP "$2,694.00 " "$1,993.56" $0.00 "$2,176.80" $0.00 $0.00 $0.00 $0.00 $0.00 $561.50 $370.04 $370.04 $384.27 $171.13 $561.43 $111.23 "$1,593.50" "$1,593.50" $202.33 $653.04 "$2,155.03" "$2,176.80" $281.11 "$1,860.00" $281.11 $134.85 $160.64 $160.64 $433.18 $192.70 $0.00 $0.00 $0.00 $0.00 32000467 EAP CPT® 74283 THERAPEUTIC ENEMA CON/AIR RDG BOTH IP/OP "$1,218.00 " $901.32 $0.00 "$1,182.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.43 $256.43 $266.30 $0.00 $253.83 $0.00 $0.00 $0.00 $0.00 $354.72 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000468 EAP CPT® 74290 Cholecystography W/dye Rdg BOTH IP/OP "$1,066.00 " $788.84 $0.00 "$1,035.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.00 $119.00 $123.57 $0.00 $222.15 $0.00 $0.00 $0.00 $0.00 $310.56 "$1,024.85" "$1,035.20" $0.00 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000470 EAP CPT® 74300 CHOLANGIO INTRAOPERATIVE RDG BOTH IP/OP "$1,122.00 " $830.28 $0.00 "$1,122.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.82 $88.82 $92.23 $0.00 $233.82 $0.00 $0.00 $0.00 $0.00 $269.28 $888.62 $897.60 $0.00 "$1,122.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000471 EAP CPT® 74300 Xray Bile Ducts/pancreas BOTH IP/OP "$1,122.00 " $830.28 $0.00 $897.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.82 $88.82 $92.23 $0.00 $233.82 $0.00 $0.00 $0.00 $0.00 $269.28 $888.62 $897.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000477 EAP CPT® 74328 Radiological;biliary Ductal BOTH IP/OP $934.00 $691.16 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $344.53 $344.53 $357.78 $0.00 $194.65 $0.00 $0.00 $0.00 $0.00 $224.16 $739.73 $747.20 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000478 EAP CPT® 74329 Radiological;pancreatic Ductal BOTH IP/OP $934.00 $691.16 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.01 $174.01 $180.71 $0.00 $194.65 $0.00 $0.00 $0.00 $0.00 $224.16 $739.73 $747.20 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000479 EAP CPT® 74330 Radiological;biliary & Pancrea BOTH IP/OP $934.00 $691.16 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $344.53 $344.53 $357.78 $0.00 $194.65 $0.00 $0.00 $0.00 $0.00 $224.16 $739.73 $747.20 $0.00 $934.00 $0.00 $163.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000481 EAP CPT® 74340 INTRO OF LONG GI TUBE S&I RDG BOTH IP/OP $456.00 $337.44 $0.00 "$1,377.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.63 $286.63 $297.66 $0.00 $95.03 $0.00 $0.00 $0.00 $0.00 $110.64 $365.11 $368.80 $0.00 "$1,377.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000482 EAP CPT® 74340 X-ray Guide For Gi Tube BOTH IP/OP $461.00 $341.14 $0.00 "$1,377.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.63 $286.63 $297.66 $0.00 $96.07 $0.00 $0.00 $0.00 $0.00 $110.64 $365.11 $368.80 $0.00 "$1,377.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000484 EAP CPT® 74355 Pl Enteroclysis Tube Perc Spv BOTH IP/OP $844.00 $624.56 $0.00 $675.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.63 $286.63 $297.66 $0.00 $175.89 $0.00 $0.00 $0.00 $0.00 $202.56 $668.45 $675.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000485 EAP CPT® 74360 Eso-dil Intralu Dil Stric Xray BOTH IP/OP $976.00 $722.24 $0.00 $976.00 $268.62 $268.62 $0.00 $0.00 $0.00 $203.42 $344.53 $344.53 $357.78 $0.00 $203.40 $0.00 $577.30 $577.30 $0.00 $234.24 $772.99 $780.80 $0.00 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000486 EAP CPT® 74360 INTRALUMINAL DILAT STRICTU SPV BOTH IP/OP $976.00 $722.24 $0.00 $780.80 $268.62 $268.62 $0.00 $0.00 $0.00 $203.42 $344.53 $344.53 $357.78 $0.00 $203.40 $0.00 $577.30 $577.30 $0.00 $234.24 $772.99 $780.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000487 EAP CPT® 74363 BILIARY STRICTURE SPV BOTH IP/OP "$2,534.00 " "$1,875.16" $0.00 "$2,027.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.82 $218.82 $227.23 $0.00 $528.09 $0.00 $0.00 $0.00 $0.00 $608.16 "$2,006.93" "$2,027.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000488 EAP CPT® 74400 Urography Hypertensive BOTH IP/OP $888.00 $657.12 $0.00 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.81 $208.81 $216.84 $0.00 $185.06 $0.00 $0.00 $0.00 $0.00 $213.12 $703.30 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000490 EAP CPT® 74400 Urography W/wo Kub/tomog Rdg BOTH IP/OP $888.00 $657.12 $0.00 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.81 $208.81 $216.84 $0.00 $185.06 $0.00 $0.00 $0.00 $0.00 $213.12 $703.30 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000493 EAP CPT® 74410 Urography Drip Infusion Rdg BOTH IP/OP $868.00 $642.32 $0.00 $694.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.40 $222.40 $230.96 $0.00 $180.89 $0.00 $0.00 $0.00 $0.00 $208.32 $687.46 $694.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000495 EAP CPT® 74415 Urography With Nephro Exr BOTH IP/OP $868.00 $642.32 $0.00 $694.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.92 $264.92 $275.11 $0.00 $180.89 $0.00 $0.00 $0.00 $0.00 $208.32 $687.46 $694.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000496 EAP CPT® 74420 Retrograde Urography BOTH IP/OP $888.00 $657.12 $0.00 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.63 $286.63 $297.66 $0.00 $185.06 $0.00 $0.00 $0.00 $0.00 $213.12 $703.30 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000497 EAP CPT® 74420 Urogra Retro W/wo Kub Rdg BOTH IP/OP $888.00 $657.12 $0.00 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.63 $286.63 $297.66 $0.00 $185.06 $0.00 $0.00 $0.00 $0.00 $213.12 $703.30 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000500 EAP CPT® 74425 Nephrostogram BOTH IP/OP "$1,039.00 " $768.86 $67.58 "$1,021.42" "$1,021.42" "$1,021.42" $358.61 $358.61 $360.63 $216.55 $142.79 $142.79 $148.28 $352.81 $216.53 $229.33 $614.57 $614.57 $387.01 $249.36 $822.89 $831.20 $537.70 $584.68 $537.70 $67.58 $106.25 $106.25 $165.41 $368.58 $0.00 $0.00 $0.00 $0.00 32000501 EAP CPT® 74425 Loopogram/pouchogram BOTH IP/OP "$1,039.00 " $768.86 $0.00 "$1,021.42" "$1,021.42" "$1,021.42" $358.61 $358.61 $360.63 $216.55 $142.79 $142.79 $148.28 $352.81 $216.53 $229.33 $614.57 $614.57 $387.01 $249.36 $822.89 $831.20 $537.70 $0.00 $537.70 $67.58 $106.25 $106.25 $165.41 $368.58 $0.00 $0.00 $0.00 $0.00 32000502 EAP CPT® 74425 UROGRAPHY ANTEGRADE EXR BOTH IP/OP "$1,039.00 " $768.86 $67.58 "$1,021.42" "$1,021.42" "$1,021.42" $358.61 $358.61 $360.63 $216.55 $142.79 $142.79 $148.28 $352.81 $216.53 $229.33 $614.57 $614.57 $387.01 $249.36 $822.89 $831.20 $537.70 $584.68 $537.70 $67.58 $106.25 $106.25 $165.41 $368.58 $0.00 $0.00 $0.00 $0.00 32000503 EAP CPT® 74430 CYSTOGRAPHY 3+VIEW S&I RDG BOTH IP/OP "$1,235.00 " $913.90 $0.00 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $257.40 $152.43 $152.43 $158.30 $352.81 $257.37 $229.33 $730.50 $730.50 $387.01 $299.28 $987.62 $997.60 $537.70 $764.00 $537.70 $56.52 $24.49 $24.49 $198.52 $368.58 $0.00 $0.00 $0.00 $0.00 32000504 EAP CPT® 74430 Contrast Xray Bladder BOTH IP/OP "$1,247.00 " $922.78 $0.00 $997.60 $0.00 $0.00 $0.00 $0.00 $0.00 $259.91 $152.43 $152.43 $158.30 $352.81 $259.87 $229.33 $737.60 $737.60 $387.01 $299.28 $987.62 $997.60 $537.70 $764.00 $537.70 $56.52 $24.49 $24.49 $198.52 $368.58 $0.00 $0.00 $0.00 $0.00 32000505 EAP CPT® 74440 Vasography Vesicu'graphy Spv BOTH IP/OP "$1,078.00 " $797.72 $0.00 $862.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.69 $159.69 $165.83 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $258.72 $853.78 $862.40 $0.00 $385.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000506 EAP CPT® 74445 CORPORA CAVERNO'GRAM S&I SPV BOTH IP/OP "$1,078.00 " $797.72 $0.00 $862.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.12 $123.12 $127.85 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $258.72 $853.78 $862.40 $0.00 $323.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000508 EAP CPT® 74450 Retro Urethrocystography BOTH IP/OP "$2,861.00 " "$2,117.14" $0.00 "$2,105.60" $0.00 $0.00 $0.00 $0.00 $0.00 $596.30 $159.33 $159.33 $165.46 $220.56 $596.23 $143.36 "$1,692.28" "$1,692.28" $233.72 $631.68 "$2,084.54" "$2,105.60" $324.73 $915.00 $324.73 $72.23 $0.00 $0.00 $419.01 $222.60 $0.00 $0.00 $0.00 $0.00 32000509 EAP CPT® 74450 RETROGRADE URETHROGRAM RDG BOTH IP/OP "$2,861.00 " "$2,117.14" $0.00 "$2,105.60" $0.00 $0.00 $0.00 $0.00 $0.00 $596.30 $159.33 $159.33 $165.46 $220.56 $596.23 $143.36 "$1,692.28" "$1,692.28" $233.72 $631.68 "$2,084.54" "$2,105.60" $324.73 $915.00 $324.73 $72.23 $0.00 $0.00 $419.01 $222.60 $0.00 $0.00 $0.00 $0.00 32000511 EAP CPT® 74455 URETHROCYSTOGRAPHY VOID RDG BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $456.66 $0.00 $0.00 $0.00 $220.56 $456.60 $143.36 "$1,295.98" "$1,295.98" $233.72 $483.60 "$1,595.88" "$1,612.00" $324.73 $0.00 $324.73 $76.86 $82.12 $82.12 $320.79 $222.60 $0.00 $0.00 $0.00 $0.00 32000514 EAP CPT® 74485 NEPHRSTOMY/URETERAL DILAT SPV BOTH IP/OP "$2,682.00 " "$1,984.68" $0.00 "$2,145.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.19 $224.19 $232.82 $0.00 $558.93 $0.00 $0.00 $0.00 $0.00 $643.68 "$2,124.14" "$2,145.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000516 EAP CPT® 74740 HYSTEROSALPINGOGRAPHY RDG BOTH IP/OP $957.00 $708.18 $68.95 $699.20 $170.10 $170.10 $224.08 $224.08 $225.34 $199.46 $144.10 $144.10 $149.64 $220.56 $199.44 $143.36 $566.07 $566.07 $233.72 $209.76 $692.21 $699.20 $324.73 $370.58 $324.73 $68.95 $72.03 $72.03 $139.14 $222.60 $0.00 $0.00 $0.00 $0.00 32000517 EAP CPT® 74742 TRANSCERVIC CATH FALLOPIAN SPV BOTH IP/OP $623.00 $461.02 $0.00 $498.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.65 $149.65 $155.40 $0.00 $129.83 $0.00 $0.00 $0.00 $0.00 $149.52 $493.42 $498.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000547 EAP CPT® 75726 ANGIO MESENTERIC SPV BOTH IP/OP "$8,089.00 " "$5,985.86" $87.16 "$8,156.48" $340.22 $340.22 "$4,643.92" "$4,643.92" "$4,670.08" "$1,685.95" $560.51 $560.51 $582.07 "$4,572.02" "$1,685.75" "$2,971.81" "$4,784.64" "$4,784.64" "$4,609.70" "$1,961.04" "$6,471.43" "$6,536.80" "$6,404.56" "$8,156.48" "$6,404.56" $535.99 $87.16 $87.16 "$1,300.82" "$4,390.19" $0.00 $0.00 $0.00 $0.00 32000548 EAP CPT® 75726 ANGIO HEPATIC SPV BOTH IP/OP "$8,089.00 " "$5,985.86" $87.16 "$8,156.48" $340.22 $340.22 "$4,643.92" "$4,643.92" "$4,670.08" "$1,685.95" $560.51 $560.51 $582.07 "$4,572.02" "$1,685.75" "$2,971.81" "$4,784.64" "$4,784.64" "$4,609.70" "$1,961.04" "$6,471.43" "$6,536.80" "$6,404.56" "$8,156.48" "$6,404.56" $535.99 $87.16 $87.16 "$1,300.82" "$4,390.19" $0.00 $0.00 $0.00 $0.00 32000555 EAP CPT® 75746 ANGIO PULMONARY NONSELE SPV BOTH IP/OP "$2,391.00 " "$1,769.34" $0.00 "$2,787.76" $349.06 $349.06 "$2,787.76" "$2,787.76" "$2,391.00" $498.34 $545.99 $545.99 $566.99 "$2,742.67" $498.28 "$1,782.74" "$1,414.28" "$1,414.28" $0.00 $717.36 "$2,367.29" "$2,391.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000556 EAP CPT® 75756 "Artery Xray, Chest" BOTH IP/OP "$3,613.00 " "$2,673.62" $0.00 "$3,613.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.75 $577.75 $599.97 $0.00 $752.95 $0.00 $0.00 $0.00 $0.00 $875.76 "$2,890.01" "$2,919.20" $0.00 "$3,613.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000560 EAP CPT® 75809 Shuntogram Rdg BOTH IP/OP $853.00 $631.22 $53.15 $689.60 $224.93 $224.93 $106.02 $106.02 $106.62 $177.79 $156.21 $156.21 $162.22 $104.44 $177.77 $67.89 $504.55 $504.55 $112.41 $206.88 $682.70 $689.60 $156.18 $169.61 $156.18 $53.15 $68.43 $68.43 $137.23 $107.06 $0.00 $0.00 $0.00 $0.00 32000561 EAP CPT® 75810 SPLENOPORTOGRAPHY SPV BOTH IP/OP "$11,121.00 " "$8,229.54" $0.00 "$8,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,375.38" "$1,375.38" "$1,428.28" $0.00 "$2,317.62" $0.00 $0.00 $0.00 $0.00 "$2,669.04" "$8,807.83" "$8,896.80" $0.00 "$7,093.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000562 EAP CPT® 75820 EXTREMITY UNI VENOGRAM SPV BOTH IP/OP "$1,483.00 " "$1,097.42" $71.50 "$2,361.12" $262.84 $262.84 "$1,369.42" "$1,369.42" "$1,377.13" $309.09 $205.08 $205.08 $212.97 "$1,347.67" $309.06 $875.99 $877.19 $877.19 $632.36 $359.52 "$1,186.42" "$1,198.40" $878.58 "$2,361.12" $878.58 $71.50 $74.20 $74.20 $238.48 $602.25 $0.00 $0.00 $0.00 $0.00 32000563 EAP CPT® 75822 EXTREMITY BI VENOGRAM SPV BOTH IP/OP "$1,616.00 " "$1,195.84" $75.28 "$2,361.12" $312.02 $312.02 "$1,369.42" "$1,369.42" "$1,377.13" $336.81 $227.43 $227.43 $236.17 "$1,347.67" $336.77 $875.99 $955.86 $955.86 "$1,635.92" $378.48 "$1,248.98" "$1,261.60" "$1,577.00" "$2,361.12" "$1,577.00" $109.07 $75.28 $75.28 $251.06 "$1,558.02" $0.00 $0.00 $0.00 $0.00 32000564 EAP CPT® 75825 INFERIOR VENO CAVAGRAM SPV BOTH IP/OP "$8,524.00 " "$6,307.76" $0.00 "$6,748.00" $308.83 $308.83 "$2,787.76" "$2,787.76" "$2,803.47" "$1,776.61" $506.96 $506.96 $526.46 "$2,742.67" "$1,776.40" "$1,782.74" "$5,041.95" "$5,041.95" $0.00 "$2,024.40" "$6,680.52" "$6,748.00" $0.00 "$4,727.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000565 EAP CPT® 75827 SUPERIOR VENO CAVAGRAM SPV BOTH IP/OP "$2,543.00 " "$1,881.82" $0.00 "$2,543.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $508.79 $508.79 $528.36 $0.00 $529.96 $0.00 $0.00 $0.00 $0.00 $603.84 "$1,992.67" "$2,012.80" $0.00 "$2,543.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000566 EAP CPT® 75831 RENAL VENOGRAPH UNI SELEC SPV BOTH IP/OP "$7,721.00 " "$5,713.54" $0.00 "$6,239.20" $319.28 $319.28 "$2,787.76" "$2,787.76" "$2,803.47" "$1,609.25" $514.24 $514.24 $534.02 "$2,742.67" "$1,609.06" "$1,782.74" "$4,566.97" "$4,566.97" $0.00 "$1,871.76" "$6,176.81" "$6,239.20" $0.00 "$4,727.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000567 EAP CPT® 75833 RENAL VENOGRAM BI SELECT SPV BOTH IP/OP "$8,009.00 " "$5,926.66" $0.00 "$7,649.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.89 $546.89 $567.93 $0.00 "$1,669.08" $0.00 $0.00 $0.00 $0.00 "$1,922.16" "$6,343.13" "$6,407.20" $0.00 "$7,649.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000568 EAP CPT® 75840 ADRENAL VENO UNILAT SEL SPV BOTH IP/OP "$5,361.00 " "$3,967.14" $0.00 "$5,361.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.59 $510.59 $530.23 $0.00 "$1,117.23" $0.00 $0.00 $0.00 $0.00 "$1,299.60" "$4,288.68" "$4,332.00" $0.00 "$5,361.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000569 EAP CPT® 75842 ADRENAL VENOGRPHY BI SELCT SPV BOTH IP/OP "$5,630.00 " "$4,166.20" $0.00 "$4,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $548.70 $548.70 $569.81 $0.00 "$1,173.29" $0.00 $0.00 $0.00 $0.00 "$1,351.20" "$4,458.96" "$4,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000570 EAP CPT® 75860 SINUS/JUGULAR VENOGRAM SPN BOTH IP/OP "$3,267.00 " "$2,417.58" $0.00 "$4,727.44" $327.33 $327.33 "$2,787.76" "$2,787.76" "$2,803.47" $680.92 $524.20 $524.20 $544.36 "$2,742.67" $680.84 "$1,782.74" "$1,932.43" "$1,932.43" $0.00 $792.00 "$2,613.60" "$2,640.00" $0.00 "$4,727.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000571 EAP CPT® 75870 SUPER SAGG SINUS VENOGRAM SPN BOTH IP/OP "$2,716.00 " "$2,009.84" $0.00 "$2,172.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $522.39 $522.39 $542.48 $0.00 $566.01 $0.00 $0.00 $0.00 $0.00 $651.84 "$2,151.07" "$2,172.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000572 EAP CPT® 75872 EPIDURAL VENOGRAM SPN BOTH IP/OP "$1,855.00 " "$1,372.70" $0.00 "$1,855.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $574.13 $574.13 $596.21 $0.00 $386.58 $0.00 $0.00 $0.00 $0.00 $445.20 "$1,469.16" "$1,484.00" $0.00 "$1,855.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000573 EAP CPT® 75880 ORBITAL VENOGRAM SPN BOTH IP/OP "$1,855.00 " "$1,372.70" $0.00 "$1,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.42 $211.42 $219.55 $0.00 $386.58 $0.00 $0.00 $0.00 $0.00 $445.20 "$1,469.16" "$1,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000574 EAP CPT® 75885 TRANS-HEP PORT W/HEMODYNAM SPV BOTH IP/OP "$7,625.00 " "$5,642.50" $0.00 "$7,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $516.04 $516.04 $535.89 $0.00 "$1,589.05" $0.00 $0.00 $0.00 $0.00 "$1,848.48" "$6,099.98" "$6,161.60" $0.00 "$7,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000575 EAP CPT® 75887 TRANS-HEP PORT W/O HEMODYN SPV BOTH IP/OP "$4,003.00 " "$2,962.22" $0.00 "$4,003.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $521.49 $521.49 $541.54 $0.00 $834.23 $0.00 $0.00 $0.00 $0.00 $970.32 "$3,202.06" "$3,234.40" $0.00 "$4,003.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000576 EAP CPT® 75889 HEPATIC WEDGE VENO W/EVAL SPV BOTH IP/OP "$7,625.00 " "$5,642.50" $0.00 "$7,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $515.13 $515.13 $534.95 $0.00 "$1,589.05" $0.00 $0.00 $0.00 $0.00 "$1,848.48" "$6,099.98" "$6,161.60" $0.00 "$7,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000577 EAP CPT® 75891 HEPATIC WEDG VENO W/O EVAL SPV BOTH IP/OP "$8,009.00 " "$5,926.66" $0.00 "$6,407.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $515.13 $515.13 $534.95 $0.00 "$1,669.08" $0.00 $0.00 $0.00 $0.00 "$1,922.16" "$6,343.13" "$6,407.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000578 EAP CPT® 75893 VENOUS SAMPLING W/WO ANGI SPV BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $514.24 $514.24 $534.02 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$1,200.00" "$3,960.00" "$4,000.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000579 EAP CPT® 75894 Transcath Embolization BOTH IP/OP "$11,713.00 " "$8,667.62" $0.00 "$12,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,635.61" "$2,635.61" "$2,736.98" $0.00 "$2,440.99" $0.00 $0.00 $0.00 $0.00 "$2,561.04" "$8,451.43" "$8,536.80" $0.00 "$12,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000580 EAP CPT® 75894 "Transcath Embolization, S&i" BOTH IP/OP "$10,671.00 " "$7,896.54" $0.00 "$12,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,635.61" "$2,635.61" "$2,736.98" $0.00 "$2,223.84" $0.00 $0.00 $0.00 $0.00 "$2,561.04" "$8,451.43" "$8,536.80" $0.00 "$12,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000585 EAP CPT® 75901 Remove Cva Device Obstruct BOTH IP/OP $585.00 $432.90 $0.00 $585.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.60 $361.60 $375.51 $0.00 $121.91 $0.00 $0.00 $0.00 $0.00 $141.84 $468.07 $472.80 $0.00 $585.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000592 EAP CPT® 75956 Endovasc Thor Ao Repr BOTH IP/OP "$2,118.00 " "$1,567.32" $0.00 "$1,694.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.98" "$1,571.98" "$1,632.55" $0.00 $441.39 $0.00 $0.00 $0.00 $0.00 $508.32 "$1,677.46" "$1,694.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000593 EAP CPT® 75957 Endovasc Thor Aor Repr BOTH IP/OP "$2,287.00 " "$1,692.38" $0.00 "$1,829.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,697.41" "$1,697.41" "$1,762.82" $0.00 $476.61 $0.00 $0.00 $0.00 $0.00 $548.88 "$1,811.30" "$1,829.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000594 EAP CPT® 75958 Place Prox Ext Thor Ao BOTH IP/OP "$1,761.00 " "$1,303.14" $0.00 "$1,408.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.01" "$1,307.01" "$1,357.38" $0.00 $366.99 $0.00 $0.00 $0.00 $0.00 $422.64 "$1,394.71" "$1,408.80" $0.00 "$1,235.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000595 EAP CPT® 75959 Place Dist Ext Thor Ao BOTH IP/OP "$1,693.00 " "$1,252.82" $0.00 "$1,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.54" "$1,256.54" "$1,304.96" $0.00 $352.82 $0.00 $0.00 $0.00 $0.00 $406.32 "$1,340.86" "$1,354.40" $0.00 "$1,083.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000607 EAP CPT® 75984 CHNG DRN TUBE CATH W DYE SPV BOTH IP/OP "$2,247.00 " "$1,662.78" $0.00 "$1,816.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.56 $191.56 $198.93 $0.00 $468.27 $0.00 $0.00 $0.00 $0.00 $544.80 "$1,797.84" "$1,816.00" $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000608 EAP CPT® 75989 Us Drain Percut S&i BOTH IP/OP "$3,905.00 " "$2,889.70" $0.00 "$3,124.00" $726.00 $726.00 $0.00 $0.00 $0.00 $813.90 $785.72 $785.72 $815.94 $0.00 $813.80 $0.00 "$2,309.81" "$2,309.81" $0.00 $937.20 "$3,092.76" "$3,124.00" $0.00 "$2,241.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000609 EAP CPT® 75989 Drain Of Abscess Perc S&i BOTH IP/OP "$4,282.00 " "$3,168.68" $0.00 "$3,124.00" $726.00 $726.00 $0.00 $0.00 $0.00 $892.48 $785.72 $785.72 $815.94 $0.00 $892.37 $0.00 "$2,532.80" "$2,532.80" $0.00 $937.20 "$3,092.76" "$3,124.00" $0.00 "$2,241.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000612 EAP CPT® 76000 Fluoro Modified Barium Swallow BOTH IP/OP "$1,426.00 " "$1,055.24" $26.65 "$1,152.00" $108.06 $108.06 $224.08 $224.08 $225.34 $297.21 $216.68 $216.68 $225.02 $220.56 $297.18 $143.36 $843.48 $843.48 $233.72 $345.60 "$1,140.48" "$1,152.00" $324.73 $370.58 $324.73 $58.43 $26.65 $26.65 $229.25 $222.60 $0.00 $0.00 $0.00 $0.00 32000613 EAP CPT® 76000 FLUOROSCOPY MAX 1 HOUR RDG BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.72 $345.60 "$1,140.48" "$1,152.00" $324.73 $0.00 $324.73 $58.43 $26.65 $26.65 $229.25 $222.60 $0.00 $0.00 $0.00 $0.00 32000614 EAP CPT® 76000 Fluoro Time Up To 1 Hr BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.72 $345.60 "$1,140.48" "$1,152.00" $324.73 $0.00 $324.73 $58.43 $26.65 $26.65 $229.25 $222.60 $0.00 $0.00 $0.00 $0.00 32000615 EAP CPT® 76000 Prosthetic Valve Cine Fluoro BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.72 $345.60 "$1,140.48" "$1,152.00" $324.73 $0.00 $324.73 $58.43 $26.65 $26.65 $229.25 $222.60 $0.00 $0.00 $0.00 $0.00 32000619 EAP CPT® 76010 NOSE TO RECTUM FBODY CHILD RDG BOTH IP/OP $370.00 $273.80 $0.00 $296.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.96 $45.96 $47.73 $0.00 $77.11 $0.00 $0.00 $0.00 $0.00 $88.80 $293.04 $296.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000621 EAP CPT® 76080 ABSCESS/FISTULA/SINUS S&I BCT BOTH IP/OP $865.00 $640.10 $0.00 $865.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.90 $88.90 $92.32 $0.00 $180.27 $0.00 $0.00 $0.00 $0.00 $209.76 $692.21 $699.20 $0.00 $865.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000624 EAP CPT® 76098 RAD EXAM SURGICAL SPECMEN BIC BOTH IP/OP "$1,550.00 " "$1,147.00" $27.37 "$1,127.20" $37.91 $37.91 $470.55 $470.55 $473.20 $323.06 $28.74 $28.74 $29.84 $462.81 $323.02 $300.83 $916.83 $916.83 $483.00 $338.16 "$1,115.93" "$1,127.20" $671.06 $798.44 $671.06 $220.51 $27.37 $27.37 $224.31 $460.00 $0.00 $0.00 $0.00 $0.00 32000625 EAP CPT® 76098 Rad Exam Surgical Specmen Cbc BOTH IP/OP "$1,409.00 " "$1,042.66" $27.37 "$1,127.20" $37.91 $37.91 $470.55 $470.55 $473.20 $293.67 $28.74 $28.74 $29.84 $462.81 $293.64 $300.83 $833.42 $833.42 $483.00 $338.16 "$1,115.93" "$1,127.20" $671.06 $798.44 $671.06 $220.51 $27.37 $27.37 $224.31 $460.00 $0.00 $0.00 $0.00 $0.00 32000733 EAP CPT® 77001 FLUORO GUIDE CV ACCESS DEV SPV BOTH IP/OP "$1,059.00 " $783.66 $0.00 "$1,059.00" $191.88 $191.88 $0.00 $0.00 $0.00 $220.72 $211.68 $211.68 $219.82 $0.00 $220.70 $0.00 $626.40 $626.40 $0.00 $256.80 $847.44 $856.00 $0.00 "$1,059.00" $0.00 $79.65 $78.52 $78.52 $170.34 $0.00 $0.00 $0.00 $0.00 $0.00 32000734 EAP CPT® 77002 Fluoro Guide Needle Place Rdg BOTH IP/OP $717.00 $530.58 $0.00 "$1,513.00" $212.04 $212.04 $0.00 $0.00 $0.00 $149.44 $109.62 $109.62 $113.83 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $173.76 $573.41 $579.20 $0.00 "$1,513.00" $0.00 $71.68 $81.40 $81.40 $115.26 $0.00 $0.00 $0.00 $0.00 $0.00 32000735 EAP CPT® 77002 FLUORO GUIDED BX/ASPIRAT SPN BOTH IP/OP $724.00 $535.76 $0.00 $579.20 $0.00 $0.00 $0.00 $0.00 $0.00 $149.44 $0.00 $0.00 $0.00 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $173.76 $573.41 $579.20 $0.00 $0.00 $0.00 $71.68 $81.40 $81.40 $115.26 $0.00 $0.00 $0.00 $0.00 $0.00 32000736 EAP CPT® 77002 Fluoro Guidance For Needle Pla BOTH IP/OP $724.00 $535.76 $0.00 $579.20 $0.00 $0.00 $0.00 $0.00 $0.00 $149.44 $0.00 $0.00 $0.00 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $173.76 $573.41 $579.20 $0.00 $0.00 $0.00 $71.68 $81.40 $81.40 $115.26 $0.00 $0.00 $0.00 $0.00 $0.00 32000738 EAP CPT® 77003 Fluoroscopy For Spine Procedur BOTH IP/OP $924.00 $683.76 $0.00 $863.00 $214.45 $214.45 $0.00 $0.00 $0.00 $192.58 $76.94 $76.94 $79.90 $0.00 $192.56 $0.00 $546.55 $546.55 $0.00 $223.92 $738.94 $746.40 $0.00 $863.00 $0.00 $69.40 $72.03 $72.03 $148.53 $0.00 $0.00 $0.00 $0.00 $0.00 32000739 EAP CPT® 77003 FLOURO GUIDE FOR SPINE RDG BOTH IP/OP $924.00 $683.76 $0.00 $863.00 $214.45 $214.45 $0.00 $0.00 $0.00 $192.58 $76.94 $76.94 $79.90 $0.00 $192.56 $0.00 $546.55 $546.55 $0.00 $223.92 $738.94 $746.40 $0.00 $863.00 $0.00 $69.40 $72.03 $72.03 $148.53 $0.00 $0.00 $0.00 $0.00 $0.00 32000740 EAP CPT® 77003 Fluoroguide For Spine Inject BOTH IP/OP $924.00 $683.76 $0.00 $863.00 $214.45 $214.45 $0.00 $0.00 $0.00 $192.58 $76.94 $76.94 $79.90 $0.00 $192.56 $0.00 $546.55 $546.55 $0.00 $223.92 $738.94 $746.40 $0.00 $863.00 $0.00 $69.40 $72.03 $72.03 $148.53 $0.00 $0.00 $0.00 $0.00 $0.00 32000751 EAP CPT® 77053 Galactogram Single Duct Bic BOTH IP/OP "$1,073.00 " $794.02 $0.00 "$1,063.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.79 $144.79 $150.36 $0.00 $223.61 $0.00 $0.00 $0.00 $0.00 $318.96 "$1,052.57" "$1,063.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000752 EAP CPT® 77054 Galactogram Multi Duct Bic BOTH IP/OP "$1,248.00 " $923.52 $0.00 "$1,236.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.37 $199.37 $207.04 $0.00 $260.08 $0.00 $0.00 $0.00 $0.00 $371.04 "$1,224.43" "$1,236.80" $0.00 "$1,231.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000764 EAP CPT® 77072 BONE AGE STUDIES X-RAY RDG BOTH IP/OP $510.00 $377.40 $15.85 $412.00 $52.40 $52.40 $106.02 $106.02 $106.62 $106.30 $34.16 $34.16 $35.48 $104.44 $106.28 $67.89 $301.67 $301.67 $112.41 $123.60 $407.88 $412.00 $156.18 $169.61 $156.18 $21.36 $15.85 $15.85 $81.99 $107.06 $0.00 $0.00 $0.00 $0.00 32000766 EAP CPT® 77073 BONE LENGTH STUDIES RDG BOTH IP/OP $629.00 $465.46 $30.61 $508.00 $81.44 $81.44 $106.02 $106.02 $106.62 $131.10 $59.12 $59.12 $61.40 $104.44 $131.08 $67.89 $372.05 $372.05 $112.41 $152.40 $502.92 $508.00 $156.18 $169.61 $156.18 $40.42 $30.61 $30.61 $101.09 $107.06 $0.00 $0.00 $0.00 $0.00 32000768 EAP CPT® 77074 BONE SURVEY OSSEOUS LIMIT RDG BOTH IP/OP $430.00 $318.20 $0.00 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.40 $113.40 $117.76 $0.00 $89.61 $0.00 $0.00 $0.00 $0.00 $103.68 $342.14 $345.60 $0.00 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000770 EAP CPT® 77075 BONE SURVEY OSSEOUS COMPL RDG BOTH IP/OP $453.00 $335.22 $67.89 $364.00 $198.32 $198.32 $106.02 $106.02 $106.62 $94.42 $179.33 $179.33 $186.22 $104.44 $94.41 $67.89 $267.95 $267.95 $112.41 $109.20 $360.36 $364.00 $156.18 $169.61 $156.18 $85.39 $68.07 $68.07 $72.44 $107.06 $0.00 $0.00 $0.00 $0.00 32000772 EAP CPT® 77076 BONE SURVEY OSSEOUS INFANT RDG BOTH IP/OP $290.00 $214.60 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.33 $145.33 $150.92 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $69.84 $230.47 $232.80 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000773 EAP CPT® 77080 Bone Density Scan Axial BOTH IP/OP $866.00 $640.84 $29.89 $700.00 $93.51 $93.51 $106.02 $106.02 $106.62 $180.50 $152.48 $152.48 $158.35 $104.44 $180.47 $67.89 $512.24 $512.24 $112.41 $210.00 $693.00 $700.00 $156.18 $169.61 $156.18 $108.31 $29.89 $29.89 $139.30 $107.06 $0.00 $0.00 $0.00 $0.00 32000774 EAP CPT® 77081 BONE DENSISTY SCAN PERIPH NUC BOTH IP/OP $162.00 $119.88 $22.33 $137.87 $63.70 $63.70 $78.77 $78.77 $79.21 $33.76 $48.21 $48.21 $50.07 $77.54 $33.76 $50.40 $95.82 $95.82 $80.04 $39.36 $129.89 $131.20 $111.21 $137.87 $111.21 $38.50 $22.33 $22.33 $26.11 $76.23 $0.00 $0.00 $0.00 $0.00 32000784 EAP CPT® 75860 Sinus/jugular Venogram Nir BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$4,727.44" $327.33 $327.33 "$2,787.76" "$2,787.76" "$2,803.47" $655.50 $524.20 $524.20 $544.36 "$2,742.67" $655.42 "$1,782.74" "$1,860.27" "$1,860.27" $0.00 $792.00 "$2,613.60" "$2,640.00" $0.00 "$4,727.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000785 EAP CPT® 75870 Super Sagg Sinus Venogram Nir BOTH IP/OP "$2,716.00 " "$2,009.84" $0.00 "$2,172.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $522.39 $522.39 $542.48 $0.00 $566.01 $0.00 $0.00 $0.00 $0.00 $651.84 "$2,151.07" "$2,172.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000786 EAP CPT® 75872 Epidural Venogram Nir BOTH IP/OP "$1,855.00 " "$1,372.70" $0.00 "$1,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $574.13 $574.13 $596.21 $0.00 $386.58 $0.00 $0.00 $0.00 $0.00 $445.20 "$1,469.16" "$1,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000787 EAP CPT® 75894 Transcath Embolization Nir BOTH IP/OP "$10,671.00 " "$7,896.54" $0.00 "$12,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,635.61" "$2,635.61" "$2,736.98" $0.00 "$2,223.84" $0.00 $0.00 $0.00 $0.00 "$2,561.04" "$8,451.43" "$8,536.80" $0.00 "$12,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000790 EAP CPT® 76000 Fluoroscopy Max 1 Hour Nir BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $241.15 $0.00 $0.00 $0.00 $220.56 $241.12 $143.36 $684.37 $684.37 $233.72 $345.60 "$1,140.48" "$1,152.00" $324.73 $0.00 $324.73 $58.43 $26.65 $26.65 $229.25 $222.60 $0.00 $0.00 $0.00 $0.00 32000796 EAP CPT® 74263 "Ct Colonography, Screen" BOTH IP/OP "$1,621.00 " "$1,199.54" $0.00 "$1,404.90" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.82 $0.00 "$1,106.00" "$1,106.00" $0.00 $389.04 "$1,283.83" "$1,296.80" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000797 EAP CPT® 74261 "Ct Colonography, W/o Dye" BOTH IP/OP "$1,621.00 " "$1,199.54" $0.00 "$1,404.90" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.82 $0.00 "$1,106.00" "$1,106.00" $0.00 $389.04 "$1,283.83" "$1,296.80" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000798 EAP CPT® 74262 "Ct Colonography, W/dye" BOTH IP/OP "$1,621.00 " "$1,199.54" $0.00 "$1,404.90" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.82 $0.00 "$1,106.00" "$1,106.00" $0.00 $389.04 "$1,283.83" "$1,296.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000800 EAP CPT® 76000 Fluoroscopy 1st Hour BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.72 $345.60 "$1,140.48" "$1,152.00" $324.73 $0.00 $324.73 $58.43 $26.65 $26.65 $229.25 $222.60 $0.00 $0.00 $0.00 $0.00 32000801 EAP CPT® 72072 Throacic Spine 4 View Rdg BOTH IP/OP "$1,196.00 " $885.04 $0.00 "$1,031.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.28 $67.28 $69.87 $0.00 $249.25 $0.00 $0.00 $0.00 $0.00 $287.04 $947.23 $956.80 $0.00 "$1,031.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000802 EAP CPT® 77071 Manual Appl Stress Pfrmd Phys/qhp Joint Films BOTH IP/OP $433.00 $320.42 $26.91 $349.60 $110.48 $110.48 $78.77 $78.77 $79.21 $90.25 $321.37 $321.37 $333.76 $77.54 $90.24 $50.40 $256.12 $256.12 $80.04 $104.88 $346.10 $349.60 $111.21 $137.87 $111.21 $26.91 $54.05 $54.05 $69.57 $76.23 $0.00 $0.00 $0.00 $0.00 32000810 EAP CPT® 74190 "Peritoneogram, Radiological Supervision And Interpretation" BOTH IP/OP $911.00 $674.14 $0.00 $728.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.79 $142.79 $148.28 $0.00 $189.85 $0.00 $0.00 $0.00 $0.00 $218.64 $721.51 $728.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000812 EAP CPT® 74450 "Urethrocystography, Retrograde, Radiological Supervision" BOTH IP/OP "$2,150.00 " "$1,591.00" $0.00 "$2,105.60" $0.00 $0.00 $0.00 $0.00 $0.00 $448.11 $159.33 $159.33 $165.46 $220.56 $448.06 $143.36 "$1,271.73" "$1,271.73" $233.72 $631.68 "$2,084.54" "$2,105.60" $324.73 $915.00 $324.73 $72.23 $0.00 $0.00 $419.01 $222.60 $0.00 $0.00 $0.00 $0.00 32000813 EAP CPT® 74455 "Urethrocystography, Voiding, Radiological Supervision" BOTH IP/OP "$2,191.00 " "$1,621.34" $76.86 "$1,612.00" $186.23 $186.23 $224.08 $224.08 $225.34 $456.66 $181.73 $181.73 $188.72 $220.56 $456.60 $143.36 "$1,295.98" "$1,295.98" $233.72 $483.60 "$1,595.88" "$1,612.00" $324.73 $370.58 $324.73 $76.86 $82.12 $82.12 $320.79 $222.60 $0.00 $0.00 $0.00 $0.00 32000814 EAP CPT® 74470 "Radiologic Examination, Renal Cyst Study" BOTH IP/OP $927.00 $685.98 $0.00 $908.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.54 $136.54 $141.79 $0.00 $193.19 $0.00 $0.00 $0.00 $0.00 $272.40 $898.92 $908.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000815 EAP CPT® 75733 "Adrenal, Bilateral" BOTH IP/OP "$4,426.00 " "$3,275.24" $0.00 "$4,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $647.63 $647.63 $672.54 $0.00 $922.38 $0.00 $0.00 $0.00 $0.00 "$1,073.04" "$3,541.03" "$3,576.80" $0.00 "$4,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000820 EAP CPT® 75809 Shuntogram For Investigation BOTH IP/OP $862.00 $637.88 $53.15 $689.60 $224.93 $224.93 $106.02 $106.02 $106.62 $179.66 $156.21 $156.21 $162.22 $104.44 $179.64 $67.89 $509.87 $509.87 $112.41 $206.88 $682.70 $689.60 $156.18 $169.61 $156.18 $53.15 $68.43 $68.43 $137.23 $107.06 $0.00 $0.00 $0.00 $0.00 32000821 EAP CPT® 75902 Mechanical Removal Of Intraluminal (intracatheter) Frome BOTH IP/OP "$1,027.00 " $759.98 $0.00 $821.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.80 $192.80 $200.21 $0.00 $214.03 $0.00 $0.00 $0.00 $0.00 $246.48 $813.38 $821.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000822 EAP CPT® 75970 "Transcatheter Biopsy, Radiological Supervision And Interpretation" BOTH IP/OP "$3,027.00 " "$2,239.98" $0.00 "$3,027.00" "$1,022.08" "$1,022.08" $0.00 $0.00 $0.00 $0.00 "$1,259.39" "$1,259.39" "$1,307.83" $0.00 $630.83 $0.00 $0.00 $0.00 $0.00 $733.92 "$2,421.94" "$2,446.40" $0.00 "$3,027.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000823 EAP CPT® 75984 Change Of Percutaneous Tube Or Drainage Catheter With Contrast BOTH IP/OP "$2,247.00 " "$1,662.78" $0.00 "$1,816.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.56 $191.56 $198.93 $0.00 $468.27 $0.00 $0.00 $0.00 $0.00 $544.80 "$1,797.84" "$1,816.00" $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000824 EAP CPT® 75989 Radiological Guidance For Percutaneous Drainage BOTH IP/OP "$4,282.00 " "$3,168.68" $0.00 "$3,124.00" $726.00 $726.00 $0.00 $0.00 $0.00 $892.48 $785.72 $785.72 $815.94 $0.00 $892.37 $0.00 "$2,532.80" "$2,532.80" $0.00 $937.20 "$3,092.76" "$3,124.00" $0.00 "$2,241.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000825 EAP CPT® 76080 "Abscess, Fistula, Sinus Tract Study" BOTH IP/OP $865.00 $640.10 $0.00 $865.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.90 $88.90 $92.32 $0.00 $180.27 $0.00 $0.00 $0.00 $0.00 $209.76 $692.21 $699.20 $0.00 $865.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000826 EAP CPT® 76940 "Ultrasound Guidance For, And Monitoring Of, Parenchymaln" BOTH IP/OP "$1,128.00 " $834.72 $0.00 "$1,443.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.95 $184.95 $192.07 $0.00 $235.08 $0.00 $0.00 $0.00 $0.00 $273.36 $902.09 $911.20 $0.00 "$1,443.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000828 EAP CPT® 0075T "Intravascular Stent, Perc, Initial Vessel" BOTH IP/OP "$14,320.00 " "$10,596.80" $0.00 "$10,875.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,984.29" $0.00 $0.00 $0.00 $0.00 "$6,797.00" "$10,766.45" "$10,875.20" $0.00 "$9,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000829 EAP CPT® 0076T "Intravascular Stent, Perc, Ea Add'l Vessel" BOTH IP/OP "$11,316.00 " "$8,373.84" $0.00 "$10,362.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,722.37" $0.00 "$2,358.25" $0.00 $0.00 $0.00 $0.00 "$6,476.50" "$10,258.78" "$10,362.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000840 EAP CPT® 76496 Fluroscopy Procedure BOTH IP/OP $528.00 $390.72 $0.00 $473.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.43 $210.43 $218.53 $0.00 $110.04 $0.00 $0.00 $0.00 $0.00 $125.76 $415.01 $419.20 $0.00 $473.00 $0.00 $82.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000843 EAP CPT® 49422 Removal Of Tunneled Intraperitoneal Catheter BOTH IP/OP "$3,643.00 " "$2,695.82" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $759.20 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,704.68" "$2,732.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000854 EAP CPT® 72081 Xr T-l Spine Incl Skull 1 View BOTH IP/OP $424.00 $313.76 $28.45 $310.40 $88.70 $88.70 $78.77 $78.77 $79.21 $88.37 $63.38 $63.38 $65.82 $77.54 $88.36 $50.40 $250.80 $250.80 $80.04 $93.12 $307.30 $310.40 $111.21 $137.87 $111.21 $37.03 $28.45 $28.45 $61.77 $76.23 $0.00 $0.00 $0.00 $0.00 32000855 EAP CPT® 72083 Xr T-l Spine 4 Or 5 Views BOTH IP/OP "$1,228.00 " $908.72 $0.00 "$1,182.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.05 $125.05 $129.86 $0.00 $255.92 $0.00 $0.00 $0.00 $0.00 $294.72 $972.58 $982.40 $0.00 "$1,182.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000856 EAP CPT® 72084 Xr T-l Spine Incl Skll 6+ View BOTH IP/OP "$1,228.00 " $908.72 $0.00 $982.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.07 $150.07 $155.84 $0.00 $255.92 $0.00 $0.00 $0.00 $0.00 $294.72 $972.58 $982.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000857 EAP CPT® 73501 Xr Hip Unilat W/pelvis 1 View BOTH IP/OP $378.00 $279.72 $22.33 $280.00 $67.72 $67.72 $78.77 $78.77 $79.21 $78.78 $50.89 $50.89 $52.84 $77.54 $78.78 $50.40 $223.59 $223.59 $80.04 $84.00 $277.20 $280.00 $111.21 $137.87 $111.21 $28.22 $22.33 $22.33 $55.72 $76.23 $0.00 $0.00 $0.00 $0.00 32000858 EAP CPT® 73502 Xr Hip Unilat W/pelvis 2-3 Vw BOTH IP/OP $378.00 $279.72 $34.22 $280.00 $94.33 $94.33 $78.77 $78.77 $79.21 $78.78 $75.00 $75.00 $77.89 $77.54 $78.78 $50.40 $223.59 $223.59 $80.04 $84.00 $277.20 $280.00 $111.21 $137.87 $111.21 $39.45 $34.22 $34.22 $55.72 $76.23 $0.00 $0.00 $0.00 $0.00 32000859 EAP CPT® 73503 Xr Hip Unilat W/pelvis 4+ Vw BOTH IP/OP $627.00 $463.98 $42.50 $464.80 $117.72 $117.72 $106.02 $106.02 $106.62 $130.68 $92.89 $92.89 $96.47 $104.44 $130.67 $67.89 $370.87 $370.87 $112.41 $139.44 $460.15 $464.80 $156.18 $169.61 $156.18 $49.31 $42.50 $42.50 $92.50 $107.06 $0.00 $0.00 $0.00 $0.00 32000860 EAP CPT® 73521 Xr Hip Bilat W/pelvis 2 Views BOTH IP/OP $627.00 $463.98 $28.81 $464.80 $90.29 $90.29 $106.02 $106.02 $106.62 $130.68 $70.54 $70.54 $73.26 $104.44 $130.67 $67.89 $370.87 $370.87 $112.41 $139.44 $460.15 $464.80 $156.18 $169.61 $156.18 $37.75 $28.81 $28.81 $92.50 $107.06 $0.00 $0.00 $0.00 $0.00 32000861 EAP CPT® 73522 Xr Hip Bilat W/pelvis 3-4 View BOTH IP/OP $627.00 $463.98 $37.46 $464.80 $111.25 $111.25 $106.02 $106.02 $106.62 $130.68 $83.92 $83.92 $87.15 $104.44 $130.67 $67.89 $370.87 $370.87 $112.41 $139.44 $460.15 $464.80 $156.18 $169.61 $156.18 $46.58 $37.46 $37.46 $92.50 $107.06 $0.00 $0.00 $0.00 $0.00 32000862 EAP CPT® 73523 Xr Hip Bilat W/pelvis 5+ Views BOTH IP/OP "$1,194.00 " $883.56 $0.00 $884.80 $128.99 $128.99 $106.02 $106.02 $106.62 $248.86 $100.92 $100.92 $104.80 $104.44 $248.83 $67.89 $706.25 $706.25 $0.00 $265.44 $875.95 $884.80 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000863 EAP CPT® 73551 Xr Femur 1 View BOTH IP/OP $361.00 $267.14 $0.00 $465.00 $63.70 $63.70 $78.77 $78.77 $79.21 $0.00 $48.20 $48.20 $50.06 $0.00 $75.23 $0.00 $0.00 $0.00 $80.04 $79.44 $262.15 $264.80 $111.21 $465.00 $111.21 $26.17 $20.89 $20.89 $52.70 $76.23 $0.00 $0.00 $0.00 $0.00 32000864 EAP CPT® 73552 Xr Femur Min 2 Views BOTH IP/OP $361.00 $267.14 $25.57 $264.80 $74.18 $74.18 $78.77 $78.77 $79.21 $75.24 $57.14 $57.14 $59.34 $77.54 $75.23 $50.40 $213.53 $213.53 $80.04 $79.44 $262.15 $264.80 $111.21 $137.87 $111.21 $30.93 $25.57 $25.57 $52.70 $76.23 $0.00 $0.00 $0.00 $0.00 32000865 EAP CPT® 76499 Radiographic Procedure BOTH IP/OP $150.00 $111.00 $0.00 $137.87 $0.00 $0.00 $78.77 $78.77 $79.21 $31.26 $111.33 $111.33 $115.62 $77.54 $31.26 $50.40 $88.73 $88.73 $0.00 $35.76 $118.01 $119.20 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000866 EAP CPT® 77077 Joint Survey Single View BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.21 $66.21 $68.75 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $66.00 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000867 EAP CPT® 76000 Fluoro Additional Hour BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.72 $345.60 "$1,140.48" "$1,152.00" $324.73 $0.00 $324.73 $58.43 $26.65 $26.65 $229.25 $222.60 $0.00 $0.00 $0.00 $0.00 32000868 EAP CPT® 75807 Lymph Vessel X-ray Trunk BOTH IP/OP "$3,673.00 " "$2,718.02" $0.00 "$3,673.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $624.83 $624.83 $648.86 $0.00 $765.45 $0.00 $0.00 $0.00 $0.00 $890.40 "$2,938.32" "$2,968.00" $0.00 "$3,673.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000869 EAP CPT® 74248 Xr Small Bowel Follow-through Add On BOTH IP/OP "$2,246.00 " "$1,662.04" $0.00 "$1,680.00" $187.57 $187.57 $0.00 $0.00 $0.00 $468.12 $110.26 $110.26 $114.50 $0.00 $468.07 $0.00 "$1,328.51" "$1,328.51" $0.00 $504.00 "$1,663.20" "$1,680.00" $0.00 "$1,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32000870 EAP CPT® 72275 Epidurography BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,067.20" $0.00 $0.00 $0.00 $0.00 $0.00 $275.33 $0.00 $0.00 $0.00 $0.00 $275.30 $0.00 $781.37 $781.37 $0.00 $320.16 "$1,056.53" "$1,067.20" $0.00 $0.00 $0.00 $107.42 $92.56 $92.56 $212.37 $0.00 $0.00 $0.00 $0.00 $0.00 32200006 EAP CPT® 73040 Shoulder Arthrography Rdg BOTH IP/OP "$1,216.00 " $899.84 $94.00 $976.00 $227.33 $227.33 $358.61 $358.61 $360.63 $253.44 $902.52 $902.52 $937.29 $352.81 $253.41 $229.33 $719.26 $719.26 $387.01 $292.80 $966.24 $976.00 $537.70 $584.68 $537.70 $107.06 $94.00 $94.00 $194.22 $368.58 $0.00 $0.00 $0.00 $0.00 32300001 EAP CPT® 75605 THORACIC ARCH ANGIO SPN BOTH IP/OP "$5,612.00 " "$4,152.88" $0.00 "$18,212.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,165.23" "$4,165.23" "$4,325.73" $0.00 "$1,169.54" $0.00 $0.00 $0.00 $0.00 "$1,360.56" "$4,489.85" "$4,535.20" $0.00 "$18,212.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32300002 EAP CPT® 75625 AORTOGRAM ABD CATHETER SPV BOTH IP/OP "$5,567.00 " "$4,119.58" $69.51 "$4,727.44" $312.87 $312.87 "$2,787.76" "$2,787.76" "$2,803.47" "$1,160.30" "$4,131.83" "$4,131.83" "$4,291.04" "$2,742.67" "$1,160.16" "$1,782.74" "$3,292.88" "$3,292.88" "$2,779.42" "$1,349.52" "$4,453.42" "$4,498.40" "$3,861.64" "$4,727.44" "$3,861.64" $536.35 $69.51 $69.51 $895.18 "$2,647.07" $0.00 $0.00 $0.00 $0.00 32300003 EAP CPT® 75630 Aortography Bilat Lower BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$6,658.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,299.25" $0.00 "$1,432.75" $0.00 $0.00 $0.00 $0.00 "$1,666.56" "$5,499.65" "$5,555.20" $0.00 "$6,658.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32300013 EAP CPT® 75705 ANGIO SPINAL SELECTIVE SPN BOTH IP/OP "$9,855.00 " "$7,292.70" $0.00 "$9,989.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,596.23" $0.00 "$2,053.78" $0.00 $0.00 $0.00 $0.00 "$2,389.20" "$7,884.36" "$7,964.00" $0.00 "$9,989.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32300014 EAP CPT® 75710 ANGIO EXTREMITY UNILAT SPV BOTH IP/OP "$8,204.00 " "$6,070.96" $78.52 "$6,323.64" $369.31 $369.31 "$2,787.76" "$2,787.76" "$2,803.47" "$1,709.92" "$4,181.12" "$4,181.12" "$6,323.64" "$2,742.67" "$1,709.71" "$1,782.74" "$4,852.67" "$4,852.67" "$2,779.42" "$1,813.92" "$5,985.94" "$6,046.40" "$3,861.64" "$4,727.44" "$3,861.64" $536.72 $78.52 $78.52 "$1,203.23" "$2,647.07" $0.00 $0.00 $0.00 $0.00 32300015 EAP CPT® 75716 ANGIO EXTREMITY BILAT SPV BOTH IP/OP "$8,615.00 " "$6,375.10" $80.32 "$6,640.44" $424.93 $424.93 "$2,787.76" "$2,787.76" "$2,803.47" "$1,795.58" "$4,181.12" "$4,181.12" "$6,640.44" "$2,742.67" "$1,795.37" "$1,782.74" "$5,095.77" "$5,095.77" "$2,779.42" "$1,904.64" "$6,285.31" "$6,348.80" "$3,861.64" "$4,727.44" "$3,861.64" $544.44 $80.32 $80.32 "$1,263.41" "$2,647.07" $0.00 $0.00 $0.00 $0.00 32300018 EAP CPT® 75726 Angio Visceral BOTH IP/OP "$8,089.00 " "$5,985.86" $87.16 "$8,156.48" $340.22 $340.22 "$4,643.92" "$4,643.92" "$4,670.08" "$1,685.95" "$4,181.12" "$4,181.12" "$6,235.00" "$4,572.02" "$1,685.75" "$2,971.81" "$4,784.64" "$4,784.64" "$4,609.70" "$1,961.04" "$6,471.43" "$6,536.80" "$6,404.56" "$8,156.48" "$6,404.56" $535.99 $87.16 $87.16 "$1,300.82" "$4,390.19" $0.00 $0.00 $0.00 $0.00 32300019 EAP CPT® 75731 ANGIO ADRENAL UNILAT SPV BOTH IP/OP "$4,162.00 " "$3,079.88" $0.00 "$4,162.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,089.04" "$3,089.04" "$3,208.07" $0.00 $867.36 $0.00 $0.00 $0.00 $0.00 "$1,008.96" "$3,329.57" "$3,363.20" $0.00 "$4,162.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32300021 EAP CPT® 75736 ANGIO PELVIC SELECTIVE SPV BOTH IP/OP "$8,804.00 " "$6,514.96" $0.00 "$8,156.48" $364.43 $364.43 "$4,643.92" "$4,643.92" "$4,670.08" $0.00 "$4,181.12" "$4,181.12" "$6,786.12" $0.00 "$1,834.75" $0.00 $0.00 $0.00 "$4,609.70" "$1,920.96" "$6,339.17" "$6,403.20" "$6,404.56" "$8,156.48" "$6,404.56" $535.99 $97.61 $97.61 "$1,274.24" "$4,390.19" $0.00 $0.00 $0.00 $0.00 32300022 EAP CPT® 75741 ANGIO PULMONARY UNILAT SPV BOTH IP/OP "$5,405.00 " "$3,999.70" $0.00 "$4,727.44" $343.41 $343.41 "$2,787.76" "$2,787.76" "$2,803.47" $0.00 "$4,011.59" "$4,011.59" "$4,166.17" $0.00 "$1,126.40" $0.00 $0.00 $0.00 $0.00 "$1,310.40" "$4,324.32" "$4,368.00" $0.00 "$4,727.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32300023 EAP CPT® 75743 ANGIO PULMONARY BILATERAL SPV BOTH IP/OP "$5,466.00 " "$4,044.84" $0.00 "$5,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,056.87" "$4,056.87" "$4,213.19" $0.00 "$1,139.11" $0.00 $0.00 $0.00 $0.00 "$1,325.04" "$4,372.63" "$4,416.80" $0.00 "$5,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32300024 EAP CPT® 75774 ANGIO SELECTIVE ADD'L VESS SPV BOTH IP/OP "$3,796.00 " "$2,809.04" $0.00 "$3,884.00" $196.71 $196.71 $0.00 $0.00 $0.00 $791.18 "$2,817.39" "$2,817.39" "$2,925.96" $0.00 $791.09 $0.00 "$2,245.33" "$2,245.33" $0.00 $920.16 "$3,036.53" "$3,067.20" $0.00 "$3,884.00" $0.00 $497.07 $59.79 $59.79 $610.37 $0.00 $0.00 $0.00 $0.00 $0.00 32300026 EAP CPT® 75898 ANGIO W/EXIST CATH FU STDY SPV BOTH IP/OP "$2,784.00 " "$2,060.16" $0.00 "$2,219.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,066.28" "$2,066.28" "$2,145.91" $0.00 $580.19 $0.00 $0.00 $0.00 $0.00 $607.44 "$2,004.55" "$2,024.80" $0.00 "$2,219.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32300066 EAP CPT® 75705 Angio Spinal Selective Nir BOTH IP/OP "$9,955.00 " "$7,366.70" $0.00 "$9,989.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,673.31" $0.00 "$2,074.62" $0.00 $0.00 $0.00 $0.00 "$2,389.20" "$7,884.36" "$7,964.00" $0.00 "$9,989.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32300071 EAP CPT® 75716 Inject: Illiac Angio BOTH IP/OP "$7,936.00 " "$5,872.64" $0.00 "$6,348.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,795.58" $0.00 $0.00 $0.00 "$2,742.67" "$1,795.37" "$1,782.74" "$5,095.77" "$5,095.77" "$2,779.42" "$1,904.64" "$6,285.31" "$6,348.80" "$3,861.64" $0.00 "$3,861.64" $544.44 $80.32 $80.32 "$1,263.41" "$2,647.07" $0.00 $0.00 $0.00 $0.00 32300072 EAP CPT® 37197 "Transcatheter Retrieval,percutaneous Of Intravas Fb Inci" BOTH IP/OP "$34,751.00 " "$25,715.74" $0.00 "$26,786.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$26,786.07" $0.00 "$7,242.11" $0.00 $0.00 $0.00 "$2,779.42" "$2,858.00" "$26,126.50" "$26,390.40" "$3,861.64" "$3,725.00" "$3,861.64" $0.00 $315.16 $315.16 "$5,251.69" "$2,647.07" $0.00 $0.00 $0.00 $0.00 32400001 EAP CPT® 71045 Chest X-ray BOTH IP/OP $623.00 $461.02 $16.57 $508.00 $45.30 $45.30 $78.77 $78.77 $79.21 $129.85 $26.80 $26.80 $27.83 $77.54 $129.83 $50.40 $368.50 $368.50 $80.04 $152.40 $502.92 $508.00 $111.21 $137.87 $111.21 $19.10 $16.57 $16.57 $101.09 $76.23 $0.00 $0.00 $0.00 $0.00 32400002 EAP CPT® 71045 CHEST X-RAY 1 VIEW RDG BOTH IP/OP $697.00 $515.78 $16.57 $508.00 $45.30 $45.30 $78.77 $78.77 $79.21 $145.27 $26.80 $26.80 $27.83 $77.54 $145.25 $50.40 $412.28 $412.28 $80.04 $152.40 $502.92 $508.00 $111.21 $137.87 $111.21 $19.10 $16.57 $16.57 $101.09 $76.23 $0.00 $0.00 $0.00 $0.00 32400003 EAP CPT® 71045 Line Placement-chest BOTH IP/OP $623.00 $461.02 $16.57 $508.00 $45.30 $45.30 $78.77 $78.77 $79.21 $129.85 $26.80 $26.80 $27.83 $77.54 $129.83 $50.40 $368.50 $368.50 $80.04 $152.40 $502.92 $508.00 $111.21 $137.87 $111.21 $19.10 $16.57 $16.57 $101.09 $76.23 $0.00 $0.00 $0.00 $0.00 32400006 EAP CPT® 71046 CHEST 2 VIEW(PA & LATERAL) RDG BOTH IP/OP $730.00 $540.20 $21.97 $532.00 $69.46 $69.46 $78.77 $78.77 $79.21 $152.15 $49.06 $49.06 $50.94 $77.54 $152.13 $50.40 $431.80 $431.80 $80.04 $159.60 $526.68 $532.00 $111.21 $137.87 $111.21 $29.30 $21.97 $21.97 $105.87 $76.23 $0.00 $0.00 $0.00 $0.00 32400008 EAP CPT® 71047 CHEST 2VIEW W/APICAL LORDO RDG BOTH IP/OP $752.00 $556.48 $27.73 $548.00 $88.81 $88.81 $78.77 $78.77 $79.21 $156.74 $62.44 $62.44 $64.84 $77.54 $156.72 $50.40 $444.81 $444.81 $80.04 $164.40 $542.52 $548.00 $111.21 $137.87 $111.21 $37.47 $27.73 $27.73 $109.05 $76.23 $0.00 $0.00 $0.00 $0.00 32400010 EAP CPT® 71048 CHEST X-RAY 4+VIEW RDG BOTH IP/OP $809.00 $598.66 $28.81 $589.60 $95.25 $95.25 $106.02 $106.02 $106.62 $168.62 $64.20 $64.20 $66.67 $104.44 $168.60 $67.89 $478.52 $478.52 $112.41 $176.88 $583.70 $589.60 $156.18 $169.61 $156.18 $40.18 $28.81 $28.81 $117.33 $107.06 $0.00 $0.00 $0.00 $0.00 32400012 EAP CPT® 71046 CHEST X-RAY 3VW DECUBITUS RDG BOTH IP/OP $771.00 $570.54 $21.97 $561.60 $69.46 $69.46 $78.77 $78.77 $79.21 $160.70 $49.06 $49.06 $50.94 $77.54 $160.68 $50.40 $456.05 $456.05 $80.04 $168.48 $555.98 $561.60 $111.21 $137.87 $111.21 $29.30 $21.97 $21.97 $111.76 $76.23 $0.00 $0.00 $0.00 $0.00 33100001 EAP CPT® 96411 Iv Chemo Push-ea Addtl Med BOTH IP/OP $478.00 $353.72 $38.61 $385.45 $183.66 $183.66 $60.38 $60.38 $60.72 $99.63 $354.77 $354.77 $368.44 $59.39 $99.62 $38.61 $282.74 $282.74 $60.65 $178.50 $282.74 $285.60 $84.26 $385.45 $84.26 $55.87 $59.80 $59.80 $56.83 $57.76 $0.00 $0.00 $0.00 $0.00 33100002 EAP CPT® 96409 Iv Chemo Push-1st Med Initl1vs BOTH IP/OP $830.00 $614.20 $97.03 $639.76 $326.62 $326.62 $199.22 $199.22 $200.34 $172.99 $616.03 $616.03 $639.76 $195.04 $172.97 $126.78 $490.95 $490.95 $184.28 $310.00 $491.04 $496.00 $256.03 $616.20 $256.03 $97.03 $109.86 $109.86 $98.70 $175.50 $0.00 $0.00 $0.00 $0.00 33100004 EAP CPT® 96411 Iv Chemo Push1st Med Dur Infus BOTH IP/OP $478.00 $353.72 $38.61 $385.45 $183.66 $183.66 $60.38 $60.38 $60.72 $99.63 $354.77 $354.77 $368.44 $59.39 $99.62 $38.61 $282.74 $282.74 $60.65 $178.50 $282.74 $285.60 $84.26 $385.45 $84.26 $55.87 $59.80 $59.80 $56.83 $57.76 $0.00 $0.00 $0.00 $0.00 33100006 EAP CPT® 96411 Iv Chemo Push-1 Med Dur Infus BOTH IP/OP $357.00 $264.18 $38.61 $385.45 $183.66 $183.66 $60.38 $60.38 $60.72 $74.41 $264.97 $264.97 $275.18 $59.39 $74.40 $38.61 $211.17 $211.17 $60.65 $178.50 $282.74 $285.60 $84.26 $385.45 $84.26 $55.87 $59.80 $59.80 $56.83 $57.76 $0.00 $0.00 $0.00 $0.00 33100007 EAP CPT® 96401 Inject Chemo-im/sq Non Hormona BOTH IP/OP $496.00 $367.04 $38.61 $382.32 $219.15 $219.15 $60.38 $60.38 $60.72 $103.38 $368.13 $368.13 $382.32 $59.39 $103.37 $38.61 $293.38 $293.38 $60.65 $185.00 $293.04 $296.00 $84.26 $322.40 $84.26 $57.91 $79.97 $79.97 $58.90 $57.76 $0.00 $0.00 $0.00 $0.00 33100008 EAP CPT® 96402 Inject Chemo-im/sq Hormonal BOTH IP/OP $619.00 $458.06 $32.07 $477.13 $95.99 $95.99 $60.38 $60.38 $60.72 $129.02 $459.42 $459.42 $477.13 $59.39 $129.00 $38.61 $366.14 $366.14 $60.65 $231.00 $365.90 $369.60 $84.26 $428.35 $84.26 $72.30 $32.07 $32.07 $73.55 $57.76 $0.00 $0.00 $0.00 $0.00 33300001 EAP CPT® 77280 Simulation-simple BOTH IP/OP "$1,882.00 " "$1,392.68" $79.04 "$1,126.40" $626.37 $626.37 $123.57 $123.57 $124.26 $392.26 $371.97 $371.97 $386.27 $121.59 $392.21 $79.04 "$1,113.20" "$1,113.20" $126.96 $337.92 "$1,115.14" "$1,126.40" $176.40 $211.67 $176.40 $220.35 $244.20 $244.20 $224.15 $120.92 $0.00 $0.00 $0.00 $0.00 33300002 EAP CPT® 77285 Simulation-intermediat BOTH IP/OP "$2,531.00 " "$1,872.94" $210.99 "$1,515.20" $998.00 $998.00 $329.78 $329.78 $331.64 $527.52 $661.39 $661.39 $686.83 $324.60 $527.46 $210.99 "$1,497.09" "$1,497.09" $336.15 $454.56 "$1,500.05" "$1,515.20" $467.03 $569.27 $467.03 $296.41 $414.20 $414.20 $301.52 $320.14 $0.00 $0.00 $0.00 $0.00 33300003 EAP CPT® 77290 Simulation-complex BOTH IP/OP "$3,403.00 " "$2,518.22" $210.99 "$2,036.80" "$1,180.16" "$1,180.16" $329.78 $329.78 $331.64 $709.27 "$1,034.52" "$1,034.52" "$1,074.31" $324.60 $709.19 $210.99 "$2,012.87" "$2,012.87" $336.15 $611.04 "$2,016.43" "$2,036.80" $467.03 $569.27 $467.03 $398.45 $422.12 $422.12 $405.32 $320.14 $0.00 $0.00 $0.00 $0.00 33300004 EAP CPT® 77295 3d Radiotherapy Plan W/ Vol Histo BOTH IP/OP "$12,364.00 " "$9,149.36" $265.08 "$7,400.80" "$1,122.08" "$1,122.08" "$1,229.74" "$1,229.74" "$1,236.66" "$2,576.97" "$1,140.85" "$1,140.85" "$1,184.73" "$1,209.70" "$2,576.66" $786.30 "$7,313.31" "$7,313.31" "$1,249.00" "$2,220.24" "$7,326.79" "$7,400.80" "$1,735.32" "$2,127.56" "$1,735.32" "$1,447.78" $265.08 $265.08 "$1,472.76" "$1,189.52" $0.00 $0.00 $0.00 $0.00 33300007 EAP CPT® 77300 Central Axis Calculation BOTH IP/OP $916.00 $677.84 $34.22 $548.00 $152.35 $152.35 $123.57 $123.57 $124.26 $190.92 $100.51 $100.51 $104.37 $121.59 $190.89 $79.04 $541.81 $541.81 $126.96 $164.40 $542.52 $548.00 $176.40 $211.67 $176.40 $107.20 $34.22 $34.22 $109.05 $120.92 $0.00 $0.00 $0.00 $0.00 33300008 EAP CPT® 77301 Imrt BOTH IP/OP "$7,048.00 " "$5,215.52" $786.30 "$4,564.49" "$4,469.34" "$4,469.34" "$1,229.74" "$1,229.74" "$1,236.66" "$1,468.98" "$4,395.44" "$4,395.44" "$4,564.49" "$1,209.70" "$1,468.80" $786.30 "$4,168.89" "$4,168.89" "$1,249.00" "$1,265.52" "$4,176.22" "$4,218.40" "$1,735.32" "$2,127.56" "$1,735.32" $825.22 "$1,513.43" "$1,513.43" $839.46 "$1,189.52" $0.00 $0.00 $0.00 $0.00 33300012 EAP CPT® 77321 Telether Plan Special BOTH IP/OP "$1,950.00 " "$1,443.00" $44.30 "$1,167.20" $212.81 $212.81 $329.78 $329.78 $331.64 $406.43 $187.24 $187.24 $194.44 $324.60 $406.38 $210.99 "$1,153.43" "$1,153.43" $336.15 $350.16 "$1,155.53" "$1,167.20" $467.03 $569.27 $467.03 $228.33 $44.30 $44.30 $232.27 $320.14 $0.00 $0.00 $0.00 $0.00 33300014 EAP CPT® 77331 Tld/microdosimetry BOTH IP/OP $889.00 $657.86 $0.00 $879.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.88 $46.88 $48.69 $0.00 $185.27 $0.00 $0.00 $0.00 $0.00 $159.60 $526.68 $532.00 $0.00 $879.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33300015 EAP CPT® 77332 Block Simple BOTH IP/OP "$1,023.00 " $757.02 $23.77 $612.00 $153.96 $153.96 $123.57 $123.57 $124.26 $213.22 $126.87 $126.87 $131.75 $121.59 $213.19 $79.04 $605.10 $605.10 $126.96 $183.60 $605.88 $612.00 $176.40 $211.67 $176.40 $119.72 $23.77 $23.77 $121.79 $120.92 $0.00 $0.00 $0.00 $0.00 33300016 EAP CPT® 77332 Bolus Simple BOTH IP/OP $765.00 $566.10 $23.77 $612.00 $153.96 $153.96 $123.57 $123.57 $124.26 $159.45 $126.87 $126.87 $131.75 $121.59 $159.43 $79.04 $452.50 $452.50 $126.96 $183.60 $605.88 $612.00 $176.40 $211.67 $176.40 $119.72 $23.77 $23.77 $121.79 $120.92 $0.00 $0.00 $0.00 $0.00 33300017 EAP CPT® 77333 Block Intermed BOTH IP/OP "$1,426.00 " "$1,055.24" $0.00 $844.80 $0.00 $0.00 $0.00 $0.00 $0.00 $220.10 $0.00 $0.00 $0.00 $121.59 $220.07 $79.04 $624.62 $624.62 $0.00 $253.44 $836.35 $844.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33300018 EAP CPT® 77333 Bolus Inter. BOTH IP/OP "$1,056.00 " $781.44 $0.00 $844.80 $220.86 $220.86 $123.57 $123.57 $124.26 $220.10 $67.24 $67.24 $69.82 $121.59 $220.07 $79.04 $624.62 $624.62 $0.00 $253.44 $836.35 $844.80 $0.00 $211.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33300019 EAP CPT® 77334 Device Complex BOTH IP/OP "$1,488.00 " "$1,101.12" $67.35 $890.40 $299.06 $299.06 $329.78 $329.78 $331.64 $310.14 $240.51 $240.51 $249.76 $324.60 $310.10 $210.99 $880.15 $880.15 $336.15 $267.12 $881.50 $890.40 $467.03 $569.27 $467.03 $174.18 $67.35 $67.35 $177.19 $320.14 $0.00 $0.00 $0.00 $0.00 33300020 EAP CPT® 77334 Compensator Filter BOTH IP/OP "$1,113.00 " $823.62 $67.35 $890.40 $299.06 $299.06 $329.78 $329.78 $331.64 $231.98 $240.51 $240.51 $249.76 $324.60 $231.95 $210.99 $658.34 $658.34 $336.15 $267.12 $881.50 $890.40 $467.03 $569.27 $467.03 $174.18 $67.35 $67.35 $177.19 $320.14 $0.00 $0.00 $0.00 $0.00 33300021 EAP CPT® 77334 Positioning Mold BOTH IP/OP "$1,113.00 " $823.62 $67.35 $890.40 $299.06 $299.06 $329.78 $329.78 $331.64 $231.98 $240.51 $240.51 $249.76 $324.60 $231.95 $210.99 $658.34 $658.34 $336.15 $267.12 $881.50 $890.40 $467.03 $569.27 $467.03 $174.18 $67.35 $67.35 $177.19 $320.14 $0.00 $0.00 $0.00 $0.00 33300022 EAP CPT® 77336 Continuing Physics/wk BOTH IP/OP $962.00 $711.88 $79.04 $576.00 $181.47 $181.47 $123.57 $123.57 $124.26 $200.50 $155.36 $155.36 $161.33 $121.59 $200.48 $79.04 $569.02 $569.02 $126.96 $172.80 $570.24 $576.00 $176.40 $211.67 $176.40 $112.68 $81.03 $81.03 $114.62 $120.92 $0.00 $0.00 $0.00 $0.00 33300023 EAP CPT® 77370 Spec Medical Physics Consult BOTH IP/OP "$1,142.00 " $845.08 $79.04 $684.00 $279.07 $279.07 $123.57 $123.57 $124.26 $238.02 $293.91 $293.91 $305.22 $121.59 $237.99 $79.04 $675.49 $675.49 $126.96 $205.20 $677.16 $684.00 $176.40 $211.67 $176.40 $133.81 $126.41 $126.41 $136.12 $120.92 $0.00 $0.00 $0.00 $0.00 33300024 EAP CPT® 77401 "Rad Delivery, Superf &/or Orthovolt, Per Day" BOTH IP/OP $899.00 $665.26 $0.00 $719.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.93 $79.93 $83.01 $0.00 $187.35 $0.00 $0.00 $0.00 $0.00 $215.76 $712.01 $719.20 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33300026 EAP CPT® 77306 Telether Plan Simple BOTH IP/OP "$1,192.00 " $882.08 $0.00 "$2,906.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.75 $182.75 $189.78 $0.00 $248.41 $0.00 $0.00 $0.00 $336.15 $214.08 $706.46 $713.60 $467.03 "$2,906.00" $467.03 $139.60 $76.36 $76.36 $142.01 $320.14 $0.00 $0.00 $0.00 $0.00 33300028 EAP CPT® 77307 Telether Plan Complex BOTH IP/OP "$1,998.00 " "$1,478.52" $138.30 "$1,196.00" $660.98 $660.98 $329.78 $329.78 $331.64 $416.43 $335.12 $335.12 $348.01 $324.60 $416.38 $210.99 "$1,181.82" "$1,181.82" $336.15 $358.80 "$1,184.04" "$1,196.00" $467.03 $569.27 $467.03 $233.97 $138.30 $138.30 $238.00 $320.14 $0.00 $0.00 $0.00 $0.00 33300030 EAP CPT® 77318 Brachyther Plan Complex BOTH IP/OP "$2,101.00 " "$1,554.74" $0.00 "$2,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $504.45 $504.45 $523.85 $0.00 $437.85 $0.00 $0.00 $0.00 $0.00 $377.28 "$1,245.02" "$1,257.60" $0.00 "$2,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33300031 EAP CPT® 77407 "Rad Tx Del >= 1 Mev, Intermed" BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $531.75 $531.75 $552.20 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $291.36 $961.49 $971.20 $0.00 $804.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33300033 EAP CPT® 77412 "Rad Tx Del >= 1 Mev, Complex" BOTH IP/OP "$1,771.00 " "$1,310.54" $0.00 "$1,060.00" $615.91 $615.91 $235.40 $235.40 $236.72 $369.12 $515.25 $515.25 $535.06 $231.63 $369.08 $150.56 "$1,047.55" "$1,047.55" $237.05 $318.00 "$1,049.40" "$1,060.00" $329.36 $417.25 $329.36 $207.36 $0.00 $0.00 $210.94 $225.77 $0.00 $0.00 $0.00 $0.00 33300035 EAP CPT® 77385 Imrt Tx Delivery Simple BOTH IP/OP "$4,467.00 " "$3,305.58" $0.00 "$3,443.16" $783.58 $783.58 $528.37 $528.37 $531.35 $931.03 "$3,315.41" "$3,315.41" "$3,443.16" $519.99 $930.92 $337.99 "$2,642.23" "$2,642.23" $540.41 $802.08 "$2,646.86" "$2,673.60" $750.83 $908.47 $750.83 $523.02 $0.00 $0.00 $532.05 $514.68 $0.00 $0.00 $0.00 $0.00 33300037 EAP CPT® 77386 Imrt Tx Delivery Complex BOTH IP/OP "$4,467.00 " "$3,305.58" $0.00 "$3,443.16" $786.03 $786.03 $528.37 $528.37 $531.35 $931.03 "$3,315.41" "$3,315.41" "$3,443.16" $519.99 $930.92 $337.99 "$2,642.23" "$2,642.23" $540.41 $802.08 "$2,646.86" "$2,673.60" $750.83 $908.47 $750.83 $523.02 $0.00 $0.00 $532.05 $514.68 $0.00 $0.00 $0.00 $0.00 33300040 EAP CPT® 77387 Guidance For Radiation Tx Dlvr BOTH IP/OP "$1,005.00 " $743.70 $0.00 "$3,306.00" $146.70 $146.70 $0.00 $0.00 $0.00 $209.47 $95.28 $95.28 $98.95 $0.00 $209.44 $0.00 $594.46 $594.46 $0.00 $180.48 $595.58 $601.60 $0.00 "$3,306.00" $0.00 $117.69 $0.00 $0.00 $119.72 $0.00 $0.00 $0.00 $0.00 $0.00 33300047 EAP CPT® 77417 Port Image(s) BOTH IP/OP $631.00 $466.94 $0.00 $796.00 $25.00 $25.00 $0.00 $0.00 $0.00 $131.52 $40.22 $40.22 $41.76 $0.00 $131.50 $0.00 $373.24 $373.24 $0.00 $113.28 $373.82 $377.60 $0.00 $796.00 $0.00 $73.87 $11.52 $11.52 $75.14 $0.00 $0.00 $0.00 $0.00 $0.00 33300049 EAP CPT® 77402 "Rad Tx Del >= 1 Mev, Simple" BOTH IP/OP "$1,202.00 " $889.48 $0.00 "$1,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.51 $339.51 $352.57 $0.00 $250.50 $0.00 $0.00 $0.00 $123.07 $215.76 $712.01 $719.20 $170.99 "$1,136.00" $170.99 $140.69 $0.00 $0.00 $143.12 $117.21 $0.00 $0.00 $0.00 $0.00 33300050 EAP CPT® 77470 Special Treatment BOTH IP/OP "$6,620.00 " "$4,898.80" $25.93 "$3,962.40" $329.68 $329.68 $528.37 $528.37 $531.35 "$1,379.77" $379.95 $379.95 $394.57 $519.99 "$1,379.61" $337.99 "$3,915.73" "$3,915.73" $540.41 "$1,188.72" "$3,922.78" "$3,962.40" $750.83 $908.47 $750.83 $775.14 $25.93 $25.93 $788.52 $514.68 $0.00 $0.00 $0.00 $0.00 33300052 EAP CPT® 77763 Intracavitary Complex BOTH IP/OP "$2,833.00 " "$2,096.42" $0.00 "$2,266.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $617.13 $617.13 $640.86 $0.00 $590.40 $0.00 $0.00 $0.00 $0.00 $679.92 "$2,243.74" "$2,266.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33300053 EAP CPT® 77338 Imrt Treatment Device BOTH IP/OP "$1,470.00 " "$1,087.80" $172.15 "$1,160.81" "$1,160.81" "$1,160.81" $329.78 $329.78 $331.64 $306.38 $646.24 $646.24 $671.09 $324.60 $306.35 $210.99 $869.51 $869.51 $336.15 $264.00 $871.20 $880.00 $467.03 $569.27 $467.03 $172.15 $264.36 $264.36 $175.12 $320.14 $0.00 $0.00 $0.00 $0.00 33300055 EAP CPT® 77372 Cranial Only X 1 BOTH IP/OP "$10,692.00 " "$7,912.08" "$1,067.19" "$12,204.45" "$2,454.91" "$2,454.91" "$7,573.86" "$7,573.86" "$7,616.52" "$2,228.48" "$2,033.64" "$2,033.64" "$2,111.85" "$7,449.57" "$2,228.21" "$4,842.22" "$6,324.32" "$6,324.32" "$7,965.75" "$1,920.00" "$6,336.00" "$6,400.00" "$8,000.00" "$12,204.45" "$8,000.00" "$1,252.00" "$1,067.19" "$1,067.19" "$1,273.60" "$7,586.43" $0.00 $0.00 $0.00 $0.00 33300057 EAP CPT® 77373 Robt Lin-radsurg Fract 1-5 BOTH IP/OP "$7,072.00 " "$5,233.28" $828.04 "$4,232.80" "$3,115.99" "$3,115.99" "$1,688.97" "$1,688.97" "$1,698.48" "$1,473.98" "$3,765.33" "$3,765.33" "$3,910.15" "$1,661.65" "$1,473.80" "$1,080.07" "$4,183.09" "$4,183.09" "$1,773.65" "$1,269.84" "$4,190.47" "$4,232.80" "$2,464.25" "$2,804.83" "$2,464.25" $828.04 "$1,228.18" "$1,228.18" $842.33 "$1,689.19" $0.00 $0.00 $0.00 $0.00 33300067 EAP CPT® 77014 Cbct Infusion Radioactive Mat BOTH IP/OP "$1,462.00 " "$1,081.88" $0.00 "$2,159.00" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $304.72 $785.72 $785.72 $815.94 $0.00 $304.68 $0.00 $864.77 $864.77 $0.00 $262.56 $866.45 $875.20 $0.00 "$2,159.00" $0.00 $171.21 $78.16 $78.16 $174.16 $0.00 $0.00 $0.00 $0.00 $0.00 33300073 EAP CPT® 57156 Ins Vag Brachytx Device BOTH IP/OP "$1,386.00 " "$1,025.64" $0.00 "$1,386.00" "$1,386.00" "$1,386.00" $274.65 $274.65 $276.20 $288.88 "$1,028.69" "$1,028.69" "$1,068.33" $269.78 $288.84 $175.35 "$1,386.00" "$1,386.00" $0.00 "$1,138.00" $901.30 $910.40 $0.00 "$1,386.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33300088 EAP CPT® 77293 Resp Motion Mgmt Sim BOTH IP/OP "$1,270.00 " $939.80 $0.00 "$1,270.00" "$1,066.51" "$1,066.51" $0.00 $0.00 $0.00 $264.70 $823.32 $823.32 $854.98 $0.00 $264.67 $0.00 $751.21 $751.21 $0.00 $228.00 $752.40 $760.00 $0.00 "$1,270.00" $0.00 $148.68 $350.81 $350.81 $151.24 $0.00 $0.00 $0.00 $0.00 $0.00 33500001 EAP CPT® 96450 Iv Chemo Into Cns W/spinal Pun BOTH IP/OP "$1,346.00 " $996.04 $0.00 "$1,037.50" $535.21 $535.21 $310.51 $310.51 $312.26 $280.54 $999.00 $999.00 "$1,037.50" $297.83 $280.51 $193.59 $796.16 $796.16 $0.00 $502.50 $795.96 $804.00 $0.00 $815.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33500002 EAP CPT® 96413 "Chemo Tx Admn Iv Nfs Tq Up 1 Hr, Sng Or 1st Sbst/drug" BOTH IP/OP "$1,213.00 " $897.62 $141.79 $934.98 $405.93 $405.93 $310.51 $310.51 $312.26 $252.82 $900.29 $900.29 $934.98 $297.83 $252.79 $193.59 $717.49 $717.49 $310.51 $453.00 $717.55 $724.80 $431.41 $832.65 $431.41 $141.79 $142.28 $142.28 $144.24 $295.72 $0.00 $0.00 $0.00 $0.00 33500003 EAP CPT® 96416 Iv Chemo Inf Prolonged Gtr8hrs BOTH IP/OP "$1,346.00 " $996.04 $142.28 "$1,037.50" $410.10 $410.10 $310.51 $310.51 $312.26 $280.54 $999.00 $999.00 "$1,037.50" $297.83 $280.51 $193.59 $796.16 $796.16 $310.51 $502.50 $795.96 $804.00 $431.41 $808.60 $431.41 $157.28 $142.28 $142.28 $160.00 $295.72 $0.00 $0.00 $0.00 $0.00 33500004 EAP CPT® 96415 Iv Chemo Inf Med Ea Addtl Hr BOTH IP/OP $337.00 $249.38 $30.63 $259.76 $83.48 $83.48 $60.38 $60.38 $60.72 $70.24 $250.12 $250.12 $259.76 $59.39 $70.23 $38.61 $199.34 $199.34 $60.65 $126.00 $199.58 $201.60 $84.26 $219.05 $84.26 $39.44 $30.63 $30.63 $40.12 $57.76 $0.00 $0.00 $0.00 $0.00 33500005 EAP CPT® 96417 Iv Chemo Inf Ea New Med 16-90 BOTH IP/OP $529.00 $391.46 $38.61 $442.00 $192.01 $192.01 $60.38 $60.38 $60.72 $110.26 $392.62 $392.62 $407.75 $59.39 $110.24 $38.61 $312.90 $312.90 $60.65 $197.50 $312.84 $316.00 $84.26 $442.00 $84.26 $61.82 $69.16 $69.16 $62.88 $57.76 $0.00 $0.00 $0.00 $0.00 33500007 EAP CPT® 96416 Iv Chem Inf Prolong Gtr 8hr Pu BOTH IP/OP "$1,346.00 " $996.04 $142.28 "$1,037.50" $410.10 $410.10 $310.51 $310.51 $312.26 $280.54 $999.00 $999.00 "$1,037.50" $297.83 $280.51 $193.59 $796.16 $796.16 $310.51 $502.50 $795.96 $804.00 $431.41 $808.60 $431.41 $157.28 $142.28 $142.28 $160.00 $295.72 $0.00 $0.00 $0.00 $0.00 34000004 EAP CPT® 79440 Nuclearrx Intra-articular Nuc BOTH IP/OP "$1,139.00 " $842.86 $0.00 $911.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.33 $149.33 $155.08 $0.00 $237.37 $0.00 $0.00 $0.00 $0.00 $273.36 $902.09 $911.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34000005 EAP CPT® 78265 Nm Gastric Emptying Img Std BOTH IP/OP $832.00 $615.68 $0.00 $948.99 $832.00 $832.00 $367.10 $367.10 $369.17 $0.00 $913.84 $913.84 $948.99 $0.00 $173.39 $0.00 $0.00 $0.00 $0.00 $199.68 $658.94 $665.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100005 EAP CPT® 78018 THYROID CA/METS IMAGE WHOL NUC BOTH IP/OP "$1,629.00 " "$1,205.46" $250.40 "$1,316.00" $738.46 $738.46 $476.55 $476.55 $479.24 $339.52 $662.46 $662.46 $687.94 $469.05 $339.48 $304.88 $963.55 $963.55 $456.86 $394.80 "$1,302.84" "$1,316.00" $634.74 $800.61 $634.74 $250.40 $280.57 $280.57 $261.88 $435.10 $0.00 $0.00 $0.00 $0.00 34100006 EAP CPT® 78020 Thyroid Carcinoma Metatases Up BOTH IP/OP "$1,082.00 " $800.68 $0.00 $874.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.33 $149.33 $155.08 $0.00 $225.49 $0.00 $0.00 $0.00 $0.00 $262.32 $865.66 $874.40 $0.00 $776.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100007 EAP CPT® 78070 PARATHYROID SCAN NUC BOTH IP/OP "$1,933.00 " "$1,430.42" $107.84 "$1,562.40" $707.81 $707.81 $367.10 $367.10 $369.17 $402.89 $321.33 $321.33 $333.69 $361.44 $402.84 $234.94 "$1,143.37" "$1,143.37" $354.53 $468.72 "$1,546.78" "$1,562.40" $492.57 $616.81 $492.57 $107.84 $265.80 $265.80 $310.92 $337.65 $0.00 $0.00 $0.00 $0.00 34100008 EAP CPT® 78075 ADRENAL SCAN CORTX&/MEDU NUC BOTH IP/OP "$12,239.00 " "$9,056.86" $0.00 "$9,890.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $908.41 $908.41 $943.35 $0.00 "$2,550.61" $0.00 $0.00 $0.00 $0.00 "$2,967.12" "$9,791.50" "$9,890.40" $0.00 "$2,581.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100009 EAP CPT® 78102 BONE MARROW LIMITED NUC BOTH IP/OP "$1,469.00 " "$1,087.06" $0.00 "$1,463.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.73 $325.73 $338.26 $0.00 $306.14 $0.00 $0.00 $0.00 $0.00 $352.56 "$1,163.45" "$1,175.20" $0.00 "$1,463.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100010 EAP CPT® 78104 BONE MARROW WHOLE BODY NUC BOTH IP/OP "$1,469.00 " "$1,087.06" $0.00 "$1,175.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.48 $507.48 $527.00 $0.00 $306.14 $0.00 $0.00 $0.00 $0.00 $352.56 "$1,163.45" "$1,175.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100011 EAP CPT® 78140 RBC LABELED SEQ LIVER NUC BOTH IP/OP "$1,312.00 " $970.88 $0.00 "$1,049.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $288.89 $288.89 $300.00 $0.00 $273.42 $0.00 $0.00 $0.00 $0.00 $314.88 "$1,039.10" "$1,049.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100012 EAP CPT® 78185 SPLEEN SCAN W/ W/O FLOW NUC BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.17 $408.17 $423.87 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $338.40 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100013 EAP CPT® 78195 LYMPHOSCINTIGRAPHY NUC BOTH IP/OP "$1,629.00 " "$1,205.46" $211.12 "$1,316.00" $840.05 $840.05 $476.55 $476.55 $479.24 $339.52 $667.18 $667.18 $692.84 $469.05 $339.48 $304.88 $963.55 $963.55 $456.86 $394.80 "$1,302.84" "$1,316.00" $634.74 $800.61 $634.74 $211.12 $306.14 $306.14 $261.88 $435.10 $0.00 $0.00 $0.00 $0.00 34100015 EAP CPT® 78215 Liver & Spleen Imaging Static BOTH IP/OP "$1,454.00 " "$1,075.96" $0.00 "$1,175.20" $457.93 $457.93 $367.10 $367.10 $369.17 $303.05 $390.75 $390.75 $405.78 $361.44 $303.01 $234.94 $860.04 $860.04 $0.00 $352.56 "$1,163.45" "$1,175.20" $0.00 $616.81 $0.00 $136.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100016 EAP CPT® 78216 LIVER/SPLEEN W/VASCU FLOW NUC BOTH IP/OP "$1,469.00 " "$1,087.06" $0.00 "$1,175.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.22 $271.22 $281.65 $0.00 $306.14 $0.00 $0.00 $0.00 $0.00 $352.56 "$1,163.45" "$1,175.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100019 EAP CPT® 78262 GI REFLUX NUC BOTH IP/OP "$2,128.00 " "$1,574.72" $0.00 "$1,702.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.19 $500.19 $519.43 $0.00 $443.48 $0.00 $0.00 $0.00 $0.00 $510.72 "$1,685.38" "$1,702.40" $0.00 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100020 EAP CPT® 78264 GASTRIC EMPTYING NUC BOTH IP/OP "$3,115.00 " "$2,305.10" $196.51 "$2,295.20" $793.29 $793.29 $367.10 $367.10 $369.17 $649.24 $574.62 $574.62 $596.72 $361.44 $649.17 $234.94 "$1,842.52" "$1,842.52" $354.53 $688.56 "$2,272.25" "$2,295.20" $492.57 $616.81 $492.57 $196.51 $303.26 $303.26 $456.74 $337.65 $0.00 $0.00 $0.00 $0.00 34100021 EAP CPT® 78278 ACUTE GI BLEEDING IMAGING NUC BOTH IP/OP "$2,498.00 " "$1,848.52" $0.00 "$2,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.78 $685.78 $712.15 $0.00 $520.58 $0.00 $0.00 $0.00 $0.00 $552.24 "$1,822.39" "$1,840.80" $0.00 "$2,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100022 EAP CPT® 78290 BOWEL IMAGING MECKLES SCAN NUC BOTH IP/OP "$2,402.00 " "$1,777.48" $0.00 "$1,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.22 $638.22 $662.76 $0.00 $500.58 $0.00 $0.00 $0.00 $0.00 $531.12 "$1,752.70" "$1,770.40" $0.00 "$1,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100023 EAP CPT® 78291 SHUNT PATENCY LEVEEN/DENV NUC BOTH IP/OP "$2,255.00 " "$1,668.70" $0.00 "$1,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.47 $478.47 $496.88 $0.00 $469.94 $0.00 $0.00 $0.00 $0.00 $541.20 "$1,785.96" "$1,804.00" $0.00 "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100024 EAP CPT® 78300 BONE IMAGING LIMITED NUC BOTH IP/OP "$1,481.00 " "$1,095.94" $0.00 "$1,481.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $336.30 $336.30 $349.24 $0.00 $308.64 $0.00 $0.00 $0.00 $0.00 $359.04 "$1,184.83" "$1,196.80" $0.00 "$1,481.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100025 EAP CPT® 78306 Nm Bone Imaging Whole Body BOTH IP/OP "$2,737.00 " "$2,025.38" $205.40 "$2,212.00" $592.52 $592.52 $367.10 $367.10 $369.17 $570.46 $502.02 $502.02 $521.33 $361.44 $570.39 $234.94 "$1,618.94" "$1,618.94" $354.53 $663.60 "$2,189.88" "$2,212.00" $492.57 $616.81 $492.57 $205.40 $266.89 $266.89 $440.19 $337.65 $0.00 $0.00 $0.00 $0.00 34100026 EAP CPT® 78315 Nm Bone Imaging 3 Phase Study BOTH IP/OP "$2,737.00 " "$2,025.38" $0.00 "$2,737.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $683.05 $683.05 $709.32 $0.00 $570.39 $0.00 $0.00 $0.00 $354.53 $663.60 "$2,189.88" "$2,212.00" $492.57 "$2,737.00" $492.57 $232.73 $305.42 $305.42 $440.19 $337.65 $0.00 $0.00 $0.00 $0.00 34100028 EAP CPT® 78445 Ceretec Vascular Flow Imaging BOTH IP/OP "$1,584.00 " "$1,172.16" $0.00 "$1,267.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.22 $342.22 $355.38 $0.00 $330.11 $0.00 $0.00 $0.00 $0.00 $380.16 "$1,254.53" "$1,267.20" $0.00 $938.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100029 EAP CPT® 78453 Cardiac Scan Thallium (planar) BOTH IP/OP "$5,102.00 " "$3,775.48" $0.00 "$4,661.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $568.46 $568.46 $590.33 $0.00 "$1,063.26" $0.00 $0.00 $0.00 $0.00 "$1,398.48" "$4,614.98" "$4,661.60" $0.00 "$1,984.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100030 EAP CPT® 78451 CARDIAC PERFUSION SINGLE NUC BOTH IP/OP "$6,945.00 " "$5,139.30" $167.51 "$5,612.00" $799.71 $799.71 "$1,272.60" "$1,272.60" "$1,279.77" "$1,447.51" $634.33 $634.33 $658.72 "$1,251.64" "$1,447.34" $813.57 "$4,107.97" "$4,107.97" "$1,232.99" "$1,683.60" "$5,555.88" "$5,612.00" "$1,713.08" "$2,106.29" "$1,713.08" $167.51 $278.41 $278.41 "$1,116.79" "$1,174.28" $0.00 $0.00 $0.00 $0.00 34100031 EAP CPT® 78452 Cardiac Scan BOTH IP/OP "$9,411.00 " "$6,964.14" $286.29 "$7,604.80" "$1,110.89" "$1,110.89" "$1,272.60" "$1,272.60" "$1,279.77" "$1,961.49" $928.32 $928.32 $964.03 "$1,251.64" "$1,961.25" $813.57 "$5,566.61" "$5,566.61" "$1,232.99" "$2,281.44" "$7,528.75" "$7,604.80" "$1,713.08" "$2,106.29" "$1,713.08" $286.29 $403.03 $403.03 "$1,513.36" "$1,174.28" $0.00 $0.00 $0.00 $0.00 34100032 EAP CPT® 78472 CARDIAC SCAN GATED NUC BOTH IP/OP "$3,623.00 " "$2,681.02" $185.13 "$2,928.00" $538.53 $538.53 $367.10 $367.10 $369.17 $755.12 $519.79 $519.79 $539.78 $361.44 $755.03 $234.94 "$2,143.00" "$2,143.00" $354.53 $878.40 "$2,898.72" "$2,928.00" $492.57 $616.81 $492.57 $259.91 $185.13 $185.13 $582.67 $337.65 $0.00 $0.00 $0.00 $0.00 34100034 EAP CPT® 78580 Pulm (lung) Perfusion Imag BOTH IP/OP "$2,905.00 " "$2,149.70" $167.63 "$2,329.60" $563.53 $563.53 $367.10 $367.10 $369.17 $605.47 $418.26 $418.26 $434.34 $361.44 $605.40 $234.94 "$1,718.31" "$1,718.31" $354.53 $698.88 "$2,306.30" "$2,329.60" $492.57 $616.81 $492.57 $167.63 $206.74 $206.74 $463.59 $337.65 $0.00 $0.00 $0.00 $0.00 34100038 EAP CPT® 78606 BRAIN SCAN W/VASCULAR FLO NUC BOTH IP/OP "$2,511.00 " "$1,858.14" $0.00 "$2,511.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $660.09 $660.09 $685.48 $0.00 $523.29 $0.00 $0.00 $0.00 $0.00 $547.92 "$1,808.14" "$1,826.40" $0.00 "$2,511.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100040 EAP CPT® 78630 CISTERNOGRAPHY NUC BOTH IP/OP "$1,521.00 " "$1,125.54" $0.00 "$1,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $700.89 $700.89 $727.84 $0.00 $316.98 $0.00 $0.00 $0.00 $0.00 $365.04 "$1,204.63" "$1,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100041 EAP CPT® 78701 Kidney Imag W/vascul Flo Nuc BOTH IP/OP "$4,099.00 " "$3,033.26" $0.00 "$3,279.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.66 $443.66 $460.73 $0.00 $854.23 $0.00 $0.00 $0.00 $0.00 $983.76 "$3,246.41" "$3,279.20" $0.00 "$1,845.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100042 EAP CPT® 78707 Kid.img.mor.w/vas.singlew/o Ph BOTH IP/OP "$3,679.00 " "$2,722.46" $191.97 "$2,755.20" $548.20 $548.20 $476.55 $476.55 $479.24 $766.80 $466.46 $466.46 $484.40 $469.05 $766.70 $304.88 "$2,176.13" "$2,176.13" $456.86 $826.56 "$2,727.65" "$2,755.20" $634.74 $800.61 $634.74 $218.15 $191.97 $191.97 $548.28 $435.10 $0.00 $0.00 $0.00 $0.00 34100043 EAP CPT® 78708 Kid.img.mor.w/vas.singlew/phar BOTH IP/OP "$3,968.00 " "$2,936.32" $122.10 "$2,972.00" $413.58 $413.58 $476.55 $476.55 $479.24 $827.03 $324.90 $324.90 $337.39 $469.05 $826.93 $304.88 "$2,347.07" "$2,347.07" $456.86 $891.60 "$2,942.28" "$2,972.00" $634.74 $800.61 $634.74 $228.29 $122.10 $122.10 $591.43 $435.10 $0.00 $0.00 $0.00 $0.00 34100044 EAP CPT® 78709 Kid.img.mor.w/vas.multi W&w/o BOTH IP/OP "$3,969.00 " "$2,937.06" $0.00 "$2,972.80" $859.37 $859.37 $476.55 $476.55 $479.24 $827.24 $686.09 $686.09 $712.48 $469.05 $827.14 $304.88 "$2,347.66" "$2,347.66" $0.00 $891.84 "$2,943.07" "$2,972.80" $0.00 $800.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100045 EAP CPT® 78740 Voiding Cystogram Nuc BOTH IP/OP "$3,569.00 " "$2,641.06" $0.00 "$2,855.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $428.28 $428.28 $444.75 $0.00 $743.78 $0.00 $0.00 $0.00 $0.00 $856.56 "$2,826.65" "$2,855.20" $0.00 "$1,695.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100046 EAP CPT® 78800 Nm Rp Loclzj Tum Plnr 1 Area Single Day Imaging BOTH IP/OP "$1,356.00 " "$1,003.44" $162.68 "$1,096.00" $453.92 $453.92 $367.10 $367.10 $369.17 $282.62 $367.43 $367.43 $381.56 $361.44 $282.59 $234.94 $802.07 $802.07 $354.53 $328.80 "$1,085.04" "$1,096.00" $492.57 $616.81 $492.57 $162.68 $233.75 $233.75 $218.10 $337.65 $0.00 $0.00 $0.00 $0.00 34100047 EAP CPT® 78801 Nm Rp Loclzj Tum Plnr 2+ Areas Or 2+ Days BOTH IP/OP "$1,295.00 " $958.30 $0.00 "$1,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.02 $502.02 $521.33 $0.00 $269.88 $0.00 $0.00 $0.00 $0.00 $310.80 "$1,025.64" "$1,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100048 EAP CPT® 78802 TUMOR SINGLE DAY BOTH IP/OP "$1,371.00 " "$1,014.54" $0.00 "$1,371.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $680.45 $680.45 $706.62 $0.00 $285.72 $0.00 $0.00 $0.00 $0.00 $332.40 "$1,096.92" "$1,108.00" $0.00 "$1,371.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100049 EAP CPT® 78803 NM TUMOR LOCALALIZATION SPECT BOTH IP/OP "$4,783.00 " "$3,539.42" $0.00 "$3,864.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $731.39 $731.39 $759.52 $0.00 $996.78 $0.00 $0.00 $0.00 "$1,232.99" "$1,159.44" "$3,826.15" "$3,864.80" "$1,713.08" "$2,266.00" "$1,713.08" $0.00 $346.84 $346.84 $769.10 "$1,174.28" $0.00 $0.00 $0.00 $0.00 34100057 EAP CPT® 78451 Myocardial Ejection Fraction BOTH IP/OP "$6,142.00 " "$4,545.08" $167.51 "$5,612.00" $799.71 $799.71 "$1,272.60" "$1,272.60" "$1,279.77" "$1,280.15" $634.33 $634.33 $658.72 "$1,251.64" "$1,279.99" $813.57 "$3,632.99" "$3,632.99" "$1,232.99" "$1,683.60" "$5,555.88" "$5,612.00" "$1,713.08" "$2,106.29" "$1,713.08" $167.51 $278.41 $278.41 "$1,116.79" "$1,174.28" $0.00 $0.00 $0.00 $0.00 34100060 EAP CPT® 78804 TUMOR IMAGING WHOLE BODY NUC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,253.14" "$1,253.14" "$1,301.34" $0.00 $521.00 $0.00 $0.00 $0.00 "$1,232.99" $606.00 "$1,999.80" "$2,020.00" "$1,713.08" "$2,500.00" "$1,713.08" $395.16 $629.22 $629.22 $401.98 "$1,174.28" $0.00 $0.00 $0.00 $0.00 34100062 EAP CPT® 78226 Hepatobiliary Imag W Glbldr BOTH IP/OP "$2,589.00 " "$1,915.86" $234.94 "$2,092.00" $780.38 $780.38 $367.10 $367.10 $369.17 $539.61 $738.89 $738.89 $767.31 $361.44 $539.55 $234.94 "$1,531.39" "$1,531.39" $354.53 $627.60 "$2,071.08" "$2,092.00" $492.57 $616.81 $492.57 $315.27 $300.74 $300.74 $416.31 $337.65 $0.00 $0.00 $0.00 $0.00 34100063 EAP CPT® 78227 Hepatobil Imag Pharma W Glbldr BOTH IP/OP "$2,615.00 " "$1,935.10" $0.00 "$2,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,026.06" "$1,026.06" "$1,065.53" $0.00 $544.97 $0.00 $0.00 $0.00 $0.00 $627.60 "$2,071.08" "$2,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100064 EAP CPT® 78579 Pulmonary Ventilation Imaging BOTH IP/OP "$1,086.00 " $803.64 $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $381.40 $381.40 $396.07 $0.00 $226.32 $0.00 $0.00 $0.00 $0.00 $261.36 $862.49 $871.20 $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100065 EAP CPT® 78582 Pulmon Vent Imag W Perfus BOTH IP/OP "$1,696.00 " "$1,255.04" $270.64 "$1,360.00" $789.25 $789.25 $476.55 $476.55 $479.24 $353.49 $684.86 $684.86 $711.20 $469.05 $353.45 $304.88 "$1,003.18" "$1,003.18" $456.86 $408.00 "$1,346.40" "$1,360.00" $634.74 $800.61 $634.74 $308.89 $289.94 $289.94 $270.64 $435.10 $0.00 $0.00 $0.00 $0.00 34100066 EAP CPT® 78598 Quant Diff Pulm Perfu + Vent BOTH IP/OP "$1,700.00 " "$1,258.00" $0.00 "$1,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.58 $662.58 $688.07 $0.00 $354.28 $0.00 $0.00 $0.00 $0.00 $408.00 "$1,346.40" "$1,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100067 EAP CPT® 78597 Quant Diff Pulm Perfusion BOTH IP/OP "$1,086.00 " $803.64 $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.86 $408.86 $424.58 $0.00 $226.32 $0.00 $0.00 $0.00 $0.00 $261.36 $862.49 $871.20 $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100070 EAP CPT® 78645 Shunt Evaluation BOTH IP/OP $922.00 $682.28 $0.00 $737.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $652.41 $652.41 $677.51 $0.00 $192.14 $0.00 $0.00 $0.00 $0.00 $221.28 $730.22 $737.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100072 EAP CPT® 78012 Thyroid Uptake Sing/multi Inc Supres Disch BOTH IP/OP "$4,484.00 " "$3,318.16" $0.00 "$3,716.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.90 $185.90 $193.05 $0.00 $934.47 $0.00 $0.00 $0.00 $0.00 "$1,114.80" "$3,678.84" "$3,716.00" $0.00 "$1,275.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100073 EAP CPT® 78013 Thyroid Imaging BOTH IP/OP "$2,280.00 " "$1,687.20" $0.00 "$1,842.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $484.05 $484.05 $502.66 $0.00 $475.15 $0.00 $0.00 $0.00 $0.00 $552.72 "$1,823.98" "$1,842.40" $0.00 "$1,243.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100074 EAP CPT® 78014 Thyroid Imaging W/multi Determ Inc Suprs/dc BOTH IP/OP "$5,018.00 " "$3,713.32" $222.22 "$4,055.20" $569.98 $569.98 $367.10 $367.10 $369.17 "$1,045.88" $550.89 $550.89 $572.08 $361.44 "$1,045.75" $234.94 "$2,968.15" "$2,968.15" $354.53 "$1,216.56" "$4,014.65" "$4,055.20" $492.57 $616.81 $492.57 $232.84 $222.22 $222.22 $806.98 $337.65 $0.00 $0.00 $0.00 $0.00 34100075 EAP CPT® 78071 Parathyrd Planar W/wo Subtrj BOTH IP/OP "$1,132.00 " $837.68 $0.00 $938.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.59 $768.59 $798.15 $0.00 $235.91 $0.00 $0.00 $0.00 $0.00 $281.52 $929.02 $938.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34100076 EAP CPT® 78072 Parathyrd Planar W/spect&ct BOTH IP/OP "$3,095.00 " "$2,290.30" $74.44 "$2,500.80" $726.00 $726.00 $476.55 $476.55 $479.24 $645.08 $785.72 $785.72 $815.94 $469.05 $645.00 $304.88 "$1,830.69" "$1,830.69" $456.86 $750.24 "$2,475.79" "$2,500.80" $634.74 $800.61 $634.74 $74.44 $381.06 $381.06 $497.66 $435.10 $0.00 $0.00 $0.00 $0.00 34100077 EAP CPT® 78831 Nm Rp Loclzj Tum Spect 2 Area/1 Day Or 1 Area/2+ Day BOTH IP/OP "$2,001.00 " "$1,480.74" $0.00 "$1,616.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,480.71" "$1,480.71" "$1,537.66" $0.00 $417.01 $0.00 $0.00 $0.00 $0.00 $485.04 "$1,600.63" "$1,616.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34200013 EAP CPT® 79005 INIT HYPERTHYROID THERAPY NUC BOTH IP/OP "$2,958.00 " "$2,188.92" $51.14 "$2,390.40" $314.37 $314.37 $246.41 $246.41 $247.80 $616.52 $155.69 $155.69 $161.68 $239.24 $616.45 $155.51 "$1,749.66" "$1,749.66" $238.10 $717.12 "$2,366.50" "$2,390.40" $330.81 $396.31 $330.81 $196.86 $51.14 $51.14 $475.69 $226.76 $0.00 $0.00 $0.00 $0.00 34200014 EAP CPT® 77316 Brachyther Plan Simple BOTH IP/OP $904.00 $668.96 $145.35 $730.40 $431.30 $431.30 $329.78 $329.78 $331.64 $188.42 $285.20 $285.20 $296.17 $324.60 $188.39 $210.99 $534.72 $534.72 $336.15 $219.12 $723.10 $730.40 $467.03 $569.27 $467.03 $177.21 $146.23 $146.23 $145.35 $320.14 $0.00 $0.00 $0.00 $0.00 34200015 EAP CPT® 77317 Brachyther Plan Inter BOTH IP/OP "$1,196.00 " $885.04 $191.61 $966.40 $561.87 $561.87 $329.78 $329.78 $331.64 $249.28 $371.63 $371.63 $385.93 $324.60 $249.25 $210.99 $707.43 $707.43 $336.15 $289.92 $956.74 $966.40 $467.03 $569.27 $467.03 $231.84 $191.61 $191.61 $192.31 $320.14 $0.00 $0.00 $0.00 $0.00 34200016 EAP CPT® 79445 Nuclear Rx Intra-arterial BOTH IP/OP "$1,324.00 " $979.76 $0.00 "$1,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.82 $262.82 $272.93 $0.00 $275.92 $0.00 $0.00 $0.00 $0.00 $317.76 "$1,048.61" "$1,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34200017 EAP CPT® 77770 Hdr Brachytx 1 Channel BOTH IP/OP "$4,521.00 " "$3,345.54" $236.63 "$3,653.60" $733.58 $733.58 $690.83 $690.83 $694.72 $942.29 $554.68 $554.68 $576.02 $679.00 $942.18 $441.35 "$2,674.17" "$2,674.17" $742.70 "$1,096.08" "$3,617.06" "$3,653.60" "$1,031.88" "$1,145.32" "$1,031.88" $308.15 $236.63 $236.63 $727.07 $707.33 $0.00 $0.00 $0.00 $0.00 34200018 EAP CPT® 77771 Hdr Brachytx 2-12 Channel BOTH IP/OP "$5,523.00 " "$4,087.02" $405.91 "$4,463.20" "$1,366.38" "$1,366.38" $690.83 $690.83 $694.72 "$1,151.13" "$1,010.25" "$1,010.25" "$1,049.10" $679.00 "$1,150.99" $441.35 "$3,266.85" "$3,266.85" $742.70 "$1,338.96" "$4,418.57" "$4,463.20" "$1,031.88" "$1,145.32" "$1,031.88" $573.41 $405.91 $405.91 $888.18 $707.33 $0.00 $0.00 $0.00 $0.00 34200019 EAP CPT® 77772 Hdr Brachytx Over 12 Chan BOTH IP/OP "$6,877.00 " "$5,088.98" $0.00 "$6,877.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,594.37" "$1,594.37" "$1,655.69" $0.00 "$1,433.17" $0.00 $0.00 $0.00 $0.00 "$1,667.04" "$5,501.23" "$5,556.80" $0.00 "$6,877.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34300001 EAP HCPCS A9500 Tc-99m Sestambi/cardiolite Nu BOTH IP/OP $516.00 $381.84 $0.00 $412.80 $0.00 $0.00 $0.00 $0.00 $0.00 $107.55 $0.00 $0.00 $0.00 $0.00 $107.53 $0.00 $305.21 $305.21 $0.00 $258.00 $408.67 $412.80 $0.00 $335.40 $0.00 $106.29 $0.00 $0.00 $82.15 $0.00 $0.00 $0.00 $0.00 $0.00 34300002 EAP HCPCS A9502 Tetrofosmin Myoview Nuc BOTH IP/OP $812.00 $600.88 $0.00 $649.60 $0.00 $0.00 $0.00 $0.00 $0.00 $155.45 $0.00 $0.00 $0.00 $0.00 $131.76 $0.00 $480.30 $480.30 $0.00 $406.00 $643.10 $649.60 $0.00 $527.80 $0.00 $125.46 $0.00 $0.00 $129.27 $0.00 $0.00 $0.00 $0.00 $0.00 34300003 EAP HCPCS A9503 99mtc Mdp Nuc BOTH IP/OP $312.00 $230.88 $0.00 $249.60 $0.00 $0.00 $0.00 $0.00 $0.00 $65.03 $0.00 $0.00 $0.00 $0.00 $65.02 $0.00 $184.55 $184.55 $0.00 $156.00 $247.10 $249.60 $0.00 $202.80 $0.00 $48.83 $0.00 $0.00 $49.67 $0.00 $0.00 $0.00 $0.00 $0.00 34300004 EAP HCPCS A9505 Ti-201 Thallous Chloride Nuc BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $85.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34300005 EAP HCPCS A9516 I-123 Iodine Capsule Nuc BOTH IP/OP "$2,008.00 " "$1,485.92" $0.00 "$1,606.40" $0.00 $0.00 $0.00 $0.00 $0.00 $418.52 $0.00 $0.00 $0.00 $0.00 $418.47 $0.00 "$1,187.73" "$1,187.73" $0.00 "$1,004.00" "$1,590.34" "$1,606.40" $0.00 "$1,305.20" $0.00 $314.25 $0.00 $0.00 $319.67 $0.00 $0.00 $0.00 $0.00 $0.00 34300006 EAP HCPCS A9521 99mtc Ceretec-labld - Wbc BOTH IP/OP "$1,888.00 " "$1,397.12" $0.00 "$1,510.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.46 $0.00 $0.00 $0.00 $0.00 $944.00 "$1,495.30" "$1,510.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34300007 EAP HCPCS A9537 99mtc Hepat-biliary-unprep Nu BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.82 $0.00 $0.00 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $217.75 $0.00 $52.00 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 34300008 EAP HCPCS A9539 99mtc Dtpa BOTH IP/OP $409.00 $302.66 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.24 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $265.85 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 34300009 EAP HCPCS A9540 99mtc Maauc BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.58 $0.00 $0.00 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 34300010 EAP HCPCS A9541 Tc-99m S Colloid Nuc BOTH IP/OP $523.00 $387.02 $0.00 $339.95 $0.00 $0.00 $0.00 $0.00 $0.00 $109.01 $0.00 $0.00 $0.00 $0.00 $108.99 $0.00 $309.35 $309.35 $0.00 $167.50 $265.32 $268.00 $0.00 $339.95 $0.00 $48.79 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 34300011 EAP HCPCS A9521 99mtc Ceretec-bd BOTH IP/OP "$4,651.00 " "$3,441.74" $0.00 "$3,023.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $969.27 $0.00 $0.00 $0.00 $0.00 $404.50 $640.73 $647.20 $0.00 "$3,023.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34300016 EAP HCPCS A9582 "I123-mibg,10 Mci" BOTH IP/OP "$10,753.00 " "$7,957.22" $0.00 "$8,288.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,288.41" $0.00 "$2,240.93" $0.00 $0.00 $0.00 $0.00 "$4,475.50" "$7,089.19" "$7,160.80" $0.00 "$6,989.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34300020 EAP HCPCS A9572 Indium In-111 Pentetreotide BOTH IP/OP "$12,489.00 " "$9,241.86" $0.00 "$8,117.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,602.71" $0.00 $0.00 $0.00 $0.00 "$2,152.00" "$3,408.77" "$3,443.20" $0.00 "$8,117.85" $0.00 $673.58 $0.00 $0.00 $685.20 $0.00 $0.00 $0.00 $0.00 $0.00 34300021 EAP HCPCS A9512 Technetiumtc-99m Pertechnetate BOTH IP/OP $227.00 $167.98 $0.00 $181.60 $0.00 $0.00 $0.00 $0.00 $0.00 $47.31 $0.00 $0.00 $0.00 $0.00 $47.31 $0.00 $134.27 $134.27 $0.00 $113.50 $179.78 $181.60 $0.00 $147.55 $0.00 $35.53 $0.00 $0.00 $36.14 $0.00 $0.00 $0.00 $0.00 $0.00 34300024 EAP CPT® A9520 "Lymphoseek, Diag, Up To 0.5mci" BOTH IP/OP "$1,571.00 " "$1,162.54" $0.00 "$1,021.15" $0.00 $0.00 $0.00 $0.00 $0.00 $327.44 $0.00 $0.00 $0.00 $0.00 $327.40 $0.00 $929.25 $929.25 $0.00 $414.00 $655.78 $662.40 $0.00 "$1,021.15" $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 34300025 EAP HCPCS A9580 "Sodium Fluoride F-18, Diagnostic" BOTH IP/OP $312.00 $230.88 $0.00 $249.60 $0.00 $0.00 $0.00 $0.00 $0.00 $65.03 $0.00 $0.00 $0.00 $0.00 $65.02 $0.00 $184.55 $184.55 $0.00 $156.00 $247.10 $249.60 $0.00 $202.80 $0.00 $48.83 $0.00 $0.00 $49.67 $0.00 $0.00 $0.00 $0.00 $0.00 34300026 EAP HCPCS A9587 "Gallium Ga-68, Dotatate, Diagnostic" BOTH IP/OP "$8,000.00 " "$5,920.00" $0.00 "$6,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,166.40" $0.00 "$1,667.20" $0.00 $0.00 $0.00 $0.00 "$4,000.00" "$6,336.00" "$6,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34300027 EAP HCPCS A9588 "Fluciclovine F-18, Diagnostic" BOTH IP/OP "$11,015.00 " "$8,151.10" $0.00 "$8,812.00" "$5,981.15" "$5,981.15" $0.00 $0.00 $0.00 "$2,295.80" "$4,181.12" "$4,181.12" "$8,490.36" $0.00 "$2,295.53" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,507.50" "$8,723.88" "$8,812.00" $0.00 "$7,159.75" $0.00 "$1,723.85" $0.00 $0.00 "$1,753.59" $0.00 $0.00 $0.00 $0.00 $0.00 34300028 EAP HCPCS A9584 "Iodine 1-123 Ioflupane, Diagnostic" BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34300029 EAP HCPCS A9587 "Gallium Ga-68, Dotatate, Diagnostic, 0.1 Millicurie" BOTH IP/OP $167.00 $123.58 $0.00 $133.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.95 $123.95 $128.72 $0.00 $34.80 $0.00 $0.00 $0.00 $0.00 $83.50 $132.26 $133.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34400001 EAP HCPCS A9527 "Iodine I-125, Sodium Iodide, Per Millicurie" BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $39.97 $39.97 $40.37 $43.14 $153.64 $153.64 $159.56 $26.73 $43.14 $17.37 $122.44 $122.44 $32.83 $103.50 $163.94 $165.60 $45.34 $134.55 $45.34 $32.40 $0.00 $0.00 $32.95 $31.27 $0.00 $0.00 $0.00 $0.00 35000001 EAP CPT® 73200 Upp Ext Ct W/o Dye Bilat Ect BOTH IP/OP "$7,981.00 " "$5,905.94" $67.89 "$6,436.80" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 "$1,663.44" $785.72 $785.72 $815.94 $104.44 "$1,663.24" $67.89 "$1,106.00" "$1,106.00" $112.41 "$1,608.00" "$6,372.43" "$6,436.80" $156.18 $540.00 $156.18 "$1,259.20" $130.02 $130.02 "$1,280.92" $107.06 $0.00 $0.00 $0.00 $0.00 35000002 EAP CPT® 73201 Upp Ext Ct W/dye Bilat Ect BOTH IP/OP "$8,891.00 " "$6,579.34" $166.40 "$7,170.40" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 "$1,853.11" $785.72 $785.72 $815.94 $352.81 "$1,852.88" $229.33 "$1,106.00" "$1,106.00" $387.01 $774.00 "$7,098.70" "$7,170.40" $537.70 $540.00 $537.70 "$1,402.71" $166.40 $166.40 "$1,426.91" $368.58 $0.00 $0.00 $0.00 $0.00 35000003 EAP CPT® 73202 Upp Ext Ct W&wo Dye Bilat Ect BOTH IP/OP "$9,863.00 " "$7,298.62" $0.00 "$7,954.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,055.45" $0.00 "$1,106.00" "$1,106.00" $0.00 $923.00 "$7,874.86" "$7,954.40" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000005 EAP CPT® 73700 LOW EXT CT W/O DYE RT ECT BOTH IP/OP "$3,488.00 " "$2,581.12" $0.00 "$2,790.40" $0.00 $0.00 $0.00 $0.00 $0.00 $787.01 $0.00 $0.00 $0.00 $104.44 $786.92 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,762.50" "$2,790.40" $156.18 $0.00 $156.18 $545.87 $105.89 $105.89 $555.29 $107.06 $0.00 $0.00 $0.00 $0.00 35000006 EAP CPT® 73701 LOW EXT CT W/DYE RT ECT BOTH IP/OP "$4,789.00 " "$3,543.86" $0.00 "$3,831.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,080.68" $0.00 $0.00 $0.00 $171.13 "$1,080.55" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,149.36" "$3,792.89" "$3,831.20" $281.11 $0.00 $281.11 $749.48 $137.23 $137.23 $762.41 $192.70 $0.00 $0.00 $0.00 $0.00 35000007 EAP CPT® 73702 LOW EXT CT W&WO DYE LT ECT BOTH IP/OP "$6,038.00 " "$4,468.12" $0.00 "$4,461.60" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,258.32" $0.00 "$1,106.00" "$1,106.00" $202.33 $923.00 "$4,416.98" "$4,461.60" $281.11 $540.00 $281.11 $872.80 $174.32 $174.32 $887.86 $192.70 $0.00 $0.00 $0.00 $0.00 35000009 EAP CPT® 75635 ABD AORTA&ILLIOFEMORAL CTA ECT BOTH IP/OP "$6,653.00 " "$4,923.22" $111.23 "$4,927.20" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,386.65" $785.72 $785.72 $815.94 $171.13 "$1,386.49" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$4,877.93" "$4,927.20" $281.11 $540.00 $281.11 $963.88 $329.20 $329.20 $980.51 $192.70 $0.00 $0.00 $0.00 $0.00 35000010 EAP CPT® 76376 3drendering W/o Postprocess BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,626.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $458.54 $785.72 $785.72 $815.94 $0.00 $458.48 $0.00 "$1,106.00" "$1,106.00" $0.00 $487.92 "$1,610.14" "$1,626.40" $0.00 $540.00 $0.00 $318.16 $13.33 $13.33 $323.65 $0.00 $0.00 $0.00 $0.00 $0.00 35000011 EAP CPT® 76377 3d Rendering W/postprocess BOTH IP/OP "$4,133.00 " "$3,058.42" $0.00 "$3,056.00" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $861.42 $785.72 $785.72 $815.94 $0.00 $861.32 $0.00 "$1,106.00" "$1,106.00" $0.00 $916.80 "$3,025.44" "$3,056.00" $0.00 $540.00 $0.00 $597.83 $32.41 $32.41 $608.14 $0.00 $0.00 $0.00 $0.00 $0.00 35000013 EAP CPT® 77011 CT GUIDED STEREOTAT LOC NCT BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,404.90" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.49 $0.00 "$1,106.00" "$1,106.00" $0.00 $414.00 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000014 EAP CPT® 77012 CT GUIDANCE NEEDLE PLC BCT BOTH IP/OP "$2,365.00 " "$1,750.10" $0.00 "$1,911.20" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $492.93 $785.72 $785.72 $815.94 $0.00 $492.87 $0.00 "$1,106.00" "$1,106.00" $0.00 $573.36 "$1,892.09" "$1,911.20" $0.00 $540.00 $0.00 $373.88 $77.80 $77.80 $380.33 $0.00 $0.00 $0.00 $0.00 $0.00 35000015 EAP CPT® 77013 "Ct, Visceral Tissue Ablation" BOTH IP/OP "$2,734.00 " "$2,023.16" $0.00 "$2,209.60" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $569.83 $0.00 $0.00 $0.00 $0.00 $569.77 $0.00 "$1,106.00" "$1,106.00" $0.00 $662.88 "$2,187.50" "$2,209.60" $0.00 $540.00 $0.00 $432.25 $0.00 $0.00 $439.71 $0.00 $0.00 $0.00 $0.00 $0.00 35000104 EAP CPT® 73206 Upp Ext Cta W&wo Dye Rt Ect BOTH IP/OP "$3,509.00 " "$2,596.66" $111.23 "$2,829.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 $731.36 $785.72 $785.72 $815.94 $171.13 $731.28 $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$2,801.30" "$2,829.60" $281.11 $540.00 $281.11 $553.54 $241.31 $241.31 $563.09 $192.70 $0.00 $0.00 $0.00 $0.00 35000108 EAP CPT® 20982 Ablation Bone Tumor Perc W/img BOTH IP/OP "$13,275.00 " "$9,823.50" $0.00 "$9,956.00" "$2,321.55" "$2,321.55" "$6,099.77" "$6,099.77" "$6,134.13" "$2,766.84" $0.00 $0.00 $0.00 "$6,004.45" "$2,766.51" "$3,902.89" "$4,877.00" "$4,877.00" $0.00 "$5,452.00" "$9,856.44" "$9,956.00" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000202 EAP CPT® 73201 Upp Ext Ct W/dye Lt/rt Ect BOTH IP/OP "$4,446.00 " "$3,290.04" $166.40 "$3,585.60" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 $926.66 $785.72 $785.72 $815.94 $352.81 $926.55 $229.33 "$1,106.00" "$1,106.00" $387.01 $774.00 "$3,549.74" "$3,585.60" $537.70 $540.00 $537.70 $701.43 $166.40 $166.40 $713.53 $368.58 $0.00 $0.00 $0.00 $0.00 35000303 EAP CPT® 73202 Upp Ext Ct W&wo Dye Lt/rt Ect BOTH IP/OP "$4,933.00 " "$3,650.42" $0.00 "$3,978.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,028.04" $0.00 "$1,106.00" "$1,106.00" $0.00 $923.00 "$3,938.62" "$3,978.40" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000305 EAP CPT® 75571 Ct Hrt W/o Dye W/ca Test BOTH IP/OP $125.00 $92.50 $19.72 $540.00 $125.00 $125.00 $78.77 $78.77 $79.21 $84.41 $125.00 $125.00 $125.00 $77.54 $84.40 $50.40 $405.00 $405.00 $80.04 $30.24 $99.79 $100.80 $111.21 $540.00 $111.21 $19.72 $76.72 $76.72 $20.06 $76.23 $0.00 $0.00 $0.00 $0.00 35000306 EAP CPT® 75572 Ct Hrt W/3d Image BOTH IP/OP "$1,534.00 " "$1,135.16" $0.00 "$1,404.90" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.69 $0.00 "$1,106.00" "$1,106.00" $0.00 $372.00 "$1,227.60" "$1,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000307 EAP CPT® 75573 "Ct Hrt W/3d Image, Congen" BOTH IP/OP "$1,268.00 " $938.32 $0.00 "$1,268.00" "$1,268.00" "$1,268.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.25 $0.00 "$1,106.00" "$1,106.00" $0.00 $307.44 "$1,014.55" "$1,024.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000308 EAP CPT® 75574 Ct Angio Hrt W/3d Image BOTH IP/OP "$2,297.00 " "$1,699.78" $111.23 "$1,701.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 $478.75 $785.72 $785.72 $815.94 $171.13 $478.69 $111.23 "$1,106.00" "$1,106.00" $202.33 $510.48 "$1,684.58" "$1,701.60" $281.11 $540.00 $281.11 $332.88 $244.20 $244.20 $338.62 $192.70 $0.00 $0.00 $0.00 $0.00 35000309 EAP CPT® 75571 Ct Heart W/o Dye;qual Calc Oct BOTH IP/OP $125.00 $92.50 $19.72 $540.00 $125.00 $125.00 $78.77 $78.77 $79.21 $26.05 $125.00 $125.00 $125.00 $77.54 $26.05 $50.40 $125.00 $125.00 $80.04 $30.24 $99.79 $100.80 $111.21 $540.00 $111.21 $19.72 $76.72 $76.72 $20.06 $76.23 $0.00 $0.00 $0.00 $0.00 35000311 EAP CPT® 73700 Low Ext Ct W/o Dye Bilat Ect BOTH IP/OP "$6,983.00 " "$5,167.42" $67.89 "$5,586.40" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 "$1,455.43" $785.72 $785.72 $815.94 $104.44 "$1,455.26" $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$5,530.54" "$5,586.40" $156.18 $540.00 $156.18 "$1,092.84" $105.89 $105.89 "$1,111.69" $107.06 $0.00 $0.00 $0.00 $0.00 35000312 EAP CPT® 73701 Low Ext Ct W/dye Bilat Ect BOTH IP/OP "$9,578.00 " "$7,087.72" $111.23 "$7,662.40" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,996.29" $785.72 $785.72 $815.94 $171.13 "$1,996.06" $111.23 "$1,106.00" "$1,106.00" $202.33 "$2,298.72" "$7,585.78" "$7,662.40" $281.11 $540.00 $281.11 "$1,498.96" $137.23 $137.23 "$1,524.82" $192.70 $0.00 $0.00 $0.00 $0.00 35000313 EAP CPT® 73702 Low Ext Ct W&wo Dye Bilat Ect BOTH IP/OP "$11,163.00 " "$8,260.62" $0.00 "$8,930.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,326.37" $0.00 "$1,106.00" "$1,106.00" $202.33 $923.00 "$8,841.10" "$8,930.40" $281.11 $540.00 $281.11 "$1,747.01" $174.32 $174.32 "$1,777.15" $192.70 $0.00 $0.00 $0.00 $0.00 35000314 EAP CPT® 73706 Low Ext Cta W&wo Dye Bilat Ect BOTH IP/OP "$12,088.00 " "$8,945.12" $111.23 "$9,670.40" $726.00 $726.00 $173.95 $173.95 $174.93 "$2,519.44" $785.72 $785.72 $815.94 $171.13 "$2,519.14" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$9,573.70" "$9,670.40" $281.11 $540.00 $281.11 "$1,891.77" $264.37 $264.37 "$1,924.41" $192.70 $0.00 $0.00 $0.00 $0.00 35000315 EAP CPT® 73206 Upp Ext Cta W&wo Dye Bilat Ect BOTH IP/OP "$7,023.00 " "$5,197.02" $111.23 "$5,664.00" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,463.77" $785.72 $785.72 $815.94 $171.13 "$1,463.59" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$5,607.36" "$5,664.00" $281.11 $540.00 $281.11 "$1,108.02" $241.31 $241.31 "$1,127.14" $192.70 $0.00 $0.00 $0.00 $0.00 35000352 EAP CPT® 74176 "Ct, Abd And Pelvis W/o Contrast" BOTH IP/OP "$7,437.00 " "$5,503.38" $113.81 "$5,508.00" "$1,404.90" "$1,404.90" $224.08 $224.08 $225.34 "$1,550.06" $785.72 $785.72 $815.94 $220.56 "$1,549.87" $143.36 "$1,106.00" "$1,106.00" $233.72 "$1,652.40" "$5,452.92" "$5,508.00" $324.73 $540.00 $324.73 "$1,077.50" $113.81 $113.81 "$1,096.09" $222.60 $0.00 $0.00 $0.00 $0.00 35000353 EAP CPT® 74177 "Ct, Abd And Pelvis W/contrast" BOTH IP/OP "$10,201.00 " "$7,548.74" $229.33 "$7,555.20" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 "$2,126.14" $785.72 $785.72 $815.94 $352.81 "$2,125.89" $229.33 "$1,106.00" "$1,106.00" $387.01 "$2,266.56" "$7,479.65" "$7,555.20" $537.70 $540.00 $537.70 "$1,477.99" $238.43 $238.43 "$1,503.48" $368.58 $0.00 $0.00 $0.00 $0.00 35000354 EAP CPT® 37220 Iliac Revasc BOTH IP/OP "$11,190.00 " "$8,280.60" $0.00 "$8,497.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,332.00" $0.00 $0.00 $0.00 $0.00 "$4,975.00" "$8,412.62" "$8,497.60" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000355 EAP CPT® 37221 Iliac Revasc W/stent BOTH IP/OP "$32,950.00 " "$24,383.00" $0.00 "$25,023.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,866.78" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$24,772.97" "$25,023.20" $0.00 "$5,164.00" $0.00 "$4,457.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000356 EAP CPT® 37222 Iliac Revasc Add-on BOTH IP/OP "$27,325.00 " "$20,220.50" $0.00 "$25,023.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,694.53" $0.00 $0.00 $0.00 $0.00 "$15,639.50" "$24,772.97" "$25,023.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000357 EAP CPT® 37223 Iliac Revasc W/stent Add-on BOTH IP/OP "$32,950.00 " "$24,383.00" $0.00 "$25,023.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,866.78" $0.00 $0.00 $0.00 $0.00 "$15,639.50" "$24,772.97" "$25,023.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000358 EAP CPT® 37224 Fem/popl Revas W/tla BOTH IP/OP "$21,928.00 " "$16,226.72" $0.00 "$17,203.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,569.80" $0.00 $0.00 $0.00 "$4,968.47" "$4,975.00" "$17,031.17" "$17,203.20" "$6,903.03" "$4,334.00" "$6,903.03" "$3,623.42" $466.92 $466.92 "$3,423.44" "$4,731.88" $0.00 $0.00 $0.00 $0.00 35000359 EAP CPT® 37225 Fem/popl Revas W/ather BOTH IP/OP "$46,544.00 " "$34,442.56" $0.00 "$36,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,699.77" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$36,150.05" "$36,515.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000360 EAP CPT® 37226 Fem/popl Revasc W/stent BOTH IP/OP "$46,544.00 " "$34,442.56" $0.00 "$36,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,699.77" $0.00 $0.00 $0.00 "$9,937.60" "$6,105.00" "$36,150.05" "$36,515.20" "$13,806.97" "$5,164.00" "$13,806.97" "$7,751.33" $545.88 $545.88 "$7,266.52" "$9,464.38" $0.00 $0.00 $0.00 $0.00 35000361 EAP CPT® 37227 Fem/popl Revasc Stnt & Ather BOTH IP/OP "$80,612.00 " "$59,652.88" $0.00 "$63,242.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,799.54" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$62,609.98" "$63,242.40" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000362 EAP CPT® 37228 Tib/per Revasc W/tla BOTH IP/OP "$21,928.00 " "$16,226.72" $0.00 "$17,203.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,569.80" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$17,031.17" "$17,203.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000363 EAP CPT® 37229 Tib/per Revasc W/ather BOTH IP/OP "$41,457.00 " "$30,678.18" $0.00 "$36,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,639.64" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$36,150.05" "$36,515.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000364 EAP CPT® 37230 Tib/per Revasc W/stent BOTH IP/OP "$46,544.00 " "$34,442.56" $0.00 "$36,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,699.77" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$36,150.05" "$36,515.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000365 EAP CPT® 37231 Tib/per Revasc Stent & Ather BOTH IP/OP "$62,684.00 " "$46,386.16" $0.00 "$49,177.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$13,063.35" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$48,685.82" "$49,177.60" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000366 EAP CPT® 37232 Tib/per Revasc Add-on BOTH IP/OP "$19,531.00 " "$14,452.94" $0.00 "$17,203.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,070.26" $0.00 $0.00 $0.00 $0.00 "$10,752.00" "$17,031.17" "$17,203.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000367 EAP CPT® 37233 Tibper Revasc W/ather Add-on BOTH IP/OP "$41,457.00 " "$30,678.18" $0.00 "$36,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,639.64" $0.00 $0.00 $0.00 $0.00 "$22,822.00" "$36,150.05" "$36,515.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000368 EAP CPT® 37234 Revsc Opn/prq Tib/pero Stent BOTH IP/OP "$19,531.00 " "$14,452.94" $0.00 "$17,203.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,070.26" $0.00 $0.00 $0.00 $0.00 "$10,752.00" "$17,031.17" "$17,203.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000369 EAP CPT® 37235 Tib/per Revasc Stnt & Ather BOTH IP/OP "$19,531.00 " "$14,452.94" $0.00 "$17,203.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,070.26" $0.00 $0.00 $0.00 $0.00 "$10,752.00" "$17,031.17" "$17,203.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35000381 EAP CPT® 74178 "Ct, Abd And Pelvis W&w/o Contrast" BOTH IP/OP "$11,888.00 " "$8,797.12" $229.33 "$8,804.80" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 "$2,477.76" $785.72 $785.72 $815.94 $352.81 "$2,477.46" $229.33 "$1,106.00" "$1,106.00" $387.01 "$2,641.44" "$8,716.75" "$8,804.80" $537.70 $540.00 $537.70 "$1,722.44" $270.49 $270.49 "$1,752.16" $368.58 $0.00 $0.00 $0.00 $0.00 35100001 EAP CPT® 70450 HEAD/BRAIN CT W/O DYE ECT BOTH IP/OP "$4,085.00 " "$3,022.90" $67.89 "$2,971.20" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $851.42 $785.72 $785.72 $815.94 $104.44 $851.31 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,941.49" "$2,971.20" $156.18 $540.00 $156.18 $581.24 $73.47 $73.47 $591.27 $107.06 $0.00 $0.00 $0.00 $0.00 35100002 EAP CPT® 70460 HEAD/BRAIN CT W/ DYE ECT BOTH IP/OP "$5,603.00 " "$4,146.22" $107.69 "$4,075.20" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,167.81" $785.72 $785.72 $815.94 $171.13 "$1,167.67" $111.23 "$1,106.00" "$1,106.00" $202.33 $774.00 "$4,034.45" "$4,075.20" $281.11 $540.00 $281.11 $797.21 $107.69 $107.69 $810.96 $192.70 $0.00 $0.00 $0.00 $0.00 35100003 EAP CPT® 70470 HEAD/BRAIN CT W&WO DYE ECT BOTH IP/OP "$6,525.00 " "$4,828.50" $0.00 "$4,746.40" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 $0.00 $785.72 $785.72 $815.94 $0.00 "$1,359.81" $0.00 "$1,106.00" "$1,106.00" $202.33 $923.00 "$4,698.94" "$4,746.40" $281.11 $540.00 $281.11 $928.51 $128.94 $128.94 $944.53 $192.70 $0.00 $0.00 $0.00 $0.00 35100004 EAP CPT® 70480 ORBIT/SELLA/EAR W/O DYE ECT BOTH IP/OP "$4,725.00 " "$3,496.50" $67.89 "$3,489.60" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $984.81 $785.72 $785.72 $815.94 $104.44 $984.69 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$3,454.70" "$3,489.60" $156.18 $540.00 $156.18 $682.65 $137.95 $137.95 $694.43 $107.06 $0.00 $0.00 $0.00 $0.00 35100005 EAP CPT® 70481 ORBIT/SELLA/EAR W/DYE ECT BOTH IP/OP "$6,480.00 " "$4,795.20" $111.23 "$4,785.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,350.59" $785.72 $785.72 $815.94 $171.13 "$1,350.43" $111.23 "$1,106.00" "$1,106.00" $202.33 $774.00 "$4,737.74" "$4,785.60" $281.11 $540.00 $281.11 $936.18 $168.92 $168.92 $952.33 $192.70 $0.00 $0.00 $0.00 $0.00 35100006 EAP CPT® 70482 ORB/SELLA/EAR W&WO DYE ECT BOTH IP/OP "$7,547.00 " "$5,584.78" $0.00 "$5,573.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,572.98" $785.72 $785.72 $815.94 $171.13 "$1,572.79" $111.23 "$1,106.00" "$1,106.00" $202.33 $923.00 "$5,517.86" "$5,573.60" $281.11 $540.00 $281.11 $0.00 $186.57 $186.57 "$1,109.15" $192.70 $0.00 $0.00 $0.00 $0.00 35100007 EAP CPT® 70486 MAXILLOFAC CT W/O DYE ECT BOTH IP/OP "$4,725.00 " "$3,496.50" $67.89 "$3,489.60" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $984.81 $785.72 $785.72 $815.94 $104.44 $984.69 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$3,454.70" "$3,489.60" $156.18 $540.00 $156.18 $682.65 $97.25 $97.25 $694.43 $107.06 $0.00 $0.00 $0.00 $0.00 35100008 EAP CPT® 70487 MAXILLOFAC CT W/DYE ECT BOTH IP/OP "$6,480.00 " "$4,795.20" $111.23 "$4,785.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,350.59" $785.72 $785.72 $815.94 $171.13 "$1,350.43" $111.23 "$1,106.00" "$1,106.00" $202.33 $774.00 "$4,737.74" "$4,785.60" $281.11 $540.00 $281.11 $936.18 $111.65 $111.65 $952.33 $192.70 $0.00 $0.00 $0.00 $0.00 35100009 EAP CPT® 70488 MAXILLOFAC CT W&WO DYE ECT BOTH IP/OP "$7,547.00 " "$5,584.78" $0.00 "$5,573.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 $0.00 $785.72 $785.72 $815.94 $0.00 "$1,572.79" $0.00 "$1,106.00" "$1,106.00" $202.33 $923.00 "$5,517.86" "$5,573.60" $281.11 $540.00 $281.11 "$1,090.34" $141.55 $141.55 "$1,109.15" $192.70 $0.00 $0.00 $0.00 $0.00 35100010 EAP CPT® 70490 SOFT TISS NECK CT W/O DYE ECT BOTH IP/OP "$3,955.00 " "$2,926.70" $67.89 "$2,877.60" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $824.32 $785.72 $785.72 $815.94 $104.44 $824.22 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,848.82" "$2,877.60" $156.18 $540.00 $156.18 $562.93 $101.21 $101.21 $572.64 $107.06 $0.00 $0.00 $0.00 $0.00 35100011 EAP CPT® 70491 SOFT TISS NECK CT W/DYE ECT BOTH IP/OP "$5,424.00 " "$4,013.76" $111.23 "$3,946.40" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,130.50" $785.72 $785.72 $815.94 $171.13 "$1,130.36" $111.23 "$1,106.00" "$1,106.00" $202.33 $774.00 "$3,906.94" "$3,946.40" $281.11 $540.00 $281.11 $772.01 $134.70 $134.70 $785.33 $192.70 $0.00 $0.00 $0.00 $0.00 35100012 EAP CPT® 70492 SOFT TISS NECK CT W&WO DYE ECT BOTH IP/OP "$6,319.00 " "$4,676.06" $111.23 "$4,597.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,317.04" $785.72 $785.72 $815.94 $171.13 "$1,316.88" $111.23 "$1,106.00" "$1,106.00" $202.33 $923.00 "$4,551.62" "$4,597.60" $281.11 $540.00 $281.11 $899.41 $164.96 $164.96 $914.92 $192.70 $0.00 $0.00 $0.00 $0.00 35100013 EAP CPT® 70496 HEAD CTA W & W/O DYE ECT BOTH IP/OP "$6,849.00 " "$5,068.26" $111.23 "$4,983.20" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,427.50" $785.72 $785.72 $815.94 $171.13 "$1,427.33" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$4,933.37" "$4,983.20" $281.11 $540.00 $281.11 $974.84 $211.42 $211.42 $991.66 $192.70 $0.00 $0.00 $0.00 $0.00 35100014 EAP CPT® 70498 NECK CTA W & W/O DYE ECT BOTH IP/OP "$6,849.00 " "$5,068.26" $111.23 "$4,983.20" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,427.50" $785.72 $785.72 $815.94 $171.13 "$1,427.33" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$4,933.37" "$4,983.20" $281.11 $540.00 $281.11 $974.84 $211.06 $211.06 $991.66 $192.70 $0.00 $0.00 $0.00 $0.00 35100015 EAP CPT® 0042T "BRAIN PERFUSION W/CONT CT, ECT" BOTH IP/OP "$6,102.00 " "$4,515.48" $0.00 "$4,438.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 "$1,271.81" $785.72 $785.72 $815.94 $0.00 "$1,271.66" $0.00 "$1,106.00" "$1,106.00" $0.00 "$2,774.00" "$4,394.02" "$4,438.40" $0.00 $540.00 $0.00 $868.26 $0.00 $0.00 $883.24 $0.00 $0.00 $0.00 $0.00 $0.00 35200001 EAP CPT® 71250 THORAX CT W/O DYE BCT BOTH IP/OP "$3,675.00 " "$2,719.50" $67.89 "$2,723.20" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $765.96 $785.72 $785.72 $815.94 $104.44 $765.87 $67.89 "$1,106.00" "$1,106.00" $112.41 $816.96 "$2,695.97" "$2,723.20" $156.18 $540.00 $156.18 $532.73 $101.21 $101.21 $541.92 $107.06 $0.00 $0.00 $0.00 $0.00 35200002 EAP CPT® 71260 THORAX CT W/DYE BCT BOTH IP/OP "$5,044.00 " "$3,732.56" $111.23 "$3,737.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,051.30" $785.72 $785.72 $815.94 $171.13 "$1,051.17" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,121.28" "$3,700.22" "$3,737.60" $281.11 $540.00 $281.11 $731.17 $135.06 $135.06 $743.78 $192.70 $0.00 $0.00 $0.00 $0.00 35200003 EAP CPT® 71270 THORAX CT W&WO DYE BCT BOTH IP/OP "$5,874.00 " "$4,346.76" $0.00 "$4,352.80" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,224.29" $785.72 $785.72 $815.94 $171.13 "$1,224.14" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,305.84" "$4,309.27" "$4,352.80" $281.11 $540.00 $281.11 $0.00 $164.96 $164.96 $866.21 $192.70 $0.00 $0.00 $0.00 $0.00 35200004 EAP CPT® 71275 THORAX CTA W&WO DYE BCT BOTH IP/OP "$6,367.00 " "$4,711.58" $111.23 "$4,718.40" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,327.04" $785.72 $785.72 $815.94 $171.13 "$1,326.88" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,415.52" "$4,671.22" "$4,718.40" $281.11 $540.00 $281.11 $923.04 $214.30 $214.30 $938.96 $192.70 $0.00 $0.00 $0.00 $0.00 35200005 EAP CPT® 72125 CERVICAL SPINE CT W/O DYE ECT BOTH IP/OP "$7,128.00 " "$5,274.72" $67.89 "$5,184.00" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 "$1,485.65" $785.72 $785.72 $815.94 $104.44 "$1,485.48" $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$5,132.16" "$5,184.00" $156.18 $540.00 $156.18 "$1,014.12" $106.61 $106.61 "$1,031.62" $107.06 $0.00 $0.00 $0.00 $0.00 35200006 EAP CPT® 72126 CERVICAL SPINE CT W/DYE ECT BOTH IP/OP "$9,771.00 " "$7,230.54" $0.00 "$7,106.40" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 "$2,036.52" $785.72 $785.72 $815.94 $352.81 "$2,036.28" $229.33 "$1,106.00" "$1,106.00" $387.01 $774.00 "$7,035.34" "$7,106.40" $537.70 $540.00 $537.70 $0.00 $135.78 $135.78 "$1,414.17" $368.58 $0.00 $0.00 $0.00 $0.00 35200007 EAP CPT® 72127 CERVICAL SPINE CT W&WO DYE ECT BOTH IP/OP "$10,974.00 " "$8,120.76" $0.00 "$7,980.80" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,286.98" $0.00 "$1,106.00" "$1,106.00" $0.00 $923.00 "$7,900.99" "$7,980.80" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200008 EAP CPT® 72128 THORACIC SPINE CT W/O DYE ECT BOTH IP/OP "$4,233.00 " "$3,132.42" $67.89 "$3,420.80" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $882.26 $785.72 $785.72 $815.94 $104.44 $882.16 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$3,386.59" "$3,420.80" $156.18 $540.00 $156.18 $669.19 $106.61 $106.61 $680.74 $107.06 $0.00 $0.00 $0.00 $0.00 35200009 EAP CPT® 72129 THORACIC SPINE CT W/DYE ECT BOTH IP/OP "$5,804.00 " "$4,294.96" $0.00 "$4,690.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,209.55" $0.00 "$1,106.00" "$1,106.00" $202.33 $774.00 "$4,643.50" "$4,690.40" $281.11 $540.00 $281.11 $917.56 $137.23 $137.23 $933.39 $192.70 $0.00 $0.00 $0.00 $0.00 35200010 EAP CPT® 72130 THORACIC SPINE CT W&WO DYE ECT BOTH IP/OP "$6,518.00 " "$4,823.32" $0.00 "$5,267.20" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,358.35" $0.00 "$1,106.00" "$1,106.00" $0.00 $923.00 "$5,214.53" "$5,267.20" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200011 EAP CPT® 72131 LUMBAR SPINE CT W/O DYE ECT BOTH IP/OP "$3,544.00 " "$2,622.56" $67.89 "$2,864.00" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $738.66 $785.72 $785.72 $815.94 $104.44 $738.57 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,835.36" "$2,864.00" $156.18 $540.00 $156.18 $560.27 $105.89 $105.89 $569.94 $107.06 $0.00 $0.00 $0.00 $0.00 35200012 EAP CPT® 72132 LUMBAR SPINE CT W/DYE ECT BOTH IP/OP "$4,861.00 " "$3,597.14" $0.00 "$3,928.00" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 "$1,013.15" $785.72 $785.72 $815.94 $352.81 "$1,013.03" $229.33 "$1,106.00" "$1,106.00" $0.00 $774.00 "$3,888.72" "$3,928.00" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200013 EAP CPT® 72133 LUMBAR SPINE CT W&WO DYE ECT BOTH IP/OP "$5,459.00 " "$4,039.66" $0.00 "$4,411.20" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,137.66" $0.00 "$1,106.00" "$1,106.00" $0.00 $923.00 "$4,367.09" "$4,411.20" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200014 EAP CPT® 72191 PELVIS CTA W&WO DYE BCT BOTH IP/OP "$6,137.00 " "$4,541.38" $0.00 "$4,959.20" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,279.10" $785.72 $785.72 $815.94 $171.13 "$1,278.95" $111.23 "$1,106.00" "$1,106.00" $0.00 "$1,048.00" "$4,909.61" "$4,959.20" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200015 EAP CPT® 72192 ORTHO PELVIS CT W/O DYE BCT BOTH IP/OP "$4,157.00 " "$3,076.18" $67.89 "$3,111.20" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $866.42 $785.72 $785.72 $815.94 $104.44 $866.32 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$3,080.09" "$3,111.20" $156.18 $540.00 $156.18 $608.63 $91.84 $91.84 $619.13 $107.06 $0.00 $0.00 $0.00 $0.00 35200016 EAP CPT® 72192 PELVIS CT W/O DYE BCT BOTH IP/OP "$3,889.00 " "$2,877.86" $0.00 "$3,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $866.42 $0.00 $0.00 $0.00 $104.44 $866.32 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$3,080.09" "$3,111.20" $156.18 $0.00 $156.18 $608.63 $91.84 $91.84 $619.13 $107.06 $0.00 $0.00 $0.00 $0.00 35200017 EAP CPT® 72193 PELVIS CT W/DYE BCT BOTH IP/OP "$5,705.00 " "$4,221.70" $111.23 "$4,269.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,189.06" $785.72 $785.72 $815.94 $171.13 "$1,188.92" $111.23 "$1,106.00" "$1,106.00" $202.33 $774.00 "$4,226.90" "$4,269.60" $281.11 $540.00 $281.11 $835.24 $186.21 $186.21 $849.65 $192.70 $0.00 $0.00 $0.00 $0.00 35200018 EAP CPT® 72194 PELVIS CT W&WO DYE BCT BOTH IP/OP "$6,641.00 " "$4,914.34" $0.00 "$4,970.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 "$1,384.15" $0.00 $0.00 $0.00 $171.13 "$1,383.98" $111.23 "$1,106.00" "$1,106.00" $202.33 $923.00 "$4,920.70" "$4,970.40" $281.11 $540.00 $281.11 $972.33 $213.58 $213.58 $989.11 $192.70 $0.00 $0.00 $0.00 $0.00 35200019 EAP CPT® 73200 Upp Ext Ct W/o Dye Bilat Bct BOTH IP/OP "$7,981.00 " "$5,905.94" $67.89 "$6,436.80" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 "$1,663.44" $785.72 $785.72 $815.94 $104.44 "$1,663.24" $67.89 "$1,106.00" "$1,106.00" $112.41 "$1,608.00" "$6,372.43" "$6,436.80" $156.18 $540.00 $156.18 "$1,259.20" $130.02 $130.02 "$1,280.92" $107.06 $0.00 $0.00 $0.00 $0.00 35200020 EAP CPT® 73200 UPP EXT CT W/O DYE LT BCT BOTH IP/OP "$4,400.00 " "$3,256.00" $67.89 "$3,217.60" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $917.07 $785.72 $785.72 $815.94 $104.44 $916.96 $67.89 "$1,106.00" "$1,106.00" $112.41 "$1,608.00" "$3,185.42" "$3,217.60" $156.18 $540.00 $156.18 $629.44 $130.02 $130.02 $640.30 $107.06 $0.00 $0.00 $0.00 $0.00 35200021 EAP CPT® 73200 UPP EXT CT W/O DYE RT BCT BOTH IP/OP "$4,022.00 " "$2,976.28" $0.00 "$3,217.60" $0.00 $0.00 $0.00 $0.00 $0.00 $917.07 $0.00 $0.00 $0.00 $104.44 $916.96 $67.89 "$1,106.00" "$1,106.00" $112.41 "$1,608.00" "$3,185.42" "$3,217.60" $156.18 $0.00 $156.18 $629.44 $130.02 $130.02 $640.30 $107.06 $0.00 $0.00 $0.00 $0.00 35200022 EAP CPT® 73201 Upp Ext Ct W/dye Bilat Bct BOTH IP/OP "$8,891.00 " "$6,579.34" $166.40 "$7,170.40" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 "$1,853.11" $785.72 $785.72 $815.94 $352.81 "$1,852.88" $229.33 "$1,106.00" "$1,106.00" $387.01 $774.00 "$7,098.70" "$7,170.40" $537.70 $540.00 $537.70 "$1,402.71" $166.40 $166.40 "$1,426.91" $368.58 $0.00 $0.00 $0.00 $0.00 35200023 EAP CPT® 73201 Upp Ext Ct W/dye Lt BOTH IP/OP "$4,904.00 " "$3,628.96" $166.40 "$3,585.60" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 "$1,022.12" $785.72 $785.72 $815.94 $352.81 "$1,021.99" $229.33 "$1,106.00" "$1,106.00" $387.01 $774.00 "$3,549.74" "$3,585.60" $537.70 $540.00 $537.70 $701.43 $166.40 $166.40 $713.53 $368.58 $0.00 $0.00 $0.00 $0.00 35200024 EAP CPT® 73201 UPP EXT CT W/DYE RT BCT BOTH IP/OP "$4,482.00 " "$3,316.68" $0.00 "$3,585.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,022.12" $0.00 $0.00 $0.00 $352.81 "$1,021.99" $229.33 "$1,106.00" "$1,106.00" $387.01 $774.00 "$3,549.74" "$3,585.60" $537.70 $0.00 $537.70 $701.43 $166.40 $166.40 $713.53 $368.58 $0.00 $0.00 $0.00 $0.00 35200025 EAP CPT® 73202 Upp Ext Ct W&wo Dye Bilat Bct BOTH IP/OP "$9,863.00 " "$7,298.62" $0.00 "$7,954.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,055.45" $0.00 "$1,106.00" "$1,106.00" $0.00 $923.00 "$7,874.86" "$7,954.40" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200026 EAP CPT® 73202 UPP EXT CT W&WO DYE LT BCT BOTH IP/OP "$4,933.00 " "$3,650.42" $0.00 "$3,978.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,028.04" $0.00 "$1,106.00" "$1,106.00" $0.00 $923.00 "$3,938.62" "$3,978.40" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200027 EAP CPT® 73202 UPP EXT CT W&WO DYE RT BCT BOTH IP/OP "$5,441.00 " "$4,026.34" $0.00 "$3,978.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.90" $0.00 "$1,106.00" "$1,106.00" $0.00 $923.00 "$3,938.62" "$3,978.40" $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200028 EAP CPT® 73206 UPP EXT CTA W&WO DYE BILAT BCT BOTH IP/OP "$7,023.00 " "$5,197.02" $111.23 "$5,664.00" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,463.77" $785.72 $785.72 $815.94 $171.13 "$1,463.59" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$5,607.36" "$5,664.00" $281.11 $540.00 $281.11 "$1,108.02" $241.31 $241.31 "$1,127.14" $192.70 $0.00 $0.00 $0.00 $0.00 35200029 EAP CPT® 73206 UPP EXT CTA W&WO DYE LT BCT BOTH IP/OP "$3,870.00 " "$2,863.80" $111.23 "$2,829.60" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 $806.60 $785.72 $785.72 $815.94 $171.13 $806.51 $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$2,801.30" "$2,829.60" $281.11 $540.00 $281.11 $553.54 $241.31 $241.31 $563.09 $192.70 $0.00 $0.00 $0.00 $0.00 35200030 EAP CPT® 73206 UPP EXT CTA W&WO DYE RT BCT BOTH IP/OP "$3,537.00 " "$2,617.38" $0.00 "$2,829.60" $0.00 $0.00 $0.00 $0.00 $0.00 $806.60 $0.00 $0.00 $0.00 $171.13 $806.51 $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$2,801.30" "$2,829.60" $281.11 $0.00 $281.11 $553.54 $241.31 $241.31 $563.09 $192.70 $0.00 $0.00 $0.00 $0.00 35200031 EAP CPT® 73700 Low Ext Ct W/o Dye Bilat Bct BOTH IP/OP "$6,983.00 " "$5,167.42" $67.89 "$5,586.40" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 "$1,455.43" $785.72 $785.72 $815.94 $104.44 "$1,455.26" $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$5,530.54" "$5,586.40" $156.18 $540.00 $156.18 "$1,092.84" $105.89 $105.89 "$1,111.69" $107.06 $0.00 $0.00 $0.00 $0.00 35200032 EAP CPT® 73700 LOW EXT CT W/O DYE LT BCT BOTH IP/OP "$3,776.00 " "$2,794.24" $67.89 "$2,790.40" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $787.01 $785.72 $785.72 $815.94 $104.44 $786.92 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,762.50" "$2,790.40" $156.18 $540.00 $156.18 $545.87 $105.89 $105.89 $555.29 $107.06 $0.00 $0.00 $0.00 $0.00 35200033 EAP CPT® 73700 LOW EXT CT W/O DYE RT BCT BOTH IP/OP "$3,488.00 " "$2,581.12" $0.00 "$2,790.40" $0.00 $0.00 $0.00 $0.00 $0.00 $787.01 $0.00 $0.00 $0.00 $104.44 $786.92 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,762.50" "$2,790.40" $156.18 $0.00 $156.18 $545.87 $105.89 $105.89 $555.29 $107.06 $0.00 $0.00 $0.00 $0.00 35200034 EAP CPT® 73701 Low Ext Ct W/dye Bilat Bct BOTH IP/OP "$9,578.00 " "$7,087.72" $111.23 "$7,662.40" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,996.29" $785.72 $785.72 $815.94 $171.13 "$1,996.06" $111.23 "$1,106.00" "$1,106.00" $202.33 "$2,298.72" "$7,585.78" "$7,662.40" $281.11 $540.00 $281.11 "$1,498.96" $137.23 $137.23 "$1,524.82" $192.70 $0.00 $0.00 $0.00 $0.00 35200035 EAP CPT® 73701 LOW EXT CT W/DYE LT BCT BOTH IP/OP "$5,185.00 " "$3,836.90" $111.23 "$3,831.20" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,080.68" $785.72 $785.72 $815.94 $171.13 "$1,080.55" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,149.36" "$3,792.89" "$3,831.20" $281.11 $540.00 $281.11 $749.48 $137.23 $137.23 $762.41 $192.70 $0.00 $0.00 $0.00 $0.00 35200036 EAP CPT® 73701 LOW EXT CT W/DYE RT BCT BOTH IP/OP "$4,789.00 " "$3,543.86" $0.00 "$3,831.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,080.68" $0.00 $0.00 $0.00 $171.13 "$1,080.55" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,149.36" "$3,792.89" "$3,831.20" $281.11 $0.00 $281.11 $749.48 $137.23 $137.23 $762.41 $192.70 $0.00 $0.00 $0.00 $0.00 35200037 EAP CPT® 73702 Low Ext Ct W&wo Dye Bilat Bct BOTH IP/OP "$11,163.00 " "$8,260.62" $0.00 "$8,930.40" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,326.37" $0.00 "$1,106.00" "$1,106.00" $202.33 $923.00 "$8,841.10" "$8,930.40" $281.11 $540.00 $281.11 "$1,747.01" $174.32 $174.32 "$1,777.15" $192.70 $0.00 $0.00 $0.00 $0.00 35200038 EAP CPT® 73702 LOW EXT CT W&WO DYE LT BCT BOTH IP/OP "$5,577.00 " "$4,126.98" $0.00 "$4,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.33 $923.00 "$4,416.98" "$4,461.60" $281.11 $0.00 $281.11 $872.80 $174.32 $174.32 $887.86 $192.70 $0.00 $0.00 $0.00 $0.00 35200039 EAP CPT® 73702 LOW EXT CT W&WO DYE RT BCT BOTH IP/OP "$6,038.00 " "$4,468.12" $0.00 "$4,461.60" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,258.32" $0.00 "$1,106.00" "$1,106.00" $202.33 $923.00 "$4,416.98" "$4,461.60" $281.11 $540.00 $281.11 $872.80 $174.32 $174.32 $887.86 $192.70 $0.00 $0.00 $0.00 $0.00 35200040 EAP CPT® 73706 Low Ext Cta W&wo Dye Bilat Bct BOTH IP/OP "$12,088.00 " "$8,945.12" $0.00 "$9,670.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,045.07" $0.00 $0.00 $0.00 $171.13 "$2,044.82" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$9,573.70" "$9,670.40" $281.11 $0.00 $281.11 "$1,891.77" $264.37 $264.37 "$1,924.41" $192.70 $0.00 $0.00 $0.00 $0.00 35200041 EAP CPT® 73706 LOW EXT CTA W&WO DYE LT BCT BOTH IP/OP "$6,541.00 " "$4,840.34" $111.23 "$4,833.60" $726.00 $726.00 $173.95 $173.95 $174.93 "$1,363.31" $785.72 $785.72 $815.94 $171.13 "$1,363.14" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$4,785.26" "$4,833.60" $281.11 $540.00 $281.11 $945.57 $264.37 $264.37 $961.89 $192.70 $0.00 $0.00 $0.00 $0.00 35200042 EAP CPT® 73706 LOW EXT CTA W&WO DYE RT BCT BOTH IP/OP "$6,042.00 " "$4,471.08" $0.00 "$4,833.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,363.31" $0.00 $0.00 $0.00 $171.13 "$1,363.14" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$4,785.26" "$4,833.60" $281.11 $0.00 $281.11 $945.57 $264.37 $264.37 $961.89 $192.70 $0.00 $0.00 $0.00 $0.00 35200043 EAP CPT® 74150 ABDOMEN CT W/O DYE BCT BOTH IP/OP "$3,994.00 " "$2,955.56" $67.89 "$2,958.40" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $832.45 $785.72 $785.72 $815.94 $104.44 $832.35 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,928.82" "$2,958.40" $156.18 $540.00 $156.18 $578.74 $90.40 $90.40 $588.72 $107.06 $0.00 $0.00 $0.00 $0.00 35200044 EAP CPT® 74150 ABDOMEN CT W/O DYE LIMITED BCT BOTH IP/OP "$3,661.00 " "$2,709.14" $67.89 "$2,958.40" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $763.04 $785.72 $785.72 $815.94 $104.44 $762.95 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,928.82" "$2,958.40" $156.18 $540.00 $156.18 $578.74 $90.40 $90.40 $588.72 $107.06 $0.00 $0.00 $0.00 $0.00 35200045 EAP CPT® 74150 "Stone Protocol, Bct" BOTH IP/OP "$3,661.00 " "$2,709.14" $67.89 "$2,958.40" "$1,404.90" "$1,404.90" $106.02 $106.02 $106.62 $763.04 $785.72 $785.72 $815.94 $104.44 $762.95 $67.89 "$1,106.00" "$1,106.00" $112.41 $566.00 "$2,928.82" "$2,958.40" $156.18 $540.00 $156.18 $578.74 $90.40 $90.40 $588.72 $107.06 $0.00 $0.00 $0.00 $0.00 35200046 EAP CPT® 74160 ABDOMEN CT W/DYE BCT BOTH IP/OP "$5,483.00 " "$4,057.42" $111.23 "$4,060.80" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,142.79" $785.72 $785.72 $815.94 $171.13 "$1,142.66" $111.23 "$1,106.00" "$1,106.00" $202.33 $774.00 "$4,020.19" "$4,060.80" $281.11 $540.00 $281.11 $794.39 $185.49 $185.49 $808.10 $192.70 $0.00 $0.00 $0.00 $0.00 35200047 EAP CPT® 74160 ABDOMEN CT W/DYE LIMITED BCT BOTH IP/OP "$5,025.00 " "$3,718.50" $111.23 "$4,060.80" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,047.34" $785.72 $785.72 $815.94 $171.13 "$1,047.21" $111.23 "$1,106.00" "$1,106.00" $202.33 $774.00 "$4,020.19" "$4,060.80" $281.11 $540.00 $281.11 $794.39 $185.49 $185.49 $808.10 $192.70 $0.00 $0.00 $0.00 $0.00 35200048 EAP CPT® 74170 ABDOMEN CT W&WO DYE BCT BOTH IP/OP "$6,385.00 " "$4,724.90" $111.23 "$4,728.80" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,330.79" $785.72 $785.72 $815.94 $171.13 "$1,330.63" $111.23 "$1,106.00" "$1,106.00" $202.33 $923.00 "$4,681.51" "$4,728.80" $281.11 $540.00 $281.11 $925.07 $211.06 $211.06 $941.03 $192.70 $0.00 $0.00 $0.00 $0.00 35200049 EAP CPT® 74175 ABDOMEN CTA W&WO DYE BCT BOTH IP/OP "$6,919.00 " "$5,120.06" $111.23 "$5,124.80" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,442.09" $785.72 $785.72 $815.94 $171.13 "$1,441.92" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$5,073.55" "$5,124.80" $281.11 $540.00 $281.11 "$1,002.54" $235.19 $235.19 "$1,019.84" $192.70 $0.00 $0.00 $0.00 $0.00 35200058 EAP CPT® 75635 Abd Aorta&illiofemor Cta Bct BOTH IP/OP "$6,097.00 " "$4,511.78" $111.23 "$4,927.20" "$1,404.90" "$1,404.90" $173.95 $173.95 $174.93 "$1,270.77" $785.72 $785.72 $815.94 $171.13 "$1,270.61" $111.23 "$1,106.00" "$1,106.00" $202.33 "$1,048.00" "$4,877.93" "$4,927.20" $281.11 $540.00 $281.11 $963.88 $329.20 $329.20 $980.51 $192.70 $0.00 $0.00 $0.00 $0.00 35200059 EAP CPT® 76380 FOLLOW UP STUDY CT LIMITED BCT BOTH IP/OP "$1,494.00 " "$1,105.56" $0.00 "$1,404.90" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.35 $0.00 "$1,106.00" "$1,106.00" $0.00 $358.56 "$1,183.25" "$1,195.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35200060 EAP CPT® 74174 "Cta, Abdomen And Pelvis, W Dye" BOTH IP/OP "$8,464.00 " "$6,263.36" $229.33 "$6,268.80" "$1,404.90" "$1,404.90" $358.61 $358.61 $360.63 "$1,764.11" $785.72 $785.72 $815.94 $352.81 "$1,763.90" $229.33 "$1,106.00" "$1,106.00" $387.01 "$1,880.64" "$6,206.11" "$6,268.80" $537.70 $540.00 $537.70 "$1,226.33" $298.94 $298.94 "$1,247.49" $368.58 $0.00 $0.00 $0.00 $0.00 35200063 EAP HCPCS G0297 Low Dose Ct Scan For Lung BOTH IP/OP $632.00 $467.68 $50.40 $632.00 $632.00 $632.00 $106.02 $106.02 $106.62 $131.72 $632.00 $632.00 $632.00 $77.54 $131.71 $50.40 $632.00 $632.00 $80.04 $313.50 $496.58 $501.60 $111.21 $540.00 $111.21 $98.13 $189.09 $189.09 $99.82 $76.23 $0.00 $0.00 $0.00 $0.00 36000003 EAP CPT® 58611 Ligate Oviduct(s) Add-on BOTH IP/OP $499.00 $369.26 $0.00 $475.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.99 $0.00 $0.00 $0.00 $0.00 $475.00 $376.20 $380.00 $0.00 $324.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000027 EAP CPT® 19499 Breast Surgery Procedure Cbc BOTH IP/OP "$6,169.00 " "$4,565.06" $0.00 "$4,899.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,285.62" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,850.21" "$4,899.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000028 EAP Custom 36000028 L&d Level 1 1st 30 Min BOTH IP/OP "$1,771.00 " "$1,310.54" $0.00 "$1,243.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $369.08 $0.00 $0.00 $0.00 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 "$1,243.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000029 EAP Custom 36000029 L&d Level 2 1st 30 Min BOTH IP/OP "$2,152.00 " "$1,592.48" $0.00 "$1,510.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.48 $0.00 $0.00 $0.00 $0.00 $893.00 "$1,414.51" "$1,428.80" $0.00 "$1,510.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000038 EAP Custom 36000038 L&d Level 3 1st 30 Min BOTH IP/OP "$2,404.00 " "$1,778.96" $0.00 "$1,687.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.99 $0.00 $0.00 $0.00 $0.00 $998.00 "$1,580.83" "$1,596.80" $0.00 "$1,687.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000039 EAP Custom 36000039 L&d Level 4 1st 30 Min BOTH IP/OP "$2,657.00 " "$1,966.18" $0.00 "$1,865.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $553.72 $0.00 $0.00 $0.00 $0.00 "$1,103.00" "$1,747.15" "$1,764.80" $0.00 "$1,865.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000040 EAP Custom 36000040 L&d Level 5 1st 30 Min BOTH IP/OP "$1,957.00 " "$1,448.18" $0.00 "$1,932.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.84 $0.00 $0.00 $0.00 $0.00 "$1,208.00" "$1,913.47" "$1,932.80" $0.00 "$1,374.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000042 EAP Custom 36000042 L&d Level 6 1st 30 Min BOTH IP/OP "$3,163.00 " "$2,340.62" $0.00 "$2,220.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.17 $0.00 $0.00 $0.00 $0.00 "$1,313.00" "$2,079.79" "$2,100.80" $0.00 "$2,220.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000043 EAP Custom 36000043 L&d Level 1 Add 15 Min BOTH IP/OP $797.00 $589.78 $0.00 $559.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.09 $0.00 $0.00 $0.00 $0.00 $331.00 $524.30 $529.60 $0.00 $559.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000044 EAP Custom 36000044 L&d Level 2 Add 15 Min BOTH IP/OP $969.00 $717.06 $0.00 $680.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.94 $0.00 $0.00 $0.00 $0.00 $402.00 $636.77 $643.20 $0.00 $680.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000045 EAP Custom 36000045 L&d Level 3 Add 15 Min BOTH IP/OP "$1,081.00 " $799.94 $0.00 $759.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.28 $0.00 $0.00 $0.00 $0.00 $448.50 $710.42 $717.60 $0.00 $759.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000046 EAP Custom 36000046 L&d Level 4 Add 15 Min BOTH IP/OP "$1,195.00 " $884.30 $0.00 $839.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $496.00 $785.66 $793.60 $0.00 $839.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000047 EAP Custom 36000047 L&d Level 5 Add 15 Min BOTH IP/OP $881.00 $651.94 $0.00 $870.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.60 $0.00 $0.00 $0.00 $0.00 $544.00 $861.70 $870.40 $0.00 $618.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000048 EAP Custom 36000048 L&d Level 6 Add 15 Min BOTH IP/OP "$1,422.00 " "$1,052.28" $0.00 $998.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.34 $0.00 $0.00 $0.00 $0.00 $590.50 $935.35 $944.80 $0.00 $998.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000110 EAP Custom 36000110 Perfusionist BOTH IP/OP "$3,589.00 " "$2,655.86" $0.00 "$2,871.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $747.95 $0.00 $0.00 $0.00 $0.00 "$1,794.50" "$2,842.49" "$2,871.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000116 EAP CPT® 36680 Placement Of A Needle For Intraosseous Infusion BOTH IP/OP $684.00 $506.16 $0.00 $684.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.55 $0.00 $0.00 $0.00 $0.00 $582.00 $460.94 $465.60 $0.00 $684.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000117 EAP Custom 36000117 Level 1 1st 30 Min BOTH IP/OP "$11,028.00 " "$8,160.72" $0.00 "$7,741.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,298.24" $0.00 $0.00 $0.00 $0.00 "$4,578.50" "$7,252.34" "$7,325.60" $0.00 "$7,741.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000118 EAP Custom 36000118 Level 2 1st 30 Min BOTH IP/OP "$13,392.00 " "$9,910.08" $0.00 "$9,400.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,790.89" $0.00 $0.00 $0.00 $0.00 "$5,560.00" "$8,807.04" "$8,896.00" $0.00 "$9,400.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000119 EAP Custom 36000119 Level 3 1st 30 Min BOTH IP/OP "$14,968.00 " "$11,076.32" $0.00 "$10,507.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,119.33" $0.00 $0.00 $0.00 $0.00 "$6,214.00" "$9,842.98" "$9,942.40" $0.00 "$10,507.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000120 EAP Custom 36000120 Level 4 1st 30 Min BOTH IP/OP "$16,545.00 " "$12,243.30" $0.00 "$11,614.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,447.98" $0.00 $0.00 $0.00 $0.00 "$6,869.00" "$10,880.50" "$10,990.40" $0.00 "$11,614.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000121 EAP Custom 36000121 Level 5 1st 30 Min BOTH IP/OP "$18,117.00 " "$13,406.58" $0.00 "$12,717.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,775.58" $0.00 $0.00 $0.00 $0.00 "$7,521.50" "$11,914.06" "$12,034.40" $0.00 "$12,717.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000122 EAP Custom 36000122 Level 6 1st 30 Min BOTH IP/OP "$19,694.00 " "$14,573.56" $0.00 "$13,825.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,104.23" $0.00 $0.00 $0.00 $0.00 "$8,176.00" "$12,950.78" "$13,081.60" $0.00 "$13,825.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000123 EAP Custom 36000123 Level 1 Add 15 Min BOTH IP/OP "$4,964.00 " "$3,673.36" $0.00 "$3,484.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,034.50" $0.00 $0.00 $0.00 $0.00 "$2,061.00" "$3,264.62" "$3,297.60" $0.00 "$3,484.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000124 EAP Custom 36000124 Level 2 Add 15 Min BOTH IP/OP "$6,030.00 " "$4,462.20" $0.00 "$4,232.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.65" $0.00 $0.00 $0.00 $0.00 "$2,503.50" "$3,965.54" "$4,005.60" $0.00 "$4,232.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000125 EAP Custom 36000125 Level 3 Add 15 Min BOTH IP/OP "$6,740.00 " "$4,987.60" $0.00 "$4,731.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,404.62" $0.00 $0.00 $0.00 $0.00 "$2,798.00" "$4,432.03" "$4,476.80" $0.00 "$4,731.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000126 EAP Custom 36000126 Level 4 Add 15 Min BOTH IP/OP "$7,445.00 " "$5,509.30" $0.00 "$5,226.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,551.54" $0.00 $0.00 $0.00 $0.00 "$3,091.00" "$4,896.14" "$4,945.60" $0.00 "$5,226.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000127 EAP Custom 36000127 Level 5 Add 15 Min BOTH IP/OP "$7,979.00 " "$5,904.46" $0.00 "$5,601.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,662.82" $0.00 $0.00 $0.00 $0.00 "$3,312.50" "$5,247.00" "$5,300.00" $0.00 "$5,601.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36000128 EAP Custom 36000128 Level 6 Add 15 Min BOTH IP/OP "$8,864.00 " "$6,559.36" $0.00 "$6,222.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,847.26" $0.00 $0.00 $0.00 $0.00 "$3,680.00" "$5,829.12" "$5,888.00" $0.00 "$6,222.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100001 EAP CPT® 10021 Fna Bx W/o Img Gdn 1st Les BOTH IP/OP "$1,308.00 " $967.92 $0.00 "$1,521.00" "$1,308.00" "$1,308.00" $336.60 $336.60 $338.49 $272.62 $0.00 $0.00 $0.00 $331.46 $272.59 $215.45 $113.00 $113.00 $320.45 "$1,317.00" "$1,043.06" "$1,053.60" $445.22 "$1,521.00" $445.22 $93.38 $57.69 $57.69 $209.67 $305.19 $0.00 $0.00 $0.00 $0.00 36100002 EAP CPT® 69100 Biopsy Of External Ear BOTH IP/OP "$2,056.00 " "$1,521.44" $0.00 "$2,074.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $428.47 $0.00 $0.00 $0.00 $0.00 "$2,074.00" "$1,642.61" "$1,659.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100003 EAP CPT® 22510 Percut Vertebroplasty Thor BOTH IP/OP "$7,794.00 " "$5,767.56" $0.00 "$6,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,624.27" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$6,172.85" "$6,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100005 EAP CPT® 22511 Percut Vertebroplasty Lumb BOTH IP/OP "$7,794.00 " "$5,767.56" $0.00 "$6,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,624.27" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$6,172.85" "$6,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100006 EAP CPT® 22512 Percut Vertebroplasty Add'l BOTH IP/OP "$7,794.00 " "$5,767.56" $0.00 "$6,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,624.27" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$6,172.85" "$6,235.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100007 EAP CPT® 22513 "Percut Kyphoplasty, Thor" BOTH IP/OP "$21,530.00 " "$15,932.20" $0.00 "$17,397.60" "$2,984.10" "$2,984.10" "$6,099.77" "$6,099.77" "$6,134.13" "$4,487.39" $0.00 $0.00 $0.00 "$6,004.45" "$4,486.85" "$3,902.89" "$4,877.00" "$4,877.00" $0.00 "$6,105.00" "$17,223.62" "$17,397.60" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100008 EAP CPT® 10040 Acne Surgery BOTH IP/OP $568.00 $420.32 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.37 $0.00 $0.00 $0.00 $0.00 $562.00 $445.10 $449.60 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100009 EAP CPT® 10060 Drainage Abscess Simple/single BOTH IP/OP "$1,334.00 " $987.16 $74.65 "$1,334.00" "$1,334.00" "$1,334.00" $174.88 $174.88 $175.86 $278.04 "$1,257.08" "$1,257.08" "$1,305.43" $172.08 $278.01 $111.85 $113.00 $113.00 $175.24 "$1,320.00" "$1,045.44" "$1,056.00" $243.48 "$1,216.00" $243.48 $74.65 $103.45 $103.45 $210.14 $166.90 $0.00 $0.00 $0.00 $0.00 36100010 EAP CPT® 99291 Hypothermia (critical Care) 1st 30-74 Min BOTH IP/OP "$4,975.00 " "$3,681.50" $0.00 "$4,975.00" "$4,975.00" "$4,975.00" $725.39 $725.39 $729.47 "$1,036.91" "$3,261.45" "$3,261.45" $0.00 $663.88 "$1,036.79" $431.52 "$4,975.00" "$4,975.00" $668.62 "$2,157.50" "$3,417.48" "$3,452.00" $928.96 "$4,850.95" $928.96 $182.90 $226.49 $226.49 $686.95 $636.78 $0.00 $0.00 $0.00 $0.00 36100012 EAP CPT® 99292 Hypothermia (critical Care) Addl 30 Min BOTH IP/OP "$1,110.00 " $821.40 $0.00 "$2,821.00" "$1,110.00" "$1,110.00" $0.00 $0.00 $0.00 $231.35 "$1,110.00" "$1,110.00" $0.00 $0.00 $231.32 $0.00 "$1,110.00" "$1,110.00" $0.00 $592.50 $938.52 $948.00 $0.00 "$2,821.00" $0.00 $0.00 $113.96 $113.96 $188.65 $0.00 $0.00 $0.00 $0.00 $0.00 36100013 EAP CPT® 22514 "Percut Kyphoplasty, Lumb" BOTH IP/OP "$21,530.00 " "$15,932.20" $0.00 "$17,397.60" "$2,984.10" "$2,984.10" "$6,099.77" "$6,099.77" "$6,134.13" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,486.85" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$17,223.62" "$17,397.60" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100014 EAP CPT® 22515 "Percut Kyphoplasty, Add-on" BOTH IP/OP "$21,530.00 " "$15,932.20" $0.00 "$17,397.60" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 "$4,487.39" $0.00 $0.00 $0.00 $0.00 "$4,486.85" $0.00 "$4,877.00" "$4,877.00" $0.00 "$10,873.50" "$17,223.62" "$17,397.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100016 EAP CPT® 62302 Myelography Via Lumbar Injection;cervical;including S&i BOTH IP/OP $764.00 $565.36 $0.00 $611.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.22 $0.00 $0.00 $0.00 $0.00 $382.00 $605.09 $611.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100017 EAP CPT® 62303 Myelography Via Lumbar Injection;thoracic;including S&i BOTH IP/OP $804.00 $594.96 $0.00 $804.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.55 $0.00 $0.00 $0.00 $0.00 $382.00 $605.09 $611.20 $0.00 $804.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100018 EAP CPT® 62304 Myelography Via Lumbar Injection;lumbosacral;including S&i BOTH IP/OP "$1,729.00 " "$1,279.46" $0.00 "$1,729.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $360.32 $0.00 $0.00 $0.00 $0.00 $821.50 "$1,301.26" "$1,314.40" $0.00 "$1,729.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100019 EAP CPT® 62305 Myelography Via Lumbar Injection' 2or More Regions;including S&i BOTH IP/OP "$3,914.00 " "$2,896.36" $0.00 "$2,976.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $815.68 $0.00 $0.00 $0.00 $0.00 "$1,860.00" "$2,946.24" "$2,976.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100020 EAP CPT® 10061 Drainage Abscess Complex/multiple BOTH IP/OP "$1,394.00 " "$1,031.56" $0.00 "$1,394.00" "$1,394.00" "$1,394.00" $336.60 $336.60 $338.49 $290.54 "$1,257.08" "$1,257.08" "$1,305.43" $331.46 $290.51 $215.45 "$1,394.00" "$1,394.00" $320.45 "$1,380.00" "$1,092.96" "$1,104.00" $445.22 "$1,394.00" $445.22 $0.00 $187.80 $187.80 $219.70 $305.19 $0.00 $0.00 $0.00 $0.00 36100022 EAP CPT® 20604 Drain /inject-finger/toe With Us Guidance BOTH IP/OP $935.00 $691.90 $0.00 $936.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.31 $194.85 $162.70 $113.00 $113.00 $262.54 $936.00 $741.31 $748.80 $364.76 $935.00 $364.76 $69.40 $47.60 $47.60 $149.01 $250.04 $0.00 $0.00 $0.00 $0.00 36100023 EAP CPT® 20606 Drain/inject-wrist Elbow Ankle With Us Guidance BOTH IP/OP $935.00 $691.90 $0.00 $936.00 $935.00 $935.00 $618.38 $618.38 $621.87 $194.88 $0.00 $0.00 $0.00 $608.20 $194.85 $395.33 $113.00 $113.00 $626.89 $936.00 $741.31 $748.80 $870.98 $935.00 $870.98 $76.82 $54.81 $54.81 $149.01 $597.04 $0.00 $0.00 $0.00 $0.00 36100024 EAP CPT® 20611 Drain/inject-shoulder Hip Knee With Us Guidance BOTH IP/OP "$2,198.00 " "$1,626.52" $0.00 "$2,200.00" "$2,198.00" "$2,198.00" $254.43 $254.43 $255.86 $458.12 $0.00 $0.00 $0.00 $250.31 $458.06 $162.70 $113.00 $113.00 $262.54 "$2,200.00" "$1,742.40" "$1,760.00" $364.76 "$1,750.00" $364.76 $88.61 $62.38 $62.38 $350.24 $250.04 $0.00 $0.00 $0.00 $0.00 36100025 EAP CPT® 20983 Ablation Therapy Bone Tumor(s) Perq BOTH IP/OP "$6,719.00 " "$4,972.06" $0.00 "$5,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,400.24" $0.00 $0.00 $0.00 $0.00 "$5,452.00" "$4,988.81" "$5,039.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100026 EAP CPT® 64566 Percutaneous Tibial Nerve Stimulation BOTH IP/OP $617.00 $456.58 $0.00 $617.00 $617.00 $617.00 $254.43 $254.43 $255.86 $128.60 $0.00 $0.00 $0.00 $250.31 $128.58 $162.70 $617.00 $617.00 $262.54 $617.00 $488.66 $493.60 $364.76 $617.00 $364.76 $122.82 $32.45 $32.45 $98.23 $250.04 $0.00 $0.00 $0.00 $0.00 36100027 EAP CPT® 46607 Anoscopy Hra W/biopsy BOTH IP/OP "$3,451.00 " "$2,553.74" $0.00 "$3,451.00" "$2,321.55" "$2,321.55" "$1,009.84" "$1,009.84" "$1,015.53" $719.27 $0.00 $0.00 $0.00 $993.84 $719.19 $646.00 "$3,451.00" "$3,451.00" "$1,007.17" "$2,255.00" "$2,641.32" "$2,668.00" "$1,399.33" "$1,898.00" "$1,399.33" $0.00 $131.60 $131.60 $530.93 $959.21 $0.00 $0.00 $0.00 $0.00 36100028 EAP CPT® 10080 Drainage Of Pilonidal Cyst BOTH IP/OP $712.00 $526.88 $0.00 "$1,524.00" $712.00 $712.00 $606.01 $606.01 $609.42 $0.00 $712.00 $712.00 $712.00 $0.00 $148.38 $0.00 $0.00 $0.00 $0.00 $705.00 $558.36 $564.00 $0.00 "$1,524.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100030 EAP CPT® 10120 Remove Foreign Body Sq Simple BOTH IP/OP $768.00 $568.32 $0.00 "$1,750.00" $768.00 $768.00 $336.60 $336.60 $338.49 $160.07 $768.00 $768.00 $768.00 $331.46 $160.05 $215.45 $113.00 $113.00 $0.00 $760.00 $601.92 $608.00 $0.00 "$1,750.00" $0.00 $85.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100034 EAP CPT® 10121 "Removal Of Fb, Sc Tissue Compl" BOTH IP/OP "$7,169.00 " "$5,305.06" $0.00 "$5,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.02" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,619.24" "$5,676.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100035 EAP CPT® 10140 Drainage Of Hematoma/fluid BOTH IP/OP "$6,515.00 " "$4,821.10" $0.00 "$5,158.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,357.73" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,106.82" "$5,158.40" $0.00 "$2,500.00" $0.00 $89.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100036 EAP CPT® 52204 Cystoscopy W/diopsy (s) BOTH IP/OP "$13,064.00 " "$9,667.36" $0.00 "$10,482.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,722.54" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$10,377.58" "$10,482.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100037 EAP CPT® 52354 Cystouretero W/diopsy BOTH IP/OP "$6,056.00 " "$4,481.44" $0.00 "$4,859.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,262.07" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$4,810.61" "$4,859.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100041 EAP CPT® 10160 Aspiration Abscess Hematoma Bulla/cyst BOTH IP/OP $645.00 $477.30 $0.00 $645.00 $645.00 $645.00 $336.60 $336.60 $338.49 $134.43 $0.00 $0.00 $0.00 $331.46 $134.42 $215.45 $113.00 $113.00 $320.45 $638.00 $505.30 $510.40 $445.22 $645.00 $445.22 $78.53 $97.69 $97.69 $101.57 $305.19 $0.00 $0.00 $0.00 $0.00 36100042 EAP CPT® 31600 "Tracheostomy, Planned" BOTH IP/OP "$4,986.00 " "$3,689.64" $0.00 "$3,903.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,864.17" "$3,903.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100044 EAP CPT® 36473 Endoven Abltj Incmptnt Vein Mchnchem 1st Vein BOTH IP/OP "$8,848.00 " "$6,547.52" $0.00 "$5,627.20" "$2,984.10" "$2,984.10" "$2,787.76" "$2,787.76" "$2,803.47" "$1,844.14" $0.00 $0.00 $0.00 "$2,742.67" "$1,843.92" "$1,782.74" $113.00 $113.00 "$2,779.42" "$2,858.00" "$5,570.93" "$5,627.20" "$3,861.64" "$3,725.00" "$3,861.64" "$1,443.33" $186.78 $186.78 "$1,119.81" "$2,647.07" $0.00 $0.00 $0.00 $0.00 36100045 EAP CPT® 36474 Endoven Abltj Incmptnt Vein Mchn Sbsq Veins-add On BOTH IP/OP "$2,213.00 " "$1,637.62" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $461.19 $0.00 $0.00 $0.00 $0.00 $879.50 "$1,393.13" "$1,407.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100046 EAP CPT® 64611 Chemodenerv Parotid/subm Salivary Glands Bilateral BOTH IP/OP $469.00 $347.06 $0.00 $472.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.74 $0.00 $0.00 $0.00 $262.54 $472.00 $373.82 $377.60 $364.76 $469.00 $364.76 $94.40 $108.82 $108.82 $75.14 $250.04 $0.00 $0.00 $0.00 $0.00 36100049 EAP CPT® 10180 I&d Complex Post Op Wound Inf BOTH IP/OP "$6,264.00 " "$4,635.36" $0.00 "$4,959.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,305.42" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,909.61" "$4,959.20" $0.00 "$3,250.00" $0.00 $130.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100050 EAP CPT® 52315 Cystoscopy And Treatment BOTH IP/OP "$8,062.00 " "$5,965.88" $0.00 "$6,514.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,680.12" $0.00 $0.00 $0.00 "$1,776.76" "$2,327.00" "$6,449.26" "$6,514.40" "$2,468.57" "$3,250.00" "$2,468.57" $535.80 $285.23 $285.23 "$1,296.37" "$1,692.15" $0.00 $0.00 $0.00 $0.00 36100051 EAP CPT® 11000 Debridement Of Skin BOTH IP/OP "$3,090.00 " "$2,286.60" $0.00 "$2,350.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $643.96 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,326.90" "$2,350.40" $0.00 "$1,443.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100057 EAP CPT® 11001 "Debride, Each Add 10% Of Body" BOTH IP/OP "$1,665.00 " "$1,232.10" $0.00 "$1,671.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.99 $0.00 $0.00 $0.00 $0.00 "$1,671.00" "$1,323.43" "$1,336.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100058 EAP CPT® 97597 Debridement First 20 Sq Cm Or Less BOTH IP/OP $740.00 $547.60 $0.00 $848.25 $740.00 $740.00 $174.88 $174.88 $175.86 $154.23 $0.00 $0.00 $0.00 $172.08 $154.22 $111.85 $437.71 $437.71 $175.24 $674.00 $533.81 $539.20 $243.48 $848.25 $243.48 $48.15 $37.87 $37.87 $107.30 $166.90 $0.00 $0.00 $0.00 $0.00 36100060 EAP CPT® 49418 Insertion Of Tunneled Intraperitoneal Catheter BOTH IP/OP "$8,783.00 " "$6,499.42" $0.00 "$6,587.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,830.38" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$6,521.33" "$6,587.20" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100061 EAP CPT® 97598 Debridement Open Wound Ea Addl 20 Sq Cm BOTH IP/OP $561.00 $415.14 $0.00 $448.80 $0.00 $0.00 $0.00 $0.00 $0.00 $128.39 $0.00 $0.00 $0.00 $0.00 $128.37 $0.00 $364.36 $364.36 $0.00 $280.50 $444.31 $448.80 $0.00 $0.00 $0.00 $61.13 $26.68 $26.68 $89.31 $0.00 $0.00 $0.00 $0.00 $0.00 36100063 EAP CPT® 11042 "Debridement Skin,and Subcutane" BOTH IP/OP "$2,172.00 " "$1,607.28" $63.09 "$2,172.00" "$2,172.00" "$2,172.00" $336.60 $336.60 $338.49 $452.70 "$1,541.95" "$1,541.95" "$1,601.25" $331.46 $452.64 $215.45 "$2,172.00" "$2,172.00" $320.45 "$2,065.00" "$1,635.48" "$1,652.00" $445.22 "$1,750.00" $445.22 $70.00 $63.09 $63.09 $328.75 $305.19 $0.00 $0.00 $0.00 $0.00 36100065 EAP CPT® 11043 Debridement Skin/sq/muscle BOTH IP/OP "$4,347.00 " "$3,216.78" $161.16 "$3,306.40" "$2,753.10" "$2,753.10" $510.03 $510.03 $512.91 $906.02 "$1,541.95" "$1,541.95" "$1,601.25" $502.38 $905.91 $326.54 "$2,836.00" "$2,836.00" $498.48 "$2,327.00" "$3,273.34" "$3,306.40" $692.57 "$1,750.00" $692.57 $168.42 $161.16 $161.16 $657.97 $474.74 $0.00 $0.00 $0.00 $0.00 36100067 EAP CPT® 11044 "Debridement, Bone" BOTH IP/OP "$5,344.00 " "$3,954.56" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.69" $0.00 $0.00 $0.00 "$1,376.63" "$2,327.00" "$4,023.36" "$4,064.00" "$1,912.65" "$2,150.00" "$1,912.65" $0.00 $236.52 $236.52 $808.74 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100070 EAP CPT® 11055 "Pare Wart/callus/hyperkaratotic Lesion, Single" BOTH IP/OP $365.00 $270.10 $0.00 $624.00 $365.00 $365.00 $174.88 $174.88 $175.86 $76.08 $0.00 $0.00 $0.00 $172.08 $76.07 $111.85 $113.00 $113.00 $175.24 $365.00 $289.08 $292.00 $243.48 $624.00 $243.48 $21.20 $16.59 $16.59 $58.11 $166.90 $0.00 $0.00 $0.00 $0.00 36100073 EAP CPT® 11056 "Pare Wart/callus, 2-4 Lesions" BOTH IP/OP $365.00 $270.10 $0.00 $814.00 $365.00 $365.00 $174.88 $174.88 $175.86 $76.08 $0.00 $0.00 $0.00 $172.08 $76.07 $111.85 $113.00 $113.00 $175.24 $365.00 $289.08 $292.00 $243.48 $814.00 $243.48 $28.23 $24.16 $24.16 $58.11 $166.90 $0.00 $0.00 $0.00 $0.00 36100074 EAP CPT® 11057 "Pare Wart/callus, >4 Lesions" BOTH IP/OP $927.00 $685.98 $0.00 $927.00 $927.00 $927.00 $174.88 $174.88 $175.86 $193.21 $0.00 $0.00 $0.00 $172.08 $193.19 $111.85 $113.00 $113.00 $175.24 $926.00 $733.39 $740.80 $243.48 $927.00 $243.48 $31.34 $30.66 $30.66 $147.42 $166.90 $0.00 $0.00 $0.00 $0.00 36100078 EAP CPT® 11200 Removal Of Skin Tags (1-15) BOTH IP/OP $712.00 $526.88 $55.43 $712.00 $712.00 $712.00 $174.88 $174.88 $175.86 $148.40 $712.00 $712.00 $712.00 $172.08 $148.38 $111.85 $113.00 $113.00 $175.24 $711.00 $563.11 $568.80 $243.48 $614.00 $243.48 $55.43 $75.69 $75.69 $113.19 $166.90 $0.00 $0.00 $0.00 $0.00 36100081 EAP CPT® 11201 Removal Of Skin Tags;ea Add 10 BOTH IP/OP "$1,016.00 " $751.84 $0.00 "$1,016.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.73 $0.00 $0.00 $0.00 $0.00 "$1,015.00" $803.88 $812.00 $0.00 "$1,016.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100082 EAP CPT® 11300 Shave Les Trunk Arm Leg <0.5cm BOTH IP/OP $365.00 $270.10 $0.00 $365.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.07 $0.00 $0.00 $0.00 $0.00 $365.00 $289.08 $292.00 $0.00 $266.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100083 EAP CPT® 11301 Shave Trunk Arm Leg 0.6-1.0cm BOTH IP/OP $365.00 $270.10 $0.00 $365.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.07 $0.00 $0.00 $0.00 $0.00 $365.00 $289.08 $292.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100084 EAP CPT® 11302 Shave Trunk Arm Leg 1.1-2.0cm BOTH IP/OP $752.00 $556.48 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.72 $0.00 $0.00 $0.00 $0.00 $752.00 $595.58 $601.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100085 EAP CPT® 11303 Shave Trunk Arm Leg >2.0cm BOTH IP/OP "$1,136.00 " $840.64 $0.00 "$1,136.00" $616.85 $616.85 $336.60 $336.60 $338.49 $236.77 "$1,136.00" "$1,136.00" "$1,136.00" $331.46 $236.74 $215.45 $113.00 $113.00 $0.00 "$1,135.00" $898.92 $908.00 $0.00 "$1,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100086 EAP CPT® 11305 Shave Skin Lesion 0.5 Cm/< BOTH IP/OP $752.00 $556.48 $0.00 $752.00 $408.34 $408.34 $174.88 $174.88 $175.86 $156.74 $0.00 $0.00 $0.00 $172.08 $156.72 $111.85 $113.00 $113.00 $0.00 $752.00 $595.58 $601.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100088 EAP CPT® 11306 Shave Scalp/neck/hnd/ft 0.6-1. BOTH IP/OP $752.00 $556.48 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.72 $0.00 $0.00 $0.00 $0.00 $752.00 $595.58 $601.60 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100089 EAP CPT® 11307 Shave Scalp/neck/hnd/ft 1.1-2. BOTH IP/OP $670.00 $495.80 $0.00 $670.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $670.00 $530.64 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100090 EAP CPT® 11308 Shave Scalp/neck/hnd/feet >2.0 BOTH IP/OP $721.00 $533.54 $0.00 $721.00 $391.50 $391.50 $336.60 $336.60 $338.49 $150.27 $0.00 $0.00 $0.00 $331.46 $150.26 $215.45 $113.00 $113.00 $320.45 $720.00 $570.24 $576.00 $445.22 $721.00 $445.22 $100.61 $76.09 $76.09 $114.62 $305.19 $0.00 $0.00 $0.00 $0.00 36100091 EAP CPT® 11310 Shaving Fac Ear Nos Lip <.5cm BOTH IP/OP $720.00 $532.80 $0.00 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $720.00 $570.24 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100092 EAP CPT® 27570 Manipulation Knee Joint Under General Anes BOTH IP/OP "$4,221.00 " "$3,123.54" $0.00 "$3,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.66 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,343.03" "$3,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100094 EAP CPT® 11311 Shav Fac/ear/eye/nos/lip 0.6-1 BOTH IP/OP $752.00 $556.48 $0.00 $752.00 $408.34 $408.34 $174.88 $174.88 $175.86 $156.74 $0.00 $0.00 $0.00 $172.08 $156.72 $111.85 $113.00 $113.00 $0.00 $752.00 $595.58 $601.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100096 EAP CPT® 11312 Shav Fac/ear/eye/nos/lip 1.1-2 BOTH IP/OP $752.00 $556.48 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.72 $0.00 $0.00 $0.00 $0.00 $752.00 $595.58 $601.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100098 EAP CPT® 11313 Shav Face/ear/eye/nose/lip >2. BOTH IP/OP "$1,483.00 " "$1,097.42" $0.00 "$1,483.00" $805.27 $805.27 $336.60 $336.60 $338.49 $309.09 $0.00 $0.00 $0.00 $331.46 $309.06 $215.45 $113.00 $113.00 $0.00 "$1,483.00" "$1,174.54" "$1,186.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100099 EAP CPT® 11400 Exc Benign Lesion T/a/l 0.5 Cm/< BOTH IP/OP "$2,074.00 " "$1,534.76" $0.00 "$2,071.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $432.22 $0.00 $0.00 $0.00 $0.00 "$2,071.00" "$1,640.23" "$1,656.80" $0.00 "$1,866.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100100 EAP CPT® 64999 Quadratus Lumborum-anes BOTH IP/OP "$4,470.00 " "$3,307.80" $0.00 "$3,550.40" "$2,321.55" "$2,321.55" $254.43 $254.43 $255.86 $0.00 $0.00 $0.00 $0.00 $0.00 $931.55 $0.00 $0.00 $0.00 $262.54 "$2,255.00" "$3,514.90" "$3,550.40" $364.76 "$2,607.00" $364.76 $694.55 $0.00 $0.00 $706.53 $250.04 $0.00 $0.00 $0.00 $0.00 36100101 EAP CPT® 11401 Exc Benign Lesion T/a/l 0.6-1.0 Cm BOTH IP/OP "$2,327.00 " "$1,721.98" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $336.60 $336.60 $338.49 $485.00 "$1,257.08" "$1,257.08" "$1,305.43" $331.46 $484.95 $215.45 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$1,840.61" "$1,859.20" $0.00 "$2,150.00" $0.00 $105.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100103 EAP CPT® 11402 Exc Benign Lesion T/a/l 1.1-2.0 Cm BOTH IP/OP "$2,327.00 " "$1,721.98" $117.87 "$2,321.55" "$2,321.55" "$2,321.55" $606.01 $606.01 $609.42 $485.00 "$1,257.08" "$1,257.08" "$1,305.43" $596.11 $484.95 $387.47 "$1,871.00" "$1,871.00" $611.80 "$2,255.00" "$1,840.61" "$1,859.20" $850.02 "$2,150.00" $850.02 $121.81 $117.87 $117.87 $369.98 $582.67 $0.00 $0.00 $0.00 $0.00 36100105 EAP CPT® 11403 Exc Benign Lesion T/a/l 2.1-3.0 Cm BOTH IP/OP "$6,030.00 " "$4,462.20" $142.90 "$4,817.60" "$2,321.55" "$2,321.55" $606.01 $606.01 $609.42 "$1,256.80" "$1,257.08" "$1,257.08" "$1,305.43" $596.11 "$1,256.65" $387.47 "$1,871.00" "$1,871.00" $611.80 "$2,255.00" "$4,769.42" "$4,817.60" $850.02 "$2,150.00" $850.02 $142.90 $152.47 $152.47 $958.70 $582.67 $0.00 $0.00 $0.00 $0.00 36100107 EAP CPT® 11404 Exc Benign Lesion T/a/l 3.1-4.0 Cm BOTH IP/OP "$10,505.00 " "$7,773.70" $0.00 "$8,393.60" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" "$2,189.50" "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" "$2,189.24" $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$8,309.66" "$8,393.60" "$1,912.65" "$2,500.00" "$1,912.65" $0.00 $167.97 $167.97 "$1,670.33" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100109 EAP CPT® 11406 "Exc, Benign,>4.0 Cm, T/a/l" BOTH IP/OP "$11,772.00 " "$8,711.28" $197.38 "$9,405.60" "$2,753.10" "$2,753.10" "$1,370.21" "$1,370.21" "$1,377.93" "$2,453.58" "$1,541.95" "$1,541.95" "$1,601.25" "$1,348.50" "$2,453.28" $876.52 "$2,836.00" "$2,836.00" "$1,376.63" "$2,327.00" "$9,311.54" "$9,405.60" "$1,912.65" "$2,500.00" "$1,912.65" $197.38 $255.57 $255.57 "$1,871.71" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100110 EAP CPT® 64505 N Block Spenopalatine Gangl BOTH IP/OP "$2,665.00 " "$1,972.10" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $254.43 $254.43 $255.86 $555.45 $0.00 $0.00 $0.00 $250.31 $555.39 $162.70 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$2,036.23" "$2,056.80" $0.00 "$1,199.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100111 EAP CPT® 11420 Exc Benign Scalp Genit Hand Ft BOTH IP/OP "$6,030.00 " "$4,462.20" $0.00 "$4,817.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.80" $0.00 $0.00 $0.00 "$1,348.50" "$1,256.65" $876.52 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$4,769.42" "$4,817.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100112 EAP CPT® 30140 Resect Inferior Turbinate Submucous Bilateral BOTH IP/OP "$5,043.00 " "$3,731.82" $0.00 "$4,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,050.96" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,994.06" "$4,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100115 EAP CPT® 11421 Exc Benign Scalp Genit Hnd Ft BOTH IP/OP "$6,030.00 " "$4,462.20" $0.00 "$4,817.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.80" $0.00 $0.00 $0.00 $596.11 "$1,256.65" $387.47 "$1,871.00" "$1,871.00" $611.80 "$2,255.00" "$4,769.42" "$4,817.60" $850.02 "$2,150.00" $850.02 $111.86 $112.83 $112.83 $958.70 $582.67 $0.00 $0.00 $0.00 $0.00 36100118 EAP CPT® 11422 Exc Ben Scal Gent Hd Ft Neck BOTH IP/OP "$5,541.00 " "$4,100.34" $127.73 "$4,427.20" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" "$1,154.88" "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" "$1,154.74" $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$4,382.93" "$4,427.20" "$1,912.65" "$2,150.00" "$1,912.65" $127.73 $139.85 $139.85 $881.01 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100120 EAP CPT® 11423 Exc Beng Scp Gent Hd Ft Nk BOTH IP/OP "$6,030.00 " "$4,462.20" $0.00 "$4,817.60" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" "$1,256.80" "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" "$1,256.65" $876.52 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$4,769.42" "$4,817.60" $0.00 "$2,500.00" $0.00 $156.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100121 EAP CPT® 31295 Sinus Endo W/balloon Dil BOTH IP/OP "$6,390.00 " "$4,728.60" $0.00 "$5,112.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,331.68" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$5,060.88" "$5,112.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100122 EAP CPT® 11424 "Exc Beng Sc, Genit Hd Ft Neck" BOTH IP/OP "$4,851.00 " "$3,589.74" $0.00 "$3,876.00" "$2,753.10" "$2,753.10" "$1,370.21" "$1,370.21" "$1,377.93" "$1,011.07" "$1,541.95" "$1,541.95" "$1,601.25" "$1,348.50" "$1,010.95" $876.52 "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$3,837.24" "$3,876.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100123 EAP CPT® 31513 Injection Into Vocal Cord BOTH IP/OP "$6,225.00 " "$4,606.50" $0.00 "$5,208.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,297.29" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,156.71" "$5,208.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100124 EAP CPT® 11426 "Exc,benign,>4.0 Cm,sclp/h/f" BOTH IP/OP "$6,408.00 " "$4,741.92" $0.00 "$5,120.00" "$2,753.10" "$2,753.10" "$2,309.02" "$2,309.02" "$2,322.02" "$1,335.59" "$1,541.95" "$1,541.95" "$1,601.25" "$2,271.46" "$1,335.43" "$1,476.45" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$5,068.80" "$5,120.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100126 EAP CPT® 11440 Exc Benign Face Ear Nose Muc BOTH IP/OP "$1,776.00 " "$1,314.24" $0.00 "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.12 $0.00 $0.00 $0.00 $611.80 "$1,774.00" "$1,405.01" "$1,419.20" $850.02 "$1,776.00" $850.02 $101.18 $105.96 $105.96 $282.42 $582.67 $0.00 $0.00 $0.00 $0.00 36100130 EAP CPT® 11441 Exc Benign Face Ear Nose Muc BOTH IP/OP "$3,293.00 " "$2,436.82" $0.00 "$2,631.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $686.26 $0.00 $0.00 $0.00 $611.80 "$2,255.00" "$2,604.89" "$2,631.20" $850.02 "$2,150.00" $850.02 $0.00 $134.44 $134.44 $523.61 $582.67 $0.00 $0.00 $0.00 $0.00 36100132 EAP CPT® 11442 "Exc, Beng Fc, Er,nos,muc 1.1-2" BOTH IP/OP "$3,246.00 " "$2,402.04" $139.44 "$2,593.60" "$2,321.55" "$2,321.55" $606.01 $606.01 $609.42 $676.55 "$1,257.08" "$1,257.08" "$1,305.43" $596.11 $676.47 $387.47 "$1,871.00" "$1,871.00" $611.80 "$2,255.00" "$2,567.66" "$2,593.60" $850.02 "$2,150.00" $850.02 $139.44 $149.22 $149.22 $516.13 $582.67 $0.00 $0.00 $0.00 $0.00 36100135 EAP CPT® 11443 Exc Benign Lesion F/e/e/n/l/m 2.1-3.0cm BOTH IP/OP "$6,030.00 " "$4,462.20" $0.00 "$4,817.60" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" "$1,256.80" $0.00 $0.00 $0.00 "$1,348.50" "$1,256.65" $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$4,769.42" "$4,817.60" "$1,912.65" "$2,150.00" "$1,912.65" $177.41 $183.11 $183.11 $958.70 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100138 EAP CPT® 11444 Exc Benign Lesion F/e/e/n/l/m 3.1-4.0cm BOTH IP/OP "$2,484.00 " "$1,838.16" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" $517.73 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $517.67 $876.52 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$1,964.95" "$1,984.80" $0.00 "$2,150.00" $0.00 $220.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100141 EAP CPT® 11446 "Exc Benign,>4.0 Cm,f/e/mem" BOTH IP/OP "$15,310.00 " "$11,329.40" $0.00 "$12,232.80" "$2,753.10" "$2,753.10" "$2,309.02" "$2,309.02" "$2,322.02" "$3,190.99" "$1,541.95" "$1,541.95" "$1,601.25" "$2,271.46" "$3,190.60" "$1,476.45" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$12,110.47" "$12,232.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100142 EAP CPT® 11601 "Exc.malig,tr/a/l,0.6-1.0cm" BOTH IP/OP "$2,235.00 " "$1,653.90" $0.00 "$2,235.00" "$2,235.00" "$2,235.00" $606.01 $606.01 $609.42 $465.83 $0.00 $0.00 $0.00 $596.11 $465.77 $387.47 "$1,871.00" "$1,871.00" $0.00 "$2,232.00" "$1,767.74" "$1,785.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100143 EAP CPT® 11602 "Exc.malig,tr/a/l,1.1-2.0cm" BOTH IP/OP "$2,327.00 " "$1,721.98" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $336.60 $336.60 $338.49 $485.00 $0.00 $0.00 $0.00 $331.46 $484.95 $215.45 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$1,840.61" "$1,859.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100144 EAP CPT® 11603 "Exc.malig Tr/a/l,2.1-3.0cm" BOTH IP/OP "$5,176.00 " "$3,830.24" $0.00 "$4,135.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,078.68" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,093.85" "$4,135.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100145 EAP CPT® 11604 Exc Malign Tr Arm Leg 3.1-4.0 BOTH IP/OP "$5,176.00 " "$3,830.24" $0.00 "$4,135.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,078.68" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,093.85" "$4,135.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100146 EAP CPT® 11606 "Exc Malig>4.0 Cm,trnk/a/l" BOTH IP/OP "$10,505.00 " "$7,773.70" $0.00 "$8,393.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.24" $0.00 $0.00 $0.00 "$1,376.63" "$2,327.00" "$8,309.66" "$8,393.60" "$1,912.65" "$1,976.00" "$1,912.65" $252.57 $329.86 $329.86 "$1,670.33" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100147 EAP CPT® 11621 "Exc Malign Scap Gent Hd,ft Nk" BOTH IP/OP "$3,293.00 " "$2,436.82" $0.00 "$2,631.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $686.26 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,604.89" "$2,631.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100148 EAP CPT® 11622 Exc Malignant Lesion S/n/h/f/g 1.1-2.0 Cm BOTH IP/OP "$6,030.00 " "$4,462.20" $0.00 "$4,817.60" "$2,321.55" "$2,321.55" $606.01 $606.01 $609.42 "$1,256.80" $0.00 $0.00 $0.00 $596.11 "$1,256.65" $387.47 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$4,769.42" "$4,817.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100150 EAP CPT® 11623 Exc Malignant Lesion S/n/h/f/g 2.1-3.0 Cm BOTH IP/OP "$11,307.00 " "$8,367.18" $0.00 "$9,045.60" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,356.38" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$8,955.14" "$9,045.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100152 EAP CPT® 11624 Exc Malign Scp Gent Hd Ft Nk BOTH IP/OP "$10,091.00 " "$7,467.34" $0.00 "$8,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,102.96" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,992.07" "$8,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100153 EAP CPT® 11626 "Excis Malig,>4.0 Cm,scp/h/ft" BOTH IP/OP "$13,133.00 " "$9,718.42" $0.00 "$10,506.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,736.92" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$10,401.34" "$10,506.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100154 EAP CPT® 11640 Exc Malignant Lesion F/e/e/n/l 0.5 Cm/< BOTH IP/OP "$3,168.00 " "$2,344.32" $0.00 "$2,531.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.38 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,505.89" "$2,531.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100156 EAP CPT® 11641 Exc Malignant Lesion F/e/e/n/l 0.6-1.0 Cm BOTH IP/OP "$3,044.00 " "$2,252.56" $0.00 "$2,435.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $634.37 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,410.85" "$2,435.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100159 EAP CPT® 11642 Exc Malignant Lesion F/e/e/n/l 1.1-2.0 Cm BOTH IP/OP "$6,030.00 " "$4,462.20" $0.00 "$4,817.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.65" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,769.42" "$4,817.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100161 EAP CPT® 11643 Exc Malign Fc Ear Nose Mus Mem BOTH IP/OP "$5,789.00 " "$4,283.86" $0.00 "$4,631.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.43" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,584.89" "$4,631.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100162 EAP CPT® 11644 Exc Malign Fc Ear Nose Muc Mem BOTH IP/OP "$10,091.00 " "$7,467.34" $0.00 "$8,072.80" "$2,753.10" "$2,753.10" "$1,370.21" "$1,370.21" "$1,377.93" "$2,103.22" "$1,541.95" "$1,541.95" "$1,601.25" "$1,348.50" "$2,102.96" $876.52 "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$7,992.07" "$8,072.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100163 EAP CPT® 11646 "Exc,malig,>4.0 Cm,f/e/mem" BOTH IP/OP "$13,656.00 " "$10,105.44" $0.00 "$10,924.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,845.91" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$10,815.55" "$10,924.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100165 EAP CPT® 11719 Trim Of Nondystrophic Nail(s) Any BOTH IP/OP $285.00 $210.90 $0.00 $288.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.39 $0.00 $0.00 $0.00 $0.00 $288.00 $228.10 $230.40 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100166 EAP CPT® 11720 Debridement Nail Any Method 1-5 BOTH IP/OP $199.00 $147.26 $0.00 $201.00 $199.00 $199.00 $54.21 $54.21 $54.51 $41.48 $0.00 $0.00 $0.00 $53.35 $41.47 $34.67 $113.00 $113.00 $55.17 $201.00 $159.19 $160.80 $76.65 $199.00 $76.65 $25.44 $15.15 $15.15 $32.00 $52.54 $0.00 $0.00 $0.00 $0.00 36100169 EAP CPT® 11721 Debridement Nail Any Method 6/> BOTH IP/OP $199.00 $147.26 $0.00 $298.00 $199.00 $199.00 $54.21 $54.21 $54.51 $41.48 $0.00 $0.00 $0.00 $53.35 $41.47 $34.67 $113.00 $113.00 $55.17 $201.00 $159.19 $160.80 $76.65 $298.00 $76.65 $39.87 $25.97 $25.97 $32.00 $52.54 $0.00 $0.00 $0.00 $0.00 36100173 EAP CPT® 11730 Avulsion Nail Plate Partial/complete Simple 1st BOTH IP/OP $427.00 $315.98 $56.62 $431.00 $427.00 $427.00 $174.88 $174.88 $175.86 $89.00 $427.00 $427.00 $427.00 $172.08 $88.99 $111.85 $113.00 $113.00 $175.24 $431.00 $341.35 $344.80 $243.48 $427.00 $243.48 $63.22 $56.62 $56.62 $68.62 $166.90 $0.00 $0.00 $0.00 $0.00 36100176 EAP CPT® 11732 Avulsion Nail Plate Partial/complete Simple Ea Addl BOTH IP/OP $207.00 $153.18 $0.00 $209.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $209.00 $165.53 $167.20 $0.00 $207.00 $0.00 $31.24 $18.03 $18.03 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 36100178 EAP CPT® 11740 Evacuation Subungual Hematoma BOTH IP/OP $248.00 $183.52 $0.00 $377.00 $248.00 $248.00 $109.81 $109.81 $110.43 $51.69 $0.00 $0.00 $0.00 $107.30 $51.68 $69.74 $113.00 $113.00 $0.00 $250.00 $198.00 $200.00 $0.00 $377.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100180 EAP CPT® 11750 Excision Nail Matrix Permanent Removal BOTH IP/OP "$1,397.00 " "$1,033.78" $0.00 "$2,150.00" "$1,397.00" "$1,397.00" $336.60 $336.60 $338.49 $291.17 "$1,257.08" "$1,257.08" "$1,305.43" $331.46 $291.13 $215.45 "$1,397.00" "$1,397.00" $0.00 "$1,410.00" "$1,116.72" "$1,128.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100183 EAP CPT® 11765 Wedge Excision Skin Nail Fold BOTH IP/OP $554.00 $409.96 $0.00 $559.00 $554.00 $554.00 $336.60 $336.60 $338.49 $0.00 $554.00 $554.00 $554.00 $0.00 $115.45 $0.00 $0.00 $0.00 $320.45 $559.00 $442.73 $447.20 $445.22 $554.00 $445.22 $52.25 $95.17 $95.17 $88.99 $305.19 $0.00 $0.00 $0.00 $0.00 36100186 EAP CPT® 11900 Intralesional Inj Up To 7 Les BOTH IP/OP $338.00 $250.12 $0.00 $521.00 $338.00 $338.00 $174.88 $174.88 $175.86 $70.45 $0.00 $0.00 $0.00 $172.08 $70.44 $111.85 $113.00 $113.00 $175.24 $341.00 $270.07 $272.80 $243.48 $521.00 $243.48 $36.36 $31.37 $31.37 $54.29 $166.90 $0.00 $0.00 $0.00 $0.00 36100188 EAP CPT® 11901 Injection Intralesional >7 Lesions BOTH IP/OP $276.00 $204.24 $0.00 $279.00 $276.00 $276.00 $174.88 $174.88 $175.86 $57.53 $0.00 $0.00 $0.00 $172.08 $57.52 $111.85 $113.00 $113.00 $175.24 $279.00 $220.97 $223.20 $243.48 $276.00 $243.48 $51.85 $49.03 $49.03 $44.42 $166.90 $0.00 $0.00 $0.00 $0.00 36100190 EAP CPT® 11952 Saline Injection < 10.0cc BOTH IP/OP $556.00 $411.44 $0.00 $562.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.87 $0.00 $0.00 $0.00 $0.00 $562.00 $445.10 $449.60 $0.00 $556.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100191 EAP CPT® 11954 Saline Injection > 10.0cc BOTH IP/OP $562.00 $415.88 $0.00 $562.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.12 $0.00 $0.00 $0.00 $0.00 $562.00 $445.10 $449.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100192 EAP CPT® 11960 Insert Tissue Expander(s) BOTH IP/OP "$5,416.00 " "$4,007.84" $0.00 "$4,332.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,128.69" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,289.47" "$4,332.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100193 EAP CPT® 11981 "Insert,implant Contraceptive" BOTH IP/OP $286.00 $211.64 $0.00 "$1,750.00" $286.00 $286.00 $109.81 $109.81 $110.43 $59.61 $0.00 $0.00 $0.00 $107.30 $59.60 $69.74 $113.00 $113.00 $109.35 $285.00 $225.72 $228.00 $151.93 "$1,750.00" $151.93 $112.89 $67.06 $67.06 $45.37 $104.14 $0.00 $0.00 $0.00 $0.00 36100196 EAP CPT® 12001 "Lac Repair, S,n,h,f <2.5cm" BOTH IP/OP $704.00 $520.96 $0.00 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $704.00 $557.57 $563.20 $243.48 $0.00 $243.48 $116.22 $46.87 $46.87 $112.08 $166.90 $0.00 $0.00 $0.00 $0.00 36100197 EAP CPT® 12001 Lac Repr Sclp Nck Hnd Ft <2.6c BOTH IP/OP $704.00 $520.96 $0.00 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $704.00 $557.57 $563.20 $243.48 $0.00 $243.48 $116.22 $46.87 $46.87 $112.08 $166.90 $0.00 $0.00 $0.00 $0.00 36100198 EAP CPT® 12001 Lac Repr Sclp Nck Hnd Ft<2.6cm BOTH IP/OP $704.00 $520.96 $0.00 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $704.00 $557.57 $563.20 $243.48 $0.00 $243.48 $116.22 $46.87 $46.87 $112.08 $166.90 $0.00 $0.00 $0.00 $0.00 36100199 EAP CPT® 12002 "Lac Repair, S,n,h,f 2.6-7.5cm" BOTH IP/OP $879.00 $650.46 $0.00 $879.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $879.00 $696.17 $703.20 $243.48 $0.00 $243.48 $127.88 $62.38 $62.38 $139.94 $166.90 $0.00 $0.00 $0.00 $0.00 36100200 EAP CPT® 12002 Lac Repr Fce Ear Lp 2.6-5.0 BOTH IP/OP $867.00 $641.58 $62.38 "$1,134.00" $470.78 $470.78 $174.88 $174.88 $175.86 $180.70 $867.00 $867.00 $867.00 $172.08 $180.68 $111.85 $113.00 $113.00 $175.24 $879.00 $696.17 $703.20 $243.48 "$1,134.00" $243.48 $127.88 $62.38 $62.38 $139.94 $166.90 $0.00 $0.00 $0.00 $0.00 36100201 EAP CPT® 12002 Lac Repr Sclp Nck Hnd Ft 2.6-7 BOTH IP/OP $938.00 $694.12 $62.38 "$1,134.00" $509.33 $509.33 $174.88 $174.88 $175.86 $195.50 $938.00 $938.00 $938.00 $172.08 $195.48 $111.85 $113.00 $113.00 $175.24 $879.00 $696.17 $703.20 $243.48 "$1,134.00" $243.48 $127.88 $62.38 $62.38 $139.94 $166.90 $0.00 $0.00 $0.00 $0.00 36100202 EAP CPT® 12004 Rep Sc/nk/ax/gen/tk 7.6-12.5 BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $970.00 $768.24 $776.00 $243.48 $0.00 $243.48 $152.49 $77.52 $77.52 $154.42 $166.90 $0.00 $0.00 $0.00 $0.00 36100203 EAP CPT® 12011 Lac Repr Fce Ear Eye Lp <2.6cm BOTH IP/OP $729.00 $539.46 $0.00 $729.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $729.00 $577.37 $583.20 $243.48 $0.00 $243.48 $123.67 $58.77 $58.77 $116.06 $166.90 $0.00 $0.00 $0.00 $0.00 36100206 EAP CPT® 20552 Bilat Inject Trigger Point 1-2 Musc BOTH IP/OP $961.00 $711.14 $0.00 "$1,750.00" $961.00 $961.00 $254.43 $254.43 $255.86 $200.30 $0.00 $0.00 $0.00 $250.31 $200.27 $162.70 $961.00 $961.00 $262.54 $962.00 $761.90 $769.60 $364.76 "$1,750.00" $364.76 $66.56 $40.02 $40.02 $153.15 $250.04 $0.00 $0.00 $0.00 $0.00 36100207 EAP CPT® 12013 Lac Repr Fce Ear Eye Lp 2.6-5. BOTH IP/OP $894.00 $661.56 $0.00 $894.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $894.00 $708.05 $715.20 $243.48 $0.00 $243.48 $140.24 $62.02 $62.02 $142.32 $166.90 $0.00 $0.00 $0.00 $0.00 36100208 EAP CPT® 16036 Escharotomy Each Addl Incision BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.58 $0.00 $0.00 $0.00 $0.00 "$1,198.00" $948.82 $958.40 $0.00 "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100209 EAP CPT® 16035 Escharotomy First Incision BOTH IP/OP $770.00 $569.80 $0.00 $770.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $732.00 $579.74 $585.60 $0.00 $770.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100211 EAP CPT® 12014 Rp Si Fa Ear Nos Lip 5.1cm-7.5 BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $970.00 $768.24 $776.00 $243.48 $0.00 $243.48 $166.21 $79.33 $79.33 $154.42 $166.90 $0.00 $0.00 $0.00 $0.00 36100214 EAP CPT® 12015 Smpl Rpr Sprfsl Face 7.6-12.5c BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $215.72 $0.00 $0.00 $0.00 $172.08 $215.69 $111.85 $113.00 $113.00 $0.00 $970.00 $768.24 $776.00 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100215 EAP CPT® 12016 Smpl Rpr Sprfsl Face 12.6-20cm BOTH IP/OP $957.00 $708.18 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.44 $0.00 $0.00 $0.00 $0.00 $970.00 $768.24 $776.00 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100216 EAP CPT® 12017 Smpl Rpr Sprfsl Face 20.1-30.0 BOTH IP/OP "$1,559.00 " "$1,153.66" $0.00 "$1,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.90 $0.00 $0.00 $0.00 $0.00 "$1,580.00" "$1,251.36" "$1,264.00" $0.00 "$1,134.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100217 EAP CPT® 12020 Wound Dehiscence Simple Closur BOTH IP/OP "$2,965.00 " "$2,194.10" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $617.91 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,200.18" "$2,222.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100219 EAP CPT® 12021 Packing Of Wound Dehisience BOTH IP/OP "$3,923.00 " "$2,903.02" $117.17 "$2,940.80" "$2,321.55" "$2,321.55" $336.60 $336.60 $338.49 $817.65 "$1,257.08" "$1,257.08" "$1,305.43" $331.46 $817.55 $215.45 "$1,871.00" "$1,871.00" $320.45 "$2,255.00" "$2,911.39" "$2,940.80" $445.22 "$1,750.00" $445.22 $117.17 $144.54 $144.54 $585.22 $305.19 $0.00 $0.00 $0.00 $0.00 36100221 EAP CPT® 12031 Int Rep Sclp Trnk Extrm <2.5cm BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.45 $970.00 $768.24 $776.00 $445.22 $0.00 $445.22 $141.63 $157.16 $157.16 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 36100222 EAP CPT® 12032 Int Rep Sclp Trk Ext 2.6-7.5cm BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.45 $970.00 $768.24 $776.00 $445.22 $0.00 $445.22 $161.36 $196.82 $196.82 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 36100223 EAP CPT® 12034 Int Rep Sclp Trk Ext7.6-12.5cm BOTH IP/OP $465.00 $344.10 $0.00 $465.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $465.00 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100224 EAP CPT® 12041 Int Repr N-hf/genit <2.6cm BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.45 $970.00 $768.24 $776.00 $445.22 $0.00 $445.22 $157.82 $152.13 $152.13 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 36100225 EAP CPT® 12042 Int Repr Nck Hnd Ft 2.6-7.5 Cm BOTH IP/OP $465.00 $344.10 $0.00 $465.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $465.00 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100226 EAP CPT® 12044 Int Repr Nck Hnd Ft 7.6-12.5cm BOTH IP/OP $948.00 $701.52 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $948.00 $750.82 $758.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100227 EAP CPT® 12051 Int Repr Fce Ear Eye Lp<2.5cm BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.45 $970.00 $768.24 $776.00 $445.22 $0.00 $445.22 $0.00 $174.83 $174.83 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 36100228 EAP CPT® 12052 Int Repr F/e/l/mm 2.6-5.0cm BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.45 $970.00 $768.24 $776.00 $445.22 $0.00 $445.22 $183.25 $206.92 $206.92 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 36100229 EAP CPT® 12053 Int Wnd Repr Face/mm 5.1-7.5cm BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,610.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.45 "$1,610.00" "$1,275.12" "$1,288.00" $445.22 $0.00 $445.22 $204.98 $223.51 $223.51 $256.31 $305.19 $0.00 $0.00 $0.00 $0.00 36100230 EAP CPT® 12054 Int Rep Fce Ear Lp 7.6-12.5 Cm BOTH IP/OP $957.00 $708.18 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.46 $0.00 $0.00 $0.00 $331.46 $199.44 $215.45 $957.00 $957.00 $0.00 $970.00 $768.24 $776.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100231 EAP CPT® 12055 Rep Int Fce Ear Lp 12.6-20.0cm BOTH IP/OP $957.00 $708.18 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.44 $0.00 $0.00 $0.00 $0.00 $970.00 $768.24 $776.00 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100232 EAP CPT® 12056 Rep Int Fce Ear Lp 20.1-30.0cm BOTH IP/OP "$1,559.00 " "$1,153.66" $0.00 "$1,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.90 $0.00 $0.00 $0.00 $0.00 "$1,580.00" "$1,251.36" "$1,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100233 EAP CPT® 12057 Lac Rep Inter Over 30.0cm BOTH IP/OP "$4,870.00 " "$3,603.80" $0.00 "$3,948.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,014.91" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,908.52" "$3,948.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100234 EAP CPT® 13100 "Repr Complex,1.1 To 2.5 Cm" BOTH IP/OP "$2,495.00 " "$1,846.30" $0.00 "$2,327.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $519.96 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$1,851.70" "$1,870.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100235 EAP CPT® 13101 Repr Complex Trk 2.6-7.5cm BOTH IP/OP "$2,602.00 " "$1,925.48" $0.00 "$2,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $542.32 $0.00 $0.00 $0.00 $502.38 $542.26 $326.54 "$2,602.00" "$2,602.00" $0.00 "$2,438.00" "$1,930.90" "$1,950.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100236 EAP CPT® 13120 Repr Comp Scalp Arms Lgs 1.1 BOTH IP/OP "$1,319.00 " $976.06 $0.00 "$1,427.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $274.88 $0.00 $0.00 $0.00 $0.00 "$1,337.00" "$1,058.90" "$1,069.60" $0.00 "$1,427.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100237 EAP CPT® 13121 Repr Comp Scalp Arms Lgs 2.5-7 BOTH IP/OP "$1,442.00 " "$1,067.08" $0.00 "$1,442.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $498.48 "$1,442.00" "$1,142.06" "$1,153.60" $692.57 $0.00 $692.57 $0.00 $270.39 $270.39 $229.57 $474.74 $0.00 $0.00 $0.00 $0.00 36100238 EAP CPT® 13131 "Repr Complex Mouth Neck Hds,ft" BOTH IP/OP "$1,337.00 " $989.38 $0.00 "$1,337.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,337.00" "$1,058.90" "$1,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100239 EAP CPT® 13132 "Repr Comp Mouth,neck,hds,ft2.6" BOTH IP/OP "$1,337.00 " $989.38 $0.00 "$1,337.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $498.48 "$1,337.00" "$1,058.90" "$1,069.60" $692.57 $0.00 $692.57 $0.00 $317.62 $317.62 $212.85 $474.74 $0.00 $0.00 $0.00 $0.00 36100241 EAP CPT® 13151 Repr Comp Eye Nose Ears Lips BOTH IP/OP "$2,307.00 " "$1,707.18" $0.00 "$2,338.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $480.78 $0.00 $0.00 $0.00 $0.00 "$2,338.00" "$1,851.70" "$1,870.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100242 EAP CPT® 13151 Rpr Complx Eyelid Etc.1.1-2.5c BOTH IP/OP "$2,307.00 " "$1,707.18" $0.00 "$2,338.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $480.78 $0.00 $0.00 $0.00 $0.00 "$2,338.00" "$1,851.70" "$1,870.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100243 EAP CPT® 13152 "Repr Comp Eyel, Nose,ears Lips" BOTH IP/OP "$2,533.00 " "$1,874.42" $0.00 "$2,533.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $521.00 $0.00 $0.00 $0.00 $0.00 "$2,533.00" "$2,006.14" "$2,026.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100244 EAP CPT® 14000 "Tiss Tran,trnk,<10 Sq Cm" BOTH IP/OP "$8,323.00 " "$6,159.02" $0.00 "$6,658.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,734.51" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,591.82" "$6,658.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100245 EAP CPT® 14020 "Tiss Trans,s/a/l/<10 Sq Cm" BOTH IP/OP "$8,323.00 " "$6,159.02" $0.00 "$6,658.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,734.51" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$6,591.82" "$6,658.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100246 EAP CPT® 14040 Tiss Xfr Head Mouth Chk Hnd <1 BOTH IP/OP "$8,323.00 " "$6,159.02" $0.00 "$6,658.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,734.51" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,591.82" "$6,658.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100247 EAP CPT® 14060 Tiss Trans E/n/e/l <10 Sq Cm BOTH IP/OP "$9,690.00 " "$7,170.60" $0.00 "$7,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,019.40" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$7,674.48" "$7,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100248 EAP CPT® 15788 Chem Peel Face Epidermal BOTH IP/OP $529.00 $391.46 $0.00 $529.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $110.24 $0.00 $0.00 $0.00 $0.00 $496.00 $392.83 $396.80 $0.00 $529.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100249 EAP CPT® 15820 Blepharoplasty Lower Eyelid BOTH IP/OP "$14,915.00 " "$11,037.10" $0.00 "$12,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,108.29" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$11,970.29" "$12,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100250 EAP CPT® 15822 Blepharoplasty Upper Eyelid BOTH IP/OP "$14,915.00 " "$11,037.10" $0.00 "$12,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,108.29" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$11,970.29" "$12,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100251 EAP CPT® 16000 Init Trmnt Burn 1st Degree BOTH IP/OP "$1,690.00 " "$1,250.60" $0.00 "$1,690.00" $917.67 $917.67 $174.88 $174.88 $175.86 $352.24 $0.00 $0.00 $0.00 $172.08 $352.20 $111.85 $113.00 $113.00 $175.24 "$1,607.00" "$1,272.74" "$1,285.60" $243.48 "$1,690.00" $243.48 $0.00 $47.96 $47.96 $255.83 $166.90 $0.00 $0.00 $0.00 $0.00 36100252 EAP CPT® 16000 Init. Treatment 1st Degree Bur BOTH IP/OP "$1,607.00 " "$1,189.18" $0.00 "$1,607.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 "$1,607.00" "$1,272.74" "$1,285.60" $243.48 $0.00 $243.48 $0.00 $47.96 $47.96 $255.83 $166.90 $0.00 $0.00 $0.00 $0.00 36100253 EAP CPT® 16000 "Inital Treatment, 1% Burn" BOTH IP/OP "$1,690.00 " "$1,250.60" $0.00 "$1,690.00" $917.67 $917.67 $174.88 $174.88 $175.86 $352.24 $0.00 $0.00 $0.00 $172.08 $352.20 $111.85 $113.00 $113.00 $175.24 "$1,607.00" "$1,272.74" "$1,285.60" $243.48 "$1,690.00" $243.48 $0.00 $47.96 $47.96 $255.83 $166.90 $0.00 $0.00 $0.00 $0.00 36100254 EAP CPT® 16020 PART THICK BURN DRESS/DEBRD;SM BOTH IP/OP "$1,690.00 " "$1,250.60" $0.00 "$1,690.00" "$1,690.00" "$1,690.00" $174.88 $174.88 $175.86 $352.24 $0.00 $0.00 $0.00 $172.08 $352.20 $111.85 "$1,690.00" "$1,690.00" $175.24 "$1,607.00" "$1,272.74" "$1,285.60" $243.48 "$1,690.00" $243.48 $54.62 $56.23 $56.23 $255.83 $166.90 $0.00 $0.00 $0.00 $0.00 36100255 EAP CPT® 16025 Part Thick Burn Dress/debrd;md (tbsa 5%-10%) BOTH IP/OP "$3,421.00 " "$2,531.54" $107.09 "$2,836.00" "$2,753.10" "$2,753.10" $174.88 $174.88 $175.86 $713.02 "$1,541.95" "$1,541.95" "$1,601.25" $172.08 $712.94 $111.85 "$2,836.00" "$2,836.00" $175.24 "$2,255.00" "$2,575.58" "$2,601.60" $243.48 "$1,750.00" $243.48 $107.09 $114.64 $114.64 $517.72 $166.90 $0.00 $0.00 $0.00 $0.00 36100256 EAP CPT® 16030 Part Thick Burn Dress/debrd;lg (tbsa >10%) BOTH IP/OP "$4,574.00 " "$3,384.76" $134.39 "$3,478.40" "$2,753.10" "$2,753.10" $336.60 $336.60 $338.49 $953.34 "$1,541.95" "$1,541.95" "$1,601.25" $331.46 $953.22 $215.45 "$2,836.00" "$2,836.00" $320.45 "$2,255.00" "$3,443.62" "$3,478.40" $445.22 "$1,305.00" $445.22 $134.39 $138.43 $138.43 $692.20 $305.19 $0.00 $0.00 $0.00 $0.00 36100257 EAP CPT® 17000 "Dest, Premalignant Lesion 1st" BOTH IP/OP $389.00 $287.86 $48.44 $389.00 $389.00 $389.00 $174.88 $174.88 $175.86 $81.08 $389.00 $389.00 $389.00 $172.08 $81.07 $111.85 $113.00 $113.00 $175.24 $389.00 $308.09 $311.20 $243.48 $389.00 $243.48 $48.44 $55.15 $55.15 $61.93 $166.90 $0.00 $0.00 $0.00 $0.00 36100258 EAP CPT® 17000 "Destruc Lesion Benign, 1st" BOTH IP/OP $389.00 $287.86 $0.00 $389.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.08 $0.00 $0.00 $0.00 $172.08 $81.07 $111.85 $113.00 $113.00 $175.24 $389.00 $308.09 $311.20 $243.48 $0.00 $243.48 $48.44 $55.15 $55.15 $61.93 $166.90 $0.00 $0.00 $0.00 $0.00 36100259 EAP CPT® 17003 "Dest, Premalignant Lesion 2-14" BOTH IP/OP $389.00 $287.86 $0.00 $389.00 $389.00 $389.00 $0.00 $0.00 $0.00 $81.08 $0.00 $0.00 $0.00 $0.00 $81.07 $0.00 $230.09 $230.09 $0.00 $389.00 $308.09 $311.20 $0.00 $389.00 $0.00 $12.73 $2.16 $2.16 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 36100260 EAP CPT® 17004 "Les Dest, Benign Premal > 15" BOTH IP/OP $807.00 $597.18 $0.00 $807.00 $807.00 $807.00 $336.60 $336.60 $338.49 $168.20 $0.00 $0.00 $0.00 $331.46 $168.18 $215.45 $807.00 $807.00 $0.00 $806.00 $638.35 $644.80 $0.00 $807.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100261 EAP CPT® 17004 Lesion Destr Benign >15 BOTH IP/OP $806.00 $596.44 $0.00 $806.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.99 $0.00 $0.00 $0.00 $331.46 $167.97 $215.45 $806.00 $806.00 $0.00 $806.00 $638.35 $644.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100262 EAP CPT® 17110 "Dest Flat Warts Mollu,milla" BOTH IP/OP $365.00 $270.10 $0.00 "$1,750.00" $365.00 $365.00 $174.88 $174.88 $175.86 $76.08 $0.00 $0.00 $0.00 $172.08 $76.07 $111.85 $113.00 $113.00 $175.24 $365.00 $289.08 $292.00 $243.48 "$1,750.00" $243.48 $49.09 $68.84 $68.84 $58.11 $166.90 $0.00 $0.00 $0.00 $0.00 36100263 EAP CPT® 17110 "Dest Flat Warts, Up To 14 Les" BOTH IP/OP $365.00 $270.10 $0.00 $365.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $365.00 $289.08 $292.00 $243.48 $0.00 $243.48 $49.09 $68.84 $68.84 $58.11 $166.90 $0.00 $0.00 $0.00 $0.00 36100264 EAP CPT® 17110 Destr Flat Wart Mollu Milia <1 BOTH IP/OP $365.00 $270.10 $0.00 $365.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $365.00 $289.08 $292.00 $243.48 $0.00 $243.48 $49.09 $68.84 $68.84 $58.11 $166.90 $0.00 $0.00 $0.00 $0.00 36100266 EAP CPT® 17111 "Dest. Flat Warts, >15 Lesions" BOTH IP/OP $807.00 $597.18 $0.00 $807.00 $807.00 $807.00 $174.88 $174.88 $175.86 $0.00 $0.00 $0.00 $0.00 $0.00 $168.18 $0.00 $0.00 $0.00 $175.24 $806.00 $638.35 $644.80 $243.48 $807.00 $243.48 $66.36 $84.34 $84.34 $128.32 $166.90 $0.00 $0.00 $0.00 $0.00 36100268 EAP CPT® 17250 "Cauterization, Medical" BOTH IP/OP $752.00 $556.48 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $752.00 $595.58 $601.60 $243.48 $0.00 $243.48 $37.05 $38.57 $38.57 $119.72 $166.90 $0.00 $0.00 $0.00 $0.00 36100269 EAP CPT® 17250 Chemical Cautery Tissue BOTH IP/OP $753.00 $557.22 $0.00 "$1,305.00" $753.00 $753.00 $174.88 $174.88 $175.86 $156.94 $0.00 $0.00 $0.00 $172.08 $156.93 $111.85 $113.00 $113.00 $175.24 $752.00 $595.58 $601.60 $243.48 "$1,305.00" $243.48 $37.05 $38.57 $38.57 $119.72 $166.90 $0.00 $0.00 $0.00 $0.00 36100270 EAP CPT® 36569 Mid Line Insertion BOTH IP/OP "$6,447.00 " "$4,770.78" $98.45 "$4,343.20" "$2,321.55" "$2,321.55" "$1,369.42" "$1,369.42" "$1,377.13" "$1,343.72" "$1,257.08" "$1,257.08" "$1,305.43" "$1,347.67" "$1,343.55" $875.99 "$1,871.00" "$1,871.00" "$1,635.92" "$2,255.00" "$4,299.77" "$4,343.20" "$2,272.90" "$4,190.55" "$2,272.90" $346.84 $98.45 $98.45 $864.30 "$1,558.02" $0.00 $0.00 $0.00 $0.00 36100272 EAP CPT® 17260 Lesion Dstr Malig Trnk Arm <.5 BOTH IP/OP $670.00 $495.80 $0.00 $670.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $670.00 $530.64 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100273 EAP CPT® 17261 Les Dstr Malig Trnk Arm 0.6-1. BOTH IP/OP $753.00 $557.22 $0.00 $753.00 $753.00 $753.00 $174.88 $174.88 $175.86 $156.94 $0.00 $0.00 $0.00 $172.08 $156.93 $111.85 $113.00 $113.00 $175.24 $752.00 $595.58 $601.60 $243.48 $753.00 $243.48 $94.09 $89.76 $89.76 $119.72 $166.90 $0.00 $0.00 $0.00 $0.00 36100274 EAP CPT® 17262 Les Dstr Malig Trnk Arm 1.1-2. BOTH IP/OP $753.00 $557.22 $0.00 $753.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.93 $0.00 $0.00 $0.00 $0.00 $752.00 $595.58 $601.60 $0.00 $753.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100275 EAP CPT® 17263 Les Dstr Malig Trnk Arm 2.1-3. BOTH IP/OP $646.00 $478.04 $0.00 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.63 $0.00 $0.00 $0.00 $0.00 $645.00 $510.84 $516.00 $0.00 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100276 EAP CPT® 17264 Les Dstr Malig Trnk Arm 3.1-4. BOTH IP/OP $645.00 $477.30 $0.00 $645.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.42 $0.00 $0.00 $0.00 $0.00 $645.00 $510.84 $516.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100277 EAP CPT® 17266 Les Dstr Malig Trnk Arm >4.0 BOTH IP/OP "$1,428.00 " "$1,056.72" $0.00 "$1,428.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.60 $0.00 $0.00 $0.00 $0.00 "$1,428.00" "$1,130.98" "$1,142.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100278 EAP CPT® 17271 Les Dstr Malig Sclp Nck 0.6-1. BOTH IP/OP $946.00 $700.04 $0.00 $946.00 $946.00 $946.00 $174.88 $174.88 $175.86 $197.17 $0.00 $0.00 $0.00 $172.08 $197.15 $111.85 $113.00 $113.00 $175.24 $945.00 $748.44 $756.00 $243.48 $946.00 $243.48 $115.27 $108.87 $108.87 $150.44 $166.90 $0.00 $0.00 $0.00 $0.00 36100279 EAP CPT® 17272 Les Dstr Malig Sclp Nck 1.1-2. BOTH IP/OP $646.00 $478.04 $0.00 $646.00 $646.00 $646.00 $174.88 $174.88 $175.86 $134.64 $0.00 $0.00 $0.00 $172.08 $134.63 $111.85 $113.00 $113.00 $175.24 $645.00 $510.84 $516.00 $243.48 $646.00 $243.48 $136.47 $126.90 $126.90 $102.68 $166.90 $0.00 $0.00 $0.00 $0.00 36100280 EAP CPT® 17273 Les Dstr Malig Sclp Nck 2.1-3. BOTH IP/OP $974.00 $720.76 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $974.00 $771.41 $779.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100281 EAP CPT® 17274 Les Dstr Malig Sclp Nck 3.1-4. BOTH IP/OP "$1,430.00 " "$1,058.20" $0.00 "$1,430.00" "$1,430.00" "$1,430.00" $336.60 $336.60 $338.49 $298.05 $0.00 $0.00 $0.00 $331.46 $298.01 $215.45 "$1,430.00" "$1,430.00" $320.45 "$1,428.00" "$1,130.98" "$1,142.40" $445.22 "$1,430.00" $445.22 $192.94 $175.94 $175.94 $227.34 $305.19 $0.00 $0.00 $0.00 $0.00 36100282 EAP CPT® 17280 Lesion Dstr Malig Face Ear <.5 BOTH IP/OP $646.00 $478.04 $0.00 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.63 $0.00 $0.00 $0.00 $0.00 $645.00 $510.84 $516.00 $0.00 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100283 EAP CPT® 17281 Les Dstr Malig Face Ear 0.6-1. BOTH IP/OP "$1,726.00 " "$1,277.24" $0.00 "$1,726.00" "$1,726.00" "$1,726.00" $336.60 $336.60 $338.49 $359.74 $0.00 $0.00 $0.00 $331.46 $359.70 $215.45 $113.00 $113.00 $0.00 "$1,724.00" "$1,365.41" "$1,379.20" $0.00 "$1,726.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100284 EAP CPT® 17282 Les Dstr Malig Face Ear 1.1-2. BOTH IP/OP $974.00 $720.76 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $974.00 $771.41 $779.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100285 EAP CPT® 19000 "Punc Asp Cyst, Breast" BOTH IP/OP "$1,141.00 " $844.34 $0.00 "$1,141.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.80 "$1,141.00" $903.67 $912.80 $850.02 $0.00 $850.02 $59.58 $45.43 $45.43 $181.65 $582.67 $0.00 $0.00 $0.00 $0.00 36100288 EAP CPT® 19000 Puncture Aspiration Of Breast BOTH IP/OP "$1,141.00 " $844.34 $0.00 "$1,141.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.80 "$1,141.00" $903.67 $912.80 $850.02 $0.00 $850.02 $59.58 $45.43 $45.43 $181.65 $582.67 $0.00 $0.00 $0.00 $0.00 36100289 EAP CPT® 19001 Each Additiona Cyst-breast BOTH IP/OP $921.00 $681.54 $0.00 "$1,141.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.94 $0.00 $0.00 $0.00 $0.00 "$1,141.00" $903.67 $912.80 $0.00 $909.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100297 EAP CPT® 19000 Punc Aspiration Cyst Of Breast BOTH IP/OP "$1,141.00 " $844.34 $0.00 "$1,141.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.80 "$1,141.00" $903.67 $912.80 $850.02 $0.00 $850.02 $59.58 $45.43 $45.43 $181.65 $582.67 $0.00 $0.00 $0.00 $0.00 36100298 EAP CPT® 19000 PUNCT ASPIR CYST BREAST BIC BOTH IP/OP "$1,130.00 " $836.20 $45.43 "$1,141.00" "$1,130.00" "$1,130.00" $606.01 $606.01 $609.42 $235.52 "$1,130.00" "$1,130.00" "$1,130.00" $596.11 $235.49 $387.47 "$1,130.00" "$1,130.00" $611.80 "$1,141.00" $903.67 $912.80 $850.02 "$1,130.00" $850.02 $59.58 $45.43 $45.43 $181.65 $582.67 $0.00 $0.00 $0.00 $0.00 36100299 EAP CPT® 54065 Destruction Penis Lesion(s) BOTH IP/OP "$7,192.00 " "$5,322.08" $0.00 "$5,812.00" "$2,321.55" "$2,321.55" "$1,667.97" "$1,667.97" "$1,677.37" $0.00 "$1,257.08" "$1,257.08" "$1,305.43" $0.00 "$1,498.81" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,753.88" "$5,812.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100300 EAP CPT® 19001 Punc Aspir Ea Add'l Cyst Breas BOTH IP/OP $921.00 $681.54 $0.00 "$1,141.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.94 $0.00 $0.00 $0.00 $0.00 "$1,141.00" $903.67 $912.80 $0.00 $909.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100301 EAP CPT® 19001 PUNCT ASPIR EA ADDT CYST BIC BOTH IP/OP "$1,130.00 " $836.20 $0.00 "$1,141.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.49 $0.00 $0.00 $0.00 $0.00 "$1,141.00" $903.67 $912.80 $0.00 $909.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100303 EAP CPT® 19020 Incision Of Breast Lesion Rt BOTH IP/OP "$7,031.00 " "$5,202.94" $0.00 "$5,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,465.44" $0.00 $0.00 $0.00 "$1,348.50" "$1,465.26" $876.52 "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$5,624.78" "$5,681.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100304 EAP CPT® 19030 GALACTOGRAM INJECTION BIC BOTH IP/OP $764.00 $565.36 $0.00 $946.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.22 $0.00 $0.00 $0.00 $0.00 $946.00 $749.23 $756.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100306 EAP CPT® 19100 Breast Bx Needle W/0 Imaging BOTH IP/OP "$1,927.00 " "$1,425.98" $0.00 "$1,946.00" "$1,927.00" "$1,927.00" "$1,370.21" "$1,370.21" "$1,377.93" $401.63 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $401.59 $876.52 "$1,871.00" "$1,871.00" $0.00 "$1,946.00" "$1,541.23" "$1,556.80" $0.00 "$1,927.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100307 EAP CPT® 19100 "Breast Bx, Needle" BOTH IP/OP "$1,571.00 " "$1,162.54" $0.00 "$1,946.00" "$1,571.00" "$1,571.00" "$1,370.21" "$1,370.21" "$1,377.93" $327.44 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $327.40 $876.52 "$1,571.00" "$1,571.00" $0.00 "$1,946.00" "$1,541.23" "$1,556.80" $0.00 "$1,927.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100318 EAP CPT® 19296 Place Po Breast Cath For Rad BOTH IP/OP "$17,549.00 " "$12,986.26" $0.00 "$17,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,657.21" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$17,214.91" "$17,388.80" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100319 EAP CPT® 19297 Br Cath For Rad Concur W/pt Ma BOTH IP/OP "$17,549.00 " "$12,986.26" $0.00 "$17,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,657.21" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$17,214.91" "$17,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100320 EAP CPT® 19357 Breast Reconst Tiss Expander BOTH IP/OP "$11,975.00 " "$8,861.50" $0.00 "$11,825.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,495.59" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$11,707.34" "$11,825.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100321 EAP CPT® 19499 Duct Lav Aspiration BOTH IP/OP "$6,124.00 " "$4,531.76" $0.00 "$4,899.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,276.24" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,850.21" "$4,899.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100322 EAP CPT® 20103 "Explore Wound, Extremity" BOTH IP/OP "$3,502.00 " "$2,591.48" $0.00 "$2,801.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.80 "$2,255.00" "$2,773.58" "$2,801.60" $850.02 $0.00 $850.02 $323.52 $360.85 $360.85 $557.52 $582.67 $0.00 $0.00 $0.00 $0.00 36100323 EAP CPT® 20206 BX MUSCLE NEEDLE PERCUT BCT BOTH IP/OP "$1,504.00 " "$1,112.96" $60.21 "$1,504.00" "$1,504.00" "$1,504.00" "$1,370.21" "$1,370.21" "$1,377.93" $313.47 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $313.43 $876.52 "$1,504.00" "$1,504.00" "$1,376.63" "$1,500.00" "$1,188.00" "$1,200.00" "$1,500.00" "$1,504.00" "$1,500.00" $104.27 $60.21 $60.21 $238.80 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100324 EAP CPT® 20206 Bx Muscle Needle Us BOTH IP/OP "$1,500.00 " "$1,110.00" $60.21 "$1,504.00" "$1,500.00" "$1,500.00" "$1,370.21" "$1,370.21" "$1,377.93" $312.64 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $312.60 $876.52 "$1,500.00" "$1,500.00" "$1,376.63" "$1,500.00" "$1,188.00" "$1,200.00" "$1,500.00" "$1,504.00" "$1,500.00" $104.27 $60.21 $60.21 $238.80 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100325 EAP CPT® 20220 Biopsy Bone Trcar/needl Sprfcl BOTH IP/OP "$2,013.00 " "$1,489.62" $0.00 "$2,013.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.00" "$1,594.30" "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100326 EAP CPT® 20220 BX BONE TROCAR/NDLE SUPF BCT BOTH IP/OP "$2,018.00 " "$1,493.32" $0.00 "$2,150.00" "$2,018.00" "$2,018.00" "$1,370.21" "$1,370.21" "$1,377.93" $420.60 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $420.55 $876.52 "$1,871.00" "$1,871.00" $0.00 "$2,013.00" "$1,594.30" "$1,610.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100327 EAP CPT® 20225 Biopsy Bone Trocar/needle Deep BOTH IP/OP "$3,050.00 " "$2,257.00" $0.00 "$2,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,376.63" "$2,327.00" "$2,415.60" "$2,440.00" "$1,912.65" $0.00 "$1,912.65" $126.60 $137.03 $137.03 $485.56 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100328 EAP CPT® 20225 BX BONE TROCAR/NDLE DEEP BCT BOTH IP/OP "$3,057.00 " "$2,262.18" $126.60 "$2,836.00" "$2,753.10" "$2,753.10" "$1,370.21" "$1,370.21" "$1,377.93" $637.16 "$1,541.95" "$1,541.95" "$1,601.25" "$1,348.50" $637.08 $876.52 "$2,836.00" "$2,836.00" "$1,376.63" "$2,327.00" "$2,415.60" "$2,440.00" "$1,912.65" "$2,500.00" "$1,912.65" $126.60 $137.03 $137.03 $485.56 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100329 EAP CPT® 20501 Inject Sinus Tract Diagnostic BOTH IP/OP "$1,226.00 " $907.24 $0.00 "$1,238.00" "$1,226.00" "$1,226.00" $0.00 $0.00 $0.00 $255.53 $0.00 $0.00 $0.00 $0.00 $255.50 $0.00 $725.18 $725.18 $0.00 "$1,238.00" $980.50 $990.40 $0.00 "$1,068.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100330 EAP CPT® 20520 Remove Foreign Body (simple) BOTH IP/OP "$1,594.00 " "$1,179.56" $0.00 "$1,594.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $332.19 $0.00 $0.00 $0.00 $0.00 "$1,550.00" "$1,227.60" "$1,240.00" $0.00 "$1,594.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100331 EAP CPT® 20525 Remove Foreign Body (compl.) BOTH IP/OP "$2,653.00 " "$1,963.22" $0.00 "$2,741.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.89 $0.00 $0.00 $0.00 $0.00 "$2,741.00" "$2,170.87" "$2,192.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100332 EAP CPT® 20526 Carpal Tunnel Injection BOTH IP/OP $903.00 $668.22 $0.00 $904.00 $903.00 $903.00 $254.43 $254.43 $255.86 $188.21 $0.00 $0.00 $0.00 $250.31 $188.19 $162.70 $903.00 $903.00 $262.54 $904.00 $715.97 $723.20 $364.76 $903.00 $364.76 $141.48 $59.49 $59.49 $143.92 $250.04 $0.00 $0.00 $0.00 $0.00 36100333 EAP CPT® 20550 Inject Tendon Sheath Ligament BOTH IP/OP $719.00 $532.06 $40.75 $720.00 $719.00 $719.00 $254.43 $254.43 $255.86 $149.86 $719.00 $719.00 $719.00 $250.31 $149.84 $162.70 $719.00 $719.00 $262.54 $720.00 $570.24 $576.00 $364.76 $719.00 $364.76 $70.34 $40.75 $40.75 $114.62 $250.04 $0.00 $0.00 $0.00 $0.00 36100336 EAP CPT® 20551 Inj Tendon Origin/insertion BOTH IP/OP $903.00 $668.22 $0.00 $904.00 $903.00 $903.00 $254.43 $254.43 $255.86 $188.21 $0.00 $0.00 $0.00 $250.31 $188.19 $162.70 $903.00 $903.00 $262.54 $904.00 $715.97 $723.20 $364.76 $903.00 $364.76 $66.56 $41.47 $41.47 $143.92 $250.04 $0.00 $0.00 $0.00 $0.00 36100337 EAP CPT® 20552 Inject Trigger Point 1-2 Musc BOTH IP/OP $640.00 $473.60 $0.00 "$1,750.00" $640.00 $640.00 $254.43 $254.43 $255.86 $133.39 $0.00 $0.00 $0.00 $250.31 $133.38 $162.70 $640.00 $640.00 $262.54 $641.00 $507.67 $512.80 $364.76 "$1,750.00" $364.76 $66.56 $40.02 $40.02 $102.05 $250.04 $0.00 $0.00 $0.00 $0.00 36100338 EAP CPT® 20553 Trigger Point Injections: Three Or More Muscles BOTH IP/OP $903.00 $668.22 $0.00 "$1,750.00" $903.00 $903.00 $254.43 $254.43 $255.86 $188.21 $0.00 $0.00 $0.00 $250.31 $188.19 $162.70 $903.00 $903.00 $262.54 $904.00 $715.97 $723.20 $364.76 "$1,750.00" $364.76 $66.56 $45.07 $45.07 $143.92 $250.04 $0.00 $0.00 $0.00 $0.00 36100339 EAP CPT® 20600 Drain/inject-finger/toe Wo Us Guidance BOTH IP/OP $935.00 $691.90 $37.50 $936.00 $935.00 $935.00 $254.43 $254.43 $255.86 $194.88 $935.00 $935.00 $935.00 $250.31 $194.85 $162.70 $935.00 $935.00 $262.54 $936.00 $741.31 $748.80 $364.76 $935.00 $364.76 $54.79 $37.50 $37.50 $149.01 $250.04 $0.00 $0.00 $0.00 $0.00 36100340 EAP CPT® 50561 Kindey Endoscopy & Treatment BOTH IP/OP "$6,215.00 " "$4,599.10" $0.00 "$4,972.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,295.21" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,922.28" "$4,972.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100345 EAP CPT® 20605 Drain/inject-wrist Elbow Ankle Wo Us Guidance BOTH IP/OP $935.00 $691.90 $0.00 "$1,288.00" $935.00 $935.00 $254.43 $254.43 $255.86 $194.88 $0.00 $0.00 $0.00 $250.31 $194.85 $162.70 $935.00 $935.00 $262.54 $936.00 $741.31 $748.80 $364.76 "$1,288.00" $364.76 $60.50 $38.94 $38.94 $149.01 $250.04 $0.00 $0.00 $0.00 $0.00 36100348 EAP CPT® 20610 Drain/inject-shoulder Hip Knee Wo Us Guidance BOTH IP/OP "$2,198.00 " "$1,626.52" $47.59 "$2,200.00" "$2,198.00" "$2,198.00" $254.43 $254.43 $255.86 $458.12 "$1,257.08" "$1,257.08" "$1,305.43" $250.31 $458.06 $162.70 "$1,871.00" "$1,871.00" $262.54 "$2,200.00" "$1,742.40" "$1,760.00" $364.76 "$1,750.00" $364.76 $70.76 $47.59 $47.59 $350.24 $250.04 $0.00 $0.00 $0.00 $0.00 36100349 EAP CPT® 41009 Drainage Of Mouth Lesion BOTH IP/OP "$6,979.00 " "$5,164.46" $0.00 "$6,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,454.42" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,490.44" "$6,556.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100354 EAP CPT® 20612 "Aspiration/inj.,gangion Cyst" BOTH IP/OP "$1,050.00 " $777.00 $0.00 "$1,051.00" "$1,050.00" "$1,050.00" $254.43 $254.43 $255.86 $0.00 $0.00 $0.00 $0.00 $250.31 $218.82 $162.70 "$1,050.00" "$1,050.00" $262.54 "$1,051.00" $832.39 $840.80 $364.76 "$1,050.00" $364.76 $54.88 $42.90 $42.90 $167.32 $250.04 $0.00 $0.00 $0.00 $0.00 36100355 EAP CPT® 20670 Arch Bar Removal BOTH IP/OP "$6,755.00 " "$4,998.70" $0.00 "$5,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,498.16" $0.00 $0.00 $0.00 "$1,348.50" "$1,497.98" $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$5,349.96" "$5,404.00" "$1,912.65" $0.00 "$1,912.65" $166.32 $150.66 $150.66 "$1,075.40" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100356 EAP CPT® 20670 Removal Implant; Superficial BOTH IP/OP "$7,188.00 " "$5,319.12" $150.66 "$5,404.00" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" "$1,498.16" "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" "$1,497.98" $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$5,349.96" "$5,404.00" "$1,912.65" "$2,500.00" "$1,912.65" $166.32 $150.66 $150.66 "$1,075.40" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100357 EAP CPT® 21025 "Sequestrectomy, Mandible" BOTH IP/OP "$12,260.00 " "$9,072.40" $0.00 "$9,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,554.98" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$9,709.92" "$9,808.00" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100358 EAP CPT® 21026 "Sequestrectomy, Maxilla" BOTH IP/OP "$8,448.00 " "$6,251.52" $0.00 "$6,758.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,760.56" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,690.82" "$6,758.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100359 EAP CPT® 21031 Excision Of Torus Mandibularis BOTH IP/OP "$3,080.00 " "$2,279.20" $0.00 "$3,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $641.87 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,439.36" "$2,464.00" $0.00 "$3,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100360 EAP CPT® 21032 Excision Of Maxillary Torus BOTH IP/OP "$4,910.00 " "$3,633.40" $0.00 "$4,877.00" "$2,321.55" "$2,321.55" "$2,664.14" "$2,664.14" "$2,679.15" "$1,023.37" $0.00 $0.00 $0.00 "$2,622.61" "$1,023.24" "$1,704.70" "$4,877.00" "$4,877.00" $0.00 "$2,327.00" "$3,888.72" "$3,928.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100361 EAP CPT® 21208 "Osteoplasty, Facial Bones" BOTH IP/OP "$7,747.00 " "$5,732.78" $0.00 "$6,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.47" $0.00 $0.00 $0.00 $0.00 "$4,975.00" "$6,135.62" "$6,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100362 EAP CPT® 21320 Closed Nasal Bone W/stabiliza BOTH IP/OP "$4,482.00 " "$3,316.68" $0.00 "$3,585.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $934.05 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,549.74" "$3,585.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100364 EAP CPT® 21440 Reduce Alveolar Ridge Fracture BOTH IP/OP "$2,518.00 " "$1,863.32" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $524.75 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,014.06" "$2,034.40" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100365 EAP CPT® 21453 Reduce Mandibular Interdental BOTH IP/OP "$7,522.00 " "$5,566.28" $0.00 "$7,020.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,567.58" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$6,950.59" "$7,020.80" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100366 EAP CPT® 21480 "Reduce Tmj Disloca, Ix Or Sub" BOTH IP/OP $257.00 $190.18 $0.00 $257.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.56 $0.00 $0.00 $0.00 $0.00 $257.00 $203.54 $205.60 $0.00 $257.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100368 EAP CPT® 21550 Biopsy Neck BOTH IP/OP "$4,410.00 " "$3,263.40" $0.00 "$3,519.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $919.04 $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$3,484.01" "$3,519.20" "$1,912.65" "$2,500.00" "$1,912.65" $132.10 $161.13 $161.13 $700.32 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100369 EAP CPT® 21550 "Biopsy, Neck/thorax" BOTH IP/OP "$4,399.00 " "$3,255.26" $0.00 "$3,519.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $916.75 $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$3,484.01" "$3,519.20" "$1,912.65" $0.00 "$1,912.65" $132.10 $161.13 $161.13 $700.32 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100376 EAP CPT® 23350 Injection Shoulder Arthrograph BOTH IP/OP "$1,471.00 " "$1,088.54" $0.00 "$1,486.00" "$1,471.00" "$1,471.00" $0.00 $0.00 $0.00 $306.59 $0.00 $0.00 $0.00 $0.00 $306.56 $0.00 $870.10 $870.10 $0.00 "$1,486.00" "$1,176.91" "$1,188.80" $0.00 $952.00 $0.00 $202.19 $53.01 $53.01 $236.57 $0.00 $0.00 $0.00 $0.00 $0.00 36100379 EAP CPT® 24220 Injection Elbow Arthrography BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$2,200.00" "$1,742.40" "$1,760.00" $0.00 "$1,049.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100380 EAP CPT® 25246 Injection Wrist Arthrography BOTH IP/OP "$1,633.00 " "$1,208.42" $0.00 "$1,487.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.32 $0.00 $0.00 $0.00 $0.00 "$1,487.00" "$1,177.70" "$1,189.60" $0.00 "$1,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100382 EAP CPT® 26010 "I&d Finger Abscess, Simple" BOTH IP/OP "$1,407.00 " "$1,041.18" $0.00 "$1,407.00" $0.00 $0.00 $0.00 $0.00 $0.00 $293.25 $0.00 $0.00 $0.00 $172.08 $293.22 $111.85 $113.00 $113.00 $0.00 "$1,407.00" "$1,114.34" "$1,125.60" $0.00 "$1,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100383 EAP CPT® 26011 Abscess Finger Complicated BOTH IP/OP "$4,878.00 " "$3,609.72" $0.00 "$3,901.60" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" "$1,016.70" "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" "$1,016.58" $876.52 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,862.58" "$3,901.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100384 EAP CPT® 26035 "Decompression Fingers, Hand" BOTH IP/OP "$3,306.00 " "$2,446.44" $0.00 "$2,809.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.97 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,781.50" "$2,809.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100386 EAP CPT® 27093 Injection Hip Arthro W/o Anes BOTH IP/OP "$1,657.00 " "$1,226.18" $0.00 "$1,674.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.32 $0.00 $0.00 $0.00 $0.00 "$1,674.00" "$1,325.81" "$1,339.20" $0.00 "$1,140.00" $0.00 $243.74 $72.12 $72.12 $266.50 $0.00 $0.00 $0.00 $0.00 $0.00 36100388 EAP CPT® 27095 Injection Hip Arthro W Anes BOTH IP/OP "$2,101.00 " "$1,554.74" $0.00 "$2,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $437.85 $0.00 $0.00 $0.00 $0.00 "$2,101.00" "$1,663.99" "$1,680.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100389 EAP CPT® 27096 Sacroiliac Jt Inj With Arthrography BOTH IP/OP "$2,110.00 " "$1,561.40" $0.00 "$2,131.00" "$2,110.00" "$2,110.00" $618.38 $618.38 $621.87 $439.78 $0.00 $0.00 $0.00 $608.20 $439.72 $395.33 $113.00 $113.00 $0.00 "$2,131.00" "$1,687.75" "$1,704.80" $86.18 "$2,110.00" $86.18 $398.44 $86.18 $86.18 $339.26 $0.00 $0.00 $0.00 $0.00 $0.00 36100391 EAP CPT® 27630 "Excision, Les Ankle/lower Leg" BOTH IP/OP "$7,251.00 " "$5,365.74" $0.00 "$5,800.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,511.11" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$5,742.79" "$5,800.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100392 EAP CPT® 27648 Injection Ankle Arthrography BOTH IP/OP "$1,873.00 " "$1,386.02" $0.00 "$1,892.00" "$1,873.00" "$1,873.00" $0.00 $0.00 $0.00 $390.38 $0.00 $0.00 $0.00 $0.00 $390.33 $0.00 "$1,107.88" "$1,107.88" $0.00 "$1,892.00" "$1,498.46" "$1,513.60" $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100393 EAP CPT® 28080 "Excision,les. Interdigital Leg" BOTH IP/OP "$4,873.00 " "$3,606.02" $0.00 "$4,127.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,015.53" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,085.93" "$4,127.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100394 EAP CPT® 28090 "Excision, Cyst Foot" BOTH IP/OP "$4,873.00 " "$3,606.02" $0.00 "$4,127.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,015.53" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,085.93" "$4,127.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100395 EAP CPT® 28092 "Excision, Lesion, Toe(s) Each" BOTH IP/OP "$4,873.00 " "$3,606.02" $0.00 "$4,127.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,015.53" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,085.93" "$4,127.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100396 EAP CPT® 28190 "Removal Fb, Foot Sc" BOTH IP/OP "$1,304.00 " $964.96 $0.00 "$1,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.80 "$1,304.00" "$1,032.77" "$1,043.20" $850.02 $0.00 $850.02 $173.39 $138.80 $138.80 $207.60 $582.67 $0.00 $0.00 $0.00 $0.00 36100397 EAP CPT® 28192 "Removal Fb, Foot Deep" BOTH IP/OP "$5,468.00 " "$4,046.32" $0.00 "$4,374.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,139.53" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,330.66" "$4,374.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100398 EAP CPT® 28193 "Removal Fb, Foot, Complicated" BOTH IP/OP "$5,468.00 " "$4,046.32" $0.00 "$4,374.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,139.53" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$4,330.66" "$4,374.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100399 EAP CPT® 29130 "Splinting, Finger" BOTH IP/OP $859.00 $635.66 $0.00 $859.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $859.00 $680.33 $687.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100402 EAP CPT® 29260 "Splint Application, Wrist" BOTH IP/OP "$1,018.00 " $753.32 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.53 "$1,018.00" $806.26 $814.40 $46.58 $0.00 $46.58 $44.15 $20.20 $20.20 $162.07 $31.93 $0.00 $0.00 $0.00 $0.00 36100403 EAP CPT® 29515 Splint Application Ankle BOTH IP/OP $888.00 $657.12 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.13 $888.00 $703.30 $710.40 $186.36 $0.00 $186.36 $80.51 $51.19 $51.19 $141.37 $127.75 $0.00 $0.00 $0.00 $0.00 36100404 EAP CPT® 29515 "Splint Application, Ankle" BOTH IP/OP $794.00 $587.56 $0.00 $943.00 $431.14 $431.14 $137.58 $137.58 $138.36 $165.49 $0.00 $0.00 $0.00 $135.31 $165.47 $87.95 $113.00 $113.00 $134.13 $888.00 $703.30 $710.40 $186.36 $943.00 $186.36 $80.51 $51.19 $51.19 $141.37 $127.75 $0.00 $0.00 $0.00 $0.00 36100405 EAP CPT® 29530 "Wrapping, Knee" BOTH IP/OP $681.00 $503.94 $0.00 $762.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $762.00 $603.50 $609.60 $0.00 $341.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100406 EAP CPT® 29540 Strapping Of Ankle And/or Ft BOTH IP/OP $345.00 $255.30 $0.00 $345.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.00 $273.24 $276.00 $0.00 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100407 EAP CPT® 29540 "Wrapping, Ankle" BOTH IP/OP $366.00 $270.84 $0.00 $345.00 $198.74 $198.74 $137.58 $137.58 $138.36 $76.28 $0.00 $0.00 $0.00 $135.31 $76.27 $87.95 $113.00 $113.00 $0.00 $345.00 $273.24 $276.00 $0.00 $237.90 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100408 EAP CPT® 29550 "Splinting, Toes" BOTH IP/OP $751.00 $555.74 $0.00 $707.00 $407.79 $407.79 $54.21 $54.21 $54.51 $156.53 $0.00 $0.00 $0.00 $53.35 $156.51 $34.67 $113.00 $113.00 $0.00 $707.00 $559.94 $565.60 $0.00 $281.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100409 EAP CPT® 29580 Unna Boot BOTH IP/OP $828.00 $612.72 $0.00 $780.00 $449.60 $449.60 $137.58 $137.58 $138.36 $172.58 $0.00 $0.00 $0.00 $135.31 $172.56 $87.95 $113.00 $113.00 $134.13 $780.00 $617.76 $624.00 $186.36 $538.20 $186.36 $54.52 $28.49 $28.49 $124.18 $127.75 $0.00 $0.00 $0.00 $0.00 36100411 EAP CPT® 30100 "Biopsy, Intranasal" BOTH IP/OP "$1,837.00 " "$1,359.38" $0.00 "$1,837.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.83 $0.00 $0.00 $0.00 "$1,353.31" "$1,833.00" "$1,451.74" "$1,466.40" "$1,833.00" "$1,837.00" "$1,833.00" $68.81 $68.85 $68.85 $291.81 "$1,288.86" $0.00 $0.00 $0.00 $0.00 36100412 EAP CPT® 30300 Remove Fb Intranasal BOTH IP/OP $272.00 $201.28 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.68 $0.00 $0.00 $0.00 $0.00 $272.00 $215.42 $217.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100414 EAP CPT® 30901 Control Nasal Hemorr Ant Simpl BOTH IP/OP $348.00 $257.52 $0.00 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.00 $275.62 $278.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100416 EAP CPT® 30903 Control Nasal Hemorr Ant Compl BOTH IP/OP $358.00 $264.92 $0.00 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.00 $283.54 $286.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100418 EAP CPT® 30905 Control Nasal Hemorr Post Init BOTH IP/OP $518.00 $383.32 $0.00 $518.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.95 $0.00 $0.00 $0.00 $0.00 $518.00 $410.26 $414.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100420 EAP CPT® 31000 Maxillary Sinus Irrigation BOTH IP/OP $605.00 $447.70 $0.00 $605.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.08 $0.00 $0.00 $0.00 $0.00 $605.00 $479.16 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100422 EAP CPT® 31231 Nasal Endoscopy Dx Uni/bilat BOTH IP/OP $887.00 $656.38 $65.62 $887.00 $887.00 $887.00 $160.31 $160.31 $161.21 $184.87 $887.00 $887.00 $887.00 $157.55 $184.85 $102.41 $113.00 $113.00 $157.01 $822.00 $651.02 $657.60 $218.14 $887.00 $218.14 $98.38 $65.62 $65.62 $130.86 $149.53 $0.00 $0.00 $0.00 $0.00 36100423 EAP CPT® 31500 Endotracheal Intubation BOTH IP/OP "$2,893.00 " "$2,140.82" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,147.18" "$2,147.18" "$2,229.92" $0.00 $602.90 $0.00 $0.00 $0.00 $204.24 "$2,255.00" "$2,103.55" "$2,124.80" $283.76 "$1,750.00" $283.76 $0.00 $149.30 $149.30 $422.84 $194.51 $0.00 $0.00 $0.00 $0.00 36100428 EAP CPT® 31502 Et/trach Change BOTH IP/OP "$1,571.00 " "$1,162.54" $36.42 "$1,571.00" "$1,571.00" "$1,571.00" $206.03 $206.03 $207.19 $327.44 "$1,166.00" "$1,166.00" "$1,210.93" $202.80 $327.40 $131.82 "$1,571.00" "$1,571.00" $204.24 "$1,442.00" "$1,142.06" "$1,153.60" $283.76 "$1,571.00" $283.76 $63.79 $36.42 $36.42 $229.57 $194.51 $0.00 $0.00 $0.00 $0.00 36100429 EAP CPT® 31502 Trach Set Change BOTH IP/OP "$1,379.00 " "$1,020.46" $0.00 "$1,571.00" "$1,379.00" "$1,379.00" $206.03 $206.03 $207.19 $287.42 $0.00 $0.00 $0.00 $202.80 $287.38 $131.82 "$1,379.00" "$1,379.00" $204.24 "$1,442.00" "$1,142.06" "$1,153.60" $283.76 "$1,571.00" $283.76 $63.79 $36.42 $36.42 $229.57 $194.51 $0.00 $0.00 $0.00 $0.00 36100430 EAP CPT® 31502 Tracheotomy Tube Change BOTH IP/OP "$1,442.00 " "$1,067.08" $0.00 "$1,442.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.24 "$1,442.00" "$1,142.06" "$1,153.60" $283.76 $0.00 $283.76 $63.79 $36.42 $36.42 $229.57 $194.51 $0.00 $0.00 $0.00 $0.00 36100432 EAP CPT® 31505 "Laryngoscopy, Indirect, Dx" BOTH IP/OP $372.00 $275.28 $0.00 $648.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.21 $0.00 $0.00 $0.00 $0.00 $648.00 $513.22 $518.40 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100434 EAP CPT® 31510 "Laryngoscopy, Indir, W Bx" BOTH IP/OP "$4,546.00 " "$3,364.04" $0.00 "$3,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $947.39 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,765.96" "$3,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100435 EAP CPT® 31528 Laryngoscopy And Dilation BOTH IP/OP "$9,657.00 " "$7,146.18" $0.00 "$8,080.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,012.52" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,999.99" "$8,080.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100437 EAP CPT® 31575 "Laryngoscopy, Fiberoptic, Dx" BOTH IP/OP $745.00 $551.30 $0.00 "$1,750.00" $745.00 $745.00 $160.31 $160.31 $161.21 $155.28 $0.00 $0.00 $0.00 $157.55 $155.26 $102.41 $113.00 $113.00 $157.01 $684.00 $541.73 $547.20 $218.14 "$1,750.00" $218.14 $103.39 $68.49 $68.49 $108.89 $149.53 $0.00 $0.00 $0.00 $0.00 36100438 EAP CPT® 31605 Tracheostomy-crico BOTH IP/OP "$1,598.00 " "$1,182.52" $0.00 "$1,598.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.02 $0.00 $0.00 $0.00 $0.00 "$1,598.00" "$1,265.62" "$1,278.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100442 EAP CPT® 31612 Trach Punc Percut Aspir BOTH IP/OP "$10,209.00 " "$7,554.66" $0.00 "$7,991.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,127.56" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,911.29" "$7,991.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100444 EAP CPT® 31615 Tracheobronchoscopy BOTH IP/OP "$3,046.00 " "$2,254.04" $0.00 "$2,384.00" $0.00 $0.00 $0.00 $0.00 $0.00 $634.86 $0.00 $0.00 $0.00 $433.55 $634.79 $281.81 "$1,871.00" "$1,871.00" $443.02 "$2,255.00" "$2,360.16" "$2,384.00" $615.51 "$1,718.00" $615.51 $0.00 $118.25 $118.25 $474.42 $421.92 $0.00 $0.00 $0.00 $0.00 36100446 EAP CPT® 31622 Bronchoscopy W Or W/o Washing BOTH IP/OP "$4,212.00 " "$3,116.88" $0.00 "$2,996.80" "$2,753.10" "$2,753.10" "$1,456.99" "$1,456.99" "$1,465.20" $877.89 "$1,257.08" "$1,257.08" "$1,305.43" "$1,434.17" $877.78 $932.21 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$2,966.83" "$2,996.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100448 EAP CPT® 31623 Bronchoscopy W/brushing BOTH IP/OP "$3,942.00 " "$2,917.08" $137.76 "$2,836.00" "$2,753.10" "$2,753.10" "$1,456.99" "$1,456.99" "$1,465.20" $821.61 "$1,541.95" "$1,541.95" "$1,601.25" "$1,434.17" $821.51 $932.21 "$2,836.00" "$2,836.00" "$1,434.81" "$2,327.00" "$2,458.37" "$2,483.20" "$1,993.48" "$2,500.00" "$1,993.48" $224.43 $137.76 $137.76 $494.16 "$1,366.49" $0.00 $0.00 $0.00 $0.00 36100449 EAP CPT® 31624 Bronchoscopy W/bal BOTH IP/OP "$3,942.00 " "$2,917.08" $139.56 "$3,085.60" "$2,753.10" "$2,753.10" "$1,456.99" "$1,456.99" "$1,465.20" $821.61 "$1,541.95" "$1,541.95" "$1,601.25" "$1,434.17" $821.51 $932.21 "$2,836.00" "$2,836.00" "$1,434.81" "$2,327.00" "$3,054.74" "$3,085.60" "$1,993.48" "$2,500.00" "$1,993.48" $217.26 $139.56 $139.56 $614.03 "$1,366.49" $0.00 $0.00 $0.00 $0.00 36100450 EAP CPT® 31625 BRONCH DX /ENDOBRONCHIAL BX SINGLE/MULTIPLE LOBE BOTH IP/OP "$3,942.00 " "$2,917.08" $162.28 "$3,085.60" "$2,753.10" "$2,753.10" "$1,456.99" "$1,456.99" "$1,465.20" $821.61 "$1,541.95" "$1,541.95" "$1,601.25" "$1,434.17" $821.51 $932.21 "$2,836.00" "$2,836.00" "$1,434.81" "$2,327.00" "$3,054.74" "$3,085.60" "$1,993.48" "$2,500.00" "$1,993.48" $246.87 $162.28 $162.28 $614.03 "$1,366.49" $0.00 $0.00 $0.00 $0.00 36100452 EAP CPT® 31628 Transbronch Bx W&w/o Fluo BOTH IP/OP "$3,582.00 " "$2,650.68" $182.48 "$3,505.00" "$2,753.10" "$2,753.10" "$3,016.56" "$3,016.56" "$3,033.56" $746.58 "$1,541.95" "$1,541.95" "$1,601.25" "$2,969.20" $746.49 "$1,929.98" "$2,836.00" "$2,836.00" "$2,945.54" "$2,327.00" "$2,775.96" "$2,804.00" "$3,505.00" "$2,500.00" "$3,505.00" $278.79 $182.48 $182.48 $558.00 "$2,805.28" $0.00 $0.00 $0.00 $0.00 36100453 EAP CPT® 31629 Bron W/trans Needl Aspir BOTH IP/OP "$4,091.00 " "$3,027.34" $193.66 "$4,003.00" "$2,753.10" "$2,753.10" "$3,016.56" "$3,016.56" "$3,033.56" $852.67 "$1,541.95" "$1,541.95" "$1,601.25" "$2,969.20" $852.56 "$1,929.98" "$2,836.00" "$2,836.00" "$2,945.54" "$2,327.00" "$3,170.38" "$3,202.40" "$4,003.00" "$3,725.00" "$4,003.00" $211.89 $193.66 $193.66 $637.28 "$2,805.28" $0.00 $0.00 $0.00 $0.00 36100454 EAP CPT® 31630 Bronchoscopy Dilate/fx Repr BOTH IP/OP "$10,854.00 " "$8,031.96" $0.00 "$8,496.00" "$2,753.10" "$2,753.10" "$3,016.56" "$3,016.56" "$3,033.56" "$2,262.24" "$1,541.95" "$1,541.95" "$1,601.25" "$2,969.20" "$2,261.97" "$1,929.98" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$8,411.04" "$8,496.00" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100455 EAP CPT® 31631 Tracheal Broncial W&w/o Stent BOTH IP/OP "$9,733.00 " "$7,202.42" $0.00 "$7,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,028.36" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,708.54" "$7,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100456 EAP CPT® 31635 "Bronch Tx, Fb Removal" BOTH IP/OP "$10,854.00 " "$8,031.96" $0.00 "$8,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,261.97" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,411.04" "$8,496.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100457 EAP CPT® 31635 Bronchoscopy W/fb Removal BOTH IP/OP "$10,854.00 " "$8,031.96" $0.00 "$8,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,261.97" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,411.04" "$8,496.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100458 EAP CPT® 31640 Bronchoscopy W/ Tumor BOTH IP/OP "$12,526.00 " "$9,269.24" $260.01 "$9,804.80" "$2,753.10" "$2,753.10" "$3,016.56" "$3,016.56" "$3,033.56" "$2,610.73" "$1,541.95" "$1,541.95" "$1,601.25" "$2,969.20" "$2,610.42" "$1,929.98" "$2,836.00" "$2,836.00" "$2,945.54" "$2,327.00" "$9,706.75" "$9,804.80" "$4,092.44" "$3,725.00" "$4,092.44" $319.32 $260.01 $260.01 "$1,951.16" "$2,805.28" $0.00 $0.00 $0.00 $0.00 36100459 EAP CPT® 31643 Bronchoscopy Intracav Rad Addl BOTH IP/OP "$10,051.00 " "$7,437.74" $0.00 "$7,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,094.63" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,789.32" "$7,868.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100460 EAP CPT® 31645 Bron W/aspir Trachbron Int BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,434.81" "$2,255.00" "$9,424.80" "$9,520.00" "$1,993.48" $0.00 "$1,993.48" $199.84 $152.54 $152.54 "$1,894.48" "$1,366.49" $0.00 $0.00 $0.00 $0.00 36100461 EAP CPT® 31645 "Bronchoscopy, Clear Airways" BOTH IP/OP "$12,162.00 " "$8,999.88" $152.54 "$9,520.00" "$2,753.10" "$2,753.10" "$1,456.99" "$1,456.99" "$1,465.20" "$2,534.86" "$1,257.08" "$1,257.08" "$1,305.43" "$1,434.17" "$2,534.56" $932.21 "$1,871.00" "$1,871.00" "$1,434.81" "$2,255.00" "$9,424.80" "$9,520.00" "$1,993.48" "$2,500.00" "$1,993.48" $199.84 $152.54 $152.54 "$1,894.48" "$1,366.49" $0.00 $0.00 $0.00 $0.00 36100462 EAP CPT® 31646 Bron W/asp Trachbron Sub BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,479.96" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$9,424.80" "$9,520.00" $0.00 "$1,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100463 EAP CPT® 31646 "Bronchoscopy, Reclear Airway" BOTH IP/OP "$12,162.00 " "$8,999.88" $0.00 "$9,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,534.56" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$9,424.80" "$9,520.00" $0.00 "$1,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100464 EAP CPT® 31720 Cath Aspir Nasotracbronch BOTH IP/OP $250.00 $185.00 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100467 EAP CPT® 31720 Nasotreacheal Suction BOTH IP/OP $256.00 $189.44 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.35 $0.00 $0.00 $0.00 $0.00 $250.00 $198.00 $200.00 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100468 EAP CPT® 31720 Suctioning Nasotracheal BOTH IP/OP $250.00 $185.00 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $250.00 $198.00 $200.00 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100469 EAP CPT® 31899 Bronchi Medication Injection BOTH IP/OP "$4,452.00 " "$3,294.48" $0.00 "$4,297.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.80 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,254.62" "$4,297.60" $0.00 $343.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100470 EAP CPT® 32400 Biopsy Pleura Perc Needle BOTH IP/OP "$4,094.00 " "$3,029.56" $0.00 "$3,275.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$3,242.45" "$3,275.20" "$1,912.65" $0.00 "$1,912.65" $123.21 $89.44 $89.44 $651.76 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100471 EAP CPT® 32400 Pleural Biopsy BOTH IP/OP "$4,104.00 " "$3,036.96" $0.00 "$3,275.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $855.27 $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$3,242.45" "$3,275.20" "$1,912.65" "$2,500.00" "$1,912.65" $123.21 $89.44 $89.44 $651.76 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100472 EAP CPT® 32405 BX LUNG/MEDIAST PERCUT NDL BCT BOTH IP/OP "$2,601.00 " "$1,924.74" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$2,059.99" "$2,080.80" "$1,912.65" $0.00 "$1,912.65" $151.70 $93.40 $93.40 $414.08 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100473 EAP CPT® 32405 Bx Lung/mediastinum Us BOTH IP/OP "$2,601.00 " "$1,924.74" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$2,059.99" "$2,080.80" "$1,912.65" $0.00 "$1,912.65" $151.70 $93.40 $93.40 $414.08 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100474 EAP CPT® 32405 Lung/mediastinum Bx BOTH IP/OP "$2,601.00 " "$1,924.74" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$2,059.99" "$2,080.80" "$1,912.65" $0.00 "$1,912.65" $151.70 $93.40 $93.40 $414.08 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100480 EAP CPT® 32550 Insert Indwelling Cath BOTH IP/OP "$20,731.00 " "$15,340.94" $0.00 "$15,694.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,320.34" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$15,537.46" "$15,694.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100481 EAP CPT® 32550 Insert/indwelling Tun Pleural BOTH IP/OP "$16,257.00 " "$12,030.18" $0.00 "$15,694.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,387.96" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$15,537.46" "$15,694.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100482 EAP CPT® 32551 Chest Tube Insertion BOTH IP/OP "$2,893.00 " "$2,140.82" $0.00 "$2,272.90" $0.00 $0.00 $0.00 $0.00 $0.00 $602.97 $0.00 $0.00 $0.00 "$1,347.67" $602.90 $875.99 "$1,871.00" "$1,871.00" "$1,635.92" "$2,255.00" "$1,971.29" "$1,991.20" "$2,272.90" "$2,150.00" "$2,272.90" $0.00 $164.42 $164.42 $396.25 "$1,558.02" $0.00 $0.00 $0.00 $0.00 36100485 EAP CPT® 32560 Chemical Pleurodesis BOTH IP/OP "$2,169.00 " "$1,605.06" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.02 $0.00 $0.00 $0.00 $0.00 "$2,053.00" "$1,625.98" "$1,642.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100486 EAP CPT® 32999 Removal Of Pleural Catheter BOTH IP/OP "$1,359.00 " "$1,005.66" $0.00 "$1,373.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.22 $0.00 $0.00 $0.00 $632.36 "$1,373.00" "$1,087.42" "$1,098.40" $878.58 "$1,359.00" $878.58 $214.87 $0.00 $0.00 $218.58 $602.25 $0.00 $0.00 $0.00 $0.00 36100488 EAP CPT® 33206 Insrt New/repl Pcmkr/ld-atrial BOTH IP/OP "$30,541.00 " "$22,600.34" $0.00 "$24,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,780.81" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$24,188.47" "$24,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100489 EAP CPT® 33207 Insrt New/repl Pcmkr/ld-vent BOTH IP/OP "$31,143.00 " "$23,045.82" $0.00 "$24,432.80" "$5,693.10" "$5,693.10" "$10,125.82" "$10,125.82" "$10,182.87" "$6,490.98" "$2,192.53" "$2,192.53" "$2,276.86" "$9,967.71" "$6,490.20" "$6,479.01" "$4,877.00" "$4,877.00" $0.00 "$6,105.00" "$24,188.47" "$24,432.80" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100490 EAP CPT® 33208 Insrt New/repl Pcmkr/ld- A / V BOTH IP/OP "$13,386.00 " "$9,905.64" $545.42 "$13,127.00" "$5,693.10" "$5,693.10" "$10,125.82" "$10,125.82" "$10,182.87" "$2,789.98" "$2,571.13" "$2,571.13" "$2,670.02" "$9,967.71" "$2,789.64" "$6,479.01" "$4,877.00" "$4,877.00" "$10,282.07" "$6,105.00" "$10,396.58" "$10,501.60" "$13,127.00" "$5,343.00" "$13,127.00" $611.79 $545.42 $545.42 "$2,089.82" "$9,792.45" $0.00 $0.00 $0.00 $0.00 36100491 EAP CPT® 33210 Temp Pacemaker Wire BOTH IP/OP "$25,023.00 " "$18,517.02" $0.00 "$19,631.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,214.79" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$19,434.89" "$19,631.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100492 EAP CPT® 33212 Insrt Pcmkr W Exist Sngl Ld BOTH IP/OP "$19,776.00 " "$14,634.24" $0.00 "$15,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,121.32" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$15,360.05" "$15,515.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100493 EAP CPT® 33213 Insrt Pcmkr W Exist Dual Lds BOTH IP/OP "$22,852.00 " "$16,910.48" $0.00 "$17,928.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,762.36" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$17,748.72" "$17,928.00" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100494 EAP CPT® 33214 Upgrade Pacemaker System BOTH IP/OP "$11,993.00 " "$8,874.82" $0.00 "$10,563.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,499.34" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$10,457.57" "$10,563.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100495 EAP CPT® 33215 Reposition Icd Lead BOTH IP/OP "$14,372.00 " "$10,635.28" $0.00 "$11,275.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,995.12" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$11,162.45" "$11,275.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100496 EAP CPT® 33216 Insrt Sngl Icd Lead Transveno BOTH IP/OP "$15,719.00 " "$11,632.06" $0.00 "$12,332.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,275.84" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$12,208.68" "$12,332.00" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100497 EAP CPT® 33217 Insrt Dual Icd Lead Transveno BOTH IP/OP "$30,222.00 " "$22,364.28" $0.00 "$23,710.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,298.26" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$23,473.30" "$23,710.40" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100498 EAP CPT® 33218 Repair Sngl Lead Pcmkr / Icd BOTH IP/OP "$26,919.00 " "$19,920.06" $0.00 "$23,710.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,609.92" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$23,473.30" "$23,710.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100499 EAP CPT® 33220 Repair Dual Leads Pcmkr / Icd BOTH IP/OP "$14,001.00 " "$10,360.74" $0.00 "$12,332.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,917.81" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$12,208.68" "$12,332.00" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100500 EAP CPT® 33223 Relocation Skin Pkt Cardiovert-defib BOTH IP/OP "$6,168.00 " "$4,564.32" $0.00 "$4,839.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,285.41" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,790.81" "$4,839.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100501 EAP CPT® 33224 Insert Lead To Prev Pcmkr / Icd BOTH IP/OP "$13,464.00 " "$9,963.36" $0.00 "$10,563.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,805.90" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$10,457.57" "$10,563.20" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100502 EAP CPT® 33225 L Ventr Pacing Lead Add +pock BOTH IP/OP "$50,601.00 " "$37,444.74" $0.00 "$39,698.40" "$3,735.90" "$3,735.90" $0.00 $0.00 $0.00 "$9,417.94" $0.00 $0.00 $0.00 $0.00 "$10,545.25" $0.00 "$4,877.00" "$4,877.00" $0.00 "$24,811.50" "$39,301.42" "$39,698.40" $0.00 "$5,343.00" $0.00 $418.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100503 EAP CPT® 33226 Reposition Lv Pcmkr Lead BOTH IP/OP "$7,930.00 " "$5,868.20" $0.00 "$6,344.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,280.56" "$6,344.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100504 EAP CPT® 33233 Remove Pcmkr Only BOTH IP/OP "$12,134.00 " "$8,979.16" $0.00 "$10,687.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,528.73" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$10,580.33" "$10,687.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100505 EAP CPT® 33234 Remove Pcmkr Electrode BOTH IP/OP "$7,315.00 " "$5,413.10" $0.00 "$5,739.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,524.45" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,681.81" "$5,739.20" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100506 EAP CPT® 33241 Remove Icd Generator Only BOTH IP/OP "$6,919.00 " "$5,120.06" $0.00 "$5,428.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.92" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,373.72" "$5,428.00" $0.00 "$3,725.00" $0.00 $240.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100507 EAP CPT® 33244 Transvenous Removal Icd Lead BOTH IP/OP "$11,879.00 " "$8,790.46" $0.00 "$9,319.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,475.58" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$9,226.01" "$9,319.20" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100508 EAP CPT® 33249 Insrt/repl Sgl/dual Icd Ld/gen BOTH IP/OP "$40,394.00 " "$29,891.56" $959.62 "$39,613.00" "$5,693.10" "$5,693.10" "$31,988.05" "$31,988.05" "$32,168.25" "$8,419.12" "$4,181.12" "$4,181.12" "$31,135.70" "$31,473.45" "$8,418.11" "$20,457.74" "$4,877.00" "$4,877.00" "$32,377.52" "$6,105.00" "$31,373.50" "$31,690.40" "$39,613.00" "$5,410.00" "$39,613.00" "$1,016.82" $959.62 $959.62 "$6,306.39" "$30,835.73" $0.00 $0.00 $0.00 $0.00 36100518 EAP CPT® 33968 Remove Intra-aortic Balloon BOTH IP/OP "$1,998.00 " "$1,478.52" $0.00 "$1,998.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $416.38 $0.00 $0.00 $0.00 $0.00 "$1,959.00" "$1,551.53" "$1,567.20" $0.00 "$1,998.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100519 EAP CPT® 34201 Emb. Or Thromb; Femoropop BOTH IP/OP "$13,033.00 " "$9,644.42" $0.00 "$10,426.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,716.08" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$10,322.14" "$10,426.40" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100520 EAP CPT® 34203 Emb. Or Thromb;popliteal-tibio BOTH IP/OP "$13,033.00 " "$9,644.42" $0.00 "$10,426.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,716.08" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$10,322.14" "$10,426.40" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100535 EAP CPT® 35286 Repair Blood Vessel With Graft Other Than Vein Lower Exteremity BOTH IP/OP "$13,185.00 " "$9,756.90" $0.00 "$10,548.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,747.75" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$10,442.52" "$10,548.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100536 EAP CPT® 35355 "Thromb., Iliofemoral" BOTH IP/OP "$6,828.00 " "$5,052.72" $0.00 "$5,462.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,422.96" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,407.78" "$5,462.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100537 EAP CPT® 35371 "Thromb., Common Femoral" BOTH IP/OP "$5,569.00 " "$4,121.06" $0.00 "$4,455.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,160.58" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,410.65" "$4,455.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100538 EAP CPT® 35372 "Thromb., Deep Femoral" BOTH IP/OP "$6,697.00 " "$4,955.78" $0.00 "$5,357.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,395.65" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,304.02" "$5,357.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100556 EAP CPT® 36002 Pseudoaneurysm Inject/treat BOTH IP/OP "$2,313.00 " "$1,711.62" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,831.90" "$1,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100557 EAP CPT® 36005 Injection Contrast Venography BOTH IP/OP "$3,362.00 " "$2,487.88" $0.00 "$2,552.80" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $700.72 $0.00 $0.00 $0.00 $0.00 $700.64 $0.00 "$1,988.62" "$1,988.62" $0.00 "$2,255.00" "$2,527.27" "$2,552.80" $0.00 $837.00 $0.00 $315.51 $49.76 $49.76 $508.01 $0.00 $0.00 $0.00 $0.00 $0.00 36100558 EAP CPT® 36010 "Intro Cath, Sup/inf Vena Cava" BOTH IP/OP "$7,585.00 " "$5,612.90" $0.00 "$5,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.90" $0.00 $0.00 $0.00 $0.00 "$1,580.71" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,255.00" "$5,702.40" "$5,760.00" $0.00 "$1,750.00" $0.00 $0.00 $115.03 $115.03 "$1,146.24" $0.00 $0.00 $0.00 $0.00 $0.00 36100559 EAP CPT® 36011 Select Cath Venous 1st Order BOTH IP/OP "$2,771.00 " "$2,050.54" $0.00 "$2,630.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.48 $0.00 $0.00 $0.00 $0.00 "$2,630.00" "$2,082.96" "$2,104.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100560 EAP CPT® 36012 Select Cath Venous 2nd Order BOTH IP/OP "$16,258.00 " "$12,030.92" $0.00 "$12,346.40" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 "$3,388.57" $0.00 $0.00 $0.00 $0.00 "$3,388.17" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,255.00" "$12,222.94" "$12,346.40" $0.00 "$1,750.00" $0.00 $197.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100561 EAP CPT® 36013 Intro Cath Rt Heart/main Pulm BOTH IP/OP "$12,826.00 " "$9,491.24" $0.00 "$11,745.60" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 "$2,673.26" $0.00 $0.00 $0.00 $0.00 "$2,672.94" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,255.00" "$11,628.14" "$11,745.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100562 EAP CPT® 36014 Select Cath Lt/rt Pulm Artery BOTH IP/OP "$14,945.00 " "$11,059.30" $0.00 "$11,349.60" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,114.54" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$11,236.10" "$11,349.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100563 EAP CPT® 36015 Select Cath Segmental Pulm Art BOTH IP/OP "$2,294.00 " "$1,697.56" $0.00 "$2,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.07 $0.00 $0.00 $0.00 $0.00 "$2,178.00" "$1,724.98" "$1,742.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100565 EAP CPT® 36140 Intro Needle Extremity Artery BOTH IP/OP "$5,160.00 " "$3,818.40" $0.00 "$3,918.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,075.34" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,879.22" "$3,918.40" $0.00 "$1,206.00" $0.00 $113.12 $93.75 $93.75 $779.76 $0.00 $0.00 $0.00 $0.00 $0.00 36100567 EAP CPT® 36160 Intro Needle Aortic/translumba BOTH IP/OP "$7,974.00 " "$5,900.76" $0.00 "$7,302.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,661.78" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,229.38" "$7,302.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100568 EAP CPT® 36200 Intro Catheter Aorta BOTH IP/OP "$8,501.00 " "$6,290.74" $0.00 "$6,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,771.61" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,391.44" "$6,456.00" $0.00 "$1,750.00" $0.00 $0.00 $146.39 $146.39 "$1,284.74" $0.00 $0.00 $0.00 $0.00 $0.00 36100569 EAP CPT® 36215 Selct Art 1st Ord Thor/brach BOTH IP/OP "$3,917.00 " "$2,898.58" $0.00 "$2,753.10" "$2,753.10" "$2,753.10" $0.00 $0.00 $0.00 $816.40 $0.00 $0.00 $0.00 $0.00 $816.30 $0.00 "$2,316.91" "$2,316.91" $0.00 "$2,255.00" "$2,612.02" "$2,638.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100570 EAP CPT® 36216 Selct Art 2nd Ord Thor/brach BOTH IP/OP "$3,917.00 " "$2,898.58" $0.00 "$2,638.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $816.30 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,612.02" "$2,638.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100571 EAP CPT® 36217 Selct Art 3rd Ord Thor/brach BOTH IP/OP "$3,917.00 " "$2,898.58" $0.00 "$2,638.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $816.30 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,612.02" "$2,638.40" $0.00 "$1,750.00" $0.00 $342.41 $343.25 $343.25 $525.04 $0.00 $0.00 $0.00 $0.00 $0.00 36100572 EAP CPT® 36218 Selct Art Add'l 2nd/3rd Th/br BOTH IP/OP "$1,886.00 " "$1,395.64" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.04 $0.00 $0.00 $0.00 $0.00 "$1,588.00" "$1,257.70" "$1,270.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100573 EAP Custom 36100573 Selct Art 1st Ord Abd/pelv BOTH IP/OP "$3,581.00 " "$2,649.94" $0.00 "$3,279.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $746.28 $0.00 $0.00 $0.00 $0.00 "$2,049.50" "$3,246.41" "$3,279.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100574 EAP CPT® 36245 Selct Art 1st Ord Abd/pelv/le BOTH IP/OP "$3,917.00 " "$2,898.58" $0.00 "$2,753.10" "$2,753.10" "$2,753.10" $0.00 $0.00 $0.00 $816.40 "$1,826.79" "$1,826.79" "$1,897.05" $0.00 $816.30 $0.00 "$2,316.91" "$2,316.91" $0.00 "$2,255.00" "$2,612.02" "$2,638.40" $0.00 "$1,750.00" $0.00 $264.78 $248.44 $248.44 $525.04 $0.00 $0.00 $0.00 $0.00 $0.00 36100575 EAP CPT® 36246 Selct Art 2nd Ord Abd/pelv/le BOTH IP/OP "$4,056.00 " "$3,001.44" $0.00 "$2,753.10" "$2,753.10" "$2,753.10" $0.00 $0.00 $0.00 $845.37 "$1,826.79" "$1,826.79" "$1,897.05" $0.00 $845.27 $0.00 "$2,399.12" "$2,399.12" $0.00 "$2,255.00" "$2,704.68" "$2,732.00" $0.00 "$1,750.00" $0.00 $288.99 $265.02 $265.02 $543.67 $0.00 $0.00 $0.00 $0.00 $0.00 36100576 EAP CPT® 36247 Selct Art 3rd Ord Abd/pelv/le BOTH IP/OP "$4,335.00 " "$3,207.90" $0.00 "$2,920.00" "$2,753.10" "$2,753.10" $0.00 $0.00 $0.00 $903.52 $0.00 $0.00 $0.00 $0.00 $903.41 $0.00 "$2,564.15" "$2,564.15" $0.00 "$2,255.00" "$2,890.80" "$2,920.00" $0.00 "$1,750.00" $0.00 $341.72 $315.51 $315.51 $581.08 $0.00 $0.00 $0.00 $0.00 $0.00 36100577 EAP CPT® 36248 "Selct Art, Addt'l, Abd/pelv/le" BOTH IP/OP "$4,056.00 " "$3,001.44" $0.00 "$2,753.10" "$2,753.10" "$2,753.10" $0.00 $0.00 $0.00 $845.37 $0.00 $0.00 $0.00 $0.00 $845.27 $0.00 "$2,399.12" "$2,399.12" $0.00 "$2,255.00" "$2,704.68" "$2,732.00" $0.00 "$1,750.00" $0.00 $56.19 $50.85 $50.85 $543.67 $0.00 $0.00 $0.00 $0.00 $0.00 36100582 EAP CPT® 36406 "Phelb, Micro-10bopc" BOTH IP/OP $89.00 $65.86 $0.00 $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $111.00 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100583 EAP CPT® 36406 "Phelb,micro-ward 12 Midnight" BOTH IP/OP $89.00 $65.86 $0.00 $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $111.00 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100584 EAP CPT® 36406 "Phleb,cap-ward 12n" BOTH IP/OP $89.00 $65.86 $0.00 $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $111.00 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100585 EAP CPT® 36406 "Phleb,cap-ward 6pm" BOTH IP/OP $89.00 $65.86 $0.00 $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $111.00 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100586 EAP CPT® 36406 "Phleb,cap-ward 7am" BOTH IP/OP $89.00 $65.86 $0.00 $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $111.00 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100587 EAP CPT® 36406 "Phleb,nursery 1pm" BOTH IP/OP $89.00 $65.86 $0.00 $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $111.00 $87.91 $88.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100592 EAP CPT® 36468 "Injection(s), Spider Vein" BOTH IP/OP $447.00 $330.78 $0.00 $447.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.15 $0.00 $0.00 $0.00 $0.00 $355.00 $281.16 $284.00 $0.00 $447.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100594 EAP CPT® 36470 Injection Therapy Of Vein BOTH IP/OP $717.00 $530.58 $0.00 $717.00 $717.00 $717.00 $336.60 $336.60 $338.49 $0.00 $0.00 $0.00 $0.00 $0.00 $149.42 $0.00 $0.00 $0.00 $0.00 $570.00 $451.44 $456.00 $0.00 $717.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100596 EAP CPT® 36475 "Endovenous Rf, 1st Vein" BOTH IP/OP "$14,476.00 " "$10,712.24" $0.00 "$11,508.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,016.80" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$11,393.71" "$11,508.80" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100597 EAP CPT® 36476 "Endovenous Rf, Vein Add On" BOTH IP/OP "$14,476.00 " "$10,712.24" $0.00 "$11,508.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,016.80" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$11,393.71" "$11,508.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100598 EAP CPT® 36478 "Endovenous Laser, 1st Vein" BOTH IP/OP "$14,476.00 " "$10,712.24" $0.00 "$11,508.80" "$2,984.10" "$2,984.10" "$2,787.76" "$2,787.76" "$2,803.47" $0.00 "$4,607.43" "$4,607.43" "$4,784.64" $0.00 "$3,016.80" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$11,393.71" "$11,508.80" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100599 EAP CPT® 36479 Endovenous Laser Vein Add-on BOTH IP/OP "$14,476.00 " "$10,712.24" $0.00 "$11,508.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,016.80" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$11,393.71" "$11,508.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100600 EAP CPT® 36481 Percut Portal Vein Cath BOTH IP/OP "$6,954.00 " "$5,145.96" $0.00 "$5,528.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,449.21" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,473.51" "$5,528.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100601 EAP CPT® 36500 Venous Cath Selct Org Bld Samp BOTH IP/OP "$3,040.00 " "$2,249.60" $0.00 "$2,285.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.54 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,262.74" "$2,285.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100602 EAP CPT® 36555 INS NON-TUN CVC <5 SPV BOTH IP/OP "$6,197.00 " "$4,585.78" $0.00 "$4,175.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,291.45" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,133.45" "$4,175.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100603 EAP CPT® 36556 Central Line Placement BOTH IP/OP "$6,532.00 " "$4,833.68" $0.00 "$4,400.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,361.27" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,356.79" "$4,400.80" $0.00 "$2,500.00" $0.00 $311.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100607 EAP CPT® 36557 INS TUN CVC W/O PORT <5 SPV BOTH IP/OP "$7,565.00 " "$5,598.10" $0.00 "$6,928.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,576.55" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,858.72" "$6,928.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100608 EAP CPT® 36558 INS TUN CVC W/O PORT >5 SPV BOTH IP/OP "$11,867.00 " "$8,781.58" $0.00 "$7,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,473.38" $0.00 $0.00 $0.00 "$2,742.67" "$2,473.08" "$1,782.74" "$2,836.00" "$2,836.00" "$2,779.42" "$2,327.00" "$7,914.46" "$7,994.40" "$3,861.64" "$3,725.00" "$3,861.64" $693.87 $272.22 $272.22 "$1,590.89" "$2,647.07" $0.00 $0.00 $0.00 $0.00 36100609 EAP CPT® 36560 INS TUN CVC W/PORT <5 SPV BOTH IP/OP "$16,153.00 " "$11,953.22" $0.00 "$14,792.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,366.29" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$14,644.08" "$14,792.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100610 EAP CPT® 36561 INS TUN CVC W/PORT >5 SPV BOTH IP/OP "$23,715.00 " "$17,549.10" $351.16 "$15,976.00" "$2,984.10" "$2,984.10" "$2,787.76" "$2,787.76" "$2,803.47" "$4,942.80" "$1,826.79" "$1,826.79" "$1,897.05" "$2,742.67" "$4,942.21" "$1,782.74" "$3,856.00" "$3,856.00" "$2,779.42" "$2,858.00" "$15,816.24" "$15,976.00" "$3,861.64" "$3,725.00" "$3,861.64" "$1,322.94" $351.16 $351.16 "$3,179.22" "$2,647.07" $0.00 $0.00 $0.00 $0.00 36100611 EAP CPT® 36563 INS TUN CVC W/PUMP SPV BOTH IP/OP "$34,457.00 " "$25,498.18" $0.00 "$31,554.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,180.84" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$31,238.86" "$31,554.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100612 EAP CPT® 36565 Insert Tunneled Cv Cath BOTH IP/OP "$22,459.00 " "$16,619.66" $0.00 "$15,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,680.46" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$14,979.10" "$15,130.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100613 EAP CPT® 36566 Insert Tunneled Cv Cath W/port BOTH IP/OP "$9,620.00 " "$7,118.80" $0.00 "$8,809.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,004.81" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$8,721.50" "$8,809.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100614 EAP CPT® 36568 INS PERH CVC W/O PORT <5 SPV BOTH IP/OP "$7,208.00 " "$5,333.92" $0.00 "$5,115.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,064.05" "$5,115.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100615 EAP CPT® 36568 Insert/picc Catheter Discontin BOTH IP/OP "$7,208.00 " "$5,333.92" $0.00 "$5,115.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,064.05" "$5,115.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100616 EAP CPT® 36568 Insertion Of Picc Catheter BOTH IP/OP "$7,593.00 " "$5,618.82" $0.00 "$5,115.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,582.38" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,064.05" "$5,115.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100618 EAP CPT® 36569 Cvc/picc Line Place Exchange BOTH IP/OP "$6,120.00 " "$4,528.80" $0.00 "$4,343.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,635.92" "$2,255.00" "$4,299.77" "$4,343.20" "$2,272.90" $0.00 "$2,272.90" $346.84 $98.45 $98.45 $864.30 "$1,558.02" $0.00 $0.00 $0.00 $0.00 36100619 EAP CPT® 36569 Insert Picc Wo Port/pump >5 BOTH IP/OP "$4,743.00 " "$3,509.82" $98.45 "$4,343.20" "$2,321.55" "$2,321.55" "$1,369.42" "$1,369.42" "$1,377.13" $988.56 "$1,257.08" "$1,257.08" "$1,305.43" "$1,347.67" $988.44 $875.99 "$1,871.00" "$1,871.00" "$1,635.92" "$2,255.00" "$4,299.77" "$4,343.20" "$2,272.90" "$2,500.00" "$2,272.90" $346.84 $98.45 $98.45 $864.30 "$1,558.02" $0.00 $0.00 $0.00 $0.00 36100620 EAP CPT® 36570 Ins Perh Cvc W/port <5spv BOTH IP/OP "$14,840.00 " "$10,981.60" $0.00 "$13,589.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,092.66" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$13,453.70" "$13,589.60" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100621 EAP CPT® 36571 INS PERH CVC W/ PORT >5 SPV BOTH IP/OP "$10,048.00 " "$7,435.52" $325.53 "$7,630.40" "$2,984.10" "$2,984.10" "$2,787.76" "$2,787.76" "$2,803.47" "$2,094.25" "$1,826.79" "$1,826.79" "$1,897.05" "$2,742.67" "$2,094.00" "$1,782.74" "$3,856.00" "$3,856.00" "$2,779.42" "$2,858.00" "$7,554.10" "$7,630.40" "$3,861.64" "$3,725.00" "$3,861.64" "$1,542.56" $325.53 $325.53 "$1,518.45" "$2,647.07" $0.00 $0.00 $0.00 $0.00 36100622 EAP CPT® 36575 Repair Cv Cath Wo Port/pump BOTH IP/OP "$4,589.00 " "$3,395.86" $0.00 "$4,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $956.35 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,160.38" "$4,202.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100623 EAP CPT® 36575 REPAIR TUN/N-TUN CVC WO PT SPV BOTH IP/OP "$4,589.00 " "$3,395.86" $0.00 "$4,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $956.35 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,160.38" "$4,202.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100624 EAP CPT® 36576 REPAIR CVC W/PORT/PUMP SPV BOTH IP/OP "$4,589.00 " "$3,395.86" $0.00 "$4,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $956.35 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,160.38" "$4,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100626 EAP CPT® 36578 Replce Cat Cvc W/port/pump Spv BOTH IP/OP "$12,764.00 " "$9,445.36" $0.00 "$11,688.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.02" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$11,571.91" "$11,688.80" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100627 EAP CPT® 36580 Replace Cv Cath Non-tun Wo Por BOTH IP/OP "$6,828.00 " "$5,052.72" $0.00 "$6,252.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,422.96" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,190.27" "$6,252.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100628 EAP CPT® 36580 REPLCE NON-TUN CVC WO PORT SPV BOTH IP/OP "$8,234.00 " "$6,093.16" $0.00 "$6,252.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,715.97" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,190.27" "$6,252.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100629 EAP CPT® 36581 REPLCE TUN CVC W/O PORT SPV BOTH IP/OP "$5,567.00 " "$4,119.58" $191.10 "$4,228.00" "$2,753.10" "$2,753.10" "$2,787.76" "$2,787.76" "$2,803.47" "$1,160.30" "$1,541.95" "$1,541.95" "$1,601.25" "$2,742.67" "$1,160.16" "$1,782.74" "$2,836.00" "$2,836.00" "$2,779.42" "$2,327.00" "$4,185.72" "$4,228.00" "$3,861.64" "$3,725.00" "$3,861.64" $638.75 $191.10 $191.10 $841.37 "$2,647.07" $0.00 $0.00 $0.00 $0.00 36100630 EAP CPT® 36582 REPLCE TUN CVC W/ PORT SPV BOTH IP/OP "$22,026.00 " "$16,299.24" $0.00 "$16,727.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,590.22" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$16,559.93" "$16,727.20" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100631 EAP CPT® 36583 Replce Tun Cvc W/pump Spv BOTH IP/OP "$34,457.00 " "$25,498.18" $0.00 "$31,554.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,180.84" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$31,238.86" "$31,554.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100632 EAP CPT® 36584 Replace Picc Wo Port/pump BOTH IP/OP "$8,528.00 " "$6,310.72" $0.00 "$7,809.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,777.24" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,731.50" "$7,809.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100633 EAP CPT® 36584 Replacement Of A Picc Catheter BOTH IP/OP "$9,762.00 " "$7,223.88" $0.00 "$7,809.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,731.50" "$7,809.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100634 EAP CPT® 36584 REPLCE COMP PICC W/O PORT SPV BOTH IP/OP "$10,284.00 " "$7,610.16" $0.00 "$7,809.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,143.19" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,731.50" "$7,809.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100635 EAP CPT® 36585 REPLCE COMP PICC W/PORT SPV BOTH IP/OP "$17,895.00 " "$13,242.30" $283.37 "$13,589.60" "$2,984.10" "$2,984.10" "$2,787.76" "$2,787.76" "$2,803.47" "$3,729.77" "$1,826.79" "$1,826.79" "$1,897.05" "$2,742.67" "$3,729.32" "$1,782.74" "$3,856.00" "$3,856.00" "$2,779.42" "$2,858.00" "$13,453.70" "$13,589.60" "$3,861.64" "$3,725.00" "$3,861.64" "$1,518.02" $283.37 $283.37 "$2,704.33" "$2,647.07" $0.00 $0.00 $0.00 $0.00 36100636 EAP CPT® 36589 REMOVAL TUN CVC W/O PORT SPV BOTH IP/OP "$4,906.00 " "$3,630.44" $143.13 "$3,725.60" "$2,321.55" "$2,321.55" $526.39 $526.39 $529.35 "$1,022.53" "$1,257.08" "$1,257.08" "$1,305.43" $519.10 "$1,022.41" $337.41 "$1,871.00" "$1,871.00" $632.36 "$2,255.00" "$3,688.34" "$3,725.60" $878.58 "$2,150.00" $878.58 $171.53 $143.13 $143.13 $741.39 $602.25 $0.00 $0.00 $0.00 $0.00 36100637 EAP CPT® 36589 Removal Venous Access Device BOTH IP/OP "$4,657.00 " "$3,446.18" $0.00 "$3,725.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.36 "$2,255.00" "$3,688.34" "$3,725.60" $878.58 $0.00 $878.58 $171.53 $143.13 $143.13 $741.39 $602.25 $0.00 $0.00 $0.00 $0.00 36100638 EAP CPT® 36590 REMOVAL TUN CVC W/PORT SPV BOTH IP/OP "$4,906.00 " "$3,630.44" $198.64 "$3,725.60" "$2,321.55" "$2,321.55" "$1,369.42" "$1,369.42" "$1,377.13" "$1,022.53" "$1,257.08" "$1,257.08" "$1,305.43" "$1,347.67" "$1,022.41" $875.99 "$1,871.00" "$1,871.00" $632.36 "$2,255.00" "$3,688.34" "$3,725.60" $878.58 "$2,500.00" $878.58 $371.18 $198.64 $198.64 $741.39 $602.25 $0.00 $0.00 $0.00 $0.00 36100639 EAP CPT® 36590 Remove Cv Cath BOTH IP/OP "$4,068.00 " "$3,010.32" $198.64 "$3,725.60" "$2,321.55" "$2,321.55" "$1,369.42" "$1,369.42" "$1,377.13" $847.87 "$1,257.08" "$1,257.08" "$1,305.43" "$1,347.67" $847.77 $875.99 "$1,871.00" "$1,871.00" $632.36 "$2,255.00" "$3,688.34" "$3,725.60" $878.58 "$2,500.00" $878.58 $371.18 $198.64 $198.64 $741.39 $602.25 $0.00 $0.00 $0.00 $0.00 36100640 EAP CPT® 36591 Blood Draw Central Line BOTH IP/OP $311.00 $230.14 $0.00 $527.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.81 $0.00 $0.00 $0.00 $109.35 $262.00 $207.50 $209.60 $151.93 $527.00 $151.93 $0.00 $25.21 $25.21 $41.71 $104.14 $0.00 $0.00 $0.00 $0.00 36100641 EAP CPT® 36593 Declot Vasc Cath By Thrombolyt BOTH IP/OP "$2,030.00 " "$1,502.20" $0.00 "$1,624.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.51 "$1,624.00" "$1,286.21" "$1,299.20" $431.41 $0.00 $431.41 $30.97 $32.05 $32.05 $258.54 $295.72 $0.00 $0.00 $0.00 $0.00 36100642 EAP CPT® 36593 Declot Vascular Access Device BOTH IP/OP "$2,043.00 " "$1,511.82" $0.00 "$2,043.00" "$2,043.00" "$2,043.00" $310.51 $310.51 $312.26 $425.81 $0.00 $0.00 $0.00 $297.83 $425.76 $193.59 $113.00 $113.00 $310.51 "$1,624.00" "$1,286.21" "$1,299.20" $431.41 "$1,289.00" $431.41 $30.97 $32.05 $32.05 $258.54 $295.72 $0.00 $0.00 $0.00 $0.00 36100645 EAP CPT® 36595 MECH REMOVAL OBSTR CVC SPV BOTH IP/OP "$16,371.00 " "$12,114.54" $0.00 "$12,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,411.72" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$12,308.47" "$12,432.80" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100646 EAP CPT® 36596 MECH REMOVAL CATH OBST CVC SPV BOTH IP/OP "$5,648.00 " "$4,179.52" $0.00 "$5,172.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,177.04" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,120.28" "$5,172.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100647 EAP CPT® 36597 REPOSIT CVC W/ FLUORO GUID SPV BOTH IP/OP "$8,057.00 " "$5,962.18" $0.00 "$6,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,679.08" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,057.22" "$6,118.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100648 EAP CPT® 36598 "Inj W/fluro, Eval Cv Device" BOTH IP/OP "$1,173.00 " $868.02 $0.00 "$1,173.00" "$1,173.00" "$1,173.00" $199.22 $199.22 $200.34 $244.48 $0.00 $0.00 $0.00 $195.04 $244.45 $126.78 "$1,173.00" "$1,173.00" $184.28 "$1,100.00" $871.20 $880.00 $256.03 $803.00 $256.03 $126.13 $38.59 $38.59 $175.12 $175.50 $0.00 $0.00 $0.00 $0.00 36100649 EAP CPT® 36600 Arterial Puncture BOTH IP/OP $302.00 $223.48 $16.23 $404.00 $302.00 $302.00 $109.81 $109.81 $110.43 $62.94 $224.14 $224.14 $232.78 $107.30 $62.94 $69.74 $113.00 $113.00 $109.35 $284.00 $224.93 $227.20 $151.93 $404.00 $151.93 $24.37 $16.23 $16.23 $45.21 $104.14 $0.00 $0.00 $0.00 $0.00 36100650 EAP CPT® 20610 Bilateral Drain/inject-shoulder Hip Knee Wo Us Guidance BOTH IP/OP "$4,395.00 " "$3,252.30" $47.59 "$3,520.00" "$2,321.55" "$2,321.55" $254.43 $254.43 $255.86 $916.03 "$1,257.08" "$1,257.08" "$1,305.43" $250.31 $915.92 $162.70 "$1,871.00" "$1,871.00" $262.54 "$2,255.00" "$3,484.80" "$3,520.00" $364.76 "$1,750.00" $364.76 $70.76 $47.59 $47.59 $700.48 $250.04 $0.00 $0.00 $0.00 $0.00 36100652 EAP CPT® 36620 Arterial Line Insert BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,750.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $328.27 $0.00 $0.00 $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 "$1,339.00" "$1,060.49" "$1,071.20" $0.00 "$1,750.00" $0.00 $59.97 $46.17 $46.17 $213.17 $0.00 $0.00 $0.00 $0.00 $0.00 36100655 EAP CPT® 36860 Cannula Declot W/o Balloon BOTH IP/OP "$9,536.00 " "$7,056.64" $0.00 "$8,732.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,987.30" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,645.47" "$8,732.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100657 EAP CPT® 37182 Insert Hepatic Shunt (tips) BOTH IP/OP "$15,415.00 " "$11,407.10" $0.00 "$11,706.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,212.49" $0.00 $0.00 $0.00 $0.00 "$7,316.50" "$11,589.34" "$11,706.40" $0.00 "$10,019.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100658 EAP CPT® 37183 Remove Hepatic Shunt (tips) BOTH IP/OP "$61,100.00 " "$45,214.00" $0.00 "$46,400.80" "$5,965.05" "$5,965.05" "$4,826.66" "$4,826.66" "$4,853.85" $0.00 $0.00 $0.00 $0.00 $0.00 "$12,733.24" $0.00 $0.00 $0.00 $0.00 "$4,975.00" "$45,936.79" "$46,400.80" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100659 EAP CPT® 37184 Prim Art Mech Thrombectomy BOTH IP/OP "$39,064.00 " "$28,907.36" $0.00 "$29,665.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,140.94" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$29,368.94" "$29,665.60" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100660 EAP CPT® 37185 Prim Art M-thrombect Add-on BOTH IP/OP "$36,020.00 " "$26,654.80" $0.00 "$31,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,506.57" $0.00 $0.00 $0.00 $0.00 "$19,570.00" "$30,998.88" "$31,312.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100661 EAP CPT® 37186 Sec Art Thrombect Add-on BOTH IP/OP "$31,656.00 " "$23,425.44" $0.00 "$28,988.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,597.11" $0.00 $0.00 $0.00 $0.00 "$18,118.00" "$28,698.91" "$28,988.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100662 EAP CPT® 37187 Venous Mech Thrombectomy BOTH IP/OP "$19,167.00 " "$14,183.58" $0.00 "$15,488.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,994.40" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$15,333.91" "$15,488.80" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100663 EAP CPT® 37188 Venous M-thrombectomy Add-on BOTH IP/OP "$15,850.00 " "$11,729.00" $0.00 "$12,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,303.14" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$12,679.92" "$12,808.00" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100664 EAP CPT® 37195 "Thrombolytic Therapy, Stroke" BOTH IP/OP "$14,728.00 " "$10,898.72" $0.00 "$11,184.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,069.32" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$11,072.95" "$11,184.80" $0.00 "$1,408.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100665 EAP CPT® 37200 Transcatheter Biopsy BOTH IP/OP "$17,005.00 " "$12,583.70" $0.00 "$13,571.20" "$3,735.90" "$3,735.90" "$4,643.92" "$4,643.92" "$4,670.08" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,543.84" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$13,435.49" "$13,571.20" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100681 EAP CPT® 37215 "Transcath Stent, Cca W/eps" BOTH IP/OP "$18,633.00 " "$13,788.42" $0.00 "$14,150.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,883.12" $0.00 $0.00 $0.00 "$1,114.70" "$8,844.00" "$14,008.90" "$14,150.40" "$1,046.93" "$12,111.45" "$1,046.93" "$1,065.02" "$1,046.93" "$1,046.93" "$2,815.93" "$1,046.93" $0.00 $0.00 $0.00 $0.00 36100682 EAP CPT® 37216 "Transcath Stent, Cca W/o Eps" BOTH IP/OP "$21,388.00 " "$15,827.12" $0.00 "$16,242.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,457.26" $0.00 $0.00 $0.00 $0.00 "$10,151.50" "$16,079.98" "$16,242.40" $0.00 "$7,557.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100685 EAP CPT® 37609 Temporal Artery Biopsy BOTH IP/OP "$10,925.00 " "$8,084.50" $214.12 "$8,571.20" "$2,753.10" "$2,753.10" "$1,370.21" "$1,370.21" "$1,377.93" "$2,277.04" "$1,541.95" "$1,541.95" "$1,601.25" "$1,348.50" "$2,276.77" $876.52 "$2,836.00" "$2,836.00" "$1,376.63" "$2,327.00" "$8,485.49" "$8,571.20" "$1,912.65" "$2,500.00" "$1,912.65" $242.02 $214.12 $214.12 "$1,705.67" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100687 EAP CPT® 37765 Phleb Veins-extrem-up To 20 BOTH IP/OP "$17,595.00 " "$13,020.30" $0.00 "$14,218.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,666.80" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$14,076.22" "$14,218.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100688 EAP CPT® 37766 Phleb Veins-extrem-20+ BOTH IP/OP "$17,362.00 " "$12,847.88" $0.00 "$14,029.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,618.24" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$13,889.30" "$14,029.60" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100689 EAP CPT® 37799 Vascular Surgery Procedure BOTH IP/OP "$11,080.00 " "$8,199.20" $0.00 "$8,953.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,309.07" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$8,864.06" "$8,953.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100690 EAP CPT® 38200 Splenoportography Inj BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 "$1,250.00" $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100691 EAP CPT® 38220 Diagnostic Bone Marrow; Aspiration(s) BOTH IP/OP "$1,504.00 " "$1,112.96" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.43 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$1,188.00" "$1,200.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100692 EAP CPT® 38220 Diagnostic Bone Marrow; Aspiration(s) BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100693 EAP CPT® 38221 Diagnostic Bone Marrow; Biopsy(ies) BOTH IP/OP "$1,527.00 " "$1,129.98" $0.00 "$2,150.00" "$1,527.00" "$1,527.00" "$1,370.21" "$1,370.21" "$1,377.93" $318.26 $0.00 $0.00 $0.00 "$1,348.50" $318.23 $876.52 "$1,527.00" "$1,527.00" "$1,376.63" "$1,523.00" "$1,206.22" "$1,218.40" "$1,523.00" "$2,150.00" "$1,523.00" $245.12 $72.12 $72.12 $242.46 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100694 EAP CPT® 38500 Biopsy Lymph Nodes Sprfcl Open BOTH IP/OP "$4,110.00 " "$3,041.40" $0.00 "$3,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $856.52 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,255.12" "$3,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100695 EAP CPT® 38505 BX LYMPH NODE(S) NDL BCT BOTH IP/OP "$1,805.00 " "$1,335.70" $72.83 "$2,500.00" "$1,805.00" "$1,805.00" "$1,370.21" "$1,370.21" "$1,377.93" $376.21 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $376.16 $876.52 "$1,805.00" "$1,805.00" "$1,376.63" "$1,801.00" "$1,426.39" "$1,440.80" "$1,801.00" "$2,500.00" "$1,801.00" $115.87 $72.83 $72.83 $286.72 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100696 EAP CPT® 38525 "Bx, Open Deep Ax Node" BOTH IP/OP "$5,701.00 " "$4,218.74" $0.00 "$4,560.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,188.09" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,515.19" "$4,560.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100697 EAP CPT® 38790 Inj Lymphangiography BOTH IP/OP "$4,411.00 " "$3,264.14" $0.00 "$3,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $919.25 $0.00 $0.00 $0.00 $0.00 "$2,200.00" "$3,484.80" "$3,520.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100698 EAP CPT® 38792 Identify Sentinel Node BOTH IP/OP $485.00 $358.90 $0.00 $485.00 $485.00 $485.00 $367.10 $367.10 $369.17 $101.09 $0.00 $0.00 $0.00 $361.44 $101.07 $234.94 $485.00 $485.00 $0.00 $484.00 $383.33 $387.20 $0.00 $485.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100699 EAP CPT® 40490 Biopsy Of Lip BOTH IP/OP $578.00 $427.72 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.46 $0.00 $0.00 $0.00 $0.00 $577.00 $456.98 $461.60 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100701 EAP CPT® 40800 "I&d, Intra-oral, Simple" BOTH IP/OP $698.00 $516.52 $0.00 $705.00 $379.01 $379.01 $606.01 $606.01 $609.42 $145.48 $0.00 $0.00 $0.00 $596.11 $145.46 $387.47 $113.00 $113.00 $611.80 $705.00 $558.36 $564.00 $705.00 $698.00 $705.00 $87.87 $128.30 $128.30 $112.24 $582.67 $0.00 $0.00 $0.00 $0.00 36100702 EAP CPT® 40801 "I&d Intra-oral, Complex" BOTH IP/OP "$1,566.00 " "$1,158.84" $0.00 "$1,582.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.35 $0.00 $0.00 $0.00 $0.00 "$1,582.00" "$1,252.94" "$1,265.60" $0.00 "$1,566.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100703 EAP CPT® 40808 Biopsy Vestibule Of Mouth BOTH IP/OP $874.00 $646.76 $0.00 $874.00 $874.00 $874.00 $440.43 $440.43 $442.92 $182.16 $0.00 $0.00 $0.00 $433.55 $182.14 $281.81 $113.00 $113.00 $443.02 $872.00 $690.62 $697.60 $615.51 $874.00 $615.51 $81.68 $89.03 $89.03 $138.82 $421.92 $0.00 $0.00 $0.00 $0.00 36100704 EAP CPT® 36593 Declot Vascular Access Device BOTH IP/OP "$2,030.00 " "$1,502.20" $0.00 "$1,624.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.51 "$1,624.00" "$1,286.21" "$1,299.20" $431.41 $0.00 $431.41 $30.97 $32.05 $32.05 $258.54 $295.72 $0.00 $0.00 $0.00 $0.00 36100705 EAP CPT® 40812 Exc/les/mouth W/simple Repair BOTH IP/OP "$6,659.00 " "$4,927.66" $0.00 "$5,380.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,387.74" $0.00 $0.00 $0.00 "$1,353.31" "$2,255.00" "$5,326.99" "$5,380.80" "$1,880.24" "$2,500.00" "$1,880.24" $161.83 $196.45 $196.45 "$1,070.78" "$1,288.86" $0.00 $0.00 $0.00 $0.00 36100706 EAP CPT® 40814 Exc/les/mouth W/complex Repair BOTH IP/OP "$5,169.00 " "$3,825.06" $0.00 "$4,176.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,077.22" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,135.03" "$4,176.80" $0.00 "$3,359.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100707 EAP CPT® 40819 Exc Frenum Libial Buccal BOTH IP/OP "$2,245.00 " "$1,661.30" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $467.86 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,087.71" "$2,108.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100708 EAP CPT® 40820 Dest/les Vestibule Mouth BOTH IP/OP "$5,179.00 " "$3,832.46" $0.00 "$4,864.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.30" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,816.15" "$4,864.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100709 EAP CPT® 41015 I&d Extraoral Sublingual BOTH IP/OP $945.00 $699.30 $0.00 $955.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.94 $0.00 $0.00 $0.00 $0.00 $955.00 $756.36 $764.00 $0.00 $945.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100710 EAP CPT® 41016 "I&d,floor Of Mouth-submental" BOTH IP/OP "$5,296.00 " "$3,919.04" $0.00 "$4,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,103.69" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,439.16" "$4,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100711 EAP CPT® 41017 "I&d,floor/mouth-submandibular" BOTH IP/OP "$2,620.00 " "$1,938.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.01 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,095.63" "$2,116.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100712 EAP CPT® 41018 "I&d,floor Of Mouth-masticator" BOTH IP/OP "$2,215.00 " "$1,639.10" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $461.61 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,856.45" "$1,875.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100713 EAP CPT® 41100 Biopsy Anterior 2/3 Of Tongue BOTH IP/OP $991.00 $733.34 $108.86 $991.00 $991.00 $991.00 $440.43 $440.43 $442.92 $206.55 $991.00 $991.00 $991.00 $433.55 $206.52 $281.81 $991.00 $991.00 $443.02 $989.00 $783.29 $791.20 $615.51 $991.00 $615.51 $116.06 $108.86 $108.86 $157.45 $421.92 $0.00 $0.00 $0.00 $0.00 36100715 EAP CPT® 41105 Biopsy Posterior 1/3 Tongue BOTH IP/OP "$2,240.00 " "$1,657.60" $0.00 "$2,664.14" "$2,240.00" "$2,240.00" "$2,664.14" "$2,664.14" "$2,240.00" $466.87 "$1,541.95" "$1,541.95" "$1,601.25" "$2,622.61" $466.82 "$1,704.70" "$2,240.00" "$2,240.00" $0.00 "$2,235.00" "$1,770.12" "$1,788.00" $0.00 "$2,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100717 EAP CPT® 41108 "Biopsy, Floor Of Mouth" BOTH IP/OP "$1,504.00 " "$1,112.96" $90.18 "$1,504.00" "$1,504.00" "$1,504.00" "$1,370.21" "$1,370.21" "$1,377.93" $313.47 "$1,504.00" "$1,504.00" "$1,504.00" "$1,348.50" $313.43 $876.52 "$1,504.00" "$1,504.00" "$1,376.63" "$1,500.00" "$1,188.00" "$1,200.00" "$1,500.00" "$1,504.00" "$1,500.00" $90.18 $90.83 $90.83 $238.80 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100718 EAP CPT® 41116 Exc Lesion Floor Of Mouth BOTH IP/OP "$4,520.00 " "$3,344.80" $0.00 "$3,607.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $941.97 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,571.13" "$3,607.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100719 EAP CPT® 41822 Excision Of Fibrous Tuberosity BOTH IP/OP "$4,451.00 " "$3,293.74" $0.00 "$3,594.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.59 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,558.46" "$3,594.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100720 EAP CPT® 41823 Excision Of Osseoustuberosity BOTH IP/OP "$4,910.00 " "$3,633.40" $0.00 "$3,928.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,023.24" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,888.72" "$3,928.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100721 EAP CPT® 41826 Exc W/simple Repair Dentoalveo BOTH IP/OP "$3,486.00 " "$2,579.64" $0.00 "$2,788.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $726.48 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,760.91" "$2,788.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100722 EAP CPT® 41850 "Destruct Lesion, Dentoalveolar" BOTH IP/OP "$5,372.00 " "$3,975.28" $0.00 "$4,297.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,119.52" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,254.62" "$4,297.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100723 EAP CPT® 41874 "Alveoloplasty, Each Quadrant" BOTH IP/OP "$3,051.00 " "$2,257.74" $0.00 "$3,080.00" "$2,321.55" "$2,321.55" "$2,664.14" "$2,664.14" "$2,679.15" $635.90 $0.00 $0.00 $0.00 "$2,622.61" $635.83 "$1,704.70" "$3,051.00" "$3,051.00" "$2,626.99" "$3,080.00" "$2,439.36" "$2,464.00" "$3,080.00" "$2,500.00" "$3,080.00" $0.00 $259.89 $259.89 $490.34 "$2,501.89" $0.00 $0.00 $0.00 $0.00 36100724 EAP CPT® 41899 Completely Bony BOTH IP/OP "$1,862.00 " "$1,377.88" $0.00 "$1,880.00" "$1,862.00" "$1,862.00" $206.03 $206.03 $207.19 $388.09 $0.00 $0.00 $0.00 $202.80 $388.04 $131.82 "$1,862.00" "$1,862.00" $204.24 "$1,880.00" "$1,488.96" "$1,504.00" $283.76 "$1,750.00" $283.76 $294.22 $0.00 $0.00 $299.30 $194.51 $0.00 $0.00 $0.00 $0.00 36100725 EAP CPT® 42100 "Biopsy Palate, Uvula" BOTH IP/OP "$1,837.00 " "$1,359.38" $0.00 "$1,837.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.83 $0.00 $0.00 $0.00 $0.00 "$1,833.00" "$1,451.74" "$1,466.40" $0.00 "$1,837.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100727 EAP CPT® 42104 "Exc Palate, Uvula,w/o Closure" BOTH IP/OP "$3,431.00 " "$2,538.94" $0.00 "$2,772.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $715.02 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,745.07" "$2,772.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100728 EAP CPT® 42140 Uvulectomy BOTH IP/OP "$3,002.00 " "$2,221.48" $0.00 "$2,401.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.62 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,377.58" "$2,401.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100729 EAP CPT® 42160 "Dest Lesion, Palate Or Uvula" BOTH IP/OP "$7,516.00 " "$5,561.84" $0.00 "$6,005.60" "$2,321.55" "$2,321.55" "$2,664.14" "$2,664.14" "$2,679.15" "$1,566.52" "$1,257.08" "$1,257.08" "$1,305.43" "$2,622.61" "$1,566.33" "$1,704.70" "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$5,945.54" "$6,005.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100730 EAP CPT® 42400 "Biopsy Of Salivary Gland,needl" BOTH IP/OP "$4,676.00 " "$3,460.24" $0.00 "$3,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $974.48 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,698.64" "$3,736.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100732 EAP CPT® 42700 I&d Peritonsillar Abscess BOTH IP/OP $436.00 $322.64 $70.05 $440.00 $436.00 $436.00 $206.03 $206.03 $207.19 $90.87 $436.00 $436.00 $436.00 $202.80 $90.86 $131.82 $436.00 $436.00 $204.24 $440.00 $348.48 $352.00 $283.76 $436.00 $283.76 $122.16 $139.13 $139.13 $70.05 $194.51 $0.00 $0.00 $0.00 $0.00 36100733 EAP CPT® 42405 Biopsy Of Salivary Gland BOTH IP/OP "$9,563.00 " "$7,076.62" $0.00 "$7,640.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,992.93" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,564.39" "$7,640.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100734 EAP CPT® 42800 "Biopsy, Oropharynx" BOTH IP/OP "$5,168.00 " "$3,824.32" $0.00 "$4,877.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,077.14" $0.00 $0.00 $0.00 "$1,296.54" "$1,077.01" $842.75 "$4,877.00" "$4,877.00" $0.00 "$2,255.00" "$4,093.06" "$4,134.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100735 EAP CPT® 42804 "Biopsy, Nasopharynx" BOTH IP/OP "$3,142.00 " "$2,325.08" $0.00 "$2,513.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $654.79 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,488.46" "$2,513.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100738 EAP CPT® 43246 G-tube Insertion BOTH IP/OP "$5,939.00 " "$4,394.86" $0.00 "$4,568.80" "$2,753.10" "$2,753.10" "$1,581.72" "$1,581.72" "$1,590.63" "$1,237.84" "$1,541.95" "$1,541.95" "$1,601.25" "$1,557.45" "$1,237.69" "$1,012.34" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$4,523.11" "$4,568.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100740 EAP CPT® 43450 Dil Eso/unguide Bougie 1>1 Pas BOTH IP/OP "$2,096.00 " "$1,551.04" $0.00 "$2,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $436.81 $0.00 $0.00 $0.00 $0.00 "$2,096.00" "$1,660.03" "$1,676.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100742 EAP CPT® 43752 Naso Gastric Tube Place BOTH IP/OP "$2,134.00 " "$1,579.16" $42.55 "$2,134.00" "$2,134.00" "$2,134.00" $264.30 $264.30 $265.79 $444.78 "$1,257.08" "$1,257.08" "$1,305.43" $258.98 $444.73 $168.34 $113.00 $113.00 $364.66 "$2,052.00" "$1,625.18" "$1,641.60" $506.64 "$1,750.00" $506.64 $321.14 $42.55 $42.55 $326.68 $347.29 $0.00 $0.00 $0.00 $0.00 36100747 EAP CPT® 43761 Reposition Gastrostomy Tube BOTH IP/OP "$5,739.00 " "$4,246.86" $0.00 "$4,415.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,196.01" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,371.05" "$4,415.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100748 EAP CPT® 44015 Jejunostomy Intra-op Ent Alime BOTH IP/OP "$6,352.00 " "$4,700.48" $0.00 "$5,253.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,323.76" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,201.06" "$5,253.60" $0.00 "$1,114.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100749 EAP CPT® 44373 Peg Conversion To Pej BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $845.06 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,211.56" "$3,244.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100751 EAP CPT® 44500 Intro Of Long Gi Tube BOTH IP/OP "$1,291.00 " $955.34 $0.00 "$1,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.04 $0.00 $0.00 $0.00 $0.00 "$1,304.00" "$1,032.77" "$1,043.20" $0.00 "$1,291.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100754 EAP CPT® 45000 Drain Pelvic Abscess Us BOTH IP/OP "$6,884.00 " "$5,094.16" $0.00 "$5,507.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,434.63" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,452.13" "$5,507.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100757 EAP CPT® 46040 Perirectal Abscess BOTH IP/OP "$2,951.00 " "$2,183.74" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $614.99 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,360.95" "$2,384.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100758 EAP CPT® 46600 "Anoscopy, Diagnostic, Inc Spec Collect" BOTH IP/OP $561.00 $415.14 $0.00 $561.00 $561.00 $561.00 $109.81 $109.81 $110.43 $116.93 $0.00 $0.00 $0.00 $107.30 $116.91 $69.74 $113.00 $113.00 $109.35 $542.00 $429.26 $433.60 $151.93 $235.00 $151.93 $37.41 $42.17 $42.17 $86.29 $104.14 $0.00 $0.00 $0.00 $0.00 36100759 EAP CPT® 46606 Anoscopy And Biopsy BOTH IP/OP "$2,211.00 " "$1,636.14" $52.76 "$2,211.00" "$2,211.00" "$2,211.00" "$1,009.84" "$1,009.84" "$1,015.53" $460.83 "$1,257.08" "$1,257.08" "$1,305.43" $993.84 $460.77 $646.00 "$2,211.00" "$2,211.00" "$1,007.17" "$2,137.00" "$1,692.50" "$1,709.60" "$1,399.33" "$2,211.00" "$1,399.33" $52.76 $78.23 $78.23 $340.21 $959.21 $0.00 $0.00 $0.00 $0.00 36100760 EAP CPT® 46900 Destr Condyloma Anal - Chemic BOTH IP/OP $945.00 $699.30 $0.00 $955.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.94 $0.00 $0.00 $0.00 $0.00 $955.00 $756.36 $764.00 $0.00 $945.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100763 EAP CPT® 46916 Anal Cryo Surgery BOTH IP/OP $429.00 $317.46 $0.00 $433.00 $429.00 $429.00 $174.88 $174.88 $175.86 $89.41 $0.00 $0.00 $0.00 $172.08 $89.40 $111.85 $113.00 $113.00 $175.24 $433.00 $342.94 $346.40 $243.48 $429.00 $243.48 $138.83 $146.36 $146.36 $68.93 $166.90 $0.00 $0.00 $0.00 $0.00 36100764 EAP CPT® 47000 "Liver Biopsy, Needle, Percut" BOTH IP/OP "$2,078.00 " "$1,537.72" $92.31 "$2,078.00" "$2,078.00" "$2,078.00" "$1,370.21" "$1,370.21" "$1,377.93" $433.11 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $433.06 $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,073.00" "$1,641.82" "$1,658.40" "$1,912.65" "$2,078.00" "$1,912.65" $233.09 $92.31 $92.31 $330.02 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100769 EAP CPT® 47001 BX LIVER ADDTL PROC PERCUT BCT BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $566.92 $0.00 $0.00 $0.00 $0.00 $566.85 $0.00 "$1,608.88" "$1,608.88" $0.00 "$2,255.00" "$2,148.70" "$2,170.40" $0.00 $989.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100770 EAP CPT® 47015 Exploratory Laparotomy BOTH IP/OP "$4,765.00 " "$3,526.10" $0.00 "$3,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $993.03 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,811.90" "$3,850.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100771 EAP CPT® 47380 "Ablation, Open Liver Tumor, Rf" BOTH IP/OP "$6,657.00 " "$4,926.18" $0.00 "$5,325.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,387.32" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,272.34" "$5,325.60" $0.00 "$3,965.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100773 EAP CPT® 47382 "Ablation, Liver Tumor; Rf" BOTH IP/OP "$8,888.00 " "$6,577.12" $0.00 "$7,182.40" "$3,735.90" "$3,735.90" "$4,927.54" "$4,927.54" "$4,955.30" "$1,852.48" $0.00 $0.00 $0.00 "$4,850.03" "$1,852.26" "$3,152.52" "$4,877.00" "$4,877.00" "$4,847.92" "$5,452.00" "$7,110.58" "$7,182.40" "$6,735.53" "$4,334.00" "$6,735.53" $637.15 $774.64 $774.64 "$1,429.30" "$4,617.06" $0.00 $0.00 $0.00 $0.00 36100774 EAP CPT® 47490 DRAIN CHOLECYSTOSTOMY S&I BCT BOTH IP/OP "$5,844.00 " "$4,324.56" $0.00 "$4,722.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,217.89" $0.00 $0.00 $0.00 "$3,118.48" "$2,255.00" "$4,675.18" "$4,722.40" "$4,332.71" "$3,250.00" "$4,332.71" $444.58 $345.72 $345.72 $939.76 "$2,969.98" $0.00 $0.00 $0.00 $0.00 36100781 EAP CPT® 47555 DILAT BIL STRICT W/O STENT SPV BOTH IP/OP "$4,136.00 " "$3,060.64" $0.00 "$3,308.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.94 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$3,275.71" "$3,308.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100783 EAP CPT® 47556 Biliary Dil Strict W/stent BOTH IP/OP "$8,728.00 " "$6,458.72" $0.00 "$6,982.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,818.92" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$6,912.58" "$6,982.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100786 EAP CPT® 48000 PANCREATITIS PLACE DRAIN BCT BOTH IP/OP "$9,260.00 " "$6,852.40" $0.00 "$7,408.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,929.78" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,333.92" "$7,408.00" $0.00 "$5,889.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100787 EAP CPT® 48102 BX PANCREAS PERCUT NDL BCT BOTH IP/OP "$2,114.00 " "$1,564.36" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $440.56 $0.00 $0.00 $0.00 $0.00 "$2,114.00" "$1,674.29" "$1,691.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100800 EAP CPT® 37211 Thrombolytic Art Therapy W/s/i Any Meth Init Day BOTH IP/OP "$25,698.00 " "$19,016.52" $0.00 "$19,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,355.46" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$19,320.05" "$19,515.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100802 EAP CPT® 37212 Thrombolytic Venous Therapy W S/i Any Meth Init Day BOTH IP/OP "$25,698.00 " "$19,016.52" $0.00 "$19,515.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,355.46" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$19,320.05" "$19,515.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100804 EAP CPT® 49180 Ablation Abd Standard Bct BOTH IP/OP "$2,922.00 " "$2,162.28" $0.00 "$2,337.60" $0.00 $0.00 $0.00 $0.00 $0.00 $649.66 $0.00 $0.00 $0.00 "$1,348.50" $649.58 $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$2,314.22" "$2,337.60" "$1,912.65" $0.00 "$1,912.65" $203.88 $87.64 $87.64 $465.18 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100805 EAP CPT® 49180 Bx Abd/retroper Mass Us BOTH IP/OP "$2,922.00 " "$2,162.28" $0.00 "$2,337.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$2,314.22" "$2,337.60" "$1,912.65" $0.00 "$1,912.65" $203.88 $87.64 $87.64 $465.18 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100806 EAP CPT® 49180 Bx Retroperitone Mass Perc Bct BOTH IP/OP "$3,117.00 " "$2,306.58" $87.64 "$2,500.00" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" $649.66 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $649.58 $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$2,314.22" "$2,337.60" "$1,912.65" "$2,500.00" "$1,912.65" $203.88 $87.64 $87.64 $465.18 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100807 EAP CPT® 49419 Insert. Of Intrperitoneal Cath BOTH IP/OP "$11,483.00 " "$8,497.42" $0.00 "$10,746.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,393.06" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$10,638.94" "$10,746.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100808 EAP CPT® 49421 Peritoneal Dialysis Cat.placem BOTH IP/OP "$11,842.00 " "$8,763.08" $0.00 "$11,082.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,467.87" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$10,971.58" "$11,082.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100809 EAP CPT® 49423 CATHETER EXCH RAD GUIDE BCT BOTH IP/OP "$3,484.00 " "$2,578.16" $0.00 "$3,606.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $726.07 $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$3,228.19" "$3,260.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100810 EAP CPT® 37213 Throm Art/ven Therapy W S/i Inc F/u Cath Subsq Day BOTH IP/OP "$43,713.00 " "$32,347.62" $0.00 "$33,196.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,109.79" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$32,864.83" "$33,196.80" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100811 EAP CPT® 49424 Inj Dye Via Previous Drn Bct BOTH IP/OP "$3,484.00 " "$2,578.16" $0.00 "$3,260.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $726.07 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,228.19" "$3,260.80" $0.00 $840.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100812 EAP CPT® 49427 "Injection, Abdominal Shunt" BOTH IP/OP $373.00 $276.02 $0.00 $436.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.73 $0.00 $0.00 $0.00 $0.00 $436.00 $345.31 $348.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100813 EAP CPT® 49440 Gastrostomy Tube Place S&i Spv BOTH IP/OP "$5,144.00 " "$3,806.56" $0.00 "$3,957.60" "$2,753.10" "$2,753.10" "$1,581.72" "$1,581.72" "$1,590.63" "$1,072.14" $0.00 $0.00 $0.00 "$1,557.45" "$1,072.01" "$1,012.34" "$1,871.00" "$1,871.00" "$1,561.98" "$2,255.00" "$3,918.02" "$3,957.60" "$2,170.16" "$2,500.00" "$2,170.16" $774.21 $213.84 $213.84 $787.56 "$1,487.60" $0.00 $0.00 $0.00 $0.00 36100814 EAP CPT® 49446 G Tube Check BOTH IP/OP "$6,735.00 " "$4,983.90" $0.00 "$5,181.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,403.57" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,129.78" "$5,181.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100815 EAP CPT® 49450 Replace G/c Tube Perc BOTH IP/OP "$3,451.00 " "$2,553.74" $0.00 "$2,655.20" "$2,321.55" "$2,321.55" $787.99 $787.99 $792.43 $719.27 $0.00 $0.00 $0.00 $775.94 $719.19 $504.36 "$1,871.00" "$1,871.00" $788.23 "$2,255.00" "$2,628.65" "$2,655.20" "$1,095.14" "$2,150.00" "$1,095.14" $685.21 $68.88 $68.88 $528.38 $750.70 $0.00 $0.00 $0.00 $0.00 36100816 EAP CPT® 49452 Replace G-j Tube Perc BOTH IP/OP "$3,451.00 " "$2,553.74" $0.00 "$2,655.20" "$2,321.55" "$2,321.55" $787.99 $787.99 $792.43 $719.27 $0.00 $0.00 $0.00 $775.94 $719.19 $504.36 "$1,871.00" "$1,871.00" $788.23 "$2,255.00" "$2,628.65" "$2,655.20" "$1,095.14" "$2,150.00" "$1,095.14" $885.13 $144.98 $144.98 $528.38 $750.70 $0.00 $0.00 $0.00 $0.00 36100818 EAP CPT® 50200 BX RENAL PERCUT TROCAR/NDL BCT BOTH IP/OP "$2,343.00 " "$1,733.82" $133.42 "$2,500.00" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" $488.34 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $488.28 $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$1,850.90" "$1,869.60" "$1,912.65" "$2,500.00" "$1,912.65" $161.61 $133.42 $133.42 $372.05 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100819 EAP CPT® 50200 Percutaneous Kidney Biopsy BOTH IP/OP "$2,337.00 " "$1,729.38" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $487.09 $0.00 $0.00 $0.00 "$1,348.50" $487.03 $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$1,850.90" "$1,869.60" "$1,912.65" $0.00 "$1,912.65" $161.61 $133.42 $133.42 $372.05 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36100821 EAP CPT® 50382 "Change Urter Stent, Percut" BOTH IP/OP "$7,354.00 " "$5,441.96" $0.00 "$5,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,532.57" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,829.12" "$5,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100822 EAP CPT® 50384 "Remove Urter Stent, Percut" BOTH IP/OP "$6,508.00 " "$4,815.92" $0.00 "$5,258.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,356.27" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,205.82" "$5,258.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100823 EAP CPT® 50387 Change Ext/int Ureter Stent BOTH IP/OP "$2,713.00 " "$2,007.62" $0.00 "$2,713.00" "$2,321.55" "$2,321.55" "$1,743.67" "$1,743.67" "$1,753.49" $565.46 $0.00 $0.00 $0.00 "$1,718.44" $565.39 "$1,116.98" "$2,713.00" "$2,713.00" "$1,776.76" "$2,255.00" "$2,170.08" "$2,192.00" "$2,468.57" "$2,500.00" "$2,468.57" $790.32 $87.64 $87.64 $436.21 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36100824 EAP CPT® 50389 Remove Renal Tube With Fluro BOTH IP/OP $987.00 $730.38 $0.00 $997.00 $987.00 $987.00 $560.26 $560.26 $563.41 $205.72 $0.00 $0.00 $0.00 $550.87 $205.69 $358.07 $987.00 $987.00 $558.17 $997.00 $789.62 $797.60 $775.50 $987.00 $775.50 $541.78 $55.90 $55.90 $158.72 $531.59 $0.00 $0.00 $0.00 $0.00 36100825 EAP CPT® 50390 Aspir/inject Renal Cyst/pelvis BOTH IP/OP "$4,429.00 " "$3,277.46" $0.00 "$3,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $923.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,334.32" "$3,368.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100831 EAP CPT® 50592 "Ablation, Renal Tumor, Rf" BOTH IP/OP "$16,043.00 " "$11,871.82" $0.00 "$12,200.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,343.36" $0.00 $0.00 $0.00 "$4,847.92" "$5,452.00" "$12,078.79" "$12,200.80" "$6,735.53" "$4,334.00" "$6,735.53" "$6,100.60" $357.73 $357.73 "$2,427.96" "$4,617.06" $0.00 $0.00 $0.00 $0.00 36100832 EAP CPT® 50684 Injection For Ureter Xray BOTH IP/OP $774.00 $572.76 $0.00 $619.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.30 $0.00 $0.00 $0.00 $0.00 $387.00 $613.01 $619.20 $0.00 $327.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100833 EAP CPT® 50688 Change Of Ureter Tube/stent BOTH IP/OP "$2,286.00 " "$1,691.64" $0.00 "$2,286.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $476.40 $0.00 $0.00 $0.00 $0.00 "$2,173.00" "$1,721.02" "$1,738.40" $0.00 "$2,286.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100834 EAP CPT® 50690 Inject For Ureter X-ray BOTH IP/OP $829.00 $613.46 $0.00 $829.00 $829.00 $829.00 $0.00 $0.00 $0.00 $172.78 $829.00 $829.00 $829.00 $0.00 $172.76 $0.00 $490.35 $490.35 $0.00 $394.00 $624.10 $630.40 $0.00 $829.00 $0.00 $298.44 $72.83 $72.83 $125.45 $0.00 $0.00 $0.00 $0.00 $0.00 36100835 EAP CPT® 51080 DRN PERIVESIC/PREVESIC ABS BCT BOTH IP/OP "$3,734.00 " "$2,763.16" $0.00 "$2,987.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $778.17 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,957.33" "$2,987.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100836 EAP CPT® 51100 Drain Bladder By Needle BOTH IP/OP $647.00 $478.78 $0.00 $647.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.83 $0.00 $0.00 $0.00 $0.00 $647.00 $512.42 $517.60 $0.00 $647.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100839 EAP CPT® 51102 Bladder Tap-suprapub W Cath In BOTH IP/OP "$5,564.00 " "$4,117.36" $0.00 "$4,451.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,159.54" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,406.69" "$4,451.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100840 EAP CPT® 51102 Drain Bl W/cath Insertion BOTH IP/OP "$5,564.00 " "$4,117.36" $0.00 "$4,451.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,159.54" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,406.69" "$4,451.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100841 EAP CPT® 51102 Drainage Of Bladder BOTH IP/OP "$5,564.00 " "$4,117.36" $0.00 "$4,451.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,159.54" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,406.69" "$4,451.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100842 EAP CPT® 51600 Inject Cystography/voiding BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,275.00" $692.33 $692.33 $0.00 $0.00 $0.00 $265.74 "$1,257.08" "$1,257.08" "$1,275.00" $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.00 "$1,009.01" "$1,019.20" $0.00 "$1,275.00" $0.00 $280.11 $46.16 $46.16 $202.82 $0.00 $0.00 $0.00 $0.00 $0.00 36100844 EAP CPT® 51610 Inject Cystography/void Retro BOTH IP/OP "$2,406.00 " "$1,780.44" $0.00 "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $501.41 $0.00 $0.00 $0.00 $0.00 "$1,202.00" "$1,903.97" "$1,923.20" $0.00 "$1,022.00" $0.00 $301.43 $66.70 $66.70 $382.72 $0.00 $0.00 $0.00 $0.00 $0.00 36100846 EAP CPT® 51700 Bladder Irrigation &/or Instil BOTH IP/OP $504.00 $372.96 $0.00 $504.00 $504.00 $504.00 $259.14 $259.14 $260.60 $105.05 $0.00 $0.00 $0.00 $255.07 $105.03 $165.80 $113.00 $113.00 $0.00 $504.00 $399.17 $403.20 $0.00 $504.00 $0.00 $100.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100848 EAP CPT® 51701 Insert Straight Cath In & Out BOTH IP/OP $865.00 $640.10 $0.00 $865.00 $865.00 $865.00 $109.81 $109.81 $110.43 $180.29 $0.00 $0.00 $0.00 $107.30 $180.27 $69.74 $113.00 $113.00 $109.35 $864.00 $684.29 $691.20 $151.93 $548.00 $151.93 $57.62 $27.40 $27.40 $137.55 $104.14 $0.00 $0.00 $0.00 $0.00 36100849 EAP CPT® 51702 Cath Insert Indwelling BOTH IP/OP "$1,070.00 " $791.80 $0.00 "$1,070.00" "$1,070.00" "$1,070.00" $109.81 $109.81 $110.43 $223.01 $0.00 $0.00 $0.00 $107.30 $222.99 $69.74 $113.00 $113.00 $109.35 "$1,069.00" $846.65 $855.20 $151.93 "$1,070.00" $151.93 $91.18 $26.68 $26.68 $170.18 $104.14 $0.00 $0.00 $0.00 $0.00 36100850 EAP CPT® 51702 Insert Foley Cath BOTH IP/OP "$1,069.00 " $791.06 $0.00 "$1,069.00" $0.00 $0.00 $0.00 $0.00 $0.00 $223.01 $0.00 $0.00 $0.00 $107.30 $222.99 $69.74 $113.00 $113.00 $109.35 "$1,069.00" $846.65 $855.20 $151.93 $0.00 $151.93 $91.18 $26.68 $26.68 $170.18 $104.14 $0.00 $0.00 $0.00 $0.00 36100851 EAP CPT® 51703 Insert Complicated Cath BOTH IP/OP "$1,809.00 " "$1,338.66" $0.00 "$1,809.00" "$1,809.00" "$1,809.00" $135.96 $135.96 $136.73 $0.00 $0.00 $0.00 $0.00 $0.00 $377.00 $0.00 $0.00 $0.00 $138.76 "$1,808.00" "$1,431.94" "$1,446.40" $192.78 $899.00 $192.78 $170.19 $80.41 $80.41 $287.83 $132.15 $0.00 $0.00 $0.00 $0.00 36100852 EAP CPT® 51705 Change Cysto Tube Simple BOTH IP/OP $626.00 $463.24 $0.00 $626.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.46 $0.00 $0.00 $0.00 $235.59 $625.00 $495.00 $500.00 $327.32 $626.00 $327.32 $86.33 $54.08 $54.08 $99.50 $224.37 $0.00 $0.00 $0.00 $0.00 36100853 EAP CPT® 51710 Change Cysto Tube Complicated BOTH IP/OP "$3,957.00 " "$2,928.18" $0.00 "$3,163.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $824.64 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,131.57" "$3,163.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100854 EAP CPT® 51720 Instill Bladder Anticancer Age BOTH IP/OP "$1,029.00 " $761.46 $0.00 "$1,029.00" "$1,029.00" "$1,029.00" $259.14 $259.14 $260.60 $214.47 $0.00 $0.00 $0.00 $255.07 $214.44 $165.80 "$1,029.00" "$1,029.00" $235.59 "$1,028.00" $814.18 $822.40 $327.32 "$1,029.00" $327.32 $147.65 $45.44 $45.44 $163.66 $224.37 $0.00 $0.00 $0.00 $0.00 36100855 EAP CPT® 51726 Cystometrogram BOTH IP/OP "$1,648.00 " "$1,219.52" $0.00 "$1,649.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.44 $0.00 $0.00 $0.00 $0.00 "$1,648.00" "$1,305.22" "$1,318.40" $0.00 "$1,649.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100858 EAP CPT® 51798 Residual Urine By Ultrasound BOTH IP/OP $205.00 $151.70 $0.00 $207.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $55.17 $207.00 $163.94 $165.60 $76.65 $205.00 $76.65 $19.99 $10.44 $10.44 $32.95 $52.54 $0.00 $0.00 $0.00 $0.00 36100860 EAP CPT® 52000 Cystourethroscopy BOTH IP/OP "$3,069.00 " "$2,271.06" $84.02 "$2,480.00" "$2,321.55" "$2,321.55" $560.26 $560.26 $563.41 $639.66 "$1,257.08" "$1,257.08" "$1,305.43" $550.87 $639.58 $358.07 "$1,871.00" "$1,871.00" $558.17 "$2,255.00" "$2,455.20" "$2,480.00" $775.50 "$2,150.00" $775.50 $152.62 $84.02 $84.02 $493.52 $531.59 $0.00 $0.00 $0.00 $0.00 36100861 EAP CPT® 52005 Cystourethro W Ureteral Cath BOTH IP/OP "$5,902.00 " "$4,367.48" $0.00 "$4,769.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,229.98" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,721.90" "$4,769.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100862 EAP CPT® 52281 Perc Dilate Ureter W Balloon BOTH IP/OP "$6,114.00 " "$4,524.36" $0.00 "$4,940.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,274.31" $0.00 $0.00 $0.00 "$1,718.44" "$1,274.16" "$1,116.98" "$2,836.00" "$2,836.00" "$1,776.76" "$2,327.00" "$4,891.39" "$4,940.80" "$2,468.57" "$2,500.00" "$2,468.57" $208.00 $157.57 $157.57 $983.22 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36100863 EAP CPT® 52310 Cysto W Stent Removal BOTH IP/OP "$5,725.00 " "$4,236.50" $156.86 "$4,626.40" "$2,753.10" "$2,753.10" "$1,743.67" "$1,743.67" "$1,753.49" "$1,193.23" "$1,541.95" "$1,541.95" "$1,601.25" "$1,718.44" "$1,193.09" "$1,116.98" "$2,836.00" "$2,836.00" "$1,776.76" "$2,327.00" "$4,580.14" "$4,626.40" "$2,468.57" "$2,500.00" "$2,468.57" $409.12 $156.86 $156.86 $920.65 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36100864 EAP CPT® 52332 Cysto W Ureter Stent Plcmnt BOTH IP/OP "$10,798.00 " "$7,990.52" $0.00 "$8,725.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,250.30" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,638.34" "$8,725.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100865 EAP CPT® 53600 Dilate Urethra Strict Male Ini BOTH IP/OP $687.00 $508.38 $0.00 $694.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $235.59 $694.00 $549.65 $555.20 $327.32 $687.00 $327.32 $0.00 $65.99 $65.99 $110.48 $224.37 $0.00 $0.00 $0.00 $0.00 36100866 EAP CPT® 53601 Dilate Stricture Male Subseq BOTH IP/OP $314.00 $232.36 $0.00 $317.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.44 $0.00 $0.00 $0.00 $0.00 $317.00 $251.06 $253.60 $0.00 $314.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100867 EAP CPT® 53620 Dilate Strict Male Filiform Ix BOTH IP/OP "$4,447.00 " "$3,290.78" $0.00 "$3,557.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $926.75 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,522.02" "$3,557.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100868 EAP CPT® 53621 Dilate Strict Male Filiform Su BOTH IP/OP $804.00 $594.96 $0.00 $804.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.55 $0.00 $0.00 $0.00 $0.00 $804.00 $636.77 $643.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100869 EAP CPT® 53660 Dilate Urethra Strict Female I BOTH IP/OP $286.00 $211.64 $0.00 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.60 $0.00 $0.00 $0.00 $0.00 $286.00 $226.51 $228.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100870 EAP CPT® 53661 Dilate Urethra Strict Female S BOTH IP/OP $286.00 $211.64 $0.00 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.60 $0.00 $0.00 $0.00 $0.00 $286.00 $226.51 $228.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100871 EAP CPT® 54001 Dorsal Slit Exc Newborn BOTH IP/OP "$6,461.00 " "$4,781.14" $0.00 "$5,162.40" "$2,753.10" "$2,753.10" "$1,743.67" "$1,743.67" "$1,753.49" "$1,346.63" "$1,541.95" "$1,541.95" "$1,601.25" "$1,718.44" "$1,346.47" "$1,116.98" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$5,110.78" "$5,162.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100872 EAP CPT® 54015 "Incise And Drain Penis, Deep" BOTH IP/OP "$4,851.00 " "$3,589.74" $0.00 "$3,880.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,010.95" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$3,841.99" "$3,880.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100873 EAP CPT® 54050 "Les, Dest, Chem Penis, Simple" BOTH IP/OP $755.00 $558.70 $0.00 $763.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.34 $0.00 $0.00 $0.00 $320.45 $763.00 $604.30 $610.40 $445.22 $755.00 $445.22 $92.54 $107.78 $107.78 $121.47 $305.19 $0.00 $0.00 $0.00 $0.00 36100875 EAP CPT® 54056 Cryosurg Penis Lesion(s) Simpl BOTH IP/OP $304.00 $224.96 $0.00 $307.00 $165.07 $165.07 $174.88 $174.88 $175.86 $63.36 $0.00 $0.00 $0.00 $172.08 $63.35 $111.85 $113.00 $113.00 $175.24 $307.00 $243.14 $245.60 $243.48 $304.00 $243.48 $104.42 $112.46 $112.46 $48.87 $166.90 $0.00 $0.00 $0.00 $0.00 36100876 EAP CPT® 54100 Biopsy Of Penis BOTH IP/OP "$6,079.00 " "$4,498.46" $0.00 "$4,912.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.86" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,862.88" "$4,912.00" $0.00 "$2,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100877 EAP CPT® 54150 Circumcision BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$2,681.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $474.53 $0.00 $0.00 $0.00 $0.00 "$2,079.00" "$1,646.57" "$1,663.20" $0.00 "$2,681.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100878 EAP CPT® 54200 Treatment Of Penis Lesion BOTH IP/OP $590.00 $436.60 $0.00 $672.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.96 $0.00 $0.00 $0.00 $0.00 $672.00 $532.22 $537.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100879 EAP CPT® 54230 Inject Corpora Cavernosography BOTH IP/OP "$1,666.00 " "$1,232.84" $0.00 "$1,897.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.19 $0.00 $0.00 $0.00 $0.00 "$1,897.00" "$1,502.42" "$1,517.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100880 EAP CPT® 54450 Paraphimosis Reduction BOTH IP/OP $618.00 $457.32 $0.00 $624.00 $618.00 $618.00 $259.14 $259.14 $260.60 $0.00 $618.00 $618.00 $618.00 $0.00 $128.79 $0.00 $0.00 $0.00 $235.59 $624.00 $494.21 $499.20 $327.32 $618.00 $327.32 $70.76 $59.86 $59.86 $99.34 $224.37 $0.00 $0.00 $0.00 $0.00 36100881 EAP CPT® 54700 "Incise And Drain, Testes" BOTH IP/OP "$3,277.00 " "$2,424.98" $0.00 "$2,621.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $682.93 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,595.38" "$2,621.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100882 EAP CPT® 54860 Removal Of Epididymis BOTH IP/OP "$7,853.00 " "$5,811.22" $0.00 "$6,282.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,636.57" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$6,219.58" "$6,282.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100883 EAP CPT® 55000 Aspiration Of Hydrocele BOTH IP/OP $988.00 $731.12 $0.00 $998.00 $536.48 $536.48 $606.01 $606.01 $609.42 $0.00 $0.00 $0.00 $0.00 $0.00 $205.90 $0.00 $0.00 $0.00 $611.80 $998.00 $790.42 $798.40 $850.02 $988.00 $850.02 $92.61 $87.97 $87.97 $158.88 $582.67 $0.00 $0.00 $0.00 $0.00 36100884 EAP CPT® 55250 Removal Of Sperm Duct(s) BOTH IP/OP "$2,475.00 " "$1,831.50" $0.00 "$2,475.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $515.79 $0.00 $0.00 $0.00 "$1,776.76" "$2,327.00" "$1,980.00" "$2,000.00" "$2,468.57" "$2,475.00" "$2,468.57" $321.77 $236.13 $236.13 $398.00 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36100885 EAP CPT® 55700 Biopsy Prostate Needle/punch BOTH IP/OP "$4,505.00 " "$3,333.70" $135.95 "$3,595.20" "$2,753.10" "$2,753.10" "$1,743.67" "$1,743.67" "$1,753.49" $938.95 "$1,541.95" "$1,541.95" "$1,601.25" "$1,718.44" $938.84 "$1,116.98" "$2,836.00" "$2,836.00" "$1,776.76" "$2,327.00" "$3,559.25" "$3,595.20" "$2,468.57" "$2,500.00" "$2,468.57" $147.73 $135.95 $135.95 $715.44 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36100887 EAP CPT® 56405 I And D Vulva Perineal Absces BOTH IP/OP $291.00 $215.34 $0.00 "$1,750.00" $291.00 $291.00 $274.65 $274.65 $276.20 $60.65 $291.00 $291.00 $291.00 $269.78 $60.64 $175.35 $291.00 $291.00 $0.00 $294.00 $232.85 $235.20 $0.00 "$1,750.00" $0.00 $107.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100898 EAP CPT® 56420 Bartholin Gland Abscess BOTH IP/OP $665.00 $492.10 $0.00 "$1,224.00" $665.00 $665.00 $165.90 $165.90 $166.84 $138.60 $0.00 $0.00 $0.00 $163.24 $138.59 $106.10 $665.00 $665.00 $166.54 $672.00 $532.22 $537.60 $231.38 "$1,224.00" $231.38 $106.60 $107.06 $107.06 $106.98 $158.61 $0.00 $0.00 $0.00 $0.00 36100902 EAP CPT® 37214 Cess Therapy Cath Removalw/ Vess Close BOTH IP/OP "$8,844.00 " "$6,544.56" $0.00 "$7,075.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$7,004.45" "$7,075.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100903 EAP CPT® 56501 "Cryosurgery, Vulvar" BOTH IP/OP "$6,455.00 " "$4,776.70" $0.00 "$5,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,345.22" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,163.84" "$5,216.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100904 EAP CPT® 56501 Destroy Lesion(s) Vulva Simple BOTH IP/OP "$6,455.00 " "$4,776.70" $0.00 "$5,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,345.22" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,163.84" "$5,216.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100906 EAP CPT® 56515 Destroy Lesion(s) Vulva Extens BOTH IP/OP "$4,384.00 " "$3,244.16" $0.00 "$3,542.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $913.63 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$3,506.98" "$3,542.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100909 EAP CPT® 56605 "Vulvar Biopsy, One Lesion" BOTH IP/OP $641.00 $474.34 $63.10 $641.00 $641.00 $641.00 $617.38 $617.38 $620.86 $133.60 $641.00 $641.00 $641.00 $607.07 $133.58 $394.60 $641.00 $641.00 $640.34 $586.00 $464.11 $468.80 $586.00 $641.00 $586.00 $84.36 $63.10 $63.10 $93.29 $609.84 $0.00 $0.00 $0.00 $0.00 36100914 EAP CPT® 56606 "Vulvar Bx, Each Addl Lesion" BOTH IP/OP $557.00 $412.18 $0.00 $557.00 $557.00 $557.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.08 $0.00 $0.00 $0.00 $0.00 $556.00 $440.35 $444.80 $0.00 $557.00 $0.00 $53.12 $31.01 $31.01 $88.52 $0.00 $0.00 $0.00 $0.00 $0.00 36100920 EAP CPT® 56820 "Colposcopy, Vulva" BOTH IP/OP $501.00 $370.74 $0.00 $502.00 $501.00 $501.00 $165.90 $165.90 $166.84 $104.42 $0.00 $0.00 $0.00 $163.24 $104.41 $106.10 $113.00 $113.00 $166.54 $502.00 $397.58 $401.60 $231.38 $501.00 $231.38 $116.33 $89.05 $89.05 $79.92 $158.61 $0.00 $0.00 $0.00 $0.00 36100921 EAP CPT® 56821 "Colposcopy, Vulva + Vulva Bx" BOTH IP/OP "$1,623.00 " "$1,201.02" $0.00 "$1,627.00" "$1,623.00" "$1,623.00" $274.65 $274.65 $276.20 $338.27 $0.00 $0.00 $0.00 $269.78 $338.23 $175.35 "$1,623.00" "$1,623.00" $271.52 "$1,627.00" "$1,288.58" "$1,301.60" $377.23 "$1,623.00" $377.23 $150.61 $118.98 $118.98 $259.02 $258.59 $0.00 $0.00 $0.00 $0.00 36100923 EAP CPT® 57020 Colpocentesis BOTH IP/OP "$3,281.00 " "$2,427.94" $0.00 "$4,294.21" "$2,753.10" "$2,753.10" "$4,294.21" "$4,294.21" "$3,281.00" $683.84 "$1,541.95" "$1,541.95" "$1,601.25" "$4,226.19" $683.76 "$2,747.02" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$2,605.68" "$2,632.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100925 EAP CPT® 57061 Destroy Vaginal Lesion(s) Simp BOTH IP/OP "$4,198.00 " "$3,106.52" $0.00 "$4,198.00" "$2,321.55" "$2,321.55" "$2,555.04" "$2,555.04" "$2,569.43" $874.97 "$1,257.08" "$1,257.08" "$1,305.43" "$2,514.14" $874.86 "$1,634.19" "$4,198.00" "$4,198.00" $0.00 "$2,327.00" "$3,358.08" "$3,392.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100926 EAP CPT® 57065 Destroy Vaginal Lesion(s) Exte BOTH IP/OP "$4,256.00 " "$3,149.44" $0.00 "$3,404.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.95 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,370.75" "$3,404.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100929 EAP CPT® 57100 Vaginal Biopsy Simple BOTH IP/OP "$3,448.00 " "$2,551.52" $68.51 "$3,440.00" "$2,321.55" "$2,321.55" $617.38 $617.38 $620.86 $718.65 "$1,257.08" "$1,257.08" "$1,305.43" $607.07 $718.56 $394.60 "$1,871.00" "$1,871.00" $640.34 "$3,440.00" "$2,724.48" "$2,752.00" $889.66 "$2,150.00" $889.66 $71.96 $68.51 $68.51 $547.65 $609.84 $0.00 $0.00 $0.00 $0.00 36100930 EAP CPT® 27096 Bil Sacroiliac Jt Inj With Arthrography BOTH IP/OP "$3,165.00 " "$2,342.10" $0.00 "$2,557.60" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $659.67 $0.00 $0.00 $0.00 $0.00 $659.59 $0.00 $113.00 $113.00 $0.00 "$2,255.00" "$2,532.02" "$2,557.60" $86.18 "$1,750.00" $86.18 $398.44 $86.18 $86.18 $508.96 $0.00 $0.00 $0.00 $0.00 $0.00 36100933 EAP CPT® 57150 Vaginal Irrigation BOTH IP/OP $472.00 $349.28 $0.00 $477.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.36 $0.00 $0.00 $0.00 $0.00 $477.00 $377.78 $381.60 $0.00 $472.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100934 EAP CPT® 57155 Insertion Of T&o BOTH IP/OP "$4,229.00 " "$3,129.46" $0.00 "$2,327.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.32 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$1,980.00" "$2,000.00" $0.00 "$2,150.00" $0.00 $410.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100935 EAP CPT® 57160 Pessary Insertion BOTH IP/OP $335.00 $247.90 $0.00 $338.00 $181.91 $181.91 $165.90 $165.90 $166.84 $69.82 $0.00 $0.00 $0.00 $163.24 $69.81 $106.10 $113.00 $113.00 $166.54 $338.00 $267.70 $270.40 $231.38 $335.00 $231.38 $60.59 $48.68 $48.68 $53.81 $158.61 $0.00 $0.00 $0.00 $0.00 36100936 EAP CPT® 57170 Diaphragm Cervical Cap Fittin BOTH IP/OP $500.00 $370.00 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $500.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100938 EAP CPT® 57170 Diaphragm Fitting BOTH IP/OP $500.00 $370.00 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $500.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100939 EAP CPT® 57210 Colpoperineorrhaphy BOTH IP/OP "$10,423.00 " "$7,713.02" $0.00 "$8,338.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,172.15" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,255.02" "$8,338.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100940 EAP CPT® 57420 Colposcopy Of Vagina BOTH IP/OP "$1,237.00 " $915.38 $0.00 "$1,240.00" "$1,237.00" "$1,237.00" $274.65 $274.65 $276.20 $257.82 $0.00 $0.00 $0.00 $269.78 $257.79 $175.35 "$1,237.00" "$1,237.00" $271.52 "$1,240.00" $982.08 $992.00 $377.23 "$1,237.00" $377.23 $121.31 $94.46 $94.46 $197.41 $258.59 $0.00 $0.00 $0.00 $0.00 36100941 EAP CPT® 57420 "Colposcopy, Vagina With Cervix" BOTH IP/OP "$1,237.00 " $915.38 $0.00 "$1,240.00" "$1,237.00" "$1,237.00" $274.65 $274.65 $276.20 $257.82 $0.00 $0.00 $0.00 $269.78 $257.79 $175.35 "$1,237.00" "$1,237.00" $271.52 "$1,240.00" $982.08 $992.00 $377.23 "$1,237.00" $377.23 $121.31 $94.46 $94.46 $197.41 $258.59 $0.00 $0.00 $0.00 $0.00 36100942 EAP CPT® 57421 Colposcopy Bx Of Vagina+cervix BOTH IP/OP "$1,039.00 " $768.86 $0.00 "$1,042.00" "$1,039.00" "$1,039.00" $617.38 $617.38 $620.86 $216.55 $0.00 $0.00 $0.00 $607.07 $216.53 $394.60 "$1,039.00" "$1,039.00" $640.34 "$1,042.00" $825.26 $833.60 $889.66 "$1,039.00" $889.66 $158.06 $128.00 $128.00 $165.89 $609.84 $0.00 $0.00 $0.00 $0.00 36100943 EAP CPT® 57421 COLPOSCOPY OF VAGINA W/BX BOTH IP/OP "$1,039.00 " $768.86 $0.00 "$1,042.00" "$1,039.00" "$1,039.00" $617.38 $617.38 $620.86 $216.55 $0.00 $0.00 $0.00 $607.07 $216.53 $394.60 "$1,039.00" "$1,039.00" $640.34 "$1,042.00" $825.26 $833.60 $889.66 "$1,039.00" $889.66 $158.06 $128.00 $128.00 $165.89 $609.84 $0.00 $0.00 $0.00 $0.00 36100944 EAP CPT® 57421 "COLPOSCOPY, VAGINA W/ BX" BOTH IP/OP "$1,039.00 " $768.86 $0.00 "$1,042.00" "$1,039.00" "$1,039.00" $617.38 $617.38 $620.86 $216.55 $0.00 $0.00 $0.00 $607.07 $216.53 $394.60 "$1,039.00" "$1,039.00" $640.34 "$1,042.00" $825.26 $833.60 $889.66 "$1,039.00" $889.66 $158.06 $128.00 $128.00 $165.89 $609.84 $0.00 $0.00 $0.00 $0.00 36100945 EAP CPT® 57452 Colposcopy Without Biopsy BOTH IP/OP $556.00 $411.44 $77.33 $557.00 $556.00 $556.00 $165.90 $165.90 $166.84 $115.88 $556.00 $556.00 $556.00 $163.24 $115.87 $106.10 $556.00 $556.00 $166.54 $557.00 $441.14 $445.60 $231.38 $556.00 $231.38 $77.33 $95.18 $95.18 $88.67 $158.61 $0.00 $0.00 $0.00 $0.00 36100951 EAP CPT® 57454 Colposcopy W/bx & Ecc BOTH IP/OP "$1,185.00 " $876.90 $99.94 "$1,188.00" "$1,185.00" "$1,185.00" $274.65 $274.65 $276.20 $246.98 "$1,185.00" "$1,185.00" "$1,185.00" $269.78 $246.95 $175.35 "$1,185.00" "$1,185.00" $271.52 "$1,188.00" $940.90 $950.40 $377.23 "$1,185.00" $377.23 $99.94 $140.25 $140.25 $189.13 $258.59 $0.00 $0.00 $0.00 $0.00 36100956 EAP CPT® 57455 Colposcopy + Cx Bx BOTH IP/OP "$1,218.00 " $901.32 $115.02 "$1,221.00" "$1,218.00" "$1,218.00" $274.65 $274.65 $276.20 $253.86 "$1,218.00" "$1,218.00" "$1,218.00" $269.78 $253.83 $175.35 "$1,218.00" "$1,218.00" $271.52 "$1,221.00" $967.03 $976.80 $377.23 "$1,218.00" $377.23 $145.54 $115.02 $115.02 $194.38 $258.59 $0.00 $0.00 $0.00 $0.00 36100960 EAP CPT® 57456 Colposcopy + Ecc BOTH IP/OP "$1,218.00 " $901.32 $106.36 "$1,221.00" "$1,218.00" "$1,218.00" $274.65 $274.65 $276.20 $253.86 "$1,218.00" "$1,218.00" "$1,218.00" $269.78 $253.83 $175.35 "$1,218.00" "$1,218.00" $271.52 "$1,221.00" $967.03 $976.80 $377.23 "$1,218.00" $377.23 $137.69 $106.36 $106.36 $194.38 $258.59 $0.00 $0.00 $0.00 $0.00 36100961 EAP CPT® 57460 Colposcopy W/leep Bx BOTH IP/OP "$4,730.00 " "$3,500.20" $168.01 "$4,730.00" "$2,753.10" "$2,753.10" "$2,555.04" "$2,555.04" "$2,569.43" $985.85 "$1,541.95" "$1,541.95" "$1,601.25" "$2,514.14" $985.73 "$1,634.19" "$4,730.00" "$4,730.00" "$2,505.44" "$2,255.00" "$3,756.46" "$3,794.40" "$3,480.98" "$3,250.00" "$3,480.98" $178.42 $168.01 $168.01 $755.09 "$2,386.14" $0.00 $0.00 $0.00 $0.00 36100963 EAP CPT® 57461 Colposcopy W/leep Cone BOTH IP/OP "$8,498.00 " "$6,288.52" $194.34 "$6,816.80" "$2,984.10" "$2,984.10" "$2,555.04" "$2,555.04" "$2,569.43" "$1,771.20" "$1,257.08" "$1,257.08" "$1,305.43" "$2,514.14" "$1,770.98" "$1,634.19" "$2,836.00" "$2,836.00" "$2,505.44" "$2,255.00" "$6,748.63" "$6,816.80" "$3,480.98" "$3,250.00" "$3,480.98" $325.94 $194.34 $194.34 "$1,356.54" "$2,386.14" $0.00 $0.00 $0.00 $0.00 36100964 EAP CPT® 57500 Cervical Biopsy BOTH IP/OP "$3,362.00 " "$2,487.88" $71.26 "$2,683.20" "$2,321.55" "$2,321.55" $617.38 $617.38 $620.86 $700.72 "$1,257.08" "$1,257.08" "$1,305.43" $607.07 $700.64 $394.60 "$1,871.00" "$1,871.00" $640.34 "$2,255.00" "$2,656.37" "$2,683.20" $889.66 "$2,150.00" $889.66 $71.26 $78.23 $78.23 $533.96 $609.84 $0.00 $0.00 $0.00 $0.00 36100967 EAP CPT® 57511 "Cryosurgery, Cervix" BOTH IP/OP $785.00 $580.90 $0.00 $793.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.59 $0.00 $0.00 $0.00 $0.00 $793.00 $628.06 $634.40 $0.00 $785.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100968 EAP CPT® 57522 Leep + Ecc + Cone BOTH IP/OP "$8,652.00 " "$6,402.48" $255.93 "$6,991.20" "$2,753.10" "$2,753.10" "$2,555.04" "$2,555.04" "$2,569.43" "$1,803.29" "$1,541.95" "$1,541.95" "$1,601.25" "$2,514.14" "$1,803.08" "$1,634.19" "$2,836.00" "$2,836.00" "$2,505.44" "$2,327.00" "$6,921.29" "$6,991.20" "$3,480.98" "$3,250.00" "$3,480.98" $255.93 $259.91 $259.91 "$1,391.25" "$2,386.14" $0.00 $0.00 $0.00 $0.00 36100969 EAP CPT® 57720 Revision Of Cervix BOTH IP/OP "$6,223.00 " "$4,605.02" $0.00 "$5,028.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,296.87" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,978.51" "$5,028.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100970 EAP CPT® 58100 Endometrial Biopsy BOTH IP/OP $343.00 $253.82 $55.08 $652.00 $343.00 $343.00 $165.90 $165.90 $166.84 $71.49 $343.00 $343.00 $343.00 $163.24 $71.48 $106.10 $113.00 $113.00 $166.54 $346.00 $274.03 $276.80 $231.38 $652.00 $231.38 $59.72 $67.07 $67.07 $55.08 $158.61 $0.00 $0.00 $0.00 $0.00 36100971 EAP CPT® 0237T "Atherectomy, Branchiocephalic Artery" BOTH IP/OP "$12,918.00 " "$9,559.32" $0.00 "$10,334.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,692.11" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$10,231.06" "$10,334.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100972 EAP CPT® 0236T "Atherectomy, Aorta" BOTH IP/OP "$24,595.00 " "$18,200.30" $0.00 "$19,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,125.60" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$19,479.24" "$19,676.00" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100973 EAP CPT® 0234T "Atherectomy, Renal Artery" BOTH IP/OP "$24,595.00 " "$18,200.30" $0.00 "$19,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,125.60" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$19,479.24" "$19,676.00" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100974 EAP CPT® 58110 Endometrial Bx In Conj W/colp BOTH IP/OP $238.00 $176.12 $0.00 $238.00 $238.00 $238.00 $0.00 $0.00 $0.00 $49.61 $0.00 $0.00 $0.00 $0.00 $49.60 $0.00 $140.78 $140.78 $0.00 $120.00 $190.08 $192.00 $0.00 $238.00 $0.00 $50.14 $42.91 $42.91 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 36100975 EAP CPT® 0238T "Atherectomy, Lilac Artery" BOTH IP/OP "$18,351.00 " "$13,579.74" $0.00 "$14,680.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,824.35" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$14,533.99" "$14,680.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100978 EAP CPT® 58300 Insertion Iud BOTH IP/OP $676.00 $500.24 $0.00 "$1,381.00" $676.00 $676.00 $0.00 $0.00 $51.66 $140.90 $0.00 $0.00 $0.00 $0.00 $140.88 $0.00 $113.00 $113.00 $0.00 $675.00 $534.60 $540.00 $405.00 "$1,381.00" $405.00 $69.90 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 36100980 EAP CPT® 37197 Retrieve Fb Percut Intravascul W/ S And I BOTH IP/OP "$28,818.00 " "$21,325.32" $0.00 "$26,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,005.67" $0.00 $0.00 $0.00 "$2,779.42" "$2,858.00" "$26,126.50" "$26,390.40" "$3,861.64" "$3,725.00" "$3,861.64" $0.00 $315.16 $315.16 "$5,251.69" "$2,647.07" $0.00 $0.00 $0.00 $0.00 36100981 EAP CPT® 36221 Non Sel Cath Plac Aort W Angio Inc S/i BOTH IP/OP "$67,249.00 " "$49,764.26" $0.00 "$45,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$14,014.69" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$44,850.96" "$45,304.00" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100982 EAP CPT® 36222 Sel Cath Plac Ext Carotid Angio W S&i BOTH IP/OP "$19,446.00 " "$14,390.04" $0.00 "$13,100.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,053.03" $0.00 $0.00 $0.00 "$2,742.67" "$4,052.55" "$1,782.74" "$4,877.00" "$4,877.00" $0.00 "$2,858.00" "$12,969.79" "$13,100.80" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100983 EAP CPT® 58301 "Iud, Removal" BOTH IP/OP $281.00 $207.94 $0.00 "$1,279.00" $281.00 $281.00 $274.65 $274.65 $276.20 $58.57 $0.00 $0.00 $0.00 $269.78 $58.56 $175.35 $281.00 $281.00 $271.52 $280.00 $221.76 $224.00 $280.00 "$1,279.00" $280.00 $81.66 $70.31 $70.31 $44.58 $258.59 $0.00 $0.00 $0.00 $0.00 36100984 EAP CPT® 36223 Sel Cath Plac Common/inom Intracranial Carotid BOTH IP/OP "$18,704.00 " "$13,840.96" $330.96 "$12,600.00" "$2,753.10" "$2,753.10" "$4,643.92" "$4,643.92" "$4,670.08" "$3,898.38" "$2,192.53" "$2,192.53" "$2,276.86" "$4,572.02" "$3,897.91" "$2,971.81" "$4,877.00" "$4,877.00" "$4,609.70" "$2,858.00" "$12,474.00" "$12,600.00" "$6,404.56" "$3,725.00" "$6,404.56" "$1,513.65" $330.96 $330.96 "$2,507.40" "$4,390.19" $0.00 $0.00 $0.00 $0.00 36100985 EAP CPT® 36224 Sel Cath Plac Internalcarotid Intracranial Carotid BOTH IP/OP "$21,402.00 " "$15,837.48" $376.00 "$14,417.60" "$2,984.10" "$2,984.10" "$4,643.92" "$4,643.92" "$4,670.08" "$4,460.71" "$2,192.53" "$2,192.53" "$2,276.86" "$4,572.02" "$4,460.18" "$2,971.81" "$4,877.00" "$4,877.00" "$4,609.70" "$4,975.00" "$14,273.42" "$14,417.60" "$6,404.56" "$4,334.00" "$6,404.56" "$1,644.17" $376.00 $376.00 "$2,869.10" "$4,390.19" $0.00 $0.00 $0.00 $0.00 36100986 EAP CPT® 36225 "Sel Cath Plac Sub Clav,/innom Uni W/angio And S/i" BOTH IP/OP "$18,704.00 " "$13,840.96" $0.00 "$12,600.00" "$2,753.10" "$2,753.10" "$2,787.76" "$2,787.76" "$2,803.47" "$3,898.38" "$1,826.79" "$1,826.79" "$1,897.05" "$2,742.67" "$3,897.91" "$1,782.74" "$4,877.00" "$4,877.00" $0.00 "$2,858.00" "$12,474.00" "$12,600.00" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100987 EAP CPT® 36226 "Sel Cath Plac Sub Clav,/vert W/angio And S/i" BOTH IP/OP "$60,254.00 " "$44,587.96" $370.60 "$40,591.20" "$2,984.10" "$2,984.10" "$4,643.92" "$4,643.92" "$4,670.08" "$9,417.94" "$2,192.53" "$2,192.53" "$2,276.86" "$4,572.02" "$12,556.93" "$2,971.81" "$4,877.00" "$4,877.00" "$4,609.70" "$4,975.00" "$40,185.29" "$40,591.20" "$6,404.56" "$4,334.00" "$6,404.56" "$1,676.21" $370.60 $370.60 "$8,077.65" "$4,390.19" $0.00 $0.00 $0.00 $0.00 36100988 EAP CPT® 36227 Sel Cath Plac Ext Carotid Angio W S&i BOTH IP/OP "$18,704.00 " "$13,840.96" $0.00 "$12,600.00" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 "$3,898.38" $0.00 $0.00 $0.00 $0.00 "$3,897.91" $0.00 "$4,877.00" "$4,877.00" $0.00 "$7,875.00" "$12,474.00" "$12,600.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100989 EAP CPT® 58340 Inject Hysterosalpingography BOTH IP/OP "$1,109.00 " $820.66 $0.00 "$1,233.00" "$1,109.00" "$1,109.00" $0.00 $0.00 $0.00 $231.14 $0.00 $0.00 $0.00 $0.00 $231.12 $0.00 $655.97 $655.97 $0.00 "$1,055.00" $835.56 $844.00 $0.00 "$1,233.00" $0.00 $214.45 $59.48 $59.48 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 36100990 EAP CPT® 58345 Transcervical Intro Of Cathete BOTH IP/OP "$6,236.00 " "$4,614.64" $0.00 "$4,988.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,299.58" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,938.91" "$4,988.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100991 EAP CPT® 58558 "Hysteroscopy, Biopsy" BOTH IP/OP "$5,957.00 " "$4,408.18" $0.00 "$4,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,241.44" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,486.68" "$4,532.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36100993 EAP CPT® 59000 Amniocentesis Us BOTH IP/OP "$1,106.00 " $818.44 $83.99 "$1,117.00" "$1,106.00" "$1,106.00" $617.38 $617.38 $620.86 $230.52 "$1,106.00" "$1,106.00" "$1,106.00" $607.07 $230.49 $394.60 $654.20 $654.20 $640.34 "$1,117.00" $884.66 $893.60 $889.66 "$1,106.00" $889.66 $95.25 $83.99 $83.99 $177.83 $609.84 $0.00 $0.00 $0.00 $0.00 36100999 EAP CPT® 59200 Insert Cervical Dilator BOTH IP/OP $760.00 $562.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.38 $0.00 $0.00 $0.00 $0.00 $768.00 $608.26 $614.40 $0.00 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101000 EAP CPT® 59300 Episitomy/vaginal Repair BOTH IP/OP "$6,453.00 " "$4,775.22" $0.00 "$7,432.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,916.86" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,358.47" "$7,432.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101001 EAP CPT® 59414 Delivery Of Placenta BOTH IP/OP "$6,078.00 " "$4,497.72" $0.00 "$4,877.00" "$3,300.35" "$3,300.35" "$2,555.04" "$2,555.04" "$2,569.43" "$1,266.81" $0.00 $0.00 $0.00 "$2,514.14" "$1,266.66" "$1,634.19" "$4,877.00" "$4,877.00" $0.00 "$2,255.00" "$4,813.78" "$4,862.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101002 EAP CPT® 59525 Remove Uterus After Cesarean BOTH IP/OP "$7,130.00 " "$5,276.20" $0.00 "$7,040.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,485.89" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,970.39" "$7,040.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101003 EAP CPT® 59812 Trtmt Of Spontaneous Abortion BOTH IP/OP "$3,629.00 " "$2,685.46" $267.54 "$3,666.00" "$3,629.00" "$3,629.00" "$2,555.04" "$2,555.04" "$2,569.43" $756.37 "$2,571.13" "$2,571.13" "$2,670.02" "$2,514.14" $756.28 "$1,634.19" "$3,629.00" "$3,629.00" "$2,505.44" "$3,666.00" "$2,903.47" "$2,932.80" "$3,480.98" "$3,250.00" "$3,480.98" $267.54 $316.83 $316.83 $583.63 "$2,386.14" $0.00 $0.00 $0.00 $0.00 36101004 EAP CPT® 59820 Trmt Of Missed Abort.-1st Trim BOTH IP/OP "$3,769.00 " "$2,789.06" $0.00 "$3,807.00" "$3,769.00" "$3,769.00" "$2,555.04" "$2,555.04" "$2,569.43" $785.55 "$2,571.13" "$2,571.13" "$2,670.02" "$2,514.14" $785.46 "$1,634.19" "$3,769.00" "$3,769.00" $0.00 "$3,807.00" "$3,015.14" "$3,045.60" $0.00 "$3,250.00" $0.00 $302.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101005 EAP CPT® 59840 Ind/abortion/dilation&curettag BOTH IP/OP "$3,706.00 " "$2,742.44" $0.00 "$3,743.00" "$3,706.00" "$3,706.00" "$2,555.04" "$2,555.04" "$2,569.43" $772.42 "$2,571.13" "$2,571.13" "$2,670.02" "$2,514.14" $772.33 "$1,634.19" "$3,706.00" "$3,706.00" $0.00 "$3,743.00" "$2,964.46" "$2,994.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101007 EAP CPT® 59855 Abortion By Vag. Sup. Insert BOTH IP/OP "$1,807.00 " "$1,337.18" $0.00 "$1,825.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $376.58 $0.00 $0.00 $0.00 $0.00 "$1,825.00" "$1,445.40" "$1,460.00" $0.00 "$1,186.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101008 EAP CPT® 59855 Induced Abortion After 16 Wks BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,825.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.33 $0.00 $0.00 $0.00 $0.00 "$1,825.00" "$1,445.40" "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101009 EAP CPT® 59871 Removal Ceralage Suture BOTH IP/OP "$3,549.00 " "$2,626.26" $0.00 "$3,585.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $739.61 $0.00 $0.00 $0.00 $0.00 "$3,585.00" "$2,839.32" "$2,868.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101010 EAP CPT® 59871 Remove Cerclage Suture BOTH IP/OP "$3,549.00 " "$2,626.26" $0.00 "$3,585.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $739.61 $0.00 $0.00 $0.00 $0.00 "$3,585.00" "$2,839.32" "$2,868.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101011 EAP CPT® 60100 BX THYROID PERC NEEDLE BCT BOTH IP/OP $760.00 $562.40 $81.14 "$2,150.00" $760.00 $760.00 $606.01 $606.01 $609.42 $158.40 $760.00 $760.00 $760.00 $596.11 $158.38 $387.47 $760.00 $760.00 $611.80 $760.00 $601.92 $608.00 $760.00 "$2,150.00" $760.00 $93.18 $81.14 $81.14 $120.99 $582.67 $0.00 $0.00 $0.00 $0.00 36101012 EAP CPT® 60100 Bx Thyroid Us BOTH IP/OP $762.00 $563.88 $81.14 "$2,150.00" $762.00 $762.00 $606.01 $606.01 $609.42 $158.82 $762.00 $762.00 $762.00 $596.11 $158.80 $387.47 $762.00 $762.00 $611.80 $760.00 $601.92 $608.00 $760.00 "$2,150.00" $760.00 $93.18 $81.14 $81.14 $120.99 $582.67 $0.00 $0.00 $0.00 $0.00 36101013 EAP CPT® 60100 Thyroid Biopsy Perc Needle BOTH IP/OP $760.00 $562.40 $0.00 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.40 $0.00 $0.00 $0.00 $596.11 $158.38 $387.47 $760.00 $760.00 $611.80 $760.00 $601.92 $608.00 $760.00 $0.00 $760.00 $93.18 $81.14 $81.14 $120.99 $582.67 $0.00 $0.00 $0.00 $0.00 36101015 EAP CPT® 61070 PUNCT SHUNT TUBE/RESERVO BCT BOTH IP/OP "$2,212.00 " "$1,636.88" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $460.98 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,798.63" "$1,816.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101016 EAP CPT® 61624 EMBOLIZA INTRACRAN/SP CORD SPN BOTH IP/OP "$12,218.00 " "$9,041.32" $0.00 "$13,594.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,546.23" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$8,942.47" "$9,032.80" $0.00 "$13,594.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101019 EAP CPT® 61626 Embolization Extracranial BOTH IP/OP "$27,904.00 " "$20,648.96" $0.00 "$20,629.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,815.19" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$20,423.30" "$20,629.60" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101020 EAP CPT® 61630 Intracranial Angioplasty BOTH IP/OP "$20,055.00 " "$14,840.70" $0.00 "$14,826.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,179.46" $0.00 $0.00 $0.00 "$1,522.96" "$9,266.50" "$14,678.14" "$14,826.40" "$1,424.57" "$8,895.25" "$1,424.57" "$2,900.41" "$1,424.57" "$1,424.57" "$2,950.45" "$1,424.57" $0.00 $0.00 $0.00 $0.00 36101021 EAP CPT® 61635 Intracran Angioplasty W/stent BOTH IP/OP "$31,953.00 " "$23,645.22" $0.00 "$23,623.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,659.01" $0.00 $0.00 $0.00 "$1,621.20" "$14,764.50" "$23,386.97" "$23,623.20" "$1,514.43" "$11,306.10" "$1,514.43" "$1,268.01" "$1,514.43" "$1,514.43" "$4,701.02" "$1,514.43" $0.00 $0.00 $0.00 $0.00 36101022 EAP CPT® 61640 "Dilate Ic Vasospasm, Init" BOTH IP/OP "$30,077.00 " "$22,256.98" $0.00 "$22,236.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,268.05" $0.00 $0.00 $0.00 $0.00 "$13,897.50" "$22,013.64" "$22,236.00" $0.00 "$6,088.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101023 EAP CPT® 61642 Dilate Ic Vasospasm Add-on BOTH IP/OP "$26,318.00 " "$19,475.32" $0.00 "$19,456.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,484.67" $0.00 $0.00 $0.00 $0.00 "$12,160.50" "$19,262.23" "$19,456.80" $0.00 "$5,218.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101024 EAP CPT® 61710 Emblz Carotid Cavern Fistula BOTH IP/OP "$13,680.00 " "$10,123.20" $0.00 "$11,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,850.91" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$11,122.85" "$11,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101025 EAP CPT® 62268 SPINAL CORD CYST PERC ASPI BCT BOTH IP/OP "$3,101.00 " "$2,294.74" $0.00 "$2,475.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $646.25 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,450.45" "$2,475.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101026 EAP CPT® 62269 BX SPINAL CORD PERC NEEDLE BCT BOTH IP/OP "$3,394.00 " "$2,511.56" $0.00 "$2,708.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $707.31 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,681.71" "$2,708.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101027 EAP CPT® 62270 Dx Lumbar Puncture W/o Imaging BOTH IP/OP $835.00 $617.90 $64.55 "$2,150.00" $835.00 $835.00 $618.38 $618.38 $621.87 $174.03 $835.00 $835.00 $835.00 $608.20 $174.01 $395.33 $835.00 $835.00 $626.89 $635.00 $502.92 $508.00 $635.00 "$2,150.00" $635.00 $120.04 $64.55 $64.55 $101.09 $597.04 $0.00 $0.00 $0.00 $0.00 36101032 EAP CPT® 62272 Therapeutic Lumbar Puncture W/o Imaging BOTH IP/OP $923.00 $683.02 $0.00 $923.00 $923.00 $923.00 $618.38 $618.38 $621.87 $192.38 $923.00 $923.00 $923.00 $608.20 $192.35 $395.33 $923.00 $923.00 $0.00 $877.00 $694.58 $701.60 $0.00 $923.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101033 EAP CPT® 55876 Placement Of Prostate Fiducial Markers BOTH IP/OP "$3,543.00 " "$2,621.82" $0.00 "$2,827.20" "$2,321.55" "$2,321.55" "$1,229.74" "$1,229.74" "$1,236.66" $738.45 $0.00 $0.00 $0.00 "$1,209.70" $738.36 $786.30 "$1,871.00" "$1,871.00" "$1,249.00" "$2,255.00" "$2,798.93" "$2,827.20" "$1,735.32" "$2,459.00" "$1,735.32" $138.46 $104.92 $104.92 $562.61 "$1,189.52" $0.00 $0.00 $0.00 $0.00 36101039 EAP CPT® 62273 Injection Epidural Blood Patch BOTH IP/OP "$1,679.00 " "$1,242.46" $0.00 "$1,679.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.90 $0.00 $0.00 $0.00 $626.89 "$1,596.00" "$1,264.03" "$1,276.80" $870.98 "$1,679.00" $870.98 $123.36 $117.56 $117.56 $254.08 $597.04 $0.00 $0.00 $0.00 $0.00 36101040 EAP CPT® 62280 Inject Subarachnoid Neurolytic BOTH IP/OP "$1,845.00 " "$1,365.30" $0.00 "$1,845.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.50 $0.00 $0.00 $0.00 $0.00 "$1,845.00" "$1,461.24" "$1,476.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101041 EAP CPT® 62282 Epidur Lumbar Sacral Neurolyti BOTH IP/OP "$1,751.00 " "$1,295.74" $0.00 "$1,751.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $364.91 $0.00 $0.00 $0.00 $0.00 "$1,751.00" "$1,386.79" "$1,400.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101042 EAP CPT® 62284 Injection Myelo/ct Spinal BOTH IP/OP "$1,572.00 " "$1,163.28" $0.00 "$1,572.00" "$1,572.00" "$1,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $327.60 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$1,183.25" "$1,195.20" $0.00 "$1,572.00" $0.00 $158.11 $90.14 $90.14 $237.84 $0.00 $0.00 $0.00 $0.00 $0.00 36101043 EAP CPT® 62287 Aspir Perc Diskectomy BOTH IP/OP "$6,339.00 " "$4,690.86" $0.00 "$6,105.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,321.05" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$5,020.49" "$5,071.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101044 EAP CPT® 62290 Inject Diskography Ea Lev Lumb BOTH IP/OP "$2,963.00 " "$2,192.62" $0.00 "$2,370.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $617.49 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,346.70" "$2,370.40" $0.00 "$1,606.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101045 EAP CPT® 62291 Inject Diskography Ea Lev Cerv BOTH IP/OP "$2,594.00 " "$1,919.56" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $540.59 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,054.45" "$2,075.20" $0.00 "$1,664.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101048 EAP CPT® 63650 Implant Neuroelectrodes BOTH IP/OP "$16,380.00 " "$12,121.20" $0.00 "$13,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,413.59" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$12,972.96" "$13,104.00" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101049 EAP CPT® 64408 Inj Anes/strd Cranial/vagus Nerve BOTH IP/OP "$1,831.00 " "$1,354.94" $0.00 "$2,005.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $381.58 $0.00 $0.00 $0.00 $0.00 "$2,005.00" "$1,587.96" "$1,604.00" $0.00 "$1,019.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101051 EAP CPT® 64425 Inj Anes/strd Ilioinguinal/iliohypogastric Nerve BOTH IP/OP "$3,566.00 " "$2,638.84" $0.00 "$2,752.80" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $743.24 "$1,257.08" "$1,257.08" "$1,305.43" $608.20 $743.15 $395.33 "$1,871.00" "$1,871.00" $626.89 "$2,255.00" "$2,725.27" "$2,752.80" $870.98 "$2,150.00" $870.98 $0.00 $57.69 $57.69 $547.81 $597.04 $0.00 $0.00 $0.00 $0.00 36101052 EAP CPT® 64450 Inj Anes/strd Other Peripheral Nerve BOTH IP/OP "$2,850.00 " "$2,109.00" $44.35 "$2,321.55" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $594.01 "$1,257.08" "$1,257.08" "$1,305.43" $608.20 $593.94 $395.33 "$1,871.00" "$1,871.00" $626.89 "$2,255.00" "$2,178.00" "$2,200.00" $870.98 "$2,150.00" $870.98 $85.27 $44.35 $44.35 $437.80 $597.04 $0.00 $0.00 $0.00 $0.00 36101059 EAP CPT® 64483 Inject Anest Txforamen L/s Sng BOTH IP/OP "$1,767.00 " "$1,307.58" $115.74 "$1,767.00" "$1,767.00" "$1,767.00" $801.66 $801.66 $806.18 $368.29 "$1,257.08" "$1,257.08" "$1,305.43" $788.26 $368.24 $512.37 "$1,767.00" "$1,767.00" $814.44 "$1,705.00" "$1,350.36" "$1,364.00" "$1,131.55" "$1,767.00" "$1,131.55" $197.93 $115.74 $115.74 $271.44 $775.65 $0.00 $0.00 $0.00 $0.00 36101061 EAP CPT® 64484 Transfor Inj Lum/sac Addt Spn BOTH IP/OP "$1,767.00 " "$1,307.58" $0.00 "$1,767.00" "$1,767.00" "$1,767.00" $0.00 $0.00 $0.00 $368.29 "$1,257.08" "$1,257.08" "$1,305.43" $0.00 $368.24 $0.00 "$1,045.18" "$1,045.18" $0.00 "$1,705.00" "$1,350.36" "$1,364.00" $0.00 "$1,750.00" $0.00 $183.06 $54.09 $54.09 $271.44 $0.00 $0.00 $0.00 $0.00 $0.00 36101062 EAP CPT® 64520 Inject Anest Lumbar Thoracic BOTH IP/OP "$5,436.00 " "$4,022.64" $0.00 "$4,196.00" "$2,321.55" "$2,321.55" $801.66 $801.66 $806.18 "$1,133.00" "$1,257.08" "$1,257.08" "$1,305.43" $788.26 "$1,132.86" $512.37 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$4,154.04" "$4,196.00" $0.00 "$2,150.00" $0.00 $125.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101064 EAP CPT® 64530 "N Block Inj, Celiac Pelus" BOTH IP/OP "$8,849.00 " "$6,548.26" $0.00 "$6,830.40" "$2,321.55" "$2,321.55" $801.66 $801.66 $806.18 "$1,844.35" "$1,257.08" "$1,257.08" "$1,305.43" $788.26 "$1,844.13" $512.37 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$6,762.10" "$6,830.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101065 EAP CPT® 64612 Chemodenerve Mus Inv Fac Nerve BOTH IP/OP $728.00 $538.72 $0.00 "$1,199.00" $728.00 $728.00 $254.43 $254.43 $255.86 $151.73 $0.00 $0.00 $0.00 $250.31 $151.72 $162.70 $728.00 $728.00 $262.54 $732.00 $579.74 $585.60 $364.76 "$1,199.00" $364.76 $151.15 $120.74 $120.74 $116.53 $250.04 $0.00 $0.00 $0.00 $0.00 36101070 EAP CPT® 64640 Destr Peripheral Nerve BOTH IP/OP "$2,501.00 " "$1,850.74" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.44 "$2,255.00" "$1,980.79" "$2,000.80" "$1,131.55" $0.00 "$1,131.55" $198.96 $121.87 $121.87 $398.16 $775.65 $0.00 $0.00 $0.00 $0.00 36101072 EAP CPT® 64680 Destr Neurolyitc Celiac Plexus BOTH IP/OP "$4,672.00 " "$3,457.28" $0.00 "$3,737.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $973.64 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,700.22" "$3,737.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101075 EAP CPT® 65205 "Fb Removal, Eye" BOTH IP/OP $378.00 $279.72 $0.00 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $382.00 $302.54 $305.60 $0.00 $378.00 $0.00 $132.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101076 EAP CPT® 65205 Remove Fb Eye Conj Superficial BOTH IP/OP $313.00 $231.62 $0.00 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $382.00 $302.54 $305.60 $0.00 $378.00 $0.00 $132.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101077 EAP CPT® 65222 Remove Fb Eye Corneal W/sl BOTH IP/OP $800.00 $592.00 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.74 $0.00 $0.00 $0.00 $107.30 $166.72 $69.74 $113.00 $113.00 $0.00 $808.00 $639.94 $646.40 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101078 EAP CPT® 65270 Repair Laceration Conjunctiva BOTH IP/OP "$4,186.00 " "$3,097.64" $0.00 "$3,380.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $872.36 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,346.99" "$3,380.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101079 EAP CPT® 65275 Rpr Lacer Cornea Non-perfor BOTH IP/OP "$8,972.00 " "$6,639.28" $0.00 "$7,247.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,869.76" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$7,174.73" "$7,247.20" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101080 EAP CPT® 65286 Cornea Sclera Wound Tissue Glu BOTH IP/OP "$3,275.00 " "$2,423.50" $0.00 "$2,817.36" "$2,753.10" "$2,753.10" "$2,022.30" "$2,022.30" "$2,033.69" $682.59 $0.00 $0.00 $0.00 "$1,992.71" $682.51 "$1,295.26" "$1,871.00" "$1,871.00" "$2,027.80" "$2,255.00" "$2,619.14" "$2,645.60" "$2,817.36" "$2,500.00" "$2,817.36" $433.21 $506.49 $506.49 $526.47 "$1,931.24" $0.00 $0.00 $0.00 $0.00 36101081 EAP CPT® 65290 Repair Wound Extraocular Muscl BOTH IP/OP "$4,425.00 " "$3,274.50" $0.00 "$4,326.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $922.17 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,283.14" "$4,326.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101082 EAP CPT® 65400 Excise Lesn Cornea Not Pterygm BOTH IP/OP "$5,997.00 " "$4,437.78" $0.00 "$4,844.00" "$2,321.55" "$2,321.55" $788.63 $788.63 $793.07 "$1,249.92" "$1,257.08" "$1,257.08" "$1,305.43" $775.88 "$1,249.77" $504.32 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$4,795.56" "$4,844.00" $0.00 "$2,150.00" $0.00 $484.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101083 EAP CPT® 65410 Biopsy Of Cornea BOTH IP/OP "$3,307.00 " "$2,447.18" $0.00 "$2,645.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $563.93 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,619.14" "$2,645.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101084 EAP CPT® 65420 Excise Pterygium W/o Graft BOTH IP/OP "$2,706.00 " "$2,002.44" $0.00 "$2,645.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $563.93 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,619.14" "$2,645.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101085 EAP CPT® 65430 Scraping Cornea Diagnostic BOTH IP/OP $525.00 $388.50 $0.00 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.45 $0.00 $0.00 $0.00 $0.00 $530.00 $419.76 $424.00 $0.00 $525.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101086 EAP CPT® 65772 Relax Cornea Incision Astigmat BOTH IP/OP "$4,930.00 " "$3,648.20" $0.00 "$4,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,027.41" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$4,771.80" "$4,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101087 EAP CPT® 65800 Paracentesis Ant Chamb Eye Wdx BOTH IP/OP "$4,717.00 " "$3,490.58" $0.00 "$3,773.60" $0.00 $0.00 $0.00 $0.00 $0.00 $973.76 $0.00 $0.00 $0.00 "$1,992.71" $973.64 "$1,295.26" "$1,871.00" "$1,871.00" "$2,027.80" "$2,255.00" "$3,735.86" "$3,773.60" "$2,817.36" "$1,750.00" "$2,817.36" $0.00 $93.03 $93.03 $750.95 "$1,931.24" $0.00 $0.00 $0.00 $0.00 36101089 EAP CPT® 65815 Eye Paracentesis Ant Blood Rem BOTH IP/OP "$7,374.00 " "$5,456.76" $0.00 "$7,208.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,536.74" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,136.71" "$7,208.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101090 EAP CPT® 65855 Trabeculoplasty By Laser BOTH IP/OP "$2,930.00 " "$2,168.20" $211.62 "$2,753.10" "$2,753.10" "$2,753.10" $490.09 $490.09 $492.86 $610.69 "$2,571.13" "$2,571.13" "$2,670.02" $482.91 $610.61 $313.89 "$1,871.00" "$1,871.00" $508.42 "$2,255.00" "$2,344.32" "$2,368.00" $706.38 "$2,150.00" $706.38 $354.58 $211.62 $211.62 $471.23 $484.21 $0.00 $0.00 $0.00 $0.00 36101091 EAP CPT® 65860 Incise Inner Eye Adhesions BOTH IP/OP "$1,369.00 " "$1,013.06" $0.00 "$1,475.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.30 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$1,168.20" "$1,180.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101092 EAP CPT® 66250 Repair Operative Wound Ant Eye BOTH IP/OP "$3,567.00 " "$2,639.58" $0.00 "$2,853.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $743.36 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,825.06" "$2,853.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101093 EAP CPT® 66710 Destruction Ciliary Body BOTH IP/OP "$4,407.00 " "$3,261.18" $399.78 "$3,561.60" "$2,753.10" "$2,753.10" "$1,948.73" "$1,948.73" "$1,959.70" $918.53 "$1,541.95" "$1,541.95" "$1,601.25" "$1,919.09" $918.42 "$1,247.41" "$2,836.00" "$2,836.00" "$1,940.89" "$2,327.00" "$3,525.98" "$3,561.60" "$2,696.60" "$3,250.00" "$2,696.60" $412.49 $399.78 $399.78 $708.76 "$1,848.46" $0.00 $0.00 $0.00 $0.00 36101094 EAP CPT® 66710 Transscleral Cyclophotocoagula BOTH IP/OP "$4,407.00 " "$3,261.18" $399.78 "$3,561.60" "$2,753.10" "$2,753.10" "$1,948.73" "$1,948.73" "$1,959.70" $918.53 "$1,541.95" "$1,541.95" "$1,601.25" "$1,919.09" $918.42 "$1,247.41" "$2,836.00" "$2,836.00" "$1,940.89" "$2,327.00" "$3,525.98" "$3,561.60" "$2,696.60" "$3,250.00" "$2,696.60" $412.49 $399.78 $399.78 $708.76 "$1,848.46" $0.00 $0.00 $0.00 $0.00 36101095 EAP CPT® 66720 Destroy Ciliary Body Cryother BOTH IP/OP "$2,644.00 " "$1,956.56" $0.00 "$2,327.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $551.01 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,156.62" "$2,178.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101096 EAP CPT® 66761 Iridotomy Laser Surgery BOTH IP/OP "$7,642.00 " "$5,655.08" $0.00 "$6,175.20" "$2,321.55" "$2,321.55" $490.09 $490.09 $492.86 "$1,592.78" $0.00 $0.00 $0.00 $482.91 "$1,592.59" $313.89 "$1,871.00" "$1,871.00" $508.42 "$2,255.00" "$6,113.45" "$6,175.20" $706.38 "$2,150.00" $706.38 $315.03 $240.80 $240.80 "$1,228.86" $484.21 $0.00 $0.00 $0.00 $0.00 36101097 EAP CPT® 66762 Iridoplasty Photocoagulation BOTH IP/OP "$1,046.00 " $774.04 $0.00 "$1,057.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.99 $0.00 $0.00 $0.00 $508.42 "$1,057.00" $837.14 $845.60 $706.38 "$1,046.00" $706.38 $348.17 $432.93 $432.93 $168.27 $484.21 $0.00 $0.00 $0.00 $0.00 36101098 EAP CPT® 66821 Yag Laser Capsulotomy BOTH IP/OP "$2,125.00 " "$1,572.50" $188.16 "$2,146.00" "$2,125.00" "$2,125.00" $490.09 $490.09 $492.86 $442.90 "$1,541.95" "$1,541.95" "$1,601.25" $482.91 $442.85 $313.89 "$2,125.00" "$2,125.00" $508.42 "$2,146.00" "$1,699.63" "$1,716.80" $706.38 "$2,125.00" $706.38 $188.16 $317.54 $317.54 $341.64 $484.21 $0.00 $0.00 $0.00 $0.00 36101099 EAP CPT® 67015 Posterior Sclerotomy BOTH IP/OP "$15,938.00 " "$11,794.12" $0.00 "$12,750.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,321.48" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$12,622.90" "$12,750.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101100 EAP CPT® 67025 Inject Vitreous Pars Pla/limbl BOTH IP/OP "$8,619.00 " "$6,378.06" $643.81 "$6,964.80" "$2,321.55" "$2,321.55" "$2,022.30" "$2,022.30" "$2,033.69" "$1,796.42" "$1,257.08" "$1,257.08" "$1,305.43" "$1,992.71" "$1,796.20" "$1,295.26" "$1,871.00" "$1,871.00" "$2,027.80" "$2,255.00" "$6,895.15" "$6,964.80" "$2,817.36" "$3,250.00" "$2,817.36" $651.56 $643.81 $643.81 "$1,386.00" "$1,931.24" $0.00 $0.00 $0.00 $0.00 36101101 EAP CPT® 67028 Injection Intravitreal Drug BOTH IP/OP "$2,178.00 " "$1,611.72" $100.58 "$2,200.00" "$2,178.00" "$2,178.00" $310.51 $310.51 $312.26 $453.95 "$1,257.08" "$1,257.08" "$1,305.43" $297.83 $453.90 $193.59 "$1,871.00" "$1,871.00" $310.51 "$2,200.00" "$1,742.40" "$1,760.00" $431.41 "$1,750.00" $431.41 $307.74 $100.58 $100.58 $350.24 $295.72 $0.00 $0.00 $0.00 $0.00 36101102 EAP CPT® 67031 "Sever Vitreous, Laser" BOTH IP/OP "$2,310.00 " "$1,709.40" $0.00 "$2,310.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $481.40 $0.00 $0.00 $0.00 $0.00 "$2,310.00" "$1,829.52" "$1,848.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101103 EAP CPT® 67101 Retinal Detach Rpr Cryo/diath BOTH IP/OP "$7,769.00 " "$5,749.06" $0.00 "$6,277.60" "$3,735.90" "$3,735.90" "$2,022.30" "$2,022.30" "$2,033.69" $0.00 "$2,192.53" "$2,192.53" "$2,276.86" $0.00 "$1,619.06" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,214.82" "$6,277.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101104 EAP CPT® 67105 Repair Retinal Detach Laser BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,387.00" "$1,373.00" "$1,373.00" $490.09 $490.09 $492.86 $286.17 "$1,373.00" "$1,373.00" "$1,373.00" $482.91 $286.13 $313.89 "$1,373.00" "$1,373.00" $0.00 "$1,387.00" "$1,098.50" "$1,109.60" $0.00 "$1,373.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101105 EAP CPT® 67141 Cryotherapy Retinal Tear BOTH IP/OP "$1,917.00 " "$1,418.58" $0.00 "$1,917.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $399.50 $0.00 $0.00 $0.00 $0.00 "$1,917.00" "$1,518.26" "$1,533.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101106 EAP CPT® 67145 Photocoagulation Retinal Tear BOTH IP/OP "$1,043.00 " $771.82 $0.00 "$1,054.00" "$1,043.00" "$1,043.00" $490.09 $490.09 $492.86 $217.39 $0.00 $0.00 $0.00 $482.91 $217.36 $313.89 "$1,043.00" "$1,043.00" $508.42 "$1,054.00" $834.77 $843.20 $706.38 "$1,043.00" $706.38 $412.94 $506.47 $506.47 $167.80 $484.21 $0.00 $0.00 $0.00 $0.00 36101107 EAP CPT® 67208 Destroy Lesion Retina Cryo/dia BOTH IP/OP "$4,906.00 " "$3,630.44" $0.00 "$3,964.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,022.41" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,925.15" "$3,964.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101108 EAP CPT® 67210 Destroy Lesion Retina Photocoa BOTH IP/OP "$1,009.00 " $746.66 $0.00 "$1,019.00" "$1,009.00" "$1,009.00" $490.09 $490.09 $492.86 $210.30 $0.00 $0.00 $0.00 $482.91 $210.28 $313.89 "$1,009.00" "$1,009.00" $0.00 "$1,019.00" $807.05 $815.20 $0.00 "$1,009.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101109 EAP CPT® 67220 Destr Choroid Lesion Phoptocoa BOTH IP/OP "$1,514.00 " "$1,120.36" $0.00 "$1,514.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.52 $0.00 $0.00 $0.00 $0.00 "$1,514.00" "$1,199.09" "$1,211.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101110 EAP CPT® 67227 Destroy Retinopathy Cryo/diath BOTH IP/OP "$4,468.00 " "$3,306.32" $0.00 "$3,574.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $931.13 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,538.66" "$3,574.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101111 EAP CPT® 67228 Destroy Retinopathy Photocoag BOTH IP/OP "$7,387.00 " "$5,466.38" $311.48 "$5,969.60" "$2,321.55" "$2,321.55" $490.09 $490.09 $492.86 "$1,539.64" "$1,257.08" "$1,257.08" "$1,305.43" $482.91 "$1,539.45" $313.89 "$1,871.00" "$1,871.00" $508.42 "$2,255.00" "$5,909.90" "$5,969.60" $706.38 "$2,150.00" $706.38 $821.55 $311.48 $311.48 "$1,187.95" $484.21 $0.00 $0.00 $0.00 $0.00 36101112 EAP CPT® 67335 Place Adjust Suture Strabismus BOTH IP/OP "$6,484.00 " "$4,798.16" $0.00 "$5,187.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,351.27" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$5,135.33" "$5,187.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101113 EAP CPT® 67345 Chemodenerv Extraocular Muscle BOTH IP/OP $846.00 $626.04 $0.00 $851.00 $846.00 $846.00 $254.74 $254.74 $256.18 $176.33 $0.00 $0.00 $0.00 $250.42 $176.31 $162.77 $846.00 $846.00 $0.00 $851.00 $673.99 $680.80 $0.00 $846.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101114 EAP CPT® 67415 Fna Orbital Contents BOTH IP/OP "$11,904.00 " "$8,808.96" $0.00 "$9,523.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,480.79" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$9,427.97" "$9,523.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101115 EAP CPT® 67500 Inject Medication Retrobulbar BOTH IP/OP $703.00 $520.22 $0.00 $703.00 $381.73 $381.73 $254.74 $254.74 $256.18 $146.52 $0.00 $0.00 $0.00 $250.42 $146.51 $162.77 $113.00 $113.00 $271.28 $639.00 $506.09 $511.20 $376.91 $703.00 $376.91 $179.43 $62.75 $62.75 $101.73 $258.37 $0.00 $0.00 $0.00 $0.00 36101116 EAP CPT® 67505 Inject Alcohol Retrobulbar BOTH IP/OP $843.00 $623.82 $0.00 $843.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.68 $0.00 $0.00 $0.00 $0.00 $843.00 $667.66 $674.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101117 EAP CPT® 67515 Inject Medication Tenon's Caps BOTH IP/OP "$2,002.00 " "$1,481.48" $0.00 "$1,871.00" $0.00 $0.00 $0.00 $0.00 $0.00 $417.27 $0.00 $0.00 $0.00 $250.42 $417.22 $162.77 "$1,871.00" "$1,871.00" $271.28 "$1,820.00" "$1,441.44" "$1,456.00" $376.91 "$1,750.00" $376.91 $137.37 $60.20 $60.20 $289.74 $258.37 $0.00 $0.00 $0.00 $0.00 36101118 EAP CPT® 67700 Blepharotomy Eyelid BOTH IP/OP "$1,339.00 " $990.86 $0.00 "$1,339.00" $0.00 $0.00 $0.00 $0.00 $0.00 $279.08 $0.00 $0.00 $0.00 $250.42 $279.05 $162.77 "$1,339.00" "$1,339.00" $0.00 "$1,339.00" "$1,060.49" "$1,071.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101119 EAP CPT® 67710 Severing Of Tarsorrhaphy BOTH IP/OP "$2,216.00 " "$1,639.84" $0.00 "$2,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $461.81 $0.00 $0.00 $0.00 $0.00 "$2,216.00" "$1,755.07" "$1,772.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101120 EAP CPT® 67715 Canthotomy BOTH IP/OP "$9,511.00 " "$7,038.14" $0.00 "$7,636.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,982.09" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,560.43" "$7,636.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101121 EAP CPT® 67800 Excise Chalazion Single BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,339.00" "$1,334.00" "$1,334.00" $254.74 $254.74 $256.18 $0.00 $0.00 $0.00 $0.00 $0.00 $278.01 $0.00 $0.00 $0.00 $271.28 "$1,339.00" "$1,060.49" "$1,071.20" $376.91 "$1,334.00" $376.91 $174.52 $104.90 $104.90 $213.17 $258.37 $0.00 $0.00 $0.00 $0.00 36101122 EAP CPT® 67801 Excise Chalazion Multiple BOTH IP/OP "$2,208.00 " "$1,633.92" $0.00 "$2,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $460.15 $0.00 $0.00 $0.00 $0.00 "$2,216.00" "$1,755.07" "$1,772.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101123 EAP CPT® 67805 "Excise Chalazion,mult,diff Lid" BOTH IP/OP "$1,668.00 " "$1,234.32" $0.00 "$1,674.00" "$1,668.00" "$1,668.00" $254.74 $254.74 $256.18 $347.65 $0.00 $0.00 $0.00 $250.42 $347.61 $162.77 "$1,668.00" "$1,668.00" $0.00 "$1,674.00" "$1,325.81" "$1,339.20" $0.00 "$1,668.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101124 EAP CPT® 67810 Biopsy Of Eyelid BOTH IP/OP "$1,150.00 " $851.00 $0.00 "$1,154.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $271.28 "$1,154.00" $913.97 $923.20 $376.91 "$1,150.00" $376.91 $152.92 $72.11 $72.11 $183.72 $258.37 $0.00 $0.00 $0.00 $0.00 36101125 EAP CPT® 67825 Correct Trichiasis Electrosurg BOTH IP/OP "$1,150.00 " $851.00 $0.00 "$1,154.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 "$1,154.00" $913.97 $923.20 $0.00 "$1,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101126 EAP CPT® 67840 Excise Lesion Eyelid Smpl Clos BOTH IP/OP "$2,572.00 " "$1,903.28" $160.78 "$2,572.00" "$2,572.00" "$2,572.00" $788.63 $788.63 $793.07 $536.07 "$1,257.08" "$1,257.08" "$1,305.43" $775.88 $536.00 $504.32 "$1,871.00" "$1,871.00" $809.34 "$2,255.00" "$2,044.15" "$2,064.80" "$1,124.47" "$2,150.00" "$1,124.47" $209.29 $160.78 $160.78 $410.90 $770.80 $0.00 $0.00 $0.00 $0.00 36101127 EAP CPT® 67875 Temporary Tarsorraphy BOTH IP/OP "$3,736.00 " "$2,764.64" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $778.68 $0.00 $0.00 $0.00 $775.88 $778.58 $504.32 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$2,970.00" "$3,000.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101128 EAP CPT® 67880 Construct Intemar Adhes Etc. BOTH IP/OP "$7,543.00 " "$5,581.82" $0.00 "$6,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.96" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$5,995.44" "$6,056.00" $0.00 "$3,250.00" $0.00 $389.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101129 EAP CPT® 67909 Reduce Ptosis Overcorrection BOTH IP/OP "$9,164.00 " "$6,781.36" $0.00 "$7,331.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.78" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$7,257.89" "$7,331.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101130 EAP CPT® 67914 Repair Ectropion By Suture BOTH IP/OP "$5,265.00 " "$3,896.10" $0.00 "$4,227.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,097.23" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,184.93" "$4,227.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101131 EAP CPT® 67916 "Rpr Ectropion, Blephar Tarsal" BOTH IP/OP "$9,164.00 " "$6,781.36" $0.00 "$7,331.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.78" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$7,257.89" "$7,331.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101132 EAP CPT® 67921 Repair Entropion By Suture BOTH IP/OP "$5,284.00 " "$3,910.16" $0.00 "$4,227.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,101.19" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,184.93" "$4,227.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101133 EAP CPT® 67923 "Rpr Entropion, Blephar Tarsal" BOTH IP/OP "$9,164.00 " "$6,781.36" $0.00 "$7,331.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.78" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$7,257.89" "$7,331.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101134 EAP CPT® 67924 "Rpr Entropion, Blephar Extnsv" BOTH IP/OP "$9,164.00 " "$6,781.36" $0.00 "$7,331.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.78" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$7,257.89" "$7,331.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101135 EAP CPT® 67930 Suture Wound Eyelid Partial Th BOTH IP/OP "$5,476.00 " "$4,052.24" $0.00 "$4,396.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,141.20" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,352.83" "$4,396.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101136 EAP CPT® 67935 Suture Wound Eyelid Full Thick BOTH IP/OP "$10,632.00 " "$7,867.68" $0.00 "$8,536.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,215.71" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,451.43" "$8,536.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101138 EAP CPT® 67938 Remove Foreign Body Eyelid BOTH IP/OP "$1,204.00 " $890.96 $0.00 "$1,208.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.91 $0.00 $0.00 $0.00 $0.00 "$1,208.00" $956.74 $966.40 $0.00 "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101139 EAP CPT® 67950 Canthoplasty BOTH IP/OP "$9,333.00 " "$6,906.42" $0.00 "$7,541.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,945.00" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,466.18" "$7,541.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101140 EAP CPT® 68020 I & D Conjunctiva Cyst BOTH IP/OP "$3,391.00 " "$2,509.34" $0.00 "$2,712.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $706.68 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,685.67" "$2,712.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101141 EAP CPT® 68100 Biopsy Of Conjunctiva BOTH IP/OP "$2,389.00 " "$1,767.86" $0.00 "$2,389.00" "$2,321.55" "$2,321.55" "$1,948.73" "$1,948.73" "$1,959.70" $497.93 $0.00 $0.00 $0.00 "$1,919.09" $497.87 "$1,247.41" "$2,389.00" "$2,389.00" $0.00 "$2,255.00" "$1,877.83" "$1,896.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101142 EAP CPT® 68110 Excise Lesion Conjunctiva <1 C BOTH IP/OP "$4,701.00 " "$3,478.74" $0.00 "$3,732.00" $0.00 $0.00 $0.00 $0.00 $0.00 $979.81 $0.00 $0.00 $0.00 "$1,919.09" $979.69 "$1,247.41" "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,694.68" "$3,732.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101143 EAP CPT® 68110 Incision Conjunctival Lesion BOTH IP/OP "$4,701.00 " "$3,478.74" $0.00 "$3,732.00" $0.00 $0.00 $0.00 $0.00 $0.00 $979.81 $0.00 $0.00 $0.00 "$1,919.09" $979.69 "$1,247.41" "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,694.68" "$3,732.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101144 EAP CPT® 68115 Excise Lesion Conjunctiva >1 C BOTH IP/OP "$5,304.00 " "$3,924.96" $0.00 "$4,243.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,114.03" $0.00 $0.00 $0.00 "$1,919.09" "$1,113.90" "$1,247.41" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$4,200.77" "$4,243.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101145 EAP CPT® 68200 Injection Subconjunctiva BOTH IP/OP $264.00 $195.36 $0.00 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.02 $0.00 $0.00 $0.00 $0.00 $262.00 $207.50 $209.60 $0.00 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101146 EAP CPT® 68400 I & D Lacrimal Gland BOTH IP/OP $850.00 $629.00 $0.00 $850.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.14 $0.00 $0.00 $0.00 $0.00 $850.00 $673.20 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101147 EAP CPT® 68420 I & D Lacrimal Sac BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.24 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,398.97" "$2,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101148 EAP CPT® 68440 Snip Incision Lacrimal Punctum BOTH IP/OP $661.00 $489.14 $0.00 $661.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.75 $0.00 $0.00 $0.00 $0.00 $661.00 $523.51 $528.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101149 EAP CPT® 68510 Biopsy Of Lacrimal Gland BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.24 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,398.97" "$2,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101150 EAP CPT® 68705 Correct Everted Punctum Cauter BOTH IP/OP $661.00 $489.14 $0.00 $661.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.75 $0.00 $0.00 $0.00 $0.00 $661.00 $523.51 $528.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101151 EAP CPT® 68760 Close Lacri Punct Laser Ligate BOTH IP/OP $623.00 $461.02 $0.00 $623.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.83 $0.00 $0.00 $0.00 $0.00 $623.00 $493.42 $498.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101152 EAP CPT® 68761 Close Tear Duct Opening BOTH IP/OP $584.00 $432.16 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.71 $0.00 $0.00 $0.00 $0.00 $579.00 $458.57 $463.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101153 EAP CPT® 68770 Closure Lacrimal Fistula BOTH IP/OP "$5,253.00 " "$3,887.22" $0.00 "$4,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,094.73" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$4,160.38" "$4,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101154 EAP CPT® 68801 Dilate Lacrimal Punctum BOTH IP/OP $523.00 $387.02 $0.00 $523.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.99 $0.00 $0.00 $0.00 $0.00 $519.00 $411.05 $415.20 $0.00 $523.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101155 EAP CPT® 68810 Probe Nasolacrimal Duct BOTH IP/OP $670.00 $495.80 $0.00 $670.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $670.00 $530.64 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101156 EAP CPT® 68815 Probe Nasolacrimal Duct W Tube BOTH IP/OP "$5,253.00 " "$3,887.22" $0.00 "$4,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,094.73" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,160.38" "$4,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101157 EAP CPT® 68840 Probe Lacrimal Canaliculi BOTH IP/OP $670.00 $495.80 $0.00 $670.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $670.00 $530.64 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101158 EAP CPT® 69105 Biopsy External Ear Canal BOTH IP/OP "$3,660.00 " "$2,708.40" $0.00 "$3,660.00" "$1,987.38" "$1,987.38" "$1,317.34" "$1,317.34" "$1,324.76" $762.84 $0.00 $0.00 $0.00 "$1,296.54" $762.74 $842.75 "$3,660.00" "$3,660.00" "$1,353.31" "$2,255.00" "$2,924.06" "$2,953.60" "$1,880.24" "$2,500.00" "$1,880.24" $69.63 $64.16 $64.16 $587.77 "$1,288.86" $0.00 $0.00 $0.00 $0.00 36101160 EAP CPT® 69145 Excision Aural Mass BOTH IP/OP "$14,091.00 " "$10,427.34" $0.00 "$11,372.00" "$2,753.10" "$2,753.10" "$2,309.02" "$2,309.02" "$2,322.02" "$2,936.92" "$1,541.95" "$1,541.95" "$1,601.25" "$2,271.46" "$2,936.56" "$1,476.45" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$11,258.28" "$11,372.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101162 EAP CPT® 69200 Remove Fb Ear W/o Anes BOTH IP/OP $408.00 $301.92 $0.00 $564.00 $221.54 $221.54 $109.81 $109.81 $110.43 $85.04 $0.00 $0.00 $0.00 $107.30 $85.03 $69.74 $113.00 $113.00 $109.35 $412.00 $326.30 $329.60 $151.93 $564.00 $151.93 $58.58 $48.67 $48.67 $65.59 $104.14 $0.00 $0.00 $0.00 $0.00 36101165 EAP CPT® 69220 "Debridement,ear Wash Placement" BOTH IP/OP $326.00 $241.24 $0.00 $329.00 $177.02 $177.02 $174.88 $174.88 $175.86 $0.00 $0.00 $0.00 $0.00 $0.00 $67.94 $0.00 $0.00 $0.00 $175.24 $329.00 $260.57 $263.20 $243.48 $326.00 $243.48 $62.84 $52.64 $52.64 $52.38 $166.90 $0.00 $0.00 $0.00 $0.00 36101171 EAP CPT® 69420 "Myringotomy W Aspir, E Tube In" BOTH IP/OP "$1,533.00 " "$1,134.42" $96.31 "$1,547.00" "$1,533.00" "$1,533.00" $206.03 $206.03 $207.19 $319.52 "$1,533.00" "$1,533.00" "$1,533.00" $202.80 $319.48 $131.82 "$1,533.00" "$1,533.00" $204.24 "$1,547.00" "$1,225.22" "$1,237.60" $283.76 "$1,533.00" $283.76 $96.31 $122.18 $122.18 $246.28 $194.51 $0.00 $0.00 $0.00 $0.00 36101173 EAP CPT® 69424 Remove Ventilating Tube W Anes BOTH IP/OP "$10,633.00 " "$7,868.42" $0.00 "$8,506.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,215.92" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$8,421.34" "$8,506.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101176 EAP CPT® 69433 Tympanostomy Local Anes BOTH IP/OP "$1,455.00 " "$1,076.70" $116.53 "$1,470.00" "$1,455.00" "$1,455.00" $440.43 $440.43 $442.92 $303.26 "$1,257.08" "$1,257.08" "$1,305.43" $433.55 $303.22 $281.81 "$1,455.00" "$1,455.00" $443.02 "$1,470.00" "$1,164.24" "$1,176.00" $615.51 "$1,455.00" $615.51 $116.53 $134.08 $134.08 $234.02 $421.92 $0.00 $0.00 $0.00 $0.00 36101177 EAP CPT® 69540 Excision Of Aural Polyp BOTH IP/OP "$2,303.00 " "$1,704.22" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.95 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,823.98" "$1,842.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101179 EAP CPT® 69610 Tympanic Membrane Repair BOTH IP/OP "$3,245.00 " "$2,401.30" $0.00 "$2,596.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $676.26 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,570.04" "$2,596.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101181 EAP CPT® 92977 Thrombolytic By Iv For Ami BOTH IP/OP "$3,599.00 " "$2,663.26" $0.00 "$3,381.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $750.03 $0.00 $0.00 $0.00 $0.00 "$2,113.50" "$3,347.78" "$3,381.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101183 EAP CPT® 92978 Ivus Initial Vessel BOTH IP/OP "$8,205.00 " "$6,071.70" $0.00 "$5,967.20" "$4,455.32" "$4,455.32" $0.00 $0.00 $0.00 "$1,710.13" $0.00 $0.00 $0.00 $0.00 "$1,709.92" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,729.50" "$5,907.53" "$5,967.20" $0.00 "$1,750.00" $0.00 $273.18 $0.00 $0.00 "$1,187.47" $0.00 $0.00 $0.00 $0.00 $0.00 36101184 EAP CPT® 92979 Ivus - Addit Vessel BOTH IP/OP "$8,818.00 " "$6,525.32" $0.00 "$6,796.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,796.91" $0.00 "$1,837.67" $0.00 $0.00 $0.00 $0.00 "$3,729.50" "$5,907.53" "$5,967.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101185 EAP CPT® 27096 Inject Si Joint Arthrgrphy&/anes/steroid W/image BOTH IP/OP "$2,110.00 " "$1,561.40" $0.00 "$2,131.00" "$2,110.00" "$2,110.00" $618.38 $618.38 $621.87 $439.78 $0.00 $0.00 $0.00 $608.20 $439.72 $395.33 $113.00 $113.00 $626.89 "$2,131.00" "$1,687.75" "$1,704.80" $86.18 "$2,110.00" $86.18 $398.44 $86.18 $86.18 $339.26 $597.04 $0.00 $0.00 $0.00 $0.00 36101186 EAP CPT® 27096 Bil Inject Si Joint Arthrgrphy&/anes/steroid W/image BOTH IP/OP "$3,165.00 " "$2,342.10" $0.00 "$2,557.60" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $659.67 $0.00 $0.00 $0.00 $608.20 $659.59 $395.33 $113.00 $113.00 $626.89 "$2,255.00" "$2,532.02" "$2,557.60" $86.18 "$2,150.00" $86.18 $398.44 $86.18 $86.18 $508.96 $597.04 $0.00 $0.00 $0.00 $0.00 36101187 EAP HCPCS G0269 Closure Device Placement BOTH IP/OP "$2,840.00 " "$2,101.60" $0.00 "$2,276.00" "$1,542.12" "$1,542.12" $0.00 $0.00 $0.00 $591.93 $0.00 $0.00 $0.00 $0.00 $591.86 $0.00 "$1,679.86" "$1,679.86" $0.00 "$1,422.50" "$2,253.24" "$2,276.00" $0.00 "$1,750.00" $0.00 $445.24 $0.00 $0.00 $452.92 $0.00 $0.00 $0.00 $0.00 $0.00 36101192 EAP CPT® 41899 Partially Bony BOTH IP/OP "$1,862.00 " "$1,377.88" $0.00 "$1,880.00" "$1,862.00" "$1,862.00" $206.03 $206.03 $207.19 $388.09 $0.00 $0.00 $0.00 $202.80 $388.04 $131.82 "$1,862.00" "$1,862.00" $204.24 "$1,880.00" "$1,488.96" "$1,504.00" $283.76 "$1,750.00" $283.76 $294.22 $0.00 $0.00 $299.30 $194.51 $0.00 $0.00 $0.00 $0.00 36101193 EAP CPT® 41899 Soft Tissue BOTH IP/OP "$1,862.00 " "$1,377.88" $0.00 "$1,880.00" "$1,862.00" "$1,862.00" $206.03 $206.03 $207.19 $388.09 $0.00 $0.00 $0.00 $202.80 $388.04 $131.82 "$1,862.00" "$1,862.00" $204.24 "$1,880.00" "$1,488.96" "$1,504.00" $283.76 "$1,750.00" $283.76 $294.22 $0.00 $0.00 $299.30 $194.51 $0.00 $0.00 $0.00 $0.00 36101198 EAP CPT® 62320 Njx Interlaminar Crv/thrc BOTH IP/OP "$1,385.00 " "$1,024.90" $0.00 "$1,385.00" "$1,385.00" "$1,385.00" $618.38 $618.38 $621.87 $288.67 $0.00 $0.00 $0.00 $608.20 $288.63 $395.33 "$1,385.00" "$1,385.00" $0.00 "$1,316.00" "$1,042.27" "$1,052.80" $0.00 "$1,385.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101202 EAP CPT® 15792 Tca Peel BOTH IP/OP "$1,056.00 " $781.44 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.07 $0.00 $0.00 $0.00 $0.00 $990.00 $784.08 $792.00 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101204 EAP CPT® 17000 "Destruc Lesion Benign, 1st" BOTH IP/OP $389.00 $287.86 $0.00 $389.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $389.00 $308.09 $311.20 $243.48 $0.00 $243.48 $48.44 $55.15 $55.15 $61.93 $166.90 $0.00 $0.00 $0.00 $0.00 36101208 EAP CPT® 36600 Arterial Puncture BOTH IP/OP $227.00 $167.98 $0.00 $404.00 $227.00 $227.00 $109.81 $109.81 $110.43 $47.31 $0.00 $0.00 $0.00 $107.30 $47.31 $69.74 $113.00 $113.00 $109.35 $284.00 $224.93 $227.20 $151.93 $404.00 $151.93 $24.37 $16.23 $16.23 $45.21 $104.14 $0.00 $0.00 $0.00 $0.00 36101209 EAP CPT® 46611 Hr Anoscopy W/ Bx BOTH IP/OP "$2,999.00 " "$2,219.26" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $624.99 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,295.22" "$2,318.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101210 EAP CPT® 46614 Hr Ano/w Control Of Bleeding BOTH IP/OP "$1,516.00 " "$1,121.84" $0.00 "$1,516.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.93 $0.00 $0.00 $0.00 $0.00 "$1,516.00" "$1,200.67" "$1,212.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101211 EAP CPT® 46615 Hr Ano W/ablation Of Tumor BOTH IP/OP "$6,197.00 " "$4,585.78" $0.00 "$4,791.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,291.45" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,743.29" "$4,791.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101212 EAP CPT® 51727 Cystometrogram W/urethral Pres BOTH IP/OP $790.00 $584.60 $0.00 $790.00 $790.00 $790.00 $560.26 $560.26 $563.41 $164.66 $0.00 $0.00 $0.00 $550.87 $164.64 $358.07 $113.00 $113.00 $0.00 $790.00 $625.68 $632.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101213 EAP CPT® 51728 Cystometrogram W/voiding Press BOTH IP/OP $791.00 $585.34 $0.00 $791.00 $791.00 $791.00 $560.26 $560.26 $563.41 $164.86 $0.00 $0.00 $0.00 $550.87 $164.84 $358.07 $113.00 $113.00 $0.00 $790.00 $625.68 $632.00 $0.00 $791.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101214 EAP CPT® 51729 Cystometrogram W/vp&up BOTH IP/OP $791.00 $585.34 $0.00 $791.00 $791.00 $791.00 $560.26 $560.26 $563.41 $164.86 $0.00 $0.00 $0.00 $550.87 $164.84 $358.07 $113.00 $113.00 $558.17 $790.00 $625.68 $632.00 $775.50 $791.00 $775.50 $235.63 $252.48 $252.48 $125.77 $531.59 $0.00 $0.00 $0.00 $0.00 36101216 EAP CPT® 49429 Removal Of Peritoneal-venous Shunt BOTH IP/OP "$9,158.00 " "$6,776.92" $0.00 "$8,570.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,908.53" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$8,484.70" "$8,570.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101217 EAP CPT® 21040 Excision Benign Tumor/cyst Mandible Encl & Curt BOTH IP/OP "$4,993.00 " "$3,694.82" $0.00 "$3,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,040.54" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,954.46" "$3,994.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101219 EAP CPT® 57800 Insert Smit Sleeve BOTH IP/OP "$5,262.00 " "$3,893.88" $0.00 "$4,209.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,096.60" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,167.50" "$4,209.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101225 EAP CPT® 64415 Inj Anes/strd Brachial Plexus BOTH IP/OP "$2,280.00 " "$1,687.20" $0.00 "$2,280.00" "$2,280.00" "$2,280.00" $801.66 $801.66 $806.18 $475.21 "$1,257.08" "$1,257.08" "$1,305.43" $788.26 $475.15 $512.37 "$1,871.00" "$1,871.00" $814.44 "$1,890.00" "$1,496.88" "$1,512.00" "$1,131.55" $0.00 "$1,131.55" $107.25 $66.00 $66.00 $300.89 $775.65 $0.00 $0.00 $0.00 $0.00 36101226 EAP CPT® 64417 Inj Anes/strd Axillary Nerve BOTH IP/OP "$1,969.00 " "$1,457.06" $0.00 "$1,969.00" "$1,969.00" "$1,969.00" $801.66 $801.66 $806.18 $410.39 "$1,257.08" "$1,257.08" "$1,305.43" $788.26 $410.34 $512.37 "$1,871.00" "$1,871.00" $814.44 "$1,890.00" "$1,496.88" "$1,512.00" "$1,131.55" $0.00 "$1,131.55" $106.55 $63.11 $63.11 $300.89 $775.65 $0.00 $0.00 $0.00 $0.00 36101227 EAP CPT® 64420 Inj Anes/strd Intercostal Nerve 1st Level BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,959.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.26 $0.00 $0.00 $0.00 $626.89 "$1,890.00" "$1,496.88" "$1,512.00" $870.98 "$1,959.00" $870.98 $95.79 $62.02 $62.02 $300.89 $597.04 $0.00 $0.00 $0.00 $0.00 36101228 EAP CPT® 64421 Inj Anes/strd Intercostal Nerve Addl Level BOTH IP/OP "$3,789.00 " "$2,803.86" $0.00 "$2,924.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $789.63 $0.00 $0.00 $0.00 $814.44 "$2,255.00" "$2,895.55" "$2,924.80" "$1,131.55" "$2,150.00" "$1,131.55" $124.25 $26.33 $26.33 $582.04 $775.65 $0.00 $0.00 $0.00 $0.00 36101229 EAP CPT® 64445 Inj Anes/strd Sciatic Nerve BOTH IP/OP "$3,789.00 " "$2,803.86" $0.00 "$2,924.80" $0.00 $0.00 $0.00 $0.00 $0.00 $789.72 $0.00 $0.00 $0.00 $608.20 $789.63 $395.33 "$1,871.00" "$1,871.00" $626.89 "$2,255.00" "$2,895.55" "$2,924.80" $870.98 "$2,150.00" $870.98 $117.68 $55.89 $55.89 $582.04 $597.04 $0.00 $0.00 $0.00 $0.00 36101230 EAP CPT® 64447 Inj Anes/strd Femoral Nerve BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,890.00" "$1,294.51" "$1,294.51" $618.38 $618.38 $621.87 $496.89 $0.00 $0.00 $0.00 $608.20 $496.83 $395.33 "$1,871.00" "$1,871.00" $626.89 "$1,890.00" "$1,496.88" "$1,512.00" $870.98 $0.00 $870.98 $74.36 $55.18 $55.18 $300.89 $597.04 $0.00 $0.00 $0.00 $0.00 36101231 EAP CPT® 64490 Bilat_inj Paravert F Jnt C/t 1 Lev BOTH IP/OP "$5,684.00 " "$4,206.16" $0.00 "$4,387.20" "$2,321.55" "$2,321.55" $801.66 $801.66 $806.18 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,184.55" $0.00 $0.00 $0.00 $814.44 "$2,255.00" "$4,343.33" "$4,387.20" "$1,131.55" "$2,150.00" "$1,131.55" $122.58 $109.61 $109.61 $873.05 $775.65 $0.00 $0.00 $0.00 $0.00 36101232 EAP CPT® 64491 Bilat_inj Paravert F Jnt C/t 2 Lev BOTH IP/OP "$2,740.00 " "$2,027.60" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $571.02 $0.00 $0.00 $0.00 $0.00 "$1,322.00" "$2,094.05" "$2,115.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101233 EAP CPT® 64492 Bilat_inj Paravert F Jnt C/t 3 Lev BOTH IP/OP "$2,441.00 " "$1,806.34" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $508.70 $0.00 $0.00 $0.00 $0.00 "$1,177.50" "$1,865.16" "$1,884.00" $0.00 "$1,741.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101234 EAP CPT® 64493 Bilat_inj Paravert F Jnt L/s 1 Lev BOTH IP/OP "$5,684.00 " "$4,206.16" $0.00 "$4,387.20" "$2,321.55" "$2,321.55" $801.66 $801.66 $806.18 "$1,184.69" $0.00 $0.00 $0.00 $788.26 "$1,184.55" $512.37 "$1,871.00" "$1,871.00" $814.44 "$2,255.00" "$4,343.33" "$4,387.20" "$1,131.55" "$2,150.00" "$1,131.55" $111.04 $93.03 $93.03 $873.05 $775.65 $0.00 $0.00 $0.00 $0.00 36101235 EAP CPT® 64494 Bilat_inj Paravert F Jnt L/s 2 Lev BOTH IP/OP "$2,583.00 " "$1,911.42" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $538.36 $0.00 $0.00 $0.00 $0.00 $538.30 $0.00 "$1,527.84" "$1,527.84" $0.00 "$1,246.00" "$1,973.66" "$1,993.60" $0.00 "$1,750.00" $0.00 $54.06 $53.73 $53.73 $396.73 $0.00 $0.00 $0.00 $0.00 $0.00 36101236 EAP CPT® 64495 Bilat_inj Paravert F Jnt L/s 3 Lev BOTH IP/OP "$2,478.00 " "$1,833.72" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $516.48 $0.00 $0.00 $0.00 $0.00 $516.42 $0.00 "$1,465.74" "$1,465.74" $0.00 "$1,195.50" "$1,893.67" "$1,912.80" $0.00 "$1,750.00" $0.00 $0.00 $54.45 $54.45 $380.65 $0.00 $0.00 $0.00 $0.00 $0.00 36101252 EAP CPT® 19126 Excision Addl Breast Lesion BOTH IP/OP $508.00 $375.92 $0.00 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.87 $0.00 $0.00 $0.00 $0.00 $508.00 $402.34 $406.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101253 EAP CPT® 57520 Conization Of Cervix BOTH IP/OP "$2,862.00 " "$2,117.88" $0.00 "$2,327.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $596.44 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,266.70" "$2,289.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101264 EAP CPT® 69210 Removal Impacted Cerumen Instrument Unilat BOTH IP/OP $408.00 $301.92 $0.00 $564.00 $408.00 $408.00 $54.21 $54.21 $54.51 $85.04 $0.00 $0.00 $0.00 $53.35 $85.03 $34.67 $113.00 $113.00 $55.17 $412.00 $326.30 $329.60 $76.65 $564.00 $76.65 $47.34 $34.61 $34.61 $65.59 $52.54 $0.00 $0.00 $0.00 $0.00 36101266 EAP CPT® 36569 Picc W/o Port BOTH IP/OP "$4,743.00 " "$3,509.82" $98.45 "$4,343.20" "$2,321.55" "$2,321.55" "$1,369.42" "$1,369.42" "$1,377.13" $988.56 "$1,257.08" "$1,257.08" "$1,305.43" "$1,347.67" $988.44 $875.99 "$1,871.00" "$1,871.00" "$1,635.92" "$2,255.00" "$4,299.77" "$4,343.20" "$2,272.90" "$2,500.00" "$2,272.90" $346.84 $98.45 $98.45 $864.30 "$1,558.02" $0.00 $0.00 $0.00 $0.00 36101267 EAP CPT® 67820 Revised Eye Lashes BOTH IP/OP $316.00 $233.84 $0.00 $317.00 $171.59 $171.59 $109.81 $109.81 $110.43 $65.86 $0.00 $0.00 $0.00 $107.30 $65.85 $69.74 $113.00 $113.00 $109.35 $317.00 $251.06 $253.60 $151.93 $316.00 $151.93 $67.50 $28.84 $28.84 $50.47 $104.14 $0.00 $0.00 $0.00 $0.00 36101270 EAP CPT® 19000 Drain Breast Cyst BOTH IP/OP $921.00 $681.54 $45.43 "$1,141.00" $921.00 $921.00 $606.01 $606.01 $609.42 $191.96 $921.00 $921.00 $921.00 $596.11 $191.94 $387.47 $921.00 $921.00 $611.80 "$1,141.00" $903.67 $912.80 $850.02 "$1,130.00" $850.02 $59.58 $45.43 $45.43 $181.65 $582.67 $0.00 $0.00 $0.00 $0.00 36101273 EAP CPT® 21925 Bx Soft Tissue Back/flank BOTH IP/OP "$5,368.00 " "$3,972.32" $0.00 "$4,294.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,118.69" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,251.46" "$4,294.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101274 EAP CPT® 31535 Laryngoscopy W/biopsy BOTH IP/OP "$9,759.00 " "$7,221.66" $0.00 "$7,168.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,033.78" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,096.32" "$7,168.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101275 EAP CPT® 31577 "Removal Foreign Body, Larynx" BOTH IP/OP "$1,746.00 " "$1,292.04" $0.00 "$1,826.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $363.87 $0.00 $0.00 $0.00 $0.00 "$1,826.00" "$1,446.19" "$1,460.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101280 EAP CPT® 44370 "Small Bowel Endoscop/stent,spv" BOTH IP/OP "$7,753.00 " "$5,737.22" $0.00 "$6,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,615.73" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$6,140.38" "$6,202.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101281 EAP CPT® 49411 Ins Mark Abd/pel For Rt Perq BOTH IP/OP "$2,721.00 " "$2,013.54" $0.00 "$2,546.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $567.06 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,520.94" "$2,546.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101284 EAP CPT® 54161 Circum 28 Days Or Older BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,426.40" "$2,753.10" "$2,753.10" "$1,743.67" "$1,743.67" "$1,753.49" $888.72 "$1,541.95" "$1,541.95" "$1,601.25" "$1,718.44" $888.62 "$1,116.98" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$3,392.14" "$3,426.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101285 EAP CPT® 58999 Female Genital System Procedur BOTH IP/OP $263.00 $194.62 $0.00 $263.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.81 $0.00 $0.00 $0.00 $0.00 $250.00 $198.00 $200.00 $0.00 $263.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101286 EAP CPT® 59412 Antepartum Manipulation BOTH IP/OP "$4,901.00 " "$3,626.74" $0.00 "$3,920.80" "$2,661.24" "$2,661.24" "$2,555.04" "$2,555.04" "$2,569.43" "$1,021.49" $0.00 $0.00 $0.00 "$2,514.14" "$1,021.37" "$1,634.19" "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,881.59" "$3,920.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101287 EAP CPT® 59870 Evacuate Mole Of Uterus BOTH IP/OP "$4,868.00 " "$3,602.32" $0.00 "$3,933.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,014.49" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$3,894.26" "$3,933.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101288 EAP CPT® 60300 Aspir/inj Thyroid Cyst BOTH IP/OP "$1,745.00 " "$1,291.30" $0.00 "$1,745.00" "$1,745.00" "$1,745.00" $606.01 $606.01 $609.42 $363.70 $0.00 $0.00 $0.00 $596.11 $363.66 $387.47 $113.00 $113.00 $611.80 "$1,741.00" "$1,378.87" "$1,392.80" $850.02 "$1,745.00" $850.02 $86.36 $51.21 $51.21 $277.17 $582.67 $0.00 $0.00 $0.00 $0.00 36101290 EAP CPT® 61623 Endovasc Tempry Vesel Ocl Nir BOTH IP/OP "$17,372.00 " "$12,855.28" $0.00 "$12,843.20" "$4,778.55" "$4,778.55" "$9,781.76" "$9,781.76" "$9,836.87" "$3,620.76" $0.00 $0.00 $0.00 "$9,625.35" "$3,620.32" "$6,256.48" "$4,877.00" "$4,877.00" $0.00 "$6,105.00" "$12,714.77" "$12,843.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101292 EAP CPT® 61641 Dilate Ic Vasospasm Add-on BOTH IP/OP "$13,302.00 " "$9,843.48" $0.00 "$9,834.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,772.14" $0.00 $0.00 $0.00 $0.00 "$6,146.50" "$9,736.06" "$9,834.40" $0.00 "$3,992.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101295 EAP CPT® 65210 Remove Foreign Body From Eye BOTH IP/OP $605.00 $447.70 $0.00 $611.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $611.00 $483.91 $488.80 $0.00 $605.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101296 EAP CPT® 69200 Removal Fb Ear W/o Anesth BOTH IP/OP $412.00 $304.88 $0.00 $412.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.04 $0.00 $0.00 $0.00 $107.30 $85.03 $69.74 $113.00 $113.00 $109.35 $412.00 $326.30 $329.60 $151.93 $0.00 $151.93 $58.58 $48.67 $48.67 $65.59 $104.14 $0.00 $0.00 $0.00 $0.00 36101298 EAP CPT® 74220 "Contrast X-ray, Esophagus,spv" BOTH IP/OP "$1,126.00 " $833.24 $0.00 $950.40 $200.75 $200.75 $173.95 $173.95 $174.93 $234.69 $0.00 $0.00 $0.00 $171.13 $234.66 $111.23 $666.03 $666.03 $202.33 $285.12 $940.90 $950.40 $281.11 $611.65 $281.11 $68.55 $66.99 $66.99 $189.13 $192.70 $0.00 $0.00 $0.00 $0.00 36101302 EAP CPT® 92953 Temp Transcut Pacing BOTH IP/OP "$2,499.00 " "$1,849.26" $0.00 "$1,999.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $520.79 $0.00 $0.00 $0.00 $0.00 "$1,249.50" "$1,979.21" "$1,999.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101310 EAP CPT® 31641 Bronchoscopy Treat Blockage BOTH IP/OP "$9,910.00 " "$7,333.40" $265.77 "$7,757.60" "$2,753.10" "$2,753.10" "$3,016.56" "$3,016.56" "$3,033.56" "$2,065.49" "$1,541.95" "$1,541.95" "$1,601.25" "$2,969.20" "$2,065.24" "$1,929.98" "$2,836.00" "$2,836.00" "$2,945.54" "$2,327.00" "$7,680.02" "$7,757.60" "$4,092.44" "$3,725.00" "$4,092.44" $324.15 $265.77 $265.77 "$1,543.76" "$2,805.28" $0.00 $0.00 $0.00 $0.00 36101311 EAP CPT® 64416 Inj Anes/strd Brachial Plexus By Cont Infusion BOTH IP/OP "$4,307.00 " "$3,187.18" $0.00 "$3,445.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,411.14" "$3,445.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101312 EAP CPT® 64446 Inj Anes/strd Sicatic Nerve By Cont Infusion BOTH IP/OP "$4,292.00 " "$3,176.08" $0.00 "$3,759.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $894.45 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,721.61" "$3,759.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101313 EAP CPT® 64448 Inj Anes/strd Femoral Nerve By Cont Infusion BOTH IP/OP "$3,481.00 " "$2,575.94" $0.00 "$3,048.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $725.44 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,018.31" "$3,048.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101314 EAP CPT® 64449 Inj Anes/strd Lumbar Plexus By Cont Infusion BOTH IP/OP "$3,355.00 " "$2,482.70" $0.00 "$2,938.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.18 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,909.02" "$2,938.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101315 EAP CPT® 64486 Tap Block Unil By Injection BOTH IP/OP "$1,767.00 " "$1,307.58" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $368.24 $0.00 $0.00 $0.00 $0.00 $852.50 "$1,350.36" "$1,364.00" $0.00 "$1,750.00" $0.00 $119.70 $58.43 $58.43 $271.44 $0.00 $0.00 $0.00 $0.00 $0.00 36101316 EAP CPT® 64487 Tap Block Uni By Infusion BOTH IP/OP "$1,557.00 " "$1,152.18" $0.00 "$1,364.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.48 $0.00 $0.00 $0.00 $0.00 $852.50 "$1,350.36" "$1,364.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101317 EAP CPT® 64488 Tap Block Bi Injection BOTH IP/OP "$1,767.00 " "$1,307.58" $0.00 "$1,767.00" "$1,767.00" "$1,767.00" $0.00 $0.00 $0.00 $368.29 $0.00 $0.00 $0.00 $0.00 $368.24 $0.00 "$1,045.18" "$1,045.18" $0.00 $852.50 "$1,350.36" "$1,364.00" $0.00 "$1,750.00" $0.00 $147.17 $72.14 $72.14 $271.44 $0.00 $0.00 $0.00 $0.00 $0.00 36101318 EAP CPT® 64489 Tap Block Bi By Infusion BOTH IP/OP "$1,557.00 " "$1,152.18" $0.00 "$1,364.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.48 $0.00 $0.00 $0.00 $0.00 $852.50 "$1,350.36" "$1,364.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101350 EAP CPT® 31525 "Dx Laryngoscopy, Except Nb" BOTH IP/OP "$6,130.00 " "$4,536.20" $0.00 "$5,129.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,277.49" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,078.30" "$5,129.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101351 EAP CPT® 49451 "Replace Duod/jej Tube Perc,spv" BOTH IP/OP "$2,862.00 " "$2,117.88" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $596.44 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,179.58" "$2,201.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101355 EAP CPT® 69000 Drain External Ear Lesion BOTH IP/OP $694.00 $513.56 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.63 $0.00 $0.00 $0.00 $0.00 $700.00 $554.40 $560.00 $0.00 $694.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101370 EAP CPT® 92511 Nasopharyngoscopy W/endoscope BOTH IP/OP $606.00 $448.44 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.29 $0.00 $0.00 $0.00 $157.01 $612.00 $484.70 $489.60 $218.14 $393.90 $218.14 $64.35 $38.94 $38.94 $97.43 $149.53 $0.00 $0.00 $0.00 $0.00 36101371 EAP CPT® 77002 Fluoro Guidance For Needle Pla BOTH IP/OP $724.00 $535.76 $0.00 $579.20 $0.00 $0.00 $0.00 $0.00 $0.00 $149.44 $0.00 $0.00 $0.00 $0.00 $149.42 $0.00 $424.11 $424.11 $0.00 $173.76 $573.41 $579.20 $0.00 $0.00 $0.00 $71.68 $81.40 $81.40 $115.26 $0.00 $0.00 $0.00 $0.00 $0.00 36101375 EAP CPT® 12021 Wound Dehiscence With Packing BOTH IP/OP "$3,676.00 " "$2,720.24" $0.00 "$2,940.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.45 "$2,255.00" "$2,911.39" "$2,940.80" $445.22 $0.00 $445.22 $117.17 $144.54 $144.54 $585.22 $305.19 $0.00 $0.00 $0.00 $0.00 36101390 EAP CPT® 49180 Ablation Abd Standa BOTH IP/OP "$2,498.00 " "$1,848.52" $87.64 "$2,500.00" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" $520.65 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $520.58 $876.52 "$1,871.00" "$1,871.00" "$1,376.63" "$2,255.00" "$2,314.22" "$2,337.60" "$1,912.65" "$2,500.00" "$1,912.65" $203.88 $87.64 $87.64 $465.18 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36101396 EAP CPT® 32555 Aspirate Pleura W/ Imaging BOTH IP/OP "$3,461.00 " "$2,561.14" $0.00 "$2,768.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.36 "$2,255.00" "$2,741.11" "$2,768.80" $878.58 $0.00 $878.58 $626.46 $116.13 $116.13 $550.99 $602.25 $0.00 $0.00 $0.00 $0.00 36101398 EAP CPT® 31647 Bronchial Valve Init Insert BOTH IP/OP "$5,148.00 " "$3,809.52" $0.00 "$4,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,096.39" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,077.22" "$4,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101399 EAP CPT® 31648 Bronchial Valve Addl Insert BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.24 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,398.97" "$2,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101400 EAP CPT® 31649 Bronchial Valve Remov Init BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101401 EAP CPT® 31651 Bronchial Valve Remov Addl BOTH IP/OP $947.00 $700.78 $0.00 $757.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.35 $0.00 $0.00 $0.00 $0.00 $473.50 $750.02 $757.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101402 EAP CPT® 32556 Insert Cath Pleura W/o Image BOTH IP/OP "$3,737.00 " "$2,765.38" $0.00 "$2,828.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $778.79 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,800.51" "$2,828.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101403 EAP CPT® 32557 Insert Cath Pleura W/ Image BOTH IP/OP "$2,776.00 " "$2,054.24" $0.00 "$2,753.10" "$2,753.10" "$2,753.10" "$1,369.42" "$1,369.42" "$1,377.13" $0.00 $0.00 $0.00 $0.00 $0.00 $578.52 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,080.58" "$2,101.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101404 EAP CPT® 31626 Navigation Bronchoscopy W/markers BOTH IP/OP "$5,560.00 " "$4,114.40" $0.00 "$5,671.09" "$2,984.10" "$2,984.10" "$5,671.09" "$5,671.09" "$5,560.00" "$1,158.84" $0.00 $0.00 $0.00 "$5,580.65" "$1,158.70" "$3,627.42" "$3,856.00" "$3,856.00" "$5,456.35" "$2,858.00" "$4,192.06" "$4,234.40" "$5,293.00" "$3,725.00" "$5,293.00" $317.84 $205.55 $205.55 $842.65 "$5,196.52" $0.00 $0.00 $0.00 $0.00 36101405 EAP CPT® 61650 Endovasc Intracran Adm Rx 1st BOTH IP/OP "$10,002.00 " "$7,401.48" $0.00 "$7,394.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,084.42" $0.00 $0.00 $0.00 $0.00 "$4,621.50" "$7,320.46" "$7,394.40" $0.00 "$6,501.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101406 EAP CPT® 61651 Endovasc Intracran Adm Rx Add BOTH IP/OP "$9,649.00 " "$7,140.26" $0.00 "$7,133.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,010.85" $0.00 $0.00 $0.00 $0.00 "$4,458.50" "$7,062.26" "$7,133.60" $0.00 "$6,271.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101407 EAP CPT® 37252 Us Vascular Non-coronary Init BOTH IP/OP "$15,412.00 " "$11,404.88" $0.00 "$12,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,211.86" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$11,970.29" "$12,091.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101408 EAP CPT® 37253 Us Vascular Non-coron Add Ea BOTH IP/OP "$11,429.00 " "$8,457.46" $0.00 "$8,966.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,381.80" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$8,876.74" "$8,966.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101409 EAP CPT® 47532 Xr Cholangiogram Transhepatic BOTH IP/OP "$3,224.00 " "$2,385.76" $0.00 "$3,224.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $671.88 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,579.54" "$2,605.60" $0.00 "$3,224.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101410 EAP CPT® 47531 Xr Cholangiogram Thru Cath BOTH IP/OP "$3,224.00 " "$2,385.76" $0.00 "$3,257.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $671.88 $0.00 $0.00 $0.00 "$3,118.48" "$2,255.00" "$2,579.54" "$2,605.60" "$3,257.00" "$1,750.00" "$3,257.00" $360.21 $73.56 $73.56 $518.51 "$2,969.98" $0.00 $0.00 $0.00 $0.00 36101411 EAP CPT® 47533 Pl Bil Drn Cath Perc Ext Rad BOTH IP/OP "$5,443.00 " "$4,027.82" $0.00 "$4,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,134.32" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,310.86" "$4,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101412 EAP CPT® 47534 Pl Bil Drn Cath Perc Int/ext R BOTH IP/OP "$6,143.00 " "$4,545.82" $0.00 "$4,964.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.20" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,914.36" "$4,964.00" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101413 EAP CPT® 47535 Conv Ext Bil Drn Cath To Int/e BOTH IP/OP "$5,443.00 " "$4,027.82" $0.00 "$4,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,134.32" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,310.86" "$4,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101414 EAP CPT® 47536 Exch Bil Drn Cath Perc Rad BOTH IP/OP "$6,143.00 " "$4,545.82" $0.00 "$6,143.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.35" $0.00 $0.00 $0.00 "$3,051.04" "$1,280.20" "$1,983.18" "$6,143.00" "$6,143.00" "$3,118.48" "$2,255.00" "$4,914.36" "$4,964.00" "$4,332.71" "$3,725.00" "$4,332.71" $789.54 $138.48 $138.48 $987.84 "$2,969.98" $0.00 $0.00 $0.00 $0.00 36101415 EAP CPT® 47537 Rmvl Bil Drn Cath Perc Fluor G BOTH IP/OP "$1,195.00 " $884.30 $0.00 "$1,207.00" "$1,195.00" "$1,195.00" $787.99 $787.99 $792.43 $249.07 $0.00 $0.00 $0.00 $775.94 $249.04 $504.36 "$1,195.00" "$1,195.00" $788.23 "$1,207.00" $955.94 $965.60 "$1,095.14" "$1,195.00" "$1,095.14" $390.05 $100.61 $100.61 $192.15 $750.70 $0.00 $0.00 $0.00 $0.00 36101416 EAP CPT® 47538 PLMT STENT BILE DUCT PERC RAD EXIS ACCS BOTH IP/OP "$10,193.00 " "$7,542.82" $0.00 "$8,236.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,124.22" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$8,154.43" "$8,236.80" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101417 EAP CPT® 47539 PLMT STENT BILE DUCT PERC RAD NEW ACCS W/O CATH BOTH IP/OP "$10,193.00 " "$7,542.82" $0.00 "$8,236.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,124.22" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$8,154.43" "$8,236.80" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101418 EAP CPT® 47540 PLMT STENT BILE DUCT PERC RAD NEW ACCS W/ CATH BOTH IP/OP "$10,296.00 " "$7,619.04" $0.00 "$8,236.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,145.69" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$8,154.43" "$8,236.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101419 EAP CPT® 47541 Place Access Biliary Sm Bowel BOTH IP/OP "$5,443.00 " "$4,027.82" $0.00 "$4,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,134.32" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,310.86" "$4,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101420 EAP CPT® 47542 Dilation Biliary Duct/ampulla BOTH IP/OP "$5,389.00 " "$3,987.86" $0.00 "$4,354.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,123.07" $0.00 $0.00 $0.00 $0.00 "$2,721.50" "$4,310.86" "$4,354.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101421 EAP CPT® 47543 Endolumin Bx Biliary Tree Perq BOTH IP/OP "$5,389.00 " "$3,987.86" $0.00 "$4,354.40" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 "$1,123.20" $0.00 $0.00 $0.00 $0.00 "$1,123.07" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,721.50" "$4,310.86" "$4,354.40" $0.00 "$1,750.00" $0.00 "$1,282.63" $151.83 $151.83 $866.53 $0.00 $0.00 $0.00 $0.00 $0.00 36101422 EAP CPT® 47544 Extract Stone Duct Biliary BOTH IP/OP "$2,246.00 " "$1,662.04" $0.00 "$2,246.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.07 $0.00 $0.00 $0.00 $0.00 "$2,246.00" "$1,778.83" "$1,796.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101423 EAP CPT® 49185 Sclerotx Fluid Collection Perq BOTH IP/OP "$2,939.00 " "$2,174.86" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $612.49 $0.00 $0.00 $0.00 $0.00 "$1,377.50" "$2,181.96" "$2,204.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101424 EAP CPT® 50432 Ins Cath Drain Renal Pelvis BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$6,538.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,362.68" $0.00 $0.00 $0.00 "$1,718.44" "$1,362.52" "$1,116.98" "$6,538.00" "$6,538.00" "$1,776.76" "$2,255.00" "$4,922.28" "$4,972.00" "$2,468.57" "$3,250.00" "$2,468.57" $817.36 $214.93 $214.93 $989.43 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36101425 EAP CPT® 50693 PLMT URETERAL STENT PRQ NEPH/URETEROGRAM PRE-EXIST BOTH IP/OP "$5,609.00 " "$4,150.66" $0.00 "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.92" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,442.33" "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101426 EAP CPT® 50694 PLMT URETERAL STENT PRQ NEPH/URETEROGRAM NEW ACCES BOTH IP/OP "$5,609.00 " "$4,150.66" $0.00 "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.92" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,442.33" "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101427 EAP CPT® 50695 PLMT URETERAL STENT PRQ NEP/URT NEW ACCES SEP CATH BOTH IP/OP "$5,609.00 " "$4,150.66" $0.00 "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.92" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,442.33" "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101428 EAP CPT® 50430 Inj Antegrade Neph/uret Comp BOTH IP/OP "$1,379.00 " "$1,020.46" $0.00 "$1,379.00" "$1,379.00" "$1,379.00" $560.26 $560.26 $563.41 $287.42 $0.00 $0.00 $0.00 $550.87 $287.38 $358.07 "$1,379.00" "$1,379.00" $558.17 "$1,311.00" "$1,038.31" "$1,048.80" $775.50 "$1,379.00" $775.50 $503.90 $160.83 $160.83 $208.71 $531.59 $0.00 $0.00 $0.00 $0.00 36101429 EAP CPT® 50431 Inj Antegrade Neph/uret Comp BOTH IP/OP "$1,379.00 " "$1,020.46" $0.00 "$1,379.00" "$1,379.00" "$1,379.00" $560.26 $560.26 $563.41 $287.42 $0.00 $0.00 $0.00 $550.87 $287.38 $358.07 "$1,379.00" "$1,379.00" $558.17 "$1,311.00" "$1,038.31" "$1,048.80" $775.50 "$1,379.00" $775.50 $156.69 $67.79 $67.79 $208.71 $531.59 $0.00 $0.00 $0.00 $0.00 36101430 EAP CPT® 50433 Place Nephroureteral Cath Prq BOTH IP/OP "$3,960.00 " "$2,930.40" $0.00 "$3,960.00" "$2,753.10" "$2,753.10" "$2,994.12" "$2,994.12" "$3,010.98" $825.36 $0.00 $0.00 $0.00 "$2,948.43" $825.26 "$1,916.48" "$3,960.00" "$3,960.00" $0.00 "$2,255.00" "$2,981.88" "$3,012.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101431 EAP CPT® 50434 Convert Nephrostomy Cath BOTH IP/OP "$2,023.00 " "$1,497.02" $0.00 "$2,023.00" "$2,023.00" "$2,023.00" "$1,743.67" "$1,743.67" "$1,753.49" $421.64 $0.00 $0.00 $0.00 "$1,718.44" $421.59 "$1,116.98" "$2,023.00" "$2,023.00" "$1,776.76" "$1,923.00" "$1,523.02" "$1,538.40" "$1,923.00" "$2,023.00" "$1,923.00" $870.58 $200.50 $200.50 $306.14 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36101432 EAP CPT® 50435 Chg Tube Nephro/pyelo BOTH IP/OP "$2,275.00 " "$1,683.50" $0.00 "$2,275.00" "$2,275.00" "$2,275.00" "$1,743.67" "$1,743.67" "$1,753.49" $474.17 $0.00 $0.00 $0.00 "$1,718.44" $474.11 "$1,116.98" "$2,275.00" "$2,275.00" "$1,776.76" "$2,163.00" "$1,713.10" "$1,730.40" "$2,163.00" "$2,150.00" "$2,163.00" $457.01 $103.85 $103.85 $344.35 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36101433 EAP CPT® 50606 Endoluminal Bx Ureter Renal BOTH IP/OP "$5,609.00 " "$4,150.66" $0.00 "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.92" $0.00 $0.00 $0.00 $0.00 "$2,804.50" "$4,442.33" "$4,487.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101437 EAP CPT® 50705 Ureteral Embolization/occusion BOTH IP/OP "$5,609.00 " "$4,150.66" $0.00 "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.92" $0.00 $0.00 $0.00 $0.00 "$2,804.50" "$4,442.33" "$4,487.20" $0.00 $656.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101438 EAP CPT® 50706 Ball Dilat Ureteral Stricture BOTH IP/OP "$5,900.00 " "$4,366.00" $0.00 "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,229.56" $0.00 $0.00 $0.00 $0.00 "$2,804.50" "$4,442.33" "$4,487.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101439 EAP CPT® 61645 Perq Arterial Translum Thromec BOTH IP/OP "$25,070.00 " "$18,551.80" $0.00 "$24,443.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,224.59" $0.00 $0.00 $0.00 $0.00 "$11,584.00" "$18,349.06" "$18,534.40" $0.00 "$24,443.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101440 EAP CPT® 62321 Inj Of Sub Spinal Canal Upper/mid Back; W/image BOTH IP/OP "$1,385.00 " "$1,024.90" $0.00 "$1,385.00" "$1,385.00" "$1,385.00" $618.38 $618.38 $621.87 $288.67 $0.00 $0.00 $0.00 $608.20 $288.63 $395.33 "$1,385.00" "$1,385.00" $626.89 "$1,316.00" "$1,042.27" "$1,052.80" $870.98 "$1,385.00" $870.98 $240.25 $111.42 $111.42 $209.51 $597.04 $0.00 $0.00 $0.00 $0.00 36101441 EAP CPT® 62323 Inj Of Sub Spinal Canal Lower Back/sacrum; W/image BOTH IP/OP "$1,385.00 " "$1,024.90" $0.00 "$2,150.00" "$1,385.00" "$1,385.00" $618.38 $618.38 $621.87 $288.67 $0.00 $0.00 $0.00 $608.20 $288.63 $395.33 "$1,385.00" "$1,385.00" $626.89 "$1,316.00" "$1,042.27" "$1,052.80" $870.98 "$2,150.00" $870.98 $235.81 $103.13 $103.13 $209.51 $597.04 $0.00 $0.00 $0.00 $0.00 36101445 EAP CPT® 31573 Laryngoscopy Flexible Therapeutic Injection Uni BOTH IP/OP "$3,859.00 " "$2,855.66" $0.00 "$3,859.00" "$2,753.10" "$2,753.10" "$1,456.99" "$1,456.99" "$1,465.20" $804.31 $0.00 $0.00 $0.00 "$1,434.17" $804.22 $932.21 "$3,859.00" "$3,859.00" $0.00 "$2,255.00" "$2,806.06" "$2,834.40" $0.00 "$2,239.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101501 EAP CPT® 30020 Drainage Of Nose Lesion BOTH IP/OP "$2,343.00 " "$1,733.82" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $488.28 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,855.66" "$1,874.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101502 EAP CPT® 31654 Bronchoscopy Rigid/flex Ebus Interven Peri Lesion BOTH IP/OP "$22,686.00 " "$16,787.64" $0.00 "$18,332.00" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 "$4,728.33" $0.00 $0.00 $0.00 $0.00 "$4,727.76" $0.00 "$2,836.00" "$2,836.00" $0.00 "$11,457.50" "$18,148.68" "$18,332.00" $0.00 "$1,750.00" $0.00 $139.20 $69.97 $69.97 "$3,648.07" $0.00 $0.00 $0.00 $0.00 $0.00 36101503 EAP CPT® 31652 Bronchoscopy Rigid/flex Ebus Sampling 1 Or 2 Node BOTH IP/OP "$5,306.00 " "$3,926.44" $0.00 "$5,306.00" "$2,753.10" "$2,753.10" "$3,016.56" "$3,016.56" "$3,033.56" "$1,105.90" $0.00 $0.00 $0.00 "$2,969.20" "$1,105.77" "$1,929.98" "$5,306.00" "$5,306.00" "$2,945.54" "$2,255.00" "$4,245.12" "$4,288.00" "$4,092.44" "$3,250.00" "$4,092.44" $874.40 $230.08 $230.08 $853.31 "$2,805.28" $0.00 $0.00 $0.00 $0.00 36101504 EAP CPT® 31653 Bronchoscopy Rigid/flex Ebus Sampling 3/> Node BOTH IP/OP "$4,682.00 " "$3,464.68" $0.00 "$4,682.00" "$2,753.10" "$2,753.10" "$3,016.56" "$3,016.56" "$3,033.56" $975.85 $0.00 $0.00 $0.00 "$2,969.20" $975.73 "$1,929.98" "$4,682.00" "$4,682.00" "$2,945.54" "$2,255.00" "$3,745.37" "$3,783.20" "$4,092.44" "$3,250.00" "$4,092.44" $929.42 $255.33 $255.33 $752.86 "$2,805.28" $0.00 $0.00 $0.00 $0.00 36101520 EAP CPT® 42330 Removal Of Salivary Stone BOTH IP/OP "$6,425.00 " "$4,754.50" $0.00 "$5,133.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,338.97" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,082.26" "$5,133.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101961 EAP CPT® 57460 Colposcopy W/leep Bx BOTH IP/OP "$4,743.00 " "$3,509.82" $0.00 "$4,743.00" "$2,753.10" "$2,753.10" "$2,555.04" "$2,555.04" "$2,569.43" $988.56 "$1,541.95" "$1,541.95" "$1,601.25" "$2,514.14" $988.44 "$1,634.19" "$4,743.00" "$4,743.00" "$2,505.44" "$2,255.00" "$3,756.46" "$3,794.40" "$3,480.98" $0.00 "$3,480.98" $178.42 $168.01 $168.01 $755.09 "$2,386.14" $0.00 $0.00 $0.00 $0.00 36101970 EAP CPT® 58100 Endometrial Biopsy BOTH IP/OP $346.00 $256.04 $0.00 $346.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.49 $0.00 $0.00 $0.00 $163.24 $71.48 $106.10 $113.00 $113.00 $166.54 $346.00 $274.03 $276.80 $231.38 $0.00 $231.38 $59.72 $67.07 $67.07 $55.08 $158.61 $0.00 $0.00 $0.00 $0.00 36101985 EAP CPT® 46999 Anus Surgery Procedure BOTH IP/OP "$1,251.00 " $925.74 $0.00 "$1,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $260.74 $0.00 $0.00 $0.00 $760.65 $260.71 $494.42 "$1,251.00" "$1,251.00" $0.00 "$1,264.00" "$1,001.09" "$1,011.20" $0.00 "$1,251.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101987 EAP CPT® 57456 Colposcopy + Ecc BOTH IP/OP "$1,218.00 " $901.32 $106.36 "$1,221.00" "$1,218.00" "$1,218.00" $274.65 $274.65 $276.20 $253.86 "$1,218.00" "$1,218.00" "$1,218.00" $269.78 $253.83 $175.35 "$1,218.00" "$1,218.00" $271.52 "$1,221.00" $967.03 $976.80 $377.23 "$1,218.00" $377.23 $137.69 $106.36 $106.36 $194.38 $258.59 $0.00 $0.00 $0.00 $0.00 36101989 EAP CPT® 23931 Drainage Of Arm Bursa BOTH IP/OP "$7,496.00 " "$5,547.04" $0.00 "$5,832.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,562.17" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,773.68" "$5,832.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101990 EAP CPT® 91111 Esophageal Capsule Endoscopy BOTH IP/OP "$3,592.00 " "$2,658.08" $0.00 "$2,627.20" "$1,950.46" "$1,950.46" $787.99 $787.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $748.57 $0.00 $0.00 $0.00 $788.23 "$1,642.00" "$2,600.93" "$2,627.20" "$1,095.14" "$2,500.00" "$1,095.14" $513.95 $828.40 $828.40 $522.81 $750.70 $0.00 $0.00 $0.00 $0.00 36101991 EAP CPT® 91110 Gi Tract Capsule Endoscopy BOTH IP/OP "$4,034.00 " "$2,985.16" $0.00 "$2,958.40" "$2,190.46" "$2,190.46" $787.99 $787.99 $792.43 $840.79 $0.00 $0.00 $0.00 $775.94 $840.69 $504.36 "$2,386.11" "$2,386.11" $788.23 "$1,849.00" "$2,928.82" "$2,958.40" "$1,095.14" "$2,500.00" "$1,095.14" $923.73 $745.92 $745.92 $588.72 $750.70 $0.00 $0.00 $0.00 $0.00 36101992 EAP CPT® 56405 "I & D, Vulva, Perineum" BOTH IP/OP $294.00 $217.56 $0.00 "$1,750.00" $294.00 $294.00 $274.65 $274.65 $276.20 $61.28 $294.00 $294.00 $294.00 $269.78 $61.27 $175.35 $294.00 $294.00 $0.00 $294.00 $232.85 $235.20 $0.00 "$1,750.00" $0.00 $107.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36101994 EAP CPT® 64425 Inject Anest Ilioin BOTH IP/OP "$3,143.00 " "$2,325.82" $0.00 "$2,752.80" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $655.08 "$1,257.08" "$1,257.08" "$1,305.43" $608.20 $655.00 $395.33 "$1,871.00" "$1,871.00" $626.89 "$2,255.00" "$2,725.27" "$2,752.80" $870.98 "$2,150.00" $870.98 $0.00 $57.69 $57.69 $547.81 $597.04 $0.00 $0.00 $0.00 $0.00 36101995 EAP CPT® 41899 Rem Imp Tooth W Mucoper Fip BOTH IP/OP "$1,862.00 " "$1,377.88" $0.00 "$1,880.00" "$1,862.00" "$1,862.00" $206.03 $206.03 $207.19 $388.09 $0.00 $0.00 $0.00 $202.80 $388.04 $131.82 "$1,862.00" "$1,862.00" $204.24 "$1,880.00" "$1,488.96" "$1,504.00" $283.76 "$1,750.00" $283.76 $294.22 $0.00 $0.00 $299.30 $194.51 $0.00 $0.00 $0.00 $0.00 36101997 EAP CPT® 12001 Repair Superficial Wound(s) BOTH IP/OP $704.00 $520.96 $0.00 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 $704.00 $557.57 $563.20 $243.48 $0.00 $243.48 $116.22 $46.87 $46.87 $112.08 $166.90 $0.00 $0.00 $0.00 $0.00 36101998 EAP CPT® 36228 Sel Cath Plc Intracrn Brnch Ic/vert Art W/angio BOTH IP/OP "$73,169.00 " "$54,145.06" $0.00 "$49,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$15,248.42" $0.00 $0.00 $0.00 $0.00 "$30,807.50" "$48,799.08" "$49,292.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102010 EAP CPT® 29580 Unna Booth BOTH IP/OP $780.00 $577.20 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.13 $780.00 $617.76 $624.00 $186.36 $0.00 $186.36 $54.52 $28.49 $28.49 $124.18 $127.75 $0.00 $0.00 $0.00 $0.00 36102050 EAP CPT® 26010 Abscess Finger Simple BOTH IP/OP "$1,407.00 " "$1,041.18" $0.00 "$1,407.00" $0.00 $0.00 $0.00 $0.00 $0.00 $293.25 $0.00 $0.00 $0.00 $172.08 $293.22 $111.85 $113.00 $113.00 $0.00 "$1,407.00" "$1,114.34" "$1,125.60" $0.00 "$1,216.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102062 EAP CPT® 29130 Application Of Finger Splint BOTH IP/OP $859.00 $635.66 $0.00 $859.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $859.00 $680.33 $687.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102063 EAP CPT® 38505 Bx Lymph Node Ndl Bic BOTH IP/OP "$1,805.00 " "$1,335.70" $72.83 "$2,500.00" "$1,805.00" "$1,805.00" "$1,370.21" "$1,370.21" "$1,377.93" $376.21 "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" $376.16 $876.52 "$1,805.00" "$1,805.00" "$1,376.63" "$1,801.00" "$1,426.39" "$1,440.80" "$1,801.00" "$2,500.00" "$1,801.00" $115.87 $72.83 $72.83 $286.72 "$1,311.08" $0.00 $0.00 $0.00 $0.00 36102064 EAP CPT® 45005 Drainage Of Rectal Abscess Ult BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102066 EAP CPT® 49060 Drain Open Retrop Abscess Ult BOTH IP/OP "$5,398.00 " "$3,994.52" $0.00 "$4,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,124.94" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,275.22" "$4,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102068 EAP CPT® 52341 Cysto W/ureter Stricture Tx BOTH IP/OP "$9,570.00 " "$7,081.80" $0.00 "$7,679.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,994.39" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$7,602.41" "$7,679.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102082 EAP CPT® 57505 Ecc Cervical Scrape BOTH IP/OP "$2,043.00 " "$1,511.82" $0.00 "$2,064.00" "$2,043.00" "$2,043.00" $617.38 $617.38 $620.86 $425.81 $0.00 $0.00 $0.00 $607.07 $425.76 $394.60 "$1,871.00" "$1,871.00" $640.34 "$2,064.00" "$1,634.69" "$1,651.20" $889.66 "$2,043.00" $889.66 $86.47 $104.52 $104.52 $328.59 $609.84 $0.00 $0.00 $0.00 $0.00 36102090 EAP CPT® 49421 Perm Peritoneal Cath Insert BOTH IP/OP "$11,842.00 " "$8,763.08" $0.00 "$11,082.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,467.87" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$10,971.58" "$11,082.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102091 EAP CPT® 49402 Techoff Cath. Removal BOTH IP/OP "$5,016.00 " "$3,711.84" $0.00 "$4,694.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,045.33" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,647.46" "$4,694.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102095 EAP CPT® 19120 "Excision Of Cyst,fibro Adrenoma" BOTH IP/OP "$5,508.00 " "$4,075.92" $0.00 "$4,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,147.87" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,352.04" "$4,396.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102100 EAP CPT® 64400 "Inj Anes/strd Trigeminal Nerve, Each Branch" BOTH IP/OP "$1,227.00 " $907.98 $0.00 "$1,227.00" "$1,227.00" "$1,227.00" $254.43 $254.43 $255.86 $255.74 $0.00 $0.00 $0.00 $250.31 $255.71 $162.70 "$1,227.00" "$1,227.00" $0.00 "$1,184.00" $937.73 $947.20 $0.00 "$1,227.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102101 EAP CPT® 64455 N Block Inj Plantar Digit BOTH IP/OP "$1,081.00 " $799.94 $0.00 "$1,081.00" "$1,081.00" "$1,081.00" $254.43 $254.43 $255.86 $225.31 $0.00 $0.00 $0.00 $250.31 $225.28 $162.70 $113.00 $113.00 $262.54 "$1,043.00" $826.06 $834.40 $364.76 "$1,081.00" $364.76 $46.42 $36.07 $36.07 $166.05 $250.04 $0.00 $0.00 $0.00 $0.00 36102150 EAP CPT® 19101 "Breast Biopsy, Open, Incisional" BOTH IP/OP "$3,347.00 " "$2,476.78" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $697.51 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,677.75" "$2,704.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102151 EAP CPT® 19125 Excision Breast Lesion BOTH IP/OP "$3,037.00 " "$2,247.38" $0.00 "$3,037.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.91 $0.00 $0.00 $0.00 $0.00 "$2,825.00" "$2,237.40" "$2,260.00" $0.00 "$3,037.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102152 EAP CPT® 66020 Injection Treatment Of Eye BOTH IP/OP "$4,930.00 " "$3,648.20" $0.00 "$4,249.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,027.41" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,207.10" "$4,249.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102153 EAP CPT® 68530 Clearance Of Tear Duct BOTH IP/OP $579.00 $428.46 $0.00 $579.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.66 $0.00 $0.00 $0.00 $0.00 $579.00 $458.57 $463.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102155 EAP CPT® 11600 Exc Tr-emt Mlg+marg 0.5 20sq Cm BOTH IP/OP "$2,528.00 " "$1,870.72" $0.00 "$1,922.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.84 $0.00 $0.00 $0.00 $0.00 "$1,201.50" "$1,903.18" "$1,922.40" $0.00 "$1,267.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102331 EAP CPT® 11046 Excl Debride- Muscle > 20sq Cm BOTH IP/OP "$2,528.00 " "$1,870.72" $0.00 "$1,922.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.84 $0.00 $0.00 $0.00 $0.00 "$1,201.50" "$1,903.18" "$1,922.40" $0.00 "$1,417.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102332 EAP CPT® 11047 Excl Debride-bone > 20 Sq Cm BOTH IP/OP "$6,167.00 " "$4,563.58" $0.00 "$4,950.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,285.20" $0.00 $0.00 $0.00 $0.00 "$3,094.00" "$4,900.90" "$4,950.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102333 EAP CPT® 11755 Biopsy Of Nail Unit BOTH IP/OP $978.00 $723.72 $0.00 $987.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.82 $0.00 $0.00 $0.00 $0.00 $987.00 $781.70 $789.60 $0.00 $978.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102334 EAP CPT® 15004 "Site Prep-100 Sq Cm (hands, Feet)" BOTH IP/OP "$2,328.00 " "$1,722.72" $0.00 "$2,327.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $485.16 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$1,843.78" "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102341 EAP CPT® 29581 Apply Multlay Comprs Lwr Leg BOTH IP/OP $478.00 $353.72 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102342 EAP CPT® 97602 REM/DEBRIDE DEVITALIZED TISSUE W/O ANES BOTH IP/OP $386.00 $285.64 $0.00 $281.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.44 $0.00 $0.00 $0.00 $0.00 $176.00 $278.78 $281.60 $0.00 $200.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102343 EAP CPT® 10036 Placement Of Soft Tissue Localization Device; Each BOTH IP/OP "$1,630.00 " "$1,206.20" $0.00 "$1,630.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.69 $0.00 $0.00 $0.00 $0.00 $820.50 "$1,299.67" "$1,312.80" $0.00 "$1,630.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102344 EAP CPT® 41110 Exc. Of Tongue Lesion W/o Closure BOTH IP/OP "$3,523.00 " "$2,607.02" $0.00 "$2,818.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,790.22" "$2,818.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102345 EAP CPT® 41820 Exc. Gum Each Quad(gingivectomy) BOTH IP/OP "$2,596.00 " "$1,921.04" $0.00 "$2,596.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.01 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,821.60" "$1,840.00" $0.00 "$2,596.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102346 EAP CPT® 30580 "Repair Upper Jaw Fistula," BOTH IP/OP "$9,049.00 " "$6,696.26" $0.00 "$7,239.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,885.81" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$7,166.81" "$7,239.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102347 EAP CPT® 26605 Treat Metacarpal Fx BOTH IP/OP $647.00 $478.78 $0.00 $647.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $647.00 $512.42 $517.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102360 EAP CPT® 55100 Drainage Of Scrotum Abcess BOTH IP/OP "$2,572.00 " "$1,903.28" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $536.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,057.62" "$2,078.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102362 EAP CPT® 19081 Breast Bx W/ Plce Local Dev And Imaging Of Spec 1st Lese BOTH IP/OP "$6,618.00 " "$4,897.32" $0.00 "$5,348.00" "$2,753.10" "$2,753.10" "$1,370.21" "$1,370.21" "$1,377.93" "$1,379.36" $0.00 $0.00 $0.00 "$1,348.50" "$1,379.19" $876.52 "$3,856.00" "$3,856.00" "$1,376.63" "$2,255.00" "$5,294.52" "$5,348.00" "$1,912.65" "$2,500.00" "$1,912.65" $649.79 $173.82 $173.82 "$1,064.25" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36102363 EAP CPT® 19082 Breast Bx W/ Plce Local Dev And Imaging Of Spec Ea Add'e BOTH IP/OP "$4,964.00 " "$3,673.36" $0.00 "$4,011.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,034.50" $0.00 $0.00 $0.00 $0.00 "$2,507.00" "$3,971.09" "$4,011.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102364 EAP CPT® 19083 Breast Bx W/ Plce Local Dev And Imaging Of Spec 1st Lese BOTH IP/OP "$7,720.00 " "$5,712.80" $0.00 "$6,238.40" "$2,753.10" "$2,753.10" "$1,370.21" "$1,370.21" "$1,377.93" "$1,609.04" $0.00 $0.00 $0.00 "$1,348.50" "$1,608.85" $876.52 "$3,856.00" "$3,856.00" "$1,376.63" "$2,255.00" "$6,176.02" "$6,238.40" "$1,912.65" "$2,500.00" "$1,912.65" $645.55 $164.44 $164.44 "$1,241.44" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36102365 EAP CPT® 19084 Breast Bx W/ Plce Local Dev And Imaging Of Spec Ea Add'e BOTH IP/OP "$5,433.00 " "$4,020.42" $0.00 "$4,390.40" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 "$1,132.37" $0.00 $0.00 $0.00 $0.00 "$1,132.24" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,744.00" "$4,346.50" "$4,390.40" $0.00 "$1,750.00" $0.00 $518.83 $81.14 $81.14 $873.69 $0.00 $0.00 $0.00 $0.00 $0.00 36102366 EAP CPT® 19085 Breast Bx W/ Plce Local Dev And Imaging Of Spec 1st Lese BOTH IP/OP "$7,925.00 " "$5,864.50" $0.00 "$6,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,651.57" $0.00 $0.00 $0.00 "$1,376.63" "$2,255.00" "$6,339.96" "$6,404.00" "$1,912.65" "$2,500.00" "$1,912.65" $0.00 $190.41 $190.41 "$1,274.40" "$1,311.08" $0.00 $0.00 $0.00 $0.00 36102367 EAP CPT® 19086 Breast Bx W/ Plce Local Dev And Imaging Of Spec Ea Add'l Lesion Inc Mri Guide BOTH IP/OP "$4,847.00 " "$3,586.78" $0.00 "$4,802.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,010.11" $0.00 $0.00 $0.00 $0.00 "$3,001.50" "$4,754.38" "$4,802.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102368 EAP CPT® 19281 Plce Breast Local Dev Percut 1st Lesion Inc Mammo Guide BOTH IP/OP "$2,033.00 " "$1,504.42" $0.00 "$2,033.00" "$2,033.00" "$2,033.00" $606.01 $606.01 $609.42 $423.73 $0.00 $0.00 $0.00 $596.11 $423.68 $387.47 "$1,871.00" "$1,871.00" $611.80 "$2,028.00" "$1,606.18" "$1,622.40" $850.02 "$1,602.00" $850.02 $234.02 $104.58 $104.58 $322.86 $582.67 $0.00 $0.00 $0.00 $0.00 36102369 EAP CPT® 19282 Plce Breast Local Dev Percut Ea Add'l Lesion Inc Mammo Guide BOTH IP/OP "$1,526.00 " "$1,129.24" $0.00 "$1,217.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $318.02 $0.00 $0.00 $0.00 $0.00 $761.00 "$1,205.42" "$1,217.60" $0.00 $922.00 $0.00 $162.73 $52.65 $52.65 $242.30 $0.00 $0.00 $0.00 $0.00 $0.00 36102370 EAP CPT® 19283 Plce Breast Local Dev Percut 1st Lesion Inc Stereo Guide BOTH IP/OP "$3,496.00 " "$2,587.04" $0.00 "$2,796.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $728.57 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,768.83" "$2,796.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102371 EAP CPT® 19284 Plce Breast Local Dev Percut Ea Add'l Lesion Inc Stereo Guide BOTH IP/OP "$2,623.00 " "$1,941.02" $0.00 "$2,098.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.63 $0.00 $0.00 $0.00 $0.00 "$1,311.50" "$2,077.42" "$2,098.40" $0.00 $992.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102372 EAP CPT® 19285 Plce Breast Local Dev Percut 1st Lesion Inc Ultrsnd Guide BOTH IP/OP "$1,641.00 " "$1,214.34" $0.00 "$1,750.00" "$1,641.00" "$1,641.00" $606.01 $606.01 $609.42 $342.03 $0.00 $0.00 $0.00 $596.11 $341.98 $387.47 "$1,641.00" "$1,641.00" $611.80 "$1,637.00" "$1,296.50" "$1,309.60" $850.02 "$1,750.00" $850.02 $450.73 $89.79 $89.79 $260.61 $582.67 $0.00 $0.00 $0.00 $0.00 36102373 EAP CPT® 19286 Plce Breast Local Dev Percut Ea Add'l Lesion Inc Ultrsnd Guide BOTH IP/OP "$1,231.00 " $910.94 $0.00 $992.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.57 $0.00 $0.00 $0.00 $0.00 $256.54 $0.00 $728.14 $728.14 $0.00 $614.00 $972.58 $982.40 $0.00 $992.00 $0.00 $434.23 $45.44 $45.44 $195.50 $0.00 $0.00 $0.00 $0.00 $0.00 36102374 EAP CPT® 19287 Plce Breast Local Dev Percut 1st Lesion Inc Stereo Guide BOTH IP/OP "$5,193.00 " "$3,842.82" $0.00 "$4,154.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,082.22" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,112.86" "$4,154.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102375 EAP CPT® 19288 Plce Breast Local Dev Percut Ea Add'l Lesion Inc Mri Guide BOTH IP/OP "$3,894.00 " "$2,881.56" $0.00 "$3,115.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $811.51 $0.00 $0.00 $0.00 $0.00 "$1,947.00" "$3,084.05" "$3,115.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36102376 EAP CPT® 10030 Perq Image-guided Catheter Fluid Collection BOTH IP/OP "$1,213.00 " $897.62 $0.00 "$1,221.00" $0.00 $0.00 $0.00 $0.00 $0.00 $252.82 $0.00 $0.00 $0.00 $596.11 $252.79 $387.47 $113.00 $113.00 $611.80 "$1,221.00" $967.03 $976.80 $850.02 "$1,213.00" $850.02 $754.70 $143.53 $143.53 $194.38 $582.67 $0.00 $0.00 $0.00 $0.00 36102380 EAP CPT® 67028 Injection Intravitreal Drug-both Eyes BOTH IP/OP "$3,267.00 " "$2,417.58" $100.58 "$2,640.00" "$2,321.55" "$2,321.55" $310.51 $310.51 $312.26 $680.92 "$1,257.08" "$1,257.08" "$1,305.43" $297.83 $680.84 $193.59 "$1,871.00" "$1,871.00" $310.51 "$2,255.00" "$2,613.60" "$2,640.00" $431.41 "$1,750.00" $431.41 $307.74 $100.58 $100.58 $525.36 $295.72 $0.00 $0.00 $0.00 $0.00 36103335 EAP CPT® 57135 Remove Vagina Lesion BOTH IP/OP "$3,669.00 " "$2,715.06" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $764.62 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,935.15" "$2,964.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103340 EAP CPT® 64642 Chemodenerv 1 Extermity 1-4 BOTH IP/OP "$3,119.00 " "$2,308.06" $0.00 "$2,508.80" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $650.08 $0.00 $0.00 $0.00 $608.20 $650.00 $395.33 $113.00 $113.00 $626.89 "$2,255.00" "$2,483.71" "$2,508.80" $870.98 "$2,150.00" $870.98 $134.17 $111.39 $111.39 $499.25 $597.04 $0.00 $0.00 $0.00 $0.00 36103341 EAP CPT® 64643 Chemodenerv 1 Exterm 1-4 Ea BOTH IP/OP "$2,339.00 " "$1,730.86" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $487.51 $0.00 $0.00 $0.00 $0.00 $487.45 $0.00 "$1,383.52" "$1,383.52" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $967.00 $0.00 $88.23 $74.27 $74.27 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 36103342 EAP CPT® 64644 Chemodenerv 1 Exterm --5/>mus BOTH IP/OP "$3,701.00 " "$2,738.74" $0.00 "$2,976.80" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $771.38 $0.00 $0.00 $0.00 $608.20 $771.29 $395.33 $113.00 $113.00 $626.89 "$2,255.00" "$2,947.03" "$2,976.80" $870.98 "$2,150.00" $870.98 $153.25 $121.48 $121.48 $592.38 $597.04 $0.00 $0.00 $0.00 $0.00 36103343 EAP CPT® 64645 Chemodenerv 1 Exterm --5/> Ea BOTH IP/OP "$2,775.00 " "$2,053.50" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $578.38 $0.00 $0.00 $0.00 $0.00 $578.31 $0.00 "$1,641.41" "$1,641.41" $0.00 "$1,395.00" "$2,209.68" "$2,232.00" $0.00 $967.00 $0.00 $107.96 $85.44 $85.44 $444.17 $0.00 $0.00 $0.00 $0.00 $0.00 36103344 EAP CPT® 64646 Chemodenerv Trunk Musc 1-5 BOTH IP/OP "$3,119.00 " "$2,308.06" $0.00 "$2,508.80" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $650.08 $0.00 $0.00 $0.00 $608.20 $650.00 $395.33 $113.00 $113.00 $626.89 "$2,255.00" "$2,483.71" "$2,508.80" $870.98 "$2,150.00" $870.98 $144.35 $119.68 $119.68 $499.25 $597.04 $0.00 $0.00 $0.00 $0.00 36103345 EAP CPT® 64647 Chemodenerv Trunk Musc 6/> BOTH IP/OP "$3,721.00 " "$2,753.54" $0.00 "$2,976.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.46 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,947.03" "$2,976.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103352 EAP CPT® 37239 Open/peq Place Stent Ea Add BOTH IP/OP "$20,475.00 " "$15,151.50" $0.00 "$16,063.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,266.99" $0.00 $0.00 $0.00 $0.00 "$10,039.50" "$15,902.57" "$16,063.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103353 EAP CPT® 37238 Open/pero Place Stent Same BOTH IP/OP "$45,270.00 " "$33,499.80" $0.00 "$35,516.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,434.27" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$35,160.84" "$35,516.00" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103354 EAP CPT® 37236 Open/perq Place Stent 1st BOTH IP/OP "$45,270.00 " "$33,499.80" $0.00 "$35,516.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,434.27" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$35,160.84" "$35,516.00" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103355 EAP CPT® 37237 Open/perq Place Stent Ea Add BOTH IP/OP "$18,237.00 " "$13,495.38" $0.00 "$16,063.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,800.59" $0.00 $0.00 $0.00 $0.00 "$10,039.50" "$15,902.57" "$16,063.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103358 EAP CPT® 37242 Vasc Embolize/occlude Artery BOTH IP/OP "$21,962.00 " "$16,251.88" $0.00 "$17,229.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,576.88" $0.00 $0.00 $0.00 "$9,937.60" "$6,105.00" "$17,057.30" "$17,229.60" "$13,806.97" "$5,164.00" "$13,806.97" "$7,460.11" $499.45 $499.45 "$3,428.69" "$9,464.38" $0.00 $0.00 $0.00 $0.00 36103359 EAP CPT® 37244 Vasc Embolize/occlude Bleed BOTH IP/OP "$21,962.00 " "$16,251.88" $0.00 "$17,229.60" "$2,984.10" "$2,984.10" "$9,781.76" "$9,781.76" "$9,836.87" "$4,577.43" $0.00 $0.00 $0.00 "$9,625.35" "$4,576.88" "$6,256.48" "$4,877.00" "$4,877.00" $0.00 "$6,105.00" "$17,057.30" "$17,229.60" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103361 EAP CPT® 37241 Vasc Embolize/occlude Venous BOTH IP/OP "$21,962.00 " "$16,251.88" $0.00 "$17,229.60" "$2,984.10" "$2,984.10" "$9,781.76" "$9,781.76" "$9,836.87" "$4,577.43" $0.00 $0.00 $0.00 "$9,625.35" "$4,576.88" "$6,256.48" "$4,877.00" "$4,877.00" $0.00 "$6,105.00" "$17,057.30" "$17,229.60" $0.00 "$14,275.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103374 EAP CPT® 64616 Chemodenerv Musc Neck Dyston BOTH IP/OP $632.00 $467.68 $0.00 $635.00 $632.00 $632.00 $254.43 $254.43 $255.86 $0.00 $0.00 $0.00 $0.00 $0.00 $131.71 $0.00 $0.00 $0.00 $262.54 $635.00 $502.92 $508.00 $364.76 $632.00 $364.76 $117.83 $113.17 $113.17 $101.09 $250.04 $0.00 $0.00 $0.00 $0.00 36103376 EAP CPT® 37243 Vasc Embolize/occlude Organ BOTH IP/OP "$23,963.00 " "$17,732.62" $0.00 "$18,800.00" "$2,984.10" "$2,984.10" "$9,781.76" "$9,781.76" "$9,836.87" "$4,994.49" $0.00 $0.00 $0.00 "$9,625.35" "$4,993.89" "$6,256.48" "$4,877.00" "$4,877.00" "$9,937.60" "$6,105.00" "$18,612.00" "$18,800.00" "$13,806.97" "$5,164.00" "$13,806.97" "$7,751.33" $587.86 $587.86 "$3,741.20" "$9,464.38" $0.00 $0.00 $0.00 $0.00 36103378 EAP CPT® 34841 "Endovas Rp Vis A Dep Viscl Aort End, S/i,angio One" BOTH IP/OP "$19,007.00 " "$14,065.18" $0.00 "$15,205.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,961.06" $0.00 $0.00 $0.00 $0.00 "$9,503.50" "$15,053.54" "$15,205.60" $0.00 "$3,949.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103379 EAP CPT® 34842 Endovas Rp Vis A Dep Viscl Aort End S/i Angio Two BOTH IP/OP "$20,567.00 " "$15,219.58" $0.00 "$16,453.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,286.16" $0.00 $0.00 $0.00 $0.00 "$10,283.50" "$16,289.06" "$16,453.60" $0.00 "$3,949.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103380 EAP CPT® 34843 Endovas Rp Vis A Dep Viscl Aort End S/i Angio Three BOTH IP/OP "$22,120.00 " "$16,368.80" $0.00 "$17,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,609.81" $0.00 $0.00 $0.00 $0.00 "$11,060.00" "$17,519.04" "$17,696.00" $0.00 "$3,949.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103381 EAP CPT® 34844 Endovas Rp Vis A Dep Viscl Aort End S/i Angio Four Or > BOTH IP/OP "$23,672.00 " "$17,517.28" $0.00 "$18,937.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,933.24" $0.00 $0.00 $0.00 $0.00 "$11,836.00" "$18,748.22" "$18,937.60" $0.00 "$3,949.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103382 EAP CPT® 34845 Endovas Rp Vis A Dep Viscl Aort End W/ Unibdy Or Mod Infrenl End S/i Angio One BOTH IP/OP "$23,049.00 " "$17,056.26" $0.00 "$18,439.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,803.41" $0.00 $0.00 $0.00 $0.00 "$11,524.50" "$18,254.81" "$18,439.20" $0.00 "$3,949.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103383 EAP CPT® 34846 Endovas Rp Vis A Dep Viscl Aort End W/ Unibdy Or Mod Infrenl End S/i Angio Two BOTH IP/OP "$24,602.00 " "$18,205.48" $0.00 "$19,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,127.06" $0.00 $0.00 $0.00 $0.00 "$12,301.00" "$19,484.78" "$19,681.60" $0.00 "$3,949.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103384 EAP CPT® 34847 Endovas Rp Vis A Dep Viscl Aort End W/ Unibdy Or Mod Infrenl End S/i Angio Three BOTH IP/OP "$26,154.00 " "$19,353.96" $0.00 "$20,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,450.49" $0.00 $0.00 $0.00 $0.00 "$13,077.00" "$20,713.97" "$20,923.20" $0.00 "$3,949.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103385 EAP CPT® 34848 Endovas Rp Vis A Dep Viscl Aort End W/ Unibdy Or Mod Infrenl End S/i Angio Four Or > BOTH IP/OP "$27,705.00 " "$20,501.70" $0.00 "$22,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,773.72" $0.00 $0.00 $0.00 $0.00 "$13,852.50" "$21,942.36" "$22,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103388 EAP CPT® 20694 "Removal, Under Anesthesia, Of External Fix System" BOTH IP/OP "$5,413.00 " "$4,005.62" $0.00 "$4,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,128.07" $0.00 $0.00 $0.00 "$1,359.37" "$2,255.00" "$4,028.90" "$4,069.60" "$1,888.67" "$3,250.00" "$1,888.67" $337.82 $350.34 $350.34 $809.85 "$1,294.64" $0.00 $0.00 $0.00 $0.00 36103390 EAP CPT® 64617 "Chemodenervation Of Muscle(s); Larynx, Unilateral, Percd" BOTH IP/OP $850.00 $629.00 $0.00 $855.00 $850.00 $850.00 $254.43 $254.43 $255.86 $177.16 $0.00 $0.00 $0.00 $250.31 $177.14 $162.70 $113.00 $113.00 $0.00 $855.00 $677.16 $684.00 $0.00 $722.00 $0.00 $183.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103391 EAP CPT® 66183 "Insertion Of Anterior Segment Aqueous Drainage Device, H" BOTH IP/OP "$6,247.00 " "$4,622.78" $0.00 "$5,384.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,301.87" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$5,330.95" "$5,384.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103392 EAP CPT® 49406 "Img-gde Fluid Collect Drain / Cath (eg, Abcss, Hema, Seu" BOTH IP/OP "$6,571.00 " "$4,862.54" $0.00 "$6,571.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,369.56" $0.00 $0.00 $0.00 "$1,348.50" "$1,369.40" $876.52 "$6,571.00" "$6,571.00" $0.00 "$2,255.00" "$4,878.72" "$4,928.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103394 EAP CPT® 52356 "Cysto, W/ Ureter And/or Pyelo; W/ Litho Inc Inst Of Ind " BOTH IP/OP "$8,403.00 " "$6,218.22" $0.00 "$6,790.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,751.19" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$6,722.50" "$6,790.40" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103395 EAP CPT® 49405 "Img-gde Fluid Collect Drain / Cath (eg, Abcss, Hema, Seu" BOTH IP/OP "$6,571.00 " "$4,862.54" $0.00 "$6,571.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,369.56" $0.00 $0.00 $0.00 "$1,348.50" "$1,369.40" $876.52 "$6,571.00" "$6,571.00" $0.00 "$2,255.00" "$4,878.72" "$4,928.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103396 EAP CPT® 23333 Removal Foreign Body Shoulder Deep Sub Fac/intra Musc BOTH IP/OP "$2,755.00 " "$2,038.70" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $574.14 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,121.77" "$2,143.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103397 EAP CPT® 31633 Tranbronchial Needle Aspiration Biospy Ea Addtl Lobe BOTH IP/OP "$2,726.00 " "$2,017.24" $0.00 "$2,726.00" "$2,726.00" "$2,726.00" $0.00 $0.00 $0.00 $568.17 $0.00 $0.00 $0.00 $0.00 $568.10 $0.00 "$2,726.00" "$2,726.00" $0.00 "$1,333.50" "$2,112.26" "$2,133.60" $0.00 "$1,750.00" $0.00 $86.74 $65.64 $65.64 $424.59 $0.00 $0.00 $0.00 $0.00 $0.00 36103398 EAP CPT® 31627 "Bronch With Computer-assisted, Image-guided Navigation" BOTH IP/OP "$3,577.00 " "$2,646.98" $0.00 "$2,800.00" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 $745.54 $0.00 $0.00 $0.00 $0.00 $745.45 $0.00 "$2,115.80" "$2,115.80" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 "$1,750.00" $0.00 $879.48 $100.26 $100.26 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 36103399 EAP HCPCS 64650 Chemodenerv Eccrine Glands BOTH IP/OP $527.00 $389.98 $0.00 $530.00 $527.00 $527.00 $254.43 $254.43 $255.86 $109.84 $0.00 $0.00 $0.00 $250.31 $109.83 $162.70 $527.00 $527.00 $0.00 $530.00 $419.76 $424.00 $0.00 $527.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103400 EAP HCPCS 64653 "Chemodenerv Eccrine Other Scalp,face,neck" BOTH IP/OP $561.00 $415.14 $0.00 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.91 $0.00 $0.00 $0.00 $0.00 $561.00 $444.31 $448.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103401 EAP HCPCS 46221 Ligation Of Hemorrhoid(s) BOTH IP/OP "$2,229.00 " "$1,649.46" $0.00 "$2,252.00" "$2,229.00" "$2,229.00" $772.82 $772.82 $777.17 $464.58 $0.00 $0.00 $0.00 $760.65 $464.52 $494.42 "$1,871.00" "$1,871.00" $766.13 "$2,252.00" "$1,783.58" "$1,801.60" "$1,064.43" "$2,150.00" "$1,064.43" $119.76 $198.96 $198.96 $358.52 $729.64 $0.00 $0.00 $0.00 $0.00 36103402 EAP CPT® 64450 Adductor Canal BOTH IP/OP "$2,850.00 " "$2,109.00" $44.35 "$2,321.55" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $594.01 "$1,257.08" "$1,257.08" "$1,305.43" $608.20 $593.94 $395.33 "$1,871.00" "$1,871.00" $626.89 "$2,255.00" "$2,178.00" "$2,200.00" $870.98 "$2,150.00" $870.98 $85.27 $44.35 $44.35 $437.80 $597.04 $0.00 $0.00 $0.00 $0.00 36103404 EAP CPT® 24200 Removal Of Arm Foreign Body BOTH IP/OP "$4,943.00 " "$3,657.82" $0.00 "$3,845.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,030.12" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,807.14" "$3,845.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103405 EAP CPT® 49425 Insert Abdomen - Venous Drain BOTH IP/OP "$24,132.00 " "$17,857.68" $0.00 "$18,098.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,029.11" $0.00 $0.00 $0.00 $0.00 "$11,311.50" "$17,917.42" "$18,098.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103406 EAP CPT® 54220 Treatment Of Penis Lesion BOTH IP/OP "$1,092.00 " $808.08 $139.18 "$1,103.00" "$1,092.00" "$1,092.00" $259.14 $259.14 $260.60 $227.60 "$1,092.00" "$1,092.00" "$1,092.00" $255.07 $227.57 $165.80 "$1,092.00" "$1,092.00" $235.59 "$1,103.00" $873.58 $882.40 $327.32 "$1,009.00" $327.32 $151.42 $139.18 $139.18 $175.60 $224.37 $0.00 $0.00 $0.00 $0.00 36103407 EAP CPT® 17106 Destruction Of Skin Lesions BOTH IP/OP "$1,627.00 " "$1,203.98" $0.00 "$1,627.00" "$1,627.00" "$1,627.00" $336.60 $336.60 $338.49 $339.11 $0.00 $0.00 $0.00 $331.46 $339.07 $215.45 "$1,627.00" "$1,627.00" $320.45 "$1,625.00" "$1,287.00" "$1,300.00" $445.22 "$1,627.00" $445.22 $0.00 $282.61 $282.61 $258.70 $305.19 $0.00 $0.00 $0.00 $0.00 36103410 EAP CPT® 54205 Injection For Peyronie Disease; W/surg Exp Plaque BOTH IP/OP "$9,133.00 " "$6,758.42" $0.00 "$8,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,903.32" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$8,235.22" "$8,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36103411 EAP CPT® 55874 Tprnl Plmt Biodegradable Matrl Periprostatic BOTH IP/OP "$6,075.00 " "$4,495.50" $0.00 "$5,452.00" "$2,321.55" "$2,321.55" "$4,296.49" "$4,296.49" "$4,320.70" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.03" $0.00 $0.00 $0.00 $0.00 "$5,452.00" "$4,799.52" "$4,848.00" $0.00 "$3,948.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191374 EAP CPT® 64615 "Destroy Mucles Facial, Trigeminal, Cervical, Spinal " BOTH IP/OP $533.00 $394.42 $0.00 $830.00 $533.00 $533.00 $254.43 $254.43 $255.86 $111.09 $0.00 $0.00 $0.00 $250.31 $111.08 $162.70 $113.00 $113.00 $262.54 $536.00 $424.51 $428.80 $364.76 $830.00 $364.76 $136.28 $127.95 $127.95 $85.33 $250.04 $0.00 $0.00 $0.00 $0.00 36191375 EAP CPT® 58145 Myomectomy Vag Method BOTH IP/OP "$5,267.00 " "$3,897.58" $0.00 "$4,007.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,097.64" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$3,967.13" "$4,007.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191376 EAP CPT® 11982 Remove Drug Implant Contraceptive BOTH IP/OP $501.00 $370.74 $0.00 "$1,750.00" $501.00 $501.00 $264.30 $264.30 $265.79 $104.42 $0.00 $0.00 $0.00 $258.98 $104.41 $168.34 $113.00 $113.00 $364.66 $500.00 $396.00 $400.00 $500.00 "$1,750.00" $500.00 $128.55 $78.96 $78.96 $79.60 $347.29 $0.00 $0.00 $0.00 $0.00 36191377 EAP CPT® 11983 Remove With Reinsertion Of Drug Implant BOTH IP/OP $502.00 $371.48 $0.00 $502.00 $502.00 $502.00 $264.30 $264.30 $265.79 $104.63 $0.00 $0.00 $0.00 $258.98 $104.62 $168.34 $113.00 $113.00 $364.66 $501.00 $396.79 $400.80 $501.00 $502.00 $501.00 $207.60 $108.53 $108.53 $79.76 $347.29 $0.00 $0.00 $0.00 $0.00 36191378 EAP CPT® 64435 Inj Anes/strd Paracervical Nerve BOTH IP/OP "$1,923.00 " "$1,423.02" $0.00 "$1,923.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $400.75 $0.00 $0.00 $0.00 $0.00 "$1,855.00" "$1,469.16" "$1,484.00" $0.00 "$1,923.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191379 EAP CPT® 65800 Anterior Chamber Tap BOTH IP/OP "$10,501.00 " "$7,770.74" $0.00 "$8,400.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,167.62" $0.00 $0.00 $0.00 "$1,992.71" "$2,167.36" "$1,295.26" "$1,871.00" "$1,871.00" "$2,027.80" "$2,255.00" "$8,316.79" "$8,400.80" "$2,817.36" $0.00 "$2,817.36" $0.00 $93.03 $93.03 "$1,671.76" "$1,931.24" $0.00 $0.00 $0.00 $0.00 36191381 EAP CPT® 31632 Transbronchial Bx W/addl Lobe BOTH IP/OP "$2,153.00 " "$1,593.22" $0.00 "$2,153.00" "$2,153.00" "$2,153.00" $0.00 $0.00 $0.00 $448.74 $0.00 $0.00 $0.00 $0.00 $448.69 $0.00 "$2,153.00" "$2,153.00" $0.00 "$1,053.50" "$1,668.74" "$1,685.60" $0.00 "$1,750.00" $0.00 $70.82 $51.57 $51.57 $335.43 $0.00 $0.00 $0.00 $0.00 $0.00 36191382 EAP CPT® 31633 Transbronchial Needle Bx W/addl Lobe BOTH IP/OP "$2,667.00 " "$1,973.58" $0.00 "$2,667.00" "$2,667.00" "$2,667.00" $0.00 $0.00 $0.00 $555.87 $0.00 $0.00 $0.00 $0.00 $555.80 $0.00 "$2,667.00" "$2,667.00" $0.00 "$1,333.50" "$2,112.26" "$2,133.60" $0.00 "$1,750.00" $0.00 $86.74 $65.64 $65.64 $424.59 $0.00 $0.00 $0.00 $0.00 $0.00 36191383 EAP CPT® 20950 Compartment Pressure Measurement BOTH IP/OP $664.00 $491.36 $0.00 $664.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.38 $0.00 $0.00 $0.00 $0.00 $664.00 $525.89 $531.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191384 EAP CPT® 23405 "Tenotomy, Shoulder Area; Single Tendon" BOTH IP/OP "$5,610.00 " "$4,151.40" $0.00 "$4,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,169.12" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,514.40" "$4,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191385 EAP CPT® 59151 Treat Ectopic Pregnancy BOTH IP/OP "$13,348.00 " "$9,877.52" $0.00 "$10,678.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,781.72" $0.00 $0.00 $0.00 $0.00 "$5,452.00" "$10,571.62" "$10,678.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191386 EAP CPT® 24357 "Tenotomy, Elbow, Lateral Or Media; Percutaneous" BOTH IP/OP "$2,899.00 " "$2,145.26" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $604.15 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,372.04" "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191387 EAP CPT® 26055 Tendon Sheath Incision BOTH IP/OP "$2,440.00 " "$1,805.60" $0.00 "$2,440.00" "$2,440.00" "$2,440.00" "$1,356.40" "$1,356.40" "$1,364.04" $0.00 "$1,541.95" "$1,541.95" "$1,601.25" "$1,334.46" $508.50 $867.40 "$2,440.00" "$2,440.00" $0.00 "$2,327.00" "$1,931.69" "$1,951.20" $0.00 "$2,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191389 EAP CPT® 64491 Inj Paravert F Jnt C/t 2 Lev BOTH IP/OP "$1,819.00 " "$1,346.06" $0.00 "$1,819.00" "$1,819.00" "$1,819.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.08 $0.00 $0.00 $0.00 $0.00 $877.50 "$1,389.96" "$1,404.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191391 EAP CPT® 27000 "Tenotomy, Adductor Of Hip, Percutaneous" BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,575.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.23 $0.00 $0.00 $0.00 $0.00 "$1,575.00" "$1,247.40" "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191392 EAP CPT® 27005 "Tenotomy, Hip Flexor(s), Open" BOTH IP/OP "$1,961.00 " "$1,451.14" $0.00 "$1,961.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.67 $0.00 $0.00 $0.00 $0.00 "$1,961.00" "$1,553.11" "$1,568.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191393 EAP CPT® 27006 "Tenotomy, Abductors And/or Extensor(s) Of Hip,open" BOTH IP/OP "$2,650.00 " "$1,961.00" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.26 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,098.80" "$2,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191394 EAP CPT® 27306 "Tenotomy, Percutaneous, Or Hamstring, Single Tendon" BOTH IP/OP "$5,757.00 " "$4,260.18" $0.00 "$4,605.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,199.76" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,559.54" "$4,605.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191395 EAP CPT® 27307 "Tenotomy, Percutaneous, Adductor Or Hamstring; Multiple Tendons" BOTH IP/OP "$8,511.00 " "$6,298.14" $0.00 "$6,808.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,773.69" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$6,740.71" "$6,808.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191396 EAP CPT® 27605 "Tenotomy, Percutaneous, Achilles Tendon ; Local Anesthesia" BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $309.51 $0.00 $0.00 $0.00 "$1,334.46" $309.47 $867.40 "$1,485.00" "$1,485.00" "$1,359.37" "$1,500.00" "$1,188.00" "$1,200.00" "$1,500.00" "$1,485.00" "$1,500.00" $0.00 $192.52 $192.52 $238.80 "$1,294.64" $0.00 $0.00 $0.00 $0.00 36191397 EAP CPT® 28008 "Fasciotomy, Foot And/or Toe" BOTH IP/OP "$2,912.00 " "$2,154.88" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $606.86 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,441.74" "$2,466.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191398 EAP CPT® 28899 "Unlisted Procedure, Foot Or Toes" BOTH IP/OP "$2,668.00 " "$1,974.32" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,098.01" "$2,119.20" $0.00 $587.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191399 EAP CPT® 64430 Inj Anes/strd Pudendal Nerve BOTH IP/OP $995.00 $736.30 $0.00 $995.00 $995.00 $995.00 $801.66 $801.66 $806.18 $207.38 $995.00 $995.00 $995.00 $788.26 $207.36 $512.37 $995.00 $995.00 $0.00 $960.00 $760.32 $768.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191400 EAP CPT® 12037 Intmd Wnd Repair S/tr/ext BOTH IP/OP "$2,035.00 " "$1,505.90" $0.00 "$2,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.09 $0.00 $0.00 $0.00 $0.00 "$1,907.00" "$1,510.34" "$1,525.60" $0.00 "$2,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191401 EAP CPT® 26070 "Arthrotomy W/expl,drain,rmvl Of Loose/fb Carpometacarpal Jnt" BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191402 EAP CPT® 26075 "Arthrotomy W/expl,drain,rmvl Of Loose/fb Metacarpophalangeal Jnt Ea" BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$2,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.68 $0.00 $0.00 $0.00 $0.00 "$2,700.00" "$2,138.40" "$2,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191403 EAP CPT® 26080 "Arthrotomy W/expl,drain,rmvl Of Loose/fb Interphalangeal Jnt Ea" BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,575.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $536.63 $0.00 $0.00 $0.00 $0.00 "$2,575.00" "$2,039.40" "$2,060.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191404 EAP Custom 26320 Removal Of Implant From Finger Or Hand BOTH IP/OP "$1,581.00 " "$1,169.94" $0.00 "$1,581.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $329.48 $0.00 $0.00 $0.00 $0.00 "$1,581.00" "$1,252.15" "$1,264.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191405 EAP CPT® 26641 "Closed Treatment Of Carpometacarpal Dislocation,thumb,w/manipulation" BOTH IP/OP "$1,104.00 " $816.96 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.07 $0.00 $0.00 $0.00 $0.00 "$1,104.00" $874.37 $883.20 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191406 EAP CPT® 26607 "Clsd Tx Of Metacarpal Fx, W/ Manip,w/external Fix Ea Bone" BOTH IP/OP "$3,176.00 " "$2,350.24" $0.00 "$2,699.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $661.88 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,672.21" "$2,699.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191407 EAP CPT® 26645 "Clsd Tx Of Carpometacarpal Fx Disloc, Thumb W/manip" BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,593.00" "$1,261.66" "$1,274.40" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191408 EAP CPT® 26650 Perc Skel Fix Of Carpometacarpal Fx Disloc Thumb W/ Manip BOTH IP/OP "$5,811.00 " "$4,300.14" $0.00 "$4,938.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,211.01" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,889.02" "$4,938.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191409 EAP CPT® 26670 "Clsd Tx Of Carpometacarpal Disloc Not Thumb, W/manip Ea Jnt,w/o Anest" BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,099.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 "$1,099.00" $870.41 $879.20 $0.00 "$1,099.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191410 EAP CPT® 26700 "Clsd Tx Of Metacarpophalangeal Disloc Single W/manip, W/o Anest" BOTH IP/OP $735.00 $543.90 $0.00 $735.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $735.00 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191450 EAP CPT® 69209 Remove Cerumen Impacted Irrig/lavage Unilat BOTH IP/OP $274.00 $202.76 $0.00 $276.00 $274.00 $274.00 $54.21 $54.21 $54.51 $57.11 $0.00 $0.00 $0.00 $53.35 $57.10 $34.67 $113.00 $113.00 $55.17 $276.00 $218.59 $220.80 $76.65 $263.00 $76.65 $12.24 $14.41 $14.41 $43.94 $52.54 $0.00 $0.00 $0.00 $0.00 36191451 EAP CPT® 66761 Iridotomy Laser Surgery-both Eyes BOTH IP/OP "$11,463.00 " "$8,482.62" $0.00 "$9,263.20" "$2,321.55" "$2,321.55" $490.09 $490.09 $492.86 "$2,389.18" $0.00 $0.00 $0.00 $482.91 "$2,388.89" $313.89 "$1,871.00" "$1,871.00" $508.42 "$2,255.00" "$9,170.57" "$9,263.20" $706.38 "$2,150.00" $706.38 $315.03 $240.80 $240.80 "$1,843.38" $484.21 $0.00 $0.00 $0.00 $0.00 36191452 EAP CPT® 64405 Inj Anes/strd Greater Occipital Nerve BOTH IP/OP "$3,313.00 " "$2,451.62" $0.00 "$2,557.60" "$2,321.55" "$2,321.55" $254.43 $254.43 $255.86 $690.51 $0.00 $0.00 $0.00 $250.31 $690.43 $162.70 "$1,871.00" "$1,871.00" $262.54 "$2,255.00" "$2,532.02" "$2,557.60" $364.76 "$1,199.00" $364.76 $102.34 $55.88 $55.88 $508.96 $250.04 $0.00 $0.00 $0.00 $0.00 36191453 EAP CPT® 64510 Inject Stellate Ganglion BOTH IP/OP "$1,767.00 " "$1,307.58" $0.00 "$1,767.00" "$1,767.00" "$1,767.00" $801.66 $801.66 $806.18 $368.29 "$1,257.08" "$1,257.08" "$1,305.43" $788.26 $368.24 $512.37 "$1,767.00" "$1,767.00" $0.00 "$1,705.00" "$1,350.36" "$1,364.00" $0.00 "$1,767.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191454 EAP CPT® 64620 Destroy Intercostal Neurolytic BOTH IP/OP "$6,513.00 " "$4,819.62" $176.30 "$5,238.40" "$2,321.55" "$2,321.55" $801.66 $801.66 $806.18 "$1,357.47" "$1,257.08" "$1,257.08" "$1,305.43" $788.26 "$1,357.31" $512.37 "$1,871.00" "$1,871.00" $814.44 "$2,255.00" "$5,186.02" "$5,238.40" "$1,131.55" "$3,250.00" "$1,131.55" $176.30 $181.36 $181.36 "$1,042.44" $775.65 $0.00 $0.00 $0.00 $0.00 36191455 EAP CPT® 64494 Inj Paravert F Jnt L/s 2 Lev BOTH IP/OP "$1,721.00 " "$1,273.54" $0.00 "$1,721.00" "$1,721.00" "$1,721.00" $0.00 $0.00 $0.00 $358.70 $0.00 $0.00 $0.00 $0.00 $358.66 $0.00 "$1,017.97" "$1,017.97" $0.00 $830.50 "$1,315.51" "$1,328.80" $0.00 "$1,721.00" $0.00 $54.06 $53.73 $53.73 $264.43 $0.00 $0.00 $0.00 $0.00 $0.00 36191456 EAP CPT® 64495 Inj Paravert F Jnt L/s 3 Lev BOTH IP/OP "$1,652.00 " "$1,222.48" $0.00 "$1,652.00" "$1,652.00" "$1,652.00" $0.00 $0.00 $0.00 $344.32 $0.00 $0.00 $0.00 $0.00 $344.28 $0.00 $977.16 $977.16 $0.00 $797.00 "$1,262.45" "$1,275.20" $0.00 "$1,652.00" $0.00 $0.00 $54.45 $54.45 $253.76 $0.00 $0.00 $0.00 $0.00 $0.00 36191457 EAP CPT® 64492 Inj Paravert F Jnt C/t 3 Lev BOTH IP/OP "$1,627.00 " "$1,203.98" $0.00 "$1,627.00" "$1,627.00" "$1,627.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.07 $0.00 $0.00 $0.00 $0.00 $785.00 "$1,243.44" "$1,256.00" $0.00 $871.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191458 EAP CPT® 64493 Inj Paravert F Jnt L/s 1 Lev BOTH IP/OP "$3,789.00 " "$2,803.86" $0.00 "$2,924.80" "$2,321.55" "$2,321.55" $801.66 $801.66 $806.18 $789.72 $0.00 $0.00 $0.00 $788.26 $789.63 $512.37 "$1,871.00" "$1,871.00" $814.44 "$2,255.00" "$2,895.55" "$2,924.80" "$1,131.55" "$2,150.00" "$1,131.55" $111.04 $93.03 $93.03 $582.04 $775.65 $0.00 $0.00 $0.00 $0.00 36191459 EAP CPT® 64490 Inj Paravert F Jnt C/t 1 Lev BOTH IP/OP "$3,789.00 " "$2,803.86" $0.00 "$2,924.80" "$2,321.55" "$2,321.55" $801.66 $801.66 $806.18 $0.00 $0.00 $0.00 $0.00 $0.00 $789.63 $0.00 $0.00 $0.00 $814.44 "$2,255.00" "$2,895.55" "$2,924.80" "$1,131.55" "$2,150.00" "$1,131.55" $122.58 $109.61 $109.61 $582.04 $775.65 $0.00 $0.00 $0.00 $0.00 36191460 EAP CPT® 64517 Nblock Inj Hypogas Plxs BOTH IP/OP "$3,493.00 " "$2,584.82" $0.00 "$2,836.00" "$2,753.10" "$2,753.10" $801.66 $801.66 $806.18 $728.03 "$1,541.95" "$1,541.95" "$1,601.25" $788.26 $727.94 $512.37 "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$2,669.04" "$2,696.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191461 EAP CPT® 64418 Inj Anes/strd Suprascapular BOTH IP/OP "$3,173.00 " "$2,348.02" $0.00 "$2,449.60" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $661.33 $0.00 $0.00 $0.00 $608.20 $661.25 $395.33 "$1,871.00" "$1,871.00" $626.89 "$2,255.00" "$2,425.10" "$2,449.60" $870.98 "$2,150.00" $870.98 $104.21 $59.14 $59.14 $487.47 $597.04 $0.00 $0.00 $0.00 $0.00 36191462 EAP CPT® 38222 Bone Marrow Biopsy(ies) & Aspiration(s) BOTH IP/OP "$2,325.00 " "$1,720.50" $0.00 "$2,325.71" "$2,321.55" "$2,321.55" "$2,309.02" "$2,309.02" "$2,322.02" $484.59 $0.00 $0.00 $0.00 "$2,271.46" $484.53 "$1,476.45" "$1,871.00" "$1,871.00" "$2,325.71" "$2,000.00" "$1,584.00" "$1,600.00" "$2,000.00" "$1,511.25" "$2,000.00" $164.87 $80.78 $80.78 $318.40 "$2,214.96" $0.00 $0.00 $0.00 $0.00 36191464 EAP CPT® 65855 "Argon Trabeculoplasty, Both Eyes" BOTH IP/OP "$4,121.00 " "$3,049.54" $211.62 "$3,552.80" "$2,753.10" "$2,753.10" $490.09 $490.09 $492.86 $858.92 "$2,571.13" "$2,571.13" "$2,670.02" $482.91 $858.82 $313.89 "$1,871.00" "$1,871.00" $508.42 "$2,255.00" "$3,517.27" "$3,552.80" $706.38 "$2,150.00" $706.38 $354.58 $211.62 $211.62 $707.01 $484.21 $0.00 $0.00 $0.00 $0.00 36191465 EAP CPT® 67040 "Pan Retinal Photocoagulation, Both Eyes" BOTH IP/OP "$15,964.00 " "$11,813.36" $0.00 "$12,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,326.90" $0.00 $0.00 $0.00 $0.00 "$4,975.00" "$12,771.00" "$12,900.00" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191466 EAP CPT® 66821 "Yag Capsulotomy, Both Eyes" BOTH IP/OP "$3,181.00 " "$2,353.94" $188.16 "$2,836.00" "$2,753.10" "$2,753.10" $490.09 $490.09 $492.86 $663.00 "$1,541.95" "$1,541.95" "$1,601.25" $482.91 $662.92 $313.89 "$2,836.00" "$2,836.00" $508.42 "$2,327.00" "$2,544.70" "$2,570.40" $706.38 "$2,150.00" $706.38 $188.16 $317.54 $317.54 $511.51 $484.21 $0.00 $0.00 $0.00 $0.00 36191467 EAP CPT® 65865 "Argon Laser Gonioplasty, One Eye" BOTH IP/OP "$4,345.00 " "$3,215.30" $0.00 "$3,511.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.50 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,476.09" "$3,511.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191468 EAP CPT® 46230 "Excision Of Multiple External Papillae Or Tags, Anus" BOTH IP/OP "$4,962.00 " "$3,671.88" $0.00 "$3,969.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,034.08" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,929.90" "$3,969.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191469 EAP CPT® 31574 Laryngoscopy W/ Inj Augmentation Unilateral BOTH IP/OP "$3,605.00 " "$2,667.70" $0.00 "$3,605.00" $0.00 $0.00 $0.00 $0.00 $0.00 $751.37 $0.00 $0.00 $0.00 "$1,434.17" $751.28 $932.21 "$3,605.00" "$3,605.00" $0.00 "$2,255.00" "$2,621.52" "$2,648.00" $0.00 "$2,239.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191470 EAP CPT® 31574 Laryngoscopy W/ Inj Augmentation Bilateral BOTH IP/OP "$4,748.00 " "$3,513.52" $0.00 "$4,748.00" $0.00 $0.00 $0.00 $0.00 $0.00 $989.60 $0.00 $0.00 $0.00 "$1,434.17" $989.48 $932.21 "$4,748.00" "$4,748.00" $0.00 "$2,255.00" "$3,933.07" "$3,972.80" $0.00 "$2,239.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191471 EAP CPT® 62355 Remove Spinal Canal Catheter BOTH IP/OP "$7,880.00 " "$5,831.20" $0.00 "$6,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,642.19" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,240.96" "$6,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191472 EAP CPT® 64561 Implant Neuroelectrodes Sacral Nerve BOTH IP/OP "$11,177.00 " "$8,270.98" $0.00 "$8,627.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,329.29" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$8,540.93" "$8,627.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191473 EAP CPT® 64461 Pvb Thoracic Single Inj Site BOTH IP/OP "$4,312.00 " "$3,190.88" $0.00 "$3,328.80" "$2,321.55" "$2,321.55" $618.38 $618.38 $621.87 $0.00 $0.00 $0.00 $0.00 $0.00 $898.62 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,295.51" "$3,328.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191474 EAP CPT® 64462 Pvb Thoracic 2nd+ Inj Site BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,189.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $521.00 $0.00 $0.00 $0.00 $0.00 "$1,368.50" "$2,167.70" "$2,189.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191475 EAP CPT® 55920 Place Needles Pelvic For Rt BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$7,920.79" "$8,000.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191476 EAP CPT® 36660 Insertion Catheter Artery BOTH IP/OP $212.00 $156.88 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $180.00 $142.56 $144.00 $0.00 $137.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191477 EAP CPT® 46910 Destruction Anal Lesion(s) BOTH IP/OP "$5,868.00 " "$4,342.32" $138.42 "$4,877.00" "$2,753.10" "$2,753.10" "$1,667.97" "$1,667.97" "$1,677.37" "$1,223.04" "$1,541.95" "$1,541.95" "$1,601.25" "$1,644.04" "$1,222.89" "$1,068.62" "$4,877.00" "$4,877.00" "$1,553.51" "$2,255.00" "$4,694.18" "$4,741.60" "$2,158.40" "$2,500.00" "$2,158.40" $144.75 $138.42 $138.42 $943.58 "$1,479.54" $0.00 $0.00 $0.00 $0.00 36191478 EAP CPT® 66500 Iridotomy By Stab Incision; Except Transfixion BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,295.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $833.60 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,262.25" "$3,295.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191479 EAP CPT® 65435 Curette/treat Cornea BOTH IP/OP "$2,421.00 " "$1,791.54" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $504.54 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,935.65" "$1,955.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191480 EAP CPT® 65810 Paracentesis Ant Cham W/ Rmvl Vitreous W/wo Air Inj BOTH IP/OP "$6,052.00 " "$4,478.48" $0.00 "$4,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,261.24" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,839.12" "$4,888.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191481 EAP CPT® 27369 Njx Px Cntrst Kne Arthg Cntrst Enhncd Ct/mri Kne BOTH IP/OP "$1,323.00 " $979.02 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.71 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $563.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191482 EAP CPT® 33285 Insertion Subq Cardiac Rhythm Monitor W/prgrmg BOTH IP/OP "$12,848.00 " "$9,507.52" $0.00 "$16,063.45" "$2,321.55" "$2,321.55" "$7,945.15" "$7,945.15" "$7,989.91" "$2,677.84" $0.00 $0.00 $0.00 "$7,813.60" "$2,677.52" "$5,078.84" "$4,877.00" "$4,877.00" "$7,664.31" "$6,105.00" "$9,979.20" "$10,080.00" "$10,648.54" "$16,063.45" "$10,648.54" "$4,971.59" $92.65 $92.65 "$2,005.92" "$7,299.34" $0.00 $0.00 $0.00 $0.00 36191483 EAP CPT® 33286 Removal Subcutaneous Cardiac Rhythm Monitor BOTH IP/OP "$13,427.00 " "$9,935.98" $91.21 "$10,533.60" "$2,321.55" "$2,321.55" $606.01 $606.01 $609.42 "$2,798.52" "$1,257.08" "$1,257.08" "$1,305.43" $596.11 "$2,798.19" $387.47 "$2,836.00" "$2,836.00" $611.80 "$2,255.00" "$10,428.26" "$10,533.60" $850.02 "$2,065.05" $850.02 $130.54 $91.21 $91.21 "$2,096.19" $582.67 $0.00 $0.00 $0.00 $0.00 36191484 EAP CPT® 10005 Fna Bx W/ Us Guide 1st Lesion BOTH IP/OP "$1,535.00 " "$1,135.90" $0.00 "$1,824.55" "$1,535.00" "$1,535.00" $606.01 $606.01 $609.42 $319.93 $0.00 $0.00 $0.00 $596.11 $319.89 $387.47 "$1,535.00" "$1,535.00" $611.80 "$1,546.00" "$1,224.43" "$1,236.80" $850.02 "$1,824.55" $850.02 $42.95 $74.65 $74.65 $246.12 $582.67 $0.00 $0.00 $0.00 $0.00 36191485 EAP CPT® 10006 Fna Bx W/ Us Guide Ea Addtl BOTH IP/OP $524.00 $387.76 $0.00 $422.40 $0.00 $0.00 $0.00 $0.00 $0.00 $109.21 $0.00 $0.00 $0.00 $0.00 $109.20 $0.00 $309.95 $309.95 $0.00 $264.00 $418.18 $422.40 $0.00 $340.60 $0.00 $58.60 $51.21 $51.21 $84.06 $0.00 $0.00 $0.00 $0.00 $0.00 36191486 EAP CPT® 10007 Fna Bx W/ Fluoro Guide 1st Lesion BOTH IP/OP "$1,535.00 " "$1,135.90" $0.00 "$1,546.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.89 $0.00 $0.00 $0.00 $0.00 "$1,546.00" "$1,224.43" "$1,236.80" $0.00 $997.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191487 EAP CPT® 10008 Fna Bx W/ Fluoro Guide Ea Addtl BOTH IP/OP $524.00 $387.76 $0.00 $422.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $264.00 $418.18 $422.40 $0.00 $340.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191488 EAP CPT® 10009 Fna Bx W/ Ct Guide 1st Lesion BOTH IP/OP "$1,535.00 " "$1,135.90" $0.00 "$1,546.00" "$1,535.00" "$1,535.00" $606.01 $606.01 $609.42 $319.93 $0.00 $0.00 $0.00 $596.11 $319.89 $387.47 "$1,535.00" "$1,535.00" $611.80 "$1,546.00" "$1,224.43" "$1,236.80" $850.02 $997.75 $850.02 $451.42 $118.28 $118.28 $246.12 $582.67 $0.00 $0.00 $0.00 $0.00 36191489 EAP CPT® 10010 Fna Bx W/ Ct Guide Ea Addtl BOTH IP/OP $524.00 $387.76 $0.00 $422.40 $0.00 $0.00 $0.00 $0.00 $0.00 $109.21 $0.00 $0.00 $0.00 $0.00 $109.20 $0.00 $309.95 $309.95 $0.00 $264.00 $418.18 $422.40 $0.00 $340.60 $0.00 $272.43 $85.83 $85.83 $84.06 $0.00 $0.00 $0.00 $0.00 $0.00 36191490 EAP CPT® 10011 Fna Bx W/ Mr Guide 1st Lesion BOTH IP/OP "$1,535.00 " "$1,135.90" $0.00 "$1,546.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.89 $0.00 $0.00 $0.00 $0.00 "$1,546.00" "$1,224.43" "$1,236.80" $0.00 $997.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191491 EAP CPT® 10012 Fna Bx W/ Mr Guide Ea Addtl BOTH IP/OP $524.00 $387.76 $0.00 $422.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $264.00 $418.18 $422.40 $0.00 $340.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191492 EAP CPT® 11102 Tangential (shave) Bx Skin; 1st Lesion BOTH IP/OP $313.00 $231.62 $0.00 $557.05 $313.00 $313.00 $174.88 $174.88 $175.86 $65.24 $0.00 $0.00 $0.00 $172.08 $65.23 $111.85 $113.00 $113.00 $175.24 $313.00 $247.90 $250.40 $243.48 $557.05 $243.48 $95.62 $40.38 $40.38 $49.83 $166.90 $0.00 $0.00 $0.00 $0.00 36191493 EAP CPT® 11104 Punch Bx Skin; 1st Lesion BOTH IP/OP $313.00 $231.62 $0.00 $557.05 $313.00 $313.00 $336.60 $336.60 $313.00 $65.24 $0.00 $0.00 $0.00 $331.46 $65.23 $215.45 $113.00 $113.00 $175.24 $313.00 $247.90 $250.40 $243.48 $557.05 $243.48 $120.20 $50.48 $50.48 $49.83 $166.90 $0.00 $0.00 $0.00 $0.00 36191494 EAP CPT® 11106 Incisional (wedge) Bx Skin; 1st Lesion BOTH IP/OP $375.00 $277.50 $0.00 $510.03 $375.00 $375.00 $510.03 $510.03 $375.00 $78.16 $0.00 $0.00 $0.00 $502.38 $78.15 $326.54 $375.00 $375.00 $320.45 $375.00 $297.00 $300.00 $375.00 $243.75 $375.00 $145.49 $60.94 $60.94 $59.70 $305.19 $0.00 $0.00 $0.00 $0.00 36191495 EAP CPT® 11103 Tangential (shave) Bx Skin; Ea Addtl BOTH IP/OP $300.00 $222.00 $0.00 $300.00 $300.00 $300.00 $0.00 $0.00 $0.00 $62.53 $0.00 $0.00 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $51.58 $23.44 $23.44 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 36191496 EAP CPT® 11105 Punch Bx Skin; Ea Addtl BOTH IP/OP $300.00 $222.00 $0.00 $300.00 $300.00 $300.00 $0.00 $0.00 $0.00 $62.53 $0.00 $0.00 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $59.11 $27.40 $27.40 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 36191497 EAP CPT® 11107 Incisional (wedge) Bx Skin; Ea Addtl BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191498 EAP CPT® 43762 Perq Replacement Gtube Not Req Rev Gastro Tract BOTH IP/OP "$1,668.00 " "$1,234.32" $0.00 "$1,604.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.61 $0.00 $0.00 $0.00 $0.00 "$1,604.00" "$1,270.37" "$1,283.20" $0.00 $727.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191499 EAP CPT® 43763 Perq Replacement Gtube Requiring Rev Gastro Tract BOTH IP/OP "$1,668.00 " "$1,234.32" $0.00 "$1,604.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.61 $0.00 $0.00 $0.00 $0.00 "$1,604.00" "$1,270.37" "$1,283.20" $0.00 $632.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191500 EAP CPT® 50436 Perq Dilation Xst Trc Endourologic Px W/img BOTH IP/OP "$9,134.00 " "$6,759.16" $0.00 "$7,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,903.53" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,234.13" "$7,307.20" $0.00 "$4,672.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191501 EAP CPT® 50437 Perq Dilation Xst Trc New Access Renal Coltj Sys BOTH IP/OP "$9,134.00 " "$6,759.16" $0.00 "$7,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,903.53" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$7,234.13" "$7,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191502 EAP CPT® 65436 Curettage/treatment Cornea BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$4,399.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,355.21" "$4,399.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191503 EAP CPT® 10004 Fna Bx W/o Img Gdn Ea Addl BOTH IP/OP $524.00 $387.76 $0.00 $524.00 $524.00 $524.00 $0.00 $0.00 $0.00 $109.21 $0.00 $0.00 $0.00 $0.00 $109.20 $0.00 $309.95 $309.95 $0.00 $264.00 $418.18 $422.40 $0.00 $340.60 $0.00 $51.12 $45.07 $45.07 $84.06 $0.00 $0.00 $0.00 $0.00 $0.00 36191504 EAP CPT® 27369 Ct/mr Contrast Enhanced Arthrg Knee Inj Px Bilateral BOTH IP/OP "$1,984.00 " "$1,468.16" $0.00 "$1,508.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.47 $0.00 $0.00 $0.00 $0.00 $943.00 "$1,493.71" "$1,508.80" $0.00 $563.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191505 EAP CPT® 64635 Bilateral Destr Lumb/sac Facet Jnt; Single BOTH IP/OP "$4,252.00 " "$3,146.48" $0.00 "$4,252.00" "$2,321.55" "$2,321.55" "$1,709.97" "$1,709.97" "$1,719.60" $886.22 $0.00 $0.00 $0.00 "$1,681.44" $886.12 "$1,092.94" "$4,252.00" "$4,252.00" "$1,724.40" "$2,255.00" "$3,385.80" "$3,420.00" "$2,395.83" "$3,250.00" "$2,395.83" $425.03 $229.68 $229.68 $680.58 "$1,642.29" $0.00 $0.00 $0.00 $0.00 36191507 EAP CPT® 69209 Remove Impacted Ear Wax Irrig/lavage Bil BOTH IP/OP $410.00 $303.40 $0.00 $414.00 $410.00 $410.00 $54.21 $54.21 $54.51 $85.45 $0.00 $0.00 $0.00 $53.35 $85.44 $34.67 $113.00 $113.00 $55.17 $414.00 $327.89 $331.20 $76.65 $263.00 $76.65 $12.24 $14.41 $14.41 $65.91 $52.54 $0.00 $0.00 $0.00 $0.00 36191508 EAP CPT® 36573 Ins Picc W/ Imaging 5 Yr+ BOTH IP/OP "$5,719.00 " "$4,232.06" $0.00 "$5,719.00" "$2,321.55" "$2,321.55" "$1,369.42" "$1,369.42" "$1,377.13" "$1,191.98" $0.00 $0.00 $0.00 "$1,347.67" "$1,191.84" $875.99 "$5,719.00" "$5,719.00" "$1,635.92" "$2,255.00" "$4,299.77" "$4,343.20" "$2,272.90" "$3,717.35" "$2,272.90" $849.64 $88.35 $88.35 $864.30 "$1,558.02" $0.00 $0.00 $0.00 $0.00 36191509 EAP CPT® 27266 Clsd Tx Post Hip Arthroplasty Disloc BOTH IP/OP "$4,283.00 " "$3,169.42" $0.00 "$3,460.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $892.58 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,426.19" "$3,460.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191510 EAP CPT® 15793 Chemical Peel (tca) Nonfacial BOTH IP/OP "$1,268.00 " $938.32 $0.00 "$1,268.00" $688.52 $688.52 $336.60 $336.60 $338.49 $264.28 $0.00 $0.00 $0.00 $331.46 $264.25 $215.45 $113.00 $113.00 $320.45 "$1,188.00" $940.90 $950.40 $445.22 "$1,268.00" $445.22 $185.92 $362.58 $362.58 $189.13 $305.19 $0.00 $0.00 $0.00 $0.00 36191511 EAP CPT® 46922 Simple Excision Of Anal Lesion(s) BOTH IP/OP "$7,021.00 " "$5,195.54" $0.00 "$5,673.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,463.18" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,616.86" "$5,673.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191512 EAP CPT® 20526 Bilateral Carpal Tunnel Inj BOTH IP/OP "$1,355.00 " "$1,002.70" $0.00 "$1,356.00" "$1,355.00" "$1,355.00" $254.43 $254.43 $255.86 $282.42 $0.00 $0.00 $0.00 $250.31 $282.38 $162.70 "$1,355.00" "$1,355.00" $262.54 "$1,356.00" "$1,073.95" "$1,084.80" $364.76 "$1,355.00" $364.76 $212.21 $59.49 $59.49 $215.88 $250.04 $0.00 $0.00 $0.00 $0.00 36191513 EAP CPT® 64483 Bil Inject Txforamen Epi L/s Sngl BOTH IP/OP "$2,651.00 " "$1,961.74" $115.74 "$2,321.55" "$2,321.55" "$2,321.55" $801.66 $801.66 $806.18 $552.53 "$1,257.08" "$1,257.08" "$1,305.43" $788.26 $552.47 $512.37 "$1,871.00" "$1,871.00" $814.44 "$2,255.00" "$2,025.94" "$2,046.40" "$1,131.55" "$2,150.00" "$1,131.55" $197.93 $115.74 $115.74 $407.23 $775.65 $0.00 $0.00 $0.00 $0.00 36191514 EAP CPT® 67110 Repair Retinal Detachment Inj Px BOTH IP/OP "$7,476.00 " "$5,532.24" $0.00 "$6,041.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,558.00" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,981.18" "$6,041.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191515 EAP CPT® 11450 Removal Sweat Gland Lesion BOTH IP/OP "$8,560.00 " "$6,334.40" $0.00 "$6,839.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,783.90" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,770.81" "$6,839.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191516 EAP CPT® 69210 Bil Removal Impacted Cerumen Instrument BOTH IP/OP $613.00 $453.62 $0.00 $618.00 $613.00 $613.00 $54.21 $54.21 $54.51 $127.76 $0.00 $0.00 $0.00 $53.35 $127.75 $34.67 $113.00 $113.00 $55.17 $618.00 $489.46 $494.40 $76.65 $564.00 $76.65 $47.34 $34.61 $34.61 $98.39 $52.54 $0.00 $0.00 $0.00 $0.00 36191517 EAP CPT® 45100 Biopsy Of Rectum BOTH IP/OP "$5,621.00 " "$4,159.54" $0.00 "$4,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,171.42" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,442.33" "$4,487.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191518 EAP CPT® 11462 Excision Hidradenitis Inguinal Simple/interm BOTH IP/OP "$7,409.00 " "$5,482.66" $0.00 "$5,920.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,544.04" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,860.80" "$5,920.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191519 EAP CPT® 20611 Bilateral Drain/inject-shoulder Hip Knee With Us Guidance BOTH IP/OP "$4,395.00 " "$3,252.30" $0.00 "$3,520.00" "$2,321.55" "$2,321.55" $254.43 $254.43 $255.86 $916.03 $0.00 $0.00 $0.00 $250.31 $915.92 $162.70 $113.00 $113.00 $262.54 "$2,255.00" "$3,484.80" "$3,520.00" $364.76 "$1,750.00" $364.76 $88.61 $62.38 $62.38 $700.48 $250.04 $0.00 $0.00 $0.00 $0.00 36191520 EAP CPT® 55899 Genital Surgery Procedure Unlisted BOTH IP/OP "$5,214.00 " "$3,858.36" $0.00 "$4,171.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,086.60" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,129.49" "$4,171.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191521 EAP CPT® 53020 Incision Of Urethra BOTH IP/OP "$6,761.00 " "$5,003.14" $0.00 "$5,424.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,408.99" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,370.55" "$5,424.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191522 EAP CPT® 31636 Bronchoscopy Initial Bronch Stent BOTH IP/OP "$9,005.00 " "$6,663.70" $0.00 "$7,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,876.64" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,131.96" "$7,204.00" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191523 EAP CPT® 31637 Bronchoscopy Addl Bronch Stent BOTH IP/OP "$4,558.00 " "$3,372.92" $0.00 "$3,646.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $949.89 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,609.94" "$3,646.40" $0.00 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191524 EAP CPT® 31638 Bronchoscopy Stent Revision Incl Dilation BOTH IP/OP "$8,711.00 " "$6,446.14" $0.00 "$6,968.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,815.37" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,899.11" "$6,968.80" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191525 EAP CPT® 64788 Remove Nf Or Nl; Cutaneous Nerve BOTH IP/OP "$7,647.00 " "$5,658.78" $0.00 "$6,117.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.63" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$6,056.42" "$6,117.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191526 EAP CPT® 64999 Unlisted Neuro Px BOTH IP/OP "$5,528.00 " "$4,090.72" $0.00 "$4,390.40" "$2,321.55" "$2,321.55" $254.43 $254.43 $255.86 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,152.04" $0.00 $0.00 $0.00 $262.54 "$2,255.00" "$4,346.50" "$4,390.40" $364.76 "$2,607.00" $364.76 $858.87 $0.00 $0.00 $873.69 $250.04 $0.00 $0.00 $0.00 $0.00 36191527 EAP CPT® 49999 Unlisted Abdominal Px BOTH IP/OP "$8,000.00 " "$5,920.00" $0.00 "$6,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,667.20" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,336.00" "$6,400.00" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191528 EAP CPT® 67911 Bil Correction Of Lid Retraction BOTH IP/OP "$6,479.00 " "$4,794.46" $0.00 "$5,202.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,350.22" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$5,150.38" "$5,202.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191529 EAP CPT® 38794 Access Thoracic Lymph Duct BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$2,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$2,000.00" "$1,584.00" "$1,600.00" $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191530 EAP CPT® 67025 Bil Inj Substitute Pars Plana/limbl W/wo Asp Spx BOTH IP/OP "$13,059.00 " "$9,663.66" $0.00 "$10,447.20" "$2,321.55" "$2,321.55" "$2,022.30" "$2,022.30" "$2,033.69" "$2,721.82" "$1,257.08" "$1,257.08" "$1,305.43" "$1,992.71" "$2,721.50" "$1,295.26" "$1,871.00" "$1,871.00" "$2,027.80" "$2,255.00" "$10,342.73" "$10,447.20" "$2,817.36" $0.00 "$2,817.36" $651.56 $643.81 $643.81 "$2,078.99" "$1,931.24" $0.00 $0.00 $0.00 $0.00 36191531 EAP CPT® 67505 Bil Retrobulbar Injection Alcohol BOTH IP/OP "$1,265.00 " $936.10 $0.00 "$1,265.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.63 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$1,001.88" "$1,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191532 EAP CPT® 68200 Bil Subconjunctival Injection BOTH IP/OP $393.00 $290.82 $0.00 $393.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.90 $0.00 $0.00 $0.00 $0.00 $393.00 $311.26 $314.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191533 EAP CPT® 67515 Bil Injection Medication/other Subst Tenon Capsule BOTH IP/OP "$2,730.00 " "$2,020.20" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $569.00 $0.00 $0.00 $0.00 $250.42 $568.93 $162.77 "$1,871.00" "$1,871.00" $271.28 "$2,255.00" "$2,162.16" "$2,184.00" $376.91 $0.00 $376.91 $137.37 $60.20 $60.20 $434.62 $258.37 $0.00 $0.00 $0.00 $0.00 36191534 EAP CPT® 36831 Thrmbc Opn Arven Fstl W/o Revj Dial Grf BOTH IP/OP "$14,743.00 " "$10,909.82" $0.00 "$11,794.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,072.44" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$11,676.46" "$11,794.40" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191535 EAP CPT® 33016 Pericardiocentesis W/imaging BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,385.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.72 $0.00 $0.00 $0.00 $0.00 "$1,385.00" "$1,096.92" "$1,108.00" $0.00 $906.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191536 EAP CPT® 33017 Perq Prcrd Drg 6yr+ W/o Congenital Car Anomaly BOTH IP/OP $405.00 $299.70 $0.00 $321.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $201.00 $318.38 $321.60 $0.00 $263.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191537 EAP CPT® 33018 Perq Prcrd Drg 0-5yr/any Age W/cgen Car Anomaly BOTH IP/OP $405.00 $299.70 $0.00 $321.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $201.00 $318.38 $321.60 $0.00 $263.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191540 EAP CPT® 62328 Dx Lumbar Puncture W/fl Or Ct Guidance BOTH IP/OP "$1,571.00 " "$1,162.54" $0.00 "$1,571.00" "$1,571.00" "$1,571.00" $618.38 $618.38 $621.87 $327.44 $0.00 $0.00 $0.00 $608.20 $327.40 $395.33 "$1,571.00" "$1,571.00" $626.89 "$1,493.00" "$1,182.46" "$1,194.40" $870.98 "$1,021.15" $870.98 $252.51 $93.39 $93.39 $237.69 $597.04 $0.00 $0.00 $0.00 $0.00 36191541 EAP CPT® 62329 Therapeutic Lumbar Puncture W/fl Or Ct Guidance BOTH IP/OP "$1,571.00 " "$1,162.54" $0.00 "$1,493.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $327.40 $0.00 $0.00 $0.00 $0.00 "$1,493.00" "$1,182.46" "$1,194.40" $0.00 "$1,021.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191550 EAP CPT® 64451 Injection Aa&/strd Nerves Nrvtg Si Joint W/img BOTH IP/OP "$1,547.00 " "$1,144.78" $0.00 "$1,547.00" "$1,547.00" "$1,547.00" $618.38 $618.38 $621.87 $0.00 $0.00 $0.00 $0.00 $0.00 $322.39 $0.00 $0.00 $0.00 $626.89 "$1,493.00" "$1,182.46" "$1,194.40" $870.98 "$1,005.55" $870.98 $204.40 $82.58 $82.58 $237.69 $597.04 $0.00 $0.00 $0.00 $0.00 36191551 EAP CPT® 64454 Injection Aa&/strd Genicular Nrv Branches W/img BOTH IP/OP "$1,547.00 " "$1,144.78" $0.00 "$1,797.25" "$1,547.00" "$1,547.00" $618.38 $618.38 $621.87 $322.43 $0.00 $0.00 $0.00 $608.20 $322.39 $395.33 "$1,547.00" "$1,547.00" $626.89 "$1,493.00" "$1,182.46" "$1,194.40" $870.98 "$1,797.25" $870.98 $206.45 $85.10 $85.10 $237.69 $597.04 $0.00 $0.00 $0.00 $0.00 36191552 EAP CPT® 64624 Destruction Neurolytic Agt Genicular Nerve W/img BOTH IP/OP "$4,084.00 " "$3,022.16" $0.00 "$4,940.00" "$2,321.55" "$2,321.55" "$1,709.97" "$1,709.97" "$1,719.60" $851.21 $0.00 $0.00 $0.00 "$1,681.44" $851.11 "$1,092.94" "$1,871.00" "$1,871.00" "$1,724.40" "$2,255.00" "$3,251.95" "$3,284.80" "$2,395.83" "$4,940.00" "$2,395.83" $0.00 $152.52 $152.52 $653.68 "$1,642.29" $0.00 $0.00 $0.00 $0.00 36191553 EAP CPT® 64625 Radiofrequency Abltj Nrv Nrvtg Si Jt W/img Gdn BOTH IP/OP "$4,084.00 " "$3,022.16" $0.00 "$4,084.00" "$3,735.90" "$3,735.90" "$1,709.97" "$1,709.97" "$1,719.60" $851.21 $0.00 $0.00 $0.00 "$1,681.44" $851.11 "$1,092.94" "$4,084.00" "$4,084.00" "$1,724.40" "$2,255.00" "$3,251.95" "$3,284.80" "$2,395.83" "$2,654.60" "$2,395.83" $0.00 $201.56 $201.56 $653.68 "$1,642.29" $0.00 $0.00 $0.00 $0.00 36191555 EAP CPT® 64405 Bil Greater Occipital Nerve Inj BOTH IP/OP "$4,971.00 " "$3,678.54" $0.00 "$3,836.80" "$2,321.55" "$2,321.55" $254.43 $254.43 $255.86 "$1,036.08" $0.00 $0.00 $0.00 $250.31 "$1,035.96" $162.70 "$1,871.00" "$1,871.00" $262.54 "$2,255.00" "$3,798.43" "$3,836.80" $364.76 "$1,199.00" $364.76 $102.34 $55.88 $55.88 $763.52 $250.04 $0.00 $0.00 $0.00 $0.00 36191556 EAP CPT® 52224 Cystourethroscopy W/ Fulguration <.5cm Lesn BOTH IP/OP "$3,924.00 " "$2,903.76" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $817.86 $0.00 $0.00 $0.00 "$2,948.43" $817.76 "$1,916.48" "$2,836.00" "$2,836.00" "$1,776.76" "$2,327.00" "$3,139.49" "$3,171.20" "$2,468.57" "$3,250.00" "$2,468.57" $272.85 $212.40 $212.40 $631.07 "$1,692.15" $0.00 $0.00 $0.00 $0.00 36191560 EAP CPT® 41008 Submandibular Abscess BOTH IP/OP "$4,919.00 " "$3,640.06" $0.00 "$3,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,025.12" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,935.45" "$3,975.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191561 EAP CPT® 42000 "I&d Abscess Plate, Uvula" BOTH IP/OP $283.00 $209.42 $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $58.98 $0.00 $0.00 $0.00 $202.80 $58.98 $131.82 $283.00 $283.00 $204.24 $286.00 $226.51 $228.80 $283.76 "$1,750.00" $283.76 $95.00 $107.41 $107.41 $45.53 $194.51 $0.00 $0.00 $0.00 $0.00 36191562 EAP CPT® 46050 I & D Perianal Abcess BOTH IP/OP "$3,991.00 " "$2,953.34" $0.00 "$3,224.80" "$2,321.55" "$2,321.55" $772.82 $772.82 $777.17 $831.82 "$1,257.08" "$1,257.08" "$1,305.43" $760.65 $831.72 $494.42 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,192.55" "$3,224.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191563 EAP CPT® 31233 "Nasal/sinus Endoscopy, Dx" BOTH IP/OP $661.00 $489.14 $0.00 $661.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.75 $0.00 $0.00 $0.00 $0.00 $661.00 $523.51 $528.80 $0.00 $661.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191564 EAP CPT® 45385 Colonoscopy W/lesion Removal BOTH IP/OP "$3,182.00 " "$2,354.68" $0.00 "$2,836.00" "$2,753.10" "$2,753.10" "$1,009.84" "$1,009.84" "$1,015.53" $0.00 "$1,541.95" "$1,541.95" "$1,601.25" $993.84 $663.13 $646.00 "$2,836.00" "$2,836.00" "$1,007.17" "$2,327.00" "$2,314.22" "$2,337.60" "$1,399.33" "$2,500.00" "$1,399.33" $450.95 $265.02 $265.02 $465.18 $959.21 $0.00 $0.00 $0.00 $0.00 36191565 EAP CPT® 43235 "Upper Gi Endoscopy, Diagnostic" BOTH IP/OP "$4,485.00 " "$3,318.90" $0.00 "$3,289.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.94 $934.67 $504.36 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,256.70" "$3,289.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191566 EAP CPT® 31515 Laryngoscopy For Aspiration BOTH IP/OP "$7,668.00 " "$5,674.32" $0.00 "$5,632.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,598.01" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,575.68" "$5,632.00" $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191567 EAP CPT® 45305 Proctosigmoidoscopy W/bx Single/multiple BOTH IP/OP "$5,063.00 " "$3,746.62" $0.00 "$4,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,055.13" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,050.29" "$4,091.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191568 EAP CPT® 45300 Proctosigmoidoscopy Dx BOTH IP/OP "$2,337.00 " "$1,729.38" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $487.03 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,869.91" "$1,888.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191569 EAP CPT® 96373 Iintra-arterial Injection BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191570 EAP CPT® 24201 REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP BOTH IP/OP "$9,504.00 " "$7,032.96" $0.00 "$7,603.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,325.71" "$2,327.00" "$7,527.17" "$7,603.20" "$3,231.26" $0.00 "$3,231.26" $360.96 $376.65 $376.65 "$1,513.04" "$2,214.96" $0.00 $0.00 $0.00 $0.00 36191571 EAP CPT® 42809 REMOVE PHARYNX FOREIGN BODY BOTH IP/OP $500.00 $370.00 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191573 EAP CPT® 43247 Egd Flexible Foreign Body Removal BOTH IP/OP "$4,228.00 " "$3,128.72" $0.00 "$3,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.12 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,376.30" "$3,410.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191585 EAP CPT® 26740 Clsd Tx Artclr Fx Mtcrphlngl/iphal Jt W/o Manip BOTH IP/OP $795.00 $588.30 $0.00 $795.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.68 $0.00 $0.00 $0.00 $0.00 $795.00 $629.64 $636.00 $0.00 $795.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36191586 EAP CPT® 10081 I&d Pilonidal Cyst Complex BOTH IP/OP "$3,502.00 " "$2,591.48" $0.00 "$2,772.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $729.82 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,745.07" "$2,772.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000023 EAP Custom 37000023 Level 1 1st 30 Min BOTH IP/OP "$1,003.00 " $742.22 $0.00 $852.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $744.43 $744.43 $773.11 $0.00 $209.03 $0.00 $0.00 $0.00 $0.00 $533.00 $844.27 $852.80 $0.00 $703.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000024 EAP Custom 37000024 Level 2 1st 30 Min BOTH IP/OP "$1,766.00 " "$1,306.84" $0.00 "$1,361.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,310.73" "$1,310.73" "$1,361.23" $0.00 $368.03 $0.00 $0.00 $0.00 $0.00 $736.50 "$1,166.62" "$1,178.40" $0.00 "$1,239.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000025 EAP Custom 37000025 Level 3 1st 30 Min BOTH IP/OP "$2,608.00 " "$1,929.92" $0.00 "$2,010.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,935.66" "$1,935.66" "$2,010.25" $0.00 $543.51 $0.00 $0.00 $0.00 $0.00 "$1,087.50" "$1,722.60" "$1,740.00" $0.00 "$1,831.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000026 EAP Custom 37000026 Level 4 1st 30 Min BOTH IP/OP "$3,052.00 " "$2,258.48" $0.00 "$2,352.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.19" "$2,265.19" "$2,352.48" $0.00 $636.04 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 "$2,142.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000027 EAP Custom 37000027 Level 5 1st 30 Min BOTH IP/OP "$3,572.00 " "$2,643.28" $0.00 "$2,753.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,651.14" "$2,651.14" "$2,753.30" $0.00 $744.40 $0.00 $0.00 $0.00 $0.00 "$1,489.50" "$2,359.37" "$2,383.20" $0.00 "$2,507.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000028 EAP Custom 37000028 Level 1 Add 15 Min BOTH IP/OP $408.00 $301.92 $0.00 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.82 $302.82 $314.49 $0.00 $85.03 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $286.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000029 EAP Custom 37000029 Level 2 Add 15 Min BOTH IP/OP $667.00 $493.58 $0.00 $514.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.05 $495.05 $514.12 $0.00 $139.00 $0.00 $0.00 $0.00 $0.00 $278.00 $440.35 $444.80 $0.00 $468.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000030 EAP Custom 37000030 Level 3 Add 15 Min BOTH IP/OP "$1,085.00 " $802.90 $0.00 $836.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $805.29 $805.29 $836.32 $0.00 $226.11 $0.00 $0.00 $0.00 $0.00 $426.50 $675.58 $682.40 $0.00 $761.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000031 EAP Custom 37000031 Level 4 Add 15 Min BOTH IP/OP "$1,203.00 " $890.22 $0.00 $927.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $892.87 $892.87 $927.27 $0.00 $250.71 $0.00 $0.00 $0.00 $0.00 $502.00 $795.17 $803.20 $0.00 $844.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000032 EAP Custom 37000032 Level 5 Add 15 Min BOTH IP/OP "$1,376.00 " "$1,018.24" $0.00 "$1,060.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,021.27" "$1,021.27" "$1,060.62" $0.00 $286.76 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $965.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000033 EAP CPT® 99151 Mod Sed Same Phys/qhp Initial 15 Mins; <5 Yrs BOTH IP/OP $504.00 $372.96 $0.00 $388.48 $273.67 $273.67 $0.00 $0.00 $0.00 $105.05 $374.07 $374.07 $388.48 $0.00 $105.03 $0.00 $298.12 $298.12 $0.00 $210.00 $332.64 $336.00 $0.00 $327.60 $0.00 $74.17 $24.16 $24.16 $66.86 $0.00 $0.00 $0.00 $0.00 $0.00 37000034 EAP CPT® 99152 Mod Sed Same Phys/qhp Initial 15 Mins 5/> Yrs BOTH IP/OP $504.00 $372.96 $0.00 $753.35 $273.67 $273.67 $0.00 $0.00 $0.00 $105.05 $374.07 $374.07 $388.48 $0.00 $105.03 $0.00 $298.12 $298.12 $0.00 $210.00 $332.64 $336.00 $0.00 $753.35 $0.00 $49.33 $12.62 $12.62 $66.86 $0.00 $0.00 $0.00 $0.00 $0.00 37000035 EAP CPT® 99153 Mod Sed Same Phys/qhp Each Addl 15 Mins BOTH IP/OP $138.00 $102.12 $0.00 $375.70 $74.93 $74.93 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $57.50 $91.08 $92.00 $0.00 $375.70 $0.00 $10.55 $10.80 $10.80 $18.31 $0.00 $0.00 $0.00 $0.00 $0.00 37000036 EAP CPT® 99155 Mod Sed Other Phys/qhp Initial 15 Mins; <5 Yrs BOTH IP/OP $504.00 $372.96 $0.00 $388.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.07 $374.07 $388.48 $0.00 $105.03 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $327.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000037 EAP CPT® 99156 Mod Sed Other Phys/qhp Initial 15 Mins 5/> Yrs BOTH IP/OP $504.00 $372.96 $0.00 $388.48 $273.67 $273.67 $0.00 $0.00 $0.00 $105.05 $374.07 $374.07 $388.48 $0.00 $105.03 $0.00 $298.12 $298.12 $0.00 $210.00 $332.64 $336.00 $0.00 $327.60 $0.00 $73.17 $80.07 $80.07 $66.86 $0.00 $0.00 $0.00 $0.00 $0.00 37000038 EAP CPT® 99157 Mod Sed Other Phys/qhp Each Addl 15 Mins BOTH IP/OP $138.00 $102.12 $0.00 $106.37 $74.93 $74.93 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $57.50 $91.08 $92.00 $0.00 $89.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000123 EAP Custom 37000123 Epidural Fee BOTH IP/OP "$2,316.00 " "$1,713.84" $0.00 "$1,785.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.94" "$1,718.94" "$1,785.17" $0.00 $482.65 $0.00 $0.00 $0.00 $0.00 $966.00 "$1,530.14" "$1,545.60" $0.00 "$1,625.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37000124 EAP Ea Add’l 60-90 Min BOTH IP/OP $520.00 $384.80 $0.00 $400.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $385.94 $385.94 $400.82 $0.00 $108.37 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $365.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37825171 EAP CPT® 36430 "Transfusion, Blood" BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.18 "$2,255.00" "$2,009.30" "$2,029.60" $540.71 $0.00 $540.71 $38.59 $35.66 $35.66 $403.89 $370.65 $0.00 $0.00 $0.00 $0.00 39000001 EAP HCPCS P9010 Whole Blood Unit BOTH IP/OP "$2,098.00 " "$1,552.52" $0.00 "$1,617.14" "$1,139.21" "$1,139.21" $151.64 $151.64 $153.17 $437.28 "$1,557.14" "$1,557.14" "$1,617.14" $150.14 $437.22 $97.59 "$1,240.97" "$1,240.97" $133.56 $956.00 "$1,514.30" "$1,529.60" $184.44 "$1,363.70" $184.44 $299.23 $0.00 $0.00 $304.39 $127.20 $0.00 $0.00 $0.00 $0.00 39000002 EAP HCPCS P9012 Pooled Cryo BOTH IP/OP $904.00 $668.96 $0.00 $696.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $670.95 $670.95 $696.80 $0.00 $188.39 $0.00 $0.00 $0.00 $0.00 $412.00 $652.61 $659.20 $0.00 $587.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000003 EAP HCPCS P9016 Rbc Leukored Unit BOTH IP/OP "$1,327.00 " $981.98 $0.00 "$1,022.85" $720.56 $720.56 $190.47 $190.47 $192.39 $276.58 $984.90 $984.90 "$1,022.85" $188.51 $276.55 $122.53 $784.92 $784.92 $197.77 $604.50 $957.53 $967.20 $273.11 "$1,013.35" $273.11 $189.21 $0.00 $0.00 $192.47 $188.35 $0.00 $0.00 $0.00 $0.00 39000004 EAP HCPCS P9017 Fresh Frozen Plasma Unit BOTH IP/OP $629.00 $465.46 $0.00 $484.83 $0.00 $0.00 $0.00 $0.00 $84.40 $131.10 $466.84 $466.84 $484.83 $82.66 $131.08 $53.73 $372.05 $372.05 $0.00 $286.50 $453.82 $458.40 $0.00 $408.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000012 EAP HCPCS P9035 Platelet Pheresis Leukored Unit BOTH IP/OP "$4,769.00 " "$3,529.06" $0.00 "$3,675.95" "$2,589.57" "$2,589.57" $491.94 $491.94 $496.91 $993.98 "$3,539.55" "$3,539.55" "$3,675.95" $486.80 $993.86 $316.42 "$2,820.86" "$2,820.86" $0.00 "$2,173.00" "$3,442.03" "$3,476.80" $0.00 "$3,099.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000013 EAP HCPCS P9037 Platelet Pheresis Leukored Irr Unit BOTH IP/OP "$5,621.00 " "$4,159.54" $0.00 "$4,332.67" "$3,052.20" "$3,052.20" $624.02 $624.02 $630.32 "$1,171.56" "$4,171.91" "$4,171.91" "$4,332.67" $617.33 "$1,171.42" $401.26 "$3,094.73" "$3,094.73" $666.42 "$2,561.00" "$4,056.62" "$4,097.60" $920.30 "$3,653.65" $920.30 $801.59 $0.00 $0.00 $815.42 $634.69 $0.00 $0.00 $0.00 $0.00 39000016 EAP HCPCS P9040 Rbc Leukored Irr Unit BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,755.11" "$1,236.41" "$1,236.41" $263.37 $263.37 $266.03 $474.58 "$1,689.99" "$1,689.99" "$1,755.11" $260.55 $474.53 $169.36 "$1,346.85" "$1,346.85" $275.90 "$1,037.50" "$1,643.40" "$1,660.00" $381.00 "$1,480.05" $381.00 $324.74 $0.00 $0.00 $330.34 $262.76 $0.00 $0.00 $0.00 $0.00 39000017 EAP HCPCS P9044 Ffp-cryo Poor Plasma BOTH IP/OP $337.00 $249.38 $0.00 $259.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.12 $250.12 $259.76 $0.00 $70.23 $0.00 $0.00 $0.00 $0.00 $153.50 $243.14 $245.60 $0.00 $219.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000021 EAP HCPCS P9054 Blood Leukored Deglyc Washed Unit BOTH IP/OP "$2,064.00 " "$1,527.36" $0.00 "$1,651.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,531.90" "$1,531.90" "$1,590.93" $0.00 $430.14 $0.00 $0.00 $0.00 $0.00 "$1,032.00" "$1,634.69" "$1,651.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000024 EAP HCPCS P9057 Blood Leukored Deglyc Washed Irr Unit BOTH IP/OP "$2,718.00 " "$2,011.32" $0.00 "$2,174.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,017.30" "$2,017.30" "$2,095.03" $0.00 $566.43 $0.00 $0.00 $0.00 $0.00 "$1,359.00" "$2,152.66" "$2,174.40" $0.00 "$1,753.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000026 EAP HCPCS P9059 Ffp-frozen 24 Hour BOTH IP/OP $776.00 $574.24 $0.00 $598.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.95 $575.95 $598.14 $0.00 $161.72 $0.00 $0.00 $0.00 $0.00 $353.50 $559.94 $565.60 $0.00 $413.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000040 EAP HCPCS P9016 Rbc-wbc Reduced BOTH IP/OP "$1,209.00 " $894.66 $0.00 "$1,013.35" $656.49 $656.49 $190.47 $190.47 $192.39 $251.99 $897.32 $897.32 $931.90 $188.51 $251.96 $122.53 $715.12 $715.12 $197.77 $604.50 $957.53 $967.20 $273.11 "$1,013.35" $273.11 $189.21 $0.00 $0.00 $192.47 $188.35 $0.00 $0.00 $0.00 $0.00 39000052 EAP CPT® 86891 Non Cardiac Cell Saver BOTH IP/OP "$1,970.00 " "$1,457.80" $0.00 "$1,576.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.55 $0.00 $0.00 $0.00 $0.00 $234.84 "$1,560.24" "$1,576.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000060 EAP HCPCS P9011 Rbc Leukored Aliquot BOTH IP/OP $396.00 $293.04 $0.00 $381.55 $215.03 $215.03 $149.18 $149.18 $150.69 $82.54 $293.91 $293.91 $305.24 $147.58 $82.53 $95.93 $234.23 $234.23 $141.20 $180.50 $285.91 $288.80 $195.00 $381.55 $195.00 $56.50 $0.00 $0.00 $57.47 $134.48 $0.00 $0.00 $0.00 $0.00 39000061 EAP HCPCS P9011 Rbc Leukored Irr Aliquot BOTH IP/OP $396.00 $293.04 $0.00 $381.55 $215.03 $215.03 $149.18 $149.18 $150.69 $82.54 $293.91 $293.91 $305.24 $147.58 $82.53 $95.93 $234.23 $234.23 $141.20 $180.50 $285.91 $288.80 $195.00 $381.55 $195.00 $56.50 $0.00 $0.00 $57.47 $134.48 $0.00 $0.00 $0.00 $0.00 39000062 EAP HCPCS P9011 "Platelet Pheresis, Lr Aliquot" BOTH IP/OP $800.00 $592.00 $0.00 $616.64 $434.40 $434.40 $149.18 $149.18 $150.69 $166.74 $593.76 $593.76 $616.64 $147.58 $166.72 $95.93 $473.20 $473.20 $141.20 $364.50 $577.37 $583.20 $195.00 $381.55 $195.00 $114.09 $0.00 $0.00 $116.06 $134.48 $0.00 $0.00 $0.00 $0.00 39000063 EAP HCPCS P9011 Platelet Pheresis Lr Irr Aliquot BOTH IP/OP $882.00 $652.68 $0.00 $679.85 $478.93 $478.93 $149.18 $149.18 $150.69 $183.83 $654.62 $654.62 $679.85 $147.58 $183.81 $95.93 $521.70 $521.70 $141.20 $402.00 $636.77 $643.20 $195.00 $381.55 $195.00 $125.83 $0.00 $0.00 $128.00 $134.48 $0.00 $0.00 $0.00 $0.00 39000064 EAP HCPCS P9012 Single Cryo BOTH IP/OP $396.00 $293.04 $0.00 $587.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $293.91 $293.91 $305.24 $0.00 $82.53 $0.00 $0.00 $0.00 $0.00 $180.50 $285.91 $288.80 $0.00 $587.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39000065 EAP HCPCS P9011 Thawed Ffp Aliquot BOTH IP/OP $396.00 $293.04 $0.00 $381.55 $215.03 $215.03 $149.18 $149.18 $150.69 $82.54 $293.91 $293.91 $305.24 $147.58 $82.53 $95.93 $234.23 $234.23 $141.20 $180.50 $285.91 $288.80 $195.00 $381.55 $195.00 $56.50 $0.00 $0.00 $57.47 $134.48 $0.00 $0.00 $0.00 $0.00 39100001 EAP CPT® 36430 "TRANSFUSION, BLOOD" BOTH IP/OP "$3,057.00 " "$2,262.18" $35.66 "$2,356.34" "$2,321.55" "$2,321.55" $386.53 $386.53 $388.71 $637.16 "$2,268.91" "$2,268.91" "$2,356.34" $380.55 $637.08 $247.36 "$1,871.00" "$1,871.00" $389.18 "$2,255.00" "$2,009.30" "$2,029.60" $540.71 "$1,750.00" $540.71 $38.59 $35.66 $35.66 $403.89 $370.65 $0.00 $0.00 $0.00 $0.00 39100005 EAP CPT® 36430 "Transfusion, Blood Or Bld Comp" BOTH IP/OP "$2,537.00 " "$1,877.38" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.18 "$2,255.00" "$2,009.30" "$2,029.60" $540.71 $0.00 $540.71 $38.59 $35.66 $35.66 $403.89 $370.65 $0.00 $0.00 $0.00 $0.00 40000002 EAP CPT® 76376 3d Rendering W/o Postproce Nir BOTH IP/OP "$3,154.00 " "$2,333.96" $0.00 "$3,091.20" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $657.37 "$2,340.90" "$2,340.90" "$2,431.10" $0.00 $657.29 $0.00 "$1,865.59" "$1,865.59" $0.00 $927.36 "$3,060.29" "$3,091.20" $0.00 "$2,200.00" $0.00 $140.81 $13.33 $13.33 $615.15 $0.00 $0.00 $0.00 $0.00 $0.00 40000003 EAP CPT® 76377 3d Rendering W/postprocess Nir BOTH IP/OP "$3,154.00 " "$2,333.96" $0.00 "$3,306.00" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $657.37 "$2,340.90" "$2,340.90" "$2,431.10" $0.00 $657.29 $0.00 "$1,865.59" "$1,865.59" $0.00 $927.36 "$3,060.29" "$3,091.20" $0.00 "$3,306.00" $0.00 $186.77 $32.41 $32.41 $615.15 $0.00 $0.00 $0.00 $0.00 $0.00 40100003 EAP CPT® 77061 Dx Digital Breast Tomosynthesis; Unilateral BOTH IP/OP $156.00 $115.44 $0.00 $310.17 $156.00 $156.00 $25.21 $25.21 $55.28 $32.51 $298.68 $298.68 $310.17 $25.21 $32.51 $16.39 $92.27 $92.27 $26.75 $36.00 $118.80 $120.00 $90.00 $156.00 $90.00 $23.48 $0.00 $0.00 $23.88 $25.21 $0.00 $0.00 $0.00 $0.00 40100008 EAP CPT® 77062 Dx Digital Breast Tomosynthesis; Bilateral BOTH IP/OP $275.00 $203.50 $0.00 $275.00 $275.00 $275.00 $25.21 $25.21 $55.28 $48.56 $234.47 $234.47 $243.49 $25.21 $48.56 $16.39 $137.82 $137.82 $26.75 $36.00 $118.80 $120.00 $90.00 $275.00 $90.00 $23.48 $0.00 $0.00 $23.88 $25.21 $0.00 $0.00 $0.00 $0.00 40100012 EAP CPT® 77065 Dx Mammo Incl Cad Uni BOTH IP/OP $337.00 $249.38 $54.13 $776.00 $303.12 $303.12 $94.36 $94.36 $111.20 $70.24 $236.28 $236.28 $245.37 $94.36 $70.23 $61.33 $199.34 $199.34 $100.65 $81.60 $269.28 $272.00 $94.36 $776.00 $94.36 $130.40 $94.36 $94.36 $54.13 $94.36 $0.00 $0.00 $0.00 $0.00 40100013 EAP CPT® 77066 Dx Mammo Incl Cad Bi BOTH IP/OP $416.00 $307.84 $66.86 "$1,039.00" $384.54 $384.54 $120.30 $120.30 $140.79 $86.70 $302.23 $302.23 $313.86 $120.30 $86.69 $78.20 $246.06 $246.06 $128.54 $100.80 $332.64 $336.00 $120.30 "$1,039.00" $120.30 $163.40 $120.30 $120.30 $66.86 $120.30 $0.00 $0.00 $0.00 $0.00 40200001 EAP CPT® 76506 Ultrasound Cranial BOTH IP/OP $621.00 $459.54 $0.00 $496.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.65 $205.65 $213.56 $0.00 $129.42 $0.00 $0.00 $0.00 $0.00 $149.04 $491.83 $496.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200002 EAP CPT® 76641 "Ultrasound, Breast,unilateal,complete" BOTH IP/OP "$1,344.00 " $994.56 $0.00 $981.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.16 $179.16 $186.05 $0.00 $280.09 $0.00 $0.00 $0.00 $0.00 $294.48 $971.78 $981.60 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200003 EAP CPT® 76506 Us Cranial Complete BOTH IP/OP $615.00 $455.10 $0.00 $496.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.65 $205.65 $213.56 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $149.04 $491.83 $496.80 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200005 EAP CPT® 76512 "Ophth Us, B W/non-quant A" BOTH IP/OP $759.00 $561.66 $21.61 $613.60 $211.15 $211.15 $106.02 $106.02 $106.62 $158.19 $104.58 $104.58 $108.60 $104.44 $158.18 $67.89 $448.95 $448.95 $112.41 $184.08 $607.46 $613.60 $156.18 $183.00 $156.18 $93.72 $21.61 $21.61 $122.11 $107.06 $0.00 $0.00 $0.00 $0.00 40200006 EAP CPT® 76514 "Echo Exam Of Eye, Thickness" BOTH IP/OP $287.00 $212.38 $3.96 $224.00 $34.66 $34.66 $24.06 $24.06 $24.19 $59.82 $8.91 $8.91 $9.26 $23.64 $59.81 $15.37 $169.76 $169.76 $23.06 $67.20 $221.76 $224.00 $32.04 $183.00 $32.04 $11.96 $3.96 $3.96 $44.58 $21.96 $0.00 $0.00 $0.00 $0.00 40200007 EAP CPT® 76519 Ultrasonography BOTH IP/OP $759.00 $561.66 $0.00 $613.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.71 $108.71 $112.89 $0.00 $158.18 $0.00 $0.00 $0.00 $112.41 $184.08 $607.46 $613.60 $156.18 $183.00 $156.18 $76.68 $36.02 $36.02 $122.11 $107.06 $0.00 $0.00 $0.00 $0.00 40200008 EAP CPT® 76642 "Ultrasound, Breast,unilateal,limited" BOTH IP/OP "$1,265.00 " $936.10 $50.40 $924.00 $202.36 $202.36 $78.77 $78.77 $79.21 $263.66 $137.30 $137.30 $142.58 $77.54 $263.63 $50.40 $748.25 $748.25 $80.04 $277.20 $914.76 $924.00 $111.21 $183.00 $111.21 $85.51 $54.39 $54.39 $183.88 $76.23 $0.00 $0.00 $0.00 $0.00 40200009 EAP CPT® 76536 Soft Tiss/head&neck W/realtime BOTH IP/OP "$1,100.00 " $814.00 $67.89 $888.80 $266.85 $266.85 $106.02 $106.02 $106.62 $229.27 $204.76 $204.76 $212.63 $104.44 $229.24 $67.89 $650.65 $650.65 $112.41 $266.64 $879.91 $888.80 $156.18 $183.00 $156.18 $82.37 $88.96 $88.96 $176.87 $107.06 $0.00 $0.00 $0.00 $0.00 40200011 EAP CPT® 76536 Us Thyroid BOTH IP/OP "$1,100.00 " $814.00 $67.89 $888.80 $266.85 $266.85 $106.02 $106.02 $106.62 $229.27 $204.76 $204.76 $212.63 $104.44 $229.24 $67.89 $650.65 $650.65 $112.41 $266.64 $879.91 $888.80 $156.18 $183.00 $156.18 $82.37 $88.96 $88.96 $176.87 $107.06 $0.00 $0.00 $0.00 $0.00 40200012 EAP CPT® 76604 "Ultrasound Exam, Chest" BOTH IP/OP "$1,206.00 " $892.44 $50.78 $880.80 $202.36 $202.36 $106.02 $106.02 $106.62 $251.36 $145.00 $145.00 $150.57 $104.44 $251.33 $67.89 $713.35 $713.35 $112.41 $264.24 $871.99 $880.80 $156.18 $183.00 $156.18 $77.40 $50.78 $50.78 $175.28 $107.06 $0.00 $0.00 $0.00 $0.00 40200014 EAP CPT® 76604 "Us Chest, Rt W/image" BOTH IP/OP "$1,206.00 " $892.44 $50.78 $880.80 $202.36 $202.36 $106.02 $106.02 $106.62 $251.36 $145.00 $145.00 $150.57 $104.44 $251.33 $67.89 $713.35 $713.35 $112.41 $264.24 $871.99 $880.80 $156.18 $183.00 $156.18 $77.40 $50.78 $50.78 $175.28 $107.06 $0.00 $0.00 $0.00 $0.00 40200018 EAP CPT® 76700 "Us Abd, Rt W/image" BOTH IP/OP "$1,489.00 " "$1,101.86" $67.89 "$1,188.80" $280.53 $280.53 $106.02 $106.02 $106.62 $310.34 $236.95 $236.95 $246.07 $104.44 $310.31 $67.89 $880.74 $880.74 $112.41 $356.64 "$1,176.91" "$1,188.80" $156.18 $183.00 $156.18 $115.39 $83.20 $83.20 $236.57 $107.06 $0.00 $0.00 $0.00 $0.00 40200020 EAP CPT® 76705 Bladder Ultrasound BOTH IP/OP "$1,412.00 " "$1,044.88" $62.67 "$1,129.60" $209.59 $209.59 $106.02 $106.02 $106.62 $294.30 $182.05 $182.05 $189.05 $104.44 $294.26 $67.89 $835.20 $835.20 $112.41 $338.88 "$1,118.30" "$1,129.60" $156.18 $183.00 $156.18 $83.78 $62.67 $62.67 $224.79 $107.06 $0.00 $0.00 $0.00 $0.00 40200021 EAP CPT® 76705 "Us Abdominal, Ltd" BOTH IP/OP "$1,415.00 " "$1,047.10" $62.67 "$1,129.60" $209.59 $209.59 $106.02 $106.02 $106.62 $294.92 $182.05 $182.05 $189.05 $104.44 $294.89 $67.89 $836.97 $836.97 $112.41 $338.88 "$1,118.30" "$1,129.60" $156.18 $183.00 $156.18 $83.78 $62.67 $62.67 $224.79 $107.06 $0.00 $0.00 $0.00 $0.00 40200022 EAP CPT® 76641 Ultrasound Breast Rt Complete BOTH IP/OP "$1,168.00 " $864.32 $0.00 $981.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.16 $179.16 $186.05 $0.00 $243.41 $0.00 $0.00 $0.00 $0.00 $294.48 $971.78 $981.60 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200023 EAP CPT® 76770 "Us Retroperit, Rt W/image; Complete" BOTH IP/OP "$1,417.00 " "$1,048.58" $67.89 "$1,144.80" $259.59 $259.59 $106.02 $106.02 $106.62 $295.34 $231.49 $231.49 $240.40 $104.44 $295.30 $67.89 $838.16 $838.16 $112.41 $343.44 "$1,133.35" "$1,144.80" $156.18 $183.00 $156.18 $112.23 $77.44 $77.44 $227.82 $107.06 $0.00 $0.00 $0.00 $0.00 40200025 EAP CPT® 76775 "Us Retroper, Rt W/image Ltd" BOTH IP/OP "$1,302.00 " $963.48 $30.25 "$1,052.00" $133.82 $133.82 $106.02 $106.02 $106.62 $271.37 $202.02 $202.02 $209.79 $104.44 $271.34 $67.89 $770.13 $770.13 $112.41 $315.60 "$1,041.48" "$1,052.00" $156.18 $183.00 $156.18 $83.43 $30.25 $30.25 $209.35 $107.06 $0.00 $0.00 $0.00 $0.00 40200027 EAP CPT® 76800 Us Spine BOTH IP/OP "$1,019.00 " $754.06 $0.00 $815.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.28 $170.28 $176.83 $0.00 $212.36 $0.00 $0.00 $0.00 $0.00 $244.56 $807.05 $815.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200028 EAP CPT® 76642 Ultrasound Breast Rt Limited BOTH IP/OP "$1,082.00 " $800.68 $50.40 $790.40 $202.36 $202.36 $78.77 $78.77 $79.21 $225.52 $137.30 $137.30 $142.58 $77.54 $225.49 $50.40 $640.00 $640.00 $80.04 $237.12 $782.50 $790.40 $111.21 $183.00 $111.21 $85.51 $54.39 $54.39 $157.29 $76.23 $0.00 $0.00 $0.00 $0.00 40200029 EAP CPT® 76641 Ultrasound Breast Rt Complete BOTH IP/OP "$1,168.00 " $864.32 $0.00 $981.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.16 $179.16 $186.05 $0.00 $243.41 $0.00 $0.00 $0.00 $0.00 $294.48 $971.78 $981.60 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200030 EAP CPT® 76642 Ultrasound Breast Rt Limited BOTH IP/OP $941.00 $696.34 $50.40 $790.40 $202.36 $202.36 $78.77 $78.77 $79.21 $196.13 $137.30 $137.30 $142.58 $77.54 $196.10 $50.40 $556.60 $556.60 $80.04 $237.12 $782.50 $790.40 $111.21 $183.00 $111.21 $85.51 $54.39 $54.39 $157.29 $76.23 $0.00 $0.00 $0.00 $0.00 40200031 EAP CPT® 76941 Cordocentesis Us Guidance BOTH IP/OP $813.00 $601.62 $0.00 $812.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.76 $147.76 $153.45 $0.00 $169.43 $0.00 $0.00 $0.00 $0.00 $243.60 $803.88 $812.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200034 EAP CPT® 76801 "Ob Us <14 Wks, Single Fetus" BOTH IP/OP $554.00 $409.96 $67.89 $444.00 $283.77 $283.77 $106.02 $106.02 $106.62 $115.47 $201.38 $201.38 $209.12 $104.44 $115.45 $67.89 $327.69 $327.69 $112.41 $133.20 $439.56 $444.00 $156.18 $183.00 $156.18 $90.90 $73.47 $73.47 $88.36 $107.06 $0.00 $0.00 $0.00 $0.00 40200035 EAP CPT® 76885 Us Infant Hips Dynamic BOTH IP/OP "$1,786.00 " "$1,321.64" $0.00 "$1,785.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.37 $244.37 $253.77 $0.00 $372.20 $0.00 $0.00 $0.00 $0.00 $535.68 "$1,767.74" "$1,785.60" $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200036 EAP CPT® 76870 Us Scrotum BOTH IP/OP "$1,540.00 " "$1,139.60" $67.89 "$1,244.80" $156.39 $156.39 $106.02 $106.02 $106.62 $320.97 $215.32 $215.32 $223.60 $104.44 $320.94 $67.89 $910.91 $910.91 $112.41 $373.44 "$1,232.35" "$1,244.80" $156.18 $183.00 $156.18 $90.49 $74.20 $74.20 $247.72 $107.06 $0.00 $0.00 $0.00 $0.00 40200037 EAP CPT® 76872 "Ultrasound,transrectal" BOTH IP/OP $615.00 $455.10 $67.89 $496.80 $217.64 $217.64 $106.02 $106.02 $106.62 $128.18 $263.43 $263.43 $273.56 $104.44 $128.17 $67.89 $363.77 $363.77 $112.41 $149.04 $491.83 $496.80 $156.18 $183.00 $156.18 $93.31 $125.34 $125.34 $98.86 $107.06 $0.00 $0.00 $0.00 $0.00 40200038 EAP CPT® 76881 "US EXTREMITY, NON-VASC RT W/IM COM" BOTH IP/OP "$1,000.00 " $740.00 $46.82 $808.00 $270.86 $270.86 $106.02 $106.02 $106.62 $208.43 $215.36 $215.36 $223.65 $104.44 $208.40 $67.89 $591.50 $591.50 $112.41 $242.40 $799.92 $808.00 $156.18 $183.00 $156.18 $109.54 $46.82 $46.82 $160.79 $107.06 $0.00 $0.00 $0.00 $0.00 40200039 EAP CPT® 76805 Ob Us >/= 14 Wks Sngl Fetus BOTH IP/OP $679.00 $502.46 $67.89 $544.80 $327.31 $327.31 $106.02 $106.02 $106.62 $141.52 $239.50 $239.50 $248.71 $104.44 $141.50 $67.89 $401.63 $401.63 $112.41 $163.44 $539.35 $544.80 $156.18 $183.00 $156.18 $130.22 $91.48 $91.48 $108.42 $107.06 $0.00 $0.00 $0.00 $0.00 40200040 EAP CPT® 76886 Us Infant Hips Static BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,724.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.09 $172.09 $178.71 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $517.44 "$1,707.55" "$1,724.80" $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200042 EAP CPT® 76937 Us Guidance For Vascular Acess BOTH IP/OP "$1,573.00 " "$1,164.02" $0.00 "$1,211.20" $71.76 $71.76 $0.00 $0.00 $0.00 $327.85 $51.04 $51.04 $53.01 $0.00 $327.81 $0.00 $930.43 $930.43 $0.00 $363.36 "$1,199.09" "$1,211.20" $0.00 $183.00 $0.00 $33.32 $22.33 $22.33 $241.03 $0.00 $0.00 $0.00 $0.00 $0.00 40200043 EAP CPT® 76940 Ult Guide For Mon. Par.tis.abl BOTH IP/OP $912.00 $674.88 $0.00 $911.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.95 $184.95 $192.07 $0.00 $190.06 $0.00 $0.00 $0.00 $0.00 $273.36 $902.09 $911.20 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200044 EAP CPT® 76810 Ob Us >/= 14 Wks Additional Fetus BOTH IP/OP $666.00 $492.84 $0.00 $533.60 $214.45 $214.45 $0.00 $0.00 $0.00 $138.81 $129.92 $129.92 $134.91 $0.00 $138.79 $0.00 $393.94 $393.94 $0.00 $160.08 $528.26 $533.60 $0.00 $183.00 $0.00 $258.70 $42.86 $42.86 $106.19 $0.00 $0.00 $0.00 $0.00 $0.00 40200045 EAP CPT® 76942 NEEDLE PLACEMENT US GUIDE BIC BOTH IP/OP "$1,083.00 " $801.42 $0.00 $875.20 $137.83 $137.83 $0.00 $0.00 $0.00 $225.72 $375.04 $375.04 $389.47 $0.00 $225.70 $0.00 $640.59 $640.59 $0.00 $262.56 $866.45 $875.20 $0.00 $183.00 $0.00 $92.25 $25.93 $25.93 $174.16 $0.00 $0.00 $0.00 $0.00 $0.00 40200047 EAP CPT® 76946 Echo Guide Amniocentesis BOTH IP/OP $770.00 $569.80 $0.00 $601.60 $75.00 $75.00 $0.00 $0.00 $0.00 $160.49 $64.66 $64.66 $67.14 $0.00 $160.47 $0.00 $455.46 $455.46 $0.00 $180.48 $595.58 $601.60 $0.00 $183.00 $0.00 $77.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200048 EAP CPT® 76810 Ob Us >/= 14 Wks Additional Fetus BOTH IP/OP $667.00 $493.58 $0.00 $533.60 $214.45 $214.45 $0.00 $0.00 $0.00 $139.02 $129.92 $129.92 $134.91 $0.00 $139.00 $0.00 $394.53 $394.53 $0.00 $160.08 $528.26 $533.60 $0.00 $183.00 $0.00 $258.70 $42.86 $42.86 $106.19 $0.00 $0.00 $0.00 $0.00 $0.00 40200049 EAP CPT® 76998 Us Guidance Intraoperative BOTH IP/OP $864.00 $639.36 $0.00 $691.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.63 $286.63 $297.66 $0.00 $180.06 $0.00 $0.00 $0.00 $0.00 $207.36 $684.29 $691.20 $0.00 $183.00 $0.00 $135.22 $0.00 $0.00 $137.55 $0.00 $0.00 $0.00 $0.00 $0.00 40200052 EAP CPT® 76811 Us Preg Uterus 1st Gest BOTH IP/OP "$1,414.00 " "$1,046.36" $83.92 "$1,133.60" $422.48 $422.48 $224.08 $224.08 $225.34 $294.71 $279.03 $279.03 $289.76 $220.56 $294.68 $143.36 $836.38 $836.38 $233.72 $340.08 "$1,122.26" "$1,133.60" $324.73 $183.00 $324.73 $237.77 $83.92 $83.92 $225.59 $222.60 $0.00 $0.00 $0.00 $0.00 40200054 EAP CPT® 76813 "Ob Us Nuchal Meas, 1 Gest" BOTH IP/OP $927.00 $685.98 $63.03 $743.20 $281.37 $281.37 $106.02 $106.02 $106.62 $193.21 $174.75 $174.75 $181.47 $104.44 $193.19 $67.89 $548.32 $548.32 $112.41 $222.96 $735.77 $743.20 $156.18 $183.00 $156.18 $118.66 $63.03 $63.03 $147.90 $107.06 $0.00 $0.00 $0.00 $0.00 40200055 EAP CPT® 76814 "Ob Us Nuchal Meas, Add-on" BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.72 $86.72 $90.05 $0.00 $115.66 $0.00 $0.00 $0.00 $0.00 $133.20 $439.56 $444.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200056 EAP CPT® 76815 "Ob Us, Limited, Fetus(s)" BOTH IP/OP $554.00 $409.96 $52.22 $444.00 $195.10 $195.10 $106.02 $106.02 $106.62 $115.47 $144.86 $144.86 $150.43 $104.44 $115.45 $67.89 $327.69 $327.69 $112.41 $133.20 $439.56 $444.00 $156.18 $183.00 $156.18 $87.30 $52.22 $52.22 $88.36 $107.06 $0.00 $0.00 $0.00 $0.00 40200062 EAP CPT® 76816 Us Preg Uterus F/u BOTH IP/OP $554.00 $409.96 $67.89 $444.00 $266.85 $266.85 $106.02 $106.02 $106.62 $115.47 $171.46 $171.46 $178.06 $104.44 $115.45 $67.89 $327.69 $327.69 $112.41 $133.20 $439.56 $444.00 $156.18 $183.00 $156.18 $71.66 $71.67 $71.67 $88.36 $107.06 $0.00 $0.00 $0.00 $0.00 40200064 EAP CPT® 76817 Transvaginal U/s Pregnant BOTH IP/OP $593.00 $438.82 $59.07 $475.20 $224.11 $224.11 $106.02 $106.02 $106.62 $123.60 $158.78 $158.78 $164.88 $104.44 $123.58 $67.89 $350.76 $350.76 $112.41 $142.56 $470.45 $475.20 $156.18 $183.00 $156.18 $94.59 $59.07 $59.07 $94.56 $107.06 $0.00 $0.00 $0.00 $0.00 40200065 EAP CPT® 76882 "Ultrasound, Extremity, Nonvascular, Limited" BOTH IP/OP $649.00 $480.26 $0.00 $795.60 $82.24 $82.24 $106.02 $106.02 $106.62 $10.15 $25.36 $25.36 $26.33 $104.44 $135.25 $67.89 $0.00 $0.00 $112.41 $157.44 $519.55 $524.80 $156.18 $795.60 $156.18 $28.65 $33.14 $33.14 $0.00 $107.06 $0.00 $0.00 $0.00 $0.00 40200067 EAP CPT® 76818 Biophysical Profile W/nst BOTH IP/OP "$1,430.00 " "$1,058.20" $66.63 "$1,055.20" $284.62 $284.62 $106.02 $106.02 $106.62 $298.05 $170.84 $170.84 $177.41 $104.44 $298.01 $67.89 $845.85 $845.85 $112.41 $316.56 "$1,044.65" "$1,055.20" $156.18 $183.00 $156.18 $101.11 $66.63 $66.63 $209.98 $107.06 $0.00 $0.00 $0.00 $0.00 40200069 EAP CPT® 76819 Biophysical Profile W/o Nst BOTH IP/OP "$1,063.00 " $786.62 $48.98 $784.80 $208.01 $208.01 $106.02 $106.02 $106.62 $221.56 $137.27 $137.27 $142.55 $104.44 $221.53 $67.89 $628.76 $628.76 $112.41 $235.44 $776.95 $784.80 $156.18 $183.00 $156.18 $96.45 $48.98 $48.98 $156.18 $107.06 $0.00 $0.00 $0.00 $0.00 40200071 EAP CPT® 76820 Fetal Dopp Velocimetry Umb Art BOTH IP/OP "$1,583.00 " "$1,171.42" $21.97 "$1,168.00" $111.28 $111.28 $106.02 $106.02 $106.62 $329.94 $73.41 $73.41 $76.24 $104.44 $329.90 $67.89 $936.34 $936.34 $112.41 $350.40 "$1,156.32" "$1,168.00" $156.18 $183.00 $156.18 $92.68 $21.97 $21.97 $232.43 $107.06 $0.00 $0.00 $0.00 $0.00 40200072 EAP CPT® 76821 Fetal Dopp Velocimetry Mid Cer BOTH IP/OP "$1,583.00 " "$1,171.42" $56.55 "$1,168.00" $214.47 $214.47 $106.02 $106.02 $106.62 $329.94 $156.00 $156.00 $162.00 $104.44 $329.90 $67.89 $936.34 $936.34 $112.41 $350.40 "$1,156.32" "$1,168.00" $156.18 $183.00 $156.18 $102.99 $56.55 $56.55 $232.43 $107.06 $0.00 $0.00 $0.00 $0.00 40200073 EAP CPT® 76825 Fetal Echo (2d) BOTH IP/OP "$2,946.00 " "$2,180.04" $153.19 "$2,142.40" $639.28 $639.28 $470.55 $470.55 $473.20 $614.02 $311.37 $311.37 $323.34 $462.81 $613.95 $300.83 "$1,742.56" "$1,742.56" $483.00 $642.72 "$2,120.98" "$2,142.40" $671.06 $183.00 $671.06 $153.19 $193.77 $193.77 $426.34 $460.00 $0.00 $0.00 $0.00 $0.00 40200074 EAP CPT® 76826 "Fetal Echo, F/u, Repeat" BOTH IP/OP "$1,629.00 " "$1,205.46" $0.00 "$1,303.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.35 $184.35 $191.44 $0.00 $339.48 $0.00 $0.00 $0.00 $0.00 $390.96 "$1,290.17" "$1,303.20" $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200075 EAP CPT® 76827 Fetal Doppler Echo BOTH IP/OP "$2,946.00 " "$2,180.04" $0.00 "$2,142.40" $174.13 $174.13 $106.02 $106.02 $106.62 $614.02 $107.91 $107.91 $112.06 $104.44 $613.95 $67.89 "$1,742.56" "$1,742.56" $112.41 $642.72 "$2,120.98" "$2,142.40" $156.18 $183.00 $156.18 $0.00 $45.38 $45.38 $426.34 $107.06 $0.00 $0.00 $0.00 $0.00 40200077 EAP CPT® 76828 "Fetal Dopp Echo,repeat" BOTH IP/OP "$1,148.00 " $849.52 $0.00 $918.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.18 $63.18 $65.61 $0.00 $239.24 $0.00 $0.00 $0.00 $0.00 $275.52 $909.22 $918.40 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200078 EAP CPT® 76812 Ob Us Detailed Addl Fetus BOTH IP/OP $289.00 $213.86 $0.00 $545.35 $289.00 $289.00 $0.00 $0.00 $0.00 $60.23 $0.00 $0.00 $0.00 $0.00 $60.23 $0.00 $170.94 $170.94 $0.00 $65.28 $215.42 $217.60 $0.00 $545.35 $0.00 $139.72 $111.65 $111.65 $43.30 $0.00 $0.00 $0.00 $0.00 $0.00 40200079 EAP CPT® 76830 US TRANSVAGINAL BOTH IP/OP "$1,612.00 " "$1,192.88" $67.89 "$1,302.40" $280.55 $280.55 $106.02 $106.02 $106.62 $335.98 $211.68 $211.68 $219.82 $104.44 $335.94 $67.89 $953.50 $953.50 $112.41 $390.72 "$1,289.38" "$1,302.40" $156.18 $183.00 $156.18 $92.96 $89.68 $89.68 $259.18 $107.06 $0.00 $0.00 $0.00 $0.00 40200083 EAP CPT® 76831 Us Hysterosono W/wo Doppler BOTH IP/OP "$2,535.00 " "$1,875.90" $84.28 "$2,048.80" $274.90 $274.90 $224.08 $224.08 $225.34 $528.36 $209.87 $209.87 $217.94 $220.56 $528.29 $143.36 "$1,499.45" "$1,499.45" $233.72 $614.64 "$2,028.31" "$2,048.80" $324.73 $183.00 $324.73 $94.72 $84.28 $84.28 $407.71 $222.60 $0.00 $0.00 $0.00 $0.00 40200085 EAP CPT® 76856 Us Pelvis(non-ob)comp W/rt Img BOTH IP/OP "$1,593.00 " "$1,178.82" $67.89 "$1,287.20" $253.12 $253.12 $106.02 $106.02 $106.62 $332.02 $212.59 $212.59 $220.76 $104.44 $331.98 $67.89 $942.26 $942.26 $112.41 $386.16 "$1,274.33" "$1,287.20" $156.18 $183.00 $156.18 $92.96 $76.36 $76.36 $256.15 $107.06 $0.00 $0.00 $0.00 $0.00 40200087 EAP CPT® 76857 Us Pelvis Ltd/fu Non-ob BOTH IP/OP "$1,018.00 " $753.32 $24.13 $822.40 $110.46 $110.46 $106.02 $106.02 $106.62 $212.18 $200.51 $200.51 $208.22 $104.44 $212.15 $67.89 $602.15 $602.15 $112.41 $246.72 $814.18 $822.40 $156.18 $183.00 $156.18 $59.67 $24.13 $24.13 $163.66 $107.06 $0.00 $0.00 $0.00 $0.00 40200092 EAP CPT® 76516 Echo Exam Of Eye BOTH IP/OP $249.00 $184.26 $25.57 $194.40 $178.94 $178.94 $106.02 $106.02 $106.62 $51.90 $97.82 $97.82 $101.58 $104.44 $51.89 $67.89 $147.28 $147.28 $112.41 $58.32 $192.46 $194.40 $156.18 $183.00 $156.18 $76.68 $25.57 $25.57 $38.69 $107.06 $0.00 $0.00 $0.00 $0.00 40200097 EAP CPT® 76510 Opth Us B & Quant A BOTH IP/OP $636.00 $470.64 $0.00 $508.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.59 $168.59 $175.08 $0.00 $132.54 $0.00 $0.00 $0.00 $0.00 $152.64 $503.71 $508.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200125 EAP CPT® 76802 Us Preg Uterus Ea Addl Gest BOTH IP/OP $487.00 $360.38 $0.00 $390.40 $148.34 $148.34 $0.00 $0.00 $0.00 $101.50 $80.66 $80.66 $83.76 $0.00 $101.49 $0.00 $288.06 $288.06 $0.00 $117.12 $386.50 $390.40 $0.00 $183.00 $0.00 $70.91 $21.97 $21.97 $77.69 $0.00 $0.00 $0.00 $0.00 $0.00 40200126 EAP CPT® 93990 Duplex Scan Of Hemodialysis Access BOTH IP/OP "$1,058.00 " $782.92 $67.89 $839.80 $300.62 $300.62 $106.02 $106.02 $106.62 $220.51 $450.12 $450.12 $467.43 $104.44 $220.49 $67.89 $625.81 $625.81 $112.41 $502.00 $795.17 $803.20 $156.18 $839.80 $156.18 $112.81 $132.54 $132.54 $159.84 $107.06 $0.00 $0.00 $0.00 $0.00 40200127 EAP CPT® 76529 Ophthalmic Ultrasonic Foreign Body Localization BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.85 $95.85 $99.53 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $52.80 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200128 EAP CPT® 76932 "Us Guidance Endomyocardial Biopsy, Imaging S & I" BOTH IP/OP $454.00 $335.96 $0.00 $363.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.61 $0.00 $0.00 $0.00 $0.00 $108.96 $359.57 $363.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40200132 EAP CPT® 76706 Us Abdl Aorta Screen Aaa BOTH IP/OP $380.00 $281.20 $60.34 $303.20 $214.45 $214.45 $106.02 $106.02 $106.62 $79.20 $166.71 $166.71 $173.12 $104.44 $79.19 $67.89 $224.77 $224.77 $112.41 $90.96 $300.17 $303.20 $156.18 $183.00 $156.18 $90.50 $87.52 $87.52 $60.34 $107.06 $0.00 $0.00 $0.00 $0.00 40200133 EAP CPT® 76516 Quantitative A-scan Us Both Eyes BOTH IP/OP $374.00 $276.76 $25.57 $292.00 $178.94 $178.94 $106.02 $106.02 $106.62 $77.95 $97.82 $97.82 $101.58 $104.44 $77.94 $67.89 $221.22 $221.22 $112.41 $87.60 $289.08 $292.00 $156.18 $183.00 $156.18 $76.68 $25.57 $25.57 $58.11 $107.06 $0.00 $0.00 $0.00 $0.00 40200134 EAP CPT® 76513 B-scan Us High Resolution One Eye BOTH IP/OP $539.00 $398.86 $64.47 $435.20 $216.82 $216.82 $106.02 $106.02 $106.62 $112.34 $125.46 $125.46 $130.28 $104.44 $112.33 $67.89 $318.82 $318.82 $112.41 $130.56 $430.85 $435.20 $156.18 $183.00 $156.18 $93.36 $64.47 $64.47 $86.60 $107.06 $0.00 $0.00 $0.00 $0.00 40200135 EAP CPT® 76513 "B-scan Us, High Resolution Both Eyes" BOTH IP/OP $808.00 $597.92 $64.47 $652.80 $216.82 $216.82 $106.02 $106.02 $106.62 $168.41 $125.46 $125.46 $130.28 $104.44 $168.39 $67.89 $477.93 $477.93 $112.41 $195.84 $646.27 $652.80 $156.18 $183.00 $156.18 $93.36 $64.47 $64.47 $129.91 $107.06 $0.00 $0.00 $0.00 $0.00 40300003 EAP CPT® 77063 "Scr Digital Breast Tomosynthesis, Bil" BOTH IP/OP $149.00 $110.26 $16.39 $209.00 $126.56 $126.56 $25.21 $25.21 $46.99 $31.06 $64.15 $64.15 $66.61 $25.21 $31.05 $16.39 $88.13 $88.13 $26.75 $36.00 $118.80 $120.00 $25.21 $209.00 $25.21 $53.24 $25.21 $25.21 $23.88 $25.21 $0.00 $0.00 $0.00 $0.00 40300004 EAP CPT® 77063 "Scr Digital Breast Tomosynthesis, Uni" BOTH IP/OP $149.00 $110.26 $16.39 $209.00 $126.56 $126.56 $25.21 $25.21 $46.99 $31.06 $64.15 $64.15 $66.61 $25.21 $31.05 $16.39 $88.13 $88.13 $26.75 $36.00 $118.80 $120.00 $25.21 $209.00 $25.21 $53.24 $25.21 $25.21 $23.88 $25.21 $0.00 $0.00 $0.00 $0.00 40300010 EAP CPT® 77067 Scr Mammo Bi Incl Cad BOTH IP/OP $366.00 $270.84 $58.90 $549.00 $310.36 $310.36 $99.77 $99.77 $113.86 $76.28 $249.62 $249.62 $259.22 $99.77 $76.27 $64.85 $216.49 $216.49 $106.31 $88.80 $293.04 $296.00 $99.77 $549.00 $99.77 $132.75 $99.77 $99.77 $58.90 $99.77 $0.00 $0.00 $0.00 $0.00 40300011 EAP CPT® 77067 Scr Mammo Unilateral Incl Cad BOTH IP/OP $366.00 $270.84 $58.90 $549.00 $310.36 $310.36 $99.77 $99.77 $113.86 $76.28 $249.62 $249.62 $259.22 $99.77 $76.27 $64.85 $216.49 $216.49 $106.31 $88.80 $293.04 $296.00 $99.77 $549.00 $99.77 $132.75 $99.77 $99.77 $58.90 $99.77 $0.00 $0.00 $0.00 $0.00 40400005 EAP CPT® 78814 PET IMG RESTG THYROID CA PET BOTH IP/OP "$10,583.00 " "$7,831.42" $0.00 "$8,466.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,153.99" "$2,153.99" "$2,236.83" $0.00 "$2,205.50" $0.00 "$3,731.00" "$3,731.00" $0.00 "$2,539.92" "$8,381.74" "$8,466.40" $0.00 "$2,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40400008 EAP CPT® 78815 Pet/ct Skull Base Mid-thigh BOTH IP/OP "$10,477.00 " "$7,752.98" $0.00 "$8,466.40" "$3,960.00" "$3,960.00" "$1,441.32" "$1,441.32" "$1,449.43" "$2,183.67" "$2,380.34" "$2,380.34" "$2,471.89" "$1,418.79" "$2,183.41" $922.21 "$3,731.00" "$3,731.00" "$1,379.58" "$2,539.92" "$8,381.74" "$8,466.40" "$1,916.75" "$2,400.00" "$1,916.75" "$2,380.22" $0.00 $0.00 "$1,684.81" "$1,313.89" $0.00 $0.00 $0.00 $0.00 40400055 EAP CPT® 78816 Pet/ct Whole Body BOTH IP/OP "$10,477.00 " "$7,752.98" $0.00 "$8,466.40" "$3,960.00" "$3,960.00" "$1,441.32" "$1,441.32" "$1,449.43" "$2,183.67" "$2,441.96" "$2,441.96" "$2,535.88" "$1,418.79" "$2,183.41" $922.21 "$3,731.00" "$3,731.00" "$1,379.58" "$2,539.92" "$8,381.74" "$8,466.40" "$1,916.75" "$2,400.00" "$1,916.75" "$1,656.24" $0.00 $0.00 "$1,684.81" "$1,313.89" $0.00 $0.00 $0.00 $0.00 40400056 EAP CPT® 78608 "Brain Imaging, Positron Emission Tomo (pet); Metabolic Eval" BOTH IP/OP "$6,836.00 " "$5,058.64" $0.00 "$5,524.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $594.83 $594.83 $617.71 $0.00 "$1,424.62" $0.00 "$3,731.00" "$3,731.00" "$1,379.58" "$1,657.20" "$5,468.76" "$5,524.00" "$1,916.75" "$2,400.00" "$1,916.75" "$1,080.63" $0.00 $0.00 "$1,099.28" "$1,313.89" $0.00 $0.00 $0.00 $0.00 40400057 EAP CPT® 78459 "Myocardial Imaging, Positron Emission Tomography (pet), Metabolic Eval" BOTH IP/OP "$5,940.00 " "$4,395.60" $0.00 "$4,800.00" "$3,960.00" "$3,960.00" "$1,272.60" "$1,272.60" "$1,279.77" "$1,238.04" $479.75 $479.75 $498.20 "$1,251.64" "$1,237.90" $813.57 "$3,731.00" "$3,731.00" "$1,232.99" "$1,440.00" "$4,752.00" "$4,800.00" "$1,713.08" "$2,400.00" "$1,713.08" $939.00 $0.00 $0.00 $955.20 "$1,174.28" $0.00 $0.00 $0.00 $0.00 40400058 EAP CPT® 78429 Pet/ct Cardiac Metabolic Eval BOTH IP/OP "$5,940.00 " "$4,395.60" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,578.55" $0.00 "$1,237.90" $0.00 "$3,731.00" "$3,731.00" "$1,379.58" "$1,440.00" "$4,752.00" "$4,800.00" "$1,916.75" "$2,400.00" "$1,916.75" $939.00 $0.00 $0.00 $955.20 "$1,313.89" $0.00 $0.00 $0.00 $0.00 41000001 EAP CPT® 94002 Ventilation Assist/mgt Initial BOTH IP/OP "$6,841.00 " "$5,062.34" $77.15 "$5,273.04" "$3,714.66" "$3,714.66" $474.42 $474.42 $477.09 "$1,425.84" "$4,181.12" "$4,181.12" "$5,273.04" $465.08 "$1,425.66" $302.30 "$4,046.45" "$4,046.45" $465.90 "$3,120.00" "$4,942.08" "$4,992.00" $647.30 "$4,446.65" $647.30 $77.15 $94.86 $94.86 $993.41 $443.71 $0.00 $0.00 $0.00 $0.00 41000009 EAP CPT® 94003 "Mech Vent, Ea Subseq Day" BOTH IP/OP "$6,231.00 " "$4,610.94" $0.00 "$4,802.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,802.85" $0.00 "$1,298.54" $0.00 $0.00 $0.00 $465.90 "$2,842.00" "$4,501.73" "$4,547.20" $647.30 "$4,050.15" $647.30 $56.62 $68.52 $68.52 $904.89 $443.71 $0.00 $0.00 $0.00 $0.00 41000017 EAP CPT® 94640 Aerosal Rx Sub Admin (o2) BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000020 EAP Custom 94640 Aerosol Continuous Subsequent BOTH IP/OP $494.00 $365.56 $18.01 $380.78 $268.24 $268.24 $183.05 $183.05 $184.08 $102.96 $366.65 $366.65 $380.78 $180.07 $102.95 $117.04 $292.20 $292.20 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000021 EAP CPT® 94640 Aerosol Treatment Initial BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000022 EAP CPT® 94640 Aersol Treatment Subsequent BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000027 EAP CPT® 94640 Delivery Assist BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000028 EAP CPT® 94640 High Humidity Aerosol Initial BOTH IP/OP $414.00 $306.36 $18.01 $377.00 $224.80 $224.80 $183.05 $183.05 $184.08 $86.29 $307.27 $307.27 $319.11 $180.07 $86.28 $117.04 $244.88 $244.88 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000029 EAP CPT® 94640 High Humidity Aerosol Subseq BOTH IP/OP $414.00 $306.36 $18.01 $377.00 $224.80 $224.80 $183.05 $183.05 $184.08 $86.29 $307.27 $307.27 $319.11 $180.07 $86.28 $117.04 $244.88 $244.88 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000031 EAP CPT® 94640 Incentive Spirometer Subsequen BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000034 EAP CPT® 94640 Init Inhala Trtmnt Airway Obs BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000040 EAP CPT® 94640 "Mdi, Initial Rx" BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000041 EAP CPT® 94640 "Mdi, Subsequent Rx" BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000042 EAP CPT® 94640 Micro Neb Subsequent BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000043 EAP CPT® 94640 "Micro Neb, Setup" BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000045 EAP CPT® 94640 Neo Micro Subsquent BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000050 EAP CPT® 94640 Sputum Induction Initial BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000055 EAP CPT® 94644 "Micro Nebulizer, Cont; Initial" BOTH IP/OP $983.00 $727.42 $0.00 $945.75 $533.77 $533.77 $109.81 $109.81 $0.00 $204.88 $729.58 $729.58 $757.70 $107.30 $204.86 $69.74 $581.44 $581.44 $0.00 $491.50 $778.54 $786.40 $0.00 $945.75 $0.00 $0.00 $54.39 $54.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41000059 EAP CPT® 94645 Repeat Neb Treatment BOTH IP/OP $524.00 $387.76 $0.00 $403.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $388.91 $388.91 $403.90 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $211.00 $334.22 $337.60 $0.00 $340.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41000062 EAP CPT® 94660 Sleep Apnea/bipap BOTH IP/OP "$2,079.00 " "$1,538.46" $39.31 "$1,602.49" "$1,128.90" "$1,128.90" $183.05 $183.05 $184.08 $433.32 "$1,543.03" "$1,543.03" "$1,602.49" $180.07 $433.26 $117.04 "$1,229.73" "$1,229.73" $184.50 "$1,000.50" "$1,584.79" "$1,600.80" $256.34 "$1,558.70" $256.34 $52.24 $39.31 $39.31 $318.56 $175.71 $0.00 $0.00 $0.00 $0.00 41000063 EAP CPT® 94660 Neo Cpap BOTH IP/OP "$2,079.00 " "$1,538.46" $39.31 "$1,602.49" "$1,128.90" "$1,128.90" $183.05 $183.05 $184.08 $433.32 "$1,543.03" "$1,543.03" "$1,602.49" $180.07 $433.26 $117.04 "$1,229.73" "$1,229.73" $184.50 "$1,000.50" "$1,584.79" "$1,600.80" $256.34 "$1,558.70" $256.34 $52.24 $39.31 $39.31 $318.56 $175.71 $0.00 $0.00 $0.00 $0.00 41000064 EAP CPT® 94660 Cpap Prescription BOTH IP/OP "$2,001.00 " "$1,480.74" $39.31 "$1,600.80" "$1,086.54" "$1,086.54" $183.05 $183.05 $184.08 $417.06 "$1,485.14" "$1,485.14" "$1,542.37" $180.07 $417.01 $117.04 "$1,183.59" "$1,183.59" $184.50 "$1,000.50" "$1,584.79" "$1,600.80" $256.34 "$1,558.70" $256.34 $52.24 $39.31 $39.31 $318.56 $175.71 $0.00 $0.00 $0.00 $0.00 41000065 EAP CPT® 94664 Patient Assessment/education BOTH IP/OP $290.00 $214.60 $16.93 $223.53 $157.47 $157.47 $183.05 $183.05 $184.08 $60.44 $215.24 $215.24 $223.53 $180.07 $60.44 $117.04 $171.54 $171.54 $184.50 $110.00 $174.24 $176.00 $220.00 $188.50 $220.00 $18.91 $16.93 $16.93 $35.02 $175.71 $0.00 $0.00 $0.00 $0.00 41000067 EAP CPT® 94667 "Chest Pt, Inital Rx" BOTH IP/OP $501.00 $370.74 $0.00 $511.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $0.00 $0.00 $109.35 $232.50 $368.28 $372.00 $151.93 $511.55 $151.93 $0.00 $25.21 $25.21 $74.03 $104.14 $0.00 $0.00 $0.00 $0.00 41000069 EAP CPT® 94667 Cpt/vest BOTH IP/OP $501.00 $370.74 $0.00 $511.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $0.00 $0.00 $109.35 $232.50 $368.28 $372.00 $151.93 $511.55 $151.93 $0.00 $25.21 $25.21 $74.03 $104.14 $0.00 $0.00 $0.00 $0.00 41000070 EAP CPT® 94667 Initial Chest Therapy BOTH IP/OP $465.00 $344.10 $0.00 $511.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $358.42 $0.00 $96.91 $0.00 $0.00 $0.00 $109.35 $232.50 $368.28 $372.00 $151.93 $511.55 $151.93 $0.00 $25.21 $25.21 $74.03 $104.14 $0.00 $0.00 $0.00 $0.00 41000072 EAP CPT® 94667 Pep/acpella Therapy BOTH IP/OP $465.00 $344.10 $0.00 $511.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $358.42 $0.00 $96.91 $0.00 $0.00 $0.00 $109.35 $232.50 $368.28 $372.00 $151.93 $511.55 $151.93 $0.00 $25.21 $25.21 $74.03 $104.14 $0.00 $0.00 $0.00 $0.00 41000073 EAP CPT® 94667 Sipap Setup BOTH IP/OP $501.00 $370.74 $0.00 $511.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $386.17 $0.00 $104.41 $0.00 $0.00 $0.00 $109.35 $232.50 $368.28 $372.00 $151.93 $511.55 $151.93 $0.00 $25.21 $25.21 $74.03 $104.14 $0.00 $0.00 $0.00 $0.00 41000074 EAP CPT® 94668 "Chest Pt, Subsequent Rx" BOTH IP/OP $373.00 $276.02 $0.00 $399.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.84 $276.84 $287.51 $0.00 $77.73 $0.00 $0.00 $0.00 $0.00 $141.50 $224.14 $226.40 $0.00 $399.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41000076 EAP CPT® 94668 Cpt/vest Sub BOTH IP/OP $283.00 $209.42 $0.00 $399.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.04 $210.04 $218.14 $0.00 $58.98 $0.00 $0.00 $0.00 $0.00 $141.50 $224.14 $226.40 $0.00 $399.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41000077 EAP CPT® 94668 Sipap Ea Shift BOTH IP/OP $373.00 $276.02 $0.00 $399.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.84 $276.84 $287.51 $0.00 $77.73 $0.00 $0.00 $0.00 $0.00 $141.50 $224.14 $226.40 $0.00 $399.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41000078 EAP CPT® 94668 Subsequent Chest Therapy BOTH IP/OP $373.00 $276.02 $0.00 $399.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.84 $276.84 $287.51 $0.00 $77.73 $0.00 $0.00 $0.00 $0.00 $141.50 $224.14 $226.40 $0.00 $399.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41000080 EAP CPT® 94003 "Mech Vent, Ea Subseq Day" BOTH IP/OP "$5,771.00 " "$4,270.54" $0.00 "$4,547.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,448.29" $0.00 "$1,202.68" $0.00 $0.00 $0.00 $465.90 "$2,842.00" "$4,501.73" "$4,547.20" $647.30 "$4,050.15" $647.30 $56.62 $68.52 $68.52 $904.89 $443.71 $0.00 $0.00 $0.00 $0.00 41000081 EAP CPT® 94664 Asthma Teaching-nebulizer &mdi BOTH IP/OP $290.00 $214.60 $16.93 $223.53 $157.47 $157.47 $183.05 $183.05 $184.08 $60.44 $215.24 $215.24 $223.53 $180.07 $60.44 $117.04 $171.54 $171.54 $184.50 $110.00 $174.24 $176.00 $220.00 $188.50 $220.00 $18.91 $16.93 $16.93 $35.02 $175.71 $0.00 $0.00 $0.00 $0.00 41000090 EAP CPT® 94003 "Mech Vent, Ea Subseq Day" BOTH IP/OP "$5,771.00 " "$4,270.54" $0.00 "$4,547.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,448.29" $0.00 "$1,202.68" $0.00 $0.00 $0.00 $465.90 "$2,842.00" "$4,501.73" "$4,547.20" $647.30 "$4,050.15" $647.30 $56.62 $68.52 $68.52 $904.89 $443.71 $0.00 $0.00 $0.00 $0.00 41000110 EAP CPT® 94002 Spec Vent Initial BOTH IP/OP "$6,841.00 " "$5,062.34" $77.15 "$5,273.04" "$3,714.66" "$3,714.66" $474.42 $474.42 $477.09 "$1,425.84" "$4,181.12" "$4,181.12" "$5,273.04" $465.08 "$1,425.66" $302.30 "$4,046.45" "$4,046.45" $465.90 "$3,120.00" "$4,942.08" "$4,992.00" $647.30 "$4,446.65" $647.30 $77.15 $94.86 $94.86 $993.41 $443.71 $0.00 $0.00 $0.00 $0.00 41000111 EAP CPT® 94002 Neo Mech Vent Initial BOTH IP/OP "$6,841.00 " "$5,062.34" $77.15 "$5,273.04" "$3,714.66" "$3,714.66" $474.42 $474.42 $477.09 "$1,425.84" "$4,181.12" "$4,181.12" "$5,273.04" $465.08 "$1,425.66" $302.30 "$4,046.45" "$4,046.45" $465.90 "$3,120.00" "$4,942.08" "$4,992.00" $647.30 "$4,446.65" $647.30 $77.15 $94.86 $94.86 $993.41 $443.71 $0.00 $0.00 $0.00 $0.00 41000112 EAP CPT® 94002 Mech Vent Initial BOTH IP/OP "$6,841.00 " "$5,062.34" $77.15 "$5,273.04" "$3,714.66" "$3,714.66" $474.42 $474.42 $477.09 "$1,425.84" "$4,181.12" "$4,181.12" "$5,273.04" $465.08 "$1,425.66" $302.30 "$4,046.45" "$4,046.45" $465.90 "$3,120.00" "$4,942.08" "$4,992.00" $647.30 "$4,446.65" $647.30 $77.15 $94.86 $94.86 $993.41 $443.71 $0.00 $0.00 $0.00 $0.00 41000119 EAP CPT® 94003 "Spec Vent, Ea Subseq Day" BOTH IP/OP "$6,231.00 " "$4,610.94" $0.00 "$4,802.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,802.85" $0.00 "$1,298.54" $0.00 $0.00 $0.00 $465.90 "$2,842.00" "$4,501.73" "$4,547.20" $647.30 "$4,050.15" $647.30 $56.62 $68.52 $68.52 $904.89 $443.71 $0.00 $0.00 $0.00 $0.00 41000120 EAP CPT® 94003 Neo Mech Vent Subseq BOTH IP/OP "$6,231.00 " "$4,610.94" $0.00 "$4,802.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,802.85" $0.00 "$1,298.54" $0.00 $0.00 $0.00 $465.90 "$2,842.00" "$4,501.73" "$4,547.20" $647.30 "$4,050.15" $647.30 $56.62 $68.52 $68.52 $904.89 $443.71 $0.00 $0.00 $0.00 $0.00 41000121 EAP CPT® 94640 "Neo Micro Neb, Setup" BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000150 EAP CPT® 94640 Sputum Induction Subseq BOTH IP/OP $535.00 $395.90 $18.01 $412.38 $290.51 $290.51 $183.05 $183.05 $184.08 $111.51 $397.08 $397.08 $412.38 $180.07 $111.49 $117.04 $316.45 $316.45 $184.50 $207.00 $327.89 $331.20 $256.34 $377.00 $256.34 $19.30 $18.01 $18.01 $65.91 $175.71 $0.00 $0.00 $0.00 $0.00 41000190 EAP CPT® 94003 Neo Ventilation Subseq BOTH IP/OP "$6,231.00 " "$4,610.94" $0.00 "$4,802.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,802.85" $0.00 "$1,298.54" $0.00 $0.00 $0.00 $465.90 "$2,842.00" "$4,501.73" "$4,547.20" $647.30 "$4,050.15" $647.30 $56.62 $68.52 $68.52 $904.89 $443.71 $0.00 $0.00 $0.00 $0.00 41000191 EAP CPT® 94669 Chest Vest Mechanical Oscillat BOTH IP/OP "$1,866.00 " "$1,380.84" $0.00 "$1,492.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.95" "$1,384.95" "$1,438.31" $0.00 $388.87 $0.00 $0.00 $0.00 $0.00 $933.00 "$1,477.87" "$1,492.80" $0.00 $563.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41200001 EAP CPT® 94642 Aerosol Inhal. Of Pentamidine BOTH IP/OP $353.00 $261.22 $0.00 $272.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.00 $262.00 $272.09 $0.00 $73.57 $0.00 $0.00 $0.00 $184.50 $142.00 $224.93 $227.20 $256.34 $229.45 $256.34 $31.57 $0.00 $0.00 $45.21 $175.71 $0.00 $0.00 $0.00 $0.00 42000002 EAP CPT® 92526 Pediatric Feeding BOTH IP/OP $792.00 $586.08 $0.00 $582.40 $430.06 $430.06 $86.29 $86.29 $87.06 $165.07 $444.74 $444.74 $461.84 $84.61 $165.05 $55.00 $468.47 $468.47 $88.84 $364.00 $576.58 $582.40 $122.68 $133.74 $122.68 $113.93 $84.61 $84.61 $0.00 $84.61 $0.00 $0.00 $0.00 $0.00 42000006 EAP CPT® 97012 "Traction, Mechanical" BOTH IP/OP $206.00 $152.44 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $42.93 $0.00 $0.00 $0.00 $0.00 $103.00 $163.15 $164.80 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000007 EAP CPT® 97014 Electrical Stim Unsupervised BOTH IP/OP $291.00 $215.34 $0.00 $461.84 $27.09 $27.09 $13.21 $13.21 $14.03 $60.65 $444.74 $444.74 $461.84 $13.17 $60.64 $8.56 $172.13 $172.13 $13.83 $150.50 $238.39 $240.80 $180.60 $19.04 $180.60 $14.50 $0.00 $0.00 $0.00 $13.17 $0.00 $0.00 $0.00 $0.00 42000009 EAP CPT® 97018 Paraffin Bath BOTH IP/OP $278.00 $205.72 $0.00 $461.84 $18.66 $18.66 $5.89 $5.89 $11.16 $57.94 $444.74 $444.74 $461.84 $5.63 $57.94 $3.66 $164.44 $164.44 $5.91 $126.50 $200.38 $202.40 $8.16 $8.99 $8.16 $10.67 $5.63 $5.63 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 42000010 EAP CPT® 97022 Whirlpool BOTH IP/OP $328.00 $242.72 $0.00 $461.84 $40.34 $40.34 $18.09 $18.09 $23.78 $68.36 $444.74 $444.74 $461.84 $16.98 $68.36 $11.04 $194.01 $194.01 $17.83 $150.00 $237.60 $240.00 $24.62 $26.94 $24.62 $14.51 $16.98 $16.98 $0.00 $16.98 $0.00 $0.00 $0.00 $0.00 42000011 EAP CPT® 97032 Elec Stim Cons Atten Ea 15 Min BOTH IP/OP $301.00 $222.74 $0.00 $461.84 $32.52 $32.52 $14.96 $14.96 $19.43 $62.74 $444.74 $444.74 $461.84 $14.41 $62.73 $9.37 $178.04 $178.04 $15.13 $150.50 $238.39 $240.80 $20.89 $22.74 $20.89 $16.22 $14.41 $14.41 $0.00 $14.41 $0.00 $0.00 $0.00 $0.00 42000012 EAP CPT® 97035 Ultrasound Ea 15 Min BOTH IP/OP $162.00 $119.88 $0.00 $461.84 $21.67 $21.67 $14.61 $14.61 $12.94 $33.76 $444.74 $444.74 $461.84 $13.93 $33.76 $9.05 $95.82 $95.82 $14.63 $82.00 $129.89 $131.20 $20.20 $22.74 $20.20 $11.96 $13.93 $13.93 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 42000013 EAP CPT® 97036 Hubbard Tank Ea 15 Min BOTH IP/OP $200.00 $148.00 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000015 EAP CPT® 97110 Exercise Each 15 Minutes BOTH IP/OP $351.00 $259.74 $0.00 $461.84 $55.39 $55.39 $30.26 $30.26 $32.74 $73.16 $444.74 $444.74 $461.84 $29.58 $73.15 $19.23 $207.62 $207.62 $31.06 $159.50 $252.65 $255.20 $42.89 $46.51 $42.89 $22.45 $29.58 $29.58 $0.00 $29.58 $0.00 $0.00 $0.00 $0.00 42000016 EAP CPT® 97112 Neuro-musc Re-ed Ea 15 Min BOTH IP/OP $332.00 $245.68 $0.00 $461.84 $57.82 $57.82 $35.14 $35.14 $33.84 $69.20 $444.74 $444.74 $461.84 $33.96 $69.19 $22.07 $196.38 $196.38 $35.66 $151.00 $239.18 $241.60 $49.24 $53.38 $49.24 $23.53 $33.96 $33.96 $0.00 $33.96 $0.00 $0.00 $0.00 $0.00 42000017 EAP CPT® 97116 Gait Training Ea 15 Min BOTH IP/OP $332.00 $245.68 $0.00 $461.84 $48.15 $48.15 $30.26 $30.26 $28.80 $69.20 $444.74 $444.74 $461.84 $29.26 $69.19 $19.02 $196.38 $196.38 $30.72 $151.00 $239.18 $241.60 $42.43 $46.51 $42.43 $21.09 $29.26 $29.26 $0.00 $29.26 $0.00 $0.00 $0.00 $0.00 42000018 EAP CPT® 97139 Tilt Table - Each 15 Min BOTH IP/OP $198.00 $146.52 $0.00 $461.84 $39.36 $39.36 $0.00 $0.00 $13.61 $41.27 $444.74 $444.74 $461.84 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $90.00 $142.56 $144.00 $108.00 $191.00 $108.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000019 EAP CPT® 97140 Joint Mobilization Ea 15 Min BOTH IP/OP $468.00 $346.32 $0.00 $461.84 $51.16 $51.16 $27.82 $27.82 $30.24 $97.54 $444.74 $444.74 $461.84 $27.26 $97.53 $17.72 $276.82 $276.82 $28.62 $219.50 $347.69 $351.20 $39.53 $42.82 $39.53 $25.71 $27.26 $27.26 $0.00 $27.26 $0.00 $0.00 $0.00 $0.00 42000020 EAP CPT® 97150 Group Activity/exercise BOTH IP/OP $143.00 $105.82 $0.00 $461.84 $29.49 $29.49 $18.10 $18.10 $17.62 $29.80 $444.74 $444.74 $461.84 $17.78 $29.80 $11.56 $84.58 $84.58 $18.67 $71.50 $113.26 $114.40 $25.78 $28.02 $25.78 $18.34 $17.78 $17.78 $0.00 $17.78 $0.00 $0.00 $0.00 $0.00 42000021 EAP CPT® 97530 Functional Activities Ea 15 Mi BOTH IP/OP $331.00 $244.94 $0.00 $461.84 $59.61 $59.61 $39.32 $39.32 $35.29 $68.99 $444.74 $444.74 $461.84 $37.56 $68.98 $24.41 $195.79 $195.79 $39.44 $150.50 $238.39 $240.80 $54.46 $58.66 $54.46 $21.84 $37.56 $37.56 $0.00 $37.56 $0.00 $0.00 $0.00 $0.00 42000023 EAP CPT® 97542 W/c Management Training Ea 15m BOTH IP/OP $290.00 $214.60 $0.00 $461.84 $52.38 $52.38 $32.70 $32.70 $30.95 $60.44 $444.74 $444.74 $461.84 $31.95 $60.44 $20.77 $171.54 $171.54 $33.55 $132.00 $209.09 $211.20 $46.33 $50.21 $46.33 $15.60 $31.95 $31.95 $0.00 $31.95 $0.00 $0.00 $0.00 $0.00 42000026 EAP CPT® 97760 Orthotic Fit/train Init Ea 15 BOTH IP/OP $344.00 $254.56 $0.00 $461.84 $186.79 $186.79 $50.11 $50.11 $38.52 $71.70 $444.74 $444.74 $461.84 $46.79 $71.69 $30.41 $203.48 $203.48 $49.13 $156.50 $247.90 $250.40 $67.85 $76.61 $67.85 $48.98 $46.79 $46.79 $0.00 $46.79 $0.00 $0.00 $0.00 $0.00 42000027 EAP CPT® 97761 Prosthetic Training Ea 15 Min BOTH IP/OP $164.00 $121.36 $0.00 $461.84 $89.05 $89.05 $42.45 $42.45 $33.46 $0.00 $444.74 $444.74 $461.84 $0.00 $34.18 $0.00 $0.00 $0.00 $42.05 $74.50 $118.01 $119.20 $58.07 $66.05 $58.07 $23.32 $40.05 $40.05 $0.00 $40.05 $0.00 $0.00 $0.00 $0.00 42000028 EAP CPT® 97763 Orthotics/prosth Mgmt &/trainj Sbsq Enctr 15 Min BOTH IP/OP $344.00 $254.56 $0.00 $461.84 $186.79 $186.79 $54.99 $54.99 $0.00 $71.70 $444.74 $444.74 $461.84 $49.92 $71.69 $32.45 $203.48 $203.48 $52.42 $156.50 $247.90 $250.40 $72.38 $84.00 $72.38 $46.64 $49.92 $49.92 $0.00 $49.92 $0.00 $0.00 $0.00 $0.00 42000034 EAP CPT® 97545 Work Hardening-pt BOTH IP/OP $207.00 $153.18 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000045 EAP CPT® 97139 Scar Management Ea 15 Min BOTH IP/OP $198.00 $146.52 $0.00 $461.84 $39.36 $39.36 $0.00 $0.00 $13.61 $41.27 $444.74 $444.74 $461.84 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $90.00 $142.56 $144.00 $108.00 $191.00 $108.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000050 EAP CPT® 97546 Work Hardening Add-on BOTH IP/OP $102.00 $75.48 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000060 EAP CPT® 29581 Apply Multlay Comprs Lwr Leg-lt BOTH IP/OP $478.00 $353.72 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000068 EAP CPT® 29584 Apply Multlay Comprs Arm/hand-lt BOTH IP/OP $427.00 $315.98 $0.00 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $88.99 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000088 EAP CPT® 97022 FLUIDIOTHERAPY-GP BOTH IP/OP $328.00 $242.72 $0.00 $461.84 $40.34 $40.34 $18.09 $18.09 $23.78 $68.36 $444.74 $444.74 $461.84 $16.98 $68.36 $11.04 $194.01 $194.01 $17.83 $150.00 $237.60 $240.00 $24.62 $26.94 $24.62 $14.51 $16.98 $16.98 $0.00 $16.98 $0.00 $0.00 $0.00 $0.00 42000090 EAP CPT® 29581 Apply Multlay Comprs Lwr Leg-rt BOTH IP/OP $478.00 $353.72 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000093 EAP CPT® 29584 Apply Multlay Comprs Arm/hand-rt BOTH IP/OP $427.00 $315.98 $0.00 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $88.99 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $508.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000100 EAP HCPCS G8978 Mobility Current Status BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000101 EAP HCPCS G8979 Mobility Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000102 EAP HCPCS G8980 Mobility D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000103 EAP HCPCS G8981 Body Pos Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000104 EAP HCPCS G8982 Body Pos Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000105 EAP HCPCS G8983 Body Pos D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000106 EAP HCPCS G8984 Carry Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000107 EAP HCPCS G8985 Carry Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000108 EAP HCPCS G8986 Carry D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000109 EAP HCPCS G8987 Self-care Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000110 EAP HCPCS G8988 Self-care Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000111 EAP HCPCS G8989 Self-care D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000112 EAP HCPCS G8990 Other Pt/ot Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000113 EAP HCPCS G8991 Other Pt/ot Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000114 EAP HCPCS G8992 Other Pt/ot D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000115 EAP HCPCS G8993 Sub Pt/ot Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000116 EAP HCPCS G8994 Sub Pt/ot Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000117 EAP HCPCS G8995 Sub Pt/ot D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000125 EAP CPT® 97597 Debridement First 20 Sq Cm Or Less BOTH IP/OP $740.00 $547.60 $0.00 "$1,305.00" $740.00 $740.00 $174.88 $174.88 $175.86 $154.23 $444.74 $444.74 $461.84 $172.08 $154.22 $111.85 $437.71 $437.71 $175.24 $674.00 $533.81 $539.20 $243.48 "$1,305.00" $243.48 $48.15 $37.87 $37.87 $0.00 $166.90 $0.00 $0.00 $0.00 $0.00 42000126 EAP CPT® 97610 Pt Low Frequency Non Contrast/thermal Per Day BOTH IP/OP $514.00 $380.36 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $107.12 $0.00 $0.00 $0.00 $0.00 $257.00 $407.09 $411.20 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000226 EAP CPT® 97598 Debridement Open Wound Ea Addl 20 Sq Cm BOTH IP/OP $616.00 $455.84 $0.00 $924.00 $616.00 $616.00 $0.00 $0.00 $0.00 $128.39 $444.74 $444.74 $461.84 $0.00 $128.37 $0.00 $364.36 $364.36 $0.00 $280.50 $444.31 $448.80 $0.00 $924.00 $0.00 $61.13 $26.68 $26.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000227 EAP CPT® 97014 Pt Electric Stim Ther Unsupervised Wound BOTH IP/OP $291.00 $215.34 $0.00 $461.84 $27.09 $27.09 $0.00 $0.00 $13.56 $60.65 $444.74 $444.74 $461.84 $0.00 $60.64 $0.00 $172.13 $172.13 $0.00 $150.50 $238.39 $240.80 $180.60 $181.00 $180.60 $14.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000228 EAP CPT® 97014 Pt Electric Stim Ther Unsupervised Non-wound BOTH IP/OP $301.00 $222.74 $0.00 $461.84 $27.09 $27.09 $13.21 $13.21 $14.03 $62.74 $444.74 $444.74 $461.84 $13.17 $62.73 $8.56 $178.04 $178.04 $13.83 $150.50 $238.39 $240.80 $180.60 $19.04 $180.60 $14.50 $0.00 $0.00 $0.00 $13.17 $0.00 $0.00 $0.00 $0.00 42400010 EAP CPT® 97161 Pt Eval Low Complex BOTH IP/OP $726.00 $537.24 $0.00 $528.00 $138.52 $138.52 $101.63 $101.63 $0.00 $151.32 $444.74 $444.74 $461.84 $82.44 $151.30 $53.59 $429.43 $429.43 $86.56 $330.00 $522.72 $528.00 $119.54 $158.58 $119.54 $77.58 $82.44 $82.44 $0.00 $82.44 $0.00 $0.00 $0.00 $0.00 42400011 EAP CPT® 97162 Pt Eval Mod Complex BOTH IP/OP $743.00 $549.82 $0.00 $540.00 $138.52 $138.52 $101.63 $101.63 $0.00 $154.86 $444.74 $444.74 $461.84 $82.44 $154.84 $53.59 $439.48 $439.48 $86.56 $337.50 $534.60 $540.00 $119.54 $158.58 $119.54 $77.58 $82.44 $82.44 $0.00 $82.44 $0.00 $0.00 $0.00 $0.00 42400012 EAP CPT® 97163 Pt Eval High Complex BOTH IP/OP $759.00 $561.66 $0.00 $552.00 $138.52 $138.52 $101.63 $101.63 $0.00 $158.19 $444.74 $444.74 $461.84 $82.44 $158.18 $53.59 $448.95 $448.95 $86.56 $345.00 $546.48 $552.00 $119.54 $158.58 $119.54 $77.58 $82.44 $82.44 $0.00 $82.44 $0.00 $0.00 $0.00 $0.00 42400013 EAP CPT® 97164 Pt Re-eval BOTH IP/OP $528.00 $390.72 $0.00 $461.84 $93.38 $93.38 $69.58 $69.58 $0.00 $110.05 $444.74 $444.74 $461.84 $56.39 $110.04 $36.65 $312.31 $312.31 $59.21 $240.00 $380.16 $384.00 $81.77 $109.95 $81.77 $52.74 $56.39 $56.39 $0.00 $56.39 $0.00 $0.00 $0.00 $0.00 43000002 EAP CPT® 92526 Dysphagia Treatment BOTH IP/OP $728.00 $538.72 $0.00 $582.40 $395.30 $395.30 $86.29 $86.29 $87.06 $151.73 $444.74 $444.74 $461.84 $84.61 $151.72 $55.00 $430.61 $430.61 $88.84 $364.00 $576.58 $582.40 $122.68 $133.74 $122.68 $113.93 $84.61 $84.61 $0.00 $84.61 $0.00 $0.00 $0.00 $0.00 43000005 EAP CPT® 95851 Range Of Motion Measurement BOTH IP/OP $36.00 $26.64 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000008 EAP CPT® 97014 Electrical Stim Unsupervised BOTH IP/OP $291.00 $215.34 $0.00 $461.84 $27.09 $27.09 $13.21 $13.21 $14.03 $60.65 $444.74 $444.74 $461.84 $13.17 $60.64 $8.56 $172.13 $172.13 $13.83 $150.50 $238.39 $240.80 $180.60 $19.04 $180.60 $14.50 $0.00 $0.00 $0.00 $13.17 $0.00 $0.00 $0.00 $0.00 43000010 EAP CPT® 97018 Paraffin Bath BOTH IP/OP $278.00 $205.72 $0.00 $461.84 $18.66 $18.66 $5.89 $5.89 $11.16 $57.94 $444.74 $444.74 $461.84 $5.63 $57.94 $3.66 $164.44 $164.44 $5.91 $126.50 $200.38 $202.40 $8.16 $8.99 $8.16 $10.67 $5.63 $5.63 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 43000011 EAP CPT® 97022 Whirlpool BOTH IP/OP $328.00 $242.72 $0.00 $461.84 $40.34 $40.34 $18.09 $18.09 $23.78 $68.36 $444.74 $444.74 $461.84 $16.98 $68.36 $11.04 $194.01 $194.01 $17.83 $150.00 $237.60 $240.00 $24.62 $26.94 $24.62 $14.51 $16.98 $16.98 $0.00 $16.98 $0.00 $0.00 $0.00 $0.00 43000012 EAP CPT® 97032 Elec Stim Cons Atten Ea 15 Min BOTH IP/OP $301.00 $222.74 $0.00 $461.84 $32.52 $32.52 $14.96 $14.96 $19.43 $62.74 $444.74 $444.74 $461.84 $14.41 $62.73 $9.37 $178.04 $178.04 $15.13 $150.50 $238.39 $240.80 $20.89 $22.74 $20.89 $16.22 $14.41 $14.41 $0.00 $14.41 $0.00 $0.00 $0.00 $0.00 43000013 EAP CPT® 97035 Ultrasound Heat Ea 15 Min BOTH IP/OP $162.00 $119.88 $0.00 $461.84 $21.67 $21.67 $14.61 $14.61 $12.94 $33.76 $444.74 $444.74 $461.84 $13.93 $33.76 $9.05 $95.82 $95.82 $14.63 $82.00 $129.89 $131.20 $20.20 $22.74 $20.20 $11.96 $13.93 $13.93 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 43000014 EAP CPT® 97022 Fluidiotherapy BOTH IP/OP $328.00 $242.72 $0.00 $461.84 $40.34 $40.34 $18.09 $18.09 $23.78 $68.36 $444.74 $444.74 $461.84 $16.98 $68.36 $11.04 $194.01 $194.01 $17.83 $150.00 $237.60 $240.00 $24.62 $26.94 $24.62 $14.51 $16.98 $16.98 $0.00 $16.98 $0.00 $0.00 $0.00 $0.00 43000015 EAP CPT® 97110 Therapeutic Exercise Ea 15min BOTH IP/OP $351.00 $259.74 $0.00 $461.84 $55.39 $55.39 $30.26 $30.26 $32.74 $73.16 $444.74 $444.74 $461.84 $29.58 $73.15 $19.23 $207.62 $207.62 $31.06 $159.50 $252.65 $255.20 $42.89 $46.51 $42.89 $22.45 $29.58 $29.58 $0.00 $29.58 $0.00 $0.00 $0.00 $0.00 43000016 EAP CPT® 97112 Neuromuscular Re-ed Ea. 15 Min BOTH IP/OP $332.00 $245.68 $0.00 $461.84 $57.82 $57.82 $35.14 $35.14 $33.84 $69.20 $444.74 $444.74 $461.84 $33.96 $69.19 $22.07 $196.38 $196.38 $35.66 $151.00 $239.18 $241.60 $49.24 $53.38 $49.24 $23.53 $33.96 $33.96 $0.00 $33.96 $0.00 $0.00 $0.00 $0.00 43000018 EAP CPT® 97139 Scar Management Ea 15 Min BOTH IP/OP $198.00 $146.52 $0.00 $461.84 $39.36 $39.36 $0.00 $0.00 $13.61 $41.27 $444.74 $444.74 $461.84 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $90.00 $142.56 $144.00 $108.00 $124.15 $108.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000019 EAP CPT® 97140 Joint Mobilization Ea 15 Min BOTH IP/OP $468.00 $346.32 $0.00 $461.84 $51.16 $51.16 $27.82 $27.82 $30.24 $97.54 $444.74 $444.74 $461.84 $27.26 $97.53 $17.72 $276.82 $276.82 $28.62 $219.50 $347.69 $351.20 $39.53 $42.82 $39.53 $25.71 $27.26 $27.26 $0.00 $27.26 $0.00 $0.00 $0.00 $0.00 43000020 EAP CPT® 97150 Group Activity/exercise BOTH IP/OP $143.00 $105.82 $0.00 $461.84 $29.49 $29.49 $18.10 $18.10 $17.62 $29.80 $444.74 $444.74 $461.84 $17.78 $29.80 $11.56 $84.58 $84.58 $18.67 $71.50 $113.26 $114.40 $25.78 $0.00 $25.78 $18.34 $17.78 $17.78 $0.00 $17.78 $0.00 $0.00 $0.00 $0.00 43000021 EAP CPT® 97530 Activ.to Increase Func.ea 15mi BOTH IP/OP $331.00 $244.94 $0.00 $461.84 $59.61 $59.61 $39.32 $39.32 $35.29 $68.99 $444.74 $444.74 $461.84 $37.56 $68.98 $24.41 $195.79 $195.79 $39.44 $150.50 $238.39 $240.80 $54.46 $58.66 $54.46 $21.84 $37.56 $37.56 $0.00 $37.56 $0.00 $0.00 $0.00 $0.00 43000023 EAP CPT® 97533 Sensory Integrat Tech Ea 15min BOTH IP/OP $191.00 $141.34 $0.00 $461.84 $49.98 $49.98 $60.56 $60.56 $29.51 $0.00 $444.74 $444.74 $461.84 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $100.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000024 EAP CPT® 97535 Adl Training Each 15 Mins BOTH IP/OP $278.00 $205.72 $0.00 $461.84 $59.61 $59.61 $33.74 $33.74 $35.29 $57.94 $444.74 $444.74 $461.84 $32.79 $57.94 $21.31 $164.44 $164.44 $34.43 $126.50 $200.38 $202.40 $47.55 $51.79 $47.55 $23.39 $32.79 $32.79 $0.00 $32.79 $0.00 $0.00 $0.00 $0.00 43000028 EAP CPT® 97760 "Splint/ort-fab,fit/tra/q 15min" BOTH IP/OP $344.00 $254.56 $0.00 $461.84 $186.79 $186.79 $50.11 $50.11 $38.52 $71.70 $444.74 $444.74 $461.84 $46.79 $71.69 $30.41 $203.48 $203.48 $49.13 $156.50 $247.90 $250.40 $67.85 $76.61 $67.85 $48.98 $46.79 $46.79 $0.00 $46.79 $0.00 $0.00 $0.00 $0.00 43000029 EAP CPT® 97761 Prosth/training Ea 15 Min BOTH IP/OP $164.00 $121.36 $0.00 $461.84 $89.05 $89.05 $42.45 $42.45 $33.46 $0.00 $444.74 $444.74 $461.84 $0.00 $34.18 $0.00 $0.00 $0.00 $42.05 $74.50 $118.01 $119.20 $58.07 $66.05 $58.07 $23.32 $40.05 $40.05 $0.00 $40.05 $0.00 $0.00 $0.00 $0.00 43000030 EAP CPT® 97763 Orthotics/prosth Mgmt &/trainj Sbsq Enctr 15 Min BOTH IP/OP $344.00 $254.56 $0.00 $461.84 $186.79 $186.79 $54.99 $54.99 $0.00 $71.70 $444.74 $444.74 $461.84 $49.92 $71.69 $32.45 $203.48 $203.48 $52.42 $156.50 $247.90 $250.40 $72.38 $84.00 $72.38 $46.64 $49.92 $49.92 $0.00 $49.92 $0.00 $0.00 $0.00 $0.00 43000044 EAP CPT® 97545 Work Hardening-ot BOTH IP/OP $207.00 $153.18 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000051 EAP CPT® 97598 "WOUND CARE,EACH ADDITIONAL 20 SQ CEMENT &PULSED LAVAGE)" BOTH IP/OP $616.00 $455.84 $0.00 $616.00 $616.00 $616.00 $0.00 $0.00 $0.00 $128.39 $444.74 $444.74 $461.84 $0.00 $128.37 $0.00 $364.36 $364.36 $0.00 $280.50 $444.31 $448.80 $0.00 $600.60 $0.00 $61.13 $26.68 $26.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000060 EAP CPT® 97546 Work Hardening Add-on-ot BOTH IP/OP $102.00 $75.48 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000062 EAP CPT® 29581 Apply Multlay Comprs Lwr Leg-lt BOTH IP/OP $478.00 $353.72 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000065 EAP CPT® 29584 Apply Multlay Comprs Arm/hand-lt BOTH IP/OP $508.00 $375.92 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $105.87 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $330.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000070 EAP CPT® 29581 Apply Multlay Comprs Lwr Leg-rt BOTH IP/OP $478.00 $353.72 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000080 EAP CPT® 97129 Occ Ther Ivntj Cog Funcj Cntct 1st 15 Minutes BOTH IP/OP $379.00 $280.46 $0.00 $461.84 $41.10 $41.10 $24.17 $24.17 $18.64 $78.99 $444.74 $444.74 $461.84 $24.17 $78.98 $15.71 $224.18 $224.18 $0.00 $172.50 $273.24 $276.00 $24.17 $246.35 $24.17 $23.23 $24.17 $24.17 $0.00 $24.17 $0.00 $0.00 $0.00 $0.00 43000081 EAP CPT® 97130 Occ Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes BOTH IP/OP $379.00 $280.46 $0.00 $461.84 $39.28 $39.28 $23.44 $23.44 $17.80 $78.99 $444.74 $444.74 $461.84 $23.44 $78.98 $15.24 $224.18 $224.18 $0.00 $172.50 $273.24 $276.00 $23.44 $197.60 $23.44 $22.20 $23.44 $23.44 $0.00 $23.44 $0.00 $0.00 $0.00 $0.00 43000093 EAP CPT® 29584 Apply Multlay Comprs Arm/hand-rt BOTH IP/OP $508.00 $375.92 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $105.87 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $330.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000100 EAP HCPCS G8978 Mobility Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000101 EAP HCPCS G8979 Mobility Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000102 EAP HCPCS G8980 Mobility D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000103 EAP HCPCS G8981 Body Pos Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000104 EAP HCPCS G8982 Body Pos Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000106 EAP HCPCS G8984 Carry Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000107 EAP HCPCS G8985 Carry Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000108 EAP HCPCS G8986 Carry D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000109 EAP HCPCS G8987 Self-care Current Status BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000110 EAP HCPCS G8988 Self-care Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000111 EAP HCPCS G8989 Self-care D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000112 EAP HCPCS G8990 Other Pt/ot Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000113 EAP HCPCS G8991 Other Pt/ot Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000114 EAP HCPCS G8992 Other Pt/ot D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000115 EAP HCPCS G8993 Sub Pt/ot Current Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000116 EAP HCPCS G8994 Sub Pt/ot Goal Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000117 EAP HCPCS G8995 Sub Pt/ot D/c Status BOTH IP/OP $0.01 $0.01 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000118 EAP CPT® 97014 Ot Electric Stim Ther Unsupervised Wound BOTH IP/OP $291.00 $215.34 $0.00 $461.84 $27.09 $27.09 $0.00 $0.00 $13.56 $60.65 $444.74 $444.74 $461.84 $0.00 $60.64 $0.00 $172.13 $172.13 $0.00 $150.50 $238.39 $240.80 $180.60 $117.65 $180.60 $14.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43000119 EAP CPT® 97014 Ot Electric Stim Ther Unsupervised Non-wound BOTH IP/OP $301.00 $222.74 $0.00 $461.84 $27.09 $27.09 $13.21 $13.21 $14.03 $62.74 $444.74 $444.74 $461.84 $13.17 $62.73 $8.56 $178.04 $178.04 $13.83 $150.50 $238.39 $240.80 $180.60 $19.04 $180.60 $14.50 $0.00 $0.00 $0.00 $13.17 $0.00 $0.00 $0.00 $0.00 43400001 EAP CPT® 92610 Nicu/ped/swallowing Evaluation BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $643.46 $643.46 $74.65 $74.65 $56.49 $246.98 $444.74 $444.74 $461.84 $74.65 $246.95 $48.52 $700.93 $700.93 $77.89 $592.50 $938.52 $948.00 $74.65 $837.20 $74.65 $42.12 $74.65 $74.65 $0.00 $74.65 $0.00 $0.00 $0.00 $0.00 43400060 EAP CPT® 97165 Ot Eval Low Complex BOTH IP/OP $726.00 $537.24 $0.00 $528.00 $157.79 $157.79 $98.49 $98.49 $0.00 $151.32 $444.74 $444.74 $461.84 $87.25 $151.30 $56.71 $429.43 $429.43 $91.61 $330.00 $522.72 $528.00 $126.51 $158.58 $126.51 $75.19 $87.25 $87.25 $0.00 $87.25 $0.00 $0.00 $0.00 $0.00 43400061 EAP CPT® 97166 Ot Eval Mod Complex BOTH IP/OP $743.00 $549.82 $0.00 $540.00 $157.79 $157.79 $98.49 $98.49 $0.00 $154.86 $444.74 $444.74 $461.84 $86.93 $154.84 $56.50 $439.48 $439.48 $91.28 $337.50 $534.60 $540.00 $126.05 $158.58 $126.05 $75.19 $86.93 $86.93 $0.00 $86.93 $0.00 $0.00 $0.00 $0.00 43400062 EAP CPT® 97167 Ot Eval High Complex BOTH IP/OP $759.00 $561.66 $0.00 $552.00 $157.79 $157.79 $98.49 $98.49 $0.00 $158.19 $444.74 $444.74 $461.84 $86.93 $158.18 $56.50 $448.95 $448.95 $91.28 $345.00 $546.48 $552.00 $126.05 $158.58 $126.05 $75.19 $86.93 $86.93 $0.00 $86.93 $0.00 $0.00 $0.00 $0.00 43400063 EAP CPT® 97168 Ot Re-eval BOTH IP/OP $528.00 $390.72 $0.00 $528.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $110.04 $0.00 $0.00 $0.00 $62.92 $240.00 $380.16 $384.00 $86.88 $528.00 $86.88 $49.67 $59.92 $59.92 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 44000001 EAP CPT® 92507 Individual Speech Therapy BOTH IP/OP $629.00 $465.46 $44.25 $461.84 $148.00 $148.00 $77.93 $77.93 $80.21 $131.10 $444.74 $444.74 $461.84 $77.07 $131.08 $50.10 $372.05 $372.05 $80.92 $286.00 $453.02 $457.60 $111.75 $120.54 $111.75 $44.25 $77.07 $77.07 $91.06 $77.07 $0.00 $0.00 $0.00 $0.00 44000004 EAP CPT® 92526 Treatmet Of Swallow & Oral Fun BOTH IP/OP $792.00 $586.08 $55.00 $582.40 $430.06 $430.06 $86.29 $86.29 $87.06 $165.07 $444.74 $444.74 $461.84 $84.61 $165.05 $55.00 $468.47 $468.47 $88.84 $364.00 $576.58 $582.40 $122.68 $133.74 $122.68 $113.93 $84.61 $84.61 $115.90 $84.61 $0.00 $0.00 $0.00 $0.00 44000007 EAP CPT® 92609 Ther Ser/speech-generating Dev BOTH IP/OP $509.00 $376.66 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $106.08 $0.00 $0.00 $0.00 $0.00 $254.50 $403.13 $407.20 $0.00 $375.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44000044 EAP CPT® 92524 Behavioral And Qualitative Analysis Of Voice And Resonae BOTH IP/OP $920.00 $680.80 $56.95 $676.80 $166.61 $166.61 $111.62 $111.62 $91.21 $191.75 $444.74 $444.74 $461.84 $87.62 $191.73 $56.95 $544.18 $544.18 $92.00 $423.00 $670.03 $676.80 $127.05 $172.90 $127.05 $91.88 $87.62 $87.62 $134.68 $87.62 $0.00 $0.00 $0.00 $0.00 44000050 EAP CPT® 97129 Speech Ther Ivntj Cog Funcj Cntct 1st 15 Minutes BOTH IP/OP $379.00 $280.46 $0.00 $461.84 $41.10 $41.10 $24.17 $24.17 $18.64 $78.99 $444.74 $444.74 $461.84 $24.17 $78.98 $15.71 $224.18 $224.18 $0.00 $172.50 $273.24 $276.00 $24.17 $246.35 $24.17 $23.23 $24.17 $24.17 $54.92 $24.17 $0.00 $0.00 $0.00 $0.00 44000051 EAP CPT® 97130 Speech Ther Ivntj Cog Funcj Cntct Ea Addl 15 Minutes BOTH IP/OP $379.00 $280.46 $0.00 $461.84 $39.28 $39.28 $23.44 $23.44 $17.80 $78.99 $444.74 $444.74 $461.84 $23.44 $78.98 $15.24 $224.18 $224.18 $0.00 $172.50 $273.24 $276.00 $23.44 $197.60 $23.44 $22.20 $23.44 $23.44 $54.92 $23.44 $0.00 $0.00 $0.00 $0.00 44300005 EAP CPT® 92508 Group Speech Ther Each 15min BOTH IP/OP $188.00 $139.12 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44400003 EAP CPT® 92597 Evaluation For Voice Prosthesi BOTH IP/OP "$1,176.00 " $870.24 $46.40 $865.60 $638.57 $638.57 $72.36 $72.36 $72.95 $245.11 $444.74 $444.74 $461.84 $71.39 $245.08 $46.40 $695.60 $695.60 $74.96 $541.00 $856.94 $865.60 $103.52 $113.15 $103.52 $169.33 $71.39 $71.39 $172.25 $71.39 $0.00 $0.00 $0.00 $0.00 44400005 EAP CPT® 92607 Eval Speech Device First Hour BOTH IP/OP $553.00 $409.22 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $115.25 $0.00 $0.00 $0.00 $0.00 $276.50 $437.98 $442.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44400007 EAP CPT® 92608 Eval/speech Dvc (add'l 30 Min) BOTH IP/OP $200.00 $148.00 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44400009 EAP CPT® 92610 Eval.of Swallow & Oral Func. BOTH IP/OP "$1,288.00 " $953.12 $42.12 $948.00 $699.38 $699.38 $74.65 $74.65 $56.49 $268.45 $444.74 $444.74 $461.84 $74.65 $268.42 $48.52 $761.85 $761.85 $77.89 $592.50 $938.52 $948.00 $74.65 $837.20 $74.65 $42.12 $74.65 $74.65 $188.65 $74.65 $0.00 $0.00 $0.00 $0.00 44400012 EAP CPT® 92611 Motion Fluo Eval Of Swallowing BOTH IP/OP "$1,288.00 " $953.12 $45.81 $948.00 $699.38 $699.38 $94.46 $94.46 $74.78 $268.45 $444.74 $444.74 $461.84 $94.46 $268.42 $61.40 $761.85 $761.85 $93.79 $592.50 $938.52 $948.00 $94.46 $837.20 $94.46 $45.81 $94.46 $94.46 $188.65 $94.46 $0.00 $0.00 $0.00 $0.00 44400014 EAP CPT® 92612 Flex Fib Endo Eval/swallowing BOTH IP/OP "$2,142.00 " "$1,585.08" $0.00 "$1,576.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $446.39 $0.00 $0.00 $0.00 $0.00 $985.00 "$1,560.24" "$1,576.00" $0.00 "$1,392.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44400017 EAP CPT® 96105 Assessment Of Aphasia BOTH IP/OP $607.00 $449.18 $0.00 $485.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $126.50 $0.00 $0.00 $0.00 $0.00 $303.50 $480.74 $485.60 $0.00 $253.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44400020 EAP CPT® 92540 Basic Vestibular Exam BOTH IP/OP $911.00 $674.14 $0.00 $702.20 $494.67 $494.67 $135.96 $135.96 $136.73 $189.88 $676.14 $676.14 $702.20 $133.75 $189.85 $86.94 $538.86 $538.86 $0.00 $419.00 $663.70 $670.40 $0.00 $513.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44400030 EAP CPT® 92570 Acoustic Immittance Testing BOTH IP/OP $273.00 $202.02 $0.00 $461.84 $148.24 $148.24 $135.96 $135.96 $136.73 $56.90 $444.74 $444.74 $461.84 $133.75 $56.89 $86.94 $161.48 $161.48 $0.00 $138.00 $218.59 $220.80 $0.00 $177.45 $0.00 $23.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44400031 EAP CPT® 92550 Tympanometry And Reflex Thresh BOTH IP/OP $156.00 $115.44 $15.45 $461.84 $84.71 $84.71 $135.96 $135.96 $136.73 $32.51 $444.74 $444.74 $461.84 $133.75 $32.51 $86.94 $92.27 $92.27 $138.76 $79.00 $125.14 $126.40 $158.00 $101.40 $158.00 $15.45 $22.71 $22.71 $25.15 $132.15 $0.00 $0.00 $0.00 $0.00 44400033 EAP CPT® 92618 Ex For Non-speech Dev Rx Add BOTH IP/OP $150.00 $111.00 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44400034 EAP CPT® 92522 "Eval Of Only Speech Snd Prod (motor Speech, Artic, Etc)" BOTH IP/OP $772.00 $571.28 $58.20 $568.00 $172.58 $172.58 $114.03 $114.03 $93.49 $160.90 $444.74 $444.74 $461.84 $89.54 $160.88 $58.20 $456.64 $456.64 $94.02 $355.00 $562.32 $568.00 $129.83 $175.01 $129.83 $88.23 $89.54 $89.54 $113.03 $89.54 $0.00 $0.00 $0.00 $0.00 44400035 EAP CPT® 92521 "Evaluation Of Speech Fluency (eg, Stuttering, Clutterin)" BOTH IP/OP $811.00 $600.14 $0.00 $596.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $169.01 $0.00 $0.00 $0.00 $114.94 $373.00 $590.83 $596.80 $158.73 $596.00 $158.73 $108.68 $109.47 $109.47 $118.76 $109.47 $0.00 $0.00 $0.00 $0.00 44400036 EAP CPT® 92523 "Eval Of Speech, Language & Cognition-communication" BOTH IP/OP "$1,188.00 " $879.12 $122.04 $874.40 $368.39 $368.39 $234.49 $234.49 $190.53 $247.61 $444.74 $444.74 $461.84 $187.76 $247.58 $122.04 $702.70 $702.70 $197.15 $546.50 $865.66 $874.40 $272.25 $358.96 $272.25 $183.27 $187.76 $187.76 $174.01 $187.76 $0.00 $0.00 $0.00 $0.00 44400056 EAP CPT® 92523 "EVAL OF SPEECH, LANGUAGE & COGNITION-COMM" BOTH IP/OP "$1,188.00 " $879.12 $122.04 $874.40 $368.39 $368.39 $234.49 $234.49 $190.53 $247.61 $444.74 $444.74 $461.84 $187.76 $247.58 $122.04 $702.70 $702.70 $197.15 $546.50 $865.66 $874.40 $272.25 $358.96 $272.25 $183.27 $187.76 $187.76 $174.01 $187.76 $0.00 $0.00 $0.00 $0.00 45000003 EAP CPT® 52310 Cystoscopy And Treatament BOTH IP/OP "$5,725.00 " "$4,236.50" $156.86 "$4,626.40" "$2,753.10" "$2,753.10" "$1,743.67" "$1,743.67" "$1,753.49" "$1,193.23" "$1,541.95" "$1,541.95" "$1,601.25" "$1,718.44" "$1,193.09" "$1,116.98" "$2,836.00" "$2,836.00" "$1,776.76" "$2,327.00" "$4,580.14" "$4,626.40" "$2,468.57" "$2,500.00" "$2,468.57" $409.12 $156.86 $156.86 $920.65 "$1,692.15" $0.00 $0.00 $0.00 $0.00 45000005 EAP CPT® 45300 Proctosigmidoscopy Dx BOTH IP/OP "$2,361.00 " "$1,747.14" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.03 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,869.91" "$1,888.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000006 EAP CPT® 24675 Closed Tratment Of Proximal Ulna/w Manipulation BOTH IP/OP "$1,594.00 " "$1,179.56" $0.00 "$1,594.00" "$1,594.00" "$1,594.00" "$1,356.40" "$1,356.40" "$1,364.04" $332.23 "$1,257.08" "$1,257.08" "$1,305.43" "$1,334.46" $332.19 $867.40 "$1,594.00" "$1,594.00" $0.00 "$1,550.00" "$1,227.60" "$1,240.00" $0.00 "$1,594.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000009 EAP CPT® 29126 Applyfore Arm Splint BOTH IP/OP $732.00 $541.68 $0.00 $689.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.55 $0.00 $0.00 $0.00 $0.00 $689.00 $545.69 $551.20 $0.00 $524.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000018 EAP CPT® 11760 Repair Of Nail Bed BOTH IP/OP $752.00 $556.48 $0.00 $759.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.74 $0.00 $0.00 $0.00 $502.38 $156.72 $326.54 $113.00 $113.00 $0.00 $759.00 $601.13 $607.20 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000020 EAP CPT® 12001 Lac Repr Sclp Nck Hnd Ft <2.6c BOTH IP/OP $751.00 $555.74 $46.87 $751.00 $751.00 $751.00 $174.88 $174.88 $175.86 $156.53 $751.00 $751.00 $751.00 $172.08 $156.51 $111.85 $113.00 $113.00 $175.24 $704.00 $557.57 $563.20 $243.48 $751.00 $243.48 $116.22 $46.87 $46.87 $112.08 $166.90 $0.00 $0.00 $0.00 $0.00 45000021 EAP CPT® 27550 "Treat Knee Dislocation,w/o Anesthesia" BOTH IP/OP $902.00 $667.48 $0.00 $902.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.98 $0.00 $0.00 $0.00 $0.00 $857.00 $678.74 $685.60 $0.00 $902.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000022 EAP CPT® 12002 Lac Repr Sclp Nck Hnd Ft 2.6-7 BOTH IP/OP $938.00 $694.12 $62.38 "$1,134.00" $509.33 $509.33 $174.88 $174.88 $175.86 $195.50 $938.00 $938.00 $938.00 $172.08 $195.48 $111.85 $113.00 $113.00 $175.24 $879.00 $696.17 $703.20 $243.48 "$1,134.00" $243.48 $127.88 $62.38 $62.38 $139.94 $166.90 $0.00 $0.00 $0.00 $0.00 45000023 EAP CPT® 12004 Rep Sc/nk/ax/gen/tk 7.6-12.5cm BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,134.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $175.24 $970.00 $768.24 $776.00 $243.48 "$1,134.00" $243.48 $152.49 $77.52 $77.52 $154.42 $166.90 $0.00 $0.00 $0.00 $0.00 45000025 EAP CPT® 12005 Rep Sc/nk/ax/gen/ 12.6-20.0 Cm BOTH IP/OP $970.00 $717.80 $0.00 "$1,134.00" $970.00 $970.00 $336.60 $336.60 $338.49 $202.17 $970.00 $970.00 $970.00 $331.46 $202.15 $215.45 $970.00 $970.00 $0.00 $909.00 $719.93 $727.20 $0.00 "$1,134.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000027 EAP CPT® 12006 Rep Sc/nk/ax/gen/ 20.1-30.0 Cm BOTH IP/OP $465.00 $344.10 $0.00 $465.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $436.00 $345.31 $348.80 $0.00 $465.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000029 EAP CPT® 12007 Rep Sc/nk/ax/gen/tk > 30.0 Cm BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.15 $0.00 $0.00 $0.00 $0.00 $909.00 $719.93 $727.20 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000030 EAP CPT® 12011 Lac Rep.fac/ear/lid/nose<2.5cm BOTH IP/OP $778.00 $575.72 $58.77 $891.00 $422.45 $422.45 $174.88 $174.88 $175.86 $162.15 $778.00 $778.00 $778.00 $172.08 $162.14 $111.85 $113.00 $113.00 $175.24 $729.00 $577.37 $583.20 $243.48 $891.00 $243.48 $123.67 $58.77 $58.77 $116.06 $166.90 $0.00 $0.00 $0.00 $0.00 45000031 EAP CPT® 12013 Lac Repr Fce Ear Eye Lp 2.6-5. BOTH IP/OP $954.00 $705.96 $62.02 $954.00 $518.02 $518.02 $174.88 $174.88 $175.86 $198.84 $954.00 $954.00 $954.00 $172.08 $198.81 $111.85 $113.00 $113.00 $175.24 $894.00 $708.05 $715.20 $243.48 $954.00 $243.48 $140.24 $62.02 $62.02 $142.32 $166.90 $0.00 $0.00 $0.00 $0.00 45000032 EAP CPT® 12014 Lac Repr Fce Ear Eye Lp 5.1-7. BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $215.72 $0.00 $0.00 $0.00 $172.08 $215.69 $111.85 $113.00 $113.00 $175.24 $970.00 $768.24 $776.00 $243.48 "$1,035.00" $243.48 $166.21 $79.33 $79.33 $154.42 $166.90 $0.00 $0.00 $0.00 $0.00 45000034 EAP CPT® 12015 Lac Rep Fce Ear Eye Lp 7.6-12. BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $215.72 $0.00 $0.00 $0.00 $172.08 $215.69 $111.85 $113.00 $113.00 $0.00 $970.00 $768.24 $776.00 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000035 EAP CPT® 27510 "Treatment Of Thigh Fracture,w Manipulation" BOTH IP/OP "$1,589.00 " "$1,175.86" $0.00 "$1,589.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.15 $0.00 $0.00 $0.00 $0.00 "$1,589.00" "$1,258.49" "$1,271.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000036 EAP CPT® 12016 Lac Rep Fce Ear Eye Lp12.6-20. BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $970.00 $768.24 $776.00 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000038 EAP CPT® 12017 Rp Si Fa Ear Nos Lip 20.1-30.0 BOTH IP/OP "$1,686.00 " "$1,247.64" $0.00 "$1,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.36 $0.00 $0.00 $0.00 $0.00 "$1,580.00" "$1,251.36" "$1,264.00" $0.00 "$1,134.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000041 EAP CPT® 12031 Int Rep Sclp Trnk Extrm <2.5cm BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $215.72 $0.00 $0.00 $0.00 $331.46 $215.69 $215.45 $113.00 $113.00 $320.45 $970.00 $768.24 $776.00 $445.22 "$1,035.00" $445.22 $141.63 $157.16 $157.16 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 45000042 EAP CPT® 12032 Int Rep Sclp Trk Ext 2.6-7.5cm BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,257.00" "$1,035.00" "$1,035.00" $336.60 $336.60 $338.49 $215.72 $0.00 $0.00 $0.00 $331.46 $215.69 $215.45 $113.00 $113.00 $320.45 $970.00 $768.24 $776.00 $445.22 "$1,257.00" $445.22 $161.36 $196.82 $196.82 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 45000043 EAP CPT® 12034 Int Rep Sclp Trk Ext7.6-12.5cm BOTH IP/OP $496.00 $367.04 $0.00 $496.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.38 $0.00 $0.00 $0.00 $331.46 $103.37 $215.45 $496.00 $496.00 $0.00 $465.00 $368.28 $372.00 $0.00 $496.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000044 EAP CPT® 12035 Int Rep Sclp Trk Extrm12.6-20. BOTH IP/OP $970.00 $717.80 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.15 $0.00 $0.00 $0.00 $0.00 $909.00 $719.93 $727.20 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000045 EAP CPT® 28455 Treatment Of Tarsal Bone Fracture BOTH IP/OP "$6,532.00 " "$4,833.68" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,361.27" $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$1,188.00" "$1,200.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000046 EAP CPT® 12036 Int Rep S/tr/ext/20.1-30.0cm BOTH IP/OP $894.00 $661.56 $0.00 $894.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.31 $0.00 $0.00 $0.00 $0.00 $838.00 $663.70 $670.40 $0.00 $894.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000047 EAP CPT® 56440 Marsupialization Of Bartholin Cyst BOTH IP/OP "$7,879.00 " "$5,830.46" $0.00 "$6,303.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,641.98" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,240.17" "$6,303.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000048 EAP CPT® 12037 Intmd Wnd Repair S/tr/ext BOTH IP/OP "$1,882.00 " "$1,392.68" $0.00 "$2,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $392.21 $0.00 $0.00 $0.00 $0.00 "$1,907.00" "$1,510.34" "$1,525.60" $0.00 "$2,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000049 EAP CPT® 12041 Int Repr N-hf/genit <2.6cm BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.46 $215.69 $0.00 $113.00 $113.00 $320.45 $970.00 $768.24 $776.00 $445.22 "$1,035.00" $445.22 $157.82 $152.13 $152.13 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 45000051 EAP CPT® 12042 Int Repr Nck Hnd Ft 2.6-7.5 Cm BOTH IP/OP $615.00 $455.10 $0.00 $615.00 $615.00 $615.00 $336.60 $336.60 $338.49 $128.18 $615.00 $615.00 $615.00 $331.46 $128.17 $215.45 $113.00 $113.00 $0.00 $465.00 $368.28 $372.00 $0.00 $615.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000052 EAP CPT® 12044 Int Repr Nck Hnd Ft 7.6-12.5cm BOTH IP/OP "$1,012.00 " $748.88 $0.00 "$1,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.90 $0.00 $0.00 $0.00 $0.00 $948.00 $750.82 $758.40 $0.00 "$1,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000053 EAP CPT® 12045 Int Rep Nck Hnd Ft 12.6-20.0cm BOTH IP/OP "$2,196.00 " "$1,625.04" $0.00 "$2,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.65 $0.00 $0.00 $0.00 $0.00 "$2,058.00" "$1,629.94" "$1,646.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000054 EAP CPT® 12046 Int Rep Nck Hnd Ft 20.1-30.0cm BOTH IP/OP "$1,314.00 " $972.36 $0.00 "$1,332.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.84 $0.00 $0.00 $0.00 $0.00 "$1,332.00" "$1,054.94" "$1,065.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000055 EAP CPT® 12051 Int Repr Fce Ear Eye Lp<2.5cm BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" "$1,035.00" "$1,035.00" $336.60 $336.60 $338.49 $215.72 $0.00 $0.00 $0.00 $331.46 $215.69 $215.45 $113.00 $113.00 $320.45 $970.00 $768.24 $776.00 $445.22 "$1,035.00" $445.22 $0.00 $174.83 $174.83 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 45000056 EAP CPT® 12052 Int Repr F/e/l/mm 2.6-5.0cm BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" "$1,035.00" "$1,035.00" $336.60 $336.60 $338.49 $215.72 $0.00 $0.00 $0.00 $331.46 $215.69 $215.45 $113.00 $113.00 $320.45 $970.00 $768.24 $776.00 $445.22 "$1,035.00" $445.22 $183.25 $206.92 $206.92 $154.42 $305.19 $0.00 $0.00 $0.00 $0.00 45000057 EAP CPT® 12053 Int Wnd Repr Face/mm 5.1-7.5cm BOTH IP/OP "$1,718.00 " "$1,271.32" $0.00 "$1,718.00" "$1,718.00" "$1,718.00" $336.60 $336.60 $338.49 $0.00 $0.00 $0.00 $0.00 $0.00 $358.03 $0.00 $0.00 $0.00 $320.45 "$1,610.00" "$1,275.12" "$1,288.00" $445.22 "$1,134.00" $445.22 $204.98 $223.51 $223.51 $256.31 $305.19 $0.00 $0.00 $0.00 $0.00 45000058 EAP CPT® 12054 Int Rep Fce Ear Lp 7.6-12.5 Cm BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $215.72 $0.00 $0.00 $0.00 $331.46 $215.69 $215.45 "$1,035.00" "$1,035.00" $0.00 $970.00 $768.24 $776.00 $0.00 $957.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000059 EAP CPT® 12055 Rep Int Fce Ear Lp 12.6-20.0cm BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $970.00 $768.24 $776.00 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000060 EAP CPT® 16000 Init Trmnt Burn 1st Degree BOTH IP/OP "$1,690.00 " "$1,250.60" $0.00 "$1,690.00" $917.67 $917.67 $174.88 $174.88 $175.86 $352.24 $0.00 $0.00 $0.00 $172.08 $352.20 $111.85 $113.00 $113.00 $175.24 "$1,607.00" "$1,272.74" "$1,285.60" $243.48 "$1,690.00" $243.48 $0.00 $47.96 $47.96 $255.83 $166.90 $0.00 $0.00 $0.00 $0.00 45000061 EAP CPT® 16020 Part Thick Burn Dress/debrd;sm (tbsa<5%) BOTH IP/OP "$1,607.00 " "$1,189.18" $0.00 "$1,607.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 "$1,607.00" "$1,272.74" "$1,285.60" $243.48 $0.00 $243.48 $54.62 $56.23 $56.23 $255.83 $166.90 $0.00 $0.00 $0.00 $0.00 45000062 EAP CPT® 16030 Part Thick Burn Dress/debrd;lg (tbsa >10%) BOTH IP/OP "$4,348.00 " "$3,217.52" $0.00 "$3,478.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.45 "$2,255.00" "$3,443.62" "$3,478.40" $445.22 $0.00 $445.22 $134.39 $138.43 $138.43 $692.20 $305.19 $0.00 $0.00 $0.00 $0.00 45000063 EAP CPT® 19020 Incision Of Breast Lesion BOTH IP/OP "$7,031.00 " "$5,202.94" $0.00 "$5,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,465.44" $0.00 $0.00 $0.00 "$1,348.50" "$1,465.26" $876.52 "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$5,624.78" "$5,681.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000067 EAP CPT® 24565 Treat Humerus Fracture BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,550.00" "$1,227.60" "$1,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000069 EAP CPT® 25535 Clsd Fracture Ulna W Manip BOTH IP/OP $662.00 $489.88 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.96 $0.00 $0.00 $0.00 $0.00 $625.00 $495.00 $500.00 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000070 EAP CPT® 25600 Treat Fracture Radius/ulna BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.62 $260.50 $128.45 $113.00 $113.00 $0.00 "$1,180.00" $934.56 $944.00 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000071 EAP CPT® 26010 "I&d Finger Abscess, Simple" BOTH IP/OP "$1,407.00 " "$1,041.18" $0.00 "$1,407.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,407.00" "$1,114.34" "$1,125.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000072 EAP CPT® 27760 Clsd Tx Medial Malleolus Fx BOTH IP/OP $680.00 $503.20 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.71 $0.00 $0.00 $0.00 $0.00 $720.00 $570.24 $576.00 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000073 EAP CPT® 27780 Clsd Fracture Fibula W/o Manip BOTH IP/OP "$1,057.00 " $782.18 $0.00 "$1,119.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.28 $0.00 $0.00 $0.00 $0.00 "$1,119.00" $886.25 $895.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000075 EAP CPT® 27786 Clsd Tx Distal Fibular Fx BOTH IP/OP "$1,204.00 " $890.96 $0.00 "$1,153.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.91 $0.00 $0.00 $0.00 $0.00 "$1,153.00" $913.18 $922.40 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000077 EAP CPT® 28400 Clsd Fracture Heel W/o Manip BOTH IP/OP $811.00 $600.14 $0.00 $811.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.01 $0.00 $0.00 $0.00 $0.00 $811.00 $642.31 $648.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000078 EAP CPT® 28430 Treatment Of Ankle Fracture BOTH IP/OP $820.00 $606.80 $0.00 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.89 $0.00 $0.00 $0.00 $0.00 $811.00 $642.31 $648.80 $0.00 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000079 EAP CPT® 28515 Clsd Fracture Toe W Manip BOTH IP/OP $547.00 $404.78 $0.00 $547.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.99 $0.00 $0.00 $0.00 $0.00 $541.00 $428.47 $432.80 $0.00 $547.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000080 EAP CPT® 28540 Treat Foot Dislocation BOTH IP/OP $398.00 $294.52 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.94 $0.00 $0.00 $0.00 $0.00 $398.00 $315.22 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000081 EAP CPT® 28630 Closed Tx Metatarsophal Jt Dis BOTH IP/OP $547.00 $404.78 $0.00 $547.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.99 $0.00 $0.00 $0.00 $0.00 $541.00 $428.47 $432.80 $0.00 $547.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000082 EAP CPT® 29105 App'l Long Arm Splint BOTH IP/OP $859.00 $635.66 $0.00 $859.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.13 $859.00 $680.33 $687.20 $186.36 $0.00 $186.36 $94.27 $43.63 $43.63 $136.75 $127.75 $0.00 $0.00 $0.00 $0.00 45000083 EAP CPT® 29240 Strapping Of Shoulder BOTH IP/OP $727.00 $537.98 $0.00 $813.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.51 $0.00 $0.00 $0.00 $0.00 $813.00 $643.90 $650.40 $0.00 $302.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000084 EAP CPT® 29240 Apply Shoulder Immobilizer BOTH IP/OP $727.00 $537.98 $0.00 $813.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.51 $0.00 $0.00 $0.00 $0.00 $813.00 $643.90 $650.40 $0.00 $302.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000087 EAP CPT® 36600 Arterial Puncture BOTH IP/OP $300.00 $222.00 $0.00 $284.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.35 $284.00 $224.93 $227.20 $151.93 $0.00 $151.93 $24.37 $16.23 $16.23 $45.21 $104.14 $0.00 $0.00 $0.00 $0.00 45000088 EAP CPT® 41250 Repair Tongue Laceration BOTH IP/OP $794.00 $587.56 $0.00 $802.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.47 $0.00 $0.00 $0.00 $0.00 $802.00 $635.18 $641.60 $0.00 $794.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000089 EAP CPT® 41800 Drainage Of Gum Lesion BOTH IP/OP $634.00 $469.16 $69.74 $640.00 $634.00 $634.00 $109.81 $109.81 $110.43 $132.14 $634.00 $634.00 $634.00 $107.30 $132.13 $69.74 $634.00 $634.00 $109.35 $640.00 $506.88 $512.00 $151.93 $634.00 $151.93 $87.50 $157.47 $157.47 $101.89 $104.14 $0.00 $0.00 $0.00 $0.00 45000090 EAP CPT® 42700 I&d Peritonsillar Abscess BOTH IP/OP $436.00 $322.64 $70.05 $440.00 $436.00 $436.00 $206.03 $206.03 $207.19 $90.87 $436.00 $436.00 $436.00 $202.80 $90.86 $131.82 $436.00 $436.00 $204.24 $440.00 $348.48 $352.00 $283.76 $436.00 $283.76 $122.16 $139.13 $139.13 $70.05 $194.51 $0.00 $0.00 $0.00 $0.00 45000093 EAP CPT® 46050 I & D Perianal Abcess BOTH IP/OP "$4,031.00 " "$2,982.94" $0.00 "$3,224.80" "$2,321.55" "$2,321.55" $772.82 $772.82 $777.17 $840.16 "$1,257.08" "$1,257.08" "$1,305.43" $760.65 $840.06 $494.42 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,192.55" "$3,224.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000094 EAP CPT® 56420 I & D Bartholin Abscess BOTH IP/OP $665.00 $492.10 $0.00 "$1,224.00" $665.00 $665.00 $165.90 $165.90 $166.84 $138.60 $0.00 $0.00 $0.00 $163.24 $138.59 $106.10 $665.00 $665.00 $166.54 $672.00 $532.22 $537.60 $231.38 "$1,224.00" $231.38 $106.60 $107.06 $107.06 $106.98 $158.61 $0.00 $0.00 $0.00 $0.00 45000096 EAP CPT® 69000 Drain External Ear Lesion BOTH IP/OP $694.00 $513.56 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.63 $0.00 $0.00 $0.00 $0.00 $700.00 $554.40 $560.00 $0.00 $694.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000112 EAP CPT® 12056 Rep Int Fce Ear Lp 20.1-30.0cm BOTH IP/OP "$1,559.00 " "$1,153.66" $0.00 "$1,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.90 $0.00 $0.00 $0.00 $0.00 "$1,580.00" "$1,251.36" "$1,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000113 EAP CPT® 13120 Cmplx Rpr Sclp Arm Lgs 1.1-2.5 BOTH IP/OP "$1,427.00 " "$1,055.98" $0.00 "$1,427.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.39 $0.00 $0.00 $0.00 $0.00 "$1,337.00" "$1,058.90" "$1,069.60" $0.00 "$1,427.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000114 EAP CPT® 13121 Repr Comp Scalp Arms Lgs 2.5-7 BOTH IP/OP "$1,539.00 " "$1,138.86" $0.00 "$1,539.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.73 $0.00 $0.00 $0.00 $498.48 "$1,442.00" "$1,142.06" "$1,153.60" $692.57 "$1,539.00" $692.57 $0.00 $270.39 $270.39 $229.57 $474.74 $0.00 $0.00 $0.00 $0.00 45000115 EAP CPT® 13122 Cmplx Rpr Sclp Arm Lgs Ea Add BOTH IP/OP "$1,378.00 " "$1,019.72" $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.18 $0.00 $0.00 $0.00 $0.00 "$1,291.00" "$1,022.47" "$1,032.80" $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000116 EAP CPT® 13131 "Repr Complex Mouth Neck Hds,ft" BOTH IP/OP "$1,427.00 " "$1,055.98" $0.00 "$1,427.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.39 $0.00 $0.00 $0.00 $0.00 "$1,337.00" "$1,058.90" "$1,069.60" $0.00 "$1,427.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000117 EAP CPT® 13132 "Repr Comp Mouth,neck,hds,ft2.6" BOTH IP/OP "$1,427.00 " "$1,055.98" $0.00 "$1,427.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.39 $0.00 $0.00 $0.00 $498.48 "$1,337.00" "$1,058.90" "$1,069.60" $692.57 "$1,427.00" $692.57 $0.00 $317.62 $317.62 $212.85 $474.74 $0.00 $0.00 $0.00 $0.00 45000118 EAP CPT® 13133 Repair Wound/lesion Add-on BOTH IP/OP "$1,336.00 " $988.64 $0.00 "$1,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.42 $0.00 $0.00 $0.00 $0.00 "$1,252.00" $991.58 "$1,001.60" $0.00 "$1,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000120 EAP CPT® 13151 Cmplx Rpr Eye Nose Ear 1.1-2.5 BOTH IP/OP "$2,495.00 " "$1,846.30" $0.00 "$2,338.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $519.96 $0.00 $0.00 $0.00 $0.00 "$2,338.00" "$1,851.70" "$1,870.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000121 EAP CPT® 13152 "Repr Comp Eyel, Nose,ears Lips" BOTH IP/OP "$2,703.00 " "$2,000.22" $0.00 "$2,533.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $563.31 $0.00 $0.00 $0.00 $0.00 "$2,533.00" "$2,006.14" "$2,026.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000122 EAP CPT® 13153 Cmplx Rpr Eye Nose Ear Add-on BOTH IP/OP "$1,378.00 " "$1,019.72" $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.18 $0.00 $0.00 $0.00 $0.00 "$1,291.00" "$1,022.47" "$1,032.80" $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000123 EAP CPT® 13160 Second Closr Surg Wound; Comp BOTH IP/OP "$10,207.00 " "$7,553.18" $0.00 "$8,274.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,127.14" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,191.66" "$8,274.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000124 EAP CPT® 16025 Part Thick Burn Dress/debrd;md (tbsa 5%-10%) BOTH IP/OP "$3,252.00 " "$2,406.48" $0.00 "$2,601.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.24 "$2,255.00" "$2,575.58" "$2,601.60" $243.48 $0.00 $243.48 $107.09 $114.64 $114.64 $517.72 $166.90 $0.00 $0.00 $0.00 $0.00 45000125 EAP CPT® 26675 Treat Hand Dislocation BOTH IP/OP "$3,905.00 " "$2,889.70" $0.00 "$3,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $813.80 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,285.22" "$3,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000126 EAP CPT® 19000 Punc Aspiration Cyst Of Breast BOTH IP/OP "$1,141.00 " $844.34 $0.00 "$1,141.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.80 "$1,141.00" $903.67 $912.80 $850.02 $0.00 $850.02 $59.58 $45.43 $45.43 $181.65 $582.67 $0.00 $0.00 $0.00 $0.00 45000128 EAP CPT® 20102 "Explore Wound, Abdomen" BOTH IP/OP "$4,018.00 " "$2,973.32" $0.00 "$3,214.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $837.35 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,182.26" "$3,214.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000129 EAP CPT® 20103 "Explore Wound, Extremity" BOTH IP/OP "$3,502.00 " "$2,591.48" $0.00 "$2,801.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $729.82 $0.00 $0.00 $0.00 $611.80 "$2,255.00" "$2,773.58" "$2,801.60" $850.02 "$2,500.00" $850.02 $323.52 $360.85 $360.85 $557.52 $582.67 $0.00 $0.00 $0.00 $0.00 45000133 EAP CPT® 20612 "Aspiration/inj.,gangion Cyst" BOTH IP/OP "$1,051.00 " $777.74 $0.00 "$1,051.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.54 "$1,051.00" $832.39 $840.80 $364.76 $0.00 $364.76 $54.88 $42.90 $42.90 $167.32 $250.04 $0.00 $0.00 $0.00 $0.00 45000134 EAP CPT® 20822 "Replantation Digit, Complete" BOTH IP/OP "$9,548.00 " "$7,065.52" $0.00 "$7,638.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,989.80" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$7,562.02" "$7,638.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000135 EAP CPT® 21110 Interdental Fixation BOTH IP/OP "$1,478.00 " "$1,093.72" $0.00 "$1,478.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.02 $0.00 $0.00 $0.00 $0.00 "$1,389.00" "$1,100.09" "$1,111.20" $0.00 "$1,478.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000136 EAP CPT® 21310 Nasal Bone Fx Wo Manip BOTH IP/OP $506.00 $374.44 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.45 $0.00 $0.00 $0.00 $0.00 $506.00 $400.75 $404.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000138 EAP CPT® 21315 Treatment Of Nose Fracture BOTH IP/OP "$4,285.00 " "$3,170.90" $0.00 "$3,462.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $892.99 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,427.78" "$3,462.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000140 EAP CPT® 21421 Maxillary Fracture BOTH IP/OP "$9,532.00 " "$7,053.68" $0.00 "$7,702.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,986.47" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$7,625.38" "$7,702.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000141 EAP CPT® 21450 Mandibular Fx Wo Manip BOTH IP/OP $810.00 $599.40 $0.00 $818.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.80 $0.00 $0.00 $0.00 $0.00 $818.00 $647.86 $654.40 $0.00 $810.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000142 EAP CPT® 21480 Reset Dislocated Jaw BOTH IP/OP $254.00 $187.96 $0.00 $257.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $257.00 $203.54 $205.60 $0.00 $257.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000148 EAP CPT® 23500 Clavicular Fx Wo Manip BOTH IP/OP "$1,101.00 " $814.74 $0.00 "$1,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.45 $0.00 $0.00 $0.00 $0.00 "$1,037.00" $821.30 $829.60 $0.00 "$1,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000150 EAP CPT® 23540 Acromioclavicular Disloca BOTH IP/OP $815.00 $603.10 $0.00 $815.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.85 $0.00 $0.00 $0.00 $0.00 $815.00 $645.48 $652.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000154 EAP CPT® 23605 CLSD TXT PROXIMAL HUMERUS W/MANIPU BOTH IP/OP "$6,187.00 " "$4,578.38" $0.00 "$4,813.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.37" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,765.46" "$4,813.60" $0.00 "$3,250.00" $0.00 $410.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000156 EAP CPT® 23615 Treat Humerus Fracture BOTH IP/OP "$36,769.00 " "$27,209.06" $0.00 "$28,604.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,662.66" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$28,318.75" "$28,604.80" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000158 EAP CPT® 23650 Shoulder Disloca W Manip BOTH IP/OP "$1,131.00 " $836.94 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.70 $0.00 $0.00 $0.00 $216.27 "$1,100.00" $871.20 $880.00 $300.48 "$1,378.00" $300.48 $251.06 $301.31 $301.31 $175.12 $205.98 $0.00 $0.00 $0.00 $0.00 45000160 EAP CPT® 23655 Shoulder Disloca W Humeral BOTH IP/OP "$5,598.00 " "$4,142.52" $0.00 "$4,355.20" "$2,321.55" "$2,321.55" "$1,356.40" "$1,356.40" "$1,364.04" $0.00 "$1,257.08" "$1,257.08" "$1,305.43" $0.00 "$1,166.62" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,311.65" "$4,355.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000162 EAP CPT® 23675 Shoulder Disloca W Neck Fx BOTH IP/OP "$1,594.00 " "$1,179.56" $0.00 "$1,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $332.19 $0.00 $0.00 $0.00 $0.00 "$1,550.00" "$1,227.60" "$1,240.00" $0.00 "$1,489.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000163 EAP CPT® 24201 Removal Of Arm Foreign Body BOTH IP/OP "$9,773.00 " "$7,232.02" $0.00 "$7,603.20" "$2,753.10" "$2,753.10" "$2,309.02" "$2,309.02" "$2,322.02" $0.00 "$1,541.95" "$1,541.95" "$1,601.25" $0.00 "$2,036.69" $0.00 $0.00 $0.00 "$2,325.71" "$2,327.00" "$7,527.17" "$7,603.20" "$3,231.26" "$2,500.00" "$3,231.26" $360.96 $376.65 $376.65 "$1,513.04" "$2,214.96" $0.00 $0.00 $0.00 $0.00 45000164 EAP CPT® 24341 Repair Tendon/muscle Upper Arm BOTH IP/OP "$17,367.00 " "$12,851.58" $0.00 "$14,352.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,619.28" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$14,209.27" "$14,352.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000165 EAP CPT® 24500 Clsd Txt Humeral Shaft Fx W/out Manip BOTH IP/OP $712.00 $526.88 $0.00 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.00 $563.90 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000167 EAP CPT® 24500 Apply Humeral Splint BOTH IP/OP $712.00 $526.88 $0.00 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.00 $563.90 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000168 EAP CPT® 24505 Clsd Txt Humeral Shaft W/manipulation BOTH IP/OP "$1,594.00 " "$1,179.56" $0.00 "$1,594.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $332.19 $0.00 $0.00 $0.00 $0.00 "$1,550.00" "$1,227.60" "$1,240.00" $0.00 "$1,594.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000174 EAP CPT® 24577 Treat Humerus Fracture BOTH IP/OP "$2,383.00 " "$1,763.42" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $496.62 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,949.90" "$1,969.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000175 EAP CPT® 24600 Elbow Disloca Wo Anes BOTH IP/OP $879.00 $650.46 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.18 $0.00 $0.00 $0.00 $0.00 $855.00 $677.16 $684.00 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000176 EAP CPT® 24605 Treat Elbow Dislocation BOTH IP/OP "$9,171.00 " "$6,786.54" $0.00 "$7,134.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,911.24" $0.00 $0.00 $0.00 "$1,359.37" "$2,327.00" "$7,063.06" "$7,134.40" "$1,888.67" "$2,500.00" "$1,888.67" $330.49 $491.61 $491.61 "$1,419.75" "$1,294.64" $0.00 $0.00 $0.00 $0.00 45000177 EAP CPT® 24620 Treat Elbow Fracture BOTH IP/OP "$8,190.00 " "$6,060.60" $0.00 "$6,371.20" "$2,753.10" "$2,753.10" "$1,356.40" "$1,356.40" "$1,364.04" $0.00 "$1,541.95" "$1,541.95" "$1,601.25" $0.00 "$1,706.80" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,307.49" "$6,371.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000179 EAP CPT® 24650 Radial Hd/neck Fx Wo Manip BOTH IP/OP "$1,128.00 " $834.72 $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.08 $0.00 $0.00 $0.00 $0.00 "$1,097.00" $868.82 $877.60 $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000181 EAP CPT® 24655 CLSD TXT RADIAL HD/NECK FX W/OUT M BOTH IP/OP "$2,532.00 " "$1,873.68" $0.00 "$2,321.55" "$2,321.55" "$2,321.55" "$1,356.40" "$1,356.40" "$1,364.04" $527.73 "$1,257.08" "$1,257.08" "$1,305.43" "$1,334.46" $527.67 $867.40 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$1,949.90" "$1,969.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000184 EAP CPT® 25500 Radial Shaft Fx Wo Manip BOTH IP/OP "$1,047.00 " $774.78 $0.00 "$1,061.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.19 $0.00 $0.00 $0.00 $0.00 "$1,061.00" $840.31 $848.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000186 EAP CPT® 25505 CLSD TXT RADIAL SHAFT FX W/MANIPUL BOTH IP/OP "$2,452.00 " "$1,814.48" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $511.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,833.48" "$1,852.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000189 EAP CPT® 25520 Treat Fracture Of Radius BOTH IP/OP "$2,483.00 " "$1,837.42" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.46 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,857.24" "$1,876.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000190 EAP CPT® 25530 Ulnar Shaft Fx Wo Manip BOTH IP/OP "$1,274.00 " $942.76 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $265.50 $0.00 $0.00 $0.00 $0.00 "$1,203.00" $952.78 $962.40 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000192 EAP CPT® 25560 Radial/ulner Fx Wo Manip BOTH IP/OP $891.00 $659.34 $0.00 $903.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.68 $0.00 $0.00 $0.00 $0.00 $903.00 $715.18 $722.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000194 EAP CPT® 25565 Treat Fracture Radius & Ulna BOTH IP/OP "$2,483.00 " "$1,837.42" $373.32 "$2,483.00" "$2,483.00" "$2,483.00" "$1,356.40" "$1,356.40" "$1,364.04" $517.52 "$1,541.95" "$1,541.95" "$1,601.25" "$1,334.46" $517.46 $867.40 "$2,483.00" "$2,483.00" "$1,359.37" "$2,327.00" "$1,857.24" "$1,876.00" "$1,888.67" "$1,750.00" "$1,888.67" $473.67 $482.25 $482.25 $373.32 "$1,294.64" $0.00 $0.00 $0.00 $0.00 45000196 EAP CPT® 25605 Treat Fracture Radius/ulna BOTH IP/OP "$2,483.00 " "$1,837.42" $373.32 "$2,483.00" "$2,483.00" "$2,483.00" "$1,356.40" "$1,356.40" "$1,364.04" $517.52 "$1,826.79" "$1,826.79" "$1,897.05" "$1,334.46" $517.46 $867.40 "$2,483.00" "$2,483.00" "$1,359.37" "$2,345.00" "$1,857.24" "$1,876.00" "$1,888.67" "$2,150.00" "$1,888.67" $469.11 $530.90 $530.90 $373.32 "$1,294.64" $0.00 $0.00 $0.00 $0.00 45000200 EAP CPT® 25635 Treat Wrist Bone Fracture BOTH IP/OP "$2,483.00 " "$1,837.42" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.46 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,857.24" "$1,876.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000203 EAP CPT® 25650 Treat Wrist Bone Fracture BOTH IP/OP $992.00 $734.08 $0.00 $992.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.73 $0.00 $0.00 $0.00 $0.00 $937.00 $742.10 $749.60 $0.00 $992.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000205 EAP CPT® 25675 Treat Wrist Dislocation BOTH IP/OP $509.00 $376.66 $0.00 $509.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.08 $0.00 $0.00 $0.00 $0.00 $487.00 $385.70 $389.60 $0.00 $509.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000206 EAP CPT® 25680 Trans-scapoperilunar Fx Disloc BOTH IP/OP "$1,085.00 " $802.90 $0.00 "$1,099.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $226.11 $0.00 $0.00 $0.00 $0.00 "$1,099.00" $870.41 $879.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000207 EAP CPT® 25690 Treat Wrist Dislocation BOTH IP/OP "$8,034.00 " "$5,945.16" $0.00 "$6,068.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,674.29" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,008.11" "$6,068.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000209 EAP CPT® 26410 Repair Hand Tendon BOTH IP/OP "$3,718.00 " "$2,751.32" $0.00 "$2,973.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $774.83 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,943.86" "$2,973.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000210 EAP CPT® 26418 Repair Finger Tendon BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,651.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.35 $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$3,614.69" "$3,651.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000211 EAP CPT® 26600 "Metacarpal Fx, Single,wo Manip" BOTH IP/OP "$1,078.00 " $797.72 $0.00 "$1,078.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 "$1,078.00" $853.78 $862.40 $0.00 "$1,078.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000213 EAP CPT® 26605 Treat Metacarpal Fracture BOTH IP/OP $647.00 $478.78 $0.00 $647.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.83 $0.00 $0.00 $0.00 $0.00 $647.00 $512.42 $517.60 $0.00 $647.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000215 EAP CPT® 26641 Treat Thumb Disolcation BOTH IP/OP "$1,104.00 " $816.96 $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,104.00" $874.37 $883.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000216 EAP CPT® 26645 Treat Thumb Fracture BOTH IP/OP "$1,593.00 " "$1,178.82" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.98 $0.00 $0.00 $0.00 $0.00 "$1,593.00" "$1,261.66" "$1,274.40" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000217 EAP CPT® 26670 Treat Hand Dislocation BOTH IP/OP "$1,099.00 " $813.26 $0.00 "$1,099.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.03 $0.00 $0.00 $0.00 $0.00 "$1,099.00" $870.41 $879.20 $0.00 "$1,099.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000218 EAP CPT® 26700 "Metacarpophlangeal Disloc,sing" BOTH IP/OP $735.00 $543.90 $0.00 $735.00 $399.11 $399.11 $200.72 $200.72 $201.85 $153.19 $0.00 $0.00 $0.00 $197.62 $153.17 $128.45 $113.00 $113.00 $0.00 $735.00 $582.12 $588.00 $0.00 $735.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000219 EAP CPT® 26705 Treat Knuckle Dislocation BOTH IP/OP "$1,593.00 " "$1,178.82" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.98 $0.00 $0.00 $0.00 $0.00 "$1,593.00" "$1,261.66" "$1,274.40" $0.00 "$1,489.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000220 EAP CPT® 26720 "Phalangeal Shaft Fx, Wo Manip" BOTH IP/OP $678.00 $501.72 $0.00 $678.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.30 $0.00 $0.00 $0.00 $0.00 $678.00 $536.98 $542.40 $0.00 $678.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000223 EAP CPT® 26725 Closd Fracture Finger W Manip BOTH IP/OP "$1,116.00 " $825.84 $0.00 "$1,116.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.57 $0.00 $0.00 $0.00 $0.00 "$1,116.00" $883.87 $892.80 $0.00 "$1,116.00" $0.00 $234.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000224 EAP CPT® 26746 "Treat Finger Fracture, Each" BOTH IP/OP "$7,420.00 " "$5,490.80" $0.00 "$5,934.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,546.33" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$5,875.06" "$5,934.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000227 EAP CPT® 26755 "Treat Finger Fracture, Each" BOTH IP/OP $649.00 $480.26 $0.00 $649.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.25 $0.00 $0.00 $0.00 $0.00 $649.00 $514.01 $519.20 $0.00 $649.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000229 EAP CPT® 26756 "Pin Finger Fracture, Each" BOTH IP/OP "$6,983.00 " "$5,167.42" $0.00 "$5,934.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.26" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,875.06" "$5,934.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000230 EAP CPT® 26765 "Treat Finger Fracture, Each" BOTH IP/OP "$7,322.00 " "$5,418.28" $0.00 "$5,856.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,525.90" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$5,797.44" "$5,856.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000231 EAP CPT® 26770 Interphalan Jt Disloca W Manip BOTH IP/OP $650.00 $481.00 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.46 $0.00 $0.00 $0.00 $0.00 $650.00 $514.80 $520.00 $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000233 EAP CPT® 26775 Treat Finger Dislocation BOTH IP/OP "$4,733.00 " "$3,502.42" $0.00 "$4,022.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $986.36 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,982.18" "$4,022.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000235 EAP CPT® 26785 Dislocation Of Finger BOTH IP/OP "$16,294.00 " "$12,057.56" $0.00 "$13,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,395.67" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$12,901.68" "$13,032.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000236 EAP CPT® 26951 Amputation Of Finger/thumb BOTH IP/OP "$7,787.00 " "$5,762.38" $0.00 "$5,690.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,622.81" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,633.50" "$5,690.40" $0.00 "$2,500.00" $0.00 $412.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000238 EAP CPT® 27230 Femoral Fx Neck Wo Manip BOTH IP/OP $612.00 $452.88 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.54 $0.00 $0.00 $0.00 $0.00 $612.00 $484.70 $489.60 $0.00 $505.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000239 EAP CPT® 27232 Treat Thigh Fracture BOTH IP/OP "$3,641.00 " "$2,694.34" $0.00 "$2,912.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.78 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,883.67" "$2,912.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000240 EAP CPT® 27246 Trochanteric Fx Wo Manip BOTH IP/OP $612.00 $452.88 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.54 $0.00 $0.00 $0.00 $0.00 $612.00 $484.70 $489.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000241 EAP CPT® 27250 Hip Disloca Wo Anes BOTH IP/OP $572.00 $423.28 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $578.00 $457.78 $462.40 $0.00 $572.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000244 EAP CPT® 27256 Treat Hip Dislocation BOTH IP/OP $941.00 $696.34 $0.00 $941.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.10 $0.00 $0.00 $0.00 $0.00 $568.00 $449.86 $454.40 $0.00 $941.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000245 EAP CPT® 69020 Er Drain Absc Ext Auditory Can BOTH IP/OP $600.00 $444.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $600.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000246 EAP CPT® 27500 Femoral Shaft Fx Wo Manip BOTH IP/OP "$1,560.00 " "$1,154.40" $0.00 "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.10 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$1,235.52" "$1,248.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000248 EAP CPT® 27508 "Femoral Fx,distal End,wo Manip" BOTH IP/OP "$1,091.00 " $807.34 $0.00 "$1,091.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.36 $0.00 $0.00 $0.00 $0.00 "$1,091.00" $864.07 $872.80 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000250 EAP CPT® 27520 Patellar Fx Wo Manip BOTH IP/OP "$1,494.00 " "$1,105.56" $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.35 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$1,183.25" "$1,195.20" $0.00 $505.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000252 EAP CPT® 27530 Tibial Fx Wo Manip BOTH IP/OP "$1,494.00 " "$1,105.56" $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.35 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$1,183.25" "$1,195.20" $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000254 EAP CPT® 27535 Treat Knee Fracture BOTH IP/OP "$5,367.00 " "$3,971.58" $0.00 "$4,293.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,118.48" $0.00 $0.00 $0.00 $0.00 "$2,683.50" "$4,250.66" "$4,293.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000255 EAP CPT® 27560 Treat Kneecap Dislocation BOTH IP/OP "$1,047.00 " $774.78 $0.00 "$1,047.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.19 $0.00 $0.00 $0.00 $0.00 $995.00 $788.04 $796.00 $0.00 "$1,047.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000259 EAP CPT® 27750 Tibial Shaft Fx Wo Manip BOTH IP/OP "$1,070.00 " $791.80 $0.00 "$1,133.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.99 $0.00 $0.00 $0.00 $0.00 "$1,133.00" $897.34 $906.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000261 EAP CPT® 27752 Treatment Of Tibia Fracture BOTH IP/OP "$7,594.00 " "$5,619.56" $0.00 "$5,820.00" "$2,321.55" "$2,321.55" "$1,356.40" "$1,356.40" "$1,364.04" "$1,582.78" "$1,257.08" "$1,257.08" "$1,305.43" "$1,334.46" "$1,582.59" $867.40 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$5,761.80" "$5,820.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000264 EAP CPT® 27762 Treatment Of Ankle Fracture BOTH IP/OP "$7,594.00 " "$5,619.56" $0.00 "$5,820.00" "$2,321.55" "$2,321.55" "$1,356.40" "$1,356.40" "$1,364.04" $0.00 "$1,257.08" "$1,257.08" "$1,305.43" $0.00 "$1,582.59" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,761.80" "$5,820.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000267 EAP CPT® 27788 Treatment Of Ankle Fracture BOTH IP/OP "$1,028.00 " $760.72 $0.00 $941.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.24 $0.00 $0.00 $0.00 $0.00 $275.00 $217.80 $220.00 $0.00 $941.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000269 EAP CPT® 29125 App'l Short Arm Splint BOTH IP/OP $952.00 $704.48 $0.00 $952.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.35 $952.00 $753.98 $761.60 $151.93 $0.00 $151.93 $72.40 $40.73 $40.73 $151.56 $104.14 $0.00 $0.00 $0.00 $0.00 45000270 EAP CPT® 27808 Clsd Frac Bimall Ankle Wo Mani BOTH IP/OP "$1,135.00 " $839.90 $0.00 "$1,135.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.53 $0.00 $0.00 $0.00 $0.00 "$1,087.00" $860.90 $869.60 $0.00 "$1,135.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000272 EAP CPT® 27810 Closed Tx Bimal Ankle Fx W/man BOTH IP/OP "$2,348.00 " "$1,737.52" $0.00 "$2,249.00" $0.00 $0.00 $0.00 $0.00 $0.00 $489.38 $0.00 $0.00 $0.00 "$1,334.46" $489.32 $867.40 "$1,871.00" "$1,871.00" $0.00 "$2,249.00" "$1,781.21" "$1,799.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000273 EAP CPT® 27816 Clsd Fx Trimall Ankle Wo Mani BOTH IP/OP $902.00 $667.48 $0.00 $955.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.98 $0.00 $0.00 $0.00 $0.00 $955.00 $756.36 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000275 EAP CPT® 27818 Trimalleolar Ankle Fx With Man BOTH IP/OP "$2,348.00 " "$1,737.52" $358.04 "$2,321.55" "$2,321.55" "$2,321.55" "$1,356.40" "$1,356.40" "$1,364.04" $489.38 "$1,257.08" "$1,257.08" "$1,305.43" "$1,334.46" $489.32 $867.40 "$1,871.00" "$1,871.00" "$1,359.37" "$2,249.00" "$1,781.21" "$1,799.20" "$1,888.67" "$2,150.00" "$1,888.67" $492.83 $451.99 $451.99 $358.04 "$1,294.64" $0.00 $0.00 $0.00 $0.00 45000277 EAP CPT® 27825 Treat Lower Leg Fracture BOTH IP/OP "$7,594.00 " "$5,619.56" $0.00 "$5,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,582.59" $0.00 $0.00 $0.00 "$1,359.37" "$2,327.00" "$5,761.80" "$5,820.00" "$1,888.67" "$2,500.00" "$1,888.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000278 EAP CPT® 27840 Ankle Disloca Wo Anes BOTH IP/OP "$2,348.00 " "$1,737.52" $0.00 "$2,249.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.32 $0.00 $0.00 $0.00 $0.00 "$2,249.00" "$1,781.21" "$1,799.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000283 EAP CPT® 28470 Clsd Tx Metatar Fx Wo Manip Ea BOTH IP/OP $981.00 $725.94 $0.00 $981.00 $981.00 $981.00 $200.72 $200.72 $201.85 $0.00 $0.00 $0.00 $0.00 $197.62 $204.44 $128.45 $113.00 $113.00 $216.27 $981.00 $776.95 $784.80 $300.48 $981.00 $300.48 $214.80 $210.83 $210.83 $0.00 $205.98 $0.00 $0.00 $0.00 $0.00 45000285 EAP CPT® 28475 Clsd Tx Metatar Fx W/manip BOTH IP/OP $419.00 $310.06 $0.00 $419.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.32 $0.00 $0.00 $0.00 $0.00 $415.00 $328.68 $332.00 $0.00 $419.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000286 EAP CPT® 28490 "Clsd Tx Fx Grt Toe,phal/phalan" BOTH IP/OP $898.00 $664.52 $0.00 $898.00 $898.00 $898.00 $200.72 $200.72 $201.85 $0.00 $0.00 $0.00 $0.00 $0.00 $187.14 $0.00 $0.00 $0.00 $0.00 $898.00 $711.22 $718.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000289 EAP CPT® 28510 Clsd Fx Toe W/o Manipulation BOTH IP/OP $991.00 $733.34 $0.00 $991.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.52 $0.00 $0.00 $0.00 $0.00 $981.00 $776.95 $784.80 $0.00 $991.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000291 EAP CPT® 28600 Treat Foot Dislocation BOTH IP/OP $832.00 $615.68 $0.00 $832.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.39 $0.00 $0.00 $0.00 $0.00 $832.00 $658.94 $665.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000292 EAP CPT® 28660 Treat Toe Dislocation BOTH IP/OP $232.00 $171.68 $0.00 $232.00 $232.00 $232.00 $200.72 $200.72 $201.85 $48.35 $0.00 $0.00 $0.00 $197.62 $48.35 $128.45 $113.00 $113.00 $0.00 $230.00 $182.16 $184.00 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000296 EAP CPT® 29130 App'l Finger Splint BOTH IP/OP $859.00 $635.66 $0.00 $859.00 $466.44 $466.44 $109.81 $109.81 $110.43 $0.00 $0.00 $0.00 $0.00 $0.00 $179.02 $0.00 $0.00 $0.00 $0.00 $859.00 $680.33 $687.20 $0.00 $859.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000298 EAP CPT® 29200 Apply Clavicle Strap BOTH IP/OP $579.00 $428.46 $0.00 $559.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.66 $0.00 $0.00 $0.00 $0.00 $545.00 $431.64 $436.00 $0.00 $559.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000299 EAP CPT® 29280 Strapping Hand Or Finger BOTH IP/OP $511.00 $378.14 $0.00 $481.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.49 $0.00 $0.00 $0.00 $0.00 $481.00 $380.95 $384.80 $0.00 $477.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000300 EAP CPT® 29345 Apply Long Leg Cast BOTH IP/OP $705.00 $521.70 $0.00 $838.00 $705.00 $705.00 $234.93 $234.93 $236.25 $146.94 $0.00 $0.00 $0.00 $231.14 $146.92 $150.24 $113.00 $113.00 $0.00 $789.00 $624.89 $631.20 $0.00 $838.00 $0.00 $170.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000301 EAP CPT® 29358 Long Leg Application BOTH IP/OP "$1,062.00 " $785.88 $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.32 $0.00 $0.00 $0.00 $0.00 "$1,188.00" $940.90 $950.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000302 EAP CPT® 29515 Apply Short Leg Splint BOTH IP/OP $888.00 $657.12 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.13 $888.00 $703.30 $710.40 $186.36 $0.00 $186.36 $80.51 $51.19 $51.19 $141.37 $127.75 $0.00 $0.00 $0.00 $0.00 45000304 EAP CPT® 29505 App'l Long Leg Splint BOTH IP/OP "$1,535.00 " "$1,135.90" $0.00 "$1,535.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.13 "$1,535.00" "$1,215.72" "$1,228.00" $186.36 $0.00 $186.36 $94.49 $52.27 $52.27 $244.37 $127.75 $0.00 $0.00 $0.00 $0.00 45000310 EAP CPT® 29530 Apply Knee Immobilizer BOTH IP/OP $809.00 $598.66 $0.00 $762.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.60 $0.00 $0.00 $0.00 $0.00 $762.00 $603.50 $609.60 $0.00 $341.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000313 EAP CPT® 29580 Strapping; Unna Boot BOTH IP/OP $780.00 $577.20 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.13 $780.00 $617.76 $624.00 $186.36 $0.00 $186.36 $54.52 $28.49 $28.49 $124.18 $127.75 $0.00 $0.00 $0.00 $0.00 45000315 EAP CPT® 30300 "Remove Fb, Intranasal" BOTH IP/OP $269.00 $199.06 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.06 $0.00 $0.00 $0.00 $0.00 $272.00 $215.42 $217.60 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000317 EAP CPT® 30901 Control Nasal Hemorr Ant Simpl BOTH IP/OP $345.00 $255.30 $0.00 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.90 $0.00 $0.00 $0.00 $0.00 $348.00 $275.62 $278.40 $0.00 $345.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000319 EAP CPT® 30903 Control Nasal Hemorr Ant Compl BOTH IP/OP $354.00 $261.96 $0.00 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.77 $0.00 $0.00 $0.00 $0.00 $358.00 $283.54 $286.40 $0.00 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000320 EAP CPT® 30905 Control Nasal Hemorr Post Init BOTH IP/OP $518.00 $383.32 $0.00 $518.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.95 $0.00 $0.00 $0.00 $0.00 $518.00 $410.26 $414.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000322 EAP CPT® 31233 "Nasal/sinus Endoscopy, Dx" BOTH IP/OP $661.00 $489.14 $0.00 $661.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $661.00 $523.51 $528.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000323 EAP CPT® 31500 Endotracheal Intubation BOTH IP/OP "$2,656.00 " "$1,965.44" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.24 "$2,255.00" "$2,103.55" "$2,124.80" $283.76 $0.00 $283.76 $0.00 $149.30 $149.30 $422.84 $194.51 $0.00 $0.00 $0.00 $0.00 45000326 EAP CPT® 31515 Laryngoscopy For Aspiration BOTH IP/OP "$6,731.00 " "$4,980.94" $0.00 "$5,632.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,402.74" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,575.68" "$5,632.00" $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000327 EAP CPT® 31525 "Dx Laryngoscopy, Except Nb" BOTH IP/OP "$6,130.00 " "$4,536.20" $0.00 "$5,129.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,277.49" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,078.30" "$5,129.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000328 EAP CPT® 31575 "Laryngoscopy, Fiberoptic, Dx" BOTH IP/OP $684.00 $506.16 $0.00 $684.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.01 $684.00 $541.73 $547.20 $218.14 $0.00 $218.14 $103.39 $68.49 $68.49 $108.89 $149.53 $0.00 $0.00 $0.00 $0.00 45000330 EAP CPT® 31605 "Tracheostomy, Cricothyroid" BOTH IP/OP "$1,598.00 " "$1,182.52" $0.00 "$1,598.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.02 $0.00 $0.00 $0.00 $0.00 "$1,598.00" "$1,265.62" "$1,278.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000332 EAP CPT® 31720 Nasotreacheal Suction BOTH IP/OP $250.00 $185.00 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000333 EAP CPT® 32160 Thoracotomy W/cardiac Massage BOTH IP/OP "$5,460.00 " "$4,040.40" $0.00 "$4,133.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,137.86" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,092.26" "$4,133.60" $0.00 "$2,964.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000337 EAP CPT® 35206 Repair Blood Vessel Lesion BOTH IP/OP "$8,232.00 " "$6,091.68" $0.00 "$6,525.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,715.55" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,460.34" "$6,525.60" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000347 EAP CPT® 36589 Removal Venous Access Device BOTH IP/OP "$4,657.00 " "$3,446.18" $0.00 "$3,725.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.36 "$2,255.00" "$3,688.34" "$3,725.60" $878.58 $0.00 $878.58 $171.53 $143.13 $143.13 $741.39 $602.25 $0.00 $0.00 $0.00 $0.00 45000348 EAP CPT® 36593 Declot Vascular Access Device BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,624.00" "$1,299.00" "$1,299.00" $310.51 $310.51 $312.26 $270.74 $0.00 $0.00 $0.00 $297.83 $270.71 $193.59 $113.00 $113.00 $310.51 "$1,624.00" "$1,286.21" "$1,299.20" $431.41 "$1,289.00" $431.41 $30.97 $32.05 $32.05 $258.54 $295.72 $0.00 $0.00 $0.00 $0.00 45000352 EAP CPT® 40800 I & D Of Abscess Of Mouth BOTH IP/OP $705.00 $521.70 $0.00 $705.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.80 $705.00 $558.36 $564.00 $705.00 $0.00 $705.00 $87.87 $128.30 $128.30 $112.24 $582.67 $0.00 $0.00 $0.00 $0.00 45000353 EAP CPT® 40801 Drainage Of Mouth Lesion BOTH IP/OP "$1,582.00 " "$1,170.68" $0.00 "$1,582.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,582.00" "$1,252.94" "$1,265.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000355 EAP CPT® 41008 Submandibular Abscess BOTH IP/OP "$4,969.00 " "$3,677.06" $0.00 "$3,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,935.45" "$3,975.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000356 EAP CPT® 41252 Repair Tongue Laceration 2.6cm BOTH IP/OP "$2,783.00 " "$2,059.42" $0.00 "$2,327.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $579.98 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,226.31" "$2,248.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000357 EAP CPT® 42000 "I&d Abscess Plate, Uvula" BOTH IP/OP $283.00 $209.42 $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $58.98 $0.00 $0.00 $0.00 $202.80 $58.98 $131.82 $283.00 $283.00 $204.24 $286.00 $226.51 $228.80 $283.76 "$1,750.00" $283.76 $95.00 $107.41 $107.41 $45.53 $194.51 $0.00 $0.00 $0.00 $0.00 45000358 EAP CPT® 42809 Remove Fb Pharynx BOTH IP/OP $495.00 $366.30 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.16 $0.00 $0.00 $0.00 $0.00 $500.00 $396.00 $400.00 $0.00 $495.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000359 EAP CPT® 43247 Ugi Endo-rem Of Foreign Body BOTH IP/OP "$4,263.00 " "$3,154.62" $0.00 "$3,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,376.30" "$3,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000360 EAP CPT® 43752 N/g Tube Placement BOTH IP/OP "$2,134.00 " "$1,579.16" $42.55 "$2,134.00" "$2,134.00" "$2,134.00" $264.30 $264.30 $265.79 $444.78 "$1,257.08" "$1,257.08" "$1,305.43" $258.98 $444.73 $168.34 $113.00 $113.00 $364.66 "$2,052.00" "$1,625.18" "$1,641.60" $506.64 "$1,750.00" $506.64 $321.14 $42.55 $42.55 $326.68 $347.29 $0.00 $0.00 $0.00 $0.00 45000361 EAP CPT® 44500 Intro Of Long Gi Tube BOTH IP/OP "$1,291.00 " $955.34 $0.00 "$1,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.04 $0.00 $0.00 $0.00 $0.00 "$1,304.00" "$1,032.77" "$1,043.20" $0.00 "$1,291.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000362 EAP CPT® 45300 Proctosigmoidoscopy BOTH IP/OP "$2,361.00 " "$1,747.14" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.03 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,869.91" "$1,888.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000363 EAP CPT® 45305 Proctosigmoidoscopy W/bx BOTH IP/OP "$5,114.00 " "$3,784.36" $0.00 "$4,091.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,065.76" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,050.29" "$4,091.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000364 EAP CPT® 45385 Lesion Removal Colonoscopy BOTH IP/OP "$2,922.00 " "$2,162.28" $0.00 "$2,836.00" "$2,753.10" "$2,753.10" "$1,009.84" "$1,009.84" "$1,015.53" $0.00 "$1,541.95" "$1,541.95" "$1,601.25" $993.84 $608.94 $646.00 "$2,836.00" "$2,836.00" "$1,007.17" "$2,327.00" "$2,314.22" "$2,337.60" "$1,399.33" "$2,500.00" "$1,399.33" $450.95 $265.02 $265.02 $465.18 $959.21 $0.00 $0.00 $0.00 $0.00 45000366 EAP CPT® 46040 Incision Of Rectal Abscess BOTH IP/OP "$2,951.00 " "$2,183.74" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $614.99 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,360.95" "$2,384.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000367 EAP CPT® 46083 Incise External Hemorrhoid BOTH IP/OP "$1,099.00 " $813.26 $0.00 "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.03 $0.00 $0.00 $0.00 $0.00 "$1,110.00" $879.12 $888.00 $0.00 "$1,099.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000371 EAP CPT® 51701 "Urinary Cath, Straight" BOTH IP/OP $865.00 $640.10 $0.00 $865.00 $865.00 $865.00 $109.81 $109.81 $110.43 $180.29 $0.00 $0.00 $0.00 $107.30 $180.27 $69.74 $113.00 $113.00 $109.35 $864.00 $684.29 $691.20 $151.93 $548.00 $151.93 $57.62 $27.40 $27.40 $137.55 $104.14 $0.00 $0.00 $0.00 $0.00 45000372 EAP CPT® 51701 Insert Straight Cath BOTH IP/OP $865.00 $640.10 $0.00 $865.00 $865.00 $865.00 $109.81 $109.81 $110.43 $180.29 $0.00 $0.00 $0.00 $107.30 $180.27 $69.74 $113.00 $113.00 $109.35 $864.00 $684.29 $691.20 $151.93 $548.00 $151.93 $57.62 $27.40 $27.40 $137.55 $104.14 $0.00 $0.00 $0.00 $0.00 45000374 EAP CPT® 51702 Cath Insert Indwelling BOTH IP/OP "$1,070.00 " $791.80 $0.00 "$1,070.00" "$1,070.00" "$1,070.00" $109.81 $109.81 $110.43 $223.01 $0.00 $0.00 $0.00 $107.30 $222.99 $69.74 $113.00 $113.00 $109.35 "$1,069.00" $846.65 $855.20 $151.93 "$1,070.00" $151.93 $91.18 $26.68 $26.68 $170.18 $104.14 $0.00 $0.00 $0.00 $0.00 45000375 EAP CPT® 51703 "Insert Bladder Cath, Complex" BOTH IP/OP "$1,809.00 " "$1,338.66" $0.00 "$1,809.00" "$1,809.00" "$1,809.00" $135.96 $135.96 $136.73 $0.00 $0.00 $0.00 $0.00 $0.00 $377.00 $0.00 $0.00 $0.00 $138.76 "$1,808.00" "$1,431.94" "$1,446.40" $192.78 $899.00 $192.78 $170.19 $80.41 $80.41 $287.83 $132.15 $0.00 $0.00 $0.00 $0.00 45000376 EAP CPT® 51705 Cystostomy Tube BOTH IP/OP $626.00 $463.24 $0.00 $626.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.46 $0.00 $0.00 $0.00 $235.59 $625.00 $495.00 $500.00 $327.32 $626.00 $327.32 $86.33 $54.08 $54.08 $99.50 $224.37 $0.00 $0.00 $0.00 $0.00 45000377 EAP CPT® 52000 Cystoscopy BOTH IP/OP "$3,069.00 " "$2,271.06" $84.02 "$2,480.00" "$2,321.55" "$2,321.55" $560.26 $560.26 $563.41 $639.66 "$1,257.08" "$1,257.08" "$1,305.43" $550.87 $639.58 $358.07 "$1,871.00" "$1,871.00" $558.17 "$2,255.00" "$2,455.20" "$2,480.00" $775.50 "$2,150.00" $775.50 $152.62 $84.02 $84.02 $493.52 $531.59 $0.00 $0.00 $0.00 $0.00 45000378 EAP CPT® 54220 Treatment Of Penis Lesion BOTH IP/OP "$1,092.00 " $808.08 $139.18 "$1,103.00" "$1,092.00" "$1,092.00" $259.14 $259.14 $260.60 $227.60 "$1,092.00" "$1,092.00" "$1,092.00" $255.07 $227.57 $165.80 "$1,092.00" "$1,092.00" $235.59 "$1,103.00" $873.58 $882.40 $327.32 "$1,009.00" $327.32 $151.42 $139.18 $139.18 $175.60 $224.37 $0.00 $0.00 $0.00 $0.00 45000380 EAP CPT® 54700 I & D Scrotum BOTH IP/OP "$3,277.00 " "$2,424.98" $0.00 "$2,621.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $682.93 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,595.38" "$2,621.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000381 EAP CPT® 55100 Drainage Of Scrotum Abscess BOTH IP/OP "$2,572.00 " "$1,903.28" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $536.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,057.62" "$2,078.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000383 EAP CPT® 56405 I & D Of Vulva/perineum BOTH IP/OP $291.00 $215.34 $0.00 "$1,750.00" $291.00 $291.00 $274.65 $274.65 $276.20 $60.65 $291.00 $291.00 $291.00 $269.78 $60.64 $175.35 $291.00 $291.00 $0.00 $294.00 $232.85 $235.20 $0.00 "$1,750.00" $0.00 $107.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000384 EAP CPT® 57180 Vag. Exam With Packing BOTH IP/OP $382.00 $282.68 $0.00 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.61 $0.00 $0.00 $0.00 $0.00 $382.00 $302.54 $305.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000385 EAP CPT® 57415 Remove Vaginal Fb W/anesthesia BOTH IP/OP "$8,477.00 " "$6,272.98" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,766.61" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,732.00" "$6,800.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000391 EAP CPT® 62273 Injection Epidural Blood Patch BOTH IP/OP "$1,679.00 " "$1,242.46" $0.00 "$1,679.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.90 $0.00 $0.00 $0.00 $626.89 "$1,596.00" "$1,264.03" "$1,276.80" $870.98 "$1,679.00" $870.98 $123.36 $117.56 $117.56 $254.08 $597.04 $0.00 $0.00 $0.00 $0.00 45000394 EAP CPT® 64450 Inject Anest Peripheral Nerve BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $594.01 $0.00 $0.00 $0.00 $608.20 $593.94 $395.33 "$1,871.00" "$1,871.00" $626.89 "$2,255.00" "$2,178.00" "$2,200.00" $870.98 $0.00 $870.98 $85.27 $44.35 $44.35 $437.80 $597.04 $0.00 $0.00 $0.00 $0.00 45000395 EAP CPT® 65205 Remove Fb Eye Conj Superficial BOTH IP/OP $378.00 $279.72 $0.00 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $382.00 $302.54 $305.60 $0.00 $378.00 $0.00 $132.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000398 EAP CPT® 65220 Eye Exam W/o Slit Lamp BOTH IP/OP "$1,563.00 " "$1,156.62" $0.00 "$1,578.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.73 $0.00 $0.00 $0.00 $0.00 "$1,578.00" "$1,249.78" "$1,262.40" $0.00 "$1,029.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000399 EAP CPT® 65222 Eye Exam Slit Lamp BOTH IP/OP $800.00 $592.00 $0.00 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.74 $0.00 $0.00 $0.00 $107.30 $166.72 $69.74 $113.00 $113.00 $0.00 $808.00 $639.94 $646.40 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000400 EAP CPT® 65800 Paracentesis Ant Chamb Eye Wdx BOTH IP/OP "$4,672.00 " "$3,457.28" $0.00 "$3,773.60" "$2,321.55" "$2,321.55" "$2,022.30" "$2,022.30" "$2,033.69" $973.76 "$1,257.08" "$1,257.08" "$1,305.43" "$1,992.71" $973.64 "$1,295.26" "$1,871.00" "$1,871.00" "$2,027.80" "$2,255.00" "$3,735.86" "$3,773.60" "$2,817.36" "$1,750.00" "$2,817.36" $0.00 $93.03 $93.03 $750.95 "$1,931.24" $0.00 $0.00 $0.00 $0.00 45000402 EAP CPT® 66999 Irrigation Eye BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$2,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $412.63 $0.00 $0.00 $0.00 $0.00 "$2,000.00" "$1,584.00" "$1,600.00" $0.00 "$1,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000403 EAP CPT® 67228 Destroy Retinopathy Photocoag BOTH IP/OP "$7,462.00 " "$5,521.88" $311.48 "$5,969.60" "$2,321.55" "$2,321.55" $490.09 $490.09 $492.86 "$1,555.27" "$1,257.08" "$1,257.08" "$1,305.43" $482.91 "$1,555.08" $313.89 "$1,871.00" "$1,871.00" $508.42 "$2,255.00" "$5,909.90" "$5,969.60" $706.38 "$2,150.00" $706.38 $821.55 $311.48 $311.48 "$1,187.95" $484.21 $0.00 $0.00 $0.00 $0.00 45000404 EAP CPT® 67700 Drainage Of Eyelid Abscess BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,339.00" $0.00 $0.00 $0.00 $0.00 $0.00 $278.04 $0.00 $0.00 $0.00 $250.42 $278.01 $162.77 "$1,334.00" "$1,334.00" $0.00 "$1,339.00" "$1,060.49" "$1,071.20" $0.00 "$1,339.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000405 EAP CPT® 67715 Incision Of Eye Lid Fold BOTH IP/OP "$9,511.00 " "$7,038.14" $0.00 "$7,636.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,982.09" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,560.43" "$7,636.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000406 EAP CPT® 67840 Excise Lesion Eyelid Smpl Clos BOTH IP/OP "$2,581.00 " "$1,909.94" $160.78 "$2,581.00" "$2,581.00" "$2,581.00" $788.63 $788.63 $793.07 $537.94 "$1,257.08" "$1,257.08" "$1,305.43" $775.88 $537.88 $504.32 "$1,871.00" "$1,871.00" $809.34 "$2,255.00" "$2,044.15" "$2,064.80" "$1,124.47" "$2,150.00" "$1,124.47" $209.29 $160.78 $160.78 $410.90 $770.80 $0.00 $0.00 $0.00 $0.00 45000407 EAP CPT® 69005 Drain External Ear Lesion BOTH IP/OP "$9,524.00 " "$7,047.76" $0.00 "$7,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,984.80" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,543.01" "$7,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000409 EAP CPT® 69200 Removal Fb Ear BOTH IP/OP $412.00 $304.88 $0.00 $412.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.04 $0.00 $0.00 $0.00 $107.30 $85.03 $69.74 $113.00 $113.00 $109.35 $412.00 $326.30 $329.60 $151.93 $0.00 $151.93 $58.58 $48.67 $48.67 $65.59 $104.14 $0.00 $0.00 $0.00 $0.00 45000412 EAP CPT® 90945 Peritoneal Dialysis BOTH IP/OP "$1,724.00 " "$1,275.76" $0.00 "$1,379.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.28 $0.00 $0.00 $0.00 $0.00 $862.00 "$1,365.41" "$1,379.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000413 EAP CPT® 92511 Nasopharyngoscopy W/endoscope BOTH IP/OP $606.00 $448.44 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.29 $0.00 $0.00 $0.00 $157.01 $612.00 $484.70 $489.60 $218.14 $393.90 $218.14 $64.35 $38.94 $38.94 $97.43 $149.53 $0.00 $0.00 $0.00 $0.00 45000426 EAP CPT® 96373 Inject-intra-arterial Only BOTH IP/OP $266.00 $196.84 $0.00 "$1,062.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.43 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 "$1,062.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000443 EAP CPT® 99281 Minimal Care BOTH IP/OP $564.00 $417.36 $0.00 $564.00 $564.00 $564.00 $70.64 $70.64 $71.04 $67.13 $444.74 $444.74 $461.84 $69.58 $117.54 $45.23 $564.00 $564.00 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $0.00 $19.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000445 EAP CPT® 99281 Acute Visit Level 1 BOTH IP/OP $564.00 $417.36 $0.00 $564.00 $564.00 $564.00 $70.64 $70.64 $71.04 $67.13 $444.74 $444.74 $461.84 $69.58 $117.54 $45.23 $564.00 $564.00 $0.00 $195.00 $308.88 $312.00 $0.00 $564.00 $0.00 $19.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000447 EAP CPT® 99282 Limited Care BOTH IP/OP "$1,060.00 " $784.40 $0.00 "$1,060.00" "$1,060.00" "$1,060.00" $127.92 $127.92 $128.64 $220.93 $592.99 $592.99 $615.79 $126.12 $220.90 $81.98 "$1,049.00" "$1,049.00" $128.34 $420.50 $666.07 $672.80 $178.31 $0.00 $178.31 $30.21 $44.36 $44.36 $133.89 $122.22 $0.00 $0.00 $0.00 $0.00 45000449 EAP CPT® 99282 Acute Visit Level 2 BOTH IP/OP "$1,060.00 " $784.40 $30.21 "$1,060.00" "$1,060.00" "$1,060.00" $127.92 $127.92 $128.64 $220.93 $592.99 $592.99 $615.79 $126.12 $220.90 $81.98 "$1,049.00" "$1,049.00" $128.34 $420.50 $666.07 $672.80 $178.31 $992.00 $178.31 $30.21 $44.36 $44.36 $133.89 $122.22 $0.00 $0.00 $0.00 $0.00 45000451 EAP CPT® 99283 Moderate Care BOTH IP/OP "$1,580.00 " "$1,169.20" $0.00 "$1,580.00" "$1,404.90" "$1,404.90" $225.37 $225.37 $226.64 $329.31 $741.24 $741.24 $769.75 $221.97 $329.27 $144.28 "$1,580.00" "$1,580.00" $224.00 $691.00 "$1,094.54" "$1,105.60" $311.21 $0.00 $311.21 $61.31 $66.37 $66.37 $220.01 $213.33 $0.00 $0.00 $0.00 $0.00 45000453 EAP CPT® 99283 Acute Visit Level 3 BOTH IP/OP "$1,295.00 " $958.30 $61.31 "$1,295.00" "$1,295.00" "$1,295.00" $225.37 $225.37 $226.64 $269.91 $741.24 $741.24 $769.75 $221.97 $269.88 $144.28 "$1,295.00" "$1,295.00" $224.00 $691.00 "$1,094.54" "$1,105.60" $311.21 "$1,274.00" $311.21 $61.31 $66.37 $66.37 $220.01 $213.33 $0.00 $0.00 $0.00 $0.00 45000455 EAP CPT® 99284 Extended Care BOTH IP/OP "$3,050.00 " "$2,257.00" $0.00 "$3,050.00" "$2,566.20" "$2,566.20" $354.25 $354.25 $356.25 $635.70 "$2,890.83" "$2,890.83" "$3,002.01" $348.62 $635.62 $226.60 "$3,050.00" "$3,050.00" $352.82 "$1,080.50" "$1,711.51" "$1,728.80" $490.20 $0.00 $490.20 $94.21 $121.91 $121.91 $344.03 $336.02 $0.00 $0.00 $0.00 $0.00 45000457 EAP CPT® 99284 Acute Visit Level 4 BOTH IP/OP "$3,050.00 " "$2,257.00" $94.21 "$3,050.00" "$2,566.20" "$2,566.20" $354.25 $354.25 $356.25 $635.70 "$2,890.83" "$2,890.83" "$3,002.01" $348.62 $635.62 $226.60 "$3,050.00" "$3,050.00" $352.82 "$1,080.50" "$1,711.51" "$1,728.80" $490.20 "$2,164.00" $490.20 $94.21 $121.91 $121.91 $344.03 $336.02 $0.00 $0.00 $0.00 $0.00 45000459 EAP CPT® 99285 Comprehensive Care BOTH IP/OP "$3,503.00 " "$2,592.22" $0.00 "$3,503.00" "$3,503.00" "$3,503.00" $508.49 $508.49 $511.35 $730.11 "$3,261.45" "$3,261.45" "$3,386.89" $500.41 $730.03 $325.27 "$3,503.00" "$3,503.00" $505.99 "$1,530.00" "$2,423.52" "$2,448.00" $703.01 $0.00 $703.01 $148.14 $177.09 $177.09 $487.15 $481.90 $0.00 $0.00 $0.00 $0.00 45000461 EAP CPT® 99285 Acute Visit Level 5 BOTH IP/OP "$2,866.00 " "$2,120.84" $148.14 "$2,932.00" "$2,866.00" "$2,866.00" $508.49 $508.49 $511.35 $597.35 "$2,866.00" "$2,866.00" "$2,866.00" $500.41 $597.27 $325.27 "$2,866.00" "$2,866.00" $505.99 "$1,530.00" "$2,423.52" "$2,448.00" $703.01 "$2,932.00" $703.01 $148.14 $177.09 $177.09 $487.15 $481.90 $0.00 $0.00 $0.00 $0.00 45000462 EAP CPT® 99291 Critical Care 1st Hr BOTH IP/OP "$4,975.00 " "$3,681.50" $182.90 "$4,975.00" "$4,975.00" "$4,975.00" $725.39 $725.39 $729.47 "$1,036.91" "$3,261.45" "$3,261.45" "$3,386.89" $663.88 "$1,036.79" $431.52 "$4,975.00" "$4,975.00" $668.62 "$2,157.50" "$3,417.48" "$3,452.00" $928.96 "$4,850.95" $928.96 $182.90 $226.49 $226.49 $686.95 $636.78 $0.00 $0.00 $0.00 $0.00 45000464 EAP CPT® 99292 Critical Care Add'l 0.5 Hr BOTH IP/OP "$1,359.00 " "$1,005.66" $0.00 "$2,821.00" "$1,359.00" "$1,359.00" $0.00 $0.00 $0.00 $283.25 "$1,359.00" "$1,359.00" "$1,359.00" $0.00 $283.22 $0.00 "$1,359.00" "$1,359.00" $0.00 $592.50 $938.52 $948.00 $0.00 "$2,821.00" $0.00 $0.00 $113.96 $113.96 $188.65 $0.00 $0.00 $0.00 $0.00 $0.00 45000468 EAP CPT® 99465 Newborn Resuscitation BOTH IP/OP "$1,530.00 " "$1,132.20" $0.00 "$1,224.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $318.85 $0.00 $0.00 $0.00 $0.00 $765.00 "$1,211.76" "$1,224.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000471 EAP Custom 45000471 Strapping BOTH IP/OP $68.00 $50.32 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.17 $0.00 $0.00 $0.00 $0.00 $34.00 $53.86 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000473 EAP CPT® 29131 Application Finger Splint Dynamic BOTH IP/OP $517.00 $382.58 $0.00 $517.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.76 $0.00 $0.00 $0.00 $53.35 $107.74 $34.67 $113.00 $113.00 $0.00 $487.00 $385.70 $389.60 $0.00 $517.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000476 EAP CPT® 40830 Repair Mouth Laceration BOTH IP/OP "$1,099.00 " $813.26 $0.00 "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.03 $0.00 $0.00 $0.00 $0.00 "$1,110.00" $879.12 $888.00 $0.00 "$1,099.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000477 EAP CPT® 26775 Treat Finger Dislocation BOTH IP/OP "$5,029.00 " "$3,721.46" $0.00 "$4,022.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,048.04" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,982.18" "$4,022.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000479 EAP CPT® 28665 Txt Toe Dislocation W/anesth BOTH IP/OP "$4,530.00 " "$3,352.20" $0.00 "$3,585.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.05 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,549.74" "$3,585.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000480 EAP CPT® 27784 Treatment Of Fibula Fracture BOTH IP/OP "$16,355.00 " "$12,102.70" $0.00 "$12,534.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,408.38" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$12,409.06" "$12,534.40" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000481 EAP CPT® 43235 "Upper Gi Endoscopy, Diagnosis" BOTH IP/OP "$4,485.00 " "$3,318.90" $0.00 "$3,289.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.94 $934.67 $504.36 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,256.70" "$3,289.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000491 EAP CPT® 12020 Wound Dehiscence Simple Closur BOTH IP/OP "$2,965.00 " "$2,194.10" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $617.91 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,200.18" "$2,222.40" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000492 EAP CPT® 26011 Abscess Finger Complicated BOTH IP/OP "$4,878.00 " "$3,609.72" $0.00 "$3,901.60" "$2,321.55" "$2,321.55" "$1,370.21" "$1,370.21" "$1,377.93" "$1,016.70" "$1,257.08" "$1,257.08" "$1,305.43" "$1,348.50" "$1,016.58" $876.52 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$3,862.58" "$3,901.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000493 EAP CPT® 29260 "Splint Application, Wrist" BOTH IP/OP "$1,081.00 " $799.94 $0.00 "$1,018.00" $586.98 $586.98 $54.21 $54.21 $54.51 $225.31 $0.00 $0.00 $0.00 $53.35 $225.28 $34.67 $113.00 $113.00 $33.53 "$1,018.00" $806.26 $814.40 $46.58 $389.00 $46.58 $44.15 $20.20 $20.20 $162.07 $31.93 $0.00 $0.00 $0.00 $0.00 45000494 EAP CPT® 53600 Dilate Urethra Strict Male Ini BOTH IP/OP $687.00 $508.38 $0.00 $694.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $235.59 $694.00 $549.65 $555.20 $327.32 $687.00 $327.32 $0.00 $65.99 $65.99 $110.48 $224.37 $0.00 $0.00 $0.00 $0.00 45000495 EAP CPT® 54001 Dorsal Slit Except Newborn BOTH IP/OP "$6,453.00 " "$4,775.22" $0.00 "$5,162.40" "$2,753.10" "$2,753.10" "$1,743.67" "$1,743.67" "$1,753.49" "$1,344.97" "$1,541.95" "$1,541.95" "$1,601.25" "$1,718.44" "$1,344.81" "$1,116.98" "$2,836.00" "$2,836.00" $0.00 "$2,327.00" "$5,110.78" "$5,162.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000496 EAP CPT® 58301 Removal Iud BOTH IP/OP $281.00 $207.94 $0.00 "$1,279.00" $281.00 $281.00 $274.65 $274.65 $276.20 $58.57 $0.00 $0.00 $0.00 $269.78 $58.56 $175.35 $281.00 $281.00 $271.52 $280.00 $221.76 $224.00 $280.00 "$1,279.00" $280.00 $81.66 $70.31 $70.31 $44.58 $258.59 $0.00 $0.00 $0.00 $0.00 45000498 EAP CPT® 27781 Clsd Fracture Fibular BOTH IP/OP "$6,322.00 " "$4,678.28" $0.00 "$5,057.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,007.02" "$5,057.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000499 EAP CPT® 69000 Drain External Ear Lesion BOTH IP/OP $700.00 $518.00 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.88 $0.00 $0.00 $0.00 $0.00 $700.00 $554.40 $560.00 $0.00 $694.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000501 EAP CPT® 28190 Removal Of Foot Foreign Body BOTH IP/OP "$1,318.00 " $975.32 $0.00 "$1,318.00" "$1,318.00" "$1,318.00" $606.01 $606.01 $609.42 $0.00 "$1,257.08" "$1,257.08" "$1,305.43" $0.00 $274.67 $0.00 $0.00 $0.00 $611.80 "$1,304.00" "$1,032.77" "$1,043.20" $850.02 "$1,318.00" $850.02 $173.39 $138.80 $138.80 $207.60 $582.67 $0.00 $0.00 $0.00 $0.00 45000502 EAP CPT® 49451 Replace Duod/jej Tube Perc BOTH IP/OP "$2,862.00 " "$2,117.88" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $596.44 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,179.58" "$2,201.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000505 EAP CPT® 25260 Repair Forearm Tendon/muscle BOTH IP/OP "$6,859.00 " "$5,075.66" $0.00 "$5,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.42" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$5,432.33" "$5,487.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000506 EAP CPT® 42960 Control Throat Bleeding BOTH IP/OP "$5,082.00 " "$3,760.68" $0.00 "$4,065.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,059.09" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,024.94" "$4,065.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000508 EAP CPT® 25270 Repair Forearm Tendon/muscle BOTH IP/OP "$5,401.00 " "$3,996.74" $0.00 "$4,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.57" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$4,862.09" "$4,911.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000512 EAP CPT® 36425 Vein Access Cutdown > 1 Yr BOTH IP/OP $399.00 $295.26 $0.00 $499.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.15 $0.00 $0.00 $0.00 $0.00 $499.00 $395.21 $399.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000520 EAP Custom 45000520 Screened To Clinic BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000525 EAP CPT® 64420 Intercostal Nerve Block BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,959.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.26 $0.00 $0.00 $0.00 $626.89 "$1,890.00" "$1,496.88" "$1,512.00" $870.98 "$1,959.00" $870.98 $95.79 $62.02 $62.02 $300.89 $597.04 $0.00 $0.00 $0.00 $0.00 45000526 EAP CPT® 64421 Intercostal Nerve Block/multi BOTH IP/OP "$3,789.00 " "$2,803.86" $0.00 "$2,924.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $789.63 $0.00 $0.00 $0.00 $814.44 "$2,255.00" "$2,895.55" "$2,924.80" "$1,131.55" "$2,150.00" "$1,131.55" $124.25 $26.33 $26.33 $582.04 $775.65 $0.00 $0.00 $0.00 $0.00 45000529 EAP CPT® 64400 Trigeminal Nerve Block BOTH IP/OP "$1,227.00 " $907.98 $0.00 "$1,227.00" "$1,227.00" "$1,227.00" $254.43 $254.43 $255.86 $255.74 $0.00 $0.00 $0.00 $250.31 $255.71 $162.70 "$1,227.00" "$1,227.00" $0.00 "$1,184.00" $937.73 $947.20 $0.00 "$1,227.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000535 EAP CPT® 36569 Insert Picc Cath BOTH IP/OP "$4,743.00 " "$3,509.82" $98.45 "$4,343.20" "$2,321.55" "$2,321.55" "$1,369.42" "$1,369.42" "$1,377.13" $988.56 "$1,257.08" "$1,257.08" "$1,305.43" "$1,347.67" $988.44 $875.99 "$1,871.00" "$1,871.00" "$1,635.92" "$2,255.00" "$4,299.77" "$4,343.20" "$2,272.90" "$2,500.00" "$2,272.90" $346.84 $98.45 $98.45 $864.30 "$1,558.02" $0.00 $0.00 $0.00 $0.00 45000536 EAP CPT® 54235 Penile Injection BOTH IP/OP $898.00 $664.52 $0.00 "$1,128.00" $487.61 $487.61 $259.14 $259.14 $260.60 $187.17 $0.00 $0.00 $0.00 $255.07 $187.14 $165.80 $113.00 $113.00 $235.59 $907.00 $718.34 $725.60 $327.32 "$1,128.00" $327.32 $70.35 $75.71 $75.71 $144.39 $224.37 $0.00 $0.00 $0.00 $0.00 45000537 EAP CPT® 46320 Rem. Of Hemorrhoid Clot BOTH IP/OP "$6,695.00 " "$4,954.30" $0.00 "$5,356.00" "$2,321.55" "$2,321.55" "$1,009.84" "$1,009.84" "$1,015.53" "$1,395.41" $0.00 $0.00 $0.00 $993.84 "$1,395.24" $646.00 "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$5,302.44" "$5,356.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000538 EAP CPT® 26735 Open Tx Of Phalangeal Shaft Fx BOTH IP/OP "$8,714.00 " "$6,448.36" $0.00 "$6,969.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.00" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$6,899.90" "$6,969.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000541 EAP CPT® 23665 Treat Dislocation /fx BOTH IP/OP "$1,745.00 " "$1,291.30" $0.00 "$1,745.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $363.66 $0.00 $0.00 $0.00 $0.00 "$1,697.00" "$1,344.02" "$1,357.60" $0.00 "$1,745.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000542 EAP CPT® 40654 Repair Lip/complex BOTH IP/OP "$1,515.00 " "$1,121.10" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.73 $0.00 $0.00 $0.00 $0.00 "$1,426.00" "$1,129.39" "$1,140.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000543 EAP CPT® 31530 Laryngoscopy W/fb Rem BOTH IP/OP "$7,908.00 " "$5,851.92" $0.00 "$5,808.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,648.03" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,750.71" "$5,808.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000544 EAP CPT® 28435 Treatment Of Ankle Fx BOTH IP/OP "$1,516.00 " "$1,121.84" $0.00 "$1,516.00" "$1,516.00" "$1,516.00" "$1,356.40" "$1,356.40" "$1,364.04" $0.00 "$1,516.00" "$1,516.00" "$1,516.00" $0.00 $315.93 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$1,188.00" "$1,200.00" $0.00 "$1,516.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000545 EAP CPT® 23625 Treat Humerus Fx BOTH IP/OP "$7,014.00 " "$5,190.36" $0.00 "$5,456.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.72" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,402.23" "$5,456.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000546 EAP CPT® 23545 Treat Clavicle Dislocation BOTH IP/OP "$1,245.00 " $921.30 $0.00 "$1,245.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 "$1,245.00" $986.04 $996.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000550 EAP CPT® 52332 Cysto W Ureter Stent Plcmnt BOTH IP/OP "$10,798.00 " "$7,990.52" $0.00 "$8,725.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,250.30" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,638.34" "$8,725.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000560 EAP CPT® 24535 Treat Humerus Fx BOTH IP/OP "$1,745.00 " "$1,291.30" $0.00 "$1,745.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $363.66 $0.00 $0.00 $0.00 $0.00 "$1,697.00" "$1,344.02" "$1,357.60" $0.00 "$1,745.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000561 EAP CPT® 24640 Treat Elbow Dis/nursemaid BOTH IP/OP $615.00 $455.10 $0.00 $615.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $499.00 $395.21 $399.20 $0.00 $615.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000562 EAP CPT® 28405 Treat Heel Fx BOTH IP/OP "$5,013.00 " "$3,709.62" $0.00 "$3,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,044.71" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,928.32" "$3,968.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000563 EAP CPT® 40831 Repair Mouth Lacerations BOTH IP/OP "$2,115.00 " "$1,565.10" $0.00 "$2,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $440.77 $0.00 $0.00 $0.00 $0.00 "$2,136.00" "$1,691.71" "$1,708.80" $0.00 "$2,115.00" $0.00 $170.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000564 EAP CPT® 23675 Treat Dislocation/fracture BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,550.00" "$1,227.60" "$1,240.00" $0.00 "$1,489.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000565 EAP CPT® 20101 Exploration Of Penetrating Wound (chest) BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000571 EAP CPT® 90792 Psych Diag Eval W/med Srvcs BOTH IP/OP $482.00 $356.68 $0.00 $457.60 $261.73 $261.73 $130.30 $130.30 $131.03 $100.46 $0.00 $0.00 $0.00 $128.07 $0.00 $83.25 $285.10 $285.10 $131.75 $286.00 $453.02 $457.60 $183.04 $374.40 $183.04 $117.89 $142.86 $142.86 $91.06 $125.47 $0.00 $0.00 $0.00 $0.00 45000572 EAP CPT® 90863 Pharma Mgmt Inc Prescpt/med Review W Psytx (add-on) BOTH IP/OP $331.00 $244.94 $0.00 $264.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.98 $0.00 $0.00 $0.00 $0.00 $165.50 $262.15 $264.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000574 EAP CPT® 32555 Aspirate Pleura W/ Imaging BOTH IP/OP "$3,461.00 " "$2,561.14" $0.00 "$2,768.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.36 "$2,255.00" "$2,741.11" "$2,768.80" $878.58 $0.00 $878.58 $626.46 $116.13 $116.13 $550.99 $602.25 $0.00 $0.00 $0.00 $0.00 45000575 EAP CPT® 27781 Treatment Fibula Fracture BOTH IP/OP "$6,599.00 " "$4,883.26" $0.00 "$5,057.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,375.23" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,007.02" "$5,057.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000576 EAP CPT® 45900 Reduction Of Rectal Prolapse BOTH IP/OP "$1,534.00 " "$1,135.16" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.69 $0.00 $0.00 $0.00 $0.00 "$1,534.00" "$1,214.93" "$1,227.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000580 EAP Custom 45000580 I & D Complex Post Op Wound Inf BOTH IP/OP "$6,628.00 " "$4,904.72" $0.00 "$6,522.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,381.28" $0.00 $0.00 $0.00 $0.00 "$4,076.50" "$6,457.18" "$6,522.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000581 EAP CPT® 21451 Treata Lower Jaw Fracture BOTH IP/OP "$5,346.00 " "$3,956.04" $0.00 "$4,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,114.11" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$4,276.80" "$4,320.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000584 EAP Custom 45000584 I & D Floor Mouth Sub Mandibular BOTH IP/OP "$1,227.00 " $907.98 $0.00 "$1,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.71 $0.00 $0.00 $0.00 $0.00 $720.50 "$1,141.27" "$1,152.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000585 EAP CPT® 13102 "Repair,complex,trunk,each Additional 5cm Or Less" BOTH IP/OP "$3,100.00 " "$2,294.00" $0.00 "$2,512.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $646.04 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,487.67" "$2,512.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000589 EAP CPT® 41016 "I&d Mouth Floor Les, Abcess,cyst, Hemat" BOTH IP/OP "$5,296.00 " "$3,919.04" $0.00 "$4,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,103.69" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,439.16" "$4,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000590 EAP CPT® 27265 Treat Hip Dislocation BOTH IP/OP $891.00 $659.34 $0.00 $891.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.68 $0.00 $0.00 $0.00 $0.00 $891.00 $705.67 $712.80 $0.00 $681.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000592 EAP CPT® 41016 "I&d,floor Of Mouth-submental" BOTH IP/OP "$5,549.00 " "$4,106.26" $0.00 "$4,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,156.41" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,439.16" "$4,484.00" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000593 EAP CPT® 21320 Closed Tx Nose Fx W/stabj BOTH IP/OP "$4,437.00 " "$3,283.38" $0.00 "$3,585.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.67 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,549.74" "$3,585.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000594 EAP CPT® 21453 Reduce Mandibular Interdental BOTH IP/OP "$8,688.00 " "$6,429.12" $0.00 "$7,020.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,810.58" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$6,950.59" "$7,020.80" $0.00 "$5,647.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000595 EAP CPT® 11012 Deb Skin Bone At Fx Site BOTH IP/OP "$8,257.00 " "$6,110.18" $0.00 "$6,280.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,720.76" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$6,217.20" "$6,280.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000598 EAP CPT® 25624 Closed Treatment Of Carpal Scaphoid Fracture With Manipulation BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$2,295.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$2,295.00" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000599 EAP CPT® 28825 "Amputation Toe, Interphalangeal Joint" BOTH IP/OP "$5,435.00 " "$4,021.90" $0.00 "$4,302.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,132.65" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,259.38" "$4,302.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000600 EAP CPT® 28495 Closed Fracture Treatment Of Great Toe Or Phalanx BOTH IP/OP $588.00 $435.12 $0.00 $588.00 $588.00 $588.00 $200.72 $200.72 $201.85 $122.55 $0.00 $0.00 $0.00 $197.62 $122.54 $128.45 $113.00 $113.00 $0.00 $582.00 $460.94 $465.60 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000606 EAP CPT® 28505 "Open Tx, Internal Fixation Grt Toe Fx" BOTH IP/OP "$6,418.00 " "$4,749.32" $0.00 "$5,134.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,337.51" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$5,083.06" "$5,134.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000607 EAP CPT® 40652 Repair Lip BOTH IP/OP "$2,180.00 " "$1,613.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.31 $0.00 $0.00 $0.00 $0.00 "$2,051.00" "$1,624.39" "$1,640.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000608 EAP CPT® 26952 Amputation Of Finger/thumb BOTH IP/OP "$6,468.00 " "$4,786.32" $0.00 "$4,726.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,347.93" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$4,679.14" "$4,726.40" $0.00 "$4,204.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000609 EAP CPT® 51102 Drain Bl W/cath Insertion BOTH IP/OP "$5,564.00 " "$4,117.36" $0.00 "$4,451.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,159.54" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,406.69" "$4,451.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000610 EAP CPT® 57200 Repair Of Vagina BOTH IP/OP "$5,461.00 " "$4,041.14" $0.00 "$4,368.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,138.07" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,325.11" "$4,368.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000611 EAP CPT® 27532 Tx Fx Tibial Prox W/ Or W/o Manip W/tract Closed BOTH IP/OP "$5,978.00 " "$4,423.72" $0.00 "$4,782.40" "$2,321.55" "$2,321.55" "$2,757.87" "$2,757.87" "$2,773.41" $0.00 "$1,257.08" "$1,257.08" "$1,305.43" $0.00 "$1,245.82" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,734.58" "$4,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000612 EAP Custom 45000612 Level 3 Partial Trauma Activation W/o Prenotificat BOTH IP/OP "$7,507.00 " "$5,555.18" $0.00 "$5,367.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,564.46" $0.00 $0.00 $0.00 $0.00 "$2,345.00" "$3,714.48" "$3,752.00" $0.00 "$5,367.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000613 EAP CPT® 41007 Drainage Of Mouth Lesion BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,348.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $521.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,325.31" "$2,348.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000620 EAP CPT® 20650 Insert And Remove Bone Pin BOTH IP/OP "$6,356.00 " "$4,703.44" $0.00 "$5,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,324.59" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$5,033.95" "$5,084.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45000634 EAP CPT® 61107 Twist Drill Hole Implt Ventricular Cath/device BOTH IP/OP "$4,189.00 " "$3,099.86" $0.00 "$3,096.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $872.99 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,065.83" "$3,096.80" $0.00 "$2,722.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000001 EAP CPT® 94010 Spiro Lung Vol/pf BOTH IP/OP $685.00 $506.90 $27.37 $528.00 $371.96 $371.96 $135.96 $135.96 $136.73 $142.77 $508.41 $508.41 $528.00 $133.75 $142.75 $86.94 $405.18 $405.18 $138.76 $266.00 $421.34 $425.60 $192.78 $445.25 $192.78 $28.79 $27.37 $27.37 $84.69 $132.15 $0.00 $0.00 $0.00 $0.00 46000006 EAP CPT® 94060 Bronchospasm Eval Pre And Post BOTH IP/OP $784.00 $580.16 $46.82 $709.15 $425.71 $425.71 $257.73 $257.73 $259.18 $163.41 $581.88 $581.88 $604.31 $253.45 $163.39 $164.75 $463.74 $463.74 $253.05 $304.50 $482.33 $487.20 $351.58 $709.15 $351.58 $55.45 $46.82 $46.82 $96.95 $241.00 $0.00 $0.00 $0.00 $0.00 46000007 EAP CPT® 94060 Spirometry Pre & Post BOTH IP/OP $784.00 $580.16 $46.82 $709.15 $425.71 $425.71 $257.73 $257.73 $259.18 $163.41 $581.88 $581.88 $604.31 $253.45 $163.39 $164.75 $463.74 $463.74 $253.05 $304.50 $482.33 $487.20 $351.58 $709.15 $351.58 $55.45 $46.82 $46.82 $96.95 $241.00 $0.00 $0.00 $0.00 $0.00 46000010 EAP CPT® 94070 Bronchoprovocation BOTH IP/OP "$1,441.00 " "$1,066.34" $0.00 "$1,119.20" $782.46 $782.46 $257.73 $257.73 $259.18 $300.34 "$1,069.51" "$1,069.51" "$1,110.72" $253.45 $300.30 $164.75 $852.35 $852.35 $0.00 $699.50 "$1,108.01" "$1,119.20" $0.00 $936.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000012 EAP CPT® 94150 Peak Flow Determination BOTH IP/OP $267.00 $197.58 $0.00 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.17 $198.17 $205.80 $0.00 $55.64 $0.00 $0.00 $0.00 $0.00 $133.50 $211.46 $213.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000015 EAP CPT® 94200 Max Volume Ventilation (mvv) BOTH IP/OP $109.00 $80.66 $0.00 $88.00 $59.19 $59.19 $54.21 $54.21 $54.51 $22.72 $80.90 $80.90 $84.02 $53.35 $22.72 $34.67 $64.47 $64.47 $0.00 $55.00 $87.12 $88.00 $0.00 $70.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000019 EAP CPT® 94250 Expired Gas Analysis BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000027 EAP CPT® 94375 "Maxflw-vol Curves, I+r" BOTH IP/OP $266.00 $196.84 $24.49 $268.00 $144.44 $144.44 $257.73 $257.73 $259.18 $55.44 $197.43 $197.43 $205.03 $253.45 $55.43 $164.75 $157.34 $157.34 $253.05 $134.00 $212.26 $214.40 $268.00 $172.90 $268.00 $35.48 $24.49 $24.49 $42.67 $241.00 $0.00 $0.00 $0.00 $0.00 46000028 EAP CPT® 94400 Breathing Response To Co2 BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000029 EAP CPT® 94400 Co2 Response Curve BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000030 EAP CPT® 94450 Hypoxic Response Curve BOTH IP/OP $219.00 $162.06 $0.00 $175.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.54 $162.54 $168.81 $0.00 $45.64 $0.00 $0.00 $0.00 $0.00 $109.50 $173.45 $175.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000031 EAP CPT® 94618 Six Minute Walk(pulm Stress Simple) BOTH IP/OP $311.00 $230.14 $10.80 $411.45 $168.87 $168.87 $109.81 $109.81 $110.43 $64.82 $230.82 $230.82 $239.72 $107.30 $64.81 $69.74 $183.96 $183.96 $109.35 $157.00 $248.69 $251.20 $151.93 $411.45 $151.93 $33.08 $10.80 $10.80 $49.99 $104.14 $0.00 $0.00 $0.00 $0.00 46000033 EAP CPT® 94680 02 Anal BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $115.62 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000035 EAP CPT® 94681 Et/co2 Oxygen Uptake BOTH IP/OP "$1,529.00 " "$1,131.46" $43.22 "$1,178.55" $830.25 $830.25 $257.73 $257.73 $259.18 $318.68 "$1,134.82" "$1,134.82" "$1,178.55" $253.45 $318.64 $164.75 $904.40 $904.40 $253.05 $695.00 "$1,100.88" "$1,112.00" $351.58 $993.85 $351.58 $66.54 $43.22 $43.22 $221.29 $241.00 $0.00 $0.00 $0.00 $0.00 46000037 EAP CPT® 94681 Met Cart V02 BOTH IP/OP "$1,529.00 " "$1,131.46" $43.22 "$1,178.55" $830.25 $830.25 $257.73 $257.73 $259.18 $318.68 "$1,134.82" "$1,134.82" "$1,178.55" $253.45 $318.64 $164.75 $904.40 $904.40 $253.05 $695.00 "$1,100.88" "$1,112.00" $351.58 $993.85 $351.58 $66.54 $43.22 $43.22 $221.29 $241.00 $0.00 $0.00 $0.00 $0.00 46000039 EAP CPT® 94681 O2 Uptake Incl Co2 Output BOTH IP/OP $279.00 $206.46 $43.22 $993.85 $151.50 $151.50 $257.73 $257.73 $259.18 $58.15 $207.07 $207.07 $215.05 $253.45 $58.14 $164.75 $165.03 $165.03 $253.05 $139.50 $220.97 $223.20 $279.00 $993.85 $279.00 $66.54 $43.22 $43.22 $44.42 $241.00 $0.00 $0.00 $0.00 $0.00 46000042 EAP CPT® 94750 Pulmonary Compliance BOTH IP/OP "$1,179.00 " $872.46 $0.00 $943.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.76 $589.50 $933.77 $943.20 $192.78 $0.00 $192.78 $36.60 $78.16 $78.16 $187.70 $132.15 $0.00 $0.00 $0.00 $0.00 46000044 EAP CPT® 94760 Neo Pulse Oximetry Single BOTH IP/OP $440.00 $325.60 $0.00 $354.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.57 $326.57 $339.15 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $221.50 $350.86 $354.40 $0.00 $286.00 $0.00 $10.16 $2.52 $2.52 $70.53 $0.00 $0.00 $0.00 $0.00 $0.00 46000046 EAP CPT® 94760 Pulse Oximetry BOTH IP/OP $440.00 $325.60 $0.00 $354.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.57 $326.57 $339.15 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $221.50 $350.86 $354.40 $0.00 $286.00 $0.00 $10.16 $2.52 $2.52 $70.53 $0.00 $0.00 $0.00 $0.00 $0.00 46000049 EAP CPT® 94761 Adult Pulse Ox Multiple BOTH IP/OP $576.00 $426.24 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.51 $427.51 $443.98 $0.00 $120.04 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $253.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000050 EAP CPT® 94761 Neo Pulse Ox Multiple BOTH IP/OP $576.00 $426.24 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.51 $427.51 $443.98 $0.00 $120.04 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $253.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000051 EAP CPT® 94761 "Oximetry, Multiple" BOTH IP/OP $576.00 $426.24 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.51 $427.51 $443.98 $0.00 $120.04 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $253.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000055 EAP CPT® 94762 Oximetry Continuous BOTH IP/OP $759.00 $561.66 $25.94 $611.20 $412.14 $412.14 $135.96 $135.96 $136.73 $158.19 $563.33 $563.33 $585.04 $133.75 $158.18 $86.94 $448.95 $448.95 $138.76 $382.00 $605.09 $611.20 $192.78 $410.80 $192.78 $25.94 $26.65 $26.65 $121.63 $132.15 $0.00 $0.00 $0.00 $0.00 46000056 EAP CPT® 94762 Pulse Ox-overnight BOTH IP/OP $674.00 $498.76 $25.94 $543.20 $365.98 $365.98 $135.96 $135.96 $136.73 $140.48 $500.24 $500.24 $519.52 $133.75 $140.46 $86.94 $398.67 $398.67 $138.76 $339.50 $537.77 $543.20 $192.78 $410.80 $192.78 $25.94 $26.65 $26.65 $108.10 $132.15 $0.00 $0.00 $0.00 $0.00 46000059 EAP CPT® 94770 Transcut Co2 Monitor BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000060 EAP CPT® 94799 Breathing Exercise BOTH IP/OP "$1,459.00 " "$1,079.66" $0.00 "$1,124.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,082.87" "$1,082.87" "$1,124.60" $0.00 $304.06 $0.00 $0.00 $0.00 $0.00 $663.50 "$1,050.98" "$1,061.60" $0.00 $865.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000061 EAP CPT® 94799 Mini Bal Lavage BOTH IP/OP "$1,459.00 " "$1,079.66" $0.00 "$1,124.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,082.87" "$1,082.87" "$1,124.60" $0.00 $304.06 $0.00 $0.00 $0.00 $0.00 $663.50 "$1,050.98" "$1,061.60" $0.00 $865.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000066 EAP CPT® 94610 Surfactant Administration BOTH IP/OP $397.00 $293.78 $0.00 $317.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $294.65 $294.65 $306.01 $0.00 $82.73 $0.00 $0.00 $0.00 $0.00 $198.50 $314.42 $317.60 $0.00 $258.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000070 EAP CPT® 94681 Met Cart Vco2 BOTH IP/OP "$1,529.00 " "$1,131.46" $43.22 "$1,178.55" $830.25 $830.25 $257.73 $257.73 $259.18 $318.68 "$1,134.82" "$1,134.82" "$1,178.55" $253.45 $318.64 $164.75 $904.40 $904.40 $253.05 $695.00 "$1,100.88" "$1,112.00" $351.58 $993.85 $351.58 $66.54 $43.22 $43.22 $221.29 $241.00 $0.00 $0.00 $0.00 $0.00 46000071 EAP CPT® 94726 Plethysmo Lung Vol / Air Resist BOTH IP/OP $314.00 $232.36 $40.44 $758.55 $170.50 $170.50 $257.73 $257.73 $259.18 $65.45 $233.05 $233.05 $242.03 $253.45 $65.44 $164.75 $185.73 $185.73 $253.05 $127.00 $201.17 $203.20 $254.00 $758.55 $254.00 $51.52 $41.78 $41.78 $40.44 $241.00 $0.00 $0.00 $0.00 $0.00 46000072 EAP CPT® 94728 Pul Func Oscillometry BOTH IP/OP $254.00 $187.96 $0.00 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.52 $188.52 $195.78 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $127.00 $201.17 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000075 EAP CPT® 94726 Pulm Func Test Plethysmogr BOTH IP/OP "$1,167.00 " $863.58 $40.44 $899.52 $633.68 $633.68 $257.73 $257.73 $259.18 $243.23 $866.15 $866.15 $899.52 $253.45 $243.20 $164.75 $690.28 $690.28 $253.05 $127.00 $201.17 $203.20 $254.00 $758.55 $254.00 $51.52 $41.78 $41.78 $40.44 $241.00 $0.00 $0.00 $0.00 $0.00 46000076 EAP CPT® 94727 Pulm Func Test By Gas BOTH IP/OP $331.00 $244.94 $0.00 $255.13 $179.73 $179.73 $135.96 $135.96 $136.73 $68.99 $245.67 $245.67 $255.13 $133.75 $68.98 $86.94 $195.79 $195.79 $138.76 $127.00 $201.17 $203.20 $192.78 $215.15 $192.78 $0.00 $31.69 $31.69 $40.44 $132.15 $0.00 $0.00 $0.00 $0.00 46000077 EAP CPT® 94728 Pulm Func Test Oscillometry BOTH IP/OP $254.00 $187.96 $0.00 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.52 $188.52 $195.78 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $127.00 $201.17 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000078 EAP CPT® 94729 C02/membrane Diffuse Capac BOTH IP/OP $379.00 $280.46 $0.00 $629.85 $205.80 $205.80 $0.00 $0.00 $0.00 $78.99 $281.29 $281.29 $292.13 $0.00 $78.98 $0.00 $224.18 $224.18 $0.00 $153.50 $243.14 $245.60 $0.00 $629.85 $0.00 $51.25 $47.90 $47.90 $48.87 $0.00 $0.00 $0.00 $0.00 $0.00 46000082 EAP CPT® 32554 Aspirate Pleura W/o Imaging BOTH IP/OP "$2,630.00 " "$1,946.20" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $548.16 "$1,951.99" "$1,951.99" "$2,027.20" $519.10 $548.09 $337.41 "$1,871.00" "$1,871.00" $632.36 "$2,255.00" "$1,971.29" "$1,991.20" $878.58 "$2,150.00" $878.58 $543.38 $93.40 $93.40 $396.25 $602.25 $0.00 $0.00 $0.00 $0.00 46000083 EAP CPT® 32555 Aspirate Pleura W/ Imaging BOTH IP/OP "$3,657.00 " "$2,706.18" $116.13 "$2,818.82" "$2,321.55" "$2,321.55" $526.39 $526.39 $529.35 $762.21 "$2,714.23" "$2,714.23" "$2,818.82" $519.10 $762.12 $337.41 "$1,871.00" "$1,871.00" $632.36 "$2,255.00" "$2,741.11" "$2,768.80" $878.58 "$2,150.00" $878.58 $626.46 $116.13 $116.13 $550.99 $602.25 $0.00 $0.00 $0.00 $0.00 46000084 EAP CPT® 31647 Bronchial Valve Init Insert BOTH IP/OP "$5,261.00 " "$3,893.14" $0.00 "$4,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,904.71" "$3,904.71" "$4,055.18" $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$4,077.22" "$4,118.40" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000085 EAP CPT® 31648 Bronchial Valve Addl Insert BOTH IP/OP "$2,999.00 " "$2,219.26" $0.00 "$2,999.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,225.86" "$2,225.86" "$2,311.63" $0.00 $631.24 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,398.97" "$2,423.20" $0.00 "$2,999.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000086 EAP CPT® 31649 Bronchial Valve Remov Init BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.17" "$1,102.17" "$1,144.64" $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$1,188.00" "$1,200.00" $0.00 "$1,485.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000087 EAP CPT® 31651 Bronchial Valve Remov Addl BOTH IP/OP $947.00 $700.78 $0.00 $757.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $702.86 $702.86 $729.95 $0.00 $197.35 $0.00 $0.00 $0.00 $0.00 $473.50 $750.02 $757.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000088 EAP CPT® 32556 Insert Cath Pleura W/o Image BOTH IP/OP "$2,930.00 " "$2,168.20" $0.00 "$2,828.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,174.65" "$2,174.65" "$2,258.44" $0.00 $610.61 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,800.51" "$2,828.80" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000089 EAP CPT® 32557 Insert Cath Pleura W/ Image BOTH IP/OP "$2,627.00 " "$1,943.98" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,080.58" "$2,101.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000090 EAP CPT® 94452 High Altitude Simulation Testing(hast) BOTH IP/OP $447.00 $330.78 $0.00 $357.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.76 $331.76 $344.55 $0.00 $93.15 $0.00 $0.00 $0.00 $0.00 $223.50 $354.02 $357.60 $0.00 $213.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46000091 EAP CPT® 94453 High Altitude Simulation Testing(hast) O2 Titration BOTH IP/OP $500.00 $370.00 $53.67 $400.00 $271.50 $271.50 $109.81 $109.81 $110.43 $104.21 $371.10 $371.10 $385.40 $107.30 $104.20 $69.74 $295.75 $295.75 $109.35 $250.00 $396.00 $400.00 $151.93 $325.00 $151.93 $74.05 $53.67 $53.67 $79.60 $104.14 $0.00 $0.00 $0.00 $0.00 47000001 EAP CPT® 92551 "Ipv Scr, 2 Ears, Pure Tone,air" BOTH IP/OP $30.00 $22.20 $0.00 $97.50 $16.29 $16.29 $0.00 $0.00 $11.81 $6.25 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $18.00 $97.50 $18.00 $9.01 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 47000006 EAP CPT® 92592 "Hearing Aid Check, Monaural" BOTH IP/OP $146.00 $108.04 $0.00 $117.60 $79.28 $79.28 $0.00 $0.00 $22.24 $30.43 $108.36 $108.36 $112.54 $0.00 $30.43 $0.00 $86.36 $86.36 $0.00 $73.50 $116.42 $117.60 $88.20 $33.80 $88.20 $23.01 $0.00 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 47000007 EAP CPT® 92593 "Hearing Aid Check, Binaural" BOTH IP/OP $288.00 $213.12 $0.00 $232.80 $156.38 $156.38 $0.00 $0.00 $37.15 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $145.50 $230.47 $232.80 $174.60 $187.20 $174.60 $45.54 $0.00 $0.00 $46.33 $0.00 $0.00 $0.00 $0.00 $0.00 47000022 EAP CPT® 95992 Canalith Repositioning Proc BOTH IP/OP $102.00 $75.48 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $78.62 $38.95 $21.26 $25.32 $60.33 $60.33 $40.49 $51.50 $81.58 $82.40 $38.95 $66.30 $38.95 $16.12 $38.95 $38.95 $16.40 $38.95 $0.00 $0.00 $0.00 $0.00 47000023 EAP CPT® 92626 Eval Aud Funcj Cand/po Surg Implt Dev 1st Hr BOTH IP/OP $508.00 $375.92 $0.00 $406.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $377.04 $377.04 $391.57 $0.00 $105.87 $0.00 $0.00 $0.00 $0.00 $254.00 $402.34 $406.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47000024 EAP CPT® 92591 Hearing Aid Examination & Selection Binaural BOTH IP/OP $345.00 $255.30 $0.00 $278.40 $187.34 $187.34 $0.00 $0.00 $72.56 $71.91 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $174.00 $275.62 $278.40 $208.80 $216.45 $208.80 $54.46 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 47000025 EAP Electroacous Eval Hearing Aid Binaural BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.25 $166.25 $172.66 $0.00 $46.68 $0.00 $0.00 $0.00 $0.00 $112.00 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100001 EAP CPT® 92511 "Nasal Pharyngoscopy, Simple" BOTH IP/OP $606.00 $448.44 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.77 $449.77 $467.10 $0.00 $126.29 $0.00 $0.00 $0.00 $157.01 $612.00 $484.70 $489.60 $218.14 $393.90 $218.14 $64.35 $38.94 $38.94 $97.43 $149.53 $0.00 $0.00 $0.00 $0.00 47100002 EAP CPT® 92541 Spontaneous Nystagmus Test BOTH IP/OP $647.00 $478.78 $4.32 $523.20 $351.32 $351.32 $109.81 $109.81 $110.43 $134.85 $480.20 $480.20 $498.71 $107.30 $134.83 $69.74 $382.70 $382.70 $109.35 $327.00 $517.97 $523.20 $151.93 $212.55 $151.93 $36.09 $4.32 $4.32 $104.12 $104.14 $0.00 $0.00 $0.00 $0.00 47100003 EAP CPT® 92542 POSITIONAL NYSTAGMUS TEST BOTH IP/OP $899.00 $665.26 $0.00 $726.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $667.24 $667.24 $692.95 $0.00 $187.35 $0.00 $0.00 $0.00 $0.00 $454.00 $719.14 $726.40 $0.00 $212.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100005 EAP CPT® 92544 Optokinetic Nystagmus Test BOTH IP/OP $654.00 $483.96 $0.00 $523.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $485.40 $485.40 $504.10 $0.00 $136.29 $0.00 $0.00 $0.00 $0.00 $327.00 $517.97 $523.20 $0.00 $302.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100006 EAP CPT® 92545 Oscillating Tracking Test BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $426.77 $426.77 $443.21 $0.00 $119.83 $0.00 $0.00 $0.00 $0.00 $287.50 $455.40 $460.00 $0.00 $302.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100007 EAP CPT® 92551 Hearing Screening BOTH IP/OP $164.00 $121.36 $0.00 $132.00 $89.05 $89.05 $0.00 $0.00 $11.81 $34.18 $121.72 $121.72 $126.41 $0.00 $34.18 $0.00 $97.01 $97.01 $0.00 $82.50 $130.68 $132.00 $99.00 $97.50 $99.00 $9.01 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 47100011 EAP CPT® 92552 Air Conduction (both) BOTH IP/OP $276.00 $204.24 $17.48 $220.80 $149.87 $149.87 $109.81 $109.81 $110.43 $57.53 $204.85 $204.85 $212.74 $107.30 $57.52 $69.74 $163.25 $163.25 $109.35 $138.00 $218.59 $220.80 $151.93 $98.15 $151.93 $17.48 $32.05 $32.05 $43.94 $104.14 $0.00 $0.00 $0.00 $0.00 47100012 EAP CPT® 92552 Air Conduction (one) BOTH IP/OP $276.00 $204.24 $17.48 $220.80 $149.87 $149.87 $109.81 $109.81 $110.43 $57.53 $204.85 $204.85 $212.74 $107.30 $57.52 $69.74 $163.25 $163.25 $109.35 $138.00 $218.59 $220.80 $151.93 $98.15 $151.93 $17.48 $32.05 $32.05 $43.94 $104.14 $0.00 $0.00 $0.00 $0.00 47100013 EAP CPT® 92552 Audiometry BOTH IP/OP $273.00 $202.02 $17.48 $220.80 $148.24 $148.24 $109.81 $109.81 $110.43 $56.90 $202.62 $202.62 $210.43 $107.30 $56.89 $69.74 $161.48 $161.48 $109.35 $138.00 $218.59 $220.80 $151.93 $98.15 $151.93 $17.48 $32.05 $32.05 $43.94 $104.14 $0.00 $0.00 $0.00 $0.00 47100014 EAP CPT® 92552 Audiometry - Air Only BOTH IP/OP $273.00 $202.02 $17.48 $220.80 $148.24 $148.24 $109.81 $109.81 $110.43 $56.90 $202.62 $202.62 $210.43 $107.30 $56.89 $69.74 $161.48 $161.48 $109.35 $138.00 $218.59 $220.80 $151.93 $98.15 $151.93 $17.48 $32.05 $32.05 $43.94 $104.14 $0.00 $0.00 $0.00 $0.00 47100015 EAP CPT® 92552 Audiometry-air Conduction BOTH IP/OP $276.00 $204.24 $17.48 $220.80 $149.87 $149.87 $109.81 $109.81 $110.43 $57.53 $204.85 $204.85 $212.74 $107.30 $57.52 $69.74 $163.25 $163.25 $109.35 $138.00 $218.59 $220.80 $151.93 $98.15 $151.93 $17.48 $32.05 $32.05 $43.94 $104.14 $0.00 $0.00 $0.00 $0.00 47100017 EAP CPT® 92553 Air & Bone Conduction (both) BOTH IP/OP $622.00 $460.28 $0.00 $497.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.37 $0.00 $0.00 $0.00 $138.76 $311.00 $492.62 $497.60 $192.78 $0.00 $192.78 $25.68 $38.90 $38.90 $99.02 $132.15 $0.00 $0.00 $0.00 $0.00 47100018 EAP CPT® 92592 Air And Bone Conduction (one) BOTH IP/OP $295.00 $218.30 $0.00 $238.40 $160.19 $160.19 $0.00 $0.00 $22.24 $61.49 $218.95 $218.95 $227.39 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $149.00 $236.02 $238.40 $178.80 $33.80 $178.80 $46.64 $0.00 $0.00 $47.44 $0.00 $0.00 $0.00 $0.00 $0.00 47100019 EAP CPT® 92553 Audiometry - Air And Bone BOTH IP/OP $616.00 $455.84 $0.00 $497.60 $334.49 $334.49 $135.96 $135.96 $136.73 $0.00 $457.20 $457.20 $474.81 $0.00 $128.37 $0.00 $0.00 $0.00 $138.76 $311.00 $492.62 $497.60 $192.78 $284.70 $192.78 $25.68 $38.90 $38.90 $99.02 $132.15 $0.00 $0.00 $0.00 $0.00 47100020 EAP CPT® 92555 Speech Audiometry Threshold BOTH IP/OP $218.00 $161.32 $14.98 $176.00 $118.37 $118.37 $32.96 $32.96 $33.15 $45.44 $161.80 $161.80 $168.03 $32.43 $45.43 $21.08 $128.95 $128.95 $33.53 $110.00 $174.24 $176.00 $46.58 $126.10 $46.58 $14.98 $24.13 $24.13 $35.02 $31.93 $0.00 $0.00 $0.00 $0.00 47100023 EAP CPT® 92556 "Speech Audiometry, Complete" BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $123.33 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100026 EAP CPT® 92557 Audiometric Battery BOTH IP/OP $736.00 $544.64 $33.54 $594.40 $399.65 $399.65 $135.96 $135.96 $136.73 $153.40 $546.26 $546.26 $567.31 $133.75 $153.38 $86.94 $435.34 $435.34 $138.76 $371.50 $588.46 $594.40 $192.78 $478.40 $192.78 $47.03 $33.54 $33.54 $118.29 $132.15 $0.00 $0.00 $0.00 $0.00 47100028 EAP CPT® 92557 Compre Audiometric Battery BOTH IP/OP $743.00 $549.82 $0.00 $594.40 $0.00 $0.00 $0.00 $0.00 $0.00 $153.40 $0.00 $0.00 $0.00 $133.75 $153.38 $86.94 $435.34 $435.34 $138.76 $371.50 $588.46 $594.40 $192.78 $0.00 $192.78 $47.03 $33.54 $33.54 $118.29 $132.15 $0.00 $0.00 $0.00 $0.00 47100029 EAP CPT® 92562 Loudness Balance Test BOTH IP/OP $227.00 $167.98 $0.00 $181.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.48 $168.48 $174.97 $0.00 $47.31 $0.00 $0.00 $0.00 $0.00 $113.50 $179.78 $181.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100032 EAP CPT® 92565 "Stenger Test, Pure Tone" BOTH IP/OP $278.00 $205.72 $0.00 $224.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.33 $206.33 $214.28 $0.00 $57.94 $0.00 $0.00 $0.00 $0.00 $140.50 $222.55 $224.80 $0.00 $180.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100033 EAP CPT® 92567 Tympanometry BOTH IP/OP $158.00 $116.92 $11.18 $168.35 $85.79 $85.79 $32.96 $32.96 $33.15 $32.93 $117.27 $117.27 $121.79 $32.43 $32.93 $21.08 $93.46 $93.46 $33.53 $80.00 $126.72 $128.00 $46.58 $168.35 $46.58 $20.66 $11.18 $11.18 $25.47 $31.93 $0.00 $0.00 $0.00 $0.00 47100034 EAP CPT® 92567 "Tympanometry, Binaural" BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $32.43 $32.93 $21.08 $93.46 $93.46 $33.53 $80.00 $126.72 $128.00 $46.58 $0.00 $46.58 $20.66 $11.18 $11.18 $25.47 $31.93 $0.00 $0.00 $0.00 $0.00 47100036 EAP CPT® 92568 Acoustic Reflex Testing BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.85 $204.85 $212.74 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $138.00 $218.59 $220.80 $0.00 $163.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100038 EAP CPT® 92568 Acoustic Reflex Testing (bt) BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.85 $204.85 $212.74 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $138.00 $218.59 $220.80 $0.00 $163.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100040 EAP CPT® 92568 Acoustic Reflex(one) BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.85 $204.85 $212.74 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $138.00 $218.59 $220.80 $0.00 $163.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100044 EAP CPT® 92570 "Acoustic Reflex Testing, Both" BOTH IP/OP $273.00 $202.02 $0.00 $220.80 $148.24 $148.24 $135.96 $135.96 $136.73 $56.90 $202.62 $202.62 $210.43 $133.75 $56.89 $86.94 $161.48 $161.48 $0.00 $138.00 $218.59 $220.80 $0.00 $177.45 $0.00 $23.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100045 EAP CPT® 92570 "Acoustic Reflex Testing, One" BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $149.87 $149.87 $135.96 $135.96 $136.73 $57.53 $204.85 $204.85 $212.74 $133.75 $57.52 $86.94 $163.25 $163.25 $0.00 $138.00 $218.59 $220.80 $0.00 $177.45 $0.00 $23.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100049 EAP CPT® 92577 "Stenger Test, Speech" BOTH IP/OP $495.00 $366.30 $14.05 $500.00 $268.79 $268.79 $475.36 $475.36 $478.04 $103.17 $367.39 $367.39 $381.55 $467.50 $103.16 $303.87 $292.79 $292.79 $487.04 $250.00 $396.00 $400.00 $500.00 $321.75 $500.00 $28.15 $14.05 $14.05 $79.60 $463.84 $0.00 $0.00 $0.00 $0.00 47100052 EAP CPT® 92579 Visual Reinforcement Audiometr BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.18 $244.18 $253.59 $0.00 $68.56 $0.00 $0.00 $0.00 $0.00 $164.50 $260.57 $263.20 $0.00 $204.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100053 EAP CPT® 92582 Conditioning Play Audiometry BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $0.00 $0.00 $0.00 $207.00 $327.89 $331.20 $0.00 $195.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100057 EAP CPT® 92585 Auditory Brainstern Response BOTH IP/OP $727.00 $537.98 $0.00 $581.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $363.50 $575.78 $581.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100059 EAP CPT® 92585 "Auditory Evok Potent, Compre" BOTH IP/OP $727.00 $537.98 $0.00 $581.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $363.50 $575.78 $581.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100061 EAP CPT® 92587 Evoke Otoacoustic Emission Ltd BOTH IP/OP $431.00 $318.94 $0.00 $410.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.89 $319.89 $332.21 $0.00 $89.82 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $410.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100064 EAP CPT® 92588 Evoke Otoacoustic Dx/compre BOTH IP/OP $442.00 $327.08 $0.00 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.05 $328.05 $340.69 $0.00 $92.11 $0.00 $0.00 $0.00 $0.00 $222.50 $352.44 $356.00 $0.00 $287.30 $0.00 $40.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100066 EAP CPT® 92567 "Tympanometry, Monoaural" BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.35 $0.00 $0.00 $0.00 $32.43 $33.34 $21.08 $94.64 $94.64 $33.53 $80.00 $126.72 $128.00 $46.58 $0.00 $46.58 $20.66 $11.18 $11.18 $25.47 $31.93 $0.00 $0.00 $0.00 $0.00 47100067 EAP CPT® 92590 Hearing Aid Eval 75 Min BOTH IP/OP $288.00 $213.12 $0.00 $232.80 $156.38 $156.38 $0.00 $0.00 $56.60 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $145.50 $230.47 $232.80 $174.60 $46.80 $174.60 $45.54 $0.00 $0.00 $46.33 $0.00 $0.00 $0.00 $0.00 $0.00 47100072 EAP CPT® 92594 Electroacoustic Eval Monaural BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $85.79 $85.79 $0.00 $0.00 $21.19 $0.00 $117.27 $117.27 $121.79 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $33.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100073 EAP CPT® 92596 Ear Protector Attenuation Meas BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.84 $181.84 $188.85 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100086 EAP CPT® 92551 "Hearing Test, Diagnostic" BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $89.60 $89.60 $0.00 $0.00 $11.81 $34.39 $122.46 $122.46 $127.18 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $99.00 $97.50 $99.00 $9.01 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 47100088 EAP CPT® 95885 Ncs/emg <=4 Limb BOTH IP/OP $240.00 $177.60 $0.00 $366.60 $130.32 $130.32 $0.00 $0.00 $0.00 $50.02 $178.13 $178.13 $184.99 $0.00 $50.02 $0.00 $141.96 $141.96 $0.00 $118.00 $186.91 $188.80 $0.00 $366.60 $0.00 $53.47 $44.66 $44.66 $37.57 $0.00 $0.00 $0.00 $0.00 $0.00 47100089 EAP CPT® 95886 Ncs/emg 5+limb BOTH IP/OP $240.00 $177.60 $0.00 $464.10 $130.32 $130.32 $0.00 $0.00 $0.00 $50.02 $178.13 $178.13 $184.99 $0.00 $50.02 $0.00 $141.96 $141.96 $0.00 $118.00 $186.91 $188.80 $0.00 $464.10 $0.00 $83.61 $51.87 $51.87 $37.57 $0.00 $0.00 $0.00 $0.00 $0.00 47100098 EAP CPT® 95887 Muscl Test W/n Test Non-extr BOTH IP/OP $127.00 $93.98 $0.00 $100.00 $68.96 $68.96 $0.00 $0.00 $0.00 $26.47 $94.26 $94.26 $97.89 $0.00 $26.47 $0.00 $75.12 $75.12 $0.00 $62.50 $99.00 $100.00 $0.00 $82.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100099 EAP CPT® 95938 Somatosensory Testing BOTH IP/OP $556.00 $411.44 $0.00 "$4,513.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $412.66 $412.66 $428.56 $0.00 $115.87 $0.00 $0.00 $0.00 $0.00 $287.50 $455.40 $460.00 $0.00 "$4,513.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100110 EAP CPT® 92547 Vertical Electrodes BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $84.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100132 EAP CPT® 92537 "Caloric Vstblar Test W/rec,bilat" BOTH IP/OP "$1,168.00 " $864.32 $10.08 $944.00 $634.22 $634.22 $135.96 $135.96 $136.73 $243.44 $866.89 $866.89 $900.29 $133.75 $243.41 $86.94 $690.87 $690.87 $138.76 $590.00 $934.56 $944.00 $192.78 $555.75 $192.78 $38.69 $10.08 $10.08 $187.86 $132.15 $0.00 $0.00 $0.00 $0.00 47100133 EAP CPT® 92538 "Caloric Vstblar Test W/rec,bilat;monothermal" BOTH IP/OP "$1,168.00 " $864.32 $6.48 $944.00 $634.22 $634.22 $135.96 $135.96 $136.73 $243.44 $866.89 $866.89 $900.29 $133.75 $243.41 $86.94 $690.87 $690.87 $138.76 $590.00 $934.56 $944.00 $192.78 $561.60 $192.78 $19.67 $6.48 $6.48 $187.86 $132.15 $0.00 $0.00 $0.00 $0.00 47100134 EAP CPT® 92567 "Tympanometry, Monaural" BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.35 $0.00 $0.00 $0.00 $32.43 $33.34 $21.08 $94.64 $94.64 $33.53 $80.00 $126.72 $128.00 $46.58 $0.00 $46.58 $20.66 $11.18 $11.18 $25.47 $31.93 $0.00 $0.00 $0.00 $0.00 47100135 EAP CPT® 92602 Reprogram Cochlear Implt <7 BOTH IP/OP $676.00 $500.24 $0.00 $540.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $501.73 $501.73 $521.06 $0.00 $140.88 $0.00 $0.00 $0.00 $0.00 $338.00 $535.39 $540.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100137 EAP Gll Fitting Visit BOTH IP/OP $215.00 $159.10 $0.00 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.57 $159.57 $165.72 $0.00 $44.81 $0.00 $0.00 $0.00 $0.00 $107.50 $170.28 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47100138 EAP Gll Visit - Post 4th Visit BOTH IP/OP $25.00 $18.50 $0.00 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.56 $18.56 $19.27 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $12.50 $19.80 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47200002 EAP CPT® 92603 Cochlear Implt Exam 7 > Yrs BOTH IP/OP $267.00 $197.58 $42.98 $216.00 $144.98 $144.98 $135.96 $135.96 $136.73 $55.65 $198.17 $198.17 $205.80 $133.75 $55.64 $86.94 $157.93 $157.93 $138.76 $135.00 $213.84 $216.00 $192.78 $173.55 $192.78 $88.28 $125.50 $125.50 $42.98 $132.15 $0.00 $0.00 $0.00 $0.00 47200003 EAP CPT® 92604 Reprogram Codhlear Implt 7 > Yrs BOTH IP/OP $631.00 $466.94 $0.00 $509.60 $342.63 $342.63 $135.96 $135.96 $136.73 $131.52 $468.33 $468.33 $486.37 $133.75 $131.50 $86.94 $373.24 $373.24 $0.00 $318.50 $504.50 $509.60 $0.00 $410.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47200010 EAP HCPCS C1887 Maxc Catheter Reperfusion 4max BOTH IP/OP "$4,108.00 " "$3,039.92" $0.00 "$3,286.40" "$2,230.64" "$2,230.64" $0.00 $0.00 $0.00 $856.21 "$3,048.96" "$3,048.96" "$3,166.45" $0.00 $856.11 $0.00 "$2,429.88" "$2,429.88" $0.00 "$2,054.00" "$3,253.54" "$3,286.40" $0.00 $0.00 $0.00 $642.90 $0.00 $0.00 $653.99 $0.00 $0.00 $0.00 $0.00 $0.00 47200011 EAP HCPCS C1757 Psc041 Catheter Thrmb 141cm 4.1fr .041in Reperfusion BOTH IP/OP "$3,813.00 " "$2,821.62" $0.00 "$3,050.40" "$2,070.46" "$2,070.46" $0.00 $0.00 $0.00 $794.72 "$2,830.01" "$2,830.01" "$2,939.06" $0.00 $794.63 $0.00 "$2,255.39" "$2,255.39" $0.00 "$1,906.50" "$3,019.90" "$3,050.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47900001 EAP CPT® 92586 Hearing Screening (aabr) BOTH IP/OP $439.00 $324.86 $0.00 $351.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.50 $347.69 $351.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47900003 EAP CPT® 92587 Hearing Screening (oae) BOTH IP/OP $431.00 $318.94 $0.00 $410.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.89 $319.89 $332.21 $0.00 $89.82 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $410.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000001 EAP CPT® 33967 Perc Insertion Intraaortic Bal BOTH IP/OP "$5,482.00 " "$4,056.68" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,068.74" "$4,068.74" "$4,225.53" $0.00 "$1,142.45" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,873.67" "$3,912.80" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000002 EAP CPT® 92950 Cardio Res - Cpr BOTH IP/OP "$2,336.00 " "$1,728.64" $0.00 "$1,800.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,733.78" "$1,733.78" "$1,800.59" $0.00 $486.82 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000003 EAP CPT® 92953 Temp Transcut Pacing BOTH IP/OP "$2,474.00 " "$1,830.76" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,836.20" "$1,836.20" "$1,906.96" $0.00 $515.58 $0.00 $0.00 $0.00 $0.00 "$1,249.50" "$1,979.21" "$1,999.20" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000004 EAP CPT® 92960 Cardioversion BOTH IP/OP "$2,742.00 " "$2,029.08" $112.51 "$2,150.00" "$1,488.91" "$1,488.91" $547.07 $547.07 $550.15 $571.50 "$2,035.11" "$2,035.11" "$2,113.53" $538.55 $571.43 $350.05 "$1,621.89" "$1,621.89" $538.04 "$1,082.50" "$1,714.68" "$1,732.00" $747.53 "$2,150.00" $747.53 $154.62 $112.51 $112.51 $344.67 $512.42 $0.00 $0.00 $0.00 $0.00 48000005 EAP CPT® 92971 Circulatory Assist - External BOTH IP/OP "$1,227.00 " $907.98 $0.00 $981.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $910.68 $910.68 $945.77 $0.00 $255.71 $0.00 $0.00 $0.00 $0.00 $613.50 $971.78 $981.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000011 EAP CPT® 92986 "Perc Balloon Vplasty, Aortic" BOTH IP/OP "$20,704.00 " "$15,320.96" $0.00 "$16,563.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,958.64" $0.00 "$4,314.71" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$16,397.57" "$16,563.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000012 EAP CPT® 92987 "Perc Balloon Vplasty, Mitral" BOTH IP/OP "$20,704.00 " "$15,320.96" $0.00 "$16,563.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,958.64" $0.00 "$4,314.71" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$16,397.57" "$16,563.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000013 EAP CPT® 92990 "Perc Balloon Vplasty, Pulm" BOTH IP/OP "$20,704.00 " "$15,320.96" $0.00 "$16,563.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,958.64" $0.00 "$4,314.71" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$16,397.57" "$16,563.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000014 EAP CPT® 93282 Single Lead Icd Programming / Evaluation In Person BOTH IP/OP $328.00 $242.72 $23.14 $252.82 $140.08 $140.08 $36.26 $36.26 $36.47 $68.36 $243.44 $243.44 $252.82 $35.61 $68.36 $23.14 $194.01 $194.01 $36.36 $132.00 $209.09 $211.20 $50.51 $213.20 $50.51 $68.00 $30.97 $30.97 $42.03 $34.63 $0.00 $0.00 $0.00 $0.00 48000015 EAP CPT® 93283 Dual Lead Icd Program/ Eval In Person BOTH IP/OP $328.00 $242.72 $23.14 $252.82 $180.76 $180.76 $36.26 $36.26 $36.47 $68.36 $243.44 $243.44 $252.82 $35.61 $68.36 $23.14 $194.01 $194.01 $36.36 $132.00 $209.09 $211.20 $50.51 $213.20 $50.51 $82.80 $33.86 $33.86 $42.03 $34.63 $0.00 $0.00 $0.00 $0.00 48000016 EAP CPT® 93285 Sq-cardiac Rhythm Monitor / Loop Recorder Program / Eval In Person BOTH IP/OP $204.00 $150.96 $23.14 $157.24 $93.14 $93.14 $36.26 $36.26 $36.47 $42.52 $151.41 $151.41 $157.24 $35.61 $42.51 $23.14 $120.67 $120.67 $36.36 $82.00 $129.89 $131.20 $50.51 $132.60 $50.51 $45.96 $27.73 $27.73 $26.11 $34.63 $0.00 $0.00 $0.00 $0.00 48000017 EAP CPT® 93289 Pacemaker Interrog / Eval In Person BOTH IP/OP $328.00 $242.72 $23.14 $252.82 $145.54 $145.54 $36.26 $36.26 $36.47 $68.36 $243.44 $243.44 $252.82 $35.61 $68.36 $23.14 $194.01 $194.01 $36.36 $132.00 $209.09 $211.20 $50.51 $146.25 $50.51 $63.29 $28.81 $28.81 $42.03 $34.63 $0.00 $0.00 $0.00 $0.00 48000019 EAP CPT® 93307 2d Echo BOTH IP/OP "$3,555.00 " "$2,630.70" $0.00 "$2,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $316.71 $316.71 $328.89 $0.00 $740.86 $0.00 $0.00 $0.00 $0.00 "$1,810.50" "$2,867.83" "$2,896.80" $0.00 "$1,316.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000020 EAP CPT® 93312 Transesophageal Echo BOTH IP/OP "$4,858.00 " "$3,594.92" $138.31 "$3,482.40" $544.66 $544.66 $470.55 $470.55 $473.20 "$1,012.53" $522.69 $522.69 $542.80 $462.81 "$1,012.41" $300.83 "$2,873.51" "$2,873.51" $483.00 "$2,176.50" "$3,447.58" "$3,482.40" $671.06 "$2,526.55" $671.06 $268.29 $138.31 $138.31 $693.00 $460.00 $0.00 $0.00 $0.00 $0.00 48000021 EAP CPT® 93320 Echo Doppler Complete BOTH IP/OP "$2,768.00 " "$2,048.32" $0.00 "$1,984.00" $119.72 $119.72 $0.00 $0.00 $0.00 $576.92 $143.29 $143.29 $148.80 $0.00 $576.85 $0.00 "$1,637.27" "$1,637.27" $0.00 "$1,240.00" "$1,964.16" "$1,984.00" $0.00 "$1,976.65" $0.00 $90.75 $35.66 $35.66 $394.82 $0.00 $0.00 $0.00 $0.00 $0.00 48000022 EAP CPT® 93325 Color Flow Mapping BOTH IP/OP "$1,693.00 " "$1,252.82" $0.00 "$1,976.65" $56.34 $56.34 $0.00 $0.00 $0.00 $352.86 $122.81 $122.81 $127.54 $0.00 $352.82 $0.00 "$1,001.41" "$1,001.41" $0.00 $834.50 "$1,321.85" "$1,335.20" $0.00 "$1,976.65" $0.00 $116.25 $21.97 $21.97 $265.70 $0.00 $0.00 $0.00 $0.00 $0.00 48000023 EAP CPT® 93350 Transthoracic Echo BOTH IP/OP "$3,694.00 " "$2,733.56" $0.00 "$2,955.20" $0.00 $0.00 $0.00 $0.00 $0.00 $781.18 $0.00 $0.00 $0.00 $462.81 $781.08 $300.83 "$2,216.94" "$2,216.94" $483.00 "$1,847.00" "$2,925.65" "$2,955.20" $671.06 $0.00 $671.06 $118.63 $120.30 $120.30 $588.08 $460.00 $0.00 $0.00 $0.00 $0.00 48000024 EAP CPT® 93503 Insertion Swan Ganz BOTH IP/OP "$8,527.00 " "$6,309.98" $0.00 "$6,890.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,572.61" $0.00 "$1,777.03" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,821.50" "$6,890.40" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000025 EAP CPT® 93580 Perc Closure Atrial Septal Def BOTH IP/OP "$19,473.00 " "$14,410.02" $0.00 "$15,009.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,009.79" $0.00 "$4,058.17" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$14,770.01" "$14,919.20" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000026 EAP CPT® 33222 Relocation Skin Pkt For Pacemaker BOTH IP/OP "$27,668.00 " "$20,474.32" $0.00 "$21,706.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,766.01" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$21,489.34" "$21,706.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000027 EAP CPT® 93640 Ep Eval Icd Leads Init Implant BOTH IP/OP "$5,142.00 " "$3,805.08" $0.00 "$4,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,816.39" "$3,816.39" "$3,963.45" $0.00 "$1,071.59" $0.00 $0.00 $0.00 $0.00 "$2,571.00" "$4,072.46" "$4,113.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000028 EAP CPT® 93641 Test Icd Gen Initial Implant BOTH IP/OP "$5,361.00 " "$3,967.14" $0.00 "$5,361.00" "$5,361.00" "$5,361.00" $0.00 $0.00 $0.00 "$1,117.37" "$3,978.93" "$3,978.93" "$4,132.26" $0.00 "$1,117.23" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,478.50" "$3,925.94" "$3,965.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000029 EAP CPT® 93642 Ep Eval Icd Gen & Programming BOTH IP/OP "$5,562.00 " "$4,115.88" $0.00 "$5,562.00" "$5,562.00" "$5,562.00" "$1,084.66" "$1,084.66" "$1,090.77" $0.00 "$4,128.12" "$4,128.12" "$4,287.19" $0.00 "$1,159.12" $0.00 $0.00 $0.00 $990.46 "$2,571.00" "$4,072.46" "$4,113.60" "$1,376.12" "$2,500.00" "$1,376.12" $590.04 $83.20 $83.20 $818.61 $943.30 $0.00 $0.00 $0.00 $0.00 48000030 EAP CPT® 93660 Tilt Table Evaluation BOTH IP/OP "$1,423.00 " "$1,053.02" $0.00 "$1,423.00" $772.69 $772.69 $475.36 $475.36 $0.00 $296.59 "$1,056.15" "$1,056.15" "$1,096.85" $467.50 $296.55 $303.87 $841.70 $841.70 $0.00 $718.50 "$1,138.10" "$1,149.60" $0.00 "$1,423.00" $0.00 $173.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000040 EAP CPT® 93788 Ambulatory Bp Analysis BOTH IP/OP $212.00 $156.88 $0.00 $169.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.35 $157.35 $163.41 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $106.00 $167.90 $169.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000045 EAP CPT® 93458 Lt Heart Cath Including V Gram BOTH IP/OP "$22,078.00 " "$16,337.72" $786.98 "$14,473.60" "$10,292.10" "$10,292.10" "$2,823.89" "$2,823.89" "$2,839.80" "$4,601.61" "$5,345.48" "$5,345.48" "$5,773.12" "$2,778.48" "$4,601.06" "$1,806.01" "$13,059.14" "$13,059.14" "$2,858.33" "$2,858.00" "$14,328.86" "$14,473.60" "$3,971.26" "$4,334.00" "$3,971.26" "$1,000.10" $786.98 $786.98 "$2,880.25" "$2,722.22" $0.00 $0.00 $0.00 $0.00 48000046 EAP CPT® 93459 Lhc W/ V Gram And Grafts BOTH IP/OP "$22,078.00 " "$16,337.72" $842.80 "$14,473.60" "$10,292.10" "$10,292.10" "$2,823.89" "$2,823.89" "$2,839.80" "$4,601.61" "$5,345.48" "$5,345.48" "$5,773.12" "$2,778.48" "$4,601.06" "$1,806.01" "$13,059.14" "$13,059.14" "$2,858.33" "$2,858.00" "$14,328.86" "$14,473.60" "$3,971.26" "$4,334.00" "$3,971.26" "$1,104.45" $842.80 $842.80 "$2,880.25" "$2,722.22" $0.00 $0.00 $0.00 $0.00 48000047 EAP CPT® 93460 R&lhc W/v Gram BOTH IP/OP "$22,078.00 " "$16,337.72" $0.00 "$14,473.60" "$10,292.10" "$10,292.10" "$2,823.89" "$2,823.89" "$2,839.80" "$4,601.61" "$5,345.48" "$5,345.48" "$5,773.12" "$2,778.48" "$4,601.06" "$1,806.01" "$13,059.14" "$13,059.14" $0.00 "$2,858.00" "$14,328.86" "$14,473.60" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000048 EAP CPT® 93461 R&lhc W/v Gram And Grafts BOTH IP/OP "$22,078.00 " "$16,337.72" $0.00 "$14,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,601.06" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$14,328.86" "$14,473.60" $0.00 "$4,334.00" $0.00 "$1,354.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000050 EAP CPT® 33235 Removal Pacemaker Electrodes BOTH IP/OP "$9,098.00 " "$6,732.52" $0.00 "$8,013.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,012.74" $0.00 "$1,896.02" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,933.46" "$8,013.60" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000053 EAP CPT® 94621 Pulm Exer Stress Test; Complex BOTH IP/OP "$1,097.00 " $811.78 $0.00 $877.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.19 $814.19 $845.57 $0.00 $228.61 $0.00 $0.00 $0.00 $0.00 $548.50 $868.82 $877.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000054 EAP Custom 48000054 Cpet Patient Interface Kit BOTH IP/OP $424.00 $313.76 $0.00 $339.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $314.69 $314.69 $326.82 $0.00 $88.36 $0.00 $0.00 $0.00 $0.00 $212.00 $335.81 $339.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000055 EAP Custom 48000055 Analyze/ind/term Tachycardia BOTH IP/OP $238.00 $176.12 $0.00 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $183.45 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $127.00 $201.17 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000057 EAP CPT® 92920 Prq Cardiac Angioplast 1 Art BOTH IP/OP "$17,577.00 " "$13,006.98" $0.00 "$13,631.20" "$9,544.31" "$9,544.31" "$4,826.66" "$4,826.66" "$4,853.85" "$3,663.49" "$4,181.12" "$4,181.12" "$13,548.35" "$4,750.73" "$3,663.05" "$3,087.98" "$10,396.80" "$10,396.80" $0.00 "$4,975.00" "$13,494.89" "$13,631.20" $0.00 "$3,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000058 EAP CPT® 92921 Prq Cardiac Angio Addl Art BOTH IP/OP "$28,094.00 " "$20,789.56" $0.00 "$21,786.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,654.86" $0.00 "$5,854.79" $0.00 $0.00 $0.00 $0.00 "$13,616.50" "$21,568.54" "$21,786.40" $0.00 "$6,409.00" $0.00 "$4,261.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000059 EAP CPT® 92928 Prq Card Stent W/angio 1 Vsl BOTH IP/OP "$32,293.00 " "$23,896.82" $0.00 "$25,043.20" "$17,535.10" "$17,535.10" "$9,781.76" "$9,781.76" "$9,836.87" "$6,730.67" "$4,181.12" "$4,181.12" "$24,891.44" "$9,625.35" "$6,729.86" "$6,256.48" "$19,101.31" "$19,101.31" $0.00 "$6,105.00" "$24,792.77" "$25,043.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000060 EAP CPT® 92929 Prq Card Stent W/angio Addl BOTH IP/OP "$44,709.00 " "$33,084.66" $0.00 "$34,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$34,461.70" $0.00 "$9,317.36" $0.00 $0.00 $0.00 $0.00 "$21,670.00" "$34,325.28" "$34,672.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000061 EAP CPT® 92937 Prq Revasc Byp Graft 1 Vsl BOTH IP/OP "$14,275.00 " "$10,563.50" $0.00 "$11,070.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,003.17" $0.00 "$2,974.91" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$10,959.70" "$11,070.40" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000062 EAP CPT® 92938 Prq Revasc Byp Graft Addl BOTH IP/OP "$12,738.00 " "$9,426.12" $0.00 "$9,878.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,818.45" $0.00 "$2,654.60" $0.00 $0.00 $0.00 $0.00 "$6,174.00" "$9,779.62" "$9,878.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000063 EAP CPT® 92941 Prq Card Revasc Mi 1 Vsl BOTH IP/OP "$39,045.00 " "$28,893.30" $0.00 "$30,279.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$30,095.89" $0.00 "$8,136.98" $0.00 $0.00 $0.00 $0.00 "$18,924.50" "$29,976.41" "$30,279.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000064 EAP CPT® 92943 Prq Card Revasc Chronic 1vsl BOTH IP/OP "$29,217.00 " "$21,620.58" $0.00 "$22,657.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,089.55" "$4,181.12" "$4,181.12" "$22,520.46" "$15,396.06" "$6,088.82" "$10,007.44" "$17,281.86" "$17,281.86" $0.00 "$6,105.00" "$22,431.02" "$22,657.60" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000065 EAP CPT® 92944 Prq Card Revasc Chronic Addl BOTH IP/OP "$20,209.00 " "$14,954.66" $0.00 "$15,672.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,577.10" $0.00 "$4,211.56" $0.00 $0.00 $0.00 $0.00 "$9,795.00" "$15,515.28" "$15,672.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000066 EAP CPT® 33223 Relocation Skin Pkt Cardiovert-defib BOTH IP/OP "$5,494.00 " "$4,065.56" $0.00 "$4,839.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,144.95" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$4,790.81" "$4,839.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000067 EAP CPT® 93261 S-icd Interrog / Eval In Person BOTH IP/OP $208.00 $153.92 $23.14 $167.05 $132.26 $132.26 $36.26 $36.26 $36.47 $43.35 $154.38 $154.38 $160.33 $35.61 $43.35 $23.14 $123.03 $123.03 $36.36 $83.50 $132.26 $133.60 $50.51 $167.05 $50.51 $58.66 $29.17 $29.17 $26.59 $34.63 $0.00 $0.00 $0.00 $0.00 48000070 EAP CPT® 92933 Prq Trluml Coronary Angio/athe BOTH IP/OP "$20,912.00 " "$15,474.88" $0.00 "$16,216.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$16,118.97" $0.00 "$4,358.06" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$16,054.63" "$16,216.80" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000071 EAP CPT® 33999 Insertion Of Impella Device - Rp BOTH IP/OP "$13,372.00 " "$9,895.28" $0.00 "$10,805.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,307.14" $0.00 "$2,786.72" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$10,697.54" "$10,805.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000072 EAP CPT® 93621 Comp Ep Exam W/lt Atrial Pacing/record BOTH IP/OP "$12,625.00 " "$9,342.50" $0.00 "$8,856.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,307.47" $0.00 $0.00 $0.00 $0.00 "$2,307.20" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,535.50" "$8,768.23" "$8,856.80" $0.00 $0.00 $0.00 "$1,732.61" $0.00 $0.00 "$1,762.50" $0.00 $0.00 $0.00 $0.00 $0.00 48000110 EAP CPT® 93297 Icm Interrog / Eval Remote Up To 30 Days BOTH IP/OP $333.00 $246.42 $0.00 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.00 $210.67 $212.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48000111 EAP CPT® 93298 S-icd/loop Recorder Interrog / Eval Remote Up To 30 Days BOTH IP/OP $204.00 $150.96 $23.14 $212.80 $59.48 $59.48 $36.26 $36.26 $36.47 $42.52 $151.41 $151.41 $157.24 $35.61 $42.51 $23.14 $120.67 $120.67 $36.36 $133.00 $210.67 $212.80 $28.13 $132.60 $28.13 $28.19 $28.13 $28.13 $42.35 $34.63 $0.00 $0.00 $0.00 $0.00 48100001 EAP CPT® 33240 Insrt Icd Pulse Gen W Sngl Lead BOTH IP/OP "$29,623.00 " "$21,921.02" $0.00 "$29,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,173.43" $0.00 $0.00 $0.00 "$22,779.64" "$6,105.00" "$23,007.60" "$23,240.00" "$29,050.00" "$5,410.00" "$29,050.00" $517.77 $381.75 $381.75 "$4,624.76" "$21,694.90" $0.00 $0.00 $0.00 $0.00 48100003 EAP CPT® 33249 Insrt/repl Sgl/dual Icd Ld/gen BOTH IP/OP "$39,613.00 " "$29,313.62" $0.00 "$39,613.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$32,377.52" "$6,105.00" "$31,373.50" "$31,690.40" "$39,613.00" $0.00 "$39,613.00" "$1,016.82" $959.62 $959.62 "$6,306.39" "$30,835.73" $0.00 $0.00 $0.00 $0.00 48100004 EAP CPT® 92973 Perc Coronary Thrombectomy BOTH IP/OP "$9,050.00 " "$6,697.00" $0.00 "$6,975.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,975.74" $0.00 "$1,886.02" $0.00 $0.00 $0.00 $0.00 "$4,336.50" "$6,869.02" "$6,938.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100006 EAP CPT® 93505 Endomyocardial Biopsy BOTH IP/OP "$3,290.00 " "$2,434.60" $0.00 "$3,290.00" "$3,290.00" "$3,290.00" "$2,787.76" "$2,787.76" "$2,803.47" $685.72 "$2,441.84" "$2,441.84" "$2,535.93" "$2,742.67" $685.64 "$1,782.74" "$1,946.04" "$1,946.04" $0.00 "$2,255.00" "$2,631.82" "$2,658.40" $0.00 "$3,250.00" $0.00 $339.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100020 EAP CPT® 93561 Therm Dilu Stdy Cardoutput Se BOTH IP/OP $261.00 $193.14 $0.00 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.27 $0.00 $0.00 $0.00 $0.00 $246.00 $194.83 $196.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100021 EAP CPT® 93562 Measure Card Output BOTH IP/OP $88.00 $65.12 $0.00 $83.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.30 $0.00 $0.00 $0.00 $0.00 $83.00 $65.74 $66.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100022 EAP CPT® 93571 Intravasc Cornary Flow Measure BOTH IP/OP "$5,647.00 " "$4,178.78" $0.00 "$4,352.71" "$3,066.32" "$3,066.32" $0.00 $0.00 $0.00 "$1,176.98" "$4,181.12" "$4,181.12" "$4,352.71" $0.00 "$1,176.83" $0.00 "$3,340.20" "$3,340.20" $0.00 "$2,704.00" "$4,283.14" "$4,326.40" $0.00 "$1,750.00" $0.00 $261.34 $0.00 $0.00 $860.95 $0.00 $0.00 $0.00 $0.00 $0.00 48100023 EAP CPT® 93572 Intravasc Cor. Flow Addit Vess BOTH IP/OP "$5,581.00 " "$4,129.94" $0.00 "$4,301.83" "$3,030.48" "$3,030.48" $0.00 $0.00 $0.00 "$1,163.22" "$4,142.22" "$4,142.22" "$4,301.83" $0.00 "$1,163.08" $0.00 "$3,301.16" "$3,301.16" $0.00 "$2,672.00" "$4,232.45" "$4,275.20" $0.00 "$1,750.00" $0.00 $239.81 $0.00 $0.00 $850.76 $0.00 $0.00 $0.00 $0.00 $0.00 48100026 EAP CPT® 33270 Insert Subcutaneous Aicd BOTH IP/OP "$129,402.00 " "$95,757.48" $574.64 "$101,520.00" "$2,984.10" "$2,984.10" "$31,988.05" "$31,988.05" "$32,168.25" "$9,417.94" "$4,181.12" "$4,181.12" "$99,743.06" "$31,473.45" "$26,967.38" "$20,457.74" "$4,877.00" "$4,877.00" "$32,377.52" "$6,105.00" "$100,504.80" "$101,520.00" "$44,984.24" "$5,410.00" "$44,984.24" $574.64 $592.28 $592.28 "$8,138.89" "$30,835.73" $0.00 $0.00 $0.00 $0.00 48100029 EAP CPT® 93462 Left Heart Cath By Transeptal Puncture BOTH IP/OP "$12,155.00 " "$8,994.70" $0.00 "$7,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,533.10" $0.00 $0.00 $0.00 $0.00 "$4,980.00" "$7,888.32" "$7,968.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100030 EAP CPT® 93451 Right Heart Cath BOTH IP/OP "$22,078.00 " "$16,337.72" $0.00 "$14,473.60" "$10,292.10" "$10,292.10" "$2,823.89" "$2,823.89" "$2,839.80" $0.00 "$5,345.48" "$5,345.48" "$5,773.12" $0.00 "$4,601.06" $0.00 $0.00 $0.00 "$2,858.33" "$2,858.00" "$14,328.86" "$14,473.60" "$3,971.26" "$4,334.00" "$3,971.26" $725.02 $725.39 $725.39 "$2,880.25" "$2,722.22" $0.00 $0.00 $0.00 $0.00 48100031 EAP CPT® 93452 Lhc W/v Gram BOTH IP/OP "$22,078.00 " "$16,337.72" $0.00 "$14,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,601.06" $0.00 $0.00 $0.00 "$2,858.33" "$2,858.00" "$14,328.86" "$14,473.60" "$3,971.26" "$4,334.00" "$3,971.26" $803.53 $686.49 $686.49 "$2,880.25" "$2,722.22" $0.00 $0.00 $0.00 $0.00 48100032 EAP CPT® 93453 R/lhc W/v Gram (s&i) BOTH IP/OP "$22,078.00 " "$16,337.72" $0.00 "$14,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,601.06" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$14,328.86" "$14,473.60" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100033 EAP CPT® 93454 Coronary Angio W/o Lhc BOTH IP/OP "$22,078.00 " "$16,337.72" $685.77 "$14,473.60" "$10,292.10" "$10,292.10" "$2,823.89" "$2,823.89" "$2,839.80" "$4,601.61" "$5,345.48" "$5,345.48" "$5,773.12" "$2,778.48" "$4,601.06" "$1,806.01" "$13,059.14" "$13,059.14" "$2,858.33" "$2,255.00" "$14,328.86" "$14,473.60" "$3,971.26" "$4,334.00" "$3,971.26" $828.78 $685.77 $685.77 "$2,880.25" "$2,722.22" $0.00 $0.00 $0.00 $0.00 48100034 EAP CPT® 93455 Coronary Angio W/o Lhc W/graft Inj BOTH IP/OP "$22,078.00 " "$16,337.72" $0.00 "$14,473.60" "$10,292.10" "$10,292.10" "$2,823.89" "$2,823.89" "$2,839.80" "$4,601.61" "$5,345.48" "$5,345.48" "$5,773.12" "$2,778.48" "$4,601.06" "$1,806.01" "$13,059.14" "$13,059.14" $0.00 "$2,255.00" "$14,328.86" "$14,473.60" $0.00 "$4,334.00" $0.00 $967.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100035 EAP CPT® 93456 Rhc/coronary Angio W/o Lhc BOTH IP/OP "$22,078.00 " "$16,337.72" $0.00 "$14,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,601.06" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$14,328.86" "$14,473.60" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100036 EAP CPT® 93457 Rhc/coronary Angio W/o Lhc W/graft Inj BOTH IP/OP "$22,078.00 " "$16,337.72" $0.00 "$14,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,601.06" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$14,328.86" "$14,473.60" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100037 EAP CPT® 33991 Insert Vad Art&vein Access BOTH IP/OP "$31,345.00 " "$23,195.30" $0.00 "$27,608.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$24,160.73" $0.00 "$6,532.30" $0.00 $0.00 $0.00 $0.00 "$17,255.50" "$27,332.71" "$27,608.80" $0.00 "$13,874.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100040 EAP CPT® 93567 Inj. Supravalvular Aortography BOTH IP/OP $185.00 $136.90 $0.00 $185.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.55 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $185.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100042 EAP HCPCS G0278 Iliac/fem Angio W/cardiac Cath BOTH IP/OP "$2,706.00 " "$2,002.44" $0.00 "$2,186.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,008.39" "$2,008.39" "$2,085.78" $0.00 $563.93 $0.00 $0.00 $0.00 $0.00 "$1,366.50" "$2,164.54" "$2,186.40" $0.00 "$1,758.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100050 EAP CPT® 33227 Remove/repl Pcmkr W Sngl Ld BOTH IP/OP "$39,256.00 " "$29,049.44" $0.00 "$31,404.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$7,431.39" $0.00 $0.00 $0.00 "$7,813.60" "$7,430.50" "$5,078.84" "$4,877.00" "$4,877.00" $0.00 "$6,105.00" "$31,090.75" "$31,404.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100051 EAP CPT® 33229 Remove/replac Pcmkr W Dual Ld BOTH IP/OP "$43,902.00 " "$32,487.48" $0.00 "$34,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$33,839.66" $0.00 "$9,149.18" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$34,097.98" "$34,442.40" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100052 EAP CPT® 33229 Remove/replac Pcmkr W Multi Ld BOTH IP/OP "$43,053.00 " "$31,859.22" $0.00 "$34,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$34,097.98" "$34,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100053 EAP CPT® 33230 Insrt Icd W Exist Dual Lds BOTH IP/OP "$77,559.00 " "$57,393.66" $0.00 "$68,313.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$59,782.48" $0.00 "$16,163.30" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$67,630.46" "$68,313.60" $0.00 "$5,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100054 EAP CPT® 33231 Insrt Icd W Exist Multi Lds BOTH IP/OP "$77,559.00 " "$57,393.66" $0.00 "$68,313.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$59,782.48" $0.00 "$16,163.30" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$67,630.46" "$68,313.60" $0.00 "$5,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100055 EAP CPT® 33262 Remove/repl Icd W Sngl Ld BOTH IP/OP "$87,076.00 " "$64,436.24" $351.54 "$68,313.60" "$2,984.10" "$2,984.10" "$22,456.40" "$22,456.40" "$22,582.91" "$9,417.94" "$4,181.12" "$4,181.12" "$67,118.18" "$22,082.15" "$18,146.64" "$14,353.40" "$4,877.00" "$4,877.00" "$22,779.64" "$6,105.00" "$67,630.46" "$68,313.60" "$31,649.28" "$5,410.00" "$31,649.28" $351.54 $390.40 $390.40 "$8,138.89" "$21,694.90" $0.00 $0.00 $0.00 $0.00 48100056 EAP CPT® 33263 Remove/repl Icd W Dual Lds BOTH IP/OP "$87,076.00 " "$64,436.24" $0.00 "$68,313.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$67,118.18" $0.00 "$18,146.64" $0.00 $0.00 $0.00 "$22,779.64" "$6,105.00" "$67,630.46" "$68,313.60" "$31,649.28" "$5,410.00" "$31,649.28" $365.37 $405.90 $405.90 "$8,138.89" "$21,694.90" $0.00 $0.00 $0.00 $0.00 48100057 EAP CPT® 33264 Remove/repl Icd W Multi Lds BOTH IP/OP "$87,076.00 " "$64,436.24" $0.00 "$68,313.60" "$2,984.10" "$2,984.10" "$31,988.05" "$31,988.05" "$32,168.25" "$9,417.94" "$4,181.12" "$4,181.12" "$67,118.18" "$31,473.45" "$18,146.64" "$20,457.74" "$4,877.00" "$4,877.00" "$32,377.52" "$6,105.00" "$67,630.46" "$68,313.60" "$44,984.24" "$5,410.00" "$44,984.24" $0.00 $424.28 $424.28 "$8,138.89" "$30,835.73" $0.00 $0.00 $0.00 $0.00 48100058 EAP CPT® 33221 Insrt Pcmkr Gen Only Exist Multi BOTH IP/OP "$39,104.00 " "$28,936.96" $0.00 "$34,442.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$30,141.36" $0.00 "$8,149.27" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$34,097.98" "$34,442.40" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100059 EAP CPT® 33228 Remv & Replc Pm Gen Dual Lead BOTH IP/OP "$42,575.00 " "$31,505.50" $0.00 "$33,401.60" "$2,984.10" "$2,984.10" "$10,125.82" "$10,125.82" "$10,182.87" "$8,873.69" "$4,181.12" "$4,181.12" "$32,816.81" "$9,967.71" "$8,872.63" "$6,479.01" "$4,877.00" "$4,877.00" "$10,282.07" "$6,105.00" "$33,067.58" "$33,401.60" "$14,285.57" "$5,164.00" "$14,285.57" $0.00 $370.57 $370.57 "$6,646.92" "$9,792.45" $0.00 $0.00 $0.00 $0.00 48100060 EAP CPT® 93600 Bundle Of Hils Recording BOTH IP/OP "$5,320.00 " "$3,936.80" $0.00 "$4,256.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,948.50" "$3,948.50" "$4,100.66" $0.00 "$1,108.69" $0.00 $0.00 $0.00 $0.00 "$2,660.00" "$4,213.44" "$4,256.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100061 EAP CPT® 93602 Intra-atrial Recording BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,624.80" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100062 EAP CPT® 93603 Right Ventricular Recording BOTH IP/OP "$9,546.00 " "$7,064.04" $0.00 "$7,636.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,358.06" $0.00 "$1,989.39" $0.00 $0.00 $0.00 $0.00 "$4,773.00" "$7,560.43" "$7,636.80" $0.00 "$1,329.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100063 EAP CPT® 93610 Intra-atrial Pacing BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,624.80" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100064 EAP CPT® 93612 Intra-ventricular Pacing BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,624.80" $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100065 EAP CPT® 93618 Induction Of Arrythmia By Electrial Pacing BOTH IP/OP "$4,835.00 " "$3,577.90" $0.00 "$3,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,588.54" "$3,588.54" "$3,726.82" $0.00 "$1,007.61" $0.00 $0.00 $0.00 $0.00 "$2,417.50" "$3,829.32" "$3,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100066 EAP CPT® 93624 Follow-up Ep Study W/pacing & Recording BOTH IP/OP "$10,198.00 " "$7,546.52" $0.00 "$8,158.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,860.62" $0.00 "$2,125.26" $0.00 $0.00 $0.00 $0.00 "$5,099.00" "$8,076.82" "$8,158.40" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100067 EAP CPT® 93619 Complete Eps W/oinduction Of Arrhythmia BOTH IP/OP "$14,885.00 " "$11,014.90" $0.00 "$11,473.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,473.36" $0.00 "$3,102.03" $0.00 $0.00 $0.00 $0.00 "$6,999.50" "$11,087.21" "$11,199.20" $0.00 "$9,675.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100068 EAP CPT® 93620 Complete Eps With Induction Arrhythmia BOTH IP/OP "$16,933.00 " "$12,530.42" $0.00 "$13,051.96" "$5,693.10" "$5,693.10" "$5,919.35" "$5,919.35" "$5,952.70" "$3,529.26" "$4,181.12" "$4,181.12" "$13,051.96" "$5,825.74" "$3,528.84" "$3,786.73" "$10,015.87" "$10,015.87" "$5,903.01" "$7,962.50" "$12,612.60" "$12,740.00" "$8,201.44" "$4,334.00" "$8,201.44" "$1,092.52" $0.00 $0.00 "$2,535.26" "$5,621.91" $0.00 $0.00 $0.00 $0.00 48100069 EAP CPT® 93621 Left Atrial Or Coronary Sinus Pacing & Recording BOTH IP/OP "$13,424.00 " "$9,933.76" $0.00 "$10,347.22" "$5,693.10" "$5,693.10" $0.00 $0.00 $0.00 "$2,797.90" "$4,181.12" "$4,181.12" "$10,347.22" $0.00 "$2,797.56" $0.00 "$7,940.30" "$7,940.30" $0.00 "$6,312.50" "$9,999.00" "$10,100.00" $0.00 "$1,750.00" $0.00 "$1,975.81" $0.00 $0.00 "$2,009.90" $0.00 $0.00 $0.00 $0.00 $0.00 48100070 EAP CPT® 93622 Left Ventricular Pacing & Recording BOTH IP/OP "$12,767.00 " "$9,447.58" $0.00 "$9,840.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,840.80" $0.00 "$2,660.64" $0.00 $0.00 $0.00 $0.00 "$6,003.50" "$9,509.54" "$9,605.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100071 EAP CPT® 93609 Catheter Mapping Of Tachycardia BOTH IP/OP "$7,163.00 " "$5,300.62" $0.00 "$5,730.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,521.24" $0.00 "$1,492.77" $0.00 $0.00 $0.00 $0.00 "$3,581.50" "$5,673.10" "$5,730.40" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100072 EAP CPT® 93613 Electrophys Map 3d BOTH IP/OP "$13,202.00 " "$9,769.48" $0.00 "$10,176.10" "$7,168.69" "$7,168.69" $0.00 $0.00 $0.00 "$2,751.63" "$4,181.12" "$4,181.12" "$10,176.10" $0.00 "$2,751.30" $0.00 "$7,808.98" "$7,808.98" $0.00 "$6,001.00" "$9,505.58" "$9,601.60" $0.00 "$1,750.00" $0.00 $373.18 $311.12 $311.12 "$1,910.72" $0.00 $0.00 $0.00 $0.00 $0.00 48100073 EAP CPT® 93623 Program Stimulation And Pacing After Drug Infusion BOTH IP/OP "$7,519.00 " "$5,564.06" $0.00 "$5,795.65" "$4,082.82" "$4,082.82" $0.00 $0.00 $0.00 "$1,567.15" "$4,181.12" "$4,181.12" "$5,795.65" $0.00 "$1,566.96" $0.00 "$4,447.49" "$4,447.49" $0.00 "$3,535.50" "$5,600.23" "$5,656.80" $0.00 "$1,750.00" $0.00 $223.88 $0.00 $0.00 "$1,125.70" $0.00 $0.00 $0.00 $0.00 $0.00 48100074 EAP CPT® 93650 Av Node Ablation BOTH IP/OP "$11,950.00 " "$8,843.00" $0.00 "$9,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,211.06" $0.00 "$2,490.38" $0.00 $0.00 $0.00 $0.00 "$5,975.00" "$9,464.40" "$9,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100077 EAP CPT® 93662 Intracardiac Echocardiography BOTH IP/OP "$5,649.00 " "$4,180.26" $0.00 "$4,354.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,354.25" $0.00 "$1,177.25" $0.00 $0.00 $0.00 $0.00 "$2,531.00" "$4,009.10" "$4,049.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100078 EAP CPT® 93631 Heart Pacing Mapping BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" "$3,915.66" $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100079 EAP CPT® 37197 Trans Cath Retrval Fb Inc S/i BOTH IP/OP "$28,818.00 " "$21,325.32" $0.00 "$26,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$22,212.91" $0.00 "$6,005.67" $0.00 $0.00 $0.00 "$2,779.42" "$2,858.00" "$26,126.50" "$26,390.40" "$3,861.64" "$3,725.00" "$3,861.64" $0.00 $315.16 $315.16 "$5,251.69" "$2,647.07" $0.00 $0.00 $0.00 $0.00 48100080 EAP CPT® 93653 "Comp Ep Eval Inc Arrhyth Ind Ventric Pac, His Rec, Cath Ablat" BOTH IP/OP "$40,706.00 " "$30,122.44" $777.53 "$31,376.18" "$5,693.10" "$5,693.10" "$20,897.13" "$20,897.13" "$21,014.85" "$8,484.15" "$4,181.12" "$4,181.12" "$31,376.18" "$20,571.92" "$8,483.13" "$13,371.75" "$24,077.60" "$24,077.60" "$20,495.33" "$18,817.50" "$29,806.92" "$30,108.00" "$28,475.53" "$5,343.00" "$28,475.53" $777.53 $875.69 $875.69 "$5,991.49" "$19,519.36" $0.00 $0.00 $0.00 $0.00 48100081 EAP CPT® 93654 "Comp Ep Eval Inc Arrhyth Ind Ventric Pac, His Rec, Cath Ablat W/tx Ve" BOTH IP/OP "$40,706.00 " "$30,122.44" $0.00 "$31,376.18" "$5,693.10" "$5,693.10" "$20,897.13" "$20,897.13" "$21,014.85" $0.00 "$4,181.12" "$4,181.12" "$31,376.18" $0.00 "$8,483.13" $0.00 $0.00 $0.00 "$20,495.33" "$18,817.50" "$29,806.92" "$30,108.00" "$28,475.53" "$15,317.90" "$28,475.53" $0.00 "$1,172.76" "$1,172.76" "$5,991.49" "$19,519.36" $0.00 $0.00 $0.00 $0.00 48100082 EAP CPT® 93655 Ablatae Arrhythmia - Add On BOTH IP/OP "$37,635.00 " "$27,849.90" $0.00 "$30,108.00" "$2,321.55" "$2,321.55" $0.00 $0.00 $0.00 "$7,844.07" "$4,181.12" "$4,181.12" "$29,009.06" $0.00 "$7,843.13" $0.00 "$22,261.10" "$22,261.10" $0.00 "$18,817.50" "$29,806.92" "$30,108.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100083 EAP CPT® 93656 "Comp Ep Eval Inc Trans Sept Cath, Insert Elect Cath, Induct Arrhyth," BOTH IP/OP "$40,706.00 " "$30,122.44" $0.00 "$31,376.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$31,376.18" $0.00 "$8,483.13" $0.00 $0.00 $0.00 $0.00 "$18,817.50" "$29,806.92" "$30,108.00" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100084 EAP CPT® 93657 Tx L/r Atrial Fib Addl BOTH IP/OP "$40,706.00 " "$30,122.44" $0.00 "$31,376.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$31,376.18" $0.00 "$8,483.13" $0.00 $0.00 $0.00 $0.00 "$18,817.50" "$29,806.92" "$30,108.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100085 EAP CPT® 93530 Rt Hearat Cath Congenital BOTH IP/OP "$20,015.00 " "$14,811.10" $0.00 "$16,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,419.75" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$15,851.88" "$16,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100086 EAP CPT® 93463 MED ADMIN & HEMODYNAMIC MEASURMENT (W/NITRIC OXIDE) BOTH IP/OP "$3,396.00 " "$2,513.04" $0.00 "$3,396.00" "$1,844.03" "$1,844.03" $0.00 $0.00 $0.00 $0.00 "$3,396.00" "$3,396.00" "$3,396.00" $0.00 $707.73 $0.00 $0.00 $0.00 $0.00 "$1,602.50" "$2,538.36" "$2,564.00" $0.00 $640.00 $0.00 $101.49 $101.70 $101.70 $510.24 $0.00 $0.00 $0.00 $0.00 $0.00 48100090 EAP CPT® 93581 Percut Trans Cath Close Congent Ventric Sept Defect W/ T BOTH IP/OP "$16,546.00 " "$12,244.04" $0.00 "$15,408.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,753.66" $0.00 "$3,448.19" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$15,253.92" "$15,408.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100091 EAP CPT® 93582 Percut Trans Cath Close Patent Duct Arteriosus BOTH IP/OP "$18,778.00 " "$13,895.72" $0.00 "$17,486.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$14,474.08" $0.00 "$3,913.34" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$17,311.54" "$17,486.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100092 EAP CPT® 93583 Percut Trans Cath Septal Reduct Therpy (alcohol Sept Ab BOTH IP/OP "$27,795.00 " "$20,568.30" $0.00 "$25,883.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,424.39" $0.00 "$5,792.48" $0.00 $0.00 $0.00 $0.00 "$16,177.00" "$25,624.37" "$25,883.20" $0.00 "$11,982.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100095 EAP CPT® 93566 Inject R Ventr/atrial Angio BOTH IP/OP "$3,057.00 " "$2,262.18" $0.00 "$2,931.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $637.08 $0.00 $0.00 $0.00 $0.00 "$1,832.00" "$2,901.89" "$2,931.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100096 EAP CPT® 93568 Inject Pulm Art Hrt Cath BOTH IP/OP "$2,738.00 " "$2,026.12" $0.00 "$2,624.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $570.60 $0.00 $0.00 $0.00 $0.00 "$1,640.50" "$2,598.55" "$2,624.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100097 EAP CPT® 92998 Pulmonary Artery Pta Add'l Vessel BOTH IP/OP "$13,019.00 " "$9,634.06" $0.00 "$10,415.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,035.05" $0.00 "$2,713.16" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$10,311.05" "$10,415.20" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100098 EAP CPT® 92924 Coronary Atherectomy BOTH IP/OP "$25,780.00 " "$19,077.20" $0.00 "$19,871.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,871.22" $0.00 "$5,372.55" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$19,269.36" "$19,464.00" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100099 EAP CPT® 92925 Atherectomy Add'l Vessel BOTH IP/OP "$22,259.00 " "$16,471.66" $0.00 "$19,464.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$17,157.24" $0.00 "$4,638.78" $0.00 $0.00 $0.00 $0.00 "$12,165.00" "$19,269.36" "$19,464.00" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100100 EAP CPT® 93568 Inj. Proc During Cath Pulmonary Angiography BOTH IP/OP "$3,441.00 " "$2,546.34" $0.00 "$2,624.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $717.10 $0.00 $0.00 $0.00 $0.00 "$1,640.50" "$2,598.55" "$2,624.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100101 EAP CPT® 93566 Inject Pro. During Cath/rv/ra./s&i BOTH IP/OP "$3,057.00 " "$2,262.18" $0.00 "$2,931.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $637.08 $0.00 $0.00 $0.00 $0.00 "$1,832.00" "$2,901.89" "$2,931.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100102 EAP CPT® 93565 Inj. Pro During Cath/lv/la/s&i BOTH IP/OP "$2,659.00 " "$1,967.66" $0.00 "$2,148.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.14 $0.00 $0.00 $0.00 $0.00 "$1,343.00" "$2,127.31" "$2,148.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100103 EAP CPT® 33990 Insertion Of Impella Device - Cp BOTH IP/OP "$35,191.00 " "$26,041.34" $0.00 "$27,608.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$27,125.22" $0.00 "$7,333.80" $0.00 $0.00 $0.00 $0.00 "$17,255.50" "$27,332.71" "$27,608.80" $0.00 "$13,224.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100104 EAP CPT® 33992 Removal Of Impella BOTH IP/OP "$12,888.00 " "$9,537.12" $0.00 "$10,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$9,934.07" $0.00 "$2,685.86" $0.00 $0.00 $0.00 $0.00 "$6,319.50" "$10,010.09" "$10,111.20" $0.00 "$5,678.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100105 EAP CPT® 33993 Respositioning Of Impella BOTH IP/OP "$17,220.00 " "$12,742.80" $0.00 "$15,167.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,273.18" $0.00 "$3,588.65" $0.00 $0.00 $0.00 $0.00 "$9,479.50" "$15,015.53" "$15,167.20" $0.00 "$3,223.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100106 EAP CPT® 34812 Open Of Femoral Artery BOTH IP/OP "$8,696.00 " "$6,435.04" $0.00 "$6,956.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,702.88" $0.00 "$1,812.25" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,887.23" "$6,956.80" $0.00 "$3,227.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100107 EAP HCPCS 93531 R & L Heart Cath Congenital BOTH IP/OP "$29,098.00 " "$21,532.52" $0.00 "$23,278.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,425.60" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$23,045.62" "$23,278.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100108 EAP HCPCS 93563 Inject Congenital Card Cath BOTH IP/OP "$3,180.00 " "$2,353.20" $0.00 "$3,048.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.71 $0.00 $0.00 $0.00 $0.00 "$1,905.50" "$3,018.31" "$3,048.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100109 EAP CPT® 33947 Ecmo/ecls Initiation Artery BOTH IP/OP "$4,152.00 " "$3,072.48" $0.00 "$12,587.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,081.61" "$3,081.61" "$3,200.36" $0.00 $865.28 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,620.23" "$3,656.80" $0.00 "$12,587.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100110 EAP CPT® 33947 Ecmo/ecls Insj Prph Cannula BOTH IP/OP "$6,244.00 " "$4,620.56" $0.00 "$12,587.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,812.88" $0.00 "$1,301.25" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,445.00" "$5,500.00" $0.00 "$12,587.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100111 EAP CPT® 36901 Intro Cath Dialysis Circuit BOTH IP/OP "$3,666.00 " "$2,712.84" $0.00 "$2,825.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,720.91" "$2,720.91" "$2,825.75" $0.00 $763.99 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,444.90" "$2,469.60" $0.00 "$2,150.00" $0.00 $550.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100112 EAP CPT® 36902 Intro Cath Dialysis Circuit; W Angio BOTH IP/OP "$18,144.00 " "$13,426.56" $0.00 "$13,985.40" "$5,693.10" "$5,693.10" "$4,826.66" "$4,826.66" "$4,853.85" "$3,781.66" "$4,181.12" "$4,181.12" "$13,985.40" "$4,750.73" "$3,781.21" "$3,087.98" "$4,877.00" "$4,877.00" $0.00 "$4,975.00" "$12,100.97" "$12,223.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100113 EAP CPT® 36903 Intro Cath Dialysis Circuit; W Trans Intra Stent BOTH IP/OP "$36,671.00 " "$27,136.54" $0.00 "$28,266.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,266.01" $0.00 "$7,642.24" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$24,457.75" "$24,704.80" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100114 EAP CPT® 36904 Thrmbc/nfs Dialysis Circuit BOTH IP/OP "$18,144.00 " "$13,426.56" $0.00 "$13,985.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,985.40" $0.00 "$3,781.21" $0.00 $0.00 $0.00 $0.00 "$4,975.00" "$12,100.97" "$12,223.20" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100115 EAP CPT® 36905 Thrmbc/nfs Dialysis Circuit; W Angio BOTH IP/OP "$36,671.00 " "$27,136.54" $0.00 "$28,266.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$28,266.01" $0.00 "$7,642.24" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$24,457.75" "$24,704.80" $0.00 "$5,343.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100116 EAP CPT® 36906 Thrmbc/nfs Dialysis Circuit; W Trans Intra Stent BOTH IP/OP "$55,585.00 " "$41,132.90" $0.00 "$42,844.92" "$5,693.10" "$5,693.10" "$15,640.07" "$15,640.07" "$15,728.18" "$9,417.94" "$4,181.12" "$4,181.12" "$42,844.92" "$15,396.06" "$11,583.91" "$10,007.44" "$4,877.00" "$4,877.00" $0.00 "$6,105.00" "$37,071.14" "$37,445.60" $0.00 "$5,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100117 EAP CPT® 36907 Balo Angiop Ctr Dialysis Seg BOTH IP/OP "$3,666.00 " "$2,712.84" $0.00 "$2,825.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,720.91" "$2,720.91" "$2,825.75" $0.00 $763.99 $0.00 $0.00 $0.00 $0.00 "$1,543.50" "$2,444.90" "$2,469.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100118 EAP CPT® 37246 Trluml Balo Angiop 1st Art BOTH IP/OP "$15,477.00 " "$11,452.98" $0.00 "$12,142.40" "$5,693.10" "$5,693.10" "$4,826.66" "$4,826.66" "$4,853.85" "$3,225.79" "$4,181.12" "$4,181.12" "$11,929.67" "$4,750.73" "$3,225.41" "$3,087.98" "$4,877.00" "$4,877.00" $0.00 "$4,975.00" "$12,020.98" "$12,142.40" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100119 EAP CPT® 37247 Trluml Balo Angiop Addl Art BOTH IP/OP "$7,740.00 " "$5,727.60" $0.00 "$6,072.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,965.99" $0.00 "$1,613.02" $0.00 $0.00 $0.00 $0.00 "$3,795.00" "$6,011.28" "$6,072.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100120 EAP CPT® 37248 Trluml Balo Angiop 1st Vein BOTH IP/OP "$15,477.00 " "$11,452.98" $0.00 "$12,142.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,929.67" $0.00 "$3,225.41" $0.00 $0.00 $0.00 $0.00 "$4,975.00" "$12,020.98" "$12,142.40" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100121 EAP CPT® 37249 Trluml Balo Angiop Addl Vein BOTH IP/OP "$7,740.00 " "$5,727.60" $0.00 "$6,072.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,965.99" $0.00 "$1,613.02" $0.00 $0.00 $0.00 $0.00 "$3,795.00" "$6,011.28" "$6,072.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100122 EAP CPT® 36908 Tcat Plmt Iv Stent Ctr Dialysis Seg W/img S&i BOTH IP/OP "$3,261.00 " "$2,413.14" $0.00 "$2,513.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,420.31" "$2,420.31" "$2,513.58" $0.00 $679.59 $0.00 $0.00 $0.00 $0.00 "$1,373.00" "$2,174.83" "$2,196.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100123 EAP CPT® 36909 Dialyis Circuit Vasc Emboli Occls Evasc Img S&i BOTH IP/OP "$3,261.00 " "$2,413.14" $0.00 "$2,196.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $679.59 $0.00 $0.00 $0.00 $0.00 "$1,373.00" "$2,174.83" "$2,196.80" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100124 EAP CPT® 62321 Njx Dx/ther Sbst Intrlmnr Crv/thrc W/img Gdn BOTH IP/OP "$1,385.00 " "$1,024.90" $0.00 "$1,385.00" "$1,385.00" "$1,385.00" $618.38 $618.38 $621.87 $288.67 "$1,027.95" "$1,027.95" "$1,067.56" $608.20 $288.63 $395.33 "$1,385.00" "$1,385.00" $626.89 "$1,316.00" "$1,042.27" "$1,052.80" $870.98 $0.00 $870.98 $240.25 $111.42 $111.42 $209.51 $597.04 $0.00 $0.00 $0.00 $0.00 48100125 EAP CPT® 62323 Njx Dx/ther Sbst Intrlmnr Lmbr/sac W/img Gdn BOTH IP/OP "$1,385.00 " "$1,024.90" $103.13 "$2,150.00" "$1,385.00" "$1,385.00" $618.38 $618.38 $621.87 $288.67 "$1,027.95" "$1,027.95" "$1,067.56" $608.20 $288.63 $395.33 "$1,385.00" "$1,385.00" $626.89 "$1,316.00" "$1,042.27" "$1,052.80" $870.98 "$2,150.00" $870.98 $235.81 $103.13 $103.13 $209.51 $597.04 $0.00 $0.00 $0.00 $0.00 48100126 EAP HCPCS C9600 Perc Drug-eluting Cor Stent; Single Vessel BOTH IP/OP "$30,247.00 " "$22,382.78" $0.00 "$23,314.39" "$16,424.12" "$16,424.12" "$9,781.76" "$9,781.76" "$9,836.87" "$6,304.23" "$4,181.12" "$4,181.12" "$23,314.39" "$9,625.35" "$6,303.47" "$6,256.48" "$17,891.10" "$17,891.10" "$9,937.60" "$11,676.00" "$18,494.78" "$18,681.60" "$13,806.97" "$5,164.00" "$13,806.97" "$3,654.59" $0.00 $0.00 "$3,717.64" "$9,464.38" $0.00 $0.00 $0.00 $0.00 48100127 EAP HCPCS C9601 Perc Drug-eluting Cor Stent; Ea Addl Branch BOTH IP/OP "$25,675.00 " "$18,999.50" $0.00 "$19,790.29" "$13,941.53" "$13,941.53" $0.00 $0.00 $0.00 "$5,351.31" "$4,181.12" "$4,181.12" "$19,790.29" $0.00 "$5,350.67" $0.00 "$15,186.76" "$15,186.76" $0.00 "$9,911.00" "$15,699.02" "$15,857.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100128 EAP HCPCS C9602 Perc Drug-eluting Cor Stent & Atherect; Singl Vess BOTH IP/OP "$25,675.00 " "$18,999.50" $0.00 "$19,790.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,790.29" $0.00 "$5,350.67" $0.00 $0.00 $0.00 $0.00 "$9,911.00" "$15,699.02" "$15,857.60" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100129 EAP HCPCS C9603 Perc Drug-eluting Cor Stent & Atherect; Ea Addl Br BOTH IP/OP "$28,009.00 " "$20,726.66" $0.00 "$21,589.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,589.34" $0.00 "$5,837.08" $0.00 $0.00 $0.00 $0.00 "$10,812.00" "$17,126.21" "$17,299.20" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100130 EAP HCPCS C9604 Perc Drug-eluting Cor Revasc Of Or Thro Cabg;sing BOTH IP/OP "$26,434.00 " "$19,561.16" $0.00 "$20,375.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$20,375.33" $0.00 "$5,508.85" $0.00 $0.00 $0.00 $0.00 "$10,204.00" "$16,163.14" "$16,326.40" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100131 EAP HCPCS C9605 Perc Drug-eluting Cor Revasc Of Or Thr Cabg; Ea Ad BOTH IP/OP "$25,675.00 " "$18,999.50" $0.00 "$19,790.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$19,790.29" $0.00 "$5,350.67" $0.00 $0.00 $0.00 $0.00 "$9,911.00" "$15,699.02" "$15,857.60" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100132 EAP HCPCS C9606 Perc Drug-eluting Cor W/ Ami;single Ves BOTH IP/OP "$28,038.00 " "$20,748.12" $0.00 "$21,611.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$21,611.69" $0.00 "$5,843.12" $0.00 $0.00 $0.00 $0.00 "$10,823.00" "$17,143.63" "$17,316.80" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100133 EAP HCPCS C9607 Perc Drug-eluting Cor Revasc Cto;single Vess BOTH IP/OP "$25,675.00 " "$18,999.50" $0.00 "$19,790.29" $0.00 $0.00 $0.00 $0.00 $0.00 "$5,351.31" "$4,181.12" "$4,181.12" "$19,790.29" "$15,396.06" "$5,350.67" "$10,007.44" "$15,186.76" "$15,186.76" $0.00 "$9,911.00" "$15,699.02" "$15,857.60" $0.00 "$5,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100134 EAP HCPCS C9608 Perc Drug-eluting Cor Revasc Cto; Ea Addl Vessel BOTH IP/OP "$26,553.00 " "$19,649.22" $0.00 "$20,467.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$20,467.05" $0.00 "$5,533.65" $0.00 $0.00 $0.00 $0.00 "$10,250.00" "$16,236.00" "$16,400.00" $0.00 "$1,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100136 EAP CPT® 33272 Removal Sq Implant Defib Electrode BOTH IP/OP "$10,938.00 " "$8,094.12" $0.00 "$8,750.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,070.45" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$8,662.90" "$8,750.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48100140 EAP CPT® 33274 Transcath Insj/rpl Perm Leadless Pm Rv W/img BOTH IP/OP "$43,271.00 " "$32,020.54" $0.00 "$33,947.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$33,353.29" $0.00 "$9,017.68" $0.00 $0.00 $0.00 $0.00 "$6,105.00" "$33,607.73" "$33,947.20" $0.00 "$28,126.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48200001 EAP CPT® 93017 STRESS ECHO BOTH IP/OP "$3,621.00 " "$2,679.54" $0.00 "$2,896.80" $0.00 $0.00 $0.00 $0.00 $0.00 $747.20 $0.00 $0.00 $0.00 $253.45 $747.11 $164.75 "$2,120.53" "$2,120.53" $253.05 "$1,810.50" "$2,867.83" "$2,896.80" $351.58 $0.00 $351.58 $64.64 $34.22 $34.22 $576.46 $241.00 $0.00 $0.00 $0.00 $0.00 48200002 EAP CPT® 93017 Cardiac Stress Test BOTH IP/OP "$3,585.00 " "$2,652.90" $34.22 "$2,896.80" $86.88 $86.88 $257.73 $257.73 $259.18 $747.20 "$2,660.79" "$2,660.79" "$2,763.32" $253.45 $747.11 $164.75 "$2,120.53" "$2,120.53" $253.05 "$1,810.50" "$2,867.83" "$2,896.80" $351.58 "$2,330.25" $351.58 $64.64 $34.22 $34.22 $576.46 $241.00 $0.00 $0.00 $0.00 $0.00 48300001 EAP CPT® 93306 "Tte, Complete" BOTH IP/OP "$4,414.00 " "$3,266.36" $136.14 "$3,402.31" $504.77 $504.77 $470.55 $470.55 $473.20 $919.99 "$3,276.07" "$3,276.07" "$3,402.31" $462.81 $919.88 $300.83 "$2,610.88" "$2,610.88" $483.00 "$1,977.50" "$3,132.36" "$3,164.00" $671.06 "$2,869.10" $671.06 $254.50 $136.14 $136.14 $629.64 $460.00 $0.00 $0.00 $0.00 $0.00 48300003 EAP CPT® 93308 Tte. Limited BOTH IP/OP "$2,613.00 " "$1,933.62" $74.20 "$1,976.65" $276.25 $276.25 $224.08 $224.08 $225.34 $544.61 $205.76 $205.76 $213.68 $220.56 $544.55 $143.36 "$1,545.59" "$1,545.59" $233.72 "$1,171.00" "$1,854.86" "$1,873.60" $324.73 "$1,976.65" $324.73 $108.83 $74.20 $74.20 $372.85 $222.60 $0.00 $0.00 $0.00 $0.00 48300004 EAP CPT® 93350 Echo W/stress Test BOTH IP/OP "$3,748.00 " "$2,773.52" $118.63 "$2,955.20" $532.14 $532.14 $470.55 $470.55 $473.20 $781.18 $328.30 $328.30 $340.92 $462.81 $781.08 $300.83 "$2,216.94" "$2,216.94" $483.00 "$1,847.00" "$2,925.65" "$2,955.20" $671.06 "$2,436.20" $671.06 $118.63 $120.30 $120.30 $588.08 $460.00 $0.00 $0.00 $0.00 $0.00 48300005 EAP CPT® 93303 Transthoracic Echo For Congenital Anomalies BOTH IP/OP "$2,416.00 " "$1,787.84" $0.00 "$1,968.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.07 $372.07 $386.38 $0.00 $503.49 $0.00 $0.00 $0.00 $0.00 "$1,230.50" "$1,949.11" "$1,968.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48300006 EAP CPT® 93304 Transthoracic Echo Follow-up Limited Study BOTH IP/OP "$1,512.00 " "$1,118.88" $0.00 "$1,232.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.35 $239.35 $248.55 $0.00 $315.10 $0.00 $0.00 $0.00 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48300007 EAP HCPCS C8924 Tte 2d W Or W/o Fol W/contrast; Follow-up Or Ltd BOTH IP/OP "$2,899.00 " "$2,145.26" $0.00 "$2,234.55" "$1,574.16" "$1,574.16" $358.61 $358.61 $360.63 $604.22 "$2,151.64" "$2,151.64" "$2,234.55" $352.81 $604.15 $229.33 "$1,714.76" "$1,714.76" $387.01 "$1,298.50" "$2,056.82" "$2,077.60" $537.70 "$1,508.00" $537.70 $406.43 $0.00 $0.00 $413.44 $368.58 $0.00 $0.00 $0.00 $0.00 48300008 EAP HCPCS C8929 Tte 2d W Or W/o Fol W/contrast; Doppler BOTH IP/OP "$4,697.00 " "$3,475.78" $0.00 "$3,620.45" "$2,550.47" "$2,550.47" $696.71 $696.71 $700.64 $978.97 "$3,486.11" "$3,486.11" "$3,620.45" $685.44 $978.85 $445.54 "$2,778.28" "$2,778.28" $693.78 "$2,104.50" "$3,333.53" "$3,367.20" $963.92 "$2,898.35" $963.92 $658.71 $0.00 $0.00 $670.07 $660.75 $0.00 $0.00 $0.00 $0.00 48300009 EAP CPT® 93321 Doppler Echo Exam Heart (add-on) BOTH IP/OP $670.00 $495.80 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.89 $65.89 $68.43 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $435.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 49000001 EAP CPT® 59821 Trmt Of Missed Abort.-2nd Trim BOTH IP/OP "$3,666.00 " "$2,712.84" $0.00 "$3,666.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $763.99 $0.00 $0.00 $0.00 $0.00 "$3,666.00" "$2,903.47" "$2,932.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000003 EAP CPT® 19499 "Duct Lav Ea Brst, Sing Duct" BOTH IP/OP "$6,124.00 " "$4,531.76" $0.00 "$4,899.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,276.24" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,850.21" "$4,899.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000004 EAP CPT® 23500 Shoulder-clavicular BOTH IP/OP "$1,037.00 " $767.38 $0.00 "$1,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.11 $0.00 $0.00 $0.00 $0.00 "$1,037.00" $821.30 $829.60 $0.00 "$1,101.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000005 EAP CPT® 23540 Treat Clavicle Dislocation BOTH IP/OP $815.00 $603.10 $0.00 $815.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.85 $0.00 $0.00 $0.00 $0.00 $815.00 $645.48 $652.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000006 EAP CPT® 23620 Humerus-proximal BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,069.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 "$1,069.00" $846.65 $855.20 $0.00 $797.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000007 EAP CPT® 23675 Humerus-neck BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,550.00" "$1,227.60" "$1,240.00" $0.00 "$1,489.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000008 EAP CPT® 24500 Humerus-shaft BOTH IP/OP $689.00 $509.86 $0.00 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.59 $0.00 $0.00 $0.00 $0.00 $712.00 $563.90 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000009 EAP CPT® 24530 Humerus-condyle-supra BOTH IP/OP "$1,035.00 " $765.90 $0.00 "$1,069.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 "$1,069.00" $846.65 $855.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000010 EAP CPT® 24560 Humerus-distal Closed BOTH IP/OP $978.00 $723.72 $0.00 "$1,010.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.82 $0.00 $0.00 $0.00 $0.00 "$1,010.00" $799.92 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000011 EAP CPT® 24576 Humerus-condyle-medial BOTH IP/OP "$1,053.00 " $779.22 $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.45 $0.00 $0.00 $0.00 $0.00 "$1,088.00" $861.70 $870.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000012 EAP CPT® 24650 Elbow-radial Head BOTH IP/OP "$1,062.00 " $785.88 $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.32 $0.00 $0.00 $0.00 $0.00 "$1,097.00" $868.82 $877.60 $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000013 EAP CPT® 24670 Elbow-olecranon BOTH IP/OP $978.00 $723.72 $0.00 "$1,010.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.82 $0.00 $0.00 $0.00 $0.00 "$1,010.00" $799.92 $808.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000014 EAP CPT® 25530 Forearm-ulnar Shaft BOTH IP/OP "$1,203.00 " $890.22 $0.00 "$1,203.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,203.00" $952.78 $962.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000015 EAP CPT® 25560 Forearm-both Bones BOTH IP/OP $891.00 $659.34 $0.00 $903.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.68 $0.00 $0.00 $0.00 $0.00 $903.00 $715.18 $722.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000016 EAP CPT® 25600 Wrist-colles BOTH IP/OP "$1,165.00 " $862.10 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.62 $242.79 $128.45 $113.00 $113.00 $0.00 "$1,180.00" $934.56 $944.00 $0.00 "$1,233.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000017 EAP CPT® 25622 Wrist-scaphoid BOTH IP/OP "$1,077.00 " $796.98 $0.00 "$1,091.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.45 $0.00 $0.00 $0.00 $0.00 "$1,091.00" $864.07 $872.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000018 EAP CPT® 25630 Wrist-capitate BOTH IP/OP "$1,223.00 " $905.02 $0.00 "$1,223.00" "$1,223.00" "$1,223.00" $200.72 $200.72 $201.85 $254.90 $0.00 $0.00 $0.00 $197.62 $254.87 $128.45 $113.00 $113.00 $216.27 "$1,155.00" $914.76 $924.00 $300.48 "$1,223.00" $300.48 $266.34 $293.00 $293.00 $183.88 $205.98 $0.00 $0.00 $0.00 $0.00 51000019 EAP CPT® 26600 Hand-metacarpal Bone BOTH IP/OP "$1,078.00 " $797.72 $0.00 "$1,078.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.53 $0.00 $0.00 $0.00 $0.00 "$1,078.00" $853.78 $862.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000020 EAP CPT® 26750 Hand-phallax BOTH IP/OP $974.00 $720.76 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 "$1,035.00" $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000021 EAP CPT® 27750 Tibia-proximal BOTH IP/OP "$1,070.00 " $791.80 $0.00 "$1,133.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.99 $0.00 $0.00 $0.00 $0.00 "$1,133.00" $897.34 $906.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000022 EAP CPT® 27760 Ankle-medical Malleolus BOTH IP/OP $752.00 $556.48 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.72 $0.00 $0.00 $0.00 $0.00 $720.00 $570.24 $576.00 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000023 EAP CPT® 27780 Tiba-distal BOTH IP/OP "$1,057.00 " $782.18 $0.00 "$1,119.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.28 $0.00 $0.00 $0.00 $0.00 "$1,119.00" $886.25 $895.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000024 EAP CPT® 27786 Ankle-lateral Malleolus BOTH IP/OP "$1,204.00 " $890.96 $0.00 "$1,153.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.91 $0.00 $0.00 $0.00 $0.00 "$1,153.00" $913.18 $922.40 $0.00 "$1,035.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000025 EAP CPT® 27808 Treatment Of Ankle Fracture BOTH IP/OP "$1,087.00 " $804.38 $0.00 "$1,087.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,087.00" $860.90 $869.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000026 EAP CPT® 28470 Foot-metatarsal BOTH IP/OP $981.00 $725.94 $0.00 $981.00 $981.00 $981.00 $200.72 $200.72 $201.85 $0.00 $0.00 $0.00 $0.00 $197.62 $204.44 $128.45 $113.00 $113.00 $216.27 $981.00 $776.95 $784.80 $300.48 $0.00 $300.48 $214.80 $210.83 $210.83 $156.18 $205.98 $0.00 $0.00 $0.00 $0.00 51000027 EAP CPT® 28510 Treatment Of Toe Fracture BOTH IP/OP $981.00 $725.94 $0.00 $991.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.44 $0.00 $0.00 $0.00 $0.00 $981.00 $776.95 $784.80 $0.00 $991.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000028 EAP CPT® 29105 Long Arm Splint BOTH IP/OP $859.00 $635.66 $0.00 $859.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.13 $859.00 $680.33 $687.20 $186.36 $0.00 $186.36 $94.27 $43.63 $43.63 $136.75 $127.75 $0.00 $0.00 $0.00 $0.00 51000029 EAP CPT® 29125 "Splint, Short Arm" BOTH IP/OP $952.00 $704.48 $0.00 $952.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.35 $952.00 $753.98 $761.60 $151.93 $0.00 $151.93 $72.40 $40.73 $40.73 $151.56 $104.14 $0.00 $0.00 $0.00 $0.00 51000030 EAP CPT® 29130 "Splint, Finger" BOTH IP/OP $859.00 $635.66 $0.00 $859.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $859.00 $680.33 $687.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000031 EAP CPT® 29505 Long Leg Splint BOTH IP/OP "$1,372.00 " "$1,015.28" $0.00 "$1,535.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.92 $0.00 $0.00 $0.00 $134.13 "$1,535.00" "$1,215.72" "$1,228.00" $186.36 $940.00 $186.36 $94.49 $52.27 $52.27 $244.37 $127.75 $0.00 $0.00 $0.00 $0.00 51000032 EAP CPT® 29515 "Splint, Short Leg" BOTH IP/OP $943.00 $697.82 $0.00 $943.00 $512.05 $512.05 $137.58 $137.58 $138.36 $196.54 $0.00 $0.00 $0.00 $135.31 $196.52 $87.95 $113.00 $113.00 $134.13 $888.00 $703.30 $710.40 $186.36 $943.00 $186.36 $80.51 $51.19 $51.19 $141.37 $127.75 $0.00 $0.00 $0.00 $0.00 51000036 EAP CPT® 51702 Cath Insert Indwelling BOTH IP/OP "$1,069.00 " $791.06 $0.00 "$1,069.00" $0.00 $0.00 $0.00 $0.00 $0.00 $223.01 $0.00 $0.00 $0.00 $107.30 $222.99 $69.74 $113.00 $113.00 $109.35 "$1,069.00" $846.65 $855.20 $151.93 $0.00 $151.93 $91.18 $26.68 $26.68 $170.18 $104.14 $0.00 $0.00 $0.00 $0.00 51000038 EAP CPT® 59070 Amnio Infusion (adb) BOTH IP/OP $439.00 $324.86 $0.00 $443.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.49 $0.00 $0.00 $0.00 $0.00 $443.00 $350.86 $354.40 $0.00 $439.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000039 EAP CPT® 59899 Maternity Care Procedure BOTH IP/OP $183.00 $135.42 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.14 $0.00 $0.00 $0.00 $0.00 $183.00 $144.94 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000041 EAP CPT® 92002 "Ophalmol Exam, Inter, Np" BOTH IP/OP $313.00 $231.62 $0.00 $323.29 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $65.23 $73.97 $185.14 $185.14 $116.27 $122.50 $194.04 $196.00 $161.54 $313.00 $161.54 $60.73 $48.33 $48.33 $39.00 $110.73 $0.00 $0.00 $0.00 $0.00 51000042 EAP CPT® 92004 "Opthalmol Exam, Compre, Np" BOTH IP/OP $411.00 $304.14 $0.00 $329.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $85.65 $73.97 $243.11 $243.11 $116.27 $202.00 $319.97 $323.20 $161.54 $329.00 $161.54 $101.46 $99.90 $99.90 $64.32 $110.73 $0.00 $0.00 $0.00 $0.00 51000043 EAP CPT® 92012 "Opthalmol Exam, Inter, Ep" BOTH IP/OP $313.00 $231.62 $0.00 $323.29 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $65.23 $73.97 $185.14 $185.14 $116.27 $111.00 $175.82 $177.60 $161.54 $313.00 $161.54 $51.64 $53.01 $53.01 $35.34 $110.73 $0.00 $0.00 $0.00 $0.00 51000044 EAP CPT® 92014 "Opthalmol Exam, Compre, Ep" BOTH IP/OP $380.00 $281.20 $0.00 $380.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $79.19 $73.97 $224.77 $224.77 $116.27 $187.00 $296.21 $299.20 $161.54 $380.00 $161.54 $74.47 $80.42 $80.42 $59.54 $110.73 $0.00 $0.00 $0.00 $0.00 51000046 EAP CPT® 92020 Gonioscopy Exam BOTH IP/OP $272.00 $201.28 $0.00 $323.29 $0.00 $0.00 $109.81 $109.81 $110.43 $67.13 $311.31 $311.31 $323.29 $107.30 $56.68 $69.74 $160.89 $160.89 $109.35 $134.00 $212.26 $214.40 $151.93 $294.00 $151.93 $33.89 $21.28 $21.28 $42.67 $104.14 $0.00 $0.00 $0.00 $0.00 51000050 EAP CPT® 96372 Inject-im/sq Only BOTH IP/OP $260.00 $192.40 $0.00 $200.41 $141.18 $141.18 $60.38 $60.38 $60.72 $54.19 $192.97 $192.97 $200.41 $59.39 $0.00 $38.61 $153.79 $153.79 $60.65 $111.50 $176.62 $178.40 $84.26 $169.00 $84.26 $20.00 $14.42 $14.42 $35.50 $57.76 $0.00 $0.00 $0.00 $0.00 51000057 EAP CPT® 99201 Visit Level 1 - Np BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.27 $164.50 $260.57 $263.20 $27.04 $0.00 $27.04 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000058 EAP CPT® 99202 Visit Level 2 - Np BOTH IP/OP $384.00 $284.16 $0.00 $384.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $227.14 $227.14 $116.27 $189.00 $299.38 $302.40 $51.57 $384.00 $51.57 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000059 EAP CPT® 99203 Visit Level 3 - Np BOTH IP/OP $449.00 $332.26 $0.00 $449.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $265.58 $265.58 $116.27 $221.00 $350.06 $353.60 $77.17 $449.00 $77.17 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000060 EAP CPT® 99204 Visit Level 4 - Np BOTH IP/OP $579.00 $428.46 $0.00 $579.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $342.48 $342.48 $116.27 $284.50 $450.65 $455.20 $131.98 $579.00 $131.98 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000061 EAP CPT® 99205 Visit Level 5-np BOTH IP/OP $697.00 $515.78 $0.00 $697.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $412.28 $412.28 $116.27 $343.00 $543.31 $548.80 $172.37 $697.00 $172.37 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000062 EAP CPT® 99211 Visit Level 1 - Ep BOTH IP/OP $325.00 $240.50 $0.00 $325.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $192.24 $192.24 $116.27 $145.00 $229.68 $232.00 $9.38 $325.00 $9.38 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000063 EAP CPT® 99212 Visit Level 2-ep BOTH IP/OP $348.00 $257.52 $0.00 $348.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $205.84 $205.84 $116.27 $156.50 $247.90 $250.40 $26.32 $348.00 $26.32 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000064 EAP CPT® 99213 Visit Level 3-ep BOTH IP/OP $434.00 $321.16 $0.00 $434.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $256.71 $256.71 $116.27 $199.50 $316.01 $319.20 $52.29 $434.00 $52.29 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000065 EAP CPT® 99214 Visit Level 4-ep BOTH IP/OP $526.00 $389.24 $0.00 $526.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $311.13 $311.13 $116.27 $245.50 $388.87 $392.80 $80.42 $526.00 $80.42 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000066 EAP CPT® 99215 Visit Level 5-ep BOTH IP/OP $576.00 $426.24 $0.00 $576.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $340.70 $340.70 $116.27 $270.50 $428.47 $432.80 $113.60 $576.00 $113.60 $108.52 $0.00 $0.00 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000086 EAP HCPCS G0127 Trim Of Dystrophic Nail(s) BOTH IP/OP $121.00 $89.54 $0.00 $122.00 $65.70 $65.70 $54.21 $54.21 $54.51 $25.22 $0.00 $0.00 $0.00 $53.35 $25.22 $34.67 $113.00 $113.00 $55.17 $122.00 $96.62 $97.60 $76.65 $121.00 $76.65 $19.09 $7.94 $7.94 $19.42 $52.54 $0.00 $0.00 $0.00 $0.00 51000087 EAP HCPCS G0402 New Medicare Phys Exam BOTH IP/OP $375.00 $277.50 $0.00 $323.29 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $78.15 $73.97 $221.81 $221.81 $116.27 $184.50 $292.25 $295.20 $161.54 $243.75 $161.54 $57.75 $129.11 $129.11 $58.74 $110.73 $0.00 $0.00 $0.00 $0.00 51000090 EAP Custom 51000090 Annual Health Screen BOTH IP/OP $168.00 $124.32 $0.00 $323.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.31 $311.31 $323.29 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000157 EAP CPT® 99201 Visit Level Bccp 1 - Np BOTH IP/OP $329.00 $243.46 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.27 $164.50 $260.57 $263.20 $27.04 $0.00 $27.04 $108.52 $27.04 $27.04 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000158 EAP CPT® 99202 Visit Level Bccp 2 - Np BOTH IP/OP $384.00 $284.16 $0.00 $384.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $227.14 $227.14 $116.27 $189.00 $299.38 $302.40 $51.57 $384.00 $51.57 $108.52 $51.57 $51.57 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000159 EAP CPT® 99203 Visit Level Bccp 3 - Np BOTH IP/OP $449.00 $332.26 $0.00 $449.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $265.58 $265.58 $116.27 $221.00 $350.06 $353.60 $77.17 $449.00 $77.17 $108.52 $77.17 $77.17 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000161 EAP CPT® 99205 Visit Level Bccp 5-np BOTH IP/OP $697.00 $515.78 $0.00 $697.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $412.28 $412.28 $116.27 $343.00 $543.31 $548.80 $172.37 $697.00 $172.37 $108.52 $172.37 $172.37 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000162 EAP CPT® 99211 Visit Level Bccp 1 - Ep BOTH IP/OP $325.00 $240.50 $0.00 $323.29 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $192.24 $192.24 $116.27 $145.00 $229.68 $232.00 $9.38 $0.00 $9.38 $108.52 $9.38 $9.38 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000163 EAP CPT® 99212 Visit Level Bccp 2 - Ep BOTH IP/OP $340.00 $251.60 $0.00 $348.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $201.11 $201.11 $116.27 $156.50 $247.90 $250.40 $26.32 $348.00 $26.32 $108.52 $26.32 $26.32 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000164 EAP CPT® 99213 Visit Level Bccp 3 - Ep BOTH IP/OP $434.00 $321.16 $0.00 $434.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $256.71 $256.71 $116.27 $199.50 $316.01 $319.20 $52.29 $434.00 $52.29 $108.52 $52.29 $52.29 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000166 EAP CPT® 99215 Visit Level Bccp 5-ep BOTH IP/OP $576.00 $426.24 $0.00 $576.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $340.70 $340.70 $116.27 $270.50 $428.47 $432.80 $113.60 $576.00 $113.60 $108.52 $113.60 $113.60 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000190 EAP CPT® 92133 Cmptr Ophth Img Optic Nerve BOTH IP/OP $342.00 $253.08 $0.00 $342.00 $0.00 $0.00 $54.21 $54.21 $54.51 $67.13 $311.31 $311.31 $323.29 $53.35 $71.27 $34.67 $202.29 $202.29 $55.17 $168.00 $266.11 $268.80 $76.65 $342.00 $76.65 $42.26 $15.13 $15.13 $53.49 $52.54 $0.00 $0.00 $0.00 $0.00 51000191 EAP CPT® 92134 Cptr Ophth Dx Img Post Segmt BOTH IP/OP $342.00 $253.08 $0.00 $342.00 $0.00 $0.00 $54.21 $54.21 $54.51 $67.13 $311.31 $311.31 $323.29 $53.35 $71.27 $34.67 $202.29 $202.29 $55.17 $168.00 $266.11 $268.80 $76.65 $342.00 $76.65 $42.26 $15.49 $15.49 $53.49 $52.54 $0.00 $0.00 $0.00 $0.00 51000211 EAP CPT® 99497 Advance Care Planning First 30 Mins BOTH IP/OP $173.00 $128.02 $0.00 $323.29 $0.00 $0.00 $72.87 $72.87 $73.28 $67.13 $311.31 $311.31 $323.29 $71.76 $36.05 $46.64 $102.33 $102.33 $78.77 $85.00 $134.64 $136.00 $109.44 $173.00 $109.44 $26.61 $80.42 $80.42 $27.06 $75.02 $0.00 $0.00 $0.00 $0.00 51000212 EAP CPT® 99498 Advance Care Planning Ea Addl 30 Mins (add-on) BOTH IP/OP $158.00 $116.92 $0.00 $323.29 $0.00 $0.00 $0.00 $0.00 $0.00 $67.13 $311.31 $311.31 $323.29 $0.00 $32.93 $0.00 $93.46 $93.46 $0.00 $77.50 $122.76 $124.00 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000260 EAP CPT® 99204 Visit Level Bccp 4 - Np BOTH IP/OP $579.00 $428.46 $0.00 $579.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $342.48 $342.48 $116.27 $284.50 $450.65 $455.20 $131.98 $579.00 $131.98 $108.52 $131.98 $131.98 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000265 EAP CPT® 99214 Visit Level Bccp 4-ep BOTH IP/OP $526.00 $389.24 $0.00 $526.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $0.00 $73.97 $311.13 $311.13 $116.27 $245.50 $388.87 $392.80 $80.42 $526.00 $80.42 $108.52 $80.42 $80.42 $99.16 $110.73 $0.00 $0.00 $0.00 $0.00 51000313 EAP CPT® 99495 DISCHARGE PHONE CALL AND F/U APPT WITHIN 14 DAYS BOTH IP/OP $285.00 $210.90 $0.00 $323.29 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $59.39 $73.97 $168.58 $168.58 $116.27 $140.00 $221.76 $224.00 $161.54 $0.00 $161.54 $43.82 $125.50 $125.50 $44.58 $110.73 $0.00 $0.00 $0.00 $0.00 51000314 EAP CPT® 99496 DISCHARGE PHONE CALL AND F/U APPT WITHIN 7 DAYS BOTH IP/OP $417.00 $308.58 $0.00 $328.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $86.90 $73.97 $246.66 $246.66 $116.27 $205.00 $324.72 $328.00 $161.54 $0.00 $161.54 $64.17 $165.53 $165.53 $65.27 $110.73 $0.00 $0.00 $0.00 $0.00 51000315 EAP CPT® 99205 Isolation Evaluation - Np BOTH IP/OP "$1,700.00 " "$1,258.00" $0.00 "$1,360.00" $0.00 $0.00 $172.37 $172.37 $185.53 $67.13 $311.31 $311.31 $323.29 $172.37 $0.00 $112.04 "$1,005.55" "$1,005.55" $181.26 $850.00 "$1,346.40" "$1,360.00" $172.37 $697.00 $172.37 $108.52 $172.37 $172.37 $99.16 $172.37 $0.00 $0.00 $0.00 $0.00 51000316 EAP CPT® 99215 Isolation Evaluation - Ep BOTH IP/OP "$1,320.00 " $976.80 $0.00 "$1,056.00" $0.00 $0.00 $113.60 $113.60 $147.16 $67.13 $311.31 $311.31 $323.29 $113.60 $0.00 $73.84 $780.78 $780.78 $118.93 $660.00 "$1,045.44" "$1,056.00" $113.60 $576.00 $113.60 $108.52 $113.60 $113.60 $99.16 $113.60 $0.00 $0.00 $0.00 $0.00 51000320 EAP CPT® 97605 Neg Press Wd Tx - 50 Sq Cm Or Less BOTH IP/OP $317.00 $234.58 $0.00 $246.40 $172.13 $172.13 $174.88 $174.88 $175.86 $66.07 $0.00 $0.00 $0.00 $172.08 $66.06 $111.85 $187.51 $187.51 $175.24 $154.00 $243.94 $246.40 $243.48 $206.05 $243.48 $33.92 $26.69 $26.69 $49.03 $166.90 $0.00 $0.00 $0.00 $0.00 51000321 EAP CPT® 97606 Neg Press Wd Tx-> Than 50 Sq Cm BOTH IP/OP $524.00 $387.76 $0.00 $407.20 $0.00 $0.00 $0.00 $0.00 $0.00 $109.21 $0.00 $0.00 $0.00 $331.46 $109.20 $215.45 $309.95 $309.95 $0.00 $254.50 $403.13 $407.20 $0.00 $340.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000322 EAP CPT® G0438 "Annual Wellness Visit, Initial Visit" BOTH IP/OP $409.00 $302.66 $0.00 $409.00 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $85.24 $73.97 $241.92 $241.92 $116.27 $201.00 $318.38 $321.60 $172.69 $409.00 $172.69 $62.91 $172.69 $172.69 $64.00 $110.73 $0.00 $0.00 $0.00 $0.00 51000323 EAP CPT® G0439 "Annual Wellness Visit, Subseq Visit" BOTH IP/OP $291.00 $215.34 $0.00 $323.29 $0.00 $0.00 $115.71 $115.71 $116.36 $67.13 $311.31 $311.31 $323.29 $113.80 $60.64 $73.97 $172.13 $172.13 $116.27 $143.00 $226.51 $228.80 $117.16 $291.00 $117.16 $44.76 $117.16 $117.16 $45.53 $110.73 $0.00 $0.00 $0.00 $0.00 51000324 EAP CPT® 99487 Complex Chronic Care Mgmt - 1st Hr Per Month BOTH IP/OP $175.00 $129.50 $0.00 $323.29 $0.00 $0.00 $130.30 $130.30 $131.03 $67.13 $311.31 $311.31 $323.29 $128.07 $36.47 $83.25 $103.51 $103.51 $78.77 $86.00 $136.22 $137.60 $109.44 $175.00 $109.44 $26.92 $53.37 $53.37 $27.38 $75.02 $0.00 $0.00 $0.00 $0.00 51000325 EAP CPT® 99490 Chronic Care Mgmt - 20 Min. Per Month BOTH IP/OP $175.00 $129.50 $0.00 $323.29 $0.00 $0.00 $72.87 $72.87 $73.28 $67.13 $311.31 $311.31 $323.29 $71.76 $36.47 $46.64 $103.51 $103.51 $78.77 $86.00 $136.22 $137.60 $109.44 $175.00 $109.44 $26.92 $32.82 $32.82 $27.38 $75.02 $0.00 $0.00 $0.00 $0.00 51000326 EAP CPT® 99489 Complex Chronic Care Mgmt – Ea Addl 30 Min Per Month BOTH IP/OP $87.00 $64.38 $0.00 $323.29 $0.00 $0.00 $0.00 $0.00 $0.00 $67.13 $311.31 $311.31 $323.29 $0.00 $18.13 $0.00 $51.46 $51.46 $0.00 $43.00 $68.11 $68.80 $0.00 $87.00 $0.00 $13.46 $26.33 $26.33 $13.69 $0.00 $0.00 $0.00 $0.00 $0.00 51000327 EAP CPT® 92230 Eye Exam With Photos BOTH IP/OP $712.00 $526.88 $0.00 $712.00 $0.00 $0.00 $475.36 $475.36 $478.04 $67.13 $311.31 $311.31 $323.29 $467.50 $148.38 $303.87 $421.15 $421.15 $0.00 $350.00 $554.40 $560.00 $0.00 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51000328 EAP CPT® 92326 Replacement Of Contact Lens BOTH IP/OP $150.00 $111.00 $0.00 $323.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.31 $311.31 $323.29 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51100021 EAP CPT® 64640 Destr Peripheral Nerve BOTH IP/OP "$2,488.00 " "$1,841.12" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $518.56 $0.00 $0.00 $0.00 $788.26 $518.50 $512.37 "$1,871.00" "$1,871.00" $814.44 "$2,255.00" "$1,980.79" "$2,000.80" "$1,131.55" "$2,150.00" "$1,131.55" $198.96 $121.87 $121.87 $398.16 $775.65 $0.00 $0.00 $0.00 $0.00 61000001 EAP CPT® 70336 Mri Tmj Mri BOTH IP/OP "$4,123.00 " "$3,051.02" $143.36 "$3,332.00" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 $859.34 "$1,171.15" "$1,171.15" "$1,216.20" $220.56 $859.23 $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,298.68" "$3,332.00" $324.73 $800.00 $324.73 $651.82 $236.99 $236.99 $663.07 $222.60 $0.00 $0.00 $0.00 $0.00 61000002 EAP CPT® 70540 Mri:orbit/face/neckw/o Contr. BOTH IP/OP "$5,561.00 " "$4,115.14" $143.36 "$4,229.60" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,159.05" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,158.91" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$4,187.30" "$4,229.60" $324.73 $800.00 $324.73 $827.42 $195.93 $195.93 $841.69 $222.60 $0.00 $0.00 $0.00 $0.00 61000003 EAP CPT® 70542 Mri Orbit/face/neck/w/dye Mri BOTH IP/OP "$5,964.00 " "$4,413.36" $229.33 "$4,536.00" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,243.05" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,242.90" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,162.00" "$4,490.64" "$4,536.00" $537.70 $800.00 $537.70 $887.36 $230.87 $230.87 $902.66 $368.58 $0.00 $0.00 $0.00 $0.00 61000004 EAP CPT® 70543 Mri Orb/face/neck W&wo Dye Mri BOTH IP/OP "$8,010.00 " "$5,927.40" $229.33 "$6,092.00" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,669.48" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,669.28" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$6,031.08" "$6,092.00" $537.70 $800.00 $537.70 "$1,191.75" $285.62 $285.62 "$1,212.31" $368.58 $0.00 $0.00 $0.00 $0.00 61000005 EAP CPT® 70544 Mra Head W/o Dye BOTH IP/OP "$5,561.00 " "$4,115.14" $143.36 "$4,229.60" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,159.05" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,158.91" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$4,187.30" "$4,229.60" $324.73 $800.00 $324.73 $827.42 $187.29 $187.29 $841.69 $222.60 $0.00 $0.00 $0.00 $0.00 61000006 EAP CPT® 70545 Mra Head W/ Dye BOTH IP/OP "$5,964.00 " "$4,413.36" $198.45 "$4,536.00" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,243.05" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,242.90" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,162.00" "$4,490.64" "$4,536.00" $537.70 $800.00 $537.70 $887.36 $198.45 $198.45 $902.66 $368.58 $0.00 $0.00 $0.00 $0.00 61000007 EAP CPT® 70546 Mra Head W & W/o Dye BOTH IP/OP "$8,010.00 " "$5,927.40" $229.33 "$6,092.00" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,669.48" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,669.28" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$6,031.08" "$6,092.00" $537.70 $800.00 $537.70 "$1,191.75" $300.74 $300.74 "$1,212.31" $368.58 $0.00 $0.00 $0.00 $0.00 61000008 EAP CPT® 70547 Mra Neck W/o Dye BOTH IP/OP "$5,561.00 " "$4,115.14" $143.36 "$4,229.60" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,159.05" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,158.91" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$4,187.30" "$4,229.60" $324.73 $800.00 $324.73 $827.42 $188.01 $188.01 $841.69 $222.60 $0.00 $0.00 $0.00 $0.00 61000009 EAP CPT® 70548 Mra Neck W/ Dye BOTH IP/OP "$6,193.00 " "$4,582.82" $202.06 "$4,710.40" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,290.78" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,290.62" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,162.00" "$4,663.30" "$4,710.40" $537.70 $800.00 $537.70 $921.47 $202.06 $202.06 $937.37 $368.58 $0.00 $0.00 $0.00 $0.00 61000010 EAP CPT® 70549 Mra Neck W&wo Dye BOTH IP/OP "$8,010.00 " "$5,927.40" $229.33 "$6,092.00" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,669.48" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,669.28" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$6,031.08" "$6,092.00" $537.70 $800.00 $537.70 "$1,191.75" $302.90 $302.90 "$1,212.31" $368.58 $0.00 $0.00 $0.00 $0.00 61000011 EAP CPT® 71550 Mri Chest W/o Dye BOTH IP/OP "$4,941.00 " "$3,656.34" $0.00 "$3,992.80" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,029.70" $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,043.00" "$3,952.87" "$3,992.80" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000012 EAP CPT® 71551 Mri Chest W/dye BOTH IP/OP "$3,511.00 " "$2,598.14" $0.00 "$2,836.80" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $731.69 $0.00 "$1,758.00" "$1,758.00" $693.78 "$1,162.00" "$2,808.43" "$2,836.80" $963.92 $800.00 $963.92 $554.95 $355.13 $355.13 $564.52 $660.75 $0.00 $0.00 $0.00 $0.00 61000013 EAP CPT® 71552 Mri Chest W&wo Dye BOTH IP/OP "$6,183.00 " "$4,575.42" $229.33 "$4,996.00" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,288.69" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,288.54" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$4,946.04" "$4,996.00" $537.70 $800.00 $537.70 $977.34 $446.61 $446.61 $994.20 $368.58 $0.00 $0.00 $0.00 $0.00 61000014 EAP CPT® 71555 Mra Chest W&wo Dye BOTH IP/OP "$5,145.00 " "$3,807.30" $0.00 "$4,157.60" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 $0.00 "$1,171.15" "$1,171.15" "$1,216.20" $0.00 "$1,072.22" $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,247.28" "$4,116.02" "$4,157.60" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000015 EAP CPT® 72159 Mra Spinal Canal W/wo Dye BOTH IP/OP "$8,413.00 " "$6,225.62" $0.00 "$6,798.40" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,753.27" $0.00 "$1,758.00" "$1,758.00" $0.00 "$2,039.52" "$6,730.42" "$6,798.40" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000016 EAP CPT® 72198 Mra Pelvis W/wo Dye BOTH IP/OP "$6,417.00 " "$4,748.58" $0.00 "$5,131.20" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,337.30" $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,539.36" "$5,079.89" "$5,131.20" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000017 EAP CPT® 73218 Mri Upp Ext Nt Jt Wo Dye B Mri BOTH IP/OP "$10,051.00 " "$7,437.74" $143.36 "$8,040.80" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$2,094.88" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$2,094.63" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$7,960.39" "$8,040.80" $324.73 $800.00 $324.73 "$1,572.98" $288.50 $288.50 "$1,600.12" $222.60 $0.00 $0.00 $0.00 $0.00 61000018 EAP CPT® 73218 Mri Upp Ext Nt Jt Wo Dye L Mri BOTH IP/OP "$5,026.00 " "$3,719.24" $0.00 "$4,020.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.12" $0.00 $0.00 $0.00 $220.56 "$1,037.00" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,980.59" "$4,020.80" $324.73 $0.00 $324.73 $786.57 $288.50 $288.50 $800.14 $222.60 $0.00 $0.00 $0.00 $0.00 61000019 EAP CPT® 73218 Mri Upp Ext Nt Jt Wo Dye R Mri BOTH IP/OP "$4,976.00 " "$3,682.24" $143.36 "$4,020.80" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,037.12" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,037.00" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,980.59" "$4,020.80" $324.73 $800.00 $324.73 $786.57 $288.50 $288.50 $800.14 $222.60 $0.00 $0.00 $0.00 $0.00 61000020 EAP CPT® 73219 Mri Upp Ext Not Jt W/dye B Mri BOTH IP/OP "$10,778.00 " "$7,975.72" $0.00 "$8,622.40" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$2,246.40" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$2,246.14" $229.33 "$1,758.00" "$1,758.00" $0.00 "$1,162.00" "$8,536.18" "$8,622.40" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000021 EAP CPT® 73219 Mri Upp Ext Not Jt W/dye L Mri BOTH IP/OP "$5,393.00 " "$3,990.82" $0.00 "$4,314.40" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,124.04" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,123.90" $229.33 "$1,758.00" "$1,758.00" $0.00 "$1,162.00" "$4,271.26" "$4,314.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000022 EAP CPT® 73219 Mri Upp Ext Not Jt W/dye R Mri BOTH IP/OP "$5,339.00 " "$3,950.86" $0.00 "$4,314.40" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,112.78" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,112.65" $229.33 "$1,758.00" "$1,758.00" $0.00 "$1,162.00" "$4,271.26" "$4,314.40" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000023 EAP CPT® 73220 Mri Upp Ext Nt Jt W&wo Bi Mri BOTH IP/OP "$13,949.00 " "$10,322.26" $229.33 "$11,159.20" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$2,907.32" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$2,906.97" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$11,047.61" "$11,159.20" $537.70 $800.00 $537.70 "$2,183.02" $376.02 $376.02 "$2,220.68" $368.58 $0.00 $0.00 $0.00 $0.00 61000024 EAP CPT® 73220 Mri Upp Ext Nt Jt W&wo Lt Mri BOTH IP/OP "$6,906.00 " "$5,110.44" $229.33 "$5,580.80" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,439.38" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,439.21" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$5,524.99" "$5,580.80" $537.70 $800.00 $537.70 "$1,091.74" $376.02 $376.02 "$1,110.58" $368.58 $0.00 $0.00 $0.00 $0.00 61000025 EAP CPT® 73220 Mri Upp Ext Nt Jt W&wo Rt Mri BOTH IP/OP "$6,976.00 " "$5,162.24" $0.00 "$5,580.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,439.38" $0.00 $0.00 $0.00 $352.81 "$1,439.21" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$5,524.99" "$5,580.80" $537.70 $0.00 $537.70 "$1,091.74" $376.02 $376.02 "$1,110.58" $368.58 $0.00 $0.00 $0.00 $0.00 61000026 EAP CPT® 73221 Mri Upp Ext Jnt W/o Dye Bi Mri BOTH IP/OP "$10,051.00 " "$7,437.74" $143.36 "$8,040.80" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$2,094.88" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$2,094.63" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$7,960.39" "$8,040.80" $324.73 $800.00 $324.73 "$1,572.98" $162.80 $162.80 "$1,600.12" $222.60 $0.00 $0.00 $0.00 $0.00 61000027 EAP CPT® 73221 Mri Upp Ext Jnt W/o Dye Lt Mri BOTH IP/OP "$5,026.00 " "$3,719.24" $0.00 "$4,020.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.12" $0.00 $0.00 $0.00 $220.56 "$1,037.00" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,980.59" "$4,020.80" $324.73 $0.00 $324.73 $786.57 $162.80 $162.80 $800.14 $222.60 $0.00 $0.00 $0.00 $0.00 61000028 EAP CPT® 73221 Mri Upp Ext Jnt W/o Dye Rt Mri BOTH IP/OP "$4,976.00 " "$3,682.24" $143.36 "$4,020.80" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,037.12" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,037.00" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,980.59" "$4,020.80" $324.73 $800.00 $324.73 $786.57 $162.80 $162.80 $800.14 $222.60 $0.00 $0.00 $0.00 $0.00 61000030 EAP CPT® 73222 Mri Upp Ext Jnt W/dye Bi Mri BOTH IP/OP "$11,196.00 " "$8,285.04" $287.06 "$8,956.80" "$2,060.10" "$2,060.10" $696.71 $696.71 $700.64 "$2,333.53" "$1,171.15" "$1,171.15" "$1,216.20" $685.44 "$2,333.25" $445.54 "$1,758.00" "$1,758.00" $693.78 "$1,162.00" "$8,867.23" "$8,956.80" $963.92 $800.00 $963.92 "$1,752.17" $287.06 $287.06 "$1,782.40" $660.75 $0.00 $0.00 $0.00 $0.00 61000031 EAP CPT® 73222 Mri Upp Ext Jnt W/dye Lt Mri BOTH IP/OP "$5,541.00 " "$4,100.34" $287.06 "$4,477.60" "$2,060.10" "$2,060.10" $696.71 $696.71 $700.64 "$1,154.88" "$1,171.15" "$1,171.15" "$1,216.20" $685.44 "$1,154.74" $445.54 "$1,758.00" "$1,758.00" $693.78 "$1,162.00" "$4,432.82" "$4,477.60" $963.92 $800.00 $963.92 $875.93 $287.06 $287.06 $891.04 $660.75 $0.00 $0.00 $0.00 $0.00 61000032 EAP CPT® 73222 Mri Upp Ext Jnt W/dye Rt Mri BOTH IP/OP "$5,541.00 " "$4,100.34" $287.06 "$4,477.60" "$2,060.10" "$2,060.10" $696.71 $696.71 $700.64 "$1,154.88" "$1,171.15" "$1,171.15" "$1,216.20" $685.44 "$1,154.74" $445.54 "$1,758.00" "$1,758.00" $693.78 "$1,162.00" "$4,432.82" "$4,477.60" $963.92 $800.00 $963.92 $875.93 $287.06 $287.06 $891.04 $660.75 $0.00 $0.00 $0.00 $0.00 61000033 EAP CPT® 73223 Mri Upp Ext Jnt W&wo Dye B Mri BOTH IP/OP "$13,949.00 " "$10,322.26" $0.00 "$11,159.20" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 "$2,907.32" $0.00 $0.00 $0.00 $352.81 "$2,906.97" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$11,047.61" "$11,159.20" $537.70 $800.00 $537.70 "$2,183.02" $348.65 $348.65 "$2,220.68" $368.58 $0.00 $0.00 $0.00 $0.00 61000034 EAP CPT® 73223 Mri Uppr Ext Jnt W&wo Dye Lt BOTH IP/OP "$6,976.00 " "$5,162.24" $0.00 "$5,580.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,439.38" $0.00 $0.00 $0.00 $352.81 "$1,439.21" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$5,524.99" "$5,580.80" $537.70 $0.00 $537.70 "$1,091.74" $348.65 $348.65 "$1,110.58" $368.58 $0.00 $0.00 $0.00 $0.00 61000035 EAP CPT® 73223 Mri Uppr Ext Jnt W&wo Dye Rt BOTH IP/OP "$6,906.00 " "$5,110.44" $0.00 "$5,580.80" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 "$1,439.38" $0.00 $0.00 $0.00 $352.81 "$1,439.21" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$5,524.99" "$5,580.80" $537.70 $800.00 $537.70 "$1,091.74" $348.65 $348.65 "$1,110.58" $368.58 $0.00 $0.00 $0.00 $0.00 61000036 EAP CPT® 73225 Mra Upp Ext W/wo Dye Bilat BOTH IP/OP "$27,844.00 " "$20,604.56" $0.00 "$22,275.20" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,802.69" $0.00 "$1,758.00" "$1,758.00" $0.00 "$6,682.56" "$22,052.45" "$22,275.20" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000037 EAP CPT® 73225 Mra Upp Ext W/wo Dye Lt BOTH IP/OP "$13,918.00 " "$10,299.32" $0.00 "$11,134.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,340.32" "$11,023.06" "$11,134.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000038 EAP CPT® 73225 Mra Upp Ext W/wo Dye Rt BOTH IP/OP "$13,918.00 " "$10,299.32" $0.00 "$11,134.40" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,900.51" $0.00 "$1,758.00" "$1,758.00" $0.00 "$3,340.32" "$11,023.06" "$11,134.40" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000040 EAP CPT® 73718 Mri Low Ext Nt Jt Wo Dye B Mri BOTH IP/OP "$11,745.00 " "$8,691.30" $143.36 "$9,396.00" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$2,447.95" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$2,447.66" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$9,302.04" "$9,396.00" $324.73 $800.00 $324.73 "$1,838.09" $192.33 $192.33 "$1,869.80" $222.60 $0.00 $0.00 $0.00 $0.00 61000041 EAP CPT® 73718 Mri Low Ext Nt Jt Wo Dye L Mri BOTH IP/OP "$4,151.00 " "$3,071.74" $0.00 "$3,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $889.14 $0.00 $0.00 $0.00 $220.56 $889.03 $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,287.59" "$3,320.80" $324.73 $0.00 $324.73 $649.63 $192.33 $192.33 $660.84 $222.60 $0.00 $0.00 $0.00 $0.00 61000042 EAP CPT® 73718 Mri Low Ext Nt Jt Wo Dye R Mri BOTH IP/OP "$4,266.00 " "$3,156.84" $143.36 "$3,320.80" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 $889.14 "$1,171.15" "$1,171.15" "$1,216.20" $220.56 $889.03 $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,287.59" "$3,320.80" $324.73 $800.00 $324.73 $649.63 $192.33 $192.33 $660.84 $222.60 $0.00 $0.00 $0.00 $0.00 61000043 EAP CPT® 73719 Mri Low Ext Nt Jt W/dye B Mri BOTH IP/OP "$9,248.00 " "$6,843.52" $0.00 "$7,398.40" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,927.28" $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,162.00" "$7,324.42" "$7,398.40" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000044 EAP CPT® 73719 Mri Low Ext Nt Jt W/dye L Mri BOTH IP/OP "$4,759.00 " "$3,521.66" $0.00 "$3,704.80" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $991.78 $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,162.00" "$3,667.75" "$3,704.80" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000045 EAP CPT® 73719 Mri Low Ext Nt Jt W/dye R Mri BOTH IP/OP "$4,759.00 " "$3,521.66" $0.00 "$3,704.80" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $991.78 $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,162.00" "$3,667.75" "$3,704.80" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000046 EAP CPT® 73720 Mri Low Ext Not Jnt W&wo B Mri BOTH IP/OP "$11,957.00 " "$8,848.18" $229.33 "$9,565.60" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$2,492.14" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$2,491.84" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$9,469.94" "$9,565.60" $537.70 $800.00 $537.70 "$1,871.27" $286.34 $286.34 "$1,903.55" $368.58 $0.00 $0.00 $0.00 $0.00 61000047 EAP CPT® 73720 Mri Low Ext Not Jnt W&wo L Mri BOTH IP/OP "$6,146.00 " "$4,548.04" $229.33 "$4,784.80" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,280.98" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,280.83" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$4,736.95" "$4,784.80" $537.70 $800.00 $537.70 $936.03 $286.34 $286.34 $952.18 $368.58 $0.00 $0.00 $0.00 $0.00 61000048 EAP CPT® 73720 Mri Low Ext Not Jnt W&wo R Mri BOTH IP/OP "$5,981.00 " "$4,425.94" $0.00 "$4,784.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.98" $0.00 $0.00 $0.00 $352.81 "$1,280.83" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$4,736.95" "$4,784.80" $537.70 $0.00 $537.70 $936.03 $286.34 $286.34 $952.18 $368.58 $0.00 $0.00 $0.00 $0.00 61000050 EAP CPT® 73721 Mri Low Ext Jnt W/o Dye Bi Mri BOTH IP/OP "$8,531.00 " "$6,312.94" $143.36 "$6,641.60" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,778.07" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,777.86" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,992.48" "$6,575.18" "$6,641.60" $324.73 $800.00 $324.73 "$1,299.26" $162.80 $162.80 "$1,321.68" $222.60 $0.00 $0.00 $0.00 $0.00 61000051 EAP CPT® 73721 Mri Low Ext Jnt W/o Dye Lt Mri BOTH IP/OP "$4,266.00 " "$3,156.84" $143.36 "$3,320.80" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 $889.14 "$1,171.15" "$1,171.15" "$1,216.20" $220.56 $889.03 $143.36 "$1,758.00" "$1,758.00" $233.72 $996.24 "$3,287.59" "$3,320.80" $324.73 $800.00 $324.73 $649.63 $162.80 $162.80 $660.84 $222.60 $0.00 $0.00 $0.00 $0.00 61000052 EAP CPT® 73721 Mri Low Ext Jnt W/o Dye Rt Mri BOTH IP/OP "$4,151.00 " "$3,071.74" $0.00 "$3,320.80" $0.00 $0.00 $0.00 $0.00 $0.00 $889.14 $0.00 $0.00 $0.00 $220.56 $889.03 $143.36 "$1,758.00" "$1,758.00" $233.72 $996.24 "$3,287.59" "$3,320.80" $324.73 $0.00 $324.73 $649.63 $162.80 $162.80 $660.84 $222.60 $0.00 $0.00 $0.00 $0.00 61000053 EAP CPT® 73722 Mri Low Ext Jnt W/dye Bi Mri BOTH IP/OP "$8,903.00 " "$6,588.22" $0.00 "$7,122.40" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,855.39" $0.00 "$1,758.00" "$1,758.00" $693.78 "$1,162.00" "$7,051.18" "$7,122.40" $963.92 $800.00 $963.92 "$1,393.32" $287.78 $287.78 "$1,417.36" $660.75 $0.00 $0.00 $0.00 $0.00 61000054 EAP CPT® 73722 Mri Low Ext Jnt W/dye Lt Mri BOTH IP/OP "$4,578.00 " "$3,387.72" $0.00 "$3,564.00" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $954.06 $0.00 "$1,758.00" "$1,758.00" $693.78 "$1,162.00" "$3,528.36" "$3,564.00" $963.92 $800.00 $963.92 $697.21 $287.78 $287.78 $709.24 $660.75 $0.00 $0.00 $0.00 $0.00 61000055 EAP CPT® 73722 Mri Low Ext Jnt W/dye Rt Mri BOTH IP/OP "$4,578.00 " "$3,387.72" $0.00 "$3,564.00" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $954.06 $0.00 "$1,758.00" "$1,758.00" $693.78 "$1,162.00" "$3,528.36" "$3,564.00" $963.92 $800.00 $963.92 $697.21 $287.78 $287.78 $709.24 $660.75 $0.00 $0.00 $0.00 $0.00 61000056 EAP CPT® 73723 Mri Low Ext Jnt W&wo Dye B Mri BOTH IP/OP "$12,288.00 " "$9,093.12" $229.33 "$9,565.60" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$2,561.13" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$2,560.82" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$9,469.94" "$9,565.60" $537.70 $800.00 $537.70 "$1,871.27" $347.93 $347.93 "$1,903.55" $368.58 $0.00 $0.00 $0.00 $0.00 61000057 EAP CPT® 73723 Mri Low Ext Jnt W&wo Dye L Mri BOTH IP/OP "$6,146.00 " "$4,548.04" $229.33 "$4,784.80" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,280.98" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,280.83" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$4,736.95" "$4,784.80" $537.70 $800.00 $537.70 $936.03 $347.93 $347.93 $952.18 $368.58 $0.00 $0.00 $0.00 $0.00 61000058 EAP CPT® 73723 Mri Low Ext Jnt W&wo Dye R Mri BOTH IP/OP "$5,981.00 " "$4,425.94" $0.00 "$4,784.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.98" $0.00 $0.00 $0.00 $352.81 "$1,280.83" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$4,736.95" "$4,784.80" $537.70 $0.00 $537.70 $936.03 $347.93 $347.93 $952.18 $368.58 $0.00 $0.00 $0.00 $0.00 61000059 EAP CPT® 74181 Mri Abdomen W/o Dye BOTH IP/OP "$5,552.00 " "$4,108.48" $143.36 "$4,474.40" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,157.18" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,157.04" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$4,429.66" "$4,474.40" $324.73 $800.00 $324.73 $875.30 $153.43 $153.43 $890.41 $222.60 $0.00 $0.00 $0.00 $0.00 61000060 EAP CPT® 74182 Mri Abdomen W/ Dye BOTH IP/OP "$5,491.00 " "$4,063.34" $229.33 "$4,425.60" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,144.46" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,144.32" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,162.00" "$4,381.34" "$4,425.60" $537.70 $800.00 $537.70 $865.76 $267.97 $267.97 $880.69 $368.58 $0.00 $0.00 $0.00 $0.00 61000062 EAP CPT® 74183 Mri Abdomen W&wo Dye BOTH IP/OP "$6,073.00 " "$4,494.02" $229.33 "$4,894.40" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,265.77" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,265.61" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$4,845.46" "$4,894.40" $537.70 $800.00 $537.70 $957.47 $284.90 $284.90 $973.99 $368.58 $0.00 $0.00 $0.00 $0.00 61000063 EAP CPT® 74185 Mra Abdomen Wo Cont BOTH IP/OP "$3,369.00 " "$2,493.06" $0.00 "$2,715.20" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $702.10 $0.00 "$1,758.00" "$1,758.00" $0.00 $814.56 "$2,688.05" "$2,715.20" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000064 EAP CPT® 75557 Mri Card Morph W/o Cont BOTH IP/OP "$3,922.00 " "$2,902.28" $0.00 "$3,169.60" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 $817.44 "$1,171.15" "$1,171.15" "$1,216.20" $220.56 $817.34 $143.36 "$1,758.00" "$1,758.00" $0.00 $950.88 "$3,137.90" "$3,169.60" $0.00 $800.00 $0.00 $620.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000065 EAP CPT® 75559 Mri Card Morph W/o W/stress BOTH IP/OP "$3,112.00 " "$2,302.88" $0.00 "$2,489.60" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $648.54 $0.00 "$1,758.00" "$1,758.00" $0.00 $746.88 "$2,464.70" "$2,489.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000066 EAP CPT® 75561 Mri Card Morph W&w/o BOTH IP/OP "$4,708.00 " "$3,483.92" $229.33 "$3,804.80" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 $981.26 "$1,171.15" "$1,171.15" "$1,216.20" $352.81 $981.15 $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,141.44" "$3,766.75" "$3,804.80" $537.70 $800.00 $537.70 $744.31 $295.70 $295.70 $757.16 $368.58 $0.00 $0.00 $0.00 $0.00 61000067 EAP CPT® 75563 Mri Card Morph W&w/o W/stress BOTH IP/OP "$5,552.00 " "$4,108.48" $0.00 "$4,441.60" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,157.04" $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,332.48" "$4,397.18" "$4,441.60" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000068 EAP CPT® 76390 Mri Spectroscopy BOTH IP/OP "$4,990.00 " "$3,692.60" $0.00 "$3,689.60" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 "$1,040.04" $0.00 $0.00 $0.00 $77.54 "$1,039.92" $50.40 "$1,758.00" "$1,758.00" $0.00 "$1,106.88" "$3,652.70" "$3,689.60" "$2,767.20" $800.00 "$2,767.20" $721.78 $0.00 $0.00 $734.23 $0.00 $0.00 $0.00 $0.00 $0.00 61000069 EAP HCPCS C8900 Mra Abdomen W Dye BOTH IP/OP "$4,319.00 " "$3,196.06" $0.00 "$3,480.80" $0.00 $0.00 $0.00 $0.00 $360.63 $900.19 $0.00 $0.00 $0.00 $352.81 $900.08 $229.33 "$1,758.00" "$1,758.00" $387.01 "$2,175.50" "$3,445.99" "$3,480.80" $537.70 $800.00 $537.70 $680.93 $0.00 $0.00 $692.68 $368.58 $0.00 $0.00 $0.00 $0.00 61000070 EAP HCPCS C8901 Mra Abdomen W/o Dye BOTH IP/OP "$2,291.00 " "$1,695.34" $0.00 "$1,846.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $477.44 $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,154.00" "$1,827.94" "$1,846.40" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000071 EAP HCPCS C8909 Mra Chest W Dye BOTH IP/OP "$4,649.00 " "$3,440.26" $0.00 "$3,756.80" "$2,524.41" "$2,524.41" $358.61 $358.61 $360.63 $968.97 "$1,171.15" "$1,171.15" "$1,216.20" $352.81 $968.85 $229.33 "$1,758.00" "$1,758.00" $387.01 "$2,348.00" "$3,719.23" "$3,756.80" $537.70 $800.00 $537.70 $0.00 $0.00 $0.00 $747.60 $368.58 $0.00 $0.00 $0.00 $0.00 61000072 EAP HCPCS C8910 Mra Chest W/o Dye BOTH IP/OP "$5,409.00 " "$4,002.66" $0.00 "$4,371.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,127.24" $0.00 "$1,758.00" "$1,758.00" $0.00 "$2,732.00" "$4,327.49" "$4,371.20" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000073 EAP HCPCS C8914 Mra Low Ext W&wo Dye Bi Mri BOTH IP/OP "$4,133.00 " "$3,058.42" $0.00 "$3,306.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.32 $0.00 "$1,758.00" "$1,758.00" $0.00 "$2,066.50" "$3,273.34" "$3,306.40" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000074 EAP HCPCS C8914 Mra Low Ext W&wo Dye Lt BOTH IP/OP "$2,898.00 " "$2,144.52" $0.00 "$2,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.94 $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,449.00" "$2,295.22" "$2,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000075 EAP HCPCS C8914 Mra Low Ext W/wo Dye Rt BOTH IP/OP "$2,898.00 " "$2,144.52" $0.00 "$2,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.94 $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,449.00" "$2,295.22" "$2,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000077 EAP HCPCS C8903 "Mri W/cont, Brst, Uni, Mri" BOTH IP/OP "$1,389.00 " "$1,027.86" $0.00 "$1,389.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.47 $0.00 "$1,389.00" "$1,389.00" $0.00 $868.00 "$1,374.91" "$1,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000081 EAP HCPCS C8905 "Mri W/ofol W/con,brst,uni,mri" BOTH IP/OP "$1,753.00 " "$1,297.22" $0.00 "$1,753.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.33 $0.00 "$1,753.00" "$1,753.00" $0.00 "$1,095.50" "$1,735.27" "$1,752.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000082 EAP HCPCS C8906 "Mri W/con, Brst, Bi,mri" BOTH IP/OP "$1,389.00 " "$1,027.86" $0.00 "$1,389.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.47 $0.00 "$1,389.00" "$1,389.00" $0.00 $868.00 "$1,374.91" "$1,388.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000087 EAP HCPCS C8908 "Mri W/ofol W/con, Brst, Bi,mri" BOTH IP/OP "$4,339.00 " "$3,210.86" $0.00 "$3,506.40" "$1,122.00" "$1,122.00" $358.61 $358.61 $360.63 $904.36 "$1,171.15" "$1,171.15" "$1,216.20" $352.81 $904.25 $229.33 "$1,758.00" "$1,758.00" $387.01 "$2,191.50" "$3,471.34" "$3,506.40" $537.70 $800.00 $537.70 $685.94 $0.00 $0.00 $697.77 $368.58 $0.00 $0.00 $0.00 $0.00 61000090 EAP CPT® 72220 Cervical Spine Flex Ext Nir BOTH IP/OP $488.00 $361.12 $22.69 $768.00 $63.70 $63.70 $78.77 $78.77 $79.21 $101.71 $488.00 $488.00 $488.00 $77.54 $101.70 $50.40 $488.00 $488.00 $80.04 $146.40 $483.12 $488.00 $111.21 $768.00 $111.21 $95.47 $22.69 $22.69 $97.11 $76.23 $0.00 $0.00 $0.00 $0.00 61000098 EAP CPT® 76376 3d Rendering W/o Postproce Mri BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,659.00" "$1,404.90" "$1,404.90" $0.00 $0.00 $0.00 $345.78 "$1,171.15" "$1,171.15" "$1,216.20" $0.00 $345.74 $0.00 "$1,659.00" "$1,659.00" $0.00 $487.92 "$1,610.14" "$1,626.40" $0.00 $800.00 $0.00 $318.16 $13.33 $13.33 $323.65 $0.00 $0.00 $0.00 $0.00 $0.00 61000099 EAP CPT® 76377 3d Rendering W/postprocess Mri BOTH IP/OP "$2,033.00 " "$1,504.42" $0.00 "$1,758.00" $0.00 $0.00 $0.00 $0.00 $0.00 $458.54 $0.00 $0.00 $0.00 $0.00 $458.48 $0.00 "$1,758.00" "$1,758.00" $0.00 $487.92 "$1,610.14" "$1,626.40" $0.00 $0.00 $0.00 $318.16 $32.41 $32.41 $323.65 $0.00 $0.00 $0.00 $0.00 $0.00 61000110 EAP CPT® 77021 "Mri Guide Needle Place, Cbc" BOTH IP/OP "$3,150.00 " "$2,331.00" $0.00 "$2,520.00" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $656.46 $0.00 "$1,758.00" "$1,758.00" $0.00 $756.00 "$2,494.80" "$2,520.00" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000116 EAP HCPCS C8932 "Mra, W/o Dye, Spinal Canal" BOTH IP/OP "$4,243.00 " "$3,139.82" $0.00 "$3,394.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $884.24 $0.00 "$1,758.00" "$1,758.00" $0.00 "$2,121.50" "$3,360.46" "$3,394.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000117 EAP HCPCS C8933 "Mra, W/o&w/dye, Spinal Canal" BOTH IP/OP "$3,605.00 " "$2,667.70" $0.00 "$2,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $751.28 $0.00 "$1,758.00" "$1,758.00" $0.00 "$1,802.50" "$2,855.16" "$2,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000118 EAP HCPCS C8934 "Mra, W/dye, Upper Extremity" BOTH IP/OP "$4,210.00 " "$3,115.40" $0.00 "$3,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $877.36 $0.00 "$1,758.00" "$1,758.00" $0.00 "$2,105.00" "$3,334.32" "$3,368.00" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000119 EAP HCPCS C8935 "Mra, W/odye, Upper Extremity" BOTH IP/OP "$4,210.00 " "$3,115.40" $0.00 "$3,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $877.36 $0.00 "$1,758.00" "$1,758.00" $0.00 "$2,105.00" "$3,334.32" "$3,368.00" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000120 EAP HCPCS C8936 "Mra, W/o&w/dye, Upper Extremity" BOTH IP/OP "$4,210.00 " "$3,115.40" $0.00 "$3,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $877.36 $0.00 "$1,758.00" "$1,758.00" $0.00 "$2,105.00" "$3,334.32" "$3,368.00" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000121 EAP CPT® 73725 Mri Ang Lwr Ext W Or W/o Dye BOTH IP/OP "$3,816.00 " "$2,823.84" $0.00 "$3,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $795.25 $0.00 "$1,758.00" "$1,758.00" $0.00 $915.84 "$3,022.27" "$3,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000122 EAP CPT® 77021 Mri Guidance For Needle Placement BOTH IP/OP "$3,150.00 " "$2,331.00" $0.00 "$2,520.00" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $656.46 $0.00 "$1,758.00" "$1,758.00" $0.00 $756.00 "$2,494.80" "$2,520.00" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000124 EAP CPT® 77048 Mri Breast W And/or Wo Cont Incl Cad Uni BOTH IP/OP $491.00 $363.34 $0.00 $491.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.32 $0.00 $491.00 $491.00 $0.00 $117.84 $388.87 $392.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000125 EAP CPT® 77049 Mri Breast W And/or Wo Cont Incl Cad Bil BOTH IP/OP $491.00 $363.34 $0.00 $800.00 $491.00 $491.00 $285.62 $285.62 $335.44 $102.34 $491.00 $491.00 $491.00 $285.62 $102.32 $185.65 $491.00 $491.00 $0.00 $117.84 $388.87 $392.80 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61000126 EAP CPT® 77047 Mri Breast Without Contrast Material Bilateral BOTH IP/OP "$2,874.00 " "$2,126.76" $143.36 "$2,299.20" "$1,122.00" "$1,122.00" $224.08 $224.08 $225.34 $599.01 "$1,171.15" "$1,171.15" "$1,216.20" $220.56 $598.94 $143.36 "$1,758.00" "$1,758.00" $233.72 $689.76 "$2,276.21" "$2,299.20" $324.73 $800.00 $324.73 $449.78 $173.24 $173.24 $457.54 $222.60 $0.00 $0.00 $0.00 $0.00 61000127 EAP CPT® 77046 MRI BREAST WO CONTRAST UNI BOTH IP/OP $554.00 $409.96 $0.00 $554.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.45 $0.00 $554.00 $554.00 $0.00 $132.96 $438.77 $443.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61100001 EAP CPT® 70551 Mri Brain W/o Dye BOTH IP/OP "$5,561.00 " "$4,115.14" $143.36 "$4,229.60" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,159.05" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,158.91" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$4,187.30" "$4,229.60" $324.73 $800.00 $324.73 $827.42 $150.19 $150.19 $841.69 $222.60 $0.00 $0.00 $0.00 $0.00 61100003 EAP CPT® 70552 Mri Brain W/dye BOTH IP/OP "$6,193.00 " "$4,582.82" $0.00 "$4,710.40" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 "$1,290.78" $0.00 $0.00 $0.00 $352.81 "$1,290.62" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,162.00" "$4,663.30" "$4,710.40" $537.70 $800.00 $537.70 $921.47 $221.87 $221.87 $937.37 $368.58 $0.00 $0.00 $0.00 $0.00 61100005 EAP CPT® 70553 Mri Brain W&wo Dye BOTH IP/OP "$8,010.00 " "$5,927.40" $229.33 "$6,092.00" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,669.48" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,669.28" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$6,031.08" "$6,092.00" $537.70 $800.00 $537.70 "$1,191.75" $252.84 $252.84 "$1,212.31" $368.58 $0.00 $0.00 $0.00 $0.00 61200001 EAP CPT® 72141 Mri Cervical Spine W/o Dye BOTH IP/OP "$5,640.00 " "$4,173.60" $143.36 "$4,255.20" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 "$1,175.52" "$1,171.15" "$1,171.15" "$1,216.20" $220.56 "$1,175.38" $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$4,212.65" "$4,255.20" $324.73 $800.00 $324.73 $832.42 $144.07 $144.07 $846.78 $222.60 $0.00 $0.00 $0.00 $0.00 61200004 EAP CPT® 72142 Mri Cervical Spine W Contrast BOTH IP/OP "$6,282.00 " "$4,648.68" $0.00 "$4,739.20" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 "$1,309.33" $0.00 $0.00 $0.00 $352.81 "$1,309.17" $229.33 "$1,758.00" "$1,758.00" $0.00 "$1,162.00" "$4,691.81" "$4,739.20" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61200005 EAP CPT® 72146 Mri Thoracic Spine W/o Dye BOTH IP/OP "$4,510.00 " "$3,337.40" $143.36 "$3,460.00" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 $940.00 "$1,171.15" "$1,171.15" "$1,216.20" $220.56 $939.88 $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,038.00" "$3,425.40" "$3,460.00" $324.73 $800.00 $324.73 $676.86 $144.07 $144.07 $688.54 $222.60 $0.00 $0.00 $0.00 $0.00 61200006 EAP CPT® 72147 Mri Thoracic Spine W/dye BOTH IP/OP "$5,023.00 " "$3,717.02" $0.00 "$3,853.60" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.79" $0.00 "$1,758.00" "$1,758.00" $387.01 "$1,162.00" "$3,815.06" "$3,853.60" $537.70 $800.00 $537.70 $753.86 $226.55 $226.55 $766.87 $368.58 $0.00 $0.00 $0.00 $0.00 61200007 EAP CPT® 72148 Mri Lumbar Spine W/o Dye BOTH IP/OP "$4,264.00 " "$3,155.36" $143.36 "$3,445.60" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 $888.72 "$1,171.15" "$1,171.15" "$1,216.20" $220.56 $888.62 $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,411.14" "$3,445.60" $324.73 $800.00 $324.73 $674.05 $144.43 $144.43 $685.67 $222.60 $0.00 $0.00 $0.00 $0.00 61200008 EAP CPT® 72149 Mri Lumbar Spine W/ Dye BOTH IP/OP "$4,587.00 " "$3,394.38" $0.00 "$3,706.40" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.93 $0.00 "$1,758.00" "$1,758.00" $387.01 "$1,162.00" "$3,669.34" "$3,706.40" $537.70 $800.00 $537.70 $725.06 $223.67 $223.67 $737.57 $368.58 $0.00 $0.00 $0.00 $0.00 61200009 EAP CPT® 72156 Mri Cervical Spine W&wo Dye BOTH IP/OP "$8,124.00 " "$6,011.76" $229.33 "$6,129.60" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,693.24" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,693.04" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$6,068.30" "$6,129.60" $537.70 $800.00 $537.70 "$1,199.10" $255.72 $255.72 "$1,219.79" $368.58 $0.00 $0.00 $0.00 $0.00 61200010 EAP CPT® 72157 Mri Thoracic Spine W&wo Dye BOTH IP/OP "$6,499.00 " "$4,809.26" $229.33 "$4,985.60" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,354.55" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,354.39" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,495.68" "$4,935.74" "$4,985.60" $537.70 $800.00 $537.70 $975.31 $256.44 $256.44 $992.13 $368.58 $0.00 $0.00 $0.00 $0.00 61200011 EAP CPT® 72158 Mri Lumbar Spine W&wo Dye BOTH IP/OP "$6,144.00 " "$4,546.56" $229.33 "$4,964.80" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,280.56" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,280.41" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$4,915.15" "$4,964.80" $537.70 $800.00 $537.70 $971.24 $255.00 $255.00 $988.00 $368.58 $0.00 $0.00 $0.00 $0.00 61200012 EAP CPT® 72195 Mri Pelvis W/o Dye BOTH IP/OP "$4,089.00 " "$3,025.86" $143.36 "$3,269.60" "$2,060.10" "$2,060.10" $224.08 $224.08 $225.34 $852.25 "$1,171.15" "$1,171.15" "$1,216.20" $220.56 $852.15 $143.36 "$1,758.00" "$1,758.00" $233.72 "$1,043.00" "$3,236.90" "$3,269.60" $324.73 $800.00 $324.73 $639.62 $194.85 $194.85 $650.65 $222.60 $0.00 $0.00 $0.00 $0.00 61200013 EAP CPT® 72196 Mri Pelvis W/ Dye BOTH IP/OP "$4,633.00 " "$3,428.42" $226.19 "$3,704.80" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 $965.63 "$1,171.15" "$1,171.15" "$1,216.20" $352.81 $965.52 $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,162.00" "$3,667.75" "$3,704.80" $537.70 $800.00 $537.70 $724.75 $226.19 $226.19 $737.26 $368.58 $0.00 $0.00 $0.00 $0.00 61200014 EAP CPT® 72197 Mri Pelvis W&wo Dye BOTH IP/OP "$5,028.00 " "$3,720.72" $229.33 "$4,020.00" "$2,060.10" "$2,060.10" $358.61 $358.61 $360.63 "$1,047.96" "$1,171.15" "$1,171.15" "$1,216.20" $352.81 "$1,047.84" $229.33 "$1,758.00" "$1,758.00" $387.01 "$1,608.00" "$3,979.80" "$4,020.00" $537.70 $800.00 $537.70 $786.41 $284.18 $284.18 $799.98 $368.58 $0.00 $0.00 $0.00 $0.00 61400000 EAP CPT® 75565 Mr Cardiac Mri For Velocity Flow Mapping BOTH IP/OP "$2,506.00 " "$1,854.44" $0.00 "$2,060.10" "$2,060.10" "$2,060.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $522.25 $0.00 "$1,758.00" "$1,758.00" $0.00 $601.44 "$1,984.75" "$2,004.80" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61800010 EAP HCPCS C8902 "Mra W/o Fol W/cont, Abd, Cbc" BOTH IP/OP "$1,744.00 " "$1,290.56" $0.00 "$1,744.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $363.45 $0.00 "$1,744.00" "$1,744.00" $0.00 $872.00 "$1,381.25" "$1,395.20" $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62200001 EAP Custom 62200001 Intro Aortic Balloons BOTH IP/OP "$5,547.00 " "$4,104.78" $0.00 "$4,437.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,155.99" $0.00 $0.00 $0.00 $0.00 "$2,773.50" "$4,393.22" "$4,437.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62300002 EAP HCPCS A6234 Hydrocolloid Dsg 16 Sq In Or Less BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $27.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62300003 EAP HCPCS A6235 Hydrocolloid Dsg more than 16sq in BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.30 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $85.15 $0.00 $20.50 $0.00 $0.00 $20.86 $0.00 $0.00 $0.00 $0.00 $0.00 62300006 EAP HCPCS A6196 Alginate Dressing <= 16 Sq In BOTH IP/OP $44.00 $32.56 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $28.60 $0.00 $6.89 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $0.00 62400002 EAP Custom 62400002 Trevo Retriever-ide#g100056 BOTH IP/OP "$4,937.00 " "$3,653.38" $0.00 "$3,949.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,028.87" $0.00 $0.00 $0.00 $0.00 "$2,468.50" "$3,910.10" "$3,949.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62400003 EAP Custom 62400003 Trevo 18 Microcatheter-ide#g100056 BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.47 $0.00 $0.00 $0.00 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600011 EAP CPT® 90670 PNEUMONIA VACCINE PREVNAR BOTH IP/OP $30.00 $22.20 $4.38 $252.18 $13.50 $13.50 $7.80 $7.80 $230.14 $6.25 $22.27 $22.27 $23.12 $7.80 $30.00 $5.07 $17.75 $17.75 $4.38 $15.00 $23.76 $24.00 $4.38 $13.50 $4.38 $252.18 $7.80 $7.80 $240.12 $7.80 $0.00 $0.00 $0.00 $0.00 63600012 EAP CPT® 90732 PNEUMONIA VACCINE PNEUMOVAX BOTH IP/OP $30.00 $22.20 $4.38 $134.20 $13.50 $13.50 $7.80 $7.80 $119.92 $9.40 $22.27 $22.27 $23.12 $7.80 $30.00 $5.07 $17.75 $17.75 $4.38 $15.00 $23.76 $24.00 $4.38 $13.50 $4.38 $134.20 $7.80 $7.80 $127.78 $7.80 $0.00 $0.00 $0.00 $0.00 63600022 EAP CPT® 90651 GARDASIL-9 VACCINE BOTH IP/OP $493.00 $364.82 $0.00 $394.40 $221.85 $221.85 $0.00 $0.00 $229.60 $102.75 $365.90 $365.90 $380.00 $0.00 $297.98 $0.00 $291.61 $291.61 $0.00 $246.50 $390.46 $394.40 $295.80 $221.85 $295.80 $267.82 $0.00 $0.00 $255.01 $0.00 $0.00 $0.00 $0.00 $0.00 63600025 EAP HCPCS J2182 Rx Eap Nucala Charge BOTH IP/OP $80.00 $59.20 $0.00 "$5,945.60" $36.00 $36.00 $28.69 $28.69 $28.69 $16.67 $59.38 $59.38 $61.66 $28.29 $33.24 $18.39 $47.32 $47.32 $31.21 "$3,716.00" "$5,886.14" "$5,945.60" $43.09 $36.00 $43.09 $34.42 $0.00 $0.00 $32.77 $29.72 $0.00 $0.00 $0.00 $0.00 63600101 EAP HCPCS A9562 Rad-99mtc Mag 3(ren)-pr BOTH IP/OP $784.00 $580.16 $0.00 $509.60 $0.00 $0.00 $0.00 $0.00 $0.00 $163.41 $0.00 $0.00 $0.00 $0.00 $163.39 $0.00 $463.74 $463.74 $0.00 $175.00 $277.20 $280.00 $0.00 $509.60 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 63600104 EAP HCPCS J7197 Anti-thrombin Iii BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600112 EAP HCPCS J0881 Darbepoetin Alfa 1 BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $3.09 $3.09 $3.09 $3.60 $11.88 $11.88 $12.33 $3.15 $3.71 $2.05 $9.46 $9.46 $4.04 $8.00 $12.67 $12.80 $5.59 $7.20 $5.59 $4.49 $0.00 $0.00 $4.27 $3.79 $0.00 $0.00 $0.00 $0.00 63600116 EAP HCPCS J7189 Factor 7a Novoseven BOTH IP/OP $5.00 $3.70 $0.00 $4.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.71 $3.71 $3.85 $0.00 $1.04 $0.00 $0.00 $0.00 $0.00 $2.50 $3.96 $4.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600119 EAP HCPCS A9552 Fdg Unit Dose (supp BOTH IP/OP "$1,722.00 " "$1,274.28" $0.00 "$1,377.60" $0.00 $0.00 $0.00 $0.00 $0.00 $358.91 $0.00 $0.00 $0.00 $0.00 $358.86 $0.00 "$1,018.56" "$1,018.56" $0.00 $861.00 "$1,363.82" "$1,377.60" $0.00 "$1,119.30" $0.00 $227.28 $0.00 $0.00 $274.14 $0.00 $0.00 $0.00 $0.00 $0.00 63600120 EAP HCPCS A9556 Ga-67 Gallium Citra BOTH IP/OP $169.00 $125.06 $0.00 $109.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.22 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $109.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600122 EAP HCPCS A9517 "I131 Therapy, 1mci" BOTH IP/OP $350.00 $259.00 $0.00 $269.78 $190.05 $190.05 $20.12 $20.12 $20.12 $72.95 $259.77 $259.77 $269.78 $20.12 $72.94 $13.08 $207.03 $207.03 $21.80 $30.00 $47.52 $48.00 $30.10 $227.50 $30.10 $9.39 $0.00 $0.00 $9.55 $20.69 $0.00 $0.00 $0.00 $0.00 63600133 EAP HCPCS J1885 Ketorolac 15mg Inj BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $15.30 $15.30 $0.00 $0.00 $0.00 $0.32 $25.23 $25.23 $26.21 $0.00 $0.57 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 63600134 EAP HCPCS J1885 Ketorolac 30mg BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $15.30 $15.30 $0.00 $0.00 $0.00 $0.32 $25.23 $25.23 $26.21 $0.00 $0.57 $0.00 $20.11 $20.11 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 63600138 EAP HCPCS J0561 Penicillin G Benzathine Inj BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $13.50 $13.50 $15.04 $15.04 $15.04 $6.25 $22.27 $22.27 $23.12 $14.95 $17.57 $9.72 $17.75 $17.75 $14.51 $15.00 $23.76 $24.00 $20.04 $13.50 $20.04 $16.17 $0.00 $0.00 $15.39 $13.82 $0.00 $0.00 $0.00 $0.00 63600146 EAP HCPCS Q9967 Locm 300-349mg/ml I BOTH IP/OP $2.00 $1.48 $0.00 $1.60 $0.90 $0.90 $0.00 $0.00 $0.00 $0.42 $1.48 $1.48 $0.00 $0.00 $0.14 $0.00 $1.18 $1.18 $0.00 $1.00 $1.58 $1.60 $0.00 $0.00 $0.00 $0.13 $0.00 $0.00 $0.32 $0.00 $0.00 $0.00 $0.00 $0.00 63600170 EAP HCPCS J0561 Penicillin G Benz L BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $71.10 $71.10 $15.04 $15.04 $15.04 $32.93 $117.27 $117.27 $121.79 $14.95 $17.57 $9.72 $93.46 $93.46 $14.51 $79.00 $125.14 $126.40 $20.04 $71.10 $20.04 $16.17 $0.00 $0.00 $15.39 $13.82 $0.00 $0.00 $0.00 $0.00 63600174 EAP HCPCS J0561 Penicillin G Benz L BOTH IP/OP $159.00 $117.66 $0.00 $127.20 $71.55 $71.55 $15.04 $15.04 $15.04 $33.14 $118.01 $118.01 $122.56 $14.95 $17.57 $9.72 $94.05 $94.05 $14.51 $79.50 $125.93 $127.20 $20.04 $0.00 $20.04 $16.17 $0.00 $0.00 $15.39 $13.82 $0.00 $0.00 $0.00 $0.00 63600182 EAP HCPCS J2820 Sargramostim 50mcg BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.14 $129.14 $134.12 $0.00 $58.18 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600209 EAP HCPCS A9551 Tc-99m Dmsa Nuc BOTH IP/OP "$1,886.00 " "$1,395.64" $0.00 "$1,225.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.04 $0.00 $0.00 $0.00 $0.00 $307.50 $487.08 $492.00 $0.00 "$1,225.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600210 EAP HCPCS A9600 Sr-89 Therapy Radio BOTH IP/OP "$3,784.00 " "$2,800.16" $0.00 "$3,027.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,808.48" "$2,808.48" "$2,916.71" $0.00 $788.59 $0.00 $0.00 $0.00 $0.00 "$1,892.00" "$2,996.93" "$3,027.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600211 EAP HCPCS A9604 Sm 153 Lexidronam 5 BOTH IP/OP "$48,815.00 " "$36,123.10" $0.00 "$37,626.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$37,626.60" $0.00 "$10,173.05" $0.00 $0.00 $0.00 $0.00 "$6,754.50" "$10,699.13" "$10,807.20" $0.00 "$31,729.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600212 EAP HCPCS A9548 In 111pentetate Dtp BOTH IP/OP "$7,022.00 " "$5,196.28" $0.00 "$4,564.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,463.38" $0.00 $0.00 $0.00 $0.00 "$1,547.00" "$2,450.45" "$2,475.20" $0.00 "$4,564.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600324 EAP CPT® 90632 HEP A VACCINE BOTH IP/OP $72.00 $53.28 $0.00 $72.00 $32.40 $32.40 $0.00 $0.00 $0.00 $56.67 $53.44 $53.44 $55.50 $0.00 $72.00 $0.00 $42.59 $42.59 $0.00 $36.00 $57.02 $57.60 $0.00 $32.40 $0.00 $70.39 $0.00 $0.00 $67.03 $0.00 $0.00 $0.00 $0.00 $0.00 63600325 EAP CPT® 90633 HEPA VACCINE PED/ADOL 2 DOSE IM BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $32.40 $32.40 $0.00 $0.00 $0.00 $9.40 $53.44 $53.44 $55.50 $0.00 $15.00 $0.00 $42.59 $42.59 $0.00 $36.00 $57.02 $57.60 $0.00 $32.40 $0.00 $11.27 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $0.00 63600326 EAP CPT® 90636 HEP A/B TWINRX VACCINE BOTH IP/OP $98.00 $72.52 $0.00 $122.20 $44.10 $44.10 $0.00 $0.00 $0.00 $107.88 $72.74 $72.74 $75.54 $0.00 $98.00 $0.00 $57.97 $57.97 $0.00 $49.00 $77.62 $78.40 $0.00 $44.10 $0.00 $122.20 $0.00 $0.00 $116.36 $0.00 $0.00 $0.00 $0.00 $0.00 63600327 EAP CPT® 90647 PEDVAXHIB VACCINE BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $17.10 $17.10 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $17.10 $0.00 $5.95 $0.00 $0.00 $6.05 $0.00 $0.00 $0.00 $0.00 $0.00 63600335 EAP CPT® 90675 RABIES VACCINE BOTH IP/OP "$1,011.00 " $748.14 $0.00 $808.80 $454.95 $454.95 $341.95 $341.95 $341.95 $174.76 $750.36 $750.36 $779.28 $327.53 $384.85 $212.90 $598.01 $598.01 $312.47 $505.50 $800.71 $808.80 $431.50 $0.00 $431.50 $326.44 $0.00 $0.00 $310.83 $294.72 $0.00 $0.00 $0.00 $0.00 63600336 EAP CPT® 90680 ROTAVIRUS 3 DOSE VACCINE BOTH IP/OP $108.00 $79.92 $0.00 $86.40 $48.60 $48.60 $0.00 $0.00 $0.00 $22.51 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $63.88 $63.88 $0.00 $54.00 $85.54 $86.40 $0.00 $48.60 $0.00 $16.90 $0.00 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $0.00 63600337 EAP CPT® 90698 PENTACEL VACCINE BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $65.00 $102.96 $104.00 $0.00 $84.50 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 63600338 EAP CPT® 90700 DTAP VACCINE BOTH IP/OP $38.00 $28.12 $0.00 $30.40 $17.10 $17.10 $0.00 $0.00 $0.00 $7.92 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $22.48 $22.48 $0.00 $19.00 $30.10 $30.40 $0.00 $17.10 $0.00 $5.95 $0.00 $0.00 $6.05 $0.00 $0.00 $0.00 $0.00 $0.00 63600344 EAP CPT® 90707 MMR VACCINE BOTH IP/OP $83.00 $61.42 $0.00 $92.45 $37.35 $37.35 $0.00 $0.00 $0.00 $11.75 $61.60 $61.60 $63.98 $0.00 $83.00 $0.00 $49.09 $49.09 $0.00 $41.50 $65.74 $66.40 $0.00 $37.35 $0.00 $92.45 $0.00 $0.00 $88.03 $0.00 $0.00 $0.00 $0.00 $0.00 63600346 EAP CPT® 90710 MMRV VACCINE BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $8.55 $8.55 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $3.96 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $8.55 $0.00 $2.97 $0.00 $0.00 $3.02 $0.00 $0.00 $0.00 $0.00 $0.00 63600348 EAP CPT® 90713 POLIO VACCINE BOTH IP/OP $32.00 $23.68 $0.00 $32.00 $14.40 $14.40 $0.00 $0.00 $0.00 $9.40 $23.75 $23.75 $24.67 $0.00 $32.00 $0.00 $18.93 $18.93 $0.00 $16.00 $25.34 $25.60 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600349 EAP CPT® 90714 TENIVAC VACCINE BOTH IP/OP $30.00 $22.20 $0.00 $30.00 $13.50 $13.50 $0.00 $0.00 $0.00 $11.75 $22.27 $22.27 $23.12 $0.00 $30.00 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $13.50 $0.00 $29.50 $0.00 $0.00 $28.09 $0.00 $0.00 $0.00 $0.00 $0.00 63600350 EAP CPT® 90715 TDAP VACCINE BOTH IP/OP $54.00 $39.96 $0.00 $43.20 $24.30 $24.30 $0.00 $0.00 $0.00 $11.25 $40.08 $40.08 $41.62 $0.00 $42.06 $0.00 $31.94 $31.94 $0.00 $27.00 $42.77 $43.20 $0.00 $24.30 $0.00 $39.53 $0.00 $0.00 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 63600351 EAP CPT® 90716 VARICELLA VACCINE BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $186.30 $186.30 $0.00 $0.00 $136.66 $9.40 $307.27 $307.27 $319.11 $0.00 $177.40 $0.00 $244.88 $244.88 $0.00 $207.00 $327.89 $331.20 $248.40 $186.30 $248.40 $159.48 $0.00 $0.00 $151.85 $0.00 $0.00 $0.00 $0.00 $0.00 63600355 EAP CPT® 90723 DTAP HEPB VACCINE BOTH IP/OP $108.00 $79.92 $0.00 $86.40 $48.60 $48.60 $0.00 $0.00 $79.00 $22.51 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $63.88 $63.88 $0.00 $54.00 $85.54 $86.40 $64.80 $48.60 $64.80 $16.90 $0.00 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $0.00 63600360 EAP CPT® 90746 HEP B VACCINE ADULT 3 DOSE BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $103.50 $103.50 $59.80 $59.80 $69.65 $70.16 $170.71 $170.71 $177.28 $59.80 $81.84 $38.87 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $138.00 $103.50 $138.00 $78.80 $59.80 $59.80 $75.03 $59.80 $0.00 $0.00 $0.00 $0.00 63600374 EAP HCPCS J0561 Penicillin G Benz La 1.2 Mu BOTH IP/OP $159.00 $117.66 $0.00 $127.20 $71.55 $71.55 $15.04 $15.04 $15.04 $33.14 $118.01 $118.01 $122.56 $14.95 $17.57 $9.72 $94.05 $94.05 $14.51 $79.50 $125.93 $127.20 $20.04 $71.55 $20.04 $16.17 $0.00 $0.00 $15.39 $13.82 $0.00 $0.00 $0.00 $0.00 63600380 EAP HCPCS J0131 "Acetaminophen, Iv 1000mg/100 Ml" BOTH IP/OP $58.00 $42.92 $0.00 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.05 $43.05 $44.71 $0.00 $12.09 $0.00 $0.00 $0.00 $0.00 $29.00 $45.94 $46.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600381 EAP HCPCS J0461 "Atropine 0.4mg/ml,20 Ml" BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $95.58 $0.00 $0.09 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $0.00 $0.09 $0.00 $0.00 $0.09 $0.00 $0.00 $0.00 $0.00 $0.00 63600382 EAP HCPCS J0690 "Cefazolin Sodium, 1 Gm Vial" BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.69 $11.88 $11.88 $12.33 $0.00 $0.88 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.96 $0.00 $0.00 $0.92 $0.00 $0.00 $0.00 $0.00 $0.00 63600383 EAP HCPCS S0077 "Clindamycin Phosphate, 300 Mg" BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $17.55 $17.55 $0.00 $0.00 $1.35 $3.54 $28.95 $28.95 $30.06 $0.00 $1.66 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $23.40 $0.00 $23.40 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 63600384 EAP HCPCS J1100 "Dexamethasone,4mg/ml 5ml" BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.11 $11.88 $11.88 $12.33 $0.00 $0.14 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $7.20 $0.00 $0.14 $0.00 $0.00 $0.13 $0.00 $0.00 $0.00 $0.00 $0.00 63600385 EAP HCPCS J1200 Diphenhydramine Hci Up To 50 Mg BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.86 $11.88 $11.88 $12.33 $0.00 $1.16 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $1.06 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 63600386 EAP HCPCS J0171 "Epinephrine1 Mg/1 Ml, 30 Ml" BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $12.15 $12.15 $0.00 $0.00 $0.00 $5.63 $20.04 $20.04 $20.81 $0.00 $0.87 $0.00 $15.97 $15.97 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.96 $0.00 $0.00 $0.92 $0.00 $0.00 $0.00 $0.00 $0.00 63600387 EAP HCPCS J1940 "Furosemide, Up To 20 Mg" BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.25 $11.88 $11.88 $12.33 $0.00 $0.56 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 63600388 EAP HCPCS J1644 "Heparin Sodium, Per 1000 Units/ml, 10 Ml" BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.24 $11.88 $11.88 $12.33 $0.00 $0.29 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 63600389 EAP HCPCS J0360 "Hydralazine Hci, Up To 20 Mg" BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $21.15 $21.15 $0.00 $0.00 $0.00 $5.77 $34.88 $34.88 $36.23 $0.00 $6.11 $0.00 $27.80 $27.80 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $4.41 $0.00 $0.00 $4.20 $0.00 $0.00 $0.00 $0.00 $0.00 63600390 EAP HCPCS J1720 "Hydrocortisone Sod Succ Up, To 100" BOTH IP/OP $19.00 $14.06 $0.00 $17.40 $8.55 $8.55 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $17.40 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $15.33 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $0.00 63600391 EAP HCPCS J1885 Ketorolac 60mg/2ml BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.32 $11.88 $11.88 $12.33 $0.00 $0.57 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 63600392 EAP HCPCS J2405 "Ondansetron Hci, Per 1mg" BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.25 $11.88 $11.88 $12.33 $0.00 $0.11 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.11 $0.00 $0.00 $0.10 $0.00 $0.00 $0.00 $0.00 $0.00 63600393 EAP HCPCS J2590 "Oxytocin, Up To 10 Units" BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $1.47 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 63600394 EAP HCPCS J2370 "Phenylephrine 10mg/ml, 1ml" BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $21.15 $21.15 $0.00 $0.00 $0.00 $0.96 $34.88 $34.88 $36.23 $0.00 $4.14 $0.00 $27.80 $27.80 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 63600395 EAP HCPCS J0330 "Succinylcholine Chloride, Up To 20 Mg/ml,10 Ml" BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $14.85 $14.85 $0.00 $0.00 $0.00 $6.88 $24.49 $24.49 $25.44 $0.00 $6.88 $0.00 $19.52 $19.52 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 63600396 EAP HCPCS J3370 Vancomycin 1gm Vial BOTH IP/OP $24.00 $17.76 $0.00 $19.20 $10.80 $10.80 $0.00 $0.00 $0.00 $3.62 $17.81 $17.81 $18.50 $0.00 $3.34 $0.00 $14.20 $14.20 $0.00 $12.00 $19.01 $19.20 $0.00 $10.80 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 63600402 EAP HCPCS J2791 "Njx, Rho(d) Immune Globulin (human), (rhophylac)" BOTH IP/OP $534.00 $395.16 $0.00 $427.20 $240.30 $240.30 $0.00 $0.00 $0.00 $111.30 $396.33 $396.33 $411.61 $0.00 $5.52 $0.00 $315.86 $315.86 $0.00 $267.00 $422.93 $427.20 $0.00 $240.30 $0.00 $0.00 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 63600404 EAP HCPCS J7194 Factor 9 BOTH IP/OP $2.00 $1.48 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.48 $1.48 $1.54 $0.00 $0.42 $0.00 $0.00 $0.00 $0.00 $1.00 $1.58 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600405 EAP HCPCS J2790 Rh Immune Globulin- 300 Mcg BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $58.95 $58.95 $0.00 $0.00 $0.00 $101.36 $97.23 $97.23 $100.97 $0.00 $88.76 $0.00 $77.49 $77.49 $0.00 $65.50 $103.75 $104.80 $0.00 $58.95 $0.00 $87.71 $0.00 $0.00 $83.52 $0.00 $0.00 $0.00 $0.00 $0.00 63600460 EAP HCPCS J7189 Novoseven F7 1.0 BOTH IP/OP "$5,380.00 " "$3,981.20" $0.00 "$4,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,993.04" "$3,993.04" "$4,146.90" $0.00 "$1,121.19" $0.00 $0.00 $0.00 $0.00 "$2,690.00" "$4,260.96" "$4,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600461 EAP HCPCS J7189 Novoseven F7 2.0 BOTH IP/OP "$10,222.00 " "$7,564.28" $0.00 "$8,177.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,586.77" "$7,586.77" "$7,879.12" $0.00 "$2,130.26" $0.00 $0.00 $0.00 $0.00 "$5,111.00" "$8,095.82" "$8,177.60" $0.00 "$4,599.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63600462 EAP CPT® 90734 MENVEO VACCINE BOTH IP/OP $410.00 $303.40 $0.00 $328.00 $184.50 $184.50 $0.00 $0.00 $129.14 $9.40 $304.30 $304.30 $316.03 $0.00 $158.35 $0.00 $242.52 $242.52 $0.00 $205.00 $324.72 $328.00 $246.00 $184.50 $246.00 $143.71 $0.00 $0.00 $136.84 $0.00 $0.00 $0.00 $0.00 $0.00 63600467 EAP CPT® 90620 MENINGITIS VACCINE BOTH IP/OP $569.62 $421.52 $0.00 $455.70 $256.33 $256.33 $0.00 $0.00 $171.96 $118.72 $422.77 $422.77 $439.06 $0.00 $225.31 $0.00 $336.93 $336.93 $0.00 $284.81 $451.14 $455.70 $341.77 $256.33 $341.77 $200.63 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 63600526 EAP HCPCS C9250 Kit Tiss Clsr 4ml Artiss Frzn Slnt BOTH IP/OP $811.00 $600.14 $0.00 $648.80 $364.95 $364.95 $156.84 $156.84 $156.84 $169.03 $601.92 $601.92 $625.12 $156.84 $169.01 $101.95 $479.71 $479.71 $173.09 $405.50 $642.31 $648.80 $239.03 $0.00 $239.03 $126.92 $0.00 $0.00 $129.11 $164.85 $0.00 $0.00 $0.00 $0.00 63600527 EAP HCPCS C9250 Kit Tiss Clsr 10ml Artiss Frzn Slnt BOTH IP/OP "$1,814.00 " "$1,342.36" $0.00 "$1,451.20" $816.30 $816.30 $156.84 $156.84 $156.84 $378.08 "$1,346.35" "$1,346.35" "$1,398.23" $156.84 $378.04 $101.95 $894.30 $894.30 $173.09 $907.00 "$1,436.69" "$1,451.20" $239.03 $0.00 $239.03 $283.89 $0.00 $0.00 $288.79 $164.85 $0.00 $0.00 $0.00 $0.00 63600528 EAP HCPCS C9250 Kit Tiss Clsr 2ml Artiss Frzn Slnt BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $156.84 $156.84 $156.84 $99.00 $352.55 $352.55 $366.13 $156.84 $98.99 $101.95 $280.96 $280.96 $173.09 $237.50 $376.20 $380.00 $239.03 $0.00 $239.03 $74.34 $0.00 $0.00 $75.62 $164.85 $0.00 $0.00 $0.00 $0.00 63603027 EAP HCPCS J1610 Glucagon 1 Mg BOTH IP/OP $415.00 $307.10 $0.00 $332.00 $186.75 $186.75 $166.77 $166.77 $166.77 $88.07 $308.01 $308.01 $319.88 $171.74 $201.79 $111.63 $245.47 $245.47 $209.24 $207.50 $328.68 $332.00 $288.94 $0.00 $288.94 $255.63 $0.00 $0.00 $243.41 $199.13 $0.00 $0.00 $0.00 $0.00 63603176 EAP HCPCS J2792 "Rho(d) Immune Globulin H, Sd Winrho" BOTH IP/OP $215.00 $159.10 $0.00 "$1,185.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.57 $159.57 $165.72 $0.00 $36.91 $0.00 $0.00 $0.00 $0.00 $741.00 "$1,173.74" "$1,185.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63603287 EAP CPT® 90634 HEPA VACCINE PED/ADOL-3 DOSE-IM BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $26.21 $0.00 $7.09 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63603296 EAP CPT® 90696 DTAP IPV VACCINE BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $83.25 $83.25 $0.00 $0.00 $0.00 $38.56 $137.31 $137.31 $142.60 $0.00 $38.55 $0.00 $109.43 $109.43 $0.00 $92.50 $146.52 $148.00 $0.00 $83.25 $0.00 $28.95 $0.00 $0.00 $29.45 $0.00 $0.00 $0.00 $0.00 $0.00 63603300 EAP CPT® 90747 HEP B VACCINE IMMUNOSUPRESSED BOTH IP/OP $100.00 $74.00 $0.00 $157.59 $45.00 $45.00 $26.00 $26.00 $140.76 $140.32 $74.22 $74.22 $77.08 $26.00 $100.00 $16.90 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $60.00 $45.00 $60.00 $157.59 $26.00 $26.00 $150.05 $26.00 $0.00 $0.00 $0.00 $0.00 63603301 EAP CPT® 90744 HEP B VACCINE PED/ADULT 3 DOSE BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $45.00 $45.00 $26.00 $26.00 $28.21 $20.84 $74.22 $74.22 $77.08 $26.00 $20.84 $16.90 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $60.00 $45.00 $60.00 $15.65 $26.00 $26.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 63604091 EAP HCPCS C9250 Kit Tiss Clsr Frzn Slnt Artiss 4ml BOTH IP/OP $836.00 $618.64 $0.00 $668.80 $376.20 $376.20 $156.84 $156.84 $156.84 $174.24 $620.48 $620.48 $644.39 $156.84 $174.22 $101.95 $494.49 $494.49 $173.09 $418.00 $662.11 $668.80 $239.03 $376.20 $239.03 $130.83 $0.00 $0.00 $133.09 $164.85 $0.00 $0.00 $0.00 $0.00 63604093 EAP CPT® 90648 HIBERIX VACCINE BOTH IP/OP $87.19 $64.52 $0.00 $69.75 $39.24 $39.24 $0.00 $0.00 $0.00 $18.17 $64.71 $64.71 $67.21 $0.00 $18.17 $0.00 $51.57 $51.57 $0.00 $43.60 $69.05 $69.75 $0.00 $39.24 $0.00 $13.65 $0.00 $0.00 $13.88 $0.00 $0.00 $0.00 $0.00 $0.00 63690324 EAP HCPCS J1050 Depo Provera Inject 1mg BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $22.50 $22.50 $0.00 $0.00 $0.00 $10.42 $37.11 $37.11 $38.54 $0.00 $0.67 $0.00 $29.58 $29.58 $0.00 $25.00 $39.60 $40.00 $0.00 $22.50 $0.00 $0.66 $0.00 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $0.00 63690325 EAP HCPCS J0696 Ceftriaxone Per 250 Mg BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $15.75 $15.75 $0.00 $0.00 $0.00 $1.41 $25.98 $25.98 $26.98 $0.00 $0.59 $0.00 $20.70 $20.70 $0.00 $17.50 $27.72 $28.00 $0.00 $15.75 $0.00 $0.71 $0.00 $0.00 $0.67 $0.00 $0.00 $0.00 $0.00 $0.00 63690332 EAP HCPCS J0694 Cefoxitin 1gm Vial BOTH IP/OP $25.00 $18.50 $0.00 $20.00 $11.25 $11.25 $0.00 $0.00 $0.00 $8.06 $18.56 $18.56 $19.27 $0.00 $5.42 $0.00 $14.79 $14.79 $0.00 $12.50 $19.80 $20.00 $0.00 $0.00 $0.00 $6.22 $0.00 $0.00 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 63690333 EAP HCPCS J1200 Diphenhydramine 50 Mg/ml BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.86 $11.88 $11.88 $12.33 $0.00 $1.16 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $1.06 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 63690334 EAP HCPCS J0360 Hydralazine 20mg/1ml BOTH IP/OP $47.00 $34.78 $0.00 $37.60 $21.15 $21.15 $0.00 $0.00 $0.00 $5.77 $34.88 $34.88 $36.23 $0.00 $6.11 $0.00 $27.80 $27.80 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $4.41 $0.00 $0.00 $4.20 $0.00 $0.00 $0.00 $0.00 $0.00 63690335 EAP HCPCS J1720 Hydrocortisone Sod Succ 100mg Vial BOTH IP/OP $19.00 $14.06 $0.00 $17.40 $8.55 $8.55 $0.00 $0.00 $0.00 $3.96 $14.10 $14.10 $14.65 $0.00 $17.40 $0.00 $11.24 $11.24 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $15.33 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $0.00 63690336 EAP HCPCS J1885 Ketorolac 60 Mg/2ml BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $0.32 $11.88 $11.88 $12.33 $0.00 $0.57 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 63690337 EAP HCPCS J2590 Oxytocin 10unit/1ml BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $7.20 $7.20 $0.00 $0.00 $0.00 $1.47 $11.88 $11.88 $12.33 $0.00 $3.33 $0.00 $9.46 $9.46 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 63690341 EAP CPT® 90656 Flu Vaccine Pf > 18 Yrs 2018-2019 BOTH IP/OP $25.00 $18.50 $0.00 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.56 $18.56 $19.27 $0.00 $5.21 $0.00 $0.00 $0.00 $3.65 $12.50 $19.80 $20.00 $3.65 $11.25 $3.65 $3.91 $6.50 $6.50 $3.98 $6.50 $0.00 $0.00 $0.00 $0.00 63690342 EAP CPT® 90685 Flu Vaccine Pf 6-35 Months 2018-2019 BOTH IP/OP $25.00 $18.50 $3.65 $25.00 $11.25 $11.25 $6.50 $6.50 $21.13 $5.21 $18.56 $18.56 $19.27 $6.50 $25.00 $4.23 $14.79 $14.79 $3.65 $12.50 $19.80 $20.00 $3.65 $11.25 $3.65 $3.91 $6.50 $6.50 $3.98 $6.50 $0.00 $0.00 $0.00 $0.00 63690347 EAP CPT® 90688 Flu Iiv4 Vaccine Splt 0.5ml Im (2018-2019) BOTH IP/OP $25.00 $18.50 $0.00 $23.39 $11.25 $11.25 $6.50 $6.50 $19.17 $0.00 $18.56 $18.56 $19.27 $0.00 $23.39 $0.00 $0.00 $0.00 $3.65 $12.50 $19.80 $20.00 $3.65 $11.25 $3.65 $0.00 $6.50 $6.50 $19.96 $6.50 $0.00 $0.00 $0.00 $0.00 63690350 EAP CPT® 90685 Flu Vaccine Pf 6m - 35m 2019-2020 BOTH IP/OP $25.00 $18.50 $3.65 $25.00 $11.25 $11.25 $6.50 $6.50 $21.13 $5.21 $18.56 $18.56 $19.27 $6.50 $25.00 $4.23 $14.79 $14.79 $3.65 $12.50 $19.80 $20.00 $3.65 $11.25 $3.65 $3.91 $6.50 $6.50 $3.98 $6.50 $0.00 $0.00 $0.00 $0.00 63690351 EAP CPT® 90686 Flu Vaccine Pf 3 & Up 2019-2020 BOTH IP/OP $25.00 $18.50 $3.65 $24.12 $11.25 $11.25 $6.50 $6.50 $6.50 $5.21 $18.56 $18.56 $19.27 $6.50 $24.12 $4.23 $14.79 $14.79 $3.65 $12.50 $19.80 $20.00 $3.65 $11.25 $3.65 $22.36 $6.50 $6.50 $21.29 $6.50 $0.00 $0.00 $0.00 $0.00 63690355 EAP CPT® 90674 2020-2021 FLU VACCINE BOTH IP/OP $25.00 $18.50 $3.65 $33.05 $11.25 $11.25 $6.50 $6.50 $6.50 $5.21 $18.56 $18.56 $19.27 $6.50 $25.00 $4.23 $14.79 $14.79 $3.65 $12.50 $19.80 $20.00 $3.65 $11.25 $3.65 $33.05 $6.50 $6.50 $31.47 $6.50 $0.00 $0.00 $0.00 $0.00 63690358 EAP CPT® 90686 2020-2021 FLU VACCINE BOTH IP/OP $25.00 $18.50 $3.65 $24.12 $11.25 $11.25 $6.50 $6.50 $6.50 $5.21 $18.56 $18.56 $19.27 $6.50 $24.12 $4.23 $14.79 $14.79 $3.65 $12.50 $19.80 $20.00 $3.65 $11.25 $3.65 $22.36 $6.50 $6.50 $21.29 $6.50 $0.00 $0.00 $0.00 $0.00 63690360 EAP CPT® 90681 ROTAVIRUS 2 DOSE VACCINE BOTH IP/OP $108.00 $79.92 $0.00 $119.46 $48.60 $48.60 $0.00 $0.00 $119.46 $22.51 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $63.88 $63.88 $0.00 $54.00 $85.54 $86.40 $64.80 $48.60 $64.80 $0.00 $0.00 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $0.00 63690370 EAP CPT® 90648 ACTHIB VACCINE BOTH IP/OP $71.00 $52.54 $0.00 $56.80 $31.95 $31.95 $0.00 $0.00 $0.00 $14.80 $52.70 $52.70 $54.73 $0.00 $14.80 $0.00 $42.00 $42.00 $0.00 $35.50 $56.23 $56.80 $0.00 $31.95 $0.00 $11.11 $0.00 $0.00 $11.30 $0.00 $0.00 $0.00 $0.00 $0.00 68000010 EAP Custom 68000010 Level 2 Partial Trauma Activation W/o Prenotificat BOTH IP/OP "$14,957.00 " "$11,068.18" $0.00 "$10,694.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,117.04" $0.00 $0.00 $0.00 $0.00 "$6,181.50" "$9,791.50" "$9,890.40" $0.00 "$10,694.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68000065 EAP Custom 68000065 Level 1 Full Trauma Activation W/o Prenotification BOTH IP/OP "$27,981.00 " "$20,705.94" $0.00 "$20,006.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,831.24" $0.00 $0.00 $0.00 $0.00 "$11,563.50" "$18,316.58" "$18,501.60" $0.00 "$20,006.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68100003 EAP Custom 68100003 Level 1 Full Trauma Activation BOTH IP/OP "$27,981.00 " "$20,705.94" $0.00 "$20,006.35" "$5,630.00" "$5,630.00" $0.00 $0.00 $0.00 $0.00 "$4,447.44" "$4,447.44" "$4,618.49" $0.00 "$5,831.24" $0.00 "$5,671.00" "$5,671.00" $0.00 "$11,563.50" "$18,316.58" "$18,501.60" $0.00 "$20,006.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68100004 EAP Custom 68100004 Level 2 Partial Trauma Activation BOTH IP/OP "$14,957.00 " "$11,068.18" $0.00 "$10,694.45" "$5,630.00" "$5,630.00" $0.00 $0.00 $0.00 $0.00 "$4,447.44" "$4,447.44" "$4,618.49" $0.00 "$3,117.04" $0.00 "$5,671.00" "$5,671.00" $0.00 "$6,181.50" "$9,791.50" "$9,890.40" $0.00 "$10,694.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68100005 EAP Custom 68100005 Level 3 Partial Trauma Activation BOTH IP/OP "$7,507.00 " "$5,555.18" $0.00 "$5,671.00" "$5,630.00" "$5,630.00" $0.00 $0.00 $0.00 $0.00 "$4,447.44" "$4,447.44" "$4,618.49" $0.00 "$1,564.46" $0.00 "$5,671.00" "$5,671.00" $0.00 "$3,102.00" "$4,913.57" "$4,963.20" $0.00 "$5,367.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000001 EAP CPT® 29035 "Apply Body Cast, Shldr To Hips" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,578.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 "$1,578.00" "$1,249.78" "$1,262.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000002 EAP CPT® 29040 Apply Body Cast Risser/minerva BOTH IP/OP "$1,062.00 " $785.88 $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.32 $0.00 $0.00 $0.00 $0.00 "$1,188.00" $940.90 $950.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000003 EAP CPT® 29065 Apply Long Arm Cast BOTH IP/OP "$1,466.00 " "$1,084.84" $0.00 "$1,750.00" $796.04 $796.04 $234.93 $234.93 $236.25 $305.55 $0.00 $0.00 $0.00 $231.14 $305.51 $150.24 $113.00 $113.00 $230.50 "$1,380.00" "$1,092.96" "$1,104.00" $320.24 "$1,750.00" $320.24 $126.54 $70.29 $70.29 $219.70 $219.52 $0.00 $0.00 $0.00 $0.00 70000004 EAP CPT® 29075 Apply Short Arm Cast BOTH IP/OP $943.00 $697.82 $0.00 "$1,750.00" $512.05 $512.05 $234.93 $234.93 $236.25 $196.54 $0.00 $0.00 $0.00 $231.14 $196.52 $150.24 $113.00 $113.00 $230.50 $888.00 $703.30 $710.40 $320.24 "$1,750.00" $320.24 $110.88 $63.44 $63.44 $141.37 $219.52 $0.00 $0.00 $0.00 $0.00 70000005 EAP CPT® 29105 Apply Long Arm Splint BOTH IP/OP $912.00 $674.88 $0.00 $859.00 $495.22 $495.22 $137.58 $137.58 $138.36 $190.08 $0.00 $0.00 $0.00 $135.31 $190.06 $87.95 $113.00 $113.00 $134.13 $859.00 $680.33 $687.20 $186.36 $840.00 $186.36 $94.27 $43.63 $43.63 $136.75 $127.75 $0.00 $0.00 $0.00 $0.00 70000006 EAP CPT® 29125 Apply Short Arm Splint Static BOTH IP/OP "$1,011.00 " $748.14 $0.00 "$1,011.00" $548.97 $548.97 $109.81 $109.81 $110.43 $210.72 $0.00 $0.00 $0.00 $107.30 $210.69 $69.74 $113.00 $113.00 $109.35 $952.00 $753.98 $761.60 $151.93 "$1,011.00" $151.93 $72.40 $40.73 $40.73 $151.56 $104.14 $0.00 $0.00 $0.00 $0.00 70000007 EAP CPT® 29305 "Apply Hip Spica Cast, One Leg" BOTH IP/OP $612.00 $452.88 $0.00 $685.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.54 $0.00 $0.00 $0.00 $0.00 $685.00 $542.52 $548.00 $0.00 $608.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000008 EAP CPT® 29325 Apply Hip Spica Cast Both Legs BOTH IP/OP "$1,104.00 " $816.96 $0.00 "$1,235.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.07 $0.00 $0.00 $0.00 $0.00 "$1,235.00" $978.12 $988.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000009 EAP CPT® 29345 Apply Long Leg Cast BOTH IP/OP $838.00 $620.12 $0.00 $838.00 $838.00 $838.00 $234.93 $234.93 $236.25 $174.66 $0.00 $0.00 $0.00 $231.14 $174.64 $150.24 $113.00 $113.00 $0.00 $789.00 $624.89 $631.20 $0.00 $838.00 $0.00 $170.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000010 EAP CPT® 29358 Apply Long Leg Cast Brace BOTH IP/OP "$1,062.00 " $785.88 $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.32 $0.00 $0.00 $0.00 $0.00 "$1,188.00" $940.90 $950.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000011 EAP CPT® 29365 Apply Cylinder Cast BOTH IP/OP "$1,312.00 " $970.88 $0.00 "$1,235.00" $0.00 $0.00 $0.00 $0.00 $0.00 $273.45 $0.00 $0.00 $0.00 $231.14 $273.42 $150.24 $113.00 $113.00 $230.50 "$1,235.00" $978.12 $988.00 $320.24 $604.00 $320.24 $144.43 $90.11 $90.11 $196.61 $219.52 $0.00 $0.00 $0.00 $0.00 70000012 EAP CPT® 29405 Apply Short Leg Cast BOTH IP/OP $943.00 $697.82 $0.00 "$1,366.00" $512.05 $512.05 $234.93 $234.93 $236.25 $196.54 $0.00 $0.00 $0.00 $231.14 $196.52 $150.24 $113.00 $113.00 $230.50 $888.00 $703.30 $710.40 $320.24 "$1,366.00" $320.24 $118.65 $60.92 $60.92 $141.37 $219.52 $0.00 $0.00 $0.00 $0.00 70000013 EAP CPT® 29425 Apply Short Leg Cast Walking BOTH IP/OP "$1,403.00 " "$1,038.22" $0.00 "$1,321.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.39 $0.00 $0.00 $0.00 $230.50 "$1,321.00" "$1,046.23" "$1,056.80" $320.24 $805.00 $320.24 $123.49 $57.32 $57.32 $210.30 $219.52 $0.00 $0.00 $0.00 $0.00 70000014 EAP CPT® 29435 Apply Short Leg Cast Ptb BOTH IP/OP $794.00 $587.56 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.47 $0.00 $0.00 $0.00 $0.00 $888.00 $703.30 $710.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000015 EAP CPT® 29445 "Long Leg Cast, Rigid" BOTH IP/OP "$1,935.00 " "$1,431.90" $0.00 "$1,822.00" "$1,050.71" "$1,050.71" $234.93 $234.93 $236.25 $403.30 $0.00 $0.00 $0.00 $231.14 $403.25 $150.24 $113.00 $113.00 $230.50 "$1,822.00" "$1,443.02" "$1,457.60" $320.24 "$1,750.00" $320.24 $206.12 $106.00 $106.00 $290.06 $219.52 $0.00 $0.00 $0.00 $0.00 70000016 EAP CPT® 29505 Apply Long Leg Splint BOTH IP/OP "$1,630.00 " "$1,206.20" $0.00 "$1,535.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.69 $0.00 $0.00 $0.00 $134.13 "$1,535.00" "$1,215.72" "$1,228.00" $186.36 $940.00 $186.36 $94.49 $52.27 $52.27 $244.37 $127.75 $0.00 $0.00 $0.00 $0.00 70000017 EAP CPT® 29515 Apply Short Leg Splint BOTH IP/OP $943.00 $697.82 $0.00 $943.00 $512.05 $512.05 $137.58 $137.58 $138.36 $196.54 $0.00 $0.00 $0.00 $135.31 $196.52 $87.95 $113.00 $113.00 $134.13 $888.00 $703.30 $710.40 $186.36 $943.00 $186.36 $80.51 $51.19 $51.19 $141.37 $127.75 $0.00 $0.00 $0.00 $0.00 70000018 EAP CPT® 29705 Removal Full Arm/leg Cast BOTH IP/OP $943.00 $697.82 $0.00 $943.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.52 $0.00 $0.00 $0.00 $230.50 $888.00 $703.30 $710.40 $320.24 $943.00 $320.24 $51.73 $47.23 $47.23 $141.37 $219.52 $0.00 $0.00 $0.00 $0.00 70000019 EAP CPT® 29730 Windowing Of Cast BOTH IP/OP $612.00 $452.88 $0.00 $685.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.54 $0.00 $0.00 $0.00 $0.00 $685.00 $542.52 $548.00 $0.00 $322.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000200 EAP HCPCS C1725 Catheter Angio 100cm 4fr Sfvu Pgtl Curve Brd Strl BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 70000217 EAP HCPCS C1725 Catheter Angio Cbr 2 Curve 5fr 65cm Vscr Radiopq BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 70000219 EAP HCPCS C1757 Catheter Thrmb 135cm 5fr Unfs Flw-thru Hub Infus BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000220 EAP HCPCS C1757 Catheter Thrmb 135cm 5fr Unfs Flw-thru Hub Infus BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70000224 EAP HCPCS C1725 Catheter Angio Ang Brnstn Curve 5fr 100cm 10cm BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 70000225 EAP HCPCS C1725 Catheter Angio Sos O2 Curve 5fr 80cm Vscr Radiopq BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $95.03 $95.03 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $134.89 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $113.75 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 70000226 EAP HCPCS C1725 Catheter Angio Cbr 2 Curve 4fr 65cm Vscr Radiopq BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 70000584 EAP HCPCS C1876 Stent Endoprsth Trchbr 90mm 16mm 9fr Mtl Wlstnt BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 70000587 EAP HCPCS C1769 Guidewire Vasc 260cm .035in Flxb Flpy Tip Fltwr BOTH IP/OP "$2,653.00 " "$1,963.22" $0.00 "$2,122.40" "$1,440.58" "$1,440.58" $0.00 $0.00 $0.00 $552.95 "$1,969.06" "$1,969.06" "$2,044.93" $0.00 $552.89 $0.00 "$1,569.25" "$1,569.25" $0.00 "$1,326.50" "$2,101.18" "$2,122.40" $0.00 $0.00 $0.00 $415.19 $0.00 $0.00 $422.36 $0.00 $0.00 $0.00 $0.00 $0.00 70000602 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Intmd Tip Radiopq X BOTH IP/OP "$1,075.00 " $795.50 $0.00 $860.00 $583.73 $583.73 $0.00 $0.00 $0.00 $224.06 $797.87 $797.87 $828.61 $0.00 $224.03 $0.00 $635.86 $635.86 $0.00 $537.50 $851.40 $860.00 $0.00 $0.00 $0.00 $168.24 $0.00 $0.00 $171.14 $0.00 $0.00 $0.00 $0.00 $0.00 70000603 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Flpy Intmd Tip Radiopq BOTH IP/OP "$1,075.00 " $795.50 $0.00 $860.00 $583.73 $583.73 $0.00 $0.00 $0.00 $224.06 $797.87 $797.87 $828.61 $0.00 $224.03 $0.00 $635.86 $635.86 $0.00 $537.50 $851.40 $860.00 $0.00 $0.00 $0.00 $168.24 $0.00 $0.00 $171.14 $0.00 $0.00 $0.00 $0.00 $0.00 70000626 EAP HCPCS C1769 Guidewire Vasc 145cm .035in Flxb Flpy Tip Fltwr BOTH IP/OP $331.00 $244.94 $0.00 $264.80 $179.73 $179.73 $0.00 $0.00 $0.00 $68.99 $245.67 $245.67 $255.13 $0.00 $68.98 $0.00 $195.79 $195.79 $0.00 $165.50 $262.15 $264.80 $0.00 $215.15 $0.00 $51.80 $0.00 $0.00 $52.70 $0.00 $0.00 $0.00 $0.00 $0.00 70000720 EAP HCPCS C1769 Guidewire Vasc 260cm .035in Fix Core Flx Tp Hvdty BOTH IP/OP $74.00 $54.76 $0.00 $59.20 $0.00 $0.00 $0.00 $0.00 $0.00 $15.42 $0.00 $0.00 $0.00 $0.00 $15.42 $0.00 $43.77 $43.77 $0.00 $37.00 $58.61 $59.20 $0.00 $0.00 $0.00 $11.58 $0.00 $0.00 $11.78 $0.00 $0.00 $0.00 $0.00 $0.00 70000762 EAP HCPCS C1725 Catheter Angio 100cm 5fr Trnb Ad Bcn Jb1 Curve Ss BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $9.86 $0.00 $0.00 $10.03 $0.00 $0.00 $0.00 $0.00 $0.00 70000764 EAP HCPCS C1725 Catheter Angio 100cm 5fr Trnb Ad Bcn Sim2 Curve Ss BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 70000820 EAP HCPCS C1773 Set Rtrvl 80cm 6.3fr 11fr Gnth Tlp Coons Vc 3w BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $339.38 $339.38 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $481.75 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 70000823 EAP HCPCS C1769 Guidewire Vasc 60cm .018in Flpy Sftp Ang Tpr 7cm BOTH IP/OP $98.00 $72.52 $0.00 $76.00 $53.21 $53.21 $0.00 $0.00 $0.00 $19.80 $72.74 $72.74 $75.54 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $63.70 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 70000977 EAP HCPCS C1887 Catheter Guid Blue Ylw 100cm 6fr Crds Vsbr Ar2 BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $50.50 $50.50 $0.00 $0.00 $0.00 $19.38 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $55.01 $55.01 $0.00 $46.50 $73.66 $74.40 $0.00 $0.00 $0.00 $14.55 $0.00 $0.00 $14.81 $0.00 $0.00 $0.00 $0.00 $0.00 70000983 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Act Mp1 Curve Peri BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70000997 EAP HCPCS C1887 Catheter Guid Blue Ylw 100cm 6fr Crds Vsbr Jr4st BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $50.50 $50.50 $0.00 $0.00 $0.00 $19.38 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $55.01 $55.01 $0.00 $46.50 $73.66 $74.40 $0.00 $0.00 $0.00 $14.55 $0.00 $0.00 $14.81 $0.00 $0.00 $0.00 $0.00 $0.00 70000998 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Ar1 Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001000 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Std Jl3.5 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001001 EAP HCPCS C1887 Catheter Guid 7fr Shr Nx Bal Std Jr3.5 Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001003 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Std Jl5 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001005 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Std Jr5 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001006 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Mp1 Curve Peri BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001013 EAP HCPCS C1887 Catheter Guid 7fr Shr Nx Bal Std Jr4 Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001014 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Ima Curve Peri BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001028 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Ar1 Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001029 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Std Jl4 Curve BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $64.07 $64.07 $0.00 $0.00 $0.00 $24.59 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $69.80 $69.80 $0.00 $59.00 $93.46 $94.40 $0.00 $0.00 $0.00 $18.47 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 70001030 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Std Jr4 Curve BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $64.07 $64.07 $0.00 $0.00 $0.00 $24.59 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $69.80 $69.80 $0.00 $59.00 $93.46 $94.40 $0.00 $0.00 $0.00 $18.47 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 70001041 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Std Jl4 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001043 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Std Jr4 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001045 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Al1 Curve Coron BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $64.07 $64.07 $0.00 $0.00 $0.00 $24.59 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $69.80 $69.80 $0.00 $59.00 $93.46 $94.40 $0.00 $0.00 $0.00 $18.47 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 70001047 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Al1 Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001048 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Std Jl4 Curve BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $64.07 $64.07 $0.00 $0.00 $0.00 $24.59 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $69.80 $69.80 $0.00 $59.00 $93.46 $94.40 $0.00 $76.70 $0.00 $18.47 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 70001049 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Std Jr4 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001050 EAP HCPCS C1887 Catheter Guid Blue Ylw 100cm 6fr Crds Vsbr Xb3 BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $50.50 $50.50 $0.00 $0.00 $0.00 $19.38 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $55.01 $55.01 $0.00 $46.50 $73.66 $74.40 $0.00 $0.00 $0.00 $14.55 $0.00 $0.00 $14.81 $0.00 $0.00 $0.00 $0.00 $0.00 70001051 EAP HCPCS C1887 Catheter Guid Blue Ylw 100cm 6fr Crds Vsbr Xb3.5 BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $50.50 $50.50 $0.00 $0.00 $0.00 $19.38 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $55.01 $55.01 $0.00 $46.50 $73.66 $74.40 $0.00 $0.00 $0.00 $14.55 $0.00 $0.00 $14.81 $0.00 $0.00 $0.00 $0.00 $0.00 70001053 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Std Jl3.5 Curve BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $24.59 $0.00 $0.00 $0.00 $0.00 $24.59 $0.00 $69.80 $69.80 $0.00 $59.00 $93.46 $94.40 $0.00 $0.00 $0.00 $18.47 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 70001054 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Al2 Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001055 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Std Jr3.5 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001056 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Al.75 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001057 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Al.75 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 70001234 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Sft Rbn Tip Kink Rst BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 70001408 EAP HCPCS C1757 Snare Vasc 120cm 9-15mm 6fr Ensnr Std 3 Prefrm BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $449.60 $449.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $638.22 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70001510 EAP HCPCS L0625 Support Orthopedic Universal Binder Velcro Closure Yellow BOTH IP/OP $538.00 $398.12 $0.00 $430.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $399.30 $399.30 $414.69 $0.00 $112.12 $0.00 $0.00 $0.00 $0.00 $269.00 $426.10 $430.40 $0.00 $349.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000014 EAP Custom 71000014 PHASE II RECOVERY < 6HRS BOTH IP/OP "$2,822.00 " "$2,088.28" $0.00 "$2,175.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,094.49" "$2,094.49" "$2,175.20" $0.00 $588.10 $0.00 $0.00 $0.00 $0.00 "$1,245.50" "$1,972.87" "$1,992.80" $0.00 "$1,980.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000033 EAP Custom 71000033 Phase Ii Recovery > 6hrs BOTH IP/OP "$4,229.00 " "$3,129.46" $0.00 "$3,259.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,138.76" "$3,138.76" "$3,259.71" $0.00 $881.32 $0.00 $0.00 $0.00 $0.00 "$1,866.50" "$2,956.54" "$2,986.40" $0.00 "$2,968.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000040 EAP Custom 71000040 Level 1 1st 30 Min BOTH IP/OP "$2,001.00 " "$1,480.74" $0.00 "$1,542.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,485.14" "$1,485.14" "$1,542.37" $0.00 $417.01 $0.00 $0.00 $0.00 $0.00 $883.00 "$1,398.67" "$1,412.80" $0.00 "$1,404.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000041 EAP Custom 71000041 Level 2 1st 30 Min BOTH IP/OP "$2,403.00 " "$1,778.22" $0.00 "$1,852.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,783.51" "$1,783.51" "$1,852.23" $0.00 $500.79 $0.00 $0.00 $0.00 $0.00 "$1,060.50" "$1,679.83" "$1,696.80" $0.00 "$1,686.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000042 EAP Custom 71000042 Level 3 1st 30 Min BOTH IP/OP "$3,201.00 " "$2,368.74" $0.00 "$2,467.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,375.78" "$2,375.78" "$2,467.33" $0.00 $667.09 $0.00 $0.00 $0.00 $0.00 "$1,412.50" "$2,237.40" "$2,260.00" $0.00 "$2,247.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000043 EAP Custom 71000043 Level 4 1st 30 Min BOTH IP/OP "$3,467.00 " "$2,565.58" $0.00 "$2,672.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,573.21" "$2,573.21" "$2,672.36" $0.00 $722.52 $0.00 $0.00 $0.00 $0.00 "$1,530.00" "$2,423.52" "$2,448.00" $0.00 "$2,433.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000044 EAP Custom 71000044 Level 5 1st 30 Min BOTH IP/OP "$4,801.00 " "$3,552.74" $0.00 "$3,700.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,563.30" "$3,563.30" "$3,700.61" $0.00 "$1,000.53" $0.00 $0.00 $0.00 $0.00 "$2,118.50" "$3,355.70" "$3,389.60" $0.00 "$3,370.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000045 EAP Custom 71000045 Level 1 Add 15 Min BOTH IP/OP "$1,049.00 " $776.26 $0.00 $808.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $778.57 $778.57 $808.57 $0.00 $218.61 $0.00 $0.00 $0.00 $0.00 $462.50 $732.60 $740.00 $0.00 $736.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000046 EAP Custom 71000046 Level 2 Add 15 Min BOTH IP/OP "$1,261.00 " $933.14 $0.00 $971.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $935.91 $935.91 $971.98 $0.00 $262.79 $0.00 $0.00 $0.00 $0.00 $556.50 $881.50 $890.40 $0.00 $884.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000047 EAP Custom 71000047 Level 3 Add 15 Min BOTH IP/OP "$1,678.00 " "$1,241.72" $0.00 "$1,293.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,245.41" "$1,245.41" "$1,293.40" $0.00 $349.70 $0.00 $0.00 $0.00 $0.00 $740.50 "$1,172.95" "$1,184.80" $0.00 "$1,177.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000048 EAP Custom 71000048 Level 4 Add 15 Min BOTH IP/OP "$1,823.00 " "$1,349.02" $0.00 "$1,405.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,353.03" "$1,353.03" "$1,405.17" $0.00 $379.91 $0.00 $0.00 $0.00 $0.00 $804.50 "$1,274.33" "$1,287.20" $0.00 "$1,279.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000049 EAP Custom 71000049 Level 5 Add 15 Min BOTH IP/OP "$2,521.00 " "$1,865.54" $0.00 "$1,943.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,871.09" "$1,871.09" "$1,943.19" $0.00 $525.38 $0.00 $0.00 $0.00 $0.00 "$1,112.50" "$1,762.20" "$1,780.00" $0.00 "$1,769.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000050 EAP Gi Procedure Recovery BOTH IP/OP $636.00 $470.64 $0.00 $490.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $472.04 $472.04 $490.23 $0.00 $132.54 $0.00 $0.00 $0.00 $0.00 $280.50 $444.31 $448.80 $0.00 $445.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000051 EAP Cardiology Recovery BOTH IP/OP $636.00 $470.64 $0.00 $490.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $472.04 $472.04 $490.23 $0.00 $132.54 $0.00 $0.00 $0.00 $0.00 $280.50 $444.31 $448.80 $0.00 $445.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000133 EAP Custom 71000133 Phase Ii Recovery > 6hrs BOTH IP/OP "$3,435.00 " "$2,541.90" $0.00 "$3,080.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,549.46" "$2,549.46" "$2,647.70" $0.00 $715.85 $0.00 $0.00 $0.00 $0.00 "$1,925.50" "$3,049.99" "$3,080.80" $0.00 "$2,410.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71000134 EAP Ir Recovery BOTH IP/OP $636.00 $470.64 $0.00 $490.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $472.04 $472.04 $490.23 $0.00 $132.54 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $445.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71900020 EAP Custom 71900020 Extended Recovery 1st 30 Mins BOTH IP/OP "$1,308.00 " $967.92 $0.00 "$1,172.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.80 $970.80 "$1,008.21" $0.00 $272.59 $0.00 $0.00 $0.00 $0.00 $733.00 "$1,161.07" "$1,172.80" $0.00 $917.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71900021 EAP Custom 71900021 Extended Recovery Ea Addtl 15 Mins BOTH IP/OP $739.00 $546.86 $0.00 $662.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $548.49 $548.49 $569.62 $0.00 $154.01 $0.00 $0.00 $0.00 $0.00 $414.00 $655.78 $662.40 $0.00 $518.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72000001 EAP CPT® 59030 Fetal Scalp Blood BOTH IP/OP "$1,104.00 " $816.96 $0.00 "$1,115.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.07 $0.00 $0.00 $0.00 $0.00 "$1,115.00" $883.08 $892.00 $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72000006 EAP CPT® 59612 Vaginal Delivery After Prior Cesarean Delivery BOTH IP/OP "$8,307.00 " "$6,147.18" $0.00 "$6,645.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,731.18" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,579.14" "$6,645.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72200001 EAP CPT® 59409 Vaginal Delivery Only Complica BOTH IP/OP "$6,614.00 " "$4,894.36" $0.00 "$4,877.00" "$2,321.55" "$2,321.55" "$2,555.04" "$2,555.04" "$2,569.43" "$1,378.52" $0.00 $0.00 $0.00 "$2,514.14" "$1,378.36" "$1,634.19" "$4,877.00" "$4,877.00" $0.00 "$2,255.00" "$4,210.27" "$4,252.80" $0.00 "$3,250.00" $0.00 $892.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72200002 EAP CPT® 59409 Vaginal Delivery Only Uncompl. BOTH IP/OP "$6,435.00 " "$4,761.90" $0.00 "$4,877.00" "$2,321.55" "$2,321.55" "$2,555.04" "$2,555.04" "$2,569.43" "$1,341.21" $0.00 $0.00 $0.00 "$2,514.14" "$1,341.05" "$1,634.19" "$4,877.00" "$4,877.00" $0.00 "$2,255.00" "$3,374.71" "$3,408.80" $0.00 "$3,250.00" $0.00 $892.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73000001 EAP CPT® 93005 Ekg BOTH IP/OP $606.00 $448.44 $8.64 $467.10 $18.80 $18.80 $54.21 $54.21 $54.51 $126.31 $449.77 $449.77 $467.10 $53.35 $126.29 $34.67 $358.45 $358.45 $55.17 $245.00 $388.08 $392.00 $76.65 $394.55 $76.65 $17.51 $8.64 $8.64 $78.01 $52.54 $0.00 $0.00 $0.00 $0.00 73000007 EAP CPT® 93041 "Rhythm Ecg, Tracing" BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73000010 EAP CPT® 93041 Ekg Rhythm Strip 3 Lead BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73000011 EAP CPT® 93017 Cardiac Stress Test BOTH IP/OP "$3,585.00 " "$2,652.90" $34.22 "$2,896.80" $86.88 $86.88 $257.73 $257.73 $259.18 $747.20 "$2,660.79" "$2,660.79" "$2,763.32" $253.45 $747.11 $164.75 "$2,120.53" "$2,120.53" $253.05 "$1,810.50" "$2,867.83" "$2,896.80" $351.58 "$2,330.25" $351.58 $64.64 $34.22 $34.22 $576.46 $241.00 $0.00 $0.00 $0.00 $0.00 73100001 EAP CPT® 93225 "Ecg Monitoring, Continuous" BOTH IP/OP "$1,032.00 " $763.68 $25.93 $820.80 $58.71 $58.71 $109.81 $109.81 $110.43 $215.09 $765.95 $765.95 $795.47 $107.30 $215.07 $69.74 $610.43 $610.43 $109.35 $513.00 $812.59 $820.80 $151.93 $594.75 $151.93 $47.49 $25.93 $25.93 $163.34 $104.14 $0.00 $0.00 $0.00 $0.00 73100002 EAP CPT® 93226 Ecg Monitoring Analysis&report BOTH IP/OP "$1,644.00 " "$1,216.56" $0.00 "$1,315.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,220.18" "$1,220.18" "$1,267.20" $0.00 $342.61 $0.00 $0.00 $0.00 $0.00 $822.00 "$1,302.05" "$1,315.20" $0.00 $752.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73100003 EAP CPT® 93270 Cardiac Event Recording BOTH IP/OP $709.00 $524.66 $9.00 $572.80 $20.35 $20.35 $36.26 $36.26 $36.47 $147.77 $526.22 $526.22 $546.50 $35.61 $147.76 $23.14 $419.37 $419.37 $36.36 $358.00 $567.07 $572.80 $50.51 $206.05 $50.51 $47.49 $9.00 $9.00 $113.99 $34.63 $0.00 $0.00 $0.00 $0.00 73100004 EAP CPT® 93271 Cardiac Event Analysis BOTH IP/OP $716.00 $529.84 $0.00 $572.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $531.42 $531.42 $551.89 $0.00 $149.21 $0.00 $0.00 $0.00 $0.00 $358.00 $567.07 $572.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73100005 EAP CPT® 0296T Ext Ecg > 48hr To 21 Day Rcrd W/conect Intl Rcrd BOTH IP/OP $681.00 $503.94 $0.00 $656.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $656.00 $519.55 $524.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000001 EAP CPT® 95812 Eeg Up To 1 Hour BOTH IP/OP $835.00 $617.90 $0.00 $643.62 $453.41 $453.41 $257.73 $257.73 $259.18 $174.03 $619.74 $619.74 $643.62 $253.45 $174.01 $164.75 $493.90 $493.90 $0.00 $312.50 $495.00 $500.00 $0.00 $542.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000002 EAP CPT® 95813 Eeg Extended Monitoring 61-119 Minutes BOTH IP/OP "$1,873.00 " "$1,386.02" $0.00 "$1,443.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,390.14" "$1,390.14" "$1,443.71" $0.00 $390.33 $0.00 $0.00 $0.00 $0.00 $854.50 "$1,353.53" "$1,367.20" $0.00 "$1,217.45" $0.00 $183.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000003 EAP CPT® 95816 "Eeg, Awake And Drowsy" BOTH IP/OP "$1,050.00 " $777.00 $124.97 "$1,109.55" $570.15 $570.15 $257.73 $257.73 $259.18 $218.85 $779.31 $779.31 $809.34 $253.45 $218.82 $164.75 $621.08 $621.08 $253.05 $392.50 $621.72 $628.00 $351.58 "$1,109.55" $351.58 $128.39 $311.91 $311.91 $124.97 $241.00 $0.00 $0.00 $0.00 $0.00 74000004 EAP CPT® 95819 "Eeg, W/awake & Asleep Record" BOTH IP/OP "$1,794.00 " "$1,327.56" $110.11 "$1,382.82" $974.14 $974.14 $257.73 $257.73 $259.18 $373.91 "$1,331.51" "$1,331.51" "$1,382.82" $253.45 $373.87 $164.75 "$1,061.15" "$1,061.15" $253.05 $818.50 "$1,296.50" "$1,309.60" $351.58 "$1,208.35" $351.58 $110.11 $381.06 $381.06 $260.61 $241.00 $0.00 $0.00 $0.00 $0.00 74000005 EAP CPT® 95822 "Eeg, Sleep Only" BOTH IP/OP "$1,752.00 " "$1,296.48" $0.00 "$1,565.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,300.33" "$1,300.33" "$1,350.44" $0.00 $365.12 $0.00 $0.00 $0.00 $0.00 $655.50 "$1,038.31" "$1,048.80" $0.00 "$1,565.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000009 EAP CPT® 92585 Ssep Ue BOTH IP/OP "$1,264.00 " $935.36 $0.00 "$1,011.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.00 "$1,001.09" "$1,011.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000011 EAP CPT® 95930 Vep BOTH IP/OP "$1,158.00 " $856.92 $0.00 $957.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $859.47 $859.47 $892.59 $0.00 $241.33 $0.00 $0.00 $0.00 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000012 EAP CPT® 95938 Ssep 4 Ext BOTH IP/OP $768.00 $568.32 $0.00 "$4,513.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $570.01 $570.01 $591.97 $0.00 $160.05 $0.00 $0.00 $0.00 $0.00 $287.50 $455.40 $460.00 $0.00 "$4,513.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000013 EAP CPT® 95929 Cmep Lower Limbs BOTH IP/OP $981.00 $725.94 $0.00 $811.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $728.10 $728.10 $756.15 $0.00 $204.44 $0.00 $0.00 $0.00 $0.00 $507.00 $803.09 $811.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000014 EAP CPT® 95939 Cmep Upper Limbs BOTH IP/OP "$1,351.00 " $999.74 $0.00 "$1,041.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,002.71" "$1,002.71" "$1,041.35" $0.00 $281.55 $0.00 $0.00 $0.00 $0.00 $505.50 $800.71 $808.80 $0.00 $878.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000015 EAP CPT® 95940 Intraoperative Monitoring Neuro In Or Ea 15 Min BOTH IP/OP "$4,241.00 " "$3,138.34" $0.00 "$3,268.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,147.67" "$3,147.67" "$3,268.96" $0.00 $883.82 $0.00 $0.00 $0.00 $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 "$2,756.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000017 EAP CPT® 95961 Functional Cortical Mapping By Intra Operative Stimulation Initial Hr BOTH IP/OP $905.00 $669.70 $0.00 $771.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $671.69 $671.69 $697.57 $0.00 $188.60 $0.00 $0.00 $0.00 $0.00 $482.00 $763.49 $771.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000018 EAP CPT® 95962 Functional Monitor By Stimulation Ea Add'l Hour BOTH IP/OP $661.00 $489.14 $0.00 $563.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $490.59 $490.59 $509.50 $0.00 $137.75 $0.00 $0.00 $0.00 $0.00 $352.00 $557.57 $563.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000019 EAP CPT® 92585 Baer Auditory Evoked Potentials For Evoked Response Ans Or Testing Cns BOTH IP/OP $967.00 $715.58 $0.00 $773.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.50 $765.86 $773.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000020 EAP CPT® 95958 Eeg Monitoring/function Test BOTH IP/OP "$1,943.00 " "$1,437.82" $0.00 "$1,607.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,442.09" "$1,442.09" "$1,497.66" $0.00 $404.92 $0.00 $0.00 $0.00 $0.00 "$1,004.50" "$1,591.13" "$1,607.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000021 EAP CPT® 95958 Eeg Hemisphere Function (wada) BOTH IP/OP "$1,943.00 " "$1,437.82" $0.00 "$1,607.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,442.09" "$1,442.09" "$1,497.66" $0.00 $404.92 $0.00 $0.00 $0.00 $0.00 "$1,004.50" "$1,591.13" "$1,607.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000030 EAP CPT® 95941 Ionm Remote/nearby/>1 Patient In Or Per Hour BOTH IP/OP "$3,680.00 " "$2,723.20" $0.00 "$2,836.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,731.30" "$2,731.30" "$2,836.54" $0.00 $766.91 $0.00 $0.00 $0.00 $0.00 "$1,679.00" "$2,659.54" "$2,686.40" $0.00 $576.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000050 EAP CPT® 95700 EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS BOTH IP/OP "$4,241.00 " "$3,138.34" $0.00 "$3,268.96" "$2,302.86" "$2,302.86" $257.73 $257.73 $259.18 $883.93 "$3,147.67" "$3,147.67" "$3,268.96" $253.45 $883.82 $164.75 "$2,508.55" "$2,508.55" $253.05 "$1,935.00" "$3,065.04" "$3,096.00" $351.58 "$2,756.65" $351.58 $605.66 $0.00 $0.00 $616.10 $241.00 $0.00 $0.00 $0.00 $0.00 74000052 EAP CPT® 95706 Eeg W/o Video (ceribell) 2-12 Hr Intermittent Mntr BOTH IP/OP "$4,241.00 " "$3,138.34" $0.00 "$3,268.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,147.67" "$3,147.67" "$3,268.96" $0.00 $883.82 $0.00 $0.00 $0.00 $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 "$1,589.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000054 EAP CPT® 95708 Eeg W/o Vid By Tech Ea Incr 12-26hr Unmonitored BOTH IP/OP "$6,903.00 " "$5,108.22" $0.00 "$5,320.83" "$3,748.33" "$3,748.33" $475.36 $475.36 $478.04 "$1,438.76" "$4,181.12" "$4,181.12" "$5,320.83" $467.50 "$1,438.59" $303.87 "$3,094.73" "$3,094.73" $487.04 "$3,150.00" "$4,989.60" "$5,040.00" $676.67 "$4,486.95" $676.67 $985.95 $0.00 $0.00 "$1,002.96" $463.84 $0.00 $0.00 $0.00 $0.00 74000055 EAP CPT® 95709 Eeg W/o Video (ceribell) Ea Incr 12-26 Hr Intmt Mntr BOTH IP/OP "$10,349.00 " "$7,658.26" $0.00 "$7,977.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,977.01" $0.00 "$2,156.73" $0.00 $0.00 $0.00 $0.00 "$4,722.50" "$7,480.44" "$7,556.00" $0.00 "$4,548.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000057 EAP CPT® 95711 Veeg By Tech 2-12 Hours Unmonitored BOTH IP/OP "$4,241.00 " "$3,138.34" $0.00 "$3,268.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,147.67" "$3,147.67" "$3,268.96" $0.00 $883.82 $0.00 $0.00 $0.00 $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $568.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74000058 EAP CPT® 95712 Veeg By Tech 2-12 Hr Intermittent Monitoring BOTH IP/OP "$4,241.00 " "$3,138.34" $0.00 "$3,268.96" "$2,302.86" "$2,302.86" $257.73 $257.73 $259.18 $883.93 "$3,147.67" "$3,147.67" "$3,268.96" $253.45 $883.82 $164.75 "$2,508.55" "$2,508.55" $253.05 "$1,935.00" "$3,065.04" "$3,096.00" $351.58 "$2,756.65" $351.58 $0.00 $0.00 $0.00 $616.10 $241.00 $0.00 $0.00 $0.00 $0.00 74000060 EAP CPT® 95714 Veeg By Tech Ea Incr 12-26 Hr Unmonitored BOTH IP/OP "$6,903.00 " "$5,108.22" $0.00 "$5,320.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,320.83" $0.00 "$1,438.59" $0.00 $0.00 $0.00 $487.04 "$3,150.00" "$4,989.60" "$5,040.00" $676.67 "$4,486.95" $676.67 $985.95 $0.00 $0.00 "$1,002.96" $463.84 $0.00 $0.00 $0.00 $0.00 74000061 EAP CPT® 95715 Veeg By Tech Ea Incr 12-26 Hr Intermittent Mntr BOTH IP/OP "$10,349.00 " "$7,658.26" $0.00 "$7,977.01" "$5,619.51" "$5,619.51" $475.36 $475.36 $478.04 "$2,156.99" "$4,181.12" "$4,181.12" "$7,977.01" $467.50 "$2,156.73" $303.87 "$3,094.73" "$3,094.73" $487.04 "$4,722.50" "$7,480.44" "$7,556.00" $676.67 "$6,726.85" $676.67 $0.00 $0.00 $0.00 "$1,503.64" $463.84 $0.00 $0.00 $0.00 $0.00 74000065 EAP CPT® 95955 Eeg During (carotid) Surgery BOTH IP/OP "$1,096.00 " $811.04 $0.00 $844.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $813.45 $813.45 $844.80 $0.00 $228.41 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $584.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000001 EAP CPT® 31622 Bronchoscopy BOTH IP/OP "$4,121.00 " "$3,049.54" $0.00 "$2,996.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,966.83" "$2,996.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000029 EAP CPT® 43260 Ercp-w/wo Biopsy BOTH IP/OP "$6,432.00 " "$4,759.68" $0.00 "$5,145.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,328.97" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,094.14" "$5,145.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000046 EAP CPT® 44360 Sb Endoscop Excluding Ileum Dx BOTH IP/OP "$3,384.00 " "$2,504.16" $0.00 "$2,729.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.23 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,702.30" "$2,729.60" $0.00 "$1,879.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000047 EAP CPT® 44361 Sb Endo-bx Single Multiple BOTH IP/OP "$2,728.00 " "$2,018.72" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $568.52 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$1,980.79" "$2,000.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000050 EAP CPT® 44366 Sb Endo-ctrl Of Bleed Any Meth BOTH IP/OP "$3,030.00 " "$2,242.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.45 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,199.38" "$2,221.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000051 EAP CPT® 44369 "Sb Endo-ablat Of Tum,les Other" BOTH IP/OP "$3,030.00 " "$2,242.20" $256.01 "$2,836.00" "$2,753.10" "$2,753.10" "$1,581.72" "$1,581.72" "$1,590.63" $631.53 "$1,541.95" "$1,541.95" "$1,601.25" "$1,557.45" $631.45 "$1,012.34" "$2,836.00" "$2,836.00" "$1,561.98" "$2,327.00" "$2,199.38" "$2,221.60" "$2,170.16" "$2,500.00" "$2,170.16" $328.65 $256.01 $256.01 $442.10 "$1,487.60" $0.00 $0.00 $0.00 $0.00 75000076 EAP CPT® 45334 "Sigmoid, Flex W Control Bleedi" BOTH IP/OP "$3,337.00 " "$2,469.38" $0.00 "$2,669.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.43 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,642.90" "$2,669.60" $0.00 "$1,893.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000089 EAP CPT® 46600 "Anoscopy, Diagnostic, Inc Spec Collect" BOTH IP/OP $542.00 $401.08 $0.00 $542.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.35 $542.00 $429.26 $433.60 $151.93 $0.00 $151.93 $37.41 $42.17 $42.17 $86.29 $104.14 $0.00 $0.00 $0.00 $0.00 75000091 EAP CPT® 46606 Anoscopy With Biopsy BOTH IP/OP "$2,137.00 " "$1,581.38" $0.00 "$2,211.00" $0.00 $0.00 $0.00 $0.00 $0.00 $460.83 $0.00 $0.00 $0.00 $993.84 $460.77 $646.00 "$2,211.00" "$2,211.00" "$1,007.17" "$2,137.00" "$1,692.50" "$1,709.60" "$1,399.33" $0.00 "$1,399.33" $52.76 $78.23 $78.23 $340.21 $959.21 $0.00 $0.00 $0.00 $0.00 75000100 EAP HCPCS G0121 Colon Ca Scrn Not Hi Rsk Ind BOTH IP/OP "$4,021.00 " "$2,975.54" $0.00 "$3,216.80" "$2,753.10" "$2,753.10" $772.82 $772.82 $777.17 $0.00 "$1,541.95" "$1,541.95" "$1,601.25" $760.65 $837.98 $494.42 "$2,836.00" "$2,836.00" $766.13 "$2,327.00" "$3,184.63" "$3,216.80" "$1,064.43" "$2,091.00" "$1,064.43" $629.29 $193.26 $193.26 $640.14 $729.64 $0.00 $0.00 $0.00 $0.00 75000101 EAP CPT® 45391 "Colonoscopy, Endoscopic Ultrasound Examination" BOTH IP/OP "$3,045.00 " "$2,253.30" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $634.58 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,214.43" "$2,236.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000102 EAP CPT® 45341 Sigmoidscopy W/ultrasound BOTH IP/OP "$4,341.00 " "$3,212.34" $0.00 "$3,188.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $904.66 $0.00 $0.00 $0.00 $766.13 "$2,255.00" "$3,156.91" "$3,188.80" "$1,064.43" "$2,500.00" "$1,064.43" $219.13 $128.72 $128.72 $634.57 $729.64 $0.00 $0.00 $0.00 $0.00 75000110 EAP CPT® 45335 Sigmoidoscopy W/submuc Inj BOTH IP/OP "$2,361.00 " "$1,747.14" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.03 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,869.91" "$1,888.80" $0.00 "$1,239.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000120 EAP CPT® 43238 Upper Gi Endoscopy W/us Fn Bx BOTH IP/OP "$2,842.00 " "$2,103.08" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $592.27 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$2,063.16" "$2,084.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000125 EAP CPT® 43242 Upper Gi Endoscopy W/us Fn Bx BOTH IP/OP "$5,337.00 " "$3,949.38" $0.00 "$3,914.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,112.23" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,875.26" "$3,914.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000127 EAP CPT® 43242 Transendoscopic Us W/ Fn Bx BOTH IP/OP "$4,893.00 " "$3,620.82" $0.00 "$3,914.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,019.70" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,875.26" "$3,914.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000128 EAP CPT® 45327 Proctosigmoidoscopy W/stent BOTH IP/OP "$11,233.00 " "$8,312.42" $0.00 "$8,986.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,340.96" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$8,896.54" "$8,986.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000130 EAP CPT® 45335 Sigmoidoscopy W/submuc Inj BOTH IP/OP "$2,361.00 " "$1,747.14" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.03 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,869.91" "$1,888.80" $0.00 "$1,239.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000132 EAP CPT® 45340 Sig W/balloon Dilation BOTH IP/OP "$5,946.00 " "$4,400.04" $0.00 "$4,756.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,239.15" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,709.23" "$4,756.80" $0.00 "$1,893.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000136 EAP CPT® 91034 "Esoph, Gastroesoph Reflux Test W/rec, Anlys,rpt " BOTH IP/OP "$2,483.00 " "$1,837.42" $0.00 "$2,483.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.46 $0.00 $0.00 $0.00 $0.00 "$1,552.00" "$2,458.37" "$2,483.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000137 EAP CPT® 91038 "Esoph Gastro Reflux Test, Prolonged 1-24 Hrs." BOTH IP/OP "$2,693.00 " "$1,992.82" $0.00 "$1,978.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $561.22 $0.00 $0.00 $0.00 $0.00 "$1,236.50" "$1,958.62" "$1,978.40" $0.00 "$1,684.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000138 EAP CPT® 91010 Esophageal Motility Study W/ Interp & Report BOTH IP/OP "$3,327.00 " "$2,461.98" $0.00 "$2,444.00" "$2,321.55" "$2,321.55" $475.36 $475.36 $478.04 $693.43 $0.00 $0.00 $0.00 $467.50 $693.35 $303.87 "$1,967.92" "$1,967.92" $487.04 "$1,527.50" "$2,419.56" "$2,444.00" $676.67 "$1,750.00" $676.67 $111.47 $137.22 $137.22 $486.36 $463.84 $0.00 $0.00 $0.00 $0.00 75000139 EAP CPT® 91037 "Esoph Gastroesoph Reflux Test Funct W/rec, Anlys,rpt " BOTH IP/OP "$2,254.00 " "$1,667.96" $0.00 "$1,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.73 $0.00 $0.00 $0.00 $0.00 "$1,035.00" "$1,639.44" "$1,656.00" $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000140 EAP CPT® 91120 Rectal Sensation Tone & Comply Balloon Distention BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,008.80" $745.54 $745.54 $257.73 $257.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.13 $0.00 $0.00 $0.00 $138.76 $630.50 $998.71 "$1,008.80" $192.78 $440.00 $192.78 $462.13 $445.89 $445.89 $200.75 $132.15 $0.00 $0.00 $0.00 $0.00 75000141 EAP CPT® 91122 Anorectal Manometry BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,373.00" $745.54 $745.54 $259.14 $259.14 $260.60 $286.17 $0.00 $0.00 $0.00 $255.07 $286.13 $165.80 $812.13 $812.13 $235.59 $630.50 $998.71 "$1,008.80" $327.32 "$1,373.00" $327.32 $125.40 $164.96 $164.96 $200.75 $224.37 $0.00 $0.00 $0.00 $0.00 75000142 EAP CPT® 51784 "Emg Anal Or Urethral Sphincter, Other Than Needle" BOTH IP/OP $210.00 $155.40 $0.00 $212.00 $114.03 $114.03 $135.96 $135.96 $136.73 $43.77 $0.00 $0.00 $0.00 $133.75 $43.76 $86.94 $113.00 $113.00 $138.76 $212.00 $167.90 $169.60 $192.78 $210.00 $192.78 $94.94 $29.53 $29.53 $33.75 $132.15 $0.00 $0.00 $0.00 $0.00 75000146 EAP CPT® 91022 Duodenal Motility Study BOTH IP/OP "$1,128.00 " $834.72 $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.08 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000147 EAP CPT® 91117 Colon Motility 6hrs Or >inc Provoc Test W/ Interp& Repot BOTH IP/OP $865.00 $640.10 $0.00 $692.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.27 $0.00 $0.00 $0.00 $0.00 $432.50 $685.08 $692.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000182 EAP CPT® 46601 Diagnostic Anoscopy BOTH IP/OP $637.00 $471.38 $0.00 $637.00 $637.00 $637.00 $109.81 $109.81 $110.43 $132.77 $0.00 $0.00 $0.00 $107.30 $132.75 $69.74 $637.00 $637.00 $109.35 $560.00 $443.52 $448.00 $151.93 $292.00 $151.93 $87.64 $97.71 $97.71 $89.15 $104.14 $0.00 $0.00 $0.00 $0.00 75000200 EAP Custom 75000200 Colonscopy Dx BOTH IP/OP "$3,855.00 " "$2,852.70" $0.00 "$2,832.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $803.38 $0.00 $0.00 $0.00 $0.00 "$1,770.00" "$2,803.68" "$2,832.00" $0.00 "$2,756.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000201 EAP Custom 75000201 Colonscopy Thera 1 Intervention BOTH IP/OP "$4,243.00 " "$3,139.82" $0.00 "$3,116.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $884.24 $0.00 $0.00 $0.00 $0.00 "$1,948.00" "$3,085.63" "$3,116.80" $0.00 "$3,033.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000202 EAP Custom 75000202 Colonscopy Thera 2 Intervention BOTH IP/OP "$4,665.00 " "$3,452.10" $0.00 "$3,427.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.19 $0.00 $0.00 $0.00 $0.00 "$2,142.00" "$3,392.93" "$3,427.20" $0.00 "$3,335.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000203 EAP Custom 75000203 Colonscopy Thera 3 Intervention BOTH IP/OP "$5,132.00 " "$3,797.68" $0.00 "$3,770.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,069.51" $0.00 $0.00 $0.00 $0.00 "$2,356.50" "$3,732.70" "$3,770.40" $0.00 "$3,669.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000204 EAP Custom 75000204 Egd Dx BOTH IP/OP "$3,286.00 " "$2,431.64" $0.00 "$2,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $684.80 $0.00 $0.00 $0.00 $0.00 "$1,506.50" "$2,386.30" "$2,410.40" $0.00 "$2,349.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000205 EAP Custom 75000205 Egd Thera 1 Intervention BOTH IP/OP "$3,615.00 " "$2,675.10" $0.00 "$2,651.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.37 $0.00 $0.00 $0.00 $0.00 "$1,657.00" "$2,624.69" "$2,651.20" $0.00 "$2,585.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000206 EAP Custom 75000206 Egd Thera 2 Intervention BOTH IP/OP "$3,977.00 " "$2,942.98" $0.00 "$2,916.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $828.81 $0.00 $0.00 $0.00 $0.00 "$1,822.50" "$2,886.84" "$2,916.00" $0.00 "$2,843.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000207 EAP Custom 75000207 Egd Thera 3 Intervention BOTH IP/OP "$4,374.00 " "$3,236.76" $0.00 "$3,208.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $911.54 $0.00 $0.00 $0.00 $0.00 "$2,005.00" "$3,175.92" "$3,208.00" $0.00 "$3,127.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000208 EAP Custom 75000208 Ercp Dx BOTH IP/OP "$6,193.00 " "$4,582.82" $0.00 "$4,549.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,290.62" $0.00 $0.00 $0.00 $0.00 "$2,843.50" "$4,504.10" "$4,549.60" $0.00 "$4,427.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000209 EAP Custom 75000209 Ercp Thera 1 Intervention BOTH IP/OP "$6,810.00 " "$5,039.40" $0.00 "$5,003.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,419.20" $0.00 $0.00 $0.00 $0.00 "$3,127.00" "$4,953.17" "$5,003.20" $0.00 "$4,869.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000210 EAP Custom 75000210 Ercp Thera 2 Intervention BOTH IP/OP "$7,493.00 " "$5,544.82" $0.00 "$5,504.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,561.54" $0.00 $0.00 $0.00 $0.00 "$3,440.50" "$5,449.75" "$5,504.80" $0.00 "$5,357.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000211 EAP Custom 75000211 Ercp Thera 3 Intervention BOTH IP/OP "$8,242.00 " "$6,099.08" $0.00 "$6,054.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,717.63" $0.00 $0.00 $0.00 $0.00 "$3,784.00" "$5,993.86" "$6,054.40" $0.00 "$5,357.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000212 EAP Custom 75000212 Sigmoidoscopy Dx BOTH IP/OP "$3,919.00 " "$2,900.06" $0.00 "$2,879.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $816.72 $0.00 $0.00 $0.00 $0.00 "$1,799.50" "$2,850.41" "$2,879.20" $0.00 "$2,802.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000213 EAP Custom 75000213 Sigmoidoscopy Thera 1 Intervention BOTH IP/OP "$4,311.00 " "$3,190.14" $0.00 "$3,167.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.41 $0.00 $0.00 $0.00 $0.00 "$1,979.50" "$3,135.53" "$3,167.20" $0.00 "$3,082.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000214 EAP Custom 75000214 Sigmoidoscopy Thera 2 Intervention BOTH IP/OP "$4,741.00 " "$3,508.34" $0.00 "$3,483.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $988.02 $0.00 $0.00 $0.00 $0.00 "$2,177.00" "$3,448.37" "$3,483.20" $0.00 "$3,389.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000215 EAP Custom 75000215 Sigmoidoscopy Thera 3 Intervention BOTH IP/OP "$5,217.00 " "$3,860.58" $0.00 "$3,832.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,087.22" $0.00 $0.00 $0.00 $0.00 "$2,395.50" "$3,794.47" "$3,832.80" $0.00 "$3,730.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000216 EAP Custom 75000216 Colonscopy Via Stoma Dx BOTH IP/OP "$3,081.00 " "$2,279.94" $0.00 "$2,263.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $642.08 $0.00 $0.00 $0.00 $0.00 "$1,414.50" "$2,240.57" "$2,263.20" $0.00 "$2,202.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000217 EAP Custom 75000217 Colonscopy Via Stoma 1 Intervention BOTH IP/OP "$3,389.00 " "$2,507.86" $0.00 "$2,489.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $706.27 $0.00 $0.00 $0.00 $0.00 "$1,556.00" "$2,464.70" "$2,489.60" $0.00 "$2,423.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000218 EAP Custom 75000218 Colonscopy Via Stoma 2 Intervention BOTH IP/OP "$3,727.00 " "$2,757.98" $0.00 "$2,738.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $776.71 $0.00 $0.00 $0.00 $0.00 "$1,711.50" "$2,711.02" "$2,738.40" $0.00 "$2,665.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000219 EAP Custom 75000219 Colonscopy Via Stoma 3 Intervention BOTH IP/OP "$4,101.00 " "$3,034.74" $0.00 "$3,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $854.65 $0.00 $0.00 $0.00 $0.00 "$1,882.50" "$2,981.88" "$3,012.00" $0.00 "$2,932.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000220 EAP CPT® 91112 Gi Wireless Capsule Measure BOTH IP/OP "$3,844.00 " "$2,844.56" $0.00 "$3,075.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $801.09 $0.00 $0.00 $0.00 $0.00 "$1,922.00" "$3,044.45" "$3,075.20" $0.00 "$2,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000221 EAP HCPCS 91299 Patency Pill Placement BOTH IP/OP "$1,081.00 " $799.94 $0.00 $864.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.28 $0.00 $0.00 $0.00 $0.00 $540.50 $856.15 $864.80 $0.00 $317.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000222 EAP Egd Transoral Biopsy Single/multi-ip Bedside BOTH IP/OP "$3,388.00 " "$2,507.12" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $706.06 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 "$2,202.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100002 EAP CPT® 36511 Leukopheresis BOTH IP/OP "$6,450.00 " "$4,773.00" $0.00 "$5,905.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,344.18" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,846.54" "$5,905.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100003 EAP CPT® 36512 THERAPEUTIC APHERESIS RED BLOOD CELLS BOTH IP/OP "$8,063.00 " "$5,966.62" $0.00 "$6,123.20" "$2,753.10" "$2,753.10" "$1,328.28" "$1,328.28" "$1,335.77" "$1,680.53" $0.00 $0.00 $0.00 "$1,306.48" "$1,680.33" $849.21 "$4,877.00" "$4,877.00" "$1,327.51" "$2,255.00" "$6,061.97" "$6,123.20" "$1,844.40" "$2,500.00" "$1,844.40" $88.77 $112.51 $112.51 "$1,218.52" "$1,264.30" $0.00 $0.00 $0.00 $0.00 76100004 EAP CPT® 36513 Plateletpheresis BOTH IP/OP "$8,063.00 " "$5,966.62" $0.00 "$6,123.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,680.33" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,061.97" "$6,123.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100005 EAP CPT® 36514 Plasmapheresis BOTH IP/OP "$7,805.00 " "$5,775.70" $0.00 "$7,146.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,626.56" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,074.94" "$7,146.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100006 EAP CPT® 51700 Bladder Irrig/instill Simple BOTH IP/OP $504.00 $372.96 $0.00 $504.00 $504.00 $504.00 $259.14 $259.14 $260.60 $105.05 $0.00 $0.00 $0.00 $255.07 $105.03 $165.80 $113.00 $113.00 $0.00 $504.00 $399.17 $403.20 $0.00 $504.00 $0.00 $100.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100007 EAP CPT® 51700 Badder Irrig/instill Simple BOTH IP/OP $504.00 $372.96 $0.00 $504.00 $504.00 $504.00 $259.14 $259.14 $260.60 $105.05 $0.00 $0.00 $0.00 $255.07 $105.03 $165.80 $113.00 $113.00 $0.00 $504.00 $399.17 $403.20 $0.00 $504.00 $0.00 $100.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100009 EAP CPT® 92136 Iol Calculations (ophthalmic Biometry) BOTH IP/OP $416.00 $307.84 $0.00 $336.00 $225.89 $225.89 $109.81 $109.81 $110.43 $86.70 $0.00 $0.00 $0.00 $107.30 $86.69 $69.74 $246.06 $246.06 $109.35 $210.00 $332.64 $336.00 $151.93 $270.40 $151.93 $90.57 $31.69 $31.69 $66.86 $104.14 $0.00 $0.00 $0.00 $0.00 76100011 EAP CPT® 51701 Insert Straight Cath BOTH IP/OP $865.00 $640.10 $0.00 $865.00 $865.00 $865.00 $109.81 $109.81 $110.43 $180.29 $0.00 $0.00 $0.00 $107.30 $180.27 $69.74 $113.00 $113.00 $109.35 $864.00 $684.29 $691.20 $151.93 $548.00 $151.93 $57.62 $27.40 $27.40 $137.55 $104.14 $0.00 $0.00 $0.00 $0.00 76100013 EAP CPT® 51703 "Urinary Cath, Indwelling" BOTH IP/OP "$1,809.00 " "$1,338.66" $0.00 "$1,809.00" "$1,809.00" "$1,809.00" $135.96 $135.96 $136.73 $0.00 $0.00 $0.00 $0.00 $0.00 $377.00 $0.00 $0.00 $0.00 $138.76 "$1,808.00" "$1,431.94" "$1,446.40" $192.78 $899.00 $192.78 $170.19 $80.41 $80.41 $287.83 $132.15 $0.00 $0.00 $0.00 $0.00 76100014 EAP CPT® 51702 Cath Insert Indwelling BOTH IP/OP "$1,069.00 " $791.06 $0.00 "$1,069.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.35 "$1,069.00" $846.65 $855.20 $151.93 $0.00 $151.93 $91.18 $26.68 $26.68 $170.18 $104.14 $0.00 $0.00 $0.00 $0.00 76100016 EAP CPT® 51703 Cath Insertion Complicated BOTH IP/OP "$1,808.00 " "$1,337.92" $0.00 "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.76 "$1,808.00" "$1,431.94" "$1,446.40" $192.78 $0.00 $192.78 $170.19 $80.41 $80.41 $287.83 $132.15 $0.00 $0.00 $0.00 $0.00 76100017 EAP CPT® 51703 "Insert Bladder Cath, Complex" BOTH IP/OP "$1,808.00 " "$1,337.92" $0.00 "$1,808.00" "$1,808.00" "$1,808.00" $135.96 $135.96 $136.73 $0.00 $0.00 $0.00 $0.00 $0.00 $376.79 $0.00 $0.00 $0.00 $138.76 "$1,808.00" "$1,431.94" "$1,446.40" $192.78 $899.00 $192.78 $170.19 $80.41 $80.41 $287.83 $132.15 $0.00 $0.00 $0.00 $0.00 76100020 EAP CPT® 51701 Bladder Irrig/instill Simple BOTH IP/OP $864.00 $639.36 $0.00 $864.00 $864.00 $864.00 $109.81 $109.81 $110.43 $180.08 $0.00 $0.00 $0.00 $107.30 $180.06 $69.74 $113.00 $113.00 $109.35 $864.00 $684.29 $691.20 $151.93 $548.00 $151.93 $57.62 $27.40 $27.40 $137.55 $104.14 $0.00 $0.00 $0.00 $0.00 76100028 EAP CPT® 40810 Exc. Lesion Mucosa&sub W/o Repair BOTH IP/OP "$5,204.00 " "$3,850.96" $0.00 "$4,877.00" "$2,321.55" "$2,321.55" "$2,664.14" "$2,664.14" "$2,679.15" "$1,084.64" $0.00 $0.00 $0.00 "$2,622.61" "$1,084.51" "$1,704.70" "$4,877.00" "$4,877.00" "$2,626.99" "$2,255.00" "$4,163.54" "$4,205.60" "$3,649.85" "$2,500.00" "$3,649.85" $822.72 $127.59 $127.59 $836.91 "$2,501.89" $0.00 $0.00 $0.00 $0.00 76100029 EAP CPT® 40804 "Rem Embedded Fb, Mouth Simple" BOTH IP/OP $800.00 $592.00 $0.00 $939.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.72 $0.00 $0.00 $0.00 $0.00 $939.00 $743.69 $751.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100030 EAP CPT® 54520 Orchiectomy Simple BOTH IP/OP "$4,759.00 " "$3,521.66" $0.00 "$3,845.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $991.78 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$3,807.14" "$3,845.60" $0.00 "$3,725.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100031 EAP CPT® 54535 Orchiectomy Radical/tumor BOTH IP/OP "$7,279.00 " "$5,386.46" $0.00 "$5,823.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,516.94" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,764.97" "$5,823.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100032 EAP CPT® 40799 Lip Surgery Procedure BOTH IP/OP $244.00 $180.56 $0.00 $244.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.85 $0.00 $0.00 $0.00 $0.00 $230.00 $182.16 $184.00 $0.00 $244.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100034 EAP CPT® 53040 Drainage Of Urethra Abscess BOTH IP/OP "$6,748.00 " "$4,993.52" $0.00 "$5,414.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,406.28" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,360.26" "$5,414.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100035 EAP CPT® 42106 Exc. Lesion Mouth Roof(palate) BOTH IP/OP "$2,709.00 " "$2,004.66" $0.00 "$2,255.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $564.56 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,145.53" "$2,167.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100040 EAP CPT® 21497 Indental Wiring BOTH IP/OP "$4,596.00 " "$3,401.04" $0.00 "$3,713.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $957.81 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,676.46" "$3,713.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100041 EAP CPT® 41800 Drainage Of Gum Lesion BOTH IP/OP $640.00 $473.60 $0.00 $640.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.35 $640.00 $506.88 $512.00 $151.93 $0.00 $151.93 $87.50 $157.47 $157.47 $101.89 $104.14 $0.00 $0.00 $0.00 $0.00 76100042 EAP CPT® 29799 Casting/strapping Procedure BOTH IP/OP $198.00 $146.52 $0.00 $198.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100043 EAP CPT® 31820 Closure Of Windpipe Lesion BOTH IP/OP "$6,588.00 " "$4,875.12" $0.00 "$6,360.00" "$2,321.55" "$2,321.55" "$2,664.14" "$2,664.14" "$2,679.15" "$1,373.10" "$1,257.08" "$1,257.08" "$1,305.43" "$2,622.61" "$1,372.94" "$1,704.70" "$1,871.00" "$1,871.00" $0.00 "$2,255.00" "$6,296.40" "$6,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100044 EAP CPT® 40650 Lip Repair BOTH IP/OP "$1,705.00 " "$1,261.70" $0.00 "$1,705.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $355.32 $0.00 $0.00 $0.00 $0.00 "$1,604.00" "$1,270.37" "$1,283.20" $0.00 "$1,705.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100045 EAP CPT® 41000 Drainage Of Mouth Lesion BOTH IP/OP "$3,430.00 " "$2,538.20" $98.48 "$2,772.00" "$2,321.55" "$2,321.55" $440.43 $440.43 $442.92 $714.90 "$1,257.08" "$1,257.08" "$1,305.43" $433.55 $714.81 $281.81 "$1,871.00" "$1,871.00" $443.02 "$2,255.00" "$2,744.28" "$2,772.00" $615.51 "$2,150.00" $615.51 $98.48 $112.82 $112.82 $551.63 $421.92 $0.00 $0.00 $0.00 $0.00 76100046 EAP CPT® 36511 Leukopheresis BOTH IP/OP "$7,776.00 " "$5,754.24" $0.00 "$5,905.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,620.52" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$5,846.54" "$5,905.60" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100047 EAP CPT® 36513 Plateletpheresis BOTH IP/OP "$8,063.00 " "$5,966.62" $0.00 "$6,123.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,680.33" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$6,061.97" "$6,123.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100048 EAP CPT® 36514 Plasmapheresis BOTH IP/OP "$9,881.00 " "$7,311.94" $0.00 "$7,146.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$7,074.94" "$7,146.40" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100055 EAP CPT® 65778 Cover Eye W/ Membrane BOTH IP/OP "$3,166.00 " "$2,342.84" $0.00 "$2,557.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.79 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,532.02" "$2,557.60" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100060 EAP CPT® 54235 Penile Injection BOTH IP/OP $898.00 $664.52 $0.00 "$1,128.00" $487.61 $487.61 $259.14 $259.14 $260.60 $187.17 $0.00 $0.00 $0.00 $255.07 $187.14 $165.80 $113.00 $113.00 $235.59 $907.00 $718.34 $725.60 $327.32 "$1,128.00" $327.32 $70.35 $75.71 $75.71 $144.39 $224.37 $0.00 $0.00 $0.00 $0.00 76100061 EAP CPT® 20240 Bone Bx Exc. BOTH IP/OP "$2,386.00 " "$1,765.64" $0.00 "$2,386.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $497.24 $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$1,884.96" "$1,904.00" $0.00 "$2,386.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100062 EAP CPT® 21337 Treat Nasa Septal Fx BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $474.53 $0.00 $0.00 $0.00 $0.00 "$2,300.00" "$1,821.60" "$1,840.00" $0.00 "$2,277.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100063 EAP CPT® 31579 Direct Laryngoscopy BOTH IP/OP "$1,660.00 " "$1,228.40" $0.00 "$1,660.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.94 $0.00 $0.00 $0.00 $0.00 "$1,524.00" "$1,207.01" "$1,219.20" $0.00 "$1,660.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100064 EAP CPT® 31237 Nasal/sinus Endoscopy BOTH IP/OP "$7,080.00 " "$5,239.20" $163.68 "$5,246.40" "$2,753.10" "$2,753.10" "$1,456.99" "$1,456.99" "$1,465.20" "$1,475.65" "$1,541.95" "$1,541.95" "$1,601.25" "$1,434.17" "$1,475.47" $932.21 "$2,836.00" "$2,836.00" "$1,434.81" "$2,327.00" "$5,193.94" "$5,246.40" "$1,993.48" "$2,500.00" "$1,993.48" $226.31 $163.68 $163.68 "$1,044.03" "$1,366.49" $0.00 $0.00 $0.00 $0.00 76100070 EAP CPT® 20615 Treatment Of Bone Cyst BOTH IP/OP $919.00 $680.06 $0.00 $919.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.52 $0.00 $0.00 $0.00 $0.00 $919.00 $727.85 $735.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100071 EAP CPT® 41830 Removal Of Gum Tissue BOTH IP/OP "$3,478.00 " "$2,573.72" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $724.82 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,780.71" "$2,808.80" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100072 EAP CPT® 31237 Nasal/sinus Endoscopy BOTH IP/OP "$6,558.00 " "$4,852.92" $0.00 "$5,246.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,434.81" "$2,327.00" "$5,193.94" "$5,246.40" "$1,993.48" $0.00 "$1,993.48" $226.31 $163.68 $163.68 "$1,044.03" "$1,366.49" $0.00 $0.00 $0.00 $0.00 76100073 EAP CPT® 42310 Drainage Of Salivary Gland BOTH IP/OP "$1,573.00 " "$1,164.02" $0.00 "$1,573.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $327.81 $0.00 $0.00 $0.00 $0.00 "$1,571.00" "$1,244.23" "$1,256.80" $0.00 "$1,573.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100076 EAP CPT® 53852 Prostatic Rf Thermotx (tuna) BOTH IP/OP "$15,721.00 " "$11,633.54" $0.00 "$12,576.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,276.26" $0.00 $0.00 $0.00 $0.00 "$3,902.00" "$12,451.03" "$12,576.80" $0.00 "$4,334.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100077 EAP CPT® 53850 Prostatic Microwave Thermotx (tumt) BOTH IP/OP "$15,721.00 " "$11,633.54" $0.00 "$12,576.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,276.26" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$12,451.03" "$12,576.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100078 EAP CPT® 31571 Laryngoscopy W/vc Inj+scope BOTH IP/OP "$12,143.00 " "$8,985.82" $0.00 "$8,919.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,530.60" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$8,830.01" "$8,919.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100086 EAP CPT® 36512 Therapetic Phlebotomy BOTH IP/OP "$8,063.00 " "$5,966.62" $0.00 "$6,123.20" "$2,753.10" "$2,753.10" "$1,328.28" "$1,328.28" "$1,335.77" "$1,680.53" $0.00 $0.00 $0.00 "$1,306.48" "$1,680.33" $849.21 "$4,877.00" "$4,877.00" "$1,327.51" "$2,255.00" "$6,061.97" "$6,123.20" "$1,844.40" "$2,500.00" "$1,844.40" $88.77 $112.51 $112.51 "$1,218.52" "$1,264.30" $0.00 $0.00 $0.00 $0.00 76100087 EAP CPT® 21299 Cranio/maxillofacial Proc. BOTH IP/OP $272.00 $201.28 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.68 $0.00 $0.00 $0.00 $0.00 $272.00 $215.42 $217.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100088 EAP CPT® 20527 Inj Dupuytren Cord W Enzyme BOTH IP/OP $514.00 $380.36 $0.00 $514.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.12 $0.00 $0.00 $0.00 $0.00 $514.00 $407.09 $411.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100089 EAP CPT® 20615 Nasal Surgery Proc BOTH IP/OP $919.00 $680.06 $0.00 $919.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.52 $0.00 $0.00 $0.00 $0.00 $919.00 $727.85 $735.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100090 EAP CPT® 15271 Skin Sub Graft Trnk/arm/leg 25 BOTH IP/OP "$2,131.00 " "$1,576.94" $0.00 "$2,131.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.10 $0.00 $0.00 $0.00 $0.00 "$1,997.00" "$1,581.62" "$1,597.60" $0.00 "$2,131.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100091 EAP CPT® 15272 Skin Sub Graft T/a/l Addl 25 BOTH IP/OP $622.00 $460.28 $0.00 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.62 $0.00 $0.00 $0.00 $0.00 $291.50 $461.74 $466.40 $0.00 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100092 EAP CPT® 15273 Skin Sub Grft T/a/lg Child 100 BOTH IP/OP "$3,292.00 " "$2,436.08" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $686.05 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$2,607.26" "$2,633.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100093 EAP CPT® 15274 Skin Sub Grft T/a/lg Ch Addl 100 BOTH IP/OP "$1,578.00 " "$1,167.72" $0.00 "$1,262.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.86 $0.00 $0.00 $0.00 $0.00 $789.00 "$1,249.78" "$1,262.40" $0.00 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100094 EAP CPT® 15275 Skin Sub Grft Face/nk/hf/g 25 BOTH IP/OP "$2,179.00 " "$1,612.46" $0.00 "$2,179.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.10 $0.00 $0.00 $0.00 $0.00 "$2,179.00" "$1,725.77" "$1,743.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100095 EAP CPT® 15276 Skin Sub Grft F/n/hf/g Addl 25 BOTH IP/OP $583.00 $431.42 $0.00 $466.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.50 $0.00 $0.00 $0.00 $0.00 $291.50 $461.74 $466.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100096 EAP CPT® 15277 Skin Sub Grft F/n/hf/g Child 100 BOTH IP/OP "$2,570.00 " "$1,901.80" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $535.59 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$1,907.14" "$1,926.40" $0.00 "$2,500.00" $0.00 $283.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100097 EAP CPT® 15278 Skin Sub Grft F/n/hf/g Ch Add 100 BOTH IP/OP "$1,684.00 " "$1,246.16" $0.00 "$1,684.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.95 $0.00 $0.00 $0.00 $0.00 $789.00 "$1,249.78" "$1,262.40" $0.00 "$1,684.00" $0.00 $81.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100098 EAP CPT® 29581 Apply Multlay Comprs Lwr Leg BOTH IP/OP $453.00 $335.22 $0.00 $478.00 $245.98 $245.98 $137.58 $137.58 $138.36 $94.42 $0.00 $0.00 $0.00 $135.31 $94.41 $87.95 $113.00 $113.00 $0.00 $478.00 $378.58 $382.40 $0.00 $458.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100102 EAP CPT® 29584 Apply Multlay Comprs Arm/hand BOTH IP/OP $427.00 $315.98 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.99 $0.00 $0.00 $0.00 $0.00 $478.00 $378.58 $382.40 $0.00 $330.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100103 EAP CPT® 46220 Exc. Anal Ext. Tag/papilla BOTH IP/OP "$4,310.00 " "$3,189.40" $0.00 "$3,483.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.20 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$3,448.37" "$3,483.20" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100104 EAP CPT® 17999 Skin Tissue Procedure BOTH IP/OP $252.00 $186.48 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.52 $0.00 $0.00 $0.00 $0.00 $250.00 $198.00 $200.00 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100105 EAP CPT® 31570 Laryngoscope W/vc Inj BOTH IP/OP "$8,010.00 " "$5,927.40" $235.43 "$5,883.20" "$2,753.10" "$2,753.10" "$3,016.56" "$3,016.56" "$3,033.56" "$1,669.48" "$1,541.95" "$1,541.95" "$1,601.25" "$2,969.20" "$1,669.28" "$1,929.98" "$2,836.00" "$2,836.00" "$2,945.54" "$2,327.00" "$5,824.37" "$5,883.20" "$4,092.44" "$2,500.00" "$4,092.44" $296.20 $235.43 $235.43 "$1,170.76" "$2,805.28" $0.00 $0.00 $0.00 $0.00 76100106 EAP CPT® 41899 Bx Of Gum Mass BOTH IP/OP "$1,862.00 " "$1,377.88" $0.00 "$1,880.00" "$1,862.00" "$1,862.00" $206.03 $206.03 $207.19 $388.09 $0.00 $0.00 $0.00 $202.80 $388.04 $131.82 "$1,862.00" "$1,862.00" $204.24 "$1,880.00" "$1,488.96" "$1,504.00" $283.76 "$1,750.00" $283.76 $294.22 $0.00 $0.00 $299.30 $194.51 $0.00 $0.00 $0.00 $0.00 76100107 EAP CPT® 40899 Vestibule Of Mouth (unlisted) BOTH IP/OP $262.00 $193.88 $0.00 $308.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.60 $0.00 $0.00 $0.00 $0.00 $308.00 $243.94 $246.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100110 EAP CPT® 49082 Abdom Paracentesis W/o Imag BOTH IP/OP "$1,861.00 " "$1,377.14" $0.00 "$1,861.00" "$1,861.00" "$1,861.00" $787.99 $787.99 $792.43 $387.88 $0.00 $0.00 $0.00 $775.94 $387.83 $504.36 "$1,861.00" "$1,861.00" $788.23 "$1,769.00" "$1,401.05" "$1,415.20" "$1,095.14" "$1,706.00" "$1,095.14" $0.00 $77.15 $77.15 $281.62 $750.70 $0.00 $0.00 $0.00 $0.00 76100112 EAP CPT® 49083 Abdom Paracentesis W Imag BOTH IP/OP "$1,861.00 " "$1,377.14" $0.00 "$2,150.00" "$1,861.00" "$1,861.00" $787.99 $787.99 $792.43 $387.88 $0.00 $0.00 $0.00 $775.94 $387.83 $504.36 "$1,861.00" "$1,861.00" $788.23 "$1,769.00" "$1,401.05" "$1,415.20" "$1,095.14" "$2,150.00" "$1,095.14" $296.18 $112.15 $112.15 $281.62 $750.70 $0.00 $0.00 $0.00 $0.00 76100113 EAP CPT® 49084 Peritoneal Lavage W Imag BOTH IP/OP "$1,861.00 " "$1,377.14" $0.00 "$1,861.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $387.83 $0.00 $0.00 $0.00 $0.00 "$1,769.00" "$1,401.05" "$1,415.20" $0.00 "$1,861.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100114 EAP CPT® 20680 Removal Of Support Implant BOTH IP/OP "$5,413.00 " "$4,005.62" $0.00 "$4,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,128.07" $0.00 $0.00 $0.00 "$2,325.71" "$2,858.00" "$4,028.90" "$4,069.60" "$3,231.26" "$3,250.00" "$3,231.26" $0.00 $437.25 $437.25 $809.85 "$2,214.96" $0.00 $0.00 $0.00 $0.00 76100115 EAP CPT® 25605 Treat Fracture Radius Ulna BOTH IP/OP "$2,345.00 " "$1,735.30" $0.00 "$2,345.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.37" "$2,345.00" "$1,857.24" "$1,876.00" "$1,888.67" $0.00 "$1,888.67" $469.11 $530.90 $530.90 $373.32 "$1,294.64" $0.00 $0.00 $0.00 $0.00 76100116 EAP CPT® 27825 Treat Lower Leg Fracture BOTH IP/OP "$6,872.00 " "$5,085.28" $0.00 "$5,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.12" $0.00 $0.00 $0.00 "$1,359.37" "$2,327.00" "$5,761.80" "$5,820.00" "$1,888.67" "$2,500.00" "$1,888.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100117 EAP CPT® 41899 Alveoplasty W/extractions BOTH IP/OP "$2,369.00 " "$1,753.06" $0.00 "$2,369.00" "$2,321.55" "$2,321.55" $206.03 $206.03 $207.19 $493.76 $0.00 $0.00 $0.00 $202.80 $493.70 $131.82 "$2,369.00" "$2,369.00" $204.24 "$2,327.00" "$1,893.67" "$1,912.80" $283.76 "$1,750.00" $283.76 $374.19 $0.00 $0.00 $380.65 $194.51 $0.00 $0.00 $0.00 $0.00 76100118 EAP CPT® 26705 Treat Knuckle Dislocation BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,593.00" "$1,261.66" "$1,274.40" $0.00 "$1,489.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100119 EAP CPT® 51784 Anal/urinary Muscle Study BOTH IP/OP $210.00 $155.40 $0.00 $212.00 $114.03 $114.03 $135.96 $135.96 $136.73 $43.77 $0.00 $0.00 $0.00 $133.75 $43.76 $86.94 $113.00 $113.00 $138.76 $212.00 $167.90 $169.60 $192.78 $210.00 $192.78 $94.94 $29.53 $29.53 $33.75 $132.15 $0.00 $0.00 $0.00 $0.00 76100120 EAP CPT® 26951 Amputation Of Finger Thumb BOTH IP/OP "$7,787.00 " "$5,762.38" $0.00 "$5,690.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,622.81" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$5,633.50" "$5,690.40" $0.00 "$2,500.00" $0.00 $412.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100121 EAP CPT® 26705 Treat Knuckle Dislocation BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 "$1,593.00" "$1,261.66" "$1,274.40" $0.00 "$1,489.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100122 EAP CPT® 62273 Injection Epidural Blood Patch BOTH IP/OP "$1,679.00 " "$1,242.46" $0.00 "$1,679.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.90 $0.00 $0.00 $0.00 $626.89 "$1,596.00" "$1,264.03" "$1,276.80" $870.98 "$1,679.00" $870.98 $123.36 $117.56 $117.56 $254.08 $597.04 $0.00 $0.00 $0.00 $0.00 76100123 EAP CPT® 67904 Blepharoptosis BOTH IP/OP "$5,049.00 " "$3,736.26" $0.00 "$4,053.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,052.21" $0.00 $0.00 $0.00 $0.00 "$3,606.00" "$4,013.06" "$4,053.60" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100124 EAP CPT® 11760 Repair Nail Bed BOTH IP/OP $759.00 $561.66 $0.00 $759.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.19 $0.00 $0.00 $0.00 $502.38 $158.18 $326.54 $113.00 $113.00 $0.00 $759.00 $601.13 $607.20 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100125 EAP CPT® 17270 Destruction Malignant Lesion 0.5cm Or Less BOTH IP/OP $477.00 $352.98 $0.00 $477.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.41 $0.00 $0.00 $0.00 $0.00 $477.00 $377.78 $381.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100126 EAP CPT® 41599 Tongue/mouth Unlisted Proc. BOTH IP/OP $271.00 $200.54 $0.00 $271.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.48 $0.00 $0.00 $0.00 $0.00 $271.00 $214.63 $216.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100129 EAP CPT® 28405 Treat Heel Fx BOTH IP/OP "$4,960.00 " "$3,670.40" $0.00 "$3,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.66" $0.00 $0.00 $0.00 $0.00 "$2,327.00" "$3,928.32" "$3,968.00" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100130 EAP CPT® 31576 "Laryngoscopy, Fiberoptic W/bx" BOTH IP/OP "$7,908.00 " "$5,851.92" $0.00 "$5,808.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,648.03" $0.00 $0.00 $0.00 "$1,434.81" "$2,327.00" "$5,750.71" "$5,808.80" "$1,993.48" "$2,500.00" "$1,993.48" $149.37 $121.86 $121.86 "$1,155.95" "$1,366.49" $0.00 $0.00 $0.00 $0.00 76100131 EAP CPT® 42999 Throat Proc. ( Phary/ Aden/tons) BOTH IP/OP $206.00 $152.44 $0.00 $225.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.93 $0.00 $0.00 $0.00 $0.00 $225.00 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100132 EAP CPT® 59150 Treat Ectopic Pregnancy BOTH IP/OP "$21,864.00 " "$16,179.36" $0.00 "$17,491.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,556.46" $0.00 $0.00 $0.00 $0.00 "$5,452.00" "$17,316.29" "$17,491.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100133 EAP CPT® 24999 Upper Arm/elbow Surg BOTH IP/OP $483.00 $357.42 $0.00 $483.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $0.00 $0.00 $0.00 $0.00 $483.00 $382.54 $386.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100134 EAP CPT® 52001 Cysto Rem Of Clots BOTH IP/OP "$5,099.00 " "$3,773.26" $0.00 "$4,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.63" $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$4,078.80" "$4,120.00" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100135 EAP CPT® 92025 Topography BOTH IP/OP $288.00 $213.12 $0.00 $232.80 $156.38 $156.38 $54.21 $54.21 $54.51 $60.03 $0.00 $0.00 $0.00 $53.35 $60.02 $34.67 $170.35 $170.35 $55.17 $145.50 $230.47 $232.80 $76.65 $150.15 $76.65 $45.54 $17.29 $17.29 $46.33 $52.54 $0.00 $0.00 $0.00 $0.00 76100136 EAP CPT® 59001 Amniocentesis Therapeutic BOTH IP/OP "$2,089.00 " "$1,545.86" $0.00 "$2,089.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $435.35 $0.00 $0.00 $0.00 $0.00 "$2,089.00" "$1,654.49" "$1,671.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100138 EAP CPT® 25111 Removal Of Ganglion Cyst BOTH IP/OP "$4,220.00 " "$3,122.80" $0.00 "$3,376.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.45 $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$3,342.24" "$3,376.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100139 EAP CPT® 92025 Corneal Topography BOTH IP/OP $291.00 $215.34 $0.00 $232.80 $0.00 $0.00 $0.00 $0.00 $0.00 $60.03 $0.00 $0.00 $0.00 $53.35 $60.02 $34.67 $170.35 $170.35 $55.17 $145.50 $230.47 $232.80 $76.65 $0.00 $76.65 $45.54 $17.29 $17.29 $46.33 $52.54 $0.00 $0.00 $0.00 $0.00 76100140 EAP CPT® 27509 Treatment Of Thigh Fracture BOTH IP/OP "$16,329.00 " "$12,083.46" $0.00 "$13,063.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,402.96" $0.00 $0.00 $0.00 $0.00 "$2,858.00" "$12,932.57" "$13,063.20" $0.00 "$3,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76100141 EAP CPT® 92504 Ear Microscopy Examination BOTH IP/OP $89.00 $65.86 $0.00 $72.00 $48.33 $48.33 $0.00 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $18.55 $0.00 $52.64 $52.64 $0.00 $45.00 $71.28 $72.00 $0.00 $57.85 $0.00 $25.24 $9.74 $9.74 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 76200002 EAP HCPCS G0378 Observation Room BOTH IP/OP $141.00 $104.34 $0.00 $150.00 $141.00 $141.00 $0.00 $0.00 $0.00 $29.39 $104.65 $104.65 $108.68 $0.00 $29.38 $0.00 $83.40 $83.40 $0.00 $80.60 $98.21 $99.20 $0.00 $150.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 76200028 EAP HCPCS G0378 Obs. Rm. Ecc BOTH IP/OP $141.00 $104.34 $0.00 $150.00 $141.00 $141.00 $0.00 $0.00 $0.00 $29.39 $104.65 $104.65 $108.68 $0.00 $29.38 $0.00 $83.40 $83.40 $0.00 $80.60 $98.21 $99.20 $0.00 $150.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 76200077 EAP HCPCS G0378 Observation Room Carveout BOTH IP/OP $141.00 $104.34 $0.00 $150.00 $141.00 $141.00 $0.00 $0.00 $0.00 $29.39 $104.65 $104.65 $108.68 $0.00 $29.38 $0.00 $83.40 $83.40 $0.00 $80.60 $98.21 $99.20 $0.00 $150.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 77000001 EAP HCPCS G0101 Pelvic/breast Exam BOTH IP/OP $282.00 $208.68 $29.20 $217.37 $153.13 $153.13 $72.87 $72.87 $73.28 $58.78 $209.30 $209.30 $217.37 $71.76 $58.77 $46.64 $166.80 $166.80 $78.77 $132.00 $209.09 $211.20 $109.44 $183.30 $109.44 $41.32 $29.20 $29.20 $42.03 $75.02 $0.00 $0.00 $0.00 $0.00 77100006 EAP CPT® 90471 Immunization Admin 1st BOTH IP/OP $62.00 $45.88 $9.08 $75.40 $33.67 $33.67 $60.38 $60.38 $60.72 $12.92 $46.02 $46.02 $47.79 $59.39 $12.92 $38.61 $36.67 $36.67 $60.65 $29.00 $45.94 $46.40 $58.00 $75.40 $58.00 $9.08 $14.42 $14.42 $9.23 $57.76 $0.00 $0.00 $0.00 $0.00 77100007 EAP CPT® 90471 Administration Pneumo Vaccine BOTH IP/OP $62.00 $45.88 $9.08 $75.40 $33.67 $33.67 $38.97 $38.97 $39.19 $12.92 $46.02 $46.02 $47.79 $38.34 $12.92 $24.92 $36.67 $36.67 $38.22 $29.00 $45.94 $46.40 $58.00 $75.40 $58.00 $9.08 $14.42 $14.42 $9.23 $36.40 $0.00 $0.00 $0.00 $0.00 77100011 EAP CPT® 90472 Immunization Each Additional BOTH IP/OP $62.00 $45.88 $0.00 $75.40 $33.67 $33.67 $0.00 $0.00 $0.00 $12.92 $46.02 $46.02 $47.79 $0.00 $12.92 $0.00 $36.67 $36.67 $0.00 $29.00 $45.94 $46.40 $0.00 $75.40 $0.00 $9.08 $12.98 $12.98 $9.23 $0.00 $0.00 $0.00 $0.00 $0.00 77100018 EAP HCPCS 90471 Administration Flu Vaccine BOTH IP/OP $62.00 $45.88 $9.08 $75.40 $33.67 $33.67 $38.97 $38.97 $39.19 $12.92 $46.02 $46.02 $47.79 $38.34 $12.92 $24.92 $36.67 $36.67 $38.22 $29.00 $45.94 $46.40 $58.00 $75.40 $58.00 $9.08 $14.42 $14.42 $9.23 $36.40 $0.00 $0.00 $0.00 $0.00 77100035 EAP CPT® 90471 Immunization Admin. (ped) BOTH IP/OP $62.00 $45.88 $9.08 $75.40 $33.67 $33.67 $60.38 $60.38 $60.72 $12.92 $46.02 $46.02 $47.79 $59.39 $12.92 $38.61 $36.67 $36.67 $60.65 $29.00 $45.94 $46.40 $58.00 $75.40 $58.00 $9.08 $14.42 $14.42 $9.23 $57.76 $0.00 $0.00 $0.00 $0.00 77100040 EAP CPT® 90471 Administration Of Hepatitis B Vaccine BOTH IP/OP $62.00 $45.88 $9.08 $75.40 $33.67 $33.67 $38.97 $38.97 $39.19 $12.92 $46.02 $46.02 $47.79 $38.34 $12.92 $24.92 $36.67 $36.67 $38.22 $29.00 $45.94 $46.40 $58.00 $75.40 $58.00 $9.08 $14.42 $14.42 $9.23 $36.40 $0.00 $0.00 $0.00 $0.00 77100044 EAP CPT® 90471 R-immunization Administration-24 BOTH IP/OP $66.00 $48.84 $9.08 $75.40 $35.84 $35.84 $60.38 $60.38 $60.72 $13.76 $48.99 $48.99 $50.87 $59.39 $13.75 $38.61 $39.04 $39.04 $60.65 $29.00 $45.94 $46.40 $58.00 $75.40 $58.00 $9.08 $14.42 $14.42 $9.23 $57.76 $0.00 $0.00 $0.00 $0.00 78000010 EAP HCPCS Q3014 Telehealth Facility Fee BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $35.30 $35.30 $0.00 $0.00 $26.81 $20.52 $0.00 $0.00 $0.00 $0.00 $20.52 $27.02 $38.45 $38.45 $0.00 $32.50 $51.48 $52.00 $39.00 $31.14 $39.00 $22.96 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 80000611 EAP HCPCS C1769 Guidewire Vasc 150cm .035in Fix Core Flxb 3mm Rad BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $250.51 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 80000635 EAP HCPCS C1894 Sheath Introd 10cm 6fr Pncl Peri Snpon Dilat Lock BOTH IP/OP $219.00 $162.06 $0.00 $175.20 $118.92 $118.92 $0.00 $0.00 $0.00 $45.65 $162.54 $162.54 $168.81 $0.00 $45.64 $0.00 $129.54 $129.54 $0.00 $109.50 $173.45 $175.20 $0.00 $142.35 $0.00 $34.27 $0.00 $0.00 $34.86 $0.00 $0.00 $0.00 $0.00 $0.00 80002673 EAP HCPCS C1729 Catheter Xtrn Drn 80cm Strl Edm Cls Tip Ba Imprg Sil Lmbr BOTH IP/OP $566.00 $418.84 $0.00 $452.80 $307.34 $307.34 $0.00 $0.00 $0.00 $0.00 $420.09 $420.09 $436.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.00 $448.27 $452.80 $0.00 $367.90 $0.00 $88.58 $0.00 $0.00 $90.11 $0.00 $0.00 $0.00 $0.00 $0.00 80003182 EAP HCPCS C1751 Catheter Art Ln 110cm 7fr Std Fem Vn 4 Lum S Tip BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 80003186 EAP HCPCS C1887 Catheter Guid Blue Ylw 100cm 7fr Crds Vsbr Jl4st BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $50.50 $50.50 $0.00 $0.00 $0.00 $19.38 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $55.01 $55.01 $0.00 $46.50 $73.66 $74.40 $0.00 $0.00 $0.00 $14.55 $0.00 $0.00 $14.81 $0.00 $0.00 $0.00 $0.00 $0.00 80003206 EAP HCPCS C1725 Catheter Pa 110cm 7fr 10mm Arw 1 Lum Bln Wdg Prss BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $91.22 $91.22 $0.00 $0.00 $0.00 $35.02 $124.69 $124.69 $129.49 $0.00 $35.01 $0.00 $99.37 $99.37 $0.00 $84.00 $133.06 $134.40 $0.00 $109.20 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 80003226 EAP HCPCS C1884 System Embl Prtc 300cm .014in 110um 3.2fr Crtd BOTH IP/OP "$4,188.00 " "$3,099.12" $0.00 "$3,350.40" "$2,274.08" "$2,274.08" $0.00 $0.00 $0.00 $872.88 "$3,108.33" "$3,108.33" "$3,228.11" $0.00 $872.78 $0.00 "$2,477.20" "$2,477.20" $0.00 "$2,094.00" "$3,316.90" "$3,350.40" $0.00 $0.00 $0.00 $655.42 $0.00 $0.00 $666.73 $0.00 $0.00 $0.00 $0.00 $0.00 80003239 EAP HCPCS C1757 Catheter Thrmb 140cm 6fr .07in Xprt Ap Aspirat BOTH IP/OP "$1,238.00 " $916.12 $0.00 $990.40 $672.23 $672.23 $0.00 $0.00 $0.00 $258.03 $918.84 $918.84 $954.25 $0.00 $258.00 $0.00 $732.28 $732.28 $0.00 $619.00 $980.50 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80006190 EAP HCPCS C1769 Guidewire Vasc 145cm .035in Fix Core Flpy Flx Tp BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $26.61 $26.61 $0.00 $0.00 $0.00 $10.21 $36.37 $36.37 $37.77 $0.00 $10.21 $0.00 $28.98 $28.98 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $7.67 $0.00 $0.00 $7.80 $0.00 $0.00 $0.00 $0.00 $0.00 80006520 EAP HCPCS C1876 System Coron Stent 8mm 3.5mm Mtlnk Vsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006521 EAP HCPCS C1876 System Coron Stent 8mm 4mm Mtlnk Vsn Cocr Rapex Lp BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006522 EAP HCPCS C1876 System Coron Stent 12mm 3mm Mtlnk Vsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006523 EAP HCPCS C1874 System Coron Stent 12mm 3.5mm Mtlnk Vsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006524 EAP HCPCS C1876 System Coron Stent 12mm 4mm Mtlnk Vsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006526 EAP HCPCS C1876 System Coron Stent 15mm 3.5mm Mtlnk Vsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006531 EAP HCPCS C1876 System Coron Stent 23mm 3mm Mtlnk Vsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006535 EAP HCPCS C1874 System Coron Stent 28mm 3.5mm Mtlnk Vsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006536 EAP HCPCS C1876 System Coron Stent 28mm 4mm Mtlnk Vsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80006635 EAP HCPCS C1769 Guidewire Vasc 145cm .038in Atrm Flpy Flx Tp Xstif BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $35.30 $35.30 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $50.10 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 80006680 EAP HCPCS C1894 Sheath Introd 10cm 7fr Pncl Peri Ss Hydphi Ptfe BOTH IP/OP $219.00 $162.06 $0.00 $175.20 $118.92 $118.92 $0.00 $0.00 $0.00 $45.65 $162.54 $162.54 $168.81 $0.00 $45.64 $0.00 $129.54 $129.54 $0.00 $109.50 $173.45 $175.20 $0.00 $0.00 $0.00 $34.27 $0.00 $0.00 $34.86 $0.00 $0.00 $0.00 $0.00 $0.00 80006701 EAP HCPCS C1773 Kit Snr 120cm 15mm 6fr Agn Ntnl Cath Preform Loop BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $434.40 $434.40 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $616.64 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 80008328 EAP HCPCS C1876 System Coron Stent 8mm 2.5mm Mtlnk Mvsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80008330 EAP HCPCS C1876 System Coron Stent 15mm 2.5mm Mtlnk Mvsn Cocr BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80008333 EAP HCPCS C1876 System Coron Stent 28mm 2.5mm Mtlnk Mvsn Cocr BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80008338 EAP HCPCS A6198 Dressing Brn 16x16in Strl Lf Actct Anbctrl Fst Act Brr Cntrl BOTH IP/OP $156.00 $115.44 $0.00 $148.00 $84.71 $84.71 $0.00 $0.00 $0.00 $0.00 $115.78 $115.78 $120.24 $0.00 $32.51 $0.00 $0.00 $0.00 $0.00 $92.50 $146.52 $148.00 $0.00 $101.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80008439 EAP HCPCS C1894 Sheath Guid 45cm 6fr Pn Dstn Hs Curve Ss Nyl BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $111.32 $111.32 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $158.01 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 80008456 EAP HCPCS C1894 Introd Shth 6fr 4cm Radiopq Lg Bore Stpck Pinch BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $106.50 $168.70 $170.40 $0.00 $0.00 $0.00 $33.33 $0.00 $0.00 $33.91 $0.00 $0.00 $0.00 $0.00 $0.00 80008503 EAP HCPCS C1725 Catheter Angiographic Chuang C Curve 5fr 80cm Torcon Nb BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $34.21 $34.21 $0.00 $0.00 $0.00 $13.13 $46.76 $46.76 $48.56 $0.00 $13.13 $0.00 $37.26 $37.26 $0.00 $31.50 $49.90 $50.40 $0.00 $40.95 $0.00 $9.86 $0.00 $0.00 $10.03 $0.00 $0.00 $0.00 $0.00 $0.00 80008556 EAP HCPCS C1894 Introd Shth 10fr 2.5cm 25cm Dilat Kink Rst Pncl BOTH IP/OP $499.00 $369.26 $0.00 $399.20 $270.96 $270.96 $0.00 $0.00 $0.00 $104.00 $370.36 $370.36 $384.63 $0.00 $103.99 $0.00 $295.16 $295.16 $0.00 $249.50 $395.21 $399.20 $0.00 $0.00 $0.00 $78.09 $0.00 $0.00 $79.44 $0.00 $0.00 $0.00 $0.00 $0.00 80008561 EAP HCPCS C1894 Sheath Introd 25cm 5fr Pncl Peri Ss Hydphi Ptfe BOTH IP/OP $499.00 $369.26 $0.00 $399.20 $270.96 $270.96 $0.00 $0.00 $0.00 $104.00 $370.36 $370.36 $384.63 $0.00 $103.99 $0.00 $295.16 $295.16 $0.00 $249.50 $395.21 $399.20 $0.00 $0.00 $0.00 $78.09 $0.00 $0.00 $79.44 $0.00 $0.00 $0.00 $0.00 $0.00 80008562 EAP HCPCS C1757 Catheter Thrmb 135cm 5fr Unfs Flw-thru Hub Infus BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80008565 EAP HCPCS C1894 Sheath Introd 25cm 6fr Pncl Peri Ss Hydphi Ptfe BOTH IP/OP $499.00 $369.26 $0.00 $399.20 $270.96 $270.96 $0.00 $0.00 $0.00 $104.00 $370.36 $370.36 $384.63 $0.00 $103.99 $0.00 $295.16 $295.16 $0.00 $249.50 $395.21 $399.20 $0.00 $0.00 $0.00 $78.09 $0.00 $0.00 $79.44 $0.00 $0.00 $0.00 $0.00 $0.00 80008566 EAP HCPCS C1894 Introd Shth 8fr 2.5cm 25cm Dilat Mini Gwire Kink BOTH IP/OP $499.00 $369.26 $0.00 $399.20 $270.96 $270.96 $0.00 $0.00 $0.00 $104.00 $370.36 $370.36 $384.63 $0.00 $103.99 $0.00 $295.16 $295.16 $0.00 $249.50 $395.21 $399.20 $0.00 $0.00 $0.00 $78.09 $0.00 $0.00 $79.44 $0.00 $0.00 $0.00 $0.00 $0.00 80008570 EAP HCPCS C1894 Sheath Introd 25cm 7fr Pncl Peri Ss Hydphi Ptfe BOTH IP/OP $499.00 $369.26 $0.00 $399.20 $270.96 $270.96 $0.00 $0.00 $0.00 $104.00 $370.36 $370.36 $384.63 $0.00 $103.99 $0.00 $295.16 $295.16 $0.00 $249.50 $395.21 $399.20 $0.00 $0.00 $0.00 $78.09 $0.00 $0.00 $79.44 $0.00 $0.00 $0.00 $0.00 $0.00 80008625 EAP HCPCS C1894 Sheath Introd 10cm 10fr Pncl Peri Ss Hydphi Ptfe BOTH IP/OP $219.00 $162.06 $0.00 $175.20 $118.92 $118.92 $0.00 $0.00 $0.00 $45.65 $162.54 $162.54 $168.81 $0.00 $45.64 $0.00 $129.54 $129.54 $0.00 $109.50 $173.45 $175.20 $0.00 $0.00 $0.00 $34.27 $0.00 $0.00 $34.86 $0.00 $0.00 $0.00 $0.00 $0.00 80008715 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Lcb Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80008870 EAP HCPCS C1887 Catheter Guid Blue Ylw 100cm 7fr Crds Vsbr Mpa1 BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 80008873 EAP HCPCS C1887 Catheter Guid Blue Ylw 100cm 7fr Crds Vsbr Jr3.5 BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $50.50 $50.50 $0.00 $0.00 $0.00 $19.38 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $55.01 $55.01 $0.00 $46.50 $73.66 $74.40 $0.00 $0.00 $0.00 $14.55 $0.00 $0.00 $14.81 $0.00 $0.00 $0.00 $0.00 $0.00 80008874 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Ima Curve Peri BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80008930 EAP HCPCS C1760 Device Clsr 70cm 6fr Angsl Vip .035in Vasc Clgn BOTH IP/OP "$1,600.00 " "$1,184.00" $0.00 "$6,400.00" $868.80 $868.80 $0.00 $0.00 $0.00 $333.48 "$1,187.52" "$1,187.52" "$1,233.28" $0.00 $333.44 $0.00 $946.40 $946.40 $0.00 "$4,000.00" "$6,336.00" "$6,400.00" $0.00 "$1,040.00" $0.00 "$1,252.00" $0.00 $0.00 "$1,273.60" $0.00 $0.00 $0.00 $0.00 $0.00 80009063 EAP HCPCS C1725 Catheter Angio 100cm 5fr Gldcath Radifocus Ang BOTH IP/OP $607.00 $449.18 $0.00 $485.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $303.50 $480.74 $485.60 $0.00 $0.00 $0.00 $95.00 $0.00 $0.00 $96.63 $0.00 $0.00 $0.00 $0.00 $0.00 80009071 EAP HCPCS C1725 Catheter Angio 65cm 5fr Gldcath Radifocus C2 Curve BOTH IP/OP $607.00 $449.18 $0.00 $485.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $303.50 $480.74 $485.60 $0.00 $0.00 $0.00 $95.00 $0.00 $0.00 $96.63 $0.00 $0.00 $0.00 $0.00 $0.00 80009072 EAP HCPCS C1769 Guidewire Vasc Std Ang .035in 260cm 3cm Gldwr Gld Tch Flxb BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $301.37 $301.37 $0.00 $0.00 $0.00 $115.68 $411.92 $411.92 $427.79 $0.00 $115.66 $0.00 $328.28 $328.28 $0.00 $277.50 $439.56 $444.00 $0.00 $360.75 $0.00 $86.86 $0.00 $0.00 $88.36 $0.00 $0.00 $0.00 $0.00 $0.00 80009076 EAP HCPCS C1769 Guidewire Vasc 150cm .035in Radiopq Std Shft Flxb BOTH IP/OP $402.00 $297.48 $0.00 $309.86 $218.29 $218.29 $0.00 $0.00 $0.00 $75.66 $298.36 $298.36 $309.86 $0.00 $75.65 $0.00 $214.71 $214.71 $0.00 $181.50 $287.50 $290.40 $0.00 $261.30 $0.00 $56.81 $0.00 $0.00 $57.79 $0.00 $0.00 $0.00 $0.00 $0.00 80009079 EAP HCPCS C1894 Sheath Introd 10cm 5fr Pncl Peri Ss Hydphi Ptfe BOTH IP/OP $219.00 $162.06 $0.00 $175.20 $118.92 $118.92 $0.00 $0.00 $0.00 $45.65 $162.54 $162.54 $168.81 $0.00 $45.64 $0.00 $129.54 $129.54 $0.00 $109.50 $173.45 $175.20 $0.00 $142.35 $0.00 $34.27 $0.00 $0.00 $34.86 $0.00 $0.00 $0.00 $0.00 $0.00 80009081 EAP HCPCS C1894 Sheath Introd 10cm 8fr Pncl Peri Ss Hydphi Ptfe BOTH IP/OP $219.00 $162.06 $0.00 $175.20 $118.92 $118.92 $0.00 $0.00 $0.00 $45.65 $162.54 $162.54 $168.81 $0.00 $45.64 $0.00 $129.54 $129.54 $0.00 $109.50 $173.45 $175.20 $0.00 $142.35 $0.00 $34.27 $0.00 $0.00 $34.86 $0.00 $0.00 $0.00 $0.00 $0.00 80009082 EAP HCPCS C1894 Sheath Introd 10cm 9fr Pncl Peri Ss Hydphi Ptfe BOTH IP/OP $272.00 $201.28 $0.00 $209.66 $147.70 $147.70 $0.00 $0.00 $0.00 $45.65 $201.88 $201.88 $209.66 $0.00 $45.64 $0.00 $129.54 $129.54 $0.00 $109.50 $173.45 $175.20 $0.00 $176.80 $0.00 $34.27 $0.00 $0.00 $34.86 $0.00 $0.00 $0.00 $0.00 $0.00 80009106 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Sft Rbn Tip Kink Rst BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80009617 EAP HCPCS B4087 Tube Jjnstm 12fr 2-3ml Strl Lf Mc Slk Med Port Radopq Strp BOTH IP/OP $337.00 $249.38 $0.00 $269.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.12 $250.12 $259.76 $0.00 $70.23 $0.00 $0.00 $0.00 $0.00 $168.50 $266.90 $269.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80009798 EAP HCPCS C1760 Device Clsr 5-7fr Cardiva Ctlst Ii Fem Art Prtmn BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" "$2,890.50" $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 80009995 EAP HCPCS C1894 Sheath Guid 45cm 6fr Pn Dstn Str Ss Nyl Hydphi BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $112.40 $112.40 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $159.56 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 80010072 EAP HCPCS C1887 Catheter Guid 100cm 6fr Shr Nx Bal Al1 Curve Coron BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $64.07 $64.07 $0.00 $0.00 $0.00 $24.59 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $69.80 $69.80 $0.00 $59.00 $93.46 $94.40 $0.00 $0.00 $0.00 $18.47 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 80010120 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Core To Tip Radiopq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80010121 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Core To Tip Radiopq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80010122 EAP HCPCS C1769 Extension Gwire 145cm .014in Doc BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 80010594 EAP HCPCS C1725 Catheter Angio 100cm 5fr Prfm Pgtl Curve Peri BOTH IP/OP $226.00 $167.24 $0.00 $180.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.00 $178.99 $180.80 $0.00 $0.00 $0.00 $35.37 $0.00 $0.00 $35.98 $0.00 $0.00 $0.00 $0.00 $0.00 80010631 EAP HCPCS C1874 Stent Trchbr 5mm 6fr 22mm 120cm Cover Cath Introd BOTH IP/OP "$6,288.00 " "$4,653.12" $0.00 "$5,030.40" "$2,829.60" "$2,829.60" $0.00 $0.00 $0.00 "$1,310.58" "$4,181.12" "$4,181.12" "$4,846.79" $0.00 "$1,310.42" $0.00 "$3,099.98" "$3,099.98" $0.00 "$3,144.00" "$4,980.10" "$5,030.40" $0.00 $0.00 $0.00 $984.07 $0.00 $0.00 "$1,001.05" $0.00 $0.00 $0.00 $0.00 $0.00 80010639 EAP HCPCS C1876 System Coron Stent 13mm 4.5mm Mtlnk Ul Xcelon BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80016126 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Ebu3 Curve Coron Nyl BOTH IP/OP $120.00 $88.80 $0.00 $130.40 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $81.50 $129.10 $130.40 $0.00 $78.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80016128 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Ebu4 Curve Coron Nyl BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $0.00 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 80016129 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Ebu3 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80016130 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Ebu3.5 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80016131 EAP HCPCS C1887 Catheter Guid 100cm 7fr Shr Nx Bal Ebu4 Curve BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80016135 EAP HCPCS C1757 Catheter Thrmb 145cm 7fr .080in Xprt Ap Aspirat BOTH IP/OP "$1,238.00 " $916.12 $0.00 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.00 $980.50 $990.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80016142 EAP HCPCS C1753 Catheter Us 150cm 3.3-2.9fr 20mm Ee Pltn 20mhz BOTH IP/OP "$1,813.00 " "$1,341.62" $0.00 "$1,450.40" $984.46 $984.46 $0.00 $0.00 $0.00 $377.87 "$1,345.61" "$1,345.61" "$1,397.46" $0.00 $377.83 $0.00 "$1,072.39" "$1,072.39" $0.00 $906.50 "$1,435.90" "$1,450.40" $0.00 $0.00 $0.00 $283.73 $0.00 $0.00 $288.63 $0.00 $0.00 $0.00 $0.00 $0.00 80016144 EAP HCPCS C1773 Kit Snr Agn 90d Mic 175cm 2.3-3fr 2mm Cath Loop BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $760.20 $760.20 $0.00 $0.00 $0.00 $291.80 "$1,039.08" "$1,039.08" "$1,079.12" $0.00 $291.76 $0.00 $828.10 $828.10 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $219.10 $0.00 $0.00 $222.88 $0.00 $0.00 $0.00 $0.00 $0.00 80017153 EAP HCPCS C1752 Catheter Sct Kt 2 Lum Coil Xtd Lgth BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80017258 EAP HCPCS C1725 Catheter Baldilat 2.5mm 12mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80017262 EAP HCPCS C1725 Catheter Baldilat 2.5mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80017266 EAP HCPCS C1725 Catheter Baldilat 2.5mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80017278 EAP HCPCS C1725 Catheter Baldilat 2.5mm 25mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80017284 EAP HCPCS C1725 Catheter Baldilat 3.5mm 25mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80017293 EAP HCPCS C1725 Catheter Baldilat 2.75mm 12mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80017362 EAP Custom 80017362 Envelope Abs 2.7x2.5in Tyrx Polyarylate BOTH IP/OP "$1,738.00 " "$1,286.12" $0.00 "$1,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.94" "$1,289.94" "$1,339.65" $0.00 $362.20 $0.00 $0.00 $0.00 $0.00 $869.00 "$1,376.50" "$1,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80017977 EAP Custom 80017977 Envelope Abs 3.3x2.9in Anbctrl Tyrx Polyarylate BOTH IP/OP "$2,238.00 " "$1,656.12" $0.00 "$1,790.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,661.04" "$1,661.04" "$1,725.05" $0.00 $466.40 $0.00 $0.00 $0.00 $0.00 "$1,119.00" "$1,772.50" "$1,790.40" $0.00 "$1,454.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80018159 EAP HCPCS C1894 Tray Cath Lf A Neos 2 Tier Dsgn Fn Tip Fcp Ins Deph Fr Mgln BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $68.96 $68.96 $0.00 $0.00 $0.00 $26.47 $94.26 $94.26 $97.89 $0.00 $26.47 $0.00 $75.12 $75.12 $0.00 $63.50 $100.58 $101.60 $0.00 $82.55 $0.00 $19.88 $0.00 $0.00 $20.22 $0.00 $0.00 $0.00 $0.00 $0.00 80018208 EAP HCPCS C1752 Set Catheter .035in 24cm 70cm Sidehole Removable S BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $243.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80018623 EAP HCPCS C1725 Catheter Baldilat 1.5mm 145cm 12mm Otw 2 Lum Ult BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018626 EAP HCPCS C1725 Catheter Baldilat 2mm 145cm 12mm Otw 2 Lum Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018627 EAP HCPCS C1725 Catheter Baldilat 2mm 145cm 15mm Otw 2 Lum Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018653 EAP Dressing Foam 20x8in Gentle Adherence Polyurethane Foam Pad BOTH IP/OP $167.00 $123.58 $0.00 $133.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.95 $123.95 $128.72 $0.00 $34.80 $0.00 $0.00 $0.00 $0.00 $83.50 $132.26 $133.60 $0.00 $108.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80018673 EAP HCPCS C1725 Catheter Baldilat 2.75mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018676 EAP HCPCS C1725 Catheter Baldilat 3mm 12mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018677 EAP HCPCS C1725 Catheter Baldilat 3mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018678 EAP HCPCS C1725 Catheter Baldilat 3mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018679 EAP HCPCS C1725 Catheter Baldilat 3mm 25mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018680 EAP HCPCS C1725 Catheter Baldilat 3.25mm 12mm Coron Rapex Radiopq BOTH IP/OP $488.00 $361.12 $0.00 $390.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.00 $386.50 $390.40 $0.00 $0.00 $0.00 $76.37 $0.00 $0.00 $77.69 $0.00 $0.00 $0.00 $0.00 $0.00 80018683 EAP HCPCS C1725 Catheter Baldilat 3.5mm 8mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018684 EAP HCPCS C1725 Catheter Baldilat 3.5mm 12mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018685 EAP HCPCS C1725 Catheter Baldilat 3.5mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018686 EAP HCPCS C1725 Catheter Baldilat 3.5mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018689 EAP HCPCS C1725 Catheter Baldilat 3.75mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018690 EAP HCPCS C1725 Catheter Baldilat 3.75mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018691 EAP HCPCS C1725 Catheter Baldilat 4mm 8mm Coron Rapex Radiopq Smth BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018692 EAP HCPCS C1725 Catheter Baldilat 4mm 12mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018693 EAP HCPCS C1725 Catheter Baldilat 4mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018694 EAP HCPCS C1725 Catheter Baldilat 4mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80018696 EAP HCPCS C1725 Catheter Baldilat 5mm 12mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80074158 EAP HCPCS C1898 Lead Pacing 10mm Space Small Str 6.2fr 2mm 52cm 20 BOTH IP/OP "$1,013.00 " $749.62 $0.00 $810.40 $455.85 $455.85 $0.00 $0.00 $0.00 $211.13 $751.85 $751.85 $780.82 $0.00 $211.11 $0.00 $599.19 $599.19 $0.00 $506.50 $802.30 $810.40 $0.00 $455.85 $0.00 $158.53 $0.00 $0.00 $161.27 $0.00 $0.00 $0.00 $0.00 $0.00 80074159 EAP HCPCS C1898 Lead Pacing 10mm Space Small Str 6.2fr 2mm 58cm 20 BOTH IP/OP "$1,013.00 " $749.62 $0.00 $810.40 $455.85 $455.85 $0.00 $0.00 $0.00 $211.13 $751.85 $751.85 $780.82 $0.00 $211.11 $0.00 $599.19 $599.19 $0.00 $506.50 $802.30 $810.40 $0.00 $455.85 $0.00 $158.53 $0.00 $0.00 $161.27 $0.00 $0.00 $0.00 $0.00 $0.00 80078368 EAP HCPCS C1884 System Embl Prtc 320cm Crtd Lwr Xtrmt Cptr Wire BOTH IP/OP "$3,488.00 " "$2,581.12" $0.00 "$2,790.40" "$1,893.98" "$1,893.98" $0.00 $0.00 $0.00 $726.99 "$2,588.79" "$2,588.79" "$2,688.55" $0.00 $726.90 $0.00 "$2,063.15" "$2,063.15" $0.00 "$1,744.00" "$2,762.50" "$2,790.40" $0.00 $0.00 $0.00 $545.87 $0.00 $0.00 $555.29 $0.00 $0.00 $0.00 $0.00 $0.00 80078369 EAP HCPCS C1884 System Embl Prtc 320cm Crtd Lwr Xtrmt Cptr Wire BOTH IP/OP "$4,170.00 " "$3,085.80" $0.00 "$3,214.24" "$2,264.31" "$2,264.31" $0.00 $0.00 $0.00 $869.13 "$3,094.97" "$3,094.97" "$3,214.24" $0.00 $869.03 $0.00 "$2,466.56" "$2,466.56" $0.00 "$1,744.00" "$2,762.50" "$2,790.40" $0.00 "$2,710.50" $0.00 $545.87 $0.00 $0.00 $555.29 $0.00 $0.00 $0.00 $0.00 $0.00 80078384 EAP HCPCS C1769 Guidewire Vasc 260cm .035in Radiopq Flxb Core To BOTH IP/OP $623.00 $461.02 $0.00 $498.40 $338.29 $338.29 $0.00 $0.00 $0.00 $129.85 $462.39 $462.39 $480.21 $0.00 $129.83 $0.00 $368.50 $368.50 $0.00 $311.50 $493.42 $498.40 $0.00 $404.95 $0.00 $97.50 $0.00 $0.00 $99.18 $0.00 $0.00 $0.00 $0.00 $0.00 80079016 EAP HCPCS C1894 Sheath Guid 80cm 6fr 2.2mm Flxr Sh Aq Radiopq Stf BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $205.25 $205.25 $0.00 $0.00 $0.00 $78.78 $280.55 $280.55 $291.36 $0.00 $78.78 $0.00 $223.59 $223.59 $0.00 $189.00 $299.38 $302.40 $0.00 $245.70 $0.00 $59.16 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 80079147 EAP HCPCS C1760 Device Clsr 6fr Prgld Prcls Vasc Suture Mediate BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $292.50 $292.50 $0.00 $0.00 $0.00 $135.48 $482.43 $482.43 $501.02 $0.00 $135.46 $0.00 $384.48 $384.48 $0.00 $325.00 $514.80 $520.00 $0.00 $292.50 $0.00 $101.73 $0.00 $0.00 $103.48 $0.00 $0.00 $0.00 $0.00 $0.00 80079222 EAP HCPCS C1894 Introducer Sheath Short 7fr 21ga 4cm Orange Hub Tubing BOTH IP/OP $48.00 $35.52 $0.00 $37.00 $26.06 $26.06 $0.00 $0.00 $0.00 $8.96 $35.63 $35.63 $37.00 $0.00 $8.96 $0.00 $25.43 $25.43 $0.00 $21.50 $34.06 $34.40 $0.00 $31.20 $0.00 $6.73 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 80079510 EAP HCPCS C1769 Guidewire Vasc 180cm .016in Str Tip Strbl BOTH IP/OP $744.00 $550.56 $0.00 $595.20 $403.99 $403.99 $0.00 $0.00 $0.00 $155.07 $552.20 $552.20 $573.48 $0.00 $155.05 $0.00 $440.08 $440.08 $0.00 $372.00 $589.25 $595.20 $0.00 $483.60 $0.00 $116.44 $0.00 $0.00 $118.44 $0.00 $0.00 $0.00 $0.00 $0.00 80079568 EAP Custom 80079568 Coil Embl 15cm 4mm Intlk Fbr Idc 18 Coil 2d Std BOTH IP/OP $943.00 $697.82 $0.00 $754.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.89 $699.89 $726.86 $0.00 $196.52 $0.00 $0.00 $0.00 $0.00 $471.50 $746.86 $754.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80079570 EAP Custom 80079570 Coil Embl 15cm 5mm Intlk Fbr Idc 18 Coil 2d Std BOTH IP/OP $943.00 $697.82 $0.00 $754.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.89 $699.89 $726.86 $0.00 $196.52 $0.00 $0.00 $0.00 $0.00 $471.50 $746.86 $754.40 $0.00 $424.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80097224 EAP HCPCS C1725 Catheter Angio 100cm 5fr Imprs Sim2 Curve Crbrl Ss BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 80097225 EAP HCPCS C1725 Catheter Angio 100cm 5fr Crds Tmp Vert Curve Crbrl BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 80097341 EAP Custom C1751 Axium Coil Detacher BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $73.31 $73.31 $0.00 $0.00 $0.00 $28.14 $100.20 $100.20 $104.06 $0.00 $28.13 $0.00 $79.85 $79.85 $0.00 $67.50 $106.92 $108.00 $0.00 $87.75 $0.00 $21.13 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $0.00 80097344 EAP HCPCS C1769 Guidewire Vascular Taper .018in 300cm 8cm Radiopq Str Tip BOTH IP/OP $197.00 $145.78 $0.00 $157.60 $106.97 $106.97 $0.00 $0.00 $0.00 $41.06 $146.21 $146.21 $151.85 $0.00 $41.05 $0.00 $116.53 $116.53 $0.00 $98.50 $156.02 $157.60 $0.00 $128.05 $0.00 $30.83 $0.00 $0.00 $31.36 $0.00 $0.00 $0.00 $0.00 $0.00 80097387 EAP HCPCS C1876 System Cor Stnt 2.25mm 12mm Intgr Microtrac Rx 1 Strn Intgr BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $787.50 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 80097412 EAP HCPCS C1876 System Cor Stnt 3mm 9mm Intgr Microtrac Rx 1 Strn Intgr Tip BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $787.50 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 80097421 EAP HCPCS C1876 System Cor Stnt 4mm 12mm Intgr Microtrac Rx 1 Strn Intgr Tip BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $787.50 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 80097435 EAP HCPCS C1757 System Thrmb 135cm 4fr 2mm Angjt Ult Cx-strm BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" "$2,436.98" "$2,436.98" $0.00 $0.00 $0.00 $935.41 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 "$2,654.65" "$2,654.65" $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,917.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80097440 EAP Custom 80097440 Pad Thrp Lg Arcticgel BOTH IP/OP "$4,960.00 " "$3,670.40" $0.00 "$3,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,681.31" "$3,681.31" "$3,823.17" $0.00 "$1,033.66" $0.00 $0.00 $0.00 $0.00 "$2,480.00" "$3,928.32" "$3,968.00" $0.00 "$3,224.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80097469 EAP HCPCS C1725 Catheter Baldilat 2mm 12mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80097470 EAP HCPCS C1725 Catheter Baldilat 2mm 15mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80097471 EAP HCPCS C1725 Catheter Baldilat 2.5mm 12mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80097472 EAP HCPCS C1725 Catheter Baldilat 2.5mm 15mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80097473 EAP HCPCS C1725 Catheter Baldilat 3mm 12mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80097474 EAP HCPCS C1725 Catheter Baldilat 3mm 15mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80097475 EAP HCPCS C1725 Catheter Baldilat 3.5mm 12mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80097476 EAP HCPCS C1725 Catheter Baldilat 3.5mm 15mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80097477 EAP Custom 80097477 Catheter Baldilat 4mm 15mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80100003 EAP Custom 80100003 Hemodialysis-acute-i/p BOTH IP/OP "$3,300.00 " "$2,442.00" $0.00 "$2,145.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $687.72 $0.00 $0.00 $0.00 $0.00 "$1,194.00" "$1,891.30" "$1,910.40" $0.00 "$2,145.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80100234 EAP HCPCS C1894 Sheath Guid 70cm 6fr 2.2mm Flxr Chk-flo Str Tip Hi BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 80100235 EAP HCPCS C1894 Sheath Guid 70cm 6fr 2.2mm Flxr Chk-flo Curve BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 80100236 EAP HCPCS C1894 Introd Shth 8.8fr 7fr 110cm Gw Radiopq Band Hi Flx BOTH IP/OP $503.00 $372.22 $0.00 $402.40 $273.13 $273.13 $0.00 $0.00 $0.00 $104.84 $373.33 $373.33 $387.71 $0.00 $104.83 $0.00 $297.52 $297.52 $0.00 $251.50 $398.38 $402.40 $0.00 $0.00 $0.00 $78.72 $0.00 $0.00 $80.08 $0.00 $0.00 $0.00 $0.00 $0.00 80100237 EAP HCPCS C1894 Sheath Guid 70cm 7fr 2.5mm Flxr Introd / Flxr Guid BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $146.25 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 80100239 EAP HCPCS C1894 Sheath Guid 70cm 8fr 2.9mm Flxr Chk-flo Curve BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 80100242 EAP HCPCS C1894 Sheath Guid 45cm 6fr .087in Flxr Chk-flo Anl0 BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80100243 EAP HCPCS C1894 Sheath Guid 45cm 6fr 2.2mm Flxr Chk-flo Multpur BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80100244 EAP HCPCS C1894 Sheath Guid 45cm 6fr 2.2in Flxr Chk-flo Anl2 Curve BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80100245 EAP HCPCS C1894 Sheath Guid 45cm 7fr .1in Flxr Chk-flo Anl0 Curve BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80100246 EAP HCPCS C1894 Sheath Guid 45cm 7fr 2.5mm Flxr Chk-flo Anl3 Curve BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80100247 EAP HCPCS C1894 Sheath Guid .018/.038in Anl0 Curve 8fr .113in 45cm Radiopq BOTH IP/OP $203.00 $150.22 $0.00 $156.47 $110.23 $110.23 $0.00 $0.00 $0.00 $0.00 $150.67 $150.67 $156.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $131.95 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80100254 EAP HCPCS C1769 Guidewire Vasc 180cm .035in Flx Tp Fix Core Exch BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $23.35 $23.35 $0.00 $0.00 $0.00 $8.96 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $25.43 $25.43 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $6.73 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 80100273 EAP HCPCS C1725 Catheter Angio 100cm 5fr Trnb Ad Bcn Kmp Curve Ss BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $9.86 $0.00 $0.00 $10.03 $0.00 $0.00 $0.00 $0.00 $0.00 80100275 EAP HCPCS C1725 Catheter Angio 65cm 5fr Trnb Ad Bcn Kmp Curve Ss BOTH IP/OP $325.00 $240.50 $0.00 $250.51 $176.48 $176.48 $0.00 $0.00 $0.00 $65.24 $241.22 $241.22 $250.51 $0.00 $65.23 $0.00 $185.14 $185.14 $0.00 $156.50 $247.90 $250.40 $0.00 $211.25 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 80100322 EAP HCPCS C1876 Stent Bil 5mm 19mm 150cm Prmnt Bln Xpd Cath BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100329 EAP HCPCS C1876 Stent Bil 6mm 17mm 135cm 20mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100330 EAP HCPCS C1876 Stent Bil 6mm 37mm 135cm 40mm Radiopq Otw Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100331 EAP HCPCS C1876 Stent Bil 7mm 17mm 135cm 20mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100332 EAP HCPCS C1876 Stent Bil 7mm 37mm 135cm 40mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100333 EAP HCPCS C1876 Stent Bil 8mm 17mm 135cm 20mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100334 EAP HCPCS C1876 Stent Bil 8mm 37mm 135cm 40mm Otw Prmnt Bln Xpd BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100335 EAP HCPCS C1876 Stent Bil 9mm 25mm 135cm 30mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100336 EAP HCPCS C1876 Stent Bil 9mm 57mm 135cm 60mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100337 EAP HCPCS C1725 Catheter Baldilat 4mm 135cm 20mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100340 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 40mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100343 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 80mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100350 EAP HCPCS C1725 Catheter Baldilat 2mm 144cm 40mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100353 EAP HCPCS C1725 Catheter Baldilat 4mm 143cm 20mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100355 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 100mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100356 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 120mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100357 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 150mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100358 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 80mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100359 EAP HCPCS C1725 Catheter Baldilat 3mm 150cm 100mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100361 EAP HCPCS C1725 Catheter Baldilat 3mm 150cm 150mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100362 EAP HCPCS C1725 Catheter Baldilat 3mm 150cm 80mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100363 EAP HCPCS C1725 Catheter Baldilat 4mm 150cm 150mm Otw Infl Port Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100364 EAP HCPCS C1725 Catheter Baldilat 4mm 150cm 80mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100366 EAP HCPCS C1725 Catheter Baldilat 4mm 135cm 200mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100371 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 200mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100374 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 200mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100377 EAP HCPCS C1725 Catheter Baldilat 8mm 75cm 100mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100381 EAP HCPCS C1726 Catheter Baldilat 2mm 150cm 150mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100382 EAP HCPCS C1726 Catheter Baldilat 2mm 150cm 220mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100383 EAP HCPCS C1726 Catheter Baldilat 3mm 150cm 100mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100385 EAP HCPCS C1725 Catheter Baldilat 3mm 150cm 220mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100386 EAP HCPCS C1726 Catheter Baldilat 4mm 150cm 100mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100392 EAP HCPCS C1876 Stent Bil 10mm 37mm 75cm 40mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80100413 EAP HCPCS C1725 Catheter Baldilat 4mm 135cm 40mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100416 EAP HCPCS C1725 Catheter Baldilat 6mm 20mm 135cm Otw Tpr Tip Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100418 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 40mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100420 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 60mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100425 EAP HCPCS C1725 Catheter Baldilat 7mm 135cm 60mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100428 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 20mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100430 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 40mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100432 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 40mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100433 EAP HCPCS C1725 Catheter Baldilat 4mm 75cm 20mm Hi-prs Nybax BOTH IP/OP $430.00 $318.20 $0.00 $350.40 $233.49 $233.49 $0.00 $0.00 $0.00 $91.29 $319.15 $319.15 $331.44 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $279.50 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100434 EAP HCPCS C1725 Catheter Baldilat 4mm 135cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100435 EAP HCPCS C1726 Catheter Baldilat 4mm 75cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100436 EAP HCPCS C1725 Catheter Baldilat 4mm 135cm 120mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100437 EAP HCPCS C1725 Catheter Baldilat 5mm 75cm 20mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100438 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100439 EAP HCPCS C1725 Catheter Baldilat 5mm 75cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100440 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 100mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100441 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 150mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100443 EAP HCPCS C1725 Catheter Baldilat 6mm 75cm 20mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100444 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100445 EAP HCPCS C1725 Catheter Baldilat 6mm 75cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100446 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 100mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100447 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 150mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100448 EAP HCPCS C1725 Catheter Baldilat 7mm 75cm 20mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100449 EAP HCPCS C1725 Catheter Baldilat 7mm 135cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100450 EAP HCPCS C1725 Catheter Baldilat 7mm 75cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100451 EAP HCPCS C1725 Catheter Baldilat 8mm 75cm 20mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100453 EAP HCPCS C1725 Catheter Baldilat 8mm 75cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100454 EAP HCPCS C1725 Catheter Baldilat 8mm 75cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100456 EAP HCPCS C1725 Catheter Baldilat 10mm 75cm 20mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80100470 EAP HCPCS C1757 SET THROMBECTOMY 6FR 3MM 120CM 15MM OTW CONTRAST INJEC PORT BOTH IP/OP "$4,225.00 " "$3,126.50" $0.00 "$3,380.00" "$2,294.18" "$2,294.18" $0.00 $0.00 $0.00 $880.60 "$3,135.80" "$3,135.80" "$3,256.63" $0.00 $880.49 $0.00 "$2,499.09" "$2,499.09" $0.00 "$2,112.50" "$3,346.20" "$3,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80100527 EAP HCPCS C1768 Graft Vascular Gore Heparin Propaten Ptfe Standard Wall BOTH IP/OP "$3,148.00 " "$2,329.52" $0.00 "$2,518.40" "$1,416.60" "$1,416.60" $0.00 $0.00 $0.00 $656.12 "$2,336.45" "$2,336.45" "$2,426.48" $0.00 $656.04 $0.00 "$1,551.96" "$1,551.96" $0.00 "$1,574.00" "$2,493.22" "$2,518.40" $0.00 $0.00 $0.00 $492.66 $0.00 $0.00 $501.16 $0.00 $0.00 $0.00 $0.00 $0.00 80100552 EAP HCPCS C1894 Set Introd 30cm 14fr 4.6mm Chk-flo 41cm Acpt .038 BOTH IP/OP $318.00 $235.32 $0.00 $254.40 $172.67 $172.67 $0.00 $0.00 $0.00 $66.28 $236.02 $236.02 $245.11 $0.00 $66.27 $0.00 $188.10 $188.10 $0.00 $159.00 $251.86 $254.40 $0.00 $0.00 $0.00 $49.77 $0.00 $0.00 $50.63 $0.00 $0.00 $0.00 $0.00 $0.00 80100555 EAP HCPCS C1726 CATHETER BLNDIL 5MM 135CM 20MM PR CTBLN OTW TPR TIP INFL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 80100582 EAP HCPCS C1769 GUIDEWIRE VASCULAR ANGLED .035IN 260CM 25CM GLIDEW BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $244.35 $244.35 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $346.86 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $292.50 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 80100584 EAP HCPCS C1887 Catheter Angiographic Angle 4fr .041in 100cm 15cm 2 Braid BOTH IP/OP $121.00 $89.54 $0.00 $96.80 $65.70 $65.70 $0.00 $0.00 $0.00 $25.22 $89.81 $89.81 $93.27 $0.00 $25.22 $0.00 $71.57 $71.57 $0.00 $60.50 $95.83 $96.80 $0.00 $78.65 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 80100610 EAP HCPCS C1726 Catheter Baldilat 2.5mm 150cm 120mm Otw Ult Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100611 EAP HCPCS C1726 Catheter Baldilat 2.5mm 150cm 220mm Otw Ult Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80100614 EAP HCPCS C1725 Catheter Baldilat 4mm 150cm 220mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80200001 EAP Custom 80200001 Peritoneal Dialysis-inpat BOTH IP/OP "$1,724.00 " "$1,275.76" $0.00 "$1,120.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.28 $0.00 $0.00 $0.00 $0.00 $458.50 $726.26 $733.60 $0.00 "$1,120.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80200005 EAP HCPCS C1751 Catheter Cen Ven .032in 9.3fr 38cm 75cm 3 Infus Lumen Extn BOTH IP/OP "$1,955.00 " "$1,446.70" $0.00 "$1,564.00" "$1,061.57" "$1,061.57" $0.00 $0.00 $0.00 $407.47 "$1,451.00" "$1,451.00" "$1,506.91" $0.00 $407.42 $0.00 "$1,156.38" "$1,156.38" $0.00 $977.50 "$1,548.36" "$1,564.00" $0.00 "$1,270.75" $0.00 $305.96 $0.00 $0.00 $311.24 $0.00 $0.00 $0.00 $0.00 $0.00 80200008 EAP HCPCS C1769 Guidewire Vasc 180cm .014in Atrm X Flpy Tip BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $130.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 80200010 EAP HCPCS C1725 Catheter Angio 100cm 5fr Optitorque Jacky Radl 3.5 BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 80200013 EAP HCPCS C1894 Set Acces 10cm 5fr 21ga Mpnch Slht .018in Ss BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $54.30 $54.30 $0.00 $0.00 $0.00 $20.84 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $0.00 $65.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 80200098 EAP HCPCS C1769 Guidewire Vasc 260cm .018in Flpy Tip Radiopq Shrt BOTH IP/OP $203.00 $150.22 $0.00 $162.40 $110.23 $110.23 $0.00 $0.00 $0.00 $42.31 $150.67 $150.67 $156.47 $0.00 $42.31 $0.00 $120.07 $120.07 $0.00 $101.50 $160.78 $162.40 $0.00 $131.95 $0.00 $31.77 $0.00 $0.00 $32.32 $0.00 $0.00 $0.00 $0.00 $0.00 80200103 EAP HCPCS C1887 Catheter Intvn 6fr 5.1fr .056in 150cm 25cm Rapex BOTH IP/OP "$1,183.00 " $875.42 $0.00 $946.40 $642.37 $642.37 $0.00 $0.00 $0.00 $246.57 $878.02 $878.02 $911.86 $0.00 $246.54 $0.00 $699.74 $699.74 $0.00 $591.50 $936.94 $946.40 $0.00 $768.95 $0.00 $185.14 $0.00 $0.00 $188.33 $0.00 $0.00 $0.00 $0.00 $0.00 80200104 EAP HCPCS C1725 Catheter Guid 100cm 7fr Lnchr Ebu3.75 Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80200105 EAP HCPCS C1725 Catheter Angio 100cm 5fr Optitorque Radl Tig 4.5 BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $47.78 $47.78 $0.00 $0.00 $0.00 $18.34 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $52.05 $52.05 $0.00 $44.00 $69.70 $70.40 $0.00 $57.20 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 80200129 EAP HCPCS C1725 Catheter Baldilat 9mm 75cm 60mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80200207 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 100mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80200262 EAP HCPCS C1753 Catheter Us .018in 3.4fr 135cm Intvasc Exch Vsn Pv BOTH IP/OP "$1,688.00 " "$1,249.12" $0.00 "$1,350.40" $916.58 $916.58 $0.00 $0.00 $0.00 $351.82 "$1,252.83" "$1,252.83" "$1,301.11" $0.00 $351.78 $0.00 $998.45 $998.45 $0.00 $844.00 "$1,336.90" "$1,350.40" $0.00 $0.00 $0.00 $264.17 $0.00 $0.00 $268.73 $0.00 $0.00 $0.00 $0.00 $0.00 80202089 EAP Custom 80202089 SET TUBING 2.6MR 2 WAY COMMUNICATION IRRIGATION PUMP BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $96.35 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $81.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202090 EAP HCPCS C1733 Catheter Ep 110cm 7fr Safire Tx 2-5-2mm Spc 1mm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" "$1,153.88" "$1,153.88" $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 "$1,381.25" $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80202091 EAP HCPCS C1733 Safire Tx Catheter 8mm Large Curl BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $814.50 $814.50 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80202094 EAP HCPCS C1733 Catheter Ep 115cm 7fr Safire Comfortgrip 2-5-2mm BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 "$1,056.25" $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 80202112 EAP HCPCS C1893 Introd Shth 8.5fr 180cm 63cm Hmsts Vlv Sdprt Dilat BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $197.11 $197.11 $0.00 $0.00 $0.00 $75.66 $269.42 $269.42 $279.80 $0.00 $75.65 $0.00 $214.71 $214.71 $0.00 $181.50 $287.50 $290.40 $0.00 $0.00 $0.00 $56.81 $0.00 $0.00 $57.79 $0.00 $0.00 $0.00 $0.00 $0.00 80202116 EAP HCPCS C1894 Introd Shth 8fr 50cm 12cm 2 Distal Gwire Hmsts Vlv BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $15.20 $15.20 $0.00 $0.00 $0.00 $5.84 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $16.56 $16.56 $0.00 $14.00 $22.18 $22.40 $0.00 $18.20 $0.00 $4.38 $0.00 $0.00 $4.46 $0.00 $0.00 $0.00 $0.00 $0.00 80202118 EAP HCPCS C1894 Introd Shth 6fr 50cm 12cm 2 Distal Gwire Hmsts Vlv BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $15.20 $15.20 $0.00 $0.00 $0.00 $5.84 $20.78 $20.78 $21.58 $0.00 $5.84 $0.00 $16.56 $16.56 $0.00 $14.00 $22.18 $22.40 $0.00 $18.20 $0.00 $4.38 $0.00 $0.00 $4.46 $0.00 $0.00 $0.00 $0.00 $0.00 80202121 EAP HCPCS C1893 Introd Shth 8fr 60cm Fstcth Strl Latex Free Disp BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $169.96 $169.96 $0.00 $0.00 $0.00 $65.24 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $185.14 $185.14 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 80202130 EAP HCPCS C1766 Introd Cath 40cm 8.5fr 17ga Epicardium Rspn Agilis BOTH IP/OP "$2,638.00 " "$1,952.12" $0.00 "$2,110.40" "$1,432.43" "$1,432.43" $0.00 $0.00 $0.00 $549.83 "$1,957.92" "$1,957.92" "$2,033.37" $0.00 $549.76 $0.00 "$1,560.38" "$1,560.38" $0.00 "$1,319.00" "$2,089.30" "$2,110.40" $0.00 $0.00 $0.00 $412.85 $0.00 $0.00 $419.97 $0.00 $0.00 $0.00 $0.00 $0.00 80202131 EAP HCPCS C1730 Catheter Ep 120cm 5fr Rspn 5mm Spc Crnnd Curve BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $106.50 $168.70 $170.40 $0.00 $138.45 $0.00 $33.33 $0.00 $0.00 $33.91 $0.00 $0.00 $0.00 $0.00 $0.00 80202133 EAP HCPCS C1730 Catheter Ep 120cm 5fr Rspn 5mm Spc Jsphsn Curve BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $106.50 $168.70 $170.40 $0.00 $138.45 $0.00 $33.33 $0.00 $0.00 $33.91 $0.00 $0.00 $0.00 $0.00 $0.00 80202150 EAP HCPCS C1731 Catheter Ep 95cm 7fr Lvwr 2-10-2mm Spc Sup Lg Curl BOTH IP/OP "$1,938.00 " "$1,434.12" $0.00 "$1,550.40" "$1,052.33" "$1,052.33" $0.00 $0.00 $0.00 $403.93 "$1,438.38" "$1,438.38" "$1,493.81" $0.00 $403.88 $0.00 "$1,146.33" "$1,146.33" $0.00 $969.00 "$1,534.90" "$1,550.40" $0.00 "$1,259.70" $0.00 $303.30 $0.00 $0.00 $308.53 $0.00 $0.00 $0.00 $0.00 $0.00 80202158 EAP Kit Eltrd Ns Lf Ensite Navx Srfc Disp BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 "$1,462.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202163 EAP HCPCS C1898 Lead Packing Tendril Sts Steroid Silicone Helix L46cm Od6fr BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $506.25 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 80202164 EAP HCPCS C1898 Lead Pacing Tendril Sts Optim Steroid L52 Cm Od6 Fr Endocard Is-1 Bipolar Con BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $506.25 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 80202165 EAP HCPCS C1898 Lead Pacing Tendril Sts Steroid Silicone Helix L58 Od6 Fr Endocard BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $867.15 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $506.25 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 80202189 EAP HCPCS C1751 Kit Cath .032in 8.5fr 18ga 16cm Lf 2.5in Blu Flxtp Arwg+ard BOTH IP/OP $349.00 $258.26 $0.00 $279.20 $189.51 $189.51 $0.00 $0.00 $0.00 $72.74 $259.03 $259.03 $269.01 $0.00 $72.73 $0.00 $206.43 $206.43 $0.00 $174.50 $276.41 $279.20 $0.00 $226.85 $0.00 $54.62 $0.00 $0.00 $55.56 $0.00 $0.00 $0.00 $0.00 $0.00 80202203 EAP HCPCS C1729 Tray Catheterization 16fr 2 Conctr Temperature Sense BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $37.47 $37.47 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $53.19 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $34.50 $54.65 $55.20 $0.00 $44.85 $0.00 $10.80 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $0.00 80202219 EAP HCPCS C1726 Catheter Blndil 11 Atm 8mm 180cm 4cm Hrcn Rx Loprfl Radopq BOTH IP/OP $603.00 $446.22 $0.00 $482.40 $327.43 $327.43 $0.00 $0.00 $0.00 $125.68 $447.55 $447.55 $464.79 $0.00 $125.67 $0.00 $356.67 $356.67 $0.00 $301.50 $477.58 $482.40 $0.00 $391.95 $0.00 $94.37 $0.00 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202586 EAP Coil Embolization .02in Complex 14mm 40cm Soft The Penumbra BOTH IP/OP "$6,188.00 " "$4,579.12" $0.00 "$4,950.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,769.71" $0.00 "$1,289.58" $0.00 $0.00 $0.00 $0.00 "$3,094.00" "$4,900.90" "$4,950.40" $0.00 "$2,784.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202609 EAP Coil Embl .02in Cmplx 5mm 9cm The Penumbra Coil 400 Sft BOTH IP/OP "$5,490.00 " "$4,062.60" $0.00 "$4,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,074.68" "$4,074.68" "$4,231.69" $0.00 "$1,144.12" $0.00 $0.00 $0.00 $0.00 "$2,745.00" "$4,348.08" "$4,392.00" $0.00 "$2,470.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202611 EAP Coil Embolization .02in Standard Complex 10mm 30cm Complex BOTH IP/OP "$5,513.00 " "$4,079.62" $0.00 "$4,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,091.75" "$4,091.75" "$4,249.42" $0.00 "$1,148.91" $0.00 $0.00 $0.00 $0.00 "$2,756.50" "$4,366.30" "$4,410.40" $0.00 "$2,480.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202615 EAP Coil Embolization .02in Standard Complex 12mm 35cm Complex BOTH IP/OP "$5,570.00 " "$4,121.80" $0.00 "$4,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,134.05" "$4,134.05" "$4,293.36" $0.00 "$1,160.79" $0.00 $0.00 $0.00 $0.00 "$2,785.00" "$4,411.44" "$4,456.00" $0.00 "$2,506.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202624 EAP Coil Embl .02in Cmplx 7mm 15cm The Penumbra Coil 400 Sft BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" "$4,335.75" $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 "$2,531.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202641 EAP Coil Embolization .02in Complex 10mm 30cm Soft The Penumbra BOTH IP/OP "$5,963.00 " "$4,412.62" $0.00 "$4,770.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,596.28" $0.00 "$1,242.69" $0.00 $0.00 $0.00 $0.00 "$2,981.50" "$4,722.70" "$4,770.40" $0.00 "$2,683.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80202926 EAP HCPCS C1887 Set Interventional .038in 10fr 40cm 62.5cm Catheter Cannu BOTH IP/OP "$1,131.00 " $836.94 $0.00 $904.80 $614.13 $614.13 $0.00 $0.00 $0.00 $235.73 $839.43 $839.43 $871.77 $0.00 $235.70 $0.00 $668.99 $668.99 $0.00 $565.50 $895.75 $904.80 $0.00 $735.15 $0.00 $177.00 $0.00 $0.00 $180.06 $0.00 $0.00 $0.00 $0.00 $0.00 80202933 EAP HCPCS C1894 Introd Cath 80cm 10fr 3.4mm Chk-flo Flxr Lg Vlv BOTH IP/OP $265.00 $196.10 $0.00 $212.00 $143.90 $143.90 $0.00 $0.00 $0.00 $55.23 $196.68 $196.68 $204.26 $0.00 $55.23 $0.00 $156.75 $156.75 $0.00 $132.50 $209.88 $212.00 $0.00 $172.25 $0.00 $41.47 $0.00 $0.00 $42.19 $0.00 $0.00 $0.00 $0.00 $0.00 80202945 EAP HCPCS C1894 Sheath Guid 45cm 7fr 2.5mm Flxr Chk-flo Anl2 Curve BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80202946 EAP HCPCS C1894 Sheath Guid 90cm 6fr 2.2mm Flxr Chk-flo Anl1 Curve BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $205.25 $205.25 $0.00 $0.00 $0.00 $78.78 $280.55 $280.55 $291.36 $0.00 $78.78 $0.00 $223.59 $223.59 $0.00 $189.00 $299.38 $302.40 $0.00 $245.70 $0.00 $59.16 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 80202963 EAP HCPCS C1894 Sheath Guid 45cm 8fr 2.9mm Flxr Chk-flo Anl1 Curve BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80203000 EAP HCPCS C1751 Kit Catheter 8.5fr 16cm 3 Lumen Expand Chloraprep Safety BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $412.50 $653.40 $660.00 $0.00 $536.25 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 80206800 EAP Kit Ndl Gd 21ga 96in Strt Us BOTH IP/OP $54.00 $39.96 $0.00 $43.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.08 $40.08 $41.62 $0.00 $11.25 $0.00 $0.00 $0.00 $0.00 $27.00 $42.77 $43.20 $0.00 $35.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80206851 EAP Custom 27220128 Dressing Gel 144x10in Effective Protection Knit Roll BOTH IP/OP $118.00 $87.32 $0.00 $94.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.58 $87.58 $90.95 $0.00 $24.59 $0.00 $0.00 $0.00 $0.00 $59.00 $93.46 $94.40 $0.00 $76.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80206898 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 120mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206901 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 120mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206904 EAP HCPCS C1725 Catheter Baldilat 7mm 135cm 120mm Hi-prs Nybax BOTH IP/OP $430.00 $318.20 $0.00 $350.40 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $331.44 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $219.00 $346.90 $350.40 $0.00 $279.50 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206906 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 120mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206908 EAP HCPCS C1725 Catheter Baldilat 3mm 135cm 150mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206910 EAP HCPCS C1725 Catheter Baldilat 4mm 135cm 150mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206916 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 150mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206930 EAP HCPCS C1725 Catheter Baldilat 3mm 135cm 200mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206935 EAP HCPCS C1725 Catheter Baldilat 7mm 135cm 200mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206937 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 200mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206941 EAP HCPCS C1726 Catheter Baldilat 3mm 75cm 20mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206949 EAP HCPCS C1725 Catheter Baldilat 9mm 135cm 20mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206952 EAP HCPCS C1725 CAT BALD LP 5.8FR 10MM 135CM 20MM HIGH PRE BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206954 EAP HCPCS C1725 CAT BALD LP 5.8FR 12MM 135CM 20MM HIGH PRES BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206956 EAP HCPCS C1725 Catheter Baldilat 12mm 75cm 20mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206984 EAP HCPCS C1725 Catheter Baldilat 3mm 135cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206986 EAP HCPCS C1725 Catheter Baldilat 3mm 75cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206988 EAP HCPCS C1725 Catheter Baldilat 9mm 135cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206990 EAP HCPCS C1725 Catheter Baldilat 10mm 135cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206992 EAP HCPCS C1725 Catheter Baldilat 12mm 135cm 40mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206997 EAP HCPCS C1753 CATHETER BALDILAT LP 5.3FR 4MM 135CM 60MM HIGH PRESSURE BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80206999 EAP HCPCS C1725 CATHETER BALDILAT LP 5.3FR 4MM 75CM 60MM HIGH PRESSURE BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207000 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 60mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207002 EAP HCPCS C1725 Catheter Baldilat 5mm 75cm 60mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207003 EAP HCPCS C1725 CAT BALD LP 5.3FR 6MM 135CM 60MM HIGH PRES BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207005 EAP HCPCS C1725 CAT BALD .035IN 6MM 75CM 60MM HIGH PRES LP BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207009 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 60mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207011 EAP HCPCS C1725 CAT BALD .035IN 8MM 75CM 60MM HIGH PRE LP BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207012 EAP HCPCS C1725 CAT BALD LP 5.8FR 9MM 135CM 60MM HIGH PRES BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207014 EAP HCPCS C1725 Catheter Baldilat 10mm 135cm 60mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207016 EAP HCPCS C1725 "MUSTANG 7FR 12.0MM X 60MM, 135CM" BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207018 EAP HCPCS C1725 CAT BALD LP 5.8FR 12MM 75CM 60MM HIGH PRES BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207019 EAP HCPCS C1725 Catheter Baldilat 3mm 135cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207021 EAP HCPCS C1725 Catheter Baldilat 3mm 75cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207022 EAP HCPCS C1725 Catheter Baldilat 4mm 135cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207024 EAP HCPCS C1725 Catheter Baldilat 4mm 75cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207025 EAP HCPCS C1725 Catheter Balloon Dilatation Mustang Nybax L135cm L80mm Od5.3fr BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207027 EAP HCPCS C1725 Catheter Baldilat 5mm 75cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207028 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207030 EAP HCPCS C1725 Catheter Baldilat 6mm 75cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207031 EAP HCPCS C1725 Catheter Baldilat 7mm 135cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207033 EAP HCPCS C1725 Catheter Baldilat 7mm 75cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207039 EAP HCPCS C1725 Catheter Baldilat 10mm 135cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207041 EAP HCPCS C1725 Catheter Baldilat 10mm 75cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207044 EAP HCPCS C1725 Catheter Baldilat 12mm 75cm 80mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207045 EAP HCPCS C1725 Catheter Baldilat 3mm 135cm 100mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207048 EAP HCPCS C1725 Catheter Baldilat 4mm 135cm 100mm Hi-prs Nybax BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207050 EAP HCPCS C1725 Catheter Blndil 4mm 75cm 100mm Mustang BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207054 EAP HCPCS C1725 CAT BALD LP 5.3FR 7MM 135CM 100MM HIGH PRES BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80207066 EAP HCPCS C1725 Catheter Baldilat 4mm 30mm 135cm Otw Tpr Tip Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207067 EAP Custom 80207067 STERLING OTW 4MM X 60MM X 135CM BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80207074 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 30mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207075 EAP HCPCS C1725 Catheter Baldilat 5mm 135cm 60mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207077 EAP HCPCS C1725 STERLING OTW 5MM X 100MM X 135CM BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207083 EAP HCPCS C1725 Catheter Baldilat 6mm 135cm 30mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207084 EAP HCPCS C1725 STERLING OTW 6MM X 100MM X 135CM BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207089 EAP HCPCS C1725 Catheter Baldilat 7mm 135cm 30mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207090 EAP HCPCS C1725 Catheter Baldilat 7mm 135cm 80mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207091 EAP HCPCS C1725 Catheter Baldilat 7mm 135cm 100mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207096 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 30mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207101 EAP HCPCS C1725 Catheter Baldilat 9mm 135cm 20mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207102 EAP HCPCS C1725 Catheter Baldilat 9mm 135cm 30mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207103 EAP HCPCS C1725 Catheter Baldilat 9mm 135cm 60mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207104 EAP HCPCS C1725 Catheter Baldilat 9mm 135cm 80mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207111 EAP HCPCS C1725 Catheter Baldilat 10mm 135cm 30mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207113 EAP HCPCS C1725 Catheter Baldilat 10mm 135cm 60mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207114 EAP HCPCS C1725 Catheter Baldilat 10mm 135cm 80mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207119 EAP HCPCS C1725 Catheter Baldilat 2.5mm 150cm 80mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207125 EAP HCPCS C1725 Catheter Baldilat 3.5mm 150cm 80mm Otw Infl Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207145 EAP HCPCS C1725 CAT BALD 14 ATM ULT LP 6FR 2.5MM 143CM 20MM BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207168 EAP HCPCS C1753 Catheter Baldilat 2mm 150cm 60mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207169 EAP HCPCS C1753 Catheter Baldilat 2.5mm 150cm 60mm Otw Ult Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207170 EAP HCPCS C1753 Catheter Baldilat 3mm 150cm 60mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207171 EAP HCPCS C1753 Catheter Baldilat 3.5mm 150cm 60mm Otw Ult Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207172 EAP HCPCS C1753 Catheter Baldilat 4mm 150cm 60mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207173 EAP HCPCS C1753 Catheter Baldilat 2mm 150cm 80mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207174 EAP HCPCS C1753 Catheter Baldilat 2.5mm 150cm 80mm Otw Ult Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207177 EAP HCPCS C1753 Catheter Baldilat 4mm 150cm 80mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207178 EAP HCPCS C1725 CAT BALD ULT LP TAP 6FR 2.5MM 150CM 100MM OTW BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207190 EAP HCPCS C1753 Catheter Baldilat 3.5mm 150cm 120mm Otw Ult Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207191 EAP HCPCS C1753 Catheter Baldilat 2.5mm 150cm 150mm Otw Ult Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207192 EAP HCPCS C1725 Catheter Baldilat 3.5mm 150cm 150mm Otw Ult Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207193 EAP HCPCS C1753 Catheter Baldilat 4mm 150cm 150mm Otw Ult Lp Nybax BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207199 EAP HCPCS C1725 COYOTE 3.5MM X 220MM X 150CM BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80207206 EAP HCPCS C1725 Catheter Baldilat 14mm 75cm 60mm Peri Lv Scrch Rst BOTH IP/OP $513.00 $379.62 $0.00 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.50 $406.30 $410.40 $0.00 $0.00 $0.00 $80.28 $0.00 $0.00 $81.67 $0.00 $0.00 $0.00 $0.00 $0.00 80207210 EAP HCPCS C1725 Catheter Baldilat 16mm 75cm 60mm Peri Lv Scrch Rst BOTH IP/OP $513.00 $379.62 $0.00 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.50 $406.30 $410.40 $0.00 $0.00 $0.00 $80.28 $0.00 $0.00 $81.67 $0.00 $0.00 $0.00 $0.00 $0.00 80207214 EAP HCPCS C1725 Catheter Baldilat 18mm 75cm 60mm Peri Lv Scrch Rst BOTH IP/OP $513.00 $379.62 $0.00 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.50 $406.30 $410.40 $0.00 $0.00 $0.00 $80.28 $0.00 $0.00 $81.67 $0.00 $0.00 $0.00 $0.00 $0.00 80207556 EAP HCPCS C1725 Catheter Baldilat 8mm 135cm 20mm Otw Inflat Port BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 80207580 EAP HCPCS C1876 Stent Bil 7mm 27mm 135cm 30mm Otw Radiopq Bln Xpd BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80207581 EAP HCPCS C1876 Stent Bil 8mm 27mm 135cm 30mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80207585 EAP HCPCS C1876 Stent Bil 7mm 57mm 135cm 60mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80207586 EAP HCPCS C1876 Stent Bil 8mm 57mm 135cm 60mm Otw Radiopq Nc Bln BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80207662 EAP HCPCS C1876 STENT ENDO 100CM 14MM 40MM 75CM UNCONSTRAIN FLEX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 80207663 EAP HCPCS C1876 Stent Endoprsth Trchbr 60mm 14mm 9fr Mtl Wlstnt BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 80207665 EAP HCPCS C1876 Stent Endoprsth Trchbr Vns 40mm 16mm Elgiloy BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 80207666 EAP HCPCS C1876 Stent Endoprsth Trchbr 60mm 16mm 9fr Mtl Wlstnt BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 80207668 EAP HCPCS C1876 Stent Endoprsth Trchbr 60mm 18mm 9fr Mtl Wlstnt BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 80207678 EAP HCPCS C1876 Stent Endoprsth Trchbr 90mm 14mm 9fr Mtl Wlstnt BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" "$1,734.30" $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 80207773 EAP HCPCS C1725 Catheter Angio 100cm 5fr Imgr2 Bern Curve Crbrl BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 80207912 EAP HCPCS C1726 Device Athrcm 165cm .018in Truepath .017in Peri BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$2,128.56" "$2,128.56" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" "$3,021.54" $0.00 $816.93 $0.00 "$2,318.68" "$2,318.68" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 "$2,548.00" $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 80207913 EAP HCPCS C1769 Wire Cath Extn Truepath Chrnc Tot Ocl Dev BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $114.03 $114.03 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $161.87 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 80207925 EAP HCPCS C1769 GUI VAS ST STR .035IN 260CM FLEXIBLE TIP BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $54.30 $54.30 $0.00 $0.00 $0.00 $20.84 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $0.00 $65.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 80207926 EAP HCPCS C1769 Guidewire Vasc 260cm .038in Flpy Tip Fltwr Coil BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $54.30 $54.30 $0.00 $0.00 $0.00 $20.84 $74.22 $74.22 $77.08 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 80207935 EAP HCPCS C1769 Guidewire Vasc 260cm .035in Flpy Tip Fltwr Coil 3 BOTH IP/OP $104.00 $76.96 $0.00 $83.20 $56.47 $56.47 $0.00 $0.00 $0.00 $21.68 $77.19 $77.19 $80.16 $0.00 $21.67 $0.00 $61.52 $61.52 $0.00 $52.00 $82.37 $83.20 $0.00 $67.60 $0.00 $16.28 $0.00 $0.00 $16.56 $0.00 $0.00 $0.00 $0.00 $0.00 80207943 EAP HCPCS C1769 Guidewire Vasc 260cm .018in Flpy Tip Radiopq Lng BOTH IP/OP $203.00 $150.22 $0.00 $162.40 $110.23 $110.23 $0.00 $0.00 $0.00 $42.31 $150.67 $150.67 $156.47 $0.00 $42.31 $0.00 $120.07 $120.07 $0.00 $101.50 $160.78 $162.40 $0.00 $131.95 $0.00 $31.77 $0.00 $0.00 $32.32 $0.00 $0.00 $0.00 $0.00 $0.00 80207946 EAP HCPCS C1769 Guidewire Vasc 260cm .025in Flpy Tip Radiopq Shrt BOTH IP/OP $202.00 $149.48 $0.00 $161.60 $109.69 $109.69 $0.00 $0.00 $0.00 $42.10 $149.92 $149.92 $155.70 $0.00 $42.10 $0.00 $119.48 $119.48 $0.00 $101.00 $159.98 $161.60 $0.00 $131.30 $0.00 $31.61 $0.00 $0.00 $32.16 $0.00 $0.00 $0.00 $0.00 $0.00 80207949 EAP HCPCS C1769 GUIDEWIRE VASCULAR STR SHORT TAPER .014IN 300CM 8CM ROBUST BOTH IP/OP $319.00 $236.06 $0.00 $255.20 $173.22 $173.22 $0.00 $0.00 $0.00 $66.49 $236.76 $236.76 $245.89 $0.00 $66.48 $0.00 $188.69 $188.69 $0.00 $159.50 $252.65 $255.20 $0.00 $0.00 $0.00 $49.92 $0.00 $0.00 $50.78 $0.00 $0.00 $0.00 $0.00 $0.00 80208087 EAP HCPCS C1887 Mcth Infus 150cm 3-2.8fr .027in Rngd Hfl Hydphi BOTH IP/OP $721.00 $533.54 $0.00 $576.80 $391.50 $391.50 $0.00 $0.00 $0.00 $150.27 $535.13 $535.13 $555.75 $0.00 $150.26 $0.00 $426.47 $426.47 $0.00 $360.50 $571.03 $576.80 $0.00 $0.00 $0.00 $112.84 $0.00 $0.00 $114.78 $0.00 $0.00 $0.00 $0.00 $0.00 80208096 EAP HCPCS C1887 Mcth Infus 130cm 3-2.4fr Rngd Stc 18 90d Peri Hdr BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $572.87 $572.87 $0.00 $0.00 $0.00 $219.89 $783.02 $783.02 $813.19 $0.00 $219.86 $0.00 $624.03 $624.03 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 80208101 EAP HCPCS C1769 Guidewire Vasc 180cm .016in Strbl Microfabricate BOTH IP/OP $744.00 $550.56 $0.00 $595.20 $403.99 $403.99 $0.00 $0.00 $0.00 $155.07 $552.20 $552.20 $573.48 $0.00 $155.05 $0.00 $440.08 $440.08 $0.00 $372.00 $589.25 $595.20 $0.00 $0.00 $0.00 $116.44 $0.00 $0.00 $118.44 $0.00 $0.00 $0.00 $0.00 $0.00 80215246 EAP HCPCS C1725 Catheter Angio 100cm 5fr Optitorque Radl Tig 4 BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $47.78 $47.78 $0.00 $0.00 $0.00 $18.34 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $52.05 $52.05 $0.00 $44.00 $69.70 $70.40 $0.00 $57.20 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 80284625 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Ebu3.75 Curve Coron BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80298657 EAP HCPCS C1894 Set Introd 25 5/8in 6fr 8fr S Arwflx Perc 3w Stpck BOTH IP/OP $257.00 $190.18 $0.00 $205.60 $139.55 $139.55 $0.00 $0.00 $0.00 $53.57 $190.75 $190.75 $198.10 $0.00 $53.56 $0.00 $152.02 $152.02 $0.00 $128.50 $203.54 $205.60 $0.00 $0.00 $0.00 $40.22 $0.00 $0.00 $40.91 $0.00 $0.00 $0.00 $0.00 $0.00 80307573 EAP HCPCS C1729 Tray Surg 14fr 18ga 29cm 5cm 19 Sideport Catheter Echogenic BOTH IP/OP $450.00 $333.00 $0.00 $490.95 $244.35 $244.35 $0.00 $0.00 $0.00 $172.99 $333.99 $333.99 $346.86 $0.00 $172.97 $0.00 $490.95 $490.95 $0.00 $208.50 $330.26 $333.60 $0.00 $292.50 $0.00 $65.26 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 80307582 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip Radiopq BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 80307684 EAP HCPCS C1766 Introd Shth 8.5fr Strbl Cath Agilis Nxt 22.4mm BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" "$1,541.60" $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 80307685 EAP HCPCS C1766 Introd Shth 8.5fr 71cm 50mm Gwire Strbl Radiopq BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" "$1,541.60" $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 80307691 EAP HCPCS C1730 Catheter Ep 115cm 5fr Lvwr Crnnd-2 5mm Spc 1mm BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 80307719 EAP HCPCS C1894 Sheath Guid 55cm 6fr 2.2mm Flxr Chk-flo Str BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 80307720 EAP HCPCS C1894 Sheath Guid 55cm 6fr 2.2mm Flxr Hi-flx Chk-flo BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 80307775 EAP Custom 80307775 Coil Embolization 360d 5mm 10cm Detachable Soft Target BOTH IP/OP "$4,755.00 " "$3,518.70" $0.00 "$3,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,529.16" "$3,529.16" "$3,665.15" $0.00 $990.94 $0.00 $0.00 $0.00 $0.00 "$2,377.50" "$3,765.96" "$3,804.00" $0.00 "$2,139.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80307945 EAP HCPCS C1725 Catheter Baldilat 2.5mm 20mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307951 EAP HCPCS C1725 Catheter Baldilat 3.5mm 20mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307953 EAP HCPCS C1725 Catheter Baldilat 4mm 8mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307954 EAP HCPCS C1725 Catheter Baldilat 4mm 12mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307956 EAP HCPCS C1725 Catheter Baldilat 2mm 8mm Coron Rapex Radiopq Smth BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307957 EAP HCPCS C1725 Catheter Baldilat 2.25mm 8mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307959 EAP HCPCS C1725 Catheter Baldilat 2.25mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307960 EAP HCPCS C1725 Catheter Baldilat 2.25mm 20mm Coron Rapex Radiopq BOTH IP/OP $175.00 $129.50 $0.00 $200.00 $95.03 $95.03 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $134.89 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $125.00 $198.00 $200.00 $0.00 $113.75 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307961 EAP HCPCS C1725 Catheter Baldilat 2.75mm 8mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307962 EAP HCPCS C1725 Catheter Baldilat 3.25mm 8mm Coron Rapex Radiopq BOTH IP/OP $213.00 $157.62 $0.00 $200.00 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $125.00 $198.00 $200.00 $0.00 $138.45 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307963 EAP HCPCS C1725 Catheter Baldilat 3.25mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307964 EAP HCPCS C1725 Catheter Baldilat 3.75mm 8mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307965 EAP HCPCS C1725 Catheter Baldilat 4.5mm 8mm Coron Rapex Radiopq BOTH IP/OP $213.00 $157.62 $0.00 $200.00 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $125.00 $198.00 $200.00 $0.00 $138.45 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307966 EAP HCPCS C1725 Catheter Baldilat 4.5mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80307967 EAP HCPCS C1725 Catheter Baldilat 5mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80308041 EAP HCPCS C1724 Catheter Athrcm 135cm 7fr 2.1mm Navitus Jetstream BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308043 EAP HCPCS C1724 Catheter Athrcm Jetstream Navitus Rot BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308065 EAP HCPCS C1724 Catheter Athrcm 120cm 7fr 2.4/3.4mm Jetstream BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308067 EAP HCPCS C1894 Introducer Sheath 6fr 25cm 2.5cm Dilat Kink Resistant BOTH IP/OP $43.00 $31.82 $0.00 $33.60 $23.35 $23.35 $0.00 $0.00 $0.00 $8.96 $31.91 $31.91 $33.14 $0.00 $8.96 $0.00 $25.43 $25.43 $0.00 $21.00 $33.26 $33.60 $0.00 $27.95 $0.00 $6.57 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $0.00 80308097 EAP HCPCS C1725 Kit Cath Ins 8fr Sns Plus Stlk Fo Bln Iab Dev 50cc BOTH IP/OP "$2,614.00 " "$1,934.36" $0.00 "$2,091.20" "$1,419.40" "$1,419.40" $0.00 $0.00 $0.00 $544.82 "$1,940.11" "$1,940.11" "$2,014.87" $0.00 $544.76 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,307.00" "$2,070.29" "$2,091.20" $0.00 $0.00 $0.00 $409.09 $0.00 $0.00 $416.15 $0.00 $0.00 $0.00 $0.00 $0.00 80308098 EAP HCPCS C1725 Catheter Iab 6in 7.5fr 16mm Sns Plus .025in 2 Stlk BOTH IP/OP "$2,725.00 " "$2,016.50" $0.00 "$2,180.00" "$1,479.68" "$1,479.68" $0.00 $0.00 $0.00 $567.96 "$2,022.50" "$2,022.50" "$2,100.43" $0.00 $567.89 $0.00 "$1,611.84" "$1,611.84" $0.00 "$1,362.50" "$2,158.20" "$2,180.00" $0.00 $0.00 $0.00 $426.46 $0.00 $0.00 $433.82 $0.00 $0.00 $0.00 $0.00 $0.00 80308211 EAP HCPCS C1894 Kit Introd 10cm 6fr 21ga Glidesheath Slndr .021in BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $74.93 $74.93 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $69.00 $109.30 $110.40 $0.00 $89.70 $0.00 $21.60 $0.00 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 80308259 EAP HCPCS C1817 Occluder Cardio 4mm 22mm 32-36mm Spt 2 Disc Slf BOTH IP/OP "$15,163.00 " "$11,220.62" $0.00 "$12,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,687.64" $0.00 "$3,159.97" $0.00 $0.00 $0.00 $0.00 "$7,581.50" "$12,009.10" "$12,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308260 EAP HCPCS C1817 Occluder Cardio 4mm 24mm 34-38mm Spt 2 Disc Slf BOTH IP/OP "$15,163.00 " "$11,220.62" $0.00 "$12,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$11,687.64" $0.00 "$3,159.97" $0.00 $0.00 $0.00 $0.00 "$7,581.50" "$12,009.10" "$12,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308262 EAP Custom 80308262 Catheter Dlv Sys 45d 10fr 80cm Lfric Radiopq Tip BOTH IP/OP "$1,630.00 " "$1,206.20" $0.00 "$1,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,209.79" "$1,209.79" "$1,256.40" $0.00 $339.69 $0.00 $0.00 $0.00 $0.00 $815.00 "$1,290.96" "$1,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308264 EAP Custom 80308264 Balloon Sz 70cm 40mm Amplzr 3 Lum Radiopq Sft BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $512.12 $512.12 $531.85 $0.00 $143.80 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308265 EAP HCPCS C1759 Catheter Us Cnsl Viewflexxice Viewmate BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,395.60" $0.00 "$1,458.80" $0.00 $0.00 $0.00 $0.00 "$3,500.00" "$5,544.00" "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308295 EAP HCPCS C1753 Catheter Us 20mhz Shrt Tpr 5fr 2.9fr 150cm 24cm BOTH IP/OP "$1,813.00 " "$1,341.62" $0.00 "$1,450.40" $984.46 $984.46 $0.00 $0.00 $0.00 $377.87 "$1,345.61" "$1,345.61" "$1,397.46" $0.00 $377.83 $0.00 "$1,072.39" "$1,072.39" $0.00 $906.50 "$1,435.90" "$1,450.40" $0.00 $0.00 $0.00 $283.73 $0.00 $0.00 $288.63 $0.00 $0.00 $0.00 $0.00 $0.00 80308611 EAP HCPCS C1760 Device Clsr 5fr Vascade Fem Art BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $236.25 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 80308612 EAP HCPCS C1760 System Cmpr 6/7fr Vascade Vasc Clgn Babsr BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $404.67 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 80308880 EAP HCPCS C1887 Catheter Sprt 150cm 1.5fr .026-.039in Qkcrs 15mm BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $331.44 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 80308883 EAP Custom 80308883 QUICK CROSS 4F .018IN X 150CM BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.15 $319.15 $331.44 $0.00 $89.61 $0.00 $0.00 $0.00 $0.00 $215.00 $340.56 $344.00 $0.00 $279.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308885 EAP HCPCS C1887 CATHETER GUID .035IN 4.8-3.7FR 90CM LOW CROSSING P BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $226.97 $226.97 $0.00 $0.00 $0.00 $87.12 $310.24 $310.24 $322.19 $0.00 $87.11 $0.00 $247.25 $247.25 $0.00 $209.00 $331.06 $334.40 $0.00 $271.70 $0.00 $65.42 $0.00 $0.00 $66.55 $0.00 $0.00 $0.00 $0.00 $0.00 80308887 EAP HCPCS C1887 Catheter Sprt 150cm 3.1fr .05-.063in Qkcrs 50mm BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $226.97 $226.97 $0.00 $0.00 $0.00 $87.12 $310.24 $310.24 $322.19 $0.00 $87.11 $0.00 $247.25 $247.25 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $65.42 $0.00 $0.00 $66.55 $0.00 $0.00 $0.00 $0.00 $0.00 80308888 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Core To Tip Radiopq BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 80308889 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip Radiopq BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 80308892 EAP HCPCS C1729 Kit Pressure Monitr 38cm Transducer Catheter Tunneling BOTH IP/OP "$2,146.00 " "$1,588.04" $0.00 "$1,654.14" "$1,165.28" "$1,165.28" $0.00 $0.00 $0.00 $447.28 "$1,592.76" "$1,592.76" "$1,654.14" $0.00 $447.23 $0.00 "$1,269.36" "$1,269.36" $0.00 "$1,014.00" "$1,606.18" "$1,622.40" $0.00 "$1,394.90" $0.00 $317.38 $0.00 $0.00 $322.86 $0.00 $0.00 $0.00 $0.00 $0.00 80308949 EAP HCPCS C1724 System Athrcm 135cm 1.25mm Rtbl Rtl+ Dmd Precnct BOTH IP/OP "$3,092.00 " "$2,288.08" $0.00 "$2,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,294.88" "$2,294.88" "$2,383.31" $0.00 $644.37 $0.00 $0.00 $0.00 $0.00 "$1,546.00" "$2,448.86" "$2,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308950 EAP HCPCS C1724 System Athrcm 135cm 1.5mm Rtbl Rtl+ Dmd Precnct BOTH IP/OP "$2,988.00 " "$2,211.12" $0.00 "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,217.69" "$2,217.69" "$2,303.15" $0.00 $622.70 $0.00 $0.00 $0.00 $0.00 "$1,494.00" "$2,366.50" "$2,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308951 EAP HCPCS C1724 System Athrcm 135cm 1.75mm Rtbl Rtl+ Dmd Precnct BOTH IP/OP "$3,092.00 " "$2,288.08" $0.00 "$2,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,294.88" "$2,294.88" "$2,383.31" $0.00 $644.37 $0.00 $0.00 $0.00 $0.00 "$1,546.00" "$2,448.86" "$2,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80308954 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Atrm X Flpy Tip BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $106.50 $168.70 $170.40 $0.00 $0.00 $0.00 $33.33 $0.00 $0.00 $33.91 $0.00 $0.00 $0.00 $0.00 $0.00 80308956 EAP HCPCS C1887 Catheter Guid 150cm 1.8-2.6fr Finecross Mg Coron BOTH IP/OP "$1,063.00 " $786.62 $0.00 $850.40 $577.21 $577.21 $0.00 $0.00 $0.00 $221.56 $788.96 $788.96 $819.36 $0.00 $221.53 $0.00 $628.76 $628.76 $0.00 $531.50 $841.90 $850.40 $0.00 $690.95 $0.00 $166.36 $0.00 $0.00 $169.23 $0.00 $0.00 $0.00 $0.00 $0.00 80308957 EAP HCPCS C1769 Guidewire Vasc 330cm .014in Sprg Tip X Sprt Stf BOTH IP/OP "$2,070.00 " "$1,531.80" $0.00 "$1,656.00" "$1,124.01" "$1,124.01" $0.00 $0.00 $0.00 $431.44 "$1,536.35" "$1,536.35" "$1,595.56" $0.00 $431.39 $0.00 "$1,224.41" "$1,224.41" $0.00 "$1,035.00" "$1,639.44" "$1,656.00" $0.00 $0.00 $0.00 $323.96 $0.00 $0.00 $329.54 $0.00 $0.00 $0.00 $0.00 $0.00 80308958 EAP HCPCS C1769 Guidewire Vasc 330cm .014in Flpy Flxb Sprg Tip 2.2 BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $224.80 $224.80 $0.00 $0.00 $0.00 $86.29 $307.27 $307.27 $319.11 $0.00 $86.28 $0.00 $244.88 $244.88 $0.00 $207.00 $327.89 $331.20 $0.00 $0.00 $0.00 $64.79 $0.00 $0.00 $65.91 $0.00 $0.00 $0.00 $0.00 $0.00 80308964 EAP HCPCS C1769 Guidewire Vasc 180cm .035in Flxb Core To Tip BOTH IP/OP $496.00 $367.04 $0.00 $396.80 $269.33 $269.33 $0.00 $0.00 $0.00 $103.38 $368.13 $368.13 $382.32 $0.00 $103.37 $0.00 $293.38 $293.38 $0.00 $248.00 $392.83 $396.80 $0.00 $0.00 $0.00 $77.62 $0.00 $0.00 $78.96 $0.00 $0.00 $0.00 $0.00 $0.00 80308966 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Kink Rst Radiopq Strbl BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80308967 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip Radiopq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80308968 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip Radiopq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80308971 EAP HCPCS C1730 Catheter Ep 65cm 6fr Rspn 5-5-5mm Spc Csl Curve Mp BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $475.13 $475.13 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $674.45 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 80308973 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Core To Tip Radiopq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80309134 EAP HCPCS C1725 Catheter Baldilat 1.5mm 145cm 6mm Otw 2 Lum Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309137 EAP HCPCS C1725 Catheter Baldilat 2mm 145cm 20mm Otw 2 Lum Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309140 EAP HCPCS C1725 Catheter Baldilat 1.2mm 12mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309141 EAP HCPCS C1725 Catheter Baldilat 1.2mm 15mm Coron Rapex Ult Lp BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 80309142 EAP HCPCS C1725 Catheter Baldilat 1.2mm 20mm Coron Rapex Ult Lp BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 80309152 EAP HCPCS C1725 Catheter Baldilat 2.25mm 12mm Coron Rapex Ult Lp BOTH IP/OP $175.00 $129.50 $0.00 $200.00 $95.03 $95.03 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $134.89 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $125.00 $198.00 $200.00 $0.00 $113.75 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309153 EAP HCPCS C1725 Catheter Baldilat 2.25mm 15mm Coron Rapex Ult Lp BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 80309166 EAP HCPCS C1725 Catheter Baldilat 3mm 6mm Coron Rapex Ult Lp BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $169.96 $169.96 $0.00 $0.00 $0.00 $65.24 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $185.14 $185.14 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $0.00 $48.98 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 80309172 EAP HCPCS C1725 Catheter Baldilat 3.25mm 20mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309175 EAP HCPCS C1725 Catheter Baldilat 3.5mm 6mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309176 EAP HCPCS C1725 Catheter Baldilat 3.5mm 30mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309185 EAP HCPCS C1725 Catheter Baldilat 4mm 20mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309186 EAP HCPCS C1725 Catheter Baldilat 4mm 25mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309187 EAP HCPCS C1725 Catheter Baldilat 4mm 30mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309188 EAP HCPCS C1725 Catheter Baldilat 1.5mm 6mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309192 EAP HCPCS C1725 Catheter Baldilat 1.5mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309193 EAP HCPCS C1725 Catheter Baldilat 2mm 15mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309197 EAP HCPCS C1725 Catheter Baldilat 4.5mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309198 EAP HCPCS C1725 Catheter Baldilat 5mm 20mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309200 EAP HCPCS C1876 System Coron Stent 12mm 2.75mm Mtlnk Vsn Cocr BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80309201 EAP HCPCS C1876 System Coron Stent 15mm 2.75mm Mtlnk Vsn Cocr BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80309203 EAP HCPCS C1876 System Coron Stent 23mm 2.75mm Mtlnk Vsn Cocr BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80309206 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Core To Tip Radiopq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80309208 EAP Custom 80309208 Catheter Pcng Eltrd Bipol Distal Tip Bln Flw Ast BOTH IP/OP "$1,950.00 " "$1,443.00" $0.00 "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,447.29" "$1,447.29" "$1,503.06" $0.00 $406.38 $0.00 $0.00 $0.00 $0.00 $975.00 "$1,544.40" "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309257 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Std Jr5 Curve Coron BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $0.00 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 80309258 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Lcb Curve Coron Nyl BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $0.00 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 80309261 EAP HCPCS C1887 Catheter Guid 100cm 7fr Lnchr Al1 Curve Coron Peri BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80309262 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Radl Curve Peri Nyl BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80309263 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Lara Curve Coron Nyl BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $0.00 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 80309264 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr 30d Mac3 Curve Coron BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $0.00 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 80309265 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Std Ima Curve Coron BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $61.36 $61.36 $0.00 $0.00 $0.00 $23.55 $83.87 $83.87 $87.10 $0.00 $23.55 $0.00 $66.84 $66.84 $0.00 $56.50 $89.50 $90.40 $0.00 $0.00 $0.00 $17.68 $0.00 $0.00 $17.99 $0.00 $0.00 $0.00 $0.00 $0.00 80309266 EAP HCPCS C1725 Catheter Angio 125cm 5fr Stsr Jr4 Curve Peri Pebax BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 80309276 EAP HCPCS C1769 "GUIDEWIRE HI-TORQUE COMM ES .014"" 300CM" BOTH IP/OP $988.00 $731.12 $0.00 $790.40 $536.48 $536.48 $0.00 $0.00 $0.00 $205.92 $733.29 $733.29 $761.55 $0.00 $205.90 $0.00 $584.40 $584.40 $0.00 $494.00 $782.50 $790.40 $0.00 $642.20 $0.00 $154.62 $0.00 $0.00 $157.29 $0.00 $0.00 $0.00 $0.00 $0.00 80309278 EAP HCPCS C1725 Catheter Baldilat 6mm 150cm 200mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80309279 EAP HCPCS C1725 Catheter Angio 110cm 6fr Langston 145d Pgtl Curve BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $8.92 $0.00 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $0.00 80309287 EAP HCPCS C1725 Catheter Baldilat 3mm 8mm Coron Rapex Radiopq Smth BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309335 EAP HCPCS C1725 Catheter Baldilat 4.5mm 15mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309338 EAP HCPCS C1725 Catheter Baldilat 4.5mm 12mm Coron Rapex Radiopq BOTH IP/OP $213.00 $157.62 $0.00 $200.00 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $125.00 $198.00 $200.00 $0.00 $138.45 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309343 EAP HCPCS C1880 Filter Embl 49mm 65cm Vc Radiopq Preld Flsh Sdprt BOTH IP/OP "$2,313.00 " "$1,711.62" $0.00 "$1,850.40" "$1,040.85" "$1,040.85" $0.00 $0.00 $0.00 $482.09 "$1,716.71" "$1,716.71" "$1,782.86" $0.00 $482.03 $0.00 "$1,368.14" "$1,368.14" $0.00 "$1,156.50" "$1,831.90" "$1,850.40" $0.00 $0.00 $0.00 $361.98 $0.00 $0.00 $368.23 $0.00 $0.00 $0.00 $0.00 $0.00 80309345 EAP HCPCS C1880 Filter Embl Navalign Dlv Uniset Strl Disp Pltn BOTH IP/OP "$2,313.00 " "$1,711.62" $0.00 "$1,850.40" "$1,040.85" "$1,040.85" $0.00 $0.00 $0.00 $482.09 "$1,716.71" "$1,716.71" "$1,782.86" $0.00 $482.03 $0.00 "$1,368.14" "$1,368.14" $0.00 "$1,156.50" "$1,831.90" "$1,850.40" $0.00 $0.00 $0.00 $361.98 $0.00 $0.00 $368.23 $0.00 $0.00 $0.00 $0.00 $0.00 80309346 EAP HCPCS C1725 Catheter Baldilat 2mm 12mm Coron Rapex Radiopq BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80309407 EAP HCPCS C1876 System Coron Stent 8mm 2mm Mtlnk Mvsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80309409 EAP HCPCS C1876 System Coron Stent 15mm 2mm Mtlnk Mvsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80309410 EAP HCPCS C1876 System Coron Stent 18mm 2mm Mtlnk Mvsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80309411 EAP HCPCS C1876 System Coron Stent 23mm 2mm Mtlnk Mvsn Cocr Rapex BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80309438 EAP HCPCS C1900 Lead Pcng Lv Atn Starfix BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" "$3,179.55" $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 "$1,856.25" $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309448 EAP HCPCS C1725 Catheter Pa 110cm 5fr 8mm Arw 1 Lum Bln Wdg Prss BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 80309457 EAP Custom 80309457 System Drg Dlv Ekosonic Mach 4 Microsonic Tx Zn BOTH IP/OP "$6,738.00 " "$4,986.12" $0.00 "$5,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,193.65" $0.00 "$1,404.20" $0.00 $0.00 $0.00 $0.00 "$3,369.00" "$5,336.50" "$5,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309459 EAP Custom 80309459 Device Thrmb 135cm 5.4fr Ekosonic Mach 4 Evas BOTH IP/OP "$6,738.00 " "$4,986.12" $0.00 "$5,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,193.65" $0.00 "$1,404.20" $0.00 $0.00 $0.00 $0.00 "$3,369.00" "$5,336.50" "$5,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309461 EAP Custom 80309461 Device Drg Dlv Ekosonic Mach 4 Infus Cath Us Core BOTH IP/OP "$6,738.00 " "$4,986.12" $0.00 "$5,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,193.65" $0.00 "$1,404.20" $0.00 $0.00 $0.00 $0.00 "$3,369.00" "$5,336.50" "$5,390.40" $0.00 "$4,379.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309462 EAP Custom 80309462 Device Drg Dlv Ekosonic Mach 4 Infus Cath Us Core BOTH IP/OP "$6,738.00 " "$4,986.12" $0.00 "$5,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,193.65" $0.00 "$1,404.20" $0.00 $0.00 $0.00 $0.00 "$3,369.00" "$5,336.50" "$5,390.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309492 EAP HCPCS A6212 Dressing 6x3.5in Anmc Wtprf Flxb N Linr Strp Ionic BOTH IP/OP $45.00 $33.30 $0.00 $51.20 $24.44 $24.44 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $34.69 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $32.00 $50.69 $51.20 $0.00 $29.25 $0.00 $10.02 $0.00 $0.00 $10.19 $0.00 $0.00 $0.00 $0.00 $0.00 80309550 EAP Custom 80309550 Set Vntrc Ast 17.4x13.8in Impella Cp 9.3in 10-40c BOTH IP/OP "$62,500.00 " "$46,250.00" $0.00 "$50,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$48,175.00" $0.00 "$13,025.00" $0.00 $0.00 $0.00 $0.00 "$31,250.00" "$49,500.00" "$50,000.00" $0.00 "$40,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309582 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Sft Rbn Tip Kink Rst BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80309672 EAP HCPCS C1757 Catheter Thrmb 10mm Flowtriever Strl Latex Free BOTH IP/OP "$11,625.00 " "$8,602.50" $0.00 "$9,300.00" "$6,312.38" "$6,312.38" $0.00 $0.00 $0.00 "$2,422.94" "$4,181.12" "$4,181.12" "$8,960.55" $0.00 "$2,422.65" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,812.50" "$9,207.00" "$9,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309673 EAP HCPCS C1757 Catheter Thrmb 14mm Flowtriever Strl Latex Free BOTH IP/OP "$11,625.00 " "$8,602.50" $0.00 "$9,300.00" "$6,312.38" "$6,312.38" $0.00 $0.00 $0.00 "$2,422.94" "$4,181.12" "$4,181.12" "$8,960.55" $0.00 "$2,422.65" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,812.50" "$9,207.00" "$9,300.00" $0.00 "$7,556.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309674 EAP HCPCS C1757 Catheter Thrmb 18mm Flowtriever Strl Latex Free BOTH IP/OP "$11,625.00 " "$8,602.50" $0.00 "$9,300.00" "$6,312.38" "$6,312.38" $0.00 $0.00 $0.00 "$2,422.94" "$4,181.12" "$4,181.12" "$8,960.55" $0.00 "$2,422.65" $0.00 "$3,094.73" "$3,094.73" $0.00 "$5,812.50" "$9,207.00" "$9,300.00" $0.00 "$7,556.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309675 EAP HCPCS C1757 Catheter Guid 6.7mm Flowtriever 1 Ins Aspirate BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$5,500.00" "$3,733.13" "$3,733.13" $0.00 $0.00 $0.00 "$1,432.92" "$4,181.12" "$4,181.12" "$5,299.25" $0.00 "$1,432.75" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,437.50" "$5,445.00" "$5,500.00" $0.00 "$4,468.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309676 EAP Custom 80309676 FT RETRACTION ASPIRATOR DEVICE SE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80309726 EAP HCPCS C1887 Catheter Vasc 135cm 2.6-2.9fr 1.6fr Turnpike Ml Lr BOTH IP/OP "$1,313.00 " $971.62 $0.00 "$1,050.40" $712.96 $712.96 $0.00 $0.00 $0.00 $273.66 $974.51 $974.51 "$1,012.06" $0.00 $273.63 $0.00 $776.64 $776.64 $0.00 $656.50 "$1,039.90" "$1,050.40" $0.00 $853.45 $0.00 $205.48 $0.00 $0.00 $209.03 $0.00 $0.00 $0.00 $0.00 $0.00 80309727 EAP HCPCS C1887 Catheter Vasc 150cm 2.6-3.1fr 1.6fr Turnpike Ml Lr BOTH IP/OP "$1,488.00 " "$1,101.12" $0.00 "$1,190.40" $807.98 $807.98 $0.00 $0.00 $0.00 $310.14 "$1,104.39" "$1,104.39" "$1,146.95" $0.00 $310.10 $0.00 $880.15 $880.15 $0.00 $744.00 "$1,178.50" "$1,190.40" $0.00 $0.00 $0.00 $232.87 $0.00 $0.00 $236.89 $0.00 $0.00 $0.00 $0.00 $0.00 80309751 EAP HCPCS C1874 System Coron Stent 12mm 4mm Promus Prmr Mnrl BOTH IP/OP "$4,250.00 " "$3,145.00" $0.00 "$3,400.00" "$1,912.50" "$1,912.50" $0.00 $0.00 $0.00 $885.81 "$3,154.35" "$3,154.35" "$3,275.90" $0.00 $885.70 $0.00 "$2,095.25" "$2,095.25" $0.00 "$2,125.00" "$3,366.00" "$3,400.00" $0.00 $0.00 $0.00 $665.13 $0.00 $0.00 $676.60 $0.00 $0.00 $0.00 $0.00 $0.00 80309753 EAP HCPCS C1874 System Coron Stent 20mm 4mm Promus Prmr Mnrl BOTH IP/OP "$4,250.00 " "$3,145.00" $0.00 "$3,400.00" "$1,912.50" "$1,912.50" $0.00 $0.00 $0.00 $885.81 "$3,154.35" "$3,154.35" "$3,275.90" $0.00 $885.70 $0.00 "$2,095.25" "$2,095.25" $0.00 "$2,125.00" "$3,366.00" "$3,400.00" $0.00 $0.00 $0.00 $665.13 $0.00 $0.00 $676.60 $0.00 $0.00 $0.00 $0.00 $0.00 80309754 EAP HCPCS C1874 System Coron Stent 24mm 4mm Promus Prmr Mnrl BOTH IP/OP "$4,250.00 " "$3,145.00" $0.00 "$3,400.00" "$1,912.50" "$1,912.50" $0.00 $0.00 $0.00 $885.81 "$3,154.35" "$3,154.35" "$3,275.90" $0.00 $885.70 $0.00 "$2,095.25" "$2,095.25" $0.00 "$2,125.00" "$3,366.00" "$3,400.00" $0.00 $0.00 $0.00 $665.13 $0.00 $0.00 $676.60 $0.00 $0.00 $0.00 $0.00 $0.00 80310083 EAP HCPCS C1884 System Embl Prtc 190cm .014in 110um Crtd Gwire BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$2,029.73" "$2,029.73" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$2,211.03" "$2,211.03" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 80310085 EAP HCPCS C1894 Introd Shth Ped 5fr 21ga 40cm 7cm Gry Hub Dilat BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $55.93 $55.93 $0.00 $0.00 $0.00 $21.47 $76.45 $76.45 $79.39 $0.00 $21.47 $0.00 $60.92 $60.92 $0.00 $51.50 $81.58 $82.40 $0.00 $0.00 $0.00 $16.12 $0.00 $0.00 $16.40 $0.00 $0.00 $0.00 $0.00 $0.00 80310086 EAP HCPCS C1894 Introd Shth Ped 6fr 21ga 40cm 7cm Grn Hub Dilat BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $55.39 $55.39 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $78.62 $0.00 $21.26 $0.00 $60.33 $60.33 $0.00 $51.00 $80.78 $81.60 $0.00 $66.30 $0.00 $15.96 $0.00 $0.00 $16.24 $0.00 $0.00 $0.00 $0.00 $0.00 80310399 EAP HCPCS C1876 Stent Vasc Epic Nitinol L60mm L120cm Od9mm Iliac BOTH IP/OP "$1,463.00 " "$1,082.62" $0.00 "$1,170.40" $658.35 $658.35 $0.00 $0.00 $0.00 $304.93 "$1,085.84" "$1,085.84" "$1,127.68" $0.00 $304.89 $0.00 $865.36 $865.36 $0.00 $731.50 "$1,158.70" "$1,170.40" $0.00 $658.35 $0.00 $228.96 $0.00 $0.00 $232.91 $0.00 $0.00 $0.00 $0.00 $0.00 80310402 EAP HCPCS C1876 Stent Vasc 9mm 80mm 159cm 120cm Slf Xpd Ilc Art Ep BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80310534 EAP HCPCS C1769 Guidewire Vasc 260cm .035in Flxb Sprg Coil Tip Std BOTH IP/OP $251.00 $185.74 $0.00 $200.80 $136.29 $136.29 $0.00 $0.00 $0.00 $52.31 $186.29 $186.29 $193.47 $0.00 $52.31 $0.00 $148.47 $148.47 $0.00 $125.50 $198.79 $200.80 $0.00 $0.00 $0.00 $39.28 $0.00 $0.00 $39.96 $0.00 $0.00 $0.00 $0.00 $0.00 80310535 EAP HCPCS C1769 Guidewire Vasc 180cm .035in Flxb Sprg Coil Tip Std BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $70.59 $70.59 $0.00 $0.00 $0.00 $27.10 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $76.90 $76.90 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 80310536 EAP HCPCS C1769 Guidewire Vasc 260cm .035in Flxb Sprg Coil Tip Std BOTH IP/OP "$1,045.00 " $773.30 $0.00 $836.00 $567.44 $567.44 $0.00 $0.00 $0.00 $217.80 $775.60 $775.60 $805.49 $0.00 $217.78 $0.00 $618.12 $618.12 $0.00 $522.50 $827.64 $836.00 $0.00 $679.25 $0.00 $163.54 $0.00 $0.00 $166.36 $0.00 $0.00 $0.00 $0.00 $0.00 80310824 EAP HCPCS C1733 Catheter Ablt 115cm 8fr 4mm 1-4-1mm Spc F-j Curve BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$2,239.88" "$2,239.88" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" "$3,179.55" $0.00 $859.65 $0.00 "$2,439.94" "$2,439.94" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 "$2,681.25" $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 80315167 EAP HCPCS C1894 Sheath Introd 28cm 9.8mm 26fr Gore Dryseal Hydphi BOTH IP/OP $863.00 $638.62 $0.00 $690.40 $468.61 $468.61 $0.00 $0.00 $0.00 $179.87 $640.52 $640.52 $665.20 $0.00 $179.85 $0.00 $510.46 $510.46 $0.00 $431.50 $683.50 $690.40 $0.00 $560.95 $0.00 $135.06 $0.00 $0.00 $137.39 $0.00 $0.00 $0.00 $0.00 $0.00 80315263 EAP HCPCS C1725 CATR BALD 14 ATM LP TAER 7FR 5MM 150CM 150MM BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80315264 EAP HCPCS C1725 Catheter Baldilat 5mm 150cm 200mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80315265 EAP HCPCS C1725 Catheter Baldilat 6mm 150cm 150mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80315266 EAP HCPCS C1725 Catheter Baldilat 6mm 150cm 220mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80315267 EAP HCPCS C1725 Catheter Baldilat 7mm 150cm 120mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80315268 EAP HCPCS C1725 Catheter Baldilat 7mm 150cm 150mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80316943 EAP HCPCS C1757 Set Thrmb 145cm 3-4fr 1.5mm Angjt Ult Solent Dista BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,715.00" "$2,715.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" "$3,854.00" $0.00 "$1,042.00" $0.00 "$2,957.50" "$2,957.50" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80317120 EAP HCPCS C1760 Device Clsr 6fr Strcls Se Vasc Ntnl Clip Strl Disp BOTH IP/OP $788.00 $583.12 $0.00 $630.40 $354.60 $354.60 $0.00 $0.00 $0.00 $164.24 $584.85 $584.85 $607.39 $0.00 $164.22 $0.00 $466.10 $466.10 $0.00 $394.00 $624.10 $630.40 $0.00 $0.00 $0.00 $123.32 $0.00 $0.00 $125.45 $0.00 $0.00 $0.00 $0.00 $0.00 80318107 EAP HCPCS C1894 Introd Cath 90cm 6fr Chk-flo Flxr Raabe BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80318555 EAP HCPCS C1725 Catheter Guid 135cm 3.2fr Stingray Lp Hydphi Strl BOTH IP/OP "$4,738.00 " "$3,506.12" $0.00 "$3,790.40" "$2,572.73" "$2,572.73" $0.00 $0.00 $0.00 $987.52 "$3,516.54" "$3,516.54" "$3,652.05" $0.00 $987.40 $0.00 "$2,802.53" "$2,802.53" $0.00 "$2,369.00" "$3,752.50" "$3,790.40" $0.00 $0.00 $0.00 $741.50 $0.00 $0.00 $754.29 $0.00 $0.00 $0.00 $0.00 $0.00 80318556 EAP HCPCS C1769 Guidewire Vasc 185cm .014in 20cm Stingray Hydphi BOTH IP/OP "$1,228.00 " $908.72 $0.00 $982.40 $666.80 $666.80 $0.00 $0.00 $0.00 $255.95 $911.42 $911.42 $946.54 $0.00 $255.92 $0.00 $726.36 $726.36 $0.00 $614.00 $972.58 $982.40 $0.00 $0.00 $0.00 $192.18 $0.00 $0.00 $195.50 $0.00 $0.00 $0.00 $0.00 $0.00 80318557 EAP HCPCS C1769 Guidewire Vasc 300cm .014in 20cm Stingray Hydphi BOTH IP/OP "$1,228.00 " $908.72 $0.00 $982.40 $666.80 $666.80 $0.00 $0.00 $0.00 $255.95 $911.42 $911.42 $946.54 $0.00 $255.92 $0.00 $726.36 $726.36 $0.00 $614.00 $972.58 $982.40 $0.00 $0.00 $0.00 $192.18 $0.00 $0.00 $195.50 $0.00 $0.00 $0.00 $0.00 $0.00 80318677 EAP HCPCS C1764 System Crd Monitr Rvl Linq Mycarelink Ins Loop BOTH IP/OP "$11,613.00 " "$8,593.62" $0.00 "$9,290.40" "$5,225.85" "$5,225.85" $0.00 $0.00 $0.00 "$2,420.44" "$4,181.12" "$4,181.12" "$8,951.30" $0.00 "$2,420.15" $0.00 "$5,725.21" "$5,725.21" $0.00 "$5,806.50" "$9,197.50" "$9,290.40" $0.00 "$5,225.85" $0.00 "$1,817.43" $0.00 $0.00 "$1,848.79" $0.00 $0.00 $0.00 $0.00 $0.00 80320653 EAP HCPCS C1894 Kit Introd 10cm 7fr 21ga Glidesheath Slndr .021in BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $74.93 $74.93 $0.00 $0.00 $0.00 $28.76 $102.42 $102.42 $106.37 $0.00 $28.76 $0.00 $81.63 $81.63 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $21.60 $0.00 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 80320723 EAP HCPCS C1769 Guidewire Vasc 80cm .035in Flxb Core To Tip BOTH IP/OP $73.00 $54.02 $0.00 $58.40 $39.64 $39.64 $0.00 $0.00 $0.00 $15.22 $54.18 $54.18 $56.27 $0.00 $15.21 $0.00 $43.18 $43.18 $0.00 $36.50 $57.82 $58.40 $0.00 $0.00 $0.00 $11.42 $0.00 $0.00 $11.62 $0.00 $0.00 $0.00 $0.00 $0.00 80320735 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 2.0X10 MM 5F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320736 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 2.0X15 MM 5F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320737 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 2.0X20 MM 5F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320738 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 2.5X10 MM 5F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320739 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 2.5X15 MM 5F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320740 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 2.5X20 MM 5F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320741 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 3.0X10 MM 6F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320742 EAP HCPCS C1725 Catheter Baldilat 3mm 140cm 15mm Rapex Ntnl Latex BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320743 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 3.0X20 MM 6F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320744 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 3.5X10 MM 6F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320745 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 3.5X15 MM 6F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320746 EAP HCPCS C1725 CHOCOLATE PTCA BALLOON CATHETER 3.5X20 MM 6F BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 "$1,218.75" $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320748 EAP HCPCS C1887 CATHETER GUID EBU3.75 CURVE 8FR .09IN 90CM LEFT BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80320749 EAP HCPCS C1887 CATHETER GUID JR4 CURVE 8FR .088IN 90CM CORON SHR BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80320750 EAP HCPCS C1887 CATHETER GUID JL4 CURVE 8FR 90CM CORON SHR NX BAL BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80320781 EAP Dressing 8x8in Anbctrl Latex Hydrofera Foam Blue BOTH IP/OP $33.00 $24.42 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.49 $24.49 $25.44 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $21.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80320787 EAP HCPCS C1729 Set Drain .038in 18fr L 40cm 32 Side Port Luer Lock Lock BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $152.04 $152.04 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $215.82 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $182.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 80320793 EAP HCPCS C1894 Introducer Sheath 9fr 25cm 2.5cm Dilat Kink Resistant BOTH IP/OP $429.00 $317.46 $0.00 $339.20 $232.95 $232.95 $0.00 $0.00 $0.00 $89.41 $318.40 $318.40 $330.67 $0.00 $89.40 $0.00 $253.75 $253.75 $0.00 $212.00 $335.81 $339.20 $0.00 $278.85 $0.00 $66.36 $0.00 $0.00 $67.50 $0.00 $0.00 $0.00 $0.00 $0.00 80320799 EAP HCPCS C1896 Electrode Dfbr 45cm Trplr Eblm S-icd 11.5fr Sbq BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" "$7,708.00" $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80320811 EAP HCPCS C1769 Guidewire Vasc 300cm .035in Core To Tip Radiopq BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 80320812 EAP HCPCS C1725 Catheter Angio 100cm 5fr Crds Infnt Jl3.5 Curve BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $52.67 $52.67 $0.00 $0.00 $0.00 $20.22 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $57.38 $57.38 $0.00 $48.50 $76.82 $77.60 $0.00 $63.05 $0.00 $15.18 $0.00 $0.00 $15.44 $0.00 $0.00 $0.00 $0.00 $0.00 80320813 EAP HCPCS C1887 CATHETER ANGIO JL 4 CRV 5FR .047IN 100CM INFNT THRLMN RADOPQ BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $52.67 $52.67 $0.00 $0.00 $0.00 $20.22 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $57.38 $57.38 $0.00 $48.50 $76.82 $77.60 $0.00 $63.05 $0.00 $15.18 $0.00 $0.00 $15.44 $0.00 $0.00 $0.00 $0.00 $0.00 80320814 EAP HCPCS C1725 Catheter Angio 100cm 5fr Crds Infnt Jr4 Curve BOTH IP/OP $97.00 $71.78 $0.00 $77.60 $52.67 $52.67 $0.00 $0.00 $0.00 $20.22 $71.99 $71.99 $74.77 $0.00 $20.21 $0.00 $57.38 $57.38 $0.00 $48.50 $76.82 $77.60 $0.00 $63.05 $0.00 $15.18 $0.00 $0.00 $15.44 $0.00 $0.00 $0.00 $0.00 $0.00 80320817 EAP HCPCS C1894 SET INTROD 6FR 8FR 17.75IN 3 W BOTH IP/OP $249.00 $184.26 $0.00 $199.20 $135.21 $135.21 $0.00 $0.00 $0.00 $51.90 $184.81 $184.81 $191.93 $0.00 $51.89 $0.00 $147.28 $147.28 $0.00 $124.50 $197.21 $199.20 $0.00 $0.00 $0.00 $38.97 $0.00 $0.00 $39.64 $0.00 $0.00 $0.00 $0.00 $0.00 80320820 EAP HCPCS C1893 Introd Shth 10fr 67cm 63cm Gwire Hmsts Vlv Sh BOTH IP/OP $638.00 $472.12 $0.00 $510.40 $346.43 $346.43 $0.00 $0.00 $0.00 $132.98 $473.52 $473.52 $491.77 $0.00 $132.96 $0.00 $377.38 $377.38 $0.00 $319.00 $505.30 $510.40 $0.00 $0.00 $0.00 $99.85 $0.00 $0.00 $101.57 $0.00 $0.00 $0.00 $0.00 $0.00 80320821 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Sft Rbn Tip Kink Rst BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80320844 EAP HCPCS C1876 System Coron Stent 28mm 5mm Mtlnk Ul Xcelon Mcgld BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80320846 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 220mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80320847 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 40mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80320848 EAP HCPCS C1725 Catheter Baldilat 3mm 150cm 220mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80320849 EAP HCPCS C1725 Catheter Baldilat 3mm 150cm 40mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80320850 EAP HCPCS C1725 Catheter Baldilat 4mm 150cm 220mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80320851 EAP HCPCS C1725 Catheter Baldilat 7mm 150cm 200mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80320852 EAP HCPCS C1725 Catheter Baldilat 7mm 150cm 220mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80320854 EAP HCPCS C1757 Catheter Thrmb 135cm 4fr Unfs Flw-thru Hub Infus BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $237.83 $237.83 $0.00 $0.00 $0.00 $91.29 $325.08 $325.08 $337.61 $0.00 $91.28 $0.00 $259.08 $259.08 $0.00 $219.00 $346.90 $350.40 $0.00 $284.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80320860 EAP HCPCS C1725 Catheter Baldilat 26mm 100cm 4cm Flxb Distal Tip BOTH IP/OP "$1,712.00 " "$1,266.88" $0.00 "$1,369.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $856.00 "$1,355.90" "$1,369.60" $0.00 $0.00 $0.00 $267.93 $0.00 $0.00 $272.55 $0.00 $0.00 $0.00 $0.00 $0.00 80320864 EAP HCPCS C1876 System Coron Stent 13mm 5mm Mtlnk Ul Xcelon Mcgld BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $915.71 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $534.60 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 80320865 EAP Custom 80320865 Balloon Sz 70cm 27mm Amplzr 3 Lum Sft Distal Tip BOTH IP/OP $775.00 $573.50 $0.00 $652.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.21 $575.21 $597.37 $0.00 $161.51 $0.00 $0.00 $0.00 $0.00 $407.50 $645.48 $652.00 $0.00 $503.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80320866 EAP HCPCS C1887 Catheter Guid 90cm 6fr Lnchr Ima Curve Peri Nyl Lg BOTH IP/OP $120.00 $88.80 $0.00 $130.40 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $81.50 $129.10 $130.40 $0.00 $78.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80320868 EAP HCPCS C1887 Catheter Guid 100cm 5fr Lnchr Ebu5 Curve Coron Nyl BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $78.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 80320869 EAP HCPCS C1887 Catheter Guid 100cm 6fr Lnchr Ebu3.5 Curve Peri BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80320870 EAP HCPCS C1769 CATHETER GUID EXTRA BACKUP 4.5 LEFT CURVE 6FR .071 BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $78.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 80321053 EAP HCPCS C2617 Zimmon Pancreatic Stent 7fr 12cm BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $80.10 $80.10 $0.00 $0.00 $0.00 $37.10 $132.11 $132.11 $137.20 $0.00 $37.10 $0.00 $105.29 $105.29 $0.00 $89.00 $140.98 $142.40 $0.00 $80.10 $0.00 $27.86 $0.00 $0.00 $28.34 $0.00 $0.00 $0.00 $0.00 $0.00 80321087 EAP HCPCS C1757 "INDIGO CATHETER 8, XTORQ TIP 115CM" BOTH IP/OP "$7,225.00 " "$5,346.50" $0.00 "$5,780.00" "$3,923.18" "$3,923.18" $0.00 $0.00 $0.00 "$1,505.87" "$4,181.12" "$4,181.12" "$5,569.03" $0.00 "$1,505.69" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,612.50" "$5,722.20" "$5,780.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80321088 EAP Custom 80321088 INDIGO SEPARATOR 8 BOTH IP/OP "$4,700.00 " "$3,478.00" $0.00 "$3,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,488.34" "$3,488.34" "$3,622.76" $0.00 $979.48 $0.00 $0.00 $0.00 $0.00 "$2,350.00" "$3,722.40" "$3,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80321095 EAP HCPCS C1773 Kit Snr Agn 90d 200cm 2.3-3fr 7mm Mcth Loop Coil BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 80321110 EAP HCPCS C1769 Guidewire Vasc 175cm .014in Radiopq Prox Conctr BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $814.50 $814.50 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80321111 EAP Custom 80321111 Kit Cath 135cm 2.7fr Img 1 Syr Rapex Tip Radiopq BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.63" "$1,391.63" "$1,445.25" $0.00 $390.75 $0.00 $0.00 $0.00 $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80321115 EAP HCPCS C1887 Catheter Intvn 5fr .056in .046in 150cm 25cm Rapex BOTH IP/OP "$1,023.00 " $757.02 $0.00 $818.40 $555.49 $555.49 $0.00 $0.00 $0.00 $213.22 $759.27 $759.27 $788.53 $0.00 $213.19 $0.00 $605.10 $605.10 $0.00 $511.50 $810.22 $818.40 $0.00 $664.95 $0.00 $160.10 $0.00 $0.00 $162.86 $0.00 $0.00 $0.00 $0.00 $0.00 80321116 EAP HCPCS C1887 CATHETER INTVN 7FR .078IN .062IN 150CM 25CM RAPEX BOTH IP/OP "$1,023.00 " $757.02 $0.00 $818.40 $555.49 $555.49 $0.00 $0.00 $0.00 $213.22 $759.27 $759.27 $788.53 $0.00 $213.19 $0.00 $605.10 $605.10 $0.00 $511.50 $810.22 $818.40 $0.00 $664.95 $0.00 $160.10 $0.00 $0.00 $162.86 $0.00 $0.00 $0.00 $0.00 $0.00 80321117 EAP HCPCS C1887 Catheter Intvn 8fr .088in .071in 150cm 25cm Rapex BOTH IP/OP "$1,023.00 " $757.02 $0.00 $818.40 $555.49 $555.49 $0.00 $0.00 $0.00 $213.22 $759.27 $759.27 $788.53 $0.00 $213.19 $0.00 $605.10 $605.10 $0.00 $511.50 $810.22 $818.40 $0.00 $0.00 $0.00 $160.10 $0.00 $0.00 $162.86 $0.00 $0.00 $0.00 $0.00 $0.00 80321162 EAP HCPCS C1887 SHEATH GUID 65CM 8FR PN DSTN .038IN STR HYDPHI BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $121.63 $121.63 $0.00 $0.00 $0.00 $46.69 $166.25 $166.25 $172.66 $0.00 $46.68 $0.00 $132.50 $132.50 $0.00 $112.00 $177.41 $179.20 $0.00 $145.60 $0.00 $35.06 $0.00 $0.00 $35.66 $0.00 $0.00 $0.00 $0.00 $0.00 80321939 EAP HCPCS C1773 SEPARATOR THRMB INDG 6 LATEX FREE BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$2,160.00" "$1,466.10" "$1,466.10" $0.00 $0.00 $0.00 $562.75 "$2,003.94" "$2,003.94" "$2,081.16" $0.00 $562.68 $0.00 "$1,597.05" "$1,597.05" $0.00 "$1,350.00" "$2,138.40" "$2,160.00" $0.00 $0.00 $0.00 $422.55 $0.00 $0.00 $429.84 $0.00 $0.00 $0.00 $0.00 $0.00 80321943 EAP HCPCS C1757 CATHETER THRMB 6FR INDG ASPIRAT LATEX FREE BOTH IP/OP "$4,725.00 " "$3,496.50" $0.00 "$3,780.00" "$2,565.68" "$2,565.68" $0.00 $0.00 $0.00 $984.81 "$3,506.90" "$3,506.90" "$3,642.03" $0.00 $984.69 $0.00 "$2,794.84" "$2,794.84" $0.00 "$2,362.50" "$3,742.20" "$3,780.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80321958 EAP Coloplast Fistula Wound Mgr.-small 14021 BOTH IP/OP $29.00 $21.46 $0.00 $23.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.52 $21.52 $22.35 $0.00 $6.04 $0.00 $0.00 $0.00 $0.00 $14.50 $22.97 $23.20 $0.00 $18.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80321959 EAP System 156-228mm Ost Midi Ctf 2 Spout Drain Port BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.26 $94.26 $97.89 $0.00 $26.47 $0.00 $0.00 $0.00 $0.00 $63.50 $100.58 $101.60 $0.00 $82.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80321960 EAP Coloplast Fistula Wound Mgr.-large 14041 BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $65.00 $102.96 $104.00 $0.00 $84.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80322020 EAP HCPCS C1753 CATHETER ULTRASOUND .035IN 8.5FR 90CM 100CM OTW RADIOPQ BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,357.50" "$1,357.50" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" "$1,927.00" $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 "$1,625.00" $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 80322156 EAP HCPCS C1725 Catheter Baldilat 2.5mm 30mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322157 EAP HCPCS C1725 Catheter Baldilat 2mm 25mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322159 EAP HCPCS C1725 CATHETER BALDILAT ULTRA LP 5FR 1.5MM 12MM 2 LUMEN BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322160 EAP HCPCS C1874 Catheter Baldilat 1.5mm 8mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322163 EAP HCPCS C1725 Catheter Baldilat 3mm 25mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322164 EAP HCPCS C1725 Catheter Baldilat 3mm 20mm Coron Rapex Ult Lp BOTH IP/OP $175.00 $129.50 $0.00 $200.00 $95.03 $95.03 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $134.89 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $125.00 $198.00 $200.00 $0.00 $113.75 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322165 EAP HCPCS C1725 Catheter Baldilat 3mm 8mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322166 EAP HCPCS C1725 Catheter Baldilat 2.5mm 25mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322167 EAP HCPCS C1725 Trek Coronary Dilatation Catheter 2.50 Mm X 8 Mm / Rapid-exchange BOTH IP/OP $213.00 $157.62 $0.00 $170.40 $115.66 $115.66 $0.00 $0.00 $0.00 $44.39 $158.09 $158.09 $164.18 $0.00 $44.39 $0.00 $125.99 $125.99 $0.00 $106.50 $168.70 $170.40 $0.00 $138.45 $0.00 $33.33 $0.00 $0.00 $33.91 $0.00 $0.00 $0.00 $0.00 $0.00 80322168 EAP HCPCS C1725 Catheter Baldilat 2mm 20mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322169 EAP HCPCS C1725 Catheter Baldilat 2mm 8mm Coron Rapex Ult Lp BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322170 EAP HCPCS C1725 CATHETER BALDILAT ULTRA LP 5FR 1.5MM 15MM 2 LUMEN BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80322173 EAP HCPCS C1769 Guidewire Vasc 190cm .014in Jointless Sprg Coil BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80322174 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Core To Tip Radiopq BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80322178 EAP HCPCS C1769 Guidewire Vasc 300cm .014in Jointless Sprg Coil BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80322247 EAP HCPCS A6213 Dressing 6x6in Adh Hydrofera Foam Blue BOTH IP/OP $336.00 $248.64 $0.00 $268.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.38 $249.38 $258.99 $0.00 $70.02 $0.00 $0.00 $0.00 $0.00 $168.00 $266.11 $268.80 $0.00 $218.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80322311 EAP HCPCS C1769 GUIDEWIRE VASC 180CM ASAHI PTCA SION BLUE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 80322312 EAP HCPCS C1769 GUIDEWIRE VASC 180CM .014IN STR 3CM SION ASAHI SS BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $243.75 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 80322313 EAP HCPCS C1769 GUIDEWIRE VASC 300CM .014IN 3 RADIOPQ SEG STR 3CM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 80322314 EAP HCPCS C1769 GUIDEWIRE VASC RG3 BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $312.23 $312.23 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $443.21 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $373.75 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 80322339 EAP HCPCS C1887 CATHETER GUID AL1 CURVE 8FR 90CM CORON SH LNCHR BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80322340 EAP HCPCS C1887 CATHETER GUID 3DRC CURVE 8FR 90CM CORON LNCHR BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80322342 EAP HCPCS C1887 CATHETER GUID AL1.5 CURVE 8FR .09IN 90CM CORON BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80322343 EAP HCPCS C1887 CATHETER GUID AL1.5 CURVE 8FR 90CM CORON SH LNCHR BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80322347 EAP HCPCS C1887 CATHETER GUID XB3.5 CURVE 8FR 90CM CORON SH LNCHR BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $105.95 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80322349 EAP HCPCS C1887 CATHETER GUID XB4 CURVE 8FR 90CM CORON SH LNCHR BOTH IP/OP $163.00 $120.62 $0.00 $130.40 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $96.41 $96.41 $0.00 $81.50 $129.10 $130.40 $0.00 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80322411 EAP Custom 80322411 OMNI FLUSH (VCF) 5FR 100CM BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80322620 EAP HCPCS C1750 Kit Cath 61cm Palindrome Prcs Smtr Tip 44cm Chrnc BOTH IP/OP "$1,445.00 " "$1,069.30" $0.00 "$1,156.00" $784.64 $784.64 $0.00 $0.00 $0.00 $301.17 "$1,072.48" "$1,072.48" "$1,113.81" $0.00 $301.14 $0.00 $854.72 $854.72 $0.00 $722.50 "$1,144.44" "$1,156.00" $0.00 $939.25 $0.00 $226.14 $0.00 $0.00 $230.04 $0.00 $0.00 $0.00 $0.00 $0.00 80322779 EAP Custom 80322779 Set Ndl 15ga 45mm Strl Lf Ezio Ez-cnct Wrst Band Std Ll Cath BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.35 $252.35 $262.07 $0.00 $70.86 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $221.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80323591 EAP Stabilit First Fracture Kit With Powercurve BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,395.60" $0.00 "$1,458.80" $0.00 $0.00 $0.00 $0.00 "$3,500.00" "$5,544.00" "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80323627 EAP HCPCS C1874 Stent Vascular Zilver Ptx 125cm 80mm 100mm Od6 Fr BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" "$2,436.98" "$2,436.98" $0.00 $0.00 $0.00 $935.41 "$3,330.99" "$3,330.99" "$3,459.35" $0.00 $935.30 $0.00 "$2,654.65" "$2,654.65" $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 "$2,917.20" $0.00 $702.37 $0.00 $0.00 $714.49 $0.00 $0.00 $0.00 $0.00 $0.00 80323828 EAP HCPCS C1769 GUIDEWIRE VASC 190CM .014IN STRBL RADIOPQ KINK RST BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80323833 EAP Custom 80323833 IMPELLA RP US HDE PUMP SET BOTH IP/OP "$62,500.00 " "$46,250.00" $0.00 "$50,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$48,175.00" $0.00 "$13,025.00" $0.00 $0.00 $0.00 $0.00 "$31,250.00" "$49,500.00" "$50,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80324729 EAP Custom 80324729 TURNPIKE CATHETER LP 135CM BOTH IP/OP "$1,313.00 " $971.62 $0.00 "$1,050.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $974.51 $974.51 "$1,012.06" $0.00 $273.63 $0.00 $0.00 $0.00 $0.00 $656.50 "$1,039.90" "$1,050.40" $0.00 $853.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80324730 EAP Custom 80324730 TURNPIKE CATHETER LP 150CM BOTH IP/OP "$1,488.00 " "$1,101.12" $0.00 "$1,190.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,104.39" "$1,104.39" "$1,146.95" $0.00 $310.10 $0.00 $0.00 $0.00 $0.00 $744.00 "$1,178.50" "$1,190.40" $0.00 $967.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80324863 EAP HCPCS C1874 Stent Endoprsth Sprfc Fem Art Ilium 10cm 7mm 7fr BOTH IP/OP "$8,950.00 " "$6,623.00" $0.00 "$7,160.00" "$4,027.50" "$4,027.50" $0.00 $0.00 $0.00 "$1,865.40" "$4,181.12" "$4,181.12" "$6,898.66" $0.00 "$1,865.18" $0.00 "$4,412.35" "$4,412.35" $0.00 "$4,475.00" "$7,088.40" "$7,160.00" $0.00 $0.00 $0.00 "$1,400.68" $0.00 $0.00 "$1,424.84" $0.00 $0.00 $0.00 $0.00 $0.00 80324866 EAP HCPCS C1892 Introd Shth 9fr 13cm Optiseal BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $70.59 $70.59 $0.00 $0.00 $0.00 $27.10 $96.49 $96.49 $100.20 $0.00 $27.09 $0.00 $76.90 $76.90 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 80325074 EAP HCPCS C1773 Snare Vasc 47in .71-1.18in .055in .074in Ensnr BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $449.60 $449.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $638.22 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 80325086 EAP HCPCS C1817 Occluder Cardio 25mm Spt Sft Wire Frm Flrscp Img BOTH IP/OP "$19,778.00 " "$14,635.72" $0.00 "$15,822.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,244.88" $0.00 "$4,121.74" $0.00 $0.00 $0.00 $0.00 "$9,889.00" "$15,664.18" "$15,822.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80325087 EAP HCPCS C1817 Occluder Cardio 30mm Spt Sft Wire Frm Flrscp Img BOTH IP/OP "$19,778.00 " "$14,635.72" $0.00 "$15,822.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$15,244.88" $0.00 "$4,121.74" $0.00 $0.00 $0.00 $0.00 "$9,889.00" "$15,664.18" "$15,822.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80325319 EAP Spinestar Ablation Instr 17.5 Cm L15 Mm L10 Mm Od11 Ga Therm BOTH IP/OP "$7,250.00 " "$5,365.00" $0.00 "$5,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,588.30" $0.00 "$1,510.90" $0.00 $0.00 $0.00 $0.00 "$3,625.00" "$5,742.00" "$5,800.00" $0.00 "$4,712.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80325443 EAP HCPCS C1887 Sheath Guid 65cm 6fr .109in .087in Pn Dstn Str Ss BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $173.43 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 80325494 EAP HCPCS C1725 Catheter Angio 125cm 6fr Crds St+ Jr4 Curve Coron BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $45.61 $45.61 $0.00 $0.00 $0.00 $17.51 $62.34 $62.34 $64.75 $0.00 $17.51 $0.00 $49.69 $49.69 $0.00 $42.00 $66.53 $67.20 $0.00 $54.60 $0.00 $13.15 $0.00 $0.00 $13.37 $0.00 $0.00 $0.00 $0.00 $0.00 80325495 EAP HCPCS C1725 Catheter Angio 125cm 6fr Crds St+ Jl4 Curve Coron BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $45.61 $45.61 $0.00 $0.00 $0.00 $17.51 $62.34 $62.34 $64.75 $0.00 $17.51 $0.00 $49.69 $49.69 $0.00 $42.00 $66.53 $67.20 $0.00 $54.60 $0.00 $13.15 $0.00 $0.00 $13.37 $0.00 $0.00 $0.00 $0.00 $0.00 80325526 EAP HCPCS C1876 INNOVA 5MM X 60MM X 75CM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80325555 EAP HCPCS C1876 STENT VASC BLUE 40MM 6MM INNOVA SPRFC FEM ART SLF BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80325566 EAP HCPCS C1876 INNOVA 8MM X 20MM X 130CM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80325567 EAP HCPCS C1876 INNOVA 8MM X 40MM X 130CM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80325568 EAP HCPCS C1876 INNOVA 8MM X 60MM X 130CM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80325569 EAP HCPCS C1876 INNOVA 8MM X 80MM X 130CM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80325650 EAP HCPCS C1757 SYSTEM THRMB ZELANTEDVT BOTH IP/OP "$7,313.00 " "$5,411.62" $0.00 "$5,850.40" "$3,970.96" "$3,970.96" $0.00 $0.00 $0.00 "$1,524.21" "$4,181.12" "$4,181.12" "$5,636.86" $0.00 "$1,524.03" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,656.50" "$5,791.90" "$5,850.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80325671 EAP HCPCS C1874 STENT VASC 60MM 6MM GORE TIGRIS CBAS NTNL FLPLMR BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 80325673 EAP HCPCS C1874 STENT VASC 100MM 6MM GORE TIGRIS CBAS NTNL FLPLMR BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 80325675 EAP HCPCS C1874 STENT VASC 60MM 7MM GORE TIGRIS CBAS NTNL FLPLMR BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 80325676 EAP HCPCS C1874 STENT VASC 100MM 7MM GORE TIGRIS CBAS NTNL FLPLMR BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $779.09 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 "$1,842.83" "$1,842.83" $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 $0.00 $0.00 $585.00 $0.00 $0.00 $595.09 $0.00 $0.00 $0.00 $0.00 $0.00 80326084 EAP HCPCS C1887 CATHETER ANGIO RADIALTIGER CURVE 6FR 4MM 110CM BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $47.78 $47.78 $0.00 $0.00 $0.00 $18.34 $65.31 $65.31 $67.83 $0.00 $18.34 $0.00 $52.05 $52.05 $0.00 $44.00 $69.70 $70.40 $0.00 $57.20 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 80326288 EAP HCPCS C1769 Guidewire Vasc 325cm .012in Viperwire Adv Coron BOTH IP/OP $488.00 $361.12 $0.00 $390.40 $264.98 $264.98 $0.00 $0.00 $0.00 $101.71 $362.19 $362.19 $376.15 $0.00 $101.70 $0.00 $288.65 $288.65 $0.00 $244.00 $386.50 $390.40 $0.00 $317.20 $0.00 $76.37 $0.00 $0.00 $77.69 $0.00 $0.00 $0.00 $0.00 $0.00 80326302 EAP HCPCS C1724 CATHETER ATHRCM 145CM STLTH 360 1.25MM ORBTL CLS BOTH IP/OP "$9,488.00 " "$7,021.12" $0.00 "$7,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,313.35" $0.00 "$1,977.30" $0.00 $0.00 $0.00 $0.00 "$4,744.00" "$7,514.50" "$7,590.40" $0.00 "$6,167.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80326668 EAP HCPCS C1722 Generator Pcmkr 83.1x69.1mm Eblm S-icd 12.7mm 59.5 BOTH IP/OP "$42,500.00 " "$31,450.00" $0.00 "$34,000.00" "$19,125.00" "$19,125.00" $0.00 $0.00 $0.00 "$8,858.06" "$4,181.12" "$4,181.12" "$32,759.00" $0.00 "$8,857.00" $0.00 "$20,952.50" "$20,952.50" $0.00 "$21,250.00" "$33,660.00" "$34,000.00" $0.00 "$19,125.00" $0.00 "$6,651.25" $0.00 $0.00 "$6,766.00" $0.00 $0.00 $0.00 $0.00 $0.00 80332586 EAP HCPCS C1751 Catheter Angel BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" "$3,054.38" "$3,054.38" $0.00 $0.00 $0.00 "$1,172.39" "$4,174.88" "$4,174.88" "$4,335.75" $0.00 "$1,172.25" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 "$3,656.25" $0.00 $880.31 $0.00 $0.00 $895.50 $0.00 $0.00 $0.00 $0.00 $0.00 80332596 EAP HCPCS C1757 Retriever Escp 3mm 20mm Trevo Xp Provue BOTH IP/OP "$13,118.00 " "$9,707.32" $0.00 "$10,494.40" "$7,123.07" "$7,123.07" $0.00 $0.00 $0.00 "$2,734.12" "$4,181.12" "$4,181.12" "$10,111.35" $0.00 "$2,733.79" $0.00 "$3,094.73" "$3,094.73" $0.00 "$6,559.00" "$10,389.46" "$10,494.40" $0.00 "$8,526.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80333053 EAP HCPCS C1769 GUIDEWIRE VASC 185CM STRL LF VERRATA + PRSS DISP BOTH IP/OP "$1,688.00 " "$1,249.12" $0.00 "$1,350.40" $916.58 $916.58 $0.00 $0.00 $0.00 $351.82 "$1,252.83" "$1,252.83" "$1,301.11" $0.00 $351.78 $0.00 $998.45 $998.45 $0.00 $844.00 "$1,336.90" "$1,350.40" $0.00 "$1,097.20" $0.00 $264.17 $0.00 $0.00 $268.73 $0.00 $0.00 $0.00 $0.00 $0.00 80338397 EAP HCPCS C1769 Guidewire Vasc 180cm .035in Flx Tp Ang 25cm 5cm BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $260.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 80339398 EAP HCPCS C1874 Stent Eprsth .035in 9mm 13mm 8 BOTH IP/OP "$6,725.00 " "$4,976.50" $0.00 "$5,380.00" "$3,026.25" "$3,026.25" $0.00 $0.00 $0.00 "$1,401.66" "$4,181.12" "$4,181.12" "$5,183.63" $0.00 "$1,401.49" $0.00 "$3,315.43" "$3,315.43" $0.00 "$3,362.50" "$5,326.20" "$5,380.00" $0.00 "$3,026.25" $0.00 "$1,052.46" $0.00 $0.00 "$1,070.62" $0.00 $0.00 $0.00 $0.00 $0.00 80339402 EAP HCPCS C1874 Stent Endoprsth 29mm 11mm 16sq Mm 8fr Gore Vbhn BOTH IP/OP "$8,548.00 " "$6,325.52" $0.00 "$6,838.40" "$3,846.60" "$3,846.60" $0.00 $0.00 $0.00 "$1,781.62" "$4,181.12" "$4,181.12" "$6,588.80" $0.00 "$1,781.40" $0.00 "$4,214.16" "$4,214.16" $0.00 "$4,274.00" "$6,770.02" "$6,838.40" $0.00 $0.00 $0.00 "$1,337.76" $0.00 $0.00 "$1,360.84" $0.00 $0.00 $0.00 $0.00 $0.00 80339410 EAP HCPCS C1874 Stent Endoprsth 39mm 7mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$8,548.00 " "$6,325.52" $0.00 "$6,838.40" "$3,846.60" "$3,846.60" $0.00 $0.00 $0.00 "$1,781.62" "$4,181.12" "$4,181.12" "$6,588.80" $0.00 "$1,781.40" $0.00 "$4,214.16" "$4,214.16" $0.00 "$4,274.00" "$6,770.02" "$6,838.40" $0.00 $0.00 $0.00 "$1,337.76" $0.00 $0.00 "$1,360.84" $0.00 $0.00 $0.00 $0.00 $0.00 80339412 EAP HCPCS C1874 Stent Endoprsth 39mm 8mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$8,548.00 " "$6,325.52" $0.00 "$6,838.40" "$3,846.60" "$3,846.60" $0.00 $0.00 $0.00 "$1,781.62" "$4,181.12" "$4,181.12" "$6,588.80" $0.00 "$1,781.40" $0.00 "$4,214.16" "$4,214.16" $0.00 "$4,274.00" "$6,770.02" "$6,838.40" $0.00 $0.00 $0.00 "$1,337.76" $0.00 $0.00 "$1,360.84" $0.00 $0.00 $0.00 $0.00 $0.00 80339426 EAP HCPCS C1874 Stent Endoprsth 59mm 7mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$8,548.00 " "$6,325.52" $0.00 "$6,838.40" "$3,846.60" "$3,846.60" $0.00 $0.00 $0.00 "$1,781.62" "$4,181.12" "$4,181.12" "$6,588.80" $0.00 "$1,781.40" $0.00 "$4,214.16" "$4,214.16" $0.00 "$4,274.00" "$6,770.02" "$6,838.40" $0.00 $0.00 $0.00 "$1,337.76" $0.00 $0.00 "$1,360.84" $0.00 $0.00 $0.00 $0.00 $0.00 80339428 EAP HCPCS C1874 Stent Endoprsth 59mm 8mm 11mm 7fr Gore Vbhn 135cm BOTH IP/OP "$8,138.00 " "$6,022.12" $0.00 "$6,510.40" "$3,662.10" "$3,662.10" $0.00 $0.00 $0.00 "$1,696.16" "$4,181.12" "$4,181.12" "$6,272.77" $0.00 "$1,695.96" $0.00 "$4,012.03" "$4,012.03" $0.00 "$4,069.00" "$6,445.30" "$6,510.40" $0.00 $0.00 $0.00 "$1,273.60" $0.00 $0.00 "$1,295.57" $0.00 $0.00 $0.00 $0.00 $0.00 80339456 EAP HCPCS C1887 Catheter Guid Blue Ylw 100cm 6fr Crds Vsbr 3drc BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $50.50 $50.50 $0.00 $0.00 $0.00 $19.38 $69.02 $69.02 $71.68 $0.00 $19.38 $0.00 $55.01 $55.01 $0.00 $46.50 $73.66 $74.40 $0.00 $60.45 $0.00 $14.55 $0.00 $0.00 $14.81 $0.00 $0.00 $0.00 $0.00 $0.00 80339903 EAP Catheter Angio Tpr Loprfl Rc2 Crv 5fr 65cm Strl Trnb Ad BOTH IP/OP $313.00 $231.62 $0.00 $250.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.31 $232.31 $241.26 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $156.50 $247.90 $250.40 $0.00 $203.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80340523 EAP HCPCS C1894 Sheath Guid 90cm 2.5fr Chk-flo Flxr Raabe BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $102.08 $102.08 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $144.91 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $122.20 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 80341173 EAP HCPCS C1769 Guidewire Vasc 260cm .035in Radiopq Flpy Flx Tp BOTH IP/OP $551.00 $407.74 $0.00 $440.80 $299.19 $299.19 $0.00 $0.00 $0.00 $114.84 $408.95 $408.95 $424.71 $0.00 $114.83 $0.00 $325.92 $325.92 $0.00 $275.50 $436.39 $440.80 $0.00 $0.00 $0.00 $86.23 $0.00 $0.00 $87.72 $0.00 $0.00 $0.00 $0.00 $0.00 80341288 EAP HCPCS C1769 Guidewire Vasc Ang Shrt Tpr .018in 60cm 7cm Cp Mdrl Dist Tip BOTH IP/OP $106.00 $78.44 $0.00 $84.80 $57.56 $57.56 $0.00 $0.00 $0.00 $22.09 $78.67 $78.67 $81.70 $0.00 $22.09 $0.00 $62.70 $62.70 $0.00 $53.00 $83.95 $84.80 $0.00 $68.90 $0.00 $16.59 $0.00 $0.00 $16.88 $0.00 $0.00 $0.00 $0.00 $0.00 80341936 EAP HCPCS C1769 Guidewire Vasc 15cm Strg 2 Crv Tpr .035in 180cm 7cm Lndrqs BOTH IP/OP $753.00 $557.22 $0.00 $602.40 $408.88 $408.88 $0.00 $0.00 $0.00 $156.94 $558.88 $558.88 $580.41 $0.00 $156.93 $0.00 $445.40 $445.40 $0.00 $376.50 $596.38 $602.40 $0.00 $489.45 $0.00 $117.84 $0.00 $0.00 $119.88 $0.00 $0.00 $0.00 $0.00 $0.00 80349650 EAP KIT MCTRDCR .018IN TPR 5FR 40CM 7CM VSI SMTH NDL GW REG DIL BOTH IP/OP $474.00 $350.76 $0.00 $379.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.80 $351.80 $365.36 $0.00 $98.78 $0.00 $0.00 $0.00 $0.00 $237.00 $375.41 $379.20 $0.00 $308.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80359050 EAP HCPCS C1753 Catheter Us Kodama BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $162.90 $162.90 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $195.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 80359064 EAP HCPCS A6198 Dressing Brn 48x4in Strl Lf Actct Flx 3 Anmc Brr 1 Lyr Knit BOTH IP/OP $179.00 $132.46 $0.00 $168.80 $97.20 $97.20 $0.00 $0.00 $0.00 $0.00 $132.85 $132.85 $137.97 $0.00 $37.30 $0.00 $0.00 $0.00 $0.00 $105.50 $167.11 $168.80 $0.00 $116.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80370959 EAP HCPCS C1874 System Coron Stent 24mm 2.75mm Cbr Pzf Polyzene-f BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370960 EAP HCPCS C1874 System Coron Stent 30mm 2.75mm Cbr Pzf Polyzene-f BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370964 EAP HCPCS C1874 System Cor Stnt 3mm 18mm Cbr Pzf Rx Dlv Sys Polyzene-f Cocr BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370965 EAP HCPCS C1874 System Coron Stent 24mm 3mm Cbr Pzf Polyzene-f BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370966 EAP HCPCS C1874 System Coron Stent 30mm 3mm Cbr Pzf Cocr Hydphi BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370969 EAP HCPCS C1876 System Coronary Stent Cobra Pzf Polyzene-f L15mm BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370970 EAP HCPCS C1876 System Cor Stnt 3.5mm 18mm Cbr Pzf Rx Dlv Sys Polyzene-f BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370972 EAP HCPCS C1876 System Coronary Stent Cobra L30mm Id3.5mm Rapid Exchange BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370976 EAP HCPCS C1876 System Coronary Stent Cobra L18mm Id4mm Rapid Exchange BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80370978 EAP HCPCS C1876 System Coronary Stent Cobra L30 Mm Id4 Mm Rapid Exchange BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" "$1,637.95" $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $956.25 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 80371591 EAP HCPCS C1874 STENT EPRSTH 8MM 7FR 10CM 120CM VBHN DLV SYS HEP SPRFC FEM BOTH IP/OP "$8,738.00 " "$6,466.12" $0.00 "$6,990.40" "$3,932.10" "$3,932.10" $0.00 $0.00 $0.00 "$1,821.22" "$4,181.12" "$4,181.12" "$6,735.25" $0.00 "$1,821.00" $0.00 "$4,307.83" "$4,307.83" $0.00 "$4,369.00" "$6,920.50" "$6,990.40" $0.00 "$3,369.60" $0.00 "$1,367.50" $0.00 $0.00 "$1,391.09" $0.00 $0.00 $0.00 $0.00 $0.00 80379042 EAP HCPCS C1752 Kit Cath 13fr 20cm Strl Pwr-trialysis 3 Lum Shrt Term Dlys BOTH IP/OP $596.00 $441.04 $0.00 $476.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $442.35 $442.35 $459.40 $0.00 $124.21 $0.00 $0.00 $0.00 $0.00 $298.00 $472.03 $476.80 $0.00 $387.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80379099 EAP HCPCS C2621 Percepta Quad Crtp Mri Surescan BOTH IP/OP "$16,500.00 " "$12,210.00" $0.00 "$13,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$12,718.20" $0.00 "$3,438.60" $0.00 $0.00 $0.00 $0.00 "$8,250.00" "$13,068.00" "$13,200.00" $0.00 "$7,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80379103 EAP HCPCS C1729 Catheter Primafit Sage BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $14.66 $14.66 $0.00 $0.00 $0.00 $5.63 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $15.97 $15.97 $0.00 $13.50 $21.38 $21.60 $0.00 $17.55 $0.00 $4.23 $0.00 $0.00 $4.30 $0.00 $0.00 $0.00 $0.00 $0.00 80379488 EAP HCPCS C1726 Rigiflex Ii Single Use Achalasia Balloon Dilator BOTH IP/OP "$1,690.00 " "$1,250.60" $0.00 "$1,352.00" $917.67 $917.67 $0.00 $0.00 $0.00 $352.24 "$1,254.32" "$1,254.32" "$1,302.65" $0.00 $352.20 $0.00 $999.64 $999.64 $0.00 $845.00 "$1,338.48" "$1,352.00" $0.00 "$1,098.50" $0.00 $264.49 $0.00 $0.00 $269.05 $0.00 $0.00 $0.00 $0.00 $0.00 80379641 EAP HCPCS C1786 SYSTEM DLV 3.2V 120MAH 6.7MM 25.9MM MICRA SURESCAN HBRD BOTH IP/OP "$26,875.00 " "$19,887.50" $0.00 "$21,500.00" "$12,093.75" "$12,093.75" $0.00 $0.00 $0.00 "$5,601.42" "$4,181.12" "$4,181.12" "$20,715.25" $0.00 "$5,600.75" $0.00 "$13,249.38" "$13,249.38" $0.00 "$13,437.50" "$21,285.00" "$21,500.00" $0.00 "$12,093.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80379642 EAP HCPCS C1894 INTRODUCER SHTH 23FR 55.7CM 69.9CM MICRA STPCK RADOPQ DIL BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $814.50 $814.50 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" "$1,156.20" $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $975.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 80379742 EAP Custom 80379742 Set Hmdial 27x22x9cm 165ml Strl Lf Prismaflex Hmfltr Bg BOTH IP/OP $426.00 $315.24 $0.00 $328.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $316.18 $316.18 $328.36 $0.00 $88.78 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $276.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80379801 EAP HCPCS C2623 CATHETER BLNDIL 7MM 75CM 60MM LUTONIX DRG COAT ACPT .035IN BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 80379803 EAP HCPCS C2623 CATHETER BLNDIL 8MM 75CM 60MM LUTONIX DRG COAT ACPT .035IN BOTH IP/OP "$4,250.00 " "$3,145.00" $0.00 "$3,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,154.35" "$3,154.35" "$3,275.90" $0.00 $885.70 $0.00 $0.00 $0.00 $0.00 "$2,125.00" "$3,366.00" "$3,400.00" $0.00 "$2,762.50" $0.00 $665.13 $0.00 $0.00 $676.60 $0.00 $0.00 $0.00 $0.00 $0.00 80379806 EAP HCPCS C2623 CATHETER BLNDIL 10MM 75CM 40MM LUTONIX DRG COAT ACPT .035IN BOTH IP/OP "$4,250.00 " "$3,145.00" $0.00 "$3,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,125.00" "$3,366.00" "$3,400.00" $0.00 $0.00 $0.00 $665.13 $0.00 $0.00 $676.60 $0.00 $0.00 $0.00 $0.00 $0.00 80390076 EAP HCPCS C2623 Catheter Baldilat 4mm 130cm 100mm Pcltxl Latex BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 80390081 EAP HCPCS C2623 Catheter Baldilat 4mm 130cm 60mm Pcltxl Latex Free BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 80390085 EAP HCPCS C2623 Catheter Baldilat 5mm 130cm 100mm Pcltxl Latex BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 80390093 EAP HCPCS C2623 Catheter Baldilat 5mm 130cm 60mm Pcltxl Latex Free BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" "$2,697.80" $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 "$2,275.00" $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 80390101 EAP HCPCS C2623 Catheter Blndil 5f 6mm 130cm 150mm Lutonix BOTH IP/OP "$4,250.00 " "$3,145.00" $0.00 "$3,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,154.35" "$3,154.35" "$3,275.90" $0.00 $885.70 $0.00 $0.00 $0.00 $0.00 "$2,125.00" "$3,366.00" "$3,400.00" $0.00 $0.00 $0.00 $665.13 $0.00 $0.00 $676.60 $0.00 $0.00 $0.00 $0.00 $0.00 80397351 EAP HCPCS C1898 Lead Pacing Capsure Sense Steroid Eluting L52 Cm Atrium Right Vent BOTH IP/OP "$1,013.00 " $749.62 $0.00 $810.40 $455.85 $455.85 $0.00 $0.00 $0.00 $211.13 $751.85 $751.85 $780.82 $0.00 $211.11 $0.00 $599.19 $599.19 $0.00 $506.50 $802.30 $810.40 $0.00 $455.85 $0.00 $158.53 $0.00 $0.00 $161.27 $0.00 $0.00 $0.00 $0.00 $0.00 80397520 EAP HCPCS C1887 Catheter Gd 9fr 7.2fr 45cm Atn Cmnd Surevalve Lh BOTH IP/OP $588.00 $435.12 $0.00 $470.40 $319.28 $319.28 $0.00 $0.00 $0.00 $122.55 $436.41 $436.41 $453.23 $0.00 $122.54 $0.00 $347.80 $347.80 $0.00 $294.00 $465.70 $470.40 $0.00 $0.00 $0.00 $92.02 $0.00 $0.00 $93.61 $0.00 $0.00 $0.00 $0.00 $0.00 80397527 EAP HCPCS C1887 Catheter Gd .035in Mp Rt Crv 9fr 7.2fr 45cm Atn Cmnd BOTH IP/OP $588.00 $435.12 $0.00 $470.40 $319.28 $319.28 $0.00 $0.00 $0.00 $122.55 $436.41 $436.41 $453.23 $0.00 $122.54 $0.00 $347.80 $347.80 $0.00 $294.00 $465.70 $470.40 $0.00 $0.00 $0.00 $92.02 $0.00 $0.00 $93.61 $0.00 $0.00 $0.00 $0.00 $0.00 80397542 EAP HCPCS C1777 Lead Pacing Sprint Quattro Secure L58 Cm 1 Coil Defib BOTH IP/OP "$7,875.00 " "$5,827.50" $0.00 "$6,300.00" "$3,543.75" "$3,543.75" $0.00 $0.00 $0.00 "$1,641.35" "$4,181.12" "$4,181.12" "$6,070.05" $0.00 "$1,641.15" $0.00 "$3,882.38" "$3,882.38" $0.00 "$3,937.50" "$6,237.00" "$6,300.00" $0.00 "$3,543.75" $0.00 "$1,232.44" $0.00 $0.00 "$1,253.70" $0.00 $0.00 $0.00 $0.00 $0.00 80397543 EAP HCPCS C1777 Lead Pacing Sprint Quattro Secure Steroid Eluting Silicone Helix L65 BOTH IP/OP "$7,875.00 " "$5,827.50" $0.00 "$6,300.00" "$3,543.75" "$3,543.75" $0.00 $0.00 $0.00 "$1,641.35" "$4,181.12" "$4,181.12" "$6,070.05" $0.00 "$1,641.15" $0.00 "$3,882.38" "$3,882.38" $0.00 "$3,937.50" "$6,237.00" "$6,300.00" $0.00 "$3,543.75" $0.00 "$1,232.44" $0.00 $0.00 "$1,253.70" $0.00 $0.00 $0.00 $0.00 $0.00 80398493 EAP HCPCS C1769 GUIDEWIRE VASC 300CM .014IN RADIOPQ KINK RST STR 3 BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $101.81 $101.81 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $144.53 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 80398507 EAP HCPCS C1769 GUIDEWIRE VASC 300CM .014IN STR 3CM HTORQ WHSPR LS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $101.81 $101.81 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $144.53 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 80398619 EAP HCPCS C1874 System Coron Stent 38mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398620 EAP HCPCS C1874 System Coron Stent 33mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398621 EAP HCPCS C1874 System Coron Stent 28mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398622 EAP HCPCS C1874 System Coron Stent 23mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398629 EAP HCPCS C1874 System Coron Stent 18mm 4mm Xience Srr Everolimus BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$2,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $787.50 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398631 EAP HCPCS C1874 System Coron Stent 15mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398632 EAP HCPCS C1874 System Coron Stent 12mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398634 EAP HCPCS C1874 System Coron Stent 8mm 4mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398635 EAP HCPCS C1874 System Coron Stent 38mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398636 EAP HCPCS C1874 System Coron Stent 33mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398638 EAP HCPCS C1874 System Coron Stent 28mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398639 EAP HCPCS C1874 System Coron Stent 23mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398640 EAP HCPCS C1874 System Coron Stent 18mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398647 EAP HCPCS C1874 System Coron Stent 15mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398650 EAP HCPCS C1874 System Coron Stent 12mm 3.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398655 EAP HCPCS C1874 System Coron Stent 8mm 3.5mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398661 EAP HCPCS C1874 System Coron Stent 38mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398666 EAP HCPCS C1874 System Coron Stent 33mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398672 EAP HCPCS C1874 System Coron Stent 28mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398673 EAP HCPCS C1874 System Coron Stent 23mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398679 EAP HCPCS C1874 System Coron Stent 18mm 3.25mm Xience Srr BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$2,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $787.50 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398680 EAP HCPCS C1874 System Coron Stent 15mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398682 EAP HCPCS C1874 System Coron Stent 12mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398683 EAP HCPCS C1874 System Coron Stent 8mm 3.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398684 EAP HCPCS C1874 System Coron Stent 38mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398685 EAP HCPCS C1874 System Coron Stent 33mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398686 EAP HCPCS C1874 System Coron Stent 28mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398687 EAP HCPCS C1874 System Coron Stent 23mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398688 EAP HCPCS C1874 System Coron Stent 18mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398689 EAP HCPCS C1874 System Coron Stent 15mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398690 EAP HCPCS C1874 System Coron Stent 12mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398691 EAP HCPCS C1874 System Coron Stent 8mm 3mm Xience Srr Everolimus BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398692 EAP HCPCS C1874 System Coron Stent 38mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398693 EAP HCPCS C1874 System Coron Stent 33mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398699 EAP HCPCS C1874 System Coron Stent 28mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398700 EAP HCPCS C1874 System Coron Stent 23mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398701 EAP HCPCS C1874 System Coron Stent 18mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398702 EAP HCPCS C1874 System Coron Stent 15mm 2.75mm Xience Srr BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$2,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $787.50 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398703 EAP HCPCS C1874 System Coron Stent 12mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398704 EAP HCPCS C1874 System Coron Stent 8mm 2.75mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398705 EAP HCPCS C1874 System Coron Stent 38mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398706 EAP HCPCS C1874 System Coron Stent 33mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398707 EAP HCPCS C1874 System Coron Stent 28mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398708 EAP HCPCS C1874 System Coron Stent 23mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398709 EAP HCPCS C1874 System Coron Stent 18mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398710 EAP HCPCS C1874 System Coron Stent 15mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398770 EAP HCPCS C1874 System Coron Stent 12mm 2.5mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398771 EAP HCPCS C1874 System Coron Stent 8mm 2.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398772 EAP HCPCS C1874 System Coron Stent 12mm 2.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398773 EAP HCPCS C1874 System Coron Stent 15mm 2.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398774 EAP HCPCS C1874 System Coron Stent 18mm 2.25mm Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398775 EAP HCPCS C1874 System Coron Stent 23mm 2.25mm Xience Srr BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$2,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $787.50 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398776 EAP HCPCS C1874 System Coron Stent 28mm 2.25mm Xience Srr BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$2,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $787.50 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398777 EAP HCPCS C1874 Stent Coron 33mm 2.25mm Everolimus Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398778 EAP HCPCS C1874 Stent Coron 38mm 2.25mm Everolimus Xience Srr BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" "$2,312.40" $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 "$1,350.00" $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398779 EAP HCPCS C1874 System Coron Stent 8mm 2.5mm Xience Srr Everolimus BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$2,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" "$1,348.90" $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $787.50 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 80398790 EAP HCPCS C1769 GUIDEWIRE VASC 300CM .014IN RADIOPQ CORE TO TIP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 80399090 EAP Advance Capsule Endoscopy Delivery Device BOTH IP/OP $413.00 $305.62 $0.00 $330.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.53 $306.53 $318.34 $0.00 $86.07 $0.00 $0.00 $0.00 $0.00 $206.50 $327.10 $330.40 $0.00 $268.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80399207 EAP HCPCS C1887 Catheter Infus 10d 3.5fr 135cm Otw 2 Lum Brd Trq BOTH IP/OP "$1,068.00 " $790.32 $0.00 $854.40 $579.92 $579.92 $0.00 $0.00 $0.00 $222.60 $792.67 $792.67 $823.21 $0.00 $222.57 $0.00 $631.72 $631.72 $0.00 $534.00 $845.86 $854.40 $0.00 $0.00 $0.00 $167.14 $0.00 $0.00 $170.03 $0.00 $0.00 $0.00 $0.00 $0.00 80399275 EAP HCPCS C1887 CATHETER INTVN 5.1FR 150CM 13CM TRAPLINER RX GD XTN RADOPQ BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 "$1,056.25" $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 80399276 EAP HCPCS C1887 CATHETER INTVN 5.7FR 150CM 13CM TRAPLINER RX GD XTN RADOPQ BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 "$1,056.25" $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 80399277 EAP HCPCS C1887 CATHETER INTVN 6.5FR 150CM 13CM TRAPLINER RX GD XTN RADOPQ BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 "$1,056.25" $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 80405583 EAP HCPCS C1757 CATHETER THRMB .044IN 140CM STRL LF INDG SYS ASP KT COR BOTH IP/OP "$4,850.00 " "$3,589.00" $0.00 "$3,880.00" "$2,182.50" "$2,182.50" $0.00 $0.00 $0.00 "$1,010.86" "$3,599.67" "$3,599.67" "$3,738.38" $0.00 "$1,010.74" $0.00 "$2,391.05" "$2,391.05" $0.00 "$2,425.00" "$3,841.20" "$3,880.00" $0.00 "$2,182.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80405584 EAP Custom 80405584 SEPARATOR THRMB STRL LF INDG SYS 4 DISP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" "$1,695.76" $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80405589 EAP HCPCS C1874 SYSTEM COR STNT 2MM 8MM 140CM RSLT ONYX RX DLV SYS RADOPQ 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 "$1,541.25" $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 80405590 EAP HCPCS C1874 SYSTEM COR STNT 2MM 12MM 140CM RSLT ONYX RX DLV SYS RADOPQ 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 "$1,541.25" $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 80405591 EAP HCPCS C1874 SYSTEM COR STNT 2MM 15MM 140CM RSLT ONYX RX DLV SYS RADOPQ 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 80405592 EAP HCPCS C1874 SYSTEM COR STNT 2MM 18MM 140CM RSLT ONYX RX DLV SYS RADOPQ 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 "$1,541.25" $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 80405593 EAP HCPCS C1874 SYSTEM COR STNT 2MM 22MM 140CM RSLT ONYX RX DLV SYS RADOPQ 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 80405594 EAP HCPCS C1874 SYSTEM COR STNT 2MM 26MM 140CM RSLT ONYX RX DLV SYS RADOPQ 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 "$1,541.25" $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 80405595 EAP HCPCS C1874 SYSTEM COR STNT 2MM 30MM 140CM RSLT ONYX RX DLV SYS RADOPQ 1 BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" "$2,639.99" $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 80406242 EAP Custom 80406242 PLUG OCL 3MM 12X5.3MM MVP MECH DTCH FULL RESHEATHABLE NTNL BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80406243 EAP Custom 80406243 PLUG OCL 5MM 12X6.5MM STRL LF MVP MECH DTCH FULL BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80406244 EAP Custom 80406244 PLUG OCL MIC 7MM STRL LF MVP MECH VASC DISP V03 BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" "$1,682.10" "$1,682.10" $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80406245 EAP Custom 80406245 PLUG OCL 9MM STRL LF MVP V03 BOTH IP/OP "$3,738.00 " "$2,766.12" $0.00 "$2,990.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.34" "$2,774.34" "$2,881.25" $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 "$1,869.00" "$2,960.50" "$2,990.40" $0.00 "$1,682.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80406248 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 180CM STRL LF CNFNZ PRO 12 DISP BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $216.45 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 80406249 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 300CM STRL LF FIELDER FC DISP BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $107.51 $107.51 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $152.62 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80406250 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 180CM STRL LF FIELDER FC DISP BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $107.51 $107.51 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $152.62 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $128.70 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80406251 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 300CM STRL LF GRAND SLAM DISP BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $156.38 $156.38 $0.00 $0.00 $0.00 $60.03 $213.75 $213.75 $221.99 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 80406252 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 180CM STRL LF MRCLBRS 6 DISP BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $216.45 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 80406253 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 300CM STRL LF MRCLBRS 6 DISP BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $216.45 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 80406254 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 300CM STRL LF MRCLBRS 3 DISP BOTH IP/OP $333.00 $246.42 $0.00 $266.40 $180.82 $180.82 $0.00 $0.00 $0.00 $69.41 $247.15 $247.15 $256.68 $0.00 $69.40 $0.00 $196.97 $196.97 $0.00 $166.50 $263.74 $266.40 $0.00 $216.45 $0.00 $52.11 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 80406255 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 180CM STRL LF P-H2O DISP BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $107.51 $107.51 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $152.62 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $128.70 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80406256 EAP HCPCS C1769 GUIDEWIRE VASC .014IN 300CM STRL LF P-H2O DISP BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80406275 EAP HCPCS C1894 Vascular Vein Kit BOTH IP/OP $353.00 $261.22 $0.00 $282.40 $191.68 $191.68 $0.00 $0.00 $0.00 $73.57 $262.00 $262.00 $272.09 $0.00 $73.57 $0.00 $208.80 $208.80 $0.00 $176.50 $279.58 $282.40 $0.00 $229.45 $0.00 $55.24 $0.00 $0.00 $56.20 $0.00 $0.00 $0.00 $0.00 $0.00 80406279 EAP HCPCS C1785 Pacemaker Assurity Mri 6mm X 50mm X 47mm 10.44 Cc 2 Chmbr Is-1 Con BOTH IP/OP "$12,225.00 " "$9,046.50" $0.00 "$9,780.00" "$5,501.25" "$5,501.25" $0.00 $0.00 $0.00 "$2,548.00" "$4,181.12" "$4,181.12" "$9,423.03" $0.00 "$2,547.69" $0.00 "$6,026.93" "$6,026.93" $0.00 "$6,112.50" "$9,682.20" "$9,780.00" $0.00 "$5,501.25" $0.00 "$1,913.21" $0.00 $0.00 "$1,946.22" $0.00 $0.00 $0.00 $0.00 $0.00 80406478 EAP Dressing Gel Strl Lf Isrb Abs Tube Nadh Cdxmr Iod 10gm BOTH IP/OP $35.00 $25.90 $0.00 $28.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $18.00 $28.51 $28.80 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80406479 EAP Dressing Gel Strl Iodoflex 3 In 1 Mode Abs Pd Nadh Cdxmr Iod BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $23.12 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80406513 EAP Marker Endoscopic Spot Ex Tattoo Prefill Perm Syringe BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.09 $705.09 $732.26 $0.00 $197.98 $0.00 $0.00 $0.00 $0.00 $475.00 $752.40 $760.00 $0.00 $617.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80406525 EAP HCPCS C1894 "Kit Triple Lumen Cvc, Agb+ 7 French, Pressure Rated, 20cm" BOTH IP/OP $366.00 $270.84 $0.00 $288.00 $198.74 $198.74 $0.00 $0.00 $0.00 $76.28 $271.65 $271.65 $282.11 $0.00 $76.27 $0.00 $216.49 $216.49 $0.00 $180.00 $285.12 $288.00 $0.00 $237.90 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 80411625 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 20mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411627 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 30mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411630 EAP HCPCS C1725 Catheter Baldilat 2mm 150cm 60mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411635 EAP HCPCS C1725 Catheter Baldilat 2.5mm 150cm 30mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411637 EAP HCPCS C1725 Catheter Baldilat 2.5mm 150cm 40mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411639 EAP HCPCS C1725 Catheter Baldilat 2.5mm 150cm 60mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411641 EAP HCPCS C1725 Catheter Baldilat 2.5mm 150cm 220mm Otw Inflat BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $276.25 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411645 EAP HCPCS C1725 Catheter Baldilat 3mm 150cm 30mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411648 EAP HCPCS C1725 Catheter Baldilat 3mm 150cm 60mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411651 EAP HCPCS C1725 Catheter Baldilat 3.5mm 150cm 20mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411653 EAP HCPCS C1725 Catheter Baldilat 3.5mm 150cm 30mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411655 EAP HCPCS C1725 Catheter Baldilat 3.5mm 150cm 40mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411657 EAP HCPCS C1725 Catheter Baldilat 3.5mm 150cm 60mm Otw Inflat Port BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411659 EAP HCPCS C1725 Catheter Baldilat 3.5mm 150cm 220mm Otw Inflat BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411662 EAP HCPCS C1725 Catheter Baldilat 5mm 150cm 120mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411666 EAP HCPCS C1725 Catheter Baldilat 5mm 150cm 220mm Peri Otw Tpr Tip BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80411668 EAP HCPCS C1725 Catheter Baldilat 6mm 120mm 150cm Otw Tpr Tip Lp BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $327.59 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 80412733 EAP HCPCS C2630 Catheter Ablation Tacticath 2-2-2 Mm Space Damato Type BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$5,202.90" $0.00 "$1,406.70" $0.00 $0.00 $0.00 $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 "$4,387.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80416033 EAP HCPCS C1895 "Lead Defibrillator Reliance 4-front, Dual Coil 59cm" BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" "$2,925.00" "$2,925.00" $0.00 $0.00 $0.00 "$1,354.76" "$4,181.12" "$4,181.12" "$5,010.20" $0.00 "$1,354.60" $0.00 "$3,204.50" "$3,204.50" $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 "$2,925.00" $0.00 "$1,017.25" $0.00 $0.00 "$1,034.80" $0.00 $0.00 $0.00 $0.00 $0.00 80416166 EAP HCPCS C1722 Dfbr Crd .99cm 5.37x7.79cm Momentum Heartlogic BOTH IP/OP "$22,643.00 " "$16,755.82" $0.00 "$18,114.40" "$10,189.35" "$10,189.35" $0.00 $0.00 $0.00 "$4,719.37" "$4,181.12" "$4,181.12" "$17,453.22" $0.00 "$4,718.80" $0.00 "$11,163.00" "$11,163.00" $0.00 "$11,321.50" "$17,933.26" "$18,114.40" $0.00 $0.00 $0.00 "$3,543.63" $0.00 $0.00 "$3,604.77" $0.00 $0.00 $0.00 $0.00 $0.00 80416179 EAP HCPCS C1721 Resonate El Aicd Dual Chamber 5.37cm 7.68cm 0.99cm BOTH IP/OP "$28,250.00 " "$20,905.00" $0.00 "$22,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$5,888.01" "$4,181.12" "$4,181.12" "$21,775.10" $0.00 "$5,887.30" $0.00 "$13,927.25" "$13,927.25" $0.00 "$14,125.00" "$22,374.00" "$22,600.00" $0.00 "$12,712.50" $0.00 "$4,421.13" $0.00 $0.00 "$4,497.40" $0.00 $0.00 $0.00 $0.00 $0.00 80416197 EAP HCPCS C1786 Pacemaker Crd .75cm 4.45x4.81cm Acld Pacesafe Ltd BOTH IP/OP "$6,680.00 " "$4,943.20" $0.00 "$5,344.00" "$3,006.00" "$3,006.00" $0.00 $0.00 $0.00 "$1,392.28" "$4,181.12" "$4,181.12" "$5,148.94" $0.00 "$1,392.11" $0.00 "$3,293.24" "$3,293.24" $0.00 "$3,340.00" "$5,290.56" "$5,344.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80416198 EAP HCPCS C1785 Pacemaker Crd .75cm 4.45x5.02cm Acld Pacesafe Ltd BOTH IP/OP "$7,625.00 " "$5,642.50" $0.00 "$6,100.00" "$3,431.25" "$3,431.25" $0.00 $0.00 $0.00 "$1,589.24" "$4,181.12" "$4,181.12" "$5,877.35" $0.00 "$1,589.05" $0.00 "$3,759.13" "$3,759.13" $0.00 "$3,812.50" "$6,039.00" "$6,100.00" $0.00 $0.00 $0.00 "$1,193.31" $0.00 $0.00 "$1,213.90" $0.00 $0.00 $0.00 $0.00 $0.00 80435214 EAP HCPCS C1887 Kit Catheter Gd 9fr 80cm Strl Lf Mrc Bln Sil With Axs Catalyst BOTH IP/OP "$7,979.00 " "$5,904.46" $0.00 "$6,383.20" "$4,332.60" "$4,332.60" $0.00 $0.00 $0.00 "$1,663.02" "$4,181.12" "$4,181.12" "$6,150.21" $0.00 "$1,662.82" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,989.50" "$6,319.37" "$6,383.20" $0.00 $0.00 $0.00 "$1,248.71" $0.00 $0.00 "$1,270.26" $0.00 $0.00 $0.00 $0.00 $0.00 80435215 EAP HCPCS C1887 Kit Catheter Gd 9fr 95cm Strl Lf Mrc Bln Sil With Axs Catalyst BOTH IP/OP "$7,979.00 " "$5,904.46" $0.00 "$6,383.20" "$4,332.60" "$4,332.60" $0.00 $0.00 $0.00 "$1,663.02" "$4,181.12" "$4,181.12" "$6,150.21" $0.00 "$1,662.82" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,989.50" "$6,319.37" "$6,383.20" $0.00 $0.00 $0.00 "$1,248.71" $0.00 $0.00 "$1,270.26" $0.00 $0.00 $0.00 $0.00 $0.00 80436768 EAP HCPCS C1817 Plug Cardio 11mm 6mm 4fr Amplzr .038in Lp Ntnl BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,762.73" "$1,762.73" "$1,830.65" $0.00 $494.95 $0.00 $0.00 $0.00 $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 "$1,068.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80436769 EAP HCPCS C1817 Plug Cardio 13.5mm 8mm 4fr Amplzr .038in Lp Ntnl BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,762.73" "$1,762.73" "$1,830.65" $0.00 $494.95 $0.00 $0.00 $0.00 $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 "$1,068.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80436770 EAP HCPCS C1769 Kit Trevo 3x20 Packaged With Synchro2 Std Custom Grady BOTH IP/OP "$14,432.00 " "$10,679.68" $0.00 "$11,545.60" "$7,836.58" "$7,836.58" $0.00 $0.00 $0.00 "$3,007.99" "$4,181.12" "$4,181.12" "$11,124.19" $0.00 "$3,007.63" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,216.00" "$11,430.14" "$11,545.60" $0.00 $0.00 $0.00 "$2,258.61" $0.00 $0.00 "$2,297.57" $0.00 $0.00 $0.00 $0.00 $0.00 80436771 EAP HCPCS C1769 Kit Trevo 4x20 Packaged With Synchro2 Std Custom Grady BOTH IP/OP "$14,432.00 " "$10,679.68" $0.00 "$11,545.60" "$7,836.58" "$7,836.58" $0.00 $0.00 $0.00 "$3,007.99" "$4,181.12" "$4,181.12" "$11,124.19" $0.00 "$3,007.63" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,216.00" "$11,430.14" "$11,545.60" $0.00 $0.00 $0.00 "$2,258.61" $0.00 $0.00 "$2,297.57" $0.00 $0.00 $0.00 $0.00 $0.00 80436772 EAP HCPCS C1769 Kit Trevo 4x30 Packaged With Synchro2 Std Custom Grady BOTH IP/OP "$14,432.00 " "$10,679.68" $0.00 "$11,545.60" "$7,836.58" "$7,836.58" $0.00 $0.00 $0.00 "$3,007.99" "$4,181.12" "$4,181.12" "$11,124.19" $0.00 "$3,007.63" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,216.00" "$11,430.14" "$11,545.60" $0.00 $0.00 $0.00 "$2,258.61" $0.00 $0.00 "$2,297.57" $0.00 $0.00 $0.00 $0.00 $0.00 80436773 EAP HCPCS C1769 Kit Trevo 6x25 Packaged With Synchro2 Std Custom Grady BOTH IP/OP "$14,432.00 " "$10,679.68" $0.00 "$11,545.60" "$7,836.58" "$7,836.58" $0.00 $0.00 $0.00 "$3,007.99" "$4,181.12" "$4,181.12" "$11,124.19" $0.00 "$3,007.63" $0.00 "$3,094.73" "$3,094.73" $0.00 "$7,216.00" "$11,430.14" "$11,545.60" $0.00 $0.00 $0.00 "$2,258.61" $0.00 $0.00 "$2,297.57" $0.00 $0.00 $0.00 $0.00 $0.00 80436775 EAP HCPCS C1884 Kit Intvn Enroute Neuroprotection Transcarotid BOTH IP/OP "$8,875.00 " "$6,567.50" $0.00 "$7,100.00" "$4,819.13" "$4,819.13" $0.00 $0.00 $0.00 "$1,849.77" "$4,181.12" "$4,181.12" "$6,840.85" $0.00 "$1,849.55" $0.00 "$3,094.73" "$3,094.73" $0.00 "$4,437.50" "$7,029.00" "$7,100.00" $0.00 $0.00 $0.00 "$1,388.94" $0.00 $0.00 "$1,412.90" $0.00 $0.00 $0.00 $0.00 $0.00 80436776 EAP HCPCS C1894 Kit Mctrdcr 21ga 7cm Ndl BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$2,375.63" "$2,375.63" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" "$3,372.25" $0.00 $911.75 $0.00 "$2,587.81" "$2,587.81" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 80436777 EAP HCPCS C1769 Guidewire Vasc 5cm .014in 95cm 15cm Enroute Radopq Ptfe BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,289.63" "$1,289.63" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" "$1,830.65" $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 80436779 EAP HCPCS C1729 Tray Cath 14fr 60in 350ml Ltx Bdx Lbr Adv Urmtr Drn Tube BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 80436780 EAP HCPCS C1729 Tray Cath 16fr 60in 350ml Strl Ltx Lbrcth Urmtr Drn Tube BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 80436781 EAP HCPCS C1729 Tray Cath 18fr 60in 350ml Ltx Bdx Lbr Adv Urmtr Drn Tube BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 80436783 EAP HCPCS C1757 Catheter Asp .074in 125cm Strl Lf Axs Vecta 74 Lum Disp BOTH IP/OP "$7,375.00 " "$5,457.50" $0.00 "$5,900.00" "$4,004.63" "$4,004.63" $0.00 $0.00 $0.00 "$1,537.13" "$4,181.12" "$4,181.12" "$5,684.65" $0.00 "$1,536.95" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,687.50" "$5,841.00" "$5,900.00" $0.00 "$4,793.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80436784 EAP HCPCS C1757 Catheter Asp .074in 132cm Strl Lf Axs Vecta 74 Lum Disp BOTH IP/OP "$7,375.00 " "$5,457.50" $0.00 "$5,900.00" "$4,004.63" "$4,004.63" $0.00 $0.00 $0.00 "$1,537.13" "$4,181.12" "$4,181.12" "$5,684.65" $0.00 "$1,536.95" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,687.50" "$5,841.00" "$5,900.00" $0.00 "$4,793.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80436791 EAP HCPCS C1894 Kit Intro .021in 80cm 6fr 21ga 25cm Strl 1.5in Glidesheath BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $78.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 80436798 EAP HCPCS C1894 Sheath Intro 8.2mm 22fr 33cm Gore Dryseal Flx Hdrph BOTH IP/OP "$1,585.00 " "$1,172.90" $0.00 "$1,268.00" $860.66 $860.66 $0.00 $0.00 $0.00 $330.35 "$1,176.39" "$1,176.39" "$1,221.72" $0.00 $330.31 $0.00 $937.53 $937.53 $0.00 $792.50 "$1,255.32" "$1,268.00" $0.00 "$1,030.25" $0.00 $248.05 $0.00 $0.00 $252.33 $0.00 $0.00 $0.00 $0.00 $0.00 80436802 EAP HCPCS C1894 Sheath Introducer Gore Dryseal Flex Hydro L33 Cm Od9.5 Mm Id26 Fr BOTH IP/OP "$1,585.00 " "$1,172.90" $0.00 "$1,268.00" $860.66 $860.66 $0.00 $0.00 $0.00 $330.35 "$1,176.39" "$1,176.39" "$1,221.72" $0.00 $330.31 $0.00 $937.53 $937.53 $0.00 $792.50 "$1,255.32" "$1,268.00" $0.00 "$1,030.25" $0.00 $248.05 $0.00 $0.00 $252.33 $0.00 $0.00 $0.00 $0.00 $0.00 80436934 EAP HCPCS C1876 Stent Eprsth 14mm 90mm 100mm Vici Vns Stnt Cath Ntnl Acpt BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" "$4,046.70" $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 "$2,362.50" $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80438566 EAP HCPCS C1760 Device Clsr 18fr Manta Vasc BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 80438567 EAP HCPCS C1760 Device Clsr 14fr Manta Vasc BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" "$2,408.75" $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 "$1,406.25" $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 80438594 EAP HCPCS C1894 Kit Intro .018in Mic 5fr 21ga 3fr 45cm Strl 15cm BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $135.75 $135.75 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $192.70 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $162.50 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 80438603 EAP Custom 80438603 Sheath Gd Strg 6fr 119cm Strl Lf R2p Destination Slndr Disp BOTH IP/OP $754.00 $557.96 $0.00 $603.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $377.00 $597.17 $603.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80438604 EAP HCPCS C1887 Catheter Intvn 45d .014in Mic 2.1-2.5fr .017in .021in 150cm BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 80438605 EAP HCPCS C1887 Catheter Intvn 90d Mic 2.4fr .017in .018in 130cm 40cm BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 80438606 EAP HCPCS C1887 Catheter Intvn 90d .014in Mic 2.1-2.5fr .017in .021in 150cm BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 80438607 EAP HCPCS C1887 Catheter Intvn 120d Mic 2.4-3.2fr .017-.018in 130cm 80cm BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 80438608 EAP HCPCS C1887 Catheter Intvn 120d .014in Mic 2.1-2.5fr .017in .021in 150cm BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 80438609 EAP HCPCS C1887 Catheter Intvn 90d Mic 2.4fr .017in .018in 130cm 80cm BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 80438610 EAP HCPCS C1887 Catheter Intvn 45d .014in Mic 2.1-2.5fr .017in .021in 130cm BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 80438611 EAP HCPCS C1887 Catheter Intvn 120d Mic 3.2-2.4fr .018-.017in 150cm 80cm BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 80438621 EAP Bronchoscope Glidescope BOTH IP/OP $369.00 $273.06 $0.00 $284.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.87 $273.87 $284.43 $0.00 $76.90 $0.00 $0.00 $0.00 $0.00 $18.50 $29.30 $29.60 $0.00 $239.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80463074 EAP HCPCS C1887 Catheter Gd Mp1 Crv 6fr 100cm Strl Lf Lnchr Lg Lum Radopq BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $92.50 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $78.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 80467372 EAP HCPCS C1769 Guidewire Vasc 220cm .007-.012in Distal Tip BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 80467373 EAP HCPCS C1769 Guidewire Vasc 220cm .007-.012in Distal Tip BOTH IP/OP "$1,495.00 " "$1,106.30" $0.00 "$1,196.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $747.50 "$1,184.04" "$1,196.00" $0.00 $0.00 $0.00 $233.97 $0.00 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 80467374 EAP HCPCS C1769 Guidewire Vasc 220cm .008-.012in Hbrd Radiopq Str BOTH IP/OP "$1,426.00 " "$1,055.24" $0.00 "$1,140.00" $774.32 $774.32 $0.00 $0.00 $0.00 $297.21 "$1,058.38" "$1,058.38" "$1,099.16" $0.00 $297.18 $0.00 $843.48 $843.48 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $926.90 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 80467375 EAP HCPCS C1769 Guidewire Vasc 220cm .008-.012in Distal Tip BOTH IP/OP "$1,495.00 " "$1,106.30" $0.00 "$1,196.00" $811.79 $811.79 $0.00 $0.00 $0.00 $311.60 "$1,109.59" "$1,109.59" "$1,152.35" $0.00 $311.56 $0.00 $884.29 $884.29 $0.00 $747.50 "$1,184.04" "$1,196.00" $0.00 $971.75 $0.00 $233.97 $0.00 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 80467376 EAP HCPCS C1769 Guidewire Vasc 200cm .012-.014in Hbrd Radiopq Str BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $562.01 $562.01 $0.00 $0.00 $0.00 $215.72 $768.18 $768.18 $797.78 $0.00 $215.69 $0.00 $612.20 $612.20 $0.00 $517.50 $819.72 $828.00 $0.00 $672.75 $0.00 $161.98 $0.00 $0.00 $164.77 $0.00 $0.00 $0.00 $0.00 $0.00 80467377 EAP HCPCS C1769 Guidewire Vasc 2 Ang .012-.014 BOTH IP/OP "$1,093.00 " $808.82 $0.00 $874.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.50 $865.66 $874.40 $0.00 $0.00 $0.00 $171.05 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $0.00 80467378 EAP HCPCS C1769 Guidewire Vasc 310cm .010in Radiopq Atrm Tip Str BOTH IP/OP "$1,598.00 " "$1,182.52" $0.00 "$1,278.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $799.00 "$1,265.62" "$1,278.40" $0.00 $0.00 $0.00 $250.09 $0.00 $0.00 $254.40 $0.00 $0.00 $0.00 $0.00 $0.00 80467379 EAP HCPCS C1769 Guidewire Vasc 310cm .012in Radiopq Atrm Tip Str BOTH IP/OP "$1,598.00 " "$1,182.52" $0.00 "$1,278.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $799.00 "$1,265.62" "$1,278.40" $0.00 $0.00 $0.00 $250.09 $0.00 $0.00 $254.40 $0.00 $0.00 $0.00 $0.00 $0.00 80467381 EAP HCPCS C1894 Introducer Sheath 088 80 Cm BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $597.30 $597.30 $0.00 $0.00 $0.00 $0.00 $816.42 $816.42 $847.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $550.00 $871.20 $880.00 $0.00 $715.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 80467382 EAP HCPCS C1894 Introducer Sheath 088 90 Cm BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $597.30 $597.30 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $847.88 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $715.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 80467383 EAP HCPCS C1894 Introducer Sheath 088 100 Cm BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 80467384 EAP HCPCS C1769 Guidewire Vasc 180cm .035in Std Tip Radiopq Strbl BOTH IP/OP $155.00 $114.70 $0.00 $140.00 $84.17 $84.17 $0.00 $0.00 $0.00 $32.31 $115.04 $115.04 $119.47 $0.00 $32.30 $0.00 $91.68 $91.68 $0.00 $87.50 $138.60 $140.00 $0.00 $100.75 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 80467385 EAP HCPCS C1769 Guidewire Vasc 300cm .035in Std Tip Radiopq Strbl BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 80467387 EAP HCPCS C1751 Kit Cath 6fr 60cm Prln 2 Lum Basic Gwire Mini Scpl BOTH IP/OP $438.00 $324.12 $0.00 $350.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $346.90 $350.40 $0.00 $0.00 $0.00 $68.55 $0.00 $0.00 $69.73 $0.00 $0.00 $0.00 $0.00 $0.00 80467396 EAP HCPCS C2628 Catheter Blnocc Thk.9mm 3cm 7mm 1.1in 6- Mm 2fr BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80467397 EAP HCPCS C2628 Catheter Blnocc Thk.9mm 3cm 7mm 1.1in 6- Mm 2fr BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80467398 EAP HCPCS C2628 Catheter Blnocc Thk.9mm 3cm 7mm 1.1in 6- Mm 2fr BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80467399 EAP HCPCS C2628 Catheter Blnocc Thk.9mm 3cm 7mm 1.1in 6- Mm 2fr BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80467400 EAP HCPCS C2628 Catheter Blnocc Thk.9mm 3cm 3mm 1.1in 6- Mm 2fr BOTH IP/OP "$5,238.00 " "$3,876.12" $0.00 "$4,190.40" "$2,844.23" "$2,844.23" $0.00 $0.00 $0.00 "$1,091.73" "$3,887.64" "$3,887.64" "$4,037.45" $0.00 "$1,091.60" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,619.00" "$4,148.50" "$4,190.40" $0.00 "$3,404.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80469324 EAP HCPCS C1895 Lead Dfbr 64cm 7.3fr Rlnc 4-frn Rv Mp35n Irox Strd BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" "$2,925.00" "$2,925.00" $0.00 $0.00 $0.00 "$1,354.76" "$4,181.12" "$4,181.12" "$5,010.20" $0.00 "$1,354.60" $0.00 "$3,204.50" "$3,204.50" $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 "$2,925.00" $0.00 "$1,017.25" $0.00 $0.00 "$1,034.80" $0.00 $0.00 $0.00 $0.00 $0.00 80469325 EAP HCPCS C1777 Lead Dfbr 64cm 7.3fr Rlnc 4-frn Rv Mp35n Irox Strd 1 Coil BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" "$2,925.00" "$2,925.00" $0.00 $0.00 $0.00 "$1,354.76" "$4,181.12" "$4,181.12" "$5,010.20" $0.00 "$1,354.60" $0.00 "$3,204.50" "$3,204.50" $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 "$2,925.00" $0.00 "$1,017.25" $0.00 $0.00 "$1,034.80" $0.00 $0.00 $0.00 $0.00 $0.00 80469326 EAP HCPCS C1895 Lead Dfbr 59cm 7.3fr Rlnc 4-frn Rv Mp35n Irox Strd 2 Coil BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" "$2,925.00" "$2,925.00" $0.00 $0.00 $0.00 "$1,354.76" "$4,181.12" "$4,181.12" "$5,010.20" $0.00 "$1,354.60" $0.00 "$3,204.50" "$3,204.50" $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 "$2,925.00" $0.00 "$1,017.25" $0.00 $0.00 "$1,034.80" $0.00 $0.00 $0.00 $0.00 $0.00 80472492 EAP HCPCS C1887 Catheter Dlv Sys 45d Mic .025in 135cm Lntrn Hflo BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" "$1,252.55" $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 "$1,056.25" $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 80472499 EAP Coil Embl Std .02in 3mm 20cm Penumbra Coil 400 Ruby Cmplx Lg BOTH IP/OP "$2,475.00 " "$1,831.50" $0.00 "$1,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,836.95" "$1,836.95" "$1,907.73" $0.00 $515.79 $0.00 $0.00 $0.00 $0.00 "$1,237.50" "$1,960.20" "$1,980.00" $0.00 "$1,113.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80472510 EAP Coil Embl Std .02in 7mm 25cm Penumbra Coil 400 Ruby Cmplx Lg BOTH IP/OP "$2,475.00 " "$1,831.50" $0.00 "$1,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,836.95" "$1,836.95" "$1,907.73" $0.00 $515.79 $0.00 $0.00 $0.00 $0.00 "$1,237.50" "$1,960.20" "$1,980.00" $0.00 "$1,113.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80472512 EAP COIL EMBL STD .02IN 8MM 25CM PENUMBRA COIL 400 RUBY CMPLX LG BOTH IP/OP "$2,475.00 " "$1,831.50" $0.00 "$1,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,836.95" "$1,836.95" "$1,907.73" $0.00 $515.79 $0.00 $0.00 $0.00 $0.00 "$1,237.50" "$1,960.20" "$1,980.00" $0.00 "$1,113.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80472530 EAP Coil Embl .02in 2mm 4cm Penumbra Coil 400 Ruby Cmplx Lg BOTH IP/OP "$1,975.00 " "$1,461.50" $0.00 "$1,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,465.85" "$1,465.85" "$1,522.33" $0.00 $411.59 $0.00 $0.00 $0.00 $0.00 $987.50 "$1,564.20" "$1,580.00" $0.00 $888.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80472552 EAP Coil Embl J-sft 30cm Strl Lf Pod Pk BOTH IP/OP "$3,225.00 " "$2,386.50" $0.00 "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,393.60" "$2,393.60" "$2,485.83" $0.00 $672.09 $0.00 $0.00 $0.00 $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 "$1,451.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80472555 EAP COIL EMBL J-SFT 60CM STRL LF POD PK BOTH IP/OP "$3,225.00 " "$2,386.50" $0.00 "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,393.60" "$2,393.60" "$2,485.83" $0.00 $672.09 $0.00 $0.00 $0.00 $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 "$1,451.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80472556 EAP Handle Inst Ruby Dtch Coil BOTH IP/OP $595.00 $440.30 $0.00 $476.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $441.61 $441.61 $458.63 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $297.50 $471.24 $476.00 $0.00 $267.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80488974 EAP HCPCS C1882 Cobalt Hf Quad Crt-d Mri Surescan BOTH IP/OP "$44,750.00 " "$33,115.00" $0.00 "$35,800.00" "$20,137.50" "$20,137.50" $0.00 $0.00 $0.00 "$9,327.02" "$4,181.12" "$4,181.12" "$34,493.30" $0.00 "$9,325.90" $0.00 "$22,061.75" "$22,061.75" $0.00 "$22,375.00" "$35,442.00" "$35,800.00" $0.00 "$20,137.50" $0.00 $0.00 $0.00 $0.00 "$7,124.20" $0.00 $0.00 $0.00 $0.00 $0.00 82000002 EAP CPT® G0257 Emergency Dialysis BOTH IP/OP "$3,267.00 " "$2,417.58" $0.00 "$2,123.55" "$1,773.98" "$1,773.98" $637.82 $637.82 $641.42 $680.92 $0.00 $0.00 $0.00 $627.13 $680.84 $407.64 "$1,932.43" "$1,932.43" $641.91 "$1,194.00" "$1,891.30" "$1,910.40" $891.85 "$2,123.55" $891.85 $373.72 $0.00 $0.00 $380.17 $611.34 $0.00 $0.00 $0.00 $0.00 83100001 EAP CPT® 90947 Intpatient Dialysis Crrt BOTH IP/OP "$3,267.00 " "$2,417.58" $0.00 "$2,123.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $680.84 $0.00 $0.00 $0.00 $0.00 "$1,194.00" "$1,891.30" "$1,910.40" $0.00 "$2,123.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83100005 EAP CPT® 90945 Peritoneal Dialysis Op BOTH IP/OP "$1,724.00 " "$1,275.76" $0.00 "$1,379.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.28 $0.00 $0.00 $0.00 $0.00 $862.00 "$1,365.41" "$1,379.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000011 EAP CPT® 90882 Brief Evaluation Management BOTH IP/OP $62.00 $45.88 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.02 $46.02 $47.79 $0.00 $12.92 $0.00 $0.00 $0.00 $0.00 $31.00 $49.10 $49.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000012 EAP CPT® 90885 Psych Eval Of Records BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $308.32 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000013 EAP CPT® 90887 Consultation With Family BOTH IP/OP $242.00 $179.08 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.61 $179.61 $186.53 $0.00 $50.43 $0.00 $0.00 $0.00 $0.00 $120.00 $190.08 $192.00 $0.00 $157.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000014 EAP CPT® 90889 Preparation Of Reports BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.13 $178.13 $184.99 $0.00 $50.02 $0.00 $0.00 $0.00 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000017 EAP HCPCS H0004 Group Outpatient Services BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $11.40 $0.00 $11.40 $2.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000020 EAP HCPCS H0004 Group Outpatient Services BOTH IP/OP $19.00 $14.06 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $3.38 $24.42 $14.10 $14.10 $14.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $51.00 $12.35 $51.00 $13.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000022 EAP HCPCS H0004 Group Outpatient Services BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $15.13 $24.42 $63.09 $63.09 $65.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $51.00 $0.00 $51.00 $13.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000023 EAP HCPCS H0020 Methadone Administration BOTH IP/OP $131.00 $96.94 $0.00 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.23 $97.23 $100.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.50 $103.75 $104.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000024 EAP HCPCS H0031 Mh Assessment By A Non-physician BOTH IP/OP $168.00 $124.32 $0.00 $133.60 $0.00 $0.00 $0.00 $0.00 $29.90 $27.68 $124.69 $124.69 $129.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $132.26 $133.60 $100.20 $109.20 $100.20 $26.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000026 EAP HCPCS H0032 Service Plan Development BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $15.13 $27.68 $63.09 $63.09 $65.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $51.00 $55.25 $51.00 $13.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000027 EAP HCPCS H0038 Peer Support BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $4.98 $1.80 $20.78 $20.78 $21.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $16.80 $18.20 $16.80 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000028 EAP HCPCS H0039 Assertive Community Treatment BOTH IP/OP $93.00 $68.82 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $16.55 $28.95 $69.02 $69.02 $71.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.50 $73.66 $74.40 $55.80 $60.45 $55.80 $14.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000030 EAP HCPCS H2010 Medication Administ Comp BOTH IP/OP $86.00 $63.64 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $15.31 $28.99 $63.83 $63.83 $66.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $51.00 $55.90 $51.00 $13.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000035 EAP HCPCS H2014 Group Skills Train/devl 15 Min BOTH IP/OP $15.00 $11.10 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $2.67 $16.80 $11.13 $11.13 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $9.00 $11.05 $9.00 $2.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000045 EAP HCPCS H2011 Crisis Intervention BOTH IP/OP $137.00 $101.38 $0.00 $108.80 $0.00 $0.00 $0.00 $0.00 $24.39 $28.15 $101.68 $101.68 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.00 $107.71 $108.80 $81.60 $89.05 $81.60 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000048 EAP HCPCS H2017 Psychosocial Rehabilitation BOTH IP/OP $28.00 $20.72 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $4.98 $0.00 $20.78 $20.78 $21.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.00 $22.18 $22.40 $16.80 $18.20 $16.80 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000049 EAP HCPCS H2014 Grp/fam Skill Train W/pat15min BOTH IP/OP $17.00 $12.58 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $3.03 $16.80 $12.62 $12.62 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $10.20 $0.00 $10.20 $2.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000051 EAP HCPCS H2014 Group Skills Training 15mins BOTH IP/OP $17.00 $12.58 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $3.03 $16.80 $12.62 $12.62 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $10.20 $0.00 $10.20 $2.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000052 EAP HCPCS H2014 Family Training W/pat 15mins BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $0.00 $0.00 $0.00 $0.00 $12.82 $16.80 $53.44 $53.44 $55.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $57.02 $57.60 $43.20 $0.00 $43.20 $11.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000053 EAP HCPCS H2014 Family Training W/o Pat 15mins BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $0.00 $0.00 $0.00 $0.00 $12.82 $16.80 $53.44 $53.44 $55.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $57.02 $57.60 $43.20 $0.00 $43.20 $11.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000054 EAP HCPCS T1001 Nursing Assessment BOTH IP/OP $99.00 $73.26 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $17.62 $0.00 $73.48 $73.48 $76.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.00 $77.62 $78.40 $58.80 $64.35 $58.80 $15.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000055 EAP HCPCS T1001 Nursing Assessment BOTH IP/OP $98.00 $72.52 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.00 $77.62 $78.40 $58.80 $0.00 $58.80 $15.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000056 EAP HCPCS T1002 Rn Services 15mins BOTH IP/OP $99.00 $73.26 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $17.62 $0.00 $73.48 $73.48 $76.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.00 $77.62 $78.40 $58.80 $64.35 $58.80 $15.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000057 EAP HCPCS T1003 Lpn Services 15mins BOTH IP/OP $75.00 $55.50 $0.00 $59.20 $0.00 $0.00 $0.00 $0.00 $13.35 $0.00 $55.67 $55.67 $57.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.00 $58.61 $59.20 $44.40 $48.75 $44.40 $11.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000058 EAP HCPCS T2038 Community Transitional Planning BOTH IP/OP $70.00 $51.80 $0.00 $55.20 $0.00 $0.00 $0.00 $0.00 $12.46 $0.00 $51.95 $51.95 $53.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.50 $54.65 $55.20 $41.40 $45.50 $41.40 $10.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000060 EAP HCPCS H0004 Multi-group Family Couns 15min BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $11.40 $0.00 $11.40 $2.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000067 EAP CPT® 90791 Psych Dx Eval (no Med Service) BOTH IP/OP $576.00 $426.24 $0.00 $457.60 $312.77 $312.77 $130.30 $130.30 $131.03 $120.05 $427.51 $427.51 $443.98 $128.07 $0.00 $83.25 $340.70 $340.70 $131.75 $286.00 $453.02 $457.60 $183.04 $374.40 $183.04 $143.47 $127.71 $127.71 $91.06 $125.47 $0.00 $0.00 $0.00 $0.00 90000068 EAP CPT® 90792 Psych Dx Eval (with Med Service) BOTH IP/OP $576.00 $426.24 $0.00 $457.60 $312.77 $312.77 $130.30 $130.30 $131.03 $120.05 $427.51 $427.51 $443.98 $128.07 $0.00 $83.25 $340.70 $340.70 $131.75 $286.00 $453.02 $457.60 $183.04 $374.40 $183.04 $117.89 $142.86 $142.86 $91.06 $125.47 $0.00 $0.00 $0.00 $0.00 90000069 EAP CPT® 90785 Interactive Complexity BOTH IP/OP $321.00 $237.54 $0.00 $255.20 $174.30 $174.30 $0.00 $0.00 $0.00 $66.90 $238.25 $238.25 $247.43 $0.00 $0.00 $0.00 $189.87 $189.87 $0.00 $159.50 $252.65 $255.20 $0.00 $208.65 $0.00 $49.92 $14.07 $14.07 $50.78 $0.00 $0.00 $0.00 $0.00 $0.00 90000070 EAP HCPCS T1016 Case Management BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $33.40 $33.40 $34.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $27.00 $29.25 $27.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000071 EAP HCPCS T1016 "Case Management - Practitioner Level 5," BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $33.40 $33.40 $34.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $27.00 $0.00 $27.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000072 EAP HCPCS T1016 "Case Management - Practitioner Level 4," BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $33.40 $33.40 $34.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $27.00 $0.00 $27.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000073 EAP HCPCS T1016 "Case Management - Practitioner Level 5," BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $33.40 $33.40 $34.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $27.00 $0.00 $27.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000074 EAP HCPCS T1016 "CASE MANAGEMENT-PRACTITIONER LEVEL 4, COLLATERAL CONTACT" BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $33.40 $33.40 $34.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $27.00 $0.00 $27.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000075 EAP HCPCS T1016 "Case Management-practitioner Level 5, Collateral Contact" BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $27.00 $0.00 $27.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000076 EAP HCPCS T1016 "CASE MANAGEMENT-PRACTITIONER LEVEL 4,COLLATERAL CONTACT" BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $33.40 $33.40 $34.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $27.00 $0.00 $27.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000077 EAP HCPCS T1016 "CASE MANAGEMENT-PREACTITIONER LEVEL 5,OUT-COLLATERAL" BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $27.00 $0.00 $27.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000078 EAP HCPCS H0025 Peer Support Whole Health & Wellness BOTH IP/OP $34.00 $25.16 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $6.05 $0.00 $25.23 $25.23 $26.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $20.40 $22.10 $20.40 $5.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90000080 EAP CPT® G0447 Behavior Counsel Obesity 15m BOTH IP/OP $101.00 $74.74 $15.65 $100.00 $54.84 $54.84 $72.87 $72.87 $73.28 $21.05 $74.96 $74.96 $77.85 $71.76 $21.05 $46.64 $59.74 $59.74 $78.77 $50.00 $79.20 $80.00 $100.00 $65.65 $100.00 $15.65 $24.16 $24.16 $15.92 $75.02 $0.00 $0.00 $0.00 $0.00 90000081 EAP HCPCS G0444 "Annual Depression Screening, 15 Minutes" BOTH IP/OP $71.00 $52.54 $0.00 $56.00 $38.55 $38.55 $25.59 $25.59 $25.74 $14.80 $52.70 $52.70 $54.73 $25.14 $14.80 $16.34 $42.00 $42.00 $27.40 $35.00 $55.44 $56.00 $38.07 $0.00 $38.07 $10.96 $9.74 $9.74 $11.14 $26.10 $0.00 $0.00 $0.00 $0.00 91400004 EAP CPT® 90832 Individual Psychotherapy 30 Mins BOTH IP/OP $541.00 $400.34 $0.00 $429.60 $293.76 $293.76 $130.30 $130.30 $131.03 $112.76 $401.53 $401.53 $417.00 $128.07 $0.00 $83.25 $320.00 $320.00 $131.75 $268.50 $425.30 $429.60 $183.04 $351.65 $183.04 $59.54 $63.85 $63.85 $85.49 $125.47 $0.00 $0.00 $0.00 $0.00 91400006 EAP CPT® 90837 Individual Psychotherapy 60 Min BOTH IP/OP $658.00 $486.92 $0.00 $522.40 $357.29 $357.29 $130.30 $130.30 $131.03 $137.14 $488.37 $488.37 $507.19 $128.07 $0.00 $83.25 $389.21 $389.21 $131.75 $326.50 $517.18 $522.40 $183.04 $427.70 $183.04 $124.37 $127.35 $127.35 $103.96 $125.47 $0.00 $0.00 $0.00 $0.00 91400024 EAP CPT® 90834 Individual Psychotherapy 45 Min BOTH IP/OP $541.00 $400.34 $0.00 $429.60 $293.76 $293.76 $130.30 $130.30 $131.03 $112.76 $401.53 $401.53 $417.00 $128.07 $0.00 $83.25 $320.00 $320.00 $131.75 $268.50 $425.30 $429.60 $183.04 $351.65 $183.04 $84.04 $85.14 $85.14 $85.49 $125.47 $0.00 $0.00 $0.00 $0.00 91400061 EAP CPT® 90833 Psychotherapy W/pat W/e&m Srvcs 30 Min (add-on) BOTH IP/OP $382.00 $282.68 $0.00 $303.20 $0.00 $0.00 $0.00 $0.00 $0.00 $69.65 $283.52 $283.52 $294.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.50 $300.17 $303.20 $0.00 $248.30 $0.00 $39.40 $66.38 $66.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91400062 EAP CPT® 90836 INDIVIDUAL COUNSELING 45 MIN ADD ON BOTH IP/OP $541.00 $400.34 $0.00 $429.60 $293.76 $293.76 $0.00 $0.00 $0.00 $112.76 $401.53 $401.53 $417.00 $0.00 $0.00 $0.00 $320.00 $320.00 $0.00 $268.50 $425.30 $429.60 $0.00 $351.65 $0.00 $84.04 $84.05 $84.05 $85.49 $0.00 $0.00 $0.00 $0.00 $0.00 91400063 EAP CPT® 90838 "Psychotherapy, 60min W/pat And Or Fam W E/m(add-on)" BOTH IP/OP $658.00 $486.92 $0.00 $522.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $488.37 $488.37 $507.19 $0.00 $137.13 $0.00 $0.00 $0.00 $0.00 $326.50 $517.18 $522.40 $0.00 $427.70 $0.00 $102.19 $110.39 $110.39 $103.96 $0.00 $0.00 $0.00 $0.00 $0.00 91400071 EAP CPT® 90839 Psychotherapy For Crisis First 60 Minutes BOTH IP/OP $682.00 $504.68 $0.00 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $142.15 $506.18 $506.18 $525.69 $128.07 $0.00 $83.25 $403.40 $403.40 $131.75 $338.50 $536.18 $541.60 $183.04 $443.30 $183.04 $105.95 $133.12 $133.12 $107.78 $125.47 $0.00 $0.00 $0.00 $0.00 91400072 EAP CPT® 90840 PSYCHOTHERAPY ADDITIONAL 30 MINUTES BOTH IP/OP $218.00 $161.32 $0.00 $172.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.80 $161.80 $168.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.00 $171.07 $172.80 $0.00 $141.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91500001 EAP CPT® 90853 Psy Group Therapy BOTH IP/OP $247.00 $182.78 $0.00 $197.60 $134.12 $134.12 $72.87 $72.87 $73.28 $51.48 $183.32 $183.32 $190.39 $71.76 $0.00 $46.64 $146.10 $146.10 $78.77 $123.50 $195.62 $197.60 $109.44 $160.55 $109.44 $34.39 $25.25 $25.25 $39.32 $75.02 $0.00 $0.00 $0.00 $0.00 91500006 EAP HCPCS H2014 Group Skills Training 15mins BOTH IP/OP $17.00 $12.58 $0.00 $16.80 $0.00 $0.00 $0.00 $0.00 $3.03 $16.80 $12.62 $12.62 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.50 $13.46 $13.60 $10.20 $0.00 $10.20 $2.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91600001 EAP CPT® 90846 Family Psychotherapy W/o Patient Present 50 Min BOTH IP/OP "$1,054.00 " $779.96 $0.00 $836.80 $572.32 $572.32 $130.30 $130.30 $131.03 $219.68 $782.28 $782.28 $812.42 $128.07 $0.00 $83.25 $623.44 $623.44 $131.75 $523.00 $828.43 $836.80 $183.04 $685.10 $183.04 $163.70 $102.82 $102.82 $166.52 $125.47 $0.00 $0.00 $0.00 $0.00 91600009 EAP CPT® 90847 Psy Family Therapy W Pt BOTH IP/OP "$1,054.00 " $779.96 $0.00 $836.80 $572.32 $572.32 $130.30 $130.30 $131.03 $219.68 $782.28 $782.28 $812.42 $128.07 $0.00 $83.25 $623.44 $623.44 $131.75 $523.00 $828.43 $836.80 $183.04 $685.10 $183.04 $105.59 $106.79 $106.79 $166.52 $125.47 $0.00 $0.00 $0.00 $0.00 91600010 EAP CPT® 90849 Multiple Family Group Therapy BOTH IP/OP $258.00 $190.92 $0.00 $206.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.49 $191.49 $198.87 $0.00 $53.77 $0.00 $0.00 $0.00 $0.00 $129.00 $204.34 $206.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91600012 EAP HCPCS H2014 Group Outpatient Services BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $0.00 $0.00 $0.00 $0.00 $12.82 $16.80 $53.44 $53.44 $55.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $57.02 $57.60 $43.20 $0.00 $43.20 $11.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91600013 EAP HCPCS H2014 Group Outpatient Services BOTH IP/OP $72.00 $53.28 $0.00 $57.60 $0.00 $0.00 $0.00 $0.00 $12.82 $16.80 $53.44 $53.44 $55.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $57.02 $57.60 $43.20 $0.00 $43.20 $11.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800005 EAP CPT® 96110 "NICU/PED/DEVELOP.TESTING,LIMI" BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $0.00 $0.00 $0.00 $0.00 $10.07 $0.00 $142.50 $142.50 $147.99 $0.00 $40.01 $0.00 $0.00 $0.00 $0.00 $96.00 $152.06 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800013 EAP CPT® 96125 Cognitive Testing BOTH IP/OP $702.00 $519.48 $0.00 $561.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $146.30 $0.00 $0.00 $0.00 $0.00 $351.00 $555.98 $561.60 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800017 EAP CPT® 96125 Cognitive Testing_52 BOTH IP/OP $353.00 $261.22 $0.00 $461.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.74 $444.74 $461.84 $0.00 $73.57 $0.00 $0.00 $0.00 $0.00 $176.50 $279.58 $282.40 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800019 EAP CPT® 96130 Psychological Tst Eval Svc Phys/qhp First Hour BOTH IP/OP $568.00 $420.32 $0.00 $451.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.57 $421.57 $437.81 $0.00 $118.37 $0.00 $0.00 $0.00 $138.76 $282.00 $446.69 $451.20 $192.78 $369.20 $192.78 $112.86 $111.11 $111.11 $89.79 $132.15 $0.00 $0.00 $0.00 $0.00 91800020 EAP CPT® 96131 Psychological Tst Eval Svc Phys/qhp Ea Addl Hour BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800021 EAP CPT® 96112 Developmental Tst Admin Phys/qhp 1st Hour BOTH IP/OP $699.00 $517.26 $0.00 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $518.80 $518.80 $538.79 $0.00 $145.67 $0.00 $0.00 $0.00 $0.00 $349.50 $553.61 $559.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800022 EAP CPT® 96113 Developmental Tst Admin Phys/qhp Ea Addl 30 Min BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800023 EAP CPT® 96116 Neurobehavioral Status Xm Phys/qhp 1st Hour BOTH IP/OP $609.00 $450.66 $86.57 $484.00 $330.69 $330.69 $253.61 $253.61 $255.04 $126.93 $452.00 $452.00 $469.42 $249.66 $126.92 $162.28 $360.22 $360.22 $239.36 $302.50 $479.16 $484.00 $332.56 $395.85 $332.56 $101.28 $86.57 $86.57 $96.32 $227.96 $0.00 $0.00 $0.00 $0.00 91800024 EAP CPT® 96121 Neurobehavioral Status Xm Phys/qhp Ea Addl Hour BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $231.24 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800025 EAP CPT® 96132 Neuropsychol Tst Eval Phys/qhp 1st Hour BOTH IP/OP $329.00 $243.46 $52.06 $261.60 $178.65 $178.65 $253.61 $253.61 $255.04 $68.57 $244.18 $244.18 $253.59 $249.66 $68.56 $162.28 $194.60 $194.60 $138.76 $163.50 $258.98 $261.60 $192.78 $213.85 $192.78 $126.78 $109.67 $109.67 $52.06 $132.15 $0.00 $0.00 $0.00 $0.00 91800026 EAP CPT® 96133 Neuropsychol Tst Eval Physl/qph Ea Addl Hr BOTH IP/OP $165.00 $122.10 $0.00 $131.20 $89.60 $89.60 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $127.18 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.00 $129.89 $131.20 $0.00 $107.25 $0.00 $79.70 $84.42 $84.42 $26.11 $0.00 $0.00 $0.00 $0.00 $0.00 91800027 EAP CPT® 96138 Psycl/nrpsycl Tst Tech 2+ Tst 1st 30 Min BOTH IP/OP $41.00 $30.34 $6.53 $253.61 $22.26 $22.26 $253.61 $253.61 $41.00 $8.55 $30.43 $30.43 $31.60 $249.66 $8.54 $162.28 $24.25 $24.25 $23.06 $20.50 $32.47 $32.80 $32.04 $26.65 $32.04 $36.79 $38.54 $38.54 $6.53 $21.96 $0.00 $0.00 $0.00 $0.00 91800028 EAP CPT® 96139 Psycl/nrpsyc Tst Tech 2+ Tst Ea Addl 30 Min BOTH IP/OP $20.00 $14.80 $0.00 $38.54 $10.86 $10.86 $0.00 $0.00 $0.00 $4.17 $14.84 $14.84 $15.42 $0.00 $4.17 $0.00 $11.83 $11.83 $0.00 $10.00 $15.84 $16.00 $0.00 $13.00 $0.00 $36.79 $38.54 $38.54 $3.18 $0.00 $0.00 $0.00 $0.00 $0.00 91800029 EAP CPT® 96136 Psycl/nrpsycl Tst Phy/qhp Tst 1st 30 Min BOTH IP/OP $55.00 $40.70 $8.76 $109.81 $29.87 $29.87 $109.81 $109.81 $55.00 $11.46 $40.82 $40.82 $42.39 $107.30 $11.46 $69.74 $32.53 $32.53 $23.06 $27.50 $43.56 $44.00 $32.04 $35.75 $32.04 $45.41 $25.25 $25.25 $8.76 $21.96 $0.00 $0.00 $0.00 $0.00 91800030 EAP CPT® 96137 Psycl/nrpsycl Tst Phy/qhp Tst Addl 30 Min BOTH IP/OP $21.00 $15.54 $0.00 $41.97 $11.40 $11.40 $0.00 $0.00 $0.00 $4.38 $15.59 $15.59 $16.19 $0.00 $4.38 $0.00 $12.42 $12.42 $0.00 $10.50 $16.63 $16.80 $0.00 $13.65 $0.00 $41.97 $19.84 $19.84 $3.34 $0.00 $0.00 $0.00 $0.00 $0.00 91800031 EAP CPT® 96156 Health Behavior Assessment/re-assessment BOTH IP/OP $189.00 $139.86 $29.93 $150.40 $102.63 $102.63 $72.87 $72.87 $73.28 $39.39 $140.28 $140.28 $145.68 $71.76 $39.39 $46.64 $111.79 $111.79 $78.77 $94.00 $148.90 $150.40 $109.44 $122.85 $109.44 $94.62 $90.55 $90.55 $29.93 $75.02 $0.00 $0.00 $0.00 $0.00 91800032 EAP CPT® 96158 Health Behavior Ivntj Indiv F2f 1st 30 Min BOTH IP/OP $189.00 $139.86 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $140.28 $140.28 $145.68 $0.00 $39.39 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $122.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800033 EAP CPT® 96159 Health Behavior Ivntj Indiv F2f Ea Addl 15 Min BOTH IP/OP $94.00 $69.56 $0.00 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.00 $74.45 $75.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800034 EAP CPT® 96164 Health Behavior Ivntj Group F2f 1st 30 Min BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.50 $84.74 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800035 EAP CPT® 96165 Health Behavior Ivntj Group F2f Ea Addl 15 Min BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.50 $84.74 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800036 EAP CPT® 96167 Health Behavior Invtj Fam W/pt F2f 1st 30 Min BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.50 $84.74 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91800037 EAP CPT® 96168 Health Behavior Ivntj Fam W/pt F2f Ea Add 15 Min BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.50 $84.74 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000001 EAP CPT® 51725 "Cystometrogram, Simple" BOTH IP/OP "$1,683.00 " "$1,245.42" $0.00 "$1,683.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.74 $0.00 $0.00 $0.00 $235.59 "$1,682.00" "$1,332.14" "$1,345.60" $327.32 "$1,683.00" $327.32 $92.84 $139.03 $139.03 $267.77 $224.37 $0.00 $0.00 $0.00 $0.00 92000002 EAP CPT® 51726 "Cystometrogram, Complex" BOTH IP/OP "$1,649.00 " "$1,220.26" $0.00 "$1,649.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.65 $0.00 $0.00 $0.00 $0.00 "$1,648.00" "$1,305.22" "$1,318.40" $0.00 "$1,649.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000003 EAP CPT® 51736 Uroflowmetry Simple BOTH IP/OP $293.00 $216.82 $0.00 $293.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.46 $217.46 $225.84 $0.00 $61.06 $0.00 $0.00 $0.00 $0.00 $293.00 $232.06 $234.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000004 EAP CPT® 51741 "Uroflowmetry, Complex" BOTH IP/OP $277.00 $204.98 $5.76 $280.00 $150.41 $150.41 $135.96 $135.96 $136.73 $57.73 $205.59 $205.59 $213.51 $133.75 $57.73 $86.94 $113.00 $113.00 $138.76 $280.00 $221.76 $224.00 $192.78 $277.00 $192.78 $64.97 $5.76 $5.76 $44.58 $132.15 $0.00 $0.00 $0.00 $0.00 92000007 EAP CPT® 51797 Intra-abdominal Pressure Test BOTH IP/OP $460.00 $340.40 $0.00 $465.00 $460.00 $460.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $354.57 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $465.00 $368.28 $372.00 $0.00 $460.00 $0.00 $97.70 $124.26 $124.26 $74.03 $0.00 $0.00 $0.00 $0.00 $0.00 92000009 EAP CPT® 59020 Fetal Contraction Stress Test BOTH IP/OP "$2,603.00 " "$1,926.22" $0.00 "$2,255.00" "$1,413.43" "$1,413.43" $165.90 $165.90 $166.84 $0.00 "$1,931.95" "$1,931.95" "$2,006.39" $0.00 $542.47 $0.00 $0.00 $0.00 $0.00 "$2,255.00" "$2,082.17" "$2,103.20" $0.00 "$1,579.00" $0.00 $65.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000010 EAP CPT® 59025 Fetal Non Stress Test BOTH IP/OP $427.00 $315.98 $19.09 "$1,750.00" $231.86 $231.86 $165.90 $165.90 $166.84 $89.00 $316.92 $316.92 $329.13 $163.24 $88.99 $106.10 $252.57 $252.57 $166.54 $431.00 $341.35 $344.80 $231.38 "$1,750.00" $231.38 $40.51 $19.09 $19.09 $68.62 $158.61 $0.00 $0.00 $0.00 $0.00 92000011 EAP CPT® 92081 Vision Screen BOTH IP/OP $267.00 $197.58 $17.65 $215.20 $144.98 $144.98 $54.21 $54.21 $54.51 $55.65 $198.17 $198.17 $205.80 $53.35 $55.64 $34.67 $157.93 $157.93 $55.17 $134.50 $213.05 $215.20 $76.65 $76.05 $76.65 $46.21 $17.65 $17.65 $42.82 $52.54 $0.00 $0.00 $0.00 $0.00 92000012 EAP CPT® 92081 "Vision Test, Routine" BOTH IP/OP $269.00 $199.06 $0.00 $215.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.17 $134.50 $213.05 $215.20 $76.65 $0.00 $76.65 $46.21 $17.65 $17.65 $42.82 $52.54 $0.00 $0.00 $0.00 $0.00 92000013 EAP CPT® 92081 Visual Exam Limited-lt BOTH IP/OP $269.00 $199.06 $17.65 $215.20 $146.07 $146.07 $54.21 $54.21 $54.51 $56.07 $199.65 $199.65 $207.35 $53.35 $56.06 $34.67 $159.11 $159.11 $55.17 $134.50 $213.05 $215.20 $76.65 $76.05 $76.65 $46.21 $17.65 $17.65 $42.82 $52.54 $0.00 $0.00 $0.00 $0.00 92000014 EAP CPT® 92081 Visual Field Exam Unilat/bilat BOTH IP/OP $529.00 $391.46 $17.65 $427.20 $287.25 $287.25 $54.21 $54.21 $54.51 $110.26 $392.62 $392.62 $407.75 $53.35 $110.24 $34.67 $312.90 $312.90 $55.17 $267.00 $422.93 $427.20 $76.65 $76.05 $76.65 $46.21 $17.65 $17.65 $85.01 $52.54 $0.00 $0.00 $0.00 $0.00 92000016 EAP CPT® 92081 Visual Field Exam Limited-lt BOTH IP/OP $269.00 $199.06 $17.65 $215.20 $146.07 $146.07 $54.21 $54.21 $54.51 $56.07 $199.65 $199.65 $207.35 $53.35 $56.06 $34.67 $159.11 $159.11 $55.17 $134.50 $213.05 $215.20 $76.65 $76.05 $76.65 $46.21 $17.65 $17.65 $42.82 $52.54 $0.00 $0.00 $0.00 $0.00 92000017 EAP CPT® 92081 Visual Field Exam Limited-rt BOTH IP/OP $269.00 $199.06 $17.65 $215.20 $146.07 $146.07 $54.21 $54.21 $54.51 $56.07 $199.65 $199.65 $207.35 $53.35 $56.06 $34.67 $159.11 $159.11 $55.17 $134.50 $213.05 $215.20 $76.65 $76.05 $76.65 $46.21 $17.65 $17.65 $42.82 $52.54 $0.00 $0.00 $0.00 $0.00 92000020 EAP CPT® 92082 Visual Field Exam Uni/bil Intermed BOTH IP/OP $570.00 $421.80 $0.00 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $423.05 $423.05 $439.36 $0.00 $118.79 $0.00 $0.00 $0.00 $0.00 $287.50 $455.40 $460.00 $0.00 $82.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000028 EAP CPT® 92083 Visual Field Exam Uni/bil Extended BOTH IP/OP $578.00 $427.72 $36.02 $466.40 $313.85 $313.85 $109.81 $109.81 $110.43 $120.47 $428.99 $428.99 $445.52 $107.30 $120.46 $69.74 $341.89 $341.89 $109.35 $291.50 $461.74 $466.40 $151.93 $300.95 $151.93 $56.79 $36.02 $36.02 $92.81 $104.14 $0.00 $0.00 $0.00 $0.00 92000032 EAP CPT® 92235 Flourescein Angioscopy W Photo BOTH IP/OP $959.00 $709.66 $61.59 $768.00 $520.74 $520.74 $257.73 $257.73 $259.18 $199.88 $711.77 $711.77 $739.20 $253.45 $199.86 $164.75 $567.25 $567.25 $253.05 $480.00 $760.32 $768.00 $351.58 $188.50 $351.58 $100.45 $61.59 $61.59 $152.83 $241.00 $0.00 $0.00 $0.00 $0.00 92000033 EAP CPT® 92235 Flourescein Photo W Photo Both BOTH IP/OP $960.00 $710.40 $61.59 $768.00 $521.28 $521.28 $257.73 $257.73 $259.18 $200.09 $712.51 $712.51 $739.97 $253.45 $200.06 $164.75 $567.84 $567.84 $253.05 $480.00 $760.32 $768.00 $351.58 $188.50 $351.58 $100.45 $61.59 $61.59 $152.83 $241.00 $0.00 $0.00 $0.00 $0.00 92000035 EAP CPT® 92250 Ophthalmoscopy W/ Fundus Photo BOTH IP/OP $407.00 $301.18 $23.77 $326.40 $221.00 $221.00 $109.81 $109.81 $110.43 $84.83 $302.08 $302.08 $313.72 $107.30 $84.82 $69.74 $240.74 $240.74 $109.35 $204.00 $323.14 $326.40 $151.93 $211.90 $151.93 $59.03 $23.77 $23.77 $64.95 $104.14 $0.00 $0.00 $0.00 $0.00 92000036 EAP CPT® 92285 Slit Lamp Photography BOTH IP/OP $159.00 $117.66 $0.00 $128.80 $86.34 $86.34 $54.21 $54.21 $54.51 $33.14 $118.01 $118.01 $122.56 $53.35 $33.14 $34.67 $94.05 $94.05 $0.00 $80.50 $127.51 $128.80 $0.00 $82.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000037 EAP CPT® 95810 Polysomnography BOTH IP/OP "$5,967.00 " "$4,415.58" $495.59 "$4,821.60" "$1,604.30" "$1,604.30" $895.94 $895.94 $900.99 "$1,243.67" "$3,372.63" "$3,372.63" "$3,502.34" $881.57 "$1,243.52" $573.02 "$3,094.73" "$3,094.73" $911.62 "$3,013.50" "$4,773.38" "$4,821.60" "$1,266.58" "$3,878.55" "$1,266.58" $594.31 $495.59 $495.59 $959.50 $868.21 $0.00 $0.00 $0.00 $0.00 92000038 EAP CPT® 95811 Polysomnography W/cpap BOTH IP/OP "$7,160.00 " "$5,298.40" $518.64 "$5,785.60" "$1,685.49" "$1,685.49" $895.94 $895.94 $900.99 "$1,492.32" "$2,890.83" "$2,890.83" "$3,002.01" $881.57 "$1,492.14" $573.02 "$3,094.73" "$3,094.73" $911.62 "$3,616.00" "$5,727.74" "$5,785.60" "$1,266.58" "$5,541.90" "$1,266.58" $618.03 $518.64 $518.64 "$1,151.33" $868.21 $0.00 $0.00 $0.00 $0.00 92000039 EAP CPT® 95857 Tensilon Test BOTH IP/OP $257.00 $190.18 $0.00 $205.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.75 $190.75 $198.10 $0.00 $53.56 $0.00 $0.00 $0.00 $0.00 $128.50 $203.54 $205.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000041 EAP CPT® 95970 Analyze Neurostim No Prog BOTH IP/OP $345.00 $255.30 $0.00 $294.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.06 $256.06 $265.93 $0.00 $71.90 $0.00 $0.00 $0.00 $0.00 $184.00 $291.46 $294.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000050 EAP CPT® 95972 "Complex Programming, Up To 1 Hr" BOTH IP/OP $443.00 $327.82 $0.00 $377.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.79 $328.79 $341.46 $0.00 $92.32 $0.00 $0.00 $0.00 $0.00 $236.00 $373.82 $377.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000054 EAP CPT® 51728 Cystometrogram W/vp BOTH IP/OP $790.00 $584.60 $0.00 $791.00 $790.00 $790.00 $560.26 $560.26 $563.41 $164.66 $586.34 $586.34 $608.93 $550.87 $164.64 $358.07 $113.00 $113.00 $0.00 $790.00 $625.68 $632.00 $0.00 $791.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000055 EAP CPT® 95873 Guide Nerv Destr Elec Stim BOTH IP/OP $168.00 $124.32 $0.00 $132.00 $91.22 $91.22 $0.00 $0.00 $0.00 $35.02 $124.69 $124.69 $129.49 $0.00 $35.01 $0.00 $99.37 $99.37 $0.00 $82.50 $130.68 $132.00 $0.00 $109.20 $0.00 $27.56 $57.63 $57.63 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 92000056 EAP CPT® 95874 Guide Nerv Destr Needle Emg BOTH IP/OP $197.00 $145.78 $0.00 $155.20 $106.97 $106.97 $0.00 $0.00 $0.00 $41.06 $146.21 $146.21 $151.85 $0.00 $41.05 $0.00 $116.53 $116.53 $0.00 $97.00 $153.65 $155.20 $0.00 $152.75 $0.00 $27.93 $60.15 $60.15 $30.88 $0.00 $0.00 $0.00 $0.00 $0.00 92000057 EAP CPT® 95971 Analyze Neurostim Simple BOTH IP/OP $375.00 $277.50 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $289.05 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000058 EAP CPT® 91200 Liver Elastography BOTH IP/OP $305.00 $225.70 $23.41 $242.40 $165.62 $165.62 $135.96 $135.96 $136.73 $63.57 $226.37 $226.37 $235.09 $133.75 $63.56 $86.94 $180.41 $180.41 $138.76 $151.50 $239.98 $242.40 $192.78 $198.25 $192.78 $34.27 $23.41 $23.41 $48.24 $132.15 $0.00 $0.00 $0.00 $0.00 92000059 EAP CPT® 92132 Cmptr Ophthalmic Dx Img Ant Segmt W/i&r Uni/bi BOTH IP/OP $210.00 $155.40 $15.13 $168.00 $114.03 $114.03 $54.21 $54.21 $54.51 $43.77 $155.86 $155.86 $161.87 $53.35 $43.76 $34.67 $124.22 $124.22 $55.17 $105.00 $166.32 $168.00 $76.65 $104.65 $76.65 $34.49 $15.13 $15.13 $33.43 $52.54 $0.00 $0.00 $0.00 $0.00 92000060 EAP CPT® 92240 Icg Angiography - One Eye BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $697.67 $697.67 $724.55 $0.00 $195.90 $0.00 $0.00 $0.00 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000061 EAP CPT® 92240 Icg Angiography - Both Eyes BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" "$1,086.83" $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000062 EAP CPT® 92060 Sensormotor Xm W/mlt Meas Ocular Devij W/i&r Spx BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $154.16 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $84.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000065 EAP CPT® 92283 Color Vision Examination BOTH IP/OP $198.00 $146.52 $0.00 $160.00 $107.51 $107.51 $54.21 $54.21 $54.51 $41.27 $146.96 $146.96 $152.62 $53.35 $41.26 $34.67 $117.12 $117.12 $0.00 $100.00 $158.40 $160.00 $0.00 $76.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000066 EAP CPT® 95976 Elec Alys Implt Smpl Cn Npgt Prgrmg BOTH IP/OP $554.00 $409.96 $0.00 $472.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.18 $411.18 $427.02 $0.00 $115.45 $0.00 $0.00 $0.00 $0.00 $295.00 $467.28 $472.00 $0.00 $104.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000067 EAP CPT® 95977 Elec Alys Implt Cplx Cn Npgt Prgrmg BOTH IP/OP $554.00 $409.96 $0.00 $472.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.18 $411.18 $427.02 $0.00 $115.45 $0.00 $0.00 $0.00 $0.00 $295.00 $467.28 $472.00 $0.00 $330.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000068 EAP CPT® 0509T Electroretinography (erg) W/i&r Pattern (perg) BOTH IP/OP $327.00 $241.98 $0.00 $261.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.70 $242.70 $252.05 $0.00 $68.15 $0.00 $0.00 $0.00 $0.00 $163.50 $258.98 $261.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000069 EAP CPT® 92273 "Electroretinography (erg), W/i&r; Full Field" BOTH IP/OP $606.00 $448.44 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.77 $449.77 $467.10 $0.00 $126.29 $0.00 $0.00 $0.00 $0.00 $606.00 $479.95 $484.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000070 EAP CPT® 92274 "Electroretinography (erg), W/i&r; Multifocal (mferg)" BOTH IP/OP $327.00 $241.98 $0.00 $261.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.70 $242.70 $252.05 $0.00 $68.15 $0.00 $0.00 $0.00 $0.00 $163.50 $258.98 $261.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000071 EAP CPT® 95249 Cont Gluc Mntr Pt Prov Eqp BOTH IP/OP $155.00 $114.70 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.04 $115.04 $119.47 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $155.00 $122.76 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000072 EAP CPT® 95250 Cont Gluc Mntr Phys/qhp Prov Eqp BOTH IP/OP $302.00 $223.48 $0.00 $240.00 $163.99 $163.99 $115.71 $115.71 $116.36 $62.94 $224.14 $224.14 $232.78 $113.80 $62.94 $73.97 $178.63 $178.63 $0.00 $150.00 $237.60 $240.00 $0.00 $157.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000073 EAP HCPCS G0399 HOME SLEEP STUDY BOTH IP/OP $772.00 $571.28 $0.00 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.98 $572.98 $595.06 $0.00 $160.88 $0.00 $0.00 $0.00 $0.00 $390.00 $617.76 $624.00 $0.00 $501.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000074 EAP CPT® 92201 Ophthalmoscopy Ext Retinal Drawing Uni Or Bil BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000075 EAP CPT® 92202 Ophthalmoscopy Ext Optic Nerve Drawing Uni Or Bil BOTH IP/OP $175.00 $129.50 $15.15 $140.00 $95.03 $95.03 $54.21 $54.21 $54.51 $36.47 $129.89 $129.89 $134.89 $53.35 $36.47 $34.67 $103.51 $103.51 $55.17 $87.50 $138.60 $140.00 $76.65 $109.85 $76.65 $15.37 $15.15 $15.15 $27.86 $52.54 $0.00 $0.00 $0.00 $0.00 92000080 EAP CPT® 95800 Slp Stdy Unattended W/hrt Rate/o2 Sat/resp/slp Time BOTH IP/OP $772.00 $571.28 $0.00 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.98 $572.98 $595.06 $0.00 $160.88 $0.00 $0.00 $0.00 $0.00 $390.00 $617.76 $624.00 $0.00 $501.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000081 EAP CPT® 95801 Slp Stdy Unatnd W/min Hrt Rate/o2 Sat/resp Analysis BOTH IP/OP $644.00 $476.56 $0.00 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $477.98 $477.98 $496.40 $0.00 $134.21 $0.00 $0.00 $0.00 $0.00 $325.00 $514.80 $520.00 $0.00 $418.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92000085 EAP CPT® 99453 Rem Mntr Physiol Param 1st Set Up Pt Educaj Eqp BOTH IP/OP $277.00 $204.98 $0.00 $221.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.27 $138.50 $219.38 $221.60 $161.54 $0.00 $161.54 $43.35 $18.73 $18.73 $44.10 $110.73 $0.00 $0.00 $0.00 $0.00 92000086 EAP CPT® 99454 Rem Mntr Physiol Param 1st Dev Supply Ea 30 D BOTH IP/OP $87.00 $64.38 $0.00 $69.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.36 $43.50 $68.90 $69.60 $50.51 $0.00 $50.51 $13.62 $62.31 $62.31 $13.85 $34.63 $0.00 $0.00 $0.00 $0.00 92100001 EAP CPT® 93279 Single Lead Pacemaker Program / Eval In Person BOTH IP/OP $204.00 $150.96 $23.14 $157.24 $111.12 $111.12 $36.26 $36.26 $36.47 $42.52 $151.41 $151.41 $157.24 $35.61 $42.51 $23.14 $120.67 $120.67 $36.36 $82.00 $129.89 $131.20 $50.51 $132.60 $50.51 $53.20 $28.81 $28.81 $26.11 $34.63 $0.00 $0.00 $0.00 $0.00 92100002 EAP CPT® 93280 Dual Lead Pacemaker Program / Eval In Person BOTH IP/OP $204.00 $150.96 $23.14 $157.24 $129.12 $129.12 $36.26 $36.26 $36.47 $42.52 $151.41 $151.41 $157.24 $35.61 $42.51 $23.14 $120.67 $120.67 $36.36 $82.00 $129.89 $131.20 $50.51 $132.60 $50.51 $62.94 $33.50 $33.50 $26.11 $34.63 $0.00 $0.00 $0.00 $0.00 92100003 EAP CPT® 93288 Pacemaker Sngl/dual/multi Interrog / Eval In Person BOTH IP/OP $204.00 $150.96 $0.00 $157.24 $82.95 $82.95 $36.26 $36.26 $36.47 $42.52 $151.41 $151.41 $157.24 $35.61 $42.51 $23.14 $120.67 $120.67 $0.00 $82.00 $129.89 $131.20 $0.00 $132.60 $0.00 $41.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100005 EAP CPT® 93880 US DUPLEX CA BOTH IP/OP "$3,057.00 " "$2,262.18" $143.36 "$2,268.80" $448.48 $448.48 $224.08 $224.08 $225.34 $637.16 $541.69 $541.69 $562.53 $220.56 $637.08 $143.36 "$1,808.22" "$1,808.22" $233.72 "$1,418.00" "$2,246.11" "$2,268.80" $324.73 "$1,823.90" $324.73 $179.50 $162.44 $162.44 $451.49 $222.60 $0.00 $0.00 $0.00 $0.00 92100007 EAP CPT® 93882 US DUPLEX CA BOTH IP/OP "$2,599.00 " "$1,923.26" $67.89 "$1,928.80" $285.70 $285.70 $106.02 $106.02 $106.62 $541.70 $356.80 $356.80 $370.53 $104.44 $541.63 $67.89 "$1,537.31" "$1,537.31" $112.41 "$1,205.50" "$1,909.51" "$1,928.80" $156.18 "$1,063.40" $156.18 $119.45 $105.17 $105.17 $383.83 $107.06 $0.00 $0.00 $0.00 $0.00 92100009 EAP CPT® 93886 Us Transcran Intracran Complete BOTH IP/OP "$2,429.00 " "$1,797.46" $143.36 "$2,381.60" $597.96 $597.96 $224.08 $224.08 $225.34 $506.26 $624.57 $624.57 $648.59 $220.56 $506.20 $143.36 "$1,436.75" "$1,436.75" $233.72 "$1,346.50" "$2,132.86" "$2,154.40" $324.73 "$2,381.60" $324.73 $214.18 $228.71 $228.71 $428.73 $222.60 $0.00 $0.00 $0.00 $0.00 92100011 EAP CPT® 93888 Us Transcran Intracran Limited BOTH IP/OP "$2,429.00 " "$1,797.46" $0.00 "$2,154.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $425.90 $425.90 $442.28 $0.00 $506.20 $0.00 $0.00 $0.00 $0.00 "$1,346.50" "$2,132.86" "$2,154.40" $0.00 "$1,541.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100013 EAP Custom 92100013 Ankle/brachial Indices (abi) BOTH IP/OP $768.00 $568.32 $0.00 $614.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $570.01 $570.01 $591.97 $0.00 $160.05 $0.00 $0.00 $0.00 $0.00 $384.00 $608.26 $614.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100014 EAP CPT® 93922 Abi -non-inv Doppler Test BOTH IP/OP "$1,074.00 " $794.76 $0.00 $868.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.29 $269.29 $279.64 $0.00 $223.82 $0.00 $0.00 $0.00 $0.00 $542.50 $859.32 $868.00 $0.00 $705.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100015 EAP CPT® 93923 Ext Arterial Pvr Study BOTH IP/OP "$1,355.00 " "$1,002.70" $86.94 "$1,095.20" $305.26 $305.26 $135.96 $135.96 $136.73 $282.42 $406.72 $406.72 $422.37 $133.75 $282.38 $86.94 $801.48 $801.48 $138.76 $684.50 "$1,084.25" "$1,095.20" $192.78 "$1,033.50" $192.78 $115.78 $112.01 $112.01 $217.94 $132.15 $0.00 $0.00 $0.00 $0.00 92100017 EAP CPT® 93925 Us Low Ext Arteries Comp BOTH IP/OP "$2,478.00 " "$1,833.72" $143.36 "$1,860.00" $573.70 $573.70 $224.08 $224.08 $225.34 $516.48 $695.99 $695.99 $722.76 $220.56 $516.42 $143.36 "$1,465.74" "$1,465.74" $233.72 "$1,162.50" "$1,841.40" "$1,860.00" $324.73 "$1,288.95" $324.73 $179.51 $218.26 $218.26 $370.14 $222.60 $0.00 $0.00 $0.00 $0.00 92100018 EAP CPT® 93926 Low Ext Arteries Ltd BOTH IP/OP "$1,346.00 " $996.04 $67.89 "$1,063.40" $299.80 $299.80 $106.02 $106.02 $106.62 $280.54 $441.03 $441.03 $458.00 $104.44 $280.51 $67.89 $796.16 $796.16 $112.41 $631.50 "$1,000.30" "$1,010.40" $156.18 "$1,063.40" $156.18 $120.13 $127.86 $127.86 $201.07 $107.06 $0.00 $0.00 $0.00 $0.00 92100020 EAP CPT® 93930 Upper Ext Arteries Comp BOTH IP/OP "$2,291.00 " "$1,695.34" $143.36 "$1,720.00" $461.02 $461.02 $224.08 $224.08 $225.34 $477.50 $548.65 $548.65 $569.75 $220.56 $477.44 $143.36 "$1,355.13" "$1,355.13" $233.72 "$1,075.00" "$1,702.80" "$1,720.00" $324.73 "$1,188.20" $324.73 $183.19 $168.92 $168.92 $342.28 $222.60 $0.00 $0.00 $0.00 $0.00 92100022 EAP CPT® 93931 Upper Ext Arteries Ltd BOTH IP/OP "$1,346.00 " $996.04 $67.89 "$1,063.40" $284.91 $284.91 $106.02 $106.02 $106.62 $280.54 $367.39 $367.39 $381.52 $104.44 $280.51 $67.89 $796.16 $796.16 $112.41 $631.50 "$1,000.30" "$1,010.40" $156.18 "$1,063.40" $156.18 $121.65 $105.89 $105.89 $201.07 $107.06 $0.00 $0.00 $0.00 $0.00 92100025 EAP CPT® 93970 Us Ext Veins Doppler Comp BOTH IP/OP "$2,823.00 " "$2,089.02" $143.36 "$2,133.60" $436.74 $436.74 $224.08 $224.08 $225.34 $588.38 $544.52 $544.52 $565.47 $220.56 $588.31 $143.36 "$1,669.80" "$1,669.80" $233.72 "$1,333.50" "$2,112.26" "$2,133.60" $324.73 "$1,638.65" $324.73 $199.35 $163.16 $163.16 $424.59 $222.60 $0.00 $0.00 $0.00 $0.00 92100026 EAP CPT® 93970 Periph.vas. Bil. W/mapping BOTH IP/OP "$2,667.00 " "$1,973.58" $0.00 "$2,133.60" $0.00 $0.00 $0.00 $0.00 $0.00 $588.38 $0.00 $0.00 $0.00 $220.56 $588.31 $143.36 "$1,669.80" "$1,669.80" $233.72 "$1,333.50" "$2,112.26" "$2,133.60" $324.73 $0.00 $324.73 $199.35 $163.16 $163.16 $424.59 $222.60 $0.00 $0.00 $0.00 $0.00 92100028 EAP CPT® 93971 Us Ext Veins Doppler Ltd BOTH IP/OP "$2,071.00 " "$1,532.54" $67.89 "$1,564.80" $266.11 $266.11 $106.02 $106.02 $106.62 $431.65 $360.55 $360.55 $374.41 $104.44 $431.60 $67.89 "$1,225.00" "$1,225.00" $112.41 $978.00 "$1,549.15" "$1,564.80" $156.18 "$1,346.15" $156.18 $132.53 $101.21 $101.21 $311.40 $107.06 $0.00 $0.00 $0.00 $0.00 92100029 EAP CPT® 93971 Periph.vas. Uni. & Ext Non-vas BOTH IP/OP "$1,604.00 " "$1,186.96" $67.89 "$1,564.80" $266.11 $266.11 $106.02 $106.02 $106.62 $334.31 $360.55 $360.55 $374.41 $104.44 $334.27 $67.89 $948.77 $948.77 $112.41 $978.00 "$1,549.15" "$1,564.80" $156.18 "$1,346.15" $156.18 $132.53 $101.21 $101.21 $311.40 $107.06 $0.00 $0.00 $0.00 $0.00 92100030 EAP CPT® 93971 Periph.vas. Uni. W/mapping BOTH IP/OP "$1,604.00 " "$1,186.96" $67.89 "$1,564.80" $266.11 $266.11 $106.02 $106.02 $106.62 $334.31 $360.55 $360.55 $374.41 $104.44 $334.27 $67.89 $948.77 $948.77 $112.41 $978.00 "$1,549.15" "$1,564.80" $156.18 "$1,346.15" $156.18 $132.53 $101.21 $101.21 $311.40 $107.06 $0.00 $0.00 $0.00 $0.00 92100032 EAP CPT® 93975 Abd/retroper Doppler Comp Us BOTH IP/OP "$3,461.00 " "$2,561.14" $143.36 "$2,660.80" $621.46 $621.46 $224.08 $224.08 $225.34 $721.36 $711.04 $711.04 $738.39 $220.56 $721.27 $143.36 "$2,047.18" "$2,047.18" $233.72 "$1,663.00" "$2,634.19" "$2,660.80" $324.73 "$2,249.65" $324.73 $268.31 $223.31 $223.31 $529.50 $222.60 $0.00 $0.00 $0.00 $0.00 92100033 EAP CPT® 93976 Abd/retroper Doppler Ltd Us BOTH IP/OP "$1,882.00 " "$1,392.68" $67.89 "$1,447.20" $334.96 $334.96 $106.02 $106.02 $106.62 $392.26 $390.03 $390.03 $405.03 $104.44 $392.21 $67.89 "$1,113.20" "$1,113.20" $112.41 $904.50 "$1,432.73" "$1,447.20" $156.18 "$1,223.30" $156.18 $179.32 $126.42 $126.42 $287.99 $107.06 $0.00 $0.00 $0.00 $0.00 92100034 EAP Custom 92100034 Sngl Lead Pm Program Eval BOTH IP/OP $204.00 $150.96 $0.00 $163.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.41 $151.41 $157.24 $0.00 $42.51 $0.00 $0.00 $0.00 $0.00 $102.00 $161.57 $163.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100035 EAP Custom 92100035 Sngl Lead Icd Program Eval BOTH IP/OP $262.00 $193.88 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.46 $194.46 $201.95 $0.00 $54.60 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $170.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100036 EAP CPT® 93286 Pacemaker Sngl/dual/multi Peri-procedure Eval In Person BOTH IP/OP $234.00 $173.16 $0.00 $180.37 $60.27 $60.27 $0.00 $0.00 $0.00 $48.77 $173.67 $173.67 $180.37 $0.00 $48.77 $0.00 $138.41 $138.41 $0.00 $94.00 $148.90 $150.40 $0.00 $92.95 $0.00 $29.42 $25.21 $25.21 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 92100037 EAP CPT® 93287 Icd Sngl/dual/multi Peri-procedure Eval In Person BOTH IP/OP $311.00 $230.14 $0.00 $239.72 $81.39 $81.39 $0.00 $0.00 $0.00 $64.82 $230.82 $230.82 $239.72 $0.00 $64.81 $0.00 $183.96 $183.96 $0.00 $125.00 $198.00 $200.00 $0.00 $97.50 $0.00 $34.26 $25.21 $25.21 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 92100038 EAP CPT® 93296 Pacemaker/icd Interrog / Eval Remote Up To 90 Days BOTH IP/OP $253.00 $187.22 $0.00 $195.01 $57.92 $57.92 $36.26 $36.26 $36.47 $52.73 $187.78 $187.78 $195.01 $35.61 $52.73 $23.14 $149.65 $149.65 $36.36 $102.00 $161.57 $163.20 $50.51 $189.80 $50.51 $0.00 $25.93 $25.93 $32.48 $34.63 $0.00 $0.00 $0.00 $0.00 92100039 EAP Custom 92100039 Mult Lead Pm Program Eval BOTH IP/OP $163.00 $120.62 $0.00 $131.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $0.00 $0.00 $0.00 $82.00 $129.89 $131.20 $0.00 $105.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100040 EAP CPT® 93284 Multi-lead Icd Program / Eval In Person BOTH IP/OP $328.00 $242.72 $23.14 $252.82 $200.32 $200.32 $36.26 $36.26 $36.47 $68.36 $243.44 $243.44 $252.82 $35.61 $68.36 $23.14 $194.01 $194.01 $36.36 $132.00 $209.09 $211.20 $50.51 $213.20 $50.51 $96.97 $36.38 $36.38 $42.03 $34.63 $0.00 $0.00 $0.00 $0.00 92100041 EAP CPT® 93291 Interrog / Eval Scrms Or Loop Recorder In Clinic BOTH IP/OP $203.00 $150.22 $15.37 $163.20 $81.39 $81.39 $24.06 $24.06 $24.19 $42.31 $150.67 $150.67 $156.47 $23.64 $42.31 $15.37 $120.07 $120.07 $23.06 $102.00 $161.57 $163.20 $32.04 $131.95 $32.04 $39.45 $24.85 $24.85 $32.48 $21.96 $0.00 $0.00 $0.00 $0.00 92100043 EAP Custom 92100043 Icd Interrogation BOTH IP/OP $262.00 $193.88 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.46 $194.46 $201.95 $0.00 $54.60 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $170.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100044 EAP Custom 92100044 Dual Lead Pm Program Eval BOTH IP/OP $204.00 $150.96 $0.00 $163.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.41 $151.41 $157.24 $0.00 $42.51 $0.00 $0.00 $0.00 $0.00 $102.00 $161.57 $163.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100045 EAP Custom 92100045 Dual Lead Icd Program Eval BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.94 $195.94 $203.49 $0.00 $55.02 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100050 EAP CPT® 93978 Aorta Duplex BOTH IP/OP "$1,539.00 " "$1,138.86" $143.36 "$1,348.00" $422.69 $422.69 $224.08 $224.08 $225.34 $320.77 $510.54 $510.54 $530.17 $220.56 $320.73 $143.36 $910.32 $910.32 $233.72 $842.50 "$1,334.52" "$1,348.00" $324.73 "$1,233.70" $324.73 $187.25 $151.27 $151.27 $268.25 $222.60 $0.00 $0.00 $0.00 $0.00 92100052 EAP CPT® 93880 Carotid Duplex BOTH IP/OP "$2,558.00 " "$1,892.92" $143.36 "$2,268.80" $448.48 $448.48 $224.08 $224.08 $225.34 $533.15 $541.69 $541.69 $562.53 $220.56 $533.09 $143.36 "$1,513.06" "$1,513.06" $233.72 "$1,418.00" "$2,246.11" "$2,268.80" $324.73 "$1,823.90" $324.73 $179.50 $162.44 $162.44 $451.49 $222.60 $0.00 $0.00 $0.00 $0.00 92100063 EAP CPT® 93978 Vascular Study Ult BOTH IP/OP "$1,753.00 " "$1,297.22" $143.36 "$1,348.00" $422.69 $422.69 $224.08 $224.08 $225.34 $365.37 $510.54 $510.54 $530.17 $220.56 $365.33 $143.36 "$1,036.90" "$1,036.90" $233.72 $842.50 "$1,334.52" "$1,348.00" $324.73 "$1,233.70" $324.73 $187.25 $151.27 $151.27 $268.25 $222.60 $0.00 $0.00 $0.00 $0.00 92100065 EAP CPT® 93979 Vascular Study Limited Ult BOTH IP/OP $965.00 $714.10 $0.00 $845.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.68 $354.68 $368.32 $0.00 $201.11 $0.00 $0.00 $0.00 $0.00 $528.50 $837.14 $845.60 $0.00 $440.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100072 EAP CPT® 93281 Multi-lead Pacemaker Program / Eval In Person BOTH IP/OP $204.00 $150.96 $23.14 $157.24 $151.80 $151.80 $36.26 $36.26 $36.47 $42.52 $151.41 $151.41 $157.24 $35.61 $42.51 $23.14 $120.67 $120.67 $36.36 $82.00 $129.89 $131.20 $50.51 $132.60 $50.51 $73.61 $34.22 $34.22 $26.11 $34.63 $0.00 $0.00 $0.00 $0.00 92100080 EAP CPT® 93886 Transcran Doppler Comp Us BOTH IP/OP "$2,903.00 " "$2,148.22" $143.36 "$2,381.60" $597.96 $597.96 $224.08 $224.08 $225.34 $605.06 $624.57 $624.57 $648.59 $220.56 $604.99 $143.36 "$1,717.12" "$1,717.12" $233.72 "$1,346.50" "$2,132.86" "$2,154.40" $324.73 "$2,381.60" $324.73 $214.18 $228.71 $228.71 $428.73 $222.60 $0.00 $0.00 $0.00 $0.00 92100081 EAP CPT® 93888 Transcran Doppler Ltd Us BOTH IP/OP "$2,903.00 " "$2,148.22" $0.00 "$2,154.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $425.90 $425.90 $442.28 $0.00 $604.99 $0.00 $0.00 $0.00 $0.00 "$1,346.50" "$2,132.86" "$2,154.40" $0.00 "$1,541.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100082 EAP CPT® 93890 Tcd. Vasoreactivity Study BOTH IP/OP "$1,989.00 " "$1,471.86" $0.00 "$1,476.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.52 $526.52 $546.77 $0.00 $414.51 $0.00 $0.00 $0.00 $0.00 $922.50 "$1,461.24" "$1,476.00" $0.00 "$1,292.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100083 EAP CPT® 93892 Tcd. Emboli Detct W/o Inj BOTH IP/OP $967.00 $715.58 $0.00 $717.60 $0.00 $0.00 $0.00 $0.00 $106.62 $201.55 $571.93 $571.93 $593.92 $104.44 $201.52 $67.89 $571.98 $571.98 $112.41 $448.50 $710.42 $717.60 $156.18 $628.55 $156.18 $256.10 $255.72 $255.72 $142.80 $107.06 $0.00 $0.00 $0.00 $0.00 92100084 EAP CPT® 93893 Tcd. Emboli Detect W/inj BOTH IP/OP $967.00 $715.58 $0.00 $717.60 $378.79 $378.79 $106.02 $106.02 $106.62 $201.55 $569.21 $569.21 $591.11 $104.44 $201.52 $67.89 $571.98 $571.98 $112.41 $448.50 $710.42 $717.60 $156.18 $628.55 $156.18 $0.00 $302.18 $302.18 $142.80 $107.06 $0.00 $0.00 $0.00 $0.00 92100086 EAP CPT® 93922 Abi -non-inv Doppler Test BOTH IP/OP "$1,085.00 " $802.90 $0.00 $868.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.29 $269.29 $279.64 $0.00 $226.11 $0.00 $0.00 $0.00 $0.00 $542.50 $859.32 $868.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100088 EAP CPT® 93922 Limited Bilateral Pvr Exam BOTH IP/OP "$1,085.00 " $802.90 $0.00 $868.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.29 $269.29 $279.64 $0.00 $226.11 $0.00 $0.00 $0.00 $0.00 $542.50 $859.32 $868.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100089 EAP CPT® 93980 Penile Vascular Study BOTH IP/OP "$1,392.00 " "$1,030.08" $0.00 "$1,219.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.01 $295.01 $306.35 $0.00 $290.09 $0.00 $0.00 $0.00 $0.00 $762.00 "$1,207.01" "$1,219.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100090 EAP CPT® 93924 Vas Lab Pvr Lower Ext With Exercise BOTH IP/OP "$1,188.00 " $879.12 $127.08 $960.00 $380.40 $380.40 $257.73 $257.73 $259.18 $247.61 $506.06 $506.06 $525.53 $253.45 $247.58 $164.75 $702.70 $702.70 $138.76 $600.00 $950.40 $960.00 $192.78 $772.20 $192.78 $127.08 $141.19 $141.19 $191.04 $132.15 $0.00 $0.00 $0.00 $0.00 92100091 EAP CPT® 93985 Vessel Mapping For Hd Access Bilateral BOTH IP/OP $580.00 $429.20 $88.67 "$1,133.60" $580.00 $580.00 $224.08 $224.08 $225.34 $120.89 $430.48 $430.48 $447.06 $220.56 $120.87 $143.36 $343.07 $343.07 $233.72 $278.50 $441.14 $445.60 $324.73 "$1,133.60" $324.73 $256.89 $231.59 $231.59 $88.67 $222.60 $0.00 $0.00 $0.00 $0.00 92100092 EAP CPT® 93986 Vessel Mapping For Hd Access Unilateral BOTH IP/OP $279.00 $206.46 $42.67 $279.00 $279.00 $279.00 $106.02 $106.02 $106.62 $58.15 $207.07 $207.07 $215.05 $104.44 $58.14 $67.89 $165.03 $165.03 $112.41 $134.00 $212.26 $214.40 $156.18 $181.35 $156.18 $130.33 $131.82 $131.82 $42.67 $107.06 $0.00 $0.00 $0.00 $0.00 92200001 EAP CPT® 95860 Electromyogram - 1 Extermity BOTH IP/OP $440.00 $325.60 $0.00 $345.60 $0.00 $0.00 $0.00 $0.00 $0.00 $91.71 $326.57 $326.57 $339.15 $107.30 $91.70 $69.74 $260.26 $260.26 $109.35 $216.00 $342.14 $345.60 $151.93 $286.00 $151.93 $70.97 $68.79 $68.79 $68.77 $104.14 $0.00 $0.00 $0.00 $0.00 92200002 EAP CPT® 95861 Electromyorgam - 2 Extermities BOTH IP/OP $421.00 $311.54 $0.00 $336.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.47 $312.47 $324.51 $0.00 $87.74 $0.00 $0.00 $0.00 $0.00 $210.50 $333.43 $336.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92200003 EAP CPT® 95869 Emg Limited (thoracic Psp) BOTH IP/OP $186.00 $137.64 $0.00 $146.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.05 $138.05 $143.37 $0.00 $38.76 $0.00 $0.00 $0.00 $0.00 $91.50 $144.94 $146.40 $0.00 $120.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92200004 EAP CPT® 95870 Emg Limited Ext BOTH IP/OP $317.00 $234.58 $0.00 $248.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.28 $235.28 $244.34 $0.00 $66.06 $0.00 $0.00 $0.00 $0.00 $155.50 $246.31 $248.80 $0.00 $206.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92200010 EAP CPT® 95937 Rns BOTH IP/OP $192.00 $142.08 $27.86 $175.00 $104.26 $104.26 $135.96 $135.96 $136.73 $40.02 $142.50 $142.50 $147.99 $133.75 $40.01 $86.94 $113.57 $113.57 $138.76 $87.50 $138.60 $140.00 $175.00 $124.80 $175.00 $50.14 $60.15 $60.15 $27.86 $132.15 $0.00 $0.00 $0.00 $0.00 92200011 EAP CPT® 95907 Nvr Cndj Tst 1-2 Studies BOTH IP/OP $706.00 $522.44 $0.00 $544.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.99 $523.99 $544.18 $0.00 $147.13 $0.00 $0.00 $0.00 $138.76 $339.50 $537.77 $543.20 $192.78 $458.90 $192.78 $90.38 $42.14 $42.14 $108.10 $132.15 $0.00 $0.00 $0.00 $0.00 92200012 EAP CPT® 95908 Nrv Cndj Tst 3-4 Studies BOTH IP/OP "$1,040.00 " $769.60 $54.75 "$1,702.35" $564.72 $564.72 $257.73 $257.73 $259.18 $216.76 $771.89 $771.89 $801.63 $253.45 $216.74 $164.75 $615.16 $615.16 $253.05 $500.50 $792.79 $800.80 $351.58 "$1,702.35" $351.58 $111.50 $54.75 $54.75 $159.36 $241.00 $0.00 $0.00 $0.00 $0.00 92200013 EAP CPT® 95909 Nrv Cndj Tst 5-6 Studies BOTH IP/OP "$1,374.00 " "$1,016.76" $65.55 "$2,553.20" $746.08 $746.08 $257.73 $257.73 $259.18 $286.38 "$1,019.78" "$1,019.78" "$1,059.08" $253.45 $286.34 $164.75 $812.72 $812.72 $253.05 $661.00 "$1,047.02" "$1,057.60" $351.58 "$2,553.20" $351.58 $133.60 $65.55 $65.55 $210.46 $241.00 $0.00 $0.00 $0.00 $0.00 92200014 EAP CPT® 95910 Nrv Cndj Test 7-8 Studies BOTH IP/OP "$1,711.00 " "$1,266.14" $84.28 "$3,403.40" $929.07 $929.07 $257.73 $257.73 $259.18 $356.62 "$1,269.90" "$1,269.90" "$1,318.84" $253.45 $356.57 $164.75 "$1,012.06" "$1,012.06" $253.05 $823.00 "$1,303.63" "$1,316.80" $351.58 "$3,403.40" $351.58 $175.83 $84.28 $84.28 $262.04 $241.00 $0.00 $0.00 $0.00 $0.00 92200015 EAP CPT® 95911 Nrv Cndj Test 9-10 Studies BOTH IP/OP "$2,045.00 " "$1,513.30" $96.53 "$4,253.60" "$1,110.44" "$1,110.44" $475.36 $475.36 $478.04 $426.23 "$1,517.80" "$1,517.80" "$1,576.29" $467.50 $426.18 $303.87 "$1,209.62" "$1,209.62" $487.04 $984.00 "$1,558.66" "$1,574.40" $676.67 "$4,253.60" $676.67 $212.84 $96.53 $96.53 $313.31 $463.84 $0.00 $0.00 $0.00 $0.00 92200016 EAP CPT® 95912 Nvr Cndj Tst 11-12 Studies BOTH IP/OP "$2,380.00 " "$1,761.20" $104.09 "$1,834.50" "$1,292.34" "$1,292.34" $475.36 $475.36 $478.04 $496.05 "$1,766.44" "$1,766.44" "$1,834.50" $467.50 $495.99 $303.87 "$1,407.77" "$1,407.77" $487.04 "$1,145.00" "$1,813.68" "$1,832.00" $676.67 "$1,547.00" $676.67 $249.19 $104.09 $104.09 $364.57 $463.84 $0.00 $0.00 $0.00 $0.00 92200017 EAP CPT® 95913 Nrv Cndj Tst 13- Or More Studies BOTH IP/OP "$2,715.00 " "$2,009.10" $115.61 "$3,462.55" "$1,474.25" "$1,474.25" $475.36 $475.36 $478.04 $565.87 "$2,015.07" "$2,015.07" "$2,092.72" $467.50 $565.81 $303.87 "$1,605.92" "$1,605.92" $487.04 "$1,306.00" "$2,068.70" "$2,089.60" $676.67 "$3,462.55" $676.67 $288.80 $115.61 $115.61 $415.83 $463.84 $0.00 $0.00 $0.00 $0.00 92200018 EAP CPT® 95872 Needle Emg W/1 Fiber Electrode Quan Meas Jitter BOTH IP/OP $647.00 $478.78 $0.00 $508.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $480.20 $480.20 $498.71 $0.00 $134.83 $0.00 $0.00 $0.00 $138.76 $318.00 $503.71 $508.80 $192.78 $370.50 $192.78 $101.87 $47.18 $47.18 $101.25 $132.15 $0.00 $0.00 $0.00 $0.00 92200040 EAP CPT® 95933 Orbicularis Oculi Reflex BOTH IP/OP $461.00 $341.14 $0.00 $355.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.15 $342.15 $355.34 $0.00 $96.07 $0.00 $0.00 $0.00 $55.17 $210.50 $333.43 $336.80 $76.65 $167.70 $76.65 $65.19 $51.50 $51.50 $67.02 $52.54 $0.00 $0.00 $0.00 $0.00 92200041 EAP CPT® 95925 Short-latency Somatosens Ep Std Upr Limbs BOTH IP/OP "$1,372.00 " "$1,015.28" $0.00 "$1,097.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,018.30" "$1,018.30" "$1,057.54" $0.00 $285.92 $0.00 $0.00 $0.00 $0.00 $686.00 "$1,086.62" "$1,097.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92200042 EAP CPT® 95926 Short-latency Somatosens Ep Std Lwr Limbs BOTH IP/OP "$1,372.00 " "$1,015.28" $0.00 "$1,097.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,018.30" "$1,018.30" "$1,057.54" $0.00 $285.92 $0.00 $0.00 $0.00 $0.00 $686.00 "$1,086.62" "$1,097.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92200043 EAP CPT® 95867 Emg Cranial Nerve Unilateral BOTH IP/OP $625.00 $462.50 $0.00 $491.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $481.75 $0.00 $130.25 $0.00 $0.00 $0.00 $138.76 $307.00 $486.29 $491.20 $192.78 $375.70 $192.78 $68.25 $65.91 $65.91 $97.75 $132.15 $0.00 $0.00 $0.00 $0.00 92200044 EAP CPT® 95868 Emg Cranial Nerve Bilateral BOTH IP/OP $836.00 $618.64 $0.00 $668.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $620.48 $620.48 $644.39 $0.00 $174.22 $0.00 $0.00 $0.00 $0.00 $418.00 $662.11 $668.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92400001 EAP CPT® 95004 "Perc. Allergy Test, Immed. Rea" BOTH IP/OP $999.00 $739.26 $0.00 $900.99 $542.46 $542.46 $895.94 $895.94 $900.99 $208.22 $741.46 $741.46 $770.03 $881.57 $208.19 $573.02 $590.91 $590.91 $0.00 $504.50 $799.13 $807.20 $0.00 $45.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92400002 EAP CPT® 95004 "Allergy Testing, Extracts" BOTH IP/OP $941.00 $696.34 $0.00 $900.99 $510.96 $510.96 $895.94 $895.94 $900.99 $196.13 $698.41 $698.41 $725.32 $881.57 $196.10 $573.02 $556.60 $556.60 $0.00 $475.00 $752.40 $760.00 $0.00 $45.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92400011 EAP CPT® 95028 Intradermal Test # BOTH IP/OP $163.00 $120.62 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $120.98 $125.64 $0.00 $33.97 $0.00 $0.00 $0.00 $33.53 $82.50 $130.68 $132.00 $46.58 $105.95 $46.58 $8.93 $12.97 $12.97 $26.27 $31.93 $0.00 $0.00 $0.00 $0.00 92400012 EAP CPT® 95044 Patch Tests - Each BOTH IP/OP $904.00 $668.96 $5.40 $913.00 $490.87 $490.87 $895.94 $895.94 $900.99 $188.42 $670.95 $670.95 $696.80 $881.57 $188.39 $573.02 $534.72 $534.72 $911.62 $456.50 $723.10 $730.40 $913.00 $587.60 $913.00 $7.85 $5.40 $5.40 $145.35 $868.21 $0.00 $0.00 $0.00 $0.00 92400030 EAP CPT® 95180 Rapid Desensitization BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.75 $285.75 $296.76 $0.00 $80.23 $0.00 $0.00 $0.00 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92400034 EAP CPT® 95076 Ingest Challenge Ini 120 Min BOTH IP/OP $695.00 $514.30 $0.00 $561.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $515.83 $515.83 $535.71 $0.00 $144.84 $0.00 $0.00 $0.00 $0.00 $351.00 $555.98 $561.60 $0.00 $451.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92900002 EAP CPT® 93293 "Transtelephonic Rhythm Strip Pm Eval / Sngl, Dual, Multi-lead" BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.94 $195.94 $203.49 $0.00 $55.02 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $138.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94000002 EAP CPT® 95115 Allergy Injection BOTH IP/OP $40.00 $29.60 $0.00 $39.19 $21.72 $21.72 $38.97 $38.97 $39.19 $8.34 $29.69 $29.69 $30.83 $38.34 $8.34 $24.92 $23.66 $23.66 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94000003 EAP CPT® 95117 "Allergy Injections, 2 Or More" BOTH IP/OP $67.00 $49.58 $0.00 $51.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.73 $49.73 $51.64 $0.00 $13.96 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $36.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94000005 EAP CPT® 96900 "Actinotherapy, Uvl" BOTH IP/OP $215.00 $159.10 $0.00 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.81 $0.00 $0.00 $0.00 $32.43 $44.81 $21.08 $127.17 $127.17 $0.00 $107.50 $170.28 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94000006 EAP CPT® 96910 "Photochemotherapy,uvb" BOTH IP/OP $126.00 $93.24 $20.22 $118.14 $68.42 $68.42 $54.21 $54.21 $54.51 $26.26 $93.52 $93.52 $97.12 $53.35 $26.26 $34.67 $74.53 $74.53 $55.17 $63.50 $100.58 $101.60 $76.65 $80.60 $76.65 $22.14 $118.14 $118.14 $20.22 $52.54 $0.00 $0.00 $0.00 $0.00 94000007 EAP CPT® 96912 "Photochemotherapy, Puva" BOTH IP/OP $204.00 $150.96 $0.00 $164.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.41 $151.41 $157.24 $0.00 $42.51 $0.00 $0.00 $0.00 $0.00 $103.00 $163.15 $164.80 $0.00 $78.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94000021 EAP CPT® 99195 Phlebotomy BOTH IP/OP $189.00 $139.86 $17.15 $151.93 $102.63 $102.63 $109.81 $109.81 $110.43 $39.39 $140.28 $140.28 $145.68 $107.30 $39.39 $69.74 $111.79 $111.79 $109.35 $94.00 $148.90 $150.40 $151.93 $122.85 $151.93 $17.15 $102.65 $102.65 $29.93 $104.14 $0.00 $0.00 $0.00 $0.00 94000022 EAP CPT® 99195 Therapeutic Phlebotomy BOTH IP/OP $189.00 $139.86 $17.15 $151.93 $102.63 $102.63 $109.81 $109.81 $110.43 $39.39 $140.28 $140.28 $145.68 $107.30 $39.39 $69.74 $111.79 $111.79 $109.35 $94.00 $148.90 $150.40 $151.93 $122.85 $151.93 $17.15 $102.65 $102.65 $29.93 $104.14 $0.00 $0.00 $0.00 $0.00 94000031 EAP CPT® 95907 Nerve conductionstudies 1-2 studie BOTH IP/OP $706.00 $522.44 $0.00 $544.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.99 $523.99 $544.18 $0.00 $147.13 $0.00 $0.00 $0.00 $138.76 $339.50 $537.77 $543.20 $192.78 $458.90 $192.78 $90.38 $42.14 $42.14 $108.10 $132.15 $0.00 $0.00 $0.00 $0.00 94200001 EAP CPT® 97802 "Mnt - Individual, Initial Per 15 Min" BOTH IP/OP $98.00 $72.52 $15.18 $127.40 $53.21 $53.21 $34.61 $34.61 $33.05 $20.43 $72.74 $72.74 $75.54 $34.61 $20.42 $22.50 $57.97 $57.97 $29.55 $48.50 $76.82 $77.60 $34.61 $127.40 $34.61 $15.18 $34.61 $34.61 $15.44 $34.61 $0.00 $0.00 $0.00 $0.00 94200002 EAP CPT® 97803 "Mnt - Individual, Follow-up Per 15 Min" BOTH IP/OP $85.00 $62.90 $13.15 $67.20 $46.16 $46.16 $29.21 $29.21 $28.17 $17.72 $63.09 $63.09 $65.52 $29.21 $17.71 $18.99 $50.28 $50.28 $25.06 $42.00 $66.53 $67.20 $29.21 $58.50 $29.21 $13.15 $29.21 $29.21 $13.37 $29.21 $0.00 $0.00 $0.00 $0.00 94200003 EAP CPT® 97804 "Mnt - Group, Initial Or Follow-up Per 30 Min" BOTH IP/OP $46.00 $34.04 $7.20 $55.25 $24.98 $24.98 $16.23 $16.23 $15.66 $9.59 $34.14 $34.14 $35.46 $16.23 $9.59 $10.55 $27.21 $27.21 $13.82 $23.00 $36.43 $36.80 $16.23 $55.25 $16.23 $7.20 $16.23 $16.23 $7.32 $16.23 $0.00 $0.00 $0.00 $0.00 94200004 EAP HCPCS G0108 "Dsmt - Individual, Initial Or Follow-up Per 30 Min" BOTH IP/OP $155.00 $114.70 $24.10 $123.20 $84.17 $84.17 $56.97 $56.97 $55.96 $32.31 $115.04 $115.04 $119.47 $56.97 $32.30 $37.03 $91.68 $91.68 $57.08 $77.00 $121.97 $123.20 $56.97 $114.40 $56.97 $24.10 $56.97 $56.97 $24.52 $56.97 $0.00 $0.00 $0.00 $0.00 94200005 EAP HCPCS G0109 "Dsmt - Group, Initial Or Follow-up Per 30 Min" BOTH IP/OP $118.00 $87.32 $10.31 $93.60 $64.07 $64.07 $15.86 $15.86 $15.66 $24.59 $87.58 $87.58 $90.95 $15.86 $24.59 $10.31 $69.80 $69.80 $15.50 $58.50 $92.66 $93.60 $15.86 $76.70 $15.86 $18.31 $15.86 $15.86 $18.63 $15.86 $0.00 $0.00 $0.00 $0.00 94200012 EAP HCPCS G0270 Mnt - Individual (beyond Initial 3hrs Or Beyond 2hrs In Subq Yrs) - Per 15 Min BOTH IP/OP $108.00 $79.92 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.16 $80.16 $83.25 $0.00 $22.51 $0.00 $0.00 $0.00 $25.06 $53.50 $84.74 $85.60 $29.21 $65.00 $29.21 $16.75 $29.21 $29.21 $17.03 $29.21 $0.00 $0.00 $0.00 $0.00 94200013 EAP HCPCS G0271 Mnt - Group (beyond Initial 3hrs Or Beyond 2hrs In Sebq Yrs) - Per 30 Min BOTH IP/OP $59.00 $43.66 $0.00 $47.20 $0.00 $0.00 $0.00 $0.00 $0.00 $12.30 $43.79 $43.79 $45.48 $16.23 $12.30 $10.55 $34.90 $34.90 $13.82 $29.50 $46.73 $47.20 $16.23 $38.35 $16.23 $9.23 $16.23 $16.23 $0.00 $16.23 $0.00 $0.00 $0.00 $0.00 94200014 EAP CPT® 99412 Childbirth Education Class BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $19.01 $19.01 $0.00 $0.00 $12.84 $7.29 $25.98 $25.98 $26.98 $0.00 $7.29 $0.00 $20.70 $20.70 $0.00 $17.50 $27.72 $28.00 $21.00 $22.75 $21.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 94200015 EAP CPT® 99078 Centering Preg Group Session BOTH IP/OP $126.00 $93.24 $0.00 $100.00 $68.42 $68.42 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $97.12 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $62.50 $99.00 $100.00 $0.00 $81.90 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 94300001 EAP CPT® 93797 Cardiac Rehab - Regular BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.13 $106.13 $110.22 $0.00 $29.80 $0.00 $0.00 $0.00 $0.00 $71.50 $113.26 $114.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94600011 EAP Custom 94600011 Kinair Iii W/o Scale BOTH IP/OP $178.00 $131.72 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.11 $132.11 $137.20 $0.00 $37.10 $0.00 $0.00 $0.00 $0.00 $89.00 $140.98 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99900120 EAP HCPCS G1004 "Cdsm National Decision Support Company, Medicare Auc Program" BOTH IP/OP $0.01 $0.01 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.00 $0.00 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99900132 EAP Custom 99900132 "Trauma Protocol, Ect" BOTH IP/OP "$27,445.00 " "$20,309.30" $0.00 "$20,223.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,719.54" $0.00 $0.00 $0.00 $0.00 "$12,639.50" "$20,020.97" "$20,223.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99900529 EAP Custom 99900529 "Head/neck Cta W&w/o Dye,nct" BOTH IP/OP "$13,698.00 " "$10,136.52" $0.00 "$9,966.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,854.66" $0.00 "$1,106.00" "$1,106.00" $0.00 "$6,229.00" "$9,866.74" "$9,966.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0159T EAP CPT® 0159T Computer Aided Breast Mri BOTH IP/OP $118.00 $87.32 $0.00 $93.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C9803 EAP HCPCS C9803 Hopd Covid-19 Spec Collect BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.06 $28.50 $45.14 $45.60 $32.04 $0.00 $32.04 $8.92 $0.00 $0.00 $9.07 $21.96 $0.00 $0.00 $0.00 $0.00 CMPR7501 EAP Colonoscopy Procedure BOTH IP/OP "$1,413.00 " "$1,045.62" $0.00 "$1,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $294.47 $0.00 $0.00 $0.00 $0.00 $706.50 "$1,119.10" "$1,130.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CMPR7502 EAP Sigmoidoscopy Procedure BOTH IP/OP $761.00 $563.14 $0.00 $608.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.59 $0.00 $0.00 $0.00 $0.00 $380.50 $602.71 $608.80 $0.00 $494.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CMPR7504 EAP Dilation Of Esophagus Procedure BOTH IP/OP "$3,267.00 " "$2,417.58" $0.00 "$2,613.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $680.84 $0.00 $0.00 $0.00 $0.00 "$1,633.50" "$2,587.46" "$2,613.60" $0.00 "$2,123.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CMPR7505 EAP Endoscopic Cannulation Procedure BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.74 $0.00 $0.00 $0.00 $0.00 $222.50 $352.44 $356.00 $0.00 $289.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G0008 EAP HCPCS G0008 ADMIN INFLUENZA VIRUS VAC BOTH IP/OP $73.00 $54.02 $0.00 $73.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.82 $0.00 $0.00 $73.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G0009 EAP HCPCS G0009 ADMIN PNEUMOCOCCAL VACCINE BOTH IP/OP $73.00 $54.02 $0.00 $57.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G0010 EAP HCPCS G0010 ADMIN HEPATITIS B VACCINE BOTH IP/OP $73.00 $54.02 $0.00 $57.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G0105 EAP HCPCS G0105 COLORECTAL SCRN; HI RISK IND BOTH IP/OP "$1,187.00 " $878.38 $0.00 "$1,187.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,187.00" $940.10 $949.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G0121 EAP HCPCS G0121 COLON CA SCRN NOT HI RSK IND BOTH IP/OP $985.00 $728.90 $0.00 "$1,189.00" $985.00 $985.00 $772.82 $772.82 $777.17 $0.00 $985.00 $985.00 $985.00 $760.65 $205.27 $494.42 $985.00 $985.00 $766.13 "$1,189.00" $941.69 $951.20 "$1,064.43" $0.00 "$1,064.43" $186.08 $193.26 $193.26 $189.29 $729.64 $0.00 $0.00 $0.00 $0.00 G0297 EAP HCPCS G0297 Ldct for lung ca screen BOTH IP/OP $662.00 $489.88 $0.00 $529.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.04 $331.00 $524.30 $529.60 $111.21 $0.00 $111.21 $103.60 $189.09 $189.09 $105.39 $76.23 $0.00 $0.00 $0.00 $0.00 G0438 EAP HCPCS G0438 FIRST ANNUAL WELLNESS VISIT BOTH IP/OP $468.00 $346.32 $0.00 $483.20 $0.00 $0.00 $172.69 $172.69 $168.58 $67.13 $311.31 $311.31 $323.29 $172.69 $97.53 $112.25 $276.82 $276.82 $184.17 $302.00 $478.37 $483.20 $172.69 $468.00 $172.69 $0.00 $172.69 $172.69 $96.16 $172.69 $0.00 $0.00 $0.00 $0.00 G0447 EAP HCPCS G0447 "Face-to-face Behavioral Counseling For Obesity, 15 Minus" BOTH IP/OP $74.00 $54.76 $14.55 $93.00 $40.18 $40.18 $72.87 $72.87 $73.28 $15.42 $54.92 $54.92 $57.04 $71.76 $15.42 $46.64 $43.77 $43.77 $78.77 $46.50 $73.66 $74.40 $93.00 $48.10 $93.00 $14.55 $24.16 $24.16 $14.81 $75.02 $0.00 $0.00 $0.00 $0.00 G2012 EAP HCPCS G2012 PR BRIEF CHECK IN BY MD/QHP BY TELEPHONE BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $13.34 $0.00 $13.34 $8.14 $13.34 $13.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101 ERX HCPCS 25000001 00904-6719-60 ACETAMINOPHEN 325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101 ERX HCPCS 25000001 00904-6773-61 ACETAMINOPHEN 325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101 ERX HCPCS 25000001 49348-0973-10 ACETAMINOPHEN 325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101 ERX HCPCS 25000001 50580-0600-02 ACETAMINOPHEN 325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101 ERX HCPCS 25000001 57896-0102-10 ACETAMINOPHEN 325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101 ERX HCPCS 25000001 63739-0440-01 ACETAMINOPHEN 325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101 ERX HCPCS 25000001 69618-0010-01 ACETAMINOPHEN 325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102 ERX HCPCS 25000001 00904-6730-61 ACETAMINOPHEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102 ERX HCPCS 25000001 49348-0042-14 ACETAMINOPHEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102 ERX HCPCS 25000001 50580-0412-01 ACETAMINOPHEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102 ERX HCPCS 25000001 50580-0412-02 ACETAMINOPHEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102 ERX HCPCS 25000001 57896-0204-01 ACETAMINOPHEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103 ERX HCPCS 25000001 45802-0732-00 ACETAMINOPHEN 120 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103 ERX HCPCS 25000001 45802-0732-30 ACETAMINOPHEN 120 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104 ERX HCPCS 25000001 ACETAMINOPHEN 325 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 104 ERX HCPCS 25000001 51672-2116-02 ACETAMINOPHEN 325 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 105 ERX HCPCS 25000001 45802-0730-00 ACETAMINOPHEN 650 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 105 ERX HCPCS 25000001 45802-0730-30 ACETAMINOPHEN 650 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 105 ERX HCPCS 25000001 45802-0730-32 ACETAMINOPHEN 650 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 113 ERX HCPCS 63700001 00527-1050-01 ACETAZOLAMIDE 250 MG PO TABS BOTH IP/OP $12.08 $8.94 $0.00 $8.77 $0.00 $0.00 $0.00 $2.15 $0.00 $0.00 $0.00 $0.00 $0.00 $2.52 $0.00 $0.00 $0.00 $0.00 $5.48 $8.68 $8.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 113 ERX HCPCS 63700001 51672-4023-01 ACETAZOLAMIDE 250 MG PO TABS BOTH IP/OP $12.08 $8.94 $0.00 $8.77 $0.00 $0.00 $0.00 $2.15 $0.00 $0.00 $0.00 $0.00 $0.00 $2.52 $0.00 $0.00 $0.00 $0.00 $5.48 $8.68 $8.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 114 ERX HCPCS J1120 00143-9503-01 ACETAZOLAMIDE SODIUM 500 MG IJ SOLR BOTH IP/OP $101.81 $75.34 $0.00 $78.48 $45.81 $45.81 $0.00 $0.00 $0.00 $41.60 $75.56 $75.56 $78.48 $0.00 $23.66 $0.00 $60.22 $60.22 $0.00 $46.16 $73.12 $73.86 $0.00 $0.00 $16.61 $0.00 $0.00 $15.82 $0.00 $0.00 $0.00 $0.00 $0.00 114 ERX HCPCS J1120 39822-0190-01 ACETAZOLAMIDE SODIUM 500 MG IJ SOLR BOTH IP/OP $101.81 $75.34 $0.00 $78.48 $45.81 $45.81 $0.00 $0.00 $0.00 $41.60 $75.56 $75.56 $78.48 $0.00 $23.66 $0.00 $60.22 $60.22 $0.00 $46.16 $73.12 $73.86 $0.00 $0.00 $16.61 $0.00 $0.00 $15.82 $0.00 $0.00 $0.00 $0.00 $0.00 114 ERX HCPCS J1120 39822-0190-07 ACETAZOLAMIDE SODIUM 500 MG IJ SOLR BOTH IP/OP $101.81 $75.34 $0.00 $78.48 $45.81 $45.81 $0.00 $0.00 $0.00 $41.60 $75.56 $75.56 $78.48 $0.00 $23.66 $0.00 $60.22 $60.22 $0.00 $46.16 $73.12 $73.86 $0.00 $0.00 $16.61 $0.00 $0.00 $15.82 $0.00 $0.00 $0.00 $0.00 $0.00 114 ERX HCPCS J1120 67457-0853-50 ACETAZOLAMIDE SODIUM 500 MG IJ SOLR BOTH IP/OP $101.81 $75.34 $0.00 $78.48 $45.81 $45.81 $0.00 $0.00 $0.00 $41.60 $75.56 $75.56 $78.48 $0.00 $23.66 $0.00 $60.22 $60.22 $0.00 $46.16 $73.12 $73.86 $0.00 $0.00 $16.61 $0.00 $0.00 $15.82 $0.00 $0.00 $0.00 $0.00 $0.00 123 ERX HCPCS J7608 00409-3308-03 ACETYLCYSTEINE 20 % IN SOLN BOTH IP/OP $47.03 $34.80 $0.00 $36.25 $21.16 $21.16 $0.00 $0.00 $5.74 $9.80 $34.91 $34.91 $36.25 $0.00 $9.80 $0.00 $27.82 $27.82 $0.00 $21.33 $33.78 $34.12 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123 ERX HCPCS J7608 00517-7604-01 ACETYLCYSTEINE 20 % IN SOLN BOTH IP/OP $47.03 $34.80 $0.00 $36.25 $21.16 $21.16 $0.00 $0.00 $5.74 $9.80 $34.91 $34.91 $36.25 $0.00 $9.80 $0.00 $27.82 $27.82 $0.00 $21.33 $33.78 $34.12 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123 ERX HCPCS J7608 00517-7604-25 ACETYLCYSTEINE 20 % IN SOLN BOTH IP/OP $47.03 $34.80 $0.00 $36.25 $21.16 $21.16 $0.00 $0.00 $5.74 $9.80 $34.91 $34.91 $36.25 $0.00 $9.80 $0.00 $27.82 $27.82 $0.00 $21.33 $33.78 $34.12 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123 ERX HCPCS J7608 63323-0690-30 ACETYLCYSTEINE 20 % IN SOLN BOTH IP/OP $47.03 $34.80 $0.00 $36.25 $21.16 $21.16 $0.00 $0.00 $5.74 $9.80 $34.91 $34.91 $36.25 $0.00 $9.80 $0.00 $27.82 $27.82 $0.00 $21.33 $33.78 $34.12 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123 ERX HCPCS J7608 63323-0694-04 ACETYLCYSTEINE 20 % IN SOLN BOTH IP/OP $47.03 $34.80 $0.00 $36.25 $21.16 $21.16 $0.00 $0.00 $5.74 $9.80 $34.91 $34.91 $36.25 $0.00 $9.80 $0.00 $27.82 $27.82 $0.00 $21.33 $33.78 $34.12 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123 ERX HCPCS J7608 99999-6005-92 ACETYLCYSTEINE 20 % IN SOLN BOTH IP/OP $47.03 $34.80 $0.00 $36.25 $21.16 $21.16 $0.00 $0.00 $5.74 $9.80 $34.91 $34.91 $36.25 $0.00 $9.80 $0.00 $27.82 $27.82 $0.00 $21.33 $33.78 $34.12 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 250 ERX HCPCS 25000001 00378-6990-31 ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 250 ERX HCPCS 25000001 00487-9501-01 ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 250 ERX HCPCS 25000001 00487-9501-03 ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 250 ERX HCPCS 25000001 00487-9501-25 ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 250 ERX HCPCS 25000001 00591-3797-83 ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 250 ERX HCPCS 25000001 76204-0200-01 ALBUTEROL SULFATE (2.5 MG/3ML) 0.083% IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 252 ERX HCPCS 25000001 99999-6010-97 ALBUTEROL SULFATE 2 MG/5ML PO SYRP BOTH IP/OP $21.37 $15.81 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 $15.86 $15.86 $16.47 $0.00 $4.45 $0.00 $0.00 $0.00 $0.00 $35.70 $15.35 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 252 ERX HCPCS 25000001 99999-6004-59 ALBUTEROL SULFATE 2 MG/5ML PO SYRP BOTH IP/OP $21.37 $15.81 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 $15.86 $15.86 $16.47 $0.00 $4.45 $0.00 $0.00 $0.00 $0.00 $35.70 $56.55 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 252 ERX HCPCS 25000001 00472-0825-16 ALBUTEROL SULFATE 2 MG/5ML PO SYRP BOTH IP/OP $21.37 $15.81 $0.00 $85.23 $0.00 $0.00 $0.00 $0.00 $0.00 $15.86 $15.86 $16.47 $0.00 $4.45 $0.00 $0.00 $0.00 $0.00 $35.70 $85.23 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 253 ERX HCPCS 63700001 51079-0657-20 ALBUTEROL SULFATE 2 MG PO TABS BOTH IP/OP $29.54 $21.86 $0.00 $21.43 $0.00 $0.00 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $6.16 $0.00 $0.00 $0.00 $0.00 $13.40 $21.22 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 253 ERX HCPCS 63700001 68084-0949-95 ALBUTEROL SULFATE 2 MG PO TABS BOTH IP/OP $29.54 $21.86 $0.00 $21.43 $0.00 $0.00 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $6.16 $0.00 $0.00 $0.00 $0.00 $13.40 $21.22 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 254 ERX HCPCS 63700001 00378-0572-01 ALBUTEROL SULFATE 4 MG PO TABS BOTH IP/OP $26.79 $19.82 $0.00 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.40 $21.22 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 254 ERX HCPCS 63700001 53489-0177-01 ALBUTEROL SULFATE 4 MG PO TABS BOTH IP/OP $26.79 $19.82 $0.00 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.40 $21.22 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 254 ERX HCPCS 63700001 69543-0291-10 ALBUTEROL SULFATE 4 MG PO TABS BOTH IP/OP $26.79 $19.82 $0.00 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.40 $21.22 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310 ERX HCPCS 63700001 00904-6571-61 ALLOPURINOL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310 ERX HCPCS 63700001 16714-0041-10 ALLOPURINOL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310 ERX HCPCS 63700001 16714-0041-12 ALLOPURINOL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310 ERX HCPCS 63700001 51079-0205-20 ALLOPURINOL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310 ERX HCPCS 63700001 62584-0988-01 ALLOPURINOL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310 ERX HCPCS 63700001 62584-0988-11 ALLOPURINOL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310 ERX HCPCS 63700001 63739-0410-10 ALLOPURINOL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311 ERX HCPCS 63700001 00591-5544-01 ALLOPURINOL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311 ERX HCPCS 63700001 00904-6572-61 ALLOPURINOL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311 ERX HCPCS 63700001 50268-0064-11 ALLOPURINOL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311 ERX HCPCS 63700001 50268-0064-15 ALLOPURINOL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311 ERX HCPCS 63700001 51079-0206-01 ALLOPURINOL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311 ERX HCPCS 63700001 51079-0206-20 ALLOPURINOL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311 ERX HCPCS 63700001 62584-0713-01 ALLOPURINOL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324 ERX HCPCS 25000001 00228-2027-10 ALPRAZOLAM 0.25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324 ERX HCPCS 25000001 59762-3719-01 ALPRAZOLAM 0.25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 326 ERX HCPCS 25000001 00904-5860-61 ALPRAZOLAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 345 ERX HCPCS 25000001 00395-0049-96 ALUM AMMONIUM POWD BOTH IP/OP $34.70 $25.68 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 $25.75 $25.75 $26.75 $0.00 $7.23 $0.00 $0.00 $0.00 $0.00 $15.39 $24.38 $24.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 346 ERX HCPCS 25000001 49452-0370-01 ALUM POTASSIUM POWD BOTH IP/OP $384.30 $284.38 $0.00 $304.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.58 $304.37 $24.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 346 ERX HCPCS 25000001 51927-1692-00 ALUM POTASSIUM POWD BOTH IP/OP $6.00 $4.44 $0.00 $24.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.58 $4.75 $24.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 353 ERX HCPCS 63700001 99999-6009-93 ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP BOTH IP/OP $12.07 $8.93 $0.00 $8.80 $0.00 $0.00 $0.00 $2.15 $0.00 $0.00 $0.00 $0.00 $0.00 $2.52 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 353 ERX HCPCS 63700001 00536-0091-85 ALUMINUM HYDROXIDE GEL 320 MG/5ML PO SUSP BOTH IP/OP $12.07 $8.93 $0.00 $18.51 $0.00 $0.00 $0.00 $2.15 $0.00 $0.00 $0.00 $0.00 $0.00 $2.52 $0.00 $0.00 $0.00 $0.00 $5.50 $18.51 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364 ERX HCPCS 63700001 00904-6630-61 AMANTADINE HCL 100 MG PO CAPS BOTH IP/OP $8.13 $6.02 $0.00 $5.90 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364 ERX HCPCS 63700001 42543-0493-01 AMANTADINE HCL 100 MG PO CAPS BOTH IP/OP $8.13 $6.02 $0.00 $5.90 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364 ERX HCPCS 63700001 62332-0246-31 AMANTADINE HCL 100 MG PO CAPS BOTH IP/OP $8.13 $6.02 $0.00 $5.90 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365 ERX HCPCS 63700001 00121-0646-16 AMANTADINE HCL 50 MG/5ML PO SYRP BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365 ERX HCPCS 63700001 50383-0807-16 AMANTADINE HCL 50 MG/5ML PO SYRP BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365 ERX HCPCS 63700001 60432-0093-16 AMANTADINE HCL 50 MG/5ML PO SYRP BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365 ERX HCPCS 63700001 99999-6008-86 AMANTADINE HCL 50 MG/5ML PO SYRP BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 391 ERX HCPCS 63700001 00574-0292-01 AMILORIDE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 391 ERX HCPCS 63700001 49884-0117-01 AMILORIDE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 391 ERX HCPCS 63700001 50268-0071-15 AMILORIDE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 403 ERX HCPCS 25000001 00409-4346-16 AMINOCAPROIC ACID 250 MG/ML IV SOLN BOTH IP/OP $36.63 $27.11 $0.00 $28.23 $0.00 $0.00 $0.00 $0.00 $0.00 $27.19 $27.19 $28.23 $0.00 $7.63 $0.00 $0.00 $0.00 $0.00 $16.34 $25.88 $26.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 403 ERX HCPCS 25000001 00409-4346-73 AMINOCAPROIC ACID 250 MG/ML IV SOLN BOTH IP/OP $36.63 $27.11 $0.00 $28.23 $0.00 $0.00 $0.00 $0.00 $0.00 $27.19 $27.19 $28.23 $0.00 $7.63 $0.00 $0.00 $0.00 $0.00 $16.34 $25.88 $26.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 403 ERX HCPCS 25000001 00517-9120-25 AMINOCAPROIC ACID 250 MG/ML IV SOLN BOTH IP/OP $36.63 $27.11 $0.00 $28.23 $0.00 $0.00 $0.00 $0.00 $0.00 $27.19 $27.19 $28.23 $0.00 $7.63 $0.00 $0.00 $0.00 $0.00 $16.34 $25.88 $26.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 407 ERX HCPCS J0280 00409-5921-01 AMINOPHYLLINE 25 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.51 $16.33 $16.33 $16.96 $0.00 $10.07 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 407 ERX HCPCS J0280 00409-5922-01 AMINOPHYLLINE 25 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.51 $16.33 $16.33 $16.96 $0.00 $10.07 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 407 ERX HCPCS J0280 00409-5922-16 AMINOPHYLLINE 25 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.51 $16.33 $16.33 $16.96 $0.00 $10.07 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 432 ERX HCPCS 63700001 16714-0446-01 AMITRIPTYLINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 432 ERX HCPCS 63700001 51079-0131-01 AMITRIPTYLINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 432 ERX HCPCS 63700001 51079-0131-20 AMITRIPTYLINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 435 ERX HCPCS 63700001 16714-0447-01 AMITRIPTYLINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 435 ERX HCPCS 63700001 51079-0107-20 AMITRIPTYLINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 436 ERX HCPCS 63700001 51079-0133-01 AMITRIPTYLINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 436 ERX HCPCS 63700001 51079-0133-20 AMITRIPTYLINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 437 ERX HCPCS 63700001 16714-0449-01 AMITRIPTYLINE HCL 75 MG PO TABS BOTH IP/OP $7.61 $5.63 $0.00 $5.52 $0.00 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $3.45 $5.46 $5.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 449 ERX HCPCS 63700001 00591-5714-01 AMOXAPINE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450 ERX HCPCS 63700001 00781-2020-01 AMOXICILLIN 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450 ERX HCPCS 63700001 00781-2020-05 AMOXICILLIN 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450 ERX HCPCS 63700001 16714-0298-02 AMOXICILLIN 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 451 ERX HCPCS 63700001 00781-2613-05 AMOXICILLIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 451 ERX HCPCS 63700001 16714-0299-03 AMOXICILLIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 451 ERX HCPCS 63700001 16714-0299-04 AMOXICILLIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 451 ERX HCPCS 63700001 65862-0017-05 AMOXICILLIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 452 ERX HCPCS 63700001 00093-2268-01 AMOXICILLIN 250 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 453 ERX HCPCS 25000001 00143-9888-80 AMOXICILLIN 125 MG/5ML PO SUSR BOTH IP/OP $11.86 $8.78 $0.00 $9.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.93 $9.39 $9.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 453 ERX HCPCS 25000001 00781-6039-58 AMOXICILLIN 125 MG/5ML PO SUSR BOTH IP/OP $11.86 $8.78 $0.00 $9.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.93 $9.39 $9.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 454 ERX HCPCS 63700001 00093-4155-79 AMOXICILLIN 250 MG/5ML PO SUSR BOTH IP/OP $29.54 $21.86 $0.00 $21.43 $0.00 $0.00 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $6.16 $0.00 $0.00 $0.00 $0.00 $13.40 $15.90 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 454 ERX HCPCS 63700001 00781-6041-58 AMOXICILLIN 250 MG/5ML PO SUSR BOTH IP/OP $29.54 $21.86 $0.00 $21.43 $0.00 $0.00 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $6.16 $0.00 $0.00 $0.00 $0.00 $13.40 $15.90 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 454 ERX HCPCS 63700001 00093-4155-80 AMOXICILLIN 250 MG/5ML PO SUSR BOTH IP/OP $29.54 $21.86 $0.00 $21.43 $0.00 $0.00 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $6.16 $0.00 $0.00 $0.00 $0.00 $13.40 $21.22 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 454 ERX HCPCS 63700001 00143-9889-15 AMOXICILLIN 250 MG/5ML PO SUSR BOTH IP/OP $29.54 $21.86 $0.00 $21.43 $0.00 $0.00 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $6.16 $0.00 $0.00 $0.00 $0.00 $13.40 $21.22 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 454 ERX HCPCS 63700001 00781-6041-55 AMOXICILLIN 250 MG/5ML PO SUSR BOTH IP/OP $29.54 $21.86 $0.00 $21.43 $0.00 $0.00 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $6.16 $0.00 $0.00 $0.00 $0.00 $13.40 $21.22 $21.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 464 ERX HCPCS J0285 39822-1055-05 AMPHOTERICIN B 50 MG IV SOLR BOTH IP/OP $189.57 $140.28 $0.00 $146.12 $0.00 $0.00 $0.00 $0.00 $0.00 $140.70 $140.70 $146.12 $0.00 $50.11 $0.00 $0.00 $0.00 $0.00 $83.13 $131.67 $133.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 466 ERX HCPCS 63700001 00781-2145-01 AMPICILLIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 469 ERX HCPCS J0290 00781-3404-85 AMPICILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $36.19 $26.78 $0.00 $27.90 $16.29 $16.29 $0.00 $0.00 $0.00 $5.22 $26.86 $26.86 $27.90 $0.00 $1.90 $0.00 $21.41 $21.41 $0.00 $16.41 $25.99 $26.26 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 469 ERX HCPCS J0290 00781-3404-95 AMPICILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $36.19 $26.78 $0.00 $27.90 $16.29 $16.29 $0.00 $0.00 $0.00 $5.22 $26.86 $26.86 $27.90 $0.00 $1.90 $0.00 $21.41 $21.41 $0.00 $16.41 $25.99 $26.26 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 469 ERX HCPCS J0290 00781-9404-95 AMPICILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $36.19 $26.78 $0.00 $27.90 $16.29 $16.29 $0.00 $0.00 $0.00 $5.22 $26.86 $26.86 $27.90 $0.00 $1.90 $0.00 $21.41 $21.41 $0.00 $16.41 $25.99 $26.26 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 469 ERX HCPCS J0290 25021-0136-10 AMPICILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $36.19 $26.78 $0.00 $27.90 $16.29 $16.29 $0.00 $0.00 $0.00 $5.22 $26.86 $26.86 $27.90 $0.00 $1.90 $0.00 $21.41 $21.41 $0.00 $16.41 $25.99 $26.26 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 469 ERX HCPCS J0290 44567-0102-10 AMPICILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $36.19 $26.78 $0.00 $27.90 $16.29 $16.29 $0.00 $0.00 $0.00 $5.22 $26.86 $26.86 $27.90 $0.00 $1.90 $0.00 $21.41 $21.41 $0.00 $16.41 $25.99 $26.26 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 469 ERX HCPCS J0290 55150-0113-10 AMPICILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $36.19 $26.78 $0.00 $27.90 $16.29 $16.29 $0.00 $0.00 $0.00 $5.22 $26.86 $26.86 $27.90 $0.00 $1.90 $0.00 $21.41 $21.41 $0.00 $16.41 $25.99 $26.26 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 469 ERX HCPCS J0290 67457-0351-01 AMPICILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $36.19 $26.78 $0.00 $27.90 $16.29 $16.29 $0.00 $0.00 $0.00 $5.22 $26.86 $26.86 $27.90 $0.00 $1.90 $0.00 $21.41 $21.41 $0.00 $16.41 $25.99 $26.26 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 469 ERX HCPCS J0290 67457-0351-10 AMPICILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $36.19 $26.78 $0.00 $27.90 $16.29 $16.29 $0.00 $0.00 $0.00 $5.22 $26.86 $26.86 $27.90 $0.00 $1.90 $0.00 $21.41 $21.41 $0.00 $16.41 $25.99 $26.26 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 471 ERX HCPCS 25000001 00781-3400-78 AMPICILLIN SODIUM 125 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 471 ERX HCPCS 25000001 00781-3400-95 AMPICILLIN SODIUM 125 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 472 ERX HCPCS J0290 00781-3408-95 AMPICILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $70.20 $51.95 $0.00 $54.11 $31.59 $31.59 $0.00 $0.00 $0.00 $10.43 $52.10 $52.10 $54.11 $0.00 $3.79 $0.00 $41.52 $41.52 $0.00 $31.84 $50.43 $50.94 $0.00 $0.00 $4.61 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $0.00 472 ERX HCPCS J0290 00781-9408-95 AMPICILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $70.20 $51.95 $0.00 $54.11 $31.59 $31.59 $0.00 $0.00 $0.00 $10.43 $52.10 $52.10 $54.11 $0.00 $3.79 $0.00 $41.52 $41.52 $0.00 $31.84 $50.43 $50.94 $0.00 $0.00 $4.61 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $0.00 472 ERX HCPCS J0290 25021-0137-20 AMPICILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $70.20 $51.95 $0.00 $54.11 $31.59 $31.59 $0.00 $0.00 $0.00 $10.43 $52.10 $52.10 $54.11 $0.00 $3.79 $0.00 $41.52 $41.52 $0.00 $31.84 $50.43 $50.94 $0.00 $0.00 $4.61 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $0.00 472 ERX HCPCS J0290 44567-0103-10 AMPICILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $70.20 $51.95 $0.00 $54.11 $31.59 $31.59 $0.00 $0.00 $0.00 $10.43 $52.10 $52.10 $54.11 $0.00 $3.79 $0.00 $41.52 $41.52 $0.00 $31.84 $50.43 $50.94 $0.00 $0.00 $4.61 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $0.00 472 ERX HCPCS J0290 55150-0114-20 AMPICILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $70.20 $51.95 $0.00 $54.11 $31.59 $31.59 $0.00 $0.00 $0.00 $10.43 $52.10 $52.10 $54.11 $0.00 $3.79 $0.00 $41.52 $41.52 $0.00 $31.84 $50.43 $50.94 $0.00 $0.00 $4.61 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $0.00 474 ERX HCPCS J0290 00781-3407-78 AMPICILLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.61 $16.33 $16.33 $16.96 $0.00 $0.95 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.15 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 474 ERX HCPCS J0290 00781-3407-95 AMPICILLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.61 $16.33 $16.33 $16.96 $0.00 $0.95 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.15 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 474 ERX HCPCS J0290 00781-9407-78 AMPICILLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.61 $16.33 $16.33 $16.96 $0.00 $0.95 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.15 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 474 ERX HCPCS J0290 00781-9407-95 AMPICILLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.61 $16.33 $16.33 $16.96 $0.00 $0.95 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.15 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 474 ERX HCPCS J0290 44567-0101-10 AMPICILLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.61 $16.33 $16.33 $16.96 $0.00 $0.95 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.15 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 474 ERX HCPCS J0290 55150-0112-10 AMPICILLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.61 $16.33 $16.33 $16.96 $0.00 $0.95 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.15 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 612 ERX HCPCS 63700001 72140-0452-31 AQUAPHOR EX OINT BOTH IP/OP $24.31 $17.99 $0.00 $123.20 $0.00 $0.00 $0.00 $4.33 $0.00 $0.00 $0.00 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $77.00 $16.55 $123.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 612 ERX HCPCS 63700001 72140-0031-47 AQUAPHOR EX OINT BOTH IP/OP $24.31 $17.99 $0.00 $123.20 $0.00 $0.00 $0.00 $4.33 $0.00 $0.00 $0.00 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $77.00 $121.97 $123.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 654 ERX HCPCS 25000001 67457-0118-50 ASCORBIC ACID 500 MG/ML IJ SOLN BOTH IP/OP $364.90 $270.03 $0.00 $281.26 $0.00 $0.00 $0.00 $0.00 $0.00 $270.83 $270.83 $281.26 $0.00 $76.05 $0.00 $0.00 $0.00 $0.00 $165.62 $262.33 $264.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 680 ERX HCPCS 25000001 00536-1008-36 ASPIRIN 81 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 680 ERX HCPCS 25000001 00904-4040-73 ASPIRIN 81 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 680 ERX HCPCS 25000001 00904-6794-80 ASPIRIN 81 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 680 ERX HCPCS 25000001 63739-0434-01 ASPIRIN 81 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 680 ERX HCPCS 25000001 66553-0002-01 ASPIRIN 81 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 681 ERX HCPCS 25000001 66553-0001-01 ASPIRIN 325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 693 ERX HCPCS 25000001 00574-7034-12 ASPIRIN 300 MG RECTAL SUPP BOTH IP/OP $6.11 $4.52 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.53 $4.53 $4.71 $0.00 $1.27 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 716 ERX HCPCS 63700001 00781-1507-01 ATENOLOL 100 MG PO TABS BOTH IP/OP $6.26 $4.63 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 716 ERX HCPCS 63700001 51079-0685-01 ATENOLOL 100 MG PO TABS BOTH IP/OP $6.26 $4.63 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 716 ERX HCPCS 63700001 51079-0685-20 ATENOLOL 100 MG PO TABS BOTH IP/OP $6.26 $4.63 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 716 ERX HCPCS 63700001 68382-0024-01 ATENOLOL 100 MG PO TABS BOTH IP/OP $6.26 $4.63 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 717 ERX HCPCS 63700001 00093-0787-01 ATENOLOL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 717 ERX HCPCS 63700001 00781-1078-01 ATENOLOL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 717 ERX HCPCS 63700001 51079-0759-01 ATENOLOL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 717 ERX HCPCS 63700001 51079-0759-20 ATENOLOL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 718 ERX HCPCS 63700001 00781-1506-01 ATENOLOL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 718 ERX HCPCS 63700001 51079-0684-20 ATENOLOL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 718 ERX HCPCS 63700001 68382-0023-01 ATENOLOL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 731 ERX HCPCS J0461 00517-0401-25 ATROPINE SULFATE 0.4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $1.79 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.88 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $0.00 731 ERX HCPCS J0461 99999-6008-06 ATROPINE SULFATE 0.4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $1.79 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.88 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $0.00 734 ERX HCPCS J0461 00517-1010-25 ATROPINE SULFATE 1 MG/ML IJ SOLN BOTH IP/OP $63.16 $46.74 $0.00 $48.68 $28.42 $28.42 $0.00 $0.00 $0.00 $13.16 $46.88 $46.88 $48.68 $0.00 $8.93 $0.00 $37.36 $37.36 $0.00 $27.55 $43.63 $44.07 $0.00 $0.00 $9.40 $0.00 $0.00 $8.95 $0.00 $0.00 $0.00 $0.00 $0.00 735 ERX HCPCS 25000001 24208-0825-55 ATROPINE SULFATE 1 % OP OINT BOTH IP/OP $81.11 $60.02 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $0.00 $60.20 $60.20 $62.52 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $36.77 $58.24 $58.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 736 ERX HCPCS 25000001 17478-0215-02 ATROPINE SULFATE 1 % OP SOLN BOTH IP/OP $184.74 $136.71 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 $137.11 $137.11 $142.40 $0.00 $38.50 $0.00 $0.00 $0.00 $0.00 $78.05 $123.63 $124.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 736 ERX HCPCS 25000001 00065-0303-55 ATROPINE SULFATE 1 % OP SOLN BOTH IP/OP $184.74 $136.71 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 $137.11 $137.11 $142.40 $0.00 $38.50 $0.00 $0.00 $0.00 $0.00 $78.05 $145.65 $124.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 736 ERX HCPCS 25000001 17478-0215-05 ATROPINE SULFATE 1 % OP SOLN BOTH IP/OP $184.74 $136.71 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 $137.11 $137.11 $142.40 $0.00 $38.50 $0.00 $0.00 $0.00 $0.00 $78.05 $145.65 $124.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 850 ERX HCPCS 25000001 45802-0060-70 BACITRACIN 500 UNIT/GM EX OINT BOTH IP/OP $14.52 $10.74 $0.00 $11.19 $0.00 $0.00 $0.00 $0.00 $0.00 $10.78 $10.78 $11.19 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $6.59 $10.43 $10.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 850 ERX HCPCS 25000001 00713-0280-31 BACITRACIN 500 UNIT/GM EX OINT BOTH IP/OP $14.52 $10.74 $0.00 $11.19 $0.00 $0.00 $0.00 $0.00 $0.00 $10.78 $10.78 $11.19 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $6.59 $10.43 $10.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 851 ERX HCPCS 25000001 00009-0233-01 BACITRACIN 50000 UNITS IM SOLR BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 851 ERX HCPCS 25000001 00009-0233-03 BACITRACIN 50000 UNITS IM SOLR BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 851 ERX HCPCS 25000001 63323-0329-31 BACITRACIN 50000 UNITS IM SOLR BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 851 ERX HCPCS 25000001 70594-0026-01 BACITRACIN 50000 UNITS IM SOLR BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 851 ERX HCPCS 25000001 70594-0026-02 BACITRACIN 50000 UNITS IM SOLR BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 852 ERX HCPCS 25000001 00574-4022-35 BACITRACIN 500 UNIT/GM OP OINT BOTH IP/OP $361.25 $267.33 $0.00 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.63 $286.11 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 854 ERX HCPCS 25000001 45802-0143-03 BACITRACIN-NEOMYCIN-POLYMYXIN 400-5-5000 EX OINT BOTH IP/OP $25.82 $19.11 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 $19.16 $19.16 $19.90 $0.00 $5.38 $0.00 $0.00 $0.00 $0.00 $11.71 $18.54 $18.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 856 ERX HCPCS 25000001 24208-0555-55 BACITRACIN-POLYMYXIN B 500-10000 UNIT/GM OP OINT BOTH IP/OP $110.60 $81.84 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 $82.09 $82.09 $85.25 $0.00 $23.05 $0.00 $0.00 $0.00 $0.00 $50.14 $79.42 $80.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 860 ERX HCPCS 63700001 00904-6475-61 BACLOFEN 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 860 ERX HCPCS 63700001 16714-0071-04 BACLOFEN 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 860 ERX HCPCS 63700001 63739-0479-10 BACLOFEN 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 860 ERX HCPCS 63700001 68084-0855-01 BACLOFEN 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 987 ERX HCPCS 25000001 54162-0100-01 BENZOIN COMPOUND EX TINC BOTH IP/OP $41.74 $30.89 $0.00 $32.17 $0.00 $0.00 $0.00 $0.00 $0.00 $30.98 $30.98 $32.17 $0.00 $8.70 $0.00 $0.00 $0.00 $0.00 $18.02 $11.09 $28.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 987 ERX HCPCS 25000001 54162-0100-02 BENZOIN COMPOUND EX TINC BOTH IP/OP $41.74 $30.89 $0.00 $32.17 $0.00 $0.00 $0.00 $0.00 $0.00 $30.98 $30.98 $32.17 $0.00 $8.70 $0.00 $0.00 $0.00 $0.00 $18.02 $16.06 $28.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 987 ERX HCPCS 25000001 54162-0100-04 BENZOIN COMPOUND EX TINC BOTH IP/OP $41.74 $30.89 $0.00 $32.17 $0.00 $0.00 $0.00 $0.00 $0.00 $30.98 $30.98 $32.17 $0.00 $8.70 $0.00 $0.00 $0.00 $0.00 $18.02 $28.42 $28.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 987 ERX HCPCS 25000001 00395-0243-92 BENZOIN COMPOUND EX TINC BOTH IP/OP $41.74 $30.89 $0.00 $32.17 $0.00 $0.00 $0.00 $0.00 $0.00 $30.98 $30.98 $32.17 $0.00 $8.70 $0.00 $0.00 $0.00 $0.00 $18.02 $28.54 $28.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 00904-6564-60 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 00904-6564-61 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 42291-0164-01 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 42291-0164-50 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 60687-0346-01 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 60687-0346-11 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 63739-0029-10 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 67877-0573-01 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 988 ERX HCPCS 63700001 68382-0247-01 BENZONATATE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 989 ERX HCPCS 25000001 00536-1056-56 BENZOYL PEROXIDE 10 % EX GEL BOTH IP/OP $29.03 $21.48 $0.00 $22.38 $0.00 $0.00 $0.00 $0.00 $0.00 $21.55 $21.55 $22.38 $0.00 $6.05 $0.00 $0.00 $0.00 $0.00 $13.17 $20.85 $21.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 991 ERX HCPCS 25000001 00536-1055-56 BENZOYL PEROXIDE 5 % EX GEL BOTH IP/OP $23.87 $17.66 $0.00 $18.40 $0.00 $0.00 $0.00 $0.00 $0.00 $17.72 $17.72 $18.40 $0.00 $4.97 $0.00 $0.00 $0.00 $0.00 $10.83 $17.15 $17.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 998 ERX HCPCS 63700001 00603-2437-21 BENZTROPINE MESYLATE 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 998 ERX HCPCS 63700001 60687-0356-01 BENZTROPINE MESYLATE 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 998 ERX HCPCS 63700001 60687-0356-11 BENZTROPINE MESYLATE 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 998 ERX HCPCS 63700001 69315-0136-01 BENZTROPINE MESYLATE 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 999 ERX HCPCS 63700001 00603-2438-21 BENZTROPINE MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 999 ERX HCPCS 63700001 10135-0607-01 BENZTROPINE MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 999 ERX HCPCS 63700001 60687-0368-01 BENZTROPINE MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 999 ERX HCPCS 63700001 60687-0368-11 BENZTROPINE MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 999 ERX HCPCS 63700001 76385-0104-01 BENZTROPINE MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000 ERX HCPCS 63700001 00603-2439-21 BENZTROPINE MESYLATE 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000 ERX HCPCS 63700001 69315-0138-01 BENZTROPINE MESYLATE 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1029 ERX HCPCS 63700001 00168-0056-15 BETAMETHASONE DIPROPIONATE 0.05 % EX OINT BOTH IP/OP $213.36 $157.89 $0.00 $154.94 $0.00 $0.00 $0.00 $37.98 $0.00 $0.00 $0.00 $0.00 $0.00 $44.46 $0.00 $0.00 $0.00 $0.00 $96.84 $153.39 $154.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1029 ERX HCPCS 63700001 00472-0381-15 BETAMETHASONE DIPROPIONATE 0.05 % EX OINT BOTH IP/OP $213.36 $157.89 $0.00 $154.94 $0.00 $0.00 $0.00 $37.98 $0.00 $0.00 $0.00 $0.00 $0.00 $44.46 $0.00 $0.00 $0.00 $0.00 $96.84 $153.39 $154.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1044 ERX HCPCS 63700001 00832-0512-01 BETHANECHOL CHLORIDE 25 MG PO TABS BOTH IP/OP $8.98 $6.65 $0.00 $6.51 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.07 $6.45 $6.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1044 ERX HCPCS 63700001 00832-0512-89 BETHANECHOL CHLORIDE 25 MG PO TABS BOTH IP/OP $8.98 $6.65 $0.00 $6.51 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.07 $6.45 $6.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1044 ERX HCPCS 63700001 65162-0573-10 BETHANECHOL CHLORIDE 25 MG PO TABS BOTH IP/OP $8.98 $6.65 $0.00 $6.51 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.07 $6.45 $6.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1079 ERX HCPCS 63700001 00904-6407-61 BISACODYL 5 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1079 ERX HCPCS 63700001 00904-7927-60 BISACODYL 5 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1079 ERX HCPCS 63700001 49483-0003-01 BISACODYL 5 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1080 ERX HCPCS 63700001 00574-7050-12 BISACODYL 10 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1080 ERX HCPCS 63700001 00574-7050-50 BISACODYL 10 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1080 ERX HCPCS 63700001 57896-0443-05 BISACODYL 10 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1080 ERX HCPCS 63700001 57896-0444-05 BISACODYL 10 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1080 ERX HCPCS 63700001 68784-0102-12 BISACODYL 10 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1080 ERX HCPCS 63700001 81421-0021-01 BISACODYL 10 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1090 ERX HCPCS 25000001 37000-0032-01 BISMUTH SUBSALICYLATE 262 MG/15ML PO SUSP BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1259 ERX HCPCS 25000001 46017-0018-16 CAFFEINE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1259 ERX HCPCS 25000001 70677-0021-01 CAFFEINE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1262 ERX HCPCS 25000001 00517-2502-10 CAFFEINE-SODIUM BENZOATE 125-125 MG/ML IJ SOLN BOTH IP/OP $58.05 $42.96 $0.00 $46.53 $0.00 $0.00 $0.00 $0.00 $0.00 $44.81 $44.81 $46.53 $0.00 $12.10 $0.00 $0.00 $0.00 $0.00 $23.98 $37.98 $38.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1306 ERX HCPCS 25000001 00409-1631-10 CALCIUM CHLORIDE 10 % IV SOLN BOTH IP/OP $89.52 $66.24 $0.00 $69.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.44 $66.44 $69.00 $0.00 $18.66 $0.00 $0.00 $0.00 $0.00 $40.59 $64.29 $64.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1306 ERX HCPCS 25000001 00409-4928-34 CALCIUM CHLORIDE 10 % IV SOLN BOTH IP/OP $89.52 $66.24 $0.00 $69.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.44 $66.44 $69.00 $0.00 $18.66 $0.00 $0.00 $0.00 $0.00 $40.59 $64.29 $64.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1306 ERX HCPCS 25000001 00517-2710-25 CALCIUM CHLORIDE 10 % IV SOLN BOTH IP/OP $89.52 $66.24 $0.00 $69.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.44 $66.44 $69.00 $0.00 $18.66 $0.00 $0.00 $0.00 $0.00 $40.59 $64.29 $64.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1306 ERX HCPCS 25000001 00517-6710-01 CALCIUM CHLORIDE 10 % IV SOLN BOTH IP/OP $89.52 $66.24 $0.00 $69.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.44 $66.44 $69.00 $0.00 $18.66 $0.00 $0.00 $0.00 $0.00 $40.59 $64.29 $64.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1306 ERX HCPCS 25000001 00517-6710-10 CALCIUM CHLORIDE 10 % IV SOLN BOTH IP/OP $89.52 $66.24 $0.00 $69.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.44 $66.44 $69.00 $0.00 $18.66 $0.00 $0.00 $0.00 $0.00 $40.59 $64.29 $64.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1306 ERX HCPCS 25000001 76329-3304-01 CALCIUM CHLORIDE 10 % IV SOLN BOTH IP/OP $89.52 $66.24 $0.00 $69.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.44 $66.44 $69.00 $0.00 $18.66 $0.00 $0.00 $0.00 $0.00 $40.59 $64.29 $64.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1308 ERX HCPCS 63700001 00904-5062-60 CALCIUM CITRATE 950 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1312 ERX HCPCS J0610 63323-0360-19 CALCIUM GLUCONATE 10 % IV SOLN BOTH IP/OP $32.00 $23.68 $0.00 $25.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.00 $25.34 $25.60 $0.00 $0.00 $4.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1350 ERX HCPCS 63700001 00536-2525-25 CAPSAICIN 0.025 % EX CREA BOTH IP/OP $41.74 $30.89 $0.00 $30.28 $0.00 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 $8.70 $0.00 $0.00 $0.00 $0.00 $18.93 $29.98 $30.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1355 ERX HCPCS 63700001 00904-3854-61 CARBAMAZEPINE 100 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1356 ERX HCPCS 25000001 99999-6004-61 CARBAMAZEPINE 100 MG/5ML PO SUSP BOTH IP/OP $107.00 $79.18 $0.00 $82.48 $0.00 $0.00 $0.00 $0.00 $0.00 $79.42 $79.42 $82.48 $0.00 $22.30 $0.00 $0.00 $0.00 $0.00 $48.51 $76.84 $77.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1356 ERX HCPCS 25000001 00078-0508-83 CARBAMAZEPINE 100 MG/5ML PO SUSP BOTH IP/OP $107.00 $79.18 $0.00 $472.86 $0.00 $0.00 $0.00 $0.00 $0.00 $79.42 $79.42 $82.48 $0.00 $22.30 $0.00 $0.00 $0.00 $0.00 $48.51 $472.86 $77.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1356 ERX HCPCS 25000001 60432-0129-16 CARBAMAZEPINE 100 MG/5ML PO SUSP BOTH IP/OP $107.00 $79.18 $0.00 $472.86 $0.00 $0.00 $0.00 $0.00 $0.00 $79.42 $79.42 $82.48 $0.00 $22.30 $0.00 $0.00 $0.00 $0.00 $48.51 $472.86 $77.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1357 ERX HCPCS 63700001 00904-6172-61 CARBAMAZEPINE 200 MG PO TABS BOTH IP/OP $6.08 $4.50 $0.00 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.04 $4.82 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1357 ERX HCPCS 63700001 51079-0385-20 CARBAMAZEPINE 200 MG PO TABS BOTH IP/OP $6.08 $4.50 $0.00 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.04 $4.82 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1395 ERX HCPCS 63700001 42543-0700-01 CARISOPRODOL 350 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1445 ERX HCPCS J0690 00143-9262-25 CEFAZOLIN SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1445 ERX HCPCS J0690 00143-9924-90 CEFAZOLIN SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1445 ERX HCPCS J0690 00781-3451-96 CEFAZOLIN SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1445 ERX HCPCS J0690 25021-0101-10 CEFAZOLIN SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1445 ERX HCPCS J0690 44567-0707-25 CEFAZOLIN SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1445 ERX HCPCS J0690 60505-6142-05 CEFAZOLIN SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1445 ERX HCPCS J0690 63323-0237-10 CEFAZOLIN SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1446 ERX HCPCS J0690 00143-9261-01 CEFAZOLIN SODIUM 10 G IJ SOLR BOTH IP/OP $60.34 $44.65 $0.00 $46.51 $27.15 $27.15 $0.00 $0.00 $0.00 $13.87 $44.78 $44.78 $46.51 $0.00 $17.53 $0.00 $35.69 $35.69 $0.00 $27.36 $43.34 $43.78 $0.00 $0.00 $19.27 $0.00 $0.00 $18.35 $0.00 $0.00 $0.00 $0.00 $0.00 1446 ERX HCPCS J0690 00143-9261-10 CEFAZOLIN SODIUM 10 G IJ SOLR BOTH IP/OP $60.34 $44.65 $0.00 $46.51 $27.15 $27.15 $0.00 $0.00 $0.00 $13.87 $44.78 $44.78 $46.51 $0.00 $17.53 $0.00 $35.69 $35.69 $0.00 $27.36 $43.34 $43.78 $0.00 $0.00 $19.27 $0.00 $0.00 $18.35 $0.00 $0.00 $0.00 $0.00 $0.00 1446 ERX HCPCS J0690 00143-9983-03 CEFAZOLIN SODIUM 10 G IJ SOLR BOTH IP/OP $60.34 $44.65 $0.00 $46.51 $27.15 $27.15 $0.00 $0.00 $0.00 $13.87 $44.78 $44.78 $46.51 $0.00 $17.53 $0.00 $35.69 $35.69 $0.00 $27.36 $43.34 $43.78 $0.00 $0.00 $19.27 $0.00 $0.00 $18.35 $0.00 $0.00 $0.00 $0.00 $0.00 1446 ERX HCPCS J0690 00781-3452-95 CEFAZOLIN SODIUM 10 G IJ SOLR BOTH IP/OP $60.34 $44.65 $0.00 $46.51 $27.15 $27.15 $0.00 $0.00 $0.00 $13.87 $44.78 $44.78 $46.51 $0.00 $17.53 $0.00 $35.69 $35.69 $0.00 $27.36 $43.34 $43.78 $0.00 $0.00 $19.27 $0.00 $0.00 $18.35 $0.00 $0.00 $0.00 $0.00 $0.00 1446 ERX HCPCS J0690 25021-0102-99 CEFAZOLIN SODIUM 10 G IJ SOLR BOTH IP/OP $60.34 $44.65 $0.00 $46.51 $27.15 $27.15 $0.00 $0.00 $0.00 $13.87 $44.78 $44.78 $46.51 $0.00 $17.53 $0.00 $35.69 $35.69 $0.00 $27.36 $43.34 $43.78 $0.00 $0.00 $19.27 $0.00 $0.00 $18.35 $0.00 $0.00 $0.00 $0.00 $0.00 1446 ERX HCPCS J0690 44567-0708-10 CEFAZOLIN SODIUM 10 G IJ SOLR BOTH IP/OP $60.34 $44.65 $0.00 $46.51 $27.15 $27.15 $0.00 $0.00 $0.00 $13.87 $44.78 $44.78 $46.51 $0.00 $17.53 $0.00 $35.69 $35.69 $0.00 $27.36 $43.34 $43.78 $0.00 $0.00 $19.27 $0.00 $0.00 $18.35 $0.00 $0.00 $0.00 $0.00 $0.00 1446 ERX HCPCS J0690 63323-0238-61 CEFAZOLIN SODIUM 10 G IJ SOLR BOTH IP/OP $60.34 $44.65 $0.00 $46.51 $27.15 $27.15 $0.00 $0.00 $0.00 $13.87 $44.78 $44.78 $46.51 $0.00 $17.53 $0.00 $35.69 $35.69 $0.00 $27.36 $43.34 $43.78 $0.00 $0.00 $19.27 $0.00 $0.00 $18.35 $0.00 $0.00 $0.00 $0.00 $0.00 1448 ERX HCPCS J0690 00143-9923-90 CEFAZOLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.69 $16.33 $16.33 $16.96 $0.00 $0.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.96 $0.00 $0.00 $0.92 $0.00 $0.00 $0.00 $0.00 $0.00 1448 ERX HCPCS J0690 00781-3450-95 CEFAZOLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.69 $16.33 $16.33 $16.96 $0.00 $0.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.96 $0.00 $0.00 $0.92 $0.00 $0.00 $0.00 $0.00 $0.00 1448 ERX HCPCS J0690 25021-0100-10 CEFAZOLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.69 $16.33 $16.33 $16.96 $0.00 $0.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.96 $0.00 $0.00 $0.92 $0.00 $0.00 $0.00 $0.00 $0.00 1448 ERX HCPCS J0690 63323-0236-10 CEFAZOLIN SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.69 $16.33 $16.33 $16.96 $0.00 $0.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.96 $0.00 $0.00 $0.92 $0.00 $0.00 $0.00 $0.00 $0.00 1465 ERX HCPCS J0697 00143-9979-22 CEFUROXIME SODIUM 750 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1465 ERX HCPCS J0697 25021-0118-10 CEFUROXIME SODIUM 750 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1622 ERX HCPCS 25000001 00555-0033-02 CHLORDIAZEPOXIDE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1622 ERX HCPCS 25000001 51079-0375-01 CHLORDIAZEPOXIDE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1622 ERX HCPCS 25000001 51079-0375-20 CHLORDIAZEPOXIDE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1623 ERX HCPCS 25000001 51079-0141-01 CHLORDIAZEPOXIDE HCL 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1623 ERX HCPCS 25000001 51079-0141-20 CHLORDIAZEPOXIDE HCL 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1624 ERX HCPCS 25000001 00555-0158-02 CHLORDIAZEPOXIDE HCL 5 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1624 ERX HCPCS 25000001 51079-0374-01 CHLORDIAZEPOXIDE HCL 5 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1624 ERX HCPCS 25000001 51079-0374-20 CHLORDIAZEPOXIDE HCL 5 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1637 ERX HCPCS 63700001 64980-0177-50 CHLOROQUINE PHOSPHATE 250 MG PO TABS BOTH IP/OP $38.53 $28.51 $0.00 $27.95 $0.00 $0.00 $0.00 $6.86 $0.00 $0.00 $0.00 $0.00 $0.00 $8.03 $0.00 $0.00 $0.00 $0.00 $17.47 $27.67 $27.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1645 ERX HCPCS 63700001 00904-0012-59 CHLORPHENIRAMINE MALEATE 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1645 ERX HCPCS 63700001 10135-0133-01 CHLORPHENIRAMINE MALEATE 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1649 ERX HCPCS J3230 00641-1397-31 CHLORPROMAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $133.82 $99.03 $0.00 $103.15 $60.22 $60.22 $0.00 $0.00 $0.00 $9.35 $99.32 $99.32 $103.15 $0.00 $38.62 $0.00 $79.15 $79.15 $0.00 $60.67 $96.10 $97.07 $0.00 $0.00 $37.08 $0.00 $0.00 $35.31 $0.00 $0.00 $0.00 $0.00 $0.00 1649 ERX HCPCS J3230 00641-1397-35 CHLORPROMAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $133.82 $99.03 $0.00 $103.15 $60.22 $60.22 $0.00 $0.00 $0.00 $9.35 $99.32 $99.32 $103.15 $0.00 $38.62 $0.00 $79.15 $79.15 $0.00 $60.67 $96.10 $97.07 $0.00 $0.00 $37.08 $0.00 $0.00 $35.31 $0.00 $0.00 $0.00 $0.00 $0.00 1653 ERX HCPCS Q0161 00781-5913-01 CHLORPROMAZINE HCL 10 MG PO TABS BOTH IP/OP $25.20 $18.65 $0.00 $20.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.60 $19.96 $20.16 $0.00 $0.00 $3.94 $0.00 $0.00 $4.01 $0.00 $0.00 $0.00 $0.00 $0.00 1653 ERX HCPCS Q0161 00832-0300-00 CHLORPROMAZINE HCL 10 MG PO TABS BOTH IP/OP $25.20 $18.65 $0.00 $20.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.60 $19.96 $20.16 $0.00 $0.00 $3.94 $0.00 $0.00 $4.01 $0.00 $0.00 $0.00 $0.00 $0.00 1653 ERX HCPCS Q0161 51079-0518-01 CHLORPROMAZINE HCL 10 MG PO TABS BOTH IP/OP $25.20 $18.65 $0.00 $20.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.60 $19.96 $20.16 $0.00 $0.00 $3.94 $0.00 $0.00 $4.01 $0.00 $0.00 $0.00 $0.00 $0.00 1653 ERX HCPCS Q0161 51079-0518-20 CHLORPROMAZINE HCL 10 MG PO TABS BOTH IP/OP $25.20 $18.65 $0.00 $20.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.60 $19.96 $20.16 $0.00 $0.00 $3.94 $0.00 $0.00 $4.01 $0.00 $0.00 $0.00 $0.00 $0.00 1654 ERX HCPCS Q0161 00832-0303-00 CHLORPROMAZINE HCL 100 MG PO TABS BOTH IP/OP $77.83 $57.59 $0.00 $62.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.92 $61.64 $62.26 $0.00 $0.00 $12.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1654 ERX HCPCS Q0161 51079-0516-01 CHLORPROMAZINE HCL 100 MG PO TABS BOTH IP/OP $77.83 $57.59 $0.00 $62.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.92 $61.64 $62.26 $0.00 $0.00 $12.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1654 ERX HCPCS Q0161 51079-0516-20 CHLORPROMAZINE HCL 100 MG PO TABS BOTH IP/OP $77.83 $57.59 $0.00 $62.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.92 $61.64 $62.26 $0.00 $0.00 $12.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1655 ERX HCPCS Q0161 00781-5917-01 CHLORPROMAZINE HCL 200 MG PO TABS BOTH IP/OP $92.82 $68.69 $0.00 $74.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.41 $73.51 $74.26 $0.00 $0.00 $14.53 $0.00 $0.00 $14.78 $0.00 $0.00 $0.00 $0.00 $0.00 1655 ERX HCPCS Q0161 00832-0304-00 CHLORPROMAZINE HCL 200 MG PO TABS BOTH IP/OP $92.82 $68.69 $0.00 $74.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.41 $73.51 $74.26 $0.00 $0.00 $14.53 $0.00 $0.00 $14.78 $0.00 $0.00 $0.00 $0.00 $0.00 1655 ERX HCPCS Q0161 51079-0517-01 CHLORPROMAZINE HCL 200 MG PO TABS BOTH IP/OP $92.82 $68.69 $0.00 $74.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.41 $73.51 $74.26 $0.00 $0.00 $14.53 $0.00 $0.00 $14.78 $0.00 $0.00 $0.00 $0.00 $0.00 1655 ERX HCPCS Q0161 51079-0517-20 CHLORPROMAZINE HCL 200 MG PO TABS BOTH IP/OP $92.82 $68.69 $0.00 $74.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.41 $73.51 $74.26 $0.00 $0.00 $14.53 $0.00 $0.00 $14.78 $0.00 $0.00 $0.00 $0.00 $0.00 1656 ERX HCPCS Q0161 00781-5914-01 CHLORPROMAZINE HCL 25 MG PO TABS BOTH IP/OP $36.34 $26.89 $0.00 $29.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.17 $28.78 $29.07 $0.00 $0.00 $5.69 $0.00 $0.00 $5.79 $0.00 $0.00 $0.00 $0.00 $0.00 1656 ERX HCPCS Q0161 00832-0301-00 CHLORPROMAZINE HCL 25 MG PO TABS BOTH IP/OP $36.34 $26.89 $0.00 $29.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.17 $28.78 $29.07 $0.00 $0.00 $5.69 $0.00 $0.00 $5.79 $0.00 $0.00 $0.00 $0.00 $0.00 1656 ERX HCPCS Q0161 51079-0519-01 CHLORPROMAZINE HCL 25 MG PO TABS BOTH IP/OP $36.34 $26.89 $0.00 $29.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.17 $28.78 $29.07 $0.00 $0.00 $5.69 $0.00 $0.00 $5.79 $0.00 $0.00 $0.00 $0.00 $0.00 1656 ERX HCPCS Q0161 51079-0519-20 CHLORPROMAZINE HCL 25 MG PO TABS BOTH IP/OP $36.34 $26.89 $0.00 $29.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.17 $28.78 $29.07 $0.00 $0.00 $5.69 $0.00 $0.00 $5.79 $0.00 $0.00 $0.00 $0.00 $0.00 1657 ERX HCPCS Q0161 00781-5915-01 CHLORPROMAZINE HCL 50 MG PO TABS BOTH IP/OP $43.48 $32.18 $0.00 $33.51 $19.57 $19.57 $0.00 $0.00 $0.00 $9.06 $32.27 $32.27 $33.51 $0.00 $9.06 $0.00 $25.72 $25.72 $0.00 $19.72 $31.23 $31.54 $0.00 $0.00 $6.17 $0.00 $0.00 $6.28 $0.00 $0.00 $0.00 $0.00 $0.00 1657 ERX HCPCS Q0161 00832-0302-00 CHLORPROMAZINE HCL 50 MG PO TABS BOTH IP/OP $43.48 $32.18 $0.00 $33.51 $19.57 $19.57 $0.00 $0.00 $0.00 $9.06 $32.27 $32.27 $33.51 $0.00 $9.06 $0.00 $25.72 $25.72 $0.00 $19.72 $31.23 $31.54 $0.00 $0.00 $6.17 $0.00 $0.00 $6.28 $0.00 $0.00 $0.00 $0.00 $0.00 1657 ERX HCPCS Q0161 00832-0302-89 CHLORPROMAZINE HCL 50 MG PO TABS BOTH IP/OP $43.48 $32.18 $0.00 $33.51 $19.57 $19.57 $0.00 $0.00 $0.00 $9.06 $32.27 $32.27 $33.51 $0.00 $9.06 $0.00 $25.72 $25.72 $0.00 $19.72 $31.23 $31.54 $0.00 $0.00 $6.17 $0.00 $0.00 $6.28 $0.00 $0.00 $0.00 $0.00 $0.00 1657 ERX HCPCS Q0161 51079-0130-01 CHLORPROMAZINE HCL 50 MG PO TABS BOTH IP/OP $43.48 $32.18 $0.00 $33.51 $19.57 $19.57 $0.00 $0.00 $0.00 $9.06 $32.27 $32.27 $33.51 $0.00 $9.06 $0.00 $25.72 $25.72 $0.00 $19.72 $31.23 $31.54 $0.00 $0.00 $6.17 $0.00 $0.00 $6.28 $0.00 $0.00 $0.00 $0.00 $0.00 1657 ERX HCPCS Q0161 51079-0130-20 CHLORPROMAZINE HCL 50 MG PO TABS BOTH IP/OP $43.48 $32.18 $0.00 $33.51 $19.57 $19.57 $0.00 $0.00 $0.00 $9.06 $32.27 $32.27 $33.51 $0.00 $9.06 $0.00 $25.72 $25.72 $0.00 $19.72 $31.23 $31.54 $0.00 $0.00 $6.17 $0.00 $0.00 $6.28 $0.00 $0.00 $0.00 $0.00 $0.00 1661 ERX HCPCS 63700001 00378-0222-01 CHLORTHALIDONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1661 ERX HCPCS 63700001 16714-0800-01 CHLORTHALIDONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1661 ERX HCPCS 63700001 43598-0719-01 CHLORTHALIDONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1661 ERX HCPCS 63700001 57664-0648-88 CHLORTHALIDONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1661 ERX HCPCS 63700001 68382-0970-01 CHLORTHALIDONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1662 ERX HCPCS 63700001 00378-0213-01 CHLORTHALIDONE 50 MG PO TABS BOTH IP/OP $6.24 $4.62 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1662 ERX HCPCS 63700001 57664-0649-88 CHLORTHALIDONE 50 MG PO TABS BOTH IP/OP $6.24 $4.62 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1662 ERX HCPCS 63700001 64980-0304-01 CHLORTHALIDONE 50 MG PO TABS BOTH IP/OP $6.24 $4.62 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1662 ERX HCPCS 63700001 66689-0346-99 CHLORTHALIDONE 50 MG PO TABS BOTH IP/OP $6.24 $4.62 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1664 ERX HCPCS 63700001 00591-2520-01 CHLORZOXAZONE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1676 ERX HCPCS J0725 55566-1501-01 CHORIONIC GONADOTROPIN 10000 UNITS IM SOLR BOTH IP/OP $75.45 $55.83 $0.00 $58.16 $0.00 $0.00 $0.00 $0.00 $0.00 $56.00 $56.00 $58.16 $0.00 $26.57 $0.00 $0.00 $0.00 $0.00 $32.90 $52.11 $52.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1683 ERX HCPCS 63700001 00904-4314-60 CHROMIUM 200 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1740 ERX HCPCS 63700001 00904-5959-61 CLINDAMYCIN HCL 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1740 ERX HCPCS 63700001 63739-0059-10 CLINDAMYCIN HCL 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1742 ERX HCPCS 25000001 00168-0201-30 CLINDAMYCIN PHOSPHATE 1 % EX SOLN BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1742 ERX HCPCS 25000001 45802-0562-01 CLINDAMYCIN PHOSPHATE 1 % EX SOLN BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1753 ERX HCPCS 63700001 49884-0701-55 CLOMIPHENE CITRATE 50 MG PO TABS BOTH IP/OP $29.00 $21.46 $0.00 $21.04 $0.00 $0.00 $0.00 $5.16 $0.00 $0.00 $0.00 $0.00 $0.00 $6.04 $0.00 $0.00 $0.00 $0.00 $13.15 $20.83 $21.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1754 ERX HCPCS 63700001 00406-8807-01 CLOMIPRAMINE HCL 50 MG PO CAPS BOTH IP/OP $47.11 $34.86 $0.00 $34.18 $0.00 $0.00 $0.00 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1754 ERX HCPCS 63700001 00781-2037-01 CLOMIPRAMINE HCL 50 MG PO CAPS BOTH IP/OP $47.11 $34.86 $0.00 $34.18 $0.00 $0.00 $0.00 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1754 ERX HCPCS 63700001 51672-4012-06 CLOMIPRAMINE HCL 50 MG PO CAPS BOTH IP/OP $47.11 $34.86 $0.00 $34.18 $0.00 $0.00 $0.00 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1755 ERX HCPCS 25000001 00597-0006-01 CLONIDINE HCL 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1755 ERX HCPCS 25000001 29300-0135-01 CLONIDINE HCL 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1755 ERX HCPCS 25000001 51079-0299-01 CLONIDINE HCL 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1755 ERX HCPCS 25000001 51079-0299-20 CLONIDINE HCL 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1755 ERX HCPCS 25000001 62332-0054-91 CLONIDINE HCL 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1755 ERX HCPCS 25000001 63739-0060-10 CLONIDINE HCL 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1756 ERX HCPCS 25000001 29300-0136-01 CLONIDINE HCL 0.2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1756 ERX HCPCS 25000001 51079-0300-01 CLONIDINE HCL 0.2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1756 ERX HCPCS 25000001 51079-0300-20 CLONIDINE HCL 0.2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1756 ERX HCPCS 25000001 62332-0055-31 CLONIDINE HCL 0.2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1767 ERX HCPCS 25000001 00904-7822-31 CLOTRIMAZOLE 1 % EX CREA BOTH IP/OP $35.96 $26.61 $0.00 $27.72 $0.00 $0.00 $0.00 $0.00 $0.00 $26.69 $26.69 $27.72 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $16.31 $25.83 $26.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1767 ERX HCPCS 25000001 45802-0434-11 CLOTRIMAZOLE 1 % EX CREA BOTH IP/OP $35.96 $26.61 $0.00 $27.72 $0.00 $0.00 $0.00 $0.00 $0.00 $26.69 $26.69 $27.72 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $16.31 $25.83 $26.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1768 ERX HCPCS 25000001 51672-1260-03 CLOTRIMAZOLE 1 % EX SOLN BOTH IP/OP $259.32 $191.90 $0.00 $199.88 $0.00 $0.00 $0.00 $0.00 $0.00 $192.47 $192.47 $199.88 $0.00 $54.04 $0.00 $0.00 $0.00 $0.00 $117.70 $186.44 $188.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1768 ERX HCPCS 25000001 70954-0036-20 CLOTRIMAZOLE 1 % EX SOLN BOTH IP/OP $259.32 $191.90 $0.00 $199.88 $0.00 $0.00 $0.00 $0.00 $0.00 $192.47 $192.47 $199.88 $0.00 $54.04 $0.00 $0.00 $0.00 $0.00 $117.70 $186.44 $188.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1770 ERX HCPCS 25000001 00395-1949-88 CLOVE OIL OIL BOTH IP/OP $27.20 $20.13 $0.00 $20.97 $0.00 $0.00 $0.00 $0.00 $0.00 $20.19 $20.19 $20.97 $0.00 $5.67 $0.00 $0.00 $0.00 $0.00 $11.86 $18.79 $18.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1802 ERX HCPCS 25000001 00054-0244-24 CODEINE SULFATE 30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1821 ERX HCPCS 63700001 00254-2008-01 COLCHICINE 0.6 MG PO TABS BOTH IP/OP $28.23 $20.89 $0.00 $20.48 $0.00 $0.00 $0.00 $5.02 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $0.00 $0.00 $0.00 $0.00 $12.80 $20.28 $20.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1821 ERX HCPCS 63700001 64764-0119-01 COLCHICINE 0.6 MG PO TABS BOTH IP/OP $28.23 $20.89 $0.00 $20.48 $0.00 $0.00 $0.00 $5.02 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $0.00 $0.00 $0.00 $0.00 $12.80 $20.28 $20.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1821 ERX HCPCS 63700001 65162-0710-09 COLCHICINE 0.6 MG PO TABS BOTH IP/OP $28.23 $20.89 $0.00 $20.48 $0.00 $0.00 $0.00 $5.02 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $0.00 $0.00 $0.00 $0.00 $12.80 $20.28 $20.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1821 ERX HCPCS 63700001 66993-0165-02 COLCHICINE 0.6 MG PO TABS BOTH IP/OP $28.23 $20.89 $0.00 $20.48 $0.00 $0.00 $0.00 $5.02 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $0.00 $0.00 $0.00 $0.00 $12.80 $20.28 $20.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1985 ERX HCPCS 25000001 00409-4092-01 CUPRIC CHLORIDE 0.4 MG/ML IV SOLN BOTH IP/OP $98.36 $72.79 $0.00 $75.82 $0.00 $0.00 $0.00 $0.00 $0.00 $73.00 $73.00 $75.82 $0.00 $20.50 $0.00 $0.00 $0.00 $0.00 $41.04 $65.01 $65.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2007 ERX HCPCS J3420 00143-9621-01 CYANOCOBALAMIN 1000 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.31 $16.33 $16.33 $16.96 $0.00 $2.49 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.60 $0.00 $0.00 $2.47 $0.00 $0.00 $0.00 $0.00 $0.00 2007 ERX HCPCS J3420 00143-9621-25 CYANOCOBALAMIN 1000 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.31 $16.33 $16.33 $16.96 $0.00 $2.49 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.60 $0.00 $0.00 $2.47 $0.00 $0.00 $0.00 $0.00 $0.00 2007 ERX HCPCS J3420 00517-0031-25 CYANOCOBALAMIN 1000 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.31 $16.33 $16.33 $16.96 $0.00 $2.49 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.60 $0.00 $0.00 $2.47 $0.00 $0.00 $0.00 $0.00 $0.00 2007 ERX HCPCS J3420 63323-0044-00 CYANOCOBALAMIN 1000 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.31 $16.33 $16.33 $16.96 $0.00 $2.49 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.60 $0.00 $0.00 $2.47 $0.00 $0.00 $0.00 $0.00 $0.00 2007 ERX HCPCS J3420 63323-0044-01 CYANOCOBALAMIN 1000 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.31 $16.33 $16.33 $16.96 $0.00 $2.49 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.60 $0.00 $0.00 $2.47 $0.00 $0.00 $0.00 $0.00 $0.00 2007 ERX HCPCS J3420 70069-0005-10 CYANOCOBALAMIN 1000 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.31 $16.33 $16.33 $16.96 $0.00 $2.49 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.60 $0.00 $0.00 $2.47 $0.00 $0.00 $0.00 $0.00 $0.00 2017 ERX HCPCS 63700001 52817-0332-10 CYCLOBENZAPRINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2017 ERX HCPCS 63700001 52817-0332-50 CYCLOBENZAPRINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2017 ERX HCPCS 63700001 63739-0531-10 CYCLOBENZAPRINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2017 ERX HCPCS 63700001 69097-0846-07 CYCLOBENZAPRINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2025 ERX HCPCS 25000001 17478-0100-02 CYCLOPENTOLATE HCL 1 % OP SOLN BOTH IP/OP $206.33 $152.68 $0.00 $174.96 $0.00 $0.00 $0.00 $0.00 $0.00 $168.46 $168.46 $174.96 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $66.97 $50.56 $107.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2025 ERX HCPCS 25000001 24208-0735-01 CYCLOPENTOLATE HCL 1 % OP SOLN BOTH IP/OP $206.33 $152.68 $0.00 $174.96 $0.00 $0.00 $0.00 $0.00 $0.00 $168.46 $168.46 $174.96 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $66.97 $50.56 $107.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2025 ERX HCPCS 25000001 61314-0396-01 CYCLOPENTOLATE HCL 1 % OP SOLN BOTH IP/OP $206.33 $152.68 $0.00 $174.96 $0.00 $0.00 $0.00 $0.00 $0.00 $168.46 $168.46 $174.96 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $66.97 $50.56 $107.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2025 ERX HCPCS 25000001 17478-0100-12 CYCLOPENTOLATE HCL 1 % OP SOLN BOTH IP/OP $206.33 $152.68 $0.00 $174.96 $0.00 $0.00 $0.00 $0.00 $0.00 $168.46 $168.46 $174.96 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $66.97 $106.07 $107.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2025 ERX HCPCS 25000001 24208-0735-06 CYCLOPENTOLATE HCL 1 % OP SOLN BOTH IP/OP $206.33 $152.68 $0.00 $174.96 $0.00 $0.00 $0.00 $0.00 $0.00 $168.46 $168.46 $174.96 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $66.97 $106.07 $107.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2025 ERX HCPCS 25000001 61314-0396-03 CYCLOPENTOLATE HCL 1 % OP SOLN BOTH IP/OP $206.33 $152.68 $0.00 $174.96 $0.00 $0.00 $0.00 $0.00 $0.00 $168.46 $168.46 $174.96 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $66.97 $106.07 $107.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2025 ERX HCPCS 25000001 00065-0396-05 CYCLOPENTOLATE HCL 1 % OP SOLN BOTH IP/OP $206.33 $152.68 $0.00 $174.96 $0.00 $0.00 $0.00 $0.00 $0.00 $168.46 $168.46 $174.96 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $66.97 $148.34 $107.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2033 ERX HCPCS 63700001 51991-0838-01 CYPROHEPTADINE HCL 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2091 ERX HCPCS J9130 00703-5075-01 DACARBAZINE 200 MG IV SOLR BOTH IP/OP $137.97 $102.10 $0.00 $110.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.99 $109.27 $110.38 $0.00 $0.00 $9.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2091 ERX HCPCS J9130 61703-0327-22 DACARBAZINE 200 MG IV SOLR BOTH IP/OP $137.97 $102.10 $0.00 $110.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.99 $109.27 $110.38 $0.00 $0.00 $9.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2091 ERX HCPCS J9130 63323-0128-20 DACARBAZINE 200 MG IV SOLR BOTH IP/OP $137.97 $102.10 $0.00 $110.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.99 $109.27 $110.38 $0.00 $0.00 $9.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2120 ERX HCPCS 25000001 00527-1369-01 DANAZOL 200 MG PO CAPS BOTH IP/OP $38.00 $28.12 $0.00 $29.29 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $17.24 $27.30 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2120 ERX HCPCS 25000001 00527-1369-06 DANAZOL 200 MG PO CAPS BOTH IP/OP $38.00 $28.12 $0.00 $29.29 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $17.24 $27.30 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2120 ERX HCPCS 25000001 00555-0635-02 DANAZOL 200 MG PO CAPS BOTH IP/OP $38.00 $28.12 $0.00 $29.29 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $17.24 $27.30 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2120 ERX HCPCS 25000001 00555-0635-09 DANAZOL 200 MG PO CAPS BOTH IP/OP $38.00 $28.12 $0.00 $29.29 $0.00 $0.00 $0.00 $0.00 $0.00 $28.20 $28.20 $29.29 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $17.24 $27.30 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2131 ERX HCPCS 63700001 47781-0334-31 DAPSONE 100 MG PO TABS BOTH IP/OP $11.32 $8.38 $0.00 $8.21 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.36 $0.00 $0.00 $0.00 $0.00 $5.13 $8.13 $8.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2131 ERX HCPCS 63700001 69543-0151-30 DAPSONE 100 MG PO TABS BOTH IP/OP $11.32 $8.38 $0.00 $8.21 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.36 $0.00 $0.00 $0.00 $0.00 $5.13 $8.13 $8.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2131 ERX HCPCS 63700001 70954-0136-10 DAPSONE 100 MG PO TABS BOTH IP/OP $11.32 $8.38 $0.00 $8.21 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.36 $0.00 $0.00 $0.00 $0.00 $5.13 $8.13 $8.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2131 ERX HCPCS 63700001 70954-0136-20 DAPSONE 100 MG PO TABS BOTH IP/OP $11.32 $8.38 $0.00 $8.21 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.36 $0.00 $0.00 $0.00 $0.00 $5.13 $8.13 $8.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2132 ERX HCPCS 63700001 47781-0333-31 DAPSONE 25 MG PO TABS BOTH IP/OP $11.48 $8.50 $0.00 $8.33 $0.00 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 $2.39 $0.00 $0.00 $0.00 $0.00 $5.21 $8.24 $8.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2132 ERX HCPCS 63700001 49938-0102-30 DAPSONE 25 MG PO TABS BOTH IP/OP $11.48 $8.50 $0.00 $8.33 $0.00 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 $2.39 $0.00 $0.00 $0.00 $0.00 $5.21 $8.24 $8.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2132 ERX HCPCS 63700001 70954-0135-20 DAPSONE 25 MG PO TABS BOTH IP/OP $11.48 $8.50 $0.00 $8.33 $0.00 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 $2.39 $0.00 $0.00 $0.00 $0.00 $5.21 $8.24 $8.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2286 ERX HCPCS 63700001 50742-0113-01 DESIPRAMINE HCL 25 MG PO TABS BOTH IP/OP $6.93 $5.13 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.47 $5.49 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2286 ERX HCPCS 63700001 69238-1055-01 DESIPRAMINE HCL 25 MG PO TABS BOTH IP/OP $6.93 $5.13 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.47 $5.49 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2287 ERX HCPCS 63700001 45963-0343-02 DESIPRAMINE HCL 50 MG PO TABS BOTH IP/OP $11.23 $8.31 $0.00 $8.14 $0.00 $0.00 $0.00 $2.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $5.09 $8.06 $8.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2287 ERX HCPCS 63700001 50742-0114-01 DESIPRAMINE HCL 50 MG PO TABS BOTH IP/OP $11.23 $8.31 $0.00 $8.14 $0.00 $0.00 $0.00 $2.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $5.09 $8.06 $8.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2291 ERX HCPCS 25000001 45802-0422-37 DESONIDE 0.05 % EX CREA BOTH IP/OP $299.81 $221.86 $0.00 $231.09 $0.00 $0.00 $0.00 $0.00 $0.00 $222.52 $222.52 $231.09 $0.00 $62.48 $0.00 $0.00 $0.00 $0.00 $136.08 $215.55 $217.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2291 ERX HCPCS 25000001 51672-1280-03 DESONIDE 0.05 % EX CREA BOTH IP/OP $299.81 $221.86 $0.00 $231.09 $0.00 $0.00 $0.00 $0.00 $0.00 $222.52 $222.52 $231.09 $0.00 $62.48 $0.00 $0.00 $0.00 $0.00 $136.08 $215.55 $217.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2319 ERX HCPCS J8540 54879-0003-08 DEXAMETHASONE 0.5 MG/5ML PO ELIX BOTH IP/OP $200.83 $148.61 $0.00 $159.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.38 $159.06 $130.20 $0.00 $0.00 $31.43 $0.00 $0.00 $25.91 $0.00 $0.00 $0.00 $0.00 $0.00 2319 ERX HCPCS J8540 60432-0466-08 DEXAMETHASONE 0.5 MG/5ML PO ELIX BOTH IP/OP $200.83 $148.61 $0.00 $159.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.38 $159.06 $130.20 $0.00 $0.00 $31.43 $0.00 $0.00 $25.91 $0.00 $0.00 $0.00 $0.00 $0.00 2322 ERX HCPCS J8540 00054-4179-25 DEXAMETHASONE 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $2.70 $2.70 $0.00 $0.00 $0.00 $0.14 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 2322 ERX HCPCS J8540 00054-8179-25 DEXAMETHASONE 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $2.70 $2.70 $0.00 $0.00 $0.00 $0.14 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 2327 ERX HCPCS 25000001 00054-4184-25 DEXAMETHASONE 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2327 ERX HCPCS 25000001 00054-8175-25 DEXAMETHASONE 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2332 ERX HCPCS J1100 00641-6145-25 DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.42 $16.33 $16.33 $16.96 $0.00 $0.55 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.56 $0.00 $0.00 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 2332 ERX HCPCS J1100 55150-0237-01 DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.42 $16.33 $16.33 $16.96 $0.00 $0.55 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.56 $0.00 $0.00 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 2332 ERX HCPCS J1100 63323-0165-01 DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.42 $16.33 $16.33 $16.96 $0.00 $0.55 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.56 $0.00 $0.00 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 2332 ERX HCPCS J1100 63323-0165-02 DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.42 $16.33 $16.33 $16.96 $0.00 $0.55 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.56 $0.00 $0.00 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 2332 ERX HCPCS J1100 67457-0423-12 DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.42 $16.33 $16.33 $16.96 $0.00 $0.55 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.56 $0.00 $0.00 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 2335 ERX HCPCS 25000001 24208-0720-02 DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP SOLN BOTH IP/OP $224.44 $166.09 $0.00 $173.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.58 $166.58 $173.00 $0.00 $46.77 $0.00 $0.00 $0.00 $0.00 $101.88 $161.37 $163.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2354 ERX HCPCS 63700001 00406-8958-01 DEXTROAMPHETAMINE SULFATE 5 MG PO TABS BOTH IP/OP $12.16 $9.00 $0.00 $8.82 $0.00 $0.00 $0.00 $2.16 $0.00 $0.00 $0.00 $0.00 $0.00 $2.53 $0.00 $0.00 $0.00 $0.00 $5.51 $8.73 $8.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2354 ERX HCPCS 63700001 00555-0952-02 DEXTROAMPHETAMINE SULFATE 5 MG PO TABS BOTH IP/OP $12.16 $9.00 $0.00 $8.82 $0.00 $0.00 $0.00 $2.16 $0.00 $0.00 $0.00 $0.00 $0.00 $2.53 $0.00 $0.00 $0.00 $0.00 $5.51 $8.73 $8.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2354 ERX HCPCS 63700001 13107-0035-01 DEXTROAMPHETAMINE SULFATE 5 MG PO TABS BOTH IP/OP $12.16 $9.00 $0.00 $8.82 $0.00 $0.00 $0.00 $2.16 $0.00 $0.00 $0.00 $0.00 $0.00 $2.53 $0.00 $0.00 $0.00 $0.00 $5.51 $8.73 $8.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2357 ERX HCPCS 25000001 00264-7520-20 DEXTROSE 10 % IV SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $15.20 $17.42 $24.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2357 ERX HCPCS 25000001 00338-0023-02 DEXTROSE 10 % IV SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $15.20 $17.42 $24.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2357 ERX HCPCS 25000001 00264-7520-10 DEXTROSE 10 % IV SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $15.20 $18.06 $24.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2357 ERX HCPCS 25000001 00338-0023-03 DEXTROSE 10 % IV SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $15.20 $18.06 $24.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2357 ERX HCPCS 25000001 00409-7930-03 DEXTROSE 10 % IV SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $15.20 $18.06 $24.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2357 ERX HCPCS 25000001 00338-0023-04 DEXTROSE 10 % IV SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $15.20 $24.08 $24.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2357 ERX HCPCS 25000001 00409-7930-09 DEXTROSE 10 % IV SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $15.20 $24.08 $24.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2359 ERX HCPCS 25000001 00990-7935-19 DEXTROSE 20 % IV SOLN BOTH IP/OP $53.20 $39.37 $0.00 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2361 ERX HCPCS 25000001 00409-1775-10 DEXTROSE 250 MG/ML IV SOLN BOTH IP/OP $53.13 $39.32 $0.00 $40.95 $0.00 $0.00 $0.00 $0.00 $0.00 $39.43 $39.43 $40.95 $0.00 $11.07 $0.00 $0.00 $0.00 $0.00 $20.87 $33.05 $33.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00264-7510-20 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-02 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00264-1510-31 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-11 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-31 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-41 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0551-11 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00264-7510-10 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-03 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 63323-0624-75 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-04 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-18 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-38 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0017-48 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2364 ERX HCPCS J7060 00338-0551-18 DEXTROSE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.24 $9.90 $9.90 $0.00 $0.00 $0.00 $1.28 $16.33 $16.33 $16.96 $0.00 $2.04 $0.00 $13.01 $13.01 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $4.28 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $0.00 2365 ERX HCPCS 25000001 00409-6648-02 DEXTROSE 50 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2365 ERX HCPCS 25000001 00409-6648-16 DEXTROSE 50 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2365 ERX HCPCS 25000001 00409-7517-16 DEXTROSE 50 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2365 ERX HCPCS 25000001 00409-7936-19 DEXTROSE 50 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2365 ERX HCPCS 25000001 69374-0953-50 DEXTROSE 50 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2365 ERX HCPCS 25000001 76329-3301-01 DEXTROSE 50 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2365 ERX HCPCS 25000001 99999-6007-48 DEXTROSE 50 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2367 ERX HCPCS 25000001 00264-7387-50 DEXTROSE 70 % IV SOLN BOTH IP/OP $75.42 $55.81 $0.00 $58.13 $0.00 $0.00 $0.00 $0.00 $0.00 $55.98 $55.98 $58.13 $0.00 $15.72 $0.00 $0.00 $0.00 $0.00 $34.20 $54.17 $54.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2367 ERX HCPCS 25000001 00338-0719-06 DEXTROSE 70 % IV SOLN BOTH IP/OP $75.42 $55.81 $0.00 $58.13 $0.00 $0.00 $0.00 $0.00 $0.00 $55.98 $55.98 $58.13 $0.00 $15.72 $0.00 $0.00 $0.00 $0.00 $34.20 $54.17 $54.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2401 ERX HCPCS J3360 00409-1273-32 DIAZEPAM 5 MG/ML IJ SOLN BOTH IP/OP $34.97 $25.88 $0.00 $26.95 $0.00 $0.00 $0.00 $0.00 $0.00 $25.95 $25.95 $26.95 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $15.59 $24.69 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2401 ERX HCPCS J3360 69339-0136-02 DIAZEPAM 5 MG/ML IJ SOLN BOTH IP/OP $34.97 $25.88 $0.00 $26.95 $0.00 $0.00 $0.00 $0.00 $0.00 $25.95 $25.95 $26.95 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $15.59 $24.69 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2401 ERX HCPCS J3360 69339-0136-32 DIAZEPAM 5 MG/ML IJ SOLN BOTH IP/OP $34.97 $25.88 $0.00 $26.95 $0.00 $0.00 $0.00 $0.00 $0.00 $25.95 $25.95 $26.95 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $15.59 $24.69 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2405 ERX HCPCS 25000001 00172-3926-60 DIAZEPAM 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2405 ERX HCPCS 25000001 00904-5880-61 DIAZEPAM 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2405 ERX HCPCS 25000001 51079-0285-20 DIAZEPAM 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2405 ERX HCPCS 25000001 63739-0073-10 DIAZEPAM 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2412 ERX HCPCS 25000001 55741-0402-02 DIBUCAINE 1 % EX OINT BOTH IP/OP $83.21 $61.58 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.06 $65.90 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2412 ERX HCPCS 25000001 00536-1211-95 DIBUCAINE 1 % EX OINT BOTH IP/OP $30.12 $22.29 $0.00 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2412 ERX HCPCS 25000001 54162-0011-01 DIBUCAINE 1 % EX OINT BOTH IP/OP $30.12 $22.29 $0.00 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2414 ERX HCPCS 63700001 00093-3123-01 DICLOXACILLIN SODIUM 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2414 ERX HCPCS 63700001 00781-2248-01 DICLOXACILLIN SODIUM 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2418 ERX HCPCS 63700001 00378-1610-01 DICYCLOMINE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2418 ERX HCPCS 63700001 00378-1610-05 DICYCLOMINE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2418 ERX HCPCS 63700001 00527-0586-01 DICYCLOMINE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2418 ERX HCPCS 63700001 00591-0794-01 DICYCLOMINE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2420 ERX HCPCS J0500 00378-1620-01 DICYCLOMINE HCL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $59.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $59.65 $0.00 $0.00 $0.00 $0.00 $0.00 2420 ERX HCPCS J0500 00527-1282-01 DICYCLOMINE HCL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $59.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $59.65 $0.00 $0.00 $0.00 $0.00 $0.00 2420 ERX HCPCS J0500 00591-0795-01 DICYCLOMINE HCL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $59.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $59.65 $0.00 $0.00 $0.00 $0.00 $0.00 2420 ERX HCPCS J0500 51079-0119-20 DICYCLOMINE HCL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $59.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $59.65 $0.00 $0.00 $0.00 $0.00 $0.00 2442 ERX HCPCS J1160 00641-1410-31 DIGOXIN 0.25 MG/ML IJ SOLN BOTH IP/OP $27.66 $20.47 $0.00 $21.32 $0.00 $0.00 $0.00 $0.00 $0.00 $20.53 $20.53 $21.32 $0.00 $16.94 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2442 ERX HCPCS J1160 00641-1410-35 DIGOXIN 0.25 MG/ML IJ SOLN BOTH IP/OP $27.66 $20.47 $0.00 $21.32 $0.00 $0.00 $0.00 $0.00 $0.00 $20.53 $20.53 $21.32 $0.00 $16.94 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2442 ERX HCPCS J1160 00641-6184-01 DIGOXIN 0.25 MG/ML IJ SOLN BOTH IP/OP $27.66 $20.47 $0.00 $21.32 $0.00 $0.00 $0.00 $0.00 $0.00 $20.53 $20.53 $21.32 $0.00 $16.94 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2442 ERX HCPCS J1160 00641-6184-25 DIGOXIN 0.25 MG/ML IJ SOLN BOTH IP/OP $27.66 $20.47 $0.00 $21.32 $0.00 $0.00 $0.00 $0.00 $0.00 $20.53 $20.53 $21.32 $0.00 $16.94 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2442 ERX HCPCS J1160 00781-3059-72 DIGOXIN 0.25 MG/ML IJ SOLN BOTH IP/OP $27.66 $20.47 $0.00 $21.32 $0.00 $0.00 $0.00 $0.00 $0.00 $20.53 $20.53 $21.32 $0.00 $16.94 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2442 ERX HCPCS J1160 00781-3059-95 DIGOXIN 0.25 MG/ML IJ SOLN BOTH IP/OP $27.66 $20.47 $0.00 $21.32 $0.00 $0.00 $0.00 $0.00 $0.00 $20.53 $20.53 $21.32 $0.00 $16.94 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2444 ERX HCPCS 63700001 00143-1240-01 DIGOXIN 0.125 MG PO TABS BOTH IP/OP $8.83 $6.53 $0.00 $6.41 $0.00 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 $1.84 $0.00 $0.00 $0.00 $0.00 $4.01 $6.34 $6.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2444 ERX HCPCS 63700001 16714-0590-01 DIGOXIN 0.125 MG PO TABS BOTH IP/OP $8.83 $6.53 $0.00 $6.41 $0.00 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 $1.84 $0.00 $0.00 $0.00 $0.00 $4.01 $6.34 $6.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2445 ERX HCPCS 63700001 00527-1325-01 DIGOXIN 0.25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2445 ERX HCPCS 63700001 00904-5922-61 DIGOXIN 0.25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2445 ERX HCPCS 63700001 16714-0591-01 DIGOXIN 0.25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2474 ERX HCPCS 63700001 00093-0321-01 DILTIAZEM HCL 120 MG PO TABS BOTH IP/OP $12.09 $8.95 $0.00 $8.77 $0.00 $0.00 $0.00 $2.15 $0.00 $0.00 $0.00 $0.00 $0.00 $2.52 $0.00 $0.00 $0.00 $0.00 $5.48 $8.68 $8.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2475 ERX HCPCS 63700001 00093-0318-01 DILTIAZEM HCL 30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2475 ERX HCPCS 63700001 63739-0079-10 DILTIAZEM HCL 30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2475 ERX HCPCS 63700001 68682-0006-10 DILTIAZEM HCL 30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2476 ERX HCPCS 63700001 00378-0045-05 DILTIAZEM HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2476 ERX HCPCS 63700001 51079-0746-20 DILTIAZEM HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2476 ERX HCPCS 63700001 63739-0080-10 DILTIAZEM HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2476 ERX HCPCS 63700001 68682-0007-10 DILTIAZEM HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2477 ERX HCPCS 63700001 00093-0320-01 DILTIAZEM HCL 90 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2508 ERX HCPCS J1200 00641-0376-21 DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.86 $16.33 $16.33 $16.96 $0.00 $1.16 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.06 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 2508 ERX HCPCS J1200 00641-0376-25 DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.86 $16.33 $16.33 $16.96 $0.00 $1.16 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.06 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 2508 ERX HCPCS J1200 63323-0664-01 DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.86 $16.33 $16.33 $16.96 $0.00 $1.16 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.06 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 2509 ERX HCPCS J3490 00904-5306-61 DIPHENHYDRAMINE HCL 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $3.26 $3.26 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 2510 ERX HCPCS Q0163 00904-2056-61 DIPHENHYDRAMINE HCL 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $3.26 $3.26 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 2511 ERX HCPCS Q0163 00121-0489-00 DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX BOTH IP/OP $9.01 $6.67 $0.00 $6.94 $4.05 $4.05 $0.00 $0.00 $0.00 $1.88 $6.69 $6.69 $6.94 $0.00 $1.88 $0.00 $5.33 $5.33 $0.00 $4.09 $6.47 $6.54 $0.00 $0.00 $1.28 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 2511 ERX HCPCS Q0163 00121-0489-05 DIPHENHYDRAMINE HCL 12.5 MG/5ML PO ELIX BOTH IP/OP $9.01 $6.67 $0.00 $6.94 $4.05 $4.05 $0.00 $0.00 $0.00 $1.88 $6.69 $6.69 $6.94 $0.00 $1.88 $0.00 $5.33 $5.33 $0.00 $4.09 $6.47 $6.54 $0.00 $0.00 $1.28 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 2515 ERX HCPCS 63700001 99999-6009-38 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5ML PO LIQD BOTH IP/OP $9.00 $6.66 $0.00 $8.80 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2516 ERX HCPCS 63700001 00378-0415-01 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2516 ERX HCPCS 63700001 59762-1061-01 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2528 ERX HCPCS 63700001 64980-0133-01 DIPYRIDAMOLE 25 MG PO TABS BOTH IP/OP $11.91 $8.81 $0.00 $8.64 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $0.00 $2.48 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2537 ERX HCPCS 63700001 00025-2732-31 DISOPYRAMIDE PHOSPHATE ER 100 MG PO CP12 BOTH IP/OP $21.08 $15.60 $0.00 $14.63 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $9.15 $14.49 $14.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2551 ERX HCPCS 63700001 00074-6212-13 DIVALPROEX SODIUM 125 MG PO TBEC BOTH IP/OP $8.93 $6.61 $0.00 $6.48 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2551 ERX HCPCS 63700001 00832-7122-11 DIVALPROEX SODIUM 125 MG PO TBEC BOTH IP/OP $8.93 $6.61 $0.00 $6.48 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2552 ERX HCPCS 63700001 00832-7123-15 DIVALPROEX SODIUM 250 MG PO TBEC BOTH IP/OP $9.08 $6.72 $0.00 $6.58 $0.00 $0.00 $0.00 $1.62 $0.00 $0.00 $0.00 $0.00 $0.00 $1.89 $0.00 $0.00 $0.00 $0.00 $4.12 $6.52 $6.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2552 ERX HCPCS 63700001 68084-0776-01 DIVALPROEX SODIUM 250 MG PO TBEC BOTH IP/OP $9.08 $6.72 $0.00 $6.58 $0.00 $0.00 $0.00 $1.62 $0.00 $0.00 $0.00 $0.00 $0.00 $1.89 $0.00 $0.00 $0.00 $0.00 $4.12 $6.52 $6.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2553 ERX HCPCS 63700001 00832-7124-01 DIVALPROEX SODIUM 500 MG PO TBEC BOTH IP/OP $13.47 $9.97 $0.00 $9.88 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2553 ERX HCPCS 63700001 00832-7124-11 DIVALPROEX SODIUM 500 MG PO TBEC BOTH IP/OP $13.47 $9.97 $0.00 $9.88 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2553 ERX HCPCS 63700001 62756-0798-13 DIVALPROEX SODIUM 500 MG PO TBEC BOTH IP/OP $13.47 $9.97 $0.00 $9.88 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2553 ERX HCPCS 63700001 62756-0798-88 DIVALPROEX SODIUM 500 MG PO TBEC BOTH IP/OP $13.47 $9.97 $0.00 $9.88 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2553 ERX HCPCS 63700001 68084-0782-61 DIVALPROEX SODIUM 500 MG PO TBEC BOTH IP/OP $13.47 $9.97 $0.00 $9.88 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2565 ERX HCPCS 63700001 00904-6459-59 DOCUSATE CALCIUM 240 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2565 ERX HCPCS 63700001 49348-0280-10 DOCUSATE CALCIUM 240 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2566 ERX HCPCS 63700001 00904-6455-61 DOCUSATE SODIUM 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2566 ERX HCPCS 63700001 00904-6457-60 DOCUSATE SODIUM 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2566 ERX HCPCS 63700001 00904-6457-80 DOCUSATE SODIUM 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2566 ERX HCPCS 63700001 69618-0044-10 DOCUSATE SODIUM 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2569 ERX HCPCS 63700001 50383-0771-10 DOCUSATE SODIUM 150 MG/15ML PO LIQD BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2569 ERX HCPCS 63700001 50383-0771-11 DOCUSATE SODIUM 150 MG/15ML PO LIQD BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2569 ERX HCPCS 63700001 50383-0771-16 DOCUSATE SODIUM 150 MG/15ML PO LIQD BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2595 ERX HCPCS J1265 00409-9104-20 DOPAMINE HCL 40 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2595 ERX HCPCS J1265 00409-5820-01 DOPAMINE HCL 40 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2607 ERX HCPCS 25000001 00641-6018-06 DOXAPRAM HCL 20 MG/ML IV SOLN BOTH IP/OP $221.60 $163.98 $0.00 $170.81 $0.00 $0.00 $0.00 $0.00 $0.00 $164.47 $164.47 $170.81 $0.00 $46.18 $0.00 $0.00 $0.00 $0.00 $91.51 $144.95 $146.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2608 ERX HCPCS 63700001 00378-1049-01 DOXEPIN HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2608 ERX HCPCS 63700001 51079-0436-01 DOXEPIN HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2608 ERX HCPCS 63700001 51079-0436-20 DOXEPIN HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2609 ERX HCPCS 63700001 51079-0651-01 DOXEPIN HCL 100 MG PO CAPS BOTH IP/OP $8.37 $6.19 $0.00 $6.07 $0.00 $0.00 $0.00 $1.49 $0.00 $0.00 $0.00 $0.00 $0.00 $1.74 $0.00 $0.00 $0.00 $0.00 $3.80 $6.01 $6.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2609 ERX HCPCS 63700001 51079-0651-20 DOXEPIN HCL 100 MG PO CAPS BOTH IP/OP $8.37 $6.19 $0.00 $6.07 $0.00 $0.00 $0.00 $1.49 $0.00 $0.00 $0.00 $0.00 $0.00 $1.74 $0.00 $0.00 $0.00 $0.00 $3.80 $6.01 $6.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2610 ERX HCPCS 63700001 49884-0222-01 DOXEPIN HCL 150 MG PO CAPS BOTH IP/OP $13.95 $10.32 $0.00 $10.12 $0.00 $0.00 $0.00 $2.48 $0.00 $0.00 $0.00 $0.00 $0.00 $2.91 $0.00 $0.00 $0.00 $0.00 $6.33 $10.02 $10.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2611 ERX HCPCS 63700001 51079-0437-01 DOXEPIN HCL 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2611 ERX HCPCS 63700001 51079-0437-20 DOXEPIN HCL 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2612 ERX HCPCS 63700001 51079-0438-01 DOXEPIN HCL 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2612 ERX HCPCS 63700001 51079-0438-20 DOXEPIN HCL 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2613 ERX HCPCS 63700001 00378-5375-01 DOXEPIN HCL 75 MG PO CAPS BOTH IP/OP $7.59 $5.62 $0.00 $5.50 $0.00 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 $1.58 $0.00 $0.00 $0.00 $0.00 $3.44 $5.45 $5.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2614 ERX HCPCS 63700001 54838-0512-40 DOXEPIN HCL 10 MG/ML PO CONC BOTH IP/OP $246.93 $182.73 $0.00 $125.89 $0.00 $0.00 $0.00 $43.95 $0.00 $0.00 $0.00 $0.00 $0.00 $51.46 $0.00 $0.00 $0.00 $0.00 $78.68 $65.86 $125.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2614 ERX HCPCS 63700001 60432-0651-04 DOXEPIN HCL 10 MG/ML PO CONC BOTH IP/OP $246.93 $182.73 $0.00 $125.89 $0.00 $0.00 $0.00 $43.95 $0.00 $0.00 $0.00 $0.00 $0.00 $51.46 $0.00 $0.00 $0.00 $0.00 $78.68 $124.63 $125.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2616 ERX HCPCS J9000 00069-3034-20 DOXORUBICIN HCL 2 MG/ML IV SOLN BOTH IP/OP $564.48 $417.72 $0.00 $435.10 $254.02 $254.02 $0.00 $0.00 $0.00 $89.07 $418.96 $418.96 $435.10 $0.00 $50.95 $0.00 $333.89 $333.89 $0.00 $256.20 $405.82 $409.92 $0.00 $0.00 $67.45 $0.00 $0.00 $64.22 $0.00 $0.00 $0.00 $0.00 $0.00 2616 ERX HCPCS J9000 00069-4034-01 DOXORUBICIN HCL 2 MG/ML IV SOLN BOTH IP/OP $564.48 $417.72 $0.00 $435.10 $254.02 $254.02 $0.00 $0.00 $0.00 $89.07 $418.96 $418.96 $435.10 $0.00 $50.95 $0.00 $333.89 $333.89 $0.00 $256.20 $405.82 $409.92 $0.00 $0.00 $67.45 $0.00 $0.00 $64.22 $0.00 $0.00 $0.00 $0.00 $0.00 2616 ERX HCPCS J9000 00143-9546-01 DOXORUBICIN HCL 2 MG/ML IV SOLN BOTH IP/OP $564.48 $417.72 $0.00 $435.10 $254.02 $254.02 $0.00 $0.00 $0.00 $89.07 $418.96 $418.96 $435.10 $0.00 $50.95 $0.00 $333.89 $333.89 $0.00 $256.20 $405.82 $409.92 $0.00 $0.00 $67.45 $0.00 $0.00 $64.22 $0.00 $0.00 $0.00 $0.00 $0.00 2616 ERX HCPCS J9000 45963-0733-60 DOXORUBICIN HCL 2 MG/ML IV SOLN BOTH IP/OP $564.48 $417.72 $0.00 $435.10 $254.02 $254.02 $0.00 $0.00 $0.00 $89.07 $418.96 $418.96 $435.10 $0.00 $50.95 $0.00 $333.89 $333.89 $0.00 $256.20 $405.82 $409.92 $0.00 $0.00 $67.45 $0.00 $0.00 $64.22 $0.00 $0.00 $0.00 $0.00 $0.00 2616 ERX HCPCS J9000 70860-0208-51 DOXORUBICIN HCL 2 MG/ML IV SOLN BOTH IP/OP $564.48 $417.72 $0.00 $435.10 $254.02 $254.02 $0.00 $0.00 $0.00 $89.07 $418.96 $418.96 $435.10 $0.00 $50.95 $0.00 $333.89 $333.89 $0.00 $256.20 $405.82 $409.92 $0.00 $0.00 $67.45 $0.00 $0.00 $64.22 $0.00 $0.00 $0.00 $0.00 $0.00 2622 ERX HCPCS 25000001 63323-0130-11 DOXYCYCLINE HYCLATE 100 MG IV SOLR BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2622 ERX HCPCS 25000001 63323-0130-13 DOXYCYCLINE HYCLATE 100 MG IV SOLR BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2622 ERX HCPCS 25000001 68382-0910-01 DOXYCYCLINE HYCLATE 100 MG IV SOLR BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2622 ERX HCPCS 25000001 68382-0910-10 DOXYCYCLINE HYCLATE 100 MG IV SOLR BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2654 ERX HCPCS J1790 00517-9702-01 DROPERIDOL 2.5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.87 $16.33 $16.33 $16.96 $0.00 $9.64 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $5.16 $0.00 $0.00 $0.00 $0.00 $0.00 2654 ERX HCPCS J1790 00517-9702-25 DROPERIDOL 2.5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.87 $16.33 $16.33 $16.96 $0.00 $9.64 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $5.16 $0.00 $0.00 $0.00 $0.00 $0.00 2805 ERX HCPCS 25000001 00536-7415-51 ENEMA 7-19 GM/133ML RECTAL ENEM BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2887 ERX HCPCS 25000001 45802-0038-46 ERYTHROMYCIN 2 % EX SOLN BOTH IP/OP $192.93 $142.77 $0.00 $148.71 $0.00 $0.00 $0.00 $0.00 $0.00 $143.19 $143.19 $148.71 $0.00 $40.21 $0.00 $0.00 $0.00 $0.00 $83.37 $132.06 $133.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2887 ERX HCPCS 25000001 60432-0671-60 ERYTHROMYCIN 2 % EX SOLN BOTH IP/OP $192.93 $142.77 $0.00 $148.71 $0.00 $0.00 $0.00 $0.00 $0.00 $143.19 $143.19 $148.71 $0.00 $40.21 $0.00 $0.00 $0.00 $0.00 $83.37 $132.06 $133.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2888 ERX HCPCS 25000001 00574-4024-11 ERYTHROMYCIN 5 MG/GM OP OINT BOTH IP/OP $146.70 $108.56 $0.00 $113.08 $0.00 $0.00 $0.00 $0.00 $0.00 $108.88 $108.88 $113.08 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $36.11 $57.19 $57.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2888 ERX HCPCS 25000001 00574-4024-50 ERYTHROMYCIN 5 MG/GM OP OINT BOTH IP/OP $146.70 $108.56 $0.00 $113.08 $0.00 $0.00 $0.00 $0.00 $0.00 $108.88 $108.88 $113.08 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $36.11 $57.19 $57.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2888 ERX HCPCS 25000001 17478-0070-31 ERYTHROMYCIN 5 MG/GM OP OINT BOTH IP/OP $146.70 $108.56 $0.00 $113.08 $0.00 $0.00 $0.00 $0.00 $0.00 $108.88 $108.88 $113.08 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $36.11 $57.19 $57.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2888 ERX HCPCS 25000001 24208-0910-19 ERYTHROMYCIN 5 MG/GM OP OINT BOTH IP/OP $146.70 $108.56 $0.00 $113.08 $0.00 $0.00 $0.00 $0.00 $0.00 $108.88 $108.88 $113.08 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $36.11 $57.19 $57.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2888 ERX HCPCS 25000001 00574-4024-35 ERYTHROMYCIN 5 MG/GM OP OINT BOTH IP/OP $146.70 $108.56 $0.00 $113.08 $0.00 $0.00 $0.00 $0.00 $0.00 $108.88 $108.88 $113.08 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $36.11 $105.35 $57.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2888 ERX HCPCS 25000001 17478-0070-35 ERYTHROMYCIN 5 MG/GM OP OINT BOTH IP/OP $146.70 $108.56 $0.00 $113.08 $0.00 $0.00 $0.00 $0.00 $0.00 $108.88 $108.88 $113.08 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $36.11 $105.35 $57.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2888 ERX HCPCS 25000001 24208-0910-55 ERYTHROMYCIN 5 MG/GM OP OINT BOTH IP/OP $146.70 $108.56 $0.00 $113.08 $0.00 $0.00 $0.00 $0.00 $0.00 $108.88 $108.88 $113.08 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $36.11 $105.35 $57.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2899 ERX HCPCS 63700001 24338-0132-13 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR BOTH IP/OP "$1,318.38 " $975.60 $0.00 $957.18 $0.00 $0.00 $0.00 $234.67 $0.00 $0.00 $0.00 $0.00 $0.00 $274.75 $0.00 $0.00 $0.00 $0.00 $598.24 $947.61 $957.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2899 ERX HCPCS 63700001 24338-0134-02 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR BOTH IP/OP "$1,318.38 " $975.60 $0.00 $957.18 $0.00 $0.00 $0.00 $234.67 $0.00 $0.00 $0.00 $0.00 $0.00 $274.75 $0.00 $0.00 $0.00 $0.00 $598.24 $947.61 $957.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2899 ERX HCPCS 63700001 62559-0630-01 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR BOTH IP/OP "$1,318.38 " $975.60 $0.00 $957.18 $0.00 $0.00 $0.00 $234.67 $0.00 $0.00 $0.00 $0.00 $0.00 $274.75 $0.00 $0.00 $0.00 $0.00 $598.24 $947.61 $957.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2899 ERX HCPCS 63700001 69238-1503-01 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5ML PO SUSR BOTH IP/OP "$1,318.38 " $975.60 $0.00 $957.18 $0.00 $0.00 $0.00 $234.67 $0.00 $0.00 $0.00 $0.00 $0.00 $274.75 $0.00 $0.00 $0.00 $0.00 $598.24 $947.61 $957.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2903 ERX HCPCS J1364 00409-6476-44 ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR BOTH IP/OP $344.04 $254.59 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $0.00 $255.35 $255.35 $265.19 $0.00 $91.35 $0.00 $0.00 $0.00 $0.00 $153.84 $243.68 $246.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2903 ERX HCPCS J1364 00409-6482-01 ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR BOTH IP/OP $344.04 $254.59 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $0.00 $255.35 $255.35 $265.19 $0.00 $91.35 $0.00 $0.00 $0.00 $0.00 $153.84 $243.68 $246.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2931 ERX HCPCS J1380 00574-0870-05 ESTRADIOL VALERATE 20 MG/ML IM OIL BOTH IP/OP $47.03 $34.80 $0.00 $36.25 $21.16 $21.16 $0.00 $0.00 $0.00 $9.80 $34.91 $34.91 $36.25 $0.00 $9.80 $0.00 $27.82 $27.82 $0.00 $21.33 $33.79 $34.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2931 ERX HCPCS J1380 42023-0111-01 ESTRADIOL VALERATE 20 MG/ML IM OIL BOTH IP/OP $47.03 $34.80 $0.00 $36.25 $21.16 $21.16 $0.00 $0.00 $0.00 $9.80 $34.91 $34.91 $36.25 $0.00 $9.80 $0.00 $27.82 $27.82 $0.00 $21.33 $33.79 $34.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2938 ERX HCPCS 63700001 00046-1104-81 ESTROGENS CONJUGATED 1.25 MG PO TABS BOTH IP/OP $32.11 $23.76 $0.00 $21.54 $0.00 $0.00 $0.00 $5.72 $0.00 $0.00 $0.00 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $13.47 $21.33 $21.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3000 ERX HCPCS 25000001 10119-0002-52 EYE WASH OP SOLN BOTH IP/OP $11.87 $8.78 $0.00 $9.15 $0.00 $0.00 $0.00 $0.00 $0.00 $8.81 $8.81 $9.15 $0.00 $2.47 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3059 ERX HCPCS 63700001 48783-0112-08 FERRIC SUBSULFATE PASTE BOTH IP/OP $62.85 $46.51 $0.00 $45.60 $0.00 $0.00 $0.00 $11.19 $0.00 $0.00 $0.00 $0.00 $0.00 $13.10 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3069 ERX HCPCS 63700001 99999-6004-65 FERROUS SULFATE 220 (44 FE) MG/5ML PO ELIX BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3069 ERX HCPCS 63700001 99999-6010-60 FERROUS SULFATE 220 (44 FE) MG/5ML PO ELIX BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3069 ERX HCPCS 63700001 50383-0778-16 FERROUS SULFATE 220 (44 FE) MG/5ML PO ELIX BOTH IP/OP $11.00 $8.14 $0.00 $51.25 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $51.25 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3069 ERX HCPCS 63700001 54838-0001-80 FERROUS SULFATE 220 (44 FE) MG/5ML PO ELIX BOTH IP/OP $11.00 $8.14 $0.00 $51.25 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $51.25 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3074 ERX HCPCS 63700001 00904-7590-60 FERROUS SULFATE 325 (65 FE) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3074 ERX HCPCS 63700001 00904-7591-60 FERROUS SULFATE 325 (65 FE) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3074 ERX HCPCS 63700001 00904-7591-61 FERROUS SULFATE 325 (65 FE) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3128 ERX HCPCS 25000001 00132-0202-20 FLEET PEDIATRIC 3.5-9.5 GM/66ML RECTAL ENEM BOTH IP/OP $9.13 $6.76 $0.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 $6.78 $6.78 $7.04 $0.00 $1.90 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3177 ERX HCPCS J9200 00143-9270-01 FLOXURIDINE 0.5 G IJ SOLR BOTH IP/OP $479.81 $355.06 $0.00 $369.84 $0.00 $0.00 $0.00 $0.00 $0.00 $356.11 $356.11 $369.84 $0.00 $99.99 $0.00 $0.00 $0.00 $0.00 $217.77 $344.95 $348.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3177 ERX HCPCS J9200 63323-0145-07 FLOXURIDINE 0.5 G IJ SOLR BOTH IP/OP $479.81 $355.06 $0.00 $369.84 $0.00 $0.00 $0.00 $0.00 $0.00 $356.11 $356.11 $369.84 $0.00 $99.99 $0.00 $0.00 $0.00 $0.00 $217.77 $344.95 $348.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3184 ERX HCPCS 25000001 00168-0060-15 FLUOCINOLONE ACETONIDE 0.025 % EX CREA BOTH IP/OP $130.34 $96.45 $0.00 $100.47 $0.00 $0.00 $0.00 $0.00 $0.00 $96.74 $96.74 $100.47 $0.00 $27.16 $0.00 $0.00 $0.00 $0.00 $59.09 $93.60 $94.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3184 ERX HCPCS 25000001 52565-0020-15 FLUOCINOLONE ACETONIDE 0.025 % EX CREA BOTH IP/OP $130.34 $96.45 $0.00 $100.47 $0.00 $0.00 $0.00 $0.00 $0.00 $96.74 $96.74 $100.47 $0.00 $27.16 $0.00 $0.00 $0.00 $0.00 $59.09 $93.60 $94.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3185 ERX HCPCS 25000001 00168-0064-15 FLUOCINOLONE ACETONIDE 0.025 % EX OINT BOTH IP/OP $130.34 $96.45 $0.00 $100.47 $0.00 $0.00 $0.00 $0.00 $0.00 $96.74 $96.74 $100.47 $0.00 $27.16 $0.00 $0.00 $0.00 $0.00 $59.09 $93.60 $94.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3185 ERX HCPCS 25000001 00713-0224-15 FLUOCINOLONE ACETONIDE 0.025 % EX OINT BOTH IP/OP $130.34 $96.45 $0.00 $100.47 $0.00 $0.00 $0.00 $0.00 $0.00 $96.74 $96.74 $100.47 $0.00 $27.16 $0.00 $0.00 $0.00 $0.00 $59.09 $93.60 $94.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3186 ERX HCPCS 25000001 00168-0059-60 FLUOCINOLONE ACETONIDE 0.01 % EX SOLN BOTH IP/OP $154.71 $114.49 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $114.83 $114.83 $119.25 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3186 ERX HCPCS 25000001 51672-1365-04 FLUOCINOLONE ACETONIDE 0.01 % EX SOLN BOTH IP/OP $154.71 $114.49 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $114.83 $114.83 $119.25 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3186 ERX HCPCS 25000001 52565-0012-59 FLUOCINOLONE ACETONIDE 0.01 % EX SOLN BOTH IP/OP $154.71 $114.49 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $114.83 $114.83 $119.25 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3187 ERX HCPCS 25000001 00093-0262-15 FLUOCINONIDE 0.05 % EX CREA BOTH IP/OP $175.85 $130.13 $0.00 $135.55 $0.00 $0.00 $0.00 $0.00 $0.00 $130.52 $130.52 $135.55 $0.00 $36.65 $0.00 $0.00 $0.00 $0.00 $79.73 $126.28 $127.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3187 ERX HCPCS 25000001 51672-1253-01 FLUOCINONIDE 0.05 % EX CREA BOTH IP/OP $175.85 $130.13 $0.00 $135.55 $0.00 $0.00 $0.00 $0.00 $0.00 $130.52 $130.52 $135.55 $0.00 $36.65 $0.00 $0.00 $0.00 $0.00 $79.73 $126.28 $127.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3187 ERX HCPCS 25000001 51672-1386-01 FLUOCINONIDE 0.05 % EX CREA BOTH IP/OP $175.85 $130.13 $0.00 $135.55 $0.00 $0.00 $0.00 $0.00 $0.00 $130.52 $130.52 $135.55 $0.00 $36.65 $0.00 $0.00 $0.00 $0.00 $79.73 $126.28 $127.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3187 ERX HCPCS 25000001 00093-0262-30 FLUOCINONIDE 0.05 % EX CREA BOTH IP/OP $175.85 $130.13 $0.00 $227.30 $0.00 $0.00 $0.00 $0.00 $0.00 $130.52 $130.52 $135.55 $0.00 $36.65 $0.00 $0.00 $0.00 $0.00 $79.73 $227.30 $127.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3187 ERX HCPCS 25000001 51672-1253-02 FLUOCINONIDE 0.05 % EX CREA BOTH IP/OP $175.85 $130.13 $0.00 $227.30 $0.00 $0.00 $0.00 $0.00 $0.00 $130.52 $130.52 $135.55 $0.00 $36.65 $0.00 $0.00 $0.00 $0.00 $79.73 $227.30 $127.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3187 ERX HCPCS 25000001 51672-1386-02 FLUOCINONIDE 0.05 % EX CREA BOTH IP/OP $175.85 $130.13 $0.00 $227.30 $0.00 $0.00 $0.00 $0.00 $0.00 $130.52 $130.52 $135.55 $0.00 $36.65 $0.00 $0.00 $0.00 $0.00 $79.73 $227.30 $127.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3188 ERX HCPCS 25000001 51672-1279-01 FLUOCINONIDE 0.05 % EX GEL BOTH IP/OP $695.55 $514.71 $0.00 $536.13 $0.00 $0.00 $0.00 $0.00 $0.00 $516.24 $516.24 $536.13 $0.00 $144.95 $0.00 $0.00 $0.00 $0.00 $315.62 $499.93 $504.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3188 ERX HCPCS 25000001 51672-1279-02 FLUOCINONIDE 0.05 % EX GEL BOTH IP/OP $695.55 $514.71 $0.00 $536.13 $0.00 $0.00 $0.00 $0.00 $0.00 $516.24 $516.24 $536.13 $0.00 $144.95 $0.00 $0.00 $0.00 $0.00 $315.62 $499.93 $504.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3188 ERX HCPCS 25000001 00168-0135-60 FLUOCINONIDE 0.05 % EX GEL BOTH IP/OP $695.55 $514.71 $0.00 $536.13 $0.00 $0.00 $0.00 $0.00 $0.00 $516.24 $516.24 $536.13 $0.00 $144.95 $0.00 $0.00 $0.00 $0.00 $315.62 $499.93 $504.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3188 ERX HCPCS 25000001 51672-1279-03 FLUOCINONIDE 0.05 % EX GEL BOTH IP/OP $695.55 $514.71 $0.00 $536.13 $0.00 $0.00 $0.00 $0.00 $0.00 $516.24 $516.24 $536.13 $0.00 $144.95 $0.00 $0.00 $0.00 $0.00 $315.62 $499.93 $504.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3189 ERX HCPCS 25000001 00093-0264-15 FLUOCINONIDE 0.05 % EX OINT BOTH IP/OP $245.52 $181.68 $0.00 $189.25 $0.00 $0.00 $0.00 $0.00 $0.00 $182.22 $182.22 $189.25 $0.00 $51.17 $0.00 $0.00 $0.00 $0.00 $111.44 $176.52 $178.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3189 ERX HCPCS 25000001 16714-0502-01 FLUOCINONIDE 0.05 % EX OINT BOTH IP/OP $245.52 $181.68 $0.00 $189.25 $0.00 $0.00 $0.00 $0.00 $0.00 $182.22 $182.22 $189.25 $0.00 $51.17 $0.00 $0.00 $0.00 $0.00 $111.44 $176.52 $178.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3189 ERX HCPCS 25000001 51672-1264-01 FLUOCINONIDE 0.05 % EX OINT BOTH IP/OP $245.52 $181.68 $0.00 $189.25 $0.00 $0.00 $0.00 $0.00 $0.00 $182.22 $182.22 $189.25 $0.00 $51.17 $0.00 $0.00 $0.00 $0.00 $111.44 $176.52 $178.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3190 ERX HCPCS 25000001 00168-0134-60 FLUOCINONIDE 0.05 % EX SOLN BOTH IP/OP $337.29 $249.59 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $0.00 $250.34 $250.34 $259.98 $0.00 $70.29 $0.00 $0.00 $0.00 $0.00 $153.09 $242.49 $244.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3215 ERX HCPCS J2680 00143-9529-01 FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN BOTH IP/OP $77.92 $57.66 $0.00 $60.06 $35.06 $35.06 $0.00 $0.00 $0.00 $4.27 $57.83 $57.83 $60.06 $0.00 $12.10 $0.00 $46.09 $46.09 $0.00 $35.34 $55.97 $56.54 $0.00 $0.00 $11.73 $0.00 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $0.00 3215 ERX HCPCS J2680 42023-0129-01 FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN BOTH IP/OP $77.92 $57.66 $0.00 $60.06 $35.06 $35.06 $0.00 $0.00 $0.00 $4.27 $57.83 $57.83 $60.06 $0.00 $12.10 $0.00 $46.09 $46.09 $0.00 $35.34 $55.97 $56.54 $0.00 $0.00 $11.73 $0.00 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $0.00 3215 ERX HCPCS J2680 55150-0267-05 FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN BOTH IP/OP $77.92 $57.66 $0.00 $60.06 $35.06 $35.06 $0.00 $0.00 $0.00 $4.27 $57.83 $57.83 $60.06 $0.00 $12.10 $0.00 $46.09 $46.09 $0.00 $35.34 $55.97 $56.54 $0.00 $0.00 $11.73 $0.00 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $0.00 3215 ERX HCPCS J2680 63323-0272-05 FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN BOTH IP/OP $77.92 $57.66 $0.00 $60.06 $35.06 $35.06 $0.00 $0.00 $0.00 $4.27 $57.83 $57.83 $60.06 $0.00 $12.10 $0.00 $46.09 $46.09 $0.00 $35.34 $55.97 $56.54 $0.00 $0.00 $11.73 $0.00 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $0.00 3216 ERX HCPCS 25000001 63323-0281-10 FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN BOTH IP/OP $673.01 $498.03 $0.00 $518.76 $0.00 $0.00 $0.00 $0.00 $0.00 $499.51 $499.51 $518.76 $0.00 $140.26 $0.00 $0.00 $0.00 $0.00 $290.84 $460.69 $465.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3218 ERX HCPCS 63700001 00527-1788-01 FLUPHENAZINE HCL 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3219 ERX HCPCS 63700001 00527-1791-01 FLUPHENAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3220 ERX HCPCS 63700001 00527-1789-01 FLUPHENAZINE HCL 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3221 ERX HCPCS 63700001 00527-1790-01 FLUPHENAZINE HCL 5 MG PO TABS BOTH IP/OP $38.55 $28.53 $0.00 $27.97 $0.00 $0.00 $0.00 $6.86 $0.00 $0.00 $0.00 $0.00 $0.00 $8.03 $0.00 $0.00 $0.00 $0.00 $17.48 $27.69 $27.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3232 ERX HCPCS 25000001 63323-0184-10 FOLIC ACID 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3232 ERX HCPCS 25000001 99999-6005-63 FOLIC ACID 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3233 ERX HCPCS 63700001 62584-0897-01 FOLIC ACID 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3233 ERX HCPCS 63700001 62584-0897-11 FOLIC ACID 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3233 ERX HCPCS 63700001 63739-0537-10 FOLIC ACID 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3233 ERX HCPCS 63700001 65162-0361-10 FOLIC ACID 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3233 ERX HCPCS 63700001 65162-0361-11 FOLIC ACID 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3264 ERX HCPCS 25000001 00264-9341-55 FREAMINE III 10 % IV SOLN BOTH IP/OP $164.05 $121.40 $0.00 $126.45 $0.00 $0.00 $0.00 $0.00 $0.00 $121.76 $121.76 $126.45 $0.00 $34.19 $0.00 $0.00 $0.00 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-02 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-04 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-10 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-18 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-25 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-26 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-27 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-35 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-36 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 00409-6102-37 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 23155-0473-32 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 23155-0473-42 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 23155-0473-44 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 36000-0282-25 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 36000-0283-25 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 36000-0284-25 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 63323-0280-01 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 63323-0280-02 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 63323-0280-03 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 63323-0280-04 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3291 ERX HCPCS J1940 63323-0280-10 FUROSEMIDE 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $50.88 $9.90 $9.90 $0.00 $0.00 $0.00 $0.25 $48.99 $48.99 $50.88 $0.00 $0.56 $0.00 $39.03 $39.03 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.69 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 3292 ERX HCPCS 25000001 00054-3294-46 FUROSEMIDE 10 MG/ML PO SOLN BOTH IP/OP $43.50 $32.19 $0.00 $56.45 $0.00 $0.00 $0.00 $0.00 $0.00 $32.29 $32.29 $33.53 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $35.28 $31.24 $56.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3292 ERX HCPCS 25000001 60432-0613-60 FUROSEMIDE 10 MG/ML PO SOLN BOTH IP/OP $43.50 $32.19 $0.00 $56.45 $0.00 $0.00 $0.00 $0.00 $0.00 $32.29 $32.29 $33.53 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $35.28 $31.24 $56.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3292 ERX HCPCS 25000001 99999-6004-66 FUROSEMIDE 10 MG/ML PO SOLN BOTH IP/OP $43.50 $32.19 $0.00 $56.45 $0.00 $0.00 $0.00 $0.00 $0.00 $32.29 $32.29 $33.53 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $35.28 $31.24 $56.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3292 ERX HCPCS 25000001 00054-3294-50 FUROSEMIDE 10 MG/ML PO SOLN BOTH IP/OP $43.50 $32.19 $0.00 $56.45 $0.00 $0.00 $0.00 $0.00 $0.00 $32.29 $32.29 $33.53 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $35.28 $55.88 $56.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3294 ERX HCPCS 63700001 00054-8297-25 FUROSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3294 ERX HCPCS 63700001 00378-0208-01 FUROSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3294 ERX HCPCS 63700001 51079-0072-20 FUROSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3295 ERX HCPCS 63700001 00054-8299-25 FUROSEMIDE 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3295 ERX HCPCS 63700001 00378-0216-01 FUROSEMIDE 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3295 ERX HCPCS 63700001 00781-1966-10 FUROSEMIDE 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3295 ERX HCPCS 63700001 51079-0073-01 FUROSEMIDE 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3295 ERX HCPCS 63700001 51079-0073-20 FUROSEMIDE 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3296 ERX HCPCS 63700001 00054-4301-25 FUROSEMIDE 80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3296 ERX HCPCS 63700001 00054-8301-25 FUROSEMIDE 80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3296 ERX HCPCS 63700001 51079-0527-01 FUROSEMIDE 80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3296 ERX HCPCS 63700001 51079-0527-20 FUROSEMIDE 80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3378 ERX HCPCS 63700001 16714-0101-05 GEMFIBROZIL 600 MG PO TABS BOTH IP/OP $9.24 $6.84 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $7.32 $7.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3378 ERX HCPCS 63700001 60687-0224-01 GEMFIBROZIL 600 MG PO TABS BOTH IP/OP $9.24 $6.84 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $7.32 $7.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3423 ERX HCPCS 25000001 45802-0056-35 GENTAMICIN SULFATE 0.1 % EX CREA BOTH IP/OP $342.70 $253.60 $0.00 $264.15 $0.00 $0.00 $0.00 $0.00 $0.00 $254.35 $254.35 $264.15 $0.00 $71.42 $0.00 $0.00 $0.00 $0.00 $155.55 $246.39 $248.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3423 ERX HCPCS 25000001 45802-0056-11 GENTAMICIN SULFATE 0.1 % EX CREA BOTH IP/OP $342.70 $253.60 $0.00 $264.15 $0.00 $0.00 $0.00 $0.00 $0.00 $254.35 $254.35 $264.15 $0.00 $71.42 $0.00 $0.00 $0.00 $0.00 $155.55 $246.39 $248.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3424 ERX HCPCS 25000001 45802-0046-35 GENTAMICIN SULFATE 0.1 % EX OINT BOTH IP/OP $342.70 $253.60 $0.00 $264.15 $0.00 $0.00 $0.00 $0.00 $0.00 $254.35 $254.35 $264.15 $0.00 $71.42 $0.00 $0.00 $0.00 $0.00 $155.55 $246.39 $248.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3424 ERX HCPCS 25000001 45802-0046-11 GENTAMICIN SULFATE 0.1 % EX OINT BOTH IP/OP $342.70 $253.60 $0.00 $264.15 $0.00 $0.00 $0.00 $0.00 $0.00 $254.35 $254.35 $264.15 $0.00 $71.42 $0.00 $0.00 $0.00 $0.00 $155.55 $246.39 $248.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3424 ERX HCPCS 25000001 52565-0090-30 GENTAMICIN SULFATE 0.1 % EX OINT BOTH IP/OP $342.70 $253.60 $0.00 $264.15 $0.00 $0.00 $0.00 $0.00 $0.00 $254.35 $254.35 $264.15 $0.00 $71.42 $0.00 $0.00 $0.00 $0.00 $155.55 $246.39 $248.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3425 ERX HCPCS J1580 63323-0173-02 GENTAMICIN SULFATE 10 MG/ML (NICU) IM INJ BOTH IP/OP $22.00 $16.28 $0.00 $18.22 $10.64 $10.64 $0.00 $0.00 $0.00 $1.02 $17.55 $17.55 $18.22 $0.00 $1.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 3426 ERX HCPCS J1580 00409-1207-03 GENTAMICIN SULFATE 40 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.02 $16.33 $16.33 $16.96 $0.00 $1.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 3426 ERX HCPCS J1580 00409-1207-25 GENTAMICIN SULFATE 40 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.02 $16.33 $16.33 $16.96 $0.00 $1.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 3426 ERX HCPCS J1580 63323-0010-02 GENTAMICIN SULFATE 40 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.02 $16.33 $16.33 $16.96 $0.00 $1.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 3426 ERX HCPCS J1580 63323-0010-20 GENTAMICIN SULFATE 40 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.02 $16.33 $16.33 $16.96 $0.00 $1.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 3427 ERX HCPCS 63700001 17478-0284-35 GENTAMICIN SULFATE 0.3 % OP OINT BOTH IP/OP $150.36 $111.27 $0.00 $99.24 $0.00 $0.00 $0.00 $26.76 $0.00 $0.00 $0.00 $0.00 $0.00 $31.34 $0.00 $0.00 $0.00 $0.00 $62.03 $98.25 $99.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3428 ERX HCPCS 25000001 17478-0283-10 GENTAMICIN SULFATE 0.3 % OP SOLN BOTH IP/OP $83.77 $61.99 $0.00 $64.57 $0.00 $0.00 $0.00 $0.00 $0.00 $62.17 $62.17 $64.57 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $37.98 $60.15 $60.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3428 ERX HCPCS 25000001 24208-0580-60 GENTAMICIN SULFATE 0.3 % OP SOLN BOTH IP/OP $83.77 $61.99 $0.00 $64.57 $0.00 $0.00 $0.00 $0.00 $0.00 $62.17 $62.17 $64.57 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $37.98 $60.15 $60.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3428 ERX HCPCS 25000001 60758-0188-05 GENTAMICIN SULFATE 0.3 % OP SOLN BOTH IP/OP $83.77 $61.99 $0.00 $64.57 $0.00 $0.00 $0.00 $0.00 $0.00 $62.17 $62.17 $64.57 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $37.98 $60.15 $60.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3428 ERX HCPCS 25000001 61314-0633-05 GENTAMICIN SULFATE 0.3 % OP SOLN BOTH IP/OP $83.77 $61.99 $0.00 $64.57 $0.00 $0.00 $0.00 $0.00 $0.00 $62.17 $62.17 $64.57 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $37.98 $60.15 $60.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3430 ERX HCPCS 25000001 00395-1003-92 GENTIAN VIOLET 1 % EX SOLN BOTH IP/OP $34.86 $25.80 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 $25.87 $25.87 $26.87 $0.00 $7.26 $0.00 $0.00 $0.00 $0.00 $15.25 $24.16 $24.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3489 ERX HCPCS 63700001 00093-8344-01 GLYBURIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3489 ERX HCPCS 63700001 63739-0119-10 GLYBURIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 00143-9587-25 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 00143-9682-01 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 00143-9682-25 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 00517-4601-25 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 00781-3825-71 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 00781-3825-96 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 66794-0202-42 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 70069-0011-25 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3497 ERX HCPCS 25000001 70121-1394-05 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN BOTH IP/OP $35.44 $26.23 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $26.30 $27.32 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3578 ERX HCPCS 25000001 00378-0351-01 HALOPERIDOL 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3578 ERX HCPCS 25000001 00781-1391-01 HALOPERIDOL 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3578 ERX HCPCS 25000001 51079-0733-01 HALOPERIDOL 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3578 ERX HCPCS 25000001 51079-0733-20 HALOPERIDOL 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3579 ERX HCPCS 25000001 51079-0734-20 HALOPERIDOL 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3580 ERX HCPCS 63700001 51079-0431-20 HALOPERIDOL 10 MG PO TABS BOTH IP/OP $6.82 $5.05 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.41 $5.40 $5.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3580 ERX HCPCS 63700001 68382-0080-01 HALOPERIDOL 10 MG PO TABS BOTH IP/OP $6.82 $5.05 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.41 $5.40 $5.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3581 ERX HCPCS 63700001 00378-0214-01 HALOPERIDOL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3582 ERX HCPCS 63700001 00378-0335-01 HALOPERIDOL 20 MG PO TABS BOTH IP/OP $15.17 $11.23 $0.00 $11.01 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $6.88 $10.90 $11.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3582 ERX HCPCS 63700001 00781-1398-01 HALOPERIDOL 20 MG PO TABS BOTH IP/OP $15.17 $11.23 $0.00 $11.01 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $6.88 $10.90 $11.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3582 ERX HCPCS 63700001 68382-0081-01 HALOPERIDOL 20 MG PO TABS BOTH IP/OP $15.17 $11.23 $0.00 $11.01 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $6.88 $10.90 $11.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3583 ERX HCPCS 63700001 00378-0327-01 HALOPERIDOL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3583 ERX HCPCS 63700001 00781-1396-01 HALOPERIDOL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3583 ERX HCPCS 63700001 51079-0736-20 HALOPERIDOL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3583 ERX HCPCS 63700001 68382-0079-01 HALOPERIDOL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3584 ERX HCPCS J1630 00143-9501-25 HALOPERIDOL LACTATE 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.80 $16.33 $16.33 $16.96 $0.00 $1.71 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.42 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 3584 ERX HCPCS J1630 25021-0806-01 HALOPERIDOL LACTATE 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.80 $16.33 $16.33 $16.96 $0.00 $1.71 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.42 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 3584 ERX HCPCS J1630 63323-0474-00 HALOPERIDOL LACTATE 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.80 $16.33 $16.33 $16.96 $0.00 $1.71 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.42 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 3584 ERX HCPCS J1630 63323-0474-01 HALOPERIDOL LACTATE 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.80 $16.33 $16.33 $16.96 $0.00 $1.71 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.42 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 3584 ERX HCPCS J1630 67457-0426-00 HALOPERIDOL LACTATE 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.80 $16.33 $16.33 $16.96 $0.00 $1.71 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.42 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 3584 ERX HCPCS J1630 67457-0426-12 HALOPERIDOL LACTATE 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.80 $16.33 $16.33 $16.96 $0.00 $1.71 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.42 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 3585 ERX HCPCS 25000001 00121-0581-04 HALOPERIDOL LACTATE 2 MG/ML PO CONC BOTH IP/OP $9.50 $7.03 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.05 $7.05 $7.32 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $4.31 $6.82 $6.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3585 ERX HCPCS 25000001 00121-0581-05 HALOPERIDOL LACTATE 2 MG/ML PO CONC BOTH IP/OP $9.50 $7.03 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.05 $7.05 $7.32 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $4.31 $6.82 $6.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3585 ERX HCPCS 25000001 99999-6007-06 HALOPERIDOL LACTATE 2 MG/ML PO CONC BOTH IP/OP $9.50 $7.03 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.05 $7.05 $7.32 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $4.31 $6.82 $6.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3697 ERX HCPCS J0360 63323-0614-00 HYDRALAZINE HCL 20 MG/ML IJ SOLN BOTH IP/OP $65.77 $48.67 $0.00 $55.51 $32.40 $32.40 $0.00 $0.00 $0.00 $5.77 $53.45 $53.45 $55.51 $0.00 $6.11 $0.00 $38.90 $38.90 $0.00 $29.83 $47.24 $47.72 $0.00 $0.00 $4.41 $0.00 $0.00 $4.20 $0.00 $0.00 $0.00 $0.00 $0.00 3697 ERX HCPCS J0360 63323-0614-01 HYDRALAZINE HCL 20 MG/ML IJ SOLN BOTH IP/OP $65.77 $48.67 $0.00 $55.51 $32.40 $32.40 $0.00 $0.00 $0.00 $5.77 $53.45 $53.45 $55.51 $0.00 $6.11 $0.00 $38.90 $38.90 $0.00 $29.83 $47.24 $47.72 $0.00 $0.00 $4.41 $0.00 $0.00 $4.20 $0.00 $0.00 $0.00 $0.00 $0.00 3697 ERX HCPCS J0360 63323-0614-55 HYDRALAZINE HCL 20 MG/ML IJ SOLN BOTH IP/OP $65.77 $48.67 $0.00 $55.51 $32.40 $32.40 $0.00 $0.00 $0.00 $5.77 $53.45 $53.45 $55.51 $0.00 $6.11 $0.00 $38.90 $38.90 $0.00 $29.83 $47.24 $47.72 $0.00 $0.00 $4.41 $0.00 $0.00 $4.20 $0.00 $0.00 $0.00 $0.00 $0.00 3697 ERX HCPCS J0360 67457-0291-01 HYDRALAZINE HCL 20 MG/ML IJ SOLN BOTH IP/OP $65.77 $48.67 $0.00 $55.51 $32.40 $32.40 $0.00 $0.00 $0.00 $5.77 $53.45 $53.45 $55.51 $0.00 $6.11 $0.00 $38.90 $38.90 $0.00 $29.83 $47.24 $47.72 $0.00 $0.00 $4.41 $0.00 $0.00 $4.20 $0.00 $0.00 $0.00 $0.00 $0.00 3698 ERX HCPCS 63700001 00904-6440-61 HYDRALAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3698 ERX HCPCS 63700001 50111-0398-01 HYDRALAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3698 ERX HCPCS 63700001 51079-0074-01 HYDRALAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3698 ERX HCPCS 63700001 51079-0074-20 HYDRALAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3698 ERX HCPCS 63700001 68084-0447-01 HYDRALAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3699 ERX HCPCS 63700001 00904-6443-61 HYDRALAZINE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3699 ERX HCPCS 63700001 31722-0522-01 HYDRALAZINE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3699 ERX HCPCS 63700001 50111-0397-01 HYDRALAZINE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3700 ERX HCPCS 63700001 00904-6441-61 HYDRALAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3700 ERX HCPCS 63700001 50111-0327-01 HYDRALAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3700 ERX HCPCS 63700001 51079-0075-01 HYDRALAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3700 ERX HCPCS 63700001 51079-0075-20 HYDRALAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3700 ERX HCPCS 63700001 62584-0733-01 HYDRALAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3700 ERX HCPCS 63700001 62584-0733-11 HYDRALAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3700 ERX HCPCS 63700001 63739-0126-10 HYDRALAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3700 ERX HCPCS 63700001 63739-0327-10 HYDRALAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3701 ERX HCPCS 63700001 00904-6442-61 HYDRALAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3701 ERX HCPCS 63700001 50111-0328-01 HYDRALAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3701 ERX HCPCS 63700001 51079-0076-01 HYDRALAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3701 ERX HCPCS 63700001 62584-0734-01 HYDRALAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3701 ERX HCPCS 63700001 62584-0734-11 HYDRALAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3701 ERX HCPCS 63700001 63739-0328-10 HYDRALAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3701 ERX HCPCS 63700001 76282-0311-01 HYDRALAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3720 ERX HCPCS 63700001 16729-0183-01 HYDROCHLOROTHIAZIDE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3720 ERX HCPCS 63700001 16729-0183-17 HYDROCHLOROTHIAZIDE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3720 ERX HCPCS 63700001 29300-0128-10 HYDROCHLOROTHIAZIDE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3720 ERX HCPCS 63700001 63739-0128-10 HYDROCHLOROTHIAZIDE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3721 ERX HCPCS 63700001 16729-0184-01 HYDROCHLOROTHIAZIDE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3721 ERX HCPCS 63700001 43547-0398-10 HYDROCHLOROTHIAZIDE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3726 ERX HCPCS 63700001 45802-0438-03 HYDROCORTISONE 1 % EX CREA BOTH IP/OP $30.18 $22.33 $0.00 $8.80 $0.00 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 $6.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3726 ERX HCPCS 63700001 00168-0015-31 HYDROCORTISONE 1 % EX CREA BOTH IP/OP $30.18 $22.33 $0.00 $8.80 $0.00 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 $6.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3726 ERX HCPCS 63700001 00168-0154-31 HYDROCORTISONE 1 % EX CREA BOTH IP/OP $30.18 $22.33 $0.00 $8.80 $0.00 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 $6.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3726 ERX HCPCS 63700001 51672-2069-02 HYDROCORTISONE 1 % EX CREA BOTH IP/OP $30.18 $22.33 $0.00 $8.80 $0.00 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 $6.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3727 ERX HCPCS 63700001 45802-0004-03 HYDROCORTISONE 2.5 % EX CREA BOTH IP/OP $46.14 $34.14 $0.00 $33.47 $0.00 $0.00 $0.00 $8.21 $0.00 $0.00 $0.00 $0.00 $0.00 $9.62 $0.00 $0.00 $0.00 $0.00 $20.92 $33.14 $33.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3727 ERX HCPCS 63700001 00168-0080-31 HYDROCORTISONE 2.5 % EX CREA BOTH IP/OP $46.14 $34.14 $0.00 $33.47 $0.00 $0.00 $0.00 $8.21 $0.00 $0.00 $0.00 $0.00 $0.00 $9.62 $0.00 $0.00 $0.00 $0.00 $20.92 $33.14 $33.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3727 ERX HCPCS 63700001 00472-0337-30 HYDROCORTISONE 2.5 % EX CREA BOTH IP/OP $46.14 $34.14 $0.00 $33.47 $0.00 $0.00 $0.00 $8.21 $0.00 $0.00 $0.00 $0.00 $0.00 $9.62 $0.00 $0.00 $0.00 $0.00 $20.92 $33.14 $33.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3728 ERX HCPCS 63700001 00394-0859-32 HYDROCORTISONE 1 % EX LOTN BOTH IP/OP $27.71 $20.51 $0.00 $20.10 $0.00 $0.00 $0.00 $4.93 $0.00 $0.00 $0.00 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $12.57 $19.90 $20.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3731 ERX HCPCS 63700001 00472-0345-56 HYDROCORTISONE 1 % EX OINT BOTH IP/OP $14.55 $10.77 $0.00 $10.56 $0.00 $0.00 $0.00 $2.59 $0.00 $0.00 $0.00 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $6.60 $10.45 $10.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3731 ERX HCPCS 63700001 45802-0276-03 HYDROCORTISONE 1 % EX OINT BOTH IP/OP $14.55 $10.77 $0.00 $10.56 $0.00 $0.00 $0.00 $2.59 $0.00 $0.00 $0.00 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $6.60 $10.45 $10.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3731 ERX HCPCS 63700001 00168-0020-16 HYDROCORTISONE 1 % EX OINT BOTH IP/OP $14.55 $10.77 $0.00 $147.26 $0.00 $0.00 $0.00 $2.59 $0.00 $0.00 $0.00 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $6.60 $147.26 $10.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3732 ERX HCPCS 63700001 45802-0014-02 HYDROCORTISONE 2.5 % EX OINT BOTH IP/OP $46.09 $34.11 $0.00 $33.44 $0.00 $0.00 $0.00 $8.20 $0.00 $0.00 $0.00 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3732 ERX HCPCS 63700001 00168-0146-30 HYDROCORTISONE 2.5 % EX OINT BOTH IP/OP $46.09 $34.11 $0.00 $33.44 $0.00 $0.00 $0.00 $8.20 $0.00 $0.00 $0.00 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3733 ERX HCPCS 63700001 59762-0074-01 HYDROCORTISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3734 ERX HCPCS 63700001 00009-0044-01 HYDROCORTISONE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3734 ERX HCPCS 63700001 42543-0142-01 HYDROCORTISONE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3734 ERX HCPCS 63700001 59762-0075-01 HYDROCORTISONE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3734 ERX HCPCS 63700001 72789-0062-01 HYDROCORTISONE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3738 ERX HCPCS 25000001 00574-7090-12 HYDROCORTISONE ACETATE 25 MG RECTAL SUPP BOTH IP/OP $254.19 $188.10 $0.00 $195.93 $0.00 $0.00 $0.00 $0.00 $0.00 $188.66 $188.66 $195.93 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $99.10 $156.97 $158.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3738 ERX HCPCS 25000001 00713-0503-12 HYDROCORTISONE ACETATE 25 MG RECTAL SUPP BOTH IP/OP $254.19 $188.10 $0.00 $195.93 $0.00 $0.00 $0.00 $0.00 $0.00 $188.66 $188.66 $195.93 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $99.10 $156.97 $158.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3738 ERX HCPCS 25000001 00713-0503-24 HYDROCORTISONE ACETATE 25 MG RECTAL SUPP BOTH IP/OP $254.19 $188.10 $0.00 $195.93 $0.00 $0.00 $0.00 $0.00 $0.00 $188.66 $188.66 $195.93 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $99.10 $156.97 $158.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3738 ERX HCPCS 25000001 16477-0201-24 HYDROCORTISONE ACETATE 25 MG RECTAL SUPP BOTH IP/OP $254.19 $188.10 $0.00 $195.93 $0.00 $0.00 $0.00 $0.00 $0.00 $188.66 $188.66 $195.93 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $99.10 $156.97 $158.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3738 ERX HCPCS 25000001 65649-0411-12 HYDROCORTISONE ACETATE 25 MG RECTAL SUPP BOTH IP/OP $254.19 $188.10 $0.00 $195.93 $0.00 $0.00 $0.00 $0.00 $0.00 $188.66 $188.66 $195.93 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $99.10 $156.97 $158.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3738 ERX HCPCS 25000001 65649-0411-24 HYDROCORTISONE ACETATE 25 MG RECTAL SUPP BOTH IP/OP $254.19 $188.10 $0.00 $195.93 $0.00 $0.00 $0.00 $0.00 $0.00 $188.66 $188.66 $195.93 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $99.10 $156.97 $158.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3747 ERX HCPCS 25000001 51672-2010-02 HYDROCORTISONE-ALOE 0.5 % EX CREA BOTH IP/OP $23.09 $17.09 $0.00 $17.80 $0.00 $0.00 $0.00 $0.00 $0.00 $17.14 $17.14 $17.80 $0.00 $4.81 $0.00 $0.00 $0.00 $0.00 $10.47 $16.58 $16.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3757 ERX HCPCS J1170 00409-1283-03 HYDROMORPHONE HCL 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3757 ERX HCPCS J1170 00409-1283-31 HYDROMORPHONE HCL 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3757 ERX HCPCS J1170 00409-2552-01 HYDROMORPHONE HCL 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3757 ERX HCPCS J1170 76045-0009-01 HYDROMORPHONE HCL 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3757 ERX HCPCS J1170 76045-0009-10 HYDROMORPHONE HCL 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3757 ERX HCPCS J1170 76045-0009-11 HYDROMORPHONE HCL 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3757 ERX HCPCS J1170 99999-6010-70 HYDROMORPHONE HCL 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3758 ERX HCPCS J1170 00409-1312-30 HYDROMORPHONE HCL 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3758 ERX HCPCS J1170 00409-3365-01 HYDROMORPHONE HCL 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3758 ERX HCPCS J1170 00409-3365-11 HYDROMORPHONE HCL 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3758 ERX HCPCS J1170 00641-0121-25 HYDROMORPHONE HCL 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3758 ERX HCPCS J1170 00641-6151-01 HYDROMORPHONE HCL 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3758 ERX HCPCS J1170 00641-6151-25 HYDROMORPHONE HCL 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 3760 ERX HCPCS 25000001 42858-0301-25 HYDROMORPHONE HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3760 ERX HCPCS 25000001 68084-0423-01 HYDROMORPHONE HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3760 ERX HCPCS 25000001 68084-0423-11 HYDROMORPHONE HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3761 ERX HCPCS 25000001 00054-0264-24 HYDROMORPHONE HCL 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3761 ERX HCPCS 25000001 42858-0302-25 HYDROMORPHONE HCL 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3770 ERX HCPCS J3410 00517-5602-25 HYDROXYZINE HCL 50 MG/ML IM SOLN BOTH IP/OP $86.30 $63.86 $0.00 $69.18 $0.00 $0.00 $0.00 $0.00 $0.00 $66.61 $66.61 $69.18 $0.00 $21.22 $0.00 $0.00 $0.00 $0.00 $37.12 $58.79 $59.38 $0.00 $0.00 $16.50 $0.00 $0.00 $15.71 $0.00 $0.00 $0.00 $0.00 $0.00 3771 ERX HCPCS 63700001 99999-6010-58 HYDROXYZINE HCL 10 MG/5ML PO SYRP BOTH IP/OP $42.24 $31.26 $0.00 $30.65 $0.00 $0.00 $0.00 $7.52 $0.00 $0.00 $0.00 $0.00 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $19.16 $15.17 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3771 ERX HCPCS 63700001 60432-0150-04 HYDROXYZINE HCL 10 MG/5ML PO SYRP BOTH IP/OP $42.24 $31.26 $0.00 $30.65 $0.00 $0.00 $0.00 $7.52 $0.00 $0.00 $0.00 $0.00 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $19.16 $30.34 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3771 ERX HCPCS 63700001 99999-6004-67 HYDROXYZINE HCL 10 MG/5ML PO SYRP BOTH IP/OP $42.24 $31.26 $0.00 $30.65 $0.00 $0.00 $0.00 $7.52 $0.00 $0.00 $0.00 $0.00 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $19.16 $30.34 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3771 ERX HCPCS 63700001 60432-0150-16 HYDROXYZINE HCL 10 MG/5ML PO SYRP BOTH IP/OP $42.24 $31.26 $0.00 $110.14 $0.00 $0.00 $0.00 $7.52 $0.00 $0.00 $0.00 $0.00 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $19.16 $110.14 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3772 ERX HCPCS 63700001 16714-0081-10 HYDROXYZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3772 ERX HCPCS 63700001 68084-0253-01 HYDROXYZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3772 ERX HCPCS 63700001 68084-0253-11 HYDROXYZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3774 ERX HCPCS 63700001 16714-0082-10 HYDROXYZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3774 ERX HCPCS 63700001 63739-0486-10 HYDROXYZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3774 ERX HCPCS 63700001 68084-0254-01 HYDROXYZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3778 ERX HCPCS Q0177 00185-0615-01 HYDROXYZINE PAMOATE 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 3778 ERX HCPCS Q0177 00185-0615-05 HYDROXYZINE PAMOATE 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 3778 ERX HCPCS Q0177 51079-0078-20 HYDROXYZINE PAMOATE 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 3781 ERX HCPCS 25000001 39328-0048-16 HYOSCYAMINE SULFATE 0.125 MG/5ML PO ELIX BOTH IP/OP $57.32 $42.42 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 $42.54 $42.54 $44.18 $0.00 $11.95 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3781 ERX HCPCS 25000001 54838-0511-80 HYOSCYAMINE SULFATE 0.125 MG/5ML PO ELIX BOTH IP/OP $57.32 $42.42 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 $42.54 $42.54 $44.18 $0.00 $11.95 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3781 ERX HCPCS 25000001 58657-0427-16 HYOSCYAMINE SULFATE 0.125 MG/5ML PO ELIX BOTH IP/OP $57.32 $42.42 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 $42.54 $42.54 $44.18 $0.00 $11.95 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3781 ERX HCPCS 25000001 99999-6008-10 HYOSCYAMINE SULFATE 0.125 MG/5ML PO ELIX BOTH IP/OP $57.32 $42.42 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 $42.54 $42.54 $44.18 $0.00 $11.95 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3783 ERX HCPCS 63700001 42192-0340-01 HYOSCYAMINE SULFATE 0.125 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3841 ERX HCPCS 25000001 00904-7914-59 IBUPROFEN 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3841 ERX HCPCS 25000001 00904-7914-61 IBUPROFEN 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3841 ERX HCPCS 25000001 63739-0134-01 IBUPROFEN 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3843 ERX HCPCS 25000001 00904-5853-60 IBUPROFEN 400 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3843 ERX HCPCS 25000001 00904-5853-61 IBUPROFEN 400 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3843 ERX HCPCS 25000001 49483-0602-01 IBUPROFEN 400 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3843 ERX HCPCS 25000001 60687-0446-01 IBUPROFEN 400 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3843 ERX HCPCS 25000001 63739-0672-01 IBUPROFEN 400 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3843 ERX HCPCS 25000001 63739-0672-10 IBUPROFEN 400 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3844 ERX HCPCS 25000001 00904-5854-61 IBUPROFEN 600 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3844 ERX HCPCS 25000001 11788-0009-05 IBUPROFEN 600 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3844 ERX HCPCS 25000001 63739-0684-01 IBUPROFEN 600 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3844 ERX HCPCS 25000001 63739-0684-10 IBUPROFEN 600 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3845 ERX HCPCS 25000001 49483-0604-50 IBUPROFEN 800 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3845 ERX HCPCS 25000001 63739-0691-01 IBUPROFEN 800 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3845 ERX HCPCS 25000001 63739-0691-10 IBUPROFEN 800 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3860 ERX HCPCS 63700001 00781-1762-01 IMIPRAMINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3860 ERX HCPCS 63700001 49884-0054-01 IMIPRAMINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3860 ERX HCPCS 63700001 53489-0330-01 IMIPRAMINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3861 ERX HCPCS 63700001 00781-1764-01 IMIPRAMINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3861 ERX HCPCS 63700001 00781-1764-13 IMIPRAMINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3862 ERX HCPCS 63700001 00781-1766-01 IMIPRAMINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3862 ERX HCPCS 63700001 00781-1766-13 IMIPRAMINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3862 ERX HCPCS 63700001 49884-0056-01 IMIPRAMINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3879 ERX HCPCS 63700001 00378-0080-01 INDAPAMIDE 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3897 ERX HCPCS 63700001 31722-0542-01 INDOMETHACIN 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3897 ERX HCPCS 63700001 50268-0430-11 INDOMETHACIN 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3897 ERX HCPCS 63700001 50268-0430-15 INDOMETHACIN 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3897 ERX HCPCS 63700001 68462-0406-01 INDOMETHACIN 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3900 ERX HCPCS 25000001 69344-0101-01 INDOMETHACIN 25 MG/5ML PO SUSP BOTH IP/OP $191.60 $141.78 $0.00 $147.69 $0.00 $0.00 $0.00 $0.00 $0.00 $142.21 $142.21 $147.69 $0.00 $39.93 $0.00 $0.00 $0.00 $0.00 $86.87 $137.59 $138.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3900 ERX HCPCS 25000001 99999-6012-44 INDOMETHACIN 25 MG/5ML PO SUSP BOTH IP/OP $191.60 $141.78 $0.00 $147.69 $0.00 $0.00 $0.00 $0.00 $0.00 $142.21 $142.21 $147.69 $0.00 $39.93 $0.00 $0.00 $0.00 $0.00 $86.87 $137.59 $138.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3901 ERX HCPCS 63700001 69344-0102-33 INDOMETHACIN 50 MG RECTAL SUPP BOTH IP/OP $594.12 $439.65 $0.00 $475.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.06 $470.54 $475.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3961 ERX HCPCS 25000001 48433-0230-15 IODINE STRONG 5 % SOLN BOTH IP/OP $133.16 $98.54 $0.00 $102.64 $0.00 $0.00 $0.00 $0.00 $0.00 $98.83 $98.83 $102.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $60.37 $95.63 $96.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3961 ERX HCPCS 25000001 00395-2775-16 IODINE STRONG 5 % SOLN BOTH IP/OP $133.16 $98.54 $0.00 $201.79 $0.00 $0.00 $0.00 $0.00 $0.00 $98.83 $98.83 $102.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $60.37 $201.79 $96.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3990 ERX HCPCS J1750 00023-6082-01 IRON DEXTRAN 50 MG/ML IJ SOLN BOTH IP/OP $33.31 $24.65 $0.00 $26.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.13 $16.66 $26.38 $26.65 $20.89 $20.89 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3990 ERX HCPCS J1750 00023-6082-10 IRON DEXTRAN 50 MG/ML IJ SOLN BOTH IP/OP $33.31 $24.65 $0.00 $26.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.13 $16.66 $26.38 $26.65 $20.89 $20.89 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4008 ERX HCPCS 25000001 10019-0360-40 ISOFLURANE IN SOLN BOTH IP/OP $111.17 $82.27 $0.00 $85.69 $0.00 $0.00 $0.00 $0.00 $0.00 $82.51 $82.51 $85.69 $0.00 $23.17 $0.00 $0.00 $0.00 $0.00 $50.40 $79.83 $80.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4008 ERX HCPCS 25000001 66794-0017-10 ISOFLURANE IN SOLN BOTH IP/OP $111.17 $82.27 $0.00 $85.69 $0.00 $0.00 $0.00 $0.00 $0.00 $82.51 $82.51 $85.69 $0.00 $23.17 $0.00 $0.00 $0.00 $0.00 $50.40 $79.83 $80.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4008 ERX HCPCS 25000001 66794-0017-25 ISOFLURANE IN SOLN BOTH IP/OP $111.17 $82.27 $0.00 $103.95 $0.00 $0.00 $0.00 $0.00 $0.00 $82.51 $82.51 $85.69 $0.00 $23.17 $0.00 $0.00 $0.00 $0.00 $50.40 $103.95 $80.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4024 ERX HCPCS 25000001 00781-3056-70 ISONIAZID 100 MG/ML IJ SOLN BOTH IP/OP $354.88 $262.61 $0.00 $273.54 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $273.54 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $161.07 $255.13 $257.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4025 ERX HCPCS 63700001 99999-6004-68 ISONIAZID 50 MG/5ML PO SYRP BOTH IP/OP $69.39 $51.35 $0.00 $50.34 $0.00 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 $14.46 $0.00 $0.00 $0.00 $0.00 $31.47 $49.84 $50.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4025 ERX HCPCS 63700001 46287-0009-01 ISONIAZID 50 MG/5ML PO SYRP BOTH IP/OP $69.39 $51.35 $0.00 $857.73 $0.00 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 $14.46 $0.00 $0.00 $0.00 $0.00 $31.47 $857.73 $50.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4026 ERX HCPCS 63700001 00555-0066-02 ISONIAZID 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4027 ERX HCPCS 63700001 00555-0071-01 ISONIAZID 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4027 ERX HCPCS 63700001 00555-0071-02 ISONIAZID 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4027 ERX HCPCS 63700001 51079-0083-01 ISONIAZID 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4027 ERX HCPCS 63700001 51079-0083-20 ISONIAZID 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4030 ERX HCPCS 25000001 00574-0067-16 ISOPROPYL ALCOHOL 70 % SOLN BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4030 ERX HCPCS 25000001 49348-0030-38 ISOPROPYL ALCOHOL 70 % SOLN BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 00187-4330-01 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 00187-4330-05 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 00548-9501-00 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 00548-9502-00 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 14789-0015-05 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 14789-0015-07 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 70121-1604-01 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 70121-1604-07 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 70121-1605-01 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4034 ERX HCPCS 25000001 70121-1605-07 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN BOTH IP/OP "$2,250.90 " "$1,665.67" $0.00 "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.45" "$1,782.71" "$1,800.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4064 ERX HCPCS 63700001 00143-1771-01 ISOSORBIDE DINITRATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4064 ERX HCPCS 63700001 00781-1556-01 ISOSORBIDE DINITRATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4064 ERX HCPCS 63700001 00904-6619-61 ISOSORBIDE DINITRATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4064 ERX HCPCS 63700001 50268-0448-15 ISOSORBIDE DINITRATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4064 ERX HCPCS 63700001 63739-0569-10 ISOSORBIDE DINITRATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4064 ERX HCPCS 63700001 68084-0082-01 ISOSORBIDE DINITRATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4065 ERX HCPCS 63700001 00781-1695-01 ISOSORBIDE DINITRATE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4065 ERX HCPCS 63700001 00904-6620-61 ISOSORBIDE DINITRATE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4065 ERX HCPCS 63700001 63739-0367-10 ISOSORBIDE DINITRATE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4065 ERX HCPCS 63700001 68084-0083-01 ISOSORBIDE DINITRATE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4068 ERX HCPCS 63700001 00143-1769-01 ISOSORBIDE DINITRATE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4068 ERX HCPCS 63700001 00781-1635-01 ISOSORBIDE DINITRATE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4201 ERX HCPCS 25000001 99999-6005-50 KAYEXALATE PO POWD BOTH IP/OP $28.50 $21.09 $0.00 $22.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4236 ERX HCPCS J3490 42023-0113-10 KETAMINE HCL 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 4236 ERX HCPCS J3490 67457-0181-20 KETAMINE HCL 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 4237 ERX HCPCS 25000001 00143-9509-10 KETAMINE HCL 100 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4238 ERX HCPCS J3490 00143-9508-10 KETAMINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 4238 ERX HCPCS J3490 00409-2053-10 KETAMINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 4238 ERX HCPCS J3490 42023-0114-10 KETAMINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 4238 ERX HCPCS J3490 67457-0001-00 KETAMINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 4238 ERX HCPCS J3490 67457-0001-10 KETAMINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 4318 ERX HCPCS J7120 00264-7750-00 LACTATED RINGERS IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 4318 ERX HCPCS J7120 00338-0117-04 LACTATED RINGERS IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 4318 ERX HCPCS J7120 00990-7953-09 LACTATED RINGERS IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 4318 ERX HCPCS J7120 00264-7750-20 LACTATED RINGERS IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 4318 ERX HCPCS J7120 00338-0117-03 LACTATED RINGERS IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.56 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.00 $19.56 $17.60 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 4318 ERX HCPCS J7120 00409-7953-03 LACTATED RINGERS IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.56 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.00 $19.56 $17.60 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 4323 ERX HCPCS 63700001 08290-2367-12 LACTINEX PO PACK BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4393 ERX HCPCS J0640 00143-9552-01 LEUCOVORIN CALCIUM 350 MG IJ SOLR BOTH IP/OP $120.44 $89.13 $0.00 $92.84 $54.20 $54.20 $0.00 $0.00 $0.00 $7.32 $89.39 $89.39 $92.84 $0.00 $30.08 $0.00 $71.24 $71.24 $0.00 $54.60 $86.49 $87.36 $0.00 $0.00 $27.39 $0.00 $0.00 $26.08 $0.00 $0.00 $0.00 $0.00 $0.00 4393 ERX HCPCS J0640 00703-5145-01 LEUCOVORIN CALCIUM 350 MG IJ SOLR BOTH IP/OP $120.44 $89.13 $0.00 $92.84 $54.20 $54.20 $0.00 $0.00 $0.00 $7.32 $89.39 $89.39 $92.84 $0.00 $30.08 $0.00 $71.24 $71.24 $0.00 $54.60 $86.49 $87.36 $0.00 $0.00 $27.39 $0.00 $0.00 $26.08 $0.00 $0.00 $0.00 $0.00 $0.00 4393 ERX HCPCS J0640 67457-0530-35 LEUCOVORIN CALCIUM 350 MG IJ SOLR BOTH IP/OP $120.44 $89.13 $0.00 $92.84 $54.20 $54.20 $0.00 $0.00 $0.00 $7.32 $89.39 $89.39 $92.84 $0.00 $30.08 $0.00 $71.24 $71.24 $0.00 $54.60 $86.49 $87.36 $0.00 $0.00 $27.39 $0.00 $0.00 $26.08 $0.00 $0.00 $0.00 $0.00 $0.00 4394 ERX HCPCS J0640 00143-9555-01 LEUCOVORIN CALCIUM 50 MG IJ SOLR BOTH IP/OP $50.28 $37.21 $0.00 $38.76 $22.63 $22.63 $0.00 $0.00 $0.00 $1.05 $37.32 $37.32 $38.76 $0.00 $4.30 $0.00 $29.74 $29.74 $0.00 $22.80 $36.12 $36.48 $0.00 $0.00 $3.91 $0.00 $0.00 $3.73 $0.00 $0.00 $0.00 $0.00 $0.00 4394 ERX HCPCS J0640 25021-0813-10 LEUCOVORIN CALCIUM 50 MG IJ SOLR BOTH IP/OP $50.28 $37.21 $0.00 $38.76 $22.63 $22.63 $0.00 $0.00 $0.00 $1.05 $37.32 $37.32 $38.76 $0.00 $4.30 $0.00 $29.74 $29.74 $0.00 $22.80 $36.12 $36.48 $0.00 $0.00 $3.91 $0.00 $0.00 $3.73 $0.00 $0.00 $0.00 $0.00 $0.00 4397 ERX HCPCS 63700001 51079-0582-01 LEUCOVORIN CALCIUM 25 MG PO TABS BOTH IP/OP $57.36 $42.45 $0.00 $41.62 $0.00 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 $11.95 $0.00 $0.00 $0.00 $0.00 $26.01 $41.20 $41.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397 ERX HCPCS 63700001 51079-0582-05 LEUCOVORIN CALCIUM 25 MG PO TABS BOTH IP/OP $57.36 $42.45 $0.00 $41.62 $0.00 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 $11.95 $0.00 $0.00 $0.00 $0.00 $26.01 $41.20 $41.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397 ERX HCPCS 63700001 60687-0227-94 LEUCOVORIN CALCIUM 25 MG PO TABS BOTH IP/OP $57.36 $42.45 $0.00 $41.62 $0.00 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 $11.95 $0.00 $0.00 $0.00 $0.00 $26.01 $41.20 $41.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4398 ERX HCPCS 63700001 00054-8496-19 LEUCOVORIN CALCIUM 5 MG PO TABS BOTH IP/OP $13.62 $10.08 $0.00 $9.88 $0.00 $0.00 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4398 ERX HCPCS 63700001 00555-0484-01 LEUCOVORIN CALCIUM 5 MG PO TABS BOTH IP/OP $13.62 $10.08 $0.00 $9.88 $0.00 $0.00 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4398 ERX HCPCS 63700001 51079-0581-01 LEUCOVORIN CALCIUM 5 MG PO TABS BOTH IP/OP $13.62 $10.08 $0.00 $9.88 $0.00 $0.00 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4398 ERX HCPCS 63700001 51079-0581-06 LEUCOVORIN CALCIUM 5 MG PO TABS BOTH IP/OP $13.62 $10.08 $0.00 $9.88 $0.00 $0.00 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $6.18 $9.78 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4420 ERX HCPCS 63700001 00378-1800-77 LEVOTHYROXINE SODIUM 25 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4420 ERX HCPCS 63700001 00781-5180-92 LEVOTHYROXINE SODIUM 25 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4420 ERX HCPCS 63700001 51079-0444-20 LEVOTHYROXINE SODIUM 25 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4421 ERX HCPCS 63700001 00378-1803-77 LEVOTHYROXINE SODIUM 50 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4421 ERX HCPCS 63700001 00781-5181-92 LEVOTHYROXINE SODIUM 50 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4421 ERX HCPCS 63700001 51079-0440-20 LEVOTHYROXINE SODIUM 50 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4422 ERX HCPCS 63700001 00378-1805-77 LEVOTHYROXINE SODIUM 75 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4422 ERX HCPCS 63700001 00781-5182-92 LEVOTHYROXINE SODIUM 75 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4422 ERX HCPCS 63700001 51079-0441-20 LEVOTHYROXINE SODIUM 75 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4423 ERX HCPCS 63700001 00781-5184-92 LEVOTHYROXINE SODIUM 100 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4423 ERX HCPCS 63700001 51079-0442-20 LEVOTHYROXINE SODIUM 100 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4424 ERX HCPCS 63700001 00781-5186-92 LEVOTHYROXINE SODIUM 125 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4424 ERX HCPCS 63700001 51079-0443-20 LEVOTHYROXINE SODIUM 125 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4425 ERX HCPCS 63700001 00378-1815-77 LEVOTHYROXINE SODIUM 150 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4425 ERX HCPCS 63700001 00781-5187-92 LEVOTHYROXINE SODIUM 150 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4426 ERX HCPCS 63700001 00781-5189-92 LEVOTHYROXINE SODIUM 200 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4450 ERX HCPCS 25000001 00054-3505-47 LIDOCAINE HCL 4 % EX SOLN BOTH IP/OP $185.28 $137.11 $0.00 $142.81 $0.00 $0.00 $0.00 $0.00 $0.00 $137.51 $137.51 $142.81 $0.00 $38.61 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4451 ERX HCPCS 25000001 00409-4275-01 LIDOCAINE HCL 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4451 ERX HCPCS 25000001 63323-0484-57 LIDOCAINE HCL 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4452 ERX HCPCS 25000001 00409-4276-01 LIDOCAINE HCL 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4452 ERX HCPCS 25000001 00409-4276-16 LIDOCAINE HCL 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4452 ERX HCPCS 25000001 55150-0252-20 LIDOCAINE HCL 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4452 ERX HCPCS 25000001 63323-0485-27 LIDOCAINE HCL 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4454 ERX HCPCS 25000001 00409-4277-01 LIDOCAINE HCL 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4454 ERX HCPCS 25000001 00409-4277-16 LIDOCAINE HCL 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4454 ERX HCPCS 25000001 55150-0254-10 LIDOCAINE HCL 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4454 ERX HCPCS 25000001 55150-0255-20 LIDOCAINE HCL 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4454 ERX HCPCS 25000001 63323-0202-02 LIDOCAINE HCL 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4454 ERX HCPCS 25000001 63323-0486-17 LIDOCAINE HCL 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4454 ERX HCPCS 25000001 63323-0486-27 LIDOCAINE HCL 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4498 ERX HCPCS 25000001 60432-0834-60 LINDANE 1 % EX SHAM BOTH IP/OP $459.85 $340.29 $0.00 $354.45 $0.00 $0.00 $0.00 $0.00 $0.00 $341.30 $341.30 $354.45 $0.00 $95.83 $0.00 $0.00 $0.00 $0.00 $208.72 $330.60 $333.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4504 ERX HCPCS 63700001 59762-1207-01 LIOTHYRONINE SODIUM 25 MCG PO TABS BOTH IP/OP $13.24 $9.80 $0.00 $9.19 $0.00 $0.00 $0.00 $2.36 $0.00 $0.00 $0.00 $0.00 $0.00 $2.76 $0.00 $0.00 $0.00 $0.00 $5.75 $9.10 $9.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4504 ERX HCPCS 63700001 60793-0116-01 LIOTHYRONINE SODIUM 25 MCG PO TABS BOTH IP/OP $13.24 $9.80 $0.00 $9.19 $0.00 $0.00 $0.00 $2.36 $0.00 $0.00 $0.00 $0.00 $0.00 $2.76 $0.00 $0.00 $0.00 $0.00 $5.75 $9.10 $9.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4526 ERX HCPCS 63700001 00904-6799-61 LISINOPRIL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4526 ERX HCPCS 63700001 43547-0354-10 LISINOPRIL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4526 ERX HCPCS 63700001 60687-0333-01 LISINOPRIL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4526 ERX HCPCS 63700001 63739-0350-10 LISINOPRIL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4529 ERX HCPCS 63700001 00054-2527-25 LITHIUM CARBONATE 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4529 ERX HCPCS 63700001 00054-8527-25 LITHIUM CARBONATE 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4560 ERX HCPCS 63700001 00093-0311-01 LOPERAMIDE HCL 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4560 ERX HCPCS 63700001 51079-0690-01 LOPERAMIDE HCL 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4560 ERX HCPCS 63700001 51079-0690-20 LOPERAMIDE HCL 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4560 ERX HCPCS 63700001 60687-0229-01 LOPERAMIDE HCL 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4571 ERX HCPCS 25000001 00054-3532-44 LORAZEPAM 2 MG/ML PO CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4571 ERX HCPCS 25000001 00121-0770-01 LORAZEPAM 2 MG/ML PO CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4571 ERX HCPCS 25000001 50383-0705-30 LORAZEPAM 2 MG/ML PO CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4571 ERX HCPCS 25000001 99999-6007-84 LORAZEPAM 2 MG/ML PO CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4572 ERX HCPCS 25000001 69315-0904-01 LORAZEPAM 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4573 ERX HCPCS 25000001 00591-0241-01 LORAZEPAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4573 ERX HCPCS 25000001 00904-6008-60 LORAZEPAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4573 ERX HCPCS 25000001 00904-6008-61 LORAZEPAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4573 ERX HCPCS 25000001 69315-0905-01 LORAZEPAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4574 ERX HCPCS 25000001 00591-0242-01 LORAZEPAM 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4574 ERX HCPCS 25000001 00591-0242-05 LORAZEPAM 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4574 ERX HCPCS 25000001 00904-6009-61 LORAZEPAM 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4574 ERX HCPCS 25000001 60687-0367-01 LORAZEPAM 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4574 ERX HCPCS 25000001 60687-0367-11 LORAZEPAM 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4599 ERX HCPCS 63700001 00527-1395-01 LOXAPINE SUCCINATE 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4600 ERX HCPCS 63700001 00591-0371-01 LOXAPINE SUCCINATE 25 MG PO CAPS BOTH IP/OP $7.32 $5.42 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.66 $5.80 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4602 ERX HCPCS 63700001 00378-7050-01 LOXAPINE SUCCINATE 50 MG PO CAPS BOTH IP/OP $10.78 $7.98 $0.00 $7.82 $0.00 $0.00 $0.00 $1.92 $0.00 $0.00 $0.00 $0.00 $0.00 $2.25 $0.00 $0.00 $0.00 $0.00 $4.89 $7.75 $7.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4602 ERX HCPCS 63700001 00591-0372-01 LOXAPINE SUCCINATE 50 MG PO CAPS BOTH IP/OP $10.78 $7.98 $0.00 $7.82 $0.00 $0.00 $0.00 $1.92 $0.00 $0.00 $0.00 $0.00 $0.00 $2.25 $0.00 $0.00 $0.00 $0.00 $4.89 $7.75 $7.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4711 ERX HCPCS 63700001 00869-0686-38 MAGNESIUM CITRATE 58 MG/ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4711 ERX HCPCS 63700001 00904-6787-44 MAGNESIUM CITRATE 58 MG/ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4711 ERX HCPCS 63700001 49348-0504-49 MAGNESIUM CITRATE 58 MG/ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4711 ERX HCPCS 63700001 49348-0696-49 MAGNESIUM CITRATE 58 MG/ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4711 ERX HCPCS 63700001 70677-0051-01 MAGNESIUM CITRATE 58 MG/ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4711 ERX HCPCS 63700001 70677-0053-01 MAGNESIUM CITRATE 58 MG/ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4715 ERX HCPCS 63700001 59016-0420-17 MAGNESIUM LACTATE 84 MG (7MEQ) PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4720 ERX HCPCS J3475 51754-1000-04 MAGNESIUM SULFATE 50 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $1.77 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.48 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 4720 ERX HCPCS J3475 63323-0064-03 MAGNESIUM SULFATE 50 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $1.77 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.48 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 4720 ERX HCPCS J3475 63323-0064-11 MAGNESIUM SULFATE 50 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $1.77 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.48 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 4720 ERX HCPCS J3475 63323-0642-20 MAGNESIUM SULFATE 50 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $1.77 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.48 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 4720 ERX HCPCS J3475 63323-0642-50 MAGNESIUM SULFATE 50 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $1.77 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.48 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 4744 ERX HCPCS 25000001 00409-4091-01 MANGANESE CHLORIDE 0.1 MG/ML IV SOLN BOTH IP/OP $115.65 $85.58 $0.00 $89.14 $0.00 $0.00 $0.00 $0.00 $0.00 $85.84 $85.84 $89.14 $0.00 $24.10 $0.00 $0.00 $0.00 $0.00 $48.23 $76.40 $77.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4749 ERX HCPCS 25000001 00264-7578-10 MANNITOL 20 % IV SOLN BOTH IP/OP $108.57 $80.34 $0.00 $83.69 $0.00 $0.00 $0.00 $0.00 $0.00 $80.58 $80.58 $83.69 $0.00 $22.63 $0.00 $0.00 $0.00 $0.00 $45.94 $72.77 $73.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4749 ERX HCPCS 25000001 00338-0357-02 MANNITOL 20 % IV SOLN BOTH IP/OP $108.57 $80.34 $0.00 $83.69 $0.00 $0.00 $0.00 $0.00 $0.00 $80.58 $80.58 $83.69 $0.00 $22.63 $0.00 $0.00 $0.00 $0.00 $45.94 $72.77 $73.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4749 ERX HCPCS 25000001 00338-0357-03 MANNITOL 20 % IV SOLN BOTH IP/OP $108.57 $80.34 $0.00 $83.69 $0.00 $0.00 $0.00 $0.00 $0.00 $80.58 $80.58 $83.69 $0.00 $22.63 $0.00 $0.00 $0.00 $0.00 $45.94 $72.77 $73.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4750 ERX HCPCS J2150 00409-4031-01 MANNITOL 25 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $2.96 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4750 ERX HCPCS J2150 63323-0024-25 MANNITOL 25 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $2.96 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4759 ERX HCPCS 63700001 00378-0060-01 MAPROTILINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4760 ERX HCPCS 63700001 00378-0087-01 MAPROTILINE HCL 50 MG PO TABS BOTH IP/OP $6.50 $4.81 $0.00 $5.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.25 $5.15 $5.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4822 ERX HCPCS 63700001 00536-1018-01 MECLIZINE HCL 25 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4854 ERX HCPCS 63700001 00555-0779-02 MEDROXYPROGESTERONE ACETATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4855 ERX HCPCS 63700001 00555-0872-02 MEDROXYPROGESTERONE ACETATE 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4856 ERX HCPCS 63700001 00555-0873-02 MEDROXYPROGESTERONE ACETATE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4871 ERX HCPCS 63700001 00904-3571-61 MEGESTROL ACETATE 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4871 ERX HCPCS 63700001 49884-0290-01 MEGESTROL ACETATE 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4871 ERX HCPCS 63700001 63739-0165-10 MEGESTROL ACETATE 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4903 ERX HCPCS J2175 00409-1176-03 MEPERIDINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.67 $16.33 $16.33 $16.96 $0.00 $7.61 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.55 $0.00 $0.00 $5.28 $0.00 $0.00 $0.00 $0.00 $0.00 4903 ERX HCPCS J2175 00409-1176-30 MEPERIDINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.67 $16.33 $16.33 $16.96 $0.00 $7.61 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.55 $0.00 $0.00 $5.28 $0.00 $0.00 $0.00 $0.00 $0.00 4903 ERX HCPCS J2175 00641-6052-25 MEPERIDINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.67 $16.33 $16.33 $16.96 $0.00 $7.61 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.55 $0.00 $0.00 $5.28 $0.00 $0.00 $0.00 $0.00 $0.00 4904 ERX HCPCS J2175 00641-6053-25 MEPERIDINE HCL 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.67 $16.33 $16.33 $16.96 $0.00 $7.61 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.55 $0.00 $0.00 $5.28 $0.00 $0.00 $0.00 $0.00 $0.00 4905 ERX HCPCS J2175 00409-1179-03 MEPERIDINE HCL 75 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.67 $16.33 $16.33 $16.96 $0.00 $7.61 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.55 $0.00 $0.00 $5.28 $0.00 $0.00 $0.00 $0.00 $0.00 4905 ERX HCPCS J2175 00409-1179-30 MEPERIDINE HCL 75 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.67 $16.33 $16.33 $16.96 $0.00 $7.61 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.55 $0.00 $0.00 $5.28 $0.00 $0.00 $0.00 $0.00 $0.00 4914 ERX HCPCS J0670 00409-1038-50 MEPIVACAINE HCL 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.24 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4915 ERX HCPCS J0670 00409-2047-50 MEPIVACAINE HCL 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4952 ERX HCPCS 63700001 00054-3555-63 METHADONE HCL 5 MG/5ML PO SOLN BOTH IP/OP $39.60 $29.30 $0.00 $28.73 $0.00 $0.00 $0.00 $7.05 $0.00 $0.00 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $17.96 $28.44 $28.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4952 ERX HCPCS 63700001 66689-0711-16 METHADONE HCL 5 MG/5ML PO SOLN BOTH IP/OP $39.60 $29.30 $0.00 $28.73 $0.00 $0.00 $0.00 $7.05 $0.00 $0.00 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $17.96 $28.44 $28.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4952 ERX HCPCS 63700001 99999-6011-43 METHADONE HCL 5 MG/5ML PO SOLN BOTH IP/OP $39.60 $29.30 $0.00 $28.73 $0.00 $0.00 $0.00 $7.05 $0.00 $0.00 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $17.96 $28.44 $28.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4953 ERX HCPCS 63700001 00054-8554-24 METHADONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4953 ERX HCPCS 63700001 00406-5771-62 METHADONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4954 ERX HCPCS 63700001 00054-4570-25 METHADONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4954 ERX HCPCS 63700001 00054-8553-24 METHADONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4954 ERX HCPCS 63700001 00406-5755-23 METHADONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4954 ERX HCPCS 63700001 00406-5755-62 METHADONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4962 ERX HCPCS 63700001 00574-0791-01 METHAZOLAMIDE 50 MG PO TABS BOTH IP/OP $29.12 $21.55 $0.00 $23.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.56 $23.06 $23.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4962 ERX HCPCS 63700001 00781-1071-01 METHAZOLAMIDE 50 MG PO TABS BOTH IP/OP $29.12 $21.55 $0.00 $23.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.56 $23.06 $23.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4962 ERX HCPCS 63700001 62559-0241-01 METHAZOLAMIDE 50 MG PO TABS BOTH IP/OP $29.12 $21.55 $0.00 $23.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.56 $23.06 $23.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4966 ERX HCPCS 63700001 13925-0107-01 METHENAMINE MANDELATE 1 G PO TABS BOTH IP/OP $9.94 $7.36 $0.00 $7.21 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $0.00 $2.07 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4971 ERX HCPCS 63700001 76385-0123-50 METHOCARBAMOL 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4972 ERX HCPCS 63700001 31722-0534-01 METHOCARBAMOL 750 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4973 ERX HCPCS J8610 00054-4550-25 METHOTREXATE 2.5 MG PO TABS BOTH IP/OP $78.44 $58.05 $0.00 $60.46 $35.30 $35.30 $0.00 $0.00 $0.00 $16.35 $58.22 $58.22 $60.46 $0.00 $16.35 $0.00 $46.40 $46.40 $0.00 $35.57 $56.34 $56.91 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4973 ERX HCPCS J8610 00054-8550-25 METHOTREXATE 2.5 MG PO TABS BOTH IP/OP $78.44 $58.05 $0.00 $60.46 $35.30 $35.30 $0.00 $0.00 $0.00 $16.35 $58.22 $58.22 $60.46 $0.00 $16.35 $0.00 $46.40 $46.40 $0.00 $35.57 $56.34 $56.91 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4973 ERX HCPCS J8610 00378-0014-01 METHOTREXATE 2.5 MG PO TABS BOTH IP/OP $78.44 $58.05 $0.00 $60.46 $35.30 $35.30 $0.00 $0.00 $0.00 $16.35 $58.22 $58.22 $60.46 $0.00 $16.35 $0.00 $46.40 $46.40 $0.00 $35.57 $56.34 $56.91 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4973 ERX HCPCS J8610 00555-0572-02 METHOTREXATE 2.5 MG PO TABS BOTH IP/OP $78.44 $58.05 $0.00 $60.46 $35.30 $35.30 $0.00 $0.00 $0.00 $16.35 $58.22 $58.22 $60.46 $0.00 $16.35 $0.00 $46.40 $46.40 $0.00 $35.57 $56.34 $56.91 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4973 ERX HCPCS J8610 51079-0670-01 METHOTREXATE 2.5 MG PO TABS BOTH IP/OP $78.44 $58.05 $0.00 $60.46 $35.30 $35.30 $0.00 $0.00 $0.00 $16.35 $58.22 $58.22 $60.46 $0.00 $16.35 $0.00 $46.40 $46.40 $0.00 $35.57 $56.34 $56.91 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4973 ERX HCPCS J8610 51079-0670-05 METHOTREXATE 2.5 MG PO TABS BOTH IP/OP $78.44 $58.05 $0.00 $60.46 $35.30 $35.30 $0.00 $0.00 $0.00 $16.35 $58.22 $58.22 $60.46 $0.00 $16.35 $0.00 $46.40 $46.40 $0.00 $35.57 $56.34 $56.91 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4986 ERX HCPCS 63700001 00406-1144-01 METHYLPHENIDATE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4986 ERX HCPCS 63700001 10702-0101-01 METHYLPHENIDATE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4986 ERX HCPCS 63700001 65580-0530-01 METHYLPHENIDATE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4988 ERX HCPCS 63700001 00406-1142-01 METHYLPHENIDATE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4988 ERX HCPCS 63700001 00781-5748-01 METHYLPHENIDATE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4988 ERX HCPCS 63700001 16714-0821-01 METHYLPHENIDATE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4991 ERX HCPCS J7509 00781-5022-07 METHYLPREDNISOLONE 4 MG PO TBPK BOTH IP/OP $115.92 $85.78 $0.00 $89.35 $52.16 $52.16 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $89.35 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $52.56 $83.25 $84.09 $0.00 $0.00 $16.45 $0.00 $0.00 $16.73 $0.00 $0.00 $0.00 $0.00 $0.00 4992 ERX HCPCS J7509 00009-0073-01 METHYLPREDNISOLONE 16 MG PO TABS BOTH IP/OP $14.46 $10.70 $0.00 $11.15 $6.51 $6.51 $0.00 $0.00 $0.00 $3.01 $10.73 $10.73 $11.15 $0.00 $3.01 $0.00 $8.55 $8.55 $0.00 $6.46 $10.23 $10.34 $0.00 $0.00 $2.02 $0.00 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $0.00 4992 ERX HCPCS J7509 59746-0003-14 METHYLPREDNISOLONE 16 MG PO TABS BOTH IP/OP $14.46 $10.70 $0.00 $11.15 $6.51 $6.51 $0.00 $0.00 $0.00 $3.01 $10.73 $10.73 $11.15 $0.00 $3.01 $0.00 $8.55 $8.55 $0.00 $6.46 $10.23 $10.34 $0.00 $0.00 $2.02 $0.00 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $0.00 4992 ERX HCPCS J7509 59762-0050-01 METHYLPREDNISOLONE 16 MG PO TABS BOTH IP/OP $14.46 $10.70 $0.00 $11.15 $6.51 $6.51 $0.00 $0.00 $0.00 $3.01 $10.73 $10.73 $11.15 $0.00 $3.01 $0.00 $8.55 $8.55 $0.00 $6.46 $10.23 $10.34 $0.00 $0.00 $2.02 $0.00 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $0.00 4993 ERX HCPCS J7509 00781-5022-01 METHYLPREDNISOLONE 4 MG PO TABS BOTH IP/OP $6.92 $5.12 $0.00 $5.33 $3.11 $3.11 $0.00 $0.00 $0.00 $1.44 $5.14 $5.14 $5.33 $0.00 $1.44 $0.00 $4.09 $4.09 $0.00 $3.14 $4.97 $5.02 $0.00 $0.00 $0.98 $0.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $0.00 4993 ERX HCPCS J7509 59746-0001-06 METHYLPREDNISOLONE 4 MG PO TABS BOTH IP/OP $6.92 $5.12 $0.00 $5.33 $3.11 $3.11 $0.00 $0.00 $0.00 $1.44 $5.14 $5.14 $5.33 $0.00 $1.44 $0.00 $4.09 $4.09 $0.00 $3.14 $4.97 $5.02 $0.00 $0.00 $0.98 $0.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $0.00 4993 ERX HCPCS J7509 68084-0149-01 METHYLPREDNISOLONE 4 MG PO TABS BOTH IP/OP $6.92 $5.12 $0.00 $5.33 $3.11 $3.11 $0.00 $0.00 $0.00 $1.44 $5.14 $5.14 $5.33 $0.00 $1.44 $0.00 $4.09 $4.09 $0.00 $3.14 $4.97 $5.02 $0.00 $0.00 $0.98 $0.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $0.00 4993 ERX HCPCS J7509 68084-0149-11 METHYLPREDNISOLONE 4 MG PO TABS BOTH IP/OP $6.92 $5.12 $0.00 $5.33 $3.11 $3.11 $0.00 $0.00 $0.00 $1.44 $5.14 $5.14 $5.33 $0.00 $1.44 $0.00 $4.09 $4.09 $0.00 $3.14 $4.97 $5.02 $0.00 $0.00 $0.98 $0.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $0.00 4995 ERX HCPCS J1030 00009-3073-01 METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP BOTH IP/OP $26.70 $19.76 $0.00 $20.58 $12.02 $12.02 $0.00 $0.00 $0.00 $4.86 $19.82 $19.82 $20.58 $0.00 $6.61 $0.00 $15.79 $15.79 $0.00 $12.05 $19.09 $19.28 $0.00 $0.00 $7.39 $0.00 $0.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 4995 ERX HCPCS J1030 00009-3073-03 METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP BOTH IP/OP $26.70 $19.76 $0.00 $20.58 $12.02 $12.02 $0.00 $0.00 $0.00 $4.86 $19.82 $19.82 $20.58 $0.00 $6.61 $0.00 $15.79 $15.79 $0.00 $12.05 $19.09 $19.28 $0.00 $0.00 $7.39 $0.00 $0.00 $7.04 $0.00 $0.00 $0.00 $0.00 $0.00 5002 ERX HCPCS J2765 00409-3414-01 METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $1.32 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 5002 ERX HCPCS J2765 00409-3414-18 METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $1.32 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 5002 ERX HCPCS J2765 00703-4502-04 METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $1.32 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 5005 ERX HCPCS 25000001 00093-2203-01 METOCLOPRAMIDE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 ERX HCPCS 25000001 00093-2203-05 METOCLOPRAMIDE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 ERX HCPCS 25000001 51079-0888-20 METOCLOPRAMIDE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 ERX HCPCS 25000001 63739-0293-10 METOCLOPRAMIDE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 ERX HCPCS 25000001 68084-0676-01 METOCLOPRAMIDE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 ERX HCPCS 25000001 68084-0676-11 METOCLOPRAMIDE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5009 ERX HCPCS 63700001 51079-0801-01 METOPROLOL TARTRATE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5009 ERX HCPCS 63700001 51079-0801-20 METOPROLOL TARTRATE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5009 ERX HCPCS 63700001 57664-0477-52 METOPROLOL TARTRATE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5009 ERX HCPCS 63700001 62584-0266-01 METOPROLOL TARTRATE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5009 ERX HCPCS 63700001 62584-0266-11 METOPROLOL TARTRATE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5009 ERX HCPCS 63700001 65862-0063-01 METOPROLOL TARTRATE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5015 ERX HCPCS 63700001 00904-1453-61 METRONIDAZOLE 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5015 ERX HCPCS 63700001 50111-0333-01 METRONIDAZOLE 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5015 ERX HCPCS 63700001 50111-0333-02 METRONIDAZOLE 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016 ERX HCPCS 63700001 29300-0227-01 METRONIDAZOLE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016 ERX HCPCS 63700001 29300-0227-05 METRONIDAZOLE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016 ERX HCPCS 63700001 29300-0227-46 METRONIDAZOLE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016 ERX HCPCS 63700001 50111-0334-01 METRONIDAZOLE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016 ERX HCPCS 63700001 50268-0535-11 METRONIDAZOLE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016 ERX HCPCS 63700001 50268-0535-15 METRONIDAZOLE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016 ERX HCPCS 63700001 60687-0550-01 METRONIDAZOLE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018 ERX HCPCS 25000001 00338-1055-48 METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018 ERX HCPCS 25000001 00409-7811-24 METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018 ERX HCPCS 25000001 00409-7811-37 METRONIDAZOLE IN NACL 5-0.79 MG/ML-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5039 ERX HCPCS 63700001 00472-0735-56 MICONAZOLE NITRATE 2 % EX CREA BOTH IP/OP $22.13 $16.38 $0.00 $16.06 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.61 $0.00 $0.00 $0.00 $0.00 $10.04 $15.90 $16.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5039 ERX HCPCS 63700001 49348-0689-72 MICONAZOLE NITRATE 2 % EX CREA BOTH IP/OP $22.13 $16.38 $0.00 $16.06 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.61 $0.00 $0.00 $0.00 $0.00 $10.04 $15.90 $16.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5039 ERX HCPCS 63700001 51672-2001-02 MICONAZOLE NITRATE 2 % EX CREA BOTH IP/OP $22.13 $16.38 $0.00 $16.06 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.61 $0.00 $0.00 $0.00 $0.00 $10.04 $15.90 $16.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5086 ERX HCPCS 25000001 00869-0831-43 MINERAL OIL PO OIL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5086 ERX HCPCS 25000001 00869-4206-10 MINERAL OIL PO OIL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5086 ERX HCPCS 25000001 48433-0202-30 MINERAL OIL PO OIL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5086 ERX HCPCS 25000001 54162-0190-16 MINERAL OIL PO OIL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5086 ERX HCPCS 25000001 99999-6007-83 MINERAL OIL PO OIL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5110 ERX HCPCS 63700001 00591-5695-50 MINOCYCLINE HCL 100 MG PO CAPS BOTH IP/OP $14.24 $10.54 $0.00 $10.33 $0.00 $0.00 $0.00 $2.53 $0.00 $0.00 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $0.00 $0.00 $6.46 $10.22 $10.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5110 ERX HCPCS 63700001 65862-0211-50 MINOCYCLINE HCL 100 MG PO CAPS BOTH IP/OP $14.24 $10.54 $0.00 $10.33 $0.00 $0.00 $0.00 $2.53 $0.00 $0.00 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $0.00 $0.00 $6.46 $10.22 $10.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5111 ERX HCPCS 63700001 00591-5694-01 MINOCYCLINE HCL 50 MG PO CAPS BOTH IP/OP $7.12 $5.27 $0.00 $5.17 $0.00 $0.00 $0.00 $1.27 $0.00 $0.00 $0.00 $0.00 $0.00 $1.48 $0.00 $0.00 $0.00 $0.00 $3.23 $5.12 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5111 ERX HCPCS 63700001 63304-0694-01 MINOCYCLINE HCL 50 MG PO CAPS BOTH IP/OP $7.12 $5.27 $0.00 $5.17 $0.00 $0.00 $0.00 $1.27 $0.00 $0.00 $0.00 $0.00 $0.00 $1.48 $0.00 $0.00 $0.00 $0.00 $3.23 $5.12 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5111 ERX HCPCS 63700001 65862-0209-01 MINOCYCLINE HCL 50 MG PO CAPS BOTH IP/OP $7.12 $5.27 $0.00 $5.17 $0.00 $0.00 $0.00 $1.27 $0.00 $0.00 $0.00 $0.00 $0.00 $1.48 $0.00 $0.00 $0.00 $0.00 $3.23 $5.12 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5114 ERX HCPCS 63700001 68084-0205-01 MINOXIDIL 10 MG PO TABS BOTH IP/OP $8.89 $6.58 $0.00 $6.45 $0.00 $0.00 $0.00 $1.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $4.03 $6.38 $6.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5114 ERX HCPCS 63700001 68084-0205-11 MINOXIDIL 10 MG PO TABS BOTH IP/OP $8.89 $6.58 $0.00 $6.45 $0.00 $0.00 $0.00 $1.58 $0.00 $0.00 $0.00 $0.00 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $4.03 $6.38 $6.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5115 ERX HCPCS 63700001 00591-5642-01 MINOXIDIL 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5115 ERX HCPCS 63700001 49884-0256-01 MINOXIDIL 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5115 ERX HCPCS 63700001 68084-0204-01 MINOXIDIL 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5115 ERX HCPCS 63700001 68084-0204-11 MINOXIDIL 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5170 ERX HCPCS J2270 76045-0004-10 MORPHINE SULFATE 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 5172 ERX HCPCS J2270 76045-0005-10 MORPHINE SULFATE 4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.42 $0.00 $0.00 $0.00 $2.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5176 ERX HCPCS 25000001 00054-0237-63 MORPHINE SULFATE 10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5176 ERX HCPCS 25000001 66689-0032-50 MORPHINE SULFATE 10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5176 ERX HCPCS 25000001 68094-0001-62 MORPHINE SULFATE 10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5176 ERX HCPCS 25000001 99999-6007-18 MORPHINE SULFATE 10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5178 ERX HCPCS 25000001 00054-0235-24 MORPHINE SULFATE 15 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5178 ERX HCPCS 25000001 00054-0235-25 MORPHINE SULFATE 15 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5179 ERX HCPCS 25000001 00054-0236-25 MORPHINE SULFATE 30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5180 ERX HCPCS 25000001 00574-7112-12 MORPHINE SULFATE 10 MG RECTAL SUPP BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5330 ERX HCPCS 63700001 51079-0812-20 NADOLOL 20 MG PO TABS BOTH IP/OP $19.53 $14.45 $0.00 $14.17 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5330 ERX HCPCS 63700001 69238-1123-09 NADOLOL 20 MG PO TABS BOTH IP/OP $19.53 $14.45 $0.00 $14.17 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5331 ERX HCPCS 63700001 51079-0813-01 NADOLOL 40 MG PO TABS BOTH IP/OP $30.30 $22.42 $0.00 $21.98 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.74 $21.76 $21.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5331 ERX HCPCS 63700001 51079-0813-20 NADOLOL 40 MG PO TABS BOTH IP/OP $30.30 $22.42 $0.00 $21.98 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.74 $21.76 $21.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5331 ERX HCPCS 63700001 59762-0811-01 NADOLOL 40 MG PO TABS BOTH IP/OP $30.30 $22.42 $0.00 $21.98 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.74 $21.76 $21.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5331 ERX HCPCS 63700001 69097-0868-07 NADOLOL 40 MG PO TABS BOTH IP/OP $30.30 $22.42 $0.00 $21.98 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.74 $21.76 $21.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5331 ERX HCPCS 63700001 69238-1124-09 NADOLOL 40 MG PO TABS BOTH IP/OP $30.30 $22.42 $0.00 $21.98 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.74 $21.76 $21.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5332 ERX HCPCS 63700001 69097-0869-07 NADOLOL 80 MG PO TABS BOTH IP/OP $31.39 $23.23 $0.00 $22.78 $0.00 $0.00 $0.00 $5.59 $0.00 $0.00 $0.00 $0.00 $0.00 $6.54 $0.00 $0.00 $0.00 $0.00 $14.24 $22.55 $22.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5332 ERX HCPCS 63700001 69238-1125-09 NADOLOL 80 MG PO TABS BOTH IP/OP $31.39 $23.23 $0.00 $22.78 $0.00 $0.00 $0.00 $5.59 $0.00 $0.00 $0.00 $0.00 $0.00 $6.54 $0.00 $0.00 $0.00 $0.00 $14.24 $22.55 $22.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5333 ERX HCPCS 25000001 00781-3124-85 NAFCILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $60.76 $44.96 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $0.00 $45.10 $45.10 $46.83 $0.00 $12.66 $0.00 $0.00 $0.00 $0.00 $27.55 $43.64 $44.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5333 ERX HCPCS 25000001 00781-3124-95 NAFCILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $60.76 $44.96 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $0.00 $45.10 $45.10 $46.83 $0.00 $12.66 $0.00 $0.00 $0.00 $0.00 $27.55 $43.64 $44.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5333 ERX HCPCS 25000001 25021-0139-10 NAFCILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $60.76 $44.96 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $0.00 $45.10 $45.10 $46.83 $0.00 $12.66 $0.00 $0.00 $0.00 $0.00 $27.55 $43.64 $44.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5333 ERX HCPCS 25000001 44567-0221-10 NAFCILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $60.76 $44.96 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $0.00 $45.10 $45.10 $46.83 $0.00 $12.66 $0.00 $0.00 $0.00 $0.00 $27.55 $43.64 $44.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5333 ERX HCPCS 25000001 55150-0122-15 NAFCILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $60.76 $44.96 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $0.00 $45.10 $45.10 $46.83 $0.00 $12.66 $0.00 $0.00 $0.00 $0.00 $27.55 $43.64 $44.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5333 ERX HCPCS 25000001 63323-0327-10 NAFCILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $60.76 $44.96 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $0.00 $45.10 $45.10 $46.83 $0.00 $12.66 $0.00 $0.00 $0.00 $0.00 $27.55 $43.64 $44.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5333 ERX HCPCS 25000001 70860-0116-26 NAFCILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $60.76 $44.96 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $0.00 $45.10 $45.10 $46.83 $0.00 $12.66 $0.00 $0.00 $0.00 $0.00 $27.55 $43.64 $44.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5333 ERX HCPCS 25000001 70860-0116-41 NAFCILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $60.76 $44.96 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $0.00 $45.10 $45.10 $46.83 $0.00 $12.66 $0.00 $0.00 $0.00 $0.00 $27.55 $43.64 $44.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5335 ERX HCPCS 25000001 25021-0140-10 NAFCILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $109.15 $80.77 $0.00 $84.13 $0.00 $0.00 $0.00 $0.00 $0.00 $81.01 $81.01 $84.13 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $49.49 $78.38 $79.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5335 ERX HCPCS 25000001 44567-0222-10 NAFCILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $109.15 $80.77 $0.00 $84.13 $0.00 $0.00 $0.00 $0.00 $0.00 $81.01 $81.01 $84.13 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $49.49 $78.38 $79.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5335 ERX HCPCS 25000001 55150-0123-15 NAFCILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $109.15 $80.77 $0.00 $84.13 $0.00 $0.00 $0.00 $0.00 $0.00 $81.01 $81.01 $84.13 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $49.49 $78.38 $79.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5335 ERX HCPCS 25000001 55150-0123-16 NAFCILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $109.15 $80.77 $0.00 $84.13 $0.00 $0.00 $0.00 $0.00 $0.00 $81.01 $81.01 $84.13 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $49.49 $78.38 $79.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5335 ERX HCPCS 25000001 63323-0328-20 NAFCILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $109.15 $80.77 $0.00 $84.13 $0.00 $0.00 $0.00 $0.00 $0.00 $81.01 $81.01 $84.13 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $49.49 $78.38 $79.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5335 ERX HCPCS 25000001 70860-0117-26 NAFCILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $109.15 $80.77 $0.00 $84.13 $0.00 $0.00 $0.00 $0.00 $0.00 $81.01 $81.01 $84.13 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $49.49 $78.38 $79.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5335 ERX HCPCS 25000001 70860-0117-41 NAFCILLIN SODIUM 2 G IJ SOLR BOTH IP/OP $109.15 $80.77 $0.00 $84.13 $0.00 $0.00 $0.00 $0.00 $0.00 $81.01 $81.01 $84.13 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $49.49 $78.38 $79.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5339 ERX HCPCS J2300 00409-1463-01 NALBUPHINE HCL 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.22 $16.33 $16.33 $16.96 $0.00 $3.35 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.70 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 5339 ERX HCPCS J2300 00409-1463-49 NALBUPHINE HCL 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.22 $16.33 $16.33 $16.96 $0.00 $3.35 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.70 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 5339 ERX HCPCS J2300 00409-1464-01 NALBUPHINE HCL 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.22 $16.33 $16.33 $16.96 $0.00 $3.35 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.70 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 5339 ERX HCPCS J2300 99999-6005-73 NALBUPHINE HCL 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.22 $16.33 $16.33 $16.96 $0.00 $3.35 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.70 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 5340 ERX HCPCS J2300 00409-1465-01 NALBUPHINE HCL 20 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.22 $16.33 $16.33 $16.96 $0.00 $3.35 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.70 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 5340 ERX HCPCS J2300 00409-1467-01 NALBUPHINE HCL 20 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.22 $16.33 $16.33 $16.96 $0.00 $3.35 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.70 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 5373 ERX HCPCS J2310 00409-1215-01 NALOXONE HCL 0.4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.37 $16.33 $16.33 $16.96 $0.00 $12.85 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $15.60 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 5373 ERX HCPCS J2310 00409-1215-21 NALOXONE HCL 0.4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.37 $16.33 $16.33 $16.96 $0.00 $12.85 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $15.60 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 5373 ERX HCPCS J2310 00641-6132-25 NALOXONE HCL 0.4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.37 $16.33 $16.33 $16.96 $0.00 $12.85 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $15.60 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 5373 ERX HCPCS J2310 67457-0292-00 NALOXONE HCL 0.4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.37 $16.33 $16.33 $16.96 $0.00 $12.85 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $15.60 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 5373 ERX HCPCS J2310 67457-0292-02 NALOXONE HCL 0.4 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.37 $16.33 $16.33 $16.96 $0.00 $12.85 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $15.60 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 5384 ERX HCPCS 25000001 00065-0085-15 NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % OP SOLN BOTH IP/OP $62.85 $46.51 $0.00 $48.44 $0.00 $0.00 $0.00 $0.00 $0.00 $46.65 $46.65 $48.44 $0.00 $13.10 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5384 ERX HCPCS 25000001 12547-0493-78 NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % OP SOLN BOTH IP/OP $62.85 $46.51 $0.00 $48.44 $0.00 $0.00 $0.00 $0.00 $0.00 $46.65 $46.65 $48.44 $0.00 $13.10 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5384 ERX HCPCS 25000001 69968-0063-01 NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % OP SOLN BOTH IP/OP $62.85 $46.51 $0.00 $48.44 $0.00 $0.00 $0.00 $0.00 $0.00 $46.65 $46.65 $48.44 $0.00 $13.10 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5391 ERX HCPCS 63700001 50268-0594-15 NAPROXEN 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5391 ERX HCPCS 63700001 51079-0793-01 NAPROXEN 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5391 ERX HCPCS 63700001 51079-0793-20 NAPROXEN 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5391 ERX HCPCS 63700001 65162-0188-10 NAPROXEN 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5392 ERX HCPCS 63700001 65162-0189-50 NAPROXEN 375 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5392 ERX HCPCS 63700001 76282-0341-01 NAPROXEN 375 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5393 ERX HCPCS 63700001 51079-0795-01 NAPROXEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5393 ERX HCPCS 63700001 51079-0795-20 NAPROXEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5393 ERX HCPCS 63700001 60687-0491-01 NAPROXEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5393 ERX HCPCS 63700001 60687-0491-11 NAPROXEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5393 ERX HCPCS 63700001 63739-0403-10 NAPROXEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5393 ERX HCPCS 63700001 68462-0190-01 NAPROXEN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5472 ERX HCPCS 63700001 00093-1177-01 NEOMYCIN SULFATE 500 MG PO TABS BOTH IP/OP $8.28 $6.13 $0.00 $6.01 $0.00 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $0.00 $1.73 $0.00 $0.00 $0.00 $0.00 $3.76 $5.95 $6.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5472 ERX HCPCS 63700001 39822-0310-05 NEOMYCIN SULFATE 500 MG PO TABS BOTH IP/OP $8.28 $6.13 $0.00 $6.01 $0.00 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $0.00 $1.73 $0.00 $0.00 $0.00 $0.00 $3.76 $5.95 $6.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5472 ERX HCPCS 63700001 50383-0565-10 NEOMYCIN SULFATE 500 MG PO TABS BOTH IP/OP $8.28 $6.13 $0.00 $6.01 $0.00 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $0.00 $1.73 $0.00 $0.00 $0.00 $0.00 $3.76 $5.95 $6.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5472 ERX HCPCS 63700001 51079-0015-01 NEOMYCIN SULFATE 500 MG PO TABS BOTH IP/OP $8.28 $6.13 $0.00 $6.01 $0.00 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $0.00 $1.73 $0.00 $0.00 $0.00 $0.00 $3.76 $5.95 $6.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5472 ERX HCPCS 63700001 51079-0015-20 NEOMYCIN SULFATE 500 MG PO TABS BOTH IP/OP $8.28 $6.13 $0.00 $6.01 $0.00 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $0.00 $1.73 $0.00 $0.00 $0.00 $0.00 $3.76 $5.95 $6.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5474 ERX HCPCS 25000001 24208-0790-62 NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10000-.025 OP SOLN BOTH IP/OP $212.58 $157.31 $0.00 $163.86 $0.00 $0.00 $0.00 $0.00 $0.00 $157.78 $157.78 $163.86 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $96.49 $152.83 $154.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5539 ERX HCPCS 63700001 54629-0071-01 NIACIN 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542 ERX HCPCS 63700001 00536-4078-10 NIACIN 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5558 ERX HCPCS 63700001 00228-2497-10 NIFEDIPINE 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5558 ERX HCPCS 63700001 43386-0440-24 NIFEDIPINE 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5558 ERX HCPCS 63700001 69315-0211-01 NIFEDIPINE 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5559 ERX HCPCS 63700001 00228-2530-10 NIFEDIPINE 20 MG PO CAPS BOTH IP/OP $9.65 $7.14 $0.00 $7.01 $0.00 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $4.38 $6.94 $7.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5559 ERX HCPCS 63700001 23155-0195-01 NIFEDIPINE 20 MG PO CAPS BOTH IP/OP $9.65 $7.14 $0.00 $7.01 $0.00 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $4.38 $6.94 $7.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5595 ERX HCPCS 63700001 47781-0307-01 NITROFURANTOIN MACROCRYSTAL 50 MG PO CAPS BOTH IP/OP $9.52 $7.04 $0.00 $6.91 $0.00 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $4.32 $6.84 $6.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5599 ERX HCPCS 25000001 00517-4810-25 NITROGLYCERIN 5 MG/ML IV SOLN BOTH IP/OP $71.74 $53.09 $0.00 $55.30 $0.00 $0.00 $0.00 $0.00 $0.00 $53.25 $53.25 $55.30 $0.00 $14.95 $0.00 $0.00 $0.00 $0.00 $32.53 $51.53 $52.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5603 ERX HCPCS 25000001 00071-0417-24 NITROGLYCERIN 0.3 MG SL SUBL BOTH IP/OP $261.64 $193.61 $0.00 $201.67 $0.00 $0.00 $0.00 $0.00 $0.00 $194.19 $194.19 $201.67 $0.00 $54.53 $0.00 $0.00 $0.00 $0.00 $113.25 $179.38 $181.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5603 ERX HCPCS 25000001 59762-4921-01 NITROGLYCERIN 0.3 MG SL SUBL BOTH IP/OP $261.64 $193.61 $0.00 $201.67 $0.00 $0.00 $0.00 $0.00 $0.00 $194.19 $194.19 $201.67 $0.00 $54.53 $0.00 $0.00 $0.00 $0.00 $113.25 $179.38 $181.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5604 ERX HCPCS 25000001 00071-0418-13 NITROGLYCERIN 0.4 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5604 ERX HCPCS 25000001 43598-0436-11 NITROGLYCERIN 0.4 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5604 ERX HCPCS 25000001 43598-0436-35 NITROGLYCERIN 0.4 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5604 ERX HCPCS 25000001 59762-3304-03 NITROGLYCERIN 0.4 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5604 ERX HCPCS 25000001 68462-0639-45 NITROGLYCERIN 0.4 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5605 ERX HCPCS 25000001 00071-0419-24 NITROGLYCERIN 0.6 MG SL SUBL BOTH IP/OP $261.64 $193.61 $0.00 $201.67 $0.00 $0.00 $0.00 $0.00 $0.00 $194.19 $194.19 $201.67 $0.00 $54.53 $0.00 $0.00 $0.00 $0.00 $113.25 $179.38 $181.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5605 ERX HCPCS 25000001 59762-0489-01 NITROGLYCERIN 0.6 MG SL SUBL BOTH IP/OP $261.64 $193.61 $0.00 $201.67 $0.00 $0.00 $0.00 $0.00 $0.00 $194.19 $194.19 $201.67 $0.00 $54.53 $0.00 $0.00 $0.00 $0.00 $113.25 $179.38 $181.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5606 ERX HCPCS 25000001 00281-0326-08 NITROGLYCERIN 2 % TD OINT BOTH IP/OP $11.55 $8.55 $0.00 $8.90 $0.00 $0.00 $0.00 $0.00 $0.00 $8.57 $8.57 $8.90 $0.00 $2.41 $0.00 $0.00 $0.00 $0.00 $5.24 $8.29 $8.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5674 ERX HCPCS 63700001 50268-0603-15 NORTRIPTYLINE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5674 ERX HCPCS 63700001 60687-0281-01 NORTRIPTYLINE HCL 10 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5675 ERX HCPCS 63700001 51672-4002-01 NORTRIPTYLINE HCL 25 MG PO CAPS BOTH IP/OP $6.15 $4.55 $0.00 $4.80 $0.00 $0.00 $0.00 $1.09 $0.00 $0.00 $0.00 $0.00 $0.00 $1.28 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5677 ERX HCPCS 63700001 00093-0813-01 NORTRIPTYLINE HCL 75 MG PO CAPS BOTH IP/OP $17.68 $13.08 $0.00 $12.82 $0.00 $0.00 $0.00 $3.15 $0.00 $0.00 $0.00 $0.00 $0.00 $3.68 $0.00 $0.00 $0.00 $0.00 $8.02 $12.70 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5677 ERX HCPCS 63700001 51672-4004-01 NORTRIPTYLINE HCL 75 MG PO CAPS BOTH IP/OP $17.68 $13.08 $0.00 $12.82 $0.00 $0.00 $0.00 $3.15 $0.00 $0.00 $0.00 $0.00 $0.00 $3.68 $0.00 $0.00 $0.00 $0.00 $8.02 $12.70 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5749 ERX HCPCS 25000001 00168-0054-15 NYSTATIN 100000 UNIT/GM EX CREA BOTH IP/OP $101.68 $75.24 $0.00 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 $75.47 $75.47 $78.37 $0.00 $21.19 $0.00 $0.00 $0.00 $0.00 $46.10 $73.01 $73.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5749 ERX HCPCS 25000001 45802-0059-35 NYSTATIN 100000 UNIT/GM EX CREA BOTH IP/OP $101.68 $75.24 $0.00 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 $75.47 $75.47 $78.37 $0.00 $21.19 $0.00 $0.00 $0.00 $0.00 $46.10 $73.01 $73.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5749 ERX HCPCS 25000001 51672-1289-01 NYSTATIN 100000 UNIT/GM EX CREA BOTH IP/OP $101.68 $75.24 $0.00 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 $75.47 $75.47 $78.37 $0.00 $21.19 $0.00 $0.00 $0.00 $0.00 $46.10 $73.01 $73.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5749 ERX HCPCS 25000001 00168-0054-30 NYSTATIN 100000 UNIT/GM EX CREA BOTH IP/OP $101.68 $75.24 $0.00 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 $75.47 $75.47 $78.37 $0.00 $21.19 $0.00 $0.00 $0.00 $0.00 $46.10 $73.01 $73.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5749 ERX HCPCS 25000001 45802-0059-11 NYSTATIN 100000 UNIT/GM EX CREA BOTH IP/OP $101.68 $75.24 $0.00 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 $75.47 $75.47 $78.37 $0.00 $21.19 $0.00 $0.00 $0.00 $0.00 $46.10 $73.01 $73.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5749 ERX HCPCS 25000001 51672-1289-02 NYSTATIN 100000 UNIT/GM EX CREA BOTH IP/OP $101.68 $75.24 $0.00 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 $75.47 $75.47 $78.37 $0.00 $21.19 $0.00 $0.00 $0.00 $0.00 $46.10 $73.01 $73.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5750 ERX HCPCS 25000001 00168-0007-15 NYSTATIN 100000 UNIT/GM EX OINT BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5750 ERX HCPCS 25000001 45802-0048-35 NYSTATIN 100000 UNIT/GM EX OINT BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5750 ERX HCPCS 25000001 00168-0007-30 NYSTATIN 100000 UNIT/GM EX OINT BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5750 ERX HCPCS 25000001 00472-0166-30 NYSTATIN 100000 UNIT/GM EX OINT BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5750 ERX HCPCS 25000001 45802-0048-11 NYSTATIN 100000 UNIT/GM EX OINT BOTH IP/OP $97.28 $71.99 $0.00 $74.98 $0.00 $0.00 $0.00 $0.00 $0.00 $72.20 $72.20 $74.98 $0.00 $20.27 $0.00 $0.00 $0.00 $0.00 $44.10 $69.85 $70.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5751 ERX HCPCS 25000001 50383-0587-16 NYSTATIN 100000 UNIT/ML MT SUSP BOTH IP/OP $353.45 $261.55 $0.00 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.73 $279.93 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5751 ERX HCPCS 25000001 51672-4117-09 NYSTATIN 100000 UNIT/ML MT SUSP BOTH IP/OP $353.45 $261.55 $0.00 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.73 $279.93 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5751 ERX HCPCS 25000001 60432-0537-16 NYSTATIN 100000 UNIT/ML MT SUSP BOTH IP/OP $353.45 $261.55 $0.00 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.73 $279.93 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5751 ERX HCPCS 25000001 50383-0587-66 NYSTATIN 100000 UNIT/ML MT SUSP BOTH IP/OP $64.30 $47.58 $0.00 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.73 $50.93 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5751 ERX HCPCS 25000001 51672-4117-04 NYSTATIN 100000 UNIT/ML MT SUSP BOTH IP/OP $64.30 $47.58 $0.00 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.73 $50.93 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5751 ERX HCPCS 25000001 60432-0537-60 NYSTATIN 100000 UNIT/ML MT SUSP BOTH IP/OP $64.30 $47.58 $0.00 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.73 $50.93 $282.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5755 ERX HCPCS 25000001 51672-1272-01 NYSTATIN-TRIAMCINOLONE 100000-0.1 UNIT/GM-% EX OINT BOTH IP/OP $376.14 $278.34 $0.00 $289.93 $0.00 $0.00 $0.00 $0.00 $0.00 $279.17 $279.17 $289.93 $0.00 $78.39 $0.00 $0.00 $0.00 $0.00 $170.72 $270.42 $273.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5851 ERX HCPCS 25000001 99999-6006-21 ORA-PLUS PO LIQD BOTH IP/OP $21.12 $15.63 $0.00 $16.28 $0.00 $0.00 $0.00 $0.00 $0.00 $15.68 $15.68 $16.28 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $9.58 $15.17 $15.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5851 ERX HCPCS 25000001 00574-0303-16 ORA-PLUS PO LIQD BOTH IP/OP $21.12 $15.63 $0.00 $61.63 $0.00 $0.00 $0.00 $0.00 $0.00 $15.68 $15.68 $16.28 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $9.58 $61.63 $15.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5852 ERX HCPCS 25000001 00574-0304-16 ORA-SWEET PO SYRP BOTH IP/OP $85.82 $63.51 $0.00 $66.15 $0.00 $0.00 $0.00 $0.00 $0.00 $63.70 $63.70 $66.15 $0.00 $17.88 $0.00 $0.00 $0.00 $0.00 $38.91 $61.63 $62.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5853 ERX HCPCS 25000001 00574-0302-16 ORA-SWEET SF PO SYRP BOTH IP/OP $85.82 $63.51 $0.00 $66.15 $0.00 $0.00 $0.00 $0.00 $0.00 $63.70 $63.70 $66.15 $0.00 $17.88 $0.00 $0.00 $0.00 $0.00 $38.91 $61.63 $62.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5924 ERX HCPCS J2700 25021-0146-10 OXACILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $28.29 $20.93 $0.00 $21.81 $0.00 $0.00 $0.00 $0.00 $0.00 $21.00 $21.00 $21.81 $0.00 $3.01 $0.00 $0.00 $0.00 $0.00 $12.83 $20.31 $20.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5924 ERX HCPCS J2700 55150-0127-15 OXACILLIN SODIUM 1 G IJ SOLR BOTH IP/OP $28.29 $20.93 $0.00 $21.81 $0.00 $0.00 $0.00 $0.00 $0.00 $21.00 $21.00 $21.81 $0.00 $3.01 $0.00 $0.00 $0.00 $0.00 $12.83 $20.31 $20.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5938 ERX HCPCS 63700001 00603-4975-21 OXYBUTYNIN CHLORIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5938 ERX HCPCS 63700001 00832-0038-00 OXYBUTYNIN CHLORIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5938 ERX HCPCS 63700001 00832-0038-01 OXYBUTYNIN CHLORIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5938 ERX HCPCS 63700001 00832-0038-50 OXYBUTYNIN CHLORIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5938 ERX HCPCS 63700001 00904-2821-61 OXYBUTYNIN CHLORIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5938 ERX HCPCS 63700001 50111-0456-01 OXYBUTYNIN CHLORIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5938 ERX HCPCS 63700001 68084-0400-01 OXYBUTYNIN CHLORIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 00054-0551-25 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 00406-0512-01 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 00406-0512-05 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 00406-0512-23 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 00406-0512-62 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 00904-6437-61 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 13107-0044-01 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 68084-0355-01 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 68084-0355-11 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5940 ERX HCPCS 25000001 99999-6006-78 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5943 ERX HCPCS 25000001 00904-6761-30 OXYMETAZOLINE HCL 0.05 % NA SOLN BOTH IP/OP $16.72 $12.37 $0.00 $12.89 $0.00 $0.00 $0.00 $0.00 $0.00 $12.41 $12.41 $12.89 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5944 ERX HCPCS J2590 42023-0116-02 OXYTOCIN 10 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5944 ERX HCPCS J2590 42023-0116-25 OXYTOCIN 10 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5944 ERX HCPCS J2590 63323-0012-03 OXYTOCIN 10 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5944 ERX HCPCS J2590 63323-0012-10 OXYTOCIN 10 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5944 ERX HCPCS J2590 63323-0012-11 OXYTOCIN 10 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5944 ERX HCPCS J2590 63323-0012-12 OXYTOCIN 10 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5955 ERX HCPCS 63700001 00904-1883-61 OYSTER CALCIUM 500 (1250 CA CARB) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5955 ERX HCPCS 63700001 00904-1883-72 OYSTER CALCIUM 500 (1250 CA CARB) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5955 ERX HCPCS 63700001 51645-0827-99 OYSTER CALCIUM 500 (1250 CA CARB) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6013 ERX HCPCS 25000001 00409-4646-01 PANCURONIUM BROMIDE 1 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6030 ERX HCPCS J2440 00517-4002-25 PAPAVERINE HCL 30 MG/ML IJ SOLN BOTH IP/OP $95.91 $70.97 $0.00 $73.93 $43.16 $43.16 $0.00 $0.00 $0.00 $19.99 $71.18 $71.18 $73.93 $0.00 $19.99 $0.00 $56.73 $56.73 $0.00 $43.49 $68.88 $69.58 $0.00 $0.00 $13.61 $0.00 $0.00 $13.85 $0.00 $0.00 $0.00 $0.00 $0.00 6040 ERX HCPCS J7300 51285-0204-01 PARAGARD INTRAUTERINE COPPER IU IUD BOTH IP/OP "$2,541.15 " "$1,880.45" $0.00 "$1,958.72" "$1,143.52" "$1,143.52" $0.00 $0.00 $849.12 $750.43 "$1,886.04" "$1,886.04" "$1,958.72" $0.00 "$1,100.98" $0.00 "$1,252.79" "$1,252.79" $0.00 "$1,087.94" "$1,723.29" "$1,740.70" "$1,305.52" "$1,305.52" "$1,039.29" $0.00 $0.00 $989.58 $0.00 $0.00 $0.00 $0.00 $0.00 6040 ERX HCPCS J7300 59365-5128-01 PARAGARD INTRAUTERINE COPPER IU IUD BOTH IP/OP "$2,541.15 " "$1,880.45" $0.00 "$1,958.72" "$1,143.52" "$1,143.52" $0.00 $0.00 $849.12 $750.43 "$1,886.04" "$1,886.04" "$1,958.72" $0.00 "$1,100.98" $0.00 "$1,252.79" "$1,252.79" $0.00 "$1,087.94" "$1,723.29" "$1,740.70" "$1,305.52" "$1,305.52" "$1,039.29" $0.00 $0.00 $989.58 $0.00 $0.00 $0.00 $0.00 $0.00 6085 ERX HCPCS J2540 00049-0530-22 PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6085 ERX HCPCS J2540 00049-0530-28 PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6085 ERX HCPCS J2540 70860-0127-51 PENICILLIN G POTASSIUM 20000000 UNITS IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6086 ERX HCPCS J2540 00049-0520-83 PENICILLIN G POTASSIUM 5000000 UNITS IJ SOLR BOTH IP/OP $63.97 $47.34 $0.00 $49.31 $0.00 $0.00 $0.00 $0.00 $0.00 $47.48 $47.48 $49.31 $0.00 $8.65 $0.00 $0.00 $0.00 $0.00 $28.87 $45.72 $46.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6087 ERX HCPCS 25000001 00781-6153-94 PENICILLIN G SODIUM 5000000 UNITS IJ SOLR BOTH IP/OP $28.97 $21.44 $0.00 $22.33 $0.00 $0.00 $0.00 $0.00 $0.00 $21.50 $21.50 $22.33 $0.00 $6.04 $0.00 $0.00 $0.00 $0.00 $13.14 $20.81 $21.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6087 ERX HCPCS 25000001 00781-6153-95 PENICILLIN G SODIUM 5000000 UNITS IJ SOLR BOTH IP/OP $28.97 $21.44 $0.00 $22.33 $0.00 $0.00 $0.00 $0.00 $0.00 $21.50 $21.50 $22.33 $0.00 $6.04 $0.00 $0.00 $0.00 $0.00 $13.14 $20.81 $21.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6090 ERX HCPCS 63700001 00093-4125-73 PENICILLIN V POTASSIUM 125 MG/5ML PO SOLR BOTH IP/OP $38.13 $28.22 $0.00 $27.66 $0.00 $0.00 $0.00 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $7.95 $0.00 $0.00 $0.00 $0.00 $17.29 $27.39 $27.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6090 ERX HCPCS 63700001 00093-4125-74 PENICILLIN V POTASSIUM 125 MG/5ML PO SOLR BOTH IP/OP $38.13 $28.22 $0.00 $40.33 $0.00 $0.00 $0.00 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $7.95 $0.00 $0.00 $0.00 $0.00 $17.29 $40.33 $27.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6091 ERX HCPCS 25000001 00093-4127-73 PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR BOTH IP/OP $42.74 $31.63 $0.00 $32.94 $0.00 $0.00 $0.00 $0.00 $0.00 $31.72 $31.72 $32.94 $0.00 $8.91 $0.00 $0.00 $0.00 $0.00 $19.38 $30.70 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6091 ERX HCPCS 25000001 00093-4127-74 PENICILLIN V POTASSIUM 250 MG/5ML PO SOLR BOTH IP/OP $42.74 $31.63 $0.00 $44.54 $0.00 $0.00 $0.00 $0.00 $0.00 $31.72 $31.72 $32.94 $0.00 $8.91 $0.00 $0.00 $0.00 $0.00 $19.38 $44.54 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6092 ERX HCPCS 63700001 00093-1172-10 PENICILLIN V POTASSIUM 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6092 ERX HCPCS 63700001 16714-0234-01 PENICILLIN V POTASSIUM 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6092 ERX HCPCS 63700001 57237-0040-01 PENICILLIN V POTASSIUM 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6093 ERX HCPCS 63700001 16714-0235-01 PENICILLIN V POTASSIUM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6097 ERX HCPCS J2515 25021-0676-20 PENTOBARBITAL SODIUM 50 MG/ML IJ SOLN BOTH IP/OP "$3,796.80 " "$2,809.63" $0.00 "$2,926.57" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,817.98" "$2,817.98" "$2,926.57" $0.00 $620.66 $0.00 $0.00 $0.00 $0.00 "$1,722.00" "$2,727.65" "$2,755.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6097 ERX HCPCS J2515 76478-0501-20 PENTOBARBITAL SODIUM 50 MG/ML IJ SOLN BOTH IP/OP "$3,796.80 " "$2,809.63" $0.00 "$2,926.57" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,817.98" "$2,817.98" "$2,926.57" $0.00 $620.66 $0.00 $0.00 $0.00 $0.00 "$1,722.00" "$2,727.65" "$2,755.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6116 ERX HCPCS 25000001 00395-2015-91 PEPPERMINT OIL OIL BOTH IP/OP $98.78 $73.10 $0.00 $76.14 $0.00 $0.00 $0.00 $0.00 $0.00 $73.31 $73.31 $76.14 $0.00 $20.59 $0.00 $0.00 $0.00 $0.00 $43.05 $68.19 $68.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6157 ERX HCPCS Q0175 00781-1046-13 PERPHENAZINE 2 MG PO TABS BOTH IP/OP $8.24 $6.10 $0.00 $5.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $3.74 $5.92 $5.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6157 ERX HCPCS Q0175 52536-0162-01 PERPHENAZINE 2 MG PO TABS BOTH IP/OP $8.24 $6.10 $0.00 $5.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $3.74 $5.92 $5.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6158 ERX HCPCS Q0175 00603-5061-21 PERPHENAZINE 4 MG PO TABS BOTH IP/OP $11.26 $8.33 $0.00 $8.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.11 $8.09 $8.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6158 ERX HCPCS Q0175 00781-1047-01 PERPHENAZINE 4 MG PO TABS BOTH IP/OP $11.26 $8.33 $0.00 $8.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.11 $8.09 $8.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6158 ERX HCPCS Q0175 00781-1047-13 PERPHENAZINE 4 MG PO TABS BOTH IP/OP $11.26 $8.33 $0.00 $8.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.11 $8.09 $8.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6158 ERX HCPCS Q0175 00781-8047-01 PERPHENAZINE 4 MG PO TABS BOTH IP/OP $11.26 $8.33 $0.00 $8.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.11 $8.09 $8.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6159 ERX HCPCS Q0175 00378-5352-01 PERPHENAZINE 8 MG PO TABS BOTH IP/OP $13.67 $10.12 $0.00 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.85 $0.00 $0.00 $0.00 $0.00 $6.20 $9.82 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6159 ERX HCPCS Q0175 00603-5062-21 PERPHENAZINE 8 MG PO TABS BOTH IP/OP $13.67 $10.12 $0.00 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.85 $0.00 $0.00 $0.00 $0.00 $6.20 $9.82 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6159 ERX HCPCS Q0175 00781-1048-13 PERPHENAZINE 8 MG PO TABS BOTH IP/OP $13.67 $10.12 $0.00 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.85 $0.00 $0.00 $0.00 $0.00 $6.20 $9.82 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6159 ERX HCPCS Q0175 00781-8048-01 PERPHENAZINE 8 MG PO TABS BOTH IP/OP $13.67 $10.12 $0.00 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.85 $0.00 $0.00 $0.00 $0.00 $6.20 $9.82 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6159 ERX HCPCS Q0175 68084-0607-01 PERPHENAZINE 8 MG PO TABS BOTH IP/OP $13.67 $10.12 $0.00 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.85 $0.00 $0.00 $0.00 $0.00 $6.20 $9.82 $9.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6193 ERX HCPCS 63700001 10135-0620-01 PHENAZOPYRIDINE HCL 100 MG PO TABS BOTH IP/OP $6.67 $4.94 $0.00 $4.84 $0.00 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $0.00 $1.39 $0.00 $0.00 $0.00 $0.00 $3.03 $4.79 $4.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6193 ERX HCPCS 63700001 42937-0701-10 PHENAZOPYRIDINE HCL 100 MG PO TABS BOTH IP/OP $6.67 $4.94 $0.00 $4.84 $0.00 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $0.00 $1.39 $0.00 $0.00 $0.00 $0.00 $3.03 $4.79 $4.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6193 ERX HCPCS 63700001 51293-0801-01 PHENAZOPYRIDINE HCL 100 MG PO TABS BOTH IP/OP $6.67 $4.94 $0.00 $4.84 $0.00 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $0.00 $1.39 $0.00 $0.00 $0.00 $0.00 $3.03 $4.79 $4.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6212 ERX HCPCS 63700001 00603-1508-58 PHENOBARBITAL 20 MG/5ML PO ELIX BOTH IP/OP $6.23 $4.61 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6212 ERX HCPCS 63700001 13517-0107-16 PHENOBARBITAL 20 MG/5ML PO ELIX BOTH IP/OP $6.23 $4.61 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6212 ERX HCPCS 63700001 99999-6006-84 PHENOBARBITAL 20 MG/5ML PO ELIX BOTH IP/OP $6.23 $4.61 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6217 ERX HCPCS 63700001 00904-6575-61 PHENOBARBITAL 32.4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6220 ERX HCPCS 63700001 00603-5168-21 PHENOBARBITAL 97.2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6220 ERX HCPCS 63700001 13517-0113-01 PHENOBARBITAL 97.2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6221 ERX HCPCS J2560 00641-0477-21 PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN BOTH IP/OP $199.57 $147.68 $0.00 $153.83 $0.00 $0.00 $0.00 $0.00 $0.00 $148.12 $148.12 $153.83 $0.00 $47.25 $0.00 $0.00 $0.00 $0.00 $90.59 $143.49 $144.94 $0.00 $0.00 $49.81 $0.00 $0.00 $47.43 $0.00 $0.00 $0.00 $0.00 $0.00 6221 ERX HCPCS J2560 00641-0477-25 PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN BOTH IP/OP $199.57 $147.68 $0.00 $153.83 $0.00 $0.00 $0.00 $0.00 $0.00 $148.12 $148.12 $153.83 $0.00 $47.25 $0.00 $0.00 $0.00 $0.00 $90.59 $143.49 $144.94 $0.00 $0.00 $49.81 $0.00 $0.00 $47.43 $0.00 $0.00 $0.00 $0.00 $0.00 6224 ERX HCPCS J2560 00641-0476-25 PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN BOTH IP/OP $111.08 $82.20 $0.00 $85.62 $0.00 $0.00 $0.00 $0.00 $0.00 $82.44 $82.44 $85.62 $0.00 $47.25 $0.00 $0.00 $0.00 $0.00 $50.36 $79.77 $80.58 $0.00 $0.00 $49.81 $0.00 $0.00 $47.43 $0.00 $0.00 $0.00 $0.00 $0.00 6227 ERX HCPCS 25000001 49452-5220-02 PHENOL EX LIQD BOTH IP/OP "$1,370.11 " "$1,013.88" $0.00 "$1,056.08" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,016.90" "$1,016.90" "$1,056.08" $0.00 $285.53 $0.00 $0.00 $0.00 $0.00 $634.80 "$1,005.52" "$1,015.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6243 ERX HCPCS 25000001 00225-0800-47 PHENYLEPHRINE HCL 0.25 % NA SOLN BOTH IP/OP $15.91 $11.77 $0.00 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 $11.81 $11.81 $12.26 $0.00 $3.32 $0.00 $0.00 $0.00 $0.00 $7.22 $11.43 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6244 ERX HCPCS 25000001 00225-0805-47 PHENYLEPHRINE HCL 0.5 % NA SOLN BOTH IP/OP $15.91 $11.77 $0.00 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 $11.81 $11.81 $12.26 $0.00 $3.32 $0.00 $0.00 $0.00 $0.00 $7.22 $11.43 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6246 ERX HCPCS 25000001 17478-0201-02 PHENYLEPHRINE HCL 2.5 % OP SOLN BOTH IP/OP $362.88 $268.53 $0.00 $279.71 $0.00 $0.00 $0.00 $0.00 $0.00 $269.33 $269.33 $279.71 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $171.57 $112.63 $274.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6246 ERX HCPCS 25000001 17478-0201-15 PHENYLEPHRINE HCL 2.5 % OP SOLN BOTH IP/OP $362.88 $268.53 $0.00 $279.71 $0.00 $0.00 $0.00 $0.00 $0.00 $269.33 $269.33 $279.71 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $171.57 $271.76 $274.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6246 ERX HCPCS 25000001 42702-0102-15 PHENYLEPHRINE HCL 2.5 % OP SOLN BOTH IP/OP $362.88 $268.53 $0.00 $279.71 $0.00 $0.00 $0.00 $0.00 $0.00 $269.33 $269.33 $279.71 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $171.57 $271.76 $274.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6255 ERX HCPCS 63700001 99999-6010-65 PHENYTOIN 125 MG/5ML PO SUSP BOTH IP/OP $82.72 $61.21 $0.00 $110.54 $0.00 $0.00 $0.00 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 $17.24 $0.00 $0.00 $0.00 $0.00 $69.09 $59.42 $110.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6255 ERX HCPCS 63700001 99999-6004-70 PHENYTOIN 125 MG/5ML PO SUSP BOTH IP/OP $82.72 $61.21 $0.00 $110.54 $0.00 $0.00 $0.00 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 $17.24 $0.00 $0.00 $0.00 $0.00 $69.09 $109.44 $110.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6255 ERX HCPCS 63700001 00071-2214-20 PHENYTOIN 125 MG/5ML PO SUSP BOTH IP/OP $82.72 $61.21 $0.00 $427.28 $0.00 $0.00 $0.00 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 $17.24 $0.00 $0.00 $0.00 $0.00 $69.09 $427.28 $110.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6255 ERX HCPCS 63700001 59762-0531-02 PHENYTOIN 125 MG/5ML PO SUSP BOTH IP/OP $82.72 $61.21 $0.00 $427.28 $0.00 $0.00 $0.00 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 $17.24 $0.00 $0.00 $0.00 $0.00 $69.09 $427.28 $110.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6256 ERX HCPCS J1165 00641-0493-25 PHENYTOIN SODIUM 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.05 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6256 ERX HCPCS J1165 00641-2555-41 PHENYTOIN SODIUM 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.05 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6256 ERX HCPCS J1165 00641-2555-45 PHENYTOIN SODIUM 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.05 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6256 ERX HCPCS J1165 00641-6138-25 PHENYTOIN SODIUM 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.05 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6256 ERX HCPCS J1165 00641-6139-25 PHENYTOIN SODIUM 50 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.05 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6257 ERX HCPCS 63700001 00071-0369-40 PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6257 ERX HCPCS 63700001 00904-6187-61 PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6257 ERX HCPCS 63700001 51079-0905-20 PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6257 ERX HCPCS 63700001 51672-4111-01 PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6257 ERX HCPCS 63700001 51672-4111-03 PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6257 ERX HCPCS 63700001 68084-0376-01 PHENYTOIN SODIUM EXTENDED 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6270 ERX HCPCS 25000001 17478-0510-02 PHYSOSTIGMINE SALICYLATE 1 MG/ML IJ SOLN BOTH IP/OP $181.32 $134.18 $0.00 $139.76 $0.00 $0.00 $0.00 $0.00 $0.00 $134.58 $134.58 $139.76 $0.00 $37.79 $0.00 $0.00 $0.00 $0.00 $82.21 $130.21 $131.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6279 ERX HCPCS 25000001 00998-0203-15 PILOCARPINE HCL 1 % OP SOLN BOTH IP/OP $342.03 $253.10 $0.00 $263.64 $0.00 $0.00 $0.00 $0.00 $0.00 $253.85 $253.85 $263.64 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $155.24 $245.90 $248.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6279 ERX HCPCS 25000001 61314-0203-15 PILOCARPINE HCL 1 % OP SOLN BOTH IP/OP $342.03 $253.10 $0.00 $263.64 $0.00 $0.00 $0.00 $0.00 $0.00 $253.85 $253.85 $263.64 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $155.24 $245.90 $248.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6279 ERX HCPCS 25000001 70069-0181-01 PILOCARPINE HCL 1 % OP SOLN BOTH IP/OP $342.03 $253.10 $0.00 $263.64 $0.00 $0.00 $0.00 $0.00 $0.00 $253.85 $253.85 $263.64 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $155.24 $245.90 $248.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280 ERX HCPCS 25000001 00998-0204-15 PILOCARPINE HCL 2 % OP SOLN BOTH IP/OP $338.74 $250.67 $0.00 $261.10 $0.00 $0.00 $0.00 $0.00 $0.00 $251.41 $251.41 $261.10 $0.00 $70.59 $0.00 $0.00 $0.00 $0.00 $153.75 $243.53 $245.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280 ERX HCPCS 25000001 17478-0224-12 PILOCARPINE HCL 2 % OP SOLN BOTH IP/OP $338.74 $250.67 $0.00 $261.10 $0.00 $0.00 $0.00 $0.00 $0.00 $251.41 $251.41 $261.10 $0.00 $70.59 $0.00 $0.00 $0.00 $0.00 $153.75 $243.53 $245.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280 ERX HCPCS 25000001 61314-0204-15 PILOCARPINE HCL 2 % OP SOLN BOTH IP/OP $338.74 $250.67 $0.00 $261.10 $0.00 $0.00 $0.00 $0.00 $0.00 $251.41 $251.41 $261.10 $0.00 $70.59 $0.00 $0.00 $0.00 $0.00 $153.75 $243.53 $245.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6282 ERX HCPCS 25000001 00998-0206-15 PILOCARPINE HCL 4 % OP SOLN BOTH IP/OP $355.12 $262.79 $0.00 $273.73 $0.00 $0.00 $0.00 $0.00 $0.00 $263.57 $263.57 $273.73 $0.00 $74.01 $0.00 $0.00 $0.00 $0.00 $161.18 $255.31 $257.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6282 ERX HCPCS 25000001 61314-0206-15 PILOCARPINE HCL 4 % OP SOLN BOTH IP/OP $355.12 $262.79 $0.00 $273.73 $0.00 $0.00 $0.00 $0.00 $0.00 $263.57 $263.57 $273.73 $0.00 $74.01 $0.00 $0.00 $0.00 $0.00 $161.18 $255.31 $257.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6296 ERX HCPCS 63700001 00378-0127-01 PINDOLOL 10 MG PO TABS BOTH IP/OP $7.54 $5.58 $0.00 $5.47 $0.00 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $3.42 $5.42 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6296 ERX HCPCS 63700001 57664-0656-88 PINDOLOL 10 MG PO TABS BOTH IP/OP $7.54 $5.58 $0.00 $5.47 $0.00 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $3.42 $5.42 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6297 ERX HCPCS 63700001 00378-0052-01 PINDOLOL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6297 ERX HCPCS 63700001 57664-0655-88 PINDOLOL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6331 ERX HCPCS 25000001 00338-0221-04 PLASMA-LYTE A IV SOLN BOTH IP/OP $67.04 $49.61 $0.00 $51.67 $0.00 $0.00 $0.00 $0.00 $0.00 $49.76 $49.76 $51.67 $0.00 $13.97 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6393 ERX HCPCS 25000001 55150-0234-10 POLYMYXIN B SULFATE 500000 UNITS IJ SOLR BOTH IP/OP $51.30 $37.96 $0.00 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.65 $40.63 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6393 ERX HCPCS 25000001 63323-0367-01 POLYMYXIN B SULFATE 500000 UNITS IJ SOLR BOTH IP/OP $51.30 $37.96 $0.00 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.65 $40.63 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6393 ERX HCPCS 25000001 63323-0367-11 POLYMYXIN B SULFATE 500000 UNITS IJ SOLR BOTH IP/OP $51.30 $37.96 $0.00 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.65 $40.63 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6393 ERX HCPCS 25000001 70860-0103-10 POLYMYXIN B SULFATE 500000 UNITS IJ SOLR BOTH IP/OP $51.30 $37.96 $0.00 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.65 $40.63 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6393 ERX HCPCS 25000001 70860-0103-41 POLYMYXIN B SULFATE 500000 UNITS IJ SOLR BOTH IP/OP $51.30 $37.96 $0.00 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.65 $40.63 $41.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6420 ERX HCPCS 25000001 00409-8183-01 POTASSIUM ACETATE 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6429 ERX HCPCS J3480 00264-1940-20 KCL 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $1.69 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 6429 ERX HCPCS J3480 00409-6651-06 KCL 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $1.69 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 6429 ERX HCPCS J3480 63323-0965-03 KCL 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $1.69 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 6429 ERX HCPCS J3480 63323-0965-10 KCL 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $1.69 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 6429 ERX HCPCS J3480 63323-0965-20 KCL 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $1.69 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 6458 ERX HCPCS 25000001 49348-0622-37 POVIDONE-IODINE 10 % EX SOLN BOTH IP/OP $26.82 $19.85 $0.00 $20.67 $0.00 $0.00 $0.00 $0.00 $0.00 $19.91 $19.91 $20.67 $0.00 $5.59 $0.00 $0.00 $0.00 $0.00 $12.16 $19.26 $19.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6462 ERX HCPCS J2730 60977-0141-01 PRALIDOXIME CHLORIDE 1 G IV SOLR BOTH IP/OP $100.40 $74.30 $0.00 $77.39 $0.00 $0.00 $0.00 $0.00 $0.00 $74.52 $74.52 $77.39 $0.00 $20.92 $0.00 $0.00 $0.00 $0.00 $45.52 $72.10 $72.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6462 ERX HCPCS J2730 60977-0141-27 PRALIDOXIME CHLORIDE 1 G IV SOLR BOTH IP/OP $100.40 $74.30 $0.00 $77.39 $0.00 $0.00 $0.00 $0.00 $0.00 $74.52 $74.52 $77.39 $0.00 $20.92 $0.00 $0.00 $0.00 $0.00 $45.52 $72.10 $72.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6468 ERX HCPCS 63700001 00378-1101-01 PRAZOSIN HCL 1 MG PO CAPS BOTH IP/OP $7.60 $5.62 $0.00 $5.51 $0.00 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 $1.58 $0.00 $0.00 $0.00 $0.00 $3.45 $5.46 $5.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6468 ERX HCPCS 63700001 51079-0630-20 PRAZOSIN HCL 1 MG PO CAPS BOTH IP/OP $7.60 $5.62 $0.00 $5.51 $0.00 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 $1.58 $0.00 $0.00 $0.00 $0.00 $3.45 $5.46 $5.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6469 ERX HCPCS 63700001 00093-4068-01 PRAZOSIN HCL 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6469 ERX HCPCS 63700001 00378-2302-01 PRAZOSIN HCL 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6469 ERX HCPCS 63700001 51079-0631-20 PRAZOSIN HCL 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6469 ERX HCPCS 63700001 59762-5320-01 PRAZOSIN HCL 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6470 ERX HCPCS 63700001 00093-4069-01 PRAZOSIN HCL 5 MG PO CAPS BOTH IP/OP $18.06 $13.36 $0.00 $13.10 $0.00 $0.00 $0.00 $3.21 $0.00 $0.00 $0.00 $0.00 $0.00 $3.76 $0.00 $0.00 $0.00 $0.00 $8.19 $12.97 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6470 ERX HCPCS 63700001 51079-0632-20 PRAZOSIN HCL 5 MG PO CAPS BOTH IP/OP $18.06 $13.36 $0.00 $13.10 $0.00 $0.00 $0.00 $3.21 $0.00 $0.00 $0.00 $0.00 $0.00 $3.76 $0.00 $0.00 $0.00 $0.00 $8.19 $12.97 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6470 ERX HCPCS 63700001 70954-0021-10 PRAZOSIN HCL 5 MG PO CAPS BOTH IP/OP $18.06 $13.36 $0.00 $13.10 $0.00 $0.00 $0.00 $3.21 $0.00 $0.00 $0.00 $0.00 $0.00 $3.76 $0.00 $0.00 $0.00 $0.00 $8.19 $12.97 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6487 ERX HCPCS 25000001 60758-0119-10 PREDNISOLONE ACETATE 1 % OP SUSP BOTH IP/OP $354.82 $262.57 $0.00 $273.50 $0.00 $0.00 $0.00 $0.00 $0.00 $263.35 $263.35 $273.50 $0.00 $73.94 $0.00 $0.00 $0.00 $0.00 $161.04 $255.09 $257.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6487 ERX HCPCS 25000001 61314-0637-10 PREDNISOLONE ACETATE 1 % OP SUSP BOTH IP/OP $354.82 $262.57 $0.00 $273.50 $0.00 $0.00 $0.00 $0.00 $0.00 $263.35 $263.35 $273.50 $0.00 $73.94 $0.00 $0.00 $0.00 $0.00 $161.04 $255.09 $257.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6487 ERX HCPCS 25000001 11980-0180-05 PREDNISOLONE ACETATE 1 % OP SUSP BOTH IP/OP $354.82 $262.57 $0.00 $442.81 $0.00 $0.00 $0.00 $0.00 $0.00 $263.35 $263.35 $273.50 $0.00 $73.94 $0.00 $0.00 $0.00 $0.00 $161.04 $442.81 $257.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6487 ERX HCPCS 25000001 60758-0119-05 PREDNISOLONE ACETATE 1 % OP SUSP BOTH IP/OP $354.82 $262.57 $0.00 $442.81 $0.00 $0.00 $0.00 $0.00 $0.00 $263.35 $263.35 $273.50 $0.00 $73.94 $0.00 $0.00 $0.00 $0.00 $161.04 $442.81 $257.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6487 ERX HCPCS 25000001 61314-0637-05 PREDNISOLONE ACETATE 1 % OP SUSP BOTH IP/OP $354.82 $262.57 $0.00 $442.81 $0.00 $0.00 $0.00 $0.00 $0.00 $263.35 $263.35 $273.50 $0.00 $73.94 $0.00 $0.00 $0.00 $0.00 $161.04 $442.81 $257.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6493 ERX HCPCS 25000001 00054-4741-25 PREDNISONE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6493 ERX HCPCS 25000001 00054-8739-25 PREDNISONE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6493 ERX HCPCS 25000001 59746-0171-06 PREDNISONE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6494 ERX HCPCS 25000001 00054-0017-20 PREDNISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6494 ERX HCPCS 25000001 00054-0017-29 PREDNISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6494 ERX HCPCS 25000001 00603-5338-21 PREDNISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6494 ERX HCPCS 25000001 00603-5338-28 PREDNISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6494 ERX HCPCS 25000001 00603-5338-32 PREDNISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6494 ERX HCPCS 25000001 59746-0173-06 PREDNISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6494 ERX HCPCS 25000001 60687-0134-01 PREDNISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6494 ERX HCPCS 25000001 63739-0519-10 PREDNISONE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6496 ERX HCPCS 25000001 00054-0018-20 PREDNISONE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6496 ERX HCPCS 25000001 59746-0175-06 PREDNISONE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6497 ERX HCPCS 25000001 00054-8724-25 PREDNISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6497 ERX HCPCS 25000001 00603-5337-21 PREDNISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6497 ERX HCPCS 25000001 59746-0172-06 PREDNISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6497 ERX HCPCS 25000001 60687-0122-01 PREDNISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6497 ERX HCPCS 25000001 60687-0122-11 PREDNISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6497 ERX HCPCS 25000001 63739-0518-10 PREDNISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6498 ERX HCPCS 25000001 00054-0019-20 PREDNISONE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6498 ERX HCPCS 25000001 00054-0019-25 PREDNISONE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6541 ERX HCPCS 63700001 00024-1596-01 PRIMAQUINE PHOSPHATE 26.3 MG PO TABS BOTH IP/OP $8.10 $5.99 $0.00 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6541 ERX HCPCS 63700001 76385-0102-01 PRIMAQUINE PHOSPHATE 26.3 MG PO TABS BOTH IP/OP $8.10 $5.99 $0.00 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6544 ERX HCPCS 63700001 00591-5321-01 PRIMIDONE 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6544 ERX HCPCS 63700001 68084-0203-01 PRIMIDONE 250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6561 ERX HCPCS 63700001 00378-0156-01 PROBENECID 500 MG PO TABS BOTH IP/OP $8.24 $6.10 $0.00 $5.98 $0.00 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $3.74 $5.92 $5.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6561 ERX HCPCS 63700001 00591-5347-01 PROBENECID 500 MG PO TABS BOTH IP/OP $8.24 $6.10 $0.00 $5.98 $0.00 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $3.74 $5.92 $5.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6562 ERX HCPCS J2690 14789-0901-10 PROCAINAMIDE HCL 100 MG/ML IJ SOLN BOTH IP/OP $458.97 $339.64 $0.00 $367.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.49 $363.50 $367.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6582 ERX HCPCS S0183 59746-0115-06 PROCHLORPERAZINE MALEATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $3.60 $3.60 $0.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6583 ERX HCPCS S0183 00378-5105-01 PROCHLORPERAZINE MALEATE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $3.60 $3.60 $0.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6583 ERX HCPCS S0183 59746-0113-06 PROCHLORPERAZINE MALEATE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $3.60 $3.60 $0.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6597 ERX HCPCS J2675 00591-3128-79 PROGESTERONE 50 MG/ML IM OIL BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6618 ERX HCPCS J2550 00641-0928-21 PROMETHAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.93 $16.33 $16.33 $16.96 $0.00 $2.78 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.42 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 6618 ERX HCPCS J2550 00641-0928-25 PROMETHAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.93 $16.33 $16.33 $16.96 $0.00 $2.78 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.42 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 6618 ERX HCPCS J2550 00641-0955-25 PROMETHAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.93 $16.33 $16.33 $16.96 $0.00 $2.78 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.42 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 6618 ERX HCPCS J2550 00641-1495-31 PROMETHAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.93 $16.33 $16.33 $16.96 $0.00 $2.78 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.42 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 6618 ERX HCPCS J2550 00641-1495-35 PROMETHAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.93 $16.33 $16.33 $16.96 $0.00 $2.78 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.42 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 6618 ERX HCPCS J2550 00641-6084-25 PROMETHAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.93 $16.33 $16.33 $16.96 $0.00 $2.78 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.42 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 6618 ERX HCPCS J2550 39822-5525-03 PROMETHAZINE HCL 25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.93 $16.33 $16.33 $16.96 $0.00 $2.78 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.42 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 6622 ERX HCPCS Q0169 00904-6461-61 PROMETHAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $2.70 $2.70 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 6622 ERX HCPCS Q0169 10702-0003-01 PROMETHAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $2.70 $2.70 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 6622 ERX HCPCS Q0169 68084-0155-01 PROMETHAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $2.70 $2.70 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 6643 ERX HCPCS 63700001 00054-4721-25 PROPANTHELINE BROMIDE 15 MG PO TABS BOTH IP/OP $11.40 $8.44 $0.00 $9.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.70 $9.03 $9.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6644 ERX HCPCS 25000001 24208-0730-06 PROPARACAINE HCL 0.5 % OP SOLN BOTH IP/OP $169.36 $125.33 $0.00 $130.54 $0.00 $0.00 $0.00 $0.00 $0.00 $125.70 $125.70 $130.54 $0.00 $35.29 $0.00 $0.00 $0.00 $0.00 $76.79 $121.63 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6644 ERX HCPCS 25000001 61314-0016-01 PROPARACAINE HCL 0.5 % OP SOLN BOTH IP/OP $169.36 $125.33 $0.00 $130.54 $0.00 $0.00 $0.00 $0.00 $0.00 $125.70 $125.70 $130.54 $0.00 $35.29 $0.00 $0.00 $0.00 $0.00 $76.79 $121.63 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6654 ERX HCPCS 25000001 99999-6010-68 PROPRANOLOL HCL 20 MG/5ML PO SOLN BOTH IP/OP $20.12 $14.89 $0.00 $29.18 $0.00 $0.00 $0.00 $0.00 $0.00 $14.93 $14.93 $15.51 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $18.24 $14.45 $29.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6654 ERX HCPCS 25000001 99999-6004-71 PROPRANOLOL HCL 20 MG/5ML PO SOLN BOTH IP/OP $20.12 $14.89 $0.00 $29.18 $0.00 $0.00 $0.00 $0.00 $0.00 $14.93 $14.93 $15.51 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $18.24 $28.89 $29.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6654 ERX HCPCS 25000001 00054-3727-63 PROPRANOLOL HCL 20 MG/5ML PO SOLN BOTH IP/OP $20.12 $14.89 $0.00 $164.66 $0.00 $0.00 $0.00 $0.00 $0.00 $14.93 $14.93 $15.51 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $18.24 $164.66 $29.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6656 ERX HCPCS 63700001 00378-0182-01 PROPRANOLOL HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6656 ERX HCPCS 63700001 00378-0182-10 PROPRANOLOL HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6656 ERX HCPCS 63700001 00591-5554-01 PROPRANOLOL HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6656 ERX HCPCS 63700001 00603-5482-21 PROPRANOLOL HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6656 ERX HCPCS 63700001 00603-5482-32 PROPRANOLOL HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6656 ERX HCPCS 63700001 00904-6550-61 PROPRANOLOL HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6658 ERX HCPCS 63700001 00115-1661-01 PROPRANOLOL HCL 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6658 ERX HCPCS 63700001 00378-0184-01 PROPRANOLOL HCL 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6658 ERX HCPCS 63700001 00591-5556-01 PROPRANOLOL HCL 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6658 ERX HCPCS 63700001 00603-5484-21 PROPRANOLOL HCL 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6659 ERX HCPCS 63700001 00378-0187-01 PROPRANOLOL HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6659 ERX HCPCS 63700001 00603-5485-21 PROPRANOLOL HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660 ERX HCPCS 63700001 00378-0185-01 PROPRANOLOL HCL 80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660 ERX HCPCS 63700001 00603-5486-21 PROPRANOLOL HCL 80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6662 ERX HCPCS 63700001 00228-2348-10 PROPYLTHIOURACIL 50 MG PO TABS BOTH IP/OP $14.08 $10.42 $0.00 $10.22 $0.00 $0.00 $0.00 $2.51 $0.00 $0.00 $0.00 $0.00 $0.00 $2.93 $0.00 $0.00 $0.00 $0.00 $6.39 $4.75 $10.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6662 ERX HCPCS 63700001 67253-0651-10 PROPYLTHIOURACIL 50 MG PO TABS BOTH IP/OP $14.08 $10.42 $0.00 $10.22 $0.00 $0.00 $0.00 $2.51 $0.00 $0.00 $0.00 $0.00 $0.00 $2.93 $0.00 $0.00 $0.00 $0.00 $6.39 $4.75 $10.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6662 ERX HCPCS 63700001 67253-0651-11 PROPYLTHIOURACIL 50 MG PO TABS BOTH IP/OP $14.08 $10.42 $0.00 $10.22 $0.00 $0.00 $0.00 $2.51 $0.00 $0.00 $0.00 $0.00 $0.00 $2.93 $0.00 $0.00 $0.00 $0.00 $6.39 $4.75 $10.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6662 ERX HCPCS 63700001 68084-0964-25 PROPYLTHIOURACIL 50 MG PO TABS BOTH IP/OP $14.08 $10.42 $0.00 $10.22 $0.00 $0.00 $0.00 $2.51 $0.00 $0.00 $0.00 $0.00 $0.00 $2.93 $0.00 $0.00 $0.00 $0.00 $6.39 $4.75 $10.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6677 ERX HCPCS J2720 63323-0229-05 PROTAMINE SULFATE 10 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.60 $16.33 $16.33 $16.96 $0.00 $1.63 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.28 $0.00 $0.00 $1.22 $0.00 $0.00 $0.00 $0.00 $0.00 6677 ERX HCPCS J2720 63323-0229-15 PROTAMINE SULFATE 10 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.60 $16.33 $16.33 $16.96 $0.00 $1.63 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.28 $0.00 $0.00 $1.22 $0.00 $0.00 $0.00 $0.00 $0.00 6677 ERX HCPCS J2720 63323-0229-30 PROTAMINE SULFATE 10 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.60 $16.33 $16.33 $16.96 $0.00 $1.63 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.28 $0.00 $0.00 $1.22 $0.00 $0.00 $0.00 $0.00 $0.00 6714 ERX HCPCS 63700001 00904-5053-24 PSEUDOEPHEDRINE HCL 30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6714 ERX HCPCS 63700001 00904-5053-59 PSEUDOEPHEDRINE HCL 30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6714 ERX HCPCS 63700001 45802-0432-62 PSEUDOEPHEDRINE HCL 30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6715 ERX HCPCS 63700001 00904-5125-59 PSEUDOEPHEDRINE HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6715 ERX HCPCS 63700001 00904-6728-52 PSEUDOEPHEDRINE HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6738 ERX HCPCS 63700001 61748-0012-01 PYRAZINAMIDE 500 MG PO TABS BOTH IP/OP $51.58 $38.17 $0.00 $37.42 $0.00 $0.00 $0.00 $9.18 $0.00 $0.00 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6738 ERX HCPCS 63700001 61748-0012-11 PYRAZINAMIDE 500 MG PO TABS BOTH IP/OP $51.58 $38.17 $0.00 $37.42 $0.00 $0.00 $0.00 $9.18 $0.00 $0.00 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6744 ERX HCPCS J3415 63323-0180-01 PYRIDOXINE HCL 100 MG/ML IJ SOLN BOTH IP/OP $41.66 $30.83 $0.00 $32.11 $18.75 $18.75 $0.00 $0.00 $0.00 $0.00 $30.92 $30.92 $32.11 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $17.33 $27.45 $27.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6777 ERX HCPCS 63700001 00185-4346-01 QUINIDINE SULFATE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6781 ERX HCPCS 63700001 00093-3002-56 QUININE SULFATE 324 MG PO CAPS BOTH IP/OP $26.85 $19.87 $0.00 $21.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.43 $21.27 $21.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6781 ERX HCPCS 63700001 13310-0153-07 QUININE SULFATE 324 MG PO CAPS BOTH IP/OP $26.85 $19.87 $0.00 $21.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.43 $21.27 $21.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6781 ERX HCPCS 63700001 53489-0700-07 QUININE SULFATE 324 MG PO CAPS BOTH IP/OP $26.85 $19.87 $0.00 $21.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.43 $21.27 $21.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6839 ERX HCPCS 25000001 00327-0012-30 RENACIDIN IR SOLN BOTH IP/OP $28.92 $21.40 $0.00 $22.29 $0.00 $0.00 $0.00 $0.00 $0.00 $21.46 $21.46 $22.29 $0.00 $6.03 $0.00 $0.00 $0.00 $0.00 $13.11 $20.77 $20.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6969 ERX HCPCS 25000001 51801-0004-40 ROSE BENGAL 1.3 MG OP STRP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7030 ERX HCPCS 25000001 00904-3865-75 SALINE NASAL SPRAY 0.65 % NA SOLN BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7030 ERX HCPCS 25000001 45802-0357-58 SALINE NASAL SPRAY 0.65 % NA SOLN BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7034 ERX HCPCS 63700001 51293-0803-01 SALSALATE 500 MG PO TABS BOTH IP/OP $7.96 $5.89 $0.00 $5.78 $0.00 $0.00 $0.00 $1.42 $0.00 $0.00 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $3.61 $5.72 $5.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7035 ERX HCPCS 63700001 10135-0493-01 SALSALATE 750 MG PO TABS BOTH IP/OP $8.50 $6.29 $0.00 $6.17 $0.00 $0.00 $0.00 $2.09 $0.00 $0.00 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $3.86 $6.11 $6.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7035 ERX HCPCS 63700001 51293-0804-01 SALSALATE 750 MG PO TABS BOTH IP/OP $8.50 $6.29 $0.00 $6.17 $0.00 $0.00 $0.00 $2.09 $0.00 $0.00 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $3.86 $6.11 $6.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7222 ERX HCPCS 25000001 62991-2927-03 SILVER NITRATE CRYS BOTH IP/OP "$1,160.70 " $858.92 $0.00 $894.67 $0.00 $0.00 $0.00 $0.00 $0.00 $861.47 $861.47 $894.67 $0.00 $241.89 $0.00 $0.00 $0.00 $0.00 $526.69 $834.28 $842.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224 ERX HCPCS 25000001 43598-0210-50 SILVER SULFADIAZINE 1 % EX CREA BOTH IP/OP $63.27 $46.82 $0.00 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $46.96 $46.96 $48.77 $0.00 $13.19 $0.00 $0.00 $0.00 $0.00 $184.22 $45.44 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224 ERX HCPCS 25000001 43598-0210-55 SILVER SULFADIAZINE 1 % EX CREA BOTH IP/OP $63.27 $46.82 $0.00 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $46.96 $46.96 $48.77 $0.00 $13.19 $0.00 $0.00 $0.00 $0.00 $184.22 $45.44 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224 ERX HCPCS 25000001 61570-0131-50 SILVER SULFADIAZINE 1 % EX CREA BOTH IP/OP $63.27 $46.82 $0.00 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $46.96 $46.96 $48.77 $0.00 $13.19 $0.00 $0.00 $0.00 $0.00 $184.22 $45.44 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224 ERX HCPCS 25000001 67877-0124-05 SILVER SULFADIAZINE 1 % EX CREA BOTH IP/OP $63.27 $46.82 $0.00 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $46.96 $46.96 $48.77 $0.00 $13.19 $0.00 $0.00 $0.00 $0.00 $184.22 $45.44 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224 ERX HCPCS 25000001 67877-0124-50 SILVER SULFADIAZINE 1 % EX CREA BOTH IP/OP $63.27 $46.82 $0.00 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $46.96 $46.96 $48.77 $0.00 $13.19 $0.00 $0.00 $0.00 $0.00 $184.22 $45.44 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224 ERX HCPCS 25000001 43598-0210-40 SILVER SULFADIAZINE 1 % EX CREA BOTH IP/OP $63.27 $46.82 $0.00 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $46.96 $46.96 $48.77 $0.00 $13.19 $0.00 $0.00 $0.00 $0.00 $184.22 $291.80 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224 ERX HCPCS 25000001 61570-0131-40 SILVER SULFADIAZINE 1 % EX CREA BOTH IP/OP $63.27 $46.82 $0.00 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $46.96 $46.96 $48.77 $0.00 $13.19 $0.00 $0.00 $0.00 $0.00 $184.22 $291.80 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224 ERX HCPCS 25000001 67877-0124-40 SILVER SULFADIAZINE 1 % EX CREA BOTH IP/OP $63.27 $46.82 $0.00 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $46.96 $46.96 $48.77 $0.00 $13.19 $0.00 $0.00 $0.00 $0.00 $184.22 $291.80 $294.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7227 ERX HCPCS 63700001 00904-5068-60 SIMETHICONE 80 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7227 ERX HCPCS 63700001 63739-0225-10 SIMETHICONE 80 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7227 ERX HCPCS 63700001 69618-0033-01 SIMETHICONE 80 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7228 ERX HCPCS 63700001 00536-2220-75 SIMETHICONE 40 MG/0.6ML PO SUSP BOTH IP/OP $22.58 $16.71 $0.00 $17.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.67 $17.88 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7228 ERX HCPCS 63700001 00904-5894-30 SIMETHICONE 40 MG/0.6ML PO SUSP BOTH IP/OP $22.58 $16.71 $0.00 $17.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.67 $17.88 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7228 ERX HCPCS 63700001 49348-0740-27 SIMETHICONE 40 MG/0.6ML PO SUSP BOTH IP/OP $22.58 $16.71 $0.00 $17.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.67 $17.88 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7228 ERX HCPCS 63700001 56184-0120-41 SIMETHICONE 40 MG/0.6ML PO SUSP BOTH IP/OP $22.58 $16.71 $0.00 $17.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.67 $17.88 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7242 ERX HCPCS 25000001 00395-2661-16 SIMPLE SYRUP PO SYRP BOTH IP/OP $83.99 $62.15 $0.00 $64.74 $0.00 $0.00 $0.00 $0.00 $0.00 $62.34 $62.34 $64.74 $0.00 $17.50 $0.00 $0.00 $0.00 $0.00 $36.43 $57.70 $58.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7242 ERX HCPCS 25000001 00802-3920-16 SIMPLE SYRUP PO SYRP BOTH IP/OP $83.99 $62.15 $0.00 $64.74 $0.00 $0.00 $0.00 $0.00 $0.00 $62.34 $62.34 $64.74 $0.00 $17.50 $0.00 $0.00 $0.00 $0.00 $36.43 $57.70 $58.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7301 ERX HCPCS 25000001 00409-3299-06 SODIUM ACETATE 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7301 ERX HCPCS 25000001 00409-3299-15 SODIUM ACETATE 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7301 ERX HCPCS 25000001 00409-3299-25 SODIUM ACETATE 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7301 ERX HCPCS 25000001 00409-3299-45 SODIUM ACETATE 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7301 ERX HCPCS 25000001 00409-7299-25 SODIUM ACETATE 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7301 ERX HCPCS 25000001 00409-7299-73 SODIUM ACETATE 2 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7306 ERX HCPCS 25000001 00409-5555-02 SODIUM BICARBONATE 4.2 % IV SOLN BOTH IP/OP $54.35 $40.22 $0.00 $41.89 $0.00 $0.00 $0.00 $0.00 $0.00 $40.34 $40.34 $41.89 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $24.65 $17.42 $39.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7306 ERX HCPCS 25000001 00409-5555-12 SODIUM BICARBONATE 4.2 % IV SOLN BOTH IP/OP $54.35 $40.22 $0.00 $41.89 $0.00 $0.00 $0.00 $0.00 $0.00 $40.34 $40.34 $41.89 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $24.65 $17.42 $39.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7306 ERX HCPCS 25000001 63323-0083-05 SODIUM BICARBONATE 4.2 % IV SOLN BOTH IP/OP $54.35 $40.22 $0.00 $41.89 $0.00 $0.00 $0.00 $0.00 $0.00 $40.34 $40.34 $41.89 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $24.65 $17.42 $39.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7306 ERX HCPCS 25000001 00409-5534-34 SODIUM BICARBONATE 4.2 % IV SOLN BOTH IP/OP $54.35 $40.22 $0.00 $41.89 $0.00 $0.00 $0.00 $0.00 $0.00 $40.34 $40.34 $41.89 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $24.65 $39.04 $39.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7308 ERX HCPCS 25000001 00409-4916-34 SODIUM BICARBONATE 7.5 % IV SOLN BOTH IP/OP $70.03 $51.82 $0.00 $56.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.02 $55.46 $56.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7309 ERX HCPCS 25000001 00409-6625-02 SODIUM BICARBONATE 8.4 % IV SOLN BOTH IP/OP $22.14 $16.38 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7309 ERX HCPCS 25000001 00409-6625-25 SODIUM BICARBONATE 8.4 % IV SOLN BOTH IP/OP $22.14 $16.38 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7309 ERX HCPCS 25000001 00409-6637-34 SODIUM BICARBONATE 8.4 % IV SOLN BOTH IP/OP $22.14 $16.38 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7309 ERX HCPCS 25000001 51754-5001-05 SODIUM BICARBONATE 8.4 % IV SOLN BOTH IP/OP $22.14 $16.38 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7309 ERX HCPCS 25000001 63323-0089-50 SODIUM BICARBONATE 8.4 % IV SOLN BOTH IP/OP $22.14 $16.38 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7309 ERX HCPCS 25000001 76329-3352-01 SODIUM BICARBONATE 8.4 % IV SOLN BOTH IP/OP $22.14 $16.38 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7313 ERX HCPCS 63700001 64980-0294-10 SODIUM BICARBONATE 650 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7313 ERX HCPCS 63700001 66553-0008-01 SODIUM BICARBONATE 650 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7313 ERX HCPCS 63700001 77333-0831-10 SODIUM BICARBONATE 650 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7318 ERX HCPCS 25000001 00990-7730-37 SODIUM CHLORIDE 0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7318 ERX HCPCS 25000001 00264-7802-10 SODIUM CHLORIDE 0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7318 ERX HCPCS 25000001 00338-0043-03 SODIUM CHLORIDE 0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7318 ERX HCPCS 25000001 00409-7985-03 SODIUM CHLORIDE 0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7318 ERX HCPCS 25000001 00264-7802-00 SODIUM CHLORIDE 0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7318 ERX HCPCS 25000001 00338-0043-04 SODIUM CHLORIDE 0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7320 ERX HCPCS J7131 00409-6660-75 SODIUM CHLORIDE 2.5 MEQ/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7321 ERX HCPCS 25000001 00264-7805-10 SODIUM CHLORIDE 3 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7321 ERX HCPCS 25000001 00338-0054-03 SODIUM CHLORIDE 3 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7322 ERX HCPCS 25000001 00409-1141-02 SODIUM CHLORIDE 4 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7322 ERX HCPCS 25000001 63323-0088-61 SODIUM CHLORIDE 4 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7322 ERX HCPCS 25000001 63323-0088-63 SODIUM CHLORIDE 4 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7322 ERX HCPCS 25000001 63323-0187-30 SODIUM CHLORIDE 4 MEQ/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7323 ERX HCPCS 25000001 00264-7806-10 SODIUM CHLORIDE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7323 ERX HCPCS 25000001 00338-0056-03 SODIUM CHLORIDE 5 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7325 ERX HCPCS 25000001 00378-6985-01 SODIUM CHLORIDE 0.9 % IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7325 ERX HCPCS 25000001 00487-9301-03 SODIUM CHLORIDE 0.9 % IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7325 ERX HCPCS 25000001 00487-9301-33 SODIUM CHLORIDE 0.9 % IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7327 ERX HCPCS 25000001 00378-6997-89 SODIUM CHLORIDE 3 % IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7328 ERX HCPCS 63700001 00223-1760-02 SODIUM CHLORIDE 1000 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7331 ERX HCPCS 25000001 17478-0622-35 SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT BOTH IP/OP $80.37 $59.47 $0.00 $61.95 $0.00 $0.00 $0.00 $0.00 $0.00 $59.65 $59.65 $61.95 $0.00 $16.75 $0.00 $0.00 $0.00 $0.00 $36.45 $57.73 $58.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7331 ERX HCPCS 25000001 24208-0385-55 SODIUM CHLORIDE (HYPERTONIC) 5 % OP OINT BOTH IP/OP $80.37 $59.47 $0.00 $61.95 $0.00 $0.00 $0.00 $0.00 $0.00 $59.65 $59.65 $61.95 $0.00 $16.75 $0.00 $0.00 $0.00 $0.00 $36.45 $57.73 $58.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7332 ERX HCPCS 25000001 17478-0623-12 SODIUM CHLORIDE (HYPERTONIC) 5 % OP SOLN BOTH IP/OP $61.79 $45.72 $0.00 $47.63 $0.00 $0.00 $0.00 $0.00 $0.00 $45.86 $45.86 $47.63 $0.00 $12.88 $0.00 $0.00 $0.00 $0.00 $23.00 $36.43 $36.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7356 ERX HCPCS 25000001 10135-0146-17 SODIUM POLYSTYRENE SULFONATE PO POWD BOTH IP/OP $27.97 $20.70 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 $20.76 $20.76 $21.56 $0.00 $5.83 $0.00 $0.00 $0.00 $0.00 $12.69 $20.09 $20.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7356 ERX HCPCS 25000001 10702-0036-45 SODIUM POLYSTYRENE SULFONATE PO POWD BOTH IP/OP $27.97 $20.70 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 $20.76 $20.76 $21.56 $0.00 $5.83 $0.00 $0.00 $0.00 $0.00 $12.69 $20.09 $20.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7356 ERX HCPCS 25000001 11534-0166-15 SODIUM POLYSTYRENE SULFONATE PO POWD BOTH IP/OP $27.97 $20.70 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 $20.76 $20.76 $21.56 $0.00 $5.83 $0.00 $0.00 $0.00 $0.00 $12.69 $20.09 $20.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7356 ERX HCPCS 25000001 24658-0760-16 SODIUM POLYSTYRENE SULFONATE PO POWD BOTH IP/OP $27.97 $20.70 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 $20.76 $20.76 $21.56 $0.00 $5.83 $0.00 $0.00 $0.00 $0.00 $12.69 $20.09 $20.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7356 ERX HCPCS 25000001 99999-6007-33 SODIUM POLYSTYRENE SULFONATE PO POWD BOTH IP/OP $27.97 $20.70 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 $20.76 $20.76 $21.56 $0.00 $5.83 $0.00 $0.00 $0.00 $0.00 $12.69 $20.09 $20.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7359 ERX HCPCS 25000001 24208-0670-04 SULFACETAMIDE SODIUM 10 % OP SOLN BOTH IP/OP $211.69 $156.65 $0.00 $163.17 $0.00 $0.00 $0.00 $0.00 $0.00 $157.12 $157.12 $163.17 $0.00 $44.12 $0.00 $0.00 $0.00 $0.00 $96.09 $152.20 $153.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7359 ERX HCPCS 25000001 61314-0701-01 SULFACETAMIDE SODIUM 10 % OP SOLN BOTH IP/OP $211.69 $156.65 $0.00 $163.17 $0.00 $0.00 $0.00 $0.00 $0.00 $157.12 $157.12 $163.17 $0.00 $44.12 $0.00 $0.00 $0.00 $0.00 $96.09 $152.20 $153.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7359 ERX HCPCS 25000001 11980-0011-05 SULFACETAMIDE SODIUM 10 % OP SOLN BOTH IP/OP $211.69 $156.65 $0.00 $385.51 $0.00 $0.00 $0.00 $0.00 $0.00 $157.12 $157.12 $163.17 $0.00 $44.12 $0.00 $0.00 $0.00 $0.00 $96.09 $385.51 $153.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7364 ERX HCPCS 25000001 60267-0705-50 SODIUM THIOSULFATE 25 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7413 ERX HCPCS 25000001 54162-0700-16 SORBITOL 70 % PO SOLN BOTH IP/OP $18.02 $13.33 $0.00 $14.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7437 ERX HCPCS 63700001 00378-2146-01 SPIRONOLACTONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7437 ERX HCPCS 63700001 00904-6927-61 SPIRONOLACTONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7437 ERX HCPCS 63700001 51079-0103-01 SPIRONOLACTONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7437 ERX HCPCS 63700001 51079-0103-20 SPIRONOLACTONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7437 ERX HCPCS 63700001 59746-0216-01 SPIRONOLACTONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7437 ERX HCPCS 63700001 63739-0544-10 SPIRONOLACTONE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 00409-4887-20 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $17.42 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 00517-3020-25 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $17.42 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 00409-4887-50 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $17.42 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 63323-0185-50 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $17.42 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 00990-7990-09 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $18.06 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 00409-4887-10 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 00641-6147-01 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 00641-6147-10 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 00641-6147-25 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7484 ERX HCPCS 25000001 63323-0185-10 STERILE WATER FOR INJECTION IJ SOLN BOTH IP/OP $26.19 $19.38 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7485 ERX HCPCS 25000001 00338-0004-04 STERILE WATER FOR IRRIGATION IR SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7508 ERX HCPCS J3000 39822-0706-02 STREPTOMYCIN SULFATE 1 G IM SOLR BOTH IP/OP $325.32 $240.74 $0.00 $250.76 $0.00 $0.00 $0.00 $0.00 $0.00 $241.45 $241.45 $250.76 $0.00 $40.59 $0.00 $0.00 $0.00 $0.00 $147.66 $233.89 $236.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7536 ERX HCPCS J0330 00409-6629-02 SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7536 ERX HCPCS J0330 00781-3411-70 SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7536 ERX HCPCS J0330 00781-3411-95 SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7536 ERX HCPCS J0330 70069-0301-25 SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7536 ERX HCPCS J0330 70121-1581-01 SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7536 ERX HCPCS J0330 70121-1581-05 SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7554 ERX HCPCS 63700001 00185-0757-01 SULFADIAZINE 500 MG PO TABS BOTH IP/OP $21.15 $15.65 $0.00 $15.34 $0.00 $0.00 $0.00 $13.77 $0.00 $0.00 $0.00 $0.00 $0.00 $4.41 $0.00 $0.00 $0.00 $0.00 $9.59 $15.19 $15.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7556 ERX HCPCS 25000001 00703-9514-01 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN BOTH IP/OP $63.06 $46.66 $0.00 $48.61 $0.00 $0.00 $0.00 $0.00 $0.00 $46.80 $46.80 $48.61 $0.00 $13.14 $0.00 $0.00 $0.00 $0.00 $28.60 $45.29 $45.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7556 ERX HCPCS 25000001 00703-9514-03 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5ML IV SOLN BOTH IP/OP $63.06 $46.66 $0.00 $48.61 $0.00 $0.00 $0.00 $0.00 $0.00 $46.80 $46.80 $48.61 $0.00 $13.14 $0.00 $0.00 $0.00 $0.00 $28.60 $45.29 $45.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7557 ERX HCPCS 63700001 57237-0232-01 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7557 ERX HCPCS 63700001 65862-0419-01 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7562 ERX HCPCS 63700001 00591-0796-01 SULFASALAZINE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7562 ERX HCPCS 63700001 50268-0730-11 SULFASALAZINE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7562 ERX HCPCS 63700001 50268-0730-15 SULFASALAZINE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7579 ERX HCPCS 63700001 00591-5660-01 SULINDAC 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7579 ERX HCPCS 63700001 00591-5660-05 SULINDAC 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7579 ERX HCPCS 63700001 42806-0011-01 SULINDAC 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7579 ERX HCPCS 63700001 51079-0667-20 SULINDAC 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7711 ERX HCPCS 63700001 00591-2472-60 TAMOXIFEN CITRATE 10 MG PO TABS BOTH IP/OP $7.94 $5.88 $0.00 $5.76 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.70 $5.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7753 ERX HCPCS 63700001 00378-4010-01 TEMAZEPAM 15 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7753 ERX HCPCS 63700001 63739-0231-10 TEMAZEPAM 15 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7753 ERX HCPCS 63700001 63739-0877-10 TEMAZEPAM 15 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7753 ERX HCPCS 63700001 67877-0146-01 TEMAZEPAM 15 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7784 ERX HCPCS J1071 00009-0417-01 TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN BOTH IP/OP $26.40 $19.54 $0.00 $20.35 $11.88 $11.88 $0.00 $0.00 $0.00 $5.50 $19.59 $19.59 $20.35 $0.00 $1.76 $0.00 $15.62 $15.62 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $1.76 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 7784 ERX HCPCS J1071 00143-9659-01 TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN BOTH IP/OP $26.40 $19.54 $0.00 $20.35 $11.88 $11.88 $0.00 $0.00 $0.00 $5.50 $19.59 $19.59 $20.35 $0.00 $1.76 $0.00 $15.62 $15.62 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $1.76 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 7784 ERX HCPCS J1071 00574-0820-10 TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN BOTH IP/OP $26.40 $19.54 $0.00 $20.35 $11.88 $11.88 $0.00 $0.00 $0.00 $5.50 $19.59 $19.59 $20.35 $0.00 $1.76 $0.00 $15.62 $15.62 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $1.76 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 7784 ERX HCPCS J1071 62756-0015-40 TESTOSTERONE CYPIONATE 200 MG/ML IM SOLN BOTH IP/OP $26.40 $19.54 $0.00 $20.35 $11.88 $11.88 $0.00 $0.00 $0.00 $5.50 $19.59 $19.59 $20.35 $0.00 $1.76 $0.00 $15.62 $15.62 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $1.76 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 7785 ERX HCPCS J3121 00143-9750-01 TESTOSTERONE ENANTHATE 200 MG/ML IM SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $2.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.94 $0.00 $0.00 $2.80 $0.00 $0.00 $0.00 $0.00 $0.00 7785 ERX HCPCS J3121 99999-6005-75 TESTOSTERONE ENANTHATE 200 MG/ML IM SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $2.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.94 $0.00 $0.00 $2.80 $0.00 $0.00 $0.00 $0.00 $0.00 7789 ERX HCPCS J1670 13533-0634-02 TETANUS IMMUNE GLOBULIN 250 UNIT/ML IM INJ BOTH IP/OP "$1,602.44 " "$1,185.81" $0.00 "$1,281.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $801.22 "$1,269.13" "$1,281.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7795 ERX HCPCS 25000001 00065-0741-14 TETRACAINE HCL 0.5 % OP SOLN BOTH IP/OP $53.25 $39.41 $0.00 $45.15 $0.00 $0.00 $0.00 $0.00 $0.00 $43.48 $43.48 $45.15 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $24.15 $38.25 $38.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7796 ERX HCPCS 63700001 23155-0017-01 TETRACYCLINE HCL 250 MG PO CAPS BOTH IP/OP $29.93 $22.15 $0.00 $23.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.97 $23.70 $23.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7821 ERX HCPCS 63700001 00121-4794-15 THEOPHYLLINE 80 MG/15ML PO SOLN BOTH IP/OP $52.48 $38.84 $0.00 $38.08 $0.00 $0.00 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $23.80 $37.70 $38.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7821 ERX HCPCS 63700001 00121-4820-40 THEOPHYLLINE 80 MG/15ML PO SOLN BOTH IP/OP $52.48 $38.84 $0.00 $38.08 $0.00 $0.00 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $23.80 $37.70 $38.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7821 ERX HCPCS 63700001 27808-0033-01 THEOPHYLLINE 80 MG/15ML PO SOLN BOTH IP/OP $52.48 $38.84 $0.00 $38.08 $0.00 $0.00 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $23.80 $37.70 $38.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7825 ERX HCPCS 63700001 00904-0539-61 THERA PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7876 ERX HCPCS J3411 63323-0013-01 THIAMINE HCL 100 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 7876 ERX HCPCS J3411 63323-0013-02 THIAMINE HCL 100 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 7876 ERX HCPCS J3411 63323-0013-09 THIAMINE HCL 100 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 7876 ERX HCPCS J3411 63323-0013-21 THIAMINE HCL 100 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 7876 ERX HCPCS J3411 67457-0196-00 THIAMINE HCL 100 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 7876 ERX HCPCS J3411 67457-0196-02 THIAMINE HCL 100 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 7886 ERX HCPCS 63700001 76388-0880-25 THIOGUANINE 40 MG PO TABS BOTH IP/OP $117.09 $86.65 $0.00 $84.94 $0.00 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.40 $0.00 $0.00 $0.00 $0.00 $53.09 $84.09 $84.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7894 ERX HCPCS 63700001 51079-0565-01 THIORIDAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7894 ERX HCPCS 63700001 51079-0565-20 THIORIDAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7894 ERX HCPCS 63700001 53489-0148-01 THIORIDAZINE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7895 ERX HCPCS 63700001 51079-0580-20 THIORIDAZINE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7899 ERX HCPCS 63700001 51079-0566-01 THIORIDAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7899 ERX HCPCS 63700001 51079-0566-20 THIORIDAZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7900 ERX HCPCS 63700001 00378-0616-01 THIORIDAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7900 ERX HCPCS 63700001 51079-0567-01 THIORIDAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7900 ERX HCPCS 63700001 53489-0150-01 THIORIDAZINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7902 ERX HCPCS 63700001 00378-1001-01 THIOTHIXENE 1 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7903 ERX HCPCS 63700001 00378-5010-01 THIOTHIXENE 10 MG PO CAPS BOTH IP/OP $14.07 $10.41 $0.00 $10.21 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $0.00 $0.00 $0.00 $2.93 $0.00 $0.00 $0.00 $0.00 $6.38 $10.11 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7906 ERX HCPCS 63700001 00378-3005-01 THIOTHIXENE 5 MG PO CAPS BOTH IP/OP $15.17 $11.23 $0.00 $11.01 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $6.88 $10.90 $11.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7906 ERX HCPCS 63700001 51079-0588-01 THIOTHIXENE 5 MG PO CAPS BOTH IP/OP $15.17 $11.23 $0.00 $11.01 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $6.88 $10.90 $11.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7906 ERX HCPCS 63700001 51079-0588-20 THIOTHIXENE 5 MG PO CAPS BOTH IP/OP $15.17 $11.23 $0.00 $11.01 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $6.88 $10.90 $11.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7906 ERX HCPCS 63700001 70954-0016-10 THIOTHIXENE 5 MG PO CAPS BOTH IP/OP $15.17 $11.23 $0.00 $11.01 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $6.88 $10.90 $11.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7940 ERX HCPCS 63700001 00456-0457-01 THYROID 15 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7947 ERX HCPCS 63700001 00456-0459-01 THYROID 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7993 ERX HCPCS 25000001 63323-0305-02 TOBRAMYCIN SULFATE 10 MG/ML IJ SOLN BOTH IP/OP $26.55 $19.65 $0.00 $20.46 $0.00 $0.00 $0.00 $0.00 $0.00 $19.71 $19.71 $20.46 $0.00 $5.53 $0.00 $0.00 $0.00 $0.00 $12.04 $19.07 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7995 ERX HCPCS 25000001 17478-0290-10 TOBRAMYCIN 0.3 % OP SOLN BOTH IP/OP $26.19 $19.38 $0.00 $42.14 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $26.34 $41.71 $42.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7995 ERX HCPCS 25000001 24208-0290-05 TOBRAMYCIN 0.3 % OP SOLN BOTH IP/OP $26.19 $19.38 $0.00 $42.14 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $26.34 $41.71 $42.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7995 ERX HCPCS 25000001 61314-0643-05 TOBRAMYCIN 0.3 % OP SOLN BOTH IP/OP $26.19 $19.38 $0.00 $42.14 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $26.34 $41.71 $42.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7995 ERX HCPCS 25000001 70069-0131-01 TOBRAMYCIN 0.3 % OP SOLN BOTH IP/OP $26.19 $19.38 $0.00 $42.14 $0.00 $0.00 $0.00 $0.00 $0.00 $19.44 $19.44 $20.19 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $26.34 $41.71 $42.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8083 ERX HCPCS 63700001 00904-6869-61 TRAZODONE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8083 ERX HCPCS 63700001 50111-0434-01 TRAZODONE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8085 ERX HCPCS 63700001 00904-6868-61 TRAZODONE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8085 ERX HCPCS 63700001 50111-0433-01 TRAZODONE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8085 ERX HCPCS 63700001 50111-0433-02 TRAZODONE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8112 ERX HCPCS 63700001 45802-0063-35 TRIAMCINOLONE ACETONIDE 0.025 % EX CREA BOTH IP/OP $18.67 $13.82 $0.00 $13.54 $0.00 $0.00 $0.00 $3.32 $0.00 $0.00 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $8.47 $13.41 $13.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8113 ERX HCPCS 63700001 00168-0004-15 TRIAMCINOLONE ACETONIDE 0.1 % EX CREA BOTH IP/OP $15.09 $11.17 $0.00 $16.97 $0.00 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 $3.14 $0.00 $0.00 $0.00 $0.00 $10.61 $16.80 $16.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8113 ERX HCPCS 63700001 52565-0056-15 TRIAMCINOLONE ACETONIDE 0.1 % EX CREA BOTH IP/OP $15.09 $11.17 $0.00 $16.97 $0.00 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 $3.14 $0.00 $0.00 $0.00 $0.00 $10.61 $16.80 $16.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8113 ERX HCPCS 63700001 00168-0004-80 TRIAMCINOLONE ACETONIDE 0.1 % EX CREA BOTH IP/OP $15.09 $11.17 $0.00 $92.81 $0.00 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 $3.14 $0.00 $0.00 $0.00 $0.00 $10.61 $92.81 $16.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8113 ERX HCPCS 63700001 45802-0064-36 TRIAMCINOLONE ACETONIDE 0.1 % EX CREA BOTH IP/OP $15.09 $11.17 $0.00 $92.81 $0.00 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 $3.14 $0.00 $0.00 $0.00 $0.00 $10.61 $92.81 $16.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8114 ERX HCPCS 63700001 00168-0002-15 TRIAMCINOLONE ACETONIDE 0.5 % EX CREA BOTH IP/OP $46.51 $34.42 $0.00 $33.74 $0.00 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $21.09 $33.41 $33.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8114 ERX HCPCS 63700001 45802-0065-35 TRIAMCINOLONE ACETONIDE 0.5 % EX CREA BOTH IP/OP $46.51 $34.42 $0.00 $33.74 $0.00 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $21.09 $33.41 $33.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8117 ERX HCPCS 25000001 45802-0054-35 TRIAMCINOLONE ACETONIDE 0.025 % EX OINT BOTH IP/OP $25.65 $18.98 $0.00 $19.77 $0.00 $0.00 $0.00 $0.00 $0.00 $19.04 $19.04 $19.77 $0.00 $5.35 $0.00 $0.00 $0.00 $0.00 $11.63 $18.42 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8118 ERX HCPCS 63700001 45802-0055-35 TRIAMCINOLONE ACETONIDE 0.1 % EX OINT BOTH IP/OP $159.48 $118.02 $0.00 $115.68 $0.00 $0.00 $0.00 $28.39 $0.00 $0.00 $0.00 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $72.30 $114.52 $115.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8118 ERX HCPCS 63700001 45802-0055-05 TRIAMCINOLONE ACETONIDE 0.1 % EX OINT BOTH IP/OP $159.48 $118.02 $0.00 $115.68 $0.00 $0.00 $0.00 $28.39 $0.00 $0.00 $0.00 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $72.30 $114.52 $115.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8118 ERX HCPCS 63700001 52565-0014-26 TRIAMCINOLONE ACETONIDE 0.1 % EX OINT BOTH IP/OP $159.48 $118.02 $0.00 $115.68 $0.00 $0.00 $0.00 $28.39 $0.00 $0.00 $0.00 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $72.30 $114.52 $115.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8118 ERX HCPCS 63700001 00168-0006-80 TRIAMCINOLONE ACETONIDE 0.1 % EX OINT BOTH IP/OP $159.48 $118.02 $0.00 $115.68 $0.00 $0.00 $0.00 $28.39 $0.00 $0.00 $0.00 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $72.30 $114.52 $115.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8118 ERX HCPCS 63700001 45802-0055-36 TRIAMCINOLONE ACETONIDE 0.1 % EX OINT BOTH IP/OP $159.48 $118.02 $0.00 $115.68 $0.00 $0.00 $0.00 $28.39 $0.00 $0.00 $0.00 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $72.30 $114.52 $115.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8118 ERX HCPCS 63700001 51672-1284-08 TRIAMCINOLONE ACETONIDE 0.1 % EX OINT BOTH IP/OP $159.48 $118.02 $0.00 $115.68 $0.00 $0.00 $0.00 $28.39 $0.00 $0.00 $0.00 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $72.30 $114.52 $115.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8118 ERX HCPCS 63700001 52565-0014-80 TRIAMCINOLONE ACETONIDE 0.1 % EX OINT BOTH IP/OP $159.48 $118.02 $0.00 $115.68 $0.00 $0.00 $0.00 $28.39 $0.00 $0.00 $0.00 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $72.30 $114.52 $115.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8120 ERX HCPCS J3301 00003-0293-05 TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP BOTH IP/OP $42.74 $31.63 $0.00 $34.14 $19.23 $19.23 $0.00 $0.00 $0.00 $7.10 $31.72 $31.72 $32.94 $0.00 $5.64 $0.00 $25.28 $25.28 $0.00 $21.34 $33.80 $34.14 $0.00 $0.00 $7.33 $0.00 $0.00 $6.98 $0.00 $0.00 $0.00 $0.00 $0.00 8120 ERX HCPCS J3301 00703-0241-01 TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP BOTH IP/OP $42.74 $31.63 $0.00 $34.14 $19.23 $19.23 $0.00 $0.00 $0.00 $7.10 $31.72 $31.72 $32.94 $0.00 $5.64 $0.00 $25.28 $25.28 $0.00 $21.34 $33.80 $34.14 $0.00 $0.00 $7.33 $0.00 $0.00 $6.98 $0.00 $0.00 $0.00 $0.00 $0.00 8120 ERX HCPCS J3301 70121-1049-01 TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP BOTH IP/OP $42.74 $31.63 $0.00 $34.14 $19.23 $19.23 $0.00 $0.00 $0.00 $7.10 $31.72 $31.72 $32.94 $0.00 $5.64 $0.00 $25.28 $25.28 $0.00 $21.34 $33.80 $34.14 $0.00 $0.00 $7.33 $0.00 $0.00 $6.98 $0.00 $0.00 $0.00 $0.00 $0.00 8120 ERX HCPCS J3301 70121-1049-05 TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP BOTH IP/OP $42.74 $31.63 $0.00 $34.14 $19.23 $19.23 $0.00 $0.00 $0.00 $7.10 $31.72 $31.72 $32.94 $0.00 $5.64 $0.00 $25.28 $25.28 $0.00 $21.34 $33.80 $34.14 $0.00 $0.00 $7.33 $0.00 $0.00 $6.98 $0.00 $0.00 $0.00 $0.00 $0.00 8121 ERX HCPCS 25000001 00713-0655-40 TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE BOTH IP/OP $279.65 $206.94 $0.00 $215.55 $0.00 $0.00 $0.00 $0.00 $0.00 $207.56 $207.56 $215.55 $0.00 $58.28 $0.00 $0.00 $0.00 $0.00 $126.93 $201.06 $203.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8121 ERX HCPCS 25000001 51672-1267-05 TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE BOTH IP/OP $279.65 $206.94 $0.00 $215.55 $0.00 $0.00 $0.00 $0.00 $0.00 $207.56 $207.56 $215.55 $0.00 $58.28 $0.00 $0.00 $0.00 $0.00 $126.93 $201.06 $203.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8121 ERX HCPCS 25000001 64980-0320-05 TRIAMCINOLONE ACETONIDE 0.1 % MT PSTE BOTH IP/OP $279.65 $206.94 $0.00 $215.55 $0.00 $0.00 $0.00 $0.00 $0.00 $207.56 $207.56 $215.55 $0.00 $58.28 $0.00 $0.00 $0.00 $0.00 $126.93 $201.06 $203.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8132 ERX HCPCS 63700001 00378-1352-01 TRIAMTERENE-HCTZ 37.5-25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8132 ERX HCPCS 63700001 00591-0424-01 TRIAMTERENE-HCTZ 37.5-25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8132 ERX HCPCS 63700001 00591-0424-05 TRIAMTERENE-HCTZ 37.5-25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8132 ERX HCPCS 63700001 00781-1123-01 TRIAMTERENE-HCTZ 37.5-25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8132 ERX HCPCS 63700001 60505-2656-01 TRIAMTERENE-HCTZ 37.5-25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8134 ERX HCPCS 63700001 51079-0433-01 TRIAMTERENE-HCTZ 75-50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8134 ERX HCPCS 63700001 51079-0433-20 TRIAMTERENE-HCTZ 75-50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8134 ERX HCPCS 63700001 60505-2657-01 TRIAMTERENE-HCTZ 75-50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8162 ERX HCPCS 63700001 00378-2410-01 TRIFLUOPERAZINE HCL 10 MG PO TABS BOTH IP/OP $10.26 $7.59 $0.00 $7.44 $0.00 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $4.65 $7.37 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8163 ERX HCPCS 63700001 00378-2402-01 TRIFLUOPERAZINE HCL 2 MG PO TABS BOTH IP/OP $8.38 $6.20 $0.00 $6.08 $0.00 $0.00 $0.00 $1.49 $0.00 $0.00 $0.00 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.80 $6.02 $6.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8163 ERX HCPCS 63700001 51079-0573-01 TRIFLUOPERAZINE HCL 2 MG PO TABS BOTH IP/OP $8.38 $6.20 $0.00 $6.08 $0.00 $0.00 $0.00 $1.49 $0.00 $0.00 $0.00 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.80 $6.02 $6.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8163 ERX HCPCS 63700001 51079-0573-20 TRIFLUOPERAZINE HCL 2 MG PO TABS BOTH IP/OP $8.38 $6.20 $0.00 $6.08 $0.00 $0.00 $0.00 $1.49 $0.00 $0.00 $0.00 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.80 $6.02 $6.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8164 ERX HCPCS 63700001 00781-8034-01 TRIFLUOPERAZINE HCL 5 MG PO TABS BOTH IP/OP $6.81 $5.04 $0.00 $4.94 $0.00 $0.00 $0.00 $1.21 $0.00 $0.00 $0.00 $0.00 $0.00 $1.42 $0.00 $0.00 $0.00 $0.00 $3.09 $4.89 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8166 ERX HCPCS 63700001 00591-5335-01 TRIHEXYPHENIDYL HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8167 ERX HCPCS 63700001 00591-5337-01 TRIHEXYPHENIDYL HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8167 ERX HCPCS 63700001 16571-0161-10 TRIHEXYPHENIDYL HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8182 ERX HCPCS 63700001 43386-0330-01 TRIMETHOPRIM 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8249 ERX HCPCS 25000001 17478-0101-12 TROPICAMIDE 0.5 % OP SOLN BOTH IP/OP $96.52 $71.42 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $71.64 $71.64 $74.40 $0.00 $20.11 $0.00 $0.00 $0.00 $0.00 $43.76 $69.32 $70.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8249 ERX HCPCS 25000001 24208-0590-64 TROPICAMIDE 0.5 % OP SOLN BOTH IP/OP $96.52 $71.42 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $71.64 $71.64 $74.40 $0.00 $20.11 $0.00 $0.00 $0.00 $0.00 $43.76 $69.32 $70.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8249 ERX HCPCS 25000001 61314-0354-01 TROPICAMIDE 0.5 % OP SOLN BOTH IP/OP $96.52 $71.42 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $0.00 $71.64 $71.64 $74.40 $0.00 $20.11 $0.00 $0.00 $0.00 $0.00 $43.76 $69.32 $70.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8250 ERX HCPCS 25000001 17478-0102-12 TROPICAMIDE 1 % OP SOLN BOTH IP/OP $44.63 $33.03 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $33.12 $33.12 $34.40 $0.00 $9.30 $0.00 $0.00 $0.00 $0.00 $20.24 $32.05 $32.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8250 ERX HCPCS 25000001 61314-0355-02 TROPICAMIDE 1 % OP SOLN BOTH IP/OP $44.63 $33.03 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $33.12 $33.12 $34.40 $0.00 $9.30 $0.00 $0.00 $0.00 $0.00 $20.24 $32.05 $32.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8250 ERX HCPCS 25000001 24208-0585-59 TROPICAMIDE 1 % OP SOLN BOTH IP/OP $44.63 $33.03 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $33.12 $33.12 $34.40 $0.00 $9.30 $0.00 $0.00 $0.00 $0.00 $20.24 $32.05 $32.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8250 ERX HCPCS 25000001 61314-0355-01 TROPICAMIDE 1 % OP SOLN BOTH IP/OP $44.63 $33.03 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $33.12 $33.12 $34.40 $0.00 $9.30 $0.00 $0.00 $0.00 $0.00 $20.24 $32.05 $32.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8259 ERX HCPCS 25000001 42023-0104-01 TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8259 ERX HCPCS 25000001 49281-0752-21 TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8259 ERX HCPCS 25000001 49281-0752-22 TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8259 ERX HCPCS 25000001 99999-6005-54 TUBERCULIN PPD 5 UNIT/0.1ML ID SOLN BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8443 ERX HCPCS J3370 00409-4332-01 VANCOMYCIN HCL 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $3.62 $16.33 $16.33 $16.96 $0.00 $3.34 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 8443 ERX HCPCS J3370 00409-6534-01 VANCOMYCIN HCL 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $3.62 $16.33 $16.33 $16.96 $0.00 $3.34 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 8443 ERX HCPCS J3370 47781-0598-07 VANCOMYCIN HCL 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $3.62 $16.33 $16.33 $16.96 $0.00 $3.34 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 8443 ERX HCPCS J3370 47781-0598-91 VANCOMYCIN HCL 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $3.62 $16.33 $16.33 $16.96 $0.00 $3.34 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 8443 ERX HCPCS J3370 67457-0339-50 VANCOMYCIN HCL 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $3.62 $16.33 $16.33 $16.96 $0.00 $3.34 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 8443 ERX HCPCS J3370 70860-0104-10 VANCOMYCIN HCL 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $3.62 $16.33 $16.33 $16.96 $0.00 $3.34 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 8527 ERX HCPCS 25000001 00409-1144-05 VERAPAMIL HCL 2.5 MG/ML IV SOLN BOTH IP/OP $80.83 $59.81 $0.00 $62.30 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $62.30 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $36.66 $58.06 $58.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8527 ERX HCPCS 25000001 42571-0313-75 VERAPAMIL HCL 2.5 MG/ML IV SOLN BOTH IP/OP $80.83 $59.81 $0.00 $62.30 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $62.30 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $36.66 $58.06 $58.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8527 ERX HCPCS 25000001 42571-0313-87 VERAPAMIL HCL 2.5 MG/ML IV SOLN BOTH IP/OP $80.83 $59.81 $0.00 $62.30 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $62.30 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $36.66 $58.06 $58.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8527 ERX HCPCS 25000001 42571-0313-97 VERAPAMIL HCL 2.5 MG/ML IV SOLN BOTH IP/OP $80.83 $59.81 $0.00 $62.30 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $62.30 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $36.66 $58.06 $58.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8527 ERX HCPCS 25000001 51754-0203-04 VERAPAMIL HCL 2.5 MG/ML IV SOLN BOTH IP/OP $80.83 $59.81 $0.00 $62.30 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $62.30 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $36.66 $58.06 $58.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8527 ERX HCPCS 25000001 70121-1585-05 VERAPAMIL HCL 2.5 MG/ML IV SOLN BOTH IP/OP $80.83 $59.81 $0.00 $62.30 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $62.30 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $36.66 $58.06 $58.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8527 ERX HCPCS 25000001 72485-0108-05 VERAPAMIL HCL 2.5 MG/ML IV SOLN BOTH IP/OP $80.83 $59.81 $0.00 $62.30 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $62.30 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $36.66 $58.06 $58.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8527 ERX HCPCS 25000001 72485-0108-25 VERAPAMIL HCL 2.5 MG/ML IV SOLN BOTH IP/OP $80.83 $59.81 $0.00 $62.30 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $62.30 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $36.66 $58.06 $58.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8528 ERX HCPCS 63700001 00904-2924-61 VERAPAMIL HCL 120 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8530 ERX HCPCS 63700001 00591-0343-01 VERAPAMIL HCL 80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8530 ERX HCPCS 63700001 00904-2920-61 VERAPAMIL HCL 80 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8594 ERX HCPCS J9360 63323-0278-10 VINBLASTINE SULFATE 1 MG/ML IV SOLN BOTH IP/OP $196.37 $145.31 $0.00 $151.36 $88.37 $88.37 $0.00 $0.00 $0.00 $40.93 $145.75 $145.75 $151.36 $0.00 $39.40 $0.00 $116.15 $116.15 $0.00 $81.40 $128.94 $130.24 $0.00 $0.00 $45.71 $0.00 $0.00 $43.52 $0.00 $0.00 $0.00 $0.00 $0.00 8597 ERX HCPCS J9370 61703-0309-06 VINCRISTINE SULFATE 1 MG/ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $11.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8597 ERX HCPCS J9370 61703-0309-16 VINCRISTINE SULFATE 1 MG/ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $11.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8597 ERX HCPCS J9370 61703-0309-25 VINCRISTINE SULFATE 1 MG/ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $11.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8597 ERX HCPCS J9370 61703-0309-26 VINCRISTINE SULFATE 1 MG/ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $11.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8639 ERX HCPCS 63700001 00904-2085-60 VITAMIN A 3 MG (10000 UT) PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8647 ERX HCPCS 63700001 31604-0012-81 VITAMIN B-1 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8647 ERX HCPCS 63700001 37864-0905-99 VITAMIN B-1 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8647 ERX HCPCS 63700001 48433-0108-01 VITAMIN B-1 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8647 ERX HCPCS 63700001 51645-0905-99 VITAMIN B-1 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8647 ERX HCPCS 63700001 54629-0057-01 VITAMIN B-1 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8647 ERX HCPCS 63700001 77333-0934-10 VITAMIN B-1 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8647 ERX HCPCS 63700001 77333-0934-25 VITAMIN B-1 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8654 ERX HCPCS 63700001 10006-0730-43 VITAMIN B-12 1000 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8654 ERX HCPCS 63700001 74312-0013-80 VITAMIN B-12 1000 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8654 ERX HCPCS 63700001 77333-0938-10 VITAMIN B-12 1000 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8654 ERX HCPCS 63700001 77333-0938-25 VITAMIN B-12 1000 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8661 ERX HCPCS 63700001 43292-0555-38 VITAMIN B-2 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8667 ERX HCPCS 63700001 00904-0520-60 VITAMIN B-6 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8667 ERX HCPCS 63700001 77333-0940-10 VITAMIN B-6 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8667 ERX HCPCS 63700001 77333-0940-25 VITAMIN B-6 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8680 ERX HCPCS 63700001 00904-0523-61 VITAMIN C 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8680 ERX HCPCS 63700001 00904-0523-72 VITAMIN C 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8680 ERX HCPCS 63700001 00904-0523-80 VITAMIN C 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8680 ERX HCPCS 63700001 57896-0841-01 VITAMIN C 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8698 ERX HCPCS 63700001 00904-0270-60 VITAMIN E 100 UNITS PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8701 ERX HCPCS 63700001 00904-0274-60 VITAMIN E 400 UNITS PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8701 ERX HCPCS 63700001 10006-0700-34 VITAMIN E 400 UNITS PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8718 ERX HCPCS J3430 00409-9158-01 VITAMIN K1 10 MG/ML IJ SOLN BOTH IP/OP $49.25 $36.45 $0.00 $37.96 $0.00 $0.00 $0.00 $0.00 $0.00 $36.55 $36.55 $37.96 $0.00 $8.37 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8718 ERX HCPCS J3430 00409-9158-31 VITAMIN K1 10 MG/ML IJ SOLN BOTH IP/OP $49.25 $36.45 $0.00 $37.96 $0.00 $0.00 $0.00 $0.00 $0.00 $36.55 $36.55 $37.96 $0.00 $8.37 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8718 ERX HCPCS J3430 43598-0405-16 VITAMIN K1 10 MG/ML IJ SOLN BOTH IP/OP $49.25 $36.45 $0.00 $37.96 $0.00 $0.00 $0.00 $0.00 $0.00 $36.55 $36.55 $37.96 $0.00 $8.37 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8748 ERX HCPCS 63700001 00832-1219-01 WARFARIN SODIUM 10 MG PO TABS BOTH IP/OP $14.59 $10.80 $0.00 $11.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.30 $11.56 $11.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8749 ERX HCPCS 63700001 00832-1212-01 WARFARIN SODIUM 2 MG PO TABS BOTH IP/OP $9.81 $7.26 $0.00 $7.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.91 $7.77 $7.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8749 ERX HCPCS 63700001 00832-1212-89 WARFARIN SODIUM 2 MG PO TABS BOTH IP/OP $9.81 $7.26 $0.00 $7.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.91 $7.77 $7.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8749 ERX HCPCS 63700001 51672-4028-01 WARFARIN SODIUM 2 MG PO TABS BOTH IP/OP $9.81 $7.26 $0.00 $7.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.91 $7.77 $7.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8750 ERX HCPCS 63700001 00832-1213-01 WARFARIN SODIUM 2.5 MG PO TABS BOTH IP/OP $10.13 $7.50 $0.00 $8.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.07 $8.02 $8.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8750 ERX HCPCS 63700001 57237-0121-01 WARFARIN SODIUM 2.5 MG PO TABS BOTH IP/OP $10.13 $7.50 $0.00 $8.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.07 $8.02 $8.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8750 ERX HCPCS 63700001 68084-0027-01 WARFARIN SODIUM 2.5 MG PO TABS BOTH IP/OP $10.13 $7.50 $0.00 $8.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.07 $8.02 $8.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8751 ERX HCPCS 63700001 00832-1216-01 WARFARIN SODIUM 5 MG PO TABS BOTH IP/OP $10.55 $7.81 $0.00 $8.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.28 $8.36 $8.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8751 ERX HCPCS 63700001 57237-0124-01 WARFARIN SODIUM 5 MG PO TABS BOTH IP/OP $10.55 $7.81 $0.00 $8.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.28 $8.36 $8.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8752 ERX HCPCS 63700001 00832-1218-01 WARFARIN SODIUM 7.5 MG PO TABS BOTH IP/OP $14.06 $10.40 $0.00 $11.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.03 $11.14 $11.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8752 ERX HCPCS 63700001 51672-4034-01 WARFARIN SODIUM 7.5 MG PO TABS BOTH IP/OP $14.06 $10.40 $0.00 $11.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.03 $11.14 $11.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8752 ERX HCPCS 63700001 57237-0126-01 WARFARIN SODIUM 7.5 MG PO TABS BOTH IP/OP $14.06 $10.40 $0.00 $11.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.03 $11.14 $11.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8780 ERX HCPCS 63700001 00168-0053-21 WHITE PETROLATUM EX OINT BOTH IP/OP $92.80 $68.67 $0.00 $67.32 $0.00 $0.00 $0.00 $16.52 $0.00 $0.00 $0.00 $0.00 $0.00 $19.34 $0.00 $0.00 $0.00 $0.00 $42.08 $66.65 $67.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8780 ERX HCPCS 63700001 00168-0053-16 WHITE PETROLATUM EX OINT BOTH IP/OP $92.80 $68.67 $0.00 $67.32 $0.00 $0.00 $0.00 $16.52 $0.00 $0.00 $0.00 $0.00 $0.00 $19.34 $0.00 $0.00 $0.00 $0.00 $42.08 $66.65 $67.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8865 ERX HCPCS 25000001 00409-4090-01 ZINC CHLORIDE 1 MG/ML IV SOLN BOTH IP/OP $97.82 $72.39 $0.00 $75.40 $0.00 $0.00 $0.00 $0.00 $0.00 $72.60 $72.60 $75.40 $0.00 $20.39 $0.00 $0.00 $0.00 $0.00 $40.81 $64.64 $65.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8874 ERX HCPCS 63700001 00536-5700-98 ZINC OXIDE 20 % EX OINT BOTH IP/OP $137.76 $101.94 $0.00 $109.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.50 $109.11 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8874 ERX HCPCS 63700001 00168-0062-31 ZINC OXIDE 20 % EX OINT BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8874 ERX HCPCS 63700001 75834-0170-01 ZINC OXIDE 20 % EX OINT BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8874 ERX HCPCS 63700001 00536-5700-28 ZINC OXIDE 20 % EX OINT BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8878 ERX HCPCS 25000001 00517-6110-25 ZINC SULFATE 1 MG/ML IV SOLN BOTH IP/OP $111.65 $82.62 $0.00 $89.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.83 $88.43 $89.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8880 ERX HCPCS 63700001 37864-0991-01 ZINC SULFATE 220 (50 ZN) MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8880 ERX HCPCS 63700001 77333-0983-10 ZINC SULFATE 220 (50 ZN) MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8946 ERX HCPCS 25000001 51672-2114-00 ACETAMINOPHEN 80 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8946 ERX HCPCS 25000001 51672-2114-02 ACETAMINOPHEN 80 MG RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8958 ERX HCPCS 63700001 00591-3369-01 BUTALBITAL-APAP-CAFFEINE 50-325-40 MG PO TABS BOTH IP/OP $7.08 $5.24 $0.00 $5.14 $0.00 $0.00 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $0.00 $1.48 $0.00 $0.00 $0.00 $0.00 $3.21 $5.08 $5.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8958 ERX HCPCS 63700001 00603-2544-21 BUTALBITAL-APAP-CAFFEINE 50-325-40 MG PO TABS BOTH IP/OP $7.08 $5.24 $0.00 $5.14 $0.00 $0.00 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $0.00 $1.48 $0.00 $0.00 $0.00 $0.00 $3.21 $5.08 $5.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8958 ERX HCPCS 63700001 10702-0253-01 BUTALBITAL-APAP-CAFFEINE 50-325-40 MG PO TABS BOTH IP/OP $7.08 $5.24 $0.00 $5.14 $0.00 $0.00 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $0.00 $1.48 $0.00 $0.00 $0.00 $0.00 $3.21 $5.08 $5.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8958 ERX HCPCS 63700001 68084-0396-65 BUTALBITAL-APAP-CAFFEINE 50-325-40 MG PO TABS BOTH IP/OP $7.08 $5.24 $0.00 $5.14 $0.00 $0.00 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $0.00 $1.48 $0.00 $0.00 $0.00 $0.00 $3.21 $5.08 $5.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8962 ERX HCPCS 63700001 29033-0030-01 ACETAZOLAMIDE ER 500 MG PO CP12 BOTH IP/OP $18.00 $13.32 $0.00 $13.06 $0.00 $0.00 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $8.16 $12.93 $13.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8962 ERX HCPCS 63700001 50742-0233-01 ACETAZOLAMIDE ER 500 MG PO CP12 BOTH IP/OP $18.00 $13.32 $0.00 $13.06 $0.00 $0.00 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $8.16 $12.93 $13.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8963 ERX HCPCS 25000001 00338-0656-04 ACETIC ACID 0.25 % IR SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8968 ERX HCPCS 63700001 00378-8700-06 ACYCLOVIR 5 % EX OINT BOTH IP/OP "$1,164.52 " $861.74 $0.00 $845.47 $0.00 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $528.42 $837.02 $845.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8968 ERX HCPCS 63700001 13668-0515-01 ACYCLOVIR 5 % EX OINT BOTH IP/OP "$1,164.52 " $861.74 $0.00 $845.47 $0.00 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $528.42 $837.02 $845.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8968 ERX HCPCS 63700001 00187-0993-95 ACYCLOVIR 5 % EX OINT BOTH IP/OP "$1,164.52 " $861.74 $0.00 "$1,516.10" $0.00 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $528.42 "$1,516.10" $845.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8969 ERX HCPCS 63700001 00904-5789-61 ACYCLOVIR 200 MG PO CAPS BOTH IP/OP $6.41 $4.74 $0.00 $4.80 $0.00 $0.00 $0.00 $1.14 $0.00 $0.00 $0.00 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8969 ERX HCPCS 63700001 68084-0107-01 ACYCLOVIR 200 MG PO CAPS BOTH IP/OP $6.41 $4.74 $0.00 $4.80 $0.00 $0.00 $0.00 $1.14 $0.00 $0.00 $0.00 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8970 ERX HCPCS 63700001 99999-6004-74 ACYCLOVIR 200 MG/5ML PO SUSP BOTH IP/OP $181.76 $134.50 $0.00 $132.00 $0.00 $0.00 $0.00 $32.35 $0.00 $0.00 $0.00 $0.00 $0.00 $37.88 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8970 ERX HCPCS 63700001 00378-8712-73 ACYCLOVIR 200 MG/5ML PO SUSP BOTH IP/OP $181.76 $134.50 $0.00 $934.16 $0.00 $0.00 $0.00 $32.35 $0.00 $0.00 $0.00 $0.00 $0.00 $37.88 $0.00 $0.00 $0.00 $0.00 $82.50 $934.16 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8970 ERX HCPCS 63700001 00472-0082-16 ACYCLOVIR 200 MG/5ML PO SUSP BOTH IP/OP $181.76 $134.50 $0.00 $934.16 $0.00 $0.00 $0.00 $32.35 $0.00 $0.00 $0.00 $0.00 $0.00 $37.88 $0.00 $0.00 $0.00 $0.00 $82.50 $934.16 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8970 ERX HCPCS 63700001 50383-0810-16 ACYCLOVIR 200 MG/5ML PO SUSP BOTH IP/OP $181.76 $134.50 $0.00 $934.16 $0.00 $0.00 $0.00 $32.35 $0.00 $0.00 $0.00 $0.00 $0.00 $37.88 $0.00 $0.00 $0.00 $0.00 $82.50 $934.16 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 00904-5790-61 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 31722-0777-01 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 31722-0777-05 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 50268-0061-15 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 60505-5306-01 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 60505-5306-08 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 61442-0112-05 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 63304-0504-01 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 63739-0682-10 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8971 ERX HCPCS 63700001 68084-0108-01 ACYCLOVIR 400 MG PO TABS BOTH IP/OP $7.17 $5.31 $0.00 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.59 $5.68 $5.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8972 ERX HCPCS 63700001 31722-0778-01 ACYCLOVIR 800 MG PO TABS BOTH IP/OP $13.31 $9.85 $0.00 $10.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.66 $10.54 $10.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8972 ERX HCPCS 63700001 60505-5307-01 ACYCLOVIR 800 MG PO TABS BOTH IP/OP $13.31 $9.85 $0.00 $10.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.66 $10.54 $10.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8972 ERX HCPCS 63700001 68084-0109-01 ACYCLOVIR 800 MG PO TABS BOTH IP/OP $13.31 $9.85 $0.00 $10.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.66 $10.54 $10.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8979 ERX HCPCS 63700001 00591-2712-02 ALBENDAZOLE 200 MG PO TABS BOTH IP/OP $373.28 $276.23 $0.00 $298.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.64 $295.64 $298.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8979 ERX HCPCS 63700001 52054-0550-22 ALBENDAZOLE 200 MG PO TABS BOTH IP/OP $373.28 $276.23 $0.00 $298.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.64 $295.64 $298.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8979 ERX HCPCS 63700001 69097-0237-72 ALBENDAZOLE 200 MG PO TABS BOTH IP/OP $373.28 $276.23 $0.00 $298.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.64 $295.64 $298.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8979 ERX HCPCS 63700001 70710-1021-08 ALBENDAZOLE 200 MG PO TABS BOTH IP/OP $373.28 $276.23 $0.00 $298.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.64 $295.64 $298.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8981 ERX HCPCS P9047 00944-0493-01 ALBUMIN HUMAN 25 % IV SOLN BOTH IP/OP $199.88 $147.91 $0.00 $154.07 $89.95 $89.95 $52.45 $52.45 $52.45 $60.16 $148.35 $148.35 $154.07 $52.45 $61.63 $34.09 $118.23 $118.23 $55.07 $90.72 $143.70 $145.15 $76.05 $76.05 $61.63 $0.00 $0.00 $58.68 $52.45 $0.00 $0.00 $0.00 $0.00 8981 ERX HCPCS P9047 76125-0792-25 ALBUMIN HUMAN 25 % IV SOLN BOTH IP/OP $199.88 $147.91 $0.00 $154.07 $89.95 $89.95 $52.45 $52.45 $52.45 $60.16 $148.35 $148.35 $154.07 $52.45 $61.63 $34.09 $118.23 $118.23 $55.07 $90.72 $143.70 $145.15 $76.05 $76.05 $61.63 $0.00 $0.00 $58.68 $52.45 $0.00 $0.00 $0.00 $0.00 8982 ERX HCPCS P9045 00944-0495-05 ALBUMIN HUMAN 5 % IV SOLN BOTH IP/OP $199.53 $147.65 $0.00 $153.80 $89.79 $89.79 $52.45 $52.45 $52.45 $27.86 $148.09 $148.09 $153.80 $52.45 $41.58 $34.09 $118.02 $118.02 $55.07 $90.57 $143.45 $144.90 $76.05 $76.05 $28.35 $0.00 $0.00 $28.84 $52.45 $0.00 $0.00 $0.00 $0.00 8982 ERX HCPCS P9045 44206-0310-25 ALBUMIN HUMAN 5 % IV SOLN BOTH IP/OP $199.53 $147.65 $0.00 $153.80 $89.79 $89.79 $52.45 $52.45 $52.45 $27.86 $148.09 $148.09 $153.80 $52.45 $41.58 $34.09 $118.02 $118.02 $55.07 $90.57 $143.45 $144.90 $76.05 $76.05 $28.35 $0.00 $0.00 $28.84 $52.45 $0.00 $0.00 $0.00 $0.00 8982 ERX HCPCS P9045 44206-0310-50 ALBUMIN HUMAN 5 % IV SOLN BOTH IP/OP $199.53 $147.65 $0.00 $153.80 $89.79 $89.79 $52.45 $52.45 $52.45 $27.86 $148.09 $148.09 $153.80 $52.45 $41.58 $34.09 $118.02 $118.02 $55.07 $90.57 $143.45 $144.90 $76.05 $76.05 $28.35 $0.00 $0.00 $28.84 $52.45 $0.00 $0.00 $0.00 $0.00 8982 ERX HCPCS P9045 68516-5214-02 ALBUMIN HUMAN 5 % IV SOLN BOTH IP/OP $199.53 $147.65 $0.00 $153.80 $89.79 $89.79 $52.45 $52.45 $52.45 $27.86 $148.09 $148.09 $153.80 $52.45 $41.58 $34.09 $118.02 $118.02 $55.07 $90.57 $143.45 $144.90 $76.05 $76.05 $28.35 $0.00 $0.00 $28.84 $52.45 $0.00 $0.00 $0.00 $0.00 8982 ERX HCPCS P9045 76125-0790-26 ALBUMIN HUMAN 5 % IV SOLN BOTH IP/OP $199.53 $147.65 $0.00 $153.80 $89.79 $89.79 $52.45 $52.45 $52.45 $27.86 $148.09 $148.09 $153.80 $52.45 $41.58 $34.09 $118.02 $118.02 $55.07 $90.57 $143.45 $144.90 $76.05 $76.05 $28.35 $0.00 $0.00 $28.84 $52.45 $0.00 $0.00 $0.00 $0.00 8982 ERX HCPCS P9045 99999-6006-39 ALBUMIN HUMAN 5 % IV SOLN BOTH IP/OP $199.53 $147.65 $0.00 $153.80 $89.79 $89.79 $52.45 $52.45 $52.45 $27.86 $148.09 $148.09 $153.80 $52.45 $41.58 $34.09 $118.02 $118.02 $55.07 $90.57 $143.45 $144.90 $76.05 $76.05 $28.35 $0.00 $0.00 $28.84 $52.45 $0.00 $0.00 $0.00 $0.00 8985 ERX HCPCS 25000001 00168-0263-15 ALCLOMETASONE DIPROPIONATE 0.05 % EX CREA BOTH IP/OP $185.57 $137.32 $0.00 $143.04 $0.00 $0.00 $0.00 $0.00 $0.00 $137.73 $137.73 $143.04 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $84.14 $133.27 $134.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8985 ERX HCPCS 25000001 51672-1306-01 ALCLOMETASONE DIPROPIONATE 0.05 % EX CREA BOTH IP/OP $185.57 $137.32 $0.00 $143.04 $0.00 $0.00 $0.00 $0.00 $0.00 $137.73 $137.73 $143.04 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $84.14 $133.27 $134.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8985 ERX HCPCS 25000001 68462-0300-17 ALCLOMETASONE DIPROPIONATE 0.05 % EX CREA BOTH IP/OP $185.57 $137.32 $0.00 $143.04 $0.00 $0.00 $0.00 $0.00 $0.00 $137.73 $137.73 $143.04 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $84.14 $133.27 $134.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8985 ERX HCPCS 25000001 51672-1306-06 ALCLOMETASONE DIPROPIONATE 0.05 % EX CREA BOTH IP/OP $185.57 $137.32 $0.00 $348.39 $0.00 $0.00 $0.00 $0.00 $0.00 $137.73 $137.73 $143.04 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $84.14 $348.39 $134.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8985 ERX HCPCS 25000001 51672-1306-03 ALCLOMETASONE DIPROPIONATE 0.05 % EX CREA BOTH IP/OP $185.57 $137.32 $0.00 $464.52 $0.00 $0.00 $0.00 $0.00 $0.00 $137.73 $137.73 $143.04 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $84.14 $464.52 $134.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8985 ERX HCPCS 25000001 68462-0300-65 ALCLOMETASONE DIPROPIONATE 0.05 % EX CREA BOTH IP/OP $185.57 $137.32 $0.00 $464.52 $0.00 $0.00 $0.00 $0.00 $0.00 $137.73 $137.73 $143.04 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $84.14 $464.52 $134.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8986 ERX HCPCS 25000001 00168-0264-15 ALCLOMETASONE DIPROPIONATE 0.05 % EX OINT BOTH IP/OP $83.78 $62.00 $0.00 $64.58 $0.00 $0.00 $0.00 $0.00 $0.00 $62.18 $62.18 $64.58 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $60.18 $60.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8986 ERX HCPCS 25000001 51672-1316-01 ALCLOMETASONE DIPROPIONATE 0.05 % EX OINT BOTH IP/OP $83.78 $62.00 $0.00 $64.58 $0.00 $0.00 $0.00 $0.00 $0.00 $62.18 $62.18 $64.58 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $60.18 $60.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8986 ERX HCPCS 25000001 68462-0299-17 ALCLOMETASONE DIPROPIONATE 0.05 % EX OINT BOTH IP/OP $83.78 $62.00 $0.00 $64.58 $0.00 $0.00 $0.00 $0.00 $0.00 $62.18 $62.18 $64.58 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $60.18 $60.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8986 ERX HCPCS 25000001 00168-0264-45 ALCLOMETASONE DIPROPIONATE 0.05 % EX OINT BOTH IP/OP $83.78 $62.00 $0.00 $149.66 $0.00 $0.00 $0.00 $0.00 $0.00 $62.18 $62.18 $64.58 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $149.66 $60.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8986 ERX HCPCS 25000001 00168-0264-60 ALCLOMETASONE DIPROPIONATE 0.05 % EX OINT BOTH IP/OP $83.78 $62.00 $0.00 $199.54 $0.00 $0.00 $0.00 $0.00 $0.00 $62.18 $62.18 $64.58 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $199.54 $60.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9001 ERX HCPCS J0270 00009-3169-06 ALPROSTADIL 500 MCG/ML IJ SOLN BOTH IP/OP $436.84 $323.26 $0.00 $336.72 $0.00 $0.00 $0.00 $0.00 $0.00 $324.22 $324.22 $336.72 $0.00 $91.04 $0.00 $0.00 $0.00 $0.00 $198.27 $314.06 $317.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9001 ERX HCPCS J0270 00703-1501-01 ALPROSTADIL 500 MCG/ML IJ SOLN BOTH IP/OP $436.84 $323.26 $0.00 $336.72 $0.00 $0.00 $0.00 $0.00 $0.00 $324.22 $324.22 $336.72 $0.00 $91.04 $0.00 $0.00 $0.00 $0.00 $198.27 $314.06 $317.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9002 ERX HCPCS J2997 50242-0085-27 ALTEPLASE 100 MG IV SOLR BOTH IP/OP "$2,386.66 " "$1,766.13" $0.00 "$1,839.64" "$1,074.00" "$1,074.00" $876.70 $876.70 $876.70 $497.44 "$1,771.38" "$1,771.38" "$1,839.64" $877.50 $497.38 $570.38 "$1,176.62" "$1,176.62" $920.20 "$1,082.45" "$1,714.59" "$1,731.91" "$1,270.75" "$1,270.75" $338.81 $0.00 $0.00 $344.65 $878.85 $0.00 $0.00 $0.00 $0.00 9003 ERX HCPCS J2997 50242-0044-13 ALTEPLASE 50 MG IV SOLR BOTH IP/OP "$11,933.30 " "$8,830.64" $0.00 "$9,198.19" "$5,369.99" "$5,369.99" "$4,383.50" "$4,383.50" "$4,383.50" "$2,487.20" "$8,856.90" "$8,856.90" "$9,198.19" "$4,387.50" "$2,486.90" "$2,851.88" "$5,883.12" "$5,883.12" "$4,601.00" "$5,412.23" "$8,572.97" "$8,659.57" "$6,353.76" "$6,353.76" "$1,694.03" $0.00 $0.00 "$1,723.25" "$4,394.25" $0.00 $0.00 $0.00 $0.00 9009 ERX HCPCS 25000001 00121-1761-30 ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP BOTH IP/OP $7.92 $5.86 $0.00 $6.10 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $5.88 $6.10 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9009 ERX HCPCS 25000001 00904-6833-14 ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP BOTH IP/OP $7.92 $5.86 $0.00 $6.10 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $5.88 $6.10 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9009 ERX HCPCS 25000001 49348-0019-39 ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP BOTH IP/OP $7.92 $5.86 $0.00 $6.10 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $5.88 $6.10 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9009 ERX HCPCS 25000001 57896-0629-12 ALUM & MAG HYDROXIDE-SIMETH 200-200-20 MG/5ML PO SUSP BOTH IP/OP $7.92 $5.86 $0.00 $6.10 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $5.88 $6.10 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9020 ERX HCPCS 25000001 51224-0162-12 ALUM SULFATE-CA ACETATE EX PACK BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9028 ERX HCPCS 25000001 00096-0707-37 ALUMINUM CHLORIDE 20 % EX SOLN BOTH IP/OP $35.04 $25.93 $0.00 $27.01 $0.00 $0.00 $0.00 $0.00 $0.00 $26.01 $26.01 $27.01 $0.00 $7.30 $0.00 $0.00 $0.00 $0.00 $14.82 $23.47 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9028 ERX HCPCS 25000001 00096-0707-60 ALUMINUM CHLORIDE 20 % EX SOLN BOTH IP/OP $35.04 $25.93 $0.00 $35.04 $0.00 $0.00 $0.00 $0.00 $0.00 $26.01 $26.01 $27.01 $0.00 $7.30 $0.00 $0.00 $0.00 $0.00 $14.82 $35.04 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9063 ERX HCPCS 63700001 49411-0050-30 AMINOCAPROIC ACID 500 MG PO TABS BOTH IP/OP $94.31 $69.79 $0.00 $68.41 $0.00 $0.00 $0.00 $16.79 $0.00 $0.00 $0.00 $0.00 $0.00 $19.65 $0.00 $0.00 $0.00 $0.00 $42.76 $67.72 $68.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9063 ERX HCPCS 63700001 69680-0115-30 AMINOCAPROIC ACID 500 MG PO TABS BOTH IP/OP $94.31 $69.79 $0.00 $68.41 $0.00 $0.00 $0.00 $16.79 $0.00 $0.00 $0.00 $0.00 $0.00 $19.65 $0.00 $0.00 $0.00 $0.00 $42.76 $67.72 $68.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9066 ERX HCPCS 63700001 00245-0147-01 AMIODARONE HCL 200 MG PO TABS BOTH IP/OP $12.85 $9.51 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.43 $10.18 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9066 ERX HCPCS 63700001 00245-0147-89 AMIODARONE HCL 200 MG PO TABS BOTH IP/OP $12.85 $9.51 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.43 $10.18 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9066 ERX HCPCS 63700001 16714-0844-01 AMIODARONE HCL 200 MG PO TABS BOTH IP/OP $12.85 $9.51 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.43 $10.18 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9066 ERX HCPCS 63700001 51672-4025-04 AMIODARONE HCL 200 MG PO TABS BOTH IP/OP $12.85 $9.51 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.43 $10.18 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9066 ERX HCPCS 63700001 63739-0387-10 AMIODARONE HCL 200 MG PO TABS BOTH IP/OP $12.85 $9.51 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.43 $10.18 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9066 ERX HCPCS 63700001 68382-0227-14 AMIODARONE HCL 200 MG PO TABS BOTH IP/OP $12.85 $9.51 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.43 $10.18 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9069 ERX HCPCS 63700001 00904-6371-61 AMLODIPINE BESYLATE 10 MG PO TABS BOTH IP/OP $9.02 $6.67 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9069 ERX HCPCS 63700001 10135-0526-05 AMLODIPINE BESYLATE 10 MG PO TABS BOTH IP/OP $9.02 $6.67 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9069 ERX HCPCS 63700001 63739-0631-10 AMLODIPINE BESYLATE 10 MG PO TABS BOTH IP/OP $9.02 $6.67 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9069 ERX HCPCS 63700001 67877-0199-05 AMLODIPINE BESYLATE 10 MG PO TABS BOTH IP/OP $9.02 $6.67 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9069 ERX HCPCS 63700001 68382-0123-16 AMLODIPINE BESYLATE 10 MG PO TABS BOTH IP/OP $9.02 $6.67 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9069 ERX HCPCS 63700001 69097-0128-05 AMLODIPINE BESYLATE 10 MG PO TABS BOTH IP/OP $9.02 $6.67 $0.00 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9070 ERX HCPCS 63700001 00904-6369-61 AMLODIPINE BESYLATE 2.5 MG PO TABS BOTH IP/OP $6.58 $4.87 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $5.21 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9070 ERX HCPCS 63700001 68382-0121-16 AMLODIPINE BESYLATE 2.5 MG PO TABS BOTH IP/OP $6.58 $4.87 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $5.21 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9071 ERX HCPCS 63700001 00904-6370-61 AMLODIPINE BESYLATE 5 MG PO TABS BOTH IP/OP $6.58 $4.87 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $5.21 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9071 ERX HCPCS 63700001 50268-0084-11 AMLODIPINE BESYLATE 5 MG PO TABS BOTH IP/OP $6.58 $4.87 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $5.21 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9071 ERX HCPCS 63700001 50268-0084-15 AMLODIPINE BESYLATE 5 MG PO TABS BOTH IP/OP $6.58 $4.87 $0.00 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.29 $5.21 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9081 ERX HCPCS 63700001 00555-0972-02 AMPHETAMINE-DEXTROAMPHETAMINE 10 MG PO TABS BOTH IP/OP $7.19 $5.32 $0.00 $5.22 $0.00 $0.00 $0.00 $1.28 $0.00 $0.00 $0.00 $0.00 $0.00 $1.50 $0.00 $0.00 $0.00 $0.00 $3.26 $5.16 $5.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9083 ERX HCPCS J0295 00049-0013-83 AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9083 ERX HCPCS J0295 00641-6116-10 AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9083 ERX HCPCS J0295 25021-0142-20 AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9083 ERX HCPCS J0295 44567-0210-10 AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9083 ERX HCPCS J0295 55150-0116-20 AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9083 ERX HCPCS J0295 66794-0206-41 AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9083 ERX HCPCS J0295 67457-0348-10 AMPICILLIN-SULBACTAM SODIUM 1.5 (1-0.5) G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9084 ERX HCPCS J0295 00049-0014-83 AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR BOTH IP/OP $80.20 $59.35 $0.00 $61.82 $36.09 $36.09 $0.00 $0.00 $0.00 $8.48 $59.52 $59.52 $61.82 $0.00 $5.19 $0.00 $47.44 $47.44 $0.00 $36.37 $57.61 $58.19 $0.00 $0.00 $6.06 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 9084 ERX HCPCS J0295 00641-6117-10 AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR BOTH IP/OP $80.20 $59.35 $0.00 $61.82 $36.09 $36.09 $0.00 $0.00 $0.00 $8.48 $59.52 $59.52 $61.82 $0.00 $5.19 $0.00 $47.44 $47.44 $0.00 $36.37 $57.61 $58.19 $0.00 $0.00 $6.06 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 9084 ERX HCPCS J0295 44567-0211-10 AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR BOTH IP/OP $80.20 $59.35 $0.00 $61.82 $36.09 $36.09 $0.00 $0.00 $0.00 $8.48 $59.52 $59.52 $61.82 $0.00 $5.19 $0.00 $47.44 $47.44 $0.00 $36.37 $57.61 $58.19 $0.00 $0.00 $6.06 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 9084 ERX HCPCS J0295 55150-0117-20 AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR BOTH IP/OP $80.20 $59.35 $0.00 $61.82 $36.09 $36.09 $0.00 $0.00 $0.00 $8.48 $59.52 $59.52 $61.82 $0.00 $5.19 $0.00 $47.44 $47.44 $0.00 $36.37 $57.61 $58.19 $0.00 $0.00 $6.06 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 9084 ERX HCPCS J0295 67457-0349-10 AMPICILLIN-SULBACTAM SODIUM 3 (2-1) G IJ SOLR BOTH IP/OP $80.20 $59.35 $0.00 $61.82 $36.09 $36.09 $0.00 $0.00 $0.00 $8.48 $59.52 $59.52 $61.82 $0.00 $5.19 $0.00 $47.44 $47.44 $0.00 $36.37 $57.61 $58.19 $0.00 $0.00 $6.06 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 9096 ERX HCPCS 63700001 11086-0037-01 ANTHRALIN 1 % EX CREA BOTH IP/OP "$1,226.40 " $907.54 $0.00 $890.40 $0.00 $0.00 $0.00 $218.30 $0.00 $0.00 $0.00 $0.00 $0.00 $255.58 $0.00 $0.00 $0.00 $0.00 $556.50 $881.50 $890.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9119 ERX HCPCS 25000001 61314-0665-05 APRACLONIDINE HCL 0.5 % OP SOLN BOTH IP/OP $530.56 $392.61 $0.00 $424.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $265.28 $420.20 $424.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9120 ERX HCPCS 25000001 00065-0660-10 APRACLONIDINE HCL 1 % OP SOLN BOTH IP/OP "$2,068.25 " "$1,530.51" $0.00 "$1,594.21" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,535.06" "$1,535.06" "$1,594.21" $0.00 $431.02 $0.00 $0.00 $0.00 $0.00 $958.27 "$1,517.89" "$1,533.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9123 ERX HCPCS 25000001 00009-0436-01 ARGININE HCL (DIAGNOSTIC) 10 % IV SOLN BOTH IP/OP $157.30 $116.40 $0.00 $121.25 $0.00 $0.00 $0.00 $0.00 $0.00 $116.75 $116.75 $121.25 $0.00 $32.78 $0.00 $0.00 $0.00 $0.00 $66.94 $106.03 $107.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9183 ERX HCPCS J7500 60219-1076-01 AZATHIOPRINE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $2.70 $2.70 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 9183 ERX HCPCS J7500 68084-0229-01 AZATHIOPRINE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $2.70 $2.70 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 9183 ERX HCPCS J7500 68462-0502-01 AZATHIOPRINE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $2.70 $2.70 $0.00 $0.00 $0.00 $1.25 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $3.55 $3.55 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.94 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $0.00 9185 ERX HCPCS 25000001 63323-0401-20 AZTREONAM 1 G IJ SOLR BOTH IP/OP $83.57 $61.84 $0.00 $64.42 $0.00 $0.00 $0.00 $0.00 $0.00 $62.03 $62.03 $64.42 $0.00 $17.42 $0.00 $0.00 $0.00 $0.00 $37.57 $59.50 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9185 ERX HCPCS 25000001 63323-0401-26 AZTREONAM 1 G IJ SOLR BOTH IP/OP $83.57 $61.84 $0.00 $64.42 $0.00 $0.00 $0.00 $0.00 $0.00 $62.03 $62.03 $64.42 $0.00 $17.42 $0.00 $0.00 $0.00 $0.00 $37.57 $59.50 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9186 ERX HCPCS 25000001 00003-2570-16 AZTREONAM 2 G IJ SOLR BOTH IP/OP $84.90 $62.83 $0.00 $65.44 $0.00 $0.00 $0.00 $0.00 $0.00 $63.01 $63.01 $65.44 $0.00 $17.69 $0.00 $0.00 $0.00 $0.00 $35.15 $55.68 $56.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9186 ERX HCPCS 25000001 63323-0402-20 AZTREONAM 2 G IJ SOLR BOTH IP/OP $84.90 $62.83 $0.00 $65.44 $0.00 $0.00 $0.00 $0.00 $0.00 $63.01 $63.01 $65.44 $0.00 $17.69 $0.00 $0.00 $0.00 $0.00 $35.15 $55.68 $56.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9186 ERX HCPCS 25000001 63323-0402-30 AZTREONAM 2 G IJ SOLR BOTH IP/OP $84.90 $62.83 $0.00 $65.44 $0.00 $0.00 $0.00 $0.00 $0.00 $63.01 $63.01 $65.44 $0.00 $17.69 $0.00 $0.00 $0.00 $0.00 $35.15 $55.68 $56.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9219 ERX HCPCS 25000001 00574-7045-12 BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG RECTAL SUPP BOTH IP/OP $106.22 $78.60 $0.00 $81.87 $0.00 $0.00 $0.00 $0.00 $0.00 $78.84 $78.84 $81.87 $0.00 $22.14 $0.00 $0.00 $0.00 $0.00 $48.16 $76.29 $77.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9254 ERX HCPCS 25000001 00781-7054-49 BENZOYL PEROXIDE-ERYTHROMYCIN 5-3 % EX GEL BOTH IP/OP $605.59 $448.14 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 $449.47 $449.47 $466.79 $0.00 $126.20 $0.00 $0.00 $0.00 $0.00 $274.80 $435.28 $439.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9259 ERX HCPCS J0515 00143-9729-01 BENZTROPINE MESYLATE 1 MG/ML IJ SOLN BOTH IP/OP $69.14 $51.16 $0.00 $53.29 $31.11 $31.11 $0.00 $0.00 $0.00 $32.05 $51.32 $51.32 $53.29 $0.00 $22.92 $0.00 $40.90 $40.90 $0.00 $31.35 $49.66 $50.16 $0.00 $0.00 $0.00 $0.00 $0.00 $19.84 $0.00 $0.00 $0.00 $0.00 $0.00 9259 ERX HCPCS J0515 00143-9729-05 BENZTROPINE MESYLATE 1 MG/ML IJ SOLN BOTH IP/OP $69.14 $51.16 $0.00 $53.29 $31.11 $31.11 $0.00 $0.00 $0.00 $32.05 $51.32 $51.32 $53.29 $0.00 $22.92 $0.00 $40.90 $40.90 $0.00 $31.35 $49.66 $50.16 $0.00 $0.00 $0.00 $0.00 $0.00 $19.84 $0.00 $0.00 $0.00 $0.00 $0.00 9259 ERX HCPCS J0515 63323-0970-02 BENZTROPINE MESYLATE 1 MG/ML IJ SOLN BOTH IP/OP $69.14 $51.16 $0.00 $53.29 $31.11 $31.11 $0.00 $0.00 $0.00 $32.05 $51.32 $51.32 $53.29 $0.00 $22.92 $0.00 $40.90 $40.90 $0.00 $31.35 $49.66 $50.16 $0.00 $0.00 $0.00 $0.00 $0.00 $19.84 $0.00 $0.00 $0.00 $0.00 $0.00 9259 ERX HCPCS J0515 68382-0860-02 BENZTROPINE MESYLATE 1 MG/ML IJ SOLN BOTH IP/OP $69.14 $51.16 $0.00 $53.29 $31.11 $31.11 $0.00 $0.00 $0.00 $32.05 $51.32 $51.32 $53.29 $0.00 $22.92 $0.00 $40.90 $40.90 $0.00 $31.35 $49.66 $50.16 $0.00 $0.00 $0.00 $0.00 $0.00 $19.84 $0.00 $0.00 $0.00 $0.00 $0.00 9259 ERX HCPCS J0515 68382-0860-10 BENZTROPINE MESYLATE 1 MG/ML IJ SOLN BOTH IP/OP $69.14 $51.16 $0.00 $53.29 $31.11 $31.11 $0.00 $0.00 $0.00 $32.05 $51.32 $51.32 $53.29 $0.00 $22.92 $0.00 $40.90 $40.90 $0.00 $31.35 $49.66 $50.16 $0.00 $0.00 $0.00 $0.00 $0.00 $19.84 $0.00 $0.00 $0.00 $0.00 $0.00 9260 ERX HCPCS 25000001 49471-0001-05 BENZYLPENICILLOYL POLYLYSINE 0.25 ML ID SOLN BOTH IP/OP $599.16 $443.38 $0.00 $461.83 $0.00 $0.00 $0.00 $0.00 $0.00 $444.70 $444.70 $461.83 $0.00 $124.86 $0.00 $0.00 $0.00 $0.00 $252.54 $400.02 $404.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9266 ERX HCPCS J0702 00085-4320-01 BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP BOTH IP/OP $52.71 $39.01 $0.00 $40.63 $23.72 $23.72 $0.00 $0.00 $0.00 $7.14 $39.12 $39.12 $40.63 $0.00 $9.45 $0.00 $31.18 $31.18 $0.00 $23.49 $37.20 $37.58 $0.00 $0.00 $8.31 $0.00 $0.00 $7.91 $0.00 $0.00 $0.00 $0.00 $0.00 9266 ERX HCPCS J0702 00517-0720-01 BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP BOTH IP/OP $52.71 $39.01 $0.00 $40.63 $23.72 $23.72 $0.00 $0.00 $0.00 $7.14 $39.12 $39.12 $40.63 $0.00 $9.45 $0.00 $31.18 $31.18 $0.00 $23.49 $37.20 $37.58 $0.00 $0.00 $8.31 $0.00 $0.00 $7.91 $0.00 $0.00 $0.00 $0.00 $0.00 9266 ERX HCPCS J0702 51754-5060-01 BETAMETHASONE SOD PHOS & ACET 6 (3-3) MG/ML IJ SUSP BOTH IP/OP $52.71 $39.01 $0.00 $40.63 $23.72 $23.72 $0.00 $0.00 $0.00 $7.14 $39.12 $39.12 $40.63 $0.00 $9.45 $0.00 $31.18 $31.18 $0.00 $23.49 $37.20 $37.58 $0.00 $0.00 $8.31 $0.00 $0.00 $7.91 $0.00 $0.00 $0.00 $0.00 $0.00 9284 ERX HCPCS 63700001 00904-1315-46 BISMUTH SUBSALICYLATE 262 MG PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9289 ERX HCPCS J9040 00703-3154-01 BLEOMYCIN SULFATE 15 UNITS IJ SOLR BOTH IP/OP $159.81 $118.26 $0.00 $123.18 $71.91 $71.91 $0.00 $0.00 $0.00 $37.40 $118.61 $118.61 $123.18 $0.00 $29.66 $0.00 $94.53 $94.53 $0.00 $72.45 $114.76 $115.92 $0.00 $0.00 $26.64 $0.00 $0.00 $25.36 $0.00 $0.00 $0.00 $0.00 $0.00 9289 ERX HCPCS J9040 61703-0332-18 BLEOMYCIN SULFATE 15 UNITS IJ SOLR BOTH IP/OP $159.81 $118.26 $0.00 $123.18 $71.91 $71.91 $0.00 $0.00 $0.00 $37.40 $118.61 $118.61 $123.18 $0.00 $29.66 $0.00 $94.53 $94.53 $0.00 $72.45 $114.76 $115.92 $0.00 $0.00 $26.64 $0.00 $0.00 $25.36 $0.00 $0.00 $0.00 $0.00 $0.00 9289 ERX HCPCS J9040 63323-0136-10 BLEOMYCIN SULFATE 15 UNITS IJ SOLR BOTH IP/OP $159.81 $118.26 $0.00 $123.18 $71.91 $71.91 $0.00 $0.00 $0.00 $37.40 $118.61 $118.61 $123.18 $0.00 $29.66 $0.00 $94.53 $94.53 $0.00 $72.45 $114.76 $115.92 $0.00 $0.00 $26.64 $0.00 $0.00 $25.36 $0.00 $0.00 $0.00 $0.00 $0.00 9297 ERX HCPCS 63700001 00574-0106-01 BROMOCRIPTINE MESYLATE 2.5 MG PO TABS BOTH IP/OP $17.34 $12.83 $0.00 $12.58 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.61 $0.00 $0.00 $0.00 $0.00 $7.87 $12.46 $12.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9297 ERX HCPCS 63700001 00574-0106-03 BROMOCRIPTINE MESYLATE 2.5 MG PO TABS BOTH IP/OP $17.34 $12.83 $0.00 $12.58 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.61 $0.00 $0.00 $0.00 $0.00 $7.87 $12.46 $12.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9297 ERX HCPCS 63700001 00781-5325-01 BROMOCRIPTINE MESYLATE 2.5 MG PO TABS BOTH IP/OP $17.34 $12.83 $0.00 $12.58 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.61 $0.00 $0.00 $0.00 $0.00 $7.87 $12.46 $12.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9297 ERX HCPCS 63700001 00781-5325-31 BROMOCRIPTINE MESYLATE 2.5 MG PO TABS BOTH IP/OP $17.34 $12.83 $0.00 $12.58 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.61 $0.00 $0.00 $0.00 $0.00 $7.87 $12.46 $12.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9297 ERX HCPCS 63700001 63304-0962-01 BROMOCRIPTINE MESYLATE 2.5 MG PO TABS BOTH IP/OP $17.34 $12.83 $0.00 $12.58 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.61 $0.00 $0.00 $0.00 $0.00 $7.87 $12.46 $12.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9297 ERX HCPCS 63700001 63304-0962-30 BROMOCRIPTINE MESYLATE 2.5 MG PO TABS BOTH IP/OP $17.34 $12.83 $0.00 $12.58 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.61 $0.00 $0.00 $0.00 $0.00 $7.87 $12.46 $12.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9308 ERX HCPCS S0171 00409-1412-10 BUMETANIDE 0.25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.21 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9308 ERX HCPCS S0171 00641-6007-10 BUMETANIDE 0.25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.21 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9308 ERX HCPCS S0171 00641-6008-01 BUMETANIDE 0.25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.21 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9308 ERX HCPCS S0171 00641-6008-10 BUMETANIDE 0.25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.21 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9308 ERX HCPCS S0171 00641-6161-10 BUMETANIDE 0.25 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $1.21 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9309 ERX HCPCS 63700001 42799-0119-01 BUMETANIDE 0.5 MG PO TABS BOTH IP/OP $10.07 $7.45 $0.00 $7.31 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $4.57 $7.24 $7.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9310 ERX HCPCS 63700001 16714-0832-01 BUMETANIDE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9310 ERX HCPCS 63700001 42799-0120-01 BUMETANIDE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9316 ERX HCPCS 25000001 00409-1761-02 BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9316 ERX HCPCS 25000001 00409-3613-01 BUPIVACAINE IN DEXTROSE 0.75-8.25 % IT SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9320 ERX HCPCS J0592 00143-9246-05 BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN BOTH IP/OP $76.28 $56.45 $0.00 $58.80 $0.00 $0.00 $0.00 $0.00 $0.00 $56.62 $56.62 $58.80 $0.00 $15.90 $0.00 $0.00 $0.00 $0.00 $34.59 $54.79 $55.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9320 ERX HCPCS J0592 00409-2012-32 BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN BOTH IP/OP $76.28 $56.45 $0.00 $58.80 $0.00 $0.00 $0.00 $0.00 $0.00 $56.62 $56.62 $58.80 $0.00 $15.90 $0.00 $0.00 $0.00 $0.00 $34.59 $54.79 $55.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9321 ERX HCPCS 63700001 23155-0192-01 BUPROPION HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9321 ERX HCPCS 63700001 60505-0157-01 BUPROPION HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9322 ERX HCPCS 63700001 23155-0191-01 BUPROPION HCL 75 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9323 ERX HCPCS 63700001 00093-0054-01 BUSPIRONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9323 ERX HCPCS 63700001 00378-1150-01 BUSPIRONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9323 ERX HCPCS 63700001 51079-0986-01 BUSPIRONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9323 ERX HCPCS 63700001 51079-0986-20 BUSPIRONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9323 ERX HCPCS 63700001 64380-0742-06 BUSPIRONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9324 ERX HCPCS 63700001 00093-0053-01 BUSPIRONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9324 ERX HCPCS 63700001 51079-0985-01 BUSPIRONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9324 ERX HCPCS 63700001 51079-0985-20 BUSPIRONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9324 ERX HCPCS 63700001 64380-0741-06 BUSPIRONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9324 ERX HCPCS 63700001 64380-0741-08 BUSPIRONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9325 ERX HCPCS J8510 76388-0713-25 BUSULFAN 2 MG PO TABS BOTH IP/OP $108.50 $80.29 $0.00 $83.63 $0.00 $0.00 $0.00 $0.00 $0.00 $80.53 $80.53 $83.63 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $49.19 $77.92 $78.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9333 ERX HCPCS J0595 00409-1623-01 BUTORPHANOL TARTRATE 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $3.46 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9347 ERX HCPCS J0630 67457-0675-02 CALCITONIN (SALMON) 200 UNIT/ML IJ SOLN BOTH IP/OP "$8,494.26 " "$6,285.75" $0.00 "$5,319.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,770.20" $0.00 $0.00 $0.00 $0.00 "$3,324.78" "$5,266.44" "$5,319.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9348 ERX HCPCS J0636 17478-0931-01 CALCITRIOL 1 MCG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.21 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9350 ERX HCPCS 63700001 00054-0007-13 CALCITRIOL 0.25 MCG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9350 ERX HCPCS 63700001 00054-0007-25 CALCITRIOL 0.25 MCG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9350 ERX HCPCS 63700001 23155-0118-01 CALCITRIOL 0.25 MCG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9350 ERX HCPCS 63700001 23155-0662-01 CALCITRIOL 0.25 MCG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9350 ERX HCPCS 63700001 23155-0662-03 CALCITRIOL 0.25 MCG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9394 ERX HCPCS 25000001 17478-0080-50 CAPREOMYCIN SULFATE 1 G IJ SOLR BOTH IP/OP $754.94 $558.66 $0.00 $581.91 $0.00 $0.00 $0.00 $0.00 $0.00 $560.32 $560.32 $581.91 $0.00 $157.33 $0.00 $0.00 $0.00 $0.00 $342.57 $542.63 $548.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9400 ERX HCPCS 63700001 00143-1174-01 CAPTOPRIL 100 MG PO TABS BOTH IP/OP $15.95 $11.80 $0.00 $11.58 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $0.00 $3.32 $0.00 $0.00 $0.00 $0.00 $7.24 $11.46 $11.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9400 ERX HCPCS 63700001 00378-3022-01 CAPTOPRIL 100 MG PO TABS BOTH IP/OP $15.95 $11.80 $0.00 $11.58 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $0.00 $3.32 $0.00 $0.00 $0.00 $0.00 $7.24 $11.46 $11.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9400 ERX HCPCS 63700001 00781-8080-01 CAPTOPRIL 100 MG PO TABS BOTH IP/OP $15.95 $11.80 $0.00 $11.58 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $0.00 $3.32 $0.00 $0.00 $0.00 $0.00 $7.24 $11.46 $11.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9401 ERX HCPCS 63700001 00143-1171-01 CAPTOPRIL 12.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9401 ERX HCPCS 63700001 00378-3007-01 CAPTOPRIL 12.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9401 ERX HCPCS 63700001 00781-8052-01 CAPTOPRIL 12.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9401 ERX HCPCS 63700001 51079-0863-20 CAPTOPRIL 12.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9402 ERX HCPCS 63700001 00143-1172-01 CAPTOPRIL 25 MG PO TABS BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9402 ERX HCPCS 63700001 00378-3012-01 CAPTOPRIL 25 MG PO TABS BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9402 ERX HCPCS 63700001 00781-8061-01 CAPTOPRIL 25 MG PO TABS BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9402 ERX HCPCS 63700001 00904-5046-61 CAPTOPRIL 25 MG PO TABS BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9402 ERX HCPCS 63700001 51079-0864-01 CAPTOPRIL 25 MG PO TABS BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9402 ERX HCPCS 63700001 51079-0864-20 CAPTOPRIL 25 MG PO TABS BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9403 ERX HCPCS 63700001 00143-1173-01 CAPTOPRIL 50 MG PO TABS BOTH IP/OP $9.87 $7.30 $0.00 $7.16 $0.00 $0.00 $0.00 $1.76 $0.00 $0.00 $0.00 $0.00 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $4.48 $7.09 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9403 ERX HCPCS 63700001 00781-8075-01 CAPTOPRIL 50 MG PO TABS BOTH IP/OP $9.87 $7.30 $0.00 $7.16 $0.00 $0.00 $0.00 $1.76 $0.00 $0.00 $0.00 $0.00 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $4.48 $7.09 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9406 ERX HCPCS 63700001 63739-0107-10 CARBIDOPA-LEVODOPA 10-100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9407 ERX HCPCS 63700001 00228-2539-10 CARBIDOPA-LEVODOPA 25-100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9407 ERX HCPCS 63700001 00228-2539-50 CARBIDOPA-LEVODOPA 25-100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9407 ERX HCPCS 63700001 51079-0884-20 CARBIDOPA-LEVODOPA 25-100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9407 ERX HCPCS 63700001 68084-0093-01 CARBIDOPA-LEVODOPA 25-100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9408 ERX HCPCS 63700001 00904-6238-61 CARBIDOPA-LEVODOPA 25-250 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9413 ERX HCPCS 25000001 00009-0856-08 CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN BOTH IP/OP "$1,117.75 " $827.14 $0.00 $861.56 $0.00 $0.00 $0.00 $0.00 $0.00 $829.59 $829.59 $861.56 $0.00 $232.94 $0.00 $0.00 $0.00 $0.00 $507.20 $803.40 $811.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9413 ERX HCPCS 25000001 43598-0698-11 CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN BOTH IP/OP "$1,117.75 " $827.14 $0.00 $861.56 $0.00 $0.00 $0.00 $0.00 $0.00 $829.59 $829.59 $861.56 $0.00 $232.94 $0.00 $0.00 $0.00 $0.00 $507.20 $803.40 $811.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9413 ERX HCPCS 25000001 43598-0698-58 CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN BOTH IP/OP "$1,117.75 " $827.14 $0.00 $861.56 $0.00 $0.00 $0.00 $0.00 $0.00 $829.59 $829.59 $861.56 $0.00 $232.94 $0.00 $0.00 $0.00 $0.00 $507.20 $803.40 $811.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9430 ERX HCPCS 63700001 00143-9985-01 CEFACLOR 250 MG PO CAPS BOTH IP/OP $7.57 $5.60 $0.00 $6.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $6.00 $6.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9430 ERX HCPCS 63700001 61442-0171-30 CEFACLOR 250 MG PO CAPS BOTH IP/OP $7.57 $5.60 $0.00 $6.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $6.00 $6.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9431 ERX HCPCS 63700001 00143-9986-01 CEFACLOR 500 MG PO CAPS BOTH IP/OP $14.81 $10.96 $0.00 $11.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.41 $11.73 $11.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9431 ERX HCPCS 63700001 61442-0172-30 CEFACLOR 500 MG PO CAPS BOTH IP/OP $14.81 $10.96 $0.00 $11.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.41 $11.73 $11.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9446 ERX HCPCS 63700001 65862-0751-50 CEFIXIME 100 MG/5ML PO SUSR BOTH IP/OP $794.83 $588.17 $0.00 $577.06 $0.00 $0.00 $0.00 $141.48 $0.00 $0.00 $0.00 $0.00 $0.00 $165.64 $0.00 $0.00 $0.00 $0.00 $360.67 $571.29 $577.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9446 ERX HCPCS 63700001 68180-0202-03 CEFIXIME 100 MG/5ML PO SUSR BOTH IP/OP $794.83 $588.17 $0.00 $577.06 $0.00 $0.00 $0.00 $141.48 $0.00 $0.00 $0.00 $0.00 $0.00 $165.64 $0.00 $0.00 $0.00 $0.00 $360.67 $571.29 $577.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9452 ERX HCPCS J0698 CEFOTAXIME SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9452 ERX HCPCS J0698 00143-9931-25 CEFOTAXIME SODIUM 1 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9455 ERX HCPCS 25000001 CEFOTAXIME SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9455 ERX HCPCS 25000001 00143-9930-10 CEFOTAXIME SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9461 ERX HCPCS J0694 25021-0109-10 CEFOXITIN SODIUM 1 G IV SOLR BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $13.58 $13.58 $0.00 $0.00 $0.00 $8.06 $22.39 $22.39 $23.26 $0.00 $5.42 $0.00 $17.85 $17.85 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $6.22 $0.00 $0.00 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 9461 ERX HCPCS J0694 44567-0245-25 CEFOXITIN SODIUM 1 G IV SOLR BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $13.58 $13.58 $0.00 $0.00 $0.00 $8.06 $22.39 $22.39 $23.26 $0.00 $5.42 $0.00 $17.85 $17.85 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $6.22 $0.00 $0.00 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 9461 ERX HCPCS J0694 44567-0245-85 CEFOXITIN SODIUM 1 G IV SOLR BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $13.58 $13.58 $0.00 $0.00 $0.00 $8.06 $22.39 $22.39 $23.26 $0.00 $5.42 $0.00 $17.85 $17.85 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $6.22 $0.00 $0.00 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 9461 ERX HCPCS J0694 63323-0341-25 CEFOXITIN SODIUM 1 G IV SOLR BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $13.58 $13.58 $0.00 $0.00 $0.00 $8.06 $22.39 $22.39 $23.26 $0.00 $5.42 $0.00 $17.85 $17.85 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $6.22 $0.00 $0.00 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 9463 ERX HCPCS J0694 25021-0110-20 CEFOXITIN SODIUM 2 G IV SOLR BOTH IP/OP $92.41 $68.38 $0.00 $71.23 $41.58 $41.58 $0.00 $0.00 $0.00 $16.12 $68.59 $68.59 $71.23 $0.00 $10.84 $0.00 $54.66 $54.66 $0.00 $41.90 $66.36 $67.03 $0.00 $0.00 $12.43 $0.00 $0.00 $11.84 $0.00 $0.00 $0.00 $0.00 $0.00 9463 ERX HCPCS J0694 44567-0246-25 CEFOXITIN SODIUM 2 G IV SOLR BOTH IP/OP $92.41 $68.38 $0.00 $71.23 $41.58 $41.58 $0.00 $0.00 $0.00 $16.12 $68.59 $68.59 $71.23 $0.00 $10.84 $0.00 $54.66 $54.66 $0.00 $41.90 $66.36 $67.03 $0.00 $0.00 $12.43 $0.00 $0.00 $11.84 $0.00 $0.00 $0.00 $0.00 $0.00 9463 ERX HCPCS J0694 44567-0246-85 CEFOXITIN SODIUM 2 G IV SOLR BOTH IP/OP $92.41 $68.38 $0.00 $71.23 $41.58 $41.58 $0.00 $0.00 $0.00 $16.12 $68.59 $68.59 $71.23 $0.00 $10.84 $0.00 $54.66 $54.66 $0.00 $41.90 $66.36 $67.03 $0.00 $0.00 $12.43 $0.00 $0.00 $11.84 $0.00 $0.00 $0.00 $0.00 $0.00 9463 ERX HCPCS J0694 63323-0342-25 CEFOXITIN SODIUM 2 G IV SOLR BOTH IP/OP $92.41 $68.38 $0.00 $71.23 $41.58 $41.58 $0.00 $0.00 $0.00 $16.12 $68.59 $68.59 $71.23 $0.00 $10.84 $0.00 $54.66 $54.66 $0.00 $41.90 $66.36 $67.03 $0.00 $0.00 $12.43 $0.00 $0.00 $11.84 $0.00 $0.00 $0.00 $0.00 $0.00 9468 ERX HCPCS 63700001 16714-0394-01 CEFPODOXIME PROXETIL 100 MG PO TABS BOTH IP/OP $28.23 $20.89 $0.00 $20.49 $0.00 $0.00 $0.00 $5.02 $0.00 $0.00 $0.00 $0.00 $0.00 $5.88 $0.00 $0.00 $0.00 $0.00 $12.81 $20.28 $20.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9469 ERX HCPCS 63700001 65862-0096-20 CEFPODOXIME PROXETIL 200 MG PO TABS BOTH IP/OP $35.44 $26.23 $0.00 $25.71 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.07 $25.45 $25.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9474 ERX HCPCS J0713 00409-5082-16 CEFTAZIDIME 1 G IJ SOLR BOTH IP/OP $22.63 $16.75 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.80 $16.80 $17.44 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9474 ERX HCPCS J0713 25021-0127-20 CEFTAZIDIME 1 G IJ SOLR BOTH IP/OP $22.63 $16.75 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.80 $16.80 $17.44 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9474 ERX HCPCS J0713 44567-0235-25 CEFTAZIDIME 1 G IJ SOLR BOTH IP/OP $22.63 $16.75 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.80 $16.80 $17.44 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9476 ERX HCPCS J0713 00409-5084-11 CEFTAZIDIME 2 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9476 ERX HCPCS J0713 25021-0128-50 CEFTAZIDIME 2 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9476 ERX HCPCS J0713 44567-0236-10 CEFTAZIDIME 2 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 9487 ERX HCPCS J0696 00409-7332-01 CEFTRIAXONE SODIUM 1 G IJ SOLR BOTH IP/OP $177.56 $131.39 $0.00 $136.86 $79.90 $79.90 $0.00 $0.00 $0.00 $5.64 $131.79 $131.79 $136.86 $0.00 $2.36 $0.00 $105.03 $105.03 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 9487 ERX HCPCS J0696 00409-7332-11 CEFTRIAXONE SODIUM 1 G IJ SOLR BOTH IP/OP $177.56 $131.39 $0.00 $136.86 $79.90 $79.90 $0.00 $0.00 $0.00 $5.64 $131.79 $131.79 $136.86 $0.00 $2.36 $0.00 $105.03 $105.03 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 9487 ERX HCPCS J0696 00781-3208-95 CEFTRIAXONE SODIUM 1 G IJ SOLR BOTH IP/OP $177.56 $131.39 $0.00 $136.86 $79.90 $79.90 $0.00 $0.00 $0.00 $5.64 $131.79 $131.79 $136.86 $0.00 $2.36 $0.00 $105.03 $105.03 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 9487 ERX HCPCS J0696 25021-0106-10 CEFTRIAXONE SODIUM 1 G IJ SOLR BOTH IP/OP $177.56 $131.39 $0.00 $136.86 $79.90 $79.90 $0.00 $0.00 $0.00 $5.64 $131.79 $131.79 $136.86 $0.00 $2.36 $0.00 $105.03 $105.03 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 9487 ERX HCPCS J0696 44567-0701-25 CEFTRIAXONE SODIUM 1 G IJ SOLR BOTH IP/OP $177.56 $131.39 $0.00 $136.86 $79.90 $79.90 $0.00 $0.00 $0.00 $5.64 $131.79 $131.79 $136.86 $0.00 $2.36 $0.00 $105.03 $105.03 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 9488 ERX HCPCS J0696 00143-9856-25 CEFTRIAXONE SODIUM 2 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $11.28 $16.33 $16.33 $16.96 $0.00 $4.73 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.64 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 9488 ERX HCPCS J0696 00409-7335-03 CEFTRIAXONE SODIUM 2 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $11.28 $16.33 $16.33 $16.96 $0.00 $4.73 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.64 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 9488 ERX HCPCS J0696 00409-7335-20 CEFTRIAXONE SODIUM 2 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $11.28 $16.33 $16.33 $16.96 $0.00 $4.73 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.64 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 9488 ERX HCPCS J0696 00409-7335-21 CEFTRIAXONE SODIUM 2 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $11.28 $16.33 $16.33 $16.96 $0.00 $4.73 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.64 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 9488 ERX HCPCS J0696 44567-0702-25 CEFTRIAXONE SODIUM 2 G IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $11.28 $16.33 $16.33 $16.96 $0.00 $4.73 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.64 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 9489 ERX HCPCS J0696 00409-7337-01 CEFTRIAXONE SODIUM 250 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.41 $16.33 $16.33 $16.96 $0.00 $0.59 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.71 $0.00 $0.00 $0.67 $0.00 $0.00 $0.00 $0.00 $0.00 9489 ERX HCPCS J0696 00409-7337-11 CEFTRIAXONE SODIUM 250 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.41 $16.33 $16.33 $16.96 $0.00 $0.59 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.71 $0.00 $0.00 $0.67 $0.00 $0.00 $0.00 $0.00 $0.00 9490 ERX HCPCS J0696 00143-9858-25 CEFTRIAXONE SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9490 ERX HCPCS J0696 00409-7338-01 CEFTRIAXONE SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9490 ERX HCPCS J0696 00409-7338-11 CEFTRIAXONE SODIUM 500 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9491 ERX HCPCS J0696 00409-7334-10 CEFTRIAXONE SODIUM 10 G IV SOLR BOTH IP/OP $80.22 $59.36 $0.00 $61.83 $36.10 $36.10 $0.00 $0.00 $0.00 $56.40 $59.54 $59.54 $61.83 $0.00 $23.64 $0.00 $47.45 $47.45 $0.00 $35.83 $56.75 $57.32 $0.00 $0.00 $28.20 $0.00 $0.00 $26.85 $0.00 $0.00 $0.00 $0.00 $0.00 9491 ERX HCPCS J0696 00781-3210-46 CEFTRIAXONE SODIUM 10 G IV SOLR BOTH IP/OP $80.22 $59.36 $0.00 $61.83 $36.10 $36.10 $0.00 $0.00 $0.00 $56.40 $59.54 $59.54 $61.83 $0.00 $23.64 $0.00 $47.45 $47.45 $0.00 $35.83 $56.75 $57.32 $0.00 $0.00 $28.20 $0.00 $0.00 $26.85 $0.00 $0.00 $0.00 $0.00 $0.00 9491 ERX HCPCS J0696 25021-0108-99 CEFTRIAXONE SODIUM 10 G IV SOLR BOTH IP/OP $80.22 $59.36 $0.00 $61.83 $36.10 $36.10 $0.00 $0.00 $0.00 $56.40 $59.54 $59.54 $61.83 $0.00 $23.64 $0.00 $47.45 $47.45 $0.00 $35.83 $56.75 $57.32 $0.00 $0.00 $28.20 $0.00 $0.00 $26.85 $0.00 $0.00 $0.00 $0.00 $0.00 9495 ERX HCPCS 63700001 16714-0400-01 CEFUROXIME AXETIL 250 MG PO TABS BOTH IP/OP $18.44 $13.65 $0.00 $13.38 $0.00 $0.00 $0.00 $3.28 $0.00 $0.00 $0.00 $0.00 $0.00 $3.84 $0.00 $0.00 $0.00 $0.00 $8.36 $13.24 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9495 ERX HCPCS 63700001 57237-0058-20 CEFUROXIME AXETIL 250 MG PO TABS BOTH IP/OP $18.44 $13.65 $0.00 $13.38 $0.00 $0.00 $0.00 $3.28 $0.00 $0.00 $0.00 $0.00 $0.00 $3.84 $0.00 $0.00 $0.00 $0.00 $8.36 $13.24 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9495 ERX HCPCS 63700001 64679-0921-01 CEFUROXIME AXETIL 250 MG PO TABS BOTH IP/OP $18.44 $13.65 $0.00 $13.38 $0.00 $0.00 $0.00 $3.28 $0.00 $0.00 $0.00 $0.00 $0.00 $3.84 $0.00 $0.00 $0.00 $0.00 $8.36 $13.24 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9495 ERX HCPCS 63700001 64679-0921-02 CEFUROXIME AXETIL 250 MG PO TABS BOTH IP/OP $18.44 $13.65 $0.00 $13.38 $0.00 $0.00 $0.00 $3.28 $0.00 $0.00 $0.00 $0.00 $0.00 $3.84 $0.00 $0.00 $0.00 $0.00 $8.36 $13.24 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9495 ERX HCPCS 63700001 68180-0302-20 CEFUROXIME AXETIL 250 MG PO TABS BOTH IP/OP $18.44 $13.65 $0.00 $13.38 $0.00 $0.00 $0.00 $3.28 $0.00 $0.00 $0.00 $0.00 $0.00 $3.84 $0.00 $0.00 $0.00 $0.00 $8.36 $13.24 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9499 ERX HCPCS 63700001 50268-0151-11 CEPHALEXIN 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9499 ERX HCPCS 63700001 50268-0151-15 CEPHALEXIN 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9499 ERX HCPCS 63700001 60687-0152-01 CEPHALEXIN 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9499 ERX HCPCS 63700001 67877-0220-01 CEPHALEXIN 250 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9500 ERX HCPCS 63700001 00093-3147-05 CEPHALEXIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9500 ERX HCPCS 63700001 60687-0163-01 CEPHALEXIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9500 ERX HCPCS 63700001 60687-0163-11 CEPHALEXIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9500 ERX HCPCS 63700001 65862-0019-05 CEPHALEXIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9500 ERX HCPCS 63700001 68180-0122-02 CEPHALEXIN 500 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9501 ERX HCPCS 63700001 00093-4175-73 CEPHALEXIN 125 MG/5ML PO SUSR BOTH IP/OP $83.30 $61.64 $0.00 $66.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.65 $65.97 $66.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9501 ERX HCPCS 63700001 68180-0440-01 CEPHALEXIN 125 MG/5ML PO SUSR BOTH IP/OP $83.30 $61.64 $0.00 $66.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.65 $65.97 $66.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9502 ERX HCPCS 63700001 00093-4177-73 CEPHALEXIN 250 MG/5ML PO SUSR BOTH IP/OP $177.67 $131.48 $0.00 $80.64 $0.00 $0.00 $0.00 $31.63 $0.00 $0.00 $0.00 $0.00 $0.00 $37.03 $0.00 $0.00 $0.00 $0.00 $50.40 $79.83 $80.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9502 ERX HCPCS 63700001 68180-0441-01 CEPHALEXIN 250 MG/5ML PO SUSR BOTH IP/OP $177.67 $131.48 $0.00 $80.64 $0.00 $0.00 $0.00 $31.63 $0.00 $0.00 $0.00 $0.00 $0.00 $37.03 $0.00 $0.00 $0.00 $0.00 $50.40 $79.83 $80.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9502 ERX HCPCS 63700001 00093-4177-74 CEPHALEXIN 250 MG/5ML PO SUSR BOTH IP/OP $177.67 $131.48 $0.00 $127.73 $0.00 $0.00 $0.00 $31.63 $0.00 $0.00 $0.00 $0.00 $0.00 $37.03 $0.00 $0.00 $0.00 $0.00 $50.40 $127.73 $80.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9506 ERX HCPCS 63700001 00378-3637-01 CETIRIZINE HCL 10 MG PO TABS BOTH IP/OP $10.45 $7.73 $0.00 $7.58 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.74 $7.51 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9506 ERX HCPCS 63700001 00904-6717-61 CETIRIZINE HCL 10 MG PO TABS BOTH IP/OP $10.45 $7.73 $0.00 $7.58 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.74 $7.51 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9506 ERX HCPCS 63700001 16571-0402-10 CETIRIZINE HCL 10 MG PO TABS BOTH IP/OP $10.45 $7.73 $0.00 $7.58 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.74 $7.51 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9506 ERX HCPCS 63700001 16714-0799-04 CETIRIZINE HCL 10 MG PO TABS BOTH IP/OP $10.45 $7.73 $0.00 $7.58 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.74 $7.51 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9506 ERX HCPCS 63700001 45802-0919-39 CETIRIZINE HCL 10 MG PO TABS BOTH IP/OP $10.45 $7.73 $0.00 $7.58 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.74 $7.51 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9506 ERX HCPCS 63700001 51079-0597-01 CETIRIZINE HCL 10 MG PO TABS BOTH IP/OP $10.45 $7.73 $0.00 $7.58 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.74 $7.51 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9506 ERX HCPCS 63700001 51079-0597-20 CETIRIZINE HCL 10 MG PO TABS BOTH IP/OP $10.45 $7.73 $0.00 $7.58 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.74 $7.51 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9513 ERX HCPCS 63700001 76388-0635-25 CHLORAMBUCIL 2 MG PO TABS BOTH IP/OP $534.60 $395.60 $0.00 $356.16 $0.00 $0.00 $0.00 $95.16 $0.00 $0.00 $0.00 $0.00 $0.00 $111.41 $0.00 $0.00 $0.00 $0.00 $222.60 $352.60 $356.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9516 ERX HCPCS 25000001 00116-2001-16 CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN BOTH IP/OP $8.93 $6.61 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $6.63 $6.88 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9516 ERX HCPCS 25000001 69339-0138-15 CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN BOTH IP/OP $8.93 $6.61 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $6.63 $6.88 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9516 ERX HCPCS 25000001 69339-0138-17 CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN BOTH IP/OP $8.93 $6.61 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $6.63 $6.88 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9516 ERX HCPCS 25000001 69339-0138-19 CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN BOTH IP/OP $8.93 $6.61 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $6.63 $6.88 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9516 ERX HCPCS 25000001 99999-6004-28 CHLORHEXIDINE GLUCONATE 0.12 % MT SOLN BOTH IP/OP $8.93 $6.61 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $6.63 $6.88 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.42 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9523 ERX HCPCS J2400 63323-0475-37 CHLOROPROCAINE HCL 1 % IJ SOLN BOTH IP/OP $83.61 $61.87 $0.00 $64.45 $0.00 $0.00 $0.00 $0.00 $0.00 $62.06 $62.06 $64.45 $0.00 $17.42 $0.00 $0.00 $0.00 $0.00 $37.91 $60.04 $60.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9525 ERX HCPCS 25000001 65649-0311-12 CHLOROTHIAZIDE 250 MG/5ML PO SUSP BOTH IP/OP $7.32 $5.42 $0.00 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $5.43 $5.43 $5.64 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $44.31 $5.26 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9525 ERX HCPCS 25000001 99999-6008-62 CHLOROTHIAZIDE 250 MG/5ML PO SUSP BOTH IP/OP $7.32 $5.42 $0.00 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $5.43 $5.43 $5.64 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $44.31 $5.26 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9525 ERX HCPCS 25000001 99999-6012-04 CHLOROTHIAZIDE 250 MG/5ML PO SUSP BOTH IP/OP $7.32 $5.42 $0.00 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $5.43 $5.43 $5.64 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $44.31 $5.26 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9525 ERX HCPCS 25000001 99999-6004-75 CHLOROTHIAZIDE 250 MG/5ML PO SUSP BOTH IP/OP $7.32 $5.42 $0.00 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $5.43 $5.43 $5.64 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $44.31 $70.19 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 00517-1820-01 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 17478-0419-40 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 25021-0305-20 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 25021-0305-66 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 47335-0330-40 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 63323-0658-20 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 63323-0658-27 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 67457-0263-30 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 ERX HCPCS J1205 76478-0711-40 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9578 ERX HCPCS 63700001 00904-5351-24 CHLORPHENIRAMINE-PSEUDOEPH 4-60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9578 ERX HCPCS 63700001 00904-5351-96 CHLORPHENIRAMINE-PSEUDOEPH 4-60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9598 ERX HCPCS 25000001 45802-0138-35 CICLOPIROX OLAMINE 0.77 % EX CREA BOTH IP/OP $122.00 $90.28 $0.00 $94.04 $0.00 $0.00 $0.00 $0.00 $0.00 $90.55 $90.55 $94.04 $0.00 $25.42 $0.00 $0.00 $0.00 $0.00 $55.31 $87.61 $88.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9598 ERX HCPCS 25000001 51672-1318-01 CICLOPIROX OLAMINE 0.77 % EX CREA BOTH IP/OP $122.00 $90.28 $0.00 $94.04 $0.00 $0.00 $0.00 $0.00 $0.00 $90.55 $90.55 $94.04 $0.00 $25.42 $0.00 $0.00 $0.00 $0.00 $55.31 $87.61 $88.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9598 ERX HCPCS 25000001 68462-0297-17 CICLOPIROX OLAMINE 0.77 % EX CREA BOTH IP/OP $122.00 $90.28 $0.00 $94.04 $0.00 $0.00 $0.00 $0.00 $0.00 $90.55 $90.55 $94.04 $0.00 $25.42 $0.00 $0.00 $0.00 $0.00 $55.31 $87.61 $88.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9603 ERX HCPCS J0743 00006-3516-59 IMIPENEM-CILASTATIN 500 MG IV SOLR BOTH IP/OP $151.25 $111.93 $0.00 $116.58 $0.00 $0.00 $0.00 $0.00 $0.00 $112.26 $112.26 $116.58 $0.00 $17.89 $0.00 $0.00 $0.00 $0.00 $68.57 $108.61 $109.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9603 ERX HCPCS J0743 63323-0322-93 IMIPENEM-CILASTATIN 500 MG IV SOLR BOTH IP/OP $151.25 $111.93 $0.00 $116.58 $0.00 $0.00 $0.00 $0.00 $0.00 $112.26 $112.26 $116.58 $0.00 $17.89 $0.00 $0.00 $0.00 $0.00 $68.57 $108.61 $109.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9607 ERX HCPCS 63700001 00378-0541-01 CIMETIDINE 800 MG PO TABS BOTH IP/OP $21.03 $15.56 $0.00 $15.26 $0.00 $0.00 $0.00 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $9.54 $15.10 $15.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9610 ERX HCPCS 25000001 61314-0656-25 CIPROFLOXACIN HCL 0.3 % OP SOLN BOTH IP/OP $70.40 $52.10 $0.00 $54.26 $0.00 $0.00 $0.00 $0.00 $0.00 $52.25 $52.25 $54.26 $0.00 $14.67 $0.00 $0.00 $0.00 $0.00 $23.94 $37.92 $38.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9610 ERX HCPCS 25000001 69315-0308-02 CIPROFLOXACIN HCL 0.3 % OP SOLN BOTH IP/OP $70.40 $52.10 $0.00 $54.26 $0.00 $0.00 $0.00 $0.00 $0.00 $52.25 $52.25 $54.26 $0.00 $14.67 $0.00 $0.00 $0.00 $0.00 $23.94 $37.92 $38.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9610 ERX HCPCS 25000001 61314-0656-05 CIPROFLOXACIN HCL 0.3 % OP SOLN BOTH IP/OP $70.40 $52.10 $0.00 $54.26 $0.00 $0.00 $0.00 $0.00 $0.00 $52.25 $52.25 $54.26 $0.00 $14.67 $0.00 $0.00 $0.00 $0.00 $23.94 $50.56 $38.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9610 ERX HCPCS 25000001 69315-0308-05 CIPROFLOXACIN HCL 0.3 % OP SOLN BOTH IP/OP $70.40 $52.10 $0.00 $54.26 $0.00 $0.00 $0.00 $0.00 $0.00 $52.25 $52.25 $54.26 $0.00 $14.67 $0.00 $0.00 $0.00 $0.00 $23.94 $50.56 $38.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9616 ERX HCPCS 63700001 65862-0225-60 CLARITHROMYCIN 250 MG PO TABS BOTH IP/OP $17.18 $12.71 $0.00 $13.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.59 $13.61 $13.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9617 ERX HCPCS 63700001 00527-1932-06 CLARITHROMYCIN 500 MG PO TABS BOTH IP/OP $25.21 $18.66 $0.00 $18.29 $0.00 $0.00 $0.00 $4.49 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $11.43 $18.11 $18.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9617 ERX HCPCS 63700001 00781-1962-60 CLARITHROMYCIN 500 MG PO TABS BOTH IP/OP $25.21 $18.66 $0.00 $18.29 $0.00 $0.00 $0.00 $4.49 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $11.43 $18.11 $18.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9617 ERX HCPCS 63700001 57237-0045-60 CLARITHROMYCIN 500 MG PO TABS BOTH IP/OP $25.21 $18.66 $0.00 $18.29 $0.00 $0.00 $0.00 $4.49 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $11.43 $18.11 $18.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9617 ERX HCPCS 63700001 65862-0226-60 CLARITHROMYCIN 500 MG PO TABS BOTH IP/OP $25.21 $18.66 $0.00 $18.29 $0.00 $0.00 $0.00 $4.49 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $11.43 $18.11 $18.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9623 ERX HCPCS 25000001 00168-0202-30 CLINDAMYCIN PHOSPHATE 1 % EX GEL BOTH IP/OP $348.27 $257.72 $0.00 $268.45 $0.00 $0.00 $0.00 $0.00 $0.00 $258.49 $258.49 $268.45 $0.00 $72.58 $0.00 $0.00 $0.00 $0.00 $158.07 $250.38 $252.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9623 ERX HCPCS 25000001 59762-3743-01 CLINDAMYCIN PHOSPHATE 1 % EX GEL BOTH IP/OP $348.27 $257.72 $0.00 $268.45 $0.00 $0.00 $0.00 $0.00 $0.00 $258.49 $258.49 $268.45 $0.00 $72.58 $0.00 $0.00 $0.00 $0.00 $158.07 $250.38 $252.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9624 ERX HCPCS 25000001 00009-3448-01 CLINDAMYCIN PHOSPHATE 2 % VA CREA BOTH IP/OP $437.88 $324.03 $0.00 $337.52 $0.00 $0.00 $0.00 $0.00 $0.00 $324.99 $324.99 $337.52 $0.00 $91.25 $0.00 $0.00 $0.00 $0.00 $198.74 $314.80 $317.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9624 ERX HCPCS 25000001 00168-0277-40 CLINDAMYCIN PHOSPHATE 2 % VA CREA BOTH IP/OP $437.88 $324.03 $0.00 $337.52 $0.00 $0.00 $0.00 $0.00 $0.00 $324.99 $324.99 $337.52 $0.00 $91.25 $0.00 $0.00 $0.00 $0.00 $198.74 $314.80 $317.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9624 ERX HCPCS 25000001 59762-5009-01 CLINDAMYCIN PHOSPHATE 2 % VA CREA BOTH IP/OP $437.88 $324.03 $0.00 $337.52 $0.00 $0.00 $0.00 $0.00 $0.00 $324.99 $324.99 $337.52 $0.00 $91.25 $0.00 $0.00 $0.00 $0.00 $198.74 $314.80 $317.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9626 ERX HCPCS S0077 00781-3289-09 CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN BOTH IP/OP $62.23 $46.05 $0.00 $47.97 $28.00 $28.00 $0.00 $0.00 $2.70 $7.07 $46.19 $46.19 $47.97 $0.00 $3.31 $0.00 $36.81 $36.81 $0.00 $28.22 $44.69 $45.14 $33.86 $33.86 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 9626 ERX HCPCS S0077 00781-9221-09 CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN BOTH IP/OP $62.23 $46.05 $0.00 $47.97 $28.00 $28.00 $0.00 $0.00 $2.70 $7.07 $46.19 $46.19 $47.97 $0.00 $3.31 $0.00 $36.81 $36.81 $0.00 $28.22 $44.69 $45.14 $33.86 $33.86 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 9626 ERX HCPCS S0077 00781-9221-91 CLINDAMYCIN PHOSPHATE IN D5W 600 MG/50ML IV SOLN BOTH IP/OP $62.23 $46.05 $0.00 $47.97 $28.00 $28.00 $0.00 $0.00 $2.70 $7.07 $46.19 $46.19 $47.97 $0.00 $3.31 $0.00 $36.81 $36.81 $0.00 $28.22 $44.69 $45.14 $33.86 $33.86 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 9627 ERX HCPCS S0077 00781-3290-09 CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN BOTH IP/OP $75.84 $56.12 $0.00 $58.46 $34.13 $34.13 $0.00 $0.00 $4.06 $10.61 $56.29 $56.29 $58.46 $0.00 $4.97 $0.00 $44.86 $44.86 $0.00 $34.39 $54.47 $55.02 $41.27 $41.27 $4.94 $0.00 $0.00 $4.70 $0.00 $0.00 $0.00 $0.00 $0.00 9627 ERX HCPCS S0077 00781-9222-09 CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN BOTH IP/OP $75.84 $56.12 $0.00 $58.46 $34.13 $34.13 $0.00 $0.00 $4.06 $10.61 $56.29 $56.29 $58.46 $0.00 $4.97 $0.00 $44.86 $44.86 $0.00 $34.39 $54.47 $55.02 $41.27 $41.27 $4.94 $0.00 $0.00 $4.70 $0.00 $0.00 $0.00 $0.00 $0.00 9627 ERX HCPCS S0077 00781-9222-91 CLINDAMYCIN PHOSPHATE IN D5W 900 MG/50ML IV SOLN BOTH IP/OP $75.84 $56.12 $0.00 $58.46 $34.13 $34.13 $0.00 $0.00 $4.06 $10.61 $56.29 $56.29 $58.46 $0.00 $4.97 $0.00 $44.86 $44.86 $0.00 $34.39 $54.47 $55.02 $41.27 $41.27 $4.94 $0.00 $0.00 $4.70 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 00168-0163-15 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $332.11 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $309.77 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 00472-0400-15 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $332.11 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $309.77 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 50383-0267-15 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $332.11 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $309.77 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 51672-1258-01 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $332.11 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $309.77 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 52565-0051-15 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $332.11 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $309.77 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 00472-0400-30 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $538.28 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $538.28 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 10337-0163-30 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $538.28 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $538.28 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 00472-0400-60 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $975.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $975.00 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9630 ERX HCPCS 25000001 52565-0051-60 CLOBETASOL PROPIONATE 0.05 % EX CREA BOTH IP/OP $430.87 $318.84 $0.00 $975.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.79 $319.79 $332.11 $0.00 $89.79 $0.00 $0.00 $0.00 $0.00 $195.56 $975.00 $312.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9631 ERX HCPCS 25000001 00168-0162-15 CLOBETASOL PROPIONATE 0.05 % EX OINT BOTH IP/OP $522.30 $386.50 $0.00 $402.59 $0.00 $0.00 $0.00 $0.00 $0.00 $387.65 $387.65 $402.59 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $237.06 $375.50 $379.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9631 ERX HCPCS 25000001 10337-0162-15 CLOBETASOL PROPIONATE 0.05 % EX OINT BOTH IP/OP $522.30 $386.50 $0.00 $402.59 $0.00 $0.00 $0.00 $0.00 $0.00 $387.65 $387.65 $402.59 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $237.06 $375.50 $379.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9631 ERX HCPCS 25000001 43386-0096-60 CLOBETASOL PROPIONATE 0.05 % EX OINT BOTH IP/OP $522.30 $386.50 $0.00 $402.59 $0.00 $0.00 $0.00 $0.00 $0.00 $387.65 $387.65 $402.59 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $237.06 $375.50 $379.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9631 ERX HCPCS 25000001 50383-0268-15 CLOBETASOL PROPIONATE 0.05 % EX OINT BOTH IP/OP $522.30 $386.50 $0.00 $402.59 $0.00 $0.00 $0.00 $0.00 $0.00 $387.65 $387.65 $402.59 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $237.06 $375.50 $379.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9631 ERX HCPCS 25000001 51672-1259-01 CLOBETASOL PROPIONATE 0.05 % EX OINT BOTH IP/OP $522.30 $386.50 $0.00 $402.59 $0.00 $0.00 $0.00 $0.00 $0.00 $387.65 $387.65 $402.59 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $237.06 $375.50 $379.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9631 ERX HCPCS 25000001 52565-0039-15 CLOBETASOL PROPIONATE 0.05 % EX OINT BOTH IP/OP $522.30 $386.50 $0.00 $402.59 $0.00 $0.00 $0.00 $0.00 $0.00 $387.65 $387.65 $402.59 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $237.06 $375.50 $379.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9631 ERX HCPCS 25000001 51672-1259-02 CLOBETASOL PROPIONATE 0.05 % EX OINT BOTH IP/OP $522.30 $386.50 $0.00 $652.50 $0.00 $0.00 $0.00 $0.00 $0.00 $387.65 $387.65 $402.59 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $237.06 $652.50 $379.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9631 ERX HCPCS 25000001 00168-0162-46 CLOBETASOL PROPIONATE 0.05 % EX OINT BOTH IP/OP $522.30 $386.50 $0.00 $978.75 $0.00 $0.00 $0.00 $0.00 $0.00 $387.65 $387.65 $402.59 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $237.06 $978.75 $379.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9632 ERX HCPCS 25000001 00472-0402-25 CLOBETASOL PROPIONATE 0.05 % EX SOLN BOTH IP/OP $346.59 $256.48 $0.00 $267.15 $0.00 $0.00 $0.00 $0.00 $0.00 $257.24 $257.24 $267.15 $0.00 $72.23 $0.00 $0.00 $0.00 $0.00 $157.31 $249.17 $251.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9632 ERX HCPCS 25000001 50383-0266-25 CLOBETASOL PROPIONATE 0.05 % EX SOLN BOTH IP/OP $346.59 $256.48 $0.00 $267.15 $0.00 $0.00 $0.00 $0.00 $0.00 $257.24 $257.24 $267.15 $0.00 $72.23 $0.00 $0.00 $0.00 $0.00 $157.31 $249.17 $251.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9632 ERX HCPCS 25000001 51672-1293-02 CLOBETASOL PROPIONATE 0.05 % EX SOLN BOTH IP/OP $346.59 $256.48 $0.00 $267.15 $0.00 $0.00 $0.00 $0.00 $0.00 $257.24 $257.24 $267.15 $0.00 $72.23 $0.00 $0.00 $0.00 $0.00 $157.31 $249.17 $251.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9632 ERX HCPCS 25000001 60432-0133-25 CLOBETASOL PROPIONATE 0.05 % EX SOLN BOTH IP/OP $346.59 $256.48 $0.00 $267.15 $0.00 $0.00 $0.00 $0.00 $0.00 $257.24 $257.24 $267.15 $0.00 $72.23 $0.00 $0.00 $0.00 $0.00 $157.31 $249.17 $251.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9632 ERX HCPCS 25000001 00168-0269-50 CLOBETASOL PROPIONATE 0.05 % EX SOLN BOTH IP/OP $346.59 $256.48 $0.00 $432.99 $0.00 $0.00 $0.00 $0.00 $0.00 $257.24 $257.24 $267.15 $0.00 $72.23 $0.00 $0.00 $0.00 $0.00 $157.31 $432.99 $251.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9632 ERX HCPCS 25000001 51672-1293-03 CLOBETASOL PROPIONATE 0.05 % EX SOLN BOTH IP/OP $346.59 $256.48 $0.00 $432.99 $0.00 $0.00 $0.00 $0.00 $0.00 $257.24 $257.24 $267.15 $0.00 $72.23 $0.00 $0.00 $0.00 $0.00 $157.31 $432.99 $251.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9632 ERX HCPCS 25000001 60432-0133-50 CLOBETASOL PROPIONATE 0.05 % EX SOLN BOTH IP/OP $346.59 $256.48 $0.00 $432.99 $0.00 $0.00 $0.00 $0.00 $0.00 $257.24 $257.24 $267.15 $0.00 $72.23 $0.00 $0.00 $0.00 $0.00 $157.31 $432.99 $251.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9635 ERX HCPCS 63700001 00378-3025-01 CLOMIPRAMINE HCL 25 MG PO CAPS BOTH IP/OP $47.11 $34.86 $0.00 $34.18 $0.00 $0.00 $0.00 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9635 ERX HCPCS 63700001 00781-2027-01 CLOMIPRAMINE HCL 25 MG PO CAPS BOTH IP/OP $47.11 $34.86 $0.00 $34.18 $0.00 $0.00 $0.00 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9635 ERX HCPCS 63700001 51672-4011-05 CLOMIPRAMINE HCL 25 MG PO CAPS BOTH IP/OP $47.11 $34.86 $0.00 $34.18 $0.00 $0.00 $0.00 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9636 ERX HCPCS 63700001 00406-9908-03 CLOMIPRAMINE HCL 75 MG PO CAPS BOTH IP/OP $47.11 $34.86 $0.00 $34.18 $0.00 $0.00 $0.00 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9636 ERX HCPCS 63700001 51672-4013-05 CLOMIPRAMINE HCL 75 MG PO CAPS BOTH IP/OP $47.11 $34.86 $0.00 $34.18 $0.00 $0.00 $0.00 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9637 ERX HCPCS 25000001 00093-0832-01 CLONAZEPAM 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9637 ERX HCPCS 25000001 00228-3003-11 CLONAZEPAM 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9637 ERX HCPCS 25000001 16714-0752-01 CLONAZEPAM 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9637 ERX HCPCS 25000001 16729-0136-00 CLONAZEPAM 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9637 ERX HCPCS 25000001 63739-0263-10 CLONAZEPAM 0.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9638 ERX HCPCS 25000001 00093-3212-01 CLONAZEPAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9638 ERX HCPCS 25000001 00228-3004-11 CLONAZEPAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9638 ERX HCPCS 25000001 16714-0750-01 CLONAZEPAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9638 ERX HCPCS 25000001 16729-0137-00 CLONAZEPAM 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9644 ERX HCPCS 63700001 00054-4146-22 CLOTRIMAZOLE 10 MG MT TROC BOTH IP/OP $13.48 $9.98 $0.00 $9.78 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.11 $9.68 $9.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9644 ERX HCPCS 63700001 00574-0107-77 CLOTRIMAZOLE 10 MG MT TROC BOTH IP/OP $13.48 $9.98 $0.00 $9.78 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.11 $9.68 $9.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9647 ERX HCPCS 63700001 00093-7772-93 CLOZAPINE 100 MG PO TABS BOTH IP/OP $14.33 $10.60 $0.00 $10.40 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.50 $10.30 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9647 ERX HCPCS 63700001 00378-0860-01 CLOZAPINE 100 MG PO TABS BOTH IP/OP $14.33 $10.60 $0.00 $10.40 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.50 $10.30 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9647 ERX HCPCS 63700001 51079-0922-20 CLOZAPINE 100 MG PO TABS BOTH IP/OP $14.33 $10.60 $0.00 $10.40 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.50 $10.30 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9648 ERX HCPCS 63700001 00093-4359-93 CLOZAPINE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9648 ERX HCPCS 63700001 00378-0825-01 CLOZAPINE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9648 ERX HCPCS 63700001 51079-0921-20 CLOZAPINE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9682 ERX HCPCS 25000001 50484-0010-30 COLLAGENASE 250 UNIT/GM EX OINT BOTH IP/OP $960.98 $711.13 $0.00 $740.72 $0.00 $0.00 $0.00 $0.00 $0.00 $713.24 $713.24 $740.72 $0.00 $200.27 $0.00 $0.00 $0.00 $0.00 $395.60 $626.62 $632.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9686 ERX HCPCS J0834 00548-5900-00 COSYNTROPIN 0.25 MG IJ SOLR BOTH IP/OP $355.52 $263.08 $0.00 $274.03 $159.98 $159.98 $0.00 $0.00 $0.00 $74.10 $263.87 $263.87 $274.03 $0.00 $41.87 $0.00 $210.29 $210.29 $0.00 $161.36 $255.59 $258.18 $0.00 $0.00 $44.56 $0.00 $0.00 $42.42 $0.00 $0.00 $0.00 $0.00 $0.00 9686 ERX HCPCS J0834 67457-0227-02 COSYNTROPIN 0.25 MG IJ SOLR BOTH IP/OP $355.52 $263.08 $0.00 $274.03 $159.98 $159.98 $0.00 $0.00 $0.00 $74.10 $263.87 $263.87 $274.03 $0.00 $41.87 $0.00 $210.29 $210.29 $0.00 $161.36 $255.59 $258.18 $0.00 $0.00 $44.56 $0.00 $0.00 $42.42 $0.00 $0.00 $0.00 $0.00 $0.00 9690 ERX HCPCS J7631 00172-6406-49 CROMOLYN SODIUM 20 MG/2ML IN NEBU BOTH IP/OP $28.49 $21.08 $0.00 $21.96 $0.00 $0.00 $0.00 $0.00 $0.00 $21.15 $21.15 $21.96 $0.00 $5.94 $0.00 $0.00 $0.00 $0.00 $12.92 $20.47 $20.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9691 ERX HCPCS 25000001 17478-0291-11 CROMOLYN SODIUM 4 % OP SOLN BOTH IP/OP $143.60 $106.26 $0.00 $110.69 $0.00 $0.00 $0.00 $0.00 $0.00 $106.58 $106.58 $110.69 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $65.10 $103.12 $104.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9691 ERX HCPCS 25000001 61314-0237-10 CROMOLYN SODIUM 4 % OP SOLN BOTH IP/OP $143.60 $106.26 $0.00 $110.69 $0.00 $0.00 $0.00 $0.00 $0.00 $106.58 $106.58 $110.69 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $65.10 $103.12 $104.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9699 ERX HCPCS 25000001 00065-0395-15 CYCLOPENTOLATE HCL 0.5 % OP SOLN BOTH IP/OP $327.92 $242.66 $0.00 $269.26 $0.00 $0.00 $0.00 $0.00 $0.00 $259.27 $259.27 $269.26 $0.00 $68.34 $0.00 $0.00 $0.00 $0.00 $148.84 $235.76 $238.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9699 ERX HCPCS 25000001 17478-0096-15 CYCLOPENTOLATE HCL 0.5 % OP SOLN BOTH IP/OP $327.92 $242.66 $0.00 $269.26 $0.00 $0.00 $0.00 $0.00 $0.00 $259.27 $259.27 $269.26 $0.00 $68.34 $0.00 $0.00 $0.00 $0.00 $148.84 $235.76 $238.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9700 ERX HCPCS 25000001 00065-0397-02 CYCLOPENTOLATE HCL 2 % OP SOLN BOTH IP/OP $167.07 $123.63 $0.00 $141.69 $0.00 $0.00 $0.00 $0.00 $0.00 $136.43 $136.43 $141.69 $0.00 $34.82 $0.00 $0.00 $0.00 $0.00 $75.74 $119.97 $121.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9700 ERX HCPCS 25000001 17478-0097-02 CYCLOPENTOLATE HCL 2 % OP SOLN BOTH IP/OP $167.07 $123.63 $0.00 $141.69 $0.00 $0.00 $0.00 $0.00 $0.00 $136.43 $136.43 $141.69 $0.00 $34.82 $0.00 $0.00 $0.00 $0.00 $75.74 $119.97 $121.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9700 ERX HCPCS 25000001 17478-0097-10 CYCLOPENTOLATE HCL 2 % OP SOLN BOTH IP/OP $167.07 $123.63 $0.00 $141.69 $0.00 $0.00 $0.00 $0.00 $0.00 $136.43 $136.43 $141.69 $0.00 $34.82 $0.00 $0.00 $0.00 $0.00 $75.74 $135.27 $121.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9701 ERX HCPCS 25000001 00065-0359-02 CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN BOTH IP/OP $210.67 $155.90 $0.00 $178.62 $0.00 $0.00 $0.00 $0.00 $0.00 $171.99 $171.99 $178.62 $0.00 $43.90 $0.00 $0.00 $0.00 $0.00 $60.48 $95.80 $96.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9701 ERX HCPCS 25000001 00065-0359-05 CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP SOLN BOTH IP/OP $210.67 $155.90 $0.00 $178.62 $0.00 $0.00 $0.00 $0.00 $0.00 $171.99 $171.99 $178.62 $0.00 $43.90 $0.00 $0.00 $0.00 $0.00 $60.48 $151.46 $96.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9704 ERX HCPCS 63700001 13845-1202-02 CYCLOSERINE 250 MG PO CAPS BOTH IP/OP $290.10 $214.67 $0.00 $210.67 $0.00 $0.00 $0.00 $51.64 $0.00 $0.00 $0.00 $0.00 $0.00 $60.46 $0.00 $0.00 $0.00 $0.00 $131.67 $208.57 $210.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9705 ERX HCPCS j7516 00078-0109-01 CYCLOSPORINE 50 MG/ML IV SOLN BOTH IP/OP $181.14 $134.04 $0.00 $139.62 $0.00 $0.00 $0.00 $0.00 $0.00 $134.44 $134.44 $139.62 $0.00 $37.75 $0.00 $0.00 $0.00 $0.00 $82.12 $130.08 $131.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9705 ERX HCPCS j7516 00574-0866-10 CYCLOSPORINE 50 MG/ML IV SOLN BOTH IP/OP $181.14 $134.04 $0.00 $139.62 $0.00 $0.00 $0.00 $0.00 $0.00 $134.44 $134.44 $139.62 $0.00 $37.75 $0.00 $0.00 $0.00 $0.00 $82.12 $130.08 $131.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9706 ERX HCPCS J7502 00078-0241-15 CYCLOSPORINE 100 MG PO CAPS BOTH IP/OP $58.54 $43.32 $0.00 $45.12 $26.34 $26.34 $0.00 $0.00 $0.00 $12.20 $43.45 $43.45 $45.12 $0.00 $12.20 $0.00 $34.63 $34.63 $0.00 $26.55 $42.05 $42.47 $0.00 $0.00 $8.31 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 9706 ERX HCPCS J7502 00078-0241-61 CYCLOSPORINE 100 MG PO CAPS BOTH IP/OP $58.54 $43.32 $0.00 $45.12 $26.34 $26.34 $0.00 $0.00 $0.00 $12.20 $43.45 $43.45 $45.12 $0.00 $12.20 $0.00 $34.63 $34.63 $0.00 $26.55 $42.05 $42.47 $0.00 $0.00 $8.31 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 9706 ERX HCPCS J7502 60505-0134-00 CYCLOSPORINE 100 MG PO CAPS BOTH IP/OP $58.54 $43.32 $0.00 $45.12 $26.34 $26.34 $0.00 $0.00 $0.00 $12.20 $43.45 $43.45 $45.12 $0.00 $12.20 $0.00 $34.63 $34.63 $0.00 $26.55 $42.05 $42.47 $0.00 $0.00 $8.31 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 9707 ERX HCPCS J7515 00078-0240-15 CYCLOSPORINE (SANDIMMUNE) 25 MG PO CAPS BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $0.00 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9707 ERX HCPCS J7515 00078-0240-61 CYCLOSPORINE (SANDIMMUNE) 25 MG PO CAPS BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $0.00 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9707 ERX HCPCS J7515 60505-0133-00 CYCLOSPORINE (SANDIMMUNE) 25 MG PO CAPS BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $0.00 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9708 ERX HCPCS J7502 00078-0110-22 CYCLOSPORINE 100 MG/ML PO SOLN BOTH IP/OP "$2,330.49 " "$1,724.56" $0.00 "$1,796.34" "$1,048.72" "$1,048.72" $0.00 $0.00 $0.00 $485.73 "$1,729.69" "$1,729.69" "$1,796.34" $0.00 $485.67 $0.00 "$1,148.93" "$1,148.93" $0.00 "$1,079.76" "$1,710.34" "$1,727.62" $0.00 $0.00 $337.96 $0.00 $0.00 $343.80 $0.00 $0.00 $0.00 $0.00 $0.00 9715 ERX HCPCS 63700001 00555-0633-02 DANAZOL 50 MG PO CAPS BOTH IP/OP $15.20 $11.25 $0.00 $11.03 $0.00 $0.00 $0.00 $2.71 $0.00 $0.00 $0.00 $0.00 $0.00 $3.17 $0.00 $0.00 $0.00 $0.00 $6.90 $10.92 $11.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9716 ERX HCPCS 25000001 00143-9297-01 DANTROLENE SODIUM 20 MG IV SOLR BOTH IP/OP $295.27 $218.50 $0.00 $227.59 $0.00 $0.00 $0.00 $0.00 $0.00 $219.15 $219.15 $227.59 $0.00 $61.53 $0.00 $0.00 $0.00 $0.00 $134.02 $212.29 $214.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9716 ERX HCPCS 25000001 27505-0003-67 DANTROLENE SODIUM 20 MG IV SOLR BOTH IP/OP $295.27 $218.50 $0.00 $227.59 $0.00 $0.00 $0.00 $0.00 $0.00 $219.15 $219.15 $227.59 $0.00 $61.53 $0.00 $0.00 $0.00 $0.00 $134.02 $212.29 $214.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9716 ERX HCPCS 25000001 42023-0123-06 DANTROLENE SODIUM 20 MG IV SOLR BOTH IP/OP $295.27 $218.50 $0.00 $227.59 $0.00 $0.00 $0.00 $0.00 $0.00 $219.15 $219.15 $227.59 $0.00 $61.53 $0.00 $0.00 $0.00 $0.00 $134.02 $212.29 $214.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9717 ERX HCPCS 63700001 00115-4433-01 DANTROLENE SODIUM 100 MG PO CAPS BOTH IP/OP $9.09 $6.73 $0.00 $6.59 $0.00 $0.00 $0.00 $1.62 $0.00 $0.00 $0.00 $0.00 $0.00 $1.89 $0.00 $0.00 $0.00 $0.00 $4.12 $6.53 $6.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9718 ERX HCPCS 63700001 00115-4411-01 DANTROLENE SODIUM 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9718 ERX HCPCS 63700001 68084-0300-21 DANTROLENE SODIUM 25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9719 ERX HCPCS 63700001 00115-4422-01 DANTROLENE SODIUM 50 MG PO CAPS BOTH IP/OP $7.25 $5.37 $0.00 $5.26 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $3.29 $5.21 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9719 ERX HCPCS 63700001 42023-0125-01 DANTROLENE SODIUM 50 MG PO CAPS BOTH IP/OP $7.25 $5.37 $0.00 $5.26 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $3.29 $5.21 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9722 ERX HCPCS J0895 00409-2337-25 DEFEROXAMINE MESYLATE 2 G IJ SOLR BOTH IP/OP $148.48 $109.88 $0.00 $114.45 $0.00 $0.00 $0.00 $0.00 $0.00 $110.20 $110.20 $114.45 $0.00 $36.01 $0.00 $0.00 $0.00 $0.00 $66.32 $105.05 $106.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9722 ERX HCPCS J0895 63323-0599-30 DEFEROXAMINE MESYLATE 2 G IJ SOLR BOTH IP/OP $148.48 $109.88 $0.00 $114.45 $0.00 $0.00 $0.00 $0.00 $0.00 $110.20 $110.20 $114.45 $0.00 $36.01 $0.00 $0.00 $0.00 $0.00 $66.32 $105.05 $106.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9723 ERX HCPCS J0895 00078-0467-61 DEFEROXAMINE MESYLATE 500 MG IJ SOLR BOTH IP/OP $42.92 $31.76 $0.00 $34.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.46 $33.99 $34.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9723 ERX HCPCS J0895 00409-2336-10 DEFEROXAMINE MESYLATE 500 MG IJ SOLR BOTH IP/OP $42.92 $31.76 $0.00 $34.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.46 $33.99 $34.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9723 ERX HCPCS J0895 63323-0597-10 DEFEROXAMINE MESYLATE 500 MG IJ SOLR BOTH IP/OP $42.92 $31.76 $0.00 $34.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.46 $33.99 $34.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9726 ERX HCPCS 63700001 62584-0159-01 DEMECLOCYCLINE HCL 150 MG PO TABS BOTH IP/OP $44.55 $32.97 $0.00 $32.33 $0.00 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 $9.28 $0.00 $0.00 $0.00 $0.00 $20.21 $32.00 $32.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9726 ERX HCPCS 63700001 65162-0554-10 DEMECLOCYCLINE HCL 150 MG PO TABS BOTH IP/OP $44.55 $32.97 $0.00 $32.33 $0.00 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 $9.28 $0.00 $0.00 $0.00 $0.00 $20.21 $32.00 $32.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9727 ERX HCPCS 63700001 42806-0144-48 DEMECLOCYCLINE HCL 300 MG PO TABS BOTH IP/OP $131.77 $97.51 $0.00 $95.58 $0.00 $0.00 $0.00 $23.46 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $0.00 $0.00 $0.00 $0.00 $59.74 $94.63 $95.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9727 ERX HCPCS 63700001 65162-0555-48 DEMECLOCYCLINE HCL 300 MG PO TABS BOTH IP/OP $131.77 $97.51 $0.00 $95.58 $0.00 $0.00 $0.00 $23.46 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $0.00 $0.00 $0.00 $0.00 $59.74 $94.63 $95.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9748 ERX HCPCS J2597 00703-5054-01 DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN BOTH IP/OP $66.00 $48.84 $0.00 $73.33 $0.00 $0.00 $0.00 $0.00 $0.00 $70.61 $70.61 $73.33 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $42.60 $67.48 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9748 ERX HCPCS J2597 43598-0931-09 DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN BOTH IP/OP $66.00 $48.84 $0.00 $73.33 $0.00 $0.00 $0.00 $0.00 $0.00 $70.61 $70.61 $73.33 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $42.60 $67.48 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9748 ERX HCPCS J2597 55566-2200-00 DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN BOTH IP/OP $66.00 $48.84 $0.00 $73.33 $0.00 $0.00 $0.00 $0.00 $0.00 $70.61 $70.61 $73.33 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $42.60 $67.48 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9748 ERX HCPCS J2597 55566-2300-00 DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN BOTH IP/OP $66.00 $48.84 $0.00 $73.33 $0.00 $0.00 $0.00 $0.00 $0.00 $70.61 $70.61 $73.33 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $42.60 $67.48 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9748 ERX HCPCS J2597 62756-0529-40 DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN BOTH IP/OP $66.00 $48.84 $0.00 $73.33 $0.00 $0.00 $0.00 $0.00 $0.00 $70.61 $70.61 $73.33 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $42.60 $67.48 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9748 ERX HCPCS J2597 69918-0899-10 DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN BOTH IP/OP $66.00 $48.84 $0.00 $73.33 $0.00 $0.00 $0.00 $0.00 $0.00 $70.61 $70.61 $73.33 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $42.60 $67.48 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9748 ERX HCPCS J2597 69918-0901-10 DESMOPRESSIN ACETATE 4 MCG/ML IJ SOLN BOTH IP/OP $66.00 $48.84 $0.00 $73.33 $0.00 $0.00 $0.00 $0.00 $0.00 $70.61 $70.61 $73.33 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $42.60 $67.48 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9759 ERX HCPCS 25000001 00409-7418-03 DEXTRAN 40 IN D5W 10 % IV SOLN BOTH IP/OP $135.10 $99.97 $0.00 $104.14 $0.00 $0.00 $0.00 $0.00 $0.00 $100.27 $100.27 $104.14 $0.00 $28.15 $0.00 $0.00 $0.00 $0.00 $56.00 $88.70 $89.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9788 ERX HCPCS J7120 00264-7751-10 DEXTROSE IN LACTATED RINGERS 5 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 9788 ERX HCPCS J7120 00338-0125-03 DEXTROSE IN LACTATED RINGERS 5 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 9788 ERX HCPCS J7120 00264-7751-00 DEXTROSE IN LACTATED RINGERS 5 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 9788 ERX HCPCS J7120 00338-0125-04 DEXTROSE IN LACTATED RINGERS 5 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $1.13 $18.66 $18.66 $19.38 $0.00 $2.95 $0.00 $14.87 $14.87 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $2.77 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 9823 ERX HCPCS Q9958 00270-1410-30 DIATRIZOATE MEGLUMINE 18 % UR SOLN BOTH IP/OP $149.39 $110.55 $0.00 $110.88 $67.23 $67.23 $0.00 $0.00 $0.00 $31.14 $110.88 $110.88 $0.00 $0.00 $24.68 $0.00 $88.36 $88.36 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9828 ERX HCPCS Q9963 00270-0445-40 DIATRIZOATE MEGLUMINE & SODIUM 66-10 % (37% IODINE) SOLN BOTH IP/OP $290.24 $214.78 $0.00 $215.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.42 $215.42 $0.00 $0.00 $23.97 $0.00 $0.00 $0.00 $0.00 $131.74 $208.67 $210.78 $0.00 $0.00 $22.82 $0.00 $0.00 $41.94 $0.00 $0.00 $0.00 $0.00 $0.00 9859 ERX HCPCS J1110 00574-0850-05 DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN BOTH IP/OP $273.48 $202.38 $0.00 $210.80 $0.00 $0.00 $0.00 $0.00 $0.00 $202.98 $202.98 $210.80 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $124.13 $196.62 $198.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9859 ERX HCPCS J1110 00574-0850-10 DIHYDROERGOTAMINE MESYLATE 1 MG/ML IJ SOLN BOTH IP/OP $273.48 $202.38 $0.00 $210.80 $0.00 $0.00 $0.00 $0.00 $0.00 $202.98 $202.98 $210.80 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $124.13 $196.62 $198.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9872 ERX HCPCS J0470 17478-0526-03 DIMERCAPROL 100 MG/ML IM SOLN BOTH IP/OP $646.90 $478.71 $0.00 $498.63 $0.00 $0.00 $0.00 $0.00 $0.00 $480.13 $480.13 $498.63 $0.00 $134.81 $0.00 $0.00 $0.00 $0.00 $293.61 $465.08 $469.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9875 ERX HCPCS 25000001 00009-0827-03 DINOPROSTONE 20 MG VA SUPP BOTH IP/OP "$5,432.10 " "$4,019.75" $0.00 "$4,345.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,716.05" "$4,302.22" "$4,345.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9891 ERX HCPCS J1245 00641-2569-41 DIPYRIDAMOLE 5 MG/ML IV SOLN BOTH IP/OP $91.72 $67.87 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 $68.07 $68.07 $70.70 $0.00 $21.44 $0.00 $0.00 $0.00 $0.00 $41.58 $65.86 $66.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9891 ERX HCPCS J1245 00641-2569-44 DIPYRIDAMOLE 5 MG/ML IV SOLN BOTH IP/OP $91.72 $67.87 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 $68.07 $68.07 $70.70 $0.00 $21.44 $0.00 $0.00 $0.00 $0.00 $41.58 $65.86 $66.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9894 ERX HCPCS 63700001 00904-5522-61 DOXAZOSIN MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9894 ERX HCPCS 63700001 16729-0211-01 DOXAZOSIN MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9894 ERX HCPCS 63700001 68084-0836-25 DOXAZOSIN MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9894 ERX HCPCS 63700001 68084-0836-95 DOXAZOSIN MESYLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9895 ERX HCPCS 63700001 00378-4022-01 DOXAZOSIN MESYLATE 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9895 ERX HCPCS 63700001 51079-0958-01 DOXAZOSIN MESYLATE 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9895 ERX HCPCS 63700001 51079-0958-20 DOXAZOSIN MESYLATE 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9896 ERX HCPCS 63700001 00904-5524-61 DOXAZOSIN MESYLATE 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9896 ERX HCPCS 63700001 16729-0213-01 DOXAZOSIN MESYLATE 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9897 ERX HCPCS 63700001 16729-0415-01 DOXAZOSIN MESYLATE 8 MG PO TABS BOTH IP/OP $6.23 $4.61 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9897 ERX HCPCS 63700001 68382-0786-01 DOXAZOSIN MESYLATE 8 MG PO TABS BOTH IP/OP $6.23 $4.61 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9900 ERX HCPCS 63700001 49884-0727-03 DOXYCYCLINE MONOHYDRATE 100 MG PO CAPS BOTH IP/OP $9.93 $7.35 $0.00 $7.21 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $0.00 $2.07 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9900 ERX HCPCS 63700001 63304-0616-50 DOXYCYCLINE MONOHYDRATE 100 MG PO CAPS BOTH IP/OP $9.93 $7.35 $0.00 $7.21 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $0.00 $2.07 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9902 ERX HCPCS 25000001 69097-0228-43 DOXYCYCLINE MONOHYDRATE 25 MG/5ML PO SUSR BOTH IP/OP $92.82 $68.69 $0.00 $74.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.41 $73.51 $74.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9904 ERX HCPCS Q0167 00527-1450-06 DRONABINOL 2.5 MG PO CAPS BOTH IP/OP $22.40 $16.58 $0.00 $17.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.20 $17.74 $17.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9904 ERX HCPCS Q0167 17478-0761-06 DRONABINOL 2.5 MG PO CAPS BOTH IP/OP $22.40 $16.58 $0.00 $17.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.20 $17.74 $17.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9904 ERX HCPCS Q0167 42858-0867-06 DRONABINOL 2.5 MG PO CAPS BOTH IP/OP $22.40 $16.58 $0.00 $17.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.20 $17.74 $17.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9914 ERX HCPCS 25000001 00046-1065-05 ECHOTHIOPHATE IODIDE 0.125 % OP SOLR BOTH IP/OP $324.52 $240.14 $0.00 $259.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.26 $257.02 $259.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9915 ERX HCPCS 63700001 45802-0466-35 ECONAZOLE NITRATE 1 % EX CREA BOTH IP/OP $365.40 $270.40 $0.00 $265.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.15 $0.00 $0.00 $0.00 $0.00 $165.85 $262.70 $265.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9915 ERX HCPCS 63700001 52565-0022-15 ECONAZOLE NITRATE 1 % EX CREA BOTH IP/OP $365.40 $270.40 $0.00 $265.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.15 $0.00 $0.00 $0.00 $0.00 $165.85 $262.70 $265.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9927 ERX HCPCS 63700001 16714-0443-01 ENALAPRIL MALEATE 5 MG PO TABS BOTH IP/OP $6.36 $4.71 $0.00 $4.80 $0.00 $0.00 $0.00 $1.13 $0.00 $0.00 $0.00 $0.00 $0.00 $1.33 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9927 ERX HCPCS 63700001 64679-0924-02 ENALAPRIL MALEATE 5 MG PO TABS BOTH IP/OP $6.36 $4.71 $0.00 $4.80 $0.00 $0.00 $0.00 $1.13 $0.00 $0.00 $0.00 $0.00 $0.00 $1.33 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9929 ERX HCPCS 25000001 00143-9786-01 ENALAPRILAT 1.25 MG/ML IV INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9929 ERX HCPCS 25000001 00143-9786-10 ENALAPRILAT 1.25 MG/ML IV INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9929 ERX HCPCS 25000001 00409-2122-02 ENALAPRILAT 1.25 MG/ML IV INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9938 ERX HCPCS J0885 59676-0310-00 EPOETIN ALFA 10000 UNIT/ML IJ SOLN BOTH IP/OP $936.41 $692.94 $0.00 $679.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.15 $0.00 $0.00 $0.00 $0.00 $424.92 $673.07 $679.86 $0.00 $0.00 $133.00 $0.00 $0.00 $118.59 $0.00 $0.00 $0.00 $0.00 $0.00 9938 ERX HCPCS J0885 59676-0310-01 EPOETIN ALFA 10000 UNIT/ML IJ SOLN BOTH IP/OP $936.41 $692.94 $0.00 $679.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.15 $0.00 $0.00 $0.00 $0.00 $424.92 $673.07 $679.86 $0.00 $0.00 $133.00 $0.00 $0.00 $118.59 $0.00 $0.00 $0.00 $0.00 $0.00 9938 ERX HCPCS J0885 59676-0310-02 EPOETIN ALFA 10000 UNIT/ML IJ SOLN BOTH IP/OP $936.41 $692.94 $0.00 $679.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.15 $0.00 $0.00 $0.00 $0.00 $424.92 $673.07 $679.86 $0.00 $0.00 $133.00 $0.00 $0.00 $118.59 $0.00 $0.00 $0.00 $0.00 $0.00 9939 ERX HCPCS J0885 55513-0126-01 EPOETIN ALFA (EPOGEN) 2000 UNIT/ML IJ SOLN BOTH IP/OP $153.59 $113.66 $0.00 $111.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.01 $0.00 $0.00 $0.00 $0.00 $69.64 $110.30 $111.42 $0.00 $0.00 $21.80 $0.00 $0.00 $23.72 $0.00 $0.00 $0.00 $0.00 $0.00 9939 ERX HCPCS J0885 55513-0126-10 EPOETIN ALFA (EPOGEN) 2000 UNIT/ML IJ SOLN BOTH IP/OP $153.59 $113.66 $0.00 $111.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.01 $0.00 $0.00 $0.00 $0.00 $69.64 $110.30 $111.42 $0.00 $0.00 $21.80 $0.00 $0.00 $23.72 $0.00 $0.00 $0.00 $0.00 $0.00 9941 ERX HCPCS J0885 55513-0148-10 EPOETIN ALFA (EPOGEN) 4000 UNIT/ML IJ SOLN BOTH IP/OP $153.60 $113.66 $0.00 $111.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.01 $0.00 $0.00 $0.00 $0.00 $69.64 $110.31 $111.42 $0.00 $0.00 $21.80 $0.00 $0.00 $23.72 $0.00 $0.00 $0.00 $0.00 $0.00 9949 ERX HCPCS 63700001 00781-5405-01 ERGOTAMINE-CAFFEINE 1-100 MG PO TABS BOTH IP/OP $64.69 $47.87 $0.00 $46.94 $0.00 $0.00 $0.00 $11.51 $0.00 $0.00 $0.00 $0.00 $0.00 $13.48 $0.00 $0.00 $0.00 $0.00 $29.34 $46.47 $46.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9963 ERX HCPCS 63700001 61570-0072-01 ESTERIFIED ESTROGENS 0.3 MG PO TABS BOTH IP/OP $9.24 $6.84 $0.00 $6.41 $0.00 $0.00 $0.00 $1.64 $0.00 $0.00 $0.00 $0.00 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $4.01 $6.34 $6.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9964 ERX HCPCS 63700001 61570-0073-01 ESTERIFIED ESTROGENS 0.625 MG PO TABS BOTH IP/OP $13.12 $9.71 $0.00 $9.10 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.73 $0.00 $0.00 $0.00 $0.00 $5.69 $9.01 $9.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9965 ERX HCPCS 63700001 61570-0074-01 ESTERIFIED ESTROGENS 1.25 MG PO TABS BOTH IP/OP $18.30 $13.54 $0.00 $12.70 $0.00 $0.00 $0.00 $3.26 $0.00 $0.00 $0.00 $0.00 $0.00 $3.81 $0.00 $0.00 $0.00 $0.00 $7.94 $12.58 $12.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9967 ERX HCPCS 63700001 00378-1454-01 ESTRADIOL 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9967 ERX HCPCS 63700001 00555-0886-02 ESTRADIOL 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9968 ERX HCPCS 63700001 00378-1458-01 ESTRADIOL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9968 ERX HCPCS 63700001 00555-0887-02 ESTRADIOL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9968 ERX HCPCS 63700001 00555-0887-04 ESTRADIOL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9969 ERX HCPCS 25000001 00430-3754-14 ESTRADIOL 0.1 MG/GM VA CREA BOTH IP/OP $81.58 $60.37 $0.00 $62.88 $0.00 $0.00 $0.00 $0.00 $0.00 $60.55 $60.55 $62.88 $0.00 $17.00 $0.00 $0.00 $0.00 $0.00 $37.00 $58.60 $59.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9971 ERX HCPCS 63700001 00013-0132-02 ESTRAMUSTINE PHOSPHATE SODIUM 140 MG PO CAPS BOTH IP/OP $77.63 $57.45 $0.00 $58.50 $0.00 $0.00 $0.00 $13.82 $0.00 $0.00 $0.00 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $36.56 $57.91 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9972 ERX HCPCS J1410 00046-0749-05 ESTROGENS CONJUGATED 25 MG IJ SOLR BOTH IP/OP "$1,192.45 " $882.41 $0.00 $919.14 $536.60 $536.60 $341.50 $341.50 $341.50 $92.23 $885.04 $885.04 $919.14 $341.46 $401.21 $221.95 $705.33 $705.33 $0.00 $495.52 $784.90 $792.82 $0.00 $0.00 $362.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9973 ERX HCPCS 63700001 00046-1100-81 ESTROGENS CONJUGATED 0.3 MG PO TABS BOTH IP/OP $32.11 $23.76 $0.00 $21.54 $0.00 $0.00 $0.00 $5.72 $0.00 $0.00 $0.00 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $13.47 $21.33 $21.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9974 ERX HCPCS 63700001 00046-1102-81 ESTROGENS CONJUGATED 0.625 MG PO TABS BOTH IP/OP $32.11 $23.76 $0.00 $21.54 $0.00 $0.00 $0.00 $5.72 $0.00 $0.00 $0.00 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $13.47 $21.33 $21.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9977 ERX HCPCS 63700001 00046-0872-21 "ESTROGENS, CONJUGATED 0.625 MG/GM VA CREA" BOTH IP/OP "$1,458.11 " "$1,079.00" $0.00 $997.89 $0.00 $0.00 $0.00 $259.54 $0.00 $0.00 $0.00 $0.00 $0.00 $303.87 $0.00 $0.00 $0.00 $0.00 $623.68 $987.91 $997.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9979 ERX HCPCS 25000001 25010-0210-27 ETHACRYNATE SODIUM 50 MG IV SOLR BOTH IP/OP "$13,599.76 " "$10,063.82" $0.00 "$10,482.70" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$10,482.70" $0.00 "$2,834.19" $0.00 $0.00 $0.00 $0.00 "$6,168.03" "$9,770.16" "$9,868.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9980 ERX HCPCS 63700001 25010-0215-15 ETHACRYNIC ACID 25 MG PO TABS BOTH IP/OP $113.23 $83.79 $0.00 $82.14 $0.00 $0.00 $0.00 $20.15 $0.00 $0.00 $0.00 $0.00 $0.00 $23.60 $0.00 $0.00 $0.00 $0.00 $51.34 $81.31 $82.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9982 ERX HCPCS 63700001 54879-0001-01 ETHAMBUTOL HCL 100 MG PO TABS BOTH IP/OP $17.52 $12.96 $0.00 $14.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.76 $13.88 $14.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9982 ERX HCPCS 63700001 68180-0280-01 ETHAMBUTOL HCL 100 MG PO TABS BOTH IP/OP $17.52 $12.96 $0.00 $14.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.76 $13.88 $14.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9983 ERX HCPCS 63700001 54879-0002-01 ETHAMBUTOL HCL 400 MG PO TABS BOTH IP/OP $11.27 $8.34 $0.00 $9.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.64 $8.93 $9.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9983 ERX HCPCS 63700001 68850-0012-02 ETHAMBUTOL HCL 400 MG PO TABS BOTH IP/OP $11.27 $8.34 $0.00 $9.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.64 $8.93 $9.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9988 ERX HCPCS 25000001 00008-4117-01 ETHIONAMIDE 250 MG PO TABS BOTH IP/OP $28.19 $20.86 $0.00 $21.73 $0.00 $0.00 $0.00 $0.00 $0.00 $20.92 $20.92 $21.73 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $12.59 $19.94 $20.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9989 ERX HCPCS 63700001 00071-0237-24 ETHOSUXIMIDE 250 MG PO CAPS BOTH IP/OP $19.44 $14.39 $0.00 $13.50 $0.00 $0.00 $0.00 $3.46 $0.00 $0.00 $0.00 $0.00 $0.00 $4.05 $0.00 $0.00 $0.00 $0.00 $8.44 $13.36 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9989 ERX HCPCS 63700001 23155-0532-01 ETHOSUXIMIDE 250 MG PO CAPS BOTH IP/OP $19.44 $14.39 $0.00 $13.50 $0.00 $0.00 $0.00 $3.46 $0.00 $0.00 $0.00 $0.00 $0.00 $4.05 $0.00 $0.00 $0.00 $0.00 $8.44 $13.36 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9989 ERX HCPCS 63700001 61748-0025-01 ETHOSUXIMIDE 250 MG PO CAPS BOTH IP/OP $19.44 $14.39 $0.00 $13.50 $0.00 $0.00 $0.00 $3.46 $0.00 $0.00 $0.00 $0.00 $0.00 $4.05 $0.00 $0.00 $0.00 $0.00 $8.44 $13.36 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10001 ERX HCPCS J8560 00378-3266-94 ETOPOSIDE 50 MG PO CAPS BOTH IP/OP $337.48 $249.74 $0.00 $260.13 $0.00 $0.00 $0.00 $0.00 $0.00 $250.48 $250.48 $260.13 $0.00 $70.33 $0.00 $0.00 $0.00 $0.00 $153.17 $242.62 $245.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10010 ERX HCPCS 63700001 68180-0150-01 FAMOTIDINE 40 MG/5ML PO SUSR BOTH IP/OP $594.56 $439.97 $0.00 $431.76 $0.00 $0.00 $0.00 $105.83 $0.00 $0.00 $0.00 $0.00 $0.00 $123.91 $0.00 $0.00 $0.00 $0.00 $269.85 $427.44 $431.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10011 ERX HCPCS 63700001 00172-5728-60 FAMOTIDINE 20 MG PO TABS BOTH IP/OP $10.15 $7.51 $0.00 $7.37 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.61 $7.29 $7.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10011 ERX HCPCS 63700001 42291-0281-10 FAMOTIDINE 20 MG PO TABS BOTH IP/OP $10.15 $7.51 $0.00 $7.37 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.61 $7.29 $7.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10011 ERX HCPCS 63700001 62332-0001-31 FAMOTIDINE 20 MG PO TABS BOTH IP/OP $10.15 $7.51 $0.00 $7.37 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.61 $7.29 $7.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10014 ERX HCPCS 25000001 00338-0519-09 FAT EMULSION PLANT BASED 20 % IV EMUL BOTH IP/OP $173.25 $128.21 $0.00 $138.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $0.00 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $0.00 10023 ERX HCPCS 25000001 99999-6004-76 FELBAMATE 600 MG/5ML PO SUSP BOTH IP/OP $313.55 $232.03 $0.00 "$3,057.36" $0.00 $0.00 $0.00 $0.00 $0.00 $232.72 $232.72 $241.68 $0.00 $65.34 $0.00 $0.00 $0.00 $0.00 "$1,910.85" $225.43 "$3,057.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10023 ERX HCPCS 25000001 00037-0442-67 FELBAMATE 600 MG/5ML PO SUSP BOTH IP/OP $313.55 $232.03 $0.00 "$3,057.36" $0.00 $0.00 $0.00 $0.00 $0.00 $232.72 $232.72 $241.68 $0.00 $65.34 $0.00 $0.00 $0.00 $0.00 "$1,910.85" "$3,026.79" "$3,057.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10025 ERX HCPCS 63700001 00037-0431-01 FELBAMATE 600 MG PO TABS BOTH IP/OP $22.74 $16.83 $0.00 $18.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.37 $18.01 $18.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10025 ERX HCPCS 63700001 51525-0431-01 FELBAMATE 600 MG PO TABS BOTH IP/OP $22.74 $16.83 $0.00 $18.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.37 $18.01 $18.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10037 ERX HCPCS 63700001 00093-7355-56 FINASTERIDE 5 MG PO TABS BOTH IP/OP $13.12 $9.71 $0.00 $9.52 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.73 $0.00 $0.00 $0.00 $0.00 $5.95 $9.42 $9.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10037 ERX HCPCS 63700001 00093-7355-98 FINASTERIDE 5 MG PO TABS BOTH IP/OP $13.12 $9.71 $0.00 $9.52 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.73 $0.00 $0.00 $0.00 $0.00 $5.95 $9.42 $9.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10037 ERX HCPCS 63700001 16729-0090-01 FINASTERIDE 5 MG PO TABS BOTH IP/OP $13.12 $9.71 $0.00 $9.52 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.73 $0.00 $0.00 $0.00 $0.00 $5.95 $9.42 $9.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10037 ERX HCPCS 63700001 50268-0323-15 FINASTERIDE 5 MG PO TABS BOTH IP/OP $13.12 $9.71 $0.00 $9.52 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.73 $0.00 $0.00 $0.00 $0.00 $5.95 $9.42 $9.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10037 ERX HCPCS 63700001 57237-0062-30 FINASTERIDE 5 MG PO TABS BOTH IP/OP $13.12 $9.71 $0.00 $9.52 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.73 $0.00 $0.00 $0.00 $0.00 $5.95 $9.42 $9.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10037 ERX HCPCS 63700001 65862-0149-90 FINASTERIDE 5 MG PO TABS BOTH IP/OP $13.12 $9.71 $0.00 $9.52 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.73 $0.00 $0.00 $0.00 $0.00 $5.95 $9.42 $9.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10037 ERX HCPCS 63700001 76282-0412-90 FINASTERIDE 5 MG PO TABS BOTH IP/OP $13.12 $9.71 $0.00 $9.52 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.73 $0.00 $0.00 $0.00 $0.00 $5.95 $9.42 $9.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10041 ERX HCPCS 63700001 00054-0011-21 FLECAINIDE ACETATE 100 MG PO TABS BOTH IP/OP $15.00 $11.10 $0.00 $10.89 $0.00 $0.00 $0.00 $2.67 $0.00 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $6.81 $10.78 $10.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10041 ERX HCPCS 63700001 00054-0011-25 FLECAINIDE ACETATE 100 MG PO TABS BOTH IP/OP $15.00 $11.10 $0.00 $10.89 $0.00 $0.00 $0.00 $2.67 $0.00 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $6.81 $10.78 $10.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10041 ERX HCPCS 63700001 50268-0321-11 FLECAINIDE ACETATE 100 MG PO TABS BOTH IP/OP $15.00 $11.10 $0.00 $10.89 $0.00 $0.00 $0.00 $2.67 $0.00 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $6.81 $10.78 $10.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10041 ERX HCPCS 63700001 50268-0321-15 FLECAINIDE ACETATE 100 MG PO TABS BOTH IP/OP $15.00 $11.10 $0.00 $10.89 $0.00 $0.00 $0.00 $2.67 $0.00 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $6.81 $10.78 $10.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10041 ERX HCPCS 63700001 65162-0642-10 FLECAINIDE ACETATE 100 MG PO TABS BOTH IP/OP $15.00 $11.10 $0.00 $10.89 $0.00 $0.00 $0.00 $2.67 $0.00 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $6.81 $10.78 $10.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10042 ERX HCPCS 63700001 00054-0012-21 FLECAINIDE ACETATE 150 MG PO TABS BOTH IP/OP $18.20 $13.47 $0.00 $13.21 $0.00 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $8.26 $13.08 $13.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10042 ERX HCPCS 63700001 00054-0012-25 FLECAINIDE ACETATE 150 MG PO TABS BOTH IP/OP $18.20 $13.47 $0.00 $13.21 $0.00 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $8.26 $13.08 $13.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10042 ERX HCPCS 63700001 53746-0643-01 FLECAINIDE ACETATE 150 MG PO TABS BOTH IP/OP $18.20 $13.47 $0.00 $13.21 $0.00 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $8.26 $13.08 $13.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10042 ERX HCPCS 63700001 65162-0643-10 FLECAINIDE ACETATE 150 MG PO TABS BOTH IP/OP $18.20 $13.47 $0.00 $13.21 $0.00 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $8.26 $13.08 $13.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10043 ERX HCPCS 63700001 00054-0010-20 FLECAINIDE ACETATE 50 MG PO TABS BOTH IP/OP $8.47 $6.27 $0.00 $6.14 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $3.84 $6.08 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10043 ERX HCPCS 63700001 00054-0010-21 FLECAINIDE ACETATE 50 MG PO TABS BOTH IP/OP $8.47 $6.27 $0.00 $6.14 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $3.84 $6.08 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10043 ERX HCPCS 63700001 00054-0010-25 FLECAINIDE ACETATE 50 MG PO TABS BOTH IP/OP $8.47 $6.27 $0.00 $6.14 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $3.84 $6.08 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10043 ERX HCPCS 63700001 65162-0641-10 FLECAINIDE ACETATE 50 MG PO TABS BOTH IP/OP $8.47 $6.27 $0.00 $6.14 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $3.84 $6.08 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10044 ERX HCPCS 63700001 00172-5411-46 FLUCONAZOLE 100 MG PO TABS BOTH IP/OP $33.46 $24.76 $0.00 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.73 $26.50 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10044 ERX HCPCS 63700001 16714-0691-01 FLUCONAZOLE 100 MG PO TABS BOTH IP/OP $33.46 $24.76 $0.00 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.73 $26.50 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10044 ERX HCPCS 63700001 16714-0691-02 FLUCONAZOLE 100 MG PO TABS BOTH IP/OP $33.46 $24.76 $0.00 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.73 $26.50 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10044 ERX HCPCS 63700001 55111-0144-01 FLUCONAZOLE 100 MG PO TABS BOTH IP/OP $33.46 $24.76 $0.00 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.73 $26.50 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10044 ERX HCPCS 63700001 55111-0144-30 FLUCONAZOLE 100 MG PO TABS BOTH IP/OP $33.46 $24.76 $0.00 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.73 $26.50 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10044 ERX HCPCS 63700001 68462-0102-30 FLUCONAZOLE 100 MG PO TABS BOTH IP/OP $33.46 $24.76 $0.00 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.73 $26.50 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10045 ERX HCPCS 63700001 00172-5413-46 FLUCONAZOLE 200 MG PO TABS BOTH IP/OP $68.49 $50.68 $0.00 $49.70 $0.00 $0.00 $0.00 $12.19 $0.00 $0.00 $0.00 $0.00 $0.00 $14.27 $0.00 $0.00 $0.00 $0.00 $31.06 $49.20 $49.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10045 ERX HCPCS 63700001 00904-6501-61 FLUCONAZOLE 200 MG PO TABS BOTH IP/OP $68.49 $50.68 $0.00 $49.70 $0.00 $0.00 $0.00 $12.19 $0.00 $0.00 $0.00 $0.00 $0.00 $14.27 $0.00 $0.00 $0.00 $0.00 $31.06 $49.20 $49.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10045 ERX HCPCS 63700001 16714-0693-01 FLUCONAZOLE 200 MG PO TABS BOTH IP/OP $68.49 $50.68 $0.00 $49.70 $0.00 $0.00 $0.00 $12.19 $0.00 $0.00 $0.00 $0.00 $0.00 $14.27 $0.00 $0.00 $0.00 $0.00 $31.06 $49.20 $49.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10045 ERX HCPCS 63700001 68084-0735-01 FLUCONAZOLE 200 MG PO TABS BOTH IP/OP $68.49 $50.68 $0.00 $49.70 $0.00 $0.00 $0.00 $12.19 $0.00 $0.00 $0.00 $0.00 $0.00 $14.27 $0.00 $0.00 $0.00 $0.00 $31.06 $49.20 $49.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10049 ERX HCPCS j1450 00338-6046-48 FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $6.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10049 ERX HCPCS j1450 00409-4688-18 FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $6.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10049 ERX HCPCS j1450 25021-0113-82 FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $6.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10049 ERX HCPCS j1450 25021-0184-66 FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $6.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10049 ERX HCPCS j1450 25021-0184-82 FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $6.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10049 ERX HCPCS j1450 70655-0002-06 FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $6.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10049 ERX HCPCS j1450 70655-0002-10 FLUCONAZOLE IN SODIUM CHLORIDE 200-0.9 MG/100ML-% IV SOLN BOTH IP/OP $41.04 $30.37 $0.00 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $6.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10050 ERX HCPCS J1450 00338-6045-37 FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN BOTH IP/OP $63.84 $47.24 $0.00 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.92 $50.56 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10050 ERX HCPCS J1450 00409-4688-12 FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN BOTH IP/OP $63.84 $47.24 $0.00 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.92 $50.56 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10050 ERX HCPCS J1450 00409-4688-16 FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN BOTH IP/OP $63.84 $47.24 $0.00 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.92 $50.56 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10050 ERX HCPCS J1450 25021-0113-87 FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN BOTH IP/OP $63.84 $47.24 $0.00 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.92 $50.56 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10050 ERX HCPCS J1450 25021-0184-87 FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN BOTH IP/OP $63.84 $47.24 $0.00 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.92 $50.56 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10050 ERX HCPCS J1450 70655-0088-06 FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN BOTH IP/OP $63.84 $47.24 $0.00 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.92 $50.56 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10050 ERX HCPCS J1450 70655-0088-10 FLUCONAZOLE IN SODIUM CHLORIDE 400-0.9 MG/200ML-% IV SOLN BOTH IP/OP $63.84 $47.24 $0.00 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.92 $50.56 $51.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10051 ERX HCPCS 63700001 00054-0427-25 FLUCYTOSINE 250 MG PO CAPS BOTH IP/OP $144.75 $107.12 $0.00 $105.00 $0.00 $0.00 $0.00 $25.77 $0.00 $0.00 $0.00 $0.00 $0.00 $30.17 $0.00 $0.00 $0.00 $0.00 $65.63 $103.95 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10051 ERX HCPCS 63700001 42794-0009-08 FLUCYTOSINE 250 MG PO CAPS BOTH IP/OP $144.75 $107.12 $0.00 $105.00 $0.00 $0.00 $0.00 $25.77 $0.00 $0.00 $0.00 $0.00 $0.00 $30.17 $0.00 $0.00 $0.00 $0.00 $65.63 $103.95 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10052 ERX HCPCS 63700001 00054-0428-25 FLUCYTOSINE 500 MG PO CAPS BOTH IP/OP $245.80 $181.89 $0.00 $178.50 $0.00 $0.00 $0.00 $43.75 $0.00 $0.00 $0.00 $0.00 $0.00 $51.22 $0.00 $0.00 $0.00 $0.00 $111.57 $176.72 $178.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10052 ERX HCPCS 63700001 42494-0340-01 FLUCYTOSINE 500 MG PO CAPS BOTH IP/OP $245.80 $181.89 $0.00 $178.50 $0.00 $0.00 $0.00 $43.75 $0.00 $0.00 $0.00 $0.00 $0.00 $51.22 $0.00 $0.00 $0.00 $0.00 $111.57 $176.72 $178.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10052 ERX HCPCS 63700001 42794-0010-08 FLUCYTOSINE 500 MG PO CAPS BOTH IP/OP $245.80 $181.89 $0.00 $178.50 $0.00 $0.00 $0.00 $43.75 $0.00 $0.00 $0.00 $0.00 $0.00 $51.22 $0.00 $0.00 $0.00 $0.00 $111.57 $176.72 $178.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10052 ERX HCPCS 63700001 43386-0770-01 FLUCYTOSINE 500 MG PO CAPS BOTH IP/OP $245.80 $181.89 $0.00 $178.50 $0.00 $0.00 $0.00 $43.75 $0.00 $0.00 $0.00 $0.00 $0.00 $51.22 $0.00 $0.00 $0.00 $0.00 $111.57 $176.72 $178.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10054 ERX HCPCS 63700001 00115-7033-01 FLUDROCORTISONE ACETATE 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10054 ERX HCPCS 63700001 00555-0997-02 FLUDROCORTISONE ACETATE 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10054 ERX HCPCS 63700001 68084-0288-01 FLUDROCORTISONE ACETATE 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10054 ERX HCPCS 63700001 68084-0288-11 FLUDROCORTISONE ACETATE 0.1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10061 ERX HCPCS 25000001 59390-0218-05 FLUORESCEIN-BENOXINATE 0.25-0.4 % OP SOLN BOTH IP/OP $148.23 $109.69 $0.00 $114.26 $0.00 $0.00 $0.00 $0.00 $0.00 $110.02 $110.02 $114.26 $0.00 $30.89 $0.00 $0.00 $0.00 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10063 ERX HCPCS 25000001 00065-0096-05 FLUOROMETHOLONE ACETATE 0.1 % OP SUSP BOTH IP/OP $362.72 $268.41 $0.00 $279.58 $0.00 $0.00 $0.00 $0.00 $0.00 $269.21 $269.21 $279.58 $0.00 $75.59 $0.00 $0.00 $0.00 $0.00 $164.63 $260.77 $263.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10065 ERX HCPCS 25000001 66530-0249-40 FLUOROURACIL 5 % EX CREA BOTH IP/OP $751.61 $556.19 $0.00 $579.34 $0.00 $0.00 $0.00 $0.00 $0.00 $557.84 $557.84 $579.34 $0.00 $156.64 $0.00 $0.00 $0.00 $0.00 $341.06 $540.23 $545.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10069 ERX HCPCS 63700001 00904-5784-61 FLUOXETINE HCL 10 MG PO CAPS BOTH IP/OP $10.89 $8.06 $0.00 $7.90 $0.00 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $4.94 $7.82 $7.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10069 ERX HCPCS 63700001 65862-0192-01 FLUOXETINE HCL 10 MG PO CAPS BOTH IP/OP $10.89 $8.06 $0.00 $7.90 $0.00 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $4.94 $7.82 $7.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10069 ERX HCPCS 63700001 65862-0192-99 FLUOXETINE HCL 10 MG PO CAPS BOTH IP/OP $10.89 $8.06 $0.00 $7.90 $0.00 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $4.94 $7.82 $7.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10070 ERX HCPCS 63700001 00904-5785-61 FLUOXETINE HCL 20 MG PO CAPS BOTH IP/OP $10.41 $7.70 $0.00 $7.55 $0.00 $0.00 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.72 $7.48 $7.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10070 ERX HCPCS 63700001 68084-0605-01 FLUOXETINE HCL 20 MG PO CAPS BOTH IP/OP $10.41 $7.70 $0.00 $7.55 $0.00 $0.00 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.72 $7.48 $7.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10072 ERX HCPCS 63700001 00121-0654-02 FLUPHENAZINE HCL 2.5 MG/5ML PO ELIX BOTH IP/OP $110.01 $81.41 $0.00 $79.80 $0.00 $0.00 $0.00 $26.38 $0.00 $0.00 $0.00 $0.00 $0.00 $22.93 $0.00 $0.00 $0.00 $0.00 $49.88 $79.00 $79.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10078 ERX HCPCS 63700001 00093-0711-01 FLURBIPROFEN 100 MG PO TABS BOTH IP/OP $7.94 $5.88 $0.00 $5.76 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.70 $5.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10078 ERX HCPCS 63700001 00378-0093-01 FLURBIPROFEN 100 MG PO TABS BOTH IP/OP $7.94 $5.88 $0.00 $5.76 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.70 $5.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10082 ERX HCPCS 25000001 45802-0222-11 FLUTICASONE PROPIONATE 0.05 % EX CREA BOTH IP/OP $132.36 $97.95 $0.00 $102.02 $0.00 $0.00 $0.00 $0.00 $0.00 $98.24 $98.24 $102.02 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $60.01 $95.06 $96.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10083 ERX HCPCS 25000001 00713-0632-31 FLUTICASONE PROPIONATE 0.005 % EX OINT BOTH IP/OP $132.36 $97.95 $0.00 $102.02 $0.00 $0.00 $0.00 $0.00 $0.00 $98.24 $98.24 $102.02 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $60.01 $95.06 $96.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10083 ERX HCPCS 25000001 45802-0221-11 FLUTICASONE PROPIONATE 0.005 % EX OINT BOTH IP/OP $132.36 $97.95 $0.00 $102.02 $0.00 $0.00 $0.00 $0.00 $0.00 $98.24 $98.24 $102.02 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $60.01 $95.06 $96.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10084 ERX HCPCS 63700001 60505-0166-01 FLUVOXAMINE MALEATE 100 MG PO TABS BOTH IP/OP $11.07 $8.19 $0.00 $8.03 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.02 $7.95 $8.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10085 ERX HCPCS 63700001 62559-0159-01 FLUVOXAMINE MALEATE 50 MG PO TABS BOTH IP/OP $9.79 $7.24 $0.00 $7.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.90 $7.75 $7.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10100 ERX HCPCS A9579 00270-1111-01 GADOTERIDOL 279.3 MG/ML IV SOLN BOTH IP/OP $242.21 $179.24 $0.00 $179.77 $108.99 $108.99 $0.00 $0.00 $0.00 $50.48 $179.77 $179.77 $0.00 $0.00 $50.48 $0.00 $143.27 $143.27 $0.00 $109.94 $174.14 $175.90 $0.00 $0.00 $34.41 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 10100 ERX HCPCS A9579 00270-1111-02 GADOTERIDOL 279.3 MG/ML IV SOLN BOTH IP/OP $242.21 $179.24 $0.00 $179.77 $108.99 $108.99 $0.00 $0.00 $0.00 $50.48 $179.77 $179.77 $0.00 $0.00 $50.48 $0.00 $143.27 $143.27 $0.00 $109.94 $174.14 $175.90 $0.00 $0.00 $34.41 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 10100 ERX HCPCS A9579 00270-1111-03 GADOTERIDOL 279.3 MG/ML IV SOLN BOTH IP/OP $242.21 $179.24 $0.00 $179.77 $108.99 $108.99 $0.00 $0.00 $0.00 $50.48 $179.77 $179.77 $0.00 $0.00 $50.48 $0.00 $143.27 $143.27 $0.00 $109.94 $174.14 $175.90 $0.00 $0.00 $34.41 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 10101 ERX HCPCS J1570 42023-0173-25 GANCICLOVIR SODIUM 500 MG IV SOLR BOTH IP/OP $392.20 $290.23 $0.00 $302.31 $0.00 $0.00 $0.00 $0.00 $0.00 $291.09 $291.09 $302.31 $0.00 $58.04 $0.00 $0.00 $0.00 $0.00 $178.01 $281.96 $284.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10101 ERX HCPCS J1570 63323-0315-10 GANCICLOVIR SODIUM 500 MG IV SOLR BOTH IP/OP $392.20 $290.23 $0.00 $302.31 $0.00 $0.00 $0.00 $0.00 $0.00 $291.09 $291.09 $302.31 $0.00 $58.04 $0.00 $0.00 $0.00 $0.00 $178.01 $281.96 $284.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10116 ERX HCPCS 63700001 51079-0811-01 GLIPIZIDE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10116 ERX HCPCS 63700001 51079-0811-20 GLIPIZIDE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10117 ERX HCPCS 63700001 00904-6637-61 GLIPIZIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10117 ERX HCPCS 63700001 51079-0810-20 GLIPIZIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10126 ERX HCPCS 63700001 00093-8343-01 GLYBURIDE 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10126 ERX HCPCS 63700001 00093-9433-01 GLYBURIDE 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10126 ERX HCPCS 63700001 51079-0872-01 GLYBURIDE 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10126 ERX HCPCS 63700001 51079-0872-20 GLYBURIDE 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10126 ERX HCPCS 63700001 65862-0029-01 GLYBURIDE 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10130 ERX HCPCS 25000001 13107-0014-01 GLYCOPYRROLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10130 ERX HCPCS 25000001 42291-0303-90 GLYCOPYRROLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10130 ERX HCPCS 25000001 49884-0065-01 GLYCOPYRROLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10130 ERX HCPCS 25000001 64980-0272-01 GLYCOPYRROLATE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10137 ERX HCPCS J9202 70720-0950-36 GOSERELIN ACETATE 3.6 MG SC IMPL BOTH IP/OP "$2,435.46 " "$1,802.24" $0.00 "$1,877.25" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,807.60" "$1,807.60" "$1,877.25" $0.00 $617.13 $0.00 $0.00 $0.00 $0.00 "$1,005.33" "$1,448.98" "$1,608.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10149 ERX HCPCS 63700001 00378-1160-01 GUANFACINE HCL 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10149 ERX HCPCS 63700001 00591-0444-01 GUANFACINE HCL 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10162 ERX HCPCS J1631 00143-9295-01 HALOPERIDOL DECANOATE 100 MG/ML IM SOLN BOTH IP/OP $55.60 $41.14 $0.00 $42.86 $25.02 $25.02 $0.00 $0.00 $0.00 $3.87 $41.27 $41.27 $42.86 $0.00 $11.24 $0.00 $32.89 $32.89 $0.00 $25.22 $39.94 $40.34 $0.00 $0.00 $19.36 $0.00 $0.00 $18.44 $0.00 $0.00 $0.00 $0.00 $0.00 10162 ERX HCPCS J1631 10147-0922-05 HALOPERIDOL DECANOATE 100 MG/ML IM SOLN BOTH IP/OP $55.60 $41.14 $0.00 $42.86 $25.02 $25.02 $0.00 $0.00 $0.00 $3.87 $41.27 $41.27 $42.86 $0.00 $11.24 $0.00 $32.89 $32.89 $0.00 $25.22 $39.94 $40.34 $0.00 $0.00 $19.36 $0.00 $0.00 $18.44 $0.00 $0.00 $0.00 $0.00 $0.00 10162 ERX HCPCS J1631 25021-0833-01 HALOPERIDOL DECANOATE 100 MG/ML IM SOLN BOTH IP/OP $55.60 $41.14 $0.00 $42.86 $25.02 $25.02 $0.00 $0.00 $0.00 $3.87 $41.27 $41.27 $42.86 $0.00 $11.24 $0.00 $32.89 $32.89 $0.00 $25.22 $39.94 $40.34 $0.00 $0.00 $19.36 $0.00 $0.00 $18.44 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 00069-0058-01 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 00069-0137-01 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 00069-0137-03 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 00409-2720-03 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 00409-2720-31 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 00409-2720-32 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 00641-2450-55 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 25021-0400-10 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 25021-0400-30 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 63323-0540-01 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 63323-0540-11 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 63323-0540-15 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 63323-0540-31 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 63323-0540-36 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 63323-0540-67 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 67457-0384-99 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 67457-0385-10 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10176 ERX HCPCS J1644 67457-0385-99 HEPARIN SODIUM (PORCINE) 1000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 10177 ERX HCPCS J1644 25021-0403-04 HEPARIN SODIUM (PORCINE) 10000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.35 $16.33 $16.33 $16.96 $0.00 $2.91 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 10177 ERX HCPCS J1644 67457-0603-05 HEPARIN SODIUM (PORCINE) 10000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.35 $16.33 $16.33 $16.96 $0.00 $2.91 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 10177 ERX HCPCS J1644 67457-0603-99 HEPARIN SODIUM (PORCINE) 10000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.35 $16.33 $16.33 $16.96 $0.00 $2.91 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 10181 ERX HCPCS J1644 00069-0059-03 HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10181 ERX HCPCS J1644 00641-0400-12 HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10181 ERX HCPCS J1644 25021-0402-01 HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10181 ERX HCPCS J1644 63323-0262-01 HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10181 ERX HCPCS J1644 63739-0953-25 HEPARIN SODIUM (PORCINE) 5000 UNIT/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10203 ERX HCPCS 25000001 51927-1647-00 HYDROCHLORIC ACID 37 % LIQD BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10209 ERX HCPCS 63700001 00009-0012-01 HYDROCORTISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10209 ERX HCPCS 63700001 42543-0140-50 HYDROCORTISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10209 ERX HCPCS 63700001 59762-0073-01 HYDROCORTISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10209 ERX HCPCS 63700001 72789-0095-50 HYDROCORTISONE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10210 ERX HCPCS 25000001 62559-0138-07 HYDROCORTISONE 100 MG/60ML RECTAL ENEM BOTH IP/OP $46.06 $34.08 $0.00 $36.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.03 $36.48 $36.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10217 ERX HCPCS 25000001 00574-0420-25 HYDROCORTISONE MICRONIZED POWD BOTH IP/OP $312.30 $231.10 $0.00 $240.72 $0.00 $0.00 $0.00 $0.00 $0.00 $231.79 $231.79 $240.72 $0.00 $65.08 $0.00 $0.00 $0.00 $0.00 $141.75 $224.53 $226.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10230 ERX HCPCS 25000001 42192-0151-01 HYDROQUINONE 4 % EX CREA BOTH IP/OP $359.12 $265.75 $0.00 $276.81 $0.00 $0.00 $0.00 $0.00 $0.00 $266.54 $266.54 $276.81 $0.00 $74.84 $0.00 $0.00 $0.00 $0.00 $163.00 $258.18 $260.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10235 ERX HCPCS 63700001 00378-0373-01 HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS BOTH IP/OP $10.79 $7.98 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10235 ERX HCPCS 63700001 00591-3041-01 HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS BOTH IP/OP $10.79 $7.98 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10235 ERX HCPCS 63700001 00781-5994-01 HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS BOTH IP/OP $10.79 $7.98 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10235 ERX HCPCS 63700001 43598-0721-01 HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS BOTH IP/OP $10.79 $7.98 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10235 ERX HCPCS 63700001 63739-0777-10 HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS BOTH IP/OP $10.79 $7.98 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10235 ERX HCPCS 63700001 66993-0057-02 HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS BOTH IP/OP $10.79 $7.98 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10235 ERX HCPCS 63700001 68084-0269-01 HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS BOTH IP/OP $10.79 $7.98 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10235 ERX HCPCS 63700001 68084-0269-11 HYDROXYCHLOROQUINE SULFATE 200 MG PO TABS BOTH IP/OP $10.79 $7.98 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.40 $8.55 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10236 ERX HCPCS 63700001 00555-0882-02 HYDROXYUREA 500 MG PO CAPS BOTH IP/OP $6.18 $4.57 $0.00 $4.80 $0.00 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10236 ERX HCPCS 63700001 49884-0724-01 HYDROXYUREA 500 MG PO CAPS BOTH IP/OP $6.18 $4.57 $0.00 $4.80 $0.00 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10236 ERX HCPCS 63700001 68084-0284-01 HYDROXYUREA 500 MG PO CAPS BOTH IP/OP $6.18 $4.57 $0.00 $4.80 $0.00 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10236 ERX HCPCS 63700001 68084-0284-11 HYDROXYUREA 500 MG PO CAPS BOTH IP/OP $6.18 $4.57 $0.00 $4.80 $0.00 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10246 ERX HCPCS 25000001 45802-0140-26 IBUPROFEN 100 MG/5ML PO SUSP BOTH IP/OP $18.39 $13.61 $0.00 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.20 $14.56 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10246 ERX HCPCS 25000001 49348-0229-34 IBUPROFEN 100 MG/5ML PO SUSP BOTH IP/OP $14.14 $10.46 $0.00 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.20 $11.20 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10246 ERX HCPCS 25000001 51672-2130-08 IBUPROFEN 100 MG/5ML PO SUSP BOTH IP/OP $14.14 $10.46 $0.00 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.20 $11.20 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10246 ERX HCPCS 25000001 00121-1836-05 IBUPROFEN 100 MG/5ML PO SUSP BOTH IP/OP $6.00 $4.44 $0.00 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.20 $4.75 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10246 ERX HCPCS 25000001 00121-4774-40 IBUPROFEN 100 MG/5ML PO SUSP BOTH IP/OP $6.00 $4.44 $0.00 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.20 $4.75 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10246 ERX HCPCS 25000001 68094-0494-61 IBUPROFEN 100 MG/5ML PO SUSP BOTH IP/OP $6.00 $4.44 $0.00 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.20 $4.75 $14.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10248 ERX HCPCS J9208 10019-0925-01 IFOSFAMIDE 1 G IV SOLR BOTH IP/OP $241.73 $178.88 $0.00 $186.33 $0.00 $0.00 $0.00 $0.00 $0.00 $179.41 $179.41 $186.33 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $109.72 $173.79 $175.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10248 ERX HCPCS J9208 10019-0925-82 IFOSFAMIDE 1 G IV SOLR BOTH IP/OP $241.73 $178.88 $0.00 $186.33 $0.00 $0.00 $0.00 $0.00 $0.00 $179.41 $179.41 $186.33 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $109.72 $173.79 $175.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10248 ERX HCPCS J9208 63323-0142-10 IFOSFAMIDE 1 G IV SOLR BOTH IP/OP $241.73 $178.88 $0.00 $186.33 $0.00 $0.00 $0.00 $0.00 $0.00 $179.41 $179.41 $186.33 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $109.72 $173.79 $175.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10266 ERX HCPCS 25000001 17238-0424-06 INDOCYANINE GREEN 25 MG IV SOLR BOTH IP/OP $34.38 $25.44 $0.00 $26.50 $0.00 $0.00 $0.00 $0.00 $0.00 $25.52 $25.52 $26.50 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $15.59 $24.69 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10266 ERX HCPCS 25000001 17478-0701-02 INDOCYANINE GREEN 25 MG IV SOLR BOTH IP/OP $34.38 $25.44 $0.00 $26.50 $0.00 $0.00 $0.00 $0.00 $0.00 $25.52 $25.52 $26.50 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $15.59 $24.69 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10266 ERX HCPCS 25000001 66259-0701-25 INDOCYANINE GREEN 25 MG IV SOLR BOTH IP/OP $34.38 $25.44 $0.00 $26.50 $0.00 $0.00 $0.00 $0.00 $0.00 $25.52 $25.52 $26.50 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $15.59 $24.69 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10266 ERX HCPCS 25000001 70100-0424-02 INDOCYANINE GREEN 25 MG IV SOLR BOTH IP/OP $34.38 $25.44 $0.00 $26.50 $0.00 $0.00 $0.00 $0.00 $0.00 $25.52 $25.52 $26.50 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $15.59 $24.69 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10267 ERX HCPCS 25000001 00409-1113-01 INDOMETHACIN SODIUM 1 MG IV SOLR BOTH IP/OP "$1,387.59 " "$1,026.82" $0.00 "$1,069.55" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,029.87" "$1,029.87" "$1,069.55" $0.00 $289.17 $0.00 $0.00 $0.00 $0.00 $629.64 $997.35 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10267 ERX HCPCS 25000001 63323-0659-03 INDOMETHACIN SODIUM 1 MG IV SOLR BOTH IP/OP "$1,387.59 " "$1,026.82" $0.00 "$1,069.55" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,029.87" "$1,029.87" "$1,069.55" $0.00 $289.17 $0.00 $0.00 $0.00 $0.00 $629.64 $997.35 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10267 ERX HCPCS 25000001 63323-0659-09 INDOMETHACIN SODIUM 1 MG IV SOLR BOTH IP/OP "$1,387.59 " "$1,026.82" $0.00 "$1,069.55" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,029.87" "$1,029.87" "$1,069.55" $0.00 $289.17 $0.00 $0.00 $0.00 $0.00 $629.64 $997.35 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10267 ERX HCPCS 25000001 68382-0470-01 INDOMETHACIN SODIUM 1 MG IV SOLR BOTH IP/OP "$1,387.59 " "$1,026.82" $0.00 "$1,069.55" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,029.87" "$1,029.87" "$1,069.55" $0.00 $289.17 $0.00 $0.00 $0.00 $0.00 $629.64 $997.35 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10284 ERX HCPCS J1815 00002-8315-01 INSULIN NOVOLIN NPH 100 UNIT/ML SC SUSP BOTH IP/OP $10.00 $7.40 $0.00 $201.38 $5.43 $5.43 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $2.08 $0.00 $5.92 $5.92 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.38 $0.00 $0.00 $0.00 $0.00 $0.00 10284 ERX HCPCS J1815 00169-1834-11 INSULIN NOVOLIN NPH 100 UNIT/ML SC SUSP BOTH IP/OP $10.00 $7.40 $0.00 $201.38 $5.43 $5.43 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $2.08 $0.00 $5.92 $5.92 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.38 $0.00 $0.00 $0.00 $0.00 $0.00 10289 ERX HCPCS J1815 00002-8215-01 INSULIN NOVOLIN REGULAR 100 UNIT/ML IJ SOLN BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $5.43 $5.43 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $2.08 $0.00 $5.92 $5.92 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 10289 ERX HCPCS J1815 00169-1833-11 INSULIN NOVOLIN REGULAR 100 UNIT/ML IJ SOLN BOTH IP/OP $10.00 $7.40 $0.00 $8.00 $5.43 $5.43 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $2.08 $0.00 $5.92 $5.92 $0.00 $5.00 $7.92 $8.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 10321 ERX HCPCS Q9966 00407-1412-30 IOHEXOL 240 MG/ML IJ SOLN BOTH IP/OP $235.53 $174.29 $0.00 $177.29 $105.99 $105.99 $0.00 $0.00 $0.00 $49.09 $174.81 $174.81 $0.00 $0.00 $40.54 $0.00 $139.32 $139.32 $0.00 $110.81 $175.52 $177.29 $0.00 $0.00 $38.60 $0.00 $0.00 $35.28 $0.00 $0.00 $0.00 $0.00 $0.00 10322 ERX HCPCS Q9967 00407-1413-10 IOHEXOL 300 MG/ML IJ SOLN BOTH IP/OP $128.43 $95.04 $0.00 $95.32 $57.79 $57.79 $0.00 $0.00 $0.00 $26.77 $95.32 $95.32 $0.00 $0.00 $4.23 $0.00 $75.97 $75.97 $0.00 $58.23 $92.23 $93.16 $0.00 $0.00 $4.03 $0.00 $0.00 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 10322 ERX HCPCS Q9967 00407-1413-61 IOHEXOL 300 MG/ML IJ SOLN BOTH IP/OP $128.43 $95.04 $0.00 $95.32 $57.79 $57.79 $0.00 $0.00 $0.00 $26.77 $95.32 $95.32 $0.00 $0.00 $4.23 $0.00 $75.97 $75.97 $0.00 $58.23 $92.23 $93.16 $0.00 $0.00 $4.03 $0.00 $0.00 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 10322 ERX HCPCS Q9967 00407-1413-63 IOHEXOL 300 MG/ML IJ SOLN BOTH IP/OP $128.43 $95.04 $0.00 $95.32 $57.79 $57.79 $0.00 $0.00 $0.00 $26.77 $95.32 $95.32 $0.00 $0.00 $4.23 $0.00 $75.97 $75.97 $0.00 $58.23 $92.23 $93.16 $0.00 $0.00 $4.03 $0.00 $0.00 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 10322 ERX HCPCS Q9967 00407-1413-65 IOHEXOL 300 MG/ML IJ SOLN BOTH IP/OP $128.43 $95.04 $0.00 $95.32 $57.79 $57.79 $0.00 $0.00 $0.00 $26.77 $95.32 $95.32 $0.00 $0.00 $4.23 $0.00 $75.97 $75.97 $0.00 $58.23 $92.23 $93.16 $0.00 $0.00 $4.03 $0.00 $0.00 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 10322 ERX HCPCS Q9967 00407-1413-87 IOHEXOL 300 MG/ML IJ SOLN BOTH IP/OP $128.43 $95.04 $0.00 $95.32 $57.79 $57.79 $0.00 $0.00 $0.00 $26.77 $95.32 $95.32 $0.00 $0.00 $4.23 $0.00 $75.97 $75.97 $0.00 $58.23 $92.23 $93.16 $0.00 $0.00 $4.03 $0.00 $0.00 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 10322 ERX HCPCS Q9967 00407-1413-88 IOHEXOL 300 MG/ML IJ SOLN BOTH IP/OP $128.43 $95.04 $0.00 $95.32 $57.79 $57.79 $0.00 $0.00 $0.00 $26.77 $95.32 $95.32 $0.00 $0.00 $4.23 $0.00 $75.97 $75.97 $0.00 $58.23 $92.23 $93.16 $0.00 $0.00 $4.03 $0.00 $0.00 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 10323 ERX HCPCS Q9967 00407-1414-84 IOHEXOL 350 MG/ML IV SOLN BOTH IP/OP $314.39 $232.65 $0.00 $233.34 $141.48 $141.48 $0.00 $0.00 $0.00 $65.53 $233.34 $233.34 $0.00 $0.00 $10.58 $0.00 $185.96 $185.96 $0.00 $142.70 $226.03 $228.31 $0.00 $0.00 $10.07 $0.00 $0.00 $45.43 $0.00 $0.00 $0.00 $0.00 $0.00 10323 ERX HCPCS Q9967 00407-1414-86 IOHEXOL 350 MG/ML IV SOLN BOTH IP/OP $314.39 $232.65 $0.00 $233.34 $141.48 $141.48 $0.00 $0.00 $0.00 $65.53 $233.34 $233.34 $0.00 $0.00 $10.58 $0.00 $185.96 $185.96 $0.00 $142.70 $226.03 $228.31 $0.00 $0.00 $10.07 $0.00 $0.00 $45.43 $0.00 $0.00 $0.00 $0.00 $0.00 10323 ERX HCPCS Q9967 00407-1414-89 IOHEXOL 350 MG/ML IV SOLN BOTH IP/OP $314.39 $232.65 $0.00 $233.34 $141.48 $141.48 $0.00 $0.00 $0.00 $65.53 $233.34 $233.34 $0.00 $0.00 $10.58 $0.00 $185.96 $185.96 $0.00 $142.70 $226.03 $228.31 $0.00 $0.00 $10.07 $0.00 $0.00 $45.43 $0.00 $0.00 $0.00 $0.00 $0.00 10323 ERX HCPCS Q9967 00407-1414-91 IOHEXOL 350 MG/ML IV SOLN BOTH IP/OP $314.39 $232.65 $0.00 $233.34 $141.48 $141.48 $0.00 $0.00 $0.00 $65.53 $233.34 $233.34 $0.00 $0.00 $10.58 $0.00 $185.96 $185.96 $0.00 $142.70 $226.03 $228.31 $0.00 $0.00 $10.07 $0.00 $0.00 $45.43 $0.00 $0.00 $0.00 $0.00 $0.00 10323 ERX HCPCS Q9967 00407-1414-93 IOHEXOL 350 MG/ML IV SOLN BOTH IP/OP $314.39 $232.65 $0.00 $233.34 $141.48 $141.48 $0.00 $0.00 $0.00 $65.53 $233.34 $233.34 $0.00 $0.00 $10.58 $0.00 $185.96 $185.96 $0.00 $142.70 $226.03 $228.31 $0.00 $0.00 $10.07 $0.00 $0.00 $45.43 $0.00 $0.00 $0.00 $0.00 $0.00 10328 ERX HCPCS Q9967 00270-1316-37 IOPAMIDOL 76 % IV SOLN BOTH IP/OP $167.07 $123.63 $0.00 $124.00 $75.18 $75.18 $0.00 $0.00 $0.00 $34.82 $124.00 $124.00 $0.00 $0.00 $5.64 $0.00 $98.82 $98.82 $0.00 $75.74 $119.97 $121.18 $0.00 $0.00 $5.37 $0.00 $0.00 $24.12 $0.00 $0.00 $0.00 $0.00 $0.00 10358 ERX HCPCS Q9968 55150-0240-05 ISOSULFAN BLUE 1 % SC SOLN BOTH IP/OP "$1,903.65 " "$1,408.70" $0.00 "$1,467.33" $856.64 $856.64 $232.89 $232.89 $232.89 $396.77 "$1,412.89" "$1,412.89" "$1,467.33" $201.78 $396.72 $131.16 $938.50 $938.50 $201.63 $882.00 "$1,397.09" "$1,411.20" $278.44 $278.44 $276.07 $0.00 $0.00 $280.83 $217.98 $0.00 $0.00 $0.00 $0.00 10358 ERX HCPCS Q9968 67457-0220-05 ISOSULFAN BLUE 1 % SC SOLN BOTH IP/OP "$1,903.65 " "$1,408.70" $0.00 "$1,467.33" $856.64 $856.64 $232.89 $232.89 $232.89 $396.77 "$1,412.89" "$1,412.89" "$1,467.33" $201.78 $396.72 $131.16 $938.50 $938.50 $201.63 $882.00 "$1,397.09" "$1,411.20" $278.44 $278.44 $276.07 $0.00 $0.00 $280.83 $217.98 $0.00 $0.00 $0.00 $0.00 10359 ERX HCPCS 63700001 00555-1054-86 ISOTRETINOIN 10 MG PO CAPS BOTH IP/OP $79.15 $58.57 $0.00 $57.42 $0.00 $0.00 $0.00 $14.09 $0.00 $0.00 $0.00 $0.00 $0.00 $16.49 $0.00 $0.00 $0.00 $0.00 $35.89 $56.84 $57.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10360 ERX HCPCS 63700001 00555-1055-86 ISOTRETINOIN 20 MG PO CAPS BOTH IP/OP $93.85 $69.45 $0.00 $68.08 $0.00 $0.00 $0.00 $16.71 $0.00 $0.00 $0.00 $0.00 $0.00 $19.56 $0.00 $0.00 $0.00 $0.00 $42.55 $67.40 $68.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10361 ERX HCPCS 63700001 55111-0137-81 ISOTRETINOIN 40 MG PO CAPS BOTH IP/OP $95.84 $70.92 $0.00 $69.53 $0.00 $0.00 $0.00 $17.06 $0.00 $0.00 $0.00 $0.00 $0.00 $19.97 $0.00 $0.00 $0.00 $0.00 $43.46 $68.83 $69.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10364 ERX HCPCS 63700001 10147-1700-07 ITRACONAZOLE 100 MG PO CAPS BOTH IP/OP $93.20 $68.97 $0.00 $67.61 $0.00 $0.00 $0.00 $16.59 $0.00 $0.00 $0.00 $0.00 $0.00 $19.42 $0.00 $0.00 $0.00 $0.00 $42.26 $66.93 $67.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10364 ERX HCPCS 63700001 67877-0454-30 ITRACONAZOLE 100 MG PO CAPS BOTH IP/OP $93.20 $68.97 $0.00 $67.61 $0.00 $0.00 $0.00 $16.59 $0.00 $0.00 $0.00 $0.00 $0.00 $19.42 $0.00 $0.00 $0.00 $0.00 $42.26 $66.93 $67.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10368 ERX HCPCS 63700001 00168-0099-15 KETOCONAZOLE 2 % EX CREA BOTH IP/OP $441.26 $326.53 $0.00 $91.96 $0.00 $0.00 $0.00 $78.54 $0.00 $0.00 $0.00 $0.00 $0.00 $91.96 $0.00 $0.00 $0.00 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10368 ERX HCPCS 63700001 51672-1298-01 KETOCONAZOLE 2 % EX CREA BOTH IP/OP $441.26 $326.53 $0.00 $91.96 $0.00 $0.00 $0.00 $78.54 $0.00 $0.00 $0.00 $0.00 $0.00 $91.96 $0.00 $0.00 $0.00 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10368 ERX HCPCS 63700001 51672-1298-02 KETOCONAZOLE 2 % EX CREA BOTH IP/OP $441.26 $326.53 $0.00 $154.18 $0.00 $0.00 $0.00 $78.54 $0.00 $0.00 $0.00 $0.00 $0.00 $91.96 $0.00 $0.00 $0.00 $0.00 $54.08 $154.18 $86.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10369 ERX HCPCS 63700001 00378-0261-01 KETOCONAZOLE 200 MG PO TABS BOTH IP/OP $14.41 $10.66 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.21 $11.41 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10369 ERX HCPCS 63700001 51672-4026-01 KETOCONAZOLE 200 MG PO TABS BOTH IP/OP $14.41 $10.66 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.21 $11.41 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10369 ERX HCPCS 63700001 51672-4026-06 KETOCONAZOLE 200 MG PO TABS BOTH IP/OP $14.41 $10.66 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.21 $11.41 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10371 ERX HCPCS 63700001 00093-0314-01 KETOROLAC TROMETHAMINE 10 MG PO TABS BOTH IP/OP $9.50 $7.03 $0.00 $6.89 $0.00 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $4.31 $6.82 $6.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10371 ERX HCPCS 63700001 00378-1134-01 KETOROLAC TROMETHAMINE 10 MG PO TABS BOTH IP/OP $9.50 $7.03 $0.00 $6.89 $0.00 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $4.31 $6.82 $6.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10371 ERX HCPCS 63700001 69543-0388-10 KETOROLAC TROMETHAMINE 10 MG PO TABS BOTH IP/OP $9.50 $7.03 $0.00 $6.89 $0.00 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $4.31 $6.82 $6.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 00143-9622-01 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 00409-2267-20 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 00409-2267-54 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 00409-2339-34 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 17478-0420-40 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 47781-0586-29 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 47781-0586-56 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 72266-0102-01 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 72266-0103-01 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 99999-6007-13 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10372 ERX HCPCS 25000001 99999-6011-99 LABETALOL HCL 5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10373 ERX HCPCS 63700001 00185-0010-01 LABETALOL HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10373 ERX HCPCS 63700001 00591-0605-01 LABETALOL HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10373 ERX HCPCS 63700001 00904-5928-61 LABETALOL HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10373 ERX HCPCS 63700001 10135-0641-01 LABETALOL HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10374 ERX HCPCS 63700001 00185-0117-05 LABETALOL HCL 200 MG PO TABS BOTH IP/OP $13.26 $9.81 $0.00 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $10.50 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10374 ERX HCPCS 63700001 00904-5929-61 LABETALOL HCL 200 MG PO TABS BOTH IP/OP $13.26 $9.81 $0.00 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $10.50 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10374 ERX HCPCS 63700001 10135-0642-01 LABETALOL HCL 200 MG PO TABS BOTH IP/OP $13.26 $9.81 $0.00 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $10.50 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10375 ERX HCPCS 63700001 00185-0118-01 LABETALOL HCL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10375 ERX HCPCS 63700001 00185-0118-05 LABETALOL HCL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10375 ERX HCPCS 63700001 00591-0607-01 LABETALOL HCL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10375 ERX HCPCS 63700001 00904-5930-61 LABETALOL HCL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10375 ERX HCPCS 63700001 49884-0124-01 LABETALOL HCL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10375 ERX HCPCS 63700001 49884-0124-05 LABETALOL HCL 300 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10380 ERX HCPCS 63700001 92771-0612-08 AMMONIUM LACTATE 12 % EX LOTN BOTH IP/OP $127.67 $94.48 $0.00 $92.62 $0.00 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 $26.61 $0.00 $0.00 $0.00 $0.00 $57.89 $22.72 $92.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10380 ERX HCPCS 63700001 45802-0419-54 AMMONIUM LACTATE 12 % EX LOTN BOTH IP/OP $127.67 $94.48 $0.00 $92.62 $0.00 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 $26.61 $0.00 $0.00 $0.00 $0.00 $57.89 $91.69 $92.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10380 ERX HCPCS 63700001 00904-5984-26 AMMONIUM LACTATE 12 % EX LOTN BOTH IP/OP $127.67 $94.48 $0.00 $165.04 $0.00 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 $26.61 $0.00 $0.00 $0.00 $0.00 $57.89 $165.04 $92.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10380 ERX HCPCS 63700001 45802-0525-55 AMMONIUM LACTATE 12 % EX LOTN BOTH IP/OP $127.67 $94.48 $0.00 $165.04 $0.00 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 $26.61 $0.00 $0.00 $0.00 $0.00 $57.89 $165.04 $92.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10392 ERX HCPCS J9217 00074-3642-03 LEUPROLIDE ACETATE 7.5 MG IM KIT BOTH IP/OP "$4,793.33 " "$3,547.06" $0.00 "$3,875.74" "$2,262.69" "$2,262.69" $200.73 $200.73 $200.73 $246.83 "$3,731.94" "$3,731.94" "$3,875.74" $139.09 $163.43 $90.41 "$2,363.11" "$2,363.11" $235.93 "$2,047.05" "$3,242.53" "$3,275.28" $325.81 $325.81 $270.33 $0.00 $0.00 $257.40 $205.89 $0.00 $0.00 $0.00 $0.00 10394 ERX HCPCS 25000001 24208-0505-05 LEVOBUNOLOL HCL 0.5 % OP SOLN BOTH IP/OP $93.34 $69.07 $0.00 $71.95 $0.00 $0.00 $0.00 $0.00 $0.00 $69.28 $69.28 $71.95 $0.00 $19.45 $0.00 $0.00 $0.00 $0.00 $42.32 $67.03 $67.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10403 ERX HCPCS 63700001 00781-5183-92 LEVOTHYROXINE SODIUM 88 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10404 ERX HCPCS 63700001 00781-5185-92 LEVOTHYROXINE SODIUM 112 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10405 ERX HCPCS 63700001 00378-1823-77 LEVOTHYROXINE SODIUM 137 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10405 ERX HCPCS 63700001 00781-5191-92 LEVOTHYROXINE SODIUM 137 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10406 ERX HCPCS 63700001 00781-5188-92 LEVOTHYROXINE SODIUM 175 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10426 ERX HCPCS 25000001 00409-3177-01 LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10427 ERX HCPCS 25000001 00409-3178-01 LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10427 ERX HCPCS 25000001 00409-3178-02 LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10427 ERX HCPCS 25000001 00409-3178-16 LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10427 ERX HCPCS 25000001 63323-0482-03 LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10427 ERX HCPCS 25000001 63323-0482-17 LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10427 ERX HCPCS 25000001 63323-0482-27 LIDOCAINE-EPINEPHRINE 1 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10428 ERX HCPCS 25000001 63323-0487-17 LIDOCAINE-EPINEPHRINE 1 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10428 ERX HCPCS 25000001 63323-0487-31 LIDOCAINE-EPINEPHRINE 1 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10428 ERX HCPCS 25000001 63323-0487-37 LIDOCAINE-EPINEPHRINE 1 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10429 ERX HCPCS 25000001 00409-1209-01 LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10429 ERX HCPCS 25000001 00409-1209-65 LIDOCAINE-EPINEPHRINE 1.5 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10430 ERX HCPCS 25000001 00362-1095-60 LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10430 ERX HCPCS 25000001 51004-1095-06 LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10430 ERX HCPCS 25000001 00409-3182-01 LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10430 ERX HCPCS 25000001 63323-0483-27 LIDOCAINE-EPINEPHRINE 2 %-1:100000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10431 ERX HCPCS 25000001 00409-3183-01 LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10431 ERX HCPCS 25000001 63323-0489-02 LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10431 ERX HCPCS 25000001 63323-0489-17 LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10431 ERX HCPCS 25000001 63323-0489-21 LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10431 ERX HCPCS 25000001 63323-0489-27 LIDOCAINE-EPINEPHRINE 2 %-1:200000 IJ SOLN MPF BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10434 ERX HCPCS 25000001 00115-1468-45 LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA BOTH IP/OP $168.84 $124.94 $0.00 $135.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.42 $133.72 $135.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10434 ERX HCPCS 25000001 00115-1468-53 LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA BOTH IP/OP $30.56 $22.61 $0.00 $135.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.42 $24.20 $135.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10434 ERX HCPCS 25000001 00115-1468-60 LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA BOTH IP/OP $30.56 $22.61 $0.00 $135.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.42 $24.20 $135.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10434 ERX HCPCS 25000001 00168-0357-55 LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA BOTH IP/OP $30.56 $22.61 $0.00 $135.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.42 $24.20 $135.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10443 ERX HCPCS 63700001 42794-0018-02 LIOTHYRONINE SODIUM 5 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10443 ERX HCPCS 63700001 51862-0320-01 LIOTHYRONINE SODIUM 5 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10443 ERX HCPCS 63700001 59762-1206-01 LIOTHYRONINE SODIUM 5 MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10449 ERX HCPCS 63700001 00904-6798-61 LISINOPRIL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10449 ERX HCPCS 63700001 43547-0353-10 LISINOPRIL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10449 ERX HCPCS 63700001 60687-0325-01 LISINOPRIL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10449 ERX HCPCS 63700001 60687-0325-11 LISINOPRIL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10449 ERX HCPCS 63700001 68180-0980-01 LISINOPRIL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10450 ERX HCPCS 63700001 00904-6800-61 LISINOPRIL 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10450 ERX HCPCS 63700001 68084-0199-01 LISINOPRIL 40 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10451 ERX HCPCS 63700001 00904-6797-61 LISINOPRIL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10451 ERX HCPCS 63700001 43547-0352-10 LISINOPRIL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10451 ERX HCPCS 63700001 68180-0513-01 LISINOPRIL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10452 ERX HCPCS 63700001 00591-0861-01 LISINOPRIL-HCTZ 20-12.5 MG TABLET BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10452 ERX HCPCS 63700001 68180-0519-01 LISINOPRIL-HCTZ 20-12.5 MG TABLET BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10453 ERX HCPCS 63700001 68180-0520-01 LISINOPRIL-HCTZ 20-25 MG TABLET BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10454 ERX HCPCS 63700001 00054-0021-25 LITHIUM CARBONATE ER 300 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10454 ERX HCPCS 63700001 68462-0223-01 LITHIUM CARBONATE ER 300 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10455 ERX HCPCS 63700001 00054-0020-25 LITHIUM CARBONATE ER 450 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10455 ERX HCPCS 63700001 51079-0142-01 LITHIUM CARBONATE ER 450 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10455 ERX HCPCS 63700001 51079-0142-20 LITHIUM CARBONATE ER 450 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10455 ERX HCPCS 63700001 68462-0224-01 LITHIUM CARBONATE ER 450 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10460 ERX HCPCS 63700001 58181-3042-05 LOMUSTINE 100 MG PO CAPS BOTH IP/OP "$2,724.26 " "$2,015.95" $0.00 "$1,976.90" $0.00 $0.00 $0.00 $484.92 $0.00 $0.00 $0.00 $0.00 $0.00 $567.74 $0.00 $0.00 $0.00 $0.00 "$1,235.56" "$1,957.13" "$1,976.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10461 ERX HCPCS 63700001 58181-3041-05 LOMUSTINE 40 MG PO CAPS BOTH IP/OP "$1,275.08 " $943.56 $0.00 $925.74 $0.00 $0.00 $0.00 $226.96 $0.00 $0.00 $0.00 $0.00 $0.00 $265.73 $0.00 $0.00 $0.00 $0.00 $578.59 $916.49 $925.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10466 ERX HCPCS 63700001 00904-6852-61 LORATADINE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10466 ERX HCPCS 63700001 45802-0650-87 LORATADINE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10466 ERX HCPCS 63700001 51079-0246-20 LORATADINE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10466 ERX HCPCS 63700001 68084-0248-01 LORATADINE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10466 ERX HCPCS 63700001 68084-0248-11 LORATADINE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 00409-1985-30 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 00409-6778-02 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 00409-6778-11 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 00641-6044-01 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 00641-6044-25 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 00641-6046-10 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 00641-6048-25 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 00641-6050-10 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 76329-8261-00 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10467 ERX HCPCS J2060 76329-8261-01 LORAZEPAM 2 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 10475 ERX HCPCS J7504 00009-7224-01 "LYMPHOCYTE,ANTI-THYMO IMM GLOB 50 MG/ML IV INJ" BOTH IP/OP "$7,764.17 " "$5,745.49" $0.00 "$5,984.62" $0.00 $0.00 $0.00 $0.00 $0.00 "$5,762.57" "$5,762.57" "$5,984.62" $0.00 "$1,618.05" $0.00 $0.00 $0.00 $0.00 "$2,682.94" "$4,249.78" "$4,292.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10475 ERX HCPCS J7504 00009-7224-02 "LYMPHOCYTE,ANTI-THYMO IMM GLOB 50 MG/ML IV INJ" BOTH IP/OP "$7,764.17 " "$5,745.49" $0.00 "$5,984.62" $0.00 $0.00 $0.00 $0.00 $0.00 "$5,762.57" "$5,762.57" "$5,984.62" $0.00 "$1,618.05" $0.00 $0.00 $0.00 $0.00 "$2,682.94" "$4,249.78" "$4,292.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10478 ERX HCPCS 25000001 51079-0623-81 MAFENIDE ACETATE 85 MG/GM EX CREA BOTH IP/OP $488.10 $361.19 $0.00 $461.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.72 $0.00 $0.00 $0.00 $0.00 $288.72 $350.90 $461.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10478 ERX HCPCS 25000001 51079-0623-82 MAFENIDE ACETATE 85 MG/GM EX CREA BOTH IP/OP $488.10 $361.19 $0.00 $461.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.72 $0.00 $0.00 $0.00 $0.00 $288.72 $457.32 $461.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10521 ERX HCPCS 63700001 99999-6005-55 MEGESTROL ACETATE 40 MG/ML PO SUSP BOTH IP/OP $138.96 $102.83 $0.00 $351.36 $0.00 $0.00 $0.00 $24.73 $0.00 $0.00 $0.00 $0.00 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $219.60 $99.79 $351.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10521 ERX HCPCS 63700001 00054-3542-58 MEGESTROL ACETATE 40 MG/ML PO SUSP BOTH IP/OP $138.96 $102.83 $0.00 $351.36 $0.00 $0.00 $0.00 $24.73 $0.00 $0.00 $0.00 $0.00 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $219.60 $347.85 $351.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10521 ERX HCPCS 63700001 49884-0907-38 MEGESTROL ACETATE 40 MG/ML PO SUSP BOTH IP/OP $138.96 $102.83 $0.00 $351.36 $0.00 $0.00 $0.00 $24.73 $0.00 $0.00 $0.00 $0.00 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $219.60 $347.85 $351.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10521 ERX HCPCS 63700001 50383-0859-24 MEGESTROL ACETATE 40 MG/ML PO SUSP BOTH IP/OP $138.96 $102.83 $0.00 $351.36 $0.00 $0.00 $0.00 $24.73 $0.00 $0.00 $0.00 $0.00 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $219.60 $347.85 $351.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10521 ERX HCPCS 63700001 60432-0126-08 MEGESTROL ACETATE 40 MG/ML PO SUSP BOTH IP/OP $138.96 $102.83 $0.00 $351.36 $0.00 $0.00 $0.00 $24.73 $0.00 $0.00 $0.00 $0.00 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $219.60 $347.85 $351.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10521 ERX HCPCS 63700001 60432-0126-16 MEGESTROL ACETATE 40 MG/ML PO SUSP BOTH IP/OP $138.96 $102.83 $0.00 $601.44 $0.00 $0.00 $0.00 $24.73 $0.00 $0.00 $0.00 $0.00 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $219.60 $601.44 $351.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10523 ERX HCPCS J8600 52609-0001-05 MELPHALAN 2 MG PO TABS BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10531 ERX HCPCS 63700001 00054-4581-11 MERCAPTOPURINE 50 MG PO TABS BOTH IP/OP $17.14 $12.68 $0.00 $12.44 $0.00 $0.00 $0.00 $3.05 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $0.00 $0.00 $0.00 $0.00 $7.78 $12.32 $12.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10531 ERX HCPCS 63700001 00378-3547-52 MERCAPTOPURINE 50 MG PO TABS BOTH IP/OP $17.14 $12.68 $0.00 $12.44 $0.00 $0.00 $0.00 $3.05 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $0.00 $0.00 $0.00 $0.00 $7.78 $12.32 $12.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10533 ERX HCPCS 63700001 54092-0189-81 MESALAMINE ER 250 MG PO CPCR BOTH IP/OP $30.53 $22.59 $0.00 $22.15 $0.00 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 $6.36 $0.00 $0.00 $0.00 $0.00 $13.85 $21.93 $22.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10535 ERX HCPCS 25000001 45802-0098-28 MESALAMINE 4 G RECTAL ENEM BOTH IP/OP $93.80 $69.41 $0.00 $72.30 $0.00 $0.00 $0.00 $0.00 $0.00 $69.62 $69.62 $72.30 $0.00 $19.55 $0.00 $0.00 $0.00 $0.00 $42.53 $67.36 $68.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10535 ERX HCPCS 25000001 45802-0098-51 MESALAMINE 4 G RECTAL ENEM BOTH IP/OP $93.80 $69.41 $0.00 $72.30 $0.00 $0.00 $0.00 $0.00 $0.00 $69.62 $69.62 $72.30 $0.00 $19.55 $0.00 $0.00 $0.00 $0.00 $42.53 $67.36 $68.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10535 ERX HCPCS 25000001 62559-0420-07 MESALAMINE 4 G RECTAL ENEM BOTH IP/OP $93.80 $69.41 $0.00 $72.30 $0.00 $0.00 $0.00 $0.00 $0.00 $69.62 $69.62 $72.30 $0.00 $19.55 $0.00 $0.00 $0.00 $0.00 $42.53 $67.36 $68.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10537 ERX HCPCS J9209 00338-1305-01 MESNA 100 MG/ML IV SOLN BOTH IP/OP $92.64 $68.55 $0.00 $71.41 $41.69 $41.69 $0.00 $0.00 $0.00 $34.25 $68.76 $68.76 $71.41 $0.00 $12.41 $0.00 $54.80 $54.80 $0.00 $42.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10537 ERX HCPCS J9209 10019-0953-01 MESNA 100 MG/ML IV SOLN BOTH IP/OP $92.64 $68.55 $0.00 $71.41 $41.69 $41.69 $0.00 $0.00 $0.00 $34.25 $68.76 $68.76 $71.41 $0.00 $12.41 $0.00 $54.80 $54.80 $0.00 $42.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10537 ERX HCPCS J9209 25021-0201-10 MESNA 100 MG/ML IV SOLN BOTH IP/OP $92.64 $68.55 $0.00 $71.41 $41.69 $41.69 $0.00 $0.00 $0.00 $34.25 $68.76 $68.76 $71.41 $0.00 $12.41 $0.00 $54.80 $54.80 $0.00 $42.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10537 ERX HCPCS J9209 25021-0201-11 MESNA 100 MG/ML IV SOLN BOTH IP/OP $92.64 $68.55 $0.00 $71.41 $41.69 $41.69 $0.00 $0.00 $0.00 $34.25 $68.76 $68.76 $71.41 $0.00 $12.41 $0.00 $54.80 $54.80 $0.00 $42.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10537 ERX HCPCS J9209 63323-0733-10 MESNA 100 MG/ML IV SOLN BOTH IP/OP $92.64 $68.55 $0.00 $71.41 $41.69 $41.69 $0.00 $0.00 $0.00 $34.25 $68.76 $68.76 $71.41 $0.00 $12.41 $0.00 $54.80 $54.80 $0.00 $42.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10537 ERX HCPCS J9209 63323-0733-11 MESNA 100 MG/ML IV SOLN BOTH IP/OP $92.64 $68.55 $0.00 $71.41 $41.69 $41.69 $0.00 $0.00 $0.00 $34.25 $68.76 $68.76 $71.41 $0.00 $12.41 $0.00 $54.80 $54.80 $0.00 $42.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10544 ERX HCPCS 63700001 00904-6689-61 METFORMIN HCL 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10544 ERX HCPCS 63700001 60687-0155-01 METFORMIN HCL 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10544 ERX HCPCS 63700001 63739-0640-10 METFORMIN HCL 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10546 ERX HCPCS J1230 17478-0380-20 METHADONE HCL 10 MG/ML IJ SOLN BOTH IP/OP $32.63 $24.15 $0.00 $25.15 $0.00 $0.00 $0.00 $0.00 $0.00 $24.22 $24.22 $25.15 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $14.80 $23.44 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10546 ERX HCPCS J1230 67457-0217-20 METHADONE HCL 10 MG/ML IJ SOLN BOTH IP/OP $32.63 $24.15 $0.00 $25.15 $0.00 $0.00 $0.00 $0.00 $0.00 $24.22 $24.22 $25.15 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $14.80 $23.44 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10546 ERX HCPCS J1230 99999-6005-49 METHADONE HCL 10 MG/ML IJ SOLN BOTH IP/OP $32.63 $24.15 $0.00 $25.15 $0.00 $0.00 $0.00 $0.00 $0.00 $24.22 $24.22 $25.15 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $14.80 $23.44 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10552 ERX HCPCS 63700001 49884-0641-01 METHIMAZOLE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10552 ERX HCPCS 63700001 51293-0821-01 METHIMAZOLE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10552 ERX HCPCS 63700001 60687-0370-01 METHIMAZOLE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10552 ERX HCPCS 63700001 60687-0370-11 METHIMAZOLE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10552 ERX HCPCS 63700001 64980-0261-01 METHIMAZOLE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10553 ERX HCPCS 63700001 00185-0205-01 METHIMAZOLE 5 MG PO TABS BOTH IP/OP $9.33 $6.90 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.67 $7.39 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10553 ERX HCPCS 63700001 49884-0640-01 METHIMAZOLE 5 MG PO TABS BOTH IP/OP $9.33 $6.90 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.67 $7.39 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10553 ERX HCPCS 63700001 51293-0820-01 METHIMAZOLE 5 MG PO TABS BOTH IP/OP $9.33 $6.90 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.67 $7.39 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10553 ERX HCPCS 63700001 60687-0357-01 METHIMAZOLE 5 MG PO TABS BOTH IP/OP $9.33 $6.90 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.67 $7.39 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10553 ERX HCPCS 63700001 60687-0357-11 METHIMAZOLE 5 MG PO TABS BOTH IP/OP $9.33 $6.90 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.67 $7.39 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10553 ERX HCPCS 63700001 60793-0104-01 METHIMAZOLE 5 MG PO TABS BOTH IP/OP $9.33 $6.90 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.67 $7.39 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10571 ERX HCPCS J2210 00517-0740-01 METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN BOTH IP/OP $130.63 $96.67 $0.00 $104.74 $61.15 $61.15 $0.00 $0.00 $0.00 $0.00 $100.85 $100.85 $104.74 $0.00 $23.05 $0.00 $0.00 $0.00 $0.00 $56.95 $90.20 $91.11 $0.00 $0.00 $21.20 $0.00 $0.00 $20.18 $0.00 $0.00 $0.00 $0.00 $0.00 10571 ERX HCPCS J2210 00517-0740-20 METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN BOTH IP/OP $130.63 $96.67 $0.00 $104.74 $61.15 $61.15 $0.00 $0.00 $0.00 $0.00 $100.85 $100.85 $104.74 $0.00 $23.05 $0.00 $0.00 $0.00 $0.00 $56.95 $90.20 $91.11 $0.00 $0.00 $21.20 $0.00 $0.00 $20.18 $0.00 $0.00 $0.00 $0.00 $0.00 10571 ERX HCPCS J2210 51991-0144-17 METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN BOTH IP/OP $130.63 $96.67 $0.00 $104.74 $61.15 $61.15 $0.00 $0.00 $0.00 $0.00 $100.85 $100.85 $104.74 $0.00 $23.05 $0.00 $0.00 $0.00 $0.00 $56.95 $90.20 $91.11 $0.00 $0.00 $21.20 $0.00 $0.00 $20.18 $0.00 $0.00 $0.00 $0.00 $0.00 10571 ERX HCPCS J2210 51991-0144-99 METHYLERGONOVINE MALEATE 0.2 MG/ML IJ SOLN BOTH IP/OP $130.63 $96.67 $0.00 $104.74 $61.15 $61.15 $0.00 $0.00 $0.00 $0.00 $100.85 $100.85 $104.74 $0.00 $23.05 $0.00 $0.00 $0.00 $0.00 $56.95 $90.20 $91.11 $0.00 $0.00 $21.20 $0.00 $0.00 $20.18 $0.00 $0.00 $0.00 $0.00 $0.00 10572 ERX HCPCS 63700001 27437-0050-56 METHYLERGONOVINE MALEATE 0.2 MG PO TABS BOTH IP/OP $259.06 $191.70 $0.00 $188.14 $0.00 $0.00 $0.00 $46.11 $0.00 $0.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $0.00 $0.00 $117.59 $186.25 $188.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10572 ERX HCPCS 63700001 43386-0140-28 METHYLERGONOVINE MALEATE 0.2 MG PO TABS BOTH IP/OP $259.06 $191.70 $0.00 $188.14 $0.00 $0.00 $0.00 $46.11 $0.00 $0.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $0.00 $0.00 $117.59 $186.25 $188.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10572 ERX HCPCS 63700001 69238-1605-08 METHYLERGONOVINE MALEATE 0.2 MG PO TABS BOTH IP/OP $259.06 $191.70 $0.00 $188.14 $0.00 $0.00 $0.00 $46.11 $0.00 $0.00 $0.00 $0.00 $0.00 $53.99 $0.00 $0.00 $0.00 $0.00 $117.59 $186.25 $188.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10573 ERX HCPCS 63700001 00009-0020-01 METHYLPREDNISOLONE 2 MG PO TABS BOTH IP/OP $8.26 $6.11 $0.00 $5.90 $0.00 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10576 ERX HCPCS J7509 00009-0022-01 METHYLPREDNISOLONE 8 MG PO TABS BOTH IP/OP $8.99 $6.65 $0.00 $6.93 $4.05 $4.05 $0.00 $0.00 $0.00 $1.87 $6.67 $6.67 $6.93 $0.00 $1.87 $0.00 $5.32 $5.32 $0.00 $4.02 $6.36 $6.42 $0.00 $0.00 $1.26 $0.00 $0.00 $1.28 $0.00 $0.00 $0.00 $0.00 $0.00 10576 ERX HCPCS J7509 59746-0002-04 METHYLPREDNISOLONE 8 MG PO TABS BOTH IP/OP $8.99 $6.65 $0.00 $6.93 $4.05 $4.05 $0.00 $0.00 $0.00 $1.87 $6.67 $6.67 $6.93 $0.00 $1.87 $0.00 $5.32 $5.32 $0.00 $4.02 $6.36 $6.42 $0.00 $0.00 $1.26 $0.00 $0.00 $1.28 $0.00 $0.00 $0.00 $0.00 $0.00 10576 ERX HCPCS J7509 59762-0049-01 METHYLPREDNISOLONE 8 MG PO TABS BOTH IP/OP $8.99 $6.65 $0.00 $6.93 $4.05 $4.05 $0.00 $0.00 $0.00 $1.87 $6.67 $6.67 $6.93 $0.00 $1.87 $0.00 $5.32 $5.32 $0.00 $4.02 $6.36 $6.42 $0.00 $0.00 $1.26 $0.00 $0.00 $1.28 $0.00 $0.00 $0.00 $0.00 $0.00 10577 ERX HCPCS J2930 00009-0698-01 METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $59.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10577 ERX HCPCS J2930 25021-0810-30 METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $59.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10577 ERX HCPCS J2930 63323-0265-30 METHYLPREDNISOLONE SODIUM SUCC 1000 MG IJ SOLR BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $59.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10578 ERX HCPCS J2930 00009-0047-22 METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR BOTH IP/OP $31.33 $23.18 $0.00 $24.15 $14.10 $14.10 $0.00 $0.00 $0.00 $3.71 $23.25 $23.25 $24.15 $0.00 $6.54 $0.00 $18.53 $18.53 $0.00 $14.14 $22.40 $22.62 $0.00 $0.00 $7.43 $0.00 $0.00 $7.07 $0.00 $0.00 $0.00 $0.00 $0.00 10578 ERX HCPCS J2930 00009-0047-26 METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR BOTH IP/OP $31.33 $23.18 $0.00 $24.15 $14.10 $14.10 $0.00 $0.00 $0.00 $3.71 $23.25 $23.25 $24.15 $0.00 $6.54 $0.00 $18.53 $18.53 $0.00 $14.14 $22.40 $22.62 $0.00 $0.00 $7.43 $0.00 $0.00 $7.07 $0.00 $0.00 $0.00 $0.00 $0.00 10578 ERX HCPCS J2930 00009-0047-27 METHYLPREDNISOLONE SODIUM SUCC 125 MG IJ SOLR BOTH IP/OP $31.33 $23.18 $0.00 $24.15 $14.10 $14.10 $0.00 $0.00 $0.00 $3.71 $23.25 $23.25 $24.15 $0.00 $6.54 $0.00 $18.53 $18.53 $0.00 $14.14 $22.40 $22.62 $0.00 $0.00 $7.43 $0.00 $0.00 $7.07 $0.00 $0.00 $0.00 $0.00 $0.00 10580 ERX HCPCS J2920 00009-0039-28 METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.64 $16.33 $16.33 $16.96 $0.00 $4.83 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.38 $0.00 $0.00 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 10580 ERX HCPCS J2920 00009-0039-32 METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.64 $16.33 $16.33 $16.96 $0.00 $4.83 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.38 $0.00 $0.00 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 10580 ERX HCPCS J2920 00009-0039-33 METHYLPREDNISOLONE SODIUM SUCC 40 MG IJ SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.64 $16.33 $16.33 $16.96 $0.00 $4.83 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.38 $0.00 $0.00 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 10581 ERX HCPCS J2930 00009-0003-02 METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR BOTH IP/OP $112.49 $83.24 $0.00 $86.71 $50.62 $50.62 $0.00 $0.00 $0.00 $14.85 $83.49 $83.49 $86.71 $0.00 $26.16 $0.00 $66.54 $66.54 $0.00 $48.55 $76.90 $77.67 $0.00 $0.00 $29.70 $0.00 $0.00 $28.28 $0.00 $0.00 $0.00 $0.00 $0.00 10581 ERX HCPCS J2930 00009-0758-01 METHYLPREDNISOLONE SODIUM SUCC 500 MG IJ SOLR BOTH IP/OP $112.49 $83.24 $0.00 $86.71 $50.62 $50.62 $0.00 $0.00 $0.00 $14.85 $83.49 $83.49 $86.71 $0.00 $26.16 $0.00 $66.54 $66.54 $0.00 $48.55 $76.90 $77.67 $0.00 $0.00 $29.70 $0.00 $0.00 $28.28 $0.00 $0.00 $0.00 $0.00 $0.00 10586 ERX HCPCS 63700001 00185-5600-01 METOLAZONE 10 MG PO TABS BOTH IP/OP $11.82 $8.75 $0.00 $8.58 $0.00 $0.00 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $2.46 $0.00 $0.00 $0.00 $0.00 $5.36 $8.49 $8.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10586 ERX HCPCS 63700001 00378-6174-01 METOLAZONE 10 MG PO TABS BOTH IP/OP $11.82 $8.75 $0.00 $8.58 $0.00 $0.00 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $2.46 $0.00 $0.00 $0.00 $0.00 $5.36 $8.49 $8.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10586 ERX HCPCS 63700001 00527-2217-37 METOLAZONE 10 MG PO TABS BOTH IP/OP $11.82 $8.75 $0.00 $8.58 $0.00 $0.00 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $2.46 $0.00 $0.00 $0.00 $0.00 $5.36 $8.49 $8.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10586 ERX HCPCS 63700001 65580-0645-71 METOLAZONE 10 MG PO TABS BOTH IP/OP $11.82 $8.75 $0.00 $8.58 $0.00 $0.00 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $2.46 $0.00 $0.00 $0.00 $0.00 $5.36 $8.49 $8.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10587 ERX HCPCS 63700001 00185-5050-01 METOLAZONE 2.5 MG PO TABS BOTH IP/OP $10.27 $7.60 $0.00 $7.45 $0.00 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $4.66 $7.37 $7.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10587 ERX HCPCS 63700001 00378-6172-01 METOLAZONE 2.5 MG PO TABS BOTH IP/OP $10.27 $7.60 $0.00 $7.45 $0.00 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $4.66 $7.37 $7.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10587 ERX HCPCS 63700001 00527-2215-37 METOLAZONE 2.5 MG PO TABS BOTH IP/OP $10.27 $7.60 $0.00 $7.45 $0.00 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $4.66 $7.37 $7.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10588 ERX HCPCS 63700001 00185-0055-01 METOLAZONE 5 MG PO TABS BOTH IP/OP $11.67 $8.64 $0.00 $8.46 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 $2.43 $0.00 $0.00 $0.00 $0.00 $5.29 $8.38 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10588 ERX HCPCS 63700001 00378-6173-01 METOLAZONE 5 MG PO TABS BOTH IP/OP $11.67 $8.64 $0.00 $8.46 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 $2.43 $0.00 $0.00 $0.00 $0.00 $5.29 $8.38 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10588 ERX HCPCS 63700001 00527-2216-37 METOLAZONE 5 MG PO TABS BOTH IP/OP $11.67 $8.64 $0.00 $8.46 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 $2.43 $0.00 $0.00 $0.00 $0.00 $5.29 $8.38 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10592 ERX HCPCS 63700001 00245-0860-70 METRONIDAZOLE 0.75 % VA GEL BOTH IP/OP $547.79 $405.36 $0.00 $397.80 $0.00 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 $114.16 $0.00 $0.00 $0.00 $0.00 $248.63 $393.82 $397.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10592 ERX HCPCS 63700001 00781-7077-87 METRONIDAZOLE 0.75 % VA GEL BOTH IP/OP $547.79 $405.36 $0.00 $397.80 $0.00 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 $114.16 $0.00 $0.00 $0.00 $0.00 $248.63 $393.82 $397.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10594 ERX HCPCS 63700001 25010-0305-15 METYROSINE 250 MG PO CAPS BOTH IP/OP "$1,309.85 " $969.29 $0.00 $937.41 $0.00 $0.00 $0.00 $233.15 $0.00 $0.00 $0.00 $0.00 $0.00 $272.97 $0.00 $0.00 $0.00 $0.00 $585.88 $928.03 $937.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10595 ERX HCPCS 63700001 00093-8739-01 MEXILETINE HCL 150 MG PO CAPS BOTH IP/OP $10.63 $7.87 $0.00 $7.71 $0.00 $0.00 $0.00 $1.89 $0.00 $0.00 $0.00 $0.00 $0.00 $2.22 $0.00 $0.00 $0.00 $0.00 $4.82 $7.63 $7.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10595 ERX HCPCS 63700001 62559-0820-01 MEXILETINE HCL 150 MG PO CAPS BOTH IP/OP $10.63 $7.87 $0.00 $7.71 $0.00 $0.00 $0.00 $1.89 $0.00 $0.00 $0.00 $0.00 $0.00 $2.22 $0.00 $0.00 $0.00 $0.00 $4.82 $7.63 $7.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10596 ERX HCPCS 63700001 00093-8740-01 MEXILETINE HCL 200 MG PO CAPS BOTH IP/OP $12.69 $9.39 $0.00 $9.21 $0.00 $0.00 $0.00 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $5.76 $9.12 $9.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10608 ERX HCPCS J2250 00409-2308-49 MIDAZOLAM HCL 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.94 $16.33 $16.33 $16.96 $0.00 $0.76 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.71 $0.00 $0.00 $0.67 $0.00 $0.00 $0.00 $0.00 $0.00 10608 ERX HCPCS J2250 00641-6061-25 MIDAZOLAM HCL 5 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.94 $16.33 $16.33 $16.96 $0.00 $0.76 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.71 $0.00 $0.00 $0.67 $0.00 $0.00 $0.00 $0.00 $0.00 10609 ERX HCPCS 63700001 00245-0211-11 MIDODRINE HCL 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10609 ERX HCPCS 63700001 42291-0560-90 MIDODRINE HCL 2.5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10610 ERX HCPCS 63700001 00245-0212-01 MIDODRINE HCL 5 MG PO TABS BOTH IP/OP $17.42 $12.89 $0.00 $12.64 $0.00 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 $3.63 $0.00 $0.00 $0.00 $0.00 $7.90 $12.51 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10610 ERX HCPCS 63700001 00245-0212-11 MIDODRINE HCL 5 MG PO TABS BOTH IP/OP $17.42 $12.89 $0.00 $12.64 $0.00 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 $3.63 $0.00 $0.00 $0.00 $0.00 $7.90 $12.51 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10610 ERX HCPCS 63700001 00378-1902-01 MIDODRINE HCL 5 MG PO TABS BOTH IP/OP $17.42 $12.89 $0.00 $12.64 $0.00 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 $3.63 $0.00 $0.00 $0.00 $0.00 $7.90 $12.51 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10610 ERX HCPCS 63700001 42291-0561-90 MIDODRINE HCL 5 MG PO TABS BOTH IP/OP $17.42 $12.89 $0.00 $12.64 $0.00 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 $3.63 $0.00 $0.00 $0.00 $0.00 $7.90 $12.51 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10610 ERX HCPCS 63700001 51079-0453-20 MIDODRINE HCL 5 MG PO TABS BOTH IP/OP $17.42 $12.89 $0.00 $12.64 $0.00 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 $3.63 $0.00 $0.00 $0.00 $0.00 $7.90 $12.51 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10610 ERX HCPCS 63700001 60505-1321-01 MIDODRINE HCL 5 MG PO TABS BOTH IP/OP $17.42 $12.89 $0.00 $12.64 $0.00 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 $3.63 $0.00 $0.00 $0.00 $0.00 $7.90 $12.51 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10612 ERX HCPCS J2265 70842-0160-01 MINOCYCLINE HCL 100 MG IV SOLR BOTH IP/OP $564.56 $417.77 $0.00 $451.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.28 $447.13 $451.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10612 ERX HCPCS J2265 70842-0160-10 MINOCYCLINE HCL 100 MG IV SOLR BOTH IP/OP $564.56 $417.77 $0.00 $451.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.28 $447.13 $451.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10628 ERX HCPCS 63700001 00025-1451-34 MISOPROSTOL 100 MCG PO TABS BOTH IP/OP $10.39 $7.69 $0.00 $7.54 $0.00 $0.00 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.72 $7.47 $7.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10628 ERX HCPCS 63700001 43386-0160-06 MISOPROSTOL 100 MCG PO TABS BOTH IP/OP $10.39 $7.69 $0.00 $7.54 $0.00 $0.00 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.72 $7.47 $7.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10628 ERX HCPCS 63700001 59762-5007-01 MISOPROSTOL 100 MCG PO TABS BOTH IP/OP $10.39 $7.69 $0.00 $7.54 $0.00 $0.00 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.72 $7.47 $7.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10628 ERX HCPCS 63700001 68084-0040-01 MISOPROSTOL 100 MCG PO TABS BOTH IP/OP $10.39 $7.69 $0.00 $7.54 $0.00 $0.00 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.72 $7.47 $7.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10629 ERX HCPCS 63700001 00025-1461-60 MISOPROSTOL 200 MCG PO TABS BOTH IP/OP $26.38 $19.52 $0.00 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.19 $20.89 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10629 ERX HCPCS 63700001 43386-0161-01 MISOPROSTOL 200 MCG PO TABS BOTH IP/OP $26.38 $19.52 $0.00 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.19 $20.89 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10629 ERX HCPCS 63700001 59762-5008-01 MISOPROSTOL 200 MCG PO TABS BOTH IP/OP $26.38 $19.52 $0.00 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.19 $20.89 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10629 ERX HCPCS 63700001 59762-5008-02 MISOPROSTOL 200 MCG PO TABS BOTH IP/OP $26.38 $19.52 $0.00 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.19 $20.89 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10629 ERX HCPCS 63700001 68084-0041-01 MISOPROSTOL 200 MCG PO TABS BOTH IP/OP $26.38 $19.52 $0.00 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.19 $20.89 $21.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10630 ERX HCPCS J9280 16729-0108-11 MITOMYCIN 20 MG IV SOLR BOTH IP/OP "$1,033.42 " $764.73 $0.00 $796.56 $465.04 $465.04 $101.33 $101.33 $101.33 $35.96 $767.00 $767.00 $796.56 $77.26 $90.78 $50.22 $611.27 $611.27 $184.27 $468.94 $742.79 $750.30 $254.47 $254.47 $187.74 $0.00 $0.00 $178.76 $114.42 $0.00 $0.00 $0.00 $0.00 10631 ERX HCPCS J9280 16729-0116-38 MITOMYCIN 40 MG IV SOLR BOTH IP/OP "$1,033.42 " $764.73 $0.00 $796.56 $465.04 $465.04 $101.33 $101.33 $101.33 $35.96 $767.00 $767.00 $796.56 $77.26 $90.78 $50.22 $611.27 $611.27 $184.27 $468.94 $742.79 $750.30 $254.47 $254.47 $187.74 $0.00 $0.00 $178.76 $114.42 $0.00 $0.00 $0.00 $0.00 10632 ERX HCPCS J9280 16729-0115-05 MITOMYCIN 5 MG IV SOLR BOTH IP/OP "$1,411.35 " "$1,044.40" $0.00 "$1,087.87" $635.11 $635.11 $101.33 $101.33 $101.33 $35.96 "$1,047.50" "$1,047.50" "$1,087.87" $77.26 $90.78 $50.22 $834.81 $834.81 $184.27 $653.91 "$1,035.79" "$1,046.25" $254.47 $254.47 $187.74 $0.00 $0.00 $178.76 $114.42 $0.00 $0.00 $0.00 $0.00 10646 ERX HCPCS 25000001 45802-0257-42 MOMETASONE FUROATE 0.1 % EX CREA BOTH IP/OP $183.64 $135.89 $0.00 $141.55 $0.00 $0.00 $0.00 $0.00 $0.00 $136.30 $136.30 $141.55 $0.00 $38.27 $0.00 $0.00 $0.00 $0.00 $83.35 $132.03 $133.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10648 ERX HCPCS 25000001 45802-0119-42 MOMETASONE FUROATE 0.1 % EX OINT BOTH IP/OP $172.14 $127.38 $0.00 $132.69 $0.00 $0.00 $0.00 $0.00 $0.00 $127.76 $127.76 $132.69 $0.00 $35.87 $0.00 $0.00 $0.00 $0.00 $78.05 $123.62 $124.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10674 ERX HCPCS 25000001 00093-1010-42 MUPIROCIN 2 % EX OINT BOTH IP/OP $47.11 $34.86 $0.00 $36.31 $0.00 $0.00 $0.00 $0.00 $0.00 $34.97 $34.97 $36.31 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10674 ERX HCPCS 25000001 45802-0112-22 MUPIROCIN 2 % EX OINT BOTH IP/OP $47.11 $34.86 $0.00 $36.31 $0.00 $0.00 $0.00 $0.00 $0.00 $34.97 $34.97 $36.31 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10674 ERX HCPCS 25000001 51672-1312-00 MUPIROCIN 2 % EX OINT BOTH IP/OP $47.11 $34.86 $0.00 $36.31 $0.00 $0.00 $0.00 $0.00 $0.00 $34.97 $34.97 $36.31 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10674 ERX HCPCS 25000001 68462-0180-22 MUPIROCIN 2 % EX OINT BOTH IP/OP $47.11 $34.86 $0.00 $36.31 $0.00 $0.00 $0.00 $0.00 $0.00 $34.97 $34.97 $36.31 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.36 $33.83 $34.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10676 ERX HCPCS 63700001 68462-0358-01 NABUMETONE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10685 ERX HCPCS 63700001 00406-1170-03 DEPADE: NALTREXONE HCL 50 MG PO TABS BOTH IP/OP $17.92 $13.26 $0.00 $13.00 $0.00 $0.00 $0.00 $3.19 $0.00 $0.00 $0.00 $0.00 $0.00 $3.73 $0.00 $0.00 $0.00 $0.00 $8.13 $12.87 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10685 ERX HCPCS 63700001 51224-0206-30 DEPADE: NALTREXONE HCL 50 MG PO TABS BOTH IP/OP $17.92 $13.26 $0.00 $13.00 $0.00 $0.00 $0.00 $3.19 $0.00 $0.00 $0.00 $0.00 $0.00 $3.73 $0.00 $0.00 $0.00 $0.00 $8.13 $12.87 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10692 ERX HCPCS 25000001 00065-0645-15 NATAMYCIN 5 % OP SUSP BOTH IP/OP "$1,046.74 " $774.59 $0.00 $837.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.37 $829.02 $837.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10712 ERX HCPCS 63700001 42806-0501-09 NICARDIPINE HCL 20 MG PO CAPS BOTH IP/OP $64.92 $48.04 $0.00 $47.10 $0.00 $0.00 $0.00 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 $13.53 $0.00 $0.00 $0.00 $0.00 $29.44 $46.63 $47.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10722 ERX HCPCS 63700001 23155-0512-00 NIMODIPINE 30 MG PO CAPS BOTH IP/OP $28.90 $21.39 $0.00 $20.97 $0.00 $0.00 $0.00 $5.14 $0.00 $0.00 $0.00 $0.00 $0.00 $6.02 $0.00 $0.00 $0.00 $0.00 $13.11 $20.76 $20.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10722 ERX HCPCS 63700001 23155-0512-11 NIMODIPINE 30 MG PO CAPS BOTH IP/OP $28.90 $21.39 $0.00 $20.97 $0.00 $0.00 $0.00 $5.14 $0.00 $0.00 $0.00 $0.00 $0.00 $6.02 $0.00 $0.00 $0.00 $0.00 $13.11 $20.76 $20.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10722 ERX HCPCS 63700001 23155-0512-30 NIMODIPINE 30 MG PO CAPS BOTH IP/OP $28.90 $21.39 $0.00 $20.97 $0.00 $0.00 $0.00 $5.14 $0.00 $0.00 $0.00 $0.00 $0.00 $6.02 $0.00 $0.00 $0.00 $0.00 $13.11 $20.76 $20.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10722 ERX HCPCS 63700001 63739-0797-33 NIMODIPINE 30 MG PO CAPS BOTH IP/OP $28.90 $21.39 $0.00 $20.97 $0.00 $0.00 $0.00 $5.14 $0.00 $0.00 $0.00 $0.00 $0.00 $6.02 $0.00 $0.00 $0.00 $0.00 $13.11 $20.76 $20.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10724 ERX HCPCS 63700001 00185-0122-01 NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS BOTH IP/OP $14.82 $10.97 $0.00 $10.75 $0.00 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $6.72 $10.64 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10724 ERX HCPCS 63700001 16714-0439-01 NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS BOTH IP/OP $14.82 $10.97 $0.00 $10.75 $0.00 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $6.72 $10.64 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10724 ERX HCPCS 63700001 68084-0446-01 NITROFURANTOIN MONOHYD MACRO 100 MG PO CAPS BOTH IP/OP $14.82 $10.97 $0.00 $10.75 $0.00 $0.00 $0.00 $2.64 $0.00 $0.00 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $6.72 $10.64 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10747 ERX HCPCS 63700001 00555-0211-10 NORETHINDRONE ACETATE 5 MG PO TABS BOTH IP/OP $11.10 $8.21 $0.00 $8.06 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.04 $7.98 $8.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10747 ERX HCPCS 63700001 51285-0424-10 NORETHINDRONE ACETATE 5 MG PO TABS BOTH IP/OP $11.10 $8.21 $0.00 $8.06 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.04 $7.98 $8.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10747 ERX HCPCS 63700001 65162-0475-05 NORETHINDRONE ACETATE 5 MG PO TABS BOTH IP/OP $11.10 $8.21 $0.00 $8.06 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.04 $7.98 $8.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10749 ERX HCPCS 63700001 16714-0360-01 NORGESTIMATE-ETH ESTRADIOL 0.25-35 MG-MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10749 ERX HCPCS 63700001 16714-0360-04 NORGESTIMATE-ETH ESTRADIOL 0.25-35 MG-MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10749 ERX HCPCS 63700001 99999-6009-94 NORGESTIMATE-ETH ESTRADIOL 0.25-35 MG-MCG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10752 ERX HCPCS 63700001 16714-0365-04 NORGESTREL-ETHINYL ESTRADIOL 0.3-30 MG-MCG PO TABS BOTH IP/OP $117.81 $87.18 $0.00 $85.46 $0.00 $0.00 $0.00 $20.97 $0.00 $0.00 $0.00 $0.00 $0.00 $24.55 $0.00 $0.00 $0.00 $0.00 $53.41 $84.60 $85.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10778 ERX HCPCS Q0162 00904-6551-61 ONDANSETRON HCL 4 MG PO TABS BOTH IP/OP $86.73 $64.18 $0.00 $69.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.37 $68.69 $69.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10778 ERX HCPCS Q0162 55111-0153-30 ONDANSETRON HCL 4 MG PO TABS BOTH IP/OP $86.73 $64.18 $0.00 $69.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.37 $68.69 $69.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10778 ERX HCPCS Q0162 68084-0220-01 ONDANSETRON HCL 4 MG PO TABS BOTH IP/OP $86.73 $64.18 $0.00 $69.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.37 $68.69 $69.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10778 ERX HCPCS Q0162 68084-0220-11 ONDANSETRON HCL 4 MG PO TABS BOTH IP/OP $86.73 $64.18 $0.00 $69.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.37 $68.69 $69.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10779 ERX HCPCS Q0162 00904-6552-61 ONDANSETRON HCL 8 MG PO TABS BOTH IP/OP $144.41 $106.86 $0.00 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.21 $114.37 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10779 ERX HCPCS Q0162 55111-0154-30 ONDANSETRON HCL 8 MG PO TABS BOTH IP/OP $144.41 $106.86 $0.00 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.21 $114.37 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10779 ERX HCPCS Q0162 62756-0131-01 ONDANSETRON HCL 8 MG PO TABS BOTH IP/OP $144.41 $106.86 $0.00 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.21 $114.37 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10779 ERX HCPCS Q0162 63304-0459-30 ONDANSETRON HCL 8 MG PO TABS BOTH IP/OP $144.41 $106.86 $0.00 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.21 $114.37 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10779 ERX HCPCS Q0162 63739-0333-10 ONDANSETRON HCL 8 MG PO TABS BOTH IP/OP $144.41 $106.86 $0.00 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.21 $114.37 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10779 ERX HCPCS Q0162 68084-0221-01 ONDANSETRON HCL 8 MG PO TABS BOTH IP/OP $144.41 $106.86 $0.00 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.21 $114.37 $115.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10803 ERX HCPCS 63700001 00245-0271-11 OXANDROLONE 2.5 MG PO TABS BOTH IP/OP $23.18 $17.15 $0.00 $16.82 $0.00 $0.00 $0.00 $4.13 $0.00 $0.00 $0.00 $0.00 $0.00 $4.83 $0.00 $0.00 $0.00 $0.00 $10.51 $16.65 $16.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10803 ERX HCPCS 63700001 49884-0301-01 OXANDROLONE 2.5 MG PO TABS BOTH IP/OP $23.18 $17.15 $0.00 $16.82 $0.00 $0.00 $0.00 $4.13 $0.00 $0.00 $0.00 $0.00 $0.00 $4.83 $0.00 $0.00 $0.00 $0.00 $10.51 $16.65 $16.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10810 ERX HCPCS 63700001 99999-6004-78 OXYBUTYNIN CHLORIDE 5 MG/5ML PO SYRP BOTH IP/OP $52.80 $39.07 $0.00 $131.12 $0.00 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $0.00 $0.00 $0.00 $0.00 $81.95 $37.92 $131.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10810 ERX HCPCS 63700001 54838-0510-80 OXYBUTYNIN CHLORIDE 5 MG/5ML PO SYRP BOTH IP/OP $52.80 $39.07 $0.00 $131.12 $0.00 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $0.00 $0.00 $0.00 $0.00 $81.95 $129.81 $131.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10810 ERX HCPCS 63700001 60432-0092-16 OXYBUTYNIN CHLORIDE 5 MG/5ML PO SYRP BOTH IP/OP $52.80 $39.07 $0.00 $131.12 $0.00 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $0.00 $0.00 $0.00 $0.00 $81.95 $129.81 $131.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10811 ERX HCPCS 25000001 00327-0001-10 OXYCHLOROSENE SODIUM POWD BOTH IP/OP $25.98 $19.23 $0.00 $20.03 $0.00 $0.00 $0.00 $0.00 $0.00 $19.28 $19.28 $20.03 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $11.78 $18.66 $18.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10812 ERX HCPCS 25000001 00406-8557-30 OXYCODONE HCL 100 MG/5ML PO CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10812 ERX HCPCS 25000001 66689-0025-30 OXYCODONE HCL 100 MG/5ML PO CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10812 ERX HCPCS 25000001 68308-0020-03 OXYCODONE HCL 100 MG/5ML PO CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10812 ERX HCPCS 25000001 99999-6005-57 OXYCODONE HCL 100 MG/5ML PO CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10813 ERX HCPCS 25000001 00054-0390-63 OXYCODONE HCL 5 MG/5ML PO SOLN BOTH IP/OP $36.14 $26.74 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 $26.82 $26.82 $27.86 $0.00 $7.53 $0.00 $0.00 $0.00 $0.00 $16.39 $25.96 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10813 ERX HCPCS 25000001 66689-0401-01 OXYCODONE HCL 5 MG/5ML PO SOLN BOTH IP/OP $36.14 $26.74 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 $26.82 $26.82 $27.86 $0.00 $7.53 $0.00 $0.00 $0.00 $0.00 $16.39 $25.96 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10813 ERX HCPCS 25000001 66689-0401-50 OXYCODONE HCL 5 MG/5ML PO SOLN BOTH IP/OP $36.14 $26.74 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 $26.82 $26.82 $27.86 $0.00 $7.53 $0.00 $0.00 $0.00 $0.00 $16.39 $25.96 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10813 ERX HCPCS 25000001 66689-0403-16 OXYCODONE HCL 5 MG/5ML PO SOLN BOTH IP/OP $36.14 $26.74 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 $26.82 $26.82 $27.86 $0.00 $7.53 $0.00 $0.00 $0.00 $0.00 $16.39 $25.96 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10813 ERX HCPCS 25000001 99999-6004-35 OXYCODONE HCL 5 MG/5ML PO SOLN BOTH IP/OP $36.14 $26.74 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 $26.82 $26.82 $27.86 $0.00 $7.53 $0.00 $0.00 $0.00 $0.00 $16.39 $25.96 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10814 ERX HCPCS 25000001 00406-0552-23 OXYCODONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10814 ERX HCPCS 25000001 00406-0552-62 OXYCODONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10814 ERX HCPCS 25000001 42858-0001-10 OXYCODONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10814 ERX HCPCS 25000001 57664-0223-88 OXYCODONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10814 ERX HCPCS 25000001 68084-0354-01 OXYCODONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10814 ERX HCPCS 25000001 68084-0354-11 OXYCODONE HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10839 ERX HCPCS 63700001 52268-0100-01 PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR BOTH IP/OP $83.80 $62.01 $0.00 $60.80 $0.00 $0.00 $0.00 $14.92 $0.00 $0.00 $0.00 $0.00 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $48.15 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10839 ERX HCPCS 63700001 52268-0101-01 PEG 3350-KCL-NABCB-NACL-NASULF 236 G PO SOLR BOTH IP/OP $83.80 $62.01 $0.00 $60.80 $0.00 $0.00 $0.00 $14.92 $0.00 $0.00 $0.00 $0.00 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $48.15 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10845 ERX HCPCS J2430 59923-0601-10 PAMIDRONATE DISODIUM 30 MG IV SOLR BOTH IP/OP $78.93 $58.41 $0.00 $63.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.47 $62.51 $63.14 $0.00 $0.00 $12.35 $0.00 $0.00 $12.57 $0.00 $0.00 $0.00 $0.00 $0.00 10854 ERX HCPCS 63700001 23155-0038-01 PAROMOMYCIN SULFATE 250 MG PO CAPS BOTH IP/OP $23.76 $17.58 $0.00 $17.24 $0.00 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $10.78 $17.07 $17.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 00904-5677-61 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 13107-0155-30 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 51079-0774-01 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 51079-0774-20 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 63739-0963-10 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 63874-0538-10 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 68084-0045-01 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 68084-0045-11 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10855 ERX HCPCS 63700001 68382-0098-06 PAROXETINE HCL 20 MG PO TABS BOTH IP/OP $10.37 $7.67 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.21 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10856 ERX HCPCS 63700001 13107-0156-30 PAROXETINE HCL 30 MG PO TABS BOTH IP/OP $10.38 $7.68 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.19 $8.22 $8.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10897 ERX HCPCS J0561 60793-0700-10 PENICILLIN G BENZATHINE 600000 UNIT/ML IM SUSP BOTH IP/OP $440.87 $326.24 $0.00 $339.82 $198.39 $198.39 $90.26 $90.26 $90.26 $91.89 $327.21 $327.21 $339.82 $89.69 $105.39 $58.30 $260.77 $260.77 $87.07 $181.91 $288.14 $291.05 $120.23 $120.23 $97.01 $0.00 $0.00 $92.37 $82.92 $0.00 $0.00 $0.00 $0.00 10910 ERX HCPCS J9268 00409-0801-01 PENTOSTATIN 10 MG IV SOLR BOTH IP/OP "$6,614.75 " "$4,894.92" $0.00 "$5,098.65" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,909.47" "$4,909.47" "$5,098.65" $0.00 "$1,378.51" $0.00 $0.00 $0.00 $0.00 "$2,713.76" "$4,298.60" "$4,342.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10917 ERX HCPCS 25000001 00472-0242-60 PERMETHRIN 5 % EX CREA BOTH IP/OP $415.91 $307.77 $0.00 $320.58 $0.00 $0.00 $0.00 $0.00 $0.00 $308.69 $308.69 $320.58 $0.00 $86.68 $0.00 $0.00 $0.00 $0.00 $188.77 $299.00 $302.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10917 ERX HCPCS 25000001 16714-0897-01 PERMETHRIN 5 % EX CREA BOTH IP/OP $415.91 $307.77 $0.00 $320.58 $0.00 $0.00 $0.00 $0.00 $0.00 $308.69 $308.69 $320.58 $0.00 $86.68 $0.00 $0.00 $0.00 $0.00 $188.77 $299.00 $302.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10917 ERX HCPCS 25000001 45802-0269-37 PERMETHRIN 5 % EX CREA BOTH IP/OP $415.91 $307.77 $0.00 $320.58 $0.00 $0.00 $0.00 $0.00 $0.00 $308.69 $308.69 $320.58 $0.00 $86.68 $0.00 $0.00 $0.00 $0.00 $188.77 $299.00 $302.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10918 ERX HCPCS 25000001 63736-0120-03 PERMETHRIN 1 % EX LIQD BOTH IP/OP $42.28 $31.29 $0.00 $32.59 $0.00 $0.00 $0.00 $0.00 $0.00 $31.38 $31.38 $32.59 $0.00 $8.81 $0.00 $0.00 $0.00 $0.00 $19.17 $24.33 $30.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10933 ERX HCPCS 63700001 59762-0119-01 PHENELZINE SULFATE 15 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10945 ERX HCPCS 63700001 49884-0038-01 PHENOXYBENZAMINE HCL 10 MG PO CAPS BOTH IP/OP $434.94 $321.86 $0.00 $315.85 $0.00 $0.00 $0.00 $77.42 $0.00 $0.00 $0.00 $0.00 $0.00 $90.64 $0.00 $0.00 $0.00 $0.00 $197.41 $312.69 $315.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10945 ERX HCPCS 63700001 59212-0001-01 PHENOXYBENZAMINE HCL 10 MG PO CAPS BOTH IP/OP $434.94 $321.86 $0.00 $315.85 $0.00 $0.00 $0.00 $77.42 $0.00 $0.00 $0.00 $0.00 $0.00 $90.64 $0.00 $0.00 $0.00 $0.00 $197.41 $312.69 $315.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10947 ERX HCPCS J2760 00143-9564-01 PHENTOLAMINE MESYLATE 5 MG IJ SOLR BOTH IP/OP "$1,385.60 " "$1,025.34" $0.00 "$1,068.02" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,028.39" "$1,028.39" "$1,068.02" $0.00 $288.76 $0.00 $0.00 $0.00 $0.00 $641.98 "$1,016.90" "$1,027.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10947 ERX HCPCS J2760 00143-9564-10 PHENTOLAMINE MESYLATE 5 MG IJ SOLR BOTH IP/OP "$1,385.60 " "$1,025.34" $0.00 "$1,068.02" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,028.39" "$1,028.39" "$1,068.02" $0.00 $288.76 $0.00 $0.00 $0.00 $0.00 $641.98 "$1,016.90" "$1,027.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11018 ERX HCPCS 63700001 00071-0007-40 PHENYTOIN 50 MG PO CHEW BOTH IP/OP $9.55 $7.07 $0.00 $6.60 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $4.13 $6.53 $6.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11018 ERX HCPCS 63700001 51672-4146-01 PHENYTOIN 50 MG PO CHEW BOTH IP/OP $9.55 $7.07 $0.00 $6.60 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $4.13 $6.53 $6.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11019 ERX HCPCS 63700001 00071-3740-66 PHENYTOIN SODIUM EXTENDED 30 MG PO CAPS BOTH IP/OP $6.19 $4.58 $0.00 $4.80 $0.00 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11024 ERX HCPCS 63700001 00187-1704-05 PHYTONADIONE 5 MG PO TABS BOTH IP/OP $244.68 $181.06 $0.00 $177.70 $0.00 $0.00 $0.00 $43.55 $0.00 $0.00 $0.00 $0.00 $0.00 $50.99 $0.00 $0.00 $0.00 $0.00 $111.06 $175.92 $177.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11024 ERX HCPCS 63700001 68682-0170-30 PHYTONADIONE 5 MG PO TABS BOTH IP/OP $244.68 $181.06 $0.00 $177.70 $0.00 $0.00 $0.00 $43.55 $0.00 $0.00 $0.00 $0.00 $0.00 $50.99 $0.00 $0.00 $0.00 $0.00 $111.06 $175.92 $177.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11037 ERX HCPCS 90732 00006-4837-01 PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ BOTH IP/OP $472.08 $349.34 $9.40 $363.88 $212.44 $212.44 $122.74 $122.74 $119.92 $9.40 $350.38 $350.38 $363.88 $122.74 $147.95 $79.78 $279.24 $279.24 $56.21 $192.51 $304.93 $308.01 $56.21 $56.21 $134.20 $105.11 $105.11 $127.78 $105.11 $0.00 $0.00 $0.00 $0.00 11037 ERX HCPCS 90732 00006-4837-03 PNEUMOCOCCAL VAC POLYVALENT 25 MCG/0.5ML IJ INJ BOTH IP/OP $472.08 $349.34 $9.40 $363.88 $212.44 $212.44 $122.74 $122.74 $119.92 $9.40 $350.38 $350.38 $363.88 $122.74 $147.95 $79.78 $279.24 $279.24 $56.21 $192.51 $304.93 $308.01 $56.21 $56.21 $134.20 $105.11 $105.11 $127.78 $105.11 $0.00 $0.00 $0.00 $0.00 11038 ERX HCPCS 25000001 00574-0611-05 PODOFILOX 0.5 % EX SOLN BOTH IP/OP $363.39 $268.91 $0.00 $280.10 $0.00 $0.00 $0.00 $0.00 $0.00 $269.71 $269.71 $280.10 $0.00 $75.73 $0.00 $0.00 $0.00 $0.00 $164.93 $261.25 $263.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11038 ERX HCPCS 25000001 00591-3204-13 PODOFILOX 0.5 % EX SOLN BOTH IP/OP $363.39 $268.91 $0.00 $280.10 $0.00 $0.00 $0.00 $0.00 $0.00 $269.71 $269.71 $280.10 $0.00 $75.73 $0.00 $0.00 $0.00 $0.00 $164.93 $261.25 $263.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11058 ERX HCPCS 25000001 60258-0002-16 K & NA CIT-CIT AC 550-500-334 MG/5ML PO SYRP BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11074 ERX HCPCS J3480 00338-0709-48 POTASSIUM CHLORIDE 10 MEQ/100ML IV SOLN BOTH IP/OP $24.31 $17.99 $0.00 $18.74 $10.94 $10.94 $0.00 $0.00 $0.00 $0.12 $18.04 $18.04 $18.74 $0.00 $0.85 $0.00 $14.38 $14.38 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.82 $0.00 $0.00 $0.78 $0.00 $0.00 $0.00 $0.00 $0.00 11076 ERX HCPCS J3480 00338-0705-48 POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $1.69 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 11076 ERX HCPCS J3480 00990-7075-26 POTASSIUM CHLORIDE 20 MEQ/100ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $1.69 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 11083 ERX HCPCS 63700001 00245-0071-11 POTASSIUM CITRATE ER 10 MEQ (1080 MG) PO TBCR BOTH IP/OP $11.56 $8.55 $0.00 $8.39 $0.00 $0.00 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $0.00 $2.41 $0.00 $0.00 $0.00 $0.00 $5.25 $8.31 $8.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11087 ERX HCPCS 25000001 00486-1111-01 POTASSIUM PHOSPHATE MONOBASIC 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11110 ERX HCPCS 63700001 00093-0771-98 PRAVASTATIN SODIUM 10 MG PO TABS BOTH IP/OP $13.48 $9.98 $0.00 $9.78 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.11 $9.68 $9.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11110 ERX HCPCS 63700001 00904-5891-61 PRAVASTATIN SODIUM 10 MG PO TABS BOTH IP/OP $13.48 $9.98 $0.00 $9.78 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.11 $9.68 $9.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11110 ERX HCPCS 63700001 60505-0168-09 PRAVASTATIN SODIUM 10 MG PO TABS BOTH IP/OP $13.48 $9.98 $0.00 $9.78 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.11 $9.68 $9.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11110 ERX HCPCS 63700001 68462-0195-90 PRAVASTATIN SODIUM 10 MG PO TABS BOTH IP/OP $13.48 $9.98 $0.00 $9.78 $0.00 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $6.11 $9.68 $9.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11111 ERX HCPCS 63700001 00093-7201-98 PRAVASTATIN SODIUM 20 MG PO TABS BOTH IP/OP $10.46 $7.74 $0.00 $7.59 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11111 ERX HCPCS 63700001 00904-5892-61 PRAVASTATIN SODIUM 20 MG PO TABS BOTH IP/OP $10.46 $7.74 $0.00 $7.59 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11111 ERX HCPCS 63700001 16729-0009-15 PRAVASTATIN SODIUM 20 MG PO TABS BOTH IP/OP $10.46 $7.74 $0.00 $7.59 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11111 ERX HCPCS 63700001 51079-0458-01 PRAVASTATIN SODIUM 20 MG PO TABS BOTH IP/OP $10.46 $7.74 $0.00 $7.59 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11111 ERX HCPCS 63700001 51079-0458-20 PRAVASTATIN SODIUM 20 MG PO TABS BOTH IP/OP $10.46 $7.74 $0.00 $7.59 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11111 ERX HCPCS 63700001 63739-0649-10 PRAVASTATIN SODIUM 20 MG PO TABS BOTH IP/OP $10.46 $7.74 $0.00 $7.59 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11112 ERX HCPCS 63700001 00904-5893-61 PRAVASTATIN SODIUM 40 MG PO TABS BOTH IP/OP $18.00 $13.32 $0.00 $13.06 $0.00 $0.00 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $8.16 $12.93 $13.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11112 ERX HCPCS 63700001 55111-0231-05 PRAVASTATIN SODIUM 40 MG PO TABS BOTH IP/OP $18.00 $13.32 $0.00 $13.06 $0.00 $0.00 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $8.16 $12.93 $13.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11112 ERX HCPCS 63700001 68462-0197-90 PRAVASTATIN SODIUM 40 MG PO TABS BOTH IP/OP $18.00 $13.32 $0.00 $13.06 $0.00 $0.00 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $8.16 $12.93 $13.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11113 ERX HCPCS 63700001 50419-0747-01 PRAZIQUANTEL 600 MG PO TABS BOTH IP/OP $345.78 $255.88 $0.00 $251.11 $0.00 $0.00 $0.00 $61.55 $0.00 $0.00 $0.00 $0.00 $0.00 $72.06 $0.00 $0.00 $0.00 $0.00 $156.95 $248.60 $251.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11129 ERX HCPCS 63700001 53746-0544-01 PRIMIDONE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11129 ERX HCPCS 63700001 68084-0202-01 PRIMIDONE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11129 ERX HCPCS 63700001 68084-0202-11 PRIMIDONE 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11138 ERX HCPCS 25000001 00574-7226-12 PROCHLORPERAZINE 25 MG RECTAL SUPP BOTH IP/OP $52.73 $39.02 $0.00 $40.64 $0.00 $0.00 $0.00 $0.00 $0.00 $39.14 $39.14 $40.64 $0.00 $10.99 $0.00 $0.00 $0.00 $0.00 $23.91 $37.87 $38.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11143 ERX HCPCS 25000001 00713-0536-06 PROMETHAZINE HCL 12.5 MG RECTAL SUPP BOTH IP/OP $74.19 $54.90 $0.00 $57.19 $0.00 $0.00 $0.00 $0.00 $0.00 $55.06 $55.06 $57.19 $0.00 $15.46 $0.00 $0.00 $0.00 $0.00 $33.64 $53.29 $53.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11143 ERX HCPCS 25000001 00713-0536-12 PROMETHAZINE HCL 12.5 MG RECTAL SUPP BOTH IP/OP $74.19 $54.90 $0.00 $57.19 $0.00 $0.00 $0.00 $0.00 $0.00 $55.06 $55.06 $57.19 $0.00 $15.46 $0.00 $0.00 $0.00 $0.00 $33.64 $53.29 $53.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11143 ERX HCPCS 25000001 45802-0758-30 PROMETHAZINE HCL 12.5 MG RECTAL SUPP BOTH IP/OP $74.19 $54.90 $0.00 $57.19 $0.00 $0.00 $0.00 $0.00 $0.00 $55.06 $55.06 $57.19 $0.00 $15.46 $0.00 $0.00 $0.00 $0.00 $33.64 $53.29 $53.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11144 ERX HCPCS 25000001 00713-0526-12 PROMETHAZINE HCL 25 MG RECTAL SUPP BOTH IP/OP $74.19 $54.90 $0.00 $57.19 $0.00 $0.00 $0.00 $0.00 $0.00 $55.06 $55.06 $57.19 $0.00 $15.46 $0.00 $0.00 $0.00 $0.00 $33.64 $53.29 $53.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11144 ERX HCPCS 25000001 45802-0759-30 PROMETHAZINE HCL 25 MG RECTAL SUPP BOTH IP/OP $74.19 $54.90 $0.00 $57.19 $0.00 $0.00 $0.00 $0.00 $0.00 $55.06 $55.06 $57.19 $0.00 $15.46 $0.00 $0.00 $0.00 $0.00 $33.64 $53.29 $53.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11144 ERX HCPCS 25000001 51672-5297-01 PROMETHAZINE HCL 25 MG RECTAL SUPP BOTH IP/OP $74.19 $54.90 $0.00 $57.19 $0.00 $0.00 $0.00 $0.00 $0.00 $55.06 $55.06 $57.19 $0.00 $15.46 $0.00 $0.00 $0.00 $0.00 $33.64 $53.29 $53.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11146 ERX HCPCS 63700001 00591-0582-01 PROPAFENONE HCL 150 MG PO TABS BOTH IP/OP $6.40 $4.74 $0.00 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.07 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11146 ERX HCPCS 63700001 53489-0551-01 PROPAFENONE HCL 150 MG PO TABS BOTH IP/OP $6.40 $4.74 $0.00 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.07 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11146 ERX HCPCS 63700001 62559-0230-01 PROPAFENONE HCL 150 MG PO TABS BOTH IP/OP $6.40 $4.74 $0.00 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.07 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11146 ERX HCPCS 63700001 63739-0509-10 PROPAFENONE HCL 150 MG PO TABS BOTH IP/OP $6.40 $4.74 $0.00 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.07 $5.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11147 ERX HCPCS 63700001 00591-0583-01 PROPAFENONE HCL 225 MG PO TABS BOTH IP/OP $9.77 $7.23 $0.00 $7.09 $0.00 $0.00 $0.00 $1.74 $0.00 $0.00 $0.00 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $4.43 $7.02 $7.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11147 ERX HCPCS 63700001 00603-5449-21 PROPAFENONE HCL 225 MG PO TABS BOTH IP/OP $9.77 $7.23 $0.00 $7.09 $0.00 $0.00 $0.00 $1.74 $0.00 $0.00 $0.00 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $4.43 $7.02 $7.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11147 ERX HCPCS 63700001 53489-0552-01 PROPAFENONE HCL 225 MG PO TABS BOTH IP/OP $9.77 $7.23 $0.00 $7.09 $0.00 $0.00 $0.00 $1.74 $0.00 $0.00 $0.00 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $4.43 $7.02 $7.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11164 ERX HCPCS 63700001 00054-0210-25 PROTRIPTYLINE HCL 5 MG PO TABS BOTH IP/OP $24.03 $17.78 $0.00 $17.43 $0.00 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $10.90 $17.26 $17.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11164 ERX HCPCS 63700001 64980-0158-01 PROTRIPTYLINE HCL 5 MG PO TABS BOTH IP/OP $24.03 $17.78 $0.00 $17.43 $0.00 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $10.90 $17.26 $17.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11217 ERX HCPCS 63700001 37000-0023-04 PSYLLIUM 28 % PO PACK BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11217 ERX HCPCS 63700001 37000-0740-87 PSYLLIUM 28 % PO PACK BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11239 ERX HCPCS 63700001 00115-3511-01 PYRIDOSTIGMINE BROMIDE 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11239 ERX HCPCS 63700001 68682-0302-10 PYRIDOSTIGMINE BROMIDE 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11240 ERX HCPCS 63700001 00115-1404-08 PYRIDOSTIGMINE BROMIDE ER 180 MG PO TBCR BOTH IP/OP $95.76 $70.86 $0.00 $69.46 $0.00 $0.00 $0.00 $17.05 $0.00 $0.00 $0.00 $0.00 $0.00 $19.96 $0.00 $0.00 $0.00 $0.00 $43.42 $68.77 $69.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11240 ERX HCPCS 63700001 00187-3013-30 PYRIDOSTIGMINE BROMIDE ER 180 MG PO TBCR BOTH IP/OP $95.76 $70.86 $0.00 $69.46 $0.00 $0.00 $0.00 $17.05 $0.00 $0.00 $0.00 $0.00 $0.00 $19.96 $0.00 $0.00 $0.00 $0.00 $43.42 $68.77 $69.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11240 ERX HCPCS 63700001 47781-0335-30 PYRIDOSTIGMINE BROMIDE ER 180 MG PO TBCR BOTH IP/OP $95.76 $70.86 $0.00 $69.46 $0.00 $0.00 $0.00 $17.05 $0.00 $0.00 $0.00 $0.00 $0.00 $19.96 $0.00 $0.00 $0.00 $0.00 $43.42 $68.77 $69.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11240 ERX HCPCS 63700001 64980-0220-03 PYRIDOSTIGMINE BROMIDE ER 180 MG PO TBCR BOTH IP/OP $95.76 $70.86 $0.00 $69.46 $0.00 $0.00 $0.00 $17.05 $0.00 $0.00 $0.00 $0.00 $0.00 $19.96 $0.00 $0.00 $0.00 $0.00 $43.42 $68.77 $69.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11246 ERX HCPCS 63700001 69413-0330-10 PYRIMETHAMINE 25 MG PO TABS BOTH IP/OP "$4,068.00 " "$3,010.32" $0.00 "$2,952.00" $0.00 $0.00 $0.00 $724.10 $0.00 $0.00 $0.00 $0.00 $0.00 $847.77 $0.00 $0.00 $0.00 $0.00 "$1,845.00" "$2,922.48" "$2,952.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11246 ERX HCPCS 63700001 69413-0330-30 PYRIMETHAMINE 25 MG PO TABS BOTH IP/OP "$4,068.00 " "$3,010.32" $0.00 "$2,952.00" $0.00 $0.00 $0.00 $724.10 $0.00 $0.00 $0.00 $0.00 $0.00 $847.77 $0.00 $0.00 $0.00 $0.00 "$1,845.00" "$2,922.48" "$2,952.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11257 ERX HCPCS 90675 49281-0250-51 "RABIES VIRUS VACCINE, HDC IM INJ" BOTH IP/OP "$1,419.71 " "$1,050.59" $0.00 $951.88 $0.00 $0.00 $0.00 $0.00 $0.00 $174.76 $0.00 $0.00 $0.00 $327.53 $384.85 $212.90 $839.76 $839.76 $312.47 $594.93 $942.36 $951.88 $431.50 $431.50 $326.44 $0.00 $0.00 $310.83 $294.72 $0.00 $0.00 $0.00 $0.00 11259 ERX HCPCS 63700001 68180-0591-01 RAMIPRIL 10 MG PO CAPS BOTH IP/OP $9.29 $6.87 $0.00 $7.21 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $4.51 $7.14 $7.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11286 ERX HCPCS 63700001 65862-0290-84 RIBAVIRIN 200 MG PO CAPS BOTH IP/OP $41.63 $30.81 $0.00 $30.20 $0.00 $0.00 $0.00 $7.41 $0.00 $0.00 $0.00 $0.00 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $18.88 $29.90 $30.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11286 ERX HCPCS 63700001 68382-0260-12 RIBAVIRIN 200 MG PO CAPS BOTH IP/OP $41.63 $30.81 $0.00 $30.20 $0.00 $0.00 $0.00 $7.41 $0.00 $0.00 $0.00 $0.00 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $18.88 $29.90 $30.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11290 ERX HCPCS 63700001 00013-5301-17 RIFABUTIN 150 MG PO CAPS BOTH IP/OP $90.12 $66.69 $0.00 $64.40 $0.00 $0.00 $0.00 $16.04 $0.00 $0.00 $0.00 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $40.25 $63.76 $64.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11290 ERX HCPCS 63700001 59762-1350-01 RIFABUTIN 150 MG PO CAPS BOTH IP/OP $90.12 $66.69 $0.00 $64.40 $0.00 $0.00 $0.00 $16.04 $0.00 $0.00 $0.00 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $40.25 $63.76 $64.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11291 ERX HCPCS 25000001 00068-0597-01 RIFAMPIN 600 MG IV SOLR BOTH IP/OP $359.98 $266.39 $0.00 $277.47 $0.00 $0.00 $0.00 $0.00 $0.00 $267.18 $267.18 $277.47 $0.00 $75.02 $0.00 $0.00 $0.00 $0.00 $163.39 $258.80 $261.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11291 ERX HCPCS 25000001 00068-0599-01 RIFAMPIN 600 MG IV SOLR BOTH IP/OP $359.98 $266.39 $0.00 $277.47 $0.00 $0.00 $0.00 $0.00 $0.00 $267.18 $267.18 $277.47 $0.00 $75.02 $0.00 $0.00 $0.00 $0.00 $163.39 $258.80 $261.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11291 ERX HCPCS 25000001 63323-0351-20 RIFAMPIN 600 MG IV SOLR BOTH IP/OP $359.98 $266.39 $0.00 $277.47 $0.00 $0.00 $0.00 $0.00 $0.00 $267.18 $267.18 $277.47 $0.00 $75.02 $0.00 $0.00 $0.00 $0.00 $163.39 $258.80 $261.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11291 ERX HCPCS 25000001 67457-0445-60 RIFAMPIN 600 MG IV SOLR BOTH IP/OP $359.98 $266.39 $0.00 $277.47 $0.00 $0.00 $0.00 $0.00 $0.00 $267.18 $267.18 $277.47 $0.00 $75.02 $0.00 $0.00 $0.00 $0.00 $163.39 $258.80 $261.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11293 ERX HCPCS 63700001 00527-1315-01 RIFAMPIN 300 MG PO CAPS BOTH IP/OP $7.97 $5.90 $0.00 $5.78 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $3.62 $5.73 $5.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11293 ERX HCPCS 63700001 00527-1315-06 RIFAMPIN 300 MG PO CAPS BOTH IP/OP $7.97 $5.90 $0.00 $5.78 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $3.62 $5.73 $5.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11293 ERX HCPCS 63700001 61748-0018-01 RIFAMPIN 300 MG PO CAPS BOTH IP/OP $7.97 $5.90 $0.00 $5.78 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $3.62 $5.73 $5.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11293 ERX HCPCS 63700001 63739-0415-10 RIFAMPIN 300 MG PO CAPS BOTH IP/OP $7.97 $5.90 $0.00 $5.78 $0.00 $0.00 $0.00 $2.84 $0.00 $0.00 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $3.62 $5.73 $5.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11308 ERX HCPCS 25000001 11086-0030-10 SALICYLIC ACID 6 % EX GEL BOTH IP/OP $213.06 $157.66 $0.00 $164.23 $0.00 $0.00 $0.00 $0.00 $0.00 $158.13 $158.13 $164.23 $0.00 $44.40 $0.00 $0.00 $0.00 $0.00 $96.71 $153.18 $154.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11323 ERX HCPCS 25000001 11017-0252-20 SALICYLIC ACID 17 % EX SOLN BOTH IP/OP $25.42 $18.81 $0.00 $19.59 $0.00 $0.00 $0.00 $0.00 $0.00 $18.87 $18.87 $19.59 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.53 $18.26 $18.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11340 ERX HCPCS 63700001 60505-3438-03 SELEGILINE HCL 5 MG PO TABS BOTH IP/OP $8.81 $6.52 $0.00 $6.39 $0.00 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 $1.84 $0.00 $0.00 $0.00 $0.00 $4.00 $6.33 $6.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11349 ERX HCPCS 63700001 00904-6522-61 SENNOSIDES 8.6 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11349 ERX HCPCS 63700001 57896-0451-01 SENNOSIDES 8.6 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11349 ERX HCPCS 63700001 70677-0041-01 SENNOSIDES 8.6 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11349 ERX HCPCS 63700001 70677-0058-01 SENNOSIDES 8.6 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11350 ERX HCPCS 63700001 16714-0613-04 SERTRALINE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11350 ERX HCPCS 63700001 16714-0613-06 SERTRALINE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11350 ERX HCPCS 63700001 60687-0253-01 SERTRALINE HCL 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11351 ERX HCPCS 63700001 60687-0242-01 SERTRALINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11351 ERX HCPCS 63700001 60687-0242-11 SERTRALINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11351 ERX HCPCS 63700001 69097-0834-02 SERTRALINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11351 ERX HCPCS 63700001 76282-0213-60 SERTRALINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11351 ERX HCPCS 63700001 76282-0213-90 SERTRALINE HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11359 ERX HCPCS 25000001 12870-0001-01 SILVER NITRATE-POT NITRATE 75-25 % EX MISC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11359 ERX HCPCS 25000001 12870-0001-02 SILVER NITRATE-POT NITRATE 75-25 % EX MISC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11364 ERX HCPCS 63700001 16714-0682-02 SIMVASTATIN 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11364 ERX HCPCS 63700001 63739-0571-10 SIMVASTATIN 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11365 ERX HCPCS 63700001 16714-0683-01 SIMVASTATIN 20 MG PO TABS BOTH IP/OP $18.70 $13.84 $0.00 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.35 $14.81 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11365 ERX HCPCS 63700001 63739-0572-10 SIMVASTATIN 20 MG PO TABS BOTH IP/OP $18.70 $13.84 $0.00 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.35 $14.81 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11365 ERX HCPCS 63700001 68084-0512-01 SIMVASTATIN 20 MG PO TABS BOTH IP/OP $18.70 $13.84 $0.00 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.35 $14.81 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11366 ERX HCPCS 63700001 60687-0210-01 SIMVASTATIN 40 MG PO TABS BOTH IP/OP $18.70 $13.84 $0.00 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.35 $14.81 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11366 ERX HCPCS 63700001 60687-0210-11 SIMVASTATIN 40 MG PO TABS BOTH IP/OP $18.70 $13.84 $0.00 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.35 $14.81 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11366 ERX HCPCS 63700001 63739-0573-10 SIMVASTATIN 40 MG PO TABS BOTH IP/OP $18.70 $13.84 $0.00 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.35 $14.81 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11366 ERX HCPCS 63700001 68180-0464-09 SIMVASTATIN 40 MG PO TABS BOTH IP/OP $18.70 $13.84 $0.00 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.35 $14.81 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11367 ERX HCPCS 63700001 63739-0570-10 SIMVASTATIN 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11394 ERX HCPCS 25000001 00121-0595-16 SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11394 ERX HCPCS 25000001 00121-1190-00 SOD CITRATE-CITRIC ACID 500-334 MG/5ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11400 ERX HCPCS 25000001 00409-6609-25 SODIUM BICARBONATE 4 % IV SOLN BOTH IP/OP $34.79 $25.74 $0.00 $27.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.40 $27.55 $27.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11403 ERX HCPCS 25000001 00338-0048-04 SODIUM CHLORIDE 0.9 % IR SOLN BOTH IP/OP $22.00 $16.28 $0.00 $54.11 $0.00 $0.00 $0.00 $0.00 $0.00 $52.10 $52.10 $54.11 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11403 ERX HCPCS 25000001 00264-2201-10 SODIUM CHLORIDE 0.9 % IR SOLN BOTH IP/OP $22.00 $16.28 $0.00 $54.11 $0.00 $0.00 $0.00 $0.00 $0.00 $52.10 $52.10 $54.11 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11403 ERX HCPCS 25000001 00338-0048-03 SODIUM CHLORIDE 0.9 % IR SOLN BOTH IP/OP $22.00 $16.28 $0.00 $54.11 $0.00 $0.00 $0.00 $0.00 $0.00 $52.10 $52.10 $54.11 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11403 ERX HCPCS 25000001 99999-6011-64 SODIUM CHLORIDE 0.9 % IR SOLN BOTH IP/OP $22.00 $16.28 $0.00 $54.11 $0.00 $0.00 $0.00 $0.00 $0.00 $52.10 $52.10 $54.11 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11418 ERX HCPCS J2941 00002-7335-11 SOMATROPIN (HUMATROPE) 5 MG IJ SOLR BOTH IP/OP "$1,929.32 " "$1,427.70" $0.00 "$1,543.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.66 "$1,528.02" "$1,543.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11420 ERX HCPCS 63700001 00093-1063-01 SOTALOL HCL 240 MG PO TABS BOTH IP/OP $21.33 $15.78 $0.00 $15.48 $0.00 $0.00 $0.00 $3.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $0.00 $0.00 $0.00 $0.00 $9.68 $15.33 $15.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11420 ERX HCPCS 63700001 60505-0082-00 SOTALOL HCL 240 MG PO TABS BOTH IP/OP $21.33 $15.78 $0.00 $15.48 $0.00 $0.00 $0.00 $3.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $0.00 $0.00 $0.00 $0.00 $9.68 $15.33 $15.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11421 ERX HCPCS 63700001 60505-0080-00 SOTALOL HCL 80 MG PO TABS BOTH IP/OP $9.73 $7.20 $0.00 $7.06 $0.00 $0.00 $0.00 $1.73 $0.00 $0.00 $0.00 $0.00 $0.00 $2.03 $0.00 $0.00 $0.00 $0.00 $4.41 $6.99 $7.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11421 ERX HCPCS 63700001 68084-0654-01 SOTALOL HCL 80 MG PO TABS BOTH IP/OP $9.73 $7.20 $0.00 $7.06 $0.00 $0.00 $0.00 $1.73 $0.00 $0.00 $0.00 $0.00 $0.00 $2.03 $0.00 $0.00 $0.00 $0.00 $4.41 $6.99 $7.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11425 ERX HCPCS 63700001 53746-0515-01 SPIRONOLACTONE 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11425 ERX HCPCS 63700001 59746-0218-01 SPIRONOLACTONE 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11425 ERX HCPCS 63700001 60687-0487-01 SPIRONOLACTONE 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11425 ERX HCPCS 63700001 60687-0487-11 SPIRONOLACTONE 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11436 ERX HCPCS J9320 00703-4636-01 STREPTOZOCIN 1 G IV SOLR BOTH IP/OP "$1,223.72 " $905.55 $0.00 $943.24 $0.00 $0.00 $0.00 $0.00 $0.00 $908.24 $908.24 $943.24 $0.00 $255.02 $0.00 $0.00 $0.00 $0.00 $555.29 $879.57 $888.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11438 ERX HCPCS 63700001 55292-0201-11 SUCCIMER 100 MG PO CAPS BOTH IP/OP $103.11 $76.30 $0.00 $64.13 $0.00 $0.00 $0.00 $18.35 $0.00 $0.00 $0.00 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $40.08 $63.49 $64.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11441 ERX HCPCS 63700001 00121-0747-10 SUCRALFATE 1 GM/10ML PO SUSP BOTH IP/OP $58.71 $43.45 $0.00 $42.59 $0.00 $0.00 $0.00 $10.45 $0.00 $0.00 $0.00 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $26.62 $42.17 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11441 ERX HCPCS 63700001 00121-0747-40 SUCRALFATE 1 GM/10ML PO SUSP BOTH IP/OP $58.71 $43.45 $0.00 $42.59 $0.00 $0.00 $0.00 $10.45 $0.00 $0.00 $0.00 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $26.62 $42.17 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11441 ERX HCPCS 63700001 58914-0170-14 SUCRALFATE 1 GM/10ML PO SUSP BOTH IP/OP $58.71 $43.45 $0.00 $42.59 $0.00 $0.00 $0.00 $10.45 $0.00 $0.00 $0.00 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $26.62 $42.17 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11441 ERX HCPCS 63700001 66689-0790-01 SUCRALFATE 1 GM/10ML PO SUSP BOTH IP/OP $58.71 $43.45 $0.00 $42.59 $0.00 $0.00 $0.00 $10.45 $0.00 $0.00 $0.00 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $26.62 $42.17 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11441 ERX HCPCS 63700001 66689-0790-50 SUCRALFATE 1 GM/10ML PO SUSP BOTH IP/OP $58.71 $43.45 $0.00 $42.59 $0.00 $0.00 $0.00 $10.45 $0.00 $0.00 $0.00 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $26.62 $42.17 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11442 ERX HCPCS 63700001 00093-2210-01 SUCRALFATE 1 G PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11442 ERX HCPCS 63700001 00093-2210-05 SUCRALFATE 1 G PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11442 ERX HCPCS 63700001 00093-2210-98 SUCRALFATE 1 G PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11442 ERX HCPCS 63700001 51079-0753-20 SUCRALFATE 1 G PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11442 ERX HCPCS 63700001 59762-0401-01 SUCRALFATE 1 G PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11442 ERX HCPCS 63700001 63739-0943-10 SUCRALFATE 1 G PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11498 ERX HCPCS 25000001 00591-2473-19 TAMOXIFEN CITRATE 20 MG PO TABS BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11498 ERX HCPCS 25000001 51862-0446-01 TAMOXIFEN CITRATE 20 MG PO TABS BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11498 ERX HCPCS 25000001 51862-0446-30 TAMOXIFEN CITRATE 20 MG PO TABS BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11498 ERX HCPCS 25000001 68382-0827-01 TAMOXIFEN CITRATE 20 MG PO TABS BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $42.31 $43.94 $0.00 $11.88 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11501 ERX HCPCS Q2017 44567-0507-01 TENIPOSIDE 10 MG/ML IV SOLN BOTH IP/OP "$6,140.04 " "$4,543.63" $0.00 "$4,912.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,070.02" "$4,862.91" "$4,912.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11507 ERX HCPCS J3105 00143-9746-01 TERBUTALINE SULFATE 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.94 $16.33 $16.33 $16.96 $0.00 $2.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.49 $0.00 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $0.00 11507 ERX HCPCS J3105 00143-9746-10 TERBUTALINE SULFATE 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.94 $16.33 $16.33 $16.96 $0.00 $2.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.49 $0.00 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $0.00 11507 ERX HCPCS J3105 63323-0665-01 TERBUTALINE SULFATE 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.94 $16.33 $16.33 $16.96 $0.00 $2.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.49 $0.00 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $0.00 11507 ERX HCPCS J3105 70860-0801-01 TERBUTALINE SULFATE 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.94 $16.33 $16.33 $16.96 $0.00 $2.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.49 $0.00 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $0.00 11508 ERX HCPCS 63700001 00115-2611-01 TERBUTALINE SULFATE 2.5 MG PO TABS BOTH IP/OP $57.53 $42.57 $0.00 $41.74 $0.00 $0.00 $0.00 $10.24 $0.00 $0.00 $0.00 $0.00 $0.00 $11.99 $0.00 $0.00 $0.00 $0.00 $26.09 $41.33 $41.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11508 ERX HCPCS 63700001 00527-1318-01 TERBUTALINE SULFATE 2.5 MG PO TABS BOTH IP/OP $57.53 $42.57 $0.00 $41.74 $0.00 $0.00 $0.00 $10.24 $0.00 $0.00 $0.00 $0.00 $0.00 $11.99 $0.00 $0.00 $0.00 $0.00 $26.09 $41.33 $41.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11508 ERX HCPCS 63700001 10135-0579-01 TERBUTALINE SULFATE 2.5 MG PO TABS BOTH IP/OP $57.53 $42.57 $0.00 $41.74 $0.00 $0.00 $0.00 $10.24 $0.00 $0.00 $0.00 $0.00 $0.00 $11.99 $0.00 $0.00 $0.00 $0.00 $26.09 $41.33 $41.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11508 ERX HCPCS 63700001 62559-0721-01 TERBUTALINE SULFATE 2.5 MG PO TABS BOTH IP/OP $57.53 $42.57 $0.00 $41.74 $0.00 $0.00 $0.00 $10.24 $0.00 $0.00 $0.00 $0.00 $0.00 $11.99 $0.00 $0.00 $0.00 $0.00 $26.09 $41.33 $41.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11509 ERX HCPCS 63700001 00115-2622-01 TERBUTALINE SULFATE 5 MG PO TABS BOTH IP/OP $70.25 $51.99 $0.00 $50.98 $0.00 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $14.64 $0.00 $0.00 $0.00 $0.00 $31.86 $50.47 $50.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11509 ERX HCPCS 63700001 00527-1311-01 TERBUTALINE SULFATE 5 MG PO TABS BOTH IP/OP $70.25 $51.99 $0.00 $50.98 $0.00 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $14.64 $0.00 $0.00 $0.00 $0.00 $31.86 $50.47 $50.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11509 ERX HCPCS 63700001 10135-0580-01 TERBUTALINE SULFATE 5 MG PO TABS BOTH IP/OP $70.25 $51.99 $0.00 $50.98 $0.00 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $14.64 $0.00 $0.00 $0.00 $0.00 $31.86 $50.47 $50.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11509 ERX HCPCS 63700001 62559-0722-01 TERBUTALINE SULFATE 5 MG PO TABS BOTH IP/OP $70.25 $51.99 $0.00 $50.98 $0.00 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $14.64 $0.00 $0.00 $0.00 $0.00 $31.86 $50.47 $50.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11510 ERX HCPCS 63700001 00168-0346-46 TERCONAZOLE 0.4 % VA CREA BOTH IP/OP $171.97 $127.26 $0.00 $124.74 $0.00 $0.00 $0.00 $30.61 $0.00 $0.00 $0.00 $0.00 $0.00 $35.84 $0.00 $0.00 $0.00 $0.00 $77.97 $123.50 $124.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11510 ERX HCPCS 63700001 51672-1304-06 TERCONAZOLE 0.4 % VA CREA BOTH IP/OP $171.97 $127.26 $0.00 $124.74 $0.00 $0.00 $0.00 $30.61 $0.00 $0.00 $0.00 $0.00 $0.00 $35.84 $0.00 $0.00 $0.00 $0.00 $77.97 $123.50 $124.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11511 ERX HCPCS 63700001 51672-1302-00 TERCONAZOLE 0.8 % VA CREA BOTH IP/OP $158.03 $116.94 $0.00 $114.63 $0.00 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $71.65 $113.49 $114.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11512 ERX HCPCS 63700001 45802-0717-08 TERCONAZOLE 80 MG VA SUPP BOTH IP/OP $125.95 $93.20 $0.00 $91.36 $0.00 $0.00 $0.00 $22.42 $0.00 $0.00 $0.00 $0.00 $0.00 $26.25 $0.00 $0.00 $0.00 $0.00 $57.10 $90.45 $91.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11517 ERX HCPCS 25000001 17478-0045-32 TETRACAINE HCL 1 % IJ SOLN BOTH IP/OP $175.89 $130.16 $0.00 $135.58 $0.00 $0.00 $0.00 $0.00 $0.00 $130.55 $130.55 $135.58 $0.00 $36.66 $0.00 $0.00 $0.00 $0.00 $79.74 $126.31 $127.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11562 ERX HCPCS 25000001 17478-0288-10 TIMOLOL MALEATE 0.5 % OP SOLN BOTH IP/OP $71.23 $52.71 $0.00 $54.90 $0.00 $0.00 $0.00 $0.00 $0.00 $52.87 $52.87 $54.90 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $32.30 $51.16 $51.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11562 ERX HCPCS 25000001 61314-0227-05 TIMOLOL MALEATE 0.5 % OP SOLN BOTH IP/OP $71.23 $52.71 $0.00 $54.90 $0.00 $0.00 $0.00 $0.00 $0.00 $52.87 $52.87 $54.90 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $32.30 $51.16 $51.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11562 ERX HCPCS 25000001 64980-0514-05 TIMOLOL MALEATE 0.5 % OP SOLN BOTH IP/OP $71.23 $52.71 $0.00 $54.90 $0.00 $0.00 $0.00 $0.00 $0.00 $52.87 $52.87 $54.90 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $32.30 $51.16 $51.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11565 ERX HCPCS J3260 39822-0412-01 TOBRAMYCIN SULFATE 1.2 G IJ SOLR BOTH IP/OP $347.00 $256.78 $0.00 $463.75 $156.15 $156.15 $0.00 $0.00 $0.00 $38.42 $257.54 $257.54 $267.47 $0.00 $67.70 $0.00 $205.25 $205.25 $0.00 $289.85 $459.11 $463.75 $0.00 $0.00 $65.04 $0.00 $0.00 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 11565 ERX HCPCS J3260 39822-0412-06 TOBRAMYCIN SULFATE 1.2 G IJ SOLR BOTH IP/OP $347.00 $256.78 $0.00 $463.75 $156.15 $156.15 $0.00 $0.00 $0.00 $38.42 $257.54 $257.54 $267.47 $0.00 $67.70 $0.00 $205.25 $205.25 $0.00 $289.85 $459.11 $463.75 $0.00 $0.00 $65.04 $0.00 $0.00 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 11565 ERX HCPCS J3260 63323-0303-51 TOBRAMYCIN SULFATE 1.2 G IJ SOLR BOTH IP/OP $347.00 $256.78 $0.00 $463.75 $156.15 $156.15 $0.00 $0.00 $0.00 $38.42 $257.54 $257.54 $267.47 $0.00 $67.70 $0.00 $205.25 $205.25 $0.00 $289.85 $459.11 $463.75 $0.00 $0.00 $65.04 $0.00 $0.00 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 11565 ERX HCPCS J3260 63323-0303-55 TOBRAMYCIN SULFATE 1.2 G IJ SOLR BOTH IP/OP $347.00 $256.78 $0.00 $463.75 $156.15 $156.15 $0.00 $0.00 $0.00 $38.42 $257.54 $257.54 $267.47 $0.00 $67.70 $0.00 $205.25 $205.25 $0.00 $289.85 $459.11 $463.75 $0.00 $0.00 $65.04 $0.00 $0.00 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 11566 ERX HCPCS 25000001 00065-0648-35 TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP OINT BOTH IP/OP $725.71 $537.03 $0.00 $580.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $362.86 $574.76 $580.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11567 ERX HCPCS 25000001 00065-0647-25 TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP BOTH IP/OP $329.72 $243.99 $0.00 $254.15 $0.00 $0.00 $0.00 $0.00 $0.00 $244.72 $244.72 $254.15 $0.00 $68.71 $0.00 $0.00 $0.00 $0.00 $149.66 $237.06 $239.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11567 ERX HCPCS 25000001 61314-0647-25 TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP SUSP BOTH IP/OP $329.72 $243.99 $0.00 $254.15 $0.00 $0.00 $0.00 $0.00 $0.00 $244.72 $244.72 $254.15 $0.00 $68.71 $0.00 $0.00 $0.00 $0.00 $149.66 $237.06 $239.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11576 ERX HCPCS 25000001 00472-0117-20 TRETINOIN 0.025 % EX CREA BOTH IP/OP $329.65 $243.94 $0.00 $311.30 $0.00 $0.00 $0.00 $0.00 $0.00 $244.67 $244.67 $254.09 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $194.56 $308.18 $311.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11577 ERX HCPCS 25000001 00187-5162-20 TRETINOIN 0.05 % EX CREA BOTH IP/OP $329.65 $243.94 $0.00 $254.09 $0.00 $0.00 $0.00 $0.00 $0.00 $244.67 $244.67 $254.09 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $149.63 $237.01 $239.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11577 ERX HCPCS 25000001 00574-2205-20 TRETINOIN 0.05 % EX CREA BOTH IP/OP $329.65 $243.94 $0.00 $254.09 $0.00 $0.00 $0.00 $0.00 $0.00 $244.67 $244.67 $254.09 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $149.63 $237.01 $239.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11578 ERX HCPCS 25000001 00187-5164-20 TRETINOIN 0.1 % EX CREA BOTH IP/OP $329.65 $243.94 $0.00 $254.09 $0.00 $0.00 $0.00 $0.00 $0.00 $244.67 $244.67 $254.09 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $149.63 $237.01 $239.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11584 ERX HCPCS J3301 00003-0494-20 TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.77 $16.33 $16.33 $16.96 $0.00 $1.41 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.83 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $0.00 11589 ERX HCPCS 25000001 10481-3008-01 TRICHLOROACETIC ACID 80 % EX LIQD BOTH IP/OP $244.15 $180.67 $0.00 $195.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.08 $193.37 $195.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11595 ERX HCPCS 25000001 61314-0044-75 TRIFLURIDINE 1 % OP SOLN BOTH IP/OP $650.98 $481.73 $0.00 $501.78 $0.00 $0.00 $0.00 $0.00 $0.00 $483.16 $483.16 $501.78 $0.00 $135.66 $0.00 $0.00 $0.00 $0.00 $295.40 $467.91 $472.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11596 ERX HCPCS 25000001 17478-0703-11 POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN BOTH IP/OP $56.32 $41.68 $0.00 $43.41 $0.00 $0.00 $0.00 $0.00 $0.00 $41.80 $41.80 $43.41 $0.00 $11.74 $0.00 $0.00 $0.00 $0.00 $25.54 $40.46 $40.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11596 ERX HCPCS 25000001 24208-0315-10 POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN BOTH IP/OP $56.32 $41.68 $0.00 $43.41 $0.00 $0.00 $0.00 $0.00 $0.00 $41.80 $41.80 $43.41 $0.00 $11.74 $0.00 $0.00 $0.00 $0.00 $25.54 $40.46 $40.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11596 ERX HCPCS 25000001 60758-0908-10 POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN BOTH IP/OP $56.32 $41.68 $0.00 $43.41 $0.00 $0.00 $0.00 $0.00 $0.00 $41.80 $41.80 $43.41 $0.00 $11.74 $0.00 $0.00 $0.00 $0.00 $25.54 $40.46 $40.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11596 ERX HCPCS 25000001 61314-0628-10 POLYMYXIN B-TRIMETHOPRIM 10000-0.1 UNIT/ML-% OP SOLN BOTH IP/OP $56.32 $41.68 $0.00 $43.41 $0.00 $0.00 $0.00 $0.00 $0.00 $41.80 $41.80 $43.41 $0.00 $11.74 $0.00 $0.00 $0.00 $0.00 $25.54 $40.46 $40.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11599 ERX HCPCS 63700001 00904-2725-61 SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11599 ERX HCPCS 63700001 57237-0233-05 SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11599 ERX HCPCS 63700001 63739-0228-10 SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11624 ERX HCPCS 63700001 00591-3159-01 URSODIOL 300 MG PO CAPS BOTH IP/OP $35.96 $26.61 $0.00 $23.23 $0.00 $0.00 $0.00 $6.40 $0.00 $0.00 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $14.52 $23.00 $23.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11624 ERX HCPCS 63700001 42806-0503-01 URSODIOL 300 MG PO CAPS BOTH IP/OP $35.96 $26.61 $0.00 $23.23 $0.00 $0.00 $0.00 $6.40 $0.00 $0.00 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $14.52 $23.00 $23.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11624 ERX HCPCS 63700001 51079-0383-01 URSODIOL 300 MG PO CAPS BOTH IP/OP $35.96 $26.61 $0.00 $23.23 $0.00 $0.00 $0.00 $6.40 $0.00 $0.00 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $14.52 $23.00 $23.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11627 ERX HCPCS J3370 00143-9359-01 VANCOMYCIN HCL 10 G IV SOLR BOTH IP/OP $680.55 $503.61 $0.00 $544.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.28 $539.00 $544.44 $0.00 $0.00 $79.67 $0.00 $0.00 $75.85 $0.00 $0.00 $0.00 $0.00 $0.00 11627 ERX HCPCS J3370 00409-6510-01 VANCOMYCIN HCL 10 G IV SOLR BOTH IP/OP $680.55 $503.61 $0.00 $544.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.28 $539.00 $544.44 $0.00 $0.00 $79.67 $0.00 $0.00 $75.85 $0.00 $0.00 $0.00 $0.00 $0.00 11627 ERX HCPCS J3370 25021-0158-99 VANCOMYCIN HCL 10 G IV SOLR BOTH IP/OP $680.55 $503.61 $0.00 $544.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.28 $539.00 $544.44 $0.00 $0.00 $79.67 $0.00 $0.00 $75.85 $0.00 $0.00 $0.00 $0.00 $0.00 11627 ERX HCPCS J3370 63323-0314-61 VANCOMYCIN HCL 10 G IV SOLR BOTH IP/OP $680.55 $503.61 $0.00 $544.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.28 $539.00 $544.44 $0.00 $0.00 $79.67 $0.00 $0.00 $75.85 $0.00 $0.00 $0.00 $0.00 $0.00 11627 ERX HCPCS J3370 67457-0342-10 VANCOMYCIN HCL 10 G IV SOLR BOTH IP/OP $680.55 $503.61 $0.00 $544.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.28 $539.00 $544.44 $0.00 $0.00 $79.67 $0.00 $0.00 $75.85 $0.00 $0.00 $0.00 $0.00 $0.00 11628 ERX HCPCS 63700001 47781-0729-02 VANCOMYCIN HCL 125 MG PO CAPS BOTH IP/OP $109.64 $81.13 $0.00 $87.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.82 $86.83 $87.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 00409-1632-01 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 00409-1632-21 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 00703-2914-01 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 00703-2914-03 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 47335-0931-40 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 47335-0931-44 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 63323-0781-10 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 67457-0438-00 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11634 ERX HCPCS 25000001 67457-0438-10 VECURONIUM BROMIDE 10 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11641 ERX HCPCS 25000001 61703-0418-18 VITAMIN A 15 MG/ML IM SOLN BOTH IP/OP $422.73 $312.82 $0.00 $338.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.37 $334.80 $338.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11664 ERX HCPCS 63700001 00832-1211-01 WARFARIN SODIUM 1 MG PO TABS BOTH IP/OP $28.16 $20.84 $0.00 $22.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.08 $22.30 $22.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11664 ERX HCPCS 63700001 00832-1211-89 WARFARIN SODIUM 1 MG PO TABS BOTH IP/OP $28.16 $20.84 $0.00 $22.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.08 $22.30 $22.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11691 ERX HCPCS J3485 49702-0213-26 ZIDOVUDINE 10 MG/ML IV SOLN BOTH IP/OP $135.18 $100.03 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $0.00 $100.33 $100.33 $104.20 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $61.29 $97.08 $98.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11692 ERX HCPCS 63700001 65862-0107-01 ZIDOVUDINE 100 MG PO CAPS BOTH IP/OP $8.46 $6.26 $0.00 $6.14 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $0.00 $1.76 $0.00 $0.00 $0.00 $0.00 $3.84 $6.08 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11700 ERX HCPCS 63700001 63739-0526-10 ZOLPIDEM TARTRATE 10 MG PO TABS BOTH IP/OP $19.47 $14.41 $0.00 $14.13 $0.00 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $8.83 $13.99 $14.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11701 ERX HCPCS 63700001 00904-6082-61 ZOLPIDEM TARTRATE 5 MG PO TABS BOTH IP/OP $17.56 $12.99 $0.00 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11701 ERX HCPCS 63700001 16714-0621-01 ZOLPIDEM TARTRATE 5 MG PO TABS BOTH IP/OP $17.56 $12.99 $0.00 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11701 ERX HCPCS 63700001 68084-0189-01 ZOLPIDEM TARTRATE 5 MG PO TABS BOTH IP/OP $17.56 $12.99 $0.00 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11701 ERX HCPCS 63700001 68084-0189-11 ZOLPIDEM TARTRATE 5 MG PO TABS BOTH IP/OP $17.56 $12.99 $0.00 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11930 ERX HCPCS 25000001 00065-0345-10 LODOXAMIDE TROMETHAMINE 0.1 % OP SOLN BOTH IP/OP $599.42 $443.57 $0.00 $462.03 $0.00 $0.00 $0.00 $0.00 $0.00 $444.89 $444.89 $462.03 $0.00 $124.92 $0.00 $0.00 $0.00 $0.00 $272.00 $430.85 $435.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11931 ERX HCPCS 90648 49281-0545-03 HAEMOPHILUS B POLYSAC CONJ VAC IM SOLR BOTH IP/OP $83.91 $62.09 $0.00 $64.68 $37.76 $37.76 $0.00 $0.00 $0.00 $17.49 $62.28 $62.28 $64.68 $0.00 $17.49 $0.00 $49.63 $49.63 $0.00 $35.74 $56.60 $57.18 $0.00 $0.00 $11.19 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $0.00 11934 ERX HCPCS 25000001 00168-0357-56 LIDOCAINE-PRILOCAINE 2.5-2.5 % EX KIT BOTH IP/OP $191.38 $141.62 $0.00 $147.52 $0.00 $0.00 $0.00 $0.00 $0.00 $142.04 $142.04 $147.52 $0.00 $39.88 $0.00 $0.00 $0.00 $0.00 $86.77 $137.44 $138.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12025 ERX HCPCS 63700001 50268-0523-15 MECLIZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12025 ERX HCPCS 63700001 68084-0491-01 MECLIZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12025 ERX HCPCS 63700001 68084-0491-11 MECLIZINE HCL 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12203 ERX HCPCS 63700001 16714-0311-01 VENLAFAXINE HCL 25 MG PO TABS BOTH IP/OP $7.39 $5.47 $0.00 $5.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.70 $5.85 $5.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12203 ERX HCPCS 63700001 50268-0798-15 VENLAFAXINE HCL 25 MG PO TABS BOTH IP/OP $7.39 $5.47 $0.00 $5.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.70 $5.85 $5.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12203 ERX HCPCS 63700001 68084-0896-25 VENLAFAXINE HCL 25 MG PO TABS BOTH IP/OP $7.39 $5.47 $0.00 $5.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.70 $5.85 $5.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12206 ERX HCPCS 63700001 16714-0314-01 VENLAFAXINE HCL 75 MG PO TABS BOTH IP/OP $8.31 $6.15 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $6.58 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12207 ERX HCPCS 63700001 16714-0656-01 VENLAFAXINE HCL 37.5 MG PO TABS BOTH IP/OP $8.38 $6.20 $0.00 $6.08 $0.00 $0.00 $0.00 $1.49 $0.00 $0.00 $0.00 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.80 $6.02 $6.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12207 ERX HCPCS 63700001 68084-0844-01 VENLAFAXINE HCL 37.5 MG PO TABS BOTH IP/OP $8.38 $6.20 $0.00 $6.08 $0.00 $0.00 $0.00 $1.49 $0.00 $0.00 $0.00 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.80 $6.02 $6.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12207 ERX HCPCS 63700001 68084-0844-11 VENLAFAXINE HCL 37.5 MG PO TABS BOTH IP/OP $8.38 $6.20 $0.00 $6.08 $0.00 $0.00 $0.00 $1.49 $0.00 $0.00 $0.00 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.80 $6.02 $6.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12211 ERX HCPCS J7639 50242-0100-39 DORNASE ALFA 1 MG/ML IN SOLN BOTH IP/OP $463.35 $342.88 $0.00 $357.15 $0.00 $0.00 $0.00 $0.00 $0.00 $343.90 $343.90 $357.15 $0.00 $96.56 $0.00 $0.00 $0.00 $0.00 $210.30 $333.12 $336.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12211 ERX HCPCS J7639 50242-0100-40 DORNASE ALFA 1 MG/ML IN SOLN BOTH IP/OP $463.35 $342.88 $0.00 $357.15 $0.00 $0.00 $0.00 $0.00 $0.00 $343.90 $343.90 $357.15 $0.00 $96.56 $0.00 $0.00 $0.00 $0.00 $210.30 $333.12 $336.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12244 ERX HCPCS 63700001 51672-4154-03 CALCIPOTRIENE 0.005 % EX OINT BOTH IP/OP "$1,118.31 " $827.55 $0.00 $811.92 $0.00 $0.00 $0.00 $199.06 $0.00 $0.00 $0.00 $0.00 $0.00 $233.06 $0.00 $0.00 $0.00 $0.00 $507.45 $803.80 $811.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12244 ERX HCPCS 63700001 51672-5278-03 CALCIPOTRIENE 0.005 % EX OINT BOTH IP/OP "$1,118.31 " $827.55 $0.00 $811.92 $0.00 $0.00 $0.00 $199.06 $0.00 $0.00 $0.00 $0.00 $0.00 $233.06 $0.00 $0.00 $0.00 $0.00 $507.45 $803.80 $811.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12370 ERX HCPCS 25000001 00143-9593-01 NICARDIPINE HCL 2.5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12370 ERX HCPCS 25000001 00143-9593-10 NICARDIPINE HCL 2.5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12370 ERX HCPCS 25000001 00143-9689-01 NICARDIPINE HCL 2.5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12370 ERX HCPCS 25000001 00143-9689-10 NICARDIPINE HCL 2.5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12370 ERX HCPCS 25000001 00517-0735-01 NICARDIPINE HCL 2.5 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12411 ERX HCPCS 63700001 00378-8020-93 FLUVASTATIN SODIUM 20 MG PO CAPS BOTH IP/OP $20.98 $15.53 $0.00 $15.22 $0.00 $0.00 $0.00 $3.73 $0.00 $0.00 $0.00 $0.00 $0.00 $4.37 $0.00 $0.00 $0.00 $0.00 $9.52 $15.07 $15.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12412 ERX HCPCS 63700001 00093-7443-01 FLUVASTATIN SODIUM 40 MG PO CAPS BOTH IP/OP $20.94 $15.50 $0.00 $15.19 $0.00 $0.00 $0.00 $3.73 $0.00 $0.00 $0.00 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $9.50 $15.04 $15.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12556 ERX HCPCS Q0163 49348-0045-34 DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD BOTH IP/OP $28.80 $21.31 $0.00 $22.20 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $22.20 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12556 ERX HCPCS Q0163 58602-0022-24 DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD BOTH IP/OP $28.80 $21.31 $0.00 $22.20 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $22.20 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12556 ERX HCPCS Q0163 49348-0045-37 DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD BOTH IP/OP $28.80 $21.31 $0.00 $22.20 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $22.20 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $5.50 $20.69 $8.80 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12556 ERX HCPCS Q0163 54838-0135-70 DIPHENHYDRAMINE HCL 12.5 MG/5ML PO LIQD BOTH IP/OP $28.80 $21.31 $0.00 $22.20 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $22.20 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $5.50 $20.69 $8.80 $0.00 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12580 ERX HCPCS 25000001 00487-9801-01 IPRATROPIUM BROMIDE 0.02 % IN SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12580 ERX HCPCS 25000001 00487-9801-25 IPRATROPIUM BROMIDE 0.02 % IN SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12580 ERX HCPCS 25000001 00781-7157-86 IPRATROPIUM BROMIDE 0.02 % IN SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12580 ERX HCPCS 25000001 76204-0100-01 IPRATROPIUM BROMIDE 0.02 % IN SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12580 ERX HCPCS 25000001 76204-0100-25 IPRATROPIUM BROMIDE 0.02 % IN SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12587 ERX HCPCS J2543 63323-0304-74 PIPERACILLIN SOD-TAZOBACTAM SO 40.5 (36-4.5) G IV SOLR BOTH IP/OP $591.77 $437.91 $0.00 $456.14 $321.33 $321.33 $0.00 $0.00 $0.00 $123.34 $439.21 $439.21 $456.14 $0.00 $123.32 $0.00 $350.03 $350.03 $0.00 $268.59 $425.44 $429.74 $0.00 $0.00 $84.07 $0.00 $0.00 $74.51 $0.00 $0.00 $0.00 $0.00 $0.00 12587 ERX HCPCS J2543 63323-0304-78 PIPERACILLIN SOD-TAZOBACTAM SO 40.5 (36-4.5) G IV SOLR BOTH IP/OP $591.77 $437.91 $0.00 $456.14 $321.33 $321.33 $0.00 $0.00 $0.00 $123.34 $439.21 $439.21 $456.14 $0.00 $123.32 $0.00 $350.03 $350.03 $0.00 $268.59 $425.44 $429.74 $0.00 $0.00 $84.07 $0.00 $0.00 $74.51 $0.00 $0.00 $0.00 $0.00 $0.00 12724 ERX HCPCS 63700001 16714-0501-01 TERBINAFINE HCL 250 MG PO TABS BOTH IP/OP $48.15 $35.63 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.08 $38.13 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12724 ERX HCPCS 63700001 16714-0501-02 TERBINAFINE HCL 250 MG PO TABS BOTH IP/OP $48.15 $35.63 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.08 $38.13 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12724 ERX HCPCS 63700001 16714-0795-02 TERBINAFINE HCL 250 MG PO TABS BOTH IP/OP $48.15 $35.63 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.08 $38.13 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12724 ERX HCPCS 63700001 51991-0526-01 TERBINAFINE HCL 250 MG PO TABS BOTH IP/OP $48.15 $35.63 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.08 $38.13 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12729 ERX HCPCS 63700001 00007-3650-22 TRIAMTERENE-HCTZ 37.5-25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12729 ERX HCPCS 63700001 00781-2074-10 TRIAMTERENE-HCTZ 37.5-25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12729 ERX HCPCS 63700001 51079-0935-01 TRIAMTERENE-HCTZ 37.5-25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12729 ERX HCPCS 63700001 51079-0935-20 TRIAMTERENE-HCTZ 37.5-25 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12803 ERX HCPCS 63700001 00527-1313-01 PILOCARPINE HCL 5 MG PO TABS BOTH IP/OP $7.61 $5.63 $0.00 $5.52 $0.00 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $3.45 $5.46 $5.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12885 ERX HCPCS 63700001 00781-6022-52 CLARITHROMYCIN 125 MG/5ML PO SUSR BOTH IP/OP $231.84 $171.56 $0.00 $185.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.92 $183.62 $185.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12886 ERX HCPCS 63700001 00781-6023-52 CLARITHROMYCIN 250 MG/5ML PO SUSR BOTH IP/OP $666.96 $493.55 $0.00 $484.34 $0.00 $0.00 $0.00 $118.72 $0.00 $0.00 $0.00 $0.00 $0.00 $138.99 $0.00 $0.00 $0.00 $0.00 $302.72 $258.83 $484.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12886 ERX HCPCS 63700001 00781-6023-46 CLARITHROMYCIN 250 MG/5ML PO SUSR BOTH IP/OP $666.96 $493.55 $0.00 $484.34 $0.00 $0.00 $0.00 $118.72 $0.00 $0.00 $0.00 $0.00 $0.00 $138.99 $0.00 $0.00 $0.00 $0.00 $302.72 $479.50 $484.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12933 ERX HCPCS J7507 00378-2046-01 TACROLIMUS 1 MG PO CAPS BOTH IP/OP $18.69 $13.83 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $8.48 $13.42 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 12933 ERX HCPCS J7507 00469-0617-73 TACROLIMUS 1 MG PO CAPS BOTH IP/OP $18.69 $13.83 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $8.48 $13.42 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 12933 ERX HCPCS J7507 00781-2103-01 TACROLIMUS 1 MG PO CAPS BOTH IP/OP $18.69 $13.83 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $8.48 $13.42 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 12933 ERX HCPCS J7507 16729-0042-01 TACROLIMUS 1 MG PO CAPS BOTH IP/OP $18.69 $13.83 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $8.48 $13.42 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 12933 ERX HCPCS J7507 55111-0526-01 TACROLIMUS 1 MG PO CAPS BOTH IP/OP $18.69 $13.83 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $8.48 $13.42 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 12933 ERX HCPCS J7507 68084-0450-01 TACROLIMUS 1 MG PO CAPS BOTH IP/OP $18.69 $13.83 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $8.48 $13.42 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 $2.70 $0.00 $0.00 $0.00 $0.00 $0.00 12934 ERX HCPCS J7507 16729-0043-01 TACROLIMUS 5 MG PO CAPS BOTH IP/OP $126.69 $93.75 $0.00 $101.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.35 $100.34 $101.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12934 ERX HCPCS J7507 55111-0527-01 TACROLIMUS 5 MG PO CAPS BOTH IP/OP $126.69 $93.75 $0.00 $101.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.35 $100.34 $101.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12934 ERX HCPCS J7507 69452-0155-20 TACROLIMUS 5 MG PO CAPS BOTH IP/OP $126.69 $93.75 $0.00 $101.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.35 $100.34 $101.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12935 ERX HCPCS J7525 00469-3016-01 TACROLIMUS 5 MG/ML IV SOLN BOTH IP/OP "$5,807.66 " "$4,297.67" $0.00 $612.52 $0.00 $0.00 $0.00 $0.00 $0.00 $589.79 $589.79 $612.52 $0.00 $156.38 $0.00 $0.00 $0.00 $0.00 $330.58 $523.64 $528.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13073 ERX HCPCS 63700001 68462-0260-01 VERAPAMIL HCL CR 240 MG PO TBCR BOTH IP/OP $9.62 $7.12 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.81 $7.62 $7.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13132 ERX HCPCS 63700001 16714-0697-01 VALACYCLOVIR HCL 1 G PO TABS BOTH IP/OP $52.97 $39.20 $0.00 $38.43 $0.00 $0.00 $0.00 $9.43 $0.00 $0.00 $0.00 $0.00 $0.00 $11.04 $0.00 $0.00 $0.00 $0.00 $24.02 $38.05 $38.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13132 ERX HCPCS 63700001 57237-0043-30 VALACYCLOVIR HCL 1 G PO TABS BOTH IP/OP $52.97 $39.20 $0.00 $38.43 $0.00 $0.00 $0.00 $9.43 $0.00 $0.00 $0.00 $0.00 $0.00 $11.04 $0.00 $0.00 $0.00 $0.00 $24.02 $38.05 $38.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13133 ERX HCPCS 63700001 00378-4275-77 VALACYCLOVIR HCL 500 MG PO TABS BOTH IP/OP $30.27 $22.40 $0.00 $21.97 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.73 $21.75 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13133 ERX HCPCS 63700001 00781-5208-92 VALACYCLOVIR HCL 500 MG PO TABS BOTH IP/OP $30.27 $22.40 $0.00 $21.97 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.73 $21.75 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13133 ERX HCPCS 63700001 16714-0698-03 VALACYCLOVIR HCL 500 MG PO TABS BOTH IP/OP $30.27 $22.40 $0.00 $21.97 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.73 $21.75 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13133 ERX HCPCS 63700001 57237-0042-90 VALACYCLOVIR HCL 500 MG PO TABS BOTH IP/OP $30.27 $22.40 $0.00 $21.97 $0.00 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $13.73 $21.75 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13178 ERX HCPCS 25000001 00019-1333-21 IOVERSOL 74 % IJ SOLN BOTH IP/OP $255.15 $188.81 $0.00 $204.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.58 $202.08 $204.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13178 ERX HCPCS 25000001 00019-1333-06 IOVERSOL 74 % IJ SOLN BOTH IP/OP $79.80 $59.05 $0.00 $204.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.58 $63.20 $204.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13184 ERX HCPCS 63700001 00378-2120-01 VERAPAMIL HCL ER 120 MG PO TBCR BOTH IP/OP $8.11 $6.00 $0.00 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13184 ERX HCPCS 63700001 68462-0292-01 VERAPAMIL HCL ER 120 MG PO TBCR BOTH IP/OP $8.11 $6.00 $0.00 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13309 ERX HCPCS 63700001 31722-0516-60 STAVUDINE 20 MG PO CAPS BOTH IP/OP $24.05 $17.80 $0.00 $19.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.03 $19.05 $19.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13309 ERX HCPCS 63700001 65862-0112-60 STAVUDINE 20 MG PO CAPS BOTH IP/OP $24.05 $17.80 $0.00 $19.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.03 $19.05 $19.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13310 ERX HCPCS 63700001 31722-0517-60 STAVUDINE 30 MG PO CAPS BOTH IP/OP $25.54 $18.90 $0.00 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.77 $20.23 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13310 ERX HCPCS 63700001 65862-0046-60 STAVUDINE 30 MG PO CAPS BOTH IP/OP $25.54 $18.90 $0.00 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.77 $20.23 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13311 ERX HCPCS 63700001 31722-0518-60 STAVUDINE 40 MG PO CAPS BOTH IP/OP $26.02 $19.25 $0.00 $20.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.01 $20.61 $20.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13311 ERX HCPCS 63700001 65862-0047-60 STAVUDINE 40 MG PO CAPS BOTH IP/OP $26.02 $19.25 $0.00 $20.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.01 $20.61 $20.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13369 ERX HCPCS 63700001 SUMATRIPTAN SUCCINATE 100 MG PO TABS BOTH IP/OP $97.05 $71.82 $0.00 $70.39 $0.00 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 $20.23 $0.00 $0.00 $0.00 $0.00 $44.00 $69.69 $70.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13369 ERX HCPCS 63700001 16714-0533-11 SUMATRIPTAN SUCCINATE 100 MG PO TABS BOTH IP/OP $97.05 $71.82 $0.00 $70.39 $0.00 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 $20.23 $0.00 $0.00 $0.00 $0.00 $44.00 $69.69 $70.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13369 ERX HCPCS 63700001 62756-0522-69 SUMATRIPTAN SUCCINATE 100 MG PO TABS BOTH IP/OP $97.05 $71.82 $0.00 $70.39 $0.00 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 $20.23 $0.00 $0.00 $0.00 $0.00 $44.00 $69.69 $70.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13369 ERX HCPCS 63700001 63304-0099-19 SUMATRIPTAN SUCCINATE 100 MG PO TABS BOTH IP/OP $97.05 $71.82 $0.00 $70.39 $0.00 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 $20.23 $0.00 $0.00 $0.00 $0.00 $44.00 $69.69 $70.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13393 ERX HCPCS 25000001 00338-0520-13 FAT EMULSION PLANT BASED 30 % IV EMUL BOTH IP/OP $204.75 $151.52 $0.00 $163.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.38 $162.16 $163.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13444 ERX HCPCS 63700001 00093-1024-06 NEFAZODONE HCL 100 MG PO TABS BOTH IP/OP $20.11 $14.88 $0.00 $14.59 $0.00 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $9.12 $14.45 $14.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13445 ERX HCPCS 63700001 00093-7113-06 NEFAZODONE HCL 150 MG PO TABS BOTH IP/OP $20.49 $15.16 $0.00 $14.87 $0.00 $0.00 $0.00 $3.65 $0.00 $0.00 $0.00 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $9.30 $14.72 $14.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 00049-3500-79 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 00172-5412-11 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 00172-5412-79 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 16714-0692-10 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 16714-0692-11 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 55111-0145-12 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 59762-5017-01 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13577 ERX HCPCS 63700001 68462-0103-40 FLUCONAZOLE 150 MG PO TABS BOTH IP/OP $56.96 $42.15 $0.00 $41.33 $0.00 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $0.00 $11.87 $0.00 $0.00 $0.00 $0.00 $25.83 $40.91 $41.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13654 ERX HCPCS 25000001 00904-6784-80 ASPIRIN EC 325 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13654 ERX HCPCS 25000001 57896-0921-10 ASPIRIN EC 325 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13654 ERX HCPCS 25000001 63739-0523-01 ASPIRIN EC 325 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13691 ERX HCPCS J1950 00074-3641-03 LEUPROLIDE ACETATE 3.75 MG IM KIT BOTH IP/OP "$4,022.42 " "$2,976.59" $0.00 "$3,252.41" "$1,898.78" "$1,898.78" "$1,366.01" "$1,366.01" "$1,366.01" $549.12 "$3,131.73" "$3,131.73" "$3,252.41" "$1,406.37" "$1,652.48" $914.14 "$1,983.05" "$1,983.05" "$1,332.69" "$1,717.82" "$2,721.03" "$2,748.51" "$1,840.38" "$1,840.38" "$1,493.54" $0.00 $0.00 "$1,422.11" "$1,244.34" $0.00 $0.00 $0.00 $0.00 13691 ERX HCPCS J1950 00074-3641-04 LEUPROLIDE ACETATE 3.75 MG IM KIT BOTH IP/OP "$4,022.42 " "$2,976.59" $0.00 "$3,252.41" "$1,898.78" "$1,898.78" "$1,366.01" "$1,366.01" "$1,366.01" $549.12 "$3,131.73" "$3,131.73" "$3,252.41" "$1,406.37" "$1,652.48" $914.14 "$1,983.05" "$1,983.05" "$1,332.69" "$1,717.82" "$2,721.03" "$2,748.51" "$1,840.38" "$1,840.38" "$1,493.54" $0.00 $0.00 "$1,422.11" "$1,244.34" $0.00 $0.00 $0.00 $0.00 13748 ERX HCPCS 63700001 49348-0135-34 GUAIFENESIN 100 MG/5ML PO LIQD BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13748 ERX HCPCS 63700001 61787-0063-04 GUAIFENESIN 100 MG/5ML PO LIQD BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13818 ERX HCPCS 25000001 54162-0017-09 BACITRACIN ZINC 500 UNIT/GM EX OINT BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13884 ERX HCPCS 63700001 59762-0450-01 COLESTIPOL HCL 1 G PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13979 ERX HCPCS 63700001 00093-1136-56 ACITRETIN 25 MG PO CAPS BOTH IP/OP $134.46 $99.50 $0.00 $107.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.23 $106.49 $107.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13979 ERX HCPCS 63700001 00145-0091-25 ACITRETIN 25 MG PO CAPS BOTH IP/OP $134.46 $99.50 $0.00 $107.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.23 $106.49 $107.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13979 ERX HCPCS 63700001 42291-0088-30 ACITRETIN 25 MG PO CAPS BOTH IP/OP $134.46 $99.50 $0.00 $107.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.23 $106.49 $107.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13979 ERX HCPCS 63700001 66993-0896-30 ACITRETIN 25 MG PO CAPS BOTH IP/OP $134.46 $99.50 $0.00 $107.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.23 $106.49 $107.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13980 ERX HCPCS 63700001 00115-1750-08 ACITRETIN 10 MG PO CAPS BOTH IP/OP $120.44 $89.13 $0.00 $87.37 $0.00 $0.00 $0.00 $21.44 $0.00 $0.00 $0.00 $0.00 $0.00 $25.10 $0.00 $0.00 $0.00 $0.00 $54.61 $86.49 $87.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13980 ERX HCPCS 63700001 42291-0086-30 ACITRETIN 10 MG PO CAPS BOTH IP/OP $120.44 $89.13 $0.00 $87.37 $0.00 $0.00 $0.00 $21.44 $0.00 $0.00 $0.00 $0.00 $0.00 $25.10 $0.00 $0.00 $0.00 $0.00 $54.61 $86.49 $87.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13981 ERX HCPCS 63700001 16714-0700-01 LAMOTRIGINE 25 MG PO TABS BOTH IP/OP $15.81 $11.70 $0.00 $12.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.91 $12.52 $12.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13981 ERX HCPCS 63700001 63739-0670-10 LAMOTRIGINE 25 MG PO TABS BOTH IP/OP $15.81 $11.70 $0.00 $12.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.91 $12.52 $12.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13981 ERX HCPCS 63700001 68084-0318-01 LAMOTRIGINE 25 MG PO TABS BOTH IP/OP $15.81 $11.70 $0.00 $12.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.91 $12.52 $12.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13982 ERX HCPCS 63700001 13668-0047-01 LAMOTRIGINE 100 MG PO TABS BOTH IP/OP $19.91 $14.73 $0.00 $14.44 $0.00 $0.00 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $0.00 $4.15 $0.00 $0.00 $0.00 $0.00 $9.03 $14.30 $14.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13982 ERX HCPCS 63700001 16714-0701-01 LAMOTRIGINE 100 MG PO TABS BOTH IP/OP $19.91 $14.73 $0.00 $14.44 $0.00 $0.00 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $0.00 $4.15 $0.00 $0.00 $0.00 $0.00 $9.03 $14.30 $14.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13982 ERX HCPCS 63700001 68084-0319-01 LAMOTRIGINE 100 MG PO TABS BOTH IP/OP $19.91 $14.73 $0.00 $14.44 $0.00 $0.00 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $0.00 $4.15 $0.00 $0.00 $0.00 $0.00 $9.03 $14.30 $14.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13983 ERX HCPCS 63700001 00173-0644-60 LAMOTRIGINE 200 MG PO TABS BOTH IP/OP $25.71 $19.03 $0.00 $18.66 $0.00 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 $5.36 $0.00 $0.00 $0.00 $0.00 $11.66 $18.47 $18.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13983 ERX HCPCS 63700001 16714-0703-01 LAMOTRIGINE 200 MG PO TABS BOTH IP/OP $25.71 $19.03 $0.00 $18.66 $0.00 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 $5.36 $0.00 $0.00 $0.00 $0.00 $11.66 $18.47 $18.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13983 ERX HCPCS 63700001 51672-4133-04 LAMOTRIGINE 200 MG PO TABS BOTH IP/OP $25.71 $19.03 $0.00 $18.66 $0.00 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 $5.36 $0.00 $0.00 $0.00 $0.00 $11.66 $18.47 $18.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13983 ERX HCPCS 63700001 68382-0010-14 LAMOTRIGINE 200 MG PO TABS BOTH IP/OP $25.71 $19.03 $0.00 $18.66 $0.00 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 $5.36 $0.00 $0.00 $0.00 $0.00 $11.66 $18.47 $18.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14087 ERX HCPCS 25000001 00093-0150-01 ACETAMINOPHEN-CODEINE #3 300-30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14087 ERX HCPCS 25000001 00406-0484-62 ACETAMINOPHEN-CODEINE #3 300-30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14087 ERX HCPCS 25000001 00603-2338-21 ACETAMINOPHEN-CODEINE #3 300-30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14087 ERX HCPCS 25000001 65162-0033-10 ACETAMINOPHEN-CODEINE #3 300-30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14087 ERX HCPCS 25000001 68084-0372-01 ACETAMINOPHEN-CODEINE #3 300-30 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14113 ERX HCPCS 63700001 10939-0441-44 ASPIRIN EC 81 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14113 ERX HCPCS 63700001 63739-0212-01 ASPIRIN EC 81 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14113 ERX HCPCS 63700001 63739-0522-01 ASPIRIN EC 81 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14113 ERX HCPCS 63700001 63739-0522-10 ASPIRIN EC 81 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14132 ERX HCPCS 63700001 45802-0465-64 KETOCONAZOLE 2 % EX SHAM BOTH IP/OP $97.44 $72.11 $0.00 $77.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.72 $77.17 $77.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14190 ERX HCPCS 25000001 00472-0339-56 HYDROCORTISONE-ALOE 1 % EX CREA BOTH IP/OP $14.55 $10.77 $0.00 $11.22 $0.00 $0.00 $0.00 $0.00 $0.00 $10.80 $10.80 $11.22 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $6.60 $10.45 $10.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14196 ERX HCPCS 63700001 00046-1107-11 CONJ ESTROG-MEDROXYPROGEST ACE 0.625-2.5 MG PO TABS BOTH IP/OP $40.16 $29.72 $0.00 $26.42 $0.00 $0.00 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $0.00 $8.37 $0.00 $0.00 $0.00 $0.00 $16.52 $26.16 $26.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14232 ERX HCPCS 63700001 16714-0695-01 FLUCONAZOLE 10 MG/ML PO SUSR BOTH IP/OP $133.35 $98.68 $0.00 $96.73 $0.00 $0.00 $0.00 $23.74 $0.00 $0.00 $0.00 $0.00 $0.00 $27.79 $0.00 $0.00 $0.00 $0.00 $60.46 $95.76 $96.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14232 ERX HCPCS 63700001 59762-5029-01 FLUCONAZOLE 10 MG/ML PO SUSR BOTH IP/OP $133.35 $98.68 $0.00 $96.73 $0.00 $0.00 $0.00 $23.74 $0.00 $0.00 $0.00 $0.00 $0.00 $27.79 $0.00 $0.00 $0.00 $0.00 $60.46 $95.76 $96.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14232 ERX HCPCS 63700001 99999-6004-82 FLUCONAZOLE 10 MG/ML PO SUSR BOTH IP/OP $133.35 $98.68 $0.00 $96.73 $0.00 $0.00 $0.00 $23.74 $0.00 $0.00 $0.00 $0.00 $0.00 $27.79 $0.00 $0.00 $0.00 $0.00 $60.46 $95.76 $96.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14233 ERX HCPCS 63700001 00049-3450-19 FLUCONAZOLE 40 MG/ML PO SUSR BOTH IP/OP $130.24 $96.38 $0.00 $93.01 $0.00 $0.00 $0.00 $23.18 $0.00 $0.00 $0.00 $0.00 $0.00 $27.14 $0.00 $0.00 $0.00 $0.00 $58.13 $92.08 $93.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14233 ERX HCPCS 63700001 00054-0003-85 FLUCONAZOLE 40 MG/ML PO SUSR BOTH IP/OP $130.24 $96.38 $0.00 $93.01 $0.00 $0.00 $0.00 $23.18 $0.00 $0.00 $0.00 $0.00 $0.00 $27.14 $0.00 $0.00 $0.00 $0.00 $58.13 $92.08 $93.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14233 ERX HCPCS 63700001 16714-0696-01 FLUCONAZOLE 40 MG/ML PO SUSR BOTH IP/OP $130.24 $96.38 $0.00 $93.01 $0.00 $0.00 $0.00 $23.18 $0.00 $0.00 $0.00 $0.00 $0.00 $27.14 $0.00 $0.00 $0.00 $0.00 $58.13 $92.08 $93.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14233 ERX HCPCS 63700001 59762-5030-01 FLUCONAZOLE 40 MG/ML PO SUSR BOTH IP/OP $130.24 $96.38 $0.00 $93.01 $0.00 $0.00 $0.00 $23.18 $0.00 $0.00 $0.00 $0.00 $0.00 $27.14 $0.00 $0.00 $0.00 $0.00 $58.13 $92.08 $93.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14266 ERX HCPCS 63700001 16714-0702-01 LAMOTRIGINE 150 MG PO TABS BOTH IP/OP $19.79 $14.64 $0.00 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $15.67 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14266 ERX HCPCS 63700001 29300-0113-16 LAMOTRIGINE 150 MG PO TABS BOTH IP/OP $19.79 $14.64 $0.00 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $15.67 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14266 ERX HCPCS 63700001 51672-4132-04 LAMOTRIGINE 150 MG PO TABS BOTH IP/OP $19.79 $14.64 $0.00 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $15.67 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14468 ERX HCPCS 25000001 99999-6007-11 ACETAMINOPHEN-CODEINE 120-12 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $35.95 $4.75 $57.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14468 ERX HCPCS 25000001 00121-0504-16 ACETAMINOPHEN-CODEINE 120-12 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $35.95 $56.94 $57.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14468 ERX HCPCS 25000001 50383-0079-16 ACETAMINOPHEN-CODEINE 120-12 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $57.52 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $35.95 $56.94 $57.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14471 ERX HCPCS 63700001 00006-3519-36 DORZOLAMIDE HCL 2 % OP SOLN BOTH IP/OP $216.03 $159.86 $0.00 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.02 $171.10 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14471 ERX HCPCS 63700001 24208-0485-10 DORZOLAMIDE HCL 2 % OP SOLN BOTH IP/OP $216.03 $159.86 $0.00 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.02 $171.10 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14471 ERX HCPCS 63700001 42571-0141-26 DORZOLAMIDE HCL 2 % OP SOLN BOTH IP/OP $216.03 $159.86 $0.00 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.02 $171.10 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14471 ERX HCPCS 63700001 50383-0232-10 DORZOLAMIDE HCL 2 % OP SOLN BOTH IP/OP $216.03 $159.86 $0.00 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.02 $171.10 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14471 ERX HCPCS 63700001 61314-0019-10 DORZOLAMIDE HCL 2 % OP SOLN BOTH IP/OP $216.03 $159.86 $0.00 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.02 $171.10 $172.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14553 ERX HCPCS 63700001 59746-0385-06 TERAZOSIN HCL 5 MG PO CAPS BOTH IP/OP $6.10 $4.51 $0.00 $4.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.05 $4.83 $4.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14626 ERX HCPCS 63700001 68462-0293-01 VERAPAMIL HCL ER 180 MG PO TBCR BOTH IP/OP $9.47 $7.01 $0.00 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.74 $7.50 $7.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14632 ERX HCPCS 63700001 00378-4151-01 TRAMADOL HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14632 ERX HCPCS 63700001 00378-4151-05 TRAMADOL HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14632 ERX HCPCS 63700001 00904-6365-61 TRAMADOL HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14632 ERX HCPCS 63700001 51079-0991-01 TRAMADOL HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14632 ERX HCPCS 63700001 51079-0991-20 TRAMADOL HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14632 ERX HCPCS 63700001 57664-0377-08 TRAMADOL HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14632 ERX HCPCS 63700001 65162-0627-10 TRAMADOL HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14632 ERX HCPCS 63700001 68084-0808-01 TRAMADOL HCL 50 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14633 ERX HCPCS J9214 00085-1168-01 INTERFERON ALFA-2B 6000000 UNIT/ML IJ SOLN BOTH IP/OP "$2,050.80 " "$1,517.59" $0.00 "$1,640.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,025.40" "$1,624.23" "$1,640.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14643 ERX HCPCS J0885 59676-0320-04 EPOETIN ALFA 20000 UNIT/ML IJ SOLN BOTH IP/OP "$1,661.23 " "$1,229.31" $0.00 "$1,231.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.20 $0.00 $0.00 $0.00 $0.00 $769.68 "$1,219.17" "$1,231.49" $0.00 $0.00 $240.91 $0.00 $0.00 $237.19 $0.00 $0.00 $0.00 $0.00 $0.00 14678 ERX HCPCS 25000001 49281-0790-51 TYPHOID VI POLYSACCHARIDE VACC 25 MCG/0.5ML IM SOLN BOTH IP/OP $469.20 $347.21 $0.00 $361.66 $0.00 $0.00 $0.00 $0.00 $0.00 $348.24 $348.24 $361.66 $0.00 $97.78 $0.00 $0.00 $0.00 $0.00 $192.80 $305.39 $308.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14719 ERX HCPCS 63700001 23155-0103-05 METFORMIN HCL 850 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14719 ERX HCPCS 63700001 57664-0435-51 METFORMIN HCL 850 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14719 ERX HCPCS 63700001 60687-0143-01 METFORMIN HCL 850 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14719 ERX HCPCS 63700001 60687-0143-11 METFORMIN HCL 850 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14719 ERX HCPCS 63700001 63739-0702-10 METFORMIN HCL 850 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14792 ERX HCPCS 63700001 00185-0034-51 TIZANIDINE HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14792 ERX HCPCS 63700001 42291-0808-15 TIZANIDINE HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14792 ERX HCPCS 63700001 55111-0179-15 TIZANIDINE HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14792 ERX HCPCS 63700001 57664-0502-89 TIZANIDINE HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14792 ERX HCPCS 63700001 60505-0251-03 TIZANIDINE HCL 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14793 ERX HCPCS 63700001 00185-4400-51 TIZANIDINE HCL 4 MG PO TABS BOTH IP/OP $9.69 $7.17 $0.00 $7.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.85 $7.67 $7.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14793 ERX HCPCS 63700001 55111-0180-15 TIZANIDINE HCL 4 MG PO TABS BOTH IP/OP $9.69 $7.17 $0.00 $7.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.85 $7.67 $7.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14793 ERX HCPCS 63700001 60505-0252-03 TIZANIDINE HCL 4 MG PO TABS BOTH IP/OP $9.69 $7.17 $0.00 $7.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.85 $7.67 $7.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14820 ERX HCPCS 63700001 55111-0338-01 AMLODIPINE-BENAZEPRIL HCL 2.5-10 MG PO CAPS BOTH IP/OP $11.13 $8.24 $0.00 $8.07 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $0.00 $2.32 $0.00 $0.00 $0.00 $0.00 $5.05 $7.99 $8.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14820 ERX HCPCS 63700001 65862-0582-01 AMLODIPINE-BENAZEPRIL HCL 2.5-10 MG PO CAPS BOTH IP/OP $11.13 $8.24 $0.00 $8.07 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $0.00 $2.32 $0.00 $0.00 $0.00 $0.00 $5.05 $7.99 $8.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14821 ERX HCPCS 63700001 55111-0339-01 AMLODIPINE-BENAZEPRIL HCL 5-10 MG PO CAPS BOTH IP/OP $11.35 $8.40 $0.00 $8.23 $0.00 $0.00 $0.00 $2.02 $0.00 $0.00 $0.00 $0.00 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $5.15 $8.15 $8.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14822 ERX HCPCS 63700001 55111-0340-01 AMLODIPINE-BENAZEPRIL HCL 5-20 MG PO CAPS BOTH IP/OP $11.98 $8.87 $0.00 $8.70 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $0.00 $0.00 $5.44 $8.61 $8.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14822 ERX HCPCS 63700001 57237-0144-01 AMLODIPINE-BENAZEPRIL HCL 5-20 MG PO CAPS BOTH IP/OP $11.98 $8.87 $0.00 $8.70 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.50 $0.00 $0.00 $0.00 $0.00 $5.44 $8.61 $8.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14823 ERX HCPCS 63700001 31722-0700-90 LOSARTAN POTASSIUM 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14823 ERX HCPCS 63700001 63739-0673-10 LOSARTAN POTASSIUM 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14823 ERX HCPCS 63700001 68084-0346-01 LOSARTAN POTASSIUM 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14823 ERX HCPCS 63700001 68180-0376-09 LOSARTAN POTASSIUM 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 00006-0952-31 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 31722-0701-30 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 31722-0701-90 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 50268-0517-11 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 50268-0517-15 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 65862-0202-30 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 65862-0202-90 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 68084-0347-01 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14824 ERX HCPCS 63700001 68180-0377-09 LOSARTAN POTASSIUM 50 MG PO TABS BOTH IP/OP $9.43 $6.98 $0.00 $6.84 $0.00 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14825 ERX HCPCS 63700001 00456-4300-01 FOSFOMYCIN TROMETHAMINE 3 G PO PACK BOTH IP/OP $367.99 $272.31 $0.00 $267.23 $0.00 $0.00 $0.00 $65.50 $0.00 $0.00 $0.00 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $167.02 $264.56 $267.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14845 ERX HCPCS J1265 00338-1007-03 DOPAMINE IN D5W 1.6-5 MG/ML-% IV SOLN BOTH IP/OP $84.92 $62.84 $0.00 $65.46 $0.00 $0.00 $0.00 $0.00 $0.00 $63.03 $63.03 $65.46 $0.00 $17.70 $0.00 $0.00 $0.00 $0.00 $37.63 $59.60 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14845 ERX HCPCS J1265 00409-7809-24 DOPAMINE IN D5W 1.6-5 MG/ML-% IV SOLN BOTH IP/OP $84.92 $62.84 $0.00 $65.46 $0.00 $0.00 $0.00 $0.00 $0.00 $63.03 $63.03 $65.46 $0.00 $17.70 $0.00 $0.00 $0.00 $0.00 $37.63 $59.60 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14868 ERX HCPCS J2001 00264-9594-20 LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN BOTH IP/OP $28.29 $20.93 $0.00 $21.81 $0.00 $0.00 $0.00 $0.00 $0.00 $21.00 $21.00 $21.81 $0.00 $3.06 $0.00 $0.00 $0.00 $0.00 $12.83 $20.31 $20.52 $0.00 $0.00 $3.53 $0.00 $0.00 $3.36 $0.00 $0.00 $0.00 $0.00 $0.00 14923 ERX HCPCS 25000001 00409-1966-07 SODIUM CHLORIDE BACTERIOSTATIC 0.9 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14952 ERX HCPCS 63700001 80681-0104-00 CO-ENZYME Q-10 30 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14953 ERX HCPCS 63700001 00173-0547-00 ATOVAQUONE 750 MG/5ML PO SUSP BOTH IP/OP $140.89 $104.26 $0.00 $102.20 $0.00 $0.00 $0.00 $25.08 $0.00 $0.00 $0.00 $0.00 $0.00 $29.36 $0.00 $0.00 $0.00 $0.00 $63.88 $101.18 $102.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14953 ERX HCPCS 63700001 16714-0900-01 ATOVAQUONE 750 MG/5ML PO SUSP BOTH IP/OP $140.89 $104.26 $0.00 $102.20 $0.00 $0.00 $0.00 $25.08 $0.00 $0.00 $0.00 $0.00 $0.00 $29.36 $0.00 $0.00 $0.00 $0.00 $63.88 $101.18 $102.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14953 ERX HCPCS 63700001 31722-0629-21 ATOVAQUONE 750 MG/5ML PO SUSP BOTH IP/OP $140.89 $104.26 $0.00 $102.20 $0.00 $0.00 $0.00 $25.08 $0.00 $0.00 $0.00 $0.00 $0.00 $29.36 $0.00 $0.00 $0.00 $0.00 $63.88 $101.18 $102.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14953 ERX HCPCS 63700001 66993-0062-72 ATOVAQUONE 750 MG/5ML PO SUSP BOTH IP/OP $140.89 $104.26 $0.00 $102.20 $0.00 $0.00 $0.00 $25.08 $0.00 $0.00 $0.00 $0.00 $0.00 $29.36 $0.00 $0.00 $0.00 $0.00 $63.88 $101.18 $102.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14953 ERX HCPCS 63700001 68180-0282-01 ATOVAQUONE 750 MG/5ML PO SUSP BOTH IP/OP $140.89 $104.26 $0.00 $102.20 $0.00 $0.00 $0.00 $25.08 $0.00 $0.00 $0.00 $0.00 $0.00 $29.36 $0.00 $0.00 $0.00 $0.00 $63.88 $101.18 $102.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14953 ERX HCPCS 63700001 99999-6008-29 ATOVAQUONE 750 MG/5ML PO SUSP BOTH IP/OP $140.89 $104.26 $0.00 $102.20 $0.00 $0.00 $0.00 $25.08 $0.00 $0.00 $0.00 $0.00 $0.00 $29.36 $0.00 $0.00 $0.00 $0.00 $63.88 $101.18 $102.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14958 ERX HCPCS 63700001 00006-0717-31 LOSARTAN-HCTZ 50-12.5 MG PO TABS BOTH IP/OP $10.43 $7.72 $0.00 $7.57 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.73 $7.49 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14958 ERX HCPCS 63700001 00006-0717-54 LOSARTAN-HCTZ 50-12.5 MG PO TABS BOTH IP/OP $10.43 $7.72 $0.00 $7.57 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.73 $7.49 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14958 ERX HCPCS 63700001 00093-7367-98 LOSARTAN-HCTZ 50-12.5 MG PO TABS BOTH IP/OP $10.43 $7.72 $0.00 $7.57 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.73 $7.49 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14958 ERX HCPCS 63700001 16714-0226-01 LOSARTAN-HCTZ 50-12.5 MG PO TABS BOTH IP/OP $10.43 $7.72 $0.00 $7.57 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.73 $7.49 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14958 ERX HCPCS 63700001 16714-0226-02 LOSARTAN-HCTZ 50-12.5 MG PO TABS BOTH IP/OP $10.43 $7.72 $0.00 $7.57 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.73 $7.49 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14958 ERX HCPCS 63700001 62332-0048-90 LOSARTAN-HCTZ 50-12.5 MG PO TABS BOTH IP/OP $10.43 $7.72 $0.00 $7.57 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.73 $7.49 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14958 ERX HCPCS 63700001 65862-0468-90 LOSARTAN-HCTZ 50-12.5 MG PO TABS BOTH IP/OP $10.43 $7.72 $0.00 $7.57 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.73 $7.49 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14958 ERX HCPCS 63700001 68180-0215-09 LOSARTAN-HCTZ 50-12.5 MG PO TABS BOTH IP/OP $10.43 $7.72 $0.00 $7.57 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $0.00 $2.17 $0.00 $0.00 $0.00 $0.00 $4.73 $7.49 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14979 ERX HCPCS 25000001 00409-3977-03 BACTERIOSTATIC WATER(BENZ ALC) IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15113 ERX HCPCS J7517 00093-7334-01 MYCOPHENOLATE MOFETIL 250 MG PO CAPS BOTH IP/OP $16.63 $12.31 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $12.34 $12.34 $12.82 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $7.54 $11.94 $12.06 $0.00 $0.00 $2.36 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 15113 ERX HCPCS J7517 00093-7334-05 MYCOPHENOLATE MOFETIL 250 MG PO CAPS BOTH IP/OP $16.63 $12.31 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $12.34 $12.34 $12.82 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $7.54 $11.94 $12.06 $0.00 $0.00 $2.36 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 15113 ERX HCPCS J7517 51079-0721-20 MYCOPHENOLATE MOFETIL 250 MG PO CAPS BOTH IP/OP $16.63 $12.31 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $12.34 $12.34 $12.82 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $7.54 $11.94 $12.06 $0.00 $0.00 $2.36 $0.00 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 15119 ERX HCPCS 25000001 00074-4456-04 SEVOFLURANE IN SOLN BOTH IP/OP $658.46 $487.26 $0.00 $507.54 $0.00 $0.00 $0.00 $0.00 $0.00 $488.71 $488.71 $507.54 $0.00 $137.22 $0.00 $0.00 $0.00 $0.00 $298.79 $473.28 $478.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15168 ERX HCPCS 63700001 99999-6009-06 SENNOSIDES 8.8 MG/5ML PO SYRP BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15168 ERX HCPCS 63700001 54162-0007-08 SENNOSIDES 8.8 MG/5ML PO SYRP BOTH IP/OP $11.00 $8.14 $0.00 $38.36 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $38.36 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15235 ERX HCPCS J1642 64253-0333-35 HEPARIN SODIUM LOCK FLUSH 100 UNIT/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $18.80 $9.90 $9.90 $0.00 $0.00 $0.00 $5.29 $16.33 $16.33 $16.96 $0.00 $0.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $18.80 $0.00 $0.00 $17.90 $0.00 $0.00 $0.00 $0.00 $0.00 15255 ERX HCPCS 25000001 10956-0618-01 PYRANTEL PAMOATE 144 (50 BASE) MG/ML PO SUSP BOTH IP/OP $32.44 $24.01 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.08 $24.08 $25.00 $0.00 $6.76 $0.00 $0.00 $0.00 $0.00 $13.91 $22.03 $22.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15327 ERX HCPCS 63700001 16714-0531-11 SUMATRIPTAN SUCCINATE 25 MG PO TABS BOTH IP/OP $104.43 $77.28 $0.00 $75.75 $0.00 $0.00 $0.00 $18.59 $0.00 $0.00 $0.00 $0.00 $0.00 $21.76 $0.00 $0.00 $0.00 $0.00 $47.35 $74.99 $75.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15327 ERX HCPCS 63700001 55111-0291-09 SUMATRIPTAN SUCCINATE 25 MG PO TABS BOTH IP/OP $104.43 $77.28 $0.00 $75.75 $0.00 $0.00 $0.00 $18.59 $0.00 $0.00 $0.00 $0.00 $0.00 $21.76 $0.00 $0.00 $0.00 $0.00 $47.35 $74.99 $75.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15328 ERX HCPCS 63700001 00378-5631-59 SUMATRIPTAN SUCCINATE 50 MG PO TABS BOTH IP/OP $87.99 $65.11 $0.00 $70.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.00 $69.69 $70.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15328 ERX HCPCS 63700001 16714-0532-11 SUMATRIPTAN SUCCINATE 50 MG PO TABS BOTH IP/OP $87.99 $65.11 $0.00 $70.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.00 $69.69 $70.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15330 ERX HCPCS J0153 00409-1932-02 ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN BOTH IP/OP $514.69 $380.87 $0.00 $396.72 $231.61 $231.61 $0.00 $0.00 $0.00 $107.27 $382.00 $382.00 $396.72 $0.00 $55.73 $0.00 $304.44 $304.44 $0.00 $233.60 $370.02 $373.76 $0.00 $0.00 $65.57 $0.00 $0.00 $62.43 $0.00 $0.00 $0.00 $0.00 $0.00 15330 ERX HCPCS J0153 00703-8777-01 ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN BOTH IP/OP $514.69 $380.87 $0.00 $396.72 $231.61 $231.61 $0.00 $0.00 $0.00 $107.27 $382.00 $382.00 $396.72 $0.00 $55.73 $0.00 $304.44 $304.44 $0.00 $233.60 $370.02 $373.76 $0.00 $0.00 $65.57 $0.00 $0.00 $62.43 $0.00 $0.00 $0.00 $0.00 $0.00 15330 ERX HCPCS J0153 55150-0193-30 ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN BOTH IP/OP $514.69 $380.87 $0.00 $396.72 $231.61 $231.61 $0.00 $0.00 $0.00 $107.27 $382.00 $382.00 $396.72 $0.00 $55.73 $0.00 $304.44 $304.44 $0.00 $233.60 $370.02 $373.76 $0.00 $0.00 $65.57 $0.00 $0.00 $62.43 $0.00 $0.00 $0.00 $0.00 $0.00 15330 ERX HCPCS J0153 67457-0857-30 ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN BOTH IP/OP $514.69 $380.87 $0.00 $396.72 $231.61 $231.61 $0.00 $0.00 $0.00 $107.27 $382.00 $382.00 $396.72 $0.00 $55.73 $0.00 $304.44 $304.44 $0.00 $233.60 $370.02 $373.76 $0.00 $0.00 $65.57 $0.00 $0.00 $62.43 $0.00 $0.00 $0.00 $0.00 $0.00 15340 ERX HCPCS 63700001 00228-2550-11 DICLOFENAC SODIUM 50 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15340 ERX HCPCS 63700001 61442-0102-01 DICLOFENAC SODIUM 50 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15341 ERX HCPCS 63700001 00228-2551-06 DICLOFENAC SODIUM 75 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15341 ERX HCPCS 63700001 00228-2551-11 DICLOFENAC SODIUM 75 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15341 ERX HCPCS 63700001 68084-0333-01 DICLOFENAC SODIUM 75 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15341 ERX HCPCS 63700001 68084-0333-11 DICLOFENAC SODIUM 75 MG PO TBEC BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15349 ERX HCPCS 63700001 00378-3635-01 CETIRIZINE HCL 5 MG PO TABS BOTH IP/OP $9.49 $7.02 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15349 ERX HCPCS 63700001 16571-0401-10 CETIRIZINE HCL 5 MG PO TABS BOTH IP/OP $9.49 $7.02 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15349 ERX HCPCS 63700001 60505-2632-01 CETIRIZINE HCL 5 MG PO TABS BOTH IP/OP $9.49 $7.02 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15372 ERX HCPCS 63700001 00225-0525-47 AYR SALINE NASAL NA GEL BOTH IP/OP $12.88 $9.53 $0.00 $9.35 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $0.00 $2.68 $0.00 $0.00 $0.00 $0.00 $5.85 $9.26 $9.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15661 ERX HCPCS 63700001 16714-0631-01 ALENDRONATE SODIUM 10 MG PO TABS BOTH IP/OP $12.25 $9.07 $0.00 $8.89 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $5.56 $8.80 $8.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15661 ERX HCPCS 63700001 16714-0631-02 ALENDRONATE SODIUM 10 MG PO TABS BOTH IP/OP $12.25 $9.07 $0.00 $8.89 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $5.56 $8.80 $8.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15661 ERX HCPCS 63700001 64980-0340-01 ALENDRONATE SODIUM 10 MG PO TABS BOTH IP/OP $12.25 $9.07 $0.00 $8.89 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $5.56 $8.80 $8.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15738 ERX HCPCS 63700001 60505-0823-06 CALCITONIN (SALMON) 200 UNIT/ACT NA SOLN BOTH IP/OP $398.30 $294.74 $0.00 $764.43 $0.00 $0.00 $0.00 $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $83.01 $0.00 $0.00 $0.00 $0.00 $477.77 $756.79 $764.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15746 ERX HCPCS 63700001 16714-0816-01 BICALUTAMIDE 50 MG PO TABS BOTH IP/OP $80.79 $59.78 $0.00 $64.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.40 $63.99 $64.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15746 ERX HCPCS 63700001 16714-0816-02 BICALUTAMIDE 50 MG PO TABS BOTH IP/OP $80.79 $59.78 $0.00 $64.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.40 $63.99 $64.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15746 ERX HCPCS 63700001 60429-0177-01 BICALUTAMIDE 50 MG PO TABS BOTH IP/OP $80.79 $59.78 $0.00 $64.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.40 $63.99 $64.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15747 ERX HCPCS 63700001 00378-3632-01 CARVEDILOL 6.25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15747 ERX HCPCS 63700001 00904-6301-61 CARVEDILOL 6.25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15747 ERX HCPCS 63700001 51079-0930-01 CARVEDILOL 6.25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15747 ERX HCPCS 63700001 51079-0930-20 CARVEDILOL 6.25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15747 ERX HCPCS 63700001 68084-0854-01 CARVEDILOL 6.25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15748 ERX HCPCS 63700001 00093-7296-01 CARVEDILOL 25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15748 ERX HCPCS 63700001 00378-3634-01 CARVEDILOL 25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15748 ERX HCPCS 63700001 00904-6303-61 CARVEDILOL 25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15748 ERX HCPCS 63700001 51079-0932-01 CARVEDILOL 25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15748 ERX HCPCS 63700001 51079-0932-20 CARVEDILOL 25 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15749 ERX HCPCS 63700001 00093-7295-01 CARVEDILOL 12.5 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15749 ERX HCPCS 63700001 00781-5223-01 CARVEDILOL 12.5 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15749 ERX HCPCS 63700001 00904-6302-61 CARVEDILOL 12.5 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15749 ERX HCPCS 63700001 51079-0931-01 CARVEDILOL 12.5 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15749 ERX HCPCS 63700001 51079-0931-20 CARVEDILOL 12.5 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15749 ERX HCPCS 63700001 68382-0094-01 CARVEDILOL 12.5 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15796 ERX HCPCS 63700001 00069-3110-19 AZITHROMYCIN 100 MG/5ML PO SUSR BOTH IP/OP $122.98 $91.01 $0.00 $87.91 $0.00 $0.00 $0.00 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $54.95 $87.03 $87.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15796 ERX HCPCS 63700001 59762-3110-01 AZITHROMYCIN 100 MG/5ML PO SUSR BOTH IP/OP $122.98 $91.01 $0.00 $87.91 $0.00 $0.00 $0.00 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $54.95 $87.03 $87.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15797 ERX HCPCS 63700001 00093-2026-23 AZITHROMYCIN 200 MG/5ML PO SUSR BOTH IP/OP $134.62 $99.62 $0.00 $97.66 $0.00 $0.00 $0.00 $23.96 $0.00 $0.00 $0.00 $0.00 $0.00 $28.05 $0.00 $0.00 $0.00 $0.00 $61.04 $96.68 $97.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15797 ERX HCPCS 63700001 59762-3120-01 AZITHROMYCIN 200 MG/5ML PO SUSR BOTH IP/OP $134.62 $99.62 $0.00 $97.66 $0.00 $0.00 $0.00 $23.96 $0.00 $0.00 $0.00 $0.00 $0.00 $28.05 $0.00 $0.00 $0.00 $0.00 $61.04 $96.68 $97.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15797 ERX HCPCS 63700001 59762-3140-01 AZITHROMYCIN 200 MG/5ML PO SUSR BOTH IP/OP $134.62 $99.62 $0.00 $97.66 $0.00 $0.00 $0.00 $23.96 $0.00 $0.00 $0.00 $0.00 $0.00 $28.05 $0.00 $0.00 $0.00 $0.00 $61.04 $96.72 $97.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15816 ERX HCPCS 63700001 00121-1276-00 GUAIFENESIN-DM 100-10 MG/5ML PO SYRP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15852 ERX HCPCS J2274 00409-3815-12 MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $33.92 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15852 ERX HCPCS J2274 00641-6019-01 MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $33.92 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15852 ERX HCPCS J2274 00641-6019-10 MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $33.92 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15852 ERX HCPCS J2274 99999-6012-28 MORPHINE SULFATE (PF) 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $33.92 $0.00 $0.00 $0.00 $0.00 $0.00 $32.66 $32.66 $33.92 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15859 ERX HCPCS 25000001 00338-1049-02 NITROGLYCERIN IN D5W 200-5 MCG/ML-% IV SOLN BOTH IP/OP $95.54 $70.70 $0.00 $73.64 $0.00 $0.00 $0.00 $0.00 $0.00 $70.91 $70.91 $73.64 $0.00 $19.91 $0.00 $0.00 $0.00 $0.00 $14.73 $23.32 $23.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15861 ERX HCPCS J7042 00338-0085-03 DEXTROSE-NACL 5-0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.73 $18.66 $18.66 $19.38 $0.00 $2.53 $0.00 $14.87 $14.87 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15861 ERX HCPCS J7042 00409-7926-03 DEXTROSE-NACL 5-0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.73 $18.66 $18.66 $19.38 $0.00 $2.53 $0.00 $14.87 $14.87 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15861 ERX HCPCS J7042 00264-7612-00 DEXTROSE-NACL 5-0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.73 $18.66 $18.66 $19.38 $0.00 $2.53 $0.00 $14.87 $14.87 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15861 ERX HCPCS J7042 00338-0085-04 DEXTROSE-NACL 5-0.45 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.73 $18.66 $18.66 $19.38 $0.00 $2.53 $0.00 $14.87 $14.87 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15863 ERX HCPCS J7042 00338-0077-03 DEXTROSE-NACL 5-0.2 % IV SOLN BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $0.73 $21.77 $21.77 $22.61 $0.00 $2.53 $0.00 $17.35 $17.35 $0.00 $11.40 $17.42 $18.24 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15863 ERX HCPCS J7042 00264-7616-00 DEXTROSE-NACL 5-0.2 % IV SOLN BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $0.73 $21.77 $21.77 $22.61 $0.00 $2.53 $0.00 $17.35 $17.35 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15863 ERX HCPCS J7042 00338-0077-04 DEXTROSE-NACL 5-0.2 % IV SOLN BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $0.73 $21.77 $21.77 $22.61 $0.00 $2.53 $0.00 $17.35 $17.35 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15865 ERX HCPCS J7042 00264-7623-20 DEXTROSE-NACL 10-0.2 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.36 $16.33 $16.33 $16.96 $0.00 $1.27 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.09 $0.00 $0.00 $1.04 $0.00 $0.00 $0.00 $0.00 $0.00 15880 ERX HCPCS 63700001 50742-0623-60 LAMIVUDINE 150 MG PO TABS BOTH IP/OP $29.98 $22.19 $0.00 $21.75 $0.00 $0.00 $0.00 $5.34 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $13.60 $21.53 $21.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15880 ERX HCPCS 63700001 60505-3251-06 LAMIVUDINE 150 MG PO TABS BOTH IP/OP $29.98 $22.19 $0.00 $21.75 $0.00 $0.00 $0.00 $5.34 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $13.60 $21.53 $21.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15880 ERX HCPCS 63700001 64380-0710-03 LAMIVUDINE 150 MG PO TABS BOTH IP/OP $29.98 $22.19 $0.00 $21.75 $0.00 $0.00 $0.00 $5.34 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $13.60 $21.53 $21.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15880 ERX HCPCS 63700001 65862-0025-60 LAMIVUDINE 150 MG PO TABS BOTH IP/OP $29.98 $22.19 $0.00 $21.75 $0.00 $0.00 $0.00 $5.34 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $13.60 $21.53 $21.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15881 ERX HCPCS 63700001 99999-6010-41 LAMIVUDINE 10 MG/ML PO SOLN BOTH IP/OP $62.73 $46.42 $0.00 $153.93 $0.00 $0.00 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $0.00 $13.07 $0.00 $0.00 $0.00 $0.00 $96.21 $45.06 $153.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15881 ERX HCPCS 63700001 99999-6004-86 LAMIVUDINE 10 MG/ML PO SOLN BOTH IP/OP $62.73 $46.42 $0.00 $153.93 $0.00 $0.00 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $0.00 $13.07 $0.00 $0.00 $0.00 $0.00 $96.21 $152.39 $153.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15881 ERX HCPCS 63700001 49702-0205-48 LAMIVUDINE 10 MG/ML PO SOLN BOTH IP/OP $62.73 $46.42 $0.00 $321.18 $0.00 $0.00 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $0.00 $13.07 $0.00 $0.00 $0.00 $0.00 $96.21 $321.18 $153.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15881 ERX HCPCS 63700001 54838-0566-70 LAMIVUDINE 10 MG/ML PO SOLN BOTH IP/OP $62.73 $46.42 $0.00 $321.18 $0.00 $0.00 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $0.00 $13.07 $0.00 $0.00 $0.00 $0.00 $96.21 $321.18 $153.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15882 ERX HCPCS J7042 00338-0089-04 DEXTROSE-NACL 5-0.9 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.73 $18.66 $18.66 $19.38 $0.00 $2.53 $0.00 $14.87 $14.87 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15882 ERX HCPCS J7042 00338-0089-03 DEXTROSE-NACL 5-0.9 % IV SOLN BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.73 $18.66 $18.66 $19.38 $0.00 $2.53 $0.00 $14.87 $14.87 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 15898 ERX HCPCS J1325 66215-0402-01 EPOPROSTENOL SODIUM 1.5 MG IV SOLR BOTH IP/OP $195.05 $144.34 $0.00 $150.34 $0.00 $0.00 $0.00 $0.00 $0.00 $144.77 $144.77 $150.34 $0.00 $40.65 $0.00 $0.00 $0.00 $0.00 $88.54 $140.24 $141.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15906 ERX HCPCS J1580 00338-0503-48 GENTAMICIN IN SALINE 0.8-0.9 MG/ML-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.02 $16.33 $16.33 $16.96 $0.00 $1.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 15908 ERX HCPCS J1580 00338-0505-48 GENTAMICIN IN SALINE 1-0.9 MG/ML-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.02 $16.33 $16.33 $16.96 $0.00 $1.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 15911 ERX HCPCS J1580 00338-0509-41 GENTAMICIN IN SALINE 1.6-0.9 MG/ML-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.02 $16.33 $16.33 $16.96 $0.00 $1.97 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 16005 ERX HCPCS 63700001 00555-0808-02 TRETINOIN 10 MG PO CAPS BOTH IP/OP $627.52 $464.36 $0.00 $455.70 $0.00 $0.00 $0.00 $111.70 $0.00 $0.00 $0.00 $0.00 $0.00 $130.78 $0.00 $0.00 $0.00 $0.00 $284.81 $451.14 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16005 ERX HCPCS 63700001 10370-0268-01 TRETINOIN 10 MG PO CAPS BOTH IP/OP $627.52 $464.36 $0.00 $455.70 $0.00 $0.00 $0.00 $111.70 $0.00 $0.00 $0.00 $0.00 $0.00 $130.78 $0.00 $0.00 $0.00 $0.00 $284.81 $451.14 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16005 ERX HCPCS 63700001 68084-0075-21 TRETINOIN 10 MG PO CAPS BOTH IP/OP $627.52 $464.36 $0.00 $455.70 $0.00 $0.00 $0.00 $111.70 $0.00 $0.00 $0.00 $0.00 $0.00 $130.78 $0.00 $0.00 $0.00 $0.00 $284.81 $451.14 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16032 ERX HCPCS 63700001 00046-2575-12 CONJ ESTROG-MEDROXYPROGEST ACE PO TABS BOTH IP/OP $40.16 $29.72 $0.00 $26.42 $0.00 $0.00 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $0.00 $8.37 $0.00 $0.00 $0.00 $0.00 $16.52 $26.16 $26.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16050 ERX HCPCS 25000001 00904-6710-15 GLUCOSE 4 G PO CHEW BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16052 ERX HCPCS 63700001 00591-2464-01 DESMOPRESSIN ACETATE 0.1 MG PO TABS BOTH IP/OP $22.15 $16.39 $0.00 $16.07 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $10.05 $15.91 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16052 ERX HCPCS 63700001 10702-0169-01 DESMOPRESSIN ACETATE 0.1 MG PO TABS BOTH IP/OP $22.15 $16.39 $0.00 $16.07 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $10.05 $15.91 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16052 ERX HCPCS 63700001 68084-0606-11 DESMOPRESSIN ACETATE 0.1 MG PO TABS BOTH IP/OP $22.15 $16.39 $0.00 $16.07 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $10.05 $15.91 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16052 ERX HCPCS 63700001 68084-0606-21 DESMOPRESSIN ACETATE 0.1 MG PO TABS BOTH IP/OP $22.15 $16.39 $0.00 $16.07 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $10.05 $15.91 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16052 ERX HCPCS 63700001 68462-0275-01 DESMOPRESSIN ACETATE 0.1 MG PO TABS BOTH IP/OP $22.15 $16.39 $0.00 $16.07 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $10.05 $15.91 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16052 ERX HCPCS 63700001 69918-0101-01 DESMOPRESSIN ACETATE 0.1 MG PO TABS BOTH IP/OP $22.15 $16.39 $0.00 $16.07 $0.00 $0.00 $0.00 $3.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $10.05 $15.91 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16124 ERX HCPCS 63700001 67877-0286-60 (RILUTEK) RILUZOLE 50 MG PO TABS BOTH IP/OP $126.22 $93.40 $0.00 $91.55 $0.00 $0.00 $0.00 $22.47 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $0.00 $0.00 $0.00 $0.00 $57.22 $90.64 $91.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16124 ERX HCPCS 63700001 68462-0381-60 (RILUTEK) RILUZOLE 50 MG PO TABS BOTH IP/OP $126.22 $93.40 $0.00 $91.55 $0.00 $0.00 $0.00 $22.47 $0.00 $0.00 $0.00 $0.00 $0.00 $26.30 $0.00 $0.00 $0.00 $0.00 $57.22 $90.64 $91.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16205 ERX HCPCS 63700001 00093-7536-56 ANASTROZOLE 1 MG PO TABS BOTH IP/OP $73.45 $54.35 $0.00 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.73 $58.17 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16205 ERX HCPCS 63700001 00904-6195-46 ANASTROZOLE 1 MG PO TABS BOTH IP/OP $73.45 $54.35 $0.00 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.73 $58.17 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16205 ERX HCPCS 63700001 16729-0035-10 ANASTROZOLE 1 MG PO TABS BOTH IP/OP $73.45 $54.35 $0.00 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.73 $58.17 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16205 ERX HCPCS 63700001 60505-2985-03 ANASTROZOLE 1 MG PO TABS BOTH IP/OP $73.45 $54.35 $0.00 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.73 $58.17 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16205 ERX HCPCS 63700001 68382-0209-06 ANASTROZOLE 1 MG PO TABS BOTH IP/OP $73.45 $54.35 $0.00 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.73 $58.17 $58.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16208 ERX HCPCS 25000001 60258-0001-16 CYTRA-2 500-334 MG/5ML PO SOLN BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16218 ERX HCPCS 63700001 00054-3120-41 CALCITRIOL 1 MCG/ML PO SOLN BOTH IP/OP $601.43 $445.06 $0.00 $436.75 $0.00 $0.00 $0.00 $107.05 $0.00 $0.00 $0.00 $0.00 $0.00 $125.34 $0.00 $0.00 $0.00 $0.00 $272.97 $432.38 $436.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16218 ERX HCPCS 63700001 30698-0911-15 CALCITRIOL 1 MCG/ML PO SOLN BOTH IP/OP $601.43 $445.06 $0.00 $436.75 $0.00 $0.00 $0.00 $107.05 $0.00 $0.00 $0.00 $0.00 $0.00 $125.34 $0.00 $0.00 $0.00 $0.00 $272.97 $432.38 $436.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16218 ERX HCPCS 63700001 63304-0241-59 CALCITRIOL 1 MCG/ML PO SOLN BOTH IP/OP $601.43 $445.06 $0.00 $436.75 $0.00 $0.00 $0.00 $107.05 $0.00 $0.00 $0.00 $0.00 $0.00 $125.34 $0.00 $0.00 $0.00 $0.00 $272.97 $432.38 $436.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16355 ERX HCPCS 63700001 55111-0320-01 GLIMEPIRIDE 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16356 ERX HCPCS 63700001 68084-0326-01 GLIMEPIRIDE 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16356 ERX HCPCS 63700001 68084-0326-11 GLIMEPIRIDE 2 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16357 ERX HCPCS 63700001 55111-0322-01 GLIMEPIRIDE 4 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16369 ERX HCPCS J0692 25021-0121-20 CEFEPIME HCL 1 G IJ SOLR BOTH IP/OP $78.49 $58.08 $0.00 $60.50 $35.32 $35.32 $0.00 $0.00 $0.00 $16.36 $58.26 $58.26 $60.50 $0.00 $16.36 $0.00 $46.43 $46.43 $0.00 $35.59 $56.37 $56.94 $0.00 $0.00 $11.14 $0.00 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $0.00 16369 ERX HCPCS J0692 44567-0240-10 CEFEPIME HCL 1 G IJ SOLR BOTH IP/OP $78.49 $58.08 $0.00 $60.50 $35.32 $35.32 $0.00 $0.00 $0.00 $16.36 $58.26 $58.26 $60.50 $0.00 $16.36 $0.00 $46.43 $46.43 $0.00 $35.59 $56.37 $56.94 $0.00 $0.00 $11.14 $0.00 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $0.00 16369 ERX HCPCS J0692 60505-6144-04 CEFEPIME HCL 1 G IJ SOLR BOTH IP/OP $78.49 $58.08 $0.00 $60.50 $35.32 $35.32 $0.00 $0.00 $0.00 $16.36 $58.26 $58.26 $60.50 $0.00 $16.36 $0.00 $46.43 $46.43 $0.00 $35.59 $56.37 $56.94 $0.00 $0.00 $11.14 $0.00 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $0.00 16369 ERX HCPCS J0692 60505-6146-04 CEFEPIME HCL 1 G IJ SOLR BOTH IP/OP $78.49 $58.08 $0.00 $60.50 $35.32 $35.32 $0.00 $0.00 $0.00 $16.36 $58.26 $58.26 $60.50 $0.00 $16.36 $0.00 $46.43 $46.43 $0.00 $35.59 $56.37 $56.94 $0.00 $0.00 $11.14 $0.00 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $0.00 16369 ERX HCPCS J0692 63323-0326-20 CEFEPIME HCL 1 G IJ SOLR BOTH IP/OP $78.49 $58.08 $0.00 $60.50 $35.32 $35.32 $0.00 $0.00 $0.00 $16.36 $58.26 $58.26 $60.50 $0.00 $16.36 $0.00 $46.43 $46.43 $0.00 $35.59 $56.37 $56.94 $0.00 $0.00 $11.14 $0.00 $0.00 $11.33 $0.00 $0.00 $0.00 $0.00 $0.00 16371 ERX HCPCS J0692 44567-0241-10 CEFEPIME HCL 2 G IJ SOLR BOTH IP/OP $155.79 $115.28 $0.00 $120.08 $70.11 $70.11 $0.00 $0.00 $0.00 $32.47 $115.63 $115.63 $120.08 $0.00 $32.47 $0.00 $92.15 $92.15 $0.00 $70.63 $111.88 $113.01 $0.00 $0.00 $22.11 $0.00 $0.00 $22.49 $0.00 $0.00 $0.00 $0.00 $0.00 16371 ERX HCPCS J0692 60505-6145-04 CEFEPIME HCL 2 G IJ SOLR BOTH IP/OP $155.79 $115.28 $0.00 $120.08 $70.11 $70.11 $0.00 $0.00 $0.00 $32.47 $115.63 $115.63 $120.08 $0.00 $32.47 $0.00 $92.15 $92.15 $0.00 $70.63 $111.88 $113.01 $0.00 $0.00 $22.11 $0.00 $0.00 $22.49 $0.00 $0.00 $0.00 $0.00 $0.00 16371 ERX HCPCS J0692 60505-6147-00 CEFEPIME HCL 2 G IJ SOLR BOTH IP/OP $155.79 $115.28 $0.00 $120.08 $70.11 $70.11 $0.00 $0.00 $0.00 $32.47 $115.63 $115.63 $120.08 $0.00 $32.47 $0.00 $92.15 $92.15 $0.00 $70.63 $111.88 $113.01 $0.00 $0.00 $22.11 $0.00 $0.00 $22.49 $0.00 $0.00 $0.00 $0.00 $0.00 16371 ERX HCPCS J0692 60505-6147-04 CEFEPIME HCL 2 G IJ SOLR BOTH IP/OP $155.79 $115.28 $0.00 $120.08 $70.11 $70.11 $0.00 $0.00 $0.00 $32.47 $115.63 $115.63 $120.08 $0.00 $32.47 $0.00 $92.15 $92.15 $0.00 $70.63 $111.88 $113.01 $0.00 $0.00 $22.11 $0.00 $0.00 $22.49 $0.00 $0.00 $0.00 $0.00 $0.00 16440 ERX HCPCS 63700001 99999-6004-87 RITONAVIR 80 MG/ML PO SOLN BOTH IP/OP $630.81 $466.80 $0.00 "$2,834.32" $0.00 $0.00 $0.00 $112.28 $0.00 $0.00 $0.00 $0.00 $0.00 $131.46 $0.00 $0.00 $0.00 $0.00 "$1,771.45" $453.40 "$2,834.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16440 ERX HCPCS 63700001 00074-1940-63 RITONAVIR 80 MG/ML PO SOLN BOTH IP/OP $630.81 $466.80 $0.00 "$2,834.32" $0.00 $0.00 $0.00 $112.28 $0.00 $0.00 $0.00 $0.00 $0.00 $131.46 $0.00 $0.00 $0.00 $0.00 "$1,771.45" "$2,805.98" "$2,834.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16632 ERX HCPCS 63700001 00904-5676-61 PAROXETINE HCL 10 MG PO TABS BOTH IP/OP $11.80 $8.73 $0.00 $8.56 $0.00 $0.00 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $2.46 $0.00 $0.00 $0.00 $0.00 $5.35 $8.47 $8.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16632 ERX HCPCS 63700001 13107-0154-30 PAROXETINE HCL 10 MG PO TABS BOTH IP/OP $11.80 $8.73 $0.00 $8.56 $0.00 $0.00 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $2.46 $0.00 $0.00 $0.00 $0.00 $5.35 $8.47 $8.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16633 ERX HCPCS 63700001 60505-0101-02 PAROXETINE HCL 40 MG PO TABS BOTH IP/OP $12.72 $9.41 $0.00 $9.22 $0.00 $0.00 $0.00 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $2.65 $0.00 $0.00 $0.00 $0.00 $5.77 $9.13 $9.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16633 ERX HCPCS 63700001 68084-0047-01 PAROXETINE HCL 40 MG PO TABS BOTH IP/OP $12.72 $9.41 $0.00 $9.22 $0.00 $0.00 $0.00 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $2.65 $0.00 $0.00 $0.00 $0.00 $5.77 $9.13 $9.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16633 ERX HCPCS 63700001 68382-0001-16 PAROXETINE HCL 40 MG PO TABS BOTH IP/OP $12.72 $9.41 $0.00 $9.22 $0.00 $0.00 $0.00 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $2.65 $0.00 $0.00 $0.00 $0.00 $5.77 $9.13 $9.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16639 ERX HCPCS 25000001 00703-9258-09 GLYCINE DILUENT IV SOLN BOTH IP/OP $64.22 $47.52 $0.00 $51.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.11 $50.86 $51.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16644 ERX HCPCS 63700001 00006-0571-43 INDINAVIR SULFATE 200 MG PO CAPS BOTH IP/OP $11.58 $8.57 $0.00 $9.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.79 $9.17 $9.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16645 ERX HCPCS 63700001 00006-0573-62 INDINAVIR SULFATE 400 MG PO CAPS BOTH IP/OP $11.58 $8.57 $0.00 $9.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.79 $9.17 $9.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16825 ERX HCPCS 25000001 00942-0641-03 ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $0.00 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16825 ERX HCPCS 25000001 00942-0641-04 ACD FORMULA A 0.73-2.45-2.2 GM/100ML VI SOLN BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $0.00 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16830 ERX HCPCS 63700001 07610-0226-40 MELATONIN 3 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16830 ERX HCPCS 63700001 20555-0036-01 MELATONIN 3 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16830 ERX HCPCS 63700001 31604-0027-41 MELATONIN 3 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16830 ERX HCPCS 63700001 50268-0524-11 MELATONIN 3 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16830 ERX HCPCS 63700001 50268-0524-15 MELATONIN 3 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16830 ERX HCPCS 63700001 77333-0516-10 MELATONIN 3 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17010 ERX HCPCS 63700001 43199-0014-01 HYOSCYAMINE SULFATE ER 0.375 MG PO TB12 BOTH IP/OP $6.71 $4.97 $0.00 $4.86 $0.00 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $0.00 $1.40 $0.00 $0.00 $0.00 $0.00 $3.04 $4.82 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17010 ERX HCPCS 63700001 51525-0115-01 HYOSCYAMINE SULFATE ER 0.375 MG PO TB12 BOTH IP/OP $6.71 $4.97 $0.00 $4.86 $0.00 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $0.00 $1.40 $0.00 $0.00 $0.00 $0.00 $3.04 $4.82 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17010 ERX HCPCS 63700001 68047-0255-01 HYOSCYAMINE SULFATE ER 0.375 MG PO TB12 BOTH IP/OP $6.71 $4.97 $0.00 $4.86 $0.00 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $0.00 $1.40 $0.00 $0.00 $0.00 $0.00 $3.04 $4.82 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17012 ERX HCPCS J9040 00703-3155-01 BLEOMYCIN SULFATE 30 UNITS IJ SOLR BOTH IP/OP $377.47 $279.33 $0.00 $290.95 $169.86 $169.86 $0.00 $0.00 $0.00 $74.80 $280.16 $280.16 $290.95 $0.00 $59.31 $0.00 $223.27 $223.27 $0.00 $168.79 $267.36 $270.06 $0.00 $0.00 $53.27 $0.00 $0.00 $50.73 $0.00 $0.00 $0.00 $0.00 $0.00 17012 ERX HCPCS J9040 61703-0323-22 BLEOMYCIN SULFATE 30 UNITS IJ SOLR BOTH IP/OP $377.47 $279.33 $0.00 $290.95 $169.86 $169.86 $0.00 $0.00 $0.00 $74.80 $280.16 $280.16 $290.95 $0.00 $59.31 $0.00 $223.27 $223.27 $0.00 $168.79 $267.36 $270.06 $0.00 $0.00 $53.27 $0.00 $0.00 $50.73 $0.00 $0.00 $0.00 $0.00 $0.00 17023 ERX HCPCS 63700001 43199-0011-01 HYOSCYAMINE SULFATE 0.125 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17023 ERX HCPCS 63700001 70156-0105-01 HYOSCYAMINE SULFATE 0.125 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17122 ERX HCPCS J9201 25021-0235-50 GEMCITABINE HCL 1 G IV SOLR BOTH IP/OP $206.75 $153.00 $0.00 $811.87 $93.04 $93.04 $0.00 $0.00 $0.00 $811.87 $153.45 $153.45 $159.36 $0.00 $22.42 $0.00 $122.29 $122.29 $0.00 $93.84 $148.64 $150.14 $0.00 $0.00 $24.44 $0.00 $0.00 $23.27 $0.00 $0.00 $0.00 $0.00 $0.00 17122 ERX HCPCS J9201 63323-0125-53 GEMCITABINE HCL 1 G IV SOLR BOTH IP/OP $206.75 $153.00 $0.00 $811.87 $93.04 $93.04 $0.00 $0.00 $0.00 $811.87 $153.45 $153.45 $159.36 $0.00 $22.42 $0.00 $122.29 $122.29 $0.00 $93.84 $148.64 $150.14 $0.00 $0.00 $24.44 $0.00 $0.00 $23.27 $0.00 $0.00 $0.00 $0.00 $0.00 17280 ERX HCPCS 63700001 60505-0055-01 SELEGILINE HCL 5 MG PO CAPS BOTH IP/OP $8.76 $6.48 $0.00 $7.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.38 $6.94 $7.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17285 ERX HCPCS J9351 16729-0151-31 TOPOTECAN HCL 4 MG IV SOLR BOTH IP/OP $823.44 $609.35 $0.00 $759.50 $370.55 $370.55 $0.00 $0.00 $0.00 $171.63 $611.16 $611.16 $634.71 $0.00 $36.00 $0.00 $487.06 $487.06 $0.00 $474.69 $751.90 $759.50 $0.00 $0.00 $46.06 $0.00 $0.00 $43.86 $0.00 $0.00 $0.00 $0.00 $0.00 17377 ERX HCPCS 25000001 13668-0589-06 RISPERIDONE 1 MG/ML PO SOLN BOTH IP/OP $465.28 $344.31 $0.00 $372.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.64 $368.50 $372.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17377 ERX HCPCS 25000001 51991-0716-41 RISPERIDONE 1 MG/ML PO SOLN BOTH IP/OP $465.28 $344.31 $0.00 $372.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.64 $368.50 $372.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17377 ERX HCPCS 25000001 65162-0673-84 RISPERIDONE 1 MG/ML PO SOLN BOTH IP/OP $465.28 $344.31 $0.00 $372.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.64 $368.50 $372.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17378 ERX HCPCS J0740 23155-0216-31 CIDOFOVIR 75 MG/ML IV SOLN BOTH IP/OP "$2,299.92 " "$1,701.94" $0.00 "$1,772.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,707.00" "$1,707.00" "$1,772.78" $0.00 $479.30 $0.00 $0.00 $0.00 $0.00 "$1,065.60" "$1,687.91" "$1,704.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17379 ERX HCPCS J2185 00781-3000-95 MEROPENEM 500 MG IV SOLR BOTH IP/OP $100.36 $74.27 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $20.92 $34.21 $34.21 $35.53 $0.00 $4.66 $0.00 $59.36 $59.36 $0.00 $45.50 $72.07 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17379 ERX HCPCS J2185 55150-0207-20 MEROPENEM 500 MG IV SOLR BOTH IP/OP $100.36 $74.27 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $20.92 $34.21 $34.21 $35.53 $0.00 $4.66 $0.00 $59.36 $59.36 $0.00 $45.50 $72.07 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17379 ERX HCPCS J2185 63323-0507-20 MEROPENEM 500 MG IV SOLR BOTH IP/OP $100.36 $74.27 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $20.92 $34.21 $34.21 $35.53 $0.00 $4.66 $0.00 $59.36 $59.36 $0.00 $45.50 $72.07 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17379 ERX HCPCS J2185 63323-0507-21 MEROPENEM 500 MG IV SOLR BOTH IP/OP $100.36 $74.27 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $20.92 $34.21 $34.21 $35.53 $0.00 $4.66 $0.00 $59.36 $59.36 $0.00 $45.50 $72.07 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17379 ERX HCPCS J2185 70121-1454-01 MEROPENEM 500 MG IV SOLR BOTH IP/OP $100.36 $74.27 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $20.92 $34.21 $34.21 $35.53 $0.00 $4.66 $0.00 $59.36 $59.36 $0.00 $45.50 $72.07 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17379 ERX HCPCS J2185 70121-1454-07 MEROPENEM 500 MG IV SOLR BOTH IP/OP $100.36 $74.27 $0.00 $72.80 $0.00 $0.00 $0.00 $0.00 $20.92 $34.21 $34.21 $35.53 $0.00 $4.66 $0.00 $59.36 $59.36 $0.00 $45.50 $72.07 $72.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17380 ERX HCPCS J2185 00069-0314-01 MEROPENEM 1 G IV SOLR BOTH IP/OP $180.44 $133.53 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $37.61 $63.03 $63.03 $65.46 $0.00 $9.33 $0.00 $106.73 $106.73 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17380 ERX HCPCS J2185 00069-0314-10 MEROPENEM 1 G IV SOLR BOTH IP/OP $180.44 $133.53 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $37.61 $63.03 $63.03 $65.46 $0.00 $9.33 $0.00 $106.73 $106.73 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17380 ERX HCPCS J2185 00781-3098-95 MEROPENEM 1 G IV SOLR BOTH IP/OP $180.44 $133.53 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $37.61 $63.03 $63.03 $65.46 $0.00 $9.33 $0.00 $106.73 $106.73 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17380 ERX HCPCS J2185 55150-0208-30 MEROPENEM 1 G IV SOLR BOTH IP/OP $180.44 $133.53 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $37.61 $63.03 $63.03 $65.46 $0.00 $9.33 $0.00 $106.73 $106.73 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17380 ERX HCPCS J2185 63323-0508-30 MEROPENEM 1 G IV SOLR BOTH IP/OP $180.44 $133.53 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $37.61 $63.03 $63.03 $65.46 $0.00 $9.33 $0.00 $106.73 $106.73 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17380 ERX HCPCS J2185 70121-1453-01 MEROPENEM 1 G IV SOLR BOTH IP/OP $180.44 $133.53 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $37.61 $63.03 $63.03 $65.46 $0.00 $9.33 $0.00 $106.73 $106.73 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17380 ERX HCPCS J2185 70121-1453-07 MEROPENEM 1 G IV SOLR BOTH IP/OP $180.44 $133.53 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $37.61 $63.03 $63.03 $65.46 $0.00 $9.33 $0.00 $106.73 $106.73 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17387 ERX HCPCS 63700001 50111-0789-10 AZITHROMYCIN 600 MG PO TABS BOTH IP/OP $70.92 $52.48 $0.00 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.46 $56.17 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17387 ERX HCPCS 63700001 60687-0314-25 AZITHROMYCIN 600 MG PO TABS BOTH IP/OP $70.92 $52.48 $0.00 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.46 $56.17 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17387 ERX HCPCS 63700001 69452-0173-13 AZITHROMYCIN 600 MG PO TABS BOTH IP/OP $70.92 $52.48 $0.00 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.46 $56.17 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17403 ERX HCPCS 63700001 00597-0046-60 NEVIRAPINE 200 MG PO TABS BOTH IP/OP $68.86 $50.96 $0.00 $55.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.43 $54.54 $55.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17403 ERX HCPCS 63700001 31722-0505-60 NEVIRAPINE 200 MG PO TABS BOTH IP/OP $68.86 $50.96 $0.00 $55.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.43 $54.54 $55.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17405 ERX HCPCS J1815 00002-7510-01 INSULIN LISPRO 100 UNIT/ML SC SOLN BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $8.15 $8.15 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $8.87 $8.87 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 17464 ERX HCPCS 63700001 00093-1003-01 BUSPIRONE HCL 15 MG PO TABS BOTH IP/OP $8.46 $6.26 $0.00 $6.14 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $0.00 $1.76 $0.00 $0.00 $0.00 $0.00 $3.84 $6.08 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17464 ERX HCPCS 63700001 68382-0182-01 BUSPIRONE HCL 15 MG PO TABS BOTH IP/OP $8.46 $6.26 $0.00 $6.14 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $0.00 $1.76 $0.00 $0.00 $0.00 $0.00 $3.84 $6.08 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17465 ERX HCPCS 63700001 00052-0107-30 MIRTAZAPINE 30 MG PO TABS BOTH IP/OP $25.08 $18.56 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17465 ERX HCPCS 63700001 51079-0087-20 MIRTAZAPINE 30 MG PO TABS BOTH IP/OP $25.08 $18.56 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17465 ERX HCPCS 63700001 68084-0120-01 MIRTAZAPINE 30 MG PO TABS BOTH IP/OP $25.08 $18.56 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17465 ERX HCPCS 63700001 68084-0120-11 MIRTAZAPINE 30 MG PO TABS BOTH IP/OP $25.08 $18.56 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17466 ERX HCPCS 63700001 00904-6519-61 MIRTAZAPINE 15 MG PO TABS BOTH IP/OP $12.90 $9.55 $0.00 $10.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.45 $10.22 $10.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17466 ERX HCPCS 63700001 51079-0086-20 MIRTAZAPINE 15 MG PO TABS BOTH IP/OP $12.90 $9.55 $0.00 $10.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.45 $10.22 $10.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17500 ERX HCPCS 25000001 62991-2015-01 CAFFEINE ANHYDROUS POWD BOTH IP/OP $300.85 $222.63 $0.00 $231.90 $0.00 $0.00 $0.00 $0.00 $0.00 $223.29 $223.29 $231.90 $0.00 $62.70 $0.00 $0.00 $0.00 $0.00 $136.56 $216.30 $218.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17524 ERX HCPCS 25000001 59584-0138-01 CANDIDA ALBICANS SKN TST ANTGN ID SOLN BOTH IP/OP $112.56 $83.29 $0.00 $86.76 $0.00 $0.00 $0.00 $0.00 $0.00 $83.54 $83.54 $86.76 $0.00 $23.46 $0.00 $0.00 $0.00 $0.00 $47.25 $74.84 $75.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17594 ERX HCPCS Q9966 00407-2222-19 IODIXANOL 270 MG/ML IV SOLN BOTH IP/OP $208.90 $154.59 $0.00 $155.05 $94.01 $94.01 $0.00 $0.00 $0.00 $43.54 $155.05 $155.05 $0.00 $0.00 $27.03 $0.00 $123.56 $123.56 $0.00 $94.82 $150.19 $151.70 $0.00 $0.00 $25.73 $0.00 $0.00 $30.19 $0.00 $0.00 $0.00 $0.00 $0.00 17801 ERX HCPCS 25000001 50383-0889-15 ACETIC ACID 2 % OT SOLN BOTH IP/OP $154.42 $114.27 $0.00 $119.03 $0.00 $0.00 $0.00 $0.00 $0.00 $114.61 $114.61 $119.03 $0.00 $32.18 $0.00 $0.00 $0.00 $0.00 $70.01 $110.90 $112.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17837 ERX HCPCS 25000001 00085-1132-04 ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS BOTH IP/OP $591.08 $437.40 $0.00 $455.60 $0.00 $0.00 $0.00 $0.00 $0.00 $438.70 $438.70 $455.60 $0.00 $123.18 $0.00 $0.00 $0.00 $0.00 $126.41 $200.23 $202.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17837 ERX HCPCS 25000001 00173-0682-24 ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS BOTH IP/OP $591.08 $437.40 $0.00 $455.60 $0.00 $0.00 $0.00 $0.00 $0.00 $438.70 $438.70 $455.60 $0.00 $123.18 $0.00 $0.00 $0.00 $0.00 $126.41 $200.23 $202.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17837 ERX HCPCS 25000001 59310-0579-22 ALBUTEROL SULFATE HFA 108 (90 BASE) MCG/ACT IN AERS BOTH IP/OP $591.08 $437.40 $0.00 $455.60 $0.00 $0.00 $0.00 $0.00 $0.00 $438.70 $438.70 $455.60 $0.00 $123.18 $0.00 $0.00 $0.00 $0.00 $126.41 $387.74 $202.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17881 ERX HCPCS 63700001 17478-0715-10 BRIMONIDINE TARTRATE 0.2 % OP SOLN BOTH IP/OP $52.38 $38.76 $0.00 $38.00 $0.00 $0.00 $0.00 $9.32 $0.00 $0.00 $0.00 $0.00 $0.00 $10.92 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17881 ERX HCPCS 63700001 24208-0411-05 BRIMONIDINE TARTRATE 0.2 % OP SOLN BOTH IP/OP $52.38 $38.76 $0.00 $38.00 $0.00 $0.00 $0.00 $9.32 $0.00 $0.00 $0.00 $0.00 $0.00 $10.92 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17881 ERX HCPCS 63700001 61314-0143-05 BRIMONIDINE TARTRATE 0.2 % OP SOLN BOTH IP/OP $52.38 $38.76 $0.00 $38.00 $0.00 $0.00 $0.00 $9.32 $0.00 $0.00 $0.00 $0.00 $0.00 $10.92 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17881 ERX HCPCS 63700001 70069-0231-01 BRIMONIDINE TARTRATE 0.2 % OP SOLN BOTH IP/OP $52.38 $38.76 $0.00 $38.00 $0.00 $0.00 $0.00 $9.32 $0.00 $0.00 $0.00 $0.00 $0.00 $10.92 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17936 ERX HCPCS 63700001 00904-6377-61 OLANZAPINE 5 MG PO TABS BOTH IP/OP $50.16 $37.12 $0.00 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.08 $39.73 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17936 ERX HCPCS 63700001 43598-0164-30 OLANZAPINE 5 MG PO TABS BOTH IP/OP $50.16 $37.12 $0.00 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.08 $39.73 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17936 ERX HCPCS 63700001 60505-3111-00 OLANZAPINE 5 MG PO TABS BOTH IP/OP $50.16 $37.12 $0.00 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.08 $39.73 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17936 ERX HCPCS 63700001 66993-0681-30 OLANZAPINE 5 MG PO TABS BOTH IP/OP $50.16 $37.12 $0.00 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.08 $39.73 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17936 ERX HCPCS 63700001 68084-0723-01 OLANZAPINE 5 MG PO TABS BOTH IP/OP $50.16 $37.12 $0.00 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.08 $39.73 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17937 ERX HCPCS 63700001 00904-6376-61 OLANZAPINE 10 MG PO TABS BOTH IP/OP $75.68 $56.00 $0.00 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.84 $59.94 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17937 ERX HCPCS 63700001 33342-0070-07 OLANZAPINE 10 MG PO TABS BOTH IP/OP $75.68 $56.00 $0.00 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.84 $59.94 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17937 ERX HCPCS 63700001 43598-0166-30 OLANZAPINE 10 MG PO TABS BOTH IP/OP $75.68 $56.00 $0.00 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.84 $59.94 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17937 ERX HCPCS 63700001 60505-3113-00 OLANZAPINE 10 MG PO TABS BOTH IP/OP $75.68 $56.00 $0.00 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.84 $59.94 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17937 ERX HCPCS 63700001 68084-0740-01 OLANZAPINE 10 MG PO TABS BOTH IP/OP $75.68 $56.00 $0.00 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.84 $59.94 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17937 ERX HCPCS 63700001 69543-0383-30 OLANZAPINE 10 MG PO TABS BOTH IP/OP $75.68 $56.00 $0.00 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.84 $59.94 $60.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17938 ERX HCPCS 63700001 60505-3112-00 OLANZAPINE 7.5 MG PO TABS BOTH IP/OP $67.39 $49.87 $0.00 $48.90 $0.00 $0.00 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.04 $0.00 $0.00 $0.00 $0.00 $30.56 $48.41 $48.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17946 ERX HCPCS J8540 00054-3176-44 DEXAMETHASONE 1 MG/ML PO CONC BOTH IP/OP $124.14 $91.86 $0.00 $95.69 $55.86 $55.86 $0.00 $0.00 $0.00 $8.46 $92.14 $92.14 $95.69 $0.00 $25.87 $0.00 $73.43 $73.43 $0.00 $56.28 $89.15 $90.05 $0.00 $0.00 $17.62 $0.00 $0.00 $17.92 $0.00 $0.00 $0.00 $0.00 $0.00 17961 ERX HCPCS 63700001 31722-0509-60 ZIDOVUDINE 300 MG PO TABS BOTH IP/OP $25.21 $18.66 $0.00 $18.30 $0.00 $0.00 $0.00 $4.49 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $11.44 $18.11 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17961 ERX HCPCS 63700001 65862-0024-60 ZIDOVUDINE 300 MG PO TABS BOTH IP/OP $25.21 $18.66 $0.00 $18.30 $0.00 $0.00 $0.00 $4.49 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $11.44 $18.11 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18031 ERX HCPCS 25000001 00187-0245-03 DIHYDROERGOTAMINE MESYLATE 4 MG/ML NA SOLN BOTH IP/OP "$1,485.21 " "$1,099.06" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.32" "$1,102.32" "$1,144.80" $0.00 $309.52 $0.00 $0.00 $0.00 $0.00 $688.13 "$1,090.00" "$1,101.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18192 ERX HCPCS J2795 00409-9300-20 ROPIVACAINE HCL 2 MG/ML IJ SOLN BOTH IP/OP $24.35 $18.02 $0.00 $18.77 $10.96 $10.96 $0.00 $0.00 $0.00 $5.08 $18.07 $18.07 $18.77 $0.00 $5.07 $0.00 $14.40 $14.40 $0.00 $11.04 $17.49 $17.66 $0.00 $0.00 $3.46 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 18192 ERX HCPCS J2795 00409-9300-21 ROPIVACAINE HCL 2 MG/ML IJ SOLN BOTH IP/OP $24.35 $18.02 $0.00 $18.77 $10.96 $10.96 $0.00 $0.00 $0.00 $5.08 $18.07 $18.07 $18.77 $0.00 $5.07 $0.00 $14.40 $14.40 $0.00 $11.04 $17.49 $17.66 $0.00 $0.00 $3.46 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 18192 ERX HCPCS J2795 55150-0195-20 ROPIVACAINE HCL 2 MG/ML IJ SOLN BOTH IP/OP $24.35 $18.02 $0.00 $18.77 $10.96 $10.96 $0.00 $0.00 $0.00 $5.08 $18.07 $18.07 $18.77 $0.00 $5.07 $0.00 $14.40 $14.40 $0.00 $11.04 $17.49 $17.66 $0.00 $0.00 $3.46 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 18192 ERX HCPCS J2795 63323-0285-07 ROPIVACAINE HCL 2 MG/ML IJ SOLN BOTH IP/OP $24.35 $18.02 $0.00 $18.77 $10.96 $10.96 $0.00 $0.00 $0.00 $5.08 $18.07 $18.07 $18.77 $0.00 $5.07 $0.00 $14.40 $14.40 $0.00 $11.04 $17.49 $17.66 $0.00 $0.00 $3.46 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 18192 ERX HCPCS J2795 63323-0285-13 ROPIVACAINE HCL 2 MG/ML IJ SOLN BOTH IP/OP $24.35 $18.02 $0.00 $18.77 $10.96 $10.96 $0.00 $0.00 $0.00 $5.08 $18.07 $18.07 $18.77 $0.00 $5.07 $0.00 $14.40 $14.40 $0.00 $11.04 $17.49 $17.66 $0.00 $0.00 $3.46 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 18192 ERX HCPCS J2795 63323-0285-23 ROPIVACAINE HCL 2 MG/ML IJ SOLN BOTH IP/OP $24.35 $18.02 $0.00 $18.77 $10.96 $10.96 $0.00 $0.00 $0.00 $5.08 $18.07 $18.07 $18.77 $0.00 $5.07 $0.00 $14.40 $14.40 $0.00 $11.04 $17.49 $17.66 $0.00 $0.00 $3.46 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 18193 ERX HCPCS J2795 63323-0287-20 ROPIVACAINE HCL 7.5 MG/ML IJ SOLN BOTH IP/OP $93.80 $69.41 $0.00 $72.30 $42.21 $42.21 $0.00 $0.00 $0.00 $19.55 $69.62 $69.62 $72.30 $0.00 $19.55 $0.00 $55.48 $55.48 $0.00 $32.32 $51.19 $51.71 $0.00 $0.00 $10.12 $0.00 $0.00 $10.29 $0.00 $0.00 $0.00 $0.00 $0.00 18195 ERX HCPCS J2795 55150-0197-20 ROPIVACAINE HCL 5 MG/ML IJ SOLN BOTH IP/OP $52.80 $39.07 $0.00 $40.70 $23.76 $23.76 $0.00 $0.00 $0.00 $11.00 $39.19 $39.19 $40.70 $0.00 $11.00 $0.00 $31.23 $31.23 $0.00 $23.94 $37.92 $38.30 $0.00 $0.00 $7.49 $0.00 $0.00 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 18195 ERX HCPCS J2795 55150-0198-30 ROPIVACAINE HCL 5 MG/ML IJ SOLN BOTH IP/OP $52.80 $39.07 $0.00 $40.70 $23.76 $23.76 $0.00 $0.00 $0.00 $11.00 $39.19 $39.19 $40.70 $0.00 $11.00 $0.00 $31.23 $31.23 $0.00 $23.94 $37.92 $38.30 $0.00 $0.00 $7.49 $0.00 $0.00 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 18195 ERX HCPCS J2795 63323-0286-23 ROPIVACAINE HCL 5 MG/ML IJ SOLN BOTH IP/OP $52.80 $39.07 $0.00 $40.70 $23.76 $23.76 $0.00 $0.00 $0.00 $11.00 $39.19 $39.19 $40.70 $0.00 $11.00 $0.00 $31.23 $31.23 $0.00 $23.94 $37.92 $38.30 $0.00 $0.00 $7.49 $0.00 $0.00 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 18195 ERX HCPCS J2795 63323-0286-31 ROPIVACAINE HCL 5 MG/ML IJ SOLN BOTH IP/OP $52.80 $39.07 $0.00 $40.70 $23.76 $23.76 $0.00 $0.00 $0.00 $11.00 $39.19 $39.19 $40.70 $0.00 $11.00 $0.00 $31.23 $31.23 $0.00 $23.94 $37.92 $38.30 $0.00 $0.00 $7.49 $0.00 $0.00 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 18195 ERX HCPCS J2795 63323-0286-35 ROPIVACAINE HCL 5 MG/ML IJ SOLN BOTH IP/OP $52.80 $39.07 $0.00 $40.70 $23.76 $23.76 $0.00 $0.00 $0.00 $11.00 $39.19 $39.19 $40.70 $0.00 $11.00 $0.00 $31.23 $31.23 $0.00 $23.94 $37.92 $38.30 $0.00 $0.00 $7.49 $0.00 $0.00 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 18265 ERX HCPCS 25000001 00517-9310-25 TRACE MINERALS CR-CU-MN-ZN 1-100-30-500 MCG/ML IV SOLN BOTH IP/OP $36.67 $27.14 $0.00 $28.27 $0.00 $0.00 $0.00 $0.00 $0.00 $27.22 $27.22 $28.27 $0.00 $7.64 $0.00 $0.00 $0.00 $0.00 $16.63 $26.33 $26.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18266 ERX HCPCS 2500003 00517-9203-25 TRACE MINERALS CR-CU-MN-ZN 1-100-25-1000 MCG/ML IV SOLN BOTH IP/OP $61.10 $45.21 $0.00 $47.10 $0.00 $0.00 $0.00 $0.00 $0.00 $45.35 $45.35 $47.10 $0.00 $12.73 $0.00 $0.00 $0.00 $0.00 $25.54 $40.45 $40.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18287 ERX HCPCS 63700001 29300-0127-13 BISOPROLOL FUMARATE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18288 ERX HCPCS 63700001 00185-0771-01 BISOPROLOL FUMARATE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18292 ERX HCPCS 63700001 50111-0916-01 TORSEMIDE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18292 ERX HCPCS 63700001 50268-0755-11 TORSEMIDE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18292 ERX HCPCS 63700001 50268-0755-15 TORSEMIDE 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18293 ERX HCPCS 63700001 00054-0077-25 TORSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18293 ERX HCPCS 63700001 00054-0077-29 TORSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18293 ERX HCPCS 63700001 31722-0531-01 TORSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18293 ERX HCPCS 63700001 50111-0917-01 TORSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18293 ERX HCPCS 63700001 50268-0756-15 TORSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18293 ERX HCPCS 63700001 68084-0539-01 TORSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18293 ERX HCPCS 63700001 68084-0539-11 TORSEMIDE 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18294 ERX HCPCS 63700001 31722-0532-01 TORSEMIDE 100 MG PO TABS BOTH IP/OP $12.75 $9.44 $0.00 $9.25 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $5.78 $9.16 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18294 ERX HCPCS 63700001 50111-0918-01 TORSEMIDE 100 MG PO TABS BOTH IP/OP $12.75 $9.44 $0.00 $9.25 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $5.78 $9.16 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18295 ERX HCPCS 63700001 31722-0529-01 TORSEMIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18295 ERX HCPCS 63700001 50111-0915-01 TORSEMIDE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18302 ERX HCPCS J2543 00781-3114-91 PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR BOTH IP/OP $90.27 $66.80 $0.00 $69.58 $40.62 $40.62 $0.00 $0.00 $0.00 $26.18 $67.00 $67.00 $69.58 $0.00 $6.94 $0.00 $53.39 $53.39 $0.00 $40.93 $64.83 $65.48 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 18302 ERX HCPCS J2543 00781-3114-95 PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR BOTH IP/OP $90.27 $66.80 $0.00 $69.58 $40.62 $40.62 $0.00 $0.00 $0.00 $26.18 $67.00 $67.00 $69.58 $0.00 $6.94 $0.00 $53.39 $53.39 $0.00 $40.93 $64.83 $65.48 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 18302 ERX HCPCS J2543 44567-0803-10 PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR BOTH IP/OP $90.27 $66.80 $0.00 $69.58 $40.62 $40.62 $0.00 $0.00 $0.00 $26.18 $67.00 $67.00 $69.58 $0.00 $6.94 $0.00 $53.39 $53.39 $0.00 $40.93 $64.83 $65.48 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 18302 ERX HCPCS J2543 55150-0121-50 PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR BOTH IP/OP $90.27 $66.80 $0.00 $69.58 $40.62 $40.62 $0.00 $0.00 $0.00 $26.18 $67.00 $67.00 $69.58 $0.00 $6.94 $0.00 $53.39 $53.39 $0.00 $40.93 $64.83 $65.48 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 18302 ERX HCPCS J2543 67457-0523-00 PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR BOTH IP/OP $90.27 $66.80 $0.00 $69.58 $40.62 $40.62 $0.00 $0.00 $0.00 $26.18 $67.00 $67.00 $69.58 $0.00 $6.94 $0.00 $53.39 $53.39 $0.00 $40.93 $64.83 $65.48 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 18302 ERX HCPCS J2543 67457-0523-45 PIPERACILLIN SOD-TAZOBACTAM SO 4.5 (4-0.5) G IV SOLR BOTH IP/OP $90.27 $66.80 $0.00 $69.58 $40.62 $40.62 $0.00 $0.00 $0.00 $26.18 $67.00 $67.00 $69.58 $0.00 $6.94 $0.00 $53.39 $53.39 $0.00 $40.93 $64.83 $65.48 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 18303 ERX HCPCS J2543 00409-3385-13 PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR BOTH IP/OP $52.58 $38.91 $0.00 $40.53 $23.66 $23.66 $0.00 $0.00 $0.00 $19.63 $39.02 $39.02 $40.53 $0.00 $5.21 $0.00 $31.10 $31.10 $0.00 $23.49 $37.21 $37.58 $0.00 $0.00 $6.52 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 18303 ERX HCPCS J2543 00781-3113-95 PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR BOTH IP/OP $52.58 $38.91 $0.00 $40.53 $23.66 $23.66 $0.00 $0.00 $0.00 $19.63 $39.02 $39.02 $40.53 $0.00 $5.21 $0.00 $31.10 $31.10 $0.00 $23.49 $37.21 $37.58 $0.00 $0.00 $6.52 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 18303 ERX HCPCS J2543 55150-0120-30 PIPERACILLIN SOD-TAZOBACTAM SO 3.375 (3-0.375) G IV SOLR BOTH IP/OP $52.58 $38.91 $0.00 $40.53 $23.66 $23.66 $0.00 $0.00 $0.00 $19.63 $39.02 $39.02 $40.53 $0.00 $5.21 $0.00 $31.10 $31.10 $0.00 $23.49 $37.21 $37.58 $0.00 $0.00 $6.52 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 18304 ERX HCPCS J2543 00409-3383-02 PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR BOTH IP/OP $35.05 $25.94 $0.00 $27.02 $15.77 $15.77 $0.00 $0.00 $0.00 $13.09 $26.01 $26.01 $27.02 $0.00 $3.47 $0.00 $20.73 $20.73 $0.00 $15.66 $24.81 $25.06 $0.00 $0.00 $4.35 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 18304 ERX HCPCS J2543 00781-3110-95 PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR BOTH IP/OP $35.05 $25.94 $0.00 $27.02 $15.77 $15.77 $0.00 $0.00 $0.00 $13.09 $26.01 $26.01 $27.02 $0.00 $3.47 $0.00 $20.73 $20.73 $0.00 $15.66 $24.81 $25.06 $0.00 $0.00 $4.35 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 18304 ERX HCPCS J2543 44567-0801-10 PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR BOTH IP/OP $35.05 $25.94 $0.00 $27.02 $15.77 $15.77 $0.00 $0.00 $0.00 $13.09 $26.01 $26.01 $27.02 $0.00 $3.47 $0.00 $20.73 $20.73 $0.00 $15.66 $24.81 $25.06 $0.00 $0.00 $4.35 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 18304 ERX HCPCS J2543 55150-0119-30 PIPERACILLIN SOD-TAZOBACTAM SO 2.25 (2-0.25) G IV SOLR BOTH IP/OP $35.05 $25.94 $0.00 $27.02 $15.77 $15.77 $0.00 $0.00 $0.00 $13.09 $26.01 $26.01 $27.02 $0.00 $3.47 $0.00 $20.73 $20.73 $0.00 $15.66 $24.81 $25.06 $0.00 $0.00 $4.35 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 18307 ERX HCPCS 63700001 00904-6667-61 GABAPENTIN 400 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18307 ERX HCPCS 63700001 16714-0505-02 GABAPENTIN 400 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18307 ERX HCPCS 63700001 63739-0984-10 GABAPENTIN 400 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18307 ERX HCPCS 63700001 68084-0774-01 GABAPENTIN 400 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18307 ERX HCPCS 63700001 68084-0774-11 GABAPENTIN 400 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 00904-6666-61 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 16714-0662-01 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 49483-0606-50 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 50228-0180-05 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 63739-0236-10 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 63739-0689-10 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 65862-0199-01 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 67877-0223-01 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18308 ERX HCPCS 63700001 68084-0762-01 GABAPENTIN 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $5.05 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.16 $5.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18309 ERX HCPCS 63700001 00904-6665-61 GABAPENTIN 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18309 ERX HCPCS 63700001 16714-0503-01 GABAPENTIN 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18309 ERX HCPCS 63700001 16714-0661-01 GABAPENTIN 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18309 ERX HCPCS 63700001 63739-0591-10 GABAPENTIN 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18309 ERX HCPCS 63700001 68084-0783-01 GABAPENTIN 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18309 ERX HCPCS 63700001 69097-0813-07 GABAPENTIN 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18310 ERX HCPCS 63700001 00904-6362-61 RISPERIDONE 4 MG PO TABS BOTH IP/OP $23.59 $17.46 $0.00 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $18.68 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18310 ERX HCPCS 63700001 50458-0595-60 RISPERIDONE 4 MG PO TABS BOTH IP/OP $23.59 $17.46 $0.00 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $18.68 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18310 ERX HCPCS 63700001 51079-0465-01 RISPERIDONE 4 MG PO TABS BOTH IP/OP $23.59 $17.46 $0.00 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $18.68 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18310 ERX HCPCS 63700001 51079-0465-20 RISPERIDONE 4 MG PO TABS BOTH IP/OP $23.59 $17.46 $0.00 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $18.68 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18311 ERX HCPCS 63700001 00904-6360-61 RISPERIDONE 2 MG PO TABS BOTH IP/OP $14.95 $11.06 $0.00 $11.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.48 $11.84 $11.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18311 ERX HCPCS 63700001 51079-0463-01 RISPERIDONE 2 MG PO TABS BOTH IP/OP $14.95 $11.06 $0.00 $11.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.48 $11.84 $11.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18311 ERX HCPCS 63700001 51079-0463-20 RISPERIDONE 2 MG PO TABS BOTH IP/OP $14.95 $11.06 $0.00 $11.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.48 $11.84 $11.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18312 ERX HCPCS 63700001 00904-6361-61 RISPERIDONE 3 MG PO TABS BOTH IP/OP $17.56 $12.99 $0.00 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18312 ERX HCPCS 63700001 68084-0274-01 RISPERIDONE 3 MG PO TABS BOTH IP/OP $17.56 $12.99 $0.00 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18312 ERX HCPCS 63700001 68084-0274-11 RISPERIDONE 3 MG PO TABS BOTH IP/OP $17.56 $12.99 $0.00 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18313 ERX HCPCS 63700001 00904-6359-61 RISPERIDONE 1 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.48 $7.09 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18315 ERX HCPCS J1250 00338-1075-02 DOBUTAMINE IN D5W 2 MG/ML IV SOLN BOTH IP/OP $172.74 $127.83 $0.00 $133.15 $77.73 $77.73 $0.00 $0.00 $0.00 $13.16 $128.21 $128.21 $133.15 $0.00 $19.29 $0.00 $102.18 $102.18 $0.00 $73.07 $115.73 $116.90 $0.00 $0.00 $14.29 $0.00 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 18315 ERX HCPCS J1250 00409-2347-32 DOBUTAMINE IN D5W 2 MG/ML IV SOLN BOTH IP/OP $172.74 $127.83 $0.00 $133.15 $77.73 $77.73 $0.00 $0.00 $0.00 $13.16 $128.21 $128.21 $133.15 $0.00 $19.29 $0.00 $102.18 $102.18 $0.00 $73.07 $115.73 $116.90 $0.00 $0.00 $14.29 $0.00 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $0.00 18385 ERX HCPCS 63700001 00591-3540-60 BUPROPION HCL ER (SR) 100 MG PO TB12 BOTH IP/OP $6.98 $5.17 $0.00 $5.06 $0.00 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $3.17 $5.01 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18385 ERX HCPCS 63700001 43547-0288-10 BUPROPION HCL ER (SR) 100 MG PO TB12 BOTH IP/OP $6.98 $5.17 $0.00 $5.06 $0.00 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $3.17 $5.01 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18385 ERX HCPCS 63700001 43598-0751-01 BUPROPION HCL ER (SR) 100 MG PO TB12 BOTH IP/OP $6.98 $5.17 $0.00 $5.06 $0.00 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $3.17 $5.01 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18385 ERX HCPCS 63700001 68084-0697-01 BUPROPION HCL ER (SR) 100 MG PO TB12 BOTH IP/OP $6.98 $5.17 $0.00 $5.06 $0.00 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $3.17 $5.01 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18386 ERX HCPCS 63700001 00173-0135-55 BUPROPION HCL ER (SR) 150 MG PO TB12 BOTH IP/OP $38.44 $28.45 $0.00 $27.07 $0.00 $0.00 $0.00 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $16.92 $26.80 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18386 ERX HCPCS 63700001 00185-0415-05 BUPROPION HCL ER (SR) 150 MG PO TB12 BOTH IP/OP $38.44 $28.45 $0.00 $27.07 $0.00 $0.00 $0.00 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $16.92 $26.80 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18386 ERX HCPCS 63700001 00185-0415-60 BUPROPION HCL ER (SR) 150 MG PO TB12 BOTH IP/OP $38.44 $28.45 $0.00 $27.07 $0.00 $0.00 $0.00 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $16.92 $26.80 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18386 ERX HCPCS 63700001 00591-3541-60 BUPROPION HCL ER (SR) 150 MG PO TB12 BOTH IP/OP $38.44 $28.45 $0.00 $27.07 $0.00 $0.00 $0.00 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $16.92 $26.80 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18386 ERX HCPCS 63700001 00904-6585-61 BUPROPION HCL ER (SR) 150 MG PO TB12 BOTH IP/OP $38.44 $28.45 $0.00 $27.07 $0.00 $0.00 $0.00 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $16.92 $26.80 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18386 ERX HCPCS 63700001 63739-0714-10 BUPROPION HCL ER (SR) 150 MG PO TB12 BOTH IP/OP $38.44 $28.45 $0.00 $27.07 $0.00 $0.00 $0.00 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $16.92 $26.80 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18386 ERX HCPCS 63700001 68084-0708-25 BUPROPION HCL ER (SR) 150 MG PO TB12 BOTH IP/OP $38.44 $28.45 $0.00 $27.07 $0.00 $0.00 $0.00 $6.84 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $16.92 $26.80 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18400 ERX HCPCS 25000001 63323-0724-05 REMIFENTANIL HCL 2 MG IV SOLR BOTH IP/OP $494.25 $365.75 $0.00 $380.97 $0.00 $0.00 $0.00 $0.00 $0.00 $366.83 $366.83 $380.97 $0.00 $103.00 $0.00 $0.00 $0.00 $0.00 $224.33 $355.33 $358.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18400 ERX HCPCS 25000001 67457-0198-05 REMIFENTANIL HCL 2 MG IV SOLR BOTH IP/OP $494.25 $365.75 $0.00 $380.97 $0.00 $0.00 $0.00 $0.00 $0.00 $366.83 $366.83 $380.97 $0.00 $103.00 $0.00 $0.00 $0.00 $0.00 $224.33 $355.33 $358.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18400 ERX HCPCS 25000001 67457-0198-99 REMIFENTANIL HCL 2 MG IV SOLR BOTH IP/OP $494.25 $365.75 $0.00 $380.97 $0.00 $0.00 $0.00 $0.00 $0.00 $366.83 $366.83 $380.97 $0.00 $103.00 $0.00 $0.00 $0.00 $0.00 $224.33 $355.33 $358.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18551 ERX HCPCS 63700001 00093-0051-01 CARVEDILOL 3.125 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18551 ERX HCPCS 63700001 00904-6300-61 CARVEDILOL 3.125 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18551 ERX HCPCS 63700001 51079-0771-01 CARVEDILOL 3.125 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18551 ERX HCPCS 63700001 51079-0771-20 CARVEDILOL 3.125 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18551 ERX HCPCS 63700001 55111-0252-01 CARVEDILOL 3.125 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18551 ERX HCPCS 63700001 68382-0092-01 CARVEDILOL 3.125 MG PO TABS BOTH IP/OP $8.95 $6.62 $0.00 $6.49 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.06 $6.42 $6.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18621 ERX HCPCS 25000001 00013-8303-04 LATANOPROST 0.005 % OP SOLN BOTH IP/OP $785.75 $581.46 $0.00 $605.66 $0.00 $0.00 $0.00 $0.00 $0.00 $583.18 $583.18 $605.66 $0.00 $163.75 $0.00 $0.00 $0.00 $0.00 $339.89 $538.39 $543.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18621 ERX HCPCS 25000001 17478-0625-12 LATANOPROST 0.005 % OP SOLN BOTH IP/OP $785.75 $581.46 $0.00 $605.66 $0.00 $0.00 $0.00 $0.00 $0.00 $583.18 $583.18 $605.66 $0.00 $163.75 $0.00 $0.00 $0.00 $0.00 $339.89 $538.39 $543.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18621 ERX HCPCS 25000001 24208-0463-25 LATANOPROST 0.005 % OP SOLN BOTH IP/OP $785.75 $581.46 $0.00 $605.66 $0.00 $0.00 $0.00 $0.00 $0.00 $583.18 $583.18 $605.66 $0.00 $163.75 $0.00 $0.00 $0.00 $0.00 $339.89 $538.39 $543.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18621 ERX HCPCS 25000001 59762-0333-02 LATANOPROST 0.005 % OP SOLN BOTH IP/OP $785.75 $581.46 $0.00 $605.66 $0.00 $0.00 $0.00 $0.00 $0.00 $583.18 $583.18 $605.66 $0.00 $163.75 $0.00 $0.00 $0.00 $0.00 $339.89 $538.39 $543.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18621 ERX HCPCS 25000001 61314-0547-01 LATANOPROST 0.005 % OP SOLN BOTH IP/OP $785.75 $581.46 $0.00 $605.66 $0.00 $0.00 $0.00 $0.00 $0.00 $583.18 $583.18 $605.66 $0.00 $163.75 $0.00 $0.00 $0.00 $0.00 $339.89 $538.39 $543.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18786 ERX HCPCS 63700001 00904-6477-61 DONEPEZIL HCL 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18787 ERX HCPCS 63700001 00904-6478-61 DONEPEZIL HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18787 ERX HCPCS 63700001 60687-0303-01 DONEPEZIL HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18908 ERX HCPCS 25000001 00187-4302-02 NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18908 ERX HCPCS 25000001 25021-0310-02 NITROPRUSSIDE SODIUM 25 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18918 ERX HCPCS 63700001 00904-6351-61 LEVOFLOXACIN 250 MG PO TABS BOTH IP/OP $70.44 $52.13 $0.00 $51.11 $0.00 $0.00 $0.00 $12.54 $0.00 $0.00 $0.00 $0.00 $0.00 $14.68 $0.00 $0.00 $0.00 $0.00 $31.95 $50.60 $51.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18918 ERX HCPCS 63700001 65862-0536-50 LEVOFLOXACIN 250 MG PO TABS BOTH IP/OP $70.44 $52.13 $0.00 $51.11 $0.00 $0.00 $0.00 $12.54 $0.00 $0.00 $0.00 $0.00 $0.00 $14.68 $0.00 $0.00 $0.00 $0.00 $31.95 $50.60 $51.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18918 ERX HCPCS 63700001 68180-0240-01 LEVOFLOXACIN 250 MG PO TABS BOTH IP/OP $70.44 $52.13 $0.00 $51.11 $0.00 $0.00 $0.00 $12.54 $0.00 $0.00 $0.00 $0.00 $0.00 $14.68 $0.00 $0.00 $0.00 $0.00 $31.95 $50.60 $51.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18919 ERX HCPCS 63700001 00904-6352-61 LEVOFLOXACIN 500 MG PO TABS BOTH IP/OP $71.83 $53.15 $0.00 $57.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.92 $56.89 $57.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18919 ERX HCPCS 63700001 65862-0537-50 LEVOFLOXACIN 500 MG PO TABS BOTH IP/OP $71.83 $53.15 $0.00 $57.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.92 $56.89 $57.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18920 ERX HCPCS 63700001 68084-0342-01 TOPIRAMATE 25 MG PO TABS BOTH IP/OP $7.71 $5.71 $0.00 $6.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.86 $6.11 $6.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18921 ERX HCPCS 63700001 47335-0712-86 TOPIRAMATE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18921 ERX HCPCS 63700001 62756-0712-86 TOPIRAMATE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18921 ERX HCPCS 63700001 68084-0345-11 TOPIRAMATE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18921 ERX HCPCS 63700001 68084-0345-21 TOPIRAMATE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18921 ERX HCPCS 63700001 68382-0141-14 TOPIRAMATE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18921 ERX HCPCS 63700001 69097-0125-03 TOPIRAMATE 200 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18922 ERX HCPCS 63700001 62756-0711-86 TOPIRAMATE 100 MG PO TABS BOTH IP/OP $29.13 $21.56 $0.00 $21.13 $0.00 $0.00 $0.00 $5.19 $0.00 $0.00 $0.00 $0.00 $0.00 $6.07 $0.00 $0.00 $0.00 $0.00 $13.21 $20.92 $21.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18922 ERX HCPCS 63700001 68084-0344-01 TOPIRAMATE 100 MG PO TABS BOTH IP/OP $29.13 $21.56 $0.00 $21.13 $0.00 $0.00 $0.00 $5.19 $0.00 $0.00 $0.00 $0.00 $0.00 $6.07 $0.00 $0.00 $0.00 $0.00 $13.21 $20.92 $21.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18925 ERX HCPCS J1956 17478-0107-20 LEVOFLOXACIN 25 MG/ML IV SOLN BOTH IP/OP $84.92 $62.84 $0.00 $65.46 $38.21 $38.21 $0.00 $0.00 $0.00 $17.70 $63.03 $63.03 $65.46 $0.00 $17.70 $0.00 $50.23 $50.23 $0.00 $38.50 $60.98 $61.60 $0.00 $0.00 $12.05 $0.00 $0.00 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 18925 ERX HCPCS J1956 17478-0107-30 LEVOFLOXACIN 25 MG/ML IV SOLN BOTH IP/OP $84.92 $62.84 $0.00 $65.46 $38.21 $38.21 $0.00 $0.00 $0.00 $17.70 $63.03 $63.03 $65.46 $0.00 $17.70 $0.00 $50.23 $50.23 $0.00 $38.50 $60.98 $61.60 $0.00 $0.00 $12.05 $0.00 $0.00 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 18925 ERX HCPCS J1956 55150-0156-20 LEVOFLOXACIN 25 MG/ML IV SOLN BOTH IP/OP $84.92 $62.84 $0.00 $65.46 $38.21 $38.21 $0.00 $0.00 $0.00 $17.70 $63.03 $63.03 $65.46 $0.00 $17.70 $0.00 $50.23 $50.23 $0.00 $38.50 $60.98 $61.60 $0.00 $0.00 $12.05 $0.00 $0.00 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 19176 ERX HCPCS 63700001 00904-6290-61 ATORVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19176 ERX HCPCS 63700001 50268-0093-11 ATORVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19176 ERX HCPCS 63700001 50268-0093-15 ATORVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19176 ERX HCPCS 63700001 60505-2578-09 ATORVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19176 ERX HCPCS 63700001 62175-0890-46 ATORVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19177 ERX HCPCS 63700001 00378-3952-77 ATORVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $24.20 $17.91 $0.00 $17.56 $0.00 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $0.00 $5.04 $0.00 $0.00 $0.00 $0.00 $10.98 $17.38 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19177 ERX HCPCS 63700001 00904-6292-61 ATORVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $24.20 $17.91 $0.00 $17.56 $0.00 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $0.00 $5.04 $0.00 $0.00 $0.00 $0.00 $10.98 $17.38 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19177 ERX HCPCS 63700001 51079-0210-01 ATORVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $24.20 $17.91 $0.00 $17.56 $0.00 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $0.00 $5.04 $0.00 $0.00 $0.00 $0.00 $10.98 $17.38 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19177 ERX HCPCS 63700001 51079-0210-20 ATORVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $24.20 $17.91 $0.00 $17.56 $0.00 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $0.00 $5.04 $0.00 $0.00 $0.00 $0.00 $10.98 $17.38 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19177 ERX HCPCS 63700001 55111-0123-90 ATORVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $24.20 $17.91 $0.00 $17.56 $0.00 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $0.00 $5.04 $0.00 $0.00 $0.00 $0.00 $10.98 $17.38 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19177 ERX HCPCS 63700001 60505-2580-09 ATORVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $24.20 $17.91 $0.00 $17.56 $0.00 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $0.00 $5.04 $0.00 $0.00 $0.00 $0.00 $10.98 $17.38 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19177 ERX HCPCS 63700001 68084-0099-01 ATORVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $24.20 $17.91 $0.00 $17.56 $0.00 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $0.00 $5.04 $0.00 $0.00 $0.00 $0.00 $10.98 $17.38 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19178 ERX HCPCS 63700001 00904-6291-61 ATORVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19178 ERX HCPCS 63700001 55111-0122-90 ATORVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19178 ERX HCPCS 63700001 60505-2579-09 ATORVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19178 ERX HCPCS 63700001 68084-0098-01 ATORVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19179 ERX HCPCS 25000001 42291-0153-30 AZELASTINE HCL 0.1 % NA SOLN BOTH IP/OP $320.99 $237.53 $0.00 $256.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.50 $254.22 $256.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19179 ERX HCPCS 25000001 60505-0833-05 AZELASTINE HCL 0.1 % NA SOLN BOTH IP/OP $320.99 $237.53 $0.00 $256.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.50 $254.22 $256.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19226 ERX HCPCS 63700001 00093-5420-88 CABERGOLINE 0.5 MG PO TABS BOTH IP/OP $141.51 $104.72 $0.00 $102.65 $0.00 $0.00 $0.00 $25.19 $0.00 $0.00 $0.00 $0.00 $0.00 $29.49 $0.00 $0.00 $0.00 $0.00 $64.16 $101.62 $102.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19226 ERX HCPCS 63700001 49884-0673-14 CABERGOLINE 0.5 MG PO TABS BOTH IP/OP $141.51 $104.72 $0.00 $102.65 $0.00 $0.00 $0.00 $25.19 $0.00 $0.00 $0.00 $0.00 $0.00 $29.49 $0.00 $0.00 $0.00 $0.00 $64.16 $101.62 $102.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19226 ERX HCPCS 63700001 50742-0118-08 CABERGOLINE 0.5 MG PO TABS BOTH IP/OP $141.51 $104.72 $0.00 $102.65 $0.00 $0.00 $0.00 $25.19 $0.00 $0.00 $0.00 $0.00 $0.00 $29.49 $0.00 $0.00 $0.00 $0.00 $64.16 $101.62 $102.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19226 ERX HCPCS 63700001 59762-1005-01 CABERGOLINE 0.5 MG PO TABS BOTH IP/OP $141.51 $104.72 $0.00 $102.65 $0.00 $0.00 $0.00 $25.19 $0.00 $0.00 $0.00 $0.00 $0.00 $29.49 $0.00 $0.00 $0.00 $0.00 $64.16 $101.62 $102.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19333 ERX HCPCS J0735 00143-9724-01 CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN BOTH IP/OP $39.90 $29.53 $0.00 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.95 $31.60 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19333 ERX HCPCS J0735 39822-2000-01 CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN BOTH IP/OP $39.90 $29.53 $0.00 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.95 $31.60 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19333 ERX HCPCS J0735 67457-0218-10 CLONIDINE HCL (ANALGESIA) 100 MCG/ML EP SOLN BOTH IP/OP $39.90 $29.53 $0.00 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.95 $31.60 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19451 ERX HCPCS 90700 58160-0810-11 DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP BOTH IP/OP $105.04 $77.73 $0.00 $84.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.52 $83.19 $84.03 $0.00 $0.00 $16.44 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 19451 ERX HCPCS 90700 58160-0810-52 DIPHTH-ACELL PERTUSSIS-TETANUS 25-58-10 LF-MCG/0.5 IM SUSP BOTH IP/OP $105.04 $77.73 $0.00 $84.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.52 $83.19 $84.03 $0.00 $0.00 $16.44 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 19452 ERX HCPCS 25000001 17478-0105-05 OLOPATADINE HCL 0.1 % OP SOLN BOTH IP/OP $924.14 $683.86 $0.00 $739.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.07 $731.92 $739.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19452 ERX HCPCS 25000001 61314-0271-05 OLOPATADINE HCL 0.1 % OP SOLN BOTH IP/OP $924.14 $683.86 $0.00 $739.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.07 $731.92 $739.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19452 ERX HCPCS 25000001 65862-0757-05 OLOPATADINE HCL 0.1 % OP SOLN BOTH IP/OP $924.14 $683.86 $0.00 $739.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.07 $731.92 $739.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19452 ERX HCPCS 25000001 70069-0007-01 OLOPATADINE HCL 0.1 % OP SOLN BOTH IP/OP $924.14 $683.86 $0.00 $739.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.07 $731.92 $739.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19527 ERX HCPCS 63700001 00904-5460-52 OYSTER SHELL CALCIUM/D 500-200 MG-UNIT PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19527 ERX HCPCS 63700001 00904-5460-72 OYSTER SHELL CALCIUM/D 500-200 MG-UNIT PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19527 ERX HCPCS 63700001 00904-5460-92 OYSTER SHELL CALCIUM/D 500-200 MG-UNIT PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19691 ERX HCPCS 25000001 61010-8100-01 BENZOCAINE 20 % MT GEL BOTH IP/OP $36.21 $26.80 $0.00 $27.91 $0.00 $0.00 $0.00 $0.00 $0.00 $26.88 $26.88 $27.91 $0.00 $7.55 $0.00 $0.00 $0.00 $0.00 $16.42 $26.01 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19691 ERX HCPCS 25000001 00283-0293-31 BENZOCAINE 20 % MT GEL BOTH IP/OP $36.21 $26.80 $0.00 $27.91 $0.00 $0.00 $0.00 $0.00 $0.00 $26.88 $26.88 $27.91 $0.00 $7.55 $0.00 $0.00 $0.00 $0.00 $16.42 $26.01 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19691 ERX HCPCS 25000001 00283-0871-31 BENZOCAINE 20 % MT GEL BOTH IP/OP $36.21 $26.80 $0.00 $27.91 $0.00 $0.00 $0.00 $0.00 $0.00 $26.88 $26.88 $27.91 $0.00 $7.55 $0.00 $0.00 $0.00 $0.00 $16.42 $26.01 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19703 ERX HCPCS 63700001 00065-0246-10 BETAXOLOL HCL 0.25 % OP SUSP BOTH IP/OP "$1,088.11 " $805.20 $0.00 $790.00 $0.00 $0.00 $0.00 $193.68 $0.00 $0.00 $0.00 $0.00 $0.00 $226.76 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19704 ERX HCPCS 25000001 00065-0023-15 CARBACHOL 0.01 % IO SOLN BOTH IP/OP $173.75 $128.58 $0.00 $140.64 $0.00 $0.00 $0.00 $0.00 $0.00 $135.42 $135.42 $140.64 $0.00 $36.21 $0.00 $0.00 $0.00 $0.00 $76.49 $121.15 $122.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19711 ERX HCPCS 25000001 00168-0203-60 CLINDAMYCIN PHOSPHATE 1 % EX LOTN BOTH IP/OP $403.81 $298.82 $0.00 $311.26 $0.00 $0.00 $0.00 $0.00 $0.00 $299.71 $299.71 $311.26 $0.00 $84.15 $0.00 $0.00 $0.00 $0.00 $183.28 $290.31 $293.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19711 ERX HCPCS 25000001 59762-3744-01 CLINDAMYCIN PHOSPHATE 1 % EX LOTN BOTH IP/OP $403.81 $298.82 $0.00 $311.26 $0.00 $0.00 $0.00 $0.00 $0.00 $299.71 $299.71 $311.26 $0.00 $84.15 $0.00 $0.00 $0.00 $0.00 $183.28 $290.31 $293.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19713 ERX HCPCS j1730 00575-6200-30 DIAZOXIDE 50 MG/ML PO SUSP BOTH IP/OP "$1,320.31 " $977.03 $0.00 "$1,017.69" $0.00 $0.00 $0.00 $0.00 $0.00 $979.93 $979.93 "$1,017.69" $0.00 $275.15 $0.00 $0.00 $0.00 $0.00 $547.60 $867.40 $876.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19714 ERX HCPCS 25000001 17478-0892-25 DICLOFENAC SODIUM 0.1 % OP SOLN BOTH IP/OP $253.42 $187.53 $0.00 $195.34 $0.00 $0.00 $0.00 $0.00 $0.00 $188.09 $188.09 $195.34 $0.00 $52.81 $0.00 $0.00 $0.00 $0.00 $78.35 $124.11 $125.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19714 ERX HCPCS 25000001 61314-0014-25 DICLOFENAC SODIUM 0.1 % OP SOLN BOTH IP/OP $253.42 $187.53 $0.00 $195.34 $0.00 $0.00 $0.00 $0.00 $0.00 $188.09 $188.09 $195.34 $0.00 $52.81 $0.00 $0.00 $0.00 $0.00 $78.35 $124.11 $125.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19714 ERX HCPCS 25000001 61314-0014-05 DICLOFENAC SODIUM 0.1 % OP SOLN BOTH IP/OP $253.42 $187.53 $0.00 $195.34 $0.00 $0.00 $0.00 $0.00 $0.00 $188.09 $188.09 $195.34 $0.00 $52.81 $0.00 $0.00 $0.00 $0.00 $78.35 $182.20 $125.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19732 ERX HCPCS 25000001 00037-6830-15 HYDROCORTISONE ACETATE 10 % EX FOAM BOTH IP/OP "$1,395.30 " "$1,032.52" $0.00 "$1,075.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.59" "$1,035.59" "$1,075.50" $0.00 $290.78 $0.00 $0.00 $0.00 $0.00 $633.14 "$1,002.89" "$1,013.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19733 ERX HCPCS 25000001 17478-0209-10 KETOROLAC TROMETHAMINE 0.5 % OP SOLN BOTH IP/OP $359.09 $265.73 $0.00 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $266.52 $266.52 $276.79 $0.00 $74.83 $0.00 $0.00 $0.00 $0.00 $278.25 $258.16 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19733 ERX HCPCS 25000001 60505-1003-01 KETOROLAC TROMETHAMINE 0.5 % OP SOLN BOTH IP/OP $359.09 $265.73 $0.00 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $266.52 $266.52 $276.79 $0.00 $74.83 $0.00 $0.00 $0.00 $0.00 $278.25 $258.16 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19733 ERX HCPCS 25000001 61314-0126-05 KETOROLAC TROMETHAMINE 0.5 % OP SOLN BOTH IP/OP $359.09 $265.73 $0.00 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $266.52 $266.52 $276.79 $0.00 $74.83 $0.00 $0.00 $0.00 $0.00 $278.25 $258.16 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19733 ERX HCPCS 25000001 61314-0126-10 KETOROLAC TROMETHAMINE 0.5 % OP SOLN BOTH IP/OP $359.09 $265.73 $0.00 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $266.52 $266.52 $276.79 $0.00 $74.83 $0.00 $0.00 $0.00 $0.00 $278.25 $440.75 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19736 ERX HCPCS J1050 00009-0746-30 MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP BOTH IP/OP $187.38 $138.66 $0.00 $246.58 $84.32 $84.32 $0.00 $0.00 $0.00 $39.05 $139.07 $139.07 $144.43 $0.00 $100.64 $0.00 $110.84 $110.84 $0.00 $154.12 $244.12 $246.58 $0.00 $0.00 $98.70 $0.00 $0.00 $93.98 $0.00 $0.00 $0.00 $0.00 $0.00 19736 ERX HCPCS J1050 00009-0746-35 MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP BOTH IP/OP $187.38 $138.66 $0.00 $246.58 $84.32 $84.32 $0.00 $0.00 $0.00 $39.05 $139.07 $139.07 $144.43 $0.00 $100.64 $0.00 $110.84 $110.84 $0.00 $154.12 $244.12 $246.58 $0.00 $0.00 $98.70 $0.00 $0.00 $93.98 $0.00 $0.00 $0.00 $0.00 $0.00 19736 ERX HCPCS J1050 00548-5400-00 MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP BOTH IP/OP $187.38 $138.66 $0.00 $246.58 $84.32 $84.32 $0.00 $0.00 $0.00 $39.05 $139.07 $139.07 $144.43 $0.00 $100.64 $0.00 $110.84 $110.84 $0.00 $154.12 $244.12 $246.58 $0.00 $0.00 $98.70 $0.00 $0.00 $93.98 $0.00 $0.00 $0.00 $0.00 $0.00 19736 ERX HCPCS J1050 00703-6801-01 MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP BOTH IP/OP $187.38 $138.66 $0.00 $246.58 $84.32 $84.32 $0.00 $0.00 $0.00 $39.05 $139.07 $139.07 $144.43 $0.00 $100.64 $0.00 $110.84 $110.84 $0.00 $154.12 $244.12 $246.58 $0.00 $0.00 $98.70 $0.00 $0.00 $93.98 $0.00 $0.00 $0.00 $0.00 $0.00 19736 ERX HCPCS J1050 59762-4537-01 MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP BOTH IP/OP $187.38 $138.66 $0.00 $246.58 $84.32 $84.32 $0.00 $0.00 $0.00 $39.05 $139.07 $139.07 $144.43 $0.00 $100.64 $0.00 $110.84 $110.84 $0.00 $154.12 $244.12 $246.58 $0.00 $0.00 $98.70 $0.00 $0.00 $93.98 $0.00 $0.00 $0.00 $0.00 $0.00 19736 ERX HCPCS J1050 59762-4537-02 MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP BOTH IP/OP $187.38 $138.66 $0.00 $246.58 $84.32 $84.32 $0.00 $0.00 $0.00 $39.05 $139.07 $139.07 $144.43 $0.00 $100.64 $0.00 $110.84 $110.84 $0.00 $154.12 $244.12 $246.58 $0.00 $0.00 $98.70 $0.00 $0.00 $93.98 $0.00 $0.00 $0.00 $0.00 $0.00 19736 ERX HCPCS J1050 67457-0887-00 MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP BOTH IP/OP $187.38 $138.66 $0.00 $246.58 $84.32 $84.32 $0.00 $0.00 $0.00 $39.05 $139.07 $139.07 $144.43 $0.00 $100.64 $0.00 $110.84 $110.84 $0.00 $154.12 $244.12 $246.58 $0.00 $0.00 $98.70 $0.00 $0.00 $93.98 $0.00 $0.00 $0.00 $0.00 $0.00 19736 ERX HCPCS J1050 67457-0887-99 MEDROXYPROGESTERONE ACETATE 150 MG/ML IM SUSP BOTH IP/OP $187.38 $138.66 $0.00 $246.58 $84.32 $84.32 $0.00 $0.00 $0.00 $39.05 $139.07 $139.07 $144.43 $0.00 $100.64 $0.00 $110.84 $110.84 $0.00 $154.12 $244.12 $246.58 $0.00 $0.00 $98.70 $0.00 $0.00 $93.98 $0.00 $0.00 $0.00 $0.00 $0.00 19741 ERX HCPCS 63700001 00115-1474-46 METRONIDAZOLE 0.75 % EX GEL BOTH IP/OP $932.55 $690.09 $0.00 $677.06 $0.00 $0.00 $0.00 $165.99 $0.00 $0.00 $0.00 $0.00 $0.00 $194.34 $0.00 $0.00 $0.00 $0.00 $423.16 $670.29 $677.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19741 ERX HCPCS 63700001 00168-0275-45 METRONIDAZOLE 0.75 % EX GEL BOTH IP/OP $932.55 $690.09 $0.00 $677.06 $0.00 $0.00 $0.00 $165.99 $0.00 $0.00 $0.00 $0.00 $0.00 $194.34 $0.00 $0.00 $0.00 $0.00 $423.16 $670.29 $677.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19741 ERX HCPCS 63700001 51672-4116-06 METRONIDAZOLE 0.75 % EX GEL BOTH IP/OP $932.55 $690.09 $0.00 $677.06 $0.00 $0.00 $0.00 $165.99 $0.00 $0.00 $0.00 $0.00 $0.00 $194.34 $0.00 $0.00 $0.00 $0.00 $423.16 $670.29 $677.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19741 ERX HCPCS 63700001 66993-0962-45 METRONIDAZOLE 0.75 % EX GEL BOTH IP/OP $932.55 $690.09 $0.00 $677.06 $0.00 $0.00 $0.00 $165.99 $0.00 $0.00 $0.00 $0.00 $0.00 $194.34 $0.00 $0.00 $0.00 $0.00 $423.16 $670.29 $677.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19743 ERX HCPCS 63700001 00378-7272-53 "MICRONOR, JOLIVETTE, NORETHINDRONE 0.35 MG TAB PO" BOTH IP/OP $206.48 $152.80 $0.00 $165.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.24 $163.53 $165.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19743 ERX HCPCS 63700001 00378-7272-85 "MICRONOR, JOLIVETTE, NORETHINDRONE 0.35 MG TAB PO" BOTH IP/OP $206.48 $152.80 $0.00 $165.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.24 $163.53 $165.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19743 ERX HCPCS 63700001 50458-0194-06 "MICRONOR, JOLIVETTE, NORETHINDRONE 0.35 MG TAB PO" BOTH IP/OP $206.48 $152.80 $0.00 $165.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.24 $163.53 $165.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19769 ERX HCPCS 25000001 00065-0644-35 TOBRAMYCIN 0.3 % OP OINT BOTH IP/OP $751.11 $555.82 $0.00 $578.96 $0.00 $0.00 $0.00 $0.00 $0.00 $557.47 $557.47 $578.96 $0.00 $156.53 $0.00 $0.00 $0.00 $0.00 $340.83 $539.87 $545.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19776 ERX HCPCS 25000001 00536-1109-45 UREA 20 % EX CREA BOTH IP/OP $60.91 $45.07 $0.00 $46.95 $0.00 $0.00 $0.00 $0.00 $0.00 $45.21 $45.21 $46.95 $0.00 $12.69 $0.00 $0.00 $0.00 $0.00 $27.62 $43.75 $44.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19791 ERX HCPCS 63700001 00065-0411-30 POVIDONE-IODINE 5 % OP SOLN BOTH IP/OP $72.16 $53.40 $0.00 $50.80 $0.00 $0.00 $0.00 $13.47 $0.00 $0.00 $0.00 $0.00 $0.00 $15.04 $0.00 $0.00 $0.00 $0.00 $31.75 $50.29 $50.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19805 ERX HCPCS 63700001 00168-0323-46 METRONIDAZOLE 0.75 % EX CREA BOTH IP/OP "$1,943.71 " "$1,438.35" $0.00 "$1,440.90" $0.00 $0.00 $0.00 $345.98 $0.00 $0.00 $0.00 $0.00 $0.00 $405.07 $0.00 $0.00 $0.00 $0.00 $900.56 "$1,426.49" "$1,440.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19805 ERX HCPCS 63700001 00299-3836-45 METRONIDAZOLE 0.75 % EX CREA BOTH IP/OP "$1,943.71 " "$1,438.35" $0.00 "$1,440.90" $0.00 $0.00 $0.00 $345.98 $0.00 $0.00 $0.00 $0.00 $0.00 $405.07 $0.00 $0.00 $0.00 $0.00 $900.56 "$1,426.49" "$1,440.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19805 ERX HCPCS 63700001 00713-0633-37 METRONIDAZOLE 0.75 % EX CREA BOTH IP/OP "$1,943.71 " "$1,438.35" $0.00 "$1,440.90" $0.00 $0.00 $0.00 $345.98 $0.00 $0.00 $0.00 $0.00 $0.00 $405.07 $0.00 $0.00 $0.00 $0.00 $900.56 "$1,426.49" "$1,440.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19805 ERX HCPCS 63700001 66993-0960-45 METRONIDAZOLE 0.75 % EX CREA BOTH IP/OP "$1,943.71 " "$1,438.35" $0.00 "$1,440.90" $0.00 $0.00 $0.00 $345.98 $0.00 $0.00 $0.00 $0.00 $0.00 $405.07 $0.00 $0.00 $0.00 $0.00 $900.56 "$1,426.49" "$1,440.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19813 ERX HCPCS J7195 70504-0270-01 COAGULATION FACTOR IX (RECOMB IXINITY) 500 UNITS IV SOLR BOTH IP/OP "$2,384.30 " "$1,764.38" $0.00 "$1,837.82" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,769.63" "$1,769.63" "$1,837.82" $0.00 $496.89 $0.00 $0.00 $0.00 $0.00 "$1,081.38" "$1,712.90" "$1,730.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19813 ERX HCPCS J7195 70504-0282-05 COAGULATION FACTOR IX (RECOMB IXINITY) 500 UNITS IV SOLR BOTH IP/OP "$2,384.30 " "$1,764.38" $0.00 "$1,837.82" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,769.63" "$1,769.63" "$1,837.82" $0.00 $496.89 $0.00 $0.00 $0.00 $0.00 "$1,081.38" "$1,712.90" "$1,730.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19814 ERX HCPCS J7195 70504-0271-01 COAGULATION FACTOR IX (RECOMB IXINITY) 1000 UNITS IV SOLR BOTH IP/OP "$4,768.60 " "$3,528.76" $0.00 "$3,675.64" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,539.25" "$3,539.25" "$3,675.64" $0.00 $993.78 $0.00 $0.00 $0.00 $0.00 "$2,162.75" "$3,425.80" "$3,460.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19814 ERX HCPCS J7195 70504-0283-05 COAGULATION FACTOR IX (RECOMB IXINITY) 1000 UNITS IV SOLR BOTH IP/OP "$4,768.60 " "$3,528.76" $0.00 "$3,675.64" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,539.25" "$3,539.25" "$3,675.64" $0.00 $993.78 $0.00 $0.00 $0.00 $0.00 "$2,162.75" "$3,425.80" "$3,460.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19882 ERX HCPCS 63700001 16714-0611-01 SERTRALINE HCL 25 MG PO TABS BOTH IP/OP $11.94 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19882 ERX HCPCS 63700001 16714-0611-04 SERTRALINE HCL 25 MG PO TABS BOTH IP/OP $11.94 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19882 ERX HCPCS 63700001 60687-0231-01 SERTRALINE HCL 25 MG PO TABS BOTH IP/OP $11.94 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19882 ERX HCPCS 63700001 60687-0231-11 SERTRALINE HCL 25 MG PO TABS BOTH IP/OP $11.94 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19882 ERX HCPCS 63700001 76282-0212-18 SERTRALINE HCL 25 MG PO TABS BOTH IP/OP $11.94 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19898 ERX HCPCS J9214 00085-1133-01 INTERFERON ALFA-2B 10000000 UNIT/ML IJ SOLN BOTH IP/OP $982.82 $727.29 $0.00 $786.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $491.41 $778.39 $786.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19928 ERX HCPCS 63700001 65162-0087-74 ITRACONAZOLE 10 MG/ML ORAL SOLUTION BOTH IP/OP $182.66 $135.17 $0.00 $132.50 $0.00 $0.00 $0.00 $32.51 $0.00 $0.00 $0.00 $0.00 $0.00 $38.07 $0.00 $0.00 $0.00 $0.00 $82.81 $131.17 $132.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19928 ERX HCPCS 63700001 99999-6009-61 ITRACONAZOLE 10 MG/ML ORAL SOLUTION BOTH IP/OP $182.66 $135.17 $0.00 $132.50 $0.00 $0.00 $0.00 $32.51 $0.00 $0.00 $0.00 $0.00 $0.00 $38.07 $0.00 $0.00 $0.00 $0.00 $82.81 $131.17 $132.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20032 ERX HCPCS 63700001 63010-0010-30 NELFINAVIR MESYLATE 250 MG PO TABS BOTH IP/OP $93.73 $69.36 $0.00 $67.98 $0.00 $0.00 $0.00 $16.68 $0.00 $0.00 $0.00 $0.00 $0.00 $19.53 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20039 ERX HCPCS 25000001 00173-0523-00 SUMATRIPTAN 20 MG/ACT NA SOLN BOTH IP/OP $359.18 $265.79 $0.00 $276.86 $0.00 $0.00 $0.00 $0.00 $0.00 $266.58 $266.58 $276.86 $0.00 $74.85 $0.00 $0.00 $0.00 $0.00 $153.66 $243.40 $245.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20077 ERX HCPCS 63700001 67108-3565-09 MESNA 400 MG PO TABS BOTH IP/OP $633.76 $468.98 $0.00 $460.23 $0.00 $0.00 $0.00 $112.81 $0.00 $0.00 $0.00 $0.00 $0.00 $132.08 $0.00 $0.00 $0.00 $0.00 $287.65 $455.63 $460.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20103 ERX HCPCS 25000001 92771-0810-16 LUBRISKIN EX LOTN BOTH IP/OP $12.56 $9.29 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20103 ERX HCPCS 25000001 92771-0810-08 LUBRISKIN EX LOTN BOTH IP/OP $11.00 $8.14 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20140 ERX HCPCS 63700001 54162-0500-02 HYDROPHOR EX OINT BOTH IP/OP $46.59 $34.48 $0.00 $37.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.30 $36.90 $37.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20140 ERX HCPCS 63700001 54162-0500-01 HYDROPHOR EX OINT BOTH IP/OP $46.59 $34.48 $0.00 $37.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.30 $36.90 $37.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20140 ERX HCPCS 63700001 10356-0101-10 HYDROPHOR EX OINT BOTH IP/OP $46.59 $34.48 $0.00 $37.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.30 $36.90 $37.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20156 ERX HCPCS J9100 61703-0319-22 CYTARABINE (PF) 100 MG/ML IJ SOLN BOTH IP/OP $87.78 $64.96 $0.00 $70.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.89 $69.52 $70.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20156 ERX HCPCS J9100 63323-0120-20 CYTARABINE (PF) 100 MG/ML IJ SOLN BOTH IP/OP $87.78 $64.96 $0.00 $70.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.89 $69.52 $70.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20156 ERX HCPCS J9100 67457-0452-20 CYTARABINE (PF) 100 MG/ML IJ SOLN BOTH IP/OP $87.78 $64.96 $0.00 $70.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.89 $69.52 $70.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20330 ERX HCPCS 25000001 00023-8335-03 TAZAROTENE 0.05 % EX GEL BOTH IP/OP "$1,205.14 " $891.80 $0.00 $964.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $602.57 $954.47 $964.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20446 ERX HCPCS 63700001 00172-5241-60 ANAGRELIDE HCL 0.5 MG PO CAPS BOTH IP/OP $41.58 $30.77 $0.00 $30.17 $0.00 $0.00 $0.00 $7.40 $0.00 $0.00 $0.00 $0.00 $0.00 $8.67 $0.00 $0.00 $0.00 $0.00 $18.86 $29.87 $30.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20446 ERX HCPCS 63700001 54092-0063-01 ANAGRELIDE HCL 0.5 MG PO CAPS BOTH IP/OP $41.58 $30.77 $0.00 $30.17 $0.00 $0.00 $0.00 $7.40 $0.00 $0.00 $0.00 $0.00 $0.00 $8.67 $0.00 $0.00 $0.00 $0.00 $18.86 $29.87 $30.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20447 ERX HCPCS 63700001 00172-5240-60 ANAGRELIDE HCL 1 MG PO CAPS BOTH IP/OP $92.91 $68.75 $0.00 $67.40 $0.00 $0.00 $0.00 $16.54 $0.00 $0.00 $0.00 $0.00 $0.00 $19.36 $0.00 $0.00 $0.00 $0.00 $42.13 $66.73 $67.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20472 ERX HCPCS 25000001 00143-9310-10 ETOMIDATE 2 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20472 ERX HCPCS 25000001 00143-9506-10 ETOMIDATE 2 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20472 ERX HCPCS 25000001 55150-0221-10 ETOMIDATE 2 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20472 ERX HCPCS 25000001 55150-0222-20 ETOMIDATE 2 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20472 ERX HCPCS 25000001 68382-0545-07 ETOMIDATE 2 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20472 ERX HCPCS 25000001 72266-0146-10 ETOMIDATE 2 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20566 ERX HCPCS 63700001 50268-0525-15 MELOXICAM 7.5 MG PO TABS BOTH IP/OP $12.99 $9.61 $0.00 $9.42 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $0.00 $2.71 $0.00 $0.00 $0.00 $0.00 $5.89 $9.33 $9.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20566 ERX HCPCS 63700001 68382-0050-01 MELOXICAM 7.5 MG PO TABS BOTH IP/OP $12.99 $9.61 $0.00 $9.42 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $0.00 $2.71 $0.00 $0.00 $0.00 $0.00 $5.89 $9.33 $9.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20580 ERX HCPCS 63700001 50268-0526-15 MELOXICAM 15 MG PO TABS BOTH IP/OP $19.54 $14.46 $0.00 $14.18 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20580 ERX HCPCS 63700001 68382-0051-01 MELOXICAM 15 MG PO TABS BOTH IP/OP $19.54 $14.46 $0.00 $14.18 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20638 ERX HCPCS 63700001 00555-9045-58 "FALMINA,ORSYTHIA,LEVONORG-ETHINYL ESTRAD 0.1/0.02MG TAB" BOTH IP/OP $123.09 $91.09 $0.00 $98.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.55 $97.49 $98.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20638 ERX HCPCS 63700001 16714-0359-04 "FALMINA,ORSYTHIA,LEVONORG-ETHINYL ESTRAD 0.1/0.02MG TAB" BOTH IP/OP $123.09 $91.09 $0.00 $98.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.55 $97.49 $98.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20718 ERX HCPCS 63700001 68462-0536-70 IMIQUIMOD 5 % EX CREA BOTH IP/OP $140.20 $103.75 $0.00 $101.70 $0.00 $0.00 $0.00 $24.96 $0.00 $0.00 $0.00 $0.00 $0.00 $29.22 $0.00 $0.00 $0.00 $0.00 $63.56 $100.68 $101.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 00069-3060-75 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 00781-5776-69 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 00904-6708-06 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 50111-0787-10 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 50111-0787-51 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 50268-0098-15 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 51224-0022-30 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 59762-2198-01 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 59762-2198-03 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 59762-2198-07 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 60687-0282-01 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 65862-0641-63 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20943 ERX HCPCS 63700001 65862-0641-69 AZITHROMYCIN 250 MG PO TABS BOTH IP/OP $16.02 $11.85 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20954 ERX HCPCS J1955 54482-0147-01 LEVOCARNITINE 200 MG/ML IV SOLN BOTH IP/OP $157.72 $116.71 $0.00 $121.57 $0.00 $0.00 $0.00 $0.00 $0.00 $117.06 $117.06 $121.57 $0.00 $24.74 $0.00 $0.00 $0.00 $0.00 $69.56 $110.18 $111.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21044 ERX HCPCS J1950 00074-3663-03 LEUPROLIDE ACETATE (3 MONTH) 11.25 MG IM KIT BOTH IP/OP "$12,067.34 " "$8,929.83" $0.00 "$9,757.29" "$5,696.39" "$5,696.39" "$4,098.03" "$4,098.03" "$4,098.03" "$1,647.37" "$9,395.25" "$9,395.25" "$9,757.29" "$4,219.10" "$4,957.44" "$2,742.41" "$5,949.20" "$5,949.20" "$3,998.07" "$5,153.51" "$8,163.16" "$8,245.62" "$5,521.14" "$5,521.14" "$4,480.63" $0.00 $0.00 "$4,266.32" "$3,733.01" $0.00 $0.00 $0.00 $0.00 21045 ERX HCPCS J9217 00074-3346-03 LEUPROLIDE ACETATE (3 MONTH) 22.5 MG IM KIT BOTH IP/OP "$14,379.96 " "$10,641.17" $0.00 "$11,627.18" "$6,788.05" "$6,788.05" $602.20 $602.20 $602.20 $740.50 "$11,195.76" "$11,195.76" "$11,627.18" $417.27 $490.29 $271.23 "$7,089.32" "$7,089.32" $707.80 "$6,141.14" "$9,727.56" "$9,825.82" $977.44 $977.44 $811.00 $0.00 $0.00 $772.21 $617.66 $0.00 $0.00 $0.00 $0.00 21057 ERX HCPCS 63700001 00904-6283-61 OLANZAPINE 2.5 MG PO TABS BOTH IP/OP $46.92 $34.72 $0.00 $34.04 $0.00 $0.00 $0.00 $8.35 $0.00 $0.00 $0.00 $0.00 $0.00 $9.78 $0.00 $0.00 $0.00 $0.00 $21.28 $33.70 $34.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21057 ERX HCPCS 63700001 60505-3110-00 OLANZAPINE 2.5 MG PO TABS BOTH IP/OP $46.92 $34.72 $0.00 $34.04 $0.00 $0.00 $0.00 $8.35 $0.00 $0.00 $0.00 $0.00 $0.00 $9.78 $0.00 $0.00 $0.00 $0.00 $21.28 $33.70 $34.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21057 ERX HCPCS 63700001 68084-0525-01 OLANZAPINE 2.5 MG PO TABS BOTH IP/OP $46.92 $34.72 $0.00 $34.04 $0.00 $0.00 $0.00 $8.35 $0.00 $0.00 $0.00 $0.00 $0.00 $9.78 $0.00 $0.00 $0.00 $0.00 $21.28 $33.70 $34.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21061 ERX HCPCS 63700001 62756-0184-13 OXCARBAZEPINE 300 MG PO TABS BOTH IP/OP $10.60 $7.84 $0.00 $8.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $8.40 $8.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21061 ERX HCPCS 63700001 62756-0184-88 OXCARBAZEPINE 300 MG PO TABS BOTH IP/OP $10.60 $7.84 $0.00 $8.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $8.40 $8.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21061 ERX HCPCS 63700001 68084-0853-01 OXCARBAZEPINE 300 MG PO TABS BOTH IP/OP $10.60 $7.84 $0.00 $8.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $8.40 $8.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21062 ERX HCPCS 63700001 00904-6085-61 CITALOPRAM HYDROBROMIDE 20 MG PO TABS BOTH IP/OP $11.29 $8.35 $0.00 $8.19 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.12 $8.11 $8.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21062 ERX HCPCS 63700001 13668-0010-01 CITALOPRAM HYDROBROMIDE 20 MG PO TABS BOTH IP/OP $11.29 $8.35 $0.00 $8.19 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.12 $8.11 $8.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21062 ERX HCPCS 63700001 55111-0343-30 CITALOPRAM HYDROBROMIDE 20 MG PO TABS BOTH IP/OP $11.29 $8.35 $0.00 $8.19 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.12 $8.11 $8.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21062 ERX HCPCS 63700001 57664-0508-88 CITALOPRAM HYDROBROMIDE 20 MG PO TABS BOTH IP/OP $11.29 $8.35 $0.00 $8.19 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.12 $8.11 $8.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21062 ERX HCPCS 63700001 68084-0744-01 CITALOPRAM HYDROBROMIDE 20 MG PO TABS BOTH IP/OP $11.29 $8.35 $0.00 $8.19 $0.00 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.12 $8.11 $8.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21063 ERX HCPCS J0456 00069-3150-83 AZITHROMYCIN 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $21.89 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 21063 ERX HCPCS J0456 55150-0174-10 AZITHROMYCIN 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $21.89 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 21063 ERX HCPCS J0456 63323-0398-10 AZITHROMYCIN 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $21.89 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 21063 ERX HCPCS J0456 63323-0398-12 AZITHROMYCIN 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $21.89 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 21063 ERX HCPCS J0456 67457-0860-50 AZITHROMYCIN 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $21.89 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 21063 ERX HCPCS J0456 70860-0100-10 AZITHROMYCIN 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $21.89 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 21063 ERX HCPCS J0456 70860-0100-41 AZITHROMYCIN 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $21.89 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 21063 ERX HCPCS J0456 70860-0125-66 AZITHROMYCIN 500 MG IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $21.89 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 21064 ERX HCPCS 25000001 00904-6488-38 LUBRIFRESH P.M. OP OINT BOTH IP/OP $18.85 $13.95 $0.00 $15.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.43 $14.93 $15.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21108 ERX HCPCS J9217 00074-3683-03 LEUPROLIDE ACETATE (4 MONTH) 30 MG IM KIT BOTH IP/OP "$19,173.30 " "$14,188.24" $0.00 "$15,502.93" "$9,050.75" "$9,050.75" $802.93 $802.93 $802.93 $987.33 "$14,927.71" "$14,927.71" "$15,502.93" $556.36 $653.72 $361.63 "$9,452.44" "$9,452.44" $943.73 "$8,188.19" "$12,970.09" "$13,101.10" "$1,303.25" "$1,303.25" "$1,081.33" $0.00 $0.00 "$1,029.61" $823.54 $0.00 $0.00 $0.00 $0.00 21135 ERX HCPCS 25000001 47335-0788-91 DESMOPRESSIN ACETATE SPRAY 0.01 % NA SOLN BOTH IP/OP $719.05 $532.10 $0.00 $554.24 $0.00 $0.00 $0.00 $0.00 $0.00 $533.68 $533.68 $554.24 $0.00 $149.85 $0.00 $0.00 $0.00 $0.00 $326.29 $516.84 $522.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21135 ERX HCPCS 25000001 68382-0384-01 DESMOPRESSIN ACETATE SPRAY 0.01 % NA SOLN BOTH IP/OP $719.05 $532.10 $0.00 $554.24 $0.00 $0.00 $0.00 $0.00 $0.00 $533.68 $533.68 $554.24 $0.00 $149.85 $0.00 $0.00 $0.00 $0.00 $326.29 $516.84 $522.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21135 ERX HCPCS 25000001 69918-0501-05 DESMOPRESSIN ACETATE SPRAY 0.01 % NA SOLN BOTH IP/OP $719.05 $532.10 $0.00 $554.24 $0.00 $0.00 $0.00 $0.00 $0.00 $533.68 $533.68 $554.24 $0.00 $149.85 $0.00 $0.00 $0.00 $0.00 $326.29 $516.84 $522.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21157 ERX HCPCS 63700001 62756-0185-88 OXCARBAZEPINE 600 MG PO TABS BOTH IP/OP $21.22 $15.70 $0.00 $15.39 $0.00 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $9.62 $15.24 $15.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21157 ERX HCPCS 63700001 68084-0867-01 OXCARBAZEPINE 600 MG PO TABS BOTH IP/OP $21.22 $15.70 $0.00 $15.39 $0.00 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $9.62 $15.24 $15.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21157 ERX HCPCS 63700001 68084-0867-11 OXCARBAZEPINE 600 MG PO TABS BOTH IP/OP $21.22 $15.70 $0.00 $15.39 $0.00 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $9.62 $15.24 $15.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21284 ERX HCPCS 63700001 13107-0068-01 AMPHETAMINE-DEXTROAMPHETAMINE 5 MG PO TABS BOTH IP/OP $7.19 $5.32 $0.00 $5.22 $0.00 $0.00 $0.00 $1.28 $0.00 $0.00 $0.00 $0.00 $0.00 $1.50 $0.00 $0.00 $0.00 $0.00 $3.26 $5.16 $5.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21284 ERX HCPCS 63700001 42806-0339-01 AMPHETAMINE-DEXTROAMPHETAMINE 5 MG PO TABS BOTH IP/OP $7.19 $5.32 $0.00 $5.22 $0.00 $0.00 $0.00 $1.28 $0.00 $0.00 $0.00 $0.00 $0.00 $1.50 $0.00 $0.00 $0.00 $0.00 $3.26 $5.16 $5.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21285 ERX HCPCS J0795 55566-0302-01 CORTICORELIN OVINE TRIFLUTATE 100 MCG IV SOLR BOTH IP/OP "$2,244.90 " "$1,661.23" $0.00 "$1,795.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,122.45" "$1,777.96" "$1,795.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21287 ERX HCPCS 63700001 00597-0183-90 PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS BOTH IP/OP $32.02 $23.69 $0.00 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.01 $25.36 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21287 ERX HCPCS 63700001 33342-0031-10 PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS BOTH IP/OP $32.02 $23.69 $0.00 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.01 $25.36 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21287 ERX HCPCS 63700001 68382-0196-16 PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS BOTH IP/OP $32.02 $23.69 $0.00 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.01 $25.36 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21287 ERX HCPCS 63700001 68462-0330-90 PRAMIPEXOLE DIHYDROCHLORIDE 0.125 MG PO TABS BOTH IP/OP $32.02 $23.69 $0.00 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.01 $25.36 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21288 ERX HCPCS 63700001 33342-0034-10 PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS BOTH IP/OP $33.62 $24.88 $0.00 $26.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.81 $26.63 $26.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21288 ERX HCPCS 63700001 68382-0199-16 PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS BOTH IP/OP $33.62 $24.88 $0.00 $26.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.81 $26.63 $26.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21288 ERX HCPCS 63700001 68462-0333-90 PRAMIPEXOLE DIHYDROCHLORIDE 1 MG PO TABS BOTH IP/OP $33.62 $24.88 $0.00 $26.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.81 $26.63 $26.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21289 ERX HCPCS 63700001 00781-5252-92 PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG PO TABS BOTH IP/OP $11.21 $8.30 $0.00 $8.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.61 $8.88 $8.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21289 ERX HCPCS 63700001 33342-0035-10 PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG PO TABS BOTH IP/OP $11.21 $8.30 $0.00 $8.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.61 $8.88 $8.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21289 ERX HCPCS 63700001 68382-0200-16 PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG PO TABS BOTH IP/OP $11.21 $8.30 $0.00 $8.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.61 $8.88 $8.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21289 ERX HCPCS 63700001 68462-0334-90 PRAMIPEXOLE DIHYDROCHLORIDE 1.5 MG PO TABS BOTH IP/OP $11.21 $8.30 $0.00 $8.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.61 $8.88 $8.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21290 ERX HCPCS 63700001 13668-0092-90 PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS BOTH IP/OP $13.58 $10.05 $0.00 $9.86 $0.00 $0.00 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $2.83 $0.00 $0.00 $0.00 $0.00 $6.16 $9.76 $9.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21290 ERX HCPCS 63700001 33342-0032-10 PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS BOTH IP/OP $13.58 $10.05 $0.00 $9.86 $0.00 $0.00 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $2.83 $0.00 $0.00 $0.00 $0.00 $6.16 $9.76 $9.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21290 ERX HCPCS 63700001 68382-0197-16 PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS BOTH IP/OP $13.58 $10.05 $0.00 $9.86 $0.00 $0.00 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $2.83 $0.00 $0.00 $0.00 $0.00 $6.16 $9.76 $9.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21290 ERX HCPCS 63700001 68462-0331-90 PRAMIPEXOLE DIHYDROCHLORIDE 0.25 MG PO TABS BOTH IP/OP $13.58 $10.05 $0.00 $9.86 $0.00 $0.00 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $2.83 $0.00 $0.00 $0.00 $0.00 $6.16 $9.76 $9.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21300 ERX HCPCS 63700001 00904-5448-61 PENTOXIFYLLINE ER 400 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21321 ERX HCPCS 63700001 52544-0256-12 PROGESTERONE 8 % VA GEL BOTH IP/OP $12.03 $8.90 $0.00 $8.73 $0.00 $0.00 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $0.00 $2.51 $0.00 $0.00 $0.00 $0.00 $5.46 $8.64 $8.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21321 ERX HCPCS 63700001 52544-0256-54 PROGESTERONE 8 % VA GEL BOTH IP/OP $12.03 $8.90 $0.00 $8.73 $0.00 $0.00 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $0.00 $2.51 $0.00 $0.00 $0.00 $0.00 $5.46 $8.64 $8.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 00004-0260-01 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 00054-0166-25 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 16729-0019-01 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 51079-0379-01 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 51079-0379-20 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 60687-0438-01 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 60687-0438-11 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 64380-0725-06 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 67877-0225-01 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21374 ERX HCPCS J7517 67877-0225-05 MYCOPHENOLATE MOFETIL 500 MG PO TABS BOTH IP/OP $83.34 $61.67 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.24 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.79 $59.85 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 21381 ERX HCPCS 25000001 10858-0081-07 BARIUM SULFATE PO CAPS BOTH IP/OP $75.60 $55.94 $0.00 $60.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.80 $59.88 $60.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21381 ERX HCPCS 25000001 10858-0081-10 BARIUM SULFATE PO CAPS BOTH IP/OP $75.60 $55.94 $0.00 $60.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.80 $59.88 $60.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21509 ERX HCPCS 63700001 00078-0249-15 LETROZOLE 2.5 MG PO TABS BOTH IP/OP $108.41 $80.22 $0.00 $78.64 $0.00 $0.00 $0.00 $19.30 $0.00 $0.00 $0.00 $0.00 $0.00 $22.59 $0.00 $0.00 $0.00 $0.00 $49.15 $77.85 $78.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21509 ERX HCPCS 63700001 00093-7620-56 LETROZOLE 2.5 MG PO TABS BOTH IP/OP $108.41 $80.22 $0.00 $78.64 $0.00 $0.00 $0.00 $19.30 $0.00 $0.00 $0.00 $0.00 $0.00 $22.59 $0.00 $0.00 $0.00 $0.00 $49.15 $77.85 $78.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21509 ERX HCPCS 63700001 16729-0034-10 LETROZOLE 2.5 MG PO TABS BOTH IP/OP $108.41 $80.22 $0.00 $78.64 $0.00 $0.00 $0.00 $19.30 $0.00 $0.00 $0.00 $0.00 $0.00 $22.59 $0.00 $0.00 $0.00 $0.00 $49.15 $77.85 $78.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21509 ERX HCPCS 63700001 50268-0476-15 LETROZOLE 2.5 MG PO TABS BOTH IP/OP $108.41 $80.22 $0.00 $78.64 $0.00 $0.00 $0.00 $19.30 $0.00 $0.00 $0.00 $0.00 $0.00 $22.59 $0.00 $0.00 $0.00 $0.00 $49.15 $77.85 $78.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21509 ERX HCPCS 63700001 51991-0759-33 LETROZOLE 2.5 MG PO TABS BOTH IP/OP $108.41 $80.22 $0.00 $78.64 $0.00 $0.00 $0.00 $19.30 $0.00 $0.00 $0.00 $0.00 $0.00 $22.59 $0.00 $0.00 $0.00 $0.00 $49.15 $77.85 $78.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21509 ERX HCPCS 63700001 60505-3255-03 LETROZOLE 2.5 MG PO TABS BOTH IP/OP $108.41 $80.22 $0.00 $78.64 $0.00 $0.00 $0.00 $19.30 $0.00 $0.00 $0.00 $0.00 $0.00 $22.59 $0.00 $0.00 $0.00 $0.00 $49.15 $77.85 $78.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21570 ERX HCPCS J9030 00052-0602-02 BCG LIVE 50 MG IS SUSR BOTH IP/OP $633.30 $468.64 $0.00 $488.15 $284.99 $284.99 $0.00 $0.00 $0.00 $132.00 $470.04 $470.04 $488.15 $0.00 $167.44 $0.00 $374.60 $374.60 $148.10 $287.44 $455.30 $459.90 $204.52 $204.52 $166.26 $0.00 $0.00 $158.31 $141.05 $0.00 $0.00 $0.00 $0.00 21688 ERX HCPCS 63700001 00378-5525-01 ROPINIROLE HCL 0.25 MG PO TABS BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21688 ERX HCPCS 63700001 43547-0268-10 ROPINIROLE HCL 0.25 MG PO TABS BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21688 ERX HCPCS 63700001 62332-0030-31 ROPINIROLE HCL 0.25 MG PO TABS BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21689 ERX HCPCS 63700001 00904-6374-61 ROPINIROLE HCL 1 MG PO TABS BOTH IP/OP $10.50 $7.77 $0.00 $7.62 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $4.76 $7.54 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21689 ERX HCPCS 63700001 43547-0270-10 ROPINIROLE HCL 1 MG PO TABS BOTH IP/OP $10.50 $7.77 $0.00 $7.62 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $4.76 $7.54 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21689 ERX HCPCS 63700001 68462-0255-01 ROPINIROLE HCL 1 MG PO TABS BOTH IP/OP $10.50 $7.77 $0.00 $7.62 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $4.76 $7.54 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21690 ERX HCPCS 63700001 43547-0271-10 ROPINIROLE HCL 2 MG PO TABS BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21690 ERX HCPCS 63700001 62332-0033-31 ROPINIROLE HCL 2 MG PO TABS BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21690 ERX HCPCS 63700001 68462-0256-01 ROPINIROLE HCL 2 MG PO TABS BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21691 ERX HCPCS 63700001 43547-0274-10 ROPINIROLE HCL 5 MG PO TABS BOTH IP/OP $10.90 $8.07 $0.00 $7.90 $0.00 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $4.94 $7.82 $7.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21800 ERX HCPCS 63700001 43547-0269-10 ROPINIROLE HCL 0.5 MG PO TABS BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21810 ERX HCPCS 63700001 31722-0506-60 COMBIVIR: LAMIVUDINE-ZIDOVUDINE 150-300 MG PO TABS BOTH IP/OP $65.06 $48.14 $0.00 $47.21 $0.00 $0.00 $0.00 $11.58 $0.00 $0.00 $0.00 $0.00 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $29.51 $46.74 $47.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21810 ERX HCPCS 63700001 64380-0707-03 COMBIVIR: LAMIVUDINE-ZIDOVUDINE 150-300 MG PO TABS BOTH IP/OP $65.06 $48.14 $0.00 $47.21 $0.00 $0.00 $0.00 $11.58 $0.00 $0.00 $0.00 $0.00 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $29.51 $46.74 $47.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21823 ERX HCPCS 63700001 00054-0220-20 QUETIAPINE FUMARATE 25 MG PO TABS BOTH IP/OP $19.54 $14.46 $0.00 $14.18 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21823 ERX HCPCS 63700001 00310-0275-10 QUETIAPINE FUMARATE 25 MG PO TABS BOTH IP/OP $19.54 $14.46 $0.00 $14.18 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21823 ERX HCPCS 63700001 00904-6638-61 QUETIAPINE FUMARATE 25 MG PO TABS BOTH IP/OP $19.54 $14.46 $0.00 $14.18 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21823 ERX HCPCS 63700001 16729-0145-01 QUETIAPINE FUMARATE 25 MG PO TABS BOTH IP/OP $19.54 $14.46 $0.00 $14.18 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21823 ERX HCPCS 63700001 50268-0630-15 QUETIAPINE FUMARATE 25 MG PO TABS BOTH IP/OP $19.54 $14.46 $0.00 $14.18 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21823 ERX HCPCS 63700001 60687-0327-01 QUETIAPINE FUMARATE 25 MG PO TABS BOTH IP/OP $19.54 $14.46 $0.00 $14.18 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21824 ERX HCPCS 63700001 00054-0221-20 QUETIAPINE FUMARATE 100 MG PO TABS BOTH IP/OP $26.07 $19.29 $0.00 $20.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.04 $20.65 $20.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21824 ERX HCPCS 63700001 50268-0632-15 QUETIAPINE FUMARATE 100 MG PO TABS BOTH IP/OP $26.07 $19.29 $0.00 $20.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.04 $20.65 $20.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21824 ERX HCPCS 63700001 63739-0665-10 QUETIAPINE FUMARATE 100 MG PO TABS BOTH IP/OP $26.07 $19.29 $0.00 $20.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.04 $20.65 $20.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21825 ERX HCPCS 63700001 16714-0455-01 QUETIAPINE FUMARATE 200 MG PO TABS BOTH IP/OP $54.21 $40.12 $0.00 $39.34 $0.00 $0.00 $0.00 $9.65 $0.00 $0.00 $0.00 $0.00 $0.00 $11.30 $0.00 $0.00 $0.00 $0.00 $24.59 $38.94 $39.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21825 ERX HCPCS 63700001 47335-0905-88 QUETIAPINE FUMARATE 200 MG PO TABS BOTH IP/OP $54.21 $40.12 $0.00 $39.34 $0.00 $0.00 $0.00 $9.65 $0.00 $0.00 $0.00 $0.00 $0.00 $11.30 $0.00 $0.00 $0.00 $0.00 $24.59 $38.94 $39.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21827 ERX HCPCS 25000001 63459-0404-30 TIAGABINE HCL 4 MG PO TABS BOTH IP/OP $59.89 $44.32 $0.00 $46.16 $0.00 $0.00 $0.00 $0.00 $0.00 $44.45 $44.45 $46.16 $0.00 $12.48 $0.00 $0.00 $0.00 $0.00 $22.69 $35.94 $36.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21867 ERX HCPCS 63700001 76336-0455-18 METYRAPONE 250 MG PO CAPS BOTH IP/OP $149.19 $110.40 $0.00 $98.47 $0.00 $0.00 $0.00 $33.19 $0.00 $0.00 $0.00 $0.00 $0.00 $31.09 $0.00 $0.00 $0.00 $0.00 $61.55 $97.49 $98.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21900 ERX HCPCS J0289 00469-3051-30 AMPHOTERICIN B LIPOSOME 50 MG IV SUSR BOTH IP/OP $936.59 $693.08 $0.00 $764.49 $0.00 $0.00 $0.00 $0.00 $0.00 $736.12 $736.12 $764.49 $0.00 $195.19 $0.00 $0.00 $0.00 $0.00 $412.61 $653.57 $660.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21905 ERX HCPCS 25000001 00085-1288-01 MOMETASONE FUROATE 50 MCG/ACT NA SUSP BOTH IP/OP $799.55 $591.67 $0.00 $639.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $399.78 $633.24 $639.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22120 ERX HCPCS 90675 58160-0964-12 "RABIES VACCINE, PCEC IM SUSR" BOTH IP/OP "$1,264.92 " $936.04 $0.00 "$1,023.75" $597.68 $597.68 $341.95 $341.95 $341.95 $174.76 $985.77 $985.77 "$1,023.75" $327.53 $384.85 $212.90 $748.20 $748.20 $312.47 $551.91 $874.22 $883.05 $431.50 $431.50 $326.44 $0.00 $0.00 $310.83 $294.72 $0.00 $0.00 $0.00 $0.00 22142 ERX HCPCS 25000001 00904-6294-61 CLOPIDOGREL BISULFATE 75 MG PO TABS BOTH IP/OP $29.40 $21.76 $0.00 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.70 $23.28 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22142 ERX HCPCS 25000001 47335-0894-83 CLOPIDOGREL BISULFATE 75 MG PO TABS BOTH IP/OP $29.40 $21.76 $0.00 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.70 $23.28 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22142 ERX HCPCS 25000001 55111-0196-30 CLOPIDOGREL BISULFATE 75 MG PO TABS BOTH IP/OP $29.40 $21.76 $0.00 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.70 $23.28 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22142 ERX HCPCS 25000001 55111-0196-90 CLOPIDOGREL BISULFATE 75 MG PO TABS BOTH IP/OP $29.40 $21.76 $0.00 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.70 $23.28 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22142 ERX HCPCS 25000001 65862-0357-30 CLOPIDOGREL BISULFATE 75 MG PO TABS BOTH IP/OP $29.40 $21.76 $0.00 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.70 $23.28 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22142 ERX HCPCS 25000001 68084-0536-01 CLOPIDOGREL BISULFATE 75 MG PO TABS BOTH IP/OP $29.40 $21.76 $0.00 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.70 $23.28 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22143 ERX HCPCS 63700001 00093-7290-01 RALOXIFENE HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22143 ERX HCPCS 63700001 00093-7290-56 RALOXIFENE HCL 60 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22148 ERX HCPCS 63700001 69543-0120-10 ACARBOSE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22220 ERX HCPCS 25000001 50484-0810-15 BECAPLERMIN 0.01 % EX GEL BOTH IP/OP "$3,344.71 " "$2,475.09" $0.00 "$2,578.10" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,482.44" "$2,482.44" "$2,578.10" $0.00 $697.04 $0.00 $0.00 $0.00 $0.00 "$1,444.76" "$2,288.50" "$2,311.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22290 ERX HCPCS 25000001 00093-4136-73 CEFDINIR 125 MG/5ML PO SUSR BOTH IP/OP $280.38 $207.48 $0.00 $216.12 $0.00 $0.00 $0.00 $0.00 $0.00 $208.10 $208.10 $216.12 $0.00 $58.43 $0.00 $0.00 $0.00 $0.00 $127.26 $201.58 $203.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22290 ERX HCPCS 25000001 00781-6077-46 CEFDINIR 125 MG/5ML PO SUSR BOTH IP/OP $280.38 $207.48 $0.00 $216.12 $0.00 $0.00 $0.00 $0.00 $0.00 $208.10 $208.10 $216.12 $0.00 $58.43 $0.00 $0.00 $0.00 $0.00 $127.26 $201.58 $203.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22290 ERX HCPCS 25000001 65862-0218-01 CEFDINIR 125 MG/5ML PO SUSR BOTH IP/OP $280.38 $207.48 $0.00 $216.12 $0.00 $0.00 $0.00 $0.00 $0.00 $208.10 $208.10 $216.12 $0.00 $58.43 $0.00 $0.00 $0.00 $0.00 $127.26 $201.58 $203.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22456 ERX HCPCS 63700001 59528-0331-02 CALCIUM ACETATE (PHOS BINDER) 667 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22456 ERX HCPCS 63700001 71321-0803-20 CALCIUM ACETATE (PHOS BINDER) 667 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22469 ERX HCPCS 63700001 00904-5224-52 LACTASE 3000 UNITS PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 00338-0069-10 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 00409-3793-01 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 00641-6041-25 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 25021-0700-01 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 47781-0583-68 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 63323-0161-01 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 63323-0161-12 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 70860-0700-02 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 70860-0700-41 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22472 ERX HCPCS J1885 72611-0719-25 KETOROLAC TROMETHAMINE 15 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.32 $16.33 $16.33 $16.96 $0.00 $0.57 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 00338-0072-25 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 00409-3795-01 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 00641-6042-01 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 00641-6042-25 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 25021-0701-01 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 47781-0584-68 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 63323-0162-01 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 63323-0162-12 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 70860-0701-01 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 70860-0701-03 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22473 ERX HCPCS J1885 72611-0722-25 KETOROLAC TROMETHAMINE 30 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.61 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $0.00 22509 ERX HCPCS 63700001 00904-6808-61 MONTELUKAST SODIUM 10 MG PO TABS BOTH IP/OP $23.08 $17.08 $0.00 $16.74 $0.00 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 $4.81 $0.00 $0.00 $0.00 $0.00 $10.47 $16.58 $16.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22509 ERX HCPCS 63700001 50268-0575-15 MONTELUKAST SODIUM 10 MG PO TABS BOTH IP/OP $23.08 $17.08 $0.00 $16.74 $0.00 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 $4.81 $0.00 $0.00 $0.00 $0.00 $10.47 $16.58 $16.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22509 ERX HCPCS 63700001 65862-0574-90 MONTELUKAST SODIUM 10 MG PO TABS BOTH IP/OP $23.08 $17.08 $0.00 $16.74 $0.00 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 $4.81 $0.00 $0.00 $0.00 $0.00 $10.47 $16.58 $16.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22509 ERX HCPCS 63700001 68084-0875-01 MONTELUKAST SODIUM 10 MG PO TABS BOTH IP/OP $23.08 $17.08 $0.00 $16.74 $0.00 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 $4.81 $0.00 $0.00 $0.00 $0.00 $10.47 $16.58 $16.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22510 ERX HCPCS 63700001 50268-0574-15 MONTELUKAST SODIUM 5 MG PO CHEW BOTH IP/OP $21.08 $15.60 $0.00 $15.30 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $9.56 $15.14 $15.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22510 ERX HCPCS 63700001 57237-0213-30 MONTELUKAST SODIUM 5 MG PO CHEW BOTH IP/OP $21.08 $15.60 $0.00 $15.30 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $9.56 $15.14 $15.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22510 ERX HCPCS 63700001 65862-0568-90 MONTELUKAST SODIUM 5 MG PO CHEW BOTH IP/OP $21.08 $15.60 $0.00 $15.30 $0.00 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $9.56 $15.14 $15.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22560 ERX HCPCS 63700001 99999-6005-56 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP BOTH IP/OP $85.47 $63.25 $0.00 $61.99 $0.00 $0.00 $0.00 $15.21 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $0.00 $0.00 $0.00 $0.00 $38.75 $61.37 $61.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22560 ERX HCPCS 63700001 00121-0854-16 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP BOTH IP/OP $85.47 $63.25 $0.00 $451.69 $0.00 $0.00 $0.00 $15.21 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $0.00 $0.00 $0.00 $0.00 $38.75 $451.69 $61.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22560 ERX HCPCS 63700001 50383-0823-16 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP BOTH IP/OP $85.47 $63.25 $0.00 $451.69 $0.00 $0.00 $0.00 $15.21 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $0.00 $0.00 $0.00 $0.00 $38.75 $451.69 $61.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22560 ERX HCPCS 63700001 50383-0824-16 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP BOTH IP/OP $85.47 $63.25 $0.00 $451.69 $0.00 $0.00 $0.00 $15.21 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $0.00 $0.00 $0.00 $0.00 $38.75 $451.69 $61.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22560 ERX HCPCS 63700001 65862-0496-47 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5ML PO SUSP BOTH IP/OP $85.47 $63.25 $0.00 $451.69 $0.00 $0.00 $0.00 $15.21 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $0.00 $0.00 $0.00 $0.00 $38.75 $451.69 $61.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 00006-0960-31 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 00904-6389-61 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 13668-0115-90 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 31722-0702-30 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 31722-0702-90 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 50268-0518-15 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 63739-0698-10 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 65862-0203-30 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 65862-0203-99 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22588 ERX HCPCS 63700001 68084-0348-01 LOSARTAN POTASSIUM 100 MG PO TABS BOTH IP/OP $25.45 $18.83 $0.00 $18.46 $0.00 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 $5.30 $0.00 $0.00 $0.00 $0.00 $11.54 $18.28 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22953 ERX HCPCS 63700001 00065-0275-10 BRINZOLAMIDE 1 % OP SUSP BOTH IP/OP "$1,202.69 " $889.99 $0.00 $827.67 $0.00 $0.00 $0.00 $214.08 $0.00 $0.00 $0.00 $0.00 $0.00 $250.64 $0.00 $0.00 $0.00 $0.00 $517.30 $819.40 $827.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22959 ERX HCPCS 25000001 99999-6004-88 PAROXETINE HCL 10 MG/5ML PO SUSP BOTH IP/OP $263.17 $194.75 $0.00 $202.85 $0.00 $0.00 $0.00 $0.00 $0.00 $195.32 $195.32 $202.85 $0.00 $54.84 $0.00 $0.00 $0.00 $0.00 $119.45 $189.21 $191.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22959 ERX HCPCS 25000001 60505-0402-05 PAROXETINE HCL 10 MG/5ML PO SUSP BOTH IP/OP $263.17 $194.75 $0.00 $925.05 $0.00 $0.00 $0.00 $0.00 $0.00 $195.32 $195.32 $202.85 $0.00 $54.84 $0.00 $0.00 $0.00 $0.00 $119.45 $925.05 $191.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22981 ERX HCPCS J0287 57665-0101-41 AMPHOTERICIN B LIPID 5 MG/ML IV SUSP BOTH IP/OP $423.36 $313.29 $0.00 $326.33 $0.00 $0.00 $0.00 $0.00 $0.00 $314.22 $314.22 $326.33 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22993 ERX HCPCS J8520 00004-1100-20 CAPECITABINE 150 MG PO TABS BOTH IP/OP $68.17 $50.45 $0.00 $52.55 $0.00 $0.00 $0.00 $0.00 $0.00 $50.60 $50.60 $52.55 $0.00 $14.21 $0.00 $0.00 $0.00 $0.00 $30.92 $48.97 $49.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22994 ERX HCPCS J8521 00004-1101-50 CAPECITABINE 500 MG PO TABS BOTH IP/OP $188.16 $139.24 $0.00 $145.03 $0.00 $0.00 $0.00 $0.00 $0.00 $139.65 $139.65 $145.03 $0.00 $39.21 $0.00 $0.00 $0.00 $0.00 $85.41 $135.28 $136.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22994 ERX HCPCS J8521 72485-0205-12 CAPECITABINE 500 MG PO TABS BOTH IP/OP $188.16 $139.24 $0.00 $145.03 $0.00 $0.00 $0.00 $0.00 $0.00 $139.65 $139.65 $145.03 $0.00 $39.21 $0.00 $0.00 $0.00 $0.00 $85.41 $135.28 $136.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23009 ERX HCPCS 63700001 00003-6335-17 HYDROXYUREA 200 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23010 ERX HCPCS 63700001 00003-6336-17 HYDROXYUREA 300 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23011 ERX HCPCS 63700001 00003-6337-17 HYDROXYUREA 400 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23036 ERX HCPCS 25000001 51552-0071-05 POTASSIUM HYDROXIDE 10 % SOLN BOTH IP/OP $220.35 $163.06 $0.00 $169.85 $0.00 $0.00 $0.00 $0.00 $0.00 $163.54 $163.54 $169.85 $0.00 $45.92 $0.00 $0.00 $0.00 $0.00 $100.02 $158.42 $160.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23063 ERX HCPCS 25000001 CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN BOTH IP/OP $18.56 $13.73 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23063 ERX HCPCS 25000001 00536-1268-12 CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN BOTH IP/OP $18.56 $13.73 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23063 ERX HCPCS 25000001 54162-0550-07 CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN BOTH IP/OP $18.56 $13.73 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23063 ERX HCPCS 25000001 54162-0550-09 CAMPHOR-MENTHOL 0.5-0.5 % EX LOTN BOTH IP/OP $18.56 $13.73 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23065 ERX HCPCS 63700001 19076-9022-00 ELTA EX CREA BOTH IP/OP $128.04 $94.75 $0.00 $92.88 $0.00 $0.00 $0.00 $22.79 $0.00 $0.00 $0.00 $0.00 $0.00 $26.68 $0.00 $0.00 $0.00 $0.00 $58.05 $91.95 $92.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23128 ERX HCPCS J0133 55150-0154-10 ACYCLOVIR SODIUM 50 MG/ML IV SOLN BOTH IP/OP $67.04 $49.61 $0.00 $51.67 $30.17 $30.17 $0.00 $0.00 $0.00 $10.58 $49.76 $49.76 $51.67 $0.00 $4.70 $0.00 $39.65 $39.65 $0.00 $30.40 $48.15 $48.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23128 ERX HCPCS J0133 55150-0154-11 ACYCLOVIR SODIUM 50 MG/ML IV SOLN BOTH IP/OP $67.04 $49.61 $0.00 $51.67 $30.17 $30.17 $0.00 $0.00 $0.00 $10.58 $49.76 $49.76 $51.67 $0.00 $4.70 $0.00 $39.65 $39.65 $0.00 $30.40 $48.15 $48.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23128 ERX HCPCS J0133 63323-0325-10 ACYCLOVIR SODIUM 50 MG/ML IV SOLN BOTH IP/OP $67.04 $49.61 $0.00 $51.67 $30.17 $30.17 $0.00 $0.00 $0.00 $10.58 $49.76 $49.76 $51.67 $0.00 $4.70 $0.00 $39.65 $39.65 $0.00 $30.40 $48.15 $48.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23128 ERX HCPCS J0133 55150-0155-21 ACYCLOVIR SODIUM 50 MG/ML IV SOLN BOTH IP/OP $67.04 $49.61 $0.00 $116.42 $30.17 $30.17 $0.00 $0.00 $0.00 $10.58 $49.76 $49.76 $51.67 $0.00 $4.70 $0.00 $39.65 $39.65 $0.00 $30.40 $116.42 $48.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23128 ERX HCPCS J0133 63323-0325-20 ACYCLOVIR SODIUM 50 MG/ML IV SOLN BOTH IP/OP $67.04 $49.61 $0.00 $116.42 $30.17 $30.17 $0.00 $0.00 $0.00 $10.58 $49.76 $49.76 $51.67 $0.00 $4.70 $0.00 $39.65 $39.65 $0.00 $30.40 $116.42 $48.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23233 ERX HCPCS 25000001 49884-0902-78 MAFENIDE ACETATE 5 % EX PACK BOTH IP/OP $680.56 $503.61 $0.00 $524.58 $0.00 $0.00 $0.00 $0.00 $0.00 $505.11 $505.11 $524.58 $0.00 $141.83 $0.00 $0.00 $0.00 $0.00 $308.82 $489.17 $494.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23233 ERX HCPCS 25000001 50742-0310-25 MAFENIDE ACETATE 5 % EX PACK BOTH IP/OP $680.56 $503.61 $0.00 $524.58 $0.00 $0.00 $0.00 $0.00 $0.00 $505.11 $505.11 $524.58 $0.00 $141.83 $0.00 $0.00 $0.00 $0.00 $308.82 $489.17 $494.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23233 ERX HCPCS 25000001 50742-0310-50 MAFENIDE ACETATE 5 % EX PACK BOTH IP/OP $680.56 $503.61 $0.00 $524.58 $0.00 $0.00 $0.00 $0.00 $0.00 $505.11 $505.11 $524.58 $0.00 $141.83 $0.00 $0.00 $0.00 $0.00 $308.82 $489.17 $494.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23233 ERX HCPCS 25000001 51079-0624-85 MAFENIDE ACETATE 5 % EX PACK BOTH IP/OP $680.56 $503.61 $0.00 $524.58 $0.00 $0.00 $0.00 $0.00 $0.00 $505.11 $505.11 $524.58 $0.00 $141.83 $0.00 $0.00 $0.00 $0.00 $308.82 $489.17 $494.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23365 ERX HCPCS 63700001 00088-2102-01 RIFAPENTINE 150 MG PO TABS BOTH IP/OP $38.20 $28.27 $0.00 $55.43 $0.00 $0.00 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $34.65 $54.88 $55.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23365 ERX HCPCS 63700001 00088-2102-24 RIFAPENTINE 150 MG PO TABS BOTH IP/OP $38.20 $28.27 $0.00 $55.43 $0.00 $0.00 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $34.65 $54.88 $55.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23449 ERX HCPCS 63700001 16714-0685-01 SIMVASTATIN 80 MG PO TABS BOTH IP/OP $20.55 $15.21 $0.00 $14.91 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $9.32 $14.76 $14.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23449 ERX HCPCS 63700001 16714-0685-02 SIMVASTATIN 80 MG PO TABS BOTH IP/OP $20.55 $15.21 $0.00 $14.91 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $9.32 $14.76 $14.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23449 ERX HCPCS 63700001 65862-0054-30 SIMVASTATIN 80 MG PO TABS BOTH IP/OP $20.55 $15.21 $0.00 $14.91 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $9.32 $14.76 $14.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23458 ERX HCPCS 63700001 00143-9285-01 AMOXICILLIN 875 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23458 ERX HCPCS 63700001 57237-0029-01 AMOXICILLIN 875 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23458 ERX HCPCS 63700001 65862-0015-01 AMOXICILLIN 875 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23461 ERX HCPCS 25000001 00496-0882-05 LIDOCAINE 4 % EX CREA BOTH IP/OP $35.20 $26.05 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 $26.13 $26.13 $27.13 $0.00 $7.34 $0.00 $0.00 $0.00 $0.00 $15.96 $25.28 $25.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23461 ERX HCPCS 25000001 00496-0882-06 LIDOCAINE 4 % EX CREA BOTH IP/OP $35.20 $26.05 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 $26.13 $26.13 $27.13 $0.00 $7.34 $0.00 $0.00 $0.00 $0.00 $15.96 $25.28 $25.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23461 ERX HCPCS 25000001 52565-0122-07 LIDOCAINE 4 % EX CREA BOTH IP/OP $35.20 $26.05 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 $26.13 $26.13 $27.13 $0.00 $7.34 $0.00 $0.00 $0.00 $0.00 $15.96 $25.28 $25.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23490 ERX HCPCS 63700001 13668-0011-01 CITALOPRAM HYDROBROMIDE 40 MG PO TABS BOTH IP/OP $9.54 $7.06 $0.00 $7.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.77 $7.56 $7.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23599 ERX HCPCS 63700001 59572-0205-14 THALIDOMIDE 50 MG PO CAPS BOTH IP/OP $543.47 $402.17 $0.00 $434.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.74 $430.43 $434.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23599 ERX HCPCS 63700001 59572-0205-94 THALIDOMIDE 50 MG PO CAPS BOTH IP/OP $543.47 $402.17 $0.00 $434.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.74 $430.43 $434.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23796 ERX HCPCS J1745 57894-0030-01 INFLIXIMAB 100 MG IV SOLR BOTH IP/OP "$3,167.12 " "$2,343.67" $0.00 "$2,441.22" "$1,425.20" "$1,425.20" $378.76 $378.76 $378.76 $668.93 "$2,350.64" "$2,350.64" "$2,441.22" $395.32 $464.50 $256.96 "$1,561.39" "$1,561.39" $664.49 "$1,436.42" "$2,275.28" "$2,298.26" $917.63 $917.63 $673.86 $0.00 $0.00 $641.63 $512.00 $0.00 $0.00 $0.00 $0.00 23814 ERX HCPCS 63700001 00173-0675-02 ATOVAQUONE-PROGUANIL HCL 250-100 MG PO TABS BOTH IP/OP $34.53 $25.55 $0.00 $25.06 $0.00 $0.00 $0.00 $6.15 $0.00 $0.00 $0.00 $0.00 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $15.66 $24.81 $25.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23814 ERX HCPCS 63700001 00378-4162-01 ATOVAQUONE-PROGUANIL HCL 250-100 MG PO TABS BOTH IP/OP $34.53 $25.55 $0.00 $25.06 $0.00 $0.00 $0.00 $6.15 $0.00 $0.00 $0.00 $0.00 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $15.66 $24.81 $25.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23814 ERX HCPCS 63700001 68462-0404-01 ATOVAQUONE-PROGUANIL HCL 250-100 MG PO TABS BOTH IP/OP $34.53 $25.55 $0.00 $25.06 $0.00 $0.00 $0.00 $6.15 $0.00 $0.00 $0.00 $0.00 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $15.66 $24.81 $25.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23814 ERX HCPCS 63700001 68462-0404-67 ATOVAQUONE-PROGUANIL HCL 250-100 MG PO TABS BOTH IP/OP $34.53 $25.55 $0.00 $25.06 $0.00 $0.00 $0.00 $6.15 $0.00 $0.00 $0.00 $0.00 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $15.66 $24.81 $25.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23872 ERX HCPCS 63700001 00088-2160-30 LEFLUNOMIDE 10 MG PO TABS BOTH IP/OP $188.87 $139.76 $0.00 $130.62 $0.00 $0.00 $0.00 $35.23 $0.00 $0.00 $0.00 $0.00 $0.00 $39.36 $0.00 $0.00 $0.00 $0.00 $81.64 $129.32 $130.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23872 ERX HCPCS 63700001 23155-0043-03 LEFLUNOMIDE 10 MG PO TABS BOTH IP/OP $188.87 $139.76 $0.00 $130.62 $0.00 $0.00 $0.00 $35.23 $0.00 $0.00 $0.00 $0.00 $0.00 $39.36 $0.00 $0.00 $0.00 $0.00 $81.64 $129.32 $130.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23872 ERX HCPCS 63700001 62332-0061-30 LEFLUNOMIDE 10 MG PO TABS BOTH IP/OP $188.87 $139.76 $0.00 $130.62 $0.00 $0.00 $0.00 $35.23 $0.00 $0.00 $0.00 $0.00 $0.00 $39.36 $0.00 $0.00 $0.00 $0.00 $81.64 $129.32 $130.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23873 ERX HCPCS 63700001 23155-0044-03 LEFLUNOMIDE 20 MG PO TABS BOTH IP/OP $68.75 $50.88 $0.00 $49.88 $0.00 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $31.18 $49.38 $49.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23873 ERX HCPCS 63700001 60505-2503-01 LEFLUNOMIDE 20 MG PO TABS BOTH IP/OP $68.75 $50.88 $0.00 $49.88 $0.00 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $31.18 $49.38 $49.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23873 ERX HCPCS 63700001 62332-0062-30 LEFLUNOMIDE 20 MG PO TABS BOTH IP/OP $68.75 $50.88 $0.00 $49.88 $0.00 $0.00 $0.00 $12.24 $0.00 $0.00 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $31.18 $49.38 $49.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23876 ERX HCPCS 25000001 00409-7419-03 DEXTRAN 40 IN SALINE 10-0.9 % IV SOLN BOTH IP/OP $138.96 $102.83 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $107.11 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23898 ERX HCPCS 63700001 00056-0470-30 EFAVIRENZ 50 MG PO CAPS BOTH IP/OP $54.83 $40.57 $0.00 $39.78 $0.00 $0.00 $0.00 $9.76 $0.00 $0.00 $0.00 $0.00 $0.00 $11.43 $0.00 $0.00 $0.00 $0.00 $24.86 $39.38 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23900 ERX HCPCS 63700001 00056-0474-92 EFAVIRENZ 200 MG PO CAPS BOTH IP/OP $54.79 $40.54 $0.00 $39.75 $0.00 $0.00 $0.00 $9.75 $0.00 $0.00 $0.00 $0.00 $0.00 $11.42 $0.00 $0.00 $0.00 $0.00 $24.85 $39.35 $39.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23968 ERX HCPCS 25000001 00004-0298-09 MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR BOTH IP/OP $756.71 $559.97 $0.00 $583.27 $0.00 $0.00 $0.00 $0.00 $0.00 $561.63 $561.63 $583.27 $0.00 $157.70 $0.00 $0.00 $0.00 $0.00 $343.37 $543.90 $549.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23968 ERX HCPCS 25000001 17478-0422-40 MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR BOTH IP/OP $756.71 $559.97 $0.00 $583.27 $0.00 $0.00 $0.00 $0.00 $0.00 $561.63 $561.63 $583.27 $0.00 $157.70 $0.00 $0.00 $0.00 $0.00 $343.37 $543.90 $549.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23968 ERX HCPCS 25000001 42023-0172-04 MYCOPHENOLATE MOFETIL HCL 500 MG IV SOLR BOTH IP/OP $756.71 $559.97 $0.00 $583.27 $0.00 $0.00 $0.00 $0.00 $0.00 $561.63 $561.63 $583.27 $0.00 $157.70 $0.00 $0.00 $0.00 $0.00 $343.37 $543.90 $549.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24119 ERX HCPCS 25000001 00597-0047-24 NEVIRAPINE 50 MG/5ML PO SUSP BOTH IP/OP $623.92 $461.70 $0.00 $499.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.96 $494.14 $499.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24119 ERX HCPCS 25000001 65862-0057-24 NEVIRAPINE 50 MG/5ML PO SUSP BOTH IP/OP $623.92 $461.70 $0.00 $499.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.96 $494.14 $499.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24176 ERX HCPCS 25000001 00054-3566-99 MIDAZOLAM HCL 2 MG/ML PO SYRP BOTH IP/OP $6.00 $4.44 $0.00 $9.24 $0.00 $0.00 $0.00 $0.00 $0.00 $8.90 $8.90 $9.24 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24176 ERX HCPCS 25000001 00574-0150-04 MIDAZOLAM HCL 2 MG/ML PO SYRP BOTH IP/OP $6.00 $4.44 $0.00 $9.24 $0.00 $0.00 $0.00 $0.00 $0.00 $8.90 $8.90 $9.24 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24176 ERX HCPCS 25000001 68094-0762-59 MIDAZOLAM HCL 2 MG/ML PO SYRP BOTH IP/OP $6.00 $4.44 $0.00 $9.24 $0.00 $0.00 $0.00 $0.00 $0.00 $8.90 $8.90 $9.24 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24176 ERX HCPCS 25000001 68094-0762-62 MIDAZOLAM HCL 2 MG/ML PO SYRP BOTH IP/OP $6.00 $4.44 $0.00 $9.24 $0.00 $0.00 $0.00 $0.00 $0.00 $8.90 $8.90 $9.24 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24188 ERX HCPCS 25000001 00006-5424-02 ANTIVENIN LATRODECTUS MACTANS IJ KIT BOTH IP/OP $128.35 $94.98 $0.00 $98.93 $0.00 $0.00 $0.00 $0.00 $0.00 $95.26 $95.26 $98.93 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $58.19 $92.17 $93.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24190 ERX HCPCS 63700001 00224-1801-84 PSYLLIUM 100 % PO PACK BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24268 ERX HCPCS 63700001 00143-2260-01 ISOSORBIDE MONONITRATE CR 60 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24268 ERX HCPCS 63700001 00904-6450-61 ISOSORBIDE MONONITRATE CR 60 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24268 ERX HCPCS 63700001 13668-0105-01 ISOSORBIDE MONONITRATE CR 60 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24268 ERX HCPCS 63700001 62175-0119-37 ISOSORBIDE MONONITRATE CR 60 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24268 ERX HCPCS 63700001 68084-0592-01 ISOSORBIDE MONONITRATE CR 60 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24325 ERX HCPCS 25000001 57782-0397-26 CROMOLYN SODIUM 5.2 MG/ACT NA AERS BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24384 ERX HCPCS 63700001 00006-0747-31 LOSARTAN-HCTZ 100-25 MG PO TABS BOTH IP/OP $28.16 $20.84 $0.00 $20.43 $0.00 $0.00 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $12.77 $20.23 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24384 ERX HCPCS 63700001 00093-7368-98 LOSARTAN-HCTZ 100-25 MG PO TABS BOTH IP/OP $28.16 $20.84 $0.00 $20.43 $0.00 $0.00 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $12.77 $20.23 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24384 ERX HCPCS 63700001 16714-0225-01 LOSARTAN-HCTZ 100-25 MG PO TABS BOTH IP/OP $28.16 $20.84 $0.00 $20.43 $0.00 $0.00 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $12.77 $20.23 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24384 ERX HCPCS 63700001 16714-0225-02 LOSARTAN-HCTZ 100-25 MG PO TABS BOTH IP/OP $28.16 $20.84 $0.00 $20.43 $0.00 $0.00 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $12.77 $20.23 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24384 ERX HCPCS 63700001 68180-0217-09 LOSARTAN-HCTZ 100-25 MG PO TABS BOTH IP/OP $28.16 $20.84 $0.00 $20.43 $0.00 $0.00 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $12.77 $20.23 $20.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24385 ERX HCPCS 25000001 50383-0901-10 HYDROCORTISONE-ACETIC ACID 1-2 % OT SOLN BOTH IP/OP $638.89 $472.78 $0.00 $511.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.45 $506.00 $511.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24398 ERX HCPCS 63700001 00904-6691-61 METFORMIN HCL 1000 MG PO TABS BOTH IP/OP $6.04 $4.47 $0.00 $4.80 $0.00 $0.00 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24398 ERX HCPCS 63700001 23155-0104-05 METFORMIN HCL 1000 MG PO TABS BOTH IP/OP $6.04 $4.47 $0.00 $4.80 $0.00 $0.00 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24398 ERX HCPCS 63700001 57664-0474-53 METFORMIN HCL 1000 MG PO TABS BOTH IP/OP $6.04 $4.47 $0.00 $4.80 $0.00 $0.00 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24398 ERX HCPCS 63700001 57664-0474-58 METFORMIN HCL 1000 MG PO TABS BOTH IP/OP $6.04 $4.47 $0.00 $4.80 $0.00 $0.00 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24409 ERX HCPCS J3240 58468-0030-02 THYROTROPIN ALFA 1.1 MG IM SOLR BOTH IP/OP "$3,657.89 " "$2,706.84" $0.00 "$2,926.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.87" "$1,828.95" "$2,897.05" "$2,926.31" "$2,457.92" "$2,457.92" "$1,997.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24435 ERX HCPCS J2353 00078-0818-81 OCTREOTIDE ACETATE 20 MG IM KIT BOTH IP/OP "$11,565.98 " "$8,558.83" $0.00 "$8,915.06" "$5,204.69" "$5,204.69" "$4,131.24" "$4,131.24" "$4,131.24" "$2,410.64" "$8,584.27" "$8,584.27" "$8,915.06" "$4,107.44" "$4,826.24" "$2,669.84" "$5,702.03" "$5,702.03" "$4,337.87" "$4,348.66" "$6,888.27" "$6,957.85" "$5,990.39" "$5,990.39" "$4,843.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24438 ERX HCPCS 63700001 00378-4105-91 ABACAVIR SULFATE 300 MG PO TABS BOTH IP/OP $42.09 $31.15 $0.00 $30.54 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $0.00 $8.77 $0.00 $0.00 $0.00 $0.00 $19.09 $30.24 $30.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24438 ERX HCPCS 63700001 31722-0557-60 ABACAVIR SULFATE 300 MG PO TABS BOTH IP/OP $42.09 $31.15 $0.00 $30.54 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $0.00 $8.77 $0.00 $0.00 $0.00 $0.00 $19.09 $30.24 $30.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24438 ERX HCPCS 63700001 60505-3583-06 ABACAVIR SULFATE 300 MG PO TABS BOTH IP/OP $42.09 $31.15 $0.00 $30.54 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $0.00 $8.77 $0.00 $0.00 $0.00 $0.00 $19.09 $30.24 $30.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24438 ERX HCPCS 63700001 64380-0717-03 ABACAVIR SULFATE 300 MG PO TABS BOTH IP/OP $42.09 $31.15 $0.00 $30.54 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $0.00 $8.77 $0.00 $0.00 $0.00 $0.00 $19.09 $30.24 $30.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24438 ERX HCPCS 63700001 65862-0073-60 ABACAVIR SULFATE 300 MG PO TABS BOTH IP/OP $42.09 $31.15 $0.00 $30.54 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $0.00 $8.77 $0.00 $0.00 $0.00 $0.00 $19.09 $30.24 $30.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24438 ERX HCPCS 63700001 69097-0514-03 ABACAVIR SULFATE 300 MG PO TABS BOTH IP/OP $42.09 $31.15 $0.00 $30.54 $0.00 $0.00 $0.00 $7.49 $0.00 $0.00 $0.00 $0.00 $0.00 $8.77 $0.00 $0.00 $0.00 $0.00 $19.09 $30.24 $30.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24439 ERX HCPCS 63700001 99999-6005-00 ABACAVIR SULFATE 20 MG/ML PO SOLN BOTH IP/OP $305.64 $226.17 $0.00 $221.97 $0.00 $0.00 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $63.70 $0.00 $0.00 $0.00 $0.00 $138.73 $219.75 $221.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24439 ERX HCPCS 63700001 31722-0562-24 ABACAVIR SULFATE 20 MG/ML PO SOLN BOTH IP/OP $305.64 $226.17 $0.00 $425.53 $0.00 $0.00 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $63.70 $0.00 $0.00 $0.00 $0.00 $138.73 $425.53 $221.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24439 ERX HCPCS 63700001 49702-0222-48 ABACAVIR SULFATE 20 MG/ML PO SOLN BOTH IP/OP $305.64 $226.17 $0.00 $425.53 $0.00 $0.00 $0.00 $54.40 $0.00 $0.00 $0.00 $0.00 $0.00 $63.70 $0.00 $0.00 $0.00 $0.00 $138.73 $425.53 $221.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24467 ERX HCPCS 25000001 99999-6007-34 VITAMIN E 15 UNIT/0.3ML PO SOLN BOTH IP/OP $67.88 $50.23 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 $50.38 $50.38 $52.32 $0.00 $14.15 $0.00 $0.00 $0.00 $0.00 $30.78 $48.76 $49.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24467 ERX HCPCS 25000001 54838-0005-30 VITAMIN E 15 UNIT/0.3ML PO SOLN BOTH IP/OP $67.88 $50.23 $0.00 $112.27 $0.00 $0.00 $0.00 $0.00 $0.00 $50.38 $50.38 $52.32 $0.00 $14.15 $0.00 $0.00 $0.00 $0.00 $30.78 $112.27 $49.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24473 ERX HCPCS 63700001 00093-2065-06 CILOSTAZOL 50 MG PO TABS BOTH IP/OP $6.94 $5.14 $0.00 $5.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.47 $5.50 $5.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24473 ERX HCPCS 63700001 00185-0123-60 CILOSTAZOL 50 MG PO TABS BOTH IP/OP $6.94 $5.14 $0.00 $5.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.47 $5.50 $5.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24474 ERX HCPCS 63700001 00093-2064-06 CILOSTAZOL 100 MG PO TABS BOTH IP/OP $7.65 $5.66 $0.00 $5.55 $0.00 $0.00 $0.00 $1.36 $0.00 $0.00 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $3.47 $5.50 $5.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24500 ERX HCPCS 63700001 00025-1520-34 CELECOXIB 100 MG PO CAPS BOTH IP/OP $19.36 $14.33 $0.00 $14.05 $0.00 $0.00 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $0.00 $4.03 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24500 ERX HCPCS 63700001 00904-6502-61 CELECOXIB 100 MG PO CAPS BOTH IP/OP $19.36 $14.33 $0.00 $14.05 $0.00 $0.00 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $0.00 $4.03 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24500 ERX HCPCS 63700001 16714-0732-01 CELECOXIB 100 MG PO CAPS BOTH IP/OP $19.36 $14.33 $0.00 $14.05 $0.00 $0.00 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $0.00 $4.03 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24500 ERX HCPCS 63700001 60687-0436-01 CELECOXIB 100 MG PO CAPS BOTH IP/OP $19.36 $14.33 $0.00 $14.05 $0.00 $0.00 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $0.00 $4.03 $0.00 $0.00 $0.00 $0.00 $8.78 $13.91 $14.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24501 ERX HCPCS 63700001 33342-0157-11 CELECOXIB 200 MG PO CAPS BOTH IP/OP $31.72 $23.47 $0.00 $23.02 $0.00 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 $6.61 $0.00 $0.00 $0.00 $0.00 $14.39 $22.79 $23.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24501 ERX HCPCS 63700001 65862-0909-01 CELECOXIB 200 MG PO CAPS BOTH IP/OP $31.72 $23.47 $0.00 $23.02 $0.00 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 $6.61 $0.00 $0.00 $0.00 $0.00 $14.39 $22.79 $23.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24513 ERX HCPCS J0885 59676-0340-01 EPOETIN ALFA 40000 UNIT/ML IJ SOLN BOTH IP/OP "$2,899.13 " "$2,145.36" $0.00 "$2,103.79" "$1,574.23" "$1,574.23" $328.88 $328.88 $328.88 $604.25 $0.00 $0.00 $0.00 $326.12 $604.18 $211.98 "$1,714.84" "$1,714.84" $463.30 "$1,314.87" "$2,082.75" "$2,103.79" $639.80 $639.80 $411.55 $0.00 $0.00 $472.58 $387.84 $0.00 $0.00 $0.00 $0.00 24521 ERX HCPCS 63700001 00143-2230-01 ISOSORBIDE MONONITRATE ER 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24521 ERX HCPCS 63700001 00904-6449-61 ISOSORBIDE MONONITRATE ER 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24521 ERX HCPCS 63700001 13668-0104-01 ISOSORBIDE MONONITRATE ER 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24521 ERX HCPCS 63700001 62175-0128-37 ISOSORBIDE MONONITRATE ER 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24521 ERX HCPCS 63700001 68084-0591-01 ISOSORBIDE MONONITRATE ER 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24521 ERX HCPCS 63700001 68084-0591-11 ISOSORBIDE MONONITRATE ER 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24585 ERX HCPCS J7511 58468-0080-01 ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR BOTH IP/OP "$2,494.25 " "$1,845.75" $0.00 "$2,032.16" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,956.76" "$1,956.76" "$2,032.16" $0.00 $519.80 $0.00 $0.00 $0.00 $0.00 "$1,076.36" "$1,704.95" "$1,722.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24702 ERX HCPCS 63700001 49884-0534-11 MODAFINIL 100 MG PO TABS BOTH IP/OP $101.82 $75.35 $0.00 $73.86 $0.00 $0.00 $0.00 $18.12 $0.00 $0.00 $0.00 $0.00 $0.00 $21.22 $0.00 $0.00 $0.00 $0.00 $46.16 $73.12 $73.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24702 ERX HCPCS 63700001 60505-2526-03 MODAFINIL 100 MG PO TABS BOTH IP/OP $101.82 $75.35 $0.00 $73.86 $0.00 $0.00 $0.00 $18.12 $0.00 $0.00 $0.00 $0.00 $0.00 $21.22 $0.00 $0.00 $0.00 $0.00 $46.16 $73.12 $73.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24702 ERX HCPCS 63700001 65862-0601-30 MODAFINIL 100 MG PO TABS BOTH IP/OP $101.82 $75.35 $0.00 $73.86 $0.00 $0.00 $0.00 $18.12 $0.00 $0.00 $0.00 $0.00 $0.00 $21.22 $0.00 $0.00 $0.00 $0.00 $46.16 $73.12 $73.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24711 ERX HCPCS 63700001 68180-0518-01 LISINOPRIL-HCTZ 10-12.5 MG TABLET BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24711 ERX HCPCS 63700001 68180-0518-02 LISINOPRIL-HCTZ 10-12.5 MG TABLET BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24914 ERX HCPCS 63700001 00781-2102-01 TACROLIMUS 0.5 MG PO CAPS BOTH IP/OP $9.35 $6.92 $0.00 $6.78 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $4.24 $6.72 $6.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24914 ERX HCPCS 63700001 16729-0041-01 TACROLIMUS 0.5 MG PO CAPS BOTH IP/OP $9.35 $6.92 $0.00 $6.78 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $4.24 $6.72 $6.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24914 ERX HCPCS 63700001 51079-0817-01 TACROLIMUS 0.5 MG PO CAPS BOTH IP/OP $9.35 $6.92 $0.00 $6.78 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $4.24 $6.72 $6.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24914 ERX HCPCS 63700001 51079-0817-20 TACROLIMUS 0.5 MG PO CAPS BOTH IP/OP $9.35 $6.92 $0.00 $6.78 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $4.24 $6.72 $6.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24914 ERX HCPCS 63700001 68084-0449-01 TACROLIMUS 0.5 MG PO CAPS BOTH IP/OP $9.35 $6.92 $0.00 $6.78 $0.00 $0.00 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $4.24 $6.72 $6.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24915 ERX HCPCS 25000001 00378-9691-52 LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU BOTH IP/OP $8.39 $6.21 $0.00 $6.47 $0.00 $0.00 $0.00 $0.00 $0.00 $6.23 $6.23 $6.47 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.81 $6.03 $6.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24915 ERX HCPCS 25000001 00378-9691-62 LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU BOTH IP/OP $8.39 $6.21 $0.00 $6.47 $0.00 $0.00 $0.00 $0.00 $0.00 $6.23 $6.23 $6.47 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.81 $6.03 $6.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24915 ERX HCPCS 25000001 43598-0410-25 LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU BOTH IP/OP $8.39 $6.21 $0.00 $6.47 $0.00 $0.00 $0.00 $0.00 $0.00 $6.23 $6.23 $6.47 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.81 $6.03 $6.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24915 ERX HCPCS 25000001 66993-0022-27 LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU BOTH IP/OP $8.39 $6.21 $0.00 $6.47 $0.00 $0.00 $0.00 $0.00 $0.00 $6.23 $6.23 $6.47 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.81 $6.03 $6.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24915 ERX HCPCS 25000001 76204-0800-01 LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU BOTH IP/OP $8.39 $6.21 $0.00 $6.47 $0.00 $0.00 $0.00 $0.00 $0.00 $6.23 $6.23 $6.47 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.81 $6.03 $6.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24915 ERX HCPCS 25000001 76204-0800-11 LEVALBUTEROL HCL 0.63 MG/3ML IN NEBU BOTH IP/OP $8.39 $6.21 $0.00 $6.47 $0.00 $0.00 $0.00 $0.00 $0.00 $6.23 $6.23 $6.47 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $3.81 $6.03 $6.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24916 ERX HCPCS J7614 43598-0409-25 LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU BOTH IP/OP $26.98 $19.97 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.80 $0.00 $5.62 $0.00 $0.00 $0.00 $0.00 $12.24 $19.38 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24916 ERX HCPCS J7614 76204-0900-01 LEVALBUTEROL HCL 1.25 MG/3ML IN NEBU BOTH IP/OP $26.98 $19.97 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 $20.02 $20.02 $20.80 $0.00 $5.62 $0.00 $0.00 $0.00 $0.00 $12.24 $19.38 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24932 ERX HCPCS J2916 00024-2792-10 NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN BOTH IP/OP $147.30 $109.00 $0.00 $113.54 $66.29 $66.29 $0.00 $0.00 $0.00 $27.85 $109.33 $109.33 $113.54 $0.00 $12.79 $0.00 $87.13 $87.13 $0.00 $66.78 $105.78 $106.85 $0.00 $0.00 $11.69 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 24932 ERX HCPCS J2916 00143-9298-01 NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN BOTH IP/OP $147.30 $109.00 $0.00 $113.54 $66.29 $66.29 $0.00 $0.00 $0.00 $27.85 $109.33 $109.33 $113.54 $0.00 $12.79 $0.00 $87.13 $87.13 $0.00 $66.78 $105.78 $106.85 $0.00 $0.00 $11.69 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 24932 ERX HCPCS J2916 00143-9298-10 NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN BOTH IP/OP $147.30 $109.00 $0.00 $113.54 $66.29 $66.29 $0.00 $0.00 $0.00 $27.85 $109.33 $109.33 $113.54 $0.00 $12.79 $0.00 $87.13 $87.13 $0.00 $66.78 $105.78 $106.85 $0.00 $0.00 $11.69 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 24932 ERX HCPCS J2916 00143-9570-10 NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN BOTH IP/OP $147.30 $109.00 $0.00 $113.54 $66.29 $66.29 $0.00 $0.00 $0.00 $27.85 $109.33 $109.33 $113.54 $0.00 $12.79 $0.00 $87.13 $87.13 $0.00 $66.78 $105.78 $106.85 $0.00 $0.00 $11.69 $0.00 $0.00 $11.13 $0.00 $0.00 $0.00 $0.00 $0.00 24945 ERX HCPCS 63700001 13107-0032-34 MIRTAZAPINE 45 MG PO TABS BOTH IP/OP $11.95 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24945 ERX HCPCS 63700001 51079-0088-01 MIRTAZAPINE 45 MG PO TABS BOTH IP/OP $11.95 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24945 ERX HCPCS 63700001 51079-0088-20 MIRTAZAPINE 45 MG PO TABS BOTH IP/OP $11.95 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24945 ERX HCPCS 63700001 60505-0249-01 MIRTAZAPINE 45 MG PO TABS BOTH IP/OP $11.95 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24945 ERX HCPCS 63700001 68084-0121-01 MIRTAZAPINE 45 MG PO TABS BOTH IP/OP $11.95 $8.84 $0.00 $8.66 $0.00 $0.00 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $2.49 $0.00 $0.00 $0.00 $0.00 $5.42 $8.58 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25005 ERX HCPCS J7517 00004-0261-29 MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR BOTH IP/OP $47.45 $35.11 $0.00 $36.57 $0.00 $0.00 $0.00 $0.00 $0.00 $35.22 $35.22 $36.57 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $21.52 $34.09 $34.43 $0.00 $0.00 $6.74 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 25005 ERX HCPCS J7517 67877-0230-22 MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR BOTH IP/OP $47.45 $35.11 $0.00 $36.57 $0.00 $0.00 $0.00 $0.00 $0.00 $35.22 $35.22 $36.57 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $21.52 $34.09 $34.43 $0.00 $0.00 $6.74 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 25118 ERX HCPCS 63700001 00143-9927-01 CIPROFLOXACIN HCL 250 MG PO TABS BOTH IP/OP $19.00 $14.06 $0.00 $13.78 $0.00 $0.00 $0.00 $3.38 $0.00 $0.00 $0.00 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $8.62 $13.65 $13.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25118 ERX HCPCS 63700001 16714-0651-02 CIPROFLOXACIN HCL 250 MG PO TABS BOTH IP/OP $19.00 $14.06 $0.00 $13.78 $0.00 $0.00 $0.00 $3.38 $0.00 $0.00 $0.00 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $8.62 $13.65 $13.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25118 ERX HCPCS 63700001 55111-0126-01 CIPROFLOXACIN HCL 250 MG PO TABS BOTH IP/OP $19.00 $14.06 $0.00 $13.78 $0.00 $0.00 $0.00 $3.38 $0.00 $0.00 $0.00 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $8.62 $13.65 $13.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25118 ERX HCPCS 63700001 63739-0700-10 CIPROFLOXACIN HCL 250 MG PO TABS BOTH IP/OP $19.00 $14.06 $0.00 $13.78 $0.00 $0.00 $0.00 $3.38 $0.00 $0.00 $0.00 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $8.62 $13.65 $13.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25119 ERX HCPCS 63700001 16714-0652-02 CIPROFLOXACIN HCL 500 MG PO TABS BOTH IP/OP $12.08 $8.94 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.04 $9.57 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25119 ERX HCPCS 63700001 63739-0559-10 CIPROFLOXACIN HCL 500 MG PO TABS BOTH IP/OP $12.08 $8.94 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.04 $9.57 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25119 ERX HCPCS 63700001 68084-0070-01 CIPROFLOXACIN HCL 500 MG PO TABS BOTH IP/OP $12.08 $8.94 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.04 $9.57 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25119 ERX HCPCS 63700001 68084-0070-11 CIPROFLOXACIN HCL 500 MG PO TABS BOTH IP/OP $12.08 $8.94 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.04 $9.57 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25120 ERX HCPCS 63700001 16571-0413-05 CIPROFLOXACIN HCL 750 MG PO TABS BOTH IP/OP $29.11 $21.54 $0.00 $23.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.56 $23.06 $23.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25120 ERX HCPCS 63700001 16714-0653-01 CIPROFLOXACIN HCL 750 MG PO TABS BOTH IP/OP $29.11 $21.54 $0.00 $23.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.56 $23.06 $23.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25120 ERX HCPCS 63700001 68084-0071-01 CIPROFLOXACIN HCL 750 MG PO TABS BOTH IP/OP $29.11 $21.54 $0.00 $23.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.56 $23.06 $23.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25174 ERX HCPCS 25000001 00264-1965-10 HETASTARCH-NACL 6-0.9 % IV SOLN BOTH IP/OP $79.13 $58.56 $0.00 $60.99 $0.00 $0.00 $0.00 $0.00 $0.00 $58.73 $58.73 $60.99 $0.00 $16.49 $0.00 $0.00 $0.00 $0.00 $35.88 $56.83 $57.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25238 ERX HCPCS 63700001 00378-6320-01 VERAPAMIL HCL CR 120 MG PO CP24 BOTH IP/OP $7.32 $5.42 $0.00 $5.31 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $3.32 $5.26 $5.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25238 ERX HCPCS 63700001 00591-2880-01 VERAPAMIL HCL CR 120 MG PO CP24 BOTH IP/OP $7.32 $5.42 $0.00 $5.31 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $3.32 $5.26 $5.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25246 ERX HCPCS 25000001 00093-4161-73 AMOXICILLIN 400 MG/5ML PO SUSR BOTH IP/OP $37.24 $27.56 $0.00 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $29.49 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25246 ERX HCPCS 25000001 00143-9887-01 AMOXICILLIN 400 MG/5ML PO SUSR BOTH IP/OP $37.24 $27.56 $0.00 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $29.49 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25246 ERX HCPCS 25000001 00781-6157-46 AMOXICILLIN 400 MG/5ML PO SUSR BOTH IP/OP $37.24 $27.56 $0.00 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $29.49 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25246 ERX HCPCS 25000001 00143-9887-50 AMOXICILLIN 400 MG/5ML PO SUSR BOTH IP/OP $18.62 $13.78 $0.00 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $14.75 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25246 ERX HCPCS 25000001 00781-6157-52 AMOXICILLIN 400 MG/5ML PO SUSR BOTH IP/OP $18.62 $13.78 $0.00 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.62 $14.75 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25354 ERX HCPCS 63700001 00955-1722-50 DOXERCALCIFEROL 2.5 MCG PO CAPS BOTH IP/OP $141.43 $104.66 $0.00 $113.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.72 $112.01 $113.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25408 ERX HCPCS 25000001 67457-0187-50 ALLOPURINOL SODIUM 500 MG IV SOLR BOTH IP/OP "$10,812.91 " "$8,001.55" $0.00 "$8,334.59" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,334.59" $0.00 "$2,253.41" $0.00 $0.00 $0.00 $0.00 "$4,904.09" "$7,768.07" "$7,846.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25471 ERX HCPCS 25000001 24208-0601-10 KETOTIFEN FUMARATE 0.025 % OP SOLN BOTH IP/OP $51.08 $37.80 $0.00 $39.37 $0.00 $0.00 $0.00 $0.00 $0.00 $37.91 $37.91 $39.37 $0.00 $10.65 $0.00 $0.00 $0.00 $0.00 $19.69 $31.18 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25471 ERX HCPCS 25000001 17478-0717-10 KETOTIFEN FUMARATE 0.025 % OP SOLN BOTH IP/OP $51.08 $37.80 $0.00 $39.37 $0.00 $0.00 $0.00 $0.00 $0.00 $37.91 $37.91 $39.37 $0.00 $10.65 $0.00 $0.00 $0.00 $0.00 $19.69 $36.69 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25471 ERX HCPCS 25000001 49348-0107-17 KETOTIFEN FUMARATE 0.025 % OP SOLN BOTH IP/OP $51.08 $37.80 $0.00 $39.37 $0.00 $0.00 $0.00 $0.00 $0.00 $37.91 $37.91 $39.37 $0.00 $10.65 $0.00 $0.00 $0.00 $0.00 $19.69 $36.69 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25518 ERX HCPCS 25000001 63323-0011-15 CHLORAMPHENICOL SOD SUCCINATE 1 G IV SOLR BOTH IP/OP $180.28 $133.41 $0.00 $138.96 $0.00 $0.00 $0.00 $0.00 $0.00 $133.80 $133.80 $138.96 $0.00 $37.57 $0.00 $0.00 $0.00 $0.00 $81.74 $129.47 $130.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25519 ERX HCPCS 63700001 00904-6357-61 RISPERIDONE 0.25 MG PO TABS BOTH IP/OP $15.01 $11.11 $0.00 $10.89 $0.00 $0.00 $0.00 $2.67 $0.00 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $6.81 $10.78 $10.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25520 ERX HCPCS 63700001 00904-6358-61 RISPERIDONE 0.5 MG PO TABS BOTH IP/OP $16.24 $12.02 $0.00 $12.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.12 $12.86 $12.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25520 ERX HCPCS 63700001 68084-0271-01 RISPERIDONE 0.5 MG PO TABS BOTH IP/OP $16.24 $12.02 $0.00 $12.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.12 $12.86 $12.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25528 ERX HCPCS 63700001 33342-0054-07 PIOGLITAZONE HCL 15 MG PO TABS BOTH IP/OP $65.13 $48.20 $0.00 $47.26 $0.00 $0.00 $0.00 $11.59 $0.00 $0.00 $0.00 $0.00 $0.00 $13.57 $0.00 $0.00 $0.00 $0.00 $29.54 $46.78 $47.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25528 ERX HCPCS 63700001 33342-0054-10 PIOGLITAZONE HCL 15 MG PO TABS BOTH IP/OP $65.13 $48.20 $0.00 $47.26 $0.00 $0.00 $0.00 $11.59 $0.00 $0.00 $0.00 $0.00 $0.00 $13.57 $0.00 $0.00 $0.00 $0.00 $29.54 $46.78 $47.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25528 ERX HCPCS 63700001 64764-0151-04 PIOGLITAZONE HCL 15 MG PO TABS BOTH IP/OP $65.13 $48.20 $0.00 $47.26 $0.00 $0.00 $0.00 $11.59 $0.00 $0.00 $0.00 $0.00 $0.00 $13.57 $0.00 $0.00 $0.00 $0.00 $29.54 $46.78 $47.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25528 ERX HCPCS 63700001 65862-0512-90 PIOGLITAZONE HCL 15 MG PO TABS BOTH IP/OP $65.13 $48.20 $0.00 $47.26 $0.00 $0.00 $0.00 $11.59 $0.00 $0.00 $0.00 $0.00 $0.00 $13.57 $0.00 $0.00 $0.00 $0.00 $29.54 $46.78 $47.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25798 ERX HCPCS 25000001 00264-9341-55 TROPHAMINE 10 % IV SOLN BOTH IP/OP $181.42 $134.25 $0.00 $139.84 $0.00 $0.00 $0.00 $0.00 $0.00 $134.65 $134.65 $139.84 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25820 ERX HCPCS 63700001 00006-0032-20 IVERMECTIN 3 MG PO TABS BOTH IP/OP $23.40 $17.32 $0.00 $16.98 $0.00 $0.00 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $0.00 $0.00 $0.00 $0.00 $10.61 $16.81 $16.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25820 ERX HCPCS 63700001 42799-0806-01 IVERMECTIN 3 MG PO TABS BOTH IP/OP $23.40 $17.32 $0.00 $16.98 $0.00 $0.00 $0.00 $4.17 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $0.00 $0.00 $0.00 $0.00 $10.61 $16.81 $16.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25855 ERX HCPCS 63700001 50268-0351-15 GABAPENTIN 600 MG PO TABS BOTH IP/OP $10.56 $7.81 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $4.79 $7.59 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25855 ERX HCPCS 63700001 58657-0623-01 GABAPENTIN 600 MG PO TABS BOTH IP/OP $10.56 $7.81 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $4.79 $7.59 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25855 ERX HCPCS 63700001 63739-0560-10 GABAPENTIN 600 MG PO TABS BOTH IP/OP $10.56 $7.81 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $4.79 $7.59 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25856 ERX HCPCS 63700001 00228-2637-11 GABAPENTIN 800 MG PO TABS BOTH IP/OP $12.75 $9.44 $0.00 $9.25 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $5.78 $9.16 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25856 ERX HCPCS 63700001 00904-6586-61 GABAPENTIN 800 MG PO TABS BOTH IP/OP $12.75 $9.44 $0.00 $9.25 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $5.78 $9.16 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25856 ERX HCPCS 63700001 16714-0332-01 GABAPENTIN 800 MG PO TABS BOTH IP/OP $12.75 $9.44 $0.00 $9.25 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $5.78 $9.16 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25856 ERX HCPCS 63700001 16714-0332-02 GABAPENTIN 800 MG PO TABS BOTH IP/OP $12.75 $9.44 $0.00 $9.25 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $5.78 $9.16 $9.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25892 ERX HCPCS J8700 00085-3004-03 TEMOZOLOMIDE 5 MG PO CAPS BOTH IP/OP $95.68 $70.80 $0.00 $76.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.84 $75.78 $76.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25892 ERX HCPCS J8700 00085-3004-04 TEMOZOLOMIDE 5 MG PO CAPS BOTH IP/OP $95.68 $70.80 $0.00 $76.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.84 $75.78 $76.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25893 ERX HCPCS J8700 65162-0802-51 TEMOZOLOMIDE 20 MG PO CAPS BOTH IP/OP $199.75 $147.82 $0.00 $153.97 $0.00 $0.00 $0.00 $0.00 $0.00 $148.25 $148.25 $153.97 $0.00 $41.63 $0.00 $0.00 $0.00 $0.00 $90.67 $143.61 $145.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25894 ERX HCPCS J8700 16729-0050-53 TEMOZOLOMIDE 100 MG PO CAPS BOTH IP/OP $840.26 $621.79 $0.00 $647.67 $0.00 $0.00 $0.00 $0.00 $0.00 $623.64 $623.64 $647.67 $0.00 $175.11 $0.00 $0.00 $0.00 $0.00 $381.29 $603.96 $610.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25895 ERX HCPCS J8700 65162-0806-51 TEMOZOLOMIDE 250 MG PO CAPS BOTH IP/OP "$1,863.77 " "$1,379.19" $0.00 "$1,436.59" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,383.29" "$1,383.29" "$1,436.59" $0.00 $388.41 $0.00 $0.00 $0.00 $0.00 $863.52 "$1,367.82" "$1,381.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26224 ERX HCPCS 63700001 50268-0636-15 PANTOPRAZOLE SODIUM 20 MG PO TBEC BOTH IP/OP $16.70 $12.36 $0.00 $12.12 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $7.58 $12.00 $12.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26224 ERX HCPCS 63700001 65862-0559-90 PANTOPRAZOLE SODIUM 20 MG PO TBEC BOTH IP/OP $16.70 $12.36 $0.00 $12.12 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $7.58 $12.00 $12.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26224 ERX HCPCS 63700001 68084-0643-01 PANTOPRAZOLE SODIUM 20 MG PO TBEC BOTH IP/OP $16.70 $12.36 $0.00 $12.12 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $7.58 $12.00 $12.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26224 ERX HCPCS 63700001 68084-0643-11 PANTOPRAZOLE SODIUM 20 MG PO TBEC BOTH IP/OP $16.70 $12.36 $0.00 $12.12 $0.00 $0.00 $0.00 $2.97 $0.00 $0.00 $0.00 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $7.58 $12.00 $12.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26225 ERX HCPCS 63700001 55111-0333-90 PANTOPRAZOLE SODIUM 40 MG PO TBEC BOTH IP/OP $17.15 $12.69 $0.00 $12.44 $0.00 $0.00 $0.00 $3.05 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $0.00 $0.00 $0.00 $0.00 $7.78 $12.32 $12.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26225 ERX HCPCS 63700001 63739-0564-10 PANTOPRAZOLE SODIUM 40 MG PO TBEC BOTH IP/OP $17.15 $12.69 $0.00 $12.44 $0.00 $0.00 $0.00 $3.05 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $0.00 $0.00 $0.00 $0.00 $7.78 $12.32 $12.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26225 ERX HCPCS 63700001 66993-0068-80 PANTOPRAZOLE SODIUM 40 MG PO TBEC BOTH IP/OP $17.15 $12.69 $0.00 $12.44 $0.00 $0.00 $0.00 $3.05 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $0.00 $0.00 $0.00 $0.00 $7.78 $12.32 $12.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26225 ERX HCPCS 63700001 68084-0813-09 PANTOPRAZOLE SODIUM 40 MG PO TBEC BOTH IP/OP $17.15 $12.69 $0.00 $12.44 $0.00 $0.00 $0.00 $3.05 $0.00 $0.00 $0.00 $0.00 $0.00 $3.57 $0.00 $0.00 $0.00 $0.00 $7.78 $12.32 $12.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26226 ERX HCPCS 25000001 00008-0923-55 PANTOPRAZOLE SODIUM 40 MG IV SOLR BOTH IP/OP $25.52 $18.88 $0.00 $19.67 $0.00 $0.00 $0.00 $0.00 $0.00 $18.94 $18.94 $19.67 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26226 ERX HCPCS 25000001 00008-0923-60 PANTOPRAZOLE SODIUM 40 MG IV SOLR BOTH IP/OP $25.52 $18.88 $0.00 $19.67 $0.00 $0.00 $0.00 $0.00 $0.00 $18.94 $18.94 $19.67 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26226 ERX HCPCS 25000001 00143-9284-10 PANTOPRAZOLE SODIUM 40 MG IV SOLR BOTH IP/OP $25.52 $18.88 $0.00 $19.67 $0.00 $0.00 $0.00 $0.00 $0.00 $18.94 $18.94 $19.67 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26226 ERX HCPCS 25000001 00143-9300-01 PANTOPRAZOLE SODIUM 40 MG IV SOLR BOTH IP/OP $25.52 $18.88 $0.00 $19.67 $0.00 $0.00 $0.00 $0.00 $0.00 $18.94 $18.94 $19.67 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26226 ERX HCPCS 25000001 00143-9300-10 PANTOPRAZOLE SODIUM 40 MG IV SOLR BOTH IP/OP $25.52 $18.88 $0.00 $19.67 $0.00 $0.00 $0.00 $0.00 $0.00 $18.94 $18.94 $19.67 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26226 ERX HCPCS 25000001 55150-0202-00 PANTOPRAZOLE SODIUM 40 MG IV SOLR BOTH IP/OP $25.52 $18.88 $0.00 $19.67 $0.00 $0.00 $0.00 $0.00 $0.00 $18.94 $18.94 $19.67 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26226 ERX HCPCS 25000001 55150-0202-10 PANTOPRAZOLE SODIUM 40 MG IV SOLR BOTH IP/OP $25.52 $18.88 $0.00 $19.67 $0.00 $0.00 $0.00 $0.00 $0.00 $18.94 $18.94 $19.67 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26335 ERX HCPCS J2770 61570-0260-01 QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR BOTH IP/OP "$1,448.36 " "$1,071.79" $0.00 "$1,116.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,074.97" "$1,074.97" "$1,116.40" $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $639.10 "$1,012.33" "$1,022.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26335 ERX HCPCS J2770 61570-0260-10 QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR BOTH IP/OP "$1,448.36 " "$1,071.79" $0.00 "$1,116.40" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,074.97" "$1,074.97" "$1,116.40" $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $639.10 "$1,012.33" "$1,022.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26336 ERX HCPCS J7520 00008-1030-06 SIROLIMUS 1 MG/ML PO SOLN BOTH IP/OP "$5,122.16 " "$3,790.40" $0.00 "$3,948.16" "$2,304.97" "$2,304.97" $0.00 $0.00 $0.00 "$1,067.59" "$3,801.67" "$3,801.67" "$3,948.16" $0.00 "$1,067.46" $0.00 "$2,525.22" "$2,525.22" $0.00 "$2,222.61" "$3,520.61" "$3,556.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26371 ERX HCPCS 63700001 51079-0923-01 CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR BOTH IP/OP $7.30 $5.40 $0.00 $5.30 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 $1.52 $0.00 $0.00 $0.00 $0.00 $3.31 $5.24 $5.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26371 ERX HCPCS 63700001 51079-0923-20 CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR BOTH IP/OP $7.30 $5.40 $0.00 $5.30 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 $1.52 $0.00 $0.00 $0.00 $0.00 $3.31 $5.24 $5.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26371 ERX HCPCS 63700001 68084-0282-01 CARBIDOPA-LEVODOPA ER 50-200 MG PO TBCR BOTH IP/OP $7.30 $5.40 $0.00 $5.30 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 $1.52 $0.00 $0.00 $0.00 $0.00 $3.31 $5.24 $5.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26429 ERX HCPCS 63700001 00378-5504-01 ROPINIROLE HCL 4 MG PO TABS BOTH IP/OP $10.88 $8.05 $0.00 $7.90 $0.00 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $4.94 $7.82 $7.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26429 ERX HCPCS 63700001 43547-0273-10 ROPINIROLE HCL 4 MG PO TABS BOTH IP/OP $10.88 $8.05 $0.00 $7.90 $0.00 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $4.94 $7.82 $7.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26429 ERX HCPCS 63700001 68462-0258-01 ROPINIROLE HCL 4 MG PO TABS BOTH IP/OP $10.88 $8.05 $0.00 $7.90 $0.00 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $4.94 $7.82 $7.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26546 ERX HCPCS 63700001 16714-0819-01 OSELTAMIVIR PHOSPHATE 75 MG PO CAPS BOTH IP/OP $64.77 $47.93 $0.00 $46.99 $0.00 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $29.37 $46.52 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26546 ERX HCPCS 63700001 33342-0258-66 OSELTAMIVIR PHOSPHATE 75 MG PO CAPS BOTH IP/OP $64.77 $47.93 $0.00 $46.99 $0.00 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $29.37 $46.52 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26546 ERX HCPCS 63700001 42291-0664-10 OSELTAMIVIR PHOSPHATE 75 MG PO CAPS BOTH IP/OP $64.77 $47.93 $0.00 $46.99 $0.00 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $29.37 $46.52 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26546 ERX HCPCS 63700001 47781-0470-13 OSELTAMIVIR PHOSPHATE 75 MG PO CAPS BOTH IP/OP $64.77 $47.93 $0.00 $46.99 $0.00 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $29.37 $46.52 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26546 ERX HCPCS 63700001 64380-0799-01 OSELTAMIVIR PHOSPHATE 75 MG PO CAPS BOTH IP/OP $64.77 $47.93 $0.00 $46.99 $0.00 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $29.37 $46.52 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26546 ERX HCPCS 63700001 70710-1010-02 OSELTAMIVIR PHOSPHATE 75 MG PO CAPS BOTH IP/OP $64.77 $47.93 $0.00 $46.99 $0.00 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $29.37 $46.52 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26547 ERX HCPCS 63700001 33342-0260-11 ENTACAPONE 200 MG PO TABS BOTH IP/OP $16.56 $12.25 $0.00 $12.01 $0.00 $0.00 $0.00 $2.95 $0.00 $0.00 $0.00 $0.00 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $7.51 $11.89 $12.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26547 ERX HCPCS 63700001 64679-0781-02 ENTACAPONE 200 MG PO TABS BOTH IP/OP $16.56 $12.25 $0.00 $12.01 $0.00 $0.00 $0.00 $2.95 $0.00 $0.00 $0.00 $0.00 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $7.51 $11.89 $12.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26551 ERX HCPCS 63700001 00009-7663-04 EXEMESTANE 25 MG PO TABS BOTH IP/OP $78.10 $57.79 $0.00 $56.65 $0.00 $0.00 $0.00 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $16.28 $0.00 $0.00 $0.00 $0.00 $35.41 $56.08 $56.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26551 ERX HCPCS 63700001 00054-0080-13 EXEMESTANE 25 MG PO TABS BOTH IP/OP $78.10 $57.79 $0.00 $56.65 $0.00 $0.00 $0.00 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $16.28 $0.00 $0.00 $0.00 $0.00 $35.41 $56.08 $56.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26551 ERX HCPCS 63700001 00832-0595-30 EXEMESTANE 25 MG PO TABS BOTH IP/OP $78.10 $57.79 $0.00 $56.65 $0.00 $0.00 $0.00 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $16.28 $0.00 $0.00 $0.00 $0.00 $35.41 $56.08 $56.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26551 ERX HCPCS 63700001 47781-0108-30 EXEMESTANE 25 MG PO TABS BOTH IP/OP $78.10 $57.79 $0.00 $56.65 $0.00 $0.00 $0.00 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $16.28 $0.00 $0.00 $0.00 $0.00 $35.41 $56.08 $56.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26688 ERX HCPCS 63700001 60258-0161-01 RENA-VITE RX 1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26816 ERX HCPCS 63700001 00904-6051-61 LEVETIRACETAM 250 MG PO TABS BOTH IP/OP $10.93 $8.09 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.47 $8.66 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26816 ERX HCPCS 63700001 68084-0859-01 LEVETIRACETAM 250 MG PO TABS BOTH IP/OP $10.93 $8.09 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.47 $8.66 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26816 ERX HCPCS 63700001 68180-0112-16 LEVETIRACETAM 250 MG PO TABS BOTH IP/OP $10.93 $8.09 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.47 $8.66 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 00904-6052-61 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 16714-0355-01 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 16714-0355-02 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 50268-0473-11 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 50268-0473-15 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 51079-0821-01 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 51079-0821-20 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 63739-0411-10 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26817 ERX HCPCS 63700001 68084-0870-01 LEVETIRACETAM 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26818 ERX HCPCS 63700001 00378-5617-78 LEVETIRACETAM 750 MG PO TABS BOTH IP/OP $19.95 $14.76 $0.00 $14.48 $0.00 $0.00 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.05 $14.34 $14.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26818 ERX HCPCS 63700001 00904-6053-61 LEVETIRACETAM 750 MG PO TABS BOTH IP/OP $19.95 $14.76 $0.00 $14.48 $0.00 $0.00 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.05 $14.34 $14.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26818 ERX HCPCS 63700001 16714-0356-01 LEVETIRACETAM 750 MG PO TABS BOTH IP/OP $19.95 $14.76 $0.00 $14.48 $0.00 $0.00 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.05 $14.34 $14.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26818 ERX HCPCS 63700001 50268-0474-11 LEVETIRACETAM 750 MG PO TABS BOTH IP/OP $19.95 $14.76 $0.00 $14.48 $0.00 $0.00 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.05 $14.34 $14.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26818 ERX HCPCS 63700001 50474-0596-40 LEVETIRACETAM 750 MG PO TABS BOTH IP/OP $19.95 $14.76 $0.00 $14.48 $0.00 $0.00 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.05 $14.34 $14.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26818 ERX HCPCS 63700001 63739-0787-10 LEVETIRACETAM 750 MG PO TABS BOTH IP/OP $19.95 $14.76 $0.00 $14.48 $0.00 $0.00 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.05 $14.34 $14.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26818 ERX HCPCS 63700001 68084-0882-01 LEVETIRACETAM 750 MG PO TABS BOTH IP/OP $19.95 $14.76 $0.00 $14.48 $0.00 $0.00 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.05 $14.34 $14.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26818 ERX HCPCS 63700001 68084-0882-11 LEVETIRACETAM 750 MG PO TABS BOTH IP/OP $19.95 $14.76 $0.00 $14.48 $0.00 $0.00 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.05 $14.34 $14.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26854 ERX HCPCS 63700001 51991-0943-33 MOXIFLOXACIN HCL 400 MG PO TABS BOTH IP/OP $105.09 $77.77 $0.00 $76.23 $0.00 $0.00 $0.00 $18.71 $0.00 $0.00 $0.00 $0.00 $0.00 $21.90 $0.00 $0.00 $0.00 $0.00 $47.65 $75.47 $76.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26854 ERX HCPCS 63700001 65862-0603-30 MOXIFLOXACIN HCL 400 MG PO TABS BOTH IP/OP $105.09 $77.77 $0.00 $76.23 $0.00 $0.00 $0.00 $18.71 $0.00 $0.00 $0.00 $0.00 $0.00 $21.90 $0.00 $0.00 $0.00 $0.00 $47.65 $75.47 $76.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26950 ERX HCPCS 63700001 51285-0063-90 ESTRADIOL-NORGESTIMATE 1/1-0.09 MG (15/15) PO TABS BOTH IP/OP $30.03 $22.22 $0.00 $18.21 $0.00 $0.00 $0.00 $5.35 $0.00 $0.00 $0.00 $0.00 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $11.38 $18.03 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26952 ERX HCPCS 63700001 00904-6286-06 OLANZAPINE 15 MG PO TABS BOTH IP/OP $115.31 $85.33 $0.00 $83.65 $0.00 $0.00 $0.00 $20.53 $0.00 $0.00 $0.00 $0.00 $0.00 $24.03 $0.00 $0.00 $0.00 $0.00 $52.28 $82.81 $83.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26952 ERX HCPCS 63700001 55111-0167-30 OLANZAPINE 15 MG PO TABS BOTH IP/OP $115.31 $85.33 $0.00 $83.65 $0.00 $0.00 $0.00 $20.53 $0.00 $0.00 $0.00 $0.00 $0.00 $24.03 $0.00 $0.00 $0.00 $0.00 $52.28 $82.81 $83.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26952 ERX HCPCS 63700001 68084-0528-01 OLANZAPINE 15 MG PO TABS BOTH IP/OP $115.31 $85.33 $0.00 $83.65 $0.00 $0.00 $0.00 $20.53 $0.00 $0.00 $0.00 $0.00 $0.00 $24.03 $0.00 $0.00 $0.00 $0.00 $52.28 $82.81 $83.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26965 ERX HCPCS 63700001 00069-5800-43 DOFETILIDE 125 MCG PO CAPS BOTH IP/OP $54.62 $40.42 $0.00 $37.92 $0.00 $0.00 $0.00 $9.72 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $23.70 $37.54 $37.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26965 ERX HCPCS 63700001 00069-5800-60 DOFETILIDE 125 MCG PO CAPS BOTH IP/OP $54.62 $40.42 $0.00 $37.92 $0.00 $0.00 $0.00 $9.72 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $23.70 $37.54 $37.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26965 ERX HCPCS 63700001 42291-0411-60 DOFETILIDE 125 MCG PO CAPS BOTH IP/OP $54.62 $40.42 $0.00 $37.92 $0.00 $0.00 $0.00 $9.72 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $23.70 $37.54 $37.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26965 ERX HCPCS 63700001 51862-0125-60 DOFETILIDE 125 MCG PO CAPS BOTH IP/OP $54.62 $40.42 $0.00 $37.92 $0.00 $0.00 $0.00 $9.72 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $23.70 $37.54 $37.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26965 ERX HCPCS 63700001 69452-0131-17 DOFETILIDE 125 MCG PO CAPS BOTH IP/OP $54.62 $40.42 $0.00 $37.92 $0.00 $0.00 $0.00 $9.72 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $23.70 $37.54 $37.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26966 ERX HCPCS 63700001 00069-5810-60 DOFETILIDE 250 MCG PO CAPS BOTH IP/OP $32.54 $24.08 $0.00 $26.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.27 $25.77 $26.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26966 ERX HCPCS 63700001 59762-0038-02 DOFETILIDE 250 MCG PO CAPS BOTH IP/OP $32.54 $24.08 $0.00 $26.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.27 $25.77 $26.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26967 ERX HCPCS 25000001 00069-5820-43 DOFETILIDE 500 MCG PO CAPS BOTH IP/OP $35.85 $26.53 $0.00 $27.63 $0.00 $0.00 $0.00 $0.00 $0.00 $26.61 $26.61 $27.63 $0.00 $7.47 $0.00 $0.00 $0.00 $0.00 $16.26 $25.75 $26.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26967 ERX HCPCS 25000001 00069-5820-60 DOFETILIDE 500 MCG PO CAPS BOTH IP/OP $35.85 $26.53 $0.00 $27.63 $0.00 $0.00 $0.00 $0.00 $0.00 $26.61 $26.61 $27.63 $0.00 $7.47 $0.00 $0.00 $0.00 $0.00 $16.26 $25.75 $26.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26967 ERX HCPCS 25000001 51862-0005-60 DOFETILIDE 500 MCG PO CAPS BOTH IP/OP $35.85 $26.53 $0.00 $27.63 $0.00 $0.00 $0.00 $0.00 $0.00 $26.61 $26.61 $27.63 $0.00 $7.47 $0.00 $0.00 $0.00 $0.00 $16.26 $25.75 $26.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27022 ERX HCPCS 25000001 00045-0646-12 BUDESONIDE 32 MCG/ACT NA SUSP BOTH IP/OP $72.59 $53.72 $0.00 $58.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.30 $57.49 $58.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27023 ERX HCPCS 63700001 51672-2080-02 TERBINAFINE HCL 1 % EX CREA BOTH IP/OP $90.09 $66.67 $0.00 $71.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.31 $71.35 $26.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27023 ERX HCPCS 63700001 51672-2080-01 TERBINAFINE HCL 1 % EX CREA BOTH IP/OP $65.21 $48.26 $0.00 $51.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.31 $51.65 $26.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27023 ERX HCPCS 63700001 00067-8100-12 TERBINAFINE HCL 1 % EX CREA BOTH IP/OP $32.61 $24.13 $0.00 $26.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.31 $25.83 $26.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27027 ERX HCPCS 63700001 00187-5526-75 BEXAROTENE 75 MG PO CAPS BOTH IP/OP $871.61 $644.99 $0.00 $632.82 $0.00 $0.00 $0.00 $155.15 $0.00 $0.00 $0.00 $0.00 $0.00 $181.64 $0.00 $0.00 $0.00 $0.00 $395.51 $626.49 $632.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27032 ERX HCPCS J7674 64281-0100-00 METHACHOLINE CHLORIDE 100 MG IN SOLR BOTH IP/OP $324.80 $240.35 $0.00 $250.36 $0.00 $0.00 $0.00 $0.00 $0.00 $241.07 $241.07 $250.36 $0.00 $67.69 $0.00 $0.00 $0.00 $0.00 $141.75 $224.53 $226.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27032 ERX HCPCS J7674 64281-0100-06 METHACHOLINE CHLORIDE 100 MG IN SOLR BOTH IP/OP $324.80 $240.35 $0.00 $250.36 $0.00 $0.00 $0.00 $0.00 $0.00 $241.07 $241.07 $250.36 $0.00 $67.69 $0.00 $0.00 $0.00 $0.00 $141.75 $224.53 $226.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27049 ERX HCPCS 63700001 62756-0183-88 OXCARBAZEPINE 150 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27049 ERX HCPCS 63700001 68084-0845-01 OXCARBAZEPINE 150 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27099 ERX HCPCS 25000001 00574-0121-08 CHARCOAL ACTIVATED PO LIQD BOTH IP/OP $156.57 $115.86 $0.00 $120.68 $0.00 $0.00 $0.00 $0.00 $0.00 $116.21 $116.21 $120.68 $0.00 $32.63 $0.00 $0.00 $0.00 $0.00 $70.98 $112.43 $113.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27099 ERX HCPCS 25000001 00574-0121-74 CHARCOAL ACTIVATED PO LIQD BOTH IP/OP $156.57 $115.86 $0.00 $120.68 $0.00 $0.00 $0.00 $0.00 $0.00 $116.21 $116.21 $120.68 $0.00 $32.63 $0.00 $0.00 $0.00 $0.00 $70.98 $112.43 $113.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27099 ERX HCPCS 25000001 00574-0121-76 CHARCOAL ACTIVATED PO LIQD BOTH IP/OP $156.57 $115.86 $0.00 $120.68 $0.00 $0.00 $0.00 $0.00 $0.00 $116.21 $116.21 $120.68 $0.00 $32.63 $0.00 $0.00 $0.00 $0.00 $70.98 $112.43 $113.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27099 ERX HCPCS 25000001 66689-0201-08 CHARCOAL ACTIVATED PO LIQD BOTH IP/OP $156.57 $115.86 $0.00 $120.68 $0.00 $0.00 $0.00 $0.00 $0.00 $116.21 $116.21 $120.68 $0.00 $32.63 $0.00 $0.00 $0.00 $0.00 $70.98 $112.43 $113.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27099 ERX HCPCS 25000001 66689-0202-04 CHARCOAL ACTIVATED PO LIQD BOTH IP/OP $156.57 $115.86 $0.00 $120.68 $0.00 $0.00 $0.00 $0.00 $0.00 $116.21 $116.21 $120.68 $0.00 $32.63 $0.00 $0.00 $0.00 $0.00 $70.98 $112.43 $113.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27099 ERX HCPCS 25000001 66689-0202-08 CHARCOAL ACTIVATED PO LIQD BOTH IP/OP $156.57 $115.86 $0.00 $120.68 $0.00 $0.00 $0.00 $0.00 $0.00 $116.21 $116.21 $120.68 $0.00 $32.63 $0.00 $0.00 $0.00 $0.00 $70.98 $112.43 $113.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27112 ERX HCPCS 63700001 00093-3099-56 RISEDRONATE SODIUM 5 MG PO TABS BOTH IP/OP $37.11 $27.46 $0.00 $26.93 $0.00 $0.00 $0.00 $6.61 $0.00 $0.00 $0.00 $0.00 $0.00 $7.73 $0.00 $0.00 $0.00 $0.00 $16.83 $26.66 $26.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27181 ERX HCPCS 63700001 62175-0320-46 NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG PO TBCR BOTH IP/OP $21.86 $16.18 $0.00 $15.86 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $0.00 $4.56 $0.00 $0.00 $0.00 $0.00 $9.92 $15.71 $15.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27181 ERX HCPCS 63700001 65162-0321-09 NIACIN ER (ANTIHYPERLIPIDEMIC) 500 MG PO TBCR BOTH IP/OP $21.86 $16.18 $0.00 $15.86 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $0.00 $4.56 $0.00 $0.00 $0.00 $0.00 $9.92 $15.71 $15.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27182 ERX HCPCS 63700001 47335-0614-81 NIACIN ER (ANTIHYPERLIPIDEMIC) 750 MG PO TBCR BOTH IP/OP $25.30 $18.72 $0.00 $18.36 $0.00 $0.00 $0.00 $4.50 $0.00 $0.00 $0.00 $0.00 $0.00 $5.27 $0.00 $0.00 $0.00 $0.00 $11.48 $18.18 $18.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27183 ERX HCPCS 63700001 47335-0613-81 NIACIN ER (ANTIHYPERLIPIDEMIC) 1000 MG PO TBCR BOTH IP/OP $31.37 $23.21 $0.00 $33.35 $0.00 $0.00 $0.00 $5.58 $0.00 $0.00 $0.00 $0.00 $0.00 $6.54 $0.00 $0.00 $0.00 $0.00 $20.85 $33.02 $33.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27183 ERX HCPCS 63700001 65162-0323-09 NIACIN ER (ANTIHYPERLIPIDEMIC) 1000 MG PO TBCR BOTH IP/OP $31.37 $23.21 $0.00 $33.35 $0.00 $0.00 $0.00 $5.58 $0.00 $0.00 $0.00 $0.00 $0.00 $6.54 $0.00 $0.00 $0.00 $0.00 $20.85 $33.02 $33.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27234 ERX HCPCS 63700001 00781-5554-31 MONTELUKAST SODIUM 4 MG PO CHEW BOTH IP/OP $23.71 $17.55 $0.00 $17.20 $0.00 $0.00 $0.00 $4.22 $0.00 $0.00 $0.00 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $10.75 $17.03 $17.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27234 ERX HCPCS 63700001 27241-0016-03 MONTELUKAST SODIUM 4 MG PO CHEW BOTH IP/OP $23.71 $17.55 $0.00 $17.20 $0.00 $0.00 $0.00 $4.22 $0.00 $0.00 $0.00 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $10.75 $17.03 $17.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27234 ERX HCPCS 63700001 42291-0622-90 MONTELUKAST SODIUM 4 MG PO CHEW BOTH IP/OP $23.71 $17.55 $0.00 $17.20 $0.00 $0.00 $0.00 $4.22 $0.00 $0.00 $0.00 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $10.75 $17.03 $17.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27278 ERX HCPCS 63700001 13668-0106-01 ISOSORBIDE MONONITRATE ER 120 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27278 ERX HCPCS 63700001 62175-0129-37 ISOSORBIDE MONONITRATE ER 120 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27291 ERX HCPCS J0713 00409-5093-11 CEFTAZIDIME 2 G IV SOLR BOTH IP/OP $24.02 $17.77 $0.00 $21.74 $0.00 $0.00 $0.00 $0.00 $0.00 $17.83 $17.83 $18.51 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $13.59 $21.52 $21.74 $0.00 $0.00 $4.25 $0.00 $0.00 $4.33 $0.00 $0.00 $0.00 $0.00 $0.00 27299 ERX HCPCS J0697 00143-9977-22 CEFUROXIME SODIUM 1.5 G IV SOLR BOTH IP/OP $29.40 $21.76 $0.00 $22.66 $0.00 $0.00 $0.00 $0.00 $0.00 $21.82 $21.82 $22.66 $0.00 $4.73 $0.00 $0.00 $0.00 $0.00 $13.33 $21.11 $21.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27314 ERX HCPCS J2941 00013-2626-81 SOMATROPIN (ZOMACTON) 5 MG SC SOLR BOTH IP/OP "$1,016.16 " $751.96 $0.00 $783.26 $0.00 $0.00 $0.00 $0.00 $0.00 $754.19 $754.19 $783.26 $0.00 $211.77 $0.00 $0.00 $0.00 $0.00 $461.10 $730.38 $737.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27314 ERX HCPCS J2941 55566-1801-01 SOMATROPIN (ZOMACTON) 5 MG SC SOLR BOTH IP/OP "$1,016.16 " $751.96 $0.00 $783.26 $0.00 $0.00 $0.00 $0.00 $0.00 $754.19 $754.19 $783.26 $0.00 $211.77 $0.00 $0.00 $0.00 $0.00 $461.10 $730.38 $737.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27325 ERX HCPCS 90744 58160-0820-52 HEPATITIS B VAC RECOMBINANT 10 MCG/0.5ML IJ SUSP BOTH IP/OP $103.93 $76.91 $0.00 $83.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.97 $82.31 $83.14 $62.36 $62.36 $16.27 $27.02 $27.02 $0.00 $27.02 $0.00 $0.00 $0.00 $0.00 27326 ERX HCPCS 90746 58160-0821-11 HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSP BOTH IP/OP $233.36 $172.69 $0.00 $186.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.68 $184.82 $186.69 $140.02 $140.02 $78.80 $60.67 $60.67 $75.03 $60.67 $0.00 $0.00 $0.00 $0.00 27326 ERX HCPCS 90746 58160-0821-43 HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSP BOTH IP/OP $233.36 $172.69 $0.00 $186.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.68 $184.82 $186.69 $140.02 $140.02 $78.80 $60.67 $60.67 $75.03 $60.67 $0.00 $0.00 $0.00 $0.00 27326 ERX HCPCS 90746 58160-0821-52 HEPATITIS B VAC RECOMBINANT 20 MCG/ML IJ SUSP BOTH IP/OP $233.36 $172.69 $0.00 $186.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.68 $184.82 $186.69 $140.02 $140.02 $78.80 $60.67 $60.67 $75.03 $60.67 $0.00 $0.00 $0.00 $0.00 27386 ERX HCPCS 25000001 63323-0254-10 MINERAL OIL LIGHT OIL BOTH IP/OP $76.64 $56.71 $0.00 $59.07 $0.00 $0.00 $0.00 $0.00 $0.00 $56.88 $56.88 $59.07 $0.00 $15.97 $0.00 $0.00 $0.00 $0.00 $31.73 $50.26 $50.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27393 ERX HCPCS 63600001 00409-1134-03 MORPHINE SULFATE 50 MG/ML IV SOLN BOTH IP/OP $126.42 $93.55 $0.00 $97.44 $0.00 $0.00 $0.00 $0.00 $0.00 $93.83 $93.83 $97.44 $0.00 $26.35 $0.00 $0.00 $0.00 $0.00 $28.88 $45.75 $46.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27393 ERX HCPCS 63600001 00409-1134-05 MORPHINE SULFATE 50 MG/ML IV SOLN BOTH IP/OP $126.42 $93.55 $0.00 $97.44 $0.00 $0.00 $0.00 $0.00 $0.00 $93.83 $93.83 $97.44 $0.00 $26.35 $0.00 $0.00 $0.00 $0.00 $28.88 $89.54 $46.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27430 ERX HCPCS 25000001 13925-0515-10 PENTAMIDINE ISETHIONATE 300 MG IJ SOLR BOTH IP/OP $584.79 $432.74 $0.00 $450.76 $0.00 $0.00 $0.00 $0.00 $0.00 $434.03 $434.03 $450.76 $0.00 $121.87 $0.00 $0.00 $0.00 $0.00 $265.36 $420.33 $424.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27430 ERX HCPCS 25000001 63323-0113-10 PENTAMIDINE ISETHIONATE 300 MG IJ SOLR BOTH IP/OP $584.79 $432.74 $0.00 $450.76 $0.00 $0.00 $0.00 $0.00 $0.00 $434.03 $434.03 $450.76 $0.00 $121.87 $0.00 $0.00 $0.00 $0.00 $265.36 $420.33 $424.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27431 ERX HCPCS Q2050 43598-0283-35 DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ BOTH IP/OP "$2,408.70 " "$1,782.44" $0.00 "$1,906.99" "$1,083.92" "$1,083.92" $401.03 $401.03 $401.03 $502.03 "$1,787.74" "$1,787.74" "$1,856.63" $468.06 $549.97 $304.24 "$1,187.49" "$1,187.49" $745.65 "$1,191.87" "$1,887.92" "$1,906.99" "$1,029.70" "$1,029.70" $694.47 $0.00 $0.00 $661.26 $635.41 $0.00 $0.00 $0.00 $0.00 27431 ERX HCPCS Q2050 47335-0049-40 DOXORUBICIN HCL LIPOSOMAL 2 MG/ML IV INJ BOTH IP/OP "$2,408.70 " "$1,782.44" $0.00 "$1,906.99" "$1,083.92" "$1,083.92" $401.03 $401.03 $401.03 $502.03 "$1,787.74" "$1,787.74" "$1,856.63" $468.06 $549.97 $304.24 "$1,187.49" "$1,187.49" $745.65 "$1,191.87" "$1,887.92" "$1,906.99" "$1,029.70" "$1,029.70" $694.47 $0.00 $0.00 $661.26 $635.41 $0.00 $0.00 $0.00 $0.00 27459 ERX HCPCS 63700001 00378-4642-26 ESTRADIOL 0.05 MG/24HR TD PTTW BOTH IP/OP $47.50 $35.15 $0.00 $34.46 $0.00 $0.00 $0.00 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $21.54 $34.12 $34.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27461 ERX HCPCS 25000001 00378-4640-16 ESTRADIOL 0.1 MG/24HR TD PTTW BOTH IP/OP $67.23 $49.75 $0.00 $53.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.62 $53.25 $53.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27461 ERX HCPCS 25000001 00378-4640-26 ESTRADIOL 0.1 MG/24HR TD PTTW BOTH IP/OP $67.23 $49.75 $0.00 $53.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.62 $53.25 $53.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27471 ERX HCPCS 25000001 NITROGLYCERIN 0.1 MG/HR TD PT24 BOTH IP/OP $7.79 $5.76 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.78 $5.78 $6.00 $0.00 $1.62 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27471 ERX HCPCS 25000001 00378-9102-93 NITROGLYCERIN 0.1 MG/HR TD PT24 BOTH IP/OP $7.79 $5.76 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.78 $5.78 $6.00 $0.00 $1.62 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27471 ERX HCPCS 25000001 47781-0296-03 NITROGLYCERIN 0.1 MG/HR TD PT24 BOTH IP/OP $7.79 $5.76 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.78 $5.78 $6.00 $0.00 $1.62 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27472 ERX HCPCS 25000001 00378-9104-93 NITROGLYCERIN 0.2 MG/HR TD PT24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27473 ERX HCPCS 25000001 50742-0515-30 NITROGLYCERIN 0.3 MG/HR TD PT24 BOTH IP/OP $181.82 $134.55 $0.00 $140.15 $0.00 $0.00 $0.00 $0.00 $0.00 $134.95 $134.95 $140.15 $0.00 $37.89 $0.00 $0.00 $0.00 $0.00 $65.95 $104.46 $105.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27474 ERX HCPCS 25000001 NITROGLYCERIN 0.4 MG/HR TD PT24 BOTH IP/OP $7.74 $5.73 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 $5.74 $5.74 $5.97 $0.00 $1.61 $0.00 $0.00 $0.00 $0.00 $3.51 $5.56 $5.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27474 ERX HCPCS 25000001 00378-9112-93 NITROGLYCERIN 0.4 MG/HR TD PT24 BOTH IP/OP $7.74 $5.73 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 $5.74 $5.74 $5.97 $0.00 $1.61 $0.00 $0.00 $0.00 $0.00 $3.51 $5.56 $5.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27474 ERX HCPCS 25000001 47781-0298-03 NITROGLYCERIN 0.4 MG/HR TD PT24 BOTH IP/OP $7.74 $5.73 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 $5.74 $5.74 $5.97 $0.00 $1.61 $0.00 $0.00 $0.00 $0.00 $3.51 $5.56 $5.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27475 ERX HCPCS 25000001 NITROGLYCERIN 0.6 MG/HR TD PT24 BOTH IP/OP $10.04 $7.43 $0.00 $7.74 $0.00 $0.00 $0.00 $0.00 $0.00 $7.45 $7.45 $7.74 $0.00 $2.09 $0.00 $0.00 $0.00 $0.00 $4.56 $7.22 $7.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27475 ERX HCPCS 25000001 00378-9116-93 NITROGLYCERIN 0.6 MG/HR TD PT24 BOTH IP/OP $10.04 $7.43 $0.00 $7.74 $0.00 $0.00 $0.00 $0.00 $0.00 $7.45 $7.45 $7.74 $0.00 $2.09 $0.00 $0.00 $0.00 $0.00 $4.56 $7.22 $7.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27489 ERX HCPCS 63700001 53489-0368-01 FELODIPINE ER 2.5 MG PO TB24 BOTH IP/OP $6.34 $4.69 $0.00 $4.80 $0.00 $0.00 $0.00 $1.13 $0.00 $0.00 $0.00 $0.00 $0.00 $1.32 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27490 ERX HCPCS 63700001 00603-3582-21 FELODIPINE ER 5 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27490 ERX HCPCS 63700001 53489-0369-01 FELODIPINE ER 5 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27491 ERX HCPCS 63700001 53489-0370-01 FELODIPINE ER 10 MG PO TB24 BOTH IP/OP $10.32 $7.64 $0.00 $8.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.16 $8.17 $8.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27494 ERX HCPCS 63700001 00378-2223-01 NISOLDIPINE ER 30 MG PO TB24 BOTH IP/OP $75.18 $55.63 $0.00 $54.54 $0.00 $0.00 $0.00 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $15.67 $0.00 $0.00 $0.00 $0.00 $34.09 $54.00 $54.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27495 ERX HCPCS 63700001 00378-2224-01 NISOLDIPINE ER 40 MG PO TB24 BOTH IP/OP $75.18 $55.63 $0.00 $54.54 $0.00 $0.00 $0.00 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $15.67 $0.00 $0.00 $0.00 $0.00 $34.09 $54.00 $54.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27520 ERX HCPCS 63700001 00573-2660-12 LORATADINE-PSEUDOEPHEDRINE ER 5-120 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27520 ERX HCPCS 63700001 00573-2660-24 LORATADINE-PSEUDOEPHEDRINE ER 5-120 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27529 ERX HCPCS 63700001 63824-0057-18 PSEUDOEPHEDRINE-GUAIFENESIN ER 60-600 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27529 ERX HCPCS 63700001 63824-0057-36 PSEUDOEPHEDRINE-GUAIFENESIN ER 60-600 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27631 ERX HCPCS 63700001 68084-0313-01 DIVALPROEX SODIUM 125 MG PO CSDR BOTH IP/OP $8.20 $6.07 $0.00 $6.56 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.10 $6.49 $6.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27631 ERX HCPCS 63700001 68084-0313-11 DIVALPROEX SODIUM 125 MG PO CSDR BOTH IP/OP $8.20 $6.07 $0.00 $6.56 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.10 $6.49 $6.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27632 ERX HCPCS 63700001 54092-0172-12 CARBAMAZEPINE ER 200 MG PO CP12 BOTH IP/OP $8.92 $6.60 $0.00 $6.47 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.41 $6.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27633 ERX HCPCS 63700001 54092-0173-12 CARBAMAZEPINE ER 300 MG PO CP12 BOTH IP/OP $8.92 $6.60 $0.00 $6.47 $0.00 $0.00 $0.00 $1.59 $0.00 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 $6.41 $6.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27634 ERX HCPCS 63700001 00078-0510-05 CARBAMAZEPINE ER 100 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27634 ERX HCPCS 63700001 00781-8016-01 CARBAMAZEPINE ER 100 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27635 ERX HCPCS 63700001 00078-0511-05 CARBAMAZEPINE ER 200 MG PO TB12 BOTH IP/OP $8.72 $6.45 $0.00 $6.33 $0.00 $0.00 $0.00 $1.55 $0.00 $0.00 $0.00 $0.00 $0.00 $1.82 $0.00 $0.00 $0.00 $0.00 $3.96 $6.26 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27635 ERX HCPCS 63700001 00781-5987-01 CARBAMAZEPINE ER 200 MG PO TB12 BOTH IP/OP $8.72 $6.45 $0.00 $6.33 $0.00 $0.00 $0.00 $1.55 $0.00 $0.00 $0.00 $0.00 $0.00 $1.82 $0.00 $0.00 $0.00 $0.00 $3.96 $6.26 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27635 ERX HCPCS 63700001 51672-4124-01 CARBAMAZEPINE ER 200 MG PO TB12 BOTH IP/OP $8.72 $6.45 $0.00 $6.33 $0.00 $0.00 $0.00 $1.55 $0.00 $0.00 $0.00 $0.00 $0.00 $1.82 $0.00 $0.00 $0.00 $0.00 $3.96 $6.26 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27636 ERX HCPCS 63700001 00078-0512-05 CARBAMAZEPINE ER 400 MG PO TB12 BOTH IP/OP $27.21 $20.14 $0.00 $19.74 $0.00 $0.00 $0.00 $4.84 $0.00 $0.00 $0.00 $0.00 $0.00 $5.67 $0.00 $0.00 $0.00 $0.00 $12.34 $19.54 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27636 ERX HCPCS 63700001 00781-5988-01 CARBAMAZEPINE ER 400 MG PO TB12 BOTH IP/OP $27.21 $20.14 $0.00 $19.74 $0.00 $0.00 $0.00 $4.84 $0.00 $0.00 $0.00 $0.00 $0.00 $5.67 $0.00 $0.00 $0.00 $0.00 $12.34 $19.54 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27636 ERX HCPCS 63700001 51672-4125-01 CARBAMAZEPINE ER 400 MG PO TB12 BOTH IP/OP $27.21 $20.14 $0.00 $19.74 $0.00 $0.00 $0.00 $4.84 $0.00 $0.00 $0.00 $0.00 $0.00 $5.67 $0.00 $0.00 $0.00 $0.00 $12.34 $19.54 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27641 ERX HCPCS 63700001 00093-7335-06 TOPIRAMATE 15 MG PO CPSP BOTH IP/OP $29.96 $22.17 $0.00 $21.31 $0.00 $0.00 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $6.24 $0.00 $0.00 $0.00 $0.00 $13.32 $21.10 $21.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27641 ERX HCPCS 63700001 50458-0647-65 TOPIRAMATE 15 MG PO CPSP BOTH IP/OP $29.96 $22.17 $0.00 $21.31 $0.00 $0.00 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $6.24 $0.00 $0.00 $0.00 $0.00 $13.32 $21.10 $21.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27641 ERX HCPCS 63700001 68382-0004-14 TOPIRAMATE 15 MG PO CPSP BOTH IP/OP $29.96 $22.17 $0.00 $21.31 $0.00 $0.00 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $6.24 $0.00 $0.00 $0.00 $0.00 $13.32 $21.10 $21.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27642 ERX HCPCS 63700001 00093-7336-06 TOPIRAMATE 25 MG PO CPSP BOTH IP/OP $12.26 $9.07 $0.00 $8.90 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $5.56 $8.81 $8.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27642 ERX HCPCS 63700001 50458-0645-65 TOPIRAMATE 25 MG PO CPSP BOTH IP/OP $12.26 $9.07 $0.00 $8.90 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $5.56 $8.81 $8.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27642 ERX HCPCS 63700001 68382-0005-14 TOPIRAMATE 25 MG PO CPSP BOTH IP/OP $12.26 $9.07 $0.00 $8.90 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $5.56 $8.81 $8.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27644 ERX HCPCS 25000001 65162-0596-06 ASPIRIN-DIPYRIDAMOLE ER 25-200 MG PO CP12 BOTH IP/OP $35.01 $25.91 $0.00 $26.99 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $26.99 $0.00 $7.30 $0.00 $0.00 $0.00 $0.00 $15.88 $25.15 $25.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27659 ERX HCPCS 63700001 62175-0261-37 NIFEDIPINE ER OSMOTIC RELEASE 60 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27659 ERX HCPCS 63700001 71205-0964-00 NIFEDIPINE ER OSMOTIC RELEASE 60 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27661 ERX HCPCS 25000001 49938-0107-04 AMINOSALICYLIC ACID 4 G PO PACK BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.88 $24.88 $25.84 $0.00 $6.99 $0.00 $0.00 $0.00 $0.00 $15.20 $24.08 $24.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27662 ERX HCPCS 25000001 17478-0403-03 FLUORESCEIN SODIUM 0.6 MG OP STRP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27663 ERX HCPCS 25000001 17238-0900-11 FLUORESCEIN SODIUM 1 MG OP STRP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27663 ERX HCPCS 25000001 17238-0900-30 FLUORESCEIN SODIUM 1 MG OP STRP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27663 ERX HCPCS 25000001 17238-0900-99 FLUORESCEIN SODIUM 1 MG OP STRP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27663 ERX HCPCS 25000001 17478-0404-01 FLUORESCEIN SODIUM 1 MG OP STRP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27667 ERX HCPCS 25000001 45802-0050-03 DIBUCAINE (PERIANAL) 1 % EX OINT BOTH IP/OP $25.11 $18.58 $0.00 $19.35 $0.00 $0.00 $0.00 $0.00 $0.00 $18.64 $18.64 $19.35 $0.00 $5.23 $0.00 $0.00 $0.00 $0.00 $11.39 $18.03 $18.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27691 ERX HCPCS 63700001 00781-2147-31 LANSOPRAZOLE 15 MG PO CPDR BOTH IP/OP $23.75 $17.58 $0.00 $17.23 $0.00 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $10.77 $17.06 $17.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27692 ERX HCPCS 63700001 00093-7351-56 LANSOPRAZOLE 30 MG PO CPDR BOTH IP/OP $24.72 $18.29 $0.00 $17.94 $0.00 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 $5.15 $0.00 $0.00 $0.00 $0.00 $11.21 $17.76 $17.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27692 ERX HCPCS 63700001 00378-8030-93 LANSOPRAZOLE 30 MG PO CPDR BOTH IP/OP $24.72 $18.29 $0.00 $17.94 $0.00 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 $5.15 $0.00 $0.00 $0.00 $0.00 $11.21 $17.76 $17.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27692 ERX HCPCS 63700001 51079-0121-01 LANSOPRAZOLE 30 MG PO CPDR BOTH IP/OP $24.72 $18.29 $0.00 $17.94 $0.00 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 $5.15 $0.00 $0.00 $0.00 $0.00 $11.21 $17.76 $17.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27694 ERX HCPCS 63700001 16714-0747-01 OMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $16.52 $12.22 $0.00 $13.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.26 $13.08 $13.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27694 ERX HCPCS 63700001 16714-0747-02 OMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $16.52 $12.22 $0.00 $13.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.26 $13.08 $13.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27694 ERX HCPCS 63700001 63739-0358-10 OMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $16.52 $12.22 $0.00 $13.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.26 $13.08 $13.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27695 ERX HCPCS 63700001 00781-2234-31 OMEPRAZOLE 40 MG PO CPDR BOTH IP/OP $7.72 $5.71 $0.00 $6.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.86 $6.11 $6.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27695 ERX HCPCS 63700001 63739-0445-10 OMEPRAZOLE 40 MG PO CPDR BOTH IP/OP $7.72 $5.71 $0.00 $6.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.86 $6.11 $6.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27697 ERX HCPCS Q0162 00781-5238-64 ONDANSETRON 4 MG PO TBDP BOTH IP/OP $78.03 $57.74 $0.00 $62.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.02 $61.80 $62.42 $0.00 $0.00 $0.00 $0.00 $0.00 $12.42 $0.00 $0.00 $0.00 $0.00 $0.00 27697 ERX HCPCS Q0162 57237-0077-10 ONDANSETRON 4 MG PO TBDP BOTH IP/OP $78.03 $57.74 $0.00 $62.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.02 $61.80 $62.42 $0.00 $0.00 $0.00 $0.00 $0.00 $12.42 $0.00 $0.00 $0.00 $0.00 $0.00 27697 ERX HCPCS Q0162 65862-0390-10 ONDANSETRON 4 MG PO TBDP BOTH IP/OP $78.03 $57.74 $0.00 $62.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.02 $61.80 $62.42 $0.00 $0.00 $0.00 $0.00 $0.00 $12.42 $0.00 $0.00 $0.00 $0.00 $0.00 27698 ERX HCPCS Q0162 00781-5239-06 ONDANSETRON 8 MG PO TBDP BOTH IP/OP $129.97 $96.18 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.99 $102.94 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 $20.69 $0.00 $0.00 $0.00 $0.00 $0.00 27698 ERX HCPCS Q0162 65862-0391-10 ONDANSETRON 8 MG PO TBDP BOTH IP/OP $129.97 $96.18 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.99 $102.94 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 $20.69 $0.00 $0.00 $0.00 $0.00 $0.00 27735 ERX HCPCS Q9958 00270-0149-57 DIATRIZOATE MEGLUMINE 30 % UR SOLN BOTH IP/OP $230.07 $170.25 $0.00 $170.76 $103.53 $103.53 $0.00 $0.00 $0.00 $47.95 $170.76 $170.76 $0.00 $0.00 $24.68 $0.00 $136.09 $136.09 $0.00 $104.43 $165.41 $167.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27770 ERX HCPCS 25000001 24208-0342-05 DESMOPRESSIN ACE SPRAY REFRIG 0.01 % NA SOLN BOTH IP/OP $719.08 $532.12 $0.00 $554.27 $0.00 $0.00 $0.00 $0.00 $0.00 $533.70 $533.70 $554.27 $0.00 $149.86 $0.00 $0.00 $0.00 $0.00 $326.30 $516.85 $522.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27780 ERX HCPCS 63700001 50268-0816-15 ZONISAMIDE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27780 ERX HCPCS 63700001 60687-0230-01 ZONISAMIDE 100 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00264-7800-00 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-04 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 99999-6008-99 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 99999-6009-26 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 99999-6008-17 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00264-1800-32 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-18 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-38 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-48 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0553-18 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00990-7984-37 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 99999-6010-80 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00264-7800-20 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-02 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00990-7983-02 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 99999-6008-15 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00264-1800-31 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-11 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-31 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-41 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0553-11 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00990-7984-13 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 00338-0049-03 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 99999-6008-16 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27838 ERX HCPCS J7040 99999-6010-79 SODIUM CHLORIDE 0.9 % IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.05 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 27855 ERX HCPCS 25000001 00013-2150-36 ESTRADIOL 2 MG VA RING BOTH IP/OP "$1,568.04 " "$1,160.35" $0.00 "$1,208.65" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,163.80" "$1,163.80" "$1,208.65" $0.00 $326.78 $0.00 $0.00 $0.00 $0.00 $684.81 "$1,084.73" "$1,095.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27857 ERX HCPCS 63700001 00093-7384-98 VENLAFAXINE HCL ER 37.5 MG PO CP24 BOTH IP/OP $17.45 $12.91 $0.00 $12.66 $0.00 $0.00 $0.00 $3.11 $0.00 $0.00 $0.00 $0.00 $0.00 $3.64 $0.00 $0.00 $0.00 $0.00 $7.92 $12.54 $12.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27857 ERX HCPCS 63700001 65862-0527-30 VENLAFAXINE HCL ER 37.5 MG PO CP24 BOTH IP/OP $17.45 $12.91 $0.00 $12.66 $0.00 $0.00 $0.00 $3.11 $0.00 $0.00 $0.00 $0.00 $0.00 $3.64 $0.00 $0.00 $0.00 $0.00 $7.92 $12.54 $12.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27857 ERX HCPCS 63700001 68382-0034-06 VENLAFAXINE HCL ER 37.5 MG PO CP24 BOTH IP/OP $17.45 $12.91 $0.00 $12.66 $0.00 $0.00 $0.00 $3.11 $0.00 $0.00 $0.00 $0.00 $0.00 $3.64 $0.00 $0.00 $0.00 $0.00 $7.92 $12.54 $12.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27857 ERX HCPCS 63700001 68382-0034-16 VENLAFAXINE HCL ER 37.5 MG PO CP24 BOTH IP/OP $17.45 $12.91 $0.00 $12.66 $0.00 $0.00 $0.00 $3.11 $0.00 $0.00 $0.00 $0.00 $0.00 $3.64 $0.00 $0.00 $0.00 $0.00 $7.92 $12.54 $12.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27858 ERX HCPCS 63700001 00008-0833-21 VENLAFAXINE HCL ER 75 MG PO CP24 BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27858 ERX HCPCS 63700001 00093-7385-56 VENLAFAXINE HCL ER 75 MG PO CP24 BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27858 ERX HCPCS 63700001 00093-7385-98 VENLAFAXINE HCL ER 75 MG PO CP24 BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27858 ERX HCPCS 63700001 65862-0528-90 VENLAFAXINE HCL ER 75 MG PO CP24 BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27859 ERX HCPCS 63700001 00093-7386-56 VENLAFAXINE HCL ER 150 MG PO CP24 BOTH IP/OP $21.30 $15.76 $0.00 $15.46 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $9.66 $15.30 $15.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27859 ERX HCPCS 63700001 00093-7386-98 VENLAFAXINE HCL ER 150 MG PO CP24 BOTH IP/OP $21.30 $15.76 $0.00 $15.46 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $9.66 $15.30 $15.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27859 ERX HCPCS 63700001 63739-0512-10 VENLAFAXINE HCL ER 150 MG PO CP24 BOTH IP/OP $21.30 $15.76 $0.00 $15.46 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $9.66 $15.30 $15.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27860 ERX HCPCS 63700001 00536-1106-88 NICOTINE 7 MG/24HR TD PT24 BOTH IP/OP $7.93 $5.87 $0.00 $5.75 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27860 ERX HCPCS 63700001 70677-0030-01 NICOTINE 7 MG/24HR TD PT24 BOTH IP/OP $7.93 $5.87 $0.00 $5.75 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27862 ERX HCPCS 63700001 NICOTINE 14 MG/24HR TD PT24 BOTH IP/OP $8.98 $6.65 $0.00 $6.51 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.07 $6.45 $6.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27862 ERX HCPCS 63700001 00536-5895-88 NICOTINE 14 MG/24HR TD PT24 BOTH IP/OP $8.98 $6.65 $0.00 $6.51 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $4.07 $6.45 $6.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27863 ERX HCPCS 63700001 NICOTINE 21 MG/24HR TD PT24 BOTH IP/OP $7.93 $5.87 $0.00 $5.75 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27863 ERX HCPCS 63700001 00536-5896-71 NICOTINE 21 MG/24HR TD PT24 BOTH IP/OP $7.93 $5.87 $0.00 $5.75 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27863 ERX HCPCS 63700001 00536-5896-88 NICOTINE 21 MG/24HR TD PT24 BOTH IP/OP $7.93 $5.87 $0.00 $5.75 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27863 ERX HCPCS 63700001 43598-0448-71 NICOTINE 21 MG/24HR TD PT24 BOTH IP/OP $7.93 $5.87 $0.00 $5.75 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27863 ERX HCPCS 63700001 49348-0144-46 NICOTINE 21 MG/24HR TD PT24 BOTH IP/OP $7.93 $5.87 $0.00 $5.75 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27863 ERX HCPCS 63700001 70677-0032-01 NICOTINE 21 MG/24HR TD PT24 BOTH IP/OP $7.93 $5.87 $0.00 $5.75 $0.00 $0.00 $0.00 $1.41 $0.00 $0.00 $0.00 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $3.60 $5.69 $5.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27898 ERX HCPCS 25000001 00054-3500-49 LIDOCAINE VISCOUS HCL 2 % MT SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27898 ERX HCPCS 25000001 50383-0775-04 LIDOCAINE VISCOUS HCL 2 % MT SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27898 ERX HCPCS 25000001 50383-0775-17 LIDOCAINE VISCOUS HCL 2 % MT SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27898 ERX HCPCS 25000001 63739-0694-57 LIDOCAINE VISCOUS HCL 2 % MT SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27898 ERX HCPCS 25000001 99999-6007-04 LIDOCAINE VISCOUS HCL 2 % MT SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27905 ERX HCPCS 63700001 00378-9121-98 FENTANYL 25 MCG/HR TD PATCH 72 HR BOTH IP/OP $60.42 $44.71 $0.00 $43.84 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.59 $0.00 $0.00 $0.00 $0.00 $27.40 $43.40 $43.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27905 ERX HCPCS 63700001 47781-0424-47 FENTANYL 25 MCG/HR TD PATCH 72 HR BOTH IP/OP $60.42 $44.71 $0.00 $43.84 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.59 $0.00 $0.00 $0.00 $0.00 $27.40 $43.40 $43.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27905 ERX HCPCS 63700001 60505-7006-02 FENTANYL 25 MCG/HR TD PATCH 72 HR BOTH IP/OP $60.42 $44.71 $0.00 $43.84 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.59 $0.00 $0.00 $0.00 $0.00 $27.40 $43.40 $43.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27905 ERX HCPCS 63700001 60505-7081-02 FENTANYL 25 MCG/HR TD PATCH 72 HR BOTH IP/OP $60.42 $44.71 $0.00 $43.84 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.59 $0.00 $0.00 $0.00 $0.00 $27.40 $43.40 $43.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27905 ERX HCPCS 63700001 67767-0120-08 FENTANYL 25 MCG/HR TD PATCH 72 HR BOTH IP/OP $60.42 $44.71 $0.00 $43.84 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.59 $0.00 $0.00 $0.00 $0.00 $27.40 $43.40 $43.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27906 ERX HCPCS 63700001 47781-0426-47 FENTANYL 50 MCG/HR TD PATCH 72 HR BOTH IP/OP $150.09 $111.07 $0.00 $108.87 $0.00 $0.00 $0.00 $26.72 $0.00 $0.00 $0.00 $0.00 $0.00 $31.28 $0.00 $0.00 $0.00 $0.00 $68.05 $107.78 $108.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27906 ERX HCPCS 63700001 60505-7007-02 FENTANYL 50 MCG/HR TD PATCH 72 HR BOTH IP/OP $150.09 $111.07 $0.00 $108.87 $0.00 $0.00 $0.00 $26.72 $0.00 $0.00 $0.00 $0.00 $0.00 $31.28 $0.00 $0.00 $0.00 $0.00 $68.05 $107.78 $108.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27907 ERX HCPCS 63700001 47781-0427-47 FENTANYL 75 MCG/HR TD PATCH 72 HR BOTH IP/OP $205.80 $152.29 $0.00 $149.46 $0.00 $0.00 $0.00 $36.63 $0.00 $0.00 $0.00 $0.00 $0.00 $42.89 $0.00 $0.00 $0.00 $0.00 $93.41 $147.96 $149.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27907 ERX HCPCS 63700001 60505-7008-02 FENTANYL 75 MCG/HR TD PATCH 72 HR BOTH IP/OP $205.80 $152.29 $0.00 $149.46 $0.00 $0.00 $0.00 $36.63 $0.00 $0.00 $0.00 $0.00 $0.00 $42.89 $0.00 $0.00 $0.00 $0.00 $93.41 $147.96 $149.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27907 ERX HCPCS 63700001 60505-7013-02 FENTANYL 75 MCG/HR TD PATCH 72 HR BOTH IP/OP $205.80 $152.29 $0.00 $149.46 $0.00 $0.00 $0.00 $36.63 $0.00 $0.00 $0.00 $0.00 $0.00 $42.89 $0.00 $0.00 $0.00 $0.00 $93.41 $147.96 $149.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27908 ERX HCPCS 63700001 47781-0428-11 FENTANYL 100 MCG/HR TD PATCH 72 HR BOTH IP/OP $273.14 $202.12 $0.00 $198.36 $0.00 $0.00 $0.00 $48.62 $0.00 $0.00 $0.00 $0.00 $0.00 $56.92 $0.00 $0.00 $0.00 $0.00 $123.98 $196.38 $198.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27908 ERX HCPCS 63700001 47781-0428-47 FENTANYL 100 MCG/HR TD PATCH 72 HR BOTH IP/OP $273.14 $202.12 $0.00 $198.36 $0.00 $0.00 $0.00 $48.62 $0.00 $0.00 $0.00 $0.00 $0.00 $56.92 $0.00 $0.00 $0.00 $0.00 $123.98 $196.38 $198.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27908 ERX HCPCS 63700001 60505-7009-02 FENTANYL 100 MCG/HR TD PATCH 72 HR BOTH IP/OP $273.14 $202.12 $0.00 $198.36 $0.00 $0.00 $0.00 $48.62 $0.00 $0.00 $0.00 $0.00 $0.00 $56.92 $0.00 $0.00 $0.00 $0.00 $123.98 $196.38 $198.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27999 ERX HCPCS 25000001 00574-2002-02 SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP BOTH IP/OP $42.87 $31.72 $0.00 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.44 $33.95 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27999 ERX HCPCS 25000001 00574-2002-16 SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP BOTH IP/OP $42.87 $31.72 $0.00 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.44 $33.95 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27999 ERX HCPCS 25000001 46287-0006-01 SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP BOTH IP/OP $42.87 $31.72 $0.00 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.44 $33.95 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27999 ERX HCPCS 25000001 46287-0006-60 SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP BOTH IP/OP $42.87 $31.72 $0.00 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.44 $33.95 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27999 ERX HCPCS 25000001 99999-6010-75 SODIUM POLYSTYRENE SULFONATE 15 GM/60ML PO SUSP BOTH IP/OP $42.87 $31.72 $0.00 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.44 $33.95 $34.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28001 ERX HCPCS 25000001 00093-9614-13 SILVER NITRATE 0.5 % EX SOLN BOTH IP/OP $293.15 $216.93 $0.00 $225.96 $0.00 $0.00 $0.00 $0.00 $0.00 $217.58 $217.58 $225.96 $0.00 $61.09 $0.00 $0.00 $0.00 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28158 ERX HCPCS 63700001 00904-6287-06 OLANZAPINE 20 MG PO TABS BOTH IP/OP $153.75 $113.78 $0.00 $111.53 $0.00 $0.00 $0.00 $27.37 $0.00 $0.00 $0.00 $0.00 $0.00 $32.04 $0.00 $0.00 $0.00 $0.00 $69.71 $110.41 $111.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28158 ERX HCPCS 63700001 55111-0168-30 OLANZAPINE 20 MG PO TABS BOTH IP/OP $153.75 $113.78 $0.00 $111.53 $0.00 $0.00 $0.00 $27.37 $0.00 $0.00 $0.00 $0.00 $0.00 $32.04 $0.00 $0.00 $0.00 $0.00 $69.71 $110.41 $111.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28158 ERX HCPCS 63700001 60505-3140-00 OLANZAPINE 20 MG PO TABS BOTH IP/OP $153.75 $113.78 $0.00 $111.53 $0.00 $0.00 $0.00 $27.37 $0.00 $0.00 $0.00 $0.00 $0.00 $32.04 $0.00 $0.00 $0.00 $0.00 $69.71 $110.41 $111.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 00002-4453-01 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 00002-4453-85 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 00093-5245-65 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 13668-0086-30 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 33342-0083-07 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 49884-0320-55 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 50268-0615-11 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 50268-0615-13 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 55111-0262-81 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 60505-3275-00 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28159 ERX HCPCS 63700001 60505-3275-03 OLANZAPINE 5 MG PO TBDP BOTH IP/OP $58.66 $43.41 $0.00 $42.56 $0.00 $0.00 $0.00 $10.44 $0.00 $0.00 $0.00 $0.00 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 00002-4454-01 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 00002-4454-85 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 13668-0088-30 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 49884-0321-55 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 50268-0616-13 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 55111-0263-81 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 59746-0307-32 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 60505-3276-00 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28160 ERX HCPCS 63700001 60505-3276-03 OLANZAPINE 10 MG PO TBDP BOTH IP/OP $79.78 $59.04 $0.00 $57.87 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $36.17 $57.29 $57.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28161 ERX HCPCS 63700001 13668-0089-30 OLANZAPINE 15 MG PO TBDP BOTH IP/OP $117.09 $86.65 $0.00 $84.94 $0.00 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.40 $0.00 $0.00 $0.00 $0.00 $53.09 $84.09 $84.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28161 ERX HCPCS 63700001 33342-0085-07 OLANZAPINE 15 MG PO TBDP BOTH IP/OP $117.09 $86.65 $0.00 $84.94 $0.00 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.40 $0.00 $0.00 $0.00 $0.00 $53.09 $84.09 $84.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28161 ERX HCPCS 63700001 49884-0322-52 OLANZAPINE 15 MG PO TBDP BOTH IP/OP $117.09 $86.65 $0.00 $84.94 $0.00 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $0.00 $24.40 $0.00 $0.00 $0.00 $0.00 $53.09 $84.09 $84.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28162 ERX HCPCS 63700001 00002-4456-01 OLANZAPINE 20 MG PO TBDP BOTH IP/OP $154.40 $114.26 $0.00 $112.00 $0.00 $0.00 $0.00 $27.48 $0.00 $0.00 $0.00 $0.00 $0.00 $32.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28162 ERX HCPCS 63700001 00002-4456-85 OLANZAPINE 20 MG PO TBDP BOTH IP/OP $154.40 $114.26 $0.00 $112.00 $0.00 $0.00 $0.00 $27.48 $0.00 $0.00 $0.00 $0.00 $0.00 $32.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28162 ERX HCPCS 63700001 00093-5248-65 OLANZAPINE 20 MG PO TBDP BOTH IP/OP $154.40 $114.26 $0.00 $112.00 $0.00 $0.00 $0.00 $27.48 $0.00 $0.00 $0.00 $0.00 $0.00 $32.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28162 ERX HCPCS 63700001 13668-0090-30 OLANZAPINE 20 MG PO TBDP BOTH IP/OP $154.40 $114.26 $0.00 $112.00 $0.00 $0.00 $0.00 $27.48 $0.00 $0.00 $0.00 $0.00 $0.00 $32.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28162 ERX HCPCS 63700001 55111-0265-81 OLANZAPINE 20 MG PO TBDP BOTH IP/OP $154.40 $114.26 $0.00 $112.00 $0.00 $0.00 $0.00 $27.48 $0.00 $0.00 $0.00 $0.00 $0.00 $32.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28162 ERX HCPCS 63700001 60505-3278-00 OLANZAPINE 20 MG PO TBDP BOTH IP/OP $154.40 $114.26 $0.00 $112.00 $0.00 $0.00 $0.00 $27.48 $0.00 $0.00 $0.00 $0.00 $0.00 $32.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28162 ERX HCPCS 63700001 60505-3278-03 OLANZAPINE 20 MG PO TBDP BOTH IP/OP $154.40 $114.26 $0.00 $112.00 $0.00 $0.00 $0.00 $27.48 $0.00 $0.00 $0.00 $0.00 $0.00 $32.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28188 ERX HCPCS 25000001 67618-0200-08 CHLORHEXIDINE GLUCONATE 4 % EX LIQD BOTH IP/OP $36.75 $27.20 $0.00 $28.33 $0.00 $0.00 $0.00 $0.00 $0.00 $27.28 $27.28 $28.33 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $16.67 $26.40 $26.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28203 ERX HCPCS 25000001 00378-9055-16 LIDOCAINE 5 % EX PTCH BOTH IP/OP $39.22 $29.02 $0.00 $30.23 $0.00 $0.00 $0.00 $0.00 $0.00 $29.11 $29.11 $30.23 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $17.79 $28.17 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28203 ERX HCPCS 25000001 00591-2679-30 LIDOCAINE 5 % EX PTCH BOTH IP/OP $39.22 $29.02 $0.00 $30.23 $0.00 $0.00 $0.00 $0.00 $0.00 $29.11 $29.11 $30.23 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $17.79 $28.17 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28203 ERX HCPCS 25000001 00591-3525-30 LIDOCAINE 5 % EX PTCH BOTH IP/OP $39.22 $29.02 $0.00 $30.23 $0.00 $0.00 $0.00 $0.00 $0.00 $29.11 $29.11 $30.23 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $17.79 $28.17 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28203 ERX HCPCS 25000001 00603-1880-10 LIDOCAINE 5 % EX PTCH BOTH IP/OP $39.22 $29.02 $0.00 $30.23 $0.00 $0.00 $0.00 $0.00 $0.00 $29.11 $29.11 $30.23 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $17.79 $28.17 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28203 ERX HCPCS 25000001 00603-1880-16 LIDOCAINE 5 % EX PTCH BOTH IP/OP $39.22 $29.02 $0.00 $30.23 $0.00 $0.00 $0.00 $0.00 $0.00 $29.11 $29.11 $30.23 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $17.79 $28.17 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28205 ERX HCPCS 25000001 00295-1201-31 PEPPERMINT SPIRIT SPRT BOTH IP/OP $40.73 $30.14 $0.00 $31.39 $0.00 $0.00 $0.00 $0.00 $0.00 $30.23 $30.23 $31.39 $0.00 $8.49 $0.00 $0.00 $0.00 $0.00 $16.93 $26.82 $27.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28205 ERX HCPCS 25000001 00395-2243-91 PEPPERMINT SPIRIT SPRT BOTH IP/OP $40.73 $30.14 $0.00 $31.39 $0.00 $0.00 $0.00 $0.00 $0.00 $30.23 $30.23 $31.39 $0.00 $8.49 $0.00 $0.00 $0.00 $0.00 $16.93 $26.82 $27.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28224 ERX HCPCS 63700001 00904-6553-04 LINEZOLID 600 MG PO TABS BOTH IP/OP $540.82 $400.21 $0.00 $432.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.41 $428.33 $432.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28224 ERX HCPCS 63700001 59762-1307-02 LINEZOLID 600 MG PO TABS BOTH IP/OP $540.82 $400.21 $0.00 $432.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.41 $428.33 $432.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28224 ERX HCPCS 63700001 65162-0777-02 LINEZOLID 600 MG PO TABS BOTH IP/OP $540.82 $400.21 $0.00 $432.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.41 $428.33 $432.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28224 ERX HCPCS 63700001 67877-0419-20 LINEZOLID 600 MG PO TABS BOTH IP/OP $540.82 $400.21 $0.00 $432.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.41 $428.33 $432.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28225 ERX HCPCS 25000001 00009-5136-01 LINEZOLID 100 MG/5ML PO SUSR BOTH IP/OP "$2,119.27 " "$1,568.26" $0.00 "$1,633.53" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.92" "$1,572.92" "$1,633.53" $0.00 $441.66 $0.00 $0.00 $0.00 $0.00 $967.32 "$1,532.23" "$1,547.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28225 ERX HCPCS 25000001 00054-0319-50 LINEZOLID 100 MG/5ML PO SUSR BOTH IP/OP "$2,119.27 " "$1,568.26" $0.00 "$1,633.53" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.92" "$1,572.92" "$1,633.53" $0.00 $441.66 $0.00 $0.00 $0.00 $0.00 $967.32 "$1,532.23" "$1,547.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28225 ERX HCPCS 25000001 59762-1308-01 LINEZOLID 100 MG/5ML PO SUSR BOTH IP/OP "$2,119.27 " "$1,568.26" $0.00 "$1,633.53" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.92" "$1,572.92" "$1,633.53" $0.00 $441.66 $0.00 $0.00 $0.00 $0.00 $967.32 "$1,532.23" "$1,547.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28246 ERX HCPCS 25000001 00173-0520-00 SALMETEROL XINAFOATE 50 MCG/DOSE IN AEPB BOTH IP/OP "$1,316.09 " $973.91 $0.00 "$1,014.44" $0.00 $0.00 $0.00 $0.00 $0.00 $976.80 $976.80 "$1,014.44" $0.00 $274.27 $0.00 $0.00 $0.00 $0.00 $19.19 $30.40 $30.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28252 ERX HCPCS 63700001 00115-5522-10 FENOFIBRATE 160 MG PO TABS BOTH IP/OP $9.96 $7.37 $0.00 $7.22 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $4.52 $7.15 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28252 ERX HCPCS 63700001 42858-0660-45 FENOFIBRATE 160 MG PO TABS BOTH IP/OP $9.96 $7.37 $0.00 $7.22 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $4.52 $7.15 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28252 ERX HCPCS 63700001 68180-0363-09 FENOFIBRATE 160 MG PO TABS BOTH IP/OP $9.96 $7.37 $0.00 $7.22 $0.00 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $4.52 $7.15 $7.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28278 ERX HCPCS 63700001 55111-0352-60 RIVASTIGMINE TARTRATE 1.5 MG PO CAPS BOTH IP/OP $17.79 $13.16 $0.00 $12.90 $0.00 $0.00 $0.00 $3.17 $0.00 $0.00 $0.00 $0.00 $0.00 $3.71 $0.00 $0.00 $0.00 $0.00 $8.07 $12.77 $12.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28278 ERX HCPCS 63700001 63739-0576-10 RIVASTIGMINE TARTRATE 1.5 MG PO CAPS BOTH IP/OP $17.79 $13.16 $0.00 $12.90 $0.00 $0.00 $0.00 $3.17 $0.00 $0.00 $0.00 $0.00 $0.00 $3.71 $0.00 $0.00 $0.00 $0.00 $8.07 $12.77 $12.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28279 ERX HCPCS 63700001 55111-0353-60 RIVASTIGMINE TARTRATE 3 MG PO CAPS BOTH IP/OP $15.33 $11.34 $0.00 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.67 $12.14 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28279 ERX HCPCS 63700001 63739-0577-10 RIVASTIGMINE TARTRATE 3 MG PO CAPS BOTH IP/OP $15.33 $11.34 $0.00 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.67 $12.14 $12.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28280 ERX HCPCS 63700001 00781-2616-60 RIVASTIGMINE TARTRATE 4.5 MG PO CAPS BOTH IP/OP $17.69 $13.09 $0.00 $12.83 $0.00 $0.00 $0.00 $3.15 $0.00 $0.00 $0.00 $0.00 $0.00 $3.69 $0.00 $0.00 $0.00 $0.00 $8.02 $12.70 $12.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28280 ERX HCPCS 63700001 62756-0147-86 RIVASTIGMINE TARTRATE 4.5 MG PO CAPS BOTH IP/OP $17.69 $13.09 $0.00 $12.83 $0.00 $0.00 $0.00 $3.15 $0.00 $0.00 $0.00 $0.00 $0.00 $3.69 $0.00 $0.00 $0.00 $0.00 $8.02 $12.70 $12.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28280 ERX HCPCS 63700001 63739-0578-10 RIVASTIGMINE TARTRATE 4.5 MG PO CAPS BOTH IP/OP $17.69 $13.09 $0.00 $12.83 $0.00 $0.00 $0.00 $3.15 $0.00 $0.00 $0.00 $0.00 $0.00 $3.69 $0.00 $0.00 $0.00 $0.00 $8.02 $12.70 $12.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28281 ERX HCPCS 63700001 00781-2617-60 RIVASTIGMINE TARTRATE 6 MG PO CAPS BOTH IP/OP $26.14 $19.34 $0.00 $20.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.07 $20.70 $20.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28281 ERX HCPCS 63700001 51991-0796-06 RIVASTIGMINE TARTRATE 6 MG PO CAPS BOTH IP/OP $26.14 $19.34 $0.00 $20.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.07 $20.70 $20.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28281 ERX HCPCS 63700001 55111-0355-60 RIVASTIGMINE TARTRATE 6 MG PO CAPS BOTH IP/OP $26.14 $19.34 $0.00 $20.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.07 $20.70 $20.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28282 ERX HCPCS J1815 00088-2220-33 INSULIN GLARGINE (LANTUS) 100 UNIT/ML SC SOLN BOTH IP/OP $12.50 $9.25 $0.00 $201.38 $6.79 $6.79 $0.00 $0.00 $0.00 $2.61 $0.00 $0.00 $0.00 $0.00 $2.61 $0.00 $7.39 $7.39 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.38 $0.00 $0.00 $0.00 $0.00 $0.00 28372 ERX HCPCS 25000001 65597-0701-18 COLESEVELAM HCL 625 MG PO TABS BOTH IP/OP $18.71 $13.85 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $0.00 $13.89 $13.89 $14.42 $0.00 $3.90 $0.00 $0.00 $0.00 $0.00 $8.49 $13.44 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28372 ERX HCPCS 25000001 67877-0506-51 COLESEVELAM HCL 625 MG PO TABS BOTH IP/OP $18.71 $13.85 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $0.00 $13.89 $13.89 $14.42 $0.00 $3.90 $0.00 $0.00 $0.00 $0.00 $8.49 $13.44 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28400 ERX HCPCS 25000001 52919-0006-05 STERILE WATER FOR INJECTION IV SOLN BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $17.10 $17.42 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28400 ERX HCPCS 25000001 52919-0011-04 STERILE WATER FOR INJECTION IV SOLN BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $17.10 $17.42 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28400 ERX HCPCS 25000001 00264-7850-10 STERILE WATER FOR INJECTION IV SOLN BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $17.10 $17.42 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28400 ERX HCPCS 25000001 00264-7385-50 STERILE WATER FOR INJECTION IV SOLN BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $17.10 $18.06 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28400 ERX HCPCS 25000001 00264-7850-00 STERILE WATER FOR INJECTION IV SOLN BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $17.10 $27.09 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28400 ERX HCPCS 25000001 00338-0013-04 STERILE WATER FOR INJECTION IV SOLN BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $17.10 $27.09 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28558 ERX HCPCS 25000001 00023-5902-04 TRIPTORELIN PAMOATE 3.75 MG IM SUSR BOTH IP/OP "$2,342.14 " "$1,733.18" $0.00 "$1,873.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,171.07" "$1,854.97" "$1,873.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28643 ERX HCPCS 63700001 50742-0260-01 NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28643 ERX HCPCS 63700001 62175-0260-55 NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28643 ERX HCPCS 63700001 71205-0963-00 NIFEDIPINE ER OSMOTIC RELEASE 30 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28645 ERX HCPCS 63700001 00378-3953-77 ATORVASTATIN CALCIUM 80 MG PO TABS BOTH IP/OP $8.14 $6.02 $0.00 $5.90 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28645 ERX HCPCS 63700001 00904-6293-04 ATORVASTATIN CALCIUM 80 MG PO TABS BOTH IP/OP $8.14 $6.02 $0.00 $5.90 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28645 ERX HCPCS 63700001 16714-0877-01 ATORVASTATIN CALCIUM 80 MG PO TABS BOTH IP/OP $8.14 $6.02 $0.00 $5.90 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28645 ERX HCPCS 63700001 51079-0211-01 ATORVASTATIN CALCIUM 80 MG PO TABS BOTH IP/OP $8.14 $6.02 $0.00 $5.90 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28645 ERX HCPCS 63700001 51079-0211-03 ATORVASTATIN CALCIUM 80 MG PO TABS BOTH IP/OP $8.14 $6.02 $0.00 $5.90 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $3.69 $5.84 $5.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28686 ERX HCPCS 63700001 68462-0402-01 ATOVAQUONE-PROGUANIL HCL 62.5-25 MG PO TABS BOTH IP/OP $22.51 $16.66 $0.00 $16.33 $0.00 $0.00 $0.00 $4.01 $0.00 $0.00 $0.00 $0.00 $0.00 $4.69 $0.00 $0.00 $0.00 $0.00 $10.21 $16.16 $16.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28774 ERX HCPCS J7626 00487-9601-01 BUDESONIDE 0.25 MG/2ML IN SUSP BOTH IP/OP $24.94 $18.46 $0.00 $19.22 $0.00 $0.00 $0.00 $0.00 $0.00 $18.51 $18.51 $19.22 $0.00 $5.20 $0.00 $0.00 $0.00 $0.00 $11.31 $17.91 $18.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28774 ERX HCPCS J7626 00487-9601-30 BUDESONIDE 0.25 MG/2ML IN SUSP BOTH IP/OP $24.94 $18.46 $0.00 $19.22 $0.00 $0.00 $0.00 $0.00 $0.00 $18.51 $18.51 $19.22 $0.00 $5.20 $0.00 $0.00 $0.00 $0.00 $11.31 $17.91 $18.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28774 ERX HCPCS J7626 69097-0318-87 BUDESONIDE 0.25 MG/2ML IN SUSP BOTH IP/OP $24.94 $18.46 $0.00 $19.22 $0.00 $0.00 $0.00 $0.00 $0.00 $18.51 $18.51 $19.22 $0.00 $5.20 $0.00 $0.00 $0.00 $0.00 $11.31 $17.91 $18.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28775 ERX HCPCS J7626 00093-6816-73 BUDESONIDE 0.5 MG/2ML IN SUSP BOTH IP/OP $51.58 $38.17 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 $38.28 $38.28 $39.76 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28775 ERX HCPCS J7626 00186-1989-04 BUDESONIDE 0.5 MG/2ML IN SUSP BOTH IP/OP $51.58 $38.17 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 $38.28 $38.28 $39.76 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28775 ERX HCPCS J7626 00487-9701-01 BUDESONIDE 0.5 MG/2ML IN SUSP BOTH IP/OP $51.58 $38.17 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 $38.28 $38.28 $39.76 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28775 ERX HCPCS J7626 00487-9701-30 BUDESONIDE 0.5 MG/2ML IN SUSP BOTH IP/OP $51.58 $38.17 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 $38.28 $38.28 $39.76 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28775 ERX HCPCS J7626 00781-7516-87 BUDESONIDE 0.5 MG/2ML IN SUSP BOTH IP/OP $51.58 $38.17 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 $38.28 $38.28 $39.76 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28775 ERX HCPCS J7626 69097-0319-86 BUDESONIDE 0.5 MG/2ML IN SUSP BOTH IP/OP $51.58 $38.17 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 $38.28 $38.28 $39.76 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28775 ERX HCPCS J7626 69097-0319-87 BUDESONIDE 0.5 MG/2ML IN SUSP BOTH IP/OP $51.58 $38.17 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 $38.28 $38.28 $39.76 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $23.39 $37.05 $37.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28810 ERX HCPCS 25000001 24208-0635-62 NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP BOTH IP/OP $338.29 $250.33 $0.00 $260.75 $0.00 $0.00 $0.00 $0.00 $0.00 $251.08 $251.08 $260.75 $0.00 $70.50 $0.00 $0.00 $0.00 $0.00 $153.54 $243.21 $245.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28810 ERX HCPCS 25000001 61314-0645-11 NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SUSP BOTH IP/OP $338.29 $250.33 $0.00 $260.75 $0.00 $0.00 $0.00 $0.00 $0.00 $251.08 $251.08 $260.75 $0.00 $70.50 $0.00 $0.00 $0.00 $0.00 $153.54 $243.21 $245.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28824 ERX HCPCS 25000001 10631-0407-01 HYDROCORTISONE (PERIANAL) 2.5 % EX CREA BOTH IP/OP $303.00 $224.22 $0.00 $233.55 $0.00 $0.00 $0.00 $0.00 $0.00 $224.89 $224.89 $233.55 $0.00 $63.15 $0.00 $0.00 $0.00 $0.00 $145.53 $217.85 $220.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28824 ERX HCPCS 25000001 64980-0301-30 HYDROCORTISONE (PERIANAL) 2.5 % EX CREA BOTH IP/OP $303.00 $224.22 $0.00 $233.55 $0.00 $0.00 $0.00 $0.00 $0.00 $224.89 $224.89 $233.55 $0.00 $63.15 $0.00 $0.00 $0.00 $0.00 $145.53 $230.52 $220.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28836 ERX HCPCS 63700001 00121-0431-30 MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28836 ERX HCPCS 63700001 00536-2470-85 MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28836 ERX HCPCS 63700001 99999-6006-91 MAGNESIUM HYDROXIDE 400 MG/5ML PO SUSP BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28842 ERX HCPCS J7515 00093-5740-65 CYCLOSPORINE MODIFIED (GENGRAF) 25 MG PO CAPS BOTH IP/OP $11.53 $8.53 $0.00 $8.89 $0.00 $0.00 $0.00 $0.00 $0.00 $8.56 $8.56 $8.89 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $5.23 $8.28 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28843 ERX HCPCS J7502 00093-5742-19 CYCLOSPORINE MODIFIED 100 MG PO CAPS BOTH IP/OP $23.03 $17.04 $0.00 $17.75 $10.36 $10.36 $0.00 $0.00 $0.00 $4.80 $17.09 $17.09 $17.75 $0.00 $4.80 $0.00 $13.62 $13.62 $0.00 $10.45 $16.54 $16.71 $0.00 $0.00 $3.27 $0.00 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $0.00 28843 ERX HCPCS J7502 00093-5742-65 CYCLOSPORINE MODIFIED 100 MG PO CAPS BOTH IP/OP $23.03 $17.04 $0.00 $17.75 $10.36 $10.36 $0.00 $0.00 $0.00 $4.80 $17.09 $17.09 $17.75 $0.00 $4.80 $0.00 $13.62 $13.62 $0.00 $10.45 $16.54 $16.71 $0.00 $0.00 $3.27 $0.00 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $0.00 28844 ERX HCPCS J7502 00172-7313-20 CYCLOSPORINE MODIFIED (GENGRAF) 100 MG/ML PO SOLN BOTH IP/OP $874.69 $647.27 $0.00 $674.21 $393.61 $393.61 $0.00 $0.00 $0.00 $182.31 $649.19 $649.19 $674.21 $0.00 $182.29 $0.00 $517.38 $517.38 $0.00 $396.91 $628.70 $635.05 $0.00 $0.00 $124.23 $0.00 $0.00 $126.37 $0.00 $0.00 $0.00 $0.00 $0.00 28849 ERX HCPCS 25000001 00037-6822-10 HYDROCORT-PRAMOXINE (PERIANAL) 1-1 % EX FOAM BOTH IP/OP $633.30 $468.64 $0.00 $488.15 $0.00 $0.00 $0.00 $0.00 $0.00 $470.04 $470.04 $488.15 $0.00 $131.98 $0.00 $0.00 $0.00 $0.00 $273.76 $433.63 $438.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28899 ERX HCPCS 25000001 00406-8515-23 OXYCODONE HCL 15 MG PO TABS BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28899 ERX HCPCS 25000001 00406-8515-62 OXYCODONE HCL 15 MG PO TABS BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28899 ERX HCPCS 25000001 57664-0187-88 OXYCODONE HCL 15 MG PO TABS BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28899 ERX HCPCS 25000001 68084-0184-01 OXYCODONE HCL 15 MG PO TABS BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28899 ERX HCPCS 25000001 68094-0005-59 OXYCODONE HCL 15 MG PO TABS BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28899 ERX HCPCS 25000001 68094-0005-61 OXYCODONE HCL 15 MG PO TABS BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28900 ERX HCPCS 25000001 00406-8530-62 OXYCODONE HCL 30 MG PO TABS BOTH IP/OP $13.54 $10.02 $0.00 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.77 $10.72 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28900 ERX HCPCS 25000001 68084-0185-01 OXYCODONE HCL 30 MG PO TABS BOTH IP/OP $13.54 $10.02 $0.00 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.77 $10.72 $10.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28912 ERX HCPCS J9120 55292-0811-55 DACTINOMYCIN 0.5 MG IV SOLR BOTH IP/OP "$4,119.05 " "$3,048.10" $0.00 "$3,174.96" "$1,853.57" "$1,853.57" $838.88 $838.88 $838.88 $591.51 "$3,057.16" "$3,057.16" "$3,174.96" $890.64 "$1,046.51" $578.92 "$2,030.69" "$2,030.69" $0.00 "$1,868.16" "$2,959.16" "$2,989.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28912 ERX HCPCS J9120 66993-0489-83 DACTINOMYCIN 0.5 MG IV SOLR BOTH IP/OP "$4,119.05 " "$3,048.10" $0.00 "$3,174.96" "$1,853.57" "$1,853.57" $838.88 $838.88 $838.88 $591.51 "$3,057.16" "$3,057.16" "$3,174.96" $890.64 "$1,046.51" $578.92 "$2,030.69" "$2,030.69" $0.00 "$1,868.16" "$2,959.16" "$2,989.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28912 ERX HCPCS J9120 67457-0513-05 DACTINOMYCIN 0.5 MG IV SOLR BOTH IP/OP "$4,119.05 " "$3,048.10" $0.00 "$3,174.96" "$1,853.57" "$1,853.57" $838.88 $838.88 $838.88 $591.51 "$3,057.16" "$3,057.16" "$3,174.96" $890.64 "$1,046.51" $578.92 "$2,030.69" "$2,030.69" $0.00 "$1,868.16" "$2,959.16" "$2,989.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28913 ERX HCPCS 25000001 08065-1830-85 SODIUM HYALURONATE 10 MG/ML IO SOLN BOTH IP/OP $694.15 $513.67 $0.00 $561.81 $0.00 $0.00 $0.00 $0.00 $0.00 $540.97 $540.97 $561.81 $0.00 $144.66 $0.00 $0.00 $0.00 $0.00 $305.81 $484.40 $489.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28917 ERX HCPCS 25000001 08065-1831-50 NA HYALUR & NA CHOND-NA HYALUR 0.55-0.5 ML IO KIT BOTH IP/OP $779.70 $576.98 $0.00 $631.07 $0.00 $0.00 $0.00 $0.00 $0.00 $607.65 $607.65 $631.07 $0.00 $162.49 $0.00 $0.00 $0.00 $0.00 $343.51 $544.12 $549.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28923 ERX HCPCS 25000001 08065-1839-05 NA CHONDROIT SULF-NA HYALURON 40-30 MG/ML IO SOLN BOTH IP/OP $568.80 $420.91 $0.00 $455.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $284.40 $450.49 $455.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28929 ERX HCPCS 63700001 99999-6004-92 KALETRA:LOPINAVIR-RITONAVIR 400-100 MG/5ML PO SOLN BOTH IP/OP $530.41 $392.50 $0.00 "$1,179.96" $0.00 $0.00 $0.00 $94.41 $0.00 $0.00 $0.00 $0.00 $0.00 $110.54 $0.00 $0.00 $0.00 $0.00 $737.48 $381.33 "$1,179.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28929 ERX HCPCS 63700001 00074-3956-46 KALETRA:LOPINAVIR-RITONAVIR 400-100 MG/5ML PO SOLN BOTH IP/OP $530.41 $392.50 $0.00 "$1,179.96" $0.00 $0.00 $0.00 $94.41 $0.00 $0.00 $0.00 $0.00 $0.00 $110.54 $0.00 $0.00 $0.00 $0.00 $737.48 "$1,168.16" "$1,179.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28929 ERX HCPCS 63700001 00527-1947-48 KALETRA:LOPINAVIR-RITONAVIR 400-100 MG/5ML PO SOLN BOTH IP/OP $530.41 $392.50 $0.00 "$1,179.96" $0.00 $0.00 $0.00 $94.41 $0.00 $0.00 $0.00 $0.00 $0.00 $110.54 $0.00 $0.00 $0.00 $0.00 $737.48 "$1,168.16" "$1,179.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28947 ERX HCPCS J0883 00143-9674-01 ARGATROBAN 250 MG/2.5ML IV SOLN BOTH IP/OP "$1,585.08 " "$1,172.96" $0.00 "$1,221.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,176.45" "$1,176.45" "$1,221.78" $0.00 $330.33 $0.00 $0.00 $0.00 $0.00 $734.40 "$1,163.29" "$1,175.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28947 ERX HCPCS J0883 00409-1140-01 ARGATROBAN 250 MG/2.5ML IV SOLN BOTH IP/OP "$1,585.08 " "$1,172.96" $0.00 "$1,221.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,176.45" "$1,176.45" "$1,221.78" $0.00 $330.33 $0.00 $0.00 $0.00 $0.00 $734.40 "$1,163.29" "$1,175.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28947 ERX HCPCS J0883 42023-0182-01 ARGATROBAN 250 MG/2.5ML IV SOLN BOTH IP/OP "$1,585.08 " "$1,172.96" $0.00 "$1,221.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,176.45" "$1,176.45" "$1,221.78" $0.00 $330.33 $0.00 $0.00 $0.00 $0.00 $734.40 "$1,163.29" "$1,175.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28947 ERX HCPCS J0883 63323-0526-03 ARGATROBAN 250 MG/2.5ML IV SOLN BOTH IP/OP "$1,585.08 " "$1,172.96" $0.00 "$1,221.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,176.45" "$1,176.45" "$1,221.78" $0.00 $330.33 $0.00 $0.00 $0.00 $0.00 $734.40 "$1,163.29" "$1,175.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28947 ERX HCPCS J0883 67457-0212-02 ARGATROBAN 250 MG/2.5ML IV SOLN BOTH IP/OP "$1,585.08 " "$1,172.96" $0.00 "$1,221.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,176.45" "$1,176.45" "$1,221.78" $0.00 $330.33 $0.00 $0.00 $0.00 $0.00 $734.40 "$1,163.29" "$1,175.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28958 ERX HCPCS J7520 00008-1041-10 SIROLIMUS 1 MG PO TABS BOTH IP/OP $71.44 $52.87 $0.00 $55.07 $32.15 $32.15 $0.00 $0.00 $0.00 $14.89 $53.02 $53.02 $55.07 $0.00 $14.89 $0.00 $42.26 $42.26 $0.00 $32.40 $51.31 $51.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28958 ERX HCPCS J7520 55111-0653-01 SIROLIMUS 1 MG PO TABS BOTH IP/OP $71.44 $52.87 $0.00 $55.07 $32.15 $32.15 $0.00 $0.00 $0.00 $14.89 $53.02 $53.02 $55.07 $0.00 $14.89 $0.00 $42.26 $42.26 $0.00 $32.40 $51.31 $51.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28964 ERX HCPCS 63700001 00904-6353-61 LEVOFLOXACIN 750 MG PO TABS BOTH IP/OP $123.89 $91.68 $0.00 $99.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.95 $98.12 $99.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28964 ERX HCPCS 63700001 55111-0281-30 LEVOFLOXACIN 750 MG PO TABS BOTH IP/OP $123.89 $91.68 $0.00 $99.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.95 $98.12 $99.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28975 ERX HCPCS 63700001 64875-0001-03 MIFEPRISTONE 200 MG PO TABS BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28995 ERX HCPCS 63700001 67877-0159-01 METFORMIN HCL ER 500 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28995 ERX HCPCS 63700001 70010-0491-01 METFORMIN HCL ER 500 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29048 ERX HCPCS 63700001 16714-0633-01 ALENDRONATE SODIUM 70 MG PO TABS BOTH IP/OP $78.80 $58.31 $0.00 $57.16 $0.00 $0.00 $0.00 $14.03 $0.00 $0.00 $0.00 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $35.73 $56.59 $57.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29071 ERX HCPCS J9017 ARSENIC TRIOXIDE 10 MG/10ML IV SOLN BOTH IP/OP "$1,846.16 " "$1,366.16" $0.00 "$1,423.02" $830.77 $830.77 $128.11 $128.11 $128.11 $384.79 "$1,370.22" "$1,370.22" "$1,423.02" $131.14 $154.09 $85.24 $910.16 $910.16 $465.30 $855.36 "$1,354.89" "$1,368.58" $642.55 $642.55 $517.82 $0.00 $0.00 $493.06 $286.69 $0.00 $0.00 $0.00 $0.00 29071 ERX HCPCS J9017 50742-0438-10 ARSENIC TRIOXIDE 10 MG/10ML IV SOLN BOTH IP/OP "$1,846.16 " "$1,366.16" $0.00 "$1,423.02" $830.77 $830.77 $128.11 $128.11 $128.11 $384.79 "$1,370.22" "$1,370.22" "$1,423.02" $131.14 $154.09 $85.24 $910.16 $910.16 $465.30 $855.36 "$1,354.89" "$1,368.58" $642.55 $642.55 $517.82 $0.00 $0.00 $493.06 $286.69 $0.00 $0.00 $0.00 $0.00 29071 ERX HCPCS J9017 63323-0637-10 ARSENIC TRIOXIDE 10 MG/10ML IV SOLN BOTH IP/OP "$1,846.16 " "$1,366.16" $0.00 "$1,423.02" $830.77 $830.77 $128.11 $128.11 $128.11 $384.79 "$1,370.22" "$1,370.22" "$1,423.02" $131.14 $154.09 $85.24 $910.16 $910.16 $465.30 $855.36 "$1,354.89" "$1,368.58" $642.55 $642.55 $517.82 $0.00 $0.00 $493.06 $286.69 $0.00 $0.00 $0.00 $0.00 29072 ERX HCPCS 63700001 16714-0632-01 ALENDRONATE SODIUM 35 MG PO TABS BOTH IP/OP $71.63 $53.01 $0.00 $57.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.82 $56.73 $57.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29109 ERX HCPCS 63700001 65862-0312-30 DIDANOSINE 250 MG PO CPDR BOTH IP/OP $29.91 $22.13 $0.00 $23.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.96 $23.69 $23.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29110 ERX HCPCS 63700001 65862-0313-30 DIDANOSINE 400 MG PO CPDR BOTH IP/OP $46.71 $34.57 $0.00 $37.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.36 $36.99 $37.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29132 ERX HCPCS J1756 00517-2340-01 IRON SUCROSE 20 MG/ML IV SOLN BOTH IP/OP $229.02 $169.47 $0.00 $185.36 $108.22 $108.22 $0.00 $0.00 $0.00 $43.48 $178.48 $178.48 $185.36 $0.00 $26.79 $0.00 $135.47 $135.47 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $24.68 $0.00 $0.00 $23.49 $0.00 $0.00 $0.00 $0.00 $0.00 29132 ERX HCPCS J1756 00517-2340-10 IRON SUCROSE 20 MG/ML IV SOLN BOTH IP/OP $229.02 $169.47 $0.00 $185.36 $108.22 $108.22 $0.00 $0.00 $0.00 $43.48 $178.48 $178.48 $185.36 $0.00 $26.79 $0.00 $135.47 $135.47 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $24.68 $0.00 $0.00 $23.49 $0.00 $0.00 $0.00 $0.00 $0.00 29132 ERX HCPCS J1756 00517-2340-25 IRON SUCROSE 20 MG/ML IV SOLN BOTH IP/OP $229.02 $169.47 $0.00 $185.36 $108.22 $108.22 $0.00 $0.00 $0.00 $43.48 $178.48 $178.48 $185.36 $0.00 $26.79 $0.00 $135.47 $135.47 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $24.68 $0.00 $0.00 $23.49 $0.00 $0.00 $0.00 $0.00 $0.00 29167 ERX HCPCS 63700001 49702-0217-18 TRIZIVIR:ABACAVIR-LAMIVUDINE-ZIDOVUDINE PO TAB BOTH IP/OP $111.84 $82.76 $0.00 $81.13 $0.00 $0.00 $0.00 $19.91 $0.00 $0.00 $0.00 $0.00 $0.00 $23.31 $0.00 $0.00 $0.00 $0.00 $50.71 $80.32 $81.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29167 ERX HCPCS 63700001 68180-0286-07 TRIZIVIR:ABACAVIR-LAMIVUDINE-ZIDOVUDINE PO TAB BOTH IP/OP $111.84 $82.76 $0.00 $81.13 $0.00 $0.00 $0.00 $19.91 $0.00 $0.00 $0.00 $0.00 $0.00 $23.31 $0.00 $0.00 $0.00 $0.00 $50.71 $80.32 $81.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29169 ERX HCPCS 63700001 42192-0608-16 GABAPENTIN 250 MG/5ML PO SOLN BOTH IP/OP $9.51 $7.04 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.76 $7.53 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29169 ERX HCPCS 63700001 50383-0311-09 GABAPENTIN 250 MG/5ML PO SOLN BOTH IP/OP $9.51 $7.04 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.76 $7.53 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29169 ERX HCPCS 63700001 59762-5050-01 GABAPENTIN 250 MG/5ML PO SOLN BOTH IP/OP $9.51 $7.04 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.76 $7.53 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29169 ERX HCPCS 63700001 99999-6010-82 GABAPENTIN 250 MG/5ML PO SOLN BOTH IP/OP $9.51 $7.04 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.76 $7.53 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29169 ERX HCPCS 63700001 99999-6012-40 GABAPENTIN 250 MG/5ML PO SOLN BOTH IP/OP $9.51 $7.04 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.76 $7.53 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29267 ERX HCPCS 63700001 00904-6642-61 QUETIAPINE FUMARATE 300 MG PO TABS BOTH IP/OP $42.53 $31.47 $0.00 $30.86 $0.00 $0.00 $0.00 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $8.86 $0.00 $0.00 $0.00 $0.00 $19.29 $30.55 $30.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29267 ERX HCPCS 63700001 50268-0634-15 QUETIAPINE FUMARATE 300 MG PO TABS BOTH IP/OP $42.53 $31.47 $0.00 $30.86 $0.00 $0.00 $0.00 $7.57 $0.00 $0.00 $0.00 $0.00 $0.00 $8.86 $0.00 $0.00 $0.00 $0.00 $19.29 $30.55 $30.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29270 ERX HCPCS 63700001 60687-0195-01 DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29270 ERX HCPCS 63700001 63739-0014-10 DILTIAZEM HCL ER COATED BEADS 120 MG PO CP24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29272 ERX HCPCS 63700001 60687-0206-01 DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24 BOTH IP/OP $6.87 $5.08 $0.00 $5.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.44 $5.44 $5.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29272 ERX HCPCS 63700001 63739-0015-10 DILTIAZEM HCL ER COATED BEADS 180 MG PO CP24 BOTH IP/OP $6.87 $5.08 $0.00 $5.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.44 $5.44 $5.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29274 ERX HCPCS 63700001 10370-0831-11 DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24 BOTH IP/OP $8.60 $6.36 $0.00 $6.24 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.90 $6.18 $6.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29274 ERX HCPCS 63700001 60687-0217-01 DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24 BOTH IP/OP $8.60 $6.36 $0.00 $6.24 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.90 $6.18 $6.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29274 ERX HCPCS 63700001 60687-0217-11 DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24 BOTH IP/OP $8.60 $6.36 $0.00 $6.24 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.90 $6.18 $6.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29274 ERX HCPCS 63700001 63739-0016-10 DILTIAZEM HCL ER COATED BEADS 240 MG PO CP24 BOTH IP/OP $8.60 $6.36 $0.00 $6.24 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.90 $6.18 $6.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29276 ERX HCPCS 63700001 60687-0228-01 DILTIAZEM HCL ER COATED BEADS 300 MG PO CP24 BOTH IP/OP $11.23 $8.31 $0.00 $8.15 $0.00 $0.00 $0.00 $2.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.34 $0.00 $0.00 $0.00 $0.00 $5.10 $8.07 $8.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29277 ERX HCPCS 63700001 47335-0673-81 DILTIAZEM HCL ER BEADS 360 MG PO CP24 BOTH IP/OP $9.83 $7.27 $0.00 $7.14 $0.00 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $0.00 $2.05 $0.00 $0.00 $0.00 $0.00 $4.46 $7.06 $7.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29277 ERX HCPCS 63700001 68682-0371-90 DILTIAZEM HCL ER BEADS 360 MG PO CP24 BOTH IP/OP $9.83 $7.27 $0.00 $7.14 $0.00 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $0.00 $2.05 $0.00 $0.00 $0.00 $0.00 $4.46 $7.06 $7.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29302 ERX HCPCS J7510 99999-6005-14 PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN BOTH IP/OP $214.45 $158.69 $0.00 $363.08 $0.00 $0.00 $0.00 $0.00 $44.70 $349.60 $349.60 $363.08 $0.00 $44.69 $0.00 $278.62 $278.62 $0.00 $97.34 $154.18 $155.74 $0.00 $0.00 $30.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29302 ERX HCPCS J7510 00121-0759-08 PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN BOTH IP/OP $214.45 $158.69 $0.00 $363.08 $0.00 $0.00 $0.00 $0.00 $44.70 $349.60 $349.60 $363.08 $0.00 $44.69 $0.00 $278.62 $278.62 $0.00 $97.34 $184.48 $155.74 $0.00 $0.00 $30.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29302 ERX HCPCS J7510 60432-0212-08 PREDNISOLONE SODIUM PHOSPHATE 15 MG/5ML PO SOLN BOTH IP/OP $214.45 $158.69 $0.00 $363.08 $0.00 $0.00 $0.00 $0.00 $44.70 $349.60 $349.60 $363.08 $0.00 $44.69 $0.00 $278.62 $278.62 $0.00 $97.34 $184.48 $155.74 $0.00 $0.00 $30.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29313 ERX HCPCS J0840 50633-0110-11 CROTALIDAE POLYVAL IMMUNE FAB IV SOLR BOTH IP/OP "$17,345.96 " "$12,836.01" $0.00 "$13,370.27" $0.00 $0.00 $0.00 $0.00 $0.00 "$12,874.17" "$12,874.17" "$13,370.27" $0.00 "$3,614.90" $0.00 $0.00 $0.00 $0.00 "$7,867.08" "$12,461.45" "$12,587.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29335 ERX HCPCS J1800 00143-9872-01 PROPRANOLOL HCL 1 MG/ML IV SOLN BOTH IP/OP $40.23 $29.77 $0.00 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $29.86 $29.86 $31.01 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $18.24 $28.89 $29.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29335 ERX HCPCS J1800 00143-9872-10 PROPRANOLOL HCL 1 MG/ML IV SOLN BOTH IP/OP $40.23 $29.77 $0.00 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $29.86 $29.86 $31.01 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $18.24 $28.89 $29.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29434 ERX HCPCS 63700001 00093-7163-56 TOLTERODINE TARTRATE ER 2 MG PO CP24 BOTH IP/OP $33.68 $24.92 $0.00 $24.43 $0.00 $0.00 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $15.27 $24.19 $24.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29434 ERX HCPCS 63700001 00093-7163-98 TOLTERODINE TARTRATE ER 2 MG PO CP24 BOTH IP/OP $33.68 $24.92 $0.00 $24.43 $0.00 $0.00 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $15.27 $24.19 $24.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29434 ERX HCPCS 63700001 13668-0189-30 TOLTERODINE TARTRATE ER 2 MG PO CP24 BOTH IP/OP $33.68 $24.92 $0.00 $24.43 $0.00 $0.00 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $15.27 $24.19 $24.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29434 ERX HCPCS 63700001 31722-0607-30 TOLTERODINE TARTRATE ER 2 MG PO CP24 BOTH IP/OP $33.68 $24.92 $0.00 $24.43 $0.00 $0.00 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $15.27 $24.19 $24.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29434 ERX HCPCS 63700001 59762-0047-01 TOLTERODINE TARTRATE ER 2 MG PO CP24 BOTH IP/OP $33.68 $24.92 $0.00 $24.43 $0.00 $0.00 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $15.27 $24.19 $24.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29435 ERX HCPCS 63700001 00093-7164-05 TOLTERODINE TARTRATE ER 4 MG PO CP24 BOTH IP/OP $40.01 $29.61 $0.00 $29.02 $0.00 $0.00 $0.00 $7.12 $0.00 $0.00 $0.00 $0.00 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $18.14 $28.73 $29.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29435 ERX HCPCS 63700001 00093-7164-56 TOLTERODINE TARTRATE ER 4 MG PO CP24 BOTH IP/OP $40.01 $29.61 $0.00 $29.02 $0.00 $0.00 $0.00 $7.12 $0.00 $0.00 $0.00 $0.00 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $18.14 $28.73 $29.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29435 ERX HCPCS 63700001 31722-0608-30 TOLTERODINE TARTRATE ER 4 MG PO CP24 BOTH IP/OP $40.01 $29.61 $0.00 $29.02 $0.00 $0.00 $0.00 $7.12 $0.00 $0.00 $0.00 $0.00 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $18.14 $28.73 $29.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29435 ERX HCPCS 63700001 59762-0048-01 TOLTERODINE TARTRATE ER 4 MG PO CP24 BOTH IP/OP $40.01 $29.61 $0.00 $29.02 $0.00 $0.00 $0.00 $7.12 $0.00 $0.00 $0.00 $0.00 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $18.14 $28.73 $29.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29437 ERX HCPCS 63700001 00078-0351-05 NATEGLINIDE 60 MG PO TABS BOTH IP/OP $6.97 $5.16 $0.00 $5.06 $0.00 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $3.16 $5.01 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29437 ERX HCPCS 63700001 00591-3354-01 NATEGLINIDE 60 MG PO TABS BOTH IP/OP $6.97 $5.16 $0.00 $5.06 $0.00 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $3.16 $5.01 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29437 ERX HCPCS 63700001 49884-0984-01 NATEGLINIDE 60 MG PO TABS BOTH IP/OP $6.97 $5.16 $0.00 $5.06 $0.00 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $3.16 $5.01 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29437 ERX HCPCS 63700001 55111-0328-90 NATEGLINIDE 60 MG PO TABS BOTH IP/OP $6.97 $5.16 $0.00 $5.06 $0.00 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 $1.45 $0.00 $0.00 $0.00 $0.00 $3.16 $5.01 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29438 ERX HCPCS 63700001 00078-0352-05 NATEGLINIDE 120 MG PO TABS BOTH IP/OP $7.24 $5.36 $0.00 $5.26 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $3.29 $5.20 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29438 ERX HCPCS 63700001 49884-0985-01 NATEGLINIDE 120 MG PO TABS BOTH IP/OP $7.24 $5.36 $0.00 $5.26 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $3.29 $5.20 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29438 ERX HCPCS 63700001 55111-0329-90 NATEGLINIDE 120 MG PO TABS BOTH IP/OP $7.24 $5.36 $0.00 $5.26 $0.00 $0.00 $0.00 $1.29 $0.00 $0.00 $0.00 $0.00 $0.00 $1.51 $0.00 $0.00 $0.00 $0.00 $3.29 $5.20 $5.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29464 ERX HCPCS J2274 00641-6020-10 MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN BOTH IP/OP $48.61 $35.97 $0.00 $37.47 $0.00 $0.00 $0.00 $0.00 $0.00 $36.08 $36.08 $37.47 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $22.04 $34.91 $35.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29464 ERX HCPCS J2274 15082-0248-70 MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN BOTH IP/OP $48.61 $35.97 $0.00 $37.47 $0.00 $0.00 $0.00 $0.00 $0.00 $36.08 $36.08 $37.47 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $22.04 $34.91 $35.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29464 ERX HCPCS J2274 42852-0248-70 MORPHINE SULFATE (PF) 0.5 MG/ML IJ SOLN BOTH IP/OP $48.61 $35.97 $0.00 $37.47 $0.00 $0.00 $0.00 $0.00 $0.00 $36.08 $36.08 $37.47 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $22.04 $34.91 $35.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29531 ERX HCPCS 63700001 65862-0021-06 MIRTAZAPINE 15 MG PO TBDP BOTH IP/OP $9.87 $7.30 $0.00 $7.16 $0.00 $0.00 $0.00 $1.76 $0.00 $0.00 $0.00 $0.00 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $4.48 $7.09 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29532 ERX HCPCS 63700001 00052-0108-30 MIRTAZAPINE 30 MG PO TBDP BOTH IP/OP $10.17 $7.53 $0.00 $7.38 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.61 $7.30 $7.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29532 ERX HCPCS 63700001 65862-0022-06 MIRTAZAPINE 30 MG PO TBDP BOTH IP/OP $10.17 $7.53 $0.00 $7.38 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.61 $7.30 $7.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29567 ERX HCPCS J0637 00006-3822-10 CASPOFUNGIN ACETATE 50 MG IV SOLR BOTH IP/OP "$1,183.33 " $875.66 $0.00 $912.11 $0.00 $0.00 $0.00 $0.00 $0.00 $878.27 $878.27 $912.11 $0.00 $246.61 $0.00 $0.00 $0.00 $0.00 $536.96 $850.54 $859.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29568 ERX HCPCS J0637 00006-3823-10 CASPOFUNGIN ACETATE 70 MG IV SOLR BOTH IP/OP "$1,229.50 " $909.83 $0.00 $947.70 $0.00 $0.00 $0.00 $0.00 $0.00 $912.53 $912.53 $947.70 $0.00 $256.23 $0.00 $0.00 $0.00 $0.00 $557.91 $883.72 $892.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29745 ERX HCPCS 63700001 00093-6450-56 ESOMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $37.82 $27.99 $0.00 $27.44 $0.00 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $17.15 $27.17 $27.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29745 ERX HCPCS 63700001 00186-5020-31 ESOMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $37.82 $27.99 $0.00 $27.44 $0.00 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $17.15 $27.17 $27.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29745 ERX HCPCS 63700001 00378-2350-93 ESOMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $37.82 $27.99 $0.00 $27.44 $0.00 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $17.15 $27.17 $27.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29745 ERX HCPCS 63700001 31722-0572-30 ESOMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $37.82 $27.99 $0.00 $27.44 $0.00 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $17.15 $27.17 $27.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29745 ERX HCPCS 63700001 43598-0509-30 ESOMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $37.82 $27.99 $0.00 $27.44 $0.00 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $17.15 $27.17 $27.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29745 ERX HCPCS 63700001 65862-0783-30 ESOMEPRAZOLE 20 MG PO CPDR BOTH IP/OP $37.82 $27.99 $0.00 $27.44 $0.00 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $17.15 $27.17 $27.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29746 ERX HCPCS 63700001 00093-6451-98 ESOMEPRAZOLE MAGNESIUM 40 MG PO CPDR BOTH IP/OP $33.61 $24.87 $0.00 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.81 $26.62 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29746 ERX HCPCS 63700001 00186-5040-31 ESOMEPRAZOLE MAGNESIUM 40 MG PO CPDR BOTH IP/OP $33.61 $24.87 $0.00 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.81 $26.62 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29746 ERX HCPCS 63700001 16714-0736-01 ESOMEPRAZOLE MAGNESIUM 40 MG PO CPDR BOTH IP/OP $33.61 $24.87 $0.00 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.81 $26.62 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29746 ERX HCPCS 63700001 43598-0510-10 ESOMEPRAZOLE MAGNESIUM 40 MG PO CPDR BOTH IP/OP $33.61 $24.87 $0.00 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.81 $26.62 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29746 ERX HCPCS 63700001 65862-0784-30 ESOMEPRAZOLE MAGNESIUM 40 MG PO CPDR BOTH IP/OP $33.61 $24.87 $0.00 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.81 $26.62 $26.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29778 ERX HCPCS 63700001 00781-2164-60 ZIPRASIDONE HCL 20 MG PO CAPS BOTH IP/OP $35.48 $26.26 $0.00 $25.74 $0.00 $0.00 $0.00 $6.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.09 $25.49 $25.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29778 ERX HCPCS 63700001 00904-6269-08 ZIPRASIDONE HCL 20 MG PO CAPS BOTH IP/OP $35.48 $26.26 $0.00 $25.74 $0.00 $0.00 $0.00 $6.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.09 $25.49 $25.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29778 ERX HCPCS 63700001 00904-6269-45 ZIPRASIDONE HCL 20 MG PO CAPS BOTH IP/OP $35.48 $26.26 $0.00 $25.74 $0.00 $0.00 $0.00 $6.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.09 $25.49 $25.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29778 ERX HCPCS 63700001 33342-0144-09 ZIPRASIDONE HCL 20 MG PO CAPS BOTH IP/OP $35.48 $26.26 $0.00 $25.74 $0.00 $0.00 $0.00 $6.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.09 $25.49 $25.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29778 ERX HCPCS 63700001 65862-0702-60 ZIPRASIDONE HCL 20 MG PO CAPS BOTH IP/OP $35.48 $26.26 $0.00 $25.74 $0.00 $0.00 $0.00 $6.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.09 $25.49 $25.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29778 ERX HCPCS 63700001 68084-0103-09 ZIPRASIDONE HCL 20 MG PO CAPS BOTH IP/OP $35.48 $26.26 $0.00 $25.74 $0.00 $0.00 $0.00 $6.32 $0.00 $0.00 $0.00 $0.00 $0.00 $7.39 $0.00 $0.00 $0.00 $0.00 $16.09 $25.49 $25.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29779 ERX HCPCS 63700001 16714-0836-01 ZIPRASIDONE HCL 40 MG PO CAPS BOTH IP/OP $37.56 $27.79 $0.00 $27.25 $0.00 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $0.00 $7.83 $0.00 $0.00 $0.00 $0.00 $17.03 $26.98 $27.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29779 ERX HCPCS 63700001 60505-2529-06 ZIPRASIDONE HCL 40 MG PO CAPS BOTH IP/OP $37.56 $27.79 $0.00 $27.25 $0.00 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $0.00 $7.83 $0.00 $0.00 $0.00 $0.00 $17.03 $26.98 $27.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29779 ERX HCPCS 63700001 65862-0703-60 ZIPRASIDONE HCL 40 MG PO CAPS BOTH IP/OP $37.56 $27.79 $0.00 $27.25 $0.00 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $0.00 $7.83 $0.00 $0.00 $0.00 $0.00 $17.03 $26.98 $27.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29779 ERX HCPCS 63700001 68084-0104-09 ZIPRASIDONE HCL 40 MG PO CAPS BOTH IP/OP $37.56 $27.79 $0.00 $27.25 $0.00 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $0.00 $7.83 $0.00 $0.00 $0.00 $0.00 $17.03 $26.98 $27.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29780 ERX HCPCS 63700001 00781-2167-60 ZIPRASIDONE HCL 60 MG PO CAPS BOTH IP/OP $41.34 $30.59 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29780 ERX HCPCS 63700001 00904-6271-08 ZIPRASIDONE HCL 60 MG PO CAPS BOTH IP/OP $41.34 $30.59 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29780 ERX HCPCS 63700001 33342-0146-09 ZIPRASIDONE HCL 60 MG PO CAPS BOTH IP/OP $41.34 $30.59 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29780 ERX HCPCS 63700001 55111-0258-60 ZIPRASIDONE HCL 60 MG PO CAPS BOTH IP/OP $41.34 $30.59 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29780 ERX HCPCS 63700001 59762-2003-01 ZIPRASIDONE HCL 60 MG PO CAPS BOTH IP/OP $41.34 $30.59 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29780 ERX HCPCS 63700001 65862-0704-60 ZIPRASIDONE HCL 60 MG PO CAPS BOTH IP/OP $41.34 $30.59 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29780 ERX HCPCS 63700001 68084-0105-09 ZIPRASIDONE HCL 60 MG PO CAPS BOTH IP/OP $41.34 $30.59 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29780 ERX HCPCS 63700001 68180-0333-07 ZIPRASIDONE HCL 60 MG PO CAPS BOTH IP/OP $41.34 $30.59 $0.00 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29781 ERX HCPCS 63700001 00781-2168-60 ZIPRASIDONE HCL 80 MG PO CAPS BOTH IP/OP $45.58 $33.73 $0.00 $33.07 $0.00 $0.00 $0.00 $8.11 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29781 ERX HCPCS 63700001 00904-6272-08 ZIPRASIDONE HCL 80 MG PO CAPS BOTH IP/OP $45.58 $33.73 $0.00 $33.07 $0.00 $0.00 $0.00 $8.11 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29781 ERX HCPCS 63700001 68084-0106-09 ZIPRASIDONE HCL 80 MG PO CAPS BOTH IP/OP $45.58 $33.73 $0.00 $33.07 $0.00 $0.00 $0.00 $8.11 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $20.67 $32.74 $33.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29805 ERX HCPCS 25000001 10019-0055-61 ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN BOTH IP/OP "$1,453.64 " "$1,075.69" $0.00 "$1,120.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,078.89" "$1,078.89" "$1,120.47" $0.00 $302.94 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29805 ERX HCPCS 25000001 10019-0672-10 ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN BOTH IP/OP "$1,453.64 " "$1,075.69" $0.00 "$1,120.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,078.89" "$1,078.89" "$1,120.47" $0.00 $302.94 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29805 ERX HCPCS 25000001 25021-0308-84 ESMOLOL HCL-SODIUM CHLORIDE 2500 MG/250ML IV SOLN BOTH IP/OP "$1,453.64 " "$1,075.69" $0.00 "$1,120.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,078.89" "$1,078.89" "$1,120.47" $0.00 $302.94 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29822 ERX HCPCS 63700001 00225-0295-15 HYOSCYAMINE SULFATE 0.125 MG PO TBDP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29858 ERX HCPCS 63700001 00904-6322-61 METOPROLOL SUCCINATE ER 25 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29858 ERX HCPCS 63700001 50742-0615-01 METOPROLOL SUCCINATE ER 25 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29858 ERX HCPCS 63700001 51079-0169-20 METOPROLOL SUCCINATE ER 25 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29858 ERX HCPCS 63700001 55111-0466-01 METOPROLOL SUCCINATE ER 25 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29904 ERX HCPCS 63700001 68180-0429-01 BIMATOPROST 0.03 % OP SOLN BOTH IP/OP $452.36 $334.75 $0.00 $328.50 $0.00 $0.00 $0.00 $80.52 $0.00 $0.00 $0.00 $0.00 $0.00 $94.27 $0.00 $0.00 $0.00 $0.00 $205.32 $325.22 $328.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29967 ERX HCPCS 63700001 24689-0785-01 BUSPIRONE HCL 7.5 MG PO TABS BOTH IP/OP $6.63 $4.91 $0.00 $4.81 $0.00 $0.00 $0.00 $1.18 $0.00 $0.00 $0.00 $0.00 $0.00 $1.38 $0.00 $0.00 $0.00 $0.00 $3.01 $4.76 $4.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29967 ERX HCPCS 63700001 64380-0787-06 BUSPIRONE HCL 7.5 MG PO TABS BOTH IP/OP $6.63 $4.91 $0.00 $4.81 $0.00 $0.00 $0.00 $1.18 $0.00 $0.00 $0.00 $0.00 $0.00 $1.38 $0.00 $0.00 $0.00 $0.00 $3.01 $4.76 $4.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30070 ERX HCPCS 63700001 00904-6323-61 METOPROLOL SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30070 ERX HCPCS 63700001 50268-0541-11 METOPROLOL SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30070 ERX HCPCS 63700001 50268-0541-15 METOPROLOL SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30070 ERX HCPCS 63700001 50742-0616-01 METOPROLOL SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30070 ERX HCPCS 63700001 55111-0467-01 METOPROLOL SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30070 ERX HCPCS 63700001 55111-0467-05 METOPROLOL SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30070 ERX HCPCS 63700001 62037-0831-01 METOPROLOL SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30071 ERX HCPCS 63700001 00904-6324-61 METOPROLOL SUCCINATE ER 100 MG PO TB24 BOTH IP/OP $8.57 $6.34 $0.00 $6.22 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.89 $6.16 $6.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30071 ERX HCPCS 63700001 50742-0617-01 METOPROLOL SUCCINATE ER 100 MG PO TB24 BOTH IP/OP $8.57 $6.34 $0.00 $6.22 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.89 $6.16 $6.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30071 ERX HCPCS 63700001 55111-0468-01 METOPROLOL SUCCINATE ER 100 MG PO TB24 BOTH IP/OP $8.57 $6.34 $0.00 $6.22 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.89 $6.16 $6.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30071 ERX HCPCS 63700001 63739-0454-10 METOPROLOL SUCCINATE ER 100 MG PO TB24 BOTH IP/OP $8.57 $6.34 $0.00 $6.22 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.89 $6.16 $6.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30072 ERX HCPCS 63700001 00378-4598-77 METOPROLOL SUCCINATE ER 200 MG PO TB24 BOTH IP/OP $10.56 $7.81 $0.00 $7.66 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $4.79 $7.59 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30072 ERX HCPCS 63700001 50742-0618-01 METOPROLOL SUCCINATE ER 200 MG PO TB24 BOTH IP/OP $10.56 $7.81 $0.00 $7.66 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $4.79 $7.59 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30072 ERX HCPCS 63700001 55111-0469-01 METOPROLOL SUCCINATE ER 200 MG PO TB24 BOTH IP/OP $10.56 $7.81 $0.00 $7.66 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $4.79 $7.59 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30072 ERX HCPCS 63700001 55111-0469-05 METOPROLOL SUCCINATE ER 200 MG PO TB24 BOTH IP/OP $10.56 $7.81 $0.00 $7.66 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $4.79 $7.59 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30148 ERX HCPCS 63700001 00004-0038-22 VALGANCICLOVIR HCL 450 MG PO TABS BOTH IP/OP $223.46 $165.36 $0.00 $162.29 $0.00 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 $46.57 $0.00 $0.00 $0.00 $0.00 $101.43 $160.67 $162.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30148 ERX HCPCS 63700001 00603-6330-20 VALGANCICLOVIR HCL 450 MG PO TABS BOTH IP/OP $223.46 $165.36 $0.00 $162.29 $0.00 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 $46.57 $0.00 $0.00 $0.00 $0.00 $101.43 $160.67 $162.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30148 ERX HCPCS 63700001 16714-0765-01 VALGANCICLOVIR HCL 450 MG PO TABS BOTH IP/OP $223.46 $165.36 $0.00 $162.29 $0.00 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 $46.57 $0.00 $0.00 $0.00 $0.00 $101.43 $160.67 $162.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30148 ERX HCPCS 63700001 55111-0762-60 VALGANCICLOVIR HCL 450 MG PO TABS BOTH IP/OP $223.46 $165.36 $0.00 $162.29 $0.00 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 $46.57 $0.00 $0.00 $0.00 $0.00 $101.43 $160.67 $162.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30148 ERX HCPCS 63700001 63739-0357-33 VALGANCICLOVIR HCL 450 MG PO TABS BOTH IP/OP $223.46 $165.36 $0.00 $162.29 $0.00 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 $46.57 $0.00 $0.00 $0.00 $0.00 $101.43 $160.67 $162.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30148 ERX HCPCS 63700001 65862-0753-60 VALGANCICLOVIR HCL 450 MG PO TABS BOTH IP/OP $223.46 $165.36 $0.00 $162.29 $0.00 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 $46.57 $0.00 $0.00 $0.00 $0.00 $101.43 $160.67 $162.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30183 ERX HCPCS 25000001 47781-0570-89 LIDOCAINE-TRANSPARENT DRESSING 4 % EX KIT BOTH IP/OP $115.80 $85.69 $0.00 $89.26 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30213 ERX HCPCS 63700001 51285-0369-01 METHOTREXATE SODIUM 15 MG PO TABS BOTH IP/OP $220.06 $162.84 $0.00 $146.08 $0.00 $0.00 $0.00 $39.17 $0.00 $0.00 $0.00 $0.00 $0.00 $45.86 $0.00 $0.00 $0.00 $0.00 $91.30 $144.62 $146.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30264 ERX HCPCS 63700001 00904-6084-61 CITALOPRAM HYDROBROMIDE 10 MG PO TABS BOTH IP/OP $10.17 $7.53 $0.00 $7.38 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.62 $7.31 $7.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30264 ERX HCPCS 63700001 13668-0009-01 CITALOPRAM HYDROBROMIDE 10 MG PO TABS BOTH IP/OP $10.17 $7.53 $0.00 $7.38 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.62 $7.31 $7.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30264 ERX HCPCS 63700001 68084-0737-01 CITALOPRAM HYDROBROMIDE 10 MG PO TABS BOTH IP/OP $10.17 $7.53 $0.00 $7.38 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.62 $7.31 $7.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30264 ERX HCPCS 63700001 68084-0737-11 CITALOPRAM HYDROBROMIDE 10 MG PO TABS BOTH IP/OP $10.17 $7.53 $0.00 $7.38 $0.00 $0.00 $0.00 $1.81 $0.00 $0.00 $0.00 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.62 $7.31 $7.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30433 ERX HCPCS 63700001 50419-0402-03 DROSPIRENONE-ETHINYL ESTRADIOL 3-0.03 MG PO TABS BOTH IP/OP $504.18 $373.09 $0.00 $366.13 $0.00 $0.00 $0.00 $89.74 $0.00 $0.00 $0.00 $0.00 $0.00 $105.07 $0.00 $0.00 $0.00 $0.00 $228.83 $362.47 $366.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30479 ERX HCPCS 63700001 00054-0199-59 OXCARBAZEPINE 300 MG/5ML PO SUSP BOTH IP/OP $11.08 $8.20 $0.00 $8.04 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.03 $7.96 $8.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30479 ERX HCPCS 63700001 00078-0357-52 OXCARBAZEPINE 300 MG/5ML PO SUSP BOTH IP/OP $11.08 $8.20 $0.00 $8.04 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.03 $7.96 $8.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30479 ERX HCPCS 63700001 00781-6270-43 OXCARBAZEPINE 300 MG/5ML PO SUSP BOTH IP/OP $11.08 $8.20 $0.00 $8.04 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.03 $7.96 $8.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30479 ERX HCPCS 63700001 65162-0649-78 OXCARBAZEPINE 300 MG/5ML PO SUSP BOTH IP/OP $11.08 $8.20 $0.00 $8.04 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.03 $7.96 $8.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30479 ERX HCPCS 63700001 99999-6007-93 OXCARBAZEPINE 300 MG/5ML PO SUSP BOTH IP/OP $11.08 $8.20 $0.00 $8.04 $0.00 $0.00 $0.00 $1.97 $0.00 $0.00 $0.00 $0.00 $0.00 $2.31 $0.00 $0.00 $0.00 $0.00 $5.03 $7.96 $8.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30699 ERX HCPCS 63700001 43547-0272-10 ROPINIROLE HCL 3 MG PO TABS BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31086 ERX HCPCS J0690 66288-1100-01 CEFAZOLIN SODIUM 100 G IJ SOLR BOTH IP/OP $403.20 $298.37 $0.00 $310.79 $181.44 $181.44 $0.00 $0.00 $0.00 $138.65 $299.26 $299.26 $310.79 $0.00 $175.31 $0.00 $238.49 $238.49 $0.00 $173.85 $275.38 $278.16 $0.00 $0.00 $192.70 $0.00 $0.00 $183.48 $0.00 $0.00 $0.00 $0.00 $0.00 31087 ERX HCPCS J0690 66288-1300-01 CEFAZOLIN SODIUM 300 G IJ SOLR BOTH IP/OP "$1,016.16 " $751.96 $0.00 $783.26 $457.27 $457.27 $0.00 $0.00 $0.00 $415.95 $754.19 $754.19 $783.26 $0.00 $525.93 $0.00 $601.06 $601.06 $0.00 $461.10 $730.38 $737.76 $0.00 $0.00 $578.10 $0.00 $0.00 $550.45 $0.00 $0.00 $0.00 $0.00 $0.00 31097 ERX HCPCS J9267 44567-0506-01 PACLITAXEL 300 MG/50ML IV CONC BOTH IP/OP $229.02 $169.47 $0.00 $176.53 $103.06 $103.06 $0.00 $0.00 $0.00 $47.73 $169.98 $169.98 $176.53 $0.00 $47.24 $0.00 $135.47 $135.47 $0.00 $103.95 $164.66 $166.32 $0.00 $0.00 $49.35 $0.00 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 31097 ERX HCPCS J9267 47781-0595-07 PACLITAXEL 300 MG/50ML IV CONC BOTH IP/OP $229.02 $169.47 $0.00 $176.53 $103.06 $103.06 $0.00 $0.00 $0.00 $47.73 $169.98 $169.98 $176.53 $0.00 $47.24 $0.00 $135.47 $135.47 $0.00 $103.95 $164.66 $166.32 $0.00 $0.00 $49.35 $0.00 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 31097 ERX HCPCS J9267 61703-0342-50 PACLITAXEL 300 MG/50ML IV CONC BOTH IP/OP $229.02 $169.47 $0.00 $176.53 $103.06 $103.06 $0.00 $0.00 $0.00 $47.73 $169.98 $169.98 $176.53 $0.00 $47.24 $0.00 $135.47 $135.47 $0.00 $103.95 $164.66 $166.32 $0.00 $0.00 $49.35 $0.00 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 31097 ERX HCPCS J9267 63323-0763-50 PACLITAXEL 300 MG/50ML IV CONC BOTH IP/OP $229.02 $169.47 $0.00 $176.53 $103.06 $103.06 $0.00 $0.00 $0.00 $47.73 $169.98 $169.98 $176.53 $0.00 $47.24 $0.00 $135.47 $135.47 $0.00 $103.95 $164.66 $166.32 $0.00 $0.00 $49.35 $0.00 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 31097 ERX HCPCS J9267 67457-0434-51 PACLITAXEL 300 MG/50ML IV CONC BOTH IP/OP $229.02 $169.47 $0.00 $176.53 $103.06 $103.06 $0.00 $0.00 $0.00 $47.73 $169.98 $169.98 $176.53 $0.00 $47.24 $0.00 $135.47 $135.47 $0.00 $103.95 $164.66 $166.32 $0.00 $0.00 $49.35 $0.00 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 31097 ERX HCPCS J9267 70860-0200-50 PACLITAXEL 300 MG/50ML IV CONC BOTH IP/OP $229.02 $169.47 $0.00 $176.53 $103.06 $103.06 $0.00 $0.00 $0.00 $47.73 $169.98 $169.98 $176.53 $0.00 $47.24 $0.00 $135.47 $135.47 $0.00 $103.95 $164.66 $166.32 $0.00 $0.00 $49.35 $0.00 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $0.00 31177 ERX HCPCS 63700001 00093-8675-78 AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR BOTH IP/OP $148.23 $109.69 $0.00 $203.18 $0.00 $0.00 $0.00 $26.38 $0.00 $0.00 $0.00 $0.00 $0.00 $30.89 $0.00 $0.00 $0.00 $0.00 $126.99 $106.44 $203.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31177 ERX HCPCS 63700001 16714-0294-01 AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR BOTH IP/OP $148.23 $109.69 $0.00 $203.18 $0.00 $0.00 $0.00 $26.38 $0.00 $0.00 $0.00 $0.00 $0.00 $30.89 $0.00 $0.00 $0.00 $0.00 $126.99 $106.44 $203.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31177 ERX HCPCS 63700001 16714-0294-02 AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5ML PO SUSR BOTH IP/OP $148.23 $109.69 $0.00 $203.18 $0.00 $0.00 $0.00 $26.38 $0.00 $0.00 $0.00 $0.00 $0.00 $30.89 $0.00 $0.00 $0.00 $0.00 $126.99 $201.14 $203.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31209 ERX HCPCS 63700001 00078-0358-34 VALSARTAN 80 MG PO TABS BOTH IP/OP $39.50 $29.23 $0.00 $28.66 $0.00 $0.00 $0.00 $7.03 $0.00 $0.00 $0.00 $0.00 $0.00 $8.23 $0.00 $0.00 $0.00 $0.00 $17.91 $28.37 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31209 ERX HCPCS 63700001 00378-5813-77 VALSARTAN 80 MG PO TABS BOTH IP/OP $39.50 $29.23 $0.00 $28.66 $0.00 $0.00 $0.00 $7.03 $0.00 $0.00 $0.00 $0.00 $0.00 $8.23 $0.00 $0.00 $0.00 $0.00 $17.91 $28.37 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31209 ERX HCPCS 63700001 33342-0063-10 VALSARTAN 80 MG PO TABS BOTH IP/OP $39.50 $29.23 $0.00 $28.66 $0.00 $0.00 $0.00 $7.03 $0.00 $0.00 $0.00 $0.00 $0.00 $8.23 $0.00 $0.00 $0.00 $0.00 $17.91 $28.37 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31209 ERX HCPCS 63700001 59746-0361-90 VALSARTAN 80 MG PO TABS BOTH IP/OP $39.50 $29.23 $0.00 $28.66 $0.00 $0.00 $0.00 $7.03 $0.00 $0.00 $0.00 $0.00 $0.00 $8.23 $0.00 $0.00 $0.00 $0.00 $17.91 $28.37 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31210 ERX HCPCS 63700001 00078-0359-34 VALSARTAN 160 MG PO TABS BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31210 ERX HCPCS 63700001 33342-0064-10 VALSARTAN 160 MG PO TABS BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31210 ERX HCPCS 63700001 59746-0362-90 VALSARTAN 160 MG PO TABS BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31210 ERX HCPCS 63700001 65862-0572-90 VALSARTAN 160 MG PO TABS BOTH IP/OP $19.00 $14.06 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31211 ERX HCPCS 63700001 00078-0360-34 VALSARTAN 320 MG PO TABS BOTH IP/OP $53.72 $39.75 $0.00 $38.98 $0.00 $0.00 $0.00 $9.56 $0.00 $0.00 $0.00 $0.00 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $24.36 $38.59 $38.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31211 ERX HCPCS 63700001 33342-0065-10 VALSARTAN 320 MG PO TABS BOTH IP/OP $53.72 $39.75 $0.00 $38.98 $0.00 $0.00 $0.00 $9.56 $0.00 $0.00 $0.00 $0.00 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $24.36 $38.59 $38.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31239 ERX HCPCS 63700001 50580-0728-24 CETIRIZINE-PSEUDOEPHEDRINE ER 5-120 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31270 ERX HCPCS Q9957 11994-0011-04 PERFLUTREN LIPID MICROSPHERE 6.52 MG/ML IV SUSP BOTH IP/OP "$1,065.54 " $788.50 $0.00 $821.32 $0.00 $0.00 $0.00 $0.00 $0.00 $790.84 $790.84 $821.32 $0.00 $222.06 $0.00 $0.00 $0.00 $0.00 $422.36 $669.01 $675.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31310 ERX HCPCS J2997 50242-0041-64 ALTEPLASE 2 MG IJ SOLR BOTH IP/OP $617.14 $456.68 $0.00 $475.69 $277.71 $277.71 $175.34 $175.34 $175.34 $128.63 $458.04 $458.04 $475.69 $175.50 $128.61 $114.08 $365.04 $365.04 $184.04 $280.10 $443.68 $448.16 $254.15 $254.15 $87.67 $0.00 $0.00 $89.18 $175.77 $0.00 $0.00 $0.00 $0.00 31336 ERX HCPCS 63700001 00115-5511-10 FENOFIBRATE 54 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31336 ERX HCPCS 63700001 42858-0454-45 FENOFIBRATE 54 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31415 ERX HCPCS 63700001 00187-0650-42 METHOXSALEN RAPID 10 MG PO CAPS BOTH IP/OP $310.80 $229.99 $0.00 $248.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.40 $246.15 $248.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31432 ERX HCPCS J1162 50633-0120-11 DIGOXIN IMMUNE FAB 40 MG IV SOLR BOTH IP/OP "$112,086.96 " "$82,944.35" $0.00 "$86,396.63" $0.00 $0.00 $0.00 $0.00 $0.00 "$83,190.94" "$83,190.94" "$86,396.63" $0.00 "$23,358.92" $0.00 $0.00 $0.00 $0.00 "$48,880.20" "$74,445.31" "$78,208.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31530 ERX HCPCS 25000001 00052-0273-01 ETONOGESTREL-ETHINYL ESTRADIOL 0.12-0.015 MG/24HR VA RING BOTH IP/OP $655.73 $485.24 $0.00 $505.44 $0.00 $0.00 $0.00 $0.00 $0.00 $486.68 $486.68 $505.44 $0.00 $136.65 $0.00 $0.00 $0.00 $0.00 $297.62 $471.42 $476.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31530 ERX HCPCS 25000001 00052-0273-03 ETONOGESTREL-ETHINYL ESTRADIOL 0.12-0.015 MG/24HR VA RING BOTH IP/OP $655.73 $485.24 $0.00 $505.44 $0.00 $0.00 $0.00 $0.00 $0.00 $486.68 $486.68 $505.44 $0.00 $136.65 $0.00 $0.00 $0.00 $0.00 $297.62 $471.42 $476.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31576 ERX HCPCS 63700001 00574-9850-10 BUDESONIDE 3 MG PO CPEP BOTH IP/OP $71.62 $53.00 $0.00 $57.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.81 $56.72 $57.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31576 ERX HCPCS 63700001 16714-0829-01 BUDESONIDE 3 MG PO CPEP BOTH IP/OP $71.62 $53.00 $0.00 $57.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.81 $56.72 $57.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31684 ERX HCPCS 63700001 42291-0800-30 TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS BOTH IP/OP $23.36 $17.29 $0.00 $16.94 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 $4.87 $0.00 $0.00 $0.00 $0.00 $10.59 $16.77 $16.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31684 ERX HCPCS 63700001 61958-0401-01 TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS BOTH IP/OP $23.36 $17.29 $0.00 $16.94 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 $4.87 $0.00 $0.00 $0.00 $0.00 $10.59 $16.77 $16.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31684 ERX HCPCS 63700001 64380-0714-04 TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS BOTH IP/OP $23.36 $17.29 $0.00 $16.94 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 $4.87 $0.00 $0.00 $0.00 $0.00 $10.59 $16.77 $16.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31684 ERX HCPCS 63700001 65862-0421-30 TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS BOTH IP/OP $23.36 $17.29 $0.00 $16.94 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 $4.87 $0.00 $0.00 $0.00 $0.00 $10.59 $16.77 $16.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31688 ERX HCPCS J2501 00074-4637-01 PARICALCITOL 2 MCG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.30 $16.33 $16.33 $16.96 $0.00 $0.76 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.90 $0.00 $0.00 $0.86 $0.00 $0.00 $0.00 $0.00 $0.00 31688 ERX HCPCS J2501 55150-0212-01 PARICALCITOL 2 MCG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.30 $16.33 $16.33 $16.96 $0.00 $0.76 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.90 $0.00 $0.00 $0.86 $0.00 $0.00 $0.00 $0.00 $0.00 31688 ERX HCPCS J2501 67457-0379-25 PARICALCITOL 2 MCG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.30 $16.33 $16.33 $16.96 $0.00 $0.76 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.90 $0.00 $0.00 $0.86 $0.00 $0.00 $0.00 $0.00 $0.00 31784 ERX HCPCS 25000001 66658-0234-01 ANAKINRA 100 MG/0.67ML SC SOSY BOTH IP/OP $597.05 $441.82 $0.00 $460.21 $0.00 $0.00 $0.00 $0.00 $0.00 $443.13 $443.13 $460.21 $0.00 $124.43 $0.00 $0.00 $0.00 $0.00 $283.67 $449.33 $453.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31784 ERX HCPCS 25000001 66658-0234-07 ANAKINRA 100 MG/0.67ML SC SOSY BOTH IP/OP $597.05 $441.82 $0.00 $460.21 $0.00 $0.00 $0.00 $0.00 $0.00 $443.13 $443.13 $460.21 $0.00 $124.43 $0.00 $0.00 $0.00 $0.00 $283.67 $449.33 $453.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31876 ERX HCPCS 63700001 66215-0102-06 BOSENTAN 125 MG PO TABS BOTH IP/OP $679.29 $502.67 $0.00 $493.18 $0.00 $0.00 $0.00 $120.91 $0.00 $0.00 $0.00 $0.00 $0.00 $141.56 $0.00 $0.00 $0.00 $0.00 $308.24 $488.25 $493.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31921 ERX HCPCS J1650 00548-5607-00 ENOXAPARIN SODIUM 150 MG/ML SC SOLN BOTH IP/OP $409.82 $303.27 $0.00 $315.89 $184.42 $184.42 $0.00 $0.00 $0.00 $85.42 $304.17 $304.17 $315.89 $0.00 $85.41 $0.00 $242.41 $242.41 $0.00 $186.01 $294.63 $297.61 $0.00 $0.00 $58.22 $0.00 $0.00 $59.22 $0.00 $0.00 $0.00 $0.00 $0.00 31921 ERX HCPCS J1650 00781-3655-69 ENOXAPARIN SODIUM 150 MG/ML SC SOLN BOTH IP/OP $409.82 $303.27 $0.00 $315.89 $184.42 $184.42 $0.00 $0.00 $0.00 $85.42 $304.17 $304.17 $315.89 $0.00 $85.41 $0.00 $242.41 $242.41 $0.00 $186.01 $294.63 $297.61 $0.00 $0.00 $58.22 $0.00 $0.00 $59.22 $0.00 $0.00 $0.00 $0.00 $0.00 31921 ERX HCPCS J1650 00955-1015-10 ENOXAPARIN SODIUM 150 MG/ML SC SOLN BOTH IP/OP $409.82 $303.27 $0.00 $315.89 $184.42 $184.42 $0.00 $0.00 $0.00 $85.42 $304.17 $304.17 $315.89 $0.00 $85.41 $0.00 $242.41 $242.41 $0.00 $186.01 $294.63 $297.61 $0.00 $0.00 $58.22 $0.00 $0.00 $59.22 $0.00 $0.00 $0.00 $0.00 $0.00 31921 ERX HCPCS J1650 63323-0537-84 ENOXAPARIN SODIUM 150 MG/ML SC SOLN BOTH IP/OP $409.82 $303.27 $0.00 $315.89 $184.42 $184.42 $0.00 $0.00 $0.00 $85.42 $304.17 $304.17 $315.89 $0.00 $85.41 $0.00 $242.41 $242.41 $0.00 $186.01 $294.63 $297.61 $0.00 $0.00 $58.22 $0.00 $0.00 $59.22 $0.00 $0.00 $0.00 $0.00 $0.00 31922 ERX HCPCS J1335 00006-3843-71 ERTAPENEM SODIUM 1 G IJ SOLR BOTH IP/OP $243.74 $180.37 $0.00 $187.87 $109.68 $109.68 $0.00 $0.00 $0.00 $50.80 $180.90 $180.90 $187.87 $0.00 $33.18 $0.00 $144.17 $144.17 $0.00 $110.64 $175.25 $177.02 $0.00 $0.00 $45.47 $0.00 $0.00 $43.30 $0.00 $0.00 $0.00 $0.00 $0.00 31922 ERX HCPCS J1335 42023-0221-10 ERTAPENEM SODIUM 1 G IJ SOLR BOTH IP/OP $243.74 $180.37 $0.00 $187.87 $109.68 $109.68 $0.00 $0.00 $0.00 $50.80 $180.90 $180.90 $187.87 $0.00 $33.18 $0.00 $144.17 $144.17 $0.00 $110.64 $175.25 $177.02 $0.00 $0.00 $45.47 $0.00 $0.00 $43.30 $0.00 $0.00 $0.00 $0.00 $0.00 31922 ERX HCPCS J1335 55150-0282-20 ERTAPENEM SODIUM 1 G IJ SOLR BOTH IP/OP $243.74 $180.37 $0.00 $187.87 $109.68 $109.68 $0.00 $0.00 $0.00 $50.80 $180.90 $180.90 $187.87 $0.00 $33.18 $0.00 $144.17 $144.17 $0.00 $110.64 $175.25 $177.02 $0.00 $0.00 $45.47 $0.00 $0.00 $43.30 $0.00 $0.00 $0.00 $0.00 $0.00 32052 ERX HCPCS 25000001 00187-5100-01 PIMECROLIMUS 1 % EX CREA BOTH IP/OP $939.08 $694.92 $0.00 $723.84 $0.00 $0.00 $0.00 $0.00 $0.00 $696.99 $696.99 $723.84 $0.00 $195.70 $0.00 $0.00 $0.00 $0.00 $426.12 $674.97 $681.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32052 ERX HCPCS 25000001 68462-0609-35 PIMECROLIMUS 1 % EX CREA BOTH IP/OP $939.08 $694.92 $0.00 $723.84 $0.00 $0.00 $0.00 $0.00 $0.00 $696.99 $696.99 $723.84 $0.00 $195.70 $0.00 $0.00 $0.00 $0.00 $426.12 $674.97 $681.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32052 ERX HCPCS 25000001 68682-0110-01 PIMECROLIMUS 1 % EX CREA BOTH IP/OP $939.08 $694.92 $0.00 $723.84 $0.00 $0.00 $0.00 $0.00 $0.00 $696.99 $696.99 $723.84 $0.00 $195.70 $0.00 $0.00 $0.00 $0.00 $426.12 $674.97 $681.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32128 ERX HCPCS 63700001 00093-7270-98 PRAVASTATIN SODIUM 80 MG PO TABS BOTH IP/OP $20.09 $14.87 $0.00 $14.58 $0.00 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $9.11 $14.43 $14.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32128 ERX HCPCS 63700001 16729-0011-15 PRAVASTATIN SODIUM 80 MG PO TABS BOTH IP/OP $20.09 $14.87 $0.00 $14.58 $0.00 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $9.11 $14.43 $14.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32128 ERX HCPCS 63700001 60505-1323-09 PRAVASTATIN SODIUM 80 MG PO TABS BOTH IP/OP $20.09 $14.87 $0.00 $14.58 $0.00 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $9.11 $14.43 $14.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32128 ERX HCPCS 63700001 68462-0198-90 PRAVASTATIN SODIUM 80 MG PO TABS BOTH IP/OP $20.09 $14.87 $0.00 $14.58 $0.00 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $9.11 $14.43 $14.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32215 ERX HCPCS J1652 55111-0678-02 FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN BOTH IP/OP $189.65 $140.34 $0.00 $146.18 $0.00 $0.00 $0.00 $0.00 $0.00 $140.76 $140.76 $146.18 $0.00 $39.52 $0.00 $0.00 $0.00 $0.00 $86.08 $136.35 $137.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32215 ERX HCPCS J1652 55111-0678-10 FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN BOTH IP/OP $189.65 $140.34 $0.00 $146.18 $0.00 $0.00 $0.00 $0.00 $0.00 $140.76 $140.76 $146.18 $0.00 $39.52 $0.00 $0.00 $0.00 $0.00 $86.08 $136.35 $137.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32215 ERX HCPCS J1652 55511-0678-11 FONDAPARINUX SODIUM 2.5 MG/0.5ML SC SOLN BOTH IP/OP $189.65 $140.34 $0.00 $146.18 $0.00 $0.00 $0.00 $0.00 $0.00 $140.76 $140.76 $146.18 $0.00 $39.52 $0.00 $0.00 $0.00 $0.00 $86.08 $136.35 $137.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32298 ERX HCPCS 63700001 00056-0510-30 EFAVIRENZ 600 MG PO TABS BOTH IP/OP $151.41 $112.04 $0.00 $109.83 $0.00 $0.00 $0.00 $26.95 $0.00 $0.00 $0.00 $0.00 $0.00 $31.55 $0.00 $0.00 $0.00 $0.00 $68.65 $108.73 $109.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32298 ERX HCPCS 63700001 69097-0301-02 EFAVIRENZ 600 MG PO TABS BOTH IP/OP $151.41 $112.04 $0.00 $109.83 $0.00 $0.00 $0.00 $26.95 $0.00 $0.00 $0.00 $0.00 $0.00 $31.55 $0.00 $0.00 $0.00 $0.00 $68.65 $108.73 $109.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32354 ERX HCPCS 25000001 42192-0139-01 SULFACETAMIDE SODIUM-SULFUR 10-5 % EX CREA BOTH IP/OP $398.53 $294.91 $0.00 $307.19 $0.00 $0.00 $0.00 $0.00 $0.00 $295.79 $295.79 $307.19 $0.00 $83.05 $0.00 $0.00 $0.00 $0.00 $180.88 $286.51 $289.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32375 ERX HCPCS 25000001 24208-0344-25 FLUNISOLIDE 25 MCG/ACT (0.025%) NA SOLN BOTH IP/OP $249.67 $184.76 $0.00 $192.45 $0.00 $0.00 $0.00 $0.00 $0.00 $185.31 $185.31 $192.45 $0.00 $52.03 $0.00 $0.00 $0.00 $0.00 $113.33 $179.51 $181.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32589 ERX HCPCS J2430 61703-0324-18 PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN BOTH IP/OP $70.48 $52.16 $0.00 $54.33 $31.72 $31.72 $0.00 $0.00 $0.00 $36.23 $52.31 $52.31 $54.33 $0.00 $14.69 $0.00 $41.69 $41.69 $0.00 $31.49 $49.87 $50.38 $0.00 $0.00 $9.85 $0.00 $0.00 $10.02 $0.00 $0.00 $0.00 $0.00 $0.00 32589 ERX HCPCS J2430 67457-0430-10 PAMIDRONATE DISODIUM 30 MG/10ML IV SOLN BOTH IP/OP $70.48 $52.16 $0.00 $54.33 $31.72 $31.72 $0.00 $0.00 $0.00 $36.23 $52.31 $52.31 $54.33 $0.00 $14.69 $0.00 $41.69 $41.69 $0.00 $31.49 $49.87 $50.38 $0.00 $0.00 $9.85 $0.00 $0.00 $10.02 $0.00 $0.00 $0.00 $0.00 $0.00 32703 ERX HCPCS 25000001 08212-4271-81 ILEX SKIN PROTECTANT 58.3 % EX PSTE BOTH IP/OP $26.15 $19.35 $0.00 $20.16 $0.00 $0.00 $0.00 $0.00 $0.00 $19.41 $19.41 $20.16 $0.00 $5.45 $0.00 $0.00 $0.00 $0.00 $11.86 $18.79 $18.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32810 ERX HCPCS 25000001 89141-0456-02 GELCLAIR MT GEL BOTH IP/OP $188.53 $139.51 $0.00 $145.32 $0.00 $0.00 $0.00 $0.00 $0.00 $139.93 $139.93 $145.32 $0.00 $39.29 $0.00 $0.00 $0.00 $0.00 $85.57 $135.54 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32810 ERX HCPCS 25000001 89141-0456-03 GELCLAIR MT GEL BOTH IP/OP $188.53 $139.51 $0.00 $145.32 $0.00 $0.00 $0.00 $0.00 $0.00 $139.93 $139.93 $145.32 $0.00 $39.29 $0.00 $0.00 $0.00 $0.00 $85.57 $135.54 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32893 ERX HCPCS J9217 62935-0753-75 LEUPROLIDE ACETATE 7.5 MG SC KIT BOTH IP/OP "$1,403.86 " "$1,038.86" $0.00 "$1,082.10" $631.74 $631.74 $200.73 $200.73 $200.73 $246.83 "$1,041.94" "$1,041.94" "$1,082.10" $139.09 $163.43 $90.41 $830.38 $830.38 $235.93 $650.44 "$1,030.30" "$1,040.70" $325.81 $325.81 $270.33 $0.00 $0.00 $257.40 $205.89 $0.00 $0.00 $0.00 $0.00 32895 ERX HCPCS 63700001 00430-0472-03 RISEDRONATE SODIUM 35 MG PO TABS BOTH IP/OP $343.72 $254.35 $0.00 $249.60 $0.00 $0.00 $0.00 $61.18 $0.00 $0.00 $0.00 $0.00 $0.00 $71.63 $0.00 $0.00 $0.00 $0.00 $156.00 $247.10 $249.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32960 ERX HCPCS J7192 00026-3783-35 ANTIHEMOPHILIC FACTOR VIII RECOMB (KOGENATE FS) 500 UNITS IV KIT BOTH IP/OP "$2,364.00 " "$1,749.36" $0.00 "$1,891.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,182.00" "$1,872.29" "$1,891.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32961 ERX HCPCS J7192 00026-3785-55 ANTIHEMOPHILIC FACTOR VIII RECOMB (KOGENATE FS) 1000 UNITS IV KIT BOTH IP/OP "$4,452.20 " "$3,294.63" $0.00 "$3,431.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,304.42" "$3,304.42" "$3,431.76" $0.00 $927.84 $0.00 $0.00 $0.00 $0.00 "$2,019.25" "$3,198.49" "$3,230.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32961 ERX HCPCS J7192 00026-4785-01 ANTIHEMOPHILIC FACTOR VIII RECOMB (KOGENATE FS) 1000 UNITS IV KIT BOTH IP/OP "$4,452.20 " "$3,294.63" $0.00 "$3,431.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,304.42" "$3,304.42" "$3,431.76" $0.00 $927.84 $0.00 $0.00 $0.00 $0.00 "$2,019.25" "$3,198.49" "$3,230.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32979 ERX HCPCS 63700001 00078-0401-34 IMATINIB MESYLATE 100 MG PO TABS BOTH IP/OP "$1,312.44 " $971.21 $0.00 $952.86 $0.00 $0.00 $0.00 $233.61 $0.00 $0.00 $0.00 $0.00 $0.00 $273.51 $0.00 $0.00 $0.00 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33008 ERX HCPCS 63700001 00049-3170-30 VORICONAZOLE 50 MG PO TABS BOTH IP/OP $14.97 $11.08 $0.00 $10.70 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $0.00 $3.12 $0.00 $0.00 $0.00 $0.00 $6.69 $10.60 $10.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33008 ERX HCPCS 63700001 00781-5667-31 VORICONAZOLE 50 MG PO TABS BOTH IP/OP $14.97 $11.08 $0.00 $10.70 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $0.00 $3.12 $0.00 $0.00 $0.00 $0.00 $6.69 $10.60 $10.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33008 ERX HCPCS 63700001 16714-0514-01 VORICONAZOLE 50 MG PO TABS BOTH IP/OP $14.97 $11.08 $0.00 $10.70 $0.00 $0.00 $0.00 $2.66 $0.00 $0.00 $0.00 $0.00 $0.00 $3.12 $0.00 $0.00 $0.00 $0.00 $6.69 $10.60 $10.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33009 ERX HCPCS 63700001 00049-3180-30 VORICONAZOLE 200 MG PO TABS BOTH IP/OP $18.73 $13.86 $0.00 $13.38 $0.00 $0.00 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $0.00 $3.90 $0.00 $0.00 $0.00 $0.00 $8.37 $13.25 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33009 ERX HCPCS 63700001 00781-5668-31 VORICONAZOLE 200 MG PO TABS BOTH IP/OP $18.73 $13.86 $0.00 $13.38 $0.00 $0.00 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $0.00 $3.90 $0.00 $0.00 $0.00 $0.00 $8.37 $13.25 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33009 ERX HCPCS 63700001 16714-0515-01 VORICONAZOLE 200 MG PO TABS BOTH IP/OP $18.73 $13.86 $0.00 $13.38 $0.00 $0.00 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $0.00 $3.90 $0.00 $0.00 $0.00 $0.00 $8.37 $13.25 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33009 ERX HCPCS 63700001 51079-0165-03 VORICONAZOLE 200 MG PO TABS BOTH IP/OP $18.73 $13.86 $0.00 $13.38 $0.00 $0.00 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $0.00 $3.90 $0.00 $0.00 $0.00 $0.00 $8.37 $13.25 $13.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33010 ERX HCPCS J3465 00049-3190-01 VORICONAZOLE 200 MG IV SOLR BOTH IP/OP $512.67 $379.38 $0.00 $395.17 $0.00 $0.00 $0.00 $0.00 $0.00 $380.50 $380.50 $395.17 $0.00 $106.84 $0.00 $0.00 $0.00 $0.00 $232.69 $368.57 $372.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33010 ERX HCPCS J3465 00049-3190-28 VORICONAZOLE 200 MG IV SOLR BOTH IP/OP $512.67 $379.38 $0.00 $395.17 $0.00 $0.00 $0.00 $0.00 $0.00 $380.50 $380.50 $395.17 $0.00 $106.84 $0.00 $0.00 $0.00 $0.00 $232.69 $368.57 $372.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33010 ERX HCPCS J3465 00781-3416-94 VORICONAZOLE 200 MG IV SOLR BOTH IP/OP $512.67 $379.38 $0.00 $395.17 $0.00 $0.00 $0.00 $0.00 $0.00 $380.50 $380.50 $395.17 $0.00 $106.84 $0.00 $0.00 $0.00 $0.00 $232.69 $368.57 $372.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33010 ERX HCPCS J3465 47781-0466-71 VORICONAZOLE 200 MG IV SOLR BOTH IP/OP $512.67 $379.38 $0.00 $395.17 $0.00 $0.00 $0.00 $0.00 $0.00 $380.50 $380.50 $395.17 $0.00 $106.84 $0.00 $0.00 $0.00 $0.00 $232.69 $368.57 $372.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33083 ERX HCPCS 63700001 00245-0213-11 MIDODRINE HCL 10 MG PO TABS BOTH IP/OP $36.62 $27.10 $0.00 $13.24 $0.00 $0.00 $0.00 $6.52 $0.00 $0.00 $0.00 $0.00 $0.00 $7.63 $0.00 $0.00 $0.00 $0.00 $8.28 $13.11 $13.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33083 ERX HCPCS 63700001 00378-1903-01 MIDODRINE HCL 10 MG PO TABS BOTH IP/OP $36.62 $27.10 $0.00 $13.24 $0.00 $0.00 $0.00 $6.52 $0.00 $0.00 $0.00 $0.00 $0.00 $7.63 $0.00 $0.00 $0.00 $0.00 $8.28 $13.11 $13.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33083 ERX HCPCS 63700001 42291-0562-90 MIDODRINE HCL 10 MG PO TABS BOTH IP/OP $36.62 $27.10 $0.00 $13.24 $0.00 $0.00 $0.00 $6.52 $0.00 $0.00 $0.00 $0.00 $0.00 $7.63 $0.00 $0.00 $0.00 $0.00 $8.28 $13.11 $13.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33111 ERX HCPCS 63700001 55111-0341-01 AMLODIPINE-BENAZEPRIL HCL 10-20 MG PO CAPS BOTH IP/OP $13.92 $10.30 $0.00 $10.10 $0.00 $0.00 $0.00 $2.48 $0.00 $0.00 $0.00 $0.00 $0.00 $2.90 $0.00 $0.00 $0.00 $0.00 $6.31 $10.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33111 ERX HCPCS 63700001 65862-0586-01 AMLODIPINE-BENAZEPRIL HCL 10-20 MG PO CAPS BOTH IP/OP $13.92 $10.30 $0.00 $10.10 $0.00 $0.00 $0.00 $2.48 $0.00 $0.00 $0.00 $0.00 $0.00 $2.90 $0.00 $0.00 $0.00 $0.00 $6.31 $10.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33175 ERX HCPCS J3486 00049-3920-83 ZIPRASIDONE MESYLATE 20 MG IM SOLR BOTH IP/OP $82.44 $61.01 $0.00 $63.54 $37.10 $37.10 $0.00 $0.00 $0.00 $17.18 $61.19 $61.19 $63.54 $0.00 $17.44 $0.00 $48.76 $48.76 $0.00 $37.39 $59.22 $59.82 $0.00 $0.00 $21.10 $0.00 $0.00 $20.09 $0.00 $0.00 $0.00 $0.00 $0.00 33175 ERX HCPCS J3486 43598-0848-58 ZIPRASIDONE MESYLATE 20 MG IM SOLR BOTH IP/OP $82.44 $61.01 $0.00 $63.54 $37.10 $37.10 $0.00 $0.00 $0.00 $17.18 $61.19 $61.19 $63.54 $0.00 $17.44 $0.00 $48.76 $48.76 $0.00 $37.39 $59.22 $59.82 $0.00 $0.00 $21.10 $0.00 $0.00 $20.09 $0.00 $0.00 $0.00 $0.00 $0.00 33175 ERX HCPCS J3486 72266-0160-01 ZIPRASIDONE MESYLATE 20 MG IM SOLR BOTH IP/OP $82.44 $61.01 $0.00 $63.54 $37.10 $37.10 $0.00 $0.00 $0.00 $17.18 $61.19 $61.19 $63.54 $0.00 $17.44 $0.00 $48.76 $48.76 $0.00 $37.39 $59.22 $59.82 $0.00 $0.00 $21.10 $0.00 $0.00 $20.09 $0.00 $0.00 $0.00 $0.00 $0.00 33175 ERX HCPCS J3486 72266-0160-10 ZIPRASIDONE MESYLATE 20 MG IM SOLR BOTH IP/OP $82.44 $61.01 $0.00 $63.54 $37.10 $37.10 $0.00 $0.00 $0.00 $17.18 $61.19 $61.19 $63.54 $0.00 $17.44 $0.00 $48.76 $48.76 $0.00 $37.39 $59.22 $59.82 $0.00 $0.00 $21.10 $0.00 $0.00 $20.09 $0.00 $0.00 $0.00 $0.00 $0.00 33226 ERX HCPCS 63700001 00093-2272-34 AMOXICILLIN-POT CLAVULANATE 400-57 MG PO CHEW BOTH IP/OP $22.59 $16.72 $0.00 $16.39 $0.00 $0.00 $0.00 $4.02 $0.00 $0.00 $0.00 $0.00 $0.00 $4.71 $0.00 $0.00 $0.00 $0.00 $10.25 $16.23 $16.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33227 ERX HCPCS 63700001 00093-2274-34 AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS BOTH IP/OP $15.86 $11.74 $0.00 $11.51 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.20 $11.40 $11.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33227 ERX HCPCS 63700001 16714-0296-01 AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS BOTH IP/OP $15.86 $11.74 $0.00 $11.51 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.20 $11.40 $11.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33227 ERX HCPCS 63700001 16714-0494-01 AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS BOTH IP/OP $15.86 $11.74 $0.00 $11.51 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.20 $11.40 $11.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33227 ERX HCPCS 63700001 65862-0502-20 AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS BOTH IP/OP $15.86 $11.74 $0.00 $11.51 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.20 $11.40 $11.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33227 ERX HCPCS 63700001 66685-1002-02 AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS BOTH IP/OP $15.86 $11.74 $0.00 $11.51 $0.00 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.20 $11.40 $11.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 00093-2275-34 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 00781-1852-20 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 16714-0297-01 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 16714-0297-02 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 16714-0478-01 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 16714-0478-02 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 43598-0221-14 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 65862-0503-01 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 65862-0503-20 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33228 ERX HCPCS 63700001 66685-1001-00 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS BOTH IP/OP $20.58 $15.23 $0.00 $14.93 $0.00 $0.00 $0.00 $3.66 $0.00 $0.00 $0.00 $0.00 $0.00 $4.29 $0.00 $0.00 $0.00 $0.00 $9.33 $14.78 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33230 ERX HCPCS 63700001 16714-0293-01 AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR BOTH IP/OP $180.65 $133.68 $0.00 $98.42 $0.00 $0.00 $0.00 $32.16 $0.00 $0.00 $0.00 $0.00 $0.00 $37.65 $0.00 $0.00 $0.00 $0.00 $61.52 $97.44 $98.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33230 ERX HCPCS 63700001 66685-1012-00 AMOXICILLIN-POT CLAVULANATE 400-57 MG/5ML PO SUSR BOTH IP/OP $180.65 $133.68 $0.00 $98.42 $0.00 $0.00 $0.00 $32.16 $0.00 $0.00 $0.00 $0.00 $0.00 $37.65 $0.00 $0.00 $0.00 $0.00 $61.52 $97.44 $98.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33512 ERX HCPCS 63700001 00093-5851-01 ESCITALOPRAM OXALATE 10 MG PO TABS BOTH IP/OP $18.15 $13.43 $0.00 $13.17 $0.00 $0.00 $0.00 $3.23 $0.00 $0.00 $0.00 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $8.23 $13.04 $13.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33512 ERX HCPCS 63700001 00904-6426-61 ESCITALOPRAM OXALATE 10 MG PO TABS BOTH IP/OP $18.15 $13.43 $0.00 $13.17 $0.00 $0.00 $0.00 $3.23 $0.00 $0.00 $0.00 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $8.23 $13.04 $13.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33512 ERX HCPCS 63700001 43547-0281-10 ESCITALOPRAM OXALATE 10 MG PO TABS BOTH IP/OP $18.15 $13.43 $0.00 $13.17 $0.00 $0.00 $0.00 $3.23 $0.00 $0.00 $0.00 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $8.23 $13.04 $13.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33512 ERX HCPCS 63700001 76282-0250-90 ESCITALOPRAM OXALATE 10 MG PO TABS BOTH IP/OP $18.15 $13.43 $0.00 $13.17 $0.00 $0.00 $0.00 $3.23 $0.00 $0.00 $0.00 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $8.23 $13.04 $13.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33513 ERX HCPCS 63700001 00456-2020-01 ESCITALOPRAM OXALATE 20 MG PO TABS BOTH IP/OP $18.94 $14.02 $0.00 $13.74 $0.00 $0.00 $0.00 $3.37 $0.00 $0.00 $0.00 $0.00 $0.00 $3.95 $0.00 $0.00 $0.00 $0.00 $8.59 $13.61 $13.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33513 ERX HCPCS 63700001 00904-6427-61 ESCITALOPRAM OXALATE 20 MG PO TABS BOTH IP/OP $18.94 $14.02 $0.00 $13.74 $0.00 $0.00 $0.00 $3.37 $0.00 $0.00 $0.00 $0.00 $0.00 $3.95 $0.00 $0.00 $0.00 $0.00 $8.59 $13.61 $13.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33513 ERX HCPCS 63700001 43547-0282-10 ESCITALOPRAM OXALATE 20 MG PO TABS BOTH IP/OP $18.94 $14.02 $0.00 $13.74 $0.00 $0.00 $0.00 $3.37 $0.00 $0.00 $0.00 $0.00 $0.00 $3.95 $0.00 $0.00 $0.00 $0.00 $8.59 $13.61 $13.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33513 ERX HCPCS 63700001 65862-0375-01 ESCITALOPRAM OXALATE 20 MG PO TABS BOTH IP/OP $18.94 $14.02 $0.00 $13.74 $0.00 $0.00 $0.00 $3.37 $0.00 $0.00 $0.00 $0.00 $0.00 $3.95 $0.00 $0.00 $0.00 $0.00 $8.59 $13.61 $13.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33541 ERX HCPCS 63700001 00378-5807-93 VALSARTAN 40 MG PO TABS BOTH IP/OP $17.00 $12.58 $0.00 $12.33 $0.00 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $7.71 $12.20 $12.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33541 ERX HCPCS 63700001 33342-0062-07 VALSARTAN 40 MG PO TABS BOTH IP/OP $17.00 $12.58 $0.00 $12.33 $0.00 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $7.71 $12.20 $12.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33541 ERX HCPCS 63700001 59746-0360-30 VALSARTAN 40 MG PO TABS BOTH IP/OP $17.00 $12.58 $0.00 $12.33 $0.00 $0.00 $0.00 $3.03 $0.00 $0.00 $0.00 $0.00 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $7.71 $12.20 $12.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33591 ERX HCPCS J2783 00024-5150-10 RASBURICASE 1.5 MG IV SOLR BOTH IP/OP "$2,598.18 " "$1,922.65" $0.00 "$2,060.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,984.29" "$1,984.29" "$2,060.76" $0.00 "$1,110.58" $0.00 $0.00 $0.00 $0.00 "$1,121.60" "$1,776.61" "$1,794.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33666 ERX HCPCS J1815 00169-3685-12 INSULIN ASPART PROT & ASPART (70-30) 100 UNIT/ML SC SUSP BOTH IP/OP "$1,051.61 " $778.19 $0.00 $763.50 $571.02 $571.02 $0.00 $0.00 $0.00 $219.18 $0.00 $0.00 $0.00 $0.00 $219.16 $0.00 $622.03 $622.03 $0.00 $477.19 $755.87 $763.50 $0.00 $0.00 $0.00 $0.00 $0.00 $201.38 $0.00 $0.00 $0.00 $0.00 $0.00 33669 ERX HCPCS J9217 62935-0223-05 LEUPROLIDE ACETATE (3 MONTH) 22.5 MG SC KIT BOTH IP/OP "$3,674.95 " "$2,719.46" $0.00 "$2,832.65" "$1,653.73" "$1,653.73" $602.20 $602.20 $602.20 $740.50 "$2,727.55" "$2,727.55" "$2,832.65" $417.27 $490.29 $271.23 "$1,811.75" "$1,811.75" $707.80 "$1,666.74" "$2,640.11" "$2,666.78" $977.44 $977.44 $811.00 $0.00 $0.00 $772.21 $617.66 $0.00 $0.00 $0.00 $0.00 33816 ERX HCPCS 63700001 61958-0501-01 ADEFOVIR DIPIVOXIL 10 MG PO TABS BOTH IP/OP $226.29 $167.45 $0.00 $156.81 $0.00 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 $47.16 $0.00 $0.00 $0.00 $0.00 $98.01 $155.24 $156.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33826 ERX HCPCS 63700001 00245-0272-06 OXANDROLONE 10 MG PO TABS BOTH IP/OP $78.57 $58.14 $0.00 $57.01 $0.00 $0.00 $0.00 $13.99 $0.00 $0.00 $0.00 $0.00 $0.00 $16.37 $0.00 $0.00 $0.00 $0.00 $35.63 $56.44 $57.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33826 ERX HCPCS 63700001 49884-0302-02 OXANDROLONE 10 MG PO TABS BOTH IP/OP $78.57 $58.14 $0.00 $57.01 $0.00 $0.00 $0.00 $13.99 $0.00 $0.00 $0.00 $0.00 $0.00 $16.37 $0.00 $0.00 $0.00 $0.00 $35.63 $56.44 $57.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33863 ERX HCPCS J7192 00026-3786-65 ANTIHEMOPHILIC FACTOR VIII RECOMB (KOGENATE FS) 2000 UNITS IV KIT BOTH IP/OP "$8,904.40 " "$6,589.26" $0.00 "$6,863.51" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,608.85" "$6,608.85" "$6,863.51" $0.00 "$1,855.68" $0.00 $0.00 $0.00 $0.00 "$4,038.50" "$6,396.98" "$6,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33863 ERX HCPCS J7192 00026-4786-01 ANTIHEMOPHILIC FACTOR VIII RECOMB (KOGENATE FS) 2000 UNITS IV KIT BOTH IP/OP "$8,904.40 " "$6,589.26" $0.00 "$6,863.51" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,608.85" "$6,608.85" "$6,863.51" $0.00 "$1,855.68" $0.00 $0.00 $0.00 $0.00 "$4,038.50" "$6,396.98" "$6,461.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33937 ERX HCPCS 63700001 31722-0754-30 LAMIVUDINE 300 MG PO TABS BOTH IP/OP $59.95 $44.36 $0.00 $43.50 $0.00 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 $12.49 $0.00 $0.00 $0.00 $0.00 $27.19 $43.06 $43.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33937 ERX HCPCS 63700001 60505-3252-03 LAMIVUDINE 300 MG PO TABS BOTH IP/OP $59.95 $44.36 $0.00 $43.50 $0.00 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 $12.49 $0.00 $0.00 $0.00 $0.00 $27.19 $43.06 $43.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33937 ERX HCPCS 63700001 64380-0711-04 LAMIVUDINE 300 MG PO TABS BOTH IP/OP $59.95 $44.36 $0.00 $43.50 $0.00 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 $12.49 $0.00 $0.00 $0.00 $0.00 $27.19 $43.06 $43.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33937 ERX HCPCS 63700001 65862-0553-30 LAMIVUDINE 300 MG PO TABS BOTH IP/OP $59.95 $44.36 $0.00 $43.50 $0.00 $0.00 $0.00 $10.67 $0.00 $0.00 $0.00 $0.00 $0.00 $12.49 $0.00 $0.00 $0.00 $0.00 $27.19 $43.06 $43.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34153 ERX HCPCS 63700001 00591-3713-19 EZETIMIBE 10 MG PO TABS BOTH IP/OP $10.96 $8.11 $0.00 $7.95 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $0.00 $2.28 $0.00 $0.00 $0.00 $0.00 $4.97 $7.87 $7.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34153 ERX HCPCS 63700001 00781-5690-92 EZETIMIBE 10 MG PO TABS BOTH IP/OP $10.96 $8.11 $0.00 $7.95 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $0.00 $2.28 $0.00 $0.00 $0.00 $0.00 $4.97 $7.87 $7.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34153 ERX HCPCS 63700001 59651-0052-90 EZETIMIBE 10 MG PO TABS BOTH IP/OP $10.96 $8.11 $0.00 $7.95 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $0.00 $2.28 $0.00 $0.00 $0.00 $0.00 $4.97 $7.87 $7.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34153 ERX HCPCS 63700001 66582-0414-31 EZETIMIBE 10 MG PO TABS BOTH IP/OP $10.96 $8.11 $0.00 $7.95 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $0.00 $2.28 $0.00 $0.00 $0.00 $0.00 $4.97 $7.87 $7.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34153 ERX HCPCS 63700001 68382-0773-16 EZETIMIBE 10 MG PO TABS BOTH IP/OP $10.96 $8.11 $0.00 $7.95 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $0.00 $2.28 $0.00 $0.00 $0.00 $0.00 $4.97 $7.87 $7.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34153 ERX HCPCS 63700001 69238-1154-03 EZETIMIBE 10 MG PO TABS BOTH IP/OP $10.96 $8.11 $0.00 $7.95 $0.00 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $0.00 $2.28 $0.00 $0.00 $0.00 $0.00 $4.97 $7.87 $7.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34369 ERX HCPCS 63700001 16714-0785-01 ARIPIPRAZOLE 10 MG PO TABS BOTH IP/OP $123.03 $91.04 $0.00 $89.25 $0.00 $0.00 $0.00 $21.90 $0.00 $0.00 $0.00 $0.00 $0.00 $25.64 $0.00 $0.00 $0.00 $0.00 $55.78 $88.36 $89.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34369 ERX HCPCS 63700001 27241-0053-03 ARIPIPRAZOLE 10 MG PO TABS BOTH IP/OP $123.03 $91.04 $0.00 $89.25 $0.00 $0.00 $0.00 $21.90 $0.00 $0.00 $0.00 $0.00 $0.00 $25.64 $0.00 $0.00 $0.00 $0.00 $55.78 $88.36 $89.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34369 ERX HCPCS 63700001 43598-0556-30 ARIPIPRAZOLE 10 MG PO TABS BOTH IP/OP $123.03 $91.04 $0.00 $89.25 $0.00 $0.00 $0.00 $21.90 $0.00 $0.00 $0.00 $0.00 $0.00 $25.64 $0.00 $0.00 $0.00 $0.00 $55.78 $88.36 $89.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34369 ERX HCPCS 63700001 65162-0898-03 ARIPIPRAZOLE 10 MG PO TABS BOTH IP/OP $123.03 $91.04 $0.00 $89.25 $0.00 $0.00 $0.00 $21.90 $0.00 $0.00 $0.00 $0.00 $0.00 $25.64 $0.00 $0.00 $0.00 $0.00 $55.78 $88.36 $89.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34369 ERX HCPCS 63700001 65862-0663-30 ARIPIPRAZOLE 10 MG PO TABS BOTH IP/OP $123.03 $91.04 $0.00 $89.25 $0.00 $0.00 $0.00 $21.90 $0.00 $0.00 $0.00 $0.00 $0.00 $25.64 $0.00 $0.00 $0.00 $0.00 $55.78 $88.36 $89.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34370 ERX HCPCS 63700001 27241-0054-03 ARIPIPRAZOLE 15 MG PO TABS BOTH IP/OP $123.54 $91.42 $0.00 $89.62 $0.00 $0.00 $0.00 $21.99 $0.00 $0.00 $0.00 $0.00 $0.00 $25.75 $0.00 $0.00 $0.00 $0.00 $56.01 $88.72 $89.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34370 ERX HCPCS 63700001 31722-0828-30 ARIPIPRAZOLE 15 MG PO TABS BOTH IP/OP $123.54 $91.42 $0.00 $89.62 $0.00 $0.00 $0.00 $21.99 $0.00 $0.00 $0.00 $0.00 $0.00 $25.75 $0.00 $0.00 $0.00 $0.00 $56.01 $88.72 $89.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34370 ERX HCPCS 63700001 43598-0557-30 ARIPIPRAZOLE 15 MG PO TABS BOTH IP/OP $123.54 $91.42 $0.00 $89.62 $0.00 $0.00 $0.00 $21.99 $0.00 $0.00 $0.00 $0.00 $0.00 $25.75 $0.00 $0.00 $0.00 $0.00 $56.01 $88.72 $89.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34370 ERX HCPCS 63700001 65862-0664-30 ARIPIPRAZOLE 15 MG PO TABS BOTH IP/OP $123.54 $91.42 $0.00 $89.62 $0.00 $0.00 $0.00 $21.99 $0.00 $0.00 $0.00 $0.00 $0.00 $25.75 $0.00 $0.00 $0.00 $0.00 $56.01 $88.72 $89.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34370 ERX HCPCS 63700001 67877-0433-03 ARIPIPRAZOLE 15 MG PO TABS BOTH IP/OP $123.54 $91.42 $0.00 $89.62 $0.00 $0.00 $0.00 $21.99 $0.00 $0.00 $0.00 $0.00 $0.00 $25.75 $0.00 $0.00 $0.00 $0.00 $56.01 $88.72 $89.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34371 ERX HCPCS 63700001 16714-0787-01 ARIPIPRAZOLE 20 MG PO TABS BOTH IP/OP $174.20 $128.91 $0.00 $126.37 $0.00 $0.00 $0.00 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $36.30 $0.00 $0.00 $0.00 $0.00 $78.98 $125.10 $126.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34371 ERX HCPCS 63700001 31722-0829-30 ARIPIPRAZOLE 20 MG PO TABS BOTH IP/OP $174.20 $128.91 $0.00 $126.37 $0.00 $0.00 $0.00 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $36.30 $0.00 $0.00 $0.00 $0.00 $78.98 $125.10 $126.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34371 ERX HCPCS 63700001 43547-0306-03 ARIPIPRAZOLE 20 MG PO TABS BOTH IP/OP $174.20 $128.91 $0.00 $126.37 $0.00 $0.00 $0.00 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $36.30 $0.00 $0.00 $0.00 $0.00 $78.98 $125.10 $126.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34371 ERX HCPCS 63700001 67877-0434-03 ARIPIPRAZOLE 20 MG PO TABS BOTH IP/OP $174.20 $128.91 $0.00 $126.37 $0.00 $0.00 $0.00 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $36.30 $0.00 $0.00 $0.00 $0.00 $78.98 $125.10 $126.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34372 ERX HCPCS 63700001 65862-0666-30 ARIPIPRAZOLE 30 MG PO TABS BOTH IP/OP $175.28 $129.71 $0.00 $127.15 $0.00 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 $36.53 $0.00 $0.00 $0.00 $0.00 $79.47 $125.88 $127.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34418 ERX HCPCS 63700001 16714-0484-01 DIVALPROEX SODIUM ER 250 MG PO TB24 BOTH IP/OP $10.29 $7.61 $0.00 $7.46 $0.00 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $4.67 $7.39 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34418 ERX HCPCS 63700001 65862-0594-01 DIVALPROEX SODIUM ER 250 MG PO TB24 BOTH IP/OP $10.29 $7.61 $0.00 $7.46 $0.00 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $4.67 $7.39 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34447 ERX HCPCS 63700001 00002-3229-30 ATOMOXETINE HCL 40 MG PO CAPS BOTH IP/OP $72.01 $53.29 $0.00 $52.24 $0.00 $0.00 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $15.01 $0.00 $0.00 $0.00 $0.00 $32.65 $51.72 $52.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34448 ERX HCPCS 63700001 00002-3239-30 ATOMOXETINE HCL 60 MG PO CAPS BOTH IP/OP $72.01 $53.29 $0.00 $52.24 $0.00 $0.00 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $15.01 $0.00 $0.00 $0.00 $0.00 $32.65 $51.72 $52.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 00406-0123-23 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 00406-0123-62 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 13107-0019-01 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 51862-0585-01 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 53746-0109-01 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 57664-0126-13 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 57664-0126-88 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 63739-0704-10 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34505 ERX HCPCS 63700001 68084-0895-11 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34524 ERX HCPCS J2543 00206-8861-02 PIPERACILLIN-TAZOBACTAM IN DEX 3-0.375 GM/50ML IV SOLN BOTH IP/OP $109.00 $80.66 $0.00 $84.02 $49.05 $49.05 $0.00 $0.00 $0.00 $19.63 $80.90 $80.90 $84.02 $0.00 $5.21 $0.00 $64.47 $64.47 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $6.52 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 34550 ERX HCPCS 90723 58160-0811-52 DTAP-HEPATITIS B RECOMB-IPV IM SUSP BOTH IP/OP $360.55 $266.81 $0.00 $277.91 $162.25 $162.25 $0.00 $0.00 $79.00 $75.15 $267.60 $267.60 $277.91 $0.00 $75.14 $0.00 $213.27 $213.27 $0.00 $155.54 $246.38 $248.86 $186.65 $186.65 $48.68 $0.00 $0.00 $49.52 $0.00 $0.00 $0.00 $0.00 $0.00 34683 ERX HCPCS 63700001 ELETRIPTAN HYDROBROMIDE 20 MG PO TABS BOTH IP/OP $213.27 $157.82 $0.00 $154.88 $0.00 $0.00 $0.00 $37.96 $0.00 $0.00 $0.00 $0.00 $0.00 $44.45 $0.00 $0.00 $0.00 $0.00 $96.80 $153.33 $154.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34683 ERX HCPCS 63700001 00049-2330-45 ELETRIPTAN HYDROBROMIDE 20 MG PO TABS BOTH IP/OP $213.27 $157.82 $0.00 $154.88 $0.00 $0.00 $0.00 $37.96 $0.00 $0.00 $0.00 $0.00 $0.00 $44.45 $0.00 $0.00 $0.00 $0.00 $96.80 $153.33 $154.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34683 ERX HCPCS 63700001 00093-8310-18 ELETRIPTAN HYDROBROMIDE 20 MG PO TABS BOTH IP/OP $213.27 $157.82 $0.00 $154.88 $0.00 $0.00 $0.00 $37.96 $0.00 $0.00 $0.00 $0.00 $0.00 $44.45 $0.00 $0.00 $0.00 $0.00 $96.80 $153.33 $154.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34684 ERX HCPCS 63700001 00049-2340-45 ELETRIPTAN HYDROBROMIDE 40 MG PO TABS BOTH IP/OP $285.38 $211.18 $0.00 $197.57 $0.00 $0.00 $0.00 $50.80 $0.00 $0.00 $0.00 $0.00 $0.00 $59.47 $0.00 $0.00 $0.00 $0.00 $123.48 $195.59 $197.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34684 ERX HCPCS 63700001 00049-2340-79 ELETRIPTAN HYDROBROMIDE 40 MG PO TABS BOTH IP/OP $285.38 $211.18 $0.00 $197.57 $0.00 $0.00 $0.00 $50.80 $0.00 $0.00 $0.00 $0.00 $0.00 $59.47 $0.00 $0.00 $0.00 $0.00 $123.48 $195.59 $197.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34684 ERX HCPCS 63700001 59762-2322-08 ELETRIPTAN HYDROBROMIDE 40 MG PO TABS BOTH IP/OP $285.38 $211.18 $0.00 $197.57 $0.00 $0.00 $0.00 $50.80 $0.00 $0.00 $0.00 $0.00 $0.00 $59.47 $0.00 $0.00 $0.00 $0.00 $123.48 $195.59 $197.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34708 ERX HCPCS 25000001 67546-0212-21 NITAZOXANIDE 100 MG/5ML PO SUSR BOTH IP/OP "$1,622.38 " "$1,200.56" $0.00 "$1,250.53" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,204.13" "$1,204.13" "$1,250.53" $0.00 $338.10 $0.00 $0.00 $0.00 $0.00 $751.68 "$1,190.66" "$1,202.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34711 ERX HCPCS 63700001 00054-0176-13 BUPRENORPHINE HCL 2 MG SL SUBL BOTH IP/OP $17.35 $12.84 $0.00 $12.59 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.62 $0.00 $0.00 $0.00 $0.00 $7.87 $12.47 $12.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34711 ERX HCPCS 63700001 42858-0501-03 BUPRENORPHINE HCL 2 MG SL SUBL BOTH IP/OP $17.35 $12.84 $0.00 $12.59 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.62 $0.00 $0.00 $0.00 $0.00 $7.87 $12.47 $12.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34711 ERX HCPCS 63700001 50383-0924-93 BUPRENORPHINE HCL 2 MG SL SUBL BOTH IP/OP $17.35 $12.84 $0.00 $12.59 $0.00 $0.00 $0.00 $3.09 $0.00 $0.00 $0.00 $0.00 $0.00 $3.62 $0.00 $0.00 $0.00 $0.00 $7.87 $12.47 $12.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34712 ERX HCPCS 63700001 42858-0502-03 BUPRENORPHINE HCL 8 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $25.30 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $15.81 $25.04 $25.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34712 ERX HCPCS 63700001 50383-0930-93 BUPRENORPHINE HCL 8 MG SL SUBL BOTH IP/OP $6.00 $4.44 $0.00 $25.30 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $15.81 $25.04 $25.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34713 ERX HCPCS 25000001 00054-0188-13 BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL BOTH IP/OP $24.42 $18.07 $0.00 $18.82 $0.00 $0.00 $0.00 $0.00 $0.00 $18.12 $18.12 $18.82 $0.00 $5.09 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34713 ERX HCPCS 25000001 62175-0452-32 BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL BOTH IP/OP $24.42 $18.07 $0.00 $18.82 $0.00 $0.00 $0.00 $0.00 $0.00 $18.12 $18.12 $18.82 $0.00 $5.09 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34713 ERX HCPCS 25000001 62756-0969-83 BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL BOTH IP/OP $24.42 $18.07 $0.00 $18.82 $0.00 $0.00 $0.00 $0.00 $0.00 $18.12 $18.12 $18.82 $0.00 $5.09 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34713 ERX HCPCS 25000001 65162-0416-03 BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL SUBL BOTH IP/OP $24.42 $18.07 $0.00 $18.82 $0.00 $0.00 $0.00 $0.00 $0.00 $18.12 $18.12 $18.82 $0.00 $5.09 $0.00 $0.00 $0.00 $0.00 $11.07 $17.53 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34714 ERX HCPCS 25000001 00054-0189-13 BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL BOTH IP/OP $43.67 $32.32 $0.00 $33.66 $0.00 $0.00 $0.00 $0.00 $0.00 $32.41 $32.41 $33.66 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $19.80 $31.36 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34714 ERX HCPCS 25000001 62175-0458-32 BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL BOTH IP/OP $43.67 $32.32 $0.00 $33.66 $0.00 $0.00 $0.00 $0.00 $0.00 $32.41 $32.41 $33.66 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $19.80 $31.36 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34714 ERX HCPCS 25000001 62756-0970-83 BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL SUBL BOTH IP/OP $43.67 $32.32 $0.00 $33.66 $0.00 $0.00 $0.00 $0.00 $0.00 $32.41 $32.41 $33.66 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $19.80 $31.36 $31.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 34814 ERX HCPCS 25000001 61314-0646-10 NEOMYCIN-POLYMYXIN-HC 3.5-10000-1 OT SOLN BOTH IP/OP $352.40 $260.78 $0.00 $271.63 $0.00 $0.00 $0.00 $0.00 $0.00 $261.55 $261.55 $271.63 $0.00 $73.44 $0.00 $0.00 $0.00 $0.00 $159.95 $253.35 $255.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35134 ERX HCPCS 63700001 27808-0156-01 ROSUVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35134 ERX HCPCS 63700001 57237-0169-90 ROSUVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35134 ERX HCPCS 63700001 57237-0169-99 ROSUVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35134 ERX HCPCS 63700001 60505-4503-09 ROSUVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35134 ERX HCPCS 63700001 68462-0262-90 ROSUVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35134 ERX HCPCS 63700001 70377-0007-12 ROSUVASTATIN CALCIUM 10 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35135 ERX HCPCS 63700001 16729-0286-15 ROSUVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35135 ERX HCPCS 63700001 27808-0157-01 ROSUVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35135 ERX HCPCS 63700001 57237-0170-90 ROSUVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35135 ERX HCPCS 63700001 57237-0170-99 ROSUVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35135 ERX HCPCS 63700001 60505-4504-09 ROSUVASTATIN CALCIUM 20 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.20 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.93 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35136 ERX HCPCS 63700001 27808-0158-01 ROSUVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.19 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35136 ERX HCPCS 63700001 51407-0156-30 ROSUVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.19 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35136 ERX HCPCS 63700001 57237-0171-05 ROSUVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.19 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35136 ERX HCPCS 63700001 57237-0171-30 ROSUVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.19 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35136 ERX HCPCS 63700001 57237-0171-90 ROSUVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.19 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35136 ERX HCPCS 63700001 68462-0264-30 ROSUVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.19 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35136 ERX HCPCS 63700001 70377-0009-11 ROSUVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.19 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35136 ERX HCPCS 63700001 72205-0005-99 ROSUVASTATIN CALCIUM 40 MG PO TABS BOTH IP/OP $37.48 $27.74 $0.00 $27.19 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $0.00 $0.00 $0.00 $0.00 $17.00 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35184 ERX HCPCS 63700001 50268-0190-15 CYCLOBENZAPRINE HCL 5 MG PO TABS BOTH IP/OP $6.88 $5.09 $0.00 $4.99 $0.00 $0.00 $0.00 $1.22 $0.00 $0.00 $0.00 $0.00 $0.00 $1.43 $0.00 $0.00 $0.00 $0.00 $3.12 $4.94 $4.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35184 ERX HCPCS 63700001 52817-0330-10 CYCLOBENZAPRINE HCL 5 MG PO TABS BOTH IP/OP $6.88 $5.09 $0.00 $4.99 $0.00 $0.00 $0.00 $1.22 $0.00 $0.00 $0.00 $0.00 $0.00 $1.43 $0.00 $0.00 $0.00 $0.00 $3.12 $4.94 $4.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35184 ERX HCPCS 63700001 69097-0845-07 CYCLOBENZAPRINE HCL 5 MG PO TABS BOTH IP/OP $6.88 $5.09 $0.00 $4.99 $0.00 $0.00 $0.00 $1.22 $0.00 $0.00 $0.00 $0.00 $0.00 $1.43 $0.00 $0.00 $0.00 $0.00 $3.12 $4.94 $4.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35209 ERX HCPCS 63700001 00023-9163-30 CYCLOSPORINE 0.05 % OP EMUL BOTH IP/OP $51.53 $38.13 $0.00 $35.61 $0.00 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 $10.74 $0.00 $0.00 $0.00 $0.00 $22.26 $35.25 $35.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35262 ERX HCPCS J7520 00008-1042-05 SIROLIMUS 2 MG PO TABS BOTH IP/OP $275.26 $203.69 $0.00 $212.17 $123.87 $123.87 $0.00 $0.00 $0.00 $57.37 $204.30 $204.30 $212.17 $0.00 $57.36 $0.00 $162.82 $162.82 $0.00 $119.54 $189.34 $191.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35263 ERX HCPCS 63700001 59572-0210-15 THALIDOMIDE 100 MG PO CAPS BOTH IP/OP $972.04 $719.31 $0.00 $705.73 $0.00 $0.00 $0.00 $173.02 $0.00 $0.00 $0.00 $0.00 $0.00 $202.57 $0.00 $0.00 $0.00 $0.00 $441.08 $698.67 $705.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35264 ERX HCPCS 63700001 59572-0220-16 THALIDOMIDE 200 MG PO CAPS BOTH IP/OP "$1,004.37 " $743.23 $0.00 $803.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.19 $795.46 $803.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35264 ERX HCPCS 63700001 59572-0220-96 THALIDOMIDE 200 MG PO CAPS BOTH IP/OP "$1,004.37 " $743.23 $0.00 $803.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.19 $795.46 $803.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35439 ERX HCPCS J2850 67066-0006-01 SECRETIN ACETATE 16 MCG IV SOLR BOTH IP/OP $26.72 $19.77 $0.00 $20.60 $0.00 $0.00 $0.00 $0.00 $0.00 $19.83 $19.83 $20.60 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $12.12 $19.19 $19.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35488 ERX HCPCS J8501 APREPITANT 80 MG PO CAPS BOTH IP/OP $594.98 $440.29 $0.00 $458.61 $267.74 $267.74 $0.00 $0.00 $0.00 $125.02 $441.59 $441.59 $458.61 $0.00 $123.99 $0.00 $351.93 $351.93 $0.00 $269.99 $427.66 $431.98 $0.00 $0.00 $84.51 $0.00 $0.00 $85.96 $0.00 $0.00 $0.00 $0.00 $0.00 35488 ERX HCPCS J8501 68462-0584-76 APREPITANT 80 MG PO CAPS BOTH IP/OP $594.98 $440.29 $0.00 $458.61 $267.74 $267.74 $0.00 $0.00 $0.00 $125.02 $441.59 $441.59 $458.61 $0.00 $123.99 $0.00 $351.93 $351.93 $0.00 $269.99 $427.66 $431.98 $0.00 $0.00 $84.51 $0.00 $0.00 $85.96 $0.00 $0.00 $0.00 $0.00 $0.00 35489 ERX HCPCS J8501 APREPITANT 125 MG PO CAPS BOTH IP/OP $585.21 $433.06 $0.00 $451.08 $263.34 $263.34 $0.00 $0.00 $0.00 $195.34 $434.34 $434.34 $451.08 $0.00 $121.96 $0.00 $346.15 $346.15 $0.00 $265.61 $420.73 $424.98 $0.00 $0.00 $83.14 $0.00 $0.00 $84.57 $0.00 $0.00 $0.00 $0.00 $0.00 35489 ERX HCPCS J8501 00781-2323-68 APREPITANT 125 MG PO CAPS BOTH IP/OP $585.21 $433.06 $0.00 $451.08 $263.34 $263.34 $0.00 $0.00 $0.00 $195.34 $434.34 $434.34 $451.08 $0.00 $121.96 $0.00 $346.15 $346.15 $0.00 $265.61 $420.73 $424.98 $0.00 $0.00 $83.14 $0.00 $0.00 $84.57 $0.00 $0.00 $0.00 $0.00 $0.00 35489 ERX HCPCS J8501 68462-0585-76 APREPITANT 125 MG PO CAPS BOTH IP/OP $585.21 $433.06 $0.00 $451.08 $263.34 $263.34 $0.00 $0.00 $0.00 $195.34 $434.34 $434.34 $451.08 $0.00 $121.96 $0.00 $346.15 $346.15 $0.00 $265.61 $420.73 $424.98 $0.00 $0.00 $83.14 $0.00 $0.00 $84.57 $0.00 $0.00 $0.00 $0.00 $0.00 35490 ERX HCPCS J8501 00006-3862-03 APREPITANT 80 & 125 MG PO MISC BOTH IP/OP $904.45 $669.29 $0.00 $697.15 $407.00 $407.00 $0.00 $0.00 $0.00 $7.81 $671.28 $671.28 $697.15 $0.00 $188.49 $0.00 $534.98 $534.98 $0.00 $410.41 $650.09 $656.66 $0.00 $0.00 $128.46 $0.00 $0.00 $130.67 $0.00 $0.00 $0.00 $0.00 $0.00 35639 ERX HCPCS 25000001 10019-0075-87 ESMOLOL HCL-SODIUM CHLORIDE 2000 MG/100ML IV SOLN BOTH IP/OP "$1,566.18 " "$1,158.97" $0.00 "$1,207.21" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,162.42" "$1,162.42" "$1,207.21" $0.00 $326.39 $0.00 $0.00 $0.00 $0.00 $725.64 "$1,149.41" "$1,161.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35639 ERX HCPCS 25000001 25021-0309-82 ESMOLOL HCL-SODIUM CHLORIDE 2000 MG/100ML IV SOLN BOTH IP/OP "$1,566.18 " "$1,158.97" $0.00 "$1,207.21" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,162.42" "$1,162.42" "$1,207.21" $0.00 $326.39 $0.00 $0.00 $0.00 $0.00 $725.64 "$1,149.41" "$1,161.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35640 ERX HCPCS J3489 00409-4215-01 ZOLEDRONIC ACID 4 MG/5ML IV CONC BOTH IP/OP $183.22 $135.58 $0.00 $141.23 $82.45 $82.45 $0.00 $0.00 $0.00 $38.19 $135.99 $135.99 $141.23 $0.00 $38.76 $0.00 $108.37 $108.37 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $51.14 $0.00 $0.00 $48.69 $0.00 $0.00 $0.00 $0.00 $0.00 35640 ERX HCPCS J3489 25021-0801-66 ZOLEDRONIC ACID 4 MG/5ML IV CONC BOTH IP/OP $183.22 $135.58 $0.00 $141.23 $82.45 $82.45 $0.00 $0.00 $0.00 $38.19 $135.99 $135.99 $141.23 $0.00 $38.76 $0.00 $108.37 $108.37 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $51.14 $0.00 $0.00 $48.69 $0.00 $0.00 $0.00 $0.00 $0.00 35640 ERX HCPCS J3489 55111-0685-07 ZOLEDRONIC ACID 4 MG/5ML IV CONC BOTH IP/OP $183.22 $135.58 $0.00 $141.23 $82.45 $82.45 $0.00 $0.00 $0.00 $38.19 $135.99 $135.99 $141.23 $0.00 $38.76 $0.00 $108.37 $108.37 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $51.14 $0.00 $0.00 $48.69 $0.00 $0.00 $0.00 $0.00 $0.00 35640 ERX HCPCS J3489 63323-0961-98 ZOLEDRONIC ACID 4 MG/5ML IV CONC BOTH IP/OP $183.22 $135.58 $0.00 $141.23 $82.45 $82.45 $0.00 $0.00 $0.00 $38.19 $135.99 $135.99 $141.23 $0.00 $38.76 $0.00 $108.37 $108.37 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $51.14 $0.00 $0.00 $48.69 $0.00 $0.00 $0.00 $0.00 $0.00 35640 ERX HCPCS J3489 67457-0390-54 ZOLEDRONIC ACID 4 MG/5ML IV CONC BOTH IP/OP $183.22 $135.58 $0.00 $141.23 $82.45 $82.45 $0.00 $0.00 $0.00 $38.19 $135.99 $135.99 $141.23 $0.00 $38.76 $0.00 $108.37 $108.37 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $51.14 $0.00 $0.00 $48.69 $0.00 $0.00 $0.00 $0.00 $0.00 35687 ERX HCPCS 63700001 00781-5311-08 RISPERIDONE 1 MG PO TBDP BOTH IP/OP $56.09 $41.51 $0.00 $44.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.05 $44.42 $44.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35687 ERX HCPCS 63700001 49884-0315-91 RISPERIDONE 1 MG PO TBDP BOTH IP/OP $56.09 $41.51 $0.00 $44.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.05 $44.42 $44.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35688 ERX HCPCS 63700001 49884-0401-91 RISPERIDONE 2 MG PO TBDP BOTH IP/OP $84.00 $62.16 $0.00 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.00 $66.53 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35699 ERX HCPCS 25000001 00065-4013-03 MOXIFLOXACIN HCL 0.5 % OP SOLN BOTH IP/OP $585.75 $433.46 $0.00 $451.50 $0.00 $0.00 $0.00 $0.00 $0.00 $434.74 $434.74 $451.50 $0.00 $122.07 $0.00 $0.00 $0.00 $0.00 $265.86 $421.11 $425.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35699 ERX HCPCS 25000001 00781-7135-93 MOXIFLOXACIN HCL 0.5 % OP SOLN BOTH IP/OP $585.75 $433.46 $0.00 $451.50 $0.00 $0.00 $0.00 $0.00 $0.00 $434.74 $434.74 $451.50 $0.00 $122.07 $0.00 $0.00 $0.00 $0.00 $265.86 $421.11 $425.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35699 ERX HCPCS 25000001 60505-0582-04 MOXIFLOXACIN HCL 0.5 % OP SOLN BOTH IP/OP $585.75 $433.46 $0.00 $451.50 $0.00 $0.00 $0.00 $0.00 $0.00 $434.74 $434.74 $451.50 $0.00 $122.07 $0.00 $0.00 $0.00 $0.00 $265.86 $421.11 $425.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35699 ERX HCPCS 25000001 65862-0840-03 MOXIFLOXACIN HCL 0.5 % OP SOLN BOTH IP/OP $585.75 $433.46 $0.00 $451.50 $0.00 $0.00 $0.00 $0.00 $0.00 $434.74 $434.74 $451.50 $0.00 $122.07 $0.00 $0.00 $0.00 $0.00 $265.86 $421.11 $425.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35780 ERX HCPCS 63700001 00310-0482-30 GEFITINIB 250 MG PO TABS BOTH IP/OP $909.75 $673.22 $0.00 $660.50 $0.00 $0.00 $0.00 $161.94 $0.00 $0.00 $0.00 $0.00 $0.00 $189.59 $0.00 $0.00 $0.00 $0.00 $412.82 $653.90 $660.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35942 ERX HCPCS 63700001 00245-5317-01 KCL CRYS ER 10 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35942 ERX HCPCS 63700001 00245-5317-89 KCL CRYS ER 10 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35942 ERX HCPCS 63700001 63739-0446-10 KCL CRYS ER 10 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35942 ERX HCPCS 63700001 66758-0170-13 KCL CRYS ER 10 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35943 ERX HCPCS 63700001 00245-5319-01 POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35943 ERX HCPCS 63700001 00245-5319-89 POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35943 ERX HCPCS 63700001 00781-5720-01 POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35943 ERX HCPCS 63700001 00781-5720-10 POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35943 ERX HCPCS 63700001 63739-0447-10 POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35943 ERX HCPCS 63700001 66758-0190-13 POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35943 ERX HCPCS 63700001 68084-0360-09 POTASSIUM CHLORIDE CRYS ER 20 MEQ PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35957 ERX HCPCS 63700001 00046-1106-11 CONJ ESTROG-MEDROXYPROGEST ACE 0.45-1.5 MG PO TABS BOTH IP/OP $40.16 $29.72 $0.00 $26.42 $0.00 $0.00 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $0.00 $8.37 $0.00 $0.00 $0.00 $0.00 $16.52 $26.16 $26.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36046 ERX HCPCS J3480 00338-0704-34 POTASSIUM CHLORIDE IN NACL 20-0.45 MEQ/L-% IV SOLN BOTH IP/OP $33.52 $24.80 $0.00 $25.84 $15.08 $15.08 $0.00 $0.00 $0.00 $0.24 $24.88 $24.88 $25.84 $0.00 $1.69 $0.00 $19.83 $19.83 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $1.65 $0.00 $0.00 $1.57 $0.00 $0.00 $0.00 $0.00 $0.00 36092 ERX HCPCS 63700001 00078-0649-30 IMATINIB MESYLATE 400 MG PO TABS BOTH IP/OP "$1,182.30 " $874.90 $0.00 $858.38 $0.00 $0.00 $0.00 $210.45 $0.00 $0.00 $0.00 $0.00 $0.00 $246.39 $0.00 $0.00 $0.00 $0.00 $536.49 $849.80 $858.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36092 ERX HCPCS 63700001 16714-0705-01 IMATINIB MESYLATE 400 MG PO TABS BOTH IP/OP "$1,182.30 " $874.90 $0.00 $858.38 $0.00 $0.00 $0.00 $210.45 $0.00 $0.00 $0.00 $0.00 $0.00 $246.39 $0.00 $0.00 $0.00 $0.00 $536.49 $849.80 $858.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36092 ERX HCPCS 63700001 60505-2901-03 IMATINIB MESYLATE 400 MG PO TABS BOTH IP/OP "$1,182.30 " $874.90 $0.00 $858.38 $0.00 $0.00 $0.00 $210.45 $0.00 $0.00 $0.00 $0.00 $0.00 $246.39 $0.00 $0.00 $0.00 $0.00 $536.49 $849.80 $858.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36149 ERX HCPCS 63700001 00003-3624-12 ATAZANAVIR SULFATE 150 MG PO CAPS BOTH IP/OP $203.10 $150.29 $0.00 $147.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.33 $0.00 $0.00 $0.00 $0.00 $92.19 $146.02 $147.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36149 ERX HCPCS 63700001 16714-0860-01 ATAZANAVIR SULFATE 150 MG PO CAPS BOTH IP/OP $203.10 $150.29 $0.00 $147.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.33 $0.00 $0.00 $0.00 $0.00 $92.19 $146.02 $147.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36150 ERX HCPCS 63700001 00003-3631-12 ATAZANAVIR SULFATE 200 MG PO CAPS BOTH IP/OP $203.10 $150.29 $0.00 $147.50 $0.00 $0.00 $0.00 $36.15 $0.00 $0.00 $0.00 $0.00 $0.00 $42.33 $0.00 $0.00 $0.00 $0.00 $92.19 $146.02 $147.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36150 ERX HCPCS 63700001 16714-0861-01 ATAZANAVIR SULFATE 200 MG PO CAPS BOTH IP/OP $203.10 $150.29 $0.00 $147.50 $0.00 $0.00 $0.00 $36.15 $0.00 $0.00 $0.00 $0.00 $0.00 $42.33 $0.00 $0.00 $0.00 $0.00 $92.19 $146.02 $147.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36150 ERX HCPCS 63700001 65862-0712-60 ATAZANAVIR SULFATE 200 MG PO CAPS BOTH IP/OP $203.10 $150.29 $0.00 $147.50 $0.00 $0.00 $0.00 $36.15 $0.00 $0.00 $0.00 $0.00 $0.00 $42.33 $0.00 $0.00 $0.00 $0.00 $92.19 $146.02 $147.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36198 ERX HCPCS 63700001 00046-1101-81 ESTROGENS CONJUGATED 0.45 MG PO TABS BOTH IP/OP $32.11 $23.76 $0.00 $21.54 $0.00 $0.00 $0.00 $5.72 $0.00 $0.00 $0.00 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $13.47 $21.33 $21.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36252 ERX HCPCS 63700001 61958-0601-01 EMTRICITABINE 200 MG PO CAPS BOTH IP/OP $80.93 $59.89 $0.00 $58.71 $0.00 $0.00 $0.00 $14.41 $0.00 $0.00 $0.00 $0.00 $0.00 $16.87 $0.00 $0.00 $0.00 $0.00 $36.70 $58.12 $58.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36252 ERX HCPCS 63700001 69097-0642-02 EMTRICITABINE 200 MG PO CAPS BOTH IP/OP $80.93 $59.89 $0.00 $58.71 $0.00 $0.00 $0.00 $14.41 $0.00 $0.00 $0.00 $0.00 $0.00 $16.87 $0.00 $0.00 $0.00 $0.00 $36.70 $58.12 $58.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36438 ERX HCPCS 63700001 00904-6656-40 ARIPIPRAZOLE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $89.11 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $55.70 $88.22 $89.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36438 ERX HCPCS 63700001 16714-0784-01 ARIPIPRAZOLE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $89.11 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $55.70 $88.22 $89.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36438 ERX HCPCS 63700001 33342-0123-07 ARIPIPRAZOLE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $89.11 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $55.70 $88.22 $89.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36438 ERX HCPCS 63700001 43598-0555-30 ARIPIPRAZOLE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $89.11 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $55.70 $88.22 $89.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36438 ERX HCPCS 63700001 65862-0662-30 ARIPIPRAZOLE 5 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $89.11 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $55.70 $88.22 $89.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36576 ERX HCPCS 25000001 00065-8533-02 CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP BOTH IP/OP $785.54 $581.30 $0.00 $605.49 $0.00 $0.00 $0.00 $0.00 $0.00 $583.03 $583.03 $605.49 $0.00 $163.71 $0.00 $0.00 $0.00 $0.00 $356.45 $564.62 $570.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36576 ERX HCPCS 25000001 00781-6186-67 CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP BOTH IP/OP $785.54 $581.30 $0.00 $605.49 $0.00 $0.00 $0.00 $0.00 $0.00 $583.03 $583.03 $605.49 $0.00 $163.71 $0.00 $0.00 $0.00 $0.00 $356.45 $564.62 $570.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36576 ERX HCPCS 25000001 43598-0326-75 CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT SUSP BOTH IP/OP $785.54 $581.30 $0.00 $605.49 $0.00 $0.00 $0.00 $0.00 $0.00 $583.03 $583.03 $605.49 $0.00 $163.71 $0.00 $0.00 $0.00 $0.00 $356.45 $564.62 $570.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36590 ERX HCPCS 25000001 00121-0799-16 LEVETIRACETAM 100 MG/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36590 ERX HCPCS 25000001 00472-0235-16 LEVETIRACETAM 100 MG/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36590 ERX HCPCS 25000001 16714-0358-01 LEVETIRACETAM 100 MG/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36590 ERX HCPCS 25000001 50383-0241-16 LEVETIRACETAM 100 MG/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36590 ERX HCPCS 25000001 50474-0001-48 LEVETIRACETAM 100 MG/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36590 ERX HCPCS 25000001 51991-0651-16 LEVETIRACETAM 100 MG/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36590 ERX HCPCS 25000001 99999-6012-25 LEVETIRACETAM 100 MG/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36590 ERX HCPCS 25000001 99999-6004-94 LEVETIRACETAM 100 MG/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $106.78 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $106.78 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36612 ERX HCPCS 63700001 00310-0755-90 ROSUVASTATIN CALCIUM 5 MG PO TABS BOTH IP/OP $46.35 $34.30 $0.00 $33.63 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $21.02 $33.30 $33.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36612 ERX HCPCS 63700001 16714-0988-01 ROSUVASTATIN CALCIUM 5 MG PO TABS BOTH IP/OP $46.35 $34.30 $0.00 $33.63 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $21.02 $33.30 $33.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36612 ERX HCPCS 63700001 27808-0155-01 ROSUVASTATIN CALCIUM 5 MG PO TABS BOTH IP/OP $46.35 $34.30 $0.00 $33.63 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $21.02 $33.30 $33.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36612 ERX HCPCS 63700001 60505-4502-09 ROSUVASTATIN CALCIUM 5 MG PO TABS BOTH IP/OP $46.35 $34.30 $0.00 $33.63 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $21.02 $33.30 $33.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36612 ERX HCPCS 63700001 68462-0261-90 ROSUVASTATIN CALCIUM 5 MG PO TABS BOTH IP/OP $46.35 $34.30 $0.00 $33.63 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $21.02 $33.30 $33.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36612 ERX HCPCS 63700001 70377-0006-12 ROSUVASTATIN CALCIUM 5 MG PO TABS BOTH IP/OP $46.35 $34.30 $0.00 $33.63 $0.00 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $21.02 $33.30 $33.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36631 ERX HCPCS 25000001 00023-9277-05 KETOROLAC TROMETHAMINE 0.4 % OP SOLN BOTH IP/OP $992.16 $734.20 $0.00 $764.76 $0.00 $0.00 $0.00 $0.00 $0.00 $736.38 $736.38 $764.76 $0.00 $206.77 $0.00 $0.00 $0.00 $0.00 $428.77 $679.17 $686.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36631 ERX HCPCS 25000001 60758-0773-05 KETOROLAC TROMETHAMINE 0.4 % OP SOLN BOTH IP/OP $992.16 $734.20 $0.00 $764.76 $0.00 $0.00 $0.00 $0.00 $0.00 $736.38 $736.38 $764.76 $0.00 $206.77 $0.00 $0.00 $0.00 $0.00 $428.77 $679.17 $686.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36775 ERX HCPCS 63700001 00187-0730-90 BUPROPION HCL ER (XL) 150 MG PO TB24 BOTH IP/OP $21.88 $16.19 $0.00 $15.87 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $0.00 $4.56 $0.00 $0.00 $0.00 $0.00 $9.92 $15.71 $15.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36775 ERX HCPCS 63700001 10370-0101-03 BUPROPION HCL ER (XL) 150 MG PO TB24 BOTH IP/OP $21.88 $16.19 $0.00 $15.87 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $0.00 $4.56 $0.00 $0.00 $0.00 $0.00 $9.92 $15.71 $15.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36775 ERX HCPCS 63700001 16729-0443-15 BUPROPION HCL ER (XL) 150 MG PO TB24 BOTH IP/OP $21.88 $16.19 $0.00 $15.87 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $0.00 $4.56 $0.00 $0.00 $0.00 $0.00 $9.92 $15.71 $15.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36775 ERX HCPCS 63700001 69097-0875-02 BUPROPION HCL ER (XL) 150 MG PO TB24 BOTH IP/OP $21.88 $16.19 $0.00 $15.87 $0.00 $0.00 $0.00 $3.89 $0.00 $0.00 $0.00 $0.00 $0.00 $4.56 $0.00 $0.00 $0.00 $0.00 $9.92 $15.71 $15.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36776 ERX HCPCS 63700001 10370-0102-03 BUPROPION HCL ER (XL) 300 MG PO TB24 BOTH IP/OP $19.98 $14.79 $0.00 $14.50 $0.00 $0.00 $0.00 $3.56 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.06 $14.35 $14.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36776 ERX HCPCS 63700001 16729-0444-10 BUPROPION HCL ER (XL) 300 MG PO TB24 BOTH IP/OP $19.98 $14.79 $0.00 $14.50 $0.00 $0.00 $0.00 $3.56 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.06 $14.35 $14.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36776 ERX HCPCS 63700001 68180-0320-09 BUPROPION HCL ER (XL) 300 MG PO TB24 BOTH IP/OP $19.98 $14.79 $0.00 $14.50 $0.00 $0.00 $0.00 $3.56 $0.00 $0.00 $0.00 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $9.06 $14.35 $14.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36962 ERX HCPCS 63700001 00121-0544-10 DOCUSATE SODIUM 50 MG/5ML PO LIQD BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36962 ERX HCPCS 63700001 50383-0771-16 DOCUSATE SODIUM 50 MG/5ML PO LIQD BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36962 ERX HCPCS 63700001 99999-6006-70 DOCUSATE SODIUM 50 MG/5ML PO LIQD BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36966 ERX HCPCS 63700001 00456-3210-63 MEMANTINE HCL 10 MG PO TABS BOTH IP/OP $33.80 $25.01 $0.00 $27.04 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.77 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36966 ERX HCPCS 63700001 00904-6506-61 MEMANTINE HCL 10 MG PO TABS BOTH IP/OP $33.80 $25.01 $0.00 $27.04 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.77 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36966 ERX HCPCS 63700001 55111-0597-60 MEMANTINE HCL 10 MG PO TABS BOTH IP/OP $33.80 $25.01 $0.00 $27.04 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.77 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36976 ERX HCPCS 25000001 00904-6305-21 PHENOL 1.4 % MT LIQD BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36976 ERX HCPCS 25000001 49348-0991-36 PHENOL 1.4 % MT LIQD BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36982 ERX HCPCS 25000001 47335-0956-88 ALFUZOSIN HCL ER 10 MG PO TB24 BOTH IP/OP $17.66 $13.07 $0.00 $13.61 $0.00 $0.00 $0.00 $0.00 $0.00 $13.11 $13.11 $13.61 $0.00 $3.68 $0.00 $0.00 $0.00 $0.00 $8.01 $12.69 $12.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36983 ERX HCPCS 63700001 00185-5368-30 EPLERENONE 25 MG PO TABS BOTH IP/OP $18.19 $13.46 $0.00 $13.19 $0.00 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $8.25 $13.06 $13.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36983 ERX HCPCS 63700001 00378-1030-93 EPLERENONE 25 MG PO TABS BOTH IP/OP $18.19 $13.46 $0.00 $13.19 $0.00 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $8.25 $13.06 $13.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36984 ERX HCPCS 63700001 00185-5369-30 EPLERENONE 50 MG PO TABS BOTH IP/OP $18.19 $13.46 $0.00 $13.20 $0.00 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $8.25 $13.07 $13.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36984 ERX HCPCS 63700001 00378-1031-93 EPLERENONE 50 MG PO TABS BOTH IP/OP $18.19 $13.46 $0.00 $13.20 $0.00 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $8.25 $13.07 $13.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36986 ERX HCPCS 63700001 00002-4464-30 TADALAFIL 20 MG PO TABS BOTH IP/OP $560.45 $414.73 $0.00 $406.99 $0.00 $0.00 $0.00 $99.76 $0.00 $0.00 $0.00 $0.00 $0.00 $116.80 $0.00 $0.00 $0.00 $0.00 $254.37 $402.92 $406.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36987 ERX HCPCS 63700001 62756-0258-02 ZONISAMIDE 25 MG PO CAPS BOTH IP/OP $50.13 $37.10 $0.00 $40.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.07 $39.70 $40.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36987 ERX HCPCS 63700001 68462-0128-01 ZONISAMIDE 25 MG PO CAPS BOTH IP/OP $50.13 $37.10 $0.00 $40.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.07 $39.70 $40.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36988 ERX HCPCS 63700001 62756-0259-02 ZONISAMIDE 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36988 ERX HCPCS 63700001 68462-0129-01 ZONISAMIDE 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36989 ERX HCPCS J0878 00143-9378-01 DAPTOMYCIN 500 MG IV SOLR BOTH IP/OP $261.43 $193.46 $0.00 $367.64 $117.64 $117.64 $0.00 $0.00 $0.00 $223.25 $194.03 $194.03 $201.51 $0.00 $33.49 $0.00 $154.64 $154.64 $173.25 $229.78 $363.96 $367.64 $239.25 $239.25 $170.38 $0.00 $0.00 $162.23 $68.00 $0.00 $0.00 $0.00 $0.00 36989 ERX HCPCS J0878 25021-0174-15 DAPTOMYCIN 500 MG IV SOLR BOTH IP/OP $261.43 $193.46 $0.00 $367.64 $117.64 $117.64 $0.00 $0.00 $0.00 $223.25 $194.03 $194.03 $201.51 $0.00 $33.49 $0.00 $154.64 $154.64 $173.25 $229.78 $363.96 $367.64 $239.25 $239.25 $170.38 $0.00 $0.00 $162.23 $68.00 $0.00 $0.00 $0.00 $0.00 36989 ERX HCPCS J0878 63323-0371-10 DAPTOMYCIN 500 MG IV SOLR BOTH IP/OP $261.43 $193.46 $0.00 $367.64 $117.64 $117.64 $0.00 $0.00 $0.00 $223.25 $194.03 $194.03 $201.51 $0.00 $33.49 $0.00 $154.64 $154.64 $173.25 $229.78 $363.96 $367.64 $239.25 $239.25 $170.38 $0.00 $0.00 $162.23 $68.00 $0.00 $0.00 $0.00 $0.00 36989 ERX HCPCS J0878 63323-0371-19 DAPTOMYCIN 500 MG IV SOLR BOTH IP/OP $261.43 $193.46 $0.00 $367.64 $117.64 $117.64 $0.00 $0.00 $0.00 $223.25 $194.03 $194.03 $201.51 $0.00 $33.49 $0.00 $154.64 $154.64 $173.25 $229.78 $363.96 $367.64 $239.25 $239.25 $170.38 $0.00 $0.00 $162.23 $68.00 $0.00 $0.00 $0.00 $0.00 36989 ERX HCPCS J0878 63323-0871-15 DAPTOMYCIN 500 MG IV SOLR BOTH IP/OP $261.43 $193.46 $0.00 $367.64 $117.64 $117.64 $0.00 $0.00 $0.00 $223.25 $194.03 $194.03 $201.51 $0.00 $33.49 $0.00 $154.64 $154.64 $173.25 $229.78 $363.96 $367.64 $239.25 $239.25 $170.38 $0.00 $0.00 $162.23 $68.00 $0.00 $0.00 $0.00 $0.00 36989 ERX HCPCS J0878 67919-0011-01 DAPTOMYCIN 500 MG IV SOLR BOTH IP/OP $261.43 $193.46 $0.00 $367.64 $117.64 $117.64 $0.00 $0.00 $0.00 $223.25 $194.03 $194.03 $201.51 $0.00 $33.49 $0.00 $154.64 $154.64 $173.25 $229.78 $363.96 $367.64 $239.25 $239.25 $170.38 $0.00 $0.00 $162.23 $68.00 $0.00 $0.00 $0.00 $0.00 37170 ERX HCPCS 63700001 00456-3205-11 MEMANTINE HCL 5 MG PO TABS BOTH IP/OP $33.79 $25.00 $0.00 $27.03 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.76 $27.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37170 ERX HCPCS 63700001 00456-3205-60 MEMANTINE HCL 5 MG PO TABS BOTH IP/OP $33.79 $25.00 $0.00 $27.03 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.76 $27.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37170 ERX HCPCS 63700001 00456-3205-63 MEMANTINE HCL 5 MG PO TABS BOTH IP/OP $33.79 $25.00 $0.00 $27.03 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.76 $27.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37170 ERX HCPCS 63700001 53746-0173-60 MEMANTINE HCL 5 MG PO TABS BOTH IP/OP $33.79 $25.00 $0.00 $27.03 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.76 $27.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37170 ERX HCPCS 63700001 60687-0173-11 MEMANTINE HCL 5 MG PO TABS BOTH IP/OP $33.79 $25.00 $0.00 $27.03 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.76 $27.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37170 ERX HCPCS 63700001 60687-0173-57 MEMANTINE HCL 5 MG PO TABS BOTH IP/OP $33.79 $25.00 $0.00 $27.03 $0.00 $0.00 $0.00 $6.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.90 $26.76 $27.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37182 ERX HCPCS 63700001 49702-0207-18 FOSAMPRENAVIR CALCIUM 700 MG PO TABS BOTH IP/OP $89.45 $66.19 $0.00 $64.88 $0.00 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 $18.64 $0.00 $0.00 $0.00 $0.00 $40.55 $64.23 $64.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37459 ERX HCPCS 63700001 00046-1105-11 CONJ ESTROG-MEDROXYPROGEST ACE 0.3-1.5 MG PO TABS BOTH IP/OP $783.51 $579.80 $0.00 $515.90 $0.00 $0.00 $0.00 $139.46 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $0.00 $0.00 $0.00 $0.00 $322.44 $510.74 $515.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37482 ERX HCPCS 63700001 00245-0036-42 CHOLESTYRAMINE LIGHT 4 G PO PACK BOTH IP/OP $21.42 $15.85 $0.00 $15.54 $0.00 $0.00 $0.00 $3.81 $0.00 $0.00 $0.00 $0.00 $0.00 $4.46 $0.00 $0.00 $0.00 $0.00 $9.71 $15.38 $15.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37482 ERX HCPCS 63700001 00245-0036-89 CHOLESTYRAMINE LIGHT 4 G PO PACK BOTH IP/OP $21.42 $15.85 $0.00 $15.54 $0.00 $0.00 $0.00 $3.81 $0.00 $0.00 $0.00 $0.00 $0.00 $4.46 $0.00 $0.00 $0.00 $0.00 $9.71 $15.38 $15.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37579 ERX HCPCS 25000001 00065-0795-15 BSS IO SOLN BOTH IP/OP $51.35 $38.00 $0.00 $41.57 $0.00 $0.00 $0.00 $0.00 $0.00 $40.03 $40.03 $41.57 $0.00 $10.70 $0.00 $0.00 $0.00 $0.00 $22.61 $35.81 $36.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37616 ERX HCPCS 63700001 29300-0116-16 TOPIRAMATE 50 MG PO TABS BOTH IP/OP $19.38 $14.34 $0.00 $15.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.69 $15.35 $15.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37616 ERX HCPCS 63700001 68382-0139-14 TOPIRAMATE 50 MG PO TABS BOTH IP/OP $19.38 $14.34 $0.00 $15.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.69 $15.35 $15.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37616 ERX HCPCS 63700001 69097-0123-03 TOPIRAMATE 50 MG PO TABS BOTH IP/OP $19.38 $14.34 $0.00 $15.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.69 $15.35 $15.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37616 ERX HCPCS 63700001 69097-0817-03 TOPIRAMATE 50 MG PO TABS BOTH IP/OP $19.38 $14.34 $0.00 $15.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.69 $15.35 $15.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37630 ERX HCPCS 63700001 45802-0040-64 SELENIUM SULFIDE 2.5 % EX LOTN BOTH IP/OP $82.97 $61.40 $0.00 $60.27 $0.00 $0.00 $0.00 $14.77 $0.00 $0.00 $0.00 $0.00 $0.00 $17.29 $0.00 $0.00 $0.00 $0.00 $37.67 $59.59 $60.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37630 ERX HCPCS 63700001 60432-0528-04 SELENIUM SULFIDE 2.5 % EX LOTN BOTH IP/OP $82.97 $61.40 $0.00 $60.27 $0.00 $0.00 $0.00 $14.77 $0.00 $0.00 $0.00 $0.00 $0.00 $17.29 $0.00 $0.00 $0.00 $0.00 $37.67 $59.67 $60.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37630 ERX HCPCS 63700001 60432-0528-05 SELENIUM SULFIDE 2.5 % EX LOTN BOTH IP/OP $82.97 $61.40 $0.00 $60.27 $0.00 $0.00 $0.00 $14.77 $0.00 $0.00 $0.00 $0.00 $0.00 $17.29 $0.00 $0.00 $0.00 $0.00 $37.67 $59.67 $60.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37635 ERX HCPCS 63700001 43547-0280-10 ESCITALOPRAM OXALATE 5 MG PO TABS BOTH IP/OP $17.39 $12.87 $0.00 $12.62 $0.00 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 $3.62 $0.00 $0.00 $0.00 $0.00 $7.89 $12.49 $12.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37637 ERX HCPCS 63700001 00378-0018-01 METOPROLOL TARTRATE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37637 ERX HCPCS 63700001 51079-0255-01 METOPROLOL TARTRATE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37637 ERX HCPCS 63700001 51079-0255-20 METOPROLOL TARTRATE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37637 ERX HCPCS 63700001 52817-0360-10 METOPROLOL TARTRATE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37637 ERX HCPCS 63700001 57664-0506-52 METOPROLOL TARTRATE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37637 ERX HCPCS 63700001 62332-0112-31 METOPROLOL TARTRATE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37637 ERX HCPCS 63700001 62584-0265-01 METOPROLOL TARTRATE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37637 ERX HCPCS 63700001 62584-0265-11 METOPROLOL TARTRATE 25 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37642 ERX HCPCS 63700001 00009-0760-04 CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR BOTH IP/OP $143.60 $106.26 $0.00 $102.48 $0.00 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $64.05 $101.46 $102.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37642 ERX HCPCS 63700001 00574-0129-01 CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR BOTH IP/OP $143.60 $106.26 $0.00 $102.48 $0.00 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $64.05 $101.46 $102.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37642 ERX HCPCS 63700001 16714-0483-01 CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR BOTH IP/OP $143.60 $106.26 $0.00 $102.48 $0.00 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $64.05 $101.46 $102.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37642 ERX HCPCS 63700001 59762-0016-01 CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR BOTH IP/OP $143.60 $106.26 $0.00 $102.48 $0.00 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $64.05 $101.46 $102.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37642 ERX HCPCS 63700001 64980-0511-10 CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR BOTH IP/OP $143.60 $106.26 $0.00 $102.48 $0.00 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $64.05 $101.46 $102.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37642 ERX HCPCS 63700001 65862-0596-01 CLINDAMYCIN PALMITATE HCL 75 MG/5ML PO SOLR BOTH IP/OP $143.60 $106.26 $0.00 $102.48 $0.00 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $64.05 $101.46 $102.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37643 ERX HCPCS 63700001 00378-1258-91 PROPAFENONE HCL ER 225 MG PO CP12 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37643 ERX HCPCS 63700001 49884-0113-02 PROPAFENONE HCL ER 225 MG PO CP12 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37644 ERX HCPCS 63700001 49884-0210-02 PROPAFENONE HCL ER 325 MG PO CP12 BOTH IP/OP $41.90 $31.01 $0.00 $30.40 $0.00 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37644 ERX HCPCS 63700001 66993-0115-60 PROPAFENONE HCL ER 325 MG PO CP12 BOTH IP/OP $41.90 $31.01 $0.00 $30.40 $0.00 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37644 ERX HCPCS 63700001 68462-0409-60 PROPAFENONE HCL ER 325 MG PO CP12 BOTH IP/OP $41.90 $31.01 $0.00 $30.40 $0.00 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37645 ERX HCPCS 63700001 49884-0211-02 PROPAFENONE HCL ER 425 MG PO CP12 BOTH IP/OP $41.90 $31.01 $0.00 $30.40 $0.00 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37645 ERX HCPCS 63700001 66993-0116-60 PROPAFENONE HCL ER 425 MG PO CP12 BOTH IP/OP $41.90 $31.01 $0.00 $30.40 $0.00 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37645 ERX HCPCS 63700001 68462-0410-60 PROPAFENONE HCL ER 425 MG PO CP12 BOTH IP/OP $41.90 $31.01 $0.00 $30.40 $0.00 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37648 ERX HCPCS 63700001 00591-0900-30 GLIPIZIDE ER 2.5 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37648 ERX HCPCS 63700001 59762-0540-01 GLIPIZIDE ER 2.5 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37648 ERX HCPCS 63700001 68084-0295-21 GLIPIZIDE ER 2.5 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37649 ERX HCPCS 63700001 68084-0111-01 GLIPIZIDE ER 5 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37649 ERX HCPCS 63700001 68084-0111-11 GLIPIZIDE ER 5 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37650 ERX HCPCS 63700001 00591-0845-10 GLIPIZIDE ER 10 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37650 ERX HCPCS 63700001 68084-0112-01 GLIPIZIDE ER 10 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37650 ERX HCPCS 63700001 68084-0112-11 GLIPIZIDE ER 10 MG PO TB24 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37651 ERX HCPCS 63700001 63824-0008-15 GUAIFENESIN ER 600 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37651 ERX HCPCS 63700001 70677-0055-01 GUAIFENESIN ER 600 MG PO TB12 BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37662 ERX HCPCS 63700001 50742-0622-01 NIFEDIPINE 90 MG PO TB24 BOTH IP/OP $12.71 $9.41 $0.00 $9.22 $0.00 $0.00 $0.00 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $2.65 $0.00 $0.00 $0.00 $0.00 $5.77 $9.13 $9.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37848 ERX HCPCS 25000001 66689-0023-01 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN BOTH IP/OP $14.88 $11.01 $0.00 $11.47 $0.00 $0.00 $0.00 $0.00 $0.00 $11.04 $11.04 $11.47 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $6.16 $9.76 $9.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37848 ERX HCPCS 25000001 66689-0023-50 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15ML PO SOLN BOTH IP/OP $14.88 $11.01 $0.00 $11.47 $0.00 $0.00 $0.00 $0.00 $0.00 $11.04 $11.04 $11.47 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $6.16 $9.76 $9.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37894 ERX HCPCS J9305 00002-7623-01 PEMETREXED DISODIUM 500 MG IV SOLR BOTH IP/OP "$10,436.55 " "$7,723.05" $0.00 "$8,285.83" "$4,837.34" "$4,837.34" "$3,801.85" "$3,801.85" "$3,801.85" "$2,832.93" "$7,978.39" "$7,978.39" "$8,285.83" "$3,746.45" "$4,402.08" "$2,435.19" "$5,145.22" "$5,145.22" "$3,647.28" "$4,549.59" "$7,206.55" "$7,279.34" "$5,036.72" "$5,036.72" "$4,158.91" $0.00 $0.00 "$3,959.99" "$3,620.25" $0.00 $0.00 $0.00 $0.00 37989 ERX HCPCS J9055 66733-0948-23 CETUXIMAB 100 MG/50ML IV SOLN BOTH IP/OP "$2,155.14 " "$1,594.80" $0.00 "$1,710.99" $998.89 $998.89 $676.18 $676.18 $676.18 $584.45 "$1,647.51" "$1,647.51" "$1,710.99" $667.05 $783.78 $433.58 "$1,062.48" "$1,062.48" $651.50 $959.76 "$1,520.26" "$1,535.62" $899.70 $899.70 $742.72 $0.00 $0.00 $707.19 $647.13 $0.00 $0.00 $0.00 $0.00 38062 ERX HCPCS J7518 00078-0385-66 MYCOPHENOLATE SODIUM 180 MG PO TBEC BOTH IP/OP $19.15 $14.17 $0.00 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.99 $0.00 $0.00 $0.00 $0.00 $8.69 $13.76 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38062 ERX HCPCS J7518 00378-4201-78 MYCOPHENOLATE SODIUM 180 MG PO TBEC BOTH IP/OP $19.15 $14.17 $0.00 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.99 $0.00 $0.00 $0.00 $0.00 $8.69 $13.76 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38062 ERX HCPCS J7518 16729-0261-29 MYCOPHENOLATE SODIUM 180 MG PO TBEC BOTH IP/OP $19.15 $14.17 $0.00 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.99 $0.00 $0.00 $0.00 $0.00 $8.69 $13.76 $13.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38063 ERX HCPCS 63700001 16729-0189-29 MYCOPHENOLATE SODIUM 360 MG PO TBEC BOTH IP/OP $38.29 $28.33 $0.00 $27.78 $0.00 $0.00 $0.00 $6.82 $0.00 $0.00 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $0.00 $0.00 $17.37 $27.51 $27.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38063 ERX HCPCS 63700001 60505-2966-07 MYCOPHENOLATE SODIUM 360 MG PO TBEC BOTH IP/OP $38.29 $28.33 $0.00 $27.78 $0.00 $0.00 $0.00 $6.82 $0.00 $0.00 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $0.00 $0.00 $17.37 $27.51 $27.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38063 ERX HCPCS 63700001 68084-0918-25 MYCOPHENOLATE SODIUM 360 MG PO TBEC BOTH IP/OP $38.29 $28.33 $0.00 $27.78 $0.00 $0.00 $0.00 $6.82 $0.00 $0.00 $0.00 $0.00 $0.00 $7.98 $0.00 $0.00 $0.00 $0.00 $17.37 $27.51 $27.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38100 ERX HCPCS 63700001 55513-0073-30 CINACALCET HCL 30 MG PO TABS BOTH IP/OP $118.31 $87.55 $0.00 $85.82 $0.00 $0.00 $0.00 $21.06 $0.00 $0.00 $0.00 $0.00 $0.00 $24.66 $0.00 $0.00 $0.00 $0.00 $53.64 $84.97 $85.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38100 ERX HCPCS 63700001 67877-0503-30 CINACALCET HCL 30 MG PO TABS BOTH IP/OP $118.31 $87.55 $0.00 $85.82 $0.00 $0.00 $0.00 $21.06 $0.00 $0.00 $0.00 $0.00 $0.00 $24.66 $0.00 $0.00 $0.00 $0.00 $53.64 $84.97 $85.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38100 ERX HCPCS 63700001 70436-0007-04 CINACALCET HCL 30 MG PO TABS BOTH IP/OP $118.31 $87.55 $0.00 $85.82 $0.00 $0.00 $0.00 $21.06 $0.00 $0.00 $0.00 $0.00 $0.00 $24.66 $0.00 $0.00 $0.00 $0.00 $53.64 $84.97 $85.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38101 ERX HCPCS 63700001 47335-0380-83 CINACALCET HCL 60 MG PO TABS BOTH IP/OP $214.61 $158.81 $0.00 $155.86 $0.00 $0.00 $0.00 $38.20 $0.00 $0.00 $0.00 $0.00 $0.00 $44.72 $0.00 $0.00 $0.00 $0.00 $97.41 $154.30 $155.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38101 ERX HCPCS 63700001 55513-0074-30 CINACALCET HCL 60 MG PO TABS BOTH IP/OP $214.61 $158.81 $0.00 $155.86 $0.00 $0.00 $0.00 $38.20 $0.00 $0.00 $0.00 $0.00 $0.00 $44.72 $0.00 $0.00 $0.00 $0.00 $97.41 $154.30 $155.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38101 ERX HCPCS 63700001 70436-0008-04 CINACALCET HCL 60 MG PO TABS BOTH IP/OP $214.61 $158.81 $0.00 $155.86 $0.00 $0.00 $0.00 $38.20 $0.00 $0.00 $0.00 $0.00 $0.00 $44.72 $0.00 $0.00 $0.00 $0.00 $97.41 $154.30 $155.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38102 ERX HCPCS 63700001 55513-0075-30 CINACALCET HCL 90 MG PO TABS BOTH IP/OP $335.91 $248.57 $0.00 $243.95 $0.00 $0.00 $0.00 $59.79 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $152.47 $241.51 $243.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38102 ERX HCPCS 63700001 69097-0412-02 CINACALCET HCL 90 MG PO TABS BOTH IP/OP $335.91 $248.57 $0.00 $243.95 $0.00 $0.00 $0.00 $59.79 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $152.47 $241.51 $243.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38224 ERX HCPCS 63700001 00228-2778-11 PROPRANOLOL HCL ER 60 MG PO CP24 BOTH IP/OP $8.63 $6.39 $0.00 $6.21 $0.00 $0.00 $0.00 $1.54 $0.00 $0.00 $0.00 $0.00 $0.00 $1.80 $0.00 $0.00 $0.00 $0.00 $3.88 $6.15 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38224 ERX HCPCS 63700001 42291-0522-01 PROPRANOLOL HCL ER 60 MG PO CP24 BOTH IP/OP $8.63 $6.39 $0.00 $6.21 $0.00 $0.00 $0.00 $1.54 $0.00 $0.00 $0.00 $0.00 $0.00 $1.80 $0.00 $0.00 $0.00 $0.00 $3.88 $6.15 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38224 ERX HCPCS 63700001 62559-0530-01 PROPRANOLOL HCL ER 60 MG PO CP24 BOTH IP/OP $8.63 $6.39 $0.00 $6.21 $0.00 $0.00 $0.00 $1.54 $0.00 $0.00 $0.00 $0.00 $0.00 $1.80 $0.00 $0.00 $0.00 $0.00 $3.88 $6.15 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38225 ERX HCPCS 63700001 00228-2779-11 PROPRANOLOL HCL ER 80 MG PO CP24 BOTH IP/OP $9.56 $7.07 $0.00 $6.94 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $4.34 $6.87 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38225 ERX HCPCS 63700001 42291-0523-01 PROPRANOLOL HCL ER 80 MG PO CP24 BOTH IP/OP $9.56 $7.07 $0.00 $6.94 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $4.34 $6.87 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38225 ERX HCPCS 63700001 42291-0523-10 PROPRANOLOL HCL ER 80 MG PO CP24 BOTH IP/OP $9.56 $7.07 $0.00 $6.94 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $4.34 $6.87 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38225 ERX HCPCS 63700001 62559-0531-01 PROPRANOLOL HCL ER 80 MG PO CP24 BOTH IP/OP $9.56 $7.07 $0.00 $6.94 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $4.34 $6.87 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38226 ERX HCPCS 63700001 00228-2780-11 PROPRANOLOL HCL ER 120 MG PO CP24 BOTH IP/OP $12.50 $9.25 $0.00 $9.07 $0.00 $0.00 $0.00 $2.23 $0.00 $0.00 $0.00 $0.00 $0.00 $2.61 $0.00 $0.00 $0.00 $0.00 $5.67 $8.98 $9.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38227 ERX HCPCS 63700001 00228-2781-11 PROPRANOLOL HCL ER 160 MG PO CP24 BOTH IP/OP $9.56 $7.07 $0.00 $7.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.78 $7.57 $7.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38227 ERX HCPCS 63700001 62559-0533-01 PROPRANOLOL HCL ER 160 MG PO CP24 BOTH IP/OP $9.56 $7.07 $0.00 $7.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.78 $7.57 $7.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38245 ERX HCPCS 63700001 50383-0779-31 LACTULOSE 10 GM/15ML SOLN BOTH IP/OP $6.23 $4.61 $0.00 $4.80 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38245 ERX HCPCS 63700001 50383-0779-16 LACTULOSE 10 GM/15ML SOLN BOTH IP/OP $6.23 $4.61 $0.00 $100.96 $0.00 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.00 $100.96 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38263 ERX HCPCS 25000001 00002-7597-01 OLANZAPINE 10 MG IM SOLR BOTH IP/OP $43.48 $32.18 $0.00 $33.51 $0.00 $0.00 $0.00 $0.00 $0.00 $32.27 $32.27 $33.51 $0.00 $9.06 $0.00 $0.00 $0.00 $0.00 $19.72 $31.23 $31.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38263 ERX HCPCS 25000001 00517-0955-01 OLANZAPINE 10 MG IM SOLR BOTH IP/OP $43.48 $32.18 $0.00 $33.51 $0.00 $0.00 $0.00 $0.00 $0.00 $32.27 $32.27 $33.51 $0.00 $9.06 $0.00 $0.00 $0.00 $0.00 $19.72 $31.23 $31.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38263 ERX HCPCS 25000001 00781-3159-72 OLANZAPINE 10 MG IM SOLR BOTH IP/OP $43.48 $32.18 $0.00 $33.51 $0.00 $0.00 $0.00 $0.00 $0.00 $32.27 $32.27 $33.51 $0.00 $9.06 $0.00 $0.00 $0.00 $0.00 $19.72 $31.23 $31.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38270 ERX HCPCS J9070 00781-3244-94 CYCLOPHOSPHAMIDE 1 G IJ SOLR BOTH IP/OP "$2,276.61 " "$1,684.69" $0.00 "$1,754.81" "$1,024.47" "$1,024.47" $274.73 $274.73 $274.73 $474.50 "$1,689.70" "$1,689.70" "$1,754.81" $291.53 $342.55 $189.49 "$1,122.37" "$1,122.37" $358.46 "$1,054.80" "$1,670.80" "$1,687.68" $495.02 $495.02 $390.57 $0.00 $0.00 $371.89 $345.66 $0.00 $0.00 $0.00 $0.00 38270 ERX HCPCS J9070 10019-0956-01 CYCLOPHOSPHAMIDE 1 G IJ SOLR BOTH IP/OP "$2,276.61 " "$1,684.69" $0.00 "$1,754.81" "$1,024.47" "$1,024.47" $274.73 $274.73 $274.73 $474.50 "$1,689.70" "$1,689.70" "$1,754.81" $291.53 $342.55 $189.49 "$1,122.37" "$1,122.37" $358.46 "$1,054.80" "$1,670.80" "$1,687.68" $495.02 $495.02 $390.57 $0.00 $0.00 $371.89 $345.66 $0.00 $0.00 $0.00 $0.00 38270 ERX HCPCS J9070 16714-0857-01 CYCLOPHOSPHAMIDE 1 G IJ SOLR BOTH IP/OP "$2,276.61 " "$1,684.69" $0.00 "$1,754.81" "$1,024.47" "$1,024.47" $274.73 $274.73 $274.73 $474.50 "$1,689.70" "$1,689.70" "$1,754.81" $291.53 $342.55 $189.49 "$1,122.37" "$1,122.37" $358.46 "$1,054.80" "$1,670.80" "$1,687.68" $495.02 $495.02 $390.57 $0.00 $0.00 $371.89 $345.66 $0.00 $0.00 $0.00 $0.00 38270 ERX HCPCS J9070 70121-1239-01 CYCLOPHOSPHAMIDE 1 G IJ SOLR BOTH IP/OP "$2,276.61 " "$1,684.69" $0.00 "$1,754.81" "$1,024.47" "$1,024.47" $274.73 $274.73 $274.73 $474.50 "$1,689.70" "$1,689.70" "$1,754.81" $291.53 $342.55 $189.49 "$1,122.37" "$1,122.37" $358.46 "$1,054.80" "$1,670.80" "$1,687.68" $495.02 $495.02 $390.57 $0.00 $0.00 $371.89 $345.66 $0.00 $0.00 $0.00 $0.00 38271 ERX HCPCS J9070 00781-3233-94 CYCLOPHOSPHAMIDE 500 MG IJ SOLR BOTH IP/OP "$1,283.34 " $949.67 $0.00 $989.20 $577.50 $577.50 $137.37 $137.37 $137.37 $267.48 $952.49 $952.49 $989.20 $145.77 $171.27 $94.75 $759.10 $759.10 $179.23 $582.34 $922.43 $931.74 $247.51 $247.51 $195.29 $0.00 $0.00 $185.94 $172.83 $0.00 $0.00 $0.00 $0.00 38271 ERX HCPCS J9070 10019-0955-01 CYCLOPHOSPHAMIDE 500 MG IJ SOLR BOTH IP/OP "$1,283.34 " $949.67 $0.00 $989.20 $577.50 $577.50 $137.37 $137.37 $137.37 $267.48 $952.49 $952.49 $989.20 $145.77 $171.27 $94.75 $759.10 $759.10 $179.23 $582.34 $922.43 $931.74 $247.51 $247.51 $195.29 $0.00 $0.00 $185.94 $172.83 $0.00 $0.00 $0.00 $0.00 38271 ERX HCPCS J9070 16714-0859-01 CYCLOPHOSPHAMIDE 500 MG IJ SOLR BOTH IP/OP "$1,283.34 " $949.67 $0.00 $989.20 $577.50 $577.50 $137.37 $137.37 $137.37 $267.48 $952.49 $952.49 $989.20 $145.77 $171.27 $94.75 $759.10 $759.10 $179.23 $582.34 $922.43 $931.74 $247.51 $247.51 $195.29 $0.00 $0.00 $185.94 $172.83 $0.00 $0.00 $0.00 $0.00 38280 ERX HCPCS J9070 00781-3255-94 CYCLOPHOSPHAMIDE 2 G IJ SOLR BOTH IP/OP "$3,973.08 " "$2,940.08" $0.00 "$3,062.45" "$1,787.89" "$1,787.89" $549.46 $549.46 $549.46 $828.09 "$2,948.82" "$2,948.82" "$3,062.45" $583.06 $685.10 $378.99 "$1,958.73" "$1,958.73" $716.92 "$1,801.95" "$2,854.29" "$2,883.12" $990.03 $990.03 $781.14 $0.00 $0.00 $743.78 $691.32 $0.00 $0.00 $0.00 $0.00 38280 ERX HCPCS J9070 10019-0957-01 CYCLOPHOSPHAMIDE 2 G IJ SOLR BOTH IP/OP "$3,973.08 " "$2,940.08" $0.00 "$3,062.45" "$1,787.89" "$1,787.89" $549.46 $549.46 $549.46 $828.09 "$2,948.82" "$2,948.82" "$3,062.45" $583.06 $685.10 $378.99 "$1,958.73" "$1,958.73" $716.92 "$1,801.95" "$2,854.29" "$2,883.12" $990.03 $990.03 $781.14 $0.00 $0.00 $743.78 $691.32 $0.00 $0.00 $0.00 $0.00 38280 ERX HCPCS J9070 10019-0957-11 CYCLOPHOSPHAMIDE 2 G IJ SOLR BOTH IP/OP "$3,973.08 " "$2,940.08" $0.00 "$3,062.45" "$1,787.89" "$1,787.89" $549.46 $549.46 $549.46 $828.09 "$2,948.82" "$2,948.82" "$3,062.45" $583.06 $685.10 $378.99 "$1,958.73" "$1,958.73" $716.92 "$1,801.95" "$2,854.29" "$2,883.12" $990.03 $990.03 $781.14 $0.00 $0.00 $743.78 $691.32 $0.00 $0.00 $0.00 $0.00 38280 ERX HCPCS J9070 70121-1240-01 CYCLOPHOSPHAMIDE 2 G IJ SOLR BOTH IP/OP "$3,973.08 " "$2,940.08" $0.00 "$3,062.45" "$1,787.89" "$1,787.89" $549.46 $549.46 $549.46 $828.09 "$2,948.82" "$2,948.82" "$3,062.45" $583.06 $685.10 $378.99 "$1,958.73" "$1,958.73" $716.92 "$1,801.95" "$2,854.29" "$2,883.12" $990.03 $990.03 $781.14 $0.00 $0.00 $743.78 $691.32 $0.00 $0.00 $0.00 $0.00 38303 ERX HCPCS J0132 00574-0805-30 ACETYLCYSTEINE 200 MG/ML IV SOLN BOTH IP/OP $755.55 $559.11 $0.00 $582.38 $340.00 $340.00 $0.00 $0.00 $0.00 $117.74 $560.77 $560.77 $582.38 $0.00 $157.46 $0.00 $446.91 $446.91 $0.00 $342.85 $543.07 $548.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38303 ERX HCPCS J0132 00574-0815-30 ACETYLCYSTEINE 200 MG/ML IV SOLN BOTH IP/OP $755.55 $559.11 $0.00 $582.38 $340.00 $340.00 $0.00 $0.00 $0.00 $117.74 $560.77 $560.77 $582.38 $0.00 $157.46 $0.00 $446.91 $446.91 $0.00 $342.85 $543.07 $548.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38303 ERX HCPCS J0132 17478-0660-30 ACETYLCYSTEINE 200 MG/ML IV SOLN BOTH IP/OP $755.55 $559.11 $0.00 $582.38 $340.00 $340.00 $0.00 $0.00 $0.00 $117.74 $560.77 $560.77 $582.38 $0.00 $157.46 $0.00 $446.91 $446.91 $0.00 $342.85 $543.07 $548.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38303 ERX HCPCS J0132 25021-0812-30 ACETYLCYSTEINE 200 MG/ML IV SOLN BOTH IP/OP $755.55 $559.11 $0.00 $582.38 $340.00 $340.00 $0.00 $0.00 $0.00 $117.74 $560.77 $560.77 $582.38 $0.00 $157.46 $0.00 $446.91 $446.91 $0.00 $342.85 $543.07 $548.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38303 ERX HCPCS J0132 63323-0963-30 ACETYLCYSTEINE 200 MG/ML IV SOLN BOTH IP/OP $755.55 $559.11 $0.00 $582.38 $340.00 $340.00 $0.00 $0.00 $0.00 $117.74 $560.77 $560.77 $582.38 $0.00 $157.46 $0.00 $446.91 $446.91 $0.00 $342.85 $543.07 $548.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38303 ERX HCPCS J0132 66220-0207-30 ACETYLCYSTEINE 200 MG/ML IV SOLN BOTH IP/OP $755.55 $559.11 $0.00 $582.38 $340.00 $340.00 $0.00 $0.00 $0.00 $117.74 $560.77 $560.77 $582.38 $0.00 $157.46 $0.00 $446.91 $446.91 $0.00 $342.85 $543.07 $548.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38315 ERX HCPCS 25000001 00597-0075-41 TIOTROPIUM BROMIDE MONOHYDRATE 18 MCG IN CAPS BOTH IP/OP "$1,485.63 " "$1,099.37" $0.00 "$1,190.94" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,146.75" "$1,146.75" "$1,190.94" $0.00 $309.61 $0.00 $0.00 $0.00 $0.00 $655.56 "$1,038.41" "$1,048.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38315 ERX HCPCS 25000001 00597-0075-75 TIOTROPIUM BROMIDE MONOHYDRATE 18 MCG IN CAPS BOTH IP/OP "$1,485.63 " "$1,099.37" $0.00 "$1,190.94" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,146.75" "$1,146.75" "$1,190.94" $0.00 $309.61 $0.00 $0.00 $0.00 $0.00 $655.56 "$1,038.41" "$1,048.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38318 ERX HCPCS 63700001 63010-0027-70 NELFINAVIR MESYLATE 625 MG PO TABS BOTH IP/OP $50.87 $37.64 $0.00 $36.91 $0.00 $0.00 $0.00 $9.05 $0.00 $0.00 $0.00 $0.00 $0.00 $10.60 $0.00 $0.00 $0.00 $0.00 $23.07 $36.54 $36.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38421 ERX HCPCS 63700001 13107-0001-30 MIRTAZAPINE 7.5 MG PO TABS BOTH IP/OP $10.01 $7.41 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.01 $7.93 $8.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38421 ERX HCPCS 63700001 16714-0706-01 MIRTAZAPINE 7.5 MG PO TABS BOTH IP/OP $10.01 $7.41 $0.00 $8.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.01 $7.93 $8.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38479 ERX HCPCS 63700001 00093-5417-84 CLOZAPINE 25 MG PO TBDP BOTH IP/OP $11.40 $8.44 $0.00 $9.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.70 $9.03 $9.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38480 ERX HCPCS 63700001 00093-5419-19 CLOZAPINE 100 MG PO TBDP BOTH IP/OP $34.26 $25.35 $0.00 $24.86 $0.00 $0.00 $0.00 $6.10 $0.00 $0.00 $0.00 $0.00 $0.00 $7.14 $0.00 $0.00 $0.00 $0.00 $15.54 $24.61 $24.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38480 ERX HCPCS 63700001 00093-5419-84 CLOZAPINE 100 MG PO TBDP BOTH IP/OP $34.26 $25.35 $0.00 $24.86 $0.00 $0.00 $0.00 $6.10 $0.00 $0.00 $0.00 $0.00 $0.00 $7.14 $0.00 $0.00 $0.00 $0.00 $15.54 $24.61 $24.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38488 ERX HCPCS 63700001 00121-0721-04 FLUOXETINE HCL 20 MG/5ML PO SOLN BOTH IP/OP $14.33 $10.60 $0.00 $10.40 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.50 $10.30 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38488 ERX HCPCS 63700001 00121-4721-05 FLUOXETINE HCL 20 MG/5ML PO SOLN BOTH IP/OP $14.33 $10.60 $0.00 $10.40 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.50 $10.30 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38488 ERX HCPCS 63700001 54838-0523-40 FLUOXETINE HCL 20 MG/5ML PO SOLN BOTH IP/OP $14.33 $10.60 $0.00 $10.40 $0.00 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.50 $10.30 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38489 ERX HCPCS 63700001 99999-6005-07 ETHOSUXIMIDE 250 MG/5ML PO SOLN BOTH IP/OP $105.15 $77.81 $0.00 $76.27 $0.00 $0.00 $0.00 $18.72 $0.00 $0.00 $0.00 $0.00 $0.00 $21.91 $0.00 $0.00 $0.00 $0.00 $47.67 $75.51 $76.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38489 ERX HCPCS 63700001 00121-0670-16 ETHOSUXIMIDE 250 MG/5ML PO SOLN BOTH IP/OP $105.15 $77.81 $0.00 $492.40 $0.00 $0.00 $0.00 $18.72 $0.00 $0.00 $0.00 $0.00 $0.00 $21.91 $0.00 $0.00 $0.00 $0.00 $47.67 $492.40 $76.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38703 ERX HCPCS J0153 17478-0542-02 ADENOSINE 6 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $4.59 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 38703 ERX HCPCS J0153 17478-0953-02 ADENOSINE 6 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $4.59 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 38703 ERX HCPCS J0153 25021-0301-67 ADENOSINE 6 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $4.59 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 38703 ERX HCPCS J0153 63323-0651-21 ADENOSINE 6 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $4.59 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 38703 ERX HCPCS J0153 63323-0651-89 ADENOSINE 6 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $4.59 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 38703 ERX HCPCS J0153 67457-0855-02 ADENOSINE 6 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $4.59 $0.00 $0.00 $0.00 $0.00 $1.86 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.19 $0.00 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 38907 ERX HCPCS 63700001 43386-0551-02 TINIDAZOLE 500 MG PO TABS BOTH IP/OP $88.80 $65.71 $0.00 $71.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.40 $70.33 $71.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39063 ERX HCPCS 63700001 65649-0301-03 RIFAXIMIN 200 MG PO TABS BOTH IP/OP $134.02 $99.17 $0.00 $202.72 $0.00 $0.00 $0.00 $23.86 $0.00 $0.00 $0.00 $0.00 $0.00 $27.93 $0.00 $0.00 $0.00 $0.00 $126.70 $200.69 $202.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39136 ERX HCPCS 63700001 00574-2008-15 NYSTATIN 100000 UNIT/GM EX POWD BOTH IP/OP $106.02 $78.45 $0.00 $76.90 $0.00 $0.00 $0.00 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $22.09 $0.00 $0.00 $0.00 $0.00 $48.07 $76.13 $76.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39136 ERX HCPCS 63700001 16714-0769-01 NYSTATIN 100000 UNIT/GM EX POWD BOTH IP/OP $106.02 $78.45 $0.00 $76.90 $0.00 $0.00 $0.00 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $22.09 $0.00 $0.00 $0.00 $0.00 $48.07 $76.13 $76.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39136 ERX HCPCS 63700001 43386-0530-01 NYSTATIN 100000 UNIT/GM EX POWD BOTH IP/OP $106.02 $78.45 $0.00 $76.90 $0.00 $0.00 $0.00 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $22.09 $0.00 $0.00 $0.00 $0.00 $48.07 $76.13 $76.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39136 ERX HCPCS 63700001 68308-0152-15 NYSTATIN 100000 UNIT/GM EX POWD BOTH IP/OP $106.02 $78.45 $0.00 $76.90 $0.00 $0.00 $0.00 $18.87 $0.00 $0.00 $0.00 $0.00 $0.00 $22.09 $0.00 $0.00 $0.00 $0.00 $48.07 $76.13 $76.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39254 ERX HCPCS 63700001 67546-0111-12 NITAZOXANIDE 500 MG PO TABS BOTH IP/OP $542.85 $401.71 $0.00 $394.21 $0.00 $0.00 $0.00 $96.63 $0.00 $0.00 $0.00 $0.00 $0.00 $113.13 $0.00 $0.00 $0.00 $0.00 $246.38 $390.27 $394.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39255 ERX HCPCS 63700001 61958-0701-01 TRUVADA:EMTRICITABINE-TENOFOVIR 200-300 MG TAB PO BOTH IP/OP $255.71 $189.23 $0.00 $185.70 $0.00 $0.00 $0.00 $45.52 $0.00 $0.00 $0.00 $0.00 $0.00 $53.29 $0.00 $0.00 $0.00 $0.00 $116.07 $183.85 $185.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39267 ERX HCPCS J9045 00703-4248-01 CARBOPLATIN 450 MG/45ML IV SOLN BOTH IP/OP $270.61 $200.25 $0.00 $208.59 $121.77 $121.77 $0.00 $0.00 $0.00 $60.81 $200.85 $200.85 $208.59 $0.00 $27.95 $0.00 $160.07 $160.07 $0.00 $122.83 $194.56 $196.53 $0.00 $0.00 $28.45 $0.00 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $0.00 39267 ERX HCPCS J9045 61703-0339-50 CARBOPLATIN 450 MG/45ML IV SOLN BOTH IP/OP $270.61 $200.25 $0.00 $208.59 $121.77 $121.77 $0.00 $0.00 $0.00 $60.81 $200.85 $200.85 $208.59 $0.00 $27.95 $0.00 $160.07 $160.07 $0.00 $122.83 $194.56 $196.53 $0.00 $0.00 $28.45 $0.00 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $0.00 39275 ERX HCPCS 63700001 00002-3235-60 DULOXETINE HCL 20 MG PO CPEP BOTH IP/OP $39.53 $29.25 $0.00 $27.84 $0.00 $0.00 $0.00 $7.25 $0.00 $0.00 $0.00 $0.00 $0.00 $8.24 $0.00 $0.00 $0.00 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39275 ERX HCPCS 63700001 13668-0109-60 DULOXETINE HCL 20 MG PO CPEP BOTH IP/OP $39.53 $29.25 $0.00 $27.84 $0.00 $0.00 $0.00 $7.25 $0.00 $0.00 $0.00 $0.00 $0.00 $8.24 $0.00 $0.00 $0.00 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39275 ERX HCPCS 63700001 27241-0097-06 DULOXETINE HCL 20 MG PO CPEP BOTH IP/OP $39.53 $29.25 $0.00 $27.84 $0.00 $0.00 $0.00 $7.25 $0.00 $0.00 $0.00 $0.00 $0.00 $8.24 $0.00 $0.00 $0.00 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39275 ERX HCPCS 63700001 57237-0017-60 DULOXETINE HCL 20 MG PO CPEP BOTH IP/OP $39.53 $29.25 $0.00 $27.84 $0.00 $0.00 $0.00 $7.25 $0.00 $0.00 $0.00 $0.00 $0.00 $8.24 $0.00 $0.00 $0.00 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39275 ERX HCPCS 63700001 60505-2995-06 DULOXETINE HCL 20 MG PO CPEP BOTH IP/OP $39.53 $29.25 $0.00 $27.84 $0.00 $0.00 $0.00 $7.25 $0.00 $0.00 $0.00 $0.00 $0.00 $8.24 $0.00 $0.00 $0.00 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39275 ERX HCPCS 63700001 69097-0297-03 DULOXETINE HCL 20 MG PO CPEP BOTH IP/OP $39.53 $29.25 $0.00 $27.84 $0.00 $0.00 $0.00 $7.25 $0.00 $0.00 $0.00 $0.00 $0.00 $8.24 $0.00 $0.00 $0.00 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39276 ERX HCPCS 63700001 27241-0098-09 DULOXETINE HCL 30 MG PO CPEP BOTH IP/OP $32.90 $24.35 $0.00 $23.87 $0.00 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 $6.86 $0.00 $0.00 $0.00 $0.00 $14.92 $23.63 $23.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39276 ERX HCPCS 63700001 57237-0018-30 DULOXETINE HCL 30 MG PO CPEP BOTH IP/OP $32.90 $24.35 $0.00 $23.87 $0.00 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 $6.86 $0.00 $0.00 $0.00 $0.00 $14.92 $23.63 $23.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39276 ERX HCPCS 63700001 57237-0018-90 DULOXETINE HCL 30 MG PO CPEP BOTH IP/OP $32.90 $24.35 $0.00 $23.87 $0.00 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 $6.86 $0.00 $0.00 $0.00 $0.00 $14.92 $23.63 $23.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39277 ERX HCPCS 63700001 00228-2892-03 DULOXETINE HCL 60 MG PO CPEP BOTH IP/OP $29.80 $22.05 $0.00 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.90 $23.60 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39277 ERX HCPCS 63700001 27241-0099-03 DULOXETINE HCL 60 MG PO CPEP BOTH IP/OP $29.80 $22.05 $0.00 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.90 $23.60 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39277 ERX HCPCS 63700001 47335-0383-83 DULOXETINE HCL 60 MG PO CPEP BOTH IP/OP $29.80 $22.05 $0.00 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.90 $23.60 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39277 ERX HCPCS 63700001 57237-0019-30 DULOXETINE HCL 60 MG PO CPEP BOTH IP/OP $29.80 $22.05 $0.00 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.90 $23.60 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39277 ERX HCPCS 63700001 57237-0019-99 DULOXETINE HCL 60 MG PO CPEP BOTH IP/OP $29.80 $22.05 $0.00 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.90 $23.60 $23.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39301 ERX HCPCS 63700001 00093-5382-56 EPZICOM:ABACAVIR-LAMIVUDINE 600-300 MG PO TABS BOTH IP/OP $179.30 $132.68 $0.00 $130.06 $0.00 $0.00 $0.00 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $37.37 $0.00 $0.00 $0.00 $0.00 $81.29 $128.76 $130.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39301 ERX HCPCS 63700001 35573-0402-30 EPZICOM:ABACAVIR-LAMIVUDINE 600-300 MG PO TABS BOTH IP/OP $179.30 $132.68 $0.00 $130.06 $0.00 $0.00 $0.00 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $37.37 $0.00 $0.00 $0.00 $0.00 $81.29 $128.76 $130.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39301 ERX HCPCS 63700001 66993-0482-30 EPZICOM:ABACAVIR-LAMIVUDINE 600-300 MG PO TABS BOTH IP/OP $179.30 $132.68 $0.00 $130.06 $0.00 $0.00 $0.00 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $37.37 $0.00 $0.00 $0.00 $0.00 $81.29 $128.76 $130.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39301 ERX HCPCS 63700001 68180-0288-06 EPZICOM:ABACAVIR-LAMIVUDINE 600-300 MG PO TABS BOTH IP/OP $179.30 $132.68 $0.00 $130.06 $0.00 $0.00 $0.00 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $37.37 $0.00 $0.00 $0.00 $0.00 $81.29 $128.76 $130.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39301 ERX HCPCS 63700001 69097-0362-02 EPZICOM:ABACAVIR-LAMIVUDINE 600-300 MG PO TABS BOTH IP/OP $179.30 $132.68 $0.00 $130.06 $0.00 $0.00 $0.00 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $37.37 $0.00 $0.00 $0.00 $0.00 $81.29 $128.76 $130.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39522 ERX HCPCS 25000001 00781-6078-46 CEFDINIR 250 MG/5ML PO SUSR BOTH IP/OP $529.20 $391.61 $0.00 $407.91 $0.00 $0.00 $0.00 $0.00 $0.00 $392.77 $392.77 $407.91 $0.00 $110.29 $0.00 $0.00 $0.00 $0.00 $240.19 $380.46 $384.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39594 ERX HCPCS 63700001 49411-0051-30 AMINOCAPROIC ACID 1000 MG PO TABS BOTH IP/OP $188.61 $139.57 $0.00 $136.82 $0.00 $0.00 $0.00 $33.57 $0.00 $0.00 $0.00 $0.00 $0.00 $39.31 $0.00 $0.00 $0.00 $0.00 $85.51 $135.45 $136.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39700 ERX HCPCS 25000001 00019-1323-16 IOVERSOL 68 % IJ SOLN BOTH IP/OP $189.48 $140.22 $0.00 $151.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.74 $150.07 $151.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39700 ERX HCPCS 25000001 00019-1323-06 IOVERSOL 68 % IJ SOLN BOTH IP/OP $73.50 $54.39 $0.00 $151.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.74 $58.21 $151.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39720 ERX HCPCS 63700001 00093-5352-86 ACAMPROSATE CALCIUM 333 MG PO TBEC BOTH IP/OP $7.37 $5.45 $0.00 $5.34 $0.00 $0.00 $0.00 $1.31 $0.00 $0.00 $0.00 $0.00 $0.00 $1.54 $0.00 $0.00 $0.00 $0.00 $3.34 $5.29 $5.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39744 ERX HCPCS 25000001 00143-9684-10 FLUMAZENIL 0.5 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39744 ERX HCPCS 25000001 00143-9784-10 FLUMAZENIL 0.5 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39802 ERX HCPCS 25000001 00386-0004-04 PENTAFLUOROPROP-TETRAFLUOROETH EX AERO BOTH IP/OP $129.41 $95.76 $0.00 $99.75 $0.00 $0.00 $0.00 $0.00 $0.00 $96.05 $96.05 $99.75 $0.00 $26.97 $0.00 $0.00 $0.00 $0.00 $57.66 $91.33 $92.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39802 ERX HCPCS 25000001 00386-0008-02 PENTAFLUOROPROP-TETRAFLUOROETH EX AERO BOTH IP/OP $129.41 $95.76 $0.00 $99.75 $0.00 $0.00 $0.00 $0.00 $0.00 $96.05 $96.05 $99.75 $0.00 $26.97 $0.00 $0.00 $0.00 $0.00 $57.66 $91.33 $92.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39802 ERX HCPCS 25000001 00386-0008-03 PENTAFLUOROPROP-TETRAFLUOROETH EX AERO BOTH IP/OP $129.41 $95.76 $0.00 $99.75 $0.00 $0.00 $0.00 $0.00 $0.00 $96.05 $96.05 $99.75 $0.00 $26.97 $0.00 $0.00 $0.00 $0.00 $57.66 $91.33 $92.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39918 ERX HCPCS J3260 00409-3578-01 TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.56 $16.33 $16.33 $16.96 $0.00 $4.51 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.34 $0.00 $0.00 $4.13 $0.00 $0.00 $0.00 $0.00 $0.00 39918 ERX HCPCS J3260 36000-0244-01 TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.56 $16.33 $16.33 $16.96 $0.00 $4.51 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.34 $0.00 $0.00 $4.13 $0.00 $0.00 $0.00 $0.00 $0.00 39918 ERX HCPCS J3260 36000-0244-25 TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.56 $16.33 $16.33 $16.96 $0.00 $4.51 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.34 $0.00 $0.00 $4.13 $0.00 $0.00 $0.00 $0.00 $0.00 39918 ERX HCPCS J3260 63323-0306-02 TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.56 $16.33 $16.33 $16.96 $0.00 $4.51 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.34 $0.00 $0.00 $4.13 $0.00 $0.00 $0.00 $0.00 $0.00 39918 ERX HCPCS J3260 67457-0473-22 TOBRAMYCIN SULFATE 80 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $2.56 $16.33 $16.33 $16.96 $0.00 $4.51 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.34 $0.00 $0.00 $4.13 $0.00 $0.00 $0.00 $0.00 $0.00 39975 ERX HCPCS 63700001 54092-0252-45 LANTHANUM CARBONATE 500 MG PO CHEW BOTH IP/OP $60.37 $44.67 $0.00 $43.81 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.58 $0.00 $0.00 $0.00 $0.00 $27.38 $43.37 $43.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 39975 ERX HCPCS 63700001 54092-0252-90 LANTHANUM CARBONATE 500 MG PO CHEW BOTH IP/OP $60.37 $44.67 $0.00 $43.81 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.58 $0.00 $0.00 $0.00 $0.00 $27.38 $43.37 $43.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40055 ERX HCPCS J9045 00703-4239-01 CARBOPLATIN 600 MG/60ML IV SOLN BOTH IP/OP $166.32 $123.08 $0.00 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $37.93 $0.00 $0.00 $36.11 $0.00 $0.00 $0.00 $0.00 $0.00 40055 ERX HCPCS J9045 16729-0295-12 CARBOPLATIN 600 MG/60ML IV SOLN BOTH IP/OP $166.32 $123.08 $0.00 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $37.93 $0.00 $0.00 $36.11 $0.00 $0.00 $0.00 $0.00 $0.00 40055 ERX HCPCS J9045 25021-0202-51 CARBOPLATIN 600 MG/60ML IV SOLN BOTH IP/OP $166.32 $123.08 $0.00 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $37.93 $0.00 $0.00 $36.11 $0.00 $0.00 $0.00 $0.00 $0.00 40055 ERX HCPCS J9045 25021-0205-51 CARBOPLATIN 600 MG/60ML IV SOLN BOTH IP/OP $166.32 $123.08 $0.00 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $37.93 $0.00 $0.00 $36.11 $0.00 $0.00 $0.00 $0.00 $0.00 40055 ERX HCPCS J9045 61703-0339-56 CARBOPLATIN 600 MG/60ML IV SOLN BOTH IP/OP $166.32 $123.08 $0.00 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $37.93 $0.00 $0.00 $36.11 $0.00 $0.00 $0.00 $0.00 $0.00 40055 ERX HCPCS J9045 63323-0172-60 CARBOPLATIN 600 MG/60ML IV SOLN BOTH IP/OP $166.32 $123.08 $0.00 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $37.93 $0.00 $0.00 $36.11 $0.00 $0.00 $0.00 $0.00 $0.00 40055 ERX HCPCS J9045 71288-0100-51 CARBOPLATIN 600 MG/60ML IV SOLN BOTH IP/OP $166.32 $123.08 $0.00 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $37.93 $0.00 $0.00 $36.11 $0.00 $0.00 $0.00 $0.00 $0.00 40089 ERX HCPCS 63700001 50242-0062-01 ERLOTINIB HCL 25 MG PO TABS BOTH IP/OP $365.63 $270.57 $0.00 $265.51 $0.00 $0.00 $0.00 $65.08 $0.00 $0.00 $0.00 $0.00 $0.00 $76.20 $0.00 $0.00 $0.00 $0.00 $165.95 $262.86 $265.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40090 ERX HCPCS 63700001 50242-0063-01 ERLOTINIB HCL 100 MG PO TABS BOTH IP/OP $872.74 $645.83 $0.00 $633.63 $0.00 $0.00 $0.00 $155.35 $0.00 $0.00 $0.00 $0.00 $0.00 $181.88 $0.00 $0.00 $0.00 $0.00 $396.02 $627.30 $633.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40091 ERX HCPCS 63700001 50242-0064-01 ERLOTINIB HCL 150 MG PO TABS BOTH IP/OP $987.13 $730.48 $0.00 $716.68 $0.00 $0.00 $0.00 $175.71 $0.00 $0.00 $0.00 $0.00 $0.00 $205.72 $0.00 $0.00 $0.00 $0.00 $447.93 $709.51 $716.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40321 ERX HCPCS 63700001 00378-5271-01 ESZOPICLONE 2 MG PO TABS BOTH IP/OP $48.87 $36.16 $0.00 $35.46 $0.00 $0.00 $0.00 $8.70 $0.00 $0.00 $0.00 $0.00 $0.00 $10.18 $0.00 $0.00 $0.00 $0.00 $22.16 $35.10 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40369 ERX HCPCS 25000001 69918-0560-30 MESALAMINE 1000 MG RECTAL SUPP BOTH IP/OP $77.89 $57.64 $0.00 $124.43 $0.00 $0.00 $0.00 $0.00 $0.00 $119.81 $119.81 $124.43 $0.00 $16.23 $0.00 $0.00 $0.00 $0.00 $35.32 $55.95 $56.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40401 ERX HCPCS 63700001 00004-0244-51 SAQUINAVIR MESYLATE 500 MG PO TABS BOTH IP/OP $92.78 $68.66 $0.00 $67.30 $0.00 $0.00 $0.00 $16.51 $0.00 $0.00 $0.00 $0.00 $0.00 $19.34 $0.00 $0.00 $0.00 $0.00 $42.06 $66.62 $67.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40413 ERX HCPCS 63600001 66215-0302-00 ILOPROST 10 MCG/ML IN SOLN BOTH IP/OP $155.99 $115.43 $0.00 $120.24 $0.00 $0.00 $0.00 $0.00 $0.00 $115.78 $115.78 $120.24 $0.00 $32.51 $0.00 $0.00 $0.00 $0.00 $70.72 $112.02 $113.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40413 ERX HCPCS 63600001 66215-0302-30 ILOPROST 10 MCG/ML IN SOLN BOTH IP/OP $155.99 $115.43 $0.00 $120.24 $0.00 $0.00 $0.00 $0.00 $0.00 $115.78 $115.78 $120.24 $0.00 $32.51 $0.00 $0.00 $0.00 $0.00 $70.72 $112.02 $113.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40449 ERX HCPCS J3471 24208-0002-02 HYALURONIDASE OVINE 200 UNIT/ML IJ SOLN BOTH IP/OP $296.65 $219.52 $0.00 $228.66 $133.49 $133.49 $0.00 $0.00 $0.00 $17.63 $220.17 $220.17 $228.66 $0.00 $61.82 $0.00 $175.47 $175.47 $0.00 $122.14 $193.46 $195.42 $0.00 $0.00 $38.23 $0.00 $0.00 $38.89 $0.00 $0.00 $0.00 $0.00 $0.00 40475 ERX HCPCS J9264 68817-0134-50 NAB-PACLITAXEL 100 MG IV SUSR BOTH IP/OP "$4,100.59 " "$3,034.44" $0.00 "$3,302.97" "$1,928.30" "$1,928.30" "$1,404.40" "$1,404.40" "$1,404.40" "$1,065.73" "$3,180.42" "$3,180.42" "$3,302.97" "$1,407.70" "$1,654.05" $915.01 "$2,021.59" "$2,021.59" "$1,313.87" "$1,779.70" "$2,819.04" "$2,847.52" "$1,814.39" "$1,814.39" "$1,474.63" $0.00 $0.00 "$1,404.09" "$1,326.90" $0.00 $0.00 $0.00 $0.00 40540 ERX HCPCS 90734 49281-0589-05 MENINGOCOCCAL A C Y&W-135 CONJ IM INJ BOTH IP/OP $469.43 $347.38 $0.00 $375.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.72 $371.79 $375.54 $281.66 $281.66 $143.71 $0.00 $0.00 $136.84 $0.00 $0.00 $0.00 $0.00 $0.00 40661 ERX HCPCS J0202 58468-0357-01 ALEMTUZUMAB 30 MG/ML IV SOLN BOTH IP/OP "$4,341.90 " "$3,213.01" $0.00 "$3,473.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,170.95" "$3,438.78" "$3,473.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40661 ERX HCPCS J0202 58468-0357-03 ALEMTUZUMAB 30 MG/ML IV SOLN BOTH IP/OP "$4,341.90 " "$3,213.01" $0.00 "$3,473.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,170.95" "$3,438.78" "$3,473.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40697 ERX HCPCS 25000001 00173-0718-20 FLUTICASONE PROPIONATE HFA 44 MCG/ACT IN AERO BOTH IP/OP $716.73 $530.38 $0.00 $552.46 $0.00 $0.00 $0.00 $0.00 $0.00 $531.96 $531.96 $552.46 $0.00 $149.37 $0.00 $0.00 $0.00 $0.00 $306.55 $485.58 $490.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40698 ERX HCPCS 25000001 00173-0719-20 FLUTICASONE PROPIONATE HFA 110 MCG/ACT IN AERO BOTH IP/OP $959.51 $710.04 $0.00 $739.59 $0.00 $0.00 $0.00 $0.00 $0.00 $712.15 $712.15 $739.59 $0.00 $199.96 $0.00 $0.00 $0.00 $0.00 $410.40 $650.07 $656.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40699 ERX HCPCS 25000001 00173-0720-20 FLUTICASONE PROPIONATE HFA 220 MCG/ACT IN AERO BOTH IP/OP "$1,321.93 " $978.23 $0.00 "$1,019.92" $0.00 $0.00 $0.00 $0.00 $0.00 $981.14 $981.14 "$1,018.94" $0.00 $275.49 $0.00 $0.00 $0.00 $0.00 $637.45 "$1,009.72" "$1,019.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40801 ERX HCPCS J9217 62935-0453-45 LEUPROLIDE ACETATE (6 MONTH) 45 MG SC KIT BOTH IP/OP "$7,349.89 " "$5,438.92" $0.00 "$5,665.30" "$3,307.45" "$3,307.45" "$1,204.40" "$1,204.40" "$1,204.40" "$1,480.99" "$5,455.09" "$5,455.09" "$5,665.30" $834.54 $980.58 $542.45 "$3,623.50" "$3,623.50" "$1,415.60" "$3,333.47" "$5,280.21" "$5,333.54" "$1,954.87" "$1,954.87" "$1,621.99" $0.00 $0.00 "$1,544.41" "$1,235.32" $0.00 $0.00 $0.00 $0.00 40872 ERX HCPCS J2250 00641-6057-25 MIDAZOLAM HCL 2 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.38 $16.33 $16.33 $16.96 $0.00 $0.30 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 40872 ERX HCPCS J2250 23155-0600-31 MIDAZOLAM HCL 2 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.38 $16.33 $16.33 $16.96 $0.00 $0.30 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 40872 ERX HCPCS J2250 23155-0600-41 MIDAZOLAM HCL 2 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.38 $16.33 $16.33 $16.96 $0.00 $0.30 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 40872 ERX HCPCS J2250 47781-0588-46 MIDAZOLAM HCL 2 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.38 $16.33 $16.33 $16.96 $0.00 $0.30 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 40872 ERX HCPCS J2250 47781-0588-68 MIDAZOLAM HCL 2 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.38 $16.33 $16.33 $16.96 $0.00 $0.30 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 40872 ERX HCPCS J2250 70860-0600-02 MIDAZOLAM HCL 2 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.38 $16.33 $16.33 $16.96 $0.00 $0.30 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 40872 ERX HCPCS J2250 70860-0600-41 MIDAZOLAM HCL 2 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.38 $16.33 $16.33 $16.96 $0.00 $0.30 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 40994 ERX HCPCS 25000001 00132-0079-12 GLYCERIN (ADULT) 2 G RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40994 ERX HCPCS 25000001 00132-0079-24 GLYCERIN (ADULT) 2 G RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41124 ERX HCPCS 25000001 62991-2502-01 PHENOL LIQD BOTH IP/OP $963.60 $713.06 $0.00 $742.74 $0.00 $0.00 $0.00 $0.00 $0.00 $715.18 $715.18 $742.74 $0.00 $200.81 $0.00 $0.00 $0.00 $0.00 $437.25 $692.60 $699.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41137 ERX HCPCS A9577 00270-5164-13 GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN BOTH IP/OP $242.21 $179.24 $0.00 $179.77 $108.99 $108.99 $0.00 $0.00 $0.00 $50.48 $179.77 $179.77 $0.00 $0.00 $50.48 $0.00 $143.27 $143.27 $0.00 $109.94 $174.14 $175.90 $0.00 $0.00 $34.41 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 41137 ERX HCPCS A9577 00270-5164-14 GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN BOTH IP/OP $242.21 $179.24 $0.00 $179.77 $108.99 $108.99 $0.00 $0.00 $0.00 $50.48 $179.77 $179.77 $0.00 $0.00 $50.48 $0.00 $143.27 $143.27 $0.00 $109.94 $174.14 $175.90 $0.00 $0.00 $34.41 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 41137 ERX HCPCS A9577 00270-5164-15 GADOBENATE DIMEGLUMINE 529 MG/ML IV SOLN BOTH IP/OP $242.21 $179.24 $0.00 $179.77 $108.99 $108.99 $0.00 $0.00 $0.00 $50.48 $179.77 $179.77 $0.00 $0.00 $50.48 $0.00 $143.27 $143.27 $0.00 $109.94 $174.14 $175.90 $0.00 $0.00 $34.41 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 41139 ERX HCPCS 63700001 10147-0892-03 GALANTAMINE HYDROBROMIDE ER 16 MG PO CP24 BOTH IP/OP $25.58 $18.93 $0.00 $18.56 $0.00 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $11.60 $18.37 $18.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41142 ERX HCPCS 25000001 00597-0087-17 IPRATROPIUM BROMIDE HFA 17 MCG/ACT IN AERS BOTH IP/OP "$2,320.66 " "$1,717.29" $0.00 "$1,895.70" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,791.25" "$1,791.25" "$1,860.27" $0.00 $483.63 $0.00 $0.00 $0.00 $0.00 "$1,184.81" "$1,876.74" "$1,895.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41144 ERX HCPCS J2248 00469-3250-10 MICAFUNGIN SODIUM 50 MG IV SOLR BOTH IP/OP $342.21 $253.24 $0.00 $273.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.11 $271.03 $273.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41147 ERX HCPCS 63700001 65162-0446-03 ENTECAVIR 0.5 MG PO TABS BOTH IP/OP $155.36 $114.97 $0.00 $124.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.68 $123.05 $124.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41147 ERX HCPCS 63700001 65862-0841-30 ENTECAVIR 0.5 MG PO TABS BOTH IP/OP $155.36 $114.97 $0.00 $124.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.68 $123.05 $124.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41147 ERX HCPCS 63700001 68382-0920-06 ENTECAVIR 0.5 MG PO TABS BOTH IP/OP $155.36 $114.97 $0.00 $124.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.68 $123.05 $124.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41293 ERX HCPCS 90715 58160-0842-52 TETANUS-DIPHTH-ACELL PERTUSSIS 5-2.5-18.5 LF-MCG/0.5 IM SUSP BOTH IP/OP $158.70 $117.44 $0.00 $126.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.35 $125.69 $126.96 $0.00 $0.00 $39.53 $0.00 $0.00 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 41294 ERX HCPCS J9185 25021-0242-02 FLUDARABINE PHOSPHATE 50 MG/2ML IV SOLN BOTH IP/OP $762.12 $563.97 $0.00 $587.44 $342.95 $342.95 $0.00 $0.00 $0.00 $233.27 $565.65 $565.65 $587.44 $0.00 $81.48 $0.00 $450.79 $450.79 $0.00 $345.83 $547.79 $553.32 $0.00 $0.00 $0.00 $0.00 $0.00 $53.58 $0.00 $0.00 $0.00 $0.00 $0.00 41294 ERX HCPCS J9185 63323-0192-02 FLUDARABINE PHOSPHATE 50 MG/2ML IV SOLN BOTH IP/OP $762.12 $563.97 $0.00 $587.44 $342.95 $342.95 $0.00 $0.00 $0.00 $233.27 $565.65 $565.65 $587.44 $0.00 $81.48 $0.00 $450.79 $450.79 $0.00 $345.83 $547.79 $553.32 $0.00 $0.00 $0.00 $0.00 $0.00 $53.58 $0.00 $0.00 $0.00 $0.00 $0.00 41382 ERX HCPCS 63700001 00378-9119-98 FENTANYL 12 MCG/HR TD PATCH 72 HR BOTH IP/OP $78.37 $57.99 $0.00 $56.85 $0.00 $0.00 $0.00 $13.95 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $0.00 $0.00 $0.00 $0.00 $35.53 $56.28 $56.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41382 ERX HCPCS 63700001 47781-0423-11 FENTANYL 12 MCG/HR TD PATCH 72 HR BOTH IP/OP $78.37 $57.99 $0.00 $56.85 $0.00 $0.00 $0.00 $13.95 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $0.00 $0.00 $0.00 $0.00 $35.53 $56.28 $56.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41382 ERX HCPCS 63700001 47781-0423-47 FENTANYL 12 MCG/HR TD PATCH 72 HR BOTH IP/OP $78.37 $57.99 $0.00 $56.85 $0.00 $0.00 $0.00 $13.95 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $0.00 $0.00 $0.00 $0.00 $35.53 $56.28 $56.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41382 ERX HCPCS 63700001 60505-7080-02 FENTANYL 12 MCG/HR TD PATCH 72 HR BOTH IP/OP $78.37 $57.99 $0.00 $56.85 $0.00 $0.00 $0.00 $13.95 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $0.00 $0.00 $0.00 $0.00 $35.53 $56.28 $56.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41581 ERX HCPCS J1610 00597-0053-45 GLUCAGON HCL RDNA (DIAGNOSTIC) 1 MG IJ SOLR BOTH IP/OP $345.95 $256.00 $0.00 $288.94 $155.68 $155.68 $166.77 $166.77 $166.77 $88.07 $256.76 $256.76 $266.66 $171.74 $201.79 $111.63 $204.63 $204.63 $209.24 $157.02 $248.71 $251.22 $288.94 $288.94 $255.63 $0.00 $0.00 $243.41 $199.13 $0.00 $0.00 $0.00 $0.00 41581 ERX HCPCS J1610 00597-0260-10 GLUCAGON HCL RDNA (DIAGNOSTIC) 1 MG IJ SOLR BOTH IP/OP $345.95 $256.00 $0.00 $288.94 $155.68 $155.68 $166.77 $166.77 $166.77 $88.07 $256.76 $256.76 $266.66 $171.74 $201.79 $111.63 $204.63 $204.63 $209.24 $157.02 $248.71 $251.22 $288.94 $288.94 $255.63 $0.00 $0.00 $243.41 $199.13 $0.00 $0.00 $0.00 $0.00 41623 ERX HCPCS 25000001 99999-6010-71 LEVOCARNITINE 1 GM/10ML PO SOLN BOTH IP/OP $49.28 $36.47 $0.00 $129.52 $0.00 $0.00 $0.00 $0.00 $0.00 $36.58 $36.58 $37.99 $0.00 $10.27 $0.00 $0.00 $0.00 $0.00 $80.95 $35.39 $129.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41623 ERX HCPCS 25000001 50383-0171-04 LEVOCARNITINE 1 GM/10ML PO SOLN BOTH IP/OP $49.28 $36.47 $0.00 $129.52 $0.00 $0.00 $0.00 $0.00 $0.00 $36.58 $36.58 $37.99 $0.00 $10.27 $0.00 $0.00 $0.00 $0.00 $80.95 $128.22 $129.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41623 ERX HCPCS 25000001 54482-0145-08 LEVOCARNITINE 1 GM/10ML PO SOLN BOTH IP/OP $49.28 $36.47 $0.00 $129.52 $0.00 $0.00 $0.00 $0.00 $0.00 $36.58 $36.58 $37.99 $0.00 $10.27 $0.00 $0.00 $0.00 $0.00 $80.95 $128.22 $129.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41623 ERX HCPCS 25000001 64980-0503-12 LEVOCARNITINE 1 GM/10ML PO SOLN BOTH IP/OP $49.28 $36.47 $0.00 $129.52 $0.00 $0.00 $0.00 $0.00 $0.00 $36.58 $36.58 $37.99 $0.00 $10.27 $0.00 $0.00 $0.00 $0.00 $80.95 $128.22 $129.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41624 ERX HCPCS J3430 00409-9157-01 VITAMIN K1 1 MG/0.5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41624 ERX HCPCS J3430 00409-9157-31 VITAMIN K1 1 MG/0.5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41624 ERX HCPCS J3430 00409-9157-50 VITAMIN K1 1 MG/0.5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41628 ERX HCPCS 90715 49281-0400-10 TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP BOTH IP/OP $175.49 $129.86 $0.00 $140.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.75 $138.99 $140.39 $0.00 $0.00 $39.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41628 ERX HCPCS 90715 49281-0400-58 TETANUS-DIPHTH-ACELL PERTUSSIS 5-2-15.5 LF-MCG/0.5 IM SUSP BOTH IP/OP $175.49 $129.86 $0.00 $140.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.75 $138.99 $140.39 $0.00 $0.00 $39.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41652 ERX HCPCS J3243 00781-3481-70 TIGECYCLINE 50 MG IV SOLR BOTH IP/OP $525.84 $389.12 $0.00 $405.32 $0.00 $0.00 $0.00 $0.00 $0.00 $390.28 $390.28 $405.32 $0.00 $109.59 $0.00 $0.00 $0.00 $0.00 $238.67 $378.05 $381.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41652 ERX HCPCS J3243 00781-3481-92 TIGECYCLINE 50 MG IV SOLR BOTH IP/OP $525.84 $389.12 $0.00 $405.32 $0.00 $0.00 $0.00 $0.00 $0.00 $390.28 $390.28 $405.32 $0.00 $109.59 $0.00 $0.00 $0.00 $0.00 $238.67 $378.05 $381.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41652 ERX HCPCS J3243 63323-0960-10 TIGECYCLINE 50 MG IV SOLR BOTH IP/OP $525.84 $389.12 $0.00 $405.32 $0.00 $0.00 $0.00 $0.00 $0.00 $390.28 $390.28 $405.32 $0.00 $109.59 $0.00 $0.00 $0.00 $0.00 $238.67 $378.05 $381.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41673 ERX HCPCS J9390 64370-0532-02 VINORELBINE TARTRATE 50 MG/5ML IV SOLN BOTH IP/OP $311.10 $230.21 $0.00 $248.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.55 $246.39 $248.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41675 ERX HCPCS 90378 60574-4113-01 PALIVIZUMAB 100 MG/ML IM SOLN BOTH IP/OP "$8,338.46 " "$6,170.46" $0.00 "$6,427.28" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,188.81" "$6,188.81" "$6,427.28" $0.00 "$3,826.46" $0.00 $0.00 $0.00 $0.00 "$3,653.95" "$5,787.85" "$5,846.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41676 ERX HCPCS 63700001 00597-0003-02 TIPRANAVIR 250 MG PO CAPS BOTH IP/OP $142.38 $105.36 $0.00 $99.31 $0.00 $0.00 $0.00 $26.36 $0.00 $0.00 $0.00 $0.00 $0.00 $29.67 $0.00 $0.00 $0.00 $0.00 $62.07 $98.32 $99.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41793 ERX HCPCS 25000001 67457-0163-02 SODIUM TETRADECYL SULFATE 3 % IV SOLN BOTH IP/OP $89.17 $65.99 $0.00 $68.73 $0.00 $0.00 $0.00 $0.00 $0.00 $66.18 $66.18 $68.73 $0.00 $18.58 $0.00 $0.00 $0.00 $0.00 $40.43 $64.98 $64.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41822 ERX HCPCS 63700001 00173-0884-08 OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS BOTH IP/OP $22.76 $16.84 $0.00 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $18.03 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41822 ERX HCPCS 63700001 42291-0657-12 OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS BOTH IP/OP $22.76 $16.84 $0.00 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $18.03 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41822 ERX HCPCS 63700001 60505-3170-07 OMEGA-3-ACID ETHYL ESTERS 1 G PO CAPS BOTH IP/OP $22.76 $16.84 $0.00 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $18.03 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41828 ERX HCPCS 25000001 00085-1341-06 MOMETASONE FUROATE 220 MCG/INH IN AEPB BOTH IP/OP $279.57 $206.88 $0.00 $223.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.79 $221.42 $223.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41828 ERX HCPCS 25000001 00085-1341-07 MOMETASONE FUROATE 220 MCG/INH IN AEPB BOTH IP/OP $279.57 $206.88 $0.00 $223.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.79 $221.42 $223.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41831 ERX HCPCS 25000001 50383-0933-35 LIDOCAINE 5 % EX OINT BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41831 ERX HCPCS 25000001 52565-0008-14 LIDOCAINE 5 % EX OINT BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41831 ERX HCPCS 25000001 68462-0418-20 LIDOCAINE 5 % EX OINT BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41832 ERX HCPCS 63700001 00093-5517-98 SILDENAFIL CITRATE 20 MG PO TABS BOTH IP/OP $85.11 $62.98 $0.00 $61.74 $0.00 $0.00 $0.00 $15.15 $0.00 $0.00 $0.00 $0.00 $0.00 $17.74 $0.00 $0.00 $0.00 $0.00 $38.59 $61.12 $61.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41832 ERX HCPCS 63700001 52817-0295-90 SILDENAFIL CITRATE 20 MG PO TABS BOTH IP/OP $85.11 $62.98 $0.00 $61.74 $0.00 $0.00 $0.00 $15.15 $0.00 $0.00 $0.00 $0.00 $0.00 $17.74 $0.00 $0.00 $0.00 $0.00 $38.59 $61.12 $61.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41893 ERX HCPCS 63700001 24338-0010-18 ISOSORB DINITRATE-HYDRALAZINE 20-37.5 MG PO TABS BOTH IP/OP $16.98 $12.57 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.49 $13.45 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41938 ERX HCPCS 63700001 00054-4538-25 METHADONE HCL 40 MG PO TBSO BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42064 ERX HCPCS 63700001 64764-0805-30 RAMELTEON 8 MG PO TABS BOTH IP/OP $65.21 $48.26 $0.00 $47.31 $0.00 $0.00 $0.00 $11.61 $0.00 $0.00 $0.00 $0.00 $0.00 $13.59 $0.00 $0.00 $0.00 $0.00 $29.57 $46.84 $47.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42162 ERX HCPCS 63700001 00071-1012-68 PREGABALIN 25 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42162 ERX HCPCS 63700001 50228-0350-90 PREGABALIN 25 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42162 ERX HCPCS 63700001 62332-0119-90 PREGABALIN 25 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42162 ERX HCPCS 63700001 76282-0568-90 PREGABALIN 25 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42163 ERX HCPCS 63700001 00071-1013-41 PREGABALIN 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42163 ERX HCPCS 63700001 00071-1013-68 PREGABALIN 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42163 ERX HCPCS 63700001 50228-0351-90 PREGABALIN 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42163 ERX HCPCS 63700001 60687-0484-01 PREGABALIN 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42163 ERX HCPCS 63700001 62332-0120-90 PREGABALIN 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42163 ERX HCPCS 63700001 76282-0569-90 PREGABALIN 50 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42164 ERX HCPCS 63700001 00071-1014-41 PREGABALIN 75 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42164 ERX HCPCS 63700001 00071-1014-68 PREGABALIN 75 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42164 ERX HCPCS 63700001 50228-0352-90 PREGABALIN 75 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42164 ERX HCPCS 63700001 62332-0121-90 PREGABALIN 75 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42164 ERX HCPCS 63700001 76282-0570-90 PREGABALIN 75 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42165 ERX HCPCS 63700001 00071-1015-41 PREGABALIN 100 MG PO CAPS BOTH IP/OP $47.49 $35.14 $0.00 $32.85 $0.00 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $20.53 $32.52 $32.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42165 ERX HCPCS 63700001 00904-7001-61 PREGABALIN 100 MG PO CAPS BOTH IP/OP $47.49 $35.14 $0.00 $32.85 $0.00 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $20.53 $32.52 $32.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42165 ERX HCPCS 63700001 50228-0353-90 PREGABALIN 100 MG PO CAPS BOTH IP/OP $47.49 $35.14 $0.00 $32.85 $0.00 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $20.53 $32.52 $32.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42165 ERX HCPCS 63700001 60687-0506-01 PREGABALIN 100 MG PO CAPS BOTH IP/OP $47.49 $35.14 $0.00 $32.85 $0.00 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $20.53 $32.52 $32.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42165 ERX HCPCS 63700001 60687-0506-11 PREGABALIN 100 MG PO CAPS BOTH IP/OP $47.49 $35.14 $0.00 $32.85 $0.00 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $20.53 $32.52 $32.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42165 ERX HCPCS 63700001 62332-0122-90 PREGABALIN 100 MG PO CAPS BOTH IP/OP $47.49 $35.14 $0.00 $32.85 $0.00 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $20.53 $32.52 $32.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42166 ERX HCPCS 63700001 00071-1016-41 PREGABALIN 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42166 ERX HCPCS 63700001 00071-1016-68 PREGABALIN 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42166 ERX HCPCS 63700001 43598-0295-66 PREGABALIN 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42166 ERX HCPCS 63700001 43598-0295-79 PREGABALIN 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42166 ERX HCPCS 63700001 50228-0354-90 PREGABALIN 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42166 ERX HCPCS 63700001 60687-0517-01 PREGABALIN 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42166 ERX HCPCS 63700001 62332-0123-90 PREGABALIN 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42166 ERX HCPCS 63700001 72205-0015-90 PREGABALIN 150 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42167 ERX HCPCS 63700001 00071-1017-68 PREGABALIN 200 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42167 ERX HCPCS 63700001 50228-0355-90 PREGABALIN 200 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42167 ERX HCPCS 63700001 62332-0124-90 PREGABALIN 200 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42168 ERX HCPCS 63700001 50228-0356-90 PREGABALIN 225 MG PO CAPS BOTH IP/OP $24.52 $18.14 $0.00 $17.79 $0.00 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $11.12 $17.61 $17.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42168 ERX HCPCS 63700001 62332-0125-90 PREGABALIN 225 MG PO CAPS BOTH IP/OP $24.52 $18.14 $0.00 $17.79 $0.00 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $11.12 $17.61 $17.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42169 ERX HCPCS 63700001 00071-1018-68 PREGABALIN 300 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42169 ERX HCPCS 63700001 50228-0357-90 PREGABALIN 300 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42169 ERX HCPCS 63700001 62332-0126-90 PREGABALIN 300 MG PO CAPS BOTH IP/OP $43.18 $31.95 $0.00 $29.86 $0.00 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $18.67 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42219 ERX HCPCS 63700001 00904-6836-20 LOPERAMIDE HCL 1 MG/7.5ML PO LIQD BOTH IP/OP $14.59 $10.80 $0.00 $8.80 $0.00 $0.00 $0.00 $2.60 $0.00 $0.00 $0.00 $0.00 $0.00 $3.04 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42219 ERX HCPCS 63700001 70677-0054-01 LOPERAMIDE HCL 1 MG/7.5ML PO LIQD BOTH IP/OP $14.59 $10.80 $0.00 $8.80 $0.00 $0.00 $0.00 $2.60 $0.00 $0.00 $0.00 $0.00 $0.00 $3.04 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42918 ERX HCPCS 63700001 99999-6005-12 ZIDOVUDINE 50 MG/5ML PO SYRP BOTH IP/OP $111.64 $82.61 $0.00 $80.98 $0.00 $0.00 $0.00 $19.87 $0.00 $0.00 $0.00 $0.00 $0.00 $23.27 $0.00 $0.00 $0.00 $0.00 $50.61 $80.17 $80.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42918 ERX HCPCS 63700001 65862-0048-24 ZIDOVUDINE 50 MG/5ML PO SYRP BOTH IP/OP $111.64 $82.61 $0.00 $144.30 $0.00 $0.00 $0.00 $19.87 $0.00 $0.00 $0.00 $0.00 $0.00 $23.27 $0.00 $0.00 $0.00 $0.00 $50.61 $144.30 $80.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42939 ERX HCPCS 25000001 65628-0063-01 PROGESTERONE 200 MG VA SUPP BOTH IP/OP $28.50 $21.09 $0.00 $21.97 $0.00 $0.00 $0.00 $0.00 $0.00 $21.15 $21.15 $21.97 $0.00 $5.94 $0.00 $0.00 $0.00 $0.00 $12.92 $20.47 $20.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43010 ERX HCPCS 63700001 00904-5313-46 PRENATAL 27-0.8 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43010 ERX HCPCS 63700001 00904-5313-60 PRENATAL 27-0.8 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43230 ERX HCPCS 63700001 13668-0117-30 LOSARTAN-HCTZ 100-12.5 MG PO TABS BOTH IP/OP $14.28 $10.57 $0.00 $10.37 $0.00 $0.00 $0.00 $2.54 $0.00 $0.00 $0.00 $0.00 $0.00 $2.98 $0.00 $0.00 $0.00 $0.00 $6.48 $10.26 $10.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43230 ERX HCPCS 63700001 13668-0117-90 LOSARTAN-HCTZ 100-12.5 MG PO TABS BOTH IP/OP $14.28 $10.57 $0.00 $10.37 $0.00 $0.00 $0.00 $2.54 $0.00 $0.00 $0.00 $0.00 $0.00 $2.98 $0.00 $0.00 $0.00 $0.00 $6.48 $10.26 $10.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43230 ERX HCPCS 63700001 16714-0224-01 LOSARTAN-HCTZ 100-12.5 MG PO TABS BOTH IP/OP $14.28 $10.57 $0.00 $10.37 $0.00 $0.00 $0.00 $2.54 $0.00 $0.00 $0.00 $0.00 $0.00 $2.98 $0.00 $0.00 $0.00 $0.00 $6.48 $10.26 $10.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43230 ERX HCPCS 63700001 16714-0224-02 LOSARTAN-HCTZ 100-12.5 MG PO TABS BOTH IP/OP $14.28 $10.57 $0.00 $10.37 $0.00 $0.00 $0.00 $2.54 $0.00 $0.00 $0.00 $0.00 $0.00 $2.98 $0.00 $0.00 $0.00 $0.00 $6.48 $10.26 $10.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43230 ERX HCPCS 63700001 62332-0049-90 LOSARTAN-HCTZ 100-12.5 MG PO TABS BOTH IP/OP $14.28 $10.57 $0.00 $10.37 $0.00 $0.00 $0.00 $2.54 $0.00 $0.00 $0.00 $0.00 $0.00 $2.98 $0.00 $0.00 $0.00 $0.00 $6.48 $10.26 $10.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43391 ERX HCPCS 63700001 00074-6799-22 KALETRA:LOPINAVIR-RITONAVIR 200-50 MG PO TABS BOTH IP/OP $79.07 $58.51 $0.00 $57.35 $0.00 $0.00 $0.00 $14.07 $0.00 $0.00 $0.00 $0.00 $0.00 $16.48 $0.00 $0.00 $0.00 $0.00 $35.85 $56.78 $57.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43416 ERX HCPCS 63700001 00078-0469-15 DEFERASIROX 250 MG PO TBSO BOTH IP/OP $340.53 $251.99 $0.00 $247.29 $0.00 $0.00 $0.00 $60.61 $0.00 $0.00 $0.00 $0.00 $0.00 $70.97 $0.00 $0.00 $0.00 $0.00 $154.56 $244.82 $247.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43417 ERX HCPCS 63700001 00078-0470-15 DEFERASIROX 500 MG PO TBSO BOTH IP/OP $591.85 $437.97 $0.00 $429.70 $0.00 $0.00 $0.00 $105.35 $0.00 $0.00 $0.00 $0.00 $0.00 $123.34 $0.00 $0.00 $0.00 $0.00 $268.57 $425.41 $429.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43472 ERX HCPCS 25000001 63402-0510-01 LEVALBUTEROL TARTRATE 45 MCG/ACT IN AERO BOTH IP/OP $284.15 $210.27 $0.00 $219.02 $0.00 $0.00 $0.00 $0.00 $0.00 $210.90 $210.90 $219.02 $0.00 $59.22 $0.00 $0.00 $0.00 $0.00 $128.97 $204.29 $206.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43548 ERX HCPCS 63700001 54092-0254-10 LANTHANUM CARBONATE 1000 MG PO CHEW BOTH IP/OP $60.37 $44.67 $0.00 $43.81 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.58 $0.00 $0.00 $0.00 $0.00 $27.38 $43.37 $43.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43548 ERX HCPCS 63700001 54092-0254-90 LANTHANUM CARBONATE 1000 MG PO CHEW BOTH IP/OP $60.37 $44.67 $0.00 $43.81 $0.00 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 $12.58 $0.00 $0.00 $0.00 $0.00 $27.38 $43.37 $43.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43556 ERX HCPCS 63700001 00054-0057-46 DIGOXIN 0.05 MG/ML PO SOLN BOTH IP/OP $564.48 $417.72 $0.00 $409.92 $0.00 $0.00 $0.00 $100.48 $0.00 $0.00 $0.00 $0.00 $0.00 $117.64 $0.00 $0.00 $0.00 $0.00 $256.20 $405.82 $409.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43675 ERX HCPCS 63700001 50419-0488-58 SORAFENIB TOSYLATE 200 MG PO TABS BOTH IP/OP "$1,212.39 " $897.17 $0.00 $847.21 $0.00 $0.00 $0.00 $230.70 $0.00 $0.00 $0.00 $0.00 $0.00 $252.66 $0.00 $0.00 $0.00 $0.00 $529.51 $838.74 $847.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43718 ERX HCPCS 63700001 59572-0405-00 LENALIDOMIDE 5 MG PO CAPS BOTH IP/OP "$2,478.15 " "$1,833.83" $0.00 "$1,757.98" $0.00 $0.00 $0.00 $460.96 $0.00 $0.00 $0.00 $0.00 $0.00 $516.45 $0.00 $0.00 $0.00 $0.00 "$1,098.74" "$1,740.40" "$1,757.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43718 ERX HCPCS 63700001 59572-0405-28 LENALIDOMIDE 5 MG PO CAPS BOTH IP/OP "$2,478.15 " "$1,833.83" $0.00 "$1,757.98" $0.00 $0.00 $0.00 $460.96 $0.00 $0.00 $0.00 $0.00 $0.00 $516.45 $0.00 $0.00 $0.00 $0.00 "$1,098.74" "$1,740.40" "$1,757.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43719 ERX HCPCS 63700001 59572-0410-00 LENALIDOMIDE 10 MG PO CAPS BOTH IP/OP "$2,478.15 " "$1,833.83" $0.00 "$1,757.98" $0.00 $0.00 $0.00 $460.96 $0.00 $0.00 $0.00 $0.00 $0.00 $516.45 $0.00 $0.00 $0.00 $0.00 "$1,098.74" "$1,740.40" "$1,757.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43719 ERX HCPCS 63700001 59572-0410-28 LENALIDOMIDE 10 MG PO CAPS BOTH IP/OP "$2,478.15 " "$1,833.83" $0.00 "$1,757.98" $0.00 $0.00 $0.00 $460.96 $0.00 $0.00 $0.00 $0.00 $0.00 $516.45 $0.00 $0.00 $0.00 $0.00 "$1,098.74" "$1,740.40" "$1,757.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70257 ERX HCPCS 63700001 49884-0402-91 RISPERIDONE 3 MG PO TBDP BOTH IP/OP $49.37 $36.53 $0.00 $35.82 $0.00 $0.00 $0.00 $8.79 $0.00 $0.00 $0.00 $0.00 $0.00 $10.29 $0.00 $0.00 $0.00 $0.00 $22.39 $35.46 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70261 ERX HCPCS J1815 00169-3687-12 INSULIN DETEMIR (LEVEMIR) 100 UNIT/ML SC SOLN BOTH IP/OP $15.00 $11.10 $0.00 $201.38 $8.15 $8.15 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $8.87 $8.87 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.38 $0.00 $0.00 $0.00 $0.00 $0.00 70267 ERX HCPCS J9261 00078-0683-06 NELARABINE 5 MG/ML IV SOLN BOTH IP/OP "$2,117.88 " "$1,567.23" $0.00 "$1,694.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,058.94" "$1,677.36" "$1,694.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70284 ERX HCPCS 63700001 60258-0006-01 K & NA PHOSPHATES 280-160-250 MG PO PACK BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70306 ERX HCPCS 63700001 13668-0216-30 ARIPIPRAZOLE 2 MG PO TABS BOTH IP/OP $122.48 $90.64 $0.00 $88.85 $0.00 $0.00 $0.00 $21.80 $0.00 $0.00 $0.00 $0.00 $0.00 $25.52 $0.00 $0.00 $0.00 $0.00 $55.53 $87.96 $88.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70306 ERX HCPCS 63700001 16714-0783-01 ARIPIPRAZOLE 2 MG PO TABS BOTH IP/OP $122.48 $90.64 $0.00 $88.85 $0.00 $0.00 $0.00 $21.80 $0.00 $0.00 $0.00 $0.00 $0.00 $25.52 $0.00 $0.00 $0.00 $0.00 $55.53 $87.96 $88.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70306 ERX HCPCS 63700001 65862-0661-30 ARIPIPRAZOLE 2 MG PO TABS BOTH IP/OP $122.48 $90.64 $0.00 $88.85 $0.00 $0.00 $0.00 $21.80 $0.00 $0.00 $0.00 $0.00 $0.00 $25.52 $0.00 $0.00 $0.00 $0.00 $55.53 $87.96 $88.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70324 ERX HCPCS 63700001 00093-4405-93 CLOZAPINE 200 MG PO TABS BOTH IP/OP $27.29 $20.19 $0.00 $19.80 $0.00 $0.00 $0.00 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $12.38 $19.60 $19.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70397 ERX HCPCS 63700001 00904-6639-61 QUETIAPINE FUMARATE 50 MG PO TABS BOTH IP/OP $25.94 $19.20 $0.00 $18.82 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $11.76 $18.63 $18.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70397 ERX HCPCS 63700001 50268-0631-15 QUETIAPINE FUMARATE 50 MG PO TABS BOTH IP/OP $25.94 $19.20 $0.00 $18.82 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $11.76 $18.63 $18.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70397 ERX HCPCS 63700001 60687-0338-01 QUETIAPINE FUMARATE 50 MG PO TABS BOTH IP/OP $25.94 $19.20 $0.00 $18.82 $0.00 $0.00 $0.00 $4.62 $0.00 $0.00 $0.00 $0.00 $0.00 $5.41 $0.00 $0.00 $0.00 $0.00 $11.76 $18.63 $18.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70398 ERX HCPCS 63700001 16714-0457-01 QUETIAPINE FUMARATE 400 MG PO TABS BOTH IP/OP $83.22 $61.58 $0.00 $60.61 $0.00 $0.00 $0.00 $14.81 $0.00 $0.00 $0.00 $0.00 $0.00 $17.34 $0.00 $0.00 $0.00 $0.00 $37.88 $60.00 $60.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70405 ERX HCPCS J7187 63833-0616-02 ANTIHEMOPHILIC FACTOR-VWF 500-1200 UNITS IV SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70424 ERX HCPCS 63700001 00069-0550-38 SUNITINIB MALATE 12.5 MG PO CAPS BOTH IP/OP $747.09 $552.85 $0.00 $489.65 $0.00 $0.00 $0.00 $132.98 $0.00 $0.00 $0.00 $0.00 $0.00 $155.69 $0.00 $0.00 $0.00 $0.00 $306.03 $484.75 $489.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70425 ERX HCPCS 63700001 00069-0770-38 SUNITINIB MALATE 25 MG PO CAPS BOTH IP/OP "$1,325.32 " $980.74 $0.00 $979.30 $0.00 $0.00 $0.00 $235.91 $0.00 $0.00 $0.00 $0.00 $0.00 $276.20 $0.00 $0.00 $0.00 $0.00 $612.06 $969.50 $979.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70426 ERX HCPCS 63700001 00069-0980-38 SUNITINIB MALATE 50 MG PO CAPS BOTH IP/OP "$2,307.19 " "$1,707.32" $0.00 "$1,543.98" $0.00 $0.00 $0.00 $410.68 $0.00 $0.00 $0.00 $0.00 $0.00 $480.82 $0.00 $0.00 $0.00 $0.00 $964.99 "$1,528.54" "$1,543.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70434 ERX HCPCS 63700001 50228-0423-60 RANOLAZINE ER 500 MG PO TB12 BOTH IP/OP $34.46 $25.50 $0.00 $23.86 $0.00 $0.00 $0.00 $6.13 $0.00 $0.00 $0.00 $0.00 $0.00 $7.18 $0.00 $0.00 $0.00 $0.00 $14.91 $23.62 $23.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70434 ERX HCPCS 63700001 61958-1003-01 RANOLAZINE ER 500 MG PO TB12 BOTH IP/OP $34.46 $25.50 $0.00 $23.86 $0.00 $0.00 $0.00 $6.13 $0.00 $0.00 $0.00 $0.00 $0.00 $7.18 $0.00 $0.00 $0.00 $0.00 $14.91 $23.62 $23.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70472 ERX HCPCS 63700001 64764-0240-60 LUBIPROSTONE 24 MCG PO CAPS BOTH IP/OP $31.10 $23.01 $0.00 $22.57 $0.00 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 $6.48 $0.00 $0.00 $0.00 $0.00 $14.11 $22.34 $22.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70536 ERX HCPCS 25000001 00054-3270-99 FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP BOTH IP/OP $268.59 $198.76 $0.00 $214.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.30 $212.72 $214.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70536 ERX HCPCS 25000001 50383-0700-16 FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP BOTH IP/OP $268.59 $198.76 $0.00 $214.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.30 $212.72 $214.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70536 ERX HCPCS 25000001 60432-0264-15 FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP BOTH IP/OP $268.59 $198.76 $0.00 $214.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.30 $212.72 $214.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70536 ERX HCPCS 25000001 60505-0829-01 FLUTICASONE PROPIONATE 50 MCG/ACT NA SUSP BOTH IP/OP $268.59 $198.76 $0.00 $214.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.30 $212.72 $214.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70545 ERX HCPCS 25000001 42023-0105-01 METHOHEXITAL SODIUM 0.5 G IJ SOLR BOTH IP/OP $340.76 $252.16 $0.00 $262.66 $0.00 $0.00 $0.00 $0.00 $0.00 $252.91 $252.91 $262.66 $0.00 $71.01 $0.00 $0.00 $0.00 $0.00 $147.30 $233.32 $235.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70678 ERX HCPCS 25000001 39822-1201-02 NEOMYCIN-POLYMYXIN B GU 40-200000 IR SOLN BOTH IP/OP $167.36 $123.85 $0.00 $133.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.68 $132.55 $133.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70693 ERX HCPCS 25000001 00002-7511-01 HUMALOG MIX 75-25 VIAL BOTH IP/OP $997.59 $738.22 $0.00 $768.94 $0.00 $0.00 $0.00 $0.00 $0.00 $740.41 $740.41 $768.94 $0.00 $207.90 $0.00 $0.00 $0.00 $0.00 $452.68 $717.04 $724.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70773 ERX HCPCS 63700001 16714-0357-01 LEVETIRACETAM 1000 MG PO TABS BOTH IP/OP $6.39 $4.73 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.06 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70773 ERX HCPCS 63700001 16729-0067-12 LEVETIRACETAM 1000 MG PO TABS BOTH IP/OP $6.39 $4.73 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.06 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70773 ERX HCPCS 63700001 31722-0539-60 LEVETIRACETAM 1000 MG PO TABS BOTH IP/OP $6.39 $4.73 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.06 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70773 ERX HCPCS 63700001 68084-0893-01 LEVETIRACETAM 1000 MG PO TABS BOTH IP/OP $6.39 $4.73 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.06 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70773 ERX HCPCS 63700001 68180-0115-07 LEVETIRACETAM 1000 MG PO TABS BOTH IP/OP $6.39 $4.73 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.20 $5.06 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70784 ERX HCPCS 63700001 50419-0405-03 DROSPIRENONE-ETHINYL ESTRADIOL 3-0.02 MG PO TABS BOTH IP/OP $639.00 $472.86 $0.00 $442.24 $0.00 $0.00 $0.00 $119.37 $0.00 $0.00 $0.00 $0.00 $0.00 $133.17 $0.00 $0.00 $0.00 $0.00 $276.40 $437.82 $442.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76364 ERX HCPCS J0894 16714-0749-01 DECITABINE 50 MG IV SOLR BOTH IP/OP "$1,314.00 " $972.36 $0.00 "$2,381.28" $0.00 $0.00 $0.00 $0.00 $0.00 $975.25 $975.25 "$1,012.83" $0.00 $201.28 $0.00 $0.00 $0.00 $392.96 "$1,488.30" "$2,357.47" "$2,381.28" $542.66 $542.66 $252.63 $0.00 $0.00 $240.54 $214.05 $0.00 $0.00 $0.00 $0.00 76364 ERX HCPCS J0894 16729-0224-05 DECITABINE 50 MG IV SOLR BOTH IP/OP "$1,314.00 " $972.36 $0.00 "$2,381.28" $0.00 $0.00 $0.00 $0.00 $0.00 $975.25 $975.25 "$1,012.83" $0.00 $201.28 $0.00 $0.00 $0.00 $392.96 "$1,488.30" "$2,357.47" "$2,381.28" $542.66 $542.66 $252.63 $0.00 $0.00 $240.54 $214.05 $0.00 $0.00 $0.00 $0.00 76364 ERX HCPCS J0894 25021-0231-20 DECITABINE 50 MG IV SOLR BOTH IP/OP "$1,314.00 " $972.36 $0.00 "$2,381.28" $0.00 $0.00 $0.00 $0.00 $0.00 $975.25 $975.25 "$1,012.83" $0.00 $201.28 $0.00 $0.00 $0.00 $392.96 "$1,488.30" "$2,357.47" "$2,381.28" $542.66 $542.66 $252.63 $0.00 $0.00 $240.54 $214.05 $0.00 $0.00 $0.00 $0.00 76364 ERX HCPCS J0894 47335-0361-41 DECITABINE 50 MG IV SOLR BOTH IP/OP "$1,314.00 " $972.36 $0.00 "$2,381.28" $0.00 $0.00 $0.00 $0.00 $0.00 $975.25 $975.25 "$1,012.83" $0.00 $201.28 $0.00 $0.00 $0.00 $392.96 "$1,488.30" "$2,357.47" "$2,381.28" $542.66 $542.66 $252.63 $0.00 $0.00 $240.54 $214.05 $0.00 $0.00 $0.00 $0.00 76364 ERX HCPCS J0894 55111-0556-10 DECITABINE 50 MG IV SOLR BOTH IP/OP "$1,314.00 " $972.36 $0.00 "$2,381.28" $0.00 $0.00 $0.00 $0.00 $0.00 $975.25 $975.25 "$1,012.83" $0.00 $201.28 $0.00 $0.00 $0.00 $392.96 "$1,488.30" "$2,357.47" "$2,381.28" $542.66 $542.66 $252.63 $0.00 $0.00 $240.54 $214.05 $0.00 $0.00 $0.00 $0.00 76396 ERX HCPCS 25000001 68968-5555-03 METHYLPHENIDATE 30 MG/9HR TD PTCH BOTH IP/OP $73.91 $54.69 $0.00 $56.97 $0.00 $0.00 $0.00 $0.00 $0.00 $54.86 $54.86 $56.97 $0.00 $15.40 $0.00 $0.00 $0.00 $0.00 $30.13 $47.72 $48.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76437 ERX HCPCS 63700001 55111-0587-01 AMLODIPINE-BENAZEPRIL 5-40 MG PO CAPSULE BOTH IP/OP $16.80 $12.43 $0.00 $12.19 $0.00 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $7.62 $12.07 $12.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76437 ERX HCPCS 63700001 65862-0585-01 AMLODIPINE-BENAZEPRIL 5-40 MG PO CAPSULE BOTH IP/OP $16.80 $12.43 $0.00 $12.19 $0.00 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $7.62 $12.07 $12.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76438 ERX HCPCS 63700001 55111-0586-01 AMLODIPINE-BENAZEPRIL HCL 10-40 MG PO CAPS BOTH IP/OP $20.29 $15.01 $0.00 $14.72 $0.00 $0.00 $0.00 $3.61 $0.00 $0.00 $0.00 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $9.20 $14.57 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76438 ERX HCPCS 63700001 65862-0587-01 AMLODIPINE-BENAZEPRIL HCL 10-40 MG PO CAPS BOTH IP/OP $20.29 $15.01 $0.00 $14.72 $0.00 $0.00 $0.00 $3.61 $0.00 $0.00 $0.00 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $9.20 $14.57 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76444 ERX HCPCS 63700001 00069-0468-56 VARENICLINE TARTRATE 0.5 MG PO TABS BOTH IP/OP $36.03 $26.66 $0.00 $28.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.02 $28.54 $28.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76445 ERX HCPCS 63700001 00069-0469-56 VARENICLINE TARTRATE 1 MG PO TABS BOTH IP/OP $36.03 $26.66 $0.00 $28.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.02 $28.54 $28.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76446 ERX HCPCS 63700001 00069-0471-03 VARENICLINE STARTING 0.5 MG X 11 & 1 MG X 42 PO MISC BOTH IP/OP $38.07 $28.17 $0.00 $30.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.04 $30.15 $30.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76472 ERX HCPCS 25000001 49348-0636-34 LORATADINE 5 MG/5ML PO SYRP BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76472 ERX HCPCS 25000001 51672-2073-08 LORATADINE 5 MG/5ML PO SYRP BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76618 ERX HCPCS 25000001 00065-0356-10 OPTI-FREE REPLENISH SOLN BOTH IP/OP $40.23 $29.77 $0.00 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $29.86 $29.86 $31.01 $0.00 $8.38 $0.00 $0.00 $0.00 $0.00 $18.24 $28.89 $29.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76641 ERX HCPCS 25000001 24208-0539-20 ACETYLCHOLINE CHLORIDE 20 MG IO SOLR BOTH IP/OP $461.64 $341.61 $0.00 $355.83 $0.00 $0.00 $0.00 $0.00 $0.00 $342.63 $342.63 $355.83 $0.00 $96.21 $0.00 $0.00 $0.00 $0.00 $190.05 $301.04 $304.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76717 ERX HCPCS 63700001 00003-0527-11 DASATINIB 20 MG PO TABS BOTH IP/OP "$1,742.93 " "$1,289.77" $0.00 "$1,236.42" $0.00 $0.00 $0.00 $324.20 $0.00 $0.00 $0.00 $0.00 $0.00 $363.23 $0.00 $0.00 $0.00 $0.00 $772.77 "$1,224.06" "$1,236.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76718 ERX HCPCS 63700001 00003-0528-11 DASATINIB 50 MG PO TABS BOTH IP/OP "$1,742.93 " "$1,289.77" $0.00 "$1,236.42" $0.00 $0.00 $0.00 $324.20 $0.00 $0.00 $0.00 $0.00 $0.00 $363.23 $0.00 $0.00 $0.00 $0.00 $772.76 "$1,224.05" "$1,236.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76719 ERX HCPCS 63700001 00003-0524-11 DASATINIB 70 MG PO TABS BOTH IP/OP $982.50 $727.05 $0.00 $682.61 $0.00 $0.00 $0.00 $182.75 $0.00 $0.00 $0.00 $0.00 $0.00 $204.75 $0.00 $0.00 $0.00 $0.00 $426.63 $675.78 $682.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76780 ERX HCPCS 25000001 66993-0490-36 IBUPROFEN LYSINE 10 MG/ML IV SOLN BOTH IP/OP "$1,417.99 " "$1,049.31" $0.00 "$1,092.99" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,052.43" "$1,052.43" "$1,092.99" $0.00 $295.51 $0.00 $0.00 $0.00 $0.00 $656.99 "$1,040.66" "$1,051.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76783 ERX HCPCS 63700001 59572-0415-21 LENALIDOMIDE 15 MG PO CAPS BOTH IP/OP "$2,478.15 " "$1,833.83" $0.00 "$1,757.98" $0.00 $0.00 $0.00 $460.96 $0.00 $0.00 $0.00 $0.00 $0.00 $516.45 $0.00 $0.00 $0.00 $0.00 "$1,098.74" "$1,740.40" "$1,757.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76784 ERX HCPCS 63700001 59572-0425-00 LENALIDOMIDE 25 MG PO CAPS BOTH IP/OP "$2,478.15 " "$1,833.83" $0.00 "$1,757.98" $0.00 $0.00 $0.00 $460.96 $0.00 $0.00 $0.00 $0.00 $0.00 $516.45 $0.00 $0.00 $0.00 $0.00 "$1,098.74" "$1,740.40" "$1,757.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76784 ERX HCPCS 63700001 59572-0425-21 LENALIDOMIDE 25 MG PO CAPS BOTH IP/OP "$2,478.15 " "$1,833.83" $0.00 "$1,757.98" $0.00 $0.00 $0.00 $460.96 $0.00 $0.00 $0.00 $0.00 $0.00 $516.45 $0.00 $0.00 $0.00 $0.00 "$1,098.74" "$1,740.40" "$1,757.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76829 ERX HCPCS 63700001 00121-1744-00 GUAIFENESIN 100 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76829 ERX HCPCS 63700001 00121-1744-05 GUAIFENESIN 100 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76829 ERX HCPCS 63700001 99999-6007-12 GUAIFENESIN 100 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76835 ERX HCPCS 63700001 15584-0101-01 ATRIPLA:EFAVIRENZ-EMTRICITAB-TENOFOV 600-200-300MGTAB BOTH IP/OP $402.49 $297.84 $0.00 $292.29 $0.00 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 $83.88 $0.00 $0.00 $0.00 $0.00 $182.68 $289.37 $292.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76843 ERX HCPCS J8501 00006-0464-05 APREPITANT 40 MG PO CAPS BOTH IP/OP $432.04 $319.71 $0.00 $345.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.02 $342.18 $345.63 $0.00 $0.00 $67.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76843 ERX HCPCS J8501 00781-2321-06 APREPITANT 40 MG PO CAPS BOTH IP/OP $432.04 $319.71 $0.00 $345.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.02 $342.18 $345.63 $0.00 $0.00 $67.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76843 ERX HCPCS J8501 00781-2321-51 APREPITANT 40 MG PO CAPS BOTH IP/OP $432.04 $319.71 $0.00 $345.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.02 $342.18 $345.63 $0.00 $0.00 $67.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76843 ERX HCPCS J8501 68462-0583-40 APREPITANT 40 MG PO CAPS BOTH IP/OP $432.04 $319.71 $0.00 $345.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.02 $342.18 $345.63 $0.00 $0.00 $67.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76843 ERX HCPCS J8501 68462-0583-85 APREPITANT 40 MG PO CAPS BOTH IP/OP $432.04 $319.71 $0.00 $345.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.02 $342.18 $345.63 $0.00 $0.00 $67.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76913 ERX HCPCS 25000001 00121-1680-16 KCL 20 MEQ/15ML (10%) PO SOLN BOTH IP/OP $97.97 $72.50 $0.00 $75.52 $0.00 $0.00 $0.00 $0.00 $0.00 $72.71 $72.71 $75.52 $0.00 $20.42 $0.00 $0.00 $0.00 $0.00 $35.34 $4.75 $56.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76913 ERX HCPCS 25000001 00603-1542-58 KCL 20 MEQ/15ML (10%) PO SOLN BOTH IP/OP $97.97 $72.50 $0.00 $75.52 $0.00 $0.00 $0.00 $0.00 $0.00 $72.71 $72.71 $75.52 $0.00 $20.42 $0.00 $0.00 $0.00 $0.00 $35.34 $4.75 $56.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76913 ERX HCPCS 25000001 43386-0168-01 KCL 20 MEQ/15ML (10%) PO SOLN BOTH IP/OP $97.97 $72.50 $0.00 $75.52 $0.00 $0.00 $0.00 $0.00 $0.00 $72.71 $72.71 $75.52 $0.00 $20.42 $0.00 $0.00 $0.00 $0.00 $35.34 $4.75 $56.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76913 ERX HCPCS 25000001 66689-0047-50 KCL 20 MEQ/15ML (10%) PO SOLN BOTH IP/OP $97.97 $72.50 $0.00 $75.52 $0.00 $0.00 $0.00 $0.00 $0.00 $72.71 $72.71 $75.52 $0.00 $20.42 $0.00 $0.00 $0.00 $0.00 $35.34 $4.75 $56.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76913 ERX HCPCS 25000001 99999-6006-99 KCL 20 MEQ/15ML (10%) PO SOLN BOTH IP/OP $97.97 $72.50 $0.00 $75.52 $0.00 $0.00 $0.00 $0.00 $0.00 $72.71 $72.71 $75.52 $0.00 $20.42 $0.00 $0.00 $0.00 $0.00 $35.34 $4.75 $56.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76974 ERX HCPCS 25000001 00713-0102-06 GLYCERIN (LAXATIVE) 1.2 G RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76997 ERX HCPCS 63700001 00904-5824-60 CHOLECALCIFEROL-D3 1000 UNITS PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76997 ERX HCPCS 63700001 00904-5824-93 CHOLECALCIFEROL-D3 1000 UNITS PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76997 ERX HCPCS 63700001 20555-0033-00 CHOLECALCIFEROL-D3 1000 UNITS PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76997 ERX HCPCS 63700001 80681-0169-00 CHOLECALCIFEROL-D3 1000 UNITS PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77006 ERX HCPCS J2270 99999-6011-51 MORPHINE SULFATE PCA 5 MG/ML IV SOLN BOTH IP/OP $303.63 $224.69 $0.00 $234.04 $136.63 $136.63 $0.00 $0.00 $0.00 $63.28 $225.35 $225.35 $234.04 $0.00 $19.92 $0.00 $179.60 $179.60 $0.00 $137.82 $218.30 $220.50 $0.00 $0.00 $11.93 $0.00 $0.00 $11.36 $0.00 $0.00 $0.00 $0.00 $0.00 77006 ERX HCPCS J2270 99999-6007-23 MORPHINE SULFATE PCA 5 MG/ML IV SOLN BOTH IP/OP $303.63 $224.69 $0.00 $550.94 $136.63 $136.63 $0.00 $0.00 $0.00 $63.28 $225.35 $225.35 $234.04 $0.00 $19.92 $0.00 $179.60 $179.60 $0.00 $137.82 $550.94 $220.50 $0.00 $0.00 $11.93 $0.00 $0.00 $11.36 $0.00 $0.00 $0.00 $0.00 $0.00 77007 ERX HCPCS J1050 00009-0626-01 MEDROXYPROGESTERONE ACETATE 400 MG/ML IM SUSP BOTH IP/OP $685.44 $507.23 $0.00 $548.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $542.87 $548.35 $0.00 $0.00 $263.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77012 ERX HCPCS J7307 00052-4330-01 ETONOGESTREL 68 MG SC IMPL BOTH IP/OP "$2,795.11 " "$2,068.38" $0.00 "$2,154.47" "$1,257.80" "$1,257.80" $0.00 $0.00 $942.30 $827.51 "$2,074.53" "$2,074.53" "$2,154.47" $0.00 "$1,211.00" $0.00 "$1,377.99" "$1,377.99" $0.00 "$1,207.32" "$1,821.32" "$1,931.71" "$1,448.78" "$1,448.78" "$1,098.41" $0.00 $0.00 "$1,045.88" $0.00 $0.00 $0.00 $0.00 $0.00 77164 ERX HCPCS 25000001 17238-0610-15 HYPROMELLOSE 2.5 % OP SOLN BOTH IP/OP $29.64 $21.93 $0.00 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.82 $23.47 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77164 ERX HCPCS 25000001 17478-0064-12 HYPROMELLOSE 2.5 % OP SOLN BOTH IP/OP $29.64 $21.93 $0.00 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.82 $23.47 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77174 ERX HCPCS 25000001 00173-0716-20 FLUTICASONE-SALMETEROL 115-21 MCG/ACT IN AERO BOTH IP/OP "$1,421.75 " "$1,052.10" $0.00 "$1,095.88" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,055.22" "$1,055.22" "$1,095.88" $0.00 $296.29 $0.00 $0.00 $0.00 $0.00 $626.35 $992.14 "$1,002.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77195 ERX HCPCS J1953 00143-9574-25 LEVETIRACETAM 500 MG/5ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $6.55 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $4.46 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 77195 ERX HCPCS J1953 00143-9673-25 LEVETIRACETAM 500 MG/5ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $6.55 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $4.46 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 77195 ERX HCPCS J1953 00409-1886-02 LEVETIRACETAM 500 MG/5ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $6.55 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $4.46 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 77195 ERX HCPCS J1953 25021-0780-05 LEVETIRACETAM 500 MG/5ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $6.55 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $4.46 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 77195 ERX HCPCS J1953 50474-0002-63 LEVETIRACETAM 500 MG/5ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $6.55 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $4.46 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 77195 ERX HCPCS J1953 55150-0177-05 LEVETIRACETAM 500 MG/5ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $6.55 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $4.46 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 77308 ERX HCPCS 25000001 00517-6510-25 SELENIUM 40 MCG/ML IV SOLN BOTH IP/OP $77.56 $57.39 $0.00 $62.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.78 $61.43 $62.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77318 ERX HCPCS J1250 00409-2344-01 DOBUTAMINE HCL 250 MG/20ML IV SOLN BOTH IP/OP $28.33 $20.96 $0.00 $21.84 $12.75 $12.75 $0.00 $0.00 $0.00 $6.58 $21.03 $21.03 $21.84 $0.00 $9.65 $0.00 $16.76 $16.76 $0.00 $12.66 $20.05 $20.25 $0.00 $0.00 $7.14 $0.00 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $0.00 77318 ERX HCPCS J1250 00409-2344-02 DOBUTAMINE HCL 250 MG/20ML IV SOLN BOTH IP/OP $28.33 $20.96 $0.00 $21.84 $12.75 $12.75 $0.00 $0.00 $0.00 $6.58 $21.03 $21.03 $21.84 $0.00 $9.65 $0.00 $16.76 $16.76 $0.00 $12.66 $20.05 $20.25 $0.00 $0.00 $7.14 $0.00 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $0.00 77318 ERX HCPCS J1250 00409-2344-88 DOBUTAMINE HCL 250 MG/20ML IV SOLN BOTH IP/OP $28.33 $20.96 $0.00 $21.84 $12.75 $12.75 $0.00 $0.00 $0.00 $6.58 $21.03 $21.03 $21.84 $0.00 $9.65 $0.00 $16.76 $16.76 $0.00 $12.66 $20.05 $20.25 $0.00 $0.00 $7.14 $0.00 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $0.00 77371 ERX HCPCS 25000001 00085-1328-01 POSACONAZOLE 40 MG/ML PO SUSP BOTH IP/OP "$3,904.06 " "$2,889.00" $0.00 "$3,009.25" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,897.59" "$2,897.59" "$3,009.25" $0.00 $813.61 $0.00 $0.00 $0.00 $0.00 "$1,770.65" "$2,804.71" "$2,833.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77411 ERX HCPCS 25000001 63323-0406-03 CAFFEINE CITRATE 20 MG/ML PO SOLN BOTH IP/OP "$1,414.48 " "$1,046.72" $0.00 "$1,090.28" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,049.83" "$1,049.83" "$1,090.28" $0.00 $294.78 $0.00 $0.00 $0.00 $0.00 $84.78 $134.28 $135.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77411 ERX HCPCS 25000001 99999-6004-97 CAFFEINE CITRATE 20 MG/ML PO SOLN BOTH IP/OP "$1,414.48 " "$1,046.72" $0.00 "$1,090.28" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,049.83" "$1,049.83" "$1,090.28" $0.00 $294.78 $0.00 $0.00 $0.00 $0.00 $84.78 "$1,016.68" $135.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77412 ERX HCPCS J0706 25021-0601-03 CAFFEINE CITRATE 60 MG/3ML IV SOLN BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77412 ERX HCPCS J0706 42571-0244-69 CAFFEINE CITRATE 60 MG/3ML IV SOLN BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77412 ERX HCPCS J0706 47335-0289-40 CAFFEINE CITRATE 60 MG/3ML IV SOLN BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77412 ERX HCPCS J0706 51754-0500-01 CAFFEINE CITRATE 60 MG/3ML IV SOLN BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77412 ERX HCPCS J0706 51754-0502-01 CAFFEINE CITRATE 60 MG/3ML IV SOLN BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77412 ERX HCPCS J0706 55150-0187-03 CAFFEINE CITRATE 60 MG/3ML IV SOLN BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77412 ERX HCPCS J0706 72485-0104-01 CAFFEINE CITRATE 60 MG/3ML IV SOLN BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77539 ERX HCPCS 63700001 00006-0568-40 VORINOSTAT 100 MG PO CAPS BOTH IP/OP "$1,314.85 " $972.99 $0.00 $954.62 $0.00 $0.00 $0.00 $234.04 $0.00 $0.00 $0.00 $0.00 $0.00 $274.01 $0.00 $0.00 $0.00 $0.00 $596.64 $945.07 $954.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77615 ERX HCPCS 63700001 00006-0221-01 SITAGLIPTIN PHOSPHATE 25 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77615 ERX HCPCS 63700001 00006-0221-28 SITAGLIPTIN PHOSPHATE 25 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77615 ERX HCPCS 63700001 00006-0221-31 SITAGLIPTIN PHOSPHATE 25 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77615 ERX HCPCS 63700001 00006-0221-54 SITAGLIPTIN PHOSPHATE 25 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77616 ERX HCPCS 63700001 00006-0112-01 SITAGLIPTIN PHOSPHATE 50 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77616 ERX HCPCS 63700001 00006-0112-28 SITAGLIPTIN PHOSPHATE 50 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77616 ERX HCPCS 63700001 00006-0112-31 SITAGLIPTIN PHOSPHATE 50 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77616 ERX HCPCS 63700001 00006-0112-54 SITAGLIPTIN PHOSPHATE 50 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77617 ERX HCPCS 63700001 00006-0277-01 SITAGLIPTIN PHOSPHATE 100 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77617 ERX HCPCS 63700001 00006-0277-28 SITAGLIPTIN PHOSPHATE 100 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77617 ERX HCPCS 63700001 00006-0277-31 SITAGLIPTIN PHOSPHATE 100 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77617 ERX HCPCS 63700001 00006-0277-54 SITAGLIPTIN PHOSPHATE 100 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77617 ERX HCPCS 63700001 00006-0277-82 SITAGLIPTIN PHOSPHATE 100 MG PO TABS BOTH IP/OP $83.27 $61.62 $0.00 $57.57 $0.00 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77648 ERX HCPCS 63700001 00003-3622-12 ATAZANAVIR SULFATE 300 MG PO CAPS BOTH IP/OP $191.13 $141.44 $0.00 $138.80 $0.00 $0.00 $0.00 $34.02 $0.00 $0.00 $0.00 $0.00 $0.00 $39.83 $0.00 $0.00 $0.00 $0.00 $86.75 $137.41 $138.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77648 ERX HCPCS 63700001 00093-5528-56 ATAZANAVIR SULFATE 300 MG PO CAPS BOTH IP/OP $191.13 $141.44 $0.00 $138.80 $0.00 $0.00 $0.00 $34.02 $0.00 $0.00 $0.00 $0.00 $0.00 $39.83 $0.00 $0.00 $0.00 $0.00 $86.75 $137.41 $138.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77648 ERX HCPCS 63700001 65862-0713-30 ATAZANAVIR SULFATE 300 MG PO CAPS BOTH IP/OP $191.13 $141.44 $0.00 $138.80 $0.00 $0.00 $0.00 $34.02 $0.00 $0.00 $0.00 $0.00 $0.00 $39.83 $0.00 $0.00 $0.00 $0.00 $86.75 $137.41 $138.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77685 ERX HCPCS J2248 00469-3211-10 MICAFUNGIN SODIUM 100 MG IV SOLR BOTH IP/OP $594.66 $440.05 $0.00 $475.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.33 $470.97 $475.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77710 ERX HCPCS 25000001 00121-1576-10 METOCLOPRAMIDE HCL 10 MG/10ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77822 ERX HCPCS 63700001 00173-0388-79 BECLOMETHASONE DIPROP MONOHYD 42 MCG/SPRAY NA SUSP BOTH IP/OP "$1,027.92 " $760.66 $0.00 $746.30 $0.00 $0.00 $0.00 $182.97 $0.00 $0.00 $0.00 $0.00 $0.00 $214.22 $0.00 $0.00 $0.00 $0.00 $466.44 $738.83 $746.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78003 ERX HCPCS 63700001 50383-0087-07 GUAIFENESIN-CODEINE 100-10 MG/5ML PO SYRP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78030 ERX HCPCS 25000001 58914-0214-60 AQUADEKS PO LIQD BOTH IP/OP $96.81 $71.64 $0.00 $74.62 $0.00 $0.00 $0.00 $0.00 $0.00 $71.85 $71.85 $74.62 $0.00 $20.18 $0.00 $0.00 $0.00 $0.00 $43.89 $69.52 $70.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78064 ERX HCPCS 63700001 10147-0952-03 PALIPERIDONE ER 3 MG PO TB24 BOTH IP/OP $168.31 $124.55 $0.00 $134.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.16 $133.30 $134.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78064 ERX HCPCS 63700001 50458-0550-01 PALIPERIDONE ER 3 MG PO TB24 BOTH IP/OP $168.31 $124.55 $0.00 $134.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.16 $133.30 $134.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78065 ERX HCPCS 63700001 00378-3980-93 PALIPERIDONE ER 6 MG PO TB24 BOTH IP/OP $168.31 $124.55 $0.00 $134.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.16 $133.30 $134.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78065 ERX HCPCS 63700001 50458-0551-10 PALIPERIDONE ER 6 MG PO TB24 BOTH IP/OP $168.31 $124.55 $0.00 $134.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.16 $133.30 $134.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78066 ERX HCPCS 63700001 00591-3695-30 PALIPERIDONE ER 9 MG PO TB24 BOTH IP/OP $177.16 $131.10 $0.00 $128.50 $0.00 $0.00 $0.00 $31.53 $0.00 $0.00 $0.00 $0.00 $0.00 $36.92 $0.00 $0.00 $0.00 $0.00 $80.32 $127.22 $128.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78420 ERX HCPCS J9025 59572-0102-01 AZACITIDINE 100 MG IJ SUSR BOTH IP/OP "$1,818.94 " "$1,346.02" $0.00 "$1,402.04" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,350.02" "$1,350.02" "$1,402.04" $0.00 $108.81 $0.00 $0.00 $0.00 $0.00 $842.75 "$1,334.92" "$1,348.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78615 ERX HCPCS 63700001 00186-4020-01 ESOMEPRAZOLE 20 MG PO PACK BOTH IP/OP $48.15 $35.63 $0.00 $34.94 $0.00 $0.00 $0.00 $8.57 $0.00 $0.00 $0.00 $0.00 $0.00 $10.03 $0.00 $0.00 $0.00 $0.00 $21.84 $34.59 $34.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78616 ERX HCPCS 63700001 00186-4040-01 ESOMEPRAZOLE 40 MG PO PACK BOTH IP/OP $48.15 $35.63 $0.00 $34.94 $0.00 $0.00 $0.00 $8.57 $0.00 $0.00 $0.00 $0.00 $0.00 $10.03 $0.00 $0.00 $0.00 $0.00 $21.84 $34.59 $34.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78879 ERX HCPCS 63700001 00904-2533-21 CALAMINE 8-8 % EX LOTN BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $1.96 $0.00 $0.00 $0.00 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79088 ERX HCPCS 63700001 00121-0775-16 GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79088 ERX HCPCS 63700001 00121-1775-00 GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79088 ERX HCPCS 63700001 00121-1775-05 GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79088 ERX HCPCS 63700001 50383-0087-07 GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79088 ERX HCPCS 63700001 69543-0276-16 GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79088 ERX HCPCS 63700001 99999-6006-93 GUAIFENESIN-CODEINE 100-10 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81426 ERX HCPCS 63700001 00904-6364-61 DIVALPROEX SODIUM ER 500 MG PO TB24 BOTH IP/OP $10.36 $7.67 $0.00 $7.51 $0.00 $0.00 $0.00 $1.84 $0.00 $0.00 $0.00 $0.00 $0.00 $2.16 $0.00 $0.00 $0.00 $0.00 $4.70 $7.44 $7.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81426 ERX HCPCS 63700001 16714-0485-01 DIVALPROEX SODIUM ER 500 MG PO TB24 BOTH IP/OP $10.36 $7.67 $0.00 $7.51 $0.00 $0.00 $0.00 $1.84 $0.00 $0.00 $0.00 $0.00 $0.00 $2.16 $0.00 $0.00 $0.00 $0.00 $4.70 $7.44 $7.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81426 ERX HCPCS 63700001 16714-0485-02 DIVALPROEX SODIUM ER 500 MG PO TB24 BOTH IP/OP $10.36 $7.67 $0.00 $7.51 $0.00 $0.00 $0.00 $1.84 $0.00 $0.00 $0.00 $0.00 $0.00 $2.16 $0.00 $0.00 $0.00 $0.00 $4.70 $7.44 $7.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81426 ERX HCPCS 63700001 65862-0595-01 DIVALPROEX SODIUM ER 500 MG PO TB24 BOTH IP/OP $10.36 $7.67 $0.00 $7.51 $0.00 $0.00 $0.00 $1.84 $0.00 $0.00 $0.00 $0.00 $0.00 $2.16 $0.00 $0.00 $0.00 $0.00 $4.70 $7.44 $7.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81453 ERX HCPCS 63700001 00186-0372-20 BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO BOTH IP/OP "$1,392.01 " "$1,030.09" $0.00 $991.83 $0.00 $0.00 $0.00 $247.78 $0.00 $0.00 $0.00 $0.00 $0.00 $290.09 $0.00 $0.00 $0.00 $0.00 $619.90 $981.91 $991.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81453 ERX HCPCS 63700001 00186-0372-28 BUDESONIDE-FORMOTEROL FUMARATE 80-4.5 MCG/ACT IN AERO BOTH IP/OP "$1,392.01 " "$1,030.09" $0.00 $991.83 $0.00 $0.00 $0.00 $247.78 $0.00 $0.00 $0.00 $0.00 $0.00 $290.09 $0.00 $0.00 $0.00 $0.00 $619.90 $981.91 $991.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81454 ERX HCPCS 63700001 00186-0370-28 BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO BOTH IP/OP $902.67 $667.98 $0.00 "$1,140.94" $0.00 $0.00 $0.00 $160.68 $0.00 $0.00 $0.00 $0.00 $0.00 $188.12 $0.00 $0.00 $0.00 $0.00 $713.09 $623.60 "$1,140.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81454 ERX HCPCS 63700001 00186-0370-20 BUDESONIDE-FORMOTEROL FUMARATE 160-4.5 MCG/ACT IN AERO BOTH IP/OP $902.67 $667.98 $0.00 "$1,140.94" $0.00 $0.00 $0.00 $160.68 $0.00 $0.00 $0.00 $0.00 $0.00 $188.12 $0.00 $0.00 $0.00 $0.00 $713.09 "$1,129.53" "$1,140.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81461 ERX HCPCS J8700 00781-2694-75 TEMOZOLOMIDE 140 MG PO CAPS BOTH IP/OP "$1,032.53 " $764.07 $0.00 $795.87 $0.00 $0.00 $0.00 $0.00 $0.00 $766.34 $766.34 $795.87 $0.00 $215.18 $0.00 $0.00 $0.00 $0.00 $468.53 $742.15 $749.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81474 ERX HCPCS 63700001 59417-0103-10 LISDEXAMFETAMINE DIMESYLATE 30 MG PO CAPS BOTH IP/OP $56.15 $41.55 $0.00 $38.80 $0.00 $0.00 $0.00 $10.49 $0.00 $0.00 $0.00 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $24.25 $38.41 $38.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81479 ERX HCPCS 63700001 58914-0601-20 BIS SUBCIT-METRONID-TETRACYC 140-125-125 MG PO CAPS BOTH IP/OP $106.71 $78.97 $0.00 $77.41 $0.00 $0.00 $0.00 $18.99 $0.00 $0.00 $0.00 $0.00 $0.00 $22.24 $0.00 $0.00 $0.00 $0.00 $48.38 $76.63 $77.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81540 ERX HCPCS 63700001 00006-0577-61 JANUMET 50-1000 MG (SITAGLIPTIN-METFORMIN) PO TABS BOTH IP/OP $41.64 $30.81 $0.00 $28.78 $0.00 $0.00 $0.00 $7.78 $0.00 $0.00 $0.00 $0.00 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $17.99 $28.50 $28.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81541 ERX HCPCS 63700001 00006-0575-61 JANUMET 50-500 MG (SITAGLIPTIN-METFORMIN) PO TABS BOTH IP/OP $41.64 $30.81 $0.00 $28.78 $0.00 $0.00 $0.00 $7.78 $0.00 $0.00 $0.00 $0.00 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $17.99 $28.50 $28.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81696 ERX HCPCS J1300 25682-0001-01 ECULIZUMAB 300 MG/30ML IV SOLN BOTH IP/OP "$17,690.38 " "$13,090.88" $0.00 "$13,635.74" $0.00 $0.00 $0.00 $0.00 "$3,687.12" "$13,129.80" "$13,129.80" "$13,635.74" "$6,876.84" "$8,080.29" "$4,469.95" "$8,721.36" "$8,721.36" "$7,260.09" "$8,023.29" "$12,708.89" "$12,837.26" "$10,025.84" "$10,025.84" "$8,124.42" $0.00 $0.00 "$7,735.83" "$6,914.37" $0.00 $0.00 $0.00 $0.00 81725 ERX HCPCS 25000001 99073-0708-22 FREESTYLE LITE TEST VI STRP BOTH IP/OP $302.24 $223.66 $0.00 $232.97 $0.00 $0.00 $0.00 $0.00 $0.00 $224.32 $224.32 $232.97 $0.00 $62.99 $0.00 $0.00 $0.00 $0.00 $137.19 $217.30 $219.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81823 ERX HCPCS 25000001 00574-0069-15 GLUCOSE 40 % PO GEL BOTH IP/OP $16.56 $12.25 $0.00 $12.76 $0.00 $0.00 $0.00 $0.00 $0.00 $12.29 $12.29 $12.76 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $7.51 $11.89 $12.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81823 ERX HCPCS 25000001 00574-0069-30 GLUCOSE 40 % PO GEL BOTH IP/OP $16.56 $12.25 $0.00 $12.76 $0.00 $0.00 $0.00 $0.00 $0.00 $12.29 $12.29 $12.76 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $7.51 $11.89 $12.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81823 ERX HCPCS 25000001 00574-0070-30 GLUCOSE 40 % PO GEL BOTH IP/OP $16.56 $12.25 $0.00 $12.76 $0.00 $0.00 $0.00 $0.00 $0.00 $12.29 $12.29 $12.76 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $7.51 $11.89 $12.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82021 ERX HCPCS 25000001 00121-0677-16 TRICITRATES 550-500-334 MG/5ML PO SOLN BOTH IP/OP $206.81 $153.04 $0.00 $159.41 $0.00 $0.00 $0.00 $0.00 $0.00 $153.49 $153.49 $159.41 $0.00 $43.10 $0.00 $0.00 $0.00 $0.00 $93.87 $148.69 $150.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82085 ERX HCPCS 25000001 10019-0120-01 ESMOLOL HCL 100 MG/10ML IV SOLN BOTH IP/OP $57.86 $42.82 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.94 $42.94 $44.60 $0.00 $12.06 $0.00 $0.00 $0.00 $0.00 $26.24 $41.56 $41.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82085 ERX HCPCS 25000001 25021-0314-10 ESMOLOL HCL 100 MG/10ML IV SOLN BOTH IP/OP $57.86 $42.82 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.94 $42.94 $44.60 $0.00 $12.06 $0.00 $0.00 $0.00 $0.00 $26.24 $41.56 $41.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82085 ERX HCPCS 25000001 55150-0194-10 ESMOLOL HCL 100 MG/10ML IV SOLN BOTH IP/OP $57.86 $42.82 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.94 $42.94 $44.60 $0.00 $12.06 $0.00 $0.00 $0.00 $0.00 $26.24 $41.56 $41.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82085 ERX HCPCS 25000001 63323-0652-10 ESMOLOL HCL 100 MG/10ML IV SOLN BOTH IP/OP $57.86 $42.82 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.94 $42.94 $44.60 $0.00 $12.06 $0.00 $0.00 $0.00 $0.00 $26.24 $41.56 $41.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82085 ERX HCPCS 25000001 67457-0182-00 ESMOLOL HCL 100 MG/10ML IV SOLN BOTH IP/OP $57.86 $42.82 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.94 $42.94 $44.60 $0.00 $12.06 $0.00 $0.00 $0.00 $0.00 $26.24 $41.56 $41.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82085 ERX HCPCS 25000001 67457-0182-10 ESMOLOL HCL 100 MG/10ML IV SOLN BOTH IP/OP $57.86 $42.82 $0.00 $44.60 $0.00 $0.00 $0.00 $0.00 $0.00 $42.94 $42.94 $44.60 $0.00 $12.06 $0.00 $0.00 $0.00 $0.00 $26.24 $41.56 $41.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82100 ERX HCPCS 63700001 50474-0802-03 ROTIGOTINE 2 MG/24HR TD PT24 BOTH IP/OP $110.01 $81.41 $0.00 $79.01 $0.00 $0.00 $0.00 $20.93 $0.00 $0.00 $0.00 $0.00 $0.00 $22.93 $0.00 $0.00 $0.00 $0.00 $49.38 $78.22 $79.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82134 ERX HCPCS 25000001 83490-0307-60 SODIUM CHLORIDE 7 % IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82177 ERX HCPCS Q9956 00407-2707-03 PERFLUTREN PROTEIN A MICROSPH IV SUSP BOTH IP/OP $108.39 $80.21 $0.00 $83.55 $48.78 $48.78 $0.00 $0.00 $0.00 $22.59 $80.45 $80.45 $83.55 $0.00 $22.59 $0.00 $64.11 $64.11 $0.00 $49.14 $77.84 $78.62 $0.00 $0.00 $15.38 $0.00 $0.00 $15.65 $0.00 $0.00 $0.00 $0.00 $0.00 82228 ERX HCPCS J9330 00008-1179-01 TEMSIROLIMUS 25 MG/ML IV SOLN BOTH IP/OP "$5,016.07 " "$3,711.89" $0.00 "$3,866.39" "$2,257.23" "$2,257.23" $868.70 $868.70 $868.70 "$1,045.47" "$3,722.93" "$3,722.93" "$3,866.39" $956.18 "$1,123.51" $621.51 "$2,472.92" "$2,472.92" "$1,394.79" "$2,176.60" "$3,447.73" "$3,482.56" "$1,926.14" "$1,926.14" "$1,407.94" $0.00 $0.00 "$1,340.60" "$1,112.85" $0.00 $0.00 $0.00 $0.00 82301 ERX HCPCS S0077 00009-0775-26 CLINDAMYCIN PHOSPHATE 600 MG/4ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $2.70 $7.07 $16.33 $16.33 $16.96 $0.00 $3.31 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 82301 ERX HCPCS S0077 63323-0282-04 CLINDAMYCIN PHOSPHATE 600 MG/4ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $2.70 $7.07 $16.33 $16.33 $16.96 $0.00 $3.31 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 82302 ERX HCPCS S0077 00009-0902-18 CLINDAMYCIN PHOSPHATE 900 MG/6ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $2.70 $7.07 $16.33 $16.33 $16.96 $0.00 $3.31 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 82302 ERX HCPCS S0077 25021-0115-06 CLINDAMYCIN PHOSPHATE 900 MG/6ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $2.70 $7.07 $16.33 $16.33 $16.96 $0.00 $3.31 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 82302 ERX HCPCS S0077 67457-0816-06 CLINDAMYCIN PHOSPHATE 900 MG/6ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $2.70 $7.07 $16.33 $16.33 $16.96 $0.00 $3.31 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $13.20 $13.20 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 82363 ERX HCPCS 63700001 62332-0205-90 AMLODIPINE-VALSARTAN 5 MG-160 MG TABS BOTH IP/OP $22.91 $16.95 $0.00 $16.62 $0.00 $0.00 $0.00 $4.08 $0.00 $0.00 $0.00 $0.00 $0.00 $4.77 $0.00 $0.00 $0.00 $0.00 $10.39 $16.46 $16.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82363 ERX HCPCS 63700001 65862-0737-30 AMLODIPINE-VALSARTAN 5 MG-160 MG TABS BOTH IP/OP $22.91 $16.95 $0.00 $16.62 $0.00 $0.00 $0.00 $4.08 $0.00 $0.00 $0.00 $0.00 $0.00 $4.77 $0.00 $0.00 $0.00 $0.00 $10.39 $16.46 $16.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82364 ERX HCPCS 63700001 65862-0738-30 AMLODIPINE-VALSARTAN 5 MG-320 MG TABS BOTH IP/OP $29.06 $21.50 $0.00 $21.09 $0.00 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 $6.06 $0.00 $0.00 $0.00 $0.00 $13.18 $20.88 $21.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82365 ERX HCPCS 63700001 00378-1722-93 AMLODIPINE-VALSARTAN 10-160 MG TABLET BOTH IP/OP $26.00 $19.24 $0.00 $18.86 $0.00 $0.00 $0.00 $4.63 $0.00 $0.00 $0.00 $0.00 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $11.79 $18.68 $18.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82365 ERX HCPCS 63700001 62332-0206-90 AMLODIPINE-VALSARTAN 10-160 MG TABLET BOTH IP/OP $26.00 $19.24 $0.00 $18.86 $0.00 $0.00 $0.00 $4.63 $0.00 $0.00 $0.00 $0.00 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $11.79 $18.68 $18.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82365 ERX HCPCS 63700001 65862-0739-30 AMLODIPINE-VALSARTAN 10-160 MG TABLET BOTH IP/OP $26.00 $19.24 $0.00 $18.86 $0.00 $0.00 $0.00 $4.63 $0.00 $0.00 $0.00 $0.00 $0.00 $5.42 $0.00 $0.00 $0.00 $0.00 $11.79 $18.68 $18.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82366 ERX HCPCS 63700001 00078-0491-15 AMLODIPINE-VALSARTAN 10 MG-320 MG TABS BOTH IP/OP $33.00 $24.42 $0.00 $23.94 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $14.97 $23.70 $23.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82366 ERX HCPCS 63700001 00378-1724-93 AMLODIPINE-VALSARTAN 10 MG-320 MG TABS BOTH IP/OP $33.00 $24.42 $0.00 $23.94 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $14.97 $23.70 $23.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82366 ERX HCPCS 63700001 62332-0208-90 AMLODIPINE-VALSARTAN 10 MG-320 MG TABS BOTH IP/OP $33.00 $24.42 $0.00 $23.94 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $14.97 $23.70 $23.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82366 ERX HCPCS 63700001 65862-0740-30 AMLODIPINE-VALSARTAN 10 MG-320 MG TABS BOTH IP/OP $33.00 $24.42 $0.00 $23.94 $0.00 $0.00 $0.00 $5.87 $0.00 $0.00 $0.00 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $14.97 $23.70 $23.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82504 ERX HCPCS 63700001 00078-0501-15 RIVASTIGMINE 4.6 MG/24HR TD PT24 BOTH IP/OP $105.92 $78.38 $0.00 $76.83 $0.00 $0.00 $0.00 $18.85 $0.00 $0.00 $0.00 $0.00 $0.00 $22.07 $0.00 $0.00 $0.00 $0.00 $48.02 $76.06 $76.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82504 ERX HCPCS 63700001 00078-0501-61 RIVASTIGMINE 4.6 MG/24HR TD PT24 BOTH IP/OP $105.92 $78.38 $0.00 $76.83 $0.00 $0.00 $0.00 $18.85 $0.00 $0.00 $0.00 $0.00 $0.00 $22.07 $0.00 $0.00 $0.00 $0.00 $48.02 $76.06 $76.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87795 ERX HCPCS 25000001 10702-0056-01 OXYCODONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87795 ERX HCPCS 25000001 42858-0002-10 OXYCODONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87795 ERX HCPCS 25000001 68084-0968-01 OXYCODONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87795 ERX HCPCS 25000001 68084-0968-11 OXYCODONE HCL 10 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87801 ERX HCPCS 25000001 67768-3063-06 CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87801 ERX HCPCS 25000001 99999-6009-13 CALCIUM GLUCONATE (ANTIDOTE) 2.5 % EX GEL BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87822 ERX HCPCS 25000001 42858-0004-01 OXYCODONE HCL 20 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87834 ERX HCPCS 63700001 00023-9211-05 COMBIGAN: BRIMONIDINE-TIMOLOL 0.2-0.5 % OP SOLN BOTH IP/OP $681.21 $504.10 $0.00 $471.02 $0.00 $0.00 $0.00 $127.32 $0.00 $0.00 $0.00 $0.00 $0.00 $141.96 $0.00 $0.00 $0.00 $0.00 $294.39 $466.31 $471.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87861 ERX HCPCS J1930 15054-1120-03 LANREOTIDE ACETATE 120 MG/0.5ML SC SOLN BOTH IP/OP "$25,932.15 " "$19,189.79" $0.00 "$19,988.50" "$11,669.47" "$11,669.47" "$7,941.96" "$7,941.96" "$7,941.96" "$5,404.91" "$19,246.84" "$19,246.84" "$19,988.50" "$8,116.56" "$9,536.96" "$5,275.76" "$12,784.55" "$12,784.55" "$7,852.82" "$10,769.88" "$17,059.49" "$17,231.81" "$10,844.38" "$10,844.38" "$8,138.89" $0.00 $0.00 "$8,138.89" "$8,450.04" $0.00 $0.00 $0.00 $0.00 87861 ERX HCPCS J1930 15054-1120-04 LANREOTIDE ACETATE 120 MG/0.5ML SC SOLN BOTH IP/OP "$25,932.15 " "$19,189.79" $0.00 "$19,988.50" "$11,669.47" "$11,669.47" "$7,941.96" "$7,941.96" "$7,941.96" "$5,404.91" "$19,246.84" "$19,246.84" "$19,988.50" "$8,116.56" "$9,536.96" "$5,275.76" "$12,784.55" "$12,784.55" "$7,852.82" "$10,769.88" "$17,059.49" "$17,231.81" "$10,844.38" "$10,844.38" "$8,138.89" $0.00 $0.00 "$8,138.89" "$8,450.04" $0.00 $0.00 $0.00 $0.00 87865 ERX HCPCS 25000001 66490-0650-20 DIAZEPAM 2.5 MG RECTAL GEL BOTH IP/OP "$1,036.08 " $766.70 $0.00 $902.66 $0.00 $0.00 $0.00 $0.00 $0.00 $768.98 $768.98 $798.61 $0.00 $215.92 $0.00 $0.00 $0.00 $0.00 $564.17 $893.64 $902.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87867 ERX HCPCS 25000001 00187-0658-20 DIAZEPAM 10 MG RECTAL GEL BOTH IP/OP "$1,229.03 " $909.48 $0.00 $947.34 $0.00 $0.00 $0.00 $0.00 $0.00 $912.19 $912.19 $947.34 $0.00 $256.13 $0.00 $0.00 $0.00 $0.00 $278.85 $441.70 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87869 ERX HCPCS 25000001 00187-0659-20 DIAZEPAM 20 MG RECTAL GEL BOTH IP/OP "$1,229.03 " $909.48 $0.00 $947.34 $0.00 $0.00 $0.00 $0.00 $0.00 $912.19 $912.19 $947.34 $0.00 $256.13 $0.00 $0.00 $0.00 $0.00 $362.51 $574.21 $580.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87889 ERX HCPCS 25000001 00088-2500-33 INSULIN GLULISINE 100 UNIT/ML IJ SOLN BOTH IP/OP $994.97 $736.28 $0.00 $766.92 $0.00 $0.00 $0.00 $0.00 $0.00 $738.47 $738.47 $766.92 $0.00 $207.35 $0.00 $0.00 $0.00 $0.00 $451.49 $715.15 $722.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87912 ERX HCPCS 63700001 51801-0011-17 POTASSIUM BICARB-CITRIC ACID 20 MEQ PO TBEF BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87912 ERX HCPCS 63700001 51801-0011-30 POTASSIUM BICARB-CITRIC ACID 20 MEQ PO TBEF BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87912 ERX HCPCS 63700001 51801-0012-30 POTASSIUM BICARB-CITRIC ACID 20 MEQ PO TBEF BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87998 ERX HCPCS 63700001 49702-0223-18 MARAVIROC 150 MG PO TABS BOTH IP/OP $126.08 $93.30 $0.00 $87.15 $0.00 $0.00 $0.00 $22.44 $0.00 $0.00 $0.00 $0.00 $0.00 $26.28 $0.00 $0.00 $0.00 $0.00 $54.47 $86.28 $87.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87999 ERX HCPCS 63700001 49702-0224-18 MARAVIROC 300 MG PO TABS BOTH IP/OP $126.08 $93.30 $0.00 $87.15 $0.00 $0.00 $0.00 $22.44 $0.00 $0.00 $0.00 $0.00 $0.00 $26.28 $0.00 $0.00 $0.00 $0.00 $54.47 $86.28 $87.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88007 ERX HCPCS 63700001 50228-0424-60 RANOLAZINE ER 1000 MG PO TB12 BOTH IP/OP $56.57 $41.86 $0.00 $39.17 $0.00 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 $11.79 $0.00 $0.00 $0.00 $0.00 $24.48 $38.78 $39.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88007 ERX HCPCS 63700001 61958-1004-01 RANOLAZINE ER 1000 MG PO TB12 BOTH IP/OP $56.57 $41.86 $0.00 $39.17 $0.00 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 $11.79 $0.00 $0.00 $0.00 $0.00 $24.48 $38.78 $39.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88008 ERX HCPCS J9178 00009-5091-01 EPIRUBICIN HCL 50 MG/25ML IV SOLN BOTH IP/OP $172.03 $127.30 $0.00 $137.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.02 $136.25 $137.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88010 ERX HCPCS Q2009 00069-5474-02 FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN BOTH IP/OP $197.79 $146.36 $0.00 $152.46 $89.01 $89.01 $0.00 $0.00 $0.00 $41.22 $146.80 $146.80 $152.46 $0.00 $41.22 $0.00 $116.99 $116.99 $18.11 $89.78 $142.20 $143.64 $25.01 $25.01 $28.10 $0.00 $0.00 $28.58 $17.25 $0.00 $0.00 $0.00 $0.00 88010 ERX HCPCS Q2009 00069-6001-21 FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN BOTH IP/OP $197.79 $146.36 $0.00 $152.46 $89.01 $89.01 $0.00 $0.00 $0.00 $41.22 $146.80 $146.80 $152.46 $0.00 $41.22 $0.00 $116.99 $116.99 $18.11 $89.78 $142.20 $143.64 $25.01 $25.01 $28.10 $0.00 $0.00 $28.58 $17.25 $0.00 $0.00 $0.00 $0.00 88010 ERX HCPCS Q2009 00641-6137-01 FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN BOTH IP/OP $197.79 $146.36 $0.00 $152.46 $89.01 $89.01 $0.00 $0.00 $0.00 $41.22 $146.80 $146.80 $152.46 $0.00 $41.22 $0.00 $116.99 $116.99 $18.11 $89.78 $142.20 $143.64 $25.01 $25.01 $28.10 $0.00 $0.00 $28.58 $17.25 $0.00 $0.00 $0.00 $0.00 88010 ERX HCPCS Q2009 00641-6137-10 FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN BOTH IP/OP $197.79 $146.36 $0.00 $152.46 $89.01 $89.01 $0.00 $0.00 $0.00 $41.22 $146.80 $146.80 $152.46 $0.00 $41.22 $0.00 $116.99 $116.99 $18.11 $89.78 $142.20 $143.64 $25.01 $25.01 $28.10 $0.00 $0.00 $28.58 $17.25 $0.00 $0.00 $0.00 $0.00 88010 ERX HCPCS Q2009 63323-0403-10 FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN BOTH IP/OP $197.79 $146.36 $0.00 $152.46 $89.01 $89.01 $0.00 $0.00 $0.00 $41.22 $146.80 $146.80 $152.46 $0.00 $41.22 $0.00 $116.99 $116.99 $18.11 $89.78 $142.20 $143.64 $25.01 $25.01 $28.10 $0.00 $0.00 $28.58 $17.25 $0.00 $0.00 $0.00 $0.00 88010 ERX HCPCS Q2009 67457-0517-00 FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN BOTH IP/OP $197.79 $146.36 $0.00 $152.46 $89.01 $89.01 $0.00 $0.00 $0.00 $41.22 $146.80 $146.80 $152.46 $0.00 $41.22 $0.00 $116.99 $116.99 $18.11 $89.78 $142.20 $143.64 $25.01 $25.01 $28.10 $0.00 $0.00 $28.58 $17.25 $0.00 $0.00 $0.00 $0.00 88010 ERX HCPCS Q2009 67457-0517-01 FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN BOTH IP/OP $197.79 $146.36 $0.00 $152.46 $89.01 $89.01 $0.00 $0.00 $0.00 $41.22 $146.80 $146.80 $152.46 $0.00 $41.22 $0.00 $116.99 $116.99 $18.11 $89.78 $142.20 $143.64 $25.01 $25.01 $28.10 $0.00 $0.00 $28.58 $17.25 $0.00 $0.00 $0.00 $0.00 88010 ERX HCPCS Q2009 70121-1390-07 FOSPHENYTOIN SODIUM 500 MG PE/10ML IJ SOLN BOTH IP/OP $197.79 $146.36 $0.00 $152.46 $89.01 $89.01 $0.00 $0.00 $0.00 $41.22 $146.80 $146.80 $152.46 $0.00 $41.22 $0.00 $116.99 $116.99 $18.11 $89.78 $142.20 $143.64 $25.01 $25.01 $28.10 $0.00 $0.00 $28.58 $17.25 $0.00 $0.00 $0.00 $0.00 88011 ERX HCPCS Q2009 00069-5471-02 FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN BOTH IP/OP $75.42 $55.81 $0.00 $58.13 $33.94 $33.94 $0.00 $0.00 $0.00 $15.72 $55.98 $55.98 $58.13 $0.00 $15.72 $0.00 $44.61 $44.61 $3.62 $34.20 $54.17 $54.72 $5.00 $5.00 $10.70 $0.00 $0.00 $10.89 $3.45 $0.00 $0.00 $0.00 $0.00 88011 ERX HCPCS Q2009 00069-6001-25 FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN BOTH IP/OP $75.42 $55.81 $0.00 $58.13 $33.94 $33.94 $0.00 $0.00 $0.00 $15.72 $55.98 $55.98 $58.13 $0.00 $15.72 $0.00 $44.61 $44.61 $3.62 $34.20 $54.17 $54.72 $5.00 $5.00 $10.70 $0.00 $0.00 $10.89 $3.45 $0.00 $0.00 $0.00 $0.00 88011 ERX HCPCS Q2009 00641-6136-25 FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN BOTH IP/OP $75.42 $55.81 $0.00 $58.13 $33.94 $33.94 $0.00 $0.00 $0.00 $15.72 $55.98 $55.98 $58.13 $0.00 $15.72 $0.00 $44.61 $44.61 $3.62 $34.20 $54.17 $54.72 $5.00 $5.00 $10.70 $0.00 $0.00 $10.89 $3.45 $0.00 $0.00 $0.00 $0.00 88011 ERX HCPCS Q2009 70121-1381-05 FOSPHENYTOIN SODIUM 100 MG PE/2ML IJ SOLN BOTH IP/OP $75.42 $55.81 $0.00 $58.13 $33.94 $33.94 $0.00 $0.00 $0.00 $15.72 $55.98 $55.98 $58.13 $0.00 $15.72 $0.00 $44.61 $44.61 $3.62 $34.20 $54.17 $54.72 $5.00 $5.00 $10.70 $0.00 $0.00 $10.89 $3.45 $0.00 $0.00 $0.00 $0.00 88093 ERX HCPCS J0348 00049-0116-28 ANIDULAFUNGIN 100 MG IV SOLR BOTH IP/OP $668.89 $494.98 $0.00 $515.58 $301.00 $301.00 $0.00 $0.00 $0.00 $139.41 $496.45 $496.45 $515.58 $0.00 $66.39 $0.00 $395.65 $395.65 $0.00 $286.20 $453.34 $457.92 $0.00 $0.00 $61.10 $0.00 $0.00 $58.18 $0.00 $0.00 $0.00 $0.00 $0.00 88241 ERX HCPCS J9211 00703-4154-11 IDARUBICIN HCL 5 MG/5ML IV SOLN BOTH IP/OP $342.91 $253.75 $0.00 $264.32 $0.00 $0.00 $0.00 $0.00 $0.00 $254.51 $254.51 $264.32 $0.00 $71.46 $0.00 $0.00 $0.00 $0.00 $155.65 $246.54 $249.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88242 ERX HCPCS J9211 00013-2586-91 IDARUBICIN HCL 10 MG/10ML IV SOLN BOTH IP/OP $434.59 $321.60 $0.00 $334.98 $0.00 $0.00 $0.00 $0.00 $0.00 $322.55 $322.55 $334.98 $0.00 $90.57 $0.00 $0.00 $0.00 $0.00 $194.32 $307.80 $310.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88242 ERX HCPCS J9211 00703-4155-11 IDARUBICIN HCL 10 MG/10ML IV SOLN BOTH IP/OP $434.59 $321.60 $0.00 $334.98 $0.00 $0.00 $0.00 $0.00 $0.00 $322.55 $322.55 $334.98 $0.00 $90.57 $0.00 $0.00 $0.00 $0.00 $194.32 $307.80 $310.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88243 ERX HCPCS J9211 00703-4156-11 IDARUBICIN HCL 20 MG/20ML IV SOLN BOTH IP/OP $730.45 $540.53 $0.00 $584.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.23 $578.52 $584.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88317 ERX HCPCS 25000001 68803-0612-10 TRYPAN BLUE 0.06 % OP SOLN BOTH IP/OP $290.65 $215.08 $0.00 $224.03 $0.00 $0.00 $0.00 $0.00 $0.00 $215.72 $215.72 $224.03 $0.00 $60.57 $0.00 $0.00 $0.00 $0.00 $131.93 $208.97 $211.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88376 ERX HCPCS J9060 00703-5747-11 CISPLATIN 50 MG/50ML IV SOLN BOTH IP/OP $83.57 $61.84 $0.00 $64.42 $37.61 $37.61 $0.00 $0.00 $0.00 $13.10 $62.03 $62.03 $64.42 $0.00 $10.42 $0.00 $49.43 $49.43 $0.00 $37.89 $60.02 $60.62 $0.00 $0.00 $11.34 $0.00 $0.00 $10.80 $0.00 $0.00 $0.00 $0.00 $0.00 88376 ERX HCPCS J9060 63323-0103-51 CISPLATIN 50 MG/50ML IV SOLN BOTH IP/OP $83.57 $61.84 $0.00 $64.42 $37.61 $37.61 $0.00 $0.00 $0.00 $13.10 $62.03 $62.03 $64.42 $0.00 $10.42 $0.00 $49.43 $49.43 $0.00 $37.89 $60.02 $60.62 $0.00 $0.00 $11.34 $0.00 $0.00 $10.80 $0.00 $0.00 $0.00 $0.00 $0.00 88377 ERX HCPCS J9060 00703-5748-11 CISPLATIN 100 MG/100ML IV SOLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $22.68 $0.00 $0.00 $21.59 $0.00 $0.00 $0.00 $0.00 $0.00 88377 ERX HCPCS J9060 16729-0288-38 CISPLATIN 100 MG/100ML IV SOLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $22.68 $0.00 $0.00 $21.59 $0.00 $0.00 $0.00 $0.00 $0.00 88377 ERX HCPCS J9060 44567-0510-01 CISPLATIN 100 MG/100ML IV SOLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $22.68 $0.00 $0.00 $21.59 $0.00 $0.00 $0.00 $0.00 $0.00 88377 ERX HCPCS J9060 63323-0103-65 CISPLATIN 100 MG/100ML IV SOLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $22.68 $0.00 $0.00 $21.59 $0.00 $0.00 $0.00 $0.00 $0.00 88378 ERX HCPCS J9060 63323-0103-64 CISPLATIN 200 MG/200ML IV SOLN BOTH IP/OP $300.51 $222.38 $0.00 $231.63 $135.23 $135.23 $0.00 $0.00 $0.00 $52.41 $223.04 $223.04 $231.63 $0.00 $41.69 $0.00 $177.75 $177.75 $0.00 $136.40 $216.05 $218.23 $0.00 $0.00 $45.36 $0.00 $0.00 $43.19 $0.00 $0.00 $0.00 $0.00 $0.00 88567 ERX HCPCS 63700001 00597-0101-90 PRAMIPEXOLE DIHYDROCHLORIDE 0.75 MG PO TABS BOTH IP/OP $32.02 $23.69 $0.00 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.01 $25.36 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88567 ERX HCPCS 63700001 13668-0184-90 PRAMIPEXOLE DIHYDROCHLORIDE 0.75 MG PO TABS BOTH IP/OP $32.02 $23.69 $0.00 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.01 $25.36 $25.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88608 ERX HCPCS 63700001 00006-0227-61 RALTEGRAVIR POTASSIUM 400 MG PO TABS BOTH IP/OP $133.96 $99.13 $0.00 $92.58 $0.00 $0.00 $0.00 $25.03 $0.00 $0.00 $0.00 $0.00 $0.00 $27.92 $0.00 $0.00 $0.00 $0.00 $57.86 $91.65 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88704 ERX HCPCS 63700001 00004-0802-85 OSELTAMIVIR PHOSPHATE 30 MG PO CAPS BOTH IP/OP $47.07 $34.83 $0.00 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.54 $37.28 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88704 ERX HCPCS 63700001 16714-0817-01 OSELTAMIVIR PHOSPHATE 30 MG PO CAPS BOTH IP/OP $47.07 $34.83 $0.00 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.54 $37.28 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88704 ERX HCPCS 63700001 31722-0630-31 OSELTAMIVIR PHOSPHATE 30 MG PO CAPS BOTH IP/OP $47.07 $34.83 $0.00 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.54 $37.28 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88704 ERX HCPCS 63700001 47781-0468-13 OSELTAMIVIR PHOSPHATE 30 MG PO CAPS BOTH IP/OP $47.07 $34.83 $0.00 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.54 $37.28 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88704 ERX HCPCS 63700001 63739-0038-07 OSELTAMIVIR PHOSPHATE 30 MG PO CAPS BOTH IP/OP $47.07 $34.83 $0.00 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.54 $37.28 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88704 ERX HCPCS 63700001 68180-0675-11 OSELTAMIVIR PHOSPHATE 30 MG PO CAPS BOTH IP/OP $47.07 $34.83 $0.00 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.54 $37.28 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88705 ERX HCPCS 63700001 00004-0801-85 OSELTAMIVIR PHOSPHATE 45 MG PO CAPS BOTH IP/OP $70.07 $51.85 $0.00 $50.83 $0.00 $0.00 $0.00 $12.47 $0.00 $0.00 $0.00 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $31.77 $50.32 $50.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88720 ERX HCPCS 63700001 00078-0526-51 NILOTINIB HCL 200 MG PO CAPS BOTH IP/OP $566.86 $419.48 $0.00 $384.72 $0.00 $0.00 $0.00 $106.95 $0.00 $0.00 $0.00 $0.00 $0.00 $118.13 $0.00 $0.00 $0.00 $0.00 $240.45 $380.87 $384.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88806 ERX HCPCS 63700001 00074-0522-60 KALETRA:LOPINAVIR-RITONAVIR 100-25 MG PO TABS BOTH IP/OP $21.46 $15.88 $0.00 $15.57 $0.00 $0.00 $0.00 $3.82 $0.00 $0.00 $0.00 $0.00 $0.00 $4.47 $0.00 $0.00 $0.00 $0.00 $9.73 $15.41 $15.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88945 ERX HCPCS 63700001 53191-0362-01 CHOLECALCIFEROL-D3 50000 UNITS PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89128 ERX HCPCS J3300 00065-0543-01 TRIAMCINOLONE ACETONIDE 40 MG/ML IO SUSP BOTH IP/OP $75.63 $55.97 $0.00 $58.30 $0.00 $0.00 $0.00 $0.00 $15.76 $56.13 $56.13 $58.30 $0.00 $15.76 $0.00 $44.74 $44.74 $0.00 $34.30 $54.32 $54.87 $0.00 $0.00 $10.73 $0.00 $0.00 $10.92 $0.00 $0.00 $0.00 $0.00 $0.00 89201 ERX HCPCS 63700001 00955-1050-27 SEVELAMER CARBONATE 800 MG PO TABS BOTH IP/OP $25.54 $18.90 $0.00 $18.54 $0.00 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.59 $18.35 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89201 ERX HCPCS 63700001 16714-0814-01 SEVELAMER CARBONATE 800 MG PO TABS BOTH IP/OP $25.54 $18.90 $0.00 $18.54 $0.00 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.59 $18.35 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89201 ERX HCPCS 63700001 65162-0058-27 SEVELAMER CARBONATE 800 MG PO TABS BOTH IP/OP $25.54 $18.90 $0.00 $18.54 $0.00 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.59 $18.35 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89201 ERX HCPCS 63700001 65862-0921-27 SEVELAMER CARBONATE 800 MG PO TABS BOTH IP/OP $25.54 $18.90 $0.00 $18.54 $0.00 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 $5.32 $0.00 $0.00 $0.00 $0.00 $11.59 $18.35 $18.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89284 ERX HCPCS 63700001 00456-1405-30 NEBIVOLOL HCL 5 MG PO TABS BOTH IP/OP $26.47 $19.59 $0.00 $18.30 $0.00 $0.00 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $0.00 $5.52 $0.00 $0.00 $0.00 $0.00 $11.44 $18.11 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89286 ERX HCPCS 63700001 00456-1410-30 NEBIVOLOL HCL 10 MG PO TABS BOTH IP/OP $26.47 $19.59 $0.00 $18.30 $0.00 $0.00 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $0.00 $5.52 $0.00 $0.00 $0.00 $0.00 $11.44 $18.11 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89346 ERX HCPCS 25000001 00904-6467-07 CLOPIDOGREL BISULFATE 300 MG PO TABS BOTH IP/OP $108.29 $80.13 $0.00 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.15 $85.77 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89346 ERX HCPCS 25000001 55111-0671-06 CLOPIDOGREL BISULFATE 300 MG PO TABS BOTH IP/OP $108.29 $80.13 $0.00 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.15 $85.77 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89346 ERX HCPCS 25000001 55111-0671-31 CLOPIDOGREL BISULFATE 300 MG PO TABS BOTH IP/OP $108.29 $80.13 $0.00 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.15 $85.77 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89346 ERX HCPCS 25000001 68084-0752-25 CLOPIDOGREL BISULFATE 300 MG PO TABS BOTH IP/OP $108.29 $80.13 $0.00 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.15 $85.77 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89346 ERX HCPCS 25000001 68084-0752-95 CLOPIDOGREL BISULFATE 300 MG PO TABS BOTH IP/OP $108.29 $80.13 $0.00 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.15 $85.77 $86.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89350 ERX HCPCS J9305 00002-7640-01 PEMETREXED DISODIUM 100 MG IV SOLR BOTH IP/OP "$2,392.10 " "$1,770.15" $0.00 "$1,899.15" "$1,108.74" "$1,108.74" $760.37 $760.37 $760.37 $566.59 "$1,828.68" "$1,828.68" "$1,899.15" $749.29 $880.42 $487.04 "$1,179.31" "$1,179.31" $729.46 "$1,065.27" "$1,687.38" "$1,704.42" "$1,007.34" "$1,007.34" $831.78 $0.00 $0.00 $792.00 $724.05 $0.00 $0.00 $0.00 $0.00 89432 ERX HCPCS 63700001 59676-0570-01 ETRAVIRINE 100 MG PO TABS BOTH IP/OP $108.97 $80.64 $0.00 $77.50 $0.00 $0.00 $0.00 $19.78 $0.00 $0.00 $0.00 $0.00 $0.00 $22.71 $0.00 $0.00 $0.00 $0.00 $48.44 $76.72 $77.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89570 ERX HCPCS 25000001 00338-0322-01 THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR BOTH IP/OP $314.76 $232.92 $0.00 $251.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.38 $249.29 $251.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89570 ERX HCPCS 25000001 65293-0006-41 THROMBIN (RECOMBINANT) 5000 UNITS EX SOLR BOTH IP/OP $314.76 $232.92 $0.00 $251.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.38 $249.29 $251.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89740 ERX HCPCS 63700001 60258-0171-01 MAGNESIUM OXIDE 400 (241.3 MG) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89740 ERX HCPCS 63700001 63739-0354-01 MAGNESIUM OXIDE 400 (241.3 MG) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89740 ERX HCPCS 63700001 63739-0354-10 MAGNESIUM OXIDE 400 (241.3 MG) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89783 ERX HCPCS 63700001 59417-0102-10 LISDEXAMFETAMINE DIMESYLATE 20 MG PO CAPS BOTH IP/OP $56.15 $41.55 $0.00 $38.80 $0.00 $0.00 $0.00 $10.49 $0.00 $0.00 $0.00 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $24.25 $38.41 $38.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89791 ERX HCPCS 63700001 00008-0844-01 PANTOPRAZOLE SODIUM 40 MG PO PACK BOTH IP/OP $83.13 $61.52 $0.00 $57.71 $0.00 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 $17.32 $0.00 $0.00 $0.00 $0.00 $36.07 $57.13 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89791 ERX HCPCS 63700001 00008-0844-02 PANTOPRAZOLE SODIUM 40 MG PO PACK BOTH IP/OP $83.13 $61.52 $0.00 $57.71 $0.00 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 $17.32 $0.00 $0.00 $0.00 $0.00 $36.07 $57.13 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90996 ERX HCPCS 63600001 31382-0753-05 MEPIVACAINE HCL 3 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91001 ERX HCPCS 63700001 10122-0901-12 ZILEUTON 600 MG PO TABS BOTH IP/OP $145.10 $107.37 $0.00 $105.26 $0.00 $0.00 $0.00 $25.83 $0.00 $0.00 $0.00 $0.00 $0.00 $30.24 $0.00 $0.00 $0.00 $0.00 $65.79 $104.20 $105.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91018 ERX HCPCS 25000001 00065-0474-01 HYPROMELLOSE 0.3 % OP GEL BOTH IP/OP $29.64 $21.93 $0.00 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.82 $23.47 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91018 ERX HCPCS 25000001 00065-8064-01 HYPROMELLOSE 0.3 % OP GEL BOTH IP/OP $29.64 $21.93 $0.00 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.82 $23.47 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91018 ERX HCPCS 25000001 00078-0429-47 HYPROMELLOSE 0.3 % OP GEL BOTH IP/OP $29.64 $21.93 $0.00 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.82 $23.47 $23.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91033 ERX HCPCS 90633 58160-0825-52 HEPATITIS A VACCINE 720 EL U/0.5ML IM SUSP BOTH IP/OP $160.84 $119.02 $0.00 $123.98 $72.38 $72.38 $0.00 $0.00 $0.00 $9.40 $119.38 $119.38 $123.98 $0.00 $33.52 $0.00 $95.14 $95.14 $0.00 $70.84 $112.20 $113.34 $0.00 $0.00 $22.17 $0.00 $0.00 $22.55 $0.00 $0.00 $0.00 $0.00 $0.00 91034 ERX HCPCS 90632 58160-0826-52 HEPATITIS A VACCINE 1440 EL U/ML IM SUSP BOTH IP/OP $318.74 $235.87 $0.00 $245.68 $143.43 $143.43 $0.00 $0.00 $0.00 $56.67 $236.57 $236.57 $245.68 $0.00 $75.29 $0.00 $188.53 $188.53 $0.00 $135.14 $214.05 $216.22 $0.00 $0.00 $70.39 $0.00 $0.00 $67.03 $0.00 $0.00 $0.00 $0.00 $0.00 91037 ERX HCPCS J3470 00548-9090-10 HYALURONIDASE BOVINE 150 UNIT/ML IJ SOLN BOTH IP/OP $232.36 $171.95 $0.00 $179.10 $104.56 $104.56 $0.00 $0.00 $0.00 $29.38 $172.46 $172.46 $179.10 $0.00 $48.42 $0.00 $137.44 $137.44 $0.00 $105.47 $167.06 $168.74 $0.00 $0.00 $33.01 $0.00 $0.00 $33.58 $0.00 $0.00 $0.00 $0.00 $0.00 91047 ERX HCPCS 90371 13533-0636-03 HEPATITIS B IMMUNE GLOBULIN IM SOLN BOTH IP/OP $323.73 $239.56 $0.00 $258.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.87 $256.39 $258.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91047 ERX HCPCS 90371 13533-0636-05 HEPATITIS B IMMUNE GLOBULIN IM SOLN BOTH IP/OP $323.73 $239.56 $0.00 $258.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.87 $256.39 $258.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91047 ERX HCPCS 90371 59730-4202-01 HEPATITIS B IMMUNE GLOBULIN IM SOLN BOTH IP/OP $323.73 $239.56 $0.00 $258.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.87 $256.39 $258.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91054 ERX HCPCS J9206 00009-7529-03 IRINOTECAN HCL 100 MG/5ML IV SOLN BOTH IP/OP $157.49 $116.54 $0.00 $127.61 $70.87 $70.87 $0.00 $0.00 $0.00 $127.61 $116.89 $116.89 $121.39 $0.00 $13.79 $0.00 $93.16 $93.16 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $14.57 $0.00 $0.00 $13.87 $0.00 $0.00 $0.00 $0.00 $0.00 91054 ERX HCPCS J9206 63323-0193-55 IRINOTECAN HCL 100 MG/5ML IV SOLN BOTH IP/OP $157.49 $116.54 $0.00 $127.61 $70.87 $70.87 $0.00 $0.00 $0.00 $127.61 $116.89 $116.89 $121.39 $0.00 $13.79 $0.00 $93.16 $93.16 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $14.57 $0.00 $0.00 $13.87 $0.00 $0.00 $0.00 $0.00 $0.00 91073 ERX HCPCS 63700001 00008-1211-30 DESVENLAFAXINE SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $73.41 $54.32 $0.00 $50.20 $0.00 $0.00 $0.00 $13.07 $0.00 $0.00 $0.00 $0.00 $0.00 $15.30 $0.00 $0.00 $0.00 $0.00 $31.38 $49.70 $50.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91073 ERX HCPCS 63700001 51991-0311-33 DESVENLAFAXINE SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $73.41 $54.32 $0.00 $50.20 $0.00 $0.00 $0.00 $13.07 $0.00 $0.00 $0.00 $0.00 $0.00 $15.30 $0.00 $0.00 $0.00 $0.00 $31.38 $49.70 $50.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91073 ERX HCPCS 63700001 59762-1211-03 DESVENLAFAXINE SUCCINATE ER 50 MG PO TB24 BOTH IP/OP $73.41 $54.32 $0.00 $50.20 $0.00 $0.00 $0.00 $13.07 $0.00 $0.00 $0.00 $0.00 $0.00 $15.30 $0.00 $0.00 $0.00 $0.00 $31.38 $49.70 $50.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91238 ERX HCPCS J0744 00409-4777-02 CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 91238 ERX HCPCS J0744 25021-0114-87 CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 91238 ERX HCPCS J0744 36000-0009-24 CIPROFLOXACIN IN D5W 400 MG/200ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 91278 ERX HCPCS J2354 00641-6174-10 OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91278 ERX HCPCS J2354 00703-3301-04 OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91278 ERX HCPCS J2354 25021-0451-01 OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91278 ERX HCPCS J2354 67457-0239-01 OCTREOTIDE ACETATE 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91279 ERX HCPCS J2354 00078-0181-01 OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN BOTH IP/OP $49.98 $36.99 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $37.10 $37.10 $38.52 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $22.67 $35.90 $36.26 $0.00 $0.00 $0.00 $0.00 $0.00 $4.21 $0.00 $0.00 $0.00 $0.00 $0.00 91279 ERX HCPCS J2354 00703-3311-01 OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN BOTH IP/OP $49.98 $36.99 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $37.10 $37.10 $38.52 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $22.67 $35.90 $36.26 $0.00 $0.00 $0.00 $0.00 $0.00 $4.21 $0.00 $0.00 $0.00 $0.00 $0.00 91279 ERX HCPCS J2354 00703-3311-04 OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN BOTH IP/OP $49.98 $36.99 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $37.10 $37.10 $38.52 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $22.67 $35.90 $36.26 $0.00 $0.00 $0.00 $0.00 $0.00 $4.21 $0.00 $0.00 $0.00 $0.00 $0.00 91279 ERX HCPCS J2354 25021-0452-01 OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN BOTH IP/OP $49.98 $36.99 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $37.10 $37.10 $38.52 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $22.67 $35.90 $36.26 $0.00 $0.00 $0.00 $0.00 $0.00 $4.21 $0.00 $0.00 $0.00 $0.00 $0.00 91279 ERX HCPCS J2354 63323-0376-01 OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN BOTH IP/OP $49.98 $36.99 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $37.10 $37.10 $38.52 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $22.67 $35.90 $36.26 $0.00 $0.00 $0.00 $0.00 $0.00 $4.21 $0.00 $0.00 $0.00 $0.00 $0.00 91279 ERX HCPCS J2354 67457-0245-01 OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN BOTH IP/OP $49.98 $36.99 $0.00 $38.52 $0.00 $0.00 $0.00 $0.00 $0.00 $37.10 $37.10 $38.52 $0.00 $4.44 $0.00 $0.00 $0.00 $0.00 $22.67 $35.90 $36.26 $0.00 $0.00 $0.00 $0.00 $0.00 $4.21 $0.00 $0.00 $0.00 $0.00 $0.00 91281 ERX HCPCS J2354 00641-6176-01 OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN BOTH IP/OP $206.91 $153.11 $0.00 $159.49 $0.00 $0.00 $0.00 $0.00 $0.00 $153.57 $153.57 $159.49 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $93.92 $148.76 $150.26 $0.00 $0.00 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $0.00 $0.00 $0.00 91281 ERX HCPCS J2354 00641-6176-10 OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN BOTH IP/OP $206.91 $153.11 $0.00 $159.49 $0.00 $0.00 $0.00 $0.00 $0.00 $153.57 $153.57 $159.49 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $93.92 $148.76 $150.26 $0.00 $0.00 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $0.00 $0.00 $0.00 91281 ERX HCPCS J2354 00703-3321-01 OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN BOTH IP/OP $206.91 $153.11 $0.00 $159.49 $0.00 $0.00 $0.00 $0.00 $0.00 $153.57 $153.57 $159.49 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $93.92 $148.76 $150.26 $0.00 $0.00 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $0.00 $0.00 $0.00 91281 ERX HCPCS J2354 00703-3321-04 OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN BOTH IP/OP $206.91 $153.11 $0.00 $159.49 $0.00 $0.00 $0.00 $0.00 $0.00 $153.57 $153.57 $159.49 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $93.92 $148.76 $150.26 $0.00 $0.00 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $0.00 $0.00 $0.00 91281 ERX HCPCS J2354 25021-0453-01 OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN BOTH IP/OP $206.91 $153.11 $0.00 $159.49 $0.00 $0.00 $0.00 $0.00 $0.00 $153.57 $153.57 $159.49 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $93.92 $148.76 $150.26 $0.00 $0.00 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $0.00 $0.00 $0.00 91281 ERX HCPCS J2354 63323-0377-01 OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN BOTH IP/OP $206.91 $153.11 $0.00 $159.49 $0.00 $0.00 $0.00 $0.00 $0.00 $153.57 $153.57 $159.49 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $93.92 $148.76 $150.26 $0.00 $0.00 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $0.00 $0.00 $0.00 91281 ERX HCPCS J2354 67457-0246-01 OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN BOTH IP/OP $206.91 $153.11 $0.00 $159.49 $0.00 $0.00 $0.00 $0.00 $0.00 $153.57 $153.57 $159.49 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $93.92 $148.76 $150.26 $0.00 $0.00 $0.00 $0.00 $0.00 $21.03 $0.00 $0.00 $0.00 $0.00 $0.00 91363 ERX HCPCS J1451 00517-0710-01 FOMEPIZOLE 1.5 GM/1.5ML IV SOLN BOTH IP/OP "$2,644.50 " "$1,956.93" $0.00 "$2,115.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,322.25" "$2,094.44" "$2,115.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91363 ERX HCPCS J1451 67457-0211-02 FOMEPIZOLE 1.5 GM/1.5ML IV SOLN BOTH IP/OP "$2,644.50 " "$1,956.93" $0.00 "$2,115.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,322.25" "$2,094.44" "$2,115.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91363 ERX HCPCS J1451 70710-1478-01 FOMEPIZOLE 1.5 GM/1.5ML IV SOLN BOTH IP/OP "$2,644.50 " "$1,956.93" $0.00 "$2,115.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,322.25" "$2,094.44" "$2,115.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91408 ERX HCPCS J2785 00469-6501-89 REGADENOSON 0.4 MG/5ML IV SOLN BOTH IP/OP $876.88 $648.89 $0.00 $675.90 $394.60 $394.60 $0.00 $0.00 $0.00 $182.76 $650.82 $650.82 $675.90 $0.00 $280.58 $0.00 $518.67 $518.67 $0.00 $386.31 $611.91 $618.09 $0.00 $0.00 $278.62 $0.00 $0.00 $265.29 $0.00 $0.00 $0.00 $0.00 $0.00 91534 ERX HCPCS 63700001 64764-0080-60 LUBIPROSTONE 8 MCG PO CAPS BOTH IP/OP $31.10 $23.01 $0.00 $22.57 $0.00 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 $6.48 $0.00 $0.00 $0.00 $0.00 $14.11 $22.34 $22.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91651 ERX HCPCS J2212 65649-0551-02 METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN BOTH IP/OP $585.22 $433.06 $0.00 $451.09 $0.00 $0.00 $0.00 $0.00 $0.00 $434.35 $434.35 $451.09 $0.00 $121.96 $0.00 $0.00 $0.00 $0.00 $228.14 $361.37 $365.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91651 ERX HCPCS J2212 65649-0551-07 METHYLNALTREXONE BROMIDE 12 MG/0.6ML SC SOLN BOTH IP/OP $585.22 $433.06 $0.00 $451.09 $0.00 $0.00 $0.00 $0.00 $0.00 $434.35 $434.35 $451.09 $0.00 $121.96 $0.00 $0.00 $0.00 $0.00 $228.14 $361.37 $365.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91870 ERX HCPCS 63700001 67919-0020-10 ALVIMOPAN 12 MG PO CAPS BOTH IP/OP $637.17 $471.51 $0.00 $440.58 $0.00 $0.00 $0.00 $113.42 $0.00 $0.00 $0.00 $0.00 $0.00 $132.79 $0.00 $0.00 $0.00 $0.00 $275.36 $436.17 $440.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91877 ERX HCPCS 25000001 00085-1461-02 MOMETASONE FUROATE 110 MCG/INH IN AEPB BOTH IP/OP $621.59 $459.98 $0.00 $451.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.54 $0.00 $0.00 $0.00 $0.00 $282.06 $446.78 $451.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92074 ERX HCPCS 25000001 49281-0510-05 DTAP-IPV-HIB VACCINE IM SUSR BOTH IP/OP $425.59 $314.94 $0.00 $328.04 $0.00 $0.00 $0.00 $0.00 $0.00 $315.87 $315.87 $328.04 $0.00 $88.69 $0.00 $0.00 $0.00 $0.00 $181.56 $287.58 $290.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92079 ERX HCPCS 25000001 00143-9660-10 METOPROLOL TARTRATE 5 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92079 ERX HCPCS 25000001 00143-9873-25 METOPROLOL TARTRATE 5 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92079 ERX HCPCS 25000001 36000-0033-10 METOPROLOL TARTRATE 5 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92079 ERX HCPCS 25000001 47781-0587-17 METOPROLOL TARTRATE 5 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92079 ERX HCPCS 25000001 70860-0300-05 METOPROLOL TARTRATE 5 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92079 ERX HCPCS 25000001 70860-0300-41 METOPROLOL TARTRATE 5 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92788 ERX HCPCS 90696 58160-0812-11 DTAP-IPV VACCINE IM SUSP BOTH IP/OP $200.78 $148.58 $0.00 $160.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.39 $159.02 $160.62 $0.00 $0.00 $31.42 $0.00 $0.00 $31.96 $0.00 $0.00 $0.00 $0.00 $0.00 92851 ERX HCPCS 63700001 59676-0562-01 DARUNAVIR ETHANOLATE 600 MG PO TABS BOTH IP/OP $142.45 $105.41 $0.00 $98.89 $0.00 $0.00 $0.00 $26.78 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $0.00 $0.00 $0.00 $0.00 $61.81 $97.90 $98.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92854 ERX HCPCS J7189 00169-7202-01 COAGULATION FACTOR VIIA RECOMB 2 MG IV SOLR BOTH IP/OP "$12,158.80 " "$8,997.51" $0.00 "$9,372.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,024.26" "$9,024.26" "$9,372.00" $0.00 "$2,533.89" $0.00 $0.00 $0.00 $0.00 "$5,514.50" "$8,734.97" "$8,823.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92895 ERX HCPCS J3370 00338-3552-48 VANCOMYCIN HCL IN DEXTROSE 1000 MG/200ML IV SOLN BOTH IP/OP $125.07 $92.55 $0.00 $96.40 $56.28 $56.28 $0.00 $0.00 $0.00 $7.24 $92.83 $92.83 $96.40 $0.00 $6.68 $0.00 $73.98 $73.98 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $7.97 $0.00 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 92897 ERX HCPCS 63700001 00003-0852-22 DASATINIB 100 MG PO TABS BOTH IP/OP "$1,570.67 " "$1,162.30" $0.00 "$1,114.22" $0.00 $0.00 $0.00 $292.16 $0.00 $0.00 $0.00 $0.00 $0.00 $327.33 $0.00 $0.00 $0.00 $0.00 $696.39 "$1,103.07" "$1,114.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93084 ERX HCPCS J0282 00143-9875-10 AMIODARONE HCL 150 MG/3ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 93084 ERX HCPCS J0282 00143-9875-25 AMIODARONE HCL 150 MG/3ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 93084 ERX HCPCS J0282 55150-0180-03 AMIODARONE HCL 150 MG/3ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 93084 ERX HCPCS J0282 63323-0616-03 AMIODARONE HCL 150 MG/3ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 93084 ERX HCPCS J0282 67457-0153-03 AMIODARONE HCL 150 MG/3ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 93106 ERX HCPCS J1170 17478-0540-50 HYDROMORPHONE HCL PF 500 MG/50ML IJ SOLN BOTH IP/OP $428.40 $317.02 $0.00 $455.31 $192.78 $192.78 $0.00 $0.00 $0.00 $195.34 $317.96 $317.96 $330.21 $0.00 $428.40 $0.00 $253.40 $253.40 $0.00 $194.44 $307.99 $311.10 $0.00 $0.00 $455.31 $0.00 $0.00 $433.54 $0.00 $0.00 $0.00 $0.00 $0.00 93352 ERX HCPCS 63700001 FLORANEX PO PACK BOTH IP/OP $8.52 $6.30 $0.00 $6.18 $0.00 $0.00 $0.00 $1.52 $0.00 $0.00 $0.00 $0.00 $0.00 $1.78 $0.00 $0.00 $0.00 $0.00 $3.87 $6.12 $6.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93352 ERX HCPCS 63700001 64980-0146-12 FLORANEX PO PACK BOTH IP/OP $8.52 $6.30 $0.00 $6.18 $0.00 $0.00 $0.00 $1.52 $0.00 $0.00 $0.00 $0.00 $0.00 $1.78 $0.00 $0.00 $0.00 $0.00 $3.87 $6.12 $6.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93523 ERX HCPCS J2250 00409-2596-05 MIDAZOLAM HCL 50 MG/10ML IJ SOLN BOTH IP/OP $29.67 $21.96 $0.00 $22.87 $13.35 $13.35 $0.00 $0.00 $0.00 $9.40 $22.02 $22.02 $22.87 $0.00 $7.58 $0.00 $17.55 $17.55 $0.00 $13.46 $21.31 $21.53 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 93523 ERX HCPCS J2250 00641-6060-01 MIDAZOLAM HCL 50 MG/10ML IJ SOLN BOTH IP/OP $29.67 $21.96 $0.00 $22.87 $13.35 $13.35 $0.00 $0.00 $0.00 $9.40 $22.02 $22.02 $22.87 $0.00 $7.58 $0.00 $17.55 $17.55 $0.00 $13.46 $21.31 $21.53 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 93523 ERX HCPCS J2250 00641-6060-10 MIDAZOLAM HCL 50 MG/10ML IJ SOLN BOTH IP/OP $29.67 $21.96 $0.00 $22.87 $13.35 $13.35 $0.00 $0.00 $0.00 $9.40 $22.02 $22.02 $22.87 $0.00 $7.58 $0.00 $17.55 $17.55 $0.00 $13.46 $21.31 $21.53 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 93523 ERX HCPCS J2250 00641-6190-10 MIDAZOLAM HCL 50 MG/10ML IJ SOLN BOTH IP/OP $29.67 $21.96 $0.00 $22.87 $13.35 $13.35 $0.00 $0.00 $0.00 $9.40 $22.02 $22.02 $22.87 $0.00 $7.58 $0.00 $17.55 $17.55 $0.00 $13.46 $21.31 $21.53 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 93523 ERX HCPCS J2250 47781-0589-91 MIDAZOLAM HCL 50 MG/10ML IJ SOLN BOTH IP/OP $29.67 $21.96 $0.00 $22.87 $13.35 $13.35 $0.00 $0.00 $0.00 $9.40 $22.02 $22.02 $22.87 $0.00 $7.58 $0.00 $17.55 $17.55 $0.00 $13.46 $21.31 $21.53 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 93523 ERX HCPCS J2250 70860-0601-10 MIDAZOLAM HCL 50 MG/10ML IJ SOLN BOTH IP/OP $29.67 $21.96 $0.00 $22.87 $13.35 $13.35 $0.00 $0.00 $0.00 $9.40 $22.02 $22.02 $22.87 $0.00 $7.58 $0.00 $17.55 $17.55 $0.00 $13.46 $21.31 $21.53 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 93566 ERX HCPCS J2796 55513-0221-01 ROMIPLOSTIM 250 MCG SC SOLR BOTH IP/OP "$5,599.43 " "$4,143.58" $0.00 "$4,570.68" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,401.09" "$4,401.09" "$4,570.68" $0.00 "$2,451.81" $0.00 $0.00 $0.00 $0.00 "$2,398.07" "$3,798.54" "$3,836.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93574 ERX HCPCS A9581 50419-0320-05 GADOXETATE DISODIUM 0.25 MOL/L IV SOLN BOTH IP/OP $572.38 $423.56 $0.00 $424.82 $257.57 $257.57 $0.00 $0.00 $0.00 $119.30 $424.82 $424.82 $0.00 $0.00 $119.28 $0.00 $338.56 $338.56 $0.00 $259.79 $411.50 $415.66 $0.00 $0.00 $81.31 $0.00 $0.00 $82.72 $0.00 $0.00 $0.00 $0.00 $0.00 93748 ERX HCPCS J9293 61703-0343-18 MITOXANTRONE HCL 20 MG/10ML IV CONC BOTH IP/OP $604.65 $447.44 $0.00 $466.06 $0.00 $0.00 $0.00 $0.00 $0.00 $448.77 $448.77 $466.06 $0.00 $123.54 $0.00 $0.00 $0.00 $0.00 $270.30 $428.16 $432.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93748 ERX HCPCS J9293 63323-0132-10 MITOXANTRONE HCL 20 MG/10ML IV CONC BOTH IP/OP $604.65 $447.44 $0.00 $466.06 $0.00 $0.00 $0.00 $0.00 $0.00 $448.77 $448.77 $466.06 $0.00 $123.54 $0.00 $0.00 $0.00 $0.00 $270.30 $428.16 $432.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93823 ERX HCPCS 63700001 00597-0002-01 TIPRANAVIR 100 MG/ML PO SOLN BOTH IP/OP "$1,702.25 " "$1,259.67" $0.00 "$1,361.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.13 "$1,348.18" "$1,361.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93927 ERX HCPCS 25000001 46287-0500-30 SORBITOL 70 % SOLN BOTH IP/OP $12.32 $9.12 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $9.14 $9.14 $9.50 $0.00 $2.57 $0.00 $0.00 $0.00 $0.00 $13.50 $8.71 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93927 ERX HCPCS 25000001 99999-6005-16 SORBITOL 70 % SOLN BOTH IP/OP $12.32 $9.12 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $9.14 $9.14 $9.50 $0.00 $2.57 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93927 ERX HCPCS 25000001 46287-0500-01 SORBITOL 70 % SOLN BOTH IP/OP $12.32 $9.12 $0.00 $29.90 $0.00 $0.00 $0.00 $0.00 $0.00 $9.14 $9.14 $9.50 $0.00 $2.57 $0.00 $0.00 $0.00 $0.00 $13.50 $29.90 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93931 ERX HCPCS 25000001 00487-0201-01 IPRATROPIUM-ALBUTEROL BASE 0.5-2.5 (3) MG/3ML IN SOLN BOTH IP/OP $6.00 $4.44 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $6.65 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93931 ERX HCPCS 25000001 00487-0201-60 IPRATROPIUM-ALBUTEROL BASE 0.5-2.5 (3) MG/3ML IN SOLN BOTH IP/OP $6.00 $4.44 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $6.65 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93931 ERX HCPCS 25000001 76204-0600-01 IPRATROPIUM-ALBUTEROL BASE 0.5-2.5 (3) MG/3ML IN SOLN BOTH IP/OP $6.00 $4.44 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $6.65 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 00409-4755-03 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 00641-6078-25 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 00641-6080-25 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 23155-0547-41 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 23155-0547-42 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 36000-0012-25 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 55150-0125-02 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 60505-6130-05 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94096 ERX HCPCS J2405 70860-0776-02 ONDANSETRON HCL 4 MG/2ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94097 ERX HCPCS J2405 00143-9890-01 ONDANSETRON HCL 40 MG/20ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94097 ERX HCPCS J2405 63323-0374-20 ONDANSETRON HCL 40 MG/20ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.99 $16.33 $16.33 $16.96 $0.00 $0.42 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.42 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 94141 ERX HCPCS 25000001 63824-0713-16 BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94141 ERX HCPCS 25000001 63824-0715-16 BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94141 ERX HCPCS 25000001 99999-6009-97 BENZOCAINE-MENTHOL 15-3.6 MG MT LOZG BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94219 ERX HCPCS 25000001 10122-0313-10 NICARDIPINE HCL IN NACL 20-0.86 MG/200ML-% IV SOLN BOTH IP/OP $409.92 $303.34 $0.00 $315.97 $0.00 $0.00 $0.00 $0.00 $0.00 $304.24 $304.24 $315.97 $0.00 $85.43 $0.00 $0.00 $0.00 $0.00 $186.05 $294.70 $297.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94576 ERX HCPCS 25000001 10122-0325-10 NICARDIPINE HCL IN NACL 40-0.83 MG/200ML-% IV SOLN BOTH IP/OP $712.48 $527.24 $0.00 $549.18 $0.00 $0.00 $0.00 $0.00 $0.00 $528.80 $528.80 $549.18 $0.00 $148.48 $0.00 $0.00 $0.00 $0.00 $323.30 $512.11 $517.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95687 ERX HCPCS 63700001 65649-0103-02 MESALAMINE ER 0.375 G PO CP24 BOTH IP/OP $78.80 $58.31 $0.00 $57.16 $0.00 $0.00 $0.00 $14.03 $0.00 $0.00 $0.00 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $35.73 $56.59 $57.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95693 ERX HCPCS 63700001 39328-0057-50 FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN BOTH IP/OP $36.67 $27.14 $0.00 $26.60 $0.00 $0.00 $0.00 $6.53 $0.00 $0.00 $0.00 $0.00 $0.00 $7.64 $0.00 $0.00 $0.00 $0.00 $16.63 $26.33 $26.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95693 ERX HCPCS 63700001 50383-0627-50 FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN BOTH IP/OP $36.67 $27.14 $0.00 $26.60 $0.00 $0.00 $0.00 $6.53 $0.00 $0.00 $0.00 $0.00 $0.00 $7.64 $0.00 $0.00 $0.00 $0.00 $16.63 $26.33 $26.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95693 ERX HCPCS 63700001 54838-0011-50 FERROUS SULFATE 75 (15 FE) MG/ML PO SOLN BOTH IP/OP $36.67 $27.14 $0.00 $26.60 $0.00 $0.00 $0.00 $6.53 $0.00 $0.00 $0.00 $0.00 $0.00 $7.64 $0.00 $0.00 $0.00 $0.00 $16.63 $26.33 $26.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95811 ERX HCPCS 25000001 00409-9558-05 ROCURONIUM BROMIDE 50 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95811 ERX HCPCS 25000001 00781-3220-95 ROCURONIUM BROMIDE 50 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95811 ERX HCPCS 25000001 25021-0662-05 ROCURONIUM BROMIDE 50 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95811 ERX HCPCS 25000001 39822-4200-02 ROCURONIUM BROMIDE 50 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95811 ERX HCPCS 25000001 63323-0426-05 ROCURONIUM BROMIDE 50 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95811 ERX HCPCS 25000001 67457-0228-05 ROCURONIUM BROMIDE 50 MG/5ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 00143-9251-01 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 00143-9251-10 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 00409-9558-10 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 00409-9558-31 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 00409-9558-50 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 00409-9558-70 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 00781-3220-70 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 00781-3220-92 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 25021-0662-10 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 39822-4200-05 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 39822-4200-06 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 67457-0228-10 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95812 ERX HCPCS 25000001 70860-0651-10 ROCURONIUM BROMIDE 100 MG/10ML IV SOLN BOTH IP/OP $36.00 $26.64 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 $26.72 $26.72 $27.75 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96941 ERX HCPCS 63700001 43598-0552-30 LAMOTRIGINE 100 MG PO TBDP BOTH IP/OP $42.81 $31.68 $0.00 $31.06 $0.00 $0.00 $0.00 $7.62 $0.00 $0.00 $0.00 $0.00 $0.00 $8.92 $0.00 $0.00 $0.00 $0.00 $19.42 $30.75 $31.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96968 ERX HCPCS 63700001 00131-2477-35 LACOSAMIDE 50 MG PO TABS BOTH IP/OP $50.06 $37.04 $0.00 $34.62 $0.00 $0.00 $0.00 $8.02 $0.00 $0.00 $0.00 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $21.64 $34.28 $34.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96968 ERX HCPCS 63700001 00131-2477-60 LACOSAMIDE 50 MG PO TABS BOTH IP/OP $50.06 $37.04 $0.00 $34.62 $0.00 $0.00 $0.00 $8.02 $0.00 $0.00 $0.00 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $21.64 $34.28 $34.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96969 ERX HCPCS 63700001 00131-2478-60 LACOSAMIDE 100 MG PO TABS BOTH IP/OP $79.32 $58.70 $0.00 $59.55 $0.00 $0.00 $0.00 $12.54 $0.00 $0.00 $0.00 $0.00 $0.00 $16.53 $0.00 $0.00 $0.00 $0.00 $37.22 $58.96 $59.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96970 ERX HCPCS 63700001 00131-2479-35 LACOSAMIDE 150 MG PO TABS BOTH IP/OP $82.89 $61.34 $0.00 $57.33 $0.00 $0.00 $0.00 $13.28 $0.00 $0.00 $0.00 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $35.83 $56.75 $57.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96970 ERX HCPCS 63700001 00131-2479-60 LACOSAMIDE 150 MG PO TABS BOTH IP/OP $82.89 $61.34 $0.00 $57.33 $0.00 $0.00 $0.00 $13.28 $0.00 $0.00 $0.00 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $35.83 $56.75 $57.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96971 ERX HCPCS 63700001 00131-2480-35 LACOSAMIDE 200 MG PO TABS BOTH IP/OP $82.91 $61.35 $0.00 $57.34 $0.00 $0.00 $0.00 $13.28 $0.00 $0.00 $0.00 $0.00 $0.00 $17.28 $0.00 $0.00 $0.00 $0.00 $35.84 $56.77 $57.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96971 ERX HCPCS 63700001 00131-2480-60 LACOSAMIDE 200 MG PO TABS BOTH IP/OP $82.91 $61.35 $0.00 $57.34 $0.00 $0.00 $0.00 $13.28 $0.00 $0.00 $0.00 $0.00 $0.00 $17.28 $0.00 $0.00 $0.00 $0.00 $35.84 $56.77 $57.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96972 ERX HCPCS C9254 00131-1810-67 LACOSAMIDE 200 MG/20ML IV SOLN BOTH IP/OP $94.63 $70.03 $0.00 $77.97 $45.52 $45.52 $0.00 $0.00 $0.00 $19.72 $75.08 $75.08 $77.97 $0.00 $19.72 $0.00 $55.97 $55.97 $0.00 $40.90 $64.79 $65.44 $0.00 $0.00 $12.80 $0.00 $0.00 $13.02 $0.00 $0.00 $0.00 $0.00 $0.00 96976 ERX HCPCS 25000001 00186-0917-06 BUDESONIDE 90 MCG/ACT IN AEPB BOTH IP/OP $672.22 $497.44 $0.00 $518.15 $0.00 $0.00 $0.00 $0.00 $0.00 $498.92 $498.92 $518.15 $0.00 $140.09 $0.00 $0.00 $0.00 $0.00 $294.72 $466.84 $471.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96977 ERX HCPCS 25000001 00186-0916-12 BUDESONIDE 180 MCG/ACT IN AEPB BOTH IP/OP $900.15 $666.11 $0.00 $693.84 $0.00 $0.00 $0.00 $0.00 $0.00 $668.09 $668.09 $693.84 $0.00 $187.59 $0.00 $0.00 $0.00 $0.00 $394.64 $625.11 $631.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96982 ERX HCPCS J9100 61703-0305-38 CYTARABINE (PF) 20 MG/ML IJ SOLN BOTH IP/OP $127.38 $94.26 $0.00 $98.18 $0.00 $0.00 $0.00 $0.00 $0.00 $94.54 $94.54 $98.18 $0.00 $8.03 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96982 ERX HCPCS J9100 61703-0303-46 CYTARABINE (PF) 20 MG/ML IJ SOLN BOTH IP/OP $127.38 $94.26 $0.00 $98.18 $0.00 $0.00 $0.00 $0.00 $0.00 $94.54 $94.54 $98.18 $0.00 $8.03 $0.00 $0.00 $0.00 $0.00 $28.50 $90.09 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96986 ERX HCPCS J9155 55566-8303-01 DEGARELIX ACETATE 80 MG SC SOLR BOTH IP/OP "$1,518.11 " "$1,123.40" $0.00 "$1,170.16" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,126.74" "$1,126.74" "$1,170.16" $0.00 $387.28 $0.00 $0.00 $0.00 $0.00 $703.37 "$1,114.14" "$1,125.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96988 ERX HCPCS 25000001 66220-0160-10 CONIVAPTAN HCL IN DEXTROSE 20-5 MG/100ML-% IV SOLN BOTH IP/OP "$2,518.10 " "$1,863.39" $0.00 "$1,940.95" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,868.93" "$1,868.93" "$1,940.95" $0.00 $524.77 $0.00 $0.00 $0.00 $0.00 "$1,146.24" "$1,815.64" "$1,833.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97005 ERX HCPCS 63700001 30768-0003-48 MILK THISTLE XTRA PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97053 ERX HCPCS 63700001 59676-0563-01 DARUNAVIR ETHANOLATE 75 MG PO TABS BOTH IP/OP $142.45 $105.41 $0.00 $98.88 $0.00 $0.00 $0.00 $26.77 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $0.00 $0.00 $0.00 $0.00 $61.80 $97.89 $98.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97133 ERX HCPCS 63700001 64764-0918-30 FEBUXOSTAT 40 MG PO TABS BOTH IP/OP $55.32 $40.94 $0.00 $40.14 $0.00 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $25.09 $39.73 $40.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97134 ERX HCPCS 63700001 64764-0677-30 FEBUXOSTAT 80 MG PO TABS BOTH IP/OP $55.32 $40.94 $0.00 $40.14 $0.00 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $25.09 $39.73 $40.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97252 ERX HCPCS J3490 99999-6010-51 DILTIAZEM HCL 25 MG/5ML IV SOLN BOTH IP/OP $811.76 $600.70 $0.00 $625.70 $365.29 $365.29 $0.00 $0.00 $0.00 $169.19 $602.49 $602.49 $625.70 $0.00 $169.17 $0.00 $480.16 $480.16 $0.00 $368.35 $583.47 $589.36 $0.00 $0.00 $115.29 $0.00 $0.00 $117.28 $0.00 $0.00 $0.00 $0.00 $0.00 97253 ERX HCPCS 25000001 00641-6015-10 DILTIAZEM HCL 125 MG/25ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97254 ERX HCPCS 25000001 00409-1171-02 DILTIAZEM HCL 50 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97254 ERX HCPCS 25000001 00641-6014-01 DILTIAZEM HCL 50 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97254 ERX HCPCS 25000001 00641-6014-10 DILTIAZEM HCL 50 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97254 ERX HCPCS 25000001 00641-9218-10 DILTIAZEM HCL 50 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97254 ERX HCPCS 25000001 17478-0937-10 DILTIAZEM HCL 50 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97266 ERX HCPCS 63700001 00456-1420-90 NEBIVOLOL HCL 20 MG PO TABS BOTH IP/OP $26.47 $19.59 $0.00 $18.30 $0.00 $0.00 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $0.00 $5.52 $0.00 $0.00 $0.00 $0.00 $11.44 $18.11 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97343 ERX HCPCS 63700001 00781-3174-14 SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN BOTH IP/OP $294.95 $218.26 $0.00 $214.20 $0.00 $0.00 $0.00 $52.50 $0.00 $0.00 $0.00 $0.00 $0.00 $61.47 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97343 ERX HCPCS 63700001 55150-0173-01 SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN BOTH IP/OP $294.95 $218.26 $0.00 $214.20 $0.00 $0.00 $0.00 $52.50 $0.00 $0.00 $0.00 $0.00 $0.00 $61.47 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97343 ERX HCPCS 63700001 63323-0273-01 SUMATRIPTAN SUCCINATE 6 MG/0.5ML SC SOLN BOTH IP/OP $294.95 $218.26 $0.00 $214.20 $0.00 $0.00 $0.00 $52.50 $0.00 $0.00 $0.00 $0.00 $0.00 $61.47 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97371 ERX HCPCS J3370 00143-9355-10 VANCOMYCIN HCL 750 MG IV SOLR BOTH IP/OP $47.77 $35.35 $0.00 $36.82 $21.50 $21.50 $0.00 $0.00 $0.00 $3.62 $35.45 $35.45 $36.82 $0.00 $3.34 $0.00 $28.26 $28.26 $0.00 $21.66 $34.31 $34.66 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 97371 ERX HCPCS J3370 00409-6531-02 VANCOMYCIN HCL 750 MG IV SOLR BOTH IP/OP $47.77 $35.35 $0.00 $36.82 $21.50 $21.50 $0.00 $0.00 $0.00 $3.62 $35.45 $35.45 $36.82 $0.00 $3.34 $0.00 $28.26 $28.26 $0.00 $21.66 $34.31 $34.66 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 97371 ERX HCPCS J3370 63323-0203-20 VANCOMYCIN HCL 750 MG IV SOLR BOTH IP/OP $47.77 $35.35 $0.00 $36.82 $21.50 $21.50 $0.00 $0.00 $0.00 $3.62 $35.45 $35.45 $36.82 $0.00 $3.34 $0.00 $28.26 $28.26 $0.00 $21.66 $34.31 $34.66 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 97389 ERX HCPCS J7527 00078-0566-51 EVEROLIMUS 5 MG PO TABS BOTH IP/OP "$1,743.45 " "$1,290.15" $0.00 "$1,343.85" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,293.99" "$1,293.99" "$1,343.85" $0.00 $363.33 $0.00 $0.00 $0.00 $0.00 $807.78 "$1,279.52" "$1,292.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97390 ERX HCPCS J7527 00078-0567-51 EVEROLIMUS 10 MG PO TABS BOTH IP/OP "$1,743.45 " "$1,290.15" $0.00 "$1,343.85" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,293.99" "$1,293.99" "$1,343.85" $0.00 $363.33 $0.00 $0.00 $0.00 $0.00 $807.78 "$1,279.52" "$1,292.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97480 ERX HCPCS J7510 99999-6010-77 PREDNISOLONE 15 MG/5ML PO SOLN BOTH IP/OP $119.28 $88.27 $0.00 $145.76 $0.00 $0.00 $0.00 $0.00 $24.86 $88.53 $88.53 $91.94 $0.00 $24.86 $0.00 $70.55 $70.55 $0.00 $91.10 $85.65 $145.76 $0.00 $0.00 $28.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97480 ERX HCPCS J7510 99999-6004-79 PREDNISOLONE 15 MG/5ML PO SOLN BOTH IP/OP $119.28 $88.27 $0.00 $145.76 $0.00 $0.00 $0.00 $0.00 $24.86 $88.53 $88.53 $91.94 $0.00 $24.86 $0.00 $70.55 $70.55 $0.00 $91.10 $144.30 $145.76 $0.00 $0.00 $28.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97480 ERX HCPCS J7510 50383-0042-24 PREDNISOLONE 15 MG/5ML PO SOLN BOTH IP/OP $119.28 $88.27 $0.00 $279.44 $0.00 $0.00 $0.00 $0.00 $24.86 $88.53 $88.53 $91.94 $0.00 $24.86 $0.00 $70.55 $70.55 $0.00 $91.10 $279.44 $145.76 $0.00 $0.00 $28.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97480 ERX HCPCS J7510 50383-0042-48 PREDNISOLONE 15 MG/5ML PO SOLN BOTH IP/OP $119.28 $88.27 $0.00 $446.40 $0.00 $0.00 $0.00 $0.00 $24.86 $88.53 $88.53 $91.94 $0.00 $24.86 $0.00 $70.55 $70.55 $0.00 $91.10 $446.40 $145.76 $0.00 $0.00 $28.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97660 ERX HCPCS 25000001 48582-0512-01 BIOTENE ORALBALANCE DRY MOUTH MT GEL BOTH IP/OP $23.76 $17.58 $0.00 $18.31 $0.00 $0.00 $0.00 $0.00 $0.00 $17.63 $17.63 $18.31 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $10.78 $17.07 $17.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97716 ERX HCPCS J1885 00409-3796-01 KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.22 $0.00 $0.00 $1.16 $0.00 $0.00 $0.00 $0.00 $0.00 97716 ERX HCPCS J1885 00641-6043-25 KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.22 $0.00 $0.00 $1.16 $0.00 $0.00 $0.00 $0.00 $0.00 97716 ERX HCPCS J1885 25021-0701-02 KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.22 $0.00 $0.00 $1.16 $0.00 $0.00 $0.00 $0.00 $0.00 97716 ERX HCPCS J1885 47781-0585-68 KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.22 $0.00 $0.00 $1.16 $0.00 $0.00 $0.00 $0.00 $0.00 97716 ERX HCPCS J1885 63323-0162-02 KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.22 $0.00 $0.00 $1.16 $0.00 $0.00 $0.00 $0.00 $0.00 97716 ERX HCPCS J1885 63323-0162-14 KETOROLAC TROMETHAMINE 60 MG/2ML IM SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.22 $0.00 $0.00 $1.16 $0.00 $0.00 $0.00 $0.00 $0.00 97744 ERX HCPCS 63700001 68180-0771-06 AMLOD/VALSA/HCTZ 5-160-12.5 MG TAB BOTH IP/OP $21.65 $16.02 $0.00 $17.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.83 $17.15 $17.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97745 ERX HCPCS 63700001 68180-0773-06 AMLOD/VALSA/HCTZ 5-160-25 MG TAB BOTH IP/OP $21.65 $16.02 $0.00 $17.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.83 $17.15 $17.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97747 ERX HCPCS 63700001 68180-0774-06 AMLOD/VALSA/HCTZ 10-160-25 MG TABS BOTH IP/OP $24.56 $18.17 $0.00 $19.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.28 $19.45 $19.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97748 ERX HCPCS 63700001 68180-0775-06 AMLOD/VALSA/HCTZ 10-320-25 MG TABS BOTH IP/OP $31.17 $23.07 $0.00 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.59 $24.69 $24.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97790 ERX HCPCS J3260 63323-0306-30 TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN BOTH IP/OP $101.91 $75.41 $0.00 $78.55 $45.86 $45.86 $0.00 $0.00 $0.00 $38.42 $75.64 $75.64 $78.55 $0.00 $67.70 $0.00 $60.28 $60.28 $0.00 $46.20 $73.18 $73.92 $0.00 $0.00 $65.04 $0.00 $0.00 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 97790 ERX HCPCS J3260 67457-0428-00 TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN BOTH IP/OP $101.91 $75.41 $0.00 $78.55 $45.86 $45.86 $0.00 $0.00 $0.00 $38.42 $75.64 $75.64 $78.55 $0.00 $67.70 $0.00 $60.28 $60.28 $0.00 $46.20 $73.18 $73.92 $0.00 $0.00 $65.04 $0.00 $0.00 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 97790 ERX HCPCS J3260 67457-0428-30 TOBRAMYCIN SULFATE 1.2 GM/30ML IJ SOLN BOTH IP/OP $101.91 $75.41 $0.00 $78.55 $45.86 $45.86 $0.00 $0.00 $0.00 $38.42 $75.64 $75.64 $78.55 $0.00 $67.70 $0.00 $60.28 $60.28 $0.00 $46.20 $73.18 $73.92 $0.00 $0.00 $65.04 $0.00 $0.00 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 97830 ERX HCPCS 63700001 00173-0772-02 LAMOTRIGINE 25 MG PO TBDP BOTH IP/OP $33.73 $24.96 $0.00 $26.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.87 $26.71 $26.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97893 ERX HCPCS 63700001 59148-0020-50 TOLVAPTAN 15 MG PO TABS BOTH IP/OP $819.33 $606.30 $0.00 $594.86 $0.00 $0.00 $0.00 $145.84 $0.00 $0.00 $0.00 $0.00 $0.00 $170.75 $0.00 $0.00 $0.00 $0.00 $371.79 $588.91 $594.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97893 ERX HCPCS 63700001 99999-6011-58 TOLVAPTAN 15 MG PO TABS BOTH IP/OP $819.33 $606.30 $0.00 $594.86 $0.00 $0.00 $0.00 $145.84 $0.00 $0.00 $0.00 $0.00 $0.00 $170.75 $0.00 $0.00 $0.00 $0.00 $371.79 $588.91 $594.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97894 ERX HCPCS 25000001 59148-0021-50 TOLVAPTAN 30 MG PO TABS BOTH IP/OP "$1,677.22 " "$1,241.14" $0.00 "$1,292.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,244.83" "$1,244.83" "$1,292.80" $0.00 $349.53 $0.00 $0.00 $0.00 $0.00 $740.09 "$1,172.29" "$1,184.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98035 ERX HCPCS 63700001 00032-1212-01 PANCRELIPASE (LIP-PROT-AMYL) 12000 UNITS PO CPEP BOTH IP/OP $17.84 $13.20 $0.00 $12.19 $0.00 $0.00 $0.00 $3.37 $0.00 $0.00 $0.00 $0.00 $0.00 $3.72 $0.00 $0.00 $0.00 $0.00 $7.62 $12.07 $12.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98127 ERX HCPCS 25000001 08271-0361-00 LANCETS ULTRA THIN MISC BOTH IP/OP $11.32 $8.38 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.40 $8.40 $8.73 $0.00 $2.36 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98249 ERX HCPCS J9190 16729-0276-38 FLUOROURACIL 5 GM/100ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98249 ERX HCPCS J9190 63323-0117-61 FLUOROURACIL 5 GM/100ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $1.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98329 ERX HCPCS 25000001 00024-4142-60 DRONEDARONE HCL 400 MG PO TABS BOTH IP/OP $57.94 $42.88 $0.00 $46.76 $0.00 $0.00 $0.00 $0.00 $0.00 $45.02 $45.02 $46.76 $0.00 $12.07 $0.00 $0.00 $0.00 $0.00 $25.02 $39.63 $40.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98372 ERX HCPCS 63700001 60505-4642-03 PRASUGREL HCL 5 MG PO TABS BOTH IP/OP $69.17 $51.19 $0.00 $50.18 $0.00 $0.00 $0.00 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $31.37 $49.68 $50.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98373 ERX HCPCS 63700001 00002-5123-30 PRASUGREL HCL 10 MG PO TABS BOTH IP/OP $69.17 $51.19 $0.00 $50.18 $0.00 $0.00 $0.00 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $31.37 $49.68 $50.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98373 ERX HCPCS 63700001 00378-5186-93 PRASUGREL HCL 10 MG PO TABS BOTH IP/OP $69.17 $51.19 $0.00 $50.18 $0.00 $0.00 $0.00 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $31.37 $49.68 $50.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98373 ERX HCPCS 63700001 16729-0273-10 PRASUGREL HCL 10 MG PO TABS BOTH IP/OP $69.17 $51.19 $0.00 $50.18 $0.00 $0.00 $0.00 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $31.37 $49.68 $50.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98373 ERX HCPCS 63700001 60505-4643-03 PRASUGREL HCL 10 MG PO TABS BOTH IP/OP $69.17 $51.19 $0.00 $50.18 $0.00 $0.00 $0.00 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $31.37 $49.68 $50.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98373 ERX HCPCS 63700001 65162-0002-03 PRASUGREL HCL 10 MG PO TABS BOTH IP/OP $69.17 $51.19 $0.00 $50.18 $0.00 $0.00 $0.00 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $31.37 $49.68 $50.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98373 ERX HCPCS 63700001 65862-0830-30 PRASUGREL HCL 10 MG PO TABS BOTH IP/OP $69.17 $51.19 $0.00 $50.18 $0.00 $0.00 $0.00 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $31.37 $49.68 $50.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98373 ERX HCPCS 63700001 67877-0605-30 PRASUGREL HCL 10 MG PO TABS BOTH IP/OP $69.17 $51.19 $0.00 $50.18 $0.00 $0.00 $0.00 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $31.37 $49.68 $50.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99404 ERX HCPCS 25000001 42799-0217-01 OPIUM 10 MG/ML (1%) PO TINC BOTH IP/OP "$1,916.55 " "$1,418.25" $0.00 "$1,477.28" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,422.46" "$1,422.46" "$1,477.28" $0.00 $399.41 $0.00 $0.00 $0.00 $0.00 $887.98 "$1,406.55" "$1,420.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99404 ERX HCPCS 25000001 62559-0153-04 OPIUM 10 MG/ML (1%) PO TINC BOTH IP/OP "$1,916.55 " "$1,418.25" $0.00 "$1,477.28" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,422.46" "$1,422.46" "$1,477.28" $0.00 $399.41 $0.00 $0.00 $0.00 $0.00 $887.98 "$1,406.55" "$1,420.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99438 ERX HCPCS 63700001 16714-0809-01 LEVONORGESTREL 1.5 MG PO TABS BOTH IP/OP $136.50 $101.01 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.25 $108.11 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99438 ERX HCPCS 63700001 51285-0146-19 LEVONORGESTREL 1.5 MG PO TABS BOTH IP/OP $136.50 $101.01 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.25 $108.11 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99438 ERX HCPCS 63700001 51285-0162-88 LEVONORGESTREL 1.5 MG PO TABS BOTH IP/OP $136.50 $101.01 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.25 $108.11 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99438 ERX HCPCS 63700001 62756-0720-60 LEVONORGESTREL 1.5 MG PO TABS BOTH IP/OP $136.50 $101.01 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.25 $108.11 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99438 ERX HCPCS 63700001 68180-0852-11 LEVONORGESTREL 1.5 MG PO TABS BOTH IP/OP $136.50 $101.01 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.25 $108.11 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99438 ERX HCPCS 63700001 69536-0146-19 LEVONORGESTREL 1.5 MG PO TABS BOTH IP/OP $136.50 $101.01 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.25 $108.11 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99452 ERX HCPCS J7312 00023-3348-07 DEXAMETHASONE 0.7 MG INTRAVITREAL IMPL BOTH IP/OP "$3,615.10 " "$2,675.17" $0.00 "$2,786.52" "$1,626.80" "$1,626.80" "$1,399.97" "$1,399.97" "$1,399.97" $753.48 "$2,683.13" "$2,683.13" "$2,786.52" "$1,397.82" "$1,642.44" $908.58 "$1,782.24" "$1,782.24" "$1,470.19" "$1,639.59" "$2,597.11" "$2,623.34" "$2,030.26" "$2,030.26" "$1,645.82" $0.00 $0.00 "$1,567.10" "$1,400.55" $0.00 $0.00 $0.00 $0.00 99602 ERX HCPCS J9263 00703-3985-01 OXALIPLATIN 50 MG/10ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$1,124.48" $93.69 $93.69 $0.00 $0.00 $0.00 "$1,124.48" $154.53 $154.53 $160.48 $0.00 $12.93 $0.00 $123.15 $123.15 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $17.63 $0.00 $0.00 $16.78 $0.00 $0.00 $0.00 $0.00 $0.00 99602 ERX HCPCS J9263 00781-3315-70 OXALIPLATIN 50 MG/10ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$1,124.48" $93.69 $93.69 $0.00 $0.00 $0.00 "$1,124.48" $154.53 $154.53 $160.48 $0.00 $12.93 $0.00 $123.15 $123.15 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $17.63 $0.00 $0.00 $16.78 $0.00 $0.00 $0.00 $0.00 $0.00 99602 ERX HCPCS J9263 00781-9315-70 OXALIPLATIN 50 MG/10ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$1,124.48" $93.69 $93.69 $0.00 $0.00 $0.00 "$1,124.48" $154.53 $154.53 $160.48 $0.00 $12.93 $0.00 $123.15 $123.15 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $17.63 $0.00 $0.00 $16.78 $0.00 $0.00 $0.00 $0.00 $0.00 99602 ERX HCPCS J9263 25021-0233-10 OXALIPLATIN 50 MG/10ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$1,124.48" $93.69 $93.69 $0.00 $0.00 $0.00 "$1,124.48" $154.53 $154.53 $160.48 $0.00 $12.93 $0.00 $123.15 $123.15 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $17.63 $0.00 $0.00 $16.78 $0.00 $0.00 $0.00 $0.00 $0.00 99602 ERX HCPCS J9263 61703-0363-18 OXALIPLATIN 50 MG/10ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$1,124.48" $93.69 $93.69 $0.00 $0.00 $0.00 "$1,124.48" $154.53 $154.53 $160.48 $0.00 $12.93 $0.00 $123.15 $123.15 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $17.63 $0.00 $0.00 $16.78 $0.00 $0.00 $0.00 $0.00 $0.00 99602 ERX HCPCS J9263 67457-0469-10 OXALIPLATIN 50 MG/10ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$1,124.48" $93.69 $93.69 $0.00 $0.00 $0.00 "$1,124.48" $154.53 $154.53 $160.48 $0.00 $12.93 $0.00 $123.15 $123.15 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $17.63 $0.00 $0.00 $16.78 $0.00 $0.00 $0.00 $0.00 $0.00 99604 ERX HCPCS J9263 00703-3986-01 OXALIPLATIN 100 MG/20ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$2,248.95" $93.69 $93.69 $0.00 $0.00 $0.00 "$2,248.95" $154.53 $154.53 $160.48 $0.00 $25.85 $0.00 $123.15 $123.15 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $35.25 $0.00 $0.00 $33.56 $0.00 $0.00 $0.00 $0.00 $0.00 99604 ERX HCPCS J9263 00781-3317-80 OXALIPLATIN 100 MG/20ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$2,248.95" $93.69 $93.69 $0.00 $0.00 $0.00 "$2,248.95" $154.53 $154.53 $160.48 $0.00 $25.85 $0.00 $123.15 $123.15 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $35.25 $0.00 $0.00 $33.56 $0.00 $0.00 $0.00 $0.00 $0.00 99604 ERX HCPCS J9263 00955-1727-20 OXALIPLATIN 100 MG/20ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$2,248.95" $93.69 $93.69 $0.00 $0.00 $0.00 "$2,248.95" $154.53 $154.53 $160.48 $0.00 $25.85 $0.00 $123.15 $123.15 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $35.25 $0.00 $0.00 $33.56 $0.00 $0.00 $0.00 $0.00 $0.00 99604 ERX HCPCS J9263 25021-0233-20 OXALIPLATIN 100 MG/20ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$2,248.95" $93.69 $93.69 $0.00 $0.00 $0.00 "$2,248.95" $154.53 $154.53 $160.48 $0.00 $25.85 $0.00 $123.15 $123.15 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $35.25 $0.00 $0.00 $33.56 $0.00 $0.00 $0.00 $0.00 $0.00 99604 ERX HCPCS J9263 61703-0363-22 OXALIPLATIN 100 MG/20ML IV SOLN BOTH IP/OP $208.20 $154.07 $0.00 "$2,248.95" $93.69 $93.69 $0.00 $0.00 $0.00 "$2,248.95" $154.53 $154.53 $160.48 $0.00 $25.85 $0.00 $123.15 $123.15 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $35.25 $0.00 $0.00 $33.56 $0.00 $0.00 $0.00 $0.00 $0.00 99686 ERX HCPCS 63700001 00955-1052-90 SEVELAMER CARBONATE 0.8 G PO PACK BOTH IP/OP $47.55 $35.19 $0.00 $34.50 $0.00 $0.00 $0.00 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 $9.91 $0.00 $0.00 $0.00 $0.00 $21.56 $34.15 $34.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99686 ERX HCPCS 63700001 65862-0930-90 SEVELAMER CARBONATE 0.8 G PO PACK BOTH IP/OP $47.55 $35.19 $0.00 $34.50 $0.00 $0.00 $0.00 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 $9.91 $0.00 $0.00 $0.00 $0.00 $21.56 $34.15 $34.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99687 ERX HCPCS 63700001 58468-0131-01 SEVELAMER CARBONATE 2.4 G PO PACK BOTH IP/OP $82.67 $61.18 $0.00 $59.97 $0.00 $0.00 $0.00 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 $17.23 $0.00 $0.00 $0.00 $0.00 $37.48 $59.37 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99687 ERX HCPCS 63700001 58468-0131-02 SEVELAMER CARBONATE 2.4 G PO PACK BOTH IP/OP $82.67 $61.18 $0.00 $59.97 $0.00 $0.00 $0.00 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 $17.23 $0.00 $0.00 $0.00 $0.00 $37.48 $59.37 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99744 ERX HCPCS 25000001 58160-0818-11 HAEMOPHILUS B POLYSAC CONJ VAC 10 MCG IJ SOLR BOTH IP/OP $59.72 $44.19 $0.00 $46.03 $0.00 $0.00 $0.00 $0.00 $0.00 $44.32 $44.32 $46.03 $0.00 $12.45 $0.00 $0.00 $0.00 $0.00 $25.15 $39.83 $40.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99746 ERX HCPCS 63700001 00456-2405-60 ASENAPINE MALEATE 5 MG SL SUBL BOTH IP/OP $92.71 $68.61 $0.00 $67.25 $0.00 $0.00 $0.00 $16.50 $0.00 $0.00 $0.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $42.03 $66.58 $67.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99765 ERX HCPCS Q4074 66215-0303-00 ILOPROST 20 MCG/ML IN SOLN BOTH IP/OP $81.12 $60.03 $0.00 $62.53 $0.00 $0.00 $0.00 $0.00 $0.00 $60.21 $60.21 $62.53 $0.00 $16.91 $0.00 $0.00 $0.00 $0.00 $36.78 $58.25 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99765 ERX HCPCS Q4074 66215-0303-30 ILOPROST 20 MCG/ML IN SOLN BOTH IP/OP $81.12 $60.03 $0.00 $62.53 $0.00 $0.00 $0.00 $0.00 $0.00 $60.21 $60.21 $62.53 $0.00 $16.91 $0.00 $0.00 $0.00 $0.00 $36.78 $58.25 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100004 ERX HCPCS 63700001 16714-0866-01 PALIPERIDONE ER 1.5 MG PO TB24 BOTH IP/OP $117.84 $87.20 $0.00 $85.48 $0.00 $0.00 $0.00 $20.98 $0.00 $0.00 $0.00 $0.00 $0.00 $24.56 $0.00 $0.00 $0.00 $0.00 $53.43 $84.63 $85.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100004 ERX HCPCS 63700001 50458-0554-01 PALIPERIDONE ER 1.5 MG PO TB24 BOTH IP/OP $117.84 $87.20 $0.00 $85.48 $0.00 $0.00 $0.00 $20.98 $0.00 $0.00 $0.00 $0.00 $0.00 $24.56 $0.00 $0.00 $0.00 $0.00 $53.43 $84.63 $85.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100055 ERX HCPCS 25000001 00904-6422-81 PEG 3350 17 G PO PACK BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100055 ERX HCPCS 25000001 00904-6422-86 PEG 3350 17 G PO PACK BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100055 ERX HCPCS 25000001 00904-6931-81 PEG 3350 17 G PO PACK BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100055 ERX HCPCS 25000001 00904-6931-86 PEG 3350 17 G PO PACK BOTH IP/OP $7.11 $5.26 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.56 $5.63 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100212 ERX HCPCS 25000001 24571-0105-06 PRISMASOL BGK 4/2.5 32-4-2.5 MEQ/L IV SOLN BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100215 ERX HCPCS 25000001 24571-0103-06 PRISMASOL BGK 2/3.5 32-2-3.5 MEQ/L IV SOLN BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100258 ERX HCPCS J9302 00078-0669-13 OFATUMUMAB 100 MG/5ML IV CONC BOTH IP/OP "$1,875.28 " "$1,387.71" $0.00 "$1,445.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.83" "$1,391.83" "$1,445.47" $0.00 $751.49 $0.00 $0.00 $0.00 $0.00 $868.86 "$1,376.27" "$1,390.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100258 ERX HCPCS J9302 00078-0669-61 OFATUMUMAB 100 MG/5ML IV CONC BOTH IP/OP "$1,875.28 " "$1,387.71" $0.00 "$1,445.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.83" "$1,391.83" "$1,445.47" $0.00 $751.49 $0.00 $0.00 $0.00 $0.00 $868.86 "$1,376.27" "$1,390.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100265 ERX HCPCS J0597 63833-0825-02 C1 ESTERASE INHIBITOR (HUMAN) 500 UNITS IV KIT BOTH IP/OP "$4,631,757.00 " "$3,427,500.18" $0.00 "$3,570,158.30" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,437,690.05" "$3,437,690.05" "$3,570,158.30" $0.00 "$965,258.16" $0.00 $0.00 $0.00 $0.00 "$1,906,500.00" "$3,019,896.00" "$3,050,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100482 ERX HCPCS 63700001 42291-0266-01 VITAMIN D (ERGOCALCIFEROL) 1.25 MG (50000 UT) PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100482 ERX HCPCS 63700001 64380-0737-06 VITAMIN D (ERGOCALCIFEROL) 1.25 MG (50000 UT) PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100482 ERX HCPCS 63700001 69452-0151-20 VITAMIN D (ERGOCALCIFEROL) 1.25 MG (50000 UT) PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100597 ERX HCPCS 25000001 63481-0684-47 DICLOFENAC SODIUM 1 % TD GEL BOTH IP/OP $172.62 $127.74 $0.00 $138.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.31 $136.72 $138.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100597 ERX HCPCS 25000001 65162-0833-66 DICLOFENAC SODIUM 1 % TD GEL BOTH IP/OP $172.62 $127.74 $0.00 $138.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.31 $136.72 $138.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100597 ERX HCPCS 25000001 76282-0663-39 DICLOFENAC SODIUM 1 % TD GEL BOTH IP/OP $172.62 $127.74 $0.00 $138.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.31 $136.72 $138.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101313 ERX HCPCS 25000001 00132-0081-12 GLYCERIN (LAXATIVE) 1 G RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101316 ERX HCPCS 63700001 99999-6012-26 VALGANCICLOVIR HCL 50 MG/ML PO SOLR BOTH IP/OP $343.74 $254.37 $0.00 "$1,640.49" $0.00 $0.00 $0.00 $61.19 $0.00 $0.00 $0.00 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 "$1,025.31" $247.13 "$1,640.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101316 ERX HCPCS 63700001 00591-2579-20 VALGANCICLOVIR HCL 50 MG/ML PO SOLR BOTH IP/OP $343.74 $254.37 $0.00 "$1,640.49" $0.00 $0.00 $0.00 $61.19 $0.00 $0.00 $0.00 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 "$1,025.31" "$1,624.08" "$1,640.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101316 ERX HCPCS 63700001 27241-0159-19 VALGANCICLOVIR HCL 50 MG/ML PO SOLR BOTH IP/OP $343.74 $254.37 $0.00 "$1,640.49" $0.00 $0.00 $0.00 $61.19 $0.00 $0.00 $0.00 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 "$1,025.31" "$1,624.08" "$1,640.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101323 ERX HCPCS J3490 55150-0166-13 SILDENAFIL CITRATE 10 MG/12.5ML IV SOLN BOTH IP/OP $642.40 $475.38 $0.00 $495.16 $289.08 $289.08 $0.00 $0.00 $0.00 $133.89 $476.79 $476.79 $495.16 $0.00 $133.88 $0.00 $379.98 $379.98 $0.00 $291.50 $461.74 $466.40 $0.00 $0.00 $91.24 $0.00 $0.00 $92.81 $0.00 $0.00 $0.00 $0.00 $0.00 101445 ERX HCPCS J1742 00009-3794-01 IBUTILIDE FUMARATE 1 MG/10ML IV SOLN BOTH IP/OP "$1,412.69 " "$1,045.39" $0.00 "$1,088.90" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,048.50" "$1,048.50" "$1,088.90" $0.00 $294.40 $0.00 $0.00 $0.00 $0.00 $651.27 "$1,031.60" "$1,042.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101445 ERX HCPCS J1742 00009-3794-22 IBUTILIDE FUMARATE 1 MG/10ML IV SOLN BOTH IP/OP "$1,412.69 " "$1,045.39" $0.00 "$1,088.90" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,048.50" "$1,048.50" "$1,088.90" $0.00 $294.40 $0.00 $0.00 $0.00 $0.00 $651.27 "$1,031.60" "$1,042.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101445 ERX HCPCS J1742 67457-0366-10 IBUTILIDE FUMARATE 1 MG/10ML IV SOLN BOTH IP/OP "$1,412.69 " "$1,045.39" $0.00 "$1,088.90" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,048.50" "$1,048.50" "$1,088.90" $0.00 $294.40 $0.00 $0.00 $0.00 $0.00 $651.27 "$1,031.60" "$1,042.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101583 ERX HCPCS 63700001 68462-0719-29 NORGESTIM-ETH ESTRAD TRIPHASIC 0.18/0.215/0.25 MG-25 MCG PO TABS BOTH IP/OP $541.06 $400.38 $0.00 $392.91 $0.00 $0.00 $0.00 $96.31 $0.00 $0.00 $0.00 $0.00 $0.00 $112.76 $0.00 $0.00 $0.00 $0.00 $245.57 $388.98 $392.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101584 ERX HCPCS 63700001 16714-0363-04 "ORTHO TRI-CYCLEN,TRINESSA,0.18/0.215/0.25 MG-35 MCG PO TABS" BOTH IP/OP $188.75 $139.68 $0.00 $151.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.38 $149.49 $151.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101700 ERX HCPCS 63700001 00054-0407-13 RITONAVIR 100 MG PO TABS BOTH IP/OP $35.19 $26.04 $0.00 $28.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.60 $27.87 $28.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101700 ERX HCPCS 63700001 00074-3333-30 RITONAVIR 100 MG PO TABS BOTH IP/OP $35.19 $26.04 $0.00 $28.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.60 $27.87 $28.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101700 ERX HCPCS 63700001 31722-0597-30 RITONAVIR 100 MG PO TABS BOTH IP/OP $35.19 $26.04 $0.00 $28.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.60 $27.87 $28.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101700 ERX HCPCS 63700001 65862-0687-30 RITONAVIR 100 MG PO TABS BOTH IP/OP $35.19 $26.04 $0.00 $28.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.60 $27.87 $28.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101739 ERX HCPCS 90734 58160-0955-09 MENVEO MENINGOCOCCAL A C Y&W-135 OLIG IM SOLR BOTH IP/OP $580.85 $429.83 $0.00 $447.72 $261.38 $261.38 $0.00 $0.00 $129.14 $9.40 $431.11 $431.11 $447.72 $0.00 $158.35 $0.00 $343.57 $343.57 $0.00 $246.19 $389.96 $393.90 $295.42 $295.42 $143.71 $0.00 $0.00 $136.84 $0.00 $0.00 $0.00 $0.00 $0.00 101739 ERX HCPCS 90734 58160-0958-01 MENVEO MENINGOCOCCAL A C Y&W-135 OLIG IM SOLR BOTH IP/OP $580.85 $429.83 $0.00 $447.72 $261.38 $261.38 $0.00 $0.00 $129.14 $9.40 $431.11 $431.11 $447.72 $0.00 $158.35 $0.00 $343.57 $343.57 $0.00 $246.19 $389.96 $393.90 $295.42 $295.42 $143.71 $0.00 $0.00 $136.84 $0.00 $0.00 $0.00 $0.00 $0.00 102036 ERX HCPCS 63700001 00173-0695-04 FLUTICASONE-SALMETEROL 100-50 MCG/DOSE IN AEPB BOTH IP/OP $611.81 $452.74 $0.00 $444.29 $0.00 $0.00 $0.00 $108.90 $0.00 $0.00 $0.00 $0.00 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $277.68 $439.85 $444.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102037 ERX HCPCS 25000001 00173-0696-04 FLUTICASONE-SALMETEROL 250-50 MCG/DOSE IN AEPB BOTH IP/OP $611.81 $452.74 $0.00 $471.58 $0.00 $0.00 $0.00 $0.00 $0.00 $454.09 $454.09 $471.58 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $277.68 $439.85 $444.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102038 ERX HCPCS 25000001 00173-0697-00 FLUTICASONE-SALMETEROL 500-50 MCG/DOSE IN AEPB BOTH IP/OP $866.54 $641.24 $0.00 $667.93 $0.00 $0.00 $0.00 $0.00 $0.00 $643.15 $643.15 $667.93 $0.00 $180.59 $0.00 $0.00 $0.00 $0.00 $393.21 $622.84 $629.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102038 ERX HCPCS 25000001 00173-0697-04 FLUTICASONE-SALMETEROL 500-50 MCG/DOSE IN AEPB BOTH IP/OP $866.54 $641.24 $0.00 $667.93 $0.00 $0.00 $0.00 $0.00 $0.00 $643.15 $643.15 $667.93 $0.00 $180.59 $0.00 $0.00 $0.00 $0.00 $393.21 $622.84 $629.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102040 ERX HCPCS 63700001 00173-0526-00 LAMOTRIGINE 5 MG PO CHEW BOTH IP/OP $71.91 $53.21 $0.00 $46.44 $0.00 $0.00 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $14.99 $0.00 $0.00 $0.00 $0.00 $29.03 $45.98 $46.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102040 ERX HCPCS 63700001 68462-0228-01 LAMOTRIGINE 5 MG PO CHEW BOTH IP/OP $71.91 $53.21 $0.00 $46.44 $0.00 $0.00 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $14.99 $0.00 $0.00 $0.00 $0.00 $29.03 $45.98 $46.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 00228-2996-11 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 00228-2996-50 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 00597-0058-01 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 00781-2076-01 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 00904-6401-61 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 50268-0740-11 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 50268-0740-15 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 57237-0014-01 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 63739-0567-10 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 65862-0598-01 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 65862-0598-05 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102053 ERX HCPCS 63700001 68084-0299-01 TAMSULOSIN HCL 0.4 MG PO CAPS BOTH IP/OP $38.39 $28.41 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.20 $30.40 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102058 ERX HCPCS 90670 00005-1971-02 PNEUMOCOCCAL 13-VAL CONJ VACC IM SUSP BOTH IP/OP $792.98 $586.81 $93.73 $611.23 $356.84 $356.84 $206.17 $206.17 $230.14 $165.28 $588.55 $588.55 $611.23 $206.17 $283.63 $134.01 $469.05 $469.05 $93.73 $320.99 $508.45 $513.58 $93.73 $93.73 $252.18 $166.91 $166.91 $240.12 $166.91 $0.00 $0.00 $0.00 $0.00 102397 ERX HCPCS 63700001 65649-0303-03 RIFAXIMIN 550 MG PO TABS BOTH IP/OP $206.49 $152.80 $0.00 $128.81 $0.00 $0.00 $0.00 $36.76 $0.00 $0.00 $0.00 $0.00 $0.00 $43.03 $0.00 $0.00 $0.00 $0.00 $80.51 $127.52 $128.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102404 ERX HCPCS 63700001 00173-0696-04 ADVAIR DISKUS 250-50 MCG/DOSE IN AEPB BOTH IP/OP $611.81 $452.74 $0.00 $444.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $277.68 $439.85 $444.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 00143-9595-01 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 00143-9595-25 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 00409-4279-02 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 00409-4279-16 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 00409-4713-25 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 00409-4713-42 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 55150-0161-02 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 55150-0162-05 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 63323-0492-09 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 63323-0492-27 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102415 ERX HCPCS 25000001 63323-0492-57 LIDOCAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102416 ERX HCPCS 25000001 00143-9594-01 LIDOCAINE HCL (PF) 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102416 ERX HCPCS 25000001 00143-9594-25 LIDOCAINE HCL (PF) 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102416 ERX HCPCS 25000001 55150-0165-05 LIDOCAINE HCL (PF) 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102416 ERX HCPCS 25000001 63323-0495-07 LIDOCAINE HCL (PF) 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102429 ERX HCPCS J0585 00023-1145-01 ONABOTULINUMTOXINA 100 UNITS IJ SOLR BOTH IP/OP "$1,933.18 " "$1,430.55" $0.00 "$1,490.10" $869.93 $869.93 $618.50 $618.50 $618.50 $642.73 "$1,434.81" "$1,434.81" "$1,490.10" $608.50 $714.99 $395.53 $953.06 $953.06 $642.92 $865.44 "$1,370.86" "$1,384.70" $887.84 $887.84 $719.10 $0.00 $0.00 $684.71 $609.50 $0.00 $0.00 $0.00 $0.00 102430 ERX HCPCS J3480 00264-7865-00 KCL IN NACL 20-0.9 MEQ/L-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102430 ERX HCPCS J3480 00338-0691-04 KCL IN NACL 20-0.9 MEQ/L-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102431 ERX HCPCS J3480 00338-0695-04 KCL IN NACL 40-0.9 MEQ/L-% IV SOLN BOTH IP/OP $50.28 $37.21 $0.00 $38.76 $22.63 $22.63 $0.00 $0.00 $0.00 $0.47 $37.32 $37.32 $38.76 $0.00 $3.38 $0.00 $29.74 $29.74 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 102431 ERX HCPCS J3480 00990-7116-09 KCL IN NACL 40-0.9 MEQ/L-% IV SOLN BOTH IP/OP $50.28 $37.21 $0.00 $38.76 $22.63 $22.63 $0.00 $0.00 $0.00 $0.47 $37.32 $37.32 $38.76 $0.00 $3.38 $0.00 $29.74 $29.74 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 102452 ERX HCPCS 25000001 00264-7652-00 KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN BOTH IP/OP $46.09 $34.11 $0.00 $35.53 $0.00 $0.00 $0.00 $0.00 $0.00 $34.21 $34.21 $35.53 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102452 ERX HCPCS 25000001 00338-0803-04 KCL IN DEXTROSE-NACL 20-5-0.9 MEQ/L-%-% IV SOLN BOTH IP/OP $46.09 $34.11 $0.00 $35.53 $0.00 $0.00 $0.00 $0.00 $0.00 $34.21 $34.21 $35.53 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102453 ERX HCPCS 25000001 00338-0807-04 KCL IN DEXTROSE-NACL 40-5-0.9 MEQ/L-%-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102456 ERX HCPCS 25000001 00264-7634-00 KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN BOTH IP/OP $46.09 $34.11 $0.00 $35.53 $0.00 $0.00 $0.00 $0.00 $0.00 $34.21 $34.21 $35.53 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102456 ERX HCPCS 25000001 00338-0669-04 KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN BOTH IP/OP $46.09 $34.11 $0.00 $35.53 $0.00 $0.00 $0.00 $0.00 $0.00 $34.21 $34.21 $35.53 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102456 ERX HCPCS 25000001 00409-7993-09 KCL IN DEXTROSE-NACL 10-5-0.45 MEQ/L-%-% IV SOLN BOTH IP/OP $46.09 $34.11 $0.00 $35.53 $0.00 $0.00 $0.00 $0.00 $0.00 $34.21 $34.21 $35.53 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102458 ERX HCPCS 25000001 00338-0663-04 KCL IN DEXTROSE-NACL 20-5-0.2 MEQ/L-%-% IV SOLN BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102459 ERX HCPCS 25000001 00264-7635-00 KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $0.00 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102459 ERX HCPCS 25000001 00338-0671-04 KCL IN DEXTROSE-NACL 20-5-0.45 MEQ/L-%-% IV SOLN BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $0.00 $0.00 $0.00 $0.00 $0.00 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102464 ERX HCPCS 25000001 00264-7638-00 KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102464 ERX HCPCS 25000001 00338-0675-04 KCL IN DEXTROSE-NACL 40-5-0.45 MEQ/L-%-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102609 ERX HCPCS J3315 00023-5906-23 TRIPTORELIN PAMOATE 22.5 MG IM SUSR BOTH IP/OP "$12,003.43 " "$8,882.54" $0.00 "$9,602.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,506.72" "$9,602.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103164 ERX HCPCS 63700001 00591-3720-30 TRANEXAMIC ACID 650 MG PO TABS BOTH IP/OP $39.63 $29.33 $0.00 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.82 $31.39 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103164 ERX HCPCS 63700001 60505-3638-03 TRANEXAMIC ACID 650 MG PO TABS BOTH IP/OP $39.63 $29.33 $0.00 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.82 $31.39 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103164 ERX HCPCS 63700001 69918-0301-30 TRANEXAMIC ACID 650 MG PO TABS BOTH IP/OP $39.63 $29.33 $0.00 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.82 $31.39 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103332 ERX HCPCS 25000001 54162-0185-16 MINERAL OIL LIGHT 100 % EX OIL BOTH IP/OP $14.35 $10.62 $0.00 $11.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103727 ERX HCPCS 25000001 00143-9637-10 VALPROATE SODIUM 500 MG/5ML IV SOLN BOTH IP/OP $72.61 $53.73 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.31 $57.51 $58.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103727 ERX HCPCS 25000001 00143-9785-10 VALPROATE SODIUM 500 MG/5ML IV SOLN BOTH IP/OP $72.61 $53.73 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.31 $57.51 $58.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103727 ERX HCPCS 25000001 63323-0494-01 VALPROATE SODIUM 500 MG/5ML IV SOLN BOTH IP/OP $72.61 $53.73 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.31 $57.51 $58.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103727 ERX HCPCS 25000001 63323-0494-05 VALPROATE SODIUM 500 MG/5ML IV SOLN BOTH IP/OP $72.61 $53.73 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.31 $57.51 $58.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103756 ERX HCPCS 63700001 00078-0592-51 NILOTINIB HCL 150 MG PO CAPS BOTH IP/OP $566.86 $419.48 $0.00 $384.72 $0.00 $0.00 $0.00 $106.95 $0.00 $0.00 $0.00 $0.00 $0.00 $118.13 $0.00 $0.00 $0.00 $0.00 $240.45 $380.87 $384.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104015 ERX HCPCS J9043 00024-5824-11 CABAZITAXEL 60 MG/1.5ML IV SOLN BOTH IP/OP "$32,884.41 " "$24,334.46" $0.00 "$26,183.76" "$15,286.32" "$15,286.32" "$11,478.66" "$11,478.66" "$11,478.66" "$6,853.93" "$25,212.23" "$25,212.23" "$26,183.76" "$11,339.82" "$13,324.29" "$7,370.88" "$16,212.01" "$16,212.01" "$10,940.96" "$14,196.06" "$22,486.56" "$22,713.70" "$15,108.94" "$15,108.94" "$8,138.89" $0.00 $0.00 "$8,138.89" "$10,888.38" $0.00 $0.00 $0.00 $0.00 104022 ERX HCPCS 63700001 67618-0107-60 MAGNESIUM CHLORIDE DELAY RELEASE 71.5 MG PO TAB BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104100 ERX HCPCS J7527 00078-0594-51 EVEROLIMUS 2.5 MG PO TABS BOTH IP/OP "$1,666.80 " "$1,233.43" $0.00 "$1,284.77" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,237.10" "$1,237.10" "$1,284.77" $0.00 $347.36 $0.00 $0.00 $0.00 $0.00 $772.27 "$1,223.27" "$1,235.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104174 ERX HCPCS J1650 00075-0624-30 ENOXAPARIN SODIUM 30 MG/0.3ML SC SOLN BOTH IP/OP $30.02 $22.21 $0.00 $23.14 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $23.14 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $13.62 $21.57 $21.78 $0.00 $0.00 $4.26 $0.00 $0.00 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 104174 ERX HCPCS J1650 00548-5601-00 ENOXAPARIN SODIUM 30 MG/0.3ML SC SOLN BOTH IP/OP $30.02 $22.21 $0.00 $23.14 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $23.14 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $13.62 $21.57 $21.78 $0.00 $0.00 $4.26 $0.00 $0.00 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 104174 ERX HCPCS J1650 00548-5631-00 ENOXAPARIN SODIUM 30 MG/0.3ML SC SOLN BOTH IP/OP $30.02 $22.21 $0.00 $23.14 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $23.14 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $13.62 $21.57 $21.78 $0.00 $0.00 $4.26 $0.00 $0.00 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 104174 ERX HCPCS J1650 00703-8530-23 ENOXAPARIN SODIUM 30 MG/0.3ML SC SOLN BOTH IP/OP $30.02 $22.21 $0.00 $23.14 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $23.14 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $13.62 $21.57 $21.78 $0.00 $0.00 $4.26 $0.00 $0.00 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 104174 ERX HCPCS J1650 00781-3133-63 ENOXAPARIN SODIUM 30 MG/0.3ML SC SOLN BOTH IP/OP $30.02 $22.21 $0.00 $23.14 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $23.14 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $13.62 $21.57 $21.78 $0.00 $0.00 $4.26 $0.00 $0.00 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 104174 ERX HCPCS J1650 00955-1003-01 ENOXAPARIN SODIUM 30 MG/0.3ML SC SOLN BOTH IP/OP $30.02 $22.21 $0.00 $23.14 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $23.14 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $13.62 $21.57 $21.78 $0.00 $0.00 $4.26 $0.00 $0.00 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 104174 ERX HCPCS J1650 00955-1003-10 ENOXAPARIN SODIUM 30 MG/0.3ML SC SOLN BOTH IP/OP $30.02 $22.21 $0.00 $23.14 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $23.14 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $13.62 $21.57 $21.78 $0.00 $0.00 $4.26 $0.00 $0.00 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 104174 ERX HCPCS J1650 63323-0568-83 ENOXAPARIN SODIUM 30 MG/0.3ML SC SOLN BOTH IP/OP $30.02 $22.21 $0.00 $23.14 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $23.14 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $13.62 $21.57 $21.78 $0.00 $0.00 $4.26 $0.00 $0.00 $4.34 $0.00 $0.00 $0.00 $0.00 $0.00 104175 ERX HCPCS J1650 00548-5602-00 ENOXAPARIN SODIUM 40 MG/0.4ML SC SOLN BOTH IP/OP $42.94 $31.78 $0.00 $98.91 $19.32 $19.32 $0.00 $0.00 $0.00 $8.95 $31.87 $31.87 $33.10 $0.00 $8.95 $0.00 $25.40 $25.40 $0.00 $19.47 $98.91 $31.15 $0.00 $0.00 $19.55 $0.00 $0.00 $6.20 $0.00 $0.00 $0.00 $0.00 $0.00 104175 ERX HCPCS J1650 00703-8540-23 ENOXAPARIN SODIUM 40 MG/0.4ML SC SOLN BOTH IP/OP $42.94 $31.78 $0.00 $98.91 $19.32 $19.32 $0.00 $0.00 $0.00 $8.95 $31.87 $31.87 $33.10 $0.00 $8.95 $0.00 $25.40 $25.40 $0.00 $19.47 $98.91 $31.15 $0.00 $0.00 $19.55 $0.00 $0.00 $6.20 $0.00 $0.00 $0.00 $0.00 $0.00 104175 ERX HCPCS J1650 00781-3224-64 ENOXAPARIN SODIUM 40 MG/0.4ML SC SOLN BOTH IP/OP $42.94 $31.78 $0.00 $98.91 $19.32 $19.32 $0.00 $0.00 $0.00 $8.95 $31.87 $31.87 $33.10 $0.00 $8.95 $0.00 $25.40 $25.40 $0.00 $19.47 $98.91 $31.15 $0.00 $0.00 $19.55 $0.00 $0.00 $6.20 $0.00 $0.00 $0.00 $0.00 $0.00 104175 ERX HCPCS J1650 00955-1004-01 ENOXAPARIN SODIUM 40 MG/0.4ML SC SOLN BOTH IP/OP $42.94 $31.78 $0.00 $98.91 $19.32 $19.32 $0.00 $0.00 $0.00 $8.95 $31.87 $31.87 $33.10 $0.00 $8.95 $0.00 $25.40 $25.40 $0.00 $19.47 $98.91 $31.15 $0.00 $0.00 $19.55 $0.00 $0.00 $6.20 $0.00 $0.00 $0.00 $0.00 $0.00 104175 ERX HCPCS J1650 00955-1004-10 ENOXAPARIN SODIUM 40 MG/0.4ML SC SOLN BOTH IP/OP $42.94 $31.78 $0.00 $98.91 $19.32 $19.32 $0.00 $0.00 $0.00 $8.95 $31.87 $31.87 $33.10 $0.00 $8.95 $0.00 $25.40 $25.40 $0.00 $19.47 $98.91 $31.15 $0.00 $0.00 $19.55 $0.00 $0.00 $6.20 $0.00 $0.00 $0.00 $0.00 $0.00 104176 ERX HCPCS J1650 00548-5603-00 ENOXAPARIN SODIUM 60 MG/0.6ML SC SOLN BOTH IP/OP $22.88 $16.93 $0.00 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.44 $18.12 $18.30 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104176 ERX HCPCS J1650 00781-3356-66 ENOXAPARIN SODIUM 60 MG/0.6ML SC SOLN BOTH IP/OP $22.88 $16.93 $0.00 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.44 $18.12 $18.30 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104176 ERX HCPCS J1650 00955-1006-01 ENOXAPARIN SODIUM 60 MG/0.6ML SC SOLN BOTH IP/OP $22.88 $16.93 $0.00 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.44 $18.12 $18.30 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104176 ERX HCPCS J1650 00955-1006-10 ENOXAPARIN SODIUM 60 MG/0.6ML SC SOLN BOTH IP/OP $22.88 $16.93 $0.00 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.44 $18.12 $18.30 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104176 ERX HCPCS J1650 63323-0607-88 ENOXAPARIN SODIUM 60 MG/0.6ML SC SOLN BOTH IP/OP $22.88 $16.93 $0.00 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.44 $18.12 $18.30 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104177 ERX HCPCS J1650 00548-5604-00 ENOXAPARIN SODIUM 80 MG/0.8ML SC SOLN BOTH IP/OP $63.45 $46.95 $0.00 $50.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104177 ERX HCPCS J1650 00781-3428-68 ENOXAPARIN SODIUM 80 MG/0.8ML SC SOLN BOTH IP/OP $63.45 $46.95 $0.00 $50.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104177 ERX HCPCS J1650 00955-1008-01 ENOXAPARIN SODIUM 80 MG/0.8ML SC SOLN BOTH IP/OP $63.45 $46.95 $0.00 $50.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104177 ERX HCPCS J1650 00955-1008-10 ENOXAPARIN SODIUM 80 MG/0.8ML SC SOLN BOTH IP/OP $63.45 $46.95 $0.00 $50.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104177 ERX HCPCS J1650 63323-0531-90 ENOXAPARIN SODIUM 80 MG/0.8ML SC SOLN BOTH IP/OP $63.45 $46.95 $0.00 $50.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104178 ERX HCPCS J1650 00955-1010-10 ENOXAPARIN SODIUM 100 MG/ML SC SOLN BOTH IP/OP $75.15 $55.61 $0.00 $60.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.58 $59.52 $60.12 $0.00 $0.00 $11.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104178 ERX HCPCS J1650 63323-0605-84 ENOXAPARIN SODIUM 100 MG/ML SC SOLN BOTH IP/OP $75.15 $55.61 $0.00 $60.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.58 $59.52 $60.12 $0.00 $0.00 $11.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104179 ERX HCPCS J1650 00548-5606-00 ENOXAPARIN SODIUM 120 MG/0.8ML SC SOLN BOTH IP/OP $100.17 $74.13 $0.00 $80.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.09 $79.33 $80.14 $0.00 $0.00 $15.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104179 ERX HCPCS J1650 00781-3612-68 ENOXAPARIN SODIUM 120 MG/0.8ML SC SOLN BOTH IP/OP $100.17 $74.13 $0.00 $80.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.09 $79.33 $80.14 $0.00 $0.00 $15.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104179 ERX HCPCS J1650 00955-1012-10 ENOXAPARIN SODIUM 120 MG/0.8ML SC SOLN BOTH IP/OP $100.17 $74.13 $0.00 $80.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.09 $79.33 $80.14 $0.00 $0.00 $15.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104179 ERX HCPCS J1650 16714-0056-01 ENOXAPARIN SODIUM 120 MG/0.8ML SC SOLN BOTH IP/OP $100.17 $74.13 $0.00 $80.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.09 $79.33 $80.14 $0.00 $0.00 $15.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104179 ERX HCPCS J1650 63323-0609-90 ENOXAPARIN SODIUM 120 MG/0.8ML SC SOLN BOTH IP/OP $100.17 $74.13 $0.00 $80.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.09 $79.33 $80.14 $0.00 $0.00 $15.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104407 ERX HCPCS J0588 00259-1610-01 INCOBOTULINUMTOXINA 100 UNITS IM SOLR BOTH IP/OP "$1,498.06 " "$1,108.56" $0.00 "$1,154.70" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,111.86" "$1,111.86" "$1,154.70" $0.00 $593.02 $0.00 $0.00 $0.00 $0.00 $694.08 "$1,099.42" "$1,110.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104804 ERX HCPCS 63700001 00023-3205-03 BIMATOPROST 0.01 % OP SOLN BOTH IP/OP $760.93 $563.09 $0.00 $526.14 $0.00 $0.00 $0.00 $142.22 $0.00 $0.00 $0.00 $0.00 $0.00 $158.58 $0.00 $0.00 $0.00 $0.00 $328.84 $520.88 $526.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104817 ERX HCPCS 25000001 00310-6512-01 EXENATIDE 5 MCG/0.02ML SC SOPN BOTH IP/OP $57.12 $42.27 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.56 $45.24 $45.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104818 ERX HCPCS 25000001 00310-6524-01 EXENATIDE 10 MCG/0.04ML SC SOPN BOTH IP/OP $57.12 $42.27 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.56 $45.24 $45.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 00409-1746-10 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 00409-1746-30 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 00409-1746-71 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 00409-9042-01 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 00409-9042-17 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 63323-0468-01 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 63323-0468-02 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 63323-0468-17 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104822 ERX HCPCS 25000001 63323-0468-37 BUPIVACAINE-EPINEPHRINE (PF) 0.25% -1:200000 IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104823 ERX HCPCS 25000001 00409-9045-01 BUPIVACAINE-EPINEPHRINE (PF) 0.5-1:200000 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104823 ERX HCPCS 25000001 00409-9045-17 BUPIVACAINE-EPINEPHRINE (PF) 0.5-1:200000 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104823 ERX HCPCS 25000001 31382-0557-05 BUPIVACAINE-EPINEPHRINE (PF) 0.5-1:200000 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104823 ERX HCPCS 25000001 63323-0462-01 BUPIVACAINE-EPINEPHRINE (PF) 0.5-1:200000 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104823 ERX HCPCS 25000001 63323-0462-17 BUPIVACAINE-EPINEPHRINE (PF) 0.5-1:200000 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104823 ERX HCPCS 25000001 63323-0462-31 BUPIVACAINE-EPINEPHRINE (PF) 0.5-1:200000 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104823 ERX HCPCS 25000001 63323-0462-37 BUPIVACAINE-EPINEPHRINE (PF) 0.5-1:200000 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104825 ERX HCPCS J0670 00409-1036-30 MEPIVACAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.24 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104825 ERX HCPCS J0670 63323-0260-37 MEPIVACAINE HCL (PF) 1 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.24 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104826 ERX HCPCS J0670 00409-1067-20 MEPIVACAINE HCL (PF) 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.24 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104826 ERX HCPCS J0670 63323-0294-27 MEPIVACAINE HCL (PF) 2 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.27 $16.33 $16.33 $16.96 $0.00 $3.24 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 00409-1159-02 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 00409-1559-10 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 00409-1559-30 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 55150-0167-10 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 55150-0168-30 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 63323-0464-01 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 63323-0464-17 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 63323-0464-31 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104827 ERX HCPCS 25000001 63323-0464-37 BUPIVACAINE HCL (PF) 0.25 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104828 ERX HCPCS 25000001 00409-1162-01 BUPIVACAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104828 ERX HCPCS 25000001 00409-1162-02 BUPIVACAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104828 ERX HCPCS 25000001 00409-1162-09 BUPIVACAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104828 ERX HCPCS 25000001 00409-1162-10 BUPIVACAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104828 ERX HCPCS 25000001 55150-0169-10 BUPIVACAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104828 ERX HCPCS 25000001 55150-0170-30 BUPIVACAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104828 ERX HCPCS 25000001 63323-0466-17 BUPIVACAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104828 ERX HCPCS 25000001 63323-0466-37 BUPIVACAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104858 ERX HCPCS 25000001 12496-1202-01 SUBOXONE:BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL FILM BOTH IP/OP $25.20 $18.65 $0.00 $19.42 $0.00 $0.00 $0.00 $0.00 $0.00 $18.70 $18.70 $19.42 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $11.43 $18.10 $18.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104858 ERX HCPCS 25000001 12496-1202-03 SUBOXONE:BUPRENORPHINE HCL-NALOXONE HCL 2-0.5 MG SL FILM BOTH IP/OP $25.20 $18.65 $0.00 $19.42 $0.00 $0.00 $0.00 $0.00 $0.00 $18.70 $18.70 $19.42 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $11.43 $18.10 $18.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104859 ERX HCPCS 25000001 12496-1208-01 SUBOXONE:BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL FILM BOTH IP/OP $45.16 $33.42 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 $33.52 $33.52 $34.81 $0.00 $9.41 $0.00 $0.00 $0.00 $0.00 $20.48 $32.43 $32.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104859 ERX HCPCS 25000001 12496-1208-03 SUBOXONE:BUPRENORPHINE HCL-NALOXONE HCL 8-2 MG SL FILM BOTH IP/OP $45.16 $33.42 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 $33.52 $33.52 $34.81 $0.00 $9.41 $0.00 $0.00 $0.00 $0.00 $20.48 $32.43 $32.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104955 ERX HCPCS J0257 00944-2884-01 ALPHA1-PROTEINASE INHIBITOR 1000 MG/50ML IV SOLN BOTH IP/OP "$1,813.00 " "$1,341.62" $0.00 "$1,437.39" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.05" "$1,384.05" "$1,437.39" $0.00 $581.63 $0.00 $0.00 $0.00 $0.00 $816.00 "$1,292.54" "$1,305.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104955 ERX HCPCS J0257 00944-2884-02 ALPHA1-PROTEINASE INHIBITOR 1000 MG/50ML IV SOLN BOTH IP/OP "$1,813.00 " "$1,341.62" $0.00 "$1,437.39" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.05" "$1,384.05" "$1,437.39" $0.00 $581.63 $0.00 $0.00 $0.00 $0.00 $816.00 "$1,292.54" "$1,305.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105032 ERX HCPCS 25000001 00409-4278-01 LIDOCAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105032 ERX HCPCS 25000001 63323-0491-57 LIDOCAINE HCL (PF) 0.5 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105342 ERX HCPCS 63700001 00597-0360-82 DABIGATRAN ETEXILATE MESYLATE 150 MG PO CAPS BOTH IP/OP $39.97 $29.58 $0.00 $27.89 $0.00 $0.00 $0.00 $7.40 $0.00 $0.00 $0.00 $0.00 $0.00 $8.33 $0.00 $0.00 $0.00 $0.00 $17.43 $27.61 $27.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105514 ERX HCPCS 63700001 00597-0355-09 DABIGATRAN ETEXILATE MESYLATE 75 MG PO CAPS BOTH IP/OP $30.45 $22.53 $0.00 $24.36 $0.00 $0.00 $0.00 $7.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.23 $24.12 $24.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105737 ERX HCPCS J9179 62856-0389-01 ERIBULIN MESYLATE 1 MG/2ML IV SOLN BOTH IP/OP "$3,384.58 " "$2,504.59" $0.00 "$2,663.18" "$1,554.79" "$1,554.79" "$1,274.36" "$1,274.36" "$1,274.36" $705.43 "$2,564.37" "$2,564.37" "$2,663.18" "$1,239.30" "$1,456.18" $805.55 "$1,668.60" "$1,668.60" "$1,199.88" "$1,451.40" "$2,299.02" "$2,322.24" "$1,656.97" "$1,656.97" $0.00 $0.00 $0.00 "$1,300.49" "$1,174.22" $0.00 $0.00 $0.00 $0.00 105747 ERX HCPCS J1453 00006-3061-00 FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR BOTH IP/OP "$1,054.12 " $780.05 $0.00 $812.52 $474.35 $474.35 $0.00 $0.00 $0.00 $219.70 $782.37 $782.37 $812.52 $36.45 $42.83 $23.69 $623.51 $623.51 $310.12 $478.33 $757.67 $765.32 $428.26 $428.26 $348.98 $0.00 $0.00 $332.28 $161.25 $0.00 $0.00 $0.00 $0.00 105747 ERX HCPCS J1453 00006-3061-04 FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR BOTH IP/OP "$1,054.12 " $780.05 $0.00 $812.52 $474.35 $474.35 $0.00 $0.00 $0.00 $219.70 $782.37 $782.37 $812.52 $36.45 $42.83 $23.69 $623.51 $623.51 $310.12 $478.33 $757.67 $765.32 $428.26 $428.26 $348.98 $0.00 $0.00 $332.28 $161.25 $0.00 $0.00 $0.00 $0.00 105747 ERX HCPCS J1453 60505-6105-01 FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR BOTH IP/OP "$1,054.12 " $780.05 $0.00 $812.52 $474.35 $474.35 $0.00 $0.00 $0.00 $219.70 $782.37 $782.37 $812.52 $36.45 $42.83 $23.69 $623.51 $623.51 $310.12 $478.33 $757.67 $765.32 $428.26 $428.26 $348.98 $0.00 $0.00 $332.28 $161.25 $0.00 $0.00 $0.00 $0.00 105747 ERX HCPCS J1453 67457-0889-10 FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR BOTH IP/OP "$1,054.12 " $780.05 $0.00 $812.52 $474.35 $474.35 $0.00 $0.00 $0.00 $219.70 $782.37 $782.37 $812.52 $36.45 $42.83 $23.69 $623.51 $623.51 $310.12 $478.33 $757.67 $765.32 $428.26 $428.26 $348.98 $0.00 $0.00 $332.28 $161.25 $0.00 $0.00 $0.00 $0.00 105747 ERX HCPCS J1453 71288-0418-10 FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR BOTH IP/OP "$1,054.12 " $780.05 $0.00 $812.52 $474.35 $474.35 $0.00 $0.00 $0.00 $219.70 $782.37 $782.37 $812.52 $36.45 $42.83 $23.69 $623.51 $623.51 $310.12 $478.33 $757.67 $765.32 $428.26 $428.26 $348.98 $0.00 $0.00 $332.28 $161.25 $0.00 $0.00 $0.00 $0.00 105747 ERX HCPCS J1453 71839-0104-01 FOSAPREPITANT DIMEGLUMINE 150 MG IV SOLR BOTH IP/OP "$1,054.12 " $780.05 $0.00 $812.52 $474.35 $474.35 $0.00 $0.00 $0.00 $219.70 $782.37 $782.37 $812.52 $36.45 $42.83 $23.69 $623.51 $623.51 $310.12 $478.33 $757.67 $765.32 $428.26 $428.26 $348.98 $0.00 $0.00 $332.28 $161.25 $0.00 $0.00 $0.00 $0.00 105768 ERX HCPCS J0897 55513-0730-01 DENOSUMAB 120 MG/1.7ML SC SOLN BOTH IP/OP "$6,755.71 " "$4,999.23" $0.00 "$5,514.53" "$3,219.43" "$3,219.43" "$2,544.60" "$2,544.60" "$2,544.60" "$1,408.06" "$5,309.91" "$5,309.91" "$5,514.53" "$2,542.68" "$2,987.65" "$1,652.74" "$3,330.57" "$3,330.57" "$2,428.78" "$2,893.27" "$4,582.94" "$4,629.23" "$3,354.02" "$3,354.02" "$2,718.48" $0.00 $0.00 "$2,588.46" "$2,388.12" $0.00 $0.00 $0.00 $0.00 106031 ERX HCPCS 25000001 63402-0304-30 LURASIDONE HCL 40 MG PO TABS BOTH IP/OP $196.92 $145.72 $0.00 $151.79 $0.00 $0.00 $0.00 $0.00 $0.00 $146.15 $146.15 $151.79 $0.00 $41.04 $0.00 $0.00 $0.00 $0.00 $80.86 $128.07 $129.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106032 ERX HCPCS 25000001 63402-0308-10 LURASIDONE HCL 80 MG PO TABS BOTH IP/OP $186.89 $138.30 $0.00 $129.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.95 $0.00 $0.00 $0.00 $0.00 $80.86 $128.07 $129.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106032 ERX HCPCS 25000001 63402-0308-30 LURASIDONE HCL 80 MG PO TABS BOTH IP/OP $186.89 $138.30 $0.00 $129.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.95 $0.00 $0.00 $0.00 $0.00 $80.86 $128.07 $129.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106033 ERX HCPCS J0712 00456-0400-01 CEFTAROLINE FOSAMIL 400 MG IV SOLR BOTH IP/OP $742.20 $549.23 $0.00 $600.69 $0.00 $0.00 $0.00 $0.00 $0.00 $578.40 $578.40 $600.69 $0.00 $154.67 $0.00 $0.00 $0.00 $0.00 $320.75 $508.07 $513.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106033 ERX HCPCS J0712 00456-0400-10 CEFTAROLINE FOSAMIL 400 MG IV SOLR BOTH IP/OP $742.20 $549.23 $0.00 $600.69 $0.00 $0.00 $0.00 $0.00 $0.00 $578.40 $578.40 $600.69 $0.00 $154.67 $0.00 $0.00 $0.00 $0.00 $320.75 $508.07 $513.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106034 ERX HCPCS J0712 00456-0600-01 CEFTAROLINE FOSAMIL 600 MG IV SOLR BOTH IP/OP $742.20 $549.23 $0.00 $600.69 $0.00 $0.00 $0.00 $0.00 $0.00 $578.40 $578.40 $600.69 $0.00 $154.67 $0.00 $0.00 $0.00 $0.00 $320.75 $508.07 $513.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106034 ERX HCPCS J0712 00456-0600-10 CEFTAROLINE FOSAMIL 600 MG IV SOLR BOTH IP/OP $742.20 $549.23 $0.00 $600.69 $0.00 $0.00 $0.00 $0.00 $0.00 $578.40 $578.40 $600.69 $0.00 $154.67 $0.00 $0.00 $0.00 $0.00 $320.75 $508.07 $513.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106035 ERX HCPCS 25000001 64597-0301-60 DEXTROMETHORPHAN-QUINIDINE 20-10 MG PO CAPS BOTH IP/OP $110.01 $81.41 $0.00 $84.80 $0.00 $0.00 $0.00 $0.00 $0.00 $81.65 $81.65 $84.80 $0.00 $22.93 $0.00 $0.00 $0.00 $0.00 $43.77 $69.32 $70.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106115 ERX HCPCS J1561 13533-0800-20 IMMUNE GLOBULIN (HUMAN) 5 GM/50ML IJ SOLN BOTH IP/OP "$2,022.02 " "$1,496.29" $0.00 "$1,558.57" $909.91 $909.91 $465.09 $465.09 $465.09 $421.44 "$1,500.74" "$1,500.74" "$1,558.57" $482.19 $566.57 $313.42 $996.86 $996.86 $410.97 $879.72 "$1,359.45" "$1,407.55" $567.53 $567.53 $474.11 $0.00 $0.00 $451.44 $416.91 $0.00 $0.00 $0.00 $0.00 106116 ERX HCPCS J1561 13533-0800-71 IMMUNE GLOBULIN (HUMAN) 10 GM/100ML IJ SOLN BOTH IP/OP "$3,528.77 " "$2,611.29" $0.00 "$2,719.98" "$1,587.95" "$1,587.95" $930.18 $930.18 $930.18 $735.48 "$2,619.05" "$2,619.05" "$2,719.98" $964.38 "$1,133.15" $626.85 "$1,739.68" "$1,739.68" $821.94 "$1,502.86" "$2,322.56" "$2,404.57" "$1,135.06" "$1,135.06" $948.23 $0.00 $0.00 $902.87 $833.82 $0.00 $0.00 $0.00 $0.00 106117 ERX HCPCS J1561 13533-0800-24 IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN BOTH IP/OP "$7,057.53 " "$5,222.57" $0.00 "$5,439.94" "$3,175.89" "$3,175.89" "$1,860.36" "$1,860.36" "$1,860.36" "$1,470.97" "$5,238.10" "$5,238.10" "$5,439.94" "$1,928.76" "$2,266.29" "$1,253.69" "$3,479.36" "$3,479.36" "$1,643.88" "$3,005.71" "$4,645.12" "$4,809.14" "$2,270.12" "$2,270.12" "$1,896.45" $0.00 $0.00 "$1,805.74" "$1,667.64" $0.00 $0.00 $0.00 $0.00 106117 ERX HCPCS J1561 13533-0800-25 IMMUNE GLOBULIN (HUMAN) 20 GM/200ML IJ SOLN BOTH IP/OP "$7,057.53 " "$5,222.57" $0.00 "$5,439.94" "$3,175.89" "$3,175.89" "$1,860.36" "$1,860.36" "$1,860.36" "$1,470.97" "$5,238.10" "$5,238.10" "$5,439.94" "$1,928.76" "$2,266.29" "$1,253.69" "$3,479.36" "$3,479.36" "$1,643.88" "$3,005.71" "$4,645.12" "$4,809.14" "$2,270.12" "$2,270.12" "$1,896.45" $0.00 $0.00 "$1,805.74" "$1,667.64" $0.00 $0.00 $0.00 $0.00 106201 ERX HCPCS 63700001 00121-4675-00 VALPROIC ACID 250 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106201 ERX HCPCS 63700001 00121-4675-05 VALPROIC ACID 250 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106201 ERX HCPCS 63700001 00121-4675-40 VALPROIC ACID 250 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106201 ERX HCPCS 63700001 50383-0792-07 VALPROIC ACID 250 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106201 ERX HCPCS 63700001 68094-0193-61 VALPROIC ACID 250 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106201 ERX HCPCS 63700001 68094-0193-62 VALPROIC ACID 250 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106621 ERX HCPCS 63700001 00003-0857-22 DASATINIB 140 MG PO TABS BOTH IP/OP "$1,570.67 " "$1,162.30" $0.00 "$1,114.22" $0.00 $0.00 $0.00 $292.16 $0.00 $0.00 $0.00 $0.00 $0.00 $327.33 $0.00 $0.00 $0.00 $0.00 $696.39 "$1,103.07" "$1,114.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106632 ERX HCPCS 63700001 59676-0571-01 ETRAVIRINE 200 MG PO TABS BOTH IP/OP $108.97 $80.64 $0.00 $77.50 $0.00 $0.00 $0.00 $19.78 $0.00 $0.00 $0.00 $0.00 $0.00 $22.71 $0.00 $0.00 $0.00 $0.00 $48.44 $76.72 $77.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106862 ERX HCPCS J9351 00409-0302-01 TOPOTECAN HCL 4 MG/4ML IV SOLN BOTH IP/OP $558.64 $413.39 $0.00 $430.60 $251.39 $251.39 $0.00 $0.00 $0.00 $116.43 $414.62 $414.62 $430.60 $0.00 $36.00 $0.00 $330.44 $330.44 $0.00 $249.80 $395.68 $399.67 $0.00 $0.00 $46.06 $0.00 $0.00 $43.86 $0.00 $0.00 $0.00 $0.00 $0.00 106862 ERX HCPCS J9351 67457-0662-05 TOPOTECAN HCL 4 MG/4ML IV SOLN BOTH IP/OP $558.64 $413.39 $0.00 $430.60 $251.39 $251.39 $0.00 $0.00 $0.00 $116.43 $414.62 $414.62 $430.60 $0.00 $36.00 $0.00 $330.44 $330.44 $0.00 $249.80 $395.68 $399.67 $0.00 $0.00 $46.06 $0.00 $0.00 $43.86 $0.00 $0.00 $0.00 $0.00 $0.00 107058 ERX HCPCS J1652 55111-0679-10 FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN BOTH IP/OP $432.13 $319.78 $0.00 $333.09 $0.00 $0.00 $0.00 $0.00 $0.00 $320.73 $320.73 $333.09 $0.00 $90.06 $0.00 $0.00 $0.00 $0.00 $196.14 $310.68 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107058 ERX HCPCS J1652 55111-0679-11 FONDAPARINUX SODIUM 5 MG/0.4ML SC SOLN BOTH IP/OP $432.13 $319.78 $0.00 $333.09 $0.00 $0.00 $0.00 $0.00 $0.00 $320.73 $320.73 $333.09 $0.00 $90.06 $0.00 $0.00 $0.00 $0.00 $196.14 $310.68 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107059 ERX HCPCS J1652 55111-0680-02 FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN BOTH IP/OP $456.29 $337.65 $0.00 $351.71 $0.00 $0.00 $0.00 $0.00 $0.00 $338.66 $338.66 $351.71 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $196.14 $310.68 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107059 ERX HCPCS J1652 55111-0680-10 FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN BOTH IP/OP $456.29 $337.65 $0.00 $351.71 $0.00 $0.00 $0.00 $0.00 $0.00 $338.66 $338.66 $351.71 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $196.14 $310.68 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107059 ERX HCPCS J1652 55150-0232-00 FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN BOTH IP/OP $456.29 $337.65 $0.00 $351.71 $0.00 $0.00 $0.00 $0.00 $0.00 $338.66 $338.66 $351.71 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $196.14 $310.68 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107059 ERX HCPCS J1652 55150-0232-10 FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN BOTH IP/OP $456.29 $337.65 $0.00 $351.71 $0.00 $0.00 $0.00 $0.00 $0.00 $338.66 $338.66 $351.71 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $196.14 $310.68 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107059 ERX HCPCS J1652 67457-0584-00 FONDAPARINUX SODIUM 7.5 MG/0.6ML SC SOLN BOTH IP/OP $456.29 $337.65 $0.00 $351.71 $0.00 $0.00 $0.00 $0.00 $0.00 $338.66 $338.66 $351.71 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $196.14 $310.68 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107060 ERX HCPCS J1652 55111-0681-02 FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN BOTH IP/OP $456.29 $337.65 $0.00 $379.38 $0.00 $0.00 $0.00 $0.00 $0.00 $338.66 $338.66 $351.71 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $196.14 $379.38 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107060 ERX HCPCS J1652 55111-0681-10 FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN BOTH IP/OP $456.29 $337.65 $0.00 $379.38 $0.00 $0.00 $0.00 $0.00 $0.00 $338.66 $338.66 $351.71 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $196.14 $379.38 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107060 ERX HCPCS J1652 55111-0681-11 FONDAPARINUX SODIUM 10 MG/0.8ML SC SOLN BOTH IP/OP $456.29 $337.65 $0.00 $379.38 $0.00 $0.00 $0.00 $0.00 $0.00 $338.66 $338.66 $351.71 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $196.14 $379.38 $313.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107068 ERX HCPCS 25000001 00051-8450-30 TESTOSTERONE 50 MG/5GM (1%) TD GEL BOTH IP/OP $98.88 $73.17 $0.00 $76.22 $0.00 $0.00 $0.00 $0.00 $0.00 $73.39 $73.39 $76.22 $0.00 $20.61 $0.00 $0.00 $0.00 $0.00 $44.83 $71.01 $71.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107078 ERX HCPCS J0561 60793-0701-10 PENICILLIN G BENZATHINE 1200000 UNIT/2ML IM SUSP BOTH IP/OP $381.78 $282.52 $0.00 $294.28 $171.80 $171.80 $90.26 $90.26 $90.26 $79.57 $283.36 $283.36 $294.28 $89.69 $105.39 $58.30 $225.82 $225.82 $87.07 $157.53 $249.52 $252.04 $120.23 $120.23 $97.01 $0.00 $0.00 $92.37 $82.92 $0.00 $0.00 $0.00 $0.00 107084 ERX HCPCS J9303 55513-0954-01 PANITUMUMAB 100 MG/5ML IV SOLN BOTH IP/OP "$3,684.78 " "$2,726.74" $0.00 "$3,007.79" "$1,755.98" "$1,755.98" "$1,304.07" "$1,304.07" "$1,304.07" $768.00 "$2,896.19" "$2,896.19" "$3,007.79" "$1,303.79" "$1,531.95" $847.46 "$1,816.60" "$1,816.60" "$1,250.25" "$1,578.08" "$2,499.68" "$2,524.93" "$1,726.53" "$1,726.53" "$1,392.61" $0.00 $0.00 "$1,326.00" "$1,228.01" $0.00 $0.00 $0.00 $0.00 107086 ERX HCPCS J9303 55513-0956-01 PANITUMUMAB 400 MG/20ML IV SOLN BOTH IP/OP "$14,739.05 " "$10,906.90" $0.00 "$12,031.15" "$7,023.89" "$7,023.89" "$5,216.28" "$5,216.28" "$5,216.28" "$3,071.99" "$11,584.74" "$11,584.74" "$12,031.15" "$5,215.16" "$6,127.81" "$3,389.85" "$7,266.35" "$7,266.35" "$5,000.98" "$6,312.32" "$9,998.71" "$10,099.71" "$6,906.12" "$6,906.12" "$5,570.44" $0.00 $0.00 "$5,304.01" "$4,912.04" $0.00 $0.00 $0.00 $0.00 107089 ERX HCPCS 90378 60574-4114-01 PALIVIZUMAB 50 MG/0.5ML IM SOLN BOTH IP/OP "$4,415.91 " "$3,267.77" $0.00 "$3,403.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,277.49" "$3,277.49" "$3,403.78" $0.00 "$1,913.23" $0.00 $0.00 $0.00 $0.00 "$1,935.06" "$3,065.14" "$3,096.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107090 ERX HCPCS J3262 50242-0135-01 TOCILIZUMAB 80 MG/4ML IV SOLN BOTH IP/OP "$1,433.29 " "$1,060.63" $0.00 "$1,104.78" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,063.79" "$1,063.79" "$1,104.78" $0.00 $521.98 $0.00 $0.00 $0.00 $0.00 $664.08 "$1,051.89" "$1,062.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107091 ERX HCPCS J3262 50242-0136-01 TOCILIZUMAB 200 MG/10ML IV SOLN BOTH IP/OP "$3,126.67 " "$2,313.74" $0.00 "$2,410.04" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,320.61" "$2,320.61" "$2,410.04" $0.00 "$1,304.96" $0.00 $0.00 $0.00 $0.00 "$1,418.07" "$2,246.22" "$2,268.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107092 ERX HCPCS J3262 50242-0137-01 TOCILIZUMAB 400 MG/20ML IV SOLN BOTH IP/OP "$6,253.33 " "$4,627.46" $0.00 "$4,820.07" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,641.22" "$4,641.22" "$4,820.07" $0.00 "$2,609.91" $0.00 $0.00 $0.00 $0.00 "$2,836.14" "$4,492.44" "$4,537.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107094 ERX HCPCS J9035 50242-0060-01 BEVACIZUMAB 100 MG/4ML IV SOLN BOTH IP/OP "$2,476.90 " "$1,832.91" $0.00 "$1,909.19" "$1,114.61" "$1,114.61" $678.61 $678.61 $678.61 $674.22 "$1,838.36" "$1,838.36" "$1,909.19" $704.12 $827.34 $457.68 "$1,221.11" "$1,221.11" $852.41 "$1,147.60" "$1,817.80" "$1,836.16" "$1,177.14" "$1,177.14" $947.52 $0.00 $0.00 $902.20 $783.99 $0.00 $0.00 $0.00 $0.00 107095 ERX HCPCS J9035 50242-0061-01 BEVACIZUMAB 400 MG/16ML IV SOLN BOTH IP/OP "$8,645.21 " "$6,397.46" $0.00 "$6,663.73" "$3,890.34" "$3,890.34" "$2,714.44" "$2,714.44" "$2,714.44" "$2,696.86" "$6,416.47" "$6,416.47" "$6,663.73" "$2,816.48" "$3,309.36" "$1,830.71" "$4,262.09" "$4,262.09" "$3,409.64" "$3,920.95" "$6,210.78" "$6,273.51" "$4,708.56" "$4,708.56" "$3,790.08" $0.00 $0.00 "$3,608.80" "$3,135.96" $0.00 $0.00 $0.00 $0.00 107101 ERX HCPCS J9055 66733-0958-23 CETUXIMAB 200 MG/100ML IV SOLN BOTH IP/OP "$3,761.10 " "$2,783.21" $0.00 "$2,985.98" "$1,743.24" "$1,743.24" "$1,352.36" "$1,352.36" "$1,352.36" "$1,168.89" "$2,875.19" "$2,875.19" "$2,985.98" "$1,334.10" "$1,567.57" $867.17 "$1,854.22" "$1,854.22" "$1,303.01" "$1,639.59" "$2,597.11" "$2,623.34" "$1,799.39" "$1,799.39" "$1,485.44" $0.00 $0.00 "$1,414.39" "$1,294.26" $0.00 $0.00 $0.00 $0.00 107125 ERX HCPCS J9395 00310-0720-10 FULVESTRANT 250 MG/5ML IM SOLN BOTH IP/OP "$2,465.04 " "$1,824.13" $0.00 "$1,900.05" "$1,109.27" "$1,109.27" $156.46 $156.46 $156.46 $956.22 "$1,829.55" "$1,829.55" "$1,900.05" $159.79 $187.75 $103.86 "$1,215.26" "$1,215.26" $996.18 "$1,118.00" "$1,888.95" "$1,788.79" "$1,375.67" "$1,375.67" $998.28 $0.00 $0.00 $950.53 $494.81 $0.00 $0.00 $0.00 $0.00 107125 ERX HCPCS J9395 00310-7720-10 FULVESTRANT 250 MG/5ML IM SOLN BOTH IP/OP "$2,465.04 " "$1,824.13" $0.00 "$1,900.05" "$1,109.27" "$1,109.27" $156.46 $156.46 $156.46 $956.22 "$1,829.55" "$1,829.55" "$1,900.05" $159.79 $187.75 $103.86 "$1,215.26" "$1,215.26" $996.18 "$1,118.00" "$1,888.95" "$1,788.79" "$1,375.67" "$1,375.67" $998.28 $0.00 $0.00 $950.53 $494.81 $0.00 $0.00 $0.00 $0.00 107125 ERX HCPCS J9395 00781-3079-12 FULVESTRANT 250 MG/5ML IM SOLN BOTH IP/OP "$2,465.04 " "$1,824.13" $0.00 "$1,900.05" "$1,109.27" "$1,109.27" $156.46 $156.46 $156.46 $956.22 "$1,829.55" "$1,829.55" "$1,900.05" $159.79 $187.75 $103.86 "$1,215.26" "$1,215.26" $996.18 "$1,118.00" "$1,888.95" "$1,788.79" "$1,375.67" "$1,375.67" $998.28 $0.00 $0.00 $950.53 $494.81 $0.00 $0.00 $0.00 $0.00 107125 ERX HCPCS J9395 25021-0462-74 FULVESTRANT 250 MG/5ML IM SOLN BOTH IP/OP "$2,465.04 " "$1,824.13" $0.00 "$1,900.05" "$1,109.27" "$1,109.27" $156.46 $156.46 $156.46 $956.22 "$1,829.55" "$1,829.55" "$1,900.05" $159.79 $187.75 $103.86 "$1,215.26" "$1,215.26" $996.18 "$1,118.00" "$1,888.95" "$1,788.79" "$1,375.67" "$1,375.67" $998.28 $0.00 $0.00 $950.53 $494.81 $0.00 $0.00 $0.00 $0.00 107125 ERX HCPCS J9395 67457-0311-05 FULVESTRANT 250 MG/5ML IM SOLN BOTH IP/OP "$2,465.04 " "$1,824.13" $0.00 "$1,900.05" "$1,109.27" "$1,109.27" $156.46 $156.46 $156.46 $956.22 "$1,829.55" "$1,829.55" "$1,900.05" $159.79 $187.75 $103.86 "$1,215.26" "$1,215.26" $996.18 "$1,118.00" "$1,888.95" "$1,788.79" "$1,375.67" "$1,375.67" $998.28 $0.00 $0.00 $950.53 $494.81 $0.00 $0.00 $0.00 $0.00 107142 ERX HCPCS 90744 00006-4093-02 HEPATITIS B VAC RECOMBINANT 5 MCG/0.5ML IJ SUSP BOTH IP/OP $118.01 $87.33 $0.00 $90.96 $53.10 $53.10 $30.68 $30.68 $28.21 $24.60 $87.59 $87.59 $90.96 $30.68 $24.59 $19.94 $69.80 $69.80 $0.00 $50.04 $79.26 $80.06 $60.04 $60.04 $15.66 $27.03 $27.03 $0.00 $27.03 $0.00 $0.00 $0.00 $0.00 107142 ERX HCPCS 90744 00006-4981-00 HEPATITIS B VAC RECOMBINANT 5 MCG/0.5ML IJ SUSP BOTH IP/OP $118.01 $87.33 $0.00 $90.96 $53.10 $53.10 $30.68 $30.68 $28.21 $24.60 $87.59 $87.59 $90.96 $30.68 $24.59 $19.94 $69.80 $69.80 $0.00 $50.04 $79.26 $80.06 $60.04 $60.04 $15.66 $27.03 $27.03 $0.00 $27.03 $0.00 $0.00 $0.00 $0.00 107142 ERX HCPCS 90744 00006-4981-01 HEPATITIS B VAC RECOMBINANT 5 MCG/0.5ML IJ SUSP BOTH IP/OP $118.01 $87.33 $0.00 $90.96 $53.10 $53.10 $30.68 $30.68 $28.21 $24.60 $87.59 $87.59 $90.96 $30.68 $24.59 $19.94 $69.80 $69.80 $0.00 $50.04 $79.26 $80.06 $60.04 $60.04 $15.66 $27.03 $27.03 $0.00 $27.03 $0.00 $0.00 $0.00 $0.00 107147 ERX HCPCS J1956 00143-9722-01 LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $13.58 $13.58 $0.00 $0.00 $0.00 $6.29 $22.39 $22.39 $23.26 $0.00 $6.29 $0.00 $17.85 $17.85 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 107147 ERX HCPCS J1956 00143-9722-24 LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $13.58 $13.58 $0.00 $0.00 $0.00 $6.29 $22.39 $22.39 $23.26 $0.00 $6.29 $0.00 $17.85 $17.85 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 107147 ERX HCPCS J1956 36000-0046-24 LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $13.58 $13.58 $0.00 $0.00 $0.00 $6.29 $22.39 $22.39 $23.26 $0.00 $6.29 $0.00 $17.85 $17.85 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $4.28 $0.00 $0.00 $4.36 $0.00 $0.00 $0.00 $0.00 $0.00 107148 ERX HCPCS J1956 00143-9721-01 LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN BOTH IP/OP $30.59 $22.64 $0.00 $23.58 $13.77 $13.77 $0.00 $0.00 $0.00 $6.38 $22.70 $22.70 $23.58 $0.00 $6.37 $0.00 $18.09 $18.09 $0.00 $13.87 $21.97 $22.19 $0.00 $0.00 $4.34 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $0.00 107148 ERX HCPCS J1956 00143-9721-24 LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN BOTH IP/OP $30.59 $22.64 $0.00 $23.58 $13.77 $13.77 $0.00 $0.00 $0.00 $6.38 $22.70 $22.70 $23.58 $0.00 $6.37 $0.00 $18.09 $18.09 $0.00 $13.87 $21.97 $22.19 $0.00 $0.00 $4.34 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $0.00 107148 ERX HCPCS J1956 36000-0047-24 LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN BOTH IP/OP $30.59 $22.64 $0.00 $23.58 $13.77 $13.77 $0.00 $0.00 $0.00 $6.38 $22.70 $22.70 $23.58 $0.00 $6.37 $0.00 $18.09 $18.09 $0.00 $13.87 $21.97 $22.19 $0.00 $0.00 $4.34 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $0.00 107149 ERX HCPCS J1956 00143-9720-24 LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN BOTH IP/OP $55.31 $40.93 $0.00 $42.63 $24.89 $24.89 $0.00 $0.00 $0.00 $11.53 $41.05 $41.05 $42.63 $0.00 $11.53 $0.00 $32.72 $32.72 $0.00 $25.08 $39.73 $40.13 $0.00 $0.00 $7.85 $0.00 $0.00 $7.99 $0.00 $0.00 $0.00 $0.00 $0.00 107149 ERX HCPCS J1956 25021-0132-83 LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN BOTH IP/OP $55.31 $40.93 $0.00 $42.63 $24.89 $24.89 $0.00 $0.00 $0.00 $11.53 $41.05 $41.05 $42.63 $0.00 $11.53 $0.00 $32.72 $32.72 $0.00 $25.08 $39.73 $40.13 $0.00 $0.00 $7.85 $0.00 $0.00 $7.99 $0.00 $0.00 $0.00 $0.00 $0.00 107150 ERX HCPCS J2543 00206-8862-02 PIPERACILLIN-TAZOBACTAM IN DEX 4-0.5 GM/100ML IV SOLN FROZEN BOTH IP/OP $117.73 $87.12 $0.00 $90.75 $52.98 $52.98 $0.00 $0.00 $0.00 $26.18 $87.38 $87.38 $90.75 $0.00 $6.94 $0.00 $69.64 $69.64 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 107151 ERX HCPCS J9171 00955-1021-04 DOCETAXEL 80 MG/4ML IV CONC BOTH IP/OP "$2,486.40 " "$1,839.94" $0.00 "$1,916.52" "$1,118.88" "$1,118.88" $0.00 $0.00 $0.00 $518.23 "$1,845.41" "$1,845.41" "$1,916.52" $0.00 $45.03 $0.00 "$1,225.80" "$1,225.80" $72.66 "$1,152.00" $992.22 "$1,843.20" $100.34 $100.34 $91.18 $0.00 $0.00 $86.82 $69.44 $0.00 $0.00 $0.00 $0.00 107151 ERX HCPCS J9171 16729-0267-64 DOCETAXEL 80 MG/4ML IV CONC BOTH IP/OP "$2,486.40 " "$1,839.94" $0.00 "$1,916.52" "$1,118.88" "$1,118.88" $0.00 $0.00 $0.00 $518.23 "$1,845.41" "$1,845.41" "$1,916.52" $0.00 $45.03 $0.00 "$1,225.80" "$1,225.80" $72.66 "$1,152.00" $992.22 "$1,843.20" $100.34 $100.34 $91.18 $0.00 $0.00 $86.82 $69.44 $0.00 $0.00 $0.00 $0.00 107151 ERX HCPCS J9171 43598-0259-40 DOCETAXEL 80 MG/4ML IV CONC BOTH IP/OP "$2,486.40 " "$1,839.94" $0.00 "$1,916.52" "$1,118.88" "$1,118.88" $0.00 $0.00 $0.00 $518.23 "$1,845.41" "$1,845.41" "$1,916.52" $0.00 $45.03 $0.00 "$1,225.80" "$1,225.80" $72.66 "$1,152.00" $992.22 "$1,843.20" $100.34 $100.34 $91.18 $0.00 $0.00 $86.82 $69.44 $0.00 $0.00 $0.00 $0.00 107151 ERX HCPCS J9171 45963-0765-52 DOCETAXEL 80 MG/4ML IV CONC BOTH IP/OP "$2,486.40 " "$1,839.94" $0.00 "$1,916.52" "$1,118.88" "$1,118.88" $0.00 $0.00 $0.00 $518.23 "$1,845.41" "$1,845.41" "$1,916.52" $0.00 $45.03 $0.00 "$1,225.80" "$1,225.80" $72.66 "$1,152.00" $992.22 "$1,843.20" $100.34 $100.34 $91.18 $0.00 $0.00 $86.82 $69.44 $0.00 $0.00 $0.00 $0.00 107156 ERX HCPCS 90713 49281-0860-10 POLIOVIRUS VACCINE INACTIVATED IJ INJ BOTH IP/OP $178.89 $132.38 $0.00 $137.89 $80.50 $80.50 $0.00 $0.00 $0.00 $9.40 $132.77 $132.77 $137.89 $0.00 $43.35 $0.00 $105.81 $105.81 $0.00 $73.59 $116.56 $117.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107157 ERX HCPCS J0744 00409-4777-23 CIPROFLOXACIN IN D5W 200 MG/100ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107158 ERX HCPCS J0278 00641-6167-10 AMIKACIN SULFATE 500 MG/2ML IJ SOLN BOTH IP/OP $61.62 $45.60 $0.00 $47.50 $27.73 $27.73 $0.00 $0.00 $0.00 $3.11 $45.73 $45.73 $47.50 $0.00 $6.23 $0.00 $36.45 $36.45 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107158 ERX HCPCS J0278 00703-9032-01 AMIKACIN SULFATE 500 MG/2ML IJ SOLN BOTH IP/OP $61.62 $45.60 $0.00 $47.50 $27.73 $27.73 $0.00 $0.00 $0.00 $3.11 $45.73 $45.73 $47.50 $0.00 $6.23 $0.00 $36.45 $36.45 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107158 ERX HCPCS J0278 00703-9032-03 AMIKACIN SULFATE 500 MG/2ML IJ SOLN BOTH IP/OP $61.62 $45.60 $0.00 $47.50 $27.73 $27.73 $0.00 $0.00 $0.00 $3.11 $45.73 $45.73 $47.50 $0.00 $6.23 $0.00 $36.45 $36.45 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107158 ERX HCPCS J0278 23155-0290-41 AMIKACIN SULFATE 500 MG/2ML IJ SOLN BOTH IP/OP $61.62 $45.60 $0.00 $47.50 $27.73 $27.73 $0.00 $0.00 $0.00 $3.11 $45.73 $45.73 $47.50 $0.00 $6.23 $0.00 $36.45 $36.45 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107158 ERX HCPCS J0278 25021-0173-02 AMIKACIN SULFATE 500 MG/2ML IJ SOLN BOTH IP/OP $61.62 $45.60 $0.00 $47.50 $27.73 $27.73 $0.00 $0.00 $0.00 $3.11 $45.73 $45.73 $47.50 $0.00 $6.23 $0.00 $36.45 $36.45 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107159 ERX HCPCS J0278 00703-9040-01 AMIKACIN SULFATE 1 GM/4ML IJ SOLN BOTH IP/OP $33.29 $24.63 $0.00 $26.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.65 $26.37 $26.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107159 ERX HCPCS J0278 00703-9040-03 AMIKACIN SULFATE 1 GM/4ML IJ SOLN BOTH IP/OP $33.29 $24.63 $0.00 $26.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.65 $26.37 $26.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107159 ERX HCPCS J0278 23155-0290-42 AMIKACIN SULFATE 1 GM/4ML IJ SOLN BOTH IP/OP $33.29 $24.63 $0.00 $26.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.65 $26.37 $26.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107159 ERX HCPCS J0278 63323-0815-04 AMIKACIN SULFATE 1 GM/4ML IJ SOLN BOTH IP/OP $33.29 $24.63 $0.00 $26.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.65 $26.37 $26.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107160 ERX HCPCS 25000001 63323-0282-60 CLINDAMYCIN PHOSPHATE 9 GM/60ML IJ SOLN BOTH IP/OP $108.63 $80.39 $0.00 $83.73 $0.00 $0.00 $0.00 $0.00 $0.00 $80.63 $80.63 $83.73 $0.00 $22.64 $0.00 $0.00 $0.00 $0.00 $49.25 $78.00 $78.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107378 ERX HCPCS J0490 49401-0101-01 BELIMUMAB 120 MG IV SOLR BOTH IP/OP "$1,778.45 " "$1,316.05" $0.00 "$1,370.83" $800.30 $800.30 $578.80 $578.80 $578.80 $370.67 "$1,319.97" "$1,319.97" "$1,370.83" $570.79 $670.68 $371.01 "$1,051.95" "$1,051.95" $0.00 $780.32 "$1,236.02" "$1,248.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107379 ERX HCPCS J0490 49401-0102-01 BELIMUMAB 400 MG IV SOLR BOTH IP/OP "$5,172.65 " "$3,827.76" $0.00 "$3,987.08" "$2,327.69" "$2,327.69" "$1,929.32" "$1,929.32" "$1,929.32" "$1,078.11" "$3,839.14" "$3,839.14" "$3,987.08" "$1,902.64" "$2,235.60" "$1,236.72" "$2,550.12" "$2,550.12" $0.00 "$2,221.64" "$3,519.08" "$3,554.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107443 ERX HCPCS J9171 00409-0201-10 DOCETAXEL 80 MG/8ML IV SOLN BOTH IP/OP "$3,431.06 " "$2,538.98" $0.00 "$2,644.66" "$1,543.98" "$1,543.98" $0.00 $0.00 $0.00 $715.12 "$2,546.53" "$2,546.53" "$2,644.66" $0.00 $45.03 $0.00 "$1,691.51" "$1,691.51" $72.66 "$1,556.13" "$2,464.90" "$2,489.80" $100.34 $100.34 $91.18 $0.00 $0.00 $86.82 $69.44 $0.00 $0.00 $0.00 $0.00 107443 ERX HCPCS J9171 66758-0050-02 DOCETAXEL 80 MG/8ML IV SOLN BOTH IP/OP "$3,431.06 " "$2,538.98" $0.00 "$2,644.66" "$1,543.98" "$1,543.98" $0.00 $0.00 $0.00 $715.12 "$2,546.53" "$2,546.53" "$2,644.66" $0.00 $45.03 $0.00 "$1,691.51" "$1,691.51" $72.66 "$1,556.13" "$2,464.90" "$2,489.80" $100.34 $100.34 $91.18 $0.00 $0.00 $86.82 $69.44 $0.00 $0.00 $0.00 $0.00 107443 ERX HCPCS J9171 67457-0532-08 DOCETAXEL 80 MG/8ML IV SOLN BOTH IP/OP "$3,431.06 " "$2,538.98" $0.00 "$2,644.66" "$1,543.98" "$1,543.98" $0.00 $0.00 $0.00 $715.12 "$2,546.53" "$2,546.53" "$2,644.66" $0.00 $45.03 $0.00 "$1,691.51" "$1,691.51" $72.66 "$1,556.13" "$2,464.90" "$2,489.80" $100.34 $100.34 $91.18 $0.00 $0.00 $86.82 $69.44 $0.00 $0.00 $0.00 $0.00 107446 ERX HCPCS J9171 00409-0201-02 DOCETAXEL 20 MG/2ML IV SOLN BOTH IP/OP $290.58 $215.03 $0.00 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $60.56 $0.00 $0.00 $0.00 $0.00 $11.26 $0.00 $171.88 $171.88 $18.17 $129.94 $205.82 $207.90 $25.09 $25.09 $22.80 $0.00 $0.00 $21.70 $17.36 $0.00 $0.00 $0.00 $0.00 107491 ERX HCPCS J9228 00003-2327-11 IPILIMUMAB 50 MG/10ML IV SOLN BOTH IP/OP "$20,958.73 " "$15,509.46" $0.00 "$16,478.08" "$9,620.05" "$9,620.05" "$8,035.15" "$8,035.15" "$8,035.15" "$4,368.32" "$15,866.67" "$15,866.67" "$16,478.08" "$7,932.40" "$9,320.57" "$5,156.06" "$10,332.65" "$10,332.65" "$8,039.22" "$9,226.74" "$14,615.15" "$14,762.78" "$11,101.78" "$11,101.78" "$8,138.89" $0.00 $0.00 "$8,138.89" "$7,864.60" $0.00 $0.00 $0.00 $0.00 107492 ERX HCPCS J9228 00003-2328-22 IPILIMUMAB 200 MG/40ML IV SOLN BOTH IP/OP "$83,834.70 " "$62,037.68" $0.00 "$65,912.15" "$38,480.11" "$38,480.11" "$32,140.60" "$32,140.60" "$32,140.60" "$9,417.94" "$63,466.52" "$63,466.52" "$65,912.15" "$31,729.60" "$37,282.28" "$20,624.24" "$41,330.51" "$41,330.51" "$32,156.88" "$36,906.85" "$58,460.45" "$59,050.96" "$44,407.12" "$44,407.12" "$8,138.89" $0.00 $0.00 "$8,138.89" "$31,458.40" $0.00 $0.00 $0.00 $0.00 107815 ERX HCPCS 63700001 00597-0123-30 NEVIRAPINE ER 400 MG PO TB24 BOTH IP/OP $83.11 $61.50 $0.00 $60.30 $0.00 $0.00 $0.00 $14.79 $0.00 $0.00 $0.00 $0.00 $0.00 $17.32 $0.00 $0.00 $0.00 $0.00 $37.69 $59.69 $60.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107815 ERX HCPCS 63700001 33342-0238-07 NEVIRAPINE ER 400 MG PO TB24 BOTH IP/OP $83.11 $61.50 $0.00 $60.30 $0.00 $0.00 $0.00 $14.79 $0.00 $0.00 $0.00 $0.00 $0.00 $17.32 $0.00 $0.00 $0.00 $0.00 $37.69 $59.69 $60.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107815 ERX HCPCS 63700001 47781-0317-30 NEVIRAPINE ER 400 MG PO TB24 BOTH IP/OP $83.11 $61.50 $0.00 $60.30 $0.00 $0.00 $0.00 $14.79 $0.00 $0.00 $0.00 $0.00 $0.00 $17.32 $0.00 $0.00 $0.00 $0.00 $37.69 $59.69 $60.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 107843 ERX HCPCS 63700001 62103-0333-02 ZINC OXIDE 16 % EX OINT BOTH IP/OP $23.89 $17.68 $0.00 $12.14 $0.00 $0.00 $0.00 $4.25 $0.00 $0.00 $0.00 $0.00 $0.00 $4.98 $0.00 $0.00 $0.00 $0.00 $7.59 $12.01 $12.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 108161 ERX HCPCS 63700001 00456-1120-30 VILAZODONE HCL 20 MG PO TABS BOTH IP/OP $50.31 $37.23 $0.00 $34.76 $0.00 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 $10.48 $0.00 $0.00 $0.00 $0.00 $21.73 $34.41 $34.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 108272 ERX HCPCS 63600001 57894-0150-12 ABIRATERONE ACETATE 250 MG PO TABS BOTH IP/OP "$1,073.22 " $794.18 $0.00 $827.24 $0.00 $0.00 $0.00 $0.00 $0.00 $796.54 $796.54 $827.24 $0.00 $223.66 $0.00 $0.00 $0.00 $0.00 $487.00 $771.40 $779.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 108272 ERX HCPCS 63600001 57894-0155-12 ABIRATERONE ACETATE 250 MG PO TABS BOTH IP/OP "$1,073.22 " $794.18 $0.00 $827.24 $0.00 $0.00 $0.00 $0.00 $0.00 $796.54 $796.54 $827.24 $0.00 $223.66 $0.00 $0.00 $0.00 $0.00 $487.00 $771.40 $779.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 108405 ERX HCPCS 63700001 59676-0278-01 RILPIVIRINE HCL 25 MG PO TABS BOTH IP/OP $188.02 $139.13 $0.00 $130.52 $0.00 $0.00 $0.00 $31.77 $0.00 $0.00 $0.00 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $81.58 $129.21 $130.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 108619 ERX HCPCS J0282 43066-0150-10 AMIODARONE HCL IN DEXTROSE 150-4.21 MG/100ML-% IV SOLN BOTH IP/OP $160.58 $118.83 $0.00 $123.78 $0.00 $0.00 $0.00 $0.00 $0.00 $119.18 $119.18 $123.78 $0.00 $33.46 $0.00 $0.00 $0.00 $0.00 $72.80 $115.32 $116.48 $0.00 $0.00 $22.79 $0.00 $0.00 $23.18 $0.00 $0.00 $0.00 $0.00 $0.00 108620 ERX HCPCS J0282 43066-0360-20 AMIODARONE HCL IN DEXTROSE 360-4.14 MG/200ML-% IV SOLN BOTH IP/OP $192.24 $142.26 $0.00 $148.18 $0.00 $0.00 $0.00 $0.00 $0.00 $142.68 $142.68 $148.18 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $87.26 $138.21 $139.61 $0.00 $0.00 $27.31 $0.00 $0.00 $27.78 $0.00 $0.00 $0.00 $0.00 $0.00 108708 ERX HCPCS 63700001 52015-0080-01 FIDAXOMICIN 200 MG PO TABS BOTH IP/OP $746.74 $552.59 $0.00 $516.34 $0.00 $0.00 $0.00 $139.56 $0.00 $0.00 $0.00 $0.00 $0.00 $155.62 $0.00 $0.00 $0.00 $0.00 $322.71 $511.17 $516.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109063 ERX HCPCS J9217 00074-3473-03 LEUPROLIDE ACETATE (6 MONTH) 45 MG IM KIT BOTH IP/OP "$28,760.36 " "$21,282.67" $0.00 "$23,254.75" "$13,576.33" "$13,576.33" "$1,204.40" "$1,204.40" "$1,204.40" "$1,480.99" "$22,391.90" "$22,391.90" "$23,254.75" $834.54 $980.58 $542.45 "$14,178.86" "$14,178.86" "$1,415.60" "$12,282.46" "$19,455.41" "$19,651.93" "$1,954.87" "$1,954.87" "$1,621.99" $0.00 $0.00 "$1,544.41" "$1,235.32" $0.00 $0.00 $0.00 $0.00 109481 ERX HCPCS 63700001 50458-0580-10 RIVAROXABAN 10 MG PO TABS BOTH IP/OP $82.55 $61.09 $0.00 $57.15 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $17.20 $0.00 $0.00 $0.00 $0.00 $35.72 $56.58 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109481 ERX HCPCS 63700001 50458-0580-30 RIVAROXABAN 10 MG PO TABS BOTH IP/OP $82.55 $61.09 $0.00 $57.15 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $17.20 $0.00 $0.00 $0.00 $0.00 $35.72 $56.58 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109484 ERX HCPCS 63700001 00186-0777-39 TICAGRELOR 90 MG PO TABS BOTH IP/OP $35.65 $26.38 $0.00 $23.90 $0.00 $0.00 $0.00 $6.35 $0.00 $0.00 $0.00 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $14.94 $23.66 $23.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109651 ERX HCPCS 25000001 00004-0822-05 OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR BOTH IP/OP $612.47 $453.23 $0.00 $472.09 $0.00 $0.00 $0.00 $0.00 $0.00 $454.58 $454.58 $472.09 $0.00 $127.64 $0.00 $0.00 $0.00 $0.00 $277.98 $440.32 $444.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109651 ERX HCPCS 25000001 47781-0384-26 OSELTAMIVIR PHOSPHATE 6 MG/ML PO SUSR BOTH IP/OP $612.47 $453.23 $0.00 $472.09 $0.00 $0.00 $0.00 $0.00 $0.00 $454.58 $454.58 $472.09 $0.00 $127.64 $0.00 $0.00 $0.00 $0.00 $277.98 $440.32 $444.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110050 ERX HCPCS 25000001 99999-6006-74 PENICILLIN G 100 UNITS/ML ID INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110052 ERX HCPCS 25000001 99999-6006-75 PENICILLIN G 1000 UNITS/ML ID INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110156 ERX HCPCS 63700001 00904-2137-61 FERROUS GLUCONATE 324 (37.5 FE) MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110232 ERX HCPCS 63700001 61958-1101-01 COMPLERA:EMTRICITAB-RILPIVIR-TENOFOVIR200-25-300MGTAB BOTH IP/OP $438.35 $324.38 $0.00 $287.64 $0.00 $0.00 $0.00 $78.03 $0.00 $0.00 $0.00 $0.00 $0.00 $91.35 $0.00 $0.00 $0.00 $0.00 $179.78 $284.76 $287.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110284 ERX HCPCS 63700001 50242-0090-02 VEMURAFENIB 240 MG PO TABS BOTH IP/OP $575.10 $425.57 $0.00 $460.08 $0.00 $0.00 $0.00 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.55 $455.48 $460.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110289 ERX HCPCS 63700001 27434-0010-17 COPPER GLUCONATE 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110289 ERX HCPCS 63700001 66536-0014-44 COPPER GLUCONATE 2 MG PO CAPS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110307 ERX HCPCS J9042 51144-0050-01 BRENTUXIMAB VEDOTIN 50 MG IV SOLR BOTH IP/OP "$26,306.40 " "$19,466.74" $0.00 "$20,276.97" "$11,837.88" "$11,837.88" "$9,827.35" "$9,827.35" "$9,827.35" "$5,482.91" "$19,524.61" "$19,524.61" "$20,276.97" "$9,466.75" "$11,123.43" "$6,153.39" "$12,969.06" "$12,969.06" "$8,527.94" "$10,568.16" "$16,739.97" "$16,909.06" "$11,776.68" "$11,776.68" "$8,138.89" $0.00 $0.00 "$8,138.89" "$8,793.05" $0.00 $0.00 $0.00 $0.00 110346 ERX HCPCS J1744 54092-0702-02 ICATIBANT ACETATE 30 MG/3ML SC SOLN BOTH IP/OP "$5,424.00 " "$4,013.76" $0.00 "$21,938.27" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,025.69" "$4,025.69" "$4,180.82" $0.00 "$1,130.36" $0.00 $0.00 $0.00 $0.00 "$13,711.42" "$21,718.89" "$21,938.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110349 ERX HCPCS 63700001 00069-8141-20 CRIZOTINIB 200 MG PO CAPS BOTH IP/OP "$1,145.16 " $847.42 $0.00 $750.55 $0.00 $0.00 $0.00 $203.84 $0.00 $0.00 $0.00 $0.00 $0.00 $238.65 $0.00 $0.00 $0.00 $0.00 $469.10 $743.05 $750.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110350 ERX HCPCS 63700001 00069-8140-20 CRIZOTINIB 250 MG PO CAPS BOTH IP/OP "$1,145.16 " $847.42 $0.00 $750.55 $0.00 $0.00 $0.00 $203.84 $0.00 $0.00 $0.00 $0.00 $0.00 $238.65 $0.00 $0.00 $0.00 $0.00 $469.10 $743.05 $750.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110577 ERX HCPCS 25000001 11704-0370-01 HYDROXOCOBALAMIN 5 G IV SOLR BOTH IP/OP "$2,552.66 " "$1,888.97" $0.00 "$1,967.59" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,894.58" "$1,894.58" "$1,967.59" $0.00 $531.97 $0.00 $0.00 $0.00 $0.00 "$1,182.70" "$1,873.40" "$1,892.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110604 ERX HCPCS J3489 25021-0826-82 ZOLEDRONIC ACID 4 MG/100ML IV SOLN BOTH IP/OP $249.84 $184.88 $0.00 $457.92 $112.43 $112.43 $0.00 $0.00 $0.00 $52.07 $185.43 $185.43 $192.58 $0.00 $38.76 $0.00 $147.78 $147.78 $0.00 $286.20 $453.34 $457.92 $0.00 $0.00 $51.14 $0.00 $0.00 $48.69 $0.00 $0.00 $0.00 $0.00 $0.00 110863 ERX HCPCS 25000001 00004-0357-30 PEGINTERFERON ALFA-2A 180 MCG/0.5ML SC SOLN BOTH IP/OP "$2,512.87 " "$1,859.52" $0.00 "$2,010.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.44" "$1,990.19" "$2,010.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111020 ERX HCPCS 25000001 65702-0407-10 ACCU-CHEK AVIVA PLUS VI STRP BOTH IP/OP $325.14 $240.60 $0.00 $250.62 $0.00 $0.00 $0.00 $0.00 $0.00 $241.32 $241.32 $250.62 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $147.58 $233.77 $236.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111272 ERX HCPCS 25000001 51991-0900-01 CLOBAZAM 10 MG PO TABS BOTH IP/OP $76.70 $56.76 $0.00 $74.02 $0.00 $0.00 $0.00 $0.00 $0.00 $56.93 $56.93 $59.12 $0.00 $15.98 $0.00 $0.00 $0.00 $0.00 $46.26 $73.28 $74.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111272 ERX HCPCS 25000001 67386-0314-01 CLOBAZAM 10 MG PO TABS BOTH IP/OP $76.70 $56.76 $0.00 $74.02 $0.00 $0.00 $0.00 $0.00 $0.00 $56.93 $56.93 $59.12 $0.00 $15.98 $0.00 $0.00 $0.00 $0.00 $46.26 $73.28 $74.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111273 ERX HCPCS 25000001 67386-0315-01 CLOBAZAM 20 MG PO TABS BOTH IP/OP $161.10 $119.21 $0.00 $133.23 $0.00 $0.00 $0.00 $0.00 $0.00 $119.57 $119.57 $124.18 $0.00 $33.57 $0.00 $0.00 $0.00 $0.00 $83.27 $131.90 $133.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111314 ERX HCPCS C9290 65250-0133-09 BUPIVACAINE LIPOSOME 1.3 % IJ SUSP BOTH IP/OP $663.55 $491.03 $0.00 "$1,074.10" $313.54 $313.54 $0.00 $0.00 $0.00 $138.30 "$1,034.26" "$1,034.26" "$1,074.10" $0.00 $138.28 $0.00 $784.98 $784.98 $0.00 $286.76 $454.23 $458.82 $0.00 $0.00 $0.00 $0.00 $0.00 $91.30 $0.00 $0.00 $0.00 $0.00 $0.00 111314 ERX HCPCS C9290 65250-0133-10 BUPIVACAINE LIPOSOME 1.3 % IJ SUSP BOTH IP/OP $663.55 $491.03 $0.00 "$1,074.10" $313.54 $313.54 $0.00 $0.00 $0.00 $138.30 "$1,034.26" "$1,034.26" "$1,074.10" $0.00 $138.28 $0.00 $784.98 $784.98 $0.00 $286.76 $454.23 $458.82 $0.00 $0.00 $0.00 $0.00 $0.00 $91.30 $0.00 $0.00 $0.00 $0.00 $0.00 111314 ERX HCPCS C9290 65250-0266-09 BUPIVACAINE LIPOSOME 1.3 % IJ SUSP BOTH IP/OP $663.55 $491.03 $0.00 "$1,074.10" $313.54 $313.54 $0.00 $0.00 $0.00 $138.30 "$1,034.26" "$1,034.26" "$1,074.10" $0.00 $138.28 $0.00 $784.98 $784.98 $0.00 $286.76 $454.23 $458.82 $0.00 $0.00 $0.00 $0.00 $0.00 $91.30 $0.00 $0.00 $0.00 $0.00 $0.00 111314 ERX HCPCS C9290 65250-0266-20 BUPIVACAINE LIPOSOME 1.3 % IJ SUSP BOTH IP/OP $663.55 $491.03 $0.00 "$1,074.10" $313.54 $313.54 $0.00 $0.00 $0.00 $138.30 "$1,034.26" "$1,034.26" "$1,074.10" $0.00 $138.28 $0.00 $784.98 $784.98 $0.00 $286.76 $454.23 $458.82 $0.00 $0.00 $0.00 $0.00 $0.00 $91.30 $0.00 $0.00 $0.00 $0.00 $0.00 111320 ERX HCPCS J9201 00409-0181-01 GEMCITABINE HCL 1 GM/26.3ML IV SOLN BOTH IP/OP $188.64 $139.59 $0.00 $811.87 $84.89 $84.89 $0.00 $0.00 $0.00 $811.87 $140.01 $140.01 $145.40 $0.00 $22.42 $0.00 $111.58 $111.58 $0.00 $84.38 $133.66 $135.01 $0.00 $0.00 $24.44 $0.00 $0.00 $23.27 $0.00 $0.00 $0.00 $0.00 $0.00 111320 ERX HCPCS J9201 25021-0239-26 GEMCITABINE HCL 1 GM/26.3ML IV SOLN BOTH IP/OP $188.64 $139.59 $0.00 $811.87 $84.89 $84.89 $0.00 $0.00 $0.00 $811.87 $140.01 $140.01 $145.40 $0.00 $22.42 $0.00 $111.58 $111.58 $0.00 $84.38 $133.66 $135.01 $0.00 $0.00 $24.44 $0.00 $0.00 $23.27 $0.00 $0.00 $0.00 $0.00 $0.00 111320 ERX HCPCS J9201 60505-6114-00 GEMCITABINE HCL 1 GM/26.3ML IV SOLN BOTH IP/OP $188.64 $139.59 $0.00 $811.87 $84.89 $84.89 $0.00 $0.00 $0.00 $811.87 $140.01 $140.01 $145.40 $0.00 $22.42 $0.00 $111.58 $111.58 $0.00 $84.38 $133.66 $135.01 $0.00 $0.00 $24.44 $0.00 $0.00 $23.27 $0.00 $0.00 $0.00 $0.00 $0.00 111367 ERX HCPCS 63700001 50458-0578-10 RIVAROXABAN 15 MG PO TABS BOTH IP/OP $82.55 $61.09 $0.00 $57.15 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $17.20 $0.00 $0.00 $0.00 $0.00 $35.72 $56.58 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111367 ERX HCPCS 63700001 50458-0578-30 RIVAROXABAN 15 MG PO TABS BOTH IP/OP $82.55 $61.09 $0.00 $57.15 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $17.20 $0.00 $0.00 $0.00 $0.00 $35.72 $56.58 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111368 ERX HCPCS 63700001 50458-0579-01 RIVAROXABAN 20 MG PO TABS BOTH IP/OP $82.55 $61.09 $0.00 $57.15 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $17.20 $0.00 $0.00 $0.00 $0.00 $35.72 $56.58 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111368 ERX HCPCS 63700001 50458-0579-10 RIVAROXABAN 20 MG PO TABS BOTH IP/OP $82.55 $61.09 $0.00 $57.15 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $17.20 $0.00 $0.00 $0.00 $0.00 $35.72 $56.58 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111368 ERX HCPCS 63700001 50458-0579-90 RIVAROXABAN 20 MG PO TABS BOTH IP/OP $82.55 $61.09 $0.00 $57.15 $0.00 $0.00 $0.00 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $17.20 $0.00 $0.00 $0.00 $0.00 $35.72 $56.58 $57.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111436 ERX HCPCS 63700001 50881-0005-60 RUXOLITINIB PHOSPHATE 5 MG PO TABS BOTH IP/OP $883.19 $653.56 $0.00 $584.02 $0.00 $0.00 $0.00 $161.93 $0.00 $0.00 $0.00 $0.00 $0.00 $184.06 $0.00 $0.00 $0.00 $0.00 $365.02 $578.18 $584.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111437 ERX HCPCS 63700001 50881-0010-60 RUXOLITINIB PHOSPHATE 10 MG PO TABS BOTH IP/OP $883.19 $653.56 $0.00 $584.02 $0.00 $0.00 $0.00 $161.93 $0.00 $0.00 $0.00 $0.00 $0.00 $184.06 $0.00 $0.00 $0.00 $0.00 $365.02 $578.18 $584.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111438 ERX HCPCS 63700001 50881-0015-60 RUXOLITINIB PHOSPHATE 15 MG PO TABS BOTH IP/OP $883.19 $653.56 $0.00 $584.02 $0.00 $0.00 $0.00 $161.93 $0.00 $0.00 $0.00 $0.00 $0.00 $184.06 $0.00 $0.00 $0.00 $0.00 $365.02 $578.18 $584.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111439 ERX HCPCS 63700001 50881-0020-60 RUXOLITINIB PHOSPHATE 20 MG PO TABS BOTH IP/OP $883.19 $653.56 $0.00 $584.02 $0.00 $0.00 $0.00 $161.93 $0.00 $0.00 $0.00 $0.00 $0.00 $184.06 $0.00 $0.00 $0.00 $0.00 $365.02 $578.18 $584.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111440 ERX HCPCS 63700001 50881-0025-60 RUXOLITINIB PHOSPHATE 25 MG PO TABS BOTH IP/OP $883.19 $653.56 $0.00 $584.02 $0.00 $0.00 $0.00 $161.93 $0.00 $0.00 $0.00 $0.00 $0.00 $184.06 $0.00 $0.00 $0.00 $0.00 $365.02 $578.18 $584.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111479 ERX HCPCS J0178 61755-0005-02 AFLIBERCEPT 2 MG/0.05ML INTRAVITREAL SOLN BOTH IP/OP "$5,017.20 " "$3,712.73" $0.00 "$3,867.26" "$2,257.74" "$2,257.74" "$1,831.49" "$1,831.49" "$1,831.49" "$1,045.71" "$3,723.77" "$3,723.77" "$3,867.26" "$1,835.89" "$2,157.17" "$1,193.33" "$2,473.48" "$2,473.48" "$2,000.19" "$2,275.50" "$3,604.39" "$3,640.80" "$2,762.17" "$2,762.17" "$2,220.82" $0.00 $0.00 "$2,114.60" "$1,863.53" $0.00 $0.00 $0.00 $0.00 111525 ERX HCPCS J3490 63323-0648-10 LEVOTHYROXINE SODIUM 500 MCG IV SOLR BOTH IP/OP $425.71 $315.03 $0.00 $328.14 $191.57 $191.57 $0.00 $0.00 $0.00 $88.73 $315.96 $315.96 $328.14 $0.00 $88.72 $0.00 $251.81 $251.81 $0.00 $193.22 $306.05 $309.14 $0.00 $0.00 $60.48 $0.00 $0.00 $61.52 $0.00 $0.00 $0.00 $0.00 $0.00 111526 ERX HCPCS 25000001 42023-0201-01 LEVOTHYROXINE SODIUM 100 MCG IV SOLR BOTH IP/OP $425.72 $315.03 $0.00 $328.14 $0.00 $0.00 $0.00 $0.00 $0.00 $315.97 $315.97 $328.14 $0.00 $88.72 $0.00 $0.00 $0.00 $0.00 $193.22 $306.06 $309.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111526 ERX HCPCS 25000001 63323-0649-07 LEVOTHYROXINE SODIUM 100 MCG IV SOLR BOTH IP/OP $425.72 $315.03 $0.00 $328.14 $0.00 $0.00 $0.00 $0.00 $0.00 $315.97 $315.97 $328.14 $0.00 $88.72 $0.00 $0.00 $0.00 $0.00 $193.22 $306.06 $309.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111526 ERX HCPCS 25000001 63323-0649-16 LEVOTHYROXINE SODIUM 100 MCG IV SOLR BOTH IP/OP $425.72 $315.03 $0.00 $328.14 $0.00 $0.00 $0.00 $0.00 $0.00 $315.97 $315.97 $328.14 $0.00 $88.72 $0.00 $0.00 $0.00 $0.00 $193.22 $306.06 $309.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111526 ERX HCPCS 25000001 70860-0451-10 LEVOTHYROXINE SODIUM 100 MCG IV SOLR BOTH IP/OP $425.72 $315.03 $0.00 $328.14 $0.00 $0.00 $0.00 $0.00 $0.00 $315.97 $315.97 $328.14 $0.00 $88.72 $0.00 $0.00 $0.00 $0.00 $193.22 $306.06 $309.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111662 ERX HCPCS 25000001 46783-0221-52 POLIDOCANOL 1 % IV SOLN BOTH IP/OP $101.91 $75.41 $0.00 $78.55 $0.00 $0.00 $0.00 $0.00 $0.00 $75.64 $75.64 $78.55 $0.00 $21.24 $0.00 $0.00 $0.00 $0.00 $46.20 $73.18 $73.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112303 ERX HCPCS J1953 55150-0246-47 LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN BOTH IP/OP $128.54 $95.12 $0.00 $99.08 $57.84 $57.84 $0.00 $0.00 $0.00 $26.79 $95.40 $95.40 $99.08 $0.00 $26.79 $0.00 $76.03 $76.03 $0.00 $58.28 $92.31 $93.24 $0.00 $0.00 $18.24 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $0.00 112303 ERX HCPCS J1953 67457-0255-10 LEVETIRACETAM IN NACL 500 MG/100ML IV SOLN BOTH IP/OP $128.54 $95.12 $0.00 $99.08 $57.84 $57.84 $0.00 $0.00 $0.00 $26.79 $95.40 $95.40 $99.08 $0.00 $26.79 $0.00 $76.03 $76.03 $0.00 $58.28 $92.31 $93.24 $0.00 $0.00 $18.24 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $0.00 112304 ERX HCPCS J1953 43598-0636-10 LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN BOTH IP/OP $99.59 $73.70 $0.00 $149.94 $44.82 $44.82 $0.00 $0.00 $0.00 $20.76 $73.92 $73.92 $76.76 $0.00 $20.75 $0.00 $58.91 $58.91 $0.00 $93.72 $148.44 $149.94 $0.00 $0.00 $29.33 $0.00 $0.00 $29.84 $0.00 $0.00 $0.00 $0.00 $0.00 112304 ERX HCPCS J1953 43598-0636-52 LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN BOTH IP/OP $99.59 $73.70 $0.00 $149.94 $44.82 $44.82 $0.00 $0.00 $0.00 $20.76 $73.92 $73.92 $76.76 $0.00 $20.75 $0.00 $58.91 $58.91 $0.00 $93.72 $148.44 $149.94 $0.00 $0.00 $29.33 $0.00 $0.00 $29.84 $0.00 $0.00 $0.00 $0.00 $0.00 112304 ERX HCPCS J1953 43598-0757-10 LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN BOTH IP/OP $99.59 $73.70 $0.00 $149.94 $44.82 $44.82 $0.00 $0.00 $0.00 $20.76 $73.92 $73.92 $76.76 $0.00 $20.75 $0.00 $58.91 $58.91 $0.00 $93.72 $148.44 $149.94 $0.00 $0.00 $29.33 $0.00 $0.00 $29.84 $0.00 $0.00 $0.00 $0.00 $0.00 112304 ERX HCPCS J1953 43598-0757-52 LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN BOTH IP/OP $99.59 $73.70 $0.00 $149.94 $44.82 $44.82 $0.00 $0.00 $0.00 $20.76 $73.92 $73.92 $76.76 $0.00 $20.75 $0.00 $58.91 $58.91 $0.00 $93.72 $148.44 $149.94 $0.00 $0.00 $29.33 $0.00 $0.00 $29.84 $0.00 $0.00 $0.00 $0.00 $0.00 112304 ERX HCPCS J1953 55150-0247-47 LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN BOTH IP/OP $99.59 $73.70 $0.00 $149.94 $44.82 $44.82 $0.00 $0.00 $0.00 $20.76 $73.92 $73.92 $76.76 $0.00 $20.75 $0.00 $58.91 $58.91 $0.00 $93.72 $148.44 $149.94 $0.00 $0.00 $29.33 $0.00 $0.00 $29.84 $0.00 $0.00 $0.00 $0.00 $0.00 112304 ERX HCPCS J1953 67457-0265-00 LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN BOTH IP/OP $99.59 $73.70 $0.00 $149.94 $44.82 $44.82 $0.00 $0.00 $0.00 $20.76 $73.92 $73.92 $76.76 $0.00 $20.75 $0.00 $58.91 $58.91 $0.00 $93.72 $148.44 $149.94 $0.00 $0.00 $29.33 $0.00 $0.00 $29.84 $0.00 $0.00 $0.00 $0.00 $0.00 112304 ERX HCPCS J1953 67457-0265-10 LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN BOTH IP/OP $99.59 $73.70 $0.00 $149.94 $44.82 $44.82 $0.00 $0.00 $0.00 $20.76 $73.92 $73.92 $76.76 $0.00 $20.75 $0.00 $58.91 $58.91 $0.00 $93.72 $148.44 $149.94 $0.00 $0.00 $29.33 $0.00 $0.00 $29.84 $0.00 $0.00 $0.00 $0.00 $0.00 112304 ERX HCPCS J1953 70860-0603-82 LEVETIRACETAM IN NACL 1000 MG/100ML IV SOLN BOTH IP/OP $99.59 $73.70 $0.00 $149.94 $44.82 $44.82 $0.00 $0.00 $0.00 $20.76 $73.92 $73.92 $76.76 $0.00 $20.75 $0.00 $58.91 $58.91 $0.00 $93.72 $148.44 $149.94 $0.00 $0.00 $29.33 $0.00 $0.00 $29.84 $0.00 $0.00 $0.00 $0.00 $0.00 112305 ERX HCPCS J1953 43598-0637-10 LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN BOTH IP/OP $185.28 $137.11 $0.00 $142.81 $83.38 $83.38 $0.00 $0.00 $0.00 $38.62 $137.51 $137.51 $142.81 $0.00 $38.61 $0.00 $109.59 $109.59 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 112305 ERX HCPCS J1953 43598-0637-52 LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN BOTH IP/OP $185.28 $137.11 $0.00 $142.81 $83.38 $83.38 $0.00 $0.00 $0.00 $38.62 $137.51 $137.51 $142.81 $0.00 $38.61 $0.00 $109.59 $109.59 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 112305 ERX HCPCS J1953 43598-0759-10 LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN BOTH IP/OP $185.28 $137.11 $0.00 $142.81 $83.38 $83.38 $0.00 $0.00 $0.00 $38.62 $137.51 $137.51 $142.81 $0.00 $38.61 $0.00 $109.59 $109.59 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 112305 ERX HCPCS J1953 43598-0759-52 LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN BOTH IP/OP $185.28 $137.11 $0.00 $142.81 $83.38 $83.38 $0.00 $0.00 $0.00 $38.62 $137.51 $137.51 $142.81 $0.00 $38.61 $0.00 $109.59 $109.59 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 112305 ERX HCPCS J1953 55150-0248-47 LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN BOTH IP/OP $185.28 $137.11 $0.00 $142.81 $83.38 $83.38 $0.00 $0.00 $0.00 $38.62 $137.51 $137.51 $142.81 $0.00 $38.61 $0.00 $109.59 $109.59 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 112305 ERX HCPCS J1953 67457-0266-00 LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN BOTH IP/OP $185.28 $137.11 $0.00 $142.81 $83.38 $83.38 $0.00 $0.00 $0.00 $38.62 $137.51 $137.51 $142.81 $0.00 $38.61 $0.00 $109.59 $109.59 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 112305 ERX HCPCS J1953 67457-0266-10 LEVETIRACETAM IN NACL 1500 MG/100ML IV SOLN BOTH IP/OP $185.28 $137.11 $0.00 $142.81 $83.38 $83.38 $0.00 $0.00 $0.00 $38.62 $137.51 $137.51 $142.81 $0.00 $38.61 $0.00 $109.59 $109.59 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 112380 ERX HCPCS 25000001 63402-0302-30 LURASIDONE HCL 20 MG PO TABS BOTH IP/OP $196.92 $145.72 $0.00 $151.79 $0.00 $0.00 $0.00 $0.00 $0.00 $146.15 $146.15 $151.79 $0.00 $41.04 $0.00 $0.00 $0.00 $0.00 $80.86 $128.07 $129.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112618 ERX HCPCS J2212 65649-0552-04 METHYLNALTREXONE BROMIDE 8 MG/0.4ML SC SOLN BOTH IP/OP $585.21 $433.06 $0.00 $451.08 $0.00 $0.00 $0.00 $0.00 $0.00 $434.34 $434.34 $451.08 $0.00 $121.96 $0.00 $0.00 $0.00 $0.00 $228.14 $361.37 $365.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112638 ERX HCPCS 63600001 50242-0140-01 VISMODEGIB 150 MG PO CAPS BOTH IP/OP "$1,306.00 " $966.44 $0.00 "$1,037.87" $0.00 $0.00 $0.00 $0.00 $0.00 $998.39 $998.39 "$1,036.86" $0.00 $272.17 $0.00 $0.00 $0.00 $0.00 $648.67 "$1,027.49" "$1,037.87" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112683 ERX HCPCS 25000001 00006-0078-82 JANUMET XR 50-500 MG (SITAGLIPTIN-METFORMIN ER) PO TB24 BOTH IP/OP $41.64 $30.81 $0.00 $33.68 $0.00 $0.00 $0.00 $0.00 $0.00 $32.43 $32.43 $33.68 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $17.99 $28.50 $28.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112684 ERX HCPCS 25000001 00006-0080-82 JANUMET XR 50-1000 MG (SITAGLIPTIN-METFORMIN ER) PO TB24 BOTH IP/OP $41.64 $30.81 $0.00 $33.68 $0.00 $0.00 $0.00 $0.00 $0.00 $32.43 $32.43 $33.68 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $17.99 $28.50 $28.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112685 ERX HCPCS 25000001 00006-0081-31 JANUMET XR 100-1000 MG (SITAGLIPTIN-METFORMIN ER) PO TB24 BOTH IP/OP $83.27 $61.62 $0.00 $62.06 $0.00 $0.00 $0.00 $0.00 $0.00 $59.75 $59.75 $62.06 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $35.98 $56.99 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112904 ERX HCPCS 25000001 65702-0101-10 ACCU-CHEK AVIVA PLUS W/DEVICE KIT BOTH IP/OP $100.59 $74.44 $0.00 $80.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.30 $79.67 $80.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112975 ERX HCPCS J7527 00078-0620-51 EVEROLIMUS 7.5 MG PO TABS BOTH IP/OP "$1,743.45 " "$1,290.15" $0.00 "$1,343.85" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,293.99" "$1,293.99" "$1,343.85" $0.00 $363.33 $0.00 $0.00 $0.00 $0.00 $807.78 "$1,279.52" "$1,292.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 113303 ERX HCPCS 63700001 00487-2784-01 RACEPINEPHRINE HCL 2.25 % IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 113303 ERX HCPCS 63700001 00487-5901-99 RACEPINEPHRINE HCL 2.25 % IN NEBU BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 113304 ERX HCPCS 90716 00006-4827-00 VARICELLA VIRUS VACCINE LIVE 1350 PFU/0.5ML SC INJ BOTH IP/OP $608.24 $450.10 $0.00 $468.83 $273.71 $273.71 $0.00 $0.00 $136.66 $9.40 $451.44 $451.44 $468.83 $0.00 $177.40 $0.00 $359.77 $359.77 $0.00 $248.15 $393.07 $397.04 $297.78 $297.78 $159.48 $0.00 $0.00 $151.85 $0.00 $0.00 $0.00 $0.00 $0.00 113363 ERX HCPCS 25000001 00054-3188-63 DIAZEPAM 5 MG/5ML PO SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 113624 ERX HCPCS J1324 00004-0380-01 ENFUVIRTIDE 90 MG SC SOLR BOTH IP/OP $248.84 $184.14 $0.00 $191.81 $0.00 $0.00 $0.00 $0.00 $0.00 $184.69 $184.69 $191.81 $0.00 $51.86 $0.00 $0.00 $0.00 $0.00 $112.95 $178.90 $180.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 113624 ERX HCPCS J1324 00004-0381-40 ENFUVIRTIDE 90 MG SC SOLR BOTH IP/OP $248.84 $184.14 $0.00 $191.81 $0.00 $0.00 $0.00 $0.00 $0.00 $184.69 $184.69 $191.81 $0.00 $51.86 $0.00 $0.00 $0.00 $0.00 $112.95 $178.90 $180.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 114621 ERX HCPCS 25000001 49100-0400-08 CULTURELLE KIDS PO PACK BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115133 ERX HCPCS 25000001 99999-6007-10 TRICHLOROACETIC ACID 40 % EX SOLN BOTH IP/OP $83.80 $62.01 $0.00 $64.59 $0.00 $0.00 $0.00 $0.00 $0.00 $62.20 $62.20 $64.59 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $60.19 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115145 ERX HCPCS J7315 49771-0002-01 MITOMYCIN 0.2 MG OP KIT BOTH IP/OP "$1,436.64 " "$1,063.11" $0.00 "$1,107.36" $646.49 $646.49 $0.00 $0.00 $0.00 $299.43 "$1,066.27" "$1,066.27" "$1,107.36" $0.00 $299.40 $0.00 $849.77 $849.77 $0.00 $570.81 $904.16 $913.30 $0.00 $0.00 $178.66 $0.00 $0.00 $195.92 $0.00 $0.00 $0.00 $0.00 $0.00 115145 ERX HCPCS J7315 49771-0002-03 MITOMYCIN 0.2 MG OP KIT BOTH IP/OP "$1,436.64 " "$1,063.11" $0.00 "$1,107.36" $646.49 $646.49 $0.00 $0.00 $0.00 $299.43 "$1,066.27" "$1,066.27" "$1,107.36" $0.00 $299.40 $0.00 $849.77 $849.77 $0.00 $570.81 $904.16 $913.30 $0.00 $0.00 $178.66 $0.00 $0.00 $195.92 $0.00 $0.00 $0.00 $0.00 $0.00 115244 ERX HCPCS J9306 50242-0145-01 PERTUZUMAB 420 MG/14ML IV SOLN BOTH IP/OP "$14,997.78 " "$11,098.36" $0.00 "$12,080.51" "$7,052.71" "$7,052.71" "$5,693.10" "$5,693.10" "$5,693.10" "$3,125.91" "$11,632.27" "$11,632.27" "$12,080.51" "$5,693.94" "$6,690.38" "$3,701.06" "$7,393.91" "$7,393.91" "$5,419.89" "$6,509.18" "$10,310.53" "$10,414.68" "$7,484.61" "$7,484.61" "$6,227.97" $0.00 $0.00 "$5,930.09" "$5,435.64" $0.00 $0.00 $0.00 $0.00 115824 ERX HCPCS J9250 00143-9519-01 METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $2.62 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $2.94 $0.00 $0.00 $2.80 $0.00 $0.00 $0.00 $0.00 $0.00 115824 ERX HCPCS J9250 00143-9519-10 METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $2.62 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $2.94 $0.00 $0.00 $2.80 $0.00 $0.00 $0.00 $0.00 $0.00 115824 ERX HCPCS J9250 00703-3671-01 METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $2.62 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $2.94 $0.00 $0.00 $2.80 $0.00 $0.00 $0.00 $0.00 $0.00 115824 ERX HCPCS J9250 16729-0277-30 METHOTREXATE SODIUM (PF) 50 MG/2ML IJ SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $2.62 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $2.94 $0.00 $0.00 $2.80 $0.00 $0.00 $0.00 $0.00 $0.00 115826 ERX HCPCS J9260 00703-3678-01 METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN BOTH IP/OP $170.15 $125.91 $0.00 $131.15 $76.57 $76.57 $0.00 $0.00 $0.00 $54.05 $126.29 $126.29 $131.15 $0.00 $50.69 $0.00 $100.64 $100.64 $0.00 $76.02 $120.42 $121.63 $0.00 $0.00 $58.52 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 115826 ERX HCPCS J9260 61703-0408-41 METHOTREXATE SODIUM (PF) 1 GM/40ML IJ SOLN BOTH IP/OP $170.15 $125.91 $0.00 $131.15 $76.57 $76.57 $0.00 $0.00 $0.00 $54.05 $126.29 $126.29 $131.15 $0.00 $50.69 $0.00 $100.64 $100.64 $0.00 $76.02 $120.42 $121.63 $0.00 $0.00 $58.52 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 115839 ERX HCPCS J9047 76075-0101-01 CARFILZOMIB 60 MG IV SOLR BOTH IP/OP "$6,994.55 " "$5,175.97" $0.00 "$5,709.51" "$3,333.26" "$3,333.26" "$2,466.66" "$2,466.66" "$2,466.66" "$1,457.84" "$5,497.66" "$5,497.66" "$5,709.51" "$2,466.18" "$2,897.76" "$1,603.02" "$3,448.31" "$3,448.31" "$2,368.74" "$2,995.57" "$4,744.97" "$4,792.90" "$3,271.11" "$3,271.11" "$2,646.57" $0.00 $0.00 "$2,519.99" "$2,338.32" $0.00 $0.00 $0.00 $0.00 116010 ERX HCPCS J2300 99999-6011-83 NALBUPHINE (NUBAIN) 10 MG/0.5 ML IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $1.22 $20.04 $20.04 $20.81 $0.00 $3.35 $0.00 $15.97 $15.97 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $3.70 $0.00 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 116012 ERX HCPCS 63700001 61958-1201-01 STRIBILD:150-150-200-300 MG PO TABS BOTH IP/OP $505.27 $373.90 $0.00 $331.55 $0.00 $0.00 $0.00 $89.94 $0.00 $0.00 $0.00 $0.00 $0.00 $105.30 $0.00 $0.00 $0.00 $0.00 $207.22 $328.24 $331.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116047 ERX HCPCS J9302 00078-0690-61 OFATUMUMAB 1000 MG/50ML IV CONC BOTH IP/OP "$16,363.42 " "$12,108.93" $0.00 "$12,612.92" $0.00 $0.00 $0.00 $0.00 $0.00 "$12,144.93" "$12,144.93" "$12,612.92" $0.00 "$7,514.95" $0.00 $0.00 $0.00 $0.00 "$7,421.47" "$11,755.60" "$11,874.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116049 ERX HCPCS 63700001 00006-0473-61 RALTEGRAVIR POTASSIUM 25 MG PO CHEW BOTH IP/OP $9.09 $6.73 $0.00 $6.29 $0.00 $0.00 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $1.89 $0.00 $0.00 $0.00 $0.00 $3.93 $6.23 $6.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116050 ERX HCPCS 63700001 00006-0477-61 RALTEGRAVIR POTASSIUM 100 MG PO CHEW BOTH IP/OP $36.36 $26.91 $0.00 $25.14 $0.00 $0.00 $0.00 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $7.58 $0.00 $0.00 $0.00 $0.00 $15.71 $24.88 $25.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116053 ERX HCPCS J1100 63323-0506-01 DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.53 $16.33 $16.33 $16.96 $0.00 $0.68 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.71 $0.00 $0.00 $0.67 $0.00 $0.00 $0.00 $0.00 $0.00 116053 ERX HCPCS J1100 70069-0021-25 DEXAMETHASONE SOD PHOSPHATE PF 10 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.53 $16.33 $16.33 $16.96 $0.00 $0.68 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.71 $0.00 $0.00 $0.67 $0.00 $0.00 $0.00 $0.00 $0.00 116158 ERX HCPCS 63600001 49281-0225-10 DIPHTHERIA-TETANUS TOXOIDS DT 25-5 LFU/0.5ML IM SUSP BOTH IP/OP $261.35 $193.40 $0.00 $201.45 $0.00 $0.00 $0.00 $0.00 $0.00 $193.97 $193.97 $201.45 $0.00 $54.47 $0.00 $0.00 $0.00 $0.00 $107.73 $170.64 $172.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116294 ERX HCPCS 25000001 63402-0312-30 LURASIDONE HCL 120 MG PO TABS BOTH IP/OP $293.94 $217.52 $0.00 $226.57 $0.00 $0.00 $0.00 $0.00 $0.00 $218.16 $218.16 $226.57 $0.00 $61.26 $0.00 $0.00 $0.00 $0.00 $120.70 $191.19 $193.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116340 ERX HCPCS 25000001 00054-0404-44 MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116340 ERX HCPCS 25000001 00054-0404-50 MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116340 ERX HCPCS 25000001 00406-8003-12 MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116340 ERX HCPCS 25000001 99999-6005-51 MORPHINE SULFATE (CONCENTRATE) 100 MG/5ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116365 ERX HCPCS J2270 00409-1891-01 MORPHINE SULFATE (PF) 4 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $3.98 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 116365 ERX HCPCS J2270 00409-1891-03 MORPHINE SULFATE (PF) 4 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $3.98 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 116365 ERX HCPCS J2270 00641-6125-01 MORPHINE SULFATE (PF) 4 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $3.98 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 116365 ERX HCPCS J2270 00641-6125-25 MORPHINE SULFATE (PF) 4 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $3.98 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 116374 ERX HCPCS J2270 00409-1893-01 MORPHINE SULFATE (PF) 10 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116374 ERX HCPCS J2270 00641-6127-01 MORPHINE SULFATE (PF) 10 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116374 ERX HCPCS J2270 00641-6127-25 MORPHINE SULFATE (PF) 10 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116385 ERX HCPCS 63700001 00469-0125-99 ENZALUTAMIDE 40 MG PO CAPS BOTH IP/OP $716.91 $530.51 $0.00 $505.34 $0.00 $0.00 $0.00 $135.14 $0.00 $0.00 $0.00 $0.00 $0.00 $149.40 $0.00 $0.00 $0.00 $0.00 $315.84 $500.28 $505.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116397 ERX HCPCS J8999 00069-0135-01 BOSUTINIB 100 MG PO TABS BOTH IP/OP $583.36 $431.69 $0.00 $449.65 $0.00 $0.00 $0.00 $0.00 $0.00 $432.97 $432.97 $449.65 $0.00 $121.57 $0.00 $0.00 $0.00 $0.00 $239.02 $378.60 $382.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116398 ERX HCPCS 63600001 00069-0136-01 BOSUTINIB 500 MG PO TABS BOTH IP/OP "$1,798.68 " "$1,331.02" $0.00 "$1,386.42" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,334.98" "$1,334.98" "$1,386.42" $0.00 $374.84 $0.00 $0.00 $0.00 $0.00 $752.31 "$1,191.65" "$1,203.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117006 ERX HCPCS 25000001 12496-1204-01 SUBOXONE:BUPRENORPHINE HCL-NALOXONE HCL 4-1 MG SL FILM BOTH IP/OP $45.16 $33.42 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 $33.52 $33.52 $34.81 $0.00 $9.41 $0.00 $0.00 $0.00 $0.00 $20.48 $32.43 $32.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117006 ERX HCPCS 25000001 12496-1204-03 SUBOXONE:BUPRENORPHINE HCL-NALOXONE HCL 4-1 MG SL FILM BOTH IP/OP $45.16 $33.42 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 $33.52 $33.52 $34.81 $0.00 $9.41 $0.00 $0.00 $0.00 $0.00 $20.48 $32.43 $32.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117007 ERX HCPCS 25000001 12496-1212-01 SUBOXONE:BUPRENORPHINE HCL-NALOXONE HCL 12-3 MG SL FILM BOTH IP/OP $83.20 $61.57 $0.00 $64.13 $0.00 $0.00 $0.00 $0.00 $0.00 $61.75 $61.75 $64.13 $0.00 $17.34 $0.00 $0.00 $0.00 $0.00 $37.72 $59.75 $60.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117007 ERX HCPCS 25000001 12496-1212-03 SUBOXONE:BUPRENORPHINE HCL-NALOXONE HCL 12-3 MG SL FILM BOTH IP/OP $83.20 $61.57 $0.00 $64.13 $0.00 $0.00 $0.00 $0.00 $0.00 $61.75 $61.75 $64.13 $0.00 $17.34 $0.00 $0.00 $0.00 $0.00 $37.72 $59.75 $60.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117011 ERX HCPCS 63700001 00456-1201-30 LINACLOTIDE 145 MCG PO CAPS BOTH IP/OP $78.32 $57.96 $0.00 $54.12 $0.00 $0.00 $0.00 $14.64 $0.00 $0.00 $0.00 $0.00 $0.00 $16.32 $0.00 $0.00 $0.00 $0.00 $33.83 $53.58 $54.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117021 ERX HCPCS 25000001 50419-0171-03 REGORAFENIB 40 MG PO TABS BOTH IP/OP "$1,387.29 " "$1,026.59" $0.00 "$1,121.74" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,080.12" "$1,080.12" "$1,121.74" $0.00 $289.11 $0.00 $0.00 $0.00 $0.00 $618.63 $979.90 $989.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117385 ERX HCPCS 63700001 59676-0566-30 DARUNAVIR ETHANOLATE 800 MG PO TABS BOTH IP/OP $256.12 $189.53 $0.00 $177.99 $0.00 $0.00 $0.00 $48.14 $0.00 $0.00 $0.00 $0.00 $0.00 $53.38 $0.00 $0.00 $0.00 $0.00 $111.25 $176.21 $177.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117945 ERX HCPCS 25000001 24208-0503-07 LOTEPREDNOL ETABONATE 0.5 % OP GEL BOTH IP/OP $795.97 $589.02 $0.00 $613.53 $0.00 $0.00 $0.00 $0.00 $0.00 $590.77 $590.77 $613.53 $0.00 $165.88 $0.00 $0.00 $0.00 $0.00 $321.45 $509.17 $514.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118046 ERX HCPCS 63700001 42937-0705-18 PRENATAL PLUS IRON 29-1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118105 ERX HCPCS 63600001 76189-0535-30 PONATINIB HCL 15 MG PO TABS BOTH IP/OP "$1,589.86 " "$1,176.50" $0.00 "$1,271.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $794.93 "$1,259.17" "$1,271.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118189 ERX HCPCS 25000001 54643-5649-01 INFUVITE ADULT IV INJ BOTH IP/OP $55.44 $41.03 $0.00 $42.73 $0.00 $0.00 $0.00 $0.00 $0.00 $41.15 $41.15 $42.73 $0.00 $11.55 $0.00 $0.00 $0.00 $0.00 $23.07 $36.54 $36.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118319 ERX HCPCS 63700001 00003-0893-21 APIXABAN 2.5 MG PO TABS BOTH IP/OP $41.83 $30.95 $0.00 $28.63 $0.00 $0.00 $0.00 $7.89 $0.00 $0.00 $0.00 $0.00 $0.00 $8.72 $0.00 $0.00 $0.00 $0.00 $17.90 $28.35 $28.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118319 ERX HCPCS 63700001 00003-0893-31 APIXABAN 2.5 MG PO TABS BOTH IP/OP $41.83 $30.95 $0.00 $28.63 $0.00 $0.00 $0.00 $7.89 $0.00 $0.00 $0.00 $0.00 $0.00 $8.72 $0.00 $0.00 $0.00 $0.00 $17.90 $28.35 $28.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118352 ERX HCPCS 63700001 00003-0894-21 APIXABAN 5 MG PO TABS BOTH IP/OP $41.83 $30.95 $0.00 $28.63 $0.00 $0.00 $0.00 $7.89 $0.00 $0.00 $0.00 $0.00 $0.00 $8.72 $0.00 $0.00 $0.00 $0.00 $17.90 $28.35 $28.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118352 ERX HCPCS 63700001 00003-0894-31 APIXABAN 5 MG PO TABS BOTH IP/OP $41.83 $30.95 $0.00 $28.63 $0.00 $0.00 $0.00 $7.89 $0.00 $0.00 $0.00 $0.00 $0.00 $8.72 $0.00 $0.00 $0.00 $0.00 $17.90 $28.35 $28.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118810 ERX HCPCS 63700001 00536-4085-01 PRENATAL VITAMINS 28-0.8 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118851 ERX HCPCS 25000001 59572-0501-00 POMALIDOMIDE 1 MG PO CAPS BOTH IP/OP "$2,461.44 " "$1,821.47" $0.00 "$1,982.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.09" "$1,909.09" "$1,982.66" $0.00 $512.96 $0.00 $0.00 $0.00 $0.00 "$1,068.29" "$1,692.17" "$1,709.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118851 ERX HCPCS 25000001 59572-0501-21 POMALIDOMIDE 1 MG PO CAPS BOTH IP/OP "$2,461.44 " "$1,821.47" $0.00 "$1,982.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.09" "$1,909.09" "$1,982.66" $0.00 $512.96 $0.00 $0.00 $0.00 $0.00 "$1,068.29" "$1,692.17" "$1,709.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118852 ERX HCPCS 25000001 59572-0502-00 POMALIDOMIDE 2 MG PO CAPS BOTH IP/OP "$2,461.44 " "$1,821.47" $0.00 "$1,982.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.09" "$1,909.09" "$1,982.66" $0.00 $512.96 $0.00 $0.00 $0.00 $0.00 "$1,068.29" "$1,692.17" "$1,709.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118852 ERX HCPCS 25000001 59572-0502-21 POMALIDOMIDE 2 MG PO CAPS BOTH IP/OP "$2,461.44 " "$1,821.47" $0.00 "$1,982.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.09" "$1,909.09" "$1,982.66" $0.00 $512.96 $0.00 $0.00 $0.00 $0.00 "$1,068.29" "$1,692.17" "$1,709.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118853 ERX HCPCS 25000001 59572-0503-00 POMALIDOMIDE 3 MG PO CAPS BOTH IP/OP "$2,461.44 " "$1,821.47" $0.00 "$1,982.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.09" "$1,909.09" "$1,982.66" $0.00 $512.96 $0.00 $0.00 $0.00 $0.00 "$1,068.29" "$1,692.17" "$1,709.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118853 ERX HCPCS 25000001 59572-0503-21 POMALIDOMIDE 3 MG PO CAPS BOTH IP/OP "$2,461.44 " "$1,821.47" $0.00 "$1,982.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.09" "$1,909.09" "$1,982.66" $0.00 $512.96 $0.00 $0.00 $0.00 $0.00 "$1,068.29" "$1,692.17" "$1,709.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118854 ERX HCPCS 25000001 59572-0504-00 POMALIDOMIDE 4 MG PO CAPS BOTH IP/OP "$2,461.44 " "$1,821.47" $0.00 "$1,982.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.09" "$1,909.09" "$1,982.66" $0.00 $512.96 $0.00 $0.00 $0.00 $0.00 "$1,068.29" "$1,692.17" "$1,709.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118854 ERX HCPCS 25000001 59572-0504-21 POMALIDOMIDE 4 MG PO CAPS BOTH IP/OP "$2,461.44 " "$1,821.47" $0.00 "$1,982.66" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.09" "$1,909.09" "$1,982.66" $0.00 $512.96 $0.00 $0.00 $0.00 $0.00 "$1,068.29" "$1,692.17" "$1,709.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 118951 ERX HCPCS J9354 50242-0087-01 ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR BOTH IP/OP "$14,303.91 " "$10,584.89" $0.00 "$11,521.61" "$6,726.42" "$6,726.42" "$5,464.16" "$5,464.16" "$5,464.16" "$2,981.29" "$11,094.11" "$11,094.11" "$11,521.61" "$5,469.44" "$6,426.59" "$3,555.14" "$7,051.83" "$7,051.83" "$5,269.15" "$6,208.04" "$9,833.54" "$9,932.86" "$7,276.45" "$7,276.45" "$6,036.68" $0.00 $0.00 "$5,747.95" "$5,250.88" $0.00 $0.00 $0.00 $0.00 119091 ERX HCPCS 63700001 00406-8330-23 MORPHINE SULFATE CR 30 MG PO TB12 BOTH IP/OP $14.17 $10.49 $0.00 $10.28 $0.00 $0.00 $0.00 $2.52 $0.00 $0.00 $0.00 $0.00 $0.00 $2.95 $0.00 $0.00 $0.00 $0.00 $6.43 $10.18 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119091 ERX HCPCS 63700001 00406-8330-62 MORPHINE SULFATE CR 30 MG PO TB12 BOTH IP/OP $14.17 $10.49 $0.00 $10.28 $0.00 $0.00 $0.00 $2.52 $0.00 $0.00 $0.00 $0.00 $0.00 $2.95 $0.00 $0.00 $0.00 $0.00 $6.43 $10.18 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119102 ERX HCPCS 63700001 00456-3407-33 MEMANTINE HCL ER 7 MG PO CP24 BOTH IP/OP $77.90 $57.65 $0.00 $56.52 $0.00 $0.00 $0.00 $13.87 $0.00 $0.00 $0.00 $0.00 $0.00 $16.23 $0.00 $0.00 $0.00 $0.00 $35.33 $55.95 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119105 ERX HCPCS 63700001 00456-3428-33 MEMANTINE HCL ER 28 MG PO CP24 BOTH IP/OP $64.03 $47.38 $0.00 $46.46 $0.00 $0.00 $0.00 $11.40 $0.00 $0.00 $0.00 $0.00 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $29.04 $45.99 $46.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119105 ERX HCPCS 63700001 10370-0349-11 MEMANTINE HCL ER 28 MG PO CP24 BOTH IP/OP $64.03 $47.38 $0.00 $46.46 $0.00 $0.00 $0.00 $11.40 $0.00 $0.00 $0.00 $0.00 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $29.04 $45.99 $46.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119105 ERX HCPCS 63700001 43975-0266-03 MEMANTINE HCL ER 28 MG PO CP24 BOTH IP/OP $64.03 $47.38 $0.00 $46.46 $0.00 $0.00 $0.00 $11.40 $0.00 $0.00 $0.00 $0.00 $0.00 $13.34 $0.00 $0.00 $0.00 $0.00 $29.04 $45.99 $46.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119111 ERX HCPCS 63700001 99999-6007-75 DARUNAVIR ETHANOLATE 100 MG/ML PO SUSP BOTH IP/OP $136.30 $100.86 $0.00 $732.60 $0.00 $0.00 $0.00 $24.26 $0.00 $0.00 $0.00 $0.00 $0.00 $28.40 $0.00 $0.00 $0.00 $0.00 $287.19 $732.60 $459.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119111 ERX HCPCS 63700001 59676-0565-01 DARUNAVIR ETHANOLATE 100 MG/ML PO SUSP BOTH IP/OP $136.30 $100.86 $0.00 "$1,910.98" $0.00 $0.00 $0.00 $24.26 $0.00 $0.00 $0.00 $0.00 $0.00 $28.40 $0.00 $0.00 $0.00 $0.00 $287.19 "$1,910.98" $459.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119120 ERX HCPCS J2270 00409-1890-01 MORPHINE SULFATE (PF) 2 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $3.98 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 119120 ERX HCPCS J2270 00409-1890-03 MORPHINE SULFATE (PF) 2 MG/ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $3.98 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.39 $0.00 $0.00 $2.27 $0.00 $0.00 $0.00 $0.00 $0.00 119123 ERX HCPCS 25000001 00074-4380-10 CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN BOTH IP/OP $106.54 $78.84 $0.00 $82.12 $0.00 $0.00 $0.00 $0.00 $0.00 $79.07 $79.07 $82.12 $0.00 $22.20 $0.00 $0.00 $0.00 $0.00 $48.30 $76.51 $77.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119123 ERX HCPCS 25000001 00074-4380-81 CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN BOTH IP/OP $106.54 $78.84 $0.00 $82.12 $0.00 $0.00 $0.00 $0.00 $0.00 $79.07 $79.07 $82.12 $0.00 $22.20 $0.00 $0.00 $0.00 $0.00 $48.30 $76.51 $77.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119123 ERX HCPCS 25000001 00781-3152-95 CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN BOTH IP/OP $106.54 $78.84 $0.00 $82.12 $0.00 $0.00 $0.00 $0.00 $0.00 $79.07 $79.07 $82.12 $0.00 $22.20 $0.00 $0.00 $0.00 $0.00 $48.30 $76.51 $77.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119123 ERX HCPCS 25000001 00781-9038-70 CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN BOTH IP/OP $106.54 $78.84 $0.00 $82.12 $0.00 $0.00 $0.00 $0.00 $0.00 $79.07 $79.07 $82.12 $0.00 $22.20 $0.00 $0.00 $0.00 $0.00 $48.30 $76.51 $77.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119123 ERX HCPCS 25000001 00781-9038-95 CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN BOTH IP/OP $106.54 $78.84 $0.00 $82.12 $0.00 $0.00 $0.00 $0.00 $0.00 $79.07 $79.07 $82.12 $0.00 $22.20 $0.00 $0.00 $0.00 $0.00 $48.30 $76.51 $77.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119123 ERX HCPCS 25000001 63323-0417-10 CISATRACURIUM BESYLATE 20 MG/10ML IV SOLN BOTH IP/OP $106.54 $78.84 $0.00 $82.12 $0.00 $0.00 $0.00 $0.00 $0.00 $79.07 $79.07 $82.12 $0.00 $22.20 $0.00 $0.00 $0.00 $0.00 $48.30 $76.51 $77.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119129 ERX HCPCS 63700001 00406-8315-01 MORPHINE SULFATE CR 15 MG PO TB12 BOTH IP/OP $7.85 $5.81 $0.00 $5.70 $0.00 $0.00 $0.00 $1.40 $0.00 $0.00 $0.00 $0.00 $0.00 $1.64 $0.00 $0.00 $0.00 $0.00 $3.56 $5.64 $5.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119129 ERX HCPCS 63700001 00406-8315-23 MORPHINE SULFATE CR 15 MG PO TB12 BOTH IP/OP $7.85 $5.81 $0.00 $5.70 $0.00 $0.00 $0.00 $1.40 $0.00 $0.00 $0.00 $0.00 $0.00 $1.64 $0.00 $0.00 $0.00 $0.00 $3.56 $5.64 $5.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119129 ERX HCPCS 63700001 00406-8315-62 MORPHINE SULFATE CR 15 MG PO TB12 BOTH IP/OP $7.85 $5.81 $0.00 $5.70 $0.00 $0.00 $0.00 $1.40 $0.00 $0.00 $0.00 $0.00 $0.00 $1.64 $0.00 $0.00 $0.00 $0.00 $3.56 $5.64 $5.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119131 ERX HCPCS 63700001 00406-8390-01 MORPHINE SULFATE CR 100 MG PO TB12 BOTH IP/OP $32.00 $23.68 $0.00 $23.22 $0.00 $0.00 $0.00 $5.70 $0.00 $0.00 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $14.51 $22.98 $23.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119131 ERX HCPCS 63700001 00406-8390-62 MORPHINE SULFATE CR 100 MG PO TB12 BOTH IP/OP $32.00 $23.68 $0.00 $23.22 $0.00 $0.00 $0.00 $5.70 $0.00 $0.00 $0.00 $0.00 $0.00 $6.67 $0.00 $0.00 $0.00 $0.00 $14.51 $22.98 $23.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119134 ERX HCPCS 25000001 00143-9680-25 GLYCOPYRROLATE 1 MG/5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119134 ERX HCPCS 25000001 62295-3325-05 GLYCOPYRROLATE 1 MG/5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119134 ERX HCPCS 25000001 70121-1396-05 GLYCOPYRROLATE 1 MG/5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119650 ERX HCPCS 63700001 00065-4147-27 (SIMBRINZA) BRINZOLAMIDE-BRIMONIDINE 1-0.2 % OP SUSP BOTH IP/OP $545.97 $404.02 $0.00 $436.78 $0.00 $0.00 $0.00 $118.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $432.41 $436.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 119955 ERX HCPCS 63700001 50268-0851-15 VITAMIN B1 100 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120301 ERX HCPCS 25000001 00904-6488-38 ARTIFICIAL TEARS 83-15 % OP OINT BOTH IP/OP $14.02 $10.37 $0.00 $11.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.01 $11.10 $11.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120319 ERX HCPCS C9132 63833-0386-02 PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT BOTH IP/OP "$3,683.80 " "$2,726.01" $0.00 "$2,839.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,734.12" "$2,734.12" "$2,839.47" $0.00 $767.70 $0.00 $0.00 $0.00 $0.00 "$1,609.25" "$2,435.40" "$2,574.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120319 ERX HCPCS C9132 63833-0396-01 PROTHROMBIN COMPLEX CONC HUMAN 500 UNITS IV KIT BOTH IP/OP "$3,683.80 " "$2,726.01" $0.00 "$2,839.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,734.12" "$2,734.12" "$2,839.47" $0.00 $767.70 $0.00 $0.00 $0.00 $0.00 "$1,609.25" "$2,435.40" "$2,574.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120606 ERX HCPCS 63700001 00078-0681-66 DABRAFENIB MESYLATE 75 MG PO CAPS BOTH IP/OP $677.79 $501.56 $0.00 $466.44 $0.00 $0.00 $0.00 $127.28 $0.00 $0.00 $0.00 $0.00 $0.00 $141.25 $0.00 $0.00 $0.00 $0.00 $291.53 $461.78 $466.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120607 ERX HCPCS 63700001 00078-0666-15 TRAMETINIB DIMETHYL SULFOXIDE 0.5 MG PO TABS BOTH IP/OP "$1,534.24 " "$1,135.34" $0.00 "$1,078.06" $0.00 $0.00 $0.00 $288.11 $0.00 $0.00 $0.00 $0.00 $0.00 $319.74 $0.00 $0.00 $0.00 $0.00 $673.79 "$1,067.28" "$1,078.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120608 ERX HCPCS 63700001 00078-0668-15 TRAMETINIB DIMETHYL SULFOXIDE 2 MG PO TABS BOTH IP/OP "$1,305.45 " $966.03 $0.00 "$1,012.85" $0.00 $0.00 $0.00 $245.15 $0.00 $0.00 $0.00 $0.00 $0.00 $272.06 $0.00 $0.00 $0.00 $0.00 $633.03 "$1,002.72" "$1,012.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120650 ERX HCPCS J2710 00641-6149-10 NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $2.00 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.03 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 120650 ERX HCPCS J2710 63323-0415-10 NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $2.00 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.03 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 120650 ERX HCPCS J2710 76014-0003-10 NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $2.00 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.03 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 120650 ERX HCPCS J2710 76014-0003-33 NEOSTIGMINE METHYLSULFATE 10 MG/10ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $2.00 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.03 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 120829 ERX HCPCS 63700001 99999-6011-84 NIMODIPINE 60 MG/20ML PO SOLN BOTH IP/OP $171.64 $127.01 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.82 $135.94 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121069 ERX HCPCS J1602 57894-0350-01 GOLIMUMAB 50 MG/4ML IV SOLN BOTH IP/OP "$5,421.82 " "$4,012.15" $0.00 "$4,179.14" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,024.07" "$4,024.07" "$4,179.14" $0.00 $988.06 $0.00 $0.00 $0.00 $0.00 "$2,346.37" "$3,716.65" "$3,754.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121091 ERX HCPCS J1439 00517-0650-01 FERRIC CARBOXYMALTOSE 750 MG/15ML IV SOLN BOTH IP/OP "$3,279.05 " "$2,426.50" $0.00 "$2,527.49" "$1,475.57" "$1,475.57" $842.25 $842.25 $842.25 $683.44 "$2,433.71" "$2,433.71" "$2,527.49" $840.00 $987.00 $546.00 "$1,616.57" "$1,616.57" $863.89 "$1,401.79" "$2,220.43" "$2,242.86" "$1,192.99" "$1,192.99" $978.19 $0.00 $0.00 $931.40 $840.00 $0.00 $0.00 $0.00 $0.00 121434 ERX HCPCS 63700001 49702-0228-13 DOLUTEGRAVIR SODIUM 50 MG PO TABS BOTH IP/OP $279.18 $206.59 $0.00 $184.11 $0.00 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 $58.18 $0.00 $0.00 $0.00 $0.00 $115.07 $182.27 $184.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121712 ERX HCPCS 90680 00006-4047-41 ROTAVIRUS VAC LIVE PENTAVALENT PO SOLN BOTH IP/OP $364.38 $269.64 $0.00 $280.86 $163.97 $163.97 $0.00 $0.00 $0.00 $75.95 $270.44 $270.44 $280.86 $0.00 $75.94 $0.00 $215.53 $215.53 $0.00 $154.47 $244.67 $247.14 $0.00 $0.00 $48.35 $0.00 $0.00 $51.14 $0.00 $0.00 $0.00 $0.00 $0.00 121715 ERX HCPCS 25000001 00409-1165-01 BUPIVACAINE HCL (PF) 0.75 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121715 ERX HCPCS 25000001 00409-1582-10 BUPIVACAINE HCL (PF) 0.75 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121715 ERX HCPCS 25000001 55150-0171-10 BUPIVACAINE HCL (PF) 0.75 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121715 ERX HCPCS 25000001 63323-0472-17 BUPIVACAINE HCL (PF) 0.75 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121718 ERX HCPCS J2260 00143-9710-01 MILRINONE LACTATE 10 MG/10ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $4.43 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $3.60 $0.00 $0.00 $3.42 $0.00 $0.00 $0.00 $0.00 $0.00 121718 ERX HCPCS J2260 00143-9710-10 MILRINONE LACTATE 10 MG/10ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $4.43 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $3.60 $0.00 $0.00 $3.42 $0.00 $0.00 $0.00 $0.00 $0.00 121718 ERX HCPCS J2260 00409-0212-01 MILRINONE LACTATE 10 MG/10ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $4.43 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $3.60 $0.00 $0.00 $3.42 $0.00 $0.00 $0.00 $0.00 $0.00 121718 ERX HCPCS J2260 63323-0617-10 MILRINONE LACTATE 10 MG/10ML IV SOLN BOTH IP/OP $31.43 $23.26 $0.00 $24.23 $14.14 $14.14 $0.00 $0.00 $0.00 $6.55 $23.33 $23.33 $24.23 $0.00 $4.43 $0.00 $18.59 $18.59 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $3.60 $0.00 $0.00 $3.42 $0.00 $0.00 $0.00 $0.00 $0.00 121722 ERX HCPCS J9181 00143-9511-01 ETOPOSIDE 500 MG/25ML IV SOLN BOTH IP/OP $197.27 $145.98 $0.00 $152.06 $88.77 $88.77 $0.00 $0.00 $0.00 $41.12 $146.41 $146.41 $152.06 $0.00 $46.71 $0.00 $116.69 $116.69 $0.00 $89.54 $141.83 $143.26 $0.00 $0.00 $36.43 $0.00 $0.00 $34.68 $0.00 $0.00 $0.00 $0.00 $0.00 121722 ERX HCPCS J9181 16729-0114-08 ETOPOSIDE 500 MG/25ML IV SOLN BOTH IP/OP $197.27 $145.98 $0.00 $152.06 $88.77 $88.77 $0.00 $0.00 $0.00 $41.12 $146.41 $146.41 $152.06 $0.00 $46.71 $0.00 $116.69 $116.69 $0.00 $89.54 $141.83 $143.26 $0.00 $0.00 $36.43 $0.00 $0.00 $34.68 $0.00 $0.00 $0.00 $0.00 $0.00 121723 ERX HCPCS J9181 00703-5657-01 ETOPOSIDE 1 GM/50ML IV SOLN BOTH IP/OP $501.48 $371.10 $0.00 $386.54 $225.67 $225.67 $0.00 $0.00 $0.00 $104.52 $372.20 $372.20 $386.54 $0.00 $93.41 $0.00 $296.63 $296.63 $0.00 $227.61 $360.53 $364.18 $0.00 $0.00 $72.85 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 121723 ERX HCPCS J9181 63323-0104-50 ETOPOSIDE 1 GM/50ML IV SOLN BOTH IP/OP $501.48 $371.10 $0.00 $386.54 $225.67 $225.67 $0.00 $0.00 $0.00 $104.52 $372.20 $372.20 $386.54 $0.00 $93.41 $0.00 $296.63 $296.63 $0.00 $227.61 $360.53 $364.18 $0.00 $0.00 $72.85 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 121727 ERX HCPCS 63700001 60258-0172-01 MAGNESIUM GLUCONATE 500 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121730 ERX HCPCS 25000001 59011-0410-10 OXYCODONE HCL ER 10 MG PO T12A BOTH IP/OP $24.06 $17.80 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $0.00 $17.86 $17.86 $18.55 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $9.90 $15.67 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121730 ERX HCPCS 25000001 59011-0410-20 OXYCODONE HCL ER 10 MG PO T12A BOTH IP/OP $24.06 $17.80 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $0.00 $17.86 $17.86 $18.55 $0.00 $5.01 $0.00 $0.00 $0.00 $0.00 $9.90 $15.67 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121733 ERX HCPCS 25000001 59011-0420-10 OXYCODONE HCL ER 20 MG PO T12A BOTH IP/OP $44.81 $33.16 $0.00 $34.54 $0.00 $0.00 $0.00 $0.00 $0.00 $33.26 $33.26 $34.54 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $18.43 $29.19 $29.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121733 ERX HCPCS 25000001 59011-0420-20 OXYCODONE HCL ER 20 MG PO T12A BOTH IP/OP $44.81 $33.16 $0.00 $34.54 $0.00 $0.00 $0.00 $0.00 $0.00 $33.26 $33.26 $34.54 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $18.43 $29.19 $29.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121735 ERX HCPCS 25000001 59011-0440-10 OXYCODONE HCL ER 40 MG PO T12A BOTH IP/OP $74.83 $55.37 $0.00 $57.68 $0.00 $0.00 $0.00 $0.00 $0.00 $55.54 $55.54 $57.68 $0.00 $15.59 $0.00 $0.00 $0.00 $0.00 $30.78 $48.75 $49.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121735 ERX HCPCS 25000001 59011-0440-20 OXYCODONE HCL ER 40 MG PO T12A BOTH IP/OP $74.83 $55.37 $0.00 $57.68 $0.00 $0.00 $0.00 $0.00 $0.00 $55.54 $55.54 $57.68 $0.00 $15.59 $0.00 $0.00 $0.00 $0.00 $30.78 $48.75 $49.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121737 ERX HCPCS 25000001 59011-0480-20 OXYCODONE HCL ER 80 MG PO T12A BOTH IP/OP $123.37 $91.29 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $0.00 $91.57 $91.57 $95.09 $0.00 $25.71 $0.00 $0.00 $0.00 $0.00 $50.73 $80.36 $81.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121854 ERX HCPCS 25000001 63402-0306-30 LURASIDONE HCL 60 MG PO TABS BOTH IP/OP $196.92 $145.72 $0.00 $151.79 $0.00 $0.00 $0.00 $0.00 $0.00 $146.15 $146.15 $151.79 $0.00 $41.04 $0.00 $0.00 $0.00 $0.00 $80.86 $128.07 $129.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 00143-9532-25 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 16729-0239-30 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 16729-0239-93 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 16729-0432-30 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 16729-0432-93 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 42023-0146-25 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 55150-0209-02 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 57664-0596-50 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 63323-0421-02 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 70860-0605-03 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121934 ERX HCPCS 25000001 70860-0605-41 DEXMEDETOMIDINE HCL 200 MCG/2ML IV SOLN BOTH IP/OP $183.43 $135.74 $0.00 $141.39 $0.00 $0.00 $0.00 $0.00 $0.00 $136.14 $136.14 $141.39 $0.00 $38.23 $0.00 $0.00 $0.00 $0.00 $83.16 $131.73 $133.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121955 ERX HCPCS J9041 63020-0049-01 BORTEZOMIB 3.5 MG IJ SOLR BOTH IP/OP "$4,347.34 " "$3,217.03" $0.00 "$3,350.93" "$1,956.30" "$1,956.30" "$1,567.79" "$1,567.79" "$1,567.79" "$1,491.60" "$3,226.60" "$3,226.60" "$3,350.93" "$1,580.74" "$1,857.37" "$1,027.48" "$2,143.24" "$2,143.24" "$1,642.25" "$1,971.69" "$3,123.16" "$3,154.70" "$2,267.87" "$2,267.87" "$1,844.87" $0.00 $0.00 "$1,756.63" "$1,574.55" $0.00 $0.00 $0.00 $0.00 122027 ERX HCPCS 63700001 64764-0750-30 VORTIOXETINE HBR 20 MG PO TABS BOTH IP/OP $70.90 $52.47 $0.00 $48.99 $0.00 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 $14.78 $0.00 $0.00 $0.00 $0.00 $30.62 $48.50 $48.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 122192 ERX HCPCS J9301 50242-0070-01 OBINUTUZUMAB 1000 MG/40ML IV SOLN BOTH IP/OP "$18,573.86 " "$13,744.66" $0.00 "$14,889.37" $0.00 $0.00 $0.00 $0.00 $0.00 "$14,336.91" "$14,336.91" "$14,889.37" $0.00 "$7,582.98" $0.00 $0.00 $0.00 $0.00 "$8,178.60" "$12,954.90" "$13,085.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 122260 ERX HCPCS 63700001 57962-0140-09 IBRUTINIB 140 MG PO CAPS BOTH IP/OP "$1,161.80 " $859.73 $0.00 $785.38 $0.00 $0.00 $0.00 $222.10 $0.00 $0.00 $0.00 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $490.86 $777.52 $785.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 122260 ERX HCPCS 63700001 57962-0140-12 IBRUTINIB 140 MG PO CAPS BOTH IP/OP "$1,161.80 " $859.73 $0.00 $785.38 $0.00 $0.00 $0.00 $222.10 $0.00 $0.00 $0.00 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $490.86 $777.52 $785.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 122312 ERX HCPCS 25000001 00085-4324-02 POSACONAZOLE 100 MG PO TBEC BOTH IP/OP $720.39 $533.09 $0.00 $555.28 $0.00 $0.00 $0.00 $0.00 $0.00 $534.67 $534.67 $555.28 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $326.89 $517.79 $523.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 122959 ERX HCPCS 63700001 00310-6205-30 DAPAGLIFLOZIN PROPANEDIOL 5 MG PO TABS BOTH IP/OP $84.74 $62.71 $0.00 $57.94 $0.00 $0.00 $0.00 $15.08 $0.00 $0.00 $0.00 $0.00 $0.00 $17.66 $0.00 $0.00 $0.00 $0.00 $36.22 $57.36 $57.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 122960 ERX HCPCS 63700001 00310-6210-30 DAPAGLIFLOZIN PROPANEDIOL 10 MG PO TABS BOTH IP/OP $84.74 $62.71 $0.00 $57.94 $0.00 $0.00 $0.00 $15.08 $0.00 $0.00 $0.00 $0.00 $0.00 $17.66 $0.00 $0.00 $0.00 $0.00 $36.22 $57.36 $57.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123430 ERX HCPCS J9181 00703-5653-01 ETOPOSIDE 100 MG/5ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $9.34 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $7.29 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 123430 ERX HCPCS J9181 16729-0114-31 ETOPOSIDE 100 MG/5ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $9.34 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $7.29 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 123430 ERX HCPCS J9181 63323-0104-05 ETOPOSIDE 100 MG/5ML IV SOLN BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $9.34 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $7.29 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 123462 ERX HCPCS 25000001 00169-4060-13 (VICTOZA) LIRAGLUTIDE 18 MG/3ML SC SOPN BOTH IP/OP $455.28 $336.91 $0.00 $367.63 $0.00 $0.00 $0.00 $0.00 $0.00 $353.99 $353.99 $367.63 $0.00 $94.88 $0.00 $0.00 $0.00 $0.00 $196.80 $311.73 $314.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123464 ERX HCPCS J1720 00009-0011-03 HYDROCORTISONE NA SUCCINATE PF 100 MG IJ SOLR BOTH IP/OP $34.43 $25.48 $0.00 $26.54 $15.49 $15.49 $0.00 $0.00 $0.00 $7.18 $25.55 $25.55 $26.54 $0.00 $17.40 $0.00 $20.37 $20.37 $0.00 $12.39 $19.63 $19.82 $0.00 $0.00 $15.33 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $0.00 123464 ERX HCPCS J1720 00009-0825-01 HYDROCORTISONE NA SUCCINATE PF 100 MG IJ SOLR BOTH IP/OP $34.43 $25.48 $0.00 $26.54 $15.49 $15.49 $0.00 $0.00 $0.00 $7.18 $25.55 $25.55 $26.54 $0.00 $17.40 $0.00 $20.37 $20.37 $0.00 $12.39 $19.63 $19.82 $0.00 $0.00 $15.33 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $0.00 123468 ERX HCPCS 25000001 00641-6022-25 FAMOTIDINE 20 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123468 ERX HCPCS 25000001 63323-0739-11 FAMOTIDINE 20 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123468 ERX HCPCS 25000001 63323-0739-12 FAMOTIDINE 20 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123468 ERX HCPCS 25000001 67457-0433-22 FAMOTIDINE 20 MG/2ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123472 ERX HCPCS J1100 55150-0238-05 DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.06 $16.33 $16.33 $16.96 $0.00 $1.36 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 123472 ERX HCPCS J1100 63323-0165-05 DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.06 $16.33 $16.33 $16.96 $0.00 $1.36 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 123472 ERX HCPCS J1100 67457-0422-00 DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.06 $16.33 $16.33 $16.96 $0.00 $1.36 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 123472 ERX HCPCS J1100 67457-0422-54 DEXAMETHASONE SODIUM PHOSPHATE 20 MG/5ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.06 $16.33 $16.33 $16.96 $0.00 $1.36 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.41 $0.00 $0.00 $1.34 $0.00 $0.00 $0.00 $0.00 $0.00 123476 ERX HCPCS J0171 49502-0102-02 EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ BOTH IP/OP "$1,066.29 " $789.05 $0.00 $821.90 $479.83 $479.83 $0.00 $0.00 $0.00 $222.24 $791.40 $791.40 $821.90 $0.00 $2.60 $0.00 $630.71 $630.71 $0.00 $483.85 $766.41 $774.15 $0.00 $0.00 $2.89 $0.00 $0.00 $2.75 $0.00 $0.00 $0.00 $0.00 $0.00 123476 ERX HCPCS J0171 49502-0500-02 EPINEPHRINE 0.3 MG/0.3ML IJ SOAJ BOTH IP/OP "$1,066.29 " $789.05 $0.00 $821.90 $479.83 $479.83 $0.00 $0.00 $0.00 $222.24 $791.40 $791.40 $821.90 $0.00 $2.60 $0.00 $630.71 $630.71 $0.00 $483.85 $766.41 $774.15 $0.00 $0.00 $2.89 $0.00 $0.00 $2.75 $0.00 $0.00 $0.00 $0.00 $0.00 123622 ERX HCPCS 25000001 00085-4331-01 POSACONAZOLE 300 MG/16.7ML IV SOLN BOTH IP/OP "$1,648.64 " "$1,219.99" $0.00 "$1,270.77" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,223.62" "$1,223.62" "$1,270.77" $0.00 $343.58 $0.00 $0.00 $0.00 $0.00 $763.85 "$1,209.93" "$1,222.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123623 ERX HCPCS C9132 63833-0387-02 PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS/40 ML IV KIT BOTH IP/OP "$7,367.60 " "$5,452.02" $0.00 "$5,678.95" $0.00 $0.00 $0.00 $0.00 $0.00 "$5,468.23" "$5,468.23" "$5,678.95" $0.00 "$1,535.41" $0.00 $0.00 $0.00 $0.00 "$3,218.50" "$4,870.80" "$5,149.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123623 ERX HCPCS C9132 63833-0397-01 PROTHROMBIN COMPLEX CONC HUMAN 1000 UNITS/40 ML IV KIT BOTH IP/OP "$7,367.60 " "$5,452.02" $0.00 "$5,678.95" $0.00 $0.00 $0.00 $0.00 $0.00 "$5,468.23" "$5,468.23" "$5,678.95" $0.00 "$1,535.41" $0.00 $0.00 $0.00 $0.00 "$3,218.50" "$4,870.80" "$5,149.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123656 ERX HCPCS 63700001 59572-0631-06 APREMILAST 30 MG PO TABS BOTH IP/OP $226.28 $167.45 $0.00 $181.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.14 $179.21 $181.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123657 ERX HCPCS 25000001 59572-0632-55 APREMILAST 10 & 20 & 30 MG PO TBPK BOTH IP/OP $246.85 $182.67 $0.00 $197.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.43 $195.51 $197.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123886 ERX HCPCS J0171 76329-9060-00 EPINEPHRINE 30 MG/30ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123899 ERX HCPCS 25000001 41167-0058-20 LIDOCAINE 4 % EX CREAM- LARGE TUBE BOTH IP/OP $41.35 $30.60 $0.00 $36.75 $0.00 $0.00 $0.00 $0.00 $0.00 $30.69 $30.69 $31.87 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $22.97 $36.38 $36.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 123951 ERX HCPCS J7327 59676-0820-01 HYALURONAN 88 MG/4ML I-ARTICULAR SOSY BOTH IP/OP "$89,496.00 " "$66,227.04" $0.00 "$3,135.61" "$1,830.60" "$1,830.60" $790.78 $790.78 $790.78 $847.87 "$3,019.27" "$3,019.27" "$3,135.61" $762.80 $847.77 $495.82 "$2,005.52" "$2,005.52" $807.98 "$1,845.00" "$2,922.48" "$2,952.00" "$1,115.78" "$1,115.78" $577.49 $0.00 $0.00 $587.45 $766.34 $0.00 $0.00 $0.00 $0.00 123968 ERX HCPCS J9308 00002-7669-01 RAMUCIRUMAB 100 MG/10ML IV SOLN BOTH IP/OP "$3,407.05 " "$2,521.22" $0.00 "$2,704.92" "$1,579.16" "$1,579.16" "$1,271.14" "$1,271.14" "$1,271.14" $710.11 "$2,604.56" "$2,604.56" "$2,704.92" "$1,253.80" "$1,473.22" $814.97 "$1,679.68" "$1,679.68" "$1,226.80" "$1,485.23" "$2,352.60" "$2,376.36" "$1,694.15" "$1,694.15" "$1,402.25" $0.00 $0.00 "$1,335.18" "$1,221.26" $0.00 $0.00 $0.00 $0.00 124207 ERX HCPCS 63700001 00378-0088-01 CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124207 ERX HCPCS 63700001 51079-0978-01 CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124207 ERX HCPCS 63700001 51079-0978-20 CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124207 ERX HCPCS 63700001 62756-0461-88 CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124207 ERX HCPCS 63700001 68084-0281-01 CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124207 ERX HCPCS 63700001 68084-0281-11 CARBIDOPA-LEVODOPA ER 25-100 MG PO TBCR BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124228 ERX HCPCS J3380 64764-0300-20 VEDOLIZUMAB 300 MG IV SOLR BOTH IP/OP "$19,734.23 " "$14,603.33" $0.00 "$16,123.82" "$9,413.23" "$9,413.23" "$6,387.90" "$6,387.90" "$6,387.90" "$4,113.11" "$15,525.55" "$15,525.55" "$16,123.82" "$6,383.70" "$7,500.85" "$4,149.41" "$9,728.98" "$9,728.98" "$6,257.16" "$8,275.01" "$13,107.62" "$13,240.02" "$8,640.84" "$8,640.84" "$7,134.60" $0.00 $0.00 "$6,793.35" "$6,197.40" $0.00 $0.00 $0.00 $0.00 124458 ERX HCPCS 63700001 00069-0830-38 SUNITINIB MALATE 37.5 MG PO CAPS BOTH IP/OP "$1,987.98 " "$1,471.11" $0.00 "$1,330.37" $0.00 $0.00 $0.00 $353.86 $0.00 $0.00 $0.00 $0.00 $0.00 $414.30 $0.00 $0.00 $0.00 $0.00 $831.48 "$1,317.06" "$1,330.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124486 ERX HCPCS J0875 57970-0100-01 DALBAVANCIN HCL 500 MG IV SOLR BOTH IP/OP "$4,415.57 " "$3,267.52" $0.00 "$3,505.62" "$2,046.61" "$2,046.61" "$1,589.10" "$1,589.10" "$1,589.10" $920.32 "$3,375.55" "$3,375.55" "$3,505.62" "$1,588.90" "$1,866.96" "$1,032.79" "$2,176.88" "$2,176.88" "$1,569.23" "$1,944.32" "$3,079.79" "$3,110.90" "$2,167.03" "$2,167.03" "$1,769.55" $0.00 $0.00 "$1,684.91" "$1,494.50" $0.00 $0.00 $0.00 $0.00 124555 ERX HCPCS 25000001 00536-1186-12 PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RECTAL SUPP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124599 ERX HCPCS 63700001 00006-3603-61 RALTEGRAVIR POTASSIUM 100 MG PO PACK BOTH IP/OP $28.50 $21.09 $0.00 $22.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124607 ERX HCPCS J8530 00054-0383-25 CYCLOPHOSPHAMIDE 50 MG PO CAPS BOTH IP/OP $71.99 $53.27 $0.00 $55.49 $0.00 $0.00 $0.00 $0.00 $0.00 $53.43 $53.43 $55.49 $0.00 $15.00 $0.00 $0.00 $0.00 $0.00 $32.65 $51.71 $52.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124728 ERX HCPCS 25000001 00310-6530-04 EXENATIDE ER 2 MG SC PEN BOTH IP/OP $584.48 $432.52 $0.00 $467.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.24 $462.91 $467.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124810 ERX HCPCS 25000001 69543-0268-10 VIRT-PHOS 250 NEUTRAL 155-852-130 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 125122 ERX HCPCS 63700001 49702-0231-13 TRIUMEQ:ABACAVIR-DOLUTEGRAVIR-LAMIVUD 600-50-300 MG PO TABS BOTH IP/OP $448.77 $332.09 $0.00 $295.94 $0.00 $0.00 $0.00 $79.88 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $0.00 $0.00 $0.00 $0.00 $184.96 $292.98 $295.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 125240 ERX HCPCS 63600001 57894-0061-03 USTEKINUMAB 90 MG/ML SC SOSY BOTH IP/OP "$65,605.50 " "$48,548.07" $0.00 "$53,299.42" $0.00 $0.00 $0.00 $0.00 $0.00 "$51,321.79" "$51,321.79" "$53,299.42" $0.00 "$13,672.19" $0.00 $0.00 $0.00 $0.00 "$28,391.90" "$44,972.77" "$45,427.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 125241 ERX HCPCS 63700001 58406-0435-01 ETANERCEPT 50 MG/ML SC SOSY BOTH IP/OP "$3,417.54 " "$2,528.98" $0.00 "$2,734.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.77" "$2,706.69" "$2,734.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 125244 ERX HCPCS 63600001 00006-4897-00 HAEMOPHILUS B POLYSAC CONJ VAC 7.5 MCG/0.5 ML IM SUSP BOTH IP/OP $129.34 $95.71 $0.00 $99.70 $0.00 $0.00 $0.00 $0.00 $0.00 $96.00 $96.00 $99.70 $0.00 $26.95 $0.00 $0.00 $0.00 $0.00 $54.83 $86.85 $87.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 125258 ERX HCPCS J7321 89130-4444-01 SODIUM HYALURONATE 25 MG/2.5ML I-ARTICULAR SOSY BOTH IP/OP $831.18 $615.07 $0.00 $640.67 $374.03 $374.03 $0.00 $0.00 $0.00 $173.24 $616.90 $616.90 $640.67 $0.00 $90.76 $0.00 $491.64 $491.64 $0.00 $366.18 $580.03 $585.89 $0.00 $0.00 $97.35 $0.00 $0.00 $92.69 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 00641-6142-25 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 00641-6188-01 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 00641-6188-10 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 42023-0213-25 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 42023-0214-01 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 42023-0214-10 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 63323-0751-01 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 70121-1577-01 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 70121-1577-05 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 125724 ERX HCPCS J2370 76014-0004-10 PHENYLEPHRINE HCL 50 MG/5 ML IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.96 $16.33 $16.33 $16.96 $0.00 $4.14 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 126034 ERX HCPCS J7188 00944-5001-01 OBIZUR:ANTIHEMOPHILIC FACTOR RPFVIII 500 UNITS IV SOLR BOTH IP/OP "$3,672.50 " "$2,717.65" $0.00 "$2,830.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,725.73" "$2,725.73" "$2,830.76" $0.00 $765.35 $0.00 $0.00 $0.00 $0.00 "$1,665.63" "$2,638.35" "$2,665.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126034 ERX HCPCS J7188 00944-5011-01 OBIZUR:ANTIHEMOPHILIC FACTOR RPFVIII 500 UNITS IV SOLR BOTH IP/OP "$3,672.50 " "$2,717.65" $0.00 "$2,830.76" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,725.73" "$2,725.73" "$2,830.76" $0.00 $765.35 $0.00 $0.00 $0.00 $0.00 "$1,665.63" "$2,638.35" "$2,665.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126056 ERX HCPCS 25000001 00005-0100-05 MENINGOCOCCAL B VAC (RECOMB) IM SUSY BOTH IP/OP $588.78 $435.70 $0.00 $453.83 $0.00 $0.00 $0.00 $0.00 $0.00 $436.99 $436.99 $453.83 $0.00 $122.70 $0.00 $0.00 $0.00 $0.00 $274.08 $434.13 $438.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126084 ERX HCPCS 25000001 42023-0164-25 VASOPRESSIN 20 UNIT/ML IV SOLN BOTH IP/OP $197.44 $146.11 $0.00 $179.23 $0.00 $0.00 $0.00 $0.00 $0.00 $146.54 $146.54 $152.19 $0.00 $41.15 $0.00 $0.00 $0.00 $0.00 $112.02 $177.44 $179.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126108 ERX HCPCS 25000001 08317-5411-00 GLUCOCARD SHINE W/DEVICE KIT BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126110 ERX HCPCS 25000001 08317-5400-50 GLUCOCARD SHINE TEST VI STRP BOTH IP/OP $75.42 $55.81 $0.00 $58.13 $0.00 $0.00 $0.00 $0.00 $0.00 $55.98 $55.98 $58.13 $0.00 $15.72 $0.00 $0.00 $0.00 $0.00 $34.20 $54.17 $54.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126226 ERX HCPCS J2547 61364-0181-03 PERAMIVIR 200 MG/20ML IV SOLN BOTH IP/OP "$1,109.60 " $821.10 $0.00 $855.28 $0.00 $0.00 $0.00 $0.00 $0.00 $823.55 $823.55 $855.28 $0.00 $231.24 $0.00 $0.00 $0.00 $0.00 $503.50 $797.54 $805.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126226 ERX HCPCS J2547 72769-0181-03 PERAMIVIR 200 MG/20ML IV SOLN BOTH IP/OP "$1,109.60 " $821.10 $0.00 $855.28 $0.00 $0.00 $0.00 $0.00 $0.00 $823.55 $823.55 $855.28 $0.00 $231.24 $0.00 $0.00 $0.00 $0.00 $503.50 $797.54 $805.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126229 ERX HCPCS 63700001 00173-0873-10 UMECLIDINIUM BROMIDE 62.5 MCG/INH IN AEPB BOTH IP/OP "$1,240.77 " $918.17 $0.00 $874.63 $0.00 $0.00 $0.00 $220.86 $0.00 $0.00 $0.00 $0.00 $0.00 $258.58 $0.00 $0.00 $0.00 $0.00 $546.65 $865.89 $874.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126242 ERX HCPCS J7313 68611-0190-02 FLUOCINOLONE ACETONIDE 0.19 MG INTRAVITREAL IMPL BOTH IP/OP "$23,865.60 " "$17,660.54" $0.00 "$18,395.60" $0.00 $0.00 $0.00 $0.00 $0.00 "$17,713.05" "$17,713.05" "$18,395.60" $0.00 "$10,960.39" $0.00 $0.00 $0.00 $0.00 "$10,824.00" "$17,145.22" "$17,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126317 ERX HCPCS 90651 00006-4119-01 HPV 9-VALENT RECOMB VACCINE IM SUSP BOTH IP/OP $888.19 $657.26 $0.00 $684.62 $399.69 $399.69 $0.00 $0.00 $229.60 $185.12 $659.21 $659.21 $684.62 $0.00 $297.98 $0.00 $525.36 $525.36 $0.00 $362.22 $573.75 $579.54 $434.66 $434.66 $267.82 $0.00 $0.00 $255.01 $0.00 $0.00 $0.00 $0.00 $0.00 126317 ERX HCPCS 90651 00006-4119-03 HPV 9-VALENT RECOMB VACCINE IM SUSP BOTH IP/OP $888.19 $657.26 $0.00 $684.62 $399.69 $399.69 $0.00 $0.00 $229.60 $185.12 $659.21 $659.21 $684.62 $0.00 $297.98 $0.00 $525.36 $525.36 $0.00 $362.22 $573.75 $579.54 $434.66 $434.66 $267.82 $0.00 $0.00 $255.01 $0.00 $0.00 $0.00 $0.00 $0.00 126371 ERX HCPCS J0695 67919-0030-01 CEFTOLOZANE-TAZOBACTAM 1.5 (1-0.5) G IV SOLR BOTH IP/OP $504.89 $373.62 $0.00 $389.17 $0.00 $0.00 $0.00 $0.00 $0.00 $374.73 $374.73 $389.17 $0.00 $105.22 $0.00 $0.00 $0.00 $0.00 $229.16 $362.98 $366.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126373 ERX HCPCS J9299 00003-3772-11 NIVOLUMAB 40 MG/4ML IV SOLN BOTH IP/OP "$3,064.28 " "$2,267.57" $0.00 "$2,409.19" "$1,406.51" "$1,406.51" "$1,169.80" "$1,169.80" "$1,169.80" $638.67 "$2,319.80" "$2,319.80" "$2,409.19" "$1,154.52" "$1,356.56" $750.44 "$1,510.69" "$1,510.69" "$1,167.81" "$1,349.00" "$2,136.81" "$2,158.39" "$1,612.69" "$1,612.69" "$1,323.52" $0.00 $0.00 "$1,260.22" "$1,141.36" $0.00 $0.00 $0.00 $0.00 126374 ERX HCPCS J9299 00003-3774-12 NIVOLUMAB 100 MG/10ML IV SOLN BOTH IP/OP "$7,660.64 " "$5,668.87" $0.00 "$6,022.92" "$3,516.24" "$3,516.24" "$2,924.50" "$2,924.50" "$2,924.50" "$1,596.67" "$5,799.45" "$5,799.45" "$6,022.92" "$2,886.30" "$3,391.40" "$1,876.10" "$3,776.70" "$3,776.70" "$2,919.53" "$3,372.48" "$5,342.01" "$5,395.97" "$4,031.73" "$4,031.73" "$3,308.80" $0.00 $0.00 "$3,150.54" "$2,853.40" $0.00 $0.00 $0.00 $0.00 126594 ERX HCPCS 90620 58160-0976-02 MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY BOTH IP/OP $704.90 $521.63 $0.00 $543.34 $317.21 $317.21 $0.00 $0.00 $171.96 $146.92 $523.18 $523.18 $543.34 $0.00 $225.31 $0.00 $416.95 $416.95 $0.00 $293.95 $465.61 $470.31 $352.73 $352.73 $200.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126594 ERX HCPCS 90620 58160-0976-20 MENINGOCOCCAL B RECOMB OMV ADJ IM SUSY BOTH IP/OP $704.90 $521.63 $0.00 $543.34 $317.21 $317.21 $0.00 $0.00 $171.96 $146.92 $523.18 $523.18 $543.34 $0.00 $225.31 $0.00 $416.95 $416.95 $0.00 $293.95 $465.61 $470.31 $352.73 $352.73 $200.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126697 ERX HCPCS J9271 00006-3026-02 PEMBROLIZUMAB 100 MG/4ML IV SOLN BOTH IP/OP "$13,924.39 " "$10,304.05" $0.00 "$10,732.92" "$6,265.98" "$6,265.98" "$5,230.00" "$5,230.00" "$5,230.00" "$2,902.19" "$10,334.68" "$10,334.68" "$10,732.92" "$5,275.40" "$6,198.60" "$3,429.01" "$6,864.72" "$6,864.72" "$5,185.85" "$6,070.01" "$9,472.82" "$9,712.01" "$7,161.41" "$7,161.41" "$5,905.55" $0.00 $0.00 "$5,623.09" "$5,092.70" $0.00 $0.00 $0.00 $0.00 126882 ERX HCPCS 63700001 59676-0575-30 PREZCOBIX:DARUNAVIR-COBICISTAT 800-150 MG PO TABS BOTH IP/OP $292.74 $216.63 $0.00 $203.44 $0.00 $0.00 $0.00 $55.03 $0.00 $0.00 $0.00 $0.00 $0.00 $61.01 $0.00 $0.00 $0.00 $0.00 $127.15 $201.41 $203.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126886 ERX HCPCS 63700002 68546-0317-30 GLATIRAMER ACETATE 20 MG/ML SC SOSY BOTH IP/OP $830.92 $614.88 $0.00 $640.47 $0.00 $0.00 $0.00 $0.00 $0.00 $616.71 $616.71 $640.47 $0.00 $173.16 $0.00 $0.00 $0.00 $0.00 $377.05 $597.24 $603.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126887 ERX HCPCS 25000001 00409-4093-01 CHROMIC CHLORIDE 40 MCG/10ML IV SOLN BOTH IP/OP $91.87 $67.98 $0.00 $70.81 $0.00 $0.00 $0.00 $0.00 $0.00 $68.19 $68.19 $70.81 $0.00 $19.15 $0.00 $0.00 $0.00 $0.00 $41.04 $65.01 $65.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126888 ERX HCPCS 25000001 63323-0086-05 POTASSIUM PHOSPHATES 15 MMOLE/5ML IV SOLN BOTH IP/OP $74.46 $55.10 $0.00 $57.39 $0.00 $0.00 $0.00 $0.00 $0.00 $55.26 $55.26 $57.39 $0.00 $15.52 $0.00 $0.00 $0.00 $0.00 $33.77 $53.48 $54.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126888 ERX HCPCS 25000001 65219-0052-29 POTASSIUM PHOSPHATES 15 MMOLE/5ML IV SOLN BOTH IP/OP $74.46 $55.10 $0.00 $57.39 $0.00 $0.00 $0.00 $0.00 $0.00 $55.26 $55.26 $57.39 $0.00 $15.52 $0.00 $0.00 $0.00 $0.00 $33.77 $53.48 $54.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126893 ERX HCPCS 25000001 00781-3040-95 PYRIDOSTIGMINE BROMIDE 10 MG/2ML IV SOLN BOTH IP/OP $32.18 $23.81 $0.00 $24.80 $0.00 $0.00 $0.00 $0.00 $0.00 $23.88 $23.88 $24.80 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $14.60 $23.12 $23.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126894 ERX HCPCS J0135 00074-4339-02 ADALIMUMAB 40 MG/0.8ML SC PNKT BOTH IP/OP "$8,092.86 " "$5,988.72" $0.00 "$6,699.59" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,451.01" "$6,451.01" "$6,699.59" $0.00 "$1,686.55" $0.00 $0.00 $0.00 $0.00 "$3,417.54" "$5,413.38" "$5,468.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126894 ERX HCPCS J0135 00074-4339-06 ADALIMUMAB 40 MG/0.8ML SC PNKT BOTH IP/OP "$8,092.86 " "$5,988.72" $0.00 "$6,699.59" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,451.01" "$6,451.01" "$6,699.59" $0.00 "$1,686.55" $0.00 $0.00 $0.00 $0.00 "$3,417.54" "$5,413.38" "$5,468.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126894 ERX HCPCS J0135 00074-4339-07 ADALIMUMAB 40 MG/0.8ML SC PNKT BOTH IP/OP "$8,092.86 " "$5,988.72" $0.00 "$6,699.59" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,451.01" "$6,451.01" "$6,699.59" $0.00 "$1,686.55" $0.00 $0.00 $0.00 $0.00 "$3,417.54" "$5,413.38" "$5,468.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126921 ERX HCPCS 25000001 00078-0639-68 SECUKINUMAB 150 MG/ML SC SOAJ BOTH IP/OP "$16,080.36 " "$11,899.47" $0.00 "$13,262.36" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$13,262.36" $0.00 "$3,351.15" $0.00 $0.00 $0.00 $0.00 "$6,815.97" "$10,796.49" "$10,905.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126934 ERX HCPCS 63700001 00003-3641-11 EVOTAZ:ATAZANAVIR-COBICISTAT 300-150 MG PO TABS BOTH IP/OP $222.84 $164.90 $0.00 $161.83 $0.00 $0.00 $0.00 $39.67 $0.00 $0.00 $0.00 $0.00 $0.00 $46.44 $0.00 $0.00 $0.00 $0.00 $101.15 $160.21 $161.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126960 ERX HCPCS 25000001 00069-0187-21 PALBOCICLIB 75 MG PO CAPS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126961 ERX HCPCS 25000001 00069-0188-21 PALBOCICLIB 100 MG PO CAPS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 126962 ERX HCPCS 25000001 00069-0189-21 PALBOCICLIB 125 MG PO CAPS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127008 ERX HCPCS 63700001 62856-0720-05 LENVATINIB (20 MG DAILY DOSE) 2 X 10 MG PO CPPK BOTH IP/OP "$2,109.61 " "$1,561.11" $0.00 "$1,460.82" $0.00 $0.00 $0.00 $385.82 $0.00 $0.00 $0.00 $0.00 $0.00 $439.64 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127008 ERX HCPCS 63700001 62856-0720-30 LENVATINIB (20 MG DAILY DOSE) 2 X 10 MG PO CPPK BOTH IP/OP "$2,109.61 " "$1,561.11" $0.00 "$1,460.82" $0.00 $0.00 $0.00 $385.82 $0.00 $0.00 $0.00 $0.00 $0.00 $439.64 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127009 ERX HCPCS 63700001 62856-0714-05 LENVATINIB (14 MG DAILY DOSE) 10 & 4 MG PO CPPK BOTH IP/OP "$1,189.20 " $880.01 $0.00 $806.50 $0.00 $0.00 $0.00 $217.49 $0.00 $0.00 $0.00 $0.00 $0.00 $247.83 $0.00 $0.00 $0.00 $0.00 $504.06 $798.43 $806.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127009 ERX HCPCS 63700001 62856-0714-30 LENVATINIB (14 MG DAILY DOSE) 10 & 4 MG PO CPPK BOTH IP/OP "$1,189.20 " $880.01 $0.00 $806.50 $0.00 $0.00 $0.00 $217.49 $0.00 $0.00 $0.00 $0.00 $0.00 $247.83 $0.00 $0.00 $0.00 $0.00 $504.06 $798.43 $806.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127013 ERX HCPCS 63700001 62856-0710-05 LENVATINIB (10 MG DAILY DOSE) 10 MG PO CPPK BOTH IP/OP "$2,109.61 " "$1,561.11" $0.00 "$1,460.82" $0.00 $0.00 $0.00 $385.82 $0.00 $0.00 $0.00 $0.00 $0.00 $439.64 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127013 ERX HCPCS 63700001 62856-0710-30 LENVATINIB (10 MG DAILY DOSE) 10 MG PO CPPK BOTH IP/OP "$2,109.61 " "$1,561.11" $0.00 "$1,460.82" $0.00 $0.00 $0.00 $385.82 $0.00 $0.00 $0.00 $0.00 $0.00 $439.64 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127014 ERX HCPCS 63700001 62856-0724-05 LENVATINIB (24 MG DAILY DOSE) 2 X 10 MG & 4 MG PO CPPK BOTH IP/OP $792.81 $586.68 $0.00 $537.66 $0.00 $0.00 $0.00 $144.99 $0.00 $0.00 $0.00 $0.00 $0.00 $165.22 $0.00 $0.00 $0.00 $0.00 $336.04 $532.29 $537.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127014 ERX HCPCS 63700001 62856-0724-30 LENVATINIB (24 MG DAILY DOSE) 2 X 10 MG & 4 MG PO CPPK BOTH IP/OP $792.81 $586.68 $0.00 $537.66 $0.00 $0.00 $0.00 $144.99 $0.00 $0.00 $0.00 $0.00 $0.00 $165.22 $0.00 $0.00 $0.00 $0.00 $336.04 $532.29 $537.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127054 ERX HCPCS 25000001 SCOPOLAMINE 1 MG/3DAYS TD PT72 (1 MG BASE) BOTH IP/OP $82.61 $61.13 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 $61.31 $61.31 $63.68 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $37.45 $59.32 $59.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127054 ERX HCPCS 25000001 00378-6470-16 SCOPOLAMINE 1 MG/3DAYS TD PT72 (1 MG BASE) BOTH IP/OP $82.61 $61.13 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 $61.31 $61.31 $63.68 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $37.45 $59.32 $59.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127054 ERX HCPCS 25000001 00378-6470-99 SCOPOLAMINE 1 MG/3DAYS TD PT72 (1 MG BASE) BOTH IP/OP $82.61 $61.13 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 $61.31 $61.31 $63.68 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $37.45 $59.32 $59.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127054 ERX HCPCS 25000001 10019-0553-03 SCOPOLAMINE 1 MG/3DAYS TD PT72 (1 MG BASE) BOTH IP/OP $82.61 $61.13 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 $61.31 $61.31 $63.68 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $37.45 $59.32 $59.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127054 ERX HCPCS 25000001 10019-0553-04 SCOPOLAMINE 1 MG/3DAYS TD PT72 (1 MG BASE) BOTH IP/OP $82.61 $61.13 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 $61.31 $61.31 $63.68 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $37.45 $59.32 $59.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127054 ERX HCPCS 25000001 45802-0580-84 SCOPOLAMINE 1 MG/3DAYS TD PT72 (1 MG BASE) BOTH IP/OP $82.61 $61.13 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 $61.31 $61.31 $63.68 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $37.45 $59.32 $59.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127054 ERX HCPCS 25000001 66758-0208-58 SCOPOLAMINE 1 MG/3DAYS TD PT72 (1 MG BASE) BOTH IP/OP $82.61 $61.13 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 $61.31 $61.31 $63.68 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $37.45 $59.32 $59.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127096 ERX HCPCS 25000001 PLENAMINE 15 % IV SOLN BOTH IP/OP "$1,448.32 " "$1,071.76" $0.00 "$1,116.37" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,074.94" "$1,074.94" "$1,116.37" $0.00 $301.83 $0.00 $0.00 $0.00 $0.00 $657.20 "$1,041.00" "$1,051.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127096 ERX HCPCS 25000001 00338-0502-06 PLENAMINE 15 % IV SOLN BOTH IP/OP "$1,448.32 " "$1,071.76" $0.00 "$1,116.37" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,074.94" "$1,074.94" "$1,116.37" $0.00 $301.83 $0.00 $0.00 $0.00 $0.00 $657.20 "$1,041.00" "$1,051.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 00143-9318-01 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 00143-9318-10 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 00409-3375-04 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 00409-3375-14 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 36000-0162-10 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 67457-0852-00 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 67457-0852-04 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127226 ERX HCPCS 25000001 70121-1576-07 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN BOTH IP/OP $94.65 $70.04 $0.00 $72.96 $0.00 $0.00 $0.00 $0.00 $0.00 $70.25 $70.25 $72.96 $0.00 $19.73 $0.00 $0.00 $0.00 $0.00 $42.49 $67.30 $67.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127500 ERX HCPCS J0714 00456-2700-10 CEFTAZIDIME-AVIBACTAM 2.5 (2-0.5) G IV SOLR BOTH IP/OP "$1,257.27 " $930.38 $0.00 $969.10 $0.00 $0.00 $0.00 $0.00 $0.00 $933.15 $933.15 $969.10 $0.00 $262.02 $0.00 $0.00 $0.00 $0.00 $570.51 $903.69 $912.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127503 ERX HCPCS 25000001 00469-0520-14 ISAVUCONAZONIUM SULFATE 186 MG PO CAPS BOTH IP/OP $668.17 $494.45 $0.00 $545.41 $0.00 $0.00 $0.00 $0.00 $0.00 $525.17 $525.17 $545.41 $0.00 $139.25 $0.00 $0.00 $0.00 $0.00 $294.36 $466.27 $470.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 127504 ERX HCPCS J1833 00469-0420-99 ISAVUCONAZONIUM SULFATE 372 MG IV SOLR BOTH IP/OP "$1,138.28 " $842.33 $0.00 $929.15 $0.00 $0.00 $0.00 $0.00 $0.00 $894.68 $894.68 $929.15 $0.00 $237.22 $0.00 $0.00 $0.00 $306.23 $501.48 $794.34 $802.36 $422.89 $422.89 $156.96 $0.00 $0.00 $159.67 $294.25 $0.00 $0.00 $0.00 $0.00 127505 ERX HCPCS J7297 00023-5858-01 LEVONORGESTREL 19.5 MCG/DAY IU IUD BOTH IP/OP "$2,266.18 " "$1,676.97" $0.00 "$1,812.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.09" "$1,794.81" "$1,812.94" "$1,359.71" "$1,359.71" $880.55 $0.00 $0.00 $838.43 $0.00 $0.00 $0.00 $0.00 $0.00 127687 ERX HCPCS 63700001 55513-0800-60 IVABRADINE HCL 5 MG PO TABS BOTH IP/OP $41.19 $30.48 $0.00 $28.22 $0.00 $0.00 $0.00 $7.76 $0.00 $0.00 $0.00 $0.00 $0.00 $8.58 $0.00 $0.00 $0.00 $0.00 $17.64 $27.94 $28.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 128092 ERX HCPCS J1610 63323-0593-03 GLUCAGON HCL 1 MG IJ SOLR BOTH IP/OP $343.73 $254.36 $0.00 $288.94 $154.68 $154.68 $166.77 $166.77 $166.77 $88.07 $255.12 $255.12 $264.95 $171.74 $201.79 $111.63 $203.32 $203.32 $209.24 $156.01 $247.12 $249.62 $288.94 $288.94 $255.63 $0.00 $0.00 $243.41 $199.13 $0.00 $0.00 $0.00 $0.00 128092 ERX HCPCS J1610 63323-0596-11 GLUCAGON HCL 1 MG IJ SOLR BOTH IP/OP $343.73 $254.36 $0.00 $288.94 $154.68 $154.68 $166.77 $166.77 $166.77 $88.07 $255.12 $255.12 $264.95 $171.74 $201.79 $111.63 $203.32 $203.32 $209.24 $156.01 $247.12 $249.62 $288.94 $288.94 $255.63 $0.00 $0.00 $243.41 $199.13 $0.00 $0.00 $0.00 $0.00 128092 ERX HCPCS J1610 63323-0596-13 GLUCAGON HCL 1 MG IJ SOLR BOTH IP/OP $343.73 $254.36 $0.00 $288.94 $154.68 $154.68 $166.77 $166.77 $166.77 $88.07 $255.12 $255.12 $264.95 $171.74 $201.79 $111.63 $203.32 $203.32 $209.24 $156.01 $247.12 $249.62 $288.94 $288.94 $255.63 $0.00 $0.00 $243.41 $199.13 $0.00 $0.00 $0.00 $0.00 128092 ERX HCPCS J1610 63323-0596-16 GLUCAGON HCL 1 MG IJ SOLR BOTH IP/OP $343.73 $254.36 $0.00 $288.94 $154.68 $154.68 $166.77 $166.77 $166.77 $88.07 $255.12 $255.12 $264.95 $171.74 $201.79 $111.63 $203.32 $203.32 $209.24 $156.01 $247.12 $249.62 $288.94 $288.94 $255.63 $0.00 $0.00 $243.41 $199.13 $0.00 $0.00 $0.00 $0.00 128482 ERX HCPCS C9460 10122-0620-01 CANGRELOR TETRASODIUM 50 MG IV SOLR BOTH IP/OP "$2,260.83 " "$1,673.01" $0.00 "$1,742.65" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.99" "$1,677.99" "$1,742.65" $0.00 $471.16 $0.00 $0.00 $0.00 $0.00 "$1,078.56" "$1,708.44" "$1,725.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 128482 ERX HCPCS C9460 10122-0620-10 CANGRELOR TETRASODIUM 50 MG IV SOLR BOTH IP/OP "$2,260.83 " "$1,673.01" $0.00 "$1,742.65" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.99" "$1,677.99" "$1,742.65" $0.00 $471.16 $0.00 $0.00 $0.00 $0.00 "$1,078.56" "$1,708.44" "$1,725.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 128545 ERX HCPCS 25000001 00078-0659-20 SACUBITRIL-VALSARTAN 24-26 MG PO TABS BOTH IP/OP $35.21 $26.06 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.61 $27.89 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 128546 ERX HCPCS 25000001 00078-0777-20 SACUBITRIL-VALSARTAN 49-51 MG PO TABS BOTH IP/OP $35.21 $26.06 $0.00 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.61 $27.89 $28.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 128547 ERX HCPCS 25000001 00078-0696-20 SACUBITRIL-VALSARTAN 97-103 MG PO TABS BOTH IP/OP $48.85 $36.15 $0.00 $40.29 $0.00 $0.00 $0.00 $0.00 $0.00 $38.79 $38.79 $40.29 $0.00 $10.18 $0.00 $0.00 $0.00 $0.00 $20.71 $32.80 $33.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 128559 ERX HCPCS 63700001 99999-6006-28 AMINOCAPROIC ACID 0.25 GM/ML PO SOLN BOTH IP/OP $338.69 $250.63 $0.00 "$5,500.63" $0.00 $0.00 $0.00 $60.29 $0.00 $0.00 $0.00 $0.00 $0.00 $70.58 $0.00 $0.00 $0.00 $0.00 "$3,437.90" $243.49 "$5,500.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 128559 ERX HCPCS 63700001 49411-0052-08 AMINOCAPROIC ACID 0.25 GM/ML PO SOLN BOTH IP/OP $338.69 $250.63 $0.00 "$5,500.63" $0.00 $0.00 $0.00 $60.29 $0.00 $0.00 $0.00 $0.00 $0.00 $70.58 $0.00 $0.00 $0.00 $0.00 "$3,437.90" "$5,445.63" "$5,500.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 128685 ERX HCPCS J2280 63323-0850-74 MOXIFLOXACIN HCL 400 MG/250ML IV SOLN BOTH IP/OP $191.72 $141.87 $0.00 $147.78 $0.00 $0.00 $0.00 $0.00 $0.00 $142.29 $142.29 $147.78 $0.00 $39.95 $0.00 $0.00 $0.00 $0.00 $87.02 $137.84 $139.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129082 ERX HCPCS Q5101 61314-0318-05 FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY BOTH IP/OP $961.37 $711.41 $0.00 $741.02 $0.00 $0.00 $0.00 $0.00 $0.00 $713.53 $713.53 $741.02 $0.00 $112.10 $0.00 $0.00 $0.00 $0.00 $436.24 $691.00 $697.98 $0.00 $0.00 $193.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129082 ERX HCPCS Q5101 61314-0318-10 FILGRASTIM-SNDZ 300 MCG/0.5ML IJ SOSY BOTH IP/OP $961.37 $711.41 $0.00 $741.02 $0.00 $0.00 $0.00 $0.00 $0.00 $713.53 $713.53 $741.02 $0.00 $112.10 $0.00 $0.00 $0.00 $0.00 $436.24 $691.00 $697.98 $0.00 $0.00 $193.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129083 ERX HCPCS Q5101 61314-0326-10 FILGRASTIM-SNDZ 480 MCG/0.8ML IJ SOSY BOTH IP/OP "$1,264.28 " $935.57 $0.00 "$1,011.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.14 "$1,001.31" "$1,011.42" $0.00 $0.00 $310.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129084 ERX HCPCS J9310 50242-0051-21 RITUXIMAB 100 MG/10ML IV SOLN BOTH IP/OP "$2,547.97 " "$1,885.50" $0.00 "$1,963.98" "$1,146.59" "$1,146.59" $856.33 $856.33 $856.33 $531.06 "$1,891.10" "$1,891.10" "$1,963.98" $869.37 "$1,021.51" $565.09 "$1,256.15" "$1,256.15" $994.00 "$1,155.61" "$1,830.49" "$1,848.98" "$1,372.67" "$1,372.67" "$1,109.32" $0.00 $0.00 "$1,056.26" $946.67 $0.00 $0.00 $0.00 $0.00 129085 ERX HCPCS J9310 50242-0053-06 RITUXIMAB 500 MG/50ML IV SOLN BOTH IP/OP "$12,739.85 " "$9,427.49" $0.00 "$9,819.88" "$5,732.93" "$5,732.93" "$4,281.65" "$4,281.65" "$4,281.65" "$2,655.30" "$9,455.52" "$9,455.52" "$9,819.88" "$4,346.85" "$5,107.55" "$2,825.45" "$6,280.75" "$6,280.75" "$4,970.02" "$5,778.03" "$9,152.40" "$9,244.85" "$6,863.36" "$6,863.36" "$5,546.59" $0.00 $0.00 "$5,281.30" "$4,733.35" $0.00 $0.00 $0.00 $0.00 129088 ERX HCPCS J3475 00409-6729-23 MAGNESIUM SULFATE 4 GM/100ML IV SOLN BOTH IP/OP $36.88 $27.29 $0.00 $28.43 $16.60 $16.60 $0.00 $0.00 $0.00 $0.47 $27.37 $27.37 $28.43 $0.00 $7.07 $0.00 $21.81 $21.81 $0.00 $16.53 $26.18 $26.45 $0.00 $0.00 $5.92 $0.00 $0.00 $5.64 $0.00 $0.00 $0.00 $0.00 $0.00 129091 ERX HCPCS J3475 00409-6730-13 MAGNESIUM SULFATE 4 GM/50ML IV SOLN BOTH IP/OP $52.71 $39.01 $0.00 $41.60 $23.72 $23.72 $0.00 $0.00 $0.00 $0.47 $39.12 $39.12 $40.63 $0.00 $7.07 $0.00 $31.18 $31.18 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $5.92 $0.00 $0.00 $5.64 $0.00 $0.00 $0.00 $0.00 $0.00 129092 ERX HCPCS J2505 55513-0190-01 PEGFILGRASTIM 6 MG/0.6ML SC SOSY BOTH IP/OP "$17,405.60 " "$12,880.14" $0.00 "$13,416.24" $0.00 $0.00 $0.00 $0.00 $0.00 "$12,918.44" "$12,918.44" "$13,416.24" $0.00 "$3,627.33" $0.00 $0.00 $0.00 "$4,654.18" "$7,664.21" "$12,140.10" "$12,262.73" "$6,427.20" "$6,427.20" "$5,002.09" $0.00 $0.00 "$4,762.84" "$3,807.30" $0.00 $0.00 $0.00 $0.00 129102 ERX HCPCS J3230 00641-1398-35 CHLORPROMAZINE HCL 50 MG/2ML IJ SOLN BOTH IP/OP $83.22 $61.58 $0.00 $64.15 $37.45 $37.45 $0.00 $0.00 $0.00 $9.35 $61.77 $61.77 $64.15 $0.00 $38.62 $0.00 $49.22 $49.22 $0.00 $37.74 $59.78 $60.38 $0.00 $0.00 $37.08 $0.00 $0.00 $35.31 $0.00 $0.00 $0.00 $0.00 $0.00 129103 ERX HCPCS 63700001 62175-0310-37 METHYLPHENIDATE HCL ER 18 MG PO TB24 BOTH IP/OP $26.08 $19.30 $0.00 $18.92 $0.00 $0.00 $0.00 $4.64 $0.00 $0.00 $0.00 $0.00 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $11.83 $18.73 $18.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129105 ERX HCPCS 63700001 00406-0136-01 METHYLPHENIDATE HCL ER 36 MG PO TB24 BOTH IP/OP $27.57 $20.40 $0.00 $20.01 $0.00 $0.00 $0.00 $4.91 $0.00 $0.00 $0.00 $0.00 $0.00 $5.75 $0.00 $0.00 $0.00 $0.00 $12.51 $19.81 $20.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129106 ERX HCPCS 63700001 00406-0154-01 METHYLPHENIDATE HCL ER 54 MG PO TB24 BOTH IP/OP $30.00 $22.20 $0.00 $21.77 $0.00 $0.00 $0.00 $5.34 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $13.61 $21.55 $21.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129107 ERX HCPCS J0881 55513-0057-04 DARBEPOETIN ALFA 25 MCG/0.42ML IJ SOSY BOTH IP/OP $678.03 $501.74 $0.00 $522.63 $305.11 $305.11 $77.35 $77.35 $77.35 $89.89 $503.23 $503.23 $522.63 $78.85 $92.65 $51.25 $401.05 $401.05 $101.12 $307.67 $487.34 $492.26 $139.64 $139.64 $112.21 $0.00 $0.00 $106.85 $94.65 $0.00 $0.00 $0.00 $0.00 129109 ERX HCPCS J0881 55513-0021-01 DARBEPOETIN ALFA 40 MCG/0.4ML IJ SOSY BOTH IP/OP "$1,084.84 " $802.78 $0.00 $836.19 $488.18 $488.18 $123.76 $123.76 $123.76 $143.82 $805.17 $805.17 $836.19 $126.16 $148.24 $82.00 $641.68 $641.68 $161.78 $492.27 $779.75 $787.62 $223.42 $223.42 $179.54 $0.00 $0.00 $170.95 $151.44 $0.00 $0.00 $0.00 $0.00 129109 ERX HCPCS J0881 55513-0021-04 DARBEPOETIN ALFA 40 MCG/0.4ML IJ SOSY BOTH IP/OP "$1,084.84 " $802.78 $0.00 $836.19 $488.18 $488.18 $123.76 $123.76 $123.76 $143.82 $805.17 $805.17 $836.19 $126.16 $148.24 $82.00 $641.68 $641.68 $161.78 $492.27 $779.75 $787.62 $223.42 $223.42 $179.54 $0.00 $0.00 $170.95 $151.44 $0.00 $0.00 $0.00 $0.00 129111 ERX HCPCS J0881 55513-0023-01 DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY BOTH IP/OP "$1,443.36 " "$1,068.09" $0.00 "$1,112.54" $649.51 $649.51 $185.64 $185.64 $185.64 $215.73 "$1,071.26" "$1,071.26" "$1,112.54" $189.24 $222.36 $123.01 $853.75 $853.75 $242.68 $668.74 "$1,059.28" "$1,069.98" $335.12 $335.12 $269.31 $0.00 $0.00 $256.43 $227.16 $0.00 $0.00 $0.00 $0.00 129111 ERX HCPCS J0881 55513-0023-04 DARBEPOETIN ALFA 60 MCG/0.3ML IJ SOSY BOTH IP/OP "$1,443.36 " "$1,068.09" $0.00 "$1,112.54" $649.51 $649.51 $185.64 $185.64 $185.64 $215.73 "$1,071.26" "$1,071.26" "$1,112.54" $189.24 $222.36 $123.01 $853.75 $853.75 $242.68 $668.74 "$1,059.28" "$1,069.98" $335.12 $335.12 $269.31 $0.00 $0.00 $256.43 $227.16 $0.00 $0.00 $0.00 $0.00 129113 ERX HCPCS J0881 55513-0025-01 DARBEPOETIN ALFA 100 MCG/0.5ML IJ SOSY BOTH IP/OP "$2,405.60 " "$1,780.14" $0.00 "$1,854.24" "$1,082.52" "$1,082.52" $309.40 $309.40 $309.40 $359.55 "$1,785.44" "$1,785.44" "$1,854.24" $315.40 $370.60 $205.01 "$1,185.96" "$1,185.96" $404.46 "$1,114.56" "$1,765.46" "$1,783.30" $558.54 $558.54 $448.85 $0.00 $0.00 $427.38 $378.60 $0.00 $0.00 $0.00 $0.00 129113 ERX HCPCS J0881 55513-0025-04 DARBEPOETIN ALFA 100 MCG/0.5ML IJ SOSY BOTH IP/OP "$2,405.60 " "$1,780.14" $0.00 "$1,854.24" "$1,082.52" "$1,082.52" $309.40 $309.40 $309.40 $359.55 "$1,785.44" "$1,785.44" "$1,854.24" $315.40 $370.60 $205.01 "$1,185.96" "$1,185.96" $404.46 "$1,114.56" "$1,765.46" "$1,783.30" $558.54 $558.54 $448.85 $0.00 $0.00 $427.38 $378.60 $0.00 $0.00 $0.00 $0.00 129115 ERX HCPCS J0881 55513-0027-04 DARBEPOETIN ALFA 150 MCG/0.3ML IJ SOSY BOTH IP/OP "$3,148.64 " "$2,329.99" $0.00 "$2,426.97" "$1,416.89" "$1,416.89" $464.10 $464.10 $464.10 $539.33 "$2,336.92" "$2,336.92" "$2,426.97" $473.10 $555.89 $307.52 "$1,552.28" "$1,552.28" $606.69 "$1,428.03" "$2,262.00" "$2,284.85" $837.81 $837.81 $673.28 $0.00 $0.00 $641.07 $567.90 $0.00 $0.00 $0.00 $0.00 129116 ERX HCPCS J0881 55513-0028-01 DARBEPOETIN ALFA 200 MCG/0.4ML IJ SOSY BOTH IP/OP "$4,198.18 " "$3,106.65" $0.00 "$3,235.96" "$1,889.18" "$1,889.18" $618.80 $618.80 $618.80 $719.10 "$3,115.89" "$3,115.89" "$3,235.96" $630.80 $741.19 $410.02 "$2,069.70" "$2,069.70" $808.92 "$1,904.04" "$3,016.00" "$3,046.46" "$1,117.08" "$1,117.08" $897.70 $0.00 $0.00 $854.76 $757.20 $0.00 $0.00 $0.00 $0.00 129117 ERX HCPCS J0881 55513-0111-01 DARBEPOETIN ALFA 300 MCG/0.6ML IJ SOSY BOTH IP/OP "$6,297.27 " "$4,659.98" $0.00 "$4,853.94" "$2,833.77" "$2,833.77" $928.20 $928.20 $928.20 "$1,078.65" "$4,673.83" "$4,673.83" "$4,853.94" $946.20 "$1,111.79" $615.03 "$3,104.55" "$3,104.55" "$1,213.38" "$2,856.06" "$4,524.00" "$4,569.70" "$1,675.62" "$1,675.62" "$1,346.55" $0.00 $0.00 "$1,282.14" "$1,135.80" $0.00 $0.00 $0.00 $0.00 129118 ERX HCPCS J0881 55513-0032-01 DARBEPOETIN ALFA 500 MCG/ML IJ SOSY BOTH IP/OP "$10,495.44 " "$7,766.63" $0.00 "$8,089.89" "$4,722.95" "$4,722.95" "$1,547.00" "$1,547.00" "$1,547.00" "$1,797.75" "$7,789.72" "$7,789.72" "$8,089.89" "$1,577.00" "$1,852.98" "$1,025.05" "$5,174.25" "$5,174.25" "$2,022.30" "$4,760.10" "$7,540.00" "$7,616.16" "$2,792.70" "$2,792.70" "$2,244.25" $0.00 $0.00 "$2,136.91" "$1,893.00" $0.00 $0.00 $0.00 $0.00 129167 ERX HCPCS 63700001 00186-0776-60 TICAGRELOR 60 MG PO TABS BOTH IP/OP $35.65 $26.38 $0.00 $23.90 $0.00 $0.00 $0.00 $6.35 $0.00 $0.00 $0.00 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $14.94 $23.66 $23.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129213 ERX HCPCS J2710 62295-3324-05 NEOSTIGMINE METHYLSULFATE 5 MG/5ML IV SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.12 $16.33 $16.33 $16.96 $0.00 $2.00 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.03 $0.00 $0.00 $1.94 $0.00 $0.00 $0.00 $0.00 $0.00 129243 ERX HCPCS 25000001 64842-1025-01 TRIFLURIDINE-TIPIRACIL 15-6.14 MG PO TABS BOTH IP/OP $628.00 $464.72 $0.00 $507.78 $0.00 $0.00 $0.00 $0.00 $0.00 $488.94 $488.94 $507.78 $0.00 $130.88 $0.00 $0.00 $0.00 $0.00 $273.35 $432.99 $437.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129243 ERX HCPCS 25000001 64842-1025-02 TRIFLURIDINE-TIPIRACIL 15-6.14 MG PO TABS BOTH IP/OP $628.00 $464.72 $0.00 $507.78 $0.00 $0.00 $0.00 $0.00 $0.00 $488.94 $488.94 $507.78 $0.00 $130.88 $0.00 $0.00 $0.00 $0.00 $273.35 $432.99 $437.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129243 ERX HCPCS 25000001 64842-1025-03 TRIFLURIDINE-TIPIRACIL 15-6.14 MG PO TABS BOTH IP/OP $628.00 $464.72 $0.00 $507.78 $0.00 $0.00 $0.00 $0.00 $0.00 $488.94 $488.94 $507.78 $0.00 $130.88 $0.00 $0.00 $0.00 $0.00 $273.35 $432.99 $437.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129244 ERX HCPCS 25000001 64842-1020-01 TRIFLURIDINE-TIPIRACIL 20-8.19 MG PO TABS BOTH IP/OP $837.34 $619.63 $0.00 $677.04 $0.00 $0.00 $0.00 $0.00 $0.00 $651.92 $651.92 $677.04 $0.00 $174.50 $0.00 $0.00 $0.00 $0.00 $364.47 $577.31 $583.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129244 ERX HCPCS 25000001 64842-1020-02 TRIFLURIDINE-TIPIRACIL 20-8.19 MG PO TABS BOTH IP/OP $837.34 $619.63 $0.00 $677.04 $0.00 $0.00 $0.00 $0.00 $0.00 $651.92 $651.92 $677.04 $0.00 $174.50 $0.00 $0.00 $0.00 $0.00 $364.47 $577.31 $583.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129244 ERX HCPCS 25000001 64842-1020-03 TRIFLURIDINE-TIPIRACIL 20-8.19 MG PO TABS BOTH IP/OP $837.34 $619.63 $0.00 $677.04 $0.00 $0.00 $0.00 $0.00 $0.00 $651.92 $651.92 $677.04 $0.00 $174.50 $0.00 $0.00 $0.00 $0.00 $364.47 $577.31 $583.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129506 ERX HCPCS J9352 59676-0610-01 TRABECTEDIN 1 MG IV SOLR BOTH IP/OP "$8,399.84 " "$6,215.88" $0.00 "$6,604.10" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,359.06" "$6,359.06" "$6,604.10" $0.00 "$3,819.09" $0.00 $0.00 $0.00 $0.00 "$3,734.96" "$5,916.18" "$5,975.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129598 ERX HCPCS J3490 00597-0197-05 IDARUCIZUMAB 2.5 GM/50ML IV SOLN BOTH IP/OP "$11,605.33 " "$8,587.94" $0.00 "$9,303.19" "$5,431.29" "$5,431.29" $0.00 $0.00 $0.00 "$2,418.84" "$8,958.01" "$8,958.01" "$9,303.19" $0.00 "$2,418.55" $0.00 "$5,721.43" "$5,721.43" $0.00 "$4,928.41" "$7,806.59" "$7,885.45" $0.00 $0.00 "$1,542.59" $0.00 $0.00 "$1,569.20" $0.00 $0.00 $0.00 $0.00 $0.00 129781 ERX HCPCS 63700001 53436-0084-04 PATIROMER SORBITEX CALCIUM 8.4 G PO PACK BOTH IP/OP $174.79 $129.34 $0.00 $134.40 $0.00 $0.00 $0.00 $31.11 $0.00 $0.00 $0.00 $0.00 $0.00 $36.43 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129834 ERX HCPCS 25000001 61958-1901-01 GENVOYA:150-150-200-10 MG PO TABLET BOTH IP/OP $481.67 $356.44 $0.00 $371.27 $0.00 $0.00 $0.00 $0.00 $0.00 $357.50 $357.50 $371.27 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $197.54 $312.90 $316.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129853 ERX HCPCS 25000001 50242-0717-01 COBIMETINIB FUMARATE 20 MG PO TABS BOTH IP/OP $448.32 $331.76 $0.00 $345.57 $0.00 $0.00 $0.00 $0.00 $0.00 $332.74 $332.74 $345.57 $0.00 $93.43 $0.00 $0.00 $0.00 $0.00 $203.48 $322.31 $325.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129873 ERX HCPCS 63700001 00310-1349-30 OSIMERTINIB MESYLATE 40 MG PO TABS BOTH IP/OP "$1,575.60 " "$1,165.94" $0.00 "$1,168.02" $0.00 $0.00 $0.00 $280.46 $0.00 $0.00 $0.00 $0.00 $0.00 $328.36 $0.00 $0.00 $0.00 $0.00 $730.01 "$1,156.34" "$1,168.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129874 ERX HCPCS 63700001 00310-1350-30 OSIMERTINIB MESYLATE 80 MG PO TABS BOTH IP/OP "$1,575.60 " "$1,165.94" $0.00 "$1,168.02" $0.00 $0.00 $0.00 $280.46 $0.00 $0.00 $0.00 $0.00 $0.00 $328.36 $0.00 $0.00 $0.00 $0.00 $730.01 "$1,156.34" "$1,168.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129889 ERX HCPCS J9145 57894-0502-05 DARATUMUMAB 100 MG/5ML IV SOLN BOTH IP/OP "$1,809.95 " "$1,339.36" $0.00 "$1,470.46" $858.47 $858.47 $572.22 $572.22 $572.22 $377.24 "$1,415.89" "$1,415.89" "$1,470.46" $575.52 $676.24 $374.09 $892.31 $892.31 $566.45 $800.19 "$1,267.49" "$1,280.30" $782.25 $782.25 $634.85 $0.00 $0.00 $604.49 $539.48 $0.00 $0.00 $0.00 $0.00 129890 ERX HCPCS J9145 57894-0502-20 DARATUMUMAB 400 MG/20ML IV SOLN BOTH IP/OP "$6,317.34 " "$4,674.83" $0.00 "$5,132.38" "$2,996.33" "$2,996.33" "$2,288.88" "$2,288.88" "$2,288.88" "$1,316.69" "$4,941.95" "$4,941.95" "$5,132.38" "$2,302.08" "$2,704.94" "$1,496.35" "$3,114.45" "$3,114.45" "$2,265.82" "$2,733.95" "$4,330.57" "$4,374.31" "$3,128.98" "$3,128.98" "$2,539.41" $0.00 $0.00 "$2,417.95" "$2,157.92" $0.00 $0.00 $0.00 $0.00 129908 ERX HCPCS 25000001 69547-0353-02 NALOXONE HCL 4 MG/0.1ML NA LIQD BOTH IP/OP $260.25 $192.59 $0.00 $200.60 $0.00 $0.00 $0.00 $0.00 $0.00 $193.16 $193.16 $200.60 $0.00 $54.24 $0.00 $0.00 $0.00 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129912 ERX HCPCS 63700001 63020-0078-02 IXAZOMIB CITRATE 2.3 MG PO CAPS BOTH IP/OP "$8,589.50 " "$6,356.23" $0.00 "$6,871.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,294.75" "$6,802.88" "$6,871.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129913 ERX HCPCS 63700001 63020-0079-02 IXAZOMIB CITRATE 3 MG PO CAPS BOTH IP/OP "$8,589.50 " "$6,356.23" $0.00 "$6,871.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,294.75" "$6,802.88" "$6,871.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129914 ERX HCPCS 63700001 63020-0080-02 IXAZOMIB CITRATE 4 MG PO CAPS BOTH IP/OP "$8,589.50 " "$6,356.23" $0.00 "$6,871.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,294.75" "$6,802.88" "$6,871.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129989 ERX HCPCS J1976 00003-2291-11 ELOTUZUMAB 300 MG IV SOLR BOTH IP/OP "$5,425.79 " "$4,015.08" $0.00 "$4,244.93" "$2,478.23" "$2,478.23" "$2,058.00" "$2,058.00" "$2,058.00" "$1,130.87" "$4,087.42" "$4,087.42" "$4,244.93" "$2,031.30" "$2,387.13" "$1,320.35" "$2,674.91" "$2,674.91" "$2,046.24" "$2,388.61" "$3,783.56" "$3,821.78" "$2,825.76" "$2,825.76" "$2,319.45" $0.00 $0.00 "$2,208.51" "$1,948.80" $0.00 $0.00 $0.00 $0.00 129990 ERX HCPCS J1976 00003-4522-11 ELOTUZUMAB 400 MG IV SOLR BOTH IP/OP "$7,234.36 " "$5,353.43" $0.00 "$5,659.88" "$3,304.29" "$3,304.29" "$2,744.00" "$2,744.00" "$2,744.00" "$1,507.82" "$5,449.87" "$5,449.87" "$5,659.88" "$2,708.40" "$3,182.84" "$1,760.46" "$3,566.54" "$3,566.54" "$2,728.32" "$3,184.80" "$5,044.72" "$5,095.68" "$3,767.68" "$3,767.68" "$3,092.60" $0.00 $0.00 "$2,944.68" "$2,598.40" $0.00 $0.00 $0.00 $0.00 130051 ERX HCPCS J9034 63459-0348-04 BENDAMUSTINE HCL 100 MG/4ML IV SOLN BOTH IP/OP "$6,708.95 " "$4,964.62" $0.00 "$5,171.26" "$3,019.03" "$3,019.03" "$1,907.60" "$1,907.60" "$1,907.60" "$1,398.31" "$4,979.38" "$4,979.38" "$5,171.26" "$1,964.60" "$2,308.29" "$1,276.99" "$3,307.51" "$3,307.51" "$2,399.15" "$3,042.78" "$4,819.76" "$4,868.44" "$3,313.11" "$3,313.11" "$2,553.28" $0.00 $0.00 "$2,431.15" "$2,284.90" $0.00 $0.00 $0.00 $0.00 130073 ERX HCPCS 25000001 50242-0130-01 ALECTINIB HCL 150 MG PO CAPS BOTH IP/OP $275.13 $203.60 $0.00 $742.38 $0.00 $0.00 $0.00 $0.00 $0.00 $714.84 $714.84 $742.38 $0.00 $57.34 $0.00 $0.00 $0.00 $0.00 $121.25 $192.05 $193.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130409 ERX HCPCS 25000001 00006-5423-12 SUGAMMADEX SODIUM 200 MG/2ML IV SOLN BOTH IP/OP $443.28 $328.03 $0.00 $358.71 $0.00 $0.00 $0.00 $0.00 $0.00 $345.41 $345.41 $358.71 $0.00 $92.38 $0.00 $0.00 $0.00 $0.00 $191.64 $303.56 $306.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130411 ERX HCPCS 25000001 00006-5423-15 SUGAMMADEX SODIUM 500 MG/5ML IV SOLN BOTH IP/OP $705.54 $522.10 $0.00 $570.97 $333.34 $333.34 $0.00 $0.00 $0.00 $147.05 $549.78 $549.78 $570.97 $0.00 $147.03 $0.00 $417.33 $417.33 $0.00 $304.97 $483.06 $487.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130411 ERX HCPCS 25000001 00006-5425-15 SUGAMMADEX SODIUM 500 MG/5ML IV SOLN BOTH IP/OP $705.54 $522.10 $0.00 $570.97 $333.34 $333.34 $0.00 $0.00 $0.00 $147.05 $549.78 $549.78 $570.97 $0.00 $147.03 $0.00 $417.33 $417.33 $0.00 $304.97 $483.06 $487.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130462 ERX HCPCS 63700001 63044-0150-05 PRENATAL VITAMIN PLUS LOW IRON 27-1 MG PO TABS BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130656 ERX HCPCS 25000001 69468-0151-04 URIDINE TRIACETATE 10 G PO PACK BOTH IP/OP "$10,883.26 " "$8,053.61" $0.00 "$8,388.82" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,388.82" $0.00 "$2,268.07" $0.00 $0.00 $0.00 $0.00 "$4,935.99" "$7,818.61" "$7,897.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130656 ERX HCPCS 25000001 69468-0151-20 URIDINE TRIACETATE 10 G PO PACK BOTH IP/OP "$10,883.26 " "$8,053.61" $0.00 "$8,388.82" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$8,388.82" $0.00 "$2,268.07" $0.00 $0.00 $0.00 $0.00 "$4,935.99" "$7,818.61" "$7,897.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130661 ERX HCPCS 25000001 00006-3074-02 ELBASVIR-GRAZOPREVIR 50-100 MG PO TABS BOTH IP/OP $911.04 $674.17 $0.00 $702.23 $0.00 $0.00 $0.00 $0.00 $0.00 $676.17 $676.17 $702.23 $0.00 $189.86 $0.00 $0.00 $0.00 $0.00 $413.40 $654.83 $661.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130884 ERX HCPCS J2020 00009-4992-01 LINEZOLID 600 MG/300ML IV SOLN BOTH IP/OP $270.66 $200.29 $0.00 $208.62 $0.00 $0.00 $0.00 $0.00 $0.00 $200.88 $200.88 $208.62 $0.00 $23.35 $0.00 $0.00 $0.00 $0.00 $122.85 $194.59 $196.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130884 ERX HCPCS J2020 00009-4992-02 LINEZOLID 600 MG/300ML IV SOLN BOTH IP/OP $270.66 $200.29 $0.00 $208.62 $0.00 $0.00 $0.00 $0.00 $0.00 $200.88 $200.88 $208.62 $0.00 $23.35 $0.00 $0.00 $0.00 $0.00 $122.85 $194.59 $196.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130884 ERX HCPCS J2020 00009-5140-04 LINEZOLID 600 MG/300ML IV SOLN BOTH IP/OP $270.66 $200.29 $0.00 $208.62 $0.00 $0.00 $0.00 $0.00 $0.00 $200.88 $200.88 $208.62 $0.00 $23.35 $0.00 $0.00 $0.00 $0.00 $122.85 $194.59 $196.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130884 ERX HCPCS J2020 00781-3433-95 LINEZOLID 600 MG/300ML IV SOLN BOTH IP/OP $270.66 $200.29 $0.00 $208.62 $0.00 $0.00 $0.00 $0.00 $0.00 $200.88 $200.88 $208.62 $0.00 $23.35 $0.00 $0.00 $0.00 $0.00 $122.85 $194.59 $196.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130884 ERX HCPCS J2020 25021-0169-87 LINEZOLID 600 MG/300ML IV SOLN BOTH IP/OP $270.66 $200.29 $0.00 $208.62 $0.00 $0.00 $0.00 $0.00 $0.00 $200.88 $200.88 $208.62 $0.00 $23.35 $0.00 $0.00 $0.00 $0.00 $122.85 $194.59 $196.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130884 ERX HCPCS J2020 55150-0242-51 LINEZOLID 600 MG/300ML IV SOLN BOTH IP/OP $270.66 $200.29 $0.00 $208.62 $0.00 $0.00 $0.00 $0.00 $0.00 $200.88 $200.88 $208.62 $0.00 $23.35 $0.00 $0.00 $0.00 $0.00 $122.85 $194.59 $196.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130884 ERX HCPCS J2020 63323-0713-13 LINEZOLID 600 MG/300ML IV SOLN BOTH IP/OP $270.66 $200.29 $0.00 $208.62 $0.00 $0.00 $0.00 $0.00 $0.00 $200.88 $200.88 $208.62 $0.00 $23.35 $0.00 $0.00 $0.00 $0.00 $122.85 $194.59 $196.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130886 ERX HCPCS J9065 63323-0140-10 CLADRIBINE 10 MG/10ML IV SOLN BOTH IP/OP "$1,351.98 " "$1,000.47" $0.00 "$1,042.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,003.44" "$1,003.44" "$1,042.11" $0.00 $211.77 $0.00 $0.00 $0.00 $0.00 $626.40 $992.22 "$1,002.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130887 ERX HCPCS 25000001 00074-4382-20 CISATRACURIUM BESYLATE (PF) 200 MG/20ML IV SOLN BOTH IP/OP "$1,040.69 " $770.11 $0.00 $802.16 $0.00 $0.00 $0.00 $0.00 $0.00 $772.40 $772.40 $802.16 $0.00 $216.88 $0.00 $0.00 $0.00 $0.00 $472.23 $748.01 $755.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130887 ERX HCPCS 25000001 00074-4382-93 CISATRACURIUM BESYLATE (PF) 200 MG/20ML IV SOLN BOTH IP/OP "$1,040.69 " $770.11 $0.00 $802.16 $0.00 $0.00 $0.00 $0.00 $0.00 $772.40 $772.40 $802.16 $0.00 $216.88 $0.00 $0.00 $0.00 $0.00 $472.23 $748.01 $755.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130897 ERX HCPCS J1455 76310-0024-01 FOSCARNET SODIUM 6000 MG/250ML IV SOLN BOTH IP/OP "$1,469.18 " "$1,087.19" $0.00 "$1,132.44" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,090.43" "$1,090.43" "$1,132.44" $0.00 $306.18 $0.00 $0.00 $0.00 $0.00 $680.70 "$1,078.23" "$1,089.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130897 ERX HCPCS J1455 76310-0024-11 FOSCARNET SODIUM 6000 MG/250ML IV SOLN BOTH IP/OP "$1,469.18 " "$1,087.19" $0.00 "$1,132.44" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,090.43" "$1,090.43" "$1,132.44" $0.00 $306.18 $0.00 $0.00 $0.00 $0.00 $680.70 "$1,078.23" "$1,089.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130897 ERX HCPCS J1455 76310-0024-15 FOSCARNET SODIUM 6000 MG/250ML IV SOLN BOTH IP/OP "$1,469.18 " "$1,087.19" $0.00 "$1,132.44" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,090.43" "$1,090.43" "$1,132.44" $0.00 $306.18 $0.00 $0.00 $0.00 $0.00 $680.70 "$1,078.23" "$1,089.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130897 ERX HCPCS J1455 76310-0024-25 FOSCARNET SODIUM 6000 MG/250ML IV SOLN BOTH IP/OP "$1,469.18 " "$1,087.19" $0.00 "$1,132.44" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,090.43" "$1,090.43" "$1,132.44" $0.00 $306.18 $0.00 $0.00 $0.00 $0.00 $680.70 "$1,078.23" "$1,089.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 00013-1114-21 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 39822-1000-01 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 39822-1001-06 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 39822-1001-07 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 47781-0601-91 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 55150-0188-10 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 63323-0563-10 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 67850-0042-10 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 70860-0400-10 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130900 ERX HCPCS 25000001 70860-0400-41 TRANEXAMIC ACID 1000 MG/10ML IV SOLN BOTH IP/OP $141.05 $104.38 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $104.69 $104.69 $108.72 $0.00 $29.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130905 ERX HCPCS J2704 00409-4699-30 PROPOFOL 200 MG/20ML IV EMUL BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $6.11 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $17.35 $17.35 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 130905 ERX HCPCS J2704 00409-4699-50 PROPOFOL 200 MG/20ML IV EMUL BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $6.11 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $17.35 $17.35 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 130905 ERX HCPCS J2704 00591-2136-95 PROPOFOL 200 MG/20ML IV EMUL BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $6.11 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $17.35 $17.35 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 130905 ERX HCPCS J2704 25021-0608-20 PROPOFOL 200 MG/20ML IV EMUL BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $6.11 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $17.35 $17.35 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 130905 ERX HCPCS J2704 43598-0265-20 PROPOFOL 200 MG/20ML IV EMUL BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $6.11 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $17.35 $17.35 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 130905 ERX HCPCS J2704 43598-0265-25 PROPOFOL 200 MG/20ML IV EMUL BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $6.11 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $17.35 $17.35 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 130905 ERX HCPCS J2704 43598-0265-58 PROPOFOL 200 MG/20ML IV EMUL BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $6.11 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $17.35 $17.35 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 130905 ERX HCPCS J2704 63323-0269-29 PROPOFOL 200 MG/20ML IV EMUL BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $6.11 $21.77 $21.77 $22.61 $0.00 $6.11 $0.00 $17.35 $17.35 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 131019 ERX HCPCS 63700001 61958-2101-01 ODEFSEY:EMTRICIT-RILPIV-TENOFOV AF 200-25-25 MG TAB BOTH IP/OP $438.35 $324.38 $0.00 $287.64 $0.00 $0.00 $0.00 $78.03 $0.00 $0.00 $0.00 $0.00 $0.00 $91.35 $0.00 $0.00 $0.00 $0.00 $179.78 $284.76 $287.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131430 ERX HCPCS 25000001 00299-3921-08 CETAPHIL GENTLE CLEANSER EX LIQD BOTH IP/OP $26.82 $19.85 $0.00 $20.67 $0.00 $0.00 $0.00 $0.00 $0.00 $19.91 $19.91 $20.67 $0.00 $5.59 $0.00 $0.00 $0.00 $0.00 $12.16 $19.26 $19.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131443 ERX HCPCS J1815 00002-8824-27 INSULIN REGULAR HUMAN (CONC) 500 UNIT/ML SC SOPN BOTH IP/OP $15.00 $11.10 $0.00 $302.08 $8.15 $8.15 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $8.87 $8.87 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.08 $0.00 $0.00 $0.00 $0.00 $0.00 131448 ERX HCPCS 63700001 50474-0470-66 BRIVARACETAM 25 MG PO TABS BOTH IP/OP $93.78 $69.40 $0.00 $66.05 $0.00 $0.00 $0.00 $17.84 $0.00 $0.00 $0.00 $0.00 $0.00 $19.54 $0.00 $0.00 $0.00 $0.00 $41.28 $65.39 $66.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131449 ERX HCPCS 25000001 50474-0570-09 BRIVARACETAM 50 MG PO TABS BOTH IP/OP $93.78 $69.40 $0.00 $77.27 $0.00 $0.00 $0.00 $0.00 $0.00 $74.41 $74.41 $77.27 $0.00 $19.54 $0.00 $0.00 $0.00 $0.00 $41.28 $65.39 $66.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131451 ERX HCPCS 25000001 50474-0770-09 BRIVARACETAM 100 MG PO TABS BOTH IP/OP $93.78 $69.40 $0.00 $77.27 $0.00 $0.00 $0.00 $0.00 $0.00 $74.41 $74.41 $77.27 $0.00 $19.54 $0.00 $0.00 $0.00 $0.00 $41.28 $65.39 $66.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131458 ERX HCPCS J2786 59310-0610-31 RESLIZUMAB 100 MG/10ML IV SOLN BOTH IP/OP "$2,682.17 " "$1,984.81" $0.00 "$2,067.42" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,990.71" "$1,990.71" "$2,067.42" $0.00 "$1,188.40" $0.00 $0.00 $0.00 $0.00 "$1,169.73" "$1,815.83" "$1,871.57" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131469 ERX HCPCS J0330 62295-3323-07 SUCCINYLCHOLINE CHLORIDE 200 MG/10ML IV SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 131499 ERX HCPCS 63700001 61958-2002-01 DESCOVY:EMTRICITABINE-TENOFOVIR AF 200-25 MG TAB BOTH IP/OP $282.99 $209.41 $0.00 $185.70 $0.00 $0.00 $0.00 $50.37 $0.00 $0.00 $0.00 $0.00 $0.00 $58.98 $0.00 $0.00 $0.00 $0.00 $116.07 $183.85 $185.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131521 ERX HCPCS J7183 68982-0182-02 WILATE:ANTIHEMOPHILIC FACTOR-VWF 1000-1000 UNITS IV KIT BOTH IP/OP "$4,113.20 " "$3,043.77" $0.00 "$3,170.45" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,052.82" "$3,052.82" "$3,170.45" $0.00 $857.19 $0.00 $0.00 $0.00 $0.00 "$1,722.00" "$2,727.65" "$2,755.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131529 ERX HCPCS 25000001 00074-0576-22 VENETOCLAX 100 MG PO TABS BOTH IP/OP $433.72 $320.95 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 $336.39 $336.39 $349.36 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $187.48 $296.97 $299.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131530 ERX HCPCS 25000001 00074-0579-28 VENETOCLAX 10 & 50 & 100 MG PO TBPK BOTH IP/OP "$7,555.64 " "$5,591.17" $0.00 "$6,085.96" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,085.96" $0.00 "$1,574.60" $0.00 $0.00 $0.00 $0.00 $119.41 $189.14 $191.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131538 ERX HCPCS 25000001 24571-0116-06 PHOXILLUM BK4/2.5 32-4-2.5-1 MEQ-MMOL/L IV SOLN BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131594 ERX HCPCS 63700001 42388-0024-26 CABOZANTINIB S-MALATE 20 MG PO TABS BOTH IP/OP "$2,244.27 " "$1,660.76" $0.00 "$1,547.63" $0.00 $0.00 $0.00 $429.44 $0.00 $0.00 $0.00 $0.00 $0.00 $467.71 $0.00 $0.00 $0.00 $0.00 $967.27 "$1,532.16" "$1,547.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131595 ERX HCPCS 63700001 42388-0025-26 CABOZANTINIB S-MALATE 40 MG PO TABS BOTH IP/OP "$2,244.27 " "$1,660.76" $0.00 "$1,547.63" $0.00 $0.00 $0.00 $429.44 $0.00 $0.00 $0.00 $0.00 $0.00 $467.71 $0.00 $0.00 $0.00 $0.00 $967.27 "$1,532.16" "$1,547.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131596 ERX HCPCS 63700001 42388-0023-26 CABOZANTINIB S-MALATE 60 MG PO TABS BOTH IP/OP "$2,244.27 " "$1,660.76" $0.00 "$1,547.63" $0.00 $0.00 $0.00 $429.44 $0.00 $0.00 $0.00 $0.00 $0.00 $467.71 $0.00 $0.00 $0.00 $0.00 $967.27 "$1,532.16" "$1,547.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131610 ERX HCPCS 63700001 24510-0115-10 OXYCODONE ER 13.5 MG PO C12A BOTH IP/OP $39.84 $29.48 $0.00 $26.30 $0.00 $0.00 $0.00 $7.79 $0.00 $0.00 $0.00 $0.00 $0.00 $8.30 $0.00 $0.00 $0.00 $0.00 $16.44 $26.04 $26.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131700 ERX HCPCS J9022 50242-0917-01 ATEZOLIZUMAB 1200 MG/20ML IV SOLN BOTH IP/OP "$25,682.24 " "$19,004.86" $0.00 "$20,587.71" "$12,019.29" "$12,019.29" "$9,549.12" "$9,549.12" "$9,549.12" "$5,352.82" "$19,823.82" "$19,823.82" "$20,587.71" "$9,569.88" "$11,244.61" "$6,220.42" "$12,661.34" "$12,661.34" "$9,703.01" "$11,308.67" "$17,912.93" "$18,093.86" "$13,399.39" "$13,399.39" "$8,138.89" $0.00 $0.00 "$8,138.89" "$9,240.96" $0.00 $0.00 $0.00 $0.00 131713 ERX HCPCS 63700001 62856-0708-05 LENVATINIB (8 MG DAILY DOSE) 2 X 4 MG PO CPPK BOTH IP/OP "$1,189.20 " $880.01 $0.00 "$1,460.82" $0.00 $0.00 $0.00 $217.49 $0.00 $0.00 $0.00 $0.00 $0.00 $247.83 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131713 ERX HCPCS 63700001 62856-0708-30 LENVATINIB (8 MG DAILY DOSE) 2 X 4 MG PO CPPK BOTH IP/OP "$1,189.20 " $880.01 $0.00 "$1,460.82" $0.00 $0.00 $0.00 $217.49 $0.00 $0.00 $0.00 $0.00 $0.00 $247.83 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131714 ERX HCPCS 63700001 62856-0718-05 LENVATINIB (18 MG DAILY DOSE) 10 MG & 2 X 4 MG PO CPPK BOTH IP/OP $792.81 $586.68 $0.00 $537.66 $0.00 $0.00 $0.00 $144.99 $0.00 $0.00 $0.00 $0.00 $0.00 $165.22 $0.00 $0.00 $0.00 $0.00 $336.04 $532.29 $537.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131714 ERX HCPCS 63700001 62856-0718-30 LENVATINIB (18 MG DAILY DOSE) 10 MG & 2 X 4 MG PO CPPK BOTH IP/OP $792.81 $586.68 $0.00 $537.66 $0.00 $0.00 $0.00 $144.99 $0.00 $0.00 $0.00 $0.00 $0.00 $165.22 $0.00 $0.00 $0.00 $0.00 $336.04 $532.29 $537.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131923 ERX HCPCS 25000001 00781-3269-71 EPHEDRINE SULFATE 50 MG/ML IV SOLN BOTH IP/OP $25.35 $18.76 $0.00 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.68 $20.08 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131923 ERX HCPCS 25000001 00781-3269-95 EPHEDRINE SULFATE 50 MG/ML IV SOLN BOTH IP/OP $25.35 $18.76 $0.00 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.68 $20.08 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131923 ERX HCPCS 25000001 42023-0216-25 EPHEDRINE SULFATE 50 MG/ML IV SOLN BOTH IP/OP $25.35 $18.76 $0.00 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.68 $20.08 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131923 ERX HCPCS 25000001 76014-0005-25 EPHEDRINE SULFATE 50 MG/ML IV SOLN BOTH IP/OP $25.35 $18.76 $0.00 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.68 $20.08 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131923 ERX HCPCS 25000001 76014-0005-30 EPHEDRINE SULFATE 50 MG/ML IV SOLN BOTH IP/OP $25.35 $18.76 $0.00 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.68 $20.08 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132039 ERX HCPCS J9047 76075-0102-01 CARFILZOMIB 30 MG IV SOLR BOTH IP/OP "$3,497.29 " "$2,587.99" $0.00 "$2,854.76" "$1,666.63" "$1,666.63" "$1,233.33" "$1,233.33" "$1,233.33" $728.92 "$2,748.83" "$2,748.83" "$2,854.76" "$1,233.09" "$1,448.88" $801.51 "$1,724.16" "$1,724.16" "$1,184.37" "$1,497.79" "$2,372.49" "$2,396.46" "$1,635.56" "$1,635.56" "$1,323.29" $0.00 $0.00 "$1,259.99" "$1,169.16" $0.00 $0.00 $0.00 $0.00 132135 ERX HCPCS 63700001 72626-2701-01 (EPCLUSA) SOFOSBUVIR-VELPATASVIR 400-100 MG PO TABS BOTH IP/OP "$1,001.15 " $740.85 $0.00 $726.86 $0.00 $0.00 $0.00 $178.20 $0.00 $0.00 $0.00 $0.00 $0.00 $208.64 $0.00 $0.00 $0.00 $0.00 $454.29 $719.60 $726.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132336 ERX HCPCS 25000001 00310-4600-39 BEVESPI:GLYCOPYRROLATE-FORMOTEROL 9-4.8 MCG/ACT IN AERO BOTH IP/OP "$1,354.27 " "$1,002.16" $0.00 "$1,043.87" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,005.14" "$1,005.14" "$1,043.87" $0.00 $282.23 $0.00 $0.00 $0.00 $0.00 $609.17 $964.92 $974.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132337 ERX HCPCS 90674 70461-0320-04 INFLUENZA VAC SUBUNIT QUAD 0.5 ML IM SUSY BOTH IP/OP $107.69 $79.69 $0.00 $86.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.72 $53.85 $85.29 $86.15 $15.72 $15.72 $16.85 $28.00 $28.00 $17.14 $28.00 $0.00 $0.00 $0.00 $0.00 132344 ERX HCPCS 25000001 00065-0426-36 GENTEAL TEARS 0.1-0.2-0.3 % OP SOLN BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $0.00 $0.00 $0.00 $0.00 $0.00 $22.39 $22.39 $23.26 $0.00 $6.29 $0.00 $0.00 $0.00 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132344 ERX HCPCS 25000001 00065-0426-37 GENTEAL TEARS 0.1-0.2-0.3 % OP SOLN BOTH IP/OP $30.17 $22.33 $0.00 $23.26 $0.00 $0.00 $0.00 $0.00 $0.00 $22.39 $22.39 $23.26 $0.00 $6.29 $0.00 $0.00 $0.00 $0.00 $13.68 $21.67 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132810 ERX HCPCS 25800001 63323-0820-74 FAT EMUL FISH OIL/PLANT BASED 20 % IV EMUL BOTH IP/OP $158.26 $117.11 $0.00 $121.99 $0.00 $0.00 $0.00 $0.00 $0.00 $117.46 $117.46 $121.99 $0.00 $32.98 $0.00 $0.00 $0.00 $0.00 $54.69 $86.63 $87.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132810 ERX HCPCS 25800001 63323-0820-50 FAT EMUL FISH OIL/PLANT BASED 20 % IV EMUL BOTH IP/OP $158.26 $117.11 $0.00 $121.99 $0.00 $0.00 $0.00 $0.00 $0.00 $117.46 $117.46 $121.99 $0.00 $32.98 $0.00 $0.00 $0.00 $0.00 $54.69 $113.65 $87.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132815 ERX HCPCS J3490 00517-0374-01 METHYLENE BLUE 50 MG/10ML IV SOLN BOTH IP/OP $833.84 $617.04 $0.00 $703.40 $410.65 $410.65 $0.00 $0.00 $0.00 $173.79 $677.30 $677.30 $703.40 $0.00 $173.77 $0.00 $493.22 $493.22 $0.00 $378.37 $599.34 $605.39 $0.00 $0.00 $118.43 $0.00 $0.00 $120.47 $0.00 $0.00 $0.00 $0.00 $0.00 132815 ERX HCPCS J3490 00517-0374-05 METHYLENE BLUE 50 MG/10ML IV SOLN BOTH IP/OP $833.84 $617.04 $0.00 $703.40 $410.65 $410.65 $0.00 $0.00 $0.00 $173.79 $677.30 $677.30 $703.40 $0.00 $173.77 $0.00 $493.22 $493.22 $0.00 $378.37 $599.34 $605.39 $0.00 $0.00 $118.43 $0.00 $0.00 $120.47 $0.00 $0.00 $0.00 $0.00 $0.00 132818 ERX HCPCS J2400 00143-9210-01 CHLOROPROCAINE HCL (PF) 3 % IJ SOLN BOTH IP/OP $103.68 $76.72 $0.00 $79.92 $0.00 $0.00 $0.00 $0.00 $0.00 $76.95 $76.95 $79.92 $0.00 $21.61 $0.00 $0.00 $0.00 $0.00 $47.01 $74.46 $75.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132818 ERX HCPCS J2400 00143-9210-10 CHLOROPROCAINE HCL (PF) 3 % IJ SOLN BOTH IP/OP $103.68 $76.72 $0.00 $79.92 $0.00 $0.00 $0.00 $0.00 $0.00 $76.95 $76.95 $79.92 $0.00 $21.61 $0.00 $0.00 $0.00 $0.00 $47.01 $74.46 $75.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132818 ERX HCPCS J2400 63323-0478-27 CHLOROPROCAINE HCL (PF) 3 % IJ SOLN BOTH IP/OP $103.68 $76.72 $0.00 $79.92 $0.00 $0.00 $0.00 $0.00 $0.00 $76.95 $76.95 $79.92 $0.00 $21.61 $0.00 $0.00 $0.00 $0.00 $47.01 $74.46 $75.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132822 ERX HCPCS J3246 25208-0002-02 TIROFIBAN HCL IN NACL 12.5-0.9 MG/250ML-% IV SOLN BOTH IP/OP $837.31 $619.61 $0.00 $645.40 $0.00 $0.00 $0.00 $0.00 $0.00 $621.45 $621.45 $645.40 $0.00 $174.50 $0.00 $0.00 $0.00 $0.00 $379.95 $601.83 $607.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132824 ERX HCPCS J2310 00409-1219-01 NALOXONE HCL 4 MG/10ML IJ SOLN BOTH IP/OP $478.77 $354.29 $0.00 $369.04 $215.45 $215.45 $0.00 $0.00 $0.00 $17.48 $355.34 $355.34 $369.04 $0.00 $51.39 $0.00 $283.19 $283.19 $0.00 $217.30 $344.20 $347.68 $0.00 $0.00 $62.42 $0.00 $0.00 $59.43 $0.00 $0.00 $0.00 $0.00 $0.00 132824 ERX HCPCS J2310 17478-0042-10 NALOXONE HCL 4 MG/10ML IJ SOLN BOTH IP/OP $478.77 $354.29 $0.00 $369.04 $215.45 $215.45 $0.00 $0.00 $0.00 $17.48 $355.34 $355.34 $369.04 $0.00 $51.39 $0.00 $283.19 $283.19 $0.00 $217.30 $344.20 $347.68 $0.00 $0.00 $62.42 $0.00 $0.00 $59.43 $0.00 $0.00 $0.00 $0.00 $0.00 132824 ERX HCPCS J2310 67457-0299-10 NALOXONE HCL 4 MG/10ML IJ SOLN BOTH IP/OP $478.77 $354.29 $0.00 $369.04 $215.45 $215.45 $0.00 $0.00 $0.00 $17.48 $355.34 $355.34 $369.04 $0.00 $51.39 $0.00 $283.19 $283.19 $0.00 $217.30 $344.20 $347.68 $0.00 $0.00 $62.42 $0.00 $0.00 $59.43 $0.00 $0.00 $0.00 $0.00 $0.00 132826 ERX HCPCS J7195 58394-0633-03 COAGULATION FACTOR IX (RECOMB) 250 UNITS IV KIT BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132827 ERX HCPCS J7195 58394-0634-03 COAGULATION FACTOR IX (RECOMB) 500 UNITS IV KIT BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132828 ERX HCPCS J7195 58394-0635-03 COAGULATION FACTOR IX (RECOMB BENEFIX) 1000 UNITS IV KIT BOTH IP/OP "$3,706.40 " "$2,742.74" $0.00 "$2,856.89" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,750.89" "$2,750.89" "$2,856.89" $0.00 $772.41 $0.00 $0.00 $0.00 $0.00 "$1,681.00" "$2,662.70" "$2,689.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132829 ERX HCPCS J7195 58394-0636-03 COAGULATION FACTOR IX (RECOMB) 2000 UNITS IV KIT BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132871 ERX HCPCS 63700001 65649-0150-90 METHYLNALTREXONE BROMIDE 150 MG PO TABS BOTH IP/OP $112.06 $82.92 $0.00 $69.82 $0.00 $0.00 $0.00 $19.95 $0.00 $0.00 $0.00 $0.00 $0.00 $23.35 $0.00 $0.00 $0.00 $0.00 $43.64 $69.12 $69.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 133343 ERX HCPCS 25000001 61703-0421-53 M.V.I. PEDIATRIC IV SOLR BOTH IP/OP $28.73 $21.26 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.37 $22.75 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 133367 ERX HCPCS J3358 57894-0054-27 USTEKINUMAB 130 MG/26ML IV SOLN BOTH IP/OP "$4,770.32 " "$3,530.04" $0.00 "$3,875.52" "$2,262.56" "$2,262.56" "$1,509.95" "$1,509.95" "$1,509.95" $994.25 "$3,731.72" "$3,731.72" "$3,875.52" "$1,518.40" "$1,784.12" $986.96 "$2,351.77" "$2,351.77" "$1,643.05" "$2,064.45" "$3,270.08" "$3,303.11" "$2,268.97" "$2,268.97" "$1,822.31" $0.00 $0.00 "$1,735.15" "$1,564.81" $0.00 $0.00 $0.00 $0.00 133767 ERX HCPCS 63700001 59310-0302-40 BECLOMETHASONE DIPROP HFA 40 MCG/ACT IN AERB BOTH IP/OP $699.80 $517.85 $0.00 $483.90 $0.00 $0.00 $0.00 $124.56 $0.00 $0.00 $0.00 $0.00 $0.00 $145.84 $0.00 $0.00 $0.00 $0.00 $302.44 $479.06 $483.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 133768 ERX HCPCS 63700001 59310-0304-80 BECLOMETHASONE DIPROP HFA 80 MCG/ACT IN AERB BOTH IP/OP $937.01 $693.39 $0.00 $647.92 $0.00 $0.00 $0.00 $166.79 $0.00 $0.00 $0.00 $0.00 $0.00 $195.27 $0.00 $0.00 $0.00 $0.00 $404.95 $641.44 $647.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 133781 ERX HCPCS Q5103 00069-0809-01 INFLIXIMAB-DYYB 100 MG IV SOLR BOTH IP/OP "$2,566.33 " "$1,899.08" $0.00 "$1,978.13" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,904.73" "$1,904.73" "$1,978.13" $0.00 $534.82 $0.00 $0.00 $0.00 $0.00 "$1,163.93" "$1,843.67" "$1,862.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 133797 ERX HCPCS J7999 42852-0862-25 NOREPINEPHRINE-SODIUM CHLORIDE 8-0.9 MG/250ML-% IV SOLN BOTH IP/OP $190.85 $141.23 $0.00 $147.11 $0.00 $0.00 $0.00 $0.00 $0.00 $141.65 $141.65 $147.11 $0.00 $39.77 $0.00 $0.00 $0.00 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $27.11 $0.00 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 133797 ERX HCPCS J7999 70324-0676-01 NOREPINEPHRINE-SODIUM CHLORIDE 8-0.9 MG/250ML-% IV SOLN BOTH IP/OP $190.85 $141.23 $0.00 $147.11 $0.00 $0.00 $0.00 $0.00 $0.00 $141.65 $141.65 $147.11 $0.00 $39.77 $0.00 $0.00 $0.00 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $27.11 $0.00 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 133797 ERX HCPCS J7999 76154-0475-15 NOREPINEPHRINE-SODIUM CHLORIDE 8-0.9 MG/250ML-% IV SOLN BOTH IP/OP $190.85 $141.23 $0.00 $147.11 $0.00 $0.00 $0.00 $0.00 $0.00 $141.65 $141.65 $147.11 $0.00 $39.77 $0.00 $0.00 $0.00 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $27.11 $0.00 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 133797 ERX HCPCS J7999 99999-6011-03 NOREPINEPHRINE-SODIUM CHLORIDE 8-0.9 MG/250ML-% IV SOLN BOTH IP/OP $190.85 $141.23 $0.00 $147.11 $0.00 $0.00 $0.00 $0.00 $0.00 $141.65 $141.65 $147.11 $0.00 $39.77 $0.00 $0.00 $0.00 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $27.11 $0.00 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 133838 ERX HCPCS J7296 50419-0424-01 LEVONORGESTREL 19.5 MG IU IUD BOTH IP/OP "$2,710.06 " "$2,005.44" $0.00 "$2,193.35" "$1,280.50" "$1,280.50" $0.00 $0.00 $915.37 $564.84 "$2,111.97" "$2,111.97" "$2,193.35" $0.00 "$1,174.15" $0.00 "$1,336.06" "$1,336.06" $0.00 "$1,172.82" "$1,857.75" "$1,876.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134020 ERX HCPCS J9285 00002-8926-01 OLARATUMAB 500 MG/50ML IV SOLN BOTH IP/OP "$6,041.76 " "$4,470.90" $0.00 "$4,833.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,020.88" "$4,785.07" "$4,833.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134049 ERX HCPCS J3246 25208-0001-04 TIROFIBAN HCL 3.75 MG/15ML IV CONC BOTH IP/OP $233.19 $172.56 $0.00 $179.74 $0.00 $0.00 $0.00 $0.00 $0.00 $173.07 $173.07 $179.74 $0.00 $48.60 $0.00 $0.00 $0.00 $0.00 $105.84 $167.65 $169.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134129 ERX HCPCS 63700001 61958-2301-01 TENOFOVIR ALAFENAMIDE FUMARATE 25 MG PO TABS BOTH IP/OP $180.13 $133.30 $0.00 $131.34 $0.00 $0.00 $0.00 $32.06 $0.00 $0.00 $0.00 $0.00 $0.00 $37.54 $0.00 $0.00 $0.00 $0.00 $82.09 $130.02 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134529 ERX HCPCS 25000001 62530-0000-11 UREA 15 G PO PACK BOTH IP/OP $17.60 $13.02 $0.00 $13.57 $0.00 $0.00 $0.00 $0.00 $0.00 $13.06 $13.06 $13.57 $0.00 $3.67 $0.00 $0.00 $0.00 $0.00 $7.98 $12.64 $12.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134557 ERX HCPCS 63600001 69660-0201-91 RUCAPARIB CAMSYLATE 200 MG PO TABS BOTH IP/OP $583.64 $431.89 $0.00 $449.87 $0.00 $0.00 $0.00 $0.00 $0.00 $433.18 $433.18 $449.87 $0.00 $121.63 $0.00 $0.00 $0.00 $0.00 $254.71 $403.46 $407.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134558 ERX HCPCS 63600001 69660-0203-91 RUCAPARIB CAMSYLATE 300 MG PO TABS BOTH IP/OP $583.64 $431.89 $0.00 $449.87 $0.00 $0.00 $0.00 $0.00 $0.00 $433.18 $433.18 $449.87 $0.00 $121.63 $0.00 $0.00 $0.00 $0.00 $254.71 $403.46 $407.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134827 ERX HCPCS J7999 71285-6044-01 OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN BOTH IP/OP $53.55 $39.63 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 $39.74 $39.74 $41.28 $0.00 $11.16 $0.00 $0.00 $0.00 $0.00 $24.29 $38.47 $38.86 $0.00 $0.00 $7.60 $0.00 $0.00 $7.73 $0.00 $0.00 $0.00 $0.00 $0.00 134827 ERX HCPCS J7999 99999-6006-08 OXYTOCIN-SODIUM CHLORIDE 30-0.9 UT/500ML-% IV SOLN BOTH IP/OP $53.55 $39.63 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 $39.74 $39.74 $41.28 $0.00 $11.16 $0.00 $0.00 $0.00 $0.00 $24.29 $38.47 $38.86 $0.00 $0.00 $7.60 $0.00 $0.00 $7.73 $0.00 $0.00 $0.00 $0.00 $0.00 134890 ERX HCPCS 25000001 00283-0679-02 BENZOCAINE 20 % MT AERO BOTH IP/OP $116.62 $86.30 $0.00 $113.96 $0.00 $0.00 $0.00 $0.00 $0.00 $86.56 $86.56 $89.89 $0.00 $24.30 $0.00 $0.00 $0.00 $0.00 $71.23 $112.82 $113.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134890 ERX HCPCS 25000001 00283-0679-60 BENZOCAINE 20 % MT AERO BOTH IP/OP $116.62 $86.30 $0.00 $113.96 $0.00 $0.00 $0.00 $0.00 $0.00 $86.56 $86.56 $89.89 $0.00 $24.30 $0.00 $0.00 $0.00 $0.00 $71.23 $112.82 $113.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134897 ERX HCPCS 25000001 63323-0170-05 SODIUM PHOSPHATES 15 MMOLE/5ML IV SOLN BOTH IP/OP $81.17 $60.07 $0.00 $62.57 $0.00 $0.00 $0.00 $0.00 $0.00 $60.24 $60.24 $62.57 $0.00 $16.92 $0.00 $0.00 $0.00 $0.00 $36.81 $58.30 $58.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134898 ERX HCPCS 25000001 00409-7391-72 SODIUM PHOSPHATES 45 MMOLE/15ML IV SOLN BOTH IP/OP $152.92 $113.16 $0.00 $117.87 $0.00 $0.00 $0.00 $0.00 $0.00 $113.50 $113.50 $117.87 $0.00 $31.87 $0.00 $0.00 $0.00 $0.00 $69.33 $109.82 $110.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134898 ERX HCPCS 25000001 63323-0170-15 SODIUM PHOSPHATES 45 MMOLE/15ML IV SOLN BOTH IP/OP $152.92 $113.16 $0.00 $117.87 $0.00 $0.00 $0.00 $0.00 $0.00 $113.50 $113.50 $117.87 $0.00 $31.87 $0.00 $0.00 $0.00 $0.00 $69.33 $109.82 $110.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 134923 ERX HCPCS J0461 00409-1630-10 ATROPINE SULFATE 1 MG/10ML IJ SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $0.89 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.94 $0.00 $0.00 $0.90 $0.00 $0.00 $0.00 $0.00 $0.00 134923 ERX HCPCS J0461 00409-1630-15 ATROPINE SULFATE 1 MG/10ML IJ SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $0.89 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.94 $0.00 $0.00 $0.90 $0.00 $0.00 $0.00 $0.00 $0.00 134923 ERX HCPCS J0461 00409-4911-11 ATROPINE SULFATE 1 MG/10ML IJ SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $0.89 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.94 $0.00 $0.00 $0.90 $0.00 $0.00 $0.00 $0.00 $0.00 134923 ERX HCPCS J0461 00409-4911-34 ATROPINE SULFATE 1 MG/10ML IJ SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $0.89 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.94 $0.00 $0.00 $0.90 $0.00 $0.00 $0.00 $0.00 $0.00 134923 ERX HCPCS J0461 76329-3339-01 ATROPINE SULFATE 1 MG/10ML IJ SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $0.89 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.94 $0.00 $0.00 $0.90 $0.00 $0.00 $0.00 $0.00 $0.00 134969 ERX HCPCS J0461 00641-6006-01 ATROPINE SULFATE 8 MG/20ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $1.79 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.88 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $0.00 134969 ERX HCPCS J0461 00641-6006-10 ATROPINE SULFATE 8 MG/20ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $1.79 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.88 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $0.00 135137 ERX HCPCS 25000001 00121-1971-00 ACETAMINOPHEN 650 MG/20.3ML PO SOLN BOTH IP/OP $10.21 $7.56 $0.00 $7.87 $0.00 $0.00 $0.00 $0.00 $0.00 $7.58 $7.58 $7.87 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $4.63 $7.33 $7.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135137 ERX HCPCS 25000001 00121-1971-21 ACETAMINOPHEN 650 MG/20.3ML PO SOLN BOTH IP/OP $10.21 $7.56 $0.00 $7.87 $0.00 $0.00 $0.00 $0.00 $0.00 $7.58 $7.58 $7.87 $0.00 $2.13 $0.00 $0.00 $0.00 $0.00 $4.63 $7.33 $7.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135307 ERX HCPCS J9285 00002-7190-01 OLARATUMAB 190 MG/19ML IV SOLN BOTH IP/OP "$2,295.87 " "$1,698.94" $0.00 "$1,836.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,147.94" "$1,818.33" "$1,836.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135334 ERX HCPCS 25000001 61938-0456-03 CALFACTANT IN NACL 35-0.9 MG/ML-% INTRATRACHEA SUSP BOTH IP/OP "$1,412.54 " "$1,045.28" $0.00 "$1,088.79" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,048.39" "$1,048.39" "$1,088.79" $0.00 $294.37 $0.00 $0.00 $0.00 $0.00 $617.40 $977.96 $987.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135357 ERX HCPCS 25000001 70183-0125-84 TELOTRISTAT ETHYL(AS ETIPRATE) 250 MG PO TABS BOTH IP/OP $295.16 $218.42 $0.00 $236.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.58 $233.77 $236.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135365 ERX HCPCS 25000001 49348-0274-72 SM DOUBLE ANTIBIOTIC 500-10000 UNIT/GM EX OINT BOTH IP/OP $13.93 $10.31 $0.00 $10.74 $0.00 $0.00 $0.00 $0.00 $0.00 $10.34 $10.34 $10.74 $0.00 $2.90 $0.00 $0.00 $0.00 $0.00 $6.32 $10.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135444 ERX HCPCS 25000001 51754-1006-01 NITROPRUSSIDE SODIUM-NACL 50-0.9 MG/100ML-% IV SOLN BOTH IP/OP $229.02 $169.47 $0.00 $176.53 $0.00 $0.00 $0.00 $0.00 $0.00 $169.98 $169.98 $176.53 $0.00 $47.73 $0.00 $0.00 $0.00 $0.00 $103.95 $164.66 $166.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135513 ERX HCPCS C9399 44087-3535-01 AVELUMAB 200 MG/10ML IV SOLN BOTH IP/OP "$4,617.41 " "$3,416.88" $0.00 "$3,612.48" "$2,109.00" "$2,109.00" $0.00 $0.00 $834.23 $962.38 "$3,478.44" "$3,478.44" "$3,612.48" $0.00 $962.27 $0.00 "$2,276.38" "$2,276.38" $0.00 "$2,022.78" "$3,204.08" "$3,236.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135585 ERX HCPCS J2260 00143-9719-01 MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN BOTH IP/OP $143.21 $105.98 $0.00 $110.39 $64.44 $64.44 $0.00 $0.00 $0.00 $29.85 $106.29 $106.29 $110.39 $0.00 $8.87 $0.00 $84.71 $84.71 $0.00 $60.73 $96.19 $97.16 $0.00 $0.00 $7.19 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 135585 ERX HCPCS J2260 00143-9719-10 MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN BOTH IP/OP $143.21 $105.98 $0.00 $110.39 $64.44 $64.44 $0.00 $0.00 $0.00 $29.85 $106.29 $106.29 $110.39 $0.00 $8.87 $0.00 $84.71 $84.71 $0.00 $60.73 $96.19 $97.16 $0.00 $0.00 $7.19 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 135585 ERX HCPCS J2260 00338-6010-48 MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN BOTH IP/OP $143.21 $105.98 $0.00 $110.39 $64.44 $64.44 $0.00 $0.00 $0.00 $29.85 $106.29 $106.29 $110.39 $0.00 $8.87 $0.00 $84.71 $84.71 $0.00 $60.73 $96.19 $97.16 $0.00 $0.00 $7.19 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 135585 ERX HCPCS J2260 00409-2776-23 MILRINONE LACTATE IN DEXTROSE 20-5 MG/100ML-% IV SOLN BOTH IP/OP $143.21 $105.98 $0.00 $110.39 $64.44 $64.44 $0.00 $0.00 $0.00 $29.85 $106.29 $106.29 $110.39 $0.00 $8.87 $0.00 $84.71 $84.71 $0.00 $60.73 $96.19 $97.16 $0.00 $0.00 $7.19 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 135586 ERX HCPCS 25000001 00065-0092-65 FLUORESCEIN SODIUM 10 % IV SOLN BOTH IP/OP $38.24 $28.30 $0.00 $29.48 $0.00 $0.00 $0.00 $0.00 $0.00 $28.38 $28.38 $29.48 $0.00 $7.97 $0.00 $0.00 $0.00 $0.00 $17.34 $27.47 $27.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135586 ERX HCPCS 25000001 17478-0253-10 FLUORESCEIN SODIUM 10 % IV SOLN BOTH IP/OP $38.24 $28.30 $0.00 $29.48 $0.00 $0.00 $0.00 $0.00 $0.00 $28.38 $28.38 $29.48 $0.00 $7.97 $0.00 $0.00 $0.00 $0.00 $17.34 $27.47 $27.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135587 ERX HCPCS 25000001 17478-0250-20 FLUORESCEIN SODIUM 25 % IV SOLN BOTH IP/OP $176.12 $130.33 $0.00 $135.75 $0.00 $0.00 $0.00 $0.00 $0.00 $130.72 $130.72 $135.75 $0.00 $36.70 $0.00 $0.00 $0.00 $0.00 $79.85 $126.48 $127.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 135612 ERX HCPCS J2350 50242-0150-01 OCRELIZUMAB 300 MG/10ML IV SOLN BOTH IP/OP "$46,186.47 " "$34,177.99" $0.00 "$37,202.57" "$21,719.20" "$21,719.20" "$17,672.10" "$17,672.10" "$17,672.10" "$9,417.94" "$35,822.19" "$35,822.19" "$37,202.57" "$17,487.30" "$20,547.58" "$11,366.75" "$22,769.93" "$22,769.93" "$18,086.36" "$19,987.50" "$31,660.20" "$31,980.00" "$24,976.40" "$24,976.40" "$8,138.89" $0.00 $0.00 "$8,138.89" "$17,225.10" $0.00 $0.00 $0.00 $0.00 136063 ERX HCPCS J8999 00069-0193-01 BOSUTINIB 400 MG PO TABS BOTH IP/OP "$1,798.68 " "$1,331.02" $0.00 "$1,386.42" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,334.98" "$1,334.98" "$1,386.42" $0.00 $374.84 $0.00 $0.00 $0.00 $0.00 $752.31 "$1,191.65" "$1,203.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 136139 ERX HCPCS 63700001 69656-0103-90 NIRAPARIB TOSYLATE 100 MG PO CAPS BOTH IP/OP $591.01 $437.35 $0.00 $468.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 136459 ERX HCPCS J9355 50242-0132-01 TRASTUZUMAB 150 MG IV SOLR BOTH IP/OP "$4,226.43 " "$3,127.56" $0.00 "$3,257.73" "$1,901.89" "$1,901.89" "$1,296.15" "$1,296.15" "$1,296.15" "$1,086.41" "$3,136.86" "$3,136.86" "$3,257.73" "$1,347.17" "$1,582.92" $875.66 "$2,083.63" "$2,083.63" "$1,679.30" "$1,916.86" "$3,036.30" "$3,066.97" "$2,319.03" "$2,319.03" "$1,865.78" $0.00 $0.00 "$1,776.54" "$1,534.76" $0.00 $0.00 $0.00 $0.00 136518 ERX HCPCS 63700001 00078-0698-51 MIDOSTAURIN 25 MG PO CAPS BOTH IP/OP "$1,184.06 " $876.20 $0.00 $814.85 $0.00 $0.00 $0.00 $222.36 $0.00 $0.00 $0.00 $0.00 $0.00 $246.76 $0.00 $0.00 $0.00 $0.00 $509.28 $806.70 $814.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 136518 ERX HCPCS 63700001 00078-0698-99 MIDOSTAURIN 25 MG PO CAPS BOTH IP/OP "$1,184.06 " $876.20 $0.00 $814.85 $0.00 $0.00 $0.00 $222.36 $0.00 $0.00 $0.00 $0.00 $0.00 $246.76 $0.00 $0.00 $0.00 $0.00 $509.28 $806.70 $814.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 136524 ERX HCPCS J9173 00310-4500-12 DURVALUMAB 120 MG/2.4ML IV SOLN BOTH IP/OP "$2,457.60 " "$1,818.62" $0.00 "$1,894.32" "$1,105.92" "$1,105.92" $922.31 $922.31 $922.31 $512.23 "$1,824.03" "$1,824.03" "$1,894.32" $922.36 "$1,083.77" $599.53 "$1,211.60" "$1,211.60" $940.41 "$1,098.15" "$1,739.46" "$1,757.03" "$1,298.67" "$1,298.67" "$1,065.68" $0.00 $0.00 "$1,014.71" $895.63 $0.00 $0.00 $0.00 $0.00 136525 ERX HCPCS J9173 00310-4611-50 DURVALUMAB 500 MG/10ML IV SOLN BOTH IP/OP "$10,239.93 " "$7,577.55" $0.00 "$7,892.94" "$4,607.97" "$4,607.97" "$3,842.95" "$3,842.95" "$3,842.95" "$2,134.26" "$7,600.08" "$7,600.08" "$7,892.94" "$3,843.15" "$4,515.70" "$2,498.05" "$5,048.29" "$5,048.29" "$3,918.39" "$4,575.58" "$7,247.72" "$7,320.93" "$5,411.11" "$5,411.11" "$4,440.33" $0.00 $0.00 "$4,227.95" "$3,731.80" $0.00 $0.00 $0.00 $0.00 136642 ERX HCPCS 25000001 56151-1625-01 GLUCOSE 15 GM/32ML PO GEL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 136839 ERX HCPCS J9017 63459-0601-06 ARSENIC TRIOXIDE 12 MG/6ML IV SOLN BOTH IP/OP "$5,784.05 " "$4,280.20" $0.00 "$2,229.18" "$1,301.41" "$1,301.41" $153.73 $153.73 $153.73 $602.77 "$2,146.46" "$2,146.46" "$2,229.18" $157.37 $184.91 $102.29 "$1,425.77" "$1,425.77" $558.36 "$1,095.93" "$1,735.95" "$1,753.49" $771.06 $771.06 $621.39 $0.00 $0.00 $591.67 $344.03 $0.00 $0.00 $0.00 $0.00 137000 ERX HCPCS J9311 50242-0108-01 RITUXIMAB-HYALURONIDASE HUMAN 1400-23400 MG -UT/11.7ML SC SOLN BOTH IP/OP "$17,835.69 " "$13,198.41" $0.00 "$13,747.75" $0.00 $0.00 $0.00 $0.00 $0.00 "$13,237.65" "$13,237.65" "$13,747.75" $0.00 "$6,241.13" $0.00 $0.00 $0.00 $0.00 "$8,089.20" "$12,813.28" "$12,942.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137001 ERX HCPCS J9311 50242-0109-01 RITUXIMAB-HYALURONIDASE HUMAN 1600-26800 MG -UT/13.4ML SC SOLN BOTH IP/OP "$20,383.65 " "$15,083.90" $0.00 "$15,711.72" $0.00 $0.00 $0.00 $0.00 $0.00 "$15,128.75" "$15,128.75" "$15,711.72" $0.00 "$7,132.72" $0.00 $0.00 $0.00 $0.00 "$9,244.80" "$14,643.76" "$14,791.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137149 ERX HCPCS Q5104 00006-4305-01 INFLIXIMAB-ABDA 100 MG IV SOLR BOTH IP/OP "$2,341.55 " "$1,732.75" $0.00 "$1,804.87" "$1,053.70" "$1,053.70" $395.84 $395.84 $395.84 $488.04 "$1,737.90" "$1,737.90" "$1,804.87" $387.92 $455.81 $252.15 "$1,154.38" "$1,154.38" $560.65 "$1,084.89" "$1,718.46" "$1,735.82" $774.23 $774.23 $608.06 $0.00 $0.00 $578.98 $533.95 $0.00 $0.00 $0.00 $0.00 137149 ERX HCPCS Q5104 00006-4305-02 INFLIXIMAB-ABDA 100 MG IV SOLR BOTH IP/OP "$2,341.55 " "$1,732.75" $0.00 "$1,804.87" "$1,053.70" "$1,053.70" $395.84 $395.84 $395.84 $488.04 "$1,737.90" "$1,737.90" "$1,804.87" $387.92 $455.81 $252.15 "$1,154.38" "$1,154.38" $560.65 "$1,084.89" "$1,718.46" "$1,735.82" $774.23 $774.23 $608.06 $0.00 $0.00 $578.98 $533.95 $0.00 $0.00 $0.00 $0.00 137213 ERX HCPCS 25000001 70437-0240-26 NERATINIB MALEATE 40 MG PO TABS BOTH IP/OP $319.78 $236.64 $0.00 $246.49 $0.00 $0.00 $0.00 $0.00 $0.00 $237.34 $237.34 $246.49 $0.00 $66.64 $0.00 $0.00 $0.00 $0.00 $145.15 $229.91 $232.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137683 ERX HCPCS 25000001 99999-6004-60 CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137683 ERX HCPCS 25000001 99999-6010-66 CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137683 ERX HCPCS 25000001 00121-0766-16 CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP BOTH IP/OP $11.00 $8.14 $0.00 $37.02 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $37.02 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137683 ERX HCPCS 25000001 00054-3117-63 CALCIUM CARBONATE ANTACID 1250 MG/5ML PO SUSP BOTH IP/OP $11.00 $8.14 $0.00 $37.62 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $37.62 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137687 ERX HCPCS 25000001 00023-4554-30 CARBOXYMETHYLCELLULOSE SOD PF 1 % OP GEL BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137688 ERX HCPCS J0401 59148-0045-80 ARIPIPRAZOLE ER 300 MG IM PRSY BOTH IP/OP "$4,858.15 " "$3,595.03" $0.00 "$4,003.03" "$2,337.01" "$2,337.01" "$1,797.00" "$1,797.00" "$1,797.00" "$1,012.56" "$3,854.50" "$3,854.50" "$4,003.03" "$1,801.80" "$2,117.12" "$1,171.17" "$2,395.07" "$2,395.07" $0.00 "$1,119.17" "$1,772.77" "$1,790.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137726 ERX HCPCS J3490 70842-0120-06 MEROPENEM-VABORBACTAM 2 (1-1) G IV SOLR BOTH IP/OP $655.84 $485.32 $0.00 $555.48 $324.30 $324.30 $0.00 $0.00 $0.00 $136.69 $534.87 $534.87 $555.48 $0.00 $136.68 $0.00 $387.93 $387.93 $0.00 $283.34 $448.81 $453.34 $0.00 $0.00 $88.69 $0.00 $0.00 $90.22 $0.00 $0.00 $0.00 $0.00 $0.00 137728 ERX HCPCS J9203 00008-4510-01 GEMTUZUMAB OZOGAMICIN 4.5 MG IV SOLR BOTH IP/OP "$24,670.39 " "$18,256.09" $0.00 "$19,015.94" $0.00 $0.00 $0.00 $0.00 $0.00 "$18,310.36" "$18,310.36" "$19,015.94" $0.00 "$10,997.58" $0.00 $0.00 $0.00 $0.00 "$10,700.25" "$16,949.19" "$17,120.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137823 ERX HCPCS 25000001 00409-4712-01 LIDOCAINE IN DEXTROSE 5-7.5 % INTRASPINAL SOLN BOTH IP/OP $46.57 $34.46 $0.00 $35.90 $0.00 $0.00 $0.00 $0.00 $0.00 $34.56 $34.56 $35.90 $0.00 $9.71 $0.00 $0.00 $0.00 $0.00 $20.81 $32.96 $33.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 137829 ERX HCPCS J0171 42023-0159-01 EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $0.87 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.96 $0.00 $0.00 $0.92 $0.00 $0.00 $0.00 $0.00 $0.00 137829 ERX HCPCS J0171 42023-0159-25 EPINEPHRINE (ANAPHYLAXIS) 1 MG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $0.87 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.96 $0.00 $0.00 $0.92 $0.00 $0.00 $0.00 $0.00 $0.00 137999 ERX HCPCS J3370 66288-7100-01 VANCOMYCIN HCL 100 G IV SOLR BOTH IP/OP "$1,554.00 " "$1,149.96" $0.00 "$1,197.82" $699.30 $699.30 $0.00 $0.00 $0.00 $723.80 "$1,153.38" "$1,153.38" "$1,197.82" $0.00 $667.87 $0.00 $919.19 $919.19 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $796.65 $0.00 $0.00 $758.55 $0.00 $0.00 $0.00 $0.00 $0.00 138034 ERX HCPCS 25000001 00002-4483-54 ABEMACICLIB 50 MG PO TABS BOTH IP/OP $817.07 $604.63 $0.00 $664.42 $0.00 $0.00 $0.00 $0.00 $0.00 $639.77 $639.77 $664.42 $0.00 $170.28 $0.00 $0.00 $0.00 $0.00 $351.43 $556.66 $562.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 138035 ERX HCPCS 25000001 00002-4815-54 ABEMACICLIB 100 MG PO TABS BOTH IP/OP $817.07 $604.63 $0.00 $664.42 $0.00 $0.00 $0.00 $0.00 $0.00 $639.77 $639.77 $664.42 $0.00 $170.28 $0.00 $0.00 $0.00 $0.00 $351.43 $556.66 $562.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 138036 ERX HCPCS 25000001 00002-5337-54 ABEMACICLIB 150 MG PO TABS BOTH IP/OP $817.07 $604.63 $0.00 $664.42 $0.00 $0.00 $0.00 $0.00 $0.00 $639.77 $639.77 $664.42 $0.00 $170.28 $0.00 $0.00 $0.00 $0.00 $351.43 $556.66 $562.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 138037 ERX HCPCS 25000001 00002-6216-54 ABEMACICLIB 200 MG PO TABS BOTH IP/OP $817.07 $604.63 $0.00 $664.42 $0.00 $0.00 $0.00 $0.00 $0.00 $639.77 $639.77 $664.42 $0.00 $170.28 $0.00 $0.00 $0.00 $0.00 $351.43 $556.66 $562.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 138138 ERX HCPCS J0171 42023-0168-01 EPINEPHRINE 30 MG/30ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $2.60 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.89 $0.00 $0.00 $2.75 $0.00 $0.00 $0.00 $0.00 $0.00 138195 ERX HCPCS J7170 50242-0921-01 EMICIZUMAB-KXWH 60 MG/0.4ML SC SOLN BOTH IP/OP "$16,711.21 " "$12,366.30" $0.00 "$13,203.03" $0.00 $0.00 $0.00 $0.00 $0.00 "$12,713.14" "$12,713.14" "$13,203.03" $0.00 "$3,482.62" $0.00 $0.00 $0.00 $0.00 "$7,394.34" "$11,712.63" "$11,830.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 138537 ERX HCPCS J3490 68547-0501-02 ANGIOTENSIN II ACETATE 2.5 MG/ML IV SOLN BOTH IP/OP "$4,068.00 " "$3,010.32" $0.00 "$3,135.61" "$1,830.60" "$1,830.60" $0.00 $0.00 $0.00 $847.87 "$3,019.27" "$3,019.27" "$3,135.61" $0.00 $847.77 $0.00 "$2,005.52" "$2,005.52" $0.00 "$1,845.00" "$2,922.48" "$2,952.00" $0.00 $0.00 $577.49 $0.00 $0.00 $587.45 $0.00 $0.00 $0.00 $0.00 $0.00 138555 ERX HCPCS J9299 00003-3734-13 NIVOLUMAB 240 MG/24ML IV SOLN BOTH IP/OP "$18,385.58 " "$13,605.33" $0.00 "$14,455.06" "$8,438.99" "$8,438.99" "$7,018.80" "$7,018.80" "$7,018.80" "$3,832.01" "$13,918.71" "$13,918.71" "$14,455.06" "$6,927.12" "$8,139.37" "$4,502.63" "$9,064.09" "$9,064.09" "$7,006.86" "$8,093.97" "$12,820.85" "$12,950.35" "$9,676.14" "$9,676.14" "$7,941.12" $0.00 $0.00 "$7,561.30" "$6,848.16" $0.00 $0.00 $0.00 $0.00 138899 ERX HCPCS J8499 61958-2501-01 BIKTARVY:BICTEGRAVIR-EMTRICITABINE-TENOFOVIR ALAFENAMIDE 50-200-25 PO TAB BOTH IP/OP $481.67 $356.44 $0.00 $316.06 $261.55 $261.55 $0.00 $0.00 $85.74 $100.39 $0.00 $0.00 $0.00 $0.00 $100.38 $0.00 $284.91 $284.91 $0.00 $197.54 $312.90 $316.06 $237.05 $237.05 $0.00 $0.00 $0.00 $62.90 $0.00 $0.00 $0.00 $0.00 $0.00 138939 ERX HCPCS 25000001 59676-0600-12 APALUTAMIDE 60 MG PO TABS BOTH IP/OP "$1,329.53 " $983.85 $0.00 "$1,080.15" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,040.07" "$1,040.07" "$1,080.15" $0.00 $277.07 $0.00 $0.00 $0.00 $0.00 $649.02 "$1,028.04" "$1,038.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139004 ERX HCPCS 63700001 57962-0070-28 IBRUTINIB 70 MG PO CAPS BOTH IP/OP "$5,395.18 " "$3,992.43" $0.00 "$3,645.33" $0.00 $0.00 $0.00 "$1,031.41" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,124.36" $0.00 $0.00 $0.00 $0.00 "$2,278.33" "$3,608.87" "$3,645.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139005 ERX HCPCS J8999 57962-0014-28 IBRUTINIB 140 MG PO TABS BOTH IP/OP "$2,697.59 " "$1,996.22" $0.00 "$1,822.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.18 $0.00 $0.00 $0.00 $0.00 "$1,139.17" "$1,804.44" "$1,822.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139006 ERX HCPCS 63700001 57962-0280-28 IBRUTINIB 280 MG PO TABS BOTH IP/OP "$2,697.59 " "$1,996.22" $0.00 "$1,822.66" $0.00 $0.00 $0.00 $515.70 $0.00 $0.00 $0.00 $0.00 $0.00 $562.18 $0.00 $0.00 $0.00 $0.00 "$1,139.17" "$1,804.44" "$1,822.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139007 ERX HCPCS 63700001 57962-0420-28 IBRUTINIB 420 MG PO TABS BOTH IP/OP "$1,545.75 " "$1,143.86" $0.00 "$1,066.93" $0.00 $0.00 $0.00 $295.50 $0.00 $0.00 $0.00 $0.00 $0.00 $322.13 $0.00 $0.00 $0.00 $0.00 $666.83 "$1,056.26" "$1,066.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139008 ERX HCPCS 63700001 57962-0560-28 IBRUTINIB 560 MG PO TABS BOTH IP/OP "$1,545.75 " "$1,143.86" $0.00 "$1,066.93" $0.00 $0.00 $0.00 $295.50 $0.00 $0.00 $0.00 $0.00 $0.00 $322.13 $0.00 $0.00 $0.00 $0.00 $666.83 "$1,056.26" "$1,066.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139272 ERX HCPCS J0690 00338-3503-41 CEFAZOLIN 1G IN 50ML DEXTROSE (ISO-OSMOTIC) PREMIXED SOLUTION BOTH IP/OP $26.40 $19.54 $0.00 $20.35 $11.88 $11.88 $0.00 $0.00 $0.00 $1.39 $19.59 $19.59 $20.35 $0.00 $1.75 $0.00 $15.62 $15.62 $0.00 $11.97 $18.96 $19.15 $0.00 $0.00 $1.93 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 139273 ERX HCPCS 25000001 00781-3126-46 NAFCILLIN SODIUM 10 G IV SOLR BOTH IP/OP $466.27 $345.04 $0.00 $359.40 $0.00 $0.00 $0.00 $0.00 $0.00 $346.07 $346.07 $359.40 $0.00 $97.17 $0.00 $0.00 $0.00 $0.00 $211.63 $335.21 $338.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139273 ERX HCPCS 25000001 00781-3126-95 NAFCILLIN SODIUM 10 G IV SOLR BOTH IP/OP $466.27 $345.04 $0.00 $359.40 $0.00 $0.00 $0.00 $0.00 $0.00 $346.07 $346.07 $359.40 $0.00 $97.17 $0.00 $0.00 $0.00 $0.00 $211.63 $335.21 $338.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139275 ERX HCPCS 25000001 00065-0418-81 DEXTRAN 70-HYPROMELLOSE 0.1-0.3 % OP SOLN BOTH IP/OP $16.53 $12.23 $0.00 $13.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.27 $13.09 $13.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139276 ERX HCPCS 25000001 00065-0416-63 DEXTRAN 70-HYPROMELLOSE (PF) 0.1-0.3 % OP SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139276 ERX HCPCS 25000001 00065-8063-01 DEXTRAN 70-HYPROMELLOSE (PF) 0.1-0.3 % OP SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139283 ERX HCPCS 25000001 00023-0506-01 POLYVINYL ALCOHOL-POVIDONE PF 1.4-0.6 % OP SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139283 ERX HCPCS 25000001 00023-0506-50 POLYVINYL ALCOHOL-POVIDONE PF 1.4-0.6 % OP SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139285 ERX HCPCS 25000001 71740-0112-30 POTASSIUM IODIDE (EXPECTORANT) 1 GM/ML PO SOLN BOTH IP/OP "$1,379.70 " "$1,020.98" $0.00 "$1,063.47" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.01" "$1,024.01" "$1,063.47" $0.00 $287.53 $0.00 $0.00 $0.00 $0.00 $39.48 $62.54 $63.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139286 ERX HCPCS J0583 00409-8300-10 BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR BOTH IP/OP $584.64 $432.63 $0.00 $450.64 $0.00 $0.00 $0.00 $0.00 $0.00 $433.92 $433.92 $450.64 $0.00 $121.84 $0.00 $0.00 $0.00 $0.00 $265.35 $420.31 $424.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139286 ERX HCPCS J0583 00781-3158-94 BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR BOTH IP/OP $584.64 $432.63 $0.00 $450.64 $0.00 $0.00 $0.00 $0.00 $0.00 $433.92 $433.92 $450.64 $0.00 $121.84 $0.00 $0.00 $0.00 $0.00 $265.35 $420.31 $424.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139286 ERX HCPCS J0583 00781-3158-95 BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR BOTH IP/OP $584.64 $432.63 $0.00 $450.64 $0.00 $0.00 $0.00 $0.00 $0.00 $433.92 $433.92 $450.64 $0.00 $121.84 $0.00 $0.00 $0.00 $0.00 $265.35 $420.31 $424.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139286 ERX HCPCS J0583 55111-0652-37 BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR BOTH IP/OP $584.64 $432.63 $0.00 $450.64 $0.00 $0.00 $0.00 $0.00 $0.00 $433.92 $433.92 $450.64 $0.00 $121.84 $0.00 $0.00 $0.00 $0.00 $265.35 $420.31 $424.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139286 ERX HCPCS J0583 70860-0402-10 BIVALIRUDIN TRIFLUOROACETATE 250 MG IV SOLR BOTH IP/OP $584.64 $432.63 $0.00 $450.64 $0.00 $0.00 $0.00 $0.00 $0.00 $433.92 $433.92 $450.64 $0.00 $121.84 $0.00 $0.00 $0.00 $0.00 $265.35 $420.31 $424.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139292 ERX HCPCS J0770 39822-0615-01 COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR BOTH IP/OP $99.75 $73.82 $0.00 $79.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.88 $79.00 $79.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139292 ERX HCPCS J0770 42023-0131-01 COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR BOTH IP/OP $99.75 $73.82 $0.00 $79.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.88 $79.00 $79.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139292 ERX HCPCS J0770 63323-0393-06 COLISTIMETHATE SODIUM (CBA) 150 MG IJ SOLR BOTH IP/OP $99.75 $73.82 $0.00 $79.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.88 $79.00 $79.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139365 ERX HCPCS J1746 62064-0122-02 IBALIZUMAB-UIYK 200 MG/1.33ML IV SOLN BOTH IP/OP "$3,628.66 " "$2,685.21" $0.00 "$2,796.97" "$1,632.90" "$1,632.90" "$1,325.06" "$1,325.06" "$1,325.06" $756.30 "$2,693.19" "$2,693.19" "$2,796.97" "$1,327.88" "$1,560.26" $863.12 "$1,788.93" "$1,788.93" "$1,263.26" "$1,521.70" "$2,410.37" "$2,434.72" "$1,744.50" "$1,744.50" "$1,333.63" $0.00 $0.00 "$1,269.84" "$1,203.10" $0.00 $0.00 $0.00 $0.00 139459 ERX HCPCS 25000001 00078-0951-66 NILOTINIB HCL 50 MG PO CAPS BOTH IP/OP "$1,310.87 " $970.04 $0.00 $384.72 $0.00 $0.00 $0.00 $247.33 $0.00 $0.00 $0.00 $0.00 $0.00 $273.19 $0.00 $0.00 $0.00 $0.00 $240.45 $380.87 $384.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139649 ERX HCPCS 25000001 62327-0222-02 TALC 2 G PL POWD BOTH IP/OP $427.40 $316.28 $0.00 $348.09 $0.00 $0.00 $0.00 $0.00 $0.00 $335.17 $335.17 $348.09 $0.00 $89.07 $0.00 $0.00 $0.00 $0.00 $193.98 $307.26 $310.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139651 ERX HCPCS 25000001 62327-0333-03 TALC 3 G PL POWD BOTH IP/OP $536.26 $396.83 $0.00 $441.32 $0.00 $0.00 $0.00 $0.00 $0.00 $424.95 $424.95 $441.32 $0.00 $111.76 $0.00 $0.00 $0.00 $0.00 $243.39 $385.53 $389.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139651 ERX HCPCS 25000001 62327-0333-43 TALC 3 G PL POWD BOTH IP/OP $536.26 $396.83 $0.00 $441.32 $0.00 $0.00 $0.00 $0.00 $0.00 $424.95 $424.95 $441.32 $0.00 $111.76 $0.00 $0.00 $0.00 $0.00 $243.39 $385.53 $389.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139692 ERX HCPCS 90375 13533-0318-05 RABIES IMMUNE GLOBULIN 1500 UNIT/5ML IJ SOLN BOTH IP/OP "$9,091.15 " "$6,727.45" $0.00 "$7,007.46" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,747.45" "$6,747.45" "$7,007.46" $0.00 $314.08 $0.00 $0.00 $0.00 $0.00 "$4,123.20" "$6,531.15" "$6,597.12" $0.00 $0.00 $325.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139937 ERX HCPCS 63700001 00074-3399-30 RITONAVIR 100 MG PO PACK BOTH IP/OP $43.11 $31.90 $0.00 $31.28 $0.00 $0.00 $0.00 $7.67 $0.00 $0.00 $0.00 $0.00 $0.00 $8.98 $0.00 $0.00 $0.00 $0.00 $19.55 $30.97 $31.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139948 ERX HCPCS 25000001 64950-0362-04 COCAINE HCL 40 MG/ML NA SOLN BOTH IP/OP $858.48 $635.28 $0.00 $661.72 $0.00 $0.00 $0.00 $0.00 $0.00 $637.16 $637.16 $661.72 $0.00 $178.91 $0.00 $0.00 $0.00 $0.00 $389.55 $617.05 $623.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 139956 ERX HCPCS J0171 70324-0077-01 EPINEPHRINE HCL-NACL 8-0.9 MG/250ML-% IV SOLN BOTH IP/OP $260.25 $192.59 $0.00 $200.60 $117.11 $117.11 $0.00 $0.00 $0.00 $54.24 $193.16 $193.16 $200.60 $0.00 $69.37 $0.00 $153.94 $153.94 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $77.08 $0.00 $0.00 $73.39 $0.00 $0.00 $0.00 $0.00 $0.00 139956 ERX HCPCS J0171 76154-0814-15 EPINEPHRINE HCL-NACL 8-0.9 MG/250ML-% IV SOLN BOTH IP/OP $260.25 $192.59 $0.00 $200.60 $117.11 $117.11 $0.00 $0.00 $0.00 $54.24 $193.16 $193.16 $200.60 $0.00 $69.37 $0.00 $153.94 $153.94 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $77.08 $0.00 $0.00 $73.39 $0.00 $0.00 $0.00 $0.00 $0.00 140052 ERX HCPCS Q5106 00069-1305-01 EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN BOTH IP/OP $102.19 $75.62 $0.00 $74.13 $55.49 $55.49 $0.00 $0.00 $0.00 $21.30 $0.00 $0.00 $0.00 $0.00 $21.30 $0.00 $60.45 $60.45 $20.22 $46.33 $73.39 $74.13 $27.93 $27.93 $14.50 $0.00 $0.00 $20.81 $19.26 $0.00 $0.00 $0.00 $0.00 140052 ERX HCPCS Q5106 00069-1305-10 EPOETIN ALFA-EPBX 2000 UNIT/ML IJ SOLN BOTH IP/OP $102.19 $75.62 $0.00 $74.13 $55.49 $55.49 $0.00 $0.00 $0.00 $21.30 $0.00 $0.00 $0.00 $0.00 $21.30 $0.00 $60.45 $60.45 $20.22 $46.33 $73.39 $74.13 $27.93 $27.93 $14.50 $0.00 $0.00 $20.81 $19.26 $0.00 $0.00 $0.00 $0.00 140054 ERX HCPCS Q5106 00069-1307-01 EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN BOTH IP/OP $183.72 $135.95 $0.00 $133.42 $99.76 $99.76 $0.00 $0.00 $0.00 $38.29 $0.00 $0.00 $0.00 $0.00 $38.29 $0.00 $108.67 $108.67 $40.45 $83.39 $132.09 $133.42 $55.85 $55.85 $26.10 $0.00 $0.00 $41.62 $38.52 $0.00 $0.00 $0.00 $0.00 140054 ERX HCPCS Q5106 00069-1307-10 EPOETIN ALFA-EPBX 4000 UNIT/ML IJ SOLN BOTH IP/OP $183.72 $135.95 $0.00 $133.42 $99.76 $99.76 $0.00 $0.00 $0.00 $38.29 $0.00 $0.00 $0.00 $0.00 $38.29 $0.00 $108.67 $108.67 $40.45 $83.39 $132.09 $133.42 $55.85 $55.85 $26.10 $0.00 $0.00 $41.62 $38.52 $0.00 $0.00 $0.00 $0.00 140055 ERX HCPCS Q5106 00069-1308-01 EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN BOTH IP/OP $444.73 $329.10 $0.00 $322.96 $241.49 $241.49 $0.00 $0.00 $0.00 $92.69 $0.00 $0.00 $0.00 $0.00 $92.68 $0.00 $263.06 $263.06 $101.12 $201.85 $319.73 $322.96 $139.64 $139.64 $63.18 $0.00 $0.00 $104.05 $96.30 $0.00 $0.00 $0.00 $0.00 140055 ERX HCPCS Q5106 00069-1308-10 EPOETIN ALFA-EPBX 10000 UNIT/ML IJ SOLN BOTH IP/OP $444.73 $329.10 $0.00 $322.96 $241.49 $241.49 $0.00 $0.00 $0.00 $92.69 $0.00 $0.00 $0.00 $0.00 $92.68 $0.00 $263.06 $263.06 $101.12 $201.85 $319.73 $322.96 $139.64 $139.64 $63.18 $0.00 $0.00 $104.05 $96.30 $0.00 $0.00 $0.00 $0.00 140089 ERX HCPCS J9150 00703-5233-13 DAUNORUBICIN HCL 20 MG/4ML IV SOLN BOTH IP/OP $540.87 $400.24 $0.00 $416.90 $0.00 $0.00 $0.00 $0.00 $0.00 $401.43 $401.43 $416.90 $0.00 $94.84 $0.00 $0.00 $0.00 $0.00 $245.49 $388.85 $392.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140312 ERX HCPCS J0878 25021-0179-15 DAPTOMYCIN 350 MG IV SOLR BOTH IP/OP $970.61 $718.25 $0.00 $748.15 $436.77 $436.77 $0.00 $0.00 $0.00 $156.28 $720.39 $720.39 $748.15 $0.00 $23.44 $0.00 $574.12 $574.12 $121.28 $440.43 $697.64 $704.69 $167.48 $167.48 $119.26 $0.00 $0.00 $113.56 $47.60 $0.00 $0.00 $0.00 $0.00 140312 ERX HCPCS J0878 25021-0179-16 DAPTOMYCIN 350 MG IV SOLR BOTH IP/OP $970.61 $718.25 $0.00 $748.15 $436.77 $436.77 $0.00 $0.00 $0.00 $156.28 $720.39 $720.39 $748.15 $0.00 $23.44 $0.00 $574.12 $574.12 $121.28 $440.43 $697.64 $704.69 $167.48 $167.48 $119.26 $0.00 $0.00 $113.56 $47.60 $0.00 $0.00 $0.00 $0.00 140359 ERX HCPCS Q5108 67457-0833-06 PEGFILGRASTIM-JMDB 6 MG/0.6ML SC SOSY BOTH IP/OP "$11,322.60 " "$8,378.72" $0.00 "$8,727.46" "$5,095.17" "$5,095.17" "$2,449.66" "$2,449.66" "$2,449.66" "$2,359.91" "$8,403.63" "$8,403.63" "$8,727.46" "$2,534.22" "$2,977.71" "$1,647.24" "$5,582.04" "$5,582.04" "$4,125.40" "$5,135.25" "$8,134.24" "$8,216.40" "$5,696.99" "$5,696.99" "$1,607.33" $0.00 $0.00 "$1,635.06" "$3,928.96" $0.00 $0.00 $0.00 $0.00 140422 ERX HCPCS J1644 00409-7651-03 HEPARIN (PORCINE) 50 UNIT/ML 500 ML IV SOLN BOTH IP/OP $39.81 $29.46 $0.00 $30.69 $17.91 $17.91 $0.00 $0.00 $0.00 $5.88 $29.55 $29.55 $30.69 $0.00 $7.29 $0.00 $23.55 $23.55 $0.00 $17.10 $27.09 $27.36 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 140467 ERX HCPCS 63700001 70255-0010-02 BINIMETINIB 15 MG PO TABS BOTH IP/OP $303.55 $224.63 $0.00 $200.91 $0.00 $0.00 $0.00 $54.03 $0.00 $0.00 $0.00 $0.00 $0.00 $63.26 $0.00 $0.00 $0.00 $0.00 $125.57 $198.90 $200.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140469 ERX HCPCS 63700001 70255-0025-01 ENCORAFENIB 75 MG PO CAPS BOTH IP/OP $309.38 $228.94 $0.00 $204.78 $0.00 $0.00 $0.00 $55.07 $0.00 $0.00 $0.00 $0.00 $0.00 $64.47 $0.00 $0.00 $0.00 $0.00 $127.99 $202.73 $204.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140469 ERX HCPCS 63700001 70255-0025-02 ENCORAFENIB 75 MG PO CAPS BOTH IP/OP $309.38 $228.94 $0.00 $204.78 $0.00 $0.00 $0.00 $55.07 $0.00 $0.00 $0.00 $0.00 $0.00 $64.47 $0.00 $0.00 $0.00 $0.00 $127.99 $202.73 $204.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140469 ERX HCPCS 63700001 70255-0025-03 ENCORAFENIB 75 MG PO CAPS BOTH IP/OP $309.38 $228.94 $0.00 $204.78 $0.00 $0.00 $0.00 $55.07 $0.00 $0.00 $0.00 $0.00 $0.00 $64.47 $0.00 $0.00 $0.00 $0.00 $127.99 $202.73 $204.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140469 ERX HCPCS 63700001 70255-0025-04 ENCORAFENIB 75 MG PO CAPS BOTH IP/OP $309.38 $228.94 $0.00 $204.78 $0.00 $0.00 $0.00 $55.07 $0.00 $0.00 $0.00 $0.00 $0.00 $64.47 $0.00 $0.00 $0.00 $0.00 $127.99 $202.73 $204.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140572 ERX HCPCS 25000001 71334-0100-01 IVOSIDENIB 250 MG PO TABS BOTH IP/OP "$1,470.09 " "$1,087.87" $0.00 "$1,052.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.37 $0.00 $0.00 $0.00 $0.00 $658.10 "$1,042.43" "$1,052.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140767 ERX HCPCS J9047 76075-0103-01 CARFILZOMIB 10 MG IV SOLR BOTH IP/OP "$1,335.98 " $988.63 $0.00 "$1,090.52" $636.66 $636.66 $411.11 $411.11 $411.11 $278.45 "$1,050.06" "$1,050.06" "$1,090.52" $411.03 $482.96 $267.17 $790.23 $790.23 $394.79 $645.39 "$1,022.29" "$1,032.62" $545.19 $545.19 $441.10 $0.00 $0.00 $420.00 $389.72 $0.00 $0.00 $0.00 $0.00 140769 ERX HCPCS 63600001 76329-3316-01 EPINEPHRINE 1 MG/10ML IJ SOSY BOTH IP/OP $44.00 $32.56 $0.00 $38.18 $22.29 $22.29 $0.00 $0.00 $0.00 $9.17 $36.76 $36.76 $38.18 $0.00 $8.67 $0.00 $26.03 $26.03 $0.00 $19.95 $31.60 $31.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140776 ERX HCPCS 25000001 00310-1105-30 SODIUM ZIRCONIUM CYCLOSILICATE 5 G PO PACK BOTH IP/OP $112.64 $83.35 $0.00 $86.84 $0.00 $0.00 $0.00 $0.00 $0.00 $83.62 $83.62 $86.84 $0.00 $23.47 $0.00 $0.00 $0.00 $0.00 $47.23 $74.81 $75.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140796 ERX HCPCS 90739 43528-0003-05 HEPATITIS B VAC RECOMB ADJ 20 MCG/0.5ML IM SOSY BOTH IP/OP $510.05 $377.44 $0.00 $414.59 $242.04 $242.04 $139.85 $139.85 $131.10 $106.31 $399.21 $399.21 $414.59 $132.61 $169.45 $86.20 $301.69 $301.69 $0.00 $220.52 $349.30 $352.82 $264.62 $264.62 $154.04 $114.67 $114.67 $146.67 $114.67 $0.00 $0.00 $0.00 $0.00 140845 ERX HCPCS J2370 69374-0957-10 PHENYLEPHRINE HCL 1 MG/10ML IV SOSY BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $12.15 $12.15 $0.00 $0.00 $0.00 $0.96 $20.04 $20.04 $20.81 $0.00 $4.14 $0.00 $15.97 $15.97 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $4.31 $0.00 $0.00 $4.11 $0.00 $0.00 $0.00 $0.00 $0.00 140890 ERX HCPCS J9204 42747-0761-01 MOGAMULIZUMAB-KPKC 20 MG/5ML IV SOLN BOTH IP/OP "$10,909.21 " "$8,072.82" $0.00 "$8,534.95" "$4,982.78" "$4,982.78" "$4,252.70" "$4,252.70" "$4,252.70" "$2,273.75" "$8,218.27" "$8,218.27" "$8,534.95" "$4,200.90" "$4,936.06" "$2,730.59" "$5,378.24" "$5,378.24" $0.00 "$4,802.60" "$7,607.32" "$7,684.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140942 ERX HCPCS 63700001 62856-0712-05 LENVATINIB (12 MG DAILY DOSE) 3 X 4 MG PO CPPK BOTH IP/OP $792.81 $586.68 $0.00 "$1,460.82" $0.00 $0.00 $0.00 $144.99 $0.00 $0.00 $0.00 $0.00 $0.00 $165.22 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140942 ERX HCPCS 63700001 62856-0712-30 LENVATINIB (12 MG DAILY DOSE) 3 X 4 MG PO CPPK BOTH IP/OP $792.81 $586.68 $0.00 "$1,460.82" $0.00 $0.00 $0.00 $144.99 $0.00 $0.00 $0.00 $0.00 $0.00 $165.22 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140943 ERX HCPCS 63700001 62856-0704-05 LENVATINIB (4 MG DAILY DOSE) 4 MG PO CPPK BOTH IP/OP "$2,109.61 " "$1,561.11" $0.00 "$1,460.82" $0.00 $0.00 $0.00 $385.82 $0.00 $0.00 $0.00 $0.00 $0.00 $439.64 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140943 ERX HCPCS 63700001 62856-0704-30 LENVATINIB (4 MG DAILY DOSE) 4 MG PO CPPK BOTH IP/OP "$2,109.61 " "$1,561.11" $0.00 "$1,460.82" $0.00 $0.00 $0.00 $385.82 $0.00 $0.00 $0.00 $0.00 $0.00 $439.64 $0.00 $0.00 $0.00 $0.00 $913.01 "$1,446.21" "$1,460.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141226 ERX HCPCS J2357 50242-0215-01 OMALIZUMAB 150 MG/ML SC SOSY BOTH IP/OP "$47,284.06 " "$34,990.20" $0.00 "$37,539.84" "$21,916.10" "$21,916.10" "$16,878.15" "$16,878.15" "$16,878.15" "$9,417.94" "$36,146.95" "$36,146.95" "$37,539.84" "$16,950.60" "$19,916.96" "$11,017.89" "$23,311.04" "$23,311.04" "$1,158.51" "$1,388.04" "$2,198.65" "$2,220.86" "$1,599.84" "$1,599.84" "$1,316.94" $0.00 $0.00 "$1,253.95" "$1,130.79" $0.00 $0.00 $0.00 $0.00 141227 ERX HCPCS J2357 50242-0214-01 OMALIZUMAB 75 MG/0.5ML SC SOSY BOTH IP/OP "$3,152.25 " "$2,332.67" $0.00 "$1,434.03" $837.20 $837.20 $562.61 $562.61 $562.61 $348.98 "$1,380.83" "$1,380.83" "$1,434.03" $565.02 $663.90 $367.26 $890.49 $890.49 $579.25 $812.51 "$1,287.02" "$1,300.02" $799.92 $799.92 $658.47 $0.00 $0.00 $626.98 $565.40 $0.00 $0.00 $0.00 $0.00 141229 ERX HCPCS J0841 66621-0790-02 CROTALIDAE IMMUNE FAB (EQUINE) IV SOLR BOTH IP/OP "$13,234.56 " "$9,793.57" $0.00 "$10,201.20" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,822.69" "$9,822.69" "$10,201.20" $0.00 "$2,758.08" $0.00 $0.00 $0.00 $0.00 "$6,002.40" "$9,507.80" "$9,603.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141259 ERX HCPCS 63700001 00378-0871-16 CLONIDINE 0.1 MG/24HR TD PTWK BOTH IP/OP $127.86 $94.62 $0.00 $92.75 $0.00 $0.00 $0.00 $22.76 $0.00 $0.00 $0.00 $0.00 $0.00 $26.65 $0.00 $0.00 $0.00 $0.00 $57.97 $91.82 $92.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141259 ERX HCPCS 63700001 00378-0871-99 CLONIDINE 0.1 MG/24HR TD PTWK BOTH IP/OP $127.86 $94.62 $0.00 $92.75 $0.00 $0.00 $0.00 $22.76 $0.00 $0.00 $0.00 $0.00 $0.00 $26.65 $0.00 $0.00 $0.00 $0.00 $57.97 $91.82 $92.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141259 ERX HCPCS 63700001 00591-3508-04 CLONIDINE 0.1 MG/24HR TD PTWK BOTH IP/OP $127.86 $94.62 $0.00 $92.75 $0.00 $0.00 $0.00 $22.76 $0.00 $0.00 $0.00 $0.00 $0.00 $26.65 $0.00 $0.00 $0.00 $0.00 $57.97 $91.82 $92.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141260 ERX HCPCS 63700001 00378-0872-16 CLONIDINE 0.2 MG/24HR TD PTWK BOTH IP/OP $193.51 $143.20 $0.00 $140.53 $0.00 $0.00 $0.00 $34.44 $0.00 $0.00 $0.00 $0.00 $0.00 $40.33 $0.00 $0.00 $0.00 $0.00 $87.83 $139.12 $140.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141260 ERX HCPCS 63700001 00378-0872-99 CLONIDINE 0.2 MG/24HR TD PTWK BOTH IP/OP $193.51 $143.20 $0.00 $140.53 $0.00 $0.00 $0.00 $34.44 $0.00 $0.00 $0.00 $0.00 $0.00 $40.33 $0.00 $0.00 $0.00 $0.00 $87.83 $139.12 $140.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141261 ERX HCPCS 63700001 00378-0873-99 CLONIDINE 0.3 MG/24HR TD PTWK BOTH IP/OP $268.44 $198.65 $0.00 $194.95 $0.00 $0.00 $0.00 $47.78 $0.00 $0.00 $0.00 $0.00 $0.00 $55.94 $0.00 $0.00 $0.00 $0.00 $121.85 $193.00 $194.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141261 ERX HCPCS 63700001 51862-0455-01 CLONIDINE 0.3 MG/24HR TD PTWK BOTH IP/OP $268.44 $198.65 $0.00 $194.95 $0.00 $0.00 $0.00 $47.78 $0.00 $0.00 $0.00 $0.00 $0.00 $55.94 $0.00 $0.00 $0.00 $0.00 $121.85 $193.00 $194.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141261 ERX HCPCS 63700001 51862-0455-04 CLONIDINE 0.3 MG/24HR TD PTWK BOTH IP/OP $268.44 $198.65 $0.00 $194.95 $0.00 $0.00 $0.00 $47.78 $0.00 $0.00 $0.00 $0.00 $0.00 $55.94 $0.00 $0.00 $0.00 $0.00 $121.85 $193.00 $194.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141262 ERX HCPCS 90710 00006-4171-00 MEASLES-MUMPS-RUBELLA-VARICELL SC SUSR BOTH IP/OP $874.31 $646.99 $0.00 $673.92 $393.44 $393.44 $0.00 $0.00 $0.00 $182.23 $648.91 $648.91 $673.92 $0.00 $182.21 $0.00 $517.15 $517.15 $0.00 $356.86 $565.26 $570.97 $0.00 $0.00 $111.70 $0.00 $0.00 $119.24 $0.00 $0.00 $0.00 $0.00 $0.00 141263 ERX HCPCS J3370 00409-6533-01 VANCOMYCIN HCL 1 G IV SOLR BOTH IP/OP $36.58 $27.07 $0.00 $29.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.29 $28.97 $29.26 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 141263 ERX HCPCS J3370 00409-6533-31 VANCOMYCIN HCL 1 G IV SOLR BOTH IP/OP $36.58 $27.07 $0.00 $29.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.29 $28.97 $29.26 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 141263 ERX HCPCS J3370 63323-0284-20 VANCOMYCIN HCL 1 G IV SOLR BOTH IP/OP $36.58 $27.07 $0.00 $29.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.29 $28.97 $29.26 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 141263 ERX HCPCS J3370 67457-0340-00 VANCOMYCIN HCL 1 G IV SOLR BOTH IP/OP $36.58 $27.07 $0.00 $29.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.29 $28.97 $29.26 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 141263 ERX HCPCS J3370 67457-0340-01 VANCOMYCIN HCL 1 G IV SOLR BOTH IP/OP $36.58 $27.07 $0.00 $29.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.29 $28.97 $29.26 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 141263 ERX HCPCS J3370 70860-0105-20 VANCOMYCIN HCL 1 G IV SOLR BOTH IP/OP $36.58 $27.07 $0.00 $29.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.29 $28.97 $29.26 $0.00 $0.00 $3.98 $0.00 $0.00 $3.79 $0.00 $0.00 $0.00 $0.00 $0.00 141264 ERX HCPCS J3370 00409-6509-01 VANCOMYCIN HCL 5 G IV SOLR BOTH IP/OP $363.93 $269.31 $0.00 $280.52 $163.77 $163.77 $0.00 $0.00 $0.00 $36.19 $270.11 $270.11 $280.52 $0.00 $33.39 $0.00 $215.26 $215.26 $0.00 $162.75 $257.80 $260.40 $0.00 $0.00 $39.83 $0.00 $0.00 $37.93 $0.00 $0.00 $0.00 $0.00 $0.00 141264 ERX HCPCS J3370 25021-0157-99 VANCOMYCIN HCL 5 G IV SOLR BOTH IP/OP $363.93 $269.31 $0.00 $280.52 $163.77 $163.77 $0.00 $0.00 $0.00 $36.19 $270.11 $270.11 $280.52 $0.00 $33.39 $0.00 $215.26 $215.26 $0.00 $162.75 $257.80 $260.40 $0.00 $0.00 $39.83 $0.00 $0.00 $37.93 $0.00 $0.00 $0.00 $0.00 $0.00 141264 ERX HCPCS J3370 67457-0341-05 VANCOMYCIN HCL 5 G IV SOLR BOTH IP/OP $363.93 $269.31 $0.00 $280.52 $163.77 $163.77 $0.00 $0.00 $0.00 $36.19 $270.11 $270.11 $280.52 $0.00 $33.39 $0.00 $215.26 $215.26 $0.00 $162.75 $257.80 $260.40 $0.00 $0.00 $39.83 $0.00 $0.00 $37.93 $0.00 $0.00 $0.00 $0.00 $0.00 141306 ERX HCPCS 63700001 00006-3069-01 DORAVIRINE 100 MG PO TABS BOTH IP/OP $211.16 $156.26 $0.00 $146.06 $0.00 $0.00 $0.00 $39.46 $0.00 $0.00 $0.00 $0.00 $0.00 $44.01 $0.00 $0.00 $0.00 $0.00 $91.29 $144.60 $146.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141425 ERX HCPCS J0713 00264-3145-11 CEFTAZIDIME AND DEXTROSE 2-5 GM-%(50ML) IV SOLR BOTH IP/OP $101.86 $75.38 $0.00 $78.51 $0.00 $0.00 $0.00 $0.00 $0.00 $75.60 $75.60 $78.51 $0.00 $21.23 $0.00 $0.00 $0.00 $0.00 $46.18 $73.15 $73.89 $0.00 $0.00 $14.45 $0.00 $0.00 $14.70 $0.00 $0.00 $0.00 $0.00 $0.00 141430 ERX HCPCS J0690 00264-3105-11 CEFAZOLIN SODIUM-DEXTROSE 2-3 GM-%(50ML) IV SOLR BOTH IP/OP $64.21 $47.52 $0.00 $49.49 $28.89 $28.89 $0.00 $0.00 $0.00 $2.77 $47.66 $47.66 $49.49 $0.00 $3.51 $0.00 $37.98 $37.98 $0.00 $29.12 $46.12 $46.58 $0.00 $0.00 $3.85 $0.00 $0.00 $3.67 $0.00 $0.00 $0.00 $0.00 $0.00 141478 ERX HCPCS J9119 61755-0008-01 CEMIPLIMAB-RWLC 350 MG/7ML IV SOLN BOTH IP/OP "$25,550.40 " "$18,907.30" $0.00 "$19,694.25" "$11,497.68" "$11,497.68" "$9,685.90" "$9,685.90" "$9,685.90" "$5,325.34" "$18,963.51" "$18,963.51" "$19,694.25" "$9,639.70" "$11,326.65" "$6,265.81" "$12,596.35" "$12,596.35" "$10,086.77" "$11,193.00" "$17,729.71" "$17,908.80" "$13,929.35" "$13,929.35" "$8,138.89" $0.00 $0.00 "$8,138.89" "$9,606.45" $0.00 $0.00 $0.00 $0.00 141582 ERX HCPCS 25000001 00069-0296-30 TALAZOPARIB TOSYLATE 0.25 MG PO CAPS BOTH IP/OP "$2,242.16 " "$1,659.20" $0.00 "$1,728.26" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,664.13" "$1,664.13" "$1,728.26" $0.00 $467.27 $0.00 $0.00 $0.00 $0.00 $979.78 "$1,551.97" "$1,567.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141584 ERX HCPCS 25000001 00069-1195-30 TALAZOPARIB TOSYLATE 1 MG PO CAPS BOTH IP/OP "$1,681.61 " "$1,244.39" $0.00 "$1,296.18" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,248.09" "$1,248.09" "$1,296.18" $0.00 $350.45 $0.00 $0.00 $0.00 $0.00 $734.84 "$1,163.98" "$1,175.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141712 ERX HCPCS 63700001 00069-0227-01 LORLATINIB 25 MG PO TABS BOTH IP/OP $727.09 $538.05 $0.00 $476.54 $0.00 $0.00 $0.00 $129.42 $0.00 $0.00 $0.00 $0.00 $0.00 $151.53 $0.00 $0.00 $0.00 $0.00 $297.84 $471.78 $476.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 141713 ERX HCPCS 63700001 00069-0231-01 LORLATINIB 100 MG PO TABS BOTH IP/OP "$1,934.75 " "$1,431.72" $0.00 "$1,294.74" $0.00 $0.00 $0.00 $344.39 $0.00 $0.00 $0.00 $0.00 $0.00 $403.20 $0.00 $0.00 $0.00 $0.00 $809.22 "$1,281.80" "$1,294.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 142188 ERX HCPCS 63700001 00173-0889-39 TAFENOQUINE SUCCINATE 150 MG PO TABS BOTH IP/OP $80.45 $59.53 $0.00 $58.37 $0.00 $0.00 $0.00 $14.32 $0.00 $0.00 $0.00 $0.00 $0.00 $16.77 $0.00 $0.00 $0.00 $0.00 $36.48 $57.78 $58.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 142198 ERX HCPCS Q5111 70114-0101-01 PEGFILGRASTIM-CBQV 6 MG/0.6ML SC SOSY BOTH IP/OP "$11,322.60 " "$8,378.72" $0.00 "$8,727.46" "$5,095.17" "$5,095.17" "$2,425.19" "$2,425.19" "$2,425.19" "$2,359.91" "$8,403.63" "$8,403.63" "$8,727.46" "$2,668.50" "$3,135.49" "$1,734.53" "$5,582.04" "$5,582.04" "$4,372.91" "$5,135.25" "$8,134.24" "$8,216.40" "$6,038.77" "$6,038.77" "$4,744.93" $0.00 $0.00 "$4,517.98" "$4,164.67" $0.00 $0.00 $0.00 $0.00 142286 ERX HCPCS 25000001 67684-1901-02 LIPIODOL IJ OIL BOTH IP/OP $400.41 $296.30 $0.00 $358.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.00 $317.12 $358.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 142324 ERX HCPCS J3490 00169-2662-11 INSULIN DEGLUDEC 100 UNIT/ML SC SOLN BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $2.61 $0.00 $0.00 $0.00 $0.00 $2.61 $0.00 $7.39 $7.39 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 142346 ERX HCPCS 63700001 00078-0972-61 ELTROMBOPAG OLAMINE 12.5 MG PO PACK BOTH IP/OP $658.79 $487.50 $0.00 $447.02 $0.00 $0.00 $0.00 $125.47 $0.00 $0.00 $0.00 $0.00 $0.00 $137.29 $0.00 $0.00 $0.00 $0.00 $279.39 $442.55 $447.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 142802 ERX HCPCS C9047 58468-0225-01 CAPLACIZUMAB-YHDP 11 MG IJ KIT BOTH IP/OP "$19,797.60 " "$14,650.22" $0.00 "$15,870.39" $0.00 $0.00 $0.00 $0.00 $0.00 "$15,281.53" "$15,281.53" "$15,870.39" $0.00 "$4,125.82" $0.00 $0.00 $0.00 $0.00 "$8,979.00" "$14,222.74" "$14,366.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143112 ERX HCPCS J0780 00641-6135-25 PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN BOTH IP/OP $46.51 $34.42 $0.00 $35.85 $20.93 $20.93 $0.00 $0.00 $0.00 $2.40 $34.52 $34.52 $35.85 $0.00 $5.57 $0.00 $27.51 $27.51 $0.00 $21.09 $33.41 $33.74 $0.00 $0.00 $10.15 $0.00 $0.00 $9.67 $0.00 $0.00 $0.00 $0.00 $0.00 143112 ERX HCPCS J0780 23155-0294-41 PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN BOTH IP/OP $46.51 $34.42 $0.00 $35.85 $20.93 $20.93 $0.00 $0.00 $0.00 $2.40 $34.52 $34.52 $35.85 $0.00 $5.57 $0.00 $27.51 $27.51 $0.00 $21.09 $33.41 $33.74 $0.00 $0.00 $10.15 $0.00 $0.00 $9.67 $0.00 $0.00 $0.00 $0.00 $0.00 143112 ERX HCPCS J0780 23155-0294-42 PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN BOTH IP/OP $46.51 $34.42 $0.00 $35.85 $20.93 $20.93 $0.00 $0.00 $0.00 $2.40 $34.52 $34.52 $35.85 $0.00 $5.57 $0.00 $27.51 $27.51 $0.00 $21.09 $33.41 $33.74 $0.00 $0.00 $10.15 $0.00 $0.00 $9.67 $0.00 $0.00 $0.00 $0.00 $0.00 143112 ERX HCPCS J0780 23155-0497-42 PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN BOTH IP/OP $46.51 $34.42 $0.00 $35.85 $20.93 $20.93 $0.00 $0.00 $0.00 $2.40 $34.52 $34.52 $35.85 $0.00 $5.57 $0.00 $27.51 $27.51 $0.00 $21.09 $33.41 $33.74 $0.00 $0.00 $10.15 $0.00 $0.00 $9.67 $0.00 $0.00 $0.00 $0.00 $0.00 143112 ERX HCPCS J0780 67457-0640-00 PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN BOTH IP/OP $46.51 $34.42 $0.00 $35.85 $20.93 $20.93 $0.00 $0.00 $0.00 $2.40 $34.52 $34.52 $35.85 $0.00 $5.57 $0.00 $27.51 $27.51 $0.00 $21.09 $33.41 $33.74 $0.00 $0.00 $10.15 $0.00 $0.00 $9.67 $0.00 $0.00 $0.00 $0.00 $0.00 143112 ERX HCPCS J0780 67457-0640-02 PROCHLORPERAZINE EDISYLATE 10 MG/2ML IJ SOLN BOTH IP/OP $46.51 $34.42 $0.00 $35.85 $20.93 $20.93 $0.00 $0.00 $0.00 $2.40 $34.52 $34.52 $35.85 $0.00 $5.57 $0.00 $27.51 $27.51 $0.00 $21.09 $33.41 $33.74 $0.00 $0.00 $10.15 $0.00 $0.00 $9.67 $0.00 $0.00 $0.00 $0.00 $0.00 143120 ERX HCPCS J1190 47781-0578-07 DEXRAZOXANE HCL 500 MG IV SOLR BOTH IP/OP "$1,352.93 " "$1,001.17" $0.00 "$1,082.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $676.47 "$1,071.52" "$1,082.34" $0.00 $0.00 $0.00 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 143121 ERX HCPCS J2426 50458-0560-01 PALIPERIDONE PALMITATE ER 39 MG/0.25ML IM SUSY BOTH IP/OP "$1,522.82 " "$1,126.89" $0.00 "$1,237.20" $0.00 $0.00 $0.00 $0.00 $317.39 "$1,191.29" "$1,191.29" "$1,237.20" $493.86 $580.28 $321.01 $900.75 $900.75 $476.25 $673.25 "$1,066.43" "$1,077.20" $657.68 $657.68 $530.65 $0.00 $0.00 $505.27 $469.17 $0.00 $0.00 $0.00 $0.00 143122 ERX HCPCS J2426 50458-0561-01 PALIPERIDONE PALMITATE ER 78 MG/0.5ML IM SUSY BOTH IP/OP "$2,657.67 " "$1,966.68" $0.00 "$2,159.17" $0.00 $0.00 $0.00 $0.00 $553.92 "$2,079.06" "$2,079.06" "$2,159.17" $987.71 "$1,160.56" $642.01 "$1,310.23" "$1,310.23" $952.50 "$1,150.17" "$1,821.86" "$1,840.26" "$1,315.35" "$1,315.35" "$1,061.31" $0.00 $0.00 "$1,010.54" $938.34 $0.00 $0.00 $0.00 $0.00 143139 ERX HCPCS 25000001 76329-3390-01 LIDOCAINE HCL (CARDIAC) 100 MG/5ML IV SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143140 ERX HCPCS 25000001 00409-1323-05 LIDOCAINE HCL (CARDIAC) PF 100 MG/5ML IV SOSY BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143142 ERX HCPCS 90636 58160-0815-52 HEPATITIS A-HEP B RECOMB VAC 720-20 ELU-MCG/ML IM SUSY BOTH IP/OP $469.89 $347.72 $0.00 $362.19 $211.45 $211.45 $0.00 $0.00 $0.00 $107.88 $348.75 $348.75 $362.19 $0.00 $132.01 $0.00 $277.94 $277.94 $0.00 $199.25 $315.60 $318.79 $0.00 $0.00 $122.20 $0.00 $0.00 $116.36 $0.00 $0.00 $0.00 $0.00 $0.00 143143 ERX HCPCS J0897 55513-0710-01 DENOSUMAB 60 MG/ML SC SOSY BOTH IP/OP "$3,672.71 " "$2,717.81" $0.00 "$2,997.95" "$1,750.23" "$1,750.23" "$1,272.30" "$1,272.30" "$1,272.30" $765.48 "$2,886.71" "$2,886.71" "$2,997.95" "$1,271.34" "$1,493.82" $826.37 "$1,810.65" "$1,810.65" "$1,214.39" "$1,572.92" "$2,491.50" "$2,516.66" "$1,677.01" "$1,677.01" "$1,359.24" $0.00 $0.00 "$1,294.23" "$1,194.06" $0.00 $0.00 $0.00 $0.00 143147 ERX HCPCS 63600001 64193-0426-02 ANTIINHIBITOR COAGULANT CMPLX 500 UNITS IV SOLR BOTH IP/OP "$3,051.00 " "$2,257.74" $0.00 "$2,351.71" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,264.45" "$2,264.45" "$2,351.71" $0.00 $635.83 $0.00 $0.00 $0.00 $0.00 "$1,383.75" "$2,191.86" "$2,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143148 ERX HCPCS J7198 64193-0324-01 ANTIINHIBITOR COAGULANT CMPLX 1000 UNITS IV SOLR BOTH IP/OP "$6,102.00 " "$4,515.48" $0.00 "$4,703.42" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,528.90" "$4,528.90" "$4,703.42" $0.00 "$1,271.66" $0.00 $0.00 $0.00 $0.00 "$2,767.50" "$4,383.72" "$4,428.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143148 ERX HCPCS J7198 64193-0424-02 ANTIINHIBITOR COAGULANT CMPLX 1000 UNITS IV SOLR BOTH IP/OP "$6,102.00 " "$4,515.48" $0.00 "$4,703.42" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,528.90" "$4,528.90" "$4,703.42" $0.00 "$1,271.66" $0.00 $0.00 $0.00 $0.00 "$2,767.50" "$4,383.72" "$4,428.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143149 ERX HCPCS J7198 64193-0325-01 ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR BOTH IP/OP "$15,255.00 " "$11,288.70" $0.00 "$11,758.55" $0.00 $0.00 $0.00 $0.00 $0.00 "$11,322.26" "$11,322.26" "$11,758.55" $0.00 "$3,179.14" $0.00 $0.00 $0.00 $0.00 "$6,918.75" "$10,959.30" "$11,070.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143149 ERX HCPCS J7198 64193-0425-02 ANTIINHIBITOR COAGULANT CMPLX 2500 UNITS IV SOLR BOTH IP/OP "$15,255.00 " "$11,288.70" $0.00 "$11,758.55" $0.00 $0.00 $0.00 $0.00 $0.00 "$11,322.26" "$11,322.26" "$11,758.55" $0.00 "$3,179.14" $0.00 $0.00 $0.00 $0.00 "$6,918.75" "$10,959.30" "$11,070.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143152 ERX HCPCS 25000001 17478-0711-10 LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX GEL BOTH IP/OP $35.20 $26.05 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 $26.13 $26.13 $27.13 $0.00 $7.34 $0.00 $0.00 $0.00 $0.00 $31.70 $25.28 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143152 ERX HCPCS 25000001 17478-0711-31 LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX GEL BOTH IP/OP $35.20 $26.05 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 $26.13 $26.13 $27.13 $0.00 $7.34 $0.00 $0.00 $0.00 $0.00 $31.70 $25.28 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143152 ERX HCPCS 25000001 17478-0711-30 LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX GEL BOTH IP/OP $35.20 $26.05 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 $26.13 $26.13 $27.13 $0.00 $7.34 $0.00 $0.00 $0.00 $0.00 $31.70 $50.20 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143153 ERX HCPCS J1644 00264-9872-10 HEPARIN (PORCINE) IN NACL 1000-0.9 UT/500ML-% IV SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.24 $16.33 $16.33 $16.96 $0.00 $0.29 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 143157 ERX HCPCS J3370 70594-0042-03 VANCOMYCIN HCL 1000 MG/200ML IV SOLN BOTH IP/OP $80.45 $59.53 $0.00 $100.80 $36.20 $36.20 $0.00 $0.00 $0.00 $7.24 $59.71 $59.71 $62.01 $0.00 $6.68 $0.00 $47.59 $47.59 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $7.97 $0.00 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 143158 ERX HCPCS J3370 70594-0043-02 VANCOMYCIN HCL 1500 MG/300ML IV SOLN BOTH IP/OP $106.54 $78.84 $0.00 $136.08 $47.94 $47.94 $0.00 $0.00 $0.00 $10.86 $79.07 $79.07 $82.12 $0.00 $10.02 $0.00 $63.02 $63.02 $0.00 $85.05 $134.72 $136.08 $0.00 $0.00 $11.95 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $0.00 143187 ERX HCPCS 25000001 99999-6005-85 PYRIDOSTIGMINE BROMIDE 60 MG/5ML PO SOLN BOTH IP/OP "$4,078.16 " "$3,017.84" $0.00 "$3,143.45" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,026.81" "$3,026.81" "$3,143.45" $0.00 $849.89 $0.00 $0.00 $0.00 $0.00 $20.18 $31.97 $32.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143187 ERX HCPCS 25000001 00187-3012-20 PYRIDOSTIGMINE BROMIDE 60 MG/5ML PO SOLN BOTH IP/OP "$4,078.16 " "$3,017.84" $0.00 "$3,143.45" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,026.81" "$3,026.81" "$3,143.45" $0.00 $849.89 $0.00 $0.00 $0.00 $0.00 $20.18 "$2,561.16" $32.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143206 ERX HCPCS J9022 50242-0918-01 ATEZOLIZUMAB 840 MG/14ML IV SOLN BOTH IP/OP "$17,977.57 " "$13,303.40" $0.00 "$14,411.40" "$8,413.51" "$8,413.51" "$6,684.38" "$6,684.38" "$6,684.38" "$3,746.98" "$13,876.68" "$13,876.68" "$14,411.40" "$6,698.92" "$7,871.23" "$4,354.30" "$8,862.94" "$8,862.94" "$6,792.11" "$7,916.05" "$12,539.02" "$12,665.68" "$9,379.57" "$9,379.57" "$7,684.78" $0.00 $0.00 "$7,317.22" "$6,468.67" $0.00 $0.00 $0.00 $0.00 143520 ERX HCPCS 63700001 49702-0246-13 DOVATO:DOLUTEGRAVIR-LAMIVUDINE 50-300 MG PO TABS BOTH IP/OP $356.46 $263.78 $0.00 $242.77 $0.00 $0.00 $0.00 $63.45 $0.00 $0.00 $0.00 $0.00 $0.00 $74.29 $0.00 $0.00 $0.00 $0.00 $151.73 $240.34 $242.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144008 ERX HCPCS J9309 50242-0105-01 POLATUZUMAB VEDOTIN-PIIQ 140 MG IV SOLR BOTH IP/OP "$40,680.00 " "$30,103.20" $0.00 "$32,610.39" $0.00 $0.00 $0.00 $0.00 $0.00 "$31,400.40" "$31,400.40" "$32,610.39" $0.00 "$18,682.43" $0.00 $0.00 $0.00 $0.00 "$18,450.00" "$29,224.80" "$29,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144263 ERX HCPCS Q5107 55513-0206-01 BEVACIZUMAB-AWWB 100 MG/4ML IV SOLN BOTH IP/OP "$2,168.56 " "$1,604.73" $0.00 "$1,671.53" $975.85 $975.85 $397.68 $397.68 $397.68 $451.98 "$1,609.51" "$1,609.51" "$1,671.53" $445.57 $523.54 $289.62 "$1,069.10" "$1,069.10" $0.00 $975.46 "$1,545.13" "$1,560.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144264 ERX HCPCS Q5107 55513-0207-01 BEVACIZUMAB-AWWB 400 MG/16ML IV SOLN BOTH IP/OP "$7,568.91 " "$5,600.99" $0.00 "$5,834.12" "$3,406.01" "$3,406.01" "$1,590.72" "$1,590.72" "$1,590.72" "$1,577.55" "$5,617.65" "$5,617.65" "$5,834.12" "$1,782.28" "$2,094.18" "$1,158.48" "$3,731.47" "$3,731.47" $0.00 "$3,332.81" "$5,279.17" "$5,332.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144270 ERX HCPCS J3370 70594-0044-02 VANCOMYCIN HCL 2000 MG/400ML IV SOLN BOTH IP/OP $129.70 $95.98 $0.00 $181.44 $58.37 $58.37 $0.00 $0.00 $0.00 $14.48 $96.26 $96.26 $99.97 $0.00 $13.36 $0.00 $76.72 $76.72 $0.00 $113.40 $179.63 $181.44 $0.00 $0.00 $15.93 $0.00 $0.00 $15.17 $0.00 $0.00 $0.00 $0.00 $0.00 144275 ERX HCPCS Q5117 55513-0132-01 TRASTUZUMAB-ANNS 420 MG IV SOLR BOTH IP/OP "$10,327.80 " "$7,642.57" $0.00 "$7,960.67" "$4,647.51" "$4,647.51" "$1,991.18" "$1,991.18" "$1,991.18" "$2,152.57" "$7,665.29" "$7,665.29" "$7,960.67" "$2,233.69" "$2,624.58" "$1,451.90" "$5,091.61" "$5,091.61" $0.00 "$4,547.63" "$7,203.45" "$7,276.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144426 ERX HCPCS 63700001 24338-0124-03 ERYTHROMYCIN 333 MG PO TBEC BOTH IP/OP $44.26 $32.75 $0.00 $32.11 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $0.00 $9.22 $0.00 $0.00 $0.00 $0.00 $20.07 $31.79 $32.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144426 ERX HCPCS 63700001 24338-0124-13 ERYTHROMYCIN 333 MG PO TBEC BOTH IP/OP $44.26 $32.75 $0.00 $32.11 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $0.00 $9.22 $0.00 $0.00 $0.00 $0.00 $20.07 $31.79 $32.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144426 ERX HCPCS 63700001 52536-0183-03 ERYTHROMYCIN 333 MG PO TBEC BOTH IP/OP $44.26 $32.75 $0.00 $32.11 $0.00 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $0.00 $9.22 $0.00 $0.00 $0.00 $0.00 $20.07 $31.79 $32.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144767 ERX HCPCS 25000001 50383-0261-61 DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN BOTH IP/OP $163.57 $121.04 $0.00 $126.08 $0.00 $0.00 $0.00 $0.00 $0.00 $121.40 $121.40 $126.08 $0.00 $34.09 $0.00 $0.00 $0.00 $0.00 $74.16 $117.47 $118.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144767 ERX HCPCS 25000001 65862-0947-15 DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN BOTH IP/OP $163.57 $121.04 $0.00 $126.08 $0.00 $0.00 $0.00 $0.00 $0.00 $121.40 $121.40 $126.08 $0.00 $34.09 $0.00 $0.00 $0.00 $0.00 $74.16 $117.47 $118.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144767 ERX HCPCS 25000001 65862-0947-60 DORZOLAMIDE HCL-TIMOLOL MAL PF 2-0.5 % OP SOLN BOTH IP/OP $163.57 $121.04 $0.00 $126.08 $0.00 $0.00 $0.00 $0.00 $0.00 $121.40 $121.40 $126.08 $0.00 $34.09 $0.00 $0.00 $0.00 $0.00 $74.16 $117.47 $118.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144934 ERX HCPCS 90707 00006-4681-00 "MEASLES, MUMPS & RUBELLA VAC IJ SOLR" BOTH IP/OP $350.54 $259.40 $0.00 $270.20 $157.74 $157.74 $0.00 $0.00 $0.00 $11.75 $260.17 $260.17 $270.20 $0.00 $102.59 $0.00 $207.34 $207.34 $0.00 $148.00 $234.42 $236.79 $0.00 $0.00 $92.45 $0.00 $0.00 $88.03 $0.00 $0.00 $0.00 $0.00 $0.00 144934 ERX HCPCS 90707 00006-4681-01 "MEASLES, MUMPS & RUBELLA VAC IJ SOLR" BOTH IP/OP $350.54 $259.40 $0.00 $270.20 $157.74 $157.74 $0.00 $0.00 $0.00 $11.75 $260.17 $260.17 $270.20 $0.00 $102.59 $0.00 $207.34 $207.34 $0.00 $148.00 $234.42 $236.79 $0.00 $0.00 $92.45 $0.00 $0.00 $88.03 $0.00 $0.00 $0.00 $0.00 $0.00 144938 ERX HCPCS 25000001 00078-0639-41 SECUKINUMAB (300 MG DOSE) 150 MG/ML SC SOAJ BOTH IP/OP "$8,040.18 " "$5,949.73" $0.00 "$6,631.18" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$6,631.18" $0.00 "$1,675.57" $0.00 $0.00 $0.00 $0.00 "$3,407.99" "$5,398.25" "$5,452.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144946 ERX HCPCS J2794 50458-0306-11 RISPERIDONE MICROSPHERES ER 25 MG IM SRER BOTH IP/OP "$1,656.28 " "$1,225.65" $0.00 "$1,339.21" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.52" "$1,289.52" "$1,339.21" $0.00 $648.72 $0.00 $0.00 $0.00 $0.00 $732.24 "$1,159.87" "$1,171.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144962 ERX HCPCS 25000001 00409-4888-01 SODIUM CHLORIDE (PF) 0.9 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144962 ERX HCPCS 25000001 00409-4888-10 SODIUM CHLORIDE (PF) 0.9 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144962 ERX HCPCS 25000001 00409-4888-12 SODIUM CHLORIDE (PF) 0.9 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144962 ERX HCPCS 25000001 63323-0186-01 SODIUM CHLORIDE (PF) 0.9 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144962 ERX HCPCS 25000001 63323-0186-10 SODIUM CHLORIDE (PF) 0.9 % IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145128 ERX HCPCS 63700001 99999-6009-67 ERGOCALCIFEROL 8000 UNIT/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145128 ERX HCPCS 63700001 00091-4150-60 ERGOCALCIFEROL 8000 UNIT/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $248.93 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $248.93 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145128 ERX HCPCS 63700001 39328-0357-60 ERGOCALCIFEROL 8000 UNIT/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $248.93 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $248.93 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145128 ERX HCPCS 63700001 69543-0234-60 ERGOCALCIFEROL 8000 UNIT/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $248.93 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $248.93 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145128 ERX HCPCS 63700001 75834-0010-60 ERGOCALCIFEROL 8000 UNIT/ML PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $248.93 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $248.93 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145154 ERX HCPCS 25000001 76329-3011-05 LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY BOTH IP/OP $32.23 $23.85 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $0.00 $23.92 $23.92 $24.84 $0.00 $6.72 $0.00 $0.00 $0.00 $0.00 $14.62 $20.77 $23.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145154 ERX HCPCS 25000001 76329-3012-05 LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY BOTH IP/OP $32.23 $23.85 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $0.00 $23.92 $23.92 $24.84 $0.00 $6.72 $0.00 $0.00 $0.00 $0.00 $14.62 $20.77 $23.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145154 ERX HCPCS 25000001 76329-3013-05 LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY BOTH IP/OP $32.23 $23.85 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $0.00 $23.92 $23.92 $24.84 $0.00 $6.72 $0.00 $0.00 $0.00 $0.00 $14.62 $23.15 $23.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145230 ERX HCPCS 25000001 00087-0866-44 CHOLECALCIFEROL 400 UNIT/ML PO LIQD BOTH IP/OP $96.50 $71.41 $0.00 $74.38 $0.00 $0.00 $0.00 $0.00 $0.00 $71.62 $71.62 $74.38 $0.00 $20.11 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145230 ERX HCPCS 25000001 54838-0006-50 CHOLECALCIFEROL 400 UNIT/ML PO LIQD BOTH IP/OP $96.50 $71.41 $0.00 $74.38 $0.00 $0.00 $0.00 $0.00 $0.00 $71.62 $71.62 $74.38 $0.00 $20.11 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145469 ERX HCPCS q5114 67457-0847-44 TRASTUZUMAB-DKST 420 MG IV SOLR BOTH IP/OP "$10,026.97 " "$7,419.96" $0.00 "$7,728.79" $0.00 $0.00 $0.00 $0.00 $0.00 "$7,442.02" "$7,442.02" "$7,728.79" $0.00 "$2,089.62" $0.00 $0.00 $0.00 $0.00 "$4,547.63" "$7,203.45" "$7,276.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145473 ERX HCPCS Q5114 67457-0991-15 TRASTUZUMAB-DKST 150 MG IV SOLR BOTH IP/OP "$3,592.48 " "$2,658.44" $0.00 "$2,769.08" "$1,616.62" "$1,616.62" $835.73 $835.73 $835.73 $748.76 "$2,666.34" "$2,666.34" "$2,769.08" $898.59 "$1,055.84" $584.08 "$1,771.09" "$1,771.09" $0.00 "$1,629.33" "$2,580.86" "$2,606.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145641 ERX HCPCS Q5117 55513-0141-01 TRASTUZUMAB-ANNS 150 MG IV SOLR BOTH IP/OP "$3,688.51 " "$2,729.50" $0.00 "$2,843.10" "$1,659.83" "$1,659.83" $711.14 $711.14 $711.14 $768.78 "$2,737.61" "$2,737.61" "$2,843.10" $797.75 $937.35 $518.53 "$1,818.44" "$1,818.44" $0.00 "$1,624.16" "$2,572.66" "$2,598.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145743 ERX HCPCS Q5115 63459-0103-10 RITUXIMAB-ABBS 100 MG/10ML IV SOLN BOTH IP/OP "$2,293.14 " "$1,696.92" $0.00 "$1,767.55" "$1,031.91" "$1,031.91" $573.47 $573.47 $573.47 $477.95 "$1,701.97" "$1,701.97" "$1,767.55" $605.77 $711.78 $393.75 "$1,130.52" "$1,130.52" $0.00 "$1,040.03" "$1,647.41" "$1,664.05" $0.00 $0.00 $325.53 $0.00 $0.00 $331.15 $0.00 $0.00 $0.00 $0.00 $0.00 145744 ERX HCPCS Q5115 63459-0104-50 RITUXIMAB-ABBS 500 MG/50ML IV SOLN BOTH IP/OP "$11,465.66 " "$8,484.59" $0.00 "$8,837.73" "$5,159.55" "$5,159.55" "$2,867.35" "$2,867.35" "$2,867.35" "$2,389.73" "$8,509.81" "$8,509.81" "$8,837.73" "$3,028.85" "$3,558.90" "$1,968.75" "$5,652.57" "$5,652.57" $0.00 "$5,200.14" "$8,237.01" "$8,320.22" $0.00 $0.00 "$1,627.64" $0.00 $0.00 "$1,655.72" $0.00 $0.00 $0.00 $0.00 $0.00 145824 ERX HCPCS C9053 00078-0883-61 CRIZANLIZUMAB-TMCA 100 MG/10ML IV SOLN BOTH IP/OP "$6,488.83 " "$4,801.73" $0.00 "$5,039.07" "$2,941.86" "$2,941.86" "$2,482.44" "$2,482.44" "$2,482.44" "$1,352.43" "$4,852.10" "$4,852.10" "$5,039.07" "$2,465.82" "$2,897.34" "$1,602.78" "$3,198.99" "$3,198.99" $0.00 "$2,899.29" "$4,592.47" "$4,638.86" $0.00 $0.00 $907.48 $0.00 $0.00 $923.13 $0.00 $0.00 $0.00 $0.00 $0.00 146009 ERX HCPCS 25000001 44677-0102-02 LANSINOH LANOLIN EX CREA BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 146059 ERX HCPCS J9177 51144-0020-01 ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR BOTH IP/OP "$6,413.88 " "$4,746.27" $0.00 "$4,943.82" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$4,943.82" $0.00 "$1,336.65" $0.00 $0.00 $0.00 $0.00 "$2,696.16" "$4,110.96" "$4,313.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 146060 ERX HCPCS J9177 51144-0030-01 ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR BOTH IP/OP "$9,620.82 " "$7,119.41" $0.00 "$7,415.73" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" "$7,415.73" $0.00 "$2,004.98" $0.00 $0.00 $0.00 $0.00 "$4,044.24" "$6,166.43" "$6,470.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 146089 ERX HCPCS J9358 65597-0406-01 FAM-TRASTUZUMAB DERUXTEC-NXKI 100 MG IV SOLR BOTH IP/OP "$6,414.88 " "$4,747.01" $0.00 "$5,068.20" "$2,958.86" "$2,958.86" "$2,460.00" "$2,460.00" "$2,460.00" "$1,337.02" "$4,880.15" "$4,880.15" "$5,068.20" "$2,426.70" "$2,851.37" "$1,577.36" "$3,162.54" "$3,162.54" $0.00 "$2,824.04" "$4,473.28" "$4,518.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 146213 ERX HCPCS Q5118 00069-0315-01 BEVACIZUMAB-BVZR 100 MG/4ML IV SOLN BOTH IP/OP "$1,906.45 " "$1,410.77" $0.00 "$1,469.49" $857.90 $857.90 $505.89 $505.89 $505.89 $397.35 "$1,414.97" "$1,414.97" "$1,469.49" $523.69 $615.34 $340.40 $939.88 $939.88 $0.00 $883.30 "$1,399.15" "$1,413.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 146214 ERX HCPCS Q5118 00069-0342-01 BEVACIZUMAB-BVZR 400 MG/16ML IV SOLN BOTH IP/OP "$6,654.17 " "$4,924.09" $0.00 "$5,129.03" "$2,994.38" "$2,994.38" "$2,023.56" "$2,023.56" "$2,023.56" "$1,386.90" "$4,938.72" "$4,938.72" "$5,129.03" "$2,094.76" "$2,461.34" "$1,361.59" "$3,280.51" "$3,280.51" $0.00 "$3,017.93" "$4,780.40" "$4,828.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 146561 ERX HCPCS J3490 59630-0266-01 CEFIDEROCOL SULFATE TOSYLATE 1 G IV SOLR BOTH IP/OP $573.81 $424.62 $0.00 $442.29 $0.00 $0.00 $0.00 $0.00 $0.00 $425.88 $425.88 $442.29 $0.00 $119.58 $0.00 $0.00 $0.00 $0.00 $251.63 $398.57 $402.60 $0.00 $0.00 $78.76 $0.00 $0.00 $80.12 $0.00 $0.00 $0.00 $0.00 $0.00 146561 ERX HCPCS J3490 59630-0266-10 CEFIDEROCOL SULFATE TOSYLATE 1 G IV SOLR BOTH IP/OP $573.81 $424.62 $0.00 $442.29 $0.00 $0.00 $0.00 $0.00 $0.00 $425.88 $425.88 $442.29 $0.00 $119.58 $0.00 $0.00 $0.00 $0.00 $251.63 $398.57 $402.60 $0.00 $0.00 $78.76 $0.00 $0.00 $80.12 $0.00 $0.00 $0.00 $0.00 $0.00 146761 ERX HCPCS 25000001 00409-7295-01 POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN BOTH IP/OP $140.24 $103.78 $0.00 $108.10 $0.00 $0.00 $0.00 $0.00 $0.00 $104.09 $104.09 $108.10 $0.00 $29.23 $0.00 $0.00 $0.00 $0.00 $33.24 $52.64 $53.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 146761 ERX HCPCS 25000001 63323-0086-15 POTASSIUM PHOSPHATES(66 MEQ K) 45 MMOLE/15ML IV SOLN BOTH IP/OP $140.24 $103.78 $0.00 $108.10 $0.00 $0.00 $0.00 $0.00 $0.00 $104.09 $104.09 $108.10 $0.00 $29.23 $0.00 $0.00 $0.00 $0.00 $33.24 $52.64 $53.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147244 ERX HCPCS Q5113 63459-0305-47 TRASTUZUMAB-PKRB 420 MG IV SOLR BOTH IP/OP "$10,650.03 " "$7,881.02" $0.00 "$8,209.04" $0.00 $0.00 $0.00 $0.00 $0.00 "$7,904.45" "$7,904.45" "$8,209.04" $0.00 "$2,827.90" $0.00 $0.00 $0.00 $0.00 "$4,830.21" "$7,651.05" "$7,728.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147295 ERX HCPCS Q5113 63459-0303-43 TRASTUZUMAB-PKRB 150 MG IV SOLR BOTH IP/OP "$3,803.58 " "$2,814.65" $0.00 "$2,931.80" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,823.02" "$2,823.02" "$2,931.80" $0.00 "$1,009.97" $0.00 $0.00 $0.00 $0.00 "$1,725.08" "$2,732.52" "$2,760.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147298 ERX HCPCS J9155 55566-8403-01 DEGARELIX ACETATE(240 MG DOSE) 120 MG/VIAL SC SOLR BOTH IP/OP "$1,579.06 " "$1,168.50" $0.00 "$1,217.14" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,171.98" "$1,171.98" "$1,217.14" $0.00 $387.28 $0.00 $0.00 $0.00 $0.00 $731.61 "$1,158.87" "$1,170.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147299 ERX HCPCS 25000001 39328-0064-12 SODIUM HYPOCHLORITE 0.125 % EX SOLN BOTH IP/OP $57.48 $42.54 $0.00 $41.70 $0.00 $0.00 $0.00 $0.00 $0.00 $36.78 $36.78 $38.19 $0.00 $11.98 $0.00 $0.00 $0.00 $0.00 $26.07 $38.44 $41.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147300 ERX HCPCS 25000001 39328-0063-25 SODIUM HYPOCHLORITE 0.25 % EX SOLN BOTH IP/OP $57.48 $42.54 $0.00 $41.70 $0.00 $0.00 $0.00 $0.00 $0.00 $36.78 $36.78 $38.19 $0.00 $11.98 $0.00 $0.00 $0.00 $0.00 $26.07 $38.44 $41.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147301 ERX HCPCS 25000001 39328-0062-50 SODIUM HYPOCHLORITE 0.5 % EX SOLN BOTH IP/OP $57.48 $42.54 $0.00 $41.70 $0.00 $0.00 $0.00 $0.00 $0.00 $36.78 $36.78 $38.19 $0.00 $11.98 $0.00 $0.00 $0.00 $0.00 $26.07 $38.44 $41.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147303 ERX HCPCS 25000001 00069-0284-03 PALBOCICLIB 75 MG PO TABS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147303 ERX HCPCS 25000001 00069-0284-07 PALBOCICLIB 75 MG PO TABS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147304 ERX HCPCS 25000001 00069-0486-03 PALBOCICLIB 100 MG PO TABS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147304 ERX HCPCS 25000001 00069-0486-07 PALBOCICLIB 100 MG PO TABS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147305 ERX HCPCS 25000001 00069-0688-03 PALBOCICLIB 125 MG PO TABS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147305 ERX HCPCS 25000001 00069-0688-07 PALBOCICLIB 125 MG PO TABS BOTH IP/OP "$2,068.13 " "$1,530.42" $0.00 "$1,594.11" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,534.97" "$1,534.97" "$1,594.11" $0.00 $431.00 $0.00 $0.00 $0.00 $0.00 $853.68 "$1,352.22" "$1,365.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147467 ERX HCPCS 25000001 62559-0430-01 HYDROCORTISONE (PERIANAL) 1 % EX CREA BOTH IP/OP $208.24 $154.10 $0.00 $160.51 $0.00 $0.00 $0.00 $0.00 $0.00 $154.56 $154.56 $160.51 $0.00 $43.40 $0.00 $0.00 $0.00 $0.00 $94.52 $149.71 $151.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147467 ERX HCPCS 25000001 64980-0302-30 HYDROCORTISONE (PERIANAL) 1 % EX CREA BOTH IP/OP $208.24 $154.10 $0.00 $160.51 $0.00 $0.00 $0.00 $0.00 $0.00 $154.56 $154.56 $160.51 $0.00 $43.40 $0.00 $0.00 $0.00 $0.00 $94.52 $149.71 $151.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147467 ERX HCPCS 25000001 65649-0501-30 HYDROCORTISONE (PERIANAL) 1 % EX CREA BOTH IP/OP $208.24 $154.10 $0.00 $160.51 $0.00 $0.00 $0.00 $0.00 $0.00 $154.56 $154.56 $160.51 $0.00 $43.40 $0.00 $0.00 $0.00 $0.00 $94.52 $149.71 $151.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147827 ERX HCPCS Q5112 00006-5033-02 TRASTUZUMAB-DTTB 150 MG IV SOLR BOTH IP/OP "$3,592.48 " "$2,658.44" $0.00 "$2,769.08" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,666.34" "$2,666.34" "$2,769.08" $0.00 "$1,172.94" $0.00 $0.00 $0.00 $0.00 "$1,629.33" "$2,580.86" "$2,606.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147869 ERX HCPCS J3490 61958-2901-01 REMDESIVIR 100 MG IV SOLR BOTH IP/OP "$1,616.16 " "$1,195.96" $0.00 "$1,245.74" $727.27 $727.27 $0.00 $0.00 $0.00 $336.85 "$1,199.51" "$1,199.51" "$1,245.74" $0.00 $336.81 $0.00 $955.96 $955.96 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $238.42 $0.00 $0.00 $0.00 $0.00 $0.00 147917 ERX HCPCS 63700001 24338-0230-05 NIMODIPINE 6 MG/ML PO SOLN BOTH IP/OP $180.55 $133.61 $0.00 $137.33 $0.00 $0.00 $0.00 $32.14 $0.00 $0.00 $0.00 $0.00 $0.00 $37.63 $0.00 $0.00 $0.00 $0.00 $85.83 $135.95 $137.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147917 ERX HCPCS 63700001 24338-0230-12 NIMODIPINE 6 MG/ML PO SOLN BOTH IP/OP $180.55 $133.61 $0.00 $137.33 $0.00 $0.00 $0.00 $32.14 $0.00 $0.00 $0.00 $0.00 $0.00 $37.63 $0.00 $0.00 $0.00 $0.00 $85.83 $135.95 $137.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147933 ERX HCPCS Q5112 00006-5034-02 TRASTUZUMAB-DTTB 420 MG IV SOLR BOTH IP/OP "$10,058.93 " "$7,443.61" $0.00 "$7,753.42" $0.00 $0.00 $0.00 $0.00 $0.00 "$7,465.74" "$7,465.74" "$7,753.42" $0.00 "$3,284.24" $0.00 $0.00 $0.00 $0.00 "$4,562.13" "$7,226.41" "$7,299.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147956 ERX HCPCS 25000001 51144-0001-60 TUCATINIB 50 MG PO TABS BOTH IP/OP $360.53 $266.79 $0.00 $277.90 $0.00 $0.00 $0.00 $0.00 $0.00 $267.59 $267.59 $277.90 $0.00 $75.13 $0.00 $0.00 $0.00 $0.00 $144.90 $229.52 $231.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147957 ERX HCPCS 25000001 51144-0002-12 TUCATINIB 150 MG PO TABS BOTH IP/OP $630.02 $466.21 $0.00 $485.62 $0.00 $0.00 $0.00 $0.00 $0.00 $467.60 $467.60 $485.62 $0.00 $131.30 $0.00 $0.00 $0.00 $0.00 $282.13 $446.89 $451.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147957 ERX HCPCS 25000001 51144-0002-60 TUCATINIB 150 MG PO TABS BOTH IP/OP $630.02 $466.21 $0.00 $485.62 $0.00 $0.00 $0.00 $0.00 $0.00 $467.60 $467.60 $485.62 $0.00 $131.30 $0.00 $0.00 $0.00 $0.00 $282.13 $446.89 $451.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147974 ERX HCPCS C9066 55135-0132-01 SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR BOTH IP/OP "$5,935.08 " "$4,391.96" $0.00 "$4,574.76" "$2,670.79" "$2,670.79" "$2,250.58" "$2,250.58" "$2,250.58" "$1,237.02" "$4,405.02" "$4,405.02" "$4,574.76" "$2,185.49" "$2,567.95" "$1,420.57" "$2,925.99" "$2,925.99" $0.00 "$2,475.38" "$3,920.99" "$3,960.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 147993 ERX HCPCS J2250 51754-9130-01 MIDAZOLAM HCL-SODIUM CHLORIDE 50-0.8 MG/50ML-% IV SOLN BOTH IP/OP $75.34 $55.75 $0.00 $58.07 $33.90 $33.90 $0.00 $0.00 $0.00 $9.40 $55.92 $55.92 $58.07 $0.00 $7.58 $0.00 $44.56 $44.56 $0.00 $34.86 $55.22 $55.78 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 147993 ERX HCPCS J2250 51754-9130-05 MIDAZOLAM HCL-SODIUM CHLORIDE 50-0.8 MG/50ML-% IV SOLN BOTH IP/OP $75.34 $55.75 $0.00 $58.07 $33.90 $33.90 $0.00 $0.00 $0.00 $9.40 $55.92 $55.92 $58.07 $0.00 $7.58 $0.00 $44.56 $44.56 $0.00 $34.86 $55.22 $55.78 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 147994 ERX HCPCS J2250 51754-9131-01 MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.8 MG/100ML-% IV SOLN BOTH IP/OP $116.91 $86.51 $0.00 $90.11 $52.61 $52.61 $0.00 $0.00 $0.00 $18.80 $86.77 $86.77 $90.11 $0.00 $15.16 $0.00 $69.15 $69.15 $0.00 $53.70 $85.06 $85.92 $0.00 $0.00 $14.10 $0.00 $0.00 $13.43 $0.00 $0.00 $0.00 $0.00 $0.00 147994 ERX HCPCS J2250 51754-9131-05 MIDAZOLAM HCL-SODIUM CHLORIDE 100-0.8 MG/100ML-% IV SOLN BOTH IP/OP $116.91 $86.51 $0.00 $90.11 $52.61 $52.61 $0.00 $0.00 $0.00 $18.80 $86.77 $86.77 $90.11 $0.00 $15.16 $0.00 $69.15 $69.15 $0.00 $53.70 $85.06 $85.92 $0.00 $0.00 $14.10 $0.00 $0.00 $13.43 $0.00 $0.00 $0.00 $0.00 $0.00 148482 ERX HCPCS 25000001 70324-0326-03 SODIUM BICARBONATE-DEXTROSE 150-5 MEQ/L-% IV SOLN BOTH IP/OP $162.12 $119.97 $0.00 $124.96 $0.00 $0.00 $0.00 $0.00 $0.00 $120.33 $120.33 $124.96 $0.00 $33.79 $0.00 $0.00 $0.00 $0.00 $73.50 $116.42 $117.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 148738 ERX HCPCS 63700001 00087-0402-03 POLY-VI-SOL 50 MG/ML PO SOLN BOTH IP/OP $32.49 $24.04 $0.00 $25.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.25 $25.73 $25.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 148740 ERX HCPCS 63700001 00087-0405-01 POLY-VI-SOL/IRON 11 MG/ML PO SOLN BOTH IP/OP $35.83 $26.51 $0.00 $25.99 $0.00 $0.00 $0.00 $6.38 $0.00 $0.00 $0.00 $0.00 $0.00 $7.47 $0.00 $0.00 $0.00 $0.00 $16.25 $25.73 $25.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 149258 ERX HCPCS J3370 70594-0057-01 VANCOMYCIN HCL 1250 MG/250ML IV SOLN BOTH IP/OP $87.82 $64.99 $0.00 $126.00 $39.52 $39.52 $0.00 $0.00 $0.00 $7.24 $65.18 $65.18 $67.69 $0.00 $6.68 $0.00 $51.95 $51.95 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 149258 ERX HCPCS J3370 70594-0057-02 VANCOMYCIN HCL 1250 MG/250ML IV SOLN BOTH IP/OP $87.82 $64.99 $0.00 $126.00 $39.52 $39.52 $0.00 $0.00 $0.00 $7.24 $65.18 $65.18 $67.69 $0.00 $6.68 $0.00 $51.95 $51.95 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 149259 ERX HCPCS J3370 70594-0058-01 VANCOMYCIN HCL 1750 MG/350ML IV SOLN BOTH IP/OP $120.24 $88.98 $0.00 $158.76 $54.11 $54.11 $0.00 $0.00 $0.00 $10.86 $89.24 $89.24 $92.68 $0.00 $10.02 $0.00 $71.12 $71.12 $0.00 $99.23 $157.17 $158.76 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $0.00 149259 ERX HCPCS J3370 70594-0058-02 VANCOMYCIN HCL 1750 MG/350ML IV SOLN BOTH IP/OP $120.24 $88.98 $0.00 $158.76 $54.11 $54.11 $0.00 $0.00 $0.00 $10.86 $89.24 $89.24 $92.68 $0.00 $10.02 $0.00 $71.12 $71.12 $0.00 $99.23 $157.17 $158.76 $0.00 $0.00 $0.00 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $0.00 400291 ERX HCPCS J7040 00264-7800-10 SODIUM CHLORIDE 0.9 % IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.53 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.52 $0.00 $0.00 $1.44 $0.00 $0.00 $0.00 $0.00 $0.00 400291 ERX HCPCS J7040 00338-0049-03 SODIUM CHLORIDE 0.9 % IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.53 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.52 $0.00 $0.00 $1.44 $0.00 $0.00 $0.00 $0.00 $0.00 400291 ERX HCPCS J7040 00338-0049-04 SODIUM CHLORIDE 0.9 % IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.63 $16.33 $16.33 $16.96 $0.00 $1.53 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.52 $0.00 $0.00 $1.44 $0.00 $0.00 $0.00 $0.00 $0.00 400292 ERX HCPCS 25000001 00338-0043-03 SODIUM CHLORIDE 0.45 % IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400292 ERX HCPCS 25000001 00338-0043-04 SODIUM CHLORIDE 0.45 % IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400293 ERX HCPCS 25000001 00338-0017-02 DEXTROSE 5 % IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400293 ERX HCPCS 25000001 00338-0017-03 DEXTROSE 5 % IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400293 ERX HCPCS 25000001 00338-0017-04 DEXTROSE 5 % IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400294 ERX HCPCS 25000001 00338-0089-03 DEXTROSE 5 % AND 0.9 % NACL IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400294 ERX HCPCS 25000001 00338-0089-04 DEXTROSE 5 % AND 0.9 % NACL IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400295 ERX HCPCS 25000001 00338-0085-03 DEXTROSE 5 % AND 0.45 % NACL IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400295 ERX HCPCS 25000001 00338-0085-04 DEXTROSE 5 % AND 0.45 % NACL IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400296 ERX HCPCS 25000001 00264-7750-00 LACTATED RINGERS IV BOLUS ML BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400296 ERX HCPCS 25000001 00264-7750-20 LACTATED RINGERS IV BOLUS ML BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400296 ERX HCPCS 25000001 00338-0117-03 LACTATED RINGERS IV BOLUS ML BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400296 ERX HCPCS 25000001 00338-0117-04 LACTATED RINGERS IV BOLUS ML BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400296 ERX HCPCS 25000001 00409-7953-03 LACTATED RINGERS IV BOLUS ML BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400297 ERX HCPCS 25000001 00264-7751-10 DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400297 ERX HCPCS 25000001 00338-0125-04 DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600002 ERX HCPCS 25000001 99999-6008-77 ACETIC ACID 6% SOLN BOTH IP/OP $11.00 $8.14 $0.00 $11.86 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $7.41 $8.71 $11.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600002 ERX HCPCS 25000001 99999-6000-02 ACETIC ACID 6% SOLN BOTH IP/OP $11.00 $8.14 $0.00 $11.86 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $7.41 $11.74 $11.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600003 ERX HCPCS 25000001 99999-6006-90 ADULT MAGIC MOUTHWASH(MLX:BEN:NYS:LIDO) BOTH IP/OP $6.00 $4.44 $0.00 $17.94 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $11.21 $17.76 $17.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600007 ERX HCPCS J0290 99999-6000-07 AMPICILLIN 1 G/100ML NS MB PLUS BOTH IP/OP $69.81 $51.66 $0.00 $53.81 $31.41 $31.41 $0.00 $0.00 $0.00 $5.22 $51.81 $51.81 $53.81 $0.00 $1.90 $0.00 $41.29 $41.29 $0.00 $32.36 $51.25 $51.77 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 600007 ERX HCPCS J0290 99999-6010-85 AMPICILLIN 1 G/100ML NS MB PLUS BOTH IP/OP $69.81 $51.66 $0.00 $53.81 $31.41 $31.41 $0.00 $0.00 $0.00 $5.22 $51.81 $51.81 $53.81 $0.00 $1.90 $0.00 $41.29 $41.29 $0.00 $32.36 $51.25 $51.77 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 600008 ERX HCPCS J0290 99999-6000-08 AMPICILLIN 2 G/ NS 100ML MB PLUS BOTH IP/OP $80.07 $59.25 $0.00 $61.72 $36.03 $36.03 $0.00 $0.00 $0.00 $10.43 $59.43 $59.43 $61.72 $0.00 $3.79 $0.00 $47.36 $47.36 $0.00 $37.01 $58.62 $59.21 $0.00 $0.00 $4.61 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $0.00 600009 ERX HCPCS J0713 99999-6011-20 CEFTAZIDIME 1G/D5W 100 ML MB PLUS BOTH IP/OP $59.70 $44.18 $0.00 $46.02 $0.00 $0.00 $0.00 $0.00 $0.00 $44.31 $44.31 $46.02 $0.00 $12.44 $0.00 $0.00 $0.00 $0.00 $27.77 $43.99 $44.43 $0.00 $0.00 $8.69 $0.00 $0.00 $8.84 $0.00 $0.00 $0.00 $0.00 $0.00 600010 ERX HCPCS J0713 99999-6000-10 CEFTAZIDIME 2 G/D5W 100ML MB PLUS BOTH IP/OP $115.98 $85.83 $0.00 $89.40 $0.00 $0.00 $0.00 $0.00 $0.00 $86.08 $86.08 $89.40 $0.00 $24.17 $0.00 $0.00 $0.00 $0.00 $53.28 $84.40 $85.25 $0.00 $0.00 $16.68 $0.00 $0.00 $16.96 $0.00 $0.00 $0.00 $0.00 $0.00 600011 ERX HCPCS 25000001 99999-6011-16 NAFCILLIN 1 G/D5W 100 ML MB PLUS BOTH IP/OP $106.26 $78.63 $0.00 $81.91 $0.00 $0.00 $0.00 $0.00 $0.00 $78.87 $78.87 $81.91 $0.00 $22.14 $0.00 $0.00 $0.00 $0.00 $48.87 $77.41 $78.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600012 ERX HCPCS 25000001 99999-6000-12 NAFCILLIN 2GM/D5W 100ML MB PLUS BOTH IP/OP $157.82 $116.79 $0.00 $121.65 $0.00 $0.00 $0.00 $0.00 $0.00 $117.13 $117.13 $121.65 $0.00 $32.89 $0.00 $0.00 $0.00 $0.00 $72.25 $114.44 $115.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600013 ERX HCPCS J0743 99999-6000-13 IMIPENEM-CILAST 500MG/NS 100ML MB PLUS BOTH IP/OP $203.22 $150.38 $0.00 $156.64 $0.00 $0.00 $0.00 $0.00 $0.00 $150.83 $150.83 $156.64 $0.00 $17.89 $0.00 $0.00 $0.00 $0.00 $92.93 $147.20 $148.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600014 ERX HCPCS J0696 99999-6011-31 CEFTRIAXONE 1 G/D5W 100 ML MB PLUS BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $5.64 $38.59 $38.59 $40.08 $0.00 $2.36 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 600015 ERX HCPCS J0295 99999-6000-15 AMPICILLIN-SULB 1.5 G/NS 50ML MB PLUS BOTH IP/OP $109.57 $81.08 $0.00 $84.46 $49.31 $49.31 $0.00 $0.00 $0.00 $4.24 $81.32 $81.32 $84.46 $0.00 $2.60 $0.00 $64.81 $64.81 $0.00 $50.38 $79.79 $80.60 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 600016 ERX HCPCS J0295 99999-6000-16 AMPICILLIN-SULB 3 G/NS 100ML MB PLUS BOTH IP/OP $142.11 $105.16 $0.00 $109.54 $63.95 $63.95 $0.00 $0.00 $0.00 $8.48 $105.47 $105.47 $109.54 $0.00 $5.19 $0.00 $84.06 $84.06 $0.00 $65.13 $103.17 $104.21 $0.00 $0.00 $6.06 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 600017 ERX HCPCS j3370 99999-6000-17 VANCOMYCIN 1000 MG/250 ML D5W MB PLUS BOTH IP/OP $53.61 $39.67 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $39.79 $39.79 $41.32 $0.00 $11.17 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $31.20 $31.20 $8.14 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 600018 ERX HCPCS J0697 99999-6000-18 CEFUROXIME 0.75 G/D5W 100 ML MB PLUS BOTH IP/OP $99.00 $73.26 $0.00 $76.31 $0.00 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $76.31 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $45.58 $72.20 $72.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600018 ERX HCPCS J0697 99999-6011-23 CEFUROXIME 0.75 G/D5W 100 ML MB PLUS BOTH IP/OP $99.00 $73.26 $0.00 $76.31 $0.00 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $76.31 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $45.58 $72.20 $72.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600019 ERX HCPCS J0697 99999-6000-19 CEFUROXIME 1.5 G/D5W 100ML MB PLUS BOTH IP/OP $126.71 $93.77 $0.00 $97.67 $0.00 $0.00 $0.00 $0.00 $0.00 $94.04 $94.04 $97.67 $0.00 $4.73 $0.00 $0.00 $0.00 $0.00 $58.15 $92.10 $93.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600020 ERX HCPCS J0690 99999-6000-20 CEFAZOLIN 1GM/D5W 50ML MB PLUS BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $1.39 $38.59 $38.59 $40.08 $0.00 $1.75 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $1.93 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 600021 ERX HCPCS 25000001 99999-6000-21 DOXYCYCLINE 100MG/ NS 100ML MB PLUS BOTH IP/OP $109.78 $81.24 $0.00 $84.62 $0.00 $0.00 $0.00 $0.00 $0.00 $81.48 $81.48 $84.62 $0.00 $22.88 $0.00 $0.00 $0.00 $0.00 $50.47 $79.94 $80.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600021 ERX HCPCS 25000001 99999-6010-83 DOXYCYCLINE 100MG/ NS 100ML MB PLUS BOTH IP/OP $109.78 $81.24 $0.00 $84.62 $0.00 $0.00 $0.00 $0.00 $0.00 $81.48 $81.48 $84.62 $0.00 $22.88 $0.00 $0.00 $0.00 $0.00 $50.47 $79.94 $80.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600022 ERX HCPCS j3370 99999-6000-22 VANCOMYCIN 500MG/100 ML D5W MB PLUS BOTH IP/OP $58.60 $43.36 $0.00 $45.17 $0.00 $0.00 $0.00 $0.00 $0.00 $43.49 $43.49 $45.17 $0.00 $12.21 $0.00 $0.00 $0.00 $0.00 $27.27 $43.20 $43.63 $32.72 $32.72 $8.54 $0.00 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $0.00 600023 ERX HCPCS J0694 99999-6011-24 CEFOXITIN 1 G/D5W 100 ML MB PLUS BOTH IP/OP $119.15 $88.17 $0.00 $91.84 $53.62 $53.62 $0.00 $0.00 $0.00 $8.06 $88.43 $88.43 $91.84 $0.00 $5.42 $0.00 $70.48 $70.48 $0.00 $54.72 $86.67 $87.54 $0.00 $0.00 $6.22 $0.00 $0.00 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 600027 ERX HCPCS J0694 99999-6000-27 CEFOXITIN 2 G/D5W 100ML MB PLUS BOTH IP/OP $107.14 $79.28 $0.00 $82.58 $48.21 $48.21 $0.00 $0.00 $0.00 $16.12 $79.52 $79.52 $82.58 $0.00 $10.84 $0.00 $63.37 $63.37 $0.00 $49.28 $78.05 $78.84 $0.00 $0.00 $12.43 $0.00 $0.00 $11.84 $0.00 $0.00 $0.00 $0.00 $0.00 600028 ERX HCPCS 25000001 99999-6000-28 UVC FLUID 100ML BOTH IP/OP $34.95 $25.86 $0.00 $26.94 $0.00 $0.00 $0.00 $0.00 $0.00 $25.94 $25.94 $26.94 $0.00 $7.28 $0.00 $0.00 $0.00 $0.00 $15.85 $25.11 $25.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600029 ERX HCPCS 25000001 99999-6000-29 UAC FLUID 100ML BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600030 ERX HCPCS 25000001 99999-6000-30 PAL FLUID 100ML BOTH IP/OP $68.57 $50.74 $0.00 $52.85 $0.00 $0.00 $0.00 $0.00 $0.00 $50.89 $50.89 $52.85 $0.00 $14.29 $0.00 $0.00 $0.00 $0.00 $31.10 $49.25 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600031 ERX HCPCS J0456 99999-6000-31 AZITHROMYCIN 500MG/D5W 250ML MB PLUS BOTH IP/OP $52.51 $38.86 $0.00 $41.60 $23.63 $23.63 $0.00 $0.00 $0.00 $10.94 $38.97 $38.97 $40.47 $0.00 $10.94 $0.00 $31.06 $31.06 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $8.14 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 600032 ERX HCPCS J0698 99999-6011-21 CEFOTAXIME 1 G/D5W 100 ML MB PLUS BOTH IP/OP $96.99 $71.77 $0.00 $74.76 $0.00 $0.00 $0.00 $0.00 $0.00 $71.99 $71.99 $74.76 $0.00 $11.52 $0.00 $0.00 $0.00 $0.00 $44.67 $70.76 $71.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600033 ERX HCPCS J2543 99999-6000-33 PIPERACIL-TAZO 2.25 G/D5W 50ML MB PLUS BOTH IP/OP $77.49 $57.34 $0.00 $59.73 $34.87 $34.87 $0.00 $0.00 $0.00 $13.09 $57.51 $57.51 $59.73 $0.00 $3.47 $0.00 $45.84 $45.84 $0.00 $35.84 $56.77 $57.34 $0.00 $0.00 $4.35 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 600034 ERX HCPCS J2543 99999-6000-34 PIPERACIL-TAZ 3.375 G/D5W 50ML MB PLUS BOTH IP/OP $95.90 $70.97 $0.00 $73.92 $43.16 $43.16 $0.00 $0.00 $0.00 $19.63 $71.18 $71.18 $73.92 $0.00 $5.21 $0.00 $56.72 $56.72 $0.00 $44.19 $69.99 $70.70 $0.00 $0.00 $6.52 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 600035 ERX HCPCS J2543 99999-6000-35 PIPERACIL-TAZO 4.5 G/100 ML D5W MB PLUS BOTH IP/OP $103.43 $76.54 $0.00 $79.72 $46.54 $46.54 $0.00 $0.00 $0.00 $26.18 $76.77 $76.77 $79.72 $0.00 $6.94 $0.00 $61.18 $61.18 $0.00 $47.59 $75.38 $76.14 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 600036 ERX HCPCS J3010 99999-6000-36 FENTANYL 2000MCG/NS 100ML PREMIX BOTH IP/OP $239.43 $177.18 $0.00 $184.55 $107.74 $107.74 $0.00 $0.00 $0.00 $49.90 $177.70 $177.70 $184.55 $0.00 $14.90 $0.00 $141.62 $141.62 $0.00 $108.68 $172.14 $173.88 $0.00 $0.00 $23.27 $0.00 $0.00 $22.15 $0.00 $0.00 $0.00 $0.00 $0.00 600037 ERX HCPCS J2250 99999-6000-37 MIDAZOLAM 50MG/NS 50ML PREMIX BOTH IP/OP $113.53 $84.01 $0.00 $87.51 $51.09 $51.09 $0.00 $0.00 $0.00 $9.40 $84.26 $84.26 $87.51 $0.00 $7.58 $0.00 $67.15 $67.15 $0.00 $51.47 $81.53 $82.35 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 600038 ERX HCPCS J1335 99999-6000-38 ERTAPENEM 1 G/NS 50ML MB PLUS BOTH IP/OP $481.37 $356.21 $0.00 $197.19 $115.12 $115.12 $0.00 $0.00 $0.00 $100.33 $189.87 $189.87 $197.19 $0.00 $66.36 $0.00 $151.32 $151.32 $0.00 $116.81 $185.02 $186.89 $0.00 $0.00 $90.95 $0.00 $0.00 $86.60 $0.00 $0.00 $0.00 $0.00 $0.00 600040 ERX HCPCS J2185 99999-6000-40 MEROPENEM 1 G/NS 100 ML MB PLUS BOTH IP/OP $185.73 $137.44 $0.00 $143.16 $0.00 $0.00 $0.00 $0.00 $38.71 $137.85 $137.85 $143.16 $0.00 $9.33 $0.00 $109.86 $109.86 $0.00 $84.91 $134.49 $135.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600041 ERX HCPCS J2700 99999-6000-41 OXACILLIN 2 G/D5W 100ML MB PLUS BOTH IP/OP $131.69 $97.45 $0.00 $101.51 $0.00 $0.00 $0.00 $0.00 $0.00 $97.74 $97.74 $101.51 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $60.41 $95.68 $96.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600042 ERX HCPCS J2700 99999-6011-22 OXACILLIN 1 G/D5W 100 ML MB PLUS BOTH IP/OP $103.21 $76.38 $0.00 $79.55 $0.00 $0.00 $0.00 $0.00 $0.00 $76.60 $76.60 $79.55 $0.00 $6.02 $0.00 $0.00 $0.00 $0.00 $47.49 $75.22 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600043 ERX HCPCS J0696 99999-6011-32 CEFTRIAXONE 2 G/D5W 100 ML MB PLUS BOTH IP/OP $158.60 $117.36 $0.00 $122.25 $71.37 $71.37 $0.00 $0.00 $0.00 $11.28 $117.71 $117.71 $122.25 $0.00 $4.73 $0.00 $93.81 $93.81 $0.00 $72.60 $115.00 $116.16 $0.00 $0.00 $5.64 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 600046 ERX HCPCS 25000001 99999-6000-46 TOBRAMYCIN FORT 95MG/7ML OPHTH SOLN BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600048 ERX HCPCS 25000001 99999-6000-48 CEFAZOLIN FORT OPHTH 50 MG/ML 10ML BOTH IP/OP $52.38 $38.76 $0.00 $40.37 $0.00 $0.00 $0.00 $0.00 $0.00 $38.88 $38.88 $40.37 $0.00 $10.92 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600049 ERX HCPCS 25000001 99999-6000-49 VANCOMYCIN 30 MG/ML (3%) OPHTH SOLN BOTH IP/OP $87.52 $64.76 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 $64.96 $64.96 $67.46 $0.00 $18.24 $0.00 $0.00 $0.00 $0.00 $39.68 $62.85 $63.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600051 ERX HCPCS 25000001 99999-6000-51 GENTAMICIN FORT 95MG/7ML OPHTH SOL BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600052 ERX HCPCS 25000001 99999-6000-52 LEECH BOTH IP/OP $83.80 $62.01 $0.00 $64.59 $0.00 $0.00 $0.00 $0.00 $0.00 $62.20 $62.20 $64.59 $0.00 $17.46 $0.00 $0.00 $0.00 $0.00 $38.00 $60.19 $60.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600053 ERX HCPCS 25000001 99999-6000-53 BEER BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600054 ERX HCPCS 25000001 99999-6000-54 L.E.T. TOPICAL GEL 3ML BOTH IP/OP $20.95 $15.50 $0.00 $16.15 $0.00 $0.00 $0.00 $0.00 $0.00 $15.55 $15.55 $16.15 $0.00 $4.37 $0.00 $0.00 $0.00 $0.00 $9.50 $15.05 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600055 ERX HCPCS 25000001 99999-6000-55 MIDAZOLAM 2MG/1 ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600056 ERX HCPCS 25000001 99999-6000-56 MIDAZOLAM 5MG/2.5ML ORAL SYRINGE BOTH IP/OP $12.57 $9.30 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 $9.33 $9.33 $9.69 $0.00 $2.62 $0.00 $0.00 $0.00 $0.00 $5.70 $9.03 $9.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600058 ERX HCPCS 25000001 99999-6000-58 METHADONE 1MG/1ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600060 ERX HCPCS 25000001 99999-6000-60 METHADONE 0.5MG/0.5ML ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600061 ERX HCPCS 63700001 99999-6000-61 METHADONE 5MG/5ML ORAL SYRINGE BOTH IP/OP $10.48 $7.76 $0.00 $7.60 $0.00 $0.00 $0.00 $1.87 $0.00 $0.00 $0.00 $0.00 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $4.75 $7.52 $7.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600062 ERX HCPCS 25000001 99999-6000-62 OXYCODONE LIQ 120MG/6ML ORAL SYRINGE BOTH IP/OP $28.85 $21.35 $0.00 $22.24 $0.00 $0.00 $0.00 $0.00 $0.00 $21.41 $21.41 $22.24 $0.00 $6.01 $0.00 $0.00 $0.00 $0.00 $13.08 $20.72 $20.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600063 ERX HCPCS 25000001 99999-6000-63 DIAZEPAM ELIXIR 1MG/ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600065 ERX HCPCS 63700001 99999-6000-65 OXANDROLONE 1MG/1ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600066 ERX HCPCS 63700001 99999-6000-66 OXANDROLONE 10MG/10ML ORAL SYRINGE BOTH IP/OP $644.22 $476.72 $0.00 $467.82 $0.00 $0.00 $0.00 $114.67 $0.00 $0.00 $0.00 $0.00 $0.00 $134.26 $0.00 $0.00 $0.00 $0.00 $292.39 $463.15 $467.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600067 ERX HCPCS 25000001 99999-6000-67 MORPHINE SULFATE 20MG/ML O/S 5ML BOTH IP/OP $11.53 $8.53 $0.00 $8.89 $0.00 $0.00 $0.00 $0.00 $0.00 $8.56 $8.56 $8.89 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $5.23 $8.28 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600068 ERX HCPCS 25000001 99999-6000-68 MORPHINE SULFATE 20MG/ML O/S 3ML BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600069 ERX HCPCS 25000001 99999-6000-69 MORPHINE SULFATE 20MG/ML O/S 2ML BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600079 ERX HCPCS 25000001 99999-6000-79 CALCITRIOL 1MCG/ML ORAL SYRINGE (NICU) BOTH IP/OP $49.99 $36.99 $0.00 $38.53 $0.00 $0.00 $0.00 $0.00 $0.00 $37.10 $37.10 $38.53 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $22.67 $35.91 $36.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600107 ERX HCPCS 63700001 99999-6001-07 FUROSEMIDE 10MG/ML ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600109 ERX HCPCS 25000001 99999-6001-09 NEVIRAPINE 10MG/ML ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600112 ERX HCPCS 25000001 99999-6001-12 ALUM-MG HYDRX-SIMETH 15ML ORAL SYRINGE BOTH IP/OP $18.86 $13.96 $0.00 $14.54 $0.00 $0.00 $0.00 $0.00 $0.00 $14.00 $14.00 $14.54 $0.00 $3.93 $0.00 $0.00 $0.00 $0.00 $8.55 $13.54 $13.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600126 ERX HCPCS 63700001 99999-6001-26 KALETRA 80MG/20MG/ML ORAL SYRINGE BOTH IP/OP $54.22 $40.12 $0.00 $39.34 $0.00 $0.00 $0.00 $9.65 $0.00 $0.00 $0.00 $0.00 $0.00 $11.30 $0.00 $0.00 $0.00 $0.00 $24.59 $38.95 $39.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600134 ERX HCPCS 63700001 99999-6001-34 POSACONAZOLE 200MG/5 ML ORAL SYRINGE BOTH IP/OP $110.21 $81.56 $0.00 $79.94 $0.00 $0.00 $0.00 $19.62 $0.00 $0.00 $0.00 $0.00 $0.00 $22.97 $0.00 $0.00 $0.00 $0.00 $49.97 $79.14 $79.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600137 ERX HCPCS 63700001 99999-6001-37 ERGOCALCIFEROL 8000 UNITS/ML (NICU) ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600138 ERX HCPCS 25000001 99999-6001-38 PENICILLIN VK 50MG/ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600141 ERX HCPCS 25000001 99999-6001-41 TRIFLUOPERAZINE 10MG/ML ORAL SYRINGE BOTH IP/OP $10.02 $7.41 $0.00 $7.72 $0.00 $0.00 $0.00 $0.00 $0.00 $7.44 $7.44 $7.72 $0.00 $2.09 $0.00 $0.00 $0.00 $0.00 $4.55 $7.20 $7.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600144 ERX HCPCS 63700001 99999-6001-44 ZIDOVUDINE 10MG/ML ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600151 ERX HCPCS 25000001 99999-6001-51 BACLOFEN 1MG/ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600152 ERX HCPCS 25000001 99999-6001-52 BACLOFEN 10MG/ML ORAL SYRINGE HI CONC BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600153 ERX HCPCS 25000001 99999-6001-53 SIMETHICONE 40MG/0.6ML ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600157 ERX HCPCS 25000001 99999-6001-57 LANSOPRAZOLE 3MG/ML ORAL SYRINGE (NICU) BOTH IP/OP $68.89 $50.98 $0.00 $53.10 $0.00 $0.00 $0.00 $0.00 $0.00 $51.13 $51.13 $53.10 $0.00 $14.36 $0.00 $0.00 $0.00 $0.00 $31.24 $49.48 $49.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600159 ERX HCPCS 63700001 99999-6001-59 MULTIPLE VIT W/IRON ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600162 ERX HCPCS 25000001 99999-6001-62 PREDNISOLONE 9MG/3ML ORAL SYRINGE BOTH IP/OP $16.97 $12.56 $0.00 $13.08 $0.00 $0.00 $0.00 $0.00 $0.00 $12.60 $12.60 $13.08 $0.00 $3.54 $0.00 $0.00 $0.00 $0.00 $7.70 $12.19 $12.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600163 ERX HCPCS 25000001 99999-6001-63 PREDNISOLONE 30MG/10ML ORAL SYRINGE BOTH IP/OP $173.70 $128.54 $0.00 $133.89 $0.00 $0.00 $0.00 $0.00 $0.00 $128.92 $128.92 $133.89 $0.00 $36.20 $0.00 $0.00 $0.00 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600164 ERX HCPCS 25000001 99999-6001-64 PREDNISOLONE 15MG/5ML ORAL SYRINGE BOTH IP/OP $28.29 $20.93 $0.00 $21.81 $0.00 $0.00 $0.00 $0.00 $0.00 $21.00 $21.00 $21.81 $0.00 $5.90 $0.00 $0.00 $0.00 $0.00 $12.83 $20.31 $20.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600166 ERX HCPCS 25000001 99999-6001-66 CHLORHEXIDINE MTHWASH 0.12% 1ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600175 ERX HCPCS 63700001 99999-6001-75 NYSTATIN 100000U/ML ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600176 ERX HCPCS 25000001 99999-6001-76 NYSTATIN 50000U/0.5ML ORAL SYRNGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600177 ERX HCPCS 63700001 99999-6001-77 NYSTATIN 200000U/2ML ORAL SYRNGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600181 ERX HCPCS 63700001 99999-6001-81 SODIUM CHLORIDE 4 MEQ/ML ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600191 ERX HCPCS 63700001 99999-6001-91 FLUOXETINE 4MG/ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600199 ERX HCPCS 63700001 99999-6001-99 FLUPHENAZINE 2.5MG/5ML ORAL SYRINGE BOTH IP/OP $38.89 $28.78 $0.00 $28.22 $0.00 $0.00 $0.00 $6.92 $0.00 $0.00 $0.00 $0.00 $0.00 $8.10 $0.00 $0.00 $0.00 $0.00 $17.64 $27.93 $28.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600200 ERX HCPCS 63700001 99999-6002-00 FLUPHENAZINE 0.5MG/ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600206 ERX HCPCS 63700001 99999-6002-06 SULFAMETHOXAZOLE-TMP SUSP 1ML O/S DOSE # 1 BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600207 ERX HCPCS 63700001 99999-6002-07 SULFAMETHOXAZOLE-TMP SUSP 1ML O/S DOSE # 2 BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600208 ERX HCPCS 63700001 99999-6002-08 SULFAMETHOXAZOLE-TMP SUSP 1ML O/S DOSE # 3 BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600209 ERX HCPCS 63700001 99999-6002-09 SULFAMETHOXAZOLE-TMP SUSP 5ML O/S DOSE # 5 BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600210 ERX HCPCS 63700001 99999-6002-10 SULFAMETHOXAZOLE-TMP SUSP 20ML O/S DOSE # 6 BOTH IP/OP $10.06 $7.44 $0.00 $7.30 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $4.56 $7.22 $7.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600211 ERX HCPCS 63700001 99999-6002-11 SULFAMETHOXAZOLE-TMP SUSP 1ML O/S DOSE # 4 BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600220 ERX HCPCS 63700001 99999-6002-20 MULTIPLE VITAMIN (NICU) ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600221 ERX HCPCS 25000001 99999-6002-21 GUAIFENESIN DM 1ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600231 ERX HCPCS 25000001 99999-6002-31 NITAZOXANIDE 100MG/5ML ORAL SYRNGE BOTH IP/OP $129.31 $95.69 $0.00 $99.67 $0.00 $0.00 $0.00 $0.00 $0.00 $95.97 $95.97 $99.67 $0.00 $26.95 $0.00 $0.00 $0.00 $0.00 $58.63 $92.86 $93.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600232 ERX HCPCS 25000001 99999-6002-32 BENADRYL/MAALOX 1:1 BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600237 ERX HCPCS 63700001 99999-6002-37 RISPERIDONE 2 MG/2 ML ORAL SYRINGE BOTH IP/OP $55.15 $40.81 $0.00 $40.01 $0.00 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 $11.49 $0.00 $0.00 $0.00 $0.00 $25.01 $39.61 $40.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600240 ERX HCPCS 25000001 99999-6002-40 HYDROMORPHONE 15000MCG/30ML NS PED BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600241 ERX HCPCS 25000001 99999-6002-41 HYDROMORPHONE 30000MCG/30ML NS PED BOTH IP/OP $41.57 $30.76 $0.00 $32.04 $0.00 $0.00 $0.00 $0.00 $0.00 $30.85 $30.85 $32.04 $0.00 $8.66 $0.00 $0.00 $0.00 $0.00 $18.85 $29.86 $30.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600245 ERX HCPCS 25000001 99999-6010-93 AZTREONAM 1 G/100ML D5W MB PLUS BOTH IP/OP $195.23 $144.47 $0.00 $150.48 $0.00 $0.00 $0.00 $0.00 $0.00 $144.90 $144.90 $150.48 $0.00 $40.69 $0.00 $0.00 $0.00 $0.00 $89.21 $141.31 $142.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600246 ERX HCPCS 25000001 99999-6010-94 AZTREONAM 2 G/100ML D5W MB PLUS BOTH IP/OP $318.60 $235.76 $0.00 $245.58 $0.00 $0.00 $0.00 $0.00 $0.00 $236.46 $236.46 $245.58 $0.00 $66.40 $0.00 $0.00 $0.00 $0.00 $145.30 $230.16 $232.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600247 ERX HCPCS 25000001 99999-6002-47 KETAMINE 50MG/1 ML IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600253 ERX HCPCS 25000001 99999-6002-53 AMPHOTERICIN B 5MCG/0.1ML OPHTH SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600255 ERX HCPCS 25000001 99999-6002-55 GANCICLOVIR 2MG/0.1 ML OPHTH SYRINGE BOTH IP/OP $337.54 $249.78 $0.00 $260.18 $0.00 $0.00 $0.00 $0.00 $0.00 $250.52 $250.52 $260.18 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $153.21 $242.68 $245.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600263 ERX HCPCS 25000001 99999-6002-63 NICARDIPINE 1MG/10ML NS BOTH IP/OP $160.97 $119.12 $0.00 $124.08 $0.00 $0.00 $0.00 $0.00 $0.00 $119.47 $119.47 $124.08 $0.00 $33.55 $0.00 $0.00 $0.00 $0.00 $72.98 $115.59 $116.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600273 ERX HCPCS 25000001 99999-6002-73 AMIKACIN 400MCG/0.1ML OPHTH SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600283 ERX HCPCS 25000001 99999-6002-83 VORICONAZOLE 40MCG/0.1 ML NS OPHTH SYRINGE BOTH IP/OP $512.67 $379.38 $0.00 $395.17 $0.00 $0.00 $0.00 $0.00 $0.00 $380.50 $380.50 $395.17 $0.00 $106.84 $0.00 $0.00 $0.00 $0.00 $232.69 $368.57 $372.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600285 ERX HCPCS 25000001 99999-6002-85 COSYNTROPIN 1 MCG/1 ML (NICU) IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600297 ERX HCPCS 25000001 99999-6002-97 NACL 0.45% FLUSH 2ML IV SYRINGE (NICU) BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600306 ERX HCPCS 25000001 99999-6003-06 CEFTAZIDIME 2.25MG/0.1ML OPHTH SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600307 ERX HCPCS 25000001 99999-6003-07 VITAMIN A 5000U/0.1ML IM SYRINGE (NICU) BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600313 ERX HCPCS 25000001 99999-6003-13 VANCOMYCIN 0.75MG/0.1ML OPHTH SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600314 ERX HCPCS 25000001 99999-6003-14 VANCOMYCIN 1MG/0.1ML OPHTH SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600316 ERX HCPCS 25000001 99999-6003-16 VASOPRESSIN 4 UNITS/10 ML NS BOTH IP/OP $45.26 $33.49 $0.00 $34.89 $0.00 $0.00 $0.00 $0.00 $0.00 $33.59 $33.59 $34.89 $0.00 $9.43 $0.00 $0.00 $0.00 $0.00 $20.52 $32.50 $32.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600328 ERX HCPCS 25000001 99999-6003-28 HEPARIN FLUSH 1 UNIT/ML 0.45% NS (NICU) 6ML BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600328 ERX HCPCS 25000001 99999-6011-72 HEPARIN FLUSH 1 UNIT/ML 0.45% NS (NICU) 6ML BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600333 ERX HCPCS J2997 99999-6003-33 ALTEPLASE 1MG/1 ML SW IV SYRINGE(NICU) BOTH IP/OP $570.57 $422.22 $0.00 $439.80 $256.76 $256.76 $87.67 $87.67 $87.67 $118.92 $423.48 $423.48 $439.80 $87.75 $118.91 $57.04 $337.49 $337.49 $92.02 $258.97 $410.20 $414.34 $127.08 $127.08 $81.06 $0.00 $0.00 $82.45 $87.89 $0.00 $0.00 $0.00 $0.00 600340 ERX HCPCS 25000001 99999-6003-40 EPHEDRINE 50MG/10ML NS IV SYRINGE BOTH IP/OP $63.53 $47.01 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $0.00 $47.15 $47.15 $48.97 $0.00 $13.24 $0.00 $0.00 $0.00 $0.00 $28.81 $45.63 $46.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600356 ERX HCPCS 25000001 99999-6003-56 ON-Q PUMP 270 ML 2 ML/HR SINGLE LUMEN BOTH IP/OP $541.34 $400.59 $0.00 $417.26 $0.00 $0.00 $0.00 $0.00 $0.00 $401.78 $401.78 $417.26 $0.00 $112.82 $0.00 $0.00 $0.00 $0.00 $245.70 $389.18 $393.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600357 ERX HCPCS 25000001 99999-6003-57 ON-Q PUMP 400 ML 4 ML/HR DUAL LUMEN BOTH IP/OP "$1,424.50 " "$1,054.13" $0.00 "$1,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,057.26" "$1,057.26" "$1,098.00" $0.00 $296.87 $0.00 $0.00 $0.00 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600358 ERX HCPCS 25000001 99999-6003-58 ON-Q PUMP 400 ML 5 ML/HR SINGLE LUMEN BOTH IP/OP $766.50 $567.21 $0.00 $590.82 $0.00 $0.00 $0.00 $0.00 $0.00 $568.90 $568.90 $590.82 $0.00 $159.74 $0.00 $0.00 $0.00 $0.00 $347.82 $550.94 $556.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600359 ERX HCPCS 25000001 99999-6003-59 ON-Q C-BLOC PUMP 400ML BOTH IP/OP $876.00 $648.24 $0.00 $675.22 $0.00 $0.00 $0.00 $0.00 $0.00 $650.17 $650.17 $675.22 $0.00 $182.56 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600360 ERX HCPCS 25000001 99999-6003-60 FOSCARNET SODIUM 2.4MG/0.1ML OPHTH SYRINGE BOTH IP/OP $826.36 $611.51 $0.00 $636.96 $0.00 $0.00 $0.00 $0.00 $0.00 $613.32 $613.32 $636.96 $0.00 $172.21 $0.00 $0.00 $0.00 $0.00 $374.98 $593.96 $599.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600362 ERX HCPCS J0690 99999-6003-62 CEFAZOLIN 1GM/NS 50ML MB PLUS-OR ONLY BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $1.39 $38.59 $38.59 $40.08 $0.00 $1.75 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $1.93 $0.00 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 600364 ERX HCPCS J2543 99999-6003-64 PIPERACIL-TAZ 3.375 G/NS 50ML MB PLUS BOTH IP/OP $95.90 $70.97 $0.00 $73.92 $43.16 $43.16 $0.00 $0.00 $0.00 $19.63 $71.18 $71.18 $73.92 $0.00 $5.21 $0.00 $56.72 $56.72 $0.00 $44.19 $69.99 $70.70 $0.00 $0.00 $6.52 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 600365 ERX HCPCS J2543 99999-6003-65 PIPERACIL-TAZO 4.5 G/NS 100ML MB PLUS BOTH IP/OP $103.43 $76.54 $0.00 $79.72 $46.54 $46.54 $0.00 $0.00 $0.00 $26.18 $76.77 $76.77 $79.72 $0.00 $6.94 $0.00 $61.18 $61.18 $0.00 $47.59 $75.38 $76.14 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 600367 ERX HCPCS J0694 99999-6011-25 CEFOXITIN 1 G/NS 100 ML MB PLUS-OR ONLY BOTH IP/OP $119.15 $88.17 $0.00 $91.84 $53.62 $53.62 $0.00 $0.00 $0.00 $8.06 $88.43 $88.43 $91.84 $0.00 $5.42 $0.00 $70.48 $70.48 $0.00 $54.72 $86.67 $87.54 $0.00 $0.00 $6.22 $0.00 $0.00 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 600368 ERX HCPCS 25000001 99999-6003-68 PENICILLIN G 2 MU/NS 50ML-OR ONLY BOTH IP/OP $199.22 $147.42 $0.00 $153.56 $0.00 $0.00 $0.00 $0.00 $0.00 $147.86 $147.86 $153.56 $0.00 $41.52 $0.00 $0.00 $0.00 $0.00 $90.43 $143.23 $144.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600369 ERX HCPCS 25000001 99999-6003-69 DESMOPRESSIN 0.25MCG/0.5ML NS SYRINGE BOTH IP/OP $36.98 $27.37 $0.00 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $27.45 $27.45 $28.50 $0.00 $7.71 $0.00 $0.00 $0.00 $0.00 $16.77 $26.56 $26.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600378 ERX HCPCS 25000001 99999-6003-78 KAOPECTATE AND BENADRYL 1:1 ORAL SOLUTION BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600380 ERX HCPCS 25000001 99999-6003-80 GENTAMICIN 0.5ML (80MG/ML) WITH 0.5ML OF DEXAMETHASONE-OR BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600381 ERX HCPCS 25000001 99999-6003-81 "EPINEPHRINE 0.3ML (1:1000,1MG/ML) IN 500ML BSS PLUS-OR" BOTH IP/OP $100.50 $74.37 $0.00 $77.47 $0.00 $0.00 $0.00 $0.00 $0.00 $74.59 $74.59 $77.47 $0.00 $20.94 $0.00 $0.00 $0.00 $0.00 $46.27 $73.28 $74.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600382 ERX HCPCS 25000001 99999-6003-82 LIDOCAINE 2% 3ML/.75% MARCAINE 3ML/200MG WYDASE 1ML BOTH IP/OP $233.03 $172.44 $0.00 $179.62 $0.00 $0.00 $0.00 $0.00 $0.00 $172.95 $172.95 $179.62 $0.00 $48.56 $0.00 $0.00 $0.00 $0.00 $106.46 $168.63 $170.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600383 ERX HCPCS 25000001 99999-6003-83 SUGARCAINE MIXTURE 5ML-OR BOTH IP/OP $48.63 $35.99 $0.00 $37.48 $0.00 $0.00 $0.00 $0.00 $0.00 $36.09 $36.09 $37.48 $0.00 $10.13 $0.00 $0.00 $0.00 $0.00 $22.05 $34.93 $35.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600384 ERX HCPCS 25000001 99999-6003-84 LIDOCAINE/BUPIVACAINE/HYALURONIDASE - OR EYE BLOCK BOTH IP/OP $241.22 $178.50 $0.00 $185.93 $0.00 $0.00 $0.00 $0.00 $0.00 $179.03 $179.03 $185.93 $0.00 $50.27 $0.00 $0.00 $0.00 $0.00 $110.18 $174.53 $176.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600385 ERX HCPCS 25000001 99999-6003-85 LIDOCAINE/EPI/NS-OR TUMESCENT MIXTURE BOTH IP/OP $62.73 $46.42 $0.00 $48.35 $0.00 $0.00 $0.00 $0.00 $0.00 $46.56 $46.56 $48.35 $0.00 $13.07 $0.00 $0.00 $0.00 $0.00 $29.15 $46.17 $46.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600386 ERX HCPCS 25000001 99999-6003-86 LIDOCAINE 1% 14 ML/PAPAVERINE (30 MG/ML) 2 ML-OR BOTH IP/OP $54.06 $40.00 $0.00 $41.67 $0.00 $0.00 $0.00 $0.00 $0.00 $40.12 $40.12 $41.67 $0.00 $11.27 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600388 ERX HCPCS 25000001 99999-6003-88 "BACITRACIN 50,000 UNITS IN 1000 ML NS - OR NEURO" BOTH IP/OP $96.20 $71.19 $0.00 $76.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.10 $76.19 $76.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600389 ERX HCPCS 25000001 99999-6003-89 IOHEXOL 300 MG/ML 50 ML MIXED WITH 50ML STERILE WATER-OR GU BOTH IP/OP $245.76 $181.86 $0.00 $189.43 $0.00 $0.00 $0.00 $0.00 $0.00 $182.40 $182.40 $189.43 $0.00 $51.22 $0.00 $0.00 $0.00 $0.00 $112.24 $177.79 $179.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600390 ERX HCPCS 25000001 99999-6003-90 VASOPRESSIN 20 UNITS IN 50 ML NS - OR GYN BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600391 ERX HCPCS 25000001 99999-6003-91 VASOPRESSIN 20 UNITS IN 100 ML NS - OR GYN BOTH IP/OP $52.00 $38.48 $0.00 $585.28 $0.00 $0.00 $0.00 $0.00 $0.00 $563.56 $563.56 $585.28 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600392 ERX HCPCS 25000001 99999-6003-92 VASOPRESSIN 20 UNITS IN 200 ML OF NS - OR GYN BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600393 ERX HCPCS 25000001 99999-6003-93 INDIGO CARMINE 5 ML/100 ML 0.9% SODIUM CHLORIDE -OR BOTH IP/OP $94.61 $70.01 $0.00 $72.93 $0.00 $0.00 $0.00 $0.00 $0.00 $70.22 $70.22 $72.93 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $43.60 $69.06 $69.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600394 ERX HCPCS 25000001 99999-6003-94 INDIGO CARMINE 5 ML/200 ML 0.9% SODIUM CHLORIDE -OR BOTH IP/OP $94.61 $70.01 $0.00 $72.93 $0.00 $0.00 $0.00 $0.00 $0.00 $70.22 $70.22 $72.93 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $43.60 $69.06 $69.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600395 ERX HCPCS 25000001 99999-6003-95 INDIGO CARMINE 5 ML/250 ML 0.9% SODIUM CHLORIDE -OR BOTH IP/OP $94.61 $70.01 $0.00 $72.93 $0.00 $0.00 $0.00 $0.00 $0.00 $70.22 $70.22 $72.93 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $43.60 $69.06 $69.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600396 ERX HCPCS 25000001 99999-6003-96 INDIGO CARMINE 5 ML/300 ML 0.9% SODIUM CHLORIDE -OR BOTH IP/OP $94.61 $70.01 $0.00 $72.93 $0.00 $0.00 $0.00 $0.00 $0.00 $70.22 $70.22 $72.93 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $43.60 $69.06 $69.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600397 ERX HCPCS J3475 15082-0902-05 MAGNESIUM SULFATE 2 G IN 50ML D5W PREMIX BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $0.24 $38.59 $38.59 $40.08 $0.00 $3.53 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $2.96 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $0.00 600397 ERX HCPCS J3475 42852-0902-05 MAGNESIUM SULFATE 2 G IN 50ML D5W PREMIX BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $0.24 $38.59 $38.59 $40.08 $0.00 $3.53 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $2.96 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $0.00 600397 ERX HCPCS J3475 99999-6008-51 MAGNESIUM SULFATE 2 G IN 50ML D5W PREMIX BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $0.24 $38.59 $38.59 $40.08 $0.00 $3.53 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $2.96 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $0.00 600398 ERX HCPCS J3475 15082-0903-05 MAGNESIUM SULFATE 4 G IN 50ML D5W PREMIX BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.47 $16.33 $16.33 $16.96 $0.00 $7.07 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.92 $0.00 $0.00 $5.64 $0.00 $0.00 $0.00 $0.00 $0.00 600398 ERX HCPCS J3475 99999-6006-44 MAGNESIUM SULFATE 4 G IN 50ML D5W PREMIX BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $0.47 $16.33 $16.33 $16.96 $0.00 $7.07 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $5.92 $0.00 $0.00 $5.64 $0.00 $0.00 $0.00 $0.00 $0.00 600399 ERX HCPCS J3475 24200-0015-13 MAGNESIUM SULFATE 50 G IN 600ML LR PREMIX BOTH IP/OP $92.59 $68.52 $0.00 $88.36 $41.67 $41.67 $0.00 $0.00 $0.00 $5.88 $68.72 $68.72 $71.37 $0.00 $88.36 $0.00 $54.77 $54.77 $0.00 $42.68 $67.60 $68.28 $0.00 $0.00 $74.03 $0.00 $0.00 $70.48 $0.00 $0.00 $0.00 $0.00 $0.00 600399 ERX HCPCS J3475 24200-1015-13 MAGNESIUM SULFATE 50 G IN 600ML LR PREMIX BOTH IP/OP $92.59 $68.52 $0.00 $88.36 $41.67 $41.67 $0.00 $0.00 $0.00 $5.88 $68.72 $68.72 $71.37 $0.00 $88.36 $0.00 $54.77 $54.77 $0.00 $42.68 $67.60 $68.28 $0.00 $0.00 $74.03 $0.00 $0.00 $70.48 $0.00 $0.00 $0.00 $0.00 $0.00 600399 ERX HCPCS J3475 99999-6006-77 MAGNESIUM SULFATE 50 G IN 600ML LR PREMIX BOTH IP/OP $92.59 $68.52 $0.00 $88.36 $41.67 $41.67 $0.00 $0.00 $0.00 $5.88 $68.72 $68.72 $71.37 $0.00 $88.36 $0.00 $54.77 $54.77 $0.00 $42.68 $67.60 $68.28 $0.00 $0.00 $74.03 $0.00 $0.00 $70.48 $0.00 $0.00 $0.00 $0.00 $0.00 600403 ERX HCPCS 25000001 15082-0211-10 FENTANYL 200MCG + 0.1% BUPIVACAINE/100ML NS EPIDURAL BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600403 ERX HCPCS 25000001 99999-6007-22 FENTANYL 200MCG + 0.1% BUPIVACAINE/100ML NS EPIDURAL BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600420 ERX HCPCS 25000001 99999-6008-76 ACETIC ACID 3% SOLN BOTH IP/OP $11.00 $8.14 $0.00 $175.78 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $109.86 $8.71 $175.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600420 ERX HCPCS 25000001 99999-6004-23 ACETIC ACID 3% SOLN BOTH IP/OP $11.00 $8.14 $0.00 $175.78 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $109.86 $174.02 $175.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600421 ERX HCPCS 25000001 535rf-p401-0j NXSTAGE RFP 401 DIALYSIS SOLUTION BOTH IP/OP $91.68 $67.84 $0.00 $70.67 $0.00 $0.00 $0.00 $0.00 $0.00 $68.04 $68.04 $70.67 $0.00 $19.11 $0.00 $0.00 $0.00 $0.00 $41.57 $65.84 $66.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600421 ERX HCPCS 25000001 99999-6004-24 NXSTAGE RFP 401 DIALYSIS SOLUTION BOTH IP/OP $91.68 $67.84 $0.00 $70.67 $0.00 $0.00 $0.00 $0.00 $0.00 $68.04 $68.04 $70.67 $0.00 $19.11 $0.00 $0.00 $0.00 $0.00 $41.57 $65.84 $66.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600422 ERX HCPCS 25000001 535rf-p400-0i NXSTAGE RFP 400 DIALYSIS SOLUTION BOTH IP/OP $91.68 $67.84 $0.00 $70.67 $0.00 $0.00 $0.00 $0.00 $0.00 $68.04 $68.04 $70.67 $0.00 $19.11 $0.00 $0.00 $0.00 $0.00 $41.57 $65.84 $66.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600422 ERX HCPCS 25000001 99999-6004-25 NXSTAGE RFP 400 DIALYSIS SOLUTION BOTH IP/OP $91.68 $67.84 $0.00 $70.67 $0.00 $0.00 $0.00 $0.00 $0.00 $68.04 $68.04 $70.67 $0.00 $19.11 $0.00 $0.00 $0.00 $0.00 $41.57 $65.84 $66.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600423 ERX HCPCS 25000001 99999-6004-27 CLINDAMYCIN 50MG/ML OPHTH SOLN 5 ML BOTH IP/OP $48.61 $35.97 $0.00 $37.47 $0.00 $0.00 $0.00 $0.00 $0.00 $36.08 $36.08 $37.47 $0.00 $10.13 $0.00 $0.00 $0.00 $0.00 $22.04 $34.91 $35.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600426 ERX HCPCS 25000001 99999-6004-26 MECHLORETHAMINE 0.01% OINT BOTH IP/OP "$2,072.00 " "$1,533.28" $0.00 "$1,597.10" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,537.84" "$1,537.84" "$1,597.10" $0.00 $431.80 $0.00 $0.00 $0.00 $0.00 $960.00 "$1,520.64" "$1,536.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600435 ERX HCPCS 25000001 99999-6004-39 CHOCOLATE SYRUP BOTH IP/OP $11.00 $8.14 $0.00 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $8.48 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.71 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600438 ERX HCPCS 25000001 99999-6005-87 OR NEOMYCIN-POLYMYXIN B (NEOSPORIN GU) 3 ML/3000 ML NS IR BOTH IP/OP $238.80 $176.71 $0.00 $184.07 $0.00 $0.00 $0.00 $0.00 $0.00 $177.24 $177.24 $184.07 $0.00 $49.77 $0.00 $0.00 $0.00 $0.00 $108.39 $171.69 $173.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600450 ERX HCPCS 25000001 99999-6004-58 PENICILLIN 160 UNITS/ML D5W DESENSITIZATION BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600453 ERX HCPCS J1644 15082-0747-99 HEPARIN 4000 UNITS/1000 ML NS IR BOTH IP/OP $131.24 $97.12 $0.00 $101.16 $59.06 $59.06 $0.00 $0.00 $0.00 $0.94 $97.41 $97.41 $101.16 $0.00 $1.17 $0.00 $77.63 $77.63 $0.00 $59.50 $94.25 $95.20 $0.00 $0.00 $1.13 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 600453 ERX HCPCS J1644 42852-0747-99 HEPARIN 4000 UNITS/1000 ML NS IR BOTH IP/OP $131.24 $97.12 $0.00 $101.16 $59.06 $59.06 $0.00 $0.00 $0.00 $0.94 $97.41 $97.41 $101.16 $0.00 $1.17 $0.00 $77.63 $77.63 $0.00 $59.50 $94.25 $95.20 $0.00 $0.00 $1.13 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 600453 ERX HCPCS J1644 71285-7022-01 HEPARIN 4000 UNITS/1000 ML NS IR BOTH IP/OP $131.24 $97.12 $0.00 $101.16 $59.06 $59.06 $0.00 $0.00 $0.00 $0.94 $97.41 $97.41 $101.16 $0.00 $1.17 $0.00 $77.63 $77.63 $0.00 $59.50 $94.25 $95.20 $0.00 $0.00 $1.13 $0.00 $0.00 $1.07 $0.00 $0.00 $0.00 $0.00 $0.00 600456 ERX HCPCS 25000001 99999-6005-64 DEXTROSE 5% FLUSH 2 ML IV SYRINGE (NICU) BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600457 ERX HCPCS 25000001 00338-0023-03 DEXTROSE 10% (NICU) IV BOLUS SYRINGE BOTH IP/OP $27.24 $20.16 $0.00 $21.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.22 $20.22 $21.00 $0.00 $5.68 $0.00 $0.00 $0.00 $0.00 $11.40 $18.06 $18.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600493 ERX HCPCS 25000001 99999-6005-84 MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SYRINGE BOTH IP/OP $27.48 $20.34 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 $20.40 $20.40 $21.18 $0.00 $5.73 $0.00 $0.00 $0.00 $0.00 $12.46 $19.74 $19.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600494 ERX HCPCS 25000001 99999-6005-83 MULTIVITAMIN (AQUADEKS) ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600496 ERX HCPCS 63700001 99999-6005-77 VITAMIN K 1 MG/ML (NICU) ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600499 ERX HCPCS 25000001 99999-6005-65 AMPHOTERICIN 1MG/ML (NICU) COMPOUNDING BOTH IP/OP $94.57 $69.98 $0.00 $72.89 $0.00 $0.00 $0.00 $0.00 $0.00 $70.19 $70.19 $72.89 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $42.88 $67.91 $68.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600501 ERX HCPCS 25000001 99999-6005-66 OR ONLY-CEFAZOLIN 1G/NS 1000ML IRRIGATION SOLN BOTH IP/OP $67.23 $49.75 $0.00 $51.82 $0.00 $0.00 $0.00 $0.00 $0.00 $49.90 $49.90 $51.82 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $31.19 $49.40 $49.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600502 ERX HCPCS 25000001 99999-6005-67 OR ONLY-CEFAZOLIN 1GM/NS 1500ML IRRIG BOTH IP/OP $90.27 $66.80 $0.00 $69.58 $0.00 $0.00 $0.00 $0.00 $0.00 $67.00 $67.00 $69.58 $0.00 $18.81 $0.00 $0.00 $0.00 $0.00 $41.64 $65.95 $66.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600506 ERX HCPCS C9257 99999-6005-71 BEVACIZUMAB 5 MG/0.2 ML OPHTH SYRINGE BOTH IP/OP $132.69 $98.19 $0.00 $102.28 $59.71 $59.71 $8.49 $8.49 $8.49 $27.66 $98.48 $98.48 $102.28 $8.80 $27.65 $5.72 $78.49 $78.49 $42.63 $60.16 $95.29 $96.26 $58.87 $58.87 $18.83 $0.00 $0.00 $19.15 $39.20 $0.00 $0.00 $0.00 $0.00 600511 ERX HCPCS 25000001 99999-6005-80 HYDROXYPROGESTERONE-17 250 MG/ML IM INJ BOTH IP/OP "$2,144.52 " "$1,586.94" $0.00 "$1,653.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,591.66" "$1,591.66" "$1,653.00" $0.00 $446.92 $0.00 $0.00 $0.00 $0.00 $993.60 "$1,573.86" "$1,589.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600521 ERX HCPCS 25000001 99999-6005-97 "OR BACITRACIN 50,000 UNITS IN 1500 ML NS IR-NEURO" BOTH IP/OP $114.65 $84.84 $0.00 $88.37 $0.00 $0.00 $0.00 $0.00 $0.00 $85.09 $85.09 $88.37 $0.00 $23.89 $0.00 $0.00 $0.00 $0.00 $51.98 $82.33 $83.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600522 ERX HCPCS 25000001 99999-6005-98 OR NEOMYCIN-POLYMYXIN B 2 ML/1500 ML NS IR BOTH IP/OP $125.22 $92.66 $0.00 $96.52 $0.00 $0.00 $0.00 $0.00 $0.00 $92.94 $92.94 $96.52 $0.00 $26.10 $0.00 $0.00 $0.00 $0.00 $56.77 $89.92 $90.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600523 ERX HCPCS 25000001 99999-6005-99 "OR CEFAZOLIN 1G+BACITRACIN 50,000UNITS+GENT80/1500 ML" BOTH IP/OP $127.48 $94.34 $0.00 $98.26 $0.00 $0.00 $0.00 $0.00 $0.00 $94.62 $94.62 $98.26 $0.00 $26.57 $0.00 $0.00 $0.00 $0.00 $57.80 $91.55 $92.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600524 ERX HCPCS 25000001 99999-6006-06 CIDOFOVIR 1% CREAM 37.5G BOTH IP/OP "$2,310.55 " "$1,709.81" $0.00 "$1,780.97" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,714.89" "$1,714.89" "$1,780.97" $0.00 $481.52 $0.00 $0.00 $0.00 $0.00 "$1,070.53" "$1,695.71" "$1,712.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600531 ERX HCPCS 25000001 99999-6006-16 OR CHLORHEXIDINE 0.12% 473 ML WITH 500 ML NSIR BOTH IP/OP $81.33 $60.18 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 $60.36 $60.36 $62.69 $0.00 $16.95 $0.00 $0.00 $0.00 $0.00 $36.88 $58.42 $59.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600534 ERX HCPCS 25000001 99999-6006-19 CEFTRIAXONE +LIDOCAINE 1% IM INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600536 ERX HCPCS 25000001 99999-6006-22 OXYCHLOROSENE 0.4% IRRIGATION SOLN (2 G/500 ML NS) BOTH IP/OP $14.25 $10.55 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $0.00 $10.58 $10.58 $10.98 $0.00 $2.97 $0.00 $0.00 $0.00 $0.00 $6.46 $10.23 $10.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600539 ERX HCPCS 25000001 99999-6006-24 AMIKACIN 250 MG/ML NEBU SOLN BOTH IP/OP $18.61 $13.77 $0.00 $14.34 $0.00 $0.00 $0.00 $0.00 $0.00 $13.81 $13.81 $14.34 $0.00 $3.88 $0.00 $0.00 $0.00 $0.00 $8.44 $13.37 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600541 ERX HCPCS 25000001 99999-6006-26 TOBRAMYCIN 40 MG/ML NEBU SOLN BOTH IP/OP $17.05 $12.62 $0.00 $13.14 $0.00 $0.00 $0.00 $0.00 $0.00 $12.65 $12.65 $13.14 $0.00 $3.55 $0.00 $0.00 $0.00 $0.00 $7.73 $12.24 $12.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600543 ERX HCPCS J0878 99999-6006-30 DAPTOMYCIN 500MG/NS 50ML MB PLUS BOTH IP/OP $941.23 $696.51 $0.00 $725.50 $423.55 $423.55 $0.00 $0.00 $0.00 $223.25 $698.58 $698.58 $725.50 $0.00 $33.49 $0.00 $556.74 $556.74 $173.25 $427.79 $677.62 $684.46 $239.25 $239.25 $170.38 $0.00 $0.00 $162.23 $68.00 $0.00 $0.00 $0.00 $0.00 600544 ERX HCPCS 25000001 99999-6006-32 SODIUM BICARBONATE 1% ET IRRIGATION SOLUTION BOTH IP/OP $20.54 $15.20 $0.00 $15.83 $0.00 $0.00 $0.00 $0.00 $0.00 $15.24 $15.24 $15.83 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $9.31 $14.75 $14.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600548 ERX HCPCS 25000001 99999-6006-38 PODOPHYLLUM 40% IN BENZOIN BOTH IP/OP $277.54 $205.38 $0.00 $213.93 $0.00 $0.00 $0.00 $0.00 $0.00 $205.99 $205.99 $213.93 $0.00 $57.84 $0.00 $0.00 $0.00 $0.00 $125.97 $199.54 $201.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600550 ERX HCPCS 25000001 99999-6006-43 VITAMIN K1 1 MG/0.1ML (NICU) >=1250 G BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600556 ERX HCPCS 25000001 "PENICILLIN G 10,000 UNITS/ML ID INJ" BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600557 ERX HCPCS 25000001 99999-6006-55 SQUARIC ACID 2% TOP SOLN BOTH IP/OP $504.00 $372.96 $0.00 $388.48 $0.00 $0.00 $0.00 $0.00 $0.00 $374.07 $374.07 $388.48 $0.00 $105.03 $0.00 $0.00 $0.00 $0.00 $228.75 $362.34 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600559 ERX HCPCS 25000001 99999-6006-58 HISTAMINE BASE 1 MG/ML ID SOLN BOTH IP/OP $32.84 $24.30 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.42 $26.01 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600560 ERX HCPCS J0640 99999-6006-60 LEUCOVORIN 50 MG/50 ML NS IVPB MB PLUS BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $1.05 $38.59 $38.59 $40.08 $0.00 $4.30 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $3.91 $0.00 $0.00 $3.73 $0.00 $0.00 $0.00 $0.00 $0.00 600561 ERX HCPCS 25000001 99999-6006-59 POLYMYXIN B 10 MG/ML D5W DESENSITIZATION BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600562 ERX HCPCS 25000001 99999-6006-61 POLYMYXIN B 1 MG/ML D5W DESENSITIZATION BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600563 ERX HCPCS 25000001 99999-6006-62 POLYMYXIN B 0.1 MG/ML D5W DESENSITIZATION BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600564 ERX HCPCS 25000001 99999-6006-63 POLYMYXIN B 0.01 MG/ML D5W DESENSITIZATION BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600565 ERX HCPCS 25000001 99999-6006-64 POLYMYXIN B 0.001 MG/ML D5W DESENSITIZATION BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600566 ERX HCPCS 25000001 99999-6006-65 POLYMYXIN B 0.0001 MG/ML D5W DESENSITIZATION BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600570 ERX HCPCS 25000001 00002-1036-13 DOMPERIDONE 10 MG TABLET BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600571 ERX HCPCS 25000001 99999-6006-72 VANCOMYCIN 15 MG/ML(1.5%) OPHTH SOLN BOTH IP/OP $58.65 $43.40 $0.00 $45.21 $0.00 $0.00 $0.00 $0.00 $0.00 $43.53 $43.53 $45.21 $0.00 $12.22 $0.00 $0.00 $0.00 $0.00 $26.60 $42.13 $42.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600575 ERX HCPCS J8530 99999-6006-76 CYCLOPHOSPHAMIDE 100 MG/10 ML ORAL SYRINGE BOTH IP/OP $115.80 $85.69 $0.00 $89.26 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600578 ERX HCPCS 25000001 99999-6006-82 VANCOMYCIN 10MG-HEPARIN 5000 UNITS/2 ML FLUSH BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600589 ERX HCPCS 25000001 99999-6007-00 STREPTOMYCIN 5 MG/ML NS (NICU) IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600595 ERX HCPCS 25000001 99999-6007-08 TRICHLOROACETIC ACID 70 % EXTERNAL SOLN BOTH IP/OP $184.61 $136.61 $0.00 $142.30 $0.00 $0.00 $0.00 $0.00 $0.00 $137.02 $137.02 $142.30 $0.00 $38.47 $0.00 $0.00 $0.00 $0.00 $83.79 $132.72 $134.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600603 ERX HCPCS 25000001 99999-6007-15 DILTIAZEM 2% OINTMENT BOTH IP/OP $21.46 $15.88 $0.00 $16.54 $0.00 $0.00 $0.00 $0.00 $0.00 $15.93 $15.93 $16.54 $0.00 $4.47 $0.00 $0.00 $0.00 $0.00 $9.73 $15.41 $15.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600608 ERX HCPCS J0610 24200-0066-10 CALCIUM GLUCONATE 3 GM IN SODIUM CHLORIDE 250 ML BOTH IP/OP $62.85 $46.51 $0.00 $48.44 $28.28 $28.28 $0.00 $0.00 $0.00 $1.02 $46.65 $46.65 $48.44 $0.00 $14.55 $0.00 $37.18 $37.18 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $12.13 $0.00 $0.00 $11.55 $0.00 $0.00 $0.00 $0.00 $0.00 600626 ERX HCPCS 25000001 99999-6007-47 BOSENTAN 6.25 MG/ML (NICU) ORAL SYRINGE BOTH IP/OP $52.92 $39.16 $0.00 $40.79 $0.00 $0.00 $0.00 $0.00 $0.00 $39.28 $39.28 $40.79 $0.00 $11.03 $0.00 $0.00 $0.00 $0.00 $24.00 $38.02 $38.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600627 ERX HCPCS 25000001 99999-6007-49 CEFTAZIDIME 50MG/ML FORTIFIED OPHTH SOLN 10 ML BOTH IP/OP $41.90 $31.01 $0.00 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $31.10 $31.10 $32.30 $0.00 $8.73 $0.00 $0.00 $0.00 $0.00 $19.00 $30.10 $30.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600632 ERX HCPCS 25000001 99999-6007-51 GENTAMICIN 40 MG/ML NEBU SOLN BOTH IP/OP $10.19 $7.54 $0.00 $7.85 $0.00 $0.00 $0.00 $0.00 $0.00 $7.56 $7.56 $7.85 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $4.62 $7.32 $7.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600633 ERX HCPCS 63700001 99999-6007-52 AZATHIOPRINE 50 MG/ML ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600638 ERX HCPCS 25000001 99999-6007-56 CYCLOSPORINE 2% OPHTH SOLN BOTH IP/OP $126.11 $93.32 $0.00 $97.21 $0.00 $0.00 $0.00 $0.00 $0.00 $93.60 $93.60 $97.21 $0.00 $26.28 $0.00 $0.00 $0.00 $0.00 $57.18 $90.57 $91.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600639 ERX HCPCS 25000001 99999-6007-57 DEXTROSE 5% FLUSH IV SYRINGE (ADULT) BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600640 ERX HCPCS 25000001 99999-6007-58 PEDIATRACE ELEMENTS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600641 ERX HCPCS 25000001 99999-6007-59 METRONIDAZOLE 0.005 MG/ML NS IV DESENSITIZATION BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600642 ERX HCPCS 25000001 99999-6007-60 METRONIDAZOLE 0.05 MG/ML NS IV DESENSITIZATION BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600643 ERX HCPCS 25000001 99999-6007-61 METRONIDAZOLE 0.5 MG/ML NS IV DESENSITIZATION BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600644 ERX HCPCS 25000001 99999-6007-62 METRONIDAZOLE 5 MG/ML NS IV DESENSITIZATION BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600646 ERX HCPCS 25000001 99999-6007-64 VANCOMYCIN 125 MG/5 ML ORAL SOLUTION UNIT-DOSE CUP BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600647 ERX HCPCS 25000001 99999-6007-65 HEPARIN SODIUM NEBU 5000 UNITS/1 ML SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600658 ERX HCPCS 25000001 99999-6007-79 ASPIRIN 1 MG/1 ML SUSP DESENSITIZATION BTL A BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600660 ERX HCPCS 63600001 99999-6007-81 TERBUTALINE SULFATE 1 MG/ML NEBU SOLN BOTH IP/OP $83.33 $61.66 $0.00 $64.23 $0.00 $0.00 $0.00 $0.00 $0.00 $61.85 $61.85 $64.23 $0.00 $17.37 $0.00 $0.00 $0.00 $0.00 $37.78 $59.84 $60.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600661 ERX HCPCS 25000001 99999-6007-85 CLINDAMYCIN 1 MG/0.1 ML NS 0.5 ML INTRAVITREAL SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600668 ERX HCPCS 25000001 99999-6007-92 OSELTAMIVIR PEDS 6 MG/ML ORAL SYRINGE BOTH IP/OP $9.28 $6.87 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.89 $6.89 $7.15 $0.00 $1.93 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600672 ERX HCPCS 63700001 99999-6007-94 CHOLECALCIFEROL 400 UNIT/ML (NICU) ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600673 ERX HCPCS 25000001 99999-6007-95 AMPHOTERICIN B ORAL SOLUTION 1MG/ML BOTH IP/OP $612.87 $453.52 $0.00 $472.40 $0.00 $0.00 $0.00 $0.00 $0.00 $454.87 $454.87 $472.40 $0.00 $127.72 $0.00 $0.00 $0.00 $0.00 $278.16 $440.61 $445.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600676 ERX HCPCS 25000001 99999-6007-97 MORPHINE SULF 0.4 MG/1 ML ORAL SYRINGE (NICU) BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600683 ERX HCPCS Q4074 99999-6008-05 ILOPROST 5 MCG/0.25 ML NEB SYRINGE BOTH IP/OP $50.34 $37.25 $0.00 $38.80 $0.00 $0.00 $0.00 $0.00 $0.00 $37.36 $37.36 $38.80 $0.00 $10.49 $0.00 $0.00 $0.00 $0.00 $22.83 $36.15 $36.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600686 ERX HCPCS J0712 99999-6008-78 CEFTAROLINE FOSAMIL 400MG/NS 250 ML MB PLUS BOTH IP/OP $524.43 $388.08 $0.00 $404.23 $0.00 $0.00 $0.00 $0.00 $0.00 $389.23 $389.23 $404.23 $0.00 $109.29 $0.00 $0.00 $0.00 $0.00 $238.72 $378.12 $381.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600689 ERX HCPCS 25000001 99999-6008-11 DIGOXIN 2 MG (0.25 MG/ML)/8 ML SYRINGE INTRA-AMNIOTIC BOTH IP/OP $29.74 $22.01 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $0.00 $22.07 $22.07 $22.92 $0.00 $6.20 $0.00 $0.00 $0.00 $0.00 $13.49 $21.36 $21.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600690 ERX HCPCS 25000001 85412-0034-62 STERILE EMPTY CONTAINER 1000 ML BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600690 ERX HCPCS 25000001 99999-6009-23 STERILE EMPTY CONTAINER 1000 ML BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600692 ERX HCPCS J2543 99999-6008-21 PIPERACIL-TAZ 2.25 G/NS 50 ML MB PLUS BOTH IP/OP $77.44 $57.31 $0.00 $59.69 $34.85 $34.85 $0.00 $0.00 $0.00 $13.09 $57.48 $57.48 $59.69 $0.00 $3.47 $0.00 $45.81 $45.81 $0.00 $35.81 $56.72 $57.30 $0.00 $0.00 $4.35 $0.00 $0.00 $4.14 $0.00 $0.00 $0.00 $0.00 $0.00 600698 ERX HCPCS 25000001 99999-6008-27 LIDOCAINE HCL 0.1 % IJ SOLN-ALLERGY CLINIC BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600699 ERX HCPCS 25000001 99999-6008-28 LIDOCAINE HCL 0.01 % IJ SOLN-ALLERGY CLINIC BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600700 ERX HCPCS 25000001 99999-6008-30 ONDANSETRON 0.8 MG/ML ORAL SYRINGE (NICU) BOTH IP/OP $26.13 $19.34 $0.00 $20.14 $0.00 $0.00 $0.00 $0.00 $0.00 $19.39 $19.39 $20.14 $0.00 $5.45 $0.00 $0.00 $0.00 $0.00 $11.85 $18.77 $18.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600701 ERX HCPCS J0696 00409-7332-01 CEFTRIAXONE CUSTOM 1 G VIAL FOR DESENSITIZATION BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $5.64 $16.33 $16.33 $16.96 $0.00 $2.36 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $2.82 $0.00 $0.00 $2.69 $0.00 $0.00 $0.00 $0.00 $0.00 600706 ERX HCPCS Q9967 00407-1413-58 IOHEXOL 300 MG/ML 30 ML PO SOLUTION BOTH IP/OP $192.35 $142.34 $0.00 $142.76 $86.56 $86.56 $0.00 $0.00 $0.00 $40.09 $142.76 $142.76 $0.00 $0.00 $0.14 $0.00 $113.78 $113.78 $0.00 $87.21 $138.13 $139.53 $0.00 $0.00 $0.13 $0.00 $0.00 $27.77 $0.00 $0.00 $0.00 $0.00 $0.00 600706 ERX HCPCS Q9967 00407-1413-59 IOHEXOL 300 MG/ML 30 ML PO SOLUTION BOTH IP/OP $192.35 $142.34 $0.00 $142.76 $86.56 $86.56 $0.00 $0.00 $0.00 $40.09 $142.76 $142.76 $0.00 $0.00 $0.14 $0.00 $113.78 $113.78 $0.00 $87.21 $138.13 $139.53 $0.00 $0.00 $0.13 $0.00 $0.00 $27.77 $0.00 $0.00 $0.00 $0.00 $0.00 600707 ERX HCPCS 95165 99999-6008-39 ALLERGEN EXTRACTS PREPARATION BOTH IP/OP $96.50 $71.41 $0.00 $74.38 $0.00 $0.00 $0.00 $0.00 $0.00 $71.62 $71.62 $74.38 $0.00 $20.11 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600710 ERX HCPCS 25000001 99999-6008-42 METHOHEXITAL 1MG/ML SW IV SYRINGE-NEURO BOTH IP/OP $27.21 $20.14 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.20 $20.20 $20.97 $0.00 $5.67 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600714 ERX HCPCS 25000001 99999-6008-45 KPHOS 0.05 MM/ML D5W (NICU) IV SYRINGE BOTH IP/OP $28.83 $21.33 $0.00 $22.22 $0.00 $0.00 $0.00 $0.00 $0.00 $21.40 $21.40 $22.22 $0.00 $6.01 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600715 ERX HCPCS 25000001 99999-6008-46 SODIUM PHOSPHATE 0.05 MM/ML D5W (NICU) IV SYRINGE BOTH IP/OP $28.83 $21.33 $0.00 $22.22 $0.00 $0.00 $0.00 $0.00 $0.00 $21.40 $21.40 $22.22 $0.00 $6.01 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600722 ERX HCPCS 25000001 00338-0221-04 PLASMA-LYTE A IV BOLUS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600725 ERX HCPCS 25000001 99999-6008-55 VORICONAZOLE 100MCG/0.1 ML NS OPHTH SYRINGE BOTH IP/OP $512.67 $379.38 $0.00 $395.17 $0.00 $0.00 $0.00 $0.00 $0.00 $380.50 $380.50 $395.17 $0.00 $106.84 $0.00 $0.00 $0.00 $0.00 $232.69 $368.57 $372.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600726 ERX HCPCS 25000001 99999-6008-56 DEXTROSE 25% SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600727 ERX HCPCS 25000001 99999-6008-57 AMPHOTERICIN B 0.15% OPHTHALMIC SOLN BOTH IP/OP $57.32 $42.42 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 $42.54 $42.54 $44.18 $0.00 $11.95 $0.00 $0.00 $0.00 $0.00 $26.00 $41.18 $41.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600732 ERX HCPCS 25000001 99999-6008-64 ASCORBIC ACID OPHTH SOLN 100 MG/ML BOTH IP/OP $30.13 $22.30 $0.00 $23.22 $0.00 $0.00 $0.00 $0.00 $0.00 $22.36 $22.36 $23.22 $0.00 $6.28 $0.00 $0.00 $0.00 $0.00 $13.67 $21.65 $21.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600733 ERX HCPCS J9214 99999-6008-65 INTERFERON ALFA-2B OPHTH SOLN 1000000 UNITS/ML BOTH IP/OP "$5,464.68 " "$4,043.86" $0.00 "$4,212.18" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,055.89" "$4,055.89" "$4,212.18" $0.00 $39.06 $0.00 $0.00 $0.00 $0.00 "$2,478.45" "$3,925.86" "$3,965.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600735 ERX HCPCS 25000001 99999-6008-66 METRONIDAZOLE 0.0005MG/ML ORAL SYRINGE DESENSITIZATIO BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600736 ERX HCPCS 25000001 99999-6008-67 METRONIDAZOLE 0.005MG/ML ORAL SYRINGE DESENSITIZATION BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600737 ERX HCPCS 25000001 99999-6008-68 METRONIDAZOLE 0.05MG/ML ORAL SYRINGE DESENSITIZATION BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600738 ERX HCPCS 25000001 99999-6008-69 METRONIDAZOLE 0.5MG/ML ORAL SYRINGE DESENSITIZATION BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600739 ERX HCPCS 25000001 99999-6008-70 METRONIDAZOLE 5MG/ML ORAL SYRINGE DESENSITIZATION BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600743 ERX HCPCS 63700001 99999-6008-74 MERCAPTOPURINE 25 MG PO TAB BOTH IP/OP $8.57 $6.34 $0.00 $6.22 $0.00 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $0.00 $1.79 $0.00 $0.00 $0.00 $0.00 $3.89 $6.16 $6.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600744 ERX HCPCS 25000001 99999-6008-75 WHISKY (40% ABV) BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600745 ERX HCPCS J0712 99999-6008-79 CEFTAROLINE FOSAMIL 600MG/NS 250 ML MB PLUS BOTH IP/OP $524.43 $388.08 $0.00 $404.23 $0.00 $0.00 $0.00 $0.00 $0.00 $389.23 $389.23 $404.23 $0.00 $109.29 $0.00 $0.00 $0.00 $0.00 $238.72 $378.12 $381.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600747 ERX HCPCS J3301 99999-6008-81 TRIAMCINOLONE 40MG/1 ML + LIDOCAINE 1% 1 ML BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $3.55 $38.59 $38.59 $40.08 $0.00 $2.82 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $3.67 $0.00 $0.00 $3.49 $0.00 $0.00 $0.00 $0.00 $0.00 600756 ERX HCPCS 25000001 99999-6008-94 GENTIAN VIOLET 0.00165% SOLUTION BOTH IP/OP $144.75 $107.12 $0.00 $111.57 $0.00 $0.00 $0.00 $0.00 $0.00 $107.43 $107.43 $111.57 $0.00 $30.17 $0.00 $0.00 $0.00 $0.00 $65.63 $103.95 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600765 ERX HCPCS 25000001 99999-6009-00 NALOXONE ORAL SYRINGE 0.4 MG/ML BOTH IP/OP $329.65 $243.94 $0.00 $254.09 $0.00 $0.00 $0.00 $0.00 $0.00 $244.67 $244.67 $254.09 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $149.63 $237.01 $239.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600767 ERX HCPCS 25000001 99999-6009-02 GLYCOPYRROLATE 0.2 MG/ML NEBU SOLN BOTH IP/OP $6.00 $4.44 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $4.62 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $4.75 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600768 ERX HCPCS J1580 99999-6009-04 GENTAMICIN 80 MG/500 ML NS FOR IRRIGATION BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $1.02 $38.59 $38.59 $40.08 $0.00 $1.97 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $2.31 $0.00 $0.00 $2.20 $0.00 $0.00 $0.00 $0.00 $0.00 600772 ERX HCPCS 25000001 99999-6009-09 PEDIATRIC MAGIC MOUTH WASH BOTH IP/OP $594.72 $440.09 $0.00 $458.41 $0.00 $0.00 $0.00 $0.00 $0.00 $441.40 $441.40 $458.41 $0.00 $123.94 $0.00 $0.00 $0.00 $0.00 $269.93 $427.56 $431.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600773 ERX HCPCS 25000001 15082-0828-68 GLYCOPYRROLATE 0.6 MG/3 ML IV SYRINGE BOTH IP/OP $136.88 $101.29 $0.00 $105.51 $0.00 $0.00 $0.00 $0.00 $0.00 $101.59 $101.59 $105.51 $0.00 $28.53 $0.00 $0.00 $0.00 $0.00 $62.06 $98.30 $99.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600774 ERX HCPCS 25000001 99999-6009-11 WBC NUCLEAR ISOTOPE BOTH IP/OP "$1,022.00 " $756.28 $0.00 $787.76 $0.00 $0.00 $0.00 $0.00 $0.00 $758.53 $758.53 $787.76 $0.00 $212.98 $0.00 $0.00 $0.00 $0.00 $463.75 $734.58 $742.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600779 ERX HCPCS 25000001 99999-6009-17 DEXTROSE 5 % FLUSH-AMPHO PANEL BOTH IP/OP "$1,787.10 " "$1,322.45" $0.00 "$1,377.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,326.39" "$1,326.39" "$1,377.50" $0.00 $372.43 $0.00 $0.00 $0.00 $0.00 $828.00 "$1,311.55" "$1,324.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600779 ERX HCPCS 25000001 99999-6010-37 DEXTROSE 5 % FLUSH-AMPHO PANEL BOTH IP/OP "$1,787.10 " "$1,322.45" $0.00 "$1,377.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,326.39" "$1,326.39" "$1,377.50" $0.00 $372.43 $0.00 $0.00 $0.00 $0.00 $828.00 "$1,311.55" "$1,324.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600789 ERX HCPCS J0690 99999-6009-29 CEFAZOLIN 2 G/D5W 100 ML IVPB BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $2.77 $38.59 $38.59 $40.08 $0.00 $3.51 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $3.85 $0.00 $0.00 $3.67 $0.00 $0.00 $0.00 $0.00 $0.00 600798 ERX HCPCS 25000001 99999-6009-41 RBC NUCLEAR ISOTOPE BOTH IP/OP "$1,022.00 " $756.28 $0.00 $787.76 $0.00 $0.00 $0.00 $0.00 $0.00 $758.53 $758.53 $787.76 $0.00 $212.98 $0.00 $0.00 $0.00 $0.00 $463.75 $734.58 $742.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600799 ERX HCPCS 25000001 99999-6009-42 METRONIDAZOLE 20MG/ML PEDIATRIC ORAL SUSPENSION BOTH IP/OP $348.60 $257.96 $0.00 $268.70 $0.00 $0.00 $0.00 $0.00 $0.00 $258.73 $258.73 $268.70 $0.00 $72.65 $0.00 $0.00 $0.00 $0.00 $158.22 $250.62 $253.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600801 ERX HCPCS 63700001 99999-6009-44 MISOPROSTOL 25 MCG PO TABLET BOTH IP/OP $13.92 $10.30 $0.00 $10.10 $0.00 $0.00 $0.00 $2.48 $0.00 $0.00 $0.00 $0.00 $0.00 $2.90 $0.00 $0.00 $0.00 $0.00 $6.32 $10.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600811 ERX HCPCS 25000001 NITROGLYCERIN 200 MCG/ML D5W 5 ML IV SYRINGE ANGIO BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600811 ERX HCPCS 25000001 99999-6009-52 NITROGLYCERIN 200 MCG/ML D5W 5 ML IV SYRINGE ANGIO BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600814 ERX HCPCS 25000001 99999-6009-55 ARGATROBAN 100 MCG/1000 ML NS BOTH IP/OP "$1,138.80 " $842.71 $0.00 $877.79 $0.00 $0.00 $0.00 $0.00 $0.00 $845.22 $845.22 $877.79 $0.00 $237.33 $0.00 $0.00 $0.00 $0.00 $516.75 $818.53 $826.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600816 ERX HCPCS 63700001 99999-6011-79 HYDROXYUREA ORAL SOLN 100 MG/ML BOTH IP/OP $9.52 $7.04 $0.00 $7.20 $0.00 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $0.00 $1.98 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600821 ERX HCPCS J1956 99999-6009-64 LEVOFLOXACIN 7.5 MG/1.5 ML D5W PO SOLN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $4.05 $4.05 $0.00 $0.00 $0.00 $1.88 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $5.32 $5.32 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $1.41 $0.00 $0.00 $1.43 $0.00 $0.00 $0.00 $0.00 $0.00 600822 ERX HCPCS J1956 99999-6009-65 LEVOFLOXACIN 75 MG/15 ML D5W PO SOLN BOTH IP/OP $14.08 $10.42 $0.00 $10.85 $6.34 $6.34 $0.00 $0.00 $0.00 $2.93 $10.45 $10.45 $10.85 $0.00 $2.93 $0.00 $8.33 $8.33 $0.00 $6.39 $10.11 $10.22 $0.00 $0.00 $2.00 $0.00 $0.00 $2.03 $0.00 $0.00 $0.00 $0.00 $0.00 600824 ERX HCPCS 25000001 CANTHARIDIN 0.7% TOPICAL LIQUID BOTH IP/OP $670.32 $496.04 $0.00 $516.68 $0.00 $0.00 $0.00 $0.00 $0.00 $497.51 $497.51 $516.68 $0.00 $139.69 $0.00 $0.00 $0.00 $0.00 $304.24 $481.92 $486.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600827 ERX HCPCS C9132 99999-6009-70 "PROTHROMBIN COMPLEX CONCENTRATE, 4-FACTOR (KCENTRA) IV 1500 UNITS/60ML" BOTH IP/OP "$5,989.00 " "$4,431.86" $0.00 "$6,519.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,445.04" "$4,445.04" "$4,616.32" $0.00 "$1,248.11" $0.00 $0.00 $0.00 $0.00 "$4,074.38" "$6,453.81" "$6,519.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600845 ERX HCPCS J3370 99999-6009-81 VANCOMYCIN 1.5 G IN D5W 500 ML PREMIX BOTH IP/OP $86.23 $63.81 $0.00 $66.47 $38.80 $38.80 $0.00 $0.00 $0.00 $10.86 $64.00 $64.00 $66.47 $0.00 $10.02 $0.00 $51.01 $51.01 $0.00 $39.80 $63.04 $63.68 $0.00 $0.00 $11.95 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $0.00 600855 ERX HCPCS J2543 99999-6009-85 PIPERACIL-TAZO 4.5 G/50 ML D5W MB PLUS BOTH IP/OP $103.43 $76.54 $0.00 $79.72 $46.54 $46.54 $0.00 $0.00 $0.00 $26.18 $76.77 $76.77 $79.72 $0.00 $6.94 $0.00 $61.18 $61.18 $0.00 $47.59 $75.38 $76.14 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 600858 ERX HCPCS 25000001 00264-7750-00 LACTATED RINGERS IV BOLUS ML/KG BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600858 ERX HCPCS 25000001 00338-0117-04 LACTATED RINGERS IV BOLUS ML/KG BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600858 ERX HCPCS 25000001 00264-7750-20 LACTATED RINGERS IV BOLUS ML/KG BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600858 ERX HCPCS 25000001 00338-0117-03 LACTATED RINGERS IV BOLUS ML/KG BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600858 ERX HCPCS 25000001 00409-7953-03 LACTATED RINGERS IV BOLUS ML/KG BOTH IP/OP $25.14 $18.60 $0.00 $19.38 $11.31 $11.31 $0.00 $0.00 $0.00 $0.00 $18.66 $18.66 $19.38 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600859 ERX HCPCS 25000001 99999-6009-88 GENTAMICIN 160MG+POLYMIXIN B 200MG+NEOMYCIN 1000MG/2L IRRIGATION SOLN BOTH IP/OP $672.00 $497.28 $0.00 $517.98 $0.00 $0.00 $0.00 $0.00 $0.00 $498.76 $498.76 $517.98 $0.00 $140.04 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600865 ERX HCPCS 25000001 99999-6009-95 AMIKACIN 4 MG/ML OPHTH SOLN 10 ML BOTH IP/OP $18.61 $13.77 $0.00 $14.34 $0.00 $0.00 $0.00 $0.00 $0.00 $13.81 $13.81 $14.34 $0.00 $3.88 $0.00 $0.00 $0.00 $0.00 $8.44 $13.37 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600868 ERX HCPCS J3301 99999-6009-98 TRIAMCINOLONE ACETONIDE 2.5 MG/ML IJ SUSP BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.77 $16.33 $16.33 $16.96 $0.00 $1.41 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.83 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $0.00 600869 ERX HCPCS J3301 99999-6009-99 TRIAMCINOLONE ACETONIDE 5 MG/ML IJ SUSP BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.77 $16.33 $16.33 $16.96 $0.00 $1.41 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.83 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $0.00 600870 ERX HCPCS J3301 99999-6010-00 TRIAMCINOLONE ACETONIDE 4 MG/ML IJ SUSP BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.77 $16.33 $16.33 $16.96 $0.00 $1.41 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.83 $0.00 $0.00 $1.75 $0.00 $0.00 $0.00 $0.00 $0.00 600871 ERX HCPCS J3301 99999-6010-01 TRIAMCINOLONE ACETONIDE 20 MG/ML IJ SUSP BOTH IP/OP $22.78 $16.86 $0.00 $17.60 $10.25 $10.25 $0.00 $0.00 $0.00 $3.55 $16.91 $16.91 $17.56 $0.00 $2.82 $0.00 $13.47 $13.47 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.67 $0.00 $0.00 $3.49 $0.00 $0.00 $0.00 $0.00 $0.00 600878 ERX HCPCS 25000001 68065-1134-72 "ON-Q PAIN PUMP SINGLE LUMEN SELECT-A-FLOW, 400 ML, 2-14 ML/HR" BOTH IP/OP $803.00 $594.22 $0.00 $618.95 $0.00 $0.00 $0.00 $0.00 $0.00 $595.99 $595.99 $618.95 $0.00 $167.35 $0.00 $0.00 $0.00 $0.00 $364.38 $577.17 $583.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600878 ERX HCPCS 25000001 99999-6010-06 "ON-Q PAIN PUMP SINGLE LUMEN SELECT-A-FLOW, 400 ML, 2-14 ML/HR" BOTH IP/OP $803.00 $594.22 $0.00 $618.95 $0.00 $0.00 $0.00 $0.00 $0.00 $595.99 $595.99 $618.95 $0.00 $167.35 $0.00 $0.00 $0.00 $0.00 $364.38 $577.17 $583.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600878 ERX HCPCS 25000001 99999-6011-27 "ON-Q PAIN PUMP SINGLE LUMEN SELECT-A-FLOW, 400 ML, 2-14 ML/HR" BOTH IP/OP $803.00 $594.22 $0.00 $618.95 $0.00 $0.00 $0.00 $0.00 $0.00 $595.99 $595.99 $618.95 $0.00 $167.35 $0.00 $0.00 $0.00 $0.00 $364.38 $577.17 $583.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600879 ERX HCPCS 25000001 "ON-Q PAIN PUMP DUAL LUMEN SELECT-A-FLOW, 400 ML, 2-14 ML/HR" BOTH IP/OP $968.28 $716.53 $0.00 $746.35 $0.00 $0.00 $0.00 $0.00 $0.00 $718.66 $718.66 $746.35 $0.00 $201.79 $0.00 $0.00 $0.00 $0.00 $439.37 $695.96 $702.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600879 ERX HCPCS 25000001 68065-1316-14 "ON-Q PAIN PUMP DUAL LUMEN SELECT-A-FLOW, 400 ML, 2-14 ML/HR" BOTH IP/OP $968.28 $716.53 $0.00 $746.35 $0.00 $0.00 $0.00 $0.00 $0.00 $718.66 $718.66 $746.35 $0.00 $201.79 $0.00 $0.00 $0.00 $0.00 $439.37 $695.96 $702.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600879 ERX HCPCS 25000001 99999-6010-07 "ON-Q PAIN PUMP DUAL LUMEN SELECT-A-FLOW, 400 ML, 2-14 ML/HR" BOTH IP/OP $968.28 $716.53 $0.00 $746.35 $0.00 $0.00 $0.00 $0.00 $0.00 $718.66 $718.66 $746.35 $0.00 $201.79 $0.00 $0.00 $0.00 $0.00 $439.37 $695.96 $702.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600880 ERX HCPCS J0692 99999-6011-00 CEFEPIME 1 G/100 ML NS MB PLUS BOTH IP/OP $54.14 $40.06 $0.00 $41.73 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.18 $40.18 $41.73 $0.00 $11.28 $0.00 $32.02 $32.02 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $8.14 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 600881 ERX HCPCS J0692 99999-6011-01 CEFEPIME 2 G/100 ML NS MB PLUS BOTH IP/OP $65.28 $48.31 $0.00 $50.32 $29.38 $29.38 $0.00 $0.00 $0.00 $13.61 $48.45 $48.45 $50.32 $0.00 $13.60 $0.00 $38.61 $38.61 $0.00 $30.30 $48.00 $48.48 $0.00 $0.00 $9.48 $0.00 $0.00 $9.65 $0.00 $0.00 $0.00 $0.00 $0.00 600885 ERX HCPCS J0295 99999-6010-13 AMPICILLIN-SULB 3 G/D5W 100ML MB PLUS BOTH IP/OP $142.00 $105.08 $0.00 $109.45 $63.90 $63.90 $0.00 $0.00 $0.00 $8.48 $105.39 $105.39 $109.45 $0.00 $5.19 $0.00 $83.99 $83.99 $0.00 $65.08 $103.08 $104.12 $0.00 $0.00 $6.06 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 600886 ERX HCPCS J0290 99999-6012-11 AMPICILLIN 2 G/100ML D5W MB PLUS BOTH IP/OP $80.07 $59.25 $0.00 $61.72 $36.03 $36.03 $0.00 $0.00 $0.00 $10.43 $59.43 $59.43 $61.72 $0.00 $3.79 $0.00 $47.36 $47.36 $0.00 $37.01 $58.62 $59.21 $0.00 $0.00 $4.61 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $0.00 600889 ERX HCPCS J3370 99999-6010-17 VANCOMYCIN 1.5 G IN NS 250 ML PREMIX BOTH IP/OP $309.95 $229.36 $0.00 $238.91 $139.48 $139.48 $0.00 $0.00 $0.00 $10.86 $230.04 $230.04 $238.91 $0.00 $10.02 $0.00 $183.34 $183.34 $0.00 $141.38 $223.94 $226.20 $0.00 $0.00 $11.95 $0.00 $0.00 $11.38 $0.00 $0.00 $0.00 $0.00 $0.00 600892 ERX HCPCS J0740 CIDOFOVIR INTRALESIONAL 15 MG/ML INJ BOTH IP/OP $596.74 $441.59 $0.00 $459.97 $0.00 $0.00 $0.00 $0.00 $0.00 $442.90 $442.90 $459.97 $0.00 $124.36 $0.00 $0.00 $0.00 $0.00 $270.84 $429.01 $433.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600893 ERX HCPCS 25000001 99999-6011-34 ADULT MAGIC MOUTHWASH(MLX:BEN:LIDO) SUSPENSION BOTH IP/OP $24.73 $18.30 $0.00 $66.08 $0.00 $0.00 $0.00 $0.00 $0.00 $18.35 $18.35 $19.06 $0.00 $5.15 $0.00 $0.00 $0.00 $0.00 $41.30 $17.76 $66.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600893 ERX HCPCS 25000001 99999-6011-33 ADULT MAGIC MOUTHWASH(MLX:BEN:LIDO) SUSPENSION BOTH IP/OP $24.73 $18.30 $0.00 $66.08 $0.00 $0.00 $0.00 $0.00 $0.00 $18.35 $18.35 $19.06 $0.00 $5.15 $0.00 $0.00 $0.00 $0.00 $41.30 $65.42 $66.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600894 ERX HCPCS 25000001 99999-6011-35 NITROFURANTOIN 10MG/ML ORAL SUSPENSION BOTH IP/OP $57.07 $42.23 $0.00 $43.99 $0.00 $0.00 $0.00 $0.00 $0.00 $42.36 $42.36 $43.99 $0.00 $11.89 $0.00 $0.00 $0.00 $0.00 $25.88 $40.99 $41.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600895 ERX HCPCS J3010 99999-6011-36 FENTANYL DRIP SYRINGE BOTH IP/OP $82.42 $60.99 $0.00 $63.53 $37.09 $37.09 $0.00 $0.00 $0.00 $17.18 $61.17 $61.17 $63.53 $0.00 $18.62 $0.00 $48.75 $48.75 $0.00 $37.37 $59.19 $59.78 $0.00 $0.00 $29.08 $0.00 $0.00 $27.69 $0.00 $0.00 $0.00 $0.00 $0.00 600897 ERX HCPCS J3010 99999-6011-36 FENTANYL CITRATE PF PCA 50 MCG/ML IV SOLN 50 ML BOTH IP/OP $82.42 $60.99 $0.00 $63.53 $37.09 $37.09 $0.00 $0.00 $0.00 $17.18 $61.17 $61.17 $63.53 $0.00 $18.62 $0.00 $48.75 $48.75 $0.00 $37.37 $59.19 $59.78 $0.00 $0.00 $29.08 $0.00 $0.00 $27.69 $0.00 $0.00 $0.00 $0.00 $0.00 600898 ERX HCPCS J3010 99999-6011-38 FENTANYL 2500 MCG/50 ML PREMIX BOTH IP/OP $97.42 $72.09 $0.00 $75.09 $43.84 $43.84 $0.00 $0.00 $0.00 $20.30 $72.31 $72.31 $75.09 $0.00 $18.62 $0.00 $57.62 $57.62 $0.00 $44.87 $71.07 $71.78 $0.00 $0.00 $29.08 $0.00 $0.00 $27.69 $0.00 $0.00 $0.00 $0.00 $0.00 600900 ERX HCPCS J3010 99999-6011-41 FENTANYL 5000 MCG/100 ML PREMIX BOTH IP/OP $179.83 $133.07 $0.00 $138.61 $80.92 $80.92 $0.00 $0.00 $0.00 $37.48 $133.47 $133.47 $138.61 $0.00 $37.25 $0.00 $106.37 $106.37 $0.00 $82.23 $130.24 $131.56 $0.00 $0.00 $58.16 $0.00 $0.00 $55.38 $0.00 $0.00 $0.00 $0.00 $0.00 600915 ERX HCPCS J0834 99999-6011-50 COSYNTROPIN 2 MCG/ML SYRINGE- ENDOCRINOLOGY CLINIC BOTH IP/OP $22.00 $16.28 $0.00 $44.56 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $22.00 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $44.56 $0.00 $0.00 $42.42 $0.00 $0.00 $0.00 $0.00 $0.00 600925 ERX HCPCS 25000001 99999-6011-65 GANCICLOVIR 5 MG/ML NS (NICU) IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600926 ERX HCPCS J1561 99999-6011-67 IMMUNE GLOBULIN (HUMAN) 10 GM/100ML- MD BOTH IP/OP "$3,154.06 " "$2,334.00" $0.00 "$2,431.15" "$1,419.33" "$1,419.33" $930.18 $930.18 $930.18 $657.38 "$2,340.94" "$2,340.94" "$2,431.15" $964.38 "$1,133.15" $626.85 "$1,554.95" "$1,554.95" $821.94 "$1,430.49" "$2,265.90" "$2,288.78" "$1,135.06" "$1,135.06" $948.23 $0.00 $0.00 $902.87 $833.82 $0.00 $0.00 $0.00 $0.00 600931 ERX HCPCS J9250 99999-6011-73 METHOTREXATE PF OPHTHALMIC INJECTION 0.4 MG/0.1 ML BOTH IP/OP $57.00 $42.18 $0.00 $45.60 $25.65 $25.65 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $43.94 $0.00 $0.26 $0.00 $33.72 $33.72 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.29 $0.00 $0.00 $0.28 $0.00 $0.00 $0.00 $0.00 $0.00 600932 ERX HCPCS 25000001 99999-6011-74 SELENIUM 4 MCG/ML IV SOLN- TPN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600975 ERX HCPCS J3490 99999-6012-29 REMDESIVIR 100 MG/ NS 100 ML MB+ - EMERGENCY USE BOTH IP/OP "$1,361.80 " "$1,007.73" $0.00 "$1,049.68" $612.81 $612.81 $0.00 $0.00 $0.00 $283.83 "$1,010.73" "$1,010.73" "$1,049.68" $0.00 $283.80 $0.00 $805.50 $805.50 $0.00 $631.50 "$1,000.30" "$1,010.40" $0.00 $0.00 $197.66 $0.00 $0.00 $201.07 $0.00 $0.00 $0.00 $0.00 $0.00 600981 ERX HCPCS 25000001 99999-6012-35 TRANEXAMIC ACID - NEBULIZER 1000 MG/10 ML FOR HEMOPTYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600982 ERX HCPCS 25000001 99999-6012-36 VANCOMYCIN 500 MG/20 ML ORAL SOLUTION UNIT-DOSE CUP BOTH IP/OP $10.06 $7.44 $0.00 $7.75 $0.00 $0.00 $0.00 $0.00 $0.00 $7.47 $7.47 $7.75 $0.00 $2.10 $0.00 $0.00 $0.00 $0.00 $4.56 $7.22 $7.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600983 ERX HCPCS 25000001 99999-6012-37 DEXMEDETOMIDINE 1000 MCG/ 250 ML NS PREMIXED BOTH IP/OP $708.80 $524.51 $0.00 $546.34 $0.00 $0.00 $0.00 $0.00 $0.00 $526.07 $526.07 $546.34 $0.00 $147.71 $0.00 $0.00 $0.00 $0.00 $322.32 $510.55 $515.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600990 ERX HCPCS J2543 99999-6010-18 PIPERACIL-TAZO 4.5 G/NS 70 ML IVPB BOTH IP/OP $103.43 $76.54 $0.00 $79.72 $46.54 $46.54 $0.00 $0.00 $0.00 $26.18 $76.77 $76.77 $79.72 $0.00 $6.94 $0.00 $61.18 $61.18 $0.00 $47.59 $75.38 $76.14 $0.00 $0.00 $8.70 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 600991 ERX HCPCS 25000001 99999-6010-19 PEDIATRIC OPHTHALMIC DILATING DROPS-EYE CLINIC USE ONLY (CYCLOPENTOLATE/PHENYLEPHRINE/TETRACAINE/TROPICAMIDE) BOTH IP/OP $193.00 $142.82 $0.00 $148.76 $0.00 $0.00 $0.00 $0.00 $0.00 $143.24 $143.24 $148.76 $0.00 $40.22 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600995 ERX HCPCS 25000001 99999-6010-28 UVC FLUID 250 ML BOTH IP/OP $80.49 $59.56 $0.00 $62.04 $0.00 $0.00 $0.00 $0.00 $0.00 $59.74 $59.74 $62.04 $0.00 $16.77 $0.00 $0.00 $0.00 $0.00 $36.49 $57.80 $58.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600996 ERX HCPCS 25000001 99999-6010-29 UAC FLUID 60 ML BOTH IP/OP $22.00 $16.28 $0.00 $40.08 $0.00 $0.00 $0.00 $0.00 $0.00 $38.59 $38.59 $40.08 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600997 ERX HCPCS 25000001 99999-6010-30 PAL FLUID 60 ML BOTH IP/OP $62.85 $46.51 $0.00 $51.94 $0.00 $0.00 $0.00 $0.00 $0.00 $50.01 $50.01 $51.94 $0.00 $13.10 $0.00 $0.00 $0.00 $0.00 $28.50 $45.14 $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601004 ERX HCPCS J0697 00143-9979-22 CEFUROXIME SODIUM 750 MG IM SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601004 ERX HCPCS J0697 25021-0118-10 CEFUROXIME SODIUM 750 MG IM SOLR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601005 ERX HCPCS J0697 00143-9567-25 CEFUROXIME SODIUM 1.5 G IM SOLR BOTH IP/OP $29.40 $21.76 $0.00 $22.66 $0.00 $0.00 $0.00 $0.00 $0.00 $21.82 $21.82 $22.66 $0.00 $4.73 $0.00 $0.00 $0.00 $0.00 $13.33 $21.11 $21.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601005 ERX HCPCS J0697 00143-9977-22 CEFUROXIME SODIUM 1.5 G IM SOLR BOTH IP/OP $29.40 $21.76 $0.00 $22.66 $0.00 $0.00 $0.00 $0.00 $0.00 $21.82 $21.82 $22.66 $0.00 $4.73 $0.00 $0.00 $0.00 $0.00 $13.33 $21.11 $21.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601007 ERX HCPCS J2185 99999-6010-39 MEROPENEM 500 MG/NS 100ML MB PLUS BOTH IP/OP $189.43 $140.18 $0.00 $146.01 $0.00 $0.00 $0.00 $0.00 $39.48 $140.59 $140.59 $146.01 $0.00 $4.66 $0.00 $112.05 $112.05 $0.00 $86.68 $137.29 $138.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601009 ERX HCPCS J0295 99999-6010-92 AMPICILLIN-SULB 1.5 G/D5W 100ML MB PLUS BOTH IP/OP $109.96 $81.37 $0.00 $84.76 $49.48 $49.48 $0.00 $0.00 $0.00 $4.24 $81.61 $81.61 $84.76 $0.00 $2.60 $0.00 $65.04 $65.04 $0.00 $50.55 $80.07 $80.88 $0.00 $0.00 $3.03 $0.00 $0.00 $2.89 $0.00 $0.00 $0.00 $0.00 $0.00 601010 ERX HCPCS 25000001 42852-0301-67 KETAMINE 50MG/5ML IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601010 ERX HCPCS 25000001 71286-3022-01 KETAMINE 50MG/5ML IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601010 ERX HCPCS 25000001 99999-6010-44 KETAMINE 50MG/5ML IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601011 ERX HCPCS J1335 99999-6010-45 ERTAPENEM 1 G/NS 100ML MB PLUS BOTH IP/OP $255.82 $189.31 $0.00 $197.19 $115.12 $115.12 $0.00 $0.00 $0.00 $53.32 $189.87 $189.87 $197.19 $0.00 $66.36 $0.00 $151.32 $151.32 $0.00 $116.81 $185.02 $186.89 $0.00 $0.00 $90.95 $0.00 $0.00 $86.60 $0.00 $0.00 $0.00 $0.00 $0.00 601016 ERX HCPCS 25000001 99999-6010-53 MORPHINE 0.1% TOPICAL GEL 15G BOTH IP/OP $59.88 $44.31 $0.00 $46.16 $0.00 $0.00 $0.00 $0.00 $0.00 $44.44 $44.44 $46.16 $0.00 $12.48 $0.00 $0.00 $0.00 $0.00 $27.16 $43.01 $43.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601018 ERX HCPCS J1650 99999-6010-54 ENOXAPARIN SODIUM 10 MG/0.1ML SC SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 601019 ERX HCPCS J1650 99999-6010-55 ENOXAPARIN SODIUM 20 MG/0.2ML SC SOLN BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 601020 ERX HCPCS 25000001 99999-6010-57 ZINC (ELEMENTAL) 1 MG/ML (NICU) ORAL SYRINGE BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $6.94 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601021 ERX HCPCS J2590 42852-0703-99 OXYTOCIN 20 UNITS IN 1000ML NS PREMIX BOTH IP/OP $208.00 $153.92 $0.00 $160.33 $93.60 $93.60 $0.00 $0.00 $0.00 $2.94 $154.38 $154.38 $160.33 $0.00 $43.35 $0.00 $123.03 $123.03 $0.00 $95.00 $150.48 $152.00 $0.00 $0.00 $29.74 $0.00 $0.00 $30.25 $0.00 $0.00 $0.00 $0.00 $0.00 601021 ERX HCPCS J2590 71285-6043-01 OXYTOCIN 20 UNITS IN 1000ML NS PREMIX BOTH IP/OP $208.00 $153.92 $0.00 $160.33 $93.60 $93.60 $0.00 $0.00 $0.00 $2.94 $154.38 $154.38 $160.33 $0.00 $43.35 $0.00 $123.03 $123.03 $0.00 $95.00 $150.48 $152.00 $0.00 $0.00 $29.74 $0.00 $0.00 $30.25 $0.00 $0.00 $0.00 $0.00 $0.00 601021 ERX HCPCS J2590 99999-6011-30 OXYTOCIN 20 UNITS IN 1000ML NS PREMIX BOTH IP/OP $208.00 $153.92 $0.00 $160.33 $93.60 $93.60 $0.00 $0.00 $0.00 $2.94 $154.38 $154.38 $160.33 $0.00 $43.35 $0.00 $123.03 $123.03 $0.00 $95.00 $150.48 $152.00 $0.00 $0.00 $29.74 $0.00 $0.00 $30.25 $0.00 $0.00 $0.00 $0.00 $0.00 601024 ERX HCPCS 25000001 99999-6010-63 KETAMINE 10MG/1 ML IV SYRINGE BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601025 ERX HCPCS 25000001 99999-6010-64 NITROGLYCERIN 0.2 % OINT BOTH IP/OP $173.99 $128.75 $0.00 $134.11 $0.00 $0.00 $0.00 $0.00 $0.00 $129.14 $129.14 $134.11 $0.00 $36.26 $0.00 $0.00 $0.00 $0.00 $78.98 $125.10 $126.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601028 ERX HCPCS P9041 99999-6010-76 ALBUMIN 5 % IV CONTINUOUS INFUSION SYRINGE (NICU) BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $20.81 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601030 ERX HCPCS J1170 00409-1283-04 HYDROMORPHONE 0.5MG/0.5ML INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 601030 ERX HCPCS J1170 00409-1283-05 HYDROMORPHONE 0.5MG/0.5ML INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 601030 ERX HCPCS J1170 76045-0009-05 HYDROMORPHONE 0.5MG/0.5ML INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 601030 ERX HCPCS J1170 76045-0009-06 HYDROMORPHONE 0.5MG/0.5ML INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 601030 ERX HCPCS J1170 76045-0009-96 HYDROMORPHONE 0.5MG/0.5ML INJ BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $1.56 $16.33 $16.33 $16.96 $0.00 $3.88 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.64 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $0.00 601033 ERX HCPCS 25000001 SYMTUZA:DARUNAVIR-COBICISTAT-TENOFOVIR AF-EMTRICITABINE 800-150-10-200MG TABLET BOTH IP/OP $467.99 $346.31 $0.00 $360.73 $0.00 $0.00 $0.00 $0.00 $0.00 $347.34 $347.34 $360.73 $0.00 $97.53 $0.00 $0.00 $0.00 $0.00 $212.41 $336.45 $339.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601034 ERX HCPCS 25000001 99999-6010-84 ESMOLOL DRIP (NICU) 10 MG/ML BOTH IP/OP $179.68 $132.96 $0.00 $138.50 $0.00 $0.00 $0.00 $0.00 $0.00 $133.36 $133.36 $138.50 $0.00 $37.45 $0.00 $0.00 $0.00 $0.00 $81.56 $129.18 $130.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601034 ERX HCPCS 25000001 99999-6010-90 ESMOLOL DRIP (NICU) 10 MG/ML BOTH IP/OP $179.68 $132.96 $0.00 $250.16 $0.00 $0.00 $0.00 $0.00 $0.00 $133.36 $133.36 $138.50 $0.00 $37.45 $0.00 $0.00 $0.00 $0.00 $81.56 $250.16 $130.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601035 ERX HCPCS 25000001 76154-0477-05 VASOPRESSIN 20 UNITS/100 ML NS PREMIX BOTH IP/OP $359.52 $266.04 $0.00 $277.12 $0.00 $0.00 $0.00 $0.00 $0.00 $266.84 $266.84 $277.12 $0.00 $74.92 $0.00 $0.00 $0.00 $0.00 $163.18 $258.47 $261.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601036 ERX HCPCS 25000001 76154-0477-05 VASOPRESSIN 20 UNITS/100 ML NS FOR DIABETES INSIPIDUS PREMIX BOTH IP/OP $359.52 $266.04 $0.00 $277.12 $0.00 $0.00 $0.00 $0.00 $0.00 $266.84 $266.84 $277.12 $0.00 $74.92 $0.00 $0.00 $0.00 $0.00 $163.18 $258.47 $261.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601047 ERX HCPCS j3370 99999-6011-04 VANCOMYCIN 500MG/NS 100ML MB PLUS BOTH IP/OP $58.60 $43.36 $0.00 $45.17 $0.00 $0.00 $0.00 $0.00 $0.00 $43.49 $43.49 $45.17 $0.00 $12.21 $0.00 $0.00 $0.00 $0.00 $27.27 $43.20 $43.63 $32.72 $32.72 $8.54 $0.00 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $0.00 601048 ERX HCPCS J3370 99999-6011-05 VANCOMYCIN 750MG/D5W 250ML MB PLUS BOTH IP/OP $62.12 $45.97 $0.00 $49.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.20 $0.00 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601049 ERX HCPCS J3370 99999-6011-06 VANCOMYCIN 750MG/NS 250ML MB PLUS BOTH IP/OP $62.12 $45.97 $0.00 $49.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.20 $0.00 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601050 ERX HCPCS J1335 00006-3843-71 ERTAPENEM SODIUM 1 G IJ SOLR FOR DESENSITIZATION BOTH IP/OP $472.03 $349.30 $0.00 $363.84 $212.41 $212.41 $0.00 $0.00 $0.00 $98.38 $350.34 $350.34 $363.84 $0.00 $66.36 $0.00 $279.21 $279.21 $0.00 $214.24 $339.36 $342.78 $0.00 $0.00 $90.95 $0.00 $0.00 $86.60 $0.00 $0.00 $0.00 $0.00 $0.00 601050 ERX HCPCS J1335 42023-0221-10 ERTAPENEM SODIUM 1 G IJ SOLR FOR DESENSITIZATION BOTH IP/OP $472.03 $349.30 $0.00 $363.84 $212.41 $212.41 $0.00 $0.00 $0.00 $98.38 $350.34 $350.34 $363.84 $0.00 $66.36 $0.00 $279.21 $279.21 $0.00 $214.24 $339.36 $342.78 $0.00 $0.00 $90.95 $0.00 $0.00 $86.60 $0.00 $0.00 $0.00 $0.00 $0.00 601050 ERX HCPCS J1335 55150-0282-20 ERTAPENEM SODIUM 1 G IJ SOLR FOR DESENSITIZATION BOTH IP/OP $472.03 $349.30 $0.00 $363.84 $212.41 $212.41 $0.00 $0.00 $0.00 $98.38 $350.34 $350.34 $363.84 $0.00 $66.36 $0.00 $279.21 $279.21 $0.00 $214.24 $339.36 $342.78 $0.00 $0.00 $90.95 $0.00 $0.00 $86.60 $0.00 $0.00 $0.00 $0.00 $0.00 601053 ERX HCPCS 25000001 99999-6100-01 METHACHOLINE (PROVOCHOLINE) 1 MG/ML INHALATION SOLN C BOTH IP/OP $115.80 $85.69 $0.00 $89.26 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601053 ERX HCPCS 25000001 99999-6011-09 METHACHOLINE (PROVOCHOLINE) 1 MG/ML INHALATION SOLN C BOTH IP/OP $115.80 $85.69 $0.00 $362.34 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $362.34 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601054 ERX HCPCS 25000001 99999-6100-02 METHACHOLINE (PROVOCHOLINE) 0.25 MG/ML INH SOLN D BOTH IP/OP $115.80 $85.69 $0.00 $89.26 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601054 ERX HCPCS 25000001 99999-6011-10 METHACHOLINE (PROVOCHOLINE) 0.25 MG/ML INH SOLN D BOTH IP/OP $115.80 $85.69 $0.00 $362.34 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $362.34 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601055 ERX HCPCS 25000001 99999-6100-03 METHACHOLINE (PROVOCHOLINE) 0.0625 MG/ML INH SOLN E BOTH IP/OP $115.80 $85.69 $0.00 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $228.75 $83.16 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601055 ERX HCPCS 25000001 99999-6011-11 METHACHOLINE (PROVOCHOLINE) 0.0625 MG/ML INH SOLN E BOTH IP/OP $115.80 $85.69 $0.00 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $228.75 $362.34 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601058 ERX HCPCS 25000001 99999-6100-04 METHACHOLINE (PROVOCHOLINE) 4 MG/ML INH SOLN B BOTH IP/OP $115.80 $85.69 $0.00 $89.26 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601058 ERX HCPCS 25000001 99999-6011-14 METHACHOLINE (PROVOCHOLINE) 4 MG/ML INH SOLN B BOTH IP/OP $115.80 $85.69 $0.00 $362.34 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $362.34 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601059 ERX HCPCS 25000001 99999-6100-05 METHACHOLINE (PROVOCHOLINE) 16 MG/ML INH SOLN A BOTH IP/OP $115.80 $85.69 $0.00 $89.26 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601059 ERX HCPCS 25000001 99999-6011-15 METHACHOLINE (PROVOCHOLINE) 16 MG/ML INH SOLN A BOTH IP/OP $115.80 $85.69 $0.00 $149.69 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $85.95 $89.26 $0.00 $24.13 $0.00 $0.00 $0.00 $0.00 $52.50 $149.69 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601060 ERX HCPCS 25000001 99999-6011-17 NAFCILLIN 2 G/NS 100ML MB PLUS BOTH IP/OP $106.26 $78.63 $0.00 $81.91 $0.00 $0.00 $0.00 $0.00 $0.00 $78.87 $78.87 $81.91 $0.00 $22.14 $0.00 $0.00 $0.00 $0.00 $48.87 $77.41 $78.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601061 ERX HCPCS 25000001 99999-6011-18 NAFCILLIN 1 G/NS 100ML MB PLUS BOTH IP/OP $106.26 $78.63 $0.00 $81.91 $0.00 $0.00 $0.00 $0.00 $0.00 $78.87 $78.87 $81.91 $0.00 $22.14 $0.00 $0.00 $0.00 $0.00 $48.87 $77.41 $78.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-04 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-18 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-38 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-48 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0551-18 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00264-7510-20 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-02 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00264-1510-31 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-11 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-31 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-41 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0551-11 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00264-7510-10 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 00338-0017-03 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601063 ERX HCPCS 63600001 63323-0624-75 DEXTROSE 5% FLUID - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601064 ERX HCPCS 63600001 99999-6006-29 SODIUM CHLORIDE 3% IV SOLUTION - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601064 ERX HCPCS 63600001 00264-7805-10 SODIUM CHLORIDE 3% IV SOLUTION - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601064 ERX HCPCS 63600001 00338-0054-03 SODIUM CHLORIDE 3% IV SOLUTION - DIALYSIS BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601072 ERX HCPCS J1940 00409-6102-10 FUROSEMIDE 100 MG/10 ML INJ- OUTPATIENT IV DIURETIC CLINIC ONLY BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $1.23 $21.77 $21.77 $22.61 $0.00 $2.80 $0.00 $17.35 $17.35 $0.00 $13.11 $20.77 $20.98 $0.00 $0.00 $3.47 $0.00 $0.00 $3.30 $0.00 $0.00 $0.00 $0.00 $0.00 601072 ERX HCPCS J1940 00409-6102-27 FUROSEMIDE 100 MG/10 ML INJ- OUTPATIENT IV DIURETIC CLINIC ONLY BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $1.23 $21.77 $21.77 $22.61 $0.00 $2.80 $0.00 $17.35 $17.35 $0.00 $13.11 $20.77 $20.98 $0.00 $0.00 $3.47 $0.00 $0.00 $3.30 $0.00 $0.00 $0.00 $0.00 $0.00 601072 ERX HCPCS J1940 00409-6102-37 FUROSEMIDE 100 MG/10 ML INJ- OUTPATIENT IV DIURETIC CLINIC ONLY BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $1.23 $21.77 $21.77 $22.61 $0.00 $2.80 $0.00 $17.35 $17.35 $0.00 $13.11 $20.77 $20.98 $0.00 $0.00 $3.47 $0.00 $0.00 $3.30 $0.00 $0.00 $0.00 $0.00 $0.00 601072 ERX HCPCS J1940 23155-0473-44 FUROSEMIDE 100 MG/10 ML INJ- OUTPATIENT IV DIURETIC CLINIC ONLY BOTH IP/OP $29.33 $21.70 $0.00 $22.61 $13.20 $13.20 $0.00 $0.00 $0.00 $1.23 $21.77 $21.77 $22.61 $0.00 $2.80 $0.00 $17.35 $17.35 $0.00 $13.11 $20.77 $20.98 $0.00 $0.00 $3.47 $0.00 $0.00 $3.30 $0.00 $0.00 $0.00 $0.00 $0.00 601073 ERX HCPCS 25000001 99999-6012-08 DOXYCYCLINE 100MG/D5W 100ML MB PLUS BOTH IP/OP $109.78 $81.24 $0.00 $84.62 $0.00 $0.00 $0.00 $0.00 $0.00 $81.48 $81.48 $84.62 $0.00 $22.88 $0.00 $0.00 $0.00 $0.00 $50.47 $79.94 $80.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 601074 ERX HCPCS J0290 99999-6012-12 AMPICILLIN 1 G/50 ML NS MB PLUS BOTH IP/OP $69.81 $51.66 $0.00 $53.81 $31.41 $31.41 $0.00 $0.00 $0.00 $5.22 $51.81 $51.81 $53.81 $0.00 $1.90 $0.00 $41.29 $41.29 $0.00 $32.36 $51.25 $51.77 $0.00 $0.00 $2.30 $0.00 $0.00 $2.19 $0.00 $0.00 $0.00 $0.00 $0.00 900083 ERX HCPCS 63700001 99999-9000-83 AMLODIPINE 1MG/ML ORAL SUSP BOTH IP/OP $36.13 $26.74 $0.00 $26.22 $0.00 $0.00 $0.00 $6.43 $0.00 $0.00 $0.00 $0.00 $0.00 $7.53 $0.00 $0.00 $0.00 $0.00 $16.39 $25.95 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900092 ERX HCPCS 25000001 99999-9000-92 OMEPRAZOLE 2MG/ML ORAL SUSP 50ML BOTH IP/OP $56.10 $41.51 $0.00 $43.24 $0.00 $0.00 $0.00 $0.00 $0.00 $41.64 $41.64 $43.24 $0.00 $11.69 $0.00 $0.00 $0.00 $0.00 $25.44 $40.30 $40.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900093 ERX HCPCS 63700001 99999-9000-93 PYRAZINAMIDE 100MG/ML 120ML SUSP BOTH IP/OP $9.00 $6.66 $0.00 $84.34 $0.00 $0.00 $0.00 $1.60 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $52.71 $83.49 $84.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900094 ERX HCPCS 63700001 99999-9000-94 RIFABUTIN 1200MG/60ML SUSPENSION BOTH IP/OP $153.98 $113.95 $0.00 $111.70 $0.00 $0.00 $0.00 $27.41 $0.00 $0.00 $0.00 $0.00 $0.00 $32.09 $0.00 $0.00 $0.00 $0.00 $69.81 $110.58 $111.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900095 ERX HCPCS 63700001 99999-6010-59 RIFAMPIN 10MG/ML ORAL SUSP BOTH IP/OP $16.60 $12.28 $0.00 $48.16 $0.00 $0.00 $0.00 $2.95 $0.00 $0.00 $0.00 $0.00 $0.00 $3.46 $0.00 $0.00 $0.00 $0.00 $30.10 $11.92 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900095 ERX HCPCS 63700001 99999-9000-95 RIFAMPIN 10MG/ML ORAL SUSP BOTH IP/OP $16.60 $12.28 $0.00 $48.16 $0.00 $0.00 $0.00 $2.95 $0.00 $0.00 $0.00 $0.00 $0.00 $3.46 $0.00 $0.00 $0.00 $0.00 $30.10 $47.68 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900097 ERX HCPCS 25000001 99999-6006-02 DAKINS (1/8 STRENGTH) 0.0625% EX SOLN BOTH IP/OP $39.22 $29.02 $0.00 $30.23 $0.00 $0.00 $0.00 $0.00 $0.00 $29.11 $29.11 $30.23 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $17.79 $28.17 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900098 ERX HCPCS 25000001 99999-6008-14 URSODIOL 15MG/ML ORAL SOLUTION BOTH IP/OP $19.45 $14.39 $0.00 $42.32 $0.00 $0.00 $0.00 $0.00 $0.00 $14.44 $14.44 $14.99 $0.00 $4.05 $0.00 $0.00 $0.00 $0.00 $26.45 $13.97 $42.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900098 ERX HCPCS 25000001 99999-6008-54 URSODIOL 15MG/ML ORAL SOLUTION BOTH IP/OP $19.45 $14.39 $0.00 $42.32 $0.00 $0.00 $0.00 $0.00 $0.00 $14.44 $14.44 $14.99 $0.00 $4.05 $0.00 $0.00 $0.00 $0.00 $26.45 $41.90 $42.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900131 ERX HCPCS J1644 99999-6006-11 HEPARIN 1500 UNITS IN NS 500 ML IR USE ONLY BOTH IP/OP $75.42 $55.81 $0.00 $58.13 $33.94 $33.94 $0.00 $0.00 $0.00 $0.24 $55.98 $55.98 $58.13 $0.00 $0.29 $0.00 $44.61 $44.61 $0.00 $34.20 $54.17 $54.72 $0.00 $0.00 $0.28 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 900147 ERX HCPCS 63700001 99999-6005-86 OPIUM TINCTURE 6MG/0.6ML ORAL SYRINGE BOTH IP/OP $11.55 $8.55 $0.00 $8.38 $0.00 $0.00 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $0.00 $2.41 $0.00 $0.00 $0.00 $0.00 $5.24 $8.30 $8.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900288 ERX HCPCS 25000001 99999-6010-21 "MAFENIDE 5% (PLUS NYSTATIN 500,000 UNITS) TOP SOL-50GM/1000ML SW" BOTH IP/OP $185.11 $136.98 $0.00 $142.68 $0.00 $0.00 $0.00 $0.00 $0.00 $137.39 $137.39 $142.68 $0.00 $38.58 $0.00 $0.00 $0.00 $0.00 $83.93 $132.94 $134.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900333 ERX HCPCS J9201 00409-0181-01 GEMCITABINE 2G INTRAVESICAL SYRINGE-UROLOGY CLINIC ONLY BOTH IP/OP $365.32 $270.34 $0.00 "$1,623.73" $164.39 $164.39 $0.00 $0.00 $0.00 "$1,623.73" $271.14 $271.14 $281.59 $0.00 $44.84 $0.00 $216.09 $216.09 $0.00 $163.40 $258.83 $261.44 $0.00 $0.00 $48.88 $0.00 $0.00 $46.54 $0.00 $0.00 $0.00 $0.00 $0.00 900333 ERX HCPCS J9201 60505-6114-00 GEMCITABINE 2G INTRAVESICAL SYRINGE-UROLOGY CLINIC ONLY BOTH IP/OP $365.32 $270.34 $0.00 "$1,623.73" $164.39 $164.39 $0.00 $0.00 $0.00 "$1,623.73" $271.14 $271.14 $281.59 $0.00 $44.84 $0.00 $216.09 $216.09 $0.00 $163.40 $258.83 $261.44 $0.00 $0.00 $48.88 $0.00 $0.00 $46.54 $0.00 $0.00 $0.00 $0.00 $0.00 900575 ERX HCPCS 25000001 99999-6009-03 PHENYLEPHRINE BOLUS FROM IV BAG FOR CARDIAC NARRATOR BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $16.96 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900576 ERX HCPCS 63600001 99999-6009-80 EPINEPHRINE 16000 MCG/500 ML NS - ANE BOTH IP/OP $167.91 $124.25 $0.00 $138.74 $75.56 $75.56 $0.00 $0.00 $0.00 $35.00 $124.62 $124.62 $129.43 $0.00 $138.74 $0.00 $99.32 $99.32 $0.00 $76.13 $120.58 $121.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00409-9093-35 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00409-9093-37 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00409-9093-45 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00409-9094-12 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00409-9094-22 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00409-9094-25 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00409-9094-31 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00409-9094-61 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00641-6027-01 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00641-6027-25 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00641-6028-01 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00641-6028-25 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00641-6029-01 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00641-6029-25 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 00641-6030-01 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 17478-0030-05 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 63323-0806-14 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 4083037 ERX HCPCS J3010 63323-0806-50 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN BOTH IP/OP $22.00 $16.28 $0.00 $67.84 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $65.32 $65.32 $67.84 $0.00 $0.74 $0.00 $52.04 $52.04 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $1.16 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 00409-4699-33 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $52.82 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 25021-0608-50 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $52.82 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 43598-0548-21 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $52.82 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 43598-0548-50 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $52.82 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 00409-4699-24 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $94.80 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 00409-4699-54 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $94.80 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 00591-2136-57 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $94.80 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 25021-0608-51 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $94.80 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 43598-0549-10 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $94.80 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 43598-0549-52 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $94.80 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 40811150 ERX HCPCS J2704 63323-0269-67 PROPOFOL 10 MG/ML IV EMUL 50 OR 100 ML BOTH IP/OP $132.02 $97.69 $0.00 $158.44 $59.41 $59.41 $0.00 $0.00 $0.00 $27.52 $152.57 $152.57 $158.44 $0.00 $27.51 $0.00 $121.59 $121.59 $0.00 $59.85 $94.80 $95.76 $0.00 $0.00 $18.73 $0.00 $0.00 $19.06 $0.00 $0.00 $0.00 $0.00 $0.00 600015848 ERX HCPCS J1644 00409-7651-03 HEPARIN IN NS 50-0.45 UNIT/ML-% IJ SOLN BOTH IP/OP $39.81 $29.46 $0.00 $30.69 $17.91 $17.91 $0.00 $0.00 $0.00 $5.88 $29.55 $29.55 $30.69 $0.00 $7.29 $0.00 $23.55 $23.55 $0.00 $17.10 $27.09 $27.36 $0.00 $0.00 $7.05 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 4.081E+12 ERX HCPCS J1815 00002-7510-01 INSULIN LISPRO 100 UNIT/ML SC SOLN BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $8.15 $8.15 $0.00 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $3.13 $0.00 $8.87 $8.87 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $0.00 15 SUP Custom 27203010 00015 - HANDGRIP CRCH CHLD GRY BOTH IP/OP $15.40 $11.40 $0.00 $12.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.43 $11.43 $0.00 $0.00 $3.21 $0.00 $0.00 $0.00 $0.00 $7.70 $12.20 $12.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15.201 SUP HCPCS C1713 015.2010 - PLATE SQ RECT GRID MESH 1.5 MM SCR CRANIAL TI TIMESH BONE BOTH IP/OP "$1,010.00 " $747.40 $0.00 $808.00 $454.50 $454.50 $0.00 $0.00 $0.00 $210.51 $749.62 $749.62 $0.00 $0.00 $210.48 $0.00 $597.42 $597.42 $0.00 $505.00 $799.92 $808.00 $0.00 $0.00 $158.07 $0.00 $0.00 $160.79 $0.00 $0.00 $0.00 $0.00 $0.00 76 SUP Custom 27203010 000076 - PLUG CATH CAP STRL LATEX FREE BOTH IP/OP $0.78 $0.58 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.58 $0.58 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.39 $0.62 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86 SUP HCPCS C1886 0086 - NOVASURE 2007 ENDOMETRIAL ABLATION SYSTEM BOTH IP/OP "$3,050.00 " "$2,257.00" $0.00 "$2,440.00" "$1,656.15" "$1,656.15" $0.00 $0.00 $0.00 $635.70 "$2,263.71" "$2,263.71" $0.00 $0.00 $635.62 $0.00 "$1,804.08" "$1,804.08" $0.00 "$1,525.00" "$2,415.60" "$2,440.00" $0.00 $0.00 $477.33 $0.00 $0.00 $485.56 $0.00 $0.00 $0.00 $0.00 $0.00 90 SUP Custom 27803010 90 - PLATE BN 152X152MM MESH PNL TI CRNM BOTH IP/OP "$2,316.25 " "$1,714.03" $0.00 "$1,853.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,719.12" "$1,719.12" $0.00 $0.00 $482.71 $0.00 $0.00 $0.00 $0.00 "$1,158.13" "$1,834.47" "$1,853.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100 SUP Custom 27203010 CONTROL VRTRL 1 LOW POS IMMUN BOTH IP/OP $272.50 $201.65 $0.00 $218.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.25 $215.82 $218.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.107 SUP Custom 27803010 101.107 - SPACER SPNL SM 22X10X7MM NS LF SUST RDLCNT PEEK LMBR INTRBD BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.109 SUP Custom 27803010 101.109 - SPACER SPNL SM 22X10X9MM NS LF SUST RDLCNT PEEK LMBR INTRBD BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.111 SUP Custom 27803010 101.111 - SPACER SPNL SM 22X10X11MM NS LF SUST RDLCNT PEEK LMBR INTRBD BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.113 SUP Custom 27803010 101.113 - SPACER SPNL SM 22X10X13MM NS LF SUST RDLCNT PEEK LMBR INTRBD BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.115 SUP Custom 27803010 101.115 - SPACER SPNL SM 22X10X15MM NS LF SUST RDLCNT PEEK LMBR INTRBD BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.117 SUP Custom 27803010 101.117 - SPACER SPNL SM 22X10X17MM NS LF SUST RDLCNT PEEK LMBR INTRBD BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.205 SUP Custom 27803010 101.205 - SPACER SPNL 13MM MED PRLL 14X5MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.206 SUP Custom 27803010 101.206 - SPACER SPNL 13MM MED PRLL 14X6MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.207 SUP Custom 27803010 101.207 - SPACER SPNL 13MM MED PRLL 14X7MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.208 SUP Custom 27803010 101.208 - SPACER SPNL 13MM MED PRLL 14X8MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.209 SUP Custom 27803010 101.209 - SPACER SPNL 13MM MED PRLL 14X9MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.21 SUP Custom 27803010 101.210 - SPACER SPNL 13MM MED PRLL 14X10MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.211 SUP Custom 27803010 101.211 - SPACER SPNL 13MM MED PRLL 14X11MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.212 SUP Custom 27803010 101.212 - SPACER SPNL 13MM MED PRLL 14X12MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.225 SUP Custom 27803010 101.225 - SPACER SPNL 7D LRDTC 13MM MED 14X5MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.226 SUP Custom 27803010 101.226 - SPACER SPNL 7D LRDTC 13MM MED 14X6MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.227 SUP Custom 27803010 101.227 - SPACER SPNL 7D LRDTC 13MM MED 14X7MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.228 SUP Custom 27803010 101.228 - SPACER SPNL 7D LRDTC 13MM MED 14X8MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.229 SUP Custom 27803010 101.229 - SPACER SPNL 7D LRDTC 13MM MED 14X9MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.23 SUP Custom 27803010 101.230 - SPACER SPNL 7D LRDTC 13MM MED 14X10MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.231 SUP Custom 27803010 101.231 - SPACER SPNL 7D LRDTC 13MM MED 14X11MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.232 SUP Custom 27803010 101.232 - SPACER SPNL 7D LRDTC 13MM MED 14X12MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.245 SUP Custom 27803010 101.245 - SPACER SPNL 13MM MED CNVX 14X5MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.246 SUP Custom 27803010 101.246 - SPACER SPNL 13MM MED CNVX 14X6MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.247 SUP Custom 27803010 101.247 - SPACER SPNL 13MM MED CNVX 14X7MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.248 SUP Custom 27803010 101.248 - SPACER SPNL 13MM MED CNVX 14X8MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.249 SUP Custom 27803010 101.249 - SPACER SPNL 13MM MED CNVX 14X9MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.25 SUP Custom 27803010 101.250 - SPACER SPNL 13MM MED CNVX 14X10MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.251 SUP Custom 27803010 101.251 - SPACER SPNL 13MM MED CNVX 14X11MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.252 SUP Custom 27803010 101.252 - SPACER SPNL 13MM MED CNVX 14X12MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.309 SUP Custom 27803010 101.309 - SPACER SPNL 31MM LG 25X9MM NS LF SUST RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.311 SUP Custom 27803010 101.311 - SPACER SPNL 31MM LG 25X11MM NS LF SUST RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.313 SUP Custom 27803010 101.313 - SPACER SPNL 31MM LG 25X13MM NS LF SUST RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.315 SUP Custom 27803010 101.315 - SPACER SPNL 31MM LG 25X15MM NS LF SUST RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.317 SUP Custom 27803010 101.317 - SPACER SPNL 31MM LG 25X17MM NS LF SUST RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.319 SUP Custom 27803010 101.319 - SPACER SPNL 31MM LG 25X19MM NS LF SUST RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.321 SUP Custom 27803010 101.321 - SPACER SPNL 31MM LG 25X21MM NS LF SUST RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.409 SUP Custom 27803010 101.409 - SPACER SPNL 31MM LG 25X9MM NS LF SUST RDLCNT PEEK LAT INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.411 SUP Custom 27803010 101.411 - SPACER SPNL 31MM LG 25X11MM NS LF SUST RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.413 SUP Custom 27803010 101.413 - SPACER SPNL 31MM LG 25X13MM NS LF SUST RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.415 SUP Custom 27803010 101.415 - SPACER SPNL 31MM LG 25X15MM NS LF SUST RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.417 SUP Custom 27803010 101.417 - SPACER SPNL 31MM LG 25X17MM NS LF SUST RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.419 SUP Custom 27803010 101.419 - SPACER SPNL 31MM LG 25X19MM NS LF SUST RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.421 SUP Custom 27803010 101.421 - SPACER SPNL 31MM LG 25X21MM NS LF SUST RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.509 SUP Custom 27803010 101.509 - SPACER SPNL 31MM LG 25X9MM NS LF SUST RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.511 SUP Custom 27803010 101.511 - SPACER SPNL 31MM LG 25X11MM NS LF SUST RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.513 SUP Custom 27803010 101.513 - SPACER SPNL 31MM LG 25X13MM NS LF SUST RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.515 SUP Custom 27803010 101.515 - SPACER SPNL 31MM LG 25X15MM NS LF SUST RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.517 SUP Custom 27803010 101.517 - SPACER SPNL 31MM LG 25X17MM NS LF SUST RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.519 SUP Custom 27803010 101.519 - SPACER SPNL 31MM LG 25X19MM NS LF SUST RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.521 SUP Custom 27803010 101.521 - SPACER SPNL 31MM LG 25X21MM NS LF SUST RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.607 SUP Custom 27803010 101.607 - SPACER SPNL ARCH 27X9.5X7MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.609 SUP Custom 27803010 101.609 - SPACER SPNL ARCH 27X9.5X9MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.611 SUP Custom 27803010 101.611 - SPACER SPNL ARCH 27X9.5X11MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.613 SUP Custom 27803010 101.613 - SPACER SPNL ARCH 27X9.5X13MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.615 SUP Custom 27803010 101.615 - SPACER SPNL ARCH 27X9.5X15MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.617 SUP Custom 27803010 101.617 - SPACER SPNL ARCH 27X9.5X17MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.707 SUP Custom 27803010 101.707 - SPACER SPNL SM NAR 22X8X7MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.709 SUP Custom 27803010 101.709 - SPACER SPNL SM NAR 22X8X9MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.711 SUP Custom 27803010 101.711 - SPACER SPNL SM NAR 22X8X11MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.713 SUP Custom 27803010 101.713 - SPACER SPNL SM NAR 22X8X13MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.715 SUP Custom 27803010 101.715 - SPACER SPNL SM NAR 22X8X15MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.717 SUP Custom 27803010 101.717 - SPACER SPNL SM NAR 22X8X17MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.805 SUP Custom 27803010 101.805 - SPACER SPNL 11MM MED NAR PRLL 12X5MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.806 SUP Custom 27803010 101.806 - SPACER SPNL 11MM MED NAR PRLL 12X6MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.807 SUP Custom 27803010 101.807 - SPACER SPNL 11MM MED NAR PRLL 12X7MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.808 SUP Custom 27803010 101.808 - SPACER SPNL 11MM MED NAR PRLL 12X8MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.809 SUP Custom 27803010 101.809 - SPACER SPNL 11MM MED NAR PRLL 12X9MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.81 SUP Custom 27803010 101.810 - SPACER SPNL 11MM MED NAR PRLL 12X10MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.811 SUP Custom 27803010 101.811 - SPACER SPNL 11MM MED NAR PRLL 12X11MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.812 SUP Custom 27803010 101.812 - SPACER SPNL 11MM MED NAR PRLL 12X12MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.825 SUP Custom 27803010 101.825 - SPACER SPNL 7D LRDTC MED NAR 12X5MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.826 SUP Custom 27803010 101.826 - SPACER SPNL 7D LRDTC MED NAR 12X6MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.827 SUP Custom 27803010 101.827 - SPACER SPNL 7D LRDTC MED NAR 12X7MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.828 SUP Custom 27803010 101.828 - SPACER SPNL 7D LRDTC MED NAR 12X8MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.829 SUP Custom 27803010 101.829 - SPACER SPNL 7D LRDTC MED NAR 12X9MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.83 SUP Custom 27803010 101.830 - SPACER SPNL 7D LRDTC MED NAR 12X10MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.831 SUP Custom 27803010 101.831 - SPACER SPNL 7D LRDTC MED NAR 12X11MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.832 SUP Custom 27803010 101.832 - SPACER SPNL 7D LRDTC MED NAR 12X12MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.845 SUP Custom 27803010 101.845 - SPACER SPNL 11MM MED CNVX NAR 12X5MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.846 SUP Custom 27803010 101.846 - SPACER SPNL 11MM MED CNVX NAR 12X6MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.847 SUP Custom 27803010 101.847 - SPACER SPNL 11MM MED CNVX NAR 12X7MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.848 SUP Custom 27803010 101.848 - SPACER SPNL 11MM MED CNVX NAR 12X8MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.849 SUP Custom 27803010 101.849 - SPACER SPNL 11MM MED CNVX NAR 12X9MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.85 SUP Custom 27803010 101.850 - SPACER SPNL 11MM MED CNVX NAR 12X10MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.851 SUP Custom 27803010 101.851 - SPACER SPNL 11MM MED CNVX NAR 12X11MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101.852 SUP Custom 27803010 101.852 - SPACER SPNL 11MM MED CNVX NAR 12X12MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.041 SUP HCPCS C1713 102.041 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 70MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.042 SUP HCPCS C1713 102.042 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 75MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.043 SUP HCPCS C1713 102.043 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 80MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.044 SUP HCPCS C1713 102.044 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 85MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.045 SUP HCPCS C1713 102.045 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 90MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.051 SUP HCPCS C1713 102.051 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 70MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.052 SUP HCPCS C1713 102.052 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 75MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.053 SUP HCPCS C1713 102.053 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 80MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.054 SUP HCPCS C1713 102.054 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 85MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.055 SUP HCPCS C1713 102.055 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 90MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.061 SUP HCPCS C1713 102.061 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 70MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.062 SUP HCPCS C1713 102.062 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 75MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.063 SUP HCPCS C1713 102.063 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 80MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.064 SUP HCPCS C1713 102.064 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 85MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.065 SUP HCPCS C1713 102.065 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 90MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.071 SUP HCPCS C1713 102.071 - 7.0MM PROTEX PEDICLE SCREW 70MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.072 SUP HCPCS C1713 102.072 - 7.0MM PROTEX PEDICLE SCREW 75MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.073 SUP HCPCS C1713 102.073 - 7.0MM PROTEX PEDICLE SCREW 80MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.074 SUP HCPCS C1713 102.074 - 7.0MM PROTEX PEDICLE SCREW 85MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.075 SUP HCPCS C1713 102.075 - 7.0MM PROTEX PEDICLE SCREW 90MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.081 SUP HCPCS C1713 102.081 - 8.0MM PROTEX PEDICLE SCREW 70MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.082 SUP HCPCS C1713 102.082 - 8.0MM PROTEX PEDICLE SCREW 75MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.083 SUP HCPCS C1713 102.083 - 8.0MM PROTEX PEDICLE SCREW 80MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.084 SUP HCPCS C1713 102.084 - 8.0MM PROTEX PEDICLE SCREW 85MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.085 SUP HCPCS C1713 102.085 - 8.0MM PROTEX PEDICLE SCREW 90MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.091 SUP HCPCS C1713 102.091 - 9.0MM PROTEX PEDICLE SCREW 70MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.092 SUP HCPCS C1713 102.092 - 9.0MM PROTEX PEDICLE SCREW 75MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.093 SUP HCPCS C1713 102.093 - 9.0MM PROTEX PEDICLE SCREW 80MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.094 SUP HCPCS C1713 102.094 - 9.0MM PROTEX PEDICLE SCREW 85MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.095 SUP HCPCS C1713 102.095 - 9.0MM PROTEX PEDICLE SCREW 90MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.352 SUP HCPCS C1713 102.352 - 5.0MM PROTEX MONOAXIAL PEDICLE SCREW 30MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.353 SUP HCPCS C1713 102.353 - 5.0MM PROTEX MONOAXIAL PEDICLE SCREW 35MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.354 SUP HCPCS C1713 102.354 - 5.0MM PROTEX MONOAXIAL PEDICLE SCREW 40MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.355 SUP HCPCS C1713 102.355 - 5.0MM PROTEX MONOAXIAL PEDICLE SCREW 45MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.356 SUP HCPCS C1713 102.356 - 5.0MM PROTEX MONOAXIAL PEDICLE SCREW 50MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.357 SUP HCPCS C1713 102.357 - 5.0MM PROTEX MONOAXIAL PEDICLE SCREW 55MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.362 SUP HCPCS C1713 102.362 - 6.0MM PROTEX MONOAXIAL PEDICLE SCREW 30MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.363 SUP HCPCS C1713 102.363 - 6.0MM PROTEX MONOAXIAL PEDICLE SCREW 35MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.364 SUP HCPCS C1713 102.364 - 6.0MM PROTEX MONOAXIAL PEDICLE SCREW 40MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.365 SUP HCPCS C1713 102.365 - 6.0MM PROTEX MONOAXIAL PEDICLE SCREW 45MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.366 SUP HCPCS C1713 102.366 - 6.0MM PROTEX MONOAXIAL PEDICLE SCREW 50MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.367 SUP HCPCS C1713 102.367 - 6.0MM PROTEX MONOAXIAL PEDICLE SCREW 55MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.368 SUP HCPCS C1713 102.368 - 6.0MM PROTEX MONOAXIAL PEDICLE SCREW 60MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.369 SUP HCPCS C1713 102.369 - 6.0MM PROTEX MONOAXIAL PEDICLE SCREW 65MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.372 SUP HCPCS C1713 102.372 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 30MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.373 SUP HCPCS C1713 102.373 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 35MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.374 SUP HCPCS C1713 102.374 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 40MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.375 SUP HCPCS C1713 102.375 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 45MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.376 SUP HCPCS C1713 102.376 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 50MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.377 SUP HCPCS C1713 102.377 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 55MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.378 SUP HCPCS C1713 102.378 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 60MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.379 SUP HCPCS C1713 102.379 - 7.0MM PROTEX MONOAXIAL PEDICLE SCREW 65MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.382 SUP HCPCS C1713 102.382 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 30MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.383 SUP HCPCS C1713 102.383 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 35MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.384 SUP HCPCS C1713 102.384 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 40MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.385 SUP HCPCS C1713 102.385 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 45MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.386 SUP HCPCS C1713 102.386 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 50MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.387 SUP HCPCS C1713 102.387 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 55MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.388 SUP HCPCS C1713 102.388 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 60MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.389 SUP HCPCS C1713 102.389 - 8.0MM PROTEX MONOAXIAL PEDICLE SCREW 65MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.392 SUP HCPCS C1713 102.392 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 30MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.393 SUP HCPCS C1713 102.393 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 35MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.394 SUP HCPCS C1713 102.394 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 40MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.395 SUP HCPCS C1713 102.395 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 45MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.396 SUP HCPCS C1713 102.396 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 50MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.397 SUP HCPCS C1713 102.397 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 55MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.398 SUP HCPCS C1713 102.398 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 60MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.399 SUP HCPCS C1713 102.399 - 9.0MM PROTEX MONOAXIAL PEDICLE SCREW 65MM BOTH IP/OP "$3,627.50 " "$2,684.35" $0.00 "$2,902.00" "$1,632.38" "$1,632.38" $0.00 $0.00 $0.00 $756.06 "$2,692.33" "$2,692.33" $0.00 $0.00 $755.97 $0.00 "$1,788.36" "$1,788.36" $0.00 "$1,813.75" "$2,872.98" "$2,902.00" $0.00 $0.00 $567.70 $0.00 $0.00 $577.50 $0.00 $0.00 $0.00 $0.00 $0.00 102.452 SUP HCPCS C1713 102.452 - 5.0MM PROTEX PEDICLE SCREW 30MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.453 SUP HCPCS C1713 102.453 - 5.0MM PROTEX PEDICLE SCREW 35MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.454 SUP HCPCS C1713 102.454 - 5.0MM PROTEX PEDICLE SCREW 40MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.455 SUP HCPCS C1713 102.455 - 5.0MM PROTEX PEDICLE SCREW 45MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.456 SUP HCPCS C1713 102.456 - 5.0MM PROTEX PEDICLE SCREW 50MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.457 SUP HCPCS C1713 102.457 - 5.0MM PROTEX PEDICLE SCREW 55MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.462 SUP HCPCS C1713 102.462 - 6.0MM PROTEX PEDICLE SCREW 30MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.463 SUP HCPCS C1713 102.463 - 6.0MM PROTEX PEDICLE SCREW 35MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.464 SUP HCPCS C1713 102.464 - 6.0MM PROTEX PEDICLE SCREW 40MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.465 SUP HCPCS C1713 102.465 - 6.0MM PROTEX PEDICLE SCREW 45MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.466 SUP HCPCS C1713 102.466 - 6.0MM PROTEX PEDICLE SCREW 50MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.467 SUP HCPCS C1713 102.467 - 6.0MM PROTEX PEDICLE SCREW 55MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.468 SUP HCPCS C1713 102.468 - 6.0MM PROTEX PEDICLE SCREW 60MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.469 SUP HCPCS C1713 102.469 - 6.0MM PROTEX PEDICLE SCREW 65MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.472 SUP HCPCS C1713 102.472 - 7.0MM PROTEX PEDICLE SCREW 30MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.473 SUP HCPCS C1713 102.473 - 7.0MM PROTEX PEDICLE SCREW 35MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.474 SUP HCPCS C1713 102.474 - 7.0MM PROTEX PEDICLE SCREW 40MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.475 SUP HCPCS C1713 102.475 - 7.0MM PROTEX PEDICLE SCREW 45MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.476 SUP HCPCS C1713 102.476 - 7.0MM PROTEX PEDICLE SCREW 50MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.477 SUP HCPCS C1713 102.477 - 7.0MM PROTEX PEDICLE SCREW 55MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.478 SUP HCPCS C1713 102.478 - 7.0MM PROTEX PEDICLE SCREW 60MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.479 SUP HCPCS C1713 102.479 - 7.0MM PROTEX PEDICLE SCREW 65MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.482 SUP HCPCS C1713 102.482 - 8.0MM PROTEX PEDICLE SCREW 30MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.483 SUP HCPCS C1713 102.483 - 8.0MM PROTEX PEDICLE SCREW 35MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.484 SUP HCPCS C1713 102.484 - 8.0MM PROTEX PEDICLE SCREW 40MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.485 SUP HCPCS C1713 102.485 - 8.0MM PROTEX PEDICLE SCREW 45MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.486 SUP HCPCS C1713 102.486 - 8.0MM PROTEX PEDICLE SCREW 50MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.487 SUP HCPCS C1713 102.487 - 8.0MM PROTEX PEDICLE SCREW 55MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.488 SUP HCPCS C1713 102.488 - 8.0MM PROTEX PEDICLE SCREW 60MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.489 SUP HCPCS C1713 102.489 - 8.0MM PROTEX PEDICLE SCREW 65MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.49 SUP HCPCS C1713 102.490 - PROTEX LOCKING CAP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 102.492 SUP HCPCS C1713 102.492 - 9.0MM PROTEX PEDICLE SCREW 30MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.493 SUP HCPCS C1713 102.493 - 9.0MM PROTEX PEDICLE SCREW 35MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.494 SUP HCPCS C1713 102.494 - 9.0MM PROTEX PEDICLE SCREW 40MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.495 SUP HCPCS C1713 102.495 - 9.0MM PROTEX PEDICLE SCREW 45MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.496 SUP HCPCS C1713 102.496 - 9.0MM PROTEX PEDICLE SCREW 50MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.497 SUP HCPCS C1713 102.497 - 9.0MM PROTEX PEDICLE SCREW 55MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.498 SUP HCPCS C1713 102.498 - 9.0MM PROTEX PEDICLE SCREW 60MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.499 SUP HCPCS C1713 102.499 - 9.0MM PROTEX PEDICLE SCREW 65MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 102.51 SUP Custom 27803010 "102.510 - 6.5MM STRAIGHT ROD, 100MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.512 SUP Custom 27803010 "102.512 - 6.5MM STRAIGHT ROD, 125MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.515 SUP Custom 27803010 "102.515 - 6.5MM STRAIGHT ROD, 150MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.517 SUP Custom 27803010 "102.517 - 6.5MM STRAIGHT ROD, 200MM" BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.05 $590.05 $0.00 $0.00 $165.68 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.519 SUP Custom 27803010 "102.519 - 6.5MM STRAIGHT ROD, 300MM" BOTH IP/OP $927.50 $686.35 $0.00 $742.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.39 $688.39 $0.00 $0.00 $193.29 $0.00 $0.00 $0.00 $0.00 $463.75 $734.58 $742.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.52 SUP Custom 27803010 "102.520 - 6.5MM STRAIGHT ROD, 400MM" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.521 SUP Custom 27803010 102.521 - ROD SPNL STRG 6.5MM 500MM PRTX BOTH IP/OP "$1,060.00 " $784.40 $0.00 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $786.73 $786.73 $0.00 $0.00 $220.90 $0.00 $0.00 $0.00 $0.00 $530.00 $839.52 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.53 SUP Custom 27803010 "102.530 - 6.5MM STRAIGHT ROD, 30MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.535 SUP Custom 27803010 "102.535 - 6.5MM STRAIGHT ROD, 35MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.54 SUP Custom 27803010 "102.540 - 6.5MM STRAIGHT ROD, 40MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.545 SUP Custom 27803010 "102.545 - 6.5MM STRAIGHT ROD, 45MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.55 SUP Custom 27803010 "102.550 - 6.5MM STRAIGHT ROD, 50MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.555 SUP Custom 27803010 "102.555 - 6.5MM STRAIGHT ROD, 55MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.56 SUP Custom 27803010 "102.560 - 6.5MM STRAIGHT ROD, 60MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.565 SUP Custom 27803010 "102.565 - 6.5MM STRAIGHT ROD, 65MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.57 SUP Custom 27803010 "102.570 - 6.5MM STRAIGHT ROD, 70MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.575 SUP Custom 27803010 "102.575 - 6.5MM STRAIGHT ROD, 75MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.58 SUP Custom 27803010 "102.580 - 6.5MM STRAIGHT ROD, 80MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.585 SUP Custom 27803010 "102.585 - 6.5MM STRAIGHT ROD, 85MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.61 SUP Custom 27803010 "102.610 - 6.5MM CURVED ROD, 100MM" BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $0.00 $0.00 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.612 SUP Custom 27803010 "102.612 - 6.5MM CURVED ROD, 120MM" BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $0.00 $0.00 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.615 SUP Custom 27803010 "102.615 - 6.5MM CURVED ROD, 150MM" BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $0.00 $0.00 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.635 SUP Custom 27803010 "102.635 - 6.5MM CURVED ROD, 35MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.64 SUP Custom 27803010 "102.640 - 6.5MM CURVED ROD, 40MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.645 SUP Custom 27803010 "102.645 - 6.5MM CURVED ROD, 45MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.65 SUP Custom 27803010 "102.650 - 6.5MM CURVED ROD, 50MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.655 SUP Custom 27803010 "102.655 - 6.5MM CURVED ROD, 55MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.66 SUP Custom 27803010 "102.660 - 6.5MM CURVED ROD, 60MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.665 SUP Custom 27803010 "102.665 - 6.5MM CURVED ROD, 65MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.67 SUP Custom 27803010 "102.670 - 6.5MM CURVED ROD, 70MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.675 SUP Custom 27803010 "102.675 - 6.5MM CURVED ROD, 75MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.68 SUP Custom 27803010 "102.680 - 6.5MM CURVED ROD, 80MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.685 SUP Custom 27803010 "102.685 - 6.5MM CURVED ROD, 85MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.911 SUP Custom 27803010 "102.911 - ADJUSTABLE T CONNECTOR, 28MM-40MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.912 SUP Custom 27803010 "102.912 - ADJUSTABLE T CONNECTOR, 38MM-50MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.913 SUP Custom 27803010 "102.913 - ADJUSTABLE T CONNECTOR, 48MM-60MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.914 SUP Custom 27803010 "102.914 - ADJUSTABLE T CONNECTOR, 58MM-70MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.915 SUP Custom 27803010 "102.915 - ADJUSTABLE T CONNECTOR, 68MM-80MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.916 SUP Custom 27803010 "102.916 - ADJUSTABLE T CONNECTOR, 78MM-90MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.921 SUP Custom 27803010 "102.921 - PROTEX LAMINA HOOK, SMALL" BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.922 SUP Custom 27803010 "102.922 - PROTEX LAMINA HOOK, MEDIUM" BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.923 SUP Custom 27803010 "102.923 - PROTEX LAMINA HOOK, LARGE" BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.925 SUP Custom 27803010 "102.925 - PROTEX ANGLED LAMINA HOOK, SMALL" BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.926 SUP Custom 27803010 "102.926 - PROTEX ANGLED LAMINA HOOK, MEDIUM" BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.927 SUP Custom 27803010 "102.927 - PROTEX ANGLED LAMINA HOOK, LARGE" BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.941 SUP Custom 27803010 102.941 - PROTEX PEDICLE HOOK BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.951 SUP Custom 27803010 "102.951 - PROTEX TRANSVERSE PROCESS HOOK, RIGHT" BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.952 SUP Custom 27803010 "102.952 - PROTEX TRANSVERSE PROCESS HOOK, LEFT" BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.971 SUP Custom 27803010 "102.971 - PARALLEL CONNECTOR, 6.5MM TO 6.5MM" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.974 SUP Custom 27803010 "102.974 - OFFSET CONNECTOR, 15MM" BOTH IP/OP $572.50 $423.65 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.91 $424.91 $0.00 $0.00 $119.31 $0.00 $0.00 $0.00 $0.00 $286.25 $453.42 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.975 SUP Custom 27803010 "102.975 - OFFSET CONNECTOR, 20MM" BOTH IP/OP $572.50 $423.65 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.91 $424.91 $0.00 $0.00 $119.31 $0.00 $0.00 $0.00 $0.00 $286.25 $453.42 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.976 SUP Custom 27803010 "102.976 - OFFSET CONNECTOR, 25MM" BOTH IP/OP $572.50 $423.65 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.91 $424.91 $0.00 $0.00 $119.31 $0.00 $0.00 $0.00 $0.00 $286.25 $453.42 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.99 SUP Custom 27803010 "102.990 - 6.0MM, CLOSED OFFSET CONNECTOR, 6.5MM ROD, 15MM" BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $983.42 $983.42 $0.00 $0.00 $276.13 $0.00 $0.00 $0.00 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.991 SUP Custom 27803010 "102.991 - 6.0MM, CLOSED OFFSET CONNECTOR, 6.5MM ROD, 20MM" BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $983.42 $983.42 $0.00 $0.00 $276.13 $0.00 $0.00 $0.00 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.992 SUP Custom 27803010 "102.992 - 6.0MM, CLOSED OFFSET CONNECTOR, 6.5MM ROD, 25MM" BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $983.42 $983.42 $0.00 $0.00 $276.13 $0.00 $0.00 $0.00 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.993 SUP Custom 27803010 "102.993 - 6.0MM, CLOSED OFFSET CONNECTOR, 6.5MM ROD, 30MM" BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $983.42 $983.42 $0.00 $0.00 $276.13 $0.00 $0.00 $0.00 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.994 SUP Custom 27803010 "102.994 - 6.0MM, CLOSED OFFSET CONNECTOR, 6.5MM ROD, 35MM" BOTH IP/OP "$1,325.00 " $980.50 $0.00 "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $983.42 $983.42 $0.00 $0.00 $276.13 $0.00 $0.00 $0.00 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.995 SUP Custom 27803010 "102.995 - 6.0MM, CLOSED OFFSET CONNECTOR, 6.5MM ROD, 100MM" BOTH IP/OP "$1,457.50 " "$1,078.55" $0.00 "$1,166.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,081.76" "$1,081.76" $0.00 $0.00 $303.74 $0.00 $0.00 $0.00 $0.00 $728.75 "$1,154.34" "$1,166.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.996 SUP Custom 27803010 "102.996 - 6.0MM, CLOSED OFFSET CONNECTOR, 6.5MM ROD, 120MM" BOTH IP/OP "$1,457.50 " "$1,078.55" $0.00 "$1,166.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,081.76" "$1,081.76" $0.00 $0.00 $303.74 $0.00 $0.00 $0.00 $0.00 $728.75 "$1,154.34" "$1,166.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102.997 SUP Custom 27803010 "102.997 - 6.0MM, CLOSED OFFSET CONNECTOR, 6.5MM ROD, 150MM" BOTH IP/OP "$1,457.50 " "$1,078.55" $0.00 "$1,166.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,081.76" "$1,081.76" $0.00 $0.00 $303.74 $0.00 $0.00 $0.00 $0.00 $728.75 "$1,154.34" "$1,166.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103 SUP HCPCS C1767 103 - GENERATOR ELECTROSURGICAL NCP DEMIPULSE BOTH IP/OP "$54,430.00 " "$40,278.20" $0.00 "$43,108.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 "$43,108.56" $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104 SUP HCPCS C1713 104 - PLATE 104 SINGLE T 3H X 3H BOTH IP/OP $325.00 $240.50 $0.00 $323.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $241.33 $241.33 $0.00 $3.00 $323.14 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 105 SUP HCPCS C1713 105 - PLATE 105 SINGLE T 3H X 2H BOTH IP/OP $408.00 $301.92 $0.00 $323.14 $0.00 $0.00 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $3.00 $323.14 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 109.041 SUP HCPCS C1713 "109.041 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 70MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.042 SUP HCPCS C1713 "109.042 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 75MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.043 SUP HCPCS C1713 "109.043 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 80MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.044 SUP HCPCS C1713 "109.044 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 85MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.045 SUP HCPCS C1713 "109.045 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 90MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.051 SUP HCPCS C1713 "109.051 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 70MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.052 SUP HCPCS C1713 "109.052 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 75MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.053 SUP HCPCS C1713 "109.053 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 80MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.054 SUP HCPCS C1713 "109.054 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 85MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.055 SUP HCPCS C1713 "109.055 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 90MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.061 SUP HCPCS C1713 "109.061 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 70MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.062 SUP HCPCS C1713 "109.062 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 75MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.063 SUP HCPCS C1713 "109.063 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 80MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.064 SUP HCPCS C1713 "109.064 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 85MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.065 SUP HCPCS C1713 "109.065 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 90MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.071 SUP HCPCS C1713 109.071 - 7.0MM PROTEX SOLID PEDICLE SCREW 70MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.072 SUP HCPCS C1713 109.072 - 7.0MM PROTEX SOLID PEDICLE SCREW 75MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.073 SUP HCPCS C1713 109.073 - 7.0MM PROTEX SOLID PEDICLE SCREW 80MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.074 SUP HCPCS C1713 109.074 - 7.0MM PROTEX SOLID PEDICLE SCREW 85MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.075 SUP HCPCS C1713 109.075 - 7.0MM PROTEX SOLID PEDICLE SCREW 90MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.081 SUP HCPCS C1713 109.081 - 8.0MM PROTEX SOLID PEDICLE SCREW 70MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.082 SUP HCPCS C1713 109.082 - 8.0MM PROTEX SOLID PEDICLE SCREW 75MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.083 SUP HCPCS C1713 109.083 - 8.0MM PROTEX SOLID PEDICLE SCREW 80MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.084 SUP HCPCS C1713 109.084 - 8.0MM PROTEX SOLID PEDICLE SCREW 85MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.085 SUP HCPCS C1713 109.085 - 8.0MM PROTEX SOLID PEDICLE SCREW 90MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.091 SUP HCPCS C1713 109.091 - 9.0MM PROTEX SOLID PEDICLE SCREW 70MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.092 SUP HCPCS C1713 109.092 - 9.0MM PROTEX SOLID PEDICLE SCREW 75MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.093 SUP HCPCS C1713 109.093 - 9.0MM PROTEX SOLID PEDICLE SCREW 80MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.094 SUP HCPCS C1713 109.094 - 9.0MM PROTEX SOLID PEDICLE SCREW 85MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.095 SUP HCPCS C1713 109.095 - 9.0MM PROTEX SOLID PEDICLE SCREW 90MM BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.351 SUP HCPCS C1713 "109.351 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 25MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.352 SUP HCPCS C1713 "109.352 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 30MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.353 SUP HCPCS C1713 "109.353 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 35MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.354 SUP HCPCS C1713 "109.354 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 40MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.355 SUP HCPCS C1713 "109.355 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 45MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.356 SUP HCPCS C1713 "109.356 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 50MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.357 SUP HCPCS C1713 "109.357 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 55MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.358 SUP HCPCS C1713 "109.358 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 60MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.359 SUP HCPCS C1713 "109.359 - 5.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 65MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.362 SUP HCPCS C1713 "109.362 - 6.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 30MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.363 SUP HCPCS C1713 "109.363 - 6.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 35MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.364 SUP HCPCS C1713 "109.364 - 6.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 40MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.365 SUP HCPCS C1713 "109.365 - 6.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 45MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.366 SUP HCPCS C1713 "109.366 - 6.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 50MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.367 SUP HCPCS C1713 "109.367 - 6.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 55MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.368 SUP HCPCS C1713 "109.368 - 6.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 60MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.369 SUP HCPCS C1713 "109.369 - 6.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 65MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.372 SUP HCPCS C1713 "109.372 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 30MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.373 SUP HCPCS C1713 "109.373 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 35MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.374 SUP HCPCS C1713 "109.374 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 40MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.375 SUP HCPCS C1713 "109.375 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 45MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.376 SUP HCPCS C1713 "109.376 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 50MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.377 SUP HCPCS C1713 "109.377 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 55MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.378 SUP HCPCS C1713 "109.378 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 60MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.379 SUP HCPCS C1713 "109.379 - 7.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 65MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.382 SUP HCPCS C1713 "109.382 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 30MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.383 SUP HCPCS C1713 "109.383 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 35MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.384 SUP HCPCS C1713 "109.384 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 40MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.385 SUP HCPCS C1713 "109.385 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 45MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.386 SUP HCPCS C1713 "109.386 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 50MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.387 SUP HCPCS C1713 "109.387 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 55MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.388 SUP HCPCS C1713 "109.388 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 60MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.389 SUP HCPCS C1713 "109.389 - 8.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 65MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.392 SUP HCPCS C1713 "109.392 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 30MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.393 SUP HCPCS C1713 "109.393 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 35MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.394 SUP HCPCS C1713 "109.394 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 40MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.395 SUP HCPCS C1713 "109.395 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 45MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.396 SUP HCPCS C1713 "109.396 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 50MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.397 SUP HCPCS C1713 "109.397 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 55MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.398 SUP HCPCS C1713 "109.398 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 60MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.399 SUP HCPCS C1713 "109.399 - 9.0MM PROTEX MONOAXIAL SCREW, 6.0MM ROD, 65MM" BOTH IP/OP "$2,517.50 " "$1,862.95" $0.00 "$2,014.00" "$1,132.88" "$1,132.88" $0.00 $0.00 $0.00 $524.71 "$1,868.49" "$1,868.49" $0.00 $0.00 $524.65 $0.00 "$1,241.13" "$1,241.13" $0.00 "$1,258.75" "$1,993.86" "$2,014.00" $0.00 $0.00 $393.99 $0.00 $0.00 $400.79 $0.00 $0.00 $0.00 $0.00 $0.00 109.441 SUP HCPCS C1713 "109.441 - 4.5MM PROTEX SOLID PEDICLE SCREW, 25MM" BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.442 SUP HCPCS C1713 "109.442 - 4.5MM PROTEX SOLID PEDICLE SCREW, 30MM" BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.443 SUP HCPCS C1713 "109.443 - 4.5MM PROTEX SOLID PEDICLE SCREW, 35MM" BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.444 SUP HCPCS C1713 "109.444 - 4.5MM PROTEX SOLID PEDICLE SCREW, 40MM" BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.445 SUP HCPCS C1713 "109.445 - 4.5MM PROTEX SOLID PEDICLE SCREW, 45MM" BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.446 SUP HCPCS C1713 "109.446 - 4.5MM PROTEX SOLID PEDICLE SCREW, 50MM" BOTH IP/OP "$4,580.00 " "$3,389.20" $0.00 "$3,664.00" "$2,061.00" "$2,061.00" $0.00 $0.00 $0.00 $954.59 "$3,399.28" "$3,399.28" $0.00 $0.00 $954.47 $0.00 "$2,257.94" "$2,257.94" $0.00 "$2,290.00" "$3,627.36" "$3,664.00" $0.00 $0.00 $716.77 $0.00 $0.00 $729.14 $0.00 $0.00 $0.00 $0.00 $0.00 109.452 SUP HCPCS C1713 109.452 - 5.0MM PROTEX SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.453 SUP HCPCS C1713 109.453 - 5.0MM PROTEX SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.454 SUP HCPCS C1713 109.454 - 5.0MM PROTEX SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.455 SUP HCPCS C1713 109.455 - 5.0MM PROTEX SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.456 SUP HCPCS C1713 109.456 - 5.0MM PROTEX SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.457 SUP HCPCS C1713 109.457 - 5.0MM PROTEX SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.462 SUP HCPCS C1713 109.462 - 6.0MM PROTEX SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.463 SUP HCPCS C1713 109.463 - 6.0MM PROTEX SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.464 SUP HCPCS C1713 109.464 - 6.0MM PROTEX SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.465 SUP HCPCS C1713 109.465 - 6.0MM PROTEX SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.466 SUP HCPCS C1713 109.466 - 6.0MM PROTEX SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.467 SUP HCPCS C1713 109.467 - 6.0MM PROTEX SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.468 SUP HCPCS C1713 109.468 - 6.0MM PROTEX SOLID PEDICLE SCREW 60MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.469 SUP HCPCS C1713 109.469 - 6.0MM PROTEX SOLID PEDICLE SCREW 65MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.472 SUP HCPCS C1713 109.472 - 7.0MM PROTEX SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.473 SUP HCPCS C1713 109.473 - 7.0MM PROTEX SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.474 SUP HCPCS C1713 109.474 - 7.0MM PROTEX SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.475 SUP HCPCS C1713 109.475 - 7.0MM PROTEX SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.476 SUP HCPCS C1713 109.476 - 7.0MM PROTEX SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.477 SUP HCPCS C1713 109.477 - 7.0MM PROTEX SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.478 SUP HCPCS C1713 109.478 - 7.0MM PROTEX SOLID PEDICLE SCREW 60MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.479 SUP HCPCS C1713 109.479 - 7.0MM PROTEX SOLID PEDICLE SCREW 65MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.482 SUP HCPCS C1713 109.482 - 8.0MM PROTEX SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.483 SUP HCPCS C1713 109.483 - 8.0MM PROTEX SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.484 SUP HCPCS C1713 109.484 - 8.0MM PROTEX SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.485 SUP HCPCS C1713 109.485 - 8.0MM PROTEX SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.486 SUP HCPCS C1713 109.486 - 8.0MM PROTEX SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.487 SUP HCPCS C1713 109.487 - 8.0MM PROTEX SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.488 SUP HCPCS C1713 109.488 - 8.0MM PROTEX SOLID PEDICLE SCREW 60MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.489 SUP HCPCS C1713 109.489 - 8.0MM PROTEX SOLID PEDICLE SCREW 65MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.492 SUP HCPCS C1713 109.492 - 9.0MM PROTEX SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.493 SUP HCPCS C1713 109.493 - 9.0MM PROTEX SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.494 SUP HCPCS C1713 109.494 - 9.0MM PROTEX SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.495 SUP HCPCS C1713 109.495 - 9.0MM PROTEX SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.496 SUP HCPCS C1713 109.496 - 9.0MM PROTEX SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.497 SUP HCPCS C1713 109.497 - 9.0MM PROTEX SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.498 SUP HCPCS C1713 109.498 - 9.0MM PROTEX SOLID PEDICLE SCREW 60MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.499 SUP HCPCS C1713 109.499 - 9.0MM PROTEX SOLID PEDICLE SCREW 65MM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,311.75" "$1,311.75" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,437.10" "$1,437.10" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 109.51 SUP HCPCS C1713 "109.510 - 6.00MM STRAIGHT ROD, 100MM" BOTH IP/OP $670.00 $495.80 $0.00 $536.00 $301.50 $301.50 $0.00 $0.00 $0.00 $139.64 $497.27 $497.27 $0.00 $0.00 $139.63 $0.00 $396.31 $396.31 $0.00 $335.00 $530.64 $536.00 $0.00 $0.00 $104.86 $0.00 $0.00 $106.66 $0.00 $0.00 $0.00 $0.00 $0.00 109.512 SUP Custom 27803010 "109.512 - 6.00MM STRAIGHT ROD, 125MM" BOTH IP/OP $670.00 $495.80 $0.00 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $497.27 $497.27 $0.00 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $335.00 $530.64 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.515 SUP Custom 27803010 "109.515 - 6.00MM STRAIGHT ROD, 150MM" BOTH IP/OP $670.00 $495.80 $0.00 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $497.27 $497.27 $0.00 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $335.00 $530.64 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.517 SUP Custom 27803010 "109.517 - 6.00MM STRAIGHT ROD, 200MM" BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.05 $590.05 $0.00 $0.00 $165.68 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.519 SUP Custom 27803010 "109.519 - 6.00MM STRAIGHT ROD, 300MM" BOTH IP/OP $927.50 $686.35 $0.00 $742.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.39 $688.39 $0.00 $0.00 $193.29 $0.00 $0.00 $0.00 $0.00 $463.75 $734.58 $742.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.52 SUP Custom 27803010 "109.520 - 6.00MM STRAIGHT ROD, 400MM" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.521 SUP Custom 27803010 "109.521 - 6.00MM STRAIGHT ROD, 500MM" BOTH IP/OP "$1,060.00 " $784.40 $0.00 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $786.73 $786.73 $0.00 $0.00 $220.90 $0.00 $0.00 $0.00 $0.00 $530.00 $839.52 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.53 SUP Custom 27803010 "109.530 - 6.00MM STRAIGHT ROD, 30MM" BOTH IP/OP $670.00 $495.80 $0.00 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $497.27 $497.27 $0.00 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $335.00 $530.64 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.535 SUP Custom 27803010 "109.535 - 6.00MM STRAIGHT ROD, 35MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.54 SUP Custom 27803010 "109.540 - 6.00MM STRAIGHT ROD, 40MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.545 SUP Custom 27803010 "109.545 - 6.00MM STRAIGHT ROD, 45MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.55 SUP Custom 27803010 "109.550 - 6.00MM STRAIGHT ROD, 50MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.555 SUP Custom 27803010 "109.555 - 6.00MM STRAIGHT ROD, 55MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.56 SUP Custom 27803010 "109.560 - 6.00MM STRAIGHT ROD, 60MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.565 SUP Custom 27803010 "109.565 - 6.00MM STRAIGHT ROD, 65MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.57 SUP Custom 27803010 "109.570 - 6.00MM STRAIGHT ROD, 70MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.575 SUP Custom 27803010 "109.575 - 6.00MM STRAIGHT ROD, 75MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.58 SUP Custom 27803010 "109.580 - 6.00MM STRAIGHT ROD, 80MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.585 SUP Custom 27803010 "109.585 - 6.00MM STRAIGHT ROD, 85MM" BOTH IP/OP $465.00 $344.10 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.12 $345.12 $0.00 $0.00 $96.91 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.61 SUP Custom 27803010 "109.610 - 6.00MM CURVED ROD, 100MM" BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $0.00 $0.00 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.612 SUP Custom 27803010 "109.612 - 6.00MM CURVED ROD, 120MM" BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $0.00 $0.00 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.615 SUP Custom 27803010 "109.615 - 6.00MM CURVED ROD, 150MM" BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $0.00 $0.00 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.635 SUP Custom 27803010 "109.635 - 6.00MM CURVED ROD, 35MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.64 SUP Custom 27803010 "109.640 - 6.00MM CURVED ROD, 40MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.645 SUP Custom 27803010 "109.645 - 6.00MM CURVED ROD, 45MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.65 SUP Custom 27803010 "109.650 - 6.00MM CURVED ROD, 50MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.655 SUP Custom 27803010 "109.655 - 6.00MM CURVED ROD, 55MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.66 SUP Custom 27803010 "109.660 - 6.00MM CURVED ROD, 60MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.665 SUP Custom 27803010 "109.665 - 6.00MM CURVED ROD, 65MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.67 SUP Custom 27803010 "109.670 - 6.00MM CURVED ROD, 70MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.675 SUP Custom 27803010 "109.675 - 6.00MM CURVED ROD, 75MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.68 SUP Custom 27803010 "109.680 - 6.00MM CURVED ROD, 80MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.685 SUP Custom 27803010 "109.685 - 6.00MM CURVED ROD, 85MM" BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $0.00 $0.00 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.921 SUP Custom 27803010 "109.921 - PROTEX LAMINA HOOK, 6.0MM ROD, SMALL" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.922 SUP Custom 27803010 "109.922 - PROTEX LAMINA HOOK, 6.0MM ROD, MEDIUM" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.923 SUP Custom 27803010 "109.923 - PROTEX LAMINA HOOK, 6.0MM ROD, LARGE" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.925 SUP Custom 27803010 "109.925 - PROTEX ANGLED LAMINA HOOK, 6.0MM ROD, SMALL" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.926 SUP Custom 27803010 "109.926 - PROTEX ANGLED LAMINA HOOK, 6.0MM ROD, MEDIUM" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.927 SUP Custom 27803010 "109.927 - PROTEX ANGLED LAMINA HOOK, 6.0MM ROD, LARGE" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.941 SUP Custom 27803010 "109.941 - PROTEX PEDICLE HOOK, 6.0MM ROD" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.951 SUP Custom 27803010 "109.951 - PROTEX TRANSVERSE PROCESS HOOK, 6.0MM ROD, RIGHT" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 109.952 SUP Custom 27803010 "109.952 - PROTEX TRANSVERSE PROCESS HOOK, 6.0MM ROD, LEFT" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 $0.00 $0.00 $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.01 SUP HCPCS C1713 "110.010 - 4.0MM RIGID SCREW, SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.012 SUP HCPCS C1713 "110.012 - 4.0MM RIGID SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.014 SUP HCPCS C1713 "110.014 - 4.0MM RIGID SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.016 SUP HCPCS C1713 110.016 - SCREW BONE 4MM 16MM ASR TI ANT CERV SPN SLFDRILL RGD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.026 SUP HCPCS C1713 "110.026 - 4.0MM RIGID SCREW, SELF-TAPPING, 6MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.028 SUP HCPCS C1713 "110.028 - 4.0MM RIGID SCREW, SELF-TAPPING, 8MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.03 SUP HCPCS C1713 "110.030 - 4.0MM RIGID SCREW, SELF-TAPPING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.032 SUP HCPCS C1713 "110.032 - 4.0MM RIGID SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.034 SUP HCPCS C1713 110.034 - SCREW BONE 4MM 14MM ASR TI ANT CERV SPN SLFTAP RGD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.036 SUP HCPCS C1713 110.036 - SCREW BONE 4MM 16MM ASR TI ANT CERV SPN SLFTAP RGD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.038 SUP HCPCS C1713 110.038 - SCREW BONE 4MM 18MM ASR SPNL SLFTAP RGD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.04 SUP HCPCS C1713 "110.040 - 4.0MM RIGID SCREW, SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.05 SUP HCPCS C1713 110.050 - SCREW SET TI ANT CERV SPN RGD BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.11 SUP HCPCS C1713 "110.110 - ASSURE CERVICAL PLATE 1-LEVEL, 10MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.112 SUP HCPCS C1713 "110.112 - ASSURE CERVICAL PLATE 1-LEVEL, 12MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.114 SUP HCPCS C1713 110.114 - PLATE 14MM TI 1 LVL ASR BONE ANT CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.116 SUP HCPCS C1713 110.116 - PLATE 16MM TI 1 LVL ASR BONE ANT CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.118 SUP HCPCS C1713 "110.118 - ASSURE CERVICAL PLATE 1-LEVEL, 18MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.12 SUP HCPCS C1713 "110.120 - ASSURE CERVICAL PLATE 1-LEVEL, 20MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.122 SUP HCPCS C1713 "110.122 - ASSURE CERVICAL PLATE 1-LEVEL, 22MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.124 SUP HCPCS C1713 110.124 - PLATE 24MM TI 1 LVL ASR BONE ANT CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.126 SUP HCPCS C1713 "110.126 - ASSURE CERVICAL PLATE 1-LEVEL, 26MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 110.224 SUP HCPCS C1713 "110.224 - ASSURE CERVICAL PLATE 2-LEVEL, 24MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.226 SUP HCPCS C1713 "110.226 - ASSURE CERVICAL PLATE 2-LEVEL, 26MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.228 SUP HCPCS C1713 110.228 - PLATE 28MM TI 2 LVL ASR BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.23 SUP HCPCS C1713 110.230 - PLATE 30MM TI 2 LVL ASR BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.232 SUP HCPCS C1713 110.232 - PLATE 32MM TI 2 LVL ASR BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.234 SUP HCPCS C1713 110.234 - PLATE 34MM TI 2 LVL ASR BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.236 SUP HCPCS C1713 110.236 - PLATE 36MM TI 2 LVL ASR BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.238 SUP HCPCS C1713 "110.238 - ASSURE CERVICAL PLATE 2-LEVEL, 38MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.24 SUP HCPCS C1713 "110.240 - ASSURE CERVICAL PLATE 2-LEVEL, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.242 SUP HCPCS C1713 "110.242 - ASSURE CERVICAL PLATE 2-LEVEL, 42MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.244 SUP HCPCS C1713 "110.244 - ASSURE CERVICAL PLATE 2-LEVEL, 44MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.246 SUP HCPCS C1713 "110.246 - ASSURE CERVICAL PLATE 2-LEVEL, 46MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 110.339 SUP HCPCS C1713 "110.339 - ASSURE CERVICAL PLATE 3-LEVEL, 39MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.342 SUP HCPCS C1713 "110.342 - ASSURE CERVICAL PLATE 3-LEVEL, 42MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.345 SUP HCPCS C1713 "110.345 - ASSURE CERVICAL PLATE 3-LEVEL, 45MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.348 SUP HCPCS C1713 "110.348 - ASSURE CERVICAL PLATE 3-LEVEL, 48MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.351 SUP HCPCS C1713 "110.351 - ASSURE CERVICAL PLATE 3-LEVEL, 51MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.354 SUP HCPCS C1713 "110.354 - ASSURE CERVICAL PLATE 3-LEVEL, 54MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.357 SUP HCPCS C1713 "110.357 - ASSURE CERVICAL PLATE 3-LEVEL, 57MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.36 SUP HCPCS C1713 "110.360 - ASSURE CERVICAL PLATE 3-LEVEL, 60MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.363 SUP HCPCS C1713 "110.363 - ASSURE CERVICAL PLATE 3-LEVEL, 63MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.366 SUP HCPCS C1713 "110.366 - ASSURE CERVICAL PLATE 3-LEVEL, 66MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.369 SUP HCPCS C1713 "110.369 - ASSURE CERVICAL PLATE 3-LEVEL, 69MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 110.46 SUP HCPCS C1713 "110.460 - ASSURE CERVICAL PLATE 4-LEVEL, 60MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.464 SUP HCPCS C1713 "110.464 - ASSURE CERVICAL PLATE 4-LEVEL, 64MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.468 SUP HCPCS C1713 "110.468 - ASSURE CERVICAL PLATE 4-LEVEL, 68MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.472 SUP HCPCS C1713 "110.472 - ASSURE CERVICAL PLATE 4-LEVEL, 72MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.476 SUP HCPCS C1713 "110.476 - ASSURE CERVICAL PLATE 4-LEVEL, 76MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.48 SUP HCPCS C1713 "110.480 - ASSURE CERVICAL PLATE 4-LEVEL, 80MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.484 SUP HCPCS C1713 "110.484 - ASSURE CERVICAL PLATE 4-LEVEL, 84MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.488 SUP HCPCS C1713 "110.488 - ASSURE CERVICAL PLATE 4-LEVEL, 88MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.492 SUP HCPCS C1713 "110.492 - ASSURE CERVICAL PLATE 4-LEVEL, 92MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.496 SUP HCPCS C1713 "110.496 - ASSURE CERVICAL PLATE 4-LEVEL, 96MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.5 SUP HCPCS C1713 "110.500 - ASSURE CERVICAL PLATE 4-LEVEL, 100MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 110.512 SUP HCPCS C1713 "110.512 - 4.5MM RIGID SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.514 SUP HCPCS C1713 "110.514 - 4.5MM RIGID SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.516 SUP HCPCS C1713 "110.516 - 4.5MM RIGID SCREW, SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.526 SUP HCPCS C1713 "110.526 - 4.5MM RIGID SCREW, SELF-TAPPING, 6MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.528 SUP HCPCS C1713 "110.528 - 4.5MM RIGID SCREW, SELF-TAPPING, 8MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.53 SUP HCPCS C1713 "110.530 - 4.5MM RIGID SCREW, SELF-TAPPING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.532 SUP HCPCS C1713 "110.532 - 4.5MM RIGID SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.534 SUP HCPCS C1713 "110.534 - 4.5MM RIGID SCREW, SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.536 SUP HCPCS C1713 110.536 - SCREW BONE 4.5MM 16MM ASR TI SPNL SLFTAP RGD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.538 SUP HCPCS C1713 "110.538 - 4.5MM RIGID SCREW, SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.54 SUP HCPCS C1713 "110.540 - 4.5MM RIGID SCREW, SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.61 SUP HCPCS C1713 "110.610 - 4.0MM STANDARD SCREW, SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.612 SUP HCPCS C1713 "110.612 - 4.0MM STANDARD SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.614 SUP HCPCS C1713 "110.614 - 4.0MM STANDARD SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.616 SUP HCPCS C1713 110.616 - SCREW BONE 4MM 16MM ASR TI STD SPNL SLFDRILL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.712 SUP HCPCS C1713 "110.712 - 4.5MM STANDARD SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.714 SUP HCPCS C1713 "110.714 - 4.5MM STANDARD SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.716 SUP HCPCS C1713 110.716 - SCREW BONE 4.5MM 16MM ASR TI STD SPNL SLFDRILL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.806 SUP HCPCS C1713 110.806 - SCREW BN STD 4MM 6MM PRTX CT ST SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.808 SUP HCPCS C1713 110.808 - SCREW BONE 4MM 8MM TI STD SPNL SLFTAP BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 110.81 SUP HCPCS C1713 "110.810 - 4.0MM STANDARD SCREW, SELF-TAPPING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.812 SUP HCPCS C1713 "110.812 - 4.0MM STANDARD SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.814 SUP HCPCS C1713 110.814 - SCREW BONE 4MM 14MM ASR TI STD ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.816 SUP HCPCS C1713 110.816 - SCREW BONE 4MM 16MM ASR TI STD SPNL SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.818 SUP HCPCS C1713 110.818 - SCREW BONE 4MM 18MM ASR TI STD SPNL SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.82 SUP HCPCS C1713 "110.820 - 4.0MM STANDARD SCREW, SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.906 SUP HCPCS C1713 "110.906 - 4.5MM STANDARD SCREW, SELF-TAPPING, 6MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.908 SUP HCPCS C1713 "110.908 - 4.5MM STANDARD SCREW, SELF-TAPPING, 8MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.91 SUP HCPCS C1713 "110.910 - 4.5MM STANDARD SCREW, SELF-TAPPING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.912 SUP HCPCS C1713 110.912 - SCREW BONE 4.5MM 12MM ASR TI STD ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.914 SUP HCPCS C1713 "110.914 - 4.5MM STANDARD SCREW, SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.916 SUP HCPCS C1713 110.916 - SCREW BONE 4.5MM 16MM ASR TI STD ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.918 SUP HCPCS C1713 110.918 - SCREW BONE 4.5MM 18MM ASR TI STD SPNL SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 110.92 SUP HCPCS C1713 110.920 - SCREW BONE 4.5MM 20MM PRTX TI STD THORLMBR SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 111 SUP Custom 27203010 111 - ADAPTER SUCTION 15MM 15MM CLOSE SYSTEM SWIVEL LATEX FREE BOTH IP/OP $79.68 $58.96 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.14 $59.14 $0.00 $0.00 $16.60 $0.00 $0.00 $0.00 $0.00 $39.84 $63.11 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115 SUP HCPCS C1713 "115.000 - SET SCREW, M4 X 0.75, ROUND TIP, 2.5MM HEX" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 115.222 SUP HCPCS C1713 "115.222 - 3.5MM PROTEX CT POLYAXIAL SHOULDER SCREW, 22MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.224 SUP HCPCS C1713 "115.224 - 3.5MM PROTEX CT POLYAXIAL SHOULDER SCREW, 24MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.226 SUP HCPCS C1713 "115.226 - 3.5MM PROTEX CT POLYAXIAL SHOULDER SCREW, 26MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.228 SUP HCPCS C1713 "115.228 - 3.5MM PROTEX CT POLYAXIAL SHOULDER SCREW, 28MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.23 SUP HCPCS C1713 "115.230 - 3.5MM PROTEX CT POLYAXIAL SHOULDER SCREW, 30MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.232 SUP HCPCS C1713 "115.232 - 3.5MM PROTEX CT POLYAXIAL SHOULDER SCREW, 32MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.234 SUP HCPCS C1713 "115.234 - 3.5MM PROTEX CT POLYAXIAL SHOULDER SCREW, 34MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.236 SUP HCPCS C1713 "115.236 - 3.5MM PROTEX CT POLYAXIAL SHOULDER SCREW, 36MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.308 SUP HCPCS C1713 115.308 - SCREW BONE 3.5MM 8MM PRTX CTTI OCT SPN POLYAX BOTH IP/OP "$3,097.50 " "$2,292.15" $0.00 "$2,478.00" "$1,393.88" "$1,393.88" $0.00 $0.00 $0.00 $645.60 "$2,298.96" "$2,298.96" $0.00 $0.00 $645.52 $0.00 "$1,527.07" "$1,527.07" $0.00 "$1,548.75" "$2,453.22" "$2,478.00" $0.00 $0.00 $484.76 $0.00 $0.00 $493.12 $0.00 $0.00 $0.00 $0.00 $0.00 115.31 SUP HCPCS C1713 115.310 - SCREW BONE 3.5MM 10MM PRTX CTTI POST THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.312 SUP HCPCS C1713 115.312 - SCREW BONE 3.5MM 12MM PRTX CTTI OCT SPN POLYAX BOTH IP/OP "$3,097.50 " "$2,292.15" $0.00 "$2,478.00" "$1,393.88" "$1,393.88" $0.00 $0.00 $0.00 $645.60 "$2,298.96" "$2,298.96" $0.00 $0.00 $645.52 $0.00 "$1,527.07" "$1,527.07" $0.00 "$1,548.75" "$2,453.22" "$2,478.00" $0.00 $0.00 $484.76 $0.00 $0.00 $493.12 $0.00 $0.00 $0.00 $0.00 $0.00 115.314 SUP HCPCS C1713 115.314 - SCREW BONE 3.5MM 14MM PRTX CTTI OCT SPN POLYAX BOTH IP/OP "$3,097.50 " "$2,292.15" $0.00 "$2,478.00" "$1,393.88" "$1,393.88" $0.00 $0.00 $0.00 $645.60 "$2,298.96" "$2,298.96" $0.00 $0.00 $645.52 $0.00 "$1,527.07" "$1,527.07" $0.00 "$1,548.75" "$2,453.22" "$2,478.00" $0.00 $0.00 $484.76 $0.00 $0.00 $493.12 $0.00 $0.00 $0.00 $0.00 $0.00 115.316 SUP HCPCS C1713 115.316 - SCREW BONE 3.5MM 16MM PRTX CTTI OCT SPN POLYAX BOTH IP/OP "$3,097.50 " "$2,292.15" $0.00 "$2,478.00" "$1,393.88" "$1,393.88" $0.00 $0.00 $0.00 $645.60 "$2,298.96" "$2,298.96" $0.00 $0.00 $645.52 $0.00 "$1,527.07" "$1,527.07" $0.00 "$1,548.75" "$2,453.22" "$2,478.00" $0.00 $0.00 $484.76 $0.00 $0.00 $493.12 $0.00 $0.00 $0.00 $0.00 $0.00 115.318 SUP HCPCS C1713 115.318 - 3.5MM PROTEX CT POLYAXIAL SCREW 18MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.32 SUP HCPCS C1713 115.320 - 3.5MM PROTEX CT POLYAXIAL SCREW 20MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.322 SUP HCPCS C1713 115.322 - 3.5MM PROTEX CT POLYAXIAL SCREW 22MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.324 SUP HCPCS C1713 115.324 - 3.5MM PROTEX CT POLYAXIAL SCREW 24MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.326 SUP HCPCS C1713 115.326 - 3.5MM PROTEX CT POLYAXIAL SCREW 26MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.328 SUP HCPCS C1713 115.328 - 3.5MM PROTEX CT POLYAXIAL SCREW 28MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.33 SUP HCPCS C1713 115.330 - 3.5MM PROTEX CT POLYAXIAL SCREW 30MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.332 SUP HCPCS C1713 115.332 - 3.5MM PROTEX CT POLYAXIAL SCREW 32MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.334 SUP HCPCS C1713 115.334 - 3.5MM PROTEX CT POLYAXIAL SCREW 34MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.336 SUP HCPCS C1713 115.336 - 3.5MM PROTEX CT POLYAXIAL SCREW 36MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.338 SUP HCPCS C1713 115.338 - 3.5MM PROTEX CT POLYAXIAL SCREW 38MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.34 SUP HCPCS C1713 115.340 - 3.5MM PROTEX CT POLYAXIAL SCREW 40MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.342 SUP HCPCS C1713 115.342 - 3.5MM PROTEX CT POLYAXIAL SCREW 42MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.344 SUP HCPCS C1713 115.344 - 3.5MM PROTEX CT POLYAXIAL SCREW 44MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.346 SUP HCPCS C1713 115.346 - 3.5MM PROTEX CT POLYAXIAL SCREW 46MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.348 SUP HCPCS C1713 115.348 - 3.5MM PROTEX CT POLYAXIAL SCREW 48MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.35 SUP HCPCS C1713 115.350 - 3.5MM PROTEX CT POLYAXIAL SCREW 50MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.41 SUP HCPCS C1713 115.410 - SCREW BONE 4MM 10MM PRTX CTTI OCT SPN POLYAX SLFTAP BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.412 SUP HCPCS C1713 115.412 - SCREW BN 4MM 12MM PRTX CT PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.414 SUP HCPCS C1713 115.414 - SCREW BN 4MM 14MM PRTX CT PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.416 SUP HCPCS C1713 115.416 - 4.0MM PROTEX CT POLYAXIAL SCREW 16MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.418 SUP HCPCS C1713 115.418 - SCREW BN 4MM 18MM PRTX CT PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.42 SUP HCPCS C1713 115.420 - 4.0MM PROTEX CT POLYAXIAL SCREW 20MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.422 SUP HCPCS C1713 115.422 - 4.0MM PROTEX CT POLYAXIAL SCREW 22MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.424 SUP HCPCS C1713 115.424 - 4.0MM PROTEX CT POLYAXIAL SCREW 24MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.426 SUP HCPCS C1713 115.426 - 4.0MM PROTEX CT POLYAXIAL SCREW 26MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.428 SUP HCPCS C1713 115.428 - 4.0MM PROTEX CT POLYAXIAL SCREW 28MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.43 SUP HCPCS C1713 115.430 - 4.0MM PROTEX CT POLYAXIAL SCREW 30MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.432 SUP HCPCS C1713 115.432 - 4.0MM PROTEX CT POLYAXIAL SCREW 32MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.434 SUP HCPCS C1713 115.434 - 4.0MM PROTEX CT POLYAXIAL SCREW 34MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.436 SUP HCPCS C1713 115.436 - 4.0MM PROTEX CT POLYAXIAL SCREW 36MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.438 SUP HCPCS C1713 115.438 - 4.0MM PROTEX CT POLYAXIAL SCREW 38MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.44 SUP HCPCS C1713 115.440 - 4.0MM PROTEX CT POLYAXIAL SCREW 40MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.442 SUP HCPCS C1713 115.442 - 4.0MM PROTEX CT POLYAXIAL SCREW 42MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.444 SUP HCPCS C1713 115.444 - 4.0MM PROTEX CT POLYAXIAL SCREW 44MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.446 SUP HCPCS C1713 115.446 - 4.0MM PROTEX CT POLYAXIAL SCREW 46MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.448 SUP HCPCS C1713 115.448 - 4.0MM PROTEX CT POLYAXIAL SCREW 48MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.45 SUP HCPCS C1713 115.450 - 4.0MM PROTEX CT POLYAXIAL SCREW 50MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.5 SUP Custom 27803010 115.500 - CAP LCK PRTX CTTI STD OCT SPN POLYAX BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.501 SUP Custom 27803010 115.501 - PROTEX CT HOOK BOTH IP/OP $955.00 $706.70 $0.00 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.80 $708.80 $0.00 $0.00 $199.02 $0.00 $0.00 $0.00 $0.00 $477.50 $756.36 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.503 SUP Custom 27803010 "115.503 - PROTEX CT HOOK, RIGHT" BOTH IP/OP $955.00 $706.70 $0.00 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.80 $708.80 $0.00 $0.00 $199.02 $0.00 $0.00 $0.00 $0.00 $477.50 $756.36 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.504 SUP Custom 27803010 "115.504 - PROTEX CT HOOK, LEFT" BOTH IP/OP $955.00 $706.70 $0.00 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.80 $708.80 $0.00 $0.00 $199.02 $0.00 $0.00 $0.00 $0.00 $477.50 $756.36 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.506 SUP Custom 27803010 "115.506 - PROTEX CT HOOK, 7MM OFFSET, LEFT" BOTH IP/OP $955.00 $706.70 $0.00 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.80 $708.80 $0.00 $0.00 $199.02 $0.00 $0.00 $0.00 $0.00 $477.50 $756.36 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.507 SUP Custom 27803010 "115.507 - PROTEX CT HOOK, 5MM OFFSET, LEFT" BOTH IP/OP $955.00 $706.70 $0.00 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.80 $708.80 $0.00 $0.00 $199.02 $0.00 $0.00 $0.00 $0.00 $477.50 $756.36 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.508 SUP Custom 27803010 "115.508 - PROTEX CT HOOK, 7MM OFFSET, RIGHT" BOTH IP/OP $955.00 $706.70 $0.00 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.80 $708.80 $0.00 $0.00 $199.02 $0.00 $0.00 $0.00 $0.00 $477.50 $756.36 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.509 SUP Custom 27803010 "115.509 - PROTEX CT HOOK, 5MM OFFSET, RIGHT" BOTH IP/OP $955.00 $706.70 $0.00 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.80 $708.80 $0.00 $0.00 $199.02 $0.00 $0.00 $0.00 $0.00 $477.50 $756.36 $764.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.51 SUP HCPCS C1713 115.510 - 4.5MM PROTEX CT POLYAXIAL SCREW 10MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.512 SUP HCPCS C1713 115.512 - 4.5MM PROTEX CT POLYAXIAL SCREW 12MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.514 SUP HCPCS C1713 115.514 - 4.5MM PROTEX CT POLYAXIAL SCREW 14MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.516 SUP HCPCS C1713 115.516 - 4.5MM PROTEX CT POLYAXIAL SCREW 16MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.518 SUP HCPCS C1713 115.518 - 4.5MM PROTEX CT POLYAXIAL SCREW 18MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.52 SUP HCPCS C1713 115.520 - SCREW BONE 4.5MM 20MM PRTX CTTI OCT SPN SLFTAP BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.522 SUP HCPCS C1713 115.522 - 4.5MM PROTEX CT POLYAXIAL SCREW 22MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.524 SUP HCPCS C1713 115.524 - SCREW BONE 4.5MM 24MM PRTX CTTI OCT SPN POLYAX BOTH IP/OP "$3,365.00 " "$2,490.10" $0.00 "$2,692.00" "$1,514.25" "$1,514.25" $0.00 $0.00 $0.00 $701.35 "$2,497.50" "$2,497.50" $0.00 $0.00 $701.27 $0.00 "$1,658.95" "$1,658.95" $0.00 "$1,682.50" "$2,665.08" "$2,692.00" $0.00 $0.00 $526.62 $0.00 $0.00 $535.71 $0.00 $0.00 $0.00 $0.00 $0.00 115.526 SUP HCPCS C1713 115.526 - SCREW BONE 4.5MM 26MM PRTX CT OCT SPN SLFTAP LP POLYAX BOTH IP/OP "$3,365.00 " "$2,490.10" $0.00 "$2,692.00" "$1,514.25" "$1,514.25" $0.00 $0.00 $0.00 $701.35 "$2,497.50" "$2,497.50" $0.00 $0.00 $701.27 $0.00 "$1,658.95" "$1,658.95" $0.00 "$1,682.50" "$2,665.08" "$2,692.00" $0.00 $0.00 $526.62 $0.00 $0.00 $535.71 $0.00 $0.00 $0.00 $0.00 $0.00 115.528 SUP HCPCS C1713 115.528 - 4.5MM PROTEX CT POLYAXIAL SCREW 28MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.53 SUP HCPCS C1713 115.530 - 4.5MM PROTEX CT POLYAXIAL SCREW 30MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.532 SUP HCPCS C1713 115.532 - 4.5MM PROTEX CT POLYAXIAL SCREW 32MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.534 SUP HCPCS C1713 115.534 - 4.5MM PROTEX CT POLYAXIAL SCREW 34MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.536 SUP HCPCS C1713 115.536 - 4.5MM PROTEX CT POLYAXIAL SCREW 36MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.538 SUP HCPCS C1713 115.538 - 4.5MM PROTEX CT POLYAXIAL SCREW 38MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.54 SUP HCPCS C1713 115.540 - 4.5MM PROTEX CT POLYAXIAL SCREW 40MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.542 SUP HCPCS C1713 115.542 - 4.5MM PROTEX CT POLYAXIAL SCREW 42MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.544 SUP HCPCS C1713 115.544 - 4.5MM PROTEX CT POLYAXIAL SCREW 44MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.546 SUP HCPCS C1713 115.546 - 4.5MM PROTEX CT POLYAXIAL SCREW 46MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.548 SUP HCPCS C1713 115.548 - 4.5MM PROTEX CT POLYAXIAL SCREW 48MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.55 SUP HCPCS C1713 115.550 - 4.5MM PROTEX CT POLYAXIAL SCREW 50MM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 115.701 SUP Custom 27803010 115.701 - ROD SPNL 80MM CONNCTNG GLOBUS BOTH IP/OP $777.50 $575.35 $0.00 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.06 $577.06 $0.00 $0.00 $162.03 $0.00 $0.00 $0.00 $0.00 $388.75 $615.78 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.702 SUP Custom 27803010 "115.702 - 3.2MM STRAIGHT TI ROD, 120MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.703 SUP Custom 27803010 115.703 - ROD SPNL STRG 3.2MM 240MM NS PRTX CTTI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.704 SUP Custom 27803010 "115.704 - 3.2MM STRAIGHT TI ROD, 40MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.801 SUP Custom 27803010 115.801 - ROD SPNL 80MM 3.7MM PRTX CTTI STR BOTH IP/OP $777.50 $575.35 $0.00 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.06 $577.06 $0.00 $0.00 $162.03 $0.00 $0.00 $0.00 $0.00 $388.75 $615.78 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.802 SUP Custom 27803010 115.802 - ROD SPNL 120MM 3.7MM PRTX CTTI STR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $0.00 $0.00 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.803 SUP Custom 27803010 "115.803 - 3.7MM STRAIGHT ROD, 240MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.804 SUP Custom 27803010 "115.804 - 3.7MM STRAIGHT ROD, 40MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.911 SUP Custom 27803010 115.911 - CONCTR ROD 20-41MM 3.7MM PRTX CTTI TRNSVRS ADJ OCT SPN BOTH IP/OP "$3,482.50 " "$2,577.05" $0.00 "$2,786.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,584.71" "$2,584.71" $0.00 $0.00 $725.75 $0.00 $0.00 $0.00 $0.00 "$1,741.25" "$2,758.14" "$2,786.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.912 SUP Custom 27803010 "115.912 - ADJUSTABLE T-CONNECTOR FOR 3.7MM ROD, 41-56MM" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.918 SUP Custom 27803010 "115.918 - TOP-LOADING T-CONNECTOR FOR 3.2MM ROD, 21-33MM, STRAIGHT" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.919 SUP Custom 27803010 "115.919 - TOP-LOADING T-CONNECTOR FOR 3.2MM ROD, 26-46MM, CURVED" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.92 SUP Custom 27803010 "115.920 - TOP-LOADING T-CONNECTOR FOR 3.2MM ROD, 26-46MM, STRAIGHT" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.921 SUP Custom 27803010 "115.921 - TOP-LOADING T-CONNECTOR FOR 3.2MM ROD, 36-56MM, CURVED" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.922 SUP Custom 27803010 "115.922 - TOP-LOADING T-CONNECTOR FOR 3.2MM ROD, 36-56, STRAIGHT" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.923 SUP Custom 27803010 "115.923 - TOP-LOADING T-CONNECTOR FOR 3.7MM ROD, 21-33MM, STRAIGHT" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.924 SUP Custom 27803010 115.924 - CONCTR ROD 26-46MM CVD TOP LD T 3.7MM BOTH IP/OP "$3,915.00 " "$2,897.10" $0.00 "$3,132.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,905.71" "$2,905.71" $0.00 $0.00 $815.89 $0.00 $0.00 $0.00 $0.00 "$1,957.50" "$3,100.68" "$3,132.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.925 SUP Custom 27803010 "115.925 - TOP-LOADING T-CONNECTOR FOR 3.7MM ROD, 26-46MM, STRAIGHT" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.926 SUP Custom 27803010 "115.926 - TOP-LOADING T-CONNECTOR FOR 3.7MM ROD, 36-56MM, CURVED" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.927 SUP Custom 27803010 "115.927 - TOP-LOADING T-CONNECTOR FOR 3.7MM ROD, 36-56, STRAIGHT" BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.93 SUP Custom 27803010 "115.930 - CLAMP FOR T-CONNECTOR, LEFT" BOTH IP/OP "$1,832.50 " "$1,356.05" $0.00 "$1,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,360.08" "$1,360.08" $0.00 $0.00 $381.89 $0.00 $0.00 $0.00 $0.00 $916.25 "$1,451.34" "$1,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.931 SUP Custom 27803010 "115.931 - CLAMP FOR T-CONNECTOR, RIGHT" BOTH IP/OP "$1,832.50 " "$1,356.05" $0.00 "$1,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,360.08" "$1,360.08" $0.00 $0.00 $381.89 $0.00 $0.00 $0.00 $0.00 $916.25 "$1,451.34" "$1,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.949 SUP Custom 27803010 "115.949 - SET SCREW, M4.5X0.75, ROUND TIP, 2.5MM HEX" BOTH IP/OP $192.50 $142.45 $0.00 $154.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.87 $142.87 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.95 SUP Custom 27803010 "115.950 - OCCIPITAL CLAMP, SINGLE, SHORT" BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.05 $590.05 $0.00 $0.00 $165.68 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.951 SUP Custom 27803010 "115.951 - OCCIPITAL CLAMP, SINGLE, LONG" BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.05 $590.05 $0.00 $0.00 $165.68 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.952 SUP HCPCS C1713 "115.952 - SET SCREW, M4.5 X 0.75" BOTH IP/OP $192.50 $142.45 $0.00 $154.00 $86.63 $86.63 $0.00 $0.00 $0.00 $40.12 $142.87 $142.87 $0.00 $0.00 $40.12 $0.00 $113.86 $113.86 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $30.13 $0.00 $0.00 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 115.953 SUP Custom 27803010 "115.953 - 3.7MM OCCIPITAL ROD, 240MM, 100 DEG" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.954 SUP Custom 27803010 "115.954 - 3.7MM OCCIPITAL ROD, 240MM, 115 DEG" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.955 SUP Custom 27803010 115.955 - ROD SPNL 240MM 3.7MM PRTX CTTI 130 OCCPTL BOTH IP/OP "$1,547.50 " "$1,145.15" $0.00 "$1,238.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,148.55" "$1,148.55" $0.00 $0.00 $322.50 $0.00 $0.00 $0.00 $0.00 $773.75 "$1,225.62" "$1,238.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.956 SUP Custom 27803010 "115.956 - OCCIPITAL CLAMP, TRIPLE, SHORT" BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.957 SUP Custom 27803010 "115.957 - OCCIPITAL CLAMP, TRIPLE, LONG" BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.958 SUP Custom 27803010 "115.958 - OCCIPITAL CLAMP, DOUBLE, SHORT" BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.959 SUP Custom 27803010 115.959 - CLAMP SPNL LNG OCCPTL DBL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $0.00 $0.00 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.96 SUP Custom 27803010 "115.960 - PARALLEL CONNECTOR, 3.7MM ROD TO 3.7MM ROD" BOTH IP/OP "$1,432.50 " "$1,060.05" $0.00 "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,063.20" "$1,063.20" $0.00 $0.00 $298.53 $0.00 $0.00 $0.00 $0.00 $716.25 "$1,134.54" "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.961 SUP Custom 27803010 "115.961 - PARALLEL CONNECTOR, 3.7MM ROD TO 4.5MM ROD" BOTH IP/OP "$1,432.50 " "$1,060.05" $0.00 "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,063.20" "$1,063.20" $0.00 $0.00 $298.53 $0.00 $0.00 $0.00 $0.00 $716.25 "$1,134.54" "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.962 SUP Custom 27803010 "115.962 - PARALLEL CONNECTOR, 3.7MM ROD TO 5.0MM ROD" BOTH IP/OP "$1,432.50 " "$1,060.05" $0.00 "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,063.20" "$1,063.20" $0.00 $0.00 $298.53 $0.00 $0.00 $0.00 $0.00 $716.25 "$1,134.54" "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.963 SUP Custom 27803010 "115.963 - PARALLEL CONNECTOR, 3.7MM ROD TO 5.5MM ROD" BOTH IP/OP "$1,432.50 " "$1,060.05" $0.00 "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,063.20" "$1,063.20" $0.00 $0.00 $298.53 $0.00 $0.00 $0.00 $0.00 $716.25 "$1,134.54" "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.964 SUP Custom 27803010 "115.964 - PARALLEL CONNECTOR, 3.7MM ROD TO 6.0MM ROD" BOTH IP/OP "$1,432.50 " "$1,060.05" $0.00 "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,063.20" "$1,063.20" $0.00 $0.00 $298.53 $0.00 $0.00 $0.00 $0.00 $716.25 "$1,134.54" "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.965 SUP Custom 27803010 "115.965 - PARALLEL CONNECTOR, 3.7MM ROD TO 6.5MM ROD" BOTH IP/OP "$1,432.50 " "$1,060.05" $0.00 "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,063.20" "$1,063.20" $0.00 $0.00 $298.53 $0.00 $0.00 $0.00 $0.00 $716.25 "$1,134.54" "$1,146.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.966 SUP Custom 27803010 "115.966 - PARALLEL CONNECTOR, 3.7MM ROD TO 4.0MM ROD" BOTH IP/OP "$1,717.50 " "$1,270.95" $0.00 "$1,374.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,274.73" "$1,274.73" $0.00 $0.00 $357.93 $0.00 $0.00 $0.00 $0.00 $858.75 "$1,360.26" "$1,374.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.979 SUP Custom 27803010 "115.979 - TAPERED ROD, 3.2MM TO 3.7MM, 240MM" BOTH IP/OP "$1,620.00 " "$1,198.80" $0.00 "$1,296.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,202.36" "$1,202.36" $0.00 $0.00 $337.61 $0.00 $0.00 $0.00 $0.00 $810.00 "$1,283.04" "$1,296.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.981 SUP Custom 27803010 "115.981 - TAPERED ROD, 3.7MM TO 6.5MM, 350MM" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.983 SUP Custom 27803010 "115.983 - TAPERED ROD, 3.7MM TO 6.0MM, 350MM" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.984 SUP Custom 27803010 "115.984 - TAPERED ROD, 3.7MM TO 5.5MM, 350MM" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.985 SUP Custom 27803010 "115.985 - TAPERED ROD, 3.7MM TO 5.0MM, 350MM" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.986 SUP Custom 27803010 "115.986 - TAPERED ROD, 3.7MM TO 4.5MM, 350MM" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.987 SUP Custom 27803010 "115.987 - TAPERED ROD, 3.7MM TO 4.0MM, 350MM" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.988 SUP Custom 27803010 "115.988 - TAPERED ROD, 3.2MM TO 5.5MM, 350MM" BOTH IP/OP "$1,620.00 " "$1,198.80" $0.00 "$1,296.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,202.36" "$1,202.36" $0.00 $0.00 $337.61 $0.00 $0.00 $0.00 $0.00 $810.00 "$1,283.04" "$1,296.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.989 SUP Custom 27803010 "115.989 - TAPERED ROD, 3.7MM TO 5.5MM, 500MM" BOTH IP/OP "$1,060.00 " $784.40 $0.00 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $786.73 $786.73 $0.00 $0.00 $220.90 $0.00 $0.00 $0.00 $0.00 $530.00 $839.52 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.99 SUP Custom 27803010 115.990 - LATERAL CONNECTOR BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 115.991 SUP Custom 27803010 "115.991 - LATERAL CONNECTOR, SHORT" BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.71" "$1,133.71" $0.00 $0.00 $318.33 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.001 SUP Custom 27203010 116.001 - SPACER SPNL 0D 25MM LG 32X29MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.002 SUP Custom 27203010 116.002 - SPACER SPNL 0D 25MM LG 32X32MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.003 SUP Custom 27203010 116.003 - SPACER SPNL 0D 25MM LG 32X44MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.004 SUP Custom 27203010 116.004 - SPACER SPNL 8D 25MM LG 32X39MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.005 SUP Custom 27203010 116.005 - SPACER SPNL 8D 25MM LG 32X40MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.006 SUP Custom 27203010 116.006 - SPACER SPNL 8D 25MM LG 32X60MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.007 SUP Custom 27203010 116.007 - SPACER SPNL 16D 25MM LG 32X41MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.008 SUP Custom 27203010 116.008 - SPACER SPNL 16D 25MM LG 32X57MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.009 SUP Custom 27203010 116.009 - SPACER SPNL -8D 25MM LG 32X47MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.01 SUP Custom 27203010 116.010 - SPACER SPNL 8D 25MM LG 32X61MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.011 SUP Custom 27203010 116.011 - SPACER SPNL 16D 25MM LG 32X47MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.012 SUP Custom 27203010 116.012 - SPACER SPNL 16D 25MM LG 32X58MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.013 SUP Custom 27203010 116.013 - SPACER SPNL 16D 25MM LG 32X73MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.014 SUP Custom 27203010 116.014 - SPACER SPNL 0D 25MM LG 32X39MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.015 SUP Custom 27203010 116.015 - SPACER SPNL 16D 25MM LG 32X51MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.016 SUP Custom 27203010 116.016 - SPACER SPNL -8D 25MM LG 32X29MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.017 SUP Custom 27803010 116.017 - SPACER SPNL 0D 25MM LG 32X41MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.018 SUP Custom 27203010 116.018 - SPACER SPNL 8D 25MM LG 32X41MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.019 SUP Custom 27203010 116.019 - SPACER SPNL 0D 25MM LG 32X51MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.02 SUP Custom 27203010 116.020 - SPACER SPNL 8D 25MM LG 32X51MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.021 SUP Custom 27203010 116.021 - SPACER SPNL 16D 25MM LG 32X51MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.022 SUP Custom 27203010 116.022 - SPACER SPNL -8D 25MM LG 32X29MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.023 SUP Custom 27203010 116.023 - SPACER SPNL 0D 25MM LG 32X29MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.024 SUP Custom 27203010 116.024 - SPACER SPNL 0D 25MM LG 32X32MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,607.50 " "$13,769.55" $0.00 "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,877.80" $0.00 $0.00 $0.00 $0.00 "$9,303.75" "$14,737.14" "$14,886.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.101 SUP Custom 27203010 116.101 - SPACER SPNL 0D 12MM SM 14X15MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.102 SUP Custom 27203010 116.102 - SPACER SPNL 0D 12MM SM 14X18MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.103 SUP Custom 27203010 116.103 - SPACER SPNL 0D 12MM SM 14X23MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.104 SUP Custom 27203010 116.104 - SPACER SPNL 0D 12MM SM 14X32MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.105 SUP Custom 27203010 116.105 - SPACER SPNL 0D 12MM SM 14X42MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.106 SUP Custom 27203010 116.106 - SPACER SPNL 0D 12MM SM 14X56MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.107 SUP Custom 27203010 116.107 - SPACER SPNL 7D 12MM SM 14X15MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.108 SUP Custom 27203010 116.108 - SPACER SPNL 7D 12MM SM 14X18MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.109 SUP Custom 27203010 116.109 - SPACER SPNL 7D 12MM SM 14X26MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.11 SUP Custom 27203010 116.110 - SPACER SPNL 7D 12MM SM 14X28MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.111 SUP Custom 27203010 116.111 - SPACER SPNL 7D 12MM SM 14X42MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.112 SUP Custom 27203010 116.112 - SPACER SPNL 7D 12MM SM 14X56MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.113 SUP Custom 27203010 116.113 - SPACER SPNL 16D 12MM SM 14X56MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.114 SUP Custom 27203010 116.114 - SPACER SPNL 0D 12MM SM 14X74MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.115 SUP Custom 27203010 116.115 - SPACER SPNL 7D 12MM SM 14X74MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.116 SUP Custom 27203010 116.116 - SPACER SPNL 16D 12MM SM 14X74MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.117 SUP Custom 27203010 116.117 - SPACER SPNL 0D 12MM SM 14X19MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.118 SUP Custom 27203010 116.118 - SPACER SPNL 7D 12MM SM 14X19MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.119 SUP Custom 27203010 116.119 - SPACER SPNL 0D 12MM SM 14X29MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.12 SUP Custom 27203010 116.120 - SPACER SPNL 7D 12MM SM 14X29MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.121 SUP Custom 27203010 116.121 - SPACER SPNL 0D 12MM SM 14X15MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.122 SUP Custom 27203010 116.122 - SPACER SPNL 7D 12MM SM 14X15MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.123 SUP Custom 27203010 116.123 - SPACER SPNL 0D 12MM SM 14X18MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.124 SUP Custom 27203010 116.124 - SPACER SPNL 7D 12MM SM 14X18MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.125 SUP Custom 27203010 116.125 - SPACER SPNL 0D 12MM SM 14X19MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.126 SUP Custom 27203010 116.126 - SPACER SPNL 7D 12MM SM 14X29MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$14,315.00 " "$10,593.10" $0.00 "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,983.25" $0.00 $0.00 $0.00 $0.00 "$7,157.50" "$11,337.48" "$11,452.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.201 SUP Custom 27203010 116.201 - SPACER SPNL -6D 21MM MED 23X24MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.202 SUP Custom 27203010 116.202 - SPACER SPNL -6D 21MM MED 23X27MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.203 SUP Custom 27203010 116.203 - SPACER SPNL -6D 21MM MED 23X37MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$17,655.00 " "$13,064.70" $0.00 "$14,124.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,679.30" $0.00 $0.00 $0.00 $0.00 "$8,827.50" "$13,982.76" "$14,124.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.204 SUP Custom 27203010 116.204 - SPACER SPNL -6D 21MM MED 23X49MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$20,040.00 " "$14,829.60" $0.00 "$16,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,176.34" $0.00 $0.00 $0.00 $0.00 "$10,020.00" "$15,871.68" "$16,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.205 SUP Custom 27203010 116.205 - SPACER SPNL 0D 21MM MED 23X24MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.206 SUP Custom 27203010 116.206 - SPACER SPNL 0D 21MM MED 23X27MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.207 SUP Custom 27203010 116.207 - SPACER SPNL 0D 21MM MED 23X37MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$17,655.00 " "$13,064.70" $0.00 "$14,124.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,679.30" $0.00 $0.00 $0.00 $0.00 "$8,827.50" "$13,982.76" "$14,124.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.208 SUP Custom 27203010 116.208 - SPACER SPNL 0D 21MM MED 23X49MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$20,040.00 " "$14,829.60" $0.00 "$16,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,176.34" $0.00 $0.00 $0.00 $0.00 "$10,020.00" "$15,871.68" "$16,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.209 SUP Custom 27203010 116.209 - SPACER SPNL 0D 21MM MED 23X33MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.21 SUP Custom 27203010 116.210 - SPACER SPNL -6D 21MM MED 23X33MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.211 SUP Custom 27203010 116.211 - SPACER SPNL 0D 21MM MED 23X43MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.212 SUP Custom 27203010 116.212 - SPACER SPNL -6D 21MM MED 23X43MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.213 SUP Custom 27203010 116.213 - SPACER SPNL 8D 21MM MED 23X24MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.214 SUP Custom 27203010 116.214 - SPACER SPNL 8D 21MM MED 23X27MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.215 SUP Custom 27203010 116.215 - SPACER SPNL 8D 21MM MED 23X33MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.216 SUP Custom 27203010 116.216 - SPACER SPNL 8D 21MM MED 23X37MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.217 SUP Custom 27203010 116.217 - SPACER SPNL 8D 21MM MED 23X43MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.218 SUP Custom 27203010 116.218 - SPACER SPNL 8D 21MM MED 23X49MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.219 SUP Custom 27203010 116.219 - SPACER SPNL 8D 21MM MED 23X24MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.22 SUP Custom 27203010 116.220 - SPACER SPNL 8D 21MM MED 23X27MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.221 SUP Custom 27203010 116.221 - SPACER SPNL -6D 21MM MED 23X24MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.222 SUP Custom 27203010 116.222 - SPACER SPNL -6D 21MM MED 23X27MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.223 SUP Custom 27203010 116.223 - SPACER SPNL 0D 21MM MED 23X24MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.224 SUP Custom 27203010 116.224 - SPACER SPNL 0D 21MM MED 23X27MM NS LF XPAND SLF DSTRCT SMTH BOTH IP/OP "$16,222.50 " "$12,004.65" $0.00 "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,380.77" $0.00 $0.00 $0.00 $0.00 "$8,111.25" "$12,848.22" "$12,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.301 SUP Custom 27203010 116.301 - SPACER SPNL 0D 21MM S/MED 23X18MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$15,267.50 " "$11,297.95" $0.00 "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,181.75" $0.00 $0.00 $0.00 $0.00 "$7,633.75" "$12,091.86" "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.302 SUP Custom 27203010 116.302 - SPACER SPNL 0D 21MM S/MED 23X19MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$15,267.50 " "$11,297.95" $0.00 "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,181.75" $0.00 $0.00 $0.00 $0.00 "$7,633.75" "$12,091.86" "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.303 SUP Custom 27203010 116.303 - SPACER SPNL 0D 21MM S/MED 23X21MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$15,267.50 " "$11,297.95" $0.00 "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,181.75" $0.00 $0.00 $0.00 $0.00 "$7,633.75" "$12,091.86" "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.304 SUP Custom 27203010 116.304 - SPACER SPNL 0D 21MM S/MED 23X18MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$15,267.50 " "$11,297.95" $0.00 "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,181.75" $0.00 $0.00 $0.00 $0.00 "$7,633.75" "$12,091.86" "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.305 SUP Custom 27203010 116.305 - SPACER SPNL 0D 21MM S/MED 23X19MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$15,267.50 " "$11,297.95" $0.00 "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,181.75" $0.00 $0.00 $0.00 $0.00 "$7,633.75" "$12,091.86" "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.306 SUP Custom 27203010 116.306 - SPACER SPNL 0D 21MM S/MED 23X21MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$15,267.50 " "$11,297.95" $0.00 "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,181.75" $0.00 $0.00 $0.00 $0.00 "$7,633.75" "$12,091.86" "$12,214.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.401 SUP Custom 27203010 116.401 - SPACER SPNL 0D 25MM MED LG 32X24MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$17,412.50 " "$12,885.25" $0.00 "$13,930.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,628.77" $0.00 $0.00 $0.00 $0.00 "$8,706.25" "$13,790.70" "$13,930.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.402 SUP Custom 27203010 116.402 - SPACER SPNL 0D 25MM MED LG 32X26MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$17,412.50 " "$12,885.25" $0.00 "$13,930.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,628.77" $0.00 $0.00 $0.00 $0.00 "$8,706.25" "$13,790.70" "$13,930.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.403 SUP Custom 27203010 116.403 - SPACER SPNL 0D 25MM MED LG 32X29MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$18,130.00 " "$13,416.20" $0.00 "$14,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,778.29" $0.00 $0.00 $0.00 $0.00 "$9,065.00" "$14,358.96" "$14,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.404 SUP Custom 27203010 116.404 - SPACER SPNL 0D 25MM MED LG 32X41MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$20,277.50 " "$15,005.35" $0.00 "$16,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,225.83" $0.00 $0.00 $0.00 $0.00 "$10,138.75" "$16,059.78" "$16,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.405 SUP Custom 27203010 116.405 - SPACER SPNL 0D 25MM MED LG 32X51MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$20,992.50 " "$15,534.45" $0.00 "$16,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,374.84" $0.00 $0.00 $0.00 $0.00 "$10,496.25" "$16,626.06" "$16,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.406 SUP Custom 27203010 116.406 - SPACER SPNL 0D 25MM MED LG 32X24MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$17,417.50 " "$12,888.95" $0.00 "$13,934.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,629.81" $0.00 $0.00 $0.00 $0.00 "$8,708.75" "$13,794.66" "$13,934.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.407 SUP Custom 27203010 116.407 - SPACER SPNL 0D 25MM MED LG 32X26MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$17,417.50 " "$12,888.95" $0.00 "$13,934.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,629.81" $0.00 $0.00 $0.00 $0.00 "$8,708.75" "$13,794.66" "$13,934.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.408 SUP Custom 27203010 116.408 - SPACER SPNL 0D 25MM MED LG 32X29MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$18,130.00 " "$13,416.20" $0.00 "$14,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,778.29" $0.00 $0.00 $0.00 $0.00 "$9,065.00" "$14,358.96" "$14,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.409 SUP Custom 27203010 116.409 - SPACER SPNL 0D 25MM MED LG 32X41MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$20,277.50 " "$15,005.35" $0.00 "$16,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,225.83" $0.00 $0.00 $0.00 $0.00 "$10,138.75" "$16,059.78" "$16,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.41 SUP Custom 27203010 116.410 - SPACER SPNL 0D 25MM MED LG 32X51MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$20,992.50 " "$15,534.45" $0.00 "$16,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,374.84" $0.00 $0.00 $0.00 $0.00 "$10,496.25" "$16,626.06" "$16,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.411 SUP Custom 27203010 116.411 - SPACER SPNL 0D 25MM MED LG 32X36MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$19,202.50 " "$14,209.85" $0.00 "$15,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,001.80" $0.00 $0.00 $0.00 $0.00 "$9,601.25" "$15,208.38" "$15,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.412 SUP Custom 27203010 116.412 - SPACER SPNL 0D 25MM MED LG 32X36MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$19,202.50 " "$14,209.85" $0.00 "$15,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,001.80" $0.00 $0.00 $0.00 $0.00 "$9,601.25" "$15,208.38" "$15,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.413 SUP Custom 27203010 116.413 - SPACER SPNL 0D 25MM MED LG 32X26MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$17,417.50 " "$12,888.95" $0.00 "$13,934.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,629.81" $0.00 $0.00 $0.00 $0.00 "$8,708.75" "$13,794.66" "$13,934.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.414 SUP Custom 27203010 116.414 - SPACER SPNL 0D 25MM MED LG 32X26MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$17,417.50 " "$12,888.95" $0.00 "$13,934.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,629.81" $0.00 $0.00 $0.00 $0.00 "$8,708.75" "$13,794.66" "$13,934.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.415 SUP Custom 27203010 116.415 - SPACER SPNL 0D 25MM MED LG 32X29MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$18,130.00 " "$13,416.20" $0.00 "$14,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,778.29" $0.00 $0.00 $0.00 $0.00 "$9,065.00" "$14,358.96" "$14,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 116.416 SUP Custom 27203010 116.416 - SPACER SPNL 0D 25MM MED LG 32X29MM NS LF XPAND SLF DSTRCT BOTH IP/OP "$18,130.00 " "$13,416.20" $0.00 "$14,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,778.29" $0.00 $0.00 $0.00 $0.00 "$9,065.00" "$14,358.96" "$14,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.112 SUP HCPCS C1713 "117.112 - ASSURE TRANSLATIONAL CERVICAL PLATE 1-LEVEL, 12MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 117.114 SUP HCPCS C1713 "117.114 - ASSURE TRANSLATIONAL CERVICAL PLATE 1-LEVEL, 14MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 117.116 SUP HCPCS C1713 "117.116 - ASSURE TRANSLATIONAL CERVICAL PLATE 1-LEVEL, 16MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 117.118 SUP HCPCS C1713 "117.118 - ASSURE TRANSLATIONAL CERVICAL PLATE 1-LEVEL, 18MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 117.12 SUP HCPCS C1713 "117.120 - ASSURE TRANSLATIONAL CERVICAL PLATE 1-LEVEL, 20MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 117.122 SUP HCPCS C1713 "117.122 - ASSURE TRANSLATIONAL CERVICAL PLATE 1-LEVEL, 22MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 117.124 SUP HCPCS C1713 "117.124 - ASSURE TRANSLATIONAL CERVICAL PLATE 1-LEVEL, 24MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 117.126 SUP HCPCS C1713 "117.126 - ASSURE TRANSLATIONAL CERVICAL PLATE 1-LEVEL, 26MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 117.226 SUP HCPCS C1713 "117.226 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 26MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.228 SUP HCPCS C1713 "117.228 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 28MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.23 SUP HCPCS C1713 "117.230 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.232 SUP HCPCS C1713 "117.232 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 32MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.234 SUP HCPCS C1713 "117.234 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 34MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.236 SUP HCPCS C1713 "117.236 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 36MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.238 SUP HCPCS C1713 "117.238 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 38MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.24 SUP HCPCS C1713 "117.240 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.242 SUP HCPCS C1713 "117.242 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 42MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.244 SUP HCPCS C1713 "117.244 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 44MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.246 SUP HCPCS C1713 "117.246 - ASSURE TRANSLATIONAL CERVICAL PLATE 2-LEVEL, 46MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 117.345 SUP HCPCS C1713 "117.345 - ASSURE TRANSLATIONAL CERVICAL PLATE 3-LEVEL, 45MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.348 SUP HCPCS C1713 "117.348 - ASSURE TRANSLATIONAL CERVICAL PLATE 3-LEVEL, 48MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.351 SUP HCPCS C1713 "117.351 - ASSURE TRANSLATIONAL CERVICAL PLATE 3-LEVEL, 51MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.354 SUP HCPCS C1713 "117.354 - ASSURE TRANSLATIONAL CERVICAL PLATE 3-LEVEL, 54MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.357 SUP HCPCS C1713 "117.357 - ASSURE TRANSLATIONAL CERVICAL PLATE 3-LEVEL, 57MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.36 SUP HCPCS C1713 117.360 - PLATE BN 60MM NS ASR LVL 3 TRANSLATIONAL SPNE CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.363 SUP HCPCS C1713 "117.363 - ASSURE TRANSLATIONAL CERVICAL PLATE 3-LEVEL, 63MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.366 SUP HCPCS C1713 "117.366 - ASSURE TRANSLATIONAL CERVICAL PLATE 3-LEVEL, 66MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.369 SUP HCPCS C1713 "117.369 - ASSURE TRANSLATIONAL CERVICAL PLATE 3-LEVEL, 69MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 117.46 SUP HCPCS C1713 "117.460 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 60MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.464 SUP HCPCS C1713 "117.464 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 64MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.468 SUP HCPCS C1713 "117.468 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 68MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.472 SUP HCPCS C1713 "117.472 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 72MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.476 SUP HCPCS C1713 "117.476 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 76MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.48 SUP HCPCS C1713 "117.480 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 80MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.484 SUP HCPCS C1713 "117.484 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 84MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.488 SUP HCPCS C1713 "117.488 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 88MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.492 SUP HCPCS C1713 "117.492 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 92MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.496 SUP HCPCS C1713 "117.496 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 96MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 117.5 SUP HCPCS C1713 "117.500 - ASSURE TRANSLATIONAL CERVICAL PLATE 4-LEVEL, 100MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 124 SUP HCPCS C1713 124.000 - LOCKING CAPS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 124.001 SUP Custom 27803010 "124.001 - 5.5MM STRAIGHT ROD, CP, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.002 SUP Custom 27803010 "124.002 - 5.5MM STRAIGHT ROD, CP, 400MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.003 SUP Custom 27803010 "124.003 - 5.5MM STRAIGHT ROD, CP, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.004 SUP Custom 27803010 "124.004 - 5.5MM STRAIGHT ROD, CP2, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.005 SUP Custom 27803010 "124.005 - 5.5MM STRAIGHT ROD, CP2, 400MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.006 SUP Custom 27803010 "124.006 - 5.5MM STRAIGHT ROD, CP2, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.012 SUP Custom 27803010 "124.012 - REVERE LOW PROFILE ADJUSTABLE T-CONNECTOR, 24MM-25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.013 SUP Custom 27803010 "124.013 - REVERE LOW PROFILE ADJUSTABLE T-CONNECTOR, 26MM-28MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.014 SUP Custom 27803010 "124.014 - REVERE LOW PROFILE ADJUSTABLE T-CONNECTOR, 29MM-34MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.051 SUP HCPCS C1713 124.051 - 5.0MM REVERE PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.052 SUP HCPCS C1713 124.052 - 5.0MM REVERE PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.053 SUP HCPCS C1713 124.053 - 5.0MM REVERE PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.054 SUP HCPCS C1713 124.054 - 5.0MM REVERE PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.055 SUP HCPCS C1713 124.055 - 5.0MM REVERE PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.056 SUP HCPCS C1713 124.056 - 5.0MM REVERE PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.057 SUP HCPCS C1713 124.057 - 5.0MM REVERE PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.071 SUP HCPCS C1713 124.071 - 7.5MM REVERE PEDICLE SCREW 70MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.072 SUP HCPCS C1713 124.072 - 7.5MM REVERE PEDICLE SCREW 75MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.073 SUP HCPCS C1713 124.073 - 7.5MM REVERE PEDICLE SCREW 80MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.074 SUP HCPCS C1713 124.074 - 7.5MM REVERE PEDICLE SCREW 85MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.075 SUP HCPCS C1713 124.075 - 7.5MM REVERE PEDICLE SCREW 90MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.081 SUP HCPCS C1713 124.081 - 8.5MM REVERE PEDICLE SCREW 70MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.082 SUP HCPCS C1713 124.082 - 8.5MM REVERE PEDICLE SCREW 75MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.083 SUP HCPCS C1713 124.083 - 8.5MM REVERE PEDICLE SCREW 80MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.084 SUP HCPCS C1713 124.084 - 8.5MM REVERE PEDICLE SCREW 85MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.085 SUP HCPCS C1713 124.085 - 8.5MM REVERE PEDICLE SCREW 90MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.111 SUP HCPCS C1713 "124.111 - 5.5MM REVERE MONOAXIAL SCREW, 27MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.112 SUP HCPCS C1713 "124.112 - 5.5MM REVERE MONOAXIAL SCREW, 32MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.113 SUP HCPCS C1713 "124.113 - 5.5MM REVERE MONOAXIAL SCREW, 37MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.114 SUP HCPCS C1713 "124.114 - 5.5MM REVERE MONOAXIAL SCREW, 42MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.115 SUP HCPCS C1713 "124.115 - 5.5MM REVERE MONOAXIAL SCREW, 47MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.121 SUP HCPCS C1713 "124.121 - 6.5MM REVERE MONOAXIAL SCREW, 27MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.122 SUP HCPCS C1713 "124.122 - 6.5MM REVERE MONOAXIAL SCREW, 32MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.123 SUP HCPCS C1713 "124.123 - 6.5MM REVERE MONOAXIAL SCREW, 37MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.124 SUP HCPCS C1713 "124.124 - 6.5MM REVERE MONOAXIAL SCREW, 42MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.125 SUP HCPCS C1713 "124.125 - 6.5MM REVERE MONOAXIAL SCREW, 47MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.131 SUP HCPCS C1713 "124.131 - 7.5MM REVERE MONOAXIAL SCREW, 27MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.132 SUP HCPCS C1713 "124.132 - 7.5MM REVERE MONOAXIAL SCREW, 32MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.133 SUP HCPCS C1713 "124.133 - 7.5MM REVERE MONOAXIAL SCREW, 37MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.134 SUP HCPCS C1713 "124.134 - 7.5MM REVERE MONOAXIAL SCREW, 42MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.135 SUP HCPCS C1713 "124.135 - 7.5MM REVERE MONOAXIAL SCREW, 47MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.171 SUP HCPCS C1713 124.171 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 75MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.172 SUP HCPCS C1713 124.172 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 80MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.173 SUP HCPCS C1713 124.173 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 85MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.174 SUP HCPCS C1713 124.174 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 90MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.175 SUP HCPCS C1713 124.175 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 95MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.176 SUP HCPCS C1713 124.176 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 100MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.181 SUP HCPCS C1713 124.181 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 75MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.182 SUP HCPCS C1713 124.182 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 80MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.183 SUP HCPCS C1713 124.183 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 85MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.184 SUP HCPCS C1713 124.184 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 90MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.185 SUP HCPCS C1713 124.185 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 95MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.186 SUP HCPCS C1713 124.186 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 100MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.2 SUP HCPCS C1713 124.200 - 4.0MM REVERE MONOAXIAL SCREW 20MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.201 SUP HCPCS C1713 124.201 - 4.0MM REVERE MONOAXIAL SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.202 SUP HCPCS C1713 124.202 - 4.0MM REVERE MONOAXIAL SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.203 SUP HCPCS C1713 124.203 - 4.0MM REVERE MONOAXIAL SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.204 SUP HCPCS C1713 124.204 - 4.0MM REVERE MONOAXIAL SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.241 SUP HCPCS C1713 124.241 - 4.5MM REVERE MONOAXIAL SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.242 SUP HCPCS C1713 124.242 - 4.5MM REVERE MONOAXIAL SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.243 SUP HCPCS C1713 124.243 - 4.5MM REVERE MONOAXIAL SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.244 SUP HCPCS C1713 124.244 - 4.5MM REVERE MONOAXIAL SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.245 SUP HCPCS C1713 124.245 - 4.5MM REVERE MONOAXIAL SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.251 SUP HCPCS C1713 124.251 - 5.5MM REVERE MONOAXIAL SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.252 SUP HCPCS C1713 124.252 - 5.5MM REVERE MONOAXIAL SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.253 SUP HCPCS C1713 124.253 - 5.5MM REVERE MONOAXIAL SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.254 SUP HCPCS C1713 124.254 - 5.5MM REVERE MONOAXIAL SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.255 SUP HCPCS C1713 124.255 - 5.5MM REVERE MONOAXIAL SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.256 SUP HCPCS C1713 124.256 - 5.5MM REVERE MONOAXIAL SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.257 SUP HCPCS C1713 124.257 - 5.5MM REVERE MONOAXIAL SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.258 SUP HCPCS C1713 124.258 - 5.5MM REVERE MONOAXIAL SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.259 SUP HCPCS C1713 124.259 - 5.5MM REVERE MONOAXIAL SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.261 SUP HCPCS C1713 124.261 - 6.5MM REVERE MONOAXIAL SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.262 SUP HCPCS C1713 124.262 - 6.5MM REVERE MONOAXIAL SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.263 SUP HCPCS C1713 124.263 - 6.5MM REVERE MONOAXIAL SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.264 SUP HCPCS C1713 124.264 - 6.5MM REVERE MONOAXIAL SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.265 SUP HCPCS C1713 124.265 - 6.5MM REVERE MONOAXIAL SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.266 SUP HCPCS C1713 124.266 - 6.5MM REVERE MONOAXIAL SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.267 SUP HCPCS C1713 124.267 - 6.5MM REVERE MONOAXIAL SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.268 SUP HCPCS C1713 124.268 - 6.5MM REVERE MONOAXIAL SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.269 SUP HCPCS C1713 124.269 - 6.5MM REVERE MONOAXIAL SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.271 SUP HCPCS C1713 124.271 - 7.5MM REVERE MONOAXIAL SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.272 SUP HCPCS C1713 124.272 - 7.5MM REVERE MONOAXIAL SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.273 SUP HCPCS C1713 124.273 - 7.5MM REVERE MONOAXIAL SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.274 SUP HCPCS C1713 124.274 - 7.5MM REVERE MONOAXIAL SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.275 SUP HCPCS C1713 124.275 - 7.5MM REVERE MONOAXIAL SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.276 SUP HCPCS C1713 124.276 - 7.5MM REVERE MONOAXIAL SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.277 SUP HCPCS C1713 124.277 - 7.5MM REVERE MONOAXIAL SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.278 SUP HCPCS C1713 124.278 - 7.5MM REVERE MONOAXIAL SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.279 SUP HCPCS C1713 124.279 - 7.5MM REVERE MONOAXIAL SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.281 SUP HCPCS C1713 124.281 - 8.5MM REVERE MONOAXIAL SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.282 SUP HCPCS C1713 124.282 - 8.5MM REVERE MONOAXIAL SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.283 SUP HCPCS C1713 124.283 - 8.5MM REVERE MONOAXIAL SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.284 SUP HCPCS C1713 124.284 - 8.5MM REVERE MONOAXIAL SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.285 SUP HCPCS C1713 124.285 - 8.5MM REVERE MONOAXIAL SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.286 SUP HCPCS C1713 124.286 - 8.5MM REVERE MONOAXIAL SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.287 SUP HCPCS C1713 124.287 - 8.5MM REVERE MONOAXIAL SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.288 SUP HCPCS C1713 124.288 - 8.5MM REVERE MONOAXIAL SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.289 SUP HCPCS C1713 124.289 - 8.5MM REVERE MONOAXIAL SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.351 SUP HCPCS C1713 124.351 - 5.5MM REVERE CANNULATED PEDICLE SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.352 SUP HCPCS C1713 124.352 - 5.5MM REVERE CANNULATED PEDICLE SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.353 SUP HCPCS C1713 124.353 - 5.5MM REVERE CANNULATED PEDICLE SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.354 SUP HCPCS C1713 124.354 - 5.5MM REVERE CANNULATED PEDICLE SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.355 SUP HCPCS C1713 124.355 - 5.5MM REVERE CANNULATED PEDICLE SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.356 SUP HCPCS C1713 124.356 - 5.5MM REVERE CANNULATED PEDICLE SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.357 SUP HCPCS C1713 124.357 - 5.5MM REVERE CANNULATED PEDICLE SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.361 SUP HCPCS C1713 124.361 - 6.5MM REVERE CANNULATED PEDICLE SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.362 SUP HCPCS C1713 124.362 - 6.5MM REVERE CANNULATED PEDICLE SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.363 SUP HCPCS C1713 124.363 - 6.5MM REVERE CANNULATED PEDICLE SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.364 SUP HCPCS C1713 124.364 - 6.5MM REVERE CANNULATED PEDICLE SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.365 SUP HCPCS C1713 124.365 - 6.5MM REVERE CANNULATED PEDICLE SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.366 SUP HCPCS C1713 124.366 - 6.5MM REVERE CANNULATED PEDICLE SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.367 SUP HCPCS C1713 124.367 - 6.5MM REVERE CANNULATED PEDICLE SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.368 SUP HCPCS C1713 124.368 - 6.5MM REVERE CANNULATED PEDICLE SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.369 SUP HCPCS C1713 124.369 - 6.5MM REVERE CANNULATED PEDICLE SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.371 SUP HCPCS C1713 124.371 - 7.5MM REVERE CANNULATED PEDICLE SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.372 SUP HCPCS C1713 124.372 - 7.5MM REVERE CANNULATED PEDICLE SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.373 SUP HCPCS C1713 124.373 - 7.5MM REVERE CANNULATED PEDICLE SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.374 SUP HCPCS C1713 124.374 - 7.5MM REVERE CANNULATED PEDICLE SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.375 SUP HCPCS C1713 124.375 - 7.5MM REVERE CANNULATED PEDICLE SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.376 SUP HCPCS C1713 124.376 - 7.5MM REVERE CANNULATED PEDICLE SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.377 SUP HCPCS C1713 124.377 - 7.5MM REVERE CANNULATED PEDICLE SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.378 SUP HCPCS C1713 124.378 - 7.5MM REVERE CANNULATED PEDICLE SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.379 SUP HCPCS C1713 124.379 - 7.5MM REVERE CANNULATED PEDICLE SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.381 SUP HCPCS C1713 124.381 - 8.5MM REVERE CANNULATED PEDICLE SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.382 SUP HCPCS C1713 124.382 - 8.5MM REVERE CANNULATED PEDICLE SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.383 SUP HCPCS C1713 124.383 - 8.5MM REVERE CANNULATED PEDICLE SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.384 SUP HCPCS C1713 124.384 - 8.5MM REVERE CANNULATED PEDICLE SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.385 SUP HCPCS C1713 124.385 - 8.5MM REVERE CANNULATED PEDICLE SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.386 SUP HCPCS C1713 124.386 - 8.5MM REVERE CANNULATED PEDICLE SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.387 SUP HCPCS C1713 124.387 - 8.5MM REVERE CANNULATED PEDICLE SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.388 SUP HCPCS C1713 124.388 - 8.5MM REVERE CANNULATED PEDICLE SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.389 SUP HCPCS C1713 124.389 - 8.5MM REVERE CANNULATED PEDICLE SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.441 SUP HCPCS C1713 124.441 - 4.5MM REVERE PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.442 SUP HCPCS C1713 124.442 - SCREW BONE 4.5MM 30MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.443 SUP HCPCS C1713 124.443 - SCREW BONE 4.5MM 35MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.444 SUP HCPCS C1713 124.444 - SCREW BONE 4.5MM 40MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.445 SUP HCPCS C1713 124.445 - 4.5MM REVERE PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.451 SUP HCPCS C1713 124.451 - 5.5MM REVERE PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.452 SUP HCPCS C1713 124.452 - SCREW BONE 5.5MM 30MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.453 SUP HCPCS C1713 124.453 - SCREW BONE 5.5MM 35MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.454 SUP HCPCS C1713 124.454 - SCREW BONE 5.5MM 40MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.455 SUP HCPCS C1713 124.455 - SCREW BONE 5.5MM 45MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.456 SUP HCPCS C1713 124.456 - 5.5MM REVERE PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.457 SUP HCPCS C1713 124.457 - 5.5MM REVERE PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.461 SUP HCPCS C1713 124.461 - 6.5MM REVERE PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.462 SUP HCPCS C1713 124.462 - 6.5MM REVERE PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.463 SUP HCPCS C1713 124.463 - 6.5MM REVERE PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.464 SUP HCPCS C1713 124.464 - SCREW BONE 6.5MM 40MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.465 SUP HCPCS C1713 124.465 - SCREW BONE 6.5MM 45MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.466 SUP HCPCS C1713 124.466 - SCREW BONE 6.5MM 50MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.467 SUP HCPCS C1713 124.467 - 6.5MM REVERE PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.468 SUP HCPCS C1713 124.468 - 6.5MM REVERE PEDICLE SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.469 SUP HCPCS C1713 124.469 - 6.5MM REVERE PEDICLE SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.471 SUP HCPCS C1713 124.471 - 7.5MM REVERE PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.472 SUP HCPCS C1713 124.472 - 7.5MM REVERE PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.473 SUP HCPCS C1713 124.473 - 7.5MM REVERE PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.474 SUP HCPCS C1713 124.474 - 7.5MM REVERE PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.475 SUP HCPCS C1713 124.475 - SCREW BONE 7.5MM 45MM REVERE TI PDCL SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.476 SUP HCPCS C1713 124.476 - 7.5MM REVERE PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.477 SUP HCPCS C1713 124.477 - 7.5MM REVERE PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.478 SUP HCPCS C1713 124.478 - 7.5MM REVERE PEDICLE SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.479 SUP HCPCS C1713 124.479 - 7.5MM REVERE PEDICLE SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.481 SUP HCPCS C1713 124.481 - 8.5MM REVERE PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.482 SUP HCPCS C1713 124.482 - 8.5MM REVERE PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.483 SUP HCPCS C1713 124.483 - 8.5MM REVERE PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.484 SUP HCPCS C1713 124.484 - 8.5MM REVERE PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.485 SUP HCPCS C1713 124.485 - 8.5MM REVERE PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.486 SUP HCPCS C1713 124.486 - 8.5MM REVERE PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.487 SUP HCPCS C1713 124.487 - 8.5MM REVERE PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.488 SUP HCPCS C1713 124.488 - 8.5MM REVERE PEDICLE SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.489 SUP HCPCS C1713 124.489 - 8.5MM REVERE PEDICLE SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.51 SUP Custom 27803010 "124.510 - 5.5MM STRAIGHT ROD, 100MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.512 SUP Custom 27803010 "124.512 - 5.5MM STRAIGHT ROD, 125MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.515 SUP Custom 27803010 124.515 - ROD SPNL 150MM 5.5MM REVERE PDCL TI STR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.517 SUP Custom 27803010 124.517 - ROD SPNL 200MM 5.5MM REVERE PDCL TI STR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.519 SUP Custom 27803010 124.519 - ROD SPNL 350MM 5.5MM REVERE PDCL TI STR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.52 SUP Custom 27803010 "124.520 - 5.5MM STRAIGHT ROD, 400MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.521 SUP Custom 27803010 "124.521 - 5.5MM STRAIGHT ROD, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.53 SUP Custom 27803010 "124.530 - 5.5MM STRAIGHT ROD, 30MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.535 SUP Custom 27803010 "124.535 - 5.5MM STRAIGHT ROD, 35MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.54 SUP Custom 27803010 124.540 - ROD SPNL 40MM 5.5MM REVERE TI STR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.545 SUP Custom 27803010 "124.545 - 5.5MM STRAIGHT ROD, 45MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.55 SUP Custom 27803010 "124.550 - 5.5MM STRAIGHT ROD, 50MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.555 SUP Custom 27803010 "124.555 - 5.5MM STRAIGHT ROD, 55MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.56 SUP Custom 27803010 "124.560 - 5.5MM STRAIGHT ROD, 60MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.565 SUP Custom 27803010 "124.565 - 5.5MM STRAIGHT ROD, 65MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.57 SUP Custom 27803010 "124.570 - 5.5MM STRAIGHT ROD, 70MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.575 SUP Custom 27803010 "124.575 - 5.5MM STRAIGHT ROD, 75MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.58 SUP Custom 27803010 "124.580 - 5.5MM STRAIGHT ROD, 80MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.585 SUP Custom 27803010 124.585 - ROD SPNL 85MM 5.5MM REVERE PDCL TI STR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.61 SUP Custom 27803010 "124.610 - 5.5MM CURVED ROD, 100MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.612 SUP Custom 27803010 "124.612 - 5.5MM CURVED ROD, 125MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.615 SUP Custom 27803010 "124.615 - 5.5MM CURVED ROD, 150MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.635 SUP Custom 27803010 "124.635 - 5.5MM CURVED ROD, 35MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.64 SUP Custom 27803010 124.640 - ROD SPNL 40MM 5.5MM REVERE PDCL TI CVD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.645 SUP Custom 27803010 124.645 - ROD SPNL 45MM 5.5MM REVERE PDCL TI CVD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.65 SUP Custom 27803010 "124.650 - 5.5MM CURVED ROD, 50MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.655 SUP Custom 27803010 124.655 - ROD SPNL 55MM 5.5MM REVERE PDCL TI CVD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.66 SUP Custom 27803010 "124.660 - 5.5MM CURVED ROD, 60MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.665 SUP Custom 27803010 124.665 - ROD SPNL 65MM 5.5MM REVERE PDCL TI CVD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.67 SUP Custom 27803010 "124.670 - 5.5MM CURVED ROD, 70MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.675 SUP Custom 27803010 "124.675 - 5.5MM CURVED ROD, 75MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.68 SUP Custom 27803010 "124.680 - 5.5MM CURVED ROD, 80MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.685 SUP Custom 27803010 "124.685 - 5.5MM CURVED ROD, 85MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.69 SUP Custom 27803010 "124.690 - 5.5MM CURVED ROD, 90MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.695 SUP Custom 27803010 "124.695 - 5.5MM CURVED ROD, 95MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.751 SUP HCPCS C1713 124.751 - 5.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.752 SUP HCPCS C1713 124.752 - 5.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.753 SUP HCPCS C1713 124.753 - 5.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.754 SUP HCPCS C1713 124.754 - 5.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.755 SUP HCPCS C1713 124.755 - 5.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.756 SUP HCPCS C1713 124.756 - 5.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.757 SUP HCPCS C1713 124.757 - 5.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.758 SUP HCPCS C1713 124.758 - 5.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.761 SUP HCPCS C1713 124.761 - 6.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.762 SUP HCPCS C1713 124.762 - 6.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.763 SUP HCPCS C1713 124.763 - 6.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.764 SUP HCPCS C1713 124.764 - 6.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.765 SUP HCPCS C1713 124.765 - 6.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.766 SUP HCPCS C1713 124.766 - 6.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.767 SUP HCPCS C1713 124.767 - 6.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.768 SUP HCPCS C1713 124.768 - 6.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.771 SUP HCPCS C1713 124.771 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.772 SUP HCPCS C1713 124.772 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.773 SUP HCPCS C1713 124.773 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.774 SUP HCPCS C1713 124.774 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.775 SUP HCPCS C1713 124.775 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.776 SUP HCPCS C1713 124.776 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.777 SUP HCPCS C1713 124.777 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.778 SUP HCPCS C1713 124.778 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.779 SUP HCPCS C1713 124.779 - 6.5MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 70MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.781 SUP HCPCS C1713 124.781 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.782 SUP HCPCS C1713 124.782 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.783 SUP HCPCS C1713 124.783 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.784 SUP HCPCS C1713 124.784 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.785 SUP HCPCS C1713 124.785 - SCREW BN 7MM 50MM NS REVERE 2 DIA PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.786 SUP HCPCS C1713 124.786 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.787 SUP HCPCS C1713 124.787 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.788 SUP HCPCS C1713 124.788 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.789 SUP HCPCS C1713 124.789 - 7.0MM REVERE DUAL OUTER DIAMETER POLYAXIAL SCREW 70MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 124.851 SUP HCPCS C1713 124.851 - 5.0MM REVERE MONOAXIAL SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.852 SUP HCPCS C1713 124.852 - 5.0MM REVERE MONOAXIAL SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.853 SUP HCPCS C1713 124.853 - 5.0MM REVERE MONOAXIAL SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.854 SUP HCPCS C1713 124.854 - 5.0MM REVERE MONOAXIAL SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.855 SUP HCPCS C1713 124.855 - 5.0MM REVERE MONOAXIAL SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.856 SUP HCPCS C1713 124.856 - 5.0MM REVERE MONOAXIAL SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.857 SUP HCPCS C1713 124.857 - 5.0MM REVERE MONOAXIAL SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.871 SUP HCPCS C1713 124.871 - 7.5MM REVERE MONOAXIAL SCREW 70MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.872 SUP HCPCS C1713 124.872 - 7.5MM REVERE MONOAXIAL SCREW 75MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.873 SUP HCPCS C1713 124.873 - 7.5MM REVERE MONOAXIAL SCREW 80MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.874 SUP HCPCS C1713 124.874 - 7.5MM REVERE MONOAXIAL SCREW 85MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.875 SUP HCPCS C1713 124.875 - 7.5MM REVERE MONOAXIAL SCREW 90MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.881 SUP HCPCS C1713 124.881 - 8.5MM REVERE MONOAXIAL SCREW 70MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.882 SUP HCPCS C1713 124.882 - 8.5MM REVERE MONOAXIAL SCREW 75MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.883 SUP HCPCS C1713 124.883 - 8.5MM REVERE MONOAXIAL SCREW 80MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.884 SUP HCPCS C1713 124.884 - 8.5MM REVERE MONOAXIAL SCREW 85MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.885 SUP HCPCS C1713 124.885 - 8.5MM REVERE MONOAXIAL SCREW 90MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 124.891 SUP Custom 27803010 "124.891 - REVERE LOW PROFILE PEDICLE HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.892 SUP Custom 27803010 "124.892 - REVERE LOW PROFILE PEDICLE HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.893 SUP Custom 27803010 "124.893 - REVERE LOW PROFILE PEDICLE HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.901 SUP Custom 27803010 "124.901 - REVERE THORACIC LAMINA HOOK, NARROW, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.902 SUP Custom 27803010 "124.902 - REVERE THORACIC LAMINA HOOK, NARROW, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.904 SUP Custom 27803010 "124.904 - REVERE THORACIC LAMINA HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.905 SUP Custom 27803010 "124.905 - REVERE THORACIC LAMINA HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.907 SUP Custom 27803010 "124.907 - REVERE UPGOING THORACIC LAMINA HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.908 SUP Custom 27803010 "124.908 - REVERE UPGOING THORACIC LAMINA HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.912 SUP Custom 27803010 124.912 - CONCTR ROD 29-33MM REVERE TRNSVRS ADJ TI PDCL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.913 SUP Custom 27803010 "124.913 - REVERE ADJUSTABLE T CONNECTOR, 33MM-41MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.914 SUP Custom 27803010 124.914 - CONCTR ROD 38-51MM REVERE TRNSVRS ADJ TI PDCL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.915 SUP Custom 27803010 124.915 - CONCTR ROD 48-68MM REVERE TRNSVRS ADJ TI PDCL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.916 SUP Custom 27803010 124.916 - CONCTR ROD 58-71MM REVERE TRNSVRS ADJ TI PDCL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.917 SUP Custom 27803010 "124.917 - REVERE ADJUSTABLE T CONNECTOR, 68MM-81MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.918 SUP Custom 27803010 "124.918 - REVERE ADJUSTABLE T CONNECTOR, 78MM-91MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.921 SUP Custom 27803010 "124.921 - REVERE OFFSET LAMINA HOOK, RIGHT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.922 SUP Custom 27803010 "124.922 - REVERE OFFSET LAMINA HOOK, LEFT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.924 SUP Custom 27803010 "124.924 - REVERE TRANSVERSE PROCESS HOOK, RIGHT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.925 SUP Custom 27803010 "124.925 - REVERE TRANSVERSE PROCESS HOOK, LEFT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.927 SUP Custom 27803010 "124.927 - REVERE PEDICLE HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.928 SUP Custom 27803010 "124.928 - REVERE PEDICLE HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.929 SUP Custom 27803010 "124.929 - REVERE PEDICLE HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.931 SUP Custom 27803010 "124.931 - REVERE LAMINA HOOK, TRANSVERSE, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.932 SUP Custom 27803010 "124.932 - REVERE LAMINA HOOK, TRANSVERSE, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.933 SUP Custom 27803010 "124.933 - REVERE LAMINA HOOK, TRANSVERSE, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.935 SUP Custom 27803010 "124.935 - REVERE PEDICLE HOOK, TRANSVERSE, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.936 SUP Custom 27803010 "124.936 - REVERE PEDICLE HOOK, TRANSVERSE, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.937 SUP Custom 27803010 "124.937 - REVERE PEDICLE HOOK, TRANSVERSE, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.94 SUP Custom 27803010 "124.940 - REVERE LAMINA HOOK, NARROW, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.941 SUP Custom 27803010 "124.941 - REVERE LAMINA HOOK, NARROW, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.942 SUP Custom 27803010 "124.942 - REVERE LAMINA HOOK, NARROW, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.944 SUP Custom 27803010 "124.944 - REVERE LAMINA HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.945 SUP Custom 27803010 "124.945 - REVERE LAMINA HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.946 SUP Custom 27803010 "124.946 - REVERE LAMINA HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.948 SUP Custom 27803010 "124.948 - REVERE LAMINA HOOK, WIDE, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.949 SUP Custom 27803010 "124.949 - REVERE LAMINA HOOK, WIDE, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.95 SUP Custom 27803010 "124.950 - REVERE LAMINA HOOK, WIDE, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.952 SUP Custom 27803010 "124.952 - REVERE LAMINA HOOK, TALL BODY, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.953 SUP Custom 27803010 "124.953 - REVERE LAMINA HOOK, TALL BODY, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.954 SUP Custom 27803010 "124.954 - REVERE LAMINA HOOK, TALL BODY, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.955 SUP Custom 27803010 "124.955 - REVERE ANGLED LAMINA HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.956 SUP Custom 27803010 "124.956 - REVERE ANGLED LAMINA HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.957 SUP Custom 27803010 "124.957 - REVERE ANGLED LAMINA HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.96 SUP Custom 27803010 "124.960 - PARALLEL CONNECTOR, 5.5MM TO 5.5MM" BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.961 SUP Custom 27803010 "124.961 - PARALLEL CONNECTOR, 5.5MM TO 5.5MM, WIDE" BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.962 SUP Custom 27803010 "124.962 - ROD TO ROD CLAMP, 5.5MM TO 5.5MM" BOTH IP/OP "$1,287.50 " $952.75 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.58 $955.58 $0.00 $0.00 $268.32 $0.00 $0.00 $0.00 $0.00 $643.75 "$1,019.70" "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.963 SUP Custom 27803010 "124.963 - ROD TO ROD CLAMP, 5.5MM TO 5.5MM, WIDE" BOTH IP/OP "$1,287.50 " $952.75 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.58 $955.58 $0.00 $0.00 $268.32 $0.00 $0.00 $0.00 $0.00 $643.75 "$1,019.70" "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.964 SUP Custom 27803010 "124.964 - PARALLEL CONNECTOR CLAMP, 5.5MM TO 5.5MM" BOTH IP/OP "$1,287.50 " $952.75 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.58 $955.58 $0.00 $0.00 $268.32 $0.00 $0.00 $0.00 $0.00 $643.75 "$1,019.70" "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.965 SUP Custom 27803010 "124.965 - PARALLEL CONNECTOR CLAMP, 5.5MM TO 5.5MM, WIDE" BOTH IP/OP "$1,287.50 " $952.75 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.58 $955.58 $0.00 $0.00 $268.32 $0.00 $0.00 $0.00 $0.00 $643.75 "$1,019.70" "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.97 SUP Custom 27803010 "124.970 - 5.5MM OFFSET CONNECTOR, 15MM" BOTH IP/OP "$1,145.00 " $847.30 $0.00 $916.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $849.82 $849.82 $0.00 $0.00 $238.62 $0.00 $0.00 $0.00 $0.00 $572.50 $906.84 $916.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.971 SUP Custom 27803010 "124.971 - 5.5MM OFFSET CONNECTOR, 20MM" BOTH IP/OP "$1,145.00 " $847.30 $0.00 $916.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $849.82 $849.82 $0.00 $0.00 $238.62 $0.00 $0.00 $0.00 $0.00 $572.50 $906.84 $916.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.972 SUP Custom 27803010 "124.972 - 5.5MM OFFSET CONNECTOR, 25MM" BOTH IP/OP "$1,145.00 " $847.30 $0.00 $916.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $849.82 $849.82 $0.00 $0.00 $238.62 $0.00 $0.00 $0.00 $0.00 $572.50 $906.84 $916.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.973 SUP Custom 27803010 "124.973 - 5.5MM ROD CLAMP, 100MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.974 SUP Custom 27803010 "124.974 - 5.5MM ROD CLAMP, 120MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.975 SUP Custom 27803010 "124.975 - 5.5MM ROD CLAMP, 150MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.976 SUP Custom 27803010 "124.976 - 5.5MM OFFSET CONNECTOR, 30MM" BOTH IP/OP "$1,287.50 " $952.75 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.58 $955.58 $0.00 $0.00 $268.32 $0.00 $0.00 $0.00 $0.00 $643.75 "$1,019.70" "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.977 SUP Custom 27803010 "124.977 - 5.5MM OFFSET CONNECTOR, 35MM" BOTH IP/OP "$1,287.50 " $952.75 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.58 $955.58 $0.00 $0.00 $268.32 $0.00 $0.00 $0.00 $0.00 $643.75 "$1,019.70" "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.98 SUP Custom 27803010 "124.980 - IN-LINE CONNECTOR, 5.5MM TO 5.5MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.99 SUP Custom 27803010 "124.990 - 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 15MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.991 SUP Custom 27803010 "124.991 - 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 20MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.992 SUP Custom 27803010 "124.992 - 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 25MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.993 SUP Custom 27803010 "124.993 - 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 30MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.994 SUP Custom 27803010 "124.994 - 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 35MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.995 SUP Custom 27803010 "124.995 - 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 100MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.996 SUP Custom 27803010 "124.996 - 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 120MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124.997 SUP Custom 27803010 "124.997 - 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 150MM" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $0.00 $0.00 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129.436 SUP HCPCS C1713 "129.436 - GATEWAY THORACOLUMBAR PLATE, 36MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.438 SUP HCPCS C1713 "129.438 - GATEWAY THORACOLUMBAR PLATE, 38MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.44 SUP HCPCS C1713 "129.440 - GATEWAY THORACOLUMBAR PLATE, 40MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.442 SUP HCPCS C1713 "129.442 - GATEWAY THORACOLUMBAR PLATE, 42MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.444 SUP HCPCS C1713 "129.444 - GATEWAY THORACOLUMBAR PLATE, 44MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.448 SUP HCPCS C1713 "129.448 - GATEWAY THORACOLUMBAR PLATE, 48MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.452 SUP HCPCS C1713 "129.452 - GATEWAY THORACOLUMBAR PLATE, 52MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.456 SUP HCPCS C1713 "129.456 - GATEWAY THORACOLUMBAR PLATE, 56MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.46 SUP HCPCS C1713 "129.460 - GATEWAY THORACOLUMBAR PLATE, 60MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.464 SUP HCPCS C1713 "129.464 - GATEWAY THORACOLUMBAR PLATE, 64MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.468 SUP HCPCS C1713 "129.468 - GATEWAY THORACOLUMBAR PLATE, 68MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.472 SUP HCPCS C1713 "129.472 - GATEWAY THORACOLUMBAR PLATE, 72MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.476 SUP HCPCS C1713 "129.476 - GATEWAY THORACOLUMBAR PLATE, 76MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.48 SUP HCPCS C1713 "129.480 - GATEWAY THORACOLUMBAR PLATE, 80MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.484 SUP HCPCS C1713 "129.484 - GATEWAY THORACOLUMBAR PLATE, 84MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.488 SUP HCPCS C1713 "129.488 - GATEWAY THORACOLUMBAR PLATE, 88MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.492 SUP HCPCS C1713 "129.492 - GATEWAY THORACOLUMBAR PLATE, 92MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.496 SUP HCPCS C1713 "129.496 - GATEWAY THORACOLUMBAR PLATE, 96MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.5 SUP HCPCS C1713 "129.500 - GATEWAY THORACOLUMBAR PLATE, 100MM" BOTH IP/OP "$14,030.00 " "$10,382.20" $0.00 "$11,224.00" "$6,313.50" "$6,313.50" $0.00 $0.00 $0.00 "$2,924.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,923.85" $0.00 "$6,916.79" "$6,916.79" $0.00 "$7,015.00" "$11,111.76" "$11,224.00" $0.00 $0.00 "$2,195.70" $0.00 $0.00 "$2,233.58" $0.00 $0.00 $0.00 $0.00 $0.00 129.65 SUP Custom 27203010 "129.650 - SINGLE STAPLE, 5.0MM" BOTH IP/OP "$1,772.50 " "$1,311.65" $0.00 "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,315.55" "$1,315.55" $0.00 $0.00 $369.39 $0.00 $0.00 $0.00 $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129.655 SUP Custom 27203010 "129.655 - SINGLE STAPLE, 5.5MM" BOTH IP/OP "$1,772.50 " "$1,311.65" $0.00 "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,315.55" "$1,315.55" $0.00 $0.00 $369.39 $0.00 $0.00 $0.00 $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129.665 SUP Custom 27203010 "129.665 - SINGLE STAPLE, 6.5MM" BOTH IP/OP "$1,772.50 " "$1,311.65" $0.00 "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,315.55" "$1,315.55" $0.00 $0.00 $369.39 $0.00 $0.00 $0.00 $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129.675 SUP Custom 27203010 "129.675 - SINGLE STAPLE, 7.5MM" BOTH IP/OP "$1,772.50 " "$1,311.65" $0.00 "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,315.55" "$1,315.55" $0.00 $0.00 $369.39 $0.00 $0.00 $0.00 $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 129.685 SUP Custom 27203010 "129.685 - SINGLE STAPLE, 8.5MM" BOTH IP/OP "$1,772.50 " "$1,311.65" $0.00 "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,315.55" "$1,315.55" $0.00 $0.00 $369.39 $0.00 $0.00 $0.00 $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 130.12 SUP HCPCS C1713 "130.120 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 20MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.122 SUP HCPCS C1713 "130.122 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 22MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.124 SUP HCPCS C1713 "130.124 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 24MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.126 SUP HCPCS C1713 "130.126 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 26MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.128 SUP HCPCS C1713 "130.128 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 28MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.13 SUP HCPCS C1713 "130.130 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 30MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.132 SUP HCPCS C1713 "130.132 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 32MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.134 SUP HCPCS C1713 "130.134 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 34MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.136 SUP HCPCS C1713 "130.136 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 36MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.138 SUP HCPCS C1713 "130.138 - CITADEL ANTERIOR LUMBAR PLATE, 1-LEVEL, 38MM" BOTH IP/OP "$11,635.00 " "$8,609.90" $0.00 "$9,308.00" "$5,235.75" "$5,235.75" $0.00 $0.00 $0.00 "$2,425.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,424.73" $0.00 "$5,736.06" "$5,736.06" $0.00 "$5,817.50" "$9,214.92" "$9,308.00" $0.00 $0.00 "$1,820.88" $0.00 $0.00 "$1,852.29" $0.00 $0.00 $0.00 $0.00 $0.00 130.142 SUP HCPCS C1713 "130.142 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 42MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.148 SUP HCPCS C1713 "130.148 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 48MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.154 SUP HCPCS C1713 "130.154 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 54MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.16 SUP HCPCS C1713 "130.160 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 60MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.163 SUP HCPCS C1713 "130.163 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 63MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.166 SUP HCPCS C1713 "130.166 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 66MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.169 SUP HCPCS C1713 "130.169 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 69MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.172 SUP HCPCS C1713 "130.172 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 72MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.175 SUP HCPCS C1713 "130.175 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 75MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.178 SUP HCPCS C1713 "130.178 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 78MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.181 SUP HCPCS C1713 "130.181 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 81MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.184 SUP HCPCS C1713 "130.184 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 84MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.187 SUP HCPCS C1713 "130.187 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 87MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.19 SUP HCPCS C1713 "130.190 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 90MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.193 SUP HCPCS C1713 "130.193 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 93MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.196 SUP HCPCS C1713 "130.196 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 96MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.199 SUP HCPCS C1713 "130.199 - CITADEL ANTERIOR LUMBAR PLATE, 2-LEVEL, 99MM" BOTH IP/OP "$12,925.00 " "$9,564.50" $0.00 "$10,340.00" "$5,816.25" "$5,816.25" $0.00 $0.00 $0.00 "$2,693.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,693.57" $0.00 "$6,372.03" "$6,372.03" $0.00 "$6,462.50" "$10,236.60" "$10,340.00" $0.00 $0.00 "$2,022.76" $0.00 $0.00 "$2,057.66" $0.00 $0.00 $0.00 $0.00 $0.00 130.22 SUP HCPCS C1713 "130.220 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 1-LEVEL, 20MM" BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.222 SUP HCPCS C1713 "130.222 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 1-LEVEL, 22MM" BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.224 SUP HCPCS C1713 "130.224 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 1-LEVEL, 24MM" BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.226 SUP HCPCS C1713 "130.226 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 1-LEVEL, 26MM" BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.228 SUP HCPCS C1713 "130.228 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 1-LEVEL, 28MM" BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.23 SUP HCPCS C1713 130.230 - PLATE BN 30MM NS CITADEL LVL 1 SPNE LS ANT BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.232 SUP HCPCS C1713 130.232 - PLATE BN 32MM NS CITADEL LVL 1 SPNE LS ANT BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.234 SUP HCPCS C1713 130.234 - PLATE BN 34MM NS CITADEL LVL 1 SPNE LS ANT BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.236 SUP HCPCS C1713 "130.236 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 1-LEVEL, 36MM" BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.238 SUP HCPCS C1713 130.238 - PLATE BN 38MM NS CITADEL LVL 1 SPNE LS ANT BOTH IP/OP "$12,277.50 " "$9,085.35" $0.00 "$9,822.00" "$5,524.88" "$5,524.88" $0.00 $0.00 $0.00 "$2,558.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,558.63" $0.00 "$6,052.81" "$6,052.81" $0.00 "$6,138.75" "$9,723.78" "$9,822.00" $0.00 $0.00 "$1,921.43" $0.00 $0.00 "$1,954.58" $0.00 $0.00 $0.00 $0.00 $0.00 130.263 SUP HCPCS C1713 "130.263 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 63MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.266 SUP HCPCS C1713 "130.266 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 66MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.269 SUP HCPCS C1713 "130.269 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 69MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.272 SUP HCPCS C1713 "130.272 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 72MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.275 SUP HCPCS C1713 "130.275 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 75MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.278 SUP HCPCS C1713 "130.278 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 78MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.281 SUP HCPCS C1713 "130.281 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 81MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.284 SUP HCPCS C1713 "130.284 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 84MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.287 SUP HCPCS C1713 "130.287 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 87MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.29 SUP HCPCS C1713 "130.290 - CITADEL ANTERIOR LUMBOSACRAL PLATE, 2-LEVEL, 90MM" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.501 SUP HCPCS C1713 "130.501 - CLAMPING SET SCREW, 2.25MM" BOTH IP/OP $7.50 $5.55 $0.00 $6.00 $3.38 $3.38 $0.00 $0.00 $0.00 $1.56 $5.57 $5.57 $0.00 $0.00 $1.56 $0.00 $4.44 $4.44 $0.00 $3.75 $5.94 $6.00 $0.00 $0.00 $1.17 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $0.00 130.542 SUP HCPCS C1713 "130.542 - CITADEL ANTERIOR SYMMETRICAL LUMBROSACRAL PLATE, 2-LEVEL, 42" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.548 SUP HCPCS C1713 "130.548 - CITADEL ANTERIOR SYMMETRICAL LUMBROSACRAL PLATE, 2-LEVEL, 48" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.554 SUP HCPCS C1713 "130.554 - CITADEL ANTERIOR SYMMETRICAL LUMBROSACRAL PLATE, 2-LEVEL, 54" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.56 SUP HCPCS C1713 "130.560 - CITADEL ANTERIOR SYMMETRICAL LUMBROSACRAL PLATE, 2-LEVEL, 60" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.566 SUP HCPCS C1713 "130.566 - CITADEL ANTERIOR SYMMETRICAL LUMBROSACRAL PLATE, 2-LEVEL, 66" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.572 SUP HCPCS C1713 "130.572 - CITADEL ANTERIOR SYMMETRICAL LUMBROSACRAL PLATE, 2-LEVEL, 72" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.578 SUP HCPCS C1713 "130.578 - CITADEL ANTERIOR SYMMETRICAL LUMBROSACRAL PLATE, 2-LEVEL, 78" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.584 SUP HCPCS C1713 "130.584 - CITADEL ANTERIOR SYMMETRICAL LUMBROSACRAL PLATE, 2-LEVEL, 84" BOTH IP/OP "$13,572.50 " "$10,043.65" $0.00 "$10,858.00" "$6,107.63" "$6,107.63" $0.00 $0.00 $0.00 "$2,828.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,828.51" $0.00 "$6,691.24" "$6,691.24" $0.00 "$6,786.25" "$10,749.42" "$10,858.00" $0.00 $0.00 "$2,124.10" $0.00 $0.00 "$2,160.74" $0.00 $0.00 $0.00 $0.00 $0.00 130.622 SUP HCPCS C1713 "130.622 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 22MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.624 SUP HCPCS C1713 "130.624 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 24MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.626 SUP HCPCS C1713 "130.626 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 26MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.628 SUP HCPCS C1713 "130.628 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 28MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.63 SUP HCPCS C1713 "130.630 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 30MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.633 SUP HCPCS C1713 "130.633 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 33MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.636 SUP HCPCS C1713 "130.636 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 36MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.639 SUP HCPCS C1713 "130.639 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 39MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.642 SUP HCPCS C1713 "130.642 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 42MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.645 SUP HCPCS C1713 "130.645 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 45MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.648 SUP HCPCS C1713 "130.648 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 48MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.651 SUP HCPCS C1713 "130.651 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 51MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.654 SUP HCPCS C1713 "130.654 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 54MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.657 SUP HCPCS C1713 "130.657 - 6.5MM SELF-TAPPING SCREW, VARIABLE ANGLE, 57MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.822 SUP HCPCS C1713 "130.822 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 22MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.824 SUP HCPCS C1713 "130.824 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 24MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.826 SUP HCPCS C1713 "130.826 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 26MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.828 SUP HCPCS C1713 "130.828 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 28MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.83 SUP HCPCS C1713 "130.830 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 30MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.833 SUP HCPCS C1713 "130.833 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 33MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.836 SUP HCPCS C1713 "130.836 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 36MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.839 SUP HCPCS C1713 "130.839 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 39MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.842 SUP HCPCS C1713 "130.842 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 42MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.845 SUP HCPCS C1713 "130.845 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 45MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.848 SUP HCPCS C1713 "130.848 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 48MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.851 SUP HCPCS C1713 "130.851 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 51MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.854 SUP HCPCS C1713 "130.854 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 54MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 130.857 SUP HCPCS C1713 "130.857 - 6.5MM SELF-TAPPING SCREW, FIXED ANGLE, 57MM" BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $873.00 $873.00 $0.00 $0.00 $0.00 $404.34 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 "$1,147.51" "$1,147.51" $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $303.61 $0.00 $0.00 $308.85 $0.00 $0.00 $0.00 $0.00 $0.00 131.001 SUP Custom 27203010 "131.001 - DUAL STAPLE, SMALL, ROSTRAL" BOTH IP/OP "$2,712.50 " "$2,007.25" $0.00 "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.22" "$2,013.22" $0.00 $0.00 $565.29 $0.00 $0.00 $0.00 $0.00 "$1,356.25" "$2,148.30" "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.002 SUP Custom 27203010 "131.002 - DUAL STAPLE, SMALL, CAUDAL" BOTH IP/OP "$2,712.50 " "$2,007.25" $0.00 "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.22" "$2,013.22" $0.00 $0.00 $565.29 $0.00 $0.00 $0.00 $0.00 "$1,356.25" "$2,148.30" "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.003 SUP Custom 27203010 "131.003 - DUAL STAPLE, MEDIUM, ROSTRAL" BOTH IP/OP "$2,712.50 " "$2,007.25" $0.00 "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.22" "$2,013.22" $0.00 $0.00 $565.29 $0.00 $0.00 $0.00 $0.00 "$1,356.25" "$2,148.30" "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.004 SUP Custom 27203010 "131.004 - DUAL STAPLE, MEDIUM, CAUDAL" BOTH IP/OP "$2,712.50 " "$2,007.25" $0.00 "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.22" "$2,013.22" $0.00 $0.00 $565.29 $0.00 $0.00 $0.00 $0.00 "$1,356.25" "$2,148.30" "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.005 SUP Custom 27203010 "131.005 - DUAL STAPLE, LARGE, ROSTRAL" BOTH IP/OP "$2,712.50 " "$2,007.25" $0.00 "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.22" "$2,013.22" $0.00 $0.00 $565.29 $0.00 $0.00 $0.00 $0.00 "$1,356.25" "$2,148.30" "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.006 SUP Custom 27203010 "131.006 - DUAL STAPLE, LARGE, CAUDAL" BOTH IP/OP "$2,712.50 " "$2,007.25" $0.00 "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.22" "$2,013.22" $0.00 $0.00 $565.29 $0.00 $0.00 $0.00 $0.00 "$1,356.25" "$2,148.30" "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.007 SUP Custom 27203010 "131.007 - DUAL STAPLE, X-LARGE, ROSTRAL" BOTH IP/OP "$2,712.50 " "$2,007.25" $0.00 "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.22" "$2,013.22" $0.00 $0.00 $565.29 $0.00 $0.00 $0.00 $0.00 "$1,356.25" "$2,148.30" "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.008 SUP Custom 27203010 "131.008 - DUAL STAPLE, X-LARGE, CAUDAL" BOTH IP/OP "$2,712.50 " "$2,007.25" $0.00 "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,013.22" "$2,013.22" $0.00 $0.00 $565.29 $0.00 $0.00 $0.00 $0.00 "$1,356.25" "$2,148.30" "$2,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.011 SUP Custom 27203010 "131.011 - SINGLE STAPLE, SMALL" BOTH IP/OP "$1,945.00 " "$1,439.30" $0.00 "$1,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,443.58" "$1,443.58" $0.00 $0.00 $405.34 $0.00 $0.00 $0.00 $0.00 $972.50 "$1,540.44" "$1,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.012 SUP Custom 27203010 "131.012 - SINGLE STAPLE, MEDIUM" BOTH IP/OP "$1,945.00 " "$1,439.30" $0.00 "$1,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,443.58" "$1,443.58" $0.00 $0.00 $405.34 $0.00 $0.00 $0.00 $0.00 $972.50 "$1,540.44" "$1,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.013 SUP Custom 27203010 131.013 - STAPLE BONE LG SGL BOTH IP/OP "$1,945.00 " "$1,439.30" $0.00 "$1,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,443.58" "$1,443.58" $0.00 $0.00 $405.34 $0.00 $0.00 $0.00 $0.00 $972.50 "$1,540.44" "$1,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.113 SUP Custom 27803010 "131.113 - CROSS CONNECTOR, 13MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.114 SUP Custom 27803010 "131.114 - CROSS CONNECTOR, 14MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.115 SUP Custom 27803010 "131.115 - CROSS CONNECTOR, 15MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.116 SUP Custom 27803010 "131.116 - CROSS CONNECTOR, 16MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.117 SUP Custom 27803010 "131.117 - CROSS CONNECTOR, 17MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.118 SUP Custom 27803010 "131.118 - CROSS CONNECTOR, 18MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.119 SUP Custom 27803010 "131.119 - CROSS CONNECTOR, 19MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.12 SUP Custom 27803010 "131.120 - CROSS CONNECTOR, 20MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.121 SUP Custom 27803010 "131.121 - CROSS CONNECTOR, 21MM" BOTH IP/OP "$2,545.00 " "$1,883.30" $0.00 "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.90" "$1,888.90" $0.00 $0.00 $530.38 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.122 SUP Custom 27803010 "131.122 - CROSS CONNECTOR, 22MM" BOTH IP/OP "$2,545.00 " "$1,883.30" $0.00 "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.90" "$1,888.90" $0.00 $0.00 $530.38 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.123 SUP Custom 27803010 "131.123 - CROSS CONNECTOR, 23MM" BOTH IP/OP "$2,545.00 " "$1,883.30" $0.00 "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.90" "$1,888.90" $0.00 $0.00 $530.38 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.124 SUP Custom 27803010 "131.124 - CROSS CONNECTOR, 24MM" BOTH IP/OP "$2,545.00 " "$1,883.30" $0.00 "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.90" "$1,888.90" $0.00 $0.00 $530.38 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.125 SUP Custom 27803010 "131.125 - CROSS CONNECTOR, 25MM" BOTH IP/OP "$2,545.00 " "$1,883.30" $0.00 "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.90" "$1,888.90" $0.00 $0.00 $530.38 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.126 SUP Custom 27803010 "131.126 - CROSS CONNECTOR, 26MM" BOTH IP/OP "$2,545.00 " "$1,883.30" $0.00 "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.90" "$1,888.90" $0.00 $0.00 $530.38 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.127 SUP Custom 27803010 "131.127 - CROSS CONNECTOR, 27MM" BOTH IP/OP "$2,545.00 " "$1,883.30" $0.00 "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.90" "$1,888.90" $0.00 $0.00 $530.38 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.128 SUP Custom 27803010 "131.128 - CROSS CONNECTOR, 28MM" BOTH IP/OP "$2,545.00 " "$1,883.30" $0.00 "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.90" "$1,888.90" $0.00 $0.00 $530.38 $0.00 $0.00 $0.00 $0.00 "$1,272.50" "$2,015.64" "$2,036.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131.201 SUP HCPCS C1713 "131.201 - STAPLE WASHER, SMALL" BOTH IP/OP $722.50 $534.65 $0.00 $578.00 $325.13 $325.13 $0.00 $0.00 $0.00 $150.59 $536.24 $536.24 $0.00 $0.00 $150.57 $0.00 $427.36 $427.36 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $113.07 $0.00 $0.00 $115.02 $0.00 $0.00 $0.00 $0.00 $0.00 131.202 SUP HCPCS C1713 "131.202 - STAPLE WASHER, MEDIUM" BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $358.88 $358.88 $0.00 $0.00 $0.00 $166.22 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $471.72 $471.72 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $124.81 $0.00 $0.00 $126.96 $0.00 $0.00 $0.00 $0.00 $0.00 131.203 SUP HCPCS C1713 "131.203 - STAPLE WASHER, LARGE" BOTH IP/OP $840.00 $621.60 $0.00 $672.00 $378.00 $378.00 $0.00 $0.00 $0.00 $175.08 $623.45 $623.45 $0.00 $0.00 $175.06 $0.00 $496.86 $496.86 $0.00 $420.00 $665.28 $672.00 $0.00 $0.00 $131.46 $0.00 $0.00 $133.73 $0.00 $0.00 $0.00 $0.00 $0.00 131.351 SUP HCPCS C1713 "131.351 - 5.5MM BONE SCREW, ANTERIOR PLATE, 25MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.352 SUP HCPCS C1713 "131.352 - 5.5MM BONE SCREW, ANTERIOR PLATE, 30MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.353 SUP HCPCS C1713 "131.353 - 5.5MM BONE SCREW, ANTERIOR PLATE, 35MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.354 SUP HCPCS C1713 "131.354 - 5.5MM BONE SCREW, ANTERIOR PLATE, 40MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.355 SUP HCPCS C1713 "131.355 - 5.5MM BONE SCREW, ANTERIOR PLATE, 45MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.356 SUP HCPCS C1713 "131.356 - 5.5MM BONE SCREW, ANTERIOR PLATE, 50MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.361 SUP HCPCS C1713 "131.361 - 6.5MM BONE SCREW, ANTERIOR PLATE, 25MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.362 SUP HCPCS C1713 "131.362 - 6.5MM BONE SCREW, ANTERIOR PLATE, 30MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.363 SUP HCPCS C1713 "131.363 - 6.5MM BONE SCREW, ANTERIOR PLATE, 35MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.364 SUP HCPCS C1713 "131.364 - 6.5MM BONE SCREW, ANTERIOR PLATE, 40MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.365 SUP HCPCS C1713 "131.365 - 6.5MM BONE SCREW, ANTERIOR PLATE, 45MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 131.366 SUP HCPCS C1713 "131.366 - 6.5MM BONE SCREW, ANTERIOR PLATE, 50MM" BOTH IP/OP "$1,910.00 " "$1,413.40" $0.00 "$1,528.00" $859.50 $859.50 $0.00 $0.00 $0.00 $398.09 "$1,417.60" "$1,417.60" $0.00 $0.00 $398.04 $0.00 "$1,129.77" "$1,129.77" $0.00 $955.00 "$1,512.72" "$1,528.00" $0.00 $0.00 $298.92 $0.00 $0.00 $304.07 $0.00 $0.00 $0.00 $0.00 $0.00 132.14 SUP Custom 27803010 "132.140 - 5.5MM CURVED ROD, CONE TIP, 40MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.145 SUP Custom 27803010 "132.145 - 5.5MM CURVED ROD, CONE TIP, 45MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.15 SUP Custom 27803010 "132.150 - 5.5MM CURVED ROD, CONE TIP, 50MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.155 SUP Custom 27803010 "132.155 - 5.5MM CURVED ROD, CONE TIP, 55MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.16 SUP Custom 27803010 "132.160 - 5.5MM CURVED ROD, CONE TIP, 60MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.165 SUP Custom 27803010 "132.165 - 5.5MM CURVED ROD, CONE TIP, 65MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.17 SUP Custom 27803010 "132.170 - 5.5MM CURVED ROD, CONE TIP, 70MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.175 SUP Custom 27803010 "132.175 - 5.5MM CURVED ROD, CONE TIP, 75MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.18 SUP Custom 27803010 "132.180 - 5.5MM CURVED ROD, CONE TIP, 80MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132.185 SUP Custom 27803010 "132.185 - 5.5MM CURVED ROD, CONE TIP, 85MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 136.404 SUP HCPCS C1713 "136.404 - RELIEVE 2.2MM SCREW, SELF-DRILLING, 4MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.406 SUP HCPCS C1713 "136.406 - RELIEVE 2.2MM SCREW, SELF-DRILLING, 6MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.408 SUP HCPCS C1713 "136.408 - RELIEVE 2.2MM SCREW, SELF-DRILLING, 8MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.41 SUP HCPCS C1713 "136.410 - RELIEVE 2.2MM SCREW, SELF-DRILLING, 10MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.412 SUP HCPCS C1713 "136.412 - RELIEVE 2.2MM SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.504 SUP HCPCS C1713 "136.504 - RELIEVE 2.2MM SCREW, SELF-TAPPING, 4MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.506 SUP HCPCS C1713 "136.506 - RELIEVE 2.2MM SCREW, SELF-TAPPING, 6MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.508 SUP HCPCS C1713 "136.508 - RELIEVE 2.2MM SCREW, SELF-TAPPING, 8MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.51 SUP HCPCS C1713 "136.510 - RELIEVE 2.2MM SCREW, SELF-TAPPING, 10MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.512 SUP HCPCS C1713 "136.512 - RELIEVE 2.2MM SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 136.704 SUP HCPCS C1713 "136.704 - RELIEVE 2.6MM SCREW, SELF-TAPPING, 4MM" BOTH IP/OP $527.50 $390.35 $0.00 $422.00 $237.38 $237.38 $0.00 $0.00 $0.00 $109.94 $391.51 $391.51 $0.00 $0.00 $109.93 $0.00 $312.02 $312.02 $0.00 $263.75 $417.78 $422.00 $0.00 $0.00 $82.55 $0.00 $0.00 $83.98 $0.00 $0.00 $0.00 $0.00 $0.00 136.706 SUP HCPCS C1713 "136.706 - RELIEVE 2.6MM SCREW, SELF-TAPPING, 6MM" BOTH IP/OP $527.50 $390.35 $0.00 $422.00 $237.38 $237.38 $0.00 $0.00 $0.00 $109.94 $391.51 $391.51 $0.00 $0.00 $109.93 $0.00 $312.02 $312.02 $0.00 $263.75 $417.78 $422.00 $0.00 $0.00 $82.55 $0.00 $0.00 $83.98 $0.00 $0.00 $0.00 $0.00 $0.00 136.708 SUP HCPCS C1713 "136.708 - RELIEVE 2.6MM SCREW, SELF-TAPPING, 8MM" BOTH IP/OP $527.50 $390.35 $0.00 $422.00 $237.38 $237.38 $0.00 $0.00 $0.00 $109.94 $391.51 $391.51 $0.00 $0.00 $109.93 $0.00 $312.02 $312.02 $0.00 $263.75 $417.78 $422.00 $0.00 $0.00 $82.55 $0.00 $0.00 $83.98 $0.00 $0.00 $0.00 $0.00 $0.00 136.71 SUP HCPCS C1713 "136.710 - RELIEVE 2.6MM SCREW, SELF-TAPPING, 10MM" BOTH IP/OP $527.50 $390.35 $0.00 $422.00 $237.38 $237.38 $0.00 $0.00 $0.00 $109.94 $391.51 $391.51 $0.00 $0.00 $109.93 $0.00 $312.02 $312.02 $0.00 $263.75 $417.78 $422.00 $0.00 $0.00 $82.55 $0.00 $0.00 $83.98 $0.00 $0.00 $0.00 $0.00 $0.00 136.712 SUP HCPCS C1713 "136.712 - RELIEVE 2.6MM SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $527.50 $390.35 $0.00 $422.00 $237.38 $237.38 $0.00 $0.00 $0.00 $109.94 $391.51 $391.51 $0.00 $0.00 $109.93 $0.00 $312.02 $312.02 $0.00 $263.75 $417.78 $422.00 $0.00 $0.00 $82.55 $0.00 $0.00 $83.98 $0.00 $0.00 $0.00 $0.00 $0.00 141 SUP Custom 27203010 KIT OSOM STRP GRP A DPSTK CLIA WVD MCBLTST 50 TST BOTH IP/OP $174.90 $129.43 $0.00 $139.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.45 $138.52 $139.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 142 SUP HCPCS A4624 142 - CATHETER SCT 16FR 12FR STRL LF HALYARD DRCT O2 PORT ATRM TIP BOTH IP/OP $109.00 $80.66 $0.00 $88.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.90 $80.90 $0.00 $0.00 $22.72 $0.00 $0.00 $0.00 $0.00 $55.32 $87.63 $88.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 145 SUP Custom 27203010 CONTROL CARD MRKR LQCHK 3LVL 3ML IMMUN BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.01 SUP HCPCS C1713 "150.010 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.011 SUP HCPCS C1713 "150.011 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-DRILLING, 11MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.012 SUP HCPCS C1713 "150.012 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.013 SUP HCPCS C1713 "150.013 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-DRILLING, 13MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.014 SUP HCPCS C1713 150.014 - SCREW BONE 4.2MM 14MM PRTX CTTI OCT SPN SLFDRILL FIXANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.015 SUP HCPCS C1713 "150.015 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-DRILLING, 15MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.016 SUP HCPCS C1713 150.016 - SCREW BN 4.2MM 16MM NS PRTX CTTI SLF DRL FX ANG SPNE OCT PRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.03 SUP HCPCS C1713 "150.030 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.031 SUP HCPCS C1713 "150.031 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 11MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.032 SUP HCPCS C1713 "150.032 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.033 SUP HCPCS C1713 "150.033 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 13MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.034 SUP HCPCS C1713 "150.034 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.035 SUP HCPCS C1713 "150.035 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 15MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.036 SUP HCPCS C1713 "150.036 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.038 SUP HCPCS C1713 "150.038 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.04 SUP HCPCS C1713 "150.040 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.042 SUP HCPCS C1713 "150.042 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 22MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.044 SUP HCPCS C1713 "150.044 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 24MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.046 SUP HCPCS C1713 "150.046 - PROVIDENCE 4.2MM FIXED ANGLE SCREW, SELF-TAPPING 26MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.11 SUP HCPCS C1713 150.110 - PLATE BN 10MM NS PRV LVL 1 SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.112 SUP HCPCS C1713 150.112 - PLATE BN 12MM NS PRV LVL 1 SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.114 SUP HCPCS C1713 150.114 - PLATE BN 14MM NS PRV LVL 1 SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.116 SUP HCPCS C1713 150.116 - PLATE BN 16MM NS PRV LVL 1 SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.118 SUP HCPCS C1713 150.118 - PLATE BN 18MM NS PRV LVL 1 SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.12 SUP HCPCS C1713 "150.120 - PROVIDENCE ANTERIOR CERVICAL PLATE 1-LEVEL, 20MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.122 SUP HCPCS C1713 "150.122 - PROVIDENCE ANTERIOR CERVICAL PLATE 1-LEVEL, 22MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.124 SUP HCPCS C1713 150.124 - PLATE BN 24MM NS PRV LVL 1 SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.126 SUP HCPCS C1713 "150.126 - PROVIDENCE ANTERIOR CERVICAL PLATE 1-LEVEL, 26MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.13 SUP HCPCS C1713 "150.130 - PROVIDENCE ANTERIOR CERVICAL PLATE 1-LEVEL, EXTRA LORDOTIC," BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.132 SUP HCPCS C1713 "150.132 - PROVIDENCE ANTERIOR CERVICAL PLATE 1-LEVEL, EXTRA LORDOTIC," BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.134 SUP HCPCS C1713 "150.134 - PROVIDENCE ANTERIOR CERVICAL PLATE 1-LEVEL, EXTRA LORDOTIC," BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 150.224 SUP HCPCS C1713 150.224 - PLATE BN 24MM NS PRV LVL 2 SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.226 SUP HCPCS C1713 150.226 - PLATE BN 26MM NS PRV LVL 2 SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.228 SUP HCPCS C1713 150.228 - PLATE BN 28MM NS PRV LVL 2 SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.23 SUP HCPCS C1713 150.230 - PLATE BN 30MM NS PRV LVL 2 SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.232 SUP HCPCS C1713 150.232 - PLATE BN 32MM NS PRV 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.234 SUP HCPCS C1713 150.234 - PLATE BN 34MM NS PRV LVL 2 SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.236 SUP HCPCS C1713 150.236 - PLATE BN 36MM NS PRV LVL 2 SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.238 SUP HCPCS C1713 150.238 - PLATE BN 38MM NS PRV LVL 2 SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.24 SUP HCPCS C1713 150.240 - PLATE BN 40MM NS PRV LVL 2 SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.242 SUP HCPCS C1713 "150.242 - PROVIDENCE ANTERIOR CERVICAL PLATE 2-LEVEL, 42MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.244 SUP HCPCS C1713 "150.244 - PROVIDENCE ANTERIOR CERVICAL PLATE 2-LEVEL, 44MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.246 SUP HCPCS C1713 "150.246 - PROVIDENCE ANTERIOR CERVICAL PLATE 2-LEVEL, 46MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.254 SUP HCPCS C1713 "150.254 - PROVIDENCE ANTERIOR CERVICAL PLATE 2-LEVEL, EXTRA LORDOTIC," BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.256 SUP HCPCS C1713 "150.256 - PROVIDENCE ANTERIOR CERVICAL PLATE 2-LEVEL, EXTRA LORDOTIC," BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 150.339 SUP HCPCS C1713 150.339 - PLATE BN 39MM NS PRV LVL 3 SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.342 SUP HCPCS C1713 150.342 - PLATE BN 42MM NS PRV LVL 3 SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.345 SUP HCPCS C1713 150.345 - PLATE BN 45MM NS PRV 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.348 SUP HCPCS C1713 150.348 - PLATE BN 48MM NS PRV LVL 3 SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.351 SUP HCPCS C1713 150.351 - PLATE BN 51MM NS PRV LVL 3 SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.354 SUP HCPCS C1713 150.354 - PLATE BN 54MM NS PRV LVL 3 SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.357 SUP HCPCS C1713 150.357 - PLATE BN 57MM NS PRV LVL 3 SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.36 SUP HCPCS C1713 "150.360 - PROVIDENCE ANTERIOR CERVICAL PLATE 3-LEVEL, 60MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.363 SUP HCPCS C1713 "150.363 - PROVIDENCE ANTERIOR CERVICAL PLATE 3-LEVEL, 63MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.366 SUP HCPCS C1713 150.366 - PLATE BN 66MM NS PRV LVL 3 SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.369 SUP HCPCS C1713 150.369 - PLATE BN 69MM NS PRV LVL 3 SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.379 SUP HCPCS C1713 "150.379 - PROVIDENCE ANTERIOR CERVICAL PLATE 3-LEVEL, EXTRA LORDOTIC," BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 150.46 SUP HCPCS C1713 150.460 - PLATE BN 60MM NS PRV LVL 4 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.463 SUP HCPCS C1713 150.463 - PLATE BN 63MM NS PRV LVL 4 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.466 SUP HCPCS C1713 150.466 - PLATE BN 66MM NS PRV LVL 4 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.469 SUP HCPCS C1713 "150.469 - PROVIDENCE ANTERIOR CERVICAL PLATE 4-LEVEL, 69MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.472 SUP HCPCS C1713 "150.472 - PROVIDENCE ANTERIOR CERVICAL PLATE 4-LEVEL, 72MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.475 SUP HCPCS C1713 "150.475 - PROVIDENCE ANTERIOR CERVICAL PLATE 4-LEVEL, 75MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.478 SUP HCPCS C1713 150.478 - PLATE BN 78MM NS PRV LVL 4 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.481 SUP HCPCS C1713 "150.481 - PROVIDENCE ANTERIOR CERVICAL PLATE 4-LEVEL, 81MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.484 SUP HCPCS C1713 "150.484 - PROVIDENCE ANTERIOR CERVICAL PLATE 4-LEVEL, 84MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.487 SUP HCPCS C1713 "150.487 - PROVIDENCE ANTERIOR CERVICAL PLATE 4-LEVEL, 87MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.49 SUP HCPCS C1713 "150.490 - PROVIDENCE ANTERIOR CERVICAL PLATE 4-LEVEL, 90MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.493 SUP HCPCS C1713 "150.493 - PROVIDENCE ANTERIOR CERVICAL PLATE 4-LEVEL, 93MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.51 SUP HCPCS C1713 "150.510 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.511 SUP HCPCS C1713 "150.511 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 11MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.512 SUP HCPCS C1713 "150.512 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.513 SUP HCPCS C1713 "150.513 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 13MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.514 SUP HCPCS C1713 "150.514 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.515 SUP HCPCS C1713 "150.515 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 15MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.516 SUP HCPCS C1713 150.516 - SCREW BN 4.6MM 16MM NS PRTX CTTI SLF DRL FX ANG SPNE OCT PRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.53 SUP HCPCS C1713 "150.530 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.531 SUP HCPCS C1713 "150.531 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 11MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.532 SUP HCPCS C1713 "150.532 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.533 SUP HCPCS C1713 "150.533 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 13MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.534 SUP HCPCS C1713 "150.534 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.535 SUP HCPCS C1713 "150.535 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 15MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.536 SUP HCPCS C1713 "150.536 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.538 SUP HCPCS C1713 "150.538 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.54 SUP HCPCS C1713 "150.540 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.542 SUP HCPCS C1713 "150.542 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 22MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.544 SUP HCPCS C1713 "150.544 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 24MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.546 SUP HCPCS C1713 "150.546 - PROVIDENCE 4.6MM FIXED ANGLE SCREW, SELF-TAPPING 26MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.58 SUP HCPCS C1713 "150.580 - PROVIDENCE ANTERIOR CERVICAL PLATE 5-LEVEL, 80MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.583 SUP HCPCS C1713 "150.583 - PROVIDENCE ANTERIOR CERVICAL PLATE 5-LEVEL, 83MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.586 SUP HCPCS C1713 "150.586 - PROVIDENCE ANTERIOR CERVICAL PLATE 5-LEVEL, 86MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.589 SUP HCPCS C1713 "150.589 - PROVIDENCE ANTERIOR CERVICAL PLATE 5-LEVEL, 89MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.592 SUP HCPCS C1713 "150.592 - PROVIDENCE ANTERIOR CERVICAL PLATE 5-LEVEL, 92MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.595 SUP HCPCS C1713 150.595 - PLATE BN 95MM NS PRV LVL 5 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.598 SUP HCPCS C1713 "150.598 - PROVIDENCE ANTERIOR CERVICAL PLATE 5-LEVEL, 98MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.601 SUP HCPCS C1713 "150.601 - PROVIDENCE ANTERIOR CERVICAL PLATE 5-LEVEL, 101MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.604 SUP HCPCS C1713 "150.604 - PROVIDENCE ANTERIOR CERVICAL PLATE 5-LEVEL, 104MM" BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 150.61 SUP HCPCS C1713 "150.610 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.611 SUP HCPCS C1713 "150.611 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-DRILLING, 11MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.612 SUP HCPCS C1713 "150.612 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.613 SUP HCPCS C1713 "150.613 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-DRILLING, 13MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.614 SUP HCPCS C1713 150.614 - SCREW BONE 4.2MM 14MM PRTX CT SPNL SLFDRILL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.615 SUP HCPCS C1713 "150.615 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-DRILLING, 15MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.616 SUP HCPCS C1713 150.616 - SCREW BN 4.2MM 16MM NS PRTX CTTI SLF DRL VA SPNE OCT PRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.618 SUP HCPCS C1713 "150.618 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-DRILLING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.71 SUP HCPCS C1713 "150.710 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.711 SUP HCPCS C1713 "150.711 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 11MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.712 SUP HCPCS C1713 "150.712 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.713 SUP HCPCS C1713 "150.713 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 13MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.714 SUP HCPCS C1713 "150.714 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.715 SUP HCPCS C1713 "150.715 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 15MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.716 SUP HCPCS C1713 150.716 - SCREW BONE 4.6MM 16MM PRTX CTTI OCT SPN SLFDRILL VAR ANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.81 SUP HCPCS C1713 "150.810 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.811 SUP HCPCS C1713 "150.811 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 11MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.812 SUP HCPCS C1713 "150.812 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.813 SUP HCPCS C1713 "150.813 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 13MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.814 SUP HCPCS C1713 "150.814 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.815 SUP HCPCS C1713 "150.815 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 15MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.816 SUP HCPCS C1713 "150.816 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.818 SUP HCPCS C1713 "150.818 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.82 SUP HCPCS C1713 "150.820 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.822 SUP HCPCS C1713 "150.822 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 22MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.824 SUP HCPCS C1713 "150.824 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 24MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.826 SUP HCPCS C1713 "150.826 - PROVIDENCE 4.2MM VARIABLE ANGLE SCREW, SELF-TAPPING 26MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.91 SUP HCPCS C1713 "150.910 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.911 SUP HCPCS C1713 "150.911 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 11MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.912 SUP HCPCS C1713 "150.912 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.913 SUP HCPCS C1713 "150.913 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 13MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.914 SUP HCPCS C1713 "150.914 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.915 SUP HCPCS C1713 "150.915 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 15MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.916 SUP HCPCS C1713 "150.916 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.918 SUP HCPCS C1713 "150.918 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.92 SUP HCPCS C1713 "150.920 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.922 SUP HCPCS C1713 "150.922 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 22MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.924 SUP HCPCS C1713 "150.924 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 24MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 150.926 SUP HCPCS C1713 "150.926 - PROVIDENCE 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING 26MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 151 SUP Custom 27203010 MARKER RAD A-SPOT LT IMG SEE THR PALPABLE MASS 3ANG MAMGR BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.001 SUP Custom 27803010 151.001 - SPACER SPNL 0D 12MM 12X15MM NS LF FORTIFY NO SPK BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.002 SUP Custom 27803010 151.002 - SPACER SPNL 0D 12MM 12X16MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.003 SUP Custom 27803010 151.003 - SPACER SPNL 3.5D 12MM 12X16MM NS LF FORTIFY NO SPK BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.004 SUP Custom 27803010 151.004 - SPACER SPNL 3.5D 12MM 12X17MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.05 SUP Custom 27803010 151.050 - SPACER SPNL 12MM 12X18MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.051 SUP Custom 27803010 151.051 - SPACER SPNL 12MM 12X19MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.052 SUP Custom 27803010 151.052 - SPACER SPNL 12MM 12X21MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.053 SUP Custom 27803010 151.053 - SPACER SPNL 12MM 12X25MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.054 SUP Custom 27803010 151.054 - SPACER SPNL 12MM 12X33MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.055 SUP Custom 27803010 151.055 - SPACER SPNL 12MM 12X48MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.056 SUP Custom 27803010 151.056 - SPACER SPNL 12MM 12X67MM NS LF FORTIFY BOTH IP/OP "$16,080.00 " "$11,899.20" $0.00 "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,351.07" $0.00 $0.00 $0.00 $0.00 "$8,040.00" "$12,735.36" "$12,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.15 SUP Custom 27803010 151.150 - SPACER SPNL 20MM 20X23MM NS LF FORTIFY BOTH IP/OP "$21,100.00 " "$15,614.00" $0.00 "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,397.24" $0.00 $0.00 $0.00 $0.00 "$10,550.00" "$16,711.20" "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.151 SUP Custom 27803010 151.151 - SPACER SPNL 20MM 20X26MM NS LF FORTIFY BOTH IP/OP "$21,100.00 " "$15,614.00" $0.00 "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,397.24" $0.00 $0.00 $0.00 $0.00 "$10,550.00" "$16,711.20" "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.152 SUP Custom 27803010 151.152 - SPACER SPNL 20MM 20X31MM NS LF FORTIFY BOTH IP/OP "$21,100.00 " "$15,614.00" $0.00 "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,397.24" $0.00 $0.00 $0.00 $0.00 "$10,550.00" "$16,711.20" "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.153 SUP Custom 27803010 151.153 - SPACER SPNL 20MM 20X41MM NS LF FORTIFY BOTH IP/OP "$21,100.00 " "$15,614.00" $0.00 "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,397.24" $0.00 $0.00 $0.00 $0.00 "$10,550.00" "$16,711.20" "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.154 SUP Custom 27803010 151.154 - SPACER SPNL 20MM 20X62MM NS LF FORTIFY BOTH IP/OP "$21,100.00 " "$15,614.00" $0.00 "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,397.24" $0.00 $0.00 $0.00 $0.00 "$10,550.00" "$16,711.20" "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.155 SUP Custom 27803010 151.155 - SPACER SPNL 20MM 20X90MM NS LF FORTIFY BOTH IP/OP "$21,100.00 " "$15,614.00" $0.00 "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,397.24" $0.00 $0.00 $0.00 $0.00 "$10,550.00" "$16,711.20" "$16,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151.32 SUP HCPCS C1713 151.320 - SPACER SPNL 0D 12MM 14X12MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.321 SUP HCPCS C1713 151.321 - SPACER SPNL 0D 12MM 14X12MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.322 SUP HCPCS C1713 151.322 - SPACER SPNL 3.5D 12MM 14X12MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.323 SUP HCPCS C1713 151.323 - SPACER SPNL 3.5D 12MM 14X12MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.324 SUP HCPCS C1713 151.324 - SPACER SPNL 7D 12MM 14X12MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.331 SUP HCPCS C1713 151.331 - SPACER SPNL 0D 15MM 18X12MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.333 SUP HCPCS C1713 151.333 - SPACER SPNL 3.5D 15MM 18X12MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.334 SUP HCPCS C1713 151.334 - SPACER SPNL 7D 15MM 18X12MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.371 SUP HCPCS C1713 151.371 - SPACER SPNL 0D 12MM 14X12MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.373 SUP HCPCS C1713 151.373 - SPACER SPNL 3.5D 12MM 14X12MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.374 SUP HCPCS C1713 151.374 - SPACER SPNL 7D 12MM 14X12MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.381 SUP HCPCS C1713 151.381 - SPACER SPNL 0D 15MM 18X12MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.383 SUP HCPCS C1713 151.383 - SPACER SPNL 3.5D 15MM 18X12MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.384 SUP HCPCS C1713 151.384 - SPACER SPNL 7D 15MM 18X12MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.401 SUP HCPCS C1713 151.401 - SPACER SPNL 0D 20MM 20X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.403 SUP HCPCS C1713 151.403 - SPACER SPNL 4D 20MM 20X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.404 SUP HCPCS C1713 151.404 - SPACER SPNL 8D 20MM 20X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.411 SUP HCPCS C1713 151.411 - SPACER SPNL 0D 21MM 23X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.413 SUP HCPCS C1713 151.413 - SPACER SPNL 4D 21MM 23X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.414 SUP HCPCS C1713 151.414 - SPACER SPNL 8D 21MM 23X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.431 SUP HCPCS C1713 151.431 - SPACER SPNL 0D 25MM 30X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.433 SUP HCPCS C1713 151.433 - SPACER SPNL 4D 25MM 30X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.434 SUP HCPCS C1713 151.434 - SPACER SPNL 8D 25MM 30X20MM NS LF FORTIFY FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.451 SUP HCPCS C1713 151.451 - SPACER SPNL 0D 20MM 20X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.453 SUP HCPCS C1713 151.453 - SPACER SPNL 4D 20MM 20X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.454 SUP HCPCS C1713 151.454 - SPACER SPNL 8D 20MM 20X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.461 SUP HCPCS C1713 151.461 - SPACER SPNL 0D 21MM 23X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.463 SUP HCPCS C1713 151.463 - SPACER SPNL 4D 21MM 23X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.464 SUP HCPCS C1713 151.464 - SPACER SPNL 8D 21MM 23X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.481 SUP HCPCS C1713 151.481 - SPACER SPNL 0D 25MM 30X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.483 SUP HCPCS C1713 151.483 - SPACER SPNL 4D 25MM 30X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.484 SUP HCPCS C1713 151.484 - SPACER SPNL 8D 25MM 30X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.485 SUP HCPCS C1713 151.485 - SPACER SPNL 12D 25MM 30X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.486 SUP HCPCS C1713 151.486 - SPACER SPNL 16D 25MM 30X20MM NS LF FORTIFY FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.601 SUP HCPCS C1713 151.601 - SPACER SPNL 0D 22MM 40X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.603 SUP HCPCS C1713 151.603 - SPACER SPNL 4D 22MM 40X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.604 SUP HCPCS C1713 151.604 - SPACER SPNL 8D 22MM 40X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.605 SUP HCPCS C1713 151.605 - SPACER SPNL 12D 22MM 40X20MM NS LF FORTIFY UPR EPLT SGTL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.611 SUP HCPCS C1713 151.611 - SPACER SPNL 0D 22MM 45X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.613 SUP HCPCS C1713 151.613 - SPACER SPNL 4D 22MM 45X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.614 SUP HCPCS C1713 151.614 - SPACER SPNL 8D 22MM 45X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.615 SUP HCPCS C1713 151.615 - SPACER SPNL 12D 22MM 45X20MM NS LF FORTIFY UPR EPLT SGTL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.621 SUP HCPCS C1713 151.621 - SPACER SPNL 0D 22MM 50X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.623 SUP HCPCS C1713 151.623 - SPACER SPNL 4D 22MM 50X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.624 SUP HCPCS C1713 151.624 - SPACER SPNL 8D 22MM 50X20MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.625 SUP HCPCS C1713 151.625 - SPACER SPNL 12D 22MM 50X20MM NS LF FORTIFY UPR EPLT SGTL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.651 SUP HCPCS C1713 151.651 - SPACER SPNL 0D 22MM 40X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.653 SUP HCPCS C1713 151.653 - SPACER SPNL 4D 22MM 40X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.654 SUP HCPCS C1713 151.654 - SPACER SPNL 8D 22MM 40X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.655 SUP HCPCS C1713 151.655 - SPACER SPNL 12D 22MM 40X20MM NS LF FORTIFY LWR EPLT SGTL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.661 SUP HCPCS C1713 151.661 - SPACER SPNL 0D 22MM 45X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.663 SUP HCPCS C1713 151.663 - SPACER SPNL 4D 22MM 45X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.664 SUP HCPCS C1713 151.664 - SPACER SPNL 8D 22MM 45X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.665 SUP HCPCS C1713 151.665 - SPACER SPNL 12D 22MM 45X20MM NS LF FORTIFY LWR EPLT SGTL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.671 SUP HCPCS C1713 151.671 - SPACER SPNL 0D 22MM 50X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.673 SUP HCPCS C1713 151.673 - SPACER SPNL 4D 22MM 50X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.674 SUP HCPCS C1713 151.674 - SPACER SPNL 8D 22MM 50X20MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.675 SUP HCPCS C1713 151.675 - SPACER SPNL 12D 22MM 50X20MM NS LF FORTIFY LWR EPLT SGTL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 151.701 SUP HCPCS C1713 151.701 - SPACER SPNL 0D 14MM 16X12MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.703 SUP HCPCS C1713 151.703 - SPACER SPNL 3.5D 14MM 16X12MM NS LF FORTIFY UPR EPLT SGTL BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.704 SUP HCPCS C1713 151.704 - SPACER SPNL 7D 14MM 16X12MM NS LF FORTIFY UPR EPLT SGTL PRFL BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.751 SUP HCPCS C1713 151.751 - SPACER SPNL 0D 14MM 16X12MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.753 SUP HCPCS C1713 151.753 - SPACER SPNL 3.5D 14MM 16X12MM NS LF FORTIFY LWR EPLT SGTL BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 151.754 SUP HCPCS C1713 151.754 - SPACER SPNL 7D 14MM 16X12MM NS LF FORTIFY LWR EPLT SGTL PRFL BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 154.7 SUP Custom 27803010 "154.700 - REVERE IN-LINE EXTENSION CLAMP, 5.5MM-6.0MM, 5.5MM ROD, LEFT" BOTH IP/OP "$10,800.00 " "$7,992.00" $0.00 "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,250.72" $0.00 $0.00 $0.00 $0.00 "$5,400.00" "$8,553.60" "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.705 SUP Custom 27803010 "154.705 - REVERE IN-LINE EXTENSION CLAMP, 5.5MM-6.0MM, 5.5MM ROD, RIGH" BOTH IP/OP "$10,800.00 " "$7,992.00" $0.00 "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,250.72" $0.00 $0.00 $0.00 $0.00 "$5,400.00" "$8,553.60" "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.71 SUP Custom 27803010 "154.710 - REVERE IN-LINE EXTENSION CLAMP, 6.0MM-6.5MM, 5.5MM ROD, LEFT" BOTH IP/OP "$10,800.00 " "$7,992.00" $0.00 "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,250.72" $0.00 $0.00 $0.00 $0.00 "$5,400.00" "$8,553.60" "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.715 SUP Custom 27803010 "154.715 - REVERE IN-LINE EXTENSION CLAMP, 6.0MM-6.5MM, 5.5MM ROD, RIGH" BOTH IP/OP "$10,800.00 " "$7,992.00" $0.00 "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,250.72" $0.00 $0.00 $0.00 $0.00 "$5,400.00" "$8,553.60" "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.72 SUP Custom 27803010 "154.720 - REVERE OFFSET EXTENSION CLAMP, 5.5MM-6.0MM, 5.5MM ROD, LEFT," BOTH IP/OP "$10,800.00 " "$7,992.00" $0.00 "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,250.72" $0.00 $0.00 $0.00 $0.00 "$5,400.00" "$8,553.60" "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.725 SUP Custom 27803010 "154.725 - REVERE OFFSET EXTENSION CLAMP, 5.5MM-6.0MM, 5.5MM ROD, RIGHT" BOTH IP/OP "$10,800.00 " "$7,992.00" $0.00 "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,250.72" $0.00 $0.00 $0.00 $0.00 "$5,400.00" "$8,553.60" "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.73 SUP Custom 27803010 "154.730 - REVERE OFFSET EXTENSION CLAMP, 6.0MM-6.5MM, 5.5MM ROD, LEFT," BOTH IP/OP "$10,800.00 " "$7,992.00" $0.00 "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,250.72" $0.00 $0.00 $0.00 $0.00 "$5,400.00" "$8,553.60" "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.735 SUP Custom 27803010 "154.735 - REVERE OFFSET EXTENSION CLAMP, 6.0MM-6.5MM, 5.5MM ROD, RIGHT" BOTH IP/OP "$10,800.00 " "$7,992.00" $0.00 "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,250.72" $0.00 $0.00 $0.00 $0.00 "$5,400.00" "$8,553.60" "$8,640.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.74 SUP Custom 27803010 "154.740 - REVERE Y OFFSET CONNECTOR, 5.5MM-6.0MM" BOTH IP/OP "$2,620.00 " "$1,938.80" $0.00 "$2,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,944.56" "$1,944.56" $0.00 $0.00 $546.01 $0.00 $0.00 $0.00 $0.00 "$1,310.00" "$2,075.04" "$2,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.745 SUP Custom 27803010 "154.745 - REVERE Y OFFSET CONNECTOR, 6.0MM-6.5MM" BOTH IP/OP "$2,620.00 " "$1,938.80" $0.00 "$2,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,944.56" "$1,944.56" $0.00 $0.00 $546.01 $0.00 $0.00 $0.00 $0.00 "$1,310.00" "$2,075.04" "$2,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.754 SUP Custom 27803010 "154.754 - PARALLEL CONNECTOR CLAMP, 5.5MM TO 6.5MM, SINGLE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.756 SUP Custom 27803010 "154.756 - PARALLEL CONNECTOR CLAMP, 5.5MM TO 6.5MM, 18MM WIDE, SINGLE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.758 SUP Custom 27803010 "154.758 - ROD TO ROD CLAMP, 5.5MM TO 5.5MM, SINGLE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.76 SUP Custom 27803010 "154.760 - ROD TO ROD CLAMP, 5.5MM TO 5.5MM, 18MM WIDE, SINGLE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.854 SUP Custom 27803010 "154.854 - PARALLEL CONNECTOR CLAMP, 6.5MM TO 6.5MM, SINGLE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.856 SUP Custom 27803010 "154.856 - PARALLEL CONNECTOR CLAMP, 6.5MM TO 6.5MM, 18MM WIDE, SINGLE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.858 SUP Custom 27803010 "154.858 - ROD TO ROD CLAMP, 6.5MM TO 6.5MM, SINGLE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.86 SUP Custom 27803010 "154.860 - ROD TO ROD CLAMP, 6.5MM TO 6.5MM, 18MM WIDE, SINGLE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.862 SUP Custom 27803010 "154.862 - ROD TO ROD CLAMP, 5.5MM TO 6.5MM" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.864 SUP Custom 27803010 "154.864 - ROD TO ROD CLAMP, 5.5MM TO 6.5MM, WIDE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.865 SUP Custom 27803010 "154.865 - ROD TO ROD CLAMP ASSEMBLY, 5.5MM TO 6.5MM, 18MM WIDE" BOTH IP/OP "$1,445.00 " "$1,069.30" $0.00 "$1,156.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,072.48" "$1,072.48" $0.00 $0.00 $301.14 $0.00 $0.00 $0.00 $0.00 $722.50 "$1,144.44" "$1,156.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.866 SUP Custom 27803010 "154.866 - PARALLEL CONNECTOR CLAMP, 6.5MM TO 6.5MM" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.868 SUP Custom 27803010 "154.868 - PARALLEL CONNECTOR CLAMP, 6.5MM TO 6.5MM WIDE" BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 154.869 SUP Custom 27803010 "154.869 - PARALLEL CONNECTOR CLAMP ASSEMBLY, 6.5MM TO 6.5MM, 18MM WIDE" BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 $0.00 $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.051 SUP HCPCS C1713 "155.051 - BEACON 5.0MM POSTED SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.052 SUP HCPCS C1713 "155.052 - BEACON 5.0MM POSTED SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.053 SUP HCPCS C1713 "155.053 - BEACON 5.0MM POSTED SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.054 SUP HCPCS C1713 "155.054 - BEACON 5.0MM POSTED SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.055 SUP HCPCS C1713 "155.055 - BEACON 5.0MM POSTED SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.056 SUP HCPCS C1713 "155.056 - BEACON 5.0MM POSTED SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.057 SUP HCPCS C1713 "155.057 - BEACON 5.0MM POSTED SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.071 SUP HCPCS C1713 "155.071 - BEACON 7.5MM POSTED SCREW, 70MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.072 SUP HCPCS C1713 "155.072 - BEACON 7.5MM POSTED SCREW, 75MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.073 SUP HCPCS C1713 "155.073 - BEACON 7.5MM POSTED SCREW, 80MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.074 SUP HCPCS C1713 "155.074 - BEACON 7.5MM POSTED SCREW, 85MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.075 SUP HCPCS C1713 "155.075 - BEACON 7.5MM POSTED SCREW, 90MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.081 SUP HCPCS C1713 "155.081 - BEACON 8.5MM POSTED SCREW, 70MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.082 SUP HCPCS C1713 "155.082 - BEACON 8.5MM POSTED SCREW, 75MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.083 SUP HCPCS C1713 "155.083 - BEACON 8.5MM POSTED SCREW, 80MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.084 SUP HCPCS C1713 "155.084 - BEACON 8.5MM POSTED SCREW, 85MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.085 SUP HCPCS C1713 "155.085 - BEACON 8.5MM POSTED SCREW, 90MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.091 SUP HCPCS C1713 "155.091 - BEACON 9.5MM POSTED SCREW, 70MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.092 SUP HCPCS C1713 "155.092 - BEACON 9.5MM POSTED SCREW, 75MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.093 SUP HCPCS C1713 "155.093 - BEACON 9.5MM POSTED SCREW, 80MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.094 SUP HCPCS C1713 "155.094 - BEACON 9.5MM POSTED SCREW, 85MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.095 SUP HCPCS C1713 "155.095 - BEACON 9.5MM POSTED SCREW, 90MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.101 SUP Custom 27803010 "155.101 - BEACON 5.5MM STRAIGHT CLAMP, LARGE" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.102 SUP Custom 27803010 "155.102 - BEACON 5.5MM STRAIGHT CLAMP, MEDIUM" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.103 SUP Custom 27803010 "155.103 - BEACON 5.5MM STRAIGHT CLAMP, SMALL" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.104 SUP Custom 27803010 "155.104 - BEACON 5.5MM LEFT OFFSET CLAMP, LARGE" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.105 SUP Custom 27803010 "155.105 - BEACON 5.5MM LEFT OFFSET CLAMP, MEDIUM" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.106 SUP Custom 27803010 "155.106 - BEACON 5.5MM LEFT OFFSET CLAMP, SMALL" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.107 SUP Custom 27803010 "155.107 - BEACON 5.5MM RIGHT OFFSET CLAMP, LARGE" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.108 SUP Custom 27803010 "155.108 - BEACON 5.5MM RIGHT OFFSET CLAMP, MEDIUM" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.109 SUP Custom 27803010 "155.109 - BEACON 5.5MM RIGHT OFFSET CLAMP, SMALL" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.111 SUP Custom 27803010 "155.111 - BEACON 6.35MM STRAIGHT CLAMP, LARGE" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.112 SUP Custom 27803010 "155.112 - BEACON 6.35MM STRAIGHT CLAMP, MEDIUM" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.113 SUP Custom 27803010 "155.113 - BEACON 6.35MM STRAIGHT CLAMP, SMALL" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.114 SUP Custom 27803010 "155.114 - BEACON 6.35MM LEFT OFFSET CLAMP, LARGE" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.115 SUP Custom 27803010 "155.115 - BEACON 6.35MM LEFT OFFSET CLAMP, MEDIUM" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.116 SUP Custom 27803010 "155.116 - BEACON 6.35MM LEFT OFFSET CLAMP, SMALL" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.117 SUP Custom 27803010 "155.117 - BEACON 6.35MM RIGHT OFFSET CLAMP, LARGE" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.118 SUP Custom 27803010 "155.118 - BEACON 6.35MM RIGHT OFFSET CLAMP, MEDIUM" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.119 SUP Custom 27803010 "155.119 - BEACON 6.35MM RIGHT OFFSET CLAMP, SMALL" BOTH IP/OP "$4,995.00 " "$3,696.30" $0.00 "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,707.29" "$3,707.29" $0.00 $0.00 "$1,040.96" $0.00 $0.00 $0.00 $0.00 "$2,497.50" "$3,956.04" "$3,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.151 SUP HCPCS C1713 "155.151 - BEACON 5.0MM REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.152 SUP HCPCS C1713 "155.152 - BEACON 5.0MM REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.153 SUP HCPCS C1713 "155.153 - BEACON 5.0MM REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.154 SUP HCPCS C1713 "155.154 - BEACON 5.0MM REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.155 SUP HCPCS C1713 "155.155 - BEACON 5.0MM REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.156 SUP HCPCS C1713 "155.156 - BEACON 5.0MM REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.157 SUP HCPCS C1713 "155.157 - BEACON 5.0MM REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.171 SUP HCPCS C1713 "155.171 - BEACON 7.5MM REDUCTION SCREW, 70MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.172 SUP HCPCS C1713 "155.172 - BEACON 7.5MM REDUCTION SCREW, 75MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.173 SUP HCPCS C1713 "155.173 - BEACON 7.5MM REDUCTION SCREW, 80MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.174 SUP HCPCS C1713 "155.174 - BEACON 7.5MM REDUCTION SCREW, 85MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.175 SUP HCPCS C1713 "155.175 - BEACON 7.5MM REDUCTION SCREW, 90MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.181 SUP HCPCS C1713 "155.181 - BEACON 8.5MM REDUCTION SCREW, 70MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.182 SUP HCPCS C1713 "155.182 - BEACON 8.5MM REDUCTION SCREW, 75MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.183 SUP HCPCS C1713 "155.183 - BEACON 8.5MM REDUCTION SCREW, 80MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.184 SUP HCPCS C1713 "155.184 - BEACON 8.5MM REDUCTION SCREW, 85MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.185 SUP HCPCS C1713 "155.185 - BEACON 8.5MM REDUCTION SCREW, 90MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.341 SUP HCPCS C1713 "155.341 - BEACON 4.5MM REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.342 SUP HCPCS C1713 "155.342 - BEACON 4.5MM REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.343 SUP HCPCS C1713 "155.343 - BEACON 4.5MM REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.344 SUP HCPCS C1713 "155.344 - BEACON 4.5MM REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.345 SUP HCPCS C1713 "155.345 - BEACON 4.5MM REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.351 SUP HCPCS C1713 "155.351 - BEACON 5.5MM REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.352 SUP HCPCS C1713 "155.352 - BEACON 5.5MM REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.353 SUP HCPCS C1713 "155.353 - BEACON 5.5MM REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.354 SUP HCPCS C1713 "155.354 - BEACON 5.5MM REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.355 SUP HCPCS C1713 "155.355 - BEACON 5.5MM REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.356 SUP HCPCS C1713 "155.356 - BEACON 5.5MM REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.357 SUP HCPCS C1713 "155.357 - BEACON 5.5MM REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.361 SUP HCPCS C1713 "155.361 - BEACON 6.5MM REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.362 SUP HCPCS C1713 "155.362 - BEACON 6.5MM REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.363 SUP HCPCS C1713 "155.363 - BEACON 6.5MM REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.364 SUP HCPCS C1713 "155.364 - BEACON 6.5MM REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.365 SUP HCPCS C1713 "155.365 - BEACON 6.5MM REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.366 SUP HCPCS C1713 "155.366 - BEACON 6.5MM REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.367 SUP HCPCS C1713 "155.367 - BEACON 6.5MM REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.368 SUP HCPCS C1713 "155.368 - BEACON 6.5MM REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.369 SUP HCPCS C1713 "155.369 - BEACON 6.5MM REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.371 SUP HCPCS C1713 "155.371 - BEACON 7.5MM REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.372 SUP HCPCS C1713 "155.372 - BEACON 7.5MM REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.373 SUP HCPCS C1713 "155.373 - BEACON 7.5MM REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.374 SUP HCPCS C1713 "155.374 - BEACON 7.5MM REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.375 SUP HCPCS C1713 "155.375 - BEACON 7.5MM REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.376 SUP HCPCS C1713 "155.376 - BEACON 7.5MM REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.377 SUP HCPCS C1713 "155.377 - BEACON 7.5MM REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.378 SUP HCPCS C1713 "155.378 - BEACON 7.5MM REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.379 SUP HCPCS C1713 "155.379 - BEACON 7.5MM REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.381 SUP HCPCS C1713 "155.381 - BEACON 8.5MM REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.382 SUP HCPCS C1713 "155.382 - BEACON 8.5MM REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.383 SUP HCPCS C1713 "155.383 - BEACON 8.5MM REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.384 SUP HCPCS C1713 "155.384 - BEACON 8.5MM REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.385 SUP HCPCS C1713 "155.385 - BEACON 8.5MM REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.386 SUP HCPCS C1713 "155.386 - BEACON 8.5MM REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.387 SUP HCPCS C1713 "155.387 - BEACON 8.5MM REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.388 SUP HCPCS C1713 "155.388 - BEACON 8.5MM REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.389 SUP HCPCS C1713 "155.389 - BEACON 8.5MM REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 155.441 SUP HCPCS C1713 "155.441 - BEACON 4.5MM POSTED SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.442 SUP HCPCS C1713 "155.442 - BEACON 4.5MM POSTED SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.443 SUP HCPCS C1713 "155.443 - BEACON 4.5MM POSTED SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.444 SUP HCPCS C1713 "155.444 - BEACON 4.5MM POSTED SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.445 SUP HCPCS C1713 "155.445 - BEACON 4.5MM POSTED SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.451 SUP HCPCS C1713 "155.451 - BEACON 5.5MM POSTED SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.452 SUP HCPCS C1713 "155.452 - BEACON 5.5MM POSTED SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.453 SUP HCPCS C1713 "155.453 - BEACON 5.5MM POSTED SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.454 SUP HCPCS C1713 "155.454 - BEACON 5.5MM POSTED SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.455 SUP HCPCS C1713 "155.455 - BEACON 5.5MM POSTED SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.456 SUP HCPCS C1713 "155.456 - BEACON 5.5MM POSTED SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.457 SUP HCPCS C1713 "155.457 - BEACON 5.5MM POSTED SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.461 SUP HCPCS C1713 "155.461 - BEACON 6.5MM POSTED SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.462 SUP HCPCS C1713 "155.462 - BEACON 6.5MM POSTED SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.463 SUP HCPCS C1713 "155.463 - BEACON 6.5MM POSTED SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.464 SUP HCPCS C1713 "155.464 - BEACON 6.5MM POSTED SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.465 SUP HCPCS C1713 "155.465 - BEACON 6.5MM POSTED SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.466 SUP HCPCS C1713 "155.466 - BEACON 6.5MM POSTED SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.467 SUP HCPCS C1713 "155.467 - BEACON 6.5MM POSTED SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.468 SUP HCPCS C1713 "155.468 - BEACON 6.5MM POSTED SCREW, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.469 SUP HCPCS C1713 "155.469 - BEACON 6.5MM POSTED SCREW, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.471 SUP HCPCS C1713 "155.471 - BEACON 7.5MM POSTED SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.472 SUP HCPCS C1713 "155.472 - BEACON 7.5MM POSTED SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.473 SUP HCPCS C1713 "155.473 - BEACON 7.5MM POSTED SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.474 SUP HCPCS C1713 "155.474 - BEACON 7.5MM POSTED SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.475 SUP HCPCS C1713 "155.475 - BEACON 7.5MM POSTED SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.476 SUP HCPCS C1713 "155.476 - BEACON 7.5MM POSTED SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.477 SUP HCPCS C1713 "155.477 - BEACON 7.5MM POSTED SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.478 SUP HCPCS C1713 "155.478 - BEACON 7.5MM POSTED SCREW, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.479 SUP HCPCS C1713 "155.479 - BEACON 7.5MM POSTED SCREW, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.481 SUP HCPCS C1713 "155.481 - BEACON 8.5MM POSTED SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.482 SUP HCPCS C1713 "155.482 - BEACON 8.5MM POSTED SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.483 SUP HCPCS C1713 "155.483 - BEACON 8.5MM POSTED SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.484 SUP HCPCS C1713 "155.484 - BEACON 8.5MM POSTED SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.485 SUP HCPCS C1713 "155.485 - BEACON 8.5MM POSTED SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.486 SUP HCPCS C1713 "155.486 - BEACON 8.5MM POSTED SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.487 SUP HCPCS C1713 "155.487 - BEACON 8.5MM POSTED SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.488 SUP HCPCS C1713 "155.488 - BEACON 8.5MM POSTED SCREW, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.489 SUP HCPCS C1713 "155.489 - BEACON 8.5MM POSTED SCREW, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.491 SUP HCPCS C1713 "155.491 - BEACON 9.5MM POSTED SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.492 SUP HCPCS C1713 "155.492 - BEACON 9.5MM POSTED SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.493 SUP HCPCS C1713 "155.493 - BEACON 9.5MM POSTED SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.494 SUP HCPCS C1713 "155.494 - BEACON 9.5MM POSTED SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.495 SUP HCPCS C1713 "155.495 - BEACON 9.5MM POSTED SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.496 SUP HCPCS C1713 "155.496 - BEACON 9.5MM POSTED SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.497 SUP HCPCS C1713 "155.497 - BEACON 9.5MM POSTED SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.498 SUP HCPCS C1713 "155.498 - BEACON 9.5MM POSTED SCREW, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.499 SUP HCPCS C1713 "155.499 - BEACON 9.5MM POSTED SCREW, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.51 SUP Custom 27803010 "155.510 - 6.35MM STRAIGHT ROD, 100MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.512 SUP Custom 27803010 "155.512 - 6.35MM STRAIGHT ROD, 125MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.515 SUP Custom 27803010 155.515 - ROD SPNL STRG 6.35MM 150MM BCN HEX END BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.517 SUP Custom 27803010 "155.517 - 6.35MM STRAIGHT ROD, HEX END, 200MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.519 SUP Custom 27803010 "155.519 - 6.35MM STRAIGHT ROD, HEX END, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.52 SUP Custom 27803010 "155.520 - 6.35MM STRAIGHT ROD, HEX END, 400MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.521 SUP Custom 27803010 "155.521 - 6.35MM STRAIGHT ROD, HEX END, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.53 SUP Custom 27803010 "155.530 - 6.35MM STRAIGHT ROD, 30MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.535 SUP Custom 27803010 "155.535 - 6.35MM STRAIGHT ROD, 35MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.54 SUP Custom 27803010 "155.540 - 6.35MM STRAIGHT ROD, 40MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.545 SUP Custom 27803010 "155.545 - 6.35MM STRAIGHT ROD, 45MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.55 SUP Custom 27803010 "155.550 - 6.35MM STRAIGHT ROD, 50MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.555 SUP Custom 27803010 "155.555 - 6.35MM STRAIGHT ROD, 55MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.56 SUP Custom 27803010 "155.560 - 6.35MM STRAIGHT ROD, 60MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.565 SUP Custom 27803010 "155.565 - 6.35MM STRAIGHT ROD, 65MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.57 SUP Custom 27803010 "155.570 - 6.35MM STRAIGHT ROD, 70MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.575 SUP Custom 27803010 "155.575 - 6.35MM STRAIGHT ROD, 75MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.58 SUP Custom 27803010 "155.580 - 6.35MM STRAIGHT ROD, 80MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.585 SUP Custom 27803010 "155.585 - 6.35MM STRAIGHT ROD, 85MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.61 SUP Custom 27803010 "155.610 - 6.35MM CURVED ROD, 100MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.635 SUP Custom 27803010 "155.635 - 6.35MM CURVED ROD, 35MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.64 SUP Custom 27803010 "155.640 - 6.35MM CURVED ROD, 40MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.645 SUP Custom 27803010 "155.645 - 6.35MM CURVED ROD, 45MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.65 SUP Custom 27803010 "155.650 - 6.35MM CURVED ROD, 50MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.655 SUP Custom 27803010 "155.655 - 6.35MM CURVED ROD, 55MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.66 SUP Custom 27803010 "155.660 - 6.35MM CURVED ROD, 60MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.665 SUP Custom 27803010 "155.665 - 6.35MM CURVED ROD, 65MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.67 SUP Custom 27803010 "155.670 - 6.35MM CURVED ROD, 70MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.675 SUP Custom 27803010 "155.675 - 6.35MM CURVED ROD, 75MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.68 SUP Custom 27803010 "155.680 - 6.35MM CURVED ROD, 80MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.685 SUP Custom 27803010 "155.685 - 6.35MM CURVED ROD, 85MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.69 SUP Custom 27803010 "155.690 - 6.35MM CURVED ROD, 90MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.695 SUP HCPCS C1713 "155.695 - 6.35MM CURVED ROD, 95MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 155.761 SUP HCPCS C1713 "155.761 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.762 SUP HCPCS C1713 "155.762 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.763 SUP HCPCS C1713 "155.763 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.764 SUP HCPCS C1713 "155.764 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.765 SUP HCPCS C1713 "155.765 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.766 SUP HCPCS C1713 "155.766 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.767 SUP HCPCS C1713 "155.767 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.768 SUP HCPCS C1713 "155.768 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.769 SUP HCPCS C1713 "155.769 - BEACON 6.5MM POSTED SCREW, 17MM SHANK, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.771 SUP HCPCS C1713 "155.771 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.772 SUP HCPCS C1713 "155.772 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.773 SUP HCPCS C1713 "155.773 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.774 SUP HCPCS C1713 "155.774 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.775 SUP HCPCS C1713 "155.775 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.776 SUP HCPCS C1713 "155.776 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.777 SUP HCPCS C1713 "155.777 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.778 SUP HCPCS C1713 "155.778 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.779 SUP HCPCS C1713 "155.779 - BEACON 7.5MM POSTED SCREW, 17MM SHANK, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 155.95 SUP Custom 27803010 "155.950 - BEACON 5.5MM OFFSET CONNECTOR, OPEN, 15MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.951 SUP Custom 27803010 "155.951 - BEACON 5.5MM OFFSET CONNECTOR, OPEN, 20MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.952 SUP Custom 27803010 "155.952 - BEACON 5.5MM OFFSET CONNECTOR, OPEN, 25MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.953 SUP Custom 27803010 "155.953 - BEACON 5.5MM OFFSET CONNECTOR, OPEN, 30MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.954 SUP Custom 27803010 "155.954 - BEACON 5.5MM OFFSET CONNECTOR, OPEN, 35MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.96 SUP Custom 27803010 "155.960 - BEACON 5.5MM OFFSET CONNECTOR, CLOSED, 15MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.961 SUP Custom 27803010 "155.961 - BEACON 5.5MM OFFSET CONNECTOR, CLOSED, 20MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.962 SUP Custom 27803010 "155.962 - BEACON 5.5MM OFFSET CONNECTOR, CLOSED, 25MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.963 SUP Custom 27803010 "155.963 - BEACON 5.5MM OFFSET CONNECTOR, CLOSED, 30MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.964 SUP Custom 27803010 "155.964 - BEACON 5.5MM OFFSET CONNECTOR, CLOSED, 35MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.97 SUP Custom 27803010 "155.970 - BEACON 6.35MM OFFSET CONNECTOR, OPEN, 15MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.971 SUP Custom 27803010 "155.971 - BEACON 6.35MM OFFSET CONNECTOR, OPEN, 20MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.972 SUP Custom 27803010 "155.972 - BEACON 6.35MM OFFSET CONNECTOR, OPEN, 25MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.973 SUP Custom 27803010 "155.973 - BEACON 6.35MM OFFSET CONNECTOR, OPEN, 30MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.974 SUP Custom 27803010 "155.974 - BEACON 6.35 OFFSET CONNECTOR, OPEN, 35MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.98 SUP Custom 27803010 "155.980 - BEACON 6.35MM OFFSET CONNECTOR, CLOSED, 15MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.981 SUP Custom 27803010 "155.981 - BEACON 6.35MM OFFSET CONNECTOR, CLOSED, 20MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.982 SUP Custom 27803010 "155.982 - BEACON 6.35MM OFFSET CONNECTOR, CLOSED, 25MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.983 SUP Custom 27803010 "155.983 - BEACON 6.35MM OFFSET CONNECTOR, CLOSED, 30MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 155.984 SUP Custom 27803010 "155.984 - BEACON 6.35MM OFFSET CONNECTOR, CLOSED, 35MM" BOTH IP/OP "$1,410.00 " "$1,043.40" $0.00 "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,046.50" "$1,046.50" $0.00 $0.00 $293.84 $0.00 $0.00 $0.00 $0.00 $705.00 "$1,116.72" "$1,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 170.051 SUP HCPCS C1713 170.051 - REVERE 5.0MM UNIPLANAR FRACTURE REDUCTION SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.052 SUP HCPCS C1713 170.052 - REVERE 5.0MM UNIPLANAR FRACTURE REDUCTION SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.053 SUP HCPCS C1713 170.053 - REVERE 5.0MM UNIPLANAR FRACTURE REDUCTION SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.054 SUP HCPCS C1713 170.054 - REVERE 5.0MM UNIPLANAR FRACTURE REDUCTION SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.055 SUP HCPCS C1713 170.055 - REVERE 5.0MM UNIPLANAR FRACTURE REDUCTION SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.056 SUP HCPCS C1713 170.056 - REVERE 5.0MM UNIPLANAR FRACTURE REDUCTION SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.057 SUP HCPCS C1713 170.057 - REVERE 5.0MM UNIPLANAR FRACTURE REDUCTION SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.141 SUP HCPCS C1713 170.141 - REVERE 4.5MM UNIPLANAR FRACTURE REDUCTION SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.142 SUP HCPCS C1713 170.142 - REVERE 4.5MM UNIPLANAR FRACTURE REDUCTION SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.143 SUP HCPCS C1713 170.143 - REVERE 4.5MM UNIPLANAR FRACTURE REDUCTION SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.144 SUP HCPCS C1713 170.144 - REVERE 4.5MM UNIPLANAR FRACTURE REDUCTION SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.145 SUP HCPCS C1713 170.145 - REVERE 4.5MM UNIPLANAR FRACTURE REDUCTION SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.146 SUP HCPCS C1713 170.146 - REVERE 4.5MM UNIPLANAR FRACTURE REDUCTION SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.147 SUP HCPCS C1713 170.147 - REVERE 4.5MM UNIPLANAR FRACTURE REDUCTION SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.151 SUP HCPCS C1713 170.151 - REVERE 5.5MM UNIPLANAR FRACTURE REDUCTION SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.152 SUP HCPCS C1713 170.152 - REVERE 5.5MM UNIPLANAR FRACTURE REDUCTION SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.153 SUP HCPCS C1713 170.153 - REVERE 5.5MM UNIPLANAR FRACTURE REDUCTION SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.154 SUP HCPCS C1713 170.154 - REVERE 5.5MM UNIPLANAR FRACTURE REDUCTION SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.155 SUP HCPCS C1713 170.155 - REVERE 5.5MM UNIPLANAR FRACTURE REDUCTION SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.156 SUP HCPCS C1713 170.156 - REVERE 5.5MM UNIPLANAR FRACTURE REDUCTION SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.157 SUP HCPCS C1713 170.157 - REVERE 5.5MM UNIPLANAR FRACTURE REDUCTION SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.161 SUP HCPCS C1713 170.161 - REVERE 6.5MM UNIPLANAR FRACTURE REDUCTION SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.162 SUP HCPCS C1713 170.162 - REVERE 6.5MM UNIPLANAR FRACTURE REDUCTION SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.163 SUP HCPCS C1713 170.163 - REVERE 6.5MM UNIPLANAR FRACTURE REDUCTION SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.164 SUP HCPCS C1713 170.164 - REVERE 6.5MM UNIPLANAR FRACTURE REDUCTION SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.165 SUP HCPCS C1713 170.165 - REVERE 6.5MM UNIPLANAR FRACTURE REDUCTION SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.166 SUP HCPCS C1713 170.166 - REVERE 6.5MM UNIPLANAR FRACTURE REDUCTION SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 170.167 SUP HCPCS C1713 170.167 - REVERE 6.5MM UNIPLANAR FRACTURE REDUCTION SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.012 SUP HCPCS C1713 "171.012 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.014 SUP HCPCS C1713 "171.014 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.016 SUP HCPCS C1713 "171.016 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.113 SUP HCPCS C1713 "171.113 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 13MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.115 SUP HCPCS C1713 "171.115 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 15MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.117 SUP HCPCS C1713 "171.117 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 17MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.119 SUP HCPCS C1713 "171.119 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 19MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.121 SUP HCPCS C1713 "171.121 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 21MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.123 SUP HCPCS C1713 "171.123 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 23MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.125 SUP HCPCS C1713 "171.125 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.163 SUP HCPCS C1713 "171.163 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 13MM, EXTRA LORDOTIC" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.165 SUP HCPCS C1713 "171.165 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 15MM, EXTRA LORDOTIC" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.167 SUP HCPCS C1713 "171.167 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 17MM, EXTRA LORDOTIC" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.169 SUP HCPCS C1713 "171.169 - VIP ANTERIOR CERVICAL PLATE 1-LEVEL, 19MM, EXTRA LORDOTIC" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 171.226 SUP HCPCS C1713 "171.226 - VIP CERVICAL PLATE 2-LEVEL, 26MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.228 SUP HCPCS C1713 "171.228 - VIP CERVICAL PLATE 2-LEVEL, 28MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.23 SUP HCPCS C1713 "171.230 - VIP CERVICAL PLATE 2-LEVEL, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.232 SUP HCPCS C1713 "171.232 - VIP CERVICAL PLATE 2-LEVEL, 32MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.234 SUP HCPCS C1713 "171.234 - VIP CERVICAL PLATE 2-LEVEL, 34MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.236 SUP HCPCS C1713 "171.236 - VIP CERVICAL PLATE 2-LEVEL, 36MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.238 SUP HCPCS C1713 "171.238 - VIP CERVICAL PLATE 2-LEVEL, 38MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.24 SUP HCPCS C1713 "171.240 - VIP CERVICAL PLATE 2-LEVEL, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.242 SUP HCPCS C1713 "171.242 - VIP CERVICAL PLATE 2-LEVEL, 42MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.244 SUP HCPCS C1713 "171.244 - VIP CERVICAL PLATE 2-LEVEL, 44MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.246 SUP HCPCS C1713 "171.246 - VIP CERVICAL PLATE 2-LEVEL, 46MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.276 SUP HCPCS C1713 "171.276 - VIP ANTERIOR CERVICAL PLATE 2-LEVEL, 26MM, EXTRA LORDOTIC" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.278 SUP HCPCS C1713 "171.278 - VIP ANTERIOR CERVICAL PLATE 2-LEVEL, 28MM, EXTRA LORDOTIC" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.28 SUP HCPCS C1713 "171.280 - VIP ANTERIOR CERVICAL PLATE 2-LEVEL, 30MM, EXTRA LORDOTIC" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.282 SUP HCPCS C1713 "171.282 - VIP ANTERIOR CERVICAL PLATE 2-LEVEL, 32MM, EXTRA LORDOTIC" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 171.312 SUP HCPCS C1713 "171.312 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.314 SUP HCPCS C1713 "171.314 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.316 SUP HCPCS C1713 "171.316 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.318 SUP HCPCS C1713 "171.318 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.32 SUP HCPCS C1713 "171.320 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.322 SUP HCPCS C1713 "171.322 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING, 22MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.324 SUP HCPCS C1713 "171.324 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING, 24MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.326 SUP HCPCS C1713 "171.326 - VIP 4.6MM VARIABLE ANGLE SCREW, SELF-TAPPING, 26MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.412 SUP HCPCS C1713 "171.412 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.414 SUP HCPCS C1713 "171.414 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.416 SUP HCPCS C1713 "171.416 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.512 SUP HCPCS C1713 "171.512 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.514 SUP HCPCS C1713 "171.514 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.516 SUP HCPCS C1713 "171.516 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-TAPPING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.518 SUP HCPCS C1713 "171.518 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.52 SUP HCPCS C1713 "171.520 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.522 SUP HCPCS C1713 "171.522 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-TAPPING, 22MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.524 SUP HCPCS C1713 "171.524 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-TAPPING, 24MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.526 SUP HCPCS C1713 "171.526 - VIP 5.1MM VARIABLE ANGLE SCREW, SELF-TAPPING, 26MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.612 SUP HCPCS C1713 "171.612 - VIP 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.614 SUP HCPCS C1713 "171.614 - VIP 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.616 SUP HCPCS C1713 "171.616 - VIP 4.6MM FIXED ANGLE SCREW, SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.712 SUP HCPCS C1713 "171.712 - VIP 4.6MM FIXED ANGLE SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.714 SUP HCPCS C1713 "171.714 - VIP 4.6MM FIXED ANGLE SCREW, SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.716 SUP HCPCS C1713 "171.716 - VIP 4.6MM FIXED ANGLE SCREW, SELF-TAPPING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.718 SUP HCPCS C1713 "171.718 - VIP 4.6MM FIXED ANGLE SCREW, SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.72 SUP HCPCS C1713 "171.720 - VIP 4.6MM FIXED ANGLE SCREW, SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.722 SUP HCPCS C1713 "171.722 - VIP 4.6MM FIXED ANGLE SCREW, SELF-TAPPING, 22MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.724 SUP HCPCS C1713 "171.724 - VIP 4.6MM FIXED ANGLE SCREW, SELF-TAPPING, 24MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.726 SUP HCPCS C1713 "171.726 - VIP 4.6MM FIXED ANGLE SCREW, SELF-TAPPING, 26MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.812 SUP HCPCS C1713 "171.812 - VIP 5.1MM FIXED ANGLE SCREW, SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.814 SUP HCPCS C1713 "171.814 - VIP 5.1MM FIXED ANGLE SCREW, SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.816 SUP HCPCS C1713 "171.816 - VIP 5.1MM FIXED ANGLE SCREW, SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.912 SUP HCPCS C1713 "171.912 - VIP 5.1MM FIXED ANGLE SCREW, SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.914 SUP HCPCS C1713 "171.914 - VIP 5.1MM FIXED ANGLE SCREW, SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.916 SUP HCPCS C1713 "171.916 - VIP 5.1MM FIXED ANGLE SCREW, SELF-TAPPING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.918 SUP HCPCS C1713 "171.918 - VIP 5.1MM FIXED ANGLE SCREW, SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.92 SUP HCPCS C1713 "171.920 - VIP 5.1MM FIXED ANGLE SCREW, SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.922 SUP HCPCS C1713 "171.922 - VIP 5.1MM FIXED ANGLE SCREW, SELF-TAPPING, 22MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.924 SUP HCPCS C1713 "171.924 - VIP 5.1MM FIXED ANGLE SCREW, SELF-TAPPING, 24MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 171.926 SUP HCPCS C1713 "171.926 - VIP 5.1MM FIXED ANGLE SCREW, SELF-TAPPING, 26MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 172.511 SUP Custom 27803010 "172.511 - H-LINK 05.5MM ROD, 38MM-51MM X 40MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.512 SUP Custom 27803010 "172.512 - H-LINK 05.5MM ROD, 48MM-61MM X 40MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.513 SUP Custom 27803010 "172.513 - H-LINK 05.5MM ROD, 58MM-71MM X 40MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.521 SUP Custom 27803010 "172.521 - H-LINK 05.5MM ROD, 38MM-51MM X 45MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.522 SUP Custom 27803010 "172.522 - H-LINK 05.5MM ROD, 48MM-61MM X 45MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.523 SUP Custom 27803010 "172.523 - H-LINK 05.5MM ROD, 58MM-71MM X 45MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.531 SUP Custom 27803010 "172.531 - H-LINK 05.5MM ROD, 38MM-51MM X 35MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.532 SUP Custom 27803010 "172.532 - H-LINK 05.5MM ROD, 48MM-61MM X 35MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.533 SUP Custom 27803010 "172.533 - H-LINK 05.5MM ROD, 58MM-71MM X 35MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.581 SUP Custom 27803010 "172.581 - H-LINK 05.5MM ROD, 38MM-51MM X 100MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.582 SUP Custom 27803010 "172.582 - H-LINK 05.5MM ROD, 48MM-61MM X 100MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.583 SUP Custom 27803010 "172.583 - H-LINK 05.5MM ROD, 58MM-71MM X 100MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.611 SUP Custom 27803010 "172.611 - H-LINK 06.35MM ROD, 38MM-51MM X 40MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.612 SUP Custom 27803010 "172.612 - H-LINK 06.35MM ROD, 48MM-61MM X 40MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.613 SUP Custom 27803010 "172.613 - H-LINK 06.35MM ROD, 58MM-71MM X 40MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.621 SUP Custom 27803010 "172.621 - H-LINK 06.35MM ROD, 38MM-51MM X 45MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.622 SUP Custom 27803010 "172.622 - H-LINK 06.35MM ROD, 48MM-61MM X 45MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.623 SUP Custom 27803010 "172.623 - H-LINK 06.35MM ROD, 58MM-71MM X 45MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.681 SUP Custom 27803010 "172.681 - H-LINK 06.35MM ROD, 38MM-51MM X 100MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.682 SUP Custom 27803010 "172.682 - H-LINK 06.35MM ROD, 48MM-61MM X 100MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 172.683 SUP Custom 27803010 "172.683 - H-LINK 06.35MM ROD, 58MM-71MM X 100MM" BOTH IP/OP "$5,527.50 " "$4,090.35" $0.00 "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.51" "$4,102.51" $0.00 $0.00 "$1,151.93" $0.00 $0.00 $0.00 $0.00 "$2,763.75" "$4,377.78" "$4,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 176.12 SUP HCPCS C1713 "176.120 - BONE SCREW, FIXED ANGLE 5.5MM, 20MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.125 SUP HCPCS C1713 "176.125 - BONE SCREW, FIXED ANGLE 5.5MM, 25MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.13 SUP HCPCS C1713 "176.130 - BONE SCREW, FIXED ANGLE 5.5MM, 30MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.135 SUP HCPCS C1713 "176.135 - BONE SCREW, FIXED ANGLE 5.5MM, 35MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.14 SUP HCPCS C1713 "176.140 - BONE SCREW, FIXED ANGLE 5.5MM, 40MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.145 SUP HCPCS C1713 "176.145 - BONE SCREW, FIXED ANGLE 5.5MM, 45MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.15 SUP HCPCS C1713 "176.150 - BONE SCREW, FIXED ANGLE 5.5MM, 50MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.22 SUP HCPCS C1713 "176.220 - BONE SCREW, VARIABLE ANGLE 5.5MM, 20MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.225 SUP HCPCS C1713 "176.225 - BONE SCREW, VARIABLE ANGLE 5.5MM, 25MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.23 SUP HCPCS C1713 "176.230 - BONE SCREW, VARIABLE ANGLE 5.5MM, 30MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.235 SUP HCPCS C1713 "176.235 - BONE SCREW, VARIABLE ANGLE 5.5MM, 35MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.24 SUP HCPCS C1713 "176.240 - BONE SCREW, VARIABLE ANGLE 5.5MM, 40MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.245 SUP HCPCS C1713 "176.245 - BONE SCREW, VARIABLE ANGLE 5.5MM, 45MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 176.25 SUP HCPCS C1713 "176.250 - BONE SCREW, VARIABLE ANGLE 5.5MM, 50MM" BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 182.222 SUP HCPCS C1713 "182.222 - 3.5MM ELLIPSE POLYAXIAL SHOULDER SCREW, 22MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.224 SUP HCPCS C1713 "182.224 - 3.5MM ELLIPSE POLYAXIAL SHOULDER SCREW, 24MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.226 SUP HCPCS C1713 "182.226 - 3.5MM ELLIPSE POLYAXIAL SHOULDER SCREW, 26MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.228 SUP HCPCS C1713 "182.228 - 3.5MM ELLIPSE POLYAXIAL SHOULDER SCREW, 28MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.23 SUP HCPCS C1713 "182.230 - 3.5MM ELLIPSE POLYAXIAL SHOULDER SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.232 SUP HCPCS C1713 "182.232 - 3.5MM ELLIPSE POLYAXIAL SHOULDER SCREW, 32MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.234 SUP HCPCS C1713 "182.234 - 3.5MM ELLIPSE POLYAXIAL SHOULDER SCREW, 34MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.236 SUP HCPCS C1713 "182.236 - 3.5MM ELLIPSE POLYAXIAL SHOULDER SCREW, 36MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.308 SUP HCPCS C1713 "182.308 - 3.5MM ELLIPSE POLYAXIAL SCREW, 8MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.31 SUP HCPCS C1713 "182.310 - 3.5MM ELLIPSE POLYAXIAL SCREW, 10MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.312 SUP HCPCS C1713 "182.312 - 3.5MM ELLIPSE POLYAXIAL SCREW, 12MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.314 SUP HCPCS C1713 "182.314 - 3.5MM ELLIPSE POLYAXIAL SCREW, 14MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.316 SUP HCPCS C1713 "182.316 - 3.5MM ELLIPSE POLYAXIAL SCREW, 16MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.318 SUP HCPCS C1713 "182.318 - 3.5MM ELLIPSE POLYAXIAL SCREW, 18MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.32 SUP HCPCS C1713 "182.320 - 3.5MM ELLIPSE POLYAXIAL SCREW, 20MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.322 SUP HCPCS C1713 "182.322 - 3.5MM ELLIPSE POLYAXIAL SCREW, 22MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.324 SUP HCPCS C1713 "182.324 - 3.5MM ELLIPSE POLYAXIAL SCREW, 24MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.326 SUP HCPCS C1713 "182.326 - 3.5MM ELLIPSE POLYAXIAL SCREW, 26MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.328 SUP HCPCS C1713 "182.328 - 3.5MM ELLIPSE POLYAXIAL SCREW, 28MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.33 SUP HCPCS C1713 "182.330 - 3.5MM ELLIPSE POLYAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.332 SUP HCPCS C1713 "182.332 - 3.5MM ELLIPSE POLYAXIAL SCREW, 32MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.334 SUP HCPCS C1713 "182.334 - 3.5MM ELLIPSE POLYAXIAL SCREW, 34MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.336 SUP HCPCS C1713 "182.336 - 3.5MM ELLIPSE POLYAXIAL SCREW, 36MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.338 SUP HCPCS C1713 "182.338 - 3.5MM ELLIPSE POLYAXIAL SCREW, 38MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.34 SUP HCPCS C1713 "182.340 - 3.5MM ELLIPSE POLYAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.342 SUP HCPCS C1713 "182.342 - 3.5MM ELLIPSE POLYAXIAL SCREW, 42MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.344 SUP HCPCS C1713 "182.344 - 3.5MM ELLIPSE POLYAXIAL SCREW, 44MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.346 SUP HCPCS C1713 "182.346 - 3.5MM ELLIPSE POLYAXIAL SCREW, 46MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.348 SUP HCPCS C1713 "182.348 - 3.5MM ELLIPSE POLYAXIAL SCREW, 48MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.35 SUP HCPCS C1713 "182.350 - 3.5MM ELLIPSE POLYAXIAL SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.41 SUP HCPCS C1713 "182.410 - 4.0MM ELLIPSE POLYAXIAL SCREW, 10MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.412 SUP HCPCS C1713 "182.412 - 4.0MM ELLIPSE POLYAXIAL SCREW, 12MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.414 SUP HCPCS C1713 "182.414 - 4.0MM ELLIPSE POLYAXIAL SCREW, 14MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.416 SUP HCPCS C1713 "182.416 - 4.0MM ELLIPSE POLYAXIAL SCREW, 16MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.418 SUP HCPCS C1713 "182.418 - 4.0MM ELLIPSE POLYAXIAL SCREW, 18MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.42 SUP HCPCS C1713 "182.420 - 4.0MM ELLIPSE POLYAXIAL SCREW, 20MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.422 SUP HCPCS C1713 "182.422 - 4.0MM ELLIPSE POLYAXIAL SCREW, 22MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.424 SUP HCPCS C1713 "182.424 - 4.0MM ELLIPSE POLYAXIAL SCREW, 24MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.426 SUP HCPCS C1713 "182.426 - 4.0MM ELLIPSE POLYAXIAL SCREW, 26MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.428 SUP HCPCS C1713 "182.428 - 4.0MM ELLIPSE POLYAXIAL SCREW, 28MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.43 SUP HCPCS C1713 "182.430 - 4.0MM ELLIPSE POLYAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.432 SUP HCPCS C1713 "182.432 - 4.0MM ELLIPSE POLYAXIAL SCREW, 32MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.434 SUP HCPCS C1713 "182.434 - 4.0MM ELLIPSE POLYAXIAL SCREW, 34MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.436 SUP HCPCS C1713 "182.436 - 4.0MM ELLIPSE POLYAXIAL SCREW, 36MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.438 SUP HCPCS C1713 "182.438 - 4.0MM ELLIPSE POLYAXIAL SCREW, 38MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.44 SUP HCPCS C1713 "182.440 - 4.0MM ELLIPSE POLYAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.442 SUP HCPCS C1713 "182.442 - 4.0MM ELLIPSE POLYAXIAL SCREW, 42MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.444 SUP HCPCS C1713 "182.444 - 4.0MM ELLIPSE POLYAXIAL SCREW, 44MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.446 SUP HCPCS C1713 "182.446 - 4.0MM ELLIPSE POLYAXIAL SCREW, 46MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.448 SUP HCPCS C1713 "182.448 - 4.0MM ELLIPSE POLYAXIAL SCREW, 48MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.45 SUP HCPCS C1713 "182.450 - 4.0MM ELLIPSE POLYAXIAL SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.5 SUP HCPCS C1713 182.500 - ELLIPSE LOCKING CAP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 182.501 SUP Custom 27803010 182.501 - ELLIPSE INLINE HOOK BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.503 SUP Custom 27803010 "182.503 - ELLIPSE INLINE HOOK, RIGHT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.504 SUP Custom 27803010 "182.504 - ELLIPSE INLINE HOOK, LEFT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.506 SUP Custom 27803010 "182.506 - ELLIPSE OFFSET HOOK, LEFT, 7MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.507 SUP Custom 27803010 "182.507 - ELLIPSE OFFSET HOOK, LEFT, 5MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.508 SUP Custom 27803010 "182.508 - ELLIPSE OFFSET HOOK, RIGHT, 7MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.509 SUP Custom 27803010 "182.509 - ELLIPSE OFFSET HOOK, RIGHT, 5MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.51 SUP HCPCS C1713 "182.510 - 4.5MM ELLIPSE POLYAXIAL SCREW, 10MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.512 SUP HCPCS C1713 "182.512 - 4.5MM ELLIPSE POLYAXIAL SCREW, 12MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.514 SUP HCPCS C1713 "182.514 - 4.5MM ELLIPSE POLYAXIAL SCREW, 14MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.516 SUP HCPCS C1713 "182.516 - 4.5MM ELLIPSE POLYAXIAL SCREW, 16MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.518 SUP HCPCS C1713 "182.518 - 4.5MM ELLIPSE POLYAXIAL SCREW, 18MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.52 SUP HCPCS C1713 "182.520 - 4.5MM ELLIPSE POLYAXIAL SCREW, 20MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.522 SUP HCPCS C1713 "182.522 - 4.5MM ELLIPSE POLYAXIAL SCREW, 22MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.524 SUP HCPCS C1713 "182.524 - 4.5MM ELLIPSE POLYAXIAL SCREW, 24MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.526 SUP HCPCS C1713 "182.526 - 4.5MM ELLIPSE POLYAXIAL SCREW, 26MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.528 SUP HCPCS C1713 "182.528 - 4.5MM ELLIPSE POLYAXIAL SCREW, 28MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.53 SUP HCPCS C1713 "182.530 - 4.5MM ELLIPSE POLYAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.532 SUP HCPCS C1713 "182.532 - 4.5MM ELLIPSE POLYAXIAL SCREW, 32MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.534 SUP HCPCS C1713 "182.534 - 4.5MM ELLIPSE POLYAXIAL SCREW, 34MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.536 SUP HCPCS C1713 "182.536 - 4.5MM ELLIPSE POLYAXIAL SCREW, 36MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.538 SUP HCPCS C1713 "182.538 - 4.5MM ELLIPSE POLYAXIAL SCREW, 38MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.54 SUP HCPCS C1713 "182.540 - 4.5MM ELLIPSE POLYAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.542 SUP HCPCS C1713 "182.542 - 4.5MM ELLIPSE POLYAXIAL SCREW, 42MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.544 SUP HCPCS C1713 "182.544 - 4.5MM ELLIPSE POLYAXIAL SCREW, 44MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.546 SUP HCPCS C1713 "182.546 - 4.5MM ELLIPSE POLYAXIAL SCREW, 46MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.548 SUP HCPCS C1713 "182.548 - 4.5MM ELLIPSE POLYAXIAL SCREW, 48MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.55 SUP HCPCS C1713 "182.550 - 4.5MM ELLIPSE POLYAXIAL SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 182.801 SUP Custom 27803010 "182.801 - 3.5MM ELLIPSE ROD, 80MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.802 SUP Custom 27803010 "182.802 - 3.5MM ELLIPSE ROD, 120MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.803 SUP Custom 27803010 "182.803 - 3.5MM ELLIPSE ROD, 240MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.804 SUP Custom 27803010 "182.804 - 3.5MM ELLIPSE ROD, 40MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.9 SUP Custom 27803010 182.900 - ELLIPSE LOCKING CAP FOR HEAD-TO-HEAD T-CONNECTOR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.901 SUP Custom 27803010 182.901 - ELLIPSE LOCKING NUT FOR HEAD-TO-HEAD T-CONNECTOR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.911 SUP Custom 27803010 "182.911 - ELLIPSE HEAD TO HEAD T-CONNECTOR FOR 3.5MM ROD, 21-27MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.912 SUP Custom 27803010 "182.912 - ELLIPSE HEAD TO HEAD T-CONNECTOR FOR 3.5MM ROD, 27-33MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.913 SUP Custom 27803010 "182.913 - ELLIPSE HEAD TO HEAD T-CONNECTOR FOR 3.5MM ROD, 33-39MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.914 SUP Custom 27803010 "182.914 - ELLIPSE HEAD TO HEAD T-CONNECTOR FOR 3.5MM ROD, 39-45MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.915 SUP Custom 27803010 "182.915 - ELLIPSE HEAD TO HEAD T-CONNECTOR FOR 3.5MM ROD, 45-51MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.916 SUP Custom 27803010 "182.916 - ELLIPSE HEAD TO HEAD T-CONNECTOR FOR 3.5MM ROD, 51-57MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.917 SUP Custom 27803010 "182.917 - ELLIPSE HEAD TO HEAD T-CONNECTOR FOR 3.5MM ROD, 57-63MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.923 SUP Custom 27803010 "182.923 - ELLIPSE TOP-LOADING T-CONNECTOR FOR 3.5MM ROD, 21-33, STRAIG" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.924 SUP Custom 27803010 "182.924 - ELLIPSE TOP-LOADING T-CONNECTOR FOR 3.5MM ROD, 26-46, CURVED" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.925 SUP Custom 27803010 "182.925 - ELLIPSE TOP-LOADING T-CONNECTOR FOR 3.5MM ROD, 26-46, STRAIG" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.926 SUP Custom 27803010 "182.926 - ELLIPSE TOP-LOADING T-CONNECTOR FOR 3.5MM ROD, 36-56, CURVED" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.927 SUP Custom 27803010 "182.927 - ELLIPSE TOP-LOADING T-CONNECTOR FOR 3.5MM ROD, 36-56, STRAIG" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.95 SUP HCPCS C1713 "182.950 - ELLIPSE OCCIPITAL PLATE, SMALL" BOTH IP/OP "$7,145.00 " "$5,287.30" $0.00 "$5,716.00" "$3,215.25" "$3,215.25" $0.00 $0.00 $0.00 "$1,489.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,489.02" $0.00 "$3,522.49" "$3,522.49" $0.00 "$3,572.50" "$5,658.84" "$5,716.00" $0.00 $0.00 "$1,118.19" $0.00 $0.00 "$1,137.48" $0.00 $0.00 $0.00 $0.00 $0.00 182.952 SUP HCPCS C1713 "182.952 - ELLIPSE OCCIPITAL PLATE, LARGE" BOTH IP/OP "$7,145.00 " "$5,287.30" $0.00 "$5,716.00" "$3,215.25" "$3,215.25" $0.00 $0.00 $0.00 "$1,489.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,489.02" $0.00 "$3,522.49" "$3,522.49" $0.00 "$3,572.50" "$5,658.84" "$5,716.00" $0.00 $0.00 "$1,118.19" $0.00 $0.00 "$1,137.48" $0.00 $0.00 $0.00 $0.00 $0.00 182.953 SUP Custom 27803010 182.953 - ROD SPNL 100D 3.5MM 240MM ELLIPSE OCPTL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.954 SUP Custom 27803010 182.954 - ROD SPNL 115D 3.5MM 240MM ELLIPSE OCPTL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.955 SUP Custom 27803010 182.955 - ROD SPNL 130D 3.5MM 240MM ELLIPSE OCPTL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.96 SUP Custom 27803010 182.960 - ELLIPSE PARALLEL CONNECTOR 3.5MM ROD TO 3.5MM ROD BOTH IP/OP "$1,357.50 " "$1,004.55" $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.54" "$1,007.54" $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $678.75 "$1,075.14" "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.961 SUP Custom 27803010 182.961 - ELLIPSE PARALLEL CONNECTOR 3.5MM ROD TO 4.0MM ROD BOTH IP/OP "$1,357.50 " "$1,004.55" $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.54" "$1,007.54" $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $678.75 "$1,075.14" "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.962 SUP Custom 27803010 182.962 - ELLIPSE PARALLEL CONNECTOR 3.5MM ROD TO 4.5MM ROD BOTH IP/OP "$1,357.50 " "$1,004.55" $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.54" "$1,007.54" $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $678.75 "$1,075.14" "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.963 SUP Custom 27803010 182.963 - ELLIPSE PARALLEL CONNECTOR 3.5MM ROD TO 5.0MM ROD BOTH IP/OP "$1,357.50 " "$1,004.55" $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.54" "$1,007.54" $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $678.75 "$1,075.14" "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.964 SUP Custom 27803010 182.964 - ELLIPSE PARALLEL CONNECTOR 3.5MM ROD TO 5.5MM ROD BOTH IP/OP "$1,357.50 " "$1,004.55" $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.54" "$1,007.54" $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $678.75 "$1,075.14" "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.965 SUP Custom 27803010 182.965 - ELLIPSE PARALLEL CONNECTOR 3.5MM ROD TO 6.0MM ROD BOTH IP/OP "$1,357.50 " "$1,004.55" $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.54" "$1,007.54" $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $678.75 "$1,075.14" "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.966 SUP Custom 27803010 182.966 - ELLIPSE PARALLEL CONNECTOR 3.5MM ROD TO 6.35MM ROD BOTH IP/OP "$1,357.50 " "$1,004.55" $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.54" "$1,007.54" $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $678.75 "$1,075.14" "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.967 SUP Custom 27803010 182.967 - ELLIPSE PARALLEL CONNECTOR 3.5MM ROD TO 6.5MM ROD BOTH IP/OP "$1,357.50 " "$1,004.55" $0.00 "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,007.54" "$1,007.54" $0.00 $0.00 $282.90 $0.00 $0.00 $0.00 $0.00 $678.75 "$1,075.14" "$1,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.975 SUP Custom 27803010 182.975 - ELLIPSE LATERAL CONNECTOR BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.98 SUP Custom 27803010 "182.980 - ELLIPSE TAPERED ROD, 3.5MM TO 4.0MM, 350MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.981 SUP Custom 27803010 "182.981 - ELLIPSE TAPERED ROD, 3.5MM TO 4.5MM, 350MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.982 SUP Custom 27803010 "182.982 - ELLIPSE TAPERED ROD, 3.5MM TO 5.0MM, 350MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.983 SUP Custom 27803010 "182.983 - ELLIPSE TAPERED ROD, 3.5MM TO 5.5MM, 350MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.984 SUP Custom 27803010 "182.984 - ELLIPSE TAPERED ROD, 3.5MM TO 6.0MM, 350MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.985 SUP Custom 27803010 "182.985 - ELLIPSE TAPERED ROD, 3.5MM TO 6.35MM, 350MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.986 SUP Custom 27803010 "182.986 - ELLIPSE TAPERED ROD, 3.5MM TO 6.5MM, 350MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.989 SUP Custom 27803010 "182.989 - ELLIPSE TAPERED ROD, 3.5MM TO 5.5MM, 500MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.99 SUP Custom 27803010 "182.990 - ELLIPSE LATERAL CONNECTOR, LONG" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 182.991 SUP Custom 27803010 "182.991 - ELLIPSE LATERAL CONNECTOR, SHORT" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 184.012 SUP HCPCS C1713 "184.012 - 4.2MM BONE SCREW, VARIABLE, SELF-TAPPING, 12MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.014 SUP HCPCS C1713 "184.014 - 4.2MM BONE SCREW, VARIABLE, SELF-TAPPING, 14MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.016 SUP HCPCS C1713 "184.016 - 4.2MM BONE SCREW, VARIABLE, SELF-TAPPING, 16MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.018 SUP HCPCS C1713 "184.018 - 4.2MM BONE SCREW, VARIABLE, SELF-TAPPING, 18MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.02 SUP HCPCS C1713 184.020 - SCREW BN 4.2MM 20MM VA ST SPNE BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.032 SUP HCPCS C1713 "184.032 - 4.2MM BONE SCREW, FIXED, SELF-TAPPING, 12MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.034 SUP HCPCS C1713 "184.034 - 4.2MM BONE SCREW, FIXED, SELF-TAPPING, 14MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.036 SUP HCPCS C1713 "184.036 - 4.2MM BONE SCREW, FIXED, SELF-TAPPING, 16MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.038 SUP HCPCS C1713 "184.038 - 4.2MM BONE SCREW, FIXED, SELF-TAPPING, 18MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.04 SUP HCPCS C1713 184.040 - SCREW BN 4.2MM 20MM FX ANG ST SPNE BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.052 SUP HCPCS C1713 "184.052 - 4.2MM BONE SCREW, VARIABLE, SELF-DRILLING, 12MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.054 SUP HCPCS C1713 "184.054 - 4.2MM BONE SCREW, VARIABLE, SELF-DRILLING, 14MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.056 SUP HCPCS C1713 "184.056 - 4.2MM BONE SCREW, VARIABLE, SELF-DRILLING, 16MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.058 SUP HCPCS C1713 "184.058 - 4.2MM BONE SCREW, VARIABLE, SELF-DRILLING, 18MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.06 SUP HCPCS C1713 184.060 - SCREW BN 4.2MM 20MM VA SLF DRL SPNE BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.072 SUP HCPCS C1713 "184.072 - 4.2MM BONE SCREW, FIXED, SELF-DRILLING, 12MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.074 SUP HCPCS C1713 "184.074 - 4.2MM BONE SCREW, FIXED, SELF-DRILLING, 14MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.076 SUP HCPCS C1713 "184.076 - 4.2MM BONE SCREW, FIXED, SELF-DRILLING, 16MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.078 SUP HCPCS C1713 "184.078 - 4.2MM BONE SCREW, FIXED, SELF-DRILLING, 18MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.08 SUP HCPCS C1713 184.080 - SCREW BN 4.2MM 20MM FX ANG SLF DRL SPNE BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.112 SUP HCPCS C1713 "184.112 - 3.6MM BONE SCREW, VARIABLE, SELF-TAPPING, 12MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.114 SUP HCPCS C1713 "184.114 - 3.6MM BONE SCREW, VARIABLE, SELF-TAPPING, 14MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.116 SUP HCPCS C1713 "184.116 - 3.6MM BONE SCREW, VARIABLE, SELF-TAPPING, 16MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.118 SUP HCPCS C1713 "184.118 - 3.6MM BONE SCREW, VARIABLE, SELF-TAPPING, 18MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.12 SUP HCPCS C1713 184.120 - SCREW BN 3.6MM 20MM VA ST SPNE BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.132 SUP HCPCS C1713 "184.132 - 3.6MM BONE SCREW, FIXED, SELF-TAPPING, 12MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.134 SUP HCPCS C1713 "184.134 - 3.6MM BONE SCREW, FIXED, SELF-TAPPING, 14MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.136 SUP HCPCS C1713 "184.136 - 3.6MM BONE SCREW, FIXED, SELF-TAPPING, 16MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.138 SUP HCPCS C1713 "184.138 - 3.6MM BONE SCREW, FIXED, SELF-TAPPING, 18MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.14 SUP HCPCS C1713 184.140 - SCREW BN 3.6MM 20MM FX ANG ST SPNE BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.152 SUP HCPCS C1713 "184.152 - 3.6MM BONE SCREW, VARIABLE, SELF-DRILLING, 12MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.154 SUP HCPCS C1713 "184.154 - 3.6MM BONE SCREW, VARIABLE, SELF-DRILLING, 14MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.156 SUP HCPCS C1713 "184.156 - 3.6MM BONE SCREW, VARIABLE, SELF-DRILLING, 16MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.158 SUP HCPCS C1713 "184.158 - 3.6MM BONE SCREW, VARIABLE, SELF-DRILLING, 18MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.16 SUP HCPCS C1713 184.160 - SCREW BN 3.6MM 20MM VA SLF DRL SPNE BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.172 SUP HCPCS C1713 "184.172 - 3.6MM BONE SCREW, FIXED, SELF-DRILLING, 12MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.174 SUP HCPCS C1713 "184.174 - 3.6MM BONE SCREW, FIXED, SELF-DRILLING, 14MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.176 SUP HCPCS C1713 "184.176 - 3.6MM BONE SCREW, FIXED, SELF-DRILLING, 16MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.178 SUP HCPCS C1713 "184.178 - 3.6MM BONE SCREW, FIXED, SELF-DRILLING, 18MM" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 184.18 SUP HCPCS C1713 184.180 - SCREW BN 3.6MM 20MM FX ANG SLF DRL SPNE BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 185 SUP HCPCS C1713 185.000 - REVOLVE LOCKING CAP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 185.081 SUP HCPCS C1713 "185.081 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 70MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.082 SUP HCPCS C1713 "185.082 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 75MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.083 SUP HCPCS C1713 "185.083 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 80MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.084 SUP HCPCS C1713 "185.084 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 85MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.085 SUP HCPCS C1713 "185.085 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 90MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.24 SUP Custom 27803010 "185.240 - 5.5MM REVOLVE ROD, 40MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.245 SUP Custom 27803010 "185.245 - 5.5MM REVOLVE ROD, 45MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.25 SUP Custom 27803010 "185.250 - 5.5MM REVOLVE ROD, 50MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.255 SUP Custom 27803010 "185.255 - 5.5MM REVOLVE ROD, 55MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.26 SUP Custom 27803010 "185.260 - 5.5MM REVOLVE ROD, 60MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.265 SUP Custom 27803010 "185.265 - 5.5MM REVOLVE ROD, 65MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.27 SUP Custom 27803010 "185.270 - 5.5MM REVOLVE ROD, 70MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.275 SUP Custom 27803010 "185.275 - 5.5MM REVOLVE ROD, 75MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.28 SUP Custom 27803010 "185.280 - 5.5MM REVOLVE ROD, 80MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.29 SUP Custom 27803010 "185.290 - 5.5MM REVOLVE ROD, 90MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.3 SUP Custom 27803010 "185.300 - 5.5MM REVOLVE ROD, 100MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.31 SUP Custom 27803010 "185.310 - 5.5MM REVOLVE ROD, 110MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.32 SUP Custom 27803010 "185.320 - 5.5MM REVOLVE ROD, 120MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.33 SUP Custom 27803010 "185.330 - 5.5MM REVOLVE ROD, 130MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.34 SUP Custom 27803010 "185.340 - 5.5MM REVOLVE ROD, 140MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.35 SUP Custom 27803010 "185.350 - 5.5MM REVOLVE ROD, 150MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.36 SUP Custom 27803010 "185.360 - 5.5MM REVOLVE ROD, 160MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.37 SUP Custom 27803010 "185.370 - 5.5MM REVOLVE ROD, 170MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.38 SUP Custom 27803010 "185.380 - 5.5MM REVOLVE ROD, 180MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.39 SUP Custom 27803010 "185.390 - 5.5MM REVOLVE ROD, 190MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.4 SUP Custom 27803010 "185.400 - 5.5MM REVOLVE ROD, 200MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.41 SUP Custom 27803010 "185.410 - 5.5MM REVOLVE ROD, 210MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.42 SUP Custom 27803010 "185.420 - 5.5MM REVOLVE ROD, 220MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.43 SUP Custom 27803010 "185.430 - 5.5MM REVOLVE ROD, 230MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.44 SUP Custom 27803010 "185.440 - 5.5MM REVOLVE ROD, 240MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 185.451 SUP HCPCS C1713 "185.451 - 5.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.452 SUP HCPCS C1713 "185.452 - 5.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.453 SUP HCPCS C1713 "185.453 - 5.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.454 SUP HCPCS C1713 "185.454 - 5.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.455 SUP HCPCS C1713 "185.455 - 5.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.456 SUP HCPCS C1713 "185.456 - 5.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.457 SUP HCPCS C1713 "185.457 - 5.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.461 SUP HCPCS C1713 "185.461 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.462 SUP HCPCS C1713 "185.462 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.463 SUP HCPCS C1713 "185.463 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.464 SUP HCPCS C1713 "185.464 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.465 SUP HCPCS C1713 "185.465 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.466 SUP HCPCS C1713 "185.466 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.467 SUP HCPCS C1713 "185.467 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.468 SUP HCPCS C1713 "185.468 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.469 SUP HCPCS C1713 "185.469 - 6.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.471 SUP HCPCS C1713 "185.471 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.472 SUP HCPCS C1713 "185.472 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.473 SUP HCPCS C1713 "185.473 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.474 SUP HCPCS C1713 "185.474 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.475 SUP HCPCS C1713 "185.475 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.476 SUP HCPCS C1713 "185.476 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.477 SUP HCPCS C1713 "185.477 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.478 SUP HCPCS C1713 "185.478 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.479 SUP HCPCS C1713 "185.479 - 7.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.481 SUP HCPCS C1713 "185.481 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.482 SUP HCPCS C1713 "185.482 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.483 SUP HCPCS C1713 "185.483 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.484 SUP HCPCS C1713 "185.484 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.485 SUP HCPCS C1713 "185.485 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.486 SUP HCPCS C1713 "185.486 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.487 SUP HCPCS C1713 "185.487 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.488 SUP HCPCS C1713 "185.488 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.489 SUP HCPCS C1713 "185.489 - 8.5MM REVOLVE POLYAXIAL PEDICLE SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 185.5 SUP Custom 27803010 "185.500 - 5.5MM REVOLVE ROD, 300MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 192.142 SUP HCPCS C1768 STENT URET 7FR 24CM WO GUIDEWIRE DUAL DRMTR PLRS UL HDR+ BOTH IP/OP $356.40 $263.74 $0.00 $285.12 $160.38 $160.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.20 $282.27 $285.12 $0.00 $0.00 $55.78 $0.00 $0.00 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 198 SUP Custom 27203010 198 - CATHETER SUCTION 8FR 2.6MM 12IN SOFT Y ADAPTER TACTILE BOTH IP/OP $32.35 $23.94 $0.00 $25.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.01 $24.01 $0.00 $0.00 $6.74 $0.00 $0.00 $0.00 $0.00 $16.18 $25.62 $25.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.006 SUP HCPCS C1713 200.006 - SCREW BONE STANDARD 1.5MM 3MM 6MM CRCIFRM RECESS DCP BOTH IP/OP $54.45 $40.29 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.35 $40.41 $40.41 $0.00 $0.00 $11.35 $0.00 $32.21 $32.21 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $7.04 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.007 SUP HCPCS C1713 200.007 - SCREW BONE STANDARD 1.5MM 3MM 7MM CRCIFRM RECESS DCP BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.008 SUP HCPCS C1713 200.008 - SCREW BONE STANDARD 1.5MM 3MM 8MM CRCIFRM RECESS DCP BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.009 SUP HCPCS C1713 200.009 - SCREW BONE STANDARD 1.5MM 3MM 9MM CRCIFRM RECESS DCP BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.01 SUP HCPCS C1713 200.010 - SCREW BONE STANDARD 1.5MM 10MM CRCIFRM RECESS DCP STAINLESS BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.011 SUP HCPCS C1713 200.011 - SCREW BONE STANDARD 1.5MM 3MM 11MM CRCIFRM RECESS DCP BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.012 SUP HCPCS C1713 200.012 - SCREW BONE STANDARD 1.5MM 3MM 12MM CRCIFRM RECESS DCP BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.014 SUP HCPCS C1713 200.014 - SCREW BONE STANDARD 1.5MM 3MM 14MM CRCIFRM RECESS DCP BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.016 SUP HCPCS C1713 200.016 - SCREW BONE STANDARD 1.5MM 3MM 16MM CRCIFRM RECESS DCP BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 200.018 SUP HCPCS C1713 200.018 - SCREW BONE STANDARD 1.5MM 3MM 18MM CRCIFRM RECESS DCP BOTH IP/OP $51.33 $37.98 $0.00 $41.06 $23.10 $23.10 $0.00 $0.00 $0.00 $10.70 $38.09 $38.09 $0.00 $0.00 $10.70 $0.00 $30.36 $30.36 $0.00 $25.66 $40.65 $41.06 $0.00 $0.00 $8.03 $0.00 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $0.00 200.02 SUP HCPCS C1713 200.020 - SCREW BONE STANDARD 1.5MM 3MM 20MM CRCIFRM RECESS DCP BOTH IP/OP $51.33 $37.98 $0.00 $41.06 $23.10 $23.10 $0.00 $0.00 $0.00 $10.70 $38.09 $38.09 $0.00 $0.00 $10.70 $0.00 $30.36 $30.36 $0.00 $25.66 $40.65 $41.06 $0.00 $0.00 $8.03 $0.00 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $0.00 200.19 SUP Custom 27203010 200.190 - PIN FIX 1.8MM 12MM T8 STARDRIVE RECESS BUTTRESS LCP BOTH IP/OP $212.90 $157.55 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.01 $158.01 $0.00 $0.00 $44.37 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.191 SUP Custom 27203010 200.191 - PIN FIX 1.8MM 14MM T8 STARDRIVE RECESS BUTTRESS LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.192 SUP Custom 27203010 200.192 - PIN FIX 1.8MM 16MM T8 STARDRIVE RECESS BUTTRESS LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.193 SUP Custom 27203010 200.193 - PIN FIX 1.8MM 18MM T8 STARDRIVE RECESS BUTTRESS LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.195 SUP Custom 27203010 200.195 - PIN FIX ROUND 1.8MM 22MM T8 STARDRIVE RECESS BUTTRESS SMOOTH BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.197 SUP Custom 27203010 200.197 - PIN FIX 1.8MM 24MM BUTTRESS STARDRIVE STAINLESS STEEL BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.198 SUP Custom 27203010 200.198 - PIN FIX 1.8MM 26MM BUTTRESS STARDRIVE STAINLESS STEEL BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.199 SUP Custom 27203010 200.199 - PIN FIX 1.8MM 28MM BUTTRESS STARDRIVE STAINLESS STEEL BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200.526 SUP HCPCS C1713 200.526 - SCREW BONE 1MM 1.6MM 6MM SELF TAP CRCIFRM LP HEAD STAINLESS BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.527 SUP HCPCS C1713 200.527 - SCREW BONE LP 1MM 1.6MM 7MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.528 SUP HCPCS C1713 200.528 - SCREW BONE 1MM 1.6MM 8MM SELF TAP CRCIFRM LP HEAD STAINLESS BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.529 SUP HCPCS C1713 200.529 - SCREW BONE LP 1MM 1.6MM 9MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.53 SUP HCPCS C1713 200.530 - SCREW BONE LP 1MM 1.6MM 10MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $133.05 $98.46 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $27.73 $98.75 $98.75 $0.00 $0.00 $27.73 $0.00 $78.70 $78.70 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.531 SUP HCPCS C1713 200.531 - SCREW BONE LP 1MM 1.6MM 11MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.532 SUP HCPCS C1713 200.532 - SCREW BONE LP 1MM 1.6MM 12MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.533 SUP HCPCS C1713 200.533 - SCREW BONE 1MM 1.6MM 13MM SELF TAP CRCIFRM LP HEAD STAINLESS BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.534 SUP HCPCS C1713 200.534 - SCREW BONE LP 1MM 1.6MM 14MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 200.686 SUP HCPCS C1713 200.686 - SCREW BONE 1.3MM 2.4MM 6MM SELF TAP CRCIFRM RECESS LP HEAD BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.687 SUP HCPCS C1713 200.687 - SCREW BONE LP 1.3MM 2.4MM 7MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.688 SUP HCPCS C1713 200.688 - SCREW BONE LP 1.3MM 2.4MM 8MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.689 SUP HCPCS C1713 200.689 - SCREW BONE LP 1.3MM 2.4MM 9MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.69 SUP HCPCS C1713 200.690 - SCREW BONE 1.3MM 2.4MM 10MM SLFTAP CRCIFRM RECESS LP HEAD BOTH IP/OP $139.20 $103.01 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.01 $103.31 $103.31 $0.00 $0.00 $29.01 $0.00 $82.34 $82.34 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.691 SUP HCPCS C1713 200.691 - SCREW BONE LP 1.3MM 2.4MM 11MM SELF TAP CRCIFRM DCP BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.692 SUP HCPCS C1713 200.692 - SCREW BONE LP 1.3MM 2.4MM 12MM SELF TAP CRCIFRM DCP BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.693 SUP HCPCS C1713 200.693 - SCREW BONE 1.3MM 2.4MM 13MM SELF TAP CRCIFRM LP HEAD BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.694 SUP HCPCS C1713 200.694 - SCREW BONE LP 1.3MM 2.4MM 14MM SELF TAP CRCIFRM DCP BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.696 SUP HCPCS C1713 200.696 - SCREW BONE LP 1.3MM 2.4MM 16MM SELF TAP CRCIFRM DCP BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.698 SUP HCPCS C1713 200.698 - SCREW BONE LP 1.3MM 2.4MM 18MM SELF TAP CRCIFRM DCP BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 200.806 SUP HCPCS C1713 200.806 - SCREW BONE LP 1.5MM 3MM 6MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.807 SUP HCPCS C1713 200.807 - SCREW BONE LP 1.5MM 3MM 7MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.808 SUP HCPCS C1713 200.808 - SCREW BONE LP 1.5MM 3MM 8MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.809 SUP HCPCS C1713 200.809 - SCREW BONE LP 1.5MM 3MM 9MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.81 SUP HCPCS C1713 200.810 - SCREW BONE LP 1.5MM 3MM 10MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $59.03 $43.68 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.30 $43.81 $43.81 $0.00 $0.00 $12.30 $0.00 $34.91 $34.91 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.811 SUP HCPCS C1713 200.811 - SCREW BONE LP 1.5MM 3MM 11MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.812 SUP HCPCS C1713 200.812 - SCREW BONE LP 1.5MM 3MM 12MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.813 SUP HCPCS C1713 200.813 - SCREW BONE LP 1.5MM 3MM 13MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.814 SUP HCPCS C1713 200.814 - SCREW BONE LP 1.5MM 3MM 14MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.816 SUP HCPCS C1713 200.816 - SCREW BONE LP 1.5MM 3MM 16MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.818 SUP HCPCS C1713 200.818 - SCREW BONE LP 1.5MM 3MM 18MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.45 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.82 SUP HCPCS C1713 200.820 - SCREW BONE LP 1.5MM 3MM 20MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $59.03 $43.68 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.30 $43.81 $43.81 $0.00 $0.00 $12.30 $0.00 $34.91 $34.91 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.822 SUP HCPCS C1713 200.822 - SCREW BONE LP 1.5MM 3MM 22MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 200.824 SUP HCPCS C1713 200.824 - SCREW BONE LP 1.5MM 3MM 24MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.006 SUP HCPCS C1713 201.006 - SCREW BN STD 2MM 3.5MM 6MM NS CRFRM SS CORT MN FRAG SET MDLR BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.04 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.008 SUP HCPCS C1713 201.008 - SCREW BONE STANDARD 2MM 8MM CRCIFRM RECESS DCP STAINLESS BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.04 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.01 SUP HCPCS C1713 201.010 - SCREW BONE STANDARD 2MM 10MM CRCIFRM HEAD DCP STAINLESS BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.04 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.012 SUP HCPCS C1713 201.012 - SCREW BONE STANDARD 2MM 3.5MM 12MM CRCIFRM RECESS DCP BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.04 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.014 SUP HCPCS C1713 201.014 - SCREW BONE STANDARD 2MM 3.5MM 14MM CRCIFRM DCP STAINLESS BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.04 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.016 SUP HCPCS C1713 201.016 - SCREW BONE STANDARD 2MM 3.5MM 16MM CRCIFRM RECESS DCP BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.04 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.018 SUP HCPCS C1713 201.018 - SCREW BONE STANDARD 2MM 18MM CRCIFRM RECESS DCP STAINLESS BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.02 SUP HCPCS C1713 201.020 - SCREW BONE STANDARD 2MM 20MM CRCIFRM RECESS DCP STAINLESS BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.022 SUP HCPCS C1713 201.022 - SCREW BONE STANDARD 2MM 3.5MM 22MM CRCIFRM DCP STAINLESS BOTH IP/OP $50.68 $37.50 $0.00 $40.54 $22.80 $22.80 $0.00 $0.00 $0.00 $10.56 $37.61 $37.61 $0.00 $0.00 $10.56 $0.00 $29.97 $29.97 $0.00 $25.34 $40.14 $40.54 $0.00 $0.00 $7.93 $0.00 $0.00 $8.07 $0.00 $0.00 $0.00 $0.00 $0.00 201.024 SUP HCPCS C1713 201.024 - SCREW BONE 2MM 24MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $50.68 $37.50 $0.00 $40.54 $22.80 $22.80 $0.00 $0.00 $0.00 $10.56 $37.61 $37.61 $0.00 $0.00 $10.56 $0.00 $29.97 $29.97 $0.00 $25.34 $40.14 $40.54 $0.00 $0.00 $7.93 $0.00 $0.00 $8.07 $0.00 $0.00 $0.00 $0.00 $0.00 201.026 SUP HCPCS C1713 201.026 - SCREW BONE 2MM 26MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.028 SUP HCPCS C1713 201.028 - SCREW BONE 2MM 28MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.03 SUP HCPCS C1713 201.030 - SCREW BONE 2MM 30MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.032 SUP HCPCS C1713 201.032 - SCREW BONE 2MM 32MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.034 SUP HCPCS C1713 201.034 - SCREW BONE 2MM 34MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.036 SUP HCPCS C1713 201.036 - SCREW BONE 2MM 36MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.038 SUP HCPCS C1713 201.038 - SCREW BONE 2MM 38MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.04 SUP HCPCS C1713 201.040 - SCREW BONE 2MM 40MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.042 SUP HCPCS C1713 201.042 - SCREW BONE 2MM 42MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.044 SUP HCPCS C1713 201.044 - SCREW BONE 2MM 44MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.046 SUP HCPCS C1713 201.046 - SCREW BONE 2MM 46MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $53.75 $39.78 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $11.20 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $31.79 $31.79 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 201.506 SUP HCPCS C1713 201.506 - SCREW BONE 2.4MM 3.5MM 6MM SLFTAP STAINLESS STEEL MAXILLA BOTH IP/OP $91.25 $67.53 $0.00 $73.00 $41.06 $41.06 $0.00 $0.00 $0.00 $19.02 $67.73 $67.73 $0.00 $0.00 $19.02 $0.00 $53.97 $53.97 $0.00 $45.63 $72.27 $73.00 $0.00 $0.00 $14.28 $0.00 $0.00 $14.53 $0.00 $0.00 $0.00 $0.00 $0.00 201.508 SUP HCPCS C1713 201.508 - SCREW BONE 2.4MM 3.5MM 8MM SLFTAP STAINLESS STEEL MAXILLA BOTH IP/OP $91.25 $67.53 $0.00 $73.00 $41.06 $41.06 $0.00 $0.00 $0.00 $19.02 $67.73 $67.73 $0.00 $0.00 $19.02 $0.00 $53.97 $53.97 $0.00 $45.63 $72.27 $73.00 $0.00 $0.00 $14.28 $0.00 $0.00 $14.53 $0.00 $0.00 $0.00 $0.00 $0.00 201.51 SUP HCPCS C1713 201.510 - SCREW BONE 2.4MM 3.5MM 10MM SLFTAP STAINLESS STEEL MAXILLA BOTH IP/OP $91.25 $67.53 $0.00 $73.00 $41.06 $41.06 $0.00 $0.00 $0.00 $19.02 $67.73 $67.73 $0.00 $0.00 $19.02 $0.00 $53.97 $53.97 $0.00 $45.63 $72.27 $73.00 $0.00 $0.00 $14.28 $0.00 $0.00 $14.53 $0.00 $0.00 $0.00 $0.00 $0.00 201.512 SUP HCPCS C1713 201.512 - SCREW SS 12MM 2.4MM CORT MAXL SLFTAP BONE NONSTRL BOTH IP/OP $75.38 $55.78 $0.00 $60.30 $33.92 $33.92 $0.00 $0.00 $0.00 $15.71 $55.94 $55.94 $0.00 $0.00 $15.71 $0.00 $44.58 $44.58 $0.00 $37.69 $59.70 $60.30 $0.00 $0.00 $11.80 $0.00 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.514 SUP HCPCS C1713 201.514 - SCREW BONE 2.4MM 14MM SLFTAP STAINLESS STEEL MAXILLA BOTH IP/OP $91.25 $67.53 $0.00 $73.00 $41.06 $41.06 $0.00 $0.00 $0.00 $19.02 $67.73 $67.73 $0.00 $0.00 $19.02 $0.00 $53.97 $53.97 $0.00 $45.63 $72.27 $73.00 $0.00 $0.00 $14.28 $0.00 $0.00 $14.53 $0.00 $0.00 $0.00 $0.00 $0.00 201.612 SUP HCPCS C1713 201.612 - SCREW BONE 2.4MM 3.5MM 12MM SELF TAP CRCIFRM STAINLESS STEEL BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.614 SUP HCPCS C1713 201.614 - SCREW BONE 2.4MM 3.5MM 14MM SELF TAP STAINLESS STEEL CORTEX BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.616 SUP HCPCS C1713 201.616 - SCREW BONE 2.4MM 3.5MM 16MM SELF TAP CRCIFRM LCP STAINLESS BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.618 SUP HCPCS C1713 201.618 - SCREW BONE 2.4MM 3.5MM 18MM SELF TAP CRCIFRM STAINLESS STEEL BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.62 SUP HCPCS C1713 201.620 - SCREW BONE 2.4MM 20MM SLFTAP STAINLESS STEEL RAD CORTICAL BOTH IP/OP $87.35 $64.64 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.21 $64.83 $64.83 $0.00 $0.00 $18.20 $0.00 $51.67 $51.67 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.622 SUP HCPCS C1713 201.622 - SCREW BONE 2.4MM 3.5MM 22MM SELF TAP CRCIFRM STAINLESS STEEL BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.624 SUP HCPCS C1713 201.624 - SCREW BONE 2.4MM 3.5MM 24MM SELF TAP CRCIFRM STAINLESS STEEL BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.626 SUP HCPCS C1713 201.626 - SCREW BONE 2.4MM 3.5MM 26MM SELF TAP CRCIFRM STAINLESS STEEL BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.628 SUP HCPCS C1713 201.628 - SCREW BONE 2.4MM 28MM SLFTAP STAINLESS STEEL RAD CORTICAL BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.63 SUP HCPCS C1713 201.630 - SCREW BONE 2.4MM 3.5MM 30MM SLFTAP CRCIFRM RECESS STAINLESS BOTH IP/OP $87.35 $64.64 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.21 $64.83 $64.83 $0.00 $0.00 $18.20 $0.00 $51.67 $51.67 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.636 SUP HCPCS C1713 201.636 - SCREW BONE CONE LP 2.4MM 4.5MM 6MM SELF TAP THREAD CRCIFRM BOTH IP/OP $92.78 $68.66 $0.00 $72.06 $40.53 $40.53 $0.00 $0.00 $0.00 $19.34 $68.86 $68.86 $0.00 $0.00 $19.33 $0.00 $54.88 $54.88 $0.00 $45.04 $71.34 $72.06 $0.00 $0.00 $13.69 $0.00 $0.00 $14.34 $0.00 $0.00 $0.00 $0.00 $0.00 201.637 SUP HCPCS C1713 201.637 - SCREW BONE CONE LP 2.4MM 4.5MM 7MM SELF TAP THREAD CRCIFRM BOTH IP/OP $92.78 $68.66 $0.00 $72.06 $40.53 $40.53 $0.00 $0.00 $0.00 $19.34 $68.86 $68.86 $0.00 $0.00 $19.33 $0.00 $54.88 $54.88 $0.00 $45.04 $71.34 $72.06 $0.00 $0.00 $13.69 $0.00 $0.00 $14.34 $0.00 $0.00 $0.00 $0.00 $0.00 201.638 SUP HCPCS C1713 201.638 - SCREW BONE CONE LP 2.4MM 4.5MM 8MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.639 SUP HCPCS C1713 201.639 - SCREW BONE CONE LP 2.4MM 4.5MM 9MM SELF TAP THREAD CRCIFRM BOTH IP/OP $92.78 $68.66 $0.00 $72.06 $40.53 $40.53 $0.00 $0.00 $0.00 $19.34 $68.86 $68.86 $0.00 $0.00 $19.33 $0.00 $54.88 $54.88 $0.00 $45.04 $71.34 $72.06 $0.00 $0.00 $13.69 $0.00 $0.00 $14.34 $0.00 $0.00 $0.00 $0.00 $0.00 201.64 SUP HCPCS C1713 201.640 - SCREW BONE CONE LP 2.4MM 4.5MM 10MM SELF TAP THREAD CRCIFRM BOTH IP/OP $87.35 $64.64 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.21 $64.83 $64.83 $0.00 $0.00 $18.20 $0.00 $51.67 $51.67 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.641 SUP HCPCS C1713 201.641 - SCREW BONE CONE LP 2.4MM 4.5MM 11MM SELF TAP THREAD CRCIFRM BOTH IP/OP $92.78 $68.66 $0.00 $72.06 $40.53 $40.53 $0.00 $0.00 $0.00 $19.34 $68.86 $68.86 $0.00 $0.00 $19.33 $0.00 $54.88 $54.88 $0.00 $45.04 $71.34 $72.06 $0.00 $0.00 $13.69 $0.00 $0.00 $14.34 $0.00 $0.00 $0.00 $0.00 $0.00 201.642 SUP HCPCS C1713 201.642 - SCREW BONE CONE LP 2.4MM 4.5MM 12MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.643 SUP HCPCS C1713 201.643 - SCREW BONE CONE LP 2.4MM 4.5MM 13MM SELF TAP THREAD CRCIFRM BOTH IP/OP $92.78 $68.66 $0.00 $72.06 $40.53 $40.53 $0.00 $0.00 $0.00 $19.34 $68.86 $68.86 $0.00 $0.00 $19.33 $0.00 $54.88 $54.88 $0.00 $45.04 $71.34 $72.06 $0.00 $0.00 $13.69 $0.00 $0.00 $14.34 $0.00 $0.00 $0.00 $0.00 $0.00 201.644 SUP HCPCS C1713 201.644 - SCREW BONE CONE LP 2.4MM 4.5MM 14MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.646 SUP HCPCS C1713 201.646 - SCREW BONE CONE LP 2.4MM 4.5MM 16MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.648 SUP HCPCS C1713 201.648 - SCREW BONE CONE LP 2.4MM 4.5MM 18MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.65 SUP HCPCS C1713 201.650 - SCREW BONE CONE LP 2.4MM 4.5MM 20MM SELF TAP THREAD CRCIFRM BOTH IP/OP $87.35 $64.64 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.21 $64.83 $64.83 $0.00 $0.00 $18.20 $0.00 $51.67 $51.67 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.652 SUP HCPCS C1713 201.652 - SCREW BONE CONE LP 2.4MM 4.5MM 22MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.654 SUP HCPCS C1713 201.654 - SCREW BONE CONE LP 2.4MM 4.5MM 24MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.656 SUP HCPCS C1713 201.656 - SCREW BONE CONE LP 2.4MM 4.5MM 26MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.658 SUP HCPCS C1713 201.658 - SCREW BONE CONE LP 2.4MM 4.5MM 28MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.66 SUP HCPCS C1713 201.660 - SCREW BONE CONE LP 2.4MM 4.5MM 30MM SELF TAP THREAD CRCIFRM BOTH IP/OP $87.35 $64.64 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.21 $64.83 $64.83 $0.00 $0.00 $18.20 $0.00 $51.67 $51.67 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.662 SUP HCPCS C1713 201.662 - SCREW BONE CONE LP 2.4MM 4.5MM 32MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.664 SUP HCPCS C1713 201.664 - SCREW BONE CONE LP 2.4MM 4.5MM 34MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.666 SUP HCPCS C1713 201.666 - SCREW BONE 2.4MM 4MM 36MM SELF TAP STAINLESS STEEL SMALL BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.668 SUP HCPCS C1713 201.668 - SCREW BONE CONE LP 2.4MM 4.5MM 38MM SELF TAP THREAD CRCIFRM BOTH IP/OP $89.98 $66.59 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.75 $66.78 $66.78 $0.00 $0.00 $18.75 $0.00 $53.22 $53.22 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.67 SUP HCPCS C1713 201.670 - SCREW BONE CONE LP 2.4MM 4.5MM 40MM SELF TAP THREAD CRCIFRM BOTH IP/OP $87.35 $64.64 $0.00 $69.88 $39.31 $39.31 $0.00 $0.00 $0.00 $18.21 $64.83 $64.83 $0.00 $0.00 $18.20 $0.00 $51.67 $51.67 $0.00 $43.68 $69.18 $69.88 $0.00 $0.00 $13.27 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 201.676 SUP HCPCS C1713 201.676 - SCREW BONE 3.5MM HEAD 2.4MM 6MM SLFTAP STAINLESS STEEL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.677 SUP HCPCS C1713 201.677 - SCREW BONE 2.3MM 3.5MM 7MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.678 SUP HCPCS C1713 201.678 - SCREW BONE 3.5MM HEAD 2.4MM 8MM SLFTAP STAINLESS STEEL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.679 SUP HCPCS C1713 201.679 - SCREW BONE 2.3MM 3.5MM 9MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.68 SUP HCPCS C1713 201.680 - CLIP ANEURYSM 10MM OPENING 20X1.88MM SUPER BAYONET LATEX BOTH IP/OP $113.28 $83.83 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $23.61 $84.07 $84.07 $0.00 $0.00 $23.61 $0.00 $67.00 $67.00 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.681 SUP HCPCS C1713 201.681 - SCREW BONE 2.3MM 3.5MM 11MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.683 SUP HCPCS C1713 201.683 - SCREW BONE 3.5MM HEAD 2.4MM 13MM SLFTAP STAINLESS STEEL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.685 SUP HCPCS C1713 201.685 - SCREW BONE 3.5MM HEAD 2.3MM 15MM SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.686 SUP HCPCS C1713 201.686 - SCREW BONE 2.3MM 3.5MM 32MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.687 SUP HCPCS C1713 201.687 - SCREW BONE 2.3MM 3.5MM 34MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.688 SUP HCPCS C1713 201.688 - SCREW BONE 2.3MM 3.5MM 36MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.689 SUP HCPCS C1713 201.689 - SCREW BONE 2.3MM 3.5MM 38MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.69 SUP HCPCS C1713 201.690 - SCREW BONE 3.5MM HEAD 2.3MM 40MM SLFTAP CORTICAL BOTH IP/OP $113.28 $83.83 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $23.61 $84.07 $84.07 $0.00 $0.00 $23.61 $0.00 $67.00 $67.00 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.691 SUP HCPCS C1713 201.691 - SCREW BONE 2.3MM 3.5MM 42MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.692 SUP HCPCS C1713 201.692 - SCREW BONE 2.4MM 44MM SLFTAP STAINLESS STEEL CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.693 SUP HCPCS C1713 201.693 - SCREW BONE 2.3MM 3.5MM 46MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.694 SUP HCPCS C1713 201.694 - SCREW BONE 2.3MM 3.5MM 48MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.695 SUP HCPCS C1713 201.695 - SCREW BONE 3.5MM HEAD 2.3MM 50MM SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.696 SUP HCPCS C1713 201.696 - SCREW BONE 3.5MM HEAD 2.4MM 52MM SLFTAP STAINLESS STEEL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.697 SUP HCPCS C1713 201.697 - SCREW BONE 2.3MM 3.5MM 54MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.698 SUP HCPCS C1713 201.698 - SCREW BONE 3.5MM HEAD 2.4MM 56MM SLFTAP STAINLESS STEEL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.699 SUP HCPCS C1713 201.699 - SCREW BONE 2.3MM 3.5MM 58MM HEAD SLFTAP CORTICAL BOTH IP/OP $116.68 $86.34 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $24.32 $86.60 $86.60 $0.00 $0.00 $24.32 $0.00 $69.01 $69.01 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.7 SUP HCPCS C1713 201.700 - SCREW BONE 2.4MM 3.5MM 60MM SLFTAP CRCIFRM RECESS STAINLESS BOTH IP/OP $113.28 $83.83 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $23.61 $84.07 $84.07 $0.00 $0.00 $23.61 $0.00 $67.00 $67.00 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 201.756 SUP HCPCS C1713 201.756 - SCREW BONE T8 LP 2.4MM 4MM 6MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.757 SUP HCPCS C1713 201.757 - SCREW BONE T8 LP 2.4MM 4MM 7MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.758 SUP HCPCS C1713 201.758 - SCREW BONE T8 LP 2.4MM 4MM 8MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.759 SUP HCPCS C1713 201.759 - SCREW BONE T8 LP 2.4MM 4MM 9MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.76 SUP HCPCS C1713 201.760 - SCREW BONE T8 LP 2.4MM 4MM 10MM SELF TAP STARDRIVE LCP BOTH IP/OP $102.35 $75.74 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.33 $75.96 $75.96 $0.00 $0.00 $21.33 $0.00 $60.54 $60.54 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.761 SUP HCPCS C1713 201.761 - SCREW BONE T8 LP 2.4MM 4MM 11MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.762 SUP HCPCS C1713 201.762 - SCREW BONE T8 LP 2.4MM 4MM 12MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.763 SUP HCPCS C1713 201.763 - SCREW BONE T8 LP 2.4MM 4MM 13MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.764 SUP HCPCS C1713 201.764 - SCREW BONE T8 LP 2.4MM 4MM 14MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.766 SUP HCPCS C1713 201.766 - SCREW BONE 2.4MM 4MM 16MM T8 STARDRIVE SELF TAP LP HEAD VAR BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.768 SUP HCPCS C1713 201.768 - SCREW BONE T8 LP 2.4MM 4MM 18MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.77 SUP HCPCS C1713 201.770 - SCREW BONE T8 LP 2.4MM 4MM 20MM SELF TAP STARDRIVE LCP BOTH IP/OP $102.35 $75.74 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.33 $75.96 $75.96 $0.00 $0.00 $21.33 $0.00 $60.54 $60.54 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.772 SUP HCPCS C1713 201.772 - SCREW BONE T8 LP 2.4MM 4MM 22MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.774 SUP HCPCS C1713 201.774 - SCREW BONE T8 LP 2.4MM 4MM 24MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.776 SUP HCPCS C1713 201.776 - SCREW BONE T8 LP 2.4MM 4MM 26MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.778 SUP HCPCS C1713 201.778 - SCREW BONE T8 LP 2.4MM 4MM 28MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.78 SUP HCPCS C1713 201.780 - SCREW BONE T8 LP 2.4MM 4MM 30MM SELF TAP STARDRIVE LCP BOTH IP/OP $102.35 $75.74 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.33 $75.96 $75.96 $0.00 $0.00 $21.33 $0.00 $60.54 $60.54 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.782 SUP HCPCS C1713 201.782 - SCREW BONE 2.4MM 3.5MM 32MM SELF TAP CRCIFRM T8 STARDRIVE BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.784 SUP HCPCS C1713 201.784 - SCREW BONE T8 LP 2.4MM 4MM 34MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.786 SUP HCPCS C1713 201.786 - SCREW BONE T8 LP 2.4MM 4MM 36MM SELF TAP STARDRIVE LCP BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.788 SUP HCPCS C1713 201.788 - SCREW BONE 2.4MM 4MM 38MM VARIABLESELF TAPPING T8 STARDRIVE BOTH IP/OP $105.43 $78.02 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.97 $78.25 $78.25 $0.00 $0.00 $21.97 $0.00 $62.36 $62.36 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.79 SUP HCPCS C1713 201.790 - SCREW BONE T8 LP 2.4MM 4MM 40MM SELF TAP STARDRIVE LCP BOTH IP/OP $102.35 $75.74 $0.00 $81.88 $46.06 $46.06 $0.00 $0.00 $0.00 $21.33 $75.96 $75.96 $0.00 $0.00 $21.33 $0.00 $60.54 $60.54 $0.00 $51.18 $81.06 $81.88 $0.00 $0.00 $15.55 $0.00 $0.00 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 201.806 SUP HCPCS C1713 201.806 - SCREW BONE 2MM 3.5MM 6MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.807 SUP HCPCS C1713 201.807 - SCREW BONE 2MM 3.5MM 7MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.808 SUP HCPCS C1713 201.808 - SCREW BONE 2MM 3.5MM 8MM SELF TAP CRCIFRM STAINLESS STEEL FT BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.809 SUP HCPCS C1713 201.809 - SCREW BONE 2MM 3.5MM 9MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.81 SUP HCPCS C1713 201.810 - SCREW BONE 2MM 3.5MM 10MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $59.03 $43.68 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.30 $43.81 $43.81 $0.00 $0.00 $12.30 $0.00 $34.91 $34.91 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.811 SUP HCPCS C1713 201.811 - SCREW BONE 2MM 3.5MM 11MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.812 SUP HCPCS C1713 201.812 - SCREW BONE 2MM 3.5MM 12MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.813 SUP HCPCS C1713 201.813 - SCREW BN 2MM 13MM NS ST SS CORT MDLR HND SYS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.814 SUP HCPCS C1713 201.814 - SCREW BONE 2MM 3.5MM 14MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.816 SUP HCPCS C1713 201.816 - SCREW BONE 2MM 3.5MM 16MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.818 SUP HCPCS C1713 201.818 - SCREW BONE 2MM 3.5MM 18MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.82 SUP HCPCS C1713 201.820 - SCREW BONE 2MM 3.5MM 20MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $59.03 $43.68 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.30 $43.81 $43.81 $0.00 $0.00 $12.30 $0.00 $34.91 $34.91 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.822 SUP HCPCS C1713 201.822 - SCREW BONE 2MM 3.5MM 22MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.824 SUP HCPCS C1713 201.824 - SCREW BONE 2MM 3.5MM 24MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.826 SUP HCPCS C1713 201.826 - SCREW BONE 2MM 3.5MM 26MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.828 SUP HCPCS C1713 201.828 - SCREW BONE 2MM 3.5MM 28MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.83 SUP HCPCS C1713 201.830 - SCREW BONE 2MM 3.5MM 30MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $59.03 $43.68 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.30 $43.81 $43.81 $0.00 $0.00 $12.30 $0.00 $34.91 $34.91 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.832 SUP HCPCS C1713 201.832 - SCREW BONE 2MM 3.5MM 32MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.834 SUP HCPCS C1713 201.834 - SCREW BONE 2MM 3.5MM 34MM SELF TAP CRCIFRM LCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.836 SUP HCPCS C1713 201.836 - SCREW BONE 2MM 3.5MM 36MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.838 SUP HCPCS C1713 201.838 - SCREW BONE 2MM 3.5MM 38MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $60.80 $44.99 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.84 SUP HCPCS C1713 201.840 - SCREW BONE 2MM 3.5MM 40MM SELF TAP CRCIFRM LCP STAINLESS BOTH IP/OP $59.03 $43.68 $0.00 $47.22 $26.56 $26.56 $0.00 $0.00 $0.00 $12.30 $43.81 $43.81 $0.00 $0.00 $12.30 $0.00 $34.91 $34.91 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $8.97 $0.00 $0.00 $9.40 $0.00 $0.00 $0.00 $0.00 $0.00 201.876 SUP HCPCS C1713 201.876 - SCREW BONE T6 2MM 6MM SELF TAP STARDRIVE LCP STAINLESS STEEL BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.877 SUP HCPCS C1713 201.877 - SCREW BONE T6 2MM 7MM SELF TAP STARDRIVE LCP STAINLESS STEEL BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.878 SUP HCPCS C1713 201.878 - SCREW BONE T6 2MM 8MM SELF TAP STARDRIVE LCP STAINLESS STEEL BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.879 SUP HCPCS C1713 201.879 - SCREW BONE T6 2MM 9MM SELF TAP STARDRIVE LCP STAINLESS STEEL BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.88 SUP HCPCS C1713 201.880 - SCREW BONE T6 2MM 10MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $208.80 $154.51 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $43.52 $154.97 $154.97 $0.00 $0.00 $43.51 $0.00 $123.51 $123.51 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.881 SUP HCPCS C1713 201.881 - SCREW BONE T6 2MM 11MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.882 SUP HCPCS C1713 201.882 - SCREW BONE T6 2MM 12MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.883 SUP HCPCS C1713 201.883 - SCREW BONE T6 2MM 13MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.884 SUP HCPCS C1713 201.884 - SCREW BONE T6 2MM 14MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.886 SUP HCPCS C1713 201.886 - SCREW BONE T6 2MM 16MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.888 SUP HCPCS C1713 201.888 - SCREW BONE T6 2MM 18MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.89 SUP HCPCS C1713 201.890 - SCREW BONE T6 2MM 20MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $208.80 $154.51 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $43.52 $154.97 $154.97 $0.00 $0.00 $43.51 $0.00 $123.51 $123.51 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.892 SUP HCPCS C1713 201.892 - SCREW BONE T6 2MM 22MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.894 SUP HCPCS C1713 201.894 - SCREW BONE T6 2MM 24MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.896 SUP HCPCS C1713 201.896 - SCREW BONE T6 2MM 26MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.898 SUP HCPCS C1713 201.898 - SCREW BONE T6 2MM 28MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.9 SUP HCPCS C1713 201.900 - SCREW BONE 2MM 30MM T6 STAR DRIVE RECESS SLFTAP LCP BOTH IP/OP $208.80 $154.51 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $43.52 $154.97 $154.97 $0.00 $0.00 $43.51 $0.00 $123.51 $123.51 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 201.928 SUP HCPCS C1713 201.928 - SCREW BONE 8MM 2MM MAXFACL SS SLF DRILING IMF NONSTRL BOTH IP/OP $205.88 $152.35 $0.00 $164.70 $92.64 $92.64 $0.00 $0.00 $0.00 $42.91 $152.80 $152.80 $0.00 $0.00 $42.90 $0.00 $121.78 $121.78 $0.00 $102.94 $163.06 $164.70 $0.00 $0.00 $32.22 $0.00 $0.00 $32.78 $0.00 $0.00 $0.00 $0.00 $0.00 201.962 SUP Custom 27203010 201.962 - PIN FIX 1.8MM 12MM BUTTRESS STAINLESS STEEL DISTAL RAD BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.964 SUP Custom 27203010 201.964 - PIN FIX 1.8MM 14MM BUTTRESS STAINLESS STEEL DISTAL RAD BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.966 SUP Custom 27203010 201.966 - PIN FIX 1.8MM 16MM BUTTRESS STAINLESS STEEL DISTAL RAD BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.968 SUP Custom 27203010 201.968 - PIN FIX 1.8MM 18MM BUTTRESS LCP STAINLESS STEEL DISTAL RAD BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.972 SUP Custom 27203010 201.972 - PIN FIX 1.8MM 22MM BUTTRESS STAINLESS STEEL DISTAL RAD BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.974 SUP Custom 27203010 201.974 - PIN FIX 1.8MM 24MM BUTTRESS STAINLESS STEEL DISTAL RAD BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.976 SUP Custom 27203010 201.976 - PIN FIX 1.8MM 26MM BUTTRESS STAINLESS STEEL DISTAL RAD BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.978 SUP Custom 27203010 201.978 - PIN FIX 1.8MM 28MM BUTTRESS STAINLESS STEEL DISTAL RAD BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.98 SUP Custom 27203010 201.980 - PIN FIX 1.8MM 30MM BUTTRESS STAINLESS STEEL DISTAL RAD BOTH IP/OP $113.95 $84.32 $0.00 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.57 $84.57 $0.00 $0.00 $23.75 $0.00 $0.00 $0.00 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 202.006 SUP HCPCS C1713 202.006 - SCREW BONE 2.5MM STANDARD 2.7MM 6MM SPHERICAL HEAD SMALL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.008 SUP HCPCS C1713 202.008 - SCREW BONE STANDARD 2.7MM 5MM 8MM SPHERICAL HEAD SMALL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.01 SUP HCPCS C1713 202.010 - SCREW BN STD FT 2.7MM 5MM 10MM NS 2.5MM SPHRCL HD SM HEX BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $6.67 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.012 SUP HCPCS C1713 202.012 - SCREW BONE STANDARD 2.7MM 5MM 12MM SPHERICAL HEAD SMALL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.014 SUP HCPCS C1713 202.014 - SCREW BONE STANDARD 2.7MM 5MM 14MM SPHERICAL HEAD SMALL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.016 SUP HCPCS C1713 202.016 - SCREW BONE STANDARD 2.7MM 5MM 16MM SPHERICAL HEAD SMALL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.018 SUP HCPCS C1713 202.018 - SCREW BONE STANDARD 2.7MM 5MM 18MM SPHERICAL HEAD SMALL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.02 SUP HCPCS C1713 202.020 - SCREW BONE STANDARD 2.7MM 5MM 20MM SPHERICAL HEAD SMALL BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.022 SUP HCPCS C1713 202.022 - SCREW BONE STANDARD 2.7MM 5MM 22MM SPHERICAL HEAD SMALL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.024 SUP HCPCS C1713 202.024 - SCREW BONE STANDARD 2.7MM 5MM 24MM SPHERICAL HEAD SMALL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.026 SUP HCPCS C1713 202.026 - SCREW BONE STANDARD 2.7MM 26MM DCP STAINLESS STEEL CORTICAL BOTH IP/OP $56.58 $41.87 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.79 $41.99 $41.99 $0.00 $0.00 $11.79 $0.00 $33.46 $33.46 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.028 SUP HCPCS C1713 202.028 - SCREW BONE 2.7MM 28MM DCP SS CORT NONSTRL SM FRAG BOTH IP/OP $42.60 $31.52 $0.00 $34.08 $19.17 $19.17 $0.00 $0.00 $0.00 $8.88 $31.62 $31.62 $0.00 $0.00 $8.88 $0.00 $25.20 $25.20 $0.00 $21.30 $33.74 $34.08 $0.00 $0.00 $6.67 $0.00 $0.00 $6.78 $0.00 $0.00 $0.00 $0.00 $0.00 202.03 SUP HCPCS C1713 202.030 - SCREW BONE 2.7MM 30MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.032 SUP HCPCS C1713 202.032 - SCREW BONE 2.7MM 32MM DCP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.034 SUP HCPCS C1713 202.034 - SCREW BONE STANDARD 2.7MM 5MM 34MM 2.5MM SMALL HEXAGON BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $6.67 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.036 SUP HCPCS C1713 202.036 - SCREW BONE STANDARD SMALL HEXAGON SPHERE 2.7MM 5MM 36MM BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.038 SUP HCPCS C1713 202.038 - SCREW BONE STANDARD 2.7MM 5MM 38MM 2.5MM SMALL HEXAGON BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.04 SUP HCPCS C1713 202.040 - SCREW BONE STANDARD SMALL HEXAGON SPHERE 2.7MM 5MM 40MM BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.045 SUP HCPCS C1713 202.045 - SCREW BONE STANDARD SMALL HEXAGON SPHERE 2.7MM 5MM 45MM BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.05 SUP HCPCS C1713 202.050 - SCREW BONE STANDARD SMALL HEXAGON SPHERE 2.7MM 5MM 50MM BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.055 SUP HCPCS C1713 202.055 - SCREW BONE STANDARD SMALL HEXAGON SPHERE 2.7MM 5MM 55MM BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 202.208 SUP HCPCS C1713 202.208 - SCREW BONE T8 2.7MM 2.1MM 8MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.21 SUP HCPCS C1713 202.210 - SCREW BONE 2.7MM 10MM LOCKING SLFTAP T8 STARDRIVE RECESS LCP BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.212 SUP HCPCS C1713 202.212 - SCREW BONE T8 2.7MM 2.1MM 12MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.214 SUP HCPCS C1713 202.214 - SCREW BONE T8 2.7MM 2.1MM 14MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.216 SUP HCPCS C1713 202.216 - SCREW BONE 2.7MM 2.1MM 16MM T8 STARDRIVE RECESS SLFTAP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.218 SUP HCPCS C1713 202.218 - SCREW BONE T8 2.7MM 2.1MM 18MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.22 SUP HCPCS C1713 202.220 - SCREW BONE T8 2.7MM 2.1MM 20MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.222 SUP HCPCS C1713 202.222 - SCREW BONE T8 2.7MM 2.1MM 22MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.224 SUP HCPCS C1713 202.224 - SCREW BONE T8 2.7MM 2.1MM 24MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.226 SUP HCPCS C1713 202.226 - SCREW BONE 2.7MM 26MM LOCKING SLFTAP T8 STARDRIVE RECESS LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.228 SUP HCPCS C1713 202.228 - SCREW BONE T8 2.7MM 2.1MM 28MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.23 SUP HCPCS C1713 202.230 - SCREW BONE T8 2.7MM 2.1MM 30MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.232 SUP HCPCS C1713 202.232 - SCREW BONE T8 2.7MM 2.1MM 32MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.234 SUP HCPCS C1713 202.234 - SCREW BONE T8 2.7MM 2.1MM 34MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.236 SUP HCPCS C1713 202.236 - SCREW BONE T8 2.7MM 2.1MM 36MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.238 SUP HCPCS C1713 202.238 - SCREW BONE T8 2.7MM 2.1MM 38MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.24 SUP HCPCS C1713 202.240 - SCREW BONE T8 2.7MM 2.1MM 40MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.242 SUP HCPCS C1713 202.242 - SCREW BONE 2.7MM 42MM T8 STARDRIVE RECESS SLFTAP LOCKING LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.244 SUP HCPCS C1713 202.244 - SCREW BONE T8 2.7MM 2.1MM 44MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.246 SUP HCPCS C1713 202.246 - SCREW BONE T8 2.7MM 2.1MM 46MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.248 SUP HCPCS C1713 202.248 - SCREW BONE T8 2.7MM 2.1MM 48MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.25 SUP HCPCS C1713 202.250 - SCREW BONE T8 2.7MM 2.1MM 50MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.255 SUP HCPCS C1713 202.255 - SCREW BONE T8 2.7MM 2.1MM 55MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.26 SUP HCPCS C1713 202.260 - SCREW BONE T8 2.7MM 2.1MM 60MM SELF TAP MODULAR STARDRIVE BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 202.608 SUP HCPCS C1713 202.608 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 8MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.609 SUP HCPCS C1713 202.609 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 9MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.61 SUP HCPCS C1713 202.610 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 10MM SELF DRILL SELF BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.611 SUP HCPCS C1713 202.611 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 11MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.612 SUP HCPCS C1713 202.612 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 12MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.613 SUP HCPCS C1713 202.613 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 13MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.614 SUP HCPCS C1713 202.614 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 14MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.615 SUP HCPCS C1713 202.615 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 15MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.616 SUP HCPCS C1713 202.616 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 16MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.617 SUP HCPCS C1713 202.617 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 17MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.618 SUP HCPCS C1713 202.618 - SCREW BONE SHORT THREAD 3MM 18MM CANN STAINLESS STEEL WRIST BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.619 SUP HCPCS C1713 202.619 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 19MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.62 SUP HCPCS C1713 202.620 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 20MM SELF DRILL SELF BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.621 SUP HCPCS C1713 202.621 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 21MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.622 SUP HCPCS C1713 202.622 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 22MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.623 SUP HCPCS C1713 202.623 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 23MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.624 SUP HCPCS C1713 202.624 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 24MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.625 SUP HCPCS C1713 202.625 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 25MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.626 SUP HCPCS C1713 202.626 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 26MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.627 SUP HCPCS C1713 202.627 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 27MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.628 SUP HCPCS C1713 202.628 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 28MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.629 SUP HCPCS C1713 202.629 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 29MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.63 SUP HCPCS C1713 202.630 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 30MM SELF DRILL SELF BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.632 SUP HCPCS C1713 202.632 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 32MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.634 SUP HCPCS C1713 202.634 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 34MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.636 SUP HCPCS C1713 202.636 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 36MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.638 SUP HCPCS C1713 202.638 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 38MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.64 SUP HCPCS C1713 202.640 - SCREW BONE 1/3 THREAD LP 3MM 4MM 1.2MM 40MM SELF DRILL SELF BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.714 SUP HCPCS C1713 202.714 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 14MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.715 SUP HCPCS C1713 202.715 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 15MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.716 SUP HCPCS C1713 202.716 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 16MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.717 SUP HCPCS C1713 202.717 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 17MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.718 SUP HCPCS C1713 202.718 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 18MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.719 SUP HCPCS C1713 202.719 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 19MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.72 SUP HCPCS C1713 202.720 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 20MM SELF DRILL SELF BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.721 SUP HCPCS C1713 202.721 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 21MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.722 SUP HCPCS C1713 202.722 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 22MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $75.48 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.723 SUP HCPCS C1713 202.723 - SCREW BONE LNGTHRD 3MM 4MM 23MM CANN SLFDRILL SLFTAP BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.724 SUP HCPCS C1713 202.724 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 24MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.725 SUP HCPCS C1713 202.725 - SCREW BONE LNGTHRD 3MM 4MM 25MM CANN CRCIFRM RECESS SLFDRILL BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.726 SUP HCPCS C1713 202.726 - SCREW BONE LNGTHRD 3MM 26MM CANN STAINLESS STEEL WRIST HAND BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.727 SUP HCPCS C1713 202.727 - SCREW BONE LNGTHRD 3MM 27MM CANN STAINLESS STEEL WRIST HAND BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.728 SUP HCPCS C1713 202.728 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 28MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.729 SUP HCPCS C1713 202.729 - SCREW BONE LNGTHRD 3MM 29MM CANN STAINLESS STEEL WRIST HAND BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.73 SUP HCPCS C1713 202.730 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 30MM SELF DRILL SELF BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.732 SUP HCPCS C1713 202.732 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 32MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.734 SUP HCPCS C1713 202.734 - SCREW BONE LNGTHRD 3MM 34MM CANN STAINLESS STEEL WRIST HAND BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.736 SUP HCPCS C1713 202.736 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 36MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.738 SUP HCPCS C1713 202.738 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 38MM SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.74 SUP HCPCS C1713 202.740 - SCREW BONE .5 THREAD LP 3MM 4MM 1.2MM 40MM SELF DRILL SELF BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 202.806 SUP HCPCS C1713 202.806 - SCREW BONE 2.7MM 5MM 6MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.808 SUP HCPCS C1713 202.808 - SCREW BONE 2.7MM 5MM 8MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.81 SUP HCPCS C1713 202.810 - SCREW BONE 2.7MM 5MM 10MM SLFTAP SMALL HEXAGONAL SOCKET BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.812 SUP HCPCS C1713 202.812 - SCREW BONE SHORT THREAD 2.7MM 12MM SLFTAP DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.814 SUP HCPCS C1713 202.814 - SCREW BONE 2.7MM 5MM 14MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.816 SUP HCPCS C1713 202.816 - SCREW BONE 2.7MM 16MM SLFTAP LC-DCP STAINLESS STEEL CORTICAL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.818 SUP HCPCS C1713 202.818 - SCREW BN FT 2.7MM 5MM 18MM NS 2.5MM ST SPHRCL HD SM HEX SCKT BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.82 SUP HCPCS C1713 202.820 - SCREW BONE SHORT THREAD 2.7MM 20MM SLFTAP DCP STAINLESS BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.822 SUP HCPCS C1713 202.822 - SCREW BONE 2.7MM 22MM SLFTAP LCP DCP STAINLESS STEEL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.824 SUP HCPCS C1713 202.824 - SCREW BN FT 2.7MM 5MM 24MM NS 2.5MM ST SPHRCL HD SM HEX SCKT BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.826 SUP HCPCS C1713 202.826 - SCREW BONE SHORT THREAD 2.7MM 26MM SLFTAP DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.828 SUP HCPCS C1713 202.828 - SCREW BONE FULTHD 2.7MM 5MM 28MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.83 SUP HCPCS C1713 202.83 - SCREW BONE 2.7MM 30MM LCP DCP SS CORT DISTAL RADL/TIBIAL BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $39.62 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.83 SUP HCPCS C1713 202.830 - SCREW BONE FULTHD SMALL HEXAGON SPHERE 2.7MM 5MM 30MM SELF BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.832 SUP HCPCS C1713 202.832 - SCREW BONE 2.7MM 5MM 32MM SLFTAP SPHERICAL HEAD SMALL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.834 SUP HCPCS C1713 202.834 - SCREW BONE 2.7MM 5MM 34MM SLFTAP SPHERICAL HEAD SMALL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.836 SUP HCPCS C1713 202.836 - SCREW BONE 2.7MM 5MM 36MM SLFTAP SPHERICAL HEAD SMALL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.838 SUP HCPCS C1713 202.838 - SCREW BONE 2.7MM 5MM 38MM SLFTAP SPHERICAL HEAD SMALL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.84 SUP HCPCS C1713 202.84 - SCREW BONE 2.7MM 40MM LCP DCP SS CORT DISTAL RADL/TIBIAL BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $39.58 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.84 SUP HCPCS C1713 202.840 - SCREW BONE 2.7MM 40MM SLFTAP LCP DCP STAINLESS STEEL BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.842 SUP HCPCS C1713 202.842 - SCREW BONE 2.7MM 5MM 42MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.844 SUP HCPCS C1713 202.844 - SCREW BONE 2.7MM 5MM 44MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.845 SUP HCPCS C1713 202.845 - SCREW BONE 2.7MM 5MM 45MM SLFTAP SPHERICAL HEAD SMALL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.846 SUP HCPCS C1713 202.846 - SCREW BONE 2.7MM 5MM 46MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.848 SUP HCPCS C1713 202.848 - SCREW BONE 2.7MM 5MM 48MM SELF TAP CRCIFRM DCP STAINLESS BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.85 SUP HCPCS C1713 202.85 - SCREW BONE 2.7MM 50MM LCP DCP SS CORT DISTAL RADL/TIBIAL BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $39.58 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.85 SUP HCPCS C1713 202.850 - SCREW BONE SHORT THREAD 2.7MM 50MM SLFTAP DCP STAINLESS BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.855 SUP HCPCS C1713 202.855 - SCREW BONE 2.7MM 55MM SLFTAP LCP DCP STAINLESS STEEL BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 202.87 SUP HCPCS C1713 202.870 - SCREW BONE T8 2.7MM 5MM 10MM VAR ANG SELF TAP MODULAR BOTH IP/OP $69.60 $51.50 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.51 $51.66 $51.66 $0.00 $0.00 $14.50 $0.00 $41.17 $41.17 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.872 SUP HCPCS C1713 202.872 - SCREW BONE T8 2.7MM 5MM 12MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.874 SUP HCPCS C1713 202.874 - SCREW BONE 2.7MM 14MM T8 STARDRIVE SELF TAP LCP STAINLESS BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.876 SUP HCPCS C1713 202.876 - SCREW BONE 2.7MM 16MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.878 SUP HCPCS C1713 202.878 - SCREW BONE T8 2.7MM 5MM 18MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.88 SUP HCPCS C1713 202.880 - SCREW BONE T8 2.7MM 5MM 20MM VAR ANG SELF TAP MODULAR BOTH IP/OP $69.60 $51.50 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.51 $51.66 $51.66 $0.00 $0.00 $14.50 $0.00 $41.17 $41.17 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.882 SUP HCPCS C1713 202.882 - SCREW BONE T8 2.7MM 5MM 22MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.884 SUP HCPCS C1713 202.884 - SCREW BONE T8 2.7MM 5MM 24MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.886 SUP HCPCS C1713 202.886 - SCREW BONE T8 2.7MM 5MM 26MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.888 SUP HCPCS C1713 202.888 - SCREW BONE T8 2.7MM 5MM 28MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.89 SUP HCPCS C1713 202.890 - SCREW BONE T8 2.7MM 5MM 30MM VAR ANG SELF TAP MODULAR BOTH IP/OP $69.60 $51.50 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.51 $51.66 $51.66 $0.00 $0.00 $14.50 $0.00 $41.17 $41.17 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.892 SUP HCPCS C1713 202.892 - SCREW BONE T8 2.7MM 5MM 32MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.894 SUP HCPCS C1713 202.894 - SCREW BONE T8 2.7MM 5MM 34MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.896 SUP HCPCS C1713 202.896 - SCREW BONE T8 2.7MM 5MM 36MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.898 SUP HCPCS C1713 202.898 - SCREW BONE T8 2.7MM 5MM 38MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.9 SUP HCPCS C1713 202.900 - SCREW BONE T8 2.7MM 5MM 40MM VAR ANG SELF TAP MODULAR BOTH IP/OP $69.60 $51.50 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.51 $51.66 $51.66 $0.00 $0.00 $14.50 $0.00 $41.17 $41.17 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.962 SUP HCPCS C1713 202.962 - SCREW BONE T8 2.7MM 5MM 42MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.963 SUP HCPCS C1713 202.963 - SCREW BONE T8 2.7MM 5MM 44MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.965 SUP HCPCS C1713 202.965 - SCREW BONE T8 2.7MM 5MM 46MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.966 SUP HCPCS C1713 202.966 - SCREW BONE T8 2.7MM 5MM 48MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.967 SUP HCPCS C1713 202.967 - SCREW BONE T8 2.7MM 5MM 50MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.968 SUP HCPCS C1713 202.968 - SCREW BONE T8 2.7MM 5MM 55MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 202.969 SUP HCPCS C1713 202.969 - SCREW BONE T8 2.7MM 5MM 60MM VAR ANG SELF TAP MODULAR BOTH IP/OP $71.70 $53.06 $0.00 $55.68 $31.32 $31.32 $0.00 $0.00 $0.00 $14.94 $53.22 $53.22 $0.00 $0.00 $14.94 $0.00 $42.41 $42.41 $0.00 $34.80 $55.12 $55.68 $0.00 $0.00 $10.58 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 204.01 SUP HCPCS C1713 204.010 - SCREW BONE STANDARD 3.5MM 6MM 10MM SMALL HEXAGONAL SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.012 SUP HCPCS C1713 204.012 - SCREW BONE STANDARD 3.5MM 6MM 12MM SMALL HEXAGONAL SOCKET BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.014 SUP HCPCS C1713 204.014 - SCREW BONE 3.5MM 14MM SMALL HEXAGONAL SOCKET DCP LC-DCP BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.016 SUP HCPCS C1713 204.016 - SCREW BONE STANDARD 3.5MM 6MM 16MM HEXAGONAL SOCKET LC-DCP BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.018 SUP HCPCS C1713 204.018 - SCREW BONE STANDARD 3.5MM 6MM 18MM HEXAGONAL SOCKET LC-DCP BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.02 SUP HCPCS C1713 204.020 - SCREW BONE STANDARD 3.5MM 6MM 20MM SMALL HEXAGONAL SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.022 SUP HCPCS C1713 204.022 - SCREW BONE STANDARD SMALL HEXAGON 3.5MM 6MM 22MM SOCKET DCP BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $6.76 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.024 SUP HCPCS C1713 204.024 - SCREW BONE 2.5MM STANDARD 3.5MM 6MM 24MM SMALL HEXAGONAL BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.026 SUP HCPCS C1713 204.026 - SCREW BONE 4MM 26MM LOCKING SLFTAP STARDRIVE RECESS LCP BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.028 SUP HCPCS C1713 204.028 - SCREW BONE STANDARD 3.5MM 6MM 28MM SMALL HEXAGONAL SOCKET BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.03 SUP HCPCS C1713 204.030 - SCREW BONE SMALL STANDARD 3.5MM 6MM 30MM HEXAGONAL SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.032 SUP HCPCS C1713 204.032 - SCREW BONE STANDARD 3.5MM 6MM 32MM SLFTAP SMALL HEXAGON BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.034 SUP HCPCS C1713 204.034 - SCREW BONE T25 3.5MM 2.4MM 34MM LOCKING SLFTAP STARDRIVE BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.036 SUP HCPCS C1713 204.036 - SCREW BONE 3.5MM 36MM SMALL FRAGMENT LC-DCP STAINLESS STEEL BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.038 SUP HCPCS C1713 204.038 - SCREW BONE STANDARD 3.5MM 6MM 38MM SLFTAP SMALL HEXAGON BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.04 SUP HCPCS C1713 204.040 - SCREW BONE STANDARD 3.5MM 6MM 40MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.045 SUP HCPCS C1713 204.045 - SCREW BONE 2.5MM SMALL STANDARD 3.5MM 45MM SMALL HEXAGONAL BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.05 SUP HCPCS C1713 204.050 - SCREW BONE STANDARD 3.5MM 6MM 50MM SLFTAP SMALL HEXAGON BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.055 SUP HCPCS C1713 204.055 - SCREW BONE STANDARD 3.5MM 6MM 55MM HEXAGONAL SOCKET LC-DCP BOTH IP/OP $28.45 $21.05 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.93 $21.12 $21.12 $0.00 $0.00 $5.93 $0.00 $16.83 $16.83 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.06 SUP HCPCS C1713 204.060 - SCREW BONE STANDARD 3.5MM 6MM 60MM SELF TAP SMALL HEXAGONAL BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 204.065 SUP HCPCS C1713 204.065 - SCREW BONE STANDARD 3.5MM 6MM 65MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $46.03 $34.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.59 $34.16 $34.16 $0.00 $0.00 $9.59 $0.00 $27.22 $27.22 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.07 SUP HCPCS C1713 204.070 - SCREW BONE STANDARD 3.5MM 6MM 70MM SMALL HEXAGONAL SOCKET BOTH IP/OP $44.68 $33.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.31 $33.16 $33.16 $0.00 $0.00 $9.31 $0.00 $26.43 $26.43 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $10.33 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.075 SUP HCPCS C1713 204.075 - SCREW BONE STANDARD 3.5MM 6MM 75MM SLFTAP SMALL HEXAGON BOTH IP/OP $46.03 $34.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.59 $34.16 $34.16 $0.00 $0.00 $9.59 $0.00 $27.22 $27.22 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $10.33 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.08 SUP HCPCS C1713 204.080 - SCREW BONE STANDARD 3.5MM 6MM 80MM SMALL HEXAGONAL SOCKET BOTH IP/OP $44.68 $33.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.31 $33.16 $33.16 $0.00 $0.00 $9.31 $0.00 $26.43 $26.43 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.085 SUP HCPCS C1713 204.085 - SCREW BONE STANDARD 3.5MM 6MM 85MM SMALL HEXAGONAL SOCKET BOTH IP/OP $46.03 $34.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.59 $34.16 $34.16 $0.00 $0.00 $9.59 $0.00 $27.22 $27.22 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $10.33 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.09 SUP HCPCS C1713 204.090 - SCREW BONE STANDARD 3.5MM 6MM 90MM SMALL HEXAGONAL SOCKET BOTH IP/OP $44.68 $33.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.31 $33.16 $33.16 $0.00 $0.00 $9.31 $0.00 $26.43 $26.43 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.095 SUP HCPCS C1713 204.095 - SCREW BONE STANDARD 3.5MM 6MM 95MM SLFTAP SMALL HEXAGON BOTH IP/OP $46.03 $34.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.59 $34.16 $34.16 $0.00 $0.00 $9.59 $0.00 $27.22 $27.22 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.1 SUP HCPCS C1713 204.100 - SCREW BONE 3.5MM 100MM LC-DCP STAINLESS STEEL CORTICAL BOTH IP/OP $44.68 $33.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.31 $33.16 $33.16 $0.00 $0.00 $9.31 $0.00 $26.43 $26.43 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.105 SUP HCPCS C1713 204.105 - SCREW BONE STANDARD 3.5MM 6MM 105MM SLFTAP SMALL HEXAGON BOTH IP/OP $46.03 $34.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.59 $34.16 $34.16 $0.00 $0.00 $9.59 $0.00 $27.22 $27.22 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.11 SUP HCPCS C1713 204.110 - SCREW BONE STANDARD 3.5MM 6MM 110MM SLFTAP SMALL HEXAGON BOTH IP/OP $44.68 $33.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.31 $33.16 $33.16 $0.00 $0.00 $9.31 $0.00 $26.43 $26.43 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.115 SUP HCPCS C1713 204.115 - SCREW BONE 3.5MM 115MM LC-DCP STAINLESS STEEL CORTICAL BOTH IP/OP $46.03 $34.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.59 $34.16 $34.16 $0.00 $0.00 $9.59 $0.00 $27.22 $27.22 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.12 SUP HCPCS C1713 204.120 - SCREW BONE STANDARD 3.5MM 6MM 120MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $44.68 $33.06 $0.00 $35.74 $20.10 $20.10 $0.00 $0.00 $0.00 $9.31 $33.16 $33.16 $0.00 $0.00 $9.31 $0.00 $26.43 $26.43 $0.00 $22.34 $35.39 $35.74 $0.00 $0.00 $6.79 $0.00 $0.00 $7.11 $0.00 $0.00 $0.00 $0.00 $0.00 204.216 SUP HCPCS C1713 204.216 - SCREW BONE PTHRD 3.5MM 6MM 16MM 6MM SHAFT SMALL HEXAGONAL BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.218 SUP HCPCS C1713 204.218 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 18MM 6MM SELF TAP SOCKET BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.22 SUP HCPCS C1713 204.220 - SCREW BONE PTHRD 3.5MM 6MM 20MM 6MM SHAFT SMALL HEXAGONAL BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.222 SUP HCPCS C1713 204.222 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 22MM 6MM SELF TAP SOCKET BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.224 SUP HCPCS C1713 204.224 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 24MM 10MM SELF TAP SOCKET BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.226 SUP HCPCS C1713 204.226 - SCREW BONE PTHRD 3.5MM 6MM 26MM 10MM SHAFT SMALL HEXAGONAL BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.228 SUP HCPCS C1713 204.228 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 28MM 10MM SELF TAP SOCKET BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.23 SUP HCPCS C1713 204.230 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 30MM 10MM SELF TAP SOCKET BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.232 SUP HCPCS C1713 204.232 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 32MM 12MM SELF TAP SOCKET BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.234 SUP HCPCS C1713 204.234 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 34MM 12MM SELF TAP SOCKET BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.236 SUP HCPCS C1713 204.236 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 36MM 12MM SELF TAP SOCKET BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.238 SUP HCPCS C1713 204.238 - SCREW BONE PTHRD 3.5MM 6MM 38MM 12MM SHAFT SMALL HEXAGONAL BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.24 SUP HCPCS C1713 204.240 - SCREW BONE SMALL HEXAGON 3.5MM 6MM 40MM 12MM SELF TAP SOCKET BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 204.245 SUP HCPCS C1713 204.245 - SCREW BONE 3.5MM 45MM SHAFT LC-DCP STAINLESS STEEL TIBIA BOTH IP/OP $31.80 $23.53 $0.00 $25.44 $14.31 $14.31 $0.00 $0.00 $0.00 $6.63 $23.60 $23.60 $0.00 $0.00 $6.63 $0.00 $18.81 $18.81 $0.00 $15.90 $25.19 $25.44 $0.00 $0.00 $4.98 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 204.25 SUP HCPCS C1713 204.250 - SCREW BONE 3.5MM 6MM 50MM SMALL HEXAGON SOCKET DCP LC-DCP BOTH IP/OP $31.80 $23.53 $0.00 $25.44 $14.31 $14.31 $0.00 $0.00 $0.00 $6.63 $23.60 $23.60 $0.00 $0.00 $6.63 $0.00 $18.81 $18.81 $0.00 $15.90 $25.19 $25.44 $0.00 $0.00 $4.98 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 204.64 SUP HCPCS C1713 204.640 - SCREW BONE 3.5MM 6MM 40MM SELF TAP SMALL HEXAGONAL SOCKET BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.645 SUP HCPCS C1713 204.645 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 45MM SELF TAP SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.65 SUP HCPCS C1713 204.650 - SCREW BONE 3.5MM 6MM 50MM SELF TAP SMALL HEXAGONAL SOCKET BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.655 SUP HCPCS C1713 204.655 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 55MM SELF TAP SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.66 SUP HCPCS C1713 204.660 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 60MM SELF TAP SOCKET BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.665 SUP HCPCS C1713 204.665 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 65MM SELF TAP SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.67 SUP HCPCS C1713 204.670 - SCREW BONE 3.5MM 6MM 70MM SELF TAP SMALL HEXAGONAL SOCKET BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.675 SUP HCPCS C1713 204.675 - SCREW BONE 3.5MM 6MM 75MM SELF TAP SMALL HEXAGONAL SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.68 SUP HCPCS C1713 204.680 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 80MM SELF TAP SOCKET BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.685 SUP HCPCS C1713 204.685 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 85MM SELF TAP SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.69 SUP HCPCS C1713 204.690 - SCREW BONE 3.5MM 6MM 90MM SELF TAP SMALL HEXAGONAL SOCKET BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.695 SUP HCPCS C1713 204.695 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 95MM SELF TAP SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.7 SUP HCPCS C1713 204.700 - SCREW BONE 3.5MM 6MM 100MM SELF TAP SMALL HEXAGONAL SOCKET BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.705 SUP HCPCS C1713 204.705 - SCREW BONE 3.5MM 6MM 105MM SELF TAP SMALL HEXAGONAL SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.71 SUP HCPCS C1713 204.710 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 110MM SELF TAP SOCKET BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.715 SUP HCPCS C1713 204.715 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 115MM SELF TAP SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.72 SUP HCPCS C1713 204.720 - SCREW BONE 3.5MM 120MM SLFTAP LC-DCP STAINLESS STEEL CORTEX BOTH IP/OP $51.85 $38.37 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $10.81 $38.48 $38.48 $0.00 $0.00 $10.81 $0.00 $30.67 $30.67 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.725 SUP HCPCS C1713 204.725 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 125MM SELF TAP SOCKET BOTH IP/OP $53.43 $39.54 $0.00 $41.48 $23.33 $23.33 $0.00 $0.00 $0.00 $11.14 $39.65 $39.65 $0.00 $0.00 $11.13 $0.00 $31.60 $31.60 $0.00 $25.93 $41.07 $41.48 $0.00 $0.00 $7.88 $0.00 $0.00 $8.25 $0.00 $0.00 $0.00 $0.00 $0.00 204.73 SUP HCPCS C1713 204.730 - SCREW BONE 3.5MM 6MM 130MM SLFTAP LP SMALL HEXAGONAL SOCKET BOTH IP/OP $165.13 $122.20 $0.00 $132.10 $74.31 $74.31 $0.00 $0.00 $0.00 $34.42 $122.56 $122.56 $0.00 $0.00 $34.41 $0.00 $97.67 $97.67 $0.00 $82.56 $130.78 $132.10 $0.00 $0.00 $25.09 $0.00 $0.00 $26.29 $0.00 $0.00 $0.00 $0.00 $0.00 204.735 SUP HCPCS C1713 204.735 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 135MM SELF TAP SOCKET BOTH IP/OP $170.10 $125.87 $0.00 $132.10 $74.31 $74.31 $0.00 $0.00 $0.00 $35.45 $126.25 $126.25 $0.00 $0.00 $35.45 $0.00 $100.61 $100.61 $0.00 $82.56 $130.78 $132.10 $0.00 $0.00 $25.09 $0.00 $0.00 $26.29 $0.00 $0.00 $0.00 $0.00 $0.00 204.74 SUP HCPCS C1713 204.740 - SCREW BONE 3.5MM 6MM 140MM SLFTAP LP SMALL HEXAGONAL SOCKET BOTH IP/OP $165.13 $122.20 $0.00 $132.10 $74.31 $74.31 $0.00 $0.00 $0.00 $34.42 $122.56 $122.56 $0.00 $0.00 $34.41 $0.00 $97.67 $97.67 $0.00 $82.56 $130.78 $132.10 $0.00 $0.00 $25.09 $0.00 $0.00 $26.29 $0.00 $0.00 $0.00 $0.00 $0.00 204.745 SUP HCPCS C1713 204.745 - SCREW BONE SMALL HEXAGON LP 3.5MM 6MM 145MM SELF TAP SOCKET BOTH IP/OP $170.10 $125.87 $0.00 $132.10 $74.31 $74.31 $0.00 $0.00 $0.00 $35.45 $126.25 $126.25 $0.00 $0.00 $35.45 $0.00 $100.61 $100.61 $0.00 $82.56 $130.78 $132.10 $0.00 $0.00 $25.09 $0.00 $0.00 $26.29 $0.00 $0.00 $0.00 $0.00 $0.00 204.75 SUP HCPCS C1713 204.750 - SCREW BONE 3.5MM 6MM 150MM SLFTAP LP SMALL HEXAGONAL SOCKET BOTH IP/OP $165.13 $122.20 $0.00 $132.10 $74.31 $74.31 $0.00 $0.00 $0.00 $34.42 $122.56 $122.56 $0.00 $0.00 $34.41 $0.00 $97.67 $97.67 $0.00 $82.56 $130.78 $132.10 $0.00 $0.00 $25.09 $0.00 $0.00 $26.29 $0.00 $0.00 $0.00 $0.00 $0.00 204.81 SUP HCPCS C1713 204.810 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 10MM SELF TAP LC-DCP DCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.812 SUP HCPCS C1713 204.812 - SCREW BONE FULTHD 3.5MM 6MM 12MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.814 SUP HCPCS C1713 204.814 - SCREW BONE FULTHD 3.5MM 6MM 14MM SELF TAP SMALL HEXAGONAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.816 SUP HCPCS C1713 204.816 - SCREW BONE FULTHD 3.5MM 6MM 16MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.818 SUP HCPCS C1713 204.818 - SCREW BONE 3.5MM 18MM SLFTAP LCP STAINLESS STEEL CORTICAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.82 SUP HCPCS C1713 204.820 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 20MM SELF TAP LC-DCP DCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.822 SUP HCPCS C1713 204.822 - SCREW BONE 3.5MM 22MM SLFTAP LCP STAINLESS STEEL CORTICAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.824 SUP HCPCS C1713 204.824 - SCREW BONE 3.5MM 24MM SLFTAP LCP STAINLESS STEEL CORTICAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.826 SUP HCPCS C1713 204.826 - SCREW BONE 3.5MM 26MM SLFTAP LCP STAINLESS STEEL CORTICAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.828 SUP HCPCS C1713 204.828 - SCREW BONE 3.5MM 28MM SLFTAP HEXAGONAL RECESS DCP LC-DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.83 SUP HCPCS C1713 204.830 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 30MM SELF TAP LC-DCP DCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.832 SUP HCPCS C1713 204.832 - SCREW BONE FULTHD 3.5MM 6MM 32MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.834 SUP HCPCS C1713 204.834 - SCREW BONE FULTHD 3.5MM 6MM 34MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.836 SUP HCPCS C1713 204.836 - SCREW BONE FULTHD 3.5MM 6MM 36MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.838 SUP HCPCS C1713 204.838 - SCREW BONE 3.5MM 38MM SLFTAP HEXAGONAL RECESS DCP LC-DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.84 SUP HCPCS C1713 204.840 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 40MM SELF TAP LC-DCP DCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.842 SUP HCPCS C1713 204.842 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 42MM SELF TAP SOCKET DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.844 SUP HCPCS C1713 204.844 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 44MM SELF TAP SOCKET DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.845 SUP HCPCS C1713 204.845 - SCREW BONE 3.5MM 45MM SLFTAP LCP STAINLESS STEEL CORTICAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.846 SUP HCPCS C1713 204.846 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 46MM SELF TAP SOCKET DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.848 SUP HCPCS C1713 204.848 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 48MM SELF TAP SOCKET DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.85 SUP HCPCS C1713 204.850 - SCREW BONE FULTHD 3.5MM 6MM 50MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.855 SUP HCPCS C1713 204.855 - SCREW BONE 3.5MM 55MM SLFTAP HEXAGONAL RECESS DCP LC-DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.86 SUP HCPCS C1713 204.860 - SCREW BONE FULTHD 3.5MM 6MM 60MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.865 SUP HCPCS C1713 204.865 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 65MM SELF TAP SOCKET DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.87 SUP HCPCS C1713 204.870 - SCREW BONE FULTHD 3.5MM 6MM 70MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.875 SUP HCPCS C1713 204.875 - SCREW BONE FULTHD 3.5MM 6MM 75MM SLFTAP SMALL HEXAGONAL BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.88 SUP HCPCS C1713 204.880 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 80MM SELF TAP SOCKET DCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.885 SUP HCPCS C1713 204.885 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 85MM SELF TAP SOCKET DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.89 SUP HCPCS C1713 204.890 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 90MM SELF TAP SOCKET DCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $8.63 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.89 SUP HCPCS C1713 204.89 - SCREW BONE 3.5MM 90MM LC DCP SS CORT PROX MDL PLVC TIBIAL BOTH IP/OP $38.55 $28.53 $0.00 $40.04 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $40.04 $30.84 $0.00 $0.00 $8.63 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.895 SUP HCPCS C1713 204.895 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 95MM SELF TAP SOCKET DCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.9 SUP HCPCS C1713 204.900 - SCREW BONE 3.5MM 100MM SLFTAP LC-DCP STAINLESS STEEL TIBIA BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.905 SUP HCPCS C1713 204.905 - SCREW BONE 3.5MM 105MM SLFTAP LC-DCP STAINLESS STEEL TIBIA BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 204.91 SUP HCPCS C1713 204.910 - SCREW BONE 3.5MM 110MM SLFTAP LC-DCP STAINLESS STEEL TIBIA BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 205.01 SUP HCPCS C1713 205.010 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $343.93 $254.51 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $71.68 $255.26 $255.26 $0.00 $0.00 $71.67 $0.00 $203.43 $203.43 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.012 SUP HCPCS C1713 205.012 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $70.23 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.014 SUP HCPCS C1713 205.014 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.016 SUP HCPCS C1713 205.016 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.018 SUP HCPCS C1713 205.018 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.02 SUP HCPCS C1713 205.020 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $343.93 $254.51 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $71.68 $255.26 $255.26 $0.00 $0.00 $71.67 $0.00 $203.43 $203.43 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.022 SUP HCPCS C1713 205.022 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.024 SUP HCPCS C1713 205.024 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.026 SUP HCPCS C1713 205.026 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.028 SUP HCPCS C1713 205.028 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.03 SUP HCPCS C1713 205.030 - SCREW BONE PTHRD 3.5MM 30MM 10MM CANN HEMISPHERICAL HEAD BOTH IP/OP $343.93 $254.51 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $71.68 $255.26 $255.26 $0.00 $0.00 $71.67 $0.00 $203.43 $203.43 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.032 SUP HCPCS C1713 205.032 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.034 SUP HCPCS C1713 205.034 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.036 SUP HCPCS C1713 205.036 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.038 SUP HCPCS C1713 205.038 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.04 SUP HCPCS C1713 205.040 - SCREW BONE PTHRD 3.5MM 40MM 13MM CANN HEMISPHERICAL HEAD BOTH IP/OP $343.93 $254.51 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $71.68 $255.26 $255.26 $0.00 $0.00 $71.67 $0.00 $203.43 $203.43 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.042 SUP HCPCS C1713 205.042 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.044 SUP HCPCS C1713 205.044 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.046 SUP HCPCS C1713 205.046 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.048 SUP HCPCS C1713 205.048 - SCREW BONE SMALL HEXAGON SPHERE REVERSE CUT FLUTE LP 3.5MM 5 BOTH IP/OP $354.23 $262.13 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $73.83 $262.91 $262.91 $0.00 $0.00 $73.82 $0.00 $209.52 $209.52 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.05 SUP HCPCS C1713 205.050 - SCREW BONE PTHRD 3.5MM 50MM 16MM CANN HEMISPHERICAL HEAD BOTH IP/OP $343.93 $254.51 $0.00 $275.14 $154.77 $154.77 $0.00 $0.00 $0.00 $71.68 $255.26 $255.26 $0.00 $0.00 $71.67 $0.00 $203.43 $203.43 $0.00 $171.96 $272.39 $275.14 $0.00 $0.00 $52.26 $0.00 $0.00 $54.75 $0.00 $0.00 $0.00 $0.00 $0.00 205.21 SUP HCPCS C1713 205.210 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $353.48 $261.58 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $73.67 $262.35 $262.35 $0.00 $0.00 $73.66 $0.00 $209.08 $209.08 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.212 SUP HCPCS C1713 205.212 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.214 SUP HCPCS C1713 205.214 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.216 SUP HCPCS C1713 205.216 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.218 SUP HCPCS C1713 205.218 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.22 SUP HCPCS C1713 205.220 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $353.48 $261.58 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $73.67 $262.35 $262.35 $0.00 $0.00 $73.66 $0.00 $209.08 $209.08 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $70.23 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.222 SUP HCPCS C1713 205.222 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $70.23 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.224 SUP HCPCS C1713 205.224 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.226 SUP HCPCS C1713 205.226 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.228 SUP HCPCS C1713 205.228 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $70.23 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.23 SUP HCPCS C1713 205.230 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $353.48 $261.58 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $73.67 $262.35 $262.35 $0.00 $0.00 $73.66 $0.00 $209.08 $209.08 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.232 SUP HCPCS C1713 205.232 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.234 SUP HCPCS C1713 205.234 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.236 SUP HCPCS C1713 205.236 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.238 SUP HCPCS C1713 205.238 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.24 SUP HCPCS C1713 205.240 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $353.48 $261.58 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $73.67 $262.35 $262.35 $0.00 $0.00 $73.66 $0.00 $209.08 $209.08 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.242 SUP HCPCS C1713 205.242 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.244 SUP HCPCS C1713 205.244 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.246 SUP HCPCS C1713 205.246 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.248 SUP HCPCS C1713 205.248 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $364.08 $269.42 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $75.88 $270.22 $270.22 $0.00 $0.00 $75.87 $0.00 $215.35 $215.35 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 205.25 SUP HCPCS C1713 205.250 - SCREW BONE FULTHD SMALL HEXAGON SPHERE REVERSE CUT FLUTE 3.5 BOTH IP/OP $353.48 $261.58 $0.00 $282.78 $159.06 $159.06 $0.00 $0.00 $0.00 $73.67 $262.35 $262.35 $0.00 $0.00 $73.66 $0.00 $209.08 $209.08 $0.00 $176.74 $279.96 $282.78 $0.00 $0.00 $53.71 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $0.00 206.01 SUP HCPCS C1713 206.010 - SCREW BN FT 4MM 6MM 10MM NS SM HEX SCKT SS CANC SM FRAG SET BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.01 SUP HCPCS C1713 206.01 - SCREW BONE 4MM 10MM LC DCP SS CANC PROX MDL TIBIAL FULTHD BOTH IP/OP $31.73 $23.48 $0.00 $33.17 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $33.17 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.012 SUP HCPCS C1713 206.012 - SCREW BONE FULTHD 4MM 12MM FULTHRD LCP STAINLESS STEEL BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.014 SUP HCPCS C1713 206.014 - SCREW BONE PTHRD 4MM 6MM 14MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.016 SUP HCPCS C1713 206.016 - SCREW BONE PTHRD 4MM 6MM 16MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.018 SUP HCPCS C1713 206.018 - SCREW BONE PTHRD 4MM 6MM 18MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.02 SUP HCPCS C1713 206.020 - SCREW BONE PTHRD 4MM 6MM 20MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.02 SUP HCPCS C1713 206.02 - SCREW BONE 4MM 20MM LC DCP SS CANC PROX MDL TIBIAL FULTHD BOTH IP/OP $31.73 $23.48 $0.00 $32.19 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $32.19 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.022 SUP HCPCS C1713 206.022 - SCREW BONE FULTHD 4MM 22MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.024 SUP HCPCS C1713 206.024 - SCREW BONE PTHRD 4MM 6MM 24MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.026 SUP HCPCS C1713 206.026 - SCREW BONE 2.5MM FULTHD 4MM 26MM SELF TAP HEXAGONAL SHAFT BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.028 SUP HCPCS C1713 206.028 - SCREW BONE 2.5MM FULTHD 4MM 28MM SELF TAP HEXAGONAL SHAFT BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.03 SUP HCPCS C1713 206.030 - SCREW BONE FULTHD HEXAGON 4MM 6MM 30MM SELF TAP SOCKET LCP BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.03 SUP HCPCS C1713 206.03 - SCREW BONE 4MM 30MM LC DCP SS CANC PROX MDL TIBIAL FULTHD BOTH IP/OP $31.73 $23.48 $0.00 $32.19 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $32.19 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.032 SUP HCPCS C1713 206.032 - SCREW BONE FULTHD 4MM 32MM LOCK SELF TAP LCP STAINLESS STEEL BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.035 SUP HCPCS C1713 206.035 - SCREW BONE 2.5MM FULTHD 4MM 35MM SELF TAP HEXAGONAL SHAFT BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.036 SUP HCPCS C1713 206.036 - SCREW BONE 2.5MM FULTHD 4MM 36MM SELF TAP HEXAGONAL SHAFT BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.04 SUP HCPCS C1713 206.040 - SCREW BONE 2.5MM FULTHD 4MM 40MM LOCKING HEXAGONAL SOCKET BOTH IP/OP $31.73 $23.48 $0.00 $31.62 $17.79 $17.79 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $19.76 $25.13 $31.62 $0.00 $0.00 $6.19 $0.00 $0.00 $6.29 $0.00 $0.00 $0.00 $0.00 $0.00 206.04 SUP HCPCS C1713 206.04 - SCREW BONE 4MM 40MM LC DCP SS CANC PROX MDL TIBIAL FULTHD BOTH IP/OP $31.73 $23.48 $0.00 $31.62 $17.79 $17.79 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $19.76 $31.31 $31.62 $0.00 $0.00 $6.19 $0.00 $0.00 $6.29 $0.00 $0.00 $0.00 $0.00 $0.00 206.045 SUP HCPCS C1713 206.045 - SCREW BONE FULTHD 4MM 45MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.05 SUP HCPCS C1713 206.050 - SCREW BONE FULTHD 4MM 6MM 50MM 15MM SMALL HEXOGONAL SOCKET BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.055 SUP HCPCS C1713 206.055 - SCREW BONE PTHRD 4MM 6MM 55MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.06 SUP HCPCS C1713 206.060 - SCREW BONE FULTHD 4MM 60MM 15MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $7.23 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.06 SUP HCPCS C1713 206.06 - SCREW BONE 4MM 60MM LC DCP SS CANC PROX MDL TIBIAL FULTHD BOTH IP/OP $31.73 $23.48 $0.00 $32.19 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $32.19 $25.38 $0.00 $0.00 $7.23 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 206.065 SUP HCPCS C1713 206.065 - SCREW BONE FULTHD 4MM 65MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $35.83 $26.51 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.47 $26.59 $26.59 $0.00 $0.00 $7.47 $0.00 $21.19 $21.19 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 206.07 SUP HCPCS C1713 206.070 - SCREW BONE FULTHD 4MM 70MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $34.80 $25.75 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.25 $25.83 $25.83 $0.00 $0.00 $7.25 $0.00 $20.58 $20.58 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 206.08 SUP HCPCS C1713 206.080 - SCREW BONE FULTHD 4MM 80MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $34.80 $25.75 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.25 $25.83 $25.83 $0.00 $0.00 $7.25 $0.00 $20.58 $20.58 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 206.085 SUP HCPCS C1713 206.085 - SCREW BONE FULTHD 4MM 85MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $35.83 $26.51 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.47 $26.59 $26.59 $0.00 $0.00 $7.47 $0.00 $21.19 $21.19 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 206.09 SUP HCPCS C1713 206.090 - SCREW BONE FULTHD 4MM 90MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $34.80 $25.75 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.25 $25.83 $25.83 $0.00 $0.00 $7.25 $0.00 $20.58 $20.58 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 206.095 SUP HCPCS C1713 206.095 - SCREW BONE FULTHD 4MM 95MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $35.83 $26.51 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.47 $26.59 $26.59 $0.00 $0.00 $7.47 $0.00 $21.19 $21.19 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 206.1 SUP HCPCS C1713 206.100 - SCREW BONE FULTHD 4MM 100MM LOCKING SLFTAP LCP STAINLESS BOTH IP/OP $34.80 $25.75 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.25 $25.83 $25.83 $0.00 $0.00 $7.25 $0.00 $20.58 $20.58 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 206.414 SUP HCPCS C1713 206.414 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 14MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.416 SUP HCPCS C1713 206.416 - SCREW BONE 2.5MM SMALL FULTHD HEXAGON 4MM 6MM 16MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.418 SUP HCPCS C1713 206.418 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 18MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.42 SUP HCPCS C1713 206.420 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 20MM SELF TAP BOTH IP/OP $47.78 $35.36 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $9.96 $35.46 $35.46 $0.00 $0.00 $9.96 $0.00 $28.26 $28.26 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.422 SUP HCPCS C1713 206.422 - SCREW BONE 2.5MM SMALL FULTHD HEXAGON 4MM 6MM 22MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.424 SUP HCPCS C1713 206.424 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 24MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.426 SUP HCPCS C1713 206.426 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 26MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.428 SUP HCPCS C1713 206.428 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 28MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.43 SUP HCPCS C1713 206.430 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 30MM SELF TAP BOTH IP/OP $47.78 $35.36 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $9.96 $35.46 $35.46 $0.00 $0.00 $9.96 $0.00 $28.26 $28.26 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.432 SUP HCPCS C1713 206.432 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 32MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.434 SUP HCPCS C1713 206.434 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 34MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.436 SUP HCPCS C1713 206.436 - SCREW BONE 2.5MM SMALL FULTHD HEXAGON 4MM 6MM 36MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.438 SUP HCPCS C1713 206.438 - SCREW BONE FULTHD 4MM 6MM 38MM SLFTAP HEXAGON RECESS LCP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.44 SUP HCPCS C1713 206.440 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 40MM SELF TAP BOTH IP/OP $47.78 $35.36 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $9.96 $35.46 $35.46 $0.00 $0.00 $9.96 $0.00 $28.26 $28.26 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.442 SUP HCPCS C1713 206.442 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 42MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.444 SUP HCPCS C1713 206.444 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 44MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $10.24 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.446 SUP HCPCS C1713 206.446 - SCREW BONE 2.5MM FULTHD 4MM 6MM 46MM SELF TAP SMALL BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.448 SUP HCPCS C1713 206.448 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 48MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.45 SUP HCPCS C1713 206.450 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 50MM SELF TAP BOTH IP/OP $47.78 $35.36 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $9.96 $35.46 $35.46 $0.00 $0.00 $9.96 $0.00 $28.26 $28.26 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.452 SUP HCPCS C1713 206.452 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 52MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.454 SUP HCPCS C1713 206.454 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 54MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.456 SUP HCPCS C1713 206.456 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 56MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.458 SUP HCPCS C1713 206.458 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 58MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.46 SUP HCPCS C1713 206.460 - SCREW BONE FULTHD 4MM 6MM 60MM SLFTAP HEXAGON RECESS LCP BOTH IP/OP $47.78 $35.36 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $9.96 $35.46 $35.46 $0.00 $0.00 $9.96 $0.00 $28.26 $28.26 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.465 SUP HCPCS C1713 206.465 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 65MM SELF TAP BOTH IP/OP $49.20 $36.41 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $10.25 $36.52 $36.52 $0.00 $0.00 $10.25 $0.00 $29.10 $29.10 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.47 SUP HCPCS C1713 206.470 - SCREW BONE FULTHD 4MM 6MM 70MM SELF TAP SMALL HEXAGONAL BOTH IP/OP $47.78 $35.36 $0.00 $38.22 $21.50 $21.50 $0.00 $0.00 $0.00 $9.96 $35.46 $35.46 $0.00 $0.00 $9.96 $0.00 $28.26 $28.26 $0.00 $23.89 $37.84 $38.22 $0.00 $0.00 $7.26 $0.00 $0.00 $7.61 $0.00 $0.00 $0.00 $0.00 $0.00 206.475 SUP HCPCS C1713 206.475 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 75MM SELF TAP BOTH IP/OP $87.85 $65.01 $0.00 $68.22 $38.37 $38.37 $0.00 $0.00 $0.00 $18.31 $65.20 $65.20 $0.00 $0.00 $18.31 $0.00 $51.96 $51.96 $0.00 $42.64 $67.54 $68.22 $0.00 $0.00 $12.96 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 206.48 SUP HCPCS C1713 206.480 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 80MM SELF TAP BOTH IP/OP $85.28 $63.11 $0.00 $68.22 $38.37 $38.37 $0.00 $0.00 $0.00 $17.77 $63.29 $63.29 $0.00 $0.00 $17.77 $0.00 $50.44 $50.44 $0.00 $42.64 $67.54 $68.22 $0.00 $0.00 $12.96 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 206.485 SUP HCPCS C1713 206.485 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 85MM SELF TAP BOTH IP/OP $87.85 $65.01 $0.00 $68.22 $38.37 $38.37 $0.00 $0.00 $0.00 $18.31 $65.20 $65.20 $0.00 $0.00 $18.31 $0.00 $51.96 $51.96 $0.00 $42.64 $67.54 $68.22 $0.00 $0.00 $12.96 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 206.49 SUP HCPCS C1713 206.490 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 90MM SELF TAP BOTH IP/OP $85.28 $63.11 $0.00 $68.22 $38.37 $38.37 $0.00 $0.00 $0.00 $17.77 $63.29 $63.29 $0.00 $0.00 $17.77 $0.00 $50.44 $50.44 $0.00 $42.64 $67.54 $68.22 $0.00 $0.00 $12.96 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 206.495 SUP HCPCS C1713 206.495 - SCREW BONE 2.5MM FULTHD SMALL HEXAGON 4MM 6MM 95MM SELF TAP BOTH IP/OP $87.85 $65.01 $0.00 $68.22 $38.37 $38.37 $0.00 $0.00 $0.00 $18.31 $65.20 $65.20 $0.00 $0.00 $18.31 $0.00 $51.96 $51.96 $0.00 $42.64 $67.54 $68.22 $0.00 $0.00 $12.96 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 206.5 SUP HCPCS C1713 206.500 - SCREW BONE 4MM 100MM SLFTAP STAINLESS STEEL CORTICAL NONSTRL BOTH IP/OP $85.28 $63.11 $0.00 $68.22 $38.37 $38.37 $0.00 $0.00 $0.00 $17.77 $63.29 $63.29 $0.00 $0.00 $17.77 $0.00 $50.44 $50.44 $0.00 $42.64 $67.54 $68.22 $0.00 $0.00 $12.96 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 207.01 SUP HCPCS C1713 207.010 - SCREW BONE PTHRD 4MM 2.5MM 10MM 7MM SMALL HEXAGONAL SOCKET BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.012 SUP HCPCS C1713 207.012 - SCREW BONE PTHRD 4MM 2.5MM 12MM 7MM SMALL HEXAGONAL SOCKET BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $7.23 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.014 SUP HCPCS C1713 207.014 - SCREW BONE PTHRD 4MM 14MM 5MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.016 SUP HCPCS C1713 207.016 - SCREW BONE PTHRD 4MM 16MM 6MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.018 SUP HCPCS C1713 207.018 - SCREW BONE PTHRD 4MM 2.5MM 18MM 7MM SMALL HEXAGONAL SOCKET BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.02 SUP HCPCS C1713 207.020 - SCREW BONE PTHRD 4MM 20MM LCP STAINLESS STEEL CANCELLOUS RAD BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.02 SUP HCPCS C1713 207.02 - SCREW BONE 4MM 20MM LC DCP SS CANC PROX MDL TIBIAL P/T NSTRL BOTH IP/OP $30.03 $22.22 $0.00 $32.19 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $32.19 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.022 SUP HCPCS C1713 207.022 - SCREW BONE PTHRD 4MM 22MM 9MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.024 SUP HCPCS C1713 207.024 - SCREW BONE PTHRD 4MM 24MM 10MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.026 SUP HCPCS C1713 207.026 - SCREW BONE PTHRD 4MM 26MM 12MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.028 SUP HCPCS C1713 207.028 - SCREW BONE PTHRD 4MM 28MM 14MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.03 SUP HCPCS C1713 207.030 - SCREW BONE PTHRD 4MM 30MM 6MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.035 SUP HCPCS C1713 207.035 - SCREW BONE PTHRD 4MM 35MM LCP STAINLESS STEEL CANCELLOUS RAD BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.04 SUP HCPCS C1713 207.040 - SCREW BONE PTHRD 4MM 40MM 14MM SMALL HEXAGONAL SOCKET LCP BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.045 SUP HCPCS C1713 207.045 - SCREW BONE PTHRD 4MM 45MM SELF TAP HEXAGONAL SHAFT LC-DCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.05 SUP HCPCS C1713 207.050 - SCREW BONE 4MM 50MM LCP SS PTHRD CANC TIB NONSTRL SM FRAG BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.055 SUP HCPCS C1713 207.055 - SCREW BONE SMALL HEXAGON 4MM 6MM 55MM 15MM SOCKET LCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.06 SUP HCPCS C1713 207.060 - SCREW BONE SMALL HEXAGON 4MM 6MM 60MM 15MM SOCKET LCP BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 207.065 SUP HCPCS C1713 207.065 - SCREW BONE PTHRD 4MM 65MM PTHRD LCP STAINLESS STEEL BOTH IP/OP $35.15 $26.01 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.33 $26.09 $26.09 $0.00 $0.00 $7.33 $0.00 $20.79 $20.79 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 207.07 SUP HCPCS C1713 207.070 - SCREW BONE PTHRD 4MM 70MM PTTHRD LCP STAINLESS STEEL BOTH IP/OP $34.13 $25.26 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.11 $25.33 $25.33 $0.00 $0.00 $7.11 $0.00 $20.18 $20.18 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 207.075 SUP HCPCS C1713 207.075 - SCREW BONE PTHRD 4MM 75MM PTHRD LCP STAINLESS STEEL BOTH IP/OP $35.15 $26.01 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.33 $26.09 $26.09 $0.00 $0.00 $7.33 $0.00 $20.79 $20.79 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 207.08 SUP HCPCS C1713 207.080 - SCREW BONE PTHRD 4MM 80MM PTTHRD LCP STAINLESS STEEL BOTH IP/OP $34.13 $25.26 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.11 $25.33 $25.33 $0.00 $0.00 $7.11 $0.00 $20.18 $20.18 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 207.085 SUP HCPCS C1713 207.085 - SCREW BONE 4MM 85MM PTHRD LC-DCP DCP STAINLESS STEEL BOTH IP/OP $35.15 $26.01 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.33 $26.09 $26.09 $0.00 $0.00 $7.33 $0.00 $20.79 $20.79 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 207.09 SUP HCPCS C1713 207.090 - SCREW BONE PTHRD 4MM 90MM PTTHRD LCP STAINLESS STEEL BOTH IP/OP $34.13 $25.26 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.11 $25.33 $25.33 $0.00 $0.00 $7.11 $0.00 $20.18 $20.18 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 207.095 SUP HCPCS C1713 207.095 - SCREW BONE PTHRD 4MM 95MM PTHRD LCP STAINLESS STEEL BOTH IP/OP $35.15 $26.01 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.33 $26.09 $26.09 $0.00 $0.00 $7.33 $0.00 $20.79 $20.79 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 207.1 SUP HCPCS C1713 207.100 - SCREW BONE 4MM 100MM PTTHRD LC-DCP DCP STAINLESS STEEL BOTH IP/OP $34.13 $25.26 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.11 $25.33 $25.33 $0.00 $0.00 $7.11 $0.00 $20.18 $20.18 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 207.61 SUP HCPCS C1713 207.610 - SCREW BONE SHORT THREAD 4MM 10MM CANN LCP STAINLESS STEEL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $73.99 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.612 SUP HCPCS C1713 207.612 - SCREW BONE SHORT THREAD 4MM 12MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $73.99 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.614 SUP HCPCS C1713 207.614 - SCREW BONE SHORT THREAD 4MM 14MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $73.99 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.616 SUP HCPCS C1713 207.616 - SCREW BONE SHORT THREAD 4MM 16MM 1/3MM CANN LCP STAINLESS BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.618 SUP HCPCS C1713 207.618 - SCREW BONE SHORT THREAD 4MM 18MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.622 SUP HCPCS C1713 207.622 - SCREW BONE SHORT THREAD 4MM 22MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.624 SUP HCPCS C1713 207.624 - SCREW BONE SHORT THREAD 4MM 24MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.626 SUP HCPCS C1713 207.626 - SCREW BONE SHORT THREAD 4MM 26MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.628 SUP HCPCS C1713 207.628 - SCREW BONE SHORT THREAD 4MM 28MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.63 SUP HCPCS C1713 207.630 - SCREW BONE SHORT THREAD 4MM 30MM CANN LCP STAINLESS STEEL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.63 SUP HCPCS C1713 207.63 - SCREW BONE 4MM 30MM LCP SS ST ORTH CANN NSTRL SM FRAG SET BOTH IP/OP $357.58 $264.61 $0.00 $344.35 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $344.35 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.632 SUP HCPCS C1713 207.632 - SCREW BONE SHORT THREAD 4MM 32MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.634 SUP HCPCS C1713 207.634 - SCREW BONE SHORT THREAD 4MM 34MM 11MM CANN LCP STAINLESS BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.636 SUP HCPCS C1713 207.636 - SCREW BONE SHORT THREAD 4MM 36MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.638 SUP HCPCS C1713 207.638 - SCREW BONE SHORT THREAD 4MM 38MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.64 SUP HCPCS C1713 207.640 - SCREW BONE SHORT THREAD 4MM 40MM CANN LCP STAINLESS STEEL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.64 SUP HCPCS C1713 207.64 - SCREW BONE 4MM 40MM LCP SS ST ORTH CANN NSTRL SM FRAG SET BOTH IP/OP $357.58 $264.61 $0.00 $329.46 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $329.46 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.642 SUP HCPCS C1713 207.642 - SCREW BONE SHORT THREAD 4MM 42MM CANN SHORT THREAD LCP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.644 SUP HCPCS C1713 207.644 - SCREW BONE SHORT THREAD 4MM 44MM 1/3MM CANN LCP STAINLESS BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.646 SUP HCPCS C1713 207.646 - SCREW BONE SHORT THREAD 4MM 46MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.648 SUP HCPCS C1713 207.648 - SCREW BONE SHORT THREAD 4MM 48MM CANN LCP STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.65 SUP HCPCS C1713 207.650 - SCREW BONE SHORT THREAD HEXAGON LP 4MM 5MM 50MM SELF DRILL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.65 SUP HCPCS C1713 207.65 - SCREW BONE 4MM 50MM LCP SS ST ORTH CANN NSTRL SM FRAG SET BOTH IP/OP $357.58 $264.61 $0.00 $329.46 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $329.46 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.652 SUP HCPCS C1713 207.652 - SCREW BONE 2.5MM SHORT THREAD SMALL HEXAGON 4MM 5MM 1.35MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.654 SUP HCPCS C1713 207.654 - SCREW BONE 2.5MM SHORT THREAD SMALL HEXAGON 4MM 5MM 1.35MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.656 SUP HCPCS C1713 207.656 - SCREW BONE 2.5MM SHORT THREAD SMALL HEXAGON 4MM 5MM 1.35MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.658 SUP HCPCS C1713 207.658 - SCREW BONE 2.5MM SHORT THREAD SMALL HEXAGON 4MM 5MM 1.35MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.66 SUP HCPCS C1713 207.660 - SCREW BONE 2.5MM SHORT THREAD SMALL HEXAGON 4MM 5MM 1.35MM BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.664 SUP HCPCS C1713 207.664 - SCREW BONE 2.5MM SHORT THREAD SMALL HEXAGON 4MM 5MM 1.35MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.668 SUP HCPCS C1713 207.668 - SCREW BONE 2.5MM SHORT THREAD SMALL HEXAGON 4MM 5MM 1.35MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.672 SUP HCPCS C1713 207.672 - SCREW BONE 2.5MM SHORT THREAD SMALL HEXAGON 4MM 5MM 1.35MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.716 SUP HCPCS C1713 207.716 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.718 SUP HCPCS C1713 207.718 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.72 SUP HCPCS C1713 207.720 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.722 SUP HCPCS C1713 207.722 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.724 SUP HCPCS C1713 207.724 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.726 SUP HCPCS C1713 207.726 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.728 SUP HCPCS C1713 207.728 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $73.99 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.73 SUP HCPCS C1713 207.730 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.732 SUP HCPCS C1713 207.732 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.734 SUP HCPCS C1713 207.734 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.736 SUP HCPCS C1713 207.736 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.738 SUP HCPCS C1713 207.738 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.74 SUP HCPCS C1713 207.740 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.74 SUP HCPCS C1713 207.74 - SCREW BONE 4MM 40MM SS L/T ORTH CANN NSTRL BOTH IP/OP $357.58 $264.61 $0.00 $344.35 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $344.35 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.742 SUP HCPCS C1713 207.742 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.744 SUP HCPCS C1713 207.744 - SCREW BONE LNGTHRD 4MM 5MM 44MM CANN SLFDRILL SLFTAP SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.746 SUP HCPCS C1713 207.746 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.748 SUP HCPCS C1713 207.748 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.75 SUP HCPCS C1713 207.750 - SCREW BONE LNGTHRD 4MM 5MM 50MM CANN SLFDRILL SLFTAP SMALL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.75 SUP HCPCS C1713 207.75 - SCREW BONE 4MM 50MM SS L/T ORTH CANN NSTRL BOTH IP/OP $357.58 $264.61 $0.00 $329.46 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $329.46 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.752 SUP HCPCS C1713 207.752 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.754 SUP HCPCS C1713 207.754 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.756 SUP HCPCS C1713 207.756 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.758 SUP HCPCS C1713 207.758 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.76 SUP HCPCS C1713 207.760 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.764 SUP HCPCS C1713 207.764 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.768 SUP HCPCS C1713 207.768 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.772 SUP HCPCS C1713 207.772 - SCREW BONE .5 THREAD SMALL HEXAGON REVERSE CUT FLUTE 4MM 5MM BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 207.916 SUP HCPCS C1713 207.916 - SCREW BONE 5MM 4MM 6MM 16MM 8MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.918 SUP HCPCS C1713 207.918 - SCREW BONE 5MM 4MM 6MM 18MM 8MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.92 SUP HCPCS C1713 207.920 - SCREW BONE 5MM 4MM 6MM 20MM 10MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $35.48 $26.26 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.39 $26.33 $26.33 $0.00 $0.00 $7.39 $0.00 $20.98 $20.98 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.922 SUP HCPCS C1713 207.922 - SCREW BONE 5MM 4MM 6MM 22MM 10MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.924 SUP HCPCS C1713 207.924 - SCREW BONE 5MM 4MM 6MM 24MM 10MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.926 SUP HCPCS C1713 207.926 - SCREW BONE 5MM 4MM 6MM 26MM 12MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.928 SUP HCPCS C1713 207.928 - SCREW BONE 5MM 4MM 6MM 28MM 12MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.93 SUP HCPCS C1713 207.930 - SCREW BONE 5MM 4MM 6MM 30MM 12MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $35.48 $26.26 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.39 $26.33 $26.33 $0.00 $0.00 $7.39 $0.00 $20.98 $20.98 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.932 SUP HCPCS C1713 207.932 - SCREW BONE 5MM 4MM 6MM 32MM 14MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.934 SUP HCPCS C1713 207.934 - SCREW BONE 5MM 4MM 6MM 34MM 14MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.936 SUP HCPCS C1713 207.936 - SCREW BONE 5MM 4MM 6MM 36MM 14MM DCP LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.938 SUP HCPCS C1713 207.938 - SCREW BONE 5MM HEAD 4MM 38MM PTHRD LC-DCP DCP STAINLESS BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.94 SUP HCPCS C1713 207.940 - SCREW BONE 5MM HEAD 4MM 40MM PTHRD LC-DCP STAINLESS STEEL BOTH IP/OP $35.48 $26.26 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.39 $26.33 $26.33 $0.00 $0.00 $7.39 $0.00 $20.98 $20.98 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.942 SUP HCPCS C1713 207.942 - SCREW BONE 5MM HEAD 4MM 42MM PTHRD LC-DCP DCP STAINLESS BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.944 SUP HCPCS C1713 207.944 - SCREW BONE 5MM HEAD 4MM 44MM PTHRD LC-DCP DCP STAINLESS BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.946 SUP HCPCS C1713 207.946 - SCREW BONE 5MM HEAD 4MM 46MM PTHRD LC-DCP STAINLESS STEEL BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.948 SUP HCPCS C1713 207.948 - SCREW BONE 5MM HEAD 4MM 48MM PTHRD LC-DCP DCP STAINLESS BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.95 SUP HCPCS C1713 207.950 - SCREW BONE 5MM HEAD 4MM 50MM PTHRD LC-DCP STAINLESS STEEL BOTH IP/OP $35.48 $26.26 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.39 $26.33 $26.33 $0.00 $0.00 $7.39 $0.00 $20.98 $20.98 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 207.952 SUP HCPCS C1713 207.952 - SCREW BONE 5MM HEAD 4MM 52MM PTHRD LC-DCP DCP STAINLESS BOTH IP/OP $36.55 $27.05 $0.00 $28.38 $15.96 $15.96 $0.00 $0.00 $0.00 $7.62 $27.13 $27.13 $0.00 $0.00 $7.62 $0.00 $21.62 $21.62 $0.00 $17.74 $28.10 $28.38 $0.00 $0.00 $5.39 $0.00 $0.00 $5.65 $0.00 $0.00 $0.00 $0.00 $0.00 208.03 SUP HCPCS C1713 208.030 - SCREW BONE 7MM 8MM 30MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.035 SUP HCPCS C1713 208.035 - SCREW BONE 7MM 8MM 35MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.04 SUP HCPCS C1713 208.040 - SCREW BONE 7MM 8MM 40MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.045 SUP HCPCS C1713 208.045 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.05 SUP HCPCS C1713 208.050 - SCREW BONE 7MM 8MM 50MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.055 SUP HCPCS C1713 208.055 - SCREW BONE 7MM 8MM 55MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.06 SUP HCPCS C1713 208.060 - SCREW BONE 7MM 8MM 60MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.065 SUP HCPCS C1713 208.065 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.07 SUP HCPCS C1713 208.070 - SCREW BONE 7MM 8MM 70MM 16MM CANN LARGE HEXAGONAL SOCKET BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.075 SUP HCPCS C1713 208.075 - SCREW BONE 7MM 8MM 75MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.08 SUP HCPCS C1713 208.080 - SCREW BONE 3.5MM 7MM 8MM 80MM 16MM CANN LARGE HEXAGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.085 SUP HCPCS C1713 208.085 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.09 SUP HCPCS C1713 208.090 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.095 SUP HCPCS C1713 208.095 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.1 SUP HCPCS C1713 208.100 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.105 SUP HCPCS C1713 208.105 - SCREW BONE 7MM 8MM 105MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.11 SUP HCPCS C1713 208.110 - SCREW BONE 7MM 8MM 110MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.115 SUP HCPCS C1713 208.115 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.12 SUP HCPCS C1713 208.120 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.125 SUP HCPCS C1713 208.125 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.13 SUP HCPCS C1713 208.130 - SCREW BONE 7MM 8MM 130MM 16MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 208.135 SUP HCPCS C1713 208.135 - SCREW BONE 7MM 135MM 16MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 208.14 SUP HCPCS C1713 208.140 - SCREW BONE 7MM 140MM 16MM THREADED CANN STAINLESS STEEL BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 208.145 SUP HCPCS C1713 208.145 - SCREW BONE 7MM 145MM 16MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 208.15 SUP HCPCS C1713 208.150 - SCREW BONE 7MM 150MM 16MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 208.401 SUP HCPCS C1713 208.401 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 30 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.402 SUP HCPCS C1713 208.402 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 35 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.403 SUP HCPCS C1713 208.403 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 40 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.404 SUP HCPCS C1713 208.404 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 45 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.405 SUP HCPCS C1713 208.405 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 50 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.406 SUP HCPCS C1713 208.406 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 55 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.407 SUP HCPCS C1713 208.407 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 60 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.408 SUP HCPCS C1713 208.408 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 65 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.409 SUP HCPCS C1713 208.409 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 70 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.41 SUP HCPCS C1713 208.410 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 75 BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.411 SUP HCPCS C1713 208.411 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 80 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.412 SUP HCPCS C1713 208.412 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 85 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.413 SUP HCPCS C1713 208.413 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 90 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.414 SUP HCPCS C1713 208.414 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 95 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.415 SUP HCPCS C1713 208.415 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.416 SUP HCPCS C1713 208.416 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.417 SUP HCPCS C1713 208.417 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.418 SUP HCPCS C1713 208.418 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.419 SUP HCPCS C1713 208.419 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.42 SUP HCPCS C1713 208.420 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.421 SUP HCPCS C1713 208.421 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.422 SUP HCPCS C1713 208.422 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.423 SUP HCPCS C1713 208.423 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.424 SUP HCPCS C1713 208.424 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.425 SUP HCPCS C1713 208.425 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.426 SUP HCPCS C1713 208.426 - SCREW BONE 6.5MM 160MM 16MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.427 SUP HCPCS C1713 208.427 - SCREW BONE 6.5MM 170MM 16MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.428 SUP HCPCS C1713 208.428 - SCREW BONE 6.5MM 180MM 16MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.431 SUP HCPCS C1713 208.431 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 45 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.432 SUP HCPCS C1713 208.432 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 50 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.433 SUP HCPCS C1713 208.433 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 55 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.434 SUP HCPCS C1713 208.434 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 60 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.435 SUP HCPCS C1713 208.435 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 65 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.436 SUP HCPCS C1713 208.436 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 70 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.437 SUP HCPCS C1713 208.437 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 75 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.438 SUP HCPCS C1713 208.438 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 80 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.439 SUP HCPCS C1713 208.439 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 85 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.44 SUP HCPCS C1713 208.440 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 90 BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.441 SUP HCPCS C1713 208.441 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM 95 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.442 SUP HCPCS C1713 208.442 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.443 SUP HCPCS C1713 208.443 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.444 SUP HCPCS C1713 208.444 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.445 SUP HCPCS C1713 208.445 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.446 SUP HCPCS C1713 208.446 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.447 SUP HCPCS C1713 208.447 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.448 SUP HCPCS C1713 208.448 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.449 SUP HCPCS C1713 208.449 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.45 SUP HCPCS C1713 208.450 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.451 SUP HCPCS C1713 208.451 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.452 SUP HCPCS C1713 208.452 - SCREW BONE HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM 2.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.453 SUP HCPCS C1713 208.453 - SCREW BONE 6.5MM 160MM 32MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.454 SUP HCPCS C1713 208.454 - SCREW BONE 6.5MM 170MM 32MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.455 SUP HCPCS C1713 208.455 - SCREW BONE 6.5MM 180MM 32MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.46 SUP HCPCS C1713 208.460 - SCREW BONE FULTHD HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.461 SUP HCPCS C1713 208.461 - SCREW BONE FULTHD HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.462 SUP HCPCS C1713 208.462 - SCREW BONE FULTHD HEMISPHERE REVERSE CUT FLUTE 6.5MM 7.9MM BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.463 SUP HCPCS C1713 208.463 - SCREW BONE 6.5MM 35MM FULTHRD STAINLESS STEEL CANN NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.464 SUP HCPCS C1713 208.464 - SCREW BONE 6.5MM 40MM FULTHRD STAINLESS STEEL CANN NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.465 SUP HCPCS C1713 208.465 - SCREW BONE FULTHD 6.5MM 45MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.466 SUP HCPCS C1713 208.466 - SCREW BONE FULTHD 6.5MM 50MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.467 SUP HCPCS C1713 208.467 - SCREW BONE FULTHD 6.5MM 55MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.468 SUP HCPCS C1713 208.468 - SCREW BONE FULTHD 6.5MM 60MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.469 SUP HCPCS C1713 208.469 - SCREW BONE FULTHD 6.5MM 65MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.47 SUP HCPCS C1713 208.470 - SCREW BONE FULTHD 6.5MM 70MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.471 SUP HCPCS C1713 208.471 - SCREW BONE FULTHD 6.5MM 75MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.472 SUP HCPCS C1713 208.472 - SCREW BONE FULTHD 6.5MM 80MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.473 SUP HCPCS C1713 208.473 - SCREW BONE FULTHD 6.5MM 85MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.474 SUP HCPCS C1713 208.474 - SCREW BONE FULTHD 6.5MM 90MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.475 SUP HCPCS C1713 208.475 - SCREW BONE FULTHD 6.5MM 95MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.476 SUP HCPCS C1713 208.476 - SCREW BONE FULTHD 6.5MM 100MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.477 SUP HCPCS C1713 208.477 - SCREW BONE FULTHD 6.5MM 105MM CANN FULTHRD STAINLESS STEEL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.478 SUP HCPCS C1713 208.478 - SCREW BONE FULTHD 6.5MM 110MM CANN FULTHRD STAINLESS STEEL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.479 SUP HCPCS C1713 208.479 - SCREW BONE 6.5MM 115MM CANN FULTHRD STAINLESS STEEL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.48 SUP HCPCS C1713 208.480 - SCREW BONE 6.5MM 120MM FULTHRD STAINLESS STEEL CANN NONSTRL BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.481 SUP HCPCS C1713 208.481 - SCREW BONE 6.5MM 125MM CANN FULTHRD STAINLESS STEEL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.482 SUP HCPCS C1713 208.482 - SCREW BONE 6.5MM 130MM CANN FULTHRD STAINLESS STEEL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 208.483 SUP HCPCS C1713 208.483 - SCREW BONE FULTHD 6.5MM 140MM CANN STAINLESS STEEL BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 208.484 SUP HCPCS C1713 208.484 - SCREW BONE FULTHD 6.5MM 150MM CANN STAINLESS STEEL BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 208.485 SUP HCPCS C1713 208.485 - SCREW BONE FULTHD 6.5MM 160MM CANN STAINLESS STEEL BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 208.486 SUP HCPCS C1713 208.486 - SCREW BONE FULTHD 6.5MM 170MM CANN STAINLESS STEEL BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 208.487 SUP HCPCS C1713 208.487 - SCREW BONE 6.5MM 180MM CANN FULTHD STAINLESS STEEL BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 208.83 SUP HCPCS C1713 208.830 - SCREW BONE PTHRD 7.3MM 30MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $96.14 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.835 SUP HCPCS C1713 208.835 - SCREW BONE PTHRD 7.3MM 35MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.84 SUP HCPCS C1713 208.840 - SCREW BONE 7.3MM 40MM 16MM CANN STAINLESS STEEL FEMUR BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.845 SUP HCPCS C1713 208.845 - SCREW BONE PTHRD 7.3MM 45MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.85 SUP HCPCS C1713 208.850 - SCREW BONE 7.3MM 50MM 16MM CANN STAINLESS STEEL CANCELLOUS BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.855 SUP HCPCS C1713 208.855 - SCREW BONE PTHRD 7.3MM 55MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.86 SUP HCPCS C1713 208.860 - SCREW BONE PTHRD 7.3MM 60MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.865 SUP HCPCS C1713 208.865 - SCREW BONE PTHRD 7.3MM 65MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.87 SUP HCPCS C1713 208.870 - SCREW BONE PTHRD 7.3MM 70MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.875 SUP HCPCS C1713 208.875 - SCREW BONE PTHRD 7.3MM 75MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.88 SUP HCPCS C1713 208.880 - SCREW BONE PTHRD 7.3MM 80MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.885 SUP HCPCS C1713 208.885 - SCREW BONE PTHRD 7.3MM 85MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.89 SUP HCPCS C1713 208.890 - SCREW BONE 7.3MM 90MM 16MM CANN STAINLESS STEEL CANN NONSTRL BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.895 SUP HCPCS C1713 208.895 - SCREW BONE PTHRD 7.3MM 95MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $96.14 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.9 SUP HCPCS C1713 208.900 - SCREW BONE PTHRD 7.3MM 100MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.905 SUP HCPCS C1713 208.905 - SCREW BONE PTHRD 7.3MM 105MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.91 SUP HCPCS C1713 208.910 - SCREW BONE PTHRD 7.3MM 110MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.915 SUP HCPCS C1713 208.915 - SCREW BONE PTHRD 7.3MM 115MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.92 SUP HCPCS C1713 208.920 - SCREW BONE PTHRD 7.3MM 120MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.925 SUP HCPCS C1713 208.925 - SCREW BONE PTHRD 7.3MM 125MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.93 SUP HCPCS C1713 208.930 - SCREW BONE PTHRD 7.3MM 130MM 16MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.935 SUP HCPCS C1713 208.935 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7.3MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.94 SUP HCPCS C1713 208.940 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7.3MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.945 SUP HCPCS C1713 208.945 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7.3MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.95 SUP HCPCS C1713 208.950 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7.3MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 208.955 SUP HCPCS C1713 208.955 - SCREW BONE 7.3MM 8.2MM 155MM 16X4MM CANNULARED SLFDRILL BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 208.96 SUP HCPCS C1713 208.960 - SCREW BONE 7.3MM 8.2MM 160MM 16X4MM CANNULARED SLFDRILL BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 208.965 SUP HCPCS C1713 208.965 - SCREW BONE 7.3MM 8.2MM 165MM 16X4MM CANNULARED SLFDRILL BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 208.97 SUP HCPCS C1713 208.970 - SCREW BONE 7.3MM 8.2MM 170MM 16X4MM CANNULARED SLFDRILL BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 208.975 SUP HCPCS C1713 208.975 - SCREW BONE 7.3MM 8.2MM 75MM 16X4MM L THREAD SLFDRILL SLFTAP BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 208.98 SUP HCPCS C1713 208.980 - SCREW BONE 7.3MM 8.2MM 80MM 16X4MM L THREAD SLFDRILL SLFTAP BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209 SUP Custom 27203010 MARKER RAD OSPT SKN SEM RDLCNT RING BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 209.045 SUP HCPCS C1713 209.045 - SCREW BONE 7MM 8MM 45MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.05 SUP HCPCS C1713 209.050 - SCREW BONE 7MM 8MM 50MM 32MM CANN LARGE HEXOGONAL SOCKET BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.055 SUP HCPCS C1713 209.055 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.06 SUP HCPCS C1713 209.060 - SCREW BONE REVERSE CUT FLUTE 7MM 8MM 60MM 32MM CANN LARGE BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.065 SUP HCPCS C1713 209.065 - SCREW BONE 7MM 8MM 65MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.07 SUP HCPCS C1713 209.070 - SCREW BONE 7MM 8MM 70MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.075 SUP HCPCS C1713 209.075 - SCREW BONE 7MM 8MM 75MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.08 SUP HCPCS C1713 209.080 - SCREW BONE LARGE 7MM 8MM 80MM 32MM CANN THREADED LARGE BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.085 SUP HCPCS C1713 209.085 - SCREW BONE 7MM 8MM 85MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.09 SUP HCPCS C1713 209.090 - SCREW BONE 7MM 8MM 90MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.095 SUP HCPCS C1713 209.095 - SCREW BONE 7MM 8MM 95MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.1 SUP HCPCS C1713 209.100 - SCREW BONE 7MM 8MM 100MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.105 SUP HCPCS C1713 209.105 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.11 SUP HCPCS C1713 209.110 - SCREW BONE 7MM 8MM 110MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.115 SUP HCPCS C1713 209.115 - SCREW BONE 7MM 8MM 115MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.12 SUP HCPCS C1713 209.120 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7MM 8 BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.125 SUP HCPCS C1713 209.125 - SCREW BONE 7MM 8MM 125MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.13 SUP HCPCS C1713 209.130 - SCREW BONE 7MM 8MM 130MM 32MM CANN THREADED LARGE HEXOGONAL BOTH IP/OP $481.75 $356.50 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $100.41 $357.55 $357.55 $0.00 $0.00 $100.40 $0.00 $284.96 $284.96 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 209.135 SUP HCPCS C1713 209.135 - SCREW BONE 7MM 135MM 32MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.14 SUP HCPCS C1713 209.140 - SCREW BONE 7MM 140MM 32MM CANN THREADED BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.145 SUP HCPCS C1713 209.145 - SCREW BONE 7MM 145MM 32MM CANN THREADED BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.15 SUP HCPCS C1713 209.150 - SCREW BONE 7MM 150MM 32MM CANN THREADED BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.42 SUP HCPCS C1713 209.420 - SCREW BONE 7MM 20MM CANN FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.425 SUP HCPCS C1713 209.425 - SCREW BONE FULTHD 7MM 25MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.43 SUP HCPCS C1713 209.430 - SCREW ORTHOPEDIC 7MM 30MM CANN FULTHRD STAINLESS STEEL BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.435 SUP HCPCS C1713 209.435 - SCREW BONE FULTHD 7MM 35MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.44 SUP HCPCS C1713 209.440 - SCREW BONE 7MM 40MM CANN FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.445 SUP HCPCS C1713 209.445 - SCREW BONE FULTHD 7MM 45MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.45 SUP HCPCS C1713 209.450 - SCREW BONE FULTHD 7MM 50MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.455 SUP HCPCS C1713 209.455 - SCREW BONE FULTHD 7MM 55MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.46 SUP HCPCS C1713 209.460 - SCREW BONE 7MM 60MM CANN FULTHRD STAINLESS STEEL NONSTRL BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.465 SUP HCPCS C1713 209.465 - SCREW BONE FULTHD 7MM 65MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.47 SUP HCPCS C1713 209.470 - SCREW BONE 7MM 70MM CANN FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.475 SUP HCPCS C1713 209.475 - SCREW BONE FULTHD 7MM 75MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.48 SUP HCPCS C1713 209.480 - SCREW BONE 7MM 80MM CANN FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.485 SUP HCPCS C1713 209.485 - SCREW BONE 7MM 85MM CANN FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.49 SUP HCPCS C1713 209.490 - SCREW BONE 7MM 90MM CANN FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.495 SUP HCPCS C1713 209.495 - SCREW BONE 7MM 95MM CANN FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.5 SUP HCPCS C1713 209.500 - SCREW BONE 7MM 100MM CANN FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.505 SUP HCPCS C1713 209.505 - SCREW BONE FULTHD 7MM 105MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.51 SUP HCPCS C1713 209.510 - SCREW BONE FULTHD 7MM 8MM 110MM CANN LARGE HEXAGONAL SOCKET BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.515 SUP HCPCS C1713 209.515 - SCREW BONE FULTHD 7MM 115MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.52 SUP HCPCS C1713 209.520 - SCREW BONE 7MM 120MM CANN FULTHRD STAINLESS STEEL CORTICAL BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.525 SUP HCPCS C1713 209.525 - SCREW BONE FULTHD 7MM 125MM CANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $511.68 $378.64 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $106.65 $379.77 $379.77 $0.00 $0.00 $106.63 $0.00 $302.66 $302.66 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.53 SUP HCPCS C1713 209.530 - SCREW BONE 7MM 130MM FULTHRD STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.78 $367.62 $0.00 $397.42 $223.55 $223.55 $0.00 $0.00 $0.00 $103.54 $368.71 $368.71 $0.00 $0.00 $103.53 $0.00 $293.84 $293.84 $0.00 $248.39 $393.45 $397.42 $0.00 $0.00 $75.48 $0.00 $0.00 $79.09 $0.00 $0.00 $0.00 $0.00 $0.00 209.62 SUP HCPCS C1713 209.620 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.625 SUP HCPCS C1713 209.625 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.63 SUP HCPCS C1713 209.630 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.635 SUP HCPCS C1713 209.635 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.64 SUP HCPCS C1713 209.640 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.645 SUP HCPCS C1713 209.645 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.65 SUP HCPCS C1713 209.650 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.655 SUP HCPCS C1713 209.655 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.66 SUP HCPCS C1713 209.660 - SCREW BONE FULLY THREAD LARGE HEXAGON 7.3MM 4MM 60MM CANN BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.665 SUP HCPCS C1713 209.665 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.67 SUP HCPCS C1713 209.670 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.675 SUP HCPCS C1713 209.675 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.68 SUP HCPCS C1713 209.680 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.685 SUP HCPCS C1713 209.685 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.69 SUP HCPCS C1713 209.690 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.695 SUP HCPCS C1713 209.695 - SCREW BONE FULTHD 7.3MM 8.2MM 95MM CANN SHAFT LP HEAD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.7 SUP HCPCS C1713 209.700 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.705 SUP HCPCS C1713 209.705 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.71 SUP HCPCS C1713 209.710 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.715 SUP HCPCS C1713 209.715 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.72 SUP HCPCS C1713 209.720 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.725 SUP HCPCS C1713 209.725 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.73 SUP HCPCS C1713 209.730 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.735 SUP HCPCS C1713 209.735 - SCREW BONE FULTHD 7.3MM 8.2MM 135MM 4MM CANN SLFDRILL SLFTAP BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.74 SUP HCPCS C1713 209.740 - SCREW BONE 4MM FULTHD 7.3MM 8.2MM 140MM CANN SLFDRILL SLFTAP BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.745 SUP HCPCS C1713 209.745 - SCREW BONE FULTHD 7.3MM 8.2MM 145MM 4MM CANN SLFDRILL SLFTAP BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.75 SUP HCPCS C1713 209.750 - SCREW BONE FULTHD 7.3MM 50MM CANN NONSTRL BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.755 SUP HCPCS C1713 209.755 - SCREW BONE FULTHD 7.3MM 55MM CANN NONSTRL BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.76 SUP HCPCS C1713 209.760 - SCREW BONE 4MM FULTHD 7.3MM 8.2MM 160MM CANN SLFDRILL SLFTAP BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.765 SUP HCPCS C1713 209.765 - SCREW BONE FULTHD 7.3MM 8.2MM 165MM 4MM CANN SLFDRILL SLFTAP BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.77 SUP HCPCS C1713 209.770 - SCREW BONE FULTHD 7.3MM 8.2MM 170MM 4MM CANN SLFDRILL SLFTAP BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.775 SUP HCPCS C1713 209.775 - SCREW BONE FULTHD 7.3MM 75MM CANN STAINLESS STEEL BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.78 SUP HCPCS C1713 209.780 - SCREW BONE FULTHD 7.3MM 8.2MM 180MM 4MM CANN SLFDRILL SLFTAP BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.845 SUP HCPCS C1713 209.845 - SCREW BONE PTHRD 7.3MM 8.2MM 45MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.85 SUP HCPCS C1713 209.850 - SCREW BONE 7.3MM 8.2MM 50MM 32MM CANN SHAFT LP HEAD SLFDRILL BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.855 SUP HCPCS C1713 209.855 - SCREW BONE 4MM 7.3MM 8.2MM 55MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.86 SUP HCPCS C1713 209.860 - SCREW BONE PTHRD 7.3MM 8.2MM 60MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.865 SUP HCPCS C1713 209.865 - SCREW BONE 4MM 7.3MM 8.2MM 65MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.87 SUP HCPCS C1713 209.870 - SCREW BONE PTHRD 7.3MM 8.2MM 70MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.875 SUP HCPCS C1713 209.875 - SCREW BONE 4MM 7.3MM 8.2MM 75MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.88 SUP HCPCS C1713 209.880 - SCREW BONE PTHRD 7.3MM 8.2MM 80MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.885 SUP HCPCS C1713 209.885 - SCREW BONE 4MM PTHRD 7.3MM 8.2MM 85MM 32MM CANN SHAFT LP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.89 SUP HCPCS C1713 209.890 - SCREW BONE 4MM PTHRD 7.3MM 8.2MM 90MM 32MM CANN SHAFT LP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.895 SUP HCPCS C1713 209.895 - SCREW BONE 4MM PTHRD 7.3MM 8.2MM 95MM 32MM CANN SHAFT LP BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.9 SUP HCPCS C1713 209.900 - SCREW BONE 4MM PTHRD 7.3MM 8.2MM 100MM 32MM CANN SHAFT LP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.905 SUP HCPCS C1713 209.905 - SCREW BONE 4MM 7.3MM 8.2MM 105MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.91 SUP HCPCS C1713 209.910 - SCREW BONE 4MM PTHRD 7.3MM 8.2MM 110MM 32MM CANN SHAFT LP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.915 SUP HCPCS C1713 209.915 - SCREW BONE 7.3MM 8.2MM 115MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.92 SUP HCPCS C1713 209.920 - SCREW BONE 4MM 7.3MM 8.2MM 120MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.925 SUP HCPCS C1713 209.925 - SCREW BONE 4MM 7.3MM 8.2MM 125MM 32MM CANN SHAFT LP HEAD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.93 SUP HCPCS C1713 209.930 - SCREW BONE 4MM PTHRD 7.3MM 8.2MM 130MM 32MM CANN SHAFT LP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.935 SUP HCPCS C1713 209.935 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7.3MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.94 SUP HCPCS C1713 209.940 - SCREW BONE HEXAGON 7.3MM 4MM 140MM 32MM CANN SELF DRILL SELF BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.945 SUP HCPCS C1713 209.945 - SCREW BONE LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE 7.3MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.95 SUP HCPCS C1713 209.950 - SCREW BONE HEXAGON 7.3MM 4MM 150MM 32MM CANN SELF DRILL SELF BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 209.955 SUP HCPCS C1713 209.955 - SCREW BONE 7.3MM 8.2MM 155MM 32X4MM CANN SLFDRILL SLFTAP BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.96 SUP HCPCS C1713 209.960 - SCREW BONE 7.3MM 160MM CANN THREADED STAINLESS STEEL NONSTRL BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.965 SUP HCPCS C1713 209.965 - SCREW BONE 7.3MM 8.2MM 165MM 32X4MM CANN SLFDRILL SLFTAP BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.97 SUP HCPCS C1713 209.970 - SCREW BONE 7.3MM 8.2MM 170MM 32X4MM CANN SLFDRILL SLFTAP BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.975 SUP HCPCS C1713 209.975 - SCREW BONE 7.3MM 8.2MM 175MM 32X4MM CANN SLFDRILL SLFTAP BOTH IP/OP $500.43 $370.32 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $104.30 $371.42 $371.42 $0.00 $0.00 $104.29 $0.00 $296.00 $296.00 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 209.98 SUP HCPCS C1713 209.980 - SCREW BONE 7.3MM 180MM CANN STAINLESS STEEL NONSTRL BOTH IP/OP $485.85 $359.53 $0.00 $388.68 $218.63 $218.63 $0.00 $0.00 $0.00 $101.26 $360.60 $360.60 $0.00 $0.00 $101.25 $0.00 $287.38 $287.38 $0.00 $242.93 $384.79 $388.68 $0.00 $0.00 $73.82 $0.00 $0.00 $77.35 $0.00 $0.00 $0.00 $0.00 $0.00 211.81 SUP HCPCS C1713 211.810 - SCREW BONE .5 THREAD T8 2.4MM 3.5MM 10MM SELF DRILL SELF TAP BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.811 SUP HCPCS C1713 211.811 - SCREW BONE LNGTHRD 2.4MM 11MM 5MM CANN STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.812 SUP HCPCS C1713 211.812 - SCREW BONE .5 THREAD T8 2.4MM 3.5MM 12MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.813 SUP HCPCS C1713 211.813 - SCREW BONE LNGTHRD 2.4MM 13MM 6MM CANN STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.814 SUP HCPCS C1713 211.814 - SCREW BONE .5 THREAD T8 2.4MM 3.5MM 14MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.815 SUP HCPCS C1713 211.815 - SCREW BONE LNGTHRD 2.4MM 3.5MM 15MM 7MM CANN REVERSE CUTTING BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.816 SUP HCPCS C1713 211.816 - SCREW BONE .5 THREAD T8 2.4MM 3.5MM 16MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.817 SUP HCPCS C1713 211.817 - SCREW BONE LNGTHRD 2.4MM 17MM 8MM CANN STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.818 SUP HCPCS C1713 211.818 - SCREW BONE LNGTHRD 2.4MM 35MM 18MM 8MM CANN T8 STARDRIVE BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.819 SUP HCPCS C1713 211.819 - SCREW BONE LNGTHRD 2.4MM 19MM 9MM CANN STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.82 SUP HCPCS C1713 211.820 - SCREW BONE LNGTHRD 2.4MM 3.5MM 20MM 9MM CANN REVERSE CUTTING BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.822 SUP HCPCS C1713 211.822 - SCREW BONE LNGTHRD 2.4MM 3.5MM 22MM 10MM CANN REVERSE BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.824 SUP HCPCS C1713 211.824 - SCREW BONE LNGTHRD 2.4MM 3.5MM 24MM 10MM CANN REVERSE BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.826 SUP HCPCS C1713 211.826 - SCREW BONE LNGTHRD 2.4MM 3.5MM 26MM 12MM CANN REVERSE BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.828 SUP HCPCS C1713 211.828 - SCREW BONE LNGTHRD 2.4MM 28MM 12MM CANN STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.83 SUP HCPCS C1713 211.830 - SCREW BONE LNGTHRD 2.4MM 3.5MM 30MM 14MM CANN REVERSE BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.841 SUP HCPCS C1713 211.841 - SCREW BONE SHORT THREAD 2.4MM 3.5MM 17MM 5MM CANN SLFDRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.842 SUP HCPCS C1713 211.842 - SCREW BONE SHORT THREAD 2.4MM 3.5MM 18MM 5MM CANN T8 BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.843 SUP HCPCS C1713 211.843 - SCREW BONE SHORT THREAD 2.4MM 19MM 5MM CANN STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.844 SUP HCPCS C1713 211.844 - SCREW BONE SHORT THREAD 20MM 204MM 5MM CANN STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.845 SUP HCPCS C1713 211.845 - SCREW BONE SHORT THREAD 2.4MM 22MM 5MM CANN STAINLESS STEEL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.846 SUP HCPCS C1713 211.846 - SCREW BONE SHORT THREAD 2.4MM 3.5MM 24MM 6MM CANN REVERSE BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.847 SUP HCPCS C1713 211.847 - SCREW BONE SHORT THREAD 2.4MM 3.5MM 26MM 6MM CANN REVERSE BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.848 SUP HCPCS C1713 211.848 - SCREW BONE SHORT THREAD 2.4MM 3.5MM 28MM 6MM CANN REVERSE BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.849 SUP HCPCS C1713 211.849 - SCREW BONE SHORT THREAD 2.4MM 3.5MM 30MM 6MM CANN REVERSE BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 211.89 SUP HCPCS C1713 211.890 - SCREW BONE 2.4MM 90MM COMPRESSION LCP DHHS STAINLESS STEEL BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 212.101 SUP HCPCS C1713 212.101 - SCREW BONE FULTHD 3.5MM 2.9MM 10MM T15 STARDRIVE RECESS BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.102 SUP HCPCS C1713 212.102 - SCREW BONE FULTHD 3.5MM 12MM STARDRIVE RECESS SLFTAP TIP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.103 SUP HCPCS C1713 212.103 - SCREW BONE FULTHD 3.5MM 14MM STARDRIVE RECESS SLFTAP TIP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.104 SUP HCPCS C1713 212.104 - SCREW BONE FULTHD 3.5MM 16MM STARDRIVE RECESS SLFTAP TIP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.105 SUP HCPCS C1713 212.105 - SCREW BONE 3.5MM 18MM LOCKING SLFTAP T15 STAR DRIVE RECESS BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.106 SUP HCPCS C1713 212.106 - SCREW BONE 3.5MM 20MM LOCKING SLFTAP STARDRIVE RECESS LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.107 SUP HCPCS C1713 212.107 - SCREW BONE T15 FULTHD CONE LP 3.5MM 22MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.108 SUP HCPCS C1713 212.108 - SCREW BONE 3.5MM 24MM T15 STARDRIVE RECESS ANGULAR STABILITY BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.109 SUP HCPCS C1713 212.109 - SCREW BONE FULTHD 3.5MM 26MM STARDRIVE RECESS SLFTAP TIP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.11 SUP HCPCS C1713 212.110 - SCREW BONE 3.5MM 28MM LOCKING STARDRIVE SLFTAP LCP STAINLESS BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.11 SUP HCPCS C1713 212.11 - SCREW BONE 3.5MM 28MM LCP SS PROX MDL PLVC TIBIAL SLFTAP LCK BOTH IP/OP $227.93 $168.67 $0.00 $197.35 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $197.35 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.111 SUP HCPCS C1713 212.111 - SCREW BONE 3.5MM 30MM LOCKING SLFTAP STARDRIVE RECESS LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.112 SUP HCPCS C1713 212.112 - SCREW BONE FULTHD 3.5MM 32MM STARDRIVE RECESS SLFTAP TIP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.113 SUP HCPCS C1713 212.113 - SCREW BONE 3.5MM 34MM T15 STARDRIVE RECESS ANGULAR STABILITY BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.114 SUP HCPCS C1713 212.114 - SCREW BONE T15 FULTHD CONE LP 3.5MM 35MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.115 SUP HCPCS C1713 212.115 - SCREW BONE FULTHD 3.5MM 36MM T15 STARDRIVE SELF TAP FIX BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.116 SUP HCPCS C1713 212.116 - SCREW BONE FULTHD 3.5MM 38MM T15 STARDRIVE SELF TAP FIX BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.117 SUP HCPCS C1713 212.117 - SCREW BONE 3.5MM 40MM LOCKING STARDRIVE SLFTAP LCP STAINLESS BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.118 SUP HCPCS C1713 212.118 - SCREW BONE T15 FULTHD CONE LP 3.5MM 42MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.119 SUP HCPCS C1713 212.119 - SCREW BONE FULTHD 3.5MM 45MM STARDRIVE SELF TAP LOCK LP LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.12 SUP HCPCS C1713 212.120 - SCREW BONE T15 FULTHD CONE LP 3.5MM 48MM FIX ANGLE SELF TAP BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.121 SUP HCPCS C1713 212.121 - SCREW BONE 3.5MM 50MM LOCKING SLFTAP T15 STAR DRIVE RECESS BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.122 SUP HCPCS C1713 212.122 - SCREW BONE T15 FULTHD CONE LP 3.5MM 52MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.123 SUP HCPCS C1713 212.123 - SCREW BONE T15 FULTHD CONE LP 3.5MM 55MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.124 SUP HCPCS C1713 212.124 - SCREW BONE FULTHD 3.5MM 60MM STARDRIVE RECESS SLFTAP TIP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.125 SUP HCPCS C1713 212.125 - SCREW BONE T15 FULTHD CONE LP 3.5MM 65MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.126 SUP HCPCS C1713 212.126 - SCREW BONE T15 FULTHD CONE LP 3.5MM 70MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.127 SUP HCPCS C1713 212.127 - SCREW BONE T15 FULTHD CONE LP 3.5MM 75MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.128 SUP HCPCS C1713 212.128 - SCREW BONE T15 FULTHD CONE LP 3.5MM 80MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.129 SUP HCPCS C1713 212.129 - SCREW BONE T15 FULTHD CONE LP 3.5MM 85MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.13 SUP HCPCS C1713 212.130 - SCREW BONE T15 FULTHD CONE LP 3.5MM 90MM FIX ANGLE SELF TAP BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.131 SUP HCPCS C1713 212.131 - SCREW BONE T15 FULTHD CONE LP 3.5MM 95MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.134 SUP HCPCS C1713 212.134 - SCREW BONE FULTHD CONE LP 3.5MM 44MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.136 SUP HCPCS C1713 212.136 - SCREW BONE FULTHD CONE LP 3.5MM 46MM FIX ANGLE SELF TAP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 212.201 SUP HCPCS C1713 212.201 - SCREW BONE FULTHD 5MM 14MM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.202 SUP HCPCS C1713 212.202 - SCREW BONE T25 FULTHD CONE 5MM 16MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.203 SUP HCPCS C1713 212.203 - SCREW BONE FULTHD 5MM 18MM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.205 SUP HCPCS C1713 212.205 - SCREW BONE T25 FULTHD CONE 5MM 22MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.206 SUP HCPCS C1713 212.206 - SCREW BONE FULTHD 5MM 24MM SLFTAP TIP LOCKING FIXANG CONICAL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.207 SUP HCPCS C1713 212.207 - SCREW BONE FULTHD CONICAL 5MM 26MM SELF TAP LOCK FIX ANGLE T BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.208 SUP HCPCS C1713 212.208 - SCREW BONE T25 FULTHD CONE 5MM 28MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.209 SUP HCPCS C1713 212.209 - SCREW BONE T25 FULTHD CONE 5MM 30MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.21 SUP HCPCS C1713 212.210 - SCREW BONE FULTHD 5MM 32MM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.211 SUP HCPCS C1713 212.211 - SCREW BONE T25 FULTHD CONE 5MM 34MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.212 SUP HCPCS C1713 212.212 - SCREW BONE T25 FULTHD CONE 5MM 36MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.213 SUP HCPCS C1713 212.213 - SCREW BONE T25 FULTHD CONE 5MM 38MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.214 SUP HCPCS C1713 212.214 - SCREW BONE T25 FULTHD CONE 5MM 40MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.215 SUP HCPCS C1713 212.215 - SCREW BONE T25 FULTHD CONE 5MM 42MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.216 SUP HCPCS C1713 212.216 - SCREW BONE FULTHD 5MM 44MM SLFTAP LOCKING FIXANG T25 BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.217 SUP HCPCS C1713 212.217 - SCREW BONE T25 FULTHD CONE 5MM 46MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.218 SUP HCPCS C1713 212.218 - SCREW BONE T25 FULTHD CONE 5MM 48MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.219 SUP HCPCS C1713 212.219 - SCREW BONE T25 FULTHD CONE 5MM 50MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.22 SUP HCPCS C1713 212.220 - SCREW BONE T25 FULTHD CONE 5MM 55MM FIX ANGLE SELF TAP BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.221 SUP HCPCS C1713 212.221 - SCREW BONE T25 FULTHD CONE 5MM 60MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.222 SUP HCPCS C1713 212.222 - SCREW BONE FULTHD 5MM 65MM T25 STARDRIVE RECESS SLFTAP TIP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.223 SUP HCPCS C1713 212.223 - SCREW BONE T25 FULTHD CONE 5MM 70MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.224 SUP HCPCS C1713 212.224 - SCREW BONE FULTHD 5MM 75MM SLFTAP TIP LOCKING FIXANG T25 BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.225 SUP HCPCS C1713 212.225 - SCREW BONE FULTHD 5MM 80MM T25 STARDRIVE SELF TAP LOCK FIX BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.226 SUP HCPCS C1713 212.226 - SCREW BONE T25 FULTHD CONE 5MM 85MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.227 SUP HCPCS C1713 212.227 - SCREW BONE T25 FULTHD CONE 5MM 90MM FIX ANGLE SELF TAP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 212.251 SUP HCPCS C1713 212.251 - SCREW BONE 5MM 51MM SLFDRILL LOCKING THREADED LCP STAINLESS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.252 SUP HCPCS C1713 212.252 - SCREW BONE 5MM 18MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.253 SUP HCPCS C1713 212.253 - SCREW BONE 5MM 22MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.254 SUP HCPCS C1713 212.254 - SCREW BONE 5MM 26MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.255 SUP HCPCS C1713 212.255 - SCREW BONE 5MM 30MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.256 SUP HCPCS C1713 212.256 - SCREW BONE 5MM 35MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.257 SUP HCPCS C1713 212.257 - SCREW BONE 5MM 40MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.258 SUP HCPCS C1713 212.258 - SCREW BONE 5MM 45MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.259 SUP HCPCS C1713 212.259 - SCREW BONE 5MM 50MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.26 SUP HCPCS C1713 212.260 - SCREW BONE 5MM 55MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.261 SUP HCPCS C1713 212.261 - SCREW BONE 5MM 60MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.262 SUP HCPCS C1713 212.262 - SCREW BONE 5MM 65MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.263 SUP HCPCS C1713 212.263 - SCREW BONE 5MM 70MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.264 SUP HCPCS C1713 212.264 - SCREW BONE 5MM 75MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.265 SUP HCPCS C1713 212.265 - SCREW BONE 5MM 80MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.266 SUP HCPCS C1713 212.266 - SCREW BONE 5MM 85MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.267 SUP HCPCS C1713 212.267 - SCREW BONE 5MM 90MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 212.317 SUP HCPCS C1713 212.317 - SCREW BONE FULTHD 3.5MM 40MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.319 SUP HCPCS C1713 212.319 - SCREW BONE FULTHD 3.5MM 45MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.321 SUP HCPCS C1713 212.321 - SCREW BONE FULTHD 3.5MM 50MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.323 SUP HCPCS C1713 212.323 - SCREW BONE FULTHD 3.5MM 55MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.324 SUP HCPCS C1713 212.324 - SCREW BONE FULTHD 3.5MM 60MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.325 SUP HCPCS C1713 212.325 - SCREW BONE FULTHD CONE 3.5MM 2.9MM 65MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.326 SUP HCPCS C1713 212.326 - SCREW BONE FULTHD CONE 3.5MM 2.9MM 70MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.327 SUP HCPCS C1713 212.327 - SCREW BONE FULTHD CONE 3.5MM 2.9MM 75MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.328 SUP HCPCS C1713 212.328 - SCREW BONE FULTHD CONE 3.5MM 2.9MM 80MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.329 SUP HCPCS C1713 212.329 - SCREW BONE FULTHD CONE 3.5MM 2.9MM 85MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.33 SUP HCPCS C1713 212.330 - SCREW BONE FULTHD 3.5MM 2.9MM 90MM SLFTAP STARDRIVE RECESS BOTH IP/OP $249.75 $184.82 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $52.05 $185.36 $185.36 $0.00 $0.00 $52.05 $0.00 $147.73 $147.73 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.331 SUP HCPCS C1713 212.331 - SCREW BONE FULTHD CONE 3.5MM 2.9MM 95MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.417 SUP HCPCS C1713 212.417 - SCREW BONE 3.5MM 40MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.419 SUP HCPCS C1713 212.419 - SCREW BONE 3.5MM 45MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.421 SUP HCPCS C1713 212.421 - SCREW BONE 3.5MM 50MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.423 SUP HCPCS C1713 212.423 - SCREW BONE 3.5MM 55MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.424 SUP HCPCS C1713 212.424 - SCREW BONE 3.5MM 60MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 212.425 SUP HCPCS C1713 212.425 - SCREW BONE PTHRD CONE 3.5MM 2.9MM 65MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.426 SUP HCPCS C1713 212.426 - SCREW BONE PTHRD CONE 3.5MM 2.9MM 70MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.427 SUP HCPCS C1713 212.427 - SCREW BONE PTHRD CONE 3.5MM 2.9MM 75MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.428 SUP HCPCS C1713 212.428 - SCREW BONE PTHRD CONE 3.5MM 2.9MM 80MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.429 SUP HCPCS C1713 212.429 - SCREW BONE PTHRD CONE 3.5MM 2.9MM 85MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.43 SUP HCPCS C1713 212.430 - SCREW BONE PTHRD CONE 3.5MM 2.9MM 90MM SELF TAP SMOOTH BOTH IP/OP $249.75 $184.82 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $52.05 $185.36 $185.36 $0.00 $0.00 $52.05 $0.00 $147.73 $147.73 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.431 SUP HCPCS C1713 212.431 - SCREW BONE PTHRD CONE 3.5MM 2.9MM 95MM SELF TAP SMOOTH BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 212.504 SUP HCPCS C1713 212.504 - SCREW BONE 5MM 20MM STARDRIVE SS PROX FEM LCK SLFTAP T25 BOTH IP/OP $314.40 $232.66 $0.00 $251.52 $141.48 $141.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.20 $249.00 $251.52 $0.00 $0.00 $49.20 $0.00 $0.00 $50.05 $0.00 $0.00 $0.00 $0.00 $0.00 212.806 SUP HCPCS C1713 212.806 - SCREW BONE T8 CONE 2.4MM 1.9MM 6MM FIX ANGLE SELF TAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.807 SUP HCPCS C1713 212.807 - SCREW BONE T8 CONE 2.4MM 1.9MM 7MM FIX ANGLE SELF TAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.808 SUP HCPCS C1713 212.808 - SCREW BONE T8 CONE 2.4MM 1.9MM 8MM FIX ANGLE SELF TAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.809 SUP HCPCS C1713 212.809 - SCREW BONE T8 CONE 2.4MM 1.9MM 9MM FIX ANGLE SELF TAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.81 SUP HCPCS C1713 212.810 - SCREW BONE T8 CONE 2.4MM 1.9MM 10MM FIX ANGLE SELF TAP BOTH IP/OP $212.90 $157.55 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $44.37 $158.01 $158.01 $0.00 $0.00 $44.37 $0.00 $125.93 $125.93 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.811 SUP HCPCS C1713 212.811 - SCREW BONE T8 CONE 2.4MM 1.9MM 11MM FIX ANGLE SELF TAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.812 SUP HCPCS C1713 212.812 - SCREW BONE T8 2.4MM 12MM SELF TAP LOCK STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.813 SUP HCPCS C1713 212.813 - SCREW BONE T8 CONE 2.4MM 1.9MM 13MM FIX ANGLE SELF TAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.814 SUP HCPCS C1713 212.814 - SCREW BONE T8 2.4MM 14MM SELF TAP LOCK STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.816 SUP HCPCS C1713 212.816 - SCREW BONE T8 CONE 2.4MM 1.9MM 16MM FIX ANGLE SELF TAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.818 SUP HCPCS C1713 212.818 - SCREW BONE 2.4MM 1.9MM 18MM T8 STARDRIVE RECESS SLFTAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.82 SUP HCPCS C1713 212.820 - SCREW BONE 2.4MM 20MM T8 STARDRIVE RECESS SLFTAP LOCKING BOTH IP/OP $212.90 $157.55 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $44.37 $158.01 $158.01 $0.00 $0.00 $44.37 $0.00 $125.93 $125.93 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.822 SUP HCPCS C1713 212.822 - SCREW BONE 2.4MM 22MM T8 STARDRIVE RECESS SLFTAP LOCKING BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.824 SUP HCPCS C1713 212.824 - SCREW BONE T8 CONE 2.4MM 1.9MM 24MM FIX ANGLE SELF TAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.826 SUP HCPCS C1713 212.826 - SCREW BONE 2.4MM 26MM T8 STARDRIVE RECESS SLFTAP LOCKING BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.828 SUP HCPCS C1713 212.828 - SCREW BONE 2.4MM 1.9MM 28MM FIX ANGLE SELF TAP T8 STARDRIVE BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 212.83 SUP HCPCS C1713 212.830 - SCREW BONE T8 CONE 2.4MM 1.9MM 30MM FIX ANGLE SELF TAP BOTH IP/OP $212.90 $157.55 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $44.37 $158.01 $158.01 $0.00 $0.00 $44.37 $0.00 $125.93 $125.93 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 213.018 SUP HCPCS C1713 213.018 - SCREW BONE SMALL HEXAGON 3.5MM 2.9MM 18MM SELF TAP THREAD BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.02 SUP HCPCS C1713 213.020 - SCREW BONE SMALL HEXAGON 3.5MM 2.9MM 20MM SELF TAP THREAD BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.022 SUP HCPCS C1713 213.022 - SCREW BONE SMALL HEXAGON 3.5MM 2.9MM 22MM SELF TAP THREAD BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.024 SUP HCPCS C1713 213.024 - SCREW BONE SMALL HEXAGON 3.5MM 2.9MM 24MM SELF TAP THREAD BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.026 SUP HCPCS C1713 213.026 - SCREW BONE SMALL HEXAGON 3.5MM 2.9MM 26MM SELF TAP THREAD BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.028 SUP HCPCS C1713 213.028 - SCREW BONE SMALL HEXAGON 3.5MM 2.9MM 28MM SELF TAP THREAD BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.03 SUP HCPCS C1713 213.030 - SCREW BONE 2.5MM 3.5MM 30MM SELF TAP LOCK SMALL HEXAGONAL BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.032 SUP HCPCS C1713 213.032 - SCREW BONE SMALL HEXAGON 3.5MM 2.9MM 32MM SELF TAP THREAD BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.034 SUP HCPCS C1713 213.034 - SCREW BONE 3.5MM 2.9MM 34MM SELF TAP LOCK SMALL HEXAGONAL BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.036 SUP HCPCS C1713 213.036 - SCREW BONE 3.5MM 2.9MM 36MM SELF TAP LOCK SMALL HEXAGONAL BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.038 SUP HCPCS C1713 213.038 - SCREW BONE 3.5MM 2.9MM 38MM SELF TAP LOCK SMALL HEXAGONAL BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.04 SUP HCPCS C1713 213.040 - SCREW BONE 2.5MM 3.5MM 40MM SELF TAP SMALL HEXAGONAL RECESS BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.045 SUP HCPCS C1713 213.045 - SCREW BONE 3.5MM 2.9MM 45MM SLFTAP LOCKING SMALL HEXAGONAL BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.05 SUP HCPCS C1713 213.050 - SCREW BONE 3.5MM 2.9MM 50MM SLFTAP LOCKING SMALL HEXAGONAL BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 213.414 SUP HCPCS C1713 213.414 - SCREW BONE 5MM 14MM SLFDRILL LOCKING LISS STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.418 SUP HCPCS C1713 213.418 - SCREW BONE 5MM 18MM SLFDRILL LOCKING LCP LISS STAINLESS BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 213.422 SUP HCPCS C1713 213.422 - SCREW BONE 5MM 22MM SLFDRILL LOCKING LISS STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.426 SUP HCPCS C1713 213.426 - SCREW BONE 5MM 26MM SLFDRILL LOCKING LCP LISS STAINLESS BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 213.43 SUP HCPCS C1713 213.430 - SCREW BONE 5MM 30MM SLFDRILL LOCKING LISS STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.435 SUP HCPCS C1713 213.435 - SCREW BONE 5MM 35MM SLFDRILL LOCKING STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.44 SUP HCPCS C1713 213.440 - SCREW BONE 5MM 40MM SLFDRILL LOCKING LCP LISS STAINLESS BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 213.445 SUP HCPCS C1713 213.445 - SCREW BONE 5MM 45MM SLFDRILL LOCKING STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.45 SUP HCPCS C1713 213.450 - SCREW BONE 5MM 50MM SLFDRILL LOCKING STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.455 SUP HCPCS C1713 213.455 - SCREW BONE 5MM 55MM SLFDRILL LOCKING LCP LISS STAINLESS BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 213.465 SUP HCPCS C1713 213.465 - SCREW BONE 5MM 65MM SLFDRILL LOCKING LCP LISS STAINLESS BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 213.47 SUP HCPCS C1713 213.470 - SCREW BONE 5MM 70MM SLFDRILL LOCKING STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.475 SUP HCPCS C1713 213.475 - SCREW BONE 5MM 75MM SLFDRILL LOCKING LCP LISS STAINLESS BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 213.48 SUP HCPCS C1713 213.480 - SCREW BONE 5MM 80MM SLFDRILL LOCKING STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.485 SUP HCPCS C1713 213.485 - SCREW BONE 5MM 85MM SLFDRILL LOCKING LCP LISS STAINLESS BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 213.49 SUP HCPCS C1713 213.490 - SCREW BONE 5MM 90MM SLFDRILL LOCKING STAINLESS STEEL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 213.508 SUP HCPCS C1713 213.508 - SCREW BONE 4.5MM 8MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.509 SUP HCPCS C1713 213.509 - SCREW BONE 4.5MM 9MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.51 SUP HCPCS C1713 213.510 - SCREW BONE 4.5MM 10MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.511 SUP HCPCS C1713 213.511 - SCREW BONE 4.5MM 11MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.512 SUP HCPCS C1713 213.512 - SCREW BONE 4.5MM 12MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.513 SUP HCPCS C1713 213.513 - SCREW BONE 4.5MM 13MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.514 SUP HCPCS C1713 213.514 - SCREW BONE 4.5MM 14MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.515 SUP HCPCS C1713 213.515 - SCREW BONE 4.5MM 15MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.516 SUP HCPCS C1713 213.516 - SCREW BONE 4.5MM 16MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.517 SUP HCPCS C1713 213.517 - SCREW BONE 4.5MM 17MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.518 SUP HCPCS C1713 213.518 - SCREW BONE 4.5MM 18MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.519 SUP HCPCS C1713 213.519 - SCREW BONE 4.5MM 19MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.52 SUP HCPCS C1713 213.520 - SCREW BONE 4.5MM 20MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.521 SUP HCPCS C1713 213.521 - SCREW BONE 4.5MM 21MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.522 SUP HCPCS C1713 213.522 - SCREW BONE 4.5MM 22MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.523 SUP HCPCS C1713 213.523 - SCREW BONE 4.5MM 23MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.524 SUP HCPCS C1713 213.524 - SCREW BONE 4.5MM 24MM SS STRNL CANN NONSTRL BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.525 SUP HCPCS C1713 213.525 - 4.5MM STERNAL CANNULATED SCREW 25MM BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.526 SUP HCPCS C1713 213.526 - 4.5MM STERNAL CANNULATED SCREW 26MM BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.527 SUP HCPCS C1713 213.527 - 4.5MM STERNAL CANNULATED SCREW 27MM BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 213.528 SUP HCPCS C1713 213.528 - 4.5MM STERNAL CANNULATED SCREW 28MM BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $106.31 $106.31 $0.00 $0.00 $0.00 $49.24 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $139.74 $139.74 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $36.97 $0.00 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 214.014 SUP HCPCS C1713 214.014 - SCREW BONE STANDARD 4.5MM 8MM 14MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.016 SUP HCPCS C1713 214.016 - SCREW BONE STANDARD 4.5MM 8MM 16MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.018 SUP HCPCS C1713 214.018 - SCREW BONE 4.5MM 8MM 18MM HEXAGONAL SOCKET STAINLESS STEEL BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.02 SUP HCPCS C1713 214.020 - SCREW BONE STANDARD 4.5MM 8MM 20MM LARGE HEXAGONAL SOCKET BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.022 SUP HCPCS C1713 214.022 - SCREW BONE STANDARD 4.5MM 8MM 22MM LARGE HEXAGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.024 SUP HCPCS C1713 214.024 - SCREW BONE STANDARD 4.5MM 8MM 24MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.026 SUP HCPCS C1713 214.026 - SCREW BONE STANDARD 4.5MM 8MM 26MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.028 SUP HCPCS C1713 214.028 - SCREW BONE STANDARD 4.5MM 8MM 28MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.03 SUP HCPCS C1713 214.030 - SCREW BONE STANDARD 4.5MM 8MM 30MM LARGE HEXGONAL SOCKET BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.032 SUP HCPCS C1713 214.032 - SCREW BONE STANDARD 4.5MM 8MM 32MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.034 SUP HCPCS C1713 214.034 - SCREW BONE STANDARD 4.5MM 8MM 34MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.036 SUP HCPCS C1713 214.036 - SCREW BONE STANDARD 4.5MM 8MM 36MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.038 SUP HCPCS C1713 214.038 - SCREW BONE STANDARD 4.5MM 8MM 38MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.04 SUP HCPCS C1713 214.040 - SCREW BONE STANDARD 4.5MM 8MM 40MM LARGE HEXGONAL SOCKET BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.042 SUP HCPCS C1713 214.042 - SCREW BONE 4.5MM 8MM 42MM HEXAGONAL SOCKET STAINLESS STEEL BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.044 SUP HCPCS C1713 214.044 - SCREW BONE STANDARD 4.5MM 8MM 44MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.046 SUP HCPCS C1713 214.046 - SCREW BONE STANDARD 4.5MM 8MM 46MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.048 SUP HCPCS C1713 214.048 - SCREW BONE STANDARD LARGE HEXAGON 4.5MM 8MM 48MM SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.05 SUP HCPCS C1713 214.050 - SCREW BONE STANDARD 4.5MM 8MM 50MM LARGE HEXGONAL SOCKET BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.052 SUP HCPCS C1713 214.052 - SCREW BONE STANDARD 4.5MM 8MM 52MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.054 SUP HCPCS C1713 214.054 - SCREW BONE STANDARD 4.5MM 8MM 54MM LARGE HEXGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.056 SUP HCPCS C1713 214.056 - SCREW BONE 3.5MM STANDARD 4.5MM 8MM 56MM LARGE HEXAGONAL BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.058 SUP HCPCS C1713 214.058 - SCREW BONE STANDARD 4.5MM 8MM 58MM CORTEX PROXIMAL MEDIAL BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.06 SUP HCPCS C1713 214.060 - SCREW BONE STANDARD 4.5MM 8MM 60MM LARGE HEXAGONAL SOCKET BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.062 SUP HCPCS C1713 214.062 - SCREW BONE STANDARD 4.5MM 8MM 62MM NONSELF TAP LARGE HEXAGON BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.064 SUP HCPCS C1713 214.064 - SCREW BONE STANDARD 4.5MM 8MM 64MM LARGE HEXAGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.066 SUP HCPCS C1713 214.066 - SCREW BONE STANDARD 4.5MM 8MM 66MM NONSELF TAP LARGE HEXAGON BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.068 SUP HCPCS C1713 214.068 - SCREW BONE STANDARD 4.5MM 8MM 68MM NONSELF TAP LARGE HEXAGON BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.07 SUP HCPCS C1713 214.070 - SCREW BONE STANDARD 4.5MM 8MM 70MM NONSELF TAP LARGE HEXAGON BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.072 SUP HCPCS C1713 214.072 - SCREW BONE STANDARD 4.5MM 8MM 72MM NONSELF TAPPING LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 214.076 SUP HCPCS C1713 214.076 - SCREW BONE 4.5MM 76MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $51.30 $37.96 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.69 $38.07 $38.07 $0.00 $0.00 $10.69 $0.00 $30.34 $30.34 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.08 SUP HCPCS C1713 214.080 - SCREW BONE STANDARD 4.5MM 8MM 80MM NONSELF TAPPING LARGE BOTH IP/OP $49.80 $36.85 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.38 $36.96 $36.96 $0.00 $0.00 $10.38 $0.00 $29.46 $29.46 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.085 SUP HCPCS C1713 214.085 - SCREW BONE STANDARD 4.5MM 8MM 85MM LARGE HEXAGONAL SOCKET BOTH IP/OP $51.30 $37.96 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.69 $38.07 $38.07 $0.00 $0.00 $10.69 $0.00 $30.34 $30.34 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.09 SUP HCPCS C1713 214.090 - SCREW BONE 4.5MM 90MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $49.80 $36.85 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.38 $36.96 $36.96 $0.00 $0.00 $10.38 $0.00 $29.46 $29.46 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.095 SUP HCPCS C1713 214.095 - SCREW BONE STANDARD 4.5MM 8MM 95MM LARGE HEXAGONAL SOCKET BOTH IP/OP $51.30 $37.96 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.69 $38.07 $38.07 $0.00 $0.00 $10.69 $0.00 $30.34 $30.34 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.1 SUP HCPCS C1713 214.100 - SCREW BONE 4.5MM 100MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $49.80 $36.85 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.38 $36.96 $36.96 $0.00 $0.00 $10.38 $0.00 $29.46 $29.46 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.105 SUP HCPCS C1713 214.105 - SCREW BONE 4.5MM 105MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $51.30 $37.96 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.69 $38.07 $38.07 $0.00 $0.00 $10.69 $0.00 $30.34 $30.34 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.11 SUP HCPCS C1713 214.110 - SCREW BONE 4.5MM 110MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $49.80 $36.85 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.38 $36.96 $36.96 $0.00 $0.00 $10.38 $0.00 $29.46 $29.46 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.115 SUP HCPCS C1713 214.115 - SCREW BONE 4.5MM 115MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $51.30 $37.96 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.69 $38.07 $38.07 $0.00 $0.00 $10.69 $0.00 $30.34 $30.34 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.12 SUP HCPCS C1713 214.120 - SCREW BONE 3.5MM STANDARD 4.5MM 8MM 120MM LARGE HEXGONAL BOTH IP/OP $49.80 $36.85 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.38 $36.96 $36.96 $0.00 $0.00 $10.38 $0.00 $29.46 $29.46 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.125 SUP HCPCS C1713 214.125 - SCREW BONE 4.5MM 125MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $51.30 $37.96 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.69 $38.07 $38.07 $0.00 $0.00 $10.69 $0.00 $30.34 $30.34 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.13 SUP HCPCS C1713 214.130 - SCREW BONE 4.5MM 130MM DHS/DCP LC-DCP DCS STAINLESS STEEL BOTH IP/OP $49.80 $36.85 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.38 $36.96 $36.96 $0.00 $0.00 $10.38 $0.00 $29.46 $29.46 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.135 SUP HCPCS C1713 214.135 - SCREW BONE 4.5MM 135MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $51.30 $37.96 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.69 $38.07 $38.07 $0.00 $0.00 $10.69 $0.00 $30.34 $30.34 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.14 SUP HCPCS C1713 214.140 - SCREW BONE 4.5MM 140MM DHS/DCP LC-DCP DCS STAINLESS STEEL BOTH IP/OP $49.80 $36.85 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.38 $36.96 $36.96 $0.00 $0.00 $10.38 $0.00 $29.46 $29.46 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.145 SUP HCPCS C1713 214.145 - SCREW BONE 4.5MM 145MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $51.30 $37.96 $0.00 $39.84 $22.41 $22.41 $0.00 $0.00 $0.00 $10.69 $38.07 $38.07 $0.00 $0.00 $10.69 $0.00 $30.34 $30.34 $0.00 $24.90 $39.44 $39.84 $0.00 $0.00 $7.57 $0.00 $0.00 $7.93 $0.00 $0.00 $0.00 $0.00 $0.00 214.15 SUP HCPCS C1713 214.150 - SCREW BONE 4.5MM 150MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $68.90 $50.99 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.36 $51.14 $51.14 $0.00 $0.00 $14.36 $0.00 $40.75 $40.75 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.155 SUP HCPCS C1713 214.155 - SCREW BONE 4.5MM 155MM LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.16 SUP HCPCS C1713 214.160 - SCREW BONE 4.5MM 160MM NON SLFTAP STAINLESS STEEL CORTICAL BOTH IP/OP $68.90 $50.99 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.36 $51.14 $51.14 $0.00 $0.00 $14.36 $0.00 $40.75 $40.75 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.222 SUP HCPCS C1713 214.222 - SCREW BONE 4.5MM 22MM SHAFT LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 214.224 SUP HCPCS C1713 214.224 - SCREW BONE 4.5MM 24MM SHAFT LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 214.226 SUP HCPCS C1713 214.226 - SCREW BONE 4.5MM 26MM SHAFT LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 214.228 SUP HCPCS C1713 214.228 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 28MM 12MM SOCKET DCP BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 214.23 SUP HCPCS C1713 214.230 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 30MM 12MM SOCKET DCP BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 214.232 SUP HCPCS C1713 214.232 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 32MM 12MM SOCKET DCP BOTH IP/OP $31.03 $22.96 $0.00 $24.82 $13.96 $13.96 $0.00 $0.00 $0.00 $6.47 $23.03 $23.03 $0.00 $0.00 $6.47 $0.00 $18.35 $18.35 $0.00 $15.51 $24.58 $24.82 $0.00 $0.00 $4.71 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 214.234 SUP HCPCS C1713 214.234 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 34MM 12MM SOCKET DCP BOTH IP/OP $31.03 $22.96 $0.00 $24.82 $13.96 $13.96 $0.00 $0.00 $0.00 $6.47 $23.03 $23.03 $0.00 $0.00 $6.47 $0.00 $18.35 $18.35 $0.00 $15.51 $24.58 $24.82 $0.00 $0.00 $4.71 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 214.236 SUP HCPCS C1713 214.236 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 36MM 12MM SOCKET DCP BOTH IP/OP $31.03 $22.96 $0.00 $24.82 $13.96 $13.96 $0.00 $0.00 $0.00 $6.47 $23.03 $23.03 $0.00 $0.00 $6.47 $0.00 $18.35 $18.35 $0.00 $15.51 $24.58 $24.82 $0.00 $0.00 $4.71 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 214.238 SUP HCPCS C1713 214.238 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 38MM 12MM SOCKET DCP BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 214.24 SUP HCPCS C1713 214.240 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 40MM 12MM SOCKET DCP BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 214.242 SUP HCPCS C1713 214.242 - SCREW BONE PTHRD 4.5MM 8MM 42MM 12MM LCP STAINLESS STEEL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.244 SUP HCPCS C1713 214.244 - SCREW BONE PTHRD 4.5MM 8MM 44MM 12MM LCP STAINLESS STEEL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.246 SUP HCPCS C1713 214.246 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 46MM 12MM SOCKET DCP BOTH IP/OP $34.45 $25.49 $0.00 $27.56 $15.50 $15.50 $0.00 $0.00 $0.00 $7.18 $25.57 $25.57 $0.00 $0.00 $7.18 $0.00 $20.38 $20.38 $0.00 $17.23 $27.28 $27.56 $0.00 $0.00 $5.23 $0.00 $0.00 $5.48 $0.00 $0.00 $0.00 $0.00 $0.00 214.248 SUP HCPCS C1713 214.248 - SCREW BONE PTHRD 4.5MM 8MM 50MM 12MM LCP STAINLESS STEEL BOTH IP/OP $34.45 $25.49 $0.00 $27.56 $15.50 $15.50 $0.00 $0.00 $0.00 $7.18 $25.57 $25.57 $0.00 $0.00 $7.18 $0.00 $20.38 $20.38 $0.00 $17.23 $27.28 $27.56 $0.00 $0.00 $5.23 $0.00 $0.00 $5.48 $0.00 $0.00 $0.00 $0.00 $0.00 214.25 SUP HCPCS C1713 214.250 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 50MM 12MM SOCKET DCP BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.252 SUP HCPCS C1713 214.252 - SCREW BONE 4.5MM 52MM SHAFT LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.254 SUP HCPCS C1713 214.254 - SCREW BONE 4.5MM 54MM SHAFT LC-DCP STAINLESS STEEL CORTICAL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.256 SUP HCPCS C1713 214.256 - SCREW BONE 4.5MM 8MM 56MM 15MM SHAFT LC-DCP DHS DCS BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.26 SUP HCPCS C1713 214.260 - SCREW BONE 4.5MM 60MM SHAFT LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.268 SUP HCPCS C1713 214.268 - SCREW BONE 4.5MM 68MM SHAFT LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.272 SUP HCPCS C1713 214.272 - SCREW BONE 4.5MM 8MM 72MM 18MM SHAFT LC-DCP DHS DCS BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.276 SUP HCPCS C1713 214.276 - SCREW BONE 4.5MM 76MM SHAFT LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.28 SUP HCPCS C1713 214.280 - SCREW BONE 4.5MM 80MM SHAFT DCP LC-DCP STAINLESS STEEL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.29 SUP HCPCS C1713 214.290 - SCREW BONE 4.5MM 90MM SHAFT LC-DCP STAINLESS STEEL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.295 SUP HCPCS C1713 214.295 - SCREW BONE 4.5MM 95MM SHAFT LC-DCP STAINLESS STEEL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.3 SUP HCPCS C1713 214.300 - SCREW BONE 4.5MM 100MM SHAFT LC-DCP DCP STAINLESS STEEL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 214.52 SUP HCPCS C1713 214.520 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.522 SUP HCPCS C1713 214.522 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.524 SUP HCPCS C1713 214.524 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.526 SUP HCPCS C1713 214.526 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.528 SUP HCPCS C1713 214.528 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.53 SUP HCPCS C1713 214.530 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.532 SUP HCPCS C1713 214.532 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.534 SUP HCPCS C1713 214.534 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.536 SUP HCPCS C1713 214.536 - SCREW BONE PTHRD 4.5MM 6.5MM 36MM CANN SLFTAP SLFDRILL LARGE BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.538 SUP HCPCS C1713 214.538 - SCREW BONE PTHRD 4.5MM 6.5MM 38MM CANN LARGE HEXAGONAL BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $75.11 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.54 SUP HCPCS C1713 214.540 - SCREW BONE PTHRD 4.5MM 6.5MM 40MM CANN REVERSE CUTTING FLUTE BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $75.11 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.542 SUP HCPCS C1713 214.542 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.544 SUP HCPCS C1713 214.544 - SCREW BONE PTHRD 4.5MM 6.5MM 44MM CANN SLFTAP SLFDRILL LARGE BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $75.11 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.546 SUP HCPCS C1713 214.546 - SCREW BONE PTHRD 4.5MM 6.5MM 46MM CANN LP HEMISPHERICAL HEAD BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.548 SUP HCPCS C1713 214.548 - SCREW BONE PTHRD 4.5MM 6.5MM 48MM CANN SLFTAP SLFDRILL LARGE BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.55 SUP HCPCS C1713 214.550 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.552 SUP HCPCS C1713 214.552 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.554 SUP HCPCS C1713 214.554 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.556 SUP HCPCS C1713 214.556 - SCREW BONE PTHRD 4.5MM 6.5MM 56MM CANN SLFTAP SLFDRILL LARGE BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.56 SUP HCPCS C1713 214.560 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.564 SUP HCPCS C1713 214.564 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.568 SUP HCPCS C1713 214.568 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.572 SUP HCPCS C1713 214.572 - SCREW BONE 4.5MM 72MM 24MM CANN PTTHRD STAINLESS STEEL BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 214.576 SUP HCPCS C1713 214.576 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.58 SUP HCPCS C1713 214.580 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.72 SUP HCPCS C1713 214.720 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.722 SUP HCPCS C1713 214.722 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.724 SUP HCPCS C1713 214.724 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.726 SUP HCPCS C1713 214.726 - SCREW BONE HEMISPHERE FULTHD 4.5MM 6.5MM 1.75MM 26MM CANN BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.728 SUP HCPCS C1713 214.728 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.73 SUP HCPCS C1713 214.730 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.732 SUP HCPCS C1713 214.732 - SCREW BONE HEMISPHERE FULTHD 4.5MM 6.5MM 1.75MM 32MM CANN BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.734 SUP HCPCS C1713 214.734 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.736 SUP HCPCS C1713 214.736 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.738 SUP HCPCS C1713 214.738 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.74 SUP HCPCS C1713 214.740 - SCREW BONE 3.5MM FULTHD 4.5MM 6.5MM 40MM CANN SELF DRILL BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.742 SUP HCPCS C1713 214.742 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.744 SUP HCPCS C1713 214.744 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.746 SUP HCPCS C1713 214.746 - SCREW BONE FULTHD 4.5MM 6.5MM 46MM CANN SELF TAP LARGE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.748 SUP HCPCS C1713 214.748 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.75 SUP HCPCS C1713 214.750 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.752 SUP HCPCS C1713 214.752 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.754 SUP HCPCS C1713 214.754 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.756 SUP HCPCS C1713 214.756 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.76 SUP HCPCS C1713 214.760 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.764 SUP HCPCS C1713 214.764 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.768 SUP HCPCS C1713 214.768 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.772 SUP HCPCS C1713 214.772 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.776 SUP HCPCS C1713 214.776 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.777 SUP HCPCS C1713 214.777 - SCREW BONE FULTHD LARGE HEXAGON HEMISPHERE REVERSE CUT FLUTE BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 214.814 SUP HCPCS C1713 214.814 - SCREW BONE 4.5MM 8MM 14MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.816 SUP HCPCS C1713 214.816 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 16MM SELF TAP SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.818 SUP HCPCS C1713 214.818 - SCREW BONE 4.5MM 8MM 18MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.82 SUP HCPCS C1713 214.820 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 20MM SELF TAP SOCKET LCP BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.822 SUP HCPCS C1713 214.822 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 22MM SELF TAP SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.824 SUP HCPCS C1713 214.824 - SCREW BONE 4.5MM 8MM 24MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.826 SUP HCPCS C1713 214.826 - SCREW BONE 4.5MM 8MM 26MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.828 SUP HCPCS C1713 214.828 - SCREW BONE 4.5MM 28MM SLFTAP LCP STAINLESS STEEL PEDIATRIC BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.83 SUP HCPCS C1713 214.830 - SCREW BONE 4.5MM 8MM 30MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $38.88 $28.77 $0.00 $46.68 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $46.68 $46.68 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.83 SUP HCPCS C1713 214.83 - SCREW BONE 4.5MM 8MM 30MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $38.88 $28.77 $0.00 $89.69 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $46.68 $46.68 $0.00 $19.44 $89.69 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.832 SUP HCPCS C1713 214.832 - SCREW BONE 4.5MM 8MM 32MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.834 SUP HCPCS C1713 214.834 - SCREW BONE 4.5MM 8MM 34MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.836 SUP HCPCS C1713 214.836 - SCREW BONE 4.5MM 8MM 36MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.838 SUP HCPCS C1713 214.838 - SCREW BONE 4.5MM 38MM SLFTAP LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.84 SUP HCPCS C1713 214.840 - SCREW BONE STANDARD 4.5MM 40MM SLFTAP TIP LCP STAINLESS BOTH IP/OP $40.05 $29.64 $0.00 $181.20 $101.93 $101.93 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $46.68 $46.68 $0.00 $113.25 $30.79 $181.20 $0.00 $0.00 $35.45 $0.00 $0.00 $36.06 $0.00 $0.00 $0.00 $0.00 $0.00 214.84 SUP HCPCS C1713 214.84 - SCREW BN 4.5MM 8MM 40MM NS ST LG HEX SCKT SS CORT LG FRAG BOTH IP/OP $40.05 $29.64 $0.00 $181.20 $101.93 $101.93 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $46.68 $46.68 $0.00 $113.25 $179.39 $181.20 $0.00 $0.00 $35.45 $0.00 $0.00 $36.06 $0.00 $0.00 $0.00 $0.00 $0.00 214.842 SUP HCPCS C1713 214.842 - SCREW BONE 4.5MM 8MM 42MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.844 SUP HCPCS C1713 214.844 - SCREW BONE 4.5MM 8MM 44MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.846 SUP HCPCS C1713 214.846 - SCREW BONE 4.5MM 46MM SLFTAP TIP LCP STAINLESS STEEL BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.848 SUP HCPCS C1713 214.848 - SCREW BONE 4.5MM 48MM SLFTAP LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.85 SUP HCPCS C1713 214.850 - SCREW BONE 4.5MM 8MM 50MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $90.60 $50.96 $50.96 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $46.68 $46.68 $0.00 $56.63 $30.79 $90.60 $0.00 $0.00 $17.72 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 214.85 SUP HCPCS C1713 214.85 - SCREW BONE 4.5MM 8MM 50MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $90.60 $50.96 $50.96 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $46.68 $46.68 $0.00 $56.63 $89.69 $90.60 $0.00 $0.00 $17.72 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 214.852 SUP HCPCS C1713 214.852 - SCREW BONE 4.5MM 52MM SELF TAP LC-DCP DHS DCS STAINLESS BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.854 SUP HCPCS C1713 214.854 - SCREW BONE 4.5MM 54MM SLFTAP LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.856 SUP HCPCS C1713 214.856 - SCREW BONE 4.5MM 56MM SLFTAP LC-DCP DHS DCS STAINLESS STEEL BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.858 SUP HCPCS C1713 214.858 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 58MM SELF TAP SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.86 SUP HCPCS C1713 214.860 - SCREW BONE 4.5MM 8MM 60MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $38.88 $28.77 $0.00 $46.68 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $46.68 $46.68 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.86 SUP HCPCS C1713 214.86 - SCREW BONE 4.5MM 8MM 60MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $38.88 $28.77 $0.00 $59.80 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $46.68 $46.68 $0.00 $19.44 $59.80 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.862 SUP HCPCS C1713 214.862 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 62MM SELF TAP SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.864 SUP HCPCS C1713 214.864 - SCREW BONE 4.5MM 8MM 64MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.866 SUP HCPCS C1713 214.866 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 66MM SELF TAP SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.868 SUP HCPCS C1713 214.868 - SCREW BONE 4.5MM 8MM 68MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.87 SUP HCPCS C1713 214.870 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 70MM SELF TAP SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $60.40 $33.98 $33.98 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $46.68 $46.68 $0.00 $37.75 $30.79 $60.40 $0.00 $0.00 $11.82 $0.00 $0.00 $12.02 $0.00 $0.00 $0.00 $0.00 $0.00 214.87 SUP HCPCS C1713 214.87 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 70MM SELF TAP SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $60.40 $33.98 $33.98 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $46.68 $46.68 $0.00 $37.75 $59.80 $60.40 $0.00 $0.00 $11.82 $0.00 $0.00 $12.02 $0.00 $0.00 $0.00 $0.00 $0.00 214.872 SUP HCPCS C1713 214.872 - SCREW BONE 4.5MM 8MM 72MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 214.876 SUP HCPCS C1713 214.876 - SCREW BONE 4.5MM 8MM 76MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.88 SUP HCPCS C1713 214.880 - SCREW BONE 4.5MM 80MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $14.27 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.885 SUP HCPCS C1713 214.885 - SCREW BONE 4.5MM 8MM 85MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $14.27 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.89 SUP HCPCS C1713 214.890 - SCREW BONE 4.5MM 8MM 90MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.895 SUP HCPCS C1713 214.895 - SCREW BONE 4.5MM 8MM 95MM SELF TAP LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.9 SUP HCPCS C1713 214.900 - SCREW BONE 4.5MM 8MM 100MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $14.27 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.905 SUP HCPCS C1713 214.905 - SCREW BONE 4.5MM 8MM 105MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.91 SUP HCPCS C1713 214.910 - SCREW BONE 4.5MM 8MM 110MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.915 SUP HCPCS C1713 214.915 - SCREW BONE 4.5MM 8MM 115MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.92 SUP HCPCS C1713 214.920 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 120MM SELF TAP SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.925 SUP HCPCS C1713 214.925 - SCREW BONE 4.5MM 8MM 125MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.93 SUP HCPCS C1713 214.930 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 130MM SELF TAP SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.935 SUP HCPCS C1713 214.935 - SCREW BONE 4.5MM 8MM 135MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.94 SUP HCPCS C1713 214.940 - SCREW BONE 4.5MM 8MM 140MM SLFTAP LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 214.945 SUP HCPCS C1713 214.945 - SCREW BONE 4.5MM 8MM 145MM SELF TAP HEXAGONAL SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 215.025 SUP HCPCS C1713 215.025 - SCREW BONE 3.5MM HEXAGON 4.5MM 8MM 25MM 12MM DCP LC-DCP BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.03 SUP HCPCS C1713 215.030 - SCREW BONE PTHRD 4.5MM 8MM 30MM 15MM HEXAGONAL SOCKET LCP BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.035 SUP HCPCS C1713 215.035 - SCREW BONE 4.5MM 35MM IMPLANT LC-DCP DCP MALLEOLAR LARGE BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.04 SUP HCPCS C1713 215.040 - SCREW BONE 4.5MM 40MM DCP LC-DCP STAINLESS STEEL MALLEOLAR BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.045 SUP HCPCS C1713 215.045 - SCREW BONE 3.5MM 4.5MM 8MM 45MM 22MM HEXAGONAL SOCKET LC-DCP BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.05 SUP HCPCS C1713 215.050 - SCREW BONE PTHRD 4.5MM 8MM 50MM 24MM HEXAGONAL SOCKET LCP BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.055 SUP HCPCS C1713 215.055 - SCREW BONE 3.5MM HEXAGON 4.5MM 8MM 55MM 26MM DCP LC-DCP BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.06 SUP HCPCS C1713 215.060 - SCREW BONE 3.5MM 4.5MM 8MM 60MM 28MM HEXAGONAL SOCKET LCP BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.065 SUP HCPCS C1713 215.065 - SCREW BONE 3.5MM 4.5MM 65MM 30MM HEXAGONAL SOCKET LCP BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.07 SUP HCPCS C1713 215.070 - SCREW BONE 3.5MM 4.5MM 8MM 70MM 32MM HEXAGONAL SOCKET LCP BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.075 SUP HCPCS C1713 215.075 - SCREW BONE 4.5MM 75MM LC-DCP STAINLESS STEEL MALLEOLAR BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.08 SUP HCPCS C1713 215.080 - SCREW BONE 4.5MM 80MM LC-DCP STAINLESS STEEL MALLEOLAR BOTH IP/OP $56.30 $41.66 $0.00 $45.04 $25.34 $25.34 $0.00 $0.00 $0.00 $11.73 $41.79 $41.79 $0.00 $0.00 $11.73 $0.00 $33.30 $33.30 $0.00 $28.15 $44.59 $45.04 $0.00 $0.00 $8.81 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $0.00 215.222 SUP HCPCS C1713 "215.222 - 3.5MM SS PROTEX CT POLYAXAIL SHOULDER SCREW, 22MM" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 215.224 SUP HCPCS C1713 "215.224 - 3.5MM SS PROTEX CT POLYAXAIL SHOULDER SCREW, 24MM" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 215.226 SUP HCPCS C1713 "215.226 - 3.5MM SS PROTEX CT POLYAXAIL SHOULDER SCREW, 26MM" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 215.228 SUP HCPCS C1713 "215.228 - 3.5MM SS PROTEX CT POLYAXAIL SHOULDER SCREW, 28MM" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 215.23 SUP HCPCS C1713 "215.230 - 3.5MM SS PROTEX CT POLYAXAIL SHOULDER SCREW, 30MM" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 215.232 SUP HCPCS C1713 "215.232 - 3.5MM SS PROTEX CT POLYAXAIL SHOULDER SCREW, 32MM" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 215.234 SUP HCPCS C1713 "215.234 - 3.5MM SS PROTEX CT POLYAXAIL SHOULDER SCREW, 34MM" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 215.236 SUP HCPCS C1713 "215.236 - 3.5MM SS PROTEX CT POLYAXAIL SHOULDER SCREW, 36MM" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 215.308 SUP HCPCS C1713 "215.308 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 8MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.31 SUP HCPCS C1713 "215.310 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 10MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.312 SUP HCPCS C1713 "215.312 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 12MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.314 SUP HCPCS C1713 "215.314 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 14MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.316 SUP HCPCS C1713 "215.316 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 16MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.318 SUP HCPCS C1713 "215.318 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 18MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.32 SUP HCPCS C1713 "215.320 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 20MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.322 SUP HCPCS C1713 "215.322 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 22MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.324 SUP HCPCS C1713 "215.324 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 24MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.326 SUP HCPCS C1713 "215.326 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 26MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.328 SUP HCPCS C1713 "215.328 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 28MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.33 SUP HCPCS C1713 "215.330 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 30MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.335 SUP HCPCS C1713 "215.335 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 35MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.34 SUP HCPCS C1713 "215.340 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 40MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.345 SUP HCPCS C1713 "215.345 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 45MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.35 SUP HCPCS C1713 "215.350 - 3.5MM SS PROTEX CT POLYAXIAL SCREW, 50MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.41 SUP HCPCS C1713 "215.410 - 4.0MM SS PROTEX? CT POLYAXIAL SCREW, 10MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.412 SUP HCPCS C1713 "215.412 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 12MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.414 SUP HCPCS C1713 "215.414 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 14MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.416 SUP HCPCS C1713 "215.416 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 16MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.418 SUP HCPCS C1713 "215.418 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 18MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.42 SUP HCPCS C1713 "215.420 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 20MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.422 SUP HCPCS C1713 "215.422 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 22MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.424 SUP HCPCS C1713 "215.424 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 24MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.426 SUP HCPCS C1713 "215.426 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 26MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.428 SUP HCPCS C1713 "215.428 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 28MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.43 SUP HCPCS C1713 "215.430 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 30MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.435 SUP HCPCS C1713 "215.435 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 35MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.44 SUP HCPCS C1713 "215.440 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 40MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.445 SUP HCPCS C1713 "215.445 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 45MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.45 SUP HCPCS C1713 "215.450 - 4.0MM SS PROTEX CT POLYAXIAL SCREW, 50MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.5 SUP HCPCS C1713 215.500 - SS PROTEX CT LOCKING CAP BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 215.501 SUP HCPCS C1713 215.501 - SS PROTEX HOOK BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.503 SUP Custom 27803010 "215.503 - SS PROTEX HOOK, RIGHT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.504 SUP Custom 27803010 "215.504 - SS PROTEX HOOK, LEFT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.506 SUP Custom 27803010 "215.506 - SS PROTEX HOOK, 7MM OFFSET, LEFT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.507 SUP Custom 27803010 "215.507 - SS PROTEX HOOK, 5MM OFFSET, LEFT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.508 SUP Custom 27803010 "215.508 - SS PROTEX HOOK, 7MM OFFSET, RIGHT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.509 SUP Custom 27803010 "215.509 - SS PROTEX HOOK, 5MM OFFSET, RIGHT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.51 SUP HCPCS C1713 "215.510 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 10MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.512 SUP HCPCS C1713 "215.512 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 12MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.514 SUP HCPCS C1713 "215.514 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 14MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.516 SUP HCPCS C1713 "215.516 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 16MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.518 SUP HCPCS C1713 "215.518 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 18MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.52 SUP HCPCS C1713 "215.520 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 20MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.522 SUP HCPCS C1713 "215.522 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 22MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.524 SUP HCPCS C1713 "215.524 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 24MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.526 SUP HCPCS C1713 "215.526 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 26MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.528 SUP HCPCS C1713 "215.528 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 28MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.53 SUP HCPCS C1713 "215.530 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 30MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.535 SUP HCPCS C1713 "215.535 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 35MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.54 SUP HCPCS C1713 "215.540 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 40MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.545 SUP HCPCS C1713 "215.545 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 45MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.55 SUP HCPCS C1713 "215.550 - 4.5MM SS PROTEX CT POLYAXIAL SCREW, 50MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.625 SUP HCPCS C1713 "215.625 - 5.0MM SS PROTEX CT POLYAXIAL SCREW, 25MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.63 SUP HCPCS C1713 "215.630 - 5.0MM SS PROTEX CT POLYAXIAL SCREW, 30MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.635 SUP HCPCS C1713 "215.635 - 5.0MM SS PROTEX CT POLYAXIAL SCREW, 35MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.64 SUP HCPCS C1713 "215.640 - 5.0MM SS PROTEX CT POLYAXIAL SCREW, 40MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.645 SUP HCPCS C1713 "215.645 - 5.0MM SS PROTEX CT POLYAXIAL SCREW, 45MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.65 SUP HCPCS C1713 "215.650 - 5.0MM SS PROTEX CT POLYAXIAL SCREW, 50MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.801 SUP Custom 27803010 "215.801 - 3.7MM SS STRAIGHT ROD, 80MM" BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $0.00 $0.00 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.802 SUP Custom 27803010 "215.802 - 3.7MM SS STRAIGHT ROD, 120MM" BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.803 SUP Custom 27803010 "215.803 - 3.7MM SS STRAIGHT ROD, 240MM" BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.804 SUP Custom 27803010 "215.804 - 3.7MM SS STRAIGHT ROD, 40MM" BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $0.00 $0.00 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.806 SUP HCPCS C1713 "215.806 - 4.0MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 6MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.808 SUP HCPCS C1713 "215.808 - 4.0MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 8MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.81 SUP HCPCS C1713 "215.810 - 4.0MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 10MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.812 SUP HCPCS C1713 "215.812 - 4.0MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 12MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.814 SUP HCPCS C1713 "215.814 - 4.0MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 14MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.816 SUP HCPCS C1713 "215.816 - 4.0MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 16MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.906 SUP HCPCS C1713 "215.906 - 4.5MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 6MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.908 SUP HCPCS C1713 "215.908 - 4.5MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 8MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.91 SUP HCPCS C1713 "215.910 - 4.5MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 10MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.912 SUP HCPCS C1713 "215.912 - 4.5MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 12MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.914 SUP HCPCS C1713 "215.914 - 4.5MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 14MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.916 SUP HCPCS C1713 "215.916 - 4.5MM SS PROTEX CT OC STANDARD SCREW, SELF-TAPPING, 16MM" BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 215.923 SUP Custom 27803010 "215.923 - SS TOP LOADING T-CONNECTOR FOR 3.7MM ROD, 21-33MM, STRAIGHT" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 $0.00 $0.00 $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.925 SUP Custom 27803010 "215.925 - SS TOP LOADING T-CONNECTOR FOR 3.7MM ROD, 26-46MM, STRAIGHT" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 $0.00 $0.00 $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.927 SUP Custom 27803010 "215.927 - SS TOP LOADING T-CONNECTOR FOR 3.7MM ROD, 36-56MM, STRAIGHT" BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 $0.00 $0.00 $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.949 SUP HCPCS C1713 "215.949 - SS SET SCREW, M4.5 X 0.75, ROUND TIP, 2.5MM HEX" BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 215.95 SUP Custom 27803010 "215.950 - SS OCCIPITAL CLAMP, SINGLE, SHORT" BOTH IP/OP "$1,050.00 " $777.00 $0.00 $840.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $0.00 $0.00 $0.00 $525.00 $831.60 $840.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.951 SUP Custom 27803010 "215.951 - SS OCCIPITAL CLAMP, SINGLE, LONG" BOTH IP/OP "$1,050.00 " $777.00 $0.00 $840.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $0.00 $0.00 $0.00 $525.00 $831.60 $840.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.952 SUP HCPCS C1713 "215.952 - SS SET SCREW, M4.5 X 0.75" BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 215.953 SUP Custom 27803010 "215.953 - SS 3.7MM OCCIPITAL ROD, 240MM, 100DEG" BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $0.00 $0.00 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.954 SUP Custom 27803010 "215.954 - SS 3.7MM OCCIPITAL ROD, 240MM, 115DEG" BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $0.00 $0.00 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.955 SUP Custom 27803010 "215.955 - SS 3.7MM OCCIPITAL ROD, 240MM, 130DEG" BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $0.00 $0.00 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.956 SUP Custom 27803010 "215.956 - SS OCCIPITAL CLAMP, TRIPLE, SHORT" BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $0.00 $0.00 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.957 SUP Custom 27803010 "215.957 - SS OCCIPITAL CLAMP, TRIPLE, LONG" BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $0.00 $0.00 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.958 SUP Custom 27803010 "215.958 - SS OCCIPITAL CLAMP, DOUBLE, SHORT" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $0.00 $0.00 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.959 SUP Custom 27803010 "215.959 - SS OCCIPITAL CLAMP, DOUBLE, LONG" BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $0.00 $0.00 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.96 SUP Custom 27803010 "215.960 - SS PARALLEL CONNECTOR, 3.7MM ROD TO 3.7MM ROD" BOTH IP/OP "$1,787.50 " "$1,322.75" $0.00 "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,326.68" "$1,326.68" $0.00 $0.00 $372.52 $0.00 $0.00 $0.00 $0.00 $893.75 "$1,415.70" "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.963 SUP Custom 27803010 "215.963 - SS PARALLEL CONNECTOR, 3.7MM ROD TO 5.5MM ROD" BOTH IP/OP "$1,787.50 " "$1,322.75" $0.00 "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,326.68" "$1,326.68" $0.00 $0.00 $372.52 $0.00 $0.00 $0.00 $0.00 $893.75 "$1,415.70" "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.984 SUP Custom 27803010 "215.984 - SS TAPERED ROD, 3.7MM TO 5.5MM, 350MM" BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.99 SUP Custom 27803010 215.990 - SS LATERAL CONNECTOR BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 215.991 SUP Custom 27803010 "215.991 - SS LATERAL CONNECTOR, SHORT" BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 216.03 SUP HCPCS C1713 216.030 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 30MM 16MM SOCKET LCP DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.035 SUP HCPCS C1713 216.035 - SCREW BONE PTHRD 6.5MM 8MM 35MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.04 SUP HCPCS C1713 216.040 - SCREW BONE PTHRD 6.5MM 8MM 40MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.045 SUP HCPCS C1713 216.045 - SCREW BONE PTHRD 6.5MM 8MM 45MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.05 SUP HCPCS C1713 216.050 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 50MM 16MM SOCKET LCP DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.055 SUP HCPCS C1713 216.055 - SCREW BONE PTHRD 6.5MM 8MM 55MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.06 SUP HCPCS C1713 216.060 - SCREW BONE PTHRD 6.5MM 8MM 60MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.065 SUP HCPCS C1713 216.065 - SCREW BONE PTHRD 6.5MM 8MM 65MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.07 SUP HCPCS C1713 216.070 - SCREW BONE PTHRD 6.5MM 8MM 70MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.075 SUP HCPCS C1713 216.075 - SCREW BONE PTHRD 6.5MM 8MM 75MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.08 SUP HCPCS C1713 216.080 - SCREW BONE PTHRD 6.5MM 8MM 80MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 216.085 SUP HCPCS C1713 216.085 - SCREW BONE PTHRD 6.5MM 8MM 85MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $15.02 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 216.09 SUP HCPCS C1713 216.090 - SCREW BONE PTHRD 6.5MM 8MM 90MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $15.02 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 216.095 SUP HCPCS C1713 216.095 - SCREW BONE PTHRD 6.5MM 8MM 95MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $15.02 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 216.1 SUP HCPCS C1713 216.100 - SCREW BONE PTHRD 6.5MM 8MM 100MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $15.02 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 216.105 SUP HCPCS C1713 216.105 - SCREW BONE PTHRD 6.5MM 8MM 105MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $15.02 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 216.11 SUP HCPCS C1713 216.110 - SCREW BONE PTHRD 6.5MM 110MM 16MM THREAD LCP STAINLESS STEEL BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $15.02 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 216.115 SUP HCPCS C1713 216.115 - SCREW BONE PTHRD 6.5MM 8MM 115MM 16MM HEXAGONAL SOCKET LCP BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 216.12 SUP HCPCS C1713 216.120 - SCREW BONE PTHRD 6.5MM 8MM 120MM 16MM HEXAGONAL SOCKET LCP BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 216.125 SUP HCPCS C1713 216.125 - SCREW BONE 6.5MM 125MM 16MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 216.13 SUP HCPCS C1713 216.130 - SCREW BONE PTHRD 6.5MM 8MM 130MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 216.135 SUP HCPCS C1713 216.135 - SCREW BONE 6.5MM 135MM 16MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 216.14 SUP HCPCS C1713 216.140 - SCREW BONE PTHRD 6.5MM 8MM 140MM 16MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 216.145 SUP HCPCS C1713 216.145 - SCREW BONE 6.5MM 145MM 16MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 216.15 SUP HCPCS C1713 216.150 - SCREW BONE 6.5MM 150MM 16MM LOCKING THREADED LC-DCP BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 216.24 SUP HCPCS C1713 216.240 - SCREW BONE 6.5MM 40MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $57.63 $42.65 $0.00 $46.10 $25.93 $25.93 $0.00 $0.00 $0.00 $12.01 $42.77 $42.77 $0.00 $0.00 $12.01 $0.00 $34.09 $34.09 $0.00 $28.81 $45.64 $46.10 $0.00 $0.00 $9.02 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 216.25 SUP HCPCS C1713 216.250 - SCREW BONE 6.5MM 8MM 50MM 24MM LARGE HEXAGONAL SOCKET DCP BOTH IP/OP $57.63 $42.65 $0.00 $46.10 $25.93 $25.93 $0.00 $0.00 $0.00 $12.01 $42.77 $42.77 $0.00 $0.00 $12.01 $0.00 $34.09 $34.09 $0.00 $28.81 $45.64 $46.10 $0.00 $0.00 $9.02 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 216.26 SUP HCPCS C1713 216.260 - SCREW BONE 6.5MM 60MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $57.63 $42.65 $0.00 $46.10 $25.93 $25.93 $0.00 $0.00 $0.00 $12.01 $42.77 $42.77 $0.00 $0.00 $12.01 $0.00 $34.09 $34.09 $0.00 $28.81 $45.64 $46.10 $0.00 $0.00 $9.02 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 216.27 SUP HCPCS C1713 216.270 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 70MM 24MM SOCKET LCP DCP BOTH IP/OP $57.63 $42.65 $0.00 $46.10 $25.93 $25.93 $0.00 $0.00 $0.00 $12.01 $42.77 $42.77 $0.00 $0.00 $12.01 $0.00 $34.09 $34.09 $0.00 $28.81 $45.64 $46.10 $0.00 $0.00 $9.02 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 216.28 SUP HCPCS C1713 216.280 - SCREW BONE 6.5MM 80MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $57.63 $42.65 $0.00 $46.10 $25.93 $25.93 $0.00 $0.00 $0.00 $12.01 $42.77 $42.77 $0.00 $0.00 $12.01 $0.00 $34.09 $34.09 $0.00 $28.81 $45.64 $46.10 $0.00 $0.00 $9.02 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 216.29 SUP HCPCS C1713 216.290 - SCREW BONE 6.5MM 90MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $62.28 $46.09 $0.00 $49.82 $28.02 $28.02 $0.00 $0.00 $0.00 $12.98 $46.22 $46.22 $0.00 $0.00 $12.98 $0.00 $36.84 $36.84 $0.00 $31.14 $49.33 $49.82 $0.00 $0.00 $9.75 $0.00 $0.00 $9.91 $0.00 $0.00 $0.00 $0.00 $0.00 216.295 SUP HCPCS C1713 216.295 - SCREW BONE 6.5MM 95MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $62.28 $46.09 $0.00 $49.82 $28.02 $28.02 $0.00 $0.00 $0.00 $12.98 $46.22 $46.22 $0.00 $0.00 $12.98 $0.00 $36.84 $36.84 $0.00 $31.14 $49.33 $49.82 $0.00 $0.00 $9.75 $0.00 $0.00 $9.91 $0.00 $0.00 $0.00 $0.00 $0.00 216.3 SUP HCPCS C1713 216.300 - SCREW BONE 6.5MM 100MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $62.28 $46.09 $0.00 $49.82 $28.02 $28.02 $0.00 $0.00 $0.00 $12.98 $46.22 $46.22 $0.00 $0.00 $12.98 $0.00 $36.84 $36.84 $0.00 $31.14 $49.33 $49.82 $0.00 $0.00 $9.75 $0.00 $0.00 $9.91 $0.00 $0.00 $0.00 $0.00 $0.00 216.305 SUP HCPCS C1713 216.305 - SCREW BONE 6.5MM 105MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $62.28 $46.09 $0.00 $49.82 $28.02 $28.02 $0.00 $0.00 $0.00 $12.98 $46.22 $46.22 $0.00 $0.00 $12.98 $0.00 $36.84 $36.84 $0.00 $31.14 $49.33 $49.82 $0.00 $0.00 $9.75 $0.00 $0.00 $9.91 $0.00 $0.00 $0.00 $0.00 $0.00 216.31 SUP HCPCS C1713 216.310 - SCREW BONE 6.5MM 110MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $62.28 $46.09 $0.00 $49.82 $28.02 $28.02 $0.00 $0.00 $0.00 $12.98 $46.22 $46.22 $0.00 $0.00 $12.98 $0.00 $36.84 $36.84 $0.00 $31.14 $49.33 $49.82 $0.00 $0.00 $9.75 $0.00 $0.00 $9.91 $0.00 $0.00 $0.00 $0.00 $0.00 216.315 SUP HCPCS C1713 216.315 - SCREW BONE 6.5MM 115MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $34.88 $34.88 $0.00 $0.00 $0.00 $16.15 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $45.84 $45.84 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $12.13 $0.00 $0.00 $12.34 $0.00 $0.00 $0.00 $0.00 $0.00 216.32 SUP HCPCS C1713 216.320 - SCREW BONE 6.5MM 120MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $34.88 $34.88 $0.00 $0.00 $0.00 $16.15 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $45.84 $45.84 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $12.13 $0.00 $0.00 $12.34 $0.00 $0.00 $0.00 $0.00 $0.00 216.325 SUP HCPCS C1713 216.325 - SCREW BONE 6.5MM 125MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $34.88 $34.88 $0.00 $0.00 $0.00 $16.15 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $45.84 $45.84 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $12.13 $0.00 $0.00 $12.34 $0.00 $0.00 $0.00 $0.00 $0.00 216.33 SUP HCPCS C1713 216.330 - SCREW BONE 6.5MM 130MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $34.88 $34.88 $0.00 $0.00 $0.00 $16.15 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $45.84 $45.84 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $12.13 $0.00 $0.00 $12.34 $0.00 $0.00 $0.00 $0.00 $0.00 216.34 SUP HCPCS C1713 216.340 - SCREW BONE 6.5MM 140MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $34.88 $34.88 $0.00 $0.00 $0.00 $16.15 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $45.84 $45.84 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $12.13 $0.00 $0.00 $12.34 $0.00 $0.00 $0.00 $0.00 $0.00 216.35 SUP HCPCS C1713 216.350 - SCREW BONE 6.5MM 150MM 24MM THREAD LC-DCP STAINLESS STEEL BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $34.88 $34.88 $0.00 $0.00 $0.00 $16.15 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $45.84 $45.84 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $12.13 $0.00 $0.00 $12.34 $0.00 $0.00 $0.00 $0.00 $0.00 217.045 SUP HCPCS C1713 217.045 - SCREW BONE PTHRD 6.5MM 8MM 45MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.05 SUP HCPCS C1713 217.050 - SCREW BONE PTHRD 6.5MM 8MM 50MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.055 SUP HCPCS C1713 217.055 - SCREW BONE PTHRD 6.5MM 55MM 32MM LCP STAINLESS STEEL HUMERUS BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.06 SUP HCPCS C1713 217.060 - SCREW BONE PTHRD 6.5MM 60MM 32MM LCP STAINLESS STEEL HUMERUS BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.065 SUP HCPCS C1713 217.065 - SCREW BONE PTHRD 6.5MM 8MM 65MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.07 SUP HCPCS C1713 217.070 - SCREW BONE PTHRD 6.5MM 8MM 70MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.075 SUP HCPCS C1713 217.075 - SCREW BONE PTHRD 6.5MM 8MM 75MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.08 SUP HCPCS C1713 217.080 - SCREW BONE PTHRD 6.5MM 80MM 32MM LCP STAINLESS STEEL HUMERUS BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.08 SUP HCPCS C1713 217.08 - SCREW BONE 6.5MM 80MM 32MM LC DCP SS CANC PERIART NSTRL LG BOTH IP/OP $59.35 $43.92 $0.00 $61.88 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $61.88 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 217.085 SUP HCPCS C1713 217.085 - SCREW BONE PTHRD 6.5MM 8MM 85MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 217.09 SUP HCPCS C1713 217.090 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 90MM 32MM SOCKET LCP DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $15.02 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 217.095 SUP HCPCS C1713 217.095 - SCREW BONE PTHRD 6.5MM 8MM 95MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 217.1 SUP HCPCS C1713 217.100 - SCREW BONE PTHRD 6.5MM 8MM 100MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $15.02 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 217.105 SUP HCPCS C1713 217.105 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 105MM 32MM SOCKET LCP DCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 217.11 SUP HCPCS C1713 217.110 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 110MM 32MM SOCKET LCP DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 217.115 SUP HCPCS C1713 217.115 - SCREW BONE 6.5MM 8MM 115MM 32MM HEXAGONAL SOCKET LC-DCP BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 217.12 SUP HCPCS C1713 217.120 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 120MM 32MM SOCKET LCP DCP BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 217.125 SUP HCPCS C1713 217.125 - SCREW BONE 6.5MM 8MM 125MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 217.13 SUP HCPCS C1713 217.130 - SCREW BONE 6.5MM 8MM 130MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 217.135 SUP HCPCS C1713 217.135 - SCREW BONE 6.5MM 8MM 135MM 32MM LARGE HEXAGONAL SOCKET DCP BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 217.14 SUP HCPCS C1713 217.140 - SCREW BONE 6.5MM 8MM 140MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 217.145 SUP HCPCS C1713 217.145 - SCREW BONE 6.5MM 8MM 145MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 217.15 SUP HCPCS C1713 217.150 - SCREW BONE 6.5MM 8MM 150MM 32MM LARGE HEXAGONAL SOCKET DCP BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.009 SUP HCPCS C1713 218.009 - SCREW BONE 6.5MM 60MM LCP STAINLESS STEEL CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.01 SUP HCPCS C1713 218.010 - CASE STERILIZATION 2IN 11X7IN CASTANEDA RETRACTOR KIT BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.011 SUP HCPCS C1713 218.011 - SCREW BONE 6.5MM 70MM LCP STAINLESS STEEL CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.012 SUP HCPCS C1713 218.012 - SCREW BONE 6.5MM 75MM LCP STAINLESS STEEL CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.013 SUP HCPCS C1713 218.013 - SCREW BONE 6.5MM 80MM LCP STAINLESS STEEL CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.014 SUP HCPCS C1713 218.014 - SCREW BONE 6.5MM 85MM LCP STAINLESS STEEL CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.015 SUP HCPCS C1713 218.015 - SCREW BONE 6.5MM 90MM LCP STAINLESS STEEL CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.016 SUP HCPCS C1713 218.016 - SCREW BONE 6.5MM 95MM LCP STAINLESS STEEL CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.017 SUP HCPCS C1713 218.017 - SCREW BONE 6.5MM 100MM LCP STAINLESS STEEL CANCELLOUS BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.018 SUP HCPCS C1713 218.018 - SCREW BONE 6.5MM 105MM LCP STAINLESS STEEL CANCELLOUS BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.019 SUP HCPCS C1713 218.019 - SCREW BONE 6.5MM 110MM LCP STAINLESS STEEL CANCELLOUS BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.02 SUP HCPCS C1713 218.020 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 20MM SOCKET LCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.025 SUP HCPCS C1713 218.025 - SCREW BONE 6.5MM 25MM FULTHD LC-DCP STAINLESS STEEL BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.03 SUP HCPCS C1713 218.030 - SCREW BONE FULTHD 6.5MM 8MM 30MM LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.035 SUP HCPCS C1713 218.035 - SCREW BONE FULTHD 6.5MM 8MM 35MM LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.04 SUP HCPCS C1713 218.040 - SCREW BONE FULTHD 6.5MM 8MM 40MM LARGE HEXAGONAL SOCKET LCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.045 SUP HCPCS C1713 218.045 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 45MM SOCKET LCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $13.61 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.05 SUP HCPCS C1713 218.050 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 50MM SOCKET LCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.055 SUP HCPCS C1713 218.055 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 55MM SOCKET LCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.06 SUP HCPCS C1713 218.060 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 60MM SOCKET LCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.065 SUP HCPCS C1713 218.065 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 65MM SOCKET LCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.07 SUP HCPCS C1713 218.070 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 70MM SOCKET LCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.075 SUP HCPCS C1713 218.075 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 75MM SOCKET LCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.08 SUP HCPCS C1713 218.080 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 80MM SOCKET LCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 218.085 SUP HCPCS C1713 218.085 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 85MM SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 218.09 SUP HCPCS C1713 218.090 - SCREW BONE FULTHD 6.5MM 8MM 90MM 3.5MM HEXAGONAL SOCKET DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 218.095 SUP HCPCS C1713 218.095 - SCREW BONE FULTHD 6.5MM 8MM 95MM 3.5MM HEXAGONAL SOCKET DCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 218.1 SUP HCPCS C1713 218.100 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 100MM SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 218.105 SUP HCPCS C1713 218.105 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 105MM SOCKET LCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 218.11 SUP HCPCS C1713 218.110 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 110MM SOCKET LCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 218.115 SUP HCPCS C1713 218.115 - SCREW BONE FULTHD 6.5MM 8MM 115MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.12 SUP HCPCS C1713 218.120 - SCREW BONE FULTHD 6.5MM 8MM 120MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.125 SUP HCPCS C1713 218.125 - SCREW BONE FULTHD 6.5MM 8MM 125MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.13 SUP HCPCS C1713 218.130 - SCREW BONE 6.5MM 130MM FULTHRD LC-DCP STAINLESS STEEL BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.135 SUP HCPCS C1713 218.135 - SCREW BONE FULTHD 6.5MM 8MM 135MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.14 SUP HCPCS C1713 218.140 - SCREW BONE 6.5MM 140MM FULTHRD DCP LC-DCP STAINLESS STEEL BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.145 SUP HCPCS C1713 218.145 - SCREW BONE FULTHD 6.5MM 8MM 145MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.15 SUP HCPCS C1713 218.150 - SCREW BONE 6.5MM 150MM FULTHRD DCP LC-DCP STAINLESS STEEL BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 218.215 SUP HCPCS C1713 218.215 - SCREW BONE FULTHD 6.5MM 115MM LCP STAINLESS STEEL CANCELLOUS BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.22 SUP HCPCS C1713 218.220 - SCREW BONE FULTHD LP 6.5MM 8MM 120MM HIGH BENDING STABILITY BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.225 SUP HCPCS C1713 218.225 - SCREW BONE FULTHD 6.5MM 125MM LCP STAINLESS STEEL CANCELLOUS BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 218.23 SUP HCPCS C1713 218.230 - SCREW BONE FULTHD LP 6.5MM 8MM 130MM HIGH BENDING STABILITY BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 219.89 SUP Custom 27803010 219.89 - WASHER ORTHOPEDIC THREAD LCP STAINLESS STEEL NONSTRL 3 MM BOTH IP/OP $258.65 $191.40 $0.00 $200.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.97 $191.97 $0.00 $0.00 $53.90 $0.00 $0.00 $0.00 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.91 SUP Custom 27803010 219.91 - WASHER ORTHOPEDIC 10MM LCP STAINLESS STEEL NONSTRL 4.5MM BOTH IP/OP $49.90 $36.93 $0.00 $38.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.04 $37.04 $0.00 $0.00 $10.40 $0.00 $0.00 $0.00 $0.00 $24.21 $38.36 $38.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.931 SUP Custom 27803010 219.931 - WASHER ORTHOPEDIC 8MM 3.2MM SPIKE LCP STAINLESS STEEL BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.941 SUP Custom 27803010 219.941 - WASHER ORTHOPEDIC 13.5MM 4MM SPIKE LCP STAINLESS STEEL BOTH IP/OP $229.13 $169.56 $0.00 $177.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.06 $170.06 $0.00 $0.00 $47.75 $0.00 $0.00 $0.00 $0.00 $111.23 $176.18 $177.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.951 SUP Custom 27803010 219.951 - WASHER ORTHOPEDIC 13.5MM 5.5MM SPIKE LC-DCP PEEK-OPTIMA 6% BOTH IP/OP $226.33 $167.48 $0.00 $175.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.98 $167.98 $0.00 $0.00 $47.17 $0.00 $0.00 $0.00 $0.00 $109.86 $174.03 $175.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.96 SUP Custom 27803010 219.96 - NUT ORTHOPEDIC LC-DCP STAINLESS STEEL NONSTRL 4.5 MM BOTH IP/OP $55.85 $41.33 $0.00 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.45 $41.45 $0.00 $0.00 $11.64 $0.00 $0.00 $0.00 $0.00 $27.11 $42.95 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.97 SUP Custom 27803010 219.97 - WASHER ORTHOPEDIC 4.5MM FRAGMENT DCP STAINLESS STEEL NONSTRL BOTH IP/OP $42.85 $31.71 $0.00 $33.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.80 $31.80 $0.00 $0.00 $8.93 $0.00 $0.00 $0.00 $0.00 $20.80 $32.95 $33.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.972 SUP Custom 27803010 219.972 - WASHER ORTHOPEDIC 6.5MM 3.3MM LCP STAINLESS STEEL NONSTRL 3 BOTH IP/OP $55.85 $41.33 $0.00 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.45 $41.45 $0.00 $0.00 $11.64 $0.00 $0.00 $0.00 $0.00 $27.11 $42.95 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.98 SUP Custom 27803010 219.98 - WASHER ORTHOPEDIC SMALL 7MM 3.6MM LCP STAINLESS STEEL BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.99 SUP Custom 27803010 219.99 - WASHER ORTHOPEDIC 13MM 6.6MM LCP STAINLESS STEEL NONSTRL BOTH IP/OP $52.70 $39.00 $0.00 $40.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.11 $39.11 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $25.59 $40.53 $40.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 221.306 SUP HCPCS C1713 221.306 - PLATE BONE STR 6 HOLE LP PRECONTOUR RECONSTRUCTION ANATOMIC BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 221.312 SUP HCPCS C1713 221.312 - PLATE BONE STR 12 HOLE LP PRECONTOUR RECONSTRUCTION ANATOMIC BOTH IP/OP $465.28 $344.31 $0.00 $361.38 $203.28 $203.28 $0.00 $0.00 $0.00 $96.97 $345.33 $345.33 $0.00 $0.00 $96.96 $0.00 $275.21 $275.21 $0.00 $225.86 $357.77 $361.38 $0.00 $0.00 $68.64 $0.00 $0.00 $71.91 $0.00 $0.00 $0.00 $0.00 $0.00 221.32 SUP HCPCS C1713 221.320 - PLATE BN H 19MMX.5MM NS 8 HL XTD LOPRFL PRECONTOUR SS HND RT BOTH IP/OP $431.25 $319.13 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $89.88 $320.07 $320.07 $0.00 $0.00 $89.87 $0.00 $255.08 $255.08 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 221.321 SUP HCPCS C1713 221.321 - PLATE BN H 19MMX.5MM NS 8 HL XTD LOPRFL PRECONTOUR SS HND LT BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 221.333 SUP HCPCS C1713 221.333 - SCREW BONE 4MM 46MM T25 STARDRIVE RECESS LOCK SELF TAP LCP BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 221.334 SUP HCPCS C1713 221.334 - PLATE BONE T 4X8 HOLE LP PRECONTOUR RECONSTRUCTION ANATOMIC BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 221.335 SUP HCPCS C1713 221.335 - PLATE BONE Y 3X8 HOLE LP PRECONTOUR RECONSTRUCTION ANATOMIC BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 222.02 SUP HCPCS C1713 222.02 - PLATE BN SMTB 39X12X1MM NS 2 HL SS 3.5/4.5MM SCR LG FRAG BOTH IP/OP $122.13 $90.38 $0.00 $97.70 $54.96 $54.96 $0.00 $0.00 $0.00 $25.45 $90.64 $90.64 $0.00 $0.00 $25.45 $0.00 $72.24 $72.24 $0.00 $61.06 $96.73 $97.70 $0.00 $0.00 $18.56 $0.00 $0.00 $19.44 $0.00 $0.00 $0.00 $0.00 $0.00 222.03 SUP HCPCS C1713 222.03 - PLATE BN SMTB 55X12X1MM NS 3 HL SS 3.5/4.5MM SCR LG FRAG BOTH IP/OP $130.33 $96.44 $0.00 $104.26 $58.65 $58.65 $0.00 $0.00 $0.00 $27.16 $96.73 $96.73 $0.00 $0.00 $27.16 $0.00 $77.09 $77.09 $0.00 $65.16 $103.22 $104.26 $0.00 $0.00 $19.80 $0.00 $0.00 $20.75 $0.00 $0.00 $0.00 $0.00 $0.00 222.04 SUP HCPCS C1713 222.04 - PLATE BONE SEMITUBULAR 71X12X1MM 4 HOLE SEMITUBULAR DCP BOTH IP/OP $140.58 $104.03 $0.00 $112.46 $63.26 $63.26 $0.00 $0.00 $0.00 $29.30 $104.33 $104.33 $0.00 $0.00 $29.30 $0.00 $83.15 $83.15 $0.00 $70.29 $111.34 $112.46 $0.00 $0.00 $21.36 $0.00 $0.00 $22.38 $0.00 $0.00 $0.00 $0.00 $0.00 222.05 SUP HCPCS C1713 222.05 - PLATE BONE SEMITUBULAR 87X12X1MM 5 HOLE SEMITUBULAR DCP BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $22.60 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 222.06 SUP HCPCS C1713 222.06 - PLATE BONE SEMITUBULAR 103X12X1MM 6 HOLE SEMITUBULAR DCP BOTH IP/OP $158.30 $117.14 $0.00 $126.64 $71.24 $71.24 $0.00 $0.00 $0.00 $32.99 $117.49 $117.49 $0.00 $0.00 $32.99 $0.00 $93.63 $93.63 $0.00 $79.15 $125.37 $126.64 $0.00 $0.00 $24.05 $0.00 $0.00 $25.20 $0.00 $0.00 $0.00 $0.00 $0.00 222.07 SUP HCPCS C1713 222.07 - PLATE BONE SEMITUBULAR 119X12X1MM 7 HOLE SEMITUBULAR DCP BOTH IP/OP $169.23 $125.23 $0.00 $135.38 $76.15 $76.15 $0.00 $0.00 $0.00 $35.27 $125.60 $125.60 $0.00 $0.00 $35.27 $0.00 $100.10 $100.10 $0.00 $84.61 $134.03 $135.38 $0.00 $0.00 $25.71 $0.00 $0.00 $26.94 $0.00 $0.00 $0.00 $0.00 $0.00 222.08 SUP HCPCS C1713 222.08 - PLATE BONE SEMITUBULAR 135X12X1MM 8 HOLE SEMITUBULAR DCP BOTH IP/OP $184.25 $136.35 $0.00 $147.40 $82.91 $82.91 $0.00 $0.00 $0.00 $38.40 $136.75 $136.75 $0.00 $0.00 $38.40 $0.00 $108.98 $108.98 $0.00 $92.13 $145.93 $147.40 $0.00 $0.00 $27.99 $0.00 $0.00 $29.33 $0.00 $0.00 $0.00 $0.00 $0.00 222.09 SUP HCPCS C1713 222.09 - PLATE BONE 151X12X1MM 9 HOLE SEMITUBULAR DCP LC-DCP BOTH IP/OP $206.08 $152.50 $0.00 $164.86 $92.73 $92.73 $0.00 $0.00 $0.00 $42.95 $152.95 $152.95 $0.00 $0.00 $42.95 $0.00 $121.89 $121.89 $0.00 $103.04 $163.22 $164.86 $0.00 $0.00 $31.31 $0.00 $0.00 $32.81 $0.00 $0.00 $0.00 $0.00 $0.00 222.1 SUP HCPCS C1713 222.10 - PLATE BONE TUBE 167X12X1MM 10 HOLE LOCK LCP STAINLESS STEEL BOTH IP/OP $201.98 $149.47 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $42.10 $149.91 $149.91 $0.00 $0.00 $42.09 $0.00 $119.47 $119.47 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 222.11 SUP HCPCS C1713 222.11 - PLATE BONE 183X12X1MM 11 HOLE SEMITUBULAR LC-DCP STAINLESS BOTH IP/OP $229.13 $169.56 $0.00 $177.96 $100.10 $100.10 $0.00 $0.00 $0.00 $47.76 $170.06 $170.06 $0.00 $0.00 $47.75 $0.00 $135.53 $135.53 $0.00 $111.23 $176.18 $177.96 $0.00 $0.00 $33.80 $0.00 $0.00 $35.41 $0.00 $0.00 $0.00 $0.00 $0.00 222.12 SUP HCPCS C1713 222.12 - PLATE BONE 199X12X1MM 12 HOLE SEMITUBULAR LC-DCP STAINLESS BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 222.22 SUP HCPCS C1713 222.220 - ANCHOR SUTURE 2MM 2 END THREAD TAB TACIT BOTH IP/OP "$2,763.63 " "$2,045.09" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $576.01 "$2,051.16" "$2,051.16" $0.00 $0.00 $575.94 $0.00 "$1,362.47" "$1,362.47" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 222.221 SUP HCPCS C1713 222.221 - PLATE BONE 140MM 5 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$2,846.53 " "$2,106.43" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $593.29 "$2,112.69" "$2,112.69" $0.00 $0.00 $593.22 $0.00 "$1,403.34" "$1,403.34" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 222.222 SUP HCPCS C1713 222.222 - PLATE BONE 180MM 7 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$2,904.15 " "$2,149.07" $0.00 "$2,255.66" "$1,268.81" "$1,268.81" $0.00 $0.00 $0.00 $605.30 "$2,155.46" "$2,155.46" $0.00 $0.00 $605.22 $0.00 "$1,431.75" "$1,431.75" $0.00 "$1,409.79" "$2,233.11" "$2,255.66" $0.00 $0.00 $428.41 $0.00 $0.00 $448.88 $0.00 $0.00 $0.00 $0.00 $0.00 222.223 SUP HCPCS C1713 222.223 - PLATE BONE 180MM 7 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$2,904.15 " "$2,149.07" $0.00 "$2,255.66" "$1,268.81" "$1,268.81" $0.00 $0.00 $0.00 $605.30 "$2,155.46" "$2,155.46" $0.00 $0.00 $605.22 $0.00 "$1,431.75" "$1,431.75" $0.00 "$1,409.79" "$2,233.11" "$2,255.66" $0.00 $0.00 $428.41 $0.00 $0.00 $448.88 $0.00 $0.00 $0.00 $0.00 $0.00 222.224 SUP HCPCS C1713 222.224 - PLATE BONE 220MM 9 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$2,964.60 " "$2,193.80" $0.00 "$2,302.60" "$1,295.21" "$1,295.21" $0.00 $0.00 $0.00 $617.90 "$2,200.33" "$2,200.33" $0.00 $0.00 $617.82 $0.00 "$1,461.55" "$1,461.55" $0.00 "$1,439.13" "$2,279.57" "$2,302.60" $0.00 $0.00 $437.33 $0.00 $0.00 $458.22 $0.00 $0.00 $0.00 $0.00 $0.00 222.225 SUP HCPCS C1713 222.225 - PLATE BONE 220MM 9 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$2,964.60 " "$2,193.80" $0.00 "$2,302.60" "$1,295.21" "$1,295.21" $0.00 $0.00 $0.00 $617.90 "$2,200.33" "$2,200.33" $0.00 $0.00 $617.82 $0.00 "$1,461.55" "$1,461.55" $0.00 "$1,439.13" "$2,279.57" "$2,302.60" $0.00 $0.00 $437.33 $0.00 $0.00 $458.22 $0.00 $0.00 $0.00 $0.00 $0.00 222.226 SUP HCPCS C1713 222.226 - PLATE BONE 260MM 11 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,347.38" "$1,320.40" "$1,320.40" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,467.11" "$2,323.91" "$2,347.38" $0.00 $0.00 $445.83 $0.00 $0.00 $467.13 $0.00 $0.00 $0.00 $0.00 $0.00 222.227 SUP HCPCS C1713 222.227 - PLATE BONE 260MM 11 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,347.38" "$1,320.40" "$1,320.40" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,467.11" "$2,323.91" "$2,347.38" $0.00 $0.00 $445.83 $0.00 $0.00 $467.13 $0.00 $0.00 $0.00 $0.00 $0.00 222.228 SUP HCPCS C1713 222.228 - PLATE BONE 300MM 13 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$3,081.28 " "$2,280.15" $0.00 "$2,393.22" "$1,346.19" "$1,346.19" $0.00 $0.00 $0.00 $642.21 "$2,286.92" "$2,286.92" $0.00 $0.00 $642.14 $0.00 "$1,519.07" "$1,519.07" $0.00 "$1,495.76" "$2,369.29" "$2,393.22" $0.00 $0.00 $454.54 $0.00 $0.00 $476.25 $0.00 $0.00 $0.00 $0.00 $0.00 222.229 SUP HCPCS C1713 222.229 - PLATE BONE 300MM 13 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$3,081.28 " "$2,280.15" $0.00 "$2,393.22" "$1,346.19" "$1,346.19" $0.00 $0.00 $0.00 $642.21 "$2,286.92" "$2,286.92" $0.00 $0.00 $642.14 $0.00 "$1,519.07" "$1,519.07" $0.00 "$1,495.76" "$2,369.29" "$2,393.22" $0.00 $0.00 $454.54 $0.00 $0.00 $476.25 $0.00 $0.00 $0.00 $0.00 $0.00 222.25 SUP HCPCS C1713 222.250 - PLATE BONE 156MM 5 HOLE LCP STAINLESS STEEL FEMUR RIGHT BOTH IP/OP "$2,763.63 " "$2,045.09" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $576.01 "$2,051.16" "$2,051.16" $0.00 $0.00 $575.94 $0.00 "$1,362.47" "$1,362.47" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 222.251 SUP HCPCS C1713 222.251 - PLATE BONE 156MM 5 HOLE LCP STAINLESS STEEL LEFT CNDYLR BOTH IP/OP "$2,846.53 " "$2,106.43" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $593.29 "$2,112.69" "$2,112.69" $0.00 $0.00 $593.22 $0.00 "$1,403.34" "$1,403.34" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 222.252 SUP HCPCS C1713 222.252 - PLATE BONE 196MM 7 HOLE LCP STAINLESS STEEL FEMUR RIGHT BOTH IP/OP "$2,904.15 " "$2,149.07" $0.00 "$2,255.66" "$1,268.81" "$1,268.81" $0.00 $0.00 $0.00 $605.30 "$2,155.46" "$2,155.46" $0.00 $0.00 $605.22 $0.00 "$1,431.75" "$1,431.75" $0.00 "$1,409.79" "$2,233.11" "$2,255.66" $0.00 $0.00 $428.41 $0.00 $0.00 $448.88 $0.00 $0.00 $0.00 $0.00 $0.00 222.253 SUP HCPCS C1713 222.253 - PLATE BONE 196MM 7 HOLE LCP STAINLESS STEEL FEMUR LEFT BOTH IP/OP "$2,904.15 " "$2,149.07" $0.00 "$2,255.66" "$1,268.81" "$1,268.81" $0.00 $0.00 $0.00 $605.30 "$2,155.46" "$2,155.46" $0.00 $0.00 $605.22 $0.00 "$1,431.75" "$1,431.75" $0.00 "$1,409.79" "$2,233.11" "$2,255.66" $0.00 $0.00 $428.41 $0.00 $0.00 $448.88 $0.00 $0.00 $0.00 $0.00 $0.00 222.254 SUP HCPCS C1713 222.254 - PLATE BONE 236MM 9 HOLE LCP STAINLESS STEEL FEMUR RIGHT BOTH IP/OP "$2,964.60 " "$2,193.80" $0.00 "$2,302.60" "$1,295.21" "$1,295.21" $0.00 $0.00 $0.00 $617.90 "$2,200.33" "$2,200.33" $0.00 $0.00 $617.82 $0.00 "$1,461.55" "$1,461.55" $0.00 "$1,439.13" "$2,279.57" "$2,302.60" $0.00 $0.00 $437.33 $0.00 $0.00 $458.22 $0.00 $0.00 $0.00 $0.00 $0.00 222.255 SUP HCPCS C1713 222.255 - PLATE BONE 236MM 9 HOLE LCP STAINLESS STEEL FEMUR LEFT BOTH IP/OP "$2,964.60 " "$2,193.80" $0.00 "$2,302.60" "$1,295.21" "$1,295.21" $0.00 $0.00 $0.00 $617.90 "$2,200.33" "$2,200.33" $0.00 $0.00 $617.82 $0.00 "$1,461.55" "$1,461.55" $0.00 "$1,439.13" "$2,279.57" "$2,302.60" $0.00 $0.00 $437.33 $0.00 $0.00 $458.22 $0.00 $0.00 $0.00 $0.00 $0.00 222.256 SUP HCPCS C1713 222.256 - PLATE BONE 276MM 11 HOLE LCP STAINLESS STEEL FEMUR RIGHT BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,347.38" "$1,320.40" "$1,320.40" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,467.11" "$2,323.91" "$2,347.38" $0.00 $0.00 $445.83 $0.00 $0.00 $467.13 $0.00 $0.00 $0.00 $0.00 $0.00 222.257 SUP HCPCS C1713 222.257 - PLATE BONE 276MM 11 HOLE LCP STAINLESS STEEL FEMUR LEFT BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,347.38" "$1,320.40" "$1,320.40" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,467.11" "$2,323.91" "$2,347.38" $0.00 $0.00 $445.83 $0.00 $0.00 $467.13 $0.00 $0.00 $0.00 $0.00 $0.00 222.258 SUP HCPCS C1713 222.258 - PLATE BONE 316MM 13 HOLE LCP STAINLESS STEEL FEMUR RIGHT BOTH IP/OP "$3,081.28 " "$2,280.15" $0.00 "$2,393.22" "$1,346.19" "$1,346.19" $0.00 $0.00 $0.00 $642.21 "$2,286.92" "$2,286.92" $0.00 $0.00 $642.14 $0.00 "$1,519.07" "$1,519.07" $0.00 "$1,495.76" "$2,369.29" "$2,393.22" $0.00 $0.00 $454.54 $0.00 $0.00 $476.25 $0.00 $0.00 $0.00 $0.00 $0.00 222.259 SUP HCPCS C1713 222.259 - PLATE BONE 316MM 13 HOLE LCP STAINLESS STEEL FEMUR LEFT BOTH IP/OP "$3,081.28 " "$2,280.15" $0.00 "$2,393.22" "$1,346.19" "$1,346.19" $0.00 $0.00 $0.00 $642.21 "$2,286.92" "$2,286.92" $0.00 $0.00 $642.14 $0.00 "$1,519.07" "$1,519.07" $0.00 "$1,495.76" "$2,369.29" "$2,393.22" $0.00 $0.00 $454.54 $0.00 $0.00 $476.25 $0.00 $0.00 $0.00 $0.00 $0.00 222.402 SUP HCPCS C1713 222.402 - SCREW BONE 5MM 14MM SLFTAP LOCKING LCP LISS STAINLESS STEEL BOTH IP/OP $404.85 $299.59 $0.00 $314.44 $176.87 $176.87 $0.00 $0.00 $0.00 $84.38 $300.48 $300.48 $0.00 $0.00 $84.37 $0.00 $239.47 $239.47 $0.00 $196.53 $311.30 $314.44 $0.00 $0.00 $59.72 $0.00 $0.00 $62.57 $0.00 $0.00 $0.00 $0.00 $0.00 222.404 SUP HCPCS C1713 222.404 - SCREW BONE 5MM 18MM SLFTAP LOCKING LCP LISS STAINLESS STEEL BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 222.537 SUP HCPCS C1713 222.537 - SCREW BONE 5MM 35MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.538 SUP HCPCS C1713 222.538 - SCREW BONE 5MM 40MM LCP TI PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.541 SUP HCPCS C1713 222.541 - SCREW BONE 5MM 55MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.542 SUP HCPCS C1713 222.542 - SCREW BONE 5MM 60MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.543 SUP HCPCS C1713 222.543 - SCREW BONE 5MM 65MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $387.78 $286.96 $0.00 $310.22 $174.50 $174.50 $0.00 $0.00 $0.00 $80.82 $287.81 $287.81 $0.00 $0.00 $80.81 $0.00 $229.37 $229.37 $0.00 $193.89 $307.12 $310.22 $0.00 $0.00 $60.69 $0.00 $0.00 $61.73 $0.00 $0.00 $0.00 $0.00 $0.00 222.545 SUP HCPCS C1713 222.545 - SCREW BONE 5MM 75MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.546 SUP HCPCS C1713 222.546 - SCREW BONE 5MM 80MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.547 SUP HCPCS C1713 222.547 - SCREW BONE 5MM 85MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.548 SUP HCPCS C1713 222.548 - SCREW BONE 5MM 90MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.554 SUP HCPCS C1713 222.554 - SCREW BONE 5MM 40MM LCP SS PROX PERIART FEM/TIB CANN CONICAL BOTH IP/OP $340.75 $252.16 $0.00 $272.60 $153.34 $153.34 $0.00 $0.00 $0.00 $71.02 $252.90 $252.90 $0.00 $0.00 $71.01 $0.00 $201.55 $201.55 $0.00 $170.38 $269.87 $272.60 $0.00 $0.00 $53.33 $0.00 $0.00 $54.25 $0.00 $0.00 $0.00 $0.00 $0.00 222.564 SUP HCPCS C1713 222.564 - SCREW BONE 5MM 90MM LCP SS PROX PERIART FEM/TIB CANN CONICAL BOTH IP/OP $390.60 $289.04 $0.00 $312.48 $175.77 $175.77 $0.00 $0.00 $0.00 $81.41 $289.90 $289.90 $0.00 $0.00 $81.40 $0.00 $231.04 $231.04 $0.00 $195.30 $309.36 $312.48 $0.00 $0.00 $61.13 $0.00 $0.00 $62.18 $0.00 $0.00 $0.00 $0.00 $0.00 222.571 SUP HCPCS C1713 222.571 - SCREW BONE 7.3MM 70MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $657.98 $486.91 $0.00 $526.38 $296.09 $296.09 $0.00 $0.00 $0.00 $137.14 $488.35 $488.35 $0.00 $0.00 $137.12 $0.00 $389.19 $389.19 $0.00 $328.99 $521.12 $526.38 $0.00 $0.00 $102.97 $0.00 $0.00 $104.75 $0.00 $0.00 $0.00 $0.00 $0.00 222.572 SUP HCPCS C1713 222.572 - SCREW BONE 7.3MM 75MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $657.98 $486.91 $0.00 $526.38 $296.09 $296.09 $0.00 $0.00 $0.00 $137.14 $488.35 $488.35 $0.00 $0.00 $137.12 $0.00 $389.19 $389.19 $0.00 $328.99 $521.12 $526.38 $0.00 $0.00 $102.97 $0.00 $0.00 $104.75 $0.00 $0.00 $0.00 $0.00 $0.00 222.573 SUP HCPCS C1713 222.573 - SCREW BONE 7.3MM 80MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $657.98 $486.91 $0.00 $526.38 $296.09 $296.09 $0.00 $0.00 $0.00 $137.14 $488.35 $488.35 $0.00 $0.00 $137.12 $0.00 $389.19 $389.19 $0.00 $328.99 $521.12 $526.38 $0.00 $0.00 $102.97 $0.00 $0.00 $104.75 $0.00 $0.00 $0.00 $0.00 $0.00 222.575 SUP HCPCS C1713 222.575 - SCREW BONE 7.3MM 90MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $657.98 $486.91 $0.00 $526.38 $296.09 $296.09 $0.00 $0.00 $0.00 $137.14 $488.35 $488.35 $0.00 $0.00 $137.12 $0.00 $389.19 $389.19 $0.00 $328.99 $521.12 $526.38 $0.00 $0.00 $102.97 $0.00 $0.00 $104.75 $0.00 $0.00 $0.00 $0.00 $0.00 222.578 SUP Custom 27803010 222.578 - NUT ORTHOPEDIC 4MM 12MM SELF CUTTING SERRATED TIP LCP BOTH IP/OP $303.63 $224.69 $0.00 $235.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.35 $225.35 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $147.39 $233.47 $235.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 222.58 SUP HCPCS C1713 222.580 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 14MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.581 SUP HCPCS C1713 222.581 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 16MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.582 SUP HCPCS C1713 222.582 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 18MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.583 SUP HCPCS C1713 222.583 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 22MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.584 SUP HCPCS C1713 222.584 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 26MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.585 SUP HCPCS C1713 222.585 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 30MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.586 SUP HCPCS C1713 222.586 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 34MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.587 SUP HCPCS C1713 222.587 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 38MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.588 SUP HCPCS C1713 222.588 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 42MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.589 SUP HCPCS C1713 222.589 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 46MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.59 SUP HCPCS C1713 222.590 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 50MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.591 SUP HCPCS C1713 222.591 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 54MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.592 SUP HCPCS C1713 222.592 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 58MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.593 SUP HCPCS C1713 222.593 - SCREW BONE LARGE CONE HEXAGON 4MM 3.4MM 62MM SELF TAP LCP BOTH IP/OP $262.03 $193.90 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $54.61 $194.47 $194.47 $0.00 $0.00 $54.61 $0.00 $154.99 $154.99 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.608 SUP HCPCS C1713 222.608 - SCREW BONE 7.3MM 85MM LCP SS FULTHD PROX PERIART FEM/TIB BOTH IP/OP $514.65 $380.84 $0.00 $411.72 $231.59 $231.59 $0.00 $0.00 $0.00 $107.27 $381.97 $381.97 $0.00 $0.00 $107.25 $0.00 $304.42 $304.42 $0.00 $257.33 $407.60 $411.72 $0.00 $0.00 $80.54 $0.00 $0.00 $81.93 $0.00 $0.00 $0.00 $0.00 $0.00 222.609 SUP HCPCS C1713 222.609 - SCREW BONE 7.3MM 90MM LCP SS FULTHD PROX PERIART FEM/TIB BOTH IP/OP $534.23 $395.33 $0.00 $427.38 $240.40 $240.40 $0.00 $0.00 $0.00 $111.35 $396.50 $396.50 $0.00 $0.00 $111.33 $0.00 $315.99 $315.99 $0.00 $267.11 $423.11 $427.38 $0.00 $0.00 $83.61 $0.00 $0.00 $85.05 $0.00 $0.00 $0.00 $0.00 $0.00 222.645 SUP HCPCS C1713 222.645 - SCREW BONE 7.3MM 75MM LCP SS PROX PERIART FEM/TIB CANN BOTH IP/OP $534.23 $395.33 $0.00 $427.38 $240.40 $240.40 $0.00 $0.00 $0.00 $111.35 $396.50 $396.50 $0.00 $0.00 $111.33 $0.00 $315.99 $315.99 $0.00 $267.11 $423.11 $427.38 $0.00 $0.00 $83.61 $0.00 $0.00 $85.05 $0.00 $0.00 $0.00 $0.00 $0.00 222.646 SUP HCPCS C1713 222.646 - SCREW BONE 7.3MM 80MM LCP SS PROX PERIART FEM/TIB CANN BOTH IP/OP $588.23 $435.29 $0.00 $470.58 $264.70 $264.70 $0.00 $0.00 $0.00 $122.60 $436.58 $436.58 $0.00 $0.00 $122.59 $0.00 $347.94 $347.94 $0.00 $294.11 $465.88 $470.58 $0.00 $0.00 $92.06 $0.00 $0.00 $93.65 $0.00 $0.00 $0.00 $0.00 $0.00 222.656 SUP HCPCS C1713 222.656 - PLATE BN 170X17.5X5.2MM NS LCP CMBN 6 HL LOPRFL LMT CNTCT BOTH IP/OP "$2,887.30 " "$2,136.60" $0.00 "$2,242.56" "$1,261.44" "$1,261.44" $0.00 $0.00 $0.00 $601.79 "$2,142.95" "$2,142.95" $0.00 $0.00 $601.71 $0.00 "$1,423.44" "$1,423.44" $0.00 "$1,401.60" "$2,220.13" "$2,242.56" $0.00 $0.00 $425.92 $0.00 $0.00 $446.27 $0.00 $0.00 $0.00 $0.00 $0.00 222.657 SUP HCPCS C1713 222.657 - PLATE BN 170X17.5X5.2MM NS LCP CMBN 6 HL LOPRFL LMT CNTCT BOTH IP/OP "$2,887.30 " "$2,136.60" $0.00 "$2,242.56" "$1,261.44" "$1,261.44" $0.00 $0.00 $0.00 $601.79 "$2,142.95" "$2,142.95" $0.00 $0.00 $601.71 $0.00 "$1,423.44" "$1,423.44" $0.00 "$1,401.60" "$2,220.13" "$2,242.56" $0.00 $0.00 $425.92 $0.00 $0.00 $446.27 $0.00 $0.00 $0.00 $0.00 $0.00 222.658 SUP HCPCS C1713 222.658 - PLATE BN 206X17.5X5.2MM NS LCP CMBN 8 HL LOPRFL LMT CNTCT BOTH IP/OP "$2,940.70 " "$2,176.12" $0.00 "$2,284.04" "$1,284.77" "$1,284.77" $0.00 $0.00 $0.00 $612.92 "$2,182.59" "$2,182.59" $0.00 $0.00 $612.84 $0.00 "$1,449.77" "$1,449.77" $0.00 "$1,427.53" "$2,261.20" "$2,284.04" $0.00 $0.00 $433.80 $0.00 $0.00 $454.52 $0.00 $0.00 $0.00 $0.00 $0.00 222.659 SUP HCPCS C1713 222.659 - PLATE BN 206X17.5X5.2MM NS LCP CMBN 8 HL LOPRFL LMT CNTCT BOTH IP/OP "$2,940.70 " "$2,176.12" $0.00 "$2,284.04" "$1,284.77" "$1,284.77" $0.00 $0.00 $0.00 $612.92 "$2,182.59" "$2,182.59" $0.00 $0.00 $612.84 $0.00 "$1,449.77" "$1,449.77" $0.00 "$1,427.53" "$2,261.20" "$2,284.04" $0.00 $0.00 $433.80 $0.00 $0.00 $454.52 $0.00 $0.00 $0.00 $0.00 $0.00 222.66 SUP HCPCS C1713 222.660 - PLATE BN 242X17.5X5.2MM NS LCP CMBN 10 HL LOPRFL LMT CNTCT BOTH IP/OP "$2,961.50 " "$2,191.51" $0.00 "$2,369.20" "$1,332.68" "$1,332.68" $0.00 $0.00 $0.00 $617.25 "$2,198.03" "$2,198.03" $0.00 $0.00 $617.18 $0.00 "$1,460.02" "$1,460.02" $0.00 "$1,480.75" "$2,345.51" "$2,369.20" $0.00 $0.00 $449.98 $0.00 $0.00 $471.47 $0.00 $0.00 $0.00 $0.00 $0.00 222.661 SUP HCPCS C1713 222.661 - PLATE BN 242X17.5X5.2MM NS LCP CMBN 10 HL LOPRFL LMT CNTCT BOTH IP/OP "$3,050.35 " "$2,257.26" $0.00 "$2,369.20" "$1,332.68" "$1,332.68" $0.00 $0.00 $0.00 $635.77 "$2,263.97" "$2,263.97" $0.00 $0.00 $635.69 $0.00 "$1,503.82" "$1,503.82" $0.00 "$1,480.75" "$2,345.51" "$2,369.20" $0.00 $0.00 $449.98 $0.00 $0.00 $471.47 $0.00 $0.00 $0.00 $0.00 $0.00 222.662 SUP HCPCS C1713 222.662 - PLATE BN 278X17.5X5.2MM NS LCP CMBN 12 HL LOPRFL LMT CNTCT BOTH IP/OP "$3,112.20 " "$2,303.03" $0.00 "$2,417.24" "$1,359.70" "$1,359.70" $0.00 $0.00 $0.00 $648.66 "$2,309.87" "$2,309.87" $0.00 $0.00 $648.58 $0.00 "$1,534.31" "$1,534.31" $0.00 "$1,510.78" "$2,393.07" "$2,417.24" $0.00 $0.00 $459.10 $0.00 $0.00 $481.03 $0.00 $0.00 $0.00 $0.00 $0.00 222.663 SUP HCPCS C1713 222.663 - PLATE BN 278X17.5X5.2MM NS LCP CMBN 12 HL LOPRFL LMT CNTCT BOTH IP/OP "$3,112.20 " "$2,303.03" $0.00 "$2,417.24" "$1,359.70" "$1,359.70" $0.00 $0.00 $0.00 $648.66 "$2,309.87" "$2,309.87" $0.00 $0.00 $648.58 $0.00 "$1,534.31" "$1,534.31" $0.00 "$1,510.78" "$2,393.07" "$2,417.24" $0.00 $0.00 $459.10 $0.00 $0.00 $481.03 $0.00 $0.00 $0.00 $0.00 $0.00 222.664 SUP HCPCS C1713 222.664 - PLATE BN 314X17.5X5.2MM NS LCP CMBN 14 HL LOPRFL LMT CNTCT BOTH IP/OP "$3,280.88 " "$2,427.85" $0.00 "$2,548.26" "$1,433.40" "$1,433.40" $0.00 $0.00 $0.00 $683.82 "$2,435.07" "$2,435.07" $0.00 $0.00 $683.73 $0.00 "$1,617.47" "$1,617.47" $0.00 "$1,592.66" "$2,522.78" "$2,548.26" $0.00 $0.00 $483.98 $0.00 $0.00 $507.10 $0.00 $0.00 $0.00 $0.00 $0.00 222.665 SUP HCPCS C1713 222.665 - PLATE BN 314X17.5X5.2MM NS LCP CMBN 14 HL LOPRFL LMT CNTCT BOTH IP/OP "$3,280.88 " "$2,427.85" $0.00 "$2,548.26" "$1,433.40" "$1,433.40" $0.00 $0.00 $0.00 $683.82 "$2,435.07" "$2,435.07" $0.00 $0.00 $683.73 $0.00 "$1,617.47" "$1,617.47" $0.00 "$1,592.66" "$2,522.78" "$2,548.26" $0.00 $0.00 $483.98 $0.00 $0.00 $507.10 $0.00 $0.00 $0.00 $0.00 $0.00 222.666 SUP HCPCS C1713 222.666 - PLATE BONE CURVE 350X17.5X5.2MM 16 HOLE LP ANATOMIC HEAD BOTH IP/OP "$3,249.48 " "$2,404.62" $0.00 "$2,599.58" "$1,462.26" "$1,462.26" $0.00 $0.00 $0.00 $677.27 "$2,411.76" "$2,411.76" $0.00 $0.00 $677.19 $0.00 "$1,601.99" "$1,601.99" $0.00 "$1,624.74" "$2,573.59" "$2,599.58" $0.00 $0.00 $493.73 $0.00 $0.00 $517.32 $0.00 $0.00 $0.00 $0.00 $0.00 222.667 SUP HCPCS C1713 222.667 - PLATE BONE CURVE 350X17.5X5.2MM 16 HOLE LP ANATOMIC HEAD BOTH IP/OP "$3,249.48 " "$2,404.62" $0.00 "$2,599.58" "$1,462.26" "$1,462.26" $0.00 $0.00 $0.00 $677.27 "$2,411.76" "$2,411.76" $0.00 $0.00 $677.19 $0.00 "$1,601.99" "$1,601.99" $0.00 "$1,624.74" "$2,573.59" "$2,599.58" $0.00 $0.00 $493.73 $0.00 $0.00 $517.32 $0.00 $0.00 $0.00 $0.00 $0.00 222.668 SUP HCPCS C1713 222.668 - PLATE BONE CURVE 386X17.5X5.2MM 18 HOLE LP ANATOMIC HEAD BOTH IP/OP "$3,314.98 " "$2,453.09" $0.00 "$2,651.98" "$1,491.74" "$1,491.74" $0.00 $0.00 $0.00 $690.92 "$2,460.37" "$2,460.37" $0.00 $0.00 $690.84 $0.00 "$1,634.28" "$1,634.28" $0.00 "$1,657.49" "$2,625.46" "$2,651.98" $0.00 $0.00 $503.68 $0.00 $0.00 $527.74 $0.00 $0.00 $0.00 $0.00 $0.00 222.669 SUP HCPCS C1713 222.669 - PLATE BONE CURVE 386X17.5X5.2MM 18 HOLE LP ANATOMIC HEAD BOTH IP/OP "$3,314.98 " "$2,453.09" $0.00 "$2,651.98" "$1,491.74" "$1,491.74" $0.00 $0.00 $0.00 $690.92 "$2,460.37" "$2,460.37" $0.00 $0.00 $690.84 $0.00 "$1,634.28" "$1,634.28" $0.00 "$1,657.49" "$2,625.46" "$2,651.98" $0.00 $0.00 $503.68 $0.00 $0.00 $527.74 $0.00 $0.00 $0.00 $0.00 $0.00 222.675 SUP HCPCS C1713 222.675 - SCREW BONE 4MM 30MM LCP SS PROX PERIART FEM/TIB CANN LCK BOTH IP/OP $318.53 $235.71 $0.00 $254.82 $143.34 $143.34 $0.00 $0.00 $0.00 $66.39 $236.41 $236.41 $0.00 $0.00 $66.38 $0.00 $188.41 $188.41 $0.00 $159.26 $252.28 $254.82 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 222.676 SUP HCPCS C1713 222.676 - SCREW BONE 4MM 34MM LCP SS PROX MDL TIB LCK SLFTAP STARDRIVE BOTH IP/OP $444.08 $328.62 $0.00 $355.26 $199.83 $199.83 $0.00 $0.00 $0.00 $92.56 $329.59 $329.59 $0.00 $0.00 $92.55 $0.00 $262.67 $262.67 $0.00 $222.04 $351.71 $355.26 $0.00 $0.00 $69.50 $0.00 $0.00 $70.70 $0.00 $0.00 $0.00 $0.00 $0.00 222.677 SUP HCPCS C1713 222.677 - SCREW BONE 4MM 38MM LCP SS PROX MDL TIB LCK SLFTAP NONSTRL BOTH IP/OP $318.53 $235.71 $0.00 $254.82 $143.34 $143.34 $0.00 $0.00 $0.00 $66.39 $236.41 $236.41 $0.00 $0.00 $66.38 $0.00 $188.41 $188.41 $0.00 $159.26 $252.28 $254.82 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 223.406 SUP HCPCS C1713 223.406 - PLATE BONE 86X11X3.3MM 6 HOLE LOCKING TAPERED ROUNDED TIP BOTH IP/OP "$1,672.78 " "$1,237.86" $0.00 "$1,299.24" $730.82 $730.82 $0.00 $0.00 $0.00 $348.65 "$1,241.53" "$1,241.53" $0.00 $0.00 $348.61 $0.00 $989.45 $989.45 $0.00 $812.03 "$1,286.25" "$1,299.24" $0.00 $0.00 $246.76 $0.00 $0.00 $258.55 $0.00 $0.00 $0.00 $0.00 $0.00 223.407 SUP HCPCS C1713 223.407 - PLATE BONE 99X11X3.3MM 7 HOLE LOCKING TAPERED ROUNDED TIP BOTH IP/OP "$1,705.10 " "$1,261.77" $0.00 "$1,324.36" $744.95 $744.95 $0.00 $0.00 $0.00 $355.39 "$1,265.53" "$1,265.53" $0.00 $0.00 $355.34 $0.00 "$1,008.57" "$1,008.57" $0.00 $827.73 "$1,311.12" "$1,324.36" $0.00 $0.00 $251.53 $0.00 $0.00 $263.55 $0.00 $0.00 $0.00 $0.00 $0.00 223.408 SUP HCPCS C1713 223.408 - PLATE BONE 112X11X3.3MM 8 HOLE LCP STAINLESS STEEL BOTH IP/OP "$1,730.40 " "$1,280.50" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $360.66 "$1,284.30" "$1,284.30" $0.00 $0.00 $360.62 $0.00 "$1,023.53" "$1,023.53" $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $255.26 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 223.409 SUP HCPCS C1713 223.409 - PLATE BONE 125MM 9 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$1,758.53 " "$1,301.31" $0.00 "$1,365.84" $768.29 $768.29 $0.00 $0.00 $0.00 $366.52 "$1,305.18" "$1,305.18" $0.00 $0.00 $366.48 $0.00 "$1,040.17" "$1,040.17" $0.00 $853.65 "$1,352.18" "$1,365.84" $0.00 $0.00 $259.41 $0.00 $0.00 $271.80 $0.00 $0.00 $0.00 $0.00 $0.00 223.41 SUP HCPCS C1713 223.410 - PLATE BN TPR 138X11X3.3MM NS LCP CMBN 10 HL RND TIP THN PRFL BOTH IP/OP "$1,735.95 " "$1,284.60" $0.00 "$1,388.76" $781.18 $781.18 $0.00 $0.00 $0.00 $361.82 "$1,288.42" "$1,288.42" $0.00 $0.00 $361.77 $0.00 "$1,026.81" "$1,026.81" $0.00 $867.98 "$1,374.87" "$1,388.76" $0.00 $0.00 $330.10 $0.00 $0.00 $276.36 $0.00 $0.00 $0.00 $0.00 $0.00 223.411 SUP HCPCS C1713 223.411 - PLATE BONE 151MM 11 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$1,817.55 " "$1,344.99" $0.00 "$1,411.70" $794.08 $794.08 $0.00 $0.00 $0.00 $378.82 "$1,348.99" "$1,348.99" $0.00 $0.00 $378.78 $0.00 "$1,075.08" "$1,075.08" $0.00 $882.31 "$1,397.59" "$1,411.70" $0.00 $0.00 $268.12 $0.00 $0.00 $280.93 $0.00 $0.00 $0.00 $0.00 $0.00 223.412 SUP HCPCS C1713 223.412 - PLATE BONE 164MM 12 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,822.22" "$1,025.00" "$1,025.00" $0.00 $0.00 $0.00 $488.99 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 "$1,387.72" "$1,387.72" $0.00 "$1,138.89" "$1,804.00" "$1,822.22" $0.00 $0.00 $346.09 $0.00 $0.00 $362.62 $0.00 $0.00 $0.00 $0.00 $0.00 223.414 SUP HCPCS C1713 223.414 - PLATE BONE 190MM 14 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$2,422.00 " "$1,792.28" $0.00 "$1,881.18" "$1,058.16" "$1,058.16" $0.00 $0.00 $0.00 $504.81 "$1,797.61" "$1,797.61" $0.00 $0.00 $504.74 $0.00 "$1,432.61" "$1,432.61" $0.00 "$1,175.74" "$1,862.37" "$1,881.18" $0.00 $0.00 $357.29 $0.00 $0.00 $374.35 $0.00 $0.00 $0.00 $0.00 $0.00 223.416 SUP HCPCS C1713 223.416 - PLATE BONE 216MM 16 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$2,474.03 " "$1,830.78" $0.00 "$1,921.56" "$1,080.88" "$1,080.88" $0.00 $0.00 $0.00 $515.65 "$1,836.22" "$1,836.22" $0.00 $0.00 $515.59 $0.00 "$1,463.39" "$1,463.39" $0.00 "$1,200.98" "$1,902.34" "$1,921.56" $0.00 $0.00 $364.96 $0.00 $0.00 $382.39 $0.00 $0.00 $0.00 $0.00 $0.00 223.418 SUP HCPCS C1713 223.418 - PLATE BONE 242MM 18 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$2,422.00 " "$1,792.28" $0.00 "$1,881.18" "$1,058.16" "$1,058.16" $0.00 $0.00 $0.00 $504.81 "$1,797.61" "$1,797.61" $0.00 $0.00 $504.74 $0.00 "$1,432.61" "$1,432.61" $0.00 "$1,175.74" "$1,862.37" "$1,881.18" $0.00 $0.00 $357.29 $0.00 $0.00 $374.35 $0.00 $0.00 $0.00 $0.00 $0.00 223.506 SUP HCPCS C1713 223.506 - PLATE BN 95MM 6 HL SS TIB RT DIST MDL 3.5MM SCR BOTH IP/OP "$1,020.53 " $755.19 $0.00 $792.64 $445.86 $445.86 $0.00 $0.00 $0.00 $212.70 $757.43 $757.43 $0.00 $0.00 $212.68 $0.00 $603.64 $603.64 $0.00 $495.40 $784.71 $792.64 $0.00 $0.00 $150.55 $0.00 $0.00 $157.74 $0.00 $0.00 $0.00 $0.00 $0.00 223.507 SUP HCPCS C1713 223.507 - PLATE BN 95MM 6 HL SS TIB LT DIST MDL 3.5MM SCR BOTH IP/OP "$1,020.53 " $755.19 $0.00 $792.64 $445.86 $445.86 $0.00 $0.00 $0.00 $212.70 $757.43 $757.43 $0.00 $0.00 $212.68 $0.00 $603.64 $603.64 $0.00 $495.40 $784.71 $792.64 $0.00 $0.00 $150.55 $0.00 $0.00 $157.74 $0.00 $0.00 $0.00 $0.00 $0.00 223.508 SUP HCPCS C1713 223.508 - PLATE BN 121MM 8 HL SS TIB RT DIST MDL 3.5MM SCR BOTH IP/OP "$1,186.40 " $877.94 $0.00 $921.48 $518.33 $518.33 $0.00 $0.00 $0.00 $247.28 $880.55 $880.55 $0.00 $0.00 $247.25 $0.00 $701.76 $701.76 $0.00 $575.93 $912.27 $921.48 $0.00 $0.00 $175.01 $0.00 $0.00 $183.37 $0.00 $0.00 $0.00 $0.00 $0.00 223.509 SUP HCPCS C1713 223.509 - PLATE BN 121MM 8 HL SS TIB LT DIST MDL 3.5MM SCR BOTH IP/OP "$1,186.40 " $877.94 $0.00 $921.48 $518.33 $518.33 $0.00 $0.00 $0.00 $247.28 $880.55 $880.55 $0.00 $0.00 $247.25 $0.00 $701.76 $701.76 $0.00 $575.93 $912.27 $921.48 $0.00 $0.00 $175.01 $0.00 $0.00 $183.37 $0.00 $0.00 $0.00 $0.00 $0.00 223.51 SUP HCPCS C1713 223.510 - PLATE BONE 147X10.2X2.2MM 10 HOLE LCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,315.63 " $973.57 $0.00 "$1,052.50" $592.03 $592.03 $0.00 $0.00 $0.00 $274.21 $976.46 $976.46 $0.00 $0.00 $274.18 $0.00 $778.19 $778.19 $0.00 $657.81 "$1,041.98" "$1,052.50" $0.00 $0.00 $199.90 $0.00 $0.00 $209.45 $0.00 $0.00 $0.00 $0.00 $0.00 223.511 SUP HCPCS C1713 223.511 - PLATE BN 147MM 10 HL SS TIB LT DIST MDL 3.5MM SCR BOTH IP/OP "$1,355.10 " "$1,002.77" $0.00 "$1,052.50" $592.03 $592.03 $0.00 $0.00 $0.00 $282.44 "$1,005.76" "$1,005.76" $0.00 $0.00 $282.40 $0.00 $801.54 $801.54 $0.00 $657.81 "$1,041.98" "$1,052.50" $0.00 $0.00 $199.90 $0.00 $0.00 $209.45 $0.00 $0.00 $0.00 $0.00 $0.00 223.512 SUP HCPCS C1713 223.512 - PLATE BONE 173X10.2X2.2MM 11X3.3MM 12 HOLE LCP STAINLESS BOTH IP/OP "$1,512.53 " "$1,119.27" $0.00 "$1,174.78" $660.81 $660.81 $0.00 $0.00 $0.00 $315.25 "$1,122.60" "$1,122.60" $0.00 $0.00 $315.21 $0.00 $894.66 $894.66 $0.00 $734.24 "$1,163.04" "$1,174.78" $0.00 $0.00 $223.12 $0.00 $0.00 $233.78 $0.00 $0.00 $0.00 $0.00 $0.00 223.513 SUP HCPCS C1713 223.513 - PLATE BONE 173X10.2X2.2MM 11X3.3MM 12 HOLE LCP STAINLESS BOTH IP/OP "$1,512.53 " "$1,119.27" $0.00 "$1,174.78" $660.81 $660.81 $0.00 $0.00 $0.00 $315.25 "$1,122.60" "$1,122.60" $0.00 $0.00 $315.21 $0.00 $894.66 $894.66 $0.00 $734.24 "$1,163.04" "$1,174.78" $0.00 $0.00 $223.12 $0.00 $0.00 $233.78 $0.00 $0.00 $0.00 $0.00 $0.00 223.514 SUP HCPCS C1713 223.514 - PLATE BONE 199X10.2X2.2MM 11X3.3MM 14 HOLE LCP STAINLESS BOTH IP/OP "$1,688.23 " "$1,249.29" $0.00 "$1,311.26" $737.58 $737.58 $0.00 $0.00 $0.00 $351.87 "$1,253.00" "$1,253.00" $0.00 $0.00 $351.83 $0.00 $998.59 $998.59 $0.00 $819.54 "$1,298.15" "$1,311.26" $0.00 $0.00 $249.04 $0.00 $0.00 $260.94 $0.00 $0.00 $0.00 $0.00 $0.00 223.515 SUP HCPCS C1713 223.515 - PLATE BONE 199X10.2X2.2MM 11X3.3MM 14 HOLE LCP STAINLESS BOTH IP/OP "$1,688.23 " "$1,249.29" $0.00 "$1,311.26" $737.58 $737.58 $0.00 $0.00 $0.00 $351.87 "$1,253.00" "$1,253.00" $0.00 $0.00 $351.83 $0.00 $998.59 $998.59 $0.00 $819.54 "$1,298.15" "$1,311.26" $0.00 $0.00 $249.04 $0.00 $0.00 $260.94 $0.00 $0.00 $0.00 $0.00 $0.00 223.516 SUP HCPCS C1713 223.516 - PLATE BONE 225MM 16 HOLE STAINLESS STEEL TIBIA RIGHT DISTAL BOTH IP/OP "$1,911.75 " "$1,414.70" $0.00 "$1,484.84" $835.22 $835.22 $0.00 $0.00 $0.00 $398.46 "$1,418.90" "$1,418.90" $0.00 $0.00 $398.41 $0.00 "$1,130.80" "$1,130.80" $0.00 $928.03 "$1,469.99" "$1,484.84" $0.00 $0.00 $282.01 $0.00 $0.00 $295.48 $0.00 $0.00 $0.00 $0.00 $0.00 223.517 SUP HCPCS C1713 223.517 - PLATE BONE 225MM 16 HOLE STAINLESS STEEL TIBIA LEFT DISTAL BOTH IP/OP "$1,911.75 " "$1,414.70" $0.00 "$1,484.84" $835.22 $835.22 $0.00 $0.00 $0.00 $398.46 "$1,418.90" "$1,418.90" $0.00 $0.00 $398.41 $0.00 "$1,130.80" "$1,130.80" $0.00 $928.03 "$1,469.99" "$1,484.84" $0.00 $0.00 $282.01 $0.00 $0.00 $295.48 $0.00 $0.00 $0.00 $0.00 $0.00 223.518 SUP HCPCS C1713 223.518 - PLATE BONE 251MM 18 HOLE STAINLESS STEEL TIBIA RIGHT DISTAL BOTH IP/OP "$2,087.45 " "$1,544.71" $0.00 "$1,621.32" $911.99 $911.99 $0.00 $0.00 $0.00 $435.08 "$1,549.31" "$1,549.31" $0.00 $0.00 $435.02 $0.00 "$1,234.73" "$1,234.73" $0.00 "$1,013.33" "$1,605.11" "$1,621.32" $0.00 $0.00 $307.93 $0.00 $0.00 $322.64 $0.00 $0.00 $0.00 $0.00 $0.00 223.519 SUP HCPCS C1713 223.519 - PLATE BONE 251MM 18 HOLE STAINLESS STEEL TIBIA LEFT DISTAL BOTH IP/OP "$2,087.45 " "$1,544.71" $0.00 "$1,621.32" $911.99 $911.99 $0.00 $0.00 $0.00 $435.08 "$1,549.31" "$1,549.31" $0.00 $0.00 $435.02 $0.00 "$1,234.73" "$1,234.73" $0.00 "$1,013.33" "$1,605.11" "$1,621.32" $0.00 $0.00 $307.93 $0.00 $0.00 $322.64 $0.00 $0.00 $0.00 $0.00 $0.00 223.52 SUP HCPCS C1713 223.52 - PLATE BONE 25X11X3.3MM 2 HOLE LC-DCP STAINLESS STEEL DISTAL BOTH IP/OP $231.95 $171.64 $0.00 $180.14 $101.33 $101.33 $0.00 $0.00 $0.00 $48.34 $172.15 $172.15 $0.00 $0.00 $48.34 $0.00 $137.20 $137.20 $0.00 $112.59 $178.34 $180.14 $0.00 $0.00 $34.21 $0.00 $0.00 $35.85 $0.00 $0.00 $0.00 $0.00 $0.00 223.521 SUP HCPCS C1713 223.521 - PLATE BN 33MM NS LCP CMBN 2 HL LMT CNTCT TPR END SS 3.5MM BOTH IP/OP $490.58 $363.03 $0.00 $381.04 $214.34 $214.34 $0.00 $0.00 $0.00 $102.25 $364.10 $364.10 $0.00 $0.00 $102.24 $0.00 $290.18 $290.18 $0.00 $238.15 $377.23 $381.04 $0.00 $0.00 $72.37 $0.00 $0.00 $75.83 $0.00 $0.00 $0.00 $0.00 $0.00 223.53 SUP HCPCS C1713 223.53 - PLATE BONE 38X11X3.3MM 3 HOLE LC-DCP STAINLESS STEEL DISTAL BOTH IP/OP $236.15 $174.75 $0.00 $183.42 $103.17 $103.17 $0.00 $0.00 $0.00 $49.22 $175.27 $175.27 $0.00 $0.00 $49.21 $0.00 $139.68 $139.68 $0.00 $114.64 $181.59 $183.42 $0.00 $0.00 $34.84 $0.00 $0.00 $36.50 $0.00 $0.00 $0.00 $0.00 $0.00 223.531 SUP HCPCS C1713 223.531 - PLATE BN 46X11X3.4MM NS LCP CMBN 3 HL LMT CNTCT TPR END SS BOTH IP/OP $510.28 $377.61 $0.00 $396.32 $222.93 $222.93 $0.00 $0.00 $0.00 $106.35 $378.73 $378.73 $0.00 $0.00 $106.34 $0.00 $301.83 $301.83 $0.00 $247.70 $392.36 $396.32 $0.00 $0.00 $75.27 $0.00 $0.00 $78.87 $0.00 $0.00 $0.00 $0.00 $0.00 223.54 SUP HCPCS C1713 223.54 - PLATE BN 51MM NS LC DCP 4 HL SS 3.5MM SCR BOTH IP/OP $243.18 $179.95 $0.00 $188.88 $106.25 $106.25 $0.00 $0.00 $0.00 $50.68 $180.48 $180.48 $0.00 $0.00 $50.68 $0.00 $143.84 $143.84 $0.00 $118.05 $186.99 $188.88 $0.00 $0.00 $35.87 $0.00 $0.00 $37.59 $0.00 $0.00 $0.00 $0.00 $0.00 223.541 SUP HCPCS C1713 223.541 - PLATE BN 59MM NS LCP CMBN 4 HL SS 3.5MM SCR SM FRAG BOTH IP/OP $532.75 $394.24 $0.00 $413.80 $232.76 $232.76 $0.00 $0.00 $0.00 $111.04 $395.41 $395.41 $0.00 $0.00 $111.03 $0.00 $315.12 $315.12 $0.00 $258.63 $409.66 $413.80 $0.00 $0.00 $78.59 $0.00 $0.00 $82.35 $0.00 $0.00 $0.00 $0.00 $0.00 223.55 SUP HCPCS C1713 223.55 - PLATE BONE 64X11X3.3MM 5 HOLE LC-DCP STAINLESS STEEL BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 223.551 SUP HCPCS C1713 223.551 - PLATE BN 72X11X3.4MM NS LCP CMBN 5 HL LMT CNTCT TPR END SS BOTH IP/OP $549.63 $406.73 $0.00 $426.90 $240.13 $240.13 $0.00 $0.00 $0.00 $114.56 $407.93 $407.93 $0.00 $0.00 $114.54 $0.00 $325.10 $325.10 $0.00 $266.81 $422.63 $426.90 $0.00 $0.00 $81.08 $0.00 $0.00 $84.95 $0.00 $0.00 $0.00 $0.00 $0.00 223.56 SUP HCPCS C1713 223.56 - PLATE BONE 77X11X3.3MM 6 HOLE LC-DCP STAINLESS STEEL DISTAL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 223.561 SUP HCPCS C1713 223.561 - PLATE BN 85X11X3.4MM NS LCP CMBN 6 HL LMT CNTCT TPR END SS BOTH IP/OP $584.78 $432.74 $0.00 $454.18 $255.48 $255.48 $0.00 $0.00 $0.00 $121.88 $434.02 $434.02 $0.00 $0.00 $121.87 $0.00 $345.89 $345.89 $0.00 $283.86 $449.64 $454.18 $0.00 $0.00 $86.26 $0.00 $0.00 $90.38 $0.00 $0.00 $0.00 $0.00 $0.00 223.57 SUP HCPCS C1713 223.57 - PLATE BONE 90X11X3.3MM 7 HOLE LC-DCP STAINLESS STEEL DISTAL BOTH IP/OP $283.95 $210.12 $0.00 $220.54 $124.05 $124.05 $0.00 $0.00 $0.00 $59.18 $210.75 $210.75 $0.00 $0.00 $59.18 $0.00 $167.96 $167.96 $0.00 $137.84 $218.34 $220.54 $0.00 $0.00 $41.89 $0.00 $0.00 $43.89 $0.00 $0.00 $0.00 $0.00 $0.00 223.571 SUP HCPCS C1713 223.571 - PLATE BN 98X11X3.4MM NS LCP CMBN 7 HL LMT CNTCT TPR END SS BOTH IP/OP $608.68 $450.42 $0.00 $472.74 $265.92 $265.92 $0.00 $0.00 $0.00 $126.86 $451.76 $451.76 $0.00 $0.00 $126.85 $0.00 $360.03 $360.03 $0.00 $295.46 $468.02 $472.74 $0.00 $0.00 $89.79 $0.00 $0.00 $94.08 $0.00 $0.00 $0.00 $0.00 $0.00 223.58 SUP HCPCS C1713 223.58 - PLATE BONE 103X11X3.3MM 8 HOLE LC-DCP STAINLESS STEEL DISTAL BOTH IP/OP $299.43 $221.58 $0.00 $232.56 $130.82 $130.82 $0.00 $0.00 $0.00 $62.41 $222.23 $222.23 $0.00 $0.00 $62.40 $0.00 $177.11 $177.11 $0.00 $145.35 $230.23 $232.56 $0.00 $0.00 $44.17 $0.00 $0.00 $46.28 $0.00 $0.00 $0.00 $0.00 $0.00 223.581 SUP HCPCS C1713 223.581 - PLATE BN 111X11X3.4MM NS LCP CMBN 8 HL LMT CNTCT TPR END SS BOTH IP/OP $639.60 $473.30 $0.00 $496.76 $279.43 $279.43 $0.00 $0.00 $0.00 $133.31 $474.71 $474.71 $0.00 $0.00 $133.29 $0.00 $378.32 $378.32 $0.00 $310.48 $491.79 $496.76 $0.00 $0.00 $94.35 $0.00 $0.00 $98.86 $0.00 $0.00 $0.00 $0.00 $0.00 223.59 SUP HCPCS C1713 223.59 - PLATE BONE 116X11X3.3MM 9 HOLE LC-DCP STAINLESS STEEL DISTAL BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 223.591 SUP HCPCS C1713 223.591 - PLATE BN 124X11X3.4MM NS LCP CMBN 9 HL LMT CNTCT TPR END SS BOTH IP/OP $664.90 $492.03 $0.00 $516.42 $290.49 $290.49 $0.00 $0.00 $0.00 $138.58 $493.49 $493.49 $0.00 $0.00 $138.57 $0.00 $393.29 $393.29 $0.00 $322.76 $511.26 $516.42 $0.00 $0.00 $98.08 $0.00 $0.00 $102.77 $0.00 $0.00 $0.00 $0.00 $0.00 223.6 SUP HCPCS C1713 223.60 - PLATE BONE 129X11X3.3MM 10 HOLE LOCK LC-DCP STAINLESS STEEL BOTH IP/OP $308.43 $228.24 $0.00 $246.74 $138.79 $138.79 $0.00 $0.00 $0.00 $64.28 $228.91 $228.91 $0.00 $0.00 $64.28 $0.00 $182.43 $182.43 $0.00 $154.21 $244.28 $246.74 $0.00 $0.00 $46.86 $0.00 $0.00 $49.10 $0.00 $0.00 $0.00 $0.00 $0.00 223.6 SUP HCPCS C1713 223.6 - PLATE 129MM SS 3.5MM SCR SM FRAG SET 10 HOLE LC DCP LCP BONE BOTH IP/OP $308.43 $228.24 $0.00 $272.59 $138.79 $138.79 $0.00 $0.00 $0.00 $64.28 $228.91 $228.91 $0.00 $0.00 $64.28 $0.00 $182.43 $182.43 $0.00 $154.21 $272.59 $246.74 $0.00 $0.00 $46.86 $0.00 $0.00 $49.10 $0.00 $0.00 $0.00 $0.00 $0.00 223.601 SUP HCPCS C1713 223.601 - PLATE BN 137X11X3.4MM NS LCP CMBN 10 HL LMT CNTCT TPR END SS BOTH IP/OP $685.98 $507.63 $0.00 $532.80 $299.70 $299.70 $0.00 $0.00 $0.00 $142.97 $509.13 $509.13 $0.00 $0.00 $142.96 $0.00 $405.75 $405.75 $0.00 $333.00 $527.47 $532.80 $0.00 $0.00 $101.19 $0.00 $0.00 $106.03 $0.00 $0.00 $0.00 $0.00 $0.00 223.61 SUP HCPCS C1713 223.61 - PLATE BN 142X11X3.3MM NS LC DCP 11 HL SS 3.5MM SCR SM FRAG BOTH IP/OP $344.40 $254.86 $0.00 $267.50 $150.47 $150.47 $0.00 $0.00 $0.00 $71.78 $255.61 $255.61 $0.00 $0.00 $71.77 $0.00 $203.71 $203.71 $0.00 $167.19 $264.83 $267.50 $0.00 $0.00 $50.80 $0.00 $0.00 $53.23 $0.00 $0.00 $0.00 $0.00 $0.00 223.611 SUP HCPCS C1713 223.611 - PLATE BN 150MM NS LCP CMBN 11 HL LMT CNTCT TPR END SS 3.5MM BOTH IP/OP $715.50 $529.47 $0.00 $555.72 $312.59 $312.59 $0.00 $0.00 $0.00 $149.13 $531.04 $531.04 $0.00 $0.00 $149.11 $0.00 $423.22 $423.22 $0.00 $347.33 $550.16 $555.72 $0.00 $0.00 $105.55 $0.00 $0.00 $110.59 $0.00 $0.00 $0.00 $0.00 $0.00 223.62 SUP HCPCS C1713 223.62 - PLATE BN 155X11X3.3MM NS LC DCP 12 HL SS 3.5MM SCR SM FRAG BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 223.621 SUP HCPCS C1713 223.621 - PLATE BN 163X11X3.4MM NS LCP CMBN 12 HL LMT CNTCT TPR END SS BOTH IP/OP $756.28 $559.65 $0.00 $587.38 $330.40 $330.40 $0.00 $0.00 $0.00 $157.63 $561.31 $561.31 $0.00 $0.00 $157.61 $0.00 $447.34 $447.34 $0.00 $367.11 $581.51 $587.38 $0.00 $0.00 $111.56 $0.00 $0.00 $116.89 $0.00 $0.00 $0.00 $0.00 $0.00 223.631 SUP HCPCS C1713 223.631 - PLATE BN 176X11X3.4MM NS LCP CMBN 13 HL SS 3.5MM SCR BOTH IP/OP $871.53 $644.93 $0.00 $676.92 $380.77 $380.77 $0.00 $0.00 $0.00 $181.65 $646.85 $646.85 $0.00 $0.00 $181.63 $0.00 $515.51 $515.51 $0.00 $423.08 $670.15 $676.92 $0.00 $0.00 $128.56 $0.00 $0.00 $134.71 $0.00 $0.00 $0.00 $0.00 $0.00 223.64 SUP HCPCS C1713 223.64 - PLATE BN 181X11X3.3MM NS LC DCP 14 HL SS 3.5MM SCR SM FRAG BOTH IP/OP $681.75 $504.50 $0.00 $529.52 $297.86 $297.86 $0.00 $0.00 $0.00 $142.09 $505.99 $505.99 $0.00 $0.00 $142.08 $0.00 $403.26 $403.26 $0.00 $330.95 $524.22 $529.52 $0.00 $0.00 $100.57 $0.00 $0.00 $105.37 $0.00 $0.00 $0.00 $0.00 $0.00 223.641 SUP HCPCS C1713 223.641 - PLATE BN 189X11X3.4MM NS LCP CMBN 14 HL LMT CNTCT TPR END SS BOTH IP/OP "$1,134.40 " $839.46 $0.00 $881.08 $495.61 $495.61 $0.00 $0.00 $0.00 $236.44 $841.95 $841.95 $0.00 $0.00 $236.41 $0.00 $671.00 $671.00 $0.00 $550.68 $872.27 $881.08 $0.00 $0.00 $167.34 $0.00 $0.00 $175.33 $0.00 $0.00 $0.00 $0.00 $0.00 223.65 SUP HCPCS C1713 223.65 - PLATE BONE 195X11X3.3MM 15 HOLE LC-DCP STAINLESS STEEL BOTH IP/OP $714.10 $528.43 $0.00 $554.64 $311.99 $311.99 $0.00 $0.00 $0.00 $148.84 $530.01 $530.01 $0.00 $0.00 $148.82 $0.00 $422.39 $422.39 $0.00 $346.65 $549.09 $554.64 $0.00 $0.00 $105.34 $0.00 $0.00 $110.37 $0.00 $0.00 $0.00 $0.00 $0.00 223.651 SUP HCPCS C1713 223.651 - PLATE BONE 202X11X3.4MM 15 HOLE LCP STAINLESS STEEL PROXIMAL BOTH IP/OP "$1,214.53 " $898.75 $0.00 $943.32 $530.62 $530.62 $0.00 $0.00 $0.00 $253.14 $901.42 $901.42 $0.00 $0.00 $253.11 $0.00 $718.39 $718.39 $0.00 $589.58 $933.89 $943.32 $0.00 $0.00 $179.16 $0.00 $0.00 $187.72 $0.00 $0.00 $0.00 $0.00 $0.00 223.66 SUP HCPCS C1713 223.66 - PLATE BONE 208X11X3.3MM 16 HOLE LC-DCP STAINLESS STEEL BOTH IP/OP $782.98 $579.41 $0.00 $608.14 $342.08 $342.08 $0.00 $0.00 $0.00 $163.19 $581.12 $581.12 $0.00 $0.00 $163.17 $0.00 $463.13 $463.13 $0.00 $380.09 $602.06 $608.14 $0.00 $0.00 $115.50 $0.00 $0.00 $121.02 $0.00 $0.00 $0.00 $0.00 $0.00 223.661 SUP HCPCS C1713 223.661 - PLATE BN 215X11X3.4MM NS LCP CMBN 16 HL LMT CNTCT TPR END SS BOTH IP/OP "$1,270.75 " $940.36 $0.00 $986.98 $555.18 $555.18 $0.00 $0.00 $0.00 $264.86 $943.15 $943.15 $0.00 $0.00 $264.82 $0.00 $751.65 $751.65 $0.00 $616.86 $977.11 $986.98 $0.00 $0.00 $187.46 $0.00 $0.00 $196.41 $0.00 $0.00 $0.00 $0.00 $0.00 223.671 SUP HCPCS C1713 223.671 - PLATE BN 241X11X3.4MM NS LCP CMBN 18 HL LMT CNTCT TPR END SS BOTH IP/OP "$1,425.38 " "$1,054.78" $0.00 "$1,107.08" $622.73 $622.73 $0.00 $0.00 $0.00 $297.08 "$1,057.91" "$1,057.91" $0.00 $0.00 $297.05 $0.00 $843.11 $843.11 $0.00 $691.93 "$1,096.01" "$1,107.08" $0.00 $0.00 $210.27 $0.00 $0.00 $220.31 $0.00 $0.00 $0.00 $0.00 $0.00 223.68 SUP HCPCS C1713 223.68 - PLATE BONE 233X11X3.3MM 18 HOLE LC-DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 223.681 SUP HCPCS C1713 223.681 - PLATE BN 267X11X3.4MM NS LCP CMBN 20 HL LMT CNTCT TPR END SS BOTH IP/OP "$1,582.80 " "$1,171.27" $0.00 "$1,229.36" $691.52 $691.52 $0.00 $0.00 $0.00 $329.90 "$1,174.75" "$1,174.75" $0.00 $0.00 $329.86 $0.00 $936.23 $936.23 $0.00 $768.35 "$1,217.07" "$1,229.36" $0.00 $0.00 $233.49 $0.00 $0.00 $244.64 $0.00 $0.00 $0.00 $0.00 $0.00 223.691 SUP HCPCS C1713 223.691 - PLATE BONE 293X11X3.4MM 22 HOLE LCP STAINLESS STEEL PROXIMAL BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 223.7 SUP HCPCS C1713 223.70 - PLATE BONE 259X11X3.3MM 20 HOLE LC-DCP STAINLESS STEEL BOTH IP/OP $941.68 $696.84 $0.00 $753.34 $423.75 $423.75 $0.00 $0.00 $0.00 $196.27 $698.91 $698.91 $0.00 $0.00 $196.25 $0.00 $557.00 $557.00 $0.00 $470.84 $745.81 $753.34 $0.00 $0.00 $143.08 $0.00 $0.00 $149.91 $0.00 $0.00 $0.00 $0.00 $0.00 224 SUP Custom 27803010 224.000 - STAINLESS STEEL REVERE LOCKING CAP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.001 SUP Custom 27803010 "224.001 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.002 SUP Custom 27803010 "224.002 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 400MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.003 SUP Custom 27803010 "224.003 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.012 SUP Custom 27803010 "224.012 - REVERE LOW PROFILE ADJUSTABLE T-CONNECTOR, 24MM-25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.013 SUP Custom 27803010 "224.013 - REVERE LOW PROFILE ADJUSTABLE T-CONNECTOR, 26MM-28MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.014 SUP Custom 27803010 "224.014 - REVERE LOW PROFILE ADJUSTABLE T-CONNECTOR, 29MM-34MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.02 SUP HCPCS C1713 224.02 - PLATE BN NAR 39X12X3.8MM NS DCP 2 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 224.04 SUP HCPCS C1713 224.04 - PLATE BN NAR 71X12X3.8MM NS DCP 4 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 224.041 SUP HCPCS C1713 224.041 - PLATE BONE 61MM 4 HOLE DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $828.40 $613.02 $0.00 $662.72 $372.78 $372.78 $0.00 $0.00 $0.00 $172.66 $614.84 $614.84 $0.00 $0.00 $172.64 $0.00 $490.00 $490.00 $0.00 $414.20 $656.09 $662.72 $0.00 $0.00 $125.87 $0.00 $0.00 $131.88 $0.00 $0.00 $0.00 $0.00 $0.00 224.05 SUP HCPCS C1713 224.05 - PLATE BN NAR 87X12X3.8MM NS DCP 5 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 224.051 SUP HCPCS C1713 224.051 - 5.0MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.052 SUP HCPCS C1713 224.052 - 5.0MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.053 SUP HCPCS C1713 224.053 - 5.0MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.054 SUP HCPCS C1713 224.054 - 5.0MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.055 SUP HCPCS C1713 224.055 - 5.0MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.056 SUP HCPCS C1713 224.056 - 5.0MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.057 SUP HCPCS C1713 224.057 - 5.0MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.06 SUP HCPCS C1713 224.06 - PLATE BN NAR 103X12X3.8MM NS DCP 6 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $312.08 $230.94 $0.00 $242.38 $136.34 $136.34 $0.00 $0.00 $0.00 $65.04 $231.62 $231.62 $0.00 $0.00 $65.04 $0.00 $184.59 $184.59 $0.00 $151.49 $239.96 $242.38 $0.00 $0.00 $46.03 $0.00 $0.00 $48.23 $0.00 $0.00 $0.00 $0.00 $0.00 224.061 SUP HCPCS C1713 224.061 - 7.5MM SS REVERE REDUCTION SCREW 70MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.062 SUP HCPCS C1713 224.062 - 7.5MM SS REVERE REDUCTION SCREW 75MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.063 SUP HCPCS C1713 224.063 - 7.5MM SS REVERE REDUCTION SCREW 80MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.064 SUP HCPCS C1713 224.064 - 7.5MM SS REVERE REDUCTION SCREW 85MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.065 SUP HCPCS C1713 224.065 - 7.5MM SS REVERE REDUCTION SCREW 90MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.07 SUP HCPCS C1713 224.07 - PLATE BN NAR 119X12X3.8MM NS DCP 7 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $312.08 $230.94 $0.00 $242.38 $136.34 $136.34 $0.00 $0.00 $0.00 $65.04 $231.62 $231.62 $0.00 $0.00 $65.04 $0.00 $184.59 $184.59 $0.00 $151.49 $239.96 $242.38 $0.00 $0.00 $46.03 $0.00 $0.00 $48.23 $0.00 $0.00 $0.00 $0.00 $0.00 224.071 SUP HCPCS C1713 224.071 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 70MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.072 SUP HCPCS C1713 224.072 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 75MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.073 SUP HCPCS C1713 224.073 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 80MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.074 SUP HCPCS C1713 224.074 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 85MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.075 SUP HCPCS C1713 224.075 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 90MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.08 SUP HCPCS C1713 224.08 - PLATE BN NAR 135X12X3.8MM NS DCP 8 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $302.98 $224.21 $0.00 $242.38 $136.34 $136.34 $0.00 $0.00 $0.00 $63.15 $224.87 $224.87 $0.00 $0.00 $63.14 $0.00 $179.21 $179.21 $0.00 $151.49 $239.96 $242.38 $0.00 $0.00 $46.03 $0.00 $0.00 $48.23 $0.00 $0.00 $0.00 $0.00 $0.00 224.081 SUP HCPCS C1713 224.081 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 70MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.082 SUP HCPCS C1713 224.082 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 75MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.083 SUP HCPCS C1713 224.083 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 80MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.084 SUP HCPCS C1713 224.084 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 85MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.085 SUP HCPCS C1713 224.085 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 90MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.09 SUP HCPCS C1713 224.09 - PLATE BN NAR 151X12X3.8MM NS DCP 9 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $312.08 $230.94 $0.00 $242.38 $136.34 $136.34 $0.00 $0.00 $0.00 $65.04 $231.62 $231.62 $0.00 $0.00 $65.04 $0.00 $184.59 $184.59 $0.00 $151.49 $239.96 $242.38 $0.00 $0.00 $46.03 $0.00 $0.00 $48.23 $0.00 $0.00 $0.00 $0.00 $0.00 224.1 SUP HCPCS C1713 224.10 - PLATE BN NAR 167X12X3.8MM NS DCP 10 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $399.88 $295.91 $0.00 $319.90 $179.94 $179.94 $0.00 $0.00 $0.00 $83.34 $296.79 $296.79 $0.00 $0.00 $83.33 $0.00 $236.53 $236.53 $0.00 $199.94 $316.70 $319.90 $0.00 $0.00 $60.76 $0.00 $0.00 $63.66 $0.00 $0.00 $0.00 $0.00 $0.00 224.11 SUP HCPCS C1713 224.11 - PLATE BONE NARROW 183X12X3.8MM 11 HOLE DCP STAINLESS STEEL BOTH IP/OP $398.83 $295.13 $0.00 $319.06 $179.47 $179.47 $0.00 $0.00 $0.00 $83.13 $296.01 $296.01 $0.00 $0.00 $83.12 $0.00 $235.90 $235.90 $0.00 $199.41 $315.87 $319.06 $0.00 $0.00 $62.42 $0.00 $0.00 $63.49 $0.00 $0.00 $0.00 $0.00 $0.00 224.111 SUP HCPCS C1713 224.111 - SCREW BN 5.5MM 27MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.112 SUP HCPCS C1713 224.112 - SCREW BN 5.5MM 32MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.113 SUP HCPCS C1713 224.113 - SCREW BN 5.5MM 37MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.114 SUP HCPCS C1713 224.114 - SCREW BN 5.5MM 42MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.115 SUP HCPCS C1713 224.115 - SCREW BN 5.5MM 47MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.12 SUP HCPCS C1713 224.12 - PLATE BN NAR 199X12X3.8MM NS DCP 12 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $399.88 $295.91 $0.00 $319.90 $179.94 $179.94 $0.00 $0.00 $0.00 $83.34 $296.79 $296.79 $0.00 $0.00 $83.33 $0.00 $236.53 $236.53 $0.00 $199.94 $316.70 $319.90 $0.00 $0.00 $60.76 $0.00 $0.00 $63.66 $0.00 $0.00 $0.00 $0.00 $0.00 224.121 SUP HCPCS C1713 224.121 - SCREW BN 6.5MM 27MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.122 SUP HCPCS C1713 224.122 - SCREW BN 6.5MM 32MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.123 SUP HCPCS C1713 224.123 - SCREW BN 6.5MM 37MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.124 SUP HCPCS C1713 224.124 - SCREW BN 6.5MM 42MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.125 SUP HCPCS C1713 224.125 - SCREW BN 6.5MM 47MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.131 SUP HCPCS C1713 224.131 - SCREW BN 7.5MM 27MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.132 SUP HCPCS C1713 224.132 - SCREW BN 7.5MM 32MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.133 SUP HCPCS C1713 224.133 - SCREW BN 7.5MM 37MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.134 SUP HCPCS C1713 224.134 - SCREW BN 7.5MM 42MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.135 SUP HCPCS C1713 224.135 - SCREW BN 7.5MM 47MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.14 SUP HCPCS C1713 224.14 - PLATE NAR SS 4.5MM SCR LG FRAG SET 14 HOLE DCP BONE ORTH BOTH IP/OP $561.50 $415.51 $0.00 $449.20 $252.68 $252.68 $0.00 $0.00 $0.00 $117.03 $416.75 $416.75 $0.00 $0.00 $117.02 $0.00 $332.13 $332.13 $0.00 $280.75 $444.71 $449.20 $0.00 $0.00 $87.87 $0.00 $0.00 $89.39 $0.00 $0.00 $0.00 $0.00 $0.00 224.141 SUP HCPCS C1713 224.141 - 5.5MM SS REVERE REDUCTION SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.142 SUP HCPCS C1713 224.142 - 5.5MM SS REVERE REDUCTION SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.143 SUP HCPCS C1713 224.143 - 5.5MM SS REVERE REDUCTION SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.144 SUP HCPCS C1713 224.144 - 5.5MM SS REVERE REDUCTION SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.145 SUP HCPCS C1713 224.145 - 5.5MM SS REVERE REDUCTION SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.146 SUP HCPCS C1713 224.146 - 5.5MM SS REVERE REDUCTION SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.147 SUP HCPCS C1713 224.147 - 5.5MM SS REVERE REDUCTION SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.151 SUP HCPCS C1713 224.151 - 6.5MM SS REVERE REDUCTION SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.152 SUP HCPCS C1713 224.152 - 6.5MM SS REVERE REDUCTION SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.153 SUP HCPCS C1713 224.153 - 6.5MM SS REVERE REDUCTION SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.154 SUP HCPCS C1713 224.154 - 6.5MM SS REVERE REDUCTION SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.155 SUP HCPCS C1713 224.155 - 6.5MM SS REVERE REDUCTION SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.156 SUP HCPCS C1713 224.156 - 6.5MM SS REVERE REDUCTION SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.157 SUP HCPCS C1713 224.157 - 6.5MM SS REVERE REDUCTION SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.158 SUP HCPCS C1713 224.158 - 6.5MM SS REVERE REDUCTION SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.159 SUP HCPCS C1713 224.159 - 6.5MM SS REVERE REDUCTION SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.161 SUP HCPCS C1713 224.161 - 7.5MM SS REVERE REDUCTION SCREW 25MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.162 SUP HCPCS C1713 224.162 - 7.5MM SS REVERE REDUCTION SCREW 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.163 SUP HCPCS C1713 224.163 - 7.5MM SS REVERE REDUCTION SCREW 35MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.164 SUP HCPCS C1713 224.164 - 7.5MM SS REVERE REDUCTION SCREW 40MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.165 SUP HCPCS C1713 224.165 - 7.5MM SS REVERE REDUCTION SCREW 45MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.166 SUP HCPCS C1713 224.166 - 7.5MM SS REVERE REDUCTION SCREW 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.167 SUP HCPCS C1713 224.167 - 7.5MM SS REVERE REDUCTION SCREW 55MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.168 SUP HCPCS C1713 224.168 - 7.5MM SS REVERE REDUCTION SCREW 60MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.169 SUP HCPCS C1713 224.169 - 7.5MM SS REVERE REDUCTION SCREW 65MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.2 SUP HCPCS C1713 224.20 - PLATE BN NAR 326X12X3.8MM NS DCP 20 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $816.13 $603.94 $0.00 "$1,665.74" $367.26 $367.26 $0.00 $0.00 $0.00 $170.10 $605.73 $605.73 $0.00 $0.00 $170.08 $0.00 "$1,665.74" "$1,665.74" $0.00 $408.06 $646.37 $652.90 $0.00 $0.00 $124.00 $0.00 $0.00 $129.93 $0.00 $0.00 $0.00 $0.00 $0.00 224.2 SUP HCPCS C1713 "224.200 - 4.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 20MM" BOTH IP/OP $816.13 $603.94 $0.00 "$1,665.74" $367.26 $367.26 $0.00 $0.00 $0.00 $170.10 $605.73 $605.73 $0.00 $0.00 $170.08 $0.00 "$1,665.74" "$1,665.74" $0.00 $408.06 "$1,584.00" $652.90 $0.00 $0.00 $124.00 $0.00 $0.00 $129.93 $0.00 $0.00 $0.00 $0.00 $0.00 224.201 SUP HCPCS C1713 "224.201 - 4.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.202 SUP HCPCS C1713 "224.202 - 4.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.203 SUP HCPCS C1713 "224.203 - 4.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.204 SUP HCPCS C1713 "224.204 - 4.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.241 SUP HCPCS C1713 "224.241 - 4.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.242 SUP HCPCS C1713 "224.242 - 4.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.243 SUP HCPCS C1713 "224.243 - 4.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.244 SUP HCPCS C1713 "224.244 - 4.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.245 SUP HCPCS C1713 "224.245 - 4.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.251 SUP HCPCS C1713 224.251 - SCREW BN 5.5MM 25MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.252 SUP HCPCS C1713 "224.252 - 5.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.253 SUP HCPCS C1713 "224.253 - 5.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.254 SUP HCPCS C1713 "224.254 - 5.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.255 SUP HCPCS C1713 "224.255 - 5.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.256 SUP HCPCS C1713 "224.256 - 5.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.257 SUP HCPCS C1713 "224.257 - 5.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.258 SUP HCPCS C1713 "224.258 - 5.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.259 SUP HCPCS C1713 "224.259 - 5.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.262 SUP HCPCS C1713 "224.262 - 6.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.263 SUP HCPCS C1713 "224.263 - 6.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.264 SUP HCPCS C1713 "224.264 - 6.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.265 SUP HCPCS C1713 "224.265 - 6.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.266 SUP HCPCS C1713 "224.266 - 6.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.267 SUP HCPCS C1713 "224.267 - 6.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.268 SUP HCPCS C1713 "224.268 - 6.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.269 SUP HCPCS C1713 "224.269 - 6.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.271 SUP HCPCS C1713 "224.271 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.272 SUP HCPCS C1713 "224.272 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.273 SUP HCPCS C1713 "224.273 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.274 SUP HCPCS C1713 "224.274 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.275 SUP HCPCS C1713 "224.275 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.276 SUP HCPCS C1713 "224.276 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.277 SUP HCPCS C1713 "224.277 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.278 SUP HCPCS C1713 "224.278 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.279 SUP HCPCS C1713 "224.279 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.281 SUP HCPCS C1713 224.281 - SCREW BN 8.5MM 25MM REVERE MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.282 SUP HCPCS C1713 "224.282 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.283 SUP HCPCS C1713 "224.283 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.284 SUP HCPCS C1713 "224.284 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.285 SUP HCPCS C1713 "224.285 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.286 SUP HCPCS C1713 "224.286 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.287 SUP HCPCS C1713 "224.287 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.288 SUP HCPCS C1713 "224.288 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 60MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.289 SUP HCPCS C1713 "224.289 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 65MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.351 SUP HCPCS C1713 224.351 - 5.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 25MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.352 SUP HCPCS C1713 224.352 - 5.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 30MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.353 SUP HCPCS C1713 224.353 - 5.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 35MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.354 SUP HCPCS C1713 224.354 - 5.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 40MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.355 SUP HCPCS C1713 224.355 - 5.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 45MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.356 SUP HCPCS C1713 224.356 - 5.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 50MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.357 SUP HCPCS C1713 224.357 - 5.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 55MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.361 SUP HCPCS C1713 224.361 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 25MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.362 SUP HCPCS C1713 224.362 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 30MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.363 SUP HCPCS C1713 224.363 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 35MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.364 SUP HCPCS C1713 224.364 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 40MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.365 SUP HCPCS C1713 224.365 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 45MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.366 SUP HCPCS C1713 224.366 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 50MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.367 SUP HCPCS C1713 224.367 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 55MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.368 SUP HCPCS C1713 224.368 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 60MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.369 SUP HCPCS C1713 224.369 - 6.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 65MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.371 SUP HCPCS C1713 224.371 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 25MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.372 SUP HCPCS C1713 224.372 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 30MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.373 SUP HCPCS C1713 224.373 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 35MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.374 SUP HCPCS C1713 224.374 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 40MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.375 SUP HCPCS C1713 224.375 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 45MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.376 SUP HCPCS C1713 224.376 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 50MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.377 SUP HCPCS C1713 224.377 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 55MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.378 SUP HCPCS C1713 224.378 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 60MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.379 SUP HCPCS C1713 224.379 - 7.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 65MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.381 SUP HCPCS C1713 224.381 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 25MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.382 SUP HCPCS C1713 224.382 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 30MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.383 SUP HCPCS C1713 224.383 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 35MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.384 SUP HCPCS C1713 224.384 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 40MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.385 SUP HCPCS C1713 224.385 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 45MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.386 SUP HCPCS C1713 224.386 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 50MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.387 SUP HCPCS C1713 224.387 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 55MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.388 SUP HCPCS C1713 224.388 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 60MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.389 SUP HCPCS C1713 224.389 - 8.5MM STAINLESS STEEL REVERE CANNULATED PEDICLE SCREW 65MM BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" "$2,368.13" "$2,368.13" $0.00 $0.00 $0.00 "$1,096.84" "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 "$2,594.41" "$2,594.41" $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $823.58 $0.00 $0.00 $837.79 $0.00 $0.00 $0.00 $0.00 $0.00 224.441 SUP HCPCS C1713 224.441 - 4.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.442 SUP HCPCS C1713 224.442 - 4.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.443 SUP HCPCS C1713 224.443 - 4.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.444 SUP HCPCS C1713 224.444 - 4.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.445 SUP HCPCS C1713 224.445 - 4.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.451 SUP HCPCS C1713 224.451 - 5.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.452 SUP HCPCS C1713 224.452 - 5.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.453 SUP HCPCS C1713 224.453 - 5.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.454 SUP HCPCS C1713 224.454 - 5.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.455 SUP HCPCS C1713 224.455 - 5.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.456 SUP HCPCS C1713 224.456 - 5.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.457 SUP HCPCS C1713 224.457 - 5.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.461 SUP HCPCS C1713 224.461 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.462 SUP HCPCS C1713 224.462 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.463 SUP HCPCS C1713 224.463 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.464 SUP HCPCS C1713 224.464 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.465 SUP HCPCS C1713 224.465 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.466 SUP HCPCS C1713 224.466 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.467 SUP HCPCS C1713 224.467 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.468 SUP HCPCS C1713 224.468 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.469 SUP HCPCS C1713 224.469 - 6.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.471 SUP HCPCS C1713 224.471 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.472 SUP HCPCS C1713 224.472 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.473 SUP HCPCS C1713 224.473 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.474 SUP HCPCS C1713 224.474 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.475 SUP HCPCS C1713 224.475 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.476 SUP HCPCS C1713 224.476 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.477 SUP HCPCS C1713 224.477 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.478 SUP HCPCS C1713 224.478 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.479 SUP HCPCS C1713 224.479 - 7.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.481 SUP HCPCS C1713 224.481 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.482 SUP HCPCS C1713 224.482 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 30MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.483 SUP HCPCS C1713 224.483 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 35MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.484 SUP HCPCS C1713 224.484 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 40MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.485 SUP HCPCS C1713 224.485 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 45MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.486 SUP HCPCS C1713 224.486 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 50MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.487 SUP HCPCS C1713 224.487 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 55MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.488 SUP HCPCS C1713 224.488 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 60MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.489 SUP HCPCS C1713 224.489 - 8.5MM STAINLESS STEEL REVERE SOLID PEDICLE SCREW 65MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.506 SUP HCPCS C1713 224.506 - PLATE BONE 125MM 6 HOLE STAINLESS STEEL TIBIA RIGHT DISTAL BOTH IP/OP "$1,149.85 " $850.89 $0.00 $893.10 $502.37 $502.37 $0.00 $0.00 $0.00 $239.66 $853.42 $853.42 $0.00 $0.00 $239.63 $0.00 $680.14 $680.14 $0.00 $558.19 $884.17 $893.10 $0.00 $0.00 $169.62 $0.00 $0.00 $177.73 $0.00 $0.00 $0.00 $0.00 $0.00 224.507 SUP HCPCS C1713 224.507 - PLATE BONE 125MM 6 HOLE STAINLESS STEEL TIBIA LEFT DISTAL BOTH IP/OP "$1,149.85 " $850.89 $0.00 $893.10 $502.37 $502.37 $0.00 $0.00 $0.00 $239.66 $853.42 $853.42 $0.00 $0.00 $239.63 $0.00 $680.14 $680.14 $0.00 $558.19 $884.17 $893.10 $0.00 $0.00 $169.62 $0.00 $0.00 $177.73 $0.00 $0.00 $0.00 $0.00 $0.00 224.508 SUP HCPCS C1713 224.508 - PLATE BONE 161MM 8 HOLE STAINLESS STEEL TIBIA RIGHT DISTAL BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 224.509 SUP HCPCS C1713 224.509 - PLATE BONE 161MM 8 HOLE STAINLESS STEEL TIBIA LEFT DISTAL BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 224.51 SUP HCPCS C1713 224.510 - PLATE BONE 197X14X3.8MM 10 HOLE DCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,434.35 " "$1,061.42" $0.00 "$1,147.48" $645.46 $645.46 $0.00 $0.00 $0.00 $298.95 "$1,064.57" "$1,064.57" $0.00 $0.00 $298.92 $0.00 $848.42 $848.42 $0.00 $717.18 "$1,136.01" "$1,147.48" $0.00 $0.00 $217.94 $0.00 $0.00 $228.35 $0.00 $0.00 $0.00 $0.00 $0.00 224.511 SUP HCPCS C1713 224.511 - PLATE BONE 197X14X3.8MM 10 HOLE STAINLESS STEEL LEFT MEDIAL BOTH IP/OP "$1,477.38 " "$1,093.26" $0.00 "$1,147.48" $645.46 $645.46 $0.00 $0.00 $0.00 $307.92 "$1,096.51" "$1,096.51" $0.00 $0.00 $307.88 $0.00 $873.87 $873.87 $0.00 $717.18 "$1,136.01" "$1,147.48" $0.00 $0.00 $217.94 $0.00 $0.00 $228.35 $0.00 $0.00 $0.00 $0.00 $0.00 224.512 SUP Custom 27803010 224.512 - PLATE BONE 233X14X3.8MM 12 HOLE STAINLESS STEEL RIGHT MEDIAL BOTH IP/OP "$1,650.28 " "$1,221.21" $0.00 "$1,281.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,224.83" "$1,224.83" $0.00 $0.00 $343.92 $0.00 $0.00 $0.00 $0.00 $801.11 "$1,268.97" "$1,281.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.513 SUP HCPCS C1713 224.513 - PLATE BONE 233X14X3.8MM 12 HOLE STAINLESS STEEL LEFT MEDIAL BOTH IP/OP "$1,650.28 " "$1,221.21" $0.00 "$1,281.78" $721.00 $721.00 $0.00 $0.00 $0.00 $343.96 "$1,224.83" "$1,224.83" $0.00 $0.00 $343.92 $0.00 $976.14 $976.14 $0.00 $801.11 "$1,268.97" "$1,281.78" $0.00 $0.00 $243.44 $0.00 $0.00 $255.07 $0.00 $0.00 $0.00 $0.00 $0.00 224.514 SUP HCPCS C1713 224.514 - PLATE BONE 269X14X3.8MM 14 HOLE STAINLESS STEEL RIGHT MEDIAL BOTH IP/OP "$1,840.05 " "$1,361.64" $0.00 "$1,429.16" $803.90 $803.90 $0.00 $0.00 $0.00 $383.51 "$1,365.69" "$1,365.69" $0.00 $0.00 $383.47 $0.00 "$1,088.39" "$1,088.39" $0.00 $893.23 "$1,414.87" "$1,429.16" $0.00 $0.00 $271.44 $0.00 $0.00 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.515 SUP Custom 27803010 224.515 - PLATE BONE 269X14X3.8MM 14 HOLE STAINLESS STEEL LEFT MEDIAL BOTH IP/OP "$1,840.05 " "$1,361.64" $0.00 "$1,429.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,365.69" "$1,365.69" $0.00 $0.00 $383.47 $0.00 $0.00 $0.00 $0.00 $893.23 "$1,414.87" "$1,429.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.517 SUP Custom 27803010 "224.517 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 200MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.52 SUP Custom 27803010 224.520 - ROD SPNL 5.5MM 400MM REVERE STRG SS BOTH IP/OP $300.78 $222.58 $0.00 $396.00 $135.35 $135.35 $0.00 $0.00 $0.00 $62.69 $223.24 $223.24 $0.00 $0.00 $62.68 $0.00 $177.91 $177.91 $0.00 $150.39 $396.00 $240.62 $0.00 $0.00 $47.07 $0.00 $0.00 $47.88 $0.00 $0.00 $0.00 $0.00 $0.00 224.52 SUP HCPCS C1713 224.52 - PLATE BONE NARROW 34X13.5X4.2MM 2 HOLE LCP STAINLESS STEEL BOTH IP/OP $300.78 $222.58 $0.00 $240.62 $135.35 $135.35 $0.00 $0.00 $0.00 $62.69 $223.24 $223.24 $0.00 $0.00 $62.68 $0.00 $177.91 $177.91 $0.00 $150.39 $238.22 $240.62 $0.00 $0.00 $47.07 $0.00 $0.00 $47.88 $0.00 $0.00 $0.00 $0.00 $0.00 224.521 SUP Custom 27803010 224.521 - PLATE BN NAR 44X13.5X4.2MM NS LCP CMBN 2 HL LMT CNTCT TPR BOTH IP/OP $608.68 $450.42 $0.00 $472.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $451.76 $451.76 $0.00 $0.00 $126.85 $0.00 $0.00 $0.00 $0.00 $295.46 $468.02 $472.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.53 SUP Custom 27803010 "224.530 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 30MM" BOTH IP/OP $310.05 $229.44 $0.00 $396.00 $139.52 $139.52 $0.00 $0.00 $0.00 $64.62 $230.12 $230.12 $0.00 $0.00 $64.61 $0.00 $183.39 $183.39 $0.00 $155.03 $396.00 $248.04 $0.00 $0.00 $48.52 $0.00 $0.00 $49.36 $0.00 $0.00 $0.00 $0.00 $0.00 224.53 SUP HCPCS C1713 224.53 - PLATE BONE NARROW 62X13.5X4.2MM 3 HOLE LC-DCP STAINLESS BOTH IP/OP $310.05 $229.44 $0.00 $248.04 $139.52 $139.52 $0.00 $0.00 $0.00 $64.62 $230.12 $230.12 $0.00 $0.00 $64.61 $0.00 $183.39 $183.39 $0.00 $155.03 $245.56 $248.04 $0.00 $0.00 $48.52 $0.00 $0.00 $49.36 $0.00 $0.00 $0.00 $0.00 $0.00 224.531 SUP HCPCS C1713 224.531 - PLATE BN NAR 62X13.5X4.2MM NS LCP CMBN 3 HL LMT CNTCT TPR BOTH IP/OP $615.70 $455.62 $0.00 $478.20 $268.99 $268.99 $0.00 $0.00 $0.00 $128.33 $456.97 $456.97 $0.00 $0.00 $128.31 $0.00 $364.19 $364.19 $0.00 $298.88 $473.42 $478.20 $0.00 $0.00 $90.82 $0.00 $0.00 $95.16 $0.00 $0.00 $0.00 $0.00 $0.00 224.535 SUP Custom 27803010 "224.535 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 35MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.54 SUP Custom 27803010 "224.540 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 40MM" BOTH IP/OP $319.10 $236.13 $0.00 $396.00 $139.41 $139.41 $0.00 $0.00 $0.00 $66.51 $236.84 $236.84 $0.00 $0.00 $66.50 $0.00 $188.75 $188.75 $0.00 $154.90 $396.00 $247.84 $0.00 $0.00 $47.07 $0.00 $0.00 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 224.54 SUP HCPCS C1713 224.54 - PLATE BN NAR 70X13.5X4.2MM NS LC DCP 4 HL SS 4.5MM SCR LG BOTH IP/OP $319.10 $236.13 $0.00 $247.84 $139.41 $139.41 $0.00 $0.00 $0.00 $66.51 $236.84 $236.84 $0.00 $0.00 $66.50 $0.00 $188.75 $188.75 $0.00 $154.90 $245.36 $247.84 $0.00 $0.00 $47.07 $0.00 $0.00 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 224.541 SUP HCPCS C1713 224.541 - PLATE BN NAR 80X13.5X4.2MM NS LCP CMBN 4 HL LMT CNTCT TPR BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 224.545 SUP Custom 27803010 "224.545 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 45MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.55 SUP Custom 27803010 "224.550 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 50MM" BOTH IP/OP $319.10 $236.13 $0.00 $396.00 $139.41 $139.41 $0.00 $0.00 $0.00 $66.51 $236.84 $236.84 $0.00 $0.00 $66.50 $0.00 $188.75 $188.75 $0.00 $154.90 $396.00 $247.84 $0.00 $0.00 $47.07 $0.00 $0.00 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 224.55 SUP HCPCS C1713 224.55 - PLATE BN NAR 88X13.5X4.2MM NS LC DCP 5 HL SS 4.5MM SCR LG BOTH IP/OP $319.10 $236.13 $0.00 $247.84 $139.41 $139.41 $0.00 $0.00 $0.00 $66.51 $236.84 $236.84 $0.00 $0.00 $66.50 $0.00 $188.75 $188.75 $0.00 $154.90 $245.36 $247.84 $0.00 $0.00 $47.07 $0.00 $0.00 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 224.551 SUP HCPCS C1713 224.551 - PLATE BN NAR 98X13.5X4.2MM NS LCP CMBN 5 HL LMT CNTCT TPR BOTH IP/OP $694.40 $513.86 $0.00 $539.34 $303.38 $303.38 $0.00 $0.00 $0.00 $144.73 $515.38 $515.38 $0.00 $0.00 $144.71 $0.00 $410.74 $410.74 $0.00 $337.09 $533.95 $539.34 $0.00 $0.00 $102.44 $0.00 $0.00 $107.33 $0.00 $0.00 $0.00 $0.00 $0.00 224.555 SUP Custom 27803010 "224.555 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 55MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.56 SUP Custom 27803010 "224.560 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 60MM" BOTH IP/OP $359.85 $266.29 $0.00 $396.00 $157.22 $157.22 $0.00 $0.00 $0.00 $75.00 $267.08 $267.08 $0.00 $0.00 $74.99 $0.00 $212.85 $212.85 $0.00 $174.69 $396.00 $279.50 $0.00 $0.00 $53.08 $0.00 $0.00 $55.62 $0.00 $0.00 $0.00 $0.00 $0.00 224.56 SUP HCPCS C1713 224.56 - PLATE BN NAR 106X13.5X4.2MM NS LC DCP 6 HL SS 4.5MM SCR LG BOTH IP/OP $359.85 $266.29 $0.00 $279.50 $157.22 $157.22 $0.00 $0.00 $0.00 $75.00 $267.08 $267.08 $0.00 $0.00 $74.99 $0.00 $212.85 $212.85 $0.00 $174.69 $276.71 $279.50 $0.00 $0.00 $53.08 $0.00 $0.00 $55.62 $0.00 $0.00 $0.00 $0.00 $0.00 224.561 SUP HCPCS C1713 224.561 - PLATE BN NAR 116MM NS LCP CMBN 6 HL SS 4.5MM SCR LG FRAG SET BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 224.565 SUP Custom 27803010 "224.565 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 65MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.57 SUP Custom 27803010 "224.570 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 70MM" BOTH IP/OP $359.85 $266.29 $0.00 $396.00 $157.22 $157.22 $0.00 $0.00 $0.00 $75.00 $267.08 $267.08 $0.00 $0.00 $74.99 $0.00 $212.85 $212.85 $0.00 $174.69 $396.00 $279.50 $0.00 $0.00 $53.08 $0.00 $0.00 $55.62 $0.00 $0.00 $0.00 $0.00 $0.00 224.57 SUP HCPCS C1713 224.57 - PLATE BN NAR 124X13.5X4.2MM NS LC DCP 7 HL SS 4.5MM SCR LG BOTH IP/OP $359.85 $266.29 $0.00 $279.50 $157.22 $157.22 $0.00 $0.00 $0.00 $75.00 $267.08 $267.08 $0.00 $0.00 $74.99 $0.00 $212.85 $212.85 $0.00 $174.69 $276.71 $279.50 $0.00 $0.00 $53.08 $0.00 $0.00 $55.62 $0.00 $0.00 $0.00 $0.00 $0.00 224.571 SUP HCPCS C1713 224.571 - PLATE BN NAR 134X13.5X4.2MM NS LCP CMBN 7 HL LMT CNTCT TPR BOTH IP/OP $850.45 $629.33 $0.00 $660.54 $371.55 $371.55 $0.00 $0.00 $0.00 $177.26 $631.20 $631.20 $0.00 $0.00 $177.23 $0.00 $503.04 $503.04 $0.00 $412.84 $653.94 $660.54 $0.00 $0.00 $125.45 $0.00 $0.00 $131.45 $0.00 $0.00 $0.00 $0.00 $0.00 224.575 SUP Custom 27803010 "224.575 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 75MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.58 SUP Custom 27803010 "224.580 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 80MM" BOTH IP/OP $359.85 $266.29 $0.00 $396.00 $157.22 $157.22 $0.00 $0.00 $0.00 $75.00 $267.08 $267.08 $0.00 $0.00 $74.99 $0.00 $212.85 $212.85 $0.00 $174.69 $396.00 $279.50 $0.00 $0.00 $53.08 $0.00 $0.00 $55.62 $0.00 $0.00 $0.00 $0.00 $0.00 224.58 SUP HCPCS C1713 224.58 - PLATE BN NAR 142X13.5X4.2MM NS LC DCP 8 HL SS 4.5MM SCR LG BOTH IP/OP $359.85 $266.29 $0.00 $279.50 $157.22 $157.22 $0.00 $0.00 $0.00 $75.00 $267.08 $267.08 $0.00 $0.00 $74.99 $0.00 $212.85 $212.85 $0.00 $174.69 $276.71 $279.50 $0.00 $0.00 $53.08 $0.00 $0.00 $55.62 $0.00 $0.00 $0.00 $0.00 $0.00 224.581 SUP HCPCS C1713 224.581 - PLATE BN NAR 152X13.5X4.2MM NS LCP CMBN 8 HL LMT CNTCT TPR BOTH IP/OP $899.65 $665.74 $0.00 $698.76 $393.05 $393.05 $0.00 $0.00 $0.00 $187.51 $667.72 $667.72 $0.00 $0.00 $187.49 $0.00 $532.14 $532.14 $0.00 $436.73 $691.77 $698.76 $0.00 $0.00 $132.71 $0.00 $0.00 $139.05 $0.00 $0.00 $0.00 $0.00 $0.00 224.585 SUP Custom 27803010 "224.585 - 5.5MM STAINLESS STEEL STRAIGHT ROD, 85MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.59 SUP HCPCS C1713 224.59 - PLATE BN NAR 160X13.5X4.2MM NS LC DCP 9 HL SS 4.5MM SCR LG BOTH IP/OP $359.85 $266.29 $0.00 $279.50 $157.22 $157.22 $0.00 $0.00 $0.00 $75.00 $267.08 $267.08 $0.00 $0.00 $74.99 $0.00 $212.85 $212.85 $0.00 $174.69 $276.71 $279.50 $0.00 $0.00 $53.08 $0.00 $0.00 $55.62 $0.00 $0.00 $0.00 $0.00 $0.00 224.591 SUP HCPCS C1713 224.591 - PLATE BN NAR 170X13.5X4.2MM NS LCP CMBN 9 HL LMT CNTCT TPR BOTH IP/OP $941.83 $696.95 $0.00 $731.50 $411.47 $411.47 $0.00 $0.00 $0.00 $196.30 $699.02 $699.02 $0.00 $0.00 $196.28 $0.00 $557.09 $557.09 $0.00 $457.19 $724.19 $731.50 $0.00 $0.00 $138.93 $0.00 $0.00 $145.57 $0.00 $0.00 $0.00 $0.00 $0.00 224.6 SUP HCPCS C1713 224.60 - PLATE BN NAR 178X13.5X4.2MM NS LC DCP 10 HL SS 4.5MM SCR LG BOTH IP/OP $454.45 $336.29 $0.00 $363.56 $204.50 $204.50 $0.00 $0.00 $0.00 $94.72 $337.29 $337.29 $0.00 $0.00 $94.71 $0.00 $268.81 $268.81 $0.00 $227.23 $359.92 $363.56 $0.00 $0.00 $69.05 $0.00 $0.00 $72.35 $0.00 $0.00 $0.00 $0.00 $0.00 224.601 SUP HCPCS C1713 224.601 - PLATE BN NAR 188X13.5X4.2MM NS LCP CMBN 10 HL LMT CNTCT TPR BOTH IP/OP "$1,023.35 " $757.28 $0.00 $794.84 $447.10 $447.10 $0.00 $0.00 $0.00 $213.29 $759.53 $759.53 $0.00 $0.00 $213.27 $0.00 $605.31 $605.31 $0.00 $496.78 $786.89 $794.84 $0.00 $0.00 $150.96 $0.00 $0.00 $158.17 $0.00 $0.00 $0.00 $0.00 $0.00 224.61 SUP Custom 27803010 "224.610 - 5.5MM STAINLESS STEEL CURVED ROD, 100MM" BOTH IP/OP $468.10 $346.39 $0.00 $396.00 $204.50 $204.50 $0.00 $0.00 $0.00 $97.56 $347.42 $347.42 $0.00 $0.00 $97.55 $0.00 $276.88 $276.88 $0.00 $227.23 $396.00 $363.56 $0.00 $0.00 $69.05 $0.00 $0.00 $72.35 $0.00 $0.00 $0.00 $0.00 $0.00 224.61 SUP HCPCS C1713 224.61 - PLATE BN NAR 196X13.5X4.2MM NS LC DCP 11 HL SS 4.5MM SCR LG BOTH IP/OP $468.10 $346.39 $0.00 $363.56 $204.50 $204.50 $0.00 $0.00 $0.00 $97.56 $347.42 $347.42 $0.00 $0.00 $97.55 $0.00 $276.88 $276.88 $0.00 $227.23 $359.92 $363.56 $0.00 $0.00 $69.05 $0.00 $0.00 $72.35 $0.00 $0.00 $0.00 $0.00 $0.00 224.611 SUP HCPCS C1713 224.611 - PLATE BN NAR 206X13.5X4.2MM NS LCP CMBN 11 HL LMT CNTCT TPR BOTH IP/OP "$1,102.08 " $815.54 $0.00 $855.98 $481.49 $481.49 $0.00 $0.00 $0.00 $229.70 $817.96 $817.96 $0.00 $0.00 $229.67 $0.00 $651.88 $651.88 $0.00 $534.99 $847.42 $855.98 $0.00 $0.00 $162.57 $0.00 $0.00 $170.34 $0.00 $0.00 $0.00 $0.00 $0.00 224.612 SUP Custom 27803010 "224.612 - 5.5MM STAINLESS STEEL CURVED ROD, 125MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.615 SUP Custom 27803010 "224.615 - 5.5MM STAINLESS STEEL CURVED ROD, 150MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.62 SUP HCPCS C1713 224.62 - PLATE BN NAR 214X13.5X4.2MM NS LC DCP 12 HL SS 4.5MM SCR LG BOTH IP/OP $468.10 $346.39 $0.00 $363.56 $204.50 $204.50 $0.00 $0.00 $0.00 $97.56 $347.42 $347.42 $0.00 $0.00 $97.55 $0.00 $276.88 $276.88 $0.00 $227.23 $359.92 $363.56 $0.00 $0.00 $69.05 $0.00 $0.00 $72.35 $0.00 $0.00 $0.00 $0.00 $0.00 224.621 SUP HCPCS C1713 224.621 - PLATE BN NAR 224X13.5X4.2MM NS LCP CMBN 12 HL LMT CNTCT TPR BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 224.635 SUP Custom 27803010 "224.635 - 5.5MM STAINLESS STEEL CURVED ROD, 35MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.64 SUP Custom 27803010 "224.640 - 5.5MM STAINLESS STEEL CURVED ROD, 40MM" BOTH IP/OP $441.23 $326.51 $0.00 $396.00 $198.55 $198.55 $0.00 $0.00 $0.00 $91.96 $327.48 $327.48 $0.00 $0.00 $91.95 $0.00 $260.98 $260.98 $0.00 $220.61 $396.00 $352.98 $0.00 $0.00 $69.05 $0.00 $0.00 $70.24 $0.00 $0.00 $0.00 $0.00 $0.00 224.64 SUP HCPCS C1713 224.64 - PLATE BONE NARROW 250X13.5X4.2MM 14 HOLE LC-DCP STAINLESS BOTH IP/OP $441.23 $326.51 $0.00 $352.98 $198.55 $198.55 $0.00 $0.00 $0.00 $91.96 $327.48 $327.48 $0.00 $0.00 $91.95 $0.00 $260.98 $260.98 $0.00 $220.61 $349.45 $352.98 $0.00 $0.00 $69.05 $0.00 $0.00 $70.24 $0.00 $0.00 $0.00 $0.00 $0.00 224.641 SUP HCPCS C1713 224.641 - PLATE BN NAR 260X13.5X4.2MM NS LCP CMBN 14 HL LMT CNTCT TPR BOTH IP/OP "$1,328.38 " $983.00 $0.00 "$1,031.76" $580.37 $580.37 $0.00 $0.00 $0.00 $276.87 $985.92 $985.92 $0.00 $0.00 $276.83 $0.00 $785.73 $785.73 $0.00 $644.85 "$1,021.44" "$1,031.76" $0.00 $0.00 $195.96 $0.00 $0.00 $205.32 $0.00 $0.00 $0.00 $0.00 $0.00 224.645 SUP Custom 27803010 "224.645 - 5.5MM STAINLESS STEEL CURVED ROD, 45MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.65 SUP Custom 27803010 "224.650 - 5.5MM STAINLESS STEEL CURVED ROD, 50MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.655 SUP Custom 27803010 "224.655 - 5.5MM STAINLESS STEEL CURVED ROD, 55MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.66 SUP Custom 27803010 "224.660 - 5.5MM STAINLESS STEEL CURVED ROD, 60MM" BOTH IP/OP $562.28 $416.09 $0.00 $436.72 $245.66 $245.66 $0.00 $0.00 $0.00 $117.19 $417.32 $417.32 $0.00 $0.00 $117.18 $0.00 $332.59 $332.59 $0.00 $272.95 $396.00 $436.72 $0.00 $0.00 $82.95 $0.00 $0.00 $86.91 $0.00 $0.00 $0.00 $0.00 $0.00 224.66 SUP HCPCS C1713 224.66 - PLATE BONE NARROW 286X13.5X4.2MM 16 HOLE LC-DCP STAINLESS BOTH IP/OP $562.28 $416.09 $0.00 $436.72 $245.66 $245.66 $0.00 $0.00 $0.00 $117.19 $417.32 $417.32 $0.00 $0.00 $117.18 $0.00 $332.59 $332.59 $0.00 $272.95 $432.35 $436.72 $0.00 $0.00 $82.95 $0.00 $0.00 $86.91 $0.00 $0.00 $0.00 $0.00 $0.00 224.661 SUP HCPCS C1713 224.661 - PLATE BN NAR 296X13.5X4.2MM NS LCP CMBN 16 HL LMT CNTCT TPR BOTH IP/OP "$1,553.30 " "$1,149.44" $0.00 "$1,206.44" $678.62 $678.62 $0.00 $0.00 $0.00 $323.75 "$1,152.86" "$1,152.86" $0.00 $0.00 $323.71 $0.00 $918.78 $918.78 $0.00 $754.03 "$1,194.38" "$1,206.44" $0.00 $0.00 $229.14 $0.00 $0.00 $240.08 $0.00 $0.00 $0.00 $0.00 $0.00 224.665 SUP Custom 27803010 "224.665 - 5.5MM STAINLESS STEEL CURVED ROD, 65MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.67 SUP Custom 27803010 "224.670 - 5.5MM STAINLESS STEEL CURVED ROD, 70MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.675 SUP Custom 27803010 "224.675 - 5.5MM STAINLESS STEEL CURVED ROD, 75MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.68 SUP Custom 27803010 "224.680 - 5.5MM STAINLESS STEEL CURVED ROD, 80MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.681 SUP HCPCS C1713 224.681 - PLATE BONE NARROW 332MM 18 HOLE LCP STAINLESS STEEL BOTH IP/OP "$1,886.45 " "$1,395.97" $0.00 "$1,465.20" $824.18 $824.18 $0.00 $0.00 $0.00 $393.18 "$1,400.12" "$1,400.12" $0.00 $0.00 $393.14 $0.00 "$1,115.84" "$1,115.84" $0.00 $915.75 "$1,450.55" "$1,465.20" $0.00 $0.00 $278.28 $0.00 $0.00 $291.57 $0.00 $0.00 $0.00 $0.00 $0.00 224.685 SUP Custom 27803010 "224.685 - 5.5MM STAINLESS STEEL CURVED ROD, 85MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.7 SUP HCPCS C1713 224.70 - PLATE BONE NARROW 358MM 20 HOLE LC-DCP STAINLESS STEEL BOTH IP/OP "$1,155.95 " $855.40 $0.00 $924.76 $520.18 $520.18 $0.00 $0.00 $0.00 $240.93 $857.95 $857.95 $0.00 $0.00 $240.90 $0.00 $683.74 $683.74 $0.00 $577.98 $915.51 $924.76 $0.00 $0.00 $175.64 $0.00 $0.00 $184.03 $0.00 $0.00 $0.00 $0.00 $0.00 224.701 SUP HCPCS C1713 224.701 - PLATE BONE NARROW 368MM 20 HOLE LCP STAINLESS STEEL BOTH IP/OP "$2,398.10 " "$1,774.59" $0.00 "$1,862.62" "$1,047.72" "$1,047.72" $0.00 $0.00 $0.00 $499.82 "$1,779.87" "$1,779.87" $0.00 $0.00 $499.76 $0.00 "$1,418.48" "$1,418.48" $0.00 "$1,164.14" "$1,844.00" "$1,862.62" $0.00 $0.00 $353.76 $0.00 $0.00 $370.66 $0.00 $0.00 $0.00 $0.00 $0.00 224.702 SUP HCPCS C1713 "224.702 - SS REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.703 SUP HCPCS C1713 "224.703 - SS REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.704 SUP HCPCS C1713 "224.704 - SS REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.705 SUP HCPCS C1713 "224.705 - SS REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.706 SUP HCPCS C1713 "224.706 - SS REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.707 SUP HCPCS C1713 "224.707 - SS REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.711 SUP HCPCS C1713 "224.711 - SS REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.712 SUP HCPCS C1713 "224.712 - SS REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.713 SUP HCPCS C1713 "224.713 - SS REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.714 SUP HCPCS C1713 "224.714 - SS REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.715 SUP HCPCS C1713 "224.715 - SS REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.716 SUP HCPCS C1713 "224.716 - SS REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.717 SUP HCPCS C1713 "224.717 - SS REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.721 SUP HCPCS C1713 224.721 - PLATE BONE NARROW 404MM 22 HOLE LCP STAINLESS STEEL BOTH IP/OP "$2,618.80 " "$1,937.91" $0.00 "$2,034.02" "$1,144.14" "$1,144.14" $0.00 $0.00 $0.00 $545.82 "$1,943.67" "$1,943.67" $0.00 $0.00 $545.76 $0.00 "$1,291.07" "$1,291.07" $0.00 "$1,271.26" "$2,013.68" "$2,034.02" $0.00 $0.00 $386.32 $0.00 $0.00 $404.77 $0.00 $0.00 $0.00 $0.00 $0.00 224.722 SUP HCPCS C1713 "224.722 - SS REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.723 SUP HCPCS C1713 "224.723 - SS REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.724 SUP HCPCS C1713 "224.724 - SS REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.725 SUP HCPCS C1713 "224.725 - SS REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.726 SUP HCPCS C1713 "224.726 - SS REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.727 SUP HCPCS C1713 "224.727 - SS REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.731 SUP HCPCS C1713 "224.731 - SS REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.732 SUP HCPCS C1713 "224.732 - SS REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.733 SUP HCPCS C1713 "224.733 - SS REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.734 SUP HCPCS C1713 "224.734 - SS REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.735 SUP HCPCS C1713 "224.735 - SS REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.736 SUP HCPCS C1713 "224.736 - SS REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.737 SUP HCPCS C1713 "224.737 - SS REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.753 SUP HCPCS C1713 224.753 - PLATE BN 118X11X4.2MM NS LCP CMBN 8 HL LMT CNTCT TPR END SS BOTH IP/OP "$1,730.40 " "$1,280.50" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $360.66 "$1,284.30" "$1,284.30" $0.00 $0.00 $360.62 $0.00 "$1,023.53" "$1,023.53" $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $255.26 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 224.754 SUP HCPCS C1713 224.754 - PLATE BN 136X11X4.2MM NS LCP CMBN 9 HL LMT CNTCT TPR END SS BOTH IP/OP "$1,758.53 " "$1,301.31" $0.00 "$1,365.84" $768.29 $768.29 $0.00 $0.00 $0.00 $366.52 "$1,305.18" "$1,305.18" $0.00 $0.00 $366.48 $0.00 "$1,040.17" "$1,040.17" $0.00 $853.65 "$1,352.18" "$1,365.84" $0.00 $0.00 $259.41 $0.00 $0.00 $271.80 $0.00 $0.00 $0.00 $0.00 $0.00 224.755 SUP HCPCS C1713 224.755 - PLATE BN 154X11X4.2MM NS LCP CMBN 10 HL LMT CNTCT TPR END SS BOTH IP/OP "$1,788.05 " "$1,323.16" $0.00 "$1,388.76" $781.18 $781.18 $0.00 $0.00 $0.00 $372.67 "$1,327.09" "$1,327.09" $0.00 $0.00 $372.63 $0.00 "$1,057.63" "$1,057.63" $0.00 $867.98 "$1,374.87" "$1,388.76" $0.00 $0.00 $263.77 $0.00 $0.00 $276.36 $0.00 $0.00 $0.00 $0.00 $0.00 224.756 SUP HCPCS C1713 224.756 - PLATE BONE 172MM 11 HOLE LCP STAINLESS STEEL METAPHYSEAL BOTH IP/OP "$1,817.55 " "$1,344.99" $0.00 "$1,411.70" $794.08 $794.08 $0.00 $0.00 $0.00 $378.82 "$1,348.99" "$1,348.99" $0.00 $0.00 $378.78 $0.00 "$1,075.08" "$1,075.08" $0.00 $882.31 "$1,397.59" "$1,411.70" $0.00 $0.00 $268.12 $0.00 $0.00 $280.93 $0.00 $0.00 $0.00 $0.00 $0.00 224.757 SUP HCPCS C1713 224.757 - PLATE BONE 190MM 12 HOLE LCP STAINLESS STEEL METAPHYSEAL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,822.22" "$1,025.00" "$1,025.00" $0.00 $0.00 $0.00 $488.99 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 "$1,387.72" "$1,387.72" $0.00 "$1,138.89" "$1,804.00" "$1,822.22" $0.00 $0.00 $346.09 $0.00 $0.00 $362.62 $0.00 $0.00 $0.00 $0.00 $0.00 224.758 SUP HCPCS C1713 224.758 - PLATE BONE 208MM 8X5 HOLE LCP STAINLESS STEEL METAPHYSEAL BOTH IP/OP "$2,370.00 " "$1,753.80" $0.00 "$1,840.78" "$1,035.44" "$1,035.44" $0.00 $0.00 $0.00 $493.97 "$1,759.01" "$1,759.01" $0.00 $0.00 $493.91 $0.00 "$1,401.86" "$1,401.86" $0.00 "$1,150.49" "$1,822.38" "$1,840.78" $0.00 $0.00 $349.61 $0.00 $0.00 $366.32 $0.00 $0.00 $0.00 $0.00 $0.00 224.759 SUP HCPCS C1713 224.759 - PLATE BONE 226MM 9X5 HOLE LCP STAINLESS STEEL METAPHYSEAL BOTH IP/OP "$2,422.00 " "$1,792.28" $0.00 "$1,881.18" "$1,058.16" "$1,058.16" $0.00 $0.00 $0.00 $504.81 "$1,797.61" "$1,797.61" $0.00 $0.00 $504.74 $0.00 "$1,432.61" "$1,432.61" $0.00 "$1,175.74" "$1,862.37" "$1,881.18" $0.00 $0.00 $357.29 $0.00 $0.00 $374.35 $0.00 $0.00 $0.00 $0.00 $0.00 224.761 SUP HCPCS C1713 224.761 - PLATE BONE 262MM 11X5 HOLE LCP STAINLESS STEEL METAPHYSEAL BOTH IP/OP "$2,542.90 " "$1,881.75" $0.00 "$1,975.06" "$1,110.97" "$1,110.97" $0.00 $0.00 $0.00 $530.00 "$1,887.34" "$1,887.34" $0.00 $0.00 $529.94 $0.00 "$1,253.65" "$1,253.65" $0.00 "$1,234.41" "$1,955.31" "$1,975.06" $0.00 $0.00 $375.12 $0.00 $0.00 $393.04 $0.00 $0.00 $0.00 $0.00 $0.00 224.763 SUP HCPCS C1713 224.763 - PLATE BONE 298MM 13X5 HOLE LCP STAINLESS STEEL METAPHYSEAL BOTH IP/OP "$2,590.70 " "$1,917.12" $0.00 "$2,012.18" "$1,131.85" "$1,131.85" $0.00 $0.00 $0.00 $539.97 "$1,922.82" "$1,922.82" $0.00 $0.00 $539.90 $0.00 "$1,277.22" "$1,277.22" $0.00 "$1,257.61" "$1,992.06" "$2,012.18" $0.00 $0.00 $382.17 $0.00 $0.00 $400.42 $0.00 $0.00 $0.00 $0.00 $0.00 224.765 SUP HCPCS C1713 224.765 - PLATE BONE 334MM 20 HOLE LCP STAINLESS STEEL METAPHYSEAL BOTH IP/OP "$2,708.78 " "$2,004.50" $0.00 "$2,103.90" "$1,183.44" "$1,183.44" $0.00 $0.00 $0.00 $564.58 "$2,010.45" "$2,010.45" $0.00 $0.00 $564.51 $0.00 "$1,335.43" "$1,335.43" $0.00 "$1,314.94" "$2,082.86" "$2,103.90" $0.00 $0.00 $399.59 $0.00 $0.00 $418.68 $0.00 $0.00 $0.00 $0.00 $0.00 224.801 SUP HCPCS C1713 "224.801 - SS REVERE 4.5MM UNIPLANAR SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.802 SUP HCPCS C1713 "224.802 - SS REVERE 4.5MM UNIPLANAR SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.803 SUP HCPCS C1713 "224.803 - SS REVERE 4.5MM UNIPLANAR SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.804 SUP HCPCS C1713 "224.804 - SS REVERE 4.5MM UNIPLANAR SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.805 SUP HCPCS C1713 "224.805 - SS REVERE 4.5MM UNIPLANAR SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.806 SUP HCPCS C1713 "224.806 - SS REVERE 4.5MM UNIPLANAR SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.807 SUP HCPCS C1713 "224.807 - SS REVERE 4.5MM UNIPLANAR SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.811 SUP HCPCS C1713 "224.811 - SS REVERE 5.0MM UNIPLANAR SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.812 SUP HCPCS C1713 "224.812 - SS REVERE 5.0MM UNIPLANAR SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.813 SUP HCPCS C1713 "224.813 - SS REVERE 5.0MM UNIPLANAR SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.814 SUP HCPCS C1713 "224.814 - SS REVERE 5.0MM UNIPLANAR SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.815 SUP HCPCS C1713 "224.815 - SS REVERE 5.0MM UNIPLANAR SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.816 SUP HCPCS C1713 "224.816 - SS REVERE 5.0MM UNIPLANAR SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.817 SUP HCPCS C1713 "224.817 - SS REVERE 5.0MM UNIPLANAR SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.821 SUP HCPCS C1713 "224.821 - SS REVERE 5.5MM UNIPLANAR SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.822 SUP HCPCS C1713 "224.822 - SS REVERE 5.5MM UNIPLANAR SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.823 SUP HCPCS C1713 "224.823 - SS REVERE 5.5MM UNIPLANAR SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.824 SUP HCPCS C1713 "224.824 - SS REVERE 5.5MM UNIPLANAR SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.825 SUP HCPCS C1713 "224.825 - SS REVERE 5.5MM UNIPLANAR SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.826 SUP HCPCS C1713 "224.826 - SS REVERE 5.5MM UNIPLANAR SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.827 SUP HCPCS C1713 "224.827 - SS REVERE 5.5MM UNIPLANAR SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.831 SUP HCPCS C1713 "224.831 - SS REVERE 6.5MM UNIPLANAR SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.832 SUP HCPCS C1713 "224.832 - SS REVERE 6.5MM UNIPLANAR SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.833 SUP HCPCS C1713 "224.833 - SS REVERE 6.5MM UNIPLANAR SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.834 SUP HCPCS C1713 "224.834 - SS REVERE 6.5MM UNIPLANAR SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.835 SUP HCPCS C1713 "224.835 - SS REVERE 6.5MM UNIPLANAR SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.836 SUP HCPCS C1713 "224.836 - SS REVERE 6.5MM UNIPLANAR SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.837 SUP HCPCS C1713 "224.837 - SS REVERE 6.5MM UNIPLANAR SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 224.851 SUP HCPCS C1713 "224.851 - 5.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 25MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.852 SUP HCPCS C1713 "224.852 - 5.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.853 SUP HCPCS C1713 "224.853 - 5.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.854 SUP HCPCS C1713 "224.854 - 5.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 40MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.855 SUP HCPCS C1713 "224.855 - 5.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 45MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.856 SUP HCPCS C1713 "224.856 - 5.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 50MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.857 SUP HCPCS C1713 "224.857 - 5.0MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 55MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.871 SUP HCPCS C1713 "224.871 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 70MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.872 SUP HCPCS C1713 "224.872 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 75MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.873 SUP HCPCS C1713 "224.873 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 80MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.874 SUP HCPCS C1713 "224.874 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 85MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.875 SUP HCPCS C1713 "224.875 - 7.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 90MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.881 SUP HCPCS C1713 "224.881 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 70MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.882 SUP HCPCS C1713 "224.882 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 75MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.883 SUP HCPCS C1713 "224.883 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 80MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.884 SUP HCPCS C1713 "224.884 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 85MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.885 SUP HCPCS C1713 "224.885 - 8.5MM STAINLESS STEEL REVERE MONOAXIAL SCREW, 90MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 224.891 SUP Custom 27803010 "224.891 - SS REVERE LOW PROFILE PEDICLE HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.892 SUP Custom 27803010 "224.892 - SS REVERE LOW PROFILE PEDICLE HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.893 SUP Custom 27803010 "224.893 - SS REVERE LOW PROFILE PEDICLE HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.901 SUP Custom 27803010 "224.901 - STAINLESS STEEL REVERE THORACIC LAMINA HOOK, NARROW, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.902 SUP Custom 27803010 "224.902 - STAINLESS STEEL REVERE THORACIC LAMINA HOOK, NARROW, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.904 SUP Custom 27803010 "224.904 - STAINLESS STEEL REVERE THORACIC LAMINA HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.905 SUP Custom 27803010 "224.905 - STAINLESS STEEL REVERE THORACIC LAMINA HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.907 SUP Custom 27803010 "224.907 - STAINLESS STEEL REVERE UPGOING LAMINA HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.908 SUP Custom 27803010 "224.908 - STAINLESS STEEL REVERE UPGOING LAMINA HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.912 SUP Custom 27803010 "224.912 - STAINLESS STEEL REVERE ADJUSTABLE T CONNECTOR, 29MM-33MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.913 SUP Custom 27803010 "224.913 - STAINLESS STEEL REVERE ADJUSTABLE T CONNECTOR, 33MM-41MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.914 SUP Custom 27803010 "224.914 - STAINLESS STEEL REVERE ADJUSTABLE T CONNECTOR, 38MM-51MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.915 SUP Custom 27803010 "224.915 - STAINLESS STEEL REVERE ADJUSTABLE T CONNECTOR, 48MM-61MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.916 SUP Custom 27803010 "224.916 - STAINLESS STEEL REVERE ADJUSTABLE T CONNECTOR, 58MM-71MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.917 SUP Custom 27803010 "224.917 - STAINLESS STEEL REVERE ADJUSTABLE T CONNECTOR, 68MM-81MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.918 SUP Custom 27803010 "224.918 - STAINLESS STEEL REVERE ADJUSTABLE T CONNECTOR, 78MM-91MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.921 SUP Custom 27803010 "224.921 - STAINLESS STEEL REVERE OFFSET LAMINA HOOK, RIGHT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.922 SUP Custom 27803010 "224.922 - STAINLESS STEEL REVERE OFFSET LAMINA HOOK, LEFT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.924 SUP Custom 27803010 "224.924 - STAINLESS STEEL REVERE TRANSVERSE PROCESS HOOK, RIGHT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.925 SUP Custom 27803010 "224.925 - STAINLESS STEEL REVERE TRANSVERSE PROCESS HOOK, LEFT" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.927 SUP Custom 27803010 "224.927 - STAINLESS STEEL REVERE PEDICLE HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.928 SUP Custom 27803010 "224.928 - STAINLESS STEEL REVERE PEDICLE HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.929 SUP Custom 27803010 "224.929 - STAINLESS STEEL REVERE PEDICLE HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.931 SUP Custom 27803010 "224.931 - STAINLESS STEEL REVERE LAMINA HOOK, TRANSVERSE, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.932 SUP Custom 27803010 "224.932 - STAINLESS STEEL REVERE LAMINA HOOK, TRANSVERSE, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.933 SUP Custom 27803010 "224.933 - STAINLESS STEEL REVERE LAMINA HOOK, TRANSVERSE, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.935 SUP Custom 27803010 "224.935 - STAINLESS STEEL REVERE PEDICLE HOOK, TRANSVERSE, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.936 SUP Custom 27803010 "224.936 - STAINLESS STEEL REVERE PEDICLE HOOK, TRANSVERSE, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.937 SUP Custom 27803010 "224.937 - STAINLESS STEEL REVERE PEDICLE HOOK, TRANSVERSE, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.94 SUP Custom 27803010 "224.940 - STAINLESS STEEL REVERE LAMINA HOOK, NARROW, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.941 SUP Custom 27803010 "224.941 - STAINLESS STEEL REVERE LAMINA HOOK, NARROW, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.942 SUP Custom 27803010 "224.942 - STAINLESS STEEL REVERE LAMINA HOOK, NARROW, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.944 SUP Custom 27803010 "224.944 - STAINLESS STEEL REVERE LAMINA HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.945 SUP Custom 27803010 "224.945 - STAINLESS STEEL REVERE LAMINA HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.946 SUP Custom 27803010 "224.946 - STAINLESS STEEL REVERE LAMINA HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.948 SUP Custom 27803010 "224.948 - STAINLESS STEEL REVERE LAMINA HOOK, WIDE, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.949 SUP Custom 27803010 "224.949 - STAINLESS STEEL REVERE LAMINA HOOK, WIDE, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.95 SUP Custom 27803010 "224.950 - STAINLESS STEEL REVERE LAMINA HOOK, WIDE, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.952 SUP Custom 27803010 "224.952 - STAINLESS STEEL REVERE LAMINA HOOK, TALL BODY, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.953 SUP Custom 27803010 "224.953 - STAINLESS STEEL REVERE LAMINA HOOK, TALL BODY, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.954 SUP Custom 27803010 "224.954 - STAINLESS STEEL REVERE LAMINA HOOK, TALL BODY, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.955 SUP Custom 27803010 "224.955 - STAINLESS STEEL REVERE ANGLED LAMINA HOOK, SMALL" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.956 SUP Custom 27803010 "224.956 - STAINLESS STEEL REVERE ANGLED LAMINA HOOK, MEDIUM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.957 SUP Custom 27803010 "224.957 - STAINLESS STEEL REVERE ANGLED LAMINA HOOK, LARGE" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.96 SUP Custom 27803010 "224.960 - STAINLESS STEEL PARALLEL CONNECTOR, 5.5MM TO 5.5MM" BOTH IP/OP "$1,142.50 " $845.45 $0.00 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $847.96 $847.96 $0.00 $0.00 $238.10 $0.00 $0.00 $0.00 $0.00 $571.25 $904.86 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.961 SUP Custom 27803010 "224.961 - STAINLESS STEEL PARALLEL CONNECTOR, 5.5MM TO 5.5MM, WIDE" BOTH IP/OP "$1,142.50 " $845.45 $0.00 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $847.96 $847.96 $0.00 $0.00 $238.10 $0.00 $0.00 $0.00 $0.00 $571.25 $904.86 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.962 SUP Custom 27803010 "224.962 - STAINLESS STEEL ROD TO ROD CLAMP, 5.5MM TO 5.5MM" BOTH IP/OP "$1,142.50 " $845.45 $0.00 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $847.96 $847.96 $0.00 $0.00 $238.10 $0.00 $0.00 $0.00 $0.00 $571.25 $904.86 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.963 SUP Custom 27803010 "224.963 - STAINLESS STEEL ROD TO ROD CLAMP, 5.5MM TO 5.5MM, WIDE" BOTH IP/OP "$1,142.50 " $845.45 $0.00 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $847.96 $847.96 $0.00 $0.00 $238.10 $0.00 $0.00 $0.00 $0.00 $571.25 $904.86 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.964 SUP Custom 27803010 "224.964 - STAINLESS STEEL PARALLEL CONNECTOR CLAMP, 5.5MM TO 5.5MM" BOTH IP/OP "$1,142.50 " $845.45 $0.00 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $847.96 $847.96 $0.00 $0.00 $238.10 $0.00 $0.00 $0.00 $0.00 $571.25 $904.86 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.965 SUP Custom 27803010 "224.965 - STAINLESS STEEL PARALLEL CONNECTOR CLAMP, 5.5MM TO 5.5MM, WI" BOTH IP/OP "$1,142.50 " $845.45 $0.00 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $847.96 $847.96 $0.00 $0.00 $238.10 $0.00 $0.00 $0.00 $0.00 $571.25 $904.86 $914.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.97 SUP Custom 27803010 "224.970 - 5.5MM STAINLESS STEEL OFFSET CONNECTOR, 15MM" BOTH IP/OP "$1,025.00 " $758.50 $0.00 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.76 $760.76 $0.00 $0.00 $213.61 $0.00 $0.00 $0.00 $0.00 $512.50 $811.80 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.971 SUP Custom 27803010 "224.971 - 5.5MMM STAINLESS STEEL OFFSET CONNECTOR, 20MM" BOTH IP/OP "$1,025.00 " $758.50 $0.00 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.76 $760.76 $0.00 $0.00 $213.61 $0.00 $0.00 $0.00 $0.00 $512.50 $811.80 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.972 SUP Custom 27803010 "224.972 - 5.5MM STAINLESS STEEL OFFSET CONNECTOR, 25MM" BOTH IP/OP "$1,025.00 " $758.50 $0.00 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.76 $760.76 $0.00 $0.00 $213.61 $0.00 $0.00 $0.00 $0.00 $512.50 $811.80 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.973 SUP Custom 27803010 "224.973 - 5.5MM STAINLESS STEEL ROD CLAMP, 100MM" BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $0.00 $0.00 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.974 SUP Custom 27803010 "224.974 - 5.5MM STAINLESS STEEL ROD CLAMP, 120MM" BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $0.00 $0.00 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.975 SUP Custom 27803010 "224.975 - 5.5MM STAINLESS STEEL ROD CLAMP, 150MM" BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $0.00 $0.00 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.976 SUP Custom 27803010 "224.976 - 5.5MM STAINLESS STEEL OFFSET CONNECTOR, 30MM" BOTH IP/OP "$1,132.50 " $838.05 $0.00 $906.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $840.54 $840.54 $0.00 $0.00 $236.01 $0.00 $0.00 $0.00 $0.00 $566.25 $896.94 $906.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.977 SUP Custom 27803010 "224.977 - 5.5MM STAINLESS STEEL OFFSET CONNECTOR, 35MM" BOTH IP/OP "$1,132.50 " $838.05 $0.00 $906.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $840.54 $840.54 $0.00 $0.00 $236.01 $0.00 $0.00 $0.00 $0.00 $566.25 $896.94 $906.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.98 SUP Custom 27803010 "224.980 - STAINLESS STEEL IN-LINE CONNECTOR, 5.5MM TO 5.5MM" BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $0.00 $0.00 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.99 SUP Custom 27803010 "224.990 - SS 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 15MM" BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.991 SUP Custom 27803010 "224.991 - SS 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 20MM" BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.992 SUP Custom 27803010 "224.992 - SS 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 25MM" BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.993 SUP Custom 27803010 "224.993 - SS 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 30MM" BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.994 SUP Custom 27803010 "224.994 - SS 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 35MM" BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.995 SUP Custom 27803010 "224.995 - SS 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 100MM" BOTH IP/OP "$1,450.00 " "$1,073.00" $0.00 "$1,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,076.19" "$1,076.19" $0.00 $0.00 $302.18 $0.00 $0.00 $0.00 $0.00 $725.00 "$1,148.40" "$1,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.996 SUP Custom 27803010 "224.996 - SS 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 120MM" BOTH IP/OP "$1,450.00 " "$1,073.00" $0.00 "$1,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,076.19" "$1,076.19" $0.00 $0.00 $302.18 $0.00 $0.00 $0.00 $0.00 $725.00 "$1,148.40" "$1,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.997 SUP Custom 27803010 "224.997 - SS 5.5MM CLOSED OFFSET CONNECTOR, 5.5MM ROD, 150MM" BOTH IP/OP "$1,450.00 " "$1,073.00" $0.00 "$1,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,076.19" "$1,076.19" $0.00 $0.00 $302.18 $0.00 $0.00 $0.00 $0.00 $725.00 "$1,148.40" "$1,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 225.007 SUP HCPCS C1713 225.007 - PLATE BRD 90MM SS 3.5MM SCR 7 HOLE LC DCP BONE ORTH NONSTRL BOTH IP/OP $377.43 $279.30 $0.00 $301.94 $169.84 $169.84 $0.00 $0.00 $0.00 $78.66 $280.12 $280.12 $0.00 $0.00 $78.66 $0.00 $223.25 $223.25 $0.00 $188.71 $298.92 $301.94 $0.00 $0.00 $59.07 $0.00 $0.00 $60.09 $0.00 $0.00 $0.00 $0.00 $0.00 225.008 SUP HCPCS C1713 225.008 - PLATE BRD 103MM SS 3.5MM SCR 8 HOLE LC DCP BONE ORTH NONSTRL BOTH IP/OP $393.73 $291.36 $0.00 $314.98 $177.18 $177.18 $0.00 $0.00 $0.00 $82.06 $292.22 $292.22 $0.00 $0.00 $82.05 $0.00 $232.89 $232.89 $0.00 $196.86 $311.83 $314.98 $0.00 $0.00 $61.62 $0.00 $0.00 $62.68 $0.00 $0.00 $0.00 $0.00 $0.00 225.009 SUP HCPCS C1713 225.009 - PLATE BRD SS 3.5MM SCR 9 HOLE LCP BONE ORTH NONSTRL BOTH IP/OP $412.38 $305.16 $0.00 $329.90 $185.57 $185.57 $0.00 $0.00 $0.00 $85.95 $306.06 $306.06 $0.00 $0.00 $85.94 $0.00 $243.92 $243.92 $0.00 $206.19 $326.60 $329.90 $0.00 $0.00 $64.54 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $0.00 225.01 SUP HCPCS C1713 225.010 - PLATE BRD 129MM SS 3.5MM SCR 10 HOLE LC DCP BONE ORTH BOTH IP/OP $417.05 $308.62 $0.00 $333.64 $187.67 $187.67 $0.00 $0.00 $0.00 $86.92 $309.53 $309.53 $0.00 $0.00 $86.91 $0.00 $246.69 $246.69 $0.00 $208.53 $330.30 $333.64 $0.00 $0.00 $65.27 $0.00 $0.00 $66.39 $0.00 $0.00 $0.00 $0.00 $0.00 225.011 SUP HCPCS C1713 225.011 - PLATE BRD 142MM SS 3.5MM SCR 11 HOLE LC DCP BONE ORTH BOTH IP/OP $435.70 $322.42 $0.00 $348.56 $196.07 $196.07 $0.00 $0.00 $0.00 $90.81 $323.38 $323.38 $0.00 $0.00 $90.80 $0.00 $257.72 $257.72 $0.00 $217.85 $345.07 $348.56 $0.00 $0.00 $68.19 $0.00 $0.00 $69.36 $0.00 $0.00 $0.00 $0.00 $0.00 225.012 SUP HCPCS C1713 225.012 - PLATE BRD 155MM SS 3.5MM SCR 12 HOLE LC DCP BONE ORTH BOTH IP/OP $465.95 $344.80 $0.00 $372.76 $209.68 $209.68 $0.00 $0.00 $0.00 $97.12 $345.83 $345.83 $0.00 $0.00 $97.10 $0.00 $275.61 $275.61 $0.00 $232.98 $369.03 $372.76 $0.00 $0.00 $72.92 $0.00 $0.00 $74.18 $0.00 $0.00 $0.00 $0.00 $0.00 225.013 SUP HCPCS C1713 225.013 - PLATE BRD 168MM SS 3.5MM SCR 13 HOLE LC DCP BONE ORTH BOTH IP/OP $628.05 $464.76 $0.00 $502.44 $282.62 $282.62 $0.00 $0.00 $0.00 $130.90 $466.14 $466.14 $0.00 $0.00 $130.89 $0.00 $371.49 $371.49 $0.00 $314.03 $497.42 $502.44 $0.00 $0.00 $98.29 $0.00 $0.00 $99.99 $0.00 $0.00 $0.00 $0.00 $0.00 225.014 SUP HCPCS C1713 225.014 - PLATE BRD 181MM SS 3.5MM SCR 14 HOLE LC DCP BONE RIGHT BOTH IP/OP $709.28 $524.87 $0.00 $567.42 $319.17 $319.17 $0.00 $0.00 $0.00 $147.83 $526.42 $526.42 $0.00 $0.00 $147.81 $0.00 $419.54 $419.54 $0.00 $354.64 $561.75 $567.42 $0.00 $0.00 $111.00 $0.00 $0.00 $112.92 $0.00 $0.00 $0.00 $0.00 $0.00 225.015 SUP HCPCS C1713 225.015 - PLATE BRD 194MM SS 3.5MM SCR 15 HOLE LC DCP BONE ORTH BOTH IP/OP $788.35 $583.38 $0.00 $630.68 $354.76 $354.76 $0.00 $0.00 $0.00 $164.31 $585.11 $585.11 $0.00 $0.00 $164.29 $0.00 $466.31 $466.31 $0.00 $394.18 $624.37 $630.68 $0.00 $0.00 $123.38 $0.00 $0.00 $125.51 $0.00 $0.00 $0.00 $0.00 $0.00 225.016 SUP HCPCS C1713 225.016 - PLATE BRD 207MM SS 3.5MM SCR 16 HOLE LC DCP BONE ORTH BOTH IP/OP $869.60 $643.50 $0.00 $695.68 $391.32 $391.32 $0.00 $0.00 $0.00 $181.25 $645.42 $645.42 $0.00 $0.00 $181.22 $0.00 $514.37 $514.37 $0.00 $434.80 $688.72 $695.68 $0.00 $0.00 $136.09 $0.00 $0.00 $138.44 $0.00 $0.00 $0.00 $0.00 $0.00 225.017 SUP HCPCS C1713 225.017 - PLATE BRD 220MM SS 3.5MM SCR 17 HOLE LC DCP BONE ORTH BOTH IP/OP $948.65 $702.00 $0.00 $758.92 $426.89 $426.89 $0.00 $0.00 $0.00 $197.72 $704.09 $704.09 $0.00 $0.00 $197.70 $0.00 $561.13 $561.13 $0.00 $474.33 $751.33 $758.92 $0.00 $0.00 $148.46 $0.00 $0.00 $151.03 $0.00 $0.00 $0.00 $0.00 $0.00 225.018 SUP HCPCS C1713 225.018 - PLATE BRD 233MM SS 3.5MM SCR 18 HOLE LC DCP BONE ORTH BOTH IP/OP "$1,029.90 " $762.13 $0.00 $823.92 $463.46 $463.46 $0.00 $0.00 $0.00 $214.66 $764.39 $764.39 $0.00 $0.00 $214.63 $0.00 $609.19 $609.19 $0.00 $514.95 $815.68 $823.92 $0.00 $0.00 $161.18 $0.00 $0.00 $163.96 $0.00 $0.00 $0.00 $0.00 $0.00 225.02 SUP HCPCS C1713 225.020 - PLATE BRD 259MM SS 3.5MM SCR 20 HOLE LC DCP BONE ORTH BOTH IP/OP "$1,169.53 " $865.45 $0.00 $935.62 $526.29 $526.29 $0.00 $0.00 $0.00 $243.76 $868.02 $868.02 $0.00 $0.00 $243.73 $0.00 $691.77 $691.77 $0.00 $584.76 $926.27 $935.62 $0.00 $0.00 $183.03 $0.00 $0.00 $186.19 $0.00 $0.00 $0.00 $0.00 $0.00 225.022 SUP HCPCS C1713 225.022 - PLATE BRD 285MM SS 3.5MM SCR 22 HOLE LC DCP BONE ORTH BOTH IP/OP "$1,279.00 " $946.46 $0.00 "$1,023.20" $575.55 $575.55 $0.00 $0.00 $0.00 $266.58 $949.27 $949.27 $0.00 $0.00 $266.54 $0.00 $756.53 $756.53 $0.00 $639.50 "$1,012.97" "$1,023.20" $0.00 $0.00 $200.16 $0.00 $0.00 $203.62 $0.00 $0.00 $0.00 $0.00 $0.00 226.06 SUP HCPCS C1713 226.06 - PLATE BN BRD 103X16X4.8MM NS DCP 6 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $416.08 $307.90 $0.00 $323.18 $181.79 $181.79 $0.00 $0.00 $0.00 $86.72 $308.81 $308.81 $0.00 $0.00 $86.71 $0.00 $246.11 $246.11 $0.00 $201.99 $319.95 $323.18 $0.00 $0.00 $61.38 $0.00 $0.00 $64.31 $0.00 $0.00 $0.00 $0.00 $0.00 226.07 SUP HCPCS C1713 226.07 - PLATE BN BRD 119X16X4.8MM NS DCP 7 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $427.33 $316.22 $0.00 $331.90 $186.69 $186.69 $0.00 $0.00 $0.00 $89.07 $317.16 $317.16 $0.00 $0.00 $89.05 $0.00 $252.76 $252.76 $0.00 $207.44 $328.58 $331.90 $0.00 $0.00 $63.04 $0.00 $0.00 $66.05 $0.00 $0.00 $0.00 $0.00 $0.00 226.08 SUP HCPCS C1713 226.08 - PLATE BONE BROAD 135X16X4.8MM 8 HOLE DCP STAINLESS STEEL BOTH IP/OP $503.60 $372.66 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $104.96 $373.77 $373.77 $0.00 $0.00 $104.95 $0.00 $297.88 $297.88 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 226.09 SUP HCPCS C1713 226.09 - PLATE BN BRD 151X16X4.8MM NS DCP 9 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 226.1 SUP HCPCS C1713 226.10 - PLATE BN BRD 167X16X4.8MM NS DCP 10 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $503.60 $372.66 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $104.96 $373.77 $373.77 $0.00 $0.00 $104.95 $0.00 $297.88 $297.88 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 226.12 SUP HCPCS C1713 226.12 - PLATE BN BRD 199X16X4.8MM NS DCP 12 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 226.14 SUP HCPCS C1713 226.14 - PLATE BONE BROAD 231X16X4.8MM 14 HOLE DCP STAINLESS STEEL BOTH IP/OP $530.90 $392.87 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $110.65 $394.03 $394.03 $0.00 $0.00 $110.64 $0.00 $314.03 $314.03 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 226.16 SUP HCPCS C1713 226.16 - PLATE BONE BROAD 4.5MM 263X16X4.8MM 16 HOLE DCP STAINLESS BOTH IP/OP $563.13 $416.72 $0.00 $450.50 $253.41 $253.41 $0.00 $0.00 $0.00 $117.37 $417.95 $417.95 $0.00 $0.00 $117.36 $0.00 $333.09 $333.09 $0.00 $281.56 $446.00 $450.50 $0.00 $0.00 $88.13 $0.00 $0.00 $89.65 $0.00 $0.00 $0.00 $0.00 $0.00 226.2 SUP HCPCS C1713 226.20 - PLATE BN BRD 326X16X4.8MM NS DCP 20 HL SS 4.5MM SCR LG FRAG BOTH IP/OP $918.48 $679.68 $0.00 $734.78 $413.31 $413.31 $0.00 $0.00 $0.00 $191.43 $681.69 $681.69 $0.00 $0.00 $191.41 $0.00 $543.28 $543.28 $0.00 $459.24 $727.44 $734.78 $0.00 $0.00 $139.55 $0.00 $0.00 $146.22 $0.00 $0.00 $0.00 $0.00 $0.00 226.22 SUP HCPCS C1713 226.22 - PLATE BONE BROAD 358MM 22 HOLE DCP STAINLESS STEEL BOTH IP/OP $968.58 $716.75 $0.00 $774.86 $435.86 $435.86 $0.00 $0.00 $0.00 $201.88 $718.88 $718.88 $0.00 $0.00 $201.85 $0.00 $572.91 $572.91 $0.00 $484.29 $767.12 $774.86 $0.00 $0.00 $151.58 $0.00 $0.00 $154.20 $0.00 $0.00 $0.00 $0.00 $0.00 226.24 SUP HCPCS C1713 226.24 - PLATE BONE BROAD 390MM 24 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,037.48 " $767.74 $0.00 $829.98 $466.86 $466.86 $0.00 $0.00 $0.00 $216.24 $770.01 $770.01 $0.00 $0.00 $216.21 $0.00 $613.67 $613.67 $0.00 $518.74 $821.68 $829.98 $0.00 $0.00 $162.36 $0.00 $0.00 $165.17 $0.00 $0.00 $0.00 $0.00 $0.00 226.56 SUP HCPCS C1713 226.56 - PLATE BN BRD 106X17.5X5.2MM NS LC DCP 6 HL SS 4.5MM SCR LG BOTH IP/OP $489.18 $361.99 $0.00 $379.94 $213.72 $213.72 $0.00 $0.00 $0.00 $101.96 $363.07 $363.07 $0.00 $0.00 $101.94 $0.00 $289.35 $289.35 $0.00 $237.46 $376.14 $379.94 $0.00 $0.00 $72.16 $0.00 $0.00 $75.61 $0.00 $0.00 $0.00 $0.00 $0.00 226.561 SUP HCPCS C1713 226.561 - PLATE BN BRD 116X17.5X5.2MM NS LCP CMBN 6 HL LMT CNTCT TPR BOTH IP/OP $784.38 $580.44 $0.00 $609.22 $342.69 $342.69 $0.00 $0.00 $0.00 $163.48 $582.16 $582.16 $0.00 $0.00 $163.46 $0.00 $463.96 $463.96 $0.00 $380.76 $603.13 $609.22 $0.00 $0.00 $115.71 $0.00 $0.00 $121.23 $0.00 $0.00 $0.00 $0.00 $0.00 226.57 SUP HCPCS C1713 226.57 - PLATE BN BRD 124X17.5X5.2MM NS LC DCP 7 HL SS 4.5MM SCR LG BOTH IP/OP $529.95 $392.16 $0.00 $411.60 $231.53 $231.53 $0.00 $0.00 $0.00 $110.45 $393.33 $393.33 $0.00 $0.00 $110.44 $0.00 $313.47 $313.47 $0.00 $257.25 $407.48 $411.60 $0.00 $0.00 $78.18 $0.00 $0.00 $81.91 $0.00 $0.00 $0.00 $0.00 $0.00 226.571 SUP HCPCS C1713 226.571 - PLATE BN BRD 134MM NS LCP CMBN 7 HL SS 4.5MM SCR LG FRAG SET BOTH IP/OP $833.58 $616.85 $0.00 $647.44 $364.19 $364.19 $0.00 $0.00 $0.00 $173.74 $618.68 $618.68 $0.00 $0.00 $173.72 $0.00 $493.06 $493.06 $0.00 $404.65 $640.97 $647.44 $0.00 $0.00 $122.97 $0.00 $0.00 $128.84 $0.00 $0.00 $0.00 $0.00 $0.00 226.58 SUP HCPCS C1713 226.58 - PLATE BN BRD 142X17.5X5.2MM NS LC DCP 8 HL SS 4.5MM SCR LG BOTH IP/OP $588.98 $435.85 $0.00 $457.46 $257.32 $257.32 $0.00 $0.00 $0.00 $122.76 $437.14 $437.14 $0.00 $0.00 $122.74 $0.00 $348.38 $348.38 $0.00 $285.91 $452.89 $457.46 $0.00 $0.00 $86.88 $0.00 $0.00 $91.03 $0.00 $0.00 $0.00 $0.00 $0.00 226.581 SUP HCPCS C1713 226.581 - PLATE BN BRD 152MM NS LCP CMBN 8 HL SS 4.5MM SCR LG FRAG SET BOTH IP/OP "$1,019.13 " $754.16 $0.00 $791.56 $445.25 $445.25 $0.00 $0.00 $0.00 $212.41 $756.39 $756.39 $0.00 $0.00 $212.39 $0.00 $602.81 $602.81 $0.00 $494.73 $783.64 $791.56 $0.00 $0.00 $150.34 $0.00 $0.00 $157.52 $0.00 $0.00 $0.00 $0.00 $0.00 226.59 SUP HCPCS C1713 226.59 - PLATE BN BRD 160X17.5X5.2MM NS LC DCP 9 HL SS 4.5MM SCR LG BOTH IP/OP $588.98 $435.85 $0.00 $457.46 $257.32 $257.32 $0.00 $0.00 $0.00 $122.76 $437.14 $437.14 $0.00 $0.00 $122.74 $0.00 $348.38 $348.38 $0.00 $285.91 $452.89 $457.46 $0.00 $0.00 $86.88 $0.00 $0.00 $91.03 $0.00 $0.00 $0.00 $0.00 $0.00 226.591 SUP HCPCS C1713 226.591 - PLATE BN BRD 170X17.5X5.2MM NS LCP CMBN 9 HL LMT CNTCT TPR BOTH IP/OP "$1,102.08 " $815.54 $0.00 $855.98 $481.49 $481.49 $0.00 $0.00 $0.00 $229.70 $817.96 $817.96 $0.00 $0.00 $229.67 $0.00 $651.88 $651.88 $0.00 $534.99 $847.42 $855.98 $0.00 $0.00 $162.57 $0.00 $0.00 $170.34 $0.00 $0.00 $0.00 $0.00 $0.00 226.6 SUP HCPCS C1713 226.60 - PLATE BN BRD 178X17.5X5.2MM NS LC DCP 10 HL SS 4.5MM SCR LG BOTH IP/OP $571.83 $423.15 $0.00 $457.46 $257.32 $257.32 $0.00 $0.00 $0.00 $119.18 $424.41 $424.41 $0.00 $0.00 $119.17 $0.00 $338.23 $338.23 $0.00 $285.91 $452.89 $457.46 $0.00 $0.00 $86.88 $0.00 $0.00 $91.03 $0.00 $0.00 $0.00 $0.00 $0.00 226.601 SUP HCPCS C1713 226.601 - PLATE BN BRD 188X17.5X5.2MM NS LCP CMBN 10 HL LMT CNTCT TPR BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 226.61 SUP HCPCS C1713 226.61 - PLATE BN BRD 196X17.5X5.2MM NS LC DCP 11 HL SS 4.5MM SCR LG BOTH IP/OP $632.55 $468.09 $0.00 $491.32 $276.37 $276.37 $0.00 $0.00 $0.00 $131.84 $469.48 $469.48 $0.00 $0.00 $131.82 $0.00 $374.15 $374.15 $0.00 $307.08 $486.41 $491.32 $0.00 $0.00 $93.31 $0.00 $0.00 $97.77 $0.00 $0.00 $0.00 $0.00 $0.00 226.611 SUP HCPCS C1713 226.611 - PLATE BN BRD 206X17.5X5.2MM NS LCP CMBN 11 HL LMT CNTCT TPR BOTH IP/OP "$1,262.30 " $934.10 $0.00 $980.44 $551.50 $551.50 $0.00 $0.00 $0.00 $263.09 $936.88 $936.88 $0.00 $0.00 $263.06 $0.00 $746.65 $746.65 $0.00 $612.78 $970.64 $980.44 $0.00 $0.00 $186.21 $0.00 $0.00 $195.11 $0.00 $0.00 $0.00 $0.00 $0.00 226.62 SUP HCPCS C1713 226.62 - PLATE BN BRD 214X17.5X5.2MM NS LC DCP 12 HL SS 4.5MM SCR LG BOTH IP/OP $632.55 $468.09 $0.00 $491.32 $276.37 $276.37 $0.00 $0.00 $0.00 $131.84 $469.48 $469.48 $0.00 $0.00 $131.82 $0.00 $374.15 $374.15 $0.00 $307.08 $486.41 $491.32 $0.00 $0.00 $93.31 $0.00 $0.00 $97.77 $0.00 $0.00 $0.00 $0.00 $0.00 226.621 SUP HCPCS C1713 226.621 - PLATE BN BRD 224X17.5X5.2MM NS LCP CMBN 12 HL LMT CNTCT TPR BOTH IP/OP "$1,339.63 " $991.33 $0.00 "$1,040.48" $585.27 $585.27 $0.00 $0.00 $0.00 $279.21 $994.27 $994.27 $0.00 $0.00 $279.18 $0.00 $792.39 $792.39 $0.00 $650.30 "$1,030.08" "$1,040.48" $0.00 $0.00 $197.62 $0.00 $0.00 $207.06 $0.00 $0.00 $0.00 $0.00 $0.00 226.622 SUP HCPCS C1713 226.622 - PLATE BN BRD CRV 229X17.5X5.2MM NS LCP CMBN 12 HL LMT CNTCT BOTH IP/OP "$1,339.63 " $991.33 $0.00 "$1,040.48" $585.27 $585.27 $0.00 $0.00 $0.00 $279.21 $994.27 $994.27 $0.00 $0.00 $279.18 $0.00 $792.39 $792.39 $0.00 $650.30 "$1,030.08" "$1,040.48" $0.00 $0.00 $197.62 $0.00 $0.00 $207.06 $0.00 $0.00 $0.00 $0.00 $0.00 226.632 SUP HCPCS C1713 226.632 - PLATE BONE BROAD CURVE 247MM 13 HOLE LCP STAINLESS STEEL BOTH IP/OP "$1,419.75 " "$1,050.62" $0.00 "$1,102.72" $620.28 $620.28 $0.00 $0.00 $0.00 $295.91 "$1,053.74" "$1,053.74" $0.00 $0.00 $295.88 $0.00 $839.78 $839.78 $0.00 $689.20 "$1,091.69" "$1,102.72" $0.00 $0.00 $209.44 $0.00 $0.00 $219.44 $0.00 $0.00 $0.00 $0.00 $0.00 226.64 SUP HCPCS C1713 226.64 - PLATE BN BRD 250X17.5X5.2MM NS LC DCP 14 HL SS 4.5MM SCR LG BOTH IP/OP $632.55 $468.09 $0.00 $491.32 $276.37 $276.37 $0.00 $0.00 $0.00 $131.84 $469.48 $469.48 $0.00 $0.00 $131.82 $0.00 $374.15 $374.15 $0.00 $307.08 $486.41 $491.32 $0.00 $0.00 $93.31 $0.00 $0.00 $97.77 $0.00 $0.00 $0.00 $0.00 $0.00 226.641 SUP HCPCS C1713 226.641 - PLATE BN BRD 260X17.5X5.2MM NS LCP CMBN 14 HL LMT CNTCT TPR BOTH IP/OP "$1,491.45 " "$1,103.67" $0.00 "$1,158.40" $651.60 $651.60 $0.00 $0.00 $0.00 $310.86 "$1,106.95" "$1,106.95" $0.00 $0.00 $310.82 $0.00 $882.19 $882.19 $0.00 $724.00 "$1,146.82" "$1,158.40" $0.00 $0.00 $220.01 $0.00 $0.00 $230.52 $0.00 $0.00 $0.00 $0.00 $0.00 226.642 SUP HCPCS C1713 226.642 - PLATE BN BRD CRV 265X17.5X5.2MM NS LCP CMBN 14 HL LMT CNTCT BOTH IP/OP "$1,491.45 " "$1,103.67" $0.00 "$1,158.40" $651.60 $651.60 $0.00 $0.00 $0.00 $310.86 "$1,106.95" "$1,106.95" $0.00 $0.00 $310.82 $0.00 $882.19 $882.19 $0.00 $724.00 "$1,146.82" "$1,158.40" $0.00 $0.00 $220.01 $0.00 $0.00 $230.52 $0.00 $0.00 $0.00 $0.00 $0.00 226.652 SUP HCPCS C1713 226.652 - PLATE BONE BROAD CURVE 282MM 15 HOLE LCP STAINLESS STEEL BOTH IP/OP "$1,655.90 " "$1,225.37" $0.00 "$1,286.14" $723.45 $723.45 $0.00 $0.00 $0.00 $345.13 "$1,229.01" "$1,229.01" $0.00 $0.00 $345.09 $0.00 $979.46 $979.46 $0.00 $803.84 "$1,273.28" "$1,286.14" $0.00 $0.00 $244.27 $0.00 $0.00 $255.94 $0.00 $0.00 $0.00 $0.00 $0.00 226.66 SUP HCPCS C1713 226.66 - PLATE BN BRD 286X17.5X5.2MM NS LC DCP 16 HL SS 4.5MM SCR LG BOTH IP/OP $718.30 $531.54 $0.00 $557.90 $313.82 $313.82 $0.00 $0.00 $0.00 $149.71 $533.12 $533.12 $0.00 $0.00 $149.69 $0.00 $424.87 $424.87 $0.00 $348.69 $552.32 $557.90 $0.00 $0.00 $105.96 $0.00 $0.00 $111.02 $0.00 $0.00 $0.00 $0.00 $0.00 226.661 SUP HCPCS C1713 226.661 - PLATE BN BRD 296X17.5X5.2MM NS LCP CMBN 16 HL LMT CNTCT TPR BOTH IP/OP "$1,811.95 " "$1,340.84" $0.00 "$1,407.34" $791.63 $791.63 $0.00 $0.00 $0.00 $377.66 "$1,344.83" "$1,344.83" $0.00 $0.00 $377.61 $0.00 "$1,071.77" "$1,071.77" $0.00 $879.59 "$1,393.27" "$1,407.34" $0.00 $0.00 $267.29 $0.00 $0.00 $280.06 $0.00 $0.00 $0.00 $0.00 $0.00 226.662 SUP HCPCS C1713 226.662 - PLATE BN BRD CRV 300X17.5X5.2MM NS LCP CMBN 16 HL LMT CNTCT BOTH IP/OP "$1,811.95 " "$1,340.84" $0.00 "$1,407.34" $791.63 $791.63 $0.00 $0.00 $0.00 $377.66 "$1,344.83" "$1,344.83" $0.00 $0.00 $377.61 $0.00 "$1,071.77" "$1,071.77" $0.00 $879.59 "$1,393.27" "$1,407.34" $0.00 $0.00 $267.29 $0.00 $0.00 $280.06 $0.00 $0.00 $0.00 $0.00 $0.00 226.672 SUP HCPCS C1713 226.672 - PLATE BONE BROAD CURVE 318MM 17 HOLE LCP STAINLESS STEEL BOTH IP/OP "$1,897.68 " "$1,404.28" $0.00 "$1,473.94" $829.09 $829.09 $0.00 $0.00 $0.00 $395.52 "$1,408.45" "$1,408.45" $0.00 $0.00 $395.48 $0.00 "$1,122.47" "$1,122.47" $0.00 $921.21 "$1,459.20" "$1,473.94" $0.00 $0.00 $279.94 $0.00 $0.00 $293.31 $0.00 $0.00 $0.00 $0.00 $0.00 226.68 SUP HCPCS C1713 226.68 - PLATE BN BRD 332X17.5X5.2MM NS LC DCP 18 HL SS 4.5MM SCR LG BOTH IP/OP $788.83 $583.73 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $164.41 $585.47 $585.47 $0.00 $0.00 $164.39 $0.00 $466.59 $466.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 226.681 SUP HCPCS C1713 226.681 - PLATE BONE BROAD 332X17.5X5.2MM 18 HOLE LCP STAINLESS STEEL BOTH IP/OP "$2,204.13 " "$1,631.06" $0.00 "$1,711.94" $962.97 $962.97 $0.00 $0.00 $0.00 $459.39 "$1,635.90" "$1,635.90" $0.00 $0.00 $459.34 $0.00 "$1,303.74" "$1,303.74" $0.00 "$1,069.96" "$1,694.82" "$1,711.94" $0.00 $0.00 $325.14 $0.00 $0.00 $340.68 $0.00 $0.00 $0.00 $0.00 $0.00 226.682 SUP HCPCS C1713 226.682 - PLATE BN BRD CRV 336X17.5X5.2MM NS LCP CMBN 18 HL LMT CNTCT BOTH IP/OP "$2,067.78 " "$1,530.16" $0.00 "$1,606.04" $903.40 $903.40 $0.00 $0.00 $0.00 $430.98 "$1,534.70" "$1,534.70" $0.00 $0.00 $430.92 $0.00 "$1,223.09" "$1,223.09" $0.00 "$1,003.78" "$1,589.98" "$1,606.04" $0.00 $0.00 $305.03 $0.00 $0.00 $319.60 $0.00 $0.00 $0.00 $0.00 $0.00 226.7 SUP HCPCS C1713 226.70 - PLATE BONE BROAD 358X17.5X5.2MM 20 HOLE LC-DCP STAINLESS BOTH IP/OP "$1,155.95 " $855.40 $0.00 $924.76 $520.18 $520.18 $0.00 $0.00 $0.00 $240.93 $857.95 $857.95 $0.00 $0.00 $240.90 $0.00 $683.74 $683.74 $0.00 $577.98 $915.51 $924.76 $0.00 $0.00 $175.64 $0.00 $0.00 $184.03 $0.00 $0.00 $0.00 $0.00 $0.00 226.701 SUP HCPCS C1713 226.701 - PLATE BONE BROAD 368MM 20 HOLE LCP STAINLESS STEEL BOTH IP/OP "$2,436.08 " "$1,802.70" $0.00 "$1,892.08" "$1,064.30" "$1,064.30" $0.00 $0.00 $0.00 $507.74 "$1,808.05" "$1,808.05" $0.00 $0.00 $507.68 $0.00 "$1,440.94" "$1,440.94" $0.00 "$1,182.55" "$1,873.16" "$1,892.08" $0.00 $0.00 $359.36 $0.00 $0.00 $376.52 $0.00 $0.00 $0.00 $0.00 $0.00 226.72 SUP HCPCS C1713 226.72 - PLATE BONE BROAD 394X17.5X5.2MM 22 HOLE LC-DCP STAINLESS BOTH IP/OP "$1,209.73 " $895.20 $0.00 $967.78 $544.38 $544.38 $0.00 $0.00 $0.00 $252.14 $897.86 $897.86 $0.00 $0.00 $252.11 $0.00 $715.55 $715.55 $0.00 $604.86 $958.11 $967.78 $0.00 $0.00 $189.32 $0.00 $0.00 $192.59 $0.00 $0.00 $0.00 $0.00 $0.00 226.721 SUP HCPCS C1713 226.721 - PLATE BONE BROAD 404MM 22 HOLE LCP STAINLESS STEEL BOTH IP/OP "$2,669.40 " "$1,975.36" $0.00 "$2,073.32" "$1,166.24" "$1,166.24" $0.00 $0.00 $0.00 $556.37 "$1,981.23" "$1,981.23" $0.00 $0.00 $556.30 $0.00 "$1,316.01" "$1,316.01" $0.00 "$1,295.83" "$2,052.59" "$2,073.32" $0.00 $0.00 $393.78 $0.00 $0.00 $412.59 $0.00 $0.00 $0.00 $0.00 $0.00 227.11 SUP HCPCS C1713 227.11 - PLATE BONE BROAD 179MM 10 HOLE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $695.63 $514.77 $0.00 $556.50 $313.03 $313.03 $0.00 $0.00 $0.00 $144.99 $516.29 $516.29 $0.00 $0.00 $144.97 $0.00 $411.46 $411.46 $0.00 $347.81 $550.94 $556.50 $0.00 $0.00 $108.87 $0.00 $0.00 $110.74 $0.00 $0.00 $0.00 $0.00 $0.00 227.13 SUP HCPCS C1713 227.13 - PLATE BONE BROAD 199MM 10 HOLE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $777.78 $575.56 $0.00 $622.22 $350.00 $350.00 $0.00 $0.00 $0.00 $162.11 $577.26 $577.26 $0.00 $0.00 $162.09 $0.00 $460.05 $460.05 $0.00 $388.89 $616.00 $622.22 $0.00 $0.00 $121.72 $0.00 $0.00 $123.82 $0.00 $0.00 $0.00 $0.00 $0.00 227.14 SUP HCPCS C1713 227.14 - PLATE BONE BROAD 209MM 10 HOLE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $777.78 $575.56 $0.00 $622.22 $350.00 $350.00 $0.00 $0.00 $0.00 $162.11 $577.26 $577.26 $0.00 $0.00 $162.09 $0.00 $460.05 $460.05 $0.00 $388.89 $616.00 $622.22 $0.00 $0.00 $121.72 $0.00 $0.00 $123.82 $0.00 $0.00 $0.00 $0.00 $0.00 227.18 SUP HCPCS C1713 227.18 - PLATE BONE BROAD 249MM 10 HOLE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $809.58 $599.09 $0.00 $647.66 $364.31 $364.31 $0.00 $0.00 $0.00 $168.74 $600.87 $600.87 $0.00 $0.00 $168.72 $0.00 $478.86 $478.86 $0.00 $404.79 $641.19 $647.66 $0.00 $0.00 $126.70 $0.00 $0.00 $128.88 $0.00 $0.00 $0.00 $0.00 $0.00 227.81 SUP HCPCS C1713 227.81 - PLATE BONE BROAD 135MM 8 HOLE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $674.43 $499.08 $0.00 $539.54 $303.49 $303.49 $0.00 $0.00 $0.00 $140.57 $500.56 $500.56 $0.00 $0.00 $140.55 $0.00 $398.92 $398.92 $0.00 $337.21 $534.15 $539.54 $0.00 $0.00 $105.55 $0.00 $0.00 $107.37 $0.00 $0.00 $0.00 $0.00 $0.00 227.83 SUP HCPCS C1713 227.83 - PLATE BONE BROAD 155MM 8 HOLE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $674.43 $499.08 $0.00 $539.54 $303.49 $303.49 $0.00 $0.00 $0.00 $140.57 $500.56 $500.56 $0.00 $0.00 $140.55 $0.00 $398.92 $398.92 $0.00 $337.21 $534.15 $539.54 $0.00 $0.00 $105.55 $0.00 $0.00 $107.37 $0.00 $0.00 $0.00 $0.00 $0.00 227.84 SUP HCPCS C1713 227.84 - PLATE BONE BROAD 185MM 8 HOLE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $674.43 $499.08 $0.00 $539.54 $303.49 $303.49 $0.00 $0.00 $0.00 $140.57 $500.56 $500.56 $0.00 $0.00 $140.55 $0.00 $398.92 $398.92 $0.00 $337.21 $534.15 $539.54 $0.00 $0.00 $105.55 $0.00 $0.00 $107.37 $0.00 $0.00 $0.00 $0.00 $0.00 228.85 SUP HCPCS C1713 228.85 - PLATE BONE NARROW 175MM 8 HOLE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $502.18 $371.61 $0.00 $401.74 $225.98 $225.98 $0.00 $0.00 $0.00 $104.67 $372.71 $372.71 $0.00 $0.00 $104.65 $0.00 $297.04 $297.04 $0.00 $251.09 $397.73 $401.74 $0.00 $0.00 $78.59 $0.00 $0.00 $79.95 $0.00 $0.00 $0.00 $0.00 $0.00 229.33 SUP HCPCS C1713 229.33 - PLATE BN STRG 45X12X3MM NS LC DCP 3 HL RECON SS 4.5MM CORT BOTH IP/OP $671.93 $497.23 $0.00 $521.88 $293.56 $293.56 $0.00 $0.00 $0.00 $140.05 $498.70 $498.70 $0.00 $0.00 $140.03 $0.00 $397.44 $397.44 $0.00 $326.18 $516.66 $521.88 $0.00 $0.00 $99.12 $0.00 $0.00 $103.85 $0.00 $0.00 $0.00 $0.00 $0.00 229.331 SUP HCPCS C1713 229.331 - PLATE BONE 56MM 3 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP $802.65 $593.96 $0.00 $623.42 $350.67 $350.67 $0.00 $0.00 $0.00 $167.29 $595.73 $595.73 $0.00 $0.00 $167.27 $0.00 $474.77 $474.77 $0.00 $389.64 $617.19 $623.42 $0.00 $0.00 $118.40 $0.00 $0.00 $124.06 $0.00 $0.00 $0.00 $0.00 $0.00 229.34 SUP HCPCS C1713 229.34 - PLATE BN STRG 61X12X3MM NS LC DCP 4 HL RECON SS 4.5MM CORT BOTH IP/OP $700.03 $518.02 $0.00 $543.72 $305.84 $305.84 $0.00 $0.00 $0.00 $145.90 $519.56 $519.56 $0.00 $0.00 $145.89 $0.00 $414.06 $414.06 $0.00 $339.83 $538.28 $543.72 $0.00 $0.00 $103.27 $0.00 $0.00 $108.20 $0.00 $0.00 $0.00 $0.00 $0.00 229.341 SUP HCPCS C1713 229.341 - PLATE BONE 75MM 4 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP $840.60 $622.04 $0.00 $652.90 $367.26 $367.26 $0.00 $0.00 $0.00 $175.20 $623.89 $623.89 $0.00 $0.00 $175.18 $0.00 $497.21 $497.21 $0.00 $408.06 $646.37 $652.90 $0.00 $0.00 $124.00 $0.00 $0.00 $129.93 $0.00 $0.00 $0.00 $0.00 $0.00 229.35 SUP HCPCS C1713 229.35 - PLATE BONE STR 77X12X3MM 5 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP $761.88 $563.79 $0.00 $591.76 $332.87 $332.87 $0.00 $0.00 $0.00 $158.79 $565.46 $565.46 $0.00 $0.00 $158.77 $0.00 $450.65 $450.65 $0.00 $369.85 $585.84 $591.76 $0.00 $0.00 $112.39 $0.00 $0.00 $117.76 $0.00 $0.00 $0.00 $0.00 $0.00 229.351 SUP HCPCS C1713 229.351 - PLATE BONE 94MM 5 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP $908.08 $671.98 $0.00 $705.30 $396.73 $396.73 $0.00 $0.00 $0.00 $189.27 $673.97 $673.97 $0.00 $0.00 $189.24 $0.00 $537.13 $537.13 $0.00 $440.81 $698.25 $705.30 $0.00 $0.00 $133.96 $0.00 $0.00 $140.35 $0.00 $0.00 $0.00 $0.00 $0.00 229.36 SUP HCPCS C1713 229.36 - PLATE BN 93X12X3MM NS LC DCP 6 HL RECON SS 4.5MM SCR BOTH IP/OP $808.28 $598.13 $0.00 $627.78 $353.13 $353.13 $0.00 $0.00 $0.00 $168.46 $599.90 $599.90 $0.00 $0.00 $168.44 $0.00 $478.09 $478.09 $0.00 $392.36 $621.51 $627.78 $0.00 $0.00 $119.23 $0.00 $0.00 $124.93 $0.00 $0.00 $0.00 $0.00 $0.00 229.361 SUP HCPCS C1713 229.361 - PLATE BONE 113MM 6 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP $969.93 $717.75 $0.00 $753.34 $423.75 $423.75 $0.00 $0.00 $0.00 $202.16 $719.88 $719.88 $0.00 $0.00 $202.13 $0.00 $573.71 $573.71 $0.00 $470.84 $745.81 $753.34 $0.00 $0.00 $143.08 $0.00 $0.00 $149.91 $0.00 $0.00 $0.00 $0.00 $0.00 229.37 SUP HCPCS C1713 229.37 - PLATE BONE STR 109X12X3MM 7 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP $844.83 $625.17 $0.00 $656.18 $369.10 $369.10 $0.00 $0.00 $0.00 $176.08 $627.03 $627.03 $0.00 $0.00 $176.06 $0.00 $499.71 $499.71 $0.00 $410.11 $649.62 $656.18 $0.00 $0.00 $124.62 $0.00 $0.00 $130.58 $0.00 $0.00 $0.00 $0.00 $0.00 229.371 SUP HCPCS C1713 229.371 - PLATE BONE 132MM 7 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,014.90 " $751.03 $0.00 $788.28 $443.41 $443.41 $0.00 $0.00 $0.00 $211.53 $753.26 $753.26 $0.00 $0.00 $211.51 $0.00 $600.31 $600.31 $0.00 $492.68 $780.40 $788.28 $0.00 $0.00 $149.72 $0.00 $0.00 $156.87 $0.00 $0.00 $0.00 $0.00 $0.00 229.38 SUP HCPCS C1713 229.38 - PLATE BN STRG 125X12X3MM NS LC DCP 8 HL RECON SS 4.5MM CORT BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 229.381 SUP HCPCS C1713 229.381 - PLATE BONE 151MM 8 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,066.93 " $789.53 $0.00 $828.68 $466.13 $466.13 $0.00 $0.00 $0.00 $222.37 $791.87 $791.87 $0.00 $0.00 $222.35 $0.00 $631.09 $631.09 $0.00 $517.93 $820.39 $828.68 $0.00 $0.00 $157.39 $0.00 $0.00 $164.91 $0.00 $0.00 $0.00 $0.00 $0.00 229.39 SUP HCPCS C1713 229.39 - PLATE BONE STR 141X12X3MM 9 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP $954.48 $706.32 $0.00 $741.34 $417.00 $417.00 $0.00 $0.00 $0.00 $198.94 $708.41 $708.41 $0.00 $0.00 $198.91 $0.00 $564.57 $564.57 $0.00 $463.34 $733.93 $741.34 $0.00 $0.00 $140.80 $0.00 $0.00 $147.53 $0.00 $0.00 $0.00 $0.00 $0.00 229.391 SUP HCPCS C1713 229.391 - PLATE BONE 170MM 9 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,142.83 " $845.69 $0.00 $887.64 $499.30 $499.30 $0.00 $0.00 $0.00 $238.19 $848.20 $848.20 $0.00 $0.00 $238.16 $0.00 $675.98 $675.98 $0.00 $554.78 $878.76 $887.64 $0.00 $0.00 $168.59 $0.00 $0.00 $176.64 $0.00 $0.00 $0.00 $0.00 $0.00 229.4 SUP HCPCS C1713 229.40 - PLATE BN 157MM NS LC DCP 10 HL RECON 4.5MM SCR BOTH IP/OP $970.33 $718.04 $0.00 $776.26 $436.65 $436.65 $0.00 $0.00 $0.00 $202.24 $720.18 $720.18 $0.00 $0.00 $202.22 $0.00 $573.95 $573.95 $0.00 $485.16 $768.50 $776.26 $0.00 $0.00 $147.43 $0.00 $0.00 $154.48 $0.00 $0.00 $0.00 $0.00 $0.00 229.401 SUP HCPCS C1713 229.401 - PLATE BONE 189MM 10 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,197.65 " $886.26 $0.00 $930.22 $523.25 $523.25 $0.00 $0.00 $0.00 $249.62 $888.90 $888.90 $0.00 $0.00 $249.59 $0.00 $708.41 $708.41 $0.00 $581.39 $920.92 $930.22 $0.00 $0.00 $176.67 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $0.00 229.41 SUP HCPCS C1713 229.41 - PLATE BONE 173MM 11 HOLE STR RECONSTRUCTION LC-DCP DCP BOTH IP/OP "$1,034.60 " $765.60 $0.00 $803.56 $452.00 $452.00 $0.00 $0.00 $0.00 $215.64 $767.88 $767.88 $0.00 $0.00 $215.61 $0.00 $611.97 $611.97 $0.00 $502.23 $795.52 $803.56 $0.00 $0.00 $152.62 $0.00 $0.00 $159.91 $0.00 $0.00 $0.00 $0.00 $0.00 229.411 SUP HCPCS C1713 229.411 - PLATE BONE 208MM 11 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,237.00 " $915.38 $0.00 $960.78 $540.44 $540.44 $0.00 $0.00 $0.00 $257.82 $918.10 $918.10 $0.00 $0.00 $257.79 $0.00 $731.69 $731.69 $0.00 $600.49 $951.18 $960.78 $0.00 $0.00 $182.48 $0.00 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 229.42 SUP HCPCS C1713 229.42 - PLATE BONE STR 189X12X3MM 12 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP "$1,082.38 " $800.96 $0.00 $840.68 $472.88 $472.88 $0.00 $0.00 $0.00 $225.59 $803.34 $803.34 $0.00 $0.00 $225.57 $0.00 $640.22 $640.22 $0.00 $525.43 $832.27 $840.68 $0.00 $0.00 $159.67 $0.00 $0.00 $167.30 $0.00 $0.00 $0.00 $0.00 $0.00 229.421 SUP HCPCS C1713 229.421 - PLATE BONE 227MM 12 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 229.43 SUP HCPCS C1713 229.43 - PLATE BONE STR 205X12X3MM 13 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP "$1,152.68 " $852.98 $0.00 $895.28 $503.60 $503.60 $0.00 $0.00 $0.00 $240.25 $855.52 $855.52 $0.00 $0.00 $240.22 $0.00 $681.81 $681.81 $0.00 $559.55 $886.33 $895.28 $0.00 $0.00 $170.04 $0.00 $0.00 $178.16 $0.00 $0.00 $0.00 $0.00 $0.00 229.431 SUP HCPCS C1713 229.431 - PLATE BONE 246MM 13 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,378.98 " "$1,020.45" $0.00 "$1,071.06" $602.47 $602.47 $0.00 $0.00 $0.00 $287.41 "$1,023.48" "$1,023.48" $0.00 $0.00 $287.38 $0.00 $815.66 $815.66 $0.00 $669.41 "$1,060.35" "$1,071.06" $0.00 $0.00 $203.42 $0.00 $0.00 $213.14 $0.00 $0.00 $0.00 $0.00 $0.00 229.44 SUP HCPCS C1713 229.44 - PLATE BONE 221MM 14 HOLE RECONSTRUCTION DCP LC-DCP STAINLESS BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 229.441 SUP HCPCS C1713 229.441 - PLATE BONE 265MM 14 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,416.95 " "$1,048.54" $0.00 "$1,100.54" $619.05 $619.05 $0.00 $0.00 $0.00 $295.33 "$1,051.66" "$1,051.66" $0.00 $0.00 $295.29 $0.00 $838.13 $838.13 $0.00 $687.84 "$1,089.54" "$1,100.54" $0.00 $0.00 $209.02 $0.00 $0.00 $219.01 $0.00 $0.00 $0.00 $0.00 $0.00 229.451 SUP HCPCS C1713 229.451 - PLATE BONE 284MM 15 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,475.98 " "$1,092.23" $0.00 "$1,146.40" $644.85 $644.85 $0.00 $0.00 $0.00 $307.63 "$1,095.47" "$1,095.47" $0.00 $0.00 $307.59 $0.00 $873.04 $873.04 $0.00 $716.50 "$1,134.94" "$1,146.40" $0.00 $0.00 $217.73 $0.00 $0.00 $228.13 $0.00 $0.00 $0.00 $0.00 $0.00 229.461 SUP HCPCS C1713 229.461 - PLATE BONE 303MM 16 HOLE STR RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,515.33 " "$1,121.34" $0.00 "$1,176.96" $662.04 $662.04 $0.00 $0.00 $0.00 $315.83 "$1,124.67" "$1,124.67" $0.00 $0.00 $315.79 $0.00 $896.31 $896.31 $0.00 $735.60 "$1,165.19" "$1,176.96" $0.00 $0.00 $223.54 $0.00 $0.00 $234.22 $0.00 $0.00 $0.00 $0.00 $0.00 231.001 SUP Custom 27203010 "231.001 - STAINLESS STEEL, DUAL STAPLE, SMALL, ROSTRAL" BOTH IP/OP "$2,522.50 " "$1,866.65" $0.00 "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,872.20" "$1,872.20" $0.00 $0.00 $525.69 $0.00 $0.00 $0.00 $0.00 "$1,261.25" "$1,997.82" "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.002 SUP Custom 27203010 "231.002 - STAINLESS STEEL, DUAL STAPLE, SMALL, CAUDAL" BOTH IP/OP "$2,522.50 " "$1,866.65" $0.00 "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,872.20" "$1,872.20" $0.00 $0.00 $525.69 $0.00 $0.00 $0.00 $0.00 "$1,261.25" "$1,997.82" "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.003 SUP Custom 27203010 "231.003 - STAINLESS STEEL, DUAL STAPLE, MEDIUM, ROSTRAL" BOTH IP/OP "$2,522.50 " "$1,866.65" $0.00 "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,872.20" "$1,872.20" $0.00 $0.00 $525.69 $0.00 $0.00 $0.00 $0.00 "$1,261.25" "$1,997.82" "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.004 SUP Custom 27203010 "231.004 - STAINLESS STEEL, DUAL STAPLE, MEDIUM, CAUDAL" BOTH IP/OP "$2,522.50 " "$1,866.65" $0.00 "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,872.20" "$1,872.20" $0.00 $0.00 $525.69 $0.00 $0.00 $0.00 $0.00 "$1,261.25" "$1,997.82" "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.005 SUP Custom 27203010 "231.005 - STAINLESS STEEL, DUAL STAPLE, LARGE, ROSTRAL" BOTH IP/OP "$2,522.50 " "$1,866.65" $0.00 "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,872.20" "$1,872.20" $0.00 $0.00 $525.69 $0.00 $0.00 $0.00 $0.00 "$1,261.25" "$1,997.82" "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.006 SUP Custom 27203010 "231.006 - STAINLESS STEEL, DUAL STAPLE, LARGE, CAUDAL" BOTH IP/OP "$2,522.50 " "$1,866.65" $0.00 "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,872.20" "$1,872.20" $0.00 $0.00 $525.69 $0.00 $0.00 $0.00 $0.00 "$1,261.25" "$1,997.82" "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.007 SUP Custom 27203010 "231.007 - STAINLESS STEEL, DUAL STAPLE, X-LARGE, ROSTRAL" BOTH IP/OP "$2,522.50 " "$1,866.65" $0.00 "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,872.20" "$1,872.20" $0.00 $0.00 $525.69 $0.00 $0.00 $0.00 $0.00 "$1,261.25" "$1,997.82" "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.008 SUP Custom 27203010 "231.008 - STAINLESS STEEL, DUAL STAPLE, X-LARGE, CAUDAL" BOTH IP/OP "$2,522.50 " "$1,866.65" $0.00 "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,872.20" "$1,872.20" $0.00 $0.00 $525.69 $0.00 $0.00 $0.00 $0.00 "$1,261.25" "$1,997.82" "$2,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.011 SUP Custom 27203010 "231.011 - STAINLESS STEEL SINGLE STAPLE, SMALL" BOTH IP/OP "$1,822.50 " "$1,348.65" $0.00 "$1,458.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,352.66" "$1,352.66" $0.00 $0.00 $379.81 $0.00 $0.00 $0.00 $0.00 $911.25 "$1,443.42" "$1,458.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.012 SUP Custom 27203010 "231.012 - STAINLESS STEEL SINGLE STAPLE, MEDIUM" BOTH IP/OP "$1,822.50 " "$1,348.65" $0.00 "$1,458.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,352.66" "$1,352.66" $0.00 $0.00 $379.81 $0.00 $0.00 $0.00 $0.00 $911.25 "$1,443.42" "$1,458.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.013 SUP Custom 27203010 "231.013 - STAINLESS STEEL SINGLE STAPLE, LARGE" BOTH IP/OP "$1,822.50 " "$1,348.65" $0.00 "$1,458.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,352.66" "$1,352.66" $0.00 $0.00 $379.81 $0.00 $0.00 $0.00 $0.00 $911.25 "$1,443.42" "$1,458.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.113 SUP Custom 27803010 "231.113 - STAINLESS STEEL CROSS CONNECTOR, 13MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.114 SUP Custom 27803010 "231.114 - STAINLESS STEEL CROSS CONNECTOR, 14MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.115 SUP Custom 27803010 "231.115 - STAINLESS STEEL CROSS CONNECTOR, 15MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.116 SUP Custom 27803010 "231.116 - STAINLESS STEEL CROSS CONNECTOR, 16MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.117 SUP Custom 27803010 "231.117 - STAINLESS STEEL CROSS CONNECTOR, 17MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.118 SUP Custom 27803010 "231.118 - STAINLESS STEEL CROSS CONNECTOR, 18MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.119 SUP Custom 27803010 "231.119 - STAINLESS STEEL CROSS CONNECTOR, 19MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.12 SUP Custom 27803010 "231.120 - STAINLESS STEEL CROSS CONNECTOR, 20MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231.201 SUP HCPCS C1713 "231.201 - STAINLESS STEEL WASHER, SMALL" BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 231.202 SUP HCPCS C1713 "231.202 - STAINLESS STEEL WASHER, MEDIUM" BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 231.203 SUP HCPCS C1713 "231.203 - STAINLESS STEEL WASHER, LARGE" BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 232.006 SUP HCPCS C1713 232.006 - PLATE BONE 90D 132MM 30X9.2MM 10 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,876.20 " "$1,388.39" $0.00 "$1,500.96" $844.29 $844.29 $0.00 $0.00 $0.00 $391.05 "$1,392.52" "$1,392.52" $0.00 $0.00 $391.00 $0.00 "$1,109.77" "$1,109.77" $0.00 $938.10 "$1,485.95" "$1,500.96" $0.00 $0.00 $293.63 $0.00 $0.00 $298.69 $0.00 $0.00 $0.00 $0.00 $0.00 232.007 SUP HCPCS C1713 232.007 - PLATE BONE 90D 132MM 35X9.2MM 10 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,876.20 " "$1,388.39" $0.00 "$1,500.96" $844.29 $844.29 $0.00 $0.00 $0.00 $391.05 "$1,392.52" "$1,392.52" $0.00 $0.00 $391.00 $0.00 "$1,109.77" "$1,109.77" $0.00 $938.10 "$1,485.95" "$1,500.96" $0.00 $0.00 $293.63 $0.00 $0.00 $298.69 $0.00 $0.00 $0.00 $0.00 $0.00 232.008 SUP HCPCS C1713 232.008 - PLATE BONE 90D 132MM 40X9.2MM 10 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,876.20 " "$1,388.39" $0.00 "$1,500.96" $844.29 $844.29 $0.00 $0.00 $0.00 $391.05 "$1,392.52" "$1,392.52" $0.00 $0.00 $391.00 $0.00 "$1,109.77" "$1,109.77" $0.00 $938.10 "$1,485.95" "$1,500.96" $0.00 $0.00 $293.63 $0.00 $0.00 $298.69 $0.00 $0.00 $0.00 $0.00 $0.00 232.009 SUP HCPCS C1713 232.009 - PLATE BONE 90D 132MM 45X9.2MM 10 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,876.20 " "$1,388.39" $0.00 "$1,500.96" $844.29 $844.29 $0.00 $0.00 $0.00 $391.05 "$1,392.52" "$1,392.52" $0.00 $0.00 $391.00 $0.00 "$1,109.77" "$1,109.77" $0.00 $938.10 "$1,485.95" "$1,500.96" $0.00 $0.00 $293.63 $0.00 $0.00 $298.69 $0.00 $0.00 $0.00 $0.00 $0.00 232.046 SUP HCPCS C1713 232.046 - PLATE BONE 90D 54MM 30X9.2MM 4 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,495.93 " "$1,106.99" $0.00 "$1,196.74" $673.17 $673.17 $0.00 $0.00 $0.00 $311.79 "$1,110.28" "$1,110.28" $0.00 $0.00 $311.75 $0.00 $884.84 $884.84 $0.00 $747.96 "$1,184.78" "$1,196.74" $0.00 $0.00 $234.11 $0.00 $0.00 $238.15 $0.00 $0.00 $0.00 $0.00 $0.00 232.047 SUP HCPCS C1713 232.047 - PLATE BONE 90D 54MM 35X9.2MM 4 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,495.93 " "$1,106.99" $0.00 "$1,196.74" $673.17 $673.17 $0.00 $0.00 $0.00 $311.79 "$1,110.28" "$1,110.28" $0.00 $0.00 $311.75 $0.00 $884.84 $884.84 $0.00 $747.96 "$1,184.78" "$1,196.74" $0.00 $0.00 $234.11 $0.00 $0.00 $238.15 $0.00 $0.00 $0.00 $0.00 $0.00 232.048 SUP HCPCS C1713 232.048 - PLATE BN 90D 40X9.2MM NS 4 HL LMT CNTCT ANG BLDE CNN SS 3.5 BOTH IP/OP "$1,495.93 " "$1,106.99" $0.00 "$1,196.74" $673.17 $673.17 $0.00 $0.00 $0.00 $311.79 "$1,110.28" "$1,110.28" $0.00 $0.00 $311.75 $0.00 $884.84 $884.84 $0.00 $747.96 "$1,184.78" "$1,196.74" $0.00 $0.00 $234.11 $0.00 $0.00 $238.15 $0.00 $0.00 $0.00 $0.00 $0.00 232.049 SUP HCPCS C1713 232.049 - PLATE BONE 90D 54MM 45X9.2MM 4 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,495.93 " "$1,106.99" $0.00 "$1,196.74" $673.17 $673.17 $0.00 $0.00 $0.00 $311.79 "$1,110.28" "$1,110.28" $0.00 $0.00 $311.75 $0.00 $884.84 $884.84 $0.00 $747.96 "$1,184.78" "$1,196.74" $0.00 $0.00 $234.11 $0.00 $0.00 $238.15 $0.00 $0.00 $0.00 $0.00 $0.00 232.056 SUP HCPCS C1713 232.056 - PLATE BONE 90D 67MM 30X9.2MM 5 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,582.05 " "$1,170.72" $0.00 "$1,265.64" $711.92 $711.92 $0.00 $0.00 $0.00 $329.74 "$1,174.20" "$1,174.20" $0.00 $0.00 $329.70 $0.00 $935.78 $935.78 $0.00 $791.03 "$1,252.98" "$1,265.64" $0.00 $0.00 $247.59 $0.00 $0.00 $251.86 $0.00 $0.00 $0.00 $0.00 $0.00 232.057 SUP HCPCS C1713 232.057 - PLATE BONE 90D 67MM 35X9.2MM 5 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,582.05 " "$1,170.72" $0.00 "$1,265.64" $711.92 $711.92 $0.00 $0.00 $0.00 $329.74 "$1,174.20" "$1,174.20" $0.00 $0.00 $329.70 $0.00 $935.78 $935.78 $0.00 $791.03 "$1,252.98" "$1,265.64" $0.00 $0.00 $247.59 $0.00 $0.00 $251.86 $0.00 $0.00 $0.00 $0.00 $0.00 232.058 SUP HCPCS C1713 232.058 - PLATE BONE 90D 67MM 40X9.2MM 5 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,582.05 " "$1,170.72" $0.00 "$1,265.64" $711.92 $711.92 $0.00 $0.00 $0.00 $329.74 "$1,174.20" "$1,174.20" $0.00 $0.00 $329.70 $0.00 $935.78 $935.78 $0.00 $791.03 "$1,252.98" "$1,265.64" $0.00 $0.00 $247.59 $0.00 $0.00 $251.86 $0.00 $0.00 $0.00 $0.00 $0.00 232.059 SUP HCPCS C1713 232.059 - PLATE BONE 90D 67MM 45X9.2MM 5 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,582.05 " "$1,170.72" $0.00 "$1,265.64" $711.92 $711.92 $0.00 $0.00 $0.00 $329.74 "$1,174.20" "$1,174.20" $0.00 $0.00 $329.70 $0.00 $935.78 $935.78 $0.00 $791.03 "$1,252.98" "$1,265.64" $0.00 $0.00 $247.59 $0.00 $0.00 $251.86 $0.00 $0.00 $0.00 $0.00 $0.00 232.066 SUP HCPCS C1713 232.066 - PLATE BONE 90D 80MM 30X9.2MM 6 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,649.63 " "$1,220.73" $0.00 "$1,319.70" $742.33 $742.33 $0.00 $0.00 $0.00 $343.82 "$1,224.35" "$1,224.35" $0.00 $0.00 $343.78 $0.00 $975.75 $975.75 $0.00 $824.81 "$1,306.51" "$1,319.70" $0.00 $0.00 $258.17 $0.00 $0.00 $262.62 $0.00 $0.00 $0.00 $0.00 $0.00 232.067 SUP HCPCS C1713 232.067 - PLATE BONE 90D 80MM 35X9.2MM 6 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,649.63 " "$1,220.73" $0.00 "$1,319.70" $742.33 $742.33 $0.00 $0.00 $0.00 $343.82 "$1,224.35" "$1,224.35" $0.00 $0.00 $343.78 $0.00 $975.75 $975.75 $0.00 $824.81 "$1,306.51" "$1,319.70" $0.00 $0.00 $258.17 $0.00 $0.00 $262.62 $0.00 $0.00 $0.00 $0.00 $0.00 232.068 SUP HCPCS C1713 232.068 - PLATE BONE 90D 80MM 40X9.2MM 6 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,649.63 " "$1,220.73" $0.00 "$1,319.70" $742.33 $742.33 $0.00 $0.00 $0.00 $343.82 "$1,224.35" "$1,224.35" $0.00 $0.00 $343.78 $0.00 $975.75 $975.75 $0.00 $824.81 "$1,306.51" "$1,319.70" $0.00 $0.00 $258.17 $0.00 $0.00 $262.62 $0.00 $0.00 $0.00 $0.00 $0.00 232.069 SUP HCPCS C1713 232.069 - PLATE BONE 90D 80MM 45X9.2MM 6 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,649.63 " "$1,220.73" $0.00 "$1,319.70" $742.33 $742.33 $0.00 $0.00 $0.00 $343.82 "$1,224.35" "$1,224.35" $0.00 $0.00 $343.78 $0.00 $975.75 $975.75 $0.00 $824.81 "$1,306.51" "$1,319.70" $0.00 $0.00 $258.17 $0.00 $0.00 $262.62 $0.00 $0.00 $0.00 $0.00 $0.00 232.086 SUP HCPCS C1713 232.086 - PLATE BONE 90D 106MM 30X9.2MM 8 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,770.20 " "$1,309.95" $0.00 "$1,416.16" $796.59 $796.59 $0.00 $0.00 $0.00 $368.95 "$1,313.84" "$1,313.84" $0.00 $0.00 $368.91 $0.00 "$1,047.07" "$1,047.07" $0.00 $885.10 "$1,402.00" "$1,416.16" $0.00 $0.00 $277.04 $0.00 $0.00 $281.82 $0.00 $0.00 $0.00 $0.00 $0.00 232.087 SUP HCPCS C1713 232.087 - PLATE BN 90D 35X9.2MM NS 8 HL LMT CNTCT ANG BLDE CNN SS 3.5 BOTH IP/OP "$1,770.20 " "$1,309.95" $0.00 "$1,416.16" $796.59 $796.59 $0.00 $0.00 $0.00 $368.95 "$1,313.84" "$1,313.84" $0.00 $0.00 $368.91 $0.00 "$1,047.07" "$1,047.07" $0.00 $885.10 "$1,402.00" "$1,416.16" $0.00 $0.00 $277.04 $0.00 $0.00 $281.82 $0.00 $0.00 $0.00 $0.00 $0.00 232.088 SUP HCPCS C1713 232.088 - PLATE BONE 90D 106MM 40X9.2MM 8 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,770.20 " "$1,309.95" $0.00 "$1,416.16" $796.59 $796.59 $0.00 $0.00 $0.00 $368.95 "$1,313.84" "$1,313.84" $0.00 $0.00 $368.91 $0.00 "$1,047.07" "$1,047.07" $0.00 $885.10 "$1,402.00" "$1,416.16" $0.00 $0.00 $277.04 $0.00 $0.00 $281.82 $0.00 $0.00 $0.00 $0.00 $0.00 232.089 SUP HCPCS C1713 232.089 - PLATE BONE 90D 106MM 45X9.2MM 8 HOLE LIMITED CONTACT ANGLED BOTH IP/OP "$1,770.20 " "$1,309.95" $0.00 "$1,416.16" $796.59 $796.59 $0.00 $0.00 $0.00 $368.95 "$1,313.84" "$1,313.84" $0.00 $0.00 $368.91 $0.00 "$1,047.07" "$1,047.07" $0.00 $885.10 "$1,402.00" "$1,416.16" $0.00 $0.00 $277.04 $0.00 $0.00 $281.82 $0.00 $0.00 $0.00 $0.00 $0.00 235 SUP Custom 27803010 235 - PANEL 235 128MM X 79MM X .025 BOTH IP/OP "$1,623.50 " "$1,201.39" $0.00 "$1,298.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,204.96" "$1,204.96" $0.00 $0.00 $338.34 $0.00 $0.00 $0.00 $0.00 $811.75 "$1,285.81" "$1,298.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 235.17 SUP HCPCS C1713 235.170 - PLATE BONE 80D 8MM DISPLACEMENT 35MM DCP CAPOS STAINLESS BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.19 SUP HCPCS C1713 235.190 - PLATE BONE 80D 8MM DISPLACEMENT 45MM ANGLED DCP CAPOS BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.27 SUP HCPCS C1713 235.270 - PLATE BN 90D 8MM DSPL 35MMX74.5MM NS DCP CAPOS 3 HL T PRFL BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.29 SUP HCPCS C1713 235.290 - PLATE BN 90D 8MM DSPL 45MMX74.5MM NS DCP CAPOS 3 HL T PRFL BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.37 SUP HCPCS C1713 235.370 - PLATE BONE 100D 8MM DISPLACEMENT 35MM DCP CAPOS STAINLESS BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.39 SUP HCPCS C1713 235.390 - PLATE BONE 100D 45MM 8MM DCP CAPOS STAINLESS STEEL PEDIATRIC BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.6 SUP HCPCS C1713 235.600 - PLATE BN 90D 10MM DSPL 50MMX78MM NS DCP CAPOS 3 HL T PRFL BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.601 SUP HCPCS C1713 235.601 - PLATE BONE 100D 10MM DISPLACEMENT 50MM DCP CAPOS STAINLESS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.68 SUP HCPCS C1713 235.680 - PLATE BN 90D 10MM DSPL 40MMX78MM NS DCP CAPOS 3 HL T PRFL BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.681 SUP HCPCS C1713 235.681 - PLATE BONE 100D 10MM DISPLACEMENT 40MM DCP CAPOS STAINLESS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.7 SUP HCPCS C1713 235.700 - PLATE BN 90D 15MM DSPL 50MMX78MM NS DCP CAPOS 3 HL T PRFL BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.701 SUP HCPCS C1713 235.701 - PLATE BONE 100D 10MM DISPLACEMENT 50MM DCP CAPOS STAINLESS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.72 SUP HCPCS C1713 235.720 - PLATE BN 90D 15MM DSPL 60MMX78MM NS DCP CAPOS 3 HL T PRFL BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.721 SUP HCPCS C1713 235.721 - PLATE BONE 100D 15MM DISPLACEMENT 60MM DCP CAPOS STAINLESS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.78 SUP HCPCS C1713 235.780 - PLATE BN 90D 15MM DSPL 40MMX78MM NS DCP CAPOS 3 HL T PRFL BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 235.781 SUP HCPCS C1713 235.781 - PLATE BONE 100D 10MM DISPLACEMENT 40MM DCP CAPOS STAINLESS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.001 SUP HCPCS C1713 236.001 - PLATE BONE 90D 4MM DISPLACEMENT 26MM ANGLED DCP CAPOS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.002 SUP HCPCS C1713 236.002 - PLATE BN 90D 4MM DSPL 32MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.003 SUP HCPCS C1713 236.003 - PLATE BONE 90D 4MM DISPLACEMENT 38MM DCP CAPOS STAINLESS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.011 SUP HCPCS C1713 236.011 - PLATE BONE 90D 8MM DISPLACEMENT ANGLED 26MM DCP CAPOS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.012 SUP HCPCS C1713 236.012 - PLATE BN 90D 8MM DSPL 32MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.013 SUP HCPCS C1713 236.013 - PLATE BN 90D 8MM DSPL 38MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.101 SUP HCPCS C1713 236.101 - PLATE BONE 100D 4MM DISPLACEMENT 26MM ANGLED DCP CAPOS BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.102 SUP HCPCS C1713 236.102 - PLATE BN 100D 4MM DSPL 32MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.103 SUP HCPCS C1713 236.103 - PLATE BN 100D 4MM DSPL 38MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.104 SUP HCPCS C1713 236.104 - PLATE BN 100D 4MM DSPL 44MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.111 SUP HCPCS C1713 236.111 - PLATE BONE 100D 8MM DISPLACEMENT 26MM CANN ANGLED BLADE DCP BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.112 SUP HCPCS C1713 236.112 - PLATE BN 100D 8MM DSPL 32MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.113 SUP HCPCS C1713 236.113 - PLATE BN 100D 8MM DSPL 38MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.114 SUP HCPCS C1713 236.114 - PLATE BN 100D 8MM DSPL 44MMX67MM NS 9.5X3.2MM DCP CAPOS 3 HL BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 236.25 SUP HCPCS C1713 236.250 - PLATE BN 90D 7MM DSPL 25MMX46MM NS 8X2MM DCP CAPOS 3 HL T BOTH IP/OP $805.20 $595.85 $0.00 $644.16 $362.34 $362.34 $0.00 $0.00 $0.00 $167.82 $597.62 $597.62 $0.00 $0.00 $167.80 $0.00 $476.28 $476.28 $0.00 $402.60 $637.72 $644.16 $0.00 $0.00 $122.34 $0.00 $0.00 $128.19 $0.00 $0.00 $0.00 $0.00 $0.00 236.26 SUP HCPCS C1713 236.260 - PLATE BN 90D 7MM DSPL 32MMX46MM NS 8X2MM DCP CAPOS 3 HL T BOTH IP/OP $805.20 $595.85 $0.00 $644.16 $362.34 $362.34 $0.00 $0.00 $0.00 $167.82 $597.62 $597.62 $0.00 $0.00 $167.80 $0.00 $476.28 $476.28 $0.00 $402.60 $637.72 $644.16 $0.00 $0.00 $122.34 $0.00 $0.00 $128.19 $0.00 $0.00 $0.00 $0.00 $0.00 236.35 SUP HCPCS C1713 236.350 - PLATE BN 90D 12MM DSPL 25MMX46MM NS 8X2MM DCP CAPOS SS INF BOTH IP/OP $805.20 $595.85 $0.00 $644.16 $362.34 $362.34 $0.00 $0.00 $0.00 $167.82 $597.62 $597.62 $0.00 $0.00 $167.80 $0.00 $476.28 $476.28 $0.00 $402.60 $637.72 $644.16 $0.00 $0.00 $122.34 $0.00 $0.00 $128.19 $0.00 $0.00 $0.00 $0.00 $0.00 236.36 SUP HCPCS C1713 236.360 - PLATE BN 90D 12MM DSPL 32MMX46MM NS 8X2MM DCP CAPOS 3 HL T BOTH IP/OP $805.20 $595.85 $0.00 $644.16 $362.34 $362.34 $0.00 $0.00 $0.00 $167.82 $597.62 $597.62 $0.00 $0.00 $167.80 $0.00 $476.28 $476.28 $0.00 $402.60 $637.72 $644.16 $0.00 $0.00 $122.34 $0.00 $0.00 $128.19 $0.00 $0.00 $0.00 $0.00 $0.00 236.4 SUP HCPCS C1713 236.400 - PLATE BN 115D 5MM DSPL 2 BRCH 30MM NS DCP CAPOS 2 HL SS BOTH IP/OP $537.70 $397.90 $0.00 $430.16 $241.97 $241.97 $0.00 $0.00 $0.00 $112.07 $399.08 $399.08 $0.00 $0.00 $112.06 $0.00 $318.05 $318.05 $0.00 $268.85 $425.86 $430.16 $0.00 $0.00 $81.70 $0.00 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 236.43 SUP HCPCS C1713 236.430 - PLATE BN 115D 5MM DSPL 2 BRCH 35MM NS DCP CAPOS 2 HL SS BOTH IP/OP $537.70 $397.90 $0.00 $430.16 $241.97 $241.97 $0.00 $0.00 $0.00 $112.07 $399.08 $399.08 $0.00 $0.00 $112.06 $0.00 $318.05 $318.05 $0.00 $268.85 $425.86 $430.16 $0.00 $0.00 $81.70 $0.00 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 236.502 SUP HCPCS C1713 236.502 - PLATE BONE 86MM 2 HOLE LCP STAINLESS STEEL RIGHT OLECRANON BOTH IP/OP "$1,644.65 " "$1,217.04" $0.00 "$1,277.40" $718.54 $718.54 $0.00 $0.00 $0.00 $342.79 "$1,220.66" "$1,220.66" $0.00 $0.00 $342.75 $0.00 $972.81 $972.81 $0.00 $798.38 "$1,264.63" "$1,277.40" $0.00 $0.00 $242.61 $0.00 $0.00 $254.20 $0.00 $0.00 $0.00 $0.00 $0.00 236.503 SUP HCPCS C1713 236.503 - PLATE BONE 86MM 2 HOLE PRECONTOUR LCP STAINLESS STEEL LEFT BOTH IP/OP "$1,644.65 " "$1,217.04" $0.00 "$1,277.40" $718.54 $718.54 $0.00 $0.00 $0.00 $342.79 "$1,220.66" "$1,220.66" $0.00 $0.00 $342.75 $0.00 $972.81 $972.81 $0.00 $798.38 "$1,264.63" "$1,277.40" $0.00 $0.00 $242.61 $0.00 $0.00 $254.20 $0.00 $0.00 $0.00 $0.00 $0.00 236.504 SUP HCPCS C1713 236.504 - PLATE BONE 112MM 4 HOLE PRECONTOUR LCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,716.35 " "$1,270.10" $0.00 "$1,333.08" $749.86 $749.86 $0.00 $0.00 $0.00 $357.73 "$1,273.87" "$1,273.87" $0.00 $0.00 $357.69 $0.00 "$1,015.22" "$1,015.22" $0.00 $833.18 "$1,319.75" "$1,333.08" $0.00 $0.00 $253.19 $0.00 $0.00 $265.28 $0.00 $0.00 $0.00 $0.00 $0.00 236.505 SUP HCPCS C1713 236.505 - PLATE BONE 112MM 4 HOLE LCP STAINLESS STEEL LEFT OLECRANON BOTH IP/OP "$1,716.35 " "$1,270.10" $0.00 "$1,333.08" $749.86 $749.86 $0.00 $0.00 $0.00 $357.73 "$1,273.87" "$1,273.87" $0.00 $0.00 $357.69 $0.00 "$1,015.22" "$1,015.22" $0.00 $833.18 "$1,319.75" "$1,333.08" $0.00 $0.00 $253.19 $0.00 $0.00 $265.28 $0.00 $0.00 $0.00 $0.00 $0.00 236.506 SUP HCPCS C1713 236.506 - PLATE BONE 3.5MM 138MM 6 HOLE LCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,771.18 " "$1,310.67" $0.00 "$1,375.66" $773.81 $773.81 $0.00 $0.00 $0.00 $369.16 "$1,314.57" "$1,314.57" $0.00 $0.00 $369.11 $0.00 "$1,047.65" "$1,047.65" $0.00 $859.79 "$1,361.91" "$1,375.66" $0.00 $0.00 $348.13 $0.00 $0.00 $273.76 $0.00 $0.00 $0.00 $0.00 $0.00 236.507 SUP HCPCS C1713 236.507 - PLATE BONE 138MM 6 HOLE PRECONTOUR LCP STAINLESS STEEL LEFT BOTH IP/OP "$1,771.18 " "$1,310.67" $0.00 "$1,375.66" $773.81 $773.81 $0.00 $0.00 $0.00 $369.16 "$1,314.57" "$1,314.57" $0.00 $0.00 $369.11 $0.00 "$1,047.65" "$1,047.65" $0.00 $859.79 "$1,361.91" "$1,375.66" $0.00 $0.00 $261.28 $0.00 $0.00 $273.76 $0.00 $0.00 $0.00 $0.00 $0.00 236.508 SUP HCPCS C1713 236.508 - PLATE BONE 164MM 8 HOLE LCP STAINLESS STEEL RIGHT OLECRANON BOTH IP/OP "$1,826.00 " "$1,351.24" $0.00 "$1,418.24" $797.76 $797.76 $0.00 $0.00 $0.00 $380.58 "$1,355.26" "$1,355.26" $0.00 $0.00 $380.54 $0.00 "$1,080.08" "$1,080.08" $0.00 $886.40 "$1,404.06" "$1,418.24" $0.00 $0.00 $269.36 $0.00 $0.00 $282.23 $0.00 $0.00 $0.00 $0.00 $0.00 236.509 SUP HCPCS C1713 236.509 - PLATE BONE 164MM 8 HOLE LCP STAINLESS STEEL LEFT OLECRANON BOTH IP/OP "$1,826.00 " "$1,351.24" $0.00 "$1,418.24" $797.76 $797.76 $0.00 $0.00 $0.00 $380.58 "$1,355.26" "$1,355.26" $0.00 $0.00 $380.54 $0.00 "$1,080.08" "$1,080.08" $0.00 $886.40 "$1,404.06" "$1,418.24" $0.00 $0.00 $269.36 $0.00 $0.00 $282.23 $0.00 $0.00 $0.00 $0.00 $0.00 236.51 SUP HCPCS C1713 236.510 - PLATE BONE 190MM 10 HOLE LCP STAINLESS STEEL RIGHT OLECRANON BOTH IP/OP "$1,821.95 " "$1,348.24" $0.00 "$1,457.56" $819.88 $819.88 $0.00 $0.00 $0.00 $379.74 "$1,352.25" "$1,352.25" $0.00 $0.00 $379.69 $0.00 "$1,077.68" "$1,077.68" $0.00 $910.98 "$1,442.98" "$1,457.56" $0.00 $0.00 $276.83 $0.00 $0.00 $290.05 $0.00 $0.00 $0.00 $0.00 $0.00 236.511 SUP HCPCS C1713 236.511 - PLATE BONE 190MM 10 HOLE LCP STAINLESS STEEL LEFT OLECRANON BOTH IP/OP "$1,876.60 " "$1,388.68" $0.00 "$1,457.56" $819.88 $819.88 $0.00 $0.00 $0.00 $391.13 "$1,392.81" "$1,392.81" $0.00 $0.00 $391.08 $0.00 "$1,110.01" "$1,110.01" $0.00 $910.98 "$1,442.98" "$1,457.56" $0.00 $0.00 $276.83 $0.00 $0.00 $290.05 $0.00 $0.00 $0.00 $0.00 $0.00 236.512 SUP HCPCS C1713 236.512 - PLATE BONE 216MM 12 HOLE LCP STAINLESS STEEL RIGHT OLECRANON BOTH IP/OP "$1,910.33 " "$1,413.64" $0.00 "$1,483.76" $834.62 $834.62 $0.00 $0.00 $0.00 $398.16 "$1,417.84" "$1,417.84" $0.00 $0.00 $398.11 $0.00 "$1,129.96" "$1,129.96" $0.00 $927.35 "$1,468.92" "$1,483.76" $0.00 $0.00 $281.81 $0.00 $0.00 $295.27 $0.00 $0.00 $0.00 $0.00 $0.00 236.513 SUP HCPCS C1713 236.513 - PLATE BONE 215MM 12 HOLE LCP STAINLESS STEEL LEFT OLECRANON BOTH IP/OP "$1,910.33 " "$1,413.64" $0.00 "$1,483.76" $834.62 $834.62 $0.00 $0.00 $0.00 $398.16 "$1,417.84" "$1,417.84" $0.00 $0.00 $398.11 $0.00 "$1,129.96" "$1,129.96" $0.00 $927.35 "$1,468.92" "$1,483.76" $0.00 $0.00 $281.81 $0.00 $0.00 $295.27 $0.00 $0.00 $0.00 $0.00 $0.00 237.2 SUP HCPCS C1713 237.20 - PLATE BONE 95D 50MM 12 HOLE ANGLED BLADE DCP STAINLESS STEEL BOTH IP/OP "$1,177.78 " $871.56 $0.00 $942.22 $530.00 $530.00 $0.00 $0.00 $0.00 $245.48 $874.14 $874.14 $0.00 $0.00 $245.45 $0.00 $696.65 $696.65 $0.00 $588.89 $932.80 $942.22 $0.00 $0.00 $178.95 $0.00 $0.00 $187.50 $0.00 $0.00 $0.00 $0.00 $0.00 237.22 SUP HCPCS C1713 237.22 - PLATE BN 95D 60MM NS 204MM DCP 12 HL SS HIP CNDRL BOTH IP/OP "$1,213.13 " $897.72 $0.00 $942.22 $530.00 $530.00 $0.00 $0.00 $0.00 $252.85 $900.38 $900.38 $0.00 $0.00 $252.82 $0.00 $717.56 $717.56 $0.00 $588.89 $932.80 $942.22 $0.00 $0.00 $178.95 $0.00 $0.00 $187.50 $0.00 $0.00 $0.00 $0.00 $0.00 237.24 SUP HCPCS C1713 237.24 - PLATE BN 95D 70MM NS 240MM DCP 12 HL SS HIP CNDRL BOTH IP/OP "$1,213.13 " $897.72 $0.00 $942.22 $530.00 $530.00 $0.00 $0.00 $0.00 $252.85 $900.38 $900.38 $0.00 $0.00 $252.82 $0.00 $717.56 $717.56 $0.00 $588.89 $932.80 $942.22 $0.00 $0.00 $178.95 $0.00 $0.00 $187.50 $0.00 $0.00 $0.00 $0.00 $0.00 237.26 SUP HCPCS C1713 237.26 - PLATE BN 95D 70MM NS 204MM DCP 12 HL SS HIP CNDRL BOTH IP/OP "$1,213.13 " $897.72 $0.00 $942.22 $530.00 $530.00 $0.00 $0.00 $0.00 $252.85 $900.38 $900.38 $0.00 $0.00 $252.82 $0.00 $717.56 $717.56 $0.00 $588.89 $932.80 $942.22 $0.00 $0.00 $178.95 $0.00 $0.00 $187.50 $0.00 $0.00 $0.00 $0.00 $0.00 237.261 SUP HCPCS C1713 237.261 - PLATE 95D SS 26 HOLE ANG DCP BONE 60MM CNDYLR NONSTRL BOTH IP/OP "$2,689.95 " "$1,990.56" $0.00 "$2,151.96" "$1,210.48" "$1,210.48" $0.00 $0.00 $0.00 $560.65 "$1,996.48" "$1,996.48" $0.00 $0.00 $560.59 $0.00 "$1,326.15" "$1,326.15" $0.00 "$1,344.98" "$2,130.44" "$2,151.96" $0.00 $0.00 $420.98 $0.00 $0.00 $428.24 $0.00 $0.00 $0.00 $0.00 $0.00 237.262 SUP HCPCS C1713 237.262 - PLATE 95D SS 26 HOLE ANG DCP BONE 70MM CNDYLR NONSTRL BOTH IP/OP "$2,535.53 " "$1,876.29" $0.00 "$2,028.42" "$1,140.99" "$1,140.99" $0.00 $0.00 $0.00 $528.47 "$1,881.87" "$1,881.87" $0.00 $0.00 $528.40 $0.00 "$1,250.01" "$1,250.01" $0.00 "$1,267.76" "$2,008.14" "$2,028.42" $0.00 $0.00 $396.81 $0.00 $0.00 $403.66 $0.00 $0.00 $0.00 $0.00 $0.00 237.4 SUP HCPCS C1713 237.40 - PLATE BONE 95D 50MM 235MM 14 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,764.63 " "$1,305.83" $0.00 "$1,411.70" $794.08 $794.08 $0.00 $0.00 $0.00 $367.79 "$1,309.70" "$1,309.70" $0.00 $0.00 $367.75 $0.00 "$1,043.78" "$1,043.78" $0.00 $882.31 "$1,397.59" "$1,411.70" $0.00 $0.00 $268.12 $0.00 $0.00 $280.93 $0.00 $0.00 $0.00 $0.00 $0.00 237.42 SUP HCPCS C1713 237.42 - PLATE BONE 95D 60MM 235MM 14 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,817.55 " "$1,344.99" $0.00 "$1,411.70" $794.08 $794.08 $0.00 $0.00 $0.00 $378.82 "$1,348.99" "$1,348.99" $0.00 $0.00 $378.78 $0.00 "$1,075.08" "$1,075.08" $0.00 $882.31 "$1,397.59" "$1,411.70" $0.00 $0.00 $268.12 $0.00 $0.00 $280.93 $0.00 $0.00 $0.00 $0.00 $0.00 237.44 SUP HCPCS C1713 237.44 - PLATE BN 95D 70MM NS 235MM DCP 14 HL SS HIP CNDRL BOTH IP/OP "$1,817.55 " "$1,344.99" $0.00 "$1,411.70" $794.08 $794.08 $0.00 $0.00 $0.00 $378.82 "$1,348.99" "$1,348.99" $0.00 $0.00 $378.78 $0.00 "$1,075.08" "$1,075.08" $0.00 $882.31 "$1,397.59" "$1,411.70" $0.00 $0.00 $268.12 $0.00 $0.00 $280.93 $0.00 $0.00 $0.00 $0.00 $0.00 237.46 SUP HCPCS C1713 237.46 - PLATE BONE 95D 80MM 235MM 14 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,817.55 " "$1,344.99" $0.00 "$1,411.70" $794.08 $794.08 $0.00 $0.00 $0.00 $378.82 "$1,348.99" "$1,348.99" $0.00 $0.00 $378.78 $0.00 "$1,075.08" "$1,075.08" $0.00 $882.31 "$1,397.59" "$1,411.70" $0.00 $0.00 $268.12 $0.00 $0.00 $280.93 $0.00 $0.00 $0.00 $0.00 $0.00 237.5 SUP HCPCS C1713 237.50 - PLATE BN 95D 50MM NS 92MM DCP 5 HL SS HIP CNDRL BOTH IP/OP $978.53 $724.11 $0.00 $782.82 $440.34 $440.34 $0.00 $0.00 $0.00 $203.95 $726.26 $726.26 $0.00 $0.00 $203.92 $0.00 $578.80 $578.80 $0.00 $489.26 $775.00 $782.82 $0.00 $0.00 $148.68 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $0.00 237.52 SUP HCPCS C1713 237.52 - PLATE BONE 95D 60MM 92MM 5 HOLE DCP STAINLESS STEEL CONDYLE BOTH IP/OP "$1,007.88 " $745.83 $0.00 $782.82 $440.34 $440.34 $0.00 $0.00 $0.00 $210.07 $748.04 $748.04 $0.00 $0.00 $210.04 $0.00 $596.16 $596.16 $0.00 $489.26 $775.00 $782.82 $0.00 $0.00 $148.68 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $0.00 237.54 SUP HCPCS C1713 237.54 - PLATE BN 95D 70MM NS 92MM DCP 5 HL SS HIP CNDRL BOTH IP/OP "$1,007.88 " $745.83 $0.00 $782.82 $440.34 $440.34 $0.00 $0.00 $0.00 $210.07 $748.04 $748.04 $0.00 $0.00 $210.04 $0.00 $596.16 $596.16 $0.00 $489.26 $775.00 $782.82 $0.00 $0.00 $148.68 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $0.00 237.56 SUP HCPCS C1713 237.56 - PLATE BONE 95D 80MM 92MM 5 HOLE DCP STAINLESS STEEL CONDYLE BOTH IP/OP "$1,007.88 " $745.83 $0.00 $782.82 $440.34 $440.34 $0.00 $0.00 $0.00 $210.07 $748.04 $748.04 $0.00 $0.00 $210.04 $0.00 $596.16 $596.16 $0.00 $489.26 $775.00 $782.82 $0.00 $0.00 $148.68 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $0.00 237.62 SUP HCPCS C1713 237.62 - PLATE BONE 95D 60MM 267MM 16 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,921.58 " "$1,421.97" $0.00 "$1,492.50" $839.53 $839.53 $0.00 $0.00 $0.00 $400.50 "$1,426.19" "$1,426.19" $0.00 $0.00 $400.46 $0.00 "$1,136.61" "$1,136.61" $0.00 $932.81 "$1,477.58" "$1,492.50" $0.00 $0.00 $283.46 $0.00 $0.00 $297.01 $0.00 $0.00 $0.00 $0.00 $0.00 237.64 SUP HCPCS C1713 237.64 - PLATE BN 95D 70MM NS 267MM DCP 16 HL SS HIP CNDRL BOTH IP/OP "$1,921.58 " "$1,421.97" $0.00 "$1,492.50" $839.53 $839.53 $0.00 $0.00 $0.00 $400.50 "$1,426.19" "$1,426.19" $0.00 $0.00 $400.46 $0.00 "$1,136.61" "$1,136.61" $0.00 $932.81 "$1,477.58" "$1,492.50" $0.00 $0.00 $283.46 $0.00 $0.00 $297.01 $0.00 $0.00 $0.00 $0.00 $0.00 237.66 SUP HCPCS C1713 237.66 - PLATE BN 95D 80MM NS 267MM DCP 16 HL SS HIP CNDRL BOTH IP/OP "$1,921.58 " "$1,421.97" $0.00 "$1,492.50" $839.53 $839.53 $0.00 $0.00 $0.00 $400.50 "$1,426.19" "$1,426.19" $0.00 $0.00 $400.46 $0.00 "$1,136.61" "$1,136.61" $0.00 $932.81 "$1,477.58" "$1,492.50" $0.00 $0.00 $283.46 $0.00 $0.00 $297.01 $0.00 $0.00 $0.00 $0.00 $0.00 237.7 SUP HCPCS C1713 237.70 - PLATE BONE 95D 124MM 50MM 7 HOLE BLADE DCP STAINLESS STEEL BOTH IP/OP "$1,031.75 " $763.50 $0.00 $825.40 $464.29 $464.29 $0.00 $0.00 $0.00 $215.04 $765.76 $765.76 $0.00 $0.00 $215.02 $0.00 $610.28 $610.28 $0.00 $515.88 $817.15 $825.40 $0.00 $0.00 $156.77 $0.00 $0.00 $164.25 $0.00 $0.00 $0.00 $0.00 $0.00 237.72 SUP HCPCS C1713 237.72 - PLATE BN 95D 60MM NS 124MM DCP 7 HL SS HIP CNDRL BOTH IP/OP "$1,062.70 " $786.40 $0.00 $825.40 $464.29 $464.29 $0.00 $0.00 $0.00 $221.49 $788.74 $788.74 $0.00 $0.00 $221.47 $0.00 $628.59 $628.59 $0.00 $515.88 $817.15 $825.40 $0.00 $0.00 $156.77 $0.00 $0.00 $164.25 $0.00 $0.00 $0.00 $0.00 $0.00 237.74 SUP HCPCS C1713 237.74 - PLATE BN 95D 70MM NS 124MM DCP 7 HL SS HIP CNDRL BOTH IP/OP "$1,062.70 " $786.40 $0.00 $825.40 $464.29 $464.29 $0.00 $0.00 $0.00 $221.49 $788.74 $788.74 $0.00 $0.00 $221.47 $0.00 $628.59 $628.59 $0.00 $515.88 $817.15 $825.40 $0.00 $0.00 $156.77 $0.00 $0.00 $164.25 $0.00 $0.00 $0.00 $0.00 $0.00 237.76 SUP HCPCS C1713 237.76 - PLATE BN 95D 80MM NS 124MM DCP 7 HL SS HIP CNDRL BOTH IP/OP "$1,062.70 " $786.40 $0.00 $825.40 $464.29 $464.29 $0.00 $0.00 $0.00 $221.49 $788.74 $788.74 $0.00 $0.00 $221.47 $0.00 $628.59 $628.59 $0.00 $515.88 $817.15 $825.40 $0.00 $0.00 $156.77 $0.00 $0.00 $164.25 $0.00 $0.00 $0.00 $0.00 $0.00 237.82 SUP HCPCS C1713 237.82 - PLATE BONE 95D 299MM 60MM 18 HOLE DCP STAINLESS STEEL BOTH IP/OP "$2,126.83 " "$1,573.85" $0.00 "$1,651.90" $929.19 $929.19 $0.00 $0.00 $0.00 $443.28 "$1,578.53" "$1,578.53" $0.00 $0.00 $443.23 $0.00 "$1,258.02" "$1,258.02" $0.00 "$1,032.44" "$1,635.38" "$1,651.90" $0.00 $0.00 $313.74 $0.00 $0.00 $328.73 $0.00 $0.00 $0.00 $0.00 $0.00 237.84 SUP HCPCS C1713 237.84 - PLATE BN 95D 80MM NS 299MM DCP 18 HL SS HIP CNDRL BOTH IP/OP "$2,126.83 " "$1,573.85" $0.00 "$1,651.90" $929.19 $929.19 $0.00 $0.00 $0.00 $443.28 "$1,578.53" "$1,578.53" $0.00 $0.00 $443.23 $0.00 "$1,258.02" "$1,258.02" $0.00 "$1,032.44" "$1,635.38" "$1,651.90" $0.00 $0.00 $313.74 $0.00 $0.00 $328.73 $0.00 $0.00 $0.00 $0.00 $0.00 237.86 SUP HCPCS C1713 237.86 - PLATE BN 95D 80MM NS 299MM DCP 18 HL SS HIP CNDRL BOTH IP/OP "$2,126.83 " "$1,573.85" $0.00 "$1,651.90" $929.19 $929.19 $0.00 $0.00 $0.00 $443.28 "$1,578.53" "$1,578.53" $0.00 $0.00 $443.23 $0.00 "$1,258.02" "$1,258.02" $0.00 "$1,032.44" "$1,635.38" "$1,651.90" $0.00 $0.00 $313.74 $0.00 $0.00 $328.73 $0.00 $0.00 $0.00 $0.00 $0.00 237.9 SUP HCPCS C1713 237.90 - PLATE BN 95D 50MM NS 156MM DCP 9 HL SS HIP CNDRL BOTH IP/OP "$1,080.88 " $799.85 $0.00 $864.70 $486.39 $486.39 $0.00 $0.00 $0.00 $225.28 $802.23 $802.23 $0.00 $0.00 $225.25 $0.00 $639.34 $639.34 $0.00 $540.44 $856.06 $864.70 $0.00 $0.00 $164.23 $0.00 $0.00 $172.08 $0.00 $0.00 $0.00 $0.00 $0.00 237.92 SUP HCPCS C1713 237.92 - PLATE BN 95D 60MM NS 156MM DCP 9 HL SS HIP CNDRL BOTH IP/OP "$1,113.30 " $823.84 $0.00 $864.70 $486.39 $486.39 $0.00 $0.00 $0.00 $232.04 $826.29 $826.29 $0.00 $0.00 $232.01 $0.00 $658.52 $658.52 $0.00 $540.44 $856.06 $864.70 $0.00 $0.00 $164.23 $0.00 $0.00 $172.08 $0.00 $0.00 $0.00 $0.00 $0.00 237.94 SUP HCPCS C1713 237.94 - PLATE BN 95D 70MM NS 156MM DCP 9 HL SS HIP CNDRL BOTH IP/OP "$1,113.30 " $823.84 $0.00 $864.70 $486.39 $486.39 $0.00 $0.00 $0.00 $232.04 $826.29 $826.29 $0.00 $0.00 $232.01 $0.00 $658.52 $658.52 $0.00 $540.44 $856.06 $864.70 $0.00 $0.00 $164.23 $0.00 $0.00 $172.08 $0.00 $0.00 $0.00 $0.00 $0.00 237.96 SUP HCPCS C1713 237.96 - PLATE BN 95D 80MM NS 156MM DCP 9 HL SS HIP CNDRL BOTH IP/OP "$1,113.30 " $823.84 $0.00 $864.70 $486.39 $486.39 $0.00 $0.00 $0.00 $232.04 $826.29 $826.29 $0.00 $0.00 $232.01 $0.00 $658.52 $658.52 $0.00 $540.44 $856.06 $864.70 $0.00 $0.00 $164.23 $0.00 $0.00 $172.08 $0.00 $0.00 $0.00 $0.00 $0.00 237.995 SUP HCPCS C1713 237.995 - PLATE BONE 90D 35MM 5 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP "$1,393.90 " "$1,031.49" $0.00 "$1,115.12" $627.26 $627.26 $0.00 $0.00 $0.00 $290.52 "$1,034.55" "$1,034.55" $0.00 $0.00 $290.49 $0.00 $824.49 $824.49 $0.00 $696.95 "$1,103.97" "$1,115.12" $0.00 $0.00 $218.15 $0.00 $0.00 $221.91 $0.00 $0.00 $0.00 $0.00 $0.00 237.997 SUP HCPCS C1713 237.997 - PLATE BONE 90D 35MM 7 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP "$1,393.90 " "$1,031.49" $0.00 "$1,115.12" $627.26 $627.26 $0.00 $0.00 $0.00 $290.52 "$1,034.55" "$1,034.55" $0.00 $0.00 $290.49 $0.00 $824.49 $824.49 $0.00 $696.95 "$1,103.97" "$1,115.12" $0.00 $0.00 $218.15 $0.00 $0.00 $221.91 $0.00 $0.00 $0.00 $0.00 $0.00 238.24 SUP HCPCS C1713 238.24 - PLATE BONE 130D 70MM 12 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP "$1,193.43 " $883.14 $0.00 $926.94 $521.40 $521.40 $0.00 $0.00 $0.00 $248.74 $885.76 $885.76 $0.00 $0.00 $248.71 $0.00 $705.91 $705.91 $0.00 $579.34 $917.67 $926.94 $0.00 $0.00 $176.05 $0.00 $0.00 $184.46 $0.00 $0.00 $0.00 $0.00 $0.00 238.26 SUP HCPCS C1713 238.26 - PLATE BONE 130D 80MM 12 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP "$1,193.43 " $883.14 $0.00 $926.94 $521.40 $521.40 $0.00 $0.00 $0.00 $248.74 $885.76 $885.76 $0.00 $0.00 $248.71 $0.00 $705.91 $705.91 $0.00 $579.34 $917.67 $926.94 $0.00 $0.00 $176.05 $0.00 $0.00 $184.46 $0.00 $0.00 $0.00 $0.00 $0.00 238.28 SUP HCPCS C1713 238.28 - PLATE BONE 130D 90MM 12 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP "$1,193.43 " $883.14 $0.00 $926.94 $521.40 $521.40 $0.00 $0.00 $0.00 $248.74 $885.76 $885.76 $0.00 $0.00 $248.71 $0.00 $705.91 $705.91 $0.00 $579.34 $917.67 $926.94 $0.00 $0.00 $176.05 $0.00 $0.00 $184.46 $0.00 $0.00 $0.00 $0.00 $0.00 238.36 SUP HCPCS C1713 238.36 - PLATE BONE 130D 50MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.38 SUP HCPCS C1713 238.38 - PLATE BONE 130D 60MM 4 HOLE ANGLED BLADE DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.4 SUP HCPCS C1713 238.40 - PLATE BONE 130D 100MM 60MM 4 HOLE DCP STAINLESS STEEL SMALL BOTH IP/OP $850.25 $629.19 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $177.21 $631.06 $631.06 $0.00 $0.00 $177.19 $0.00 $502.92 $502.92 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.41 SUP HCPCS C1713 238.41 - PLATE BONE 130D 105MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.42 SUP HCPCS C1713 238.42 - PLATE BONE 130D 110MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.44 SUP HCPCS C1713 238.44 - PLATE BONE 130D 70MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.45 SUP HCPCS C1713 238.45 - PLATE BONE 130D 75MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.46 SUP HCPCS C1713 238.46 - PLATE BONE 130D 80MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.47 SUP HCPCS C1713 238.47 - PLATE BONE 130D 85MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.48 SUP HCPCS C1713 238.48 - PLATE BONE 130D 90MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.49 SUP HCPCS C1713 238.49 - PLATE BONE 130D 95MM 4 HOLE ANGLED DCP STAINLESS STEEL BOTH IP/OP $875.75 $648.06 $0.00 $680.20 $382.61 $382.61 $0.00 $0.00 $0.00 $182.53 $649.98 $649.98 $0.00 $0.00 $182.51 $0.00 $518.01 $518.01 $0.00 $425.13 $673.40 $680.20 $0.00 $0.00 $129.19 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 238.6 SUP HCPCS C1713 238.60 - PLATE BONE 130D 104MM 50MM 6 HOLE DCP STAINLESS STEEL SMALL BOTH IP/OP $913.03 $675.64 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $190.30 $677.65 $677.65 $0.00 $0.00 $190.27 $0.00 $540.05 $540.05 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 238.62 SUP HCPCS C1713 238.62 - PLATE BONE 130D 104MM 60MM 6 HOLE DCP STAINLESS STEEL BOTH IP/OP $940.40 $695.90 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $196.00 $697.96 $697.96 $0.00 $0.00 $195.98 $0.00 $556.25 $556.25 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 238.64 SUP HCPCS C1713 238.64 - PLATE BN 130D 70MM NS 104MM DCP 6 HL SS HIP CNDRL BOTH IP/OP $940.40 $695.90 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $196.00 $697.96 $697.96 $0.00 $0.00 $195.98 $0.00 $556.25 $556.25 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 238.66 SUP HCPCS C1713 238.66 - PLATE BONE 130D 104MM 80MM 6 HOLE DCP STAINLESS STEEL BOTH IP/OP $940.40 $695.90 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $196.00 $697.96 $697.96 $0.00 $0.00 $195.98 $0.00 $556.25 $556.25 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 238.68 SUP HCPCS C1713 238.68 - PLATE BN 130D 90MM NS 104MM DCP 6 HL SS HIP CNDRL BOTH IP/OP $940.40 $695.90 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $196.00 $697.96 $697.96 $0.00 $0.00 $195.98 $0.00 $556.25 $556.25 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 238.7 SUP HCPCS C1713 238.700 - PLATE BONE 116MM 13.5X3.7MM 4 HOLE LCP STAINLESS STEEL RIGHT BOTH IP/OP "$2,606.68 " "$1,928.94" $0.00 "$2,085.34" "$1,173.00" "$1,173.00" $0.00 $0.00 $0.00 $543.30 "$1,934.67" "$1,934.67" $0.00 $0.00 $543.23 $0.00 "$1,285.09" "$1,285.09" $0.00 "$1,303.34" "$2,064.49" "$2,085.34" $0.00 $0.00 $396.06 $0.00 $0.00 $414.98 $0.00 $0.00 $0.00 $0.00 $0.00 238.701 SUP HCPCS C1713 238.701 - PLATE BONE 116MM 13.5X3.7MM 4 HOLE LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,684.88 " "$1,986.81" $0.00 "$2,085.34" "$1,173.00" "$1,173.00" $0.00 $0.00 $0.00 $559.60 "$1,992.71" "$1,992.71" $0.00 $0.00 $559.53 $0.00 "$1,323.64" "$1,323.64" $0.00 "$1,303.34" "$2,064.49" "$2,085.34" $0.00 $0.00 $396.06 $0.00 $0.00 $414.98 $0.00 $0.00 $0.00 $0.00 $0.00 238.702 SUP HCPCS C1713 238.702 - PLATE BONE 142MM 6 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$2,715.80 " "$2,009.69" $0.00 "$2,109.36" "$1,186.52" "$1,186.52" $0.00 $0.00 $0.00 $566.04 "$2,015.67" "$2,015.67" $0.00 $0.00 $565.97 $0.00 "$1,338.89" "$1,338.89" $0.00 "$1,318.35" "$2,088.27" "$2,109.36" $0.00 $0.00 $400.62 $0.00 $0.00 $419.76 $0.00 $0.00 $0.00 $0.00 $0.00 238.703 SUP HCPCS C1713 238.703 - PLATE BONE 142MM 13.5X3.7MM 6 HOLE LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,715.80 " "$2,009.69" $0.00 "$2,109.36" "$1,186.52" "$1,186.52" $0.00 $0.00 $0.00 $566.04 "$2,015.67" "$2,015.67" $0.00 $0.00 $565.97 $0.00 "$1,338.89" "$1,338.89" $0.00 "$1,318.35" "$2,088.27" "$2,109.36" $0.00 $0.00 $400.62 $0.00 $0.00 $419.76 $0.00 $0.00 $0.00 $0.00 $0.00 238.704 SUP HCPCS C1713 238.704 - PLATE BONE 168MM 13.5X3.7MM 8 HOLE LCP STAINLESS STEEL RIGHT BOTH IP/OP "$2,742.50 " "$2,029.45" $0.00 "$2,130.10" "$1,198.18" "$1,198.18" $0.00 $0.00 $0.00 $571.61 "$2,035.48" "$2,035.48" $0.00 $0.00 $571.54 $0.00 "$1,352.05" "$1,352.05" $0.00 "$1,331.31" "$2,108.80" "$2,130.10" $0.00 $0.00 $404.56 $0.00 $0.00 $423.89 $0.00 $0.00 $0.00 $0.00 $0.00 238.705 SUP HCPCS C1713 238.705 - PLATE BONE 168MM 13.5X3.7MM 8 HOLE LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,742.50 " "$2,029.45" $0.00 "$2,130.10" "$1,198.18" "$1,198.18" $0.00 $0.00 $0.00 $571.61 "$2,035.48" "$2,035.48" $0.00 $0.00 $571.54 $0.00 "$1,352.05" "$1,352.05" $0.00 "$1,331.31" "$2,108.80" "$2,130.10" $0.00 $0.00 $404.56 $0.00 $0.00 $423.89 $0.00 $0.00 $0.00 $0.00 $0.00 238.706 SUP HCPCS C1713 238.706 - PLATE BONE 194MM 13.5X3.7MM 10 HOLE LCP STAINLESS STEEL BOTH IP/OP "$2,770.63 " "$2,050.27" $0.00 "$2,151.94" "$1,210.47" "$1,210.47" $0.00 $0.00 $0.00 $577.47 "$2,056.36" "$2,056.36" $0.00 $0.00 $577.40 $0.00 "$1,365.92" "$1,365.92" $0.00 "$1,344.96" "$2,130.42" "$2,151.94" $0.00 $0.00 $408.71 $0.00 $0.00 $428.24 $0.00 $0.00 $0.00 $0.00 $0.00 238.707 SUP HCPCS C1713 238.707 - PLATE BONE 194MM 13.5X3.7MM 10 HOLE LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,770.63 " "$2,050.27" $0.00 "$2,151.94" "$1,210.47" "$1,210.47" $0.00 $0.00 $0.00 $577.47 "$2,056.36" "$2,056.36" $0.00 $0.00 $577.40 $0.00 "$1,365.92" "$1,365.92" $0.00 "$1,344.96" "$2,130.42" "$2,151.94" $0.00 $0.00 $408.71 $0.00 $0.00 $428.24 $0.00 $0.00 $0.00 $0.00 $0.00 238.708 SUP HCPCS C1713 238.708 - PLATE BONE 220MM 13.5X3.7MM 12 HOLE LCP STAINLESS STEEL BOTH IP/OP "$2,801.55 " "$2,073.15" $0.00 "$2,175.96" "$1,223.98" "$1,223.98" $0.00 $0.00 $0.00 $583.91 "$2,079.31" "$2,079.31" $0.00 $0.00 $583.84 $0.00 "$1,381.16" "$1,381.16" $0.00 "$1,359.98" "$2,154.20" "$2,175.96" $0.00 $0.00 $413.27 $0.00 $0.00 $433.02 $0.00 $0.00 $0.00 $0.00 $0.00 238.709 SUP HCPCS C1713 238.709 - PLATE BONE 220MM 13.5X3.7MM 12 HOLE LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,801.55 " "$2,073.15" $0.00 "$2,175.96" "$1,223.98" "$1,223.98" $0.00 $0.00 $0.00 $583.91 "$2,079.31" "$2,079.31" $0.00 $0.00 $583.84 $0.00 "$1,381.16" "$1,381.16" $0.00 "$1,359.98" "$2,154.20" "$2,175.96" $0.00 $0.00 $413.27 $0.00 $0.00 $433.02 $0.00 $0.00 $0.00 $0.00 $0.00 238.71 SUP HCPCS C1713 238.710 - PLATE BONE 246MM 14 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$2,755.43 " "$2,039.02" $0.00 "$2,204.34" "$1,239.94" "$1,239.94" $0.00 $0.00 $0.00 $574.30 "$2,045.08" "$2,045.08" $0.00 $0.00 $574.23 $0.00 "$1,358.42" "$1,358.42" $0.00 "$1,377.71" "$2,182.30" "$2,204.34" $0.00 $0.00 $418.66 $0.00 $0.00 $438.66 $0.00 $0.00 $0.00 $0.00 $0.00 238.711 SUP HCPCS C1713 238.711 - PLATE BONE 246MM 13.5X3.7MM 14 HOLE LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,838.10 " "$2,100.19" $0.00 "$2,204.34" "$1,239.94" "$1,239.94" $0.00 $0.00 $0.00 $591.53 "$2,106.44" "$2,106.44" $0.00 $0.00 $591.46 $0.00 "$1,399.18" "$1,399.18" $0.00 "$1,377.71" "$2,182.30" "$2,204.34" $0.00 $0.00 $418.66 $0.00 $0.00 $438.66 $0.00 $0.00 $0.00 $0.00 $0.00 238.94 SUP HCPCS C1713 238.94 - PLATE BONE 130D 152MM 70MM 9 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 238.96 SUP HCPCS C1713 238.96 - PLATE BONE 130D 152MM 80MM 9 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 238.98 SUP HCPCS C1713 238.98 - PLATE BONE 130D 154MM 90MM 9 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.2 SUP HCPCS C1713 239.20 - PLATE BN 90D 10MM DSPL 50MM NS DCP SS ADLT OSTM BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.21 SUP HCPCS C1713 239.21 - PLATE BN 90D 10MM DSPL 55MM NS DCP SS ADLT OSTM BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.22 SUP HCPCS C1713 239.22 - PLATE BONE 90D 10MM 60MMX94MM 4X1 HOLE BLADE DCP STAINLESS BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.23 SUP HCPCS C1713 239.23 - PLATE BONE 90D 10MM 65MMX94MM 4X1 HOLE BLADE DCP STAINLESS BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.24 SUP HCPCS C1713 239.24 - PLATE BONE 90D 10MM 70MMX94MM 4X1 HOLE BLADE DCP STAINLESS BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.28 SUP HCPCS C1713 239.28 - PLATE BN 90D 10MM DSPL 40MM NS DCP SS ADLT OSTM BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.3 SUP HCPCS C1713 239.30 - PLATE BONE 100D 10MM 50MMX94MM 4X1 HOLE BLADE DCP STAINLESS BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.32 SUP HCPCS C1713 239.32 - PLATE BONE 100D 10MM 60MMX94MM 4X1 HOLE BLADE DCP STAINLESS BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.43 SUP HCPCS C1713 239.43 - PLATE BONE 110D 65MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.45 SUP HCPCS C1713 239.45 - PLATE BONE 110D 75MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.47 SUP HCPCS C1713 239.47 - PLATE BONE 110D 85MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.53 SUP HCPCS C1713 239.53 - PLATE BONE 120D 65MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.55 SUP HCPCS C1713 239.55 - PLATE BONE 120D 75MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.57 SUP HCPCS C1713 239.57 - PLATE BONE 120D 85MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.6 SUP HCPCS C1713 239.60 - PLATE BONE 90D 10MM 50MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.62 SUP HCPCS C1713 239.62 - PLATE BONE 90D 20MM 60MMX94MM 4X1 HOLE BLADE DCP STAINLESS BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.64 SUP HCPCS C1713 239.64 - PLATE BONE 90D 20MM 70MMX94MM 4X1 HOLE BLADE DCP STAINLESS BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.7 SUP HCPCS C1713 239.70 - PLATE BONE 90D 15MM 50MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.71 SUP HCPCS C1713 239.71 - PLATE BONE 90D 15MM 55MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.72 SUP HCPCS C1713 239.72 - PLATE BONE 90D 15MM 60MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.73 SUP HCPCS C1713 239.73 - PLATE BONE 90D 15MM 65MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.74 SUP HCPCS C1713 239.74 - PLATE BONE 90D 15MM 70MMX94MM 4X1 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.78 SUP HCPCS C1713 239.78 - PLATE BONE 90D 15MM 40MMX94MM 4X1 HOLE BLADE DCP STAINLESS BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.8 SUP HCPCS C1713 239.80 - PLATE BONE 130D 100MMX94MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.81 SUP HCPCS C1713 239.81 - PLATE BONE 130D 105MMX94MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP $977.85 $723.61 $0.00 $782.28 $440.03 $440.03 $0.00 $0.00 $0.00 $203.81 $725.76 $725.76 $0.00 $0.00 $203.78 $0.00 $578.40 $578.40 $0.00 $488.93 $774.46 $782.28 $0.00 $0.00 $153.03 $0.00 $0.00 $155.67 $0.00 $0.00 $0.00 $0.00 $0.00 239.83 SUP HCPCS C1713 239.83 - PLATE BONE 130D 65MMX94MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.84 SUP HCPCS C1713 239.84 - PLATE BONE 130D 65MM 70MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.85 SUP HCPCS C1713 239.85 - PLATE BONE 130D 75MMX94MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.86 SUP HCPCS C1713 239.86 - PLATE BONE 130D 80MMX94MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.87 SUP HCPCS C1713 239.87 - PLATE BONE 130D 85MMX94MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.88 SUP HCPCS C1713 239.88 - PLATE BONE 130D 90MMX94MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.89 SUP HCPCS C1713 239.89 - PLATE BONE 130D 95MMX94MM 4X1 HOLE: ANGLED BLADE DCP BOTH IP/OP "$1,037.40 " $767.68 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $216.22 $769.96 $769.96 $0.00 $0.00 $216.19 $0.00 $613.62 $613.62 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 239.9 SUP HCPCS C1713 239.900 - PLATE BONE 116X11X3.7MM 4 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,734.95 " "$2,023.86" $0.00 "$2,187.96" "$1,230.73" "$1,230.73" $0.00 $0.00 $0.00 $570.03 "$2,029.88" "$2,029.88" $0.00 $0.00 $569.96 $0.00 "$1,348.33" "$1,348.33" $0.00 "$1,367.48" "$2,166.08" "$2,187.96" $0.00 $0.00 $415.55 $0.00 $0.00 $435.40 $0.00 $0.00 $0.00 $0.00 $0.00 239.901 SUP HCPCS C1713 239.901 - PLATE BONE 116X11X3.7MM 4 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,734.95 " "$2,023.86" $0.00 "$2,187.96" "$1,230.73" "$1,230.73" $0.00 $0.00 $0.00 $570.03 "$2,029.88" "$2,029.88" $0.00 $0.00 $569.96 $0.00 "$1,348.33" "$1,348.33" $0.00 "$1,367.48" "$2,166.08" "$2,187.96" $0.00 $0.00 $415.55 $0.00 $0.00 $435.40 $0.00 $0.00 $0.00 $0.00 $0.00 239.904 SUP HCPCS C1713 239.904 - PLATE BONE 142X11X3.7MM 6 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,763.63 " "$2,045.09" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $576.01 "$2,051.16" "$2,051.16" $0.00 $0.00 $575.94 $0.00 "$1,362.47" "$1,362.47" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 239.905 SUP HCPCS C1713 239.905 - PLATE BONE 142X11X3.7MM 6 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,763.63 " "$2,045.09" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $576.01 "$2,051.16" "$2,051.16" $0.00 $0.00 $575.94 $0.00 "$1,362.47" "$1,362.47" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 239.908 SUP HCPCS C1713 239.908 - PLATE BONE 168X11X3.7MM 8 HOLE PRECONTOURED LCP STAINLESS BOTH IP/OP "$2,789.55 " "$2,064.27" $0.00 "$2,231.64" "$1,255.30" "$1,255.30" $0.00 $0.00 $0.00 $581.41 "$2,070.40" "$2,070.40" $0.00 $0.00 $581.34 $0.00 "$1,375.25" "$1,375.25" $0.00 "$1,394.78" "$2,209.32" "$2,231.64" $0.00 $0.00 $423.85 $0.00 $0.00 $444.10 $0.00 $0.00 $0.00 $0.00 $0.00 239.909 SUP HCPCS C1713 239.909 - PLATE BONE 168X11X3.7MM 8 HOLE PRECONTOURED LCP STAINLESS BOTH IP/OP "$2,789.55 " "$2,064.27" $0.00 "$2,231.64" "$1,255.30" "$1,255.30" $0.00 $0.00 $0.00 $581.41 "$2,070.40" "$2,070.40" $0.00 $0.00 $581.34 $0.00 "$1,375.25" "$1,375.25" $0.00 "$1,394.78" "$2,209.32" "$2,231.64" $0.00 $0.00 $423.85 $0.00 $0.00 $444.10 $0.00 $0.00 $0.00 $0.00 $0.00 239.912 SUP HCPCS C1713 239.912 - PLATE BONE 194X11X3.7MM 10 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,820.95 " "$2,087.50" $0.00 "$2,256.76" "$1,269.43" "$1,269.43" $0.00 $0.00 $0.00 $587.96 "$2,093.71" "$2,093.71" $0.00 $0.00 $587.89 $0.00 "$1,390.73" "$1,390.73" $0.00 "$1,410.48" "$2,234.19" "$2,256.76" $0.00 $0.00 $428.62 $0.00 $0.00 $449.10 $0.00 $0.00 $0.00 $0.00 $0.00 239.913 SUP HCPCS C1713 239.913 - PLATE BONE 194X11X3.7MM 10 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,820.95 " "$2,087.50" $0.00 "$2,256.76" "$1,269.43" "$1,269.43" $0.00 $0.00 $0.00 $587.96 "$2,093.71" "$2,093.71" $0.00 $0.00 $587.89 $0.00 "$1,390.73" "$1,390.73" $0.00 "$1,410.48" "$2,234.19" "$2,256.76" $0.00 $0.00 $428.62 $0.00 $0.00 $449.10 $0.00 $0.00 $0.00 $0.00 $0.00 239.916 SUP HCPCS C1713 239.916 - PLATE BONE 220X11X3.7MM 12 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,850.98 " "$2,109.73" $0.00 "$2,280.78" "$1,282.94" "$1,282.94" $0.00 $0.00 $0.00 $594.21 "$2,115.99" "$2,115.99" $0.00 $0.00 $594.14 $0.00 "$1,405.53" "$1,405.53" $0.00 "$1,425.49" "$2,257.98" "$2,280.78" $0.00 $0.00 $433.18 $0.00 $0.00 $453.88 $0.00 $0.00 $0.00 $0.00 $0.00 239.917 SUP HCPCS C1713 239.917 - PLATE BONE 220X11X3.7MM 12 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,850.98 " "$2,109.73" $0.00 "$2,280.78" "$1,282.94" "$1,282.94" $0.00 $0.00 $0.00 $594.21 "$2,115.99" "$2,115.99" $0.00 $0.00 $594.14 $0.00 "$1,405.53" "$1,405.53" $0.00 "$1,425.49" "$2,257.98" "$2,280.78" $0.00 $0.00 $433.18 $0.00 $0.00 $453.88 $0.00 $0.00 $0.00 $0.00 $0.00 239.92 SUP HCPCS C1713 239.920 - PLATE BONE 246X11X3.7MM 14 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,886.45 " "$2,135.97" $0.00 "$2,309.16" "$1,298.90" "$1,298.90" $0.00 $0.00 $0.00 $601.61 "$2,142.32" "$2,142.32" $0.00 $0.00 $601.54 $0.00 "$1,423.02" "$1,423.02" $0.00 "$1,443.23" "$2,286.07" "$2,309.16" $0.00 $0.00 $438.57 $0.00 $0.00 $459.52 $0.00 $0.00 $0.00 $0.00 $0.00 239.921 SUP HCPCS C1713 239.921 - PLATE BONE 246X11X3.7MM 14 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$2,886.45 " "$2,135.97" $0.00 "$2,309.16" "$1,298.90" "$1,298.90" $0.00 $0.00 $0.00 $601.61 "$2,142.32" "$2,142.32" $0.00 $0.00 $601.54 $0.00 "$1,423.02" "$1,423.02" $0.00 "$1,443.23" "$2,286.07" "$2,309.16" $0.00 $0.00 $438.57 $0.00 $0.00 $459.52 $0.00 $0.00 $0.00 $0.00 $0.00 239.934 SUP HCPCS C1713 239.934 - PLATE BN CNTR 81MM NS LCP CMBN 4 HL LMT CNTCT SS TIB RT PROX BOTH IP/OP "$2,663.78 " "$1,971.20" $0.00 "$2,068.96" "$1,163.79" "$1,163.79" $0.00 $0.00 $0.00 $555.20 "$1,977.05" "$1,977.05" $0.00 $0.00 $555.13 $0.00 "$1,313.24" "$1,313.24" $0.00 "$1,293.10" "$2,048.27" "$2,068.96" $0.00 $0.00 $392.95 $0.00 $0.00 $411.72 $0.00 $0.00 $0.00 $0.00 $0.00 239.935 SUP HCPCS C1713 239.935 - PLATE BN CNTR 81MM NS LCP CMBN 4 HL LMT CNTCT SS TIB LT PROX BOTH IP/OP "$2,663.78 " "$1,971.20" $0.00 "$2,068.96" "$1,163.79" "$1,163.79" $0.00 $0.00 $0.00 $555.20 "$1,977.05" "$1,977.05" $0.00 $0.00 $555.13 $0.00 "$1,313.24" "$1,313.24" $0.00 "$1,293.10" "$2,048.27" "$2,068.96" $0.00 $0.00 $392.95 $0.00 $0.00 $411.72 $0.00 $0.00 $0.00 $0.00 $0.00 239.936 SUP HCPCS C1713 239.936 - PLATE BN CNTR 107MM NS LCP CMBN 6 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,696.13 " "$1,995.14" $0.00 "$2,094.08" "$1,177.92" "$1,177.92" $0.00 $0.00 $0.00 $561.94 "$2,001.06" "$2,001.06" $0.00 $0.00 $561.87 $0.00 "$1,329.19" "$1,329.19" $0.00 "$1,308.80" "$2,073.14" "$2,094.08" $0.00 $0.00 $397.72 $0.00 $0.00 $416.72 $0.00 $0.00 $0.00 $0.00 $0.00 239.937 SUP HCPCS C1713 239.937 - PLATE BN CNTR 107MM NS LCP CMBN 6 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,696.13 " "$1,995.14" $0.00 "$2,094.08" "$1,177.92" "$1,177.92" $0.00 $0.00 $0.00 $561.94 "$2,001.06" "$2,001.06" $0.00 $0.00 $561.87 $0.00 "$1,329.19" "$1,329.19" $0.00 "$1,308.80" "$2,073.14" "$2,094.08" $0.00 $0.00 $397.72 $0.00 $0.00 $416.72 $0.00 $0.00 $0.00 $0.00 $0.00 239.938 SUP HCPCS C1713 239.938 - PLATE BN CNTR 133MM NS LCP CMBN 8 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,727.05 " "$2,018.02" $0.00 "$2,118.10" "$1,191.43" "$1,191.43" $0.00 $0.00 $0.00 $568.39 "$2,024.02" "$2,024.02" $0.00 $0.00 $568.32 $0.00 "$1,344.44" "$1,344.44" $0.00 "$1,323.81" "$2,096.92" "$2,118.10" $0.00 $0.00 $402.28 $0.00 $0.00 $421.50 $0.00 $0.00 $0.00 $0.00 $0.00 239.939 SUP HCPCS C1713 239.939 - PLATE BN CNTR 133MM NS LCP CMBN 8 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,727.05 " "$2,018.02" $0.00 "$2,118.10" "$1,191.43" "$1,191.43" $0.00 $0.00 $0.00 $568.39 "$2,024.02" "$2,024.02" $0.00 $0.00 $568.32 $0.00 "$1,344.44" "$1,344.44" $0.00 "$1,323.81" "$2,096.92" "$2,118.10" $0.00 $0.00 $402.28 $0.00 $0.00 $421.50 $0.00 $0.00 $0.00 $0.00 $0.00 239.94 SUP HCPCS C1713 239.940 - PLATE BN CNTR 159MM NS LCP CMBN 10 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,676.28 " "$1,980.45" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $557.80 "$1,986.33" "$1,986.33" $0.00 $0.00 $557.74 $0.00 "$1,319.40" "$1,319.40" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 239.941 SUP HCPCS C1713 239.941 - PLATE BN CNTR 159MM NS LCP CMBN 10 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,756.58 " "$2,039.87" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $574.54 "$2,045.93" "$2,045.93" $0.00 $0.00 $574.47 $0.00 "$1,358.99" "$1,358.99" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 239.942 SUP HCPCS C1713 239.942 - PLATE BN CNTR 185MM NS LCP CMBN 12 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,793.10 " "$2,066.89" $0.00 "$2,169.40" "$1,220.29" "$1,220.29" $0.00 $0.00 $0.00 $582.15 "$2,073.04" "$2,073.04" $0.00 $0.00 $582.08 $0.00 "$1,377.00" "$1,377.00" $0.00 "$1,355.88" "$2,147.71" "$2,169.40" $0.00 $0.00 $412.03 $0.00 $0.00 $431.71 $0.00 $0.00 $0.00 $0.00 $0.00 239.943 SUP HCPCS C1713 239.943 - PLATE BN CNTR 185MM NS LCP CMBN 12 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,793.10 " "$2,066.89" $0.00 "$2,169.40" "$1,220.29" "$1,220.29" $0.00 $0.00 $0.00 $582.15 "$2,073.04" "$2,073.04" $0.00 $0.00 $582.08 $0.00 "$1,377.00" "$1,377.00" $0.00 "$1,355.88" "$2,147.71" "$2,169.40" $0.00 $0.00 $412.03 $0.00 $0.00 $431.71 $0.00 $0.00 $0.00 $0.00 $0.00 239.944 SUP HCPCS C1713 239.944 - PLATE BN CNTR 211MM NS LCP CMBN 14 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,822.63 " "$2,088.75" $0.00 "$2,192.34" "$1,233.19" "$1,233.19" $0.00 $0.00 $0.00 $588.31 "$2,094.95" "$2,094.95" $0.00 $0.00 $588.24 $0.00 "$1,391.55" "$1,391.55" $0.00 "$1,370.21" "$2,170.42" "$2,192.34" $0.00 $0.00 $416.38 $0.00 $0.00 $436.28 $0.00 $0.00 $0.00 $0.00 $0.00 239.945 SUP HCPCS C1713 239.945 - PLATE BN CNTR 211MM NS LCP CMBN 14 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,918.23 " "$2,159.49" $0.00 "$2,266.58" "$1,274.95" "$1,274.95" $0.00 $0.00 $0.00 $608.23 "$2,165.91" "$2,165.91" $0.00 $0.00 $608.16 $0.00 "$1,438.68" "$1,438.68" $0.00 "$1,416.61" "$2,243.92" "$2,266.58" $0.00 $0.00 $430.48 $0.00 $0.00 $451.05 $0.00 $0.00 $0.00 $0.00 $0.00 239.946 SUP HCPCS C1713 239.946 - PLATE BN CNTR 237MM NS LCP CMBN 16 HL LMT CNTCT SS TIB RT BOTH IP/OP "$3,020.83 " "$2,235.41" $0.00 "$2,346.28" "$1,319.78" "$1,319.78" $0.00 $0.00 $0.00 $629.62 "$2,242.06" "$2,242.06" $0.00 $0.00 $629.54 $0.00 "$1,489.27" "$1,489.27" $0.00 "$1,466.43" "$2,322.82" "$2,346.28" $0.00 $0.00 $445.62 $0.00 $0.00 $466.91 $0.00 $0.00 $0.00 $0.00 $0.00 239.947 SUP HCPCS C1713 239.947 - PLATE BN CNTR 237MM NS LCP CMBN 16 HL LMT CNTCT SS TIB LT BOTH IP/OP "$3,020.83 " "$2,235.41" $0.00 "$2,346.28" "$1,319.78" "$1,319.78" $0.00 $0.00 $0.00 $629.62 "$2,242.06" "$2,242.06" $0.00 $0.00 $629.54 $0.00 "$1,489.27" "$1,489.27" $0.00 "$1,466.43" "$2,322.82" "$2,346.28" $0.00 $0.00 $445.62 $0.00 $0.00 $466.91 $0.00 $0.00 $0.00 $0.00 $0.00 239.954 SUP HCPCS C1713 239.954 - PLATE 94MM SS 3.5MM SCR 4 HOLE LCP BONE RIGHT PROX TIB BOTH IP/OP "$2,655.35 " "$1,964.96" $0.00 "$2,610.74" "$1,468.54" "$1,468.54" $0.00 $0.00 $0.00 $553.44 "$1,970.80" "$1,970.80" $0.00 $0.00 $553.37 $0.00 "$1,309.09" "$1,309.09" $0.00 "$1,631.71" "$2,584.64" "$2,610.74" $0.00 $0.00 $510.73 $0.00 $0.00 $519.54 $0.00 $0.00 $0.00 $0.00 $0.00 239.955 SUP HCPCS C1713 239.955 - PLATE BN CNTR 93MM NS LCP CMBN 4 HL LMT CNTCT SS TIB LT PROX BOTH IP/OP "$2,502.93 " "$1,852.17" $0.00 "$2,002.34" "$1,126.32" "$1,126.32" $0.00 $0.00 $0.00 $521.67 "$1,857.67" "$1,857.67" $0.00 $0.00 $521.61 $0.00 "$1,233.94" "$1,233.94" $0.00 "$1,251.46" "$1,982.32" "$2,002.34" $0.00 $0.00 $391.71 $0.00 $0.00 $398.47 $0.00 $0.00 $0.00 $0.00 $0.00 239.956 SUP HCPCS C1713 239.956 - PLATE 119MM SS 3.5MM SCR 6 HOLE LCP BONE RIGHT MDL PROX TIB BOTH IP/OP "$2,690.50 " "$1,990.97" $0.00 "$2,643.40" "$1,486.91" "$1,486.91" $0.00 $0.00 $0.00 $560.77 "$1,996.89" "$1,996.89" $0.00 $0.00 $560.70 $0.00 "$1,326.42" "$1,326.42" $0.00 "$1,652.13" "$2,616.97" "$2,643.40" $0.00 $0.00 $517.12 $0.00 $0.00 $526.04 $0.00 $0.00 $0.00 $0.00 $0.00 239.957 SUP HCPCS C1713 239.957 - PLATE BN CNTR 119MM NS LCP CMBN 6 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,690.50 " "$1,990.97" $0.00 "$2,089.70" "$1,175.46" "$1,175.46" $0.00 $0.00 $0.00 $560.77 "$1,996.89" "$1,996.89" $0.00 $0.00 $560.70 $0.00 "$1,326.42" "$1,326.42" $0.00 "$1,306.06" "$2,068.81" "$2,089.70" $0.00 $0.00 $396.89 $0.00 $0.00 $415.85 $0.00 $0.00 $0.00 $0.00 $0.00 239.958 SUP HCPCS C1713 239.958 - PLATE BN CNTR 145MM NS LCP CMBN 8 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,722.83 " "$2,014.89" $0.00 "$2,114.82" "$1,189.59" "$1,189.59" $0.00 $0.00 $0.00 $567.50 "$2,020.88" "$2,020.88" $0.00 $0.00 $567.44 $0.00 "$1,342.35" "$1,342.35" $0.00 "$1,321.76" "$2,093.68" "$2,114.82" $0.00 $0.00 $401.66 $0.00 $0.00 $420.85 $0.00 $0.00 $0.00 $0.00 $0.00 239.959 SUP HCPCS C1713 239.959 - PLATE BN CNTR 145MM NS LCP CMBN 8 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,722.83 " "$2,014.89" $0.00 "$2,114.82" "$1,189.59" "$1,189.59" $0.00 $0.00 $0.00 $567.50 "$2,020.88" "$2,020.88" $0.00 $0.00 $567.44 $0.00 "$1,342.35" "$1,342.35" $0.00 "$1,321.76" "$2,093.68" "$2,114.82" $0.00 $0.00 $401.66 $0.00 $0.00 $420.85 $0.00 $0.00 $0.00 $0.00 $0.00 239.96 SUP HCPCS C1713 239.960 - PLATE BN CNTR 171MM NS LCP CMBN 10 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,673.55 " "$1,978.43" $0.00 "$2,138.84" "$1,203.10" "$1,203.10" $0.00 $0.00 $0.00 $557.23 "$1,984.31" "$1,984.31" $0.00 $0.00 $557.17 $0.00 "$1,318.06" "$1,318.06" $0.00 "$1,336.78" "$2,117.45" "$2,138.84" $0.00 $0.00 $406.22 $0.00 $0.00 $425.63 $0.00 $0.00 $0.00 $0.00 $0.00 239.961 SUP HCPCS C1713 239.961 - PLATE BN CNTR 171MM NS LCP CMBN 10 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,753.75 " "$2,037.78" $0.00 "$2,138.84" "$1,203.10" "$1,203.10" $0.00 $0.00 $0.00 $573.95 "$2,043.83" "$2,043.83" $0.00 $0.00 $573.88 $0.00 "$1,357.60" "$1,357.60" $0.00 "$1,336.78" "$2,117.45" "$2,138.84" $0.00 $0.00 $406.22 $0.00 $0.00 $425.63 $0.00 $0.00 $0.00 $0.00 $0.00 239.962 SUP HCPCS C1713 239.962 - PLATE BN CNTR 197MM NS LCP CMBN 12 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,783.28 " "$2,059.63" $0.00 "$2,161.76" "$1,215.99" "$1,215.99" $0.00 $0.00 $0.00 $580.10 "$2,065.75" "$2,065.75" $0.00 $0.00 $580.03 $0.00 "$1,372.15" "$1,372.15" $0.00 "$1,351.10" "$2,140.14" "$2,161.76" $0.00 $0.00 $410.58 $0.00 $0.00 $430.19 $0.00 $0.00 $0.00 $0.00 $0.00 239.963 SUP HCPCS C1713 239.963 - PLATE BN CNTR 197MM NS LCP CMBN 12 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,783.28 " "$2,059.63" $0.00 "$2,161.76" "$1,215.99" "$1,215.99" $0.00 $0.00 $0.00 $580.10 "$2,065.75" "$2,065.75" $0.00 $0.00 $580.03 $0.00 "$1,372.15" "$1,372.15" $0.00 "$1,351.10" "$2,140.14" "$2,161.76" $0.00 $0.00 $410.58 $0.00 $0.00 $430.19 $0.00 $0.00 $0.00 $0.00 $0.00 239.964 SUP HCPCS C1713 239.964 - PLATE BN CNTR 223MM NS LCP CMBN 4 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,817.00 " "$2,084.58" $0.00 "$2,187.96" "$1,230.73" "$1,230.73" $0.00 $0.00 $0.00 $587.13 "$2,090.78" "$2,090.78" $0.00 $0.00 $587.06 $0.00 "$1,388.78" "$1,388.78" $0.00 "$1,367.48" "$2,166.08" "$2,187.96" $0.00 $0.00 $415.55 $0.00 $0.00 $435.40 $0.00 $0.00 $0.00 $0.00 $0.00 239.965 SUP HCPCS C1713 239.965 - PLATE BN CNTR 223MM NS LCP CMBN 4 HL LMT CNTCT SS TIB LT BOTH IP/OP "$2,817.00 " "$2,084.58" $0.00 "$2,187.96" "$1,230.73" "$1,230.73" $0.00 $0.00 $0.00 $587.13 "$2,090.78" "$2,090.78" $0.00 $0.00 $587.06 $0.00 "$1,388.78" "$1,388.78" $0.00 "$1,367.48" "$2,166.08" "$2,187.96" $0.00 $0.00 $415.55 $0.00 $0.00 $435.40 $0.00 $0.00 $0.00 $0.00 $0.00 239.966 SUP HCPCS C1713 239.966 - PLATE BN CNTR 249MM NS LCP CMBN 16 HL LMT CNTCT SS TIB RT BOTH IP/OP "$3,013.80 " "$2,230.21" $0.00 "$2,340.82" "$1,316.71" "$1,316.71" $0.00 $0.00 $0.00 $628.15 "$2,236.84" "$2,236.84" $0.00 $0.00 $628.08 $0.00 "$1,485.80" "$1,485.80" $0.00 "$1,463.01" "$2,317.42" "$2,340.82" $0.00 $0.00 $444.59 $0.00 $0.00 $465.82 $0.00 $0.00 $0.00 $0.00 $0.00 239.967 SUP HCPCS C1713 239.967 - PLATE BN CNTR 249MM NS LCP CMBN 16 HL LMT CNTCT SS TIB LT BOTH IP/OP "$3,013.80 " "$2,230.21" $0.00 "$2,340.82" "$1,316.71" "$1,316.71" $0.00 $0.00 $0.00 $628.15 "$2,236.84" "$2,236.84" $0.00 $0.00 $628.08 $0.00 "$1,485.80" "$1,485.80" $0.00 "$1,463.01" "$2,317.42" "$2,340.82" $0.00 $0.00 $444.59 $0.00 $0.00 $465.82 $0.00 $0.00 $0.00 $0.00 $0.00 239.968 SUP HCPCS C1713 239.968 - PLATE BN CNTR 275MM NS LCP CMBN 18 HL LMT CNTCT SS TIB RT BOTH IP/OP "$3,122.05 " "$2,310.32" $0.00 "$2,424.88" "$1,364.00" "$1,364.00" $0.00 $0.00 $0.00 $650.71 "$2,317.19" "$2,317.19" $0.00 $0.00 $650.64 $0.00 "$1,539.17" "$1,539.17" $0.00 "$1,515.55" "$2,400.63" "$2,424.88" $0.00 $0.00 $460.55 $0.00 $0.00 $482.55 $0.00 $0.00 $0.00 $0.00 $0.00 239.969 SUP HCPCS C1713 239.969 - PLATE BN CNTR 275MM NS LCP CMBN 18 HL LMT CNTCT SS TIB LT BOTH IP/OP "$3,122.05 " "$2,310.32" $0.00 "$2,424.88" "$1,364.00" "$1,364.00" $0.00 $0.00 $0.00 $650.71 "$2,317.19" "$2,317.19" $0.00 $0.00 $650.64 $0.00 "$1,539.17" "$1,539.17" $0.00 "$1,515.55" "$2,400.63" "$2,424.88" $0.00 $0.00 $460.55 $0.00 $0.00 $482.55 $0.00 $0.00 $0.00 $0.00 $0.00 239.97 SUP HCPCS C1713 239.970 - PLATE BN CNTR 301MM NS LCP CMBN 20 HL LMT CNTCT SS TIB RT BOTH IP/OP "$3,130.73 " "$2,316.74" $0.00 "$2,504.58" "$1,408.83" "$1,408.83" $0.00 $0.00 $0.00 $652.52 "$2,323.62" "$2,323.62" $0.00 $0.00 $652.44 $0.00 "$1,543.45" "$1,543.45" $0.00 "$1,565.36" "$2,479.54" "$2,504.58" $0.00 $0.00 $475.69 $0.00 $0.00 $498.41 $0.00 $0.00 $0.00 $0.00 $0.00 239.971 SUP HCPCS C1713 239.971 - PLATE BN CNTR 301MM NS LCP CMBN 20 HL LMT CNTCT SS TIB LT BOTH IP/OP "$3,224.65 " "$2,386.24" $0.00 "$2,504.58" "$1,408.83" "$1,408.83" $0.00 $0.00 $0.00 $672.10 "$2,393.34" "$2,393.34" $0.00 $0.00 $672.02 $0.00 "$1,589.75" "$1,589.75" $0.00 "$1,565.36" "$2,479.54" "$2,504.58" $0.00 $0.00 $475.69 $0.00 $0.00 $498.41 $0.00 $0.00 $0.00 $0.00 $0.00 239.984 SUP HCPCS C1713 239.984 - PLATE BONE 106MM 4 HOLE PRECONTOUR LCP STAINLESS STEEL RIGHT BOTH IP/OP "$2,665.20 " "$1,972.25" $0.00 "$2,070.06" "$1,164.41" "$1,164.41" $0.00 $0.00 $0.00 $555.49 "$1,978.11" "$1,978.11" $0.00 $0.00 $555.43 $0.00 "$1,313.94" "$1,313.94" $0.00 "$1,293.79" "$2,049.36" "$2,070.06" $0.00 $0.00 $393.16 $0.00 $0.00 $411.94 $0.00 $0.00 $0.00 $0.00 $0.00 239.985 SUP HCPCS C1713 239.985 - PLATE BONE 106MM 4 HOLE PRECONTOUR LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,665.20 " "$1,972.25" $0.00 "$2,070.06" "$1,164.41" "$1,164.41" $0.00 $0.00 $0.00 $555.49 "$1,978.11" "$1,978.11" $0.00 $0.00 $555.43 $0.00 "$1,313.94" "$1,313.94" $0.00 "$1,293.79" "$2,049.36" "$2,070.06" $0.00 $0.00 $393.16 $0.00 $0.00 $411.94 $0.00 $0.00 $0.00 $0.00 $0.00 239.986 SUP HCPCS C1713 239.986 - PLATE BONE 142MM 6 HOLE PRECONTOUR LCP STAINLESS STEEL RIGHT BOTH IP/OP "$2,697.53 " "$1,996.17" $0.00 "$2,095.16" "$1,178.53" "$1,178.53" $0.00 $0.00 $0.00 $562.23 "$2,002.10" "$2,002.10" $0.00 $0.00 $562.16 $0.00 "$1,329.88" "$1,329.88" $0.00 "$1,309.48" "$2,074.21" "$2,095.16" $0.00 $0.00 $397.93 $0.00 $0.00 $416.94 $0.00 $0.00 $0.00 $0.00 $0.00 239.987 SUP HCPCS C1713 239.987 - PLATE BONE 142MM 6 HOLE PRECONTOUR LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,697.53 " "$1,996.17" $0.00 "$2,095.16" "$1,178.53" "$1,178.53" $0.00 $0.00 $0.00 $562.23 "$2,002.10" "$2,002.10" $0.00 $0.00 $562.16 $0.00 "$1,329.88" "$1,329.88" $0.00 "$1,309.48" "$2,074.21" "$2,095.16" $0.00 $0.00 $397.93 $0.00 $0.00 $416.94 $0.00 $0.00 $0.00 $0.00 $0.00 239.988 SUP HCPCS C1713 239.988 - PLATE BONE 178MM 8 HOLE LIMITED CONTACT PROFILE LCP BOTH IP/OP "$2,728.45 " "$2,019.05" $0.00 "$2,119.18" "$1,192.04" "$1,192.04" $0.00 $0.00 $0.00 $568.68 "$2,025.06" "$2,025.06" $0.00 $0.00 $568.61 $0.00 "$1,345.13" "$1,345.13" $0.00 "$1,324.49" "$2,097.99" "$2,119.18" $0.00 $0.00 $402.49 $0.00 $0.00 $421.72 $0.00 $0.00 $0.00 $0.00 $0.00 239.989 SUP HCPCS C1713 239.989 - PLATE BONE 178MM 8 HOLE LIMITED CONTACT PROFILE LCP BOTH IP/OP "$2,728.45 " "$2,019.05" $0.00 "$2,119.18" "$1,192.04" "$1,192.04" $0.00 $0.00 $0.00 $568.68 "$2,025.06" "$2,025.06" $0.00 $0.00 $568.61 $0.00 "$1,345.13" "$1,345.13" $0.00 "$1,324.49" "$2,097.99" "$2,119.18" $0.00 $0.00 $402.49 $0.00 $0.00 $421.72 $0.00 $0.00 $0.00 $0.00 $0.00 239.99 SUP HCPCS C1713 239.990 - PLATE BONE 214MM 10 HOLE LCP STAINLESS STEEL RIGHT PROXIMAL BOTH IP/OP "$2,677.65 " "$1,981.46" $0.00 "$2,142.12" "$1,204.94" "$1,204.94" $0.00 $0.00 $0.00 $558.09 "$1,987.35" "$1,987.35" $0.00 $0.00 $558.02 $0.00 "$1,320.08" "$1,320.08" $0.00 "$1,338.83" "$2,120.70" "$2,142.12" $0.00 $0.00 $406.85 $0.00 $0.00 $426.28 $0.00 $0.00 $0.00 $0.00 $0.00 239.991 SUP HCPCS C1713 239.991 - PLATE BONE 214MM 10 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$2,757.98 " "$2,040.91" $0.00 "$2,142.12" "$1,204.94" "$1,204.94" $0.00 $0.00 $0.00 $574.83 "$2,046.97" "$2,046.97" $0.00 $0.00 $574.76 $0.00 "$1,359.68" "$1,359.68" $0.00 "$1,338.83" "$2,120.70" "$2,142.12" $0.00 $0.00 $406.85 $0.00 $0.00 $426.28 $0.00 $0.00 $0.00 $0.00 $0.00 239.992 SUP HCPCS C1713 239.992 - PLATE BONE 250MM 12 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$2,887.30 " "$2,136.60" $0.00 "$2,242.56" "$1,261.44" "$1,261.44" $0.00 $0.00 $0.00 $601.79 "$2,142.95" "$2,142.95" $0.00 $0.00 $601.71 $0.00 "$1,423.44" "$1,423.44" $0.00 "$1,401.60" "$2,220.13" "$2,242.56" $0.00 $0.00 $425.92 $0.00 $0.00 $446.27 $0.00 $0.00 $0.00 $0.00 $0.00 239.993 SUP HCPCS C1713 239.993 - PLATE BONE 250MM 12 HOLE LIMITED CONTACT PROFILE LCP BOTH IP/OP "$2,887.30 " "$2,136.60" $0.00 "$2,242.56" "$1,261.44" "$1,261.44" $0.00 $0.00 $0.00 $601.79 "$2,142.95" "$2,142.95" $0.00 $0.00 $601.71 $0.00 "$1,423.44" "$1,423.44" $0.00 "$1,401.60" "$2,220.13" "$2,242.56" $0.00 $0.00 $425.92 $0.00 $0.00 $446.27 $0.00 $0.00 $0.00 $0.00 $0.00 239.994 SUP HCPCS C1713 239.994 - PLATE BONE 286MM 14 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$2,918.23 " "$2,159.49" $0.00 "$2,266.58" "$1,274.95" "$1,274.95" $0.00 $0.00 $0.00 $608.23 "$2,165.91" "$2,165.91" $0.00 $0.00 $608.16 $0.00 "$1,438.68" "$1,438.68" $0.00 "$1,416.61" "$2,243.92" "$2,266.58" $0.00 $0.00 $430.48 $0.00 $0.00 $451.05 $0.00 $0.00 $0.00 $0.00 $0.00 239.995 SUP HCPCS C1713 239.995 - PLATE BONE 286MM 14 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$2,918.23 " "$2,159.49" $0.00 "$2,266.58" "$1,274.95" "$1,274.95" $0.00 $0.00 $0.00 $608.23 "$2,165.91" "$2,165.91" $0.00 $0.00 $608.16 $0.00 "$1,438.68" "$1,438.68" $0.00 "$1,416.61" "$2,243.92" "$2,266.58" $0.00 $0.00 $430.48 $0.00 $0.00 $451.05 $0.00 $0.00 $0.00 $0.00 $0.00 239.996 SUP HCPCS C1713 239.996 - PLATE BONE 322MM 16 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$2,947.73 " "$2,181.32" $0.00 "$2,289.50" "$1,287.84" "$1,287.84" $0.00 $0.00 $0.00 $614.38 "$2,187.80" "$2,187.80" $0.00 $0.00 $614.31 $0.00 "$1,453.23" "$1,453.23" $0.00 "$1,430.94" "$2,266.61" "$2,289.50" $0.00 $0.00 $434.84 $0.00 $0.00 $455.61 $0.00 $0.00 $0.00 $0.00 $0.00 239.997 SUP HCPCS C1713 239.997 - PLATE BONE 322MM 16 HOLE LCP STAINLESS STEEL LEFT PROXIMAL BOTH IP/OP "$2,947.73 " "$2,181.32" $0.00 "$2,289.50" "$1,287.84" "$1,287.84" $0.00 $0.00 $0.00 $614.38 "$2,187.80" "$2,187.80" $0.00 $0.00 $614.31 $0.00 "$1,453.23" "$1,453.23" $0.00 "$1,430.94" "$2,266.61" "$2,289.50" $0.00 $0.00 $434.84 $0.00 $0.00 $455.61 $0.00 $0.00 $0.00 $0.00 $0.00 240.002 SUP HCPCS C1713 240.002 - PLATE BONE 41MM 2 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$2,154.93 " "$1,594.65" $0.00 "$1,673.72" $941.47 $941.47 $0.00 $0.00 $0.00 $449.14 "$1,599.39" "$1,599.39" $0.00 $0.00 $449.09 $0.00 "$1,274.64" "$1,274.64" $0.00 "$1,046.08" "$1,656.98" "$1,673.72" $0.00 $0.00 $317.89 $0.00 $0.00 $333.07 $0.00 $0.00 $0.00 $0.00 $0.00 240.003 SUP HCPCS C1713 240.003 - PLATE BONE 41MM 2 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$2,154.93 " "$1,594.65" $0.00 "$1,673.72" $941.47 $941.47 $0.00 $0.00 $0.00 $449.14 "$1,599.39" "$1,599.39" $0.00 $0.00 $449.09 $0.00 "$1,274.64" "$1,274.64" $0.00 "$1,046.08" "$1,656.98" "$1,673.72" $0.00 $0.00 $317.89 $0.00 $0.00 $333.07 $0.00 $0.00 $0.00 $0.00 $0.00 240.004 SUP HCPCS C1713 240.004 - PLATE BONE 73MM 4 HOLE LCP STAINLESS STEEL RIGHT PROXIMAL BOTH IP/OP "$2,160.55 " "$1,598.81" $0.00 "$1,678.10" $943.93 $943.93 $0.00 $0.00 $0.00 $450.31 "$1,603.56" "$1,603.56" $0.00 $0.00 $450.26 $0.00 "$1,277.97" "$1,277.97" $0.00 "$1,048.81" "$1,661.32" "$1,678.10" $0.00 $0.00 $318.72 $0.00 $0.00 $333.94 $0.00 $0.00 $0.00 $0.00 $0.00 240.005 SUP HCPCS C1713 240.005 - PLATE BONE 73MM 4 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$2,160.55 " "$1,598.81" $0.00 "$1,678.10" $943.93 $943.93 $0.00 $0.00 $0.00 $450.31 "$1,603.56" "$1,603.56" $0.00 $0.00 $450.26 $0.00 "$1,277.97" "$1,277.97" $0.00 "$1,048.81" "$1,661.32" "$1,678.10" $0.00 $0.00 $318.72 $0.00 $0.00 $333.94 $0.00 $0.00 $0.00 $0.00 $0.00 240.006 SUP HCPCS C1713 240.006 - PLATE BONE 109MM 6 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$2,164.78 " "$1,601.94" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $451.19 "$1,606.70" "$1,606.70" $0.00 $0.00 $451.14 $0.00 "$1,280.46" "$1,280.46" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $319.34 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 240.007 SUP HCPCS C1713 240.007 - PLATE BONE 109MM 6 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$2,164.78 " "$1,601.94" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $451.19 "$1,606.70" "$1,606.70" $0.00 $0.00 $451.14 $0.00 "$1,280.46" "$1,280.46" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $319.34 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 240.008 SUP HCPCS C1713 240.008 - PLATE BONE 145MM 8 HOLE LCP STAINLESS STEEL RIGHT PROXIMAL BOTH IP/OP "$2,240.68 " "$1,658.10" $0.00 "$1,740.32" $978.93 $978.93 $0.00 $0.00 $0.00 $467.01 "$1,663.03" "$1,663.03" $0.00 $0.00 $466.96 $0.00 "$1,325.36" "$1,325.36" $0.00 "$1,087.70" "$1,722.92" "$1,740.32" $0.00 $0.00 $330.54 $0.00 $0.00 $346.32 $0.00 $0.00 $0.00 $0.00 $0.00 240.009 SUP HCPCS C1713 240.009 - PLATE BONE 145MM 8 HOLE LCP STAINLESS STEEL LEFT PROXIMAL BOTH IP/OP "$2,240.68 " "$1,658.10" $0.00 "$1,740.32" $978.93 $978.93 $0.00 $0.00 $0.00 $467.01 "$1,663.03" "$1,663.03" $0.00 $0.00 $466.96 $0.00 "$1,325.36" "$1,325.36" $0.00 "$1,087.70" "$1,722.92" "$1,740.32" $0.00 $0.00 $330.54 $0.00 $0.00 $346.32 $0.00 $0.00 $0.00 $0.00 $0.00 240.01 SUP HCPCS C1713 240.010 - PLATE BONE 181MM 10 HOLE LCP STAINLESS STEEL RIGHT PROXIMAL BOTH IP/OP "$2,180.88 " "$1,613.85" $0.00 "$1,744.70" $981.39 $981.39 $0.00 $0.00 $0.00 $454.55 "$1,618.65" "$1,618.65" $0.00 $0.00 $454.49 $0.00 "$1,289.99" "$1,289.99" $0.00 "$1,090.44" "$1,727.26" "$1,744.70" $0.00 $0.00 $331.37 $0.00 $0.00 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 240.011 SUP HCPCS C1713 240.011 - PLATE BONE 181MM 10 HOLE LCP STAINLESS STEEL LEFT PROXIMAL BOTH IP/OP "$2,246.30 " "$1,662.26" $0.00 "$1,744.70" $981.39 $981.39 $0.00 $0.00 $0.00 $468.19 "$1,667.20" "$1,667.20" $0.00 $0.00 $468.13 $0.00 "$1,328.69" "$1,328.69" $0.00 "$1,090.44" "$1,727.26" "$1,744.70" $0.00 $0.00 $331.37 $0.00 $0.00 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 240.012 SUP HCPCS C1713 240.012 - PLATE BONE 217MM 12 HOLE LCP STAINLESS STEEL RIGHT PROXIMAL BOTH IP/OP "$2,402.33 " "$1,777.72" $0.00 "$1,865.88" "$1,049.56" "$1,049.56" $0.00 $0.00 $0.00 $500.70 "$1,783.01" "$1,783.01" $0.00 $0.00 $500.64 $0.00 "$1,420.98" "$1,420.98" $0.00 "$1,166.18" "$1,847.22" "$1,865.88" $0.00 $0.00 $354.38 $0.00 $0.00 $371.31 $0.00 $0.00 $0.00 $0.00 $0.00 240.013 SUP HCPCS C1713 240.013 - PLATE BONE 217MM 12 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$2,336.25 " "$1,728.83" $0.00 "$1,814.58" "$1,020.70" "$1,020.70" $0.00 $0.00 $0.00 $486.93 "$1,733.96" "$1,733.96" $0.00 $0.00 $486.87 $0.00 "$1,381.89" "$1,381.89" $0.00 "$1,134.11" "$1,796.44" "$1,814.58" $0.00 $0.00 $344.64 $0.00 $0.00 $361.10 $0.00 $0.00 $0.00 $0.00 $0.00 240.014 SUP HCPCS C1713 240.014 - PLATE BONE 4.5MM 14 HOLE LCP STAINLESS STEEL RIGHT PROXIMAL BOTH IP/OP "$2,386.88 " "$1,766.29" $0.00 "$1,853.88" "$1,042.81" "$1,042.81" $0.00 $0.00 $0.00 $497.48 "$1,771.54" "$1,771.54" $0.00 $0.00 $497.42 $0.00 "$1,411.84" "$1,411.84" $0.00 "$1,158.68" "$1,835.34" "$1,853.88" $0.00 $0.00 $352.10 $0.00 $0.00 $368.92 $0.00 $0.00 $0.00 $0.00 $0.00 240.015 SUP HCPCS C1713 240.015 - PLATE BONE 4.5MM 14 HOLE LCP STAINLESS STEEL LEFT PROXIMAL BOTH IP/OP "$2,386.88 " "$1,766.29" $0.00 "$1,853.88" "$1,042.81" "$1,042.81" $0.00 $0.00 $0.00 $497.48 "$1,771.54" "$1,771.54" $0.00 $0.00 $497.42 $0.00 "$1,411.84" "$1,411.84" $0.00 "$1,158.68" "$1,835.34" "$1,853.88" $0.00 $0.00 $352.10 $0.00 $0.00 $368.92 $0.00 $0.00 $0.00 $0.00 $0.00 240.019 SUP Custom 27803010 240.019 - WASHER ORTHOPEDIC 4.5MM 3.5MM LCP STAINLESS STEEL NONSTRL BOTH IP/OP $99.10 $73.33 $0.00 $76.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.55 $73.55 $0.00 $0.00 $20.65 $0.00 $0.00 $0.00 $0.00 $48.10 $76.19 $76.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 240.036 SUP HCPCS C1713 240.036 - PLATE BN CNTR 82MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS TIB BOTH IP/OP "$2,666.60 " "$1,973.28" $0.00 "$2,071.14" "$1,165.02" "$1,165.02" $0.00 $0.00 $0.00 $555.79 "$1,979.15" "$1,979.15" $0.00 $0.00 $555.72 $0.00 "$1,314.63" "$1,314.63" $0.00 "$1,294.46" "$2,050.43" "$2,071.14" $0.00 $0.00 $393.37 $0.00 $0.00 $412.16 $0.00 $0.00 $0.00 $0.00 $0.00 240.037 SUP HCPCS C1713 240.037 - PLATE BN CNTR 82MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS TIB BOTH IP/OP "$2,666.60 " "$1,973.28" $0.00 "$2,071.14" "$1,165.02" "$1,165.02" $0.00 $0.00 $0.00 $555.79 "$1,979.15" "$1,979.15" $0.00 $0.00 $555.72 $0.00 "$1,314.63" "$1,314.63" $0.00 "$1,294.46" "$2,050.43" "$2,071.14" $0.00 $0.00 $393.37 $0.00 $0.00 $412.16 $0.00 $0.00 $0.00 $0.00 $0.00 240.038 SUP HCPCS C1713 240.038 - PLATE BN CNTR 118MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,698.93 " "$1,997.21" $0.00 "$2,096.26" "$1,179.15" "$1,179.15" $0.00 $0.00 $0.00 $562.52 "$2,003.14" "$2,003.14" $0.00 $0.00 $562.46 $0.00 "$1,330.57" "$1,330.57" $0.00 "$1,310.16" "$2,075.30" "$2,096.26" $0.00 $0.00 $398.14 $0.00 $0.00 $417.16 $0.00 $0.00 $0.00 $0.00 $0.00 240.039 SUP HCPCS C1713 240.039 - PLATE BN CNTR 118MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,698.93 " "$1,997.21" $0.00 "$2,096.26" "$1,179.15" "$1,179.15" $0.00 $0.00 $0.00 $562.52 "$2,003.14" "$2,003.14" $0.00 $0.00 $562.46 $0.00 "$1,330.57" "$1,330.57" $0.00 "$1,310.16" "$2,075.30" "$2,096.26" $0.00 $0.00 $398.14 $0.00 $0.00 $417.16 $0.00 $0.00 $0.00 $0.00 $0.00 240.04 SUP HCPCS C1713 240.040 - PLATE BN CNTR 154MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,650.35 " "$1,961.26" $0.00 "$2,120.28" "$1,192.66" "$1,192.66" $0.00 $0.00 $0.00 $552.40 "$1,967.09" "$1,967.09" $0.00 $0.00 $552.33 $0.00 "$1,306.62" "$1,306.62" $0.00 "$1,325.18" "$2,099.08" "$2,120.28" $0.00 $0.00 $402.70 $0.00 $0.00 $421.94 $0.00 $0.00 $0.00 $0.00 $0.00 240.041 SUP HCPCS C1713 240.041 - PLATE BN CNTR 154MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,729.85 " "$2,020.09" $0.00 "$2,120.28" "$1,192.66" "$1,192.66" $0.00 $0.00 $0.00 $568.97 "$2,026.09" "$2,026.09" $0.00 $0.00 $568.90 $0.00 "$1,345.82" "$1,345.82" $0.00 "$1,325.18" "$2,099.08" "$2,120.28" $0.00 $0.00 $402.70 $0.00 $0.00 $421.94 $0.00 $0.00 $0.00 $0.00 $0.00 240.042 SUP HCPCS C1713 240.042 - PLATE BN CNTR 190MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,759.38 " "$2,041.94" $0.00 "$2,143.20" "$1,205.55" "$1,205.55" $0.00 $0.00 $0.00 $575.12 "$2,048.01" "$2,048.01" $0.00 $0.00 $575.05 $0.00 "$1,360.37" "$1,360.37" $0.00 "$1,339.50" "$2,121.77" "$2,143.20" $0.00 $0.00 $407.05 $0.00 $0.00 $426.50 $0.00 $0.00 $0.00 $0.00 $0.00 240.043 SUP HCPCS C1713 240.043 - PLATE BN CNTR 190MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,759.38 " "$2,041.94" $0.00 "$2,143.20" "$1,205.55" "$1,205.55" $0.00 $0.00 $0.00 $575.12 "$2,048.01" "$2,048.01" $0.00 $0.00 $575.05 $0.00 "$1,360.37" "$1,360.37" $0.00 "$1,339.50" "$2,121.77" "$2,143.20" $0.00 $0.00 $407.05 $0.00 $0.00 $426.50 $0.00 $0.00 $0.00 $0.00 $0.00 240.044 SUP HCPCS C1713 240.044 - PLATE BN CNTR 226MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,791.70 " "$2,065.86" $0.00 "$2,168.32" "$1,219.68" "$1,219.68" $0.00 $0.00 $0.00 $581.86 "$2,072.00" "$2,072.00" $0.00 $0.00 $581.79 $0.00 "$1,376.31" "$1,376.31" $0.00 "$1,355.20" "$2,146.64" "$2,168.32" $0.00 $0.00 $411.82 $0.00 $0.00 $431.50 $0.00 $0.00 $0.00 $0.00 $0.00 240.045 SUP HCPCS C1713 240.045 - PLATE BN CNTR 226MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,791.70 " "$2,065.86" $0.00 "$2,168.32" "$1,219.68" "$1,219.68" $0.00 $0.00 $0.00 $581.86 "$2,072.00" "$2,072.00" $0.00 $0.00 $581.79 $0.00 "$1,376.31" "$1,376.31" $0.00 "$1,355.20" "$2,146.64" "$2,168.32" $0.00 $0.00 $411.82 $0.00 $0.00 $431.50 $0.00 $0.00 $0.00 $0.00 $0.00 240.046 SUP HCPCS C1713 240.046 - PLATE BN CNTR 262MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,821.23 " "$2,087.71" $0.00 "$2,191.24" "$1,232.57" "$1,232.57" $0.00 $0.00 $0.00 $588.01 "$2,093.91" "$2,093.91" $0.00 $0.00 $587.94 $0.00 "$1,390.86" "$1,390.86" $0.00 "$1,369.53" "$2,169.33" "$2,191.24" $0.00 $0.00 $416.18 $0.00 $0.00 $436.06 $0.00 $0.00 $0.00 $0.00 $0.00 240.047 SUP HCPCS C1713 240.047 - PLATE BN CNTR 262MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$2,821.23 " "$2,087.71" $0.00 "$2,191.24" "$1,232.57" "$1,232.57" $0.00 $0.00 $0.00 $588.01 "$2,093.91" "$2,093.91" $0.00 $0.00 $587.94 $0.00 "$1,390.86" "$1,390.86" $0.00 "$1,369.53" "$2,169.33" "$2,191.24" $0.00 $0.00 $416.18 $0.00 $0.00 $436.06 $0.00 $0.00 $0.00 $0.00 $0.00 240.064 SUP HCPCS C1713 240.064 - PLATE BONE 4 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $482.30 $356.90 $0.00 $385.84 $217.04 $217.04 $0.00 $0.00 $0.00 $100.52 $357.96 $357.96 $0.00 $0.00 $100.51 $0.00 $285.28 $285.28 $0.00 $241.15 $381.98 $385.84 $0.00 $0.00 $75.48 $0.00 $0.00 $76.78 $0.00 $0.00 $0.00 $0.00 $0.00 240.065 SUP HCPCS C1713 240.065 - PLATE BONE 5 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $514.10 $380.43 $0.00 $411.28 $231.35 $231.35 $0.00 $0.00 $0.00 $107.15 $381.57 $381.57 $0.00 $0.00 $107.14 $0.00 $304.09 $304.09 $0.00 $257.05 $407.17 $411.28 $0.00 $0.00 $80.46 $0.00 $0.00 $81.84 $0.00 $0.00 $0.00 $0.00 $0.00 240.066 SUP HCPCS C1713 240.066 - PLATE BONE 6 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $544.58 $402.99 $0.00 $435.66 $245.06 $245.06 $0.00 $0.00 $0.00 $113.50 $404.18 $404.18 $0.00 $0.00 $113.49 $0.00 $322.12 $322.12 $0.00 $272.29 $431.31 $435.66 $0.00 $0.00 $85.23 $0.00 $0.00 $86.70 $0.00 $0.00 $0.00 $0.00 $0.00 240.067 SUP HCPCS C1713 240.067 - PLATE BONE 7 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $580.35 $429.46 $0.00 $464.28 $261.16 $261.16 $0.00 $0.00 $0.00 $120.96 $430.74 $430.74 $0.00 $0.00 $120.94 $0.00 $343.28 $343.28 $0.00 $290.18 $459.64 $464.28 $0.00 $0.00 $90.82 $0.00 $0.00 $92.39 $0.00 $0.00 $0.00 $0.00 $0.00 240.068 SUP HCPCS C1713 240.068 - PLATE BONE 8 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $614.80 $454.95 $0.00 $491.84 $276.66 $276.66 $0.00 $0.00 $0.00 $128.14 $456.30 $456.30 $0.00 $0.00 $128.12 $0.00 $363.65 $363.65 $0.00 $307.40 $486.92 $491.84 $0.00 $0.00 $96.22 $0.00 $0.00 $97.88 $0.00 $0.00 $0.00 $0.00 $0.00 240.069 SUP HCPCS C1713 240.069 - PLATE BONE 9 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $643.95 $476.52 $0.00 $515.16 $289.78 $289.78 $0.00 $0.00 $0.00 $134.22 $477.94 $477.94 $0.00 $0.00 $134.20 $0.00 $380.90 $380.90 $0.00 $321.98 $510.01 $515.16 $0.00 $0.00 $100.78 $0.00 $0.00 $102.52 $0.00 $0.00 $0.00 $0.00 $0.00 240.07 SUP HCPCS C1713 240.070 - LASER SURG 20 BACKSTOP BOTH IP/OP $677.08 $501.04 $0.00 $541.66 $304.68 $304.68 $0.00 $0.00 $0.00 $141.12 $502.53 $502.53 $0.00 $0.00 $141.10 $0.00 $400.49 $400.49 $0.00 $338.54 $536.25 $541.66 $0.00 $0.00 $105.96 $0.00 $0.00 $107.79 $0.00 $0.00 $0.00 $0.00 $0.00 240.071 SUP HCPCS C1713 240.071 - PLATE BONE 11 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $734.05 $543.20 $0.00 $587.24 $330.32 $330.32 $0.00 $0.00 $0.00 $152.99 $544.81 $544.81 $0.00 $0.00 $152.98 $0.00 $434.19 $434.19 $0.00 $367.03 $581.37 $587.24 $0.00 $0.00 $114.88 $0.00 $0.00 $116.86 $0.00 $0.00 $0.00 $0.00 $0.00 240.072 SUP HCPCS C1713 240.072 - PLATE BONE 12 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $760.55 $562.81 $0.00 $608.44 $342.25 $342.25 $0.00 $0.00 $0.00 $158.52 $564.48 $564.48 $0.00 $0.00 $158.50 $0.00 $449.87 $449.87 $0.00 $380.28 $602.36 $608.44 $0.00 $0.00 $119.03 $0.00 $0.00 $121.08 $0.00 $0.00 $0.00 $0.00 $0.00 240.073 SUP HCPCS C1713 240.073 - PLATE BONE 13 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $812.23 $601.05 $0.00 $649.78 $365.50 $365.50 $0.00 $0.00 $0.00 $169.29 $602.83 $602.83 $0.00 $0.00 $169.27 $0.00 $480.43 $480.43 $0.00 $406.11 $643.29 $649.78 $0.00 $0.00 $127.11 $0.00 $0.00 $129.31 $0.00 $0.00 $0.00 $0.00 $0.00 240.074 SUP HCPCS C1713 240.074 - PLATE BONE 14 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $857.28 $634.39 $0.00 $685.82 $385.77 $385.77 $0.00 $0.00 $0.00 $178.68 $636.27 $636.27 $0.00 $0.00 $178.66 $0.00 $507.08 $507.08 $0.00 $428.64 $678.97 $685.82 $0.00 $0.00 $134.16 $0.00 $0.00 $136.48 $0.00 $0.00 $0.00 $0.00 $0.00 240.075 SUP HCPCS C1713 240.075 - PLATE BONE 15 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $912.93 $675.57 $0.00 $730.34 $410.82 $410.82 $0.00 $0.00 $0.00 $190.28 $677.57 $677.57 $0.00 $0.00 $190.25 $0.00 $540.00 $540.00 $0.00 $456.46 $723.04 $730.34 $0.00 $0.00 $142.87 $0.00 $0.00 $145.34 $0.00 $0.00 $0.00 $0.00 $0.00 240.076 SUP HCPCS C1713 240.076 - PLATE BONE 16 HOLE SCALLOPED STAINLESS STEEL TIBIA DISTAL BOTH IP/OP $995.08 $736.36 $0.00 $796.06 $447.78 $447.78 $0.00 $0.00 $0.00 $207.40 $738.54 $738.54 $0.00 $0.00 $207.37 $0.00 $588.59 $588.59 $0.00 $497.54 $788.10 $796.06 $0.00 $0.00 $155.73 $0.00 $0.00 $158.42 $0.00 $0.00 $0.00 $0.00 $0.00 240.082 SUP HCPCS C1713 240.082 - PLATE BONE 173MM 7 HOLE PILON LCP STAINLESS STEEL DISTAL BOTH IP/OP "$3,212.00 " "$2,376.88" $0.00 "$2,494.76" "$1,403.30" "$1,403.30" $0.00 $0.00 $0.00 $669.46 "$2,383.95" "$2,383.95" $0.00 $0.00 $669.38 $0.00 "$1,583.52" "$1,583.52" $0.00 "$1,559.23" "$2,469.81" "$2,494.76" $0.00 $0.00 $599.36 $0.00 $0.00 $496.46 $0.00 $0.00 $0.00 $0.00 $0.00 240.083 SUP HCPCS C1713 240.083 - PLATE BONE 173MM 9 HOLE PILON CNTOUR LCP STAINLESS STEEL BOTH IP/OP "$3,380.70 " "$2,501.72" $0.00 "$2,625.78" "$1,477.00" "$1,477.00" $0.00 $0.00 $0.00 $704.62 "$2,509.16" "$2,509.16" $0.00 $0.00 $704.54 $0.00 "$1,666.69" "$1,666.69" $0.00 "$1,641.11" "$2,599.53" "$2,625.78" $0.00 $0.00 $498.71 $0.00 $0.00 $522.53 $0.00 $0.00 $0.00 $0.00 $0.00 240.13 SUP HCPCS C1713 240.13 - PLATE BONE T 68MM 3 HOLE DCP LC-DCP STAINLESS STEEL FT BOTH IP/OP $490.25 $362.79 $0.00 $392.20 $220.61 $220.61 $0.00 $0.00 $0.00 $102.18 $363.86 $363.86 $0.00 $0.00 $102.17 $0.00 $289.98 $289.98 $0.00 $245.13 $388.28 $392.20 $0.00 $0.00 $76.72 $0.00 $0.00 $78.05 $0.00 $0.00 $0.00 $0.00 $0.00 240.14 SUP HCPCS C1713 240.14 - PLATE BN T 84MM NS 4 HL SHFT SS 4.5MM SCR LG FRAG SET BOTH IP/OP $551.03 $407.76 $0.00 $427.98 $240.74 $240.74 $0.00 $0.00 $0.00 $114.85 $408.97 $408.97 $0.00 $0.00 $114.83 $0.00 $325.93 $325.93 $0.00 $267.49 $423.70 $427.98 $0.00 $0.00 $81.29 $0.00 $0.00 $85.17 $0.00 $0.00 $0.00 $0.00 $0.00 240.141 SUP HCPCS C1713 240.141 - PLATE BN T 83MM NS LCP CMBN 4 HL LMT CNTCT TPR END SS 4.5/5 BOTH IP/OP "$1,137.20 " $841.53 $0.00 $883.26 $496.83 $496.83 $0.00 $0.00 $0.00 $237.02 $844.03 $844.03 $0.00 $0.00 $236.99 $0.00 $672.65 $672.65 $0.00 $552.04 $874.43 $883.26 $0.00 $0.00 $167.76 $0.00 $0.00 $175.77 $0.00 $0.00 $0.00 $0.00 $0.00 240.15 SUP HCPCS C1713 240.15 - PLATE BONE 100MM 5 HOLE T DCP LC-DCP STAINLESS STEEL FT BOTH IP/OP $560.48 $414.76 $0.00 $448.38 $252.21 $252.21 $0.00 $0.00 $0.00 $116.82 $415.98 $415.98 $0.00 $0.00 $116.80 $0.00 $331.52 $331.52 $0.00 $280.24 $443.90 $448.38 $0.00 $0.00 $87.71 $0.00 $0.00 $89.23 $0.00 $0.00 $0.00 $0.00 $0.00 240.16 SUP HCPCS C1713 240.16 - PLATE BN T 116MM NS 6 HL SHFT SS 4.5MM SCR LG FRAG SET BOTH IP/OP $638.70 $472.64 $0.00 $510.96 $287.42 $287.42 $0.00 $0.00 $0.00 $133.12 $474.04 $474.04 $0.00 $0.00 $133.11 $0.00 $377.79 $377.79 $0.00 $319.35 $505.85 $510.96 $0.00 $0.00 $97.05 $0.00 $0.00 $101.68 $0.00 $0.00 $0.00 $0.00 $0.00 240.161 SUP HCPCS C1713 240.161 - PLATE BN T 115MM NS LCP CMBN 6 HL LMT CNTCT TPR END SS 4.5/5 BOTH IP/OP "$1,304.48 " $965.32 $0.00 "$1,013.20" $569.93 $569.93 $0.00 $0.00 $0.00 $271.89 $968.18 $968.18 $0.00 $0.00 $271.85 $0.00 $771.60 $771.60 $0.00 $633.25 "$1,003.07" "$1,013.20" $0.00 $0.00 $192.43 $0.00 $0.00 $201.63 $0.00 $0.00 $0.00 $0.00 $0.00 240.18 SUP HCPCS C1713 240.18 - PLATE BN T 148MM NS 8 HL SHFT SS 4.5MM SCR LG FRAG SET BOTH IP/OP $865.25 $640.29 $0.00 $692.20 $389.36 $389.36 $0.00 $0.00 $0.00 $180.34 $642.19 $642.19 $0.00 $0.00 $180.32 $0.00 $511.80 $511.80 $0.00 $432.63 $685.28 $692.20 $0.00 $0.00 $131.47 $0.00 $0.00 $137.75 $0.00 $0.00 $0.00 $0.00 $0.00 240.181 SUP HCPCS C1713 240.181 - PLATE BN T 147MM NS LCP CMBN 8 HL LMT CNTCT TPR END SS 4.5/5 BOTH IP/OP "$1,505.50 " "$1,114.07" $0.00 "$1,169.32" $657.74 $657.74 $0.00 $0.00 $0.00 $313.78 "$1,117.38" "$1,117.38" $0.00 $0.00 $313.75 $0.00 $890.50 $890.50 $0.00 $730.83 "$1,157.63" "$1,169.32" $0.00 $0.00 $222.09 $0.00 $0.00 $232.69 $0.00 $0.00 $0.00 $0.00 $0.00 240.34 SUP HCPCS C1713 240.34 - PLATE BN TBTRS 80MM NS DCP 4 HL SHFT SS 4.5MM SCR LG FRAG BOTH IP/OP $814.88 $603.01 $0.00 $651.90 $366.69 $366.69 $0.00 $0.00 $0.00 $169.84 $604.80 $604.80 $0.00 $0.00 $169.82 $0.00 $482.00 $482.00 $0.00 $407.44 $645.38 $651.90 $0.00 $0.00 $127.53 $0.00 $0.00 $129.73 $0.00 $0.00 $0.00 $0.00 $0.00 240.35 SUP HCPCS C1713 240.35 - PLATE BONE T 96MM 5 HOLE BUTTRESS DCP LC-DCP STAINLESS STEEL BOTH IP/OP $857.28 $634.39 $0.00 $685.82 $385.77 $385.77 $0.00 $0.00 $0.00 $178.68 $636.27 $636.27 $0.00 $0.00 $178.66 $0.00 $507.08 $507.08 $0.00 $428.64 $678.97 $685.82 $0.00 $0.00 $134.16 $0.00 $0.00 $136.48 $0.00 $0.00 $0.00 $0.00 $0.00 240.36 SUP HCPCS C1713 240.36 - PLATE BONE T 112MM 6 HOLE BUTTRESS DCP STAINLESS STEEL FT BOTH IP/OP $940.40 $695.90 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $196.00 $697.96 $697.96 $0.00 $0.00 $195.98 $0.00 $556.25 $556.25 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 240.403 SUP HCPCS C1713 240.403 - PLATE BONE 87MM 3 HOLE BUTTRESS DCP STAINLESS STEEL TIBIAL BOTH IP/OP "$1,057.35 " $782.44 $0.00 $845.88 $475.81 $475.81 $0.00 $0.00 $0.00 $220.38 $784.77 $784.77 $0.00 $0.00 $220.35 $0.00 $625.42 $625.42 $0.00 $528.68 $837.42 $845.88 $0.00 $0.00 $165.48 $0.00 $0.00 $168.33 $0.00 $0.00 $0.00 $0.00 $0.00 240.406 SUP HCPCS C1713 240.406 - PLATE BONE LEFT ANGLE L 115MM 6 HOLE BUTTRESS LC-DCP BOTH IP/OP "$1,018.10 " $753.39 $0.00 $814.48 $458.15 $458.15 $0.00 $0.00 $0.00 $212.20 $755.63 $755.63 $0.00 $0.00 $212.17 $0.00 $602.21 $602.21 $0.00 $509.05 $806.34 $814.48 $0.00 $0.00 $154.69 $0.00 $0.00 $162.08 $0.00 $0.00 $0.00 $0.00 $0.00 240.407 SUP HCPCS C1713 240.407 - PLATE BONE LEFT ANGLE L 132MM 7 HOLE BUTTRESS LC-DCP BOTH IP/OP "$1,075.90 " $796.17 $0.00 $860.72 $484.16 $484.16 $0.00 $0.00 $0.00 $224.24 $798.53 $798.53 $0.00 $0.00 $224.22 $0.00 $636.39 $636.39 $0.00 $537.95 $852.11 $860.72 $0.00 $0.00 $168.38 $0.00 $0.00 $171.28 $0.00 $0.00 $0.00 $0.00 $0.00 240.408 SUP HCPCS C1713 240.408 - PLATE BONE LEFT ANGLE L 148MM 8 HOLE BUTTRESS LC-DCP BOTH IP/OP "$1,162.78 " $860.46 $0.00 $930.22 $523.25 $523.25 $0.00 $0.00 $0.00 $242.35 $863.01 $863.01 $0.00 $0.00 $242.32 $0.00 $687.78 $687.78 $0.00 $581.39 $920.92 $930.22 $0.00 $0.00 $176.67 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $0.00 240.44 SUP HCPCS C1713 240.44 - PLATE BN ANG LT L BTRS 86X14X3.8MM NS DCP 4 HL SHFT SS TIB BOTH IP/OP $734.23 $543.33 $0.00 $587.38 $330.40 $330.40 $0.00 $0.00 $0.00 $153.03 $544.94 $544.94 $0.00 $0.00 $153.01 $0.00 $434.29 $434.29 $0.00 $367.11 $581.51 $587.38 $0.00 $0.00 $111.56 $0.00 $0.00 $116.89 $0.00 $0.00 $0.00 $0.00 $0.00 240.46 SUP HCPCS C1713 240.46 - PLATE BN BTRS 118X14X3.8MM NS DCP 5 HL SHFT SS TIBHD RL LG BOTH IP/OP "$1,266.50 " $937.21 $0.00 "$1,013.20" $569.93 $569.93 $0.00 $0.00 $0.00 $263.97 $940.00 $940.00 $0.00 $0.00 $263.94 $0.00 $749.13 $749.13 $0.00 $633.25 "$1,003.07" "$1,013.20" $0.00 $0.00 $192.43 $0.00 $0.00 $201.63 $0.00 $0.00 $0.00 $0.00 $0.00 240.47 SUP HCPCS C1713 240.47 - PLATE BN BTRS 149X14X3.8MM NS DCP 7 HL SHFT SS TIBHD RL LG BOTH IP/OP "$1,401.48 " "$1,037.10" $0.00 "$1,088.52" $612.29 $612.29 $0.00 $0.00 $0.00 $292.10 "$1,040.17" "$1,040.17" $0.00 $0.00 $292.07 $0.00 $828.97 $828.97 $0.00 $680.33 "$1,077.63" "$1,088.52" $0.00 $0.00 $206.74 $0.00 $0.00 $216.62 $0.00 $0.00 $0.00 $0.00 $0.00 240.48 SUP HCPCS C1713 240.48 - PLATE BN BTRS 181X14X3.8MM NS DCP 9 HL SHFT SS TIBHD RL LG BOTH IP/OP "$1,495.65 " "$1,106.78" $0.00 "$1,161.68" $653.45 $653.45 $0.00 $0.00 $0.00 $311.73 "$1,110.07" "$1,110.07" $0.00 $0.00 $311.69 $0.00 $884.68 $884.68 $0.00 $726.05 "$1,150.06" "$1,161.68" $0.00 $0.00 $220.63 $0.00 $0.00 $231.17 $0.00 $0.00 $0.00 $0.00 $0.00 240.5 SUP HCPCS C1713 240.50 - PLATE BONE 240MM 13 HOLE BUTTRESS DCP STAINLESS STEEL TIBIA BOTH IP/OP "$1,604.95 " "$1,187.66" $0.00 "$1,283.96" $722.23 $722.23 $0.00 $0.00 $0.00 $334.51 "$1,191.19" "$1,191.19" $0.00 $0.00 $334.47 $0.00 $949.33 $949.33 $0.00 $802.48 "$1,271.12" "$1,283.96" $0.00 $0.00 $243.86 $0.00 $0.00 $255.51 $0.00 $0.00 $0.00 $0.00 $0.00 240.505 SUP HCPCS C1713 240.505 - PLATE BONE RIGHT ANG L 101MM 5 HOLE BUTTRESS LC-DCP BOTH IP/OP $983.15 $727.53 $0.00 $786.52 $442.42 $442.42 $0.00 $0.00 $0.00 $204.91 $729.69 $729.69 $0.00 $0.00 $204.89 $0.00 $581.53 $581.53 $0.00 $491.58 $778.65 $786.52 $0.00 $0.00 $153.86 $0.00 $0.00 $156.52 $0.00 $0.00 $0.00 $0.00 $0.00 240.506 SUP HCPCS C1713 240.506 - PLATE BONE RIGHT ANG L 115MM 6 HOLE BUTTRESS LC-DCP BOTH IP/OP "$1,018.10 " $753.39 $0.00 $814.48 $458.15 $458.15 $0.00 $0.00 $0.00 $212.20 $755.63 $755.63 $0.00 $0.00 $212.17 $0.00 $602.21 $602.21 $0.00 $509.05 $806.34 $814.48 $0.00 $0.00 $154.69 $0.00 $0.00 $162.08 $0.00 $0.00 $0.00 $0.00 $0.00 240.508 SUP HCPCS C1713 240.508 - PLATE BONE RIGHT ANG L 148MM 8 HOLE BUTTRESS LC-DCP BOTH IP/OP "$1,162.78 " $860.46 $0.00 $930.22 $523.25 $523.25 $0.00 $0.00 $0.00 $242.35 $863.01 $863.01 $0.00 $0.00 $242.32 $0.00 $687.78 $687.78 $0.00 $581.39 $920.92 $930.22 $0.00 $0.00 $176.67 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $0.00 240.509 SUP HCPCS C1713 240.509 - PLATE BONE 162MM BUTTRESS L 9 HOLE LC-DCP TITANIUM LEFT BOTH IP/OP "$1,175.28 " $869.71 $0.00 $940.22 $528.87 $528.87 $0.00 $0.00 $0.00 $244.96 $872.29 $872.29 $0.00 $0.00 $244.93 $0.00 $695.18 $695.18 $0.00 $587.64 $930.82 $940.22 $0.00 $0.00 $183.93 $0.00 $0.00 $187.10 $0.00 $0.00 $0.00 $0.00 $0.00 240.54 SUP HCPCS C1713 240.54 - PLATE BN ANG RT L BTRS 86X14X3.8MM NS DCP 4 HL SHFT SS TIB BOTH IP/OP $734.23 $543.33 $0.00 $587.38 $330.40 $330.40 $0.00 $0.00 $0.00 $153.03 $544.94 $544.94 $0.00 $0.00 $153.01 $0.00 $434.29 $434.29 $0.00 $367.11 $581.51 $587.38 $0.00 $0.00 $111.56 $0.00 $0.00 $116.89 $0.00 $0.00 $0.00 $0.00 $0.00 240.56 SUP HCPCS C1713 240.56 - PLATE BN BTRS 118X14X3.8MM NS DCP 5 HL SHFT SS TIBHD L/L 4.5 BOTH IP/OP "$1,304.48 " $965.32 $0.00 "$1,013.20" $569.93 $569.93 $0.00 $0.00 $0.00 $271.89 $968.18 $968.18 $0.00 $0.00 $271.85 $0.00 $771.60 $771.60 $0.00 $633.25 "$1,003.07" "$1,013.20" $0.00 $0.00 $192.43 $0.00 $0.00 $201.63 $0.00 $0.00 $0.00 $0.00 $0.00 240.57 SUP HCPCS C1713 240.57 - PLATE BN BTRS 149X14X3.8MM NS DCP 7 HL SHFT SS TIBHD L/L LG BOTH IP/OP "$1,401.48 " "$1,037.10" $0.00 "$1,088.52" $612.29 $612.29 $0.00 $0.00 $0.00 $292.10 "$1,040.17" "$1,040.17" $0.00 $0.00 $292.07 $0.00 $828.97 $828.97 $0.00 $680.33 "$1,077.63" "$1,088.52" $0.00 $0.00 $206.74 $0.00 $0.00 $216.62 $0.00 $0.00 $0.00 $0.00 $0.00 240.58 SUP HCPCS C1713 240.58 - PLATE BN BTRS 181X14X3.8MM NS DCP 9 HL SHFT SS TIBHD L/L LG BOTH IP/OP "$1,495.65 " "$1,106.78" $0.00 "$1,161.68" $653.45 $653.45 $0.00 $0.00 $0.00 $311.73 "$1,110.07" "$1,110.07" $0.00 $0.00 $311.69 $0.00 $884.68 $884.68 $0.00 $726.05 "$1,150.06" "$1,161.68" $0.00 $0.00 $220.63 $0.00 $0.00 $231.17 $0.00 $0.00 $0.00 $0.00 $0.00 240.6 SUP HCPCS C1713 240.60 - PLATE BONE 240X14X3.8MM 13 HOLE SHAFT BUTTRESS DCP STAINLESS BOTH IP/OP "$1,604.95 " "$1,187.66" $0.00 "$1,283.96" $722.23 $722.23 $0.00 $0.00 $0.00 $334.51 "$1,191.19" "$1,191.19" $0.00 $0.00 $334.47 $0.00 $949.33 $949.33 $0.00 $802.48 "$1,271.12" "$1,283.96" $0.00 $0.00 $243.86 $0.00 $0.00 $255.51 $0.00 $0.00 $0.00 $0.00 $0.00 240.7 SUP HCPCS C1713 240.70 - PLATE BONE BUTTRESS 221X16X5MM 11 HOLE SHAFT DCP STAINLESS BOTH IP/OP "$1,539.45 " "$1,139.19" $0.00 "$1,231.56" $692.75 $692.75 $0.00 $0.00 $0.00 $320.86 "$1,142.58" "$1,142.58" $0.00 $0.00 $320.82 $0.00 $910.58 $910.58 $0.00 $769.73 "$1,219.24" "$1,231.56" $0.00 $0.00 $233.90 $0.00 $0.00 $245.08 $0.00 $0.00 $0.00 $0.00 $0.00 240.71 SUP HCPCS C1713 240.71 - PLATE BONE BUTTRESS 253X16X5MM 11 HOLE SHAFT DCP STAINLESS BOTH IP/OP "$1,582.05 " "$1,170.72" $0.00 "$1,265.64" $711.92 $711.92 $0.00 $0.00 $0.00 $329.74 "$1,174.20" "$1,174.20" $0.00 $0.00 $329.70 $0.00 $935.78 $935.78 $0.00 $791.03 "$1,252.98" "$1,265.64" $0.00 $0.00 $247.59 $0.00 $0.00 $251.86 $0.00 $0.00 $0.00 $0.00 $0.00 240.72 SUP HCPCS C1713 240.72 - PLATE BONE 285MM BUTTRESS 15 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,624.45 " "$1,202.09" $0.00 "$1,299.56" $731.00 $731.00 $0.00 $0.00 $0.00 $338.58 "$1,205.67" "$1,205.67" $0.00 $0.00 $338.54 $0.00 $960.86 $960.86 $0.00 $812.23 "$1,286.56" "$1,299.56" $0.00 $0.00 $254.23 $0.00 $0.00 $258.61 $0.00 $0.00 $0.00 $0.00 $0.00 240.73 SUP HCPCS C1713 240.73 - PLATE BONE BUTTRESS 221X16X5MM 11 HOLE SHAFT DCP STAINLESS BOTH IP/OP "$1,537.00 " "$1,137.38" $0.00 "$1,229.60" $691.65 $691.65 $0.00 $0.00 $0.00 $320.35 "$1,140.76" "$1,140.76" $0.00 $0.00 $320.31 $0.00 $909.14 $909.14 $0.00 $768.50 "$1,217.30" "$1,229.60" $0.00 $0.00 $240.54 $0.00 $0.00 $244.69 $0.00 $0.00 $0.00 $0.00 $0.00 240.75 SUP HCPCS C1713 240.75 - PLATE BONE 285MM 15 HOLE BUTTRESS DCP STAINLESS STEEL BOTH IP/OP "$1,624.45 " "$1,202.09" $0.00 "$1,299.56" $731.00 $731.00 $0.00 $0.00 $0.00 $338.58 "$1,205.67" "$1,205.67" $0.00 $0.00 $338.54 $0.00 $960.86 $960.86 $0.00 $812.23 "$1,286.56" "$1,299.56" $0.00 $0.00 $254.23 $0.00 $0.00 $258.61 $0.00 $0.00 $0.00 $0.00 $0.00 240.8 SUP HCPCS C1713 240.80 - PLATE BONE 128MM 4 HOLE HOOK BUTTRESS DCP STAINLESS STEEL BOTH IP/OP "$1,257.43 " $930.50 $0.00 "$1,005.94" $565.84 $565.84 $0.00 $0.00 $0.00 $262.08 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $743.77 $743.77 $0.00 $628.71 $995.88 "$1,005.94" $0.00 $0.00 $196.79 $0.00 $0.00 $200.18 $0.00 $0.00 $0.00 $0.00 $0.00 240.9 SUP HCPCS C1713 240.90 - PLATE 202MM SS LG FRAG SET 10 HOLE CBR HEAD DCP BONE ORTH BOTH IP/OP "$1,158.05 " $856.96 $0.00 $926.44 $521.12 $521.12 $0.00 $0.00 $0.00 $241.37 $859.50 $859.50 $0.00 $0.00 $241.34 $0.00 $684.99 $684.99 $0.00 $579.03 $917.18 $926.44 $0.00 $0.00 $181.23 $0.00 $0.00 $184.36 $0.00 $0.00 $0.00 $0.00 $0.00 240.91 SUP HCPCS C1713 240.91 - PLATE BONE 218MM 11 HOLE COBRA HEAD LC-DCP STAINLESS STEEL BOTH IP/OP "$1,220.33 " $903.04 $0.00 $976.26 $549.15 $549.15 $0.00 $0.00 $0.00 $254.35 $905.73 $905.73 $0.00 $0.00 $254.32 $0.00 $721.82 $721.82 $0.00 $610.16 $966.50 $976.26 $0.00 $0.00 $190.98 $0.00 $0.00 $194.28 $0.00 $0.00 $0.00 $0.00 $0.00 240.92 SUP HCPCS C1713 240.92 - PLATE BN BTRS 158X16X5MM NS DCP 7 HL SHFT SS FEM LT CNDRL BOTH IP/OP "$1,356.55 " "$1,003.85" $0.00 "$1,085.24" $610.45 $610.45 $0.00 $0.00 $0.00 $282.74 "$1,006.83" "$1,006.83" $0.00 $0.00 $282.71 $0.00 $802.40 $802.40 $0.00 $678.28 "$1,074.39" "$1,085.24" $0.00 $0.00 $206.12 $0.00 $0.00 $215.96 $0.00 $0.00 $0.00 $0.00 $0.00 240.93 SUP HCPCS C1713 240.93 - PLATE BN BTRS 190X16X5MM NS DCP 9 HL SHFT SS FEM LT CNDRL BOTH IP/OP "$1,467.10 " "$1,085.65" $0.00 "$1,173.68" $660.20 $660.20 $0.00 $0.00 $0.00 $305.78 "$1,088.88" "$1,088.88" $0.00 $0.00 $305.74 $0.00 $867.79 $867.79 $0.00 $733.55 "$1,161.94" "$1,173.68" $0.00 $0.00 $222.91 $0.00 $0.00 $233.56 $0.00 $0.00 $0.00 $0.00 $0.00 240.94 SUP HCPCS C1713 240.94 - PLATE BN BTRS 158X16X5MM NS DCP 7 HL SHFT SS FEM RT CNDRL BOTH IP/OP "$1,356.55 " "$1,003.85" $0.00 "$1,085.24" $610.45 $610.45 $0.00 $0.00 $0.00 $282.74 "$1,006.83" "$1,006.83" $0.00 $0.00 $282.71 $0.00 $802.40 $802.40 $0.00 $678.28 "$1,074.39" "$1,085.24" $0.00 $0.00 $206.12 $0.00 $0.00 $215.96 $0.00 $0.00 $0.00 $0.00 $0.00 240.95 SUP HCPCS C1713 240.95 - PLATE BN BTRS 190X16X5MM NS DCP 9 HL SHFT SS FEM RT CNDRL BOTH IP/OP "$1,467.10 " "$1,085.65" $0.00 "$1,173.68" $660.20 $660.20 $0.00 $0.00 $0.00 $305.78 "$1,088.88" "$1,088.88" $0.00 $0.00 $305.74 $0.00 $867.79 $867.79 $0.00 $733.55 "$1,161.94" "$1,173.68" $0.00 $0.00 $222.91 $0.00 $0.00 $233.56 $0.00 $0.00 $0.00 $0.00 $0.00 240.98 SUP HCPCS C1713 240.98 - PLATE BONE 170MM 8 HOLE COBRA HEAD DCP STAINLESS STEEL BOTH IP/OP "$1,030.85 " $762.83 $0.00 $824.68 $463.88 $463.88 $0.00 $0.00 $0.00 $214.85 $765.10 $765.10 $0.00 $0.00 $214.83 $0.00 $609.75 $609.75 $0.00 $515.43 $816.43 $824.68 $0.00 $0.00 $161.33 $0.00 $0.00 $164.11 $0.00 $0.00 $0.00 $0.00 $0.00 240.99 SUP HCPCS C1713 240.99 - PLATE BONE 186MM 9 HOLE COBRA HEAD DCP STAINLESS STEEL BOTH IP/OP "$1,098.43 " $812.84 $0.00 $878.74 $494.29 $494.29 $0.00 $0.00 $0.00 $228.94 $815.25 $815.25 $0.00 $0.00 $228.91 $0.00 $649.72 $649.72 $0.00 $549.21 $869.96 $878.74 $0.00 $0.00 $171.90 $0.00 $0.00 $174.87 $0.00 $0.00 $0.00 $0.00 $0.00 241.004 SUP HCPCS C1713 241.004 - PLATE BN 60MM NS 4 HL SHFT SS TIB RT PROX 3.5MM SCR SM FRAG BOTH IP/OP "$2,171.80 " "$1,607.13" $0.00 "$1,686.84" $948.85 $948.85 $0.00 $0.00 $0.00 $452.66 "$1,611.91" "$1,611.91" $0.00 $0.00 $452.60 $0.00 "$1,284.62" "$1,284.62" $0.00 "$1,054.28" "$1,669.97" "$1,686.84" $0.00 $0.00 $320.38 $0.00 $0.00 $335.68 $0.00 $0.00 $0.00 $0.00 $0.00 241.005 SUP HCPCS C1713 241.005 - PLATE BONE 60MM 4 HOLE STAINLESS STEEL TIBIA LEFT PROXIMAL BOTH IP/OP "$2,171.80 " "$1,607.13" $0.00 "$1,686.84" $948.85 $948.85 $0.00 $0.00 $0.00 $452.66 "$1,611.91" "$1,611.91" $0.00 $0.00 $452.60 $0.00 "$1,284.62" "$1,284.62" $0.00 "$1,054.28" "$1,669.97" "$1,686.84" $0.00 $0.00 $320.38 $0.00 $0.00 $335.68 $0.00 $0.00 $0.00 $0.00 $0.00 241.006 SUP HCPCS C1713 241.006 - PLATE BONE 85MM 6 HOLE STAINLESS STEEL TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,180.23 " "$1,613.37" $0.00 "$1,693.38" $952.53 $952.53 $0.00 $0.00 $0.00 $454.41 "$1,618.16" "$1,618.16" $0.00 $0.00 $454.36 $0.00 "$1,289.60" "$1,289.60" $0.00 "$1,058.36" "$1,676.45" "$1,693.38" $0.00 $0.00 $321.62 $0.00 $0.00 $336.98 $0.00 $0.00 $0.00 $0.00 $0.00 241.007 SUP HCPCS C1713 241.007 - PLATE BONE 85MM 6 HOLE STAINLESS STEEL TIBIA LEFT PROXIMAL BOTH IP/OP "$2,180.23 " "$1,613.37" $0.00 "$1,693.38" $952.53 $952.53 $0.00 $0.00 $0.00 $454.41 "$1,618.16" "$1,618.16" $0.00 $0.00 $454.36 $0.00 "$1,289.60" "$1,289.60" $0.00 "$1,058.36" "$1,676.45" "$1,693.38" $0.00 $0.00 $321.62 $0.00 $0.00 $336.98 $0.00 $0.00 $0.00 $0.00 $0.00 241.008 SUP HCPCS C1713 241.008 - PLATE BN 111MM NS 8 HL SHFT SS TIB RT PROX 3.5MM SCR SM FRAG BOTH IP/OP "$2,250.53 " "$1,665.39" $0.00 "$1,747.98" $983.24 $983.24 $0.00 $0.00 $0.00 $469.07 "$1,670.34" "$1,670.34" $0.00 $0.00 $469.01 $0.00 "$1,331.19" "$1,331.19" $0.00 "$1,092.49" "$1,730.50" "$1,747.98" $0.00 $0.00 $331.99 $0.00 $0.00 $347.85 $0.00 $0.00 $0.00 $0.00 $0.00 241.009 SUP HCPCS C1713 241.009 - PLATE BN 111MM NS 8 HL SHFT SS TIB LT PROX 3.5MM SCR SM FRAG BOTH IP/OP "$2,250.53 " "$1,665.39" $0.00 "$1,747.98" $983.24 $983.24 $0.00 $0.00 $0.00 $469.07 "$1,670.34" "$1,670.34" $0.00 $0.00 $469.01 $0.00 "$1,331.19" "$1,331.19" $0.00 "$1,092.49" "$1,730.50" "$1,747.98" $0.00 $0.00 $331.99 $0.00 $0.00 $347.85 $0.00 $0.00 $0.00 $0.00 $0.00 241.01 SUP HCPCS C1713 241.010 - PLATE BONE 137MM 10 HOLE STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$2,197.25 " "$1,625.97" $0.00 "$1,757.80" $988.76 $988.76 $0.00 $0.00 $0.00 $457.96 "$1,630.80" "$1,630.80" $0.00 $0.00 $457.91 $0.00 "$1,299.67" "$1,299.67" $0.00 "$1,098.63" "$1,740.22" "$1,757.80" $0.00 $0.00 $333.85 $0.00 $0.00 $349.80 $0.00 $0.00 $0.00 $0.00 $0.00 241.011 SUP HCPCS C1713 241.011 - PLATE BN 137MM NS 10 HL SHFT SS TIB LT PROX 3.5MM SCR SM BOTH IP/OP "$2,263.18 " "$1,674.75" $0.00 "$1,757.80" $988.76 $988.76 $0.00 $0.00 $0.00 $471.70 "$1,679.73" "$1,679.73" $0.00 $0.00 $471.65 $0.00 "$1,338.67" "$1,338.67" $0.00 "$1,098.63" "$1,740.22" "$1,757.80" $0.00 $0.00 $333.85 $0.00 $0.00 $349.80 $0.00 $0.00 $0.00 $0.00 $0.00 241.012 SUP HCPCS C1713 241.012 - PLATE BN 137MM NS 12 HL SHFT SS TIB RT PROX 3.5MM SCR SM BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,823.30" "$1,025.61" "$1,025.61" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,139.56" "$1,805.07" "$1,823.30" $0.00 $0.00 $346.30 $0.00 $0.00 $362.84 $0.00 $0.00 $0.00 $0.00 $0.00 241.013 SUP HCPCS C1713 241.013 - PLATE BN 163MM NS 12 HL SHFT SS TIB LT PROX 3.5MM SCR SM BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,823.30" "$1,025.61" "$1,025.61" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,139.56" "$1,805.07" "$1,823.30" $0.00 $0.00 $346.30 $0.00 $0.00 $362.84 $0.00 $0.00 $0.00 $0.00 $0.00 241.014 SUP HCPCS C1713 241.014 - PLATE BONE 163MM 14 HOLE STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$2,398.10 " "$1,774.59" $0.00 "$1,862.62" "$1,047.72" "$1,047.72" $0.00 $0.00 $0.00 $499.82 "$1,779.87" "$1,779.87" $0.00 $0.00 $499.76 $0.00 "$1,418.48" "$1,418.48" $0.00 "$1,164.14" "$1,844.00" "$1,862.62" $0.00 $0.00 $353.76 $0.00 $0.00 $370.66 $0.00 $0.00 $0.00 $0.00 $0.00 241.015 SUP HCPCS C1713 241.015 - PLATE BONE 189MM 14 HOLE STAINLESS STEEL TIBIA LEFT PROXIMAL BOTH IP/OP "$2,398.10 " "$1,774.59" $0.00 "$1,862.62" "$1,047.72" "$1,047.72" $0.00 $0.00 $0.00 $499.82 "$1,779.87" "$1,779.87" $0.00 $0.00 $499.76 $0.00 "$1,418.48" "$1,418.48" $0.00 "$1,164.14" "$1,844.00" "$1,862.62" $0.00 $0.00 $353.76 $0.00 $0.00 $370.66 $0.00 $0.00 $0.00 $0.00 $0.00 241.016 SUP HCPCS C1713 241.016 - PLATE BN 215MM NS 16 HL SHFT SS TIB RT PROX 3.5MM SCR SM BOTH IP/OP "$2,447.30 " "$1,811.00" $0.00 "$1,900.82" "$1,069.21" "$1,069.21" $0.00 $0.00 $0.00 $510.08 "$1,816.39" "$1,816.39" $0.00 $0.00 $510.02 $0.00 "$1,447.58" "$1,447.58" $0.00 "$1,188.01" "$1,881.82" "$1,900.82" $0.00 $0.00 $361.02 $0.00 $0.00 $378.26 $0.00 $0.00 $0.00 $0.00 $0.00 241.017 SUP HCPCS C1713 241.017 - PLATE BONE 215MM 16 HOLE STAINLESS STEEL TIBIA LEFT PROXIMAL BOTH IP/OP "$2,447.30 " "$1,811.00" $0.00 "$1,900.82" "$1,069.21" "$1,069.21" $0.00 $0.00 $0.00 $510.08 "$1,816.39" "$1,816.39" $0.00 $0.00 $510.02 $0.00 "$1,447.58" "$1,447.58" $0.00 "$1,188.01" "$1,881.82" "$1,900.82" $0.00 $0.00 $361.02 $0.00 $0.00 $378.26 $0.00 $0.00 $0.00 $0.00 $0.00 241.031 SUP HCPCS C1713 241.031 - PLATE BN OB R T 52X10X1.5MM NS LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP $662.08 $489.94 $0.00 $514.24 $289.26 $289.26 $0.00 $0.00 $0.00 $137.99 $491.39 $491.39 $0.00 $0.00 $137.98 $0.00 $391.62 $391.62 $0.00 $321.40 $509.10 $514.24 $0.00 $0.00 $97.67 $0.00 $0.00 $102.33 $0.00 $0.00 $0.00 $0.00 $0.00 241.041 SUP HCPCS C1713 241.041 - PLATE BN OB R T 63X10X1.5MM NS LCP CMBN 3 HLE/HD 4 HL SHFT BOTH IP/OP $693.00 $512.82 $0.00 $538.26 $302.77 $302.77 $0.00 $0.00 $0.00 $144.44 $514.34 $514.34 $0.00 $0.00 $144.42 $0.00 $409.91 $409.91 $0.00 $336.41 $532.88 $538.26 $0.00 $0.00 $102.23 $0.00 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 241.051 SUP HCPCS C1713 241.051 - PLATE BN OB R T 74X10X1.5MM NS LCP CMBN 3 HLE/HD 5 HL SHFT BOTH IP/OP $723.93 $535.71 $0.00 $562.28 $316.28 $316.28 $0.00 $0.00 $0.00 $150.88 $537.30 $537.30 $0.00 $0.00 $150.87 $0.00 $428.20 $428.20 $0.00 $351.43 $556.66 $562.28 $0.00 $0.00 $141.20 $0.00 $0.00 $111.89 $0.00 $0.00 $0.00 $0.00 $0.00 241.061 SUP HCPCS C1713 241.061 - PLATE BONE T 85X10X1.5MM 3X6 HOLE OBLIQUE RIGHT LCP BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 241.062 SUP HCPCS C1713 241.062 - PLATE BONE 15MM 6 HOLE HOOK LC-DCP DCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,272.00 " $941.28 $0.00 "$1,017.60" $572.40 $572.40 $0.00 $0.00 $0.00 $265.12 $944.08 $944.08 $0.00 $0.00 $265.08 $0.00 $752.39 $752.39 $0.00 $636.00 "$1,007.42" "$1,017.60" $0.00 $0.00 $199.07 $0.00 $0.00 $202.50 $0.00 $0.00 $0.00 $0.00 $0.00 241.063 SUP HCPCS C1713 241.063 - PLATE BONE 15MM 6 HOLE HOOK LC-DCP STAINLESS STEEL LEFT BOTH IP/OP "$1,272.00 " $941.28 $0.00 "$1,017.60" $572.40 $572.40 $0.00 $0.00 $0.00 $265.12 $944.08 $944.08 $0.00 $0.00 $265.08 $0.00 $752.39 $752.39 $0.00 $636.00 "$1,007.42" "$1,017.60" $0.00 $0.00 $199.07 $0.00 $0.00 $202.50 $0.00 $0.00 $0.00 $0.00 $0.00 241.064 SUP HCPCS C1713 241.064 - PLATE BONE 18MM 6 HOLE HOOK LC-DCP DCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,272.00 " $941.28 $0.00 "$1,017.60" $572.40 $572.40 $0.00 $0.00 $0.00 $265.12 $944.08 $944.08 $0.00 $0.00 $265.08 $0.00 $752.39 $752.39 $0.00 $636.00 "$1,007.42" "$1,017.60" $0.00 $0.00 $199.07 $0.00 $0.00 $202.50 $0.00 $0.00 $0.00 $0.00 $0.00 241.065 SUP HCPCS C1713 241.065 - PLATE BONE 18MM 6 HOLE HOOK LC-DCP STAINLESS STEEL LEFT BOTH IP/OP "$1,272.00 " $941.28 $0.00 "$1,017.60" $572.40 $572.40 $0.00 $0.00 $0.00 $265.12 $944.08 $944.08 $0.00 $0.00 $265.08 $0.00 $752.39 $752.39 $0.00 $636.00 "$1,007.42" "$1,017.60" $0.00 $0.00 $199.07 $0.00 $0.00 $202.50 $0.00 $0.00 $0.00 $0.00 $0.00 241.066 SUP HCPCS C1713 241.066 - PLATE BONE 15MM 8 HOLE HOOK LC-DCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,364.75 " "$1,009.92" $0.00 "$1,091.80" $614.14 $614.14 $0.00 $0.00 $0.00 $284.45 "$1,012.92" "$1,012.92" $0.00 $0.00 $284.41 $0.00 $807.25 $807.25 $0.00 $682.38 "$1,080.88" "$1,091.80" $0.00 $0.00 $213.58 $0.00 $0.00 $217.27 $0.00 $0.00 $0.00 $0.00 $0.00 241.067 SUP HCPCS C1713 241.067 - PLATE BONE 15MM 8 HOLE HOOK LC-DCP STAINLESS STEEL LEFT BOTH IP/OP "$1,364.75 " "$1,009.92" $0.00 "$1,091.80" $614.14 $614.14 $0.00 $0.00 $0.00 $284.45 "$1,012.92" "$1,012.92" $0.00 $0.00 $284.41 $0.00 $807.25 $807.25 $0.00 $682.38 "$1,080.88" "$1,091.80" $0.00 $0.00 $213.58 $0.00 $0.00 $217.27 $0.00 $0.00 $0.00 $0.00 $0.00 241.068 SUP HCPCS C1713 241.068 - PLATE BONE 18MM 8 HOLE HOOK LC-DCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,364.75 " "$1,009.92" $0.00 "$1,091.80" $614.14 $614.14 $0.00 $0.00 $0.00 $284.45 "$1,012.92" "$1,012.92" $0.00 $0.00 $284.41 $0.00 $807.25 $807.25 $0.00 $682.38 "$1,080.88" "$1,091.80" $0.00 $0.00 $213.58 $0.00 $0.00 $217.27 $0.00 $0.00 $0.00 $0.00 $0.00 241.069 SUP HCPCS C1713 241.069 - PLATE BN 18MM 77X10X3.3MM NS LC DCP 8 HL HK PRECONTOUR SS BOTH IP/OP "$1,364.75 " "$1,009.92" $0.00 "$1,091.80" $614.14 $614.14 $0.00 $0.00 $0.00 $284.45 "$1,012.92" "$1,012.92" $0.00 $0.00 $284.41 $0.00 $807.25 $807.25 $0.00 $682.38 "$1,080.88" "$1,091.80" $0.00 $0.00 $213.58 $0.00 $0.00 $217.27 $0.00 $0.00 $0.00 $0.00 $0.00 241.071 SUP HCPCS C1713 241.071 - PLATE BN OB R T 96X10X1.5MM NS LCP CMBN 3 HLE/HD 7 HL SHFT BOTH IP/OP $785.78 $581.48 $0.00 $610.32 $343.31 $343.31 $0.00 $0.00 $0.00 $163.78 $583.20 $583.20 $0.00 $0.00 $163.76 $0.00 $464.79 $464.79 $0.00 $381.45 $604.22 $610.32 $0.00 $0.00 $153.59 $0.00 $0.00 $121.45 $0.00 $0.00 $0.00 $0.00 $0.00 241.081 SUP HCPCS C1713 241.081 - PLATE BONE T 107X10X1.5MM 3X8 HOLE OBLIQUE RIGHT LCP BOTH IP/OP $853.25 $631.41 $0.00 $662.72 $372.78 $372.78 $0.00 $0.00 $0.00 $177.84 $633.28 $633.28 $0.00 $0.00 $177.82 $0.00 $504.70 $504.70 $0.00 $414.20 $656.09 $662.72 $0.00 $0.00 $125.87 $0.00 $0.00 $131.88 $0.00 $0.00 $0.00 $0.00 $0.00 241.13 SUP HCPCS C1713 241.13 - PLATE BN RT ANG T 50X10X1.2MM NS LC DCP 3 HLE/HD 3 HL SHFT BOTH IP/OP $233.38 $172.70 $0.00 $186.70 $105.02 $105.02 $0.00 $0.00 $0.00 $48.64 $173.21 $173.21 $0.00 $0.00 $48.64 $0.00 $138.04 $138.04 $0.00 $116.69 $184.84 $186.70 $0.00 $0.00 $35.46 $0.00 $0.00 $37.15 $0.00 $0.00 $0.00 $0.00 $0.00 241.131 SUP HCPCS C1713 241.131 - PLATE BONE T RIGHT ANG 50X10X1.5MM 3X3 HOLE LCP STAINLESS BOTH IP/OP $591.80 $437.93 $0.00 $459.64 $258.55 $258.55 $0.00 $0.00 $0.00 $123.35 $439.23 $439.23 $0.00 $0.00 $123.33 $0.00 $350.05 $350.05 $0.00 $287.28 $455.04 $459.64 $0.00 $0.00 $87.30 $0.00 $0.00 $91.47 $0.00 $0.00 $0.00 $0.00 $0.00 241.132 SUP HCPCS C1713 241.132 - PLATE BONE T RIGHT ANG 50X11X1.5MM 4X3 HOLE LCP STAINLESS BOTH IP/OP $607.25 $449.37 $0.00 $471.66 $265.31 $265.31 $0.00 $0.00 $0.00 $126.57 $450.70 $450.70 $0.00 $0.00 $126.55 $0.00 $359.19 $359.19 $0.00 $294.79 $466.95 $471.66 $0.00 $0.00 $89.58 $0.00 $0.00 $93.86 $0.00 $0.00 $0.00 $0.00 $0.00 241.14 SUP HCPCS C1713 241.14 - PLATE BN RT ANG T 56X10X1.2MM NS LC DCP 4 HLE/HD 4 HL SHFT BOTH IP/OP $248.80 $184.11 $0.00 $193.24 $108.70 $108.70 $0.00 $0.00 $0.00 $51.86 $184.66 $184.66 $0.00 $0.00 $51.85 $0.00 $147.17 $147.17 $0.00 $120.78 $191.31 $193.24 $0.00 $0.00 $36.70 $0.00 $0.00 $38.45 $0.00 $0.00 $0.00 $0.00 $0.00 241.141 SUP HCPCS C1713 241.141 - PLATE BN RT ANG T 56X11X1.5MM NS LCP CMBN 4 HLE/HD 4 HL SHFT BOTH IP/OP $610.08 $451.46 $0.00 $473.84 $266.54 $266.54 $0.00 $0.00 $0.00 $127.15 $452.80 $452.80 $0.00 $0.00 $127.14 $0.00 $360.86 $360.86 $0.00 $296.15 $469.10 $473.84 $0.00 $0.00 $90.00 $0.00 $0.00 $94.29 $0.00 $0.00 $0.00 $0.00 $0.00 241.142 SUP HCPCS C1713 241.142 - PLATE BN RT ANG T 57X10X1.5MM NS LCP CMBN 3 HLE/HD 4 HL SHFT BOTH IP/OP $629.75 $466.02 $0.00 $489.12 $275.13 $275.13 $0.00 $0.00 $0.00 $131.26 $467.40 $467.40 $0.00 $0.00 $131.24 $0.00 $372.50 $372.50 $0.00 $305.70 $484.23 $489.12 $0.00 $0.00 $92.90 $0.00 $0.00 $97.33 $0.00 $0.00 $0.00 $0.00 $0.00 241.15 SUP HCPCS C1713 241.15 - PLATE BN RT ANG T 67X10X1.2MM NS LC DCP 3 HLE/HD 5 HL SHFT BOTH IP/OP $267.50 $197.95 $0.00 $214.00 $120.38 $120.38 $0.00 $0.00 $0.00 $55.75 $198.54 $198.54 $0.00 $0.00 $55.75 $0.00 $158.23 $158.23 $0.00 $133.75 $211.86 $214.00 $0.00 $0.00 $40.64 $0.00 $0.00 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 241.151 SUP HCPCS C1713 241.151 - PLATE BN RT ANG T 67X10X1.5MM NS LCP CMBN 3 HLE/HD 5 HL SHFT BOTH IP/OP $671.93 $497.23 $0.00 $521.88 $293.56 $293.56 $0.00 $0.00 $0.00 $140.05 $498.70 $498.70 $0.00 $0.00 $140.03 $0.00 $397.44 $397.44 $0.00 $326.18 $516.66 $521.88 $0.00 $0.00 $99.12 $0.00 $0.00 $103.85 $0.00 $0.00 $0.00 $0.00 $0.00 241.152 SUP HCPCS C1713 241.152 - PLATE BONE 67MM 3X5 HOLE T RIGHT ANG LCP STAINLESS STEEL BOTH IP/OP $691.60 $511.78 $0.00 $537.16 $302.15 $302.15 $0.00 $0.00 $0.00 $144.15 $513.31 $513.31 $0.00 $0.00 $144.13 $0.00 $409.08 $409.08 $0.00 $335.73 $531.79 $537.16 $0.00 $0.00 $102.02 $0.00 $0.00 $106.89 $0.00 $0.00 $0.00 $0.00 $0.00 241.16 SUP HCPCS C1713 241.16 - PLATE BONE ANGLE RIGHT T 75X10X1.2MM 4X6 HOLE LCP STAINLESS BOTH IP/OP $311.18 $230.27 $0.00 $248.94 $140.03 $140.03 $0.00 $0.00 $0.00 $64.86 $230.95 $230.95 $0.00 $0.00 $64.85 $0.00 $184.06 $184.06 $0.00 $155.59 $246.45 $248.94 $0.00 $0.00 $47.28 $0.00 $0.00 $49.54 $0.00 $0.00 $0.00 $0.00 $0.00 241.161 SUP HCPCS C1713 241.161 - PLATE BN RT ANG T 78X11X1.5MM NS LCP CMBN 4 HLE/HD 6 HL SHFT BOTH IP/OP $782.98 $579.41 $0.00 $608.14 $342.08 $342.08 $0.00 $0.00 $0.00 $163.19 $581.12 $581.12 $0.00 $0.00 $163.17 $0.00 $463.13 $463.13 $0.00 $380.09 $602.06 $608.14 $0.00 $0.00 $115.50 $0.00 $0.00 $121.02 $0.00 $0.00 $0.00 $0.00 $0.00 241.162 SUP HCPCS C1713 241.162 - PLATE BONE T RIGHT ANG 77X10X1.5MM 3X6 HOLE LCP STAINLESS BOTH IP/OP $804.05 $595.00 $0.00 $624.50 $351.28 $351.28 $0.00 $0.00 $0.00 $167.58 $596.77 $596.77 $0.00 $0.00 $167.56 $0.00 $475.60 $475.60 $0.00 $390.31 $618.26 $624.50 $0.00 $0.00 $118.61 $0.00 $0.00 $124.28 $0.00 $0.00 $0.00 $0.00 $0.00 241.17 SUP HCPCS C1713 241.17 - PLATE BONE T RIGHT ANG 90X10X1.2MM 4X7 HOLE LCP STAINLESS BOTH IP/OP $399.88 $295.91 $0.00 $319.90 $179.94 $179.94 $0.00 $0.00 $0.00 $83.34 $296.79 $296.79 $0.00 $0.00 $83.33 $0.00 $236.53 $236.53 $0.00 $199.94 $316.70 $319.90 $0.00 $0.00 $60.76 $0.00 $0.00 $63.66 $0.00 $0.00 $0.00 $0.00 $0.00 241.171 SUP HCPCS C1713 241.171 - PLATE BN RT ANG T 87X10X1.5MM NS LCP CMBN 3 HLE/HD 7 HL SHFT BOTH IP/OP $981.18 $726.07 $0.00 $762.08 $428.67 $428.67 $0.00 $0.00 $0.00 $204.50 $728.23 $728.23 $0.00 $0.00 $204.48 $0.00 $580.37 $580.37 $0.00 $476.30 $754.46 $762.08 $0.00 $0.00 $144.74 $0.00 $0.00 $151.65 $0.00 $0.00 $0.00 $0.00 $0.00 241.172 SUP HCPCS C1713 241.172 - PLATE BONE T RIGHT ANG 89X11X1.5MM 4X7 HOLE LCP STAINLESS BOTH IP/OP $976.95 $722.94 $0.00 $758.80 $426.83 $426.83 $0.00 $0.00 $0.00 $203.62 $725.09 $725.09 $0.00 $0.00 $203.60 $0.00 $577.87 $577.87 $0.00 $474.25 $751.21 $758.80 $0.00 $0.00 $144.12 $0.00 $0.00 $151.00 $0.00 $0.00 $0.00 $0.00 $0.00 241.18 SUP HCPCS C1713 241.18 - PLATE BONE 100MM 4 HOLE HEAD 8 HOLE SHAFT T RIGHT ANG LC-DCP BOTH IP/OP $464.03 $343.38 $0.00 $371.22 $208.81 $208.81 $0.00 $0.00 $0.00 $96.71 $344.40 $344.40 $0.00 $0.00 $96.70 $0.00 $274.47 $274.47 $0.00 $232.01 $367.51 $371.22 $0.00 $0.00 $70.50 $0.00 $0.00 $73.87 $0.00 $0.00 $0.00 $0.00 $0.00 241.181 SUP HCPCS C1713 241.181 - PLATE BONE T RIGHT ANG 97X10X1.5MM 3X8 HOLE LCP STAINLESS BOTH IP/OP "$1,175.15 " $869.61 $0.00 $912.74 $513.42 $513.42 $0.00 $0.00 $0.00 $244.93 $872.20 $872.20 $0.00 $0.00 $244.90 $0.00 $695.10 $695.10 $0.00 $570.46 $903.62 $912.74 $0.00 $0.00 $173.36 $0.00 $0.00 $181.64 $0.00 $0.00 $0.00 $0.00 $0.00 241.182 SUP HCPCS C1713 241.182 - PLATE BONE T RIGHT ANG 100X10X1.5MM 4X8 HOLE LCP STAINLESS BOTH IP/OP "$1,170.95 " $866.50 $0.00 $909.46 $511.57 $511.57 $0.00 $0.00 $0.00 $244.06 $869.08 $869.08 $0.00 $0.00 $244.03 $0.00 $692.62 $692.62 $0.00 $568.41 $900.37 $909.46 $0.00 $0.00 $172.73 $0.00 $0.00 $180.98 $0.00 $0.00 $0.00 $0.00 $0.00 241.189 SUP HCPCS C1713 241.189 - PLATE BONE 112MM 4 HOLE HEAD 9 HOLE SHAFT T RIGHT ANG LC-DCP BOTH IP/OP $517.30 $382.80 $0.00 $401.78 $226.00 $226.00 $0.00 $0.00 $0.00 $107.82 $383.94 $383.94 $0.00 $0.00 $107.81 $0.00 $305.98 $305.98 $0.00 $251.11 $397.77 $401.78 $0.00 $0.00 $76.31 $0.00 $0.00 $79.95 $0.00 $0.00 $0.00 $0.00 $0.00 241.23 SUP HCPCS C1713 241.23 - PLATE BN OBLQ T 53X10X1.5MM NS LC DCP 3 HLE/HD 3 HL SHFT SS BOTH IP/OP $401.23 $296.91 $0.00 $320.98 $180.55 $180.55 $0.00 $0.00 $0.00 $83.63 $297.79 $297.79 $0.00 $0.00 $83.62 $0.00 $237.32 $237.32 $0.00 $200.61 $317.77 $320.98 $0.00 $0.00 $60.96 $0.00 $0.00 $63.88 $0.00 $0.00 $0.00 $0.00 $0.00 241.231 SUP HCPCS C1713 241.231 - PLATE BONE 53MM 3X3 HOLE T OBLIQUE ANGLE LCP STAINLESS STEEL BOTH IP/OP $427.98 $316.71 $0.00 $342.38 $192.59 $192.59 $0.00 $0.00 $0.00 $89.20 $317.64 $317.64 $0.00 $0.00 $89.19 $0.00 $253.15 $253.15 $0.00 $213.99 $338.96 $342.38 $0.00 $0.00 $66.98 $0.00 $0.00 $68.13 $0.00 $0.00 $0.00 $0.00 $0.00 241.24 SUP HCPCS C1713 241.24 - PLATE BN OBLQ T 63X10X1.5MM NS LC DCP 3 HLE/HD 4 HL SHFT SS BOTH IP/OP $424.43 $314.08 $0.00 $339.54 $190.99 $190.99 $0.00 $0.00 $0.00 $88.46 $315.01 $315.01 $0.00 $0.00 $88.45 $0.00 $251.05 $251.05 $0.00 $212.21 $336.15 $339.54 $0.00 $0.00 $64.49 $0.00 $0.00 $67.57 $0.00 $0.00 $0.00 $0.00 $0.00 241.241 SUP HCPCS C1713 241.241 - PLATE BONE 63MM 3 HOLE HEAD 3 HOLE SHAFT T OBLIQUE STAINLESS BOTH IP/OP $449.18 $332.39 $0.00 $359.34 $202.13 $202.13 $0.00 $0.00 $0.00 $93.62 $333.38 $333.38 $0.00 $0.00 $93.61 $0.00 $265.69 $265.69 $0.00 $224.59 $355.75 $359.34 $0.00 $0.00 $70.30 $0.00 $0.00 $71.51 $0.00 $0.00 $0.00 $0.00 $0.00 241.25 SUP HCPCS C1713 241.25 - PLATE BN OBLQ T 75X10X1.5MM NS LC DCP 3 HLE/HD 5 HL SHFT SS BOTH IP/OP $436.73 $323.18 $0.00 $349.38 $196.53 $196.53 $0.00 $0.00 $0.00 $91.02 $324.14 $324.14 $0.00 $0.00 $91.01 $0.00 $258.32 $258.32 $0.00 $218.36 $345.89 $349.38 $0.00 $0.00 $66.36 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $0.00 241.252 SUP HCPCS C1713 241.252 - PLATE BONE 75MM 3 HOLE HEAD 3 HOLE SHAFT T OBLIQUE STAINLESS BOTH IP/OP $459.78 $340.24 $0.00 $367.82 $206.90 $206.90 $0.00 $0.00 $0.00 $95.83 $341.25 $341.25 $0.00 $0.00 $95.82 $0.00 $271.96 $271.96 $0.00 $229.89 $364.15 $367.82 $0.00 $0.00 $71.95 $0.00 $0.00 $73.20 $0.00 $0.00 $0.00 $0.00 $0.00 241.262 SUP HCPCS C1713 241.262 - PLATE BN 65X11X2.5MM NS LCP CMBN 3 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,731.83 " "$1,281.55" $0.00 "$1,345.10" $756.62 $756.62 $0.00 $0.00 $0.00 $360.96 "$1,285.36" "$1,285.36" $0.00 $0.00 $360.91 $0.00 "$1,024.37" "$1,024.37" $0.00 $840.69 "$1,331.65" "$1,345.10" $0.00 $0.00 $255.47 $0.00 $0.00 $267.67 $0.00 $0.00 $0.00 $0.00 $0.00 241.263 SUP HCPCS C1713 241.263 - PLATE BN 65X11X2.5MM NS LCP CMBN 3 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,731.83 " "$1,281.55" $0.00 "$1,345.10" $756.62 $756.62 $0.00 $0.00 $0.00 $360.96 "$1,285.36" "$1,285.36" $0.00 $0.00 $360.91 $0.00 "$1,024.37" "$1,024.37" $0.00 $840.69 "$1,331.65" "$1,345.10" $0.00 $0.00 $255.47 $0.00 $0.00 $267.67 $0.00 $0.00 $0.00 $0.00 $0.00 241.264 SUP HCPCS C1713 241.264 - PLATE BN 90X11X2.5MM NS LCP CMBN 5 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,921.58 " "$1,421.97" $0.00 "$1,492.50" $839.53 $839.53 $0.00 $0.00 $0.00 $400.50 "$1,426.19" "$1,426.19" $0.00 $0.00 $400.46 $0.00 "$1,136.61" "$1,136.61" $0.00 $932.81 "$1,477.58" "$1,492.50" $0.00 $0.00 $283.46 $0.00 $0.00 $297.01 $0.00 $0.00 $0.00 $0.00 $0.00 241.265 SUP HCPCS C1713 241.265 - PLATE BN 90X11X2.5MM NS LCP CMBN 5 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,921.58 " "$1,421.97" $0.00 "$1,492.50" $839.53 $839.53 $0.00 $0.00 $0.00 $400.50 "$1,426.19" "$1,426.19" $0.00 $0.00 $400.46 $0.00 "$1,136.61" "$1,136.61" $0.00 $932.81 "$1,477.58" "$1,492.50" $0.00 $0.00 $283.46 $0.00 $0.00 $297.01 $0.00 $0.00 $0.00 $0.00 $0.00 241.266 SUP HCPCS C1713 241.266 - PLATE BN 116X11X2.5MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,112.75 " "$1,563.44" $0.00 "$1,640.98" $923.05 $923.05 $0.00 $0.00 $0.00 $440.35 "$1,568.08" "$1,568.08" $0.00 $0.00 $440.30 $0.00 "$1,249.69" "$1,249.69" $0.00 "$1,025.61" "$1,624.57" "$1,640.98" $0.00 $0.00 $311.67 $0.00 $0.00 $326.56 $0.00 $0.00 $0.00 $0.00 $0.00 241.267 SUP HCPCS C1713 241.267 - PLATE BN 116X11X2.5MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,112.75 " "$1,563.44" $0.00 "$1,640.98" $923.05 $923.05 $0.00 $0.00 $0.00 $440.35 "$1,568.08" "$1,568.08" $0.00 $0.00 $440.30 $0.00 "$1,249.69" "$1,249.69" $0.00 "$1,025.61" "$1,624.57" "$1,640.98" $0.00 $0.00 $311.67 $0.00 $0.00 $326.56 $0.00 $0.00 $0.00 $0.00 $0.00 241.268 SUP HCPCS C1713 241.268 - PLATE BN 142X11X2.5MM NS LCP CMBN 9 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,281.45 " "$1,688.27" $0.00 "$1,772.00" $996.75 $996.75 $0.00 $0.00 $0.00 $475.51 "$1,693.29" "$1,693.29" $0.00 $0.00 $475.45 $0.00 "$1,349.48" "$1,349.48" $0.00 "$1,107.50" "$1,754.28" "$1,772.00" $0.00 $0.00 $336.55 $0.00 $0.00 $352.63 $0.00 $0.00 $0.00 $0.00 $0.00 241.269 SUP HCPCS C1713 241.269 - PLATE BN 142X11X2.5MM NS LCP CMBN 9 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,281.45 " "$1,688.27" $0.00 "$1,772.00" $996.75 $996.75 $0.00 $0.00 $0.00 $475.51 "$1,693.29" "$1,693.29" $0.00 $0.00 $475.45 $0.00 "$1,349.48" "$1,349.48" $0.00 "$1,107.50" "$1,754.28" "$1,772.00" $0.00 $0.00 $336.55 $0.00 $0.00 $352.63 $0.00 $0.00 $0.00 $0.00 $0.00 241.272 SUP HCPCS C1713 241.272 - PLATE BN 65X11X2.5MM NS LCP CMBN 3 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,986.25 " "$1,469.83" $0.00 "$1,542.72" $867.78 $867.78 $0.00 $0.00 $0.00 $413.98 "$1,474.19" "$1,474.19" $0.00 $0.00 $413.93 $0.00 "$1,174.87" "$1,174.87" $0.00 $964.20 "$1,527.29" "$1,542.72" $0.00 $0.00 $293.00 $0.00 $0.00 $307.00 $0.00 $0.00 $0.00 $0.00 $0.00 241.273 SUP HCPCS C1713 241.273 - PLATE BN 65X11X2.5MM NS LCP CMBN 3 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,986.25 " "$1,469.83" $0.00 "$1,542.72" $867.78 $867.78 $0.00 $0.00 $0.00 $413.98 "$1,474.19" "$1,474.19" $0.00 $0.00 $413.93 $0.00 "$1,174.87" "$1,174.87" $0.00 $964.20 "$1,527.29" "$1,542.72" $0.00 $0.00 $293.00 $0.00 $0.00 $307.00 $0.00 $0.00 $0.00 $0.00 $0.00 241.274 SUP HCPCS C1713 241.274 - PLATE BN 90X11X2.5MM NS LCP CMBN 5 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,166.18 " "$1,602.97" $0.00 "$1,682.46" $946.38 $946.38 $0.00 $0.00 $0.00 $451.49 "$1,607.74" "$1,607.74" $0.00 $0.00 $451.43 $0.00 "$1,281.29" "$1,281.29" $0.00 "$1,051.54" "$1,665.64" "$1,682.46" $0.00 $0.00 $319.55 $0.00 $0.00 $334.81 $0.00 $0.00 $0.00 $0.00 $0.00 241.275 SUP HCPCS C1713 241.275 - PLATE BN 90X11X2.5MM NS LCP CMBN 5 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,166.18 " "$1,602.97" $0.00 "$1,682.46" $946.38 $946.38 $0.00 $0.00 $0.00 $451.49 "$1,607.74" "$1,607.74" $0.00 $0.00 $451.43 $0.00 "$1,281.29" "$1,281.29" $0.00 "$1,051.54" "$1,665.64" "$1,682.46" $0.00 $0.00 $319.55 $0.00 $0.00 $334.81 $0.00 $0.00 $0.00 $0.00 $0.00 241.276 SUP HCPCS C1713 241.276 - PLATE BN 116X11X2.5MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,823.30" "$1,025.61" "$1,025.61" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,139.56" "$1,805.07" "$1,823.30" $0.00 $0.00 $346.30 $0.00 $0.00 $362.84 $0.00 $0.00 $0.00 $0.00 $0.00 241.277 SUP HCPCS C1713 241.277 - PLATE BN 116X11X2.5MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,823.30" "$1,025.61" "$1,025.61" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,139.56" "$1,805.07" "$1,823.30" $0.00 $0.00 $346.30 $0.00 $0.00 $362.84 $0.00 $0.00 $0.00 $0.00 $0.00 241.278 SUP HCPCS C1713 241.278 - PLATE BN 142X11X2.5MM NS LCP CMBN 9 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,547.13 " "$1,884.88" $0.00 "$1,978.34" "$1,112.82" "$1,112.82" $0.00 $0.00 $0.00 $530.88 "$1,890.48" "$1,890.48" $0.00 $0.00 $530.82 $0.00 "$1,255.73" "$1,255.73" $0.00 "$1,236.46" "$1,958.56" "$1,978.34" $0.00 $0.00 $375.74 $0.00 $0.00 $393.69 $0.00 $0.00 $0.00 $0.00 $0.00 241.279 SUP HCPCS C1713 241.279 - PLATE BN 142X11X2.5MM NS LCP CMBN 9 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,547.13 " "$1,884.88" $0.00 "$1,978.34" "$1,112.82" "$1,112.82" $0.00 $0.00 $0.00 $530.88 "$1,890.48" "$1,890.48" $0.00 $0.00 $530.82 $0.00 "$1,255.73" "$1,255.73" $0.00 "$1,236.46" "$1,958.56" "$1,978.34" $0.00 $0.00 $375.74 $0.00 $0.00 $393.69 $0.00 $0.00 $0.00 $0.00 $0.00 241.282 SUP HCPCS C1713 241.282 - PLATE BN 58X11X2.5MM NS LCP CMBN 3 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,731.83 " "$1,281.55" $0.00 "$1,345.10" $756.62 $756.62 $0.00 $0.00 $0.00 $360.96 "$1,285.36" "$1,285.36" $0.00 $0.00 $360.91 $0.00 "$1,024.37" "$1,024.37" $0.00 $840.69 "$1,331.65" "$1,345.10" $0.00 $0.00 $255.47 $0.00 $0.00 $267.67 $0.00 $0.00 $0.00 $0.00 $0.00 241.283 SUP HCPCS C1713 241.283 - PLATE BN 58X11X2.5MM NS LCP CMBN 3 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,731.83 " "$1,281.55" $0.00 "$1,345.10" $756.62 $756.62 $0.00 $0.00 $0.00 $360.96 "$1,285.36" "$1,285.36" $0.00 $0.00 $360.91 $0.00 "$1,024.37" "$1,024.37" $0.00 $840.69 "$1,331.65" "$1,345.10" $0.00 $0.00 $255.47 $0.00 $0.00 $267.67 $0.00 $0.00 $0.00 $0.00 $0.00 241.284 SUP HCPCS C1713 241.284 - PLATE BN 83X11X2.5MM NS LCP CMBN 5 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,921.58 " "$1,421.97" $0.00 "$1,492.50" $839.53 $839.53 $0.00 $0.00 $0.00 $400.50 "$1,426.19" "$1,426.19" $0.00 $0.00 $400.46 $0.00 "$1,136.61" "$1,136.61" $0.00 $932.81 "$1,477.58" "$1,492.50" $0.00 $0.00 $283.46 $0.00 $0.00 $297.01 $0.00 $0.00 $0.00 $0.00 $0.00 241.285 SUP HCPCS C1713 241.285 - PLATE BN 83X11X2.5MM NS LCP CMBN 5 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$1,921.58 " "$1,421.97" $0.00 "$1,492.50" $839.53 $839.53 $0.00 $0.00 $0.00 $400.50 "$1,426.19" "$1,426.19" $0.00 $0.00 $400.46 $0.00 "$1,136.61" "$1,136.61" $0.00 $932.81 "$1,477.58" "$1,492.50" $0.00 $0.00 $283.46 $0.00 $0.00 $297.01 $0.00 $0.00 $0.00 $0.00 $0.00 241.286 SUP HCPCS C1713 241.286 - PLATE BN 110X11X2.5MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,112.75 " "$1,563.44" $0.00 "$1,640.98" $923.05 $923.05 $0.00 $0.00 $0.00 $440.35 "$1,568.08" "$1,568.08" $0.00 $0.00 $440.30 $0.00 "$1,249.69" "$1,249.69" $0.00 "$1,025.61" "$1,624.57" "$1,640.98" $0.00 $0.00 $311.67 $0.00 $0.00 $326.56 $0.00 $0.00 $0.00 $0.00 $0.00 241.287 SUP HCPCS C1713 241.287 - PLATE BN 110X11X2.5MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,112.75 " "$1,563.44" $0.00 "$1,640.98" $923.05 $923.05 $0.00 $0.00 $0.00 $440.35 "$1,568.08" "$1,568.08" $0.00 $0.00 $440.30 $0.00 "$1,249.69" "$1,249.69" $0.00 "$1,025.61" "$1,624.57" "$1,640.98" $0.00 $0.00 $311.67 $0.00 $0.00 $326.56 $0.00 $0.00 $0.00 $0.00 $0.00 241.288 SUP HCPCS C1713 241.288 - PLATE BN 136X11X2.5MM NS LCP CMBN 9 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,281.45 " "$1,688.27" $0.00 "$1,772.00" $996.75 $996.75 $0.00 $0.00 $0.00 $475.51 "$1,693.29" "$1,693.29" $0.00 $0.00 $475.45 $0.00 "$1,349.48" "$1,349.48" $0.00 "$1,107.50" "$1,754.28" "$1,772.00" $0.00 $0.00 $336.55 $0.00 $0.00 $352.63 $0.00 $0.00 $0.00 $0.00 $0.00 241.289 SUP HCPCS C1713 241.289 - PLATE BN 136X11X2.5MM NS LCP CMBN 9 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,281.45 " "$1,688.27" $0.00 "$1,772.00" $996.75 $996.75 $0.00 $0.00 $0.00 $475.51 "$1,693.29" "$1,693.29" $0.00 $0.00 $475.45 $0.00 "$1,349.48" "$1,349.48" $0.00 "$1,107.50" "$1,754.28" "$1,772.00" $0.00 $0.00 $336.55 $0.00 $0.00 $352.63 $0.00 $0.00 $0.00 $0.00 $0.00 241.3 SUP HCPCS C1713 241.300 - PLATE BN 208X11X2.5MM NS LCP CMBN 14 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,279.13 " "$1,686.56" $0.00 "$1,823.30" "$1,025.61" "$1,025.61" $0.00 $0.00 $0.00 $475.03 "$1,691.57" "$1,691.57" $0.00 $0.00 $474.97 $0.00 "$1,348.10" "$1,348.10" $0.00 "$1,139.56" "$1,805.07" "$1,823.30" $0.00 $0.00 $346.30 $0.00 $0.00 $362.84 $0.00 $0.00 $0.00 $0.00 $0.00 241.301 SUP HCPCS C1713 241.301 - PLATE BN 208X11X2.5MM NS LCP CMBN 14 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,823.30" "$1,025.61" "$1,025.61" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,139.56" "$1,805.07" "$1,823.30" $0.00 $0.00 $346.30 $0.00 $0.00 $362.84 $0.00 $0.00 $0.00 $0.00 $0.00 241.302 SUP HCPCS C1713 241.302 - PLATE BN 208X11X2.5MM NS LCP CMBN 14 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,481.05 " "$1,835.98" $0.00 "$1,927.02" "$1,083.95" "$1,083.95" $0.00 $0.00 $0.00 $517.11 "$1,841.44" "$1,841.44" $0.00 $0.00 $517.05 $0.00 "$1,467.54" "$1,467.54" $0.00 "$1,204.39" "$1,907.75" "$1,927.02" $0.00 $0.00 $365.99 $0.00 $0.00 $383.48 $0.00 $0.00 $0.00 $0.00 $0.00 241.303 SUP HCPCS C1713 241.303 - PLATE BN 208X11X2.5MM NS LCP CMBN 14 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,481.05 " "$1,835.98" $0.00 "$1,927.02" "$1,083.95" "$1,083.95" $0.00 $0.00 $0.00 $517.11 "$1,841.44" "$1,841.44" $0.00 $0.00 $517.05 $0.00 "$1,467.54" "$1,467.54" $0.00 "$1,204.39" "$1,907.75" "$1,927.02" $0.00 $0.00 $365.99 $0.00 $0.00 $383.48 $0.00 $0.00 $0.00 $0.00 $0.00 241.304 SUP HCPCS C1713 241.304 - PLATE BN 201X11X2.5MM NS LCP CMBN 14 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,823.30" "$1,025.61" "$1,025.61" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,139.56" "$1,805.07" "$1,823.30" $0.00 $0.00 $346.30 $0.00 $0.00 $362.84 $0.00 $0.00 $0.00 $0.00 $0.00 241.305 SUP HCPCS C1713 241.305 - PLATE BN 201X11X2.5MM NS LCP CMBN 14 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,823.30" "$1,025.61" "$1,025.61" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,139.56" "$1,805.07" "$1,823.30" $0.00 $0.00 $346.30 $0.00 $0.00 $362.84 $0.00 $0.00 $0.00 $0.00 $0.00 241.32 SUP HCPCS C1713 241.32 - PLATE BN 1/3 TBLR 12MM 25X9X1MM NS .5MM 2 HL COLR SS 3.5MM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 241.33 SUP HCPCS C1713 241.33 - PLATE BN 1/3 TBLR 12MM 37X9X1MM NS .5MM 3 HL COLR SS 3.5MM BOTH IP/OP $107.53 $79.57 $0.00 $83.52 $46.98 $46.98 $0.00 $0.00 $0.00 $22.41 $79.81 $79.81 $0.00 $0.00 $22.41 $0.00 $63.60 $63.60 $0.00 $52.20 $82.68 $83.52 $0.00 $0.00 $15.86 $0.00 $0.00 $16.62 $0.00 $0.00 $0.00 $0.00 $0.00 241.331 SUP HCPCS C1713 241.331 - PLATE BONE 33X9X1MM .7MM 1/3 TUBULAR 3 HOLE COLLAR LCP BOTH IP/OP $282.55 $209.09 $0.00 $219.46 $123.45 $123.45 $0.00 $0.00 $0.00 $58.89 $209.71 $209.71 $0.00 $0.00 $58.88 $0.00 $167.13 $167.13 $0.00 $137.16 $217.27 $219.46 $0.00 $0.00 $41.68 $0.00 $0.00 $43.67 $0.00 $0.00 $0.00 $0.00 $0.00 241.34 SUP HCPCS C1713 241.34 - PLATE BN 1/3 TBLR 12MM 49X9X1MM NS .5MM 4 HL COLR SS 3.5MM BOTH IP/OP $123.70 $91.54 $0.00 $96.08 $54.05 $54.05 $0.00 $0.00 $0.00 $25.78 $91.81 $91.81 $0.00 $0.00 $25.78 $0.00 $73.17 $73.17 $0.00 $60.05 $95.12 $96.08 $0.00 $0.00 $18.25 $0.00 $0.00 $19.12 $0.00 $0.00 $0.00 $0.00 $0.00 241.341 SUP HCPCS C1713 241.341 - PLATE BN 1/3 TBLR 12MM 45X9X1MM NS .7MM LCP 4 HL COLR SS BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 241.35 SUP HCPCS C1713 241.35 - PLATE BN 1/3 TBLR 12MM 61X9X1MM NS .5MM 5 HL COLR SS 3.5MM BOTH IP/OP $123.70 $91.54 $0.00 $96.08 $54.05 $54.05 $0.00 $0.00 $0.00 $25.78 $91.81 $91.81 $0.00 $0.00 $25.78 $0.00 $73.17 $73.17 $0.00 $60.05 $95.12 $96.08 $0.00 $0.00 $18.25 $0.00 $0.00 $19.12 $0.00 $0.00 $0.00 $0.00 $0.00 241.351 SUP HCPCS C1713 241.351 - PLATE BN 1/3 TBLR 12MM 57X9X1MM NS .7MM LCP 5 HL COLR SS BOTH IP/OP $316.28 $234.05 $0.00 $245.66 $138.18 $138.18 $0.00 $0.00 $0.00 $65.92 $234.74 $234.74 $0.00 $0.00 $65.91 $0.00 $187.08 $187.08 $0.00 $153.54 $243.21 $245.66 $0.00 $0.00 $46.66 $0.00 $0.00 $48.89 $0.00 $0.00 $0.00 $0.00 $0.00 241.36 SUP HCPCS C1713 241.36 - PLATE BN 1/3 TBLR 12MM 73X9X1MM NS .5MM 6 HL COLR SS 3.5MM BOTH IP/OP $128.60 $95.16 $0.00 $99.88 $56.18 $56.18 $0.00 $0.00 $0.00 $26.80 $95.45 $95.45 $0.00 $0.00 $26.80 $0.00 $76.07 $76.07 $0.00 $62.43 $98.88 $99.88 $0.00 $0.00 $18.97 $0.00 $0.00 $19.88 $0.00 $0.00 $0.00 $0.00 $0.00 241.361 SUP HCPCS C1713 241.361 - PLATE BN 1/3 TBLR 12MM 69X9X1MM NS .7MM LCP 6 HL COLR SS BOTH IP/OP $316.28 $234.05 $0.00 $245.66 $138.18 $138.18 $0.00 $0.00 $0.00 $65.92 $234.74 $234.74 $0.00 $0.00 $65.91 $0.00 $187.08 $187.08 $0.00 $153.54 $243.21 $245.66 $0.00 $0.00 $46.66 $0.00 $0.00 $48.89 $0.00 $0.00 $0.00 $0.00 $0.00 241.37 SUP HCPCS C1713 241.37 - PLATE BN 1/3 TBLR 12MM 85X9X1MM NS .5MM 7 HL COLR SS 3.5MM BOTH IP/OP $128.60 $95.16 $0.00 $99.88 $56.18 $56.18 $0.00 $0.00 $0.00 $26.80 $95.45 $95.45 $0.00 $0.00 $26.80 $0.00 $76.07 $76.07 $0.00 $62.43 $98.88 $99.88 $0.00 $0.00 $18.97 $0.00 $0.00 $19.88 $0.00 $0.00 $0.00 $0.00 $0.00 241.371 SUP HCPCS C1713 241.371 - PLATE BN 1/3 TBLR 12MM 81X9X1MM NS .7MM LCP 7 HL COLR SS BOTH IP/OP $323.30 $239.24 $0.00 $251.12 $141.26 $141.26 $0.00 $0.00 $0.00 $67.38 $239.95 $239.95 $0.00 $0.00 $67.38 $0.00 $191.23 $191.23 $0.00 $156.95 $248.61 $251.12 $0.00 $0.00 $47.69 $0.00 $0.00 $49.97 $0.00 $0.00 $0.00 $0.00 $0.00 241.38 SUP HCPCS C1713 241.38 - PLATE BN 1/3 TBLR 12MM 97X9X1MM NS .5MM 8 HL COLR SS 3.5MM BOTH IP/OP $133.55 $98.83 $0.00 $103.72 $58.34 $58.34 $0.00 $0.00 $0.00 $27.84 $99.12 $99.12 $0.00 $0.00 $27.83 $0.00 $78.99 $78.99 $0.00 $64.83 $102.68 $103.72 $0.00 $0.00 $19.70 $0.00 $0.00 $20.64 $0.00 $0.00 $0.00 $0.00 $0.00 241.381 SUP HCPCS C1713 241.381 - PLATE BN 1/3 TBLR 12MM 93X9X1MM NS .7MM LCP 8 HL COLR SS BOTH IP/OP $340.18 $251.73 $0.00 $264.22 $148.62 $148.62 $0.00 $0.00 $0.00 $70.90 $252.48 $252.48 $0.00 $0.00 $70.89 $0.00 $201.21 $201.21 $0.00 $165.14 $261.58 $264.22 $0.00 $0.00 $50.18 $0.00 $0.00 $52.58 $0.00 $0.00 $0.00 $0.00 $0.00 241.39 SUP HCPCS C1713 241.39 - PLATE BONE 1/3 TUBE 109X9X1MM .5MM 9 HOLE COLLAR DCP LC-DCP BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 241.391 SUP HCPCS C1713 241.391 - PLATE BN 1/3 TBLR 12MM 105X9X1MM NS .7MM LCP 9 HL COLR SS BOTH IP/OP $340.18 $251.73 $0.00 $264.22 $148.62 $148.62 $0.00 $0.00 $0.00 $70.90 $252.48 $252.48 $0.00 $0.00 $70.89 $0.00 $201.21 $201.21 $0.00 $165.14 $261.58 $264.22 $0.00 $0.00 $50.18 $0.00 $0.00 $52.58 $0.00 $0.00 $0.00 $0.00 $0.00 241.4 SUP HCPCS C1713 241.40 - PLATE BN 1/3 TBLR 12MM 121X9X1MM NS .5MM 10 HL COLR SS 3.5MM BOTH IP/OP $133.05 $98.46 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $27.73 $98.75 $98.75 $0.00 $0.00 $27.73 $0.00 $78.70 $78.70 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 241.4 SUP HCPCS C1713 241.4 - PLATE 121MM SS SM FRAG SET 10 HOLE 1/3 TBLR COLLAR LC DCP BOTH IP/OP $133.05 $98.46 $0.00 $112.90 $59.87 $59.87 $0.00 $0.00 $0.00 $27.73 $98.75 $98.75 $0.00 $0.00 $27.73 $0.00 $78.70 $78.70 $0.00 $66.53 $112.90 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 241.401 SUP HCPCS C1713 241.401 - PLATE BN 1/3 TBLR 12MM 117X9X1MM NS .7MM LCP 10 HL COLR SS BOTH IP/OP $340.18 $251.73 $0.00 $264.22 $148.62 $148.62 $0.00 $0.00 $0.00 $70.90 $252.48 $252.48 $0.00 $0.00 $70.89 $0.00 $201.21 $201.21 $0.00 $165.14 $261.58 $264.22 $0.00 $0.00 $50.18 $0.00 $0.00 $52.58 $0.00 $0.00 $0.00 $0.00 $0.00 241.42 SUP HCPCS C1713 241.42 - PLATE BN 1/3 TBLR 12MM 145X9X1MM NS .5MM 12 HL COLR SS 3.5MM BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 241.421 SUP HCPCS C1713 241.421 - PLATE BN 1/3 TBLR 12MM 141X9X1MM NS .7MM LCP 12 HL COLR SS BOTH IP/OP $351.43 $260.06 $0.00 $272.96 $153.54 $153.54 $0.00 $0.00 $0.00 $73.25 $260.83 $260.83 $0.00 $0.00 $73.24 $0.00 $207.87 $207.87 $0.00 $170.60 $270.23 $272.96 $0.00 $0.00 $51.84 $0.00 $0.00 $54.32 $0.00 $0.00 $0.00 $0.00 $0.00 241.44 SUP HCPCS C1713 241.440 - PLATE BONE 80MM 5 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$2,774.53 " "$2,053.15" $0.00 "$2,219.62" "$1,248.54" "$1,248.54" $0.00 $0.00 $0.00 $578.28 "$2,059.25" "$2,059.25" $0.00 $0.00 $578.21 $0.00 "$1,367.84" "$1,367.84" $0.00 "$1,387.26" "$2,197.43" "$2,219.62" $0.00 $0.00 $421.57 $0.00 $0.00 $441.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.441 SUP HCPCS C1713 241.441 - PLATE BONE 80MM 5 HOLE ANATOMIC TAPERED TIP LCP STAINLESS BOTH IP/OP "$2,857.78 " "$2,114.76" $0.00 "$2,219.62" "$1,248.54" "$1,248.54" $0.00 $0.00 $0.00 $595.63 "$2,121.04" "$2,121.04" $0.00 $0.00 $595.56 $0.00 "$1,408.88" "$1,408.88" $0.00 "$1,387.26" "$2,197.43" "$2,219.62" $0.00 $0.00 $421.57 $0.00 $0.00 $441.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.442 SUP HCPCS C1713 241.442 - PLATE BONE 106MM 7 HOLE ANATOMIC TAPERED TIP LCP STAINLESS BOTH IP/OP "$2,795.93 " "$2,068.99" $0.00 "$2,171.60" "$1,221.53" "$1,221.53" $0.00 $0.00 $0.00 $582.74 "$2,075.14" "$2,075.14" $0.00 $0.00 $582.67 $0.00 "$1,378.39" "$1,378.39" $0.00 "$1,357.25" "$2,149.88" "$2,171.60" $0.00 $0.00 $412.44 $0.00 $0.00 $432.15 $0.00 $0.00 $0.00 $0.00 $0.00 241.443 SUP HCPCS C1713 241.443 - PLATE BONE 106MM 7 HOLE ANATOMIC TAPERED TIP LCP STAINLESS BOTH IP/OP "$2,795.93 " "$2,068.99" $0.00 "$2,171.60" "$1,221.53" "$1,221.53" $0.00 $0.00 $0.00 $582.74 "$2,075.14" "$2,075.14" $0.00 $0.00 $582.67 $0.00 "$1,378.39" "$1,378.39" $0.00 "$1,357.25" "$2,149.88" "$2,171.60" $0.00 $0.00 $412.44 $0.00 $0.00 $432.15 $0.00 $0.00 $0.00 $0.00 $0.00 241.444 SUP HCPCS C1713 241.444 - PLATE BONE 132MM 9 HOLE ANATOMIC TAPERED TIP LCP STAINLESS BOTH IP/OP "$2,824.03 " "$2,089.78" $0.00 "$2,193.42" "$1,233.80" "$1,233.80" $0.00 $0.00 $0.00 $588.60 "$2,095.99" "$2,095.99" $0.00 $0.00 $588.53 $0.00 "$1,392.24" "$1,392.24" $0.00 "$1,370.89" "$2,171.49" "$2,193.42" $0.00 $0.00 $416.59 $0.00 $0.00 $436.49 $0.00 $0.00 $0.00 $0.00 $0.00 241.445 SUP HCPCS C1713 241.445 - PLATE BONE 132MM 9 HOLE ANATOMIC TAPERED TIP LCP STAINLESS BOTH IP/OP "$2,824.03 " "$2,089.78" $0.00 "$2,193.42" "$1,233.80" "$1,233.80" $0.00 $0.00 $0.00 $588.60 "$2,095.99" "$2,095.99" $0.00 $0.00 $588.53 $0.00 "$1,392.24" "$1,392.24" $0.00 "$1,370.89" "$2,171.49" "$2,193.42" $0.00 $0.00 $416.59 $0.00 $0.00 $436.49 $0.00 $0.00 $0.00 $0.00 $0.00 241.446 SUP HCPCS C1713 241.446 - PLATE BONE 158MM 11 HOLE ANATOMIC TAPERED TIP LCP STAINLESS BOTH IP/OP "$2,850.75 " "$2,109.56" $0.00 "$2,214.18" "$1,245.48" "$1,245.48" $0.00 $0.00 $0.00 $594.17 "$2,115.83" "$2,115.83" $0.00 $0.00 $594.10 $0.00 "$1,405.42" "$1,405.42" $0.00 "$1,383.86" "$2,192.04" "$2,214.18" $0.00 $0.00 $420.53 $0.00 $0.00 $440.62 $0.00 $0.00 $0.00 $0.00 $0.00 241.447 SUP HCPCS C1713 241.447 - PLATE BONE 158MM 11 HOLE LCP STAINLESS STEEL LEFT DISTAL BOTH IP/OP "$2,850.75 " "$2,109.56" $0.00 "$2,214.18" "$1,245.48" "$1,245.48" $0.00 $0.00 $0.00 $594.17 "$2,115.83" "$2,115.83" $0.00 $0.00 $594.10 $0.00 "$1,405.42" "$1,405.42" $0.00 "$1,383.86" "$2,192.04" "$2,214.18" $0.00 $0.00 $420.53 $0.00 $0.00 $440.62 $0.00 $0.00 $0.00 $0.00 $0.00 241.448 SUP HCPCS C1713 241.448 - PLATE BONE 184MM 13 HOLE ANATOMIC TAPERED TIP LCP STAINLESS BOTH IP/OP "$2,883.08 " "$2,133.48" $0.00 "$2,239.28" "$1,259.60" "$1,259.60" $0.00 $0.00 $0.00 $600.90 "$2,139.82" "$2,139.82" $0.00 $0.00 $600.83 $0.00 "$1,421.36" "$1,421.36" $0.00 "$1,399.55" "$2,216.89" "$2,239.28" $0.00 $0.00 $425.30 $0.00 $0.00 $445.62 $0.00 $0.00 $0.00 $0.00 $0.00 241.449 SUP HCPCS C1713 241.449 - PLATE BONE 184MM 13 HOLE ANATOMIC TAPERED TIP LCP STAINLESS BOTH IP/OP "$2,883.08 " "$2,133.48" $0.00 "$2,239.28" "$1,259.60" "$1,259.60" $0.00 $0.00 $0.00 $600.90 "$2,139.82" "$2,139.82" $0.00 $0.00 $600.83 $0.00 "$1,421.36" "$1,421.36" $0.00 "$1,399.55" "$2,216.89" "$2,239.28" $0.00 $0.00 $425.30 $0.00 $0.00 $445.62 $0.00 $0.00 $0.00 $0.00 $0.00 241.45 SUP HCPCS C1713 241.450 - PLATE BONE 210MM 15 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$2,835.95 " "$2,098.60" $0.00 "$2,268.76" "$1,276.18" "$1,276.18" $0.00 $0.00 $0.00 $591.08 "$2,104.84" "$2,104.84" $0.00 $0.00 $591.01 $0.00 "$1,398.12" "$1,398.12" $0.00 "$1,417.98" "$2,246.07" "$2,268.76" $0.00 $0.00 $430.90 $0.00 $0.00 $451.48 $0.00 $0.00 $0.00 $0.00 $0.00 241.451 SUP HCPCS C1713 241.451 - PLATE BONE 210MM 15 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$2,921.03 " "$2,161.56" $0.00 "$2,268.76" "$1,276.18" "$1,276.18" $0.00 $0.00 $0.00 $608.81 "$2,167.98" "$2,167.98" $0.00 $0.00 $608.74 $0.00 "$1,440.07" "$1,440.07" $0.00 "$1,417.98" "$2,246.07" "$2,268.76" $0.00 $0.00 $430.90 $0.00 $0.00 $451.48 $0.00 $0.00 $0.00 $0.00 $0.00 241.452 SUP HCPCS C1713 241.452 - PLATE BONE 236MM 17 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$3,047.55 " "$2,255.19" $0.00 "$2,367.02" "$1,331.45" "$1,331.45" $0.00 $0.00 $0.00 $635.19 "$2,261.89" "$2,261.89" $0.00 $0.00 $635.11 $0.00 "$1,502.44" "$1,502.44" $0.00 "$1,479.39" "$2,343.35" "$2,367.02" $0.00 $0.00 $449.56 $0.00 $0.00 $471.04 $0.00 $0.00 $0.00 $0.00 $0.00 241.453 SUP HCPCS C1713 241.453 - PLATE BONE 236MM 17 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$3,047.55 " "$2,255.19" $0.00 "$2,367.02" "$1,331.45" "$1,331.45" $0.00 $0.00 $0.00 $635.19 "$2,261.89" "$2,261.89" $0.00 $0.00 $635.11 $0.00 "$1,502.44" "$1,502.44" $0.00 "$1,479.39" "$2,343.35" "$2,367.02" $0.00 $0.00 $449.56 $0.00 $0.00 $471.04 $0.00 $0.00 $0.00 $0.00 $0.00 241.454 SUP HCPCS C1713 241.454 - PLATE BONE 262MM 19 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$3,071.45 " "$2,272.87" $0.00 "$2,385.58" "$1,341.89" "$1,341.89" $0.00 $0.00 $0.00 $640.17 "$2,279.63" "$2,279.63" $0.00 $0.00 $640.09 $0.00 "$1,514.22" "$1,514.22" $0.00 "$1,490.99" "$2,361.73" "$2,385.58" $0.00 $0.00 $453.09 $0.00 $0.00 $474.73 $0.00 $0.00 $0.00 $0.00 $0.00 241.455 SUP HCPCS C1713 241.455 - PLATE BONE 262MM 19 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$3,071.45 " "$2,272.87" $0.00 "$2,385.58" "$1,341.89" "$1,341.89" $0.00 $0.00 $0.00 $640.17 "$2,279.63" "$2,279.63" $0.00 $0.00 $640.09 $0.00 "$1,514.22" "$1,514.22" $0.00 "$1,490.99" "$2,361.73" "$2,385.58" $0.00 $0.00 $453.09 $0.00 $0.00 $474.73 $0.00 $0.00 $0.00 $0.00 $0.00 241.456 SUP HCPCS C1713 241.456 - PLATE BONE 288MM 21 HOLE LCP STAINLESS STEEL TIBIA RIGHT BOTH IP/OP "$3,100.95 " "$2,294.70" $0.00 "$2,408.52" "$1,354.79" "$1,354.79" $0.00 $0.00 $0.00 $646.32 "$2,301.53" "$2,301.53" $0.00 $0.00 $646.24 $0.00 "$1,528.77" "$1,528.77" $0.00 "$1,505.33" "$2,384.43" "$2,408.52" $0.00 $0.00 $457.44 $0.00 $0.00 $479.30 $0.00 $0.00 $0.00 $0.00 $0.00 241.457 SUP HCPCS C1713 241.457 - PLATE BONE 288MM 21 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$3,100.95 " "$2,294.70" $0.00 "$2,408.52" "$1,354.79" "$1,354.79" $0.00 $0.00 $0.00 $646.32 "$2,301.53" "$2,301.53" $0.00 $0.00 $646.24 $0.00 "$1,528.77" "$1,528.77" $0.00 "$1,505.33" "$2,384.43" "$2,408.52" $0.00 $0.00 $457.44 $0.00 $0.00 $479.30 $0.00 $0.00 $0.00 $0.00 $0.00 241.61 SUP HCPCS C1713 241.61 - PLATE BN 60MMX1.2MM NS LCP SS CALC 3.5MM CORT 4MM CANC 3.5MM BOTH IP/OP $974.15 $720.87 $0.00 $756.62 $425.60 $425.60 $0.00 $0.00 $0.00 $203.04 $723.01 $723.01 $0.00 $0.00 $203.01 $0.00 $576.21 $576.21 $0.00 $472.89 $749.06 $756.62 $0.00 $0.00 $143.70 $0.00 $0.00 $150.57 $0.00 $0.00 $0.00 $0.00 $0.00 241.618 SUP HCPCS C1713 241.618 - PLATE BONE MINI 64MM LOCK LCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,152.68 " $852.98 $0.00 $895.28 $503.60 $503.60 $0.00 $0.00 $0.00 $240.25 $855.52 $855.52 $0.00 $0.00 $240.22 $0.00 $681.81 $681.81 $0.00 $559.55 $886.33 $895.28 $0.00 $0.00 $170.04 $0.00 $0.00 $178.16 $0.00 $0.00 $0.00 $0.00 $0.00 241.619 SUP HCPCS C1713 241.619 - PLATE BONE MINI 64MM LOCK LCP STAINLESS STEEL LEFT CALCANEAL BOTH IP/OP "$1,152.68 " $852.98 $0.00 $895.28 $503.60 $503.60 $0.00 $0.00 $0.00 $240.25 $855.52 $855.52 $0.00 $0.00 $240.22 $0.00 $681.81 $681.81 $0.00 $559.55 $886.33 $895.28 $0.00 $0.00 $170.04 $0.00 $0.00 $178.16 $0.00 $0.00 $0.00 $0.00 $0.00 241.62 SUP HCPCS C1713 241.62 - PLATE BN 70MMX1.2MM NS LCP SS CALC 3.5MM CORT 4MM CANC 3.5MM BOTH IP/OP $993.83 $735.43 $0.00 $771.90 $434.19 $434.19 $0.00 $0.00 $0.00 $207.14 $737.62 $737.62 $0.00 $0.00 $207.11 $0.00 $587.85 $587.85 $0.00 $482.44 $764.18 $771.90 $0.00 $0.00 $146.61 $0.00 $0.00 $153.61 $0.00 $0.00 $0.00 $0.00 $0.00 241.622 SUP HCPCS C1713 241.622 - PLATE BN SHRT 69MMX2MM NS LCP LCK SS CALC RT 2.7/3.5MM CORT BOTH IP/OP "$1,291.83 " $955.95 $0.00 "$1,003.36" $564.39 $564.39 $0.00 $0.00 $0.00 $269.25 $958.79 $958.79 $0.00 $0.00 $269.22 $0.00 $764.11 $764.11 $0.00 $627.10 $993.33 "$1,003.36" $0.00 $0.00 $190.57 $0.00 $0.00 $199.67 $0.00 $0.00 $0.00 $0.00 $0.00 241.623 SUP HCPCS C1713 241.623 - PLATE BN SHRT 69MMX2MM NS LCP LCK SS CALC LT 2.7/3.5MM CORT BOTH IP/OP "$1,291.83 " $955.95 $0.00 "$1,003.36" $564.39 $564.39 $0.00 $0.00 $0.00 $269.25 $958.79 $958.79 $0.00 $0.00 $269.22 $0.00 $764.11 $764.11 $0.00 $627.10 $993.33 "$1,003.36" $0.00 $0.00 $190.57 $0.00 $0.00 $199.67 $0.00 $0.00 $0.00 $0.00 $0.00 241.624 SUP HCPCS C1713 241.624 - PLATE BN LNG 76MMX2MM NS LCP LCK SS CALC RT 2.7/3.5MM CORT BOTH IP/OP "$1,377.58 " "$1,019.41" $0.00 "$1,069.96" $601.85 $601.85 $0.00 $0.00 $0.00 $287.12 "$1,022.44" "$1,022.44" $0.00 $0.00 $287.09 $0.00 $814.84 $814.84 $0.00 $668.73 "$1,059.26" "$1,069.96" $0.00 $0.00 $203.22 $0.00 $0.00 $212.92 $0.00 $0.00 $0.00 $0.00 $0.00 241.625 SUP HCPCS C1713 241.625 - PLATE BONE LONG 76MM LOCKING BENDABLE TAB LCP STAINLESS BOTH IP/OP "$1,377.58 " "$1,019.41" $0.00 "$1,069.96" $601.85 $601.85 $0.00 $0.00 $0.00 $287.12 "$1,022.44" "$1,022.44" $0.00 $0.00 $287.09 $0.00 $814.84 $814.84 $0.00 $668.73 "$1,059.26" "$1,069.96" $0.00 $0.00 $203.22 $0.00 $0.00 $212.92 $0.00 $0.00 $0.00 $0.00 $0.00 241.626 SUP HCPCS C1713 241.626 - PLATE BN XLNG 81MMX2MM NS LCP LCK SS CALC RT 2.7/3.5MM CORT BOTH IP/OP "$1,423.98 " "$1,053.75" $0.00 "$1,106.00" $622.13 $622.13 $0.00 $0.00 $0.00 $296.79 "$1,056.87" "$1,056.87" $0.00 $0.00 $296.76 $0.00 $842.28 $842.28 $0.00 $691.25 "$1,094.94" "$1,106.00" $0.00 $0.00 $210.06 $0.00 $0.00 $220.09 $0.00 $0.00 $0.00 $0.00 $0.00 241.627 SUP HCPCS C1713 241.627 - PLATE BN XLNG 81MMX2MM NS LCP LCK SS CALC LT 2.7/3.5MM CORT BOTH IP/OP "$1,423.98 " "$1,053.75" $0.00 "$1,106.00" $622.13 $622.13 $0.00 $0.00 $0.00 $296.79 "$1,056.87" "$1,056.87" $0.00 $0.00 $296.76 $0.00 $842.28 $842.28 $0.00 $691.25 "$1,094.94" "$1,106.00" $0.00 $0.00 $210.06 $0.00 $0.00 $220.09 $0.00 $0.00 $0.00 $0.00 $0.00 241.65 SUP HCPCS C1713 241.65 - PLATE BN Y 87MMX2MM NS LCP SS CALC 3.5MM CORT 4MM CANC 3.5MM BOTH IP/OP $993.83 $735.43 $0.00 $771.90 $434.19 $434.19 $0.00 $0.00 $0.00 $207.14 $737.62 $737.62 $0.00 $0.00 $207.11 $0.00 $587.85 $587.85 $0.00 $482.44 $764.18 $771.90 $0.00 $0.00 $146.61 $0.00 $0.00 $153.61 $0.00 $0.00 $0.00 $0.00 $0.00 241.68 SUP HCPCS C1713 241.680 - PLATE BONE 34MM 2 HOLE LCP STAINLESS STEEL RIGHT RADIAL HEAD BOTH IP/OP "$1,112.28 " $823.09 $0.00 $889.82 $500.52 $500.52 $0.00 $0.00 $0.00 $231.83 $825.53 $825.53 $0.00 $0.00 $231.80 $0.00 $657.91 $657.91 $0.00 $556.14 $880.93 $889.82 $0.00 $0.00 $169.00 $0.00 $0.00 $177.07 $0.00 $0.00 $0.00 $0.00 $0.00 241.681 SUP HCPCS C1713 241.681 - PLATE BN 34MM NS LCP CMBN 2 HL RIM PRECONTOUR LMT CNTCT SS BOTH IP/OP "$1,145.65 " $847.78 $0.00 $889.82 $500.52 $500.52 $0.00 $0.00 $0.00 $238.78 $850.30 $850.30 $0.00 $0.00 $238.75 $0.00 $677.65 $677.65 $0.00 $556.14 $880.93 $889.82 $0.00 $0.00 $169.00 $0.00 $0.00 $177.07 $0.00 $0.00 $0.00 $0.00 $0.00 241.682 SUP HCPCS C1713 241.682 - PLATE BONE 46MM 3 HOLE HEAD LCP STAINLESS STEEL RIGHT RADIAL BOTH IP/OP "$1,177.98 " $871.71 $0.00 $914.92 $514.64 $514.64 $0.00 $0.00 $0.00 $245.52 $874.29 $874.29 $0.00 $0.00 $245.49 $0.00 $696.77 $696.77 $0.00 $571.83 $905.77 $914.92 $0.00 $0.00 $173.77 $0.00 $0.00 $182.07 $0.00 $0.00 $0.00 $0.00 $0.00 241.683 SUP HCPCS C1713 241.683 - PLATE BONE 46MM 3 HOLE RIM LCP STAINLESS STEEL LEFT RADIAL BOTH IP/OP "$1,177.98 " $871.71 $0.00 $914.92 $514.64 $514.64 $0.00 $0.00 $0.00 $245.52 $874.29 $874.29 $0.00 $0.00 $245.49 $0.00 $696.77 $696.77 $0.00 $571.83 $905.77 $914.92 $0.00 $0.00 $173.77 $0.00 $0.00 $182.07 $0.00 $0.00 $0.00 $0.00 $0.00 241.684 SUP HCPCS C1713 241.684 - PLATE BONE 56MM 4 HOLE RIM LCP STAINLESS STEEL RIGHT RADIAL BOTH IP/OP "$1,199.05 " $887.30 $0.00 $931.30 $523.86 $523.86 $0.00 $0.00 $0.00 $249.91 $889.93 $889.93 $0.00 $0.00 $249.88 $0.00 $709.24 $709.24 $0.00 $582.06 $921.99 $931.30 $0.00 $0.00 $176.88 $0.00 $0.00 $185.33 $0.00 $0.00 $0.00 $0.00 $0.00 241.685 SUP HCPCS C1713 241.685 - PLATE BONE 56MM 4 HOLE RIM LCP STAINLESS STEEL LEFT RADIAL BOTH IP/OP "$1,199.05 " $887.30 $0.00 $931.30 $523.86 $523.86 $0.00 $0.00 $0.00 $249.91 $889.93 $889.93 $0.00 $0.00 $249.88 $0.00 $709.24 $709.24 $0.00 $582.06 $921.99 $931.30 $0.00 $0.00 $176.88 $0.00 $0.00 $185.33 $0.00 $0.00 $0.00 $0.00 $0.00 241.69 SUP HCPCS C1713 241.690 - PLATE BN 28MM NS LCP CMBN 2 HL NK PRECONTOUR LMT CNTCT SS BOTH IP/OP "$1,112.28 " $823.09 $0.00 $889.82 $500.52 $500.52 $0.00 $0.00 $0.00 $231.83 $825.53 $825.53 $0.00 $0.00 $231.80 $0.00 $657.91 $657.91 $0.00 $556.14 $880.93 $889.82 $0.00 $0.00 $169.00 $0.00 $0.00 $177.07 $0.00 $0.00 $0.00 $0.00 $0.00 241.691 SUP HCPCS C1713 241.691 - PLATE BN 40MM NS LCP CMBN 3 HL NK PRECONTOUR LMT CNTCT SS BOTH IP/OP "$1,177.98 " $871.71 $0.00 $914.92 $514.64 $514.64 $0.00 $0.00 $0.00 $245.52 $874.29 $874.29 $0.00 $0.00 $245.49 $0.00 $696.77 $696.77 $0.00 $571.83 $905.77 $914.92 $0.00 $0.00 $173.77 $0.00 $0.00 $182.07 $0.00 $0.00 $0.00 $0.00 $0.00 241.692 SUP HCPCS C1713 241.692 - PLATE BONE 50MM 4 HOLE LCP STAINLESS STEEL RADIAL HEAD BOTH IP/OP "$1,200.45 " $888.33 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $250.20 $890.97 $890.97 $0.00 $0.00 $250.17 $0.00 $710.07 $710.07 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $177.09 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 241.83 SUP HCPCS C1713 241.83 - PLATE BN CLVRLF 88X15X2MM NS 1.2MM LC DCP 3 HL THN BLDE BOTH IP/OP $552.73 $409.02 $0.00 $442.18 $248.73 $248.73 $0.00 $0.00 $0.00 $115.20 $410.23 $410.23 $0.00 $0.00 $115.19 $0.00 $326.94 $326.94 $0.00 $276.36 $437.76 $442.18 $0.00 $0.00 $83.98 $0.00 $0.00 $87.99 $0.00 $0.00 $0.00 $0.00 $0.00 241.84 SUP HCPCS C1713 241.84 - PLATE BN CLVRLF 104X15X2MM NS 1.2MM LC DCP 4 HL THN BLDE BOTH IP/OP $590.93 $437.29 $0.00 $472.74 $265.92 $265.92 $0.00 $0.00 $0.00 $123.16 $438.58 $438.58 $0.00 $0.00 $123.15 $0.00 $349.53 $349.53 $0.00 $295.46 $468.02 $472.74 $0.00 $0.00 $89.79 $0.00 $0.00 $94.08 $0.00 $0.00 $0.00 $0.00 $0.00 241.85 SUP HCPCS C1713 241.85 - PLATE BN CLVRLF 120X15X2MM NS 5 HL THN BLDE SS 3.5MM SCR BOTH IP/OP $768.35 $568.58 $0.00 $614.68 $345.76 $345.76 $0.00 $0.00 $0.00 $160.14 $570.27 $570.27 $0.00 $0.00 $160.12 $0.00 $454.48 $454.48 $0.00 $384.18 $608.53 $614.68 $0.00 $0.00 $116.75 $0.00 $0.00 $122.32 $0.00 $0.00 $0.00 $0.00 $0.00 241.86 SUP HCPCS C1713 241.86 - PLATE BONE THIN CLOVERLEAF 136MM 6 HOLE LC-DCP STAINLESS BOTH IP/OP $833.85 $617.05 $0.00 $667.08 $375.23 $375.23 $0.00 $0.00 $0.00 $173.80 $618.88 $618.88 $0.00 $0.00 $173.77 $0.00 $493.22 $493.22 $0.00 $416.93 $660.41 $667.08 $0.00 $0.00 $126.70 $0.00 $0.00 $132.75 $0.00 $0.00 $0.00 $0.00 $0.00 241.87 SUP HCPCS C1713 241.87 - PLATE BN CLVRLF 152X15X2MM NS 1.2MM LC DCP 7 HL THN BLDE BOTH IP/OP $898.00 $664.52 $0.00 $718.40 $404.10 $404.10 $0.00 $0.00 $0.00 $187.17 $666.50 $666.50 $0.00 $0.00 $187.14 $0.00 $531.17 $531.17 $0.00 $449.00 $711.22 $718.40 $0.00 $0.00 $136.44 $0.00 $0.00 $142.96 $0.00 $0.00 $0.00 $0.00 $0.00 241.88 SUP HCPCS C1713 241.88 - PLATE BN CLVRLF 168X15X2MM NS 1.2MM LC DCP 8 HL THN BLDE BOTH IP/OP $953.95 $705.92 $0.00 $763.16 $429.28 $429.28 $0.00 $0.00 $0.00 $198.83 $708.02 $708.02 $0.00 $0.00 $198.80 $0.00 $564.26 $564.26 $0.00 $476.98 $755.53 $763.16 $0.00 $0.00 $144.95 $0.00 $0.00 $151.87 $0.00 $0.00 $0.00 $0.00 $0.00 241.89 SUP HCPCS C1713 241.89 - PLATE BONE THIN 200X15X1.2MM 10 HOLE CLOVERLEAF THIN BLADE BOTH IP/OP "$1,061.30 " $785.36 $0.00 $824.30 $463.67 $463.67 $0.00 $0.00 $0.00 $221.20 $787.70 $787.70 $0.00 $0.00 $221.17 $0.00 $627.76 $627.76 $0.00 $515.19 $816.06 $824.30 $0.00 $0.00 $156.56 $0.00 $0.00 $164.04 $0.00 $0.00 $0.00 $0.00 $0.00 241.901 SUP HCPCS C1713 241.901 - PLATE BN STD 90X12X2.5MM NS LCP CMBN PHLS 3 HL SHFT LCK CMPR BOTH IP/OP "$2,857.78 " "$2,114.76" $0.00 "$2,219.62" "$1,248.54" "$1,248.54" $0.00 $0.00 $0.00 $595.63 "$2,121.04" "$2,121.04" $0.00 $0.00 $595.56 $0.00 "$1,408.88" "$1,408.88" $0.00 "$1,387.26" "$2,197.43" "$2,219.62" $0.00 $0.00 $421.57 $0.00 $0.00 $441.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.903 SUP HCPCS C1713 241.903 - PLATE BN STD 114X12X2.5MM NS LCP CMBN PHLS 5 HL SHFT LCK BOTH IP/OP "$2,947.73 " "$2,181.32" $0.00 "$2,289.50" "$1,287.84" "$1,287.84" $0.00 $0.00 $0.00 $614.38 "$2,187.80" "$2,187.80" $0.00 $0.00 $614.31 $0.00 "$1,453.23" "$1,453.23" $0.00 "$1,430.94" "$2,266.61" "$2,289.50" $0.00 $0.00 $434.84 $0.00 $0.00 $455.61 $0.00 $0.00 $0.00 $0.00 $0.00 241.918 SUP HCPCS C1713 241.918 - PLATE BN 142X12X3.7MM NS LCP CMBN PHLS LNG 5 HL SHFT LCK BOTH IP/OP "$2,975.85 " "$2,202.13" $0.00 "$2,311.34" "$1,300.13" "$1,300.13" $0.00 $0.00 $0.00 $620.24 "$2,208.68" "$2,208.68" $0.00 $0.00 $620.17 $0.00 "$1,467.09" "$1,467.09" $0.00 "$1,444.59" "$2,288.23" "$2,311.34" $0.00 $0.00 $438.99 $0.00 $0.00 $459.96 $0.00 $0.00 $0.00 $0.00 $0.00 241.919 SUP HCPCS C1713 241.919 - PLATE LNG 160MM SS 3.5MM SCR SM FRAG SET 6 HOLE LCP BONE BOTH IP/OP "$3,582.78 " "$2,651.26" $0.00 "$2,866.22" "$1,612.25" "$1,612.25" $0.00 $0.00 $0.00 $746.74 "$2,659.14" "$2,659.14" $0.00 $0.00 $746.65 $0.00 "$1,766.31" "$1,766.31" $0.00 "$1,791.39" "$2,837.56" "$2,866.22" $0.00 $0.00 $560.70 $0.00 $0.00 $570.38 $0.00 $0.00 $0.00 $0.00 $0.00 241.921 SUP HCPCS C1713 241.921 - PLATE BN 196X12X3.7MM NS LCP CMBN PHLS LNG 8 HL SHFT LCK BOTH IP/OP "$3,213.43 " "$2,377.94" $0.00 "$2,495.86" "$1,403.92" "$1,403.92" $0.00 $0.00 $0.00 $669.76 "$2,385.00" "$2,385.00" $0.00 $0.00 $669.68 $0.00 "$1,584.22" "$1,584.22" $0.00 "$1,559.91" "$2,470.91" "$2,495.86" $0.00 $0.00 $474.03 $0.00 $0.00 $496.68 $0.00 $0.00 $0.00 $0.00 $0.00 241.923 SUP HCPCS C1713 241.923 - PLATE BN 232X12X3.7MM NS LCP CMBN PHLS LNG 10 HL SHFT LCK BOTH IP/OP "$3,332.90 " "$2,466.35" $0.00 "$2,588.66" "$1,456.12" "$1,456.12" $0.00 $0.00 $0.00 $694.66 "$2,473.68" "$2,473.68" $0.00 $0.00 $694.58 $0.00 "$1,643.12" "$1,643.12" $0.00 "$1,617.91" "$2,562.78" "$2,588.66" $0.00 $0.00 $491.66 $0.00 $0.00 $515.14 $0.00 $0.00 $0.00 $0.00 $0.00 241.925 SUP HCPCS C1713 241.925 - PLATE BN 268X12X3.7MM NS LCP CMBN PHLS LNG 12 HL SHFT LCK BOTH IP/OP "$3,448.18 " "$2,551.65" $0.00 "$2,678.18" "$1,506.48" "$1,506.48" $0.00 $0.00 $0.00 $718.69 "$2,559.24" "$2,559.24" $0.00 $0.00 $718.60 $0.00 "$1,699.95" "$1,699.95" $0.00 "$1,673.86" "$2,651.40" "$2,678.18" $0.00 $0.00 $508.66 $0.00 $0.00 $532.96 $0.00 $0.00 $0.00 $0.00 $0.00 241.931 SUP HCPCS C1713 241.931 - PLATE BN OB L T 52X10X1.5MM NS LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP $663.48 $490.98 $0.00 $515.32 $289.87 $289.87 $0.00 $0.00 $0.00 $138.28 $492.43 $492.43 $0.00 $0.00 $138.27 $0.00 $392.45 $392.45 $0.00 $322.08 $510.17 $515.32 $0.00 $0.00 $97.88 $0.00 $0.00 $102.55 $0.00 $0.00 $0.00 $0.00 $0.00 241.941 SUP HCPCS C1713 241.941 - PLATE BN OB L T 63X10X1.5MM NS LCP CMBN 3 HLE/HD 4 HL SHFT BOTH IP/OP $695.83 $514.91 $0.00 $540.44 $304.00 $304.00 $0.00 $0.00 $0.00 $145.03 $516.44 $516.44 $0.00 $0.00 $145.01 $0.00 $411.58 $411.58 $0.00 $337.78 $535.04 $540.44 $0.00 $0.00 $102.64 $0.00 $0.00 $107.55 $0.00 $0.00 $0.00 $0.00 $0.00 241.951 SUP HCPCS C1713 241.951 - PLATE BN OB L T 74X10X1.5MM NS LCP CMBN 3 HLE/HD 5 HL SHFT BOTH IP/OP $726.75 $537.80 $0.00 $564.46 $317.51 $317.51 $0.00 $0.00 $0.00 $151.47 $539.39 $539.39 $0.00 $0.00 $151.45 $0.00 $429.87 $429.87 $0.00 $352.79 $558.82 $564.46 $0.00 $0.00 $107.21 $0.00 $0.00 $112.33 $0.00 $0.00 $0.00 $0.00 $0.00 241.961 SUP HCPCS C1713 241.961 - PLATE BONE T THK1.5MM 85X10MM 3X6 HOLE LEFT OBLIQUE LOCKING BOTH IP/OP $778.75 $576.28 $0.00 $604.86 $340.23 $340.23 $0.00 $0.00 $0.00 $162.31 $577.99 $577.99 $0.00 $0.00 $162.29 $0.00 $460.63 $460.63 $0.00 $378.04 $598.82 $604.86 $0.00 $0.00 $114.88 $0.00 $0.00 $120.37 $0.00 $0.00 $0.00 $0.00 $0.00 241.971 SUP HCPCS C1713 241.971 - PLATE BN OB L T 96X10X1.5MM NS LCP CMBN 3 HLE/HD 7 HL SHFT BOTH IP/OP $787.20 $582.53 $0.00 $611.40 $343.91 $343.91 $0.00 $0.00 $0.00 $164.07 $584.26 $584.26 $0.00 $0.00 $164.05 $0.00 $465.63 $465.63 $0.00 $382.13 $605.29 $611.40 $0.00 $0.00 $116.12 $0.00 $0.00 $121.67 $0.00 $0.00 $0.00 $0.00 $0.00 241.981 SUP HCPCS C1713 241.981 - PLATE BONE T THK1.5MM 107X10MM 3X8 HOLE LEFT OBLIQUE LOCKING BOTH IP/OP $856.08 $633.50 $0.00 $664.90 $374.01 $374.01 $0.00 $0.00 $0.00 $178.43 $635.38 $635.38 $0.00 $0.00 $178.41 $0.00 $506.37 $506.37 $0.00 $415.56 $658.25 $664.90 $0.00 $0.00 $126.28 $0.00 $0.00 $132.32 $0.00 $0.00 $0.00 $0.00 $0.00 242.03 SUP HCPCS C1713 242.03 - PLATE BN .25 TBLR 23X7X1MM NS .3MM 3 HL COLR SS 2.7MM SCR MN BOTH IP/OP $146.20 $108.19 $0.00 $113.54 $63.87 $63.87 $0.00 $0.00 $0.00 $30.47 $108.51 $108.51 $0.00 $0.00 $30.47 $0.00 $86.48 $86.48 $0.00 $70.96 $112.41 $113.54 $0.00 $0.00 $21.57 $0.00 $0.00 $22.59 $0.00 $0.00 $0.00 $0.00 $0.00 242.04 SUP HCPCS C1713 242.04 - PLATE BONE .25 TUBE LP 31X7X1MM .3MM 4 HOLE COLLAR STAINLESS BOTH IP/OP $156.03 $115.46 $0.00 $121.18 $68.16 $68.16 $0.00 $0.00 $0.00 $32.52 $115.80 $115.80 $0.00 $0.00 $32.52 $0.00 $92.29 $92.29 $0.00 $75.74 $119.97 $121.18 $0.00 $0.00 $23.02 $0.00 $0.00 $24.11 $0.00 $0.00 $0.00 $0.00 $0.00 242.05 SUP HCPCS C1713 242.05 - PLATE BONE 39X7X1MM .3MM 5 HOLE QUARTER TUBULAR COLLAR LCP BOTH IP/OP $165.88 $122.75 $0.00 $128.84 $72.47 $72.47 $0.00 $0.00 $0.00 $34.57 $123.11 $123.11 $0.00 $0.00 $34.57 $0.00 $98.12 $98.12 $0.00 $80.53 $127.55 $128.84 $0.00 $0.00 $24.47 $0.00 $0.00 $25.64 $0.00 $0.00 $0.00 $0.00 $0.00 242.06 SUP HCPCS C1713 242.06 - PLATE BONE .25 TUBULAR 47X7X1MM .3MM 6 HOLE COLLAR DCP BOTH IP/OP $179.93 $133.15 $0.00 $139.76 $78.62 $78.62 $0.00 $0.00 $0.00 $37.50 $133.54 $133.54 $0.00 $0.00 $37.50 $0.00 $106.43 $106.43 $0.00 $87.35 $138.36 $139.76 $0.00 $0.00 $26.54 $0.00 $0.00 $27.81 $0.00 $0.00 $0.00 $0.00 $0.00 242.07 SUP HCPCS C1713 242.07 - PLATE BONE .75 TUBE 55X7X1MM .3MM 7 HOLE COLLAR STAINLESS BOTH IP/OP $191.18 $141.47 $0.00 $148.48 $83.52 $83.52 $0.00 $0.00 $0.00 $39.85 $141.89 $141.89 $0.00 $0.00 $39.84 $0.00 $113.08 $113.08 $0.00 $92.80 $147.00 $148.48 $0.00 $0.00 $28.20 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 242.08 SUP HCPCS C1713 242.08 - PLATE BONE .25 TUBE 63MM .3MM 8 HOLE COLLAR DCP STAINLESS BOTH IP/OP $196.80 $145.63 $0.00 $152.86 $85.98 $85.98 $0.00 $0.00 $0.00 $41.02 $146.06 $146.06 $0.00 $0.00 $41.01 $0.00 $116.41 $116.41 $0.00 $95.54 $151.34 $152.86 $0.00 $0.00 $29.03 $0.00 $0.00 $30.42 $0.00 $0.00 $0.00 $0.00 $0.00 242.102 SUP HCPCS C1713 242.102 - PLATE BONE 139MM 2 HOLE LCP STAINLESS STEEL FEMUR LEFT BOTH IP/OP "$2,614.60 " "$1,934.80" $0.00 "$2,030.74" "$1,142.29" "$1,142.29" $0.00 $0.00 $0.00 $544.95 "$1,940.56" "$1,940.56" $0.00 $0.00 $544.88 $0.00 "$1,289.00" "$1,289.00" $0.00 "$1,269.21" "$2,010.44" "$2,030.74" $0.00 $0.00 $385.69 $0.00 $0.00 $404.12 $0.00 $0.00 $0.00 $0.00 $0.00 242.104 SUP HCPCS C1713 242.104 - PLATE BN 175MM NS LCP CMBN 4 HL LMT CNTCT SS FEM LT PROX 4.5 BOTH IP/OP "$2,666.60 " "$1,973.28" $0.00 "$2,071.14" "$1,165.02" "$1,165.02" $0.00 $0.00 $0.00 $555.79 "$1,979.15" "$1,979.15" $0.00 $0.00 $555.72 $0.00 "$1,314.63" "$1,314.63" $0.00 "$1,294.46" "$2,050.43" "$2,071.14" $0.00 $0.00 $393.37 $0.00 $0.00 $412.16 $0.00 $0.00 $0.00 $0.00 $0.00 242.106 SUP HCPCS C1713 242.106 - PLATE BN 211MM NS LCP CMBN 6 HL LMT CNTCT SS FEM LT PROX 4.5 BOTH IP/OP "$2,718.60 " "$2,011.76" $0.00 "$2,111.54" "$1,187.74" "$1,187.74" $0.00 $0.00 $0.00 $566.62 "$2,017.74" "$2,017.74" $0.00 $0.00 $566.56 $0.00 "$1,340.27" "$1,340.27" $0.00 "$1,319.71" "$2,090.43" "$2,111.54" $0.00 $0.00 $401.04 $0.00 $0.00 $420.20 $0.00 $0.00 $0.00 $0.00 $0.00 242.108 SUP HCPCS C1713 242.108 - PLATE BN 247MM NS LCP CMBN 8 HL LMT CNTCT SS FEM LT PROX 4.5 BOTH IP/OP "$2,852.15 " "$2,110.59" $0.00 "$2,215.26" "$1,246.08" "$1,246.08" $0.00 $0.00 $0.00 $594.46 "$2,116.87" "$2,116.87" $0.00 $0.00 $594.39 $0.00 "$1,406.11" "$1,406.11" $0.00 "$1,384.54" "$2,193.11" "$2,215.26" $0.00 $0.00 $420.74 $0.00 $0.00 $440.84 $0.00 $0.00 $0.00 $0.00 $0.00 242.11 SUP HCPCS C1713 242.110 - PLATE BN 283MM NS LCP CMBN 10 HL LMT CNTCT SS FEM LT PROX BOTH IP/OP "$2,966.98 " "$2,195.57" $0.00 "$2,373.58" "$1,335.14" "$1,335.14" $0.00 $0.00 $0.00 $618.39 "$2,202.09" "$2,202.09" $0.00 $0.00 $618.32 $0.00 "$1,462.72" "$1,462.72" $0.00 "$1,483.49" "$2,349.85" "$2,373.58" $0.00 $0.00 $450.81 $0.00 $0.00 $472.34 $0.00 $0.00 $0.00 $0.00 $0.00 242.112 SUP HCPCS C1713 242.112 - PLATE BN 319MM NS LCP CMBN 12 HL LMT CNTCT SS FEM LT PROX BOTH IP/OP "$3,235.90 " "$2,394.57" $0.00 "$2,513.32" "$1,413.74" "$1,413.74" $0.00 $0.00 $0.00 $674.44 "$2,401.68" "$2,401.68" $0.00 $0.00 $674.36 $0.00 "$1,595.30" "$1,595.30" $0.00 "$1,570.83" "$2,488.19" "$2,513.32" $0.00 $0.00 $477.35 $0.00 $0.00 $500.15 $0.00 $0.00 $0.00 $0.00 $0.00 242.114 SUP HCPCS C1713 242.114 - PLATE BN 355MM NS LCP CMBN 14 HL LMT CNTCT SS FEM LT PROX BOTH IP/OP "$3,495.95 " "$2,587.00" $0.00 "$2,715.30" "$1,527.36" "$1,527.36" $0.00 $0.00 $0.00 $728.64 "$2,594.69" "$2,594.69" $0.00 $0.00 $728.56 $0.00 "$1,723.50" "$1,723.50" $0.00 "$1,697.06" "$2,688.15" "$2,715.30" $0.00 $0.00 $515.71 $0.00 $0.00 $540.34 $0.00 $0.00 $0.00 $0.00 $0.00 242.116 SUP HCPCS C1713 242.116 - PLATE BN 391MM NS LCP CMBN 16 HL LMT CNTCT SS FEM LT PROX BOTH IP/OP "$3,601.38 " "$2,665.02" $0.00 "$2,797.20" "$1,573.43" "$1,573.43" $0.00 $0.00 $0.00 $750.62 "$2,672.94" "$2,672.94" $0.00 $0.00 $750.53 $0.00 "$1,775.48" "$1,775.48" $0.00 "$1,748.25" "$2,769.23" "$2,797.20" $0.00 $0.00 $531.26 $0.00 $0.00 $556.64 $0.00 $0.00 $0.00 $0.00 $0.00 242.12 SUP HCPCS C1713 242.120 - PLATE BONE 133MM 2 HOLE HOOK LCP STAINLESS STEEL PROXIMAL BOTH IP/OP "$2,941.03 " "$2,176.36" $0.00 "$2,352.82" "$1,323.46" "$1,323.46" $0.00 $0.00 $0.00 $612.98 "$2,182.83" "$2,182.83" $0.00 $0.00 $612.91 $0.00 "$1,449.93" "$1,449.93" $0.00 "$1,470.51" "$2,329.30" "$2,352.82" $0.00 $0.00 $446.87 $0.00 $0.00 $468.21 $0.00 $0.00 $0.00 $0.00 $0.00 242.121 SUP HCPCS C1713 242.121 - PLATE BONE 169MM 4 HOLE HOOK LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,071.45 " "$2,272.87" $0.00 "$2,385.58" "$1,341.89" "$1,341.89" $0.00 $0.00 $0.00 $640.17 "$2,279.63" "$2,279.63" $0.00 $0.00 $640.09 $0.00 "$1,514.22" "$1,514.22" $0.00 "$1,490.99" "$2,361.73" "$2,385.58" $0.00 $0.00 $453.09 $0.00 $0.00 $474.73 $0.00 $0.00 $0.00 $0.00 $0.00 242.122 SUP HCPCS C1713 242.122 - PLATE BONE 205MM 6 HOLE HOOK LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,119.23 " "$2,308.23" $0.00 "$2,422.70" "$1,362.77" "$1,362.77" $0.00 $0.00 $0.00 $650.12 "$2,315.09" "$2,315.09" $0.00 $0.00 $650.05 $0.00 "$1,537.78" "$1,537.78" $0.00 "$1,514.19" "$2,398.48" "$2,422.70" $0.00 $0.00 $460.14 $0.00 $0.00 $482.12 $0.00 $0.00 $0.00 $0.00 $0.00 242.123 SUP HCPCS C1713 242.123 - PLATE BONE 241MM 8 HOLE HOOK LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,234.50 " "$2,393.53" $0.00 "$2,512.24" "$1,413.14" "$1,413.14" $0.00 $0.00 $0.00 $674.15 "$2,400.65" "$2,400.65" $0.00 $0.00 $674.07 $0.00 "$1,594.61" "$1,594.61" $0.00 "$1,570.15" "$2,487.12" "$2,512.24" $0.00 $0.00 $477.14 $0.00 $0.00 $499.94 $0.00 $0.00 $0.00 $0.00 $0.00 242.124 SUP HCPCS C1713 242.124 - PLATE BONE 277MM 10 HOLE HOOK LCP STAINLESS STEEL PROXIMAL BOTH IP/OP "$3,400.38 " "$2,516.28" $0.00 "$2,641.06" "$1,485.60" "$1,485.60" $0.00 $0.00 $0.00 $708.72 "$2,523.76" "$2,523.76" $0.00 $0.00 $708.64 $0.00 "$1,676.38" "$1,676.38" $0.00 "$1,650.66" "$2,614.65" "$2,641.06" $0.00 $0.00 $501.61 $0.00 $0.00 $525.57 $0.00 $0.00 $0.00 $0.00 $0.00 242.125 SUP HCPCS C1713 242.125 - PLATE BONE 313MM 12 HOLE HOOK LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,511.43 " "$2,598.46" $0.00 "$2,727.32" "$1,534.12" "$1,534.12" $0.00 $0.00 $0.00 $731.87 "$2,606.18" "$2,606.18" $0.00 $0.00 $731.78 $0.00 "$1,731.13" "$1,731.13" $0.00 "$1,704.58" "$2,700.05" "$2,727.32" $0.00 $0.00 $517.99 $0.00 $0.00 $542.74 $0.00 $0.00 $0.00 $0.00 $0.00 242.126 SUP HCPCS C1713 242.126 - PLATE BONE 349MM 14 HOLE HOOK LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,552.18 " "$2,628.61" $0.00 "$2,758.98" "$1,551.93" "$1,551.93" $0.00 $0.00 $0.00 $740.36 "$2,636.42" "$2,636.42" $0.00 $0.00 $740.27 $0.00 "$1,751.22" "$1,751.22" $0.00 "$1,724.36" "$2,731.39" "$2,758.98" $0.00 $0.00 $524.01 $0.00 $0.00 $549.04 $0.00 $0.00 $0.00 $0.00 $0.00 242.127 SUP HCPCS C1713 242.127 - PLATE BONE 385MM 16 HOLE HOOK LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,670.28 " "$2,716.01" $0.00 "$2,850.68" "$1,603.51" "$1,603.51" $0.00 $0.00 $0.00 $764.98 "$2,724.08" "$2,724.08" $0.00 $0.00 $764.89 $0.00 "$1,809.45" "$1,809.45" $0.00 "$1,781.68" "$2,822.17" "$2,850.68" $0.00 $0.00 $541.42 $0.00 $0.00 $567.29 $0.00 $0.00 $0.00 $0.00 $0.00 242.128 SUP HCPCS C1713 242.128 - PLATE BONE 421MM 18 HOLE HOOK LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,788.35 " "$2,803.38" $0.00 "$2,942.40" "$1,655.10" "$1,655.10" $0.00 $0.00 $0.00 $789.59 "$2,811.71" "$2,811.71" $0.00 $0.00 $789.49 $0.00 "$1,867.66" "$1,867.66" $0.00 "$1,839.00" "$2,912.98" "$2,942.40" $0.00 $0.00 $558.84 $0.00 $0.00 $585.54 $0.00 $0.00 $0.00 $0.00 $0.00 242.204 SUP HCPCS C1713 242.204 - PLATE BONE 41MMX2.6MM 4 HOLE LC-DCP STAINLESS STEEL FT BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 242.205 SUP HCPCS C1713 242.205 - PLATE BONE 50MM 5 HOLE LC-DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 242.206 SUP HCPCS C1713 242.206 - PLATE BONE 59MM 6 HOLE LC-DCP STAINLESS STEEL FT NONSTRL 2.7 BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 242.207 SUP HCPCS C1713 242.207 - PLATE BONE 68MM 7 HOLE LC-DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $281.15 $208.05 $0.00 $218.36 $122.83 $122.83 $0.00 $0.00 $0.00 $58.60 $208.67 $208.67 $0.00 $0.00 $58.59 $0.00 $166.30 $166.30 $0.00 $136.48 $216.18 $218.36 $0.00 $0.00 $41.47 $0.00 $0.00 $43.45 $0.00 $0.00 $0.00 $0.00 $0.00 242.208 SUP HCPCS C1713 242.208 - PLATE BONE 77MM 8 HOLE LC-DCP STAINLESS STEEL FT NONSTRL 2.7 BOTH IP/OP $293.80 $217.41 $0.00 $228.18 $128.35 $128.35 $0.00 $0.00 $0.00 $61.24 $218.06 $218.06 $0.00 $0.00 $61.23 $0.00 $173.78 $173.78 $0.00 $142.61 $225.90 $228.18 $0.00 $0.00 $43.34 $0.00 $0.00 $45.41 $0.00 $0.00 $0.00 $0.00 $0.00 242.209 SUP HCPCS C1713 242.209 - PLATE BONE 86MM 9 HOLE LC-DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $300.83 $222.61 $0.00 $233.64 $131.42 $131.42 $0.00 $0.00 $0.00 $62.70 $223.27 $223.27 $0.00 $0.00 $62.69 $0.00 $177.94 $177.94 $0.00 $146.03 $231.30 $233.64 $0.00 $0.00 $44.38 $0.00 $0.00 $46.49 $0.00 $0.00 $0.00 $0.00 $0.00 242.21 SUP HCPCS C1713 242.21 - PLATE BONE 44MM 7 HOLE MULTIPLE FRAGMENT DCP STAINLESS STEEL BOTH IP/OP $126.93 $93.93 $0.00 $101.54 $57.12 $57.12 $0.00 $0.00 $0.00 $26.45 $94.20 $94.20 $0.00 $0.00 $26.45 $0.00 $75.08 $75.08 $0.00 $63.46 $100.53 $101.54 $0.00 $0.00 $19.28 $0.00 $0.00 $20.21 $0.00 $0.00 $0.00 $0.00 $0.00 242.22 SUP HCPCS C1713 242.220 - PLATE BONE 95MM 10 HOLE LC-DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $308.43 $228.24 $0.00 $246.74 $138.79 $138.79 $0.00 $0.00 $0.00 $64.28 $228.91 $228.91 $0.00 $0.00 $64.28 $0.00 $182.43 $182.43 $0.00 $154.21 $244.28 $246.74 $0.00 $0.00 $46.86 $0.00 $0.00 $49.10 $0.00 $0.00 $0.00 $0.00 $0.00 242.221 SUP HCPCS C1713 242.221 - PLATE BONE 104MM 11 HOLE LC-DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $331.75 $245.50 $0.00 $257.66 $144.93 $144.93 $0.00 $0.00 $0.00 $69.14 $246.22 $246.22 $0.00 $0.00 $69.14 $0.00 $196.23 $196.23 $0.00 $161.04 $255.09 $257.66 $0.00 $0.00 $48.94 $0.00 $0.00 $51.27 $0.00 $0.00 $0.00 $0.00 $0.00 242.222 SUP HCPCS C1713 242.222 - PLATE BONE 113MM 12 HOLE LC-DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $344.40 $254.86 $0.00 $267.50 $150.47 $150.47 $0.00 $0.00 $0.00 $71.78 $255.61 $255.61 $0.00 $0.00 $71.77 $0.00 $203.71 $203.71 $0.00 $167.19 $264.83 $267.50 $0.00 $0.00 $50.80 $0.00 $0.00 $53.23 $0.00 $0.00 $0.00 $0.00 $0.00 242.31 SUP HCPCS C1713 242.31 - PLATE BN L 32MM NS DCP 3 HLE/HD 2 HL SHFT SS FT LT 2.7MM SCR BOTH IP/OP $103.30 $76.44 $0.00 $80.24 $45.14 $45.14 $0.00 $0.00 $0.00 $21.53 $76.67 $76.67 $0.00 $0.00 $21.53 $0.00 $61.10 $61.10 $0.00 $50.15 $79.44 $80.24 $0.00 $0.00 $15.24 $0.00 $0.00 $15.97 $0.00 $0.00 $0.00 $0.00 $0.00 242.32 SUP HCPCS C1713 242.32 - PLATE BONE L 32MM 2X3 HOLE DCP STAINLESS STEEL FT RIGHT BOTH IP/OP $103.30 $76.44 $0.00 $80.24 $45.14 $45.14 $0.00 $0.00 $0.00 $21.53 $76.67 $76.67 $0.00 $0.00 $21.53 $0.00 $61.10 $61.10 $0.00 $50.15 $79.44 $80.24 $0.00 $0.00 $15.24 $0.00 $0.00 $15.97 $0.00 $0.00 $0.00 $0.00 $0.00 242.33 SUP HCPCS C1713 242.33 - PLATE BN OB L L 34X7X1MM NS DCP 3 HL SS 2.7MM SCR MN FRAG BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $50.05 $50.05 $0.00 $0.00 $0.00 $23.88 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $67.76 $67.76 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $16.90 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 242.34 SUP HCPCS C1713 242.34 - PLATE BN OB R L 34X7X1MM NS DCP 3 HL SS 2.7MM SCR MN FRAG BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $50.05 $50.05 $0.00 $0.00 $0.00 $23.88 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $67.76 $67.76 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $16.90 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 242.41 SUP HCPCS C1713 242.41 - PLATE BN T 32X7X1.2MM NS 3 HL SS 2.7MM SCR MN FRAG SET BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $50.05 $50.05 $0.00 $0.00 $0.00 $23.88 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $67.76 $67.76 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $16.90 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $0.00 242.458 SUP HCPCS C1713 242.458 - PLATE BN 48X6.3X1.6MM NS LCP 5 HLE/HD 3 HL SHFT PRECONTOUR BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $671.25 $671.25 $0.00 $0.00 $0.00 $320.23 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $908.80 $908.80 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $226.65 $0.00 $0.00 $237.47 $0.00 $0.00 $0.00 $0.00 $0.00 242.459 SUP HCPCS C1713 242.459 - PLATE BN 66X6.3X1.6MM NS LCP 5 HLE/HD 5 HL SHFT PRECONTOUR BOTH IP/OP "$1,626.38 " "$1,203.52" $0.00 "$1,263.22" $710.56 $710.56 $0.00 $0.00 $0.00 $338.98 "$1,207.10" "$1,207.10" $0.00 $0.00 $338.94 $0.00 $962.00 $962.00 $0.00 $789.51 "$1,250.59" "$1,263.22" $0.00 $0.00 $239.92 $0.00 $0.00 $251.38 $0.00 $0.00 $0.00 $0.00 $0.00 242.461 SUP HCPCS C1713 242.461 - PLATE BN 48X6.3X1.6MM NS LCP 5 HLE/HD 3 HL SHFT PRECONTOUR BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $671.25 $671.25 $0.00 $0.00 $0.00 $320.23 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $908.80 $908.80 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $226.65 $0.00 $0.00 $237.47 $0.00 $0.00 $0.00 $0.00 $0.00 242.462 SUP HCPCS C1713 242.462 - PLATE BN 66X6.3X1.6MM NS LCP 5 HLE/HD 5 HL SHFT PRECONTOUR BOTH IP/OP "$1,626.38 " "$1,203.52" $0.00 "$1,263.22" $710.56 $710.56 $0.00 $0.00 $0.00 $338.98 "$1,207.10" "$1,207.10" $0.00 $0.00 $338.94 $0.00 $962.00 $962.00 $0.00 $789.51 "$1,250.59" "$1,263.22" $0.00 $0.00 $239.92 $0.00 $0.00 $251.38 $0.00 $0.00 $0.00 $0.00 $0.00 242.464 SUP HCPCS C1713 242.464 - PLATE BN 47X6.3X1.6MM NS LCP 4 HLE/HD 3 HL SHFT PRECONTOUR BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $671.25 $671.25 $0.00 $0.00 $0.00 $320.23 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $908.80 $908.80 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $226.65 $0.00 $0.00 $237.47 $0.00 $0.00 $0.00 $0.00 $0.00 242.465 SUP HCPCS C1713 242.465 - PLATE BN 65X6.3X1.6MM NS LCP 4 HLE/HD 5 HL SHFT PRECONTOUR BOTH IP/OP "$1,626.38 " "$1,203.52" $0.00 "$1,263.22" $710.56 $710.56 $0.00 $0.00 $0.00 $338.98 "$1,207.10" "$1,207.10" $0.00 $0.00 $338.94 $0.00 $962.00 $962.00 $0.00 $789.51 "$1,250.59" "$1,263.22" $0.00 $0.00 $239.92 $0.00 $0.00 $251.38 $0.00 $0.00 $0.00 $0.00 $0.00 242.467 SUP HCPCS C1713 242.467 - PLATE BN 47X6.3X1.6MM NS LCP 4 HLE/HD 3 HL SHFT PRECONTOUR BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $671.25 $671.25 $0.00 $0.00 $0.00 $320.23 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $908.80 $908.80 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $226.65 $0.00 $0.00 $237.47 $0.00 $0.00 $0.00 $0.00 $0.00 242.468 SUP HCPCS C1713 242.468 - PLATE BN 65X6.3X1.6MM NS LCP 4 HLE/HD 5 HL SHFT PRECONTOUR BOTH IP/OP "$1,626.38 " "$1,203.52" $0.00 "$1,263.22" $710.56 $710.56 $0.00 $0.00 $0.00 $338.98 "$1,207.10" "$1,207.10" $0.00 $0.00 $338.94 $0.00 $962.00 $962.00 $0.00 $789.51 "$1,250.59" "$1,263.22" $0.00 $0.00 $239.92 $0.00 $0.00 $251.38 $0.00 $0.00 $0.00 $0.00 $0.00 242.472 SUP HCPCS C1713 242.472 - PLATE SS BONE RIGHT DISTAL DORSAL RAD NONSTRL BOTH IP/OP "$1,868.43 " "$1,382.64" $0.00 "$1,494.74" $840.79 $840.79 $0.00 $0.00 $0.00 $389.43 "$1,386.75" "$1,386.75" $0.00 $0.00 $389.38 $0.00 "$1,105.17" "$1,105.17" $0.00 $934.21 "$1,479.80" "$1,494.74" $0.00 $0.00 $292.41 $0.00 $0.00 $297.45 $0.00 $0.00 $0.00 $0.00 $0.00 242.473 SUP HCPCS C1713 242.473 - PLATE SS LCP BONE RIGHT DISTAL VOLR RADL NONSTRL BOTH IP/OP "$1,542.28 " "$1,141.29" $0.00 "$1,233.82" $694.02 $694.02 $0.00 $0.00 $0.00 $321.45 "$1,144.68" "$1,144.68" $0.00 $0.00 $321.41 $0.00 $912.26 $912.26 $0.00 $771.14 "$1,221.49" "$1,233.82" $0.00 $0.00 $241.37 $0.00 $0.00 $245.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.477 SUP HCPCS C1713 242.477 - PLATE BN T 40X6.3X1.6MM NS LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP $877.15 $649.09 $0.00 $681.28 $383.22 $383.22 $0.00 $0.00 $0.00 $182.82 $651.02 $651.02 $0.00 $0.00 $182.80 $0.00 $518.83 $518.83 $0.00 $425.80 $674.47 $681.28 $0.00 $0.00 $129.39 $0.00 $0.00 $135.57 $0.00 $0.00 $0.00 $0.00 $0.00 242.478 SUP HCPCS C1713 242.478 - PLATE BN T 49X6.3X1.6MM NS LCP CMBN 3 HLE/HD 4 HL SHFT BOTH IP/OP $913.70 $676.14 $0.00 $709.68 $399.20 $399.20 $0.00 $0.00 $0.00 $190.44 $678.15 $678.15 $0.00 $0.00 $190.42 $0.00 $540.45 $540.45 $0.00 $443.55 $702.58 $709.68 $0.00 $0.00 $134.79 $0.00 $0.00 $141.23 $0.00 $0.00 $0.00 $0.00 $0.00 242.479 SUP HCPCS C1713 242.479 - PLATE BN STRG 48X6.3X1.6MM NS LCP CMBN 5 HL LOPRFL RND EDG BOTH IP/OP $832.18 $615.81 $0.00 $646.34 $363.57 $363.57 $0.00 $0.00 $0.00 $173.45 $617.64 $617.64 $0.00 $0.00 $173.43 $0.00 $492.23 $492.23 $0.00 $403.96 $639.88 $646.34 $0.00 $0.00 $122.76 $0.00 $0.00 $128.62 $0.00 $0.00 $0.00 $0.00 $0.00 242.482 SUP HCPCS C1713 242.482 - PLATE SS BONE LEFT DISTAL DORSAL RADL NONSTRL BOTH IP/OP "$1,868.43 " "$1,382.64" $0.00 "$1,494.74" $840.79 $840.79 $0.00 $0.00 $0.00 $389.43 "$1,386.75" "$1,386.75" $0.00 $0.00 $389.38 $0.00 "$1,105.17" "$1,105.17" $0.00 $934.21 "$1,479.80" "$1,494.74" $0.00 $0.00 $292.41 $0.00 $0.00 $297.45 $0.00 $0.00 $0.00 $0.00 $0.00 242.483 SUP HCPCS C1713 242.483 - PLATE SS BONE LEFT DISTAL VOLR RADL NONSTRL BOTH IP/OP "$1,542.28 " "$1,141.29" $0.00 "$1,233.82" $694.02 $694.02 $0.00 $0.00 $0.00 $321.45 "$1,144.68" "$1,144.68" $0.00 $0.00 $321.41 $0.00 $912.26 $912.26 $0.00 $771.14 "$1,221.49" "$1,233.82" $0.00 $0.00 $241.37 $0.00 $0.00 $245.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.49 SUP HCPCS C1713 242.490 - PLATE BN STRG 57X6.3X1.6MM NS LCP CMBN 6 HL LOPRFL RND EDG BOTH IP/OP $851.60 $630.18 $0.00 $681.28 $383.22 $383.22 $0.00 $0.00 $0.00 $177.49 $632.06 $632.06 $0.00 $0.00 $177.47 $0.00 $503.72 $503.72 $0.00 $425.80 $674.47 $681.28 $0.00 $0.00 $129.39 $0.00 $0.00 $135.57 $0.00 $0.00 $0.00 $0.00 $0.00 242.491 SUP HCPCS C1713 242.491 - PLATE BN 43X7.5X1.6MM NS LCP CMBN 5 HLE/HD 3 HL SHFT BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $671.25 $671.25 $0.00 $0.00 $0.00 $320.23 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $908.80 $908.80 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $293.30 $0.00 $0.00 $237.47 $0.00 $0.00 $0.00 $0.00 $0.00 242.492 SUP HCPCS C1713 242.492 - PLATE BN 61X7.5X1.6MM NS LCP CMBN 5 HLE/HD 5 HL SHFT BOTH IP/OP "$1,626.38 " "$1,203.52" $0.00 "$1,263.22" $710.56 $710.56 $0.00 $0.00 $0.00 $338.98 "$1,207.10" "$1,207.10" $0.00 $0.00 $338.94 $0.00 $962.00 $962.00 $0.00 $789.51 "$1,250.59" "$1,263.22" $0.00 $0.00 $310.94 $0.00 $0.00 $251.38 $0.00 $0.00 $0.00 $0.00 $0.00 242.493 SUP HCPCS C1713 242.493 - PLATE BN 43X7.5X1.6MM NS LCP CMBN 5 HLE/HD 3 HL SHFT BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $671.25 $671.25 $0.00 $0.00 $0.00 $320.23 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $908.80 $908.80 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $293.30 $0.00 $0.00 $237.47 $0.00 $0.00 $0.00 $0.00 $0.00 242.494 SUP HCPCS C1713 242.494 - PLATE BN 61X7.5X1.6MM NS LCP CMBN 5 HLE/HD 5 HL SHFT BOTH IP/OP "$1,626.38 " "$1,203.52" $0.00 "$1,263.22" $710.56 $710.56 $0.00 $0.00 $0.00 $338.98 "$1,207.10" "$1,207.10" $0.00 $0.00 $338.94 $0.00 $962.00 $962.00 $0.00 $789.51 "$1,250.59" "$1,263.22" $0.00 $0.00 $239.92 $0.00 $0.00 $251.38 $0.00 $0.00 $0.00 $0.00 $0.00 242.5 SUP HCPCS C1713 242.500 - PLATE BN -90D L 40X6.3X1.6MM NS LCP CMBN 2 HLE/HD 3 HL SHFT BOTH IP/OP $822.95 $608.98 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $171.52 $610.79 $610.79 $0.00 $0.00 $171.50 $0.00 $486.77 $486.77 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 242.501 SUP HCPCS C1713 242.501 - PLATE BN -90D L 49X6.3X1.6MM NS LCP CMBN 2 HLE/HD 4 HL SHFT BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.502 SUP HCPCS C1713 242.502 - PLATE BN +90D L 40X6.3X1.6MM NS LCP CMBN 2 HLE/HD 3 HL SHFT BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 242.503 SUP HCPCS C1713 242.503 - PLATE BN +90D L 49X6.3X1.6MM NS LCP CMBN 2 HLE/HD 4 HL SHFT BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.504 SUP HCPCS C1713 242.504 - PLATE BN +90D L 40X6.3X1.6MM NS LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 242.505 SUP HCPCS C1713 242.505 - PLATE BN +90D L 49X6.3X1.6MM NS LCP CMBN 3 HLE/HD 4 HL SHFT BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.506 SUP HCPCS C1713 242.506 - PLATE BN -90D L 40X6.3X1.6MM NS LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 242.507 SUP HCPCS C1713 242.507 - PLATE BN -90D L 49X6.3X1.6MM NS LCP CMBN 3 HLE/HD 4 HL SHFT BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.508 SUP HCPCS C1713 242.508 - PLATE BN +20D L 43X6.3X1.6MM NS LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 242.509 SUP HCPCS C1713 242.509 - PLATE BN +20D L 52X6.3X1.6MM NS LCP CMBN 3 HLE/HD 4 HL SHFT BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.51 SUP HCPCS C1713 242.510 - PLATE BONE STANDARD BEND 8 HOLE FUSION LCP STAINLESS STEEL BOTH IP/OP "$1,973.43 " "$1,460.34" $0.00 "$1,578.74" $888.04 $888.04 $0.00 $0.00 $0.00 $411.31 "$1,464.68" "$1,464.68" $0.00 $0.00 $411.26 $0.00 "$1,167.28" "$1,167.28" $0.00 $986.71 "$1,562.96" "$1,578.74" $0.00 $0.00 $299.85 $0.00 $0.00 $314.17 $0.00 $0.00 $0.00 $0.00 $0.00 242.511 SUP HCPCS C1713 242.511 - PLATE BN -20D L 43X6.3X1.6MM NS LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 242.512 SUP HCPCS C1713 242.512 - PLATE BN -20D L 52X6.3X1.6MM NS LCP CMBN 3 HLE/HD 4 HL SHFT BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.52 SUP HCPCS C1713 242.520 - PLATE BONE SHORT BEND 8 HOLE STAINLESS STEEL WRIST NONSTRL BOTH IP/OP "$1,973.43 " "$1,460.34" $0.00 "$1,578.74" $888.04 $888.04 $0.00 $0.00 $0.00 $411.31 "$1,464.68" "$1,464.68" $0.00 $0.00 $411.26 $0.00 "$1,167.28" "$1,167.28" $0.00 $986.71 "$1,562.96" "$1,578.74" $0.00 $0.00 $299.85 $0.00 $0.00 $314.17 $0.00 $0.00 $0.00 $0.00 $0.00 242.53 SUP HCPCS C1713 242.530 - PLATE BONE 9 HOLE STR FUSION STAINLESS STEEL WRIST NONSTRL BOTH IP/OP "$1,973.43 " "$1,460.34" $0.00 "$1,578.74" $888.04 $888.04 $0.00 $0.00 $0.00 $411.31 "$1,464.68" "$1,464.68" $0.00 $0.00 $411.26 $0.00 "$1,167.28" "$1,167.28" $0.00 $986.71 "$1,562.96" "$1,578.74" $0.00 $0.00 $299.85 $0.00 $0.00 $314.17 $0.00 $0.00 $0.00 $0.00 $0.00 242.535 SUP HCPCS C1713 242.535 - PLATE BN 31MMX1.2MM NS 5 HL MDLR SS HND/MDFT 2.7MM SCR BOTH IP/OP $449.83 $332.87 $0.00 $349.38 $196.53 $196.53 $0.00 $0.00 $0.00 $93.75 $333.86 $333.86 $0.00 $0.00 $93.74 $0.00 $266.07 $266.07 $0.00 $218.36 $345.89 $349.38 $0.00 $0.00 $66.36 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $0.00 242.536 SUP HCPCS C1713 242.536 - PLATE BN 45MMX1.2MM NS 8 HL MDLR SS HND/MDFT 2.7MM SCR BOTH IP/OP $465.28 $344.31 $0.00 $361.38 $203.28 $203.28 $0.00 $0.00 $0.00 $96.97 $345.33 $345.33 $0.00 $0.00 $96.96 $0.00 $275.21 $275.21 $0.00 $225.86 $357.77 $361.38 $0.00 $0.00 $68.64 $0.00 $0.00 $71.91 $0.00 $0.00 $0.00 $0.00 $0.00 242.61 SUP HCPCS C1713 242.61 - PLATE BONE 57MM 7 HOLE DCP STAINLESS STEEL CONDYLE LEFT BOTH IP/OP $532.75 $394.24 $0.00 $413.80 $232.76 $232.76 $0.00 $0.00 $0.00 $111.04 $395.41 $395.41 $0.00 $0.00 $111.03 $0.00 $315.12 $315.12 $0.00 $258.63 $409.66 $413.80 $0.00 $0.00 $78.59 $0.00 $0.00 $82.35 $0.00 $0.00 $0.00 $0.00 $0.00 242.62 SUP HCPCS C1713 242.62 - PLATE BONE 57MM 7 HOLE DCP STAINLESS STEEL CONDYLE RIGHT BOTH IP/OP $532.75 $394.24 $0.00 $413.80 $232.76 $232.76 $0.00 $0.00 $0.00 $111.04 $395.41 $395.41 $0.00 $0.00 $111.03 $0.00 $315.12 $315.12 $0.00 $258.63 $409.66 $413.80 $0.00 $0.00 $78.59 $0.00 $0.00 $82.35 $0.00 $0.00 $0.00 $0.00 $0.00 242.802 SUP HCPCS C1713 242.802 - PLATE BONE 139MM 2 HOLE LCP STAINLESS STEEL RIGHT PROXIMAL BOTH IP/OP "$2,614.60 " "$1,934.80" $0.00 "$2,030.74" "$1,142.29" "$1,142.29" $0.00 $0.00 $0.00 $544.95 "$1,940.56" "$1,940.56" $0.00 $0.00 $544.88 $0.00 "$1,289.00" "$1,289.00" $0.00 "$1,269.21" "$2,010.44" "$2,030.74" $0.00 $0.00 $385.69 $0.00 $0.00 $404.12 $0.00 $0.00 $0.00 $0.00 $0.00 242.804 SUP HCPCS C1713 242.804 - PLATE BN 175MM NS LCP CMBN 4 HL LMT CNTCT SS FEM RT PROX 4.5 BOTH IP/OP "$2,666.60 " "$1,973.28" $0.00 "$2,071.14" "$1,165.02" "$1,165.02" $0.00 $0.00 $0.00 $555.79 "$1,979.15" "$1,979.15" $0.00 $0.00 $555.72 $0.00 "$1,314.63" "$1,314.63" $0.00 "$1,294.46" "$2,050.43" "$2,071.14" $0.00 $0.00 $511.85 $0.00 $0.00 $412.16 $0.00 $0.00 $0.00 $0.00 $0.00 242.806 SUP HCPCS C1713 242.806 - PLATE BN 211MM NS LCP CMBN 6 HL LMT CNTCT SS FEM RT PROX 4.5 BOTH IP/OP "$2,718.60 " "$2,011.76" $0.00 "$2,111.54" "$1,187.74" "$1,187.74" $0.00 $0.00 $0.00 $566.62 "$2,017.74" "$2,017.74" $0.00 $0.00 $566.56 $0.00 "$1,340.27" "$1,340.27" $0.00 "$1,319.71" "$2,090.43" "$2,111.54" $0.00 $0.00 $401.04 $0.00 $0.00 $420.20 $0.00 $0.00 $0.00 $0.00 $0.00 242.808 SUP HCPCS C1713 242.808 - PLATE BN 247MM NS LCP CMBN 8 HL LMT CNTCT SS FEM RT PROX 4.5 BOTH IP/OP "$2,852.15 " "$2,110.59" $0.00 "$2,215.26" "$1,246.08" "$1,246.08" $0.00 $0.00 $0.00 $594.46 "$2,116.87" "$2,116.87" $0.00 $0.00 $594.39 $0.00 "$1,406.11" "$1,406.11" $0.00 "$1,384.54" "$2,193.11" "$2,215.26" $0.00 $0.00 $420.74 $0.00 $0.00 $440.84 $0.00 $0.00 $0.00 $0.00 $0.00 242.81 SUP HCPCS C1713 242.810 - PLATE BONE 283MM 10 HOLE LCP STAINLESS STEEL FEMUR RIGHT BOTH IP/OP "$2,966.98 " "$2,195.57" $0.00 "$2,373.58" "$1,335.14" "$1,335.14" $0.00 $0.00 $0.00 $618.39 "$2,202.09" "$2,202.09" $0.00 $0.00 $618.32 $0.00 "$1,462.72" "$1,462.72" $0.00 "$1,483.49" "$2,349.85" "$2,373.58" $0.00 $0.00 $450.81 $0.00 $0.00 $472.34 $0.00 $0.00 $0.00 $0.00 $0.00 242.812 SUP HCPCS C1713 242.812 - PLATE BN 319MM NS LCP CMBN 12 HL LMT CNTCT SS FEM RT PROX BOTH IP/OP "$3,235.90 " "$2,394.57" $0.00 "$2,513.32" "$1,413.74" "$1,413.74" $0.00 $0.00 $0.00 $674.44 "$2,401.68" "$2,401.68" $0.00 $0.00 $674.36 $0.00 "$1,595.30" "$1,595.30" $0.00 "$1,570.83" "$2,488.19" "$2,513.32" $0.00 $0.00 $477.35 $0.00 $0.00 $500.15 $0.00 $0.00 $0.00 $0.00 $0.00 242.814 SUP HCPCS C1713 242.814 - PLATE BN 355MM NS LCP CMBN 14 HL LMT CNTCT SS FEM RT PROX BOTH IP/OP "$3,495.95 " "$2,587.00" $0.00 "$2,715.30" "$1,527.36" "$1,527.36" $0.00 $0.00 $0.00 $728.64 "$2,594.69" "$2,594.69" $0.00 $0.00 $728.56 $0.00 "$1,723.50" "$1,723.50" $0.00 "$1,697.06" "$2,688.15" "$2,715.30" $0.00 $0.00 $515.71 $0.00 $0.00 $540.34 $0.00 $0.00 $0.00 $0.00 $0.00 242.816 SUP HCPCS C1713 242.816 - PLATE BN 391MM NS LCP CMBN 16 HL LMT CNTCT SS FEM RT PROX BOTH IP/OP "$3,601.38 " "$2,665.02" $0.00 "$2,797.20" "$1,573.43" "$1,573.43" $0.00 $0.00 $0.00 $750.62 "$2,672.94" "$2,672.94" $0.00 $0.00 $750.53 $0.00 "$1,775.48" "$1,775.48" $0.00 "$1,748.25" "$2,769.23" "$2,797.20" $0.00 $0.00 $531.26 $0.00 $0.00 $556.64 $0.00 $0.00 $0.00 $0.00 $0.00 243.091 SUP HCPCS C1713 243.091 - PLATE BONE STR 12 HOLE ADAPTION STAINLESS STEEL HAND NONSTRL BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 243.13 SUP HCPCS C1713 243.13 - PLATE BONE STR 17X5X1MM 3 HOLE DCP STAINLESS STEEL FT BOTH IP/OP $103.30 $76.44 $0.00 $80.24 $45.14 $45.14 $0.00 $0.00 $0.00 $21.53 $76.67 $76.67 $0.00 $0.00 $21.53 $0.00 $61.10 $61.10 $0.00 $50.15 $79.44 $80.24 $0.00 $0.00 $15.24 $0.00 $0.00 $15.97 $0.00 $0.00 $0.00 $0.00 $0.00 243.14 SUP HCPCS C1713 243.14 - PLATE BONE STR 23X5X1MM 4 HOLE DCP STAINLESS STEEL FT BOTH IP/OP $113.85 $84.25 $0.00 $88.44 $49.75 $49.75 $0.00 $0.00 $0.00 $23.73 $84.50 $84.50 $0.00 $0.00 $23.73 $0.00 $67.34 $67.34 $0.00 $55.28 $87.56 $88.44 $0.00 $0.00 $16.80 $0.00 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 243.15 SUP HCPCS C1713 243.15 - PLATE BONE STR 29X5X1MM 5 HOLE DCP STAINLESS STEEL FT BOTH IP/OP $121.58 $89.97 $0.00 $94.44 $53.12 $53.12 $0.00 $0.00 $0.00 $25.34 $90.23 $90.23 $0.00 $0.00 $25.34 $0.00 $71.91 $71.91 $0.00 $59.03 $93.50 $94.44 $0.00 $0.00 $23.10 $0.00 $0.00 $18.79 $0.00 $0.00 $0.00 $0.00 $0.00 243.16 SUP HCPCS C1713 243.16 - PLATE BN STRG 35X5X1MM NS 6 HL SS 2MM SCR MN FRAG SET BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 243.19 SUP HCPCS C1713 243.19 - PLATE BONE 2MM 100MM 20 HOLE DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $420.30 $311.02 $0.00 $326.44 $183.62 $183.62 $0.00 $0.00 $0.00 $87.60 $311.95 $311.95 $0.00 $0.00 $87.59 $0.00 $248.61 $248.61 $0.00 $204.03 $323.18 $326.44 $0.00 $0.00 $62.00 $0.00 $0.00 $64.96 $0.00 $0.00 $0.00 $0.00 $0.00 243.23 SUP HCPCS C1713 243.23 - PLATE BONE 2MM 12 HOLE T DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $371.00 $274.54 $0.00 $296.80 $166.95 $166.95 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $185.50 $293.83 $296.80 $0.00 $0.00 $58.06 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 243.234 SUP HCPCS C1713 243.234 - PLATE BN T 65MMX1.2MM NS DCP 3 HLE/HD 10 HL SHFT SS FT 2MM BOTH IP/OP $462.48 $342.24 $0.00 $359.20 $202.05 $202.05 $0.00 $0.00 $0.00 $96.39 $343.25 $343.25 $0.00 $0.00 $96.38 $0.00 $273.55 $273.55 $0.00 $224.50 $355.61 $359.20 $0.00 $0.00 $68.22 $0.00 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $0.00 243.24 SUP HCPCS C1713 243.24 - PLATE BONE 2MM 50MM T 4 HOLE HEAD 9 HOLE SHAFT DCP STAINLESS BOTH IP/OP $393.60 $291.26 $0.00 $305.70 $171.96 $171.96 $0.00 $0.00 $0.00 $82.04 $292.13 $292.13 $0.00 $0.00 $82.03 $0.00 $232.81 $232.81 $0.00 $191.06 $302.65 $305.70 $0.00 $0.00 $58.06 $0.00 $0.00 $60.83 $0.00 $0.00 $0.00 $0.00 $0.00 243.31 SUP HCPCS C1713 243.31 - PLATE BONE L 17X5X1MM 2 HOLE OBLIQUE DCP STAINLESS STEEL BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $46.68 $46.68 $0.00 $0.00 $0.00 $21.62 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $61.35 $61.35 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $15.76 $0.00 $0.00 $16.51 $0.00 $0.00 $0.00 $0.00 $0.00 243.32 SUP HCPCS C1713 243.32 - PLATE BONE L 17X5X1MM 2 HOLE OBLIQUE DCP STAINLESS STEEL BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $46.68 $46.68 $0.00 $0.00 $0.00 $21.62 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $61.35 $61.35 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $15.76 $0.00 $0.00 $16.51 $0.00 $0.00 $0.00 $0.00 $0.00 243.33 SUP HCPCS C1713 243.33 - PLATE BN OB L L 19X5X1MM NS DCP 2 HL SS 2MM SCR MN FRAG SET BOTH IP/OP $103.30 $76.44 $0.00 $80.24 $45.14 $45.14 $0.00 $0.00 $0.00 $21.53 $76.67 $76.67 $0.00 $0.00 $21.53 $0.00 $61.10 $61.10 $0.00 $50.15 $79.44 $80.24 $0.00 $0.00 $15.24 $0.00 $0.00 $15.97 $0.00 $0.00 $0.00 $0.00 $0.00 243.34 SUP HCPCS C1713 243.34 - PLATE BN OB R L 19X5X1MM NS DCP 2 HL SS 2MM SCR MN FRAG SET BOTH IP/OP $103.30 $76.44 $0.00 $80.24 $45.14 $45.14 $0.00 $0.00 $0.00 $21.53 $76.67 $76.67 $0.00 $0.00 $21.53 $0.00 $61.10 $61.10 $0.00 $50.15 $79.44 $80.24 $0.00 $0.00 $15.24 $0.00 $0.00 $15.97 $0.00 $0.00 $0.00 $0.00 $0.00 243.41 SUP HCPCS C1713 243.41 - PLATE BONE T 18MM 2X2 HOLE DCP STAINLESS STEEL FT NONSTRL BOTH IP/OP $103.30 $76.44 $0.00 $80.24 $45.14 $45.14 $0.00 $0.00 $0.00 $21.53 $76.67 $76.67 $0.00 $0.00 $21.53 $0.00 $61.10 $61.10 $0.00 $50.15 $79.44 $80.24 $0.00 $0.00 $15.24 $0.00 $0.00 $15.97 $0.00 $0.00 $0.00 $0.00 $0.00 243.48 SUP HCPCS C1713 243.48 - PLATE BONE H 6MM 4 HOLE DCP STAINLESS STEEL FT NONSTRL MINI BOTH IP/OP $301.60 $223.18 $0.00 $241.28 $135.72 $135.72 $0.00 $0.00 $0.00 $62.86 $223.85 $223.85 $0.00 $0.00 $62.85 $0.00 $178.40 $178.40 $0.00 $150.80 $238.87 $241.28 $0.00 $0.00 $45.83 $0.00 $0.00 $48.01 $0.00 $0.00 $0.00 $0.00 $0.00 243.54 SUP HCPCS C1713 243.54 - PLATE BONE 2MM 22MM 4 HOLE DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $305.70 $226.22 $0.00 $244.56 $137.57 $137.57 $0.00 $0.00 $0.00 $63.72 $226.89 $226.89 $0.00 $0.00 $63.71 $0.00 $180.82 $180.82 $0.00 $152.85 $242.11 $244.56 $0.00 $0.00 $46.45 $0.00 $0.00 $48.67 $0.00 $0.00 $0.00 $0.00 $0.00 243.55 SUP HCPCS C1713 243.55 - PLATE BONE 27X5MM 5 HOLE DCP STAINLESS STEEL NONSTRL 2MM BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $65.99 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $187.28 $187.28 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 243.56 SUP HCPCS C1713 243.56 - PLATE BONE 32MM 2MM 6 HOLE DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $330.28 $244.41 $0.00 $264.22 $148.62 $148.62 $0.00 $0.00 $0.00 $68.84 $245.13 $245.13 $0.00 $0.00 $68.83 $0.00 $195.36 $195.36 $0.00 $165.14 $261.58 $264.22 $0.00 $0.00 $50.18 $0.00 $0.00 $52.58 $0.00 $0.00 $0.00 $0.00 $0.00 243.57 SUP HCPCS C1713 243.57 - PLATE BONE 2MM 37MM 7 HOLE RECONSTRUCTION DCP STAINLESS BOTH IP/OP $348.00 $257.52 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $72.53 $258.29 $258.29 $0.00 $0.00 $72.52 $0.00 $205.84 $205.84 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 243.58 SUP HCPCS C1713 243.58 - PLATE BONE 2MM 42MM 8 HOLE DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 243.584 SUP HCPCS C1713 243.584 - PLATE BN 27MMX1.2MM NS LC DCP 4 HL SS 2MM SCR MDLR HND SYS BOTH IP/OP $395.00 $292.30 $0.00 $306.80 $172.58 $172.58 $0.00 $0.00 $0.00 $82.33 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $233.64 $233.64 $0.00 $191.75 $303.73 $306.80 $0.00 $0.00 $58.27 $0.00 $0.00 $61.05 $0.00 $0.00 $0.00 $0.00 $0.00 243.585 SUP HCPCS C1713 243.585 - PLATE BONE 33MM 5 HOLE LC-DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $420.30 $311.02 $0.00 $326.44 $183.62 $183.62 $0.00 $0.00 $0.00 $87.60 $311.95 $311.95 $0.00 $0.00 $87.59 $0.00 $248.61 $248.61 $0.00 $204.03 $323.18 $326.44 $0.00 $0.00 $62.00 $0.00 $0.00 $64.96 $0.00 $0.00 $0.00 $0.00 $0.00 243.586 SUP HCPCS C1713 243.586 - PLATE BN 39MMX1.2MM NS LC DCP 6 HL SS 2MM SCR MDLR HND SYS BOTH IP/OP $463.88 $343.27 $0.00 $360.30 $202.67 $202.67 $0.00 $0.00 $0.00 $96.68 $344.29 $344.29 $0.00 $0.00 $96.67 $0.00 $274.38 $274.38 $0.00 $225.19 $356.70 $360.30 $0.00 $0.00 $68.43 $0.00 $0.00 $71.70 $0.00 $0.00 $0.00 $0.00 $0.00 243.587 SUP HCPCS C1713 243.587 - PLATE BONE 45MM 7 HOLE LC-DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $496.20 $367.19 $0.00 $385.40 $216.79 $216.79 $0.00 $0.00 $0.00 $103.42 $368.28 $368.28 $0.00 $0.00 $103.41 $0.00 $293.50 $293.50 $0.00 $240.88 $381.55 $385.40 $0.00 $0.00 $73.20 $0.00 $0.00 $76.69 $0.00 $0.00 $0.00 $0.00 $0.00 243.588 SUP HCPCS C1713 243.588 - PLATE BN 51MMX1.2MM NS LC DCP 8 HL SS 2MM SCR MDLR HND SYS BOTH IP/OP $531.35 $393.20 $0.00 $412.70 $232.14 $232.14 $0.00 $0.00 $0.00 $110.75 $394.37 $394.37 $0.00 $0.00 $110.73 $0.00 $314.29 $314.29 $0.00 $257.94 $408.58 $412.70 $0.00 $0.00 $78.38 $0.00 $0.00 $82.13 $0.00 $0.00 $0.00 $0.00 $0.00 243.61 SUP HCPCS C1713 243.61 - PLATE BN 39X5X1.2MM NS DCP 7 HL SS CNDYL LT 2MM SCR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 243.62 SUP HCPCS C1713 243.62 - PLATE BN 39X5X1.2MM NS DCP 7 HL SS CNDYL RT 2MM SCR BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 244.02 SUP HCPCS C1713 244.02 - PLATE BONE 20MM 2 HOLE DCP STAINLESS STEEL NONSTRL 2.7MM BOTH IP/OP $218.35 $161.58 $0.00 $174.68 $98.26 $98.26 $0.00 $0.00 $0.00 $45.51 $162.06 $162.06 $0.00 $0.00 $45.50 $0.00 $129.15 $129.15 $0.00 $109.18 $172.93 $174.68 $0.00 $0.00 $33.18 $0.00 $0.00 $34.76 $0.00 $0.00 $0.00 $0.00 $0.00 244.04 SUP HCPCS C1713 244.04 - PLATE BN 36X8X2MM NS DCP 4 HL SS 2.7MM SCR MN FRAG SET BOTH IP/OP $245.65 $181.78 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $51.20 $182.32 $182.32 $0.00 $0.00 $51.19 $0.00 $145.30 $145.30 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 244.05 SUP HCPCS C1713 244.05 - PLATE BONE 44X8X2MM 5 HOLE DCP STAINLESS STEEL NONSTRL 2.7MM BOTH IP/OP $279.78 $207.04 $0.00 $223.82 $125.90 $125.90 $0.00 $0.00 $0.00 $58.31 $207.65 $207.65 $0.00 $0.00 $58.31 $0.00 $165.49 $165.49 $0.00 $139.89 $221.59 $223.82 $0.00 $0.00 $42.51 $0.00 $0.00 $44.54 $0.00 $0.00 $0.00 $0.00 $0.00 244.06 SUP HCPCS C1713 244.06 - PLATE BONE 52X8X2MM 6 HOLE DCP STAINLESS STEEL NONSTRL 2.7MM BOTH IP/OP $302.98 $224.21 $0.00 $242.38 $136.34 $136.34 $0.00 $0.00 $0.00 $63.15 $224.87 $224.87 $0.00 $0.00 $63.14 $0.00 $179.21 $179.21 $0.00 $151.49 $239.96 $242.38 $0.00 $0.00 $46.03 $0.00 $0.00 $48.23 $0.00 $0.00 $0.00 $0.00 $0.00 244.07 SUP HCPCS C1713 244.07 - PLATE BN 60X8X2.5MM NS DCP 7 HL SS 2.7MM SCR MN FRAG SET BOTH IP/OP $346.65 $256.52 $0.00 $277.32 $155.99 $155.99 $0.00 $0.00 $0.00 $72.25 $257.28 $257.28 $0.00 $0.00 $72.24 $0.00 $205.04 $205.04 $0.00 $173.33 $274.55 $277.32 $0.00 $0.00 $52.67 $0.00 $0.00 $55.19 $0.00 $0.00 $0.00 $0.00 $0.00 244.08 SUP HCPCS C1713 244.08 - PLATE BONE 68X8X2.5MM 8 HOLE DCP STAINLESS STEEL NONSTRL 2.7 BOTH IP/OP $384.85 $284.79 $0.00 $307.88 $173.18 $173.18 $0.00 $0.00 $0.00 $80.21 $285.64 $285.64 $0.00 $0.00 $80.20 $0.00 $227.64 $227.64 $0.00 $192.43 $304.80 $307.88 $0.00 $0.00 $58.48 $0.00 $0.00 $61.27 $0.00 $0.00 $0.00 $0.00 $0.00 244.09 SUP HCPCS C1713 244.09 - PLATE BN 76X8X2.5MM NS DCP 9 HL SS 2.7MM SCR MN FRAG SET BOTH IP/OP $399.88 $295.91 $0.00 $319.90 $179.94 $179.94 $0.00 $0.00 $0.00 $83.34 $296.79 $296.79 $0.00 $0.00 $83.33 $0.00 $236.53 $236.53 $0.00 $199.94 $316.70 $319.90 $0.00 $0.00 $60.76 $0.00 $0.00 $63.66 $0.00 $0.00 $0.00 $0.00 $0.00 244.1 SUP HCPCS C1713 244.10 - PLATE BONE 84X8X2.5MM 10 HOLE DCP STAINLESS STEEL FT NONSTRL BOTH IP/OP $443.55 $328.23 $0.00 $354.84 $199.60 $199.60 $0.00 $0.00 $0.00 $92.45 $329.20 $329.20 $0.00 $0.00 $92.44 $0.00 $262.36 $262.36 $0.00 $221.78 $351.29 $354.84 $0.00 $0.00 $67.39 $0.00 $0.00 $70.61 $0.00 $0.00 $0.00 $0.00 $0.00 244.12 SUP HCPCS C1713 244.12 - PLATE BONE 100X8X2.5MM 12MM 12 HOLE DCP STAINLESS STEEL BOTH IP/OP $499.50 $369.63 $0.00 $399.60 $224.78 $224.78 $0.00 $0.00 $0.00 $104.11 $370.73 $370.73 $0.00 $0.00 $104.10 $0.00 $295.45 $295.45 $0.00 $249.75 $395.60 $399.60 $0.00 $0.00 $75.89 $0.00 $0.00 $79.52 $0.00 $0.00 $0.00 $0.00 $0.00 244.22 SUP HCPCS C1713 244.22 - PLATE BONE 2.7MM 26MM 2 HOLE DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $259.30 $191.88 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $54.04 $192.45 $192.45 $0.00 $0.00 $54.04 $0.00 $153.38 $153.38 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 245 SUP HCPCS C1713 245.00 - PLATE BONE STR 118MM 10 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP $813.40 $601.92 $0.00 $650.72 $366.03 $366.03 $0.00 $0.00 $0.00 $169.53 $603.71 $603.71 $0.00 $0.00 $169.51 $0.00 $481.13 $481.13 $0.00 $406.70 $644.21 $650.72 $0.00 $0.00 $123.59 $0.00 $0.00 $129.49 $0.00 $0.00 $0.00 $0.00 $0.00 245 SUP HCPCS C1713 245 - PLATE 118MM SS 3.5MM SCR SM FRAG SET 10 HOLE RECON LC DCP BOTH IP/OP $813.40 $601.92 $0.00 $749.45 $366.03 $366.03 $0.00 $0.00 $0.00 $169.53 $603.71 $603.71 $0.00 $0.00 $169.51 $0.00 $481.13 $481.13 $0.00 $406.70 $749.45 $650.72 $0.00 $0.00 $123.59 $0.00 $0.00 $129.49 $0.00 $0.00 $0.00 $0.00 $0.00 245.01 SUP HCPCS C1713 245.01 - PLATE BONE 130MM 11 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP $879.98 $651.19 $0.00 $683.46 $384.45 $384.45 $0.00 $0.00 $0.00 $183.41 $653.12 $653.12 $0.00 $0.00 $183.39 $0.00 $520.51 $520.51 $0.00 $427.16 $676.63 $683.46 $0.00 $0.00 $129.81 $0.00 $0.00 $136.01 $0.00 $0.00 $0.00 $0.00 $0.00 245.02 SUP HCPCS C1713 245.02 - PLATE BONE STR 142MM 12 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP $917.93 $679.27 $0.00 $712.94 $401.03 $401.03 $0.00 $0.00 $0.00 $191.32 $681.28 $681.28 $0.00 $0.00 $191.30 $0.00 $542.95 $542.95 $0.00 $445.59 $705.81 $712.94 $0.00 $0.00 $135.41 $0.00 $0.00 $141.88 $0.00 $0.00 $0.00 $0.00 $0.00 245.023 SUP HCPCS C1713 245.023 - PLATE BN STRG 39X10.2X2.7MM NS LC DCP 3 HL LOPRFL RECON SS BOTH IP/OP $607.25 $449.37 $0.00 $471.66 $265.31 $265.31 $0.00 $0.00 $0.00 $126.57 $450.70 $450.70 $0.00 $0.00 $126.55 $0.00 $359.19 $359.19 $0.00 $294.79 $466.95 $471.66 $0.00 $0.00 $89.58 $0.00 $0.00 $93.86 $0.00 $0.00 $0.00 $0.00 $0.00 245.024 SUP HCPCS C1713 245.024 - PLATE BONE 52X10.2X2.7MM 4 HOLE LP STAINLESS STEEL CALCANEUS BOTH IP/OP $635.38 $470.18 $0.00 $493.50 $277.59 $277.59 $0.00 $0.00 $0.00 $132.43 $471.58 $471.58 $0.00 $0.00 $132.41 $0.00 $375.82 $375.82 $0.00 $308.44 $488.57 $493.50 $0.00 $0.00 $93.73 $0.00 $0.00 $98.21 $0.00 $0.00 $0.00 $0.00 $0.00 245.025 SUP HCPCS C1713 245.025 - PLATE BN STRG 65X10.2X2.7MM NS LC DCP 5 HL LOPRFL RECON SS BOTH IP/OP $662.08 $489.94 $0.00 $514.24 $289.26 $289.26 $0.00 $0.00 $0.00 $137.99 $491.39 $491.39 $0.00 $0.00 $137.98 $0.00 $391.62 $391.62 $0.00 $321.40 $509.10 $514.24 $0.00 $0.00 $97.67 $0.00 $0.00 $102.33 $0.00 $0.00 $0.00 $0.00 $0.00 245.026 SUP HCPCS C1713 245.026 - PLATE BONE 78X10.2X2.7MM 6 HOLE LP RECONSTRUCTION STAINLESS BOTH IP/OP $733.78 $543.00 $0.00 $569.92 $320.58 $320.58 $0.00 $0.00 $0.00 $152.94 $544.61 $544.61 $0.00 $0.00 $152.92 $0.00 $434.03 $434.03 $0.00 $356.20 $564.22 $569.92 $0.00 $0.00 $108.24 $0.00 $0.00 $113.41 $0.00 $0.00 $0.00 $0.00 $0.00 245.027 SUP HCPCS C1713 245.027 - PLATE BONE 91X10.2X2.7MM 7 HOLE LP RECONSTRUCTION STAINLESS BOTH IP/OP $770.33 $570.04 $0.00 $598.30 $336.54 $336.54 $0.00 $0.00 $0.00 $160.55 $571.74 $571.74 $0.00 $0.00 $160.54 $0.00 $455.65 $455.65 $0.00 $373.94 $592.32 $598.30 $0.00 $0.00 $113.63 $0.00 $0.00 $119.06 $0.00 $0.00 $0.00 $0.00 $0.00 245.028 SUP HCPCS C1713 245.028 - PLATE BN STRG 104X10.2X2.7MM NS LC DCP 8 HL LOPRFL RECON SS BOTH IP/OP $801.25 $592.93 $0.00 $622.32 $350.06 $350.06 $0.00 $0.00 $0.00 $167.00 $594.69 $594.69 $0.00 $0.00 $166.98 $0.00 $473.94 $473.94 $0.00 $388.95 $616.10 $622.32 $0.00 $0.00 $118.20 $0.00 $0.00 $123.84 $0.00 $0.00 $0.00 $0.00 $0.00 245.029 SUP HCPCS C1713 245.029 - PLATE BONE 11.7X1.02X.27CM 9 HOLE LP RECONSTRUCTION BOTH IP/OP $822.33 $608.52 $0.00 $638.70 $359.27 $359.27 $0.00 $0.00 $0.00 $171.39 $610.33 $610.33 $0.00 $0.00 $171.37 $0.00 $486.41 $486.41 $0.00 $399.19 $632.32 $638.70 $0.00 $0.00 $121.31 $0.00 $0.00 $127.10 $0.00 $0.00 $0.00 $0.00 $0.00 245.03 SUP HCPCS C1713 245.030 - PLATE BONE 130MM 10 HOLE LP STAINLESS STEEL PELVIC NONSTRL BOTH IP/OP $826.55 $611.65 $0.00 "$1,056.80" $361.11 $361.11 $0.00 $0.00 $0.00 $172.27 $613.47 $613.47 $0.00 $0.00 $172.25 $0.00 "$1,056.80" "$1,056.80" $0.00 $401.24 $635.56 $641.98 $0.00 $0.00 $121.93 $0.00 $0.00 $127.75 $0.00 $0.00 $0.00 $0.00 $0.00 245.03 SUP HCPCS C1713 245.03 - PLATE BN 154MM NS LC DCP 13 HL RECON SS 3.5MM SCR SM FRAG BOTH IP/OP $826.55 $611.65 $0.00 "$1,056.80" $361.11 $361.11 $0.00 $0.00 $0.00 $172.27 $613.47 $613.47 $0.00 $0.00 $172.25 $0.00 "$1,056.80" "$1,056.80" $0.00 $401.24 $738.25 $641.98 $0.00 $0.00 $121.93 $0.00 $0.00 $127.75 $0.00 $0.00 $0.00 $0.00 $0.00 245.031 SUP HCPCS C1713 245.031 - PLATE BONE 143MM 11 HOLE LP RECONSTRUCTION STAINLESS STEEL BOTH IP/OP $872.93 $645.97 $0.00 $678.00 $381.38 $381.38 $0.00 $0.00 $0.00 $181.94 $647.88 $647.88 $0.00 $0.00 $181.92 $0.00 $516.34 $516.34 $0.00 $423.75 $671.22 $678.00 $0.00 $0.00 $128.77 $0.00 $0.00 $134.92 $0.00 $0.00 $0.00 $0.00 $0.00 245.032 SUP HCPCS C1713 245.032 - PLATE BN STRG 156X10.2X2.7MM NS LC DCP 12 HL LOPRFL RECON SS BOTH IP/OP $906.68 $670.94 $0.00 $704.22 $396.12 $396.12 $0.00 $0.00 $0.00 $188.97 $672.93 $672.93 $0.00 $0.00 $188.95 $0.00 $536.30 $536.30 $0.00 $440.14 $697.18 $704.22 $0.00 $0.00 $133.75 $0.00 $0.00 $140.14 $0.00 $0.00 $0.00 $0.00 $0.00 245.033 SUP HCPCS C1713 245.033 - PLATE BONE 169MM 13 HOLE LP RECONSTRUCTION STAINLESS STEEL BOTH IP/OP $950.25 $703.19 $0.00 $738.06 $415.16 $415.16 $0.00 $0.00 $0.00 $198.06 $705.28 $705.28 $0.00 $0.00 $198.03 $0.00 $562.07 $562.07 $0.00 $461.29 $730.68 $738.06 $0.00 $0.00 $140.18 $0.00 $0.00 $146.87 $0.00 $0.00 $0.00 $0.00 $0.00 245.034 SUP HCPCS C1713 245.034 - PLATE BONE 182MM 14 HOLE LP RECONSTRUCTION STAINLESS STEEL BOTH IP/OP $985.40 $729.20 $0.00 $765.36 $430.52 $430.52 $0.00 $0.00 $0.00 $205.38 $731.36 $731.36 $0.00 $0.00 $205.36 $0.00 $582.86 $582.86 $0.00 $478.35 $757.71 $765.36 $0.00 $0.00 $145.36 $0.00 $0.00 $152.31 $0.00 $0.00 $0.00 $0.00 $0.00 245.035 SUP HCPCS C1713 245.035 - PLATE BONE 195MM 15 HOLE LP RECONSTRUCTION STAINLESS STEEL BOTH IP/OP "$1,034.60 " $765.60 $0.00 $803.56 $452.00 $452.00 $0.00 $0.00 $0.00 $215.64 $767.88 $767.88 $0.00 $0.00 $215.61 $0.00 $611.97 $611.97 $0.00 $502.23 $795.52 $803.56 $0.00 $0.00 $152.62 $0.00 $0.00 $159.91 $0.00 $0.00 $0.00 $0.00 $0.00 245.036 SUP HCPCS C1713 245.036 - PLATE BONE 208MM 16 HOLE LP RECONSTRUCTION STAINLESS STEEL BOTH IP/OP "$1,080.98 " $799.93 $0.00 $839.60 $472.28 $472.28 $0.00 $0.00 $0.00 $225.30 $802.30 $802.30 $0.00 $0.00 $225.28 $0.00 $639.40 $639.40 $0.00 $524.75 $831.20 $839.60 $0.00 $0.00 $159.46 $0.00 $0.00 $167.08 $0.00 $0.00 $0.00 $0.00 $0.00 245.038 SUP HCPCS C1713 245.038 - PLATE BONE 234MM 18 HOLE LP RECONSTRUCTION STAINLESS STEEL BOTH IP/OP "$1,127.38 " $834.26 $0.00 $875.62 $492.54 $492.54 $0.00 $0.00 $0.00 $234.97 $836.74 $836.74 $0.00 $0.00 $234.94 $0.00 $666.84 $666.84 $0.00 $547.26 $866.87 $875.62 $0.00 $0.00 $166.30 $0.00 $0.00 $174.25 $0.00 $0.00 $0.00 $0.00 $0.00 245.039 SUP HCPCS C1713 245.039 - PLATE BONE 260MM 20 HOLE LP RECONSTRUCTION STAINLESS STEEL BOTH IP/OP "$1,353.68 " "$1,001.72" $0.00 "$1,051.40" $591.41 $591.41 $0.00 $0.00 $0.00 $282.14 "$1,004.70" "$1,004.70" $0.00 $0.00 $282.11 $0.00 $800.70 $800.70 $0.00 $657.13 "$1,040.89" "$1,051.40" $0.00 $0.00 $199.69 $0.00 $0.00 $209.23 $0.00 $0.00 $0.00 $0.00 $0.00 245.04 SUP HCPCS C1713 245.04 - PLATE BONE 3.5MM 166MM 14 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP $996.63 $737.51 $0.00 $774.08 $435.42 $435.42 $0.00 $0.00 $0.00 $207.72 $739.70 $739.70 $0.00 $0.00 $207.70 $0.00 $589.50 $589.50 $0.00 $483.80 $766.34 $774.08 $0.00 $0.00 $147.02 $0.00 $0.00 $154.04 $0.00 $0.00 $0.00 $0.00 $0.00 245.041 SUP HCPCS C1713 245.041 - PLATE BN 56MM NS LCP 4 HL RECON SS 3.5MM SCR SM FRAG SYS BOTH IP/OP $827.95 $612.68 $0.00 $643.08 $361.73 $361.73 $0.00 $0.00 $0.00 $172.57 $614.50 $614.50 $0.00 $0.00 $172.54 $0.00 $489.73 $489.73 $0.00 $401.93 $636.65 $643.08 $0.00 $0.00 $122.14 $0.00 $0.00 $127.97 $0.00 $0.00 $0.00 $0.00 $0.00 245.05 SUP HCPCS C1713 245.05 - PLATE BONE 3.5MM 178MM 15 HOLE RECONSTRUCTION DCP LC-DCP BOTH IP/OP "$1,034.60 " $765.60 $0.00 $803.56 $452.00 $452.00 $0.00 $0.00 $0.00 $215.64 $767.88 $767.88 $0.00 $0.00 $215.61 $0.00 $611.97 $611.97 $0.00 $502.23 $795.52 $803.56 $0.00 $0.00 $152.62 $0.00 $0.00 $159.91 $0.00 $0.00 $0.00 $0.00 $0.00 245.051 SUP HCPCS C1713 245.051 - PLATE BONE STR 70X10.1X3.5MM 5 HOLE RECONSTRUCTION LCP BOTH IP/OP $809.68 $599.16 $0.00 $628.88 $353.75 $353.75 $0.00 $0.00 $0.00 $168.76 $600.94 $600.94 $0.00 $0.00 $168.74 $0.00 $478.92 $478.92 $0.00 $393.05 $622.59 $628.88 $0.00 $0.00 $119.44 $0.00 $0.00 $125.15 $0.00 $0.00 $0.00 $0.00 $0.00 245.06 SUP HCPCS C1713 245.06 - PLATE BN 190MM NS LC DCP 16 HL RECON SS 3.5MM SCR SM FRAG BOTH IP/OP "$1,079.58 " $798.89 $0.00 $838.50 $471.66 $471.66 $0.00 $0.00 $0.00 $225.01 $801.26 $801.26 $0.00 $0.00 $224.98 $0.00 $638.57 $638.57 $0.00 $524.06 $830.12 $838.50 $0.00 $0.00 $159.25 $0.00 $0.00 $166.86 $0.00 $0.00 $0.00 $0.00 $0.00 245.061 SUP HCPCS C1713 245.061 - PLATE BONE STR 84X10.1X3.5MM 6 HOLE RECONSTRUCTION LCP BOTH IP/OP $936.20 $692.79 $0.00 $727.14 $409.02 $409.02 $0.00 $0.00 $0.00 $195.13 $694.85 $694.85 $0.00 $0.00 $195.10 $0.00 $553.76 $553.76 $0.00 $454.46 $719.87 $727.14 $0.00 $0.00 $138.10 $0.00 $0.00 $144.70 $0.00 $0.00 $0.00 $0.00 $0.00 245.071 SUP HCPCS C1713 245.071 - PLATE BONE STR 98X10.1X3.5MM 7 HOLE RECONSTRUCTION LCP BOTH IP/OP $982.58 $727.11 $0.00 $763.16 $429.28 $429.28 $0.00 $0.00 $0.00 $204.79 $729.27 $729.27 $0.00 $0.00 $204.77 $0.00 $581.19 $581.19 $0.00 $476.98 $755.53 $763.16 $0.00 $0.00 $192.28 $0.00 $0.00 $151.87 $0.00 $0.00 $0.00 $0.00 $0.00 245.08 SUP HCPCS C1713 245.08 - PLATE BONE STR 214MM 18 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP "$1,128.78 " $835.30 $0.00 $876.72 $493.16 $493.16 $0.00 $0.00 $0.00 $235.26 $837.78 $837.78 $0.00 $0.00 $235.24 $0.00 $667.67 $667.67 $0.00 $547.95 $867.95 $876.72 $0.00 $0.00 $166.51 $0.00 $0.00 $174.47 $0.00 $0.00 $0.00 $0.00 $0.00 245.081 SUP HCPCS C1713 245.081 - PLATE BONE STR 112X10.1X3.5MM 8 HOLE RECONSTRUCTION LCP BOTH IP/OP "$1,024.75 " $758.32 $0.00 $795.92 $447.71 $447.71 $0.00 $0.00 $0.00 $213.58 $760.57 $760.57 $0.00 $0.00 $213.56 $0.00 $606.14 $606.14 $0.00 $497.45 $787.96 $795.92 $0.00 $0.00 $151.17 $0.00 $0.00 $158.39 $0.00 $0.00 $0.00 $0.00 $0.00 245.091 SUP HCPCS C1713 245.091 - PLATE BN 126X10.1X3.5MM NS LCP CMBN 9 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,079.58 " $798.89 $0.00 $838.50 $471.66 $471.66 $0.00 $0.00 $0.00 $225.01 $801.26 $801.26 $0.00 $0.00 $224.98 $0.00 $638.57 $638.57 $0.00 $524.06 $830.12 $838.50 $0.00 $0.00 $159.25 $0.00 $0.00 $166.86 $0.00 $0.00 $0.00 $0.00 $0.00 245.1 SUP HCPCS C1713 245.10 - PLATE BN 238MM NS LC DCP 20 HL RECON SS 3.5MM SCR SM FRAG BOTH IP/OP "$1,329.28 " $983.67 $0.00 "$1,063.42" $598.17 $598.17 $0.00 $0.00 $0.00 $277.05 $986.59 $986.59 $0.00 $0.00 $277.02 $0.00 $786.27 $786.27 $0.00 $664.64 "$1,052.79" "$1,063.42" $0.00 $0.00 $201.97 $0.00 $0.00 $211.62 $0.00 $0.00 $0.00 $0.00 $0.00 245.101 SUP HCPCS C1713 245.101 - PLATE BONE STR 140X10.1X3.5MM 10 HOLE RECONSTRUCTION LCP BOTH IP/OP "$1,062.70 " $786.40 $0.00 $825.40 $464.29 $464.29 $0.00 $0.00 $0.00 $221.49 $788.74 $788.74 $0.00 $0.00 $221.47 $0.00 $628.59 $628.59 $0.00 $515.88 $817.15 $825.40 $0.00 $0.00 $156.77 $0.00 $0.00 $164.25 $0.00 $0.00 $0.00 $0.00 $0.00 245.111 SUP HCPCS C1713 245.111 - PLATE BN 154X10.1X3.5MM NS LCP CMBN 11 HL SHFT RECON SS 3.5 BOTH IP/OP "$1,149.85 " $850.89 $0.00 $893.10 $502.37 $502.37 $0.00 $0.00 $0.00 $239.66 $853.42 $853.42 $0.00 $0.00 $239.63 $0.00 $680.14 $680.14 $0.00 $558.19 $884.17 $893.10 $0.00 $0.00 $169.62 $0.00 $0.00 $177.73 $0.00 $0.00 $0.00 $0.00 $0.00 245.12 SUP HCPCS C1713 245.12 - PLATE BONE STR 3.5MM 263MM 22 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP "$1,425.38 " "$1,054.78" $0.00 "$1,107.08" $622.73 $622.73 $0.00 $0.00 $0.00 $297.08 "$1,057.91" "$1,057.91" $0.00 $0.00 $297.05 $0.00 $843.11 $843.11 $0.00 $691.93 "$1,096.01" "$1,107.08" $0.00 $0.00 $210.27 $0.00 $0.00 $220.31 $0.00 $0.00 $0.00 $0.00 $0.00 245.121 SUP HCPCS C1713 245.121 - PLATE BONE STR 168X10.1X3.5MM 12 HOLE RECONSTRUCTION LCP BOTH IP/OP "$1,176.58 " $870.67 $0.00 $913.84 $514.04 $514.04 $0.00 $0.00 $0.00 $245.23 $873.25 $873.25 $0.00 $0.00 $245.20 $0.00 $695.94 $695.94 $0.00 $571.15 $904.70 $913.84 $0.00 $0.00 $173.56 $0.00 $0.00 $181.85 $0.00 $0.00 $0.00 $0.00 $0.00 245.131 SUP HCPCS C1713 245.131 - PLATE BONE STR 182X10.1X3.5MM 13 HOLE RECONSTRUCTION LCP BOTH IP/OP "$1,273.55 " $942.43 $0.00 $989.18 $556.41 $556.41 $0.00 $0.00 $0.00 $265.44 $945.23 $945.23 $0.00 $0.00 $265.41 $0.00 $753.30 $753.30 $0.00 $618.24 $979.29 $989.18 $0.00 $0.00 $187.87 $0.00 $0.00 $196.85 $0.00 $0.00 $0.00 $0.00 $0.00 245.14 SUP HCPCS C1713 245.14 - PLATE BONE STR 46X10.1X3.5MM 4 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP $635.38 $470.18 $0.00 $493.50 $277.59 $277.59 $0.00 $0.00 $0.00 $132.43 $471.58 $471.58 $0.00 $0.00 $132.41 $0.00 $375.82 $375.82 $0.00 $308.44 $488.57 $493.50 $0.00 $0.00 $93.73 $0.00 $0.00 $98.21 $0.00 $0.00 $0.00 $0.00 $0.00 245.141 SUP HCPCS C1713 245.141 - PLATE BONE STR 196X10.1X3.5MM 14 HOLE RECONSTRUCTION LCP BOTH IP/OP "$1,322.75 " $978.84 $0.00 "$1,027.38" $577.90 $577.90 $0.00 $0.00 $0.00 $275.69 $981.75 $981.75 $0.00 $0.00 $275.66 $0.00 $782.41 $782.41 $0.00 $642.11 "$1,017.11" "$1,027.38" $0.00 $0.00 $195.13 $0.00 $0.00 $204.45 $0.00 $0.00 $0.00 $0.00 $0.00 245.15 SUP HCPCS C1713 245.15 - PLATE BONE STR 58MM 5 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP $646.63 $478.51 $0.00 $502.22 $282.50 $282.50 $0.00 $0.00 $0.00 $134.77 $479.93 $479.93 $0.00 $0.00 $134.76 $0.00 $382.48 $382.48 $0.00 $313.89 $497.20 $502.22 $0.00 $0.00 $95.39 $0.00 $0.00 $99.94 $0.00 $0.00 $0.00 $0.00 $0.00 245.16 SUP HCPCS C1713 245.16 - PLATE BONE STR 70MM 6 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP $742.20 $549.23 $0.00 $576.48 $324.27 $324.27 $0.00 $0.00 $0.00 $154.69 $550.86 $550.86 $0.00 $0.00 $154.67 $0.00 $439.01 $439.01 $0.00 $360.30 $570.72 $576.48 $0.00 $0.00 $109.49 $0.00 $0.00 $114.72 $0.00 $0.00 $0.00 $0.00 $0.00 245.161 SUP HCPCS C1713 245.161 - PLATE BONE STR 224X10.1X3.5MM 16 HOLE RECONSTRUCTION LCP BOTH IP/OP "$1,433.80 " "$1,061.01" $0.00 "$1,113.64" $626.42 $626.42 $0.00 $0.00 $0.00 $298.84 "$1,064.17" "$1,064.17" $0.00 $0.00 $298.80 $0.00 $848.09 $848.09 $0.00 $696.03 "$1,102.50" "$1,113.64" $0.00 $0.00 $211.51 $0.00 $0.00 $221.61 $0.00 $0.00 $0.00 $0.00 $0.00 245.17 SUP HCPCS C1713 245.17 - PLATE BONE STR 82MM 7 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP $778.75 $576.28 $0.00 $604.86 $340.23 $340.23 $0.00 $0.00 $0.00 $162.31 $577.99 $577.99 $0.00 $0.00 $162.29 $0.00 $460.63 $460.63 $0.00 $378.04 $598.82 $604.86 $0.00 $0.00 $142.33 $0.00 $0.00 $120.37 $0.00 $0.00 $0.00 $0.00 $0.00 245.18 SUP HCPCS C1713 245.18 - PLATE BONE STR 94MM 8 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP $811.08 $600.20 $0.00 $629.96 $354.35 $354.35 $0.00 $0.00 $0.00 $169.05 $601.98 $601.98 $0.00 $0.00 $169.03 $0.00 $479.75 $479.75 $0.00 $393.73 $623.66 $629.96 $0.00 $0.00 $119.65 $0.00 $0.00 $125.36 $0.00 $0.00 $0.00 $0.00 $0.00 245.181 SUP HCPCS C1713 245.181 - PLATE BONE STR 252X10.1X3.5MM 18 HOLE RECONSTRUCTION LCP BOTH IP/OP "$1,501.28 " "$1,110.95" $0.00 "$1,166.04" $655.90 $655.90 $0.00 $0.00 $0.00 $312.90 "$1,114.25" "$1,114.25" $0.00 $0.00 $312.87 $0.00 $888.00 $888.00 $0.00 $728.78 "$1,154.38" "$1,166.04" $0.00 $0.00 $221.46 $0.00 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 245.19 SUP HCPCS C1713 245.19 - PLATE BN 106MM NS LC DCP 9 HL RECON SS 3.5MM SCR SM FRAG SET BOTH IP/OP $830.78 $614.78 $0.00 $645.26 $362.96 $362.96 $0.00 $0.00 $0.00 $173.15 $616.60 $616.60 $0.00 $0.00 $173.13 $0.00 $491.40 $491.40 $0.00 $403.29 $638.81 $645.26 $0.00 $0.00 $122.55 $0.00 $0.00 $128.41 $0.00 $0.00 $0.00 $0.00 $0.00 245.2 SUP HCPCS C1713 245.20 - PLATE BN 48X8X3.3MM NS 6 HL RECON 2.7MM SCR BOTH IP/OP $559.55 $414.07 $0.00 $447.64 $251.80 $251.80 $0.00 $0.00 $0.00 $116.62 $415.30 $415.30 $0.00 $0.00 $116.61 $0.00 $330.97 $330.97 $0.00 $279.78 $443.16 $447.64 $0.00 $0.00 $85.02 $0.00 $0.00 $89.08 $0.00 $0.00 $0.00 $0.00 $0.00 245.201 SUP HCPCS C1713 245.201 - PLATE BONE STR 280X10.1X3.5MM 20 HOLE RECONSTRUCTION LCP BOTH IP/OP "$1,823.18 " "$1,349.15" $0.00 "$1,416.06" $796.53 $796.53 $0.00 $0.00 $0.00 $380.00 "$1,353.16" "$1,353.16" $0.00 $0.00 $379.95 $0.00 "$1,078.41" "$1,078.41" $0.00 $885.04 "$1,401.90" "$1,416.06" $0.00 $0.00 $268.95 $0.00 $0.00 $281.80 $0.00 $0.00 $0.00 $0.00 $0.00 245.21 SUP HCPCS C1713 245.21 - PLATE BN 64X8X3.3MM NS 8 HL RECON 2.7MM SCR BOTH IP/OP $597.43 $442.10 $0.00 $464.02 $261.01 $261.01 $0.00 $0.00 $0.00 $124.52 $443.41 $443.41 $0.00 $0.00 $124.50 $0.00 $353.38 $353.38 $0.00 $290.01 $459.38 $464.02 $0.00 $0.00 $88.13 $0.00 $0.00 $92.34 $0.00 $0.00 $0.00 $0.00 $0.00 245.22 SUP HCPCS C1713 245.22 - PLATE BN 80X8X3.3MM NS 10 HL RECON 2.7MM SCR BOTH IP/OP $638.18 $472.25 $0.00 $495.68 $278.82 $278.82 $0.00 $0.00 $0.00 $133.01 $473.65 $473.65 $0.00 $0.00 $133.00 $0.00 $377.48 $377.48 $0.00 $309.80 $490.72 $495.68 $0.00 $0.00 $94.14 $0.00 $0.00 $98.64 $0.00 $0.00 $0.00 $0.00 $0.00 245.221 SUP HCPCS C1713 245.221 - PLATE BN 308X10.1X3.5MM NS LCP CMBN 22 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,893.48 " "$1,401.18" $0.00 "$1,470.66" $827.25 $827.25 $0.00 $0.00 $0.00 $394.65 "$1,405.34" "$1,405.34" $0.00 $0.00 $394.60 $0.00 "$1,119.99" "$1,119.99" $0.00 $919.16 "$1,455.96" "$1,470.66" $0.00 $0.00 $279.32 $0.00 $0.00 $292.66 $0.00 $0.00 $0.00 $0.00 $0.00 245.23 SUP HCPCS C1713 245.23 - PLATE BONE STR 96MM 12 HOLE RECONSTRUCTION LCP STAINLESS BOTH IP/OP $761.88 $563.79 $0.00 $591.76 $332.87 $332.87 $0.00 $0.00 $0.00 $158.79 $565.46 $565.46 $0.00 $0.00 $158.77 $0.00 $450.65 $450.65 $0.00 $369.85 $585.84 $591.76 $0.00 $0.00 $112.39 $0.00 $0.00 $117.76 $0.00 $0.00 $0.00 $0.00 $0.00 245.24 SUP HCPCS C1713 245.24 - PLATE BN 112X8X3.3MM NS 14 HL RECON 2.7MM SCR BOTH IP/OP $811.08 $600.20 $0.00 $629.96 $354.35 $354.35 $0.00 $0.00 $0.00 $169.05 $601.98 $601.98 $0.00 $0.00 $169.03 $0.00 $479.75 $479.75 $0.00 $393.73 $623.66 $629.96 $0.00 $0.00 $119.65 $0.00 $0.00 $125.36 $0.00 $0.00 $0.00 $0.00 $0.00 245.25 SUP HCPCS C1713 245.25 - PLATE BONE STR 128X8X3.3MM 16 HOLE RECONSTRUCTION LCP BOTH IP/OP $882.78 $653.26 $0.00 $685.66 $385.68 $385.68 $0.00 $0.00 $0.00 $183.99 $655.20 $655.20 $0.00 $0.00 $183.97 $0.00 $522.16 $522.16 $0.00 $428.54 $678.81 $685.66 $0.00 $0.00 $130.22 $0.00 $0.00 $136.45 $0.00 $0.00 $0.00 $0.00 $0.00 245.26 SUP HCPCS C1713 245.26 - PLATE BONE 144MM 18 HOLE RECONSTRUCTION LC-DCP STAINLESS BOTH IP/OP "$1,065.88 " $788.75 $0.00 $852.70 $479.64 $479.64 $0.00 $0.00 $0.00 $222.15 $791.09 $791.09 $0.00 $0.00 $222.13 $0.00 $630.47 $630.47 $0.00 $532.94 $844.18 $852.70 $0.00 $0.00 $161.95 $0.00 $0.00 $169.69 $0.00 $0.00 $0.00 $0.00 $0.00 245.27 SUP HCPCS C1713 245.27 - PLATE BONE 160MM 20 HOLE RECONSTRUCTION DCP STAINLESS STEEL BOTH IP/OP "$1,109.03 " $820.68 $0.00 $887.22 $499.06 $499.06 $0.00 $0.00 $0.00 $231.15 $823.12 $823.12 $0.00 $0.00 $231.12 $0.00 $655.99 $655.99 $0.00 $554.51 $878.35 $887.22 $0.00 $0.00 $173.56 $0.00 $0.00 $176.56 $0.00 $0.00 $0.00 $0.00 $0.00 245.28 SUP HCPCS C1713 245.28 - PLATE BONE 176MM 22 HOLE RECONSTRUCTION DCP STAINLESS STEEL BOTH IP/OP "$1,329.28 " $983.67 $0.00 "$1,063.42" $598.17 $598.17 $0.00 $0.00 $0.00 $277.05 $986.59 $986.59 $0.00 $0.00 $277.02 $0.00 $786.27 $786.27 $0.00 $664.64 "$1,052.79" "$1,063.42" $0.00 $0.00 $201.97 $0.00 $0.00 $211.62 $0.00 $0.00 $0.00 $0.00 $0.00 245.29 SUP HCPCS C1713 245.29 - PLATE BONE 192MM 24 HOLE RECONSTRUCTION DCP STAINLESS STEEL BOTH IP/OP "$1,497.13 " "$1,107.88" $0.00 "$1,197.70" $673.71 $673.71 $0.00 $0.00 $0.00 $312.04 "$1,111.17" "$1,111.17" $0.00 $0.00 $312.00 $0.00 $885.55 $885.55 $0.00 $748.56 "$1,185.73" "$1,197.70" $0.00 $0.00 $227.48 $0.00 $0.00 $238.34 $0.00 $0.00 $0.00 $0.00 $0.00 245.3 SUP HCPCS C1713 245.30 - PLATE BONE CURVE 70X10X3.6MM 6 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP $780.63 $577.67 $0.00 $624.50 $351.28 $351.28 $0.00 $0.00 $0.00 $162.70 $579.38 $579.38 $0.00 $0.00 $162.68 $0.00 $461.74 $461.74 $0.00 $390.31 $618.26 $624.50 $0.00 $0.00 $118.61 $0.00 $0.00 $124.28 $0.00 $0.00 $0.00 $0.00 $0.00 245.31 SUP HCPCS C1713 245.31 - PLATE BN CRV 94X10X3.6MM NS LC DCP 8 HL RECON SS 3.5MM CORT BOTH IP/OP $872.93 $645.97 $0.00 $678.00 $381.38 $381.38 $0.00 $0.00 $0.00 $181.94 $647.88 $647.88 $0.00 $0.00 $181.92 $0.00 $516.34 $516.34 $0.00 $423.75 $671.22 $678.00 $0.00 $0.00 $128.77 $0.00 $0.00 $134.92 $0.00 $0.00 $0.00 $0.00 $0.00 245.32 SUP HCPCS C1713 245.32 - PLATE BN CRV 118X10X3.6MM NS LC DCP 10 HL RECON SS 3.5MM BOTH IP/OP $917.93 $679.27 $0.00 $712.94 $401.03 $401.03 $0.00 $0.00 $0.00 $191.32 $681.28 $681.28 $0.00 $0.00 $191.30 $0.00 $542.95 $542.95 $0.00 $445.59 $705.81 $712.94 $0.00 $0.00 $135.41 $0.00 $0.00 $141.88 $0.00 $0.00 $0.00 $0.00 $0.00 245.33 SUP HCPCS C1713 245.33 - PLATE BONE CURVE 142X10X3.6MM 12 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP $955.88 $707.35 $0.00 $742.42 $417.61 $417.61 $0.00 $0.00 $0.00 $199.23 $709.45 $709.45 $0.00 $0.00 $199.20 $0.00 $565.40 $565.40 $0.00 $464.01 $735.00 $742.42 $0.00 $0.00 $141.01 $0.00 $0.00 $147.74 $0.00 $0.00 $0.00 $0.00 $0.00 245.34 SUP HCPCS C1713 245.34 - PLATE BONE CURVE 166X10X3.6MM 14 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP "$1,072.55 " $793.69 $0.00 $833.04 $468.59 $468.59 $0.00 $0.00 $0.00 $223.55 $796.05 $796.05 $0.00 $0.00 $223.52 $0.00 $634.41 $634.41 $0.00 $520.65 $824.71 $833.04 $0.00 $0.00 $158.22 $0.00 $0.00 $165.77 $0.00 $0.00 $0.00 $0.00 $0.00 245.341 SUP HCPCS C1713 245.341 - PLATE BONE 55MM 4 HOLE SHAFT CVD RECONSTRUCTION LCP BOTH IP/OP "$1,291.83 " $955.95 $0.00 "$1,003.36" $564.39 $564.39 $0.00 $0.00 $0.00 $269.25 $958.79 $958.79 $0.00 $0.00 $269.22 $0.00 $764.11 $764.11 $0.00 $627.10 $993.33 "$1,003.36" $0.00 $0.00 $190.57 $0.00 $0.00 $199.67 $0.00 $0.00 $0.00 $0.00 $0.00 245.35 SUP HCPCS C1713 245.35 - PLATE BN CRV 190X10X3.6MM NS LC DCP 16 HL RECON SS 3.5MM BOTH IP/OP "$1,141.43 " $844.66 $0.00 $886.54 $498.68 $498.68 $0.00 $0.00 $0.00 $237.90 $847.17 $847.17 $0.00 $0.00 $237.87 $0.00 $675.15 $675.15 $0.00 $554.09 $877.68 $886.54 $0.00 $0.00 $168.38 $0.00 $0.00 $176.42 $0.00 $0.00 $0.00 $0.00 $0.00 245.36 SUP HCPCS C1713 245.36 - PLATE BONE CURVE 214X10X3.6MM 18 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP "$1,229.98 " $910.19 $0.00 $955.32 $537.37 $537.37 $0.00 $0.00 $0.00 $256.36 $912.89 $912.89 $0.00 $0.00 $256.33 $0.00 $727.53 $727.53 $0.00 $597.08 $945.77 $955.32 $0.00 $0.00 $181.44 $0.00 $0.00 $190.11 $0.00 $0.00 $0.00 $0.00 $0.00 245.361 SUP HCPCS C1713 245.361 - PLATE BONE 82MM 6 HOLE SHAFT CVD RECONSTRUCTION LCP BOTH IP/OP "$1,398.68 " "$1,035.02" $0.00 "$1,086.34" $611.07 $611.07 $0.00 $0.00 $0.00 $291.52 "$1,038.10" "$1,038.10" $0.00 $0.00 $291.48 $0.00 $827.32 $827.32 $0.00 $678.96 "$1,075.48" "$1,086.34" $0.00 $0.00 $206.33 $0.00 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 245.381 SUP HCPCS C1713 245.381 - PLATE BN CRV 106X10.1X3.5MM NS LCP 8 HL SHFT RECON SS 3.5MM BOTH IP/OP "$1,516.75 " "$1,122.40" $0.00 "$1,178.06" $662.66 $662.66 $0.00 $0.00 $0.00 $316.13 "$1,125.73" "$1,125.73" $0.00 $0.00 $316.09 $0.00 $897.16 $897.16 $0.00 $736.29 "$1,166.28" "$1,178.06" $0.00 $0.00 $223.74 $0.00 $0.00 $234.43 $0.00 $0.00 $0.00 $0.00 $0.00 245.401 SUP HCPCS C1713 245.401 - PLATE BONE 140MM 10 HOLE CVD RECONSTRUCTION LCP STAINLESS BOTH IP/OP "$1,588.43 " "$1,175.44" $0.00 "$1,233.74" $693.98 $693.98 $0.00 $0.00 $0.00 $331.07 "$1,178.93" "$1,178.93" $0.00 $0.00 $331.03 $0.00 $939.55 $939.55 $0.00 $771.09 "$1,221.41" "$1,233.74" $0.00 $0.00 $234.32 $0.00 $0.00 $245.51 $0.00 $0.00 $0.00 $0.00 $0.00 245.421 SUP HCPCS C1713 245.421 - PLATE BONE 149MM 12 HOLE SHAFT CVD RECONSTRUCTION LCP BOTH IP/OP "$1,662.93 " "$1,230.57" $0.00 "$1,291.60" $726.53 $726.53 $0.00 $0.00 $0.00 $346.60 "$1,234.22" "$1,234.22" $0.00 $0.00 $346.55 $0.00 $983.62 $983.62 $0.00 $807.25 "$1,278.68" "$1,291.60" $0.00 $0.00 $245.31 $0.00 $0.00 $257.03 $0.00 $0.00 $0.00 $0.00 $0.00 245.441 SUP HCPCS C1713 245.441 - PLATE BONE 166MM 14 HOLE SHAFT CVD RECONSTRUCTION LCP BOTH IP/OP "$1,868.18 " "$1,382.45" $0.00 "$1,451.00" $816.19 $816.19 $0.00 $0.00 $0.00 $389.37 "$1,386.56" "$1,386.56" $0.00 $0.00 $389.33 $0.00 "$1,105.03" "$1,105.03" $0.00 $906.88 "$1,436.49" "$1,451.00" $0.00 $0.00 $275.58 $0.00 $0.00 $288.75 $0.00 $0.00 $0.00 $0.00 $0.00 245.461 SUP HCPCS C1713 245.461 - PLATE BONE 180MM 16 HOLE SHAFT CVD RECONSTRUCTION LCP BOTH IP/OP "$1,996.08 " "$1,477.10" $0.00 "$1,550.36" $872.08 $872.08 $0.00 $0.00 $0.00 $416.03 "$1,481.49" "$1,481.49" $0.00 $0.00 $415.98 $0.00 "$1,180.68" "$1,180.68" $0.00 $968.98 "$1,534.86" "$1,550.36" $0.00 $0.00 $294.45 $0.00 $0.00 $308.52 $0.00 $0.00 $0.00 $0.00 $0.00 245.481 SUP HCPCS C1713 245.481 - PLATE BONE 190MM 18 HOLE SHAFT CVD RECONSTRUCTION LCP BOTH IP/OP "$2,152.13 " "$1,592.58" $0.00 "$1,671.54" $940.24 $940.24 $0.00 $0.00 $0.00 $448.56 "$1,597.31" "$1,597.31" $0.00 $0.00 $448.50 $0.00 "$1,272.98" "$1,272.98" $0.00 "$1,044.71" "$1,654.83" "$1,671.54" $0.00 $0.00 $317.47 $0.00 $0.00 $332.64 $0.00 $0.00 $0.00 $0.00 $0.00 245.876 SUP HCPCS C1713 245.876 - PLATE BONE 108MM RAD 78MM 6 HOLE LP CVD RECONSTRUCTION BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 245.878 SUP HCPCS C1713 245.878 - PLATE BN 108MM RDS CRV 104X10.2X2.7MM NS 8 HL LOPRFL RECON BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 245.88 SUP HCPCS C1713 245.880 - PLATE BONE 108MM RAD CVD 130MM 8 HOLE LP RECONSTRUCTION BOTH IP/OP $926.68 $685.74 $0.00 $741.34 $417.00 $417.00 $0.00 $0.00 $0.00 $193.14 $687.78 $687.78 $0.00 $0.00 $193.12 $0.00 $548.13 $548.13 $0.00 $463.34 $733.93 $741.34 $0.00 $0.00 $140.80 $0.00 $0.00 $147.53 $0.00 $0.00 $0.00 $0.00 $0.00 245.882 SUP HCPCS C1713 245.882 - PLATE BN 108MM RDS CRV 156MMX10.2MMX2.7M NS 12 HL LOPRFL BOTH IP/OP "$1,030.38 " $762.48 $0.00 $800.28 $450.16 $450.16 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $500.18 $792.28 $800.28 $0.00 $0.00 $152.00 $0.00 $0.00 $159.26 $0.00 $0.00 $0.00 $0.00 $0.00 245.884 SUP HCPCS C1713 245.884 - PLATE BONE 108MM RAD 182MM 14 HOLE LP CVD RECONSTRUCTION BOTH IP/OP "$1,107.68 " $819.68 $0.00 $860.34 $483.94 $483.94 $0.00 $0.00 $0.00 $230.87 $822.12 $822.12 $0.00 $0.00 $230.84 $0.00 $655.19 $655.19 $0.00 $537.71 $851.74 $860.34 $0.00 $0.00 $163.40 $0.00 $0.00 $171.21 $0.00 $0.00 $0.00 $0.00 $0.00 245.886 SUP HCPCS C1713 245.886 - PLATE BONE 108MM RAD 208MM 16 HOLE LP CVD RECONSTRUCTION BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 245.906 SUP HCPCS C1713 245.906 - PLATE BONE 88MM RAD 78MM 6 HOLE LP CVD RECONSTRUCTION BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 245.908 SUP HCPCS C1713 245.908 - PLATE BN 88MM RDS CRV 104MMX10.2MMX2.7M NS 8 HL LOPRFL RECON BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 245.91 SUP HCPCS C1713 245.910 - PLATE BONE 88MM RAD LP CURVE 130MM 10 HOLE RECONSTRUCTION BOTH IP/OP $926.68 $685.74 $0.00 $741.34 $417.00 $417.00 $0.00 $0.00 $0.00 $193.14 $687.78 $687.78 $0.00 $0.00 $193.12 $0.00 $548.13 $548.13 $0.00 $463.34 $733.93 $741.34 $0.00 $0.00 $140.80 $0.00 $0.00 $147.53 $0.00 $0.00 $0.00 $0.00 $0.00 245.912 SUP HCPCS C1713 245.912 - PLATE BN 88MM RDS CRV 156MMX10.2MMX2.7M NS 12 HL LOPRFL BOTH IP/OP "$1,030.38 " $762.48 $0.00 $800.28 $450.16 $450.16 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $500.18 $792.28 $800.28 $0.00 $0.00 $152.00 $0.00 $0.00 $159.26 $0.00 $0.00 $0.00 $0.00 $0.00 245.914 SUP HCPCS C1713 245.914 - PLATE BONE 88MM RAD 182MM 14 HOLE LP CVD RECONSTRUCTION BOTH IP/OP "$1,107.68 " $819.68 $0.00 $860.34 $483.94 $483.94 $0.00 $0.00 $0.00 $230.87 $822.12 $822.12 $0.00 $0.00 $230.84 $0.00 $655.19 $655.19 $0.00 $537.71 $851.74 $860.34 $0.00 $0.00 $163.40 $0.00 $0.00 $171.21 $0.00 $0.00 $0.00 $0.00 $0.00 245.916 SUP HCPCS C1713 245.916 - PLATE BONE 88MM RAD 208MM 16 HOLE LP CVD RECONSTRUCTION BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 245.92 SUP HCPCS C1713 245.920 - PLATE BONE J RIGHT 130X10X3.4MM 3.5MM 10 HOLE RECONSTRUCTION BOTH IP/OP $926.68 $685.74 $0.00 $741.34 $417.00 $417.00 $0.00 $0.00 $0.00 $193.14 $687.78 $687.78 $0.00 $0.00 $193.12 $0.00 $548.13 $548.13 $0.00 $463.34 $733.93 $741.34 $0.00 $0.00 $140.80 $0.00 $0.00 $147.53 $0.00 $0.00 $0.00 $0.00 $0.00 245.922 SUP HCPCS C1713 245.922 - PLATE BONE 88MM RAD 156MM 12 HOLE J LP RECONSTRUCTION BOTH IP/OP "$1,030.38 " $762.48 $0.00 $800.28 $450.16 $450.16 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $500.18 $792.28 $800.28 $0.00 $0.00 $152.00 $0.00 $0.00 $159.26 $0.00 $0.00 $0.00 $0.00 $0.00 245.924 SUP HCPCS C1713 245.924 - PLATE BONE 88MM RAD 182MM 14 HOLE J LP RECONSTRUCTION BOTH IP/OP "$1,107.68 " $819.68 $0.00 $860.34 $483.94 $483.94 $0.00 $0.00 $0.00 $230.87 $822.12 $822.12 $0.00 $0.00 $230.84 $0.00 $655.19 $655.19 $0.00 $537.71 $851.74 $860.34 $0.00 $0.00 $163.40 $0.00 $0.00 $171.21 $0.00 $0.00 $0.00 $0.00 $0.00 245.926 SUP HCPCS C1713 245.926 - PLATE BN 88MM RDS J 208X10.2X2.7MM NS 16 HL LOPRFL RECON SS BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 245.93 SUP HCPCS C1713 245.930 - PLATE BONE 88MM RAD J 130X10.2X2.7MM 10 HOLE LP BOTH IP/OP $926.68 $685.74 $0.00 $741.34 $417.00 $417.00 $0.00 $0.00 $0.00 $193.14 $687.78 $687.78 $0.00 $0.00 $193.12 $0.00 $548.13 $548.13 $0.00 $463.34 $733.93 $741.34 $0.00 $0.00 $140.80 $0.00 $0.00 $147.53 $0.00 $0.00 $0.00 $0.00 $0.00 245.932 SUP HCPCS C1713 245.932 - PLATE BONE 88MM RAD 156MM 12 HOLE J LP RECONSTRUCTION BOTH IP/OP "$1,030.38 " $762.48 $0.00 $800.28 $450.16 $450.16 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $500.18 $792.28 $800.28 $0.00 $0.00 $152.00 $0.00 $0.00 $159.26 $0.00 $0.00 $0.00 $0.00 $0.00 245.934 SUP HCPCS C1713 245.934 - PLATE BONE 88MM RAD 182MM 14 HOLE J LP RECONSTRUCTION BOTH IP/OP "$1,107.68 " $819.68 $0.00 $860.34 $483.94 $483.94 $0.00 $0.00 $0.00 $230.87 $822.12 $822.12 $0.00 $0.00 $230.84 $0.00 $655.19 $655.19 $0.00 $537.71 $851.74 $860.34 $0.00 $0.00 $163.40 $0.00 $0.00 $171.21 $0.00 $0.00 $0.00 $0.00 $0.00 245.936 SUP HCPCS C1713 245.936 - PLATE BN 88MM RDS J 208X10.2X2.7MM NS 16 HL LOPRFL RECON SS BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 245.98 SUP HCPCS C1713 245.98 - PLATE BN 64X8X2.5MM NS 8 HL RECON SS CALC 2.7MM SCR BOTH IP/OP $664.90 $492.03 $0.00 $516.42 $290.49 $290.49 $0.00 $0.00 $0.00 $138.58 $493.49 $493.49 $0.00 $0.00 $138.57 $0.00 $393.29 $393.29 $0.00 $322.76 $511.26 $516.42 $0.00 $0.00 $98.08 $0.00 $0.00 $102.77 $0.00 $0.00 $0.00 $0.00 $0.00 245.99 SUP HCPCS C1713 245.99 - PLATE BN 72X8X2.5MM NS 9 HL RECON SS CALC 2.7MM SCR BOTH IP/OP $688.80 $509.71 $0.00 $534.98 $300.93 $300.93 $0.00 $0.00 $0.00 $143.56 $511.23 $511.23 $0.00 $0.00 $143.55 $0.00 $407.43 $407.43 $0.00 $334.36 $529.63 $534.98 $0.00 $0.00 $101.61 $0.00 $0.00 $106.46 $0.00 $0.00 $0.00 $0.00 $0.00 246.031 SUP HCPCS C1713 246.031 - PLATE BN STRG 29X3.8X.8MM NS PRO-PK 6 HL LOPRFL PRECONTOUR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 246.19 SUP HCPCS C1713 246.19 - PLATE BONE 100MM 20 HOLE STR DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $477.93 $353.67 $0.00 $371.22 $208.81 $208.81 $0.00 $0.00 $0.00 $99.61 $354.72 $354.72 $0.00 $0.00 $99.60 $0.00 $282.69 $282.69 $0.00 $232.01 $367.51 $371.22 $0.00 $0.00 $70.50 $0.00 $0.00 $73.87 $0.00 $0.00 $0.00 $0.00 $0.00 246.191 SUP HCPCS C1713 246.191 - PLATE BN STRG 59X3.8X.8MM NS PRO-PK 12 HL LOPRFL PRECONTOUR BOTH IP/OP $465.28 $344.31 $0.00 $361.38 $203.28 $203.28 $0.00 $0.00 $0.00 $96.97 $345.33 $345.33 $0.00 $0.00 $96.96 $0.00 $275.21 $275.21 $0.00 $225.86 $357.77 $361.38 $0.00 $0.00 $68.64 $0.00 $0.00 $71.91 $0.00 $0.00 $0.00 $0.00 $0.00 246.23 SUP HCPCS C1713 246.23 - PLATE BN T 50MM NS DCP 3 HLE/HD 9 HL SHFT SS 1.5MM SCR BOTH IP/OP $417.50 $308.95 $0.00 $324.26 $182.40 $182.40 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $202.66 $321.02 $324.26 $0.00 $0.00 $61.59 $0.00 $0.00 $64.53 $0.00 $0.00 $0.00 $0.00 $0.00 246.233 SUP HCPCS C1713 246.233 - PLATE BN T 44X4X1MM NS PRO-PK 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 246.234 SUP HCPCS C1713 246.234 - PLATE BN T 44X4X1MM NS PRO-PK 4 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 246.24 SUP HCPCS C1713 246.24 - PLATE BONE 50MM 4 HOLE HEAD 9 HOLE SHAFT T DCP STAINLESS BOTH IP/OP $449.83 $332.87 $0.00 $349.38 $196.53 $196.53 $0.00 $0.00 $0.00 $93.75 $333.86 $333.86 $0.00 $0.00 $93.74 $0.00 $266.07 $266.07 $0.00 $218.36 $345.89 $349.38 $0.00 $0.00 $66.36 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $0.00 246.48 SUP HCPCS C1713 246.48 - PLATE BONE 4 HOLE H LCP STAINLESS STEEL ORTHOPEDIC NONSTRL BOTH IP/OP $411.88 $304.79 $0.00 $319.90 $179.94 $179.94 $0.00 $0.00 $0.00 $85.85 $305.69 $305.69 $0.00 $0.00 $85.83 $0.00 $243.62 $243.62 $0.00 $199.94 $316.70 $319.90 $0.00 $0.00 $60.76 $0.00 $0.00 $63.66 $0.00 $0.00 $0.00 $0.00 $0.00 246.482 SUP HCPCS C1713 246.482 - PLATE BN H 22MM NS PRO-PK 8 HL XTD LOPRFL PRECONTOUR SS RT BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 246.483 SUP HCPCS C1713 246.483 - PLATE BN H 22MM NS PRO-PK 8 HL XTD LOPRFL PRECONTOUR SS LT BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 246.61 SUP HCPCS C1713 246.61 - PLATE BN 36X3.5X.9MM NS 7 HL SS CNDYL LT 1.5MM SCR MDLR HND BOTH IP/OP $529.95 $392.16 $0.00 $411.60 $231.53 $231.53 $0.00 $0.00 $0.00 $110.45 $393.33 $393.33 $0.00 $0.00 $110.44 $0.00 $313.47 $313.47 $0.00 $257.25 $407.48 $411.60 $0.00 $0.00 $78.18 $0.00 $0.00 $81.91 $0.00 $0.00 $0.00 $0.00 $0.00 246.612 SUP HCPCS C1713 246.612 - PLATE BN Y 46X4X1MM NS PRO-PK 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 246.62 SUP HCPCS C1713 246.62 - PLATE BN 36X3.5X.9MM NS 7 HL SS CNDYL RT 1.5MM SCR MDLR HND BOTH IP/OP $529.95 $392.16 $0.00 $411.60 $231.53 $231.53 $0.00 $0.00 $0.00 $110.45 $393.33 $393.33 $0.00 $0.00 $110.44 $0.00 $313.47 $313.47 $0.00 $257.25 $407.48 $411.60 $0.00 $0.00 $78.18 $0.00 $0.00 $81.91 $0.00 $0.00 $0.00 $0.00 $0.00 247.031 SUP HCPCS C1713 247.031 - PLATE BN STRG 35X5X1.2MM NS PRO-PK 6 HL LOPRFL PRECONTOUR BOTH IP/OP $404.85 $299.59 $0.00 $314.44 $176.87 $176.87 $0.00 $0.00 $0.00 $84.38 $300.48 $300.48 $0.00 $0.00 $84.37 $0.00 $239.47 $239.47 $0.00 $196.53 $311.30 $314.44 $0.00 $0.00 $59.72 $0.00 $0.00 $62.57 $0.00 $0.00 $0.00 $0.00 $0.00 247.232 SUP HCPCS C1713 247.232 - PLATE BN T 53X5X1.2MM NS PRO-PK 2 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 247.233 SUP HCPCS C1713 247.233 - PLATE BN T 53X5X1.2MM NS PRO-PK 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 247.344 SUP HCPCS C1713 247.344 - PLATE BN 31MM NS LCP PRO-PK 4 HL LOPRFL CUT TO LGTH SS 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 247.345 SUP HCPCS C1713 247.345 - PLATE BN 38MM NS LCP PRO-PK 5 HL LOPRFL CUT TO LGTH SS 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 247.346 SUP HCPCS C1713 247.346 - PLATE BN 45MM NS LCP PRO-PK 6 HL LOPRFL CUT TO LGTH SS 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 247.347 SUP HCPCS C1713 247.347 - PLATE BN 52MM NS LCP PRO-PK 7 HL LOPRFL CUT TO LGTH SS 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 247.348 SUP HCPCS C1713 247.348 - PLATE BN 59MM NS LCP PRO-PK 8 HL LOPRFL CUT TO LGTH SS 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 247.349 SUP HCPCS C1713 247.349 - PLATE BN 54MM NS LCP PRO-PK 7 HL SHFT LOPRFL CUT TO LGTH SS BOTH IP/OP "$1,446.45 " "$1,070.37" $0.00 "$1,123.46" $631.95 $631.95 $0.00 $0.00 $0.00 $301.48 "$1,073.56" "$1,073.56" $0.00 $0.00 $301.44 $0.00 $855.58 $855.58 $0.00 $702.16 "$1,112.23" "$1,123.46" $0.00 $0.00 $213.38 $0.00 $0.00 $223.57 $0.00 $0.00 $0.00 $0.00 $0.00 247.35 SUP HCPCS C1713 247.350 - PLATE BN Y 55MM NS LCP PRO-PK 3 HLE/HD 7 HL SHFT LOPRFL CUT BOTH IP/OP $788.83 $583.73 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $164.41 $585.47 $585.47 $0.00 $0.00 $164.39 $0.00 $466.59 $466.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 247.351 SUP HCPCS C1713 247.351 - PLATE BN T 53MM NS LCP PRO-PK 2 HLE/HD 7 HL SHFT LOPRFL CUT BOTH IP/OP $812.50 $601.25 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 247.36 SUP HCPCS C1713 247.360 - PLATE BN 73MM NS LCP PRO-PK 10 HL LOPRFL CUT TO LGTH SS 2MM BOTH IP/OP $446.28 $330.25 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $93.01 $331.23 $331.23 $0.00 $0.00 $93.00 $0.00 $263.97 $263.97 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 247.362 SUP HCPCS C1713 247.362 - PLATE BN 81MM NS LCP PRO-PK 12 HL ADP LOPRFL CUT TO LGTH SS BOTH IP/OP $777.35 $575.24 $0.00 $603.76 $339.62 $339.62 $0.00 $0.00 $0.00 $162.02 $576.95 $576.95 $0.00 $0.00 $162.00 $0.00 $459.80 $459.80 $0.00 $377.35 $597.72 $603.76 $0.00 $0.00 $114.67 $0.00 $0.00 $120.15 $0.00 $0.00 $0.00 $0.00 $0.00 247.364 SUP HCPCS C1713 247.364 - PLATE BN 84MM NS LCP PRO-PK 10 HL LOPRFL CUT TO LGTH SS 2.4 BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 247.366 SUP HCPCS C1713 247.366 - PLATE BN 88MM NS LCP PRO-PK 12 HL ADP LOPRFL CUT TO LGTH SS BOTH IP/OP $856.08 $633.50 $0.00 $664.90 $374.01 $374.01 $0.00 $0.00 $0.00 $178.43 $635.38 $635.38 $0.00 $0.00 $178.41 $0.00 $506.37 $506.37 $0.00 $415.56 $658.25 $664.90 $0.00 $0.00 $126.28 $0.00 $0.00 $132.32 $0.00 $0.00 $0.00 $0.00 $0.00 247.37 SUP HCPCS C1713 247.370 - PLATE BN 97MM NS LCP PRO-PK 12 HL ADP LOPRFL CUT TO LGTH SS BOTH IP/OP $831.13 $615.04 $0.00 $664.90 $374.01 $374.01 $0.00 $0.00 $0.00 $173.23 $616.86 $616.86 $0.00 $0.00 $173.21 $0.00 $491.61 $491.61 $0.00 $415.56 $658.25 $664.90 $0.00 $0.00 $166.74 $0.00 $0.00 $132.32 $0.00 $0.00 $0.00 $0.00 $0.00 247.372 SUP HCPCS C1713 247.372 - PLATE BN 76MM NS LCP PRO-PK 8 HL LOPRFL CUT TO LGTH SS 2.7MM BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $150.97 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 247.374 SUP HCPCS C1713 247.374 - PLATE BN 94MM NS LCP PRO-PK 10 HL LOPRFL CUT TO LGTH SS 2.7 BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 247.375 SUP HCPCS C1713 247.375 - PLATE BN 44MM NS LCP PRO-PK 5 HL LOPRFL CUT TO LGTH SS 2.4MM BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 247.377 SUP HCPCS C1713 247.377 - PLATE BN 60MM NS LCP PRO-PK 7 HL LOPRFL CUT TO LGTH SS 2.4MM BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 247.612 SUP HCPCS C1713 247.612 - PLATE BN Y 48X5X1.2MM NS PRO-PK 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 247.615 SUP HCPCS C1713 247.615 - PLATE BN T 53MM NS LCP PRO-PK 3 HLE/HD 7 HL SHFT LOPRFL CUT BOTH IP/OP $812.50 $601.25 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 247.702 SUP HCPCS C1713 247.702 - PLATE BONE X SMALL 24X18MM LOCK STAINLESS STEEL ANKLE FT BOTH IP/OP "$1,439.43 " "$1,065.18" $0.00 "$1,118.00" $628.88 $628.88 $0.00 $0.00 $0.00 $300.01 "$1,068.34" "$1,068.34" $0.00 $0.00 $299.98 $0.00 $851.42 $851.42 $0.00 $698.75 "$1,106.82" "$1,118.00" $0.00 $0.00 $212.34 $0.00 $0.00 $222.48 $0.00 $0.00 $0.00 $0.00 $0.00 247.704 SUP HCPCS C1713 247.704 - PLATE BN MED X 30X20MM NS LCK RND THRD HL SS FT/ANKL 2.4/2.7 BOTH IP/OP "$1,457.70 " "$1,078.70" $0.00 "$1,132.20" $636.86 $636.86 $0.00 $0.00 $0.00 $303.82 "$1,081.90" "$1,081.90" $0.00 $0.00 $303.78 $0.00 $862.23 $862.23 $0.00 $707.63 "$1,120.88" "$1,132.20" $0.00 $0.00 $215.03 $0.00 $0.00 $225.31 $0.00 $0.00 $0.00 $0.00 $0.00 247.706 SUP HCPCS C1713 247.706 - PLATE BONE LARGE 36MM LOCK STAINLESS STEEL ORTHOPEDIC BOTH IP/OP "$1,477.38 " "$1,093.26" $0.00 "$1,147.48" $645.46 $645.46 $0.00 $0.00 $0.00 $307.92 "$1,096.51" "$1,096.51" $0.00 $0.00 $307.88 $0.00 $873.87 $873.87 $0.00 $717.18 "$1,136.01" "$1,147.48" $0.00 $0.00 $217.94 $0.00 $0.00 $228.35 $0.00 $0.00 $0.00 $0.00 $0.00 247.71 SUP HCPCS C1713 247.710 - PLATE BONE 18MM 2 HOLE LOCKING STAINLESS STEEL ANKLE FT BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $306.45 $306.45 $0.00 $0.00 $0.00 $141.94 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $402.81 $402.81 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $103.47 $0.00 $0.00 $108.42 $0.00 $0.00 $0.00 $0.00 $0.00 247.711 SUP HCPCS C1713 247.711 - PLATE BONE XS 2.4MM 4MM BOTH IP/OP "$1,460.53 " "$1,080.79" $0.00 "$1,134.38" $638.09 $638.09 $0.00 $0.00 $0.00 $304.41 "$1,084.00" "$1,084.00" $0.00 $0.00 $304.37 $0.00 $863.90 $863.90 $0.00 $708.99 "$1,123.04" "$1,134.38" $0.00 $0.00 $215.45 $0.00 $0.00 $225.74 $0.00 $0.00 $0.00 $0.00 $0.00 248.02 SUP HCPCS C1713 248.02 - PLATE BONE 25MM 2 HOLE DCP STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $238.83 $176.73 $0.00 $191.06 $107.47 $107.47 $0.00 $0.00 $0.00 $49.78 $177.26 $177.26 $0.00 $0.00 $49.77 $0.00 $141.26 $141.26 $0.00 $119.41 $189.15 $191.06 $0.00 $0.00 $36.29 $0.00 $0.00 $38.02 $0.00 $0.00 $0.00 $0.00 $0.00 248.03 SUP HCPCS C1713 248.03 - PLATE BONE 3.5MM 37X10X3.3MM 3 HOLE DCP STAINLESS STEEL BOTH IP/OP $245.65 $181.78 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $51.20 $182.32 $182.32 $0.00 $0.00 $51.19 $0.00 $145.30 $145.30 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 248.04 SUP HCPCS C1713 248.04 - PLATE BN 49X10X3.3MM NS DCP 4 HL SS PLV 3.5MM CORT SCR SM BOTH IP/OP $261.45 $193.47 $0.00 $203.08 $114.23 $114.23 $0.00 $0.00 $0.00 $54.49 $194.05 $194.05 $0.00 $0.00 $54.49 $0.00 $154.65 $154.65 $0.00 $126.93 $201.05 $203.08 $0.00 $0.00 $38.57 $0.00 $0.00 $40.41 $0.00 $0.00 $0.00 $0.00 $0.00 248.05 SUP HCPCS C1713 248.05 - PLATE BONE 61X10X3.3MM 5 HOLE DCP STAINLESS STEEL PELVIS BOTH IP/OP $272.95 $201.98 $0.00 $218.36 $122.83 $122.83 $0.00 $0.00 $0.00 $56.89 $202.58 $202.58 $0.00 $0.00 $56.88 $0.00 $161.45 $161.45 $0.00 $136.48 $216.18 $218.36 $0.00 $0.00 $41.47 $0.00 $0.00 $43.45 $0.00 $0.00 $0.00 $0.00 $0.00 248.06 SUP HCPCS C1713 248.06 - PLATE BN 73X10X3.3MM NS DCP 6 HL SS PLV 3.5MM CORT SCR SM BOTH IP/OP $292.38 $216.36 $0.00 $227.10 $127.74 $127.74 $0.00 $0.00 $0.00 $60.94 $217.00 $217.00 $0.00 $0.00 $60.93 $0.00 $172.94 $172.94 $0.00 $141.94 $224.83 $227.10 $0.00 $0.00 $43.13 $0.00 $0.00 $45.19 $0.00 $0.00 $0.00 $0.00 $0.00 248.07 SUP HCPCS C1713 248.07 - PLATE BONE 85X10X3.3MM 7 HOLE DCP STAINLESS STEEL PELVIS BOTH IP/OP $303.63 $224.69 $0.00 $235.82 $132.65 $132.65 $0.00 $0.00 $0.00 $63.28 $225.35 $225.35 $0.00 $0.00 $63.28 $0.00 $179.59 $179.59 $0.00 $147.39 $233.47 $235.82 $0.00 $0.00 $44.79 $0.00 $0.00 $46.93 $0.00 $0.00 $0.00 $0.00 $0.00 248.08 SUP HCPCS C1713 248.08 - PLATE BN 97X10X3.3MM NS DCP 8 HL SS PLV 3.5MM CORT SCR SM BOTH IP/OP $316.28 $234.05 $0.00 $245.66 $138.18 $138.18 $0.00 $0.00 $0.00 $65.92 $234.74 $234.74 $0.00 $0.00 $65.91 $0.00 $187.08 $187.08 $0.00 $153.54 $243.21 $245.66 $0.00 $0.00 $46.66 $0.00 $0.00 $48.89 $0.00 $0.00 $0.00 $0.00 $0.00 248.09 SUP HCPCS C1713 248.09 - PLATE BN 109X10X3.3MM NS DCP 9 HL SS PLV 3.5MM CORT SCR SM BOTH IP/OP $335.95 $248.60 $0.00 $260.94 $146.78 $146.78 $0.00 $0.00 $0.00 $70.02 $249.34 $249.34 $0.00 $0.00 $70.01 $0.00 $198.71 $198.71 $0.00 $163.09 $258.33 $260.94 $0.00 $0.00 $49.56 $0.00 $0.00 $51.93 $0.00 $0.00 $0.00 $0.00 $0.00 248.1 SUP HCPCS C1713 248.10 - PLATE BONE 121X10X3.3MM 10 HOLE DCP STAINLESS STEEL PELVIS BOTH IP/OP $328.90 $243.39 $0.00 $263.12 $148.01 $148.01 $0.00 $0.00 $0.00 $68.55 $244.11 $244.11 $0.00 $0.00 $68.54 $0.00 $194.54 $194.54 $0.00 $164.45 $260.49 $263.12 $0.00 $0.00 $49.97 $0.00 $0.00 $52.36 $0.00 $0.00 $0.00 $0.00 $0.00 248.12 SUP HCPCS C1713 248.12 - PLATE BONE 145X10X3.3MM 12 HOLE DCP STAINLESS STEEL PELVIS BOTH IP/OP $393.60 $291.26 $0.00 $305.70 $171.96 $171.96 $0.00 $0.00 $0.00 $82.04 $292.13 $292.13 $0.00 $0.00 $82.03 $0.00 $232.81 $232.81 $0.00 $191.06 $302.65 $305.70 $0.00 $0.00 $58.06 $0.00 $0.00 $60.83 $0.00 $0.00 $0.00 $0.00 $0.00 248.14 SUP HCPCS C1713 248.14 - PLATE BONE 169X10X3.3MM 14 HOLE DCP STAINLESS STEEL PELVIS BOTH IP/OP $723.93 $535.71 $0.00 $562.28 $316.28 $316.28 $0.00 $0.00 $0.00 $150.88 $537.30 $537.30 $0.00 $0.00 $150.87 $0.00 $428.20 $428.20 $0.00 $351.43 $556.66 $562.28 $0.00 $0.00 $106.79 $0.00 $0.00 $111.89 $0.00 $0.00 $0.00 $0.00 $0.00 248.16 SUP HCPCS C1713 248.16 - PLATE BONE 194X10X3.3MM 16 HOLE DCP STAINLESS STEEL PELVIS BOTH IP/OP $833.58 $616.85 $0.00 $647.44 $364.19 $364.19 $0.00 $0.00 $0.00 $173.74 $618.68 $618.68 $0.00 $0.00 $173.72 $0.00 $493.06 $493.06 $0.00 $404.65 $640.97 $647.44 $0.00 $0.00 $122.97 $0.00 $0.00 $128.84 $0.00 $0.00 $0.00 $0.00 $0.00 248.18 SUP HCPCS C1713 248.18 - PLATE BONE 217X10X3.3MM 18 HOLE DCP STAINLESS STEEL PELVIS BOTH IP/OP $933.38 $690.70 $0.00 $724.96 $407.79 $407.79 $0.00 $0.00 $0.00 $194.54 $692.75 $692.75 $0.00 $0.00 $194.52 $0.00 $552.09 $552.09 $0.00 $453.10 $717.71 $724.96 $0.00 $0.00 $137.69 $0.00 $0.00 $144.27 $0.00 $0.00 $0.00 $0.00 $0.00 248.2 SUP HCPCS C1713 248.20 - PLATE BONE 3.5MM 242X10X3.3MM 20 HOLE DCP STAINLESS STEEL BOTH IP/OP $999.00 $739.26 $0.00 $799.20 $449.55 $449.55 $0.00 $0.00 $0.00 $208.22 $741.46 $741.46 $0.00 $0.00 $208.19 $0.00 $590.91 $590.91 $0.00 $499.50 $791.21 $799.20 $0.00 $0.00 $151.79 $0.00 $0.00 $159.04 $0.00 $0.00 $0.00 $0.00 $0.00 248.22 SUP HCPCS C1713 248.22 - PLATE BONE 3.5MM 265X10X3.3MM 22 HOLE DCP STAINLESS STEEL BOTH IP/OP "$1,090.43 " $806.92 $0.00 $872.34 $490.69 $490.69 $0.00 $0.00 $0.00 $227.27 $809.31 $809.31 $0.00 $0.00 $227.24 $0.00 $644.99 $644.99 $0.00 $545.21 $863.62 $872.34 $0.00 $0.00 $165.68 $0.00 $0.00 $173.60 $0.00 $0.00 $0.00 $0.00 $0.00 249.615 SUP HCPCS C1713 249.615 - PLATE BONE T 58MM 7X3 HOLE LCP STAINLESS STEEL SMALL BONE BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 249.669 SUP HCPCS C1713 249.669 - PLATE BONE Y 60MM 3X7 HOLE LCP STAINLESS STEEL ANKLE FT BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 249.67 SUP HCPCS C1713 249.670 - PLATE BONE T 58MM 2X7 HOLE LCP STAINLESS STEEL ANKLE FT BOTH IP/OP "$1,311.53 " $970.53 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $273.35 $973.41 $973.41 $0.00 $0.00 $273.32 $0.00 $775.77 $775.77 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 249.674 SUP HCPCS C1713 249.674 - PLATE BONE 36MM 4 HOLE LCP STAINLESS STEEL ANKLE FT NONSTRL BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 249.676 SUP HCPCS C1713 249.676 - PLATE BONE 52MM 6 HOLE LP LCP STAINLESS STEEL SMALL BONE BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 249.678 SUP HCPCS C1713 249.678 - PLATE BONE 68MM 8 HOLE LCP STAINLESS STEEL SMALL BONE BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 249.679 SUP HCPCS C1713 249.679 - PLATE BONE 59MM 7 SHAFT HOLE LCP STAINLESS STEEL CONDYLE BOTH IP/OP "$1,103.48 " $816.58 $0.00 $857.06 $482.10 $482.10 $0.00 $0.00 $0.00 $229.99 $819.00 $819.00 $0.00 $0.00 $229.96 $0.00 $652.71 $652.71 $0.00 $535.66 $848.49 $857.06 $0.00 $0.00 $162.78 $0.00 $0.00 $170.55 $0.00 $0.00 $0.00 $0.00 $0.00 249.68 SUP HCPCS C1713 249.680 - PLATE BN 40MM NS LCP 4 HL LOPRFL CUT TO LGTH SS 2.7MM SCR BOTH IP/OP $753.35 $557.48 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $157.02 $559.14 $559.14 $0.00 $0.00 $157.00 $0.00 $445.61 $445.61 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 249.681 SUP HCPCS C1713 249.681 - PLATE BONE 49MM 5 HOLE LCP STAINLESS STEEL ANKLE FT NONSTRL BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 249.682 SUP HCPCS C1713 249.682 - PLATE BONE LP 58MM 6 HOLE CUT TO LENGTH LCP STAINLESS STEEL BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 249.683 SUP HCPCS C1713 249.683 - PLATE BONE 6.7CM 7 HOLE LCP STAINLESS STEEL SMALL BONE BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 249.684 SUP HCPCS C1713 249.684 - PLATE BONE 66MM 7 HOLE LCP STAINLESS STEEL CONDYLE NONSTRL BOTH IP/OP "$1,203.28 " $890.43 $0.00 $934.58 $525.70 $525.70 $0.00 $0.00 $0.00 $250.79 $893.07 $893.07 $0.00 $0.00 $250.76 $0.00 $711.74 $711.74 $0.00 $584.11 $925.24 $934.58 $0.00 $0.00 $177.50 $0.00 $0.00 $185.98 $0.00 $0.00 $0.00 $0.00 $0.00 249.685 SUP HCPCS C1713 249.685 - PLATE BONE T 32MM 2X3 HOLE LCP STAINLESS STEEL ANKLE FT BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 249.686 SUP HCPCS C1713 249.686 - PLATE BN OB R L 35MM NS LCP 2 HLE/HD 3 HL SHFT LOPRFL CUT TO BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 249.687 SUP HCPCS C1713 249.687 - PLATE BN OB L L 35MM NS LCP 2 HLE/HD 3 HL SHFT LOPRFL CUT TO BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $143.84 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 249.688 SUP HCPCS C1713 249.688 - PLATE BONE L 32MM 2X3 HOLE RIGHT OBLIQUE LCP STAINLESS STEEL BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 249.689 SUP HCPCS C1713 249.689 - PLATE BN L 32MM NS LCP 2 HLE/HD 3 HL SHFT LOPRFL CUT TO LGTH BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 249.69 SUP HCPCS C1713 249.690 - PLATE BONE 31MM 5 HOLE LOCKING HIND MIDFT NONSTRL 2.4-2.7MM BOTH IP/OP "$1,454.83 " "$1,076.57" $0.00 "$1,163.86" $654.67 $654.67 $0.00 $0.00 $0.00 $303.22 "$1,079.77" "$1,079.77" $0.00 $0.00 $303.19 $0.00 $860.53 $860.53 $0.00 $727.41 "$1,152.23" "$1,163.86" $0.00 $0.00 $221.05 $0.00 $0.00 $231.61 $0.00 $0.00 $0.00 $0.00 $0.00 249.691 SUP HCPCS C1713 249.691 - PLATE BN 45MM NS 8 HL LCK SS HND/MDFT 2.4/2.7MM SCR BOTH IP/OP "$1,529.40 " "$1,131.76" $0.00 "$1,187.88" $668.18 $668.18 $0.00 $0.00 $0.00 $318.77 "$1,135.12" "$1,135.12" $0.00 $0.00 $318.73 $0.00 $904.64 $904.64 $0.00 $742.43 "$1,176.00" "$1,187.88" $0.00 $0.00 $225.61 $0.00 $0.00 $236.39 $0.00 $0.00 $0.00 $0.00 $0.00 249.697 SUP HCPCS C1713 249.697 - PLATE BONE 32MM 2X4 HOLE T LCP STAINLESS STEEL CONDYLE BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 249.698 SUP HCPCS C1713 249.698 - PLATE BONE 42MM 2 HOLE HEAD 4 HOLE SHAFT L RIGHT OBLIQUE LCP BOTH IP/OP $745.03 $551.32 $0.00 $578.66 $325.50 $325.50 $0.00 $0.00 $0.00 $155.28 $552.96 $552.96 $0.00 $0.00 $155.26 $0.00 $440.68 $440.68 $0.00 $361.66 $572.88 $578.66 $0.00 $0.00 $109.90 $0.00 $0.00 $115.15 $0.00 $0.00 $0.00 $0.00 $0.00 249.699 SUP HCPCS C1713 249.699 - PLATE BONE T 42MM 2 HOLE HEAD 4 HOLE SHAFT LEFT OBLIQUE LCP BOTH IP/OP $745.03 $551.32 $0.00 $578.66 $325.50 $325.50 $0.00 $0.00 $0.00 $155.28 $552.96 $552.96 $0.00 $0.00 $155.26 $0.00 $440.68 $440.68 $0.00 $361.66 $572.88 $578.66 $0.00 $0.00 $109.90 $0.00 $0.00 $115.15 $0.00 $0.00 $0.00 $0.00 $0.00 249.701 SUP HCPCS C1713 249.701 - PLATE BONE 40MM 2 HOLE HEAD 4 HOLE SHAFT L LCP STAINLESS BOTH IP/OP $745.03 $551.32 $0.00 $578.66 $325.50 $325.50 $0.00 $0.00 $0.00 $155.28 $552.96 $552.96 $0.00 $0.00 $155.26 $0.00 $440.68 $440.68 $0.00 $361.66 $572.88 $578.66 $0.00 $0.00 $109.90 $0.00 $0.00 $115.15 $0.00 $0.00 $0.00 $0.00 $0.00 249.702 SUP HCPCS C1713 249.702 - PLATE BONE L 40MM 2X4 HOLE LCP STAINLESS STEEL LEFT SMALL BOTH IP/OP $745.03 $551.32 $0.00 $578.66 $325.50 $325.50 $0.00 $0.00 $0.00 $155.28 $552.96 $552.96 $0.00 $0.00 $155.26 $0.00 $440.68 $440.68 $0.00 $361.66 $572.88 $578.66 $0.00 $0.00 $109.90 $0.00 $0.00 $115.15 $0.00 $0.00 $0.00 $0.00 $0.00 249.906 SUP HCPCS C1713 249.906 - PLATE BN STRG 36X6.3X1.25MM NS 6 HL LOPRFL PRECONTOUR CUT TO BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 249.912 SUP HCPCS C1713 249.912 - PLATE BN STRG 72X6.3X1.25MM NS 12 HL LOPRFL PRECONTOUR CUT BOTH IP/OP $522.93 $386.97 $0.00 $406.14 $228.45 $228.45 $0.00 $0.00 $0.00 $108.99 $388.11 $388.11 $0.00 $0.00 $108.98 $0.00 $309.31 $309.31 $0.00 $253.84 $402.08 $406.14 $0.00 $0.00 $77.14 $0.00 $0.00 $80.82 $0.00 $0.00 $0.00 $0.00 $0.00 249.913 SUP HCPCS C1713 249.913 - PLATE BN T 54X6.3X1.25MM NS 2 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 249.914 SUP HCPCS C1713 249.914 - PLATE BN T 54X6.3X1.25MM NS 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $517.30 $382.80 $0.00 $401.78 $226.00 $226.00 $0.00 $0.00 $0.00 $107.82 $383.94 $383.94 $0.00 $0.00 $107.81 $0.00 $305.98 $305.98 $0.00 $251.11 $397.77 $401.78 $0.00 $0.00 $76.31 $0.00 $0.00 $79.95 $0.00 $0.00 $0.00 $0.00 $0.00 249.915 SUP HCPCS C1713 249.915 - PLATE BN Y 56X6.3X1.25MM NS 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $514.48 $380.72 $0.00 $399.60 $224.78 $224.78 $0.00 $0.00 $0.00 $107.23 $381.84 $381.84 $0.00 $0.00 $107.22 $0.00 $304.31 $304.31 $0.00 $249.75 $395.60 $399.60 $0.00 $0.00 $75.89 $0.00 $0.00 $79.52 $0.00 $0.00 $0.00 $0.00 $0.00 249.916 SUP HCPCS C1713 249.916 - PLATE BN 57X6.3X1.25MM NS 8 HL LOPRFL PRECONTOUR CUT TO LGTH BOTH IP/OP $515.90 $381.77 $0.00 $400.70 $225.39 $225.39 $0.00 $0.00 $0.00 $107.53 $382.90 $382.90 $0.00 $0.00 $107.51 $0.00 $305.15 $305.15 $0.00 $250.44 $396.70 $400.70 $0.00 $0.00 $76.10 $0.00 $0.00 $79.74 $0.00 $0.00 $0.00 $0.00 $0.00 249.917 SUP HCPCS C1713 249.917 - PLATE BN 57X6.3X1.25MM NS 8 HL LOPRFL PRECONTOUR CUT TO LGTH BOTH IP/OP $515.90 $381.77 $0.00 $400.70 $225.39 $225.39 $0.00 $0.00 $0.00 $107.53 $382.90 $382.90 $0.00 $0.00 $107.51 $0.00 $305.15 $305.15 $0.00 $250.44 $396.70 $400.70 $0.00 $0.00 $76.10 $0.00 $0.00 $79.74 $0.00 $0.00 $0.00 $0.00 $0.00 249.919 SUP HCPCS C1713 249.919 - PLATE BN T 66MM NS 3 HLE/HD 10 HL SHFT LOPRFL CUT TO LGTH SS BOTH IP/OP $472.33 $349.52 $0.00 $366.84 $206.35 $206.35 $0.00 $0.00 $0.00 $98.44 $350.56 $350.56 $0.00 $0.00 $98.43 $0.00 $279.38 $279.38 $0.00 $229.28 $363.17 $366.84 $0.00 $0.00 $69.67 $0.00 $0.00 $73.00 $0.00 $0.00 $0.00 $0.00 $0.00 249.921 SUP HCPCS C1713 249.921 - PLATE BN NS LOPRFL CUT TO LGTH SS CUBOID 2.4 MM SCR MODFT BOTH IP/OP $688.80 $509.71 $0.00 $534.98 $300.93 $300.93 $0.00 $0.00 $0.00 $143.56 $511.23 $511.23 $0.00 $0.00 $143.55 $0.00 $407.43 $407.43 $0.00 $334.36 $529.63 $534.98 $0.00 $0.00 $101.61 $0.00 $0.00 $106.46 $0.00 $0.00 $0.00 $0.00 $0.00 249.924 SUP HCPCS C1713 249.924 - PLATE BN 31X6.5X1.6MM NS LC DCP 4 HL LOPRFL PRECONTOUR CUT BOTH IP/OP $548.23 $405.69 $0.00 $425.80 $239.51 $239.51 $0.00 $0.00 $0.00 $114.26 $406.89 $406.89 $0.00 $0.00 $114.25 $0.00 $324.28 $324.28 $0.00 $266.13 $421.54 $425.80 $0.00 $0.00 $80.87 $0.00 $0.00 $84.73 $0.00 $0.00 $0.00 $0.00 $0.00 249.926 SUP HCPCS C1713 249.926 - PLATE BN 47X6.5X1.6MM NS LC DCP 6 HL LOPRFL PRECONTOUR CUT BOTH IP/OP $618.50 $457.69 $0.00 $480.40 $270.23 $270.23 $0.00 $0.00 $0.00 $128.91 $459.05 $459.05 $0.00 $0.00 $128.90 $0.00 $365.84 $365.84 $0.00 $300.25 $475.60 $480.40 $0.00 $0.00 $91.24 $0.00 $0.00 $95.60 $0.00 $0.00 $0.00 $0.00 $0.00 249.928 SUP HCPCS C1713 249.928 - PLATE BN 63X6.5X1.6MM NS LC DCP 8 HL LOPRFL PRECONTOUR CUT BOTH IP/OP $667.70 $494.10 $0.00 $518.60 $291.71 $291.71 $0.00 $0.00 $0.00 $139.17 $495.57 $495.57 $0.00 $0.00 $139.15 $0.00 $394.94 $394.94 $0.00 $324.13 $513.41 $518.60 $0.00 $0.00 $98.50 $0.00 $0.00 $103.20 $0.00 $0.00 $0.00 $0.00 $0.00 254.862 SUP Custom 27803010 "254.862 - SS ROD TO ROD CLAMP, 5.5MM TO 6.5MM" BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $0.00 $0.00 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 254.864 SUP Custom 27803010 "254.864 - SS ROD TO ROD CLAMP, 5.5MM TO 6.5MM, WIDE" BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $0.00 $0.00 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 254.866 SUP Custom 27803010 "254.866 - SS PARALLEL CONNECTOR CLAMP, 6.5MM TO 6.5MM" BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $0.00 $0.00 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 254.868 SUP Custom 27803010 "254.868 - SS PARALLEL CONNECTOR CLAMP, 6.5MM TO 6.5MM WIDE" BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $0.00 $0.00 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 260.06 SUP HCPCS C1713 260.060 - PLATE 80MM SS 4.5MM SCR 10 HOLE RECON BONE STRNL NONSTRL BOTH IP/OP "$2,682.50 " "$1,985.05" $0.00 "$2,146.00" "$1,207.13" "$1,207.13" $0.00 $0.00 $0.00 $559.10 "$1,990.95" "$1,990.95" $0.00 $0.00 $559.03 $0.00 "$1,322.47" "$1,322.47" $0.00 "$1,341.25" "$2,124.54" "$2,146.00" $0.00 $0.00 $419.81 $0.00 $0.00 $427.05 $0.00 $0.00 $0.00 $0.00 $0.00 260.062 SUP HCPCS C1713 260.062 - PLATE 96MM SS 4.5MM SCR 12 HOLE RECON BONE STRNL NONSTRL BOTH IP/OP "$2,760.00 " "$2,042.40" $0.00 "$2,208.00" "$1,242.00" "$1,242.00" $0.00 $0.00 $0.00 $575.25 "$2,048.47" "$2,048.47" $0.00 $0.00 $575.18 $0.00 "$1,360.68" "$1,360.68" $0.00 "$1,380.00" "$2,185.92" "$2,208.00" $0.00 $0.00 $431.94 $0.00 $0.00 $439.39 $0.00 $0.00 $0.00 $0.00 $0.00 260.064 SUP HCPCS C1713 260.064 - PLATE 112MM SS 4.5MM SCR 14 HOLE RECON BONE STRNL NONSTRL BOTH IP/OP "$2,835.00 " "$2,097.90" $0.00 "$2,268.00" "$1,275.75" "$1,275.75" $0.00 $0.00 $0.00 $590.88 "$2,104.14" "$2,104.14" $0.00 $0.00 $590.81 $0.00 "$1,397.66" "$1,397.66" $0.00 "$1,417.50" "$2,245.32" "$2,268.00" $0.00 $0.00 $443.68 $0.00 $0.00 $451.33 $0.00 $0.00 $0.00 $0.00 $0.00 260.066 SUP HCPCS C1713 260.066 - PLATE 128MM SS 4.5MM SCR 16 HOLE RECON BONE STRNL NONSTRL BOTH IP/OP "$2,912.50 " "$2,155.25" $0.00 "$2,330.00" "$1,310.63" "$1,310.63" $0.00 $0.00 $0.00 $607.04 "$2,161.66" "$2,161.66" $0.00 $0.00 $606.97 $0.00 "$1,435.86" "$1,435.86" $0.00 "$1,456.25" "$2,306.70" "$2,330.00" $0.00 $0.00 $455.81 $0.00 $0.00 $463.67 $0.00 $0.00 $0.00 $0.00 $0.00 260.068 SUP HCPCS C1713 260.068 - PLATE 144MM SS 4.5MM SCR 18 HOLE RECON BONE STRNL NONSTRL BOTH IP/OP "$2,990.00 " "$2,212.60" $0.00 "$2,392.00" "$1,345.50" "$1,345.50" $0.00 $0.00 $0.00 $623.19 "$2,219.18" "$2,219.18" $0.00 $0.00 $623.12 $0.00 "$1,474.07" "$1,474.07" $0.00 "$1,495.00" "$2,368.08" "$2,392.00" $0.00 $0.00 $467.94 $0.00 $0.00 $476.01 $0.00 $0.00 $0.00 $0.00 $0.00 260.07 SUP HCPCS C1713 260.070 - PLATE 160MM SS 4.5MM SCR 20 HOLE RECON BONE STRNL NONSTRL BOTH IP/OP "$3,067.50 " "$2,269.95" $0.00 "$2,454.00" "$1,380.38" "$1,380.38" $0.00 $0.00 $0.00 $639.34 "$2,276.70" "$2,276.70" $0.00 $0.00 $639.27 $0.00 "$1,512.28" "$1,512.28" $0.00 "$1,533.75" "$2,429.46" "$2,454.00" $0.00 $0.00 $480.06 $0.00 $0.00 $488.35 $0.00 $0.00 $0.00 $0.00 $0.00 260.072 SUP HCPCS C1713 260.072 - PLATE 176MM SS 4.5MM SCR 22 HOLE RECON BONE STRNL NONSTRL BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 260.074 SUP HCPCS C1713 260.074 - PLATE 192MM SS 4.5MM SCR 24 HOLE RECON BONE STRNL NONSTRL BOTH IP/OP "$3,217.50 " "$2,380.95" $0.00 "$2,574.00" "$1,447.88" "$1,447.88" $0.00 $0.00 $0.00 $670.61 "$2,388.03" "$2,388.03" $0.00 $0.00 $670.53 $0.00 "$1,586.23" "$1,586.23" $0.00 "$1,608.75" "$2,548.26" "$2,574.00" $0.00 $0.00 $503.54 $0.00 $0.00 $512.23 $0.00 $0.00 $0.00 $0.00 $0.00 275.9 SUP Custom 27803010 275.900 - CAP END 3-4MM STAINLESS STEEL ORTHOPEDIC ELSTIC NAIL BOTH IP/OP $151.48 $112.10 $0.00 $121.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.42 $112.42 $0.00 $0.00 $31.57 $0.00 $0.00 $0.00 $0.00 $75.74 $119.97 $121.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 275.905 SUP Custom 27803010 275.905 - CAP END STAINLESS STEEL NONSTRL 1.5-2.5 MM ELAST NAIL BOTH IP/OP $156.03 $115.46 $0.00 $121.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.80 $115.80 $0.00 $0.00 $32.52 $0.00 $0.00 $0.00 $0.00 $75.74 $119.97 $121.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 275.915 SUP HCPCS C1713 275.915 - NAIL INTRAMEDULLARY 1.5MM 300MM ELAST STAINLESS STEEL BOTH IP/OP $493.40 $365.12 $0.00 $383.22 $215.56 $215.56 $0.00 $0.00 $0.00 $102.84 $366.20 $366.20 $0.00 $0.00 $102.82 $0.00 $291.85 $291.85 $0.00 $239.51 $379.39 $383.22 $0.00 $0.00 $72.78 $0.00 $0.00 $76.26 $0.00 $0.00 $0.00 $0.00 $0.00 275.92 SUP HCPCS C1713 275.920 - NAIL INTRAMEDULLARY 2MM 440MM ELAST STAINLESS STEEL BOTH IP/OP $513.15 $379.73 $0.00 $410.52 $230.92 $230.92 $0.00 $0.00 $0.00 $106.95 $380.86 $380.86 $0.00 $0.00 $106.94 $0.00 $303.53 $303.53 $0.00 $256.58 $406.41 $410.52 $0.00 $0.00 $77.97 $0.00 $0.00 $81.69 $0.00 $0.00 $0.00 $0.00 $0.00 275.925 SUP HCPCS C1713 275.925 - NAIL INTRAMEDULLARY 2.5MM 440MM ELAST STAINLESS STEEL BOTH IP/OP $567.90 $420.25 $0.00 $441.08 $248.11 $248.11 $0.00 $0.00 $0.00 $118.36 $421.50 $421.50 $0.00 $0.00 $118.35 $0.00 $335.91 $335.91 $0.00 $275.68 $436.67 $441.08 $0.00 $0.00 $83.77 $0.00 $0.00 $87.77 $0.00 $0.00 $0.00 $0.00 $0.00 275.93 SUP HCPCS C1713 275.930 - NAIL INTRAMEDULLARY 3MM 440MM ELAST STAINLESS STEEL BOTH IP/OP $582.75 $431.24 $0.00 $466.20 $262.24 $262.24 $0.00 $0.00 $0.00 $121.46 $432.52 $432.52 $0.00 $0.00 $121.45 $0.00 $344.70 $344.70 $0.00 $291.38 $461.54 $466.20 $0.00 $0.00 $88.54 $0.00 $0.00 $92.77 $0.00 $0.00 $0.00 $0.00 $0.00 275.935 SUP HCPCS C1713 275.935 - NAIL INTRAMEDULLARY 3.5MM 440MM ELAST STAINLESS STEEL BOTH IP/OP $635.38 $470.18 $0.00 $493.50 $277.59 $277.59 $0.00 $0.00 $0.00 $132.43 $471.58 $471.58 $0.00 $0.00 $132.41 $0.00 $375.82 $375.82 $0.00 $308.44 $488.57 $493.50 $0.00 $0.00 $93.73 $0.00 $0.00 $98.21 $0.00 $0.00 $0.00 $0.00 $0.00 275.94 SUP HCPCS C1713 275.940 - NAIL INTRAMEDULLARY 4MM 440MM ELAST STAINLESS STEEL BOTH IP/OP $661.90 $489.81 $0.00 $529.52 $297.86 $297.86 $0.00 $0.00 $0.00 $137.96 $491.26 $491.26 $0.00 $0.00 $137.94 $0.00 $391.51 $391.51 $0.00 $330.95 $524.22 $529.52 $0.00 $0.00 $100.57 $0.00 $0.00 $105.37 $0.00 $0.00 $0.00 $0.00 $0.00 280 SUP HCPCS C1713 280.000 - SCREW BONE 12.7MM 8.2MM 2.7MM 100MM 22MM CANN LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.05 SUP HCPCS C1713 280.050 - SCREW BONE 12.7MM 8.2MM 2.7MM 105MM 22MM CANN LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.1 SUP HCPCS C1713 280.100 - SCREW BONE 12.7MM 8.2MM 2.7MM 110MM 22MM CANN LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.15 SUP HCPCS C1713 280.150 - SCREW BONE 12.7MM 8.2MM 115MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.2 SUP HCPCS C1713 280.200 - SCREW BONE 12.7MM 8.2MM 120MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.25 SUP HCPCS C1713 280.250 - SCREW BONE 12.7MM 8.2MM 125MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.251 SUP HCPCS C1713 280.251 - SCREW BONE 12.7MM 50MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.255 SUP HCPCS C1713 280.255 - SCREW BONE 12.7MM 55MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.26 SUP HCPCS C1713 280.260 - SCREW BONE 12.7MM 60MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.265 SUP HCPCS C1713 280.265 - SCREW BONE 12.7MM 65MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.27 SUP HCPCS C1713 280.270 - SCREW BONE 12.7MM 70MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.275 SUP HCPCS C1713 280.275 - SCREW BONE 12.7MM 75MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.28 SUP HCPCS C1713 280.280 - SCREW BONE 12.7MM 80MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.285 SUP HCPCS C1713 280.285 - SCREW BN 12MM 8MM 2.7MM 85MM NS 22MM DHS DCS LG CNN SS HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.29 SUP HCPCS C1713 280.290 - SCREW BONE 12.7MM 90MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.295 SUP HCPCS C1713 280.295 - SCREW BONE 12.7MM 95MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.3 SUP HCPCS C1713 280.300 - SCREW BONE 12.7MM 130MM 22MM DHS/DCS SS CNDYLR HIP LAG CANN BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.301 SUP HCPCS C1713 280.301 - SCREW BONE 12.7MM 100MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.305 SUP HCPCS C1713 280.305 - SCREW BONE 12.7MM 105MM 22MM LAG CANN DHS/DCS STAINLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.31 SUP HCPCS C1713 280.310 - SCREW BONE 12.7MM 110MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.315 SUP HCPCS C1713 280.315 - SCREW BONE 12.7MM 115MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.32 SUP HCPCS C1713 280.320 - SCREW BONE 12.7MM 120MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.325 SUP HCPCS C1713 280.325 - SCREW BONE 12.7MM 125MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.33 SUP HCPCS C1713 280.330 - SCREW BONE 12.7MM 130MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.335 SUP HCPCS C1713 280.335 - SCREW BONE 13MM 135MM 22MM LAG CANN OCTAGONAL DHS/DCS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.34 SUP HCPCS C1713 280.340 - SCREW BONE 12MM 8MM 2.7MM 140MM 22MM 1 STEP LAG CANN DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.345 SUP HCPCS C1713 280.345 - SCREW BONE 12MM 8MM 2.7MM 145MM 22MM 1 STEP LAG CANN DHS/DCS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.35 SUP HCPCS C1713 280.350 - SCREW BONE 12.7MM 8.2MM 135MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.4 SUP HCPCS C1713 280.400 - SCREW BONE 12.7MM 140MM 22MM 1 STEP LAG THREADED DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.451 SUP HCPCS C1713 280.451 - SCREW BONE 12.7MM 8.2MM 2.7MM 145MM 22MM CANN LAG DHS/DCS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.454 SUP HCPCS C1713 280.454 - SCREW BONE 14MM 2.7MM 50MM 22MM LAG CANN DHS/DCS STAINLESS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.455 SUP HCPCS C1713 280.455 - SCREW BONE 14MM 8.2MM 55MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.46 SUP HCPCS C1713 280.460 - SCREW BONE 14MM 8.2MM 60MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.465 SUP HCPCS C1713 280.465 - SCREW BONE LARGE 14MM 65MM 14MM THREAD DHS/DCS STAINLESS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.47 SUP HCPCS C1713 280.470 - SCREW BONE 14MM 8.2MM 70MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.475 SUP HCPCS C1713 280.475 - SCREW BONE 14MM 8.2MM 75MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.48 SUP HCPCS C1713 280.480 - SCREW BONE 14MM 8.2MM 80MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.485 SUP HCPCS C1713 280.485 - SCREW BONE 14MM 8.2MM 85MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.49 SUP HCPCS C1713 280.490 - SCREW BONE 14MM 8.2MM 90MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.495 SUP HCPCS C1713 280.495 - SCREW BONE 14MM 8.2MM 95MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.501 SUP HCPCS C1713 280.501 - SCREW BONE 12.7MM 8.2MM 50MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $702.85 $520.11 $0.00 $545.90 $307.07 $307.07 $0.00 $0.00 $0.00 $146.49 $521.66 $521.66 $0.00 $0.00 $146.47 $0.00 $415.74 $415.74 $0.00 $341.19 $540.44 $545.90 $0.00 $0.00 $103.68 $0.00 $0.00 $108.63 $0.00 $0.00 $0.00 $0.00 $0.00 280.504 SUP HCPCS C1713 280.504 - SCREW BONE 14MM 8MM 2.7MM 100MM 22MM LAG CANN DHS/DCS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.505 SUP HCPCS C1713 280.505 - SCREW BONE 14MM 8.2MM 105MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.51 SUP HCPCS C1713 280.510 - SCREW BONE 14MM 8.2MM 110MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.515 SUP HCPCS C1713 280.515 - SCREW BONE 14MM 8.2MM 115MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.52 SUP HCPCS C1713 280.520 - SCREW BONE 14MM 8.2MM 120MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.525 SUP HCPCS C1713 280.525 - SCREW BONE 14MM 8.2MM 125MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.53 SUP HCPCS C1713 280.530 - SCREW BONE 14MM 8.2MM 130MM 22MM CANN LAG DHS/DCS STAINLESS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.535 SUP HCPCS C1713 280.535 - SCREW BONE 14MM 135MM 22MM LAG THREAD DHS/DCS STAINLESS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.54 SUP HCPCS C1713 280.540 - SCREW BONE 14MM 8.2MM 130MM 22MM CANN LAG DHS/DCS STAINLESS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.545 SUP HCPCS C1713 280.545 - SCREW BONE 14MM 145MM 22MM LAG THREAD DHS/DCS STAINLESS BOTH IP/OP $722.53 $534.67 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $150.59 $536.26 $536.26 $0.00 $0.00 $150.57 $0.00 $427.37 $427.37 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.55 SUP HCPCS C1713 280.550 - SCREW BONE 8MM 55MM 22MM CANN THREADED LAG DHS/DCS STAINLESS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.6 SUP HCPCS C1713 280.600 - SCREW BONE 12.7MM 8.2MM 2.7MM 60MM 22MM CANN LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.65 SUP HCPCS C1713 280.650 - SCREW BONE 12.7MM 8.2MM 65MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.66 SUP HCPCS C1713 280.660 - SCREW BONE 14MM 8.2MM 60MM 22MM 1 STEP LAG CANN DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.67 SUP HCPCS C1713 280.670 - SCREW BONE 14MM 70MM 22MM 1 STEP LAG THREAD DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.68 SUP HCPCS C1713 280.680 - SCREW BONE 14MM 80MM 22MM LAG CANN DHS/DCS STAINLESS STEEL BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.69 SUP HCPCS C1713 280.690 - SCREW BONE 14MM 90MM 22MM LAG CANN DHS/DCS STAINLESS STEEL BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.7 SUP HCPCS C1713 280.700 - SCREW BN 12.7MM 8MM 2.7MM 70MM NS 22MM DHS DCS LG CNN SS HIP BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.71 SUP HCPCS C1713 280.710 - SCREW BONE 14MM 8.2MM 110MM 22MM 1 STEP LAG CANN DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.72 SUP HCPCS C1713 280.720 - SCREW BONE 14MM 8.2MM 120MM 22MM 1 STEP LAG CANN DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.73 SUP HCPCS C1713 280.730 - SCREW BONE 14MM 8.2MM 60MM 22MM 1 STEP LAG CANN DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.74 SUP HCPCS C1713 280.740 - SCREW BONE 14MM 8.2MM 140MM 22MM 1 STEP LAG CANN DHS/DCS BOTH IP/OP $701.48 $519.10 $0.00 $561.18 $315.66 $315.66 $0.00 $0.00 $0.00 $146.20 $520.63 $520.63 $0.00 $0.00 $146.19 $0.00 $414.92 $414.92 $0.00 $350.74 $555.57 $561.18 $0.00 $0.00 $106.58 $0.00 $0.00 $111.67 $0.00 $0.00 $0.00 $0.00 $0.00 280.75 SUP HCPCS C1713 280.750 - SCREW BONE 12.7MM 8.2MM 75MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.8 SUP HCPCS C1713 280.800 - SCREW BONE 12.7MM 8.2MM 80MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.85 SUP HCPCS C1713 280.850 - SCREW BONE 12.7MM 8.2MM 85MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.9 SUP HCPCS C1713 280.900 - SCREW BONE 12.7MM 8MM 2.7MM 90MM 22MM LAG DHS/DCS STAINLESS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.95 SUP HCPCS C1713 280.950 - SCREW BONE 12.7MM 8.2MM 95MM 22MM CANN THREADED LAG DHS/DCS BOTH IP/OP $622.33 $460.52 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $129.71 $461.89 $461.89 $0.00 $0.00 $129.69 $0.00 $368.11 $368.11 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 280.99 SUP HCPCS C1713 280.990 - SCREW BONE 12.7MM 36MM 22MM COMPRESSION DHS/DCS STAINLESS BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 281.01 SUP HCPCS C1713 281.010 - PLATE BONE 130D STANDARD BARREL 174MM 38MM 10 HOLE DHS/DCP BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.012 SUP HCPCS C1713 281.012 - PLATE BN 130D STD BRL 206MM NS 38MM DHS 12 HL SS HIP 4.5MM BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $278.04 $990.09 $990.09 $0.00 $0.00 $278.01 $0.00 $789.06 $789.06 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.014 SUP HCPCS C1713 281.014 - PLATE BN 130D STD BRL 238MM NS 38MM DHS 14 HL SS HIP 4.5MM BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.02 SUP HCPCS C1713 281.020 - PLATE BONE 135D STANDARD BARREL 333X19X5.8MM 38MM 20 HOLE BOTH IP/OP "$1,771.45 " "$1,310.87" $0.00 "$1,417.16" $797.15 $797.15 $0.00 $0.00 $0.00 $369.21 "$1,314.77" "$1,314.77" $0.00 $0.00 $369.17 $0.00 "$1,047.81" "$1,047.81" $0.00 $885.73 "$1,402.99" "$1,417.16" $0.00 $0.00 $269.16 $0.00 $0.00 $282.01 $0.00 $0.00 $0.00 $0.00 $0.00 281.021 SUP HCPCS C1713 281.021 - PLATE BN 130D STD BRL 46MM NS 38MM DHS 2 HL SS HIP 4.5MM BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.031 SUP HCPCS C1713 281.031 - PLATE BONE 130D STANDARD BARREL 62MM 38MM 3 HOLE DHS/DCS BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.04 SUP HCPCS C1713 281.040 - PLATE BN 130D STD BRL 12.6MM 78X19X5.8MM NS 38MM DHS DCP 4 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.05 SUP HCPCS C1713 281.050 - PLATE BN 130D STD BRL 12.6MM 94X19X5.8MM NS 38MM DHS DCP 5 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.06 SUP HCPCS C1713 281.060 - PLATE BN 130D STD BRL 12.6MM 110X19X5.8MM NS 38MM DHS DCP 6 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.081 SUP HCPCS C1713 281.081 - PLATE BONE 130D STANDARD BARREL 142MM 38MM 8 HOLE BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $278.04 $990.09 $990.09 $0.00 $0.00 $278.01 $0.00 $789.06 $789.06 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.1 SUP HCPCS C1713 281.100 - PLATE BN 135D STD BRL 12.6MM 174X19X5.8MM NS 38MM DHS DCP 10 BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.102 SUP HCPCS C1713 281.102 - PLATE BN 135D STD BRL 46MM NS 38MM DHS 2 HL SS HIP 4.5MM BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.11 SUP HCPCS C1713 281.110 - PLATE BN 135D STD BRL 12.6MM 206X19X5.8MM NS 38MM DHS DCP 12 BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.13 SUP HCPCS C1713 281.130 - PLATE BN 135D STD BRL 12.6MM 238X19X5.8MM NS 38MM DHS DCP 14 BOTH IP/OP "$1,720.95 " "$1,273.50" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $358.69 "$1,277.29" "$1,277.29" $0.00 $0.00 $358.65 $0.00 "$1,017.94" "$1,017.94" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.131 SUP HCPCS C1713 281.131 - PLATE BN 135D STD BRL 12.6MM 62X19X5.8MM NS 38MM DHS DCP 3 BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.14 SUP HCPCS C1713 281.140 - PLATE BN 135D STD BRL 12.6MM 78X19X5.8MM NS 38MM DHS DCP 4 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.15 SUP HCPCS C1713 281.150 - PLATE BN 135D STD BRL 12.6MM 94X19X5.8MM NS 38MM DHS DCP 5 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.16 SUP HCPCS C1713 281.160 - PLATE BN 135D STD BRL 12.6MM 110X19X5.8MM NS 38MM DHS DCP 6 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.17 SUP HCPCS C1713 281.170 - PLATE BN 135D STD BRL 12.6MM 270X19X5.8MM NS 38MM DHS DCP 16 BOTH IP/OP "$1,720.95 " "$1,273.50" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $358.69 "$1,277.29" "$1,277.29" $0.00 $0.00 $358.65 $0.00 "$1,017.94" "$1,017.94" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.18 SUP HCPCS C1713 281.180 - PLATE BN 135D STD BRL 12.6MM 142X19X5.8MM NS 38MM DHS DCP 8 BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.19 SUP HCPCS C1713 281.190 - PLATE BONE 135D STANDARD BARREL 302X19X5.8MM 38MM 18 HOLE BOTH IP/OP "$1,771.45 " "$1,310.87" $0.00 "$1,417.16" $797.15 $797.15 $0.00 $0.00 $0.00 $369.21 "$1,314.77" "$1,314.77" $0.00 $0.00 $369.17 $0.00 "$1,047.81" "$1,047.81" $0.00 $885.73 "$1,402.99" "$1,417.16" $0.00 $0.00 $269.16 $0.00 $0.00 $282.01 $0.00 $0.00 $0.00 $0.00 $0.00 281.2 SUP HCPCS C1713 281.200 - PLATE BN 140D STD BRL 174MM NS 38MM DHS 10 HL SS HIP 4.5MM BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.212 SUP HCPCS C1713 281.212 - PLATE BONE STANDARD BARREL 140D 206MM 38MM 12 HOLE DHS BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $278.04 $990.09 $990.09 $0.00 $0.00 $278.01 $0.00 $789.06 $789.06 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.214 SUP HCPCS C1713 281.214 - PLATE BN 140D STD BRL 238MM NS 38MM DHS 14 HL SS HIP 4.5MM BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.216 SUP HCPCS C1713 281.216 - PLATE BONE 140D STANDARD BARREL 12.6MM 270MM 38MM 16 HOLE BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.22 SUP HCPCS C1713 281.220 - PLATE BN 140D STD BRL 46MM NS 38MM DHS 2 HL SS HIP 4.5MM BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.23 SUP HCPCS C1713 281.230 - PLATE BONE 140D STANDARD BARREL 62MM 38MM 3 HOLE COMPRESSION BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.24 SUP HCPCS C1713 281.240 - PLATE BN 140D STD BRL 12.6MM 78X19X5.8MM NS 38MM DHS DCP 4 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $181.76 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.25 SUP HCPCS C1713 281.250 - PLATE BN 140D STD BRL 12.6MM 94X19X5.8MM NS 38MM DHS DCP 5 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.26 SUP HCPCS C1713 281.260 - PLATE BN 140D STD BRL 12.6MM 110X19X5.8MM NS 38MM DHS DCP 6 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.28 SUP HCPCS C1713 281.280 - PLATE BN 140D STD BRL 142MM NS 38MM DHS 8 HL SS HIP 4.5MM BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.308 SUP HCPCS C1713 281.308 - PLATE BN 145D STD BRL 142MM NS 38MM DHS 8 HL SS HIP 4.5MM BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $278.04 $990.09 $990.09 $0.00 $0.00 $278.01 $0.00 $789.06 $789.06 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.31 SUP HCPCS C1713 281.310 - PLATE BN 145D STD BRL 174MM NS 38MM DHS 10 HL SS HIP 4.5MM BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.312 SUP HCPCS C1713 281.312 - PLATE BONE 145D 206MM 38MM 12 HOLE ANGLED STANDARD BARREL BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $278.04 $990.09 $990.09 $0.00 $0.00 $278.01 $0.00 $789.06 $789.06 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.314 SUP HCPCS C1713 281.314 - PLATE BONE 145D STANDARD BARREL 238MM 38MM 14 HOLE DHS BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.316 SUP HCPCS C1713 281.316 - PLATE BONE 145D STANDARD BARREL 270MM 38MM 16 HOLE DHS BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.32 SUP HCPCS C1713 281.320 - PLATE BN 145D STD BRL 46MM NS 38MM DHS 2 HL SS HIP 4.5MM BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.33 SUP HCPCS C1713 281.330 - PLATE BONE 145D STANDARD BARREL 62MM 38MM 3 HOLE COMPRESSION BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.34 SUP HCPCS C1713 281.340 - PLATE BN 145D STD BRL 12.6MM 78X19X5.8MM NS 38MM DHS DCP 4 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.35 SUP HCPCS C1713 281.350 - PLATE BN 145D STD BRL 12.6MM 94X19X5.8MM NS 38MM DHS DCP 5 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.36 SUP HCPCS C1713 281.360 - PLATE BN 145D STD BRL 12.6MM 110X19X5.8MM NS 38MM DHS DCP 6 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.4 SUP HCPCS C1713 281.400 - PLATE BN 150D STD BRL 174MM NS 38MM DHS 10 HL SS HIP 4.5MM BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.402 SUP HCPCS C1713 281.402 - PLATE BONE 150D STANDARD BARREL 46X19X5.8MM 38MM 2 HOLE BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.41 SUP HCPCS C1713 281.410 - PLATE BONE 150D STANDARD BARREL 12.6MM 206MM 38MM 12 HOLE BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.414 SUP HCPCS C1713 281.414 - PLATE BONE 150D STANDARD BARREL 238MM 38MM 14 HOLE DHS BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.416 SUP HCPCS C1713 281.416 - PLATE BONE 150D STANDARD BARREL 270MM 38MM 16 HOLE DHS BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 281.418 SUP HCPCS C1713 281.418 - PLATE BONE 150D STANDARD BARRAL 302MM 38MM 18 HOLE DHS/DCP BOTH IP/OP "$1,824.60 " "$1,350.20" $0.00 "$1,417.16" $797.15 $797.15 $0.00 $0.00 $0.00 $380.29 "$1,354.22" "$1,354.22" $0.00 $0.00 $380.25 $0.00 "$1,079.25" "$1,079.25" $0.00 $885.73 "$1,402.99" "$1,417.16" $0.00 $0.00 $269.16 $0.00 $0.00 $282.01 $0.00 $0.00 $0.00 $0.00 $0.00 281.421 SUP HCPCS C1713 281.421 - PLATE BONE 150D STANDARD BARREL 333MM 38MM 20 HOLE DHS/DCP BOTH IP/OP "$1,824.60 " "$1,350.20" $0.00 "$1,417.16" $797.15 $797.15 $0.00 $0.00 $0.00 $380.29 "$1,354.22" "$1,354.22" $0.00 $0.00 $380.25 $0.00 "$1,079.25" "$1,079.25" $0.00 $885.73 "$1,402.99" "$1,417.16" $0.00 $0.00 $269.16 $0.00 $0.00 $282.01 $0.00 $0.00 $0.00 $0.00 $0.00 281.43 SUP HCPCS C1713 281.430 - PLATE BONE 150D STANDARD BARREL 62MM 38MM 3 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.44 SUP HCPCS C1713 281.440 - PLATE BN 150D STD BRL 12.6MM 78X19X5.8MM NS 38MM DHS DCP 4 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $181.76 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.45 SUP HCPCS C1713 281.450 - PLATE BN 150D STD BRL 12.6MM 94X19X5.8MM NS 38MM DHS DCP 5 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.46 SUP HCPCS C1713 281.460 - PLATE BN 150D STD BRL 12.6MM 110X19X5.8MM NS 38MM DHS DCP 6 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.48 SUP HCPCS C1713 281.480 - PLATE BN 150D STD BRL 142MM NS 38MM DHS 8 HL SS HIP 4.5MM BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 281.502 SUP HCPCS C1713 281.502 - PLATE BONE 130D SHORT BARREL 46MM 25MM 2 HOLE DHS/DCP BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.503 SUP HCPCS C1713 281.503 - PLATE BONE 130D SHORT BARREL 62MM 25MM 3 HOLE DHS/DCP BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.504 SUP HCPCS C1713 281.504 - PLATE BONE 130D SHORT BARREL 78MM 25MM 4 HOLE DHS/DCP BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.505 SUP HCPCS C1713 281.505 - PLATE BONE 130D SHORT BARREL 94MM 25MM 5 HOLE DHS/DCP BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.506 SUP HCPCS C1713 281.506 - PLATE BONE 130D SHORT BARREL 110MM 25MM 6 HOLE DHS/DCP BOTH IP/OP "$1,003.68 " $742.72 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $209.19 $744.93 $744.93 $0.00 $0.00 $209.17 $0.00 $593.67 $593.67 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.52 SUP HCPCS C1713 281.520 - PLATE BN 135D SHRT BRL 46MM NS 25MM DHS 2 HL SS HIP 4.5MM BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.53 SUP HCPCS C1713 281.530 - PLATE BONE 135D SHORT BARREL 62MM 25MM 3 HOLE COMPRESSION BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.54 SUP HCPCS C1713 281.540 - PLATE BN 135D SHRT BRL 12.6MM 78X19X5.8MM NS 25MM DHS DCP 4 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.55 SUP HCPCS C1713 281.550 - PLATE BONE 135D SHORT BARREL 94MM 25MM 5 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.56 SUP HCPCS C1713 281.560 - PLATE BONE 135D SHORT BARREL 110MM 6 HOLE DHS STAINLESS BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.62 SUP HCPCS C1713 281.620 - PLATE BN 140D SHRT BRL 46MM NS 25MM DHS 2 HL SS HIP 4.5MM BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.63 SUP HCPCS C1713 281.630 - PLATE BONE 140D SHORT BARREL 62MM 25MM 3 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.64 SUP HCPCS C1713 281.640 - PLATE BONE 140D SHORT BARREL 78MM 25MM 4 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.65 SUP HCPCS C1713 281.650 - PLATE BONE 140D SHORT BARREL 94MM 25MM 5 HOLE DHS STAINLESS BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.66 SUP HCPCS C1713 281.660 - PLATE BONE 140D SHORT BARREL 110MM 25MM 6 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.72 SUP HCPCS C1713 281.720 - PLATE BN 145D SHRT BRL 46MM NS 25MM DHS 2 HL SS HIP 4.5MM BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.73 SUP HCPCS C1713 281.730 - PLATE BONE 145D SHORT BARREL 62MM 25MM 3 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.74 SUP HCPCS C1713 281.740 - PLATE BONE 145D SHORT BARREL 78MM 25MM 4 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.75 SUP HCPCS C1713 281.750 - PLATE BONE 145D SHORT BARREL 94MM 25MM 5 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.76 SUP HCPCS C1713 281.760 - PLATE BONE 145D SHORT BARREL 110MM 25MM 6 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.82 SUP HCPCS C1713 281.820 - PLATE BONE 150D 2 FLAT LP SHORT BARREL 12.6MM 46X19X5.8MM 25 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.83 SUP HCPCS C1713 281.830 - PLATE BONE 150D SHORT BARREL 62MM 25MM 3 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.84 SUP HCPCS C1713 281.840 - PLATE BN 150D SHRT BRL 12.6MM 78X19X5.8MM NS 25MM DHS DCP 4 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.85 SUP HCPCS C1713 281.850 - PLATE BONE 150D SHORT BARREL 94MM 25MM 5 HOLE DHS/DCP BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.86 SUP HCPCS C1713 281.860 - PLATE BN 150D SHRT BRL 12.6MM 110X19X5.8MM NS 25MM DHS DCP 6 BOTH IP/OP $974.43 $721.08 $0.00 $779.54 $438.49 $438.49 $0.00 $0.00 $0.00 $203.09 $723.22 $723.22 $0.00 $0.00 $203.07 $0.00 $576.37 $576.37 $0.00 $487.21 $771.75 $779.54 $0.00 $0.00 $148.06 $0.00 $0.00 $155.13 $0.00 $0.00 $0.00 $0.00 $0.00 281.869 SUP HCPCS C1713 281.869 - PLATE BN SHRT 138MM NS SS DHS TROCH STAB BOTH IP/OP "$1,073.95 " $794.72 $0.00 $834.14 $469.20 $469.20 $0.00 $0.00 $0.00 $223.84 $797.09 $797.09 $0.00 $0.00 $223.81 $0.00 $635.24 $635.24 $0.00 $521.34 $825.80 $834.14 $0.00 $0.00 $158.42 $0.00 $0.00 $165.99 $0.00 $0.00 $0.00 $0.00 $0.00 281.87 SUP HCPCS C1713 281.870 - PLATE BN LNG 148MM NS SS DHS TROCH STAB BOTH IP/OP "$1,042.68 " $771.58 $0.00 $834.14 $469.20 $469.20 $0.00 $0.00 $0.00 $217.32 $773.87 $773.87 $0.00 $0.00 $217.29 $0.00 $616.74 $616.74 $0.00 $521.34 $825.80 $834.14 $0.00 $0.00 $158.42 $0.00 $0.00 $165.99 $0.00 $0.00 $0.00 $0.00 $0.00 281.9 SUP HCPCS C1713 281.900 - PLATE BN 95D SHRT BRL 12.6MM 178X16X5.4MM NS 25MM DCS DCP 10 BOTH IP/OP "$1,685.48 " "$1,247.26" $0.00 "$1,348.38" $758.46 $758.46 $0.00 $0.00 $0.00 $351.30 "$1,250.96" "$1,250.96" $0.00 $0.00 $351.25 $0.00 $996.96 $996.96 $0.00 $842.74 "$1,334.90" "$1,348.38" $0.00 $0.00 $256.09 $0.00 $0.00 $268.33 $0.00 $0.00 $0.00 $0.00 $0.00 281.925 SUP HCPCS C1713 281.925 - PLATE BN 95D SHRT BRL 210MM NS 25MM DCS 12 HL SS CNDRL 4.5MM BOTH IP/OP "$1,962.35 " "$1,452.14" $0.00 "$1,524.16" $857.34 $857.34 $0.00 $0.00 $0.00 $409.00 "$1,456.46" "$1,456.46" $0.00 $0.00 $408.95 $0.00 "$1,160.73" "$1,160.73" $0.00 $952.60 "$1,508.92" "$1,524.16" $0.00 $0.00 $289.48 $0.00 $0.00 $303.31 $0.00 $0.00 $0.00 $0.00 $0.00 281.93 SUP HCPCS C1713 281.930 - PLATE BN 95D SHRT BRL 12.6MM 242X16X5.4MM NS 25MM DCS DCP 14 BOTH IP/OP "$1,905.20 " "$1,409.85" $0.00 "$1,524.16" $857.34 $857.34 $0.00 $0.00 $0.00 $397.09 "$1,414.04" "$1,414.04" $0.00 $0.00 $397.04 $0.00 "$1,126.93" "$1,126.93" $0.00 $952.60 "$1,508.92" "$1,524.16" $0.00 $0.00 $289.48 $0.00 $0.00 $303.31 $0.00 $0.00 $0.00 $0.00 $0.00 281.94 SUP HCPCS C1713 281.940 - PLATE BN 95D SHRT BRL 12.6MM 274X16X5.4MM NS 25MM DCS DCP 16 BOTH IP/OP "$2,030.75 " "$1,502.76" $0.00 "$1,624.60" $913.84 $913.84 $0.00 $0.00 $0.00 $423.26 "$1,507.22" "$1,507.22" $0.00 $0.00 $423.21 $0.00 "$1,201.19" "$1,201.19" $0.00 "$1,015.38" "$1,608.35" "$1,624.60" $0.00 $0.00 $308.56 $0.00 $0.00 $323.30 $0.00 $0.00 $0.00 $0.00 $0.00 281.95 SUP HCPCS C1713 281.950 - PLATE BONE 95D 306MM 25MM 18 HOLE DCS STAINLESS STEEL BOTH IP/OP "$2,590.30 " "$1,916.82" $0.00 "$2,072.24" "$1,165.64" "$1,165.64" $0.00 $0.00 $0.00 $539.88 "$1,922.52" "$1,922.52" $0.00 $0.00 $539.82 $0.00 "$1,277.02" "$1,277.02" $0.00 "$1,295.15" "$2,051.52" "$2,072.24" $0.00 $0.00 $393.57 $0.00 $0.00 $412.38 $0.00 $0.00 $0.00 $0.00 $0.00 281.96 SUP HCPCS C1713 281.960 - PLATE BN 95D SHRT BRL 12.6MM 114X16X5.4MM NS 25MM DCS DCP 6 BOTH IP/OP "$1,685.48 " "$1,247.26" $0.00 "$1,348.38" $758.46 $758.46 $0.00 $0.00 $0.00 $351.30 "$1,250.96" "$1,250.96" $0.00 $0.00 $351.25 $0.00 $996.96 $996.96 $0.00 $842.74 "$1,334.90" "$1,348.38" $0.00 $0.00 $256.09 $0.00 $0.00 $268.33 $0.00 $0.00 $0.00 $0.00 $0.00 281.97 SUP HCPCS C1713 281.970 - PLATE BONE 95D 338MM 25MM 20 HOLE DCS DCP STAINLESS STEEL BOTH IP/OP "$2,676.28 " "$1,980.45" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $557.80 "$1,986.33" "$1,986.33" $0.00 $0.00 $557.74 $0.00 "$1,319.40" "$1,319.40" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 281.98 SUP HCPCS C1713 281.980 - PLATE BN 95D SHRT BRL 12.6MM 146X16X5.4MM NS 25MM DCS DCP 8 BOTH IP/OP "$1,685.48 " "$1,247.26" $0.00 "$1,348.38" $758.46 $758.46 $0.00 $0.00 $0.00 $351.30 "$1,250.96" "$1,250.96" $0.00 $0.00 $351.25 $0.00 $996.96 $996.96 $0.00 $842.74 "$1,334.90" "$1,348.38" $0.00 $0.00 $256.09 $0.00 $0.00 $268.33 $0.00 $0.00 $0.00 $0.00 $0.00 281.99 SUP HCPCS C1713 281.990 - PLATE BONE 95D BARREL 370MM 22 HOLE DCS STAINLESS STEEL BOTH IP/OP "$2,795.00 " "$2,068.30" $0.00 "$2,236.00" "$1,257.75" "$1,257.75" $0.00 $0.00 $0.00 $582.55 "$2,074.45" "$2,074.45" $0.00 $0.00 $582.48 $0.00 "$1,377.94" "$1,377.94" $0.00 "$1,397.50" "$2,213.64" "$2,236.00" $0.00 $0.00 $424.68 $0.00 $0.00 $444.96 $0.00 $0.00 $0.00 $0.00 $0.00 282.235 SUP HCPCS C1713 282.235 - BLADE IM NAIL 80MM LCP DHHS HIP SS CMPR PLT NONSTRL BOTH IP/OP $687.60 $508.82 $0.00 $550.08 $309.42 $309.42 $0.00 $0.00 $0.00 $143.31 $510.34 $510.34 $0.00 $0.00 $143.30 $0.00 $406.72 $406.72 $0.00 $343.80 $544.58 $550.08 $0.00 $0.00 $107.61 $0.00 $0.00 $109.47 $0.00 $0.00 $0.00 $0.00 $0.00 282.236 SUP HCPCS C1713 282.236 - BLADE IM NAIL 85MM LCP DHHS HIP SS CMPR PLT NONSTRL BOTH IP/OP $687.60 $508.82 $0.00 $550.08 $309.42 $309.42 $0.00 $0.00 $0.00 $143.31 $510.34 $510.34 $0.00 $0.00 $143.30 $0.00 $406.72 $406.72 $0.00 $343.80 $544.58 $550.08 $0.00 $0.00 $107.61 $0.00 $0.00 $109.47 $0.00 $0.00 $0.00 $0.00 $0.00 282.24 SUP HCPCS C1713 282.240 - BLADE 105MM HLX LCP DHHS SS ORTH SURG NONSTRL BOTH IP/OP $741.88 $548.99 $0.00 $593.50 $333.84 $333.84 $0.00 $0.00 $0.00 $154.63 $550.62 $550.62 $0.00 $0.00 $154.61 $0.00 $438.82 $438.82 $0.00 $370.94 $587.57 $593.50 $0.00 $0.00 $116.10 $0.00 $0.00 $118.11 $0.00 $0.00 $0.00 $0.00 $0.00 282.241 SUP HCPCS C1713 282.241 - BLADE FIX 110MM LCP DHHS SS HLCL STRL BOTH IP/OP $741.88 $548.99 $0.00 $593.50 $333.84 $333.84 $0.00 $0.00 $0.00 $154.63 $550.62 $550.62 $0.00 $0.00 $154.61 $0.00 $438.82 $438.82 $0.00 $370.94 $587.57 $593.50 $0.00 $0.00 $116.10 $0.00 $0.00 $118.11 $0.00 $0.00 $0.00 $0.00 $0.00 282.242 SUP HCPCS C1713 282.242 - BLADE FIX 115MM LCP DHHS SS HLCL STRL BOTH IP/OP $741.88 $548.99 $0.00 $593.50 $333.84 $333.84 $0.00 $0.00 $0.00 $154.63 $550.62 $550.62 $0.00 $0.00 $154.61 $0.00 $438.82 $438.82 $0.00 $370.94 $587.57 $593.50 $0.00 $0.00 $116.10 $0.00 $0.00 $118.11 $0.00 $0.00 $0.00 $0.00 $0.00 282.5 SUP HCPCS C1713 282.50 - PLATE 95D 92 MMX 50MM SS 5 HOLE DCP BONE SM ADLT/YTH 50MM BOTH IP/OP $934.85 $691.79 $0.00 $747.88 $420.68 $420.68 $0.00 $0.00 $0.00 $194.85 $693.85 $693.85 $0.00 $0.00 $194.82 $0.00 $552.96 $552.96 $0.00 $467.43 $740.40 $747.88 $0.00 $0.00 $142.04 $0.00 $0.00 $148.83 $0.00 $0.00 $0.00 $0.00 $0.00 282.52 SUP HCPCS C1713 282.52 - PLATE BONE 95D SMALL STATURE 92MM 60MM 5 HOLE DCP STAINLESS BOTH IP/OP $962.90 $712.55 $0.00 $747.88 $420.68 $420.68 $0.00 $0.00 $0.00 $200.69 $714.66 $714.66 $0.00 $0.00 $200.67 $0.00 $569.56 $569.56 $0.00 $467.43 $740.40 $747.88 $0.00 $0.00 $142.04 $0.00 $0.00 $148.83 $0.00 $0.00 $0.00 $0.00 $0.00 282.54 SUP HCPCS C1713 282.54 - PLATE BONE 95D SMALL STATURE 92MM 70MM 5 HOLE DCP LC-DCP BOTH IP/OP $962.90 $712.55 $0.00 $747.88 $420.68 $420.68 $0.00 $0.00 $0.00 $200.69 $714.66 $714.66 $0.00 $0.00 $200.67 $0.00 $569.56 $569.56 $0.00 $467.43 $740.40 $747.88 $0.00 $0.00 $142.04 $0.00 $0.00 $148.83 $0.00 $0.00 $0.00 $0.00 $0.00 282.58 SUP HCPCS C1713 282.58 - PLATE BONE 95D SMALL STATURE 40MM 92MM 5 HOLE DCP STAINLESS BOTH IP/OP $962.90 $712.55 $0.00 $747.88 $420.68 $420.68 $0.00 $0.00 $0.00 $200.69 $714.66 $714.66 $0.00 $0.00 $200.67 $0.00 $569.56 $569.56 $0.00 $467.43 $740.40 $747.88 $0.00 $0.00 $142.04 $0.00 $0.00 $148.83 $0.00 $0.00 $0.00 $0.00 $0.00 282.6 SUP HCPCS C1713 282.600 - SIDEPLATE BONE 130D STANDARD BARREL 54MM 38MM 2 HOLE LCP BOTH IP/OP "$1,056.33 " $781.68 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $220.16 $784.00 $784.00 $0.00 $0.00 $220.14 $0.00 $624.82 $624.82 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.601 SUP HCPCS C1713 282.601 - SIDEPLATE BONE 130D STANDARD BARREL 72MM 38MM 3 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.602 SUP HCPCS C1713 282.602 - SIDEPLATE BONE 130D STANDARD BARREL 90MM 4 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.603 SUP HCPCS C1713 282.603 - SIDEPLATE BONE 130D STANDARD BARREL 108MM 5 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.604 SUP HCPCS C1713 282.604 - SIDEPLATE BONE 130D STANDARD BARREL 126MM 38MM 6 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.61 SUP HCPCS C1713 282.610 - SIDEPLATE BONE 135D STANDARD BARREL 54MM 38MM 2 HOLE LCP BOTH IP/OP "$1,056.33 " $781.68 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $220.16 $784.00 $784.00 $0.00 $0.00 $220.14 $0.00 $624.82 $624.82 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.611 SUP HCPCS C1713 282.611 - SIDEPLATE BONE 135D STANDARD BARREL 72MM 38MM 3 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.612 SUP HCPCS C1713 282.612 - SIDEPLATE BONE 135D STANDARD BARREL 90MM 38MM 4 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.613 SUP HCPCS C1713 282.613 - SIDEPLATE BONE 135D STANDARD BARREL 108MM 38MM 5 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.614 SUP HCPCS C1713 282.614 - SIDEPLATE BONE 135D STANDARD BARREL 126MM 38MM 6 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.63 SUP HCPCS C1713 282.630 - SIDEPLATE BONE 140D STANDARD BARREL LP 54MM 38MM 2 HOLE LCP BOTH IP/OP "$1,056.33 " $781.68 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $220.16 $784.00 $784.00 $0.00 $0.00 $220.14 $0.00 $624.82 $624.82 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.631 SUP HCPCS C1713 282.631 - SIDEPLATE BONE 140D STANDARD BARREL 72MM 38MM 3 HOLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.632 SUP HCPCS C1713 282.632 - SIDEPLATE BONE 140D STANDARD BARREL 90MM 38MM 4 HOLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.633 SUP HCPCS C1713 282.633 - SIDEPLATE BONE 140D STANDARD BARREL 108MM 38MM 5 HOLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.634 SUP HCPCS C1713 282.634 - SIDEPLATE BONE 140D STANDARD BARREL 126MM 38MM 6 HOLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.64 SUP HCPCS C1713 282.640 - SIDEPLATE BONE 145D STANDARD BARREL LP 54MM 38MM 2 HOLE LCP BOTH IP/OP "$1,056.33 " $781.68 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $220.16 $784.00 $784.00 $0.00 $0.00 $220.14 $0.00 $624.82 $624.82 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.641 SUP HCPCS C1713 282.641 - SIDEPLATE BONE 145D STANDARD BARREL 72MM 38MM 3 HOLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.642 SUP HCPCS C1713 282.642 - SIDEPLATE BONE 145D STANDARD BARREL 90MM 38MM 4 HOLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.643 SUP HCPCS C1713 282.643 - SIDEPLATE BONE 145D STANDARD BARREL 108MM 38MM 5 HOLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.644 SUP HCPCS C1713 282.644 - SIDEPLATE BONE 145D STANDARD BARREL 126MM 38MM 6 HOLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.65 SUP HCPCS C1713 282.650 - SIDEPLATE BONE 150D STANDARD BARREL LP 54MM 38MM 2 HOLE LCP BOTH IP/OP "$1,056.33 " $781.68 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $220.16 $784.00 $784.00 $0.00 $0.00 $220.14 $0.00 $624.82 $624.82 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.651 SUP HCPCS C1713 282.651 - SIDEPLATE BONE 150D STANDARD BARREL 72MM 38MM 3 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.652 SUP HCPCS C1713 282.652 - SIDEPLATE BONE 150D STANDARD BARREL 90MM 38MM 4 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.653 SUP HCPCS C1713 282.653 - SIDEPLATE BONE 150D STANDARD BARREL 108MM 38MM 5 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.654 SUP HCPCS C1713 282.654 - SIDEPLATE BONE 150D STANDARD BARREL 126MM 38MM 6 HOLE LCP BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.67 SUP HCPCS C1713 282.670 - SIDEPLATE BONE 130D SHORT BARREL LP 54MM 25MM 2 HOLE LCP BOTH IP/OP "$1,056.33 " $781.68 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $220.16 $784.00 $784.00 $0.00 $0.00 $220.14 $0.00 $624.82 $624.82 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.672 SUP HCPCS C1713 282.672 - SIDEPLATE BONE 130D SHORT BARREL 90MM 25MM 4 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.676 SUP HCPCS C1713 282.676 - SIDEPLATE BONE 135D SHORT BARREL 54MM 25MM 2 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.678 SUP HCPCS C1713 282.678 - SIDEPLATE BONE 135D SHORT BARREL 90MM 25MM 4 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.683 SUP HCPCS C1713 282.683 - SIDEPLATE BONE 140D SHORT BARREL 90MM 25MM 4 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.688 SUP HCPCS C1713 282.688 - SIDEPLATE BONE 145D SHORT BARREL 90MM 25MM 4 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.691 SUP HCPCS C1713 282.691 - SIDEPLATE BONE 150D SHORT BARREL 54MM 25MM 2 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.693 SUP HCPCS C1713 282.693 - SIDEPLATE BONE 150D SHORT BARREL 90MM 25MM 4 HOLE LCP DHHS BOTH IP/OP "$1,088.00 " $805.12 $0.00 $845.06 $475.35 $475.35 $0.00 $0.00 $0.00 $226.77 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $643.55 $643.55 $0.00 $528.16 $836.61 $845.06 $0.00 $0.00 $160.50 $0.00 $0.00 $168.17 $0.00 $0.00 $0.00 $0.00 $0.00 282.7 SUP HCPCS C1713 282.70 - PLATE BONE 95D SMALL STATURE T PROFILE 124MM 50MM 7 HOLE DCP BOTH IP/OP $978.53 $724.11 $0.00 $782.82 $440.34 $440.34 $0.00 $0.00 $0.00 $203.95 $726.26 $726.26 $0.00 $0.00 $203.92 $0.00 $578.80 $578.80 $0.00 $489.26 $775.00 $782.82 $0.00 $0.00 $148.68 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $0.00 282.72 SUP HCPCS C1713 282.72 - PLATE BONE 95D SMALL STATURE 124MM 60MM 7 HOLE ANGLED DCP BOTH IP/OP "$1,007.88 " $745.83 $0.00 $782.82 $440.34 $440.34 $0.00 $0.00 $0.00 $210.07 $748.04 $748.04 $0.00 $0.00 $210.04 $0.00 $596.16 $596.16 $0.00 $489.26 $775.00 $782.82 $0.00 $0.00 $148.68 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $0.00 282.74 SUP HCPCS C1713 282.74 - PLATE BONE 95D SMALL STATURE 124MM 70MM 7 HOLE CNDYLR DCP BOTH IP/OP "$1,007.88 " $745.83 $0.00 $782.82 $440.34 $440.34 $0.00 $0.00 $0.00 $210.07 $748.04 $748.04 $0.00 $0.00 $210.04 $0.00 $596.16 $596.16 $0.00 $489.26 $775.00 $782.82 $0.00 $0.00 $148.68 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $0.00 282.78 SUP HCPCS C1713 282.78 - PLATE BONE 95D SMALL STATURE 124MM 40MM 7 HOLE DCP CAPOS BOTH IP/OP "$1,007.88 " $745.83 $0.00 $782.82 $440.34 $440.34 $0.00 $0.00 $0.00 $210.07 $748.04 $748.04 $0.00 $0.00 $210.04 $0.00 $596.16 $596.16 $0.00 $489.26 $775.00 $782.82 $0.00 $0.00 $148.68 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $0.00 282.8 SUP Custom 27803010 282.80 - STAPLE BONE 23X20X3MM STAINLESS STEEL NONSTRL BOTH IP/OP $251.75 $186.30 $0.00 $201.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.85 $186.85 $0.00 $0.00 $52.46 $0.00 $0.00 $0.00 $0.00 $125.88 $199.39 $201.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.82 SUP Custom 27803010 282.82 - STAPLE BONE 24MM STAINLESS STEEL ORTHOPEDIC NONSTRL BOTH IP/OP $251.75 $186.30 $0.00 $201.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.85 $186.85 $0.00 $0.00 $52.46 $0.00 $0.00 $0.00 $0.00 $125.88 $199.39 $201.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.9 SUP HCPCS C1713 282.90 - PLATE BONE 95D SMALL STATURE T PROFILE 156MM 50MM 9 HOLE DCP BOTH IP/OP "$1,046.78 " $774.62 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $218.17 $776.92 $776.92 $0.00 $0.00 $218.15 $0.00 $619.17 $619.17 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 282.92 SUP HCPCS C1713 282.92 - PLATE BONE 95D SMALL STATURE 156MM 60MM 9 HOLE ANGLED BLADE BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 282.94 SUP HCPCS C1713 282.94 - PLATE BONE 95D SMALL STATURE 156MM 70MM 9 HOLE DCP STAINLESS BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 282.98 SUP HCPCS C1713 282.98 - PLATE BONE 95D SMALL STATURE 156X40MM 40MM 9 HOLE CNDYLR DCP BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 283.4 SUP HCPCS C1713 283.40 - PLATE BONE 130D SMALL STATURE 50MM 60MM 4 HOLE ANGLED BLADE BOTH IP/OP $937.58 $693.81 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $195.41 $695.87 $695.87 $0.00 $0.00 $195.39 $0.00 $554.58 $554.58 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 283.42 SUP HCPCS C1713 283.42 - PLATE BONE 130D SMALL STATURE 60MM 4 HOLE ANGLED BLADE DCP BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 283.44 SUP HCPCS C1713 283.44 - PLATE BONE 130D SMALL STATURE 70MM 60MM ANGLED BLADE DCP BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 283.46 SUP HCPCS C1713 283.46 - PLATE BONE 130D SMALL STATURE 80MM 60MM 4 HOLE ANGLED BLADE BOTH IP/OP $965.70 $714.62 $0.00 $750.06 $421.91 $421.91 $0.00 $0.00 $0.00 $201.28 $716.74 $716.74 $0.00 $0.00 $201.25 $0.00 $571.21 $571.21 $0.00 $468.79 $742.56 $750.06 $0.00 $0.00 $142.46 $0.00 $0.00 $149.26 $0.00 $0.00 $0.00 $0.00 $0.00 283.6 SUP HCPCS C1713 283.60 - PLATE BONE 130D 104MM 50MM 6 HOLE ANGLED BLADE DCP STAINLESS BOTH IP/OP $993.55 $735.23 $0.00 $794.84 $447.10 $447.10 $0.00 $0.00 $0.00 $207.08 $737.41 $737.41 $0.00 $0.00 $207.06 $0.00 $587.68 $587.68 $0.00 $496.78 $786.89 $794.84 $0.00 $0.00 $150.96 $0.00 $0.00 $158.17 $0.00 $0.00 $0.00 $0.00 $0.00 283.62 SUP HCPCS C1713 283.62 - PLATE BONE 130D 104MM 60MM 6 HOLE ANGLED BLADE DCP STAINLESS BOTH IP/OP "$1,023.35 " $757.28 $0.00 $794.84 $447.10 $447.10 $0.00 $0.00 $0.00 $213.29 $759.53 $759.53 $0.00 $0.00 $213.27 $0.00 $605.31 $605.31 $0.00 $496.78 $786.89 $794.84 $0.00 $0.00 $150.96 $0.00 $0.00 $158.17 $0.00 $0.00 $0.00 $0.00 $0.00 283.64 SUP HCPCS C1713 283.64 - PLATE BLADE 130D 104MM 70MM 6 HOLE ANGLED DCP STAINLESS BOTH IP/OP "$1,023.35 " $757.28 $0.00 $794.84 $447.10 $447.10 $0.00 $0.00 $0.00 $213.29 $759.53 $759.53 $0.00 $0.00 $213.27 $0.00 $605.31 $605.31 $0.00 $496.78 $786.89 $794.84 $0.00 $0.00 $150.96 $0.00 $0.00 $158.17 $0.00 $0.00 $0.00 $0.00 $0.00 283.66 SUP HCPCS C1713 283.66 - SCREW BONE 130D 104MM 80MM 6 HOLE ANGLED BLADE DCP STAINLESS BOTH IP/OP "$1,023.35 " $757.28 $0.00 $794.84 $447.10 $447.10 $0.00 $0.00 $0.00 $213.29 $759.53 $759.53 $0.00 $0.00 $213.27 $0.00 $605.31 $605.31 $0.00 $496.78 $786.89 $794.84 $0.00 $0.00 $150.96 $0.00 $0.00 $158.17 $0.00 $0.00 $0.00 $0.00 $0.00 283.9 SUP HCPCS C1713 283.90 - PLATE BONE 130D SMALL STATURE 152MM 50MM 9 HOLE DCP CAPOS BOTH IP/OP "$1,072.70 " $793.80 $0.00 $858.16 $482.72 $482.72 $0.00 $0.00 $0.00 $223.58 $796.16 $796.16 $0.00 $0.00 $223.55 $0.00 $634.50 $634.50 $0.00 $536.35 $849.58 $858.16 $0.00 $0.00 $162.99 $0.00 $0.00 $170.77 $0.00 $0.00 $0.00 $0.00 $0.00 283.92 SUP HCPCS C1713 283.92 - PLATE BONE 130D 4.5MM 152MM 60MM 9 HOLE BLADE ANGLED DCP BOTH IP/OP "$1,104.88 " $817.61 $0.00 $858.16 $482.72 $482.72 $0.00 $0.00 $0.00 $230.28 $820.04 $820.04 $0.00 $0.00 $230.26 $0.00 $653.53 $653.53 $0.00 $536.35 $849.58 $858.16 $0.00 $0.00 $162.99 $0.00 $0.00 $170.77 $0.00 $0.00 $0.00 $0.00 $0.00 283.94 SUP HCPCS C1713 283.94 - PLATE BONE 130D 152MM 70MM 9 HOLE BLADE DCP STAINLESS STEEL BOTH IP/OP "$1,104.88 " $817.61 $0.00 $858.16 $482.72 $482.72 $0.00 $0.00 $0.00 $230.28 $820.04 $820.04 $0.00 $0.00 $230.26 $0.00 $653.53 $653.53 $0.00 $536.35 $849.58 $858.16 $0.00 $0.00 $162.99 $0.00 $0.00 $170.77 $0.00 $0.00 $0.00 $0.00 $0.00 283.96 SUP HCPCS C1713 283.96 - PLATE BONE 130D 80MM 152MM 80MM 9 HOLE ANGLED BLADE DCP BOTH IP/OP "$1,104.88 " $817.61 $0.00 $858.16 $482.72 $482.72 $0.00 $0.00 $0.00 $230.28 $820.04 $820.04 $0.00 $0.00 $230.26 $0.00 $653.53 $653.53 $0.00 $536.35 $849.58 $858.16 $0.00 $0.00 $162.99 $0.00 $0.00 $170.77 $0.00 $0.00 $0.00 $0.00 $0.00 288.025 SUP Custom 27803010 288.025 - DISTRACTOR SURG 10MM BODY STAINLESS STEEL NONSTRL BOTH IP/OP "$11,697.50 " "$8,656.15" $0.00 "$9,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.76" $0.00 $0.00 $0.00 $0.00 "$5,848.75" "$9,264.42" "$9,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.026 SUP Custom 27803010 288.026 - DISTRACTOR SURG 15MM BODY STAINLESS STEEL NONSTRL BOTH IP/OP "$11,697.50 " "$8,656.15" $0.00 "$9,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.76" $0.00 $0.00 $0.00 $0.00 "$5,848.75" "$9,264.42" "$9,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.027 SUP Custom 27803010 288.027 - DISTRACTOR SURG 20MM BODY STAINLESS STEEL NONSTRL BOTH IP/OP "$11,697.50 " "$8,656.15" $0.00 "$9,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.76" $0.00 $0.00 $0.00 $0.00 "$5,848.75" "$9,264.42" "$9,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.028 SUP Custom 27803010 288.028 - DISTRACTOR SURG 25MM BODY STAINLESS STEEL NONSTRL BOTH IP/OP "$11,697.50 " "$8,656.15" $0.00 "$9,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.76" $0.00 $0.00 $0.00 $0.00 "$5,848.75" "$9,264.42" "$9,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.038 SUP Custom 27803010 288.038 - FOOTPLATE BONE 6MM SPLINT STAINLESS STEEL RIGHT ANTERIOR BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $0.00 $0.00 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.039 SUP Custom 27803010 288.039 - FOOTPLATE BONE 10MM SPLINT STAINLESS STEEL RIGHT ANTERIOR BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $0.00 $0.00 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.04 SUP Custom 27803010 288.040 - FOOTPLATE BONE 14MM SPLINT STAINLESS STEEL RIGHT ANTERIOR BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $0.00 $0.00 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.042 SUP Custom 27803010 288.042 - FOOTPLATE BONE 6MM SPLINT STAINLESS STEEL LEFT ANTERIOR MAXL BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $0.00 $0.00 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.043 SUP Custom 27803010 288.043 - FOOTPLATE BONE 10MM SPLINT STAINLESS STEEL LEFT ANTERIOR BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $0.00 $0.00 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.044 SUP Custom 27803010 288.044 - FOOTPLATE BONE 14MM SPLINT STAINLESS STEEL LEFT ANTERIOR BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $0.00 $0.00 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.052 SUP Custom 27803010 288.052 - FOOTPLATE BONE SHORT 7MM OFFST STAINLESS STEEL POSTERIOR BOTH IP/OP "$2,952.50 " "$2,184.85" $0.00 "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,191.35" "$2,191.35" $0.00 $0.00 $615.30 $0.00 $0.00 $0.00 $0.00 "$1,476.25" "$2,338.38" "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.053 SUP Custom 27803010 288.053 - FOOTPLATE BONE SHORT 12MM OFFST STAINLESS STEEL POSTERIOR BOTH IP/OP "$2,952.50 " "$2,184.85" $0.00 "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,191.35" "$2,191.35" $0.00 $0.00 $615.30 $0.00 $0.00 $0.00 $0.00 "$1,476.25" "$2,338.38" "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.055 SUP Custom 27803010 288.055 - FOOTPLATE BONE MEDIUM 7MM OFFST STAINLESS STEEL POSTERIOR BOTH IP/OP "$2,952.50 " "$2,184.85" $0.00 "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,191.35" "$2,191.35" $0.00 $0.00 $615.30 $0.00 $0.00 $0.00 $0.00 "$1,476.25" "$2,338.38" "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.056 SUP Custom 27803010 288.056 - FOOTPLATE BONE MEDIUM 12MM OFFST STAINLESS STEEL POSTERIOR BOTH IP/OP "$2,952.50 " "$2,184.85" $0.00 "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,191.35" "$2,191.35" $0.00 $0.00 $615.30 $0.00 $0.00 $0.00 $0.00 "$1,476.25" "$2,338.38" "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.058 SUP Custom 27803010 288.058 - FOOTPLATE BONE TALL 7MM OFFST STAINLESS STEEL POSTERIOR MAXL BOTH IP/OP "$2,952.50 " "$2,184.85" $0.00 "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,191.35" "$2,191.35" $0.00 $0.00 $615.30 $0.00 $0.00 $0.00 $0.00 "$1,476.25" "$2,338.38" "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.059 SUP Custom 27803010 288.059 - FOOTPLATE BONE TALL 12MM OFFST STAINLESS STEEL POSTERIOR BOTH IP/OP "$2,952.50 " "$2,184.85" $0.00 "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,191.35" "$2,191.35" $0.00 $0.00 $615.30 $0.00 $0.00 $0.00 $0.00 "$1,476.25" "$2,338.38" "$2,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288.065 SUP HCPCS C1713 288.065 - SCREW EXTERNAL DISTRCT 3.5MM STAINLESS STEEL NONSTRL BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 291.01 SUP Custom 27803010 291.01 - WIRE CERCLAGE 1MM 280MM EYE KWIRE STAINLESS STEEL NONSTRL BOTH IP/OP $15.18 $11.23 $0.00 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.27 $11.27 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $7.37 $11.67 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.02 SUP Custom 27203010 291.02 - WIRE CERCLAGE 1.25MM 280MM EYE STAINLESS STEEL NONSTRL BOTH IP/OP $15.18 $11.23 $0.00 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.27 $11.27 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $7.37 $11.67 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.03 SUP Custom 27803010 291.03 - WIRE CERCLAGE 1MM 600MM EYE STAINLESS STEEL NONSTRL BOTH IP/OP $22.91 $16.95 $0.00 $17.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.01 $17.01 $0.00 $0.00 $4.77 $0.00 $0.00 $0.00 $0.00 $11.12 $17.62 $17.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.04 SUP Custom 27203010 291.04 - WIRE FIX 1.25MM 600MM CERCLAGE EYE STAINLESS STEEL BOTH IP/OP $22.91 $16.95 $0.00 $17.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.01 $17.01 $0.00 $0.00 $4.77 $0.00 $0.00 $0.00 $0.00 $11.12 $17.62 $17.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.05 SUP Custom 27203010 291.05 - WIRE CERCLAGE 1MM 10MR COIL STAINLESS STEEL NONSTRL BOTH IP/OP $128.60 $95.16 $0.00 $99.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.45 $95.45 $0.00 $0.00 $26.80 $0.00 $0.00 $0.00 $0.00 $62.43 $98.88 $99.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.06 SUP Custom 27803010 291.06 - WIRE CERCLAGE 1.25MM 1MM COIL STAINLESS STEEL NONSTRL BOTH IP/OP $128.60 $95.16 $0.00 $99.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.45 $95.45 $0.00 $0.00 $26.80 $0.00 $0.00 $0.00 $0.00 $62.43 $98.88 $99.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.08 SUP Custom 27803010 291.08 - WIRE CERCLAGE .8MM 280MM EYE STAINLESS STEEL NONSTRL BOTH IP/OP $10.61 $7.85 $0.00 $8.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.88 $7.88 $0.00 $0.00 $2.21 $0.00 $0.00 $0.00 $0.00 $5.15 $8.16 $8.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.09 SUP Custom 27203010 291.09 - WIRE CERCLAGE .8MM 10MR COIL STAINLESS STEEL NONSTRL BOTH IP/OP $128.60 $95.16 $0.00 $99.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.45 $95.45 $0.00 $0.00 $26.80 $0.00 $0.00 $0.00 $0.00 $62.43 $98.88 $99.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.11 SUP Custom 27803010 291.11 - WIRE CERCLAGE 1.5MM 280MM EYE STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $15.18 $11.23 $0.00 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.27 $11.27 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $7.37 $11.67 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.12 SUP Custom 27203010 291.12 - WIRE CERCLAGE 1.5MM 600MM EYE STAINLESS STEEL NONSTRL BOTH IP/OP $22.91 $16.95 $0.00 $17.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.01 $17.01 $0.00 $0.00 $4.77 $0.00 $0.00 $0.00 $0.00 $11.12 $17.62 $17.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.13 SUP Custom 27203010 291.13 - WIRE CERCLAGE 1.5MM 10MM COIL STAINLESS STEEL NONSTRL BOTH IP/OP $128.60 $95.16 $0.00 $99.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.45 $95.45 $0.00 $0.00 $26.80 $0.00 $0.00 $0.00 $0.00 $62.43 $98.88 $99.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.22 SUP Custom 27203010 291.22 - WIRE FX .4MM 150MM NS CRLGE SFT PCUT SS BOTH IP/OP $14.34 $10.61 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.64 $10.64 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.96 $11.02 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.24 SUP Custom 27203010 291.24 - WIRE CERCLAGE .6MM 175MM SOFT PRECUT STAINLESS STEEL NONSTRL BOTH IP/OP $15.18 $11.23 $0.00 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.27 $11.27 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $7.37 $11.67 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.26 SUP Custom 27203010 291.26 - WIRE CERCLAGE .8MM 200MM SOFT PRECUT STAINLESS STEEL NONSTRL BOTH IP/OP $17.29 $12.79 $0.00 $13.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.83 $12.83 $0.00 $0.00 $3.60 $0.00 $0.00 $0.00 $0.00 $8.39 $13.30 $13.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.27 SUP Custom 27203010 291.27 - WIRE CRLGE 1MM 250MM NS PCUT SFT SS BOTH IP/OP $18.84 $13.94 $0.00 $14.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.98 $13.98 $0.00 $0.00 $3.93 $0.00 $0.00 $0.00 $0.00 $9.14 $14.49 $14.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.28 SUP Custom 27203010 291.28 - WIRE CRLGE 1.25MM 300MM NS PCUT SFT SS BOTH IP/OP $21.51 $15.92 $0.00 $16.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.96 $15.96 $0.00 $0.00 $4.48 $0.00 $0.00 $0.00 $0.00 $10.44 $16.54 $16.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.02 SUP HCPCS C1713 292.020 - GWIRE ORTH 200MM 1.25MM BOTH IP/OP $24.68 $18.26 $0.00 $19.74 $11.10 $11.10 $0.00 $0.00 $0.00 $5.14 $18.31 $18.31 $0.00 $0.00 $5.14 $0.00 $14.60 $14.60 $0.00 $12.34 $19.55 $19.74 $0.00 $0.00 $3.86 $0.00 $0.00 $3.93 $0.00 $0.00 $0.00 $0.00 $0.00 292.06 SUP Custom 27203010 292.06 - WIRE FIX .6MM 70MM TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $14.34 $10.61 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.64 $10.64 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.96 $11.02 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.08 SUP Custom 27203010 292.08 - WIRE FIX .8MM 70MM TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $14.34 $10.61 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.64 $10.64 $0.00 $0.00 $2.99 $0.00 $0.00 $0.00 $0.00 $6.96 $11.02 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.1 SUP Custom 27203010 292.10 - WIRE FIX 1MM 150MM TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $15.64 $11.57 $0.00 $12.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.60 $11.60 $0.00 $0.00 $3.26 $0.00 $0.00 $0.00 $0.00 $7.82 $12.39 $12.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.11 SUP Custom 27203010 292.11 - WIRE FIX 1MM 285MM TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $20.66 $15.29 $0.00 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.34 $15.34 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $10.03 $15.89 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.13 SUP Custom 27203010 292.13 - WIRE FX 1.25MM 285MM NS KRSH TROC PNT SS BOTH IP/OP $20.66 $15.29 $0.00 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.34 $15.34 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $10.03 $15.89 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.18 SUP Custom 27203010 292.18 - WIRE FIX 1.6MM 285MM 5MM THREADED TROCAR POINT KWIRE BOTH IP/OP $20.66 $15.29 $0.00 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.34 $15.34 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $10.03 $15.89 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.21 SUP Custom 27203010 292.21 - WIRE FIX 2MM 285MM TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $23.30 $17.24 $0.00 $18.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.65 $18.45 $18.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.25 SUP Custom 27203010 292.25 - WIRE FIX 2.5MM 150MM TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $16.59 $12.28 $0.00 $12.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.31 $12.31 $0.00 $0.00 $3.46 $0.00 $0.00 $0.00 $0.00 $8.05 $12.76 $12.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.26 SUP Custom 27203010 292.26 - WIRE FIX 2.5MM 285MM TROCAR KWIRE STAINLESS STEEL NONSTRL BOTH IP/OP $20.66 $15.29 $0.00 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.34 $15.34 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $10.03 $15.89 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.3 SUP Custom 27203010 292.30 - WIRE FIX TROCAR 3MM 150MM KWIRE STAINLESS STEEL NONSTRL BOTH IP/OP $16.11 $11.92 $0.00 $12.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.95 $11.95 $0.00 $0.00 $3.36 $0.00 $0.00 $0.00 $0.00 $8.05 $12.76 $12.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.31 SUP Custom 27203010 292.31 - WIRE FIX 3MM 285MM TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $20.66 $15.29 $0.00 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.34 $15.34 $0.00 $0.00 $4.31 $0.00 $0.00 $0.00 $0.00 $10.03 $15.89 $16.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.38 SUP Custom 27203010 292.38 - WIRE FIX 1.8MM 350MM SPADE POINT KWIRE STAINLESS STEEL BOTH IP/OP $119.20 $88.21 $0.00 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.47 $88.47 $0.00 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $57.86 $91.66 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.39 SUP Custom 27203010 292.39 - WIRE FIX 1.8MM 400MM SPADE POINT REDX KWIRE STAINLESS STEEL BOTH IP/OP $370.95 $274.50 $0.00 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.32 $275.32 $0.00 $0.00 $77.31 $0.00 $0.00 $0.00 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.4 SUP Custom 27203010 292.40 - WIRE FIX 2MM 350MM SPADE POINT KWIRE STAINLESS STEEL NONSTRL BOTH IP/OP $115.73 $85.64 $0.00 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.89 $85.89 $0.00 $0.00 $24.12 $0.00 $0.00 $0.00 $0.00 $57.86 $91.66 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.41 SUP Custom 27203010 292.41 - WIRE FIX 2MM 400MM SPADE POINT REDX KWIRE STAINLESS STEEL BOTH IP/OP $370.95 $274.50 $0.00 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.32 $275.32 $0.00 $0.00 $77.31 $0.00 $0.00 $0.00 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.46 SUP Custom 27203010 292.46 - WIRE FX .6MM 70MM NS KRSH 2 END TROC PNT SS BOTH IP/OP $17.29 $12.79 $0.00 $13.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.83 $12.83 $0.00 $0.00 $3.60 $0.00 $0.00 $0.00 $0.00 $8.39 $13.30 $13.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.48 SUP Custom 27203010 292.48 - WIRE FX .8MM 70MM NS KRSH 2 END TROC PNT SS BOTH IP/OP $17.29 $12.79 $0.00 $13.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.83 $12.83 $0.00 $0.00 $3.60 $0.00 $0.00 $0.00 $0.00 $8.39 $13.30 $13.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.5 SUP Custom 27203010 292.50 - WIRE FIX 1MM 150MM 2 END TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $18.97 $14.04 $0.00 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.08 $14.08 $0.00 $0.00 $3.95 $0.00 $0.00 $0.00 $0.00 $9.49 $15.02 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.52 SUP Custom 27203010 292.52 - WIRE FIX TROCAR 1.25MM 150MM KWIRE STAINLESS STEEL NONSTRL BOTH IP/OP $19.54 $14.46 $0.00 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.50 $14.50 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $9.49 $15.02 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.56 SUP Custom 27203010 292.56 - WIRE FIX TROCAR 1.6MM 150MM 2 END KWIRE STAINLESS STEEL BOTH IP/OP $19.54 $14.46 $0.00 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.50 $14.50 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $9.49 $15.02 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.58 SUP Custom 27203010 292.58 - WIRE FX 2MM 150MM NS KRSH 2 END TROC PNT SS BOTH IP/OP $19.54 $14.46 $0.00 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.50 $14.50 $0.00 $0.00 $4.07 $0.00 $0.00 $0.00 $0.00 $9.49 $15.02 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.6 SUP Custom 27203010 292.600 - WIRE FX 1.25MM 100MM NS KRSH THRD TIP SS MN XTRNFXTR BOTH IP/OP $81.22 $60.10 $0.00 $64.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.28 $60.28 $0.00 $0.00 $16.93 $0.00 $0.00 $0.00 $0.00 $40.61 $64.33 $64.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.619 SUP HCPCS C1769 292.619 - GUIDEWIRE ORTHOPEDIC .8MM 100MM SPADE POINT STAINLESS STEEL BOTH IP/OP $28.26 $20.91 $0.00 $41.68 $14.90 $14.90 $0.00 $0.00 $0.00 $5.89 $20.97 $20.97 $0.00 $0.00 $5.89 $0.00 $16.71 $16.71 $0.00 $13.72 $21.72 $21.95 $0.00 $0.00 $41.68 $0.00 $0.00 $4.37 $0.00 $0.00 $0.00 $0.00 $0.00 292.62 SUP HCPCS C1769 292.62 - GWIRE ORTH 150MM 1.25MM SS THRD BOTH IP/OP $59.13 $43.76 $0.00 $47.30 $32.10 $32.10 $0.00 $0.00 $0.00 $12.32 $43.88 $43.88 $0.00 $0.00 $12.32 $0.00 $34.97 $34.97 $0.00 $29.56 $46.83 $47.30 $0.00 $0.00 $9.25 $0.00 $0.00 $9.41 $0.00 $0.00 $0.00 $0.00 $0.00 292.621 SUP HCPCS C1713 292.621 - GUIDEWIRE ORTHOPEDIC 1.25MM 150MM THREADED SPADE POINT ON 2 BOTH IP/OP $53.05 $39.26 $0.00 $41.20 $23.18 $23.18 $0.00 $0.00 $0.00 $11.06 $39.37 $39.37 $0.00 $0.00 $11.06 $0.00 $31.38 $31.38 $0.00 $25.75 $40.79 $41.20 $0.00 $0.00 $7.83 $0.00 $0.00 $8.20 $0.00 $0.00 $0.00 $0.00 $0.00 292.622 SUP HCPCS C1713 292.622 - GUIDEWIRE ORTHOPEDIC 1.1MM 150MM THREAD STAINLESS STEEL BOTH IP/OP $55.50 $41.07 $0.00 $43.12 $24.26 $24.26 $0.00 $0.00 $0.00 $11.57 $41.19 $41.19 $0.00 $0.00 $11.57 $0.00 $32.83 $32.83 $0.00 $26.95 $42.69 $43.12 $0.00 $0.00 $8.19 $0.00 $0.00 $8.58 $0.00 $0.00 $0.00 $0.00 $0.00 292.623 SUP HCPCS C1713 292.623 - GUIDEWIRE ORTHOPEDIC 1.1MM 150MM NONTHREADED STAINLESS STEEL BOTH IP/OP $52.70 $39.00 $0.00 $40.94 $23.03 $23.03 $0.00 $0.00 $0.00 $10.98 $39.11 $39.11 $0.00 $0.00 $10.98 $0.00 $31.17 $31.17 $0.00 $25.59 $40.53 $40.94 $0.00 $0.00 $7.77 $0.00 $0.00 $8.15 $0.00 $0.00 $0.00 $0.00 $0.00 292.626 SUP HCPCS C1769 292.626 - GUIDEWIRE ORTHOPEDIC 150MM 1 END SPADE PONT STAINLESS STEEL BOTH IP/OP $62.40 $46.18 $0.00 $49.92 $33.88 $33.88 $0.00 $0.00 $0.00 $13.01 $46.31 $46.31 $0.00 $0.00 $13.00 $0.00 $36.91 $36.91 $0.00 $31.20 $49.42 $49.92 $0.00 $0.00 $9.77 $0.00 $0.00 $9.93 $0.00 $0.00 $0.00 $0.00 $0.00 292.65 SUP HCPCS C1769 292.65 - GUIDEWIRE ORTHOPEDIC SPADE 2MM 230MM THREAD BLACK STAINLESS BOTH IP/OP $75.20 $55.65 $0.00 $58.40 $39.64 $39.64 $0.00 $0.00 $0.00 $15.67 $55.81 $55.81 $0.00 $0.00 $15.67 $0.00 $44.48 $44.48 $0.00 $36.50 $57.82 $58.40 $0.00 $0.00 $11.09 $0.00 $0.00 $11.62 $0.00 $0.00 $0.00 $0.00 $0.00 292.651 SUP HCPCS C1713 292.651 - GUIDEWIRE ORTHOPEDIC 2MM 230MM THREADED SPADE POINT BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 292.652 SUP HCPCS C1713 292.652 - GUIDEWIRE ORTHOPEDIC 2MM 230MM THREADED SPADE POINT BOTH IP/OP $73.78 $54.60 $0.00 $57.30 $32.23 $32.23 $0.00 $0.00 $0.00 $15.38 $54.76 $54.76 $0.00 $0.00 $15.37 $0.00 $43.64 $43.64 $0.00 $35.81 $56.73 $57.30 $0.00 $0.00 $10.88 $0.00 $0.00 $11.40 $0.00 $0.00 $0.00 $0.00 $0.00 292.653 SUP Custom 27203010 292.653 - GUIDEWIRE ORTHOPEDIC 2MM 330MM TROCAR THREAD STAINLESS STEEL BOTH IP/OP $111.05 $82.18 $0.00 $86.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.42 $82.42 $0.00 $0.00 $23.14 $0.00 $0.00 $0.00 $0.00 $53.91 $85.40 $86.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.655 SUP Custom 27203010 292.655 - GUIDEWIRE ORTHOPEDIC 1.6MM 410MM BOTH IP/OP $101.90 $75.41 $0.00 $79.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.63 $75.63 $0.00 $0.00 $21.24 $0.00 $0.00 $0.00 $0.00 $49.46 $78.35 $79.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.656 SUP HCPCS C1713 292.656 - GUIDEWIRE ORTHOPEDIC 2MM 230MM NONTHREADED STAINLESS STEEL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 292.68 SUP HCPCS C1713 292.68 - GUIDEWIRE ORTHOPEDIC 2.8MM 300MM TROCAR THREAD STAINLESS BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 292.69 SUP Custom 27203010 292.69 - GUIDEWIRE ORTHOPEDIC 3.2MM 300MM CALIBRATE STAINLESS STEEL BOTH IP/OP $231.95 $171.64 $0.00 $180.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.15 $172.15 $0.00 $0.00 $48.34 $0.00 $0.00 $0.00 $0.00 $112.59 $178.34 $180.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.699 SUP Custom 27203010 292.699 - WIRE FX 2MM 280MM NS KRSH THRD SPD PNT TIP SS BOTH IP/OP $76.60 $56.68 $0.00 $59.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.85 $56.85 $0.00 $0.00 $15.96 $0.00 $0.00 $0.00 $0.00 $37.19 $58.91 $59.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.708 SUP Custom 27203010 292.708 - WIRE FX 1.6MM 100MM NS KRSH THRD TIP SS MN XTRNFXTR BOTH IP/OP $836.60 $619.08 $0.00 $669.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $620.92 $620.92 $0.00 $0.00 $174.35 $0.00 $0.00 $0.00 $0.00 $418.30 $662.59 $669.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.71 SUP Custom 27203010 292.71 - WIRE FIX 1.6MM 15CM 5MM THREADED TROCAR POINT KWIRE BOTH IP/OP $294.15 $217.67 $0.00 $235.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.32 $218.32 $0.00 $0.00 $61.30 $0.00 $0.00 $0.00 $0.00 $147.08 $232.97 $235.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.72 SUP HCPCS C1713 292.72 - GUIDEWIRE ORTHOPEDIC 1.6MM 150MM THREAD STAINLESS STEEL BOTH IP/OP $63.25 $46.81 $0.00 $49.14 $27.64 $27.64 $0.00 $0.00 $0.00 $13.18 $46.94 $46.94 $0.00 $0.00 $13.18 $0.00 $37.41 $37.41 $0.00 $30.71 $48.65 $49.14 $0.00 $0.00 $11.92 $0.00 $0.00 $9.78 $0.00 $0.00 $0.00 $0.00 $0.00 292.721 SUP HCPCS C1713 292.721 - GUIDEWIRE ORTHOPEDIC 1.6MM 150MM THREADED SPADE POINT BOTH IP/OP $73.78 $54.60 $0.00 $57.30 $32.23 $32.23 $0.00 $0.00 $0.00 $15.38 $54.76 $54.76 $0.00 $0.00 $15.37 $0.00 $43.64 $43.64 $0.00 $35.81 $56.73 $57.30 $0.00 $0.00 $10.88 $0.00 $0.00 $11.40 $0.00 $0.00 $0.00 $0.00 $0.00 292.722 SUP HCPCS C1713 292.722 - GUIDEWIRE ORTHOPEDIC 1.6MM 150MM THREADED SPADE POINT BOTH IP/OP $55.18 $40.83 $0.00 $42.84 $24.10 $24.10 $0.00 $0.00 $0.00 $11.50 $40.95 $40.95 $0.00 $0.00 $11.50 $0.00 $32.64 $32.64 $0.00 $26.78 $42.41 $42.84 $0.00 $0.00 $8.14 $0.00 $0.00 $8.53 $0.00 $0.00 $0.00 $0.00 $0.00 292.727 SUP HCPCS C1713 292.727 - GUIDEWIRE ORTHOPEDIC 1.6MM 150MM NONTHREADED SPADE POINT BOTH IP/OP $53.05 $39.26 $0.00 $41.20 $23.18 $23.18 $0.00 $0.00 $0.00 $11.06 $39.37 $39.37 $0.00 $0.00 $11.06 $0.00 $31.38 $31.38 $0.00 $25.75 $40.79 $41.20 $0.00 $0.00 $7.83 $0.00 $0.00 $8.20 $0.00 $0.00 $0.00 $0.00 $0.00 292.73 SUP Custom 27203010 292.73 - WIRE FX 1.6MM 150MM NS 15MM KRSH TROC PNT THRD SS BOTH IP/OP $29.42 $21.77 $0.00 $23.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.83 $21.83 $0.00 $0.00 $6.13 $0.00 $0.00 $0.00 $0.00 $14.71 $23.30 $23.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.75 SUP Custom 27203010 292.75 - WIRE FX 2.5MM 150MM NS 15MM KRSH TROC PNT THRD SS BOTH IP/OP $34.30 $25.38 $0.00 $25.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.46 $25.46 $0.00 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $16.17 $25.61 $25.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.76 SUP Custom 27203010 292.76 - WIRE FIX 2.5MM 200MM 15MM THREADED TROCAR POINT KWIRE BOTH IP/OP $35.57 $26.32 $0.00 $27.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.40 $26.40 $0.00 $0.00 $7.41 $0.00 $0.00 $0.00 $0.00 $17.26 $27.35 $27.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.79 SUP Custom 27203010 292.79 - WIRE FX 2MM 150MM NS 15MM KRSH TROC PNT THRD SS BOTH IP/OP $32.19 $23.82 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.89 $23.89 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $15.63 $24.75 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.801 SUP Custom 27203010 292.801 - WIRE FX 2MM 150MM NS 15MM KRSH CLBRT THRD TROC PNT SS BOTH IP/OP $83.25 $61.61 $0.00 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.79 $61.79 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292.81 SUP HCPCS C1713 292.81 - GUIDEWIRE ORTHOPEDIC 2.8MM 300MM 150MM NONTHREADED STAINLESS BOTH IP/OP $189.78 $140.44 $0.00 $147.40 $82.91 $82.91 $0.00 $0.00 $0.00 $39.55 $140.85 $140.85 $0.00 $0.00 $39.55 $0.00 $112.25 $112.25 $0.00 $92.13 $145.93 $147.40 $0.00 $0.00 $27.99 $0.00 $0.00 $29.33 $0.00 $0.00 $0.00 $0.00 $0.00 293.35 SUP Custom 27203010 293.35 - PIN FIX 3.5MM 120MM STEINMANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $67.95 $50.28 $0.00 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.43 $50.43 $0.00 $0.00 $14.16 $0.00 $0.00 $0.00 $0.00 $32.99 $52.26 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.36 SUP Custom 27203010 293.36 - PIN FIX 3.5MM 150MM TRACTION STEINMANN STAINLESS STEEL BOTH IP/OP $67.95 $50.28 $0.00 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.43 $50.43 $0.00 $0.00 $14.16 $0.00 $0.00 $0.00 $0.00 $32.99 $52.26 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.4 SUP Custom 27203010 293.40 - PIN FIX 4MM 150MM STEINMANN STAINLESS STEEL NONSTRL TRACTION BOTH IP/OP $65.98 $48.83 $0.00 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.97 $48.97 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $32.99 $52.26 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.41 SUP Custom 27203010 293.41 - PIN FIX LARGE 4MM 180MM EXTERNAL IMPLANT TRACTION STEINMANN BOTH IP/OP $67.95 $50.28 $0.00 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.43 $50.43 $0.00 $0.00 $14.16 $0.00 $0.00 $0.00 $0.00 $32.99 $52.26 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.42 SUP Custom 27203010 293.42 - PIN FIX 4MM 200MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $67.95 $50.28 $0.00 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.43 $50.43 $0.00 $0.00 $14.16 $0.00 $0.00 $0.00 $0.00 $32.99 $52.26 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.44 SUP Custom 27203010 293.44 - PIN FIX 4.5MM 120MM STEINMANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.45 SUP Custom 27203010 293.45 - PIN FIX 4.5MM 150MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.46 SUP Custom 27203010 293.46 - PIN FIX 4.5MM 180MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.47 SUP Custom 27203010 293.47 - PIN FIX 4.5MM 200MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.48 SUP Custom 27203010 293.48 - PIN FIX 4.5MM 250MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.49 SUP Custom 27203010 293.49 - PIN FIX 4.5MM 225MM STEINMANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.5 SUP Custom 27203010 293.50 - PIN FIX 5MM 150MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $122.20 $90.43 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.70 $90.70 $0.00 $0.00 $25.47 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.51 SUP Custom 27203010 293.51 - PIN FIX 5MM 180MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.52 SUP Custom 27203010 293.52 - PIN FIX 5MM 200MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.53 SUP Custom 27203010 293.53 - PIN FIX 5MM 250MM STEINMANN STAINLESS STEEL NONSTRL LARGE BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.54 SUP Custom 27203010 293.54 - PIN FIX 5MM 300MM STEINMANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.58 SUP Custom 27203010 293.58 - PIN FIX 5MM 225MM STEINMANN STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.59 SUP Custom 27203010 293.59 - PIN FIX 5MM 275MM STEINMANN ORTHOPEDIC NONSTRL LARGE EXFIX BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.62 SUP Custom 27203010 293.62 - PIN FIX 4MM 150MM CENTRL THREAD STEINMANN STAINLESS STEEL BOTH IP/OP $190.48 $140.96 $0.00 $147.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.37 $141.37 $0.00 $0.00 $39.69 $0.00 $0.00 $0.00 $0.00 $92.46 $146.46 $147.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.63 SUP Custom 27203010 293.63 - PIN FIX 4.5MM 5MM 150MM CENTRL THREAD STEINMANN STAINLESS BOTH IP/OP $190.48 $140.96 $0.00 $147.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.37 $141.37 $0.00 $0.00 $39.69 $0.00 $0.00 $0.00 $0.00 $92.46 $146.46 $147.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.67 SUP Custom 27203010 293.67 - PIN FIX 4MM 180MM CENTRL THREAD STEINMANN STAINLESS STEEL BOTH IP/OP $190.48 $140.96 $0.00 $147.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.37 $141.37 $0.00 $0.00 $39.69 $0.00 $0.00 $0.00 $0.00 $92.46 $146.46 $147.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.68 SUP Custom 27203010 293.68 - PIN FX CNTR THRD 4.5MM 5MM 180MM NS STNM SS LG XTRNFXTR BOTH IP/OP $213.88 $158.27 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.74 $158.74 $0.00 $0.00 $44.57 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.69 SUP Custom 27203010 293.69 - PIN FIX 5MM 5.5MM 175MM CENTRL THREAD STEINMANN STAINLESS BOTH IP/OP $213.88 $158.27 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.74 $158.74 $0.00 $0.00 $44.57 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.72 SUP Custom 27203010 293.72 - PIN FIX 4MM 4.5MM 200MM CENTRL THREAD STEINMANN STAINLESS BOTH IP/OP $190.48 $140.96 $0.00 $147.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.37 $141.37 $0.00 $0.00 $39.69 $0.00 $0.00 $0.00 $0.00 $92.46 $146.46 $147.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.73 SUP Custom 27203010 293.73 - PIN FIX 4.5MM 200MM CENTRL THREAD STEINMANN STAINLESS STEEL BOTH IP/OP $213.88 $158.27 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.74 $158.74 $0.00 $0.00 $44.57 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.74 SUP Custom 27203010 293.74 - PIN FX CNTR THRD 5MM 5.5MM 200MM NS STNM SS LG XTRNFXTR BOTH IP/OP $213.88 $158.27 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.74 $158.74 $0.00 $0.00 $44.57 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.78 SUP Custom 27203010 293.78 - PIN FX CNTR THRD 4.5MM 5MM 225MM NS STNM SS LG XTRNFXTR BOTH IP/OP $213.88 $158.27 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.74 $158.74 $0.00 $0.00 $44.57 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.79 SUP Custom 27203010 293.790 - PIN FIX CENTRL THREAD 5MM 5.5MM 225MM STEINMANN STAINLESS BOTH IP/OP $207.65 $153.66 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.12 $154.12 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.83 SUP Custom 27203010 293.83 - PIN FIX 4.5MM 250MM CENTRL THREAD STEINMANN STAINLESS STEEL BOTH IP/OP $213.88 $158.27 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.74 $158.74 $0.00 $0.00 $44.57 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.84 SUP Custom 27203010 293.840 - PIN FIX 5MM 5.5MM 250MM 3 FLAT END CENTRL THREAD ROUND BOTH IP/OP $207.65 $153.66 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.12 $154.12 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.88 SUP Custom 27203010 293.88 - PIN FX CNTR THRD 4.5MM 5MM 275MM NS STNM SS LG XTRNFXTR BOTH IP/OP $213.88 $158.27 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.74 $158.74 $0.00 $0.00 $44.57 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.89 SUP Custom 27203010 293.890 - PIN FIX 5MM 275MM CENTRL THREAD STEINMANN STAINLESS STEEL BOTH IP/OP $207.65 $153.66 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.12 $154.12 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.93 SUP Custom 27203010 293.93 - PIN FIX 4.5MM 300MM CENTRL THREAD STEINMANN STAINLESS STEEL BOTH IP/OP $213.88 $158.27 $0.00 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.74 $158.74 $0.00 $0.00 $44.57 $0.00 $0.00 $0.00 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.94 SUP HCPCS C1713 293.940 - PIN FIX 5MM 300MM CENTRL THREAD STEINMANN STAINLESS STEEL BOTH IP/OP $207.65 $153.66 $0.00 $166.12 $93.44 $93.44 $0.00 $0.00 $0.00 $43.28 $154.12 $154.12 $0.00 $0.00 $43.27 $0.00 $122.82 $122.82 $0.00 $103.83 $164.46 $166.12 $0.00 $0.00 $31.55 $0.00 $0.00 $33.06 $0.00 $0.00 $0.00 $0.00 $0.00 294.3 SUP HCPCS C1713 294.30 - SCREW XTRNFX 4MM 3MM 80MM NS 20MM SCHNZ TROC PNT MR BOTH IP/OP $124.38 $92.04 $0.00 $99.50 $55.97 $55.97 $0.00 $0.00 $0.00 $25.92 $92.31 $92.31 $0.00 $0.00 $25.92 $0.00 $73.57 $73.57 $0.00 $62.19 $98.51 $99.50 $0.00 $0.00 $18.90 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $0.00 294.43 SUP HCPCS C1713 294.43 - SCREW XTRNFX 4MM 60MM NS SCHNZ SPD PNT SS LG XTRNFXTR BOTH IP/OP $128.10 $94.79 $0.00 $99.50 $55.97 $55.97 $0.00 $0.00 $0.00 $26.70 $95.08 $95.08 $0.00 $0.00 $26.70 $0.00 $75.77 $75.77 $0.00 $62.19 $98.51 $99.50 $0.00 $0.00 $18.90 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $0.00 294.44 SUP HCPCS C1713 294.44 - SCREW XTRNFX 4MM 80MM NS SCHNZ SPD PNT MR CONDITIONAL SS LG BOTH IP/OP $128.10 $94.79 $0.00 $99.50 $55.97 $55.97 $0.00 $0.00 $0.00 $26.70 $95.08 $95.08 $0.00 $0.00 $26.70 $0.00 $75.77 $75.77 $0.00 $62.19 $98.51 $99.50 $0.00 $0.00 $18.90 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $0.00 294.45 SUP HCPCS C1713 294.45 - SCREW XTRNFX 4MM 100MM NS 25MM SCHNZ SPD PNT SS PLVC LG BOTH IP/OP $128.10 $94.79 $0.00 $99.50 $55.97 $55.97 $0.00 $0.00 $0.00 $26.70 $95.08 $95.08 $0.00 $0.00 $26.70 $0.00 $75.77 $75.77 $0.00 $62.19 $98.51 $99.50 $0.00 $0.00 $18.90 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $0.00 294.455 SUP HCPCS C1713 294.455 - SCREW BONE 4MM 100MM 38IN SPADE POINT PTHRD SCHANZ BOTH IP/OP $128.10 $94.79 $0.00 $99.50 $55.97 $55.97 $0.00 $0.00 $0.00 $26.70 $95.08 $95.08 $0.00 $0.00 $26.70 $0.00 $75.77 $75.77 $0.00 $62.19 $98.51 $99.50 $0.00 $0.00 $18.90 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $0.00 294.46 SUP HCPCS C1713 294.46 - SCREW XTRNFX 4MM 120MM NS SCHNZ SPD PNT MR CONDITIONAL SS BOTH IP/OP $128.10 $94.79 $0.00 $99.50 $55.97 $55.97 $0.00 $0.00 $0.00 $26.70 $95.08 $95.08 $0.00 $0.00 $26.70 $0.00 $75.77 $75.77 $0.00 $62.19 $98.51 $99.50 $0.00 $0.00 $18.90 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $0.00 294.48 SUP HCPCS C1713 294.48 - SCREW XTRNFX 4MM 150MM NS 25MM SCHNZ SPD PNT SS PLVC LG BOTH IP/OP $128.10 $94.79 $0.00 $99.50 $55.97 $55.97 $0.00 $0.00 $0.00 $26.70 $95.08 $95.08 $0.00 $0.00 $26.70 $0.00 $75.77 $75.77 $0.00 $62.19 $98.51 $99.50 $0.00 $0.00 $18.90 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $0.00 294.52 SUP HCPCS C1713 294.52 - SCREW XTRNFX XLNG 5MM 100MM NS SCHNZ BLNT TROC PNT MR BOTH IP/OP $141.48 $104.70 $0.00 $109.88 $61.81 $61.81 $0.00 $0.00 $0.00 $29.49 $105.00 $105.00 $0.00 $0.00 $29.48 $0.00 $83.68 $83.68 $0.00 $68.68 $108.78 $109.88 $0.00 $0.00 $20.87 $0.00 $0.00 $21.87 $0.00 $0.00 $0.00 $0.00 $0.00 294.53 SUP HCPCS C1713 294.53 - SCREW XTRNFX 5MM 125MM NS SCHNZ BLNT TROC PNT MR CONDITIONAL BOTH IP/OP $141.48 $104.70 $0.00 $109.88 $61.81 $61.81 $0.00 $0.00 $0.00 $29.49 $105.00 $105.00 $0.00 $0.00 $29.48 $0.00 $83.68 $83.68 $0.00 $68.68 $108.78 $109.88 $0.00 $0.00 $20.87 $0.00 $0.00 $21.87 $0.00 $0.00 $0.00 $0.00 $0.00 294.54 SUP HCPCS C1713 294.54 - SCREW XTRNFX 5MM 150MM NS SCHNZ BLNT TROC PNT MR CONDITIONAL BOTH IP/OP $141.48 $104.70 $0.00 $109.88 $61.81 $61.81 $0.00 $0.00 $0.00 $29.49 $105.00 $105.00 $0.00 $0.00 $29.48 $0.00 $83.68 $83.68 $0.00 $68.68 $108.78 $109.88 $0.00 $0.00 $20.87 $0.00 $0.00 $21.87 $0.00 $0.00 $0.00 $0.00 $0.00 294.55 SUP HCPCS C1713 294.55 - SCREW XTRNFX XLNG 5MM 170MM NS 50MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $163.75 $121.18 $0.00 $127.18 $71.54 $71.54 $0.00 $0.00 $0.00 $34.13 $121.54 $121.54 $0.00 $0.00 $34.13 $0.00 $96.86 $96.86 $0.00 $79.49 $125.91 $127.18 $0.00 $0.00 $34.25 $0.00 $0.00 $25.31 $0.00 $0.00 $0.00 $0.00 $0.00 294.56 SUP HCPCS C1713 294.56 - SCREW XTRNFX 5MM 200MM NS SCHNZ BLNT TROC PNT MR CONDITIONAL BOTH IP/OP $163.75 $121.18 $0.00 $127.18 $71.54 $71.54 $0.00 $0.00 $0.00 $34.13 $121.54 $121.54 $0.00 $0.00 $34.13 $0.00 $96.86 $96.86 $0.00 $79.49 $125.91 $127.18 $0.00 $0.00 $24.16 $0.00 $0.00 $25.31 $0.00 $0.00 $0.00 $0.00 $0.00 294.57 SUP HCPCS C1713 294.57 - SCREW XTRNFX 5MM 250MM NS SCHNZ BLNT TROC PNT MR CONDITIONAL BOTH IP/OP $163.75 $121.18 $0.00 $127.18 $71.54 $71.54 $0.00 $0.00 $0.00 $34.13 $121.54 $121.54 $0.00 $0.00 $34.13 $0.00 $96.86 $96.86 $0.00 $79.49 $125.91 $127.18 $0.00 $0.00 $24.16 $0.00 $0.00 $25.31 $0.00 $0.00 $0.00 $0.00 $0.00 294.65 SUP HCPCS C1713 294.65 - SCREW XTRNFX 6MM 100MM NS 50MM SCHNZ SPD PNT SS LG XTRNFXTR BOTH IP/OP $141.48 $104.70 $0.00 $109.88 $61.81 $61.81 $0.00 $0.00 $0.00 $29.49 $105.00 $105.00 $0.00 $0.00 $29.48 $0.00 $83.68 $83.68 $0.00 $68.68 $108.78 $109.88 $0.00 $0.00 $20.87 $0.00 $0.00 $21.87 $0.00 $0.00 $0.00 $0.00 $0.00 294.66 SUP HCPCS C1713 294.66 - SCREW EXFIX BLUNT SPADE 6MM 130MM 50MM TROCAR SCHANZ BOTH IP/OP $141.48 $104.70 $0.00 $109.88 $61.81 $61.81 $0.00 $0.00 $0.00 $29.49 $105.00 $105.00 $0.00 $0.00 $29.48 $0.00 $83.68 $83.68 $0.00 $68.68 $108.78 $109.88 $0.00 $0.00 $20.87 $0.00 $0.00 $21.87 $0.00 $0.00 $0.00 $0.00 $0.00 294.67 SUP HCPCS C1713 294.67 - SCREW XTRNFX 6MM 160MM NS 50MM SCHNZ SPD PNT SS LG XTRNFXTR BOTH IP/OP $147.05 $108.82 $0.00 $114.20 $64.24 $64.24 $0.00 $0.00 $0.00 $30.65 $109.14 $109.14 $0.00 $0.00 $30.65 $0.00 $86.98 $86.98 $0.00 $71.38 $113.06 $114.20 $0.00 $0.00 $21.69 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 294.68 SUP HCPCS C1713 294.68 - SCREW XTRNFX 6MM 190MM NS 50MM SCHNZ SPD PNT SS LG XTRNFXTR BOTH IP/OP $147.05 $108.82 $0.00 $114.20 $64.24 $64.24 $0.00 $0.00 $0.00 $30.65 $109.14 $109.14 $0.00 $0.00 $30.65 $0.00 $86.98 $86.98 $0.00 $71.38 $113.06 $114.20 $0.00 $0.00 $21.69 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 294.71 SUP HCPCS C1713 294.71 - SCREW EXFIX BLUNT SPADE 4.5MM 80MM 18MM TROCAR SCHANZ BOTH IP/OP $124.75 $92.32 $0.00 $96.90 $54.51 $54.51 $0.00 $0.00 $0.00 $26.00 $92.59 $92.59 $0.00 $0.00 $26.00 $0.00 $73.79 $73.79 $0.00 $60.56 $95.93 $96.90 $0.00 $0.00 $18.40 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $0.00 294.72 SUP HCPCS C1713 294.72 - SCREW XTRNFX ST 4.5MM 100MM NS 18MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $124.75 $92.32 $0.00 $96.90 $54.51 $54.51 $0.00 $0.00 $0.00 $26.00 $92.59 $92.59 $0.00 $0.00 $26.00 $0.00 $73.79 $73.79 $0.00 $60.56 $95.93 $96.90 $0.00 $0.00 $18.40 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $0.00 294.73 SUP HCPCS C1713 294.73 - SCREW XTRNFX ST 4.5MM 125MM NS 18MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $124.75 $92.32 $0.00 $96.90 $54.51 $54.51 $0.00 $0.00 $0.00 $26.00 $92.59 $92.59 $0.00 $0.00 $26.00 $0.00 $73.79 $73.79 $0.00 $60.56 $95.93 $96.90 $0.00 $0.00 $18.40 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $0.00 294.74 SUP HCPCS C1713 294.74 - SCREW XTRNFX ST 4.5MM 150MM NS 18MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $124.75 $92.32 $0.00 $96.90 $54.51 $54.51 $0.00 $0.00 $0.00 $26.00 $92.59 $92.59 $0.00 $0.00 $26.00 $0.00 $73.79 $73.79 $0.00 $60.56 $95.93 $96.90 $0.00 $0.00 $18.40 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $0.00 294.75 SUP HCPCS C1713 294.75 - SCREW XTRNFX ST 4.5MM 175MM NS 18MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $147.05 $108.82 $0.00 $114.20 $64.24 $64.24 $0.00 $0.00 $0.00 $30.65 $109.14 $109.14 $0.00 $0.00 $30.65 $0.00 $86.98 $86.98 $0.00 $71.38 $113.06 $114.20 $0.00 $0.00 $21.69 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 294.76 SUP HCPCS C1713 294.76 - SCREW XTRNFX 4.5MM 200MM NS SCHNZ BLNT TROC PNT MR BOTH IP/OP $147.05 $108.82 $0.00 $114.20 $64.24 $64.24 $0.00 $0.00 $0.00 $30.65 $109.14 $109.14 $0.00 $0.00 $30.65 $0.00 $86.98 $86.98 $0.00 $71.38 $113.06 $114.20 $0.00 $0.00 $21.69 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 294.767 SUP HCPCS C1713 294.767 - SCREW BONE 4MM 2.5MM 65MM 18MM SLFDRILL TROCAR POINT SCHANZ BOTH IP/OP $221.68 $164.04 $0.00 $172.18 $96.85 $96.85 $0.00 $0.00 $0.00 $46.20 $164.53 $164.53 $0.00 $0.00 $46.20 $0.00 $131.12 $131.12 $0.00 $107.61 $170.46 $172.18 $0.00 $0.00 $32.70 $0.00 $0.00 $34.26 $0.00 $0.00 $0.00 $0.00 $0.00 294.768 SUP HCPCS C1713 294.768 - SCREW BONE 4MM 2.5MM 80MM 20MM SLFDRILL TROCAR POINT SCHANZ BOTH IP/OP $221.68 $164.04 $0.00 $172.18 $96.85 $96.85 $0.00 $0.00 $0.00 $46.20 $164.53 $164.53 $0.00 $0.00 $46.20 $0.00 $131.12 $131.12 $0.00 $107.61 $170.46 $172.18 $0.00 $0.00 $32.70 $0.00 $0.00 $34.26 $0.00 $0.00 $0.00 $0.00 $0.00 294.769 SUP HCPCS C1713 294.769 - SCREW XTRNFX 4MM 2.5MM 80MM NS 20MM SCHNZ SLF DRL MR BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.771 SUP HCPCS C1713 294.771 - SCREW XTRNFX 4MM 3MM 80MM NS 20MM SCHNZ SLF DRL MR BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.772 SUP HCPCS C1713 294.772 - SCREW BONE 4/3MM 100MM 20MM SLFDRILL SCHANZ STAINLESS STEEL BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.773 SUP HCPCS C1713 294.773 - SCREW BONE 4MM 3MM 65MM 18MM SELF DRILL SCHANZ STAINLESS BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.774 SUP HCPCS C1713 294.774 - SCREW BONE 4MM 60MM 20MM SELF DRILL SCHANZ STAINLESS STEEL BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.775 SUP HCPCS C1713 294.775 - SCREW XTRNFX 4MM 80MM NS 20MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.776 SUP HCPCS C1713 294.776 - SCREW XTRNFX 4MM 100MM NS 30MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.777 SUP HCPCS C1713 294.777 - SCREW XTRNFX 4MM 125MM NS 40MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.778 SUP HCPCS C1713 294.778 - SCREW XTRNFX 4MM 150MM NS 40MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.779 SUP HCPCS C1713 294.779 - SCREW XTRNFX 4MM 175MM NS 40MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 294.782 SUP HCPCS C1713 294.782 - SCREW XTRNFX 5MM 100MM NS 30MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $281.83 $208.55 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $58.74 $209.17 $209.17 $0.00 $0.00 $58.73 $0.00 $166.70 $166.70 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $41.57 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 294.783 SUP HCPCS C1713 294.783 - SCREW XTRNFX 5MM 125MM NS 40MM SCHNZ SLF DRL SS HIP CNDYL LG BOTH IP/OP $281.83 $208.55 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $58.74 $209.17 $209.17 $0.00 $0.00 $58.73 $0.00 $166.70 $166.70 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $41.57 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 294.784 SUP HCPCS C1713 294.784 - SCREW XTRNFX 5MM 150MM NS 60MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $281.83 $208.55 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $58.74 $209.17 $209.17 $0.00 $0.00 $58.73 $0.00 $166.70 $166.70 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $41.57 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 294.785 SUP HCPCS C1713 294.785 - SCREW XTRNFX 5MM 175MM NS 60MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $281.83 $208.55 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $58.74 $209.17 $209.17 $0.00 $0.00 $58.73 $0.00 $166.70 $166.70 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $41.57 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 294.786 SUP HCPCS C1713 294.786 - SCREW XTRNFX 5MM 200MM NS 80MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $281.83 $208.55 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $58.74 $209.17 $209.17 $0.00 $0.00 $58.73 $0.00 $166.70 $166.70 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $41.57 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 294.788 SUP HCPCS C1713 294.788 - SCREW XTRNFX 5MM 250MM NS 80MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $281.83 $208.55 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $58.74 $209.17 $209.17 $0.00 $0.00 $58.73 $0.00 $166.70 $166.70 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $41.57 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 294.792 SUP HCPCS C1713 294.792 - SCREW BONE 6MM 100MM 30MM SLFDRILL SCHANZ STAINLESS STEEL BOTH IP/OP $300.78 $222.58 $0.00 $233.60 $131.40 $131.40 $0.00 $0.00 $0.00 $62.69 $223.24 $223.24 $0.00 $0.00 $62.68 $0.00 $177.91 $177.91 $0.00 $146.00 $231.26 $233.60 $0.00 $0.00 $44.37 $0.00 $0.00 $46.49 $0.00 $0.00 $0.00 $0.00 $0.00 294.793 SUP HCPCS C1713 294.793 - SCREW BONE 6MM 125MM 40MM SLFDRILL SCHANZ STAINLESS STEEL BOTH IP/OP $300.78 $222.58 $0.00 $233.60 $131.40 $131.40 $0.00 $0.00 $0.00 $62.69 $223.24 $223.24 $0.00 $0.00 $62.68 $0.00 $177.91 $177.91 $0.00 $146.00 $231.26 $233.60 $0.00 $0.00 $44.37 $0.00 $0.00 $46.49 $0.00 $0.00 $0.00 $0.00 $0.00 294.794 SUP HCPCS C1713 294.794 - SCREW BONE 6MM 150MM 60MM SELF DRILL SCHANZ STAINLESS STEEL BOTH IP/OP $300.78 $222.58 $0.00 $233.60 $131.40 $131.40 $0.00 $0.00 $0.00 $62.69 $223.24 $223.24 $0.00 $0.00 $62.68 $0.00 $177.91 $177.91 $0.00 $146.00 $231.26 $233.60 $0.00 $0.00 $44.37 $0.00 $0.00 $46.49 $0.00 $0.00 $0.00 $0.00 $0.00 294.795 SUP HCPCS C1713 294.795 - SCREW BONE 6MM 175MM 60MM SLFDRILL SCHANZ STAINLESS STEEL BOTH IP/OP $300.78 $222.58 $0.00 $233.60 $131.40 $131.40 $0.00 $0.00 $0.00 $62.69 $223.24 $223.24 $0.00 $0.00 $62.68 $0.00 $177.91 $177.91 $0.00 $146.00 $231.26 $233.60 $0.00 $0.00 $44.37 $0.00 $0.00 $46.49 $0.00 $0.00 $0.00 $0.00 $0.00 294.796 SUP HCPCS C1713 294.796 - SCREW BONE 6MM 200MM 80MM SELF DRILL SCHANZ STAINLESS STEEL BOTH IP/OP $300.78 $222.58 $0.00 $233.60 $131.40 $131.40 $0.00 $0.00 $0.00 $62.69 $223.24 $223.24 $0.00 $0.00 $62.68 $0.00 $177.91 $177.91 $0.00 $146.00 $231.26 $233.60 $0.00 $0.00 $44.37 $0.00 $0.00 $46.49 $0.00 $0.00 $0.00 $0.00 $0.00 294.798 SUP HCPCS C1713 294.798 - SCREW XTRNFX 4MM 175MM NS 40MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $300.78 $222.58 $0.00 $233.60 $131.40 $131.40 $0.00 $0.00 $0.00 $62.69 $223.24 $223.24 $0.00 $0.00 $62.68 $0.00 $177.91 $177.91 $0.00 $146.00 $231.26 $233.60 $0.00 $0.00 $44.37 $0.00 $0.00 $46.49 $0.00 $0.00 $0.00 $0.00 $0.00 294.95 SUP Custom 27203010 294.950 - PIN FIX 6MM 225MM TRANSFIXATION STEINMANN STAINLESS STEEL BOTH IP/OP $208.73 $154.46 $0.00 $166.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.92 $154.92 $0.00 $0.00 $43.50 $0.00 $0.00 $0.00 $0.00 $104.36 $165.31 $166.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 296.757 SUP Custom 27803010 296.757 - NUT ORTH 6MM SCRL SS RND NONSTRL BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.94 $195.94 $0.00 $0.00 $55.02 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 296.758 SUP Custom 27803010 296.758 - WASHER SPNL 6MM SCRL SS NONSTRL BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.94 $195.94 $0.00 $0.00 $55.02 $0.00 $0.00 $0.00 $0.00 $132.00 $209.09 $211.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 296.759 SUP Custom 27803010 296.759 - NUT ORTH 6MM SCRL SS HEX NONSTRL BOTH IP/OP $244.75 $181.12 $0.00 $195.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.65 $181.65 $0.00 $0.00 $51.01 $0.00 $0.00 $0.00 $0.00 $122.38 $193.84 $195.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 296.761 SUP HCPCS C1713 296.761 - BAR SPNL 160MM 6MM SCRL SPN SS THRD NONSTRL BOTH IP/OP "$1,334.50 " $987.53 $0.00 "$1,067.60" $600.53 $600.53 $0.00 $0.00 $0.00 $278.14 $990.47 $990.47 $0.00 $0.00 $278.11 $0.00 $789.36 $789.36 $0.00 $667.25 "$1,056.92" "$1,067.60" $0.00 $0.00 $208.85 $0.00 $0.00 $212.45 $0.00 $0.00 $0.00 $0.00 $0.00 296.763 SUP HCPCS C1713 296.763 - BAR SPINAL 6MM 200MM THREADED KIT SACRAL NONSTRL BOTH IP/OP "$1,210.30 " $895.62 $0.00 $940.04 $528.77 $528.77 $0.00 $0.00 $0.00 $252.26 $898.28 $898.28 $0.00 $0.00 $252.23 $0.00 $715.89 $715.89 $0.00 $587.53 $930.64 $940.04 $0.00 $0.00 $178.54 $0.00 $0.00 $187.07 $0.00 $0.00 $0.00 $0.00 $0.00 296.765 SUP HCPCS C1713 296.765 - BAR SPNL 240MM 6MM SCRL SPN SS THRD NONSTRL BOTH IP/OP "$1,415.75 " "$1,047.66" $0.00 "$1,132.60" $637.09 $637.09 $0.00 $0.00 $0.00 $295.08 "$1,050.77" "$1,050.77" $0.00 $0.00 $295.04 $0.00 $837.42 $837.42 $0.00 $707.88 "$1,121.27" "$1,132.60" $0.00 $0.00 $221.56 $0.00 $0.00 $225.39 $0.00 $0.00 $0.00 $0.00 $0.00 296.766 SUP HCPCS C1713 296.766 - BAR SPINAL 6MM 260MM THREAD STAINLESS STEEL SACRAL SPN BOTH IP/OP "$1,210.30 " $895.62 $0.00 $940.04 $528.77 $528.77 $0.00 $0.00 $0.00 $252.26 $898.28 $898.28 $0.00 $0.00 $252.23 $0.00 $715.89 $715.89 $0.00 $587.53 $930.64 $940.04 $0.00 $0.00 $178.54 $0.00 $0.00 $187.07 $0.00 $0.00 $0.00 $0.00 $0.00 304 SUP HCPCS C1778 304 - LEAD NEUROSTIMULATOR 3MM 43CM BIPOL PERENNIAFLEX SILICONE BOTH IP/OP "$17,070.00 " "$12,631.80" $0.00 "$13,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,557.39" $0.00 $0.00 $0.00 $0.00 "$8,535.00" "$13,519.44" "$13,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.008 SUP Custom 27803010 304.008 - SPACER SPNL OBLQ 26X10X8MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.009 SUP Custom 27803010 304.009 - SPACER SPNL OBLQ 26X10X9MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.01 SUP Custom 27803010 304.010 - SPACER SPNL OBLQ 26X10X10MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.011 SUP Custom 27803010 304.011 - SPACER SPNL OBLQ 26X10X11MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.012 SUP Custom 27803010 304.012 - SPACER SPNL OBLQ 26X10X12MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.013 SUP Custom 27803010 304.013 - SPACER SPNL OBLQ 26X10X13MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.014 SUP Custom 27803010 304.014 - SPACER SPNL OBLQ 26X10X14MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.015 SUP Custom 27803010 304.015 - SPACER SPNL OBLQ 26X10X15MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.017 SUP Custom 27803010 304.017 - SPACER SPNL OBLQ 26X10X17MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.065 SUP Custom 27803010 304.065 - SPACER SPNL 13MM MED CNVX 14X5MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.066 SUP Custom 27803010 304.066 - SPACER SPNL 13MM MED CNVX 14X6MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.067 SUP Custom 27803010 304.067 - SPACER SPNL 13MM MED CNVX 14X7MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.068 SUP Custom 27803010 304.068 - SPACER SPNL 13MM MED CNVX 14X8MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.069 SUP Custom 27803010 304.069 - SPACER SPNL 13MM MED CNVX 14X9MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.07 SUP Custom 27803010 304.070 - SPACER SPNL 13MM MED CNVX 14X10MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.071 SUP Custom 27803010 304.071 - SPACER SPNL 13MM MED CNVX 14X11MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.072 SUP Custom 27803010 304.072 - SPACER SPNL 13MM MED CNVX 14X12MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.078 SUP Custom 27803010 304.078 - SPACER SPNL SM OBLQ 22X8X8MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.079 SUP Custom 27803010 304.079 - SPACER SPNL SM OBLQ 22X8X9MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.08 SUP Custom 27803010 304.080 - SPACER SPNL SM OBLQ 22X8X10MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.081 SUP Custom 27803010 304.081 - SPACER SPNL SM OBLQ 22X8X11MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.082 SUP Custom 27803010 304.082 - SPACER SPNL SM OBLQ 22X8X12MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.083 SUP Custom 27803010 304.083 - SPACER SPNL SM OBLQ 22X8X13MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.085 SUP Custom 27803010 304.085 - SPACER SPNL SM OBLQ 22X8X15MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.087 SUP Custom 27803010 304.087 - SPACER SPNL SM OBLQ 22X8X17MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.088 SUP Custom 27803010 304.088 - SPACER SPNL SM OBLQ 22X10X8MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.089 SUP Custom 27803010 304.089 - SPACER SPNL SM OBLQ 22X10X9MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.09 SUP Custom 27803010 304.090 - SPACER SPNL SM OBLQ 22X10X10MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.091 SUP Custom 27803010 304.091 - SPACER SPNL SM OBLQ 22X10X11MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.092 SUP Custom 27803010 304.092 - SPACER SPNL SM OBLQ 22X10X12MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.093 SUP Custom 27803010 304.093 - SPACER SPNL SM OBLQ 22X10X13MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.095 SUP Custom 27803010 304.095 - SPACER SPNL SM OBLQ 22X10X15MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.097 SUP Custom 27803010 304.097 - SPACER SPNL SM OBLQ 22X10X17MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.104 SUP Custom 27803010 304.104 - MARKER SRG 4MM WHT SCR LGTH SLFDRL SCR BOTH IP/OP $106.88 $79.09 $0.00 $85.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.32 $79.32 $0.00 $0.00 $22.27 $0.00 $0.00 $0.00 $0.00 $53.44 $84.65 $85.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.105 SUP Custom 27803010 304.105 - MARKER SRG 5MM WHT SCR LGTH SLF DRL SCR BOTH IP/OP $106.88 $79.09 $0.00 $85.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.32 $79.32 $0.00 $0.00 $22.27 $0.00 $0.00 $0.00 $0.00 $53.44 $84.65 $85.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.107 SUP Custom 27803010 304.107 - SPACER SPNL SM 22X10X7MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.109 SUP Custom 27803010 304.109 - SPACER SPNL SM 22X10X9MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.111 SUP Custom 27803010 304.111 - SPACER SPNL SM 22X10X11MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.113 SUP Custom 27803010 304.113 - SPACER SPNL SM 22X10X13MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.115 SUP Custom 27803010 304.115 - SPACER SPNL SM 22X10X15MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.117 SUP Custom 27803010 304.117 - SPACER SPNL SM 22X10X17MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.119 SUP Custom 27803010 304.119 - SPACER SPNL SM 22X10X19MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.121 SUP Custom 27803010 304.121 - SPACER SPNL SM 22X10X21MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.159 SUP Custom 27803010 304.159 - SPACER SPNL SM 18X10X9MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.161 SUP Custom 27803010 304.161 - SPACER SPNL SM 18X10X11MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.163 SUP Custom 27803010 304.163 - SPACER SPNL SM 18X10X13MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.165 SUP Custom 27803010 304.165 - SPACER SPNL SM 18X10X15MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.167 SUP Custom 27803010 304.167 - SPACER SPNL SM 18X10X17MM NS LF SUST O RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.205 SUP Custom 27803010 304.205 - SPACER SPNL 13MM MED PRLL 14X5MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.206 SUP Custom 27803010 304.206 - SPACER SPNL 13MM MED PRLL 14X6MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.207 SUP Custom 27803010 304.207 - SPACER SPNL 13MM MED PRLL 14X7MM NS LF SUST R RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.208 SUP Custom 27803010 304.208 - SPACER SPNL 13MM MED PRLL 14X8MM NS LF SUST R RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.209 SUP Custom 27803010 304.209 - SPACER SPNL 13MM MED PRLL 14X9MM NS LF SUST R RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.21 SUP Custom 27803010 304.210 - SPACER SPNL 13MM MED PRLL 14X10MM NS LF SUST R RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.211 SUP Custom 27803010 304.211 - SPACER SPNL 13MM MED PRLL 14X11MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.212 SUP Custom 27803010 304.212 - SPACER SPNL 13MM MED PRLL 14X12MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.225 SUP Custom 27803010 304.225 - SPACER SPNL 7D LRDTC 13MM MED 14X5MM NS LF SUST R RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.226 SUP Custom 27803010 304.226 - SPACER SPNL 7D LRDTC 13MM MED 14X6MM NS LF SUST R RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.227 SUP Custom 27803010 304.227 - SPACER SPNL 7D LRDTC 13MM MED 14X7MM NS LF SUST R RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.228 SUP Custom 27803010 304.228 - SPACER SPNL 7D LRDTC 13MM MED 14X8MM NS LF SUST R RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.229 SUP Custom 27803010 304.229 - SPACER SPNL 7D LRDTC 13MM MED 14X9MM NS LF SUST R RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.23 SUP Custom 27803010 304.230 - SPACER SPNL 7D LRDTC 13MM MED 14X10MM NS LF SUST R RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.231 SUP Custom 27803010 304.231 - SPACER SPNL 7D LRDTC 13MM MED 14X11MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.232 SUP Custom 27803010 304.232 - SPACER SPNL 7D LRDTC 13MM MED 14X12MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.245 SUP Custom 27803010 304.245 - SPACER SPNL 13MM MED CNVX 14X5MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.246 SUP Custom 27803010 304.246 - SPACER SPNL 13MM MED CNVX 14X6MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.247 SUP Custom 27803010 304.247 - SPACER SPNL 13MM MED CNVX 14X7MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.248 SUP Custom 27803010 304.248 - SPACER SPNL 13MM MED CNVX 14X8MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.249 SUP Custom 27803010 304.249 - SPACER SPNL 13MM MED CNVX 14X9MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.25 SUP Custom 27803010 304.250 - SPACER SPNL 13MM MED CNVX 14X10MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.251 SUP Custom 27803010 304.251 - SPACER SPNL 13MM MED CNVX 14X11MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.252 SUP Custom 27803010 304.252 - SPACER SPNL 13MM MED CNVX 14X12MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.265 SUP Custom 27803010 304.265 - SPACER SPNL 13MM MED PRLL 14X5MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.266 SUP Custom 27803010 304.266 - SPACER SPNL 13MM MED PRLL 14X6MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.267 SUP Custom 27803010 304.267 - SPACER SPNL 13MM MED PRLL 14X7MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.268 SUP Custom 27803010 304.268 - SPACER SPNL 13MM MED PRLL 14X8MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.269 SUP Custom 27803010 304.269 - SPACER SPNL 13MM MED PRLL 14X9MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.27 SUP Custom 27803010 304.270 - SPACER SPNL 13MM MED PRLL 14X10MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.271 SUP Custom 27803010 304.271 - SPACER SPNL 13MM MED PRLL 14X11MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.272 SUP Custom 27803010 304.272 - SPACER SPNL 13MM MED PRLL 14X12MM NS LF SUST O RDLCNT BEAD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.275 SUP Custom 27803010 304.275 - SPACER SPNL 7D LRDTC 13MM MED 14X5MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.276 SUP Custom 27803010 304.276 - SPACER SPNL 7D LRDTC 13MM MED 14X6MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.277 SUP Custom 27803010 304.277 - SPACER SPNL 7D LRDTC 13MM MED 14X7MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.278 SUP Custom 27803010 304.278 - SPACER SPNL 7D LRDTC 13MM MED 14X8MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.279 SUP Custom 27803010 304.279 - SPACER SPNL 7D LRDTC 13MM MED 14X9MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.28 SUP Custom 27803010 304.280 - SPACER SPNL 7D LRDTC 13MM MED 14X10MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.281 SUP Custom 27803010 304.281 - SPACER SPNL 7D LRDTC 13MM MED 14X11MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.282 SUP Custom 27803010 304.282 - SPACER SPNL 7D LRDTC 13MM MED 14X12MM NS LF SUST O RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.309 SUP Custom 27803010 304.309 - SPACER SPNL 31MM LG 25X9MM NS LF SUST O RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.311 SUP Custom 27803010 304.311 - SPACER SPNL 31MM LG 25X11MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.313 SUP Custom 27803010 304.313 - SPACER SPNL 31MM LG 25X13MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.315 SUP Custom 27803010 304.315 - SPACER SPNL 31MM LG 25X15MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.317 SUP Custom 27803010 304.317 - SPACER SPNL 31MM LG 25X17MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.319 SUP Custom 27803010 304.319 - SPACER SPNL 31MM LG 25X19MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.321 SUP Custom 27803010 304.321 - SPACER SPNL 31MM LG 25X21MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.351 SUP Custom 27803010 304.351 - SPACER SPNL 15D LRDTC 31MM LG 25X11MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.352 SUP Custom 27803010 304.352 - SPACER SPNL 15D LRDTC 31MM LG 25X13MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.353 SUP Custom 27803010 304.353 - SPACER SPNL 15D LRDTC 31MM LG 25X15MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.354 SUP Custom 27803010 304.354 - SPACER SPNL 15D LRDTC 31MM LG 25X17MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.355 SUP Custom 27803010 304.355 - SPACER SPNL 15D LRDTC 31MM LG 25X19MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.356 SUP Custom 27803010 304.356 - SPACER SPNL 15D LRDTC 31MM LG 25X21MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.359 SUP Custom 27803010 304.359 - SPACER SPNL 42MM XL 28X9MM NS LF SUST O RDLCNT PEEK THORLMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.361 SUP Custom 27803010 304.361 - SPACER SPNL 42MM XL 28X11MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.363 SUP Custom 27803010 304.363 - SPACER SPNL 42MM XL 28X13MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.365 SUP Custom 27803010 304.365 - SPACER SPNL 42MM XL 28X15MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.367 SUP Custom 27803010 304.367 - SPACER SPNL 42MM XL 28X17MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.369 SUP Custom 27803010 304.369 - SPACER SPNL 42MM XL 28X19MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.371 SUP Custom 27803010 304.371 - SPACER SPNL 42MM XL 28X21MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.379 SUP Custom 27803010 304.379 - SPACER SPNL 42MM XL 28X9MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.381 SUP Custom 27803010 304.381 - SPACER SPNL 42MM XL 28X11MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.383 SUP Custom 27803010 304.383 - SPACER SPNL 42MM XL 28X13MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.385 SUP Custom 27803010 304.385 - SPACER SPNL 42MM XL 28X15MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.387 SUP Custom 27803010 304.387 - SPACER SPNL 42MM XL 28X17MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.389 SUP Custom 27803010 304.389 - SPACER SPNL 42MM XL 28X19MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.391 SUP Custom 27803010 304.391 - SPACER SPNL 42MM XL 28X21MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.409 SUP Custom 27803010 304.409 - SPACER SPNL 31MM LG 25X9MM NS LF SUST O RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.411 SUP Custom 27803010 304.411 - SPACER SPNL 31MM LG 25X11MM NS LF SUST O RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.413 SUP Custom 27803010 304.413 - SPACER SPNL 31MM LG 25X13MM NS LF SUST O RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.415 SUP Custom 27803010 304.415 - SPACER SPNL 31MM LG 25X15MM NS LF SUST O RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.417 SUP Custom 27803010 304.417 - SPACER SPNL 31MM LG 25X17MM NS LF SUST O RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.419 SUP Custom 27803010 304.419 - SPACER SPNL 31MM LG 25X19MM NS LF SUST O RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.421 SUP Custom 27803010 304.421 - SPACER SPNL 31MM LG 25X21MM NS LF SUST O RDLCNT PEEK LAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.45 SUP Custom 27803010 304.450 - SPACER SPNL 4D LRDTC 31MM LG 25X9MM NS LF SUST O RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.451 SUP Custom 27803010 304.451 - SPACER SPNL 4D LRDTC 31MM LG 25X11MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.452 SUP Custom 27803010 304.452 - SPACER SPNL 4D LRDTC 31MM LG 25X13MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.453 SUP Custom 27803010 304.453 - SPACER SPNL 4D LRDTC 31MM LG 25X15MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.454 SUP Custom 27803010 304.454 - SPACER SPNL 4D LRDTC 31MM LG 25X17MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.455 SUP Custom 27803010 304.455 - SPACER SPNL 4D LRDTC 31MM LG 25X19MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.456 SUP Custom 27803010 304.456 - SPACER SPNL 4D LRDTC 31MM LG 25X21MM NS LF SUST O RDLCNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.509 SUP Custom 27803010 304.509 - SPACER SPNL 31MM LG 25X9MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.511 SUP Custom 27803010 304.511 - SPACER SPNL 31MM LG 25X11MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.513 SUP Custom 27803010 304.513 - SPACER SPNL 31MM LG 25X13MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.515 SUP Custom 27803010 304.515 - SPACER SPNL 31MM LG 25X15MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.517 SUP Custom 27803010 304.517 - SPACER SPNL 31MM LG 25X17MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.519 SUP Custom 27803010 304.519 - SPACER SPNL 31MM LG 25X19MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.521 SUP Custom 27803010 304.521 - SPACER SPNL 31MM LG 25X21MM NS LF SUST O RDLCNT PEEK ALAT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.607 SUP Custom 27803010 304.607 - SPACER SPNL SM ARCH 27X9.5X7MM NS LF SUST RDLCNT PEEK TLIF BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.609 SUP Custom 27803010 304.609 - SPACER SPNL SM ARCH 27X9.5X9MM NS LF SUST RDLCNT PEEK TLIF BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.611 SUP Custom 27803010 304.611 - SPACER SPNL SM ARCH 27X9.5X11MM NS LF SUST RDLCNT PEEK TLIF BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.613 SUP Custom 27803010 304.613 - SPACER SPNL SM ARCH 27X9.5X13MM NS LF SUST RDLCNT PEEK TLIF BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.615 SUP Custom 27803010 304.615 - SPACER SPNL SM ARCH 27X9.5X15MM NS LF SUST RDLCNT PEEK TLIF BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.617 SUP Custom 27803010 304.617 - SPACER SPNL SM ARCH 27X9.5X17MM NS LF SUST RDLCNT PEEK TLIF BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.707 SUP Custom 27803010 304.707 - SPACER SPNL SM NAR 22X8X7MM NS LF SUST R RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.709 SUP Custom 27803010 304.709 - SPACER SPNL SM NAR 22X8X9MM NS LF SUST R RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.711 SUP Custom 27803010 304.711 - SPACER SPNL SM NAR 22X8X11MM NS LF SUST R RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.713 SUP Custom 27803010 304.713 - SPACER SPNL SM NAR 22X8X13MM NS LF SUST R RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.715 SUP Custom 27803010 304.715 - SPACER SPNL SM NAR 22X8X15MM NS LF SUST R RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.717 SUP Custom 27803010 304.717 - SPACER SPNL SM NAR 22X8X17MM NS LF SUST R RDLCNT PEEK LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.808 SUP Custom 27803010 304.808 - SPACER SPNL OBLQ 30X10X8MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.809 SUP Custom 27803010 304.809 - SPACER SPNL OBLQ 30X10X9MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.81 SUP Custom 27803010 304.810 - SPACER SPNL OBLQ 30X10X10MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.811 SUP Custom 27803010 304.811 - SPACER SPNL OBLQ 30X10X11MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.812 SUP Custom 27803010 304.812 - SPACER SPNL OBLQ 30X10X12MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.813 SUP Custom 27803010 304.813 - SPACER SPNL OBLQ 30X10X13MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.814 SUP Custom 27803010 304.814 - SPACER SPNL OBLQ 30X10X14MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.815 SUP Custom 27803010 304.815 - SPACER SPNL OBLQ 30X10X15MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.817 SUP Custom 27803010 304.817 - SPACER SPNL OBLQ 30X10X17MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.868 SUP Custom 27803010 304.868 - SPACER SPNL OBLQ 30X12X8MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.869 SUP Custom 27803010 304.869 - SPACER SPNL OBLQ 30X12X9MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.87 SUP Custom 27803010 304.870 - SPACER SPNL OBLQ 30X12X10MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.871 SUP Custom 27803010 304.871 - SPACER SPNL OBLQ 30X12X11MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.872 SUP Custom 27803010 304.872 - SPACER SPNL OBLQ 30X12X12MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.873 SUP Custom 27803010 304.873 - SPACER SPNL OBLQ 30X12X13MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.874 SUP Custom 27803010 304.874 - SPACER SPNL OBLQ 30X12X14MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.875 SUP Custom 27803010 304.875 - SPACER SPNL OBLQ 30X12X15MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.877 SUP Custom 27803010 304.877 - SPACER SPNL OBLQ 30X12X17MM NS LF SUST RDLCNT PEEK LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.905 SUP Custom 27803010 304.905 - SPACER SPNL 11MM MED NAR PRLL 12X5MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.906 SUP Custom 27803010 304.906 - SPACER SPNL 11MM MED NAR PRLL 12X6MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.907 SUP Custom 27803010 304.907 - SPACER SPNL 11MM MED NAR PRLL 12X7MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.908 SUP Custom 27803010 304.908 - SPACER SPNL 11MM MED NAR PRLL 12X8MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.909 SUP Custom 27803010 304.909 - SPACER SPNL 11MM MED NAR PRLL 12X9MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.91 SUP Custom 27803010 304.910 - SPACER SPNL 11MM MED NAR PRLL 12X10MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.911 SUP Custom 27803010 304.911 - SPACER SPNL 11MM MED NAR PRLL 12X11MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.912 SUP Custom 27803010 304.912 - SPACER SPNL 11MM MED NAR PRLL 12X12MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.925 SUP Custom 27803010 304.925 - SPACER SPNL 11MM LRDTC MED NAR 12X5MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.926 SUP Custom 27803010 304.926 - SPACER SPNL 11MM LRDTC MED NAR 12X6MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.927 SUP Custom 27803010 304.927 - SPACER SPNL 11MM LRDTC MED NAR 12X7MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.928 SUP Custom 27803010 304.928 - SPACER SPNL 11MM LRDTC MED NAR 12X8MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.929 SUP Custom 27803010 304.929 - SPACER SPNL 11MM LRDTC MED NAR 12X9MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.93 SUP Custom 27803010 304.930 - SPACER SPNL 11MM LRDTC MED NAR 12X10MM NS LF SUST RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.931 SUP Custom 27803010 304.931 - SPACER SPNL 11MM LRDTC MED NAR 12X11MM NS LF SUST RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.932 SUP Custom 27803010 304.932 - SPACER SPNL 11MM LRDTC MED NAR 12X12MM NS LF SUST RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.945 SUP Custom 27803010 304.945 - SPACER SPNL 11MM MED CNVX NAR 12X5MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.946 SUP Custom 27803010 304.946 - SPACER SPNL 11MM MED CNVX NAR 12X6MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.947 SUP Custom 27803010 304.947 - SPACER SPNL 11MM MED CNVX NAR 12X7MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.948 SUP Custom 27803010 304.948 - SPACER SPNL 11MM MED CNVX NAR 12X8MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.949 SUP Custom 27803010 304.949 - SPACER SPNL 11MM MED CNVX NAR 12X9MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.95 SUP Custom 27803010 304.950 - SPACER SPNL 11MM MED CNVX NAR 12X10MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.951 SUP Custom 27803010 304.951 - SPACER SPNL 11MM MED CNVX NAR 12X11MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.952 SUP Custom 27803010 304.952 - SPACER SPNL 11MM MED CNVX NAR 12X12MM NS LF SUST RDLCNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.968 SUP Custom 27803010 304.968 - SPACER SPNL OBLQ 26X12X8MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.969 SUP Custom 27803010 304.969 - SPACER SPNL OBLQ 26X12X9MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.97 SUP Custom 27803010 304.970 - SPACER SPNL OBLQ 26X12X10MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.971 SUP Custom 27803010 304.971 - SPACER SPNL OBLQ 26X12X11MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.972 SUP Custom 27803010 304.972 - SPACER SPNL OBLQ 26X12X12MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.973 SUP Custom 27803010 304.973 - SPACER SPNL OBLQ 26X12X13MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.974 SUP Custom 27803010 304.974 - SPACER SPNL OBLQ 26X12X14MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.975 SUP Custom 27803010 304.975 - SPACER SPNL OBLQ 26X12X15MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304.977 SUP Custom 27803010 304.977 - SPACER SPNL OBLQ 26X12X17MM NS LF SUST RDLCNT PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 308 SUP HCPCS C1879 308 - MARKER CHARM MARGINMAP BRST BIOP 10MM STRL BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $0.00 $0.00 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 309.521 SUP HCPCS C1713 309.521 - SCREW BONE 3.5MM 21MM EXTRACTION FIBULA DISTAL NONSTRL BOTH IP/OP $125.10 $92.57 $0.00 $97.18 $54.66 $54.66 $0.00 $0.00 $0.00 $26.07 $92.85 $92.85 $0.00 $0.00 $26.07 $0.00 $74.00 $74.00 $0.00 $60.74 $96.21 $97.18 $0.00 $0.00 $18.46 $0.00 $0.00 $19.34 $0.00 $0.00 $0.00 $0.00 $0.00 310.02 SUP Custom 27203010 310.02 - BIT DRL 3.2MM 225MM NS QC UNV NL SYS BOTH IP/OP $286.75 $212.20 $0.00 $222.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.83 $212.83 $0.00 $0.00 $59.76 $0.00 $0.00 $0.00 $0.00 $139.20 $220.49 $222.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.1 SUP Custom 27203010 310.10 - BIT DRILL 1.1MM 45MM JACOBS CHUCK NONSTRL MINI FRAGMENT BOTH IP/OP $124.20 $91.91 $0.00 $99.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.18 $92.18 $0.00 $0.00 $25.88 $0.00 $0.00 $0.00 $0.00 $62.10 $98.37 $99.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.11 SUP Custom 27203010 310.11 - BIT DRL 1.1MM 60MM NS QC MN FRAG SYS BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.111 SUP Custom 27203010 310.111 - BIT DRL 1.1MM 55MM NS MNQK CPLNG 1.5/2MM ROT CRRT PLT BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.113 SUP Custom 27203010 310.113 - BIT DRL 1.1MM 65MM NS JLTCH CPLNG CPLNG STRYK BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.133 SUP Custom 27203010 310.133 - BIT DRILL 45MM 1.3MM 3MM STOP JLTCH CPLNG NONSTRL BOTH IP/OP $326.25 $241.43 $0.00 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.14 $242.14 $0.00 $0.00 $67.99 $0.00 $0.00 $0.00 $0.00 $163.13 $258.39 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.134 SUP Custom 27203010 310.134 - BIT DRILL 52MM 1.3MM 3MM STOP HEX CPLNG NONSTRL BOTH IP/OP $326.25 $241.43 $0.00 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.14 $242.14 $0.00 $0.00 $67.99 $0.00 $0.00 $0.00 $0.00 $163.13 $258.39 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.136 SUP Custom 27203010 310.136 - BIT DRL 4MM 1.3MM 45MM NS JLTCH CPLNG CPLNG SLF STP STRYK BOTH IP/OP $326.25 $241.43 $0.00 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.14 $242.14 $0.00 $0.00 $67.99 $0.00 $0.00 $0.00 $0.00 $163.13 $258.39 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.137 SUP Custom 27203010 310.137 - BIT DRILL 45MM 1.3MM 6MM STOP JLTCH CPLNG NONSTRL BOTH IP/OP $326.25 $241.43 $0.00 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.14 $242.14 $0.00 $0.00 $67.99 $0.00 $0.00 $0.00 $0.00 $163.13 $258.39 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.138 SUP Custom 27203010 310.138 - BIT DRILL 52MM 1.3MM 4MM STOP HEX CPLNG NONSTRL BOTH IP/OP $326.25 $241.43 $0.00 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.14 $242.14 $0.00 $0.00 $67.99 $0.00 $0.00 $0.00 $0.00 $163.13 $258.39 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.139 SUP Custom 27203010 310.139 - BIT DRILL 52MM 1.3MM 6MM STOP HEX CPLNG NONSTRL BOTH IP/OP $326.25 $241.43 $0.00 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.14 $242.14 $0.00 $0.00 $67.99 $0.00 $0.00 $0.00 $0.00 $163.13 $258.39 $261.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.14 SUP Custom 27203010 310.14 - BIT DRL 1.5MM 70MM NS JCHK MN FRAG SYS BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.141 SUP Custom 27203010 310.141 - BIT DRL 1.5MM 65MM NS MNQK CPLNG 1.5/2MM ROT CRRT PLT BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.143 SUP Custom 27203010 310.143 - BIT DRL 1.5MM 75MM NS JLTCH CPLNG CPLNG STRYK BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.15 SUP Custom 27203010 310.15 - BIT DRL 1.5MM 85MM NS QC BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.153 SUP Custom 27203010 310.153 - BIT DRILL 75MM 1.5MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.16 SUP Custom 27203010 310.16 - BIT DRILL 1.5MM 110MM QUICK COUPLING STAINLESS STEEL NONSTRL BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.161 SUP Custom 27203010 310.161 - BIT DRILL 1.5MM 110MM J LATCH DEPTH MARK NONSTRL BOTH IP/OP $279.73 $207.00 $0.00 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.61 $207.61 $0.00 $0.00 $58.29 $0.00 $0.00 $0.00 $0.00 $135.79 $215.09 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.162 SUP Custom 27203010 310.162 - BIT DRILL 1.8MM 110MM J LATCH DEPTH MARK NONSTRL BOTH IP/OP $279.73 $207.00 $0.00 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.61 $207.61 $0.00 $0.00 $58.29 $0.00 $0.00 $0.00 $0.00 $135.79 $215.09 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.17 SUP Custom 27203010 310.170 - BIT DRILL 125MM 1.5MM 8MM STOP QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.171 SUP Custom 27203010 310.171 - BIT DRILL 125MM 1.5MM 8MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.172 SUP Custom 27203010 310.172 - BIT DRILL 125MM 1.5MM 8MM STOP JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.173 SUP Custom 27203010 310.173 - BIT DRILL 125MM 1.5MM 8MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.177 SUP Custom 27203010 310.177 - BIT DRILL 1.5MM 4MM STOP JLTCH NONSTRL BOTH IP/OP $346.50 $256.41 $0.00 $277.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.17 $257.17 $0.00 $0.00 $72.21 $0.00 $0.00 $0.00 $0.00 $173.25 $274.43 $277.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.182 SUP Custom 27203010 310.182 - BIT DRILL 1.5MM 4MM STOP HEX CPLNG NONSTRL BOTH IP/OP $346.50 $256.41 $0.00 $277.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.17 $257.17 $0.00 $0.00 $72.21 $0.00 $0.00 $0.00 $0.00 $173.25 $274.43 $277.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.19 SUP Custom 27203010 310.19 - BIT DRL 2MM 100MM NS QC BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $0.00 $0.00 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.2 SUP Custom 27203010 310.20 - BIT DRILL STANDARD 2MM 85MM SET BASIC ARTICULATE TENSION BOTH IP/OP $131.68 $97.44 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.73 $97.73 $0.00 $0.00 $27.44 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.201 SUP Custom 27203010 310.201 - BIT DRL 2MM 65MM NS MNQK CPLNG BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.203 SUP Custom 27203010 310.203 - BIT DRL 2MM 75MM NS JLTCH CPLNG STRYK BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.21 SUP Custom 27203010 310.21 - BIT DRL 2MM 125MM NS QC BOTH IP/OP $151.83 $112.35 $0.00 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.68 $112.68 $0.00 $0.00 $31.64 $0.00 $0.00 $0.00 $0.00 $73.70 $116.74 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.215 SUP Custom 27203010 310.215 - BIT DRILL 1.7MM .9MM 100MM 2.4MM QUICK COUPLING CANN NONSTRL BOTH IP/OP $850.45 $629.33 $0.00 $660.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.20 $631.20 $0.00 $0.00 $177.23 $0.00 $0.00 $0.00 $0.00 $412.84 $653.94 $660.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.221 SUP Custom 27203010 310.221 - BIT DRL 2MM 150MM NS CNN QC BOTH IP/OP $788.60 $583.56 $0.00 $612.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $585.30 $585.30 $0.00 $0.00 $164.34 $0.00 $0.00 $0.00 $0.00 $382.81 $606.38 $612.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.229 SUP Custom 27203010 310.229 - BIT DRL 2.9MM 150MM NS QC 4MM CORT SCR BOTH IP/OP $168.68 $124.82 $0.00 $131.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.19 $125.19 $0.00 $0.00 $35.15 $0.00 $0.00 $0.00 $0.00 $81.89 $129.71 $131.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.23 SUP Custom 27203010 310.23 - BIT DRILL 2.5MM 180MM QUICK COUPLING GOLD STAINLESS STEEL BOTH IP/OP $151.83 $112.35 $0.00 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.68 $112.68 $0.00 $0.00 $31.64 $0.00 $0.00 $0.00 $0.00 $73.70 $116.74 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.24 SUP Custom 27203010 310.24 - BIT DRILL 2.5MM 95MM JACOBS CHUCK GOLD STAINLESS STEEL BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.243 SUP Custom 27203010 310.243 - GUIDEWIRE ORTHOPEDIC 2.5MM 200MM DRILL TIP LCP STAINLESS BOTH IP/OP $121.58 $89.97 $0.00 $94.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.23 $90.23 $0.00 $0.00 $25.34 $0.00 $0.00 $0.00 $0.00 $59.03 $93.50 $94.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.25 SUP Custom 27203010 310.25 - BIT DRL 2.5MM 110MM AU NS QC BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.26 SUP Custom 27203010 310.26 - BIT DRL 2.7MM 100MM NS QC BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.27 SUP Custom 27203010 310.27 - BIT DRL 2.7MM 85MM NS JCHK BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.28 SUP Custom 27203010 310.28 - BIT DRL 2.7MM 125MM NS QC BOTH IP/OP $151.83 $112.35 $0.00 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.68 $112.68 $0.00 $0.00 $31.64 $0.00 $0.00 $0.00 $0.00 $73.70 $116.74 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.284 SUP Custom 27203010 310.284 - BIT DRILL 2.8MM 165MM 2 FLUTE QUICK COUPLING LCP NONSTRL BOTH IP/OP $168.68 $124.82 $0.00 $131.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.19 $125.19 $0.00 $0.00 $35.15 $0.00 $0.00 $0.00 $0.00 $81.89 $129.71 $131.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.288 SUP Custom 27203010 310.288 - BIT DRL 2.8MM 165MM NS QC BOTH IP/OP $168.68 $124.82 $0.00 $131.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.19 $125.19 $0.00 $0.00 $35.15 $0.00 $0.00 $0.00 $0.00 $81.89 $129.71 $131.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.29 SUP Custom 27203010 310.29 - BIT DRILL 3.2MM 195MM QUICK COUPLING STAINLESS STEEL NONSTRL BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $0.00 $0.00 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.3 SUP Custom 27203010 310.30 - BIT DRL 3.2MM 180MM NS JCHK BOTH IP/OP $165.13 $122.20 $0.00 $132.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.56 $122.56 $0.00 $0.00 $34.41 $0.00 $0.00 $0.00 $0.00 $82.56 $130.78 $132.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.31 SUP Custom 27203010 310.31 - BIT DRL 3.2MM 145MM NS QC BOTH IP/OP $133.55 $98.83 $0.00 $103.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.12 $99.12 $0.00 $0.00 $27.83 $0.00 $0.00 $0.00 $0.00 $64.83 $102.68 $103.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.32 SUP Custom 27203010 310.32 - BIT DRL 3.2MM 130MM NS JCHK BOTH IP/OP $131.43 $97.26 $0.00 $102.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.54 $97.54 $0.00 $0.00 $27.39 $0.00 $0.00 $0.00 $0.00 $63.80 $101.06 $102.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.35 SUP Custom 27203010 310.35 - BIT DRL 3.5MM 110MM NS QC BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $0.00 $0.00 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.36 SUP Custom 27203010 310.36 - BIT DRL 3.5MM 95MM NS JCHK BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.37 SUP Custom 27203010 310.37 - BIT DRL 3.5MM 195MM NS QC BOTH IP/OP $151.83 $112.35 $0.00 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.68 $112.68 $0.00 $0.00 $31.64 $0.00 $0.00 $0.00 $0.00 $73.70 $116.74 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.38 SUP Custom 27203010 310.38 - BIT DRL 3.5MM 180MM NS JCHK BOTH IP/OP $151.83 $112.35 $0.00 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.68 $112.68 $0.00 $0.00 $31.64 $0.00 $0.00 $0.00 $0.00 $73.70 $116.74 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.4 SUP Custom 27203010 310.40 - BIT DRILL 4MM 197MM QUICK COUPLING NONSTRL BOTH IP/OP $158.30 $117.14 $0.00 $126.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.49 $117.49 $0.00 $0.00 $32.99 $0.00 $0.00 $0.00 $0.00 $79.15 $125.37 $126.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.401 SUP Custom 27203010 310.401 - BIT DRL 4MM 160MM NS QC BOTH IP/OP $160.25 $118.59 $0.00 $124.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.94 $118.94 $0.00 $0.00 $33.40 $0.00 $0.00 $0.00 $0.00 $77.79 $123.22 $124.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.423 SUP Custom 27203010 310.423 - BIT DRL 4.3MM 280MM NS QC BOTH IP/OP $708.48 $524.28 $0.00 $550.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.83 $525.83 $0.00 $0.00 $147.65 $0.00 $0.00 $0.00 $0.00 $343.91 $544.76 $550.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.43 SUP Custom 27203010 310.430 - BIT DRILL 4.3MM 221MM QUICK COUPLING CANN NONSTRL BOTH IP/OP $399.88 $295.91 $0.00 $319.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.79 $296.79 $0.00 $0.00 $83.33 $0.00 $0.00 $0.00 $0.00 $199.94 $316.70 $319.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.431 SUP Custom 27203010 310.431 - BIT DRL 4.3MM 180MM NS QC 5MM LCK SCR BOTH IP/OP $223.83 $165.63 $0.00 $179.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.91 $177.27 $179.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.44 SUP Custom 27203010 310.44 - BIT DRL 4.5MM 145MM NS QC BOTH IP/OP $133.55 $98.83 $0.00 $103.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.12 $99.12 $0.00 $0.00 $27.83 $0.00 $0.00 $0.00 $0.00 $64.83 $102.68 $103.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.45 SUP Custom 27203010 310.45 - BIT DRILL 4.5MM 130MM JACOBS CHUCK COUPLING STAINLESS STEEL BOTH IP/OP $131.43 $97.26 $0.00 $102.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.54 $97.54 $0.00 $0.00 $27.39 $0.00 $0.00 $0.00 $0.00 $63.80 $101.06 $102.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.48 SUP Custom 27203010 310.48 - BIT DRILL 4.5MM 195MM QUICK COUPLING STAINLESS STEEL NONSTRL BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $0.00 $0.00 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.49 SUP Custom 27203010 310.49 - BIT DRILL 4.5MM 180MM JACOBS CHUCK STAINLESS STEEL NONSTRL BOTH IP/OP $170.10 $125.87 $0.00 $132.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.25 $126.25 $0.00 $0.00 $35.45 $0.00 $0.00 $0.00 $0.00 $82.56 $130.78 $132.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.495 SUP Custom 27203010 310.495 - BIT DRL 7.3MM 2.9MM 300MM NS CNN LG QC BOTH IP/OP $834.98 $617.89 $0.00 $648.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.72 $619.72 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $405.33 $642.03 $648.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.507 SUP Custom 27203010 310.507 - BIT DRL 1.5MM 96MM NS MNQK CPLNG D MRK BOTH IP/OP $279.73 $207.00 $0.00 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.61 $207.61 $0.00 $0.00 $58.29 $0.00 $0.00 $0.00 $0.00 $135.79 $215.09 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.509 SUP Custom 27203010 310.509 - BIT DRL 1.8MM 110MM NS QC D MRK BOTH IP/OP $279.73 $207.00 $0.00 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.61 $207.61 $0.00 $0.00 $58.29 $0.00 $0.00 $0.00 $0.00 $135.79 $215.09 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.51 SUP Custom 27203010 310.510 - BIT DRL 1.8MM 100MM NS QC D MRK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.511 SUP Custom 27203010 310.511 - BIT DRILL 100MM 1.8MM UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.512 SUP Custom 27203010 310.512 - BIT DRL 1.8MM 100MM NS JLTCH CPLNG STRYK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.513 SUP Custom 27203010 310.513 - BIT DRILL 100MM 1.8MM MINI MANDIB QC JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.52 SUP Custom 27203010 310.520 - BIT DRL 1.8MM 125MM NS QC BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.521 SUP Custom 27203010 310.521 - BIT DRILL 125MM 1.8MM UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.522 SUP Custom 27203010 310.522 - BIT DRL 1.8MM 125MM NS JLTCH CPLNG STRYK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.523 SUP Custom 27203010 310.523 - BIT DRILL 125MM 1.8MM MINI QC 2.4MM SCR NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.53 SUP Custom 27203010 310.530 - BIT DRL 2.4MM 100MM NS QC D MRK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.531 SUP Custom 27203010 310.531 - BIT DRILL 100MM 2.4MM UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.532 SUP Custom 27203010 310.532 - BIT DRL 2.4MM 100MM NS JLTCH CPLNG STRYK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.533 SUP Custom 27203010 310.533 - BIT DRILL 100MM 2.4MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.54 SUP Custom 27203010 310.540 - BIT DRL 2.4MM 125MM NS QC BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.541 SUP Custom 27203010 310.541 - BIT DRILL 125MM 2.4MM UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.542 SUP Custom 27203010 310.542 - BIT DRILL 125MM 2.4MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.543 SUP Custom 27203010 310.543 - BIT DRILL 125MM 2.4MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.562 SUP Custom 27203010 310.562 - BIT DRILL 75MM 1.8MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.572 SUP Custom 27203010 310.572 - BIT DRL 2.4MM 75MM NS JLTCH CPLNG STRYK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.582 SUP Custom 27203010 310.582 - BIT DRILL 50MM 1.5MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.592 SUP Custom 27203010 310.592 - BIT DRILL 50MM 1.8MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.6 SUP Custom 27203010 310.60 - BIT DRILL 6MM 195MM QUICK COUPLING NONSTRL BOTH IP/OP $302.98 $224.21 $0.00 $242.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.87 $224.87 $0.00 $0.00 $63.14 $0.00 $0.00 $0.00 $0.00 $151.49 $239.96 $242.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.63 SUP Custom 27203010 310.63 - BIT DRL 5MM 2.9MM 300MM NS CNN LG QC BOTH IP/OP $822.33 $608.52 $0.00 $638.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.33 $610.33 $0.00 $0.00 $171.37 $0.00 $0.00 $0.00 $0.00 $399.19 $632.32 $638.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.632 SUP Custom 27203010 310.632 - BIT DRL SHRT FLUT 5MM 200MM NS CNN QC 7.3MM SCR BOTH IP/OP $656.45 $485.77 $0.00 $509.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $487.22 $487.22 $0.00 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $318.68 $504.78 $509.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.634 SUP Custom 27203010 310.634 - BIT DRL LNG FLUT 4.3MM 200MM NS CNN QC 5MM SCR BOTH IP/OP $656.45 $485.77 $0.00 $509.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $487.22 $487.22 $0.00 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $318.68 $504.78 $509.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.65 SUP Custom 27203010 310.65 - BIT DRL 3.2MM 1.7MM 170MM NS CNN QC BOTH IP/OP $818.13 $605.42 $0.00 $635.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.21 $607.21 $0.00 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $397.14 $629.07 $635.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.66 SUP Custom 27203010 310.66 - BIT DRL 4.5MM 1.7MM 170MM NS CNN QC BOTH IP/OP $818.13 $605.42 $0.00 $635.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.21 $607.21 $0.00 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $397.14 $629.07 $635.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.67 SUP Custom 27203010 310.67 - BIT DRL 2.7MM 160MM NS CNN QC BOTH IP/OP $833.58 $616.85 $0.00 $647.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $618.68 $618.68 $0.00 $0.00 $173.72 $0.00 $0.00 $0.00 $0.00 $404.65 $640.97 $647.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.68 SUP Custom 27203010 310.68 - BIT DRL 3.5MM 160MM NS CNN QC BOTH IP/OP $833.58 $616.85 $0.00 $647.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $618.68 $618.68 $0.00 $0.00 $173.72 $0.00 $0.00 $0.00 $0.00 $404.65 $640.97 $647.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.69 SUP Custom 27203010 310.69 - BIT DRL 4.5MM 233MM NS CNN JCHK BOTH IP/OP $818.13 $605.42 $0.00 $635.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.21 $607.21 $0.00 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $397.14 $629.07 $635.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.8 SUP Custom 27203010 310.80 - CNTRSNK DRILL CENTERING PIN 2.4 MM CORT SCR NONSTRL BOTH IP/OP "$1,460.25 " "$1,080.59" $0.00 "$1,168.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,083.80" "$1,083.80" $0.00 $0.00 $304.32 $0.00 $0.00 $0.00 $0.00 $730.13 "$1,156.52" "$1,168.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.805 SUP Custom 27203010 310.805 - COUNTERSINK W/CENTERING PINS FOR 2.4MM SCREWS/HEX COUPLING BOTH IP/OP "$1,518.75 " "$1,123.88" $0.00 "$1,215.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,127.22" "$1,127.22" $0.00 $0.00 $316.51 $0.00 $0.00 $0.00 $0.00 $759.38 "$1,202.85" "$1,215.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.81 SUP Custom 27203010 310.81 - CNTRSNK DRILL QC CENTERING PIN 1.5 MM 2 MM 2.7 MM SCR BOTH IP/OP "$1,518.75 " "$1,123.88" $0.00 "$1,215.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,127.22" "$1,127.22" $0.00 $0.00 $316.51 $0.00 $0.00 $0.00 $0.00 $759.38 "$1,202.85" "$1,215.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.811 SUP Custom 27203010 310.811 - COUNTERSINK W/CENTERING PINS FOR 2.0MM SCREWS/HEX COUPLING BOTH IP/OP "$1,584.00 " "$1,172.16" $0.00 "$1,267.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,175.64" "$1,175.64" $0.00 $0.00 $330.11 $0.00 $0.00 $0.00 $0.00 $792.00 "$1,254.53" "$1,267.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.883 SUP Custom 27203010 310.883 - CNTRSNK DRILL HEX CPLNG 2 MM 2.4 MM SCR BOTH IP/OP "$1,471.50 " "$1,088.91" $0.00 "$1,177.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,092.15" "$1,092.15" $0.00 $0.00 $306.66 $0.00 $0.00 $0.00 $0.00 $735.75 "$1,165.43" "$1,177.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311.014 SUP Custom 27203010 311.014 - SCRDRVR SM SURG RCHT NONSTRL BOTH IP/OP "$3,096.00 " "$2,291.04" $0.00 "$2,476.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,297.85" "$2,297.85" $0.00 $0.00 $645.21 $0.00 $0.00 $0.00 $0.00 "$1,548.00" "$2,452.03" "$2,476.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311.12 SUP HCPCS C1713 311.120 - TAP MNQK CPLNG SURG 1.3 MM CORTEX SCR BOTH IP/OP $326.25 $241.43 $0.00 $261.00 $146.81 $146.81 $0.00 $0.00 $0.00 $68.00 $242.14 $242.14 $0.00 $0.00 $67.99 $0.00 $192.98 $192.98 $0.00 $163.13 $258.39 $261.00 $0.00 $0.00 $51.06 $0.00 $0.00 $51.94 $0.00 $0.00 $0.00 $0.00 $0.00 311.15 SUP HCPCS C1713 311.15 - TAP SURG 50MM MINI QUICK COUPLING NONSTRL 1.5MM CORTICAL BOTH IP/OP $184.15 $136.27 $0.00 $143.02 $80.45 $80.45 $0.00 $0.00 $0.00 $38.38 $136.68 $136.68 $0.00 $0.00 $38.38 $0.00 $108.92 $108.92 $0.00 $89.39 $141.59 $143.02 $0.00 $0.00 $27.16 $0.00 $0.00 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 311.204 SUP HCPCS C1713 311.204 - TAP 100MM SURG 2MM MANDIB LCK SCR BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 311.209 SUP HCPCS C1713 311.209 - TAP HEX CPLNG SURG 2 MM COARSE PTCH SCR BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $145.80 $145.80 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $0.00 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 311.211 SUP HCPCS C1713 311.211 - TAP HEX CPLNG SURG 2 MM CORTEX SCR BOTH IP/OP $290.25 $214.79 $0.00 $232.20 $130.61 $130.61 $0.00 $0.00 $0.00 $60.50 $215.42 $215.42 $0.00 $0.00 $60.49 $0.00 $171.68 $171.68 $0.00 $145.13 $229.88 $232.20 $0.00 $0.00 $45.42 $0.00 $0.00 $46.21 $0.00 $0.00 $0.00 $0.00 $0.00 311.23 SUP HCPCS C1713 311.23 - TAP QC SURG 2.4 MM CORTEX SCR BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 311.24 SUP HCPCS C1713 311.24 - TAP LNG QC SURG 2.4MM CORTEX SCR BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 311.241 SUP HCPCS C1713 311.241 - TAP HEX CPLNG SURG 2.4 MM CORTEX SCR BOTH IP/OP $423.00 $313.02 $0.00 $338.40 $190.35 $190.35 $0.00 $0.00 $0.00 $88.16 $313.95 $313.95 $0.00 $0.00 $88.15 $0.00 $250.20 $250.20 $0.00 $211.50 $335.02 $338.40 $0.00 $0.00 $66.20 $0.00 $0.00 $67.34 $0.00 $0.00 $0.00 $0.00 $0.00 311.26 SUP Custom 27203010 311.26 - TAP SURG LONG 100MM QUICK COUPLING NONSTRL 2.7MM CORTICAL BOTH IP/OP $216.48 $160.20 $0.00 $168.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.67 $160.67 $0.00 $0.00 $45.11 $0.00 $0.00 $0.00 $0.00 $105.09 $166.46 $168.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311.32 SUP HCPCS C1713 311.32 - TAP SURG LONG 110MM QUICK COUPLING GOLD NONSTRL 3.5MM BOTH IP/OP $216.48 $160.20 $0.00 $168.14 $94.58 $94.58 $0.00 $0.00 $0.00 $45.12 $160.67 $160.67 $0.00 $0.00 $45.11 $0.00 $128.04 $128.04 $0.00 $105.09 $166.46 $168.14 $0.00 $0.00 $31.93 $0.00 $0.00 $33.46 $0.00 $0.00 $0.00 $0.00 $0.00 311.34 SUP HCPCS C1713 311.34 - TAP SURG 110MM NONSTRL 4MM CANCELLOUS SCREW BOTH IP/OP $255.58 $189.13 $0.00 $279.21 $115.01 $115.01 $0.00 $0.00 $0.00 $53.27 $189.69 $189.69 $0.00 $0.00 $53.26 $0.00 $279.21 $279.21 $0.00 $127.79 $166.46 $204.46 $0.00 $0.00 $31.93 $0.00 $0.00 $40.69 $0.00 $0.00 $0.00 $0.00 $0.00 311.349 SUP HCPCS C1713 311.349 - TAP 50MM CLBRT SURG CANC SPNL 3.5 SCR NONSTRL BOTH IP/OP $323.75 $239.58 $0.00 $259.00 $145.69 $145.69 $0.00 $0.00 $0.00 $67.48 $240.29 $240.29 $0.00 $0.00 $67.47 $0.00 $191.50 $191.50 $0.00 $161.88 $256.41 $259.00 $0.00 $0.00 $50.67 $0.00 $0.00 $51.54 $0.00 $0.00 $0.00 $0.00 $0.00 311.449 SUP Custom 27203010 311.449 - DEVICE TARGET 4.5MM PUSH PULL REDX LCP NONSTRL 4.5MM LCP BOTH IP/OP $484.98 $358.89 $0.00 $376.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.95 $359.95 $0.00 $0.00 $101.07 $0.00 $0.00 $0.00 $0.00 $235.43 $372.91 $376.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311.63 SUP Custom 27203010 311.63 - TAP SURG 147MM CANN NONSTRL 4MM SCREW BOTH IP/OP $983.93 $728.11 $0.00 $787.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $730.27 $730.27 $0.00 $0.00 $205.05 $0.00 $0.00 $0.00 $0.00 $491.96 $656.09 $787.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 312.3 SUP Custom 27203010 312.30 - SLEEVE DRILL 3.5MM 2.5MM INSERT LCP NONSTRL BOTH IP/OP $204.73 $151.50 $0.00 $163.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.95 $151.95 $0.00 $0.00 $42.66 $0.00 $0.00 $0.00 $0.00 $102.36 $162.15 $163.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 312.35 SUP Custom 27203010 312.35 - SLEEVE DRILL 2.7MM 1.25MM 2 END NONSTRL BOTH IP/OP $778.75 $576.28 $0.00 $604.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.99 $577.99 $0.00 $0.00 $162.29 $0.00 $0.00 $0.00 $0.00 $378.04 $598.82 $604.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 312.648 SUP HCPCS C1713 312.648 - GUIDE DRILL 2.8MM 2.8MM THRD BOTH IP/OP $196.80 $145.63 $0.00 $191.82 $107.90 $107.90 $0.00 $0.00 $0.00 $0.00 $146.06 $146.06 $0.00 $0.00 $41.01 $0.00 $0.00 $0.00 $0.00 $119.89 $189.91 $191.82 $0.00 $0.00 $37.52 $0.00 $0.00 $38.17 $0.00 $0.00 $0.00 $0.00 $0.00 313.25 SUP Custom 27203010 313.250 - BIT DRILL 44.5MM MINI 4MM STOP QC NONSTRL BOTH IP/OP $281.25 $208.13 $0.00 $225.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.74 $208.74 $0.00 $0.00 $58.61 $0.00 $0.00 $0.00 $0.00 $140.63 $222.75 $225.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 314.03 SUP Custom 27203010 314.03 - SHAFT SCREWDRIVER 2.5MM SMALL HEXAGON NONSTRL BOTH IP/OP $101.90 $75.41 $0.00 $79.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.63 $75.63 $0.00 $0.00 $21.24 $0.00 $0.00 $0.00 $0.00 $49.46 $78.35 $79.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 314.23 SUP Custom 27203010 314.23 - SHAFT SCREWDRIVER 4MM HEXAGONAL CANN QUICK COUPLING BOTH IP/OP $601.63 $445.21 $0.00 $467.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $446.53 $446.53 $0.00 $0.00 $125.38 $0.00 $0.00 $0.00 $0.00 $292.06 $462.63 $467.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 314.467 SUP Custom 27203010 314.467 - SHAFT SCREWDRIVER T8 105MM SELF RETAINING QUICK COUPLING BOTH IP/OP $556.65 $411.92 $0.00 $432.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.15 $413.15 $0.00 $0.00 $116.01 $0.00 $0.00 $0.00 $0.00 $270.23 $428.04 $432.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 314.57 SUP Custom 27203010 314.57 - SCREWDRIVER SURG LONG SMALL HEXAGONAL 3.5MM CORTEX 4MM BOTH IP/OP $423.13 $313.12 $0.00 $328.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $314.04 $314.04 $0.00 $0.00 $88.18 $0.00 $0.00 $0.00 $0.00 $205.40 $325.35 $328.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 314.743 SUP Custom 27203010 314.743 - REAMER SURG 520MM DRIVE SHAFT NONSTRL RIA BOTH IP/OP "$8,876.43 " "$6,568.56" $0.00 "$6,894.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,849.85" $0.00 $0.00 $0.00 $0.00 "$4,308.94" "$6,825.36" "$6,894.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.05 SUP Custom 27203010 315.05 - BIT DRILL 3.5MM 225MM 3 FLUTED QUICK COUPLING NONSTRL BOTH IP/OP $224.90 $166.43 $0.00 $174.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.92 $166.92 $0.00 $0.00 $46.87 $0.00 $0.00 $0.00 $0.00 $109.18 $172.93 $174.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.19 SUP Custom 27203010 315.19 - BIT DRILL 2MM 100MM 3 FLUTED QUICK COUPLING NONSTRL BOTH IP/OP $192.58 $142.51 $0.00 $149.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.93 $142.93 $0.00 $0.00 $40.13 $0.00 $0.00 $0.00 $0.00 $93.49 $148.09 $149.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.21 SUP Custom 27203010 315.21 - BIT DRILL 2MM 125MM 3 FLUTED QUICK COUPLING NONSTRL BOTH IP/OP $192.58 $142.51 $0.00 $149.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.93 $142.93 $0.00 $0.00 $40.13 $0.00 $0.00 $0.00 $0.00 $93.49 $148.09 $149.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.23 SUP Custom 27203010 315.23 - BIT DRILL 2.5MM 180MM 3 FLUTED NONSTRL BOTH IP/OP $209.45 $154.99 $0.00 $162.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.45 $155.45 $0.00 $0.00 $43.65 $0.00 $0.00 $0.00 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.25 SUP Custom 27203010 315.25 - BIT DRILL 2.5MM 110MM 3 FLUTED QUICK COUPLING NONSTRL BOTH IP/OP $209.45 $154.99 $0.00 $162.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.45 $155.45 $0.00 $0.00 $43.65 $0.00 $0.00 $0.00 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.26 SUP Custom 27203010 315.26 - BIT DRILL 3 FLUTED 2.7MM 110MM QUICK COUPLING NONSTRL BOTH IP/OP $216.48 $160.20 $0.00 $168.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.67 $160.67 $0.00 $0.00 $45.11 $0.00 $0.00 $0.00 $0.00 $105.09 $166.46 $168.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.28 SUP Custom 27203010 315.28 - BIT DRL 3 FLUT 2.7MM 125MM NS QC BOTH IP/OP $216.48 $160.20 $0.00 $168.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.67 $160.67 $0.00 $0.00 $45.11 $0.00 $0.00 $0.00 $0.00 $105.09 $166.46 $168.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.29 SUP Custom 27203010 315.29 - BIT DRL 3 FLUT 3.2MM 195MM NS QC BOTH IP/OP $258.65 $191.40 $0.00 $200.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.97 $191.97 $0.00 $0.00 $53.90 $0.00 $0.00 $0.00 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.31 SUP Custom 27203010 315.31 - BIT DRILL 3.2MM 145MM 3 FLUTED QUICK COUPLING NONSTRL BOTH IP/OP $174.30 $128.98 $0.00 $135.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $0.00 $0.00 $0.00 $84.61 $134.03 $135.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.33 SUP Custom 27203010 315.330 - BIT DRILL 3.2MM 210MM 68MM 3 FLUTED QUICK COUPLING BOTH IP/OP $302.98 $224.21 $0.00 $242.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.87 $224.87 $0.00 $0.00 $63.14 $0.00 $0.00 $0.00 $0.00 $151.49 $239.96 $242.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.35 SUP Custom 27203010 315.35 - BIT DRILL 3.5MM 110MM 3 FLUTED QUICK COUPLING CANN NONSTRL BOTH IP/OP $191.10 $141.41 $0.00 $148.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.83 $141.83 $0.00 $0.00 $39.83 $0.00 $0.00 $0.00 $0.00 $92.76 $146.94 $148.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.37 SUP Custom 27203010 315.37 - BIT DRILL 3.5MM 195MM 3 FLUTE QUICK COUPLING CANN NONSTRL BOTH IP/OP $285.93 $211.59 $0.00 $222.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.21 $212.21 $0.00 $0.00 $59.59 $0.00 $0.00 $0.00 $0.00 $138.79 $219.84 $222.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.4 SUP Custom 27203010 315.40 - BIT DRILL 3 FLUTE 4MM 195MM QUICK COUPLING NONSTRL BOTH IP/OP $277.58 $205.41 $0.00 $222.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.02 $206.02 $0.00 $0.00 $57.85 $0.00 $0.00 $0.00 $0.00 $138.79 $219.84 $222.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.4 SUP Custom 27203010 BIT DRILL 195MM 4MM QC 3 FLT NSTRL BOTH IP/OP $277.58 $205.41 $0.00 $238.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.02 $206.02 $0.00 $0.00 $57.85 $0.00 $0.00 $0.00 $0.00 $138.79 $238.27 $222.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.44 SUP Custom 27203010 315.44 - BIT DRILL 4.5MM 145MM QUICK COUPLING 3 FLUTE NONSTRL BOTH IP/OP $174.30 $128.98 $0.00 $135.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $0.00 $0.00 $0.00 $84.61 $134.03 $135.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.48 SUP Custom 27203010 315.48 - BIT DRL 3 FLUT 4.5MM 195MM NS QC BOTH IP/OP $258.65 $191.40 $0.00 $200.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.97 $191.97 $0.00 $0.00 $53.90 $0.00 $0.00 $0.00 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.6 SUP Custom 27203010 315.60 - BIT DRILL 6MM 195MM QUICK COUPLING 3 FLUTED NONSTRL BOTH IP/OP $324.80 $240.35 $0.00 $259.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.07 $241.07 $0.00 $0.00 $67.69 $0.00 $0.00 $0.00 $0.00 $162.40 $257.24 $259.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.92 SUP Custom 27203010 315.92 - BIT DRL 3 FLUT 2.5MM 230MM NS 200MM QC CLBRT BOTH IP/OP $350.03 $259.02 $0.00 $271.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.79 $259.79 $0.00 $0.00 $72.95 $0.00 $0.00 $0.00 $0.00 $169.91 $269.15 $271.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315.93 SUP Custom 27203010 315.93 - BIT DRILL 200MM 3.2MM 230MM 3 FLUTED QUICK COUPLING BOTH IP/OP $432.95 $320.38 $0.00 $336.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.34 $321.34 $0.00 $0.00 $90.23 $0.00 $0.00 $0.00 $0.00 $210.18 $332.92 $336.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.001 SUP Custom 27203010 316.001 - SPACER SPNL 0D 25MM LG 30X33MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.002 SUP Custom 27203010 316.002 - SPACER SPNL 0D 25MM LG 30X41MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.003 SUP Custom 27203010 316.003 - SPACER SPNL 0D 25MM LG 30X45MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.004 SUP Custom 27803010 316.004 - SPACER SPNL 0D 25MM LG 30X53MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.005 SUP Custom 27803010 316.005 - SPACER SPNL 0D 25MM LG 30X69MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,190.00 " "$16,420.60" $0.00 "$17,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,624.40" $0.00 $0.00 $0.00 $0.00 "$11,095.00" "$17,574.48" "$17,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.006 SUP Custom 27803010 316.006 - SPACER SPNL 8D 25MM LG 30X33MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.007 SUP Custom 27803010 316.007 - SPACER SPNL 8D 25MM LG 30X41MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.008 SUP Custom 27803010 316.008 - SPACER SPNL 8D 25MM LG 30X45MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.009 SUP Custom 27803010 316.009 - SPACER SPNL 8D 25MM LG 30X53MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.01 SUP Custom 27803010 316.010 - SPACER SPNL 8D 25MM LG 30X69MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,190.00 " "$16,420.60" $0.00 "$17,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,624.40" $0.00 $0.00 $0.00 $0.00 "$11,095.00" "$17,574.48" "$17,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.011 SUP Custom 27803010 316.011 - SPACER SPNL 8D 25MM LG 30X45MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.012 SUP Custom 27803010 316.012 - SPACER SPNL 16D 25MM LG 30X45MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.013 SUP Custom 27803010 316.013 - SPACER SPNL 16D 25MM LG 30X63MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,190.00 " "$16,420.60" $0.00 "$17,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,624.40" $0.00 $0.00 $0.00 $0.00 "$11,095.00" "$17,574.48" "$17,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.014 SUP Custom 27803010 316.014 - SPACER SPNL 16D 25MM LG 30X39MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.015 SUP Custom 27803010 316.015 - SPACER SPNL 16D 25MM LG 30X48MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.016 SUP Custom 27803010 316.016 - SPACER SPNL 16D 25MM LG 30X57MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.017 SUP Custom 27803010 316.017 - SPACER SPNL 16D 25MM LG 30X74MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$23,740.00 " "$17,567.60" $0.00 "$18,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,947.42" $0.00 $0.00 $0.00 $0.00 "$11,870.00" "$18,802.08" "$18,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.018 SUP Custom 27803010 316.018 - SPACER SPNL 16D 25MM LG 30X91MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$23,740.00 " "$17,567.60" $0.00 "$18,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,947.42" $0.00 $0.00 $0.00 $0.00 "$11,870.00" "$18,802.08" "$18,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.019 SUP Custom 27803010 316.019 - SPACER SPNL -8D 25MM LG 30X33MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.02 SUP Custom 27803010 316.020 - SPACER SPNL -8D 25MM LG 30X41MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.021 SUP Custom 27803010 316.021 - SPACER SPNL -8D 25MM LG 30X45MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.022 SUP Custom 27803010 316.022 - SPACER SPNL -8D 25MM LG 30X53MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.023 SUP Custom 27803010 316.023 - SPACER SPNL -8D 25MM LG 30X69MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,190.00 " "$16,420.60" $0.00 "$17,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,624.40" $0.00 $0.00 $0.00 $0.00 "$11,095.00" "$17,574.48" "$17,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.024 SUP Custom 27803010 316.024 - SPACER SPNL 0D 25MM LG 30X33MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.025 SUP Custom 27803010 316.025 - SPACER SPNL 8D 25MM LG 30X33MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.026 SUP Custom 27803010 316.026 - SPACER SPNL -8D 25MM LG 30X33MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.027 SUP Custom 27803010 316.027 - SPACER SPNL 16D 25MM LG 30X39MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$20,400.00 " "$15,096.00" $0.00 "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,251.36" $0.00 $0.00 $0.00 $0.00 "$10,200.00" "$16,156.80" "$16,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.03 SUP Custom 27203010 316.03 - BIT DRILL 44.5MM .7MM 3MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.05 SUP Custom 27203010 316.05 - BIT DRILL 44.5MM .76MM 5MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.08 SUP Custom 27203010 316.08 - BIT DRILL 44.5MM .76MM 8MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.101 SUP Custom 27803010 316.101 - SPACER SPNL 0D 13MM SM 15X20MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.102 SUP Custom 27803010 316.102 - SPACER SPNL 0D 13MM SM 15X22MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.103 SUP Custom 27803010 316.103 - SPACER SPNL 0D 13MM SM 15X28MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.104 SUP Custom 27803010 316.104 - SPACER SPNL 0D 13MM SM 15X30MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.105 SUP Custom 27803010 316.105 - SPACER SPNL 0D 13MM SM 15X32MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.106 SUP Custom 27803010 316.106 - SPACER SPNL 0D 13MM SM 15X38MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.107 SUP Custom 27803010 316.107 - SPACER SPNL 0D 13MM SM 15X44MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.108 SUP Custom 27803010 316.108 - SPACER SPNL 0D 13MM SM 15X52MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,540.00 " "$12,979.60" $0.00 "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,655.34" $0.00 $0.00 $0.00 $0.00 "$8,770.00" "$13,891.68" "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.109 SUP Custom 27803010 316.109 - SPACER SPNL 0D 13MM SM 15X58MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,540.00 " "$12,979.60" $0.00 "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,655.34" $0.00 $0.00 $0.00 $0.00 "$8,770.00" "$13,891.68" "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.11 SUP Custom 27803010 316.110 - SPACER SPNL 0D 13MM SM 15X64MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,540.00 " "$12,979.60" $0.00 "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,655.34" $0.00 $0.00 $0.00 $0.00 "$8,770.00" "$13,891.68" "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.111 SUP Custom 27803010 316.111 - SPACER SPNL 0D 13MM SM 15X72MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,972.50 " "$14,039.65" $0.00 "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,953.87" $0.00 $0.00 $0.00 $0.00 "$9,486.25" "$15,026.22" "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.112 SUP Custom 27803010 316.112 - SPACER SPNL 0D 13MM SM 15X80MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,972.50 " "$14,039.65" $0.00 "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,953.87" $0.00 $0.00 $0.00 $0.00 "$9,486.25" "$15,026.22" "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.113 SUP Custom 27803010 316.113 - SPACER SPNL 7D 13MM SM 15X20MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.114 SUP Custom 27803010 316.114 - SPACER SPNL 7D 13MM SM 15X22MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.115 SUP Custom 27803010 316.115 - SPACER SPNL 7D 13MM SM 15X28MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.116 SUP Custom 27803010 316.116 - SPACER SPNL 7D 13MM SM 15X30MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.117 SUP Custom 27803010 316.117 - SPACER SPNL 7D 13MM SM 15X32MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.118 SUP Custom 27803010 316.118 - SPACER SPNL 7D 13MM SM 15X38MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.119 SUP Custom 27803010 316.119 - SPACER SPNL 7D 13MM SM 15X44MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.12 SUP Custom 27803010 316.120 - SPACER SPNL 7D 13MM SM 15X52MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,540.00 " "$12,979.60" $0.00 "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,655.34" $0.00 $0.00 $0.00 $0.00 "$8,770.00" "$13,891.68" "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.121 SUP Custom 27803010 316.121 - SPACER SPNL 7D 13MM SM 15X58MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,540.00 " "$12,979.60" $0.00 "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,655.34" $0.00 $0.00 $0.00 $0.00 "$8,770.00" "$13,891.68" "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.122 SUP Custom 27803010 316.122 - SPACER SPNL 7D 13MM SM 15X64MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,540.00 " "$12,979.60" $0.00 "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,655.34" $0.00 $0.00 $0.00 $0.00 "$8,770.00" "$13,891.68" "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.123 SUP Custom 27803010 316.123 - SPACER SPNL 7D 13MM SM 15X72MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,972.50 " "$14,039.65" $0.00 "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,953.87" $0.00 $0.00 $0.00 $0.00 "$9,486.25" "$15,026.22" "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.124 SUP Custom 27803010 316.124 - SPACER SPNL 7D 13MM SM 15X80MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,972.50 " "$14,039.65" $0.00 "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,953.87" $0.00 $0.00 $0.00 $0.00 "$9,486.25" "$15,026.22" "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.125 SUP Custom 27803010 316.125 - SPACER SPNL 16D 13MM SM 15X56MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,540.00 " "$12,979.60" $0.00 "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,655.34" $0.00 $0.00 $0.00 $0.00 "$8,770.00" "$13,891.68" "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.126 SUP Custom 27803010 316.126 - SPACER SPNL 16D 13MM SM 15X64MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,540.00 " "$12,979.60" $0.00 "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,655.34" $0.00 $0.00 $0.00 $0.00 "$8,770.00" "$13,891.68" "$14,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.127 SUP Custom 27803010 316.127 - SPACER SPNL 16D 13MM SM 15X72MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,972.50 " "$14,039.65" $0.00 "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,953.87" $0.00 $0.00 $0.00 $0.00 "$9,486.25" "$15,026.22" "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.128 SUP Custom 27803010 316.128 - SPACER SPNL 16D 13MM SM 15X80MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,972.50 " "$14,039.65" $0.00 "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,953.87" $0.00 $0.00 $0.00 $0.00 "$9,486.25" "$15,026.22" "$15,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.129 SUP Custom 27803010 316.129 - SPACER SPNL 0D 13MM SM 15X20MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.13 SUP Custom 27203010 316.13 - BIT DRL 3MM .7MM 44.5MM NS JLTCH CPLNG SLF STP STRYK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.13 SUP Custom 27803010 316.130 - SPACER SPNL 7D 13MM SM 15X20MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP $371.25 $274.73 $0.00 "$12,755.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 "$12,755.16" $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.131 SUP Custom 27803010 316.131 - SPACER SPNL 0D 13MM SM 15X22MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.132 SUP Custom 27803010 316.132 - SPACER SPNL 7D 13MM SM 15X22MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 $0.00 $0.00 $0.00 "$8,052.50" "$12,755.16" "$12,884.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.15 SUP Custom 27203010 316.15 - BIT DRILL 44.5MM .76MM CPLNG JLTCH STOP 5MM NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.18 SUP Custom 27203010 316.18 - BIT DRILL 44.5MM .76MM JLTCH STOP 8MM NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.201 SUP Custom 27803010 316.201 - SPACER SPNL 6D 21MM MED 23X32MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.202 SUP Custom 27803010 316.202 - SPACER SPNL 6D 21MM MED 23X34MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.203 SUP Custom 27803010 316.203 - SPACER SPNL 6D 21MM MED 23X38MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,447.50 " "$14,391.15" $0.00 "$15,558.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,052.86" $0.00 $0.00 $0.00 $0.00 "$9,723.75" "$15,402.42" "$15,558.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.204 SUP Custom 27803010 316.204 - SPACER SPNL -6D 21MM MED 23X46MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,807.50 " "$14,657.55" $0.00 "$15,846.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,127.88" $0.00 $0.00 $0.00 $0.00 "$9,903.75" "$15,687.54" "$15,846.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.205 SUP Custom 27803010 316.205 - SPACER SPNL 6D 21MM MED 23X56MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.206 SUP Custom 27803010 316.206 - SPACER SPNL -6D 21MM MED 23X64MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.207 SUP Custom 27803010 316.207 - SPACER SPNL 0D 21MM MED 23X32MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.208 SUP Custom 27803010 316.208 - SPACER SPNL 0D 21MM MED 23X34MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.209 SUP Custom 27803010 316.209 - SPACER SPNL 0D 21MM MED 23X38MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,447.50 " "$14,391.15" $0.00 "$15,558.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,052.86" $0.00 $0.00 $0.00 $0.00 "$9,723.75" "$15,402.42" "$15,558.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.21 SUP Custom 27803010 316.210 - SPACER SPNL 0D 21MM MED 23X46MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,807.50 " "$14,657.55" $0.00 "$15,846.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,127.88" $0.00 $0.00 $0.00 $0.00 "$9,903.75" "$15,687.54" "$15,846.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.211 SUP Custom 27803010 316.211 - SPACER SPNL 0D 21MM MED 23X56MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.212 SUP Custom 27803010 316.212 - SPACER SPNL 0D 21MM MED 23X64MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.213 SUP Custom 27803010 316.213 - SPACER SPNL 8D 21MM MED 23X32MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$18,017.50 " "$13,332.95" $0.00 "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,754.85" $0.00 $0.00 $0.00 $0.00 "$9,008.75" "$14,269.86" "$14,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.214 SUP Custom 27803010 316.214 - SPACER SPNL 8D 21MM MED 23X34MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.215 SUP Custom 27803010 316.215 - SPACER SPNL 8D 21MM MED 23X38MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,447.50 " "$14,391.15" $0.00 "$15,558.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,052.86" $0.00 $0.00 $0.00 $0.00 "$9,723.75" "$15,402.42" "$15,558.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.216 SUP Custom 27803010 316.216 - SPACER SPNL 8D 21MM MED 23X46MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,807.50 " "$14,657.55" $0.00 "$15,846.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,127.88" $0.00 $0.00 $0.00 $0.00 "$9,903.75" "$15,687.54" "$15,846.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.217 SUP Custom 27803010 316.217 - SPACER SPNL 8D 21MM MED 23X56MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.218 SUP Custom 27803010 316.218 - SPACER SPNL 8D 21MM MED 23X64MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.219 SUP Custom 27803010 316.219 - SPACER SPNL 8D 21MM MED 23X73MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.22 SUP Custom 27803010 316.220 - SPACER SPNL 8D 21MM MED 23X42MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.221 SUP Custom 27803010 316.221 - SPACER SPNL 0D 21MM MED 23X73MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.222 SUP Custom 27803010 316.222 - SPACER SPNL 0D 21MM MED 23X82MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 $0.00 $0.00 $0.00 "$10,916.25" "$17,291.34" "$17,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.23 SUP Custom 27203010 316.23 - BIT DRILL 60MM .7MM 3MM STOP QC BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.232 SUP Custom 27203010 316.232 - BIT DRILL 60MM 1MM UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.235 SUP Custom 27203010 316.235 - BIT DRL 1MM 60MM NS JLTCH CPLNG WO SLF STP STRYK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.236 SUP Custom 27203010 316.236 - BIT DRL 1MM 60MM NS JLTCH CPLNG STRYK MDLR HND SYS BOTH IP/OP $125.80 $93.09 $0.00 $97.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.37 $93.37 $0.00 $0.00 $26.22 $0.00 $0.00 $0.00 $0.00 $61.06 $96.73 $97.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.238 SUP Custom 27203010 316.238 - BIT DRILL 50MM 1MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.25 SUP Custom 27203010 316.25 - BIT DRILL 44.5MM .76MM 5MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.28 SUP Custom 27203010 316.28 - BIT DRILL 8MM STOP QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.286 SUP Custom 27203010 316.286 - BIT DRILL MINI .76MM 44.5MM 6MM MINI QUICK COUPLING STOP BOTH IP/OP $278.33 $205.96 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.57 $206.57 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.288 SUP Custom 27203010 316.288 - BIT DRILL MINI .76MM 44.5MM 8MM QUICK COUPLING STOP LCP BOTH IP/OP $278.33 $205.96 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.57 $206.57 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.29 SUP Custom 27203010 316.290 - BIT DRILL MINI .76MM 10MM QUICK COUPLING STAINLESS STEEL BOTH IP/OP $270.23 $199.97 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.56 $200.56 $0.00 $0.00 $56.31 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.292 SUP Custom 27203010 316.292 - BIT DRILL MINI .76MM 44.5MM 12MM MINI QUICK COUPLING STOP BOTH IP/OP $278.33 $205.96 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.57 $206.57 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.294 SUP Custom 27203010 316.294 - BIT DRILL .76MM 44.5MM 14MM MINI QUICK COULPING STOP NONSTRL BOTH IP/OP $278.33 $205.96 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.57 $206.57 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.301 SUP Custom 27803010 316.301 - SPACER SPNL 0D 21MM S/MED 23X23MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,062.50 " "$12,626.25" $0.00 "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,555.83" $0.00 $0.00 $0.00 $0.00 "$8,531.25" "$13,513.50" "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.302 SUP Custom 27803010 316.302 - SPACER SPNL 0D 21MM S/MED 23X24MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,062.50 " "$12,626.25" $0.00 "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,555.83" $0.00 $0.00 $0.00 $0.00 "$8,531.25" "$13,513.50" "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.303 SUP Custom 27803010 316.303 - SPACER SPNL 0D 21MM S/MED 23X30MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,062.50 " "$12,626.25" $0.00 "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,555.83" $0.00 $0.00 $0.00 $0.00 "$8,531.25" "$13,513.50" "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.304 SUP Custom 27803010 316.304 - SPACER SPNL 0D 21MM S/MED 23X23MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,062.50 " "$12,626.25" $0.00 "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,555.83" $0.00 $0.00 $0.00 $0.00 "$8,531.25" "$13,513.50" "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.305 SUP Custom 27803010 316.305 - SPACER SPNL 0D 21MM S/MED 23X24MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$17,062.50 " "$12,626.25" $0.00 "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,555.83" $0.00 $0.00 $0.00 $0.00 "$8,531.25" "$13,513.50" "$13,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.306 SUP Custom 27203010 316.306 - BIT DRL 6MM .76MM 44.5MM NS JLTCH CPLNG SLF STP 1MM SCR MDLR BOTH IP/OP $278.33 $205.96 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.57 $206.57 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.308 SUP Custom 27203010 316.308 - BIT DRILL 8MM STOP .76MM 44.5MM J LATCH NONSTRL BOTH IP/OP $278.33 $205.96 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.57 $206.57 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.31 SUP Custom 27203010 316.310 - BIT DRL 10MM .76MM 44.5MM NS JLTCH CPLNG SLF STP 1MM SCR BOTH IP/OP $270.23 $199.97 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.56 $200.56 $0.00 $0.00 $56.31 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.312 SUP Custom 27203010 316.312 - BIT DRL 12MM .76MM 44.5MM NS JLTCH CPLNG SLF STP 1MM SCR BOTH IP/OP $278.33 $205.96 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.57 $206.57 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.314 SUP Custom 27203010 316.314 - BIT DRL 14MM .76MM 44.5MM NS JLTCH CPLNG SLF STP 1MM SCR BOTH IP/OP $278.33 $205.96 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.57 $206.57 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $135.11 $214.02 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.33 SUP Custom 27203010 316.33 - BIT DRILL 17MM .76MM 3MM STOP MINI QC 90D SCRDRVR NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.332 SUP Custom 27203010 316.332 - BIT DRILL 65MM 1.3MM UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.335 SUP Custom 27203010 316.335 - BIT DRILL 65MM 1.3MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.338 SUP Custom 27203010 316.338 - BIT DRILL 55MM 1.3MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.35 SUP Custom 27203010 316.35 - BIT DRILL 19MM .76MM 5MM STOP MINI QC 90D SCRDRVR NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.38 SUP Custom 27203010 316.38 - BIT DRILL 22MM .76MM 8MM STOP MINI QC 90D SCRDRVR NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.396 SUP Custom 27203010 316.396 - BIT DRILL MINI 1MM 50MM QUICK COUPLING STAINLESS STEEL BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.401 SUP Custom 27803010 316.401 - SPACER SPNL 0D 25MM MED LG 30X28MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,922.50 " "$14,742.65" $0.00 "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,151.85" $0.00 $0.00 $0.00 $0.00 "$9,961.25" "$15,778.62" "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.402 SUP Custom 27803010 316.402 - BIT DRILL MINI 1.3MM 55MM QUICK COUPLING STAINLESS STEEL BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.403 SUP Custom 27803010 316.403 - BIT DRILL 1.3MM 65MM J LATCH NONSTRL BOTH IP/OP $139.18 $102.99 $0.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.30 $103.30 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $67.55 $107.00 $108.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.404 SUP Custom 27803010 316.404 - SPACER SPNL 0D 25MM MED LG 30X45MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,070.00 " "$16,331.80" $0.00 "$17,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,599.39" $0.00 $0.00 $0.00 $0.00 "$11,035.00" "$17,479.44" "$17,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.405 SUP Custom 27803010 316.405 - SPACER SPNL 0D 25MM MED LG 30X55MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,785.00 " "$16,860.90" $0.00 "$18,228.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,748.39" $0.00 $0.00 $0.00 $0.00 "$11,392.50" "$18,045.72" "$18,228.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.406 SUP Custom 27803010 316.406 - SPACER SPNL 0D 25MM MED LG 30X61MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,785.00 " "$16,860.90" $0.00 "$18,228.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,748.39" $0.00 $0.00 $0.00 $0.00 "$11,392.50" "$18,045.72" "$18,228.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.407 SUP Custom 27803010 316.407 - SPACER SPNL 3D 25MM MED LG 30X28MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,922.50 " "$14,742.65" $0.00 "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,151.85" $0.00 $0.00 $0.00 $0.00 "$9,961.25" "$15,778.62" "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.408 SUP Custom 27803010 316.408 - SPACER SPNL 3D 25MM MED LG 30X35MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,922.50 " "$14,742.65" $0.00 "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,151.85" $0.00 $0.00 $0.00 $0.00 "$9,961.25" "$15,778.62" "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.409 SUP Custom 27803010 316.409 - SPACER SPNL 3D 25MM MED LG 30X39MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,070.00 " "$16,331.80" $0.00 "$17,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,599.39" $0.00 $0.00 $0.00 $0.00 "$11,035.00" "$17,479.44" "$17,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.41 SUP Custom 27803010 316.410 - SPACER SPNL 3D 25MM MED LG 30X45MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,070.00 " "$16,331.80" $0.00 "$17,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,599.39" $0.00 $0.00 $0.00 $0.00 "$11,035.00" "$17,479.44" "$17,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.411 SUP Custom 27803010 316.411 - SPACER SPNL 3D 25MM MED LG 30X55MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,785.00 " "$16,860.90" $0.00 "$18,228.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,748.39" $0.00 $0.00 $0.00 $0.00 "$11,392.50" "$18,045.72" "$18,228.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.412 SUP Custom 27803010 316.412 - SPACER SPNL 3D 25MM MED LG 30X61MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$22,785.00 " "$16,860.90" $0.00 "$18,228.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,748.39" $0.00 $0.00 $0.00 $0.00 "$11,392.50" "$18,045.72" "$18,228.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.413 SUP Custom 27803010 316.413 - SPACER SPNL 3D 25MM MED LG 30X28MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,922.50 " "$14,742.65" $0.00 "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,151.85" $0.00 $0.00 $0.00 $0.00 "$9,961.25" "$15,778.62" "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.414 SUP Custom 27803010 316.414 - SPACER SPNL 3D 25MM MED LG 30X34MM NS LF XPAND-R RDLCNT SLF BOTH IP/OP "$19,922.50 " "$14,742.65" $0.00 "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,151.85" $0.00 $0.00 $0.00 $0.00 "$9,961.25" "$15,778.62" "$15,938.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.441 SUP Custom 27203010 316.441 - BIT DRL 4MM 1MM 44.5MM NS U HL CPLNG SLF STP .5MM SCR BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.442 SUP Custom 27203010 316.442 - BIT DRL 6MM 1MM 44.5MM NS U HL CPLNG SLF STP .5MM SCR BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.443 SUP Custom 27203010 316.443 - BIT DRL 8MM 1MM 44.5MM NS U HL CPLNG SLF STP .5MM SCR BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.446 SUP Custom 27203010 316.446 - BIT DRILL 44.5MM 1MM JLTCH STOP 4MM NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.447 SUP Custom 27203010 316.447 - BIT DRILL 6MM 1MM JLTCH STOP NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.448 SUP Custom 27203010 316.448 - BIT DRILL 8MM 1MM JLTCH STOP NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.451 SUP Custom 27203010 316.451 - BIT DRILL 1MM 4MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.452 SUP Custom 27203010 316.452 - BIT DRILL 44.5MM 1MM 6MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.453 SUP Custom 27203010 316.453 - BIT DRILL 44.5MM 1MM 8MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.605 SUP Custom 27203010 316.605 - BIT DRILL 52MM .76MM 5MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.608 SUP Custom 27203010 316.608 - BIT DRILL 52MM .76MM 8MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.614 SUP Custom 27203010 316.614 - BIT DRILL 52MM 1MM 4MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.616 SUP Custom 27203010 316.616 - BIT DRILL 52MM 1MM 6MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.618 SUP Custom 27203010 316.618 - BIT DRILL 52MM 1MM 8MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.624 SUP Custom 27203010 316.624 - BIT DRILL 1.1MM STOP HEX 4MM 1.5MM CRANFCL SCR NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.626 SUP Custom 27203010 316.626 - BIT DRILL 52MM 1.1MM 6MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.628 SUP Custom 27203010 316.628 - BIT DRILL 52MM 1.1MM 8MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.632 SUP Custom 27203010 316.632 - BIT DRILL 52MM 1.1MM 12MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.644 SUP Custom 27203010 316.644 - BIT DRILL 52MM 1.5MM 4MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.646 SUP Custom 27203010 316.646 - BIT DRILL 52MM 1.5MM 6MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.648 SUP Custom 27203010 316.648 - BIT DRILL 52MM 1.5MM 8MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.652 SUP Custom 27203010 316.652 - BIT DRILL 52MM 1.5MM 12MM STOP HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.04 SUP Custom 27203010 317.04 - BIT DRILL 44.5MM 1.1MM 4MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.06 SUP Custom 27203010 317.06 - BIT DRILL 44.5MM 1.1MM 6MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.08 SUP Custom 27203010 317.08 - BIT DRILL 44.5MM 1.1MM 8MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.106 SUP Custom 27203010 317.106 - BIT DRILL 20MM 1.1MM 6MM STOP MINI QC 90D SCRDRVR NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.112 SUP Custom 27203010 317.112 - BIT DRILL 26MM 1.1MM 12MM STOP MINI QC 90D SCRDRVR NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.118 SUP Custom 27203010 317.118 - BIT DRILL 32MM 1.1MM 18MM STOP MINI QC 90D SCRDRVR NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.12 SUP Custom 27203010 317.12 - BIT DRILL 44.5MM 1.1MM 2MM STOP JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.14 SUP Custom 27203010 317.14 - BIT DRL 4MM 1.1MM 44.5MM NS JLTCH CPLNG SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.16 SUP Custom 27203010 317.16 - BIT DRL 6MM 1.1MM 44.5MM NS JLTCH CPLNG SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.18 SUP Custom 27203010 317.18 - BIT DRL 8MM 1.1MM 44.5MM NS JLTCH CPLNG SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.22 SUP Custom 27203010 317.22 - BIT DRL 12MM 1.1MM 44.5MM NS JLTCH CPLNG SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.232 SUP Custom 27203010 317.232 - BIT DRILL 65MM 1.1MM UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.235 SUP Custom 27203010 317.235 - BIT DRILL 65MM 1.1MM 40MM STOP JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.238 SUP Custom 27203010 317.238 - BIT DRILL 65MM 1.1MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.24 SUP Custom 27203010 317.24 - BIT DRILL 44.5MM 1.1MM 4MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.26 SUP Custom 27203010 317.26 - BIT DRILL 44.5MM 1.1MM 6MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.28 SUP Custom 27203010 317.28 - BIT DRILL 44.5MM 1.1MM 8MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.32 SUP Custom 27203010 317.32 - BIT DRILL 44.5MM 1.1MM 12MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.332 SUP Custom 27203010 317.332 - BIT DRILL 110MM 1.1MM UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.335 SUP Custom 27203010 317.335 - BIT DRILL 65MM 1.1MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.338 SUP Custom 27203010 317.338 - BIT DRILL 110MM 1.1MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.432 SUP Custom 27203010 317.432 - BIT DRILL 85MM 1.5MM UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.435 SUP Custom 27203010 317.435 - BIT DRL 1.5MM 85MM NS JLTCH CPLNG WO SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.438 SUP Custom 27203010 317.438 - BIT DRILL 85MM 1.5MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.452 SUP Custom 27203010 317.452 - BIT DRILL 100MM 2MM UNV HALL CPLNG NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.458 SUP Custom 27203010 317.458 - BIT DRILL 90MM 2MM MINI QC NONSTRL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.506 SUP Custom 27203010 317.506 - BIT DRILL 20MM 1.5MM 6MM STOP MINI QC NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.512 SUP Custom 27203010 317.512 - BIT DRILL 26MM 1.5MM 12MM STOP MINI QC NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.518 SUP Custom 27203010 317.518 - BIT DRILL 32MM 1.5MM 18MM STOP MINI QC NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.54 SUP Custom 27203010 317.54 - BIT DRILL 44.5MM 1.5MM 4MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.56 SUP Custom 27203010 317.56 - BIT DRILL 44.5MM 1.5MM 6MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.58 SUP Custom 27203010 317.58 - BIT DRILL 44.5MM 1.5MM 8MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.62 SUP Custom 27203010 317.62 - BIT DRILL 44.5MM 1.5MM 12MM STOP UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.64 SUP Custom 27203010 317.64 - BIT DRL 4MM 1.5MM 44.5MM NS JLTCH CPLNG SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.66 SUP Custom 27203010 317.66 - BIT DRL 6MM 1.5MM 44.5MM NS JLTCH CPLNG SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.68 SUP Custom 27203010 317.68 - BIT DRL 8MM 1.5MM 44.5MM NS JLTCH CPLNG SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.72 SUP Custom 27203010 317.72 - BIT DRL 12MM 1.5MM 44.5MM NS JLTCH CPLNG SLF STP 1/1.5MM SCR BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.74 SUP Custom 27203010 317.74 - BIT DRILL 44.5MM 1.5MM 4MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.76 SUP Custom 27203010 317.76 - BIT DRILL 44.5MM 1.5MM 6MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.78 SUP Custom 27203010 317.78 - BIT DRILL 44.5MM 1.5MM 8MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.781 SUP Custom 27203010 317.781 - BIT DRILL 91MM 1.5MM 4MM STOP GUIDE NONSTRL BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.25 $166.25 $0.00 $0.00 $46.68 $0.00 $0.00 $0.00 $0.00 $112.00 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.782 SUP Custom 27203010 317.782 - BIT DRILL 91MM 1.5MM 6MM STOP GUIDE NONSTRL BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.25 $166.25 $0.00 $0.00 $46.68 $0.00 $0.00 $0.00 $0.00 $112.00 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.806 SUP Custom 27203010 317.806 - BIT DRILL 20MM 1.8MM MINI QC BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.812 SUP Custom 27203010 317.812 - BIT DRILL 26MM 1.8MM MINI QC BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.818 SUP Custom 27203010 317.818 - BIT DRILL 32MM 18MM MINI QC BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.82 SUP Custom 27203010 317.82 - BIT DRILL 44.5MM 1.5MM 12MM STOP MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.832 SUP Custom 27203010 317.832 - BIT DRILL 110MM 1.5MM HEX CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.835 SUP Custom 27203010 317.835 - BIT DRILL 110MM 1.5MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.836 SUP Custom 27203010 317.836 - BIT DRILL 125MM 1.5MM JLTCH NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.838 SUP Custom 27203010 317.838 - BIT DRILL 110MM 1.5MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.852 SUP Custom 27203010 317.852 - BIT DRILL 110MM 2MM UNV HALL CPLNG NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.855 SUP Custom 27203010 317.855 - BIT DRL 2MM 110MM NS JLTCH CPLNG WO SLF STP STRYK BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.856 SUP Custom 27203010 317.856 - BIT DRILL 125MM 2MM JLTCH BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.858 SUP Custom 27203010 317.858 - BIT DRILL 110MM 2MM MINI QC NONSTRL BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.861 SUP Custom 27203010 317.861 - BIT DRL 1.8MM 80MM NS MNQK CPLNG D MRK BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.867 SUP Custom 27203010 317.867 - BIT DRL 1.8MM 90MM NS JLTCH CPLNG 2.4MM SCR MDLR HND SYS BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.871 SUP Custom 27203010 317.871 - BIT DRL 2.4MM 80MM NS MNQK CPLNG 2.4MM SCR MDLR HND SYS BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.872 SUP Custom 27203010 317.872 - BIT DRL 2.4MM 90MM NS JLTCH CPLNG STRYK BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.875 SUP Custom 27203010 317.875 - BIT DRL 6MM 1.5MM 100MM NS QC TROC STP BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.876 SUP Custom 27203010 317.876 - BIT DRL 8-18MM 1.5MM 100MM NS QC TROC CLBRT BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.877 SUP Custom 27203010 317.877 - BIT DRL 6MM 1.8MM 100MM NS QC TROC STP BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.878 SUP Custom 27203010 317.878 - BIT DRL 8-18MM 1.8MM 100MM NS QC TROC CLBRT BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 319.006 SUP Custom 27203010 319.006 - GAUGE DEPTH 2 MM 2.4 MM SCREW BOTH IP/OP "$1,083.80 " $802.01 $0.00 $841.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.40 $804.40 $0.00 $0.00 $225.86 $0.00 $0.00 $0.00 $0.00 $526.11 $833.37 $841.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 319.01 SUP Custom 27203010 319.01 - GAUGE DEPTH MEASURE LCP NONSTRL 2.7/3.5/4 MM SCREW BOTH IP/OP $761.88 $563.79 $0.00 $591.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $565.46 $565.46 $0.00 $0.00 $158.77 $0.00 $0.00 $0.00 $0.00 $369.85 $585.84 $591.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 323.062 SUP Custom 27203010 323.062 - BIT DRL 2MM 140MM NS QC D MRK BOTH IP/OP $279.73 $207.00 $0.00 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.61 $207.61 $0.00 $0.00 $58.29 $0.00 $0.00 $0.00 $0.00 $135.79 $215.09 $217.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 323.36 SUP Custom 27203010 323.36 - GUIDE DRILL 3.5MM LCP UNV BOTH IP/OP $815.30 $603.32 $0.00 $810.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.12 $605.12 $0.00 $0.00 $169.91 $0.00 $0.00 $0.00 $0.00 $506.66 $802.56 $810.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 323.46 SUP Custom 27203010 323.46 - GUIDE DRILL UNIVERSAL 4.5MM LC-DCP BOTH IP/OP $774.53 $573.15 $0.00 $601.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $574.85 $574.85 $0.00 $0.00 $161.41 $0.00 $0.00 $0.00 $0.00 $375.99 $595.57 $601.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.101 SUP Custom 27203010 324.101 - HOLDER IMPL VCTR ANT CERV SPN TEMP INS SLFRET HLD SLV ANT BOTH IP/OP $264.25 $195.55 $0.00 $211.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.13 $196.13 $0.00 $0.00 $55.07 $0.00 $0.00 $0.00 $0.00 $132.13 $209.29 $211.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.153 SUP Custom 27203010 324.153 - BIT DRL 2.5MM 14MM NS STP BOTH IP/OP $516.25 $382.03 $0.00 $413.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $383.16 $383.16 $0.00 $0.00 $107.59 $0.00 $0.00 $0.00 $0.00 $258.13 $408.87 $413.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.155 SUP Custom 27203010 324.155 - BIT DRL 2.5MM 16MM NS STP BOTH IP/OP $516.25 $382.03 $0.00 $413.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $383.16 $383.16 $0.00 $0.00 $107.59 $0.00 $0.00 $0.00 $0.00 $258.13 $408.87 $413.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.174 SUP HCPCS C1769 324.174 - GUIDEWIRE ORTHOPEDIC 2.5MM NONSTRL 5MM SCREW BOTH IP/OP $275.53 $203.89 $0.00 $214.00 $145.25 $145.25 $0.00 $0.00 $0.00 $57.43 $204.49 $204.49 $0.00 $0.00 $57.42 $0.00 $162.97 $162.97 $0.00 $133.75 $211.86 $214.00 $0.00 $0.00 $40.64 $0.00 $0.00 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 324.203 SUP Custom 27203010 324.203 - GUIDE DRILL 4.3MM THREAD PERCUTANEOUS BOTH IP/OP $718.30 $531.54 $0.00 $557.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $533.12 $533.12 $0.00 $0.00 $149.69 $0.00 $0.00 $0.00 $0.00 $348.69 $552.32 $557.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.21 SUP Custom 27203010 324.210 - BIT DRL 2.5MM 300MM NS 200MM QC CLBRT BOTH IP/OP $341.20 $252.49 $0.00 $272.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.24 $253.24 $0.00 $0.00 $71.11 $0.00 $0.00 $0.00 $0.00 $170.60 $270.23 $272.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.211 SUP Custom 27203010 324.211 - BIT DRL 2.8MM 300MM NS 200MM QC CLBRT BOTH IP/OP $351.43 $260.06 $0.00 $272.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.83 $260.83 $0.00 $0.00 $73.24 $0.00 $0.00 $0.00 $0.00 $170.60 $270.23 $272.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.212 SUP Custom 27203010 324.212 - BIT DRL 3.2MM 300MM NS QC CLBRT PERC BOTH IP/OP $351.43 $260.06 $0.00 $272.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.83 $260.83 $0.00 $0.00 $73.24 $0.00 $0.00 $0.00 $0.00 $170.60 $270.23 $272.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.213 SUP Custom 27203010 324.213 - BIT DRL 4.3MM 300MM NS QC CLBRT PERC BOTH IP/OP $351.43 $260.06 $0.00 $272.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.83 $260.83 $0.00 $0.00 $73.24 $0.00 $0.00 $0.00 $0.00 $170.60 $270.23 $272.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 324.214 SUP Custom 27203010 324.214 - BIT DRL 2.8MM 200MM NS QC CLBRT BOTH IP/OP $324.73 $240.30 $0.00 $252.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.01 $241.01 $0.00 $0.00 $67.67 $0.00 $0.00 $0.00 $0.00 $157.63 $249.68 $252.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 325.16 SUP Custom 27203010 325.160 - ROD EXFIX 3MM 270MM THREAD SELF DRILL NONSTRL BOTH IP/OP $459.93 $340.35 $0.00 $367.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.36 $341.36 $0.00 $0.00 $95.85 $0.00 $0.00 $0.00 $0.00 $229.96 $364.26 $367.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 328.16 SUP Custom 27203010 328.160 - ROD EXFIX 5MM 380MM THREADED SLFDRILL TIP NONSTRL BOTH IP/OP $556.83 $412.05 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.28 $413.28 $0.00 $0.00 $116.04 $0.00 $0.00 $0.00 $0.00 $278.41 $441.01 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 328.17 SUP Custom 27203010 328.170 - ROD EXFIX BLUNT 5MM 1.6MM 335MM THREAD CANN NONSTRL BOTH IP/OP $556.83 $412.05 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.28 $413.28 $0.00 $0.00 $116.04 $0.00 $0.00 $0.00 $0.00 $278.41 $441.01 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 329.08 SUP Custom 27203010 329.08 - IRON BENDING NONSTRL 3.5/4.5 MM RECONSTRUCTION PLATE BOTH IP/OP $603.05 $446.26 $0.00 $468.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $447.58 $447.58 $0.00 $0.00 $125.68 $0.00 $0.00 $0.00 $0.00 $292.74 $463.70 $468.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336.105 SUP HCPCS C1713 "336.105 - RELIEVE RADIOLUCENT PLATE, OPEN DOOR, 5MM" BOTH IP/OP "$4,877.50 " "$3,609.35" $0.00 "$3,902.00" "$2,194.88" "$2,194.88" $0.00 $0.00 $0.00 "$1,016.59" "$3,620.08" "$3,620.08" $0.00 $0.00 "$1,016.47" $0.00 "$2,404.61" "$2,404.61" $0.00 "$2,438.75" "$3,862.98" "$3,902.00" $0.00 $0.00 $763.33 $0.00 $0.00 $776.50 $0.00 $0.00 $0.00 $0.00 $0.00 336.107 SUP HCPCS C1713 "336.107 - RELIEVE RADIOLUCENT PLATE, OPEN DOOR, 7MM" BOTH IP/OP "$4,877.50 " "$3,609.35" $0.00 "$3,902.00" "$2,194.88" "$2,194.88" $0.00 $0.00 $0.00 "$1,016.59" "$3,620.08" "$3,620.08" $0.00 $0.00 "$1,016.47" $0.00 "$2,404.61" "$2,404.61" $0.00 "$2,438.75" "$3,862.98" "$3,902.00" $0.00 $0.00 $763.33 $0.00 $0.00 $776.50 $0.00 $0.00 $0.00 $0.00 $0.00 336.109 SUP HCPCS C1713 "336.109 - RELIEVE RADIOLUCENT PLATE, OPEN DOOR, 9MM" BOTH IP/OP "$4,877.50 " "$3,609.35" $0.00 "$3,902.00" "$2,194.88" "$2,194.88" $0.00 $0.00 $0.00 "$1,016.59" "$3,620.08" "$3,620.08" $0.00 $0.00 "$1,016.47" $0.00 "$2,404.61" "$2,404.61" $0.00 "$2,438.75" "$3,862.98" "$3,902.00" $0.00 $0.00 $763.33 $0.00 $0.00 $776.50 $0.00 $0.00 $0.00 $0.00 $0.00 336.111 SUP HCPCS C1713 "336.111 - RELIEVE RADIOLUCENT PLATE, OPEN DOOR, 11MM" BOTH IP/OP "$4,877.50 " "$3,609.35" $0.00 "$3,902.00" "$2,194.88" "$2,194.88" $0.00 $0.00 $0.00 "$1,016.59" "$3,620.08" "$3,620.08" $0.00 $0.00 "$1,016.47" $0.00 "$2,404.61" "$2,404.61" $0.00 "$2,438.75" "$3,862.98" "$3,902.00" $0.00 $0.00 $763.33 $0.00 $0.00 $776.50 $0.00 $0.00 $0.00 $0.00 $0.00 336.113 SUP HCPCS C1713 "336.113 - RELIEVE RADIOLUCENT PLATE, OPEN DOOR, 13MM" BOTH IP/OP "$4,877.50 " "$3,609.35" $0.00 "$3,902.00" "$2,194.88" "$2,194.88" $0.00 $0.00 $0.00 "$1,016.59" "$3,620.08" "$3,620.08" $0.00 $0.00 "$1,016.47" $0.00 "$2,404.61" "$2,404.61" $0.00 "$2,438.75" "$3,862.98" "$3,902.00" $0.00 $0.00 $763.33 $0.00 $0.00 $776.50 $0.00 $0.00 $0.00 $0.00 $0.00 337.92 SUP Custom 27203010 337.92 - CANNULA OPHTHALMIC 45D 25GA GRIESHABER DSP STERILE BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $0.00 $0.00 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338.002 SUP Custom 27203010 338.002 - GUIDEWIRE ORTHOPEDIC 2.5MM 300MM 12MM DRILL TIP THEADED BOTH IP/OP $132.13 $97.78 $0.00 $102.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.06 $98.06 $0.00 $0.00 $27.53 $0.00 $0.00 $0.00 $0.00 $64.14 $101.60 $102.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338.13 SUP Custom 27203010 338.13 - REAMER SURG 3 COMPLETE DHS NONSTRL BOTH IP/OP "$2,684.88 " "$1,986.81" $0.00 "$2,085.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,992.71" "$1,992.71" $0.00 $0.00 $559.53 $0.00 $0.00 $0.00 $0.00 "$1,303.34" "$2,064.49" "$2,085.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338.17 SUP Custom 27203010 338.17 - TAP SURG 220MM DHS/DCS 12.5MM SCREWS BOTH IP/OP $656.45 $485.77 $0.00 $509.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $487.22 $487.22 $0.00 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $318.68 $504.78 $509.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338.31 SUP Custom 27203010 338.31 - GUIDE SURG COUPLING SCREW SOLID LATEX FREE DHS/DCS STAINLESS BOTH IP/OP $746.43 $552.36 $0.00 $579.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.00 $554.00 $0.00 $0.00 $155.55 $0.00 $0.00 $0.00 $0.00 $362.34 $573.95 $579.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338.333 SUP Custom 27203010 338.333 - REAMER SURG HEAD DHS BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $0.00 $0.00 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338.348 SUP HCPCS C1713 338.348 - IMPACTOR SURG CAP LCP DHHS BOTH IP/OP $271.30 $200.76 $0.00 $210.72 $118.53 $118.53 $0.00 $0.00 $0.00 $56.55 $201.36 $201.36 $0.00 $0.00 $56.54 $0.00 $160.47 $160.47 $0.00 $131.70 $208.61 $210.72 $0.00 $0.00 $40.02 $0.00 $0.00 $41.93 $0.00 $0.00 $0.00 $0.00 $0.00 339.21 SUP Custom 27203010 339.21 - PROBE VITRECTOMY 30D 25GA DSP POINTED TIP DIATHERMY BOTH IP/OP $695.25 $514.49 $0.00 $556.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $516.01 $516.01 $0.00 $0.00 $144.89 $0.00 $0.00 $0.00 $0.00 $347.63 $550.64 $556.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.715 SUP Custom 27803010 342.715 - SPACER SPNL 0D 12MM SM 14X15MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.717 SUP Custom 27803010 342.717 - SPACER SPNL 0D 12MM SM 14X17MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.719 SUP Custom 27803010 342.719 - SPACER SPNL 0D 12MM SM 14X19MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.721 SUP Custom 27803010 342.721 - SPACER SPNL 0D 12MM SM 14X21MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.723 SUP Custom 27803010 342.723 - SPACER SPNL 0D 12MM SM 14X23MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.725 SUP Custom 27803010 342.725 - SPACER SPNL 0D 12MM SM 14X25MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.727 SUP Custom 27803010 342.727 - SPACER SPNL 0D 12MM SM 14X27MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.729 SUP Custom 27803010 342.729 - SPACER SPNL 0D 12MM SM 14X29MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.731 SUP Custom 27803010 342.731 - SPACER SPNL 0D 12MM SM 14X31MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.733 SUP Custom 27803010 342.733 - SPACER SPNL 0D 12MM SM 14X33MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.815 SUP Custom 27803010 342.815 - SPACER SPNL 7D 12MM SM 14X15MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.817 SUP Custom 27803010 342.817 - SPACER SPNL 7D 12MM SM 14X17MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.819 SUP Custom 27803010 342.819 - SPACER SPNL 7D 12MM SM 14X19MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.821 SUP Custom 27803010 342.821 - SPACER SPNL 7D 12MM SM 14X21MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.823 SUP Custom 27803010 342.823 - SPACER SPNL 7D 12MM SM 14X23MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.825 SUP Custom 27803010 342.825 - SPACER SPNL 7D 12MM SM 14X25MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.827 SUP Custom 27803010 342.827 - SPACER SPNL 7D 12MM SM 14X27MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.829 SUP Custom 27803010 342.829 - SPACER SPNL 7D 12MM SM 14X29MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.831 SUP Custom 27803010 342.831 - SPACER SPNL 7D 12MM SM 14X31MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.833 SUP Custom 27803010 342.833 - SPACER SPNL 7D 12MM SM 14X33MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.915 SUP Custom 27803010 342.915 - SPACER SPNL 5D 12MM SM 14X15MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.917 SUP Custom 27803010 342.917 - SPACER SPNL 5D 12MM SM 14X17MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.919 SUP Custom 27803010 342.919 - SPACER SPNL 5D 12MM SM 14X19MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.921 SUP Custom 27803010 342.921 - SPACER SPNL 5D 12MM SM 14X21MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.923 SUP Custom 27803010 342.923 - SPACER SPNL 5D 12MM SM 14X23MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.925 SUP Custom 27803010 342.925 - SPACER SPNL 5D 12MM SM 14X25MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.927 SUP Custom 27803010 342.927 - SPACER SPNL 5D 12MM SM 14X27MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.929 SUP Custom 27803010 342.929 - SPACER SPNL 5D 12MM SM 14X29MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.931 SUP Custom 27803010 342.931 - SPACER SPNL 5D 12MM SM 14X31MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342.933 SUP Custom 27803010 342.933 - SPACER SPNL 5D 12MM SM 14X33MM NS LF NIKO PEEK-OPTM BOTH IP/OP "$7,635.00 " "$5,649.90" $0.00 "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,591.13" $0.00 $0.00 $0.00 $0.00 "$3,817.50" "$6,046.92" "$6,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.001 SUP Custom 27803010 351.001 - ENDPLATE SPNL 0D 14MM 14X15MM NS LF FORTIFY-R FTPRNT NO SPK BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.002 SUP Custom 27803010 351.002 - ENDPLATE SPNL 0D 14MM 14X17MM NS LF FORTIFY-R FTPRNT BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.003 SUP Custom 27803010 351.003 - ENDPLATE SPNL 3.5D 14MM 14X17MM NS LF FORTIFY-R FTPRNT NO BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.004 SUP Custom 27803010 351.004 - ENDPLATE SPNL 3.5D 14MM 14X19MM NS LF FORTIFY-R FTPRNT BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.005 SUP Custom 27803010 351.005 - ENDPLATE SPNL 0D 14MM 14X16MM NS LF FORTIFY-R FTPRNT NO SPK BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.006 SUP Custom 27803010 351.006 - ENDPLATE SPNL 0D 14MM 14X18MM NS LF FORTIFY-R FTPRNT BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.007 SUP Custom 27803010 351.007 - ENDPLATE SPNL 3.5D 14MM 14X18MM NS LF FORTIFY-R FTPRNT NO BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.008 SUP Custom 27803010 351.008 - ENDPLATE SPNL 3.5D 14MM 14X20MM NS LF FORTIFY-R FTPRNT BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.009 SUP Custom 27803010 351.009 - ENDPLATE SPNL 0D 14MM 14X18MM NS LF FORTIFY-R FTPRNT NO SPK BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.01 SUP Custom 27803010 351.010 - ENDPLATE SPNL 0D 14MM 14X20MM NS LF FORTIFY-R FTPRNT BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.011 SUP Custom 27803010 351.011 - ENDPLATE SPNL 3.5D 14MM 14X20MM NS LF FORTIFY-R FTPRNT NO BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.012 SUP Custom 27803010 351.012 - ENDPLATE SPNL 3.5D 14MM 14X22MM NS LF FORTIFY-R FTPRNT BOTH IP/OP "$19,050.00 " "$14,097.00" $0.00 "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,970.02" $0.00 $0.00 $0.00 $0.00 "$9,525.00" "$15,087.60" "$15,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.05 SUP Custom 27803010 351.050 - ENDPLATE SPNL 14MM 14X24MM NS LF FORTIFY-R BOTH IP/OP "$18,600.00 " "$13,764.00" $0.00 "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,876.24" $0.00 $0.00 $0.00 $0.00 "$9,300.00" "$14,731.20" "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.051 SUP Custom 27803010 351.051 - ENDPLATE SPNL 14MM 14X28MM NS LF FORTIFY-R BOTH IP/OP "$18,600.00 " "$13,764.00" $0.00 "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,876.24" $0.00 $0.00 $0.00 $0.00 "$9,300.00" "$14,731.20" "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.052 SUP Custom 27803010 351.052 - ENDPLATE SPNL 14MM 14X35MM NS LF FORTIFY-R BOTH IP/OP "$18,600.00 " "$13,764.00" $0.00 "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,876.24" $0.00 $0.00 $0.00 $0.00 "$9,300.00" "$14,731.20" "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.053 SUP Custom 27803010 351.053 - ENDPLATE SPNL 14MM 14X49MM NS LF FORTIFY-R BOTH IP/OP "$18,600.00 " "$13,764.00" $0.00 "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,876.24" $0.00 $0.00 $0.00 $0.00 "$9,300.00" "$14,731.20" "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.054 SUP Custom 27803010 351.054 - ENDPLATE SPNL 14MM 14X66MM NS LF FORTIFY-R BOTH IP/OP "$18,600.00 " "$13,764.00" $0.00 "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,876.24" $0.00 $0.00 $0.00 $0.00 "$9,300.00" "$14,731.20" "$14,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.15 SUP Custom 27803010 351.150 - ENDPLATE SPNL 14MM 20X26MM NS LF FORTIFY-R BOTH IP/OP "$23,600.00 " "$17,464.00" $0.00 "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,918.24" $0.00 $0.00 $0.00 $0.00 "$11,800.00" "$18,691.20" "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.151 SUP Custom 27803010 351.151 - ENDPLATE SPNL 20MM 20X28MM NS LF FORTIFY-R BOTH IP/OP "$23,600.00 " "$17,464.00" $0.00 "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,918.24" $0.00 $0.00 $0.00 $0.00 "$11,800.00" "$18,691.20" "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.152 SUP Custom 27803010 351.152 - ENDPLATE SPNL 20MM 20X33MM NS LF FORTIFY-R BOTH IP/OP "$23,600.00 " "$17,464.00" $0.00 "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,918.24" $0.00 $0.00 $0.00 $0.00 "$11,800.00" "$18,691.20" "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.153 SUP Custom 27803010 351.153 - ENDPLATE SPNL 20MM 20X43MM NS LF FORTIFY-R BOTH IP/OP "$23,600.00 " "$17,464.00" $0.00 "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,918.24" $0.00 $0.00 $0.00 $0.00 "$11,800.00" "$18,691.20" "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.154 SUP Custom 27803010 351.154 - ENDPLATE SPNL 20MM 20X61MM NS LF FORTIFY-R BOTH IP/OP "$23,600.00 " "$17,464.00" $0.00 "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,918.24" $0.00 $0.00 $0.00 $0.00 "$11,800.00" "$18,691.20" "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.155 SUP Custom 27803010 351.155 - ENDPLATE SPNL 20MM 20X80MM NS LF FORTIFY-R BOTH IP/OP "$23,600.00 " "$17,464.00" $0.00 "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,918.24" $0.00 $0.00 $0.00 $0.00 "$11,800.00" "$18,691.20" "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.156 SUP Custom 27803010 351.156 - ENDPLATE SPNL 20MM 20X99MM NS LF FORTIFY-R BOTH IP/OP "$23,600.00 " "$17,464.00" $0.00 "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,918.24" $0.00 $0.00 $0.00 $0.00 "$11,800.00" "$18,691.20" "$18,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.27 SUP Custom 27203010 351.27 - BIT DRILL 13MM 300MM CANN NONSTRL BOTH IP/OP "$1,117.40 " $826.88 $0.00 $867.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $829.33 $829.33 $0.00 $0.00 $232.87 $0.00 $0.00 $0.00 $0.00 $542.43 $859.20 $867.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.3 SUP HCPCS C1713 351.300 - SPACER SPNL 0D 14MM 14MM NS LF FORTIFY-R FTPRNT UPR EPLT NO BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.301 SUP HCPCS C1713 351.301 - SPACER SPNL 0D 14MM 14MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.302 SUP HCPCS C1713 351.302 - SPACER SPNL 3.5D 14MM 14MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.303 SUP HCPCS C1713 351.303 - SPACER SPNL 3.5D 14MM 14MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.304 SUP HCPCS C1713 351.304 - SPACER SPNL 7D 14MM 14MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.311 SUP HCPCS C1713 351.311 - SPACER SPNL 0D 14MM 16MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.313 SUP HCPCS C1713 351.313 - SPACER SPNL 3.5D 14MM 16MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.314 SUP HCPCS C1713 351.314 - SPACER SPNL 7D 14MM 16MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.321 SUP HCPCS C1713 351.321 - SPACER SPNL 0D 15MM 18MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 351.323 SUP HCPCS C1713 351.323 - SPACER SPNL 3.5D 15MM 18MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 351.324 SUP HCPCS C1713 351.324 - SPACER SPNL 7D 15MM 18MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 351.351 SUP HCPCS C1713 351.351 - SPACER SPNL 0D 14MM 14MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.353 SUP HCPCS C1713 351.353 - SPACER SPNL 3.5D 14MM 14MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.354 SUP HCPCS C1713 351.354 - SPACER SPNL 7D 14MM 14MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.361 SUP HCPCS C1713 351.361 - SPACER SPNL 0D 14MM 16MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.363 SUP HCPCS C1713 351.363 - SPACER SPNL 3.5D 14MM 16MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.364 SUP HCPCS C1713 351.364 - SPACER SPNL 7D 14MM 16MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.371 SUP HCPCS C1713 351.371 - SPACER SPNL 0D 15MM 18MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 351.373 SUP HCPCS C1713 351.373 - SPACER SPNL 3.5D 15MM 18MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 351.374 SUP HCPCS C1713 351.374 - SPACER SPNL 7D 15MM 18MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 351.401 SUP HCPCS C1713 351.401 - SPACER SPNL 0D 20MM 20MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 351.403 SUP HCPCS C1713 351.403 - SPACER SPNL 4D 20MM 20MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 351.404 SUP HCPCS C1713 351.404 - SPACER SPNL 8D 20MM 20MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 351.411 SUP HCPCS C1713 351.411 - SPACER SPNL 0D 21MM 23MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.413 SUP HCPCS C1713 351.413 - SPACER SPNL 4D 21MM 23MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.414 SUP HCPCS C1713 351.414 - SPACER SPNL 8D 21MM 23MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.431 SUP HCPCS C1713 351.431 - SPACER SPNL 0D 25MM 30MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.433 SUP HCPCS C1713 351.433 - SPACER SPNL 4D 25MM 30MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.434 SUP HCPCS C1713 351.434 - SPACER SPNL 8D 25MM 30MM NS LF FORTIFY-R FTPRNT UPR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.451 SUP HCPCS C1713 351.451 - SPACER SPNL 0D 20MM 20MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 351.453 SUP HCPCS C1713 351.453 - SPACER SPNL 4D 20MM 20MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 351.454 SUP HCPCS C1713 351.454 - SPACER SPNL 8D 20MM 20MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,335.00 " $987.90 $0.00 "$1,068.00" $600.75 $600.75 $0.00 $0.00 $0.00 $278.25 $990.84 $990.84 $0.00 $0.00 $278.21 $0.00 $789.65 $789.65 $0.00 $667.50 "$1,057.32" "$1,068.00" $0.00 $0.00 $208.93 $0.00 $0.00 $212.53 $0.00 $0.00 $0.00 $0.00 $0.00 351.461 SUP HCPCS C1713 351.461 - SPACER SPNL 0D 21MM 23MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.463 SUP HCPCS C1713 351.463 - SPACER SPNL 4D 21MM 23MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.464 SUP HCPCS C1713 351.464 - SPACER SPNL 8D 21MM 23MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.481 SUP HCPCS C1713 351.481 - SPACER SPNL 0D 25MM 30MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.483 SUP HCPCS C1713 351.483 - SPACER SPNL 4D 25MM 30MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.485 SUP HCPCS C1713 351.485 - SPACER SPNL 12D 25MM 30MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.486 SUP HCPCS C1713 351.486 - SPACER SPNL 16D 25MM 30MM NS LF FORTIFY-R FTPRNT LWR EPLT BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 351.92 SUP Custom 27203010 351.92 - REAMER HAND 6MM 450MM NONSTRL BOTH IP/OP $548.48 $405.88 $0.00 $426.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.08 $407.08 $0.00 $0.00 $114.30 $0.00 $0.00 $0.00 $0.00 $266.25 $421.74 $426.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.95 SUP Custom 27203010 351.95 - REAMER HAND 9MM 450MM NONSTRL BOTH IP/OP $567.45 $419.91 $0.00 $440.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.16 $421.16 $0.00 $0.00 $118.26 $0.00 $0.00 $0.00 $0.00 $275.46 $436.34 $440.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.04 SUP Custom 27203010 352.04 - MANIPULATOR SURG FLEXIBLE STEM 5MM BOTH IP/OP "$4,752.58 " "$3,516.91" $0.00 "$4,684.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,527.36" "$3,527.36" $0.00 $0.00 $990.44 $0.00 $0.00 $0.00 $0.00 "$2,927.50" "$4,637.16" "$4,684.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.085 SUP Custom 27203010 352.085 - HEAD RMR 8.5MM MDLRY BOTH IP/OP $587.88 $435.03 $0.00 $456.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $436.32 $436.32 $0.00 $0.00 $122.51 $0.00 $0.00 $0.00 $0.00 $285.38 $452.03 $456.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.1 SUP Custom 27203010 352.100 - REAMER SURG 10MM HEAD SDCT MDLRY NSTRL BOTH IP/OP $678.55 $502.13 $0.00 $542.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.28 $537.41 $542.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.165 SUP Custom 27203010 352.165 - REAMER SURG 16.5MM HEAD SIDE CUT MEDULLARY NONSTRL BOTH IP/OP $719.88 $532.71 $0.00 $575.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $534.29 $534.29 $0.00 $0.00 $150.02 $0.00 $0.00 $0.00 $0.00 $359.94 $570.14 $575.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 355.9 SUP Custom 27203010 355.90 - BIT DRILL 4.5MM 4MM 225MM QUICK COUPLING NONSTRL BOTH IP/OP $362.55 $268.29 $0.00 $290.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.08 $269.08 $0.00 $0.00 $75.56 $0.00 $0.00 $0.00 $0.00 $181.28 $287.14 $290.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 356.95 SUP Custom 27203010 356.95 - BIT DRILL 4MM 4.5MM 225MM QUICK COUPLING 3 FLUTED NONSTRL BOTH IP/OP $446.28 $330.25 $0.00 $357.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.23 $331.23 $0.00 $0.00 $93.00 $0.00 $0.00 $0.00 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 356.97 SUP Custom 27203010 356.97 - BIT DRILL 3.2MM 215MM 80MM 3 FLUTED CALIBRATED QUICK BOTH IP/OP $408.45 $302.25 $0.00 $317.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $303.15 $303.15 $0.00 $0.00 $85.12 $0.00 $0.00 $0.00 $0.00 $198.28 $314.07 $317.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 356.972 SUP Custom 27203010 356.972 - BIT DRILL 82MM CALIBRATION 3.2MM 215MM QUICK COUPLING 3 BOTH IP/OP $404.08 $299.02 $0.00 $313.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.90 $299.90 $0.00 $0.00 $84.21 $0.00 $0.00 $0.00 $0.00 $196.15 $310.70 $313.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 356.98 SUP Custom 27203010 356.98 - BIT DRILL 4MM 270MM 95MM 3 FLUTED CALIBRATED QUICK COUPLING BOTH IP/OP $477.00 $352.98 $0.00 $370.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.03 $354.03 $0.00 $0.00 $99.41 $0.00 $0.00 $0.00 $0.00 $231.56 $366.80 $370.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 356.982 SUP Custom 27203010 356.982 - BIT DRILL 4MM 215MM 80MM 3 FLUTED CALIBRATED QUICK COUPLING BOTH IP/OP $462.43 $342.20 $0.00 $359.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.21 $343.21 $0.00 $0.00 $96.37 $0.00 $0.00 $0.00 $0.00 $224.48 $355.57 $359.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 357.039 SUP Custom 27203010 357.039 - GUIDEWIRE ORTHOPEDIC 2.8MM 350MM THREADED TROCAR POINT BOTH IP/OP $92.78 $68.66 $0.00 $72.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.86 $68.86 $0.00 $0.00 $19.33 $0.00 $0.00 $0.00 $0.00 $45.04 $71.34 $72.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 357.047 SUP Custom 27203010 357.047 - BIT DRILL 6.5MM 330MM QUICK COUPLING CANN BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 357.099 SUP Custom 27203010 357.099 - BIT DRILL 5MM 330MM 100MM 3 FLUTED CALIBRATED QUICK COUPLING BOTH IP/OP $567.93 $420.27 $0.00 $454.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.51 $421.51 $0.00 $0.00 $118.36 $0.00 $0.00 $0.00 $0.00 $283.96 $449.80 $454.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 357.394 SUP Custom 27203010 357.394 - BIT DRL 17MM 300MM NS CNN LG QC BOTH IP/OP "$1,514.18 " "$1,120.49" $0.00 "$1,176.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,123.82" "$1,123.82" $0.00 $0.00 $315.55 $0.00 $0.00 $0.00 $0.00 $735.04 "$1,164.30" "$1,176.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 357.399 SUP Custom 27203010 357.399 - GUIDEWIRE ORTHOPEDIC 3.2MM 400MM THREAD TIBIA NONSTRL BOTH IP/OP $186.73 $138.18 $0.00 $145.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.59 $138.59 $0.00 $0.00 $38.91 $0.00 $0.00 $0.00 $0.00 $90.64 $143.57 $145.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 357.403 SUP Custom 27203010 357.403 - BIT DRILL 6/10MM 435MM LARGE QUICK COUPLING CANN TAPERED BOTH IP/OP "$1,088.23 " $805.29 $0.00 $845.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $807.68 $807.68 $0.00 $0.00 $226.79 $0.00 $0.00 $0.00 $0.00 $528.26 $836.77 $845.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 357.404 SUP Custom 27203010 357.404 - BIT DRILL LARGE 11MM 280MM LARGE QUICK COUPLING CANN TAPERED BOTH IP/OP $959.85 $710.29 $0.00 $745.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.40 $712.40 $0.00 $0.00 $200.03 $0.00 $0.00 $0.00 $0.00 $465.95 $738.06 $745.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 357.407 SUP Custom 27203010 357.407 - BIT DRL 65MM 3 FLUT 4MM 260MM NS QC CLBRT BOTH IP/OP $392.40 $290.38 $0.00 $304.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $291.24 $291.24 $0.00 $0.00 $81.78 $0.00 $0.00 $0.00 $0.00 $190.49 $301.74 $304.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 358.691 SUP Custom 27203010 358.691 - BIT DRILL 102MM STOP 4.5MM 170MM 102MM JACOBS CHUCK CANN BOTH IP/OP $693.98 $513.55 $0.00 $555.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $515.07 $515.07 $0.00 $0.00 $144.62 $0.00 $0.00 $0.00 $0.00 $346.99 $549.63 $555.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 359.079 SUP Custom 27203010 359.079 - BIT DRILL LARGE 10.5MM 250MM QUICK COUPLING CANN FLEXIBLE BOTH IP/OP $921.20 $681.69 $0.00 $736.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $683.71 $683.71 $0.00 $0.00 $191.98 $0.00 $0.00 $0.00 $0.00 $460.60 $729.59 $736.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 359.081 SUP Custom 27203010 359.081 - BIT DRILL LARGE 8MM 250MM QUICK COUPLING CANN FLEXIBLE BOTH IP/OP $921.20 $681.69 $0.00 $736.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $683.71 $683.71 $0.00 $0.00 $191.98 $0.00 $0.00 $0.00 $0.00 $460.60 $729.59 $736.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.01 SUP Custom 27203010 360.01 - BIT DRILL LARGE 6MM 190MM QUICK COUPLING CANN NONSTRL BOTH IP/OP "$1,097.85 " $812.41 $0.00 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.82 $814.82 $0.00 $0.00 $228.79 $0.00 $0.00 $0.00 $0.00 $532.94 $844.18 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.02 SUP Custom 27203010 360.02 - BIT DRILL LARGE 7MM 190MM QUICK COUPLING CANN NONSTRL BOTH IP/OP "$1,097.85 " $812.41 $0.00 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.82 $814.82 $0.00 $0.00 $228.79 $0.00 $0.00 $0.00 $0.00 $532.94 $844.18 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.03 SUP Custom 27203010 360.03 - BIT DRILL LARGE 8MM 190MM QUICK COUPLING CANN NONSTRL BOTH IP/OP "$1,097.85 " $812.41 $0.00 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.82 $814.82 $0.00 $0.00 $228.79 $0.00 $0.00 $0.00 $0.00 $532.94 $844.18 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.04 SUP Custom 27203010 360.04 - BIT DRILL LARGE 9MM 190MM QUICK COUPLING CANN NONSTRL BOTH IP/OP "$1,097.85 " $812.41 $0.00 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.82 $814.82 $0.00 $0.00 $228.79 $0.00 $0.00 $0.00 $0.00 $532.94 $844.18 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.05 SUP Custom 27203010 360.05 - BIT DRILL LARGE 10MM 190MM QUICK COUPLING CANN NONSTRL BOTH IP/OP "$1,097.85 " $812.41 $0.00 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.82 $814.82 $0.00 $0.00 $228.79 $0.00 $0.00 $0.00 $0.00 $532.94 $844.18 $852.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.06 SUP Custom 27203010 360.06 - BIT DRILL LARGE 11MM 190MM QUICK COUPLING CANN NONSTRL BOTH IP/OP "$1,152.68 " $852.98 $0.00 $895.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $855.52 $855.52 $0.00 $0.00 $240.22 $0.00 $0.00 $0.00 $0.00 $559.55 $886.33 $895.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.07 SUP Custom 27203010 360.07 - BIT DRILL LARGE 12MM 190MM QUICK COUPLING CANN NONSTRL BOTH IP/OP "$1,152.68 " $852.98 $0.00 $895.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $855.52 $855.52 $0.00 $0.00 $240.22 $0.00 $0.00 $0.00 $0.00 $559.55 $886.33 $895.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.257 SUP Custom 27203010 360.257 - BIT DRL 13MM 385MM NS LG QC FLXB BOTH IP/OP $794.23 $587.73 $0.00 $616.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $589.47 $589.47 $0.00 $0.00 $165.52 $0.00 $0.00 $0.00 $0.00 $385.54 $610.70 $616.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 360.258 SUP Custom 27203010 360.258 - BIT DRL 15.5MM 385MM NS LG QC FLXB BOTH IP/OP $794.23 $587.73 $0.00 $616.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $589.47 $589.47 $0.00 $0.00 $165.52 $0.00 $0.00 $0.00 $0.00 $385.54 $610.70 $616.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.009 SUP Custom 27803010 364.009 - SPACER SPNL 0D 20MM XS 25X9MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.011 SUP Custom 27803010 364.011 - SPACER SPNL 0D 20MM XS 25X11MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.013 SUP Custom 27803010 364.013 - SPACER SPNL 0D 20MM XS 25X13MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.015 SUP Custom 27803010 364.015 - SPACER SPNL 0D 20MM XS 25X15MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.017 SUP Custom 27803010 364.017 - SPACER SPNL 0D 20MM XS 25X17MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.109 SUP Custom 27803010 364.109 - SPACER SPNL 0D 22MM SM 29X9MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.111 SUP Custom 27803010 364.111 - SPACER SPNL 0D 22MM SM 29X11MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.113 SUP Custom 27803010 364.113 - SPACER SPNL 0D 22MM SM 29X13MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.115 SUP Custom 27803010 364.115 - SPACER SPNL 0D 22MM SM 29X15MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.117 SUP Custom 27803010 364.117 - SPACER SPNL 0D 22MM SM 29X17MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.209 SUP Custom 27803010 364.209 - SPACER SPNL 8D LRDTC 22MM SM 29X9MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.211 SUP Custom 27803010 364.211 - SPACER SPNL 8D LRDTC 22MM SM 29X11MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.213 SUP Custom 27803010 364.213 - SPACER SPNL 8D LRDTC 22MM SM 29X13MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.215 SUP Custom 27803010 364.215 - SPACER SPNL 8D LRDTC 22MM SM 29X15MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.217 SUP Custom 27803010 364.217 - SPACER SPNL 8D LRDTC 22MM SM 29X17MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.311 SUP Custom 27803010 364.311 - SPACER SPNL 15D LRDTC 22MM SM 29X11MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.313 SUP Custom 27803010 364.313 - SPACER SPNL 15D LRDTC 22MM SM 29X13MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.315 SUP Custom 27803010 364.315 - SPACER SPNL 15D LRDTC 22MM SM 29X15MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.317 SUP Custom 27803010 364.317 - SPACER SPNL 15D LRDTC 22MM SM 29X17MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.409 SUP Custom 27803010 364.409 - SPACER SPNL 0D 24MM MED 35X9MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.411 SUP Custom 27803010 364.411 - SPACER SPNL 0D 24MM MED 35X11MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.413 SUP Custom 27803010 364.413 - SPACER SPNL 0D 24MM MED 35X13MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.415 SUP Custom 27803010 364.415 - SPACER SPNL 0D 24MM MED 35X15MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.417 SUP Custom 27803010 364.417 - SPACER SPNL 0D 24MM MED 35X17MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.419 SUP Custom 27803010 364.419 - SPACER SPNL 0D 24MM MED 35X19MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.421 SUP Custom 27803010 364.421 - SPACER SPNL 0D 24MM MED 35X21MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.509 SUP Custom 27803010 364.509 - SPACER SPNL 8D LRDTC 24MM MED 35X9MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.511 SUP Custom 27803010 364.511 - SPACER SPNL 8D LRDTC 24MM MED 35X11MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.513 SUP Custom 27803010 364.513 - SPACER SPNL 8D LRDTC 24MM MED 35X13MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.515 SUP Custom 27803010 364.515 - SPACER SPNL 8D LRDTC 24MM MED 35X15MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.517 SUP Custom 27803010 364.517 - SPACER SPNL 8D LRDTC 24MM MED 35X17MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.519 SUP Custom 27803010 364.519 - SPACER SPNL 8D LRDTC 24MM MED 35X19MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.521 SUP Custom 27803010 364.521 - SPACER SPNL 8D LRDTC 24MM MED 35X21MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.611 SUP Custom 27803010 364.611 - SPACER SPNL 15D LRDTC 24MM MED 35X11MM NS LF CNTNTL PEEK BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.613 SUP Custom 27803010 364.613 - SPACER SPNL 15D LRDTC 24MM MED 35X13MM NS LF CNTNTL PEEK BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.615 SUP Custom 27803010 364.615 - SPACER SPNL 15D LRDTC 24MM MED 35X15MM NS LF CNTNTL PEEK BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.617 SUP Custom 27803010 364.617 - SPACER SPNL 15D LRDTC 24MM MED 35X17MM NS LF CNTNTL PEEK BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.619 SUP Custom 27803010 364.619 - SPACER SPNL 15D LRDTC 24MM MED 35X19MM NS LF CNTNTL PEEK BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.621 SUP Custom 27803010 364.621 - SPACER SPNL 15D LRDTC 24MM MED 35X21MM NS LF CNTNTL PEEK BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.711 SUP Custom 27803010 364.711 - SPACER SPNL 8D LRDTC 28MM LG 39X11MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.713 SUP Custom 27803010 364.713 - SPACER SPNL 8D LRDTC 28MM LG 39X13MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.715 SUP Custom 27803010 364.715 - SPACER SPNL 8D LRDTC 28MM LG 39X15MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.717 SUP Custom 27803010 364.717 - SPACER SPNL 8D LRDTC 28MM LG 39X17MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.719 SUP Custom 27803010 364.719 - SPACER SPNL 8D LRDTC 28MM LG 39X19MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.721 SUP Custom 27803010 364.721 - SPACER SPNL 8D LRDTC 28MM LG 39X21MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.759 SUP Custom 27803010 "364.759 - CONTINENTAL ALIF SPACER, LARGE 5 DEG, 9MM" BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.813 SUP Custom 27803010 364.813 - SPACER SPNL 15D LRDTC 28MM LG 39X13MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.815 SUP Custom 27803010 364.815 - SPACER SPNL 15D LRDTC 28MM LG 39X15MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.817 SUP Custom 27803010 364.817 - SPACER SPNL 15D LRDTC 28MM LG 39X17MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.819 SUP Custom 27803010 364.819 - SPACER SPNL 15D LRDTC 28MM LG 39X19MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 364.821 SUP Custom 27803010 364.821 - SPACER SPNL 15D LRDTC 28MM LG 39X21MM NS LF CNTNTL PEEK ALIF BOTH IP/OP "$13,642.50 " "$10,095.45" $0.00 "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,843.10" $0.00 $0.00 $0.00 $0.00 "$6,821.25" "$10,804.86" "$10,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.005 SUP Custom 27803010 365.005 - SPACER SPNL 11MM SM PRLL 12X5MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.006 SUP Custom 27803010 365.006 - SPACER SPNL 11MM SM PRLL 12X6MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.007 SUP Custom 27803010 365.007 - SPACER SPNL 11MM SM PRLL 12X7MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.008 SUP Custom 27803010 365.008 - SPACER SPNL 11MM SM PRLL 12X8MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.009 SUP Custom 27803010 365.009 - SPACER SPNL 11MM SM PRLL 12X9MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.01 SUP Custom 27803010 365.010 - SPACER SPNL 11MM SM PRLL 12X10MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.011 SUP Custom 27803010 365.011 - SPACER SPNL 11MM SM PRLL 12X11MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.012 SUP Custom 27803010 365.012 - SPACER SPNL 11MM SM PRLL 12X12MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.045 SUP Custom 27803010 365.045 - SPACER SPNL 15MM 2XL PRLL 18X5MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.046 SUP Custom 27803010 365.046 - SPACER SPNL 15MM 2XL PRLL 18X6MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.047 SUP Custom 27803010 365.047 - SPACER SPNL 15MM 2XL PRLL 18X7MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.048 SUP Custom 27803010 365.048 - SPACER SPNL 15MM 2XL PRLL 18X8MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.049 SUP Custom 27803010 365.049 - SPACER SPNL 15MM 2XL PRLL 18X9MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.05 SUP Custom 27803010 365.050 - SPACER SPNL 15MM 2XL PRLL 18X10MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.051 SUP Custom 27803010 365.051 - SPACER SPNL 15MM 2XL PRLL 18X11MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.052 SUP Custom 27803010 365.052 - SPACER SPNL 15MM 2XL PRLL 18X12MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.065 SUP Custom 27803010 365.065 - SPACER SPNL 7D LRDTC 15MM 2XL 18X5MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.066 SUP Custom 27803010 365.066 - SPACER SPNL 7D LRDTC 15MM 2XL 18X6MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.067 SUP Custom 27803010 365.067 - SPACER SPNL 7D LRDTC 15MM 2XL 18X7MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.068 SUP Custom 27803010 365.068 - SPACER SPNL 7D LRDTC 15MM 2XL 18X8MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.069 SUP Custom 27803010 365.069 - SPACER SPNL 7D LRDTC 15MM 2XL 18X9MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.07 SUP Custom 27803010 365.070 - SPACER SPNL 7D LRDTC 15MM 2XL 18X10MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.071 SUP Custom 27803010 365.071 - SPACER SPNL 7D LRDTC 15MM 2XL 18X11MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.072 SUP Custom 27803010 365.072 - SPACER SPNL 7D LRDTC 15MM 2XL 18X12MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.105 SUP Custom 27803010 365.105 - SPACER SPNL 7D LRDTC 11MM SM 12X5MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.106 SUP Custom 27803010 365.106 - SPACER SPNL 7D LRDTC 11MM SM 12X6MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.107 SUP Custom 27803010 365.107 - SPACER SPNL 7D LRDTC 11MM SM 12X7MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.108 SUP Custom 27803010 365.108 - SPACER SPNL 7D LRDTC 11MM SM 12X8MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.109 SUP Custom 27803010 365.109 - SPACER SPNL 7D LRDTC 11MM SM 12X9MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.11 SUP Custom 27803010 365.110 - SPACER SPNL 7D LRDTC 11MM SM 12X10MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.111 SUP Custom 27803010 365.111 - SPACER SPNL 7D LRDTC 11MM SM 12X11MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.112 SUP Custom 27803010 365.112 - SPACER SPNL 7D LRDTC 11MM SM 12X12MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.305 SUP Custom 27803010 365.305 - SPACER SPNL 12MM LG PRLL 14X5MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.306 SUP Custom 27803010 365.306 - SPACER SPNL 12MM LG PRLL 14X6MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.307 SUP Custom 27803010 365.307 - SPACER SPNL 12MM LG PRLL 14X7MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.308 SUP Custom 27803010 365.308 - SPACER SPNL 12MM LG PRLL 14X8MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.309 SUP Custom 27803010 365.309 - SPACER SPNL 12MM LG PRLL 14X9MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.31 SUP Custom 27803010 365.310 - SPACER SPNL 12MM LG PRLL 14X10MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.311 SUP Custom 27803010 365.311 - SPACER SPNL 12MM LG PRLL 14X11MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.312 SUP Custom 27803010 365.312 - SPACER SPNL 12MM LG PRLL 14X12MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.405 SUP Custom 27803010 365.405 - SPACER SPNL 7D LRDTC 12MM LG 14X5MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.406 SUP Custom 27803010 365.406 - SPACER SPNL 7D LRDTC 12MM LG 14X6MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.407 SUP Custom 27803010 365.407 - SPACER SPNL 7D LRDTC 12MM LG 14X7MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.408 SUP Custom 27803010 365.408 - SPACER SPNL 7D LRDTC 12MM LG 14X8MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.409 SUP Custom 27803010 365.409 - SPACER SPNL 7D LRDTC 12MM LG 14X9MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.41 SUP Custom 27803010 365.410 - SPACER SPNL 7D LRDTC 12MM LG 14X10MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.411 SUP Custom 27803010 365.411 - SPACER SPNL 7D LRDTC 12MM LG 14X11MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.412 SUP Custom 27803010 365.412 - SPACER SPNL 7D LRDTC 12MM LG 14X12MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.705 SUP Custom 27803010 365.705 - SPACER SPNL 7D LRDTC 14MM XL 16X5MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.706 SUP Custom 27803010 365.706 - SPACER SPNL 7D LRDTC 14MM XL 16X6MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.707 SUP Custom 27803010 365.707 - SPACER SPNL 7D LRDTC 14MM XL 16X7MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.708 SUP Custom 27803010 365.708 - SPACER SPNL 7D LRDTC 14MM XL 16X8MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.709 SUP Custom 27803010 365.709 - SPACER SPNL 7D LRDTC 14MM XL 16X9MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.71 SUP Custom 27803010 365.710 - SPACER SPNL 7D LRDTC 14MM XL 16X10MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.711 SUP Custom 27803010 365.711 - SPACER SPNL 7D LRDTC 14MM XL 16X11MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.712 SUP Custom 27803010 365.712 - SPACER SPNL 7D LRDTC 14MM XL 16X12MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.805 SUP Custom 27803010 365.805 - SPACER SPNL 7D LRDTC 14MM XL 16X5MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.806 SUP Custom 27803010 365.806 - SPACER SPNL 7D LRDTC 14MM XL 16X6MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.807 SUP Custom 27803010 365.807 - SPACER SPNL 7D LRDTC 14MM XL 16X7MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.808 SUP Custom 27803010 365.808 - SPACER SPNL 7D LRDTC 14MM XL 16X8MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.809 SUP Custom 27803010 365.809 - SPACER SPNL 7D LRDTC 14MM XL 16X9MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.81 SUP Custom 27803010 365.810 - SPACER SPNL 7D LRDTC 14MM XL 16X10MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.811 SUP Custom 27803010 365.811 - SPACER SPNL 7D LRDTC 14MM XL 16X11MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 365.812 SUP Custom 27803010 365.812 - SPACER SPNL 7D LRDTC 14MM XL 16X12MM NS LF CLN PEEK ACDF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.207 SUP Custom 27803010 368.207 - SPACER SPNL SM 28X10X7MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.208 SUP Custom 27803010 368.208 - SPACER SPNL SM 28X10X8MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.209 SUP Custom 27803010 368.209 - SPACER SPNL SM 28X10X9MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.21 SUP Custom 27803010 368.210 - SPACER SPNL SM 28X10X10MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.211 SUP Custom 27803010 368.211 - SPACER SPNL SM 28X10X11MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.212 SUP Custom 27803010 368.212 - SPACER SPNL SM 28X10X12MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.213 SUP Custom 27803010 368.213 - SPACER SPNL SM 28X10X13MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.215 SUP Custom 27803010 368.215 - SPACER SPNL SM 28X10X15MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.217 SUP Custom 27803010 368.217 - SPACER SPNL SM 28X10X17MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.307 SUP Custom 27803010 368.307 - SPACER SPNL LG 33X11X7MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.308 SUP Custom 27803010 368.308 - SPACER SPNL LG 33X11X8MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.309 SUP Custom 27803010 368.309 - SPACER SPNL LG 33X11X9MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.31 SUP Custom 27803010 368.310 - SPACER SPNL LG 33X11X10MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.311 SUP Custom 27803010 368.311 - SPACER SPNL LG 33X11X11MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.312 SUP Custom 27803010 368.312 - SPACER SPNL LG 33X11X12MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.313 SUP Custom 27803010 368.313 - SPACER SPNL LG 33X11X13MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.315 SUP Custom 27803010 368.315 - SPACER SPNL LG 33X11X15MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 368.317 SUP Custom 27803010 368.317 - SPACER SPNL LG 33X11X17MM NS SGNTR PEEK TLIF BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.008 SUP Custom 27803010 "375.008 - TRANSCONTINENTAL LLIF SPACER, SMALL, 0 DEG, 8MM" BOTH IP/OP "$19,642.50 " "$14,535.45" $0.00 "$15,714.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,093.50" $0.00 $0.00 $0.00 $0.00 "$9,821.25" "$15,556.86" "$15,714.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.009 SUP Custom 27803010 375.009 - SPACER SPNL 0D SM 45X18X9MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.011 SUP Custom 27803010 375.011 - SPACER SPNL 0D SM 45X18X11MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.013 SUP Custom 27803010 375.013 - SPACER SPNL 0D SM 45X18X13MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.015 SUP Custom 27803010 375.015 - SPACER SPNL 0D SM 45X18X15MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.017 SUP Custom 27803010 375.017 - SPACER SPNL 0D SM 45X18X17MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.019 SUP Custom 27803010 375.019 - SPACER SPNL 0D SM 45X18X19MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.021 SUP Custom 27803010 375.021 - SPACER SPNL 0D SM 45X18X21MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.109 SUP Custom 27803010 375.109 - SPACER SPNL 6D LRDTC SM 45X18X9MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.111 SUP Custom 27803010 375.111 - SPACER SPNL 6D LRDTC SM 45X18X11MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.113 SUP Custom 27803010 375.113 - SPACER SPNL 6D LRDTC SM 45X18X13MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.115 SUP Custom 27803010 375.115 - SPACER SPNL 6D LRDTC SM 45X18X15MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.117 SUP Custom 27803010 375.117 - SPACER SPNL 6D LRDTC SM 45X18X17MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.119 SUP Custom 27803010 375.119 - SPACER SPNL 6D LRDTC SM 45X18X19MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.121 SUP Custom 27803010 375.121 - SPACER SPNL 6D LRDTC SM 45X18X21MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.209 SUP Custom 27803010 375.209 - SPACER SPNL 0D MED 50X18X9MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.211 SUP Custom 27803010 375.211 - SPACER SPNL 0D MED 50X18X11MM NS LF TRANSCONTINENTAL PEEK BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.213 SUP Custom 27803010 375.213 - SPACER SPNL 0D MED 50X18X13MM NS LF TRANSCONTINENTAL PEEK BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.215 SUP Custom 27803010 375.215 - SPACER SPNL 0D MED 50X18X15MM NS LF TRANSCONTINENTAL PEEK BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.217 SUP Custom 27803010 375.217 - SPACER SPNL 0D MED 50X18X17MM NS LF TRANSCONTINENTAL PEEK BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.219 SUP Custom 27803010 375.219 - SPACER SPNL 0D MED 50X18X19MM NS LF TRANSCONTINENTAL PEEK BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.221 SUP Custom 27803010 375.221 - SPACER SPNL 0D MED 50X18X21MM NS LF TRANSCONTINENTAL PEEK BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.309 SUP Custom 27803010 375.309 - SPACER SPNL 6D LRDTC MED 50X18X9MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.311 SUP Custom 27803010 375.311 - SPACER SPNL 6D LRDTC MED 50X18X11MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.313 SUP Custom 27803010 375.313 - SPACER SPNL 6D LRDTC MED 50X18X13MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.315 SUP Custom 27803010 375.315 - SPACER SPNL 6D LRDTC MED 50X18X15MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.317 SUP Custom 27803010 375.317 - SPACER SPNL 6D LRDTC MED 50X18X17MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.319 SUP Custom 27803010 375.319 - SPACER SPNL 6D LRDTC MED 50X18X19MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.321 SUP Custom 27803010 375.321 - SPACER SPNL 6D LRDTC MED 50X18X21MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.409 SUP Custom 27803010 375.409 - SPACER SPNL 0D LG 55X18X9MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.411 SUP Custom 27803010 375.411 - SPACER SPNL 0D LG 55X18X11MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.413 SUP Custom 27803010 375.413 - SPACER SPNL 0D LG 55X18X13MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.415 SUP Custom 27803010 375.415 - SPACER SPNL 0D LG 55X18X15MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.417 SUP Custom 27803010 375.417 - SPACER SPNL 0D LG 55X18X17MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.419 SUP Custom 27803010 375.419 - SPACER SPNL 0D LG 55X18X19MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.421 SUP Custom 27803010 375.421 - SPACER SPNL 0D LG 55X18X21MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.509 SUP Custom 27803010 375.509 - SPACER SPNL 6D LRDTC LG 55X18X9MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.511 SUP Custom 27803010 375.511 - SPACER SPNL 6D LRDTC LG 55X18X11MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.513 SUP Custom 27803010 375.513 - SPACER SPNL 6D LRDTC LG 55X18X13MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.515 SUP Custom 27803010 375.515 - SPACER SPNL 6D LRDTC LG 55X18X15MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.517 SUP Custom 27803010 375.517 - SPACER SPNL 6D LRDTC LG 55X18X17MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.519 SUP Custom 27803010 375.519 - SPACER SPNL 6D LRDTC LG 55X18X19MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.521 SUP Custom 27803010 375.521 - SPACER SPNL 6D LRDTC LG 55X18X21MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.609 SUP Custom 27803010 375.609 - SPACER SPNL 0D XL 60X18X9MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.611 SUP Custom 27803010 375.611 - SPACER SPNL 0D XL 60X18X11MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.613 SUP Custom 27803010 375.613 - SPACER SPNL 0D XL 60X18X13MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.615 SUP Custom 27803010 375.615 - SPACER SPNL 0D XL 60X18X15MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.617 SUP Custom 27803010 375.617 - SPACER SPNL 0D XL 60X18X17MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.619 SUP Custom 27803010 375.619 - SPACER SPNL 0D XL 60X18X19MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.621 SUP Custom 27803010 375.621 - SPACER SPNL 0D XL 60X18X21MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.709 SUP Custom 27803010 375.709 - SPACER SPNL 6D LRDTC XL 60X18X9MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.711 SUP Custom 27803010 375.711 - SPACER SPNL 6D LRDTC XL 60X18X11MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.713 SUP Custom 27803010 375.713 - SPACER SPNL 6D LRDTC XL 60X18X13MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.715 SUP Custom 27803010 375.715 - SPACER SPNL 6D LRDTC XL 60X18X15MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.717 SUP Custom 27803010 375.717 - SPACER SPNL 6D LRDTC XL 60X18X17MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.719 SUP Custom 27803010 375.719 - SPACER SPNL 6D LRDTC XL 60X18X19MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.721 SUP Custom 27803010 375.721 - SPACER SPNL 6D LRDTC XL 60X18X21MM NS LF TRANSCONTINENTAL BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.809 SUP Custom 27803010 375.809 - SPACER SPNL 0D XS 40X18X9MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.811 SUP Custom 27803010 375.811 - SPACER SPNL 0D XS 40X18X11MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.813 SUP Custom 27803010 375.813 - SPACER SPNL 0D XS 40X18X13MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.815 SUP Custom 27803010 375.815 - SPACER SPNL 0D XS 40X18X15MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375.817 SUP Custom 27803010 375.817 - SPACER SPNL 0D XS 40X18X17MM NS LF TRANSCONTINENTAL PEEK LAT BOTH IP/OP "$21,065.00 " "$15,588.10" $0.00 "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,389.95" $0.00 $0.00 $0.00 $0.00 "$10,532.50" "$16,683.48" "$16,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.111 SUP Custom 27803010 "376.111 - INDEPENDENCE SPACER, SMALL, 8&DEG, 11MM" BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.113 SUP Custom 27803010 376.113 - SPACER SPNL 8D LRDTC 24MM SM 30X13MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.115 SUP Custom 27803010 376.115 - SPACER SPNL 8D LRDTC 24MM SM 30X15MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.117 SUP Custom 27803010 376.117 - SPACER SPNL 8D LRDTC 24MM SM 30X17MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.211 SUP Custom 27803010 376.211 - SPACER SPNL 15D LRDTC 24MM SM 30X11MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.213 SUP Custom 27803010 376.213 - SPACER SPNL 15D LRDTC 24MM SM 30X13MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.215 SUP Custom 27803010 376.215 - SPACER SPNL 15D LRDTC 24MM SM 30X15MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.217 SUP Custom 27803010 376.217 - SPACER SPNL 15D LRDTC 24MM SM 30X17MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.411 SUP Custom 27803010 "376.411 - INDEPENDENCE SPACER, MEDIUM, 8&DEG, 11MM" BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.413 SUP Custom 27803010 376.413 - SPACER SPNL 8D LRDTC 26MM MED 34X13MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.415 SUP Custom 27803010 "376.415 - INDEPENDENCE SPACER, MEDIUM, 8&DEG, 15MM" BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.417 SUP Custom 27803010 376.417 - SPACER SPNL 8D LRDTC 26MM MED 34X17MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.419 SUP Custom 27803010 376.419 - SPACER SPNL 8D LRDTC 26MM MED 34X19MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.421 SUP Custom 27803010 376.421 - SPACER SPNL 8D LRDTC 26MM MED 34X21MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.511 SUP Custom 27803010 376.511 - SPACER SPNL 15D LRDTC 26MM MED 24X11MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.513 SUP Custom 27803010 376.513 - SPACER SPNL 15D LRDTC 26MM MED 34X13MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.515 SUP Custom 27803010 376.515 - SPACER SPNL 15D LRDTC 26MM MED 34X15MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.517 SUP Custom 27803010 376.517 - SPACER SPNL 15D LRDTC 26MM MED 34X17MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.519 SUP Custom 27803010 376.519 - SPACER SPNL 15D LRDTC 26MM MED 34X19MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.521 SUP Custom 27803010 376.521 - SPACER SPNL 15D LRDTC 26MM MED 34X21MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.711 SUP Custom 27803010 376.711 - SPACER SPNL 8D LRDTC 29MM LG 39X11MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.713 SUP Custom 27803010 376.713 - SPACER SPNL 8D LRDTC 29MM LG 39X13MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.715 SUP Custom 27803010 376.715 - SPACER SPNL 8D LRDTC 29MM LG 39X15MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.717 SUP Custom 27803010 376.717 - SPACER SPNL 8D LRDTC 29MM LG 39X17MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.719 SUP Custom 27803010 376.719 - SPACER SPNL 8D LRDTC 29MM LG 39X19MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.721 SUP Custom 27803010 376.721 - SPACER SPNL 8D LRDTC 29MM LG 39X21MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.813 SUP Custom 27803010 376.813 - SPACER SPNL 15D LRDTC 29MM LG 39X13MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.815 SUP Custom 27803010 "376.815 - INDEPENDENCE SPACER, LARGE, 15&DEG, 15MM" BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.817 SUP Custom 27803010 376.817 - SPACER SPNL 15D LRDTC 29MM LG 39X17MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.819 SUP Custom 27803010 376.819 - SPACER SPNL 15D LRDTC 29MM LG 39X19MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 376.821 SUP Custom 27803010 376.821 - SPACER SPNL 15D LRDTC 29MM LG 39X21MM NS LF INDPD PLT PEEK BOTH IP/OP "$25,250.00 " "$18,685.00" $0.00 "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,262.10" $0.00 $0.00 $0.00 $0.00 "$12,625.00" "$19,998.00" "$20,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.006 SUP Custom 27803010 384.006 - SPACER SPNL 0D 12MM 14X6MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.007 SUP Custom 27803010 384.007 - SPACER SPNL 0D 12MM 14X7MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.008 SUP Custom 27803010 384.008 - SPACER SPNL 0D 12MM 14X8MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.009 SUP Custom 27803010 384.009 - SPACER SPNL 0D 12MM 14X9MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.01 SUP Custom 27803010 384.010 - SPACER SPNL 0D 12MM 14X10MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.011 SUP Custom 27803010 384.011 - SPACER SPNL 0D 12MM 14X11MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.012 SUP Custom 27803010 384.012 - SPACER SPNL 0D 12MM 14X12MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.106 SUP Custom 27803010 384.106 - SPACER SPNL 7D LRDTC 12MM 14X6MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.107 SUP Custom 27803010 384.107 - SPACER SPNL 7D LRDTC 12MM 14X7MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.108 SUP Custom 27803010 384.108 - SPACER SPNL 7D LRDTC 12MM 14X8MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.109 SUP Custom 27803010 384.109 - SPACER SPNL 7D LRDTC 12MM 14X9MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.11 SUP Custom 27803010 384.110 - SPACER SPNL 7D LRDTC 12MM 14X10MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.111 SUP Custom 27803010 384.111 - SPACER SPNL 7D LRDTC 12MM 14X11MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.112 SUP Custom 27803010 384.112 - SPACER SPNL 7D LRDTC 12MM 14X12MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.206 SUP Custom 27803010 384.206 - SPACER SPNL 0D 14MM 16X6MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.207 SUP Custom 27803010 384.207 - SPACER SPNL 0D 14MM 16X7MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.208 SUP Custom 27803010 384.208 - SPACER SPNL 0D 14MM 16X8MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.209 SUP Custom 27803010 384.209 - SPACER SPNL 0D 14MM 16X9MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.21 SUP Custom 27803010 384.210 - SPACER SPNL 0D 14MM 16X10MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.211 SUP Custom 27803010 384.211 - SPACER SPNL 0D 14MM 16X14MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.212 SUP Custom 27803010 384.212 - SPACER SPNL 0D 14MM 16X12MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.306 SUP Custom 27803010 384.306 - SPACER SPNL 7D LRDTC 14MM 16X6MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.307 SUP Custom 27803010 384.307 - SPACER SPNL 7D LRDTC 14MM 16X7MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.308 SUP Custom 27803010 384.308 - SPACER SPNL 7D LRDTC 14MM 16X8MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.309 SUP Custom 27803010 384.309 - SPACER SPNL 7D LRDTC 14MM 16X9MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.31 SUP Custom 27803010 384.310 - SPACER SPNL 7D LRDTC 14MM 16X10MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.311 SUP Custom 27803010 384.311 - SPACER SPNL 7D LRDTC 14MM 16X11MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.312 SUP Custom 27803010 384.312 - SPACER SPNL 7D LRDTC 14MM 16X12MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.406 SUP Custom 27803010 384.406 - SPACER SPNL 0D 15MM 18X6MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.407 SUP Custom 27803010 384.407 - SPACER SPNL 0D 15MM 18X7MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.408 SUP Custom 27803010 384.408 - SPACER SPNL 0D 15MM 18X8MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.409 SUP Custom 27803010 384.409 - SPACER SPNL 0D 15MM 18X9MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.41 SUP Custom 27803010 384.410 - SPACER SPNL 0D 15MM 18X10MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.411 SUP Custom 27803010 384.411 - SPACER SPNL 0D 15MM 18X11MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.412 SUP Custom 27803010 384.412 - SPACER SPNL 0D 15MM 18X12MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.506 SUP Custom 27803010 384.506 - SPACER SPNL 7D LRDTC 15MM 18X6MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.507 SUP Custom 27803010 384.507 - SPACER SPNL 7D LRDTC 15MM 18X7MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.508 SUP Custom 27803010 384.508 - SPACER SPNL 7D LRDTC 15MM 18X8MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.509 SUP Custom 27803010 384.509 - SPACER SPNL 7D LRDTC 15MM 18X9MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.51 SUP Custom 27803010 384.510 - SPACER SPNL 7D LRDTC 15MM 18X10MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.511 SUP Custom 27803010 384.511 - SPACER SPNL 7D LRDTC 15MM 18X11MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384.512 SUP Custom 27803010 384.512 - SPACER SPNL 7D LRDTC 15MM 18X12MM NS LF COALITION PEEK ACDF BOTH IP/OP "$12,052.50 " "$8,918.85" $0.00 "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,511.74" $0.00 $0.00 $0.00 $0.00 "$6,026.25" "$9,545.58" "$9,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 387.21 SUP Custom 27203010 387.21 - BIT DRILL THORPE BOTH IP/OP $375.75 $278.06 $0.00 $300.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.88 $278.88 $0.00 $0.00 $78.31 $0.00 $0.00 $0.00 $0.00 $187.88 $297.59 $300.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 387.604 SUP Custom 27203010 387.604 - BIT DRILL 3MM QC STOP BOTH IP/OP $444.50 $328.93 $0.00 $355.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $329.91 $329.91 $0.00 $0.00 $92.63 $0.00 $0.00 $0.00 $0.00 $222.25 $352.04 $355.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 388.174 SUP Custom 27203010 388.174 - BIT DRILL 91MM 1.5MM STOP 4-12MM NONSTRL BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.25 $166.25 $0.00 $0.00 $46.68 $0.00 $0.00 $0.00 $0.00 $112.00 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 388.175 SUP Custom 27203010 388.175 - BIT DRILL 91MM STOP ARCH 1.5MM NONSTRL QUICK COUPLING BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $0.00 $0.00 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 388.177 SUP Custom 27203010 388.177 - BIT DRILL 91MM 10MM STOP 1.5MM NONSTRL BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $0.00 $0.00 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 388.178 SUP Custom 27203010 388.178 - BIT DRILL 91MM 1.5MM 12MM STOP GUIDE NONSTRL BOTH IP/OP $224.00 $165.76 $0.00 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.25 $166.25 $0.00 $0.00 $46.68 $0.00 $0.00 $0.00 $0.00 $112.00 $177.41 $179.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 388.394 SUP Custom 27203010 388.394 - BIT DRL 65MM 2.4MM NS QC STP BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 388.868 SUP HCPCS C1713 388.868 - TRIAL SPNL 3.5MM ROD BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $211.50 $211.50 $0.00 $0.00 $0.00 $97.96 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $278.01 $278.01 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $73.56 $0.00 $0.00 $74.82 $0.00 $0.00 $0.00 $0.00 $0.00 388.906 SUP HCPCS C1713 388.906 - TEMPLATE ROD 150MM NS COAT 5.5MM ROD BOTH IP/OP $447.50 $331.15 $0.00 $358.00 $201.38 $201.38 $0.00 $0.00 $0.00 $93.27 $332.13 $332.13 $0.00 $0.00 $93.26 $0.00 $264.70 $264.70 $0.00 $223.75 $354.42 $358.00 $0.00 $0.00 $70.03 $0.00 $0.00 $71.24 $0.00 $0.00 $0.00 $0.00 $0.00 388.907 SUP Custom 27203010 388.907 - TEMPLATE ROD 500MM NS COAT 5/5.5MM ROD BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.23 $549.23 $0.00 $0.00 $154.22 $0.00 $0.00 $0.00 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.002 SUP Custom 27203010 390.002 - CLAMP EXFIX LARGE 6 POSITION MULTIPIN MR CONDITIONAL NONSTRL BOTH IP/OP "$1,205.30 " $891.92 $0.00 $936.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $894.57 $894.57 $0.00 $0.00 $251.18 $0.00 $0.00 $0.00 $0.00 $585.09 $926.78 $936.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.003 SUP HCPCS C1713 390.003 - ROD EXFIX ATTCH NONSTRL LARGE MULTIPIN CLMP BOTH IP/OP $675.05 $499.54 $0.00 $524.32 $294.93 $294.93 $0.00 $0.00 $0.00 $140.70 $501.02 $501.02 $0.00 $0.00 $140.68 $0.00 $399.29 $399.29 $0.00 $327.70 $519.08 $524.32 $0.00 $0.00 $99.58 $0.00 $0.00 $104.34 $0.00 $0.00 $0.00 $0.00 $0.00 390.004 SUP Custom 27203010 390.004 - CLAMP EXFIX LARGE 4 POSITION MULTIPIN MR CONDITIONAL NONSTRL BOTH IP/OP "$1,128.43 " $835.04 $0.00 $876.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $837.52 $837.52 $0.00 $0.00 $235.16 $0.00 $0.00 $0.00 $0.00 $547.78 $867.68 $876.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.005 SUP Custom 27203010 390.005 - CLAMP EXFIX LARGE COMBO NONSTRL BOTH IP/OP "$1,053.80 " $779.81 $0.00 $818.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $782.13 $782.13 $0.00 $0.00 $219.61 $0.00 $0.00 $0.00 $0.00 $511.55 $810.30 $818.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.006 SUP Custom 27203010 390.006 - CLIP XTRNFX NS DYN MR CONDITIONAL LG CMBN CLP BOTH IP/OP $167.10 $123.65 $0.00 $129.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.02 $124.02 $0.00 $0.00 $34.82 $0.00 $0.00 $0.00 $0.00 $81.11 $128.49 $129.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.007 SUP Custom 27203010 390.007 - CLAMP EXFIX TUBE TO TUBE MR CONDITIONAL NONSTRL BOTH IP/OP "$1,088.33 " $805.36 $0.00 $845.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $807.75 $807.75 $0.00 $0.00 $226.81 $0.00 $0.00 $0.00 $0.00 $528.31 $836.85 $845.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.008 SUP Custom 27203010 390.008 - CLAMP EXFIX LARGE OPEN ADJUSTABLE NONSTRL BOTH IP/OP $873.33 $646.26 $0.00 $678.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $648.18 $648.18 $0.00 $0.00 $182.00 $0.00 $0.00 $0.00 $0.00 $423.95 $671.54 $678.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.009 SUP Custom 27203010 390.009 - CLAMP EXFIX LARGE 4 POSITION PIN NONSTRL LARGE EXFIX BOTH IP/OP $729.63 $539.93 $0.00 $566.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.53 $541.53 $0.00 $0.00 $152.05 $0.00 $0.00 $0.00 $0.00 $354.19 $561.04 $566.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.01 SUP Custom 27203010 390.010 - CLAMP EXFIX LARGE 6 POSITION PIN NONSTRL BOTH IP/OP $727.85 $538.61 $0.00 $582.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $540.21 $540.21 $0.00 $0.00 $151.68 $0.00 $0.00 $0.00 $0.00 $363.93 $576.46 $582.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.011 SUP Custom 27203010 390.011 - POST EXFIX STR 11MM OUTRIGGER NONSTRL BOTH IP/OP $197.18 $145.91 $0.00 $153.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.34 $146.34 $0.00 $0.00 $41.09 $0.00 $0.00 $0.00 $0.00 $95.71 $151.61 $153.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.012 SUP Custom 27203010 390.012 - POST EXFIX 30D 11MM OUTRIGGER MR SAFE NONSTRL BOTH IP/OP $197.18 $145.91 $0.00 $153.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.34 $146.34 $0.00 $0.00 $41.09 $0.00 $0.00 $0.00 $0.00 $95.71 $151.61 $153.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.013 SUP Custom 27203010 390.013 - POST EXFIX 90D 11MM OUTRIGGER NONSTRL BOTH IP/OP $217.23 $160.75 $0.00 $168.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.22 $161.22 $0.00 $0.00 $45.27 $0.00 $0.00 $0.00 $0.00 $105.45 $167.03 $168.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.026 SUP Custom 27203010 390.026 - CLAMP EXFIX MEDIUM 4 POSISTION PIN MR SAFE NONSTRL BOTH IP/OP $689.53 $510.25 $0.00 $535.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $511.77 $511.77 $0.00 $0.00 $143.70 $0.00 $0.00 $0.00 $0.00 $334.73 $530.20 $535.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.027 SUP Custom 27203010 390.027 - CLAMP EXFIX MEDIUM 6 POSISTION PIN MR SAFE NONSTRL BOTH IP/OP $707.35 $523.44 $0.00 $549.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.00 $525.00 $0.00 $0.00 $147.41 $0.00 $0.00 $0.00 $0.00 $343.38 $543.91 $549.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.028 SUP Custom 27203010 390.028 - POST XTRNFX STRG 8MM NS OTRGR MR CONDITIONAL BOTH IP/OP $187.15 $138.49 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.90 $138.90 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $90.85 $143.91 $145.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.029 SUP Custom 27203010 390.029 - POST XTRNFX 30D 8MM NS OTRGR MR CONDITIONAL BOTH IP/OP $187.15 $138.49 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.90 $138.90 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $90.85 $143.91 $145.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.03 SUP Custom 27203010 390.030 - POST XTRNFX 90D 8MM NS OTRGR MR CONDITIONAL BOTH IP/OP $199.00 $147.26 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.70 $147.70 $0.00 $0.00 $41.47 $0.00 $0.00 $0.00 $0.00 $99.50 $157.61 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.031 SUP Custom 27203010 390.031 - CLAMP EXFIX MEDIUM COMBO SELF HOLDING CLIP ON NONSTRL BOTH IP/OP $857.75 $634.74 $0.00 $666.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $636.62 $636.62 $0.00 $0.00 $178.76 $0.00 $0.00 $0.00 $0.00 $416.38 $659.54 $666.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.032 SUP Custom 27203010 390.032 - CLIP XTRNFX NS DYN MR CONDITIONAL MED CMBN CLP BOTH IP/OP $186.03 $137.66 $0.00 $144.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.07 $138.07 $0.00 $0.00 $38.77 $0.00 $0.00 $0.00 $0.00 $90.30 $143.04 $144.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.033 SUP Custom 27203010 390.033 - CLAMP EXFIX MEDIUM 4 POSISTION MULTIPIN MR SAFE NONSTRL BOTH IP/OP "$1,038.20 " $768.27 $0.00 $806.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $770.55 $770.55 $0.00 $0.00 $216.36 $0.00 $0.00 $0.00 $0.00 $503.98 $798.30 $806.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.034 SUP Custom 27203010 390.034 - CLAMP EXFIX MEDIUM MULTIPIN ROD ATTCH MRI SAFE NONSTRL BOTH IP/OP $595.95 $441.00 $0.00 $462.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $442.31 $442.31 $0.00 $0.00 $124.20 $0.00 $0.00 $0.00 $0.00 $289.30 $458.25 $462.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.035 SUP Custom 27203010 390.035 - CLAMP EXFIX MEDIUM OPEN ADJUSTABLE NONSTRL BOTH IP/OP $707.35 $523.44 $0.00 $549.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.00 $525.00 $0.00 $0.00 $147.41 $0.00 $0.00 $0.00 $0.00 $343.38 $543.91 $549.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.036 SUP Custom 27203010 390.036 - CLAMP EXFIX MEDIUM 6 POSISTION MULTIPIN MR SAFE NONSTRL BOTH IP/OP "$1,129.55 " $835.87 $0.00 $877.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $838.35 $838.35 $0.00 $0.00 $235.40 $0.00 $0.00 $0.00 $0.00 $548.33 $868.55 $877.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.037 SUP Custom 27203010 390.037 - CLAMP EXFIX MEDIUM 8-11MM COMBO MR SAFE NONSTRL BOTH IP/OP $986.95 $730.34 $0.00 $766.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.51 $732.51 $0.00 $0.00 $205.68 $0.00 $0.00 $0.00 $0.00 $479.10 $758.89 $766.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.041 SUP Custom 27203010 390.041 - CLAMP EXFIX SMALL COMBO NONSTRL BOTH IP/OP $553.63 $409.69 $0.00 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.90 $410.90 $0.00 $0.00 $115.38 $0.00 $0.00 $0.00 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.042 SUP Custom 27203010 390.042 - CLAMP EXFIX SM ADJ NONSPANNING MRI SAFE SM EXFIX NONSTRL BOTH IP/OP $955.33 $706.94 $0.00 $764.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $709.04 $709.04 $0.00 $0.00 $199.09 $0.00 $0.00 $0.00 $0.00 $477.66 $756.62 $764.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.101 SUP Custom 27203010 BASKET SPEC RTRVL 120CM 2.4FR 12MM STON 4WR SHTH 0TP NTNL BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.12 SUP HCPCS C1713 390.120 - PIN POSITIONING 40MM TITANIUM CRANIAL NONSTRL EXTERNAL BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $175.50 $175.50 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 390.122 SUP Custom 27203010 390.122 - HOLDER IMPLANT 40MM MOUNT PIN TITANIUM CRANIAL NONSTRL BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.124 SUP Custom 27803010 390.124 - PIN FIX 50MM MOUNT MIDFAC NONSTRL EXTERNAL MIDFAC DISTRCT BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.126 SUP Custom 27203010 390.126 - HOLDER IMPLANT 40MM MOUNT PIN TITANIUM MIDFAC BOTH IP/OP $677.50 $501.35 $0.00 $542.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.84 $502.84 $0.00 $0.00 $141.19 $0.00 $0.00 $0.00 $0.00 $338.75 $536.58 $542.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390.128 SUP Custom 27203010 390.128 - PIN SKULL 50MM SLFDRILL CRANIUM NONSTRL BOTH IP/OP $677.50 $501.35 $0.00 $542.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.84 $502.84 $0.00 $0.00 $141.19 $0.00 $0.00 $0.00 $0.00 $338.75 $536.58 $542.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 392.177 SUP Custom 27203010 392.177 - CAP PROTECTIVE CLEAR NONSTRL 1MM 1.25MM K WIRES BOTH IP/OP $4.82 $3.57 $0.00 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.58 $3.58 $0.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $2.34 $3.71 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 392.178 SUP Custom 27203010 392.178 - CAP PROTECTIVE NONSTRL 1.6 MM KWIRE WIRE BOTH IP/OP $4.82 $3.57 $0.00 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.58 $3.58 $0.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $2.34 $3.71 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 392.179 SUP Custom 27203010 392.179 - CAP PROTECTIVE NONSTRL 2 MM KWIRE WIRE BOTH IP/OP $4.54 $3.36 $0.00 $3.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.37 $3.37 $0.00 $0.00 $0.95 $0.00 $0.00 $0.00 $0.00 $2.27 $3.60 $3.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 392.18 SUP Custom 27203010 392.18 - CAP PROTECTIVE NONSTRL 1.8-2 MM KWIRE WIRE BOTH IP/OP $3.93 $2.91 $0.00 $3.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.91 $2.91 $0.00 $0.00 $0.82 $0.00 $0.00 $0.00 $0.00 $1.91 $3.02 $3.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 392.24 SUP Custom 27203010 392.24 - CAP PROTECTIVE NONSTRL 2.5 MM KWIRE WIRE BOTH IP/OP $4.82 $3.57 $0.00 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.58 $3.58 $0.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $2.34 $3.71 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 392.961 SUP HCPCS C1713 392.961 - FIXATOR XTRNFX LG ADJ RADL DIST BOTH IP/OP "$6,189.08 " "$4,579.92" $0.00 "$4,807.06" "$2,703.97" "$2,703.97" $0.00 $0.00 $0.00 "$1,289.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,289.80" $0.00 "$3,051.21" "$3,051.21" $0.00 "$3,004.41" "$4,758.99" "$4,807.06" $0.00 $0.00 $912.99 $0.00 $0.00 $956.60 $0.00 $0.00 $0.00 $0.00 $0.00 393.43 SUP Custom 27203010 393.43 - NUT XTRNFX NS RING TO ROD SPRG LD LG XTRNFXTR BOTH IP/OP $75.75 $56.06 $0.00 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.22 $56.22 $0.00 $0.00 $15.79 $0.00 $0.00 $0.00 $0.00 $36.78 $58.25 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.436 SUP Custom 27203010 393.436 - CLAMP EXFIX RING TO ROD NONSTRL HYBRID EXFIX BOTH IP/OP "$1,444.78 " "$1,069.14" $0.00 "$1,122.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,072.31" "$1,072.31" $0.00 $0.00 $301.09 $0.00 $0.00 $0.00 $0.00 $701.35 "$1,110.94" "$1,122.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.464 SUP Custom 27203010 393.464 - CLAMP EXFIX ADJUSTABLE WIRE PIN NONSTRL HYBRID EXFIX BOTH IP/OP "$1,289.95 " $954.56 $0.00 "$1,001.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $957.40 $957.40 $0.00 $0.00 $268.83 $0.00 $0.00 $0.00 $0.00 $626.19 $991.88 "$1,001.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.64 SUP Custom 27203010 393.64 - CLAMP EXFIX ADJUSTABLE NONSTRL 4/6 MM SCHANZ SCREW LARGE BOTH IP/OP $650.55 $481.41 $0.00 $505.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.84 $482.84 $0.00 $0.00 $135.57 $0.00 $0.00 $0.00 $0.00 $315.80 $500.23 $505.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.66 SUP Custom 27203010 393.66 - CLAMP EXFIX TRNSVRS NONSTRL 4-6 MM SCHANZ SCREW LARGE EXFIX BOTH IP/OP "$1,088.33 " $805.36 $0.00 $845.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $807.75 $807.75 $0.00 $0.00 $226.81 $0.00 $0.00 $0.00 $0.00 $528.31 $836.85 $845.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.69 SUP Custom 27203010 393.69 - CLAMP EXFIX OPEN NONSTRL PIN INSERTION CONNECT BOTH IP/OP $387.65 $286.86 $0.00 $301.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.71 $287.71 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $188.18 $298.07 $301.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.721 SUP Custom 27203010 393.721 - RING EXFIX FULL 205MM FULL RING NONSTRL HYBRID FIXATOR BOTH IP/OP $969.13 $717.16 $0.00 $752.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $719.28 $719.28 $0.00 $0.00 $201.97 $0.00 $0.00 $0.00 $0.00 $470.45 $745.19 $752.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.722 SUP Custom 27203010 393.722 - RING EXFIX .75 205MM .75 RING NONSTRL HYBRID FIXATOR BOTH IP/OP $894.50 $661.93 $0.00 $694.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $0.00 $0.00 $0.00 $434.23 $687.81 $694.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.731 SUP Custom 27203010 393.731 - RING EXFIX FULL 115MM FULL RING NONSTRL HYBRID FIXATOR BOTH IP/OP $732.98 $542.41 $0.00 $569.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $544.01 $544.01 $0.00 $0.00 $152.75 $0.00 $0.00 $0.00 $0.00 $355.81 $563.61 $569.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.732 SUP Custom 27203010 393.732 - RING EXFIX .75 115MM .75 RING NONSTRL HYBRID FIXATOR BOTH IP/OP $658.35 $487.18 $0.00 $511.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $488.63 $488.63 $0.00 $0.00 $137.20 $0.00 $0.00 $0.00 $0.00 $319.59 $506.23 $511.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.734 SUP Custom 27203010 393.734 - RING EXFIX .75 140MM NONSTRL HYBRID FIXATOR BOTH IP/OP $719.60 $532.50 $0.00 $558.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $534.09 $534.09 $0.00 $0.00 $149.96 $0.00 $0.00 $0.00 $0.00 $349.33 $553.33 $558.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.735 SUP Custom 27203010 393.735 - RING EXFIX FULL 165MM FULL RING NONSTRL HYBRID FIXATOR BOTH IP/OP $831.00 $614.94 $0.00 $645.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $616.77 $616.77 $0.00 $0.00 $173.18 $0.00 $0.00 $0.00 $0.00 $403.40 $638.99 $645.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.736 SUP Custom 27203010 393.736 - RING EXFIX .75 165MM .75 RING NONSTRL HYBRID FIXATOR BOTH IP/OP $755.25 $558.89 $0.00 $586.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $560.55 $560.55 $0.00 $0.00 $157.39 $0.00 $0.00 $0.00 $0.00 $366.63 $580.73 $586.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.737 SUP Custom 27203010 393.737 - RING EXFIX .25 165MM .25 RING NONSTRL HYBRID FIXATOR BOTH IP/OP $607.10 $449.25 $0.00 $471.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $450.59 $450.59 $0.00 $0.00 $126.52 $0.00 $0.00 $0.00 $0.00 $294.71 $466.83 $471.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 393.75 SUP Custom 27203010 393.75 - CLAMP EXFIX LARGE UNIVERSAL ADJUSTABLE NONSTRL LARGE EXFIX BOTH IP/OP "$1,033.93 " $765.11 $0.00 $827.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $767.38 $767.38 $0.00 $0.00 $215.47 $0.00 $0.00 $0.00 $0.00 $516.96 $818.87 $827.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.05 SUP Custom 27203010 394.050 - FIXATOR XTRNFX NS ADJ RADL DIST BOTH IP/OP "$2,949.25 " "$2,182.45" $0.00 "$2,359.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,188.93" "$2,188.93" $0.00 $0.00 $614.62 $0.00 $0.00 $0.00 $0.00 "$1,474.63" "$2,335.81" "$2,359.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.055 SUP Custom 27203010 394.055 - FIXATOR XTRNFX HNG ELB UNSTBL FX BOTH IP/OP "$2,315.90 " "$1,713.77" $0.00 "$1,798.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.86" "$1,718.86" $0.00 $0.00 $482.63 $0.00 $0.00 $0.00 $0.00 "$1,124.23" "$1,780.77" "$1,798.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.46 SUP Custom 27203010 394.46 - SLEEVE DISTRCT 105MM HOLD BOTH IP/OP $517.98 $383.31 $0.00 $402.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.44 $384.44 $0.00 $0.00 $107.95 $0.00 $0.00 $0.00 $0.00 $251.45 $398.30 $402.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.79 SUP Custom 27203010 394.79 - ROD EXFIX 180D CURVE 11MM 850MM CARFBR NONSTRL LARGE EXFIX BOTH IP/OP "$1,230.90 " $910.87 $0.00 $956.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $913.57 $913.57 $0.00 $0.00 $256.52 $0.00 $0.00 $0.00 $0.00 $597.53 $946.48 $956.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.791 SUP Custom 27203010 394.791 - ROD EXFIX 45D 11MM 207MM CVD SPAN ANGLED CARFBR NONSTRL BOTH IP/OP $950.20 $703.15 $0.00 $738.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.24 $705.24 $0.00 $0.00 $198.02 $0.00 $0.00 $0.00 $0.00 $461.26 $730.64 $738.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.792 SUP Custom 27203010 394.792 - ROD EXFIX 90D 11MM 382MM CVD SPAN ANGLED CARFBR NONSTRL BOTH IP/OP "$1,044.88 " $773.21 $0.00 $811.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.51 $775.51 $0.00 $0.00 $217.75 $0.00 $0.00 $0.00 $0.00 $507.23 $803.44 $811.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.793 SUP Custom 27203010 394.793 - ROD EXFIX 135D 11MM 499MM CVD SPAN ANGLED CARFBR NONSTRL BOTH IP/OP "$1,140.68 " $844.10 $0.00 $885.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.61 $846.61 $0.00 $0.00 $237.72 $0.00 $0.00 $0.00 $0.00 $553.73 $877.10 $885.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.8 SUP Custom 27203010 394.80 - ROD EXFIX 100MM 11MM SM CARFBR LG EXFIX BOTH IP/OP $360.93 $267.09 $0.00 $267.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $267.88 $267.88 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $159.65 $252.89 $255.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.81 SUP Custom 27203010 394.81 - ROD EXFIX 11MM 125MM MR CONDITIONAL CARFBR NONSTRL BOTH IP/OP $360.93 $267.09 $0.00 $280.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $267.88 $267.88 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $175.20 $277.52 $280.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.82 SUP Custom 27203010 394.82 - ROD EXFIX 11MM 150MM RADIOLUCENT MR CONDITIONAL CARFBR BOTH IP/OP $360.93 $267.09 $0.00 $280.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $267.88 $267.88 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $175.20 $277.52 $280.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.83 SUP Custom 27203010 394.83 - ROD EXFIX 11MM 200MM RADIOLUCENT MR CONDITIONAL CARFBR BOTH IP/OP $360.93 $267.09 $0.00 $280.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $267.88 $267.88 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $175.20 $277.52 $280.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.84 SUP Custom 27203010 394.84 - ROD EXFIX 11MM 250MM CARFBR NONSTRL BOTH IP/OP $387.65 $286.86 $0.00 $301.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.71 $287.71 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $188.18 $298.07 $301.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.85 SUP Custom 27203010 394.85 - ROD EXFIX 11MM 300MM MR CONDITIONAL CARFBR NONSTRL BOTH IP/OP $387.65 $286.86 $0.00 $301.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.71 $287.71 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $188.18 $298.07 $301.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.86 SUP Custom 27203010 394.86 - ROD EXFIX 11MM 350MM RADIOLUCENT MR CONDITIONAL CARFBR BOTH IP/OP $387.65 $286.86 $0.00 $301.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.71 $287.71 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $188.18 $298.07 $301.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.87 SUP Custom 27203010 394.87 - ROD EXFIX 11MM 400MM MR CONDITIONAL CARFBR NONSTRL BOTH IP/OP $425.53 $314.89 $0.00 $330.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.82 $315.82 $0.00 $0.00 $88.68 $0.00 $0.00 $0.00 $0.00 $206.56 $327.20 $330.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.88 SUP Custom 27203010 394.88 - ROD EXFIX 11MM 450MM MR CONDITIONAL CARFBR NONSTRL BOTH IP/OP $425.53 $314.89 $0.00 $330.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.82 $315.82 $0.00 $0.00 $88.68 $0.00 $0.00 $0.00 $0.00 $206.56 $327.20 $330.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.89 SUP Custom 27203010 394.89 - ROD EXFIX 11MM 500MM CARFBR NONSTRL LARGE EXFIX BOTH IP/OP $425.53 $314.89 $0.00 $330.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.82 $315.82 $0.00 $0.00 $88.68 $0.00 $0.00 $0.00 $0.00 $206.56 $327.20 $330.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.9 SUP Custom 27203010 394.90 - ROD EXFIX 11MM 550MM RADIOLUCENT CARFBR NONSTRL BOTH IP/OP $446.65 $330.52 $0.00 $357.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.50 $331.50 $0.00 $0.00 $93.08 $0.00 $0.00 $0.00 $0.00 $223.33 $353.75 $357.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.91 SUP Custom 27203010 394.91 - ROD EXFIX 11MM 600MM CARFBR NONSTRL LARGE EXFIX BOTH IP/OP $460.05 $340.44 $0.00 $357.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.45 $341.45 $0.00 $0.00 $95.87 $0.00 $0.00 $0.00 $0.00 $223.33 $353.75 $357.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.92 SUP Custom 27203010 394.92 - ROD EXFIX 11MM 650MM CARFBR NONSTRL LARGE EXFIX BOTH IP/OP $460.05 $340.44 $0.00 $357.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.45 $341.45 $0.00 $0.00 $95.87 $0.00 $0.00 $0.00 $0.00 $223.33 $353.75 $357.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.97 SUP Custom 27203010 394.97 - CAP PROTECTIVE NONSTRL 11 MM CARFBR ROD BOTH IP/OP $2.39 $1.77 $0.00 $1.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.77 $1.77 $0.00 $0.00 $0.50 $0.00 $0.00 $0.00 $0.00 $1.19 $1.89 $1.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.99 SUP Custom 27203010 394.99 - CAP PROTECTIVE BLACK NONSTRL 4MM CARFBR ROD BOTH IP/OP $4.82 $3.57 $0.00 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.58 $3.58 $0.00 $0.00 $1.00 $0.00 $0.00 $0.00 $0.00 $2.34 $3.71 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.991 SUP Custom 27203010 394.991 - CAP PROTECTIVE YELLOW NONSTRL 4MM FIX PIN BOTH IP/OP $57.85 $42.81 $0.00 $46.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.94 $42.94 $0.00 $0.00 $12.06 $0.00 $0.00 $0.00 $0.00 $28.93 $45.82 $46.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.992 SUP Custom 27203010 394.992 - CAP PROTECTIVE WHITE NONSTRL 4.5MM FIX PIN BOTH IP/OP $5.96 $4.41 $0.00 $4.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.42 $4.42 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $2.89 $4.59 $4.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 394.994 SUP Custom 27203010 394.994 - CAP PROTECTIVE GREEN NONSTRL 6MM FIX PIN BOTH IP/OP $5.96 $4.41 $0.00 $4.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.42 $4.42 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $2.89 $4.59 $4.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.103 SUP Custom 27203010 395.103 - BAR EXFIX ANGLED 3MM CONNCTNG ROD STAINLESS STEEL NONSTRL BOTH IP/OP $83.55 $61.83 $0.00 $64.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.01 $62.01 $0.00 $0.00 $17.41 $0.00 $0.00 $0.00 $0.00 $40.56 $64.25 $64.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.105 SUP Custom 27203010 395.105 - ROD EXFIX 3MM 25MM CONNCTNG RADIOLUCENT CARFBR NONSTRL MINI BOTH IP/OP $65.18 $48.23 $0.00 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.37 $48.37 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $31.64 $50.12 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.107 SUP Custom 27203010 395.107 - ROD EXFIX 3MM 45MM CARFBR NONSTRL MINI EXFIX BOTH IP/OP $65.18 $48.23 $0.00 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.37 $48.37 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $31.64 $50.12 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.109 SUP Custom 27203010 395.109 - ROD EXFIX 3MM 60MM CARFBR NONSTRL MINI EXFIX BOTH IP/OP $65.18 $48.23 $0.00 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.37 $48.37 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $31.64 $50.12 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.111 SUP Custom 27203010 395.111 - ROD EXFIX 3MM 75MM CONNCTNG RADIOLUCENT CARFBR NONSTRL MINI BOTH IP/OP $65.18 $48.23 $0.00 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.37 $48.37 $0.00 $0.00 $13.58 $0.00 $0.00 $0.00 $0.00 $31.64 $50.12 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.125 SUP Custom 27203010 395.125 - CLAMP EXFIX 1.25MM HOLD NONSTRL MINI EXFIX BOTH IP/OP "$1,142.90 " $845.75 $0.00 $887.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $848.26 $848.26 $0.00 $0.00 $238.18 $0.00 $0.00 $0.00 $0.00 $554.81 $878.83 $887.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.126 SUP Custom 27203010 395.126 - CLAMP EXFIX 1.6MM HOLD NONSTRL 1.6MM K WIRE MINI EXFIX BOTH IP/OP "$1,142.90 " $845.75 $0.00 $887.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $848.26 $848.26 $0.00 $0.00 $238.18 $0.00 $0.00 $0.00 $0.00 $554.81 $878.83 $887.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.133 SUP Custom 27203010 395.133 - CLAMP EXFIX 3MM CONNCTNG NONSTRL MINI EXFIX BOTH IP/OP "$1,062.70 " $786.40 $0.00 $825.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.74 $788.74 $0.00 $0.00 $221.47 $0.00 $0.00 $0.00 $0.00 $515.88 $817.15 $825.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.134 SUP Custom 27203010 395.134 - CLAMP EXFIX 3X4MM CONNCTNG NONSTRL MINI EXFIX SMALL EXFIX BOTH IP/OP "$1,062.70 " $786.40 $0.00 $825.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.74 $788.74 $0.00 $0.00 $221.47 $0.00 $0.00 $0.00 $0.00 $515.88 $817.15 $825.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.54 SUP Custom 27803010 395.54 - CLAMP XTRNFX 4MM 2.5MM NS OPN SEF BOTH IP/OP $521.33 $385.78 $0.00 $404.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $386.93 $386.93 $0.00 $0.00 $108.64 $0.00 $0.00 $0.00 $0.00 $253.08 $400.87 $404.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.55 SUP Custom 27803010 395.55 - CLAMP XTRNFX 4MM NS OPN SEF 4MM SCHNZ SCR BOTH IP/OP $521.33 $385.78 $0.00 $404.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $386.93 $386.93 $0.00 $0.00 $108.64 $0.00 $0.00 $0.00 $0.00 $253.08 $400.87 $404.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.56 SUP Custom 27203010 395.56 - CLAMP EXFIX SMALL 2.5MM 4MM NONSTRL SMALL EXFIX BOTH IP/OP $486.80 $360.23 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.30 $361.30 $0.00 $0.00 $101.45 $0.00 $0.00 $0.00 $0.00 $236.31 $374.32 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.57 SUP Custom 27203010 395.57 - CLAMP EXFIX 4MM 4MM NONSTRL 4MM SCHANZ SCREW CONNECT BOTH IP/OP $486.80 $360.23 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.30 $361.30 $0.00 $0.00 $101.45 $0.00 $0.00 $0.00 $0.00 $236.31 $374.32 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.575 SUP Custom 27203010 395.575 - CLAMP EXFIX MULTIVECTOR TITANIUM CARFBR RODS BOTH IP/OP "$2,157.50 " "$1,596.55" $0.00 "$1,726.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,601.30" "$1,601.30" $0.00 $0.00 $449.62 $0.00 $0.00 $0.00 $0.00 "$1,078.75" "$1,708.74" "$1,726.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.58 SUP Custom 27203010 395.58 - NUT XTRNFX NS SPRG LD BOTH IP/OP $54.85 $40.59 $0.00 $42.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.71 $40.71 $0.00 $0.00 $11.43 $0.00 $0.00 $0.00 $0.00 $26.63 $42.17 $42.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.6 SUP Custom 27203010 395.60 - ROD EXFIX 4MM 60MM CARFBR NONSTRL BOTH IP/OP $59.48 $44.02 $0.00 $47.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.14 $44.14 $0.00 $0.00 $12.39 $0.00 $0.00 $0.00 $0.00 $29.74 $47.11 $47.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.61 SUP Custom 27203010 395.61 - ROD EXFIX 4MM 80MM CARFBR NONSTRL SMALL EXFIX BOTH IP/OP $61.28 $45.35 $0.00 $47.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.48 $45.48 $0.00 $0.00 $12.77 $0.00 $0.00 $0.00 $0.00 $29.74 $47.11 $47.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.62 SUP Custom 27203010 395.62 - ROD EXFIX 4MM 100MM CARFBR NONSTRL SMALL EXFIX BOTH IP/OP $61.28 $45.35 $0.00 $47.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.48 $45.48 $0.00 $0.00 $12.77 $0.00 $0.00 $0.00 $0.00 $29.74 $47.11 $47.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.63 SUP Custom 27203010 395.63 - ROD EXFIX 4MM 120MM CARFBR NONSTRL SMALL EXFIX BOTH IP/OP $61.28 $45.35 $0.00 $47.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.48 $45.48 $0.00 $0.00 $12.77 $0.00 $0.00 $0.00 $0.00 $29.74 $47.11 $47.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.64 SUP Custom 27203010 395.64 - ROD EXFIX 4MM 140MM CARFBR NONSTRL SMALL EXFIX BOTH IP/OP $84.65 $62.64 $0.00 $65.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.83 $62.83 $0.00 $0.00 $17.64 $0.00 $0.00 $0.00 $0.00 $41.10 $65.10 $65.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.65 SUP Custom 27203010 395.65 - ROD EXFIX 4MM 160MM CARFBR NONSTRL SMALL EXFIX BOTH IP/OP $84.65 $62.64 $0.00 $65.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.83 $62.83 $0.00 $0.00 $17.64 $0.00 $0.00 $0.00 $0.00 $41.10 $65.10 $65.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.66 SUP Custom 27203010 395.66 - ROD EXFIX 4MM 180MM CARFBR NONSTRL SMALL EXFIX BOTH IP/OP $84.65 $62.64 $0.00 $65.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.83 $62.83 $0.00 $0.00 $17.64 $0.00 $0.00 $0.00 $0.00 $41.10 $65.10 $65.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.67 SUP Custom 27203010 395.67 - ROD EXFIX 4MM 200MM CARFBR NONSTRL BOTH IP/OP $84.65 $62.64 $0.00 $65.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.83 $62.83 $0.00 $0.00 $17.64 $0.00 $0.00 $0.00 $0.00 $41.10 $65.10 $65.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.68 SUP Custom 27203010 395.680 - ROD EXFIX 60D CVD 4MM 78MM CARFBR NONSTRL BOTH IP/OP $274.70 $203.28 $0.00 $219.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.88 $203.88 $0.00 $0.00 $57.25 $0.00 $0.00 $0.00 $0.00 $137.35 $217.56 $219.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.681 SUP Custom 27203010 395.681 - ROD EXFIX 90D 4MM 117MM CVD SPAN ANGLED CARFBR NONSTRL BOTH IP/OP $303.00 $224.22 $0.00 $235.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.89 $224.89 $0.00 $0.00 $63.15 $0.00 $0.00 $0.00 $0.00 $147.09 $232.99 $235.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.682 SUP Custom 27203010 395.682 - ROD EXFIX 120D 4MM 156MM CVD SPAN ANGLED CARFBR NONSTRL BOTH IP/OP $324.15 $239.87 $0.00 $251.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.58 $240.58 $0.00 $0.00 $67.55 $0.00 $0.00 $0.00 $0.00 $157.36 $249.27 $251.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.685 SUP Custom 27203010 395.685 - ROD EXFIX ANGLE 4MM 50X80MM T BAR RECYCLED CARFBR NONSTRL BOTH IP/OP $582.60 $431.12 $0.00 $452.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $432.41 $432.41 $0.00 $0.00 $121.41 $0.00 $0.00 $0.00 $0.00 $282.81 $447.98 $452.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.686 SUP Custom 27203010 395.686 - ROD EXFIX ANGLE 4MM 120X80MM T BAR CARFBR NONSTRL BOTH IP/OP $582.60 $431.12 $0.00 $452.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $432.41 $432.41 $0.00 $0.00 $121.41 $0.00 $0.00 $0.00 $0.00 $282.81 $447.98 $452.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.687 SUP Custom 27203010 395.687 - ROD EXFIX ANGLED 4MM 50X110MM T BAR ANGLED CARFBR NONSTRL BOTH IP/OP $582.60 $431.12 $0.00 $452.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $432.41 $432.41 $0.00 $0.00 $121.41 $0.00 $0.00 $0.00 $0.00 $282.81 $447.98 $452.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.688 SUP Custom 27203010 395.688 - ROD EXFIX ANGLED 4MM 120X110MM T BAR ANGLED CARFBR NONSTRL BOTH IP/OP $582.60 $431.12 $0.00 $452.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $432.41 $432.41 $0.00 $0.00 $121.41 $0.00 $0.00 $0.00 $0.00 $282.81 $447.98 $452.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.69 SUP Custom 27203010 395.690 - ROD EXFIX 45D 8MM 214MM CVD CARFBR NONSTRL BOTH IP/OP $597.00 $441.78 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.09 $443.09 $0.00 $0.00 $124.41 $0.00 $0.00 $0.00 $0.00 $298.50 $472.82 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.691 SUP Custom 27203010 395.691 - ROD EXFIX 90D 8MM 382MM CVD CARFBR NONSTRL BOTH IP/OP $614.90 $455.03 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $456.38 $456.38 $0.00 $0.00 $128.15 $0.00 $0.00 $0.00 $0.00 $298.50 $472.82 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.692 SUP Custom 27203010 395.692 - ROD EXFIX 135D 8MM 499MM CVD CARFBR NONSTRL BOTH IP/OP $579.60 $428.90 $0.00 $463.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $430.18 $430.18 $0.00 $0.00 $120.79 $0.00 $0.00 $0.00 $0.00 $289.80 $459.04 $463.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.693 SUP Custom 27203010 395.693 - ROD EXFIX 180D 8MM 540MM CVD SPAN ANGLED CARFBR NONSTRL BOTH IP/OP $579.60 $428.90 $0.00 $463.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $430.18 $430.18 $0.00 $0.00 $120.79 $0.00 $0.00 $0.00 $0.00 $289.80 $459.04 $463.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.7 SUP Custom 27203010 395.70 - BAR XTRNFX 4MM 60MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $47.05 $34.82 $0.00 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.92 $34.92 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $23.53 $37.26 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.71 SUP Custom 27203010 395.71 - BAR XTRNFX 4MM 80MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $47.05 $34.82 $0.00 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.92 $34.92 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $23.53 $37.26 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.72 SUP Custom 27203010 395.72 - BAR XTRNFX 4MM 100MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $47.05 $34.82 $0.00 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.92 $34.92 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $23.53 $37.26 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.73 SUP Custom 27203010 395.73 - BAR XTRNFX 4MM 120MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $47.05 $34.82 $0.00 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.92 $34.92 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $23.53 $37.26 $37.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.74 SUP Custom 27203010 395.74 - BAR XTRNFX 4MM 140MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $61.65 $45.62 $0.00 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.76 $45.76 $0.00 $0.00 $12.85 $0.00 $0.00 $0.00 $0.00 $30.83 $48.83 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.75 SUP Custom 27203010 395.75 - BAR XTRNFX 4MM 160MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $61.65 $45.62 $0.00 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.76 $45.76 $0.00 $0.00 $12.85 $0.00 $0.00 $0.00 $0.00 $30.83 $48.83 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.76 SUP Custom 27203010 395.76 - BAR XTRNFX 4MM 180MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $61.65 $45.62 $0.00 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.76 $45.76 $0.00 $0.00 $12.85 $0.00 $0.00 $0.00 $0.00 $30.83 $48.83 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.77 SUP Custom 27203010 395.77 - BAR XTRNFX 4MM 200MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $61.65 $45.62 $0.00 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.76 $45.76 $0.00 $0.00 $12.85 $0.00 $0.00 $0.00 $0.00 $30.83 $48.83 $49.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.779 SUP Custom 27203010 395.779 - ROD EXFIX MEDIUM 8MM 160MM CARFBR NONSTRL BOTH IP/OP $246.18 $182.17 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.71 $182.71 $0.00 $0.00 $51.30 $0.00 $0.00 $0.00 $0.00 $119.50 $189.29 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.78 SUP Custom 27203010 395.78 - BAR XTRNFX 4MM 220MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $246.18 $182.17 $0.00 $182.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.71 $182.71 $0.00 $0.00 $51.30 $0.00 $141.37 $141.37 $0.00 $38.06 $60.29 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.78 SUP HCPCS C1713 395.780 - ROD EXFIX 120MM 8MM MED CARFBR MED EXFIX NONSTRL BOTH IP/OP $246.18 $182.17 $0.00 $189.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.71 $182.71 $0.00 $0.00 $51.30 $0.00 $141.37 $141.37 $0.00 $38.06 $189.29 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.782 SUP Custom 27203010 395.782 - ROD EXFIX 8MM 200MM CARFBR DISTAL RAD NONSTRL BOTH IP/OP $243.95 $180.52 $0.00 $189.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.06 $181.06 $0.00 $0.00 $50.84 $0.00 $0.00 $0.00 $0.00 $118.43 $187.59 $189.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.784 SUP Custom 27203010 395.784 - ROD EXFIX 8MM 220MM CARFBR DISTAL RAD NONSTRL BOTH IP/OP $243.95 $180.52 $0.00 $189.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.06 $181.06 $0.00 $0.00 $50.84 $0.00 $0.00 $0.00 $0.00 $118.43 $187.59 $189.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.786 SUP Custom 27203010 395.786 - ROD EXFIX 8MM 240MM CARFBR DISTAL RAD NONSTRL BOTH IP/OP $243.95 $180.52 $0.00 $189.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.06 $181.06 $0.00 $0.00 $50.84 $0.00 $0.00 $0.00 $0.00 $118.43 $187.59 $189.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.788 SUP Custom 27203010 395.788 - ROD EXFIX 8MM 280MM CARFBR DISTAL RAD NONSTRL BOTH IP/OP $246.18 $182.17 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.71 $182.71 $0.00 $0.00 $51.30 $0.00 $0.00 $0.00 $0.00 $119.50 $189.29 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.79 SUP Custom 27203010 395.79 - BAR XTRNFX 4MM 240MM NS CNCT MRI SAFE SS METACARPUS PHALANX BOTH IP/OP $76.13 $56.34 $0.00 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.50 $56.50 $0.00 $0.00 $15.86 $0.00 $0.00 $0.00 $0.00 $38.06 $60.29 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.792 SUP Custom 27203010 395.792 - ROD EXFIX MEDIUM 8MM 320MM CARFBR NONSTRL BOTH IP/OP $246.18 $182.17 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.71 $182.71 $0.00 $0.00 $51.30 $0.00 $0.00 $0.00 $0.00 $119.50 $189.29 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.796 SUP Custom 27203010 395.796 - ROD EXFIX 8MM 360MM CARFBR NONSTRL BOTH IP/OP $265.13 $196.20 $0.00 $205.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.78 $196.78 $0.00 $0.00 $55.25 $0.00 $0.00 $0.00 $0.00 $128.70 $203.86 $205.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.797 SUP Custom 27203010 395.797 - ROD EXFIX MEDIUM 8MM 400MM CARFBR NONSTRL BOTH IP/OP $265.13 $196.20 $0.00 $205.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.78 $196.78 $0.00 $0.00 $55.25 $0.00 $0.00 $0.00 $0.00 $128.70 $203.86 $205.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.798 SUP Custom 27203010 395.798 - ROD EXFIX 8MM 460MM CARFBR NONSTRL BOTH IP/OP $265.13 $196.20 $0.00 $205.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.78 $196.78 $0.00 $0.00 $55.25 $0.00 $0.00 $0.00 $0.00 $128.70 $203.86 $205.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.8 SUP Custom 27203010 395.80 - BAR XTRNFX 4MM 250MM NS CNCT SS MN XTRNFXTR BOTH IP/OP $76.13 $56.34 $0.00 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.50 $56.50 $0.00 $0.00 $15.86 $0.00 $0.00 $0.00 $0.00 $38.06 $60.29 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.81 SUP Custom 27203010 395.81 - BAR EXFIX 4MM 260MM CONNECT NONSTRL BOTH IP/OP $76.13 $56.34 $0.00 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.50 $56.50 $0.00 $0.00 $15.86 $0.00 $0.00 $0.00 $0.00 $38.06 $60.29 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.82 SUP Custom 27203010 395.82 - BAR EXFIX 4MM 280MM CONNECT NONSTRL BOTH IP/OP $76.13 $56.34 $0.00 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.50 $56.50 $0.00 $0.00 $15.86 $0.00 $0.00 $0.00 $0.00 $38.06 $60.29 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 395.83 SUP Custom 27203010 395.83 - BAR EXFIX 4MM 300MM CONNECT NONSTRL BOTH IP/OP $76.13 $56.34 $0.00 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.50 $56.50 $0.00 $0.00 $15.86 $0.00 $0.00 $0.00 $0.00 $38.06 $60.29 $60.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 397.283 SUP Custom 27203010 397.283 - BIT DRILL 1.8MM JLTCH NONSTRL BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 397.284 SUP Custom 27203010 397.284 - BIT DRILL 2.4MM JLTCH NONSTRL BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 397.342 SUP Custom 27203010 397.342 - BIT DRL 140MM 2.5MM 400MM NS JCHK CLBRT BOTH IP/OP $969.93 $717.75 $0.00 $753.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $719.88 $719.88 $0.00 $0.00 $202.13 $0.00 $0.00 $0.00 $0.00 $470.84 $745.81 $753.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 397.343 SUP Custom 27203010 397.343 - BIT DRL 3.5MM 380MM NS JCHK BOTH IP/OP "$1,017.73 " $753.12 $0.00 $790.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $755.36 $755.36 $0.00 $0.00 $212.09 $0.00 $0.00 $0.00 $0.00 $494.04 $782.56 $790.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 398.756 SUP Custom 27203010 398.756 - CLAMP SURG 206MM HOOK ARM BONE BOTH IP/OP "$5,084.40 " "$3,762.46" $0.00 "$3,949.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,773.64" "$3,773.64" $0.00 $0.00 "$1,059.59" $0.00 $0.00 $0.00 $0.00 "$2,468.15" "$3,909.55" "$3,949.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400.006 SUP HCPCS C1713 400.006 - SCREW BONE STANDARD 1.5MM 3MM 6MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.007 SUP HCPCS C1713 400.007 - SCREW BONE STANDARD 1.5MM 3MM 7MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.008 SUP HCPCS C1713 400.008 - SCREW BONE STANDARD 1.5MM 3MM 8MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.009 SUP HCPCS C1713 400.009 - SCREW BONE STANDARD 1.5MM 3MM 9MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.01 SUP HCPCS C1713 400.010 - SCREW BONE STANDARD 1.5MM 3MM 10MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.011 SUP HCPCS C1713 400.011 - SCREW BONE STANDARD 1.5MM 3MM 11MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.012 SUP HCPCS C1713 400.012 - SCREW BONE STANDARD 1.5MM 3MM 12MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.014 SUP HCPCS C1713 400.014 - SCREW BONE STANDARD 1.5MM 3MM 14MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.016 SUP HCPCS C1713 400.016 - SCREW BONE STANDARD 1.5MM 3MM 16MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.018 SUP HCPCS C1713 400.018 - SCREW BONE STANDARD 1.5MM 3MM 18MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.02 SUP HCPCS C1713 400.020 - SCREW BONE STANDARD 1.5MM 3MM 20MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.022 SUP HCPCS C1713 400.022 - SCREW BONE 1.5MM 22MM TITANIUM CORTICAL NONSTRL MINI BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.024 SUP HCPCS C1713 400.024 - SCREW BONE STANDARD CRCIFRM 1.5MM 3MM 24MM TITANIUM CORTICAL BOTH IP/OP $52.88 $39.13 $0.00 $42.30 $23.79 $23.79 $0.00 $0.00 $0.00 $11.02 $39.24 $39.24 $0.00 $0.00 $11.02 $0.00 $31.28 $31.28 $0.00 $26.44 $41.88 $42.30 $0.00 $0.00 $8.03 $0.00 $0.00 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 400.19 SUP HCPCS C1713 400.190 - PIN FIX 1.8MM 12MM BUTTRESS T8 STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $212.90 $157.55 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $44.37 $158.01 $158.01 $0.00 $0.00 $44.37 $0.00 $125.93 $125.93 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 400.191 SUP Custom 27203010 400.191 - PIN FIX 1.8MM 14MM T8 STARDRIVE RECESS BUTTRESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400.192 SUP Custom 27203010 400.192 - PIN FIX 1.8MM 16MM T8 STARDRIVE RECESS BUTTRESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400.193 SUP Custom 27203010 400.193 - PIN FIX 1.8MM 18MM BUTTRESS T8 STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400.194 SUP HCPCS C1713 400.194 - PIN FIX 1.8MM 20MM BUTTRESS T8 STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 400.195 SUP Custom 27203010 400.195 - PIN FIX 1.8MM 22MM BUTTRESS T8 STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400.196 SUP HCPCS C1713 400.196 - PIN FIX 1.8MM 24MM BUTTRESS T8 STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 400.197 SUP Custom 27203010 400.197 - PIN FIX 1.8MM 26MM BUTTRESS T8 STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400.198 SUP HCPCS C1713 400.198 - PIN FIX 1.8MM 28MM BUTTRESS T8 STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 400.199 SUP Custom 27203010 400.199 - PIN FIX 1.8MM 30MM BUTTRESS T8 STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400.406 SUP HCPCS C1713 400.406 - SCREW BONE GOLD 6MM 1MM CORT CRANFCL TI SLFTAP +DR RECESS BOTH IP/OP $157.50 $116.55 $0.00 $126.00 $70.88 $70.88 $0.00 $0.00 $0.00 $32.83 $116.90 $116.90 $0.00 $0.00 $32.82 $0.00 $93.16 $93.16 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $24.65 $0.00 $0.00 $25.07 $0.00 $0.00 $0.00 $0.00 $0.00 400.526 SUP HCPCS C1713 400.526 - SCREW BONE 1MM 1.6MM 6MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.527 SUP HCPCS C1713 400.527 - SCREW BONE 1MM 1.6MM 7MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.528 SUP HCPCS C1713 400.528 - SCREW BONE 1MM 1.6MM 8MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.529 SUP HCPCS C1713 400.529 - SCREW BONE 1MM 1.6MM 9MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.53 SUP HCPCS C1713 400.530 - SCREW BONE 1MM 1.6MM 10MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $133.05 $98.46 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $27.73 $98.75 $98.75 $0.00 $0.00 $27.73 $0.00 $78.70 $78.70 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.531 SUP HCPCS C1713 400.531 - SCREW BONE 1MM 1.6MM 11MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.532 SUP HCPCS C1713 400.532 - SCREW BONE 1MM 1.6MM 12MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.533 SUP HCPCS C1713 400.533 - SCREW BONE 1MM 1.6MM 13MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.534 SUP HCPCS C1713 400.534 - SCREW BONE 1MM 1.6MM 14MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $137.05 $101.42 $0.00 $106.44 $59.87 $59.87 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $66.53 $105.38 $106.44 $0.00 $0.00 $20.22 $0.00 $0.00 $21.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.686 SUP HCPCS C1713 400.686 - SCREW BONE 1.3MM 2.4MM 6MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.687 SUP HCPCS C1713 400.687 - SCREW BONE 1.3MM 2.4MM 7MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.688 SUP HCPCS C1713 400.688 - SCREW BONE 1.3MM 2.4MM 8MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.689 SUP HCPCS C1713 400.689 - SCREW BONE 1.3MM 2.4MM 9MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $27.80 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.69 SUP HCPCS C1713 400.690 - SCREW BONE 1.3MM 2.4MM 10MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $139.20 $103.01 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.01 $103.31 $103.31 $0.00 $0.00 $29.01 $0.00 $82.34 $82.34 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.691 SUP HCPCS C1713 400.691 - SCREW BONE 1.3MM 2.4MM 11MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.692 SUP HCPCS C1713 400.692 - SCREW BONE 1.3MM 2.4MM 12MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.693 SUP HCPCS C1713 400.693 - SCREW BONE 1.3MM 2.4MM 13MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.694 SUP HCPCS C1713 400.694 - SCREW BONE 1.3MM 2.4MM 14MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.696 SUP HCPCS C1713 400.696 - SCREW BONE 1.3MM 2.4MM 16MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.698 SUP HCPCS C1713 400.698 - SCREW BONE 1.3MM 2.4MM 18MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $62.64 $62.64 $0.00 $0.00 $0.00 $29.88 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $84.81 $84.81 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $21.15 $0.00 $0.00 $22.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.806 SUP HCPCS C1713 400.806 - SCREW BONE 1.5MM 3MM 6MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.807 SUP HCPCS C1713 400.807 - SCREW BONE 1.5MM 3MM 7MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.808 SUP HCPCS C1713 400.808 - SCREW BONE 1.5MM 3MM 8MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.809 SUP HCPCS C1713 400.809 - SCREW BONE 1.5MM 3MM 9MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.81 SUP HCPCS C1713 400.810 - SCREW BONE 1.5MM 3MM 10MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $63.45 $46.95 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.22 $47.09 $47.09 $0.00 $0.00 $13.22 $0.00 $37.53 $37.53 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.811 SUP HCPCS C1713 400.811 - SCREW BONE 1.5MM 3MM 11MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.812 SUP HCPCS C1713 400.812 - SCREW BONE 1.5MM 3MM 12MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.814 SUP HCPCS C1713 400.814 - SCREW BONE 1.5MM 3MM 14MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.816 SUP HCPCS C1713 400.816 - SCREW BONE 1.5MM 3MM 16MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.818 SUP HCPCS C1713 400.818 - SCREW BONE 1.5MM 3MM 18MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.82 SUP HCPCS C1713 400.820 - SCREW BONE 1.5MM 3MM 20MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $63.45 $46.95 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.22 $47.09 $47.09 $0.00 $0.00 $13.22 $0.00 $37.53 $37.53 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.822 SUP HCPCS C1713 400.822 - SCREW BONE 1.5MM 3MM 22MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.824 SUP HCPCS C1713 400.824 - SCREW BONE 1.5MM 3MM 24MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.834 SUP HCPCS C1713 400.834 - SCREW BONE 4MM 1.5MM CORT CRANFCL TI SLFDRILL LP NONSTRL BOTH IP/OP $151.38 $112.02 $0.00 $121.10 $68.12 $68.12 $0.00 $0.00 $0.00 $31.55 $112.35 $112.35 $0.00 $0.00 $31.55 $0.00 $89.54 $89.54 $0.00 $75.69 $119.89 $121.10 $0.00 $0.00 $23.69 $0.00 $0.00 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.835 SUP HCPCS C1713 400.835 - SCREW BONE 5MM 1.5MM CORT CRANFCL TI SLFDRILL LP NONSTRL BOTH IP/OP $151.38 $112.02 $0.00 $121.10 $68.12 $68.12 $0.00 $0.00 $0.00 $31.55 $112.35 $112.35 $0.00 $0.00 $31.55 $0.00 $89.54 $89.54 $0.00 $75.69 $119.89 $121.10 $0.00 $0.00 $23.69 $0.00 $0.00 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.996 SUP HCPCS C1713 400.996 - SCREW BONE 1.4MM 15MM SLFDRILL WIRE FIX TITANIUM MIDFAC BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $156.38 $156.38 $0.00 $0.00 $0.00 $72.43 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $205.55 $205.55 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $54.38 $0.00 $0.00 $55.32 $0.00 $0.00 $0.00 $0.00 $0.00 400.997 SUP HCPCS C1713 400.997 - SCREW BONE 1.4MM 21MM SLFDRILL WIRE FIX TITANIUM MIDFAC BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $156.38 $156.38 $0.00 $0.00 $0.00 $72.43 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $205.55 $205.55 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $54.38 $0.00 $0.00 $55.32 $0.00 $0.00 $0.00 $0.00 $0.00 401.006 SUP HCPCS C1713 401.006 - SCREW BONE STANDARD 2MM 3.5MM 6MM CRCIFRM TITANIUM CORTICAL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.008 SUP HCPCS C1713 401.008 - SCREW BONE STANDARD 2MM 3.5MM 8MM CRCIFRM TITANIUM CORTICAL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.012 SUP HCPCS C1713 401.012 - SCREW BONE STANDARD 2MM 3.5MM 12MM CRCIFRM TITANIUM CORTICAL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.02 SUP HCPCS C1713 401.020 - SCREW BONE STANDARD 2MM 3.5MM 20MM CRCIFRM TITANIUM CORTICAL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.022 SUP HCPCS C1713 401.022 - SCREW BONE STANDARD 2MM 3.5MM 22MM CRCIFRM TITANIUM CORTICAL BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.024 SUP HCPCS C1713 401.024 - SCREW BONE STANDARD 2MM 3.5MM 24MM SLFTAP CRCIFRM RECESS BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.026 SUP HCPCS C1713 401.026 - SCREW BONE 2MM 26MM TITANIUM CORTICAL NONSTRL MINI FRAGMENT BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.028 SUP HCPCS C1713 401.028 - SCREW BONE 2MM 28MM TITANIUM CORTICAL NONSTRL MINI FRAGMENT BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.03 SUP HCPCS C1713 401.030 - SCREW BONE 2MM 30MM TITANIUM CORTICAL NONSTRL MINI FRAGMENT BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.032 SUP HCPCS C1713 401.032 - SCREW BONE 2MM 32MM TITANIUM CORTICAL NONSTRL MINI FRAGMENT BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.034 SUP HCPCS C1713 401.034 - SCREW BONE 2MM 34MM TITANIUM CORTICAL NONSTRL MINI FRAGMENT BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.036 SUP HCPCS C1713 401.036 - SCREW BONE 2MM 36MM TITANIUM CORTICAL NONSTRL MINI FRAGMENT BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.038 SUP HCPCS C1713 401.038 - SCREW BONE 2MM 38MM TITANIUM CORTICAL NONSTRL MINI FRAGMENT BOTH IP/OP $52.20 $38.63 $0.00 $41.76 $23.49 $23.49 $0.00 $0.00 $0.00 $10.88 $38.74 $38.74 $0.00 $0.00 $10.88 $0.00 $30.88 $30.88 $0.00 $26.10 $41.34 $41.76 $0.00 $0.00 $7.93 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $0.00 401.158 SUP HCPCS C1713 401.158 - SCREW BONE 8MM 2MM CORT CRANFCL TI SLFTAP FLUT TIP NONSTRL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 401.292 SUP HCPCS C1713 401.292 - SCREW BONE BLUE 6MM 2MM CRANFCL TI SLFTAP +DR RECESS LCK BOTH IP/OP "$1,091.25 " $807.53 $0.00 $873.00 $491.06 $491.06 $0.00 $0.00 $0.00 $227.44 $809.93 $809.93 $0.00 $0.00 $227.42 $0.00 $645.47 $645.47 $0.00 $545.63 $864.27 $873.00 $0.00 $0.00 $170.78 $0.00 $0.00 $173.73 $0.00 $0.00 $0.00 $0.00 $0.00 401.295 SUP HCPCS C1713 401.295 - SCREW BONE BLUE 10MM 2MM CRNMXF TI SLFTAP LCK +DR RECESS BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 401.296 SUP HCPCS C1713 401.296 - SCREW BONE BLUE 12MM 2MM CRNMXF TI SLFTAP LCK +DR RECESS BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 401.297 SUP HCPCS C1713 401.297 - SCREW BONE BLUE 14MM 2MM CRNMXF TI SLFTAP LCK +DR RECESS BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 401.298 SUP HCPCS C1713 401.298 - SCREW BONE BLUE 16MM 2MM CRNMXF TI SLFTAP LCK +DR RECESS BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 401.305 SUP HCPCS C1713 401.305 - SCREW BONE 5MM 2.4MM CRNMXF TI ER CRCIFRM RECESS NONSTRL BOTH IP/OP $119.25 $88.25 $0.00 $95.40 $53.66 $53.66 $0.00 $0.00 $0.00 $24.85 $88.51 $88.51 $0.00 $0.00 $24.85 $0.00 $70.54 $70.54 $0.00 $59.63 $94.45 $95.40 $0.00 $0.00 $18.66 $0.00 $0.00 $18.98 $0.00 $0.00 $0.00 $0.00 $0.00 401.508 SUP HCPCS C1713 401.508 - SCREW BONE 2.4MM 8MM TI CORT CRNMXF SLFTAP STRL GOLD BOTH IP/OP $169.88 $125.71 $0.00 $135.90 $76.44 $76.44 $0.00 $0.00 $0.00 $35.41 $126.08 $126.08 $0.00 $0.00 $35.40 $0.00 $100.48 $100.48 $0.00 $84.94 $134.54 $135.90 $0.00 $0.00 $26.59 $0.00 $0.00 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 401.51 SUP HCPCS C1713 401.510 - SCREW BONE 2.4MM 10MM TI CORT CRNMXF MANDIB SLFTAP NONSTRL BOTH IP/OP $169.88 $125.71 $0.00 $135.90 $76.44 $76.44 $0.00 $0.00 $0.00 $35.41 $126.08 $126.08 $0.00 $0.00 $35.40 $0.00 $100.48 $100.48 $0.00 $84.94 $134.54 $135.90 $0.00 $0.00 $26.59 $0.00 $0.00 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 401.516 SUP HCPCS C1713 401.516 - SCREW BONE 2.4MM 16MM TI CORT CRNMXF SLFTAP STRL GOLD BOTH IP/OP $169.88 $125.71 $0.00 $135.90 $76.44 $76.44 $0.00 $0.00 $0.00 $35.41 $126.08 $126.08 $0.00 $0.00 $35.40 $0.00 $100.48 $100.48 $0.00 $84.94 $134.54 $135.90 $0.00 $0.00 $26.59 $0.00 $0.00 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 401.518 SUP HCPCS C1713 401.518 - SCREW BONE 2.4MM 18MM TI CORT CRNMXF MANDIB SLFTAP NONSTRL BOTH IP/OP $169.88 $125.71 $0.00 $135.90 $76.44 $76.44 $0.00 $0.00 $0.00 $35.41 $126.08 $126.08 $0.00 $0.00 $35.40 $0.00 $100.48 $100.48 $0.00 $84.94 $134.54 $135.90 $0.00 $0.00 $26.59 $0.00 $0.00 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 401.612 SUP HCPCS C1713 401.612 - SCREW BONE 2.4MM 3.5MM 12MM SELF TAP SMALL CRCIFRM RECESS BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.614 SUP HCPCS C1713 401.614 - SCREW BONE SMALL 2.4MM 3.5MM 14MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.616 SUP HCPCS C1713 401.616 - SCREW BONE SMALL 2.4MM 3.5MM 16MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.618 SUP HCPCS C1713 401.618 - SCREW BONE SMALL 2.4MM 3.5MM 18MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.62 SUP HCPCS C1713 401.620 - SCREW BONE 2.4MM 3.5MM 20MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.622 SUP HCPCS C1713 401.622 - SCREW BONE SMALL 2.4MM 3.5MM 22MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.624 SUP HCPCS C1713 401.624 - SCREW BONE SMALL 2.4MM 3.5MM 24MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.626 SUP HCPCS C1713 401.626 - SCREW BONE SMALL 2.4MM 3.5MM 26MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.628 SUP HCPCS C1713 401.628 - SCREW BONE SMALL 2.4MM 3.5MM 28MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.63 SUP HCPCS C1713 401.630 - SCREW BONE SMALL 2.4MM 3.5MM 30MM SELF TAP CRCIFRM TITANIUM BOTH IP/OP $115.93 $85.79 $0.00 $92.74 $52.17 $52.17 $0.00 $0.00 $0.00 $24.16 $86.04 $86.04 $0.00 $0.00 $24.16 $0.00 $68.57 $68.57 $0.00 $57.96 $91.82 $92.74 $0.00 $0.00 $18.14 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $0.00 401.756 SUP HCPCS C1713 401.756 - SCREW BONE 2.4MM 6MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.757 SUP HCPCS C1713 401.757 - SCREW BONE 2.4MM 7MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.758 SUP HCPCS C1713 401.758 - SCREW BONE 2.4MM 8MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.759 SUP HCPCS C1713 401.759 - SCREW BONE 2.4MM 9MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.76 SUP HCPCS C1713 401.760 - SCREW BONE 2.4MM 4MM 10MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $101.65 $75.22 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.19 $75.44 $75.44 $0.00 $0.00 $21.18 $0.00 $60.13 $60.13 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.761 SUP HCPCS C1713 401.761 - SCREW BONE 2.4MM 11MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.762 SUP HCPCS C1713 401.762 - SCREW BONE 2.4MM 4MM 12MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.763 SUP HCPCS C1713 401.763 - SCREW BONE 2.4MM 13MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.764 SUP HCPCS C1713 401.764 - SCREW BONE 2.4MM 4MM 14MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.766 SUP HCPCS C1713 401.766 - SCREW BONE 2.4MM 4MM 16MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.768 SUP HCPCS C1713 401.768 - SCREW BONE 2.4MM 4MM 18MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.77 SUP HCPCS C1713 401.770 - SCREW BONE 2.4MM 20MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $101.65 $75.22 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.19 $75.44 $75.44 $0.00 $0.00 $21.18 $0.00 $60.13 $60.13 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.772 SUP HCPCS C1713 401.772 - SCREW BONE 2.4MM 4MM 22MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.774 SUP HCPCS C1713 401.774 - SCREW BONE 2.4MM 4MM 24MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.776 SUP HCPCS C1713 401.776 - SCREW BONE 2.4MM 26MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.778 SUP HCPCS C1713 401.778 - SCREW BONE 2.4MM 28MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.78 SUP HCPCS C1713 401.780 - SCREW BONE 2.4MM 30MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $101.65 $75.22 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.19 $75.44 $75.44 $0.00 $0.00 $21.18 $0.00 $60.13 $60.13 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.782 SUP HCPCS C1713 401.782 - SCREW BONE 2.4MM 4MM 32MM T8 STARDRIVE RECESS SELF TAP SELF BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.784 SUP HCPCS C1713 401.784 - SCREW BONE 2.4MM 4MM 34MM T8 STARDRIVE RECESS SELF TAP BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.786 SUP HCPCS C1713 401.786 - SCREW BONE 2.4MM 36MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.788 SUP HCPCS C1713 401.788 - SCREW BONE 2.4MM 4MM 38MM T8 STARDRIVE RECESS SELF TAP LCP BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.79 SUP HCPCS C1713 401.790 - SCREW BONE 2.4MM 40MM T8 STARDRIVE RECESS SLFTAP TITANIUM BOTH IP/OP $101.65 $75.22 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.19 $75.44 $75.44 $0.00 $0.00 $21.18 $0.00 $60.13 $60.13 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 401.806 SUP HCPCS C1713 401.806 - SCREW BONE 2MM 3.5MM 6MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.808 SUP HCPCS C1713 401.808 - SCREW BONE 2MM 3.5MM 8MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.81 SUP HCPCS C1713 401.810 - SCREW BONE 2MM 3.5MM 10MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $63.13 $46.72 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.16 $46.85 $46.85 $0.00 $0.00 $13.16 $0.00 $37.34 $37.34 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.812 SUP HCPCS C1713 401.812 - SCREW BONE 2MM 3.5MM 12MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.814 SUP HCPCS C1713 401.814 - SCREW BONE 2MM 3.5MM 14MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.816 SUP HCPCS C1713 401.816 - SCREW BONE 2MM 3.5MM 16MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.818 SUP HCPCS C1713 401.818 - SCREW BONE 2MM 3.5MM 18MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.82 SUP HCPCS C1713 401.820 - SCREW BONE 2MM 3.5MM 22MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $63.13 $46.72 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.16 $46.85 $46.85 $0.00 $0.00 $13.16 $0.00 $37.34 $37.34 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.822 SUP HCPCS C1713 401.822 - SCREW BONE 2MM 3.5MM 22MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.824 SUP HCPCS C1713 401.824 - SCREW BONE 2MM 3.5MM 24MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.826 SUP HCPCS C1713 401.826 - SCREW BONE 2MM 3.5MM 26MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.828 SUP HCPCS C1713 401.828 - SCREW BONE 2MM 3.5MM 28MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.83 SUP HCPCS C1713 401.830 - SCREW BONE 2MM 3.5MM 30MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $63.13 $46.72 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.16 $46.85 $46.85 $0.00 $0.00 $13.16 $0.00 $37.34 $37.34 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.832 SUP HCPCS C1713 401.832 - SCREW BONE 2MM 3.5MM 32MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.834 SUP HCPCS C1713 401.834 - SCREW BONE 2MM 3.5MM 34MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.836 SUP HCPCS C1713 401.836 - SCREW BONE 2MM 3.5MM 36MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.838 SUP HCPCS C1713 401.838 - SCREW BONE 2MM 3.5MM 38MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.876 SUP HCPCS C1713 401.876 - SCREW BONE 2MM 6MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.877 SUP HCPCS C1713 401.877 - SCREW BONE 2MM 7MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.878 SUP HCPCS C1713 401.878 - SCREW BONE 2MM 8MM SLFTAP LOCKING LCP TITANIUM CORTICAL BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.879 SUP HCPCS C1713 401.879 - SCREW BONE 2MM 9MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.88 SUP HCPCS C1713 401.880 - SCREW BONE 2MM 10MM SELF TAP STARDRIVE LCP TITANIUM SMALL BOTH IP/OP $208.80 $154.51 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $43.52 $154.97 $154.97 $0.00 $0.00 $43.51 $0.00 $123.51 $123.51 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.881 SUP HCPCS C1713 401.881 - SCREW BONE 2MM 11MM T6 STARDRIVE RECESS SLFTAP LOCKING LCP BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.882 SUP HCPCS C1713 401.882 - SCREW BONE 2MM 12MM SELF TAP STARDRIVE LCP TITANIUM SMALL BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.883 SUP HCPCS C1713 401.883 - SCREW BONE 2MM 13MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.884 SUP HCPCS C1713 401.884 - SCREW BONE 2MM 14MM SELF TAP STARDRIVE LCP TITANIUM SMALL BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.886 SUP HCPCS C1713 401.886 - SCREW BONE 2MM 16MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.888 SUP HCPCS C1713 401.888 - SCREW BONE 2MM 18MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.89 SUP HCPCS C1713 401.890 - SCREW BONE T6 2MM 20MM SELF TAP LOCK LCP TITANIUM CORTICAL BOTH IP/OP $208.80 $154.51 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $43.52 $154.97 $154.97 $0.00 $0.00 $43.51 $0.00 $123.51 $123.51 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.892 SUP HCPCS C1713 401.892 - SCREW BONE 2MM 22MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.894 SUP HCPCS C1713 401.894 - SCREW BONE 2MM 24MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.896 SUP HCPCS C1713 401.896 - SCREW BONE 2MM 26MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.898 SUP HCPCS C1713 401.898 - SCREW BONE 2MM 28MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.9 SUP HCPCS C1713 401.900 - SCREW BONE 2MM 30MM T6 STARDRIVE RECESS SLFTAP LOCKING LCP BOTH IP/OP $208.80 $154.51 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $43.52 $154.97 $154.97 $0.00 $0.00 $43.51 $0.00 $123.51 $123.51 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 401.962 SUP Custom 27203010 401.962 - PIN FIX 1.8MM 12MM BUTTRESS TITANIUM DISTAL RADIAL NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.964 SUP Custom 27203010 401.964 - PIN FIX 1.8MM 14MM BUTTRESS TITANIUM DISTAL RADIAL NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.966 SUP Custom 27203010 401.966 - PIN FIX 1.8MM 16MM BUTTRESS TITANIUM DISTAL RADIAL NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.968 SUP Custom 27203010 401.968 - PIN FIX 1.8MM 18MM BUTTRESS TITANIUM NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.97 SUP Custom 27203010 401.970 - PIN FIX 1.8MM 20MM BUTTRESS TITANIUM DISTAL RAD NONSTRL BOTH IP/OP $111.23 $82.31 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.55 $82.55 $0.00 $0.00 $23.18 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.972 SUP Custom 27203010 401.972 - PIN FIX 1.8MM 22MM BUTTRESS TITANIUM DISTAL RAD NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.974 SUP Custom 27203010 401.974 - PIN FIX 1.8MM 24MM BUTTRESS TITANIUM DISTAL RAD NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.976 SUP Custom 27203010 401.976 - PIN FIX 1.8MM 26MM BUTTRESS TITANIUM DISTAL RAD NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.978 SUP Custom 27203010 401.978 - PIN FIX 1.8MM 28MM BUTTRESS TITANIUM DISTAL RAD NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.98 SUP Custom 27203010 401.980 - PIN FIX 1.8MM 30MM BUTTRESS TITANIUM DISTAL RADIAL NONSTRL BOTH IP/OP $111.23 $82.31 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.55 $82.55 $0.00 $0.00 $23.18 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 402 SUP Custom 27204646 402 - TUNNELER SURG 2 SLEEVE DISPOSABLE BOTH IP/OP "$1,080.00 " $799.20 $0.00 $864.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $801.58 $801.58 $0.00 $0.00 $225.07 $0.00 $0.00 $0.00 $0.00 $540.00 $855.36 $864.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 402.006 SUP HCPCS C1713 402.006 - SCREW BONE 2.5MM STANDARD SMALL HEXAGON SPHERE 2.7MM 5MM 6MM BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.008 SUP HCPCS C1713 402.008 - SCREW BONE STANDARD 2.7MM 5MM 8MM SMALL HEXAGONAL SOCKET BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.01 SUP HCPCS C1713 402.010 - SCREW BONE STANDARD 4MM 2.7MM 10MM T8 STARDRIVE SLFTAP BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.012 SUP HCPCS C1713 402.012 - SCREW BONE 2.5MM STANDARD 2.7MM 5MM 12MM SPHERICAL HEAD BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.014 SUP HCPCS C1713 402.014 - SCREW BONE 2.5MM STANDARD 2.7MM 5MM 14MM SPHERICAL HEAD BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.016 SUP HCPCS C1713 402.016 - SCREW BONE 2.5MM STANDARD 2.7MM 5MM 16MM SMALL HEXAGONAL BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.018 SUP HCPCS C1713 402.018 - SCREW BONE 2.7MM 18MM TITANIUM CORTICAL NONSTRL MINI BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.02 SUP HCPCS C1713 402.020 - SCREW BONE 2.5MM STANDARD 2.7MM 5MM 20MM SPHERICAL HEAD BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.022 SUP HCPCS C1713 402.022 - SCREW BONE 2.5MM STANDARD SMALL HEXAGON SPHERE 2.7MM 5MM 22 BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.024 SUP HCPCS C1713 402.024 - SCREW BONE 2.5MM STANDARD 2.7MM 5MM 24MM SPHERICAL HEAD BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.026 SUP HCPCS C1713 402.026 - SCREW BONE 2.7MM 26MM TITANIUM CORTICAL NONSTRL MINI BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.028 SUP HCPCS C1713 402.028 - SCREW BONE STANDARD 2.7MM 5MM 28MM SMALL HEXAGONAL SOCKET BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.03 SUP HCPCS C1713 402.030 - SCREW BONE STANDARD 2.7MM 5MM 30MM SMALL HEXAGONAL SOCKET BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.032 SUP HCPCS C1713 402.032 - SCREW BONE STANDARD 2.7MM 5MM 32MM SMALL HEXAGONAL SOCKET BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.034 SUP HCPCS C1713 402.034 - SCREW BONE 2.7MM 34MM TITANIUM CORTICAL NONSTRL MINI BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.036 SUP HCPCS C1713 402.036 - SCREW BONE 2.7MM 36MM TITANIUM CORTICAL NONSTRL MINI BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.038 SUP HCPCS C1713 402.038 - SCREW BONE 2.5MM 38MM TITANIUM CORTICAL NONSTRL MINI BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.04 SUP HCPCS C1713 402.040 - SCREW BONE 2.7MM 40MM TITANIUM CORTICAL NONSTRL MINI BOTH IP/OP $54.93 $40.65 $0.00 $43.94 $24.72 $24.72 $0.00 $0.00 $0.00 $11.45 $40.77 $40.77 $0.00 $0.00 $11.45 $0.00 $32.49 $32.49 $0.00 $27.46 $43.50 $43.94 $0.00 $0.00 $8.35 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 402.208 SUP HCPCS C1713 402.208 - SCREW BONE 2.7MM 8MM SLFTAP T8 STARDRIVE RECESS LOCKING LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.21 SUP HCPCS C1713 402.210 - SCREW BONE 2.7MM 10MM T8 STARDRIVE RECESS SLFTAP LOCKING LCP BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.212 SUP HCPCS C1713 402.212 - SCREW BONE 2.7MM 12MM T8 STARDRIVE RECESS SELF TAP LOCK BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.214 SUP HCPCS C1713 402.214 - SCREW BONE 2.7MM 14MM T8 STARDRIVE RECESS SELF TAP LOCK LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.216 SUP HCPCS C1713 402.216 - SCREW BONE T8 2.7MM 16MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.218 SUP HCPCS C1713 402.218 - SCREW BONE T8 2.7MM 18MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.22 SUP HCPCS C1713 402.220 - SCREW BONE T8 2.7MM 20MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.222 SUP HCPCS C1713 402.222 - SCREW BONE 2.7MM 22MM T8 STARDRIVE RECESS SELF TAP LOCK LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.224 SUP HCPCS C1713 402.224 - SCREW BONE 2.7MM 24MM CANN SELF TAP LOCK STARDRIVE RECESS BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.226 SUP HCPCS C1713 402.226 - SCREW BONE 2.7MM 26MM CANN SELF TAP LOCK STARDRIVE RECESS BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.228 SUP HCPCS C1713 402.228 - SCREW BONE 2.7MM 28MM CANN SELF TAP LOCK STARDRIVE RECESS BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.23 SUP HCPCS C1713 402.230 - SCREW BONE 2.7MM 30MM SELF TAP LOCK T8 LCP STARDRIVE BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.232 SUP HCPCS C1713 402.232 - SCREW BONE 2.7MM 32MM CANN SELF TAP LOCK STARDRIVE RECESS BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.234 SUP HCPCS C1713 402.234 - SCREW BONE 2.7MM 34MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.236 SUP HCPCS C1713 402.236 - SCREW BONE 2.7MM 36MM CANN SELF TAP LOCK STARDRIVE RECESS BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.238 SUP HCPCS C1713 402.238 - SCREW BONE 2.7MM 38MM SLFTAP LOCKING T8 STARDRIVE RECESS LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.24 SUP HCPCS C1713 402.240 - SCREW BONE 2.7MM 40MM SELF TAP LOCK T8 LCP STARDRIVE BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.242 SUP HCPCS C1713 402.242 - SCREW BONE 2.7MM 42MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.244 SUP HCPCS C1713 402.244 - SCREW BONE 2.7MM 44MM SLFTAP LOCKING T8 STARDRIVE RECESS LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.246 SUP HCPCS C1713 402.246 - SCREW BONE 2.7MM 46MM SLFTAP LOCKING T8 STARDRIVE RECESS LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.248 SUP HCPCS C1713 402.248 - SCREW BONE 2.7MM 48MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.25 SUP HCPCS C1713 402.250 - SCREW BONE 2MM 50MM T6 STARDRIVE RECESS SLFTAP LOCKING LCP BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.255 SUP HCPCS C1713 402.255 - SCREW BONE 2.7MM 55MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $222.10 $164.35 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $46.29 $164.84 $164.84 $0.00 $0.00 $46.29 $0.00 $131.37 $131.37 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.26 SUP HCPCS C1713 402.260 - SCREW BONE 2MM 60MM T6 STARDRIVE RECESS SLFTAP LOCKING LCP BOTH IP/OP $215.63 $159.57 $0.00 $172.50 $97.03 $97.03 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $107.81 $170.78 $172.50 $0.00 $0.00 $32.76 $0.00 $0.00 $34.33 $0.00 $0.00 $0.00 $0.00 $0.00 402.608 SUP HCPCS C1713 402.608 - SCREW BONE 3MM 4MM 1.2MM 8MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.609 SUP HCPCS C1713 402.609 - SCREW BONE 3MM 4MM 1.2MM 9MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.61 SUP HCPCS C1713 402.610 - SCREW BONE 3MM 4MM 1.2MM 10MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.611 SUP HCPCS C1713 402.611 - SCREW BONE 3MM 4MM 1.2MM 11MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.612 SUP HCPCS C1713 402.612 - SCREW BONE 3MM 4MM 1.2MM 12MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.613 SUP HCPCS C1713 402.613 - SCREW BONE 3MM 4MM 1.2MM 13MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.614 SUP HCPCS C1713 402.614 - SCREW BONE SHORT THREAD 3MM 14MM 4MM CANN SELF DRILL SELF BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.615 SUP HCPCS C1713 402.615 - SCREW BONE 3MM 4MM 1.2MM 15MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.616 SUP HCPCS C1713 402.616 - SCREW BONE 3MM 4MM 1.2MM 16MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.617 SUP HCPCS C1713 402.617 - SCREW BONE 3MM 4MM 1.2MM 17MM 4MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.618 SUP HCPCS C1713 402.618 - SCREW BONE 3MM 4MM 1.2MM 18MM 5MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.619 SUP HCPCS C1713 402.619 - SCREW BONE 3MM 4MM 1.2MM 19MM 5MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.62 SUP HCPCS C1713 402.620 - SCREW BONE 3MM 4MM 1.2MM 20MM 5MM CANN TITANIUM SMALL BONE BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.621 SUP HCPCS C1713 402.621 - SCREW BONE 3MM 4MM 1.2MM 21MM 5MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.622 SUP HCPCS C1713 402.622 - SCREW BONE 3MM 4MM 1.2MM 22MM 5MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.623 SUP HCPCS C1713 402.623 - SCREW BONE 3MM 4MM 1.2MM 23MM 5MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.624 SUP HCPCS C1713 402.624 - SCREW BONE 3MM 4MM 1.2MM 24MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.625 SUP HCPCS C1713 402.625 - SCREW BONE 3MM 4MM 1.2MM 25MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.626 SUP HCPCS C1713 402.626 - SCREW BONE 3MM 4MM 1.2MM 26MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.627 SUP HCPCS C1713 402.627 - SCREW BONE 3MM 4MM 1.2MM 27MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.628 SUP HCPCS C1713 402.628 - SCREW BONE 3MM 4MM 1.2MM 28MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.629 SUP HCPCS C1713 402.629 - SCREW BONE 3MM 4MM 1.2MM 29MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.63 SUP HCPCS C1713 402.630 - SCREW BONE 3MM 4MM 1.2MM 30MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.632 SUP HCPCS C1713 402.632 - SCREW BONE 3MM 4MM 1.2MM 32MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.634 SUP HCPCS C1713 402.634 - SCREW BONE 3MM 4MM 1.2MM 34MM 7MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.636 SUP HCPCS C1713 402.636 - SCREW BONE 3MM 4MM 1.2MM 36MM 7MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.638 SUP HCPCS C1713 402.638 - SCREW BONE 3MM 4MM 1.2MM 38MM 8MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.64 SUP HCPCS C1713 402.640 - SCREW BONE 3MM 4MM 1.2MM 40MM 8MM CANN TITANIUM SMALL BONE BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.714 SUP HCPCS C1713 402.714 - SCREW BONE 3MM 4MM 1.2MM 14MM 6MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.715 SUP HCPCS C1713 402.715 - SCREW BONE LNGTHRD 3MM 15MM CANN LOCK STARDRIVE RECESS BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.716 SUP HCPCS C1713 402.716 - SCREW BONE 3MM 4MM 1.2MM 16MM 7MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.717 SUP HCPCS C1713 402.717 - SCREW BONE 3MM 4MM 1.2MM 17MM 8MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.718 SUP HCPCS C1713 402.718 - SCREW BONE 3MM 4MM 1.2MM 18MM 8MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.719 SUP HCPCS C1713 402.719 - SCREW BONE 3MM 4MM 1.2MM 19MM 9MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.72 SUP HCPCS C1713 402.720 - SCREW BONE 3MM 4MM 1.2MM 20MM 9MM CANN TITANIUM SMALL BONE BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.721 SUP HCPCS C1713 402.721 - SCREW BONE 3MM 4MM 1.2MM 21MM 9MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.722 SUP HCPCS C1713 402.722 - SCREW BONE 3MM 4MM 1.2MM 22MM 10MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.723 SUP HCPCS C1713 402.723 - SCREW BONE 3MM 4MM 1.2MM 23MM 10MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.724 SUP HCPCS C1713 402.724 - SCREW BONE 3MM 4MM 1.2MM 24MM 10MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.725 SUP HCPCS C1713 402.725 - SCREW BONE 3MM 4MM 1.2MM 25MM 10MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.726 SUP HCPCS C1713 402.726 - SCREW BONE 3MM 4MM 1.2MM 26MM 12MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.727 SUP HCPCS C1713 402.727 - SCREW BONE 3MM 4MM 1.2MM 27MM 12MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.728 SUP HCPCS C1713 402.728 - SCREW BONE 3MM 4MM 1.2MM 28MM 12MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.729 SUP HCPCS C1713 402.729 - SCREW BONE 3MM 4MM 1.2MM 29MM 12MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.73 SUP HCPCS C1713 402.730 - SCREW BONE 3MM 4MM 1.2MM 30MM 14MM CANN TITANIUM SMALL BONE BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.732 SUP HCPCS C1713 402.732 - SCREW BONE 3MM 4MM 1.2MM 32MM 14MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.734 SUP HCPCS C1713 402.734 - SCREW BONE 3MM 4MM 1.2MM 34MM 16MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.736 SUP HCPCS C1713 402.736 - SCREW BONE 3MM 4MM 1.2MM 36MM 16MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.738 SUP HCPCS C1713 402.738 - SCREW BONE 3MM 4MM 1.2MM 38MM 18MM CANN TITANIUM SMALL BONE BOTH IP/OP $372.50 $275.65 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.74 SUP HCPCS C1713 402.740 - SCREW BONE 3MM 4MM 1.2MM 40MM 18MM CANN TITANIUM SMALL BONE BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $54.95 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 402.806 SUP HCPCS C1713 402.806 - SCREW BONE FULTHD 2.7MM 5MM 6MM SELF TAP SPHERICAL HEAD BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.808 SUP HCPCS C1713 402.808 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 8MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.81 SUP HCPCS C1713 402.810 - SCREW BONE 2.7MM 5MM 10MM SELF TAP SPHERICAL HEAD SMALL BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.812 SUP HCPCS C1713 402.812 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 12MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.814 SUP HCPCS C1713 402.814 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 14MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.816 SUP HCPCS C1713 402.816 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 16MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.818 SUP HCPCS C1713 402.818 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 18MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.82 SUP HCPCS C1713 402.820 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 20MM SELF TAP BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.822 SUP HCPCS C1713 402.822 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 22MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.824 SUP HCPCS C1713 402.824 - SCREW BONE FULTHD 2.7MM 5MM 24MM SELF TAP SPHERICAL HEAD BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.826 SUP HCPCS C1713 402.826 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 26MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.828 SUP HCPCS C1713 402.828 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 28MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.83 SUP HCPCS C1713 402.830 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 30MM SELF TAP BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.832 SUP HCPCS C1713 402.832 - SCREW BONE FULTHD 2.7MM 5MM 32MM SELF TAP HEXAGONAL SOCKET BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.834 SUP HCPCS C1713 402.834 - SCREW BONE FULTHD 2.7MM 5MM 34MM SELF TAP SPHERICAL HEAD BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.836 SUP HCPCS C1713 402.836 - SCREW BONE FULTHD 2.7MM 5MM 36MM SELF TAP SPHERICAL HEAD BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.838 SUP HCPCS C1713 402.838 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 38MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.84 SUP HCPCS C1713 402.840 - SCREW BONE 2.7MM 40MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.845 SUP HCPCS C1713 402.845 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 45MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.85 SUP HCPCS C1713 402.850 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 50MM SELF TAP BOTH IP/OP $59.70 $44.18 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.44 $44.31 $44.31 $0.00 $0.00 $12.44 $0.00 $35.31 $35.31 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.855 SUP HCPCS C1713 402.855 - SCREW BONE FULTHD HEXAGON SPHERE 2.7MM 5MM 55MM SELF TAP BOTH IP/OP $61.48 $45.50 $0.00 $47.76 $26.87 $26.87 $0.00 $0.00 $0.00 $12.81 $45.63 $45.63 $0.00 $0.00 $12.81 $0.00 $36.36 $36.36 $0.00 $29.85 $47.28 $47.76 $0.00 $0.00 $9.07 $0.00 $0.00 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 402.87 SUP HCPCS C1713 402.870 - SCREW BONE T8 2.7MM 10MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $68.90 $50.99 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.36 $51.14 $51.14 $0.00 $0.00 $14.36 $0.00 $40.75 $40.75 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.872 SUP HCPCS C1713 402.872 - SCREW BONE T8 2.7MM 12MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.874 SUP HCPCS C1713 402.874 - SCREW BONE T8 2.7MM 14MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.876 SUP HCPCS C1713 402.876 - SCREW BONE T8 2.7MM 16MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.878 SUP HCPCS C1713 402.878 - SCREW BONE T8 2.7MM 18MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.88 SUP HCPCS C1713 402.880 - SCREW BONE T8 2.7MM 20MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $68.90 $50.99 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.36 $51.14 $51.14 $0.00 $0.00 $14.36 $0.00 $40.75 $40.75 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.882 SUP HCPCS C1713 402.882 - SCREW BONE 2.7MM 22MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.884 SUP HCPCS C1713 402.884 - SCREW BONE 2.7MM 24MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.886 SUP HCPCS C1713 402.886 - SCREW BONE 2.7MM 26MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.888 SUP HCPCS C1713 402.888 - SCREW BONE 2.7MM 28MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.89 SUP HCPCS C1713 402.890 - SCREW BONE 2.7MM 30MM T8 STARDRIVE SELF TAP LCP TITANIUM RAD BOTH IP/OP $68.90 $50.99 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.36 $51.14 $51.14 $0.00 $0.00 $14.36 $0.00 $40.75 $40.75 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.892 SUP HCPCS C1713 402.892 - SCREW BONE 2.7MM 32MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.894 SUP HCPCS C1713 402.894 - SCREW BONE 2.7MM 34MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.896 SUP HCPCS C1713 402.896 - SCREW BONE 2.7MM 36MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.898 SUP HCPCS C1713 402.898 - SCREW BONE 2.7MM 38MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.9 SUP HCPCS C1713 402.900 - SCREW BONE 2.7MM 5MM 40MM SLFTAP T8 STARDRIVE RECESS LCP BOTH IP/OP $68.90 $50.99 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.36 $51.14 $51.14 $0.00 $0.00 $14.36 $0.00 $40.75 $40.75 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.962 SUP HCPCS C1713 402.962 - SCREW BONE 2.7MM 42MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.963 SUP HCPCS C1713 402.963 - SCREW BONE 2.7MM 44MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.965 SUP HCPCS C1713 402.965 - SCREW BONE T8 2.7MM 46MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.966 SUP HCPCS C1713 402.966 - SCREW BONE T8 2.7MM 48MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.967 SUP HCPCS C1713 402.967 - SCREW BONE 2.7MM 50MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.968 SUP HCPCS C1713 402.968 - SCREW BONE 2.7MM 55MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 402.969 SUP HCPCS C1713 402.969 - SCREW BONE 2.7MM 60MM SLFTAP LCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 404.01 SUP HCPCS C1713 404.010 - SCREW BONE STANDARD 3.5MM 6MM 10MM SMALL HEXAGONAL SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.012 SUP HCPCS C1713 404.012 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 12MM SELF TAP SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.014 SUP HCPCS C1713 404.014 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 14MM SELF TAP SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.016 SUP HCPCS C1713 404.016 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 16MM SELF TAP SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.018 SUP HCPCS C1713 404.018 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 18MM SELF TAP SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 404.02 SUP HCPCS C1713 404.020 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 20MM SELF TAP SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 404.022 SUP HCPCS C1713 404.022 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 22MM SELF TAP SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 404.024 SUP HCPCS C1713 404.024 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 24MM SELF TAP SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 404.026 SUP HCPCS C1713 404.026 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 26MM SELF TAP SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 404.028 SUP HCPCS C1713 404.028 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 28MM SELF TAP SOCKET BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $12.43 $12.43 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.20 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 404.03 SUP HCPCS C1713 404.030 - SCREW BONE STANDARD SMALL HEXAGON 3.5MM 6MM 30MM SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.032 SUP HCPCS C1713 404.032 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 32MM SELF TAP SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.034 SUP HCPCS C1713 404.034 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 34MM SELF TAP SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.036 SUP HCPCS C1713 404.036 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 36MM SELF TAP SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.038 SUP HCPCS C1713 404.038 - SCREW BONE STANDARD 3.5MM 6MM 38MM SMALL HEXAGONAL SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.04 SUP HCPCS C1713 404.040 - SCREW BONE STANDARD 3.5MM 6MM 40MM SMALL HEXAGONAL SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.045 SUP HCPCS C1713 404.045 - SCREW BONE STANDARD HEXAGON 3.5MM 6MM 45MM SELF TAP SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.05 SUP HCPCS C1713 404.050 - SCREW BONE STANDARD 3.5MM 6MM 50MM SMALL HEXAGONAL SOCKET BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.055 SUP HCPCS C1713 404.055 - SCREW BONE 2.5MM STANDARD 3.5MM 6MM 55MM SMALL HEXAGONAL BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.06 SUP HCPCS C1713 404.060 - SCREW BONE 2.5MM STANDARD 3.5MM 6MM 60MM SMALL HEXAGONAL BOTH IP/OP $26.83 $19.85 $0.00 $21.46 $12.07 $12.07 $0.00 $0.00 $0.00 $5.59 $19.91 $19.91 $0.00 $0.00 $5.59 $0.00 $15.87 $15.87 $0.00 $13.41 $21.25 $21.46 $0.00 $0.00 $4.20 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $0.00 404.216 SUP HCPCS C1713 404.216 - SCREW BONE HEXAGON SPHERE 3.5MM 16MM SELF TAP SOCKET LC-DCP BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.218 SUP HCPCS C1713 404.218 - SCREW BONE HEXAGON SPHERE 3.5MM 18MM SELF TAP SOCKET LC-DCP BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.22 SUP HCPCS C1713 404.220 - SCREW BONE HEXAGON SPHERE 3.5MM 20MM SELF TAP SOCKET LC-DCP BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.222 SUP HCPCS C1713 404.222 - SCREW BONE HEXAGON SPHERE 3.5MM 22MM SELF TAP SOCKET LC-DCP BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.224 SUP HCPCS C1713 404.224 - SCREW BONE HEXAGON SPHERE 3.5MM 24MM SELF TAP SOCKET LC-DCP BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.226 SUP HCPCS C1713 404.226 - SCREW BONE HEXAGON SPHERE 3.5MM 26MM SELF TAP SOCKET LC-DCP BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.228 SUP HCPCS C1713 404.228 - SCREW BONE HEXAGON SPHERE 3.5MM 28MM SELF TAP SOCKET LC-DCP BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.23 SUP HCPCS C1713 404.230 - SCREW BONE PTHRD 3.5MM 6MM 30MM 10MM SMALL HEXAGONAL SOCKET BOTH IP/OP $32.75 $24.24 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $6.83 $24.31 $24.31 $0.00 $0.00 $6.83 $0.00 $19.37 $19.37 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.232 SUP HCPCS C1713 404.232 - SCREW BONE HEXAGON SPHERE 3.5MM 32MM SELF TAP SOCKET LC-DCP BOTH IP/OP $33.73 $24.96 $0.00 $26.20 $14.74 $14.74 $0.00 $0.00 $0.00 $7.03 $25.03 $25.03 $0.00 $0.00 $7.03 $0.00 $19.95 $19.95 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $4.98 $0.00 $0.00 $5.21 $0.00 $0.00 $0.00 $0.00 $0.00 404.234 SUP HCPCS C1713 404.234 - SCREW BONE HEXAGON SPHERE 3.5MM 34MM SELF TAP SOCKET LC-DCP BOTH IP/OP $31.80 $23.53 $0.00 $25.44 $14.31 $14.31 $0.00 $0.00 $0.00 $6.63 $23.60 $23.60 $0.00 $0.00 $6.63 $0.00 $18.81 $18.81 $0.00 $15.90 $25.19 $25.44 $0.00 $0.00 $4.98 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 404.236 SUP HCPCS C1713 404.236 - SCREW BONE HEXAGON SPHERE 3.5MM 36MM SELF TAP SOCKET LC-DCP BOTH IP/OP $31.80 $23.53 $0.00 $25.44 $14.31 $14.31 $0.00 $0.00 $0.00 $6.63 $23.60 $23.60 $0.00 $0.00 $6.63 $0.00 $18.81 $18.81 $0.00 $15.90 $25.19 $25.44 $0.00 $0.00 $4.98 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 404.238 SUP HCPCS C1713 404.238 - SCREW BONE HEXAGON SPHERE 3.5MM 38MM SELF TAP SOCKET LC-DCP BOTH IP/OP $31.80 $23.53 $0.00 $25.44 $14.31 $14.31 $0.00 $0.00 $0.00 $6.63 $23.60 $23.60 $0.00 $0.00 $6.63 $0.00 $18.81 $18.81 $0.00 $15.90 $25.19 $25.44 $0.00 $0.00 $4.98 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 404.24 SUP HCPCS C1713 404.240 - SCREW BONE HEXAGON SPHERE 3.5MM 40MM SELF TAP SOCKET LC-DCP BOTH IP/OP $31.80 $23.53 $0.00 $25.44 $14.31 $14.31 $0.00 $0.00 $0.00 $6.63 $23.60 $23.60 $0.00 $0.00 $6.63 $0.00 $18.81 $18.81 $0.00 $15.90 $25.19 $25.44 $0.00 $0.00 $4.98 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 404.245 SUP HCPCS C1713 404.245 - SCREW BONE HEXAGON SPHERE 3.5MM 45MM SELF TAP SOCKET LC-DCP BOTH IP/OP $31.80 $23.53 $0.00 $25.44 $14.31 $14.31 $0.00 $0.00 $0.00 $6.63 $23.60 $23.60 $0.00 $0.00 $6.63 $0.00 $18.81 $18.81 $0.00 $15.90 $25.19 $25.44 $0.00 $0.00 $4.98 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 404.25 SUP HCPCS C1713 404.250 - SCREW BONE HEXAGON SPHERE 3.5MM 50MM SELF TAP SOCKET LC-DCP BOTH IP/OP $31.80 $23.53 $0.00 $25.44 $14.31 $14.31 $0.00 $0.00 $0.00 $6.63 $23.60 $23.60 $0.00 $0.00 $6.63 $0.00 $18.81 $18.81 $0.00 $15.90 $25.19 $25.44 $0.00 $0.00 $4.98 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 404.81 SUP HCPCS C1713 404.810 - SCREW BONE FULTHD 3.5MM 6MM 10MM SLFTAP HEXAGONAL RECESS LCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.812 SUP HCPCS C1713 404.812 - SCREW BONE FULTHD 3.5MM 6MM 12MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.814 SUP HCPCS C1713 404.814 - SCREW BONE FULTHD 3.5MM 6MM 14MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.816 SUP HCPCS C1713 404.816 - SCREW BONE FULTHD 3.5MM 6MM 16MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $9.70 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.818 SUP HCPCS C1713 404.818 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 18MM SELF TAP SOCKET LCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.82 SUP HCPCS C1713 404.820 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 20MM SELF TAP SOCKET LCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $9.70 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.822 SUP HCPCS C1713 404.822 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 22MM SELF TAP SOCKET LCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.824 SUP HCPCS C1713 404.824 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 24MM SELF TAP SOCKET LCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.826 SUP HCPCS C1713 404.826 - SCREW BONE FULTHD 3.5MM 6MM 26MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.828 SUP HCPCS C1713 404.828 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 28MM SELF TAP SOCKET LCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.83 SUP HCPCS C1713 404.830 - SCREW BONE FULTHD 3.5MM 6MM 30MM SLFTAP HEXAGONAL RECESS LCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.832 SUP HCPCS C1713 404.832 - SCREW BONE FULTHD 3.5MM 6MM 32MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.834 SUP HCPCS C1713 404.834 - SCREW BONE FULTHD 3.5MM 6MM 34MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.836 SUP HCPCS C1713 404.836 - SCREW BONE FULTHD 3.5MM 6MM 36MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.838 SUP HCPCS C1713 404.838 - SCREW BONE FULTHD 3.5MM 6MM 38MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.84 SUP HCPCS C1713 404.840 - SCREW BONE HEXAGON 3.5MM 40MM SLFTAP SMALL RECESS LCP BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.845 SUP HCPCS C1713 404.845 - SCREW BONE FULTHD HEXAGON 3.5MM 6MM 45MM SELF TAP SOCKET LCP BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.85 SUP HCPCS C1713 404.850 - SCREW BONE FULTHD 3.5MM 6MM 50MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $38.55 $28.53 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.03 $28.61 $28.61 $0.00 $0.00 $8.03 $0.00 $22.80 $22.80 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 404.855 SUP HCPCS C1713 404.855 - SCREW BONE FULTHD 3.5MM 6MM 55MM SELF TAP HEXAGONAL RECESS BOTH IP/OP $39.70 $29.38 $0.00 $30.84 $17.35 $17.35 $0.00 $0.00 $0.00 $8.27 $29.47 $29.47 $0.00 $0.00 $8.27 $0.00 $23.48 $23.48 $0.00 $19.28 $30.53 $30.84 $0.00 $0.00 $5.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $0.00 406.01 SUP HCPCS C1713 406.010 - SCREW BONE FULTHD 4MM 10MM LCP TITANIUM CANCELLOUS CLAVICLE BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.012 SUP HCPCS C1713 406.012 - SCREW BONE FULTHD HEXAGON 4MM 12MM SOCKET LC-DCP TITANIUM BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.014 SUP HCPCS C1713 406.014 - SCREW BONE FULTHD HEXAGON 4MM 14MM SOCKET LC-DCP TITANIUM BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.016 SUP HCPCS C1713 406.016 - SCREW BONE FULTHD HEXAGON 4MM 16MM SOCKET LC-DCP TITANIUM BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.018 SUP HCPCS C1713 406.018 - SCREW BONE FULTHD HEXAGON 4MM 18MM SOCKET LC-DCP TITANIUM BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $7.42 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.02 SUP HCPCS C1713 406.020 - SCREW BONE FULTHD HEXAGON 4MM 20MM SOCKET LC-DCP TITANIUM BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $7.42 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.022 SUP HCPCS C1713 406.022 - SCREW BONE FULTHD 4MM 6MM 22MM 9MM SMALL HEXAGONAL SOCKET BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.024 SUP HCPCS C1713 406.024 - SCREW BONE FULTHD 4MM 6MM 24MM 10MM SMALL HEXAGONAL SOCKET BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.026 SUP HCPCS C1713 406.026 - SCREW BONE FULTHD HEXAGON 4MM 26MM SOCKET LC-DCP TITANIUM BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $7.42 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.028 SUP HCPCS C1713 406.028 - SCREW BONE FULTHD HEXAGON 4MM 28MM SOCKET LC-DCP TITANIUM BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $7.42 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.03 SUP HCPCS C1713 406.030 - SCREW BONE FULTHD 4MM 6MM 30MM LC-DCP TITANIUM TIBIA BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.032 SUP HCPCS C1713 406.032 - SCREW BONE FULTHD HEXAGON 4MM 32MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.80 $22.79 $0.00 $24.64 $13.86 $13.86 $0.00 $0.00 $0.00 $6.42 $22.86 $22.86 $0.00 $0.00 $6.42 $0.00 $18.22 $18.22 $0.00 $15.40 $24.39 $24.64 $0.00 $0.00 $4.82 $0.00 $0.00 $4.90 $0.00 $0.00 $0.00 $0.00 $0.00 406.035 SUP HCPCS C1713 406.035 - SCREW BONE FULTHD HEXAGON 4MM 35MM SOCKET LC-DCP TITANIUM BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.04 SUP HCPCS C1713 406.040 - SCREW BONE FULTHD SMALL HEXAGON 4MM 6MM 40MM SOCKET TITANIUM BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $7.42 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.045 SUP HCPCS C1713 406.045 - SCREW BONE FULTHD 4MM 6MM 45MM 15MM SMALL HEXAGONAL SOCKET BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.05 SUP HCPCS C1713 406.050 - SCREW BONE FULTHD HEXAGON 4MM 50MM SOCKET LC-DCP TITANIUM BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $4.82 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.055 SUP HCPCS C1713 406.055 - SCREW BONE FULTHD 4MM 6MM 55MM 15MM SMALL HEXAGONAL SOCKET BOTH IP/OP $32.68 $24.18 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.81 $24.25 $24.25 $0.00 $0.00 $6.81 $0.00 $19.33 $19.33 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $7.42 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.06 SUP HCPCS C1713 406.060 - SCREW BONE FULTHD 4MM 6MM 60MM 15MM SMALL HEXAGONAL SOCKET BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $14.28 $14.28 $0.00 $0.00 $0.00 $6.61 $23.55 $23.55 $0.00 $0.00 $6.61 $0.00 $18.77 $18.77 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $7.42 $0.00 $0.00 $5.05 $0.00 $0.00 $0.00 $0.00 $0.00 406.065 SUP HCPCS C1713 406.065 - SCREW BONE FULTHD 4MM 65MM LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $35.83 $26.51 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.47 $26.59 $26.59 $0.00 $0.00 $7.47 $0.00 $21.19 $21.19 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 406.07 SUP HCPCS C1713 406.070 - SCREW BONE FULTHD 4MM 70MM LCP TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $34.80 $25.75 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.25 $25.83 $25.83 $0.00 $0.00 $7.25 $0.00 $20.58 $20.58 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 406.075 SUP HCPCS C1713 406.075 - SCREW BONE FULTHD 4MM 75MM LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $35.83 $26.51 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.47 $26.59 $26.59 $0.00 $0.00 $7.47 $0.00 $21.19 $21.19 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 406.08 SUP HCPCS C1713 406.080 - SCREW BONE FULTHD 4MM 80MM LCP TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $34.80 $25.75 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.25 $25.83 $25.83 $0.00 $0.00 $7.25 $0.00 $20.58 $20.58 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 406.085 SUP HCPCS C1713 406.085 - SCREW BONE FULTHD 4MM 85MM LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $35.83 $26.51 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.47 $26.59 $26.59 $0.00 $0.00 $7.47 $0.00 $21.19 $21.19 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 406.09 SUP HCPCS C1713 406.090 - SCREW BONE FULTHD 4MM 90MM LCP TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $34.80 $25.75 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.25 $25.83 $25.83 $0.00 $0.00 $7.25 $0.00 $20.58 $20.58 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 406.095 SUP HCPCS C1713 406.095 - SCREW BONE FULTHD 4MM 95MM LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $35.83 $26.51 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.47 $26.59 $26.59 $0.00 $0.00 $7.47 $0.00 $21.19 $21.19 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 406.1 SUP HCPCS C1713 406.100 - SCREW BONE FULTHD 4MM 100MM LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $34.80 $25.75 $0.00 $27.84 $15.66 $15.66 $0.00 $0.00 $0.00 $7.25 $25.83 $25.83 $0.00 $0.00 $7.25 $0.00 $20.58 $20.58 $0.00 $17.40 $27.56 $27.84 $0.00 $0.00 $5.29 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $0.00 406.104 SUP HCPCS C1713 406.104 - SCREW BONE LOCK STARDRIVE AXON TITANIUM SPN NONSTRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 407.01 SUP HCPCS C1713 407.010 - SCREW BONE PTHRD HEXAGON 4MM 10MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.012 SUP HCPCS C1713 407.012 - SCREW BONE PTHRD HEXAGON 4MM 12MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.014 SUP HCPCS C1713 407.014 - SCREW BONE PTHRD HEXAGON 4MM 14MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.016 SUP HCPCS C1713 407.016 - SCREW BONE PTHRD 4MM 6MM 16MM 6MM SMALL HEXAGONAL SOCKET BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.018 SUP HCPCS C1713 407.018 - SCREW BONE PTHRD 4MM 6MM 18MM 7MM SMALL HEXAGONAL SOCKET BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.02 SUP HCPCS C1713 407.020 - SCREW BONE PTHRD HEXAGON 4MM 20MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.022 SUP HCPCS C1713 407.022 - SCREW BONE PTHRD 4MM 6MM 22MM 9MM SMALL HEXAGONAL SOCKET BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.024 SUP HCPCS C1713 407.024 - SCREW BONE PTHRD 4MM 6MM 24MM 10MM SMALL HEXAGONAL SOCKET BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.026 SUP HCPCS C1713 407.026 - SCREW BONE PTHRD 4MM 6MM 26MM 12MM SMALL HEXAGONAL SOCKET BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.028 SUP HCPCS C1713 407.028 - SCREW BONE PTHRD 4MM 6MM 28MM 14MM HEXAGONAL SOCKET LC-DCP BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.03 SUP HCPCS C1713 407.030 - SCREW BONE PTHRD HEXAGON 4MM 30MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.035 SUP HCPCS C1713 407.035 - SCREW BONE PTHRD HEXAGON 4MM 35MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $7.42 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.04 SUP HCPCS C1713 407.040 - SCREW BONE PTHRD HEXAGON 4MM 40MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.045 SUP HCPCS C1713 407.045 - SCREW BONE PTHRD HEXAGON 4MM 45MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.05 SUP HCPCS C1713 407.050 - SCREW BONE PTHRD HEXAGON 4MM 50MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.055 SUP HCPCS C1713 407.055 - SCREW BONE PTHRD HEXAGON 4MM 55MM SOCKET LC-DCP TITANIUM BOTH IP/OP $30.93 $22.89 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.45 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $18.29 $18.29 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.06 SUP HCPCS C1713 407.060 - SCREW BONE 4MM 60MM PTHRD LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $30.03 $22.22 $0.00 $24.02 $13.51 $13.51 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.02 $0.00 $0.00 $4.56 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 407.065 SUP HCPCS C1713 407.065 - SCREW BONE 4MM 65MM PTHRD LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $35.15 $26.01 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.33 $26.09 $26.09 $0.00 $0.00 $7.33 $0.00 $20.79 $20.79 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 407.07 SUP HCPCS C1713 407.070 - SCREW BONE PTHRD 4MM 70MM LCP TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $34.13 $25.26 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.11 $25.33 $25.33 $0.00 $0.00 $7.11 $0.00 $20.18 $20.18 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 407.075 SUP HCPCS C1713 407.075 - SCREW BONE 4MM 75MM PTHRD LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $35.15 $26.01 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.33 $26.09 $26.09 $0.00 $0.00 $7.33 $0.00 $20.79 $20.79 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 407.08 SUP HCPCS C1713 407.080 - SCREW BONE PTHRD 4MM 80MM LCP TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $34.13 $25.26 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.11 $25.33 $25.33 $0.00 $0.00 $7.11 $0.00 $20.18 $20.18 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 407.085 SUP HCPCS C1713 407.085 - SCREW BONE 4MM 85MM PTHRD LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $35.15 $26.01 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.33 $26.09 $26.09 $0.00 $0.00 $7.33 $0.00 $20.79 $20.79 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 407.09 SUP HCPCS C1713 407.090 - SCREW BONE PTHRD 4MM 90MM LCP TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $34.13 $25.26 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.11 $25.33 $25.33 $0.00 $0.00 $7.11 $0.00 $20.18 $20.18 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 407.095 SUP HCPCS C1713 407.095 - SCREW BONE 4MM 95MM PTHRD LC-DCP TITANIUM TIBIA CANCELLOUS BOTH IP/OP $35.15 $26.01 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.33 $26.09 $26.09 $0.00 $0.00 $7.33 $0.00 $20.79 $20.79 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 407.1 SUP HCPCS C1713 407.100 - SCREW BONE PTHRD 4MM 100MM LCP TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $34.13 $25.26 $0.00 $27.30 $15.36 $15.36 $0.00 $0.00 $0.00 $7.11 $25.33 $25.33 $0.00 $0.00 $7.11 $0.00 $20.18 $20.18 $0.00 $17.06 $27.03 $27.30 $0.00 $0.00 $5.18 $0.00 $0.00 $5.43 $0.00 $0.00 $0.00 $0.00 $0.00 407.61 SUP HCPCS C1713 407.610 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 10MM SELF DRILL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.612 SUP HCPCS C1713 407.612 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 12MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.614 SUP HCPCS C1713 407.614 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 14MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.616 SUP HCPCS C1713 407.616 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 16MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.618 SUP HCPCS C1713 407.618 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 18MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.62 SUP HCPCS C1713 407.620 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 20MM SELF DRILL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.622 SUP HCPCS C1713 407.622 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 22MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.624 SUP HCPCS C1713 407.624 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 24MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.626 SUP HCPCS C1713 407.626 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 26MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.628 SUP HCPCS C1713 407.628 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 28MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $73.99 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.63 SUP HCPCS C1713 407.630 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 30MM SELF DRILL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.632 SUP HCPCS C1713 407.632 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 32MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.634 SUP HCPCS C1713 407.634 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 34MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.636 SUP HCPCS C1713 407.636 - SCREW BONE SHORT THREAD 4MM 5MM 36MM CANN HEXAGONAL SOCKET BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.638 SUP HCPCS C1713 407.638 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 38MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.64 SUP HCPCS C1713 407.640 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 40MM SELF DRILL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.642 SUP HCPCS C1713 407.642 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 42MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.644 SUP HCPCS C1713 407.644 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 44MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.646 SUP HCPCS C1713 407.646 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 46MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.648 SUP HCPCS C1713 407.648 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 48MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.65 SUP HCPCS C1713 407.650 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 50MM SELF DRILL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $73.99 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.652 SUP HCPCS C1713 407.652 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 52MM SELF DRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.654 SUP HCPCS C1713 407.654 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 54MM SELF DRILL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.656 SUP HCPCS C1713 407.656 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 56MM SELF DRILL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.658 SUP HCPCS C1713 407.658 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 58MM SELF DRILL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.66 SUP HCPCS C1713 407.660 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 60MM SELF DRILL BOTH IP/OP $369.85 $273.69 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $77.09 $274.50 $274.50 $0.00 $0.00 $77.08 $0.00 $218.77 $218.77 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.664 SUP HCPCS C1713 407.664 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 64MM SELF DRILL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.668 SUP HCPCS C1713 407.668 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 68MM SELF DRILL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.672 SUP HCPCS C1713 407.672 - SCREW BONE 1/3 THREAD HEXAGON 4MM 5MM 1.35MM 72MM SELF DRILL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.716 SUP HCPCS C1713 407.716 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 16MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.718 SUP HCPCS C1713 407.718 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 18MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.72 SUP HCPCS C1713 407.720 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 20MM CANN TITANIUM SMALL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.722 SUP HCPCS C1713 407.722 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 22MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.724 SUP HCPCS C1713 407.724 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 24MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.726 SUP HCPCS C1713 407.726 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 26MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.728 SUP HCPCS C1713 407.728 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 28MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.73 SUP HCPCS C1713 407.730 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 30MM CANN TITANIUM SMALL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.732 SUP HCPCS C1713 407.732 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 32MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.734 SUP HCPCS C1713 407.734 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 34MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.736 SUP HCPCS C1713 407.736 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 36MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.738 SUP HCPCS C1713 407.738 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 38MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.74 SUP HCPCS C1713 407.740 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 40MM CANN TITANIUM SMALL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.742 SUP HCPCS C1713 407.742 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 42MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.744 SUP HCPCS C1713 407.744 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 44MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.746 SUP HCPCS C1713 407.746 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 46MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.748 SUP HCPCS C1713 407.748 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 48MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.75 SUP HCPCS C1713 407.750 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 50MM CANN TITANIUM SMALL BOTH IP/OP $357.58 $264.61 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $74.53 $265.39 $265.39 $0.00 $0.00 $74.52 $0.00 $211.51 $211.51 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.752 SUP HCPCS C1713 407.752 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 52MM CANN TITANIUM SMALL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 407.754 SUP HCPCS C1713 407.754 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 54MM CANN TITANIUM SMALL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.756 SUP HCPCS C1713 407.756 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 56MM CANN TITANIUM SMALL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.758 SUP HCPCS C1713 407.758 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 58MM CANN TITANIUM SMALL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.76 SUP HCPCS C1713 407.760 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 60MM CANN TITANIUM SMALL BOTH IP/OP $369.85 $273.69 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $77.09 $274.50 $274.50 $0.00 $0.00 $77.08 $0.00 $218.77 $218.77 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.764 SUP HCPCS C1713 407.764 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 64MM CANN TITANIUM SMALL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.768 SUP HCPCS C1713 407.768 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 68MM CANN TITANIUM SMALL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 407.772 SUP HCPCS C1713 407.772 - SCREW BONE .5 THREAD 4MM 5MM 1.35MM 72MM CANN TITANIUM SMALL BOTH IP/OP $380.95 $281.90 $0.00 $295.88 $166.43 $166.43 $0.00 $0.00 $0.00 $79.40 $282.74 $282.74 $0.00 $0.00 $79.39 $0.00 $225.33 $225.33 $0.00 $184.93 $292.92 $295.88 $0.00 $0.00 $56.20 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 408.401 SUP HCPCS C1713 408.401 - SCREW BONE 6.5MM 30MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.402 SUP HCPCS C1713 408.402 - SCREW BONE 6.5MM 35MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.403 SUP HCPCS C1713 408.403 - SCREW BONE 6.5MM 40MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.404 SUP HCPCS C1713 408.404 - SCREW BONE 6.5MM 45MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.405 SUP HCPCS C1713 408.405 - SCREW BONE 6.5MM 50MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.406 SUP HCPCS C1713 408.406 - SCREW BONE 6.5MM 55MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.407 SUP HCPCS C1713 408.407 - SCREW BONE 6.5MM 7.9MM 2.9MM 60MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.408 SUP HCPCS C1713 408.408 - SCREW BONE 6.5MM 7.9MM 2.9MM 65MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.409 SUP HCPCS C1713 408.409 - SCREW BONE 6.5MM 7.9MM 2.9MM 70MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.41 SUP HCPCS C1713 408.410 - SCREW BONE 6.5MM 7.9MM 2.9MM 75MM 16MM CANN TITANIUM LARGE BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.411 SUP HCPCS C1713 408.411 - SCREW BONE 6.5MM 7.9MM 2.9MM 80MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.412 SUP HCPCS C1713 408.412 - SCREW BONE 6.5MM 7.9MM 2.9MM 85MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.413 SUP HCPCS C1713 408.413 - SCREW BONE 6.5MM 7.9MM 2.9MM 90MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.414 SUP HCPCS C1713 408.414 - SCREW BONE 6.5MM 7.9MM 2.9MM 95MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.415 SUP HCPCS C1713 408.415 - SCREW BONE 6.5MM 7.9MM 2.9MM 100MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.416 SUP HCPCS C1713 408.416 - SCREW BONE 6.5MM 7.9MM 2.9MM 105MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.417 SUP HCPCS C1713 408.417 - SCREW BONE 6.5MM 7.9MM 2.9MM 110MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.418 SUP HCPCS C1713 408.418 - SCREW BONE 6.5MM 7.9MM 2.9MM 115MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.419 SUP HCPCS C1713 408.419 - SCREW BONE 6.5MM 7.9MM 2.9MM 120MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.42 SUP HCPCS C1713 408.420 - SCREW BONE 6.5MM 7.9MM 2.9MM 125MM 16MM CANN TITANIUM LARGE BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.421 SUP HCPCS C1713 408.421 - SCREW BONE 6.5MM 7.9MM 2.9MM 130MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.422 SUP HCPCS C1713 408.422 - SCREW BONE 6.5MM 7.9MM 2.9MM 135MM 16MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.423 SUP HCPCS C1713 408.423 - SCREW BONE 6.5MM 140MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.424 SUP HCPCS C1713 408.424 - SCREW BONE 6.5MM 145MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.425 SUP HCPCS C1713 408.425 - SCREW BONE 6.5MM 150MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.426 SUP HCPCS C1713 408.426 - SCREW BONE 6.5MM 160MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.427 SUP HCPCS C1713 408.427 - SCREW BONE 6.5MM 170MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.428 SUP HCPCS C1713 408.428 - SCREW BONE 6.5MM 180MM 16MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.431 SUP HCPCS C1713 408.431 - SCREW BONE 6.5MM 45MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.432 SUP HCPCS C1713 408.432 - SCREW BONE 6.5MM 50MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.433 SUP HCPCS C1713 408.433 - SCREW BONE 6.5MM 55MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.434 SUP HCPCS C1713 408.434 - SCREW BONE 6.5MM 7.9MM 2.9MM 60MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.435 SUP HCPCS C1713 408.435 - SCREW BONE 6.5MM 7.9MM 2.9MM 65MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.436 SUP HCPCS C1713 408.436 - SCREW BONE 6.5MM 7.9MM 2.9MM 70MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.437 SUP HCPCS C1713 408.437 - SCREW BONE 6.5MM 7.9MM 2.9MM 75MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.438 SUP HCPCS C1713 408.438 - SCREW BONE 6.5MM 7.9MM 2.9MM 80MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.439 SUP HCPCS C1713 408.439 - SCREW BONE 6.5MM 7.9MM 2.9MM 85MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.44 SUP HCPCS C1713 408.440 - SCREW BONE 6.5MM 7.9MM 2.9MM 90MM 32MM CANN TITANIUM LARGE BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.441 SUP HCPCS C1713 408.441 - SCREW BONE 6.5MM 7.9MM 2.9MM 95MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.442 SUP HCPCS C1713 408.442 - SCREW BONE 6.5MM 7.9MM 2.9MM 100MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.443 SUP HCPCS C1713 408.443 - SCREW BONE 6.5MM 7.9MM 2.9MM 105MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.444 SUP HCPCS C1713 408.444 - SCREW BONE 6.5MM 7.9MM 2.9MM 110MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.445 SUP HCPCS C1713 408.445 - SCREW BONE 6.5MM 7.9MM 2.9MM 115MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.446 SUP HCPCS C1713 408.446 - SCREW BONE 6.5MM 7.9MM 2.9MM 120MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.447 SUP HCPCS C1713 408.447 - SCREW BONE 6.5MM 7.9MM 2.9MM 125MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.448 SUP HCPCS C1713 408.448 - SCREW BONE 6.5MM 7.9MM 2.9MM 130MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.449 SUP HCPCS C1713 408.449 - SCREW BONE 6.5MM 7.9MM 2.9MM 135MM 32MM CANN TITANIUM LARGE BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.45 SUP HCPCS C1713 408.450 - SCREW BONE 6.5MM 140MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.451 SUP HCPCS C1713 408.451 - SCREW BONE 6.5MM 145MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.452 SUP HCPCS C1713 408.452 - SCREW BONE 6.5MM 150MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.453 SUP HCPCS C1713 408.453 - SCREW BONE 6.5MM 160MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.454 SUP HCPCS C1713 408.454 - SCREW BONE 6.5MM 170MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.455 SUP HCPCS C1713 408.455 - SCREW BONE 6.5MM 180MM 32MM CANN TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.46 SUP HCPCS C1713 408.460 - SCREW BONE FULTHD 6.5MM 20MM CANN TITANIUM FEMUR TIBIA ANKLE BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.461 SUP HCPCS C1713 408.461 - SCREW BONE FULTHD 6.5MM 25MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.462 SUP HCPCS C1713 408.462 - SCREW BONE FULTHD 6.5MM 30MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.463 SUP HCPCS C1713 408.463 - SCREW BONE FULTHD 6.5MM 35MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.464 SUP HCPCS C1713 408.464 - SCREW BONE FULTHD 6.5MM 40MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.465 SUP HCPCS C1713 408.465 - SCREW BONE 6.5MM 45MM FULTHRD TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.466 SUP HCPCS C1713 408.466 - SCREW BONE FULTHD 6.5MM 50MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.467 SUP HCPCS C1713 408.467 - SCREW BONE FULTHD 6.5MM 55MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.468 SUP HCPCS C1713 408.468 - SCREW BONE FULTHD 6.5MM 60MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.469 SUP HCPCS C1713 408.469 - SCREW BONE FULTHD 6.5MM 65MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.47 SUP HCPCS C1713 408.470 - SCREW BONE FULTHD 6.5MM 70MM CANN TITANIUM FEMUR TIBIA ANKLE BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.471 SUP HCPCS C1713 408.471 - SCREW BONE FULTHD 6.5MM 75MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.472 SUP HCPCS C1713 408.472 - SCREW BONE FULTHD 6.5MM 80MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.473 SUP HCPCS C1713 408.473 - SCREW BONE FULTHD 6.5MM 85MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.474 SUP HCPCS C1713 408.474 - SCREW BONE FULTHD 6.5MM 90MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.475 SUP HCPCS C1713 408.475 - SCREW BONE FULTHD 6.5MM 95MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.476 SUP HCPCS C1713 408.476 - SCREW BONE FULTHD 6.5MM 100MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.477 SUP HCPCS C1713 408.477 - SCREW BONE FULTHD 6.5MM 105MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.478 SUP HCPCS C1713 408.478 - SCREW BONE FULTHD 6.5MM 110MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.479 SUP HCPCS C1713 408.479 - SCREW BONE FULTHD 6.5MM 115MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.48 SUP HCPCS C1713 408.480 - SCREW BONE FULTHD 6.5MM 120MM CANN TITANIUM FEMUR TIBIA BOTH IP/OP $472.20 $349.43 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $98.42 $350.47 $350.47 $0.00 $0.00 $98.41 $0.00 $279.31 $279.31 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.481 SUP HCPCS C1713 408.481 - SCREW BONE FULTHD 6.5MM 125MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.482 SUP HCPCS C1713 408.482 - SCREW BONE FULTHD 6.5MM 130MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 408.483 SUP HCPCS C1713 408.483 - SCREW BONE 6.5MM 140MM CANN FULTHD TITANIUM ORTHOPEDIC BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 408.484 SUP HCPCS C1713 408.484 - SCREW BONE FULTHD 6.5MM 150MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 408.485 SUP HCPCS C1713 408.485 - SCREW BONE FULTHD 6.5MM 160MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 408.486 SUP HCPCS C1713 408.486 - SCREW BONE FULTHD 6.5MM 170MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 408.487 SUP HCPCS C1713 408.487 - SCREW BONE FULTHD 6.5MM 180MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $501.83 $371.35 $0.00 $389.78 $219.25 $219.25 $0.00 $0.00 $0.00 $104.59 $372.45 $372.45 $0.00 $0.00 $104.58 $0.00 $296.83 $296.83 $0.00 $243.61 $385.89 $389.78 $0.00 $0.00 $74.03 $0.00 $0.00 $77.57 $0.00 $0.00 $0.00 $0.00 $0.00 408.83 SUP HCPCS C1713 408.830 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 30MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.835 SUP HCPCS C1713 408.835 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 35MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.84 SUP HCPCS C1713 408.840 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 40MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.845 SUP HCPCS C1713 408.845 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 45MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.85 SUP HCPCS C1713 408.850 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 50MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.855 SUP HCPCS C1713 408.855 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 55MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.86 SUP HCPCS C1713 408.860 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 60MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.865 SUP HCPCS C1713 408.865 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 65MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.87 SUP HCPCS C1713 408.870 - SCREW BONE 7.3MM 8.2MM 2.9MM 70MM 16MM CANN SELF TAP SELF BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.875 SUP HCPCS C1713 408.875 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 75MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.88 SUP HCPCS C1713 408.880 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 80MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.885 SUP HCPCS C1713 408.885 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 85MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.89 SUP HCPCS C1713 408.890 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 90MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.895 SUP HCPCS C1713 408.895 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 95MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.9 SUP HCPCS C1713 408.900 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 100MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.905 SUP HCPCS C1713 408.905 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 105MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.91 SUP HCPCS C1713 408.910 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 110MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.915 SUP HCPCS C1713 408.915 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 115MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.92 SUP HCPCS C1713 408.920 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 120MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.925 SUP HCPCS C1713 408.925 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 125MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.93 SUP HCPCS C1713 408.930 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 130MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.935 SUP HCPCS C1713 408.935 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 135MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.94 SUP HCPCS C1713 408.940 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 140MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.945 SUP HCPCS C1713 408.945 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 145MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 408.95 SUP HCPCS C1713 408.950 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 150MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.62 SUP HCPCS C1713 409.620 - SCREW BONE FULTHD 7.3MM 20MM CANN TITANIUM FEMUR TIBIA ANKLE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.625 SUP HCPCS C1713 409.625 - SCREW BONE FULTHD 7.3MM 25MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.63 SUP HCPCS C1713 409.630 - SCREW BONE FULTHD 7.3MM 30MM CANN TITANIUM FEMUR TIBIA ANKLE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.635 SUP HCPCS C1713 409.635 - SCREW BONE FULTHD 7.3MM 35MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.64 SUP HCPCS C1713 409.640 - SCREW BONE FULTHD 7.3MM 40MM CANN TITANIUM FEMUR TIBIA ANKLE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.645 SUP HCPCS C1713 409.645 - SCREW BONE FULTHD 7.3MM 45MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.65 SUP HCPCS C1713 409.650 - SCREW BONE FULTHD 7.3MM 50MM CANN TITANIUM FEMUR TIBIA ANKLE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.655 SUP HCPCS C1713 409.655 - SCREW BONE FULTHD 7.3MM 55MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.66 SUP HCPCS C1713 409.660 - SCREW BONE FULTHD 7.3MM 60MM CANN TITANIUM FEMUR TIBIA ANKLE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.665 SUP HCPCS C1713 409.665 - SCREW BONE FULTHD 7.3MM 65MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.67 SUP HCPCS C1713 409.670 - SCREW BONE FULTHD 7.3MM 70MM CANN TITANIUM FEMUR TIBIA ANKLE BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.675 SUP HCPCS C1713 409.675 - SCREW BONE FULTHD 7.3MM 8MM 2.9MM 75MM CANN SELF DRILL GOLD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.68 SUP HCPCS C1713 409.680 - SCREW BONE FULTHD 7.3MM 8.2MM 80MM CANN SLFDRILL SLFTAP BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.685 SUP HCPCS C1713 409.685 - SCREW BONE FULTHD 7.3MM 85MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.69 SUP HCPCS C1713 409.690 - SCREW BONE FULTHD 7.3MM 8MM 2.9MM 90MM CANN SELF DRILL GOLD BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.695 SUP HCPCS C1713 409.695 - SCREW BONE FULTHD 7.3MM 8MM 2.9MM 95MM CANN SELF DRILL GOLD BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.7 SUP HCPCS C1713 409.700 - SCREW BONE FULTHD 7.3MM 100MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.705 SUP HCPCS C1713 409.705 - SCREW BONE FULTHD 7.3MM 105MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.71 SUP HCPCS C1713 409.710 - SCREW BONE FULTHD 7.3MM 110MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.715 SUP HCPCS C1713 409.715 - SCREW BONE FULTHD 7.3MM 115MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.72 SUP HCPCS C1713 409.720 - SCREW BONE FULTHD 7.3MM 120MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.725 SUP HCPCS C1713 409.725 - SCREW BONE FULTHD 7.3MM 125MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.73 SUP HCPCS C1713 409.730 - SCREW BONE FULTHD 7.3MM 130MM CANN TITANIUM ORTHOPEDIC BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.845 SUP HCPCS C1713 409.845 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 45MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.85 SUP HCPCS C1713 409.850 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 50MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.855 SUP HCPCS C1713 409.855 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 55MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.86 SUP HCPCS C1713 409.860 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 60MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.865 SUP HCPCS C1713 409.865 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 65MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.87 SUP HCPCS C1713 409.870 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 70MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.875 SUP HCPCS C1713 409.875 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 75MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.88 SUP HCPCS C1713 409.880 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 80MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.885 SUP HCPCS C1713 409.885 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 85MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.89 SUP HCPCS C1713 409.890 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 90MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.895 SUP HCPCS C1713 409.895 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 95MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.9 SUP HCPCS C1713 409.900 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 100MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.905 SUP HCPCS C1713 409.905 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 105MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.91 SUP HCPCS C1713 409.910 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 110MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.915 SUP HCPCS C1713 409.915 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 115MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.92 SUP HCPCS C1713 409.920 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 120MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.925 SUP HCPCS C1713 409.925 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 125MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.93 SUP HCPCS C1713 409.930 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 130MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.935 SUP HCPCS C1713 409.935 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 135MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.94 SUP HCPCS C1713 409.940 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 140MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.945 SUP HCPCS C1713 409.945 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 145MM BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 409.95 SUP HCPCS C1713 409.950 - SCREW BONE LARGE HEXAGON HEMISPHERE 7.3MM 8.2MM 2.9MM 150MM BOTH IP/OP $469.48 $347.42 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $97.85 $348.44 $348.44 $0.00 $0.00 $97.84 $0.00 $277.69 $277.69 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 412.101 SUP HCPCS C1713 412.101 - SCREW BONE T15 FULTHD 3.5MM 10MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.102 SUP HCPCS C1713 412.102 - SCREW BONE T15 FULTHD 3.5MM 12MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.103 SUP HCPCS C1713 412.103 - SCREW BONE T15 FULTHD 3.5MM 14MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.104 SUP HCPCS C1713 412.104 - SCREW BONE T15 FULTHD 3.5MM 16MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.105 SUP HCPCS C1713 412.105 - SCREW BONE 3.5MM 5MM 18MM SELF TAP LOCK T15 STARDRIVE RECESS BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.106 SUP HCPCS C1713 412.106 - SCREW BONE T15 FULTHD 3.5MM 20MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.107 SUP HCPCS C1713 412.107 - SCREW BONE T15 FULTHD 3.5MM 22MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.108 SUP HCPCS C1713 412.108 - SCREW BONE 3.5MM 24MM SELF TAP LOCK STARDRIVE CONICAL HEAD BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.109 SUP HCPCS C1713 412.109 - SCREW BONE T15 FULTHD 3.5MM 26MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.11 SUP HCPCS C1713 412.110 - SCREW BONE T15 FULTHD 3.5MM 28MM SELF TAP STARDRIVE LCP BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.111 SUP HCPCS C1713 412.111 - SCREW BONE T15 FULTHD 3.5MM 30MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.112 SUP HCPCS C1713 412.112 - SCREW BONE T15 FULTHD 3.5MM 32MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.113 SUP HCPCS C1713 412.113 - SCREW BONE T15 FULTHD 3.5MM 34MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.114 SUP HCPCS C1713 412.114 - SCREW BONE T15 FULTHD 3.5MM 35MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.115 SUP HCPCS C1713 412.115 - SCREW BONE T15 FULTHD 3.5MM 36MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $44.32 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.116 SUP HCPCS C1713 412.116 - SCREW BONE T15 FULTHD 3.5MM 38MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.117 SUP HCPCS C1713 412.117 - SCREW BONE T15 FULTHD 3.5MM 40MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.118 SUP HCPCS C1713 412.118 - SCREW BONE T15 FULTHD 3.5MM 42MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.119 SUP HCPCS C1713 412.119 - SCREW BONE T15 FULTHD 3.5MM 45MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.12 SUP HCPCS C1713 412.120 - SCREW BONE T15 FULTHD 3.5MM 48MM SELF TAP STARDRIVE LCP BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.121 SUP HCPCS C1713 412.121 - SCREW BONE T15 FULTHD 3.5MM 50MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.122 SUP HCPCS C1713 412.122 - SCREW BONE T15 FULTHD 3.5MM 52MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.123 SUP HCPCS C1713 412.123 - SCREW BONE T15 FULTHD 3.5MM 55MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.124 SUP HCPCS C1713 412.124 - SCREW BONE T15 FULTHD 3.5MM 60MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.125 SUP HCPCS C1713 412.125 - SCREW BONE 3.5MM 65MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.126 SUP HCPCS C1713 412.126 - SCREW BONE T15 FULTHD 3.5MM 70MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.127 SUP HCPCS C1713 412.127 - SCREW BONE T15 FULTHD 3.5MM 75MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.128 SUP HCPCS C1713 412.128 - SCREW BONE T15 FULTHD 3.5MM 80MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.129 SUP HCPCS C1713 412.129 - SCREW BONE 3.5MM 85MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.13 SUP HCPCS C1713 412.130 - SCREW BONE 3.5MM 90MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.131 SUP HCPCS C1713 412.131 - SCREW BONE 3.5MM 95MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.134 SUP HCPCS C1713 412.134 - SCREW BONE T15 FULTHD 3.5MM 44MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.136 SUP HCPCS C1713 412.136 - SCREW BONE T15 FULTHD 3.5MM 46MM SELF TAP STARDRIVE LCP BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 412.201 SUP HCPCS C1713 412.201 - SCREW BONE T25 5MM 14MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.202 SUP HCPCS C1713 412.202 - SCREW BONE T25 5MM 16MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.203 SUP HCPCS C1713 412.203 - SCREW BONE T25 5MM 18MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.204 SUP HCPCS C1713 412.204 - SCREW BONE T25 5MM 20MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.205 SUP HCPCS C1713 412.205 - SCREW BONE T25 5MM 22MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.206 SUP HCPCS C1713 412.206 - SCREW BONE T25 5MM 24MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.207 SUP HCPCS C1713 412.207 - SCREW BONE T25 5MM 26MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.208 SUP HCPCS C1713 412.208 - SCREW BONE T25 5MM 28MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.209 SUP HCPCS C1713 412.209 - SCREW BONE T25 5MM 30MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.21 SUP HCPCS C1713 412.210 - SCREW BONE T25 5MM 32MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.211 SUP HCPCS C1713 412.211 - SCREW BONE T25 5MM 34MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.212 SUP HCPCS C1713 412.212 - SCREW BONE T25 5MM 36MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.213 SUP HCPCS C1713 412.213 - SCREW BONE T25 5MM 38MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.214 SUP HCPCS C1713 412.214 - SCREW BONE T25 5MM 40MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.215 SUP HCPCS C1713 412.215 - SCREW BONE 5MM 6.6MM 42MM LOCK T25 STARDRIVE RECESS LCP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.216 SUP HCPCS C1713 412.216 - SCREW BONE 5MM 44MM LOCKING SLFTAP T25 STARDRIVE RECESS LCP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.217 SUP HCPCS C1713 412.217 - SCREW BONE T25 5MM 46MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.218 SUP HCPCS C1713 412.218 - SCREW BONE 5MM 6.6MM 48MM LOCK SELF TAP T25 STARDRIVE LCP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.219 SUP HCPCS C1713 412.219 - SCREW BONE T25 5MM 50MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.22 SUP HCPCS C1713 412.220 - SCREW BONE T25 5MM 55MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.221 SUP HCPCS C1713 412.221 - SCREW BONE 5MM 60MM LOCKING SLFTAP T25 STARDRIVE RECESS LCP BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.222 SUP HCPCS C1713 412.222 - SCREW BONE T25 5MM 65MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.223 SUP HCPCS C1713 412.223 - SCREW BONE T25 5MM 70MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.224 SUP HCPCS C1713 412.224 - SCREW BONE T25 5MM 75MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.225 SUP HCPCS C1713 412.225 - SCREW BONE T25 5MM 80MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.226 SUP HCPCS C1713 412.226 - SCREW BONE T25 5MM 85MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.227 SUP HCPCS C1713 412.227 - SCREW BONE T25 5MM 90MM SELF TAP STARDRIVE LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 412.251 SUP HCPCS C1713 412.251 - SCREW BONE 5MM 51MM SLFDRILL LOCKING TITANIUM ORTHOPEDIC BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.252 SUP HCPCS C1713 412.252 - SCREW BONE 5MM 52MM SLFDRILL LOCKING TITANIUM ORTHOPEDIC BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.253 SUP HCPCS C1713 412.253 - SCREW BONE 5MM 53MM SLFDRILL LOCKING TITANIUM ORTHOPEDIC BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.254 SUP HCPCS C1713 412.254 - SCREW BONE 5MM 54MM SLFDRILL LOCKING TITANIUM ORTHOPEDIC BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.255 SUP HCPCS C1713 412.255 - SCREW BONE 5MM 55MM SLFDRILL LOCKING TITANIUM ORTHOPEDIC BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.256 SUP HCPCS C1713 412.256 - SCREW BONE 5MM 56MM SLFDRILL LOCKING TITANIUM ORTHOPEDIC BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.257 SUP HCPCS C1713 412.257 - SCREW BONE 5MM 40MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.258 SUP HCPCS C1713 412.258 - SCREW BONE 5MM 45MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.259 SUP HCPCS C1713 412.259 - SCREW BONE 5MM 50MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.26 SUP HCPCS C1713 412.260 - SCREW BONE 5MM 55MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.261 SUP HCPCS C1713 412.261 - SCREW BONE 5MM 60MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.262 SUP HCPCS C1713 412.262 - SCREW BONE 5MM 65MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.263 SUP HCPCS C1713 412.263 - SCREW BONE 5MM 70MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.264 SUP HCPCS C1713 412.264 - SCREW BONE 5MM 75MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.265 SUP HCPCS C1713 412.265 - SCREW BONE 5MM 80MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.266 SUP HCPCS C1713 412.266 - SCREW BONE 5MM 85MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.267 SUP HCPCS C1713 412.267 - SCREW BONE 5MM 90MM SLFDRILL LOCKING STARDRIVE RECESS LISS BOTH IP/OP $385.58 $285.33 $0.00 $308.46 $173.51 $173.51 $0.00 $0.00 $0.00 $80.36 $286.17 $286.17 $0.00 $0.00 $80.35 $0.00 $228.07 $228.07 $0.00 $192.79 $305.38 $308.46 $0.00 $0.00 $60.34 $0.00 $0.00 $61.38 $0.00 $0.00 $0.00 $0.00 $0.00 412.317 SUP HCPCS C1713 412.317 - SCREW BONE FULTHD 3.5MM 40MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.319 SUP HCPCS C1713 412.319 - SCREW BONE FULTHD 3.5MM 45MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.321 SUP HCPCS C1713 412.321 - SCREW BONE FULTHD 3.5MM 50MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.323 SUP HCPCS C1713 412.323 - SCREW BONE FULTHD 3.5MM 55MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.324 SUP HCPCS C1713 412.324 - SCREW BONE FULTHD 3.5MM 60MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.325 SUP HCPCS C1713 412.325 - SCREW BONE FULTHD 3.5MM 65MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.326 SUP HCPCS C1713 412.326 - SCREW BONE FULTHD 3.5MM 70MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.327 SUP HCPCS C1713 412.327 - SCREW BONE FULTHD 3.5MM 75MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.328 SUP HCPCS C1713 412.328 - SCREW BONE FULTHD 3.5MM 80MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.329 SUP HCPCS C1713 412.329 - SCREW BONE FULTHD 3.5MM 85MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.33 SUP HCPCS C1713 412.330 - SCREW BONE FULTHD 3.5MM 90MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $249.75 $184.82 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $52.05 $185.36 $185.36 $0.00 $0.00 $52.05 $0.00 $147.73 $147.73 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.331 SUP HCPCS C1713 412.331 - SCREW BONE FULTHD 3.5MM 95MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.417 SUP HCPCS C1713 412.417 - SCREW BONE 3.5MM 40MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.419 SUP HCPCS C1713 412.419 - SCREW BONE 3.5MM 45MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.421 SUP HCPCS C1713 412.421 - SCREW BONE 3.5MM 50MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.423 SUP HCPCS C1713 412.423 - SCREW BONE 3.5MM 55MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.424 SUP HCPCS C1713 412.424 - SCREW BONE 3.5MM 60MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $264.28 $195.57 $0.00 $205.26 $115.46 $115.46 $0.00 $0.00 $0.00 $55.08 $196.14 $196.14 $0.00 $0.00 $55.07 $0.00 $156.32 $156.32 $0.00 $128.29 $203.21 $205.26 $0.00 $0.00 $38.98 $0.00 $0.00 $40.85 $0.00 $0.00 $0.00 $0.00 $0.00 412.425 SUP HCPCS C1713 412.425 - SCREW BONE 3.5MM 65MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.426 SUP HCPCS C1713 412.426 - SCREW BONE 3.5MM 70MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.427 SUP HCPCS C1713 412.427 - SCREW BONE 3.5MM 75MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.428 SUP HCPCS C1713 412.428 - SCREW BONE 3.5MM 80MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.429 SUP HCPCS C1713 412.429 - SCREW BONE 3.5MM 85MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.43 SUP HCPCS C1713 412.430 - SCREW BONE PTHRD 3.5MM 90MM SLFTAP CONICAL STARDRIVE RECESS BOTH IP/OP $249.75 $184.82 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $52.05 $185.36 $185.36 $0.00 $0.00 $52.05 $0.00 $147.73 $147.73 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.431 SUP HCPCS C1713 412.431 - SCREW BONE 3.5MM 95MM SLFTAP CONICAL STARDRIVE RECESS PTHRD BOTH IP/OP $257.25 $190.37 $0.00 $199.80 $112.39 $112.39 $0.00 $0.00 $0.00 $53.62 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $152.16 $152.16 $0.00 $124.88 $197.80 $199.80 $0.00 $0.00 $37.95 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $0.00 412.806 SUP HCPCS C1713 412.806 - SCREW BONE 2.4MM 6MM T8 STARDRIVE RECESS SLFTAP LOCKING BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.807 SUP HCPCS C1713 412.807 - SCREW BONE 2.4MM 7MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.808 SUP HCPCS C1713 412.808 - SCREW BONE 2.4MM 8MM T8 STARDRIVE RECESS SLFTAP LOCKING BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.809 SUP HCPCS C1713 412.809 - SCREW BONE 2.4MM 9MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.81 SUP HCPCS C1713 412.810 - SCREW BONE T8 CONE 2.4MM 10MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $212.90 $157.55 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $44.37 $158.01 $158.01 $0.00 $0.00 $44.37 $0.00 $125.93 $125.93 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.811 SUP HCPCS C1713 412.811 - SCREW BONE T8 CONE 2.4MM 11MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.812 SUP HCPCS C1713 412.812 - SCREW BONE T8 CONE 2.4MM 12MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.813 SUP HCPCS C1713 412.813 - SCREW BONE 2.4MM 13MM SLFTAP LOCKING LCP TITANIUM ORTHOPEDIC BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.814 SUP HCPCS C1713 412.814 - SCREW BONE T8 CONE 2.4MM 14MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.816 SUP HCPCS C1713 412.816 - SCREW BONE T8 CONE 2.4MM 16MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.818 SUP HCPCS C1713 412.818 - SCREW BONE T8 CONE 2.4MM 18MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.82 SUP HCPCS C1713 412.820 - SCREW BONE T8 CONE 2.4MM 20MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $212.90 $157.55 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $44.37 $158.01 $158.01 $0.00 $0.00 $44.37 $0.00 $125.93 $125.93 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.822 SUP HCPCS C1713 412.822 - SCREW BONE T8 CONE 2.4MM 22MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.824 SUP HCPCS C1713 412.824 - SCREW BONE T8 CONE 2.4MM 24MM SELF TAP THREAD STARDRIVE LCP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.826 SUP HCPCS C1713 412.826 - SCREW BONE 2.4MM 1.9MM 26MM T8 STARDRIVE RECESS SLFTAP BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.828 SUP HCPCS C1713 412.828 - SCREW BONE 2.4MM 28MM T8 STARDRIVE RECESS SLFTAP LOCKING BOTH IP/OP $219.30 $162.28 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $45.71 $162.76 $162.76 $0.00 $0.00 $45.70 $0.00 $129.72 $129.72 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 412.83 SUP HCPCS C1713 412.830 - SCREW BONE 2.4MM 30MM T8 STARDRIVE RECESS SLFTAP LOCKING BOTH IP/OP $212.90 $157.55 $0.00 $170.32 $95.81 $95.81 $0.00 $0.00 $0.00 $44.37 $158.01 $158.01 $0.00 $0.00 $44.37 $0.00 $125.93 $125.93 $0.00 $106.45 $168.62 $170.32 $0.00 $0.00 $32.35 $0.00 $0.00 $33.89 $0.00 $0.00 $0.00 $0.00 $0.00 413.309 SUP HCPCS C1776 413.309 - SPACER TIBIAL 2MM 5MM 5MM TOMOFIX CHRONOS TITANIUM KNEE BOTH IP/OP $182.75 $135.24 $0.00 $141.94 $79.84 $79.84 $0.00 $0.00 $0.00 $38.09 $135.64 $135.64 $0.00 $0.00 $38.09 $0.00 $108.10 $108.10 $0.00 $88.71 $140.52 $141.94 $0.00 $0.00 $26.96 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 413.324 SUP HCPCS C1713 413.324 - SCREW BONE 5MM 24MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.326 SUP HCPCS C1713 413.326 - SCREW BONE 5MM 26MM SLFTAP LOCKING HEAD TITANIUM NONSTRL BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.328 SUP HCPCS C1713 413.328 - SCREW BONE 5MM 28MM LOCKING SLFTAP HEX DRIVE TITANIUM FEMUR BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.33 SUP HCPCS C1713 413.330 - SCREW BONE 5MM 30MM SLFTAP LOCKING HEAD TOMOFIX TITANIUM BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.332 SUP HCPCS C1713 413.332 - SCREW BONE 5MM 32MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.334 SUP HCPCS C1713 413.334 - SCREW BONE 5MM 34MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.336 SUP HCPCS C1713 413.336 - SCREW BONE 5MM 36MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.338 SUP HCPCS C1713 413.338 - SCREW BONE 5MM 38MM SLFTAP LOCKING HEAD TOMOFIX TITANIUM SPN BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.34 SUP HCPCS C1713 413.340 - SCREW BONE 5MM 40MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.342 SUP HCPCS C1713 413.342 - SCREW BONE 5MM 42MM SLFTAP LOCKING HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.344 SUP HCPCS C1713 413.344 - SCREW BONE 5MM 44MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.346 SUP HCPCS C1713 413.346 - SCREW BONE 5MM 46MM SLFTAP LOCKING HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.348 SUP HCPCS C1713 413.348 - SCREW BONE 5MM 48MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.35 SUP HCPCS C1713 413.350 - SCREW BONE 5MM 50MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.355 SUP HCPCS C1713 413.355 - SCREW BONE 5MM 55MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.36 SUP HCPCS C1713 413.360 - SCREW BONE 5MM 60MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.365 SUP HCPCS C1713 413.365 - SCREW BONE 5MM 65MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.37 SUP HCPCS C1713 413.370 - SCREW BONE 5MM 70MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.375 SUP HCPCS C1713 413.375 - SCREW BONE 5MM 75MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.38 SUP HCPCS C1713 413.380 - SCREW BONE 5MM 80MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.385 SUP HCPCS C1713 413.385 - SCREW BONE 5MM 85MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.39 SUP HCPCS C1713 413.390 - SCREW BONE 5MM 90MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.414 SUP HCPCS C1713 413.414 - SCREW BONE 5MM 14MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.418 SUP HCPCS C1713 413.418 - SCREW BONE 5MM 18MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.422 SUP HCPCS C1713 413.422 - SCREW BONE 5MM 22MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.426 SUP HCPCS C1713 413.426 - SCREW BONE 5MM 26MM SELF TAP LOCK HEAD TOMOFIX TITANIUM BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 413.43 SUP HCPCS C1713 413.430 - SCREW BONE 5MM 30MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.435 SUP HCPCS C1713 413.435 - SCREW BONE 5MM 35MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.44 SUP HCPCS C1713 413.440 - SCREW BONE 5MM 40MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.445 SUP HCPCS C1713 413.445 - SCREW BONE 5MM 45MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.45 SUP HCPCS C1713 413.450 - SCREW BONE 5MM 50MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.455 SUP HCPCS C1713 413.455 - SCREW BONE 5MM 55MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.46 SUP HCPCS C1713 413.460 - SCREW BONE 5MM 60MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.465 SUP HCPCS C1713 413.465 - SCREW BONE 5MM 65MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.47 SUP HCPCS C1713 413.470 - SCREW BONE 5MM 70MM SLFDRILL LOCKING LISS TITANIUM FEMUR BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.475 SUP HCPCS C1713 413.475 - SCREW BONE 5MM 75MM SLFDRILL LOCKING TITANIUM FEMUR DISTAL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.48 SUP HCPCS C1713 413.480 - SCREW BONE 5MM 80MM SLFDRILL LOCKING TITANIUM FEMUR DISTAL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.485 SUP HCPCS C1713 413.485 - SCREW BONE 5MM 85MM SLFDRILL LOCKING TITANIUM FEMUR DISTAL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 413.49 SUP HCPCS C1713 413.490 - SCREW BONE 5MM 90MM SLFDRILL LOCKING TITANIUM FEMUR DISTAL BOTH IP/OP $378.95 $280.42 $0.00 $303.16 $170.53 $170.53 $0.00 $0.00 $0.00 $78.98 $281.26 $281.26 $0.00 $0.00 $78.97 $0.00 $224.15 $224.15 $0.00 $189.48 $300.13 $303.16 $0.00 $0.00 $59.31 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.014 SUP HCPCS C1713 414.014 - SCREW BONE 4.5MM 14MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.016 SUP HCPCS C1713 414.016 - SCREW BONE 4.5MM 8MM 16MM HEXAGONAL SOCKET LC-DCP TITANIUM BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.018 SUP HCPCS C1713 414.018 - SCREW BONE 4.5MM 18MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.02 SUP HCPCS C1713 414.020 - SCREW BONE STANDARD 4.5MM 8MM 20MM LARGE HEXAGONAL SOCKET BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.022 SUP HCPCS C1713 414.022 - SCREW BONE 4.5MM 8MM 22MM HEXAGONAL SOCKET LC-DCP TITANIUM BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.024 SUP HCPCS C1713 414.024 - SCREW BONE 4.5MM 24MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.026 SUP HCPCS C1713 414.026 - SCREW BONE 4.5MM 26MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.028 SUP HCPCS C1713 414.028 - SCREW BONE 4.5MM 28MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.03 SUP HCPCS C1713 414.030 - SCREW BONE 4.5MM 30MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.032 SUP HCPCS C1713 414.032 - SCREW BONE 3.5MM STANDARD 4.5MM 8MM 32MM LARGE HEXAGONAL BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.034 SUP HCPCS C1713 414.034 - SCREW BONE 4.5MM 34MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.036 SUP HCPCS C1713 414.036 - SCREW BONE STANDARD 4.5MM 8MM 14MM LARGE HEXAGONAL SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.038 SUP HCPCS C1713 414.038 - SCREW BONE 4.5MM 38MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.04 SUP HCPCS C1713 414.040 - SCREW BONE 3.5MM STANDARD 4.5MM 8MM 26MM LARGE HEXAGONAL BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.042 SUP HCPCS C1713 414.042 - SCREW BONE 3.5MM STANDARD 4.5MM 8MM 42MM LARGE HEXAGONAL BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.044 SUP HCPCS C1713 414.044 - SCREW BONE 3MM STANDARD 4.5MM 8MM 44X3.5MM HEXAGONAL SOCKET BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.046 SUP HCPCS C1713 414.046 - SCREW BONE 4.5MM 46MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.048 SUP HCPCS C1713 414.048 - SCREW BONE 4.5MM 48MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.05 SUP HCPCS C1713 414.050 - SCREW BONE 3.5MM STANDARD 4.5MM 8MM 50MM LARGE HEXAGONAL BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.052 SUP HCPCS C1713 414.052 - SCREW BONE 3.5MM STANDARD 4.5MM 8MM 52MM LARGE HEXAGONAL BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.054 SUP HCPCS C1713 414.054 - SCREW BONE 4.5MM 54MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.056 SUP HCPCS C1713 414.056 - SCREW BONE 4.5MM 56MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.058 SUP HCPCS C1713 414.058 - SCREW BONE STANDARD LARGE HEXAGON 4.5MM 8MM 14MM SOCKET BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.06 SUP HCPCS C1713 414.060 - SCREW BONE 4.5MM 60MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.062 SUP HCPCS C1713 414.062 - SCREW BONE 4.5MM 62MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.064 SUP HCPCS C1713 414.064 - SCREW BONE 4.5MM 64MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.066 SUP HCPCS C1713 414.066 - SCREW BONE 4.5MM 66MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.068 SUP HCPCS C1713 414.068 - SCREW BONE 4.5MM 68MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $30.55 $22.61 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.37 $22.67 $22.67 $0.00 $0.00 $6.37 $0.00 $18.07 $18.07 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.07 SUP HCPCS C1713 414.070 - SCREW BONE STANDARD 4.5MM 8MM 70MM LARGE HEXAGONAL SOCKET BOTH IP/OP $29.68 $21.96 $0.00 $23.74 $13.35 $13.35 $0.00 $0.00 $0.00 $6.19 $22.02 $22.02 $0.00 $0.00 $6.18 $0.00 $17.55 $17.55 $0.00 $14.84 $23.51 $23.74 $0.00 $0.00 $4.51 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 414.072 SUP HCPCS C1713 414.072 - SCREW BONE 4.5MM 72MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $12.96 $12.96 $0.00 $0.00 $0.00 $6.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $17.04 $17.04 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 414.076 SUP HCPCS C1713 414.076 - SCREW BONE 4.5MM 76MM SLFTAP LC-DCP TITANIUM CORTICAL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.08 SUP HCPCS C1713 414.080 - SCREW BONE 4.5MM 80MM LC DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.085 SUP HCPCS C1713 414.085 - SCREW BONE 3.5MM 85MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.09 SUP HCPCS C1713 414.090 - SCREW BONE 4.5MM 90MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.095 SUP HCPCS C1713 414.095 - SCREW BONE 4.5MM 95MM LC-DCP TITANIUM CORTICAL NONSTRL LARGE BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.1 SUP HCPCS C1713 414.100 - SCREW BONE 4.5MM 100MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.105 SUP HCPCS C1713 414.105 - SCREW BONE 4.5MM 105MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.11 SUP HCPCS C1713 414.110 - SCREW BONE 4.5MM 110MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.115 SUP HCPCS C1713 414.115 - SCREW BONE 4.5MM 115MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.12 SUP HCPCS C1713 414.120 - SCREW BONE 4.5MM 120MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.125 SUP HCPCS C1713 414.125 - SCREW BONE 4.5MM 125MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.13 SUP HCPCS C1713 414.130 - SCREW BONE 4.5MM 130MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.135 SUP HCPCS C1713 414.135 - SCREW BONE 4.5MM 135MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.14 SUP HCPCS C1713 414.140 - SCREW BONE 4.5MM 140MM LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $46.70 $34.56 $0.00 $37.36 $21.02 $21.02 $0.00 $0.00 $0.00 $9.73 $34.66 $34.66 $0.00 $0.00 $9.73 $0.00 $27.62 $27.62 $0.00 $23.35 $36.99 $37.36 $0.00 $0.00 $7.31 $0.00 $0.00 $7.43 $0.00 $0.00 $0.00 $0.00 $0.00 414.222 SUP HCPCS C1713 414.222 - SCREW BONE 4.5MM 22MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 414.224 SUP HCPCS C1713 414.224 - SCREW BONE 4.5MM 24CM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 414.226 SUP HCPCS C1713 414.226 - SCREW BONE 4.5MM 26MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 414.228 SUP HCPCS C1713 414.228 - SCREW BONE 4.5MM 28MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 414.23 SUP HCPCS C1713 414.230 - SCREW BONE 4.5MM 30MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 414.232 SUP HCPCS C1713 414.232 - SCREW BONE 4.5MM 32MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $31.03 $22.96 $0.00 $24.82 $13.96 $13.96 $0.00 $0.00 $0.00 $6.47 $23.03 $23.03 $0.00 $0.00 $6.47 $0.00 $18.35 $18.35 $0.00 $15.51 $24.58 $24.82 $0.00 $0.00 $4.71 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 414.234 SUP HCPCS C1713 414.234 - SCREW BONE 4.5MM 34MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $31.03 $22.96 $0.00 $24.82 $13.96 $13.96 $0.00 $0.00 $0.00 $6.47 $23.03 $23.03 $0.00 $0.00 $6.47 $0.00 $18.35 $18.35 $0.00 $15.51 $24.58 $24.82 $0.00 $0.00 $4.71 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 414.236 SUP HCPCS C1713 414.236 - SCREW BONE 4.5MM 36MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $31.03 $22.96 $0.00 $24.82 $13.96 $13.96 $0.00 $0.00 $0.00 $6.47 $23.03 $23.03 $0.00 $0.00 $6.47 $0.00 $18.35 $18.35 $0.00 $15.51 $24.58 $24.82 $0.00 $0.00 $4.71 $0.00 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 414.238 SUP HCPCS C1713 414.238 - SCREW BONE 4.5MM 38MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 414.24 SUP HCPCS C1713 414.240 - SCREW BONE 3.5MM 40MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $13.56 $13.56 $0.00 $0.00 $0.00 $6.28 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $17.82 $17.82 $0.00 $15.06 $23.86 $24.10 $0.00 $0.00 $4.71 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 414.242 SUP HCPCS C1713 414.242 - SCREW BONE 4.5MM 42MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.244 SUP HCPCS C1713 414.244 - SCREW BONE 4.5MM 44MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.246 SUP HCPCS C1713 414.246 - SCREW BONE 4.5MM 46MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $34.45 $25.49 $0.00 $27.56 $15.50 $15.50 $0.00 $0.00 $0.00 $7.18 $25.57 $25.57 $0.00 $0.00 $7.18 $0.00 $20.38 $20.38 $0.00 $17.23 $27.28 $27.56 $0.00 $0.00 $5.23 $0.00 $0.00 $5.48 $0.00 $0.00 $0.00 $0.00 $0.00 414.248 SUP HCPCS C1713 414.248 - SCREW BONE 4.5MM 48MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $34.45 $25.49 $0.00 $27.56 $15.50 $15.50 $0.00 $0.00 $0.00 $7.18 $25.57 $25.57 $0.00 $0.00 $7.18 $0.00 $20.38 $20.38 $0.00 $17.23 $27.28 $27.56 $0.00 $0.00 $5.23 $0.00 $0.00 $5.48 $0.00 $0.00 $0.00 $0.00 $0.00 414.25 SUP HCPCS C1713 414.250 - SCREW BONE 4.5MM 50MM LC-DCP TITANIUM FEMUR MEDIAL PROXIMAL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.252 SUP HCPCS C1713 414.252 - SCREW BONE 4.5MM 52MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $34.45 $25.49 $0.00 $27.56 $15.50 $15.50 $0.00 $0.00 $0.00 $7.18 $25.57 $25.57 $0.00 $0.00 $7.18 $0.00 $20.38 $20.38 $0.00 $17.23 $27.28 $27.56 $0.00 $0.00 $5.23 $0.00 $0.00 $5.48 $0.00 $0.00 $0.00 $0.00 $0.00 414.254 SUP HCPCS C1713 414.254 - SCREW BONE 4.5MM 54MM SHAFT LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.256 SUP HCPCS C1713 414.256 - SCREW BONE 4.5MM 56MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $34.45 $25.49 $0.00 $27.56 $15.50 $15.50 $0.00 $0.00 $0.00 $7.18 $25.57 $25.57 $0.00 $0.00 $7.18 $0.00 $20.38 $20.38 $0.00 $17.23 $27.28 $27.56 $0.00 $0.00 $5.23 $0.00 $0.00 $5.48 $0.00 $0.00 $0.00 $0.00 $0.00 414.258 SUP HCPCS C1713 414.258 - SCREW BONE 4.5MM 58MM SHAFT LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.26 SUP HCPCS C1713 414.260 - SCREW BONE 4.5MM 60MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.264 SUP HCPCS C1713 414.264 - SCREW BONE 4.5MM 64MM 20MM PTTHRD SHAFT LC-DCP TITANIUM BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.268 SUP HCPCS C1713 414.268 - SCREW BONE 4.5MM 68MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.272 SUP HCPCS C1713 414.272 - SCREW BONE 4.5MM 72MM SHAFT LCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $33.45 $24.75 $0.00 $26.76 $15.05 $15.05 $0.00 $0.00 $0.00 $6.97 $24.83 $24.83 $0.00 $0.00 $6.97 $0.00 $19.79 $19.79 $0.00 $16.73 $26.49 $26.76 $0.00 $0.00 $5.23 $0.00 $0.00 $5.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.276 SUP HCPCS C1713 414.276 - SCREW BONE 4.5MM 76MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.28 SUP HCPCS C1713 414.280 - SCREW BONE 4.5MM 80MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.285 SUP HCPCS C1713 414.285 - SCREW BONE 4.5MM 85MM SHAFT LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.29 SUP HCPCS C1713 414.290 - SCREW BONE 4.5MM 90MM SHAFT LC-DCP TITANIUM CORTICAL NONSTRL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.295 SUP HCPCS C1713 414.295 - SCREW BONE 4.5MM 95MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.3 SUP HCPCS C1713 414.300 - SCREW BONE 4.5MM 100MM SHAFT LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.305 SUP HCPCS C1713 414.305 - SCREW BONE 4.5MM 105MM SHAFT LC-DCP TITANIUM SHAFT NONSTRL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.31 SUP HCPCS C1713 414.310 - SCREW BONE 4.5MM 110MM SHAAFT LC-DCP TITANIUM CORTICAL BOTH IP/OP $39.75 $29.42 $0.00 $31.80 $17.89 $17.89 $0.00 $0.00 $0.00 $8.28 $29.50 $29.50 $0.00 $0.00 $8.28 $0.00 $23.51 $23.51 $0.00 $19.88 $31.48 $31.80 $0.00 $0.00 $6.22 $0.00 $0.00 $6.33 $0.00 $0.00 $0.00 $0.00 $0.00 414.52 SUP HCPCS C1713 414.520 - SCREW BONE 1/3 THREAD LARGE HEXAGON HEMISPHERE REVERSE CUT BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.522 SUP HCPCS C1713 414.522 - SCREW BONE 1/3 THREAD 4.5MM 6.5MM 22MM CANN LARGE HEXAGONAL BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.524 SUP HCPCS C1713 414.524 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.526 SUP HCPCS C1713 414.526 - SCREW BONE 1/3 THREAD 4.5MM 6.5MM 26MM CANN LARGE HEXAGONAL BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.528 SUP HCPCS C1713 414.528 - SCREW BONE 1/3 THREAD 4.5MM 6.5MM 28MM CANN LARGE HEXAGONAL BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.53 SUP HCPCS C1713 414.530 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.532 SUP HCPCS C1713 414.532 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.534 SUP HCPCS C1713 414.534 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.536 SUP HCPCS C1713 414.536 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.538 SUP HCPCS C1713 414.538 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.54 SUP HCPCS C1713 414.540 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.542 SUP HCPCS C1713 414.542 - SCREW BONE 1/3 THREAD 4.5MM 6.5MM 42MM CANN LARGE HEXAGONAL BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.544 SUP HCPCS C1713 414.544 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.546 SUP HCPCS C1713 414.546 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.548 SUP HCPCS C1713 414.548 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.55 SUP HCPCS C1713 414.550 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.552 SUP HCPCS C1713 414.552 - SCREW BONE 1/3 THREAD 4.5MM 6.5MM 52MM CANN LARGE HEXAGONAL BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.554 SUP HCPCS C1713 414.554 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.556 SUP HCPCS C1713 414.556 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.56 SUP HCPCS C1713 414.560 - SCREW BONE 1/3 THREAD 4.5MM 6.5MM 60MM CANN LARGE HEXAGONAL BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.564 SUP HCPCS C1713 414.564 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.568 SUP HCPCS C1713 414.568 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.572 SUP HCPCS C1713 414.572 - SCREW BONE SHORT THREAD REVERSE CUT FLUTE 4.5MM 6.5MM 1.7MM BOTH IP/OP $376.73 $278.78 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $78.52 $279.61 $279.61 $0.00 $0.00 $78.51 $0.00 $222.83 $222.83 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $55.57 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 414.576 SUP HCPCS C1713 414.576 - SCREW BONE PTHRD 4.5MM 76MM CANN TITANIUM NONSTRL BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.58 SUP HCPCS C1713 414.580 - SCREW BONE PTHRD 4.5MM 80MM CANN TITANIUM NONSTRL BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.72 SUP HCPCS C1713 414.720 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 20MM CANN TITANIUM BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.722 SUP HCPCS C1713 414.722 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 22MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.724 SUP HCPCS C1713 414.724 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 24MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.726 SUP HCPCS C1713 414.726 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 26MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.728 SUP HCPCS C1713 414.728 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 28MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.73 SUP HCPCS C1713 414.730 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 30MM CANN TITANIUM BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.732 SUP HCPCS C1713 414.732 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 32MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.734 SUP HCPCS C1713 414.734 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 34MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.736 SUP HCPCS C1713 414.736 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 36MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.738 SUP HCPCS C1713 414.738 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 38MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.74 SUP HCPCS C1713 414.740 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 40MM CANN TITANIUM BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.742 SUP HCPCS C1713 414.742 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 42MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.744 SUP HCPCS C1713 414.744 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 44MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.746 SUP HCPCS C1713 414.746 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 46MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.748 SUP HCPCS C1713 414.748 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 48MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.75 SUP HCPCS C1713 414.750 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 50MM CANN TITANIUM BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.752 SUP HCPCS C1713 414.752 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 52MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.754 SUP HCPCS C1713 414.754 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 54MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.756 SUP HCPCS C1713 414.756 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 56MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.76 SUP HCPCS C1713 414.760 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 60MM CANN TITANIUM BOTH IP/OP $376.68 $278.74 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $78.51 $279.57 $279.57 $0.00 $0.00 $78.50 $0.00 $222.80 $222.80 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.764 SUP HCPCS C1713 414.764 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 64MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.768 SUP HCPCS C1713 414.768 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 68MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.772 SUP HCPCS C1713 414.772 - SCREW BONE FULTHD 4.5MM 6.5MM 1.75MM 72MM CANN TITANIUM BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.776 SUP HCPCS C1713 414.776 - SCREW BONE FULTHD 4.5MM 76MM CANN TITANIUM NONSTRL BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.777 SUP HCPCS C1713 414.777 - SCREW BONE FULTHD 4.5MM 77MM CANN TITANIUM NONSTRL BOTH IP/OP $387.98 $287.11 $0.00 $301.34 $169.50 $169.50 $0.00 $0.00 $0.00 $80.86 $287.96 $287.96 $0.00 $0.00 $80.85 $0.00 $229.49 $229.49 $0.00 $188.34 $298.33 $301.34 $0.00 $0.00 $57.23 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 414.814 SUP HCPCS C1713 414.814 - SCREW BONE 4.5MM 8MM 14MM LARGE HEXAGONAL SOCKET SELF TAP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.816 SUP HCPCS C1713 414.816 - SCREW BONE 4.5MM 8MM 16MM LARGE HEXAGONAL SOCKET SELF TAP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.818 SUP HCPCS C1713 414.818 - SCREW BONE 4.5MM 8MM 18MM HEXAGONAL SOCKET SELF TAP TIP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.82 SUP HCPCS C1713 414.820 - SCREW BONE 4.5MM 8MM 20MM LARGE HEXAGONAL SOCKET SELF TAP BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.822 SUP HCPCS C1713 414.822 - SCREW BONE 4.5MM 8MM 22MM HEXAGONAL SOCKET SELF TAP TIP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.824 SUP HCPCS C1713 414.824 - SCREW BONE 4.5MM 8MM 24MM HEXAGONAL SOCKET SELF TAP TIP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.826 SUP HCPCS C1713 414.826 - SCREW BONE 4.5MM 8MM 26MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.828 SUP HCPCS C1713 414.828 - SCREW BONE 4.5MM 8MM 28MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.83 SUP HCPCS C1713 414.830 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 30MM SELF TAP SOCKET BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.832 SUP HCPCS C1713 414.832 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 32MM SELF TAP SOCKET BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.834 SUP HCPCS C1713 414.834 - SCREW BONE 4.5MM 8MM 34MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.836 SUP HCPCS C1713 414.836 - SCREW BONE LARGE HEXAGON 4.5MM 8MM 36MM SELF TAP SOCKET BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.838 SUP HCPCS C1713 414.838 - SCREW BONE 4.5MM 8MM 38MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.84 SUP HCPCS C1713 414.840 - SCREW BONE 4.5MM 8MM 40MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.842 SUP HCPCS C1713 414.842 - SCREW BONE 4.5MM 8MM 42MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.844 SUP HCPCS C1713 414.844 - SCREW BONE 4.5MM 8MM 44MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.846 SUP HCPCS C1713 414.846 - SCREW BONE 4.5MM 8MM 46MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.848 SUP HCPCS C1713 414.848 - SCREW BONE 4.5MM 48MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.85 SUP HCPCS C1713 414.850 - SCREW BONE 4.5MM 50MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.852 SUP HCPCS C1713 414.852 - SCREW BONE 4.5MM 52MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.854 SUP HCPCS C1713 414.854 - SCREW BONE 4.5MM 54MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.856 SUP HCPCS C1713 414.856 - SCREW BONE 4.5MM 56MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.858 SUP HCPCS C1713 414.858 - SCREW BONE 4.5MM 58MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.86 SUP HCPCS C1713 414.860 - SCREW BONE 4.5MM 8MM 60MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.862 SUP HCPCS C1713 414.862 - SCREW BONE 4.5MM 62MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.864 SUP HCPCS C1713 414.864 - SCREW BONE 4.5MM 64MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.866 SUP HCPCS C1713 414.866 - SCREW BONE 4.5MM 8MM 66MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.868 SUP HCPCS C1713 414.868 - SCREW BONE 4.5MM 8MM 68MM HEXAGONAL SOCKET SELF TAP LC-DCP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.87 SUP HCPCS C1713 414.870 - SCREW BONE 4.5MM 70MM SELF TAP LCP TITANIUM CORTEX LARGE BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.872 SUP HCPCS C1713 414.872 - SCREW BONE 4.5MM 8MM 72MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $40.05 $29.64 $0.00 $31.10 $17.49 $17.49 $0.00 $0.00 $0.00 $8.35 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $23.69 $23.69 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $5.91 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 414.876 SUP HCPCS C1713 414.876 - SCREW BONE 4.5MM 8MM 76MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $63.95 $47.32 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $13.33 $47.46 $47.46 $0.00 $0.00 $13.33 $0.00 $37.83 $37.83 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.88 SUP HCPCS C1713 414.880 - SCREW BONE 4.5MM 8MM 80MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $62.08 $45.94 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $12.94 $46.07 $46.07 $0.00 $0.00 $12.94 $0.00 $36.72 $36.72 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.885 SUP HCPCS C1713 414.885 - SCREW BONE 4.5MM 8MM 85MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $63.95 $47.32 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $13.33 $47.46 $47.46 $0.00 $0.00 $13.33 $0.00 $37.83 $37.83 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.89 SUP HCPCS C1713 414.890 - SCREW BONE 4.5MM 8MM 90MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $62.08 $45.94 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $12.94 $46.07 $46.07 $0.00 $0.00 $12.94 $0.00 $36.72 $36.72 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.895 SUP HCPCS C1713 414.895 - SCREW BONE 4.5MM 8MM 95MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $63.95 $47.32 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $13.33 $47.46 $47.46 $0.00 $0.00 $13.33 $0.00 $37.83 $37.83 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.9 SUP HCPCS C1713 414.900 - SCREW BONE 4.5MM 8MM 100MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $62.08 $45.94 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $12.94 $46.07 $46.07 $0.00 $0.00 $12.94 $0.00 $36.72 $36.72 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.905 SUP HCPCS C1713 414.905 - SCREW BONE 4.5MM 8MM 105MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $63.95 $47.32 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $13.33 $47.46 $47.46 $0.00 $0.00 $13.33 $0.00 $37.83 $37.83 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.91 SUP HCPCS C1713 414.910 - SCREW BONE 4.5MM 8MM 110MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $62.08 $45.94 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $12.94 $46.07 $46.07 $0.00 $0.00 $12.94 $0.00 $36.72 $36.72 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.915 SUP HCPCS C1713 414.915 - SCREW BONE 4.5MM 8MM 115MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $63.95 $47.32 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $13.33 $47.46 $47.46 $0.00 $0.00 $13.33 $0.00 $37.83 $37.83 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.92 SUP HCPCS C1713 414.920 - SCREW BONE 4.5MM 8MM 120MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $62.08 $45.94 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $12.94 $46.07 $46.07 $0.00 $0.00 $12.94 $0.00 $36.72 $36.72 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.925 SUP HCPCS C1713 414.925 - SCREW BONE 4.5MM 8MM 125MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $63.95 $47.32 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $13.33 $47.46 $47.46 $0.00 $0.00 $13.33 $0.00 $37.83 $37.83 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.93 SUP HCPCS C1713 414.930 - SCREW BONE 4.5MM 8MM 130MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $62.08 $45.94 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $12.94 $46.07 $46.07 $0.00 $0.00 $12.94 $0.00 $36.72 $36.72 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.935 SUP HCPCS C1713 414.935 - SCREW BONE 4.5MM 8MM 135MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $63.95 $47.32 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $13.33 $47.46 $47.46 $0.00 $0.00 $13.33 $0.00 $37.83 $37.83 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.94 SUP HCPCS C1713 414.940 - SCREW BONE 4.5MM 8MM 140MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $62.08 $45.94 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $12.94 $46.07 $46.07 $0.00 $0.00 $12.94 $0.00 $36.72 $36.72 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 414.945 SUP HCPCS C1713 414.945 - SCREW BONE 4.5MM 8MM 145MM LARGE HEXAGONAL SOCKET SLFTAP BOTH IP/OP $63.95 $47.32 $0.00 $49.66 $27.93 $27.93 $0.00 $0.00 $0.00 $13.33 $47.46 $47.46 $0.00 $0.00 $13.33 $0.00 $37.83 $37.83 $0.00 $31.04 $49.17 $49.66 $0.00 $0.00 $9.43 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $0.00 416.03 SUP HCPCS C1713 416.030 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 30MM 16MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.035 SUP HCPCS C1713 416.035 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 35MM 16MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.04 SUP HCPCS C1713 416.040 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 40MM 16MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.045 SUP HCPCS C1713 416.045 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 45MM 16MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.05 SUP HCPCS C1713 416.050 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 50MM 16MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.055 SUP HCPCS C1713 416.055 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 55MM 16MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.06 SUP HCPCS C1713 416.060 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 60MM 16MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.065 SUP HCPCS C1713 416.065 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 65MM 16MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.07 SUP HCPCS C1713 416.070 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 70MM 16MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.075 SUP HCPCS C1713 416.075 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 75MM 16MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.08 SUP HCPCS C1713 416.080 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 80MM 16MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 416.085 SUP HCPCS C1713 416.085 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 85MM 16MM SOCKET LC-DCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 416.09 SUP HCPCS C1713 416.090 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 90MM 16MM SOCKET LC-DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 416.095 SUP HCPCS C1713 416.095 - SCREW BONE 6.5MM 8MM 95MM 16MM THREAD LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 416.1 SUP HCPCS C1713 416.100 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 100MM 16MM SOCKET LC-DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 416.105 SUP HCPCS C1713 416.105 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 105MM 16MM SOCKET LC-DCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 416.11 SUP HCPCS C1713 416.110 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 110MM 16MM SOCKET LC-DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 416.115 SUP HCPCS C1713 416.115 - SCREW BONE 6.5MM 115MM 16MM LC-DCP TITANIUM CANCELLOUS BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 416.12 SUP HCPCS C1713 416.120 - SCREW BONE 6.5MM 120MM 16MM THREAD LC-DCP TITANIUM BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 417.045 SUP HCPCS C1713 417.045 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 45MM 32MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 417.05 SUP HCPCS C1713 417.050 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 50MM 32MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 417.055 SUP HCPCS C1713 417.055 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 55MM 32MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 417.06 SUP HCPCS C1713 417.060 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 60MM 32MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 417.065 SUP HCPCS C1713 417.065 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 65MM 32MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 417.07 SUP HCPCS C1713 417.070 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 70MM 32MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 417.075 SUP HCPCS C1713 417.075 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 75MM 32MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 417.08 SUP HCPCS C1713 417.080 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 80MM 32MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 417.085 SUP HCPCS C1713 417.085 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 85MM 32MM SOCKET LC-DCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 417.09 SUP HCPCS C1713 417.090 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 90MM 32MM SOCKET LC-DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 417.095 SUP HCPCS C1713 417.095 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 95MM 32MM SOCKET LC-DCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 417.1 SUP HCPCS C1713 417.100 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 100MM 32MM SOCKET LC-DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 417.105 SUP HCPCS C1713 417.105 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 105MM 32MM SOCKET LC-DCP BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 417.11 SUP HCPCS C1713 417.110 - SCREW BONE LARGE HEXAGON 6.5MM 8MM 110MM 32MM SOCKET LC-DCP BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 417.115 SUP HCPCS C1713 417.115 - SCREW BONE PTHRD 6.5MM 8MM 115MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 417.12 SUP HCPCS C1713 417.120 - SCREW BONE PTHRD 6.5MM 8MM 120MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 417.125 SUP HCPCS C1713 417.125 - SCREW BONE PTHRD 6.5MM 8MM 125MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 417.13 SUP HCPCS C1713 417.130 - SCREW BONE PTHRD 6.5MM 8MM 130MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 417.135 SUP HCPCS C1713 417.135 - SCREW BONE PTHRD 6.5MM 8MM 135MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 417.14 SUP HCPCS C1713 417.140 - SCREW BONE PTHRD 6.5MM 8MM 140MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 417.145 SUP HCPCS C1713 417.145 - SCREW BONE PTHRD 6.5MM 8MM 145MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $82.23 $60.85 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $17.14 $61.03 $61.03 $0.00 $0.00 $17.14 $0.00 $48.64 $48.64 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 417.15 SUP HCPCS C1713 417.150 - SCREW BONE PTHRD 6.5MM 8MM 150MM 32MM LARGE HEXAGONAL SOCKET BOTH IP/OP $79.83 $59.07 $0.00 $63.86 $35.92 $35.92 $0.00 $0.00 $0.00 $16.64 $59.25 $59.25 $0.00 $0.00 $16.64 $0.00 $47.22 $47.22 $0.00 $39.91 $63.23 $63.86 $0.00 $0.00 $12.13 $0.00 $0.00 $12.71 $0.00 $0.00 $0.00 $0.00 $0.00 418.009 SUP HCPCS C1713 418.009 - SCREW BONE 6.5MM 60MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.01 SUP HCPCS C1713 418.010 - SCREW BONE FULTHD 6.5MM 4MM 65MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.011 SUP HCPCS C1713 418.011 - SCREW BONE 6.5MM 70MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.012 SUP HCPCS C1713 418.012 - SCREW BONE 6.5MM 75MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.013 SUP HCPCS C1713 418.013 - SCREW BONE 6.5MM 80MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.014 SUP HCPCS C1713 418.014 - SCREW BONE 6.5MM 85MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.015 SUP HCPCS C1713 418.015 - SCREW BONE 6.5MM 90MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.016 SUP HCPCS C1713 418.016 - SCREW BONE 6.5MM 95MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.017 SUP HCPCS C1713 418.017 - SCREW BONE 6.5MM 100MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.018 SUP HCPCS C1713 418.018 - SCREW BONE 6.5MM 105MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.019 SUP HCPCS C1713 418.019 - SCREW BONE 6.5MM 110MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.025 SUP HCPCS C1713 418.025 - SCREW BONE 6.5MM 8MM 25MM HEXAGONAL SOCKET LC-DCP TITANIUM BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.03 SUP HCPCS C1713 418.030 - SCREW BONE 6.5MM 8MM 30MM HEXAGONAL SOCKET LC-DCP TITANIUM BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.035 SUP HCPCS C1713 418.035 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 35MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.04 SUP HCPCS C1713 418.040 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 40MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.045 SUP HCPCS C1713 418.045 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 45MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.05 SUP HCPCS C1713 418.050 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 50MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.055 SUP HCPCS C1713 418.055 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 55MM SOCKET LC-DCP BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.06 SUP HCPCS C1713 418.060 - SCREW BONE FULTHD LARGE HEXAGON 6.5MM 8MM 60MM SOCKET LC-DCP BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.065 SUP HCPCS C1713 418.065 - SCREW BONE FULTHD 6.5MM 8MM 65MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.07 SUP HCPCS C1713 418.070 - SCREW BONE FULTHD 6.5MM 8MM 70MM LARGE HEXAGONAL SOCKET BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.075 SUP HCPCS C1713 418.075 - SCREW BONE FULTHD 6.5MM 8MM 75MM LARGE HEXAGONAL SOCKET BOTH IP/OP $61.13 $45.24 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.74 $45.37 $45.37 $0.00 $0.00 $12.74 $0.00 $36.16 $36.16 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.08 SUP HCPCS C1713 418.080 - SCREW BONE FULTHD 6.5MM 8MM 80MM LARGE HEXAGONAL SOCKET BOTH IP/OP $59.35 $43.92 $0.00 $47.48 $26.71 $26.71 $0.00 $0.00 $0.00 $12.37 $44.05 $44.05 $0.00 $0.00 $12.37 $0.00 $35.11 $35.11 $0.00 $29.68 $47.01 $47.48 $0.00 $0.00 $9.02 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $0.00 418.085 SUP HCPCS C1713 418.085 - SCREW BONE FULTHD 6.5MM 8MM 85MM LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 418.09 SUP HCPCS C1713 418.090 - SCREW BONE FULTHD 6.5MM 8MM 90MM LARGE HEXAGONAL SOCKET BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 418.095 SUP HCPCS C1713 418.095 - SCREW BONE FULTHD 6.5MM 8MM 95MM LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 418.1 SUP HCPCS C1713 418.100 - SCREW BONE FULTHD 6.5MM 8MM 100MM LARGE HEXAGONAL SOCKET BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 418.105 SUP HCPCS C1713 418.105 - SCREW BONE FULTHD 6.5MM 8MM 105MM LARGE HEXAGONAL SOCKET BOTH IP/OP $66.08 $48.90 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.77 $49.04 $49.04 $0.00 $0.00 $13.77 $0.00 $39.08 $39.08 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 418.11 SUP HCPCS C1713 418.110 - SCREW BONE FULTHD 6.5MM 8MM 110MM LARGE HEXAGONAL SOCKET BOTH IP/OP $64.15 $47.47 $0.00 $51.32 $28.87 $28.87 $0.00 $0.00 $0.00 $13.37 $47.61 $47.61 $0.00 $0.00 $13.37 $0.00 $37.94 $37.94 $0.00 $32.08 $50.81 $51.32 $0.00 $0.00 $9.75 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $0.00 418.215 SUP HCPCS C1713 418.215 - SCREW BONE FULTHD 6.5MM 115MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.22 SUP HCPCS C1713 418.220 - SCREW BONE FULTHD 6.5MM 4MM 120MM TITANIUM CANCELLOUS BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.225 SUP HCPCS C1713 418.225 - SCREW BONE FULTHD 6.5MM 125MM TITANIUM CANCELLOUS NONSTRL BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 418.23 SUP HCPCS C1713 418.230 - SCREW BONE FULTHD 6.5MM 4MM 130MM TITANIUM CANCELLOUS BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 419.89 SUP Custom 27803010 419.89 - WASHER ORTHOPEDIC THREAD TITANIUM NONSTRL 3 MM CANN SCREWS BOTH IP/OP $258.65 $191.40 $0.00 $200.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.97 $191.97 $0.00 $0.00 $53.90 $0.00 $0.00 $0.00 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 419.91 SUP Custom 27803010 419.91 - WASHER ORTHOPEDIC 10MM TITANIUM NONSTRL 4.5MM CANN SCREW BOTH IP/OP $55.85 $41.33 $0.00 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.45 $41.45 $0.00 $0.00 $11.64 $0.00 $0.00 $0.00 $0.00 $27.11 $42.95 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 419.96 SUP Custom 27803010 419.96 - NUT ORTHOPEDIC LC-DCP TITANIUM NONSTRL 4.5 MM CORTICAL SCREW BOTH IP/OP $55.85 $41.33 $0.00 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.45 $41.45 $0.00 $0.00 $11.64 $0.00 $0.00 $0.00 $0.00 $27.11 $42.95 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 419.972 SUP Custom 27803010 419.972 - WASHER ORTHOPEDIC 6.5MM CANN TITANIUM NONSTRL 3MM SCREWS BOTH IP/OP $54.83 $40.57 $0.00 $42.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.69 $40.69 $0.00 $0.00 $11.43 $0.00 $0.00 $0.00 $0.00 $26.61 $42.16 $42.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 419.98 SUP Custom 27803010 419.98 - WASHER ORTHOPEDIC 7MM TITANIUM PROXIMAL TIBIA NONSTRL 4MM BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $0.00 $0.00 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 419.99 SUP Custom 27803010 419.99 - WASHER ORTHOPEDIC 13MM TITANIUM FEMUR NONSTRL 6.5/7.3MM CANN BOTH IP/OP $52.70 $39.00 $0.00 $40.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.11 $39.11 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $25.59 $40.53 $40.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 420 SUP HCPCS C1713 420.00 - PLATE BONE 40X29MM CRANFCL TI MESH 1MM SCR NONSTRL BOTH IP/OP "$2,607.75 " "$1,929.74" $0.00 "$2,086.20" "$1,173.49" "$1,173.49" $0.00 $0.00 $0.00 $543.52 "$1,935.47" "$1,935.47" $0.00 $0.00 $543.46 $0.00 "$1,285.62" "$1,285.62" $0.00 "$1,303.88" "$2,065.34" "$2,086.20" $0.00 $0.00 $408.11 $0.00 $0.00 $415.15 $0.00 $0.00 $0.00 $0.00 $0.00 420.01 SUP HCPCS C1713 420.01 - PLATE BONE 30X6MM CRANFCL TI 16 HOLE STRUT 1MM SCR NONSTRL BOTH IP/OP "$1,131.75 " $837.50 $0.00 $905.40 $509.29 $509.29 $0.00 $0.00 $0.00 $235.88 $839.98 $839.98 $0.00 $0.00 $235.86 $0.00 $669.43 $669.43 $0.00 $565.88 $896.35 $905.40 $0.00 $0.00 $177.12 $0.00 $0.00 $180.17 $0.00 $0.00 $0.00 $0.00 $0.00 420.02 SUP HCPCS C1713 420.02 - PLATE BONE 42X38X.4MM CRANFCL TI MESH 1MM SCR NONSTRL BOTH IP/OP "$3,145.50 " "$2,327.67" $0.00 "$2,516.40" "$1,415.48" "$1,415.48" $0.00 $0.00 $0.00 $655.60 "$2,334.59" "$2,334.59" $0.00 $0.00 $655.52 $0.00 "$1,550.73" "$1,550.73" $0.00 "$1,572.75" "$2,491.24" "$2,516.40" $0.00 $0.00 $492.27 $0.00 $0.00 $500.76 $0.00 $0.00 $0.00 $0.00 $0.00 420.031 SUP HCPCS C1713 420.031 - PLATE BONE 50X50MM MIC CRANFCL TI MESH 1MM SCR NONSTRL BOTH IP/OP "$3,746.25 " "$2,772.23" $0.00 "$2,997.00" "$1,685.81" "$1,685.81" $0.00 $0.00 $0.00 $780.81 "$2,780.47" "$2,780.47" $0.00 $0.00 $780.72 $0.00 "$1,846.90" "$1,846.90" $0.00 "$1,873.13" "$2,967.03" "$2,997.00" $0.00 $0.00 $586.29 $0.00 $0.00 $596.40 $0.00 $0.00 $0.00 $0.00 $0.00 420.04 SUP HCPCS C1713 420.04 - PLATE BONE 42X6X.4MM CRANFCL TI 22 HOLE STRUT 1MM SCR BOTH IP/OP "$1,271.25 " $940.73 $0.00 "$1,017.00" $572.06 $572.06 $0.00 $0.00 $0.00 $264.96 $943.52 $943.52 $0.00 $0.00 $264.93 $0.00 $751.94 $751.94 $0.00 $635.63 "$1,006.83" "$1,017.00" $0.00 $0.00 $198.95 $0.00 $0.00 $202.38 $0.00 $0.00 $0.00 $0.00 $0.00 420.05 SUP HCPCS C1713 420.05 - PLATE BONE 100X50X.4MM CRANFCL TI MESH 1MM SCR NONSTRL BOTH IP/OP "$3,746.25 " "$2,772.23" $0.00 "$2,997.00" "$1,685.81" "$1,685.81" $0.00 $0.00 $0.00 $780.81 "$2,780.47" "$2,780.47" $0.00 $0.00 $780.72 $0.00 "$1,846.90" "$1,846.90" $0.00 "$1,873.13" "$2,967.03" "$2,997.00" $0.00 $0.00 $586.29 $0.00 $0.00 $596.40 $0.00 $0.00 $0.00 $0.00 $0.00 420.06 SUP HCPCS C1713 420.06 - PLATE BONE 100X100X.4MM CRANFCL TI MESH 1MM SCR NONSTRL BOTH IP/OP "$5,346.00 " "$3,956.04" $0.00 "$4,276.80" "$2,405.70" "$2,405.70" $0.00 $0.00 $0.00 "$1,114.24" "$3,967.80" "$3,967.80" $0.00 $0.00 "$1,114.11" $0.00 "$2,635.58" "$2,635.58" $0.00 "$2,673.00" "$4,234.03" "$4,276.80" $0.00 $0.00 $836.65 $0.00 $0.00 $851.08 $0.00 $0.00 $0.00 $0.00 $0.00 420.07 SUP HCPCS C1713 420.070 - PLATE BONE 100X100X.1MM CRANFCL TI MESH SCRN 1MM SCR NONSTRL BOTH IP/OP "$2,691.00 " "$1,991.34" $0.00 "$2,152.80" "$1,210.95" "$1,210.95" $0.00 $0.00 $0.00 $560.87 "$1,997.26" "$1,997.26" $0.00 $0.00 $560.80 $0.00 "$1,326.66" "$1,326.66" $0.00 "$1,345.50" "$2,131.27" "$2,152.80" $0.00 $0.00 $421.14 $0.00 $0.00 $428.41 $0.00 $0.00 $0.00 $0.00 $0.00 420.071 SUP HCPCS C1713 420.071 - PLATE BONE 100X100MM CRANFCL TI MESH 1/1.5MM SCR NONSTRL BOTH IP/OP "$4,603.50 " "$3,406.59" $0.00 "$3,682.80" "$2,071.58" "$2,071.58" $0.00 $0.00 $0.00 $959.48 "$3,416.72" "$3,416.72" $0.00 $0.00 $959.37 $0.00 "$2,269.53" "$2,269.53" $0.00 "$2,301.75" "$3,645.97" "$3,682.80" $0.00 $0.00 $720.45 $0.00 $0.00 $732.88 $0.00 $0.00 $0.00 $0.00 $0.00 420.1 SUP HCPCS C1713 420.10 - PLATE BONE 100MM CRNMXF TI 34 HOLE ADP 1MM SCR NONSTRL BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $627.75 $627.75 $0.00 $0.00 $0.00 $290.75 "$1,035.37" "$1,035.37" $0.00 $0.00 $290.72 $0.00 $825.14 $825.14 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $218.32 $0.00 $0.00 $222.08 $0.00 $0.00 $0.00 $0.00 $0.00 420.21 SUP HCPCS C1713 420.21 - PLATE BONE ORBTL RIM TI 11 HOLE 1 MM SCR NONSTRL BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 420.302 SUP HCPCS C1713 420.302 - PLATE BONE .2MM ORBTL RIM TI MESH 1MM SCR NONSTRL BOTH IP/OP "$2,889.00 " "$2,137.86" $0.00 "$2,311.20" "$1,300.05" "$1,300.05" $0.00 $0.00 $0.00 $602.14 "$2,144.22" "$2,144.22" $0.00 $0.00 $602.07 $0.00 "$1,424.28" "$1,424.28" $0.00 "$1,444.50" "$2,288.09" "$2,311.20" $0.00 $0.00 $452.13 $0.00 $0.00 $459.93 $0.00 $0.00 $0.00 $0.00 $0.00 420.303 SUP HCPCS C1713 420.303 - PLATE BONE .3MM ORBTL RIM TI MESH 1MM SCR NONSTRL BOTH IP/OP "$2,889.00 " "$2,137.86" $0.00 "$2,311.20" "$1,300.05" "$1,300.05" $0.00 $0.00 $0.00 $602.14 "$2,144.22" "$2,144.22" $0.00 $0.00 $602.07 $0.00 "$1,424.28" "$1,424.28" $0.00 "$1,444.50" "$2,288.09" "$2,311.20" $0.00 $0.00 $452.13 $0.00 $0.00 $459.93 $0.00 $0.00 $0.00 $0.00 $0.00 420.304 SUP HCPCS C1713 420.304 - PLATE BONE .4MM ORBTL RIM TI MESH 1MM SCR NONSTRL BOTH IP/OP "$2,889.00 " "$2,137.86" $0.00 "$2,311.20" "$1,300.05" "$1,300.05" $0.00 $0.00 $0.00 $602.14 "$2,144.22" "$2,144.22" $0.00 $0.00 $602.07 $0.00 "$1,424.28" "$1,424.28" $0.00 "$1,444.50" "$2,288.09" "$2,311.20" $0.00 $0.00 $452.13 $0.00 $0.00 $459.93 $0.00 $0.00 $0.00 $0.00 $0.00 420.4 SUP HCPCS C1713 420.40 - PLATE BONE UNV ORBTL FLR TI 1MM SCR NONSTRL BOTH IP/OP "$2,772.00 " "$2,051.28" $0.00 "$2,217.60" "$1,247.40" "$1,247.40" $0.00 $0.00 $0.00 $577.75 "$2,057.38" "$2,057.38" $0.00 $0.00 $577.68 $0.00 "$1,366.60" "$1,366.60" $0.00 "$1,386.00" "$2,195.42" "$2,217.60" $0.00 $0.00 $433.82 $0.00 $0.00 $441.30 $0.00 $0.00 $0.00 $0.00 $0.00 420.401 SUP HCPCS C1713 420.401 - PLATE SM .3MM TI 1MM SCR ANTM BONE ORBTL FLR NONSTRL BOTH IP/OP "$2,772.00 " "$2,051.28" $0.00 "$2,217.60" "$1,247.40" "$1,247.40" $0.00 $0.00 $0.00 $577.75 "$2,057.38" "$2,057.38" $0.00 $0.00 $577.68 $0.00 "$1,366.60" "$1,366.60" $0.00 "$1,386.00" "$2,195.42" "$2,217.60" $0.00 $0.00 $433.82 $0.00 $0.00 $441.30 $0.00 $0.00 $0.00 $0.00 $0.00 420.402 SUP HCPCS C1713 420.402 - PLATE BONE LG ORBTL FLR TI ANTM 1MM SCR NONSTRL BOTH IP/OP "$2,772.00 " "$2,051.28" $0.00 "$2,217.60" "$1,247.40" "$1,247.40" $0.00 $0.00 $0.00 $577.75 "$2,057.38" "$2,057.38" $0.00 $0.00 $577.68 $0.00 "$1,366.60" "$1,366.60" $0.00 "$1,386.00" "$2,195.42" "$2,217.60" $0.00 $0.00 $433.82 $0.00 $0.00 $441.30 $0.00 $0.00 $0.00 $0.00 $0.00 420.403 SUP HCPCS C1713 420.403 - PLATE BONE MED ORBTL FLR TI ANTM 1MM SCR NONSTRL BOTH IP/OP "$2,772.00 " "$2,051.28" $0.00 "$2,217.60" "$1,247.40" "$1,247.40" $0.00 $0.00 $0.00 $577.75 "$2,057.38" "$2,057.38" $0.00 $0.00 $577.68 $0.00 "$1,366.60" "$1,366.60" $0.00 "$1,386.00" "$2,195.42" "$2,217.60" $0.00 $0.00 $433.82 $0.00 $0.00 $441.30 $0.00 $0.00 $0.00 $0.00 $0.00 420.44 SUP HCPCS C1713 420.44 - PLATE BONE MIC LEFT MDL WL CRANFCL TI 1MM SCR NONSTRL BOTH IP/OP "$2,772.00 " "$2,051.28" $0.00 "$2,217.60" "$1,247.40" "$1,247.40" $0.00 $0.00 $0.00 $577.75 "$2,057.38" "$2,057.38" $0.00 $0.00 $577.68 $0.00 "$1,366.60" "$1,366.60" $0.00 "$1,386.00" "$2,195.42" "$2,217.60" $0.00 $0.00 $433.82 $0.00 $0.00 $441.30 $0.00 $0.00 $0.00 $0.00 $0.00 420.45 SUP HCPCS C1713 420.45 - PLATE BONE MIC RIGHT MDL WL CRANFCL TI 1MM SCR NONSTRL BOTH IP/OP "$2,772.00 " "$2,051.28" $0.00 "$2,217.60" "$1,247.40" "$1,247.40" $0.00 $0.00 $0.00 $577.75 "$2,057.38" "$2,057.38" $0.00 $0.00 $577.68 $0.00 "$1,366.60" "$1,366.60" $0.00 "$1,386.00" "$2,195.42" "$2,217.60" $0.00 $0.00 $433.82 $0.00 $0.00 $441.30 $0.00 $0.00 $0.00 $0.00 $0.00 420.54 SUP HCPCS C1713 420.54 - PLATE TI 1 MM SCR L BONE LEFT ORTH NONSTRL BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 420.55 SUP HCPCS C1713 420.55 - SET BONE RIGHT TI 5 HL SHFT 4 BASE 1 MM SCR NONSTRL BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 420.62 SUP HCPCS C1713 420.62 - PLATE BONE CRANFCL TI 9 HOLE Y 1 MM SCR NONSTRL BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 420.63 SUP HCPCS C1713 420.63 - PLATE BONE CRANFCL TI 13 HOLE Y 1 MM SCR NONSTRL BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 420.631 SUP HCPCS C1713 420.631 - PLATE BONE CRANFCL TI 18 HOLE Y 1 MM SCR NONSTRL BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $231.86 $231.86 $0.00 $0.00 $0.00 $107.39 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $304.77 $304.77 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $80.64 $0.00 $0.00 $82.03 $0.00 $0.00 $0.00 $0.00 $0.00 420.68 SUP HCPCS C1713 420.68 - PLATE BONE CRANFCL TI 1X2 HOLE 2 Y 1 MM SCR NONSTRL BOTH IP/OP $591.75 $437.90 $0.00 $473.40 $266.29 $266.29 $0.00 $0.00 $0.00 $123.34 $439.20 $439.20 $0.00 $0.00 $123.32 $0.00 $350.02 $350.02 $0.00 $295.88 $468.67 $473.40 $0.00 $0.00 $92.61 $0.00 $0.00 $94.21 $0.00 $0.00 $0.00 $0.00 $0.00 420.7 SUP HCPCS C1713 420.70 - PLATE TI 1 MM SCR 5X5 HOLE T BONE ORTH NONSTRL BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 420.71 SUP HCPCS C1713 420.71 - PLATE BONE CRANFCL TI 12 HOLE T 1 MM SCR NONSTRL BOTH IP/OP $591.75 $437.90 $0.00 $473.40 $266.29 $266.29 $0.00 $0.00 $0.00 $123.34 $439.20 $439.20 $0.00 $0.00 $123.32 $0.00 $350.02 $350.02 $0.00 $295.88 $468.67 $473.40 $0.00 $0.00 $92.61 $0.00 $0.00 $94.21 $0.00 $0.00 $0.00 $0.00 $0.00 420.81 SUP HCPCS C1713 420.81 - SCREW BONE CORT CRANFCL TI 5 HOLE X NONSTRL BOTH IP/OP $499.50 $369.63 $0.00 $399.60 $224.78 $224.78 $0.00 $0.00 $0.00 $104.11 $370.73 $370.73 $0.00 $0.00 $104.10 $0.00 $295.45 $295.45 $0.00 $249.75 $395.60 $399.60 $0.00 $0.00 $78.17 $0.00 $0.00 $79.52 $0.00 $0.00 $0.00 $0.00 $0.00 420.84 SUP HCPCS C1713 420.84 - PLATE BONE CRANFCL TI 6 HOLE H 1 MM SCR NONSTRL BOTH IP/OP $528.75 $391.28 $0.00 $423.00 $237.94 $237.94 $0.00 $0.00 $0.00 $110.20 $392.44 $392.44 $0.00 $0.00 $110.19 $0.00 $312.76 $312.76 $0.00 $264.38 $418.77 $423.00 $0.00 $0.00 $82.75 $0.00 $0.00 $84.18 $0.00 $0.00 $0.00 $0.00 $0.00 420.85 SUP HCPCS C1713 420.85 - PLATE BONE CRANFCL TI 11 HOLE H 1 MM SCR NONSTRL BOTH IP/OP $591.75 $437.90 $0.00 $473.40 $266.29 $266.29 $0.00 $0.00 $0.00 $123.34 $439.20 $439.20 $0.00 $0.00 $123.32 $0.00 $350.02 $350.02 $0.00 $295.88 $468.67 $473.40 $0.00 $0.00 $92.61 $0.00 $0.00 $94.21 $0.00 $0.00 $0.00 $0.00 $0.00 420.9 SUP Custom 27803010 420.900 - BURR SURG 12MM HOLE COVER BOTH IP/OP $504.00 $372.96 $0.00 $403.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.07 $374.07 $0.00 $0.00 $105.03 $0.00 $0.00 $0.00 $0.00 $252.00 $399.17 $403.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 420.91 SUP Custom 27803010 420.91 - COVER BUR HOLE 17MM CRANFCL TI 6 HOLE 1MM SCR NONSTRL BOTH IP/OP $504.00 $372.96 $0.00 $403.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.07 $374.07 $0.00 $0.00 $105.03 $0.00 $0.00 $0.00 $0.00 $252.00 $399.17 $403.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.001 SUP HCPCS C1713 421.001 - PLATE BONE 53X38MM CRANFCL TI MESH MALBLE 1.3MM SCR NONSTRL BOTH IP/OP "$3,467.25 " "$2,565.77" $0.00 "$2,773.80" "$1,560.26" "$1,560.26" $0.00 $0.00 $0.00 $722.66 "$2,573.39" "$2,573.39" $0.00 $0.00 $722.57 $0.00 "$1,709.35" "$1,709.35" $0.00 "$1,733.63" "$2,746.06" "$2,773.80" $0.00 $0.00 $542.62 $0.00 $0.00 $551.99 $0.00 $0.00 $0.00 $0.00 $0.00 421.002 SUP HCPCS C1713 421.002 - PLATE BONE TMPR TI MESH MALBLE 1.3 MM SCR NONSTRL BOTH IP/OP "$1,851.75 " "$1,370.30" $0.00 "$1,481.40" $833.29 $833.29 $0.00 $0.00 $0.00 $385.95 "$1,374.37" "$1,374.37" $0.00 $0.00 $385.90 $0.00 "$1,095.31" "$1,095.31" $0.00 $925.88 "$1,466.59" "$1,481.40" $0.00 $0.00 $289.80 $0.00 $0.00 $294.80 $0.00 $0.00 $0.00 $0.00 $0.00 421.003 SUP HCPCS C1713 421.003 - PLATE BONE CRANIAL TI 8 HOLE CONTUR STRUT 1.3 MM SCR NONSTRL BOTH IP/OP "$1,365.75 " "$1,010.66" $0.00 "$1,092.60" $614.59 $614.59 $0.00 $0.00 $0.00 $284.66 "$1,013.66" "$1,013.66" $0.00 $0.00 $284.62 $0.00 $807.84 $807.84 $0.00 $682.88 "$1,081.67" "$1,092.60" $0.00 $0.00 $213.74 $0.00 $0.00 $217.43 $0.00 $0.00 $0.00 $0.00 $0.00 421.004 SUP HCPCS C1713 421.004 - PLATE BONE NONSTRL TEAL 45X38MM CRANFCL TI CONTUR MESH BOTH IP/OP "$3,584.25 " "$2,652.35" $0.00 "$2,867.40" "$1,612.91" "$1,612.91" $0.00 $0.00 $0.00 $747.05 "$2,660.23" "$2,660.23" $0.00 $0.00 $746.96 $0.00 "$1,767.04" "$1,767.04" $0.00 "$1,792.13" "$2,838.73" "$2,867.40" $0.00 $0.00 $560.94 $0.00 $0.00 $570.61 $0.00 $0.00 $0.00 $0.00 $0.00 421.005 SUP HCPCS C1713 421.005 - PLATE BN RECT 45X38X.6MM NS CNTR MESH RGD TI CRNFCL 1.3MM BOTH IP/OP "$3,584.25 " "$2,652.35" $0.00 "$2,867.40" "$1,612.91" "$1,612.91" $0.00 $0.00 $0.00 $747.05 "$2,660.23" "$2,660.23" $0.00 $0.00 $746.96 $0.00 "$1,767.04" "$1,767.04" $0.00 "$1,792.13" "$2,838.73" "$2,867.40" $0.00 $0.00 $560.94 $0.00 $0.00 $570.61 $0.00 $0.00 $0.00 $0.00 $0.00 421.006 SUP HCPCS C1713 421.006 - PLATE BONE 100X100MM CRANFCL TI 5 HOLE MESH MALBLE 1.3MM SCR BOTH IP/OP "$5,379.75 " "$3,981.02" $0.00 "$4,303.80" "$2,420.89" "$2,420.89" $0.00 $0.00 $0.00 "$1,121.27" "$3,992.85" "$3,992.85" $0.00 $0.00 "$1,121.14" $0.00 "$2,652.22" "$2,652.22" $0.00 "$2,689.88" "$4,260.76" "$4,303.80" $0.00 $0.00 $841.93 $0.00 $0.00 $856.46 $0.00 $0.00 $0.00 $0.00 $0.00 421.007 SUP HCPCS C1713 421.007 - PLATE BONE NONSTRL TEAL 100X100MM CRANFCL TI CONTUR MESH BOTH IP/OP "$5,595.75 " "$4,140.86" $0.00 "$4,476.60" "$2,518.09" "$2,518.09" $0.00 $0.00 $0.00 "$1,166.29" "$4,153.17" "$4,153.17" $0.00 $0.00 "$1,166.15" $0.00 "$2,758.70" "$2,758.70" $0.00 "$2,797.88" "$4,431.83" "$4,476.60" $0.00 $0.00 $875.73 $0.00 $0.00 $890.84 $0.00 $0.00 $0.00 $0.00 $0.00 421.008 SUP HCPCS C1713 421.008 - PLATE BN RECT 100X100X.6MM NS CNTR MESH RGD TI CRNFCL 1.3MM BOTH IP/OP "$5,595.75 " "$4,140.86" $0.00 "$4,476.60" "$2,518.09" "$2,518.09" $0.00 $0.00 $0.00 "$1,166.29" "$4,153.17" "$4,153.17" $0.00 $0.00 "$1,166.15" $0.00 "$2,758.70" "$2,758.70" $0.00 "$2,797.88" "$4,431.83" "$4,476.60" $0.00 $0.00 $875.73 $0.00 $0.00 $890.84 $0.00 $0.00 $0.00 $0.00 $0.00 421.009 SUP HCPCS C1713 421.009 - PLATE BONE NONSTRL GOLD 200X200MM CRANFCL TI CONTUR MESH RGD BOTH IP/OP "$22,304.25 " "$16,505.15" $0.00 "$17,843.40" "$10,036.91" "$10,036.91" $0.00 $0.00 $0.00 "$4,648.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,648.21" $0.00 "$10,996.00" "$10,996.00" $0.00 "$11,152.13" "$17,664.97" "$17,843.40" $0.00 $0.00 "$3,490.62" $0.00 $0.00 "$3,550.84" $0.00 $0.00 $0.00 $0.00 $0.00 421.01 SUP HCPCS C1713 421.010 - PLATE BN 95X3.3X.5MM NS 24 HL ADP TI CRNFCL 1.3MM CORT SCR BOTH IP/OP "$1,446.75 " "$1,070.60" $0.00 "$1,157.40" $651.04 $651.04 $0.00 $0.00 $0.00 $301.54 "$1,073.78" "$1,073.78" $0.00 $0.00 $301.50 $0.00 $855.75 $855.75 $0.00 $723.38 "$1,145.83" "$1,157.40" $0.00 $0.00 $226.42 $0.00 $0.00 $230.32 $0.00 $0.00 $0.00 $0.00 $0.00 421.011 SUP HCPCS C1713 421.011 - PLATE BONE NONSTRL TEAL CRANFCL TI CONTUR MESH MALBLE SM ARC BOTH IP/OP "$1,851.75 " "$1,370.30" $0.00 "$1,481.40" $833.29 $833.29 $0.00 $0.00 $0.00 $385.95 "$1,374.37" "$1,374.37" $0.00 $0.00 $385.90 $0.00 "$1,095.31" "$1,095.31" $0.00 $925.88 "$1,466.59" "$1,481.40" $0.00 $0.00 $289.80 $0.00 $0.00 $294.80 $0.00 $0.00 $0.00 $0.00 $0.00 421.012 SUP HCPCS C1713 421.012 - PLATE BONE NONSTRL TEAL CRANFCL TI CONTUR MESH MALBLE LG ARC BOTH IP/OP "$2,893.50 " "$2,141.19" $0.00 "$2,314.80" "$1,302.08" "$1,302.08" $0.00 $0.00 $0.00 $603.08 "$2,147.56" "$2,147.56" $0.00 $0.00 $603.01 $0.00 "$1,426.50" "$1,426.50" $0.00 "$1,446.75" "$2,291.65" "$2,314.80" $0.00 $0.00 $452.83 $0.00 $0.00 $460.65 $0.00 $0.00 $0.00 $0.00 $0.00 421.013 SUP HCPCS C1713 421.013 - PLATE BONE 1.3MM SCR GOLD CRANFCL TI CONTUR MESH RGD SM ARC BOTH IP/OP "$1,851.75 " "$1,370.30" $0.00 "$1,481.40" $833.29 $833.29 $0.00 $0.00 $0.00 $385.95 "$1,374.37" "$1,374.37" $0.00 $0.00 $385.90 $0.00 "$1,095.31" "$1,095.31" $0.00 $925.88 "$1,466.59" "$1,481.40" $0.00 $0.00 $289.80 $0.00 $0.00 $294.80 $0.00 $0.00 $0.00 $0.00 $0.00 421.014 SUP HCPCS C1713 421.014 - PLATE BONE 1.3MM SCR GOLD CRANFCL TI CONTUR MESH RGD LG ARC BOTH IP/OP "$2,893.50 " "$2,141.19" $0.00 "$2,314.80" "$1,302.08" "$1,302.08" $0.00 $0.00 $0.00 $603.08 "$2,147.56" "$2,147.56" $0.00 $0.00 $603.01 $0.00 "$1,426.50" "$1,426.50" $0.00 "$1,446.75" "$2,291.65" "$2,314.80" $0.00 $0.00 $452.83 $0.00 $0.00 $460.65 $0.00 $0.00 $0.00 $0.00 $0.00 421.015 SUP HCPCS C1713 421.015 - PLATE BONE RND CONTUR MESH MALBLE 1.3MM SCR TEAL 30MM BOTH IP/OP "$1,851.75 " "$1,370.30" $0.00 "$1,481.40" $833.29 $833.29 $0.00 $0.00 $0.00 $385.95 "$1,374.37" "$1,374.37" $0.00 $0.00 $385.90 $0.00 "$1,095.31" "$1,095.31" $0.00 $925.88 "$1,466.59" "$1,481.40" $0.00 $0.00 $289.80 $0.00 $0.00 $294.80 $0.00 $0.00 $0.00 $0.00 $0.00 421.016 SUP HCPCS C1713 421.016 - PLATE BONE RND CONTUR MESH MALBLE 1.3MM SCR TEAL 70MM BOTH IP/OP "$3,845.25 " "$2,845.49" $0.00 "$3,076.20" "$1,730.36" "$1,730.36" $0.00 $0.00 $0.00 $801.45 "$2,853.94" "$2,853.94" $0.00 $0.00 $801.35 $0.00 "$1,895.71" "$1,895.71" $0.00 "$1,922.63" "$3,045.44" "$3,076.20" $0.00 $0.00 $601.78 $0.00 $0.00 $612.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.017 SUP HCPCS C1713 421.017 - PLATE BONE RND CONTUR MESH MALBLE 1.3MM SCR TEAL 100MM BOTH IP/OP "$5,334.75 " "$3,947.72" $0.00 "$4,267.80" "$2,400.64" "$2,400.64" $0.00 $0.00 $0.00 "$1,111.90" "$3,959.45" "$3,959.45" $0.00 $0.00 "$1,111.76" $0.00 "$2,630.03" "$2,630.03" $0.00 "$2,667.38" "$4,225.12" "$4,267.80" $0.00 $0.00 $834.89 $0.00 $0.00 $849.29 $0.00 $0.00 $0.00 $0.00 $0.00 421.018 SUP HCPCS C1713 421.018 - PLATE BONE NONSTRL GOLD 30MM CRANFCL TI CONTUR MESH RGD RND BOTH IP/OP "$1,851.75 " "$1,370.30" $0.00 "$1,481.40" $833.29 $833.29 $0.00 $0.00 $0.00 $385.95 "$1,374.37" "$1,374.37" $0.00 $0.00 $385.90 $0.00 "$1,095.31" "$1,095.31" $0.00 $925.88 "$1,466.59" "$1,481.40" $0.00 $0.00 $289.80 $0.00 $0.00 $294.80 $0.00 $0.00 $0.00 $0.00 $0.00 421.019 SUP HCPCS C1713 421.019 - PLATE BONE NONSTRL GOLD 70MM CRANFCL TI CONTUR MESH RGD RND BOTH IP/OP "$3,845.25 " "$2,845.49" $0.00 "$3,076.20" "$1,730.36" "$1,730.36" $0.00 $0.00 $0.00 $801.45 "$2,853.94" "$2,853.94" $0.00 $0.00 $801.35 $0.00 "$1,895.71" "$1,895.71" $0.00 "$1,922.63" "$3,045.44" "$3,076.20" $0.00 $0.00 $601.78 $0.00 $0.00 $612.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.02 SUP HCPCS C1713 421.020 - PLATE BONE NONSTRL GOLD 100MM CRANFCL TI CONTUR MESH RGD RND BOTH IP/OP "$5,334.75 " "$3,947.72" $0.00 "$4,267.80" "$2,400.64" "$2,400.64" $0.00 $0.00 $0.00 "$1,111.90" "$3,959.45" "$3,959.45" $0.00 $0.00 "$1,111.76" $0.00 "$2,630.03" "$2,630.03" $0.00 "$2,667.38" "$4,225.12" "$4,267.80" $0.00 $0.00 $834.89 $0.00 $0.00 $849.29 $0.00 $0.00 $0.00 $0.00 $0.00 421.021 SUP HCPCS C1713 421.021 - PLATE BN 35X3.3X.5MM NS 9 HL TI CRNFCL ORBT RIM 1.3MM CORT BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $259.20 $259.20 $0.00 $0.00 $0.00 $120.05 $427.51 $427.51 $0.00 $0.00 $120.04 $0.00 $340.70 $340.70 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $90.14 $0.00 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $0.00 421.022 SUP HCPCS C1713 421.022 - PLATE BONE 13MM THK.5MM CRANIAL TI 2 HOLE STR 1.3MM SCR BOTH IP/OP $101.25 $74.93 $0.00 $81.00 $45.56 $45.56 $0.00 $0.00 $0.00 $21.10 $75.15 $75.15 $0.00 $0.00 $21.10 $0.00 $59.89 $59.89 $0.00 $50.63 $80.19 $81.00 $0.00 $0.00 $15.85 $0.00 $0.00 $16.12 $0.00 $0.00 $0.00 $0.00 $0.00 421.024 SUP HCPCS C1713 421.024 - PLATE BONE 21MM CRANFCL TI 4 HOLE STR 1.3MM SCR NONSTRL BOTH IP/OP $139.50 $103.23 $0.00 $111.60 $62.78 $62.78 $0.00 $0.00 $0.00 $29.08 $103.54 $103.54 $0.00 $0.00 $29.07 $0.00 $82.51 $82.51 $0.00 $69.75 $110.48 $111.60 $0.00 $0.00 $21.83 $0.00 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $0.00 421.034 SUP Custom 27803010 421.034 - COVER BUR HOLE 17MM CRANIAL TI 5 HOLE SHNT 1.3MM SCR NONSTRL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $0.00 $0.00 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.04 SUP HCPCS C1713 421.040 - PLATE BONE UNV ORBTL FLR TI 1.3MM SCR NONSTRL BOTH IP/OP "$2,531.25 " "$1,873.13" $0.00 "$2,025.00" "$1,139.06" "$1,139.06" $0.00 $0.00 $0.00 $527.58 "$1,878.69" "$1,878.69" $0.00 $0.00 $527.51 $0.00 "$1,247.91" "$1,247.91" $0.00 "$1,265.63" "$2,004.75" "$2,025.00" $0.00 $0.00 $396.14 $0.00 $0.00 $402.98 $0.00 $0.00 $0.00 $0.00 $0.00 421.043 SUP HCPCS C1713 421.043 - PLATE BONE MED ORBTL FLR TI ANTM 1.3MM SCR NONSTRL BOTH IP/OP "$2,553.75 " "$1,889.78" $0.00 "$2,043.00" "$1,149.19" "$1,149.19" $0.00 $0.00 $0.00 $532.27 "$1,895.39" "$1,895.39" $0.00 $0.00 $532.20 $0.00 "$1,259.00" "$1,259.00" $0.00 "$1,276.88" "$2,022.57" "$2,043.00" $0.00 $0.00 $399.66 $0.00 $0.00 $406.56 $0.00 $0.00 $0.00 $0.00 $0.00 421.044 SUP HCPCS C1713 421.044 - PLATE BONE LEFT MDL WL ORBTL FLR TI 1.3 MM SCR NONSTRL BOTH IP/OP "$2,531.25 " "$1,873.13" $0.00 "$2,025.00" "$1,139.06" "$1,139.06" $0.00 $0.00 $0.00 $527.58 "$1,878.69" "$1,878.69" $0.00 $0.00 $527.51 $0.00 "$1,247.91" "$1,247.91" $0.00 "$1,265.63" "$2,004.75" "$2,025.00" $0.00 $0.00 $396.14 $0.00 $0.00 $402.98 $0.00 $0.00 $0.00 $0.00 $0.00 421.045 SUP HCPCS C1713 421.045 - PLATE BONE RIGHT MDL WL ORBTL FLR TI 1.3 MM SCR NONSTRL BOTH IP/OP "$2,531.25 " "$1,873.13" $0.00 "$2,025.00" "$1,139.06" "$1,139.06" $0.00 $0.00 $0.00 $527.58 "$1,878.69" "$1,878.69" $0.00 $0.00 $527.51 $0.00 "$1,247.91" "$1,247.91" $0.00 "$1,265.63" "$2,004.75" "$2,025.00" $0.00 $0.00 $396.14 $0.00 $0.00 $402.98 $0.00 $0.00 $0.00 $0.00 $0.00 421.048 SUP HCPCS C1713 421.048 - PLATE BN SM .3MM NS ANTM TI ORBT FLR 1.3MM CORT SCR BOTH IP/OP "$2,553.75 " "$1,889.78" $0.00 "$2,043.00" "$1,149.19" "$1,149.19" $0.00 $0.00 $0.00 $532.27 "$1,895.39" "$1,895.39" $0.00 $0.00 $532.20 $0.00 "$1,259.00" "$1,259.00" $0.00 "$1,276.88" "$2,022.57" "$2,043.00" $0.00 $0.00 $399.66 $0.00 $0.00 $406.56 $0.00 $0.00 $0.00 $0.00 $0.00 421.049 SUP HCPCS C1713 421.049 - PLATE BN LG .3MM NS ANTM TI ORBT FLR 1.3MM CORT SCR BOTH IP/OP "$2,553.75 " "$1,889.78" $0.00 "$2,043.00" "$1,149.19" "$1,149.19" $0.00 $0.00 $0.00 $532.27 "$1,895.39" "$1,895.39" $0.00 $0.00 $532.20 $0.00 "$1,259.00" "$1,259.00" $0.00 "$1,276.88" "$2,022.57" "$2,043.00" $0.00 $0.00 $399.66 $0.00 $0.00 $406.56 $0.00 $0.00 $0.00 $0.00 $0.00 421.05 SUP HCPCS C1713 421.050 - PLATE BN 100D 9MM SPC L OB L 20X11X.5MM NS 3 HL BS 3 HL SHFT BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $259.20 $259.20 $0.00 $0.00 $0.00 $120.05 $427.51 $427.51 $0.00 $0.00 $120.04 $0.00 $340.70 $340.70 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $90.14 $0.00 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $0.00 421.051 SUP HCPCS C1713 421.051 - PLATE BN 100D 9MM SPC L OB R 20X11X.5MM NS 3 HL BS 3 HL SHFT BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $259.20 $259.20 $0.00 $0.00 $0.00 $120.05 $427.51 $427.51 $0.00 $0.00 $120.04 $0.00 $340.70 $340.70 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $90.14 $0.00 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $0.00 421.052 SUP HCPCS C1713 421.052 - PLATE BN 100D 5MM SPC L OB L 20X11X.5MM NS 3 HL BS 4 HL SHFT BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $259.20 $259.20 $0.00 $0.00 $0.00 $120.05 $427.51 $427.51 $0.00 $0.00 $120.04 $0.00 $340.70 $340.70 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $90.14 $0.00 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $0.00 421.053 SUP HCPCS C1713 421.053 - PLATE BN 100D 5MM SPC L OB R 20X11X.5MM NS 3 HL BS 4 HL SHFT BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $259.20 $259.20 $0.00 $0.00 $0.00 $120.05 $427.51 $427.51 $0.00 $0.00 $120.04 $0.00 $340.70 $340.70 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $90.14 $0.00 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $0.00 421.061 SUP HCPCS C1713 421.061 - PLATE BN Y 20X10X.5MM NS 5 HL TI CRNFCL 1.3MM CORT SCR BOTH IP/OP $522.00 $386.28 $0.00 $417.60 $234.90 $234.90 $0.00 $0.00 $0.00 $108.80 $387.43 $387.43 $0.00 $0.00 $108.78 $0.00 $308.76 $308.76 $0.00 $261.00 $413.42 $417.60 $0.00 $0.00 $81.69 $0.00 $0.00 $83.10 $0.00 $0.00 $0.00 $0.00 $0.00 421.067 SUP HCPCS C1713 421.067 - PLATE BONE 22MM CRANFCL TI 6 HOLE DBL Y 1.3MM SCR NONSTRL BOTH IP/OP $571.50 $422.91 $0.00 $457.20 $257.18 $257.18 $0.00 $0.00 $0.00 $119.11 $424.17 $424.17 $0.00 $0.00 $119.10 $0.00 $338.04 $338.04 $0.00 $285.75 $452.63 $457.20 $0.00 $0.00 $89.44 $0.00 $0.00 $90.98 $0.00 $0.00 $0.00 $0.00 $0.00 421.068 SUP HCPCS C1713 421.068 - PLATE BN 6MM SPC 2Y 15X9X.5MM NS 2 HL SHFT 1 HL ARM TI BOTH IP/OP $571.50 $422.91 $0.00 $457.20 $257.18 $257.18 $0.00 $0.00 $0.00 $119.11 $424.17 $424.17 $0.00 $0.00 $119.10 $0.00 $338.04 $338.04 $0.00 $285.75 $452.63 $457.20 $0.00 $0.00 $89.44 $0.00 $0.00 $90.98 $0.00 $0.00 $0.00 $0.00 $0.00 421.069 SUP HCPCS C1713 421.069 - PLATE BONE 18MM CRANFCL TI 6 HOLE 2Y 1.3MM SCR NONSTRL BOTH IP/OP $571.50 $422.91 $0.00 $457.20 $257.18 $257.18 $0.00 $0.00 $0.00 $119.11 $424.17 $424.17 $0.00 $0.00 $119.10 $0.00 $338.04 $338.04 $0.00 $285.75 $452.63 $457.20 $0.00 $0.00 $89.44 $0.00 $0.00 $90.98 $0.00 $0.00 $0.00 $0.00 $0.00 421.071 SUP HCPCS C1713 421.071 - PLATE BONE CRANFCL TI 7 HOLE T 1.3 MM SCR NONSTRL BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $259.20 $259.20 $0.00 $0.00 $0.00 $120.05 $427.51 $427.51 $0.00 $0.00 $120.04 $0.00 $340.70 $340.70 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $90.14 $0.00 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $0.00 421.072 SUP HCPCS C1713 421.072 - PLATE RIGHT MAXL T 1.3MM SCR BONE TI 14MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.073 SUP HCPCS C1713 421.073 - PLATE LEFT MAXL T 1.3MM SCR BONE TI 14MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.074 SUP HCPCS C1713 421.074 - PLATE RIGHT MAXL T 1.3MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.075 SUP HCPCS C1713 421.075 - PLATE LEFT MAXL T 1.3MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.076 SUP HCPCS C1713 421.076 - PLATE RIGHT MAXL T 1.3MM SCR BONE TI 10MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.077 SUP HCPCS C1713 421.077 - PLATE LEFT MAXL T 1.3MM SCR BONE TI 10MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.078 SUP HCPCS C1713 421.078 - PLATE RIGHT MAXL T 1.3MM SCR BONE TI 12MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.079 SUP HCPCS C1713 421.079 - PLATE LEFT MAXL T 1.3MM SCR BONE TI 12MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.08 SUP HCPCS C1713 421.080 - PLATE BN T 43X8X.5MM NS 2X9 HL STRUT TI CRNFCL 1.3MM CORT BOTH IP/OP "$1,190.25 " $880.79 $0.00 $952.20 $535.61 $535.61 $0.00 $0.00 $0.00 $248.08 $883.40 $883.40 $0.00 $0.00 $248.05 $0.00 $704.03 $704.03 $0.00 $595.13 $942.68 $952.20 $0.00 $0.00 $186.27 $0.00 $0.00 $189.49 $0.00 $0.00 $0.00 $0.00 $0.00 421.081 SUP HCPCS C1713 421.081 - PLATE BONE CRANFCL TI 4 HOLE X 1.3 MM SCR NONSTRL BOTH IP/OP $522.00 $386.28 $0.00 $417.60 $234.90 $234.90 $0.00 $0.00 $0.00 $108.80 $387.43 $387.43 $0.00 $0.00 $108.78 $0.00 $308.76 $308.76 $0.00 $261.00 $413.42 $417.60 $0.00 $0.00 $81.69 $0.00 $0.00 $83.10 $0.00 $0.00 $0.00 $0.00 $0.00 421.082 SUP HCPCS C1713 421.082 - PLATE MAXL T STR 1.3MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.083 SUP HCPCS C1713 421.083 - PLATE MAXL T STR 1.3MM SCR BONE TI 10MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.084 SUP HCPCS C1713 421.084 - PLATE MAXL T STR 1.3MM SCR BONE TI 12MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.085 SUP HCPCS C1713 421.085 - PLATE BONE CRANFCL TI 11 HOLE H 1.3 MM SCR NONSTRL BOTH IP/OP $609.75 $451.22 $0.00 $487.80 $274.39 $274.39 $0.00 $0.00 $0.00 $127.09 $452.56 $452.56 $0.00 $0.00 $127.07 $0.00 $360.67 $360.67 $0.00 $304.88 $482.92 $487.80 $0.00 $0.00 $95.43 $0.00 $0.00 $97.07 $0.00 $0.00 $0.00 $0.00 $0.00 421.086 SUP HCPCS C1713 421.086 - PLATE MAXL T STR 1.3MM SCR BONE TI 14MM NONSTRL BOTH IP/OP $729.00 $539.46 $0.00 $583.20 $328.05 $328.05 $0.00 $0.00 $0.00 $151.94 $541.06 $541.06 $0.00 $0.00 $151.92 $0.00 $431.20 $431.20 $0.00 $364.50 $577.37 $583.20 $0.00 $0.00 $114.09 $0.00 $0.00 $116.06 $0.00 $0.00 $0.00 $0.00 $0.00 421.09 SUP Custom 27803010 421.090 - COVER BUR HOLE 12MM CRANFCL TI 6 HOLE 1.3MM SCR NONSTRL BOTH IP/OP $632.25 $467.87 $0.00 $505.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.26 $469.26 $0.00 $0.00 $131.76 $0.00 $0.00 $0.00 $0.00 $316.13 $500.74 $505.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.091 SUP Custom 27803010 421.091 - COVER BUR HOLE 17MM CRANFCL TI 6 HOLE 1.3MM SCR NONSTRL BOTH IP/OP $632.25 $467.87 $0.00 $505.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.26 $469.26 $0.00 $0.00 $131.76 $0.00 $0.00 $0.00 $0.00 $316.13 $500.74 $505.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.092 SUP Custom 27803010 421.092 - COVER BUR HOLE 15MM CRANFCL TI 6 HOLE 1.3MM SCR NONSTRL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $0.00 $0.00 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.093 SUP Custom 27803010 421.093 - COVER BUR HOLE 24MM CRANFCL TI 6 HOLE 1.3MM SCR NONSTRL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $0.00 $0.00 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.095 SUP HCPCS C1713 421.095 - PLATE BN BX 13X8MM NS 4 HL TI CRNFCL 1.3MM SCR BOTH IP/OP $510.75 $377.96 $0.00 $408.60 $229.84 $229.84 $0.00 $0.00 $0.00 $106.45 $379.08 $379.08 $0.00 $0.00 $106.44 $0.00 $302.11 $302.11 $0.00 $255.38 $404.51 $408.60 $0.00 $0.00 $79.93 $0.00 $0.00 $81.31 $0.00 $0.00 $0.00 $0.00 $0.00 421.096 SUP HCPCS C1713 421.096 - PLATE BONE 13X13MM CRANFCL TI 4 HOLE BOX 1.3MM SCR NONSTRL BOTH IP/OP $510.75 $377.96 $0.00 $408.60 $229.84 $229.84 $0.00 $0.00 $0.00 $106.45 $379.08 $379.08 $0.00 $0.00 $106.44 $0.00 $302.11 $302.11 $0.00 $255.38 $404.51 $408.60 $0.00 $0.00 $79.93 $0.00 $0.00 $81.31 $0.00 $0.00 $0.00 $0.00 $0.00 421.099 SUP HCPCS C1713 421.099 - PLATE BONE 100X100MM CRANFCL TI MESH SCRN 1.3MM SCR NONSTRL BOTH IP/OP "$2,819.25 " "$2,086.25" $0.00 "$2,255.40" "$1,268.66" "$1,268.66" $0.00 $0.00 $0.00 $587.60 "$2,092.45" "$2,092.45" $0.00 $0.00 $587.53 $0.00 "$1,389.89" "$1,389.89" $0.00 "$1,409.63" "$2,232.85" "$2,255.40" $0.00 $0.00 $441.21 $0.00 $0.00 $448.82 $0.00 $0.00 $0.00 $0.00 $0.00 421.302 SUP HCPCS C1713 421.302 - PLATE BONE .2MM ORBTL FLR TI MESH 1.3MM SCR NONSTRL BOTH IP/OP "$2,668.50 " "$1,974.69" $0.00 "$2,134.80" "$1,200.83" "$1,200.83" $0.00 $0.00 $0.00 $556.18 "$1,980.56" "$1,980.56" $0.00 $0.00 $556.12 $0.00 "$1,315.57" "$1,315.57" $0.00 "$1,334.25" "$2,113.45" "$2,134.80" $0.00 $0.00 $417.62 $0.00 $0.00 $424.83 $0.00 $0.00 $0.00 $0.00 $0.00 421.303 SUP HCPCS C1713 421.303 - PLATE BONE .3MM ORBTL FLR TI MESH 1.3MM SCR NONSTRL BOTH IP/OP "$2,668.50 " "$1,974.69" $0.00 "$2,134.80" "$1,200.83" "$1,200.83" $0.00 $0.00 $0.00 $556.18 "$1,980.56" "$1,980.56" $0.00 $0.00 $556.12 $0.00 "$1,315.57" "$1,315.57" $0.00 "$1,334.25" "$2,113.45" "$2,134.80" $0.00 $0.00 $417.62 $0.00 $0.00 $424.83 $0.00 $0.00 $0.00 $0.00 $0.00 421.304 SUP HCPCS C1713 421.304 - PLATE BN .4MM AU NS 3 ROW SCR HL MESH MLBL TI ORBT 1.3MM SCR BOTH IP/OP "$2,668.50 " "$1,974.69" $0.00 "$2,134.80" "$1,200.83" "$1,200.83" $0.00 $0.00 $0.00 $556.18 "$1,980.56" "$1,980.56" $0.00 $0.00 $556.12 $0.00 "$1,315.57" "$1,315.57" $0.00 "$1,334.25" "$2,113.45" "$2,134.80" $0.00 $0.00 $417.62 $0.00 $0.00 $424.83 $0.00 $0.00 $0.00 $0.00 $0.00 421.306 SUP HCPCS C1713 421.306 - PLATE BN STRG 23MM NS 6 HL LOPRFL PRECONTOUR RECON TI HND BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 421.312 SUP HCPCS C1713 421.312 - PLATE BN STRG 47MM NS 12 HL LOPRFL PRECONTOUR RECON TI HND BOTH IP/OP $465.28 $344.31 $0.00 $361.38 $203.28 $203.28 $0.00 $0.00 $0.00 $96.97 $345.33 $345.33 $0.00 $0.00 $96.96 $0.00 $275.21 $275.21 $0.00 $225.86 $357.77 $361.38 $0.00 $0.00 $68.64 $0.00 $0.00 $71.91 $0.00 $0.00 $0.00 $0.00 $0.00 421.32 SUP HCPCS C1713 421.320 - PLATE BONE H 19MMX.5MM 8 HOLE EXTENDED TITANIUM RIGHT HAND BOTH IP/OP $431.25 $319.13 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $89.88 $320.07 $320.07 $0.00 $0.00 $89.87 $0.00 $255.08 $255.08 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 421.321 SUP HCPCS C1713 421.321 - PLATE BONE H 8 HOLE EXTEND PRECONTOUR LP TITANIUM HAND LEFT BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 421.333 SUP HCPCS C1713 421.333 - PLATE BONE T 32MM 3X8 HOLE PRECONTOUR LP TITANIUM HAND BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 421.334 SUP HCPCS C1713 421.334 - PLATE BONE T 32MM 4X8 HOLE PRECONTOUR LP TITANIUM HAND BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 421.335 SUP HCPCS C1713 421.335 - PLATE BONE Y 3X8 HOLE PRECONTOUR LP TITANIUM HAND NONSTRL BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 421.5 SUP HCPCS C1713 421.500 - PLATE BONE MED TMPR TI CONTUR MESH MALBLE LP NONSTRL BOTH IP/OP "$2,083.50 " "$1,541.79" $0.00 "$1,666.80" $937.58 $937.58 $0.00 $0.00 $0.00 $434.25 "$1,546.37" "$1,546.37" $0.00 $0.00 $434.20 $0.00 "$1,232.39" "$1,232.39" $0.00 "$1,041.75" "$1,650.13" "$1,666.80" $0.00 $0.00 $326.07 $0.00 $0.00 $331.69 $0.00 $0.00 $0.00 $0.00 $0.00 421.501 SUP HCPCS C1713 421.501 - PLATE BONE CRANFCL TI 8 HOLE MALBLE CONTUR MESH LP NONSTRL BOTH IP/OP "$1,572.75 " "$1,163.84" $0.00 "$1,258.20" $707.74 $707.74 $0.00 $0.00 $0.00 $327.80 "$1,167.30" "$1,167.30" $0.00 $0.00 $327.76 $0.00 $930.28 $930.28 $0.00 $786.38 "$1,245.62" "$1,258.20" $0.00 $0.00 $246.14 $0.00 $0.00 $250.38 $0.00 $0.00 $0.00 $0.00 $0.00 421.502 SUP HCPCS C1713 421.502 - PLATE BONE CRANFCL TI 2 HOLE STR LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.503 SUP HCPCS C1713 421.503 - PLATE BONE 9MM CRANFCL TI 2 HOLE STR LP NONSTRL BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $56.19 $56.19 $0.00 $0.00 $0.00 $26.03 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $73.86 $73.86 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $19.54 $0.00 $0.00 $19.88 $0.00 $0.00 $0.00 $0.00 $0.00 421.504 SUP HCPCS C1713 421.504 - PLATE BONE CRANFCL TI 4 HOLE STR LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.505 SUP HCPCS C1713 421.505 - PLATE BONE ORBTL RIM TI 12 HOLE CVD LP NONSTRL BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 421.506 SUP HCPCS C1713 421.506 - PLATE BONE CRANFCL TI 2X3 HOLE L RIGHT OBLQ LP NONSTRL BOTH IP/OP $654.75 $484.52 $0.00 $523.80 $294.64 $294.64 $0.00 $0.00 $0.00 $136.47 $485.96 $485.96 $0.00 $0.00 $136.45 $0.00 $387.28 $387.28 $0.00 $327.38 $518.56 $523.80 $0.00 $0.00 $102.47 $0.00 $0.00 $104.24 $0.00 $0.00 $0.00 $0.00 $0.00 421.507 SUP HCPCS C1713 421.507 - PLATE BONE CRANFCL TI 2X3 HOLE L LEFT OBLQ LP NONSTRL BOTH IP/OP $654.75 $484.52 $0.00 $523.80 $294.64 $294.64 $0.00 $0.00 $0.00 $136.47 $485.96 $485.96 $0.00 $0.00 $136.45 $0.00 $387.28 $387.28 $0.00 $327.38 $518.56 $523.80 $0.00 $0.00 $102.47 $0.00 $0.00 $104.24 $0.00 $0.00 $0.00 $0.00 $0.00 421.508 SUP HCPCS C1713 421.508 - PLATE BONE CRANFCL TI 3X4 HOLE L RIGHT OBLQ LP NONSTRL BOTH IP/OP $654.75 $484.52 $0.00 $523.80 $294.64 $294.64 $0.00 $0.00 $0.00 $136.47 $485.96 $485.96 $0.00 $0.00 $136.45 $0.00 $387.28 $387.28 $0.00 $327.38 $518.56 $523.80 $0.00 $0.00 $102.47 $0.00 $0.00 $104.24 $0.00 $0.00 $0.00 $0.00 $0.00 421.509 SUP HCPCS C1713 421.509 - PLATE BONE CRANFCL TI 3X4 HOLE L LEFT OBLQ LP NONSTRL BOTH IP/OP $654.75 $484.52 $0.00 $523.80 $294.64 $294.64 $0.00 $0.00 $0.00 $136.47 $485.96 $485.96 $0.00 $0.00 $136.45 $0.00 $387.28 $387.28 $0.00 $327.38 $518.56 $523.80 $0.00 $0.00 $102.47 $0.00 $0.00 $104.24 $0.00 $0.00 $0.00 $0.00 $0.00 421.51 SUP HCPCS C1713 421.510 - PLATE BN X .5MM NS 4 HL LOPRFL TI CRNMXF NEURO SYS BOTH IP/OP $636.75 $471.20 $0.00 $509.40 $286.54 $286.54 $0.00 $0.00 $0.00 $132.71 $472.60 $472.60 $0.00 $0.00 $132.70 $0.00 $376.64 $376.64 $0.00 $318.38 $504.31 $509.40 $0.00 $0.00 $99.65 $0.00 $0.00 $101.37 $0.00 $0.00 $0.00 $0.00 $0.00 421.511 SUP HCPCS C1713 421.511 - PLATE BONE 14X14MM CRANFCL TI 4 HOLE BOX LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.512 SUP HCPCS C1713 421.512 - PLATE BONE 16X16MM CRANFCL TI 4 HOLE BOX LP NONSTRL BOTH IP/OP $636.75 $471.20 $0.00 $509.40 $286.54 $286.54 $0.00 $0.00 $0.00 $132.71 $472.60 $472.60 $0.00 $0.00 $132.70 $0.00 $376.64 $376.64 $0.00 $318.38 $504.31 $509.40 $0.00 $0.00 $99.65 $0.00 $0.00 $101.37 $0.00 $0.00 $0.00 $0.00 $0.00 421.515 SUP HCPCS C1713 421.515 - PLATE BONE 15MM CRANFCL TI 5 HOLE Y LP NONSTRL BOTH IP/OP $636.75 $471.20 $0.00 $509.40 $286.54 $286.54 $0.00 $0.00 $0.00 $132.71 $472.60 $472.60 $0.00 $0.00 $132.70 $0.00 $376.64 $376.64 $0.00 $318.38 $504.31 $509.40 $0.00 $0.00 $99.65 $0.00 $0.00 $101.37 $0.00 $0.00 $0.00 $0.00 $0.00 421.516 SUP HCPCS C1713 421.516 - PLATE BONE 18MM CRANFCL TI 6 HOLE 2Y LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.517 SUP HCPCS C1713 421.517 - PLATE BONE 21MM TI 6 HOLE DBL Y LP BOTH IP/OP $636.75 $471.20 $0.00 $509.40 $286.54 $286.54 $0.00 $0.00 $0.00 $132.71 $472.60 $472.60 $0.00 $0.00 $132.70 $0.00 $376.64 $376.64 $0.00 $318.38 $504.31 $509.40 $0.00 $0.00 $99.65 $0.00 $0.00 $101.37 $0.00 $0.00 $0.00 $0.00 $0.00 421.518 SUP HCPCS C1713 421.518 - PLATE BN .5MM NS 5 HL LOPRFL ADP TI CRNMXF NEURO SYS BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.519 SUP HCPCS C1713 421.519 - PLATE BN .5MM NS 7 HL LOPRFL ADP TI CRNMXF NEURO SYS BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.52 SUP HCPCS C1713 421.520 - PLATE BN .5MM NS 20 HL LOPRFL ADP TI CRNMXF NEURO SYS BOTH IP/OP "$1,413.00 " "$1,045.62" $0.00 "$1,130.40" $635.85 $635.85 $0.00 $0.00 $0.00 $294.50 "$1,048.73" "$1,048.73" $0.00 $0.00 $294.47 $0.00 $835.79 $835.79 $0.00 $706.50 "$1,119.10" "$1,130.40" $0.00 $0.00 $221.13 $0.00 $0.00 $224.95 $0.00 $0.00 $0.00 $0.00 $0.00 421.521 SUP HCPCS C1713 421.521 - PLATE BONE 16X10MM CRANFCL TI 4 HOLE BOX LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.522 SUP HCPCS C1713 421.522 - PLATE BN .5MM NS 6 HL LOPRFL STRUT TI CRNMXF NEURO SYS BOTH IP/OP "$1,109.25 " $820.85 $0.00 $887.40 $499.16 $499.16 $0.00 $0.00 $0.00 $231.20 $823.29 $823.29 $0.00 $0.00 $231.17 $0.00 $656.12 $656.12 $0.00 $554.63 $878.53 $887.40 $0.00 $0.00 $173.60 $0.00 $0.00 $176.59 $0.00 $0.00 $0.00 $0.00 $0.00 421.523 SUP HCPCS C1713 421.523 - PLATE BN .5MM NS 8 HL LOPRFL STRUT TI CRNMXF NEURO SYS BOTH IP/OP "$1,572.75 " "$1,163.84" $0.00 "$1,258.20" $707.74 $707.74 $0.00 $0.00 $0.00 $327.80 "$1,167.30" "$1,167.30" $0.00 $0.00 $327.76 $0.00 $930.28 $930.28 $0.00 $786.38 "$1,245.62" "$1,258.20" $0.00 $0.00 $246.14 $0.00 $0.00 $250.38 $0.00 $0.00 $0.00 $0.00 $0.00 421.525 SUP Custom 27803010 421.525 - COVER BUR HOLE 12MM CRANFCL TI LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.526 SUP Custom 27803010 421.526 - COVER BUR HOLE 15MM CRANFCL TI LP NONSTRL BOTH IP/OP $661.50 $489.51 $0.00 $529.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $490.97 $490.97 $0.00 $0.00 $137.86 $0.00 $0.00 $0.00 $0.00 $330.75 $523.91 $529.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.527 SUP Custom 27803010 421.527 - COVER BUR HOLE 17MM CRANFCL TI LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.528 SUP Custom 27803010 421.528 - COVER BUR HOLE 24MM CRANFCL TI LP NONSTRL BOTH IP/OP $661.50 $489.51 $0.00 $529.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $490.97 $490.97 $0.00 $0.00 $137.86 $0.00 $0.00 $0.00 $0.00 $330.75 $523.91 $529.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.531 SUP HCPCS C1713 421.531 - PLATE BONE 45X38MM CRANFCL TI CONTUR MESH MALBLE LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.532 SUP HCPCS C1713 421.532 - PLATE THK.6MM 45X38MM TI CONTUR MESH RGD BONE NONSTRL SLVR BOTH IP/OP "$3,620.25 " "$2,678.99" $0.00 "$2,896.20" "$1,629.11" "$1,629.11" $0.00 $0.00 $0.00 $754.55 "$2,686.95" "$2,686.95" $0.00 $0.00 $754.46 $0.00 "$1,784.78" "$1,784.78" $0.00 "$1,810.13" "$2,867.24" "$2,896.20" $0.00 $0.00 $566.57 $0.00 $0.00 $576.34 $0.00 $0.00 $0.00 $0.00 $0.00 421.533 SUP HCPCS C1713 421.533 - PLATE BONE 100X100MM CRANFCL TI CONTUR MESH MALBLE LP BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.534 SUP HCPCS C1713 421.534 - PLATE BONE 100X100MM CRANFCL TI CONTUR MESH RGD LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.535 SUP HCPCS C1713 421.535 - PLATE BONE 200X200MM CRANFCL TI CONTUR MESH RGD LP NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 421.536 SUP HCPCS C1713 421.536 - PLATE BONE CRANFCL TI CONTUR MESH MALBLE LP SM ARC NONSTRL BOTH IP/OP "$2,083.50 " "$1,541.79" $0.00 "$1,666.80" $937.58 $937.58 $0.00 $0.00 $0.00 $434.25 "$1,546.37" "$1,546.37" $0.00 $0.00 $434.20 $0.00 "$1,232.39" "$1,232.39" $0.00 "$1,041.75" "$1,650.13" "$1,666.80" $0.00 $0.00 $326.07 $0.00 $0.00 $331.69 $0.00 $0.00 $0.00 $0.00 $0.00 421.537 SUP HCPCS C1713 421.537 - PLATE BONE CRANFCL TI CONTUR MESH MALBLE LP LG ARC NONSTRL BOTH IP/OP "$3,244.50 " "$2,400.93" $0.00 "$2,595.60" "$1,460.03" "$1,460.03" $0.00 $0.00 $0.00 $676.23 "$2,408.07" "$2,408.07" $0.00 $0.00 $676.15 $0.00 "$1,599.54" "$1,599.54" $0.00 "$1,622.25" "$2,569.64" "$2,595.60" $0.00 $0.00 $507.76 $0.00 $0.00 $516.52 $0.00 $0.00 $0.00 $0.00 $0.00 421.538 SUP HCPCS C1713 421.538 - PLATE BONE CRANFCL TI CONTUR MESH RGD LP SM ARC NONSTRL BOTH IP/OP "$2,083.50 " "$1,541.79" $0.00 "$1,666.80" $937.58 $937.58 $0.00 $0.00 $0.00 $434.25 "$1,546.37" "$1,546.37" $0.00 $0.00 $434.20 $0.00 "$1,232.39" "$1,232.39" $0.00 "$1,041.75" "$1,650.13" "$1,666.80" $0.00 $0.00 $326.07 $0.00 $0.00 $331.69 $0.00 $0.00 $0.00 $0.00 $0.00 421.539 SUP HCPCS C1713 421.539 - PLATE BONE CRANFCL TI CONTUR MESH RGD LP LG ARC NONSTRL BOTH IP/OP "$3,244.50 " "$2,400.93" $0.00 "$2,595.60" "$1,460.03" "$1,460.03" $0.00 $0.00 $0.00 $676.23 "$2,408.07" "$2,408.07" $0.00 $0.00 $676.15 $0.00 "$1,599.54" "$1,599.54" $0.00 "$1,622.25" "$2,569.64" "$2,595.60" $0.00 $0.00 $507.76 $0.00 $0.00 $516.52 $0.00 $0.00 $0.00 $0.00 $0.00 421.54 SUP HCPCS C1713 421.540 - PLATE BONE 30MM CRANFCL TI CONTUR MESH MALBLE LP NONSTRL BOTH IP/OP "$2,083.50 " "$1,541.79" $0.00 "$1,666.80" $937.58 $937.58 $0.00 $0.00 $0.00 $434.25 "$1,546.37" "$1,546.37" $0.00 $0.00 $434.20 $0.00 "$1,232.39" "$1,232.39" $0.00 "$1,041.75" "$1,650.13" "$1,666.80" $0.00 $0.00 $326.07 $0.00 $0.00 $331.69 $0.00 $0.00 $0.00 $0.00 $0.00 421.541 SUP HCPCS C1713 421.541 - PLATE BONE 70MM CRANFCL TI CONTUR MESH MALBLE LP NONSTRL BOTH IP/OP "$4,311.00 " "$3,190.14" $0.00 "$3,448.80" "$1,939.95" "$1,939.95" $0.00 $0.00 $0.00 $898.52 "$3,199.62" "$3,199.62" $0.00 $0.00 $898.41 $0.00 "$2,125.32" "$2,125.32" $0.00 "$2,155.50" "$3,414.31" "$3,448.80" $0.00 $0.00 $674.67 $0.00 $0.00 $686.31 $0.00 $0.00 $0.00 $0.00 $0.00 421.542 SUP HCPCS C1713 421.542 - PLATE BONE 100MM CRANFCL TI CONTUR MESH MALBLE LP NONSTRL BOTH IP/OP "$5,373.00 " "$3,976.02" $0.00 "$4,298.40" "$2,417.85" "$2,417.85" $0.00 $0.00 $0.00 "$1,119.87" "$3,987.84" "$3,987.84" $0.00 $0.00 "$1,119.73" $0.00 "$2,648.89" "$2,648.89" $0.00 "$2,686.50" "$4,255.42" "$4,298.40" $0.00 $0.00 $840.87 $0.00 $0.00 $855.38 $0.00 $0.00 $0.00 $0.00 $0.00 421.543 SUP HCPCS C1713 421.543 - PLATE TI LP CONTUR MESH RGD BONE 30MM NEURO NONSTRL BOTH IP/OP "$2,083.50 " "$1,541.79" $0.00 "$1,666.80" $937.58 $937.58 $0.00 $0.00 $0.00 $434.25 "$1,546.37" "$1,546.37" $0.00 $0.00 $434.20 $0.00 "$1,232.39" "$1,232.39" $0.00 "$1,041.75" "$1,650.13" "$1,666.80" $0.00 $0.00 $326.07 $0.00 $0.00 $331.69 $0.00 $0.00 $0.00 $0.00 $0.00 421.544 SUP HCPCS C1713 421.544 - PLATE BONE 70MM CRANFCL TI CONTUR MESH RGD LP NONSTRL BOTH IP/OP "$4,311.00 " "$3,190.14" $0.00 "$3,448.80" "$1,939.95" "$1,939.95" $0.00 $0.00 $0.00 $898.52 "$3,199.62" "$3,199.62" $0.00 $0.00 $898.41 $0.00 "$2,125.32" "$2,125.32" $0.00 "$2,155.50" "$3,414.31" "$3,448.80" $0.00 $0.00 $674.67 $0.00 $0.00 $686.31 $0.00 $0.00 $0.00 $0.00 $0.00 421.545 SUP HCPCS C1713 421.545 - PLATE BONE 100MM TI CONTUR MESH MALBLE LP RND BOTH IP/OP "$5,373.00 " "$3,976.02" $0.00 "$4,298.40" "$2,417.85" "$2,417.85" $0.00 $0.00 $0.00 "$1,119.87" "$3,987.84" "$3,987.84" $0.00 $0.00 "$1,119.73" $0.00 "$2,648.89" "$2,648.89" $0.00 "$2,686.50" "$4,255.42" "$4,298.40" $0.00 $0.00 $840.87 $0.00 $0.00 $855.38 $0.00 $0.00 $0.00 $0.00 $0.00 421.546 SUP HCPCS C1713 421.546 - PLATE BN THK.4MM LG BLU NS CNTR MESH LOPRFL TI CRNL MSTD BOTH IP/OP "$2,522.25 " "$1,866.47" $0.00 "$2,017.80" "$1,135.01" "$1,135.01" $0.00 $0.00 $0.00 $525.70 "$1,872.01" "$1,872.01" $0.00 $0.00 $525.64 $0.00 "$1,243.47" "$1,243.47" $0.00 "$1,261.13" "$1,997.62" "$2,017.80" $0.00 $0.00 $394.73 $0.00 $0.00 $401.54 $0.00 $0.00 $0.00 $0.00 $0.00 421.547 SUP HCPCS C1713 421.547 - PLATE MED .4MM MSTD CONTUR MESH MALBLE LP BONE TI BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 421.553 SUP Custom 27803010 421.553 - COVER BUR HOLE 15MM TI SHNT NEURO LP NONSTRL BOTH IP/OP $661.50 $489.51 $0.00 $529.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $490.97 $490.97 $0.00 $0.00 $137.86 $0.00 $0.00 $0.00 $0.00 $330.75 $523.91 $529.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 421.554 SUP Custom 27803010 421.554 - COVER BUR HOLE 17MM CRANFCL TI LP SHNT NONSTRL BOTH IP/OP $661.50 $489.51 $0.00 $529.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $490.97 $490.97 $0.00 $0.00 $137.86 $0.00 $0.00 $0.00 $0.00 $330.75 $523.91 $529.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 422.02 SUP HCPCS C1713 422.02 - PLATE BONE 39X12X1MM 2 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $125.55 $92.91 $0.00 $100.44 $56.50 $56.50 $0.00 $0.00 $0.00 $26.17 $93.18 $93.18 $0.00 $0.00 $26.16 $0.00 $74.26 $74.26 $0.00 $62.78 $99.44 $100.44 $0.00 $0.00 $19.08 $0.00 $0.00 $19.99 $0.00 $0.00 $0.00 $0.00 $0.00 422.03 SUP HCPCS C1713 422.03 - PLATE BONE 55X12X1MM 3 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $133.75 $98.98 $0.00 $107.00 $60.19 $60.19 $0.00 $0.00 $0.00 $27.88 $99.27 $99.27 $0.00 $0.00 $27.87 $0.00 $79.11 $79.11 $0.00 $66.88 $105.93 $107.00 $0.00 $0.00 $20.32 $0.00 $0.00 $21.29 $0.00 $0.00 $0.00 $0.00 $0.00 422.04 SUP HCPCS C1713 422.04 - PLATE BONE 71X12X1MM 4 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $144.68 $107.06 $0.00 $115.74 $65.10 $65.10 $0.00 $0.00 $0.00 $30.15 $107.38 $107.38 $0.00 $0.00 $30.15 $0.00 $85.58 $85.58 $0.00 $72.34 $114.59 $115.74 $0.00 $0.00 $21.98 $0.00 $0.00 $23.03 $0.00 $0.00 $0.00 $0.00 $0.00 422.05 SUP HCPCS C1713 422.05 - PLATE BONE 87X12X1MM 5 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $152.85 $113.11 $0.00 $122.28 $68.78 $68.78 $0.00 $0.00 $0.00 $31.86 $113.45 $113.45 $0.00 $0.00 $31.85 $0.00 $90.41 $90.41 $0.00 $76.43 $121.06 $122.28 $0.00 $0.00 $23.22 $0.00 $0.00 $24.33 $0.00 $0.00 $0.00 $0.00 $0.00 422.06 SUP HCPCS C1713 422.06 - PLATE BONE 103X12X1MM 6 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $162.40 $120.18 $0.00 $129.92 $73.08 $73.08 $0.00 $0.00 $0.00 $33.85 $120.53 $120.53 $0.00 $0.00 $33.84 $0.00 $96.06 $96.06 $0.00 $81.20 $128.62 $129.92 $0.00 $0.00 $24.68 $0.00 $0.00 $25.85 $0.00 $0.00 $0.00 $0.00 $0.00 422.07 SUP HCPCS C1713 422.07 - PLATE BONE 119X12X1MM 7 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $174.30 $128.98 $0.00 $135.38 $76.15 $76.15 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $84.61 $134.03 $135.38 $0.00 $0.00 $25.71 $0.00 $0.00 $26.94 $0.00 $0.00 $0.00 $0.00 $0.00 422.08 SUP HCPCS C1713 422.08 - PLATE BONE 135X12X1MM 8 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $184.25 $136.35 $0.00 $147.40 $82.91 $82.91 $0.00 $0.00 $0.00 $38.40 $136.75 $136.75 $0.00 $0.00 $38.40 $0.00 $108.98 $108.98 $0.00 $92.13 $145.93 $147.40 $0.00 $0.00 $27.99 $0.00 $0.00 $29.33 $0.00 $0.00 $0.00 $0.00 $0.00 422.09 SUP HCPCS C1713 422.09 - PLATE BONE 151X12X1MM 9 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $206.08 $152.50 $0.00 $164.86 $92.73 $92.73 $0.00 $0.00 $0.00 $42.95 $152.95 $152.95 $0.00 $0.00 $42.95 $0.00 $121.89 $121.89 $0.00 $103.04 $163.22 $164.86 $0.00 $0.00 $31.31 $0.00 $0.00 $32.81 $0.00 $0.00 $0.00 $0.00 $0.00 422.1 SUP HCPCS C1713 422.10 - PLATE BONE 167X12X1MM 10 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $207.45 $153.51 $0.00 $165.96 $93.35 $93.35 $0.00 $0.00 $0.00 $43.24 $153.97 $153.97 $0.00 $0.00 $43.23 $0.00 $122.71 $122.71 $0.00 $103.73 $164.30 $165.96 $0.00 $0.00 $31.52 $0.00 $0.00 $33.03 $0.00 $0.00 $0.00 $0.00 $0.00 422.11 SUP HCPCS C1713 422.11 - PLATE BONE 183X12X1MM 11 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $222.45 $164.61 $0.00 $177.96 $100.10 $100.10 $0.00 $0.00 $0.00 $46.36 $165.10 $165.10 $0.00 $0.00 $46.36 $0.00 $131.58 $131.58 $0.00 $111.23 $176.18 $177.96 $0.00 $0.00 $33.80 $0.00 $0.00 $35.41 $0.00 $0.00 $0.00 $0.00 $0.00 422.12 SUP HCPCS C1713 422.12 - PLATE BONE LARGE 183MM 12 HOLE SEMITUBULAR LC-DCP TITANIUM BOTH IP/OP $227.93 $168.67 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $47.51 $169.17 $169.17 $0.00 $0.00 $47.50 $0.00 $134.82 $134.82 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 422.22 SUP HCPCS C1713 422.220 - PLATE BONE 140MM 5 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,913.75 " "$2,156.18" $0.00 "$2,331.00" "$1,311.19" "$1,311.19" $0.00 $0.00 $0.00 $607.30 "$2,162.59" "$2,162.59" $0.00 $0.00 $607.23 $0.00 "$1,436.48" "$1,436.48" $0.00 "$1,456.88" "$2,307.69" "$2,331.00" $0.00 $0.00 $442.72 $0.00 $0.00 $463.87 $0.00 $0.00 $0.00 $0.00 $0.00 422.221 SUP HCPCS C1713 422.221 - PLATE BONE 140MM 5 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$3,001.15 " "$2,220.85" $0.00 "$2,331.00" "$1,311.19" "$1,311.19" $0.00 $0.00 $0.00 $625.51 "$2,227.45" "$2,227.45" $0.00 $0.00 $625.44 $0.00 "$1,479.57" "$1,479.57" $0.00 "$1,456.88" "$2,307.69" "$2,331.00" $0.00 $0.00 $442.72 $0.00 $0.00 $463.87 $0.00 $0.00 $0.00 $0.00 $0.00 422.222 SUP HCPCS C1713 422.222 - PLATE BONE 180MM 7 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$3,061.60 " "$2,265.58" $0.00 "$2,377.94" "$1,337.59" "$1,337.59" $0.00 $0.00 $0.00 $638.11 "$2,272.32" "$2,272.32" $0.00 $0.00 $638.04 $0.00 "$1,509.37" "$1,509.37" $0.00 "$1,486.21" "$2,354.16" "$2,377.94" $0.00 $0.00 $451.64 $0.00 $0.00 $473.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.223 SUP HCPCS C1713 422.223 - PLATE BONE 180MM 7 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$3,061.60 " "$2,265.58" $0.00 "$2,377.94" "$1,337.59" "$1,337.59" $0.00 $0.00 $0.00 $638.11 "$2,272.32" "$2,272.32" $0.00 $0.00 $638.04 $0.00 "$1,509.37" "$1,509.37" $0.00 "$1,486.21" "$2,354.16" "$2,377.94" $0.00 $0.00 $451.64 $0.00 $0.00 $473.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.224 SUP HCPCS C1713 422.224 - PLATE BONE 220MM 9 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$3,124.85 " "$2,312.39" $0.00 "$2,427.08" "$1,365.23" "$1,365.23" $0.00 $0.00 $0.00 $651.30 "$2,319.26" "$2,319.26" $0.00 $0.00 $651.22 $0.00 "$1,540.55" "$1,540.55" $0.00 "$1,516.93" "$2,402.81" "$2,427.08" $0.00 $0.00 $460.97 $0.00 $0.00 $482.99 $0.00 $0.00 $0.00 $0.00 $0.00 422.225 SUP HCPCS C1713 422.225 - PLATE BONE 220MM 9 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$3,124.85 " "$2,312.39" $0.00 "$2,427.08" "$1,365.23" "$1,365.23" $0.00 $0.00 $0.00 $651.30 "$2,319.26" "$2,319.26" $0.00 $0.00 $651.22 $0.00 "$1,540.55" "$1,540.55" $0.00 "$1,516.93" "$2,402.81" "$2,427.08" $0.00 $0.00 $460.97 $0.00 $0.00 $482.99 $0.00 $0.00 $0.00 $0.00 $0.00 422.226 SUP HCPCS C1713 422.226 - PLATE BONE 260MM 11 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$3,185.30 " "$2,357.12" $0.00 "$2,474.02" "$1,391.64" "$1,391.64" $0.00 $0.00 $0.00 $663.90 "$2,364.13" "$2,364.13" $0.00 $0.00 $663.82 $0.00 "$1,570.35" "$1,570.35" $0.00 "$1,546.26" "$2,449.28" "$2,474.02" $0.00 $0.00 $469.88 $0.00 $0.00 $492.33 $0.00 $0.00 $0.00 $0.00 $0.00 422.227 SUP HCPCS C1713 422.227 - PLATE BONE 260MM 11 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$3,185.30 " "$2,357.12" $0.00 "$2,474.02" "$1,391.64" "$1,391.64" $0.00 $0.00 $0.00 $663.90 "$2,364.13" "$2,364.13" $0.00 $0.00 $663.82 $0.00 "$1,570.35" "$1,570.35" $0.00 "$1,546.26" "$2,449.28" "$2,474.02" $0.00 $0.00 $469.88 $0.00 $0.00 $492.33 $0.00 $0.00 $0.00 $0.00 $0.00 422.228 SUP HCPCS C1713 422.228 - PLATE BONE 300MM 13 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$3,248.55 " "$2,403.93" $0.00 "$2,523.14" "$1,419.27" "$1,419.27" $0.00 $0.00 $0.00 $677.08 "$2,411.07" "$2,411.07" $0.00 $0.00 $677.00 $0.00 "$1,601.54" "$1,601.54" $0.00 "$1,576.96" "$2,497.91" "$2,523.14" $0.00 $0.00 $479.21 $0.00 $0.00 $502.10 $0.00 $0.00 $0.00 $0.00 $0.00 422.229 SUP HCPCS C1713 422.229 - PLATE BONE 300MM 13 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$3,248.55 " "$2,403.93" $0.00 "$2,523.14" "$1,419.27" "$1,419.27" $0.00 $0.00 $0.00 $677.08 "$2,411.07" "$2,411.07" $0.00 $0.00 $677.00 $0.00 "$1,601.54" "$1,601.54" $0.00 "$1,576.96" "$2,497.91" "$2,523.14" $0.00 $0.00 $479.21 $0.00 $0.00 $502.10 $0.00 $0.00 $0.00 $0.00 $0.00 422.25 SUP HCPCS C1713 422.250 - PLATE BONE 156MM 5 HOLE LCP TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$2,763.63 " "$2,045.09" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $576.01 "$2,051.16" "$2,051.16" $0.00 $0.00 $575.94 $0.00 "$1,362.47" "$1,362.47" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 422.251 SUP HCPCS C1713 422.251 - PLATE BONE 156MM 5 HOLE LCP TITANIUM FEMUR LEFT DISTAL BOTH IP/OP "$2,846.53 " "$2,106.43" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $593.29 "$2,112.69" "$2,112.69" $0.00 $0.00 $593.22 $0.00 "$1,403.34" "$1,403.34" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 422.252 SUP HCPCS C1713 422.252 - PLATE BONE 196MM 7 HOLE LCP TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$2,904.15 " "$2,149.07" $0.00 "$2,255.66" "$1,268.81" "$1,268.81" $0.00 $0.00 $0.00 $605.30 "$2,155.46" "$2,155.46" $0.00 $0.00 $605.22 $0.00 "$1,431.75" "$1,431.75" $0.00 "$1,409.79" "$2,233.11" "$2,255.66" $0.00 $0.00 $428.41 $0.00 $0.00 $448.88 $0.00 $0.00 $0.00 $0.00 $0.00 422.253 SUP HCPCS C1713 422.253 - PLATE BONE 196MM 7 HOLE LCP TITANIUM FEMUR LEFT DISTAL BOTH IP/OP "$2,904.15 " "$2,149.07" $0.00 "$2,255.66" "$1,268.81" "$1,268.81" $0.00 $0.00 $0.00 $605.30 "$2,155.46" "$2,155.46" $0.00 $0.00 $605.22 $0.00 "$1,431.75" "$1,431.75" $0.00 "$1,409.79" "$2,233.11" "$2,255.66" $0.00 $0.00 $428.41 $0.00 $0.00 $448.88 $0.00 $0.00 $0.00 $0.00 $0.00 422.254 SUP HCPCS C1713 422.254 - PLATE BONE 236MM 9 HOLE LCP TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$2,964.60 " "$2,193.80" $0.00 "$2,302.60" "$1,295.21" "$1,295.21" $0.00 $0.00 $0.00 $617.90 "$2,200.33" "$2,200.33" $0.00 $0.00 $617.82 $0.00 "$1,461.55" "$1,461.55" $0.00 "$1,439.13" "$2,279.57" "$2,302.60" $0.00 $0.00 $437.33 $0.00 $0.00 $458.22 $0.00 $0.00 $0.00 $0.00 $0.00 422.255 SUP HCPCS C1713 422.255 - PLATE BONE 236MM 9 HOLE LCP TITANIUM FEMUR LEFT DISTAL BOTH IP/OP "$2,964.60 " "$2,193.80" $0.00 "$2,302.60" "$1,295.21" "$1,295.21" $0.00 $0.00 $0.00 $617.90 "$2,200.33" "$2,200.33" $0.00 $0.00 $617.82 $0.00 "$1,461.55" "$1,461.55" $0.00 "$1,439.13" "$2,279.57" "$2,302.60" $0.00 $0.00 $437.33 $0.00 $0.00 $458.22 $0.00 $0.00 $0.00 $0.00 $0.00 422.256 SUP HCPCS C1713 422.256 - PLATE BONE 276MM 11 HOLE LCP TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,347.38" "$1,320.40" "$1,320.40" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,467.11" "$2,323.91" "$2,347.38" $0.00 $0.00 $445.83 $0.00 $0.00 $467.13 $0.00 $0.00 $0.00 $0.00 $0.00 422.257 SUP HCPCS C1713 422.257 - PLATE BONE 276MM 11 HOLE LCP TITANIUM FEMUR LEFT DISTAL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,347.38" "$1,320.40" "$1,320.40" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,467.11" "$2,323.91" "$2,347.38" $0.00 $0.00 $445.83 $0.00 $0.00 $467.13 $0.00 $0.00 $0.00 $0.00 $0.00 422.258 SUP HCPCS C1713 422.258 - PLATE BONE 316MM 13 HOLE LCP TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$3,081.28 " "$2,280.15" $0.00 "$2,393.22" "$1,346.19" "$1,346.19" $0.00 $0.00 $0.00 $642.21 "$2,286.92" "$2,286.92" $0.00 $0.00 $642.14 $0.00 "$1,519.07" "$1,519.07" $0.00 "$1,495.76" "$2,369.29" "$2,393.22" $0.00 $0.00 $454.54 $0.00 $0.00 $476.25 $0.00 $0.00 $0.00 $0.00 $0.00 422.259 SUP HCPCS C1713 422.259 - PLATE BONE 316MM 13 HOLE LCP TITANIUM FEMUR LEFT DISTAL BOTH IP/OP "$3,081.28 " "$2,280.15" $0.00 "$2,393.22" "$1,346.19" "$1,346.19" $0.00 $0.00 $0.00 $642.21 "$2,286.92" "$2,286.92" $0.00 $0.00 $642.14 $0.00 "$1,519.07" "$1,519.07" $0.00 "$1,495.76" "$2,369.29" "$2,393.22" $0.00 $0.00 $454.54 $0.00 $0.00 $476.25 $0.00 $0.00 $0.00 $0.00 $0.00 422.3 SUP HCPCS C1713 422.300 - PLATE BONE 140MM 5 HOLE LISS TITANIUM RIGHT PROXIMAL TIBIA BOTH IP/OP "$3,003.83 " "$2,222.83" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $626.07 "$2,229.44" "$2,229.44" $0.00 $0.00 $626.00 $0.00 "$1,480.89" "$1,480.89" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.301 SUP HCPCS C1713 422.301 - PLATE BONE 140MM 5 HOLE LISS TITANIUM LEFT PROXIMAL TIBIA BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.304 SUP HCPCS C1713 422.304 - PLATE BONE 3.5MM 220MM 9 HOLE LISS TITANIUM RIGHT PROXIMAL BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.305 SUP HCPCS C1713 422.305 - PLATE BONE 220MM 9 HOLE LISS TITANIUM LEFT PROXIMAL TIBIA BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.308 SUP HCPCS C1713 422.308 - PLATE BONE 300MM 13 HOLE LISS TITANIUM RIGHT PROXIMAL TIBIA BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.309 SUP HCPCS C1713 422.309 - PLATE BONE 300MM 13 HOLE LISS TITANIUM LEFT PROXIMAL TIBIA BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.34 SUP HCPCS C1713 422.340 - PLATE BONE 156MM 5 HOLE LISS TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$3,003.83 " "$2,222.83" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $626.07 "$2,229.44" "$2,229.44" $0.00 $0.00 $626.00 $0.00 "$1,480.89" "$1,480.89" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.341 SUP HCPCS C1713 422.341 - PLATE BN 156MM NS LISS 5 HL TI FEM LT DIST 5MM LCK SCR BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.344 SUP HCPCS C1713 422.344 - PLATE BN 236MM NS LISS 9 HL TI FEM RT DIST 5MM LCK SCR BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.345 SUP HCPCS C1713 422.345 - PLATE BN 236MM NS LISS 9 HL TI FEM LT DIST 5MM LCK SCR BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.348 SUP HCPCS C1713 422.348 - PLATE BN 316MM NS LISS 13 HL TI FEM RT DIST 5MM LCK SCR BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.349 SUP HCPCS C1713 422.349 - PLATE BN 316MM NS LISS 13 HL TI FEM LT DIST 5MM LCK SCR BOTH IP/OP "$3,093.93 " "$2,289.51" $0.00 "$2,403.06" "$1,351.72" "$1,351.72" $0.00 $0.00 $0.00 $644.85 "$2,296.31" "$2,296.31" $0.00 $0.00 $644.77 $0.00 "$1,525.31" "$1,525.31" $0.00 "$1,501.91" "$2,379.03" "$2,403.06" $0.00 $0.00 $456.40 $0.00 $0.00 $478.21 $0.00 $0.00 $0.00 $0.00 $0.00 422.39 SUP Custom 27203010 422.390 - INSERT SCR HL 5MM LISS TI FEM BOTH IP/OP $176.05 $130.28 $0.00 $140.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.66 $130.66 $0.00 $0.00 $36.69 $0.00 $0.00 $0.00 $0.00 $88.03 $139.43 $140.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 422.391 SUP HCPCS C1713 422.391 - SCREW BONE 3.5MM CONE HEXAGON 5MM 4.4MM 18MM SELF DRILL BOTH IP/OP $395.00 $292.30 $0.00 $306.80 $172.58 $172.58 $0.00 $0.00 $0.00 $82.33 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $233.64 $233.64 $0.00 $191.75 $303.73 $306.80 $0.00 $0.00 $58.27 $0.00 $0.00 $61.05 $0.00 $0.00 $0.00 $0.00 $0.00 422.392 SUP HCPCS C1713 422.392 - SCREW BONE 3.5MM CONE HEXAGON 5MM 4.4MM 26MM SELF DRILL BOTH IP/OP $395.00 $292.30 $0.00 $306.80 $172.58 $172.58 $0.00 $0.00 $0.00 $82.33 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $233.64 $233.64 $0.00 $191.75 $303.73 $306.80 $0.00 $0.00 $58.27 $0.00 $0.00 $61.05 $0.00 $0.00 $0.00 $0.00 $0.00 422.393 SUP HCPCS C1713 422.393 - SCREW BONE 3.5MM CONE HEXAGON 5MM 4.4MM 40MM SELF DRILL BOTH IP/OP $395.00 $292.30 $0.00 $306.80 $172.58 $172.58 $0.00 $0.00 $0.00 $82.33 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $233.64 $233.64 $0.00 $191.75 $303.73 $306.80 $0.00 $0.00 $58.27 $0.00 $0.00 $61.05 $0.00 $0.00 $0.00 $0.00 $0.00 422.394 SUP HCPCS C1713 422.394 - SCREW BONE 3.5MM CONE HEXAGON 5MM 4.4MM 55MM SELF DRILL BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 422.395 SUP HCPCS C1713 422.395 - SCREW BONE 3.5MM CONE HEXAGON 5MM 4.4MM 65MM SELF DRILL BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 422.396 SUP HCPCS C1713 422.396 - SCREW BONE 3.5MM CONE HEXAGON 5MM 4.4MM 75MM SELF DRILL BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 422.397 SUP HCPCS C1713 422.397 - SCREW BONE 3.5MM 5MM 4.4MM 85MM SLFDRILL LOCKING THREADED BOTH IP/OP $402.03 $297.50 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $83.79 $298.38 $298.38 $0.00 $0.00 $83.78 $0.00 $237.80 $237.80 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 422.402 SUP HCPCS C1713 422.402 - SCREW BONE 3.5MM CONE HEXAGON 5MM 4.4MM 14MM SELF DRILL LCP BOTH IP/OP $409.05 $302.70 $0.00 $317.72 $178.72 $178.72 $0.00 $0.00 $0.00 $85.26 $303.60 $303.60 $0.00 $0.00 $85.25 $0.00 $241.95 $241.95 $0.00 $198.58 $314.54 $317.72 $0.00 $0.00 $60.34 $0.00 $0.00 $63.23 $0.00 $0.00 $0.00 $0.00 $0.00 422.404 SUP HCPCS C1713 422.404 - SCREW BONE 3.5MM CONE HEXAGON 5MM 4.4MM 18MM SELF DRILL LCP BOTH IP/OP $409.05 $302.70 $0.00 $317.72 $178.72 $178.72 $0.00 $0.00 $0.00 $85.26 $303.60 $303.60 $0.00 $0.00 $85.25 $0.00 $241.95 $241.95 $0.00 $198.58 $314.54 $317.72 $0.00 $0.00 $60.34 $0.00 $0.00 $63.23 $0.00 $0.00 $0.00 $0.00 $0.00 422.578 SUP Custom 27803010 422.578 - NUT ORTHOPEDIC 5MM TITANIUM TIBIA PROXIMAL MEDIAL NONSTRL BOTH IP/OP $303.63 $224.69 $0.00 $235.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.35 $225.35 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $147.39 $233.47 $235.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 423.406 SUP HCPCS C1713 423.406 - PLATE BONE 86MM 6 HOLE LCP TITANIUM METAPHYSEAL NONSTRL 3.5 BOTH IP/OP "$1,720.58 " "$1,273.23" $0.00 "$1,336.36" $751.70 $751.70 $0.00 $0.00 $0.00 $358.61 "$1,277.01" "$1,277.01" $0.00 $0.00 $358.57 $0.00 "$1,017.72" "$1,017.72" $0.00 $835.23 "$1,323.00" "$1,336.36" $0.00 $0.00 $253.81 $0.00 $0.00 $265.94 $0.00 $0.00 $0.00 $0.00 $0.00 423.407 SUP HCPCS C1713 423.407 - PLATE BONE 99MM 7 HOLE LCP TITANIUM METAPHYSEAL NONSTRL 3.5 BOTH IP/OP "$1,752.90 " "$1,297.15" $0.00 "$1,361.48" $765.83 $765.83 $0.00 $0.00 $0.00 $365.35 "$1,301.00" "$1,301.00" $0.00 $0.00 $365.30 $0.00 "$1,036.84" "$1,036.84" $0.00 $850.93 "$1,347.87" "$1,361.48" $0.00 $0.00 $258.58 $0.00 $0.00 $270.93 $0.00 $0.00 $0.00 $0.00 $0.00 423.408 SUP HCPCS C1713 423.408 - PLATE BONE 112MM 8 HOLE LCP TITANIUM METAPHYSEAL NONSTRL 3.5 BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 423.409 SUP HCPCS C1713 423.409 - PLATE BONE 125MM 9 HOLE LCP TITANIUM METAPHYSEAL NONSTRL 3.5 BOTH IP/OP "$1,807.73 " "$1,337.72" $0.00 "$1,404.06" $789.78 $789.78 $0.00 $0.00 $0.00 $376.78 "$1,341.69" "$1,341.69" $0.00 $0.00 $376.73 $0.00 "$1,069.27" "$1,069.27" $0.00 $877.54 "$1,390.02" "$1,404.06" $0.00 $0.00 $266.67 $0.00 $0.00 $279.41 $0.00 $0.00 $0.00 $0.00 $0.00 423.41 SUP HCPCS C1713 423.410 - PLATE BONE 138MM 10 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$1,783.73 " "$1,319.96" $0.00 "$1,426.98" $802.68 $802.68 $0.00 $0.00 $0.00 $371.77 "$1,323.88" "$1,323.88" $0.00 $0.00 $371.73 $0.00 "$1,055.07" "$1,055.07" $0.00 $891.86 "$1,412.71" "$1,426.98" $0.00 $0.00 $271.02 $0.00 $0.00 $283.97 $0.00 $0.00 $0.00 $0.00 $0.00 423.411 SUP HCPCS C1713 423.411 - PLATE BONE 151MM 11 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$1,868.18 " "$1,382.45" $0.00 "$1,451.00" $816.19 $816.19 $0.00 $0.00 $0.00 $389.37 "$1,386.56" "$1,386.56" $0.00 $0.00 $389.33 $0.00 "$1,105.03" "$1,105.03" $0.00 $906.88 "$1,436.49" "$1,451.00" $0.00 $0.00 $275.58 $0.00 $0.00 $288.75 $0.00 $0.00 $0.00 $0.00 $0.00 423.412 SUP HCPCS C1713 423.412 - PLATE BONE 164MM 12 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,410.78 " "$1,783.98" $0.00 "$1,872.44" "$1,053.25" "$1,053.25" $0.00 $0.00 $0.00 $502.47 "$1,789.28" "$1,789.28" $0.00 $0.00 $502.41 $0.00 "$1,425.97" "$1,425.97" $0.00 "$1,170.28" "$1,853.72" "$1,872.44" $0.00 $0.00 $355.63 $0.00 $0.00 $372.62 $0.00 $0.00 $0.00 $0.00 $0.00 423.414 SUP HCPCS C1713 423.414 - PLATE BONE 190MM 14 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,489.48 " "$1,842.22" $0.00 "$1,933.58" "$1,087.64" "$1,087.64" $0.00 $0.00 $0.00 $518.87 "$1,847.69" "$1,847.69" $0.00 $0.00 $518.81 $0.00 "$1,472.52" "$1,472.52" $0.00 "$1,208.49" "$1,914.25" "$1,933.58" $0.00 $0.00 $367.24 $0.00 $0.00 $384.78 $0.00 $0.00 $0.00 $0.00 $0.00 423.416 SUP HCPCS C1713 423.416 - PLATE BONE 216MM 16 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,542.90 " "$1,881.75" $0.00 "$1,975.06" "$1,110.97" "$1,110.97" $0.00 $0.00 $0.00 $530.00 "$1,887.34" "$1,887.34" $0.00 $0.00 $529.94 $0.00 "$1,253.65" "$1,253.65" $0.00 "$1,234.41" "$1,955.31" "$1,975.06" $0.00 $0.00 $375.12 $0.00 $0.00 $393.04 $0.00 $0.00 $0.00 $0.00 $0.00 423.418 SUP HCPCS C1713 423.418 - PLATE BONE 242MM 18 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,489.48 " "$1,842.22" $0.00 "$1,933.58" "$1,087.64" "$1,087.64" $0.00 $0.00 $0.00 $518.87 "$1,847.69" "$1,847.69" $0.00 $0.00 $518.81 $0.00 "$1,472.52" "$1,472.52" $0.00 "$1,208.49" "$1,914.25" "$1,933.58" $0.00 $0.00 $367.24 $0.00 $0.00 $384.78 $0.00 $0.00 $0.00 $0.00 $0.00 423.52 SUP HCPCS C1713 423.52 - PLATE BONE 25X11X3.3MM 2 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $218.63 $161.79 $0.00 $174.90 $98.38 $98.38 $0.00 $0.00 $0.00 $45.57 $162.26 $162.26 $0.00 $0.00 $45.56 $0.00 $129.32 $129.32 $0.00 $109.31 $173.15 $174.90 $0.00 $0.00 $34.21 $0.00 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 423.521 SUP HCPCS C1713 423.521 - PLATE BONE 33MM 2 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5MM BOTH IP/OP $490.58 $363.03 $0.00 $381.04 $214.34 $214.34 $0.00 $0.00 $0.00 $102.25 $364.10 $364.10 $0.00 $0.00 $102.24 $0.00 $290.18 $290.18 $0.00 $238.15 $377.23 $381.04 $0.00 $0.00 $72.37 $0.00 $0.00 $75.83 $0.00 $0.00 $0.00 $0.00 $0.00 423.53 SUP HCPCS C1713 423.53 - PLATE BONE 38X11X3.3MM 3 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $222.60 $164.72 $0.00 $178.08 $100.17 $100.17 $0.00 $0.00 $0.00 $46.40 $165.21 $165.21 $0.00 $0.00 $46.39 $0.00 $131.67 $131.67 $0.00 $111.30 $176.30 $178.08 $0.00 $0.00 $34.84 $0.00 $0.00 $35.44 $0.00 $0.00 $0.00 $0.00 $0.00 423.531 SUP HCPCS C1713 423.531 - PLATE BONE 46MM 3 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5MM BOTH IP/OP $510.28 $377.61 $0.00 $396.32 $222.93 $222.93 $0.00 $0.00 $0.00 $106.35 $378.73 $378.73 $0.00 $0.00 $106.34 $0.00 $301.83 $301.83 $0.00 $247.70 $392.36 $396.32 $0.00 $0.00 $75.27 $0.00 $0.00 $78.87 $0.00 $0.00 $0.00 $0.00 $0.00 423.54 SUP HCPCS C1713 423.54 - PLATE BONE 3.5MM 51X11X3.3MM 4 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $229.23 $169.63 $0.00 $183.38 $103.15 $103.15 $0.00 $0.00 $0.00 $47.78 $170.13 $170.13 $0.00 $0.00 $47.77 $0.00 $135.59 $135.59 $0.00 $114.61 $181.55 $183.38 $0.00 $0.00 $35.87 $0.00 $0.00 $36.49 $0.00 $0.00 $0.00 $0.00 $0.00 423.541 SUP HCPCS C1713 423.541 - PLATE BONE 59MM 4 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5MM BOTH IP/OP $532.75 $394.24 $0.00 $413.80 $232.76 $232.76 $0.00 $0.00 $0.00 $111.04 $395.41 $395.41 $0.00 $0.00 $111.03 $0.00 $315.12 $315.12 $0.00 $258.63 $409.66 $413.80 $0.00 $0.00 $78.59 $0.00 $0.00 $82.35 $0.00 $0.00 $0.00 $0.00 $0.00 423.55 SUP HCPCS C1713 423.55 - PLATE BONE 64X11X3.3MM 5 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $241.15 $178.45 $0.00 $192.92 $108.52 $108.52 $0.00 $0.00 $0.00 $50.26 $178.98 $178.98 $0.00 $0.00 $50.26 $0.00 $142.64 $142.64 $0.00 $120.58 $190.99 $192.92 $0.00 $0.00 $37.74 $0.00 $0.00 $38.39 $0.00 $0.00 $0.00 $0.00 $0.00 423.551 SUP HCPCS C1713 423.551 - PLATE BONE 72X11X3.4MM 5 HOLE LCP TITANIUM HUMERUS RAD ULNA BOTH IP/OP $549.63 $406.73 $0.00 $426.90 $240.13 $240.13 $0.00 $0.00 $0.00 $114.56 $407.93 $407.93 $0.00 $0.00 $114.54 $0.00 $325.10 $325.10 $0.00 $266.81 $422.63 $426.90 $0.00 $0.00 $81.08 $0.00 $0.00 $84.95 $0.00 $0.00 $0.00 $0.00 $0.00 423.56 SUP HCPCS C1713 423.56 - PLATE BONE 77X11X3.3MM 6 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $258.38 $191.20 $0.00 $206.70 $116.27 $116.27 $0.00 $0.00 $0.00 $53.85 $191.77 $191.77 $0.00 $0.00 $53.85 $0.00 $152.83 $152.83 $0.00 $129.19 $204.64 $206.70 $0.00 $0.00 $40.44 $0.00 $0.00 $41.13 $0.00 $0.00 $0.00 $0.00 $0.00 423.561 SUP HCPCS C1713 423.561 - PLATE BONE 85X11X3.4MM 6 HOLE LCP TITANIUM HUMERUS RAD ULNA BOTH IP/OP $584.78 $432.74 $0.00 $454.18 $255.48 $255.48 $0.00 $0.00 $0.00 $121.88 $434.02 $434.02 $0.00 $0.00 $121.87 $0.00 $345.89 $345.89 $0.00 $283.86 $449.64 $454.18 $0.00 $0.00 $86.26 $0.00 $0.00 $90.38 $0.00 $0.00 $0.00 $0.00 $0.00 423.57 SUP HCPCS C1713 423.57 - PLATE BN 90X11X3.3MM NS LC DCP 7 HL TI 3.5MM SCR SM FRAG SET BOTH IP/OP $267.65 $198.06 $0.00 $214.12 $120.44 $120.44 $0.00 $0.00 $0.00 $55.78 $198.65 $198.65 $0.00 $0.00 $55.78 $0.00 $158.31 $158.31 $0.00 $133.83 $211.98 $214.12 $0.00 $0.00 $41.89 $0.00 $0.00 $42.61 $0.00 $0.00 $0.00 $0.00 $0.00 423.571 SUP HCPCS C1713 423.571 - PLATE BN 98X11X3.4MM NS LCP CMBN 7 HL LMT CNTCT TPR END TI BOTH IP/OP $608.68 $450.42 $0.00 $472.74 $265.92 $265.92 $0.00 $0.00 $0.00 $126.86 $451.76 $451.76 $0.00 $0.00 $126.85 $0.00 $360.03 $360.03 $0.00 $295.46 $468.02 $472.74 $0.00 $0.00 $89.79 $0.00 $0.00 $94.08 $0.00 $0.00 $0.00 $0.00 $0.00 423.58 SUP HCPCS C1713 423.58 - PLATE BONE SMALL 103X11X3.3MM 8 HOLE LC-DCP TITANIUM BOTH IP/OP $282.23 $208.85 $0.00 $225.78 $127.00 $127.00 $0.00 $0.00 $0.00 $58.82 $209.47 $209.47 $0.00 $0.00 $58.82 $0.00 $166.94 $166.94 $0.00 $141.11 $223.53 $225.78 $0.00 $0.00 $44.17 $0.00 $0.00 $44.93 $0.00 $0.00 $0.00 $0.00 $0.00 423.581 SUP HCPCS C1713 423.581 - PLATE BN 111X11X3.4MM NS LCP CMBN 8 HL LMT CNTCT TPR END TI BOTH IP/OP $639.60 $473.30 $0.00 $496.76 $279.43 $279.43 $0.00 $0.00 $0.00 $133.31 $474.71 $474.71 $0.00 $0.00 $133.29 $0.00 $378.32 $378.32 $0.00 $310.48 $491.79 $496.76 $0.00 $0.00 $94.35 $0.00 $0.00 $98.86 $0.00 $0.00 $0.00 $0.00 $0.00 423.59 SUP HCPCS C1713 423.59 - PLATE BN 116X11X3.3MM NS LC DCP 9 HL TI 3.5MM SCR SM FRAG BOTH IP/OP $304.75 $225.52 $0.00 $243.80 $137.14 $137.14 $0.00 $0.00 $0.00 $63.52 $226.19 $226.19 $0.00 $0.00 $63.51 $0.00 $180.26 $180.26 $0.00 $152.38 $241.36 $243.80 $0.00 $0.00 $47.69 $0.00 $0.00 $48.52 $0.00 $0.00 $0.00 $0.00 $0.00 423.591 SUP HCPCS C1713 423.591 - PLATE BONE 124X11X3.4MM 9 HOLE LCP TITANIUM HUMERUS RAD ULNA BOTH IP/OP $664.90 $492.03 $0.00 $516.42 $290.49 $290.49 $0.00 $0.00 $0.00 $138.58 $493.49 $493.49 $0.00 $0.00 $138.57 $0.00 $393.29 $393.29 $0.00 $322.76 $511.26 $516.42 $0.00 $0.00 $98.08 $0.00 $0.00 $102.77 $0.00 $0.00 $0.00 $0.00 $0.00 423.6 SUP HCPCS C1713 423.60 - PLATE BONE 129X11X3.3MM 10 HOLE LC-DCP TITANIUM DISTAL TIBIA BOTH IP/OP $308.73 $228.46 $0.00 $246.98 $138.93 $138.93 $0.00 $0.00 $0.00 $64.35 $229.14 $229.14 $0.00 $0.00 $64.34 $0.00 $182.61 $182.61 $0.00 $154.36 $244.51 $246.98 $0.00 $0.00 $48.32 $0.00 $0.00 $49.15 $0.00 $0.00 $0.00 $0.00 $0.00 423.601 SUP HCPCS C1713 423.601 - PLATE BONE 137X11X3.4MM 10 HOLE LCP TITANIUM HUMERUS RAD BOTH IP/OP $685.98 $507.63 $0.00 $532.80 $299.70 $299.70 $0.00 $0.00 $0.00 $142.97 $509.13 $509.13 $0.00 $0.00 $142.96 $0.00 $405.75 $405.75 $0.00 $333.00 $527.47 $532.80 $0.00 $0.00 $101.19 $0.00 $0.00 $106.03 $0.00 $0.00 $0.00 $0.00 $0.00 423.61 SUP HCPCS C1713 423.61 - PLATE BONE 142X11X3.3MM 11 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $324.63 $240.23 $0.00 $259.70 $146.08 $146.08 $0.00 $0.00 $0.00 $67.66 $240.94 $240.94 $0.00 $0.00 $67.65 $0.00 $192.02 $192.02 $0.00 $162.31 $257.11 $259.70 $0.00 $0.00 $50.80 $0.00 $0.00 $51.68 $0.00 $0.00 $0.00 $0.00 $0.00 423.611 SUP HCPCS C1713 423.611 - PLATE BONE 150MM 11 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5 BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 423.62 SUP HCPCS C1713 423.62 - PLATE BONE 3.5MM 155X11X3.3MM 12 HOLE LC-DCP TITANIUM BOTH IP/OP $347.15 $256.89 $0.00 $277.72 $156.22 $156.22 $0.00 $0.00 $0.00 $72.35 $257.65 $257.65 $0.00 $0.00 $72.35 $0.00 $205.34 $205.34 $0.00 $173.58 $274.94 $277.72 $0.00 $0.00 $54.33 $0.00 $0.00 $55.27 $0.00 $0.00 $0.00 $0.00 $0.00 423.621 SUP HCPCS C1713 423.621 - PLATE BONE 163X11X3.4MM 12 HOLE LCP TITANIUM HUMERUS RAD BOTH IP/OP $756.28 $559.65 $0.00 $587.38 $330.40 $330.40 $0.00 $0.00 $0.00 $157.63 $561.31 $561.31 $0.00 $0.00 $157.61 $0.00 $447.34 $447.34 $0.00 $367.11 $581.51 $587.38 $0.00 $0.00 $111.56 $0.00 $0.00 $116.89 $0.00 $0.00 $0.00 $0.00 $0.00 423.631 SUP HCPCS C1713 423.631 - PLATE BONE 176MM 13 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5 BOTH IP/OP $898.25 $664.71 $0.00 $697.66 $392.43 $392.43 $0.00 $0.00 $0.00 $187.22 $666.68 $666.68 $0.00 $0.00 $187.20 $0.00 $531.31 $531.31 $0.00 $436.04 $690.69 $697.66 $0.00 $0.00 $132.50 $0.00 $0.00 $138.83 $0.00 $0.00 $0.00 $0.00 $0.00 423.64 SUP HCPCS C1713 423.64 - PLATE BONE 181X11X3.3MM 14 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $642.63 $475.55 $0.00 $514.10 $289.18 $289.18 $0.00 $0.00 $0.00 $133.94 $476.96 $476.96 $0.00 $0.00 $133.92 $0.00 $380.11 $380.11 $0.00 $321.31 $508.96 $514.10 $0.00 $0.00 $100.57 $0.00 $0.00 $102.31 $0.00 $0.00 $0.00 $0.00 $0.00 423.641 SUP HCPCS C1713 423.641 - PLATE BONE 189X11X3.4MM 14 HOLE LCP TITANIUM HUMERUS RAD BOTH IP/OP "$1,134.40 " $839.46 $0.00 $881.08 $495.61 $495.61 $0.00 $0.00 $0.00 $236.44 $841.95 $841.95 $0.00 $0.00 $236.41 $0.00 $671.00 $671.00 $0.00 $550.68 $872.27 $881.08 $0.00 $0.00 $167.34 $0.00 $0.00 $175.33 $0.00 $0.00 $0.00 $0.00 $0.00 423.65 SUP HCPCS C1713 423.65 - PLATE BONE 195X11X3.3MM 15 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $673.10 $498.09 $0.00 $538.48 $302.90 $302.90 $0.00 $0.00 $0.00 $140.29 $499.57 $499.57 $0.00 $0.00 $140.27 $0.00 $398.14 $398.14 $0.00 $336.55 $533.10 $538.48 $0.00 $0.00 $105.34 $0.00 $0.00 $107.16 $0.00 $0.00 $0.00 $0.00 $0.00 423.651 SUP HCPCS C1713 423.651 - PLATE BONE 202MM 15 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5 BOTH IP/OP "$1,214.53 " $898.75 $0.00 $943.32 $530.62 $530.62 $0.00 $0.00 $0.00 $253.14 $901.42 $901.42 $0.00 $0.00 $253.11 $0.00 $718.39 $718.39 $0.00 $589.58 $933.89 $943.32 $0.00 $0.00 $179.16 $0.00 $0.00 $187.72 $0.00 $0.00 $0.00 $0.00 $0.00 423.66 SUP HCPCS C1713 423.66 - PLATE BONE 207X11X3.3MM 16 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $738.03 $546.14 $0.00 $590.42 $332.11 $332.11 $0.00 $0.00 $0.00 $153.82 $547.76 $547.76 $0.00 $0.00 $153.80 $0.00 $436.54 $436.54 $0.00 $369.01 $584.52 $590.42 $0.00 $0.00 $115.50 $0.00 $0.00 $117.49 $0.00 $0.00 $0.00 $0.00 $0.00 423.661 SUP HCPCS C1713 423.661 - PLATE BONE 215MM 16 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5 BOTH IP/OP "$1,270.75 " $940.36 $0.00 $986.98 $555.18 $555.18 $0.00 $0.00 $0.00 $264.86 $943.15 $943.15 $0.00 $0.00 $264.82 $0.00 $751.65 $751.65 $0.00 $616.86 $977.11 $986.98 $0.00 $0.00 $187.46 $0.00 $0.00 $196.41 $0.00 $0.00 $0.00 $0.00 $0.00 423.671 SUP HCPCS C1713 423.671 - PLATE BONE 241MM 18 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5 BOTH IP/OP "$1,425.38 " "$1,054.78" $0.00 "$1,107.08" $622.73 $622.73 $0.00 $0.00 $0.00 $297.08 "$1,057.91" "$1,057.91" $0.00 $0.00 $297.05 $0.00 $843.11 $843.11 $0.00 $691.93 "$1,096.01" "$1,107.08" $0.00 $0.00 $210.27 $0.00 $0.00 $220.31 $0.00 $0.00 $0.00 $0.00 $0.00 423.68 SUP HCPCS C1713 423.68 - PLATE BONE 233X11X3.3MM 18 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $825.48 $610.86 $0.00 $660.38 $371.46 $371.46 $0.00 $0.00 $0.00 $172.05 $612.67 $612.67 $0.00 $0.00 $172.03 $0.00 $488.27 $488.27 $0.00 $412.74 $653.78 $660.38 $0.00 $0.00 $129.19 $0.00 $0.00 $131.42 $0.00 $0.00 $0.00 $0.00 $0.00 423.681 SUP HCPCS C1713 423.681 - PLATE BONE 267MM 20 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5 BOTH IP/OP "$1,582.80 " "$1,171.27" $0.00 "$1,229.36" $691.52 $691.52 $0.00 $0.00 $0.00 $329.90 "$1,174.75" "$1,174.75" $0.00 $0.00 $329.86 $0.00 $936.23 $936.23 $0.00 $768.35 "$1,217.07" "$1,229.36" $0.00 $0.00 $233.49 $0.00 $0.00 $244.64 $0.00 $0.00 $0.00 $0.00 $0.00 423.691 SUP HCPCS C1713 423.691 - PLATE BONE 293MM 22 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 3.5 BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 423.7 SUP HCPCS C1713 423.70 - PLATE BONE 259X11X3.3MM 20 HOLE LC-DCP TITANIUM CLAVICLE BOTH IP/OP $914.25 $676.55 $0.00 $731.40 $411.41 $411.41 $0.00 $0.00 $0.00 $190.55 $678.56 $678.56 $0.00 $0.00 $190.53 $0.00 $540.78 $540.78 $0.00 $457.13 $724.09 $731.40 $0.00 $0.00 $143.08 $0.00 $0.00 $145.55 $0.00 $0.00 $0.00 $0.00 $0.00 424.519 SUP Custom 27803010 "424.519 - 5.5MM SS STRAIGHT ROD, HEX-END, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 424.52 SUP Custom 27803010 "424.520 - 5.5MM SS STRAIGHT ROD, HEX-END, 400MM" BOTH IP/OP $320.73 $237.34 $0.00 $396.00 $144.33 $144.33 $0.00 $0.00 $0.00 $66.85 $238.04 $238.04 $0.00 $0.00 $66.84 $0.00 $189.71 $189.71 $0.00 $160.36 $396.00 $256.58 $0.00 $0.00 $48.73 $0.00 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $0.00 424.52 SUP HCPCS C1713 424.52 - PLATE BONE NARROW 34X13.5X4.2MM 2 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $320.73 $237.34 $0.00 $256.58 $144.33 $144.33 $0.00 $0.00 $0.00 $66.85 $238.04 $238.04 $0.00 $0.00 $66.84 $0.00 $189.71 $189.71 $0.00 $160.36 $254.02 $256.58 $0.00 $0.00 $48.73 $0.00 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $0.00 424.521 SUP Custom 27803010 424.521 - PLATE BONE NARROW 44MM 2 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $588.98 $435.85 $0.00 $457.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $437.14 $437.14 $0.00 $0.00 $122.74 $0.00 $0.00 $0.00 $0.00 $285.91 $452.89 $457.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 424.53 SUP HCPCS C1713 424.53 - PLATE BONE NARROW 52X13.5X4.2MM 3 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $320.73 $237.34 $0.00 $256.58 $144.33 $144.33 $0.00 $0.00 $0.00 $66.85 $238.04 $238.04 $0.00 $0.00 $66.84 $0.00 $189.71 $189.71 $0.00 $160.36 $254.02 $256.58 $0.00 $0.00 $48.73 $0.00 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $0.00 424.531 SUP HCPCS C1713 424.531 - PLATE BONE NARROW 62MM 3 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $596.03 $441.06 $0.00 $462.92 $260.39 $260.39 $0.00 $0.00 $0.00 $124.23 $442.37 $442.37 $0.00 $0.00 $124.21 $0.00 $352.55 $352.55 $0.00 $289.33 $458.29 $462.92 $0.00 $0.00 $87.92 $0.00 $0.00 $92.12 $0.00 $0.00 $0.00 $0.00 $0.00 424.54 SUP HCPCS C1713 424.54 - PLATE BONE NARROW 70X13.5X4.2MM 4 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $320.73 $237.34 $0.00 $256.58 $144.33 $144.33 $0.00 $0.00 $0.00 $66.85 $238.04 $238.04 $0.00 $0.00 $66.84 $0.00 $189.71 $189.71 $0.00 $160.36 $254.02 $256.58 $0.00 $0.00 $48.73 $0.00 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $0.00 424.541 SUP HCPCS C1713 424.541 - PLATE BONE NARROW 80MM 4 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 424.55 SUP HCPCS C1713 424.55 - PLATE BONE NARROW 88X13.5X4.2MM 5 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $320.73 $237.34 $0.00 $256.58 $144.33 $144.33 $0.00 $0.00 $0.00 $66.85 $238.04 $238.04 $0.00 $0.00 $66.84 $0.00 $189.71 $189.71 $0.00 $160.36 $254.02 $256.58 $0.00 $0.00 $48.73 $0.00 $0.00 $51.06 $0.00 $0.00 $0.00 $0.00 $0.00 424.551 SUP HCPCS C1713 424.551 - PLATE BONE NARROW 98MM 5 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $694.40 $513.86 $0.00 $539.34 $303.38 $303.38 $0.00 $0.00 $0.00 $144.73 $515.38 $515.38 $0.00 $0.00 $144.71 $0.00 $410.74 $410.74 $0.00 $337.09 $533.95 $539.34 $0.00 $0.00 $102.44 $0.00 $0.00 $107.33 $0.00 $0.00 $0.00 $0.00 $0.00 424.56 SUP HCPCS C1713 424.56 - PLATE BONE NARROW 106X13.5X4.2MM 6 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $360.30 $266.62 $0.00 $288.24 $162.14 $162.14 $0.00 $0.00 $0.00 $75.10 $267.41 $267.41 $0.00 $0.00 $75.09 $0.00 $213.12 $213.12 $0.00 $180.15 $285.36 $288.24 $0.00 $0.00 $54.74 $0.00 $0.00 $57.36 $0.00 $0.00 $0.00 $0.00 $0.00 424.561 SUP HCPCS C1713 424.561 - PLATE BONE NARROW 116MM 6 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 424.57 SUP HCPCS C1713 424.57 - PLATE BONE NARROW 124X13.5X4.2MM 7 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $349.80 $258.85 $0.00 $279.84 $157.41 $157.41 $0.00 $0.00 $0.00 $72.91 $259.62 $259.62 $0.00 $0.00 $72.90 $0.00 $206.91 $206.91 $0.00 $174.90 $277.04 $279.84 $0.00 $0.00 $54.74 $0.00 $0.00 $55.69 $0.00 $0.00 $0.00 $0.00 $0.00 424.571 SUP HCPCS C1713 424.571 - PLATE BONE NARROW 134MM 7 HOLE LCP TITANIUM ORTHOPEDIC 4.5MM BOTH IP/OP $850.45 $629.33 $0.00 $660.54 $371.55 $371.55 $0.00 $0.00 $0.00 $177.26 $631.20 $631.20 $0.00 $0.00 $177.23 $0.00 $503.04 $503.04 $0.00 $412.84 $653.94 $660.54 $0.00 $0.00 $125.45 $0.00 $0.00 $131.45 $0.00 $0.00 $0.00 $0.00 $0.00 424.58 SUP HCPCS C1713 424.58 - PLATE BONE NARROW 4.5MM 142X13.5X4.2MM 8 HOLE LC-DCP BOTH IP/OP $371.10 $274.61 $0.00 $288.24 $162.14 $162.14 $0.00 $0.00 $0.00 $77.35 $275.43 $275.43 $0.00 $0.00 $77.34 $0.00 $219.51 $219.51 $0.00 $180.15 $285.36 $288.24 $0.00 $0.00 $54.74 $0.00 $0.00 $57.36 $0.00 $0.00 $0.00 $0.00 $0.00 424.581 SUP HCPCS C1713 424.581 - PLATE BONE NARROW 152MM 8 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $899.65 $665.74 $0.00 $698.76 $393.05 $393.05 $0.00 $0.00 $0.00 $187.51 $667.72 $667.72 $0.00 $0.00 $187.49 $0.00 $532.14 $532.14 $0.00 $436.73 $691.77 $698.76 $0.00 $0.00 $132.71 $0.00 $0.00 $139.05 $0.00 $0.00 $0.00 $0.00 $0.00 424.59 SUP HCPCS C1713 424.59 - PLATE BONE NARROW 160X13.5X4.2MM 9 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $350.75 $259.56 $0.00 $280.60 $157.84 $157.84 $0.00 $0.00 $0.00 $73.11 $260.33 $260.33 $0.00 $0.00 $73.10 $0.00 $207.47 $207.47 $0.00 $175.38 $277.79 $280.60 $0.00 $0.00 $53.29 $0.00 $0.00 $55.84 $0.00 $0.00 $0.00 $0.00 $0.00 424.591 SUP HCPCS C1713 424.591 - PLATE BONE NARROW 170MM 9 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $941.83 $696.95 $0.00 $731.50 $411.47 $411.47 $0.00 $0.00 $0.00 $196.30 $699.02 $699.02 $0.00 $0.00 $196.28 $0.00 $557.09 $557.09 $0.00 $457.19 $724.19 $731.50 $0.00 $0.00 $138.93 $0.00 $0.00 $145.57 $0.00 $0.00 $0.00 $0.00 $0.00 424.6 SUP HCPCS C1713 424.60 - PLATE BONE NARROW 4.5MM 178X13.5X4.2MM 10 HOLE LC-DCP BOTH IP/OP $454.45 $336.29 $0.00 $363.56 $204.50 $204.50 $0.00 $0.00 $0.00 $94.72 $337.29 $337.29 $0.00 $0.00 $94.71 $0.00 $268.81 $268.81 $0.00 $227.23 $359.92 $363.56 $0.00 $0.00 $69.05 $0.00 $0.00 $72.35 $0.00 $0.00 $0.00 $0.00 $0.00 424.601 SUP HCPCS C1713 424.601 - PLATE BONE NARROW 188MM 10 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,023.35 " $757.28 $0.00 $794.84 $447.10 $447.10 $0.00 $0.00 $0.00 $213.29 $759.53 $759.53 $0.00 $0.00 $213.27 $0.00 $605.31 $605.31 $0.00 $496.78 $786.89 $794.84 $0.00 $0.00 $150.96 $0.00 $0.00 $158.17 $0.00 $0.00 $0.00 $0.00 $0.00 424.61 SUP HCPCS C1713 424.61 - PLATE BONE NARROW 4.5MM 206MM 11 HOLE LCP TITANIUM NONSTRL BOTH IP/OP $468.10 $346.39 $0.00 $374.48 $210.65 $210.65 $0.00 $0.00 $0.00 $97.56 $347.42 $347.42 $0.00 $0.00 $97.55 $0.00 $276.88 $276.88 $0.00 $234.05 $370.74 $374.48 $0.00 $0.00 $71.13 $0.00 $0.00 $74.52 $0.00 $0.00 $0.00 $0.00 $0.00 424.611 SUP HCPCS C1713 424.611 - PLATE BONE NARROW 206MM 11 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,102.08 " $815.54 $0.00 $855.98 $481.49 $481.49 $0.00 $0.00 $0.00 $229.70 $817.96 $817.96 $0.00 $0.00 $229.67 $0.00 $651.88 $651.88 $0.00 $534.99 $847.42 $855.98 $0.00 $0.00 $162.57 $0.00 $0.00 $170.34 $0.00 $0.00 $0.00 $0.00 $0.00 424.62 SUP HCPCS C1713 424.62 - PLATE BONE NARROW 214X13.5X4.2MM 12 HOLE LC-DCP TITANIUM BOTH IP/OP $441.23 $326.51 $0.00 $352.98 $198.55 $198.55 $0.00 $0.00 $0.00 $91.96 $327.48 $327.48 $0.00 $0.00 $91.95 $0.00 $260.98 $260.98 $0.00 $220.61 $349.45 $352.98 $0.00 $0.00 $69.05 $0.00 $0.00 $70.24 $0.00 $0.00 $0.00 $0.00 $0.00 424.621 SUP HCPCS C1713 424.621 - PLATE BONE NARROW 224MM 12 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 424.63 SUP HCPCS C1713 424.63 - PLATE BONE NARROW 232X13.5X4.2MM 13 HOLE LC-DCP TITANIUM BOTH IP/OP $544.53 $402.95 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $113.49 $404.15 $404.15 $0.00 $0.00 $113.48 $0.00 $322.09 $322.09 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 424.631 SUP HCPCS C1713 424.631 - PLATE BONE NARROW 242MM 13 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,265.13 " $936.20 $0.00 $982.62 $552.72 $552.72 $0.00 $0.00 $0.00 $263.68 $938.98 $938.98 $0.00 $0.00 $263.65 $0.00 $748.32 $748.32 $0.00 $614.14 $972.80 $982.62 $0.00 $0.00 $186.63 $0.00 $0.00 $195.54 $0.00 $0.00 $0.00 $0.00 $0.00 424.64 SUP HCPCS C1713 424.64 - PLATE BONE NARROW 4.5MM 250X13.5X4.2MM 14 HOLE LC-DCP BOTH IP/OP $545.40 $403.60 $0.00 $423.62 $238.29 $238.29 $0.00 $0.00 $0.00 $113.67 $404.80 $404.80 $0.00 $0.00 $113.66 $0.00 $322.60 $322.60 $0.00 $264.76 $419.39 $423.62 $0.00 $0.00 $80.46 $0.00 $0.00 $84.30 $0.00 $0.00 $0.00 $0.00 $0.00 424.641 SUP HCPCS C1713 424.641 - PLATE BONE NARROW 260MM 14 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,328.38 " $983.00 $0.00 "$1,031.76" $580.37 $580.37 $0.00 $0.00 $0.00 $276.87 $985.92 $985.92 $0.00 $0.00 $276.83 $0.00 $785.73 $785.73 $0.00 $644.85 "$1,021.44" "$1,031.76" $0.00 $0.00 $195.96 $0.00 $0.00 $205.32 $0.00 $0.00 $0.00 $0.00 $0.00 424.65 SUP HCPCS C1713 424.65 - PLATE BONE NARROW 4.5MM 268MM 15 HOLE LC-DCP TITANIUM BOTH IP/OP $544.53 $402.95 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $113.49 $404.15 $404.15 $0.00 $0.00 $113.48 $0.00 $322.09 $322.09 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 424.651 SUP HCPCS C1713 424.651 - PLATE BONE NARROW 278MM 15 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,445.05 " "$1,069.34" $0.00 "$1,122.38" $631.34 $631.34 $0.00 $0.00 $0.00 $301.18 "$1,072.52" "$1,072.52" $0.00 $0.00 $301.15 $0.00 $854.75 $854.75 $0.00 $701.49 "$1,111.16" "$1,122.38" $0.00 $0.00 $213.17 $0.00 $0.00 $223.35 $0.00 $0.00 $0.00 $0.00 $0.00 424.66 SUP HCPCS C1713 424.66 - PLATE BONE NARROW 4.5MM 286MM 16 HOLE LC-DCP TITANIUM BOTH IP/OP $544.53 $402.95 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $113.49 $404.15 $404.15 $0.00 $0.00 $113.48 $0.00 $322.09 $322.09 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 424.661 SUP HCPCS C1713 424.661 - PLATE BONE NARROW 296MM 16 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,553.30 " "$1,149.44" $0.00 "$1,206.44" $678.62 $678.62 $0.00 $0.00 $0.00 $323.75 "$1,152.86" "$1,152.86" $0.00 $0.00 $323.71 $0.00 $918.78 $918.78 $0.00 $754.03 "$1,194.38" "$1,206.44" $0.00 $0.00 $229.14 $0.00 $0.00 $240.08 $0.00 $0.00 $0.00 $0.00 $0.00 424.67 SUP HCPCS C1713 424.67 - PLATE BONE NARROW 4.5MM 305MM 17 HOLE LC-DCP TITANIUM BOTH IP/OP $799.75 $591.82 $0.00 $639.80 $359.89 $359.89 $0.00 $0.00 $0.00 $166.69 $593.57 $593.57 $0.00 $0.00 $166.67 $0.00 $473.05 $473.05 $0.00 $399.88 $633.40 $639.80 $0.00 $0.00 $121.51 $0.00 $0.00 $127.32 $0.00 $0.00 $0.00 $0.00 $0.00 424.68 SUP HCPCS C1713 424.68 - PLATE BONE NARROW 4.5MM 323MM 18 HOLE LC-DCP TITANIUM BOTH IP/OP $799.75 $591.82 $0.00 $639.80 $359.89 $359.89 $0.00 $0.00 $0.00 $166.69 $593.57 $593.57 $0.00 $0.00 $166.67 $0.00 $473.05 $473.05 $0.00 $399.88 $633.40 $639.80 $0.00 $0.00 $121.51 $0.00 $0.00 $127.32 $0.00 $0.00 $0.00 $0.00 $0.00 424.681 SUP HCPCS C1713 424.681 - PLATE BONE NARROW 332MM 18 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,824.60 " "$1,350.20" $0.00 "$1,417.16" $797.15 $797.15 $0.00 $0.00 $0.00 $380.29 "$1,354.22" "$1,354.22" $0.00 $0.00 $380.25 $0.00 "$1,079.25" "$1,079.25" $0.00 $885.73 "$1,402.99" "$1,417.16" $0.00 $0.00 $269.16 $0.00 $0.00 $282.01 $0.00 $0.00 $0.00 $0.00 $0.00 424.7 SUP HCPCS C1713 424.70 - PLATE BONE NARROW 358X13.5X4.2MM 20 HOLE LC-DCP TITANIUM BOTH IP/OP "$1,123.20 " $831.17 $0.00 $898.56 $505.44 $505.44 $0.00 $0.00 $0.00 $234.10 $833.64 $833.64 $0.00 $0.00 $234.07 $0.00 $664.37 $664.37 $0.00 $561.60 $889.57 $898.56 $0.00 $0.00 $170.66 $0.00 $0.00 $178.81 $0.00 $0.00 $0.00 $0.00 $0.00 424.701 SUP HCPCS C1713 424.701 - PLATE BONE NARROW 368MM 20 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,319.40 " "$1,716.36" $0.00 "$1,801.48" "$1,013.33" "$1,013.33" $0.00 $0.00 $0.00 $483.42 "$1,721.46" "$1,721.46" $0.00 $0.00 $483.36 $0.00 "$1,371.93" "$1,371.93" $0.00 "$1,125.93" "$1,783.47" "$1,801.48" $0.00 $0.00 $342.15 $0.00 $0.00 $358.49 $0.00 $0.00 $0.00 $0.00 $0.00 424.72 SUP HCPCS C1713 424.72 - PLATE BONE NARROW 394MM 22 HOLE LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,209.18 " $894.79 $0.00 $967.34 $544.13 $544.13 $0.00 $0.00 $0.00 $252.02 $897.45 $897.45 $0.00 $0.00 $251.99 $0.00 $715.23 $715.23 $0.00 $604.59 $957.67 $967.34 $0.00 $0.00 $183.72 $0.00 $0.00 $192.50 $0.00 $0.00 $0.00 $0.00 $0.00 424.721 SUP HCPCS C1713 424.721 - PLATE BONE NARROW 404MM 22 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,533.05 " "$1,874.46" $0.00 "$1,967.42" "$1,106.67" "$1,106.67" $0.00 $0.00 $0.00 $527.95 "$1,880.03" "$1,880.03" $0.00 $0.00 $527.89 $0.00 "$1,248.79" "$1,248.79" $0.00 "$1,229.64" "$1,947.75" "$1,967.42" $0.00 $0.00 $373.67 $0.00 $0.00 $391.52 $0.00 $0.00 $0.00 $0.00 $0.00 424.753 SUP HCPCS C1713 424.753 - PLATE BONE 118MM 3/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 424.754 SUP HCPCS C1713 424.754 - PLATE BONE 136MM 4/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$1,807.73 " "$1,337.72" $0.00 "$1,404.06" $789.78 $789.78 $0.00 $0.00 $0.00 $376.78 "$1,341.69" "$1,341.69" $0.00 $0.00 $376.73 $0.00 "$1,069.27" "$1,069.27" $0.00 $877.54 "$1,390.02" "$1,404.06" $0.00 $0.00 $266.67 $0.00 $0.00 $279.41 $0.00 $0.00 $0.00 $0.00 $0.00 424.755 SUP HCPCS C1713 424.755 - PLATE BONE 154MM 5/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$1,837.25 " "$1,359.57" $0.00 "$1,426.98" $802.68 $802.68 $0.00 $0.00 $0.00 $382.93 "$1,363.61" "$1,363.61" $0.00 $0.00 $382.88 $0.00 "$1,086.73" "$1,086.73" $0.00 $891.86 "$1,412.71" "$1,426.98" $0.00 $0.00 $271.02 $0.00 $0.00 $283.97 $0.00 $0.00 $0.00 $0.00 $0.00 424.756 SUP HCPCS C1713 424.756 - PLATE BONE 172MM 6/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$1,868.18 " "$1,382.45" $0.00 "$1,451.00" $816.19 $816.19 $0.00 $0.00 $0.00 $389.37 "$1,386.56" "$1,386.56" $0.00 $0.00 $389.33 $0.00 "$1,105.03" "$1,105.03" $0.00 $906.88 "$1,436.49" "$1,451.00" $0.00 $0.00 $275.58 $0.00 $0.00 $288.75 $0.00 $0.00 $0.00 $0.00 $0.00 424.757 SUP HCPCS C1713 424.757 - PLATE BONE 190MM 7/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,410.78 " "$1,783.98" $0.00 "$1,872.44" "$1,053.25" "$1,053.25" $0.00 $0.00 $0.00 $502.47 "$1,789.28" "$1,789.28" $0.00 $0.00 $502.41 $0.00 "$1,425.97" "$1,425.97" $0.00 "$1,170.28" "$1,853.72" "$1,872.44" $0.00 $0.00 $355.63 $0.00 $0.00 $372.62 $0.00 $0.00 $0.00 $0.00 $0.00 424.758 SUP HCPCS C1713 424.758 - PLATE BONE 208MM 8/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,436.08 " "$1,802.70" $0.00 "$1,892.08" "$1,064.30" "$1,064.30" $0.00 $0.00 $0.00 $507.74 "$1,808.05" "$1,808.05" $0.00 $0.00 $507.68 $0.00 "$1,440.94" "$1,440.94" $0.00 "$1,182.55" "$1,873.16" "$1,892.08" $0.00 $0.00 $359.36 $0.00 $0.00 $376.52 $0.00 $0.00 $0.00 $0.00 $0.00 424.759 SUP HCPCS C1713 424.759 - PLATE BONE 226MM 9/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,489.48 " "$1,842.22" $0.00 "$1,933.58" "$1,087.64" "$1,087.64" $0.00 $0.00 $0.00 $518.87 "$1,847.69" "$1,847.69" $0.00 $0.00 $518.81 $0.00 "$1,472.52" "$1,472.52" $0.00 "$1,208.49" "$1,914.25" "$1,933.58" $0.00 $0.00 $367.24 $0.00 $0.00 $384.78 $0.00 $0.00 $0.00 $0.00 $0.00 424.761 SUP HCPCS C1713 424.761 - PLATE BONE 262MM 11/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,542.90 " "$1,881.75" $0.00 "$1,975.06" "$1,110.97" "$1,110.97" $0.00 $0.00 $0.00 $530.00 "$1,887.34" "$1,887.34" $0.00 $0.00 $529.94 $0.00 "$1,253.65" "$1,253.65" $0.00 "$1,234.41" "$1,955.31" "$1,975.06" $0.00 $0.00 $375.12 $0.00 $0.00 $393.04 $0.00 $0.00 $0.00 $0.00 $0.00 424.763 SUP HCPCS C1713 424.763 - PLATE BONE 298MM 13/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,590.70 " "$1,917.12" $0.00 "$2,012.18" "$1,131.85" "$1,131.85" $0.00 $0.00 $0.00 $539.97 "$1,922.82" "$1,922.82" $0.00 $0.00 $539.90 $0.00 "$1,277.22" "$1,277.22" $0.00 "$1,257.61" "$1,992.06" "$2,012.18" $0.00 $0.00 $382.17 $0.00 $0.00 $400.42 $0.00 $0.00 $0.00 $0.00 $0.00 424.765 SUP HCPCS C1713 424.765 - PLATE BONE 334MM 15/5 HOLE LCP TITANIUM METAPHYSEAL NONSTRL BOTH IP/OP "$2,708.78 " "$2,004.50" $0.00 "$2,103.90" "$1,183.44" "$1,183.44" $0.00 $0.00 $0.00 $564.58 "$2,010.45" "$2,010.45" $0.00 $0.00 $564.51 $0.00 "$1,335.43" "$1,335.43" $0.00 "$1,314.94" "$2,082.86" "$2,103.90" $0.00 $0.00 $399.59 $0.00 $0.00 $418.68 $0.00 $0.00 $0.00 $0.00 $0.00 426.56 SUP HCPCS C1713 426.56 - PLATE BONE BROAD 106X17.5X5.2MM 6 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $488.58 $361.55 $0.00 $390.86 $219.86 $219.86 $0.00 $0.00 $0.00 $101.83 $362.62 $362.62 $0.00 $0.00 $101.82 $0.00 $288.99 $288.99 $0.00 $244.29 $386.96 $390.86 $0.00 $0.00 $74.24 $0.00 $0.00 $77.78 $0.00 $0.00 $0.00 $0.00 $0.00 426.561 SUP HCPCS C1713 426.561 - PLATE BONE BROAD 116MM 6 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $784.38 $580.44 $0.00 $609.22 $342.69 $342.69 $0.00 $0.00 $0.00 $163.48 $582.16 $582.16 $0.00 $0.00 $163.46 $0.00 $463.96 $463.96 $0.00 $380.76 $603.13 $609.22 $0.00 $0.00 $115.71 $0.00 $0.00 $121.23 $0.00 $0.00 $0.00 $0.00 $0.00 426.57 SUP HCPCS C1713 426.57 - PLATE BONE BROAD 124X17.5X5.2MM 7 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $529.53 $391.85 $0.00 $423.62 $238.29 $238.29 $0.00 $0.00 $0.00 $110.37 $393.01 $393.01 $0.00 $0.00 $110.35 $0.00 $313.21 $313.21 $0.00 $264.76 $419.39 $423.62 $0.00 $0.00 $80.46 $0.00 $0.00 $84.30 $0.00 $0.00 $0.00 $0.00 $0.00 426.571 SUP HCPCS C1713 426.571 - PLATE BONE BROAD 134MM 7 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP $833.58 $616.85 $0.00 $647.44 $364.19 $364.19 $0.00 $0.00 $0.00 $173.74 $618.68 $618.68 $0.00 $0.00 $173.72 $0.00 $493.06 $493.06 $0.00 $404.65 $640.97 $647.44 $0.00 $0.00 $122.97 $0.00 $0.00 $128.84 $0.00 $0.00 $0.00 $0.00 $0.00 426.58 SUP HCPCS C1713 426.58 - PLATE BONE BROAD 3.5MM 142X17.5X5.2MM 8 HOLE LC-DCP TITANIUM BOTH IP/OP $588.20 $435.27 $0.00 $470.56 $264.69 $264.69 $0.00 $0.00 $0.00 $122.60 $436.56 $436.56 $0.00 $0.00 $122.58 $0.00 $347.92 $347.92 $0.00 $294.10 $465.85 $470.56 $0.00 $0.00 $89.37 $0.00 $0.00 $93.64 $0.00 $0.00 $0.00 $0.00 $0.00 426.581 SUP HCPCS C1713 426.581 - PLATE BONE BROAD 152MM 8 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,019.13 " $754.16 $0.00 $791.56 $445.25 $445.25 $0.00 $0.00 $0.00 $212.41 $756.39 $756.39 $0.00 $0.00 $212.39 $0.00 $602.81 $602.81 $0.00 $494.73 $783.64 $791.56 $0.00 $0.00 $150.34 $0.00 $0.00 $157.52 $0.00 $0.00 $0.00 $0.00 $0.00 426.59 SUP HCPCS C1713 426.59 - PLATE BONE BROAD 160X17.5X5.2MM 9 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $605.85 $448.33 $0.00 $470.56 $264.69 $264.69 $0.00 $0.00 $0.00 $126.27 $449.66 $449.66 $0.00 $0.00 $126.26 $0.00 $358.36 $358.36 $0.00 $294.10 $465.85 $470.56 $0.00 $0.00 $89.37 $0.00 $0.00 $93.64 $0.00 $0.00 $0.00 $0.00 $0.00 426.591 SUP HCPCS C1713 426.591 - PLATE BONE BROAD 170MM 9 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,102.08 " $815.54 $0.00 $855.98 $481.49 $481.49 $0.00 $0.00 $0.00 $229.70 $817.96 $817.96 $0.00 $0.00 $229.67 $0.00 $651.88 $651.88 $0.00 $534.99 $847.42 $855.98 $0.00 $0.00 $162.57 $0.00 $0.00 $170.34 $0.00 $0.00 $0.00 $0.00 $0.00 426.6 SUP HCPCS C1713 426.60 - PLATE BONE BROAD 178X17.5X5.2MM 10 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $588.20 $435.27 $0.00 $470.56 $264.69 $264.69 $0.00 $0.00 $0.00 $122.60 $436.56 $436.56 $0.00 $0.00 $122.58 $0.00 $347.92 $347.92 $0.00 $294.10 $465.85 $470.56 $0.00 $0.00 $89.37 $0.00 $0.00 $93.64 $0.00 $0.00 $0.00 $0.00 $0.00 426.601 SUP HCPCS C1713 426.601 - PLATE BONE BROAD 188MM 10 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,185.00 " $876.90 $0.00 $920.38 $517.71 $517.71 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $575.24 $911.18 $920.38 $0.00 $0.00 $174.81 $0.00 $0.00 $183.16 $0.00 $0.00 $0.00 $0.00 $0.00 426.61 SUP HCPCS C1713 426.61 - PLATE BONE BROAD 196X17.5X5.2MM 11 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $615.50 $455.47 $0.00 $492.40 $276.98 $276.98 $0.00 $0.00 $0.00 $128.29 $456.82 $456.82 $0.00 $0.00 $128.27 $0.00 $364.07 $364.07 $0.00 $307.75 $487.48 $492.40 $0.00 $0.00 $93.52 $0.00 $0.00 $97.99 $0.00 $0.00 $0.00 $0.00 $0.00 426.611 SUP HCPCS C1713 426.611 - PLATE BONE BROAD 206MM 11 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,262.30 " $934.10 $0.00 $980.44 $551.50 $551.50 $0.00 $0.00 $0.00 $263.09 $936.88 $936.88 $0.00 $0.00 $263.06 $0.00 $746.65 $746.65 $0.00 $612.78 $970.64 $980.44 $0.00 $0.00 $186.21 $0.00 $0.00 $195.11 $0.00 $0.00 $0.00 $0.00 $0.00 426.62 SUP HCPCS C1713 426.62 - PLATE BONE BROAD 214X17.5X5.2MM 12 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $633.98 $469.15 $0.00 $492.40 $276.98 $276.98 $0.00 $0.00 $0.00 $132.14 $470.54 $470.54 $0.00 $0.00 $132.12 $0.00 $375.00 $375.00 $0.00 $307.75 $487.48 $492.40 $0.00 $0.00 $93.52 $0.00 $0.00 $97.99 $0.00 $0.00 $0.00 $0.00 $0.00 426.621 SUP HCPCS C1713 426.621 - PLATE BONE BROAD 224MM 12 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,339.63 " $991.33 $0.00 "$1,040.48" $585.27 $585.27 $0.00 $0.00 $0.00 $279.21 $994.27 $994.27 $0.00 $0.00 $279.18 $0.00 $792.39 $792.39 $0.00 $650.30 "$1,030.08" "$1,040.48" $0.00 $0.00 $197.62 $0.00 $0.00 $207.06 $0.00 $0.00 $0.00 $0.00 $0.00 426.622 SUP HCPCS C1713 426.622 - PLATE BONE BROAD 229MM 12 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,339.63 " $991.33 $0.00 "$1,040.48" $585.27 $585.27 $0.00 $0.00 $0.00 $279.21 $994.27 $994.27 $0.00 $0.00 $279.18 $0.00 $792.39 $792.39 $0.00 $650.30 "$1,030.08" "$1,040.48" $0.00 $0.00 $197.62 $0.00 $0.00 $207.06 $0.00 $0.00 $0.00 $0.00 $0.00 426.632 SUP HCPCS C1713 426.632 - PLATE BONE BROAD 247MM 13 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,419.75 " "$1,050.62" $0.00 "$1,102.72" $620.28 $620.28 $0.00 $0.00 $0.00 $295.91 "$1,053.74" "$1,053.74" $0.00 $0.00 $295.88 $0.00 $839.78 $839.78 $0.00 $689.20 "$1,091.69" "$1,102.72" $0.00 $0.00 $209.44 $0.00 $0.00 $219.44 $0.00 $0.00 $0.00 $0.00 $0.00 426.64 SUP HCPCS C1713 426.64 - PLATE BONE BROAD 4.5MM 250X17.5X5.2MM 14 HOLE LC-DCP BOTH IP/OP $614.80 $454.95 $0.00 $491.84 $276.66 $276.66 $0.00 $0.00 $0.00 $128.14 $456.30 $456.30 $0.00 $0.00 $128.12 $0.00 $363.65 $363.65 $0.00 $307.40 $486.92 $491.84 $0.00 $0.00 $96.22 $0.00 $0.00 $97.88 $0.00 $0.00 $0.00 $0.00 $0.00 426.641 SUP HCPCS C1713 426.641 - PLATE BONE BROAD 260MM 14 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,491.45 " "$1,103.67" $0.00 "$1,158.40" $651.60 $651.60 $0.00 $0.00 $0.00 $310.86 "$1,106.95" "$1,106.95" $0.00 $0.00 $310.82 $0.00 $882.19 $882.19 $0.00 $724.00 "$1,146.82" "$1,158.40" $0.00 $0.00 $220.01 $0.00 $0.00 $230.52 $0.00 $0.00 $0.00 $0.00 $0.00 426.642 SUP HCPCS C1713 426.642 - PLATE BONE BROAD CVD 265MM 14 HOLE LCP TITANIUM ANKLE BOTH IP/OP "$1,491.45 " "$1,103.67" $0.00 "$1,158.40" $651.60 $651.60 $0.00 $0.00 $0.00 $310.86 "$1,106.95" "$1,106.95" $0.00 $0.00 $310.82 $0.00 $882.19 $882.19 $0.00 $724.00 "$1,146.82" "$1,158.40" $0.00 $0.00 $220.01 $0.00 $0.00 $230.52 $0.00 $0.00 $0.00 $0.00 $0.00 426.652 SUP HCPCS C1713 426.652 - PLATE BONE BROAD 282MM 15 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,655.90 " "$1,225.37" $0.00 "$1,286.14" $723.45 $723.45 $0.00 $0.00 $0.00 $345.13 "$1,229.01" "$1,229.01" $0.00 $0.00 $345.09 $0.00 $979.46 $979.46 $0.00 $803.84 "$1,273.28" "$1,286.14" $0.00 $0.00 $244.27 $0.00 $0.00 $255.94 $0.00 $0.00 $0.00 $0.00 $0.00 426.66 SUP HCPCS C1713 426.66 - PLATE BONE BROAD 286X17.5X5.2MM 16 HOLE LC-DCP TITANIUM LONG BOTH IP/OP $696.03 $515.06 $0.00 $556.82 $313.21 $313.21 $0.00 $0.00 $0.00 $145.07 $516.59 $516.59 $0.00 $0.00 $145.05 $0.00 $411.70 $411.70 $0.00 $348.01 $551.26 $556.82 $0.00 $0.00 $105.75 $0.00 $0.00 $110.81 $0.00 $0.00 $0.00 $0.00 $0.00 426.661 SUP HCPCS C1713 426.661 - PLATE BONE BROAD 296MM 16 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,811.95 " "$1,340.84" $0.00 "$1,407.34" $791.63 $791.63 $0.00 $0.00 $0.00 $377.66 "$1,344.83" "$1,344.83" $0.00 $0.00 $377.61 $0.00 "$1,071.77" "$1,071.77" $0.00 $879.59 "$1,393.27" "$1,407.34" $0.00 $0.00 $267.29 $0.00 $0.00 $280.06 $0.00 $0.00 $0.00 $0.00 $0.00 426.662 SUP HCPCS C1713 426.662 - PLATE BONE BROAD 300MM 16 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,811.95 " "$1,340.84" $0.00 "$1,407.34" $791.63 $791.63 $0.00 $0.00 $0.00 $377.66 "$1,344.83" "$1,344.83" $0.00 $0.00 $377.61 $0.00 "$1,071.77" "$1,071.77" $0.00 $879.59 "$1,393.27" "$1,407.34" $0.00 $0.00 $267.29 $0.00 $0.00 $280.06 $0.00 $0.00 $0.00 $0.00 $0.00 426.672 SUP HCPCS C1713 426.672 - PLATE BONE BROAD 318MM 17 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,897.68 " "$1,404.28" $0.00 "$1,473.94" $829.09 $829.09 $0.00 $0.00 $0.00 $395.52 "$1,408.45" "$1,408.45" $0.00 $0.00 $395.48 $0.00 "$1,122.47" "$1,122.47" $0.00 $921.21 "$1,459.20" "$1,473.94" $0.00 $0.00 $279.94 $0.00 $0.00 $293.31 $0.00 $0.00 $0.00 $0.00 $0.00 426.68 SUP HCPCS C1713 426.68 - PLATE BONE BROAD 4.5MM 322X17.5X5.2MM 18 HOLE LC-DCP BOTH IP/OP $788.60 $583.56 $0.00 $612.50 $344.53 $344.53 $0.00 $0.00 $0.00 $164.36 $585.30 $585.30 $0.00 $0.00 $164.34 $0.00 $466.46 $466.46 $0.00 $382.81 $606.38 $612.50 $0.00 $0.00 $116.33 $0.00 $0.00 $121.89 $0.00 $0.00 $0.00 $0.00 $0.00 426.681 SUP HCPCS C1713 426.681 - PLATE BONE BROAD 332MM 18 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,132.43 " "$1,578.00" $0.00 "$1,656.26" $931.65 $931.65 $0.00 $0.00 $0.00 $444.45 "$1,582.69" "$1,582.69" $0.00 $0.00 $444.40 $0.00 "$1,261.33" "$1,261.33" $0.00 "$1,035.16" "$1,639.70" "$1,656.26" $0.00 $0.00 $314.57 $0.00 $0.00 $329.60 $0.00 $0.00 $0.00 $0.00 $0.00 426.682 SUP HCPCS C1713 426.682 - PLATE BONE BROAD 336MM 18 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,067.78 " "$1,530.16" $0.00 "$1,606.04" $903.40 $903.40 $0.00 $0.00 $0.00 $430.98 "$1,534.70" "$1,534.70" $0.00 $0.00 $430.92 $0.00 "$1,223.09" "$1,223.09" $0.00 "$1,003.78" "$1,589.98" "$1,606.04" $0.00 $0.00 $305.03 $0.00 $0.00 $319.60 $0.00 $0.00 $0.00 $0.00 $0.00 426.7 SUP HCPCS C1713 426.70 - PLATE BONE BROAD 358X17.5X5.2MM 20 HOLE LC-DCP TITANIUM LONG BOTH IP/OP "$1,123.20 " $831.17 $0.00 $898.56 $505.44 $505.44 $0.00 $0.00 $0.00 $234.10 $833.64 $833.64 $0.00 $0.00 $234.07 $0.00 $664.37 $664.37 $0.00 $561.60 $889.57 $898.56 $0.00 $0.00 $170.66 $0.00 $0.00 $178.81 $0.00 $0.00 $0.00 $0.00 $0.00 426.701 SUP HCPCS C1713 426.701 - PLATE BONE BROAD 368MM 20 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,355.95 " "$1,743.40" $0.00 "$1,829.86" "$1,029.30" "$1,029.30" $0.00 $0.00 $0.00 $491.04 "$1,748.59" "$1,748.59" $0.00 $0.00 $490.98 $0.00 "$1,393.54" "$1,393.54" $0.00 "$1,143.66" "$1,811.57" "$1,829.86" $0.00 $0.00 $347.54 $0.00 $0.00 $364.14 $0.00 $0.00 $0.00 $0.00 $0.00 426.72 SUP HCPCS C1713 426.72 - PLATE BONE BROAD 394X17.5X5.2MM 22 HOLE LC-DCP TITANIUM LONG BOTH IP/OP "$1,209.18 " $894.79 $0.00 $967.34 $544.13 $544.13 $0.00 $0.00 $0.00 $252.02 $897.45 $897.45 $0.00 $0.00 $251.99 $0.00 $715.23 $715.23 $0.00 $604.59 $957.67 $967.34 $0.00 $0.00 $183.72 $0.00 $0.00 $192.50 $0.00 $0.00 $0.00 $0.00 $0.00 426.721 SUP HCPCS C1713 426.721 - PLATE BONE BROAD 404MM 22 HOLE LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,582.25 " "$1,910.87" $0.00 "$2,005.64" "$1,128.17" "$1,128.17" $0.00 $0.00 $0.00 $538.21 "$1,916.55" "$1,916.55" $0.00 $0.00 $538.14 $0.00 "$1,273.05" "$1,273.05" $0.00 "$1,253.53" "$1,985.58" "$2,005.64" $0.00 $0.00 $380.92 $0.00 $0.00 $399.12 $0.00 $0.00 $0.00 $0.00 $0.00 426.74 SUP HCPCS C1713 426.74 - PLATE BONE BROAD 430X17.5X5.2MM 24 HOLE LC-DCP TITANIUM LONG BOTH IP/OP "$1,295.15 " $958.41 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $269.94 $961.26 $961.26 $0.00 $0.00 $269.91 $0.00 $766.08 $766.08 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 429.331 SUP HCPCS C1713 429.331 - PLATE BONE 56MM 3 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 429.341 SUP HCPCS C1713 429.341 - PLATE BONE 75MM 4 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP $812.50 $601.25 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 429.351 SUP HCPCS C1713 429.351 - PLATE BONE 94MM 5 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP $878.55 $650.13 $0.00 $682.38 $383.84 $383.84 $0.00 $0.00 $0.00 $183.11 $652.06 $652.06 $0.00 $0.00 $183.09 $0.00 $519.66 $519.66 $0.00 $426.49 $675.56 $682.38 $0.00 $0.00 $129.60 $0.00 $0.00 $135.79 $0.00 $0.00 $0.00 $0.00 $0.00 429.361 SUP HCPCS C1713 429.361 - PLATE BONE 113MM 6 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP $937.60 $693.82 $0.00 $728.24 $409.64 $409.64 $0.00 $0.00 $0.00 $195.42 $695.89 $695.89 $0.00 $0.00 $195.40 $0.00 $554.59 $554.59 $0.00 $455.15 $720.96 $728.24 $0.00 $0.00 $138.31 $0.00 $0.00 $144.92 $0.00 $0.00 $0.00 $0.00 $0.00 429.371 SUP HCPCS C1713 429.371 - PLATE BONE 132MM 7 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP $981.18 $726.07 $0.00 $762.08 $428.67 $428.67 $0.00 $0.00 $0.00 $204.50 $728.23 $728.23 $0.00 $0.00 $204.48 $0.00 $580.37 $580.37 $0.00 $476.30 $754.46 $762.08 $0.00 $0.00 $144.74 $0.00 $0.00 $151.65 $0.00 $0.00 $0.00 $0.00 $0.00 429.381 SUP HCPCS C1713 429.381 - PLATE BONE 151MM 8 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,031.78 " $763.52 $0.00 $801.38 $450.78 $450.78 $0.00 $0.00 $0.00 $215.05 $765.78 $765.78 $0.00 $0.00 $215.02 $0.00 $610.29 $610.29 $0.00 $500.86 $793.37 $801.38 $0.00 $0.00 $152.20 $0.00 $0.00 $159.47 $0.00 $0.00 $0.00 $0.00 $0.00 429.391 SUP HCPCS C1713 429.391 - PLATE BONE 170MM 9 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,104.88 " $817.61 $0.00 $858.16 $482.72 $482.72 $0.00 $0.00 $0.00 $230.28 $820.04 $820.04 $0.00 $0.00 $230.26 $0.00 $653.53 $653.53 $0.00 $536.35 $849.58 $858.16 $0.00 $0.00 $162.99 $0.00 $0.00 $170.77 $0.00 $0.00 $0.00 $0.00 $0.00 429.401 SUP HCPCS C1713 429.401 - PLATE BONE 189MM 10 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,158.30 " $857.14 $0.00 $899.64 $506.05 $506.05 $0.00 $0.00 $0.00 $241.42 $859.69 $859.69 $0.00 $0.00 $241.39 $0.00 $685.13 $685.13 $0.00 $562.28 $890.64 $899.64 $0.00 $0.00 $170.87 $0.00 $0.00 $179.03 $0.00 $0.00 $0.00 $0.00 $0.00 429.411 SUP HCPCS C1713 429.411 - PLATE BONE 208MM 11 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,196.25 " $885.23 $0.00 $929.12 $522.63 $522.63 $0.00 $0.00 $0.00 $249.33 $887.86 $887.86 $0.00 $0.00 $249.30 $0.00 $707.58 $707.58 $0.00 $580.70 $919.83 $929.12 $0.00 $0.00 $176.47 $0.00 $0.00 $184.89 $0.00 $0.00 $0.00 $0.00 $0.00 429.421 SUP HCPCS C1713 429.421 - PLATE BONE 227MM 12 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,253.88 " $927.87 $0.00 $973.88 $547.81 $547.81 $0.00 $0.00 $0.00 $261.34 $930.63 $930.63 $0.00 $0.00 $261.31 $0.00 $741.67 $741.67 $0.00 $608.68 $964.14 $973.88 $0.00 $0.00 $184.97 $0.00 $0.00 $193.80 $0.00 $0.00 $0.00 $0.00 $0.00 429.431 SUP HCPCS C1713 429.431 - PLATE BONE 246MM 13 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,334.00 " $987.16 $0.00 "$1,036.12" $582.82 $582.82 $0.00 $0.00 $0.00 $278.04 $990.09 $990.09 $0.00 $0.00 $278.01 $0.00 $789.06 $789.06 $0.00 $647.58 "$1,025.76" "$1,036.12" $0.00 $0.00 $196.79 $0.00 $0.00 $206.19 $0.00 $0.00 $0.00 $0.00 $0.00 429.441 SUP HCPCS C1713 429.441 - PLATE BONE 265MM 14 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,370.55 " "$1,014.21" $0.00 "$1,064.50" $598.78 $598.78 $0.00 $0.00 $0.00 $285.66 "$1,017.22" "$1,017.22" $0.00 $0.00 $285.62 $0.00 $810.68 $810.68 $0.00 $665.31 "$1,053.86" "$1,064.50" $0.00 $0.00 $202.18 $0.00 $0.00 $211.84 $0.00 $0.00 $0.00 $0.00 $0.00 429.451 SUP HCPCS C1713 429.451 - PLATE BONE 284MM 15 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,428.18 " "$1,056.85" $0.00 "$1,109.26" $623.96 $623.96 $0.00 $0.00 $0.00 $297.67 "$1,059.99" "$1,059.99" $0.00 $0.00 $297.63 $0.00 $844.77 $844.77 $0.00 $693.29 "$1,098.17" "$1,109.26" $0.00 $0.00 $210.68 $0.00 $0.00 $220.74 $0.00 $0.00 $0.00 $0.00 $0.00 429.461 SUP HCPCS C1713 429.461 - PLATE BONE 303MM 16 HOLE STR RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,466.13 " "$1,084.94" $0.00 "$1,138.74" $640.54 $640.54 $0.00 $0.00 $0.00 $305.58 "$1,088.16" "$1,088.16" $0.00 $0.00 $305.54 $0.00 $867.21 $867.21 $0.00 $711.71 "$1,127.36" "$1,138.74" $0.00 $0.00 $216.28 $0.00 $0.00 $226.61 $0.00 $0.00 $0.00 $0.00 $0.00 432.006 SUP HCPCS C1713 432.006 - PLATE BONE 90D 30MM 10 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,929.20 " "$1,427.61" $0.00 "$1,543.36" $868.14 $868.14 $0.00 $0.00 $0.00 $402.09 "$1,431.85" "$1,431.85" $0.00 $0.00 $402.05 $0.00 "$1,141.12" "$1,141.12" $0.00 $964.60 "$1,527.93" "$1,543.36" $0.00 $0.00 $301.92 $0.00 $0.00 $307.13 $0.00 $0.00 $0.00 $0.00 $0.00 432.007 SUP HCPCS C1713 432.007 - PLATE BONE 90D 35MM 10 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,929.20 " "$1,427.61" $0.00 "$1,543.36" $868.14 $868.14 $0.00 $0.00 $0.00 $402.09 "$1,431.85" "$1,431.85" $0.00 $0.00 $402.05 $0.00 "$1,141.12" "$1,141.12" $0.00 $964.60 "$1,527.93" "$1,543.36" $0.00 $0.00 $301.92 $0.00 $0.00 $307.13 $0.00 $0.00 $0.00 $0.00 $0.00 432.008 SUP HCPCS C1713 432.008 - PLATE BONE 90D 40MM 10 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,929.20 " "$1,427.61" $0.00 "$1,543.36" $868.14 $868.14 $0.00 $0.00 $0.00 $402.09 "$1,431.85" "$1,431.85" $0.00 $0.00 $402.05 $0.00 "$1,141.12" "$1,141.12" $0.00 $964.60 "$1,527.93" "$1,543.36" $0.00 $0.00 $301.92 $0.00 $0.00 $307.13 $0.00 $0.00 $0.00 $0.00 $0.00 432.009 SUP HCPCS C1713 432.009 - PLATE BONE 90D 45MM 10 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,929.20 " "$1,427.61" $0.00 "$1,543.36" $868.14 $868.14 $0.00 $0.00 $0.00 $402.09 "$1,431.85" "$1,431.85" $0.00 $0.00 $402.05 $0.00 "$1,141.12" "$1,141.12" $0.00 $964.60 "$1,527.93" "$1,543.36" $0.00 $0.00 $301.92 $0.00 $0.00 $307.13 $0.00 $0.00 $0.00 $0.00 $0.00 432.046 SUP HCPCS C1713 432.046 - PLATE BONE 90D 30MM 4 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,538.33 " "$1,138.36" $0.00 "$1,230.66" $692.25 $692.25 $0.00 $0.00 $0.00 $320.63 "$1,141.74" "$1,141.74" $0.00 $0.00 $320.59 $0.00 $909.92 $909.92 $0.00 $769.16 "$1,218.36" "$1,230.66" $0.00 $0.00 $240.75 $0.00 $0.00 $244.90 $0.00 $0.00 $0.00 $0.00 $0.00 432.047 SUP HCPCS C1713 432.047 - PLATE BONE 90D 35MM 4 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,538.33 " "$1,138.36" $0.00 "$1,230.66" $692.25 $692.25 $0.00 $0.00 $0.00 $320.63 "$1,141.74" "$1,141.74" $0.00 $0.00 $320.59 $0.00 $909.92 $909.92 $0.00 $769.16 "$1,218.36" "$1,230.66" $0.00 $0.00 $240.75 $0.00 $0.00 $244.90 $0.00 $0.00 $0.00 $0.00 $0.00 432.048 SUP HCPCS C1713 432.048 - PLATE BONE 90D 40MM 4 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,538.33 " "$1,138.36" $0.00 "$1,230.66" $692.25 $692.25 $0.00 $0.00 $0.00 $320.63 "$1,141.74" "$1,141.74" $0.00 $0.00 $320.59 $0.00 $909.92 $909.92 $0.00 $769.16 "$1,218.36" "$1,230.66" $0.00 $0.00 $240.75 $0.00 $0.00 $244.90 $0.00 $0.00 $0.00 $0.00 $0.00 432.049 SUP HCPCS C1713 432.049 - PLATE BONE 90D 45MM 4 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,538.33 " "$1,138.36" $0.00 "$1,230.66" $692.25 $692.25 $0.00 $0.00 $0.00 $320.63 "$1,141.74" "$1,141.74" $0.00 $0.00 $320.59 $0.00 $909.92 $909.92 $0.00 $769.16 "$1,218.36" "$1,230.66" $0.00 $0.00 $240.75 $0.00 $0.00 $244.90 $0.00 $0.00 $0.00 $0.00 $0.00 432.056 SUP HCPCS C1713 432.056 - PLATE BONE 90D 30MM 5 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,625.78 " "$1,203.08" $0.00 "$1,300.62" $731.60 $731.60 $0.00 $0.00 $0.00 $338.85 "$1,206.65" "$1,206.65" $0.00 $0.00 $338.81 $0.00 $961.65 $961.65 $0.00 $812.89 "$1,287.62" "$1,300.62" $0.00 $0.00 $254.43 $0.00 $0.00 $258.82 $0.00 $0.00 $0.00 $0.00 $0.00 432.057 SUP HCPCS C1713 432.057 - PLATE BONE 90D 35MM 5 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,625.78 " "$1,203.08" $0.00 "$1,300.62" $731.60 $731.60 $0.00 $0.00 $0.00 $338.85 "$1,206.65" "$1,206.65" $0.00 $0.00 $338.81 $0.00 $961.65 $961.65 $0.00 $812.89 "$1,287.62" "$1,300.62" $0.00 $0.00 $254.43 $0.00 $0.00 $258.82 $0.00 $0.00 $0.00 $0.00 $0.00 432.058 SUP HCPCS C1713 432.058 - PLATE BONE 90D 40MM 5 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,625.78 " "$1,203.08" $0.00 "$1,300.62" $731.60 $731.60 $0.00 $0.00 $0.00 $338.85 "$1,206.65" "$1,206.65" $0.00 $0.00 $338.81 $0.00 $961.65 $961.65 $0.00 $812.89 "$1,287.62" "$1,300.62" $0.00 $0.00 $254.43 $0.00 $0.00 $258.82 $0.00 $0.00 $0.00 $0.00 $0.00 432.059 SUP HCPCS C1713 432.059 - PLATE BONE 90D 45MM 5 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,625.78 " "$1,203.08" $0.00 "$1,300.62" $731.60 $731.60 $0.00 $0.00 $0.00 $338.85 "$1,206.65" "$1,206.65" $0.00 $0.00 $338.81 $0.00 $961.65 $961.65 $0.00 $812.89 "$1,287.62" "$1,300.62" $0.00 $0.00 $254.43 $0.00 $0.00 $258.82 $0.00 $0.00 $0.00 $0.00 $0.00 432.066 SUP HCPCS C1713 432.066 - PLATE BONE 90D 30MM 6 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,696.00 " "$1,255.04" $0.00 "$1,356.80" $763.20 $763.20 $0.00 $0.00 $0.00 $353.49 "$1,258.77" "$1,258.77" $0.00 $0.00 $353.45 $0.00 "$1,003.18" "$1,003.18" $0.00 $848.00 "$1,343.23" "$1,356.80" $0.00 $0.00 $265.42 $0.00 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 432.067 SUP HCPCS C1713 432.067 - PLATE BONE 90D 35MM 6 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,696.00 " "$1,255.04" $0.00 "$1,356.80" $763.20 $763.20 $0.00 $0.00 $0.00 $353.49 "$1,258.77" "$1,258.77" $0.00 $0.00 $353.45 $0.00 "$1,003.18" "$1,003.18" $0.00 $848.00 "$1,343.23" "$1,356.80" $0.00 $0.00 $265.42 $0.00 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 432.068 SUP HCPCS C1713 432.068 - PLATE BONE 90D 40MM 6 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,696.00 " "$1,255.04" $0.00 "$1,356.80" $763.20 $763.20 $0.00 $0.00 $0.00 $353.49 "$1,258.77" "$1,258.77" $0.00 $0.00 $353.45 $0.00 "$1,003.18" "$1,003.18" $0.00 $848.00 "$1,343.23" "$1,356.80" $0.00 $0.00 $265.42 $0.00 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 432.069 SUP HCPCS C1713 432.069 - PLATE BONE 90D 45MM 6 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,696.00 " "$1,255.04" $0.00 "$1,356.80" $763.20 $763.20 $0.00 $0.00 $0.00 $353.49 "$1,258.77" "$1,258.77" $0.00 $0.00 $353.45 $0.00 "$1,003.18" "$1,003.18" $0.00 $848.00 "$1,343.23" "$1,356.80" $0.00 $0.00 $265.42 $0.00 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 432.086 SUP HCPCS C1713 432.086 - PLATE BONE 90D 30MM 8 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,819.23 " "$1,346.23" $0.00 "$1,455.38" $818.65 $818.65 $0.00 $0.00 $0.00 $379.17 "$1,350.23" "$1,350.23" $0.00 $0.00 $379.13 $0.00 "$1,076.07" "$1,076.07" $0.00 $909.61 "$1,440.83" "$1,455.38" $0.00 $0.00 $284.71 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 432.087 SUP HCPCS C1713 432.087 - PLATE BONE 90D 106MM 35MM 8 HOLE CANN ANGLED TITANIUM BOTH IP/OP "$1,819.23 " "$1,346.23" $0.00 "$1,455.38" $818.65 $818.65 $0.00 $0.00 $0.00 $379.17 "$1,350.23" "$1,350.23" $0.00 $0.00 $379.13 $0.00 "$1,076.07" "$1,076.07" $0.00 $909.61 "$1,440.83" "$1,455.38" $0.00 $0.00 $284.71 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 432.088 SUP HCPCS C1713 432.088 - PLATE BONE 90D 40MM 8 HOLE CANN LC ANGLE BLADE TITANIUM BOTH IP/OP "$1,819.23 " "$1,346.23" $0.00 "$1,455.38" $818.65 $818.65 $0.00 $0.00 $0.00 $379.17 "$1,350.23" "$1,350.23" $0.00 $0.00 $379.13 $0.00 "$1,076.07" "$1,076.07" $0.00 $909.61 "$1,440.83" "$1,455.38" $0.00 $0.00 $284.71 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 432.089 SUP HCPCS C1713 432.089 - PLATE BONE 90D 45MM 8 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,819.23 " "$1,346.23" $0.00 "$1,455.38" $818.65 $818.65 $0.00 $0.00 $0.00 $379.17 "$1,350.23" "$1,350.23" $0.00 $0.00 $379.13 $0.00 "$1,076.07" "$1,076.07" $0.00 $909.61 "$1,440.83" "$1,455.38" $0.00 $0.00 $284.71 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 433 SUP Custom 27203010 433 - CUTTER 433 WIRE MODIFIED W/CARBIDE BOTH IP/OP "$1,126.25 " $833.43 $0.00 $901.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $835.90 $835.90 $0.00 $0.00 $234.71 $0.00 $0.00 $0.00 $0.00 $563.13 $891.99 $901.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 436.502 SUP HCPCS C1713 436.502 - PLATE BONE 86MM 2 HOLE LCP TITANIUM RIGHT OLECRANON NONSTRL BOTH IP/OP "$1,700.90 " "$1,258.67" $0.00 "$1,321.08" $743.11 $743.11 $0.00 $0.00 $0.00 $354.51 "$1,262.41" "$1,262.41" $0.00 $0.00 $354.47 $0.00 "$1,006.08" "$1,006.08" $0.00 $825.68 "$1,307.87" "$1,321.08" $0.00 $0.00 $250.91 $0.00 $0.00 $262.89 $0.00 $0.00 $0.00 $0.00 $0.00 436.503 SUP HCPCS C1713 436.503 - PLATE BONE 86MM 2 HOLE LCP TITANIUM LEFT OLECRANON NONSTRL BOTH IP/OP "$1,700.90 " "$1,258.67" $0.00 "$1,321.08" $743.11 $743.11 $0.00 $0.00 $0.00 $354.51 "$1,262.41" "$1,262.41" $0.00 $0.00 $354.47 $0.00 "$1,006.08" "$1,006.08" $0.00 $825.68 "$1,307.87" "$1,321.08" $0.00 $0.00 $250.91 $0.00 $0.00 $262.89 $0.00 $0.00 $0.00 $0.00 $0.00 436.506 SUP HCPCS C1713 436.506 - PLATE BONE 138MM 6 HOLE LCP TITANIUM RIGHT OLECRANON NONSTRL BOTH IP/OP "$1,831.63 " "$1,355.41" $0.00 "$1,422.62" $800.22 $800.22 $0.00 $0.00 $0.00 $381.76 "$1,359.43" "$1,359.43" $0.00 $0.00 $381.71 $0.00 "$1,083.41" "$1,083.41" $0.00 $889.14 "$1,408.40" "$1,422.62" $0.00 $0.00 $270.19 $0.00 $0.00 $283.10 $0.00 $0.00 $0.00 $0.00 $0.00 436.507 SUP HCPCS C1713 436.507 - PLATE BONE 138MM 6 HOLE LCP TITANIUM LEFT OLECRANON NONSTRL BOTH IP/OP "$1,865.35 " "$1,380.36" $0.00 "$1,448.82" $814.96 $814.96 $0.00 $0.00 $0.00 $388.79 "$1,384.46" "$1,384.46" $0.00 $0.00 $388.74 $0.00 "$1,103.35" "$1,103.35" $0.00 $905.51 "$1,434.34" "$1,448.82" $0.00 $0.00 $275.17 $0.00 $0.00 $288.32 $0.00 $0.00 $0.00 $0.00 $0.00 436.51 SUP HCPCS C1713 436.510 - PLATE BONE 189MM 10 HOLE LCP TITANIUM RIGHT OLECRANON ELBOW BOTH IP/OP "$1,918.85 " "$1,419.95" $0.00 "$1,535.08" $863.48 $863.48 $0.00 $0.00 $0.00 $399.94 "$1,424.17" "$1,424.17" $0.00 $0.00 $399.89 $0.00 "$1,135.00" "$1,135.00" $0.00 $959.43 "$1,519.73" "$1,535.08" $0.00 $0.00 $291.55 $0.00 $0.00 $305.48 $0.00 $0.00 $0.00 $0.00 $0.00 436.511 SUP HCPCS C1713 436.511 - PLATE BONE 189MM 10 HOLE LCP TITANIUM LEFT OLECRANON ELBOW BOTH IP/OP "$1,976.40 " "$1,462.54" $0.00 "$1,535.08" $863.48 $863.48 $0.00 $0.00 $0.00 $411.93 "$1,466.88" "$1,466.88" $0.00 $0.00 $411.88 $0.00 "$1,169.04" "$1,169.04" $0.00 $959.43 "$1,519.73" "$1,535.08" $0.00 $0.00 $291.55 $0.00 $0.00 $305.48 $0.00 $0.00 $0.00 $0.00 $0.00 436.512 SUP HCPCS C1713 436.512 - PLATE BONE 215MM 12 HOLE LCP TITANIUM RIGHT OLECRANON ELBOW BOTH IP/OP "$2,012.95 " "$1,489.58" $0.00 "$1,563.46" $879.45 $879.45 $0.00 $0.00 $0.00 $419.55 "$1,494.01" "$1,494.01" $0.00 $0.00 $419.50 $0.00 "$1,190.66" "$1,190.66" $0.00 $977.16 "$1,547.83" "$1,563.46" $0.00 $0.00 $296.94 $0.00 $0.00 $311.13 $0.00 $0.00 $0.00 $0.00 $0.00 436.513 SUP HCPCS C1713 436.513 - PLATE BONE 215MM 13 HOLE LCP TITANIUM LEFT OLECRANON ELBOW BOTH IP/OP "$2,012.95 " "$1,489.58" $0.00 "$1,563.46" $879.45 $879.45 $0.00 $0.00 $0.00 $419.55 "$1,494.01" "$1,494.01" $0.00 $0.00 $419.50 $0.00 "$1,190.66" "$1,190.66" $0.00 $977.16 "$1,547.83" "$1,563.46" $0.00 $0.00 $296.94 $0.00 $0.00 $311.13 $0.00 $0.00 $0.00 $0.00 $0.00 437.2 SUP HCPCS C1713 437.20 - PLATE BONE 95D 50MM 12 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,268.03 " $938.34 $0.00 "$1,014.42" $570.61 $570.61 $0.00 $0.00 $0.00 $264.29 $941.13 $941.13 $0.00 $0.00 $264.26 $0.00 $750.04 $750.04 $0.00 $634.01 "$1,004.28" "$1,014.42" $0.00 $0.00 $198.45 $0.00 $0.00 $201.87 $0.00 $0.00 $0.00 $0.00 $0.00 437.22 SUP HCPCS C1713 437.22 - PLATE BONE 95D 204MM 60MM 12 HOLE DCP TITANIUM CONDYLE BOTH IP/OP "$1,268.03 " $938.34 $0.00 "$1,014.42" $570.61 $570.61 $0.00 $0.00 $0.00 $264.29 $941.13 $941.13 $0.00 $0.00 $264.26 $0.00 $750.04 $750.04 $0.00 $634.01 "$1,004.28" "$1,014.42" $0.00 $0.00 $198.45 $0.00 $0.00 $201.87 $0.00 $0.00 $0.00 $0.00 $0.00 437.24 SUP HCPCS C1713 437.24 - PLATE BONE 95D 70MM 12 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,268.03 " $938.34 $0.00 "$1,014.42" $570.61 $570.61 $0.00 $0.00 $0.00 $264.29 $941.13 $941.13 $0.00 $0.00 $264.26 $0.00 $750.04 $750.04 $0.00 $634.01 "$1,004.28" "$1,014.42" $0.00 $0.00 $198.45 $0.00 $0.00 $201.87 $0.00 $0.00 $0.00 $0.00 $0.00 437.26 SUP HCPCS C1713 437.26 - PLATE BONE 95D 204MM 80MM 12 HOLE DCP TITANIUM CONDYLE BOTH IP/OP "$1,268.03 " $938.34 $0.00 "$1,014.42" $570.61 $570.61 $0.00 $0.00 $0.00 $264.29 $941.13 $941.13 $0.00 $0.00 $264.26 $0.00 $750.04 $750.04 $0.00 $634.01 "$1,004.28" "$1,014.42" $0.00 $0.00 $198.45 $0.00 $0.00 $201.87 $0.00 $0.00 $0.00 $0.00 $0.00 437.5 SUP HCPCS C1713 437.50 - PLATE BONE 95D 50MM 5 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,045.43 " $773.62 $0.00 $836.34 $470.44 $470.44 $0.00 $0.00 $0.00 $217.89 $775.91 $775.91 $0.00 $0.00 $217.87 $0.00 $618.37 $618.37 $0.00 $522.71 $827.98 $836.34 $0.00 $0.00 $163.61 $0.00 $0.00 $166.43 $0.00 $0.00 $0.00 $0.00 $0.00 437.52 SUP HCPCS C1713 437.52 - PLATE BONE 95D 60MM 5 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,045.43 " $773.62 $0.00 $836.34 $470.44 $470.44 $0.00 $0.00 $0.00 $217.89 $775.91 $775.91 $0.00 $0.00 $217.87 $0.00 $618.37 $618.37 $0.00 $522.71 $827.98 $836.34 $0.00 $0.00 $163.61 $0.00 $0.00 $166.43 $0.00 $0.00 $0.00 $0.00 $0.00 437.54 SUP HCPCS C1713 437.54 - PLATE BONE 95D 70MM 5 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,045.43 " $773.62 $0.00 $836.34 $470.44 $470.44 $0.00 $0.00 $0.00 $217.89 $775.91 $775.91 $0.00 $0.00 $217.87 $0.00 $618.37 $618.37 $0.00 $522.71 $827.98 $836.34 $0.00 $0.00 $163.61 $0.00 $0.00 $166.43 $0.00 $0.00 $0.00 $0.00 $0.00 437.56 SUP HCPCS C1713 437.56 - PLATE BONE 95D 80MM 5 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,045.43 " $773.62 $0.00 $836.34 $470.44 $470.44 $0.00 $0.00 $0.00 $217.89 $775.91 $775.91 $0.00 $0.00 $217.87 $0.00 $618.37 $618.37 $0.00 $522.71 $827.98 $836.34 $0.00 $0.00 $163.61 $0.00 $0.00 $166.43 $0.00 $0.00 $0.00 $0.00 $0.00 437.7 SUP HCPCS C1713 437.70 - PLATE BONE 95D 50MM 7 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,093.13 " $808.92 $0.00 $874.50 $491.91 $491.91 $0.00 $0.00 $0.00 $227.83 $811.32 $811.32 $0.00 $0.00 $227.81 $0.00 $646.58 $646.58 $0.00 $546.56 $865.76 $874.50 $0.00 $0.00 $171.07 $0.00 $0.00 $174.03 $0.00 $0.00 $0.00 $0.00 $0.00 437.72 SUP HCPCS C1713 437.72 - PLATE BONE 95D 60MM 7 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,093.13 " $808.92 $0.00 $874.50 $491.91 $491.91 $0.00 $0.00 $0.00 $227.83 $811.32 $811.32 $0.00 $0.00 $227.81 $0.00 $646.58 $646.58 $0.00 $546.56 $865.76 $874.50 $0.00 $0.00 $171.07 $0.00 $0.00 $174.03 $0.00 $0.00 $0.00 $0.00 $0.00 437.74 SUP HCPCS C1713 437.74 - PLATE BONE 95D 70MM 7 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,093.13 " $808.92 $0.00 $874.50 $491.91 $491.91 $0.00 $0.00 $0.00 $227.83 $811.32 $811.32 $0.00 $0.00 $227.81 $0.00 $646.58 $646.58 $0.00 $546.56 $865.76 $874.50 $0.00 $0.00 $171.07 $0.00 $0.00 $174.03 $0.00 $0.00 $0.00 $0.00 $0.00 437.76 SUP HCPCS C1713 437.76 - PLATE BONE 95D 80MM 7 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,093.13 " $808.92 $0.00 $874.50 $491.91 $491.91 $0.00 $0.00 $0.00 $227.83 $811.32 $811.32 $0.00 $0.00 $227.81 $0.00 $646.58 $646.58 $0.00 $546.56 $865.76 $874.50 $0.00 $0.00 $171.07 $0.00 $0.00 $174.03 $0.00 $0.00 $0.00 $0.00 $0.00 437.9 SUP HCPCS C1713 437.90 - PLATE BONE 95D 50MM 9 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,147.45 " $849.11 $0.00 $917.96 $516.35 $516.35 $0.00 $0.00 $0.00 $239.16 $851.64 $851.64 $0.00 $0.00 $239.13 $0.00 $678.72 $678.72 $0.00 $573.73 $908.78 $917.96 $0.00 $0.00 $179.58 $0.00 $0.00 $182.67 $0.00 $0.00 $0.00 $0.00 $0.00 437.92 SUP HCPCS C1713 437.92 - PLATE BONE 95D 60MM 9 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,147.45 " $849.11 $0.00 $917.96 $516.35 $516.35 $0.00 $0.00 $0.00 $239.16 $851.64 $851.64 $0.00 $0.00 $239.13 $0.00 $678.72 $678.72 $0.00 $573.73 $908.78 $917.96 $0.00 $0.00 $179.58 $0.00 $0.00 $182.67 $0.00 $0.00 $0.00 $0.00 $0.00 437.94 SUP HCPCS C1713 437.94 - PLATE BONE 95D 70MM 9 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,164.68 " $861.86 $0.00 $931.74 $524.10 $524.10 $0.00 $0.00 $0.00 $242.75 $864.42 $864.42 $0.00 $0.00 $242.72 $0.00 $688.91 $688.91 $0.00 $582.34 $922.43 $931.74 $0.00 $0.00 $182.27 $0.00 $0.00 $185.42 $0.00 $0.00 $0.00 $0.00 $0.00 437.96 SUP HCPCS C1713 437.96 - PLATE BONE 95D 80MM 9 HOLE DCP TITANIUM CONDYLE NONSTRL BOTH IP/OP "$1,164.68 " $861.86 $0.00 $931.74 $524.10 $524.10 $0.00 $0.00 $0.00 $242.75 $864.42 $864.42 $0.00 $0.00 $242.72 $0.00 $688.91 $688.91 $0.00 $582.34 $922.43 $931.74 $0.00 $0.00 $182.27 $0.00 $0.00 $185.42 $0.00 $0.00 $0.00 $0.00 $0.00 438.24 SUP HCPCS C1713 438.24 - PLATE BONE 130D 70MM 12 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,276.05 " $944.28 $0.00 "$1,020.84" $574.22 $574.22 $0.00 $0.00 $0.00 $265.96 $947.08 $947.08 $0.00 $0.00 $265.93 $0.00 $754.78 $754.78 $0.00 $638.03 "$1,010.63" "$1,020.84" $0.00 $0.00 $193.88 $0.00 $0.00 $203.15 $0.00 $0.00 $0.00 $0.00 $0.00 438.26 SUP HCPCS C1713 438.26 - PLATE BONE 130D 80MM 12 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,276.05 " $944.28 $0.00 "$1,020.84" $574.22 $574.22 $0.00 $0.00 $0.00 $265.96 $947.08 $947.08 $0.00 $0.00 $265.93 $0.00 $754.78 $754.78 $0.00 $638.03 "$1,010.63" "$1,020.84" $0.00 $0.00 $193.88 $0.00 $0.00 $203.15 $0.00 $0.00 $0.00 $0.00 $0.00 438.28 SUP HCPCS C1713 438.28 - PLATE BONE 130D 90MM 12 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,276.05 " $944.28 $0.00 "$1,020.84" $574.22 $574.22 $0.00 $0.00 $0.00 $265.96 $947.08 $947.08 $0.00 $0.00 $265.93 $0.00 $754.78 $754.78 $0.00 $638.03 "$1,010.63" "$1,020.84" $0.00 $0.00 $193.88 $0.00 $0.00 $203.15 $0.00 $0.00 $0.00 $0.00 $0.00 438.36 SUP HCPCS C1713 438.36 - PLATE BONE 130D 50MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.38 SUP HCPCS C1713 438.38 - PLATE BONE 130D 60MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.4 SUP HCPCS C1713 438.40 - PLATE BONE 130D 100MM 4 HOLE ANGLE BLADE DCP TITANIUM BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.41 SUP HCPCS C1713 438.41 - PLATE BONE 130D 105MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.42 SUP HCPCS C1713 438.42 - PLATE BONE 130D 110MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.44 SUP HCPCS C1713 438.44 - PLATE BONE 130D 70MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.45 SUP HCPCS C1713 438.45 - PLATE BONE 130D 75MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.46 SUP HCPCS C1713 438.46 - PLATE BONE 130D 80MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.47 SUP HCPCS C1713 438.47 - PLATE BONE 130D 85MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.48 SUP HCPCS C1713 438.48 - PLATE BONE 130D 90MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.49 SUP HCPCS C1713 438.49 - PLATE BONE 130D 95MM 4 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP $943.05 $697.86 $0.00 $754.44 $424.37 $424.37 $0.00 $0.00 $0.00 $196.56 $699.93 $699.93 $0.00 $0.00 $196.53 $0.00 $557.81 $557.81 $0.00 $471.53 $746.90 $754.44 $0.00 $0.00 $143.29 $0.00 $0.00 $150.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.6 SUP HCPCS C1713 438.60 - PLATE BONE 130D 50MM 6 HOLE ANGLE BLADE DCP TITANIUM NONSTRL BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 438.62 SUP HCPCS C1713 438.62 - PLATE BONE 130D 60MM 6 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 438.64 SUP HCPCS C1713 438.64 - PLATE BONE 130D 70MM 6 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 438.66 SUP HCPCS C1713 438.66 - PLATE BONE 130D 80MM 6 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 438.68 SUP HCPCS C1713 438.68 - PLATE BLADE 130D 90MM 6 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,007.18 " $745.31 $0.00 $805.74 $453.23 $453.23 $0.00 $0.00 $0.00 $209.92 $747.53 $747.53 $0.00 $0.00 $209.90 $0.00 $595.74 $595.74 $0.00 $503.59 $797.69 $805.74 $0.00 $0.00 $153.03 $0.00 $0.00 $160.34 $0.00 $0.00 $0.00 $0.00 $0.00 438.7 SUP HCPCS C1713 438.700 - PLATE BONE 116MM 4 HOLE W/O TAB LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,530.75 " "$1,872.76" $0.00 "$2,024.60" "$1,138.84" "$1,138.84" $0.00 $0.00 $0.00 $527.47 "$1,878.32" "$1,878.32" $0.00 $0.00 $527.41 $0.00 "$1,247.66" "$1,247.66" $0.00 "$1,265.38" "$2,004.35" "$2,024.60" $0.00 $0.00 $396.06 $0.00 $0.00 $402.90 $0.00 $0.00 $0.00 $0.00 $0.00 438.701 SUP HCPCS C1713 438.701 - PLATE 116MM TI 3.5MM SCR 4 HOLE W/O TAB LCP BONE LEFT DISTAL BOTH IP/OP "$3,294.20 " "$2,437.71" $0.00 "$2,635.36" "$1,482.39" "$1,482.39" $0.00 $0.00 $0.00 $686.59 "$2,444.96" "$2,444.96" $0.00 $0.00 $686.51 $0.00 "$1,624.04" "$1,624.04" $0.00 "$1,647.10" "$2,609.01" "$2,635.36" $0.00 $0.00 $515.54 $0.00 $0.00 $524.44 $0.00 $0.00 $0.00 $0.00 $0.00 438.703 SUP HCPCS C1713 438.703 - PLATE 142MM TI 3.5MM SCR 6 HOLE W/O TAB LCP BONE LEFT DISTAL BOTH IP/OP "$3,234.43 " "$2,393.48" $0.00 "$2,587.54" "$1,455.49" "$1,455.49" $0.00 $0.00 $0.00 $674.14 "$2,400.59" "$2,400.59" $0.00 $0.00 $674.05 $0.00 "$1,594.57" "$1,594.57" $0.00 "$1,617.21" "$2,561.67" "$2,587.54" $0.00 $0.00 $506.19 $0.00 $0.00 $514.92 $0.00 $0.00 $0.00 $0.00 $0.00 438.705 SUP HCPCS C1713 438.705 - PLATE 168MM TI 3.5MM SCR 8 HOLE W/O TAB LCP BONE LEFT DISTAL BOTH IP/OP "$3,266.13 " "$2,416.94" $0.00 "$2,612.90" "$1,469.76" "$1,469.76" $0.00 $0.00 $0.00 $680.74 "$2,424.12" "$2,424.12" $0.00 $0.00 $680.66 $0.00 "$1,610.20" "$1,610.20" $0.00 "$1,633.06" "$2,586.77" "$2,612.90" $0.00 $0.00 $511.15 $0.00 $0.00 $519.97 $0.00 $0.00 $0.00 $0.00 $0.00 438.706 SUP HCPCS C1713 438.706 - PLATE 194MM TI 3.5MM SCR 10 HOLE W/O TAB LCP BONE RIGHT BOTH IP/OP "$3,399.05 " "$2,515.30" $0.00 "$2,719.24" "$1,529.57" "$1,529.57" $0.00 $0.00 $0.00 $708.45 "$2,522.77" "$2,522.77" $0.00 $0.00 $708.36 $0.00 "$1,675.73" "$1,675.73" $0.00 "$1,699.53" "$2,692.05" "$2,719.24" $0.00 $0.00 $531.95 $0.00 $0.00 $541.13 $0.00 $0.00 $0.00 $0.00 $0.00 438.708 SUP HCPCS C1713 438.708 - PLATE BONE 220MM 12 HOLE W/O TAB LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,640.73 " "$1,954.14" $0.00 "$2,112.58" "$1,188.33" "$1,188.33" $0.00 $0.00 $0.00 $550.39 "$1,959.95" "$1,959.95" $0.00 $0.00 $550.33 $0.00 "$1,301.88" "$1,301.88" $0.00 "$1,320.36" "$2,091.46" "$2,112.58" $0.00 $0.00 $413.27 $0.00 $0.00 $420.40 $0.00 $0.00 $0.00 $0.00 $0.00 438.71 SUP HCPCS C1713 438.710 - PLATE BONE 246MM 14 HOLE W/O TAB LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,675.18 " "$1,979.63" $0.00 "$2,140.14" "$1,203.83" "$1,203.83" $0.00 $0.00 $0.00 $557.57 "$1,985.51" "$1,985.51" $0.00 $0.00 $557.51 $0.00 "$1,318.86" "$1,318.86" $0.00 "$1,337.59" "$2,118.74" "$2,140.14" $0.00 $0.00 $418.66 $0.00 $0.00 $425.89 $0.00 $0.00 $0.00 $0.00 $0.00 438.711 SUP HCPCS C1713 438.711 - PLATE BONE 246MM 14 HOLE W/O TAB LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,756.00 " "$2,039.44" $0.00 "$2,204.80" "$1,240.20" "$1,240.20" $0.00 $0.00 $0.00 $574.42 "$2,045.50" "$2,045.50" $0.00 $0.00 $574.35 $0.00 "$1,358.71" "$1,358.71" $0.00 "$1,378.00" "$2,182.75" "$2,204.80" $0.00 $0.00 $431.31 $0.00 $0.00 $438.76 $0.00 $0.00 $0.00 $0.00 $0.00 438.94 SUP HCPCS C1713 438.94 - PLATE BONE 130D 70MM 9 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,110.90 " $822.07 $0.00 $888.72 $499.91 $499.91 $0.00 $0.00 $0.00 $231.54 $824.51 $824.51 $0.00 $0.00 $231.51 $0.00 $657.10 $657.10 $0.00 $555.45 $879.83 $888.72 $0.00 $0.00 $168.79 $0.00 $0.00 $176.86 $0.00 $0.00 $0.00 $0.00 $0.00 438.96 SUP HCPCS C1713 438.96 - PLATE BONE 130D 80MM 9 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 438.98 SUP HCPCS C1713 438.98 - PLATE BONE 130D 90MM 9 HOLE ANGLED DCP TITANIUM ORTHOPEDIC BOTH IP/OP "$1,110.90 " $822.07 $0.00 $888.72 $499.91 $499.91 $0.00 $0.00 $0.00 $231.54 $824.51 $824.51 $0.00 $0.00 $231.51 $0.00 $657.10 $657.10 $0.00 $555.45 $879.83 $888.72 $0.00 $0.00 $168.79 $0.00 $0.00 $176.86 $0.00 $0.00 $0.00 $0.00 $0.00 439.2 SUP HCPCS C1713 439.20 - PLATE 90D 10MM DSPL 50MM TI OSTMY DCP BONE ADLT ORTH NONSTRL BOTH IP/OP "$1,290.98 " $955.33 $0.00 "$1,032.78" $580.94 $580.94 $0.00 $0.00 $0.00 $269.07 $958.16 $958.16 $0.00 $0.00 $269.04 $0.00 $763.61 $763.61 $0.00 $645.49 "$1,022.46" "$1,032.78" $0.00 $0.00 $202.04 $0.00 $0.00 $205.52 $0.00 $0.00 $0.00 $0.00 $0.00 439.21 SUP HCPCS C1713 439.21 - PLATE BONE 90D 10MM DISPLACEMENT 55MM ANGLED DCP TITANIUM BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.22 SUP HCPCS C1713 439.22 - PLATE BONE 90D 10MM DISPLACEMENT 60MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.23 SUP HCPCS C1713 439.23 - PLATE BONE 90D 10MM DISPLACEMENT 65MM ANGLED DCP TITANIUM BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.24 SUP HCPCS C1713 439.24 - PLATE BONE 90D 10MM DISPLACEMENT 70MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.25 SUP HCPCS C1713 439.25 - PLATE BONE 90D 10MM DISPLACEMENT 75MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.28 SUP HCPCS C1713 439.28 - PLATE BONE 90D 10MM DISPLACEMENT 40MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.32 SUP HCPCS C1713 439.32 - PLATE BONE 100D 10MM DISPLACEMENT 60MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.43 SUP HCPCS C1713 439.43 - PLATE BONE 110D 65MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.45 SUP HCPCS C1713 439.45 - PLATE BONE 110D 75MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,110.90 " $822.07 $0.00 $888.72 $499.91 $499.91 $0.00 $0.00 $0.00 $231.54 $824.51 $824.51 $0.00 $0.00 $231.51 $0.00 $657.10 $657.10 $0.00 $555.45 $879.83 $888.72 $0.00 $0.00 $168.79 $0.00 $0.00 $176.86 $0.00 $0.00 $0.00 $0.00 $0.00 439.47 SUP HCPCS C1713 439.47 - PLATE BONE 110D 85MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.53 SUP HCPCS C1713 439.53 - PLATE BONE 120D 65MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.55 SUP HCPCS C1713 439.55 - PLATE BONE 120D 75MM ANGLED DCP TITANIUM ADULT ORTHOPEDIC BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.57 SUP HCPCS C1713 439.57 - PLATE BONE 120D 85MM ANGLED DCP TITANIUM ADULT ORTHOPEDIC BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.6 SUP HCPCS C1713 439.60 - PLATE BONE 90D 20MM DISPLACEMENT 50MM 20MM DCP TITANIUM BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.61 SUP HCPCS C1713 439.61 - PLATE BONE 90D 20MM 55MM DCP TITANIUM ADULT ORTHOPEDIC BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.62 SUP HCPCS C1713 439.62 - PLATE BN 90D 20MM DSPL 60MM NS DCP TI ADLT OSTM BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.63 SUP HCPCS C1713 439.63 - PLATE BONE 90D 20MM DISPLACEMENT 65MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.64 SUP HCPCS C1713 439.64 - PLATE BONE 90D 20MM DISPLACEMENT 70MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.65 SUP HCPCS C1713 439.65 - PLATE BONE 90D 20MM 75MM ANGLED DCP STAINLESS STEEL ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.7 SUP HCPCS C1713 439.70 - PLATE BONE 90D 15MM DISPLACEMENT 50MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.71 SUP HCPCS C1713 439.71 - PLATE BONE 90D 15MM DISPLACEMENT 55MM ANGLED DCP TITANIUM BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.72 SUP HCPCS C1713 439.72 - PLATE BONE 90D 15MM DISPLACEMENT 60MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.73 SUP HCPCS C1713 439.73 - PLATE BONE 90D 15MM DISPLACEMENT 65MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.74 SUP HCPCS C1713 439.74 - PLATE BONE 90D 15MM 70MM DCP TITANIUM ADULT ORTHOPEDIC BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.76 SUP HCPCS C1713 439.76 - PLATE BONE 90D 15MM DISPLACEMENT 80MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.78 SUP HCPCS C1713 439.78 - PLATE BONE 90D 15MM DISPLACEMENT 40MM DCP TITANIUM ADULT BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.8 SUP HCPCS C1713 439.80 - PLATE BONE 130D 100MM DCP TITANIUM ADULT NONSTRL OSTMY BOTH IP/OP "$1,110.90 " $822.07 $0.00 $888.72 $499.91 $499.91 $0.00 $0.00 $0.00 $231.54 $824.51 $824.51 $0.00 $0.00 $231.51 $0.00 $657.10 $657.10 $0.00 $555.45 $879.83 $888.72 $0.00 $0.00 $168.79 $0.00 $0.00 $176.86 $0.00 $0.00 $0.00 $0.00 $0.00 439.81 SUP HCPCS C1713 439.81 - PLATE BONE 130D 105MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.82 SUP HCPCS C1713 439.82 - PLATE BONE 130D 110MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.83 SUP HCPCS C1713 439.83 - PLATE BONE 130D 65MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.84 SUP HCPCS C1713 439.84 - PLATE BONE 130D 70MM ANGLED DCP TITANIUM ADULT ORTHOPEDIC BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.85 SUP HCPCS C1713 439.85 - PLATE BONE 130D 75MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.86 SUP HCPCS C1713 439.86 - PLATE BONE 130D 80MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.87 SUP HCPCS C1713 439.87 - PLATE BONE 130D 85MM ANGLED DCP TITANIUM ADULT ORTHOPEDIC BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.88 SUP HCPCS C1713 439.88 - PLATE BONE 130D 90MM ANGLED DCP TITANIUM ADULT ORTHOPEDIC BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.89 SUP HCPCS C1713 439.89 - PLATE BONE 130D 95MM DCP TITANIUM ADULT ORTHOPEDIC NONSTRL BOTH IP/OP "$1,078.55 " $798.13 $0.00 $862.84 $485.35 $485.35 $0.00 $0.00 $0.00 $224.80 $800.50 $800.50 $0.00 $0.00 $224.77 $0.00 $637.96 $637.96 $0.00 $539.28 $854.21 $862.84 $0.00 $0.00 $168.79 $0.00 $0.00 $171.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.934 SUP HCPCS C1713 439.934 - PLATE BONE 81MM 4 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,663.78 " "$1,971.20" $0.00 "$2,068.96" "$1,163.79" "$1,163.79" $0.00 $0.00 $0.00 $555.20 "$1,977.05" "$1,977.05" $0.00 $0.00 $555.13 $0.00 "$1,313.24" "$1,313.24" $0.00 "$1,293.10" "$2,048.27" "$2,068.96" $0.00 $0.00 $392.95 $0.00 $0.00 $411.72 $0.00 $0.00 $0.00 $0.00 $0.00 439.935 SUP HCPCS C1713 439.935 - PLATE BONE 81MM 4 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,663.78 " "$1,971.20" $0.00 "$2,068.96" "$1,163.79" "$1,163.79" $0.00 $0.00 $0.00 $555.20 "$1,977.05" "$1,977.05" $0.00 $0.00 $555.13 $0.00 "$1,313.24" "$1,313.24" $0.00 "$1,293.10" "$2,048.27" "$2,068.96" $0.00 $0.00 $392.95 $0.00 $0.00 $411.72 $0.00 $0.00 $0.00 $0.00 $0.00 439.936 SUP HCPCS C1713 439.936 - PLATE BONE 107MM 6 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,696.13 " "$1,995.14" $0.00 "$2,094.08" "$1,177.92" "$1,177.92" $0.00 $0.00 $0.00 $561.94 "$2,001.06" "$2,001.06" $0.00 $0.00 $561.87 $0.00 "$1,329.19" "$1,329.19" $0.00 "$1,308.80" "$2,073.14" "$2,094.08" $0.00 $0.00 $397.72 $0.00 $0.00 $416.72 $0.00 $0.00 $0.00 $0.00 $0.00 439.937 SUP HCPCS C1713 439.937 - PLATE BONE 107MM 6 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,696.13 " "$1,995.14" $0.00 "$2,094.08" "$1,177.92" "$1,177.92" $0.00 $0.00 $0.00 $561.94 "$2,001.06" "$2,001.06" $0.00 $0.00 $561.87 $0.00 "$1,329.19" "$1,329.19" $0.00 "$1,308.80" "$2,073.14" "$2,094.08" $0.00 $0.00 $397.72 $0.00 $0.00 $416.72 $0.00 $0.00 $0.00 $0.00 $0.00 439.938 SUP HCPCS C1713 439.938 - PLATE BONE 133MM 8 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,727.05 " "$2,018.02" $0.00 "$2,118.10" "$1,191.43" "$1,191.43" $0.00 $0.00 $0.00 $568.39 "$2,024.02" "$2,024.02" $0.00 $0.00 $568.32 $0.00 "$1,344.44" "$1,344.44" $0.00 "$1,323.81" "$2,096.92" "$2,118.10" $0.00 $0.00 $402.28 $0.00 $0.00 $421.50 $0.00 $0.00 $0.00 $0.00 $0.00 439.939 SUP HCPCS C1713 439.939 - PLATE BONE 133MM 8 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,727.05 " "$2,018.02" $0.00 "$2,118.10" "$1,191.43" "$1,191.43" $0.00 $0.00 $0.00 $568.39 "$2,024.02" "$2,024.02" $0.00 $0.00 $568.32 $0.00 "$1,344.44" "$1,344.44" $0.00 "$1,323.81" "$2,096.92" "$2,118.10" $0.00 $0.00 $402.28 $0.00 $0.00 $421.50 $0.00 $0.00 $0.00 $0.00 $0.00 439.94 SUP HCPCS C1713 439.940 - PLATE BONE 159MM 10 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,676.28 " "$1,980.45" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $557.80 "$1,986.33" "$1,986.33" $0.00 $0.00 $557.74 $0.00 "$1,319.40" "$1,319.40" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 439.941 SUP HCPCS C1713 439.941 - PLATE BONE 159MM 10 HOLE TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,756.58 " "$2,039.87" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $574.54 "$2,045.93" "$2,045.93" $0.00 $0.00 $574.47 $0.00 "$1,358.99" "$1,358.99" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 439.942 SUP HCPCS C1713 439.942 - PLATE BONE 185MM 12 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,793.10 " "$2,066.89" $0.00 "$2,169.40" "$1,220.29" "$1,220.29" $0.00 $0.00 $0.00 $582.15 "$2,073.04" "$2,073.04" $0.00 $0.00 $582.08 $0.00 "$1,377.00" "$1,377.00" $0.00 "$1,355.88" "$2,147.71" "$2,169.40" $0.00 $0.00 $412.03 $0.00 $0.00 $431.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.943 SUP HCPCS C1713 439.943 - PLATE BONE 185MM 12 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,793.10 " "$2,066.89" $0.00 "$2,169.40" "$1,220.29" "$1,220.29" $0.00 $0.00 $0.00 $582.15 "$2,073.04" "$2,073.04" $0.00 $0.00 $582.08 $0.00 "$1,377.00" "$1,377.00" $0.00 "$1,355.88" "$2,147.71" "$2,169.40" $0.00 $0.00 $412.03 $0.00 $0.00 $431.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.944 SUP HCPCS C1713 439.944 - PLATE BONE 211MM 14 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,822.63 " "$2,088.75" $0.00 "$2,192.34" "$1,233.19" "$1,233.19" $0.00 $0.00 $0.00 $588.31 "$2,094.95" "$2,094.95" $0.00 $0.00 $588.24 $0.00 "$1,391.55" "$1,391.55" $0.00 "$1,370.21" "$2,170.42" "$2,192.34" $0.00 $0.00 $416.38 $0.00 $0.00 $436.28 $0.00 $0.00 $0.00 $0.00 $0.00 439.945 SUP HCPCS C1713 439.945 - PLATE BONE 211MM 14 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,822.63 " "$2,088.75" $0.00 "$2,192.34" "$1,233.19" "$1,233.19" $0.00 $0.00 $0.00 $588.31 "$2,094.95" "$2,094.95" $0.00 $0.00 $588.24 $0.00 "$1,391.55" "$1,391.55" $0.00 "$1,370.21" "$2,170.42" "$2,192.34" $0.00 $0.00 $416.38 $0.00 $0.00 $436.28 $0.00 $0.00 $0.00 $0.00 $0.00 439.946 SUP HCPCS C1713 439.946 - PLATE BONE 237MM 16 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,922.43 " "$2,162.60" $0.00 "$2,269.86" "$1,276.80" "$1,276.80" $0.00 $0.00 $0.00 $609.11 "$2,169.02" "$2,169.02" $0.00 $0.00 $609.03 $0.00 "$1,440.76" "$1,440.76" $0.00 "$1,418.66" "$2,247.17" "$2,269.86" $0.00 $0.00 $431.11 $0.00 $0.00 $451.70 $0.00 $0.00 $0.00 $0.00 $0.00 439.947 SUP HCPCS C1713 439.947 - PLATE BONE 237MM 16 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,922.43 " "$2,162.60" $0.00 "$2,269.86" "$1,276.80" "$1,276.80" $0.00 $0.00 $0.00 $609.11 "$2,169.02" "$2,169.02" $0.00 $0.00 $609.03 $0.00 "$1,440.76" "$1,440.76" $0.00 "$1,418.66" "$2,247.17" "$2,269.86" $0.00 $0.00 $431.11 $0.00 $0.00 $451.70 $0.00 $0.00 $0.00 $0.00 $0.00 439.954 SUP HCPCS C1713 439.954 - PLATE BONE 94MM 4 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,655.35 " "$1,964.96" $0.00 "$2,062.42" "$1,160.11" "$1,160.11" $0.00 $0.00 $0.00 $553.44 "$1,970.80" "$1,970.80" $0.00 $0.00 $553.37 $0.00 "$1,309.09" "$1,309.09" $0.00 "$1,289.01" "$2,041.80" "$2,062.42" $0.00 $0.00 $391.71 $0.00 $0.00 $410.42 $0.00 $0.00 $0.00 $0.00 $0.00 439.955 SUP HCPCS C1713 439.955 - PLATE BONE 94MM 4 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,655.35 " "$1,964.96" $0.00 "$2,062.42" "$1,160.11" "$1,160.11" $0.00 $0.00 $0.00 $553.44 "$1,970.80" "$1,970.80" $0.00 $0.00 $553.37 $0.00 "$1,309.09" "$1,309.09" $0.00 "$1,289.01" "$2,041.80" "$2,062.42" $0.00 $0.00 $391.71 $0.00 $0.00 $410.42 $0.00 $0.00 $0.00 $0.00 $0.00 439.956 SUP HCPCS C1713 439.956 - PLATE BONE 119MM 6 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,690.50 " "$1,990.97" $0.00 "$2,089.70" "$1,175.46" "$1,175.46" $0.00 $0.00 $0.00 $560.77 "$1,996.89" "$1,996.89" $0.00 $0.00 $560.70 $0.00 "$1,326.42" "$1,326.42" $0.00 "$1,306.06" "$2,068.81" "$2,089.70" $0.00 $0.00 $396.89 $0.00 $0.00 $415.85 $0.00 $0.00 $0.00 $0.00 $0.00 439.957 SUP HCPCS C1713 439.957 - PLATE BONE 119MM 6 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,690.50 " "$1,990.97" $0.00 "$2,089.70" "$1,175.46" "$1,175.46" $0.00 $0.00 $0.00 $560.77 "$1,996.89" "$1,996.89" $0.00 $0.00 $560.70 $0.00 "$1,326.42" "$1,326.42" $0.00 "$1,306.06" "$2,068.81" "$2,089.70" $0.00 $0.00 $396.89 $0.00 $0.00 $415.85 $0.00 $0.00 $0.00 $0.00 $0.00 439.958 SUP HCPCS C1713 439.958 - PLATE BONE 145MM 8 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,722.83 " "$2,014.89" $0.00 "$2,114.82" "$1,189.59" "$1,189.59" $0.00 $0.00 $0.00 $567.50 "$2,020.88" "$2,020.88" $0.00 $0.00 $567.44 $0.00 "$1,342.35" "$1,342.35" $0.00 "$1,321.76" "$2,093.68" "$2,114.82" $0.00 $0.00 $401.66 $0.00 $0.00 $420.85 $0.00 $0.00 $0.00 $0.00 $0.00 439.959 SUP HCPCS C1713 439.959 - PLATE BONE 145MM 8 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,722.83 " "$2,014.89" $0.00 "$2,114.82" "$1,189.59" "$1,189.59" $0.00 $0.00 $0.00 $567.50 "$2,020.88" "$2,020.88" $0.00 $0.00 $567.44 $0.00 "$1,342.35" "$1,342.35" $0.00 "$1,321.76" "$2,093.68" "$2,114.82" $0.00 $0.00 $401.66 $0.00 $0.00 $420.85 $0.00 $0.00 $0.00 $0.00 $0.00 439.96 SUP HCPCS C1713 439.960 - PLATE BONE 171MM 10 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,673.55 " "$1,978.43" $0.00 "$2,138.84" "$1,203.10" "$1,203.10" $0.00 $0.00 $0.00 $557.23 "$1,984.31" "$1,984.31" $0.00 $0.00 $557.17 $0.00 "$1,318.06" "$1,318.06" $0.00 "$1,336.78" "$2,117.45" "$2,138.84" $0.00 $0.00 $406.22 $0.00 $0.00 $425.63 $0.00 $0.00 $0.00 $0.00 $0.00 439.961 SUP HCPCS C1713 439.961 - PLATE BONE 171MM 10 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,753.75 " "$2,037.78" $0.00 "$2,138.84" "$1,203.10" "$1,203.10" $0.00 $0.00 $0.00 $573.95 "$2,043.83" "$2,043.83" $0.00 $0.00 $573.88 $0.00 "$1,357.60" "$1,357.60" $0.00 "$1,336.78" "$2,117.45" "$2,138.84" $0.00 $0.00 $406.22 $0.00 $0.00 $425.63 $0.00 $0.00 $0.00 $0.00 $0.00 439.962 SUP HCPCS C1713 439.962 - PLATE BONE 197MM 12 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,783.28 " "$2,059.63" $0.00 "$2,161.76" "$1,215.99" "$1,215.99" $0.00 $0.00 $0.00 $580.10 "$2,065.75" "$2,065.75" $0.00 $0.00 $580.03 $0.00 "$1,372.15" "$1,372.15" $0.00 "$1,351.10" "$2,140.14" "$2,161.76" $0.00 $0.00 $410.58 $0.00 $0.00 $430.19 $0.00 $0.00 $0.00 $0.00 $0.00 439.963 SUP HCPCS C1713 439.963 - PLATE BONE 197MM 12 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,783.28 " "$2,059.63" $0.00 "$2,161.76" "$1,215.99" "$1,215.99" $0.00 $0.00 $0.00 $580.10 "$2,065.75" "$2,065.75" $0.00 $0.00 $580.03 $0.00 "$1,372.15" "$1,372.15" $0.00 "$1,351.10" "$2,140.14" "$2,161.76" $0.00 $0.00 $410.58 $0.00 $0.00 $430.19 $0.00 $0.00 $0.00 $0.00 $0.00 439.964 SUP HCPCS C1713 439.964 - PLATE BONE 223MM 14 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,817.00 " "$2,084.58" $0.00 "$2,187.96" "$1,230.73" "$1,230.73" $0.00 $0.00 $0.00 $587.13 "$2,090.78" "$2,090.78" $0.00 $0.00 $587.06 $0.00 "$1,388.78" "$1,388.78" $0.00 "$1,367.48" "$2,166.08" "$2,187.96" $0.00 $0.00 $415.55 $0.00 $0.00 $435.40 $0.00 $0.00 $0.00 $0.00 $0.00 439.965 SUP HCPCS C1713 439.965 - PLATE BONE 223MM 14 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,817.00 " "$2,084.58" $0.00 "$2,187.96" "$1,230.73" "$1,230.73" $0.00 $0.00 $0.00 $587.13 "$2,090.78" "$2,090.78" $0.00 $0.00 $587.06 $0.00 "$1,388.78" "$1,388.78" $0.00 "$1,367.48" "$2,166.08" "$2,187.96" $0.00 $0.00 $415.55 $0.00 $0.00 $435.40 $0.00 $0.00 $0.00 $0.00 $0.00 439.966 SUP HCPCS C1713 439.966 - PLATE BONE 249MM 16 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,915.40 " "$2,157.40" $0.00 "$2,264.40" "$1,273.73" "$1,273.73" $0.00 $0.00 $0.00 $607.64 "$2,163.81" "$2,163.81" $0.00 $0.00 $607.57 $0.00 "$1,437.29" "$1,437.29" $0.00 "$1,415.25" "$2,241.76" "$2,264.40" $0.00 $0.00 $430.07 $0.00 $0.00 $450.62 $0.00 $0.00 $0.00 $0.00 $0.00 439.967 SUP HCPCS C1713 439.967 - PLATE BONE 249MM 16 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,915.40 " "$2,157.40" $0.00 "$2,264.40" "$1,273.73" "$1,273.73" $0.00 $0.00 $0.00 $607.64 "$2,163.81" "$2,163.81" $0.00 $0.00 $607.57 $0.00 "$1,437.29" "$1,437.29" $0.00 "$1,415.25" "$2,241.76" "$2,264.40" $0.00 $0.00 $430.07 $0.00 $0.00 $450.62 $0.00 $0.00 $0.00 $0.00 $0.00 439.968 SUP HCPCS C1713 439.968 - PLATE BONE 275MM 18 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$3,019.43 " "$2,234.38" $0.00 "$2,345.18" "$1,319.16" "$1,319.16" $0.00 $0.00 $0.00 $629.32 "$2,241.02" "$2,241.02" $0.00 $0.00 $629.25 $0.00 "$1,488.58" "$1,488.58" $0.00 "$1,465.74" "$2,321.73" "$2,345.18" $0.00 $0.00 $445.41 $0.00 $0.00 $466.69 $0.00 $0.00 $0.00 $0.00 $0.00 439.969 SUP HCPCS C1713 439.969 - PLATE BONE 275MM 18 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$3,110.80 " "$2,301.99" $0.00 "$2,416.16" "$1,359.09" "$1,359.09" $0.00 $0.00 $0.00 $648.37 "$2,308.84" "$2,308.84" $0.00 $0.00 $648.29 $0.00 "$1,533.62" "$1,533.62" $0.00 "$1,510.10" "$2,392.00" "$2,416.16" $0.00 $0.00 $458.89 $0.00 $0.00 $480.82 $0.00 $0.00 $0.00 $0.00 $0.00 439.97 SUP HCPCS C1713 439.970 - PLATE BONE 301MM 20 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$3,028.38 " "$2,241.00" $0.00 "$2,422.70" "$1,362.77" "$1,362.77" $0.00 $0.00 $0.00 $631.19 "$2,247.66" "$2,247.66" $0.00 $0.00 $631.11 $0.00 "$1,492.99" "$1,492.99" $0.00 "$1,514.19" "$2,398.48" "$2,422.70" $0.00 $0.00 $460.14 $0.00 $0.00 $482.12 $0.00 $0.00 $0.00 $0.00 $0.00 439.971 SUP HCPCS C1713 439.971 - PLATE BONE 301MM 20 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$3,119.23 " "$2,308.23" $0.00 "$2,422.70" "$1,362.77" "$1,362.77" $0.00 $0.00 $0.00 $650.12 "$2,315.09" "$2,315.09" $0.00 $0.00 $650.05 $0.00 "$1,537.78" "$1,537.78" $0.00 "$1,514.19" "$2,398.48" "$2,422.70" $0.00 $0.00 $460.14 $0.00 $0.00 $482.12 $0.00 $0.00 $0.00 $0.00 $0.00 439.984 SUP HCPCS C1713 439.984 - PLATE BONE 106MM 4 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,665.20 " "$1,972.25" $0.00 "$2,070.06" "$1,164.41" "$1,164.41" $0.00 $0.00 $0.00 $555.49 "$1,978.11" "$1,978.11" $0.00 $0.00 $555.43 $0.00 "$1,313.94" "$1,313.94" $0.00 "$1,293.79" "$2,049.36" "$2,070.06" $0.00 $0.00 $393.16 $0.00 $0.00 $411.94 $0.00 $0.00 $0.00 $0.00 $0.00 439.985 SUP HCPCS C1713 439.985 - PLATE BONE 106MM 4 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,665.20 " "$1,972.25" $0.00 "$2,070.06" "$1,164.41" "$1,164.41" $0.00 $0.00 $0.00 $555.49 "$1,978.11" "$1,978.11" $0.00 $0.00 $555.43 $0.00 "$1,313.94" "$1,313.94" $0.00 "$1,293.79" "$2,049.36" "$2,070.06" $0.00 $0.00 $393.16 $0.00 $0.00 $411.94 $0.00 $0.00 $0.00 $0.00 $0.00 439.986 SUP HCPCS C1713 439.986 - PLATE BONE 142MM 6 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,697.53 " "$1,996.17" $0.00 "$2,095.16" "$1,178.53" "$1,178.53" $0.00 $0.00 $0.00 $562.23 "$2,002.10" "$2,002.10" $0.00 $0.00 $562.16 $0.00 "$1,329.88" "$1,329.88" $0.00 "$1,309.48" "$2,074.21" "$2,095.16" $0.00 $0.00 $397.93 $0.00 $0.00 $416.94 $0.00 $0.00 $0.00 $0.00 $0.00 439.987 SUP HCPCS C1713 439.987 - PLATE BONE 142MM 6 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,697.53 " "$1,996.17" $0.00 "$2,095.16" "$1,178.53" "$1,178.53" $0.00 $0.00 $0.00 $562.23 "$2,002.10" "$2,002.10" $0.00 $0.00 $562.16 $0.00 "$1,329.88" "$1,329.88" $0.00 "$1,309.48" "$2,074.21" "$2,095.16" $0.00 $0.00 $397.93 $0.00 $0.00 $416.94 $0.00 $0.00 $0.00 $0.00 $0.00 439.988 SUP HCPCS C1713 439.988 - PLATE BONE 178MM 8 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,728.45 " "$2,019.05" $0.00 "$2,119.18" "$1,192.04" "$1,192.04" $0.00 $0.00 $0.00 $568.68 "$2,025.06" "$2,025.06" $0.00 $0.00 $568.61 $0.00 "$1,345.13" "$1,345.13" $0.00 "$1,324.49" "$2,097.99" "$2,119.18" $0.00 $0.00 $402.49 $0.00 $0.00 $421.72 $0.00 $0.00 $0.00 $0.00 $0.00 439.989 SUP HCPCS C1713 439.989 - PLATE BONE 178MM 8 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,728.45 " "$2,019.05" $0.00 "$2,119.18" "$1,192.04" "$1,192.04" $0.00 $0.00 $0.00 $568.68 "$2,025.06" "$2,025.06" $0.00 $0.00 $568.61 $0.00 "$1,345.13" "$1,345.13" $0.00 "$1,324.49" "$2,097.99" "$2,119.18" $0.00 $0.00 $402.49 $0.00 $0.00 $421.72 $0.00 $0.00 $0.00 $0.00 $0.00 439.99 SUP HCPCS C1713 439.990 - PLATE BONE 214MM 10 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,677.65 " "$1,981.46" $0.00 "$2,142.12" "$1,204.94" "$1,204.94" $0.00 $0.00 $0.00 $558.09 "$1,987.35" "$1,987.35" $0.00 $0.00 $558.02 $0.00 "$1,320.08" "$1,320.08" $0.00 "$1,338.83" "$2,120.70" "$2,142.12" $0.00 $0.00 $406.85 $0.00 $0.00 $426.28 $0.00 $0.00 $0.00 $0.00 $0.00 439.991 SUP HCPCS C1713 439.991 - PLATE BONE 214MM 10 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,757.98 " "$2,040.91" $0.00 "$2,142.12" "$1,204.94" "$1,204.94" $0.00 $0.00 $0.00 $574.83 "$2,046.97" "$2,046.97" $0.00 $0.00 $574.76 $0.00 "$1,359.68" "$1,359.68" $0.00 "$1,338.83" "$2,120.70" "$2,142.12" $0.00 $0.00 $406.85 $0.00 $0.00 $426.28 $0.00 $0.00 $0.00 $0.00 $0.00 439.992 SUP HCPCS C1713 439.992 - PLATE BONE 250MM 12 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,793.10 " "$2,066.89" $0.00 "$2,169.40" "$1,220.29" "$1,220.29" $0.00 $0.00 $0.00 $582.15 "$2,073.04" "$2,073.04" $0.00 $0.00 $582.08 $0.00 "$1,377.00" "$1,377.00" $0.00 "$1,355.88" "$2,147.71" "$2,169.40" $0.00 $0.00 $412.03 $0.00 $0.00 $431.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.993 SUP HCPCS C1713 439.993 - PLATE BONE 250MM 12 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,793.10 " "$2,066.89" $0.00 "$2,169.40" "$1,220.29" "$1,220.29" $0.00 $0.00 $0.00 $582.15 "$2,073.04" "$2,073.04" $0.00 $0.00 $582.08 $0.00 "$1,377.00" "$1,377.00" $0.00 "$1,355.88" "$2,147.71" "$2,169.40" $0.00 $0.00 $412.03 $0.00 $0.00 $431.71 $0.00 $0.00 $0.00 $0.00 $0.00 439.994 SUP HCPCS C1713 439.994 - PLATE BONE 286MM 14 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,822.63 " "$2,088.75" $0.00 "$2,192.34" "$1,233.19" "$1,233.19" $0.00 $0.00 $0.00 $588.31 "$2,094.95" "$2,094.95" $0.00 $0.00 $588.24 $0.00 "$1,391.55" "$1,391.55" $0.00 "$1,370.21" "$2,170.42" "$2,192.34" $0.00 $0.00 $416.38 $0.00 $0.00 $436.28 $0.00 $0.00 $0.00 $0.00 $0.00 439.995 SUP HCPCS C1713 439.995 - PLATE BONE 286MM 14 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,822.63 " "$2,088.75" $0.00 "$2,192.34" "$1,233.19" "$1,233.19" $0.00 $0.00 $0.00 $588.31 "$2,094.95" "$2,094.95" $0.00 $0.00 $588.24 $0.00 "$1,391.55" "$1,391.55" $0.00 "$1,370.21" "$2,170.42" "$2,192.34" $0.00 $0.00 $416.38 $0.00 $0.00 $436.28 $0.00 $0.00 $0.00 $0.00 $0.00 439.996 SUP HCPCS C1713 439.996 - PLATE BONE 322MM 16 HOLE LCP TITANIUM TIBIA RIGHT MEDIAL BOTH IP/OP "$2,850.75 " "$2,109.56" $0.00 "$2,214.18" "$1,245.48" "$1,245.48" $0.00 $0.00 $0.00 $594.17 "$2,115.83" "$2,115.83" $0.00 $0.00 $594.10 $0.00 "$1,405.42" "$1,405.42" $0.00 "$1,383.86" "$2,192.04" "$2,214.18" $0.00 $0.00 $420.53 $0.00 $0.00 $440.62 $0.00 $0.00 $0.00 $0.00 $0.00 439.997 SUP HCPCS C1713 439.997 - PLATE BONE 322MM 16 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,850.75 " "$2,109.56" $0.00 "$2,214.18" "$1,245.48" "$1,245.48" $0.00 $0.00 $0.00 $594.17 "$2,115.83" "$2,115.83" $0.00 $0.00 $594.10 $0.00 "$1,405.42" "$1,405.42" $0.00 "$1,383.86" "$2,192.04" "$2,214.18" $0.00 $0.00 $420.53 $0.00 $0.00 $440.62 $0.00 $0.00 $0.00 $0.00 $0.00 440.036 SUP HCPCS C1713 440.036 - PLATE BONE 82MM 4 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,666.60 " "$1,973.28" $0.00 "$2,071.14" "$1,165.02" "$1,165.02" $0.00 $0.00 $0.00 $555.79 "$1,979.15" "$1,979.15" $0.00 $0.00 $555.72 $0.00 "$1,314.63" "$1,314.63" $0.00 "$1,294.46" "$2,050.43" "$2,071.14" $0.00 $0.00 $393.37 $0.00 $0.00 $412.16 $0.00 $0.00 $0.00 $0.00 $0.00 440.037 SUP HCPCS C1713 440.037 - PLATE BONE 82MM 4 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,666.60 " "$1,973.28" $0.00 "$2,071.14" "$1,165.02" "$1,165.02" $0.00 $0.00 $0.00 $555.79 "$1,979.15" "$1,979.15" $0.00 $0.00 $555.72 $0.00 "$1,314.63" "$1,314.63" $0.00 "$1,294.46" "$2,050.43" "$2,071.14" $0.00 $0.00 $393.37 $0.00 $0.00 $412.16 $0.00 $0.00 $0.00 $0.00 $0.00 440.038 SUP HCPCS C1713 440.038 - PLATE BONE 118MM 6 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,698.93 " "$1,997.21" $0.00 "$2,096.26" "$1,179.15" "$1,179.15" $0.00 $0.00 $0.00 $562.52 "$2,003.14" "$2,003.14" $0.00 $0.00 $562.46 $0.00 "$1,330.57" "$1,330.57" $0.00 "$1,310.16" "$2,075.30" "$2,096.26" $0.00 $0.00 $398.14 $0.00 $0.00 $417.16 $0.00 $0.00 $0.00 $0.00 $0.00 440.039 SUP HCPCS C1713 440.039 - PLATE BONE 118MM 6 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,698.93 " "$1,997.21" $0.00 "$2,096.26" "$1,179.15" "$1,179.15" $0.00 $0.00 $0.00 $562.52 "$2,003.14" "$2,003.14" $0.00 $0.00 $562.46 $0.00 "$1,330.57" "$1,330.57" $0.00 "$1,310.16" "$2,075.30" "$2,096.26" $0.00 $0.00 $398.14 $0.00 $0.00 $417.16 $0.00 $0.00 $0.00 $0.00 $0.00 440.04 SUP HCPCS C1713 440.040 - PLATE BONE 154MM 8 HOLE LCP TITANIUM RIGHT PROXIMAL TIBIA BOTH IP/OP "$2,650.35 " "$1,961.26" $0.00 "$2,120.28" "$1,192.66" "$1,192.66" $0.00 $0.00 $0.00 $552.40 "$1,967.09" "$1,967.09" $0.00 $0.00 $552.33 $0.00 "$1,306.62" "$1,306.62" $0.00 "$1,325.18" "$2,099.08" "$2,120.28" $0.00 $0.00 $402.70 $0.00 $0.00 $421.94 $0.00 $0.00 $0.00 $0.00 $0.00 440.041 SUP HCPCS C1713 440.041 - PLATE BONE 154MM 8 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,729.85 " "$2,020.09" $0.00 "$2,120.28" "$1,192.66" "$1,192.66" $0.00 $0.00 $0.00 $568.97 "$2,026.09" "$2,026.09" $0.00 $0.00 $568.90 $0.00 "$1,345.82" "$1,345.82" $0.00 "$1,325.18" "$2,099.08" "$2,120.28" $0.00 $0.00 $402.70 $0.00 $0.00 $421.94 $0.00 $0.00 $0.00 $0.00 $0.00 440.042 SUP HCPCS C1713 440.042 - PLATE BONE 190MM 10 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,759.38 " "$2,041.94" $0.00 "$2,143.20" "$1,205.55" "$1,205.55" $0.00 $0.00 $0.00 $575.12 "$2,048.01" "$2,048.01" $0.00 $0.00 $575.05 $0.00 "$1,360.37" "$1,360.37" $0.00 "$1,339.50" "$2,121.77" "$2,143.20" $0.00 $0.00 $407.05 $0.00 $0.00 $426.50 $0.00 $0.00 $0.00 $0.00 $0.00 440.043 SUP HCPCS C1713 440.043 - PLATE BONE 190MM 10 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,759.38 " "$2,041.94" $0.00 "$2,143.20" "$1,205.55" "$1,205.55" $0.00 $0.00 $0.00 $575.12 "$2,048.01" "$2,048.01" $0.00 $0.00 $575.05 $0.00 "$1,360.37" "$1,360.37" $0.00 "$1,339.50" "$2,121.77" "$2,143.20" $0.00 $0.00 $407.05 $0.00 $0.00 $426.50 $0.00 $0.00 $0.00 $0.00 $0.00 440.044 SUP HCPCS C1713 440.044 - PLATE BONE 226MM 12 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,791.70 " "$2,065.86" $0.00 "$2,168.32" "$1,219.68" "$1,219.68" $0.00 $0.00 $0.00 $581.86 "$2,072.00" "$2,072.00" $0.00 $0.00 $581.79 $0.00 "$1,376.31" "$1,376.31" $0.00 "$1,355.20" "$2,146.64" "$2,168.32" $0.00 $0.00 $411.82 $0.00 $0.00 $431.50 $0.00 $0.00 $0.00 $0.00 $0.00 440.045 SUP HCPCS C1713 440.045 - PLATE BONE 226MM 12 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,791.70 " "$2,065.86" $0.00 "$2,168.32" "$1,219.68" "$1,219.68" $0.00 $0.00 $0.00 $581.86 "$2,072.00" "$2,072.00" $0.00 $0.00 $581.79 $0.00 "$1,376.31" "$1,376.31" $0.00 "$1,355.20" "$2,146.64" "$2,168.32" $0.00 $0.00 $411.82 $0.00 $0.00 $431.50 $0.00 $0.00 $0.00 $0.00 $0.00 440.046 SUP HCPCS C1713 440.046 - PLATE BONE 262MM 14 HOLE LCP TITANIUM TIBIA RIGHT PROXIMAL BOTH IP/OP "$2,821.23 " "$2,087.71" $0.00 "$2,191.24" "$1,232.57" "$1,232.57" $0.00 $0.00 $0.00 $588.01 "$2,093.91" "$2,093.91" $0.00 $0.00 $587.94 $0.00 "$1,390.86" "$1,390.86" $0.00 "$1,369.53" "$2,169.33" "$2,191.24" $0.00 $0.00 $416.18 $0.00 $0.00 $436.06 $0.00 $0.00 $0.00 $0.00 $0.00 440.047 SUP HCPCS C1713 440.047 - PLATE BONE 262MM 14 HOLE LCP TITANIUM TIBIA LEFT PROXIMAL BOTH IP/OP "$2,821.23 " "$2,087.71" $0.00 "$2,191.24" "$1,232.57" "$1,232.57" $0.00 $0.00 $0.00 $588.01 "$2,093.91" "$2,093.91" $0.00 $0.00 $587.94 $0.00 "$1,390.86" "$1,390.86" $0.00 "$1,369.53" "$2,169.33" "$2,191.24" $0.00 $0.00 $416.18 $0.00 $0.00 $436.06 $0.00 $0.00 $0.00 $0.00 $0.00 440.05 SUP HCPCS C1713 440.05 - PLATE BONE 5 HOLE SPOON LC-DCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $626.43 $463.56 $0.00 $501.14 $281.89 $281.89 $0.00 $0.00 $0.00 $130.56 $464.93 $464.93 $0.00 $0.00 $130.55 $0.00 $370.53 $370.53 $0.00 $313.21 $496.13 $501.14 $0.00 $0.00 $95.18 $0.00 $0.00 $99.73 $0.00 $0.00 $0.00 $0.00 $0.00 440.06 SUP HCPCS C1713 440.06 - PLATE BONE SPOON 6 HOLE LC DCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $668.73 $494.86 $0.00 $534.98 $300.93 $300.93 $0.00 $0.00 $0.00 $139.38 $496.33 $496.33 $0.00 $0.00 $139.36 $0.00 $395.55 $395.55 $0.00 $334.36 $529.63 $534.98 $0.00 $0.00 $101.61 $0.00 $0.00 $106.46 $0.00 $0.00 $0.00 $0.00 $0.00 440.13 SUP HCPCS C1713 440.13 - PLATE BONE T 68MM 3 HOLE LC-DCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $504.95 $373.66 $0.00 $403.96 $227.23 $227.23 $0.00 $0.00 $0.00 $105.24 $374.77 $374.77 $0.00 $0.00 $105.23 $0.00 $298.68 $298.68 $0.00 $252.48 $399.92 $403.96 $0.00 $0.00 $76.72 $0.00 $0.00 $80.39 $0.00 $0.00 $0.00 $0.00 $0.00 440.14 SUP HCPCS C1713 440.14 - PLATE BONE T 84MM 4 HOLE LC-DCP TITANIUM HUMERUS TIBIAL BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $247.50 $247.50 $0.00 $0.00 $0.00 $114.63 $408.21 $408.21 $0.00 $0.00 $114.62 $0.00 $325.33 $325.33 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $83.57 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 440.141 SUP HCPCS C1713 440.141 - PLATE BONE 83MM 4 HOLE T LCP TITANIUM ORTHOPEDIC NONSTRL 4.5 BOTH IP/OP "$1,137.20 " $841.53 $0.00 $883.26 $496.83 $496.83 $0.00 $0.00 $0.00 $237.02 $844.03 $844.03 $0.00 $0.00 $236.99 $0.00 $672.65 $672.65 $0.00 $552.04 $874.43 $883.26 $0.00 $0.00 $167.76 $0.00 $0.00 $175.77 $0.00 $0.00 $0.00 $0.00 $0.00 440.15 SUP HCPCS C1713 440.15 - PLATE BONE T 100MM 5 HOLE LC-DCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $577.30 $427.20 $0.00 $461.84 $259.79 $259.79 $0.00 $0.00 $0.00 $120.32 $428.47 $428.47 $0.00 $0.00 $120.31 $0.00 $341.47 $341.47 $0.00 $288.65 $457.22 $461.84 $0.00 $0.00 $87.71 $0.00 $0.00 $91.91 $0.00 $0.00 $0.00 $0.00 $0.00 440.16 SUP HCPCS C1713 440.16 - PLATE BONE T 116MM 6 HOLE LC-DCP TITANIUM HUMERUS TIBIAL BOTH IP/OP $656.45 $485.77 $0.00 $525.16 $295.40 $295.40 $0.00 $0.00 $0.00 $136.82 $487.22 $487.22 $0.00 $0.00 $136.80 $0.00 $388.29 $388.29 $0.00 $328.23 $519.91 $525.16 $0.00 $0.00 $99.74 $0.00 $0.00 $104.51 $0.00 $0.00 $0.00 $0.00 $0.00 440.161 SUP HCPCS C1713 440.161 - PLATE BONE 115MM 6 HOLE T LCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP "$1,304.48 " $965.32 $0.00 "$1,013.20" $569.93 $569.93 $0.00 $0.00 $0.00 $271.89 $968.18 $968.18 $0.00 $0.00 $271.85 $0.00 $771.60 $771.60 $0.00 $633.25 "$1,003.07" "$1,013.20" $0.00 $0.00 $192.43 $0.00 $0.00 $201.63 $0.00 $0.00 $0.00 $0.00 $0.00 440.18 SUP HCPCS C1713 440.18 - PLATE BONE T 148MM 8 HOLE LC-DCP TITANIUM HUMERUS TIBIAL BOTH IP/OP $865.25 $640.29 $0.00 $692.20 $389.36 $389.36 $0.00 $0.00 $0.00 $180.34 $642.19 $642.19 $0.00 $0.00 $180.32 $0.00 $511.80 $511.80 $0.00 $432.63 $685.28 $692.20 $0.00 $0.00 $131.47 $0.00 $0.00 $137.75 $0.00 $0.00 $0.00 $0.00 $0.00 440.181 SUP HCPCS C1713 440.181 - PLATE BONE 147MM 8 HOLE T LCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP "$1,505.50 " "$1,114.07" $0.00 "$1,169.32" $657.74 $657.74 $0.00 $0.00 $0.00 $313.78 "$1,117.38" "$1,117.38" $0.00 $0.00 $313.75 $0.00 $890.50 $890.50 $0.00 $730.83 "$1,157.63" "$1,169.32" $0.00 $0.00 $222.09 $0.00 $0.00 $232.69 $0.00 $0.00 $0.00 $0.00 $0.00 440.34 SUP HCPCS C1713 440.34 - PLATE BONE T BUTTRESS 80MM 4 HOLE LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $839.33 $621.10 $0.00 $671.46 $377.70 $377.70 $0.00 $0.00 $0.00 $174.94 $622.95 $622.95 $0.00 $0.00 $174.92 $0.00 $496.46 $496.46 $0.00 $419.66 $664.75 $671.46 $0.00 $0.00 $127.53 $0.00 $0.00 $133.62 $0.00 $0.00 $0.00 $0.00 $0.00 440.35 SUP HCPCS C1713 440.35 - PLATE BONE T BUTTRESS 96MM 5 HOLE LC-DCP TITANIUM ORTHOPEDIC BOTH IP/OP $883.00 $653.42 $0.00 $706.40 $397.35 $397.35 $0.00 $0.00 $0.00 $184.04 $655.36 $655.36 $0.00 $0.00 $184.02 $0.00 $522.29 $522.29 $0.00 $441.50 $699.34 $706.40 $0.00 $0.00 $134.16 $0.00 $0.00 $140.57 $0.00 $0.00 $0.00 $0.00 $0.00 440.36 SUP HCPCS C1713 440.36 - PLATE BONE T BUTTRESS 112MM 6 HOLE LC-DCP TITANIUM BOTH IP/OP $913.03 $675.64 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $190.30 $677.65 $677.65 $0.00 $0.00 $190.27 $0.00 $540.05 $540.05 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 440.44 SUP HCPCS C1713 440.44 - PLATE BN ANG LT L BTRS 86X14X3.8MM NS LC DCP 4 HL SHFT TI BOTH IP/OP $756.28 $559.65 $0.00 $587.38 $330.40 $330.40 $0.00 $0.00 $0.00 $157.63 $561.31 $561.31 $0.00 $0.00 $157.61 $0.00 $447.34 $447.34 $0.00 $367.11 $581.51 $587.38 $0.00 $0.00 $111.56 $0.00 $0.00 $116.89 $0.00 $0.00 $0.00 $0.00 $0.00 440.515 SUP HCPCS C1713 440.515 - PLATE BONE 130MM 5 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL HEAD BOTH IP/OP "$1,396.15 " "$1,033.15" $0.00 "$1,116.92" $628.27 $628.27 $0.00 $0.00 $0.00 $290.99 "$1,036.22" "$1,036.22" $0.00 $0.00 $290.96 $0.00 $825.82 $825.82 $0.00 $698.08 "$1,105.75" "$1,116.92" $0.00 $0.00 $212.13 $0.00 $0.00 $222.27 $0.00 $0.00 $0.00 $0.00 $0.00 440.517 SUP HCPCS C1713 440.517 - PLATE BONE 166MM 7 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL HEAD BOTH IP/OP "$1,495.78 " "$1,106.88" $0.00 "$1,196.62" $673.10 $673.10 $0.00 $0.00 $0.00 $311.76 "$1,110.16" "$1,110.16" $0.00 $0.00 $311.72 $0.00 $884.75 $884.75 $0.00 $747.89 "$1,184.66" "$1,196.62" $0.00 $0.00 $227.27 $0.00 $0.00 $238.13 $0.00 $0.00 $0.00 $0.00 $0.00 440.519 SUP HCPCS C1713 440.519 - PLATE BONE 202MM 9 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL HEAD BOTH IP/OP "$1,604.95 " "$1,187.66" $0.00 "$1,283.96" $722.23 $722.23 $0.00 $0.00 $0.00 $334.51 "$1,191.19" "$1,191.19" $0.00 $0.00 $334.47 $0.00 $949.33 $949.33 $0.00 $802.48 "$1,271.12" "$1,283.96" $0.00 $0.00 $243.86 $0.00 $0.00 $255.51 $0.00 $0.00 $0.00 $0.00 $0.00 440.521 SUP HCPCS C1713 440.521 - PLATE BONE 238MM 11 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL BOTH IP/OP "$1,708.68 " "$1,264.42" $0.00 "$1,366.94" $768.90 $768.90 $0.00 $0.00 $0.00 $356.13 "$1,268.18" "$1,268.18" $0.00 $0.00 $356.09 $0.00 "$1,010.68" "$1,010.68" $0.00 $854.34 "$1,353.27" "$1,366.94" $0.00 $0.00 $259.62 $0.00 $0.00 $272.02 $0.00 $0.00 $0.00 $0.00 $0.00 440.523 SUP HCPCS C1713 440.523 - PLATE BONE 274MM 13 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL BOTH IP/OP "$1,776.90 " "$1,314.91" $0.00 "$1,421.52" $799.61 $799.61 $0.00 $0.00 $0.00 $370.35 "$1,318.82" "$1,318.82" $0.00 $0.00 $370.31 $0.00 "$1,051.04" "$1,051.04" $0.00 $888.45 "$1,407.30" "$1,421.52" $0.00 $0.00 $269.99 $0.00 $0.00 $282.88 $0.00 $0.00 $0.00 $0.00 $0.00 440.525 SUP HCPCS C1713 440.525 - PLATE BONE 130MM 5 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL HEAD BOTH IP/OP "$1,396.15 " "$1,033.15" $0.00 "$1,116.92" $628.27 $628.27 $0.00 $0.00 $0.00 $290.99 "$1,036.22" "$1,036.22" $0.00 $0.00 $290.96 $0.00 $825.82 $825.82 $0.00 $698.08 "$1,105.75" "$1,116.92" $0.00 $0.00 $212.13 $0.00 $0.00 $222.27 $0.00 $0.00 $0.00 $0.00 $0.00 440.527 SUP HCPCS C1713 440.527 - PLATE BONE 166MM 7 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL HEAD BOTH IP/OP "$1,495.78 " "$1,106.88" $0.00 "$1,196.62" $673.10 $673.10 $0.00 $0.00 $0.00 $311.76 "$1,110.16" "$1,110.16" $0.00 $0.00 $311.72 $0.00 $884.75 $884.75 $0.00 $747.89 "$1,184.66" "$1,196.62" $0.00 $0.00 $227.27 $0.00 $0.00 $238.13 $0.00 $0.00 $0.00 $0.00 $0.00 440.529 SUP HCPCS C1713 440.529 - PLATE BONE 202MM 9 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL HEAD BOTH IP/OP "$1,604.95 " "$1,187.66" $0.00 "$1,283.96" $722.23 $722.23 $0.00 $0.00 $0.00 $334.51 "$1,191.19" "$1,191.19" $0.00 $0.00 $334.47 $0.00 $949.33 $949.33 $0.00 $802.48 "$1,271.12" "$1,283.96" $0.00 $0.00 $243.86 $0.00 $0.00 $255.51 $0.00 $0.00 $0.00 $0.00 $0.00 440.531 SUP HCPCS C1713 440.531 - PLATE BONE 238MM 11 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL BOTH IP/OP "$1,708.68 " "$1,264.42" $0.00 "$1,366.94" $768.90 $768.90 $0.00 $0.00 $0.00 $356.13 "$1,268.18" "$1,268.18" $0.00 $0.00 $356.09 $0.00 "$1,010.68" "$1,010.68" $0.00 $854.34 "$1,353.27" "$1,366.94" $0.00 $0.00 $259.62 $0.00 $0.00 $272.02 $0.00 $0.00 $0.00 $0.00 $0.00 440.533 SUP HCPCS C1713 440.533 - PLATE BONE 274MM 13 HOLE BUTTRESS LC-DCP TITANIUM TIBIAL BOTH IP/OP "$1,776.90 " "$1,314.91" $0.00 "$1,421.52" $799.61 $799.61 $0.00 $0.00 $0.00 $370.35 "$1,318.82" "$1,318.82" $0.00 $0.00 $370.31 $0.00 "$1,051.04" "$1,051.04" $0.00 $888.45 "$1,407.30" "$1,421.52" $0.00 $0.00 $269.99 $0.00 $0.00 $282.88 $0.00 $0.00 $0.00 $0.00 $0.00 440.54 SUP HCPCS C1713 440.54 - PLATE BN ANG RT L BTRS 86X14X3.8MM NS LC DCP 4 HL SHFT TI BOTH IP/OP $754.70 $558.48 $0.00 $603.76 $339.62 $339.62 $0.00 $0.00 $0.00 $157.30 $560.14 $560.14 $0.00 $0.00 $157.28 $0.00 $446.41 $446.41 $0.00 $377.35 $597.72 $603.76 $0.00 $0.00 $114.67 $0.00 $0.00 $120.15 $0.00 $0.00 $0.00 $0.00 $0.00 440.547 SUP HCPCS C1713 440.547 - PLATE BONE 177MM 7 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,695.03 " "$1,254.32" $0.00 "$1,356.02" $762.76 $762.76 $0.00 $0.00 $0.00 $353.29 "$1,258.05" "$1,258.05" $0.00 $0.00 $353.24 $0.00 "$1,002.61" "$1,002.61" $0.00 $847.51 "$1,342.46" "$1,356.02" $0.00 $0.00 $257.54 $0.00 $0.00 $269.85 $0.00 $0.00 $0.00 $0.00 $0.00 440.549 SUP HCPCS C1713 440.549 - PLATE BONE 213MM 9 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,744.15 " "$1,290.67" $0.00 "$1,395.32" $784.87 $784.87 $0.00 $0.00 $0.00 $363.52 "$1,294.51" "$1,294.51" $0.00 $0.00 $363.48 $0.00 "$1,031.66" "$1,031.66" $0.00 $872.08 "$1,381.37" "$1,395.32" $0.00 $0.00 $265.01 $0.00 $0.00 $277.67 $0.00 $0.00 $0.00 $0.00 $0.00 440.551 SUP HCPCS C1713 440.551 - PLATE BONE 249MM 11 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,786.45 " "$1,321.97" $0.00 "$1,429.16" $803.90 $803.90 $0.00 $0.00 $0.00 $372.34 "$1,325.90" "$1,325.90" $0.00 $0.00 $372.30 $0.00 "$1,056.69" "$1,056.69" $0.00 $893.23 "$1,414.87" "$1,429.16" $0.00 $0.00 $271.44 $0.00 $0.00 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 440.553 SUP HCPCS C1713 440.553 - PLATE BONE 285MM 13 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,845.15 " "$1,365.41" $0.00 "$1,476.12" $830.32 $830.32 $0.00 $0.00 $0.00 $384.58 "$1,369.47" "$1,369.47" $0.00 $0.00 $384.53 $0.00 "$1,091.41" "$1,091.41" $0.00 $922.58 "$1,461.36" "$1,476.12" $0.00 $0.00 $280.35 $0.00 $0.00 $293.75 $0.00 $0.00 $0.00 $0.00 $0.00 440.555 SUP HCPCS C1713 440.555 - PLATE BONE 321MM 11 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,918.85 " "$1,419.95" $0.00 "$1,535.08" $863.48 $863.48 $0.00 $0.00 $0.00 $399.94 "$1,424.17" "$1,424.17" $0.00 $0.00 $399.89 $0.00 "$1,135.00" "$1,135.00" $0.00 $959.43 "$1,519.73" "$1,535.08" $0.00 $0.00 $291.55 $0.00 $0.00 $305.48 $0.00 $0.00 $0.00 $0.00 $0.00 440.567 SUP HCPCS C1713 440.567 - PLATE BONE 177MM 7 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,695.03 " "$1,254.32" $0.00 "$1,356.02" $762.76 $762.76 $0.00 $0.00 $0.00 $353.29 "$1,258.05" "$1,258.05" $0.00 $0.00 $353.24 $0.00 "$1,002.61" "$1,002.61" $0.00 $847.51 "$1,342.46" "$1,356.02" $0.00 $0.00 $257.54 $0.00 $0.00 $269.85 $0.00 $0.00 $0.00 $0.00 $0.00 440.569 SUP HCPCS C1713 440.569 - PLATE BONE 213MM 9 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,696.38 " "$1,255.32" $0.00 "$1,357.10" $763.37 $763.37 $0.00 $0.00 $0.00 $353.57 "$1,259.05" "$1,259.05" $0.00 $0.00 $353.52 $0.00 "$1,003.41" "$1,003.41" $0.00 $848.19 "$1,343.53" "$1,357.10" $0.00 $0.00 $257.75 $0.00 $0.00 $270.06 $0.00 $0.00 $0.00 $0.00 $0.00 440.571 SUP HCPCS C1713 440.571 - PLATE BONE 249MM 11 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,786.45 " "$1,321.97" $0.00 "$1,429.16" $803.90 $803.90 $0.00 $0.00 $0.00 $372.34 "$1,325.90" "$1,325.90" $0.00 $0.00 $372.30 $0.00 "$1,056.69" "$1,056.69" $0.00 $893.23 "$1,414.87" "$1,429.16" $0.00 $0.00 $271.44 $0.00 $0.00 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 440.573 SUP HCPCS C1713 440.573 - PLATE BONE 285MM 13 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,791.40 " "$1,325.64" $0.00 "$1,433.12" $806.13 $806.13 $0.00 $0.00 $0.00 $373.37 "$1,329.58" "$1,329.58" $0.00 $0.00 $373.33 $0.00 "$1,059.61" "$1,059.61" $0.00 $895.70 "$1,418.79" "$1,433.12" $0.00 $0.00 $280.35 $0.00 $0.00 $285.19 $0.00 $0.00 $0.00 $0.00 $0.00 440.575 SUP HCPCS C1713 440.575 - PLATE BONE 321MM 15 HOLE BUTTRESS LC-DCP TITANIUM CONDYLE BOTH IP/OP "$1,862.95 " "$1,378.58" $0.00 "$1,490.36" $838.33 $838.33 $0.00 $0.00 $0.00 $388.29 "$1,382.68" "$1,382.68" $0.00 $0.00 $388.24 $0.00 "$1,101.93" "$1,101.93" $0.00 $931.48 "$1,475.46" "$1,490.36" $0.00 $0.00 $291.55 $0.00 $0.00 $296.58 $0.00 $0.00 $0.00 $0.00 $0.00 440.831 SUP HCPCS C1713 440.831 - PLATE BONE SMALL 4 HOLE HIGH TOMOFIX TITANIUM TIBIAL MEDIAL BOTH IP/OP "$2,445.90 " "$1,809.97" $0.00 "$1,899.74" "$1,068.60" "$1,068.60" $0.00 $0.00 $0.00 $509.79 "$1,815.35" "$1,815.35" $0.00 $0.00 $509.73 $0.00 "$1,446.75" "$1,446.75" $0.00 "$1,187.34" "$1,880.75" "$1,899.74" $0.00 $0.00 $360.81 $0.00 $0.00 $378.05 $0.00 $0.00 $0.00 $0.00 $0.00 440.834 SUP HCPCS C1713 440.834 - PLATE BONE 4 HOLE HIGH TOMOFIX TITANIUM TIBIAL MEDIAL BOTH IP/OP "$2,445.90 " "$1,809.97" $0.00 "$1,899.74" "$1,068.60" "$1,068.60" $0.00 $0.00 $0.00 $509.79 "$1,815.35" "$1,815.35" $0.00 $0.00 $509.73 $0.00 "$1,446.75" "$1,446.75" $0.00 "$1,187.34" "$1,880.75" "$1,899.74" $0.00 $0.00 $360.81 $0.00 $0.00 $378.05 $0.00 $0.00 $0.00 $0.00 $0.00 440.843 SUP HCPCS C1713 440.843 - PLATE BONE 3 HOLE TOMOFIX TITANIUM TIBIA RIGHT LATERAL BOTH IP/OP "$2,445.90 " "$1,809.97" $0.00 "$1,899.74" "$1,068.60" "$1,068.60" $0.00 $0.00 $0.00 $509.79 "$1,815.35" "$1,815.35" $0.00 $0.00 $509.73 $0.00 "$1,446.75" "$1,446.75" $0.00 "$1,187.34" "$1,880.75" "$1,899.74" $0.00 $0.00 $360.81 $0.00 $0.00 $378.05 $0.00 $0.00 $0.00 $0.00 $0.00 440.853 SUP HCPCS C1713 440.853 - PLATE BONE 3 HOLE TOMOFIX TITANIUM TIBIA LEFT LATERAL BOTH IP/OP "$2,445.90 " "$1,809.97" $0.00 "$1,899.74" "$1,068.60" "$1,068.60" $0.00 $0.00 $0.00 $509.79 "$1,815.35" "$1,815.35" $0.00 $0.00 $509.73 $0.00 "$1,446.75" "$1,446.75" $0.00 "$1,187.34" "$1,880.75" "$1,899.74" $0.00 $0.00 $360.81 $0.00 $0.00 $378.05 $0.00 $0.00 $0.00 $0.00 $0.00 440.864 SUP HCPCS C1713 440.864 - PLATE BONE 4 HOLE TOMOFIX TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$2,445.90 " "$1,809.97" $0.00 "$1,899.74" "$1,068.60" "$1,068.60" $0.00 $0.00 $0.00 $509.79 "$1,815.35" "$1,815.35" $0.00 $0.00 $509.73 $0.00 "$1,446.75" "$1,446.75" $0.00 "$1,187.34" "$1,880.75" "$1,899.74" $0.00 $0.00 $360.81 $0.00 $0.00 $378.05 $0.00 $0.00 $0.00 $0.00 $0.00 440.874 SUP HCPCS C1713 440.874 - PLATE BONE 4 HOLE TOMOFIX TITANIUM FEMUR LEFT DISTAL LATERAL BOTH IP/OP "$2,445.90 " "$1,809.97" $0.00 "$1,899.74" "$1,068.60" "$1,068.60" $0.00 $0.00 $0.00 $509.79 "$1,815.35" "$1,815.35" $0.00 $0.00 $509.73 $0.00 "$1,446.75" "$1,446.75" $0.00 "$1,187.34" "$1,880.75" "$1,899.74" $0.00 $0.00 $360.81 $0.00 $0.00 $378.05 $0.00 $0.00 $0.00 $0.00 $0.00 440.885 SUP HCPCS C1713 440.885 - PLATE BONE 121MM 4 HOLE TOMOFIX TITANIUM RIGHT MEDIAL DISTAL BOTH IP/OP "$2,305.50 " "$1,706.07" $0.00 "$1,844.40" "$1,037.48" "$1,037.48" $0.00 $0.00 $0.00 $480.52 "$1,711.14" "$1,711.14" $0.00 $0.00 $480.47 $0.00 "$1,363.70" "$1,363.70" $0.00 "$1,152.75" "$1,825.96" "$1,844.40" $0.00 $0.00 $360.81 $0.00 $0.00 $367.04 $0.00 $0.00 $0.00 $0.00 $0.00 440.895 SUP HCPCS C1713 440.895 - PLATE BONE 121MM 4 HOLE TOMOFIX TITANIUM LEFT MEDIAL DISTAL BOTH IP/OP "$2,305.50 " "$1,706.07" $0.00 "$1,844.40" "$1,037.48" "$1,037.48" $0.00 $0.00 $0.00 $480.52 "$1,711.14" "$1,711.14" $0.00 $0.00 $480.47 $0.00 "$1,363.70" "$1,363.70" $0.00 "$1,152.75" "$1,825.96" "$1,844.40" $0.00 $0.00 $360.81 $0.00 $0.00 $367.04 $0.00 $0.00 $0.00 $0.00 $0.00 441.031 SUP HCPCS C1713 441.031 - PLATE BONE T OBLIQUE RIGHT 52X10X1.5MM 3 HOLE HEAD 3 HOLE BOTH IP/OP $684.58 $506.59 $0.00 $531.70 $299.08 $299.08 $0.00 $0.00 $0.00 $142.68 $508.09 $508.09 $0.00 $0.00 $142.67 $0.00 $404.93 $404.93 $0.00 $332.31 $526.39 $531.70 $0.00 $0.00 $100.99 $0.00 $0.00 $105.81 $0.00 $0.00 $0.00 $0.00 $0.00 441.041 SUP HCPCS C1713 441.041 - PLATE BONE T OBLIQUE RIGHT 63X10X1.5MM 3 HOLE HEAD 4 HOLE BOTH IP/OP $716.90 $530.51 $0.00 $556.82 $313.21 $313.21 $0.00 $0.00 $0.00 $149.42 $532.08 $532.08 $0.00 $0.00 $149.40 $0.00 $424.05 $424.05 $0.00 $348.01 $551.26 $556.82 $0.00 $0.00 $105.75 $0.00 $0.00 $110.81 $0.00 $0.00 $0.00 $0.00 $0.00 441.051 SUP HCPCS C1713 441.051 - PLATE BONE T OBLIQUE RIGHT 74X10X1.5MM 3 HOLE HEAD 5 HOLE BOTH IP/OP $747.83 $553.39 $0.00 $580.84 $326.72 $326.72 $0.00 $0.00 $0.00 $155.87 $555.04 $555.04 $0.00 $0.00 $155.85 $0.00 $442.34 $442.34 $0.00 $363.03 $575.03 $580.84 $0.00 $0.00 $110.32 $0.00 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $0.00 441.061 SUP HCPCS C1713 441.061 - PLATE BONE 85MM 3 HOLE HEAD 6 HOLE SHAFT T OBLIQUE RIGHT LCP BOTH IP/OP $802.65 $593.96 $0.00 $623.42 $350.67 $350.67 $0.00 $0.00 $0.00 $167.29 $595.73 $595.73 $0.00 $0.00 $167.27 $0.00 $474.77 $474.77 $0.00 $389.64 $617.19 $623.42 $0.00 $0.00 $118.40 $0.00 $0.00 $124.06 $0.00 $0.00 $0.00 $0.00 $0.00 441.062 SUP HCPCS C1713 441.062 - PLATE BONE 15MM 6 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,307.78 " $967.76 $0.00 "$1,046.22" $588.50 $588.50 $0.00 $0.00 $0.00 $272.57 $970.63 $970.63 $0.00 $0.00 $272.54 $0.00 $773.55 $773.55 $0.00 $653.89 "$1,035.76" "$1,046.22" $0.00 $0.00 $204.67 $0.00 $0.00 $208.20 $0.00 $0.00 $0.00 $0.00 $0.00 441.063 SUP HCPCS C1713 441.063 - PLATE BONE 15MM 6 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,307.78 " $967.76 $0.00 "$1,046.22" $588.50 $588.50 $0.00 $0.00 $0.00 $272.57 $970.63 $970.63 $0.00 $0.00 $272.54 $0.00 $773.55 $773.55 $0.00 $653.89 "$1,035.76" "$1,046.22" $0.00 $0.00 $204.67 $0.00 $0.00 $208.20 $0.00 $0.00 $0.00 $0.00 $0.00 441.064 SUP HCPCS C1713 441.064 - PLATE BONE 18MM 6 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,307.78 " $967.76 $0.00 "$1,046.22" $588.50 $588.50 $0.00 $0.00 $0.00 $272.57 $970.63 $970.63 $0.00 $0.00 $272.54 $0.00 $773.55 $773.55 $0.00 $653.89 "$1,035.76" "$1,046.22" $0.00 $0.00 $204.67 $0.00 $0.00 $208.20 $0.00 $0.00 $0.00 $0.00 $0.00 441.065 SUP HCPCS C1713 441.065 - PLATE BONE 18MM 6 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,307.78 " $967.76 $0.00 "$1,046.22" $588.50 $588.50 $0.00 $0.00 $0.00 $272.57 $970.63 $970.63 $0.00 $0.00 $272.54 $0.00 $773.55 $773.55 $0.00 $653.89 "$1,035.76" "$1,046.22" $0.00 $0.00 $204.67 $0.00 $0.00 $208.20 $0.00 $0.00 $0.00 $0.00 $0.00 441.066 SUP HCPCS C1713 441.066 - PLATE BONE 15MM 8 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,403.18 " "$1,038.35" $0.00 "$1,122.54" $631.43 $631.43 $0.00 $0.00 $0.00 $292.46 "$1,041.44" "$1,041.44" $0.00 $0.00 $292.42 $0.00 $829.98 $829.98 $0.00 $701.59 "$1,111.32" "$1,122.54" $0.00 $0.00 $219.60 $0.00 $0.00 $223.39 $0.00 $0.00 $0.00 $0.00 $0.00 441.067 SUP HCPCS C1713 441.067 - PLATE BONE 15MM 8 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,403.18 " "$1,038.35" $0.00 "$1,122.54" $631.43 $631.43 $0.00 $0.00 $0.00 $292.46 "$1,041.44" "$1,041.44" $0.00 $0.00 $292.42 $0.00 $829.98 $829.98 $0.00 $701.59 "$1,111.32" "$1,122.54" $0.00 $0.00 $219.60 $0.00 $0.00 $223.39 $0.00 $0.00 $0.00 $0.00 $0.00 441.068 SUP HCPCS C1713 441.068 - PLATE BN 18MM 3.5MM 77MM NS 8 HL HK TI CLVCL RT 3.5MM 4MM BOTH IP/OP "$1,403.18 " "$1,038.35" $0.00 "$1,122.54" $631.43 $631.43 $0.00 $0.00 $0.00 $292.46 "$1,041.44" "$1,041.44" $0.00 $0.00 $292.42 $0.00 $829.98 $829.98 $0.00 $701.59 "$1,111.32" "$1,122.54" $0.00 $0.00 $219.60 $0.00 $0.00 $223.39 $0.00 $0.00 $0.00 $0.00 $0.00 441.069 SUP HCPCS C1713 441.069 - PLATE BONE 18MM 77MM 8 HOLE HOOK TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,403.18 " "$1,038.35" $0.00 "$1,122.54" $631.43 $631.43 $0.00 $0.00 $0.00 $292.46 "$1,041.44" "$1,041.44" $0.00 $0.00 $292.42 $0.00 $829.98 $829.98 $0.00 $701.59 "$1,111.32" "$1,122.54" $0.00 $0.00 $219.60 $0.00 $0.00 $223.39 $0.00 $0.00 $0.00 $0.00 $0.00 441.071 SUP HCPCS C1713 441.071 - PLATE BONE T RIGHT OBLIQUE 96MM 7 HOLE SHAFT 3 HOLE HEAD LCP BOTH IP/OP $812.50 $601.25 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 441.081 SUP HCPCS C1713 441.081 - PLATE BONE 107MM 3X8 HOLE T OBLIQUE RIGHT LCP TITANIUM BOTH IP/OP $882.78 $653.26 $0.00 $685.66 $385.68 $385.68 $0.00 $0.00 $0.00 $183.99 $655.20 $655.20 $0.00 $0.00 $183.97 $0.00 $522.16 $522.16 $0.00 $428.54 $678.81 $685.66 $0.00 $0.00 $130.22 $0.00 $0.00 $136.45 $0.00 $0.00 $0.00 $0.00 $0.00 441.13 SUP HCPCS C1713 441.13 - PLATE BONE T RIGHT ANG 50X10X1.2MM 3X3 HOLE LC-DCP TITANIUM BOTH IP/OP $232.00 $171.68 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $48.35 $172.19 $172.19 $0.00 $0.00 $48.35 $0.00 $137.23 $137.23 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 441.131 SUP HCPCS C1713 441.131 - PLATE BONE T RIGHT ANG 50X10X1.5MM 3 HOLE HEAD 3 HOLE SHAFT BOTH IP/OP $611.48 $452.50 $0.00 $474.94 $267.15 $267.15 $0.00 $0.00 $0.00 $127.45 $453.84 $453.84 $0.00 $0.00 $127.43 $0.00 $361.69 $361.69 $0.00 $296.84 $470.19 $474.94 $0.00 $0.00 $90.20 $0.00 $0.00 $94.51 $0.00 $0.00 $0.00 $0.00 $0.00 441.132 SUP HCPCS C1713 441.132 - PLATE BONE 50MM 4 HEAD HOLE 3 SHAFT HOLE T RIGHT ANG LCP BOTH IP/OP $629.75 $466.02 $0.00 $489.12 $275.13 $275.13 $0.00 $0.00 $0.00 $131.26 $467.40 $467.40 $0.00 $0.00 $131.24 $0.00 $372.50 $372.50 $0.00 $305.70 $484.23 $489.12 $0.00 $0.00 $92.90 $0.00 $0.00 $97.33 $0.00 $0.00 $0.00 $0.00 $0.00 441.14 SUP HCPCS C1713 441.14 - PLATE BONE 3.5MM 56MM T 4 HEAD HOLE 4 SHAFT HOLE RIGHT ANG BOTH IP/OP $240.20 $177.75 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $50.06 $178.28 $178.28 $0.00 $0.00 $50.06 $0.00 $142.08 $142.08 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 441.141 SUP HCPCS C1713 441.141 - PLATE BONE T RIGHT ANG 56X11X1.5MM 4 HOLE HEAD 4 HOLE SHAFT BOTH IP/OP $631.15 $467.05 $0.00 $490.22 $275.75 $275.75 $0.00 $0.00 $0.00 $131.55 $468.44 $468.44 $0.00 $0.00 $131.53 $0.00 $373.33 $373.33 $0.00 $306.39 $485.32 $490.22 $0.00 $0.00 $93.11 $0.00 $0.00 $97.55 $0.00 $0.00 $0.00 $0.00 $0.00 441.142 SUP HCPCS C1713 441.142 - PLATE BONE 57MM 3 HOLE HEAD 4 HOLE SHAFT T RIGHT ANG LCP BOTH IP/OP $650.83 $481.61 $0.00 $505.50 $284.34 $284.34 $0.00 $0.00 $0.00 $135.65 $483.04 $483.04 $0.00 $0.00 $135.63 $0.00 $384.96 $384.96 $0.00 $315.94 $500.45 $505.50 $0.00 $0.00 $96.01 $0.00 $0.00 $100.59 $0.00 $0.00 $0.00 $0.00 $0.00 441.15 SUP HCPCS C1713 441.15 - PLATE BONE T RIGHT ANG 67X10X1.2MM 3X5 HOLE LC-DCP TITANIUM BOTH IP/OP $266.13 $196.94 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $55.47 $197.52 $197.52 $0.00 $0.00 $55.46 $0.00 $157.41 $157.41 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 441.151 SUP HCPCS C1713 441.151 - PLATE BONE T RIGHT ANG 67X10X1.5MM 3 HOLE HEAD 5 HOLE SHAFT BOTH IP/OP $694.40 $513.86 $0.00 $539.34 $303.38 $303.38 $0.00 $0.00 $0.00 $144.73 $515.38 $515.38 $0.00 $0.00 $144.71 $0.00 $410.74 $410.74 $0.00 $337.09 $533.95 $539.34 $0.00 $0.00 $102.44 $0.00 $0.00 $107.33 $0.00 $0.00 $0.00 $0.00 $0.00 441.152 SUP HCPCS C1713 441.152 - PLATE BONE 67MM 4 HEAD HOLE 5 SHAFT HOLE T RIGHT ANG LCP BOTH IP/OP $715.50 $529.47 $0.00 $555.72 $312.59 $312.59 $0.00 $0.00 $0.00 $149.13 $531.04 $531.04 $0.00 $0.00 $149.11 $0.00 $423.22 $423.22 $0.00 $347.33 $550.16 $555.72 $0.00 $0.00 $105.55 $0.00 $0.00 $110.59 $0.00 $0.00 $0.00 $0.00 $0.00 441.16 SUP HCPCS C1713 441.16 - PLATE BONE T RIGHT ANG 78X10X1.2MM 4X6 HOLE LC-DCP TITANIUM BOTH IP/OP $302.10 $223.55 $0.00 $241.68 $135.95 $135.95 $0.00 $0.00 $0.00 $62.97 $224.22 $224.22 $0.00 $0.00 $62.96 $0.00 $178.69 $178.69 $0.00 $151.05 $239.26 $241.68 $0.00 $0.00 $47.28 $0.00 $0.00 $48.09 $0.00 $0.00 $0.00 $0.00 $0.00 441.161 SUP HCPCS C1713 441.161 - PLATE BONE T RIGHT ANG 78X11X1.5MM 4 HOLE HEAD 6 HOLE SHAFT BOTH IP/OP $809.68 $599.16 $0.00 $628.88 $353.75 $353.75 $0.00 $0.00 $0.00 $168.76 $600.94 $600.94 $0.00 $0.00 $168.74 $0.00 $478.92 $478.92 $0.00 $393.05 $622.59 $628.88 $0.00 $0.00 $119.44 $0.00 $0.00 $125.15 $0.00 $0.00 $0.00 $0.00 $0.00 441.162 SUP HCPCS C1713 441.162 - PLATE BONE 77MM 3 HOLE HEAD 6 HOLE SHAFT T RIGHT ANG LCP BOTH IP/OP $830.78 $614.78 $0.00 $645.26 $362.96 $362.96 $0.00 $0.00 $0.00 $173.15 $616.60 $616.60 $0.00 $0.00 $173.13 $0.00 $491.40 $491.40 $0.00 $403.29 $638.81 $645.26 $0.00 $0.00 $122.55 $0.00 $0.00 $128.41 $0.00 $0.00 $0.00 $0.00 $0.00 441.171 SUP HCPCS C1713 441.171 - PLATE BONE T RIGHT ANG 87X10X1.5MM 3 HOLE HEAD 7 HOLE SHAFT BOTH IP/OP "$1,014.90 " $751.03 $0.00 $788.28 $443.41 $443.41 $0.00 $0.00 $0.00 $211.53 $753.26 $753.26 $0.00 $0.00 $211.51 $0.00 $600.31 $600.31 $0.00 $492.68 $780.40 $788.28 $0.00 $0.00 $149.72 $0.00 $0.00 $156.87 $0.00 $0.00 $0.00 $0.00 $0.00 441.172 SUP HCPCS C1713 441.172 - PLATE BONE 89MM 4 HOLE HEAD 7 HOLE SHAFT T RIGHT ANG LCP BOTH IP/OP "$1,041.63 " $770.81 $0.00 $809.02 $455.07 $455.07 $0.00 $0.00 $0.00 $217.10 $773.09 $773.09 $0.00 $0.00 $217.07 $0.00 $616.12 $616.12 $0.00 $505.64 $800.93 $809.02 $0.00 $0.00 $153.66 $0.00 $0.00 $160.99 $0.00 $0.00 $0.00 $0.00 $0.00 441.181 SUP HCPCS C1713 441.181 - PLATE BONE 97MM 3 HOLE HEAD 8 HOLE SHAFT T RIGHT ANG LCP BOTH IP/OP "$1,214.53 " $898.75 $0.00 $943.32 $530.62 $530.62 $0.00 $0.00 $0.00 $253.14 $901.42 $901.42 $0.00 $0.00 $253.11 $0.00 $718.39 $718.39 $0.00 $589.58 $933.89 $943.32 $0.00 $0.00 $179.16 $0.00 $0.00 $187.72 $0.00 $0.00 $0.00 $0.00 $0.00 441.182 SUP HCPCS C1713 441.182 - PLATE BONE 100MM 4 HOLE HEAD 8 HOLE SHAFT T RIGHT ANG LCP BOTH IP/OP "$1,210.30 " $895.62 $0.00 $940.04 $528.77 $528.77 $0.00 $0.00 $0.00 $252.26 $898.28 $898.28 $0.00 $0.00 $252.23 $0.00 $715.89 $715.89 $0.00 $587.53 $930.64 $940.04 $0.00 $0.00 $178.54 $0.00 $0.00 $187.07 $0.00 $0.00 $0.00 $0.00 $0.00 441.23 SUP HCPCS C1713 441.23 - PLATE BONE T OBLIQUE 53X10X1.2MM 3X3 HOLE LC-DCP TITANIUM BOTH IP/OP $398.50 $294.89 $0.00 $318.80 $179.33 $179.33 $0.00 $0.00 $0.00 $83.06 $295.77 $295.77 $0.00 $0.00 $83.05 $0.00 $235.71 $235.71 $0.00 $199.25 $315.61 $318.80 $0.00 $0.00 $60.55 $0.00 $0.00 $63.44 $0.00 $0.00 $0.00 $0.00 $0.00 441.24 SUP HCPCS C1713 441.24 - PLATE BONE T OBLIQUE 63X10X1.2MM 3X4 HOLE LC-DCP TITANIUM BOTH IP/OP $423.08 $313.08 $0.00 $338.46 $190.38 $190.38 $0.00 $0.00 $0.00 $88.18 $314.01 $314.01 $0.00 $0.00 $88.17 $0.00 $250.25 $250.25 $0.00 $211.54 $335.08 $338.46 $0.00 $0.00 $64.28 $0.00 $0.00 $67.35 $0.00 $0.00 $0.00 $0.00 $0.00 441.25 SUP HCPCS C1713 441.25 - PLATE BN T OBLQ 75X10X1.5MM LC DCP 3 HLE/HD 5 HL SHFT TI 3.5 BOTH IP/OP $435.35 $322.16 $0.00 $348.28 $195.91 $195.91 $0.00 $0.00 $0.00 $90.74 $323.12 $323.12 $0.00 $0.00 $90.73 $0.00 $257.51 $257.51 $0.00 $217.68 $344.80 $348.28 $0.00 $0.00 $66.15 $0.00 $0.00 $69.31 $0.00 $0.00 $0.00 $0.00 $0.00 441.262 SUP HCPCS C1713 441.262 - PLATE BONE 55MM 3 HOLE LCP TITANIUM HUMERUS RIGHT POSTLAT BOTH IP/OP "$1,790.85 " "$1,325.23" $0.00 "$1,390.96" $782.42 $782.42 $0.00 $0.00 $0.00 $373.26 "$1,329.17" "$1,329.17" $0.00 $0.00 $373.21 $0.00 "$1,059.29" "$1,059.29" $0.00 $869.35 "$1,377.05" "$1,390.96" $0.00 $0.00 $264.18 $0.00 $0.00 $276.80 $0.00 $0.00 $0.00 $0.00 $0.00 441.263 SUP HCPCS C1713 441.263 - PLATE BONE 55MM 3 HOLE LCP TITANIUM HUMERUS LEFT POSTLAT BOTH IP/OP "$1,790.85 " "$1,325.23" $0.00 "$1,390.96" $782.42 $782.42 $0.00 $0.00 $0.00 $373.26 "$1,329.17" "$1,329.17" $0.00 $0.00 $373.21 $0.00 "$1,059.29" "$1,059.29" $0.00 $869.35 "$1,377.05" "$1,390.96" $0.00 $0.00 $264.18 $0.00 $0.00 $276.80 $0.00 $0.00 $0.00 $0.00 $0.00 441.264 SUP HCPCS C1713 441.264 - PLATE BONE 5 HOLE LCP TITANIUM HUMERUS RIGHT POSTLAT DISTAL BOTH IP/OP "$1,986.25 " "$1,469.83" $0.00 "$1,542.72" $867.78 $867.78 $0.00 $0.00 $0.00 $413.98 "$1,474.19" "$1,474.19" $0.00 $0.00 $413.93 $0.00 "$1,174.87" "$1,174.87" $0.00 $964.20 "$1,527.29" "$1,542.72" $0.00 $0.00 $293.00 $0.00 $0.00 $307.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.265 SUP HCPCS C1713 441.265 - PLATE BONE 5 HOLE LCP TITANIUM HUMERUS LEFT POSTLAT DISTAL BOTH IP/OP "$1,986.25 " "$1,469.83" $0.00 "$1,542.72" $867.78 $867.78 $0.00 $0.00 $0.00 $413.98 "$1,474.19" "$1,474.19" $0.00 $0.00 $413.93 $0.00 "$1,174.87" "$1,174.87" $0.00 $964.20 "$1,527.29" "$1,542.72" $0.00 $0.00 $293.00 $0.00 $0.00 $307.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.266 SUP HCPCS C1713 441.266 - PLATE BONE 116MM 7 HOLE LCP TITANIUM HUMERUS RIGHT POSTLAT BOTH IP/OP "$2,184.45 " "$1,616.49" $0.00 "$1,696.66" $954.37 $954.37 $0.00 $0.00 $0.00 $455.29 "$1,621.30" "$1,621.30" $0.00 $0.00 $455.24 $0.00 "$1,292.10" "$1,292.10" $0.00 "$1,060.41" "$1,679.70" "$1,696.66" $0.00 $0.00 $322.24 $0.00 $0.00 $337.64 $0.00 $0.00 $0.00 $0.00 $0.00 441.267 SUP HCPCS C1713 441.267 - PLATE BONE 116MM 7 HOLE LCP TITANIUM HUMERUS LEFT POSTLAT BOTH IP/OP "$2,184.45 " "$1,616.49" $0.00 "$1,696.66" $954.37 $954.37 $0.00 $0.00 $0.00 $455.29 "$1,621.30" "$1,621.30" $0.00 $0.00 $455.24 $0.00 "$1,292.10" "$1,292.10" $0.00 "$1,060.41" "$1,679.70" "$1,696.66" $0.00 $0.00 $322.24 $0.00 $0.00 $337.64 $0.00 $0.00 $0.00 $0.00 $0.00 441.268 SUP HCPCS C1713 441.268 - PLATE BONE 9 HOLE LCP TITANIUM HUMERUS RIGHT POSTLAT DISTAL BOTH IP/OP "$2,358.75 " "$1,745.48" $0.00 "$1,832.04" "$1,030.52" "$1,030.52" $0.00 $0.00 $0.00 $491.62 "$1,750.66" "$1,750.66" $0.00 $0.00 $491.56 $0.00 "$1,395.20" "$1,395.20" $0.00 "$1,145.03" "$1,813.72" "$1,832.04" $0.00 $0.00 $347.95 $0.00 $0.00 $364.58 $0.00 $0.00 $0.00 $0.00 $0.00 441.269 SUP HCPCS C1713 441.269 - PLATE BONE 9 HOLE LCP TITANIUM HUMERUS LEFT POSTLAT DISTAL BOTH IP/OP "$2,358.75 " "$1,745.48" $0.00 "$1,832.04" "$1,030.52" "$1,030.52" $0.00 $0.00 $0.00 $491.62 "$1,750.66" "$1,750.66" $0.00 $0.00 $491.56 $0.00 "$1,395.20" "$1,395.20" $0.00 "$1,145.03" "$1,813.72" "$1,832.04" $0.00 $0.00 $347.95 $0.00 $0.00 $364.58 $0.00 $0.00 $0.00 $0.00 $0.00 441.272 SUP HCPCS C1713 441.272 - PLATE BONE 55MM 3 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS BOTH IP/OP "$2,053.73 " "$1,519.76" $0.00 "$1,595.12" $897.26 $897.26 $0.00 $0.00 $0.00 $428.05 "$1,524.27" "$1,524.27" $0.00 $0.00 $428.00 $0.00 "$1,214.78" "$1,214.78" $0.00 $996.95 "$1,579.17" "$1,595.12" $0.00 $0.00 $302.96 $0.00 $0.00 $317.43 $0.00 $0.00 $0.00 $0.00 $0.00 441.273 SUP HCPCS C1713 441.273 - PLATE BONE 3 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS LEFT BOTH IP/OP "$2,053.73 " "$1,519.76" $0.00 "$1,595.12" $897.26 $897.26 $0.00 $0.00 $0.00 $428.05 "$1,524.27" "$1,524.27" $0.00 $0.00 $428.00 $0.00 "$1,214.78" "$1,214.78" $0.00 $996.95 "$1,579.17" "$1,595.12" $0.00 $0.00 $302.96 $0.00 $0.00 $317.43 $0.00 $0.00 $0.00 $0.00 $0.00 441.274 SUP HCPCS C1713 441.274 - PLATE BONE 5 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS RIGHT BOTH IP/OP "$2,239.28 " "$1,657.07" $0.00 "$1,739.24" $978.32 $978.32 $0.00 $0.00 $0.00 $466.72 "$1,661.99" "$1,661.99" $0.00 $0.00 $466.66 $0.00 "$1,324.53" "$1,324.53" $0.00 "$1,087.03" "$1,721.85" "$1,739.24" $0.00 $0.00 $330.33 $0.00 $0.00 $346.11 $0.00 $0.00 $0.00 $0.00 $0.00 441.275 SUP HCPCS C1713 441.275 - PLATE BONE 5 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS LEFT BOTH IP/OP "$2,239.28 " "$1,657.07" $0.00 "$1,739.24" $978.32 $978.32 $0.00 $0.00 $0.00 $466.72 "$1,661.99" "$1,661.99" $0.00 $0.00 $466.66 $0.00 "$1,324.53" "$1,324.53" $0.00 "$1,087.03" "$1,721.85" "$1,739.24" $0.00 $0.00 $330.33 $0.00 $0.00 $346.11 $0.00 $0.00 $0.00 $0.00 $0.00 441.276 SUP HCPCS C1713 441.276 - PLATE BONE 116MM 7 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS BOTH IP/OP "$2,426.23 " "$1,795.41" $0.00 "$1,884.44" "$1,060.00" "$1,060.00" $0.00 $0.00 $0.00 $505.69 "$1,800.74" "$1,800.74" $0.00 $0.00 $505.63 $0.00 "$1,435.11" "$1,435.11" $0.00 "$1,177.78" "$1,865.60" "$1,884.44" $0.00 $0.00 $357.91 $0.00 $0.00 $375.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.277 SUP HCPCS C1713 441.277 - PLATE BONE 7 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS LEFT BOTH IP/OP "$2,426.23 " "$1,795.41" $0.00 "$1,884.44" "$1,060.00" "$1,060.00" $0.00 $0.00 $0.00 $505.69 "$1,800.74" "$1,800.74" $0.00 $0.00 $505.63 $0.00 "$1,435.11" "$1,435.11" $0.00 "$1,177.78" "$1,865.60" "$1,884.44" $0.00 $0.00 $357.91 $0.00 $0.00 $375.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.278 SUP HCPCS C1713 441.278 - PLATE BONE 9 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS RIGHT BOTH IP/OP "$2,632.85 " "$1,948.31" $0.00 "$2,044.94" "$1,150.28" "$1,150.28" $0.00 $0.00 $0.00 $548.75 "$1,954.10" "$1,954.10" $0.00 $0.00 $548.69 $0.00 "$1,298.00" "$1,298.00" $0.00 "$1,278.09" "$2,024.49" "$2,044.94" $0.00 $0.00 $388.39 $0.00 $0.00 $406.94 $0.00 $0.00 $0.00 $0.00 $0.00 441.279 SUP HCPCS C1713 441.279 - PLATE BONE 9 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS LEFT BOTH IP/OP "$2,632.85 " "$1,948.31" $0.00 "$2,044.94" "$1,150.28" "$1,150.28" $0.00 $0.00 $0.00 $548.75 "$1,954.10" "$1,954.10" $0.00 $0.00 $548.69 $0.00 "$1,298.00" "$1,298.00" $0.00 "$1,278.09" "$2,024.49" "$2,044.94" $0.00 $0.00 $388.39 $0.00 $0.00 $406.94 $0.00 $0.00 $0.00 $0.00 $0.00 441.282 SUP HCPCS C1713 441.282 - PLATE BONE 3 HOLE LCP TITANIUM HUMERUS RIGHT MEDIAL DISTAL BOTH IP/OP "$1,790.85 " "$1,325.23" $0.00 "$1,390.96" $782.42 $782.42 $0.00 $0.00 $0.00 $373.26 "$1,329.17" "$1,329.17" $0.00 $0.00 $373.21 $0.00 "$1,059.29" "$1,059.29" $0.00 $869.35 "$1,377.05" "$1,390.96" $0.00 $0.00 $264.18 $0.00 $0.00 $276.80 $0.00 $0.00 $0.00 $0.00 $0.00 441.283 SUP HCPCS C1713 441.283 - PLATE BONE 58MM 3 HOLE LCP TITANIUM HUMERUS LEFT DISTAL BOTH IP/OP "$1,790.85 " "$1,325.23" $0.00 "$1,390.96" $782.42 $782.42 $0.00 $0.00 $0.00 $373.26 "$1,329.17" "$1,329.17" $0.00 $0.00 $373.21 $0.00 "$1,059.29" "$1,059.29" $0.00 $869.35 "$1,377.05" "$1,390.96" $0.00 $0.00 $264.18 $0.00 $0.00 $276.80 $0.00 $0.00 $0.00 $0.00 $0.00 441.284 SUP HCPCS C1713 441.284 - PLATE BONE 5 HOLE LCP TITANIUM HUMERUS RIGHT DISTAL MEDIAL BOTH IP/OP "$1,986.25 " "$1,469.83" $0.00 "$1,542.72" $867.78 $867.78 $0.00 $0.00 $0.00 $413.98 "$1,474.19" "$1,474.19" $0.00 $0.00 $413.93 $0.00 "$1,174.87" "$1,174.87" $0.00 $964.20 "$1,527.29" "$1,542.72" $0.00 $0.00 $293.00 $0.00 $0.00 $307.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.285 SUP HCPCS C1713 441.285 - PLATE BONE 83MM 5 HOLE LCP TITANIUM HUMERUS LEFT DISTAL BOTH IP/OP "$1,986.25 " "$1,469.83" $0.00 "$1,542.72" $867.78 $867.78 $0.00 $0.00 $0.00 $413.98 "$1,474.19" "$1,474.19" $0.00 $0.00 $413.93 $0.00 "$1,174.87" "$1,174.87" $0.00 $964.20 "$1,527.29" "$1,542.72" $0.00 $0.00 $293.00 $0.00 $0.00 $307.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.286 SUP HCPCS C1713 441.286 - PLATE BONE 110MM 7 HOLE LCP TITANIUM HUMERUS RIGHT DISTAL BOTH IP/OP "$2,184.45 " "$1,616.49" $0.00 "$1,696.66" $954.37 $954.37 $0.00 $0.00 $0.00 $455.29 "$1,621.30" "$1,621.30" $0.00 $0.00 $455.24 $0.00 "$1,292.10" "$1,292.10" $0.00 "$1,060.41" "$1,679.70" "$1,696.66" $0.00 $0.00 $322.24 $0.00 $0.00 $337.64 $0.00 $0.00 $0.00 $0.00 $0.00 441.287 SUP HCPCS C1713 441.287 - PLATE BN 110X11X2.5MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT BOTH IP/OP "$2,184.45 " "$1,616.49" $0.00 "$1,696.66" $954.37 $954.37 $0.00 $0.00 $0.00 $455.29 "$1,621.30" "$1,621.30" $0.00 $0.00 $455.24 $0.00 "$1,292.10" "$1,292.10" $0.00 "$1,060.41" "$1,679.70" "$1,696.66" $0.00 $0.00 $322.24 $0.00 $0.00 $337.64 $0.00 $0.00 $0.00 $0.00 $0.00 441.288 SUP HCPCS C1713 441.288 - PLATE BONE 9 HOLE LCP TITANIUM HUMERUS RIGHT MEDIAL DISTAL BOTH IP/OP "$2,358.75 " "$1,745.48" $0.00 "$1,832.04" "$1,030.52" "$1,030.52" $0.00 $0.00 $0.00 $491.62 "$1,750.66" "$1,750.66" $0.00 $0.00 $491.56 $0.00 "$1,395.20" "$1,395.20" $0.00 "$1,145.03" "$1,813.72" "$1,832.04" $0.00 $0.00 $347.95 $0.00 $0.00 $364.58 $0.00 $0.00 $0.00 $0.00 $0.00 441.289 SUP HCPCS C1713 441.289 - PLATE BONE 136MM 9 HOLE LCP TITANIUM HUMERUS LEFT DISTAL BOTH IP/OP "$2,358.75 " "$1,745.48" $0.00 "$1,832.04" "$1,030.52" "$1,030.52" $0.00 $0.00 $0.00 $491.62 "$1,750.66" "$1,750.66" $0.00 $0.00 $491.56 $0.00 "$1,395.20" "$1,395.20" $0.00 "$1,145.03" "$1,813.72" "$1,832.04" $0.00 $0.00 $347.95 $0.00 $0.00 $364.58 $0.00 $0.00 $0.00 $0.00 $0.00 441.3 SUP HCPCS C1713 441.300 - PLATE BONE 14 HOLE LCP TITANIUM HUMERUS RIGHT POSTLAT DISTAL BOTH IP/OP "$2,355.55 " "$1,743.11" $0.00 "$1,884.44" "$1,060.00" "$1,060.00" $0.00 $0.00 $0.00 $490.96 "$1,748.29" "$1,748.29" $0.00 $0.00 $490.90 $0.00 "$1,393.31" "$1,393.31" $0.00 "$1,177.78" "$1,865.60" "$1,884.44" $0.00 $0.00 $357.91 $0.00 $0.00 $375.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.301 SUP HCPCS C1713 441.301 - PLATE BONE 14 HOLE LCP TITANIUM HUMERUS LEFT POSTLAT DISTAL BOTH IP/OP "$2,426.23 " "$1,795.41" $0.00 "$1,884.44" "$1,060.00" "$1,060.00" $0.00 $0.00 $0.00 $505.69 "$1,800.74" "$1,800.74" $0.00 $0.00 $505.63 $0.00 "$1,435.11" "$1,435.11" $0.00 "$1,177.78" "$1,865.60" "$1,884.44" $0.00 $0.00 $357.91 $0.00 $0.00 $375.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.302 SUP HCPCS C1713 441.302 - PLATE BONE 14 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS BOTH IP/OP "$2,565.40 " "$1,898.40" $0.00 "$1,992.54" "$1,120.80" "$1,120.80" $0.00 $0.00 $0.00 $534.69 "$1,904.04" "$1,904.04" $0.00 $0.00 $534.63 $0.00 "$1,264.74" "$1,264.74" $0.00 "$1,245.34" "$1,972.62" "$1,992.54" $0.00 $0.00 $378.44 $0.00 $0.00 $396.52 $0.00 $0.00 $0.00 $0.00 $0.00 441.303 SUP HCPCS C1713 441.303 - PLATE BONE 14 HOLE LATERAL SUPPORT LCP TITANIUM HUMERUS LEFT BOTH IP/OP "$2,565.40 " "$1,898.40" $0.00 "$1,992.54" "$1,120.80" "$1,120.80" $0.00 $0.00 $0.00 $534.69 "$1,904.04" "$1,904.04" $0.00 $0.00 $534.63 $0.00 "$1,264.74" "$1,264.74" $0.00 "$1,245.34" "$1,972.62" "$1,992.54" $0.00 $0.00 $378.44 $0.00 $0.00 $396.52 $0.00 $0.00 $0.00 $0.00 $0.00 441.304 SUP HCPCS C1713 441.304 - PLATE BONE 14 HOLE LCP TITANIUM HUMERUS RIGHT MEDIAL DISTAL BOTH IP/OP "$2,426.23 " "$1,795.41" $0.00 "$1,884.44" "$1,060.00" "$1,060.00" $0.00 $0.00 $0.00 $505.69 "$1,800.74" "$1,800.74" $0.00 $0.00 $505.63 $0.00 "$1,435.11" "$1,435.11" $0.00 "$1,177.78" "$1,865.60" "$1,884.44" $0.00 $0.00 $357.91 $0.00 $0.00 $375.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.305 SUP HCPCS C1713 441.305 - PLATE BONE 14 HOLE LCP TITANIUM HUMERUS LEFT DISTAL MEDIAL BOTH IP/OP "$2,426.23 " "$1,795.41" $0.00 "$1,884.44" "$1,060.00" "$1,060.00" $0.00 $0.00 $0.00 $505.69 "$1,800.74" "$1,800.74" $0.00 $0.00 $505.63 $0.00 "$1,435.11" "$1,435.11" $0.00 "$1,177.78" "$1,865.60" "$1,884.44" $0.00 $0.00 $357.91 $0.00 $0.00 $375.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.32 SUP HCPCS C1713 441.32 - PLATE BONE 25X9X1MM 2 HOLE 1/3 TUBULAR COLLAR LC-DCP BOTH IP/OP $108.25 $80.11 $0.00 $84.06 $47.28 $47.28 $0.00 $0.00 $0.00 $22.56 $80.34 $80.34 $0.00 $0.00 $22.56 $0.00 $64.03 $64.03 $0.00 $52.54 $83.22 $84.06 $0.00 $0.00 $15.97 $0.00 $0.00 $16.73 $0.00 $0.00 $0.00 $0.00 $0.00 441.33 SUP HCPCS C1713 441.33 - PLATE BONE 1/3 TUBULAR 37X9X1MM .5MM 3 HOLE COLLAR LC-DCP BOTH IP/OP $111.05 $82.18 $0.00 $86.26 $48.52 $48.52 $0.00 $0.00 $0.00 $23.15 $82.42 $82.42 $0.00 $0.00 $23.14 $0.00 $65.69 $65.69 $0.00 $53.91 $85.40 $86.26 $0.00 $0.00 $16.38 $0.00 $0.00 $17.17 $0.00 $0.00 $0.00 $0.00 $0.00 441.331 SUP HCPCS C1713 441.331 - PLATE BONE 33MM 3 HOLE 1/3 TUBULAR COLLAR LCP TITANIUM BOTH IP/OP $274.10 $202.83 $0.00 $212.90 $119.76 $119.76 $0.00 $0.00 $0.00 $57.13 $203.44 $203.44 $0.00 $0.00 $57.12 $0.00 $162.13 $162.13 $0.00 $133.06 $210.77 $212.90 $0.00 $0.00 $40.44 $0.00 $0.00 $42.37 $0.00 $0.00 $0.00 $0.00 $0.00 441.34 SUP HCPCS C1713 441.34 - PLATE BONE 1/3 TUBULAR 49X9X1MM .5MM 4 HOLE COLLAR LC-DCP BOTH IP/OP $130.73 $96.74 $0.00 $101.54 $57.12 $57.12 $0.00 $0.00 $0.00 $27.25 $97.02 $97.02 $0.00 $0.00 $27.24 $0.00 $77.32 $77.32 $0.00 $63.46 $100.53 $101.54 $0.00 $0.00 $19.28 $0.00 $0.00 $20.21 $0.00 $0.00 $0.00 $0.00 $0.00 441.341 SUP HCPCS C1713 441.341 - PLATE BONE 45MM 4 HOLE 1/3 TUBULAR COLLAR LCP TITANIUM BOTH IP/OP $316.28 $234.05 $0.00 $245.66 $138.18 $138.18 $0.00 $0.00 $0.00 $65.92 $234.74 $234.74 $0.00 $0.00 $65.91 $0.00 $187.08 $187.08 $0.00 $153.54 $243.21 $245.66 $0.00 $0.00 $46.66 $0.00 $0.00 $48.89 $0.00 $0.00 $0.00 $0.00 $0.00 441.35 SUP HCPCS C1713 441.35 - PLATE BONE 61X9X1MM 5 HOLE 1/3 TUBULAR COLLAR LC-DCP BOTH IP/OP $130.73 $96.74 $0.00 $101.54 $57.12 $57.12 $0.00 $0.00 $0.00 $27.25 $97.02 $97.02 $0.00 $0.00 $27.24 $0.00 $77.32 $77.32 $0.00 $63.46 $100.53 $101.54 $0.00 $0.00 $19.28 $0.00 $0.00 $20.21 $0.00 $0.00 $0.00 $0.00 $0.00 441.351 SUP HCPCS C1713 441.351 - PLATE BONE 1/3 TUBULAR 57X9X1MM 5 HOLE COLLAR LCP TITANIUM BOTH IP/OP $316.28 $234.05 $0.00 $245.66 $138.18 $138.18 $0.00 $0.00 $0.00 $65.92 $234.74 $234.74 $0.00 $0.00 $65.91 $0.00 $187.08 $187.08 $0.00 $153.54 $243.21 $245.66 $0.00 $0.00 $61.59 $0.00 $0.00 $48.89 $0.00 $0.00 $0.00 $0.00 $0.00 441.36 SUP HCPCS C1713 441.36 - PLATE BN 1/3 TBLR 12MM 73X9X1MM NS .5MM 6 HL COLR TI 3.5MM BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $59.25 $59.25 $0.00 $0.00 $0.00 $28.27 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $80.22 $80.22 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $20.01 $0.00 $0.00 $20.96 $0.00 $0.00 $0.00 $0.00 $0.00 441.361 SUP HCPCS C1713 441.361 - PLATE BN 1/3 TBLR 12MM 69X9X1MM NS .7MM LCP 6 HL COLR TI BOTH IP/OP $316.28 $234.05 $0.00 $245.66 $138.18 $138.18 $0.00 $0.00 $0.00 $65.92 $234.74 $234.74 $0.00 $0.00 $65.91 $0.00 $187.08 $187.08 $0.00 $153.54 $243.21 $245.66 $0.00 $0.00 $46.66 $0.00 $0.00 $48.89 $0.00 $0.00 $0.00 $0.00 $0.00 441.37 SUP HCPCS C1713 441.37 - PLATE BN 1/3 TBLR 12MM 85X9X1MM NS .5MM 7 HL COLR TI 3.5MM BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $59.25 $59.25 $0.00 $0.00 $0.00 $28.27 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $80.22 $80.22 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $20.01 $0.00 $0.00 $20.96 $0.00 $0.00 $0.00 $0.00 $0.00 441.371 SUP HCPCS C1713 441.371 - PLATE BN 1/3 TBLR 12MM 81X9X1MM NS .7MM LCP 7 HL COLR TI BOTH IP/OP $323.30 $239.24 $0.00 $251.12 $141.26 $141.26 $0.00 $0.00 $0.00 $67.38 $239.95 $239.95 $0.00 $0.00 $67.38 $0.00 $191.23 $191.23 $0.00 $156.95 $248.61 $251.12 $0.00 $0.00 $47.69 $0.00 $0.00 $49.97 $0.00 $0.00 $0.00 $0.00 $0.00 441.38 SUP HCPCS C1713 441.38 - PLATE BN 1/3 TBLR 12MM 97X9X1MM NS .5MM 8 HL COLR TI 3.5MM BOTH IP/OP $140.58 $104.03 $0.00 $109.18 $61.41 $61.41 $0.00 $0.00 $0.00 $29.30 $104.33 $104.33 $0.00 $0.00 $29.30 $0.00 $83.15 $83.15 $0.00 $68.24 $108.09 $109.18 $0.00 $0.00 $20.74 $0.00 $0.00 $21.73 $0.00 $0.00 $0.00 $0.00 $0.00 441.381 SUP HCPCS C1713 441.381 - PLATE BN 1/3 TBLR 12MM 93X9X1MM NS .7MM LCP 8 HL COLR TI BOTH IP/OP $340.18 $251.73 $0.00 $264.22 $148.62 $148.62 $0.00 $0.00 $0.00 $70.90 $252.48 $252.48 $0.00 $0.00 $70.89 $0.00 $201.21 $201.21 $0.00 $165.14 $261.58 $264.22 $0.00 $0.00 $50.18 $0.00 $0.00 $52.58 $0.00 $0.00 $0.00 $0.00 $0.00 441.39 SUP HCPCS C1713 441.39 - PLATE BONE 109X9X1MM 9 HOLE 1/3 TUBULAR COLLAR LC-DCP BOTH IP/OP $140.58 $104.03 $0.00 $109.18 $61.41 $61.41 $0.00 $0.00 $0.00 $29.30 $104.33 $104.33 $0.00 $0.00 $29.30 $0.00 $83.15 $83.15 $0.00 $68.24 $108.09 $109.18 $0.00 $0.00 $20.74 $0.00 $0.00 $21.73 $0.00 $0.00 $0.00 $0.00 $0.00 441.391 SUP HCPCS C1713 441.391 - PLATE BONE 105MM 9 HOLE 1/3 TUBULAR COLLAR LCP TITANIUM BOTH IP/OP $357.05 $264.22 $0.00 $277.32 $155.99 $155.99 $0.00 $0.00 $0.00 $74.42 $265.00 $265.00 $0.00 $0.00 $74.41 $0.00 $211.20 $211.20 $0.00 $173.33 $274.55 $277.32 $0.00 $0.00 $52.67 $0.00 $0.00 $55.19 $0.00 $0.00 $0.00 $0.00 $0.00 441.4 SUP HCPCS C1713 441.40 - PLATE BONE 121X9X1MM 10 HOLE 1/3 TUBULAR COLLAR LC-DCP BOTH IP/OP $136.48 $101.00 $0.00 $109.18 $61.41 $61.41 $0.00 $0.00 $0.00 $28.44 $101.29 $101.29 $0.00 $0.00 $28.44 $0.00 $80.72 $80.72 $0.00 $68.24 $108.09 $109.18 $0.00 $0.00 $20.74 $0.00 $0.00 $21.73 $0.00 $0.00 $0.00 $0.00 $0.00 441.401 SUP HCPCS C1713 441.401 - PLATE BONE 1/3 TUBULAR 12MM 117X9X1MM 10 HOLE COLLAR LCP BOTH IP/OP $345.80 $255.89 $0.00 $268.58 $151.08 $151.08 $0.00 $0.00 $0.00 $72.07 $256.65 $256.65 $0.00 $0.00 $72.06 $0.00 $204.54 $204.54 $0.00 $167.86 $265.90 $268.58 $0.00 $0.00 $51.01 $0.00 $0.00 $53.45 $0.00 $0.00 $0.00 $0.00 $0.00 441.42 SUP HCPCS C1713 441.42 - PLATE BONE 145X9X1MM 12 HOLE 1/3 TUBULAR COLLAR TITANIUM RAD BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 441.421 SUP HCPCS C1713 441.421 - PLATE BONE 1/3 TUBULAR 12MM 141X9X1MM 12 HOLE COLLAR LCP BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 441.44 SUP HCPCS C1713 441.440 - PLATE BONE 80MM 5 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$2,774.53 " "$2,053.15" $0.00 "$2,219.62" "$1,248.54" "$1,248.54" $0.00 $0.00 $0.00 $578.28 "$2,059.25" "$2,059.25" $0.00 $0.00 $578.21 $0.00 "$1,367.84" "$1,367.84" $0.00 "$1,387.26" "$2,197.43" "$2,219.62" $0.00 $0.00 $421.57 $0.00 $0.00 $441.70 $0.00 $0.00 $0.00 $0.00 $0.00 441.441 SUP HCPCS C1713 441.441 - PLATE BONE 80MM 5 HOLE LCP TITANIUM TIBIA LEFT DISTAL ANTLAT BOTH IP/OP "$2,857.78 " "$2,114.76" $0.00 "$2,219.62" "$1,248.54" "$1,248.54" $0.00 $0.00 $0.00 $595.63 "$2,121.04" "$2,121.04" $0.00 $0.00 $595.56 $0.00 "$1,408.88" "$1,408.88" $0.00 "$1,387.26" "$2,197.43" "$2,219.62" $0.00 $0.00 $421.57 $0.00 $0.00 $441.70 $0.00 $0.00 $0.00 $0.00 $0.00 441.442 SUP HCPCS C1713 441.442 - PLATE BONE 106MM 7 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$2,890.10 " "$2,138.67" $0.00 "$2,244.74" "$1,262.67" "$1,262.67" $0.00 $0.00 $0.00 $602.37 "$2,145.03" "$2,145.03" $0.00 $0.00 $602.30 $0.00 "$1,424.82" "$1,424.82" $0.00 "$1,402.96" "$2,222.30" "$2,244.74" $0.00 $0.00 $426.34 $0.00 $0.00 $446.70 $0.00 $0.00 $0.00 $0.00 $0.00 441.443 SUP HCPCS C1713 441.443 - PLATE BONE 106MM 7 HOLE LCP TITANIUM TIBIA LEFT DISTAL BOTH IP/OP "$2,890.10 " "$2,138.67" $0.00 "$2,244.74" "$1,262.67" "$1,262.67" $0.00 $0.00 $0.00 $602.37 "$2,145.03" "$2,145.03" $0.00 $0.00 $602.30 $0.00 "$1,424.82" "$1,424.82" $0.00 "$1,402.96" "$2,222.30" "$2,244.74" $0.00 $0.00 $426.34 $0.00 $0.00 $446.70 $0.00 $0.00 $0.00 $0.00 $0.00 441.444 SUP HCPCS C1713 441.444 - PLATE BONE 132MM 9 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$2,919.63 " "$2,160.53" $0.00 "$2,267.66" "$1,275.56" "$1,275.56" $0.00 $0.00 $0.00 $608.52 "$2,166.95" "$2,166.95" $0.00 $0.00 $608.45 $0.00 "$1,439.38" "$1,439.38" $0.00 "$1,417.29" "$2,244.99" "$2,267.66" $0.00 $0.00 $430.69 $0.00 $0.00 $451.26 $0.00 $0.00 $0.00 $0.00 $0.00 441.445 SUP HCPCS C1713 441.445 - PLATE BONE 132MM 9 HOLE LCP TITANIUM TIBIA LEFT DISTAL BOTH IP/OP "$2,919.63 " "$2,160.53" $0.00 "$2,267.66" "$1,275.56" "$1,275.56" $0.00 $0.00 $0.00 $608.52 "$2,166.95" "$2,166.95" $0.00 $0.00 $608.45 $0.00 "$1,439.38" "$1,439.38" $0.00 "$1,417.29" "$2,244.99" "$2,267.66" $0.00 $0.00 $430.69 $0.00 $0.00 $451.26 $0.00 $0.00 $0.00 $0.00 $0.00 441.446 SUP HCPCS C1713 441.446 - PLATE BONE 158MM 11 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$2,947.73 " "$2,181.32" $0.00 "$2,289.50" "$1,287.84" "$1,287.84" $0.00 $0.00 $0.00 $614.38 "$2,187.80" "$2,187.80" $0.00 $0.00 $614.31 $0.00 "$1,453.23" "$1,453.23" $0.00 "$1,430.94" "$2,266.61" "$2,289.50" $0.00 $0.00 $434.84 $0.00 $0.00 $455.61 $0.00 $0.00 $0.00 $0.00 $0.00 441.447 SUP HCPCS C1713 441.447 - PLATE BONE 158MM 11 HOLE LCP TITANIUM TIBIA LEFT DISTAL BOTH IP/OP "$2,947.73 " "$2,181.32" $0.00 "$2,289.50" "$1,287.84" "$1,287.84" $0.00 $0.00 $0.00 $614.38 "$2,187.80" "$2,187.80" $0.00 $0.00 $614.31 $0.00 "$1,453.23" "$1,453.23" $0.00 "$1,430.94" "$2,266.61" "$2,289.50" $0.00 $0.00 $434.84 $0.00 $0.00 $455.61 $0.00 $0.00 $0.00 $0.00 $0.00 441.448 SUP HCPCS C1713 441.448 - PLATE BONE 184MM 13 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$2,980.08 " "$2,205.26" $0.00 "$2,314.62" "$1,301.97" "$1,301.97" $0.00 $0.00 $0.00 $621.12 "$2,211.81" "$2,211.81" $0.00 $0.00 $621.05 $0.00 "$1,469.18" "$1,469.18" $0.00 "$1,446.64" "$2,291.48" "$2,314.62" $0.00 $0.00 $439.61 $0.00 $0.00 $460.61 $0.00 $0.00 $0.00 $0.00 $0.00 441.449 SUP HCPCS C1713 441.449 - PLATE BONE 184MM 13 HOLE LCP TITANIUM TIBIA LEFT DISTAL BOTH IP/OP "$2,980.08 " "$2,205.26" $0.00 "$2,314.62" "$1,301.97" "$1,301.97" $0.00 $0.00 $0.00 $621.12 "$2,211.81" "$2,211.81" $0.00 $0.00 $621.05 $0.00 "$1,469.18" "$1,469.18" $0.00 "$1,446.64" "$2,291.48" "$2,314.62" $0.00 $0.00 $439.61 $0.00 $0.00 $460.61 $0.00 $0.00 $0.00 $0.00 $0.00 441.45 SUP HCPCS C1713 441.450 - PLATE BONE 210MM 15 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$2,931.48 " "$2,169.30" $0.00 "$2,345.18" "$1,319.16" "$1,319.16" $0.00 $0.00 $0.00 $610.99 "$2,175.74" "$2,175.74" $0.00 $0.00 $610.92 $0.00 "$1,445.22" "$1,445.22" $0.00 "$1,465.74" "$2,321.73" "$2,345.18" $0.00 $0.00 $445.41 $0.00 $0.00 $466.69 $0.00 $0.00 $0.00 $0.00 $0.00 441.451 SUP HCPCS C1713 441.451 - PLATE BONE 210MM 15 HOLE LCP TITANIUM TIBIA LEFT DISTAL BOTH IP/OP "$3,019.43 " "$2,234.38" $0.00 "$2,345.18" "$1,319.16" "$1,319.16" $0.00 $0.00 $0.00 $629.32 "$2,241.02" "$2,241.02" $0.00 $0.00 $629.25 $0.00 "$1,488.58" "$1,488.58" $0.00 "$1,465.74" "$2,321.73" "$2,345.18" $0.00 $0.00 $445.41 $0.00 $0.00 $466.69 $0.00 $0.00 $0.00 $0.00 $0.00 441.452 SUP HCPCS C1713 441.452 - PLATE BONE 236MM 17 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$3,047.55 " "$2,255.19" $0.00 "$2,367.02" "$1,331.45" "$1,331.45" $0.00 $0.00 $0.00 $635.19 "$2,261.89" "$2,261.89" $0.00 $0.00 $635.11 $0.00 "$1,502.44" "$1,502.44" $0.00 "$1,479.39" "$2,343.35" "$2,367.02" $0.00 $0.00 $449.56 $0.00 $0.00 $471.04 $0.00 $0.00 $0.00 $0.00 $0.00 441.453 SUP HCPCS C1713 441.453 - PLATE BONE 236MM 17 HOLE LCP TITANIUM TIBIA LEFT DISTAL BOTH IP/OP "$3,047.55 " "$2,255.19" $0.00 "$2,367.02" "$1,331.45" "$1,331.45" $0.00 $0.00 $0.00 $635.19 "$2,261.89" "$2,261.89" $0.00 $0.00 $635.11 $0.00 "$1,502.44" "$1,502.44" $0.00 "$1,479.39" "$2,343.35" "$2,367.02" $0.00 $0.00 $449.56 $0.00 $0.00 $471.04 $0.00 $0.00 $0.00 $0.00 $0.00 441.454 SUP HCPCS C1713 441.454 - PLATE BONE 262MM 19 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$3,071.45 " "$2,272.87" $0.00 "$2,385.58" "$1,341.89" "$1,341.89" $0.00 $0.00 $0.00 $640.17 "$2,279.63" "$2,279.63" $0.00 $0.00 $640.09 $0.00 "$1,514.22" "$1,514.22" $0.00 "$1,490.99" "$2,361.73" "$2,385.58" $0.00 $0.00 $453.09 $0.00 $0.00 $474.73 $0.00 $0.00 $0.00 $0.00 $0.00 441.455 SUP HCPCS C1713 441.455 - PLATE BONE 262MM 19 HOLE LCP TITANIUM TIBIA LEFT DISTAL BOTH IP/OP "$3,071.45 " "$2,272.87" $0.00 "$2,385.58" "$1,341.89" "$1,341.89" $0.00 $0.00 $0.00 $640.17 "$2,279.63" "$2,279.63" $0.00 $0.00 $640.09 $0.00 "$1,514.22" "$1,514.22" $0.00 "$1,490.99" "$2,361.73" "$2,385.58" $0.00 $0.00 $453.09 $0.00 $0.00 $474.73 $0.00 $0.00 $0.00 $0.00 $0.00 441.456 SUP HCPCS C1713 441.456 - PLATE BONE 288MM 21 HOLE LCP TITANIUM TIBIA RIGHT DISTAL BOTH IP/OP "$3,100.95 " "$2,294.70" $0.00 "$2,408.52" "$1,354.79" "$1,354.79" $0.00 $0.00 $0.00 $646.32 "$2,301.53" "$2,301.53" $0.00 $0.00 $646.24 $0.00 "$1,528.77" "$1,528.77" $0.00 "$1,505.33" "$2,384.43" "$2,408.52" $0.00 $0.00 $457.44 $0.00 $0.00 $479.30 $0.00 $0.00 $0.00 $0.00 $0.00 441.457 SUP HCPCS C1713 441.457 - PLATE BONE 288MM 21 HOLE LCP TITANIUM TIBIA LEFT DISTAL BOTH IP/OP "$3,100.95 " "$2,294.70" $0.00 "$2,408.52" "$1,354.79" "$1,354.79" $0.00 $0.00 $0.00 $646.32 "$2,301.53" "$2,301.53" $0.00 $0.00 $646.24 $0.00 "$1,528.77" "$1,528.77" $0.00 "$1,505.33" "$2,384.43" "$2,408.52" $0.00 $0.00 $457.44 $0.00 $0.00 $479.30 $0.00 $0.00 $0.00 $0.00 $0.00 441.61 SUP HCPCS C1713 441.61 - PLATE BONE 60MMX1.2MM LC-DCP TITANIUM CALCANEUS NONSTRL BOTH IP/OP $992.18 $734.21 $0.00 $793.74 $446.48 $446.48 $0.00 $0.00 $0.00 $206.79 $736.39 $736.39 $0.00 $0.00 $206.77 $0.00 $586.87 $586.87 $0.00 $496.09 $785.81 $793.74 $0.00 $0.00 $150.75 $0.00 $0.00 $157.95 $0.00 $0.00 $0.00 $0.00 $0.00 441.62 SUP HCPCS C1713 441.62 - PLATE BONE 70MMX1.2MM LC-DCP TITANIUM CALCANEUS NONSTRL BOTH IP/OP "$1,015.38 " $751.38 $0.00 $812.30 $456.92 $456.92 $0.00 $0.00 $0.00 $211.63 $753.61 $753.61 $0.00 $0.00 $211.60 $0.00 $600.59 $600.59 $0.00 $507.69 $804.18 $812.30 $0.00 $0.00 $154.28 $0.00 $0.00 $161.65 $0.00 $0.00 $0.00 $0.00 $0.00 441.65 SUP HCPCS C1713 441.65 - PLATE BONE Y 87MMX2MM LC-DCP TITANIUM CALCANEUS NONSTRL BOTH IP/OP "$1,015.38 " $751.38 $0.00 $812.30 $456.92 $456.92 $0.00 $0.00 $0.00 $211.63 $753.61 $753.61 $0.00 $0.00 $211.60 $0.00 $600.59 $600.59 $0.00 $507.69 $804.18 $812.30 $0.00 $0.00 $154.28 $0.00 $0.00 $161.65 $0.00 $0.00 $0.00 $0.00 $0.00 441.68 SUP HCPCS C1713 441.680 - PLATE BONE 2.4MM 34MM IMPLANT RIM 2 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,112.28 " $823.09 $0.00 $889.82 $500.52 $500.52 $0.00 $0.00 $0.00 $231.83 $825.53 $825.53 $0.00 $0.00 $231.80 $0.00 $657.91 $657.91 $0.00 $556.14 $880.93 $889.82 $0.00 $0.00 $169.00 $0.00 $0.00 $177.07 $0.00 $0.00 $0.00 $0.00 $0.00 441.681 SUP HCPCS C1713 441.681 - PLATE BONE 2.4MM 34MM IMPLANT RIM 2 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,145.65 " $847.78 $0.00 $889.82 $500.52 $500.52 $0.00 $0.00 $0.00 $238.78 $850.30 $850.30 $0.00 $0.00 $238.75 $0.00 $677.65 $677.65 $0.00 $556.14 $880.93 $889.82 $0.00 $0.00 $169.00 $0.00 $0.00 $177.07 $0.00 $0.00 $0.00 $0.00 $0.00 441.682 SUP HCPCS C1713 441.682 - PLATE BONE 2.4MM 46MM IMPLANT RIM 3 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,177.98 " $871.71 $0.00 $914.92 $514.64 $514.64 $0.00 $0.00 $0.00 $245.52 $874.29 $874.29 $0.00 $0.00 $245.49 $0.00 $696.77 $696.77 $0.00 $571.83 $905.77 $914.92 $0.00 $0.00 $173.77 $0.00 $0.00 $182.07 $0.00 $0.00 $0.00 $0.00 $0.00 441.683 SUP HCPCS C1713 441.683 - PLATE BONE 2.4MM 46MM IMPLANT RIM 3 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,177.98 " $871.71 $0.00 $914.92 $514.64 $514.64 $0.00 $0.00 $0.00 $245.52 $874.29 $874.29 $0.00 $0.00 $245.49 $0.00 $696.77 $696.77 $0.00 $571.83 $905.77 $914.92 $0.00 $0.00 $173.77 $0.00 $0.00 $182.07 $0.00 $0.00 $0.00 $0.00 $0.00 441.684 SUP HCPCS C1713 441.684 - PLATE BONE 2.4MM 56MM IMPLANT RIM 4 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,199.05 " $887.30 $0.00 $931.30 $523.86 $523.86 $0.00 $0.00 $0.00 $249.91 $889.93 $889.93 $0.00 $0.00 $249.88 $0.00 $709.24 $709.24 $0.00 $582.06 $921.99 $931.30 $0.00 $0.00 $176.88 $0.00 $0.00 $185.33 $0.00 $0.00 $0.00 $0.00 $0.00 441.685 SUP HCPCS C1713 441.685 - PLATE BONE 2.4MM 56MM IMPLANT RIM 4 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,199.05 " $887.30 $0.00 $931.30 $523.86 $523.86 $0.00 $0.00 $0.00 $249.91 $889.93 $889.93 $0.00 $0.00 $249.88 $0.00 $709.24 $709.24 $0.00 $582.06 $921.99 $931.30 $0.00 $0.00 $176.88 $0.00 $0.00 $185.33 $0.00 $0.00 $0.00 $0.00 $0.00 441.69 SUP HCPCS C1713 441.690 - PLATE BONE 2.4MM 28MM IMPLANT 2 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,112.28 " $823.09 $0.00 $889.82 $500.52 $500.52 $0.00 $0.00 $0.00 $231.83 $825.53 $825.53 $0.00 $0.00 $231.80 $0.00 $657.91 $657.91 $0.00 $556.14 $880.93 $889.82 $0.00 $0.00 $169.00 $0.00 $0.00 $177.07 $0.00 $0.00 $0.00 $0.00 $0.00 441.691 SUP HCPCS C1713 441.691 - PLATE BONE 2.4MM 40MM IMPLANT 3 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,177.98 " $871.71 $0.00 $914.92 $514.64 $514.64 $0.00 $0.00 $0.00 $245.52 $874.29 $874.29 $0.00 $0.00 $245.49 $0.00 $696.77 $696.77 $0.00 $571.83 $905.77 $914.92 $0.00 $0.00 $173.77 $0.00 $0.00 $182.07 $0.00 $0.00 $0.00 $0.00 $0.00 441.692 SUP HCPCS C1713 441.692 - PLATE BONE 2.4MM 50MM IMPLANT 4 HOLE LCP TITANIUM RADIAL BOTH IP/OP "$1,200.45 " $888.33 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $250.20 $890.97 $890.97 $0.00 $0.00 $250.17 $0.00 $710.07 $710.07 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $177.09 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 441.83 SUP HCPCS C1713 441.83 - PLATE BONE CLOVERLEAF 88X15X2MM 3 HOLE THIN BLADE LP HEAD BOTH IP/OP $570.48 $422.16 $0.00 $456.38 $256.71 $256.71 $0.00 $0.00 $0.00 $118.90 $423.41 $423.41 $0.00 $0.00 $118.89 $0.00 $337.44 $337.44 $0.00 $285.24 $451.82 $456.38 $0.00 $0.00 $86.68 $0.00 $0.00 $90.82 $0.00 $0.00 $0.00 $0.00 $0.00 441.84 SUP HCPCS C1713 441.84 - PLATE BONE CLOVERLEAF 104X15X2MM 4 HOLE THIN BLADE LP HEAD BOTH IP/OP $610.05 $451.44 $0.00 $488.04 $274.52 $274.52 $0.00 $0.00 $0.00 $127.15 $452.78 $452.78 $0.00 $0.00 $127.13 $0.00 $360.84 $360.84 $0.00 $305.03 $483.16 $488.04 $0.00 $0.00 $92.69 $0.00 $0.00 $97.12 $0.00 $0.00 $0.00 $0.00 $0.00 441.85 SUP HCPCS C1713 441.85 - PLATE BONE CLOVERLEAF 120X15X2MM 5 HOLE THIN BLADE LP HEAD BOTH IP/OP $768.35 $568.58 $0.00 $614.68 $345.76 $345.76 $0.00 $0.00 $0.00 $160.14 $570.27 $570.27 $0.00 $0.00 $160.12 $0.00 $454.48 $454.48 $0.00 $384.18 $608.53 $614.68 $0.00 $0.00 $116.75 $0.00 $0.00 $122.32 $0.00 $0.00 $0.00 $0.00 $0.00 441.86 SUP HCPCS C1713 441.86 - PLATE BONE CLOVERLEAF 136X15X2MM 6 HOLE THIN BLADE LP HEAD BOTH IP/OP $833.85 $617.05 $0.00 $667.08 $375.23 $375.23 $0.00 $0.00 $0.00 $173.80 $618.88 $618.88 $0.00 $0.00 $173.77 $0.00 $493.22 $493.22 $0.00 $416.93 $660.41 $667.08 $0.00 $0.00 $126.70 $0.00 $0.00 $132.75 $0.00 $0.00 $0.00 $0.00 $0.00 441.87 SUP HCPCS C1713 441.87 - PLATE BONE CLOVERLEAF 152X15X2MM 7 HOLE THIN BLADE LP HEAD BOTH IP/OP $898.00 $664.52 $0.00 $718.40 $404.10 $404.10 $0.00 $0.00 $0.00 $187.17 $666.50 $666.50 $0.00 $0.00 $187.14 $0.00 $531.17 $531.17 $0.00 $449.00 $711.22 $718.40 $0.00 $0.00 $136.44 $0.00 $0.00 $142.96 $0.00 $0.00 $0.00 $0.00 $0.00 441.88 SUP HCPCS C1713 441.88 - PLATE BONE CLOVERLEAF 168X15X2MM 8 HOLE THIN BLADE LP HEAD BOTH IP/OP $953.95 $705.92 $0.00 $763.16 $429.28 $429.28 $0.00 $0.00 $0.00 $198.83 $708.02 $708.02 $0.00 $0.00 $198.80 $0.00 $564.26 $564.26 $0.00 $476.98 $755.53 $763.16 $0.00 $0.00 $144.95 $0.00 $0.00 $151.87 $0.00 $0.00 $0.00 $0.00 $0.00 441.89 SUP HCPCS C1713 441.89 - PLATE BONE CLOVERLEAF 200X15X2MM 10 HOLE THIN BLADE LP HEAD BOTH IP/OP "$1,030.38 " $762.48 $0.00 $824.30 $463.67 $463.67 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $515.19 $816.06 $824.30 $0.00 $0.00 $156.56 $0.00 $0.00 $164.04 $0.00 $0.00 $0.00 $0.00 $0.00 441.901 SUP HCPCS C1713 441.901 - PLATE BN STD 90X12X2.5MM NS LCP CMBN PHLS 3 HL SHFT LCK CMPR BOTH IP/OP "$2,954.78 " "$2,186.54" $0.00 "$2,294.96" "$1,290.92" "$1,290.92" $0.00 $0.00 $0.00 $615.85 "$2,193.03" "$2,193.03" $0.00 $0.00 $615.78 $0.00 "$1,456.70" "$1,456.70" $0.00 "$1,434.35" "$2,272.01" "$2,294.96" $0.00 $0.00 $435.88 $0.00 $0.00 $456.70 $0.00 $0.00 $0.00 $0.00 $0.00 441.903 SUP HCPCS C1713 441.903 - PLATE BONE STANDARD 114X12X2.5MM 6 HOLE HEAD 5 HOLE SHAFT BOTH IP/OP "$3,047.55 " "$2,255.19" $0.00 "$2,367.02" "$1,331.45" "$1,331.45" $0.00 $0.00 $0.00 $635.19 "$2,261.89" "$2,261.89" $0.00 $0.00 $635.11 $0.00 "$1,502.44" "$1,502.44" $0.00 "$1,479.39" "$2,343.35" "$2,367.02" $0.00 $0.00 $449.56 $0.00 $0.00 $471.04 $0.00 $0.00 $0.00 $0.00 $0.00 441.918 SUP HCPCS C1713 441.918 - PLATE BONE LONG 142MM 5 HOLE LOCKING LCP TITANIUM HUMERUS BOTH IP/OP "$3,077.05 " "$2,277.02" $0.00 "$2,389.96" "$1,344.35" "$1,344.35" $0.00 $0.00 $0.00 $641.33 "$2,283.79" "$2,283.79" $0.00 $0.00 $641.26 $0.00 "$1,516.99" "$1,516.99" $0.00 "$1,493.73" "$2,366.06" "$2,389.96" $0.00 $0.00 $453.92 $0.00 $0.00 $475.60 $0.00 $0.00 $0.00 $0.00 $0.00 441.919 SUP HCPCS C1713 441.919 - PLATE BONE LONG 160MM 6 HOLE LOCKING LCP TITANIUM HUMERUS BOTH IP/OP "$3,197.95 " "$2,366.48" $0.00 "$2,483.84" "$1,397.16" "$1,397.16" $0.00 $0.00 $0.00 $666.53 "$2,373.52" "$2,373.52" $0.00 $0.00 $666.45 $0.00 "$1,576.59" "$1,576.59" $0.00 "$1,552.40" "$2,459.00" "$2,483.84" $0.00 $0.00 $471.75 $0.00 $0.00 $494.28 $0.00 $0.00 $0.00 $0.00 $0.00 441.921 SUP HCPCS C1713 441.921 - PLATE BN 196X12X3.7MM NS LCP CMBN PHLS LNG 8 HL SHFT LCK BOTH IP/OP "$3,321.65 " "$2,458.02" $0.00 "$2,579.92" "$1,451.21" "$1,451.21" $0.00 $0.00 $0.00 $692.31 "$2,465.33" "$2,465.33" $0.00 $0.00 $692.23 $0.00 "$1,637.57" "$1,637.57" $0.00 "$1,612.45" "$2,554.12" "$2,579.92" $0.00 $0.00 $490.00 $0.00 $0.00 $513.40 $0.00 $0.00 $0.00 $0.00 $0.00 441.923 SUP HCPCS C1713 441.923 - PLATE BONE 3.5MM 232MM 10 HOLE LCP TITANIUM HUMERUS PROXIMAL BOTH IP/OP "$3,445.35 " "$2,549.56" $0.00 "$2,676.00" "$1,505.25" "$1,505.25" $0.00 $0.00 $0.00 $718.10 "$2,557.14" "$2,557.14" $0.00 $0.00 $718.01 $0.00 "$1,698.56" "$1,698.56" $0.00 "$1,672.50" "$2,649.24" "$2,676.00" $0.00 $0.00 $508.25 $0.00 $0.00 $532.52 $0.00 $0.00 $0.00 $0.00 $0.00 441.925 SUP HCPCS C1713 441.925 - PLATE BONE LONG 268MM 12 HOLE LOCKING LCP TITANIUM HUMERUS BOTH IP/OP "$3,564.83 " "$2,637.97" $0.00 "$2,768.80" "$1,557.45" "$1,557.45" $0.00 $0.00 $0.00 $743.00 "$2,645.81" "$2,645.81" $0.00 $0.00 $742.91 $0.00 "$1,757.46" "$1,757.46" $0.00 "$1,730.50" "$2,741.11" "$2,768.80" $0.00 $0.00 $525.87 $0.00 $0.00 $550.99 $0.00 $0.00 $0.00 $0.00 $0.00 441.931 SUP HCPCS C1713 441.931 - PLATE BONE T OBLIQUE LEFT 52X10X1.5MM 3 HOLE HEAD 3 HOLE BOTH IP/OP $721.13 $533.64 $0.00 $560.10 $315.06 $315.06 $0.00 $0.00 $0.00 $150.30 $535.22 $535.22 $0.00 $0.00 $150.28 $0.00 $426.55 $426.55 $0.00 $350.06 $554.50 $560.10 $0.00 $0.00 $106.38 $0.00 $0.00 $111.46 $0.00 $0.00 $0.00 $0.00 $0.00 441.941 SUP HCPCS C1713 441.941 - PLATE BONE T OBLIQUE LEFT 63X10X1.5MM 3 HOLE HEAD 4 HOLE BOTH IP/OP $756.28 $559.65 $0.00 $587.38 $330.40 $330.40 $0.00 $0.00 $0.00 $157.63 $561.31 $561.31 $0.00 $0.00 $157.61 $0.00 $447.34 $447.34 $0.00 $367.11 $581.51 $587.38 $0.00 $0.00 $111.56 $0.00 $0.00 $116.89 $0.00 $0.00 $0.00 $0.00 $0.00 441.951 SUP HCPCS C1713 441.951 - PLATE BONE T OBLIQUE LEFT 74X10X1.5MM 3 HOLE HEAD 5 HOLE BOTH IP/OP $788.60 $583.56 $0.00 $612.50 $344.53 $344.53 $0.00 $0.00 $0.00 $164.36 $585.30 $585.30 $0.00 $0.00 $164.34 $0.00 $466.46 $466.46 $0.00 $382.81 $606.38 $612.50 $0.00 $0.00 $116.33 $0.00 $0.00 $121.89 $0.00 $0.00 $0.00 $0.00 $0.00 441.961 SUP HCPCS C1713 441.961 - PLATE BONE 85MM 3 HOLE HEAD 6 HOLE SHAFT T OBLIQUE LEFT LCP BOTH IP/OP $820.93 $607.49 $0.00 $637.62 $358.66 $358.66 $0.00 $0.00 $0.00 $171.10 $609.29 $609.29 $0.00 $0.00 $171.08 $0.00 $485.58 $485.58 $0.00 $398.51 $631.25 $637.62 $0.00 $0.00 $121.10 $0.00 $0.00 $126.89 $0.00 $0.00 $0.00 $0.00 $0.00 441.971 SUP HCPCS C1713 441.971 - PLATE BONE T OBLIQUE 96X10X1.5MM 3 HOLE HEAD 7 HOLE SHAFT BOTH IP/OP $854.65 $632.44 $0.00 $663.82 $373.40 $373.40 $0.00 $0.00 $0.00 $178.13 $634.32 $634.32 $0.00 $0.00 $178.11 $0.00 $505.53 $505.53 $0.00 $414.89 $657.19 $663.82 $0.00 $0.00 $126.08 $0.00 $0.00 $132.10 $0.00 $0.00 $0.00 $0.00 $0.00 441.981 SUP HCPCS C1713 441.981 - PLATE BONE 107MM 8 SHAFT HOLE 3 HOLE HEAD T OBLIQUE LEFT LCP BOTH IP/OP $901.05 $666.78 $0.00 $699.84 $393.66 $393.66 $0.00 $0.00 $0.00 $187.80 $668.76 $668.76 $0.00 $0.00 $187.78 $0.00 $532.97 $532.97 $0.00 $437.40 $692.84 $699.84 $0.00 $0.00 $132.92 $0.00 $0.00 $139.27 $0.00 $0.00 $0.00 $0.00 $0.00 442.03 SUP HCPCS C1713 442.03 - PLATE BONE 23X7X1MM .3MM 3 HOLE .25 TUBULAR COLLAR TITANIUM BOTH IP/OP $146.03 $108.06 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $30.44 $108.38 $108.38 $0.00 $0.00 $30.43 $0.00 $86.37 $86.37 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 442.04 SUP HCPCS C1713 442.04 - PLATE BONE 31X7X1MM .3MM 4 HOLE .25 TUBULAR COLLAR TITANIUM BOTH IP/OP $156.03 $115.46 $0.00 $121.18 $68.16 $68.16 $0.00 $0.00 $0.00 $32.52 $115.80 $115.80 $0.00 $0.00 $32.52 $0.00 $92.29 $92.29 $0.00 $75.74 $119.97 $121.18 $0.00 $0.00 $23.02 $0.00 $0.00 $24.11 $0.00 $0.00 $0.00 $0.00 $0.00 442.05 SUP HCPCS C1713 442.05 - PLATE BONE 39X7X1MM .3MM 5 HOLE .25 TUBULAR COLLAR TITANIUM BOTH IP/OP $161.05 $119.18 $0.00 $128.84 $72.47 $72.47 $0.00 $0.00 $0.00 $33.57 $119.53 $119.53 $0.00 $0.00 $33.56 $0.00 $95.26 $95.26 $0.00 $80.53 $127.55 $128.84 $0.00 $0.00 $24.47 $0.00 $0.00 $25.64 $0.00 $0.00 $0.00 $0.00 $0.00 442.06 SUP HCPCS C1713 442.06 - PLATE BONE 47X7X1MM .3MM 6 HOLE .25 TUBULAR COLLAR TITANIUM BOTH IP/OP $179.93 $133.15 $0.00 $139.76 $78.62 $78.62 $0.00 $0.00 $0.00 $37.50 $133.54 $133.54 $0.00 $0.00 $37.50 $0.00 $106.43 $106.43 $0.00 $87.35 $138.36 $139.76 $0.00 $0.00 $26.54 $0.00 $0.00 $27.81 $0.00 $0.00 $0.00 $0.00 $0.00 442.07 SUP HCPCS C1713 442.07 - PLATE BONE 55X7X1MM .3MM 7 HOLE .25 TUBULAR COLLAR TITANIUM BOTH IP/OP $196.80 $145.63 $0.00 $152.86 $85.98 $85.98 $0.00 $0.00 $0.00 $41.02 $146.06 $146.06 $0.00 $0.00 $41.01 $0.00 $116.41 $116.41 $0.00 $95.54 $151.34 $152.86 $0.00 $0.00 $29.03 $0.00 $0.00 $30.42 $0.00 $0.00 $0.00 $0.00 $0.00 442.08 SUP HCPCS C1713 442.08 - PLATE BONE 63X7X1MM .3MM 8 HOLE .25 TUBULAR COLLAR TITANIUM BOTH IP/OP $199.25 $147.45 $0.00 $159.40 $89.66 $89.66 $0.00 $0.00 $0.00 $41.53 $147.88 $147.88 $0.00 $0.00 $41.52 $0.00 $117.86 $117.86 $0.00 $99.63 $157.81 $159.40 $0.00 $0.00 $30.27 $0.00 $0.00 $31.72 $0.00 $0.00 $0.00 $0.00 $0.00 442.33 SUP HCPCS C1713 442.33 - PLATE BONE L LEFT OBLIQUE 34X7X1MM 3 HOLE CNTOUR TITANIUM BOTH IP/OP $113.28 $83.83 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $23.61 $84.07 $84.07 $0.00 $0.00 $23.61 $0.00 $67.00 $67.00 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 442.34 SUP HCPCS C1713 442.34 - PLATE BONE L RIGHT OBLIQUE 34X7X1MM 3 HOLE CNTOUR TITANIUM BOTH IP/OP $113.28 $83.83 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $23.61 $84.07 $84.07 $0.00 $0.00 $23.61 $0.00 $67.00 $67.00 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 442.41 SUP HCPCS C1713 442.41 - PLATE BN T 32X7X1.2MM 3 HL TI 2.7MM SCR BOTH IP/OP $113.28 $83.83 $0.00 $90.62 $50.97 $50.97 $0.00 $0.00 $0.00 $23.61 $84.07 $84.07 $0.00 $0.00 $23.61 $0.00 $67.00 $67.00 $0.00 $56.64 $89.72 $90.62 $0.00 $0.00 $17.21 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 442.472 SUP HCPCS C1713 442.472 - PLATE BN TI RDS RT DIST DRSL BOTH IP/OP "$1,854.48 " "$1,372.32" $0.00 "$1,483.58" $834.51 $834.51 $0.00 $0.00 $0.00 $386.52 "$1,376.39" "$1,376.39" $0.00 $0.00 $386.47 $0.00 "$1,096.92" "$1,096.92" $0.00 $927.24 "$1,468.75" "$1,483.58" $0.00 $0.00 $290.23 $0.00 $0.00 $295.23 $0.00 $0.00 $0.00 $0.00 $0.00 442.473 SUP HCPCS C1713 442.473 - PLATE BN TI RDS RT DIST VOLR BOTH IP/OP "$1,530.63 " "$1,132.67" $0.00 "$1,224.50" $688.78 $688.78 $0.00 $0.00 $0.00 $319.02 "$1,136.03" "$1,136.03" $0.00 $0.00 $318.98 $0.00 $905.36 $905.36 $0.00 $765.31 "$1,212.26" "$1,224.50" $0.00 $0.00 $239.54 $0.00 $0.00 $243.68 $0.00 $0.00 $0.00 $0.00 $0.00 442.477 SUP HCPCS C1713 442.477 - PLATE BONE 40MM 3X3 HOLE LCP TITANIUM DISTAL RAD NONSTRL 2.4 BOTH IP/OP $877.15 $649.09 $0.00 $681.28 $383.22 $383.22 $0.00 $0.00 $0.00 $182.82 $651.02 $651.02 $0.00 $0.00 $182.80 $0.00 $518.83 $518.83 $0.00 $425.80 $674.47 $681.28 $0.00 $0.00 $129.39 $0.00 $0.00 $135.57 $0.00 $0.00 $0.00 $0.00 $0.00 442.478 SUP HCPCS C1713 442.478 - PLATE BONE 49MM 3X4 HOLE LCP TITANIUM DISTAL RAD NONSTRL 2.4 BOTH IP/OP $913.70 $676.14 $0.00 $709.68 $399.20 $399.20 $0.00 $0.00 $0.00 $190.44 $678.15 $678.15 $0.00 $0.00 $190.42 $0.00 $540.45 $540.45 $0.00 $443.55 $702.58 $709.68 $0.00 $0.00 $134.79 $0.00 $0.00 $141.23 $0.00 $0.00 $0.00 $0.00 $0.00 442.479 SUP HCPCS C1713 442.479 - PLATE BONE STR 48MM 5 HOLE LCP TITANIUM DISTAL RAD NONSTRL BOTH IP/OP $832.18 $615.81 $0.00 $646.34 $363.57 $363.57 $0.00 $0.00 $0.00 $173.45 $617.64 $617.64 $0.00 $0.00 $173.43 $0.00 $492.23 $492.23 $0.00 $403.96 $639.88 $646.34 $0.00 $0.00 $122.76 $0.00 $0.00 $128.62 $0.00 $0.00 $0.00 $0.00 $0.00 442.482 SUP HCPCS C1713 442.482 - PLATE BN TI RDS LT DIST DRSL BOTH IP/OP "$1,854.48 " "$1,372.32" $0.00 "$1,483.58" $834.51 $834.51 $0.00 $0.00 $0.00 $386.52 "$1,376.39" "$1,376.39" $0.00 $0.00 $386.47 $0.00 "$1,096.92" "$1,096.92" $0.00 $927.24 "$1,468.75" "$1,483.58" $0.00 $0.00 $290.23 $0.00 $0.00 $295.23 $0.00 $0.00 $0.00 $0.00 $0.00 442.483 SUP HCPCS C1713 442.483 - PLATE BN TI RDS LT DIST VOLR BOTH IP/OP "$1,530.63 " "$1,132.67" $0.00 "$1,224.50" $688.78 $688.78 $0.00 $0.00 $0.00 $319.02 "$1,136.03" "$1,136.03" $0.00 $0.00 $318.98 $0.00 $905.36 $905.36 $0.00 $765.31 "$1,212.26" "$1,224.50" $0.00 $0.00 $239.54 $0.00 $0.00 $243.68 $0.00 $0.00 $0.00 $0.00 $0.00 442.49 SUP HCPCS C1713 442.490 - PLATE BONE STR 57MM 6 HOLE LCP TITANIUM DISTAL RAD NONSTRL BOTH IP/OP $851.60 $630.18 $0.00 $681.28 $383.22 $383.22 $0.00 $0.00 $0.00 $177.49 $632.06 $632.06 $0.00 $0.00 $177.47 $0.00 $503.72 $503.72 $0.00 $425.80 $674.47 $681.28 $0.00 $0.00 $129.39 $0.00 $0.00 $135.57 $0.00 $0.00 $0.00 $0.00 $0.00 442.491 SUP HCPCS C1713 442.491 - PLATE BN 43MM LCP 5 HLE/HD 3 HL SHFT TI RDS LT DIST VOLR 2.4 BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $671.25 $671.25 $0.00 $0.00 $0.00 $320.23 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $908.80 $908.80 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $226.65 $0.00 $0.00 $237.47 $0.00 $0.00 $0.00 $0.00 $0.00 442.492 SUP HCPCS C1713 442.492 - PLATE BONE 61MM 5X5 HOLE LCP TITANIUM LEFT DISTAL VOLAR RAD BOTH IP/OP "$1,626.38 " "$1,203.52" $0.00 "$1,263.22" $710.56 $710.56 $0.00 $0.00 $0.00 $338.98 "$1,207.10" "$1,207.10" $0.00 $0.00 $338.94 $0.00 $962.00 $962.00 $0.00 $789.51 "$1,250.59" "$1,263.22" $0.00 $0.00 $239.92 $0.00 $0.00 $251.38 $0.00 $0.00 $0.00 $0.00 $0.00 442.493 SUP HCPCS C1713 442.493 - PLATE BONE 43MM 5 HOLE HEAD 3 HOLE SHAFT LCP TITANIUM RAD BOTH IP/OP "$1,536.43 " "$1,136.96" $0.00 "$1,193.34" $671.25 $671.25 $0.00 $0.00 $0.00 $320.23 "$1,140.33" "$1,140.33" $0.00 $0.00 $320.19 $0.00 $908.80 $908.80 $0.00 $745.84 "$1,181.41" "$1,193.34" $0.00 $0.00 $226.65 $0.00 $0.00 $237.47 $0.00 $0.00 $0.00 $0.00 $0.00 442.494 SUP HCPCS C1713 442.494 - PLATE BONE 61MM 5 HOLE HEAD 5 HOLE SHAFT LCP TITANIUM RAD BOTH IP/OP "$1,626.38 " "$1,203.52" $0.00 "$1,263.22" $710.56 $710.56 $0.00 $0.00 $0.00 $338.98 "$1,207.10" "$1,207.10" $0.00 $0.00 $338.94 $0.00 $962.00 $962.00 $0.00 $789.51 "$1,250.59" "$1,263.22" $0.00 $0.00 $239.92 $0.00 $0.00 $251.38 $0.00 $0.00 $0.00 $0.00 $0.00 442.5 SUP HCPCS C1713 442.500 - PLATE BONE -90D L 40MM 2X3 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $822.95 $608.98 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $171.52 $610.79 $610.79 $0.00 $0.00 $171.50 $0.00 $486.77 $486.77 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 442.501 SUP HCPCS C1713 442.501 - PLATE BONE -90D L 49MM 2X4 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 442.502 SUP HCPCS C1713 442.502 - PLATE BONE 90D L 40MM 2X3 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 442.503 SUP HCPCS C1713 442.503 - PLATE BONE 90D L 49MM 2X4 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 442.504 SUP HCPCS C1713 442.504 - PLATE BONE 90D L 40MM 3X3 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 442.505 SUP HCPCS C1713 442.505 - PLATE BONE 90D L 49MM 3X4 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 442.506 SUP HCPCS C1713 442.506 - PLATE BONE -90D L 40MM 3X3 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 442.507 SUP HCPCS C1713 442.507 - PLATE BONE -90D L 49MM 3X4 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 442.508 SUP HCPCS C1713 442.508 - PLATE BONE +20D L 43MM 3X3 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 442.509 SUP HCPCS C1713 442.509 - PLATE BONE +20D L 52MM 3X4 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 442.51 SUP HCPCS C1713 442.51 - PLATE BN STD BND NS 8 HL FSN TI WRST 2.7/3.5MM CORT SCR BOTH IP/OP "$1,973.43 " "$1,460.34" $0.00 "$1,578.74" $888.04 $888.04 $0.00 $0.00 $0.00 $411.31 "$1,464.68" "$1,464.68" $0.00 $0.00 $411.26 $0.00 "$1,167.28" "$1,167.28" $0.00 $986.71 "$1,562.96" "$1,578.74" $0.00 $0.00 $299.85 $0.00 $0.00 $314.17 $0.00 $0.00 $0.00 $0.00 $0.00 442.511 SUP HCPCS C1713 442.511 - PLATE BONE -20D L 43MM 3X3 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $847.63 $627.25 $0.00 $658.36 $370.33 $370.33 $0.00 $0.00 $0.00 $176.67 $629.11 $629.11 $0.00 $0.00 $176.65 $0.00 $501.37 $501.37 $0.00 $411.48 $651.78 $658.36 $0.00 $0.00 $125.04 $0.00 $0.00 $131.01 $0.00 $0.00 $0.00 $0.00 $0.00 442.512 SUP HCPCS C1713 442.512 - PLATE BONE -20D L 52MM 3X4 HOLE LCP TITANIUM DISTAL RAD BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 442.52 SUP HCPCS C1713 442.52 - PLATE BN SHRT BND NS 8 HL FSN TI WRST 2.7/3.5MM CORT SCR BOTH IP/OP "$1,973.43 " "$1,460.34" $0.00 "$1,578.74" $888.04 $888.04 $0.00 $0.00 $0.00 $411.31 "$1,464.68" "$1,464.68" $0.00 $0.00 $411.26 $0.00 "$1,167.28" "$1,167.28" $0.00 $986.71 "$1,562.96" "$1,578.74" $0.00 $0.00 $299.85 $0.00 $0.00 $314.17 $0.00 $0.00 $0.00 $0.00 $0.00 442.53 SUP HCPCS C1713 442.53 - PLATE BN STRG NS 9 HL FSN TI WRST 2.7/3.5MM CORT SCR BOTH IP/OP "$1,973.43 " "$1,460.34" $0.00 "$1,578.74" $888.04 $888.04 $0.00 $0.00 $0.00 $411.31 "$1,464.68" "$1,464.68" $0.00 $0.00 $411.26 $0.00 "$1,167.28" "$1,167.28" $0.00 $986.71 "$1,562.96" "$1,578.74" $0.00 $0.00 $299.85 $0.00 $0.00 $314.17 $0.00 $0.00 $0.00 $0.00 $0.00 442.61 SUP HCPCS C1713 442.61 - PLATE BN 57X7X1.5MM NS 7 HL TI CNDRL LT 2.7MM SCR BOTH IP/OP $608.68 $450.42 $0.00 $486.94 $273.90 $273.90 $0.00 $0.00 $0.00 $126.86 $451.76 $451.76 $0.00 $0.00 $126.85 $0.00 $360.03 $360.03 $0.00 $304.34 $482.07 $486.94 $0.00 $0.00 $92.48 $0.00 $0.00 $96.90 $0.00 $0.00 $0.00 $0.00 $0.00 442.62 SUP HCPCS C1713 442.62 - PLATE BN 57X7X1.5MM NS 7 HL TI CNDRL RT 2.7MM SCR BOTH IP/OP $608.68 $450.42 $0.00 $486.94 $273.90 $273.90 $0.00 $0.00 $0.00 $126.86 $451.76 $451.76 $0.00 $0.00 $126.85 $0.00 $360.03 $360.03 $0.00 $304.34 $482.07 $486.94 $0.00 $0.00 $92.48 $0.00 $0.00 $96.90 $0.00 $0.00 $0.00 $0.00 $0.00 443.054 SUP HCPCS C1713 443.054 - PLATE BONE 22X5X1MM 4 HOLE DCP TITANIUM ORTHOPEDIC NONSTRL 2 BOTH IP/OP $408.05 $301.96 $0.00 $326.44 $183.62 $183.62 $0.00 $0.00 $0.00 $85.05 $302.85 $302.85 $0.00 $0.00 $85.04 $0.00 $241.36 $241.36 $0.00 $204.03 $323.18 $326.44 $0.00 $0.00 $62.00 $0.00 $0.00 $64.96 $0.00 $0.00 $0.00 $0.00 $0.00 443.055 SUP HCPCS C1713 443.055 - PLATE BONE 27X5X1MM 5 HOLE DCP TITANIUM ORTHOPEDIC NONSTRL 2 BOTH IP/OP $450.38 $333.28 $0.00 $360.30 $202.67 $202.67 $0.00 $0.00 $0.00 $93.87 $334.27 $334.27 $0.00 $0.00 $93.86 $0.00 $266.40 $266.40 $0.00 $225.19 $356.70 $360.30 $0.00 $0.00 $68.43 $0.00 $0.00 $71.70 $0.00 $0.00 $0.00 $0.00 $0.00 443.056 SUP HCPCS C1713 443.056 - PLATE BONE 32X5X1MM 6 HOLE DCP TITANIUM ORTHOPEDIC NONSTRL 2 BOTH IP/OP $491.30 $363.56 $0.00 $393.04 $221.09 $221.09 $0.00 $0.00 $0.00 $102.40 $364.64 $364.64 $0.00 $0.00 $102.39 $0.00 $290.60 $290.60 $0.00 $245.65 $389.11 $393.04 $0.00 $0.00 $74.65 $0.00 $0.00 $78.21 $0.00 $0.00 $0.00 $0.00 $0.00 443.057 SUP HCPCS C1713 443.057 - PLATE BONE 37X5X1.5MM 7 HOLE DCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $532.25 $393.87 $0.00 $425.80 $239.51 $239.51 $0.00 $0.00 $0.00 $110.93 $395.04 $395.04 $0.00 $0.00 $110.92 $0.00 $314.83 $314.83 $0.00 $266.13 $421.54 $425.80 $0.00 $0.00 $80.87 $0.00 $0.00 $84.73 $0.00 $0.00 $0.00 $0.00 $0.00 443.058 SUP HCPCS C1713 443.058 - PLATE BONE 42X5X1.5MM 8 HOLE DCP TITANIUM ORTHOPEDIC NONSTRL BOTH IP/OP $571.83 $423.15 $0.00 $457.46 $257.32 $257.32 $0.00 $0.00 $0.00 $119.18 $424.41 $424.41 $0.00 $0.00 $119.17 $0.00 $338.23 $338.23 $0.00 $285.91 $452.89 $457.46 $0.00 $0.00 $86.88 $0.00 $0.00 $91.03 $0.00 $0.00 $0.00 $0.00 $0.00 443.178 SUP HCPCS C1713 443.178 - PLATE 31MM TI 2MM SCR 2 BND ARCH BONE SPNL NONSTRL BOTH IP/OP "$1,342.25 " $993.27 $0.00 "$1,073.80" $604.01 $604.01 $0.00 $0.00 $0.00 $279.76 $996.22 $996.22 $0.00 $0.00 $279.72 $0.00 $793.94 $793.94 $0.00 $671.13 "$1,063.06" "$1,073.80" $0.00 $0.00 $210.06 $0.00 $0.00 $213.69 $0.00 $0.00 $0.00 $0.00 $0.00 443.18 SUP HCPCS C1713 443.180 - PLATE MINI 10MM SPC 33MM TI 2MM SCR 2 BND ARCH BONE SPNL BOTH IP/OP "$1,342.25 " $993.27 $0.00 "$1,073.80" $604.01 $604.01 $0.00 $0.00 $0.00 $279.76 $996.22 $996.22 $0.00 $0.00 $279.72 $0.00 $793.94 $793.94 $0.00 $671.13 "$1,063.06" "$1,073.80" $0.00 $0.00 $210.06 $0.00 $0.00 $213.69 $0.00 $0.00 $0.00 $0.00 $0.00 443.182 SUP HCPCS C1713 443.182 - PLATE MINI 12MM SPC 35MM TI 2MM SCR 2 BND ARCH BONE SPNL BOTH IP/OP "$1,342.25 " $993.27 $0.00 "$1,073.80" $604.01 $604.01 $0.00 $0.00 $0.00 $279.76 $996.22 $996.22 $0.00 $0.00 $279.72 $0.00 $793.94 $793.94 $0.00 $671.13 "$1,063.06" "$1,073.80" $0.00 $0.00 $210.06 $0.00 $0.00 $213.69 $0.00 $0.00 $0.00 $0.00 $0.00 443.19 SUP HCPCS C1713 443.19 - PLATE BN STRG 100X5X1MM NS 20 HL TI 2MM SCR BOTH IP/OP $458.55 $339.33 $0.00 $366.84 $206.35 $206.35 $0.00 $0.00 $0.00 $95.57 $340.34 $340.34 $0.00 $0.00 $95.56 $0.00 $271.23 $271.23 $0.00 $229.28 $363.17 $366.84 $0.00 $0.00 $69.67 $0.00 $0.00 $73.00 $0.00 $0.00 $0.00 $0.00 $0.00 443.23 SUP HCPCS C1713 443.23 - PLATE BN T 50X5X1.2MM NS 3 HLE/HD 9 HL SHFT TI 2MM SCR BOTH IP/OP $390.33 $288.84 $0.00 $312.26 $175.65 $175.65 $0.00 $0.00 $0.00 $81.35 $289.70 $289.70 $0.00 $0.00 $81.34 $0.00 $230.88 $230.88 $0.00 $195.16 $309.14 $312.26 $0.00 $0.00 $59.31 $0.00 $0.00 $62.14 $0.00 $0.00 $0.00 $0.00 $0.00 443.24 SUP HCPCS C1713 443.24 - PLATE BN T 50X5X1.2MM NS 4 HLE/HD 9 HL SHFT TI 2MM SCR BOTH IP/OP $421.70 $312.06 $0.00 $337.36 $189.77 $189.77 $0.00 $0.00 $0.00 $87.89 $312.99 $312.99 $0.00 $0.00 $87.88 $0.00 $249.44 $249.44 $0.00 $210.85 $333.99 $337.36 $0.00 $0.00 $64.08 $0.00 $0.00 $67.13 $0.00 $0.00 $0.00 $0.00 $0.00 443.44 SUP HCPCS C1713 443.44 - PLATE BN 22X5X.9MM NS DCP 4 HL TI ZYG 2MM CORT SCR BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 443.45 SUP HCPCS C1713 443.45 - PLATE BN 27X5X.9MM NS DCP 5 HL TI ZYG 2MM SCR BOTH IP/OP $578.25 $427.91 $0.00 $462.60 $260.21 $260.21 $0.00 $0.00 $0.00 $120.52 $429.18 $429.18 $0.00 $0.00 $120.51 $0.00 $342.03 $342.03 $0.00 $289.13 $457.97 $462.60 $0.00 $0.00 $90.50 $0.00 $0.00 $92.06 $0.00 $0.00 $0.00 $0.00 $0.00 443.46 SUP HCPCS C1713 443.46 - PLATE BN 32X5X.9MM NS DCP 6 HL TI ZYG 2MM SCR BOTH IP/OP $621.00 $459.54 $0.00 $496.80 $279.45 $279.45 $0.00 $0.00 $0.00 $129.43 $460.91 $460.91 $0.00 $0.00 $129.42 $0.00 $367.32 $367.32 $0.00 $310.50 $491.83 $496.80 $0.00 $0.00 $97.19 $0.00 $0.00 $98.86 $0.00 $0.00 $0.00 $0.00 $0.00 443.48 SUP HCPCS C1713 443.48 - PLATE BONE H 12X11MM 4 HOLE TITANIUM CONDYLE NONSTRL 2MM BOTH IP/OP $398.50 $294.89 $0.00 $318.80 $179.33 $179.33 $0.00 $0.00 $0.00 $83.06 $295.77 $295.77 $0.00 $0.00 $83.05 $0.00 $235.71 $235.71 $0.00 $199.25 $315.61 $318.80 $0.00 $0.00 $60.55 $0.00 $0.00 $63.44 $0.00 $0.00 $0.00 $0.00 $0.00 443.54 SUP HCPCS C1713 443.54 - PLATE BONE 22MM DCP MINI CRANFCL TI 4 HOLE 2MM SCR NONSTRL BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 443.55 SUP HCPCS C1713 443.55 - PLATE BONE 27MM DCP MINI CRANFCL TI 5 HOLE 2MM SCR NONSTRL BOTH IP/OP $695.25 $514.49 $0.00 $556.20 $312.86 $312.86 $0.00 $0.00 $0.00 $144.91 $516.01 $516.01 $0.00 $0.00 $144.89 $0.00 $411.24 $411.24 $0.00 $347.63 $550.64 $556.20 $0.00 $0.00 $108.81 $0.00 $0.00 $110.68 $0.00 $0.00 $0.00 $0.00 $0.00 443.56 SUP HCPCS C1713 443.56 - PLATE BONE 32MM DCP MINI CRANFCL TI 6 HOLE 2MM SCR NONSTRL BOTH IP/OP $760.50 $562.77 $0.00 $608.40 $342.23 $342.23 $0.00 $0.00 $0.00 $158.51 $564.44 $564.44 $0.00 $0.00 $158.49 $0.00 $449.84 $449.84 $0.00 $380.25 $602.32 $608.40 $0.00 $0.00 $119.02 $0.00 $0.00 $121.07 $0.00 $0.00 $0.00 $0.00 $0.00 443.57 SUP HCPCS C1713 443.57 - PLATE BONE 37MM DCP MINI CRANFCL TI 7 HOLE 2MM SCR NONSTRL BOTH IP/OP $816.75 $604.40 $0.00 $653.40 $367.54 $367.54 $0.00 $0.00 $0.00 $170.23 $606.19 $606.19 $0.00 $0.00 $170.21 $0.00 $483.11 $483.11 $0.00 $408.38 $646.87 $653.40 $0.00 $0.00 $127.82 $0.00 $0.00 $130.03 $0.00 $0.00 $0.00 $0.00 $0.00 443.58 SUP HCPCS C1713 443.58 - PLATE BONE 42MM DCP MINI CRANFCL TI 8 HOLE 2MM SCR NONSTRL BOTH IP/OP $884.25 $654.35 $0.00 $707.40 $397.91 $397.91 $0.00 $0.00 $0.00 $184.30 $656.29 $656.29 $0.00 $0.00 $184.28 $0.00 $523.03 $523.03 $0.00 $442.13 $700.33 $707.40 $0.00 $0.00 $138.39 $0.00 $0.00 $140.77 $0.00 $0.00 $0.00 $0.00 $0.00 443.61 SUP HCPCS C1713 443.61 - PLATE BN 39X5X1.2MM NS 7 HL TI CNDRL LT 2MM SCR BOTH IP/OP $551.35 $408.00 $0.00 $441.08 $248.11 $248.11 $0.00 $0.00 $0.00 $114.92 $409.21 $409.21 $0.00 $0.00 $114.90 $0.00 $326.12 $326.12 $0.00 $275.68 $436.67 $441.08 $0.00 $0.00 $83.77 $0.00 $0.00 $87.77 $0.00 $0.00 $0.00 $0.00 $0.00 443.62 SUP HCPCS C1713 443.62 - PLATE BN 39X5X1.2MM NS 7 HL TI CNDRL RT 2MM SCR BOTH IP/OP $551.35 $408.00 $0.00 $441.08 $248.11 $248.11 $0.00 $0.00 $0.00 $114.92 $409.21 $409.21 $0.00 $0.00 $114.90 $0.00 $326.12 $326.12 $0.00 $275.68 $436.67 $441.08 $0.00 $0.00 $83.77 $0.00 $0.00 $87.77 $0.00 $0.00 $0.00 $0.00 $0.00 444.002 SUP HCPCS C1713 444.002 - PLATE BONE 2.7MM 20X8X2MM 2 HOLE DCP TITANIUM FT NONSTRL 2.7 BOTH IP/OP $474.35 $351.02 $0.00 $379.48 $213.46 $213.46 $0.00 $0.00 $0.00 $98.87 $352.06 $352.06 $0.00 $0.00 $98.85 $0.00 $280.58 $280.58 $0.00 $237.18 $375.69 $379.48 $0.00 $0.00 $74.24 $0.00 $0.00 $75.52 $0.00 $0.00 $0.00 $0.00 $0.00 444.004 SUP HCPCS C1713 444.004 - PLATE BONE 36X8X2MM 4 HOLE DCP TITANIUM FT NONSTRL 2.7MM BOTH IP/OP $593.60 $439.26 $0.00 $474.88 $267.12 $267.12 $0.00 $0.00 $0.00 $123.72 $440.57 $440.57 $0.00 $0.00 $123.71 $0.00 $351.11 $351.11 $0.00 $296.80 $470.13 $474.88 $0.00 $0.00 $92.90 $0.00 $0.00 $94.50 $0.00 $0.00 $0.00 $0.00 $0.00 444.005 SUP HCPCS C1713 444.005 - PLATE BONE 44X8X2MM 5 HOLE DCP TITANIUM FT NONSTRL 2.7MM BOTH IP/OP $669.13 $495.16 $0.00 $535.30 $301.11 $301.11 $0.00 $0.00 $0.00 $139.46 $496.62 $496.62 $0.00 $0.00 $139.45 $0.00 $395.79 $395.79 $0.00 $334.56 $529.95 $535.30 $0.00 $0.00 $104.72 $0.00 $0.00 $106.52 $0.00 $0.00 $0.00 $0.00 $0.00 444.006 SUP HCPCS C1713 444.006 - PLATE BONE 2.7MM 52X8X2MM 6 HOLE DCP TITANIUM FT NONSTRL 2.7 BOTH IP/OP $716.83 $530.45 $0.00 $573.46 $322.57 $322.57 $0.00 $0.00 $0.00 $149.40 $532.03 $532.03 $0.00 $0.00 $149.39 $0.00 $424.00 $424.00 $0.00 $358.41 $567.73 $573.46 $0.00 $0.00 $112.18 $0.00 $0.00 $114.12 $0.00 $0.00 $0.00 $0.00 $0.00 444.007 SUP HCPCS C1713 444.007 - PLATE BONE 60X8X2.5MM 7 HOLE DCP TITANIUM FT NONSTRL 2.7MM BOTH IP/OP $797.65 $590.26 $0.00 $638.12 $358.94 $358.94 $0.00 $0.00 $0.00 $166.25 $592.02 $592.02 $0.00 $0.00 $166.23 $0.00 $471.81 $471.81 $0.00 $398.83 $631.74 $638.12 $0.00 $0.00 $124.83 $0.00 $0.00 $126.99 $0.00 $0.00 $0.00 $0.00 $0.00 444.008 SUP HCPCS C1713 444.008 - PLATE BONE 68X8X2.5MM 8 HOLE DCP TITANIUM FT NONSTRL 2.7MM BOTH IP/OP $836.08 $618.70 $0.00 $668.86 $376.23 $376.23 $0.00 $0.00 $0.00 $174.26 $620.53 $620.53 $0.00 $0.00 $174.24 $0.00 $494.54 $494.54 $0.00 $418.04 $662.18 $668.86 $0.00 $0.00 $130.85 $0.00 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 444.009 SUP HCPCS C1713 444.009 - PLATE BONE 2.7MM 76X8X2.5MM 9 HOLE DCP TITANIUM FT NONSTRL BOTH IP/OP $910.28 $673.61 $0.00 $728.22 $409.62 $409.62 $0.00 $0.00 $0.00 $189.72 $675.61 $675.61 $0.00 $0.00 $189.70 $0.00 $538.43 $538.43 $0.00 $455.14 $720.94 $728.22 $0.00 $0.00 $142.46 $0.00 $0.00 $144.92 $0.00 $0.00 $0.00 $0.00 $0.00 444.01 SUP HCPCS C1713 444.010 - PLATE BONE 2.7MM 84X8X2.5MM 10 HOLE DCP TITANIUM FT NONSTRL BOTH IP/OP $985.80 $729.49 $0.00 $788.64 $443.61 $443.61 $0.00 $0.00 $0.00 $205.47 $731.66 $731.66 $0.00 $0.00 $205.44 $0.00 $583.10 $583.10 $0.00 $492.90 $780.75 $788.64 $0.00 $0.00 $154.28 $0.00 $0.00 $156.94 $0.00 $0.00 $0.00 $0.00 $0.00 444.012 SUP HCPCS C1713 444.012 - PLATE BONE 2.7MM 100X8X2.5MM 12 HOLE DCP TITANIUM FT NONSTRL BOTH IP/OP "$1,094.45 " $809.89 $0.00 $875.56 $492.50 $492.50 $0.00 $0.00 $0.00 $228.11 $812.30 $812.30 $0.00 $0.00 $228.08 $0.00 $647.37 $647.37 $0.00 $547.23 $866.80 $875.56 $0.00 $0.00 $171.28 $0.00 $0.00 $174.24 $0.00 $0.00 $0.00 $0.00 $0.00 444.022 SUP HCPCS C1713 444.022 - PLATE BONE 1.5MM 26X8X2.5MM 2 HOLE DCP TITANIUM FT NONSTRL BOTH IP/OP $494.23 $365.73 $0.00 $395.38 $222.40 $222.40 $0.00 $0.00 $0.00 $103.01 $366.81 $366.81 $0.00 $0.00 $103.00 $0.00 $292.33 $292.33 $0.00 $247.11 $391.43 $395.38 $0.00 $0.00 $77.35 $0.00 $0.00 $78.68 $0.00 $0.00 $0.00 $0.00 $0.00 445 SUP HCPCS C1713 445.00 - PLATE BONE 3.5MM 118MM 10 HOLE RECONSTRUCTION LC-DCP BOTH IP/OP $941.68 $696.84 $0.00 $753.34 $423.75 $423.75 $0.00 $0.00 $0.00 $196.27 $698.91 $698.91 $0.00 $0.00 $196.25 $0.00 $557.00 $557.00 $0.00 $470.84 $745.81 $753.34 $0.00 $0.00 $143.08 $0.00 $0.00 $149.91 $0.00 $0.00 $0.00 $0.00 $0.00 445.01 SUP HCPCS C1713 445.01 - PLATE BN 130MM NS 11 HL RECON TI 3.5MM SCR BOTH IP/OP $962.15 $711.99 $0.00 $769.72 $432.97 $432.97 $0.00 $0.00 $0.00 $200.54 $714.11 $714.11 $0.00 $0.00 $200.51 $0.00 $569.11 $569.11 $0.00 $481.08 $762.02 $769.72 $0.00 $0.00 $146.19 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $0.00 445.041 SUP HCPCS C1713 445.041 - PLATE BONE 56MM 4 HOLE RECONSTRUCTION LCP TITANIUM BOTH IP/OP $818.13 $605.42 $0.00 $635.42 $357.42 $357.42 $0.00 $0.00 $0.00 $170.52 $607.21 $607.21 $0.00 $0.00 $170.50 $0.00 $483.92 $483.92 $0.00 $397.14 $629.07 $635.42 $0.00 $0.00 $120.68 $0.00 $0.00 $126.45 $0.00 $0.00 $0.00 $0.00 $0.00 445.051 SUP HCPCS C1713 445.051 - PLATE BN 70X10.1X3.5MM NS LCP CMBN 5 HL RECON TI 3.5MM SCR BOTH IP/OP $823.73 $609.56 $0.00 $639.80 $359.89 $359.89 $0.00 $0.00 $0.00 $171.68 $611.37 $611.37 $0.00 $0.00 $171.66 $0.00 $487.23 $487.23 $0.00 $399.88 $633.40 $639.80 $0.00 $0.00 $121.51 $0.00 $0.00 $127.32 $0.00 $0.00 $0.00 $0.00 $0.00 445.061 SUP HCPCS C1713 445.061 - PLATE BN 84X10.1X3.5MM NS LCP CMBN 6 HL RECON TI 3.5MM SCR BOTH IP/OP $953.05 $705.26 $0.00 $740.24 $416.39 $416.39 $0.00 $0.00 $0.00 $198.64 $707.35 $707.35 $0.00 $0.00 $198.62 $0.00 $563.73 $563.73 $0.00 $462.65 $732.84 $740.24 $0.00 $0.00 $140.59 $0.00 $0.00 $147.31 $0.00 $0.00 $0.00 $0.00 $0.00 445.071 SUP HCPCS C1713 445.071 - PLATE BONE 98X10.1X3.5MM 7 HOLE LCP TITANIUM CLAVICLE BOTH IP/OP "$1,002.25 " $741.67 $0.00 $778.46 $437.88 $437.88 $0.00 $0.00 $0.00 $208.89 $743.87 $743.87 $0.00 $0.00 $208.87 $0.00 $592.83 $592.83 $0.00 $486.54 $770.68 $778.46 $0.00 $0.00 $147.85 $0.00 $0.00 $154.91 $0.00 $0.00 $0.00 $0.00 $0.00 445.081 SUP HCPCS C1713 445.081 - PLATE BN 112X10.1X3.5MM NS LCP CMBN 8 HL RECON TI 3.5MM SCR BOTH IP/OP "$1,045.83 " $773.91 $0.00 $812.30 $456.92 $456.92 $0.00 $0.00 $0.00 $217.98 $776.21 $776.21 $0.00 $0.00 $217.95 $0.00 $618.61 $618.61 $0.00 $507.69 $804.18 $812.30 $0.00 $0.00 $154.28 $0.00 $0.00 $161.65 $0.00 $0.00 $0.00 $0.00 $0.00 445.091 SUP HCPCS C1713 445.091 - PLATE BONE 126MM 9 HOLE RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,100.65 " $814.48 $0.00 $854.88 $480.87 $480.87 $0.00 $0.00 $0.00 $229.40 $816.90 $816.90 $0.00 $0.00 $229.38 $0.00 $651.03 $651.03 $0.00 $534.30 $846.33 $854.88 $0.00 $0.00 $162.36 $0.00 $0.00 $170.12 $0.00 $0.00 $0.00 $0.00 $0.00 445.101 SUP HCPCS C1713 445.101 - PLATE BONE 140X10.1X3.5MM 10 HOLE LCP TITANIUM CLAVICLE BOTH IP/OP "$1,082.38 " $800.96 $0.00 $840.68 $472.88 $472.88 $0.00 $0.00 $0.00 $225.59 $803.34 $803.34 $0.00 $0.00 $225.57 $0.00 $640.22 $640.22 $0.00 $525.43 $832.27 $840.68 $0.00 $0.00 $159.67 $0.00 $0.00 $167.30 $0.00 $0.00 $0.00 $0.00 $0.00 445.111 SUP HCPCS C1713 445.111 - PLATE BONE 154MM 11 HOLE RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,172.35 " $867.54 $0.00 $910.56 $512.19 $512.19 $0.00 $0.00 $0.00 $244.35 $870.12 $870.12 $0.00 $0.00 $244.32 $0.00 $693.45 $693.45 $0.00 $569.10 $901.45 $910.56 $0.00 $0.00 $172.94 $0.00 $0.00 $181.20 $0.00 $0.00 $0.00 $0.00 $0.00 445.121 SUP HCPCS C1713 445.121 - PLATE BONE 168X10.1X3.5MM 12 HOLE LCP TITANIUM CLAVICLE BOTH IP/OP "$1,176.58 " $870.67 $0.00 $913.84 $514.04 $514.04 $0.00 $0.00 $0.00 $245.23 $873.25 $873.25 $0.00 $0.00 $245.20 $0.00 $695.94 $695.94 $0.00 $571.15 $904.70 $913.84 $0.00 $0.00 $173.56 $0.00 $0.00 $181.85 $0.00 $0.00 $0.00 $0.00 $0.00 445.131 SUP HCPCS C1713 445.131 - PLATE BONE 182MM 13 HOLE RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,273.55 " $942.43 $0.00 $989.18 $556.41 $556.41 $0.00 $0.00 $0.00 $265.44 $945.23 $945.23 $0.00 $0.00 $265.41 $0.00 $753.30 $753.30 $0.00 $618.24 $979.29 $989.18 $0.00 $0.00 $187.87 $0.00 $0.00 $196.85 $0.00 $0.00 $0.00 $0.00 $0.00 445.141 SUP HCPCS C1713 445.141 - PLATE BONE 196MM 14 HOLE RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,322.75 " $978.84 $0.00 "$1,027.38" $577.90 $577.90 $0.00 $0.00 $0.00 $275.69 $981.75 $981.75 $0.00 $0.00 $275.66 $0.00 $782.41 $782.41 $0.00 $642.11 "$1,017.11" "$1,027.38" $0.00 $0.00 $195.13 $0.00 $0.00 $204.45 $0.00 $0.00 $0.00 $0.00 $0.00 445.15 SUP HCPCS C1713 445.15 - PLATE BONE 58MM 5 HOLE RECONSTRUCTION LC-DCP TITANIUM BOTH IP/OP $716.50 $530.21 $0.00 $573.20 $322.43 $322.43 $0.00 $0.00 $0.00 $149.34 $531.79 $531.79 $0.00 $0.00 $149.32 $0.00 $423.81 $423.81 $0.00 $358.25 $567.47 $573.20 $0.00 $0.00 $108.87 $0.00 $0.00 $114.07 $0.00 $0.00 $0.00 $0.00 $0.00 445.16 SUP HCPCS C1713 445.16 - PLATE BONE 70MM 6 HOLE RECONSTRUCTION LC-DCP TITANIUM BOTH IP/OP $825.68 $611.00 $0.00 $660.54 $371.55 $371.55 $0.00 $0.00 $0.00 $172.09 $612.82 $612.82 $0.00 $0.00 $172.07 $0.00 $488.39 $488.39 $0.00 $412.84 $653.94 $660.54 $0.00 $0.00 $125.45 $0.00 $0.00 $131.45 $0.00 $0.00 $0.00 $0.00 $0.00 445.161 SUP HCPCS C1713 445.161 - PLATE BONE 224MM 16 HOLE RECONSTRUCTION LCP TITANIUM BOTH IP/OP "$1,433.80 " "$1,061.01" $0.00 "$1,113.64" $626.42 $626.42 $0.00 $0.00 $0.00 $298.84 "$1,064.17" "$1,064.17" $0.00 $0.00 $298.80 $0.00 $848.09 $848.09 $0.00 $696.03 "$1,102.50" "$1,113.64" $0.00 $0.00 $211.51 $0.00 $0.00 $221.61 $0.00 $0.00 $0.00 $0.00 $0.00 445.17 SUP HCPCS C1713 445.17 - PLATE BONE 82MM 7 HOLE RECONSTRUCTION LC-DCP TITANIUM BOTH IP/OP $848.88 $628.17 $0.00 $679.10 $381.99 $381.99 $0.00 $0.00 $0.00 $176.93 $630.04 $630.04 $0.00 $0.00 $176.91 $0.00 $502.11 $502.11 $0.00 $424.44 $672.31 $679.10 $0.00 $0.00 $128.98 $0.00 $0.00 $135.14 $0.00 $0.00 $0.00 $0.00 $0.00 445.18 SUP HCPCS C1713 445.18 - PLATE BONE 94MM 8 HOLE RECONSTRUCTION LC-DCP TITANIUM BOTH IP/OP $899.38 $665.54 $0.00 $719.50 $404.72 $404.72 $0.00 $0.00 $0.00 $187.45 $667.52 $667.52 $0.00 $0.00 $187.43 $0.00 $531.98 $531.98 $0.00 $449.69 $712.31 $719.50 $0.00 $0.00 $136.65 $0.00 $0.00 $143.18 $0.00 $0.00 $0.00 $0.00 $0.00 445.181 SUP HCPCS C1713 445.181 - PLATE BN 252X10.1X3.5MM NS LCP CMBN 18 HL RECON TI 3.5MM SCR BOTH IP/OP "$1,501.28 " "$1,110.95" $0.00 "$1,166.04" $655.90 $655.90 $0.00 $0.00 $0.00 $312.90 "$1,114.25" "$1,114.25" $0.00 $0.00 $312.87 $0.00 $888.00 $888.00 $0.00 $728.78 "$1,154.38" "$1,166.04" $0.00 $0.00 $221.46 $0.00 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 445.19 SUP HCPCS C1713 445.19 - PLATE BONE 106MM 9 HOLE RECONSTRUCTION LC-DCP TITANIUM BOTH IP/OP $926.68 $685.74 $0.00 $741.34 $417.00 $417.00 $0.00 $0.00 $0.00 $193.14 $687.78 $687.78 $0.00 $0.00 $193.12 $0.00 $548.13 $548.13 $0.00 $463.34 $733.93 $741.34 $0.00 $0.00 $140.80 $0.00 $0.00 $147.53 $0.00 $0.00 $0.00 $0.00 $0.00 445.201 SUP HCPCS C1713 445.201 - PLATE BN 280X10.1X3.5MM NS LCP CMBN 20 HL RECON TI 3.5MM SCR BOTH IP/OP "$1,823.18 " "$1,349.15" $0.00 "$1,416.06" $796.53 $796.53 $0.00 $0.00 $0.00 $380.00 "$1,353.16" "$1,353.16" $0.00 $0.00 $379.95 $0.00 "$1,078.41" "$1,078.41" $0.00 $885.04 "$1,401.90" "$1,416.06" $0.00 $0.00 $268.95 $0.00 $0.00 $281.80 $0.00 $0.00 $0.00 $0.00 $0.00 445.221 SUP HCPCS C1713 445.221 - PLATE BONE 308MM 22 HOLE RECONSTRUCTION LCP TITANIUM NONSTRL BOTH IP/OP "$1,858.33 " "$1,375.16" $0.00 "$1,443.36" $811.89 $811.89 $0.00 $0.00 $0.00 $387.32 "$1,379.25" "$1,379.25" $0.00 $0.00 $387.27 $0.00 "$1,099.20" "$1,099.20" $0.00 $902.10 "$1,428.93" "$1,443.36" $0.00 $0.00 $274.13 $0.00 $0.00 $287.23 $0.00 $0.00 $0.00 $0.00 $0.00 446.014 SUP HCPCS C1713 446.014 - PLATE BN RECT 45X38X.4MM NS CNTR MESH MLBL TI CRNFCL 1.5MM BOTH IP/OP "$3,413.25 " "$2,525.81" $0.00 "$2,730.60" "$1,535.96" "$1,535.96" $0.00 $0.00 $0.00 $711.41 "$2,533.31" "$2,533.31" $0.00 $0.00 $711.32 $0.00 "$1,682.73" "$1,682.73" $0.00 "$1,706.63" "$2,703.29" "$2,730.60" $0.00 $0.00 $534.17 $0.00 $0.00 $543.39 $0.00 $0.00 $0.00 $0.00 $0.00 446.015 SUP HCPCS C1713 446.015 - PLATE BN RECT 45X38X.6MM NS CNTR MESH RGD TI CRNFCL 1.5MM BOTH IP/OP "$3,413.25 " "$2,525.81" $0.00 "$2,730.60" "$1,535.96" "$1,535.96" $0.00 $0.00 $0.00 $711.41 "$2,533.31" "$2,533.31" $0.00 $0.00 $711.32 $0.00 "$1,682.73" "$1,682.73" $0.00 "$1,706.63" "$2,703.29" "$2,730.60" $0.00 $0.00 $534.17 $0.00 $0.00 $543.39 $0.00 $0.00 $0.00 $0.00 $0.00 446.017 SUP HCPCS C1713 446.017 - PLATE BN RECT 100X100X.3MM NS CNTR MESH MLBL TI CRNFCL 1.5MM BOTH IP/OP "$5,334.75 " "$3,947.72" $0.00 "$4,267.80" "$2,400.64" "$2,400.64" $0.00 $0.00 $0.00 "$1,111.90" "$3,959.45" "$3,959.45" $0.00 $0.00 "$1,111.76" $0.00 "$2,630.03" "$2,630.03" $0.00 "$2,667.38" "$4,225.12" "$4,267.80" $0.00 $0.00 $834.89 $0.00 $0.00 $849.29 $0.00 $0.00 $0.00 $0.00 $0.00 446.018 SUP HCPCS C1713 446.018 - PLATE BN RECT 100X100X.6MM NS CNTR MESH RGD TI CRNFCL 1.5MM BOTH IP/OP "$5,334.75 " "$3,947.72" $0.00 "$4,267.80" "$2,400.64" "$2,400.64" $0.00 $0.00 $0.00 "$1,111.90" "$3,959.45" "$3,959.45" $0.00 $0.00 "$1,111.76" $0.00 "$2,630.03" "$2,630.03" $0.00 "$2,667.38" "$4,225.12" "$4,267.80" $0.00 $0.00 $834.89 $0.00 $0.00 $849.29 $0.00 $0.00 $0.00 $0.00 $0.00 446.019 SUP HCPCS C1713 446.019 - PLATE BONE NONSTRL GOLD 200X200MM CRANFCL TI CONTUR MESH RGD BOTH IP/OP "$19,163.25 " "$14,180.81" $0.00 "$15,330.60" "$8,623.46" "$8,623.46" $0.00 $0.00 $0.00 "$3,994.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,993.62" $0.00 "$9,447.48" "$9,447.48" $0.00 "$9,581.63" "$15,177.29" "$15,330.60" $0.00 $0.00 "$2,999.05" $0.00 $0.00 "$3,050.79" $0.00 $0.00 $0.00 $0.00 $0.00 446.02 SUP HCPCS C1713 446.020 - PLATE BONE CRANIAL TI 2 HOLE STR 1.5 MM SCR NONSTRL BOTH IP/OP $105.75 $78.26 $0.00 $84.60 $47.59 $47.59 $0.00 $0.00 $0.00 $22.04 $78.49 $78.49 $0.00 $0.00 $22.04 $0.00 $62.55 $62.55 $0.00 $52.88 $83.75 $84.60 $0.00 $0.00 $16.55 $0.00 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $0.00 446.024 SUP HCPCS C1713 446.024 - PLATE BONE 25MM CRANFCL TI 4 HOLE STR LP 1.5MM SCR NONSTRL BOTH IP/OP $144.00 $106.56 $0.00 $115.20 $64.80 $64.80 $0.00 $0.00 $0.00 $30.01 $106.88 $106.88 $0.00 $0.00 $30.01 $0.00 $85.18 $85.18 $0.00 $72.00 $114.05 $115.20 $0.00 $0.00 $22.54 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $0.00 446.031 SUP HCPCS C1713 446.031 - PLATE BN STRG 29X3.8X.8MM NS PRO-PK 6 HL LOPRFL PRECONTOUR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 446.032 SUP HCPCS C1713 446.032 - PLATE BN STRG 59X3.8X.8MM NS PRO-PK 12 HL LOPRFL PRECONTOUR BOTH IP/OP $465.28 $344.31 $0.00 $361.38 $203.28 $203.28 $0.00 $0.00 $0.00 $96.97 $345.33 $345.33 $0.00 $0.00 $96.96 $0.00 $275.21 $275.21 $0.00 $225.86 $357.77 $361.38 $0.00 $0.00 $68.64 $0.00 $0.00 $71.91 $0.00 $0.00 $0.00 $0.00 $0.00 446.033 SUP HCPCS C1713 446.033 - PLATE BONE NONSTRL TEAL CRANFCL TI CONTUR MESH MALBLE SM ARC BOTH IP/OP "$1,768.50 " "$1,308.69" $0.00 "$1,414.80" $795.83 $795.83 $0.00 $0.00 $0.00 $368.60 "$1,312.58" "$1,312.58" $0.00 $0.00 $368.56 $0.00 "$1,046.07" "$1,046.07" $0.00 $884.25 "$1,400.65" "$1,414.80" $0.00 $0.00 $276.77 $0.00 $0.00 $281.55 $0.00 $0.00 $0.00 $0.00 $0.00 446.034 SUP HCPCS C1713 446.034 - PLATE BONE NONSTRL TEAL CRANFCL TI CONTUR MESH MALBLE LG ARC BOTH IP/OP "$2,754.00 " "$2,037.96" $0.00 "$2,203.20" "$1,239.30" "$1,239.30" $0.00 $0.00 $0.00 $574.00 "$2,044.02" "$2,044.02" $0.00 $0.00 $573.93 $0.00 "$1,357.72" "$1,357.72" $0.00 "$1,377.00" "$2,181.17" "$2,203.20" $0.00 $0.00 $431.00 $0.00 $0.00 $438.44 $0.00 $0.00 $0.00 $0.00 $0.00 446.035 SUP HCPCS C1713 446.035 - PLATE BONE 1.5MM SCR GOLD CRANFCL TI CONTUR MESH RGD SM ARC BOTH IP/OP "$1,768.50 " "$1,308.69" $0.00 "$1,414.80" $795.83 $795.83 $0.00 $0.00 $0.00 $368.60 "$1,312.58" "$1,312.58" $0.00 $0.00 $368.56 $0.00 "$1,046.07" "$1,046.07" $0.00 $884.25 "$1,400.65" "$1,414.80" $0.00 $0.00 $276.77 $0.00 $0.00 $281.55 $0.00 $0.00 $0.00 $0.00 $0.00 446.036 SUP HCPCS C1713 446.036 - PLATE BONE 1.5MM SCR GOLD CRANFCL TI CONTUR MESH RGD LG ARC BOTH IP/OP "$2,754.00 " "$2,037.96" $0.00 "$2,203.20" "$1,239.30" "$1,239.30" $0.00 $0.00 $0.00 $574.00 "$2,044.02" "$2,044.02" $0.00 $0.00 $573.93 $0.00 "$1,357.72" "$1,357.72" $0.00 "$1,377.00" "$2,181.17" "$2,203.20" $0.00 $0.00 $431.00 $0.00 $0.00 $438.44 $0.00 $0.00 $0.00 $0.00 $0.00 446.04 SUP HCPCS C1713 446.040 - PLATE 0MM RIGHT MAXL PREBNT OFFST ORTHGNAT 1.5MM SCR BONE TI BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.041 SUP HCPCS C1713 446.041 - PLATE LEFT MAXL PREBNT 1.5MM SCR BONE TI 0MM NONSTRL BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.042 SUP HCPCS C1713 446.042 - PLATE BN 3MM PREBNT 27.1X.9MM NS TI MXL RT 1.5MM CORT SCR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.043 SUP HCPCS C1713 446.043 - PLATE BN 3MM PREBNT 27.1X.9MM NS TI MXL LT 1.5MM CORT SCR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.044 SUP HCPCS C1713 446.044 - PLATE BN 5MM PREBNT 27.1X.9MM NS TI MXL RT 1.5MM CORT SCR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.045 SUP HCPCS C1713 446.045 - PLATE BN 5MM PREBNT 27.1X.9MM NS TI MXL LT 1.5MM CORT SCR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.046 SUP HCPCS C1713 446.046 - PLATE BN 7MM PREBNT 27.1X.9MM NS TI MXL RT 1.5MM CORT SCR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.047 SUP HCPCS C1713 446.047 - PLATE LEFT MAXL PREBNT 1.5MM SCR BONE TI 7MM NONSTRL BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.048 SUP HCPCS C1713 446.048 - PLATE BN 9MM PREBNT 27.1X.9MM NS TI MXL RT 1.5MM CORT SCR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.049 SUP HCPCS C1713 446.049 - PLATE BN 9MM PREBNT 27.1X.9MM NS TI MXL LT 1.5MM CORT SCR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.05 SUP HCPCS C1713 446.050 - PLATE BONE CONTUR MESH MALBLE 1.5MM SCR TEAL 30MM CRANFCL TI BOTH IP/OP "$1,768.50 " "$1,308.69" $0.00 "$1,414.80" $795.83 $795.83 $0.00 $0.00 $0.00 $368.60 "$1,312.58" "$1,312.58" $0.00 $0.00 $368.56 $0.00 "$1,046.07" "$1,046.07" $0.00 $884.25 "$1,400.65" "$1,414.80" $0.00 $0.00 $276.77 $0.00 $0.00 $281.55 $0.00 $0.00 $0.00 $0.00 $0.00 446.051 SUP HCPCS C1713 446.051 - PLATE BONE CONTUR MESH MALBLE 1.5MM SCR TEAL 70MM CRANFCL TI BOTH IP/OP "$3,665.25 " "$2,712.29" $0.00 "$2,932.20" "$1,649.36" "$1,649.36" $0.00 $0.00 $0.00 $763.93 "$2,720.35" "$2,720.35" $0.00 $0.00 $763.84 $0.00 "$1,806.97" "$1,806.97" $0.00 "$1,832.63" "$2,902.88" "$2,932.20" $0.00 $0.00 $573.61 $0.00 $0.00 $583.51 $0.00 $0.00 $0.00 $0.00 $0.00 446.052 SUP HCPCS C1713 446.052 - PLATE BONE CONTUR MESH MALBLE 1.5MM SCR TEAL 100MM CRANFCL BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 446.053 SUP HCPCS C1713 446.053 - PLATE BONE NONSTRL GOLD 30MM CRANFCL TI CONTUR MESH RGD 1.5 BOTH IP/OP "$1,966.50 " "$1,455.21" $0.00 "$1,573.20" $884.93 $884.93 $0.00 $0.00 $0.00 $409.87 "$1,459.54" "$1,459.54" $0.00 $0.00 $409.82 $0.00 "$1,163.18" "$1,163.18" $0.00 $983.25 "$1,557.47" "$1,573.20" $0.00 $0.00 $307.76 $0.00 $0.00 $313.07 $0.00 $0.00 $0.00 $0.00 $0.00 446.054 SUP HCPCS C1713 446.054 - PLATE BONE NONSTRL GOLD 70MM CRANFCL TI CONTUR MESH RGD 1.5 BOTH IP/OP "$4,070.25 " "$3,011.99" $0.00 "$3,256.20" "$1,831.61" "$1,831.61" $0.00 $0.00 $0.00 $848.34 "$3,020.94" "$3,020.94" $0.00 $0.00 $848.24 $0.00 "$2,006.63" "$2,006.63" $0.00 "$2,035.13" "$3,223.64" "$3,256.20" $0.00 $0.00 $636.99 $0.00 $0.00 $647.98 $0.00 $0.00 $0.00 $0.00 $0.00 446.055 SUP HCPCS C1713 446.055 - PLATE BONE NONSTRL GOLD 100MM CRANFCL TI CONTUR MESH RGD 1.5 BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 446.06 SUP HCPCS C1713 446.060 - PLATE 11MM ADV RIGHT MAXL PREBNT 1.5MM SCR BONE TI NONSTRL BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.061 SUP HCPCS C1713 446.061 - PLATE LEFT MAXL PREBNT 1.5MM SCR BONE TI 11MM NONSTRL BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.09 SUP HCPCS C1713 446.090 - PLATE MANDIB 4X7 HOLE T 1.5 MM SCR BONE TI NONSTRL BOTH IP/OP $625.50 $462.87 $0.00 $500.40 $281.48 $281.48 $0.00 $0.00 $0.00 $130.37 $464.25 $464.25 $0.00 $0.00 $130.35 $0.00 $369.98 $369.98 $0.00 $312.75 $495.40 $500.40 $0.00 $0.00 $97.89 $0.00 $0.00 $99.58 $0.00 $0.00 $0.00 $0.00 $0.00 446.091 SUP HCPCS C1713 446.091 - PLATE MANDIB 4X7 HOLE T MALBLE 1.5 MM SCR BONE TI NONSTRL BOTH IP/OP $553.50 $409.59 $0.00 $442.80 $249.08 $249.08 $0.00 $0.00 $0.00 $115.36 $410.81 $410.81 $0.00 $0.00 $115.35 $0.00 $327.40 $327.40 $0.00 $276.75 $438.37 $442.80 $0.00 $0.00 $86.62 $0.00 $0.00 $88.12 $0.00 $0.00 $0.00 $0.00 $0.00 446.096 SUP HCPCS C1713 446.096 - PLATE BONE 14X14MM CRANFCL TI 4 HOLE BOX 1.5MM SCR NONSTRL BOTH IP/OP $553.50 $409.59 $0.00 $442.80 $249.08 $249.08 $0.00 $0.00 $0.00 $115.36 $410.81 $410.81 $0.00 $0.00 $115.35 $0.00 $327.40 $327.40 $0.00 $276.75 $438.37 $442.80 $0.00 $0.00 $86.62 $0.00 $0.00 $88.12 $0.00 $0.00 $0.00 $0.00 $0.00 446.097 SUP HCPCS C1713 446.097 - PLATE BONE 16X16MM CRANFCL TI 4 HOLE BOX 1.5MM SCR NONSTRL BOTH IP/OP $553.50 $409.59 $0.00 $442.80 $249.08 $249.08 $0.00 $0.00 $0.00 $115.36 $410.81 $410.81 $0.00 $0.00 $115.35 $0.00 $327.40 $327.40 $0.00 $276.75 $438.37 $442.80 $0.00 $0.00 $86.62 $0.00 $0.00 $88.12 $0.00 $0.00 $0.00 $0.00 $0.00 446.1 SUP HCPCS C1713 446.10 - PLATE 4.5MM HOLE SPC 90MM TI 1.5MM SCR 20 HOLE ADP BONE BOTH IP/OP $859.50 $636.03 $0.00 $687.60 $386.78 $386.78 $0.00 $0.00 $0.00 $179.14 $637.92 $637.92 $0.00 $0.00 $179.12 $0.00 $508.39 $508.39 $0.00 $429.75 $680.72 $687.60 $0.00 $0.00 $134.51 $0.00 $0.00 $136.83 $0.00 $0.00 $0.00 $0.00 $0.00 446.101 SUP HCPCS C1713 446.101 - PLATE BONE 90MM CRANFCL TI 20 HOLE ADP LP 1.5MM SCR NONSTRL BOTH IP/OP $819.00 $606.06 $0.00 $655.20 $368.55 $368.55 $0.00 $0.00 $0.00 $170.70 $607.86 $607.86 $0.00 $0.00 $170.68 $0.00 $484.44 $484.44 $0.00 $409.50 $648.65 $655.20 $0.00 $0.00 $128.17 $0.00 $0.00 $130.38 $0.00 $0.00 $0.00 $0.00 $0.00 446.154 SUP HCPCS C1713 446.154 - 1.5MM TI 90Ř L-PLATE 17MM 2X2 HOLES LOW-PROFILE/LEFT BOTH IP/OP $459.00 $339.66 $0.00 $367.20 $206.55 $206.55 $0.00 $0.00 $0.00 $95.67 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $271.50 $271.50 $0.00 $229.50 $363.53 $367.20 $0.00 $0.00 $71.83 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $0.00 446.155 SUP HCPCS C1713 446.155 - 1.5MM TI 90Ř L-PLATE 17MM 2X2 HOLES LOW-PROFILE/RIGHT BOTH IP/OP $459.00 $339.66 $0.00 $367.20 $206.55 $206.55 $0.00 $0.00 $0.00 $95.67 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $271.50 $271.50 $0.00 $229.50 $363.53 $367.20 $0.00 $0.00 $71.83 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $0.00 446.156 SUP HCPCS C1713 446.156 - 1.5MM TI 90Ř L-PLATE 19MM 2X2 HOLES LOW-PROFILE/LEFT BOTH IP/OP $459.00 $339.66 $0.00 $367.20 $206.55 $206.55 $0.00 $0.00 $0.00 $95.67 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $271.50 $271.50 $0.00 $229.50 $363.53 $367.20 $0.00 $0.00 $71.83 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $0.00 446.157 SUP HCPCS C1713 446.157 - 1.5MM TI 90Ř L-PLATE 19MM 2X2 HOLES LOW-PROFILE/RIGHT BOTH IP/OP $459.00 $339.66 $0.00 $367.20 $206.55 $206.55 $0.00 $0.00 $0.00 $95.67 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $271.50 $271.50 $0.00 $229.50 $363.53 $367.20 $0.00 $0.00 $71.83 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $0.00 446.158 SUP HCPCS C1713 446.158 - 1.5MM TI 90Ř L-PLATE 23MM 2X2 HOLES LOW-PROFILE/LEFT BOTH IP/OP $459.00 $339.66 $0.00 $367.20 $206.55 $206.55 $0.00 $0.00 $0.00 $95.67 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $271.50 $271.50 $0.00 $229.50 $363.53 $367.20 $0.00 $0.00 $71.83 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $0.00 446.159 SUP HCPCS C1713 446.159 - 1.5MM TI 90Ř L-PLATE 23MM 2X2 HOLES LOW-PROFILE/RIGHT BOTH IP/OP $459.00 $339.66 $0.00 $367.20 $206.55 $206.55 $0.00 $0.00 $0.00 $95.67 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $271.50 $271.50 $0.00 $229.50 $363.53 $367.20 $0.00 $0.00 $71.83 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $0.00 446.18 SUP HCPCS C1713 446.18 - PLATE BONE ORBTL RIM TI 8 HOLE RGD 1.5 MM SCR NONSTRL BOTH IP/OP $684.00 $506.16 $0.00 $547.20 $307.80 $307.80 $0.00 $0.00 $0.00 $142.56 $507.66 $507.66 $0.00 $0.00 $142.55 $0.00 $404.59 $404.59 $0.00 $342.00 $541.73 $547.20 $0.00 $0.00 $107.05 $0.00 $0.00 $108.89 $0.00 $0.00 $0.00 $0.00 $0.00 446.19 SUP HCPCS C1713 446.19 - PLATE BN STRG 100X3.8X.8MM NS 20 HL TI 1.5MM SCR BOTH IP/OP $451.23 $333.91 $0.00 $350.46 $197.13 $197.13 $0.00 $0.00 $0.00 $94.05 $334.90 $334.90 $0.00 $0.00 $94.04 $0.00 $266.90 $266.90 $0.00 $219.04 $346.96 $350.46 $0.00 $0.00 $66.56 $0.00 $0.00 $69.74 $0.00 $0.00 $0.00 $0.00 $0.00 446.2 SUP HCPCS C1713 446.20 - PLATE BN 41MM NS 10 HL TI ORBT RIM 1.5MM SCR BOTH IP/OP $722.25 $534.47 $0.00 $577.80 $325.01 $325.01 $0.00 $0.00 $0.00 $150.53 $536.05 $536.05 $0.00 $0.00 $150.52 $0.00 $427.21 $427.21 $0.00 $361.13 $572.02 $577.80 $0.00 $0.00 $113.03 $0.00 $0.00 $114.98 $0.00 $0.00 $0.00 $0.00 $0.00 446.22 SUP HCPCS C1713 446.22 - PLATE BN 49MM NS 12 HL TI ORBT RIM 1.5MM SCR BOTH IP/OP $776.25 $574.43 $0.00 $621.00 $349.31 $349.31 $0.00 $0.00 $0.00 $161.79 $576.13 $576.13 $0.00 $0.00 $161.77 $0.00 $459.15 $459.15 $0.00 $388.13 $614.79 $621.00 $0.00 $0.00 $121.48 $0.00 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $0.00 446.23 SUP HCPCS C1713 446.23 - PLATE BONE T 1.5MM 50MM 3X9 HOLE LCP TITANIUM CONDYLE BOTH IP/OP $390.78 $289.18 $0.00 $303.52 $170.73 $170.73 $0.00 $0.00 $0.00 $81.45 $290.03 $290.03 $0.00 $0.00 $81.44 $0.00 $231.14 $231.14 $0.00 $189.70 $300.48 $303.52 $0.00 $0.00 $57.65 $0.00 $0.00 $60.40 $0.00 $0.00 $0.00 $0.00 $0.00 446.233 SUP HCPCS C1713 446.233 - PLATE BN T 44X4X1MM NS PRO-PK 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 446.234 SUP HCPCS C1713 446.234 - PLATE BN T 44X4X1MM NS PRO-PK 4 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 446.24 SUP HCPCS C1713 446.24 - PLATE BN T 50X4X1MM NS 4 HLE/HD 9 HL SHFT TI 1.5MM SCR BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 446.4 SUP HCPCS C1713 446.40 - PLATE BONE UNV ORBTL FLR TI 1.5MM SCR NONSTRL BOTH IP/OP "$2,772.00 " "$2,051.28" $0.00 "$2,217.60" "$1,247.40" "$1,247.40" $0.00 $0.00 $0.00 $577.75 "$2,057.38" "$2,057.38" $0.00 $0.00 $577.68 $0.00 "$1,366.60" "$1,366.60" $0.00 "$1,386.00" "$2,195.42" "$2,217.60" $0.00 $0.00 $433.82 $0.00 $0.00 $441.30 $0.00 $0.00 $0.00 $0.00 $0.00 446.44 SUP HCPCS C1713 446.44 - PLATE BONE LEFT MDL WL CRANFCL TI 1.5 MM SCR NONSTRL BOTH IP/OP "$2,457.00 " "$1,818.18" $0.00 "$1,965.60" "$1,105.65" "$1,105.65" $0.00 $0.00 $0.00 $512.10 "$1,823.59" "$1,823.59" $0.00 $0.00 $512.04 $0.00 "$1,453.32" "$1,453.32" $0.00 "$1,228.50" "$1,945.94" "$1,965.60" $0.00 $0.00 $384.52 $0.00 $0.00 $391.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.45 SUP HCPCS C1713 446.45 - PLATE BONE RIGHT MDL WL CRANFCL TI 1.5 MM SCR NONSTRL BOTH IP/OP "$2,457.00 " "$1,818.18" $0.00 "$1,965.60" "$1,105.65" "$1,105.65" $0.00 $0.00 $0.00 $512.10 "$1,823.59" "$1,823.59" $0.00 $0.00 $512.04 $0.00 "$1,453.32" "$1,453.32" $0.00 "$1,228.50" "$1,945.94" "$1,965.60" $0.00 $0.00 $384.52 $0.00 $0.00 $391.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.48 SUP HCPCS C1713 446.48 - PLATE BONE H 1.5MM 6MM 4 HOLE TITANIUM HAND NONSTRL 1.5MM BOTH IP/OP $399.23 $295.43 $0.00 $310.08 $174.42 $174.42 $0.00 $0.00 $0.00 $83.21 $296.30 $296.30 $0.00 $0.00 $83.20 $0.00 $236.14 $236.14 $0.00 $193.80 $306.98 $310.08 $0.00 $0.00 $58.89 $0.00 $0.00 $61.71 $0.00 $0.00 $0.00 $0.00 $0.00 446.482 SUP HCPCS C1713 446.482 - PLATE BN H 22MM NS PRO-PK 8 HL XTD LOPRFL PRECONTOUR TI RT BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 446.483 SUP HCPCS C1713 446.483 - PLATE BN H 22MM NS PRO-PK 8 HL XTD LOPRFL PRECONTOUR TI LT BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 446.5 SUP HCPCS C1713 446.50 - PLATE BN OB L L NS 2X3 HL RGD TI CRNFCL 1.5MM SCR BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.504 SUP HCPCS C1713 446.504 - PLATE RIGHT MAXL 3X3 HOLE L 1.5MM SCR BONE TI 22MM NONSTRL BOTH IP/OP $596.25 $441.23 $0.00 $477.00 $268.31 $268.31 $0.00 $0.00 $0.00 $124.27 $442.54 $442.54 $0.00 $0.00 $124.26 $0.00 $352.68 $352.68 $0.00 $298.13 $472.23 $477.00 $0.00 $0.00 $93.31 $0.00 $0.00 $94.92 $0.00 $0.00 $0.00 $0.00 $0.00 446.505 SUP HCPCS C1713 446.505 - PLATE LEFT MAXL 3X3 HOLE L 1.5MM SCR BONE TI 22MM NONSTRL BOTH IP/OP $596.25 $441.23 $0.00 $477.00 $268.31 $268.31 $0.00 $0.00 $0.00 $124.27 $442.54 $442.54 $0.00 $0.00 $124.26 $0.00 $352.68 $352.68 $0.00 $298.13 $472.23 $477.00 $0.00 $0.00 $93.31 $0.00 $0.00 $94.92 $0.00 $0.00 $0.00 $0.00 $0.00 446.506 SUP HCPCS C1713 446.506 - PLATE RIGHT MAXL 3X3 HOLE L 1.5MM SCR BONE TI 24MM NONSTRL BOTH IP/OP $596.25 $441.23 $0.00 $477.00 $268.31 $268.31 $0.00 $0.00 $0.00 $124.27 $442.54 $442.54 $0.00 $0.00 $124.26 $0.00 $352.68 $352.68 $0.00 $298.13 $472.23 $477.00 $0.00 $0.00 $93.31 $0.00 $0.00 $94.92 $0.00 $0.00 $0.00 $0.00 $0.00 446.507 SUP HCPCS C1713 446.507 - PLATE LEFT MAXL 3X3 HOLE L 1.5MM SCR BONE TI 24MM NONSTRL BOTH IP/OP $596.25 $441.23 $0.00 $477.00 $268.31 $268.31 $0.00 $0.00 $0.00 $124.27 $442.54 $442.54 $0.00 $0.00 $124.26 $0.00 $352.68 $352.68 $0.00 $298.13 $472.23 $477.00 $0.00 $0.00 $93.31 $0.00 $0.00 $94.92 $0.00 $0.00 $0.00 $0.00 $0.00 446.508 SUP HCPCS C1713 446.508 - PLATE RIGHT MAXL 3X3 HOLE L 1.5MM SCR BONE TI 26MM NONSTRL BOTH IP/OP $596.25 $441.23 $0.00 $477.00 $268.31 $268.31 $0.00 $0.00 $0.00 $124.27 $442.54 $442.54 $0.00 $0.00 $124.26 $0.00 $352.68 $352.68 $0.00 $298.13 $472.23 $477.00 $0.00 $0.00 $93.31 $0.00 $0.00 $94.92 $0.00 $0.00 $0.00 $0.00 $0.00 446.509 SUP HCPCS C1713 446.509 - PLATE LEFT MAXL 3X3 HOLE L 1.5MM SCR BONE TI 26MM NONSTRL BOTH IP/OP $596.25 $441.23 $0.00 $477.00 $268.31 $268.31 $0.00 $0.00 $0.00 $124.27 $442.54 $442.54 $0.00 $0.00 $124.26 $0.00 $352.68 $352.68 $0.00 $298.13 $472.23 $477.00 $0.00 $0.00 $93.31 $0.00 $0.00 $94.92 $0.00 $0.00 $0.00 $0.00 $0.00 446.51 SUP HCPCS C1713 446.51 - PLATE BN OB R L NS 2X3 HL RGD TI CRNFCL 1.5MM SCR BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.515 SUP HCPCS C1713 446.515 - PLATE BONE TEAL 22MM 100D CRANFCL TI 5 HOLE L RIGHT OBLQ BOTH IP/OP $636.75 $471.20 $0.00 $509.40 $286.54 $286.54 $0.00 $0.00 $0.00 $132.71 $472.60 $472.60 $0.00 $0.00 $132.70 $0.00 $376.64 $376.64 $0.00 $318.38 $504.31 $509.40 $0.00 $0.00 $99.65 $0.00 $0.00 $101.37 $0.00 $0.00 $0.00 $0.00 $0.00 446.516 SUP HCPCS C1713 446.516 - PLATE BONE TEAL 22MM 100D CRANFCL TI 5 HOLE L LEFT OBLQ BOTH IP/OP $636.75 $471.20 $0.00 $509.40 $286.54 $286.54 $0.00 $0.00 $0.00 $132.71 $472.60 $472.60 $0.00 $0.00 $132.70 $0.00 $376.64 $376.64 $0.00 $318.38 $504.31 $509.40 $0.00 $0.00 $99.65 $0.00 $0.00 $101.37 $0.00 $0.00 $0.00 $0.00 $0.00 446.52 SUP HCPCS C1713 446.52 - PLATE BN OB L L 3X4 HL TI CRNFCL 1.5MM SCR BOTH IP/OP $652.50 $482.85 $0.00 $522.00 $293.63 $293.63 $0.00 $0.00 $0.00 $136.00 $484.29 $484.29 $0.00 $0.00 $135.98 $0.00 $385.95 $385.95 $0.00 $326.25 $516.78 $522.00 $0.00 $0.00 $102.12 $0.00 $0.00 $103.88 $0.00 $0.00 $0.00 $0.00 $0.00 446.527 SUP HCPCS C1713 446.527 - PLATE BONE TEAL 27MM 100D CRANFCL TI 7 HOLE L LEFT OBLQ BOTH IP/OP $666.00 $492.84 $0.00 $532.80 $299.70 $299.70 $0.00 $0.00 $0.00 $138.81 $494.31 $494.31 $0.00 $0.00 $138.79 $0.00 $393.94 $393.94 $0.00 $333.00 $527.47 $532.80 $0.00 $0.00 $104.23 $0.00 $0.00 $106.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.53 SUP HCPCS C1713 446.53 - PLATE BN OB R L NS 3X4 HL RGD TI CRNFCL 1.5MM SCR BOTH IP/OP $652.50 $482.85 $0.00 $522.00 $293.63 $293.63 $0.00 $0.00 $0.00 $136.00 $484.29 $484.29 $0.00 $0.00 $135.98 $0.00 $385.95 $385.95 $0.00 $326.25 $516.78 $522.00 $0.00 $0.00 $102.12 $0.00 $0.00 $103.88 $0.00 $0.00 $0.00 $0.00 $0.00 446.537 SUP HCPCS C1713 446.537 - PLATE BONE TEAL 27MM 100D CRANFCL TI 7 HOLE L RIGHT OBLQ BOTH IP/OP $666.00 $492.84 $0.00 $532.80 $299.70 $299.70 $0.00 $0.00 $0.00 $138.81 $494.31 $494.31 $0.00 $0.00 $138.79 $0.00 $393.94 $393.94 $0.00 $333.00 $527.47 $532.80 $0.00 $0.00 $104.23 $0.00 $0.00 $106.03 $0.00 $0.00 $0.00 $0.00 $0.00 446.538 SUP HCPCS C1713 446.538 - PLATE BONE TEAL ORBTL RIM TI 8 HOLE MALBLE 1.5MM SCR NONSTRL BOTH IP/OP $607.50 $449.55 $0.00 $486.00 $273.38 $273.38 $0.00 $0.00 $0.00 $126.62 $450.89 $450.89 $0.00 $0.00 $126.60 $0.00 $359.34 $359.34 $0.00 $303.75 $481.14 $486.00 $0.00 $0.00 $95.07 $0.00 $0.00 $96.71 $0.00 $0.00 $0.00 $0.00 $0.00 446.54 SUP HCPCS C1713 446.540 - PLATE BONE TEAL ORBTL RIM TI 10 HOLE MALBLE 1.5MM SCR BOTH IP/OP $641.25 $474.53 $0.00 $513.00 $288.56 $288.56 $0.00 $0.00 $0.00 $133.65 $475.94 $475.94 $0.00 $0.00 $133.64 $0.00 $379.30 $379.30 $0.00 $320.63 $507.87 $513.00 $0.00 $0.00 $100.36 $0.00 $0.00 $102.09 $0.00 $0.00 $0.00 $0.00 $0.00 446.542 SUP HCPCS C1713 446.542 - PLATE BONE TEAL ORBTL RIM TI 12 HOLE MALBLE 1.5MM SCR BOTH IP/OP $690.75 $511.16 $0.00 $552.60 $310.84 $310.84 $0.00 $0.00 $0.00 $143.97 $512.67 $512.67 $0.00 $0.00 $143.95 $0.00 $408.58 $408.58 $0.00 $345.38 $547.07 $552.60 $0.00 $0.00 $108.10 $0.00 $0.00 $109.97 $0.00 $0.00 $0.00 $0.00 $0.00 446.61 SUP HCPCS C1713 446.61 - PLATE BN 36X3.5X.9MM NS 7 HL TI CNDYL LT 1.5MM SCR MDLR HND BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.611 SUP HCPCS C1713 446.611 - PLATE BONE CRANFCL TI 5 HOLE Y LP 1.5 MM SCR NONSTRL BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.612 SUP HCPCS C1713 446.612 - PLATE BN Y 46X4X1MM NS PRO-PK 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $425.93 $315.19 $0.00 $330.82 $186.09 $186.09 $0.00 $0.00 $0.00 $88.77 $316.12 $316.12 $0.00 $0.00 $88.76 $0.00 $251.93 $251.93 $0.00 $206.76 $327.52 $330.82 $0.00 $0.00 $62.83 $0.00 $0.00 $65.83 $0.00 $0.00 $0.00 $0.00 $0.00 446.614 SUP HCPCS C1713 446.614 - PLATE BN 2Y 18MM 6 HL TI CRNFCL 1.5MM SCR BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.615 SUP HCPCS C1713 446.615 - PLATE BN 2Y 21MM 6 HL TI CRNFCL 1.5MM SCR BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.63 SUP HCPCS C1713 446.63 - PLATE BONE 36X3.5X.9MM 7 HOLE SLFTAP LCP TITANIUM LEFT BOTH IP/OP $539.78 $399.44 $0.00 $419.26 $235.83 $235.83 $0.00 $0.00 $0.00 $112.50 $400.62 $400.62 $0.00 $0.00 $112.49 $0.00 $319.28 $319.28 $0.00 $262.04 $415.07 $419.26 $0.00 $0.00 $79.63 $0.00 $0.00 $83.43 $0.00 $0.00 $0.00 $0.00 $0.00 446.64 SUP HCPCS C1713 446.64 - PLATE BONE 36X3.5X.9MM 7 HOLE SLFTAP LCP TITANIUM RIGHT BOTH IP/OP $539.78 $399.44 $0.00 $419.26 $235.83 $235.83 $0.00 $0.00 $0.00 $112.50 $400.62 $400.62 $0.00 $0.00 $112.49 $0.00 $319.28 $319.28 $0.00 $262.04 $415.07 $419.26 $0.00 $0.00 $79.63 $0.00 $0.00 $83.43 $0.00 $0.00 $0.00 $0.00 $0.00 446.642 SUP HCPCS C1713 446.642 - PLATE 2MM MAXL 5X3 HOLE T 1.5MM SCR BONE TI NONSTRL BOTH IP/OP $821.25 $607.73 $0.00 $657.00 $369.56 $369.56 $0.00 $0.00 $0.00 $171.17 $609.53 $609.53 $0.00 $0.00 $171.15 $0.00 $485.77 $485.77 $0.00 $410.63 $650.43 $657.00 $0.00 $0.00 $128.53 $0.00 $0.00 $130.74 $0.00 $0.00 $0.00 $0.00 $0.00 446.644 SUP HCPCS C1713 446.644 - PLATE 4MM MAXL 5X3 HOLE T 1.5MM SCR BONE TI NONSTRL BOTH IP/OP $821.25 $607.73 $0.00 $657.00 $369.56 $369.56 $0.00 $0.00 $0.00 $171.17 $609.53 $609.53 $0.00 $0.00 $171.15 $0.00 $485.77 $485.77 $0.00 $410.63 $650.43 $657.00 $0.00 $0.00 $128.53 $0.00 $0.00 $130.74 $0.00 $0.00 $0.00 $0.00 $0.00 446.646 SUP HCPCS C1713 446.646 - PLATE 6MM MAXL 5X3 HOLE T 1.5MM SCR BONE TI NONSTRL BOTH IP/OP $821.25 $607.73 $0.00 $657.00 $369.56 $369.56 $0.00 $0.00 $0.00 $171.17 $609.53 $609.53 $0.00 $0.00 $171.15 $0.00 $485.77 $485.77 $0.00 $410.63 $650.43 $657.00 $0.00 $0.00 $128.53 $0.00 $0.00 $130.74 $0.00 $0.00 $0.00 $0.00 $0.00 446.782 SUP HCPCS C1713 446.782 - PLATE SHRT MAXFACL 2X2 HOLE L RIGHT OBLQ MALBLE 1.5MM SCR BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 446.783 SUP HCPCS C1713 446.783 - PLATE SHRT MAXFACL 2X2 HOLE L LEFT OBLQ MALBLE 1.5MM SCR BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 446.784 SUP HCPCS C1713 446.784 - PLATE LNG MAXFACL 2X2 HOLE L RIGHT OBLQ MALBLE 1.5MM SCR BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 446.785 SUP HCPCS C1713 446.785 - PLATE LNG MAXFACL 2X2 HOLE L LEFT OBLQ MALBLE 1.5MM SCR BONE BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 446.786 SUP HCPCS C1713 446.786 - PLATE SHRT RIGHT MAXFACL Z MALBLE 1.5MM SCR BONE TI NONSTRL BOTH IP/OP $580.50 $429.57 $0.00 $464.40 $261.23 $261.23 $0.00 $0.00 $0.00 $120.99 $430.85 $430.85 $0.00 $0.00 $120.98 $0.00 $343.37 $343.37 $0.00 $290.25 $459.76 $464.40 $0.00 $0.00 $90.85 $0.00 $0.00 $92.42 $0.00 $0.00 $0.00 $0.00 $0.00 446.787 SUP HCPCS C1713 446.787 - PLATE SHRT LEFT MAXFACL Z MALBLE 1.5MM SCR BONE TI NONSTRL BOTH IP/OP $580.50 $429.57 $0.00 $464.40 $261.23 $261.23 $0.00 $0.00 $0.00 $120.99 $430.85 $430.85 $0.00 $0.00 $120.98 $0.00 $343.37 $343.37 $0.00 $290.25 $459.76 $464.40 $0.00 $0.00 $90.85 $0.00 $0.00 $92.42 $0.00 $0.00 $0.00 $0.00 $0.00 446.788 SUP HCPCS C1713 446.788 - PLATE LNG RIGHT MAXFACL Z MALBLE 1.5MM SCR BONE TI NONSTRL BOTH IP/OP $580.50 $429.57 $0.00 $464.40 $261.23 $261.23 $0.00 $0.00 $0.00 $120.99 $430.85 $430.85 $0.00 $0.00 $120.98 $0.00 $343.37 $343.37 $0.00 $290.25 $459.76 $464.40 $0.00 $0.00 $90.85 $0.00 $0.00 $92.42 $0.00 $0.00 $0.00 $0.00 $0.00 446.789 SUP HCPCS C1713 446.789 - PLATE LNG LEFT MAXFACL Z MALBLE 1.5MM SCR BONE TI NONSTRL BOTH IP/OP $580.50 $429.57 $0.00 $464.40 $261.23 $261.23 $0.00 $0.00 $0.00 $120.99 $430.85 $430.85 $0.00 $0.00 $120.98 $0.00 $343.37 $343.37 $0.00 $290.25 $459.76 $464.40 $0.00 $0.00 $90.85 $0.00 $0.00 $92.42 $0.00 $0.00 $0.00 $0.00 $0.00 446.792 SUP HCPCS C1713 446.792 - PLATE SHRT TI 1.5MM SCR L OBLQ 2X2 HOLE BONE RIGHT NONSTRL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 446.793 SUP HCPCS C1713 446.793 - PLATE SHRT 1.5MM TI 1.5MM SCR L OBLQ 2X2 HOLE BONE LEFT BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 446.794 SUP HCPCS C1713 446.794 - PLATE 1.5MM TI 1.5MM SCR 2X2 HOLE L RIGHT OBLQ BONE NONSTRL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 446.795 SUP HCPCS C1713 446.795 - PLATE TI 1.5 MM SCR 2X2 HOLE L LEFT OBLQ BONE NONSTRL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 446.796 SUP HCPCS C1713 446.796 - PLATE SHRT TI 1.5MM SCR Z BONE RIGHT NONSTRL BOTH IP/OP $654.75 $484.52 $0.00 $523.80 $294.64 $294.64 $0.00 $0.00 $0.00 $136.47 $485.96 $485.96 $0.00 $0.00 $136.45 $0.00 $387.28 $387.28 $0.00 $327.38 $518.56 $523.80 $0.00 $0.00 $102.47 $0.00 $0.00 $104.24 $0.00 $0.00 $0.00 $0.00 $0.00 446.797 SUP HCPCS C1713 446.797 - PLATE SHRT TI 1.5MM SCR Z BONE LEFT NONSTRL BOTH IP/OP $654.75 $484.52 $0.00 $523.80 $294.64 $294.64 $0.00 $0.00 $0.00 $136.47 $485.96 $485.96 $0.00 $0.00 $136.45 $0.00 $387.28 $387.28 $0.00 $327.38 $518.56 $523.80 $0.00 $0.00 $102.47 $0.00 $0.00 $104.24 $0.00 $0.00 $0.00 $0.00 $0.00 446.798 SUP HCPCS C1713 446.798 - PLATE LNG TI 1.5MM SCR Z BONE RIGHT NONSTRL BOTH IP/OP $654.75 $484.52 $0.00 $523.80 $294.64 $294.64 $0.00 $0.00 $0.00 $136.47 $485.96 $485.96 $0.00 $0.00 $136.45 $0.00 $387.28 $387.28 $0.00 $327.38 $518.56 $523.80 $0.00 $0.00 $102.47 $0.00 $0.00 $104.24 $0.00 $0.00 $0.00 $0.00 $0.00 446.799 SUP HCPCS C1713 446.799 - PLATE LNG TI 1.5MM SCR Z BONE LEFT NONSTRL BOTH IP/OP $654.75 $484.52 $0.00 $523.80 $294.64 $294.64 $0.00 $0.00 $0.00 $136.47 $485.96 $485.96 $0.00 $0.00 $136.45 $0.00 $387.28 $387.28 $0.00 $327.38 $518.56 $523.80 $0.00 $0.00 $102.47 $0.00 $0.00 $104.24 $0.00 $0.00 $0.00 $0.00 $0.00 446.81 SUP HCPCS C1713 446.81 - PLATE BONE CRNMXF TI 4 HOLE X 1.5 MM SCR NONSTRL BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.811 SUP HCPCS C1713 446.811 - PLATE BONE CRANFCL TI 4 HOLE X LP 1.5 MM SCR NONSTRL BOTH IP/OP $616.50 $456.21 $0.00 $493.20 $277.43 $277.43 $0.00 $0.00 $0.00 $128.49 $457.57 $457.57 $0.00 $0.00 $128.48 $0.00 $364.66 $364.66 $0.00 $308.25 $488.27 $493.20 $0.00 $0.00 $96.48 $0.00 $0.00 $98.15 $0.00 $0.00 $0.00 $0.00 $0.00 446.9 SUP HCPCS C1713 446.900 - PLATE BONE 12MM CRANFCL TI 6 HOLE 1.5MM SCR NONSTRL BOTH IP/OP $573.75 $424.58 $0.00 $459.00 $258.19 $258.19 $0.00 $0.00 $0.00 $119.58 $425.84 $425.84 $0.00 $0.00 $119.57 $0.00 $339.37 $339.37 $0.00 $286.88 $454.41 $459.00 $0.00 $0.00 $89.79 $0.00 $0.00 $91.34 $0.00 $0.00 $0.00 $0.00 $0.00 446.901 SUP Custom 27803010 446.901 - COVER BUR HOLE 15MM CRANFCL TI 6 HOLE 1.5MM SCR NONSTRL BOTH IP/OP $573.75 $424.58 $0.00 $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $425.84 $425.84 $0.00 $0.00 $119.57 $0.00 $0.00 $0.00 $0.00 $286.88 $454.41 $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 446.902 SUP Custom 27803010 446.902 - COVER BUR HOLE 24MM CRANFCL TI 6 HOLE 1.5MM SCR NONSTRL BOTH IP/OP $573.75 $424.58 $0.00 $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $425.84 $425.84 $0.00 $0.00 $119.57 $0.00 $0.00 $0.00 $0.00 $286.88 $454.41 $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 446.91 SUP Custom 27803010 446.91 - COVER BUR HOLE 17MM CRANFCL TI 6 HOLE 1.5MM SCR NONSTRL BOTH IP/OP $573.75 $424.58 $0.00 $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $425.84 $425.84 $0.00 $0.00 $119.57 $0.00 $0.00 $0.00 $0.00 $286.88 $454.41 $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 446.911 SUP Custom 27803010 446.911 - CLIP CRNL SPRG TI LT 1.5 MM BUR HL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $0.00 $0.00 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 446.912 SUP Custom 27803010 446.912 - CLIP CRNL SPRG TI RT 1.5 MM BUR HL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $0.00 $0.00 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 446.913 SUP Custom 27803010 446.913 - CLIP CRNL SPRG TI 1.5 MM BUR HL BOTH IP/OP $436.50 $323.01 $0.00 $349.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $323.97 $323.97 $0.00 $0.00 $90.97 $0.00 $0.00 $0.00 $0.00 $218.25 $345.71 $349.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 446.916 SUP HCPCS C1713 446.916 - PLATE BONE 16X10MM CRANFCL TI 4 HOLE 1.5MM SCR NONSTRL BOTH IP/OP $533.25 $394.61 $0.00 $426.60 $239.96 $239.96 $0.00 $0.00 $0.00 $111.14 $395.78 $395.78 $0.00 $0.00 $111.13 $0.00 $315.42 $315.42 $0.00 $266.63 $422.33 $426.60 $0.00 $0.00 $83.45 $0.00 $0.00 $84.89 $0.00 $0.00 $0.00 $0.00 $0.00 446.917 SUP HCPCS C1713 446.917 - PLATE CHIN 2 BND 1.5MM SCR BONE TI 4MM NONSTRL BOTH IP/OP $794.25 $587.75 $0.00 $635.40 $357.41 $357.41 $0.00 $0.00 $0.00 $165.54 $589.49 $589.49 $0.00 $0.00 $165.52 $0.00 $469.80 $469.80 $0.00 $397.13 $629.05 $635.40 $0.00 $0.00 $124.30 $0.00 $0.00 $126.44 $0.00 $0.00 $0.00 $0.00 $0.00 446.918 SUP HCPCS C1713 446.918 - PLATE CHIN 2 BND 1.5MM SCR BONE TI 6MM NONSTRL BOTH IP/OP $794.25 $587.75 $0.00 $635.40 $357.41 $357.41 $0.00 $0.00 $0.00 $165.54 $589.49 $589.49 $0.00 $0.00 $165.52 $0.00 $469.80 $469.80 $0.00 $397.13 $629.05 $635.40 $0.00 $0.00 $124.30 $0.00 $0.00 $126.44 $0.00 $0.00 $0.00 $0.00 $0.00 446.919 SUP HCPCS C1713 446.919 - PLATE CHIN 2 BND 1.5MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $794.25 $587.75 $0.00 $635.40 $357.41 $357.41 $0.00 $0.00 $0.00 $165.54 $589.49 $589.49 $0.00 $0.00 $165.52 $0.00 $469.80 $469.80 $0.00 $397.13 $629.05 $635.40 $0.00 $0.00 $124.30 $0.00 $0.00 $126.44 $0.00 $0.00 $0.00 $0.00 $0.00 446.92 SUP HCPCS C1713 446.920 - PLATE CHIN 2 BND 1.5MM SCR BONE TI 10MM NONSTRL BOTH IP/OP $794.25 $587.75 $0.00 $635.40 $357.41 $357.41 $0.00 $0.00 $0.00 $165.54 $589.49 $589.49 $0.00 $0.00 $165.52 $0.00 $469.80 $469.80 $0.00 $397.13 $629.05 $635.40 $0.00 $0.00 $124.30 $0.00 $0.00 $126.44 $0.00 $0.00 $0.00 $0.00 $0.00 446.923 SUP Custom 27803010 446.923 - COVER BUR HOLE 15MM CRANIAL TI 5 HOLE SHNT 1.5MM SCR NONSTRL BOTH IP/OP $573.75 $424.58 $0.00 $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $425.84 $425.84 $0.00 $0.00 $119.57 $0.00 $0.00 $0.00 $0.00 $286.88 $454.41 $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 447.007 SUP Custom 27803010 447.007 - FTPLT BONE ZYG TI 3 HOLE NONSTRL BOTH IP/OP $499.50 $369.63 $0.00 $399.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.73 $370.73 $0.00 $0.00 $104.10 $0.00 $0.00 $0.00 $0.00 $249.75 $395.60 $399.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 447.008 SUP HCPCS C1713 447.008 - PLATE 6MM MAXFACL 6 HOLE CVD LP BONE NONSTRL BOTH IP/OP $726.75 $537.80 $0.00 $581.40 $327.04 $327.04 $0.00 $0.00 $0.00 $151.47 $539.39 $539.39 $0.00 $0.00 $151.45 $0.00 $429.87 $429.87 $0.00 $363.38 $575.59 $581.40 $0.00 $0.00 $113.74 $0.00 $0.00 $115.70 $0.00 $0.00 $0.00 $0.00 $0.00 447.009 SUP HCPCS C1713 447.009 - PLATE 10MM TI 2MM SCR 6 HOLE SGTL SPLT CVD LP BONE NONSTRL BOTH IP/OP $726.75 $537.80 $0.00 $581.40 $327.04 $327.04 $0.00 $0.00 $0.00 $151.47 $539.39 $539.39 $0.00 $0.00 $151.45 $0.00 $429.87 $429.87 $0.00 $363.38 $575.59 $581.40 $0.00 $0.00 $113.74 $0.00 $0.00 $115.70 $0.00 $0.00 $0.00 $0.00 $0.00 447.01 SUP HCPCS C1713 447.010 - PLATE MAXFACL 6 HOLE CVD SGTL SPLT 2MM SCR BONE TI 6MM BOTH IP/OP $726.75 $537.80 $0.00 $581.40 $327.04 $327.04 $0.00 $0.00 $0.00 $151.47 $539.39 $539.39 $0.00 $0.00 $151.45 $0.00 $429.87 $429.87 $0.00 $363.38 $575.59 $581.40 $0.00 $0.00 $113.74 $0.00 $0.00 $115.70 $0.00 $0.00 $0.00 $0.00 $0.00 447.011 SUP HCPCS C1713 447.011 - PLATE MAXFACL 6 HOLE CVD SGTL SPLT 2MM SCR BONE TI 10MM BOTH IP/OP $726.75 $537.80 $0.00 $581.40 $327.04 $327.04 $0.00 $0.00 $0.00 $151.47 $539.39 $539.39 $0.00 $0.00 $151.45 $0.00 $429.87 $429.87 $0.00 $363.38 $575.59 $581.40 $0.00 $0.00 $113.74 $0.00 $0.00 $115.70 $0.00 $0.00 $0.00 $0.00 $0.00 447.013 SUP HCPCS C1713 447.013 - PLATE BONE 65MM CRANFCL TI 13 HOLE ADP 2MM SCR NONSTRL BOTH IP/OP $805.50 $596.07 $0.00 $644.40 $362.48 $362.48 $0.00 $0.00 $0.00 $167.89 $597.84 $597.84 $0.00 $0.00 $167.87 $0.00 $476.45 $476.45 $0.00 $402.75 $637.96 $644.40 $0.00 $0.00 $126.06 $0.00 $0.00 $128.24 $0.00 $0.00 $0.00 $0.00 $0.00 447.03 SUP HCPCS C1713 447.030 - PLATE 14MM MAXFACL 6 HOLE CVD 2MM SCR BILAT SGTL SPLT OSTMY BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.031 SUP HCPCS C1713 447.031 - PLATE BN STRG 35X5X1.2MM NS PRO-PK 6 HL LOPRFL PRECONTOUR BOTH IP/OP $404.85 $299.59 $0.00 $314.44 $176.87 $176.87 $0.00 $0.00 $0.00 $84.38 $300.48 $300.48 $0.00 $0.00 $84.37 $0.00 $239.47 $239.47 $0.00 $196.53 $311.30 $314.44 $0.00 $0.00 $59.72 $0.00 $0.00 $62.57 $0.00 $0.00 $0.00 $0.00 $0.00 447.032 SUP HCPCS C1713 447.032 - PLATE BN STRG 71X5X1.2MM NS PRO-PK 12 HL LOPRFL PRECONTOUR BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 447.033 SUP HCPCS C1713 447.033 - PLATE 2MM 4MM MAXFACL 6 HOLE BAR CVD LP SGTL SPLT 2MM SCR BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.034 SUP HCPCS C1713 447.034 - PLATE 8MM MAXFACL 6 HOLE CVD LP 2MM SCR BILAT SGTL SPLT BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.035 SUP HCPCS C1713 447.035 - PLATE BN CRV 4MMX1.25MM NS 6 HL SGTL SPLT TI CRNFCL 2MM SCR BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.036 SUP HCPCS C1713 447.036 - PLATE BN CRV 12MMX1.25MM NS 6 HL SGTL SPLT TI CRNFCL 2MM SCR BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.037 SUP HCPCS C1713 447.037 - PLATE 12MM MAXFACL 6 HOLE CVD LP 2MM SCR BILAT SGTL SPLT BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.038 SUP HCPCS C1713 447.038 - PLATE BN CRV 8MMX1.25MM NS 6 HL SGTL SPLT TI CRNFCL 2MM SCR BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.039 SUP HCPCS C1713 447.039 - PLATE 16MM MAXFACL 6 HOLE CVD 2MM SCR BILAT SGTL SPLT OSTMY BOTH IP/OP $783.00 $579.42 $0.00 $626.40 $352.35 $352.35 $0.00 $0.00 $0.00 $163.20 $581.14 $581.14 $0.00 $0.00 $163.18 $0.00 $463.14 $463.14 $0.00 $391.50 $620.14 $626.40 $0.00 $0.00 $122.54 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.04 SUP HCPCS C1713 447.040 - PLATE 25MM MAXL RIGHT 3X3 HOLE L 2MM SCR BONE TI NONSTRL BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $231.86 $231.86 $0.00 $0.00 $0.00 $107.39 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $304.77 $304.77 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $80.64 $0.00 $0.00 $82.03 $0.00 $0.00 $0.00 $0.00 $0.00 447.041 SUP HCPCS C1713 447.041 - PLATE BN L 25X4.8X.9MM NS 15MM 3 HL SHFT 3 HL BS TI MXL LT 2 BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $231.86 $231.86 $0.00 $0.00 $0.00 $107.39 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $304.77 $304.77 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $80.64 $0.00 $0.00 $82.03 $0.00 $0.00 $0.00 $0.00 $0.00 447.042 SUP HCPCS C1713 447.042 - PLATE RIGHT MAXL 3X3 HOLE L 2MM SCR BONE TI 27MM NONSTRL BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $231.86 $231.86 $0.00 $0.00 $0.00 $107.39 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $304.77 $304.77 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $80.64 $0.00 $0.00 $82.03 $0.00 $0.00 $0.00 $0.00 $0.00 447.043 SUP HCPCS C1713 447.043 - PLATE LEFT MAXL 3X3 HOLE L 2MM SCR BONE TI 27MM NONSTRL BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $231.86 $231.86 $0.00 $0.00 $0.00 $107.39 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $304.77 $304.77 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $80.64 $0.00 $0.00 $82.03 $0.00 $0.00 $0.00 $0.00 $0.00 447.044 SUP HCPCS C1713 447.044 - PLATE RIGHT MAXL 3X3 HOLE L 2MM SCR BONE TI 29MM NONSTRL BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $231.86 $231.86 $0.00 $0.00 $0.00 $107.39 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $304.77 $304.77 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $80.64 $0.00 $0.00 $82.03 $0.00 $0.00 $0.00 $0.00 $0.00 447.045 SUP HCPCS C1713 447.045 - PLATE LEFT MAXL 3X3 HOLE L 2MM SCR BONE TI 29MM NONSTRL BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $231.86 $231.86 $0.00 $0.00 $0.00 $107.39 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $304.77 $304.77 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $80.64 $0.00 $0.00 $82.03 $0.00 $0.00 $0.00 $0.00 $0.00 447.046 SUP HCPCS C1713 447.046 - PLATE BN MN NAR 4.8X1MM 4 HL LCK MLBL TI MNDB 2MM SCR BOTH IP/OP $843.75 $624.38 $0.00 $675.00 $379.69 $379.69 $0.00 $0.00 $0.00 $175.86 $626.23 $626.23 $0.00 $0.00 $175.84 $0.00 $499.08 $499.08 $0.00 $421.88 $668.25 $675.00 $0.00 $0.00 $132.05 $0.00 $0.00 $134.33 $0.00 $0.00 $0.00 $0.00 $0.00 447.047 SUP HCPCS C1713 447.047 - PLATE BN MN NAR 4.8X1MM 6 HL LCK MLBL TI MNDB 2MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.048 SUP HCPCS C1713 447.048 - PLATE BN MN NAR 4.8X1MM 4 HL LCK MLBL TI MNDB 2MM SCR BOTH IP/OP $843.75 $624.38 $0.00 $675.00 $379.69 $379.69 $0.00 $0.00 $0.00 $175.86 $626.23 $626.23 $0.00 $0.00 $175.84 $0.00 $499.08 $499.08 $0.00 $421.88 $668.25 $675.00 $0.00 $0.00 $132.05 $0.00 $0.00 $134.33 $0.00 $0.00 $0.00 $0.00 $0.00 447.049 SUP HCPCS C1713 447.049 - PLATE BN MN NAR 4.8X1MM 6 HL LCK TI MNDB 2MM SCR BOTH IP/OP $918.00 $679.32 $0.00 $734.40 $413.10 $413.10 $0.00 $0.00 $0.00 $191.33 $681.34 $681.34 $0.00 $0.00 $191.31 $0.00 $543.00 $543.00 $0.00 $459.00 $727.06 $734.40 $0.00 $0.00 $143.67 $0.00 $0.00 $146.15 $0.00 $0.00 $0.00 $0.00 $0.00 447.05 SUP HCPCS C1713 447.050 - PLATE MINI 1MM MANDIB 12 HOLE LCK ADP 2MM SCR BONE TI BOTH IP/OP "$1,500.75 " "$1,110.56" $0.00 "$1,200.60" $675.34 $675.34 $0.00 $0.00 $0.00 $312.79 "$1,113.86" "$1,113.86" $0.00 $0.00 $312.76 $0.00 $887.69 $887.69 $0.00 $750.38 "$1,188.59" "$1,200.60" $0.00 $0.00 $234.87 $0.00 $0.00 $238.92 $0.00 $0.00 $0.00 $0.00 $0.00 447.051 SUP HCPCS C1713 447.051 - PLATE BN MN 4.8X1MM 20 HL LCK ADP TI MNDB 2MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.053 SUP HCPCS C1713 447.053 - PLATE BN MN 4.8X1MM 4 HL LCK TNSNBND TI MNDB 2MM SCR BOTH IP/OP "$1,055.25 " $780.89 $0.00 $844.20 $474.86 $474.86 $0.00 $0.00 $0.00 $219.94 $783.21 $783.21 $0.00 $0.00 $219.91 $0.00 $624.18 $624.18 $0.00 $527.63 $835.76 $844.20 $0.00 $0.00 $165.15 $0.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 447.055 SUP HCPCS C1713 447.055 - PLATE BN MN BRD 4.8X1.3MM 4 HL LCK TI MNDB 2MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.057 SUP HCPCS C1713 447.057 - PLATE BN MN BRD CRV 4.8X1.3MM 4 HL LCK TI MNDB 2MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.07 SUP HCPCS C1713 447.070 - PLATE SM 15MMX.9MM TI 2MM SCR 4 HOLE STR OFFST PURE BONE 3MM BOTH IP/OP $571.50 $422.91 $0.00 $457.20 $257.18 $257.18 $0.00 $0.00 $0.00 $119.11 $424.17 $424.17 $0.00 $0.00 $119.10 $0.00 $338.04 $338.04 $0.00 $285.75 $452.63 $457.20 $0.00 $0.00 $89.44 $0.00 $0.00 $90.98 $0.00 $0.00 $0.00 $0.00 $0.00 447.071 SUP HCPCS C1713 447.071 - PLATE CHIN 4 HOLE STR 2MM SCR BONE TI 5MM NONSTRL BOTH IP/OP $600.75 $444.56 $0.00 $480.60 $270.34 $270.34 $0.00 $0.00 $0.00 $125.21 $445.88 $445.88 $0.00 $0.00 $125.20 $0.00 $355.34 $355.34 $0.00 $300.38 $475.79 $480.60 $0.00 $0.00 $94.02 $0.00 $0.00 $95.64 $0.00 $0.00 $0.00 $0.00 $0.00 447.072 SUP HCPCS C1713 447.072 - PLATE CHIN 4 HOLE STR 2MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $632.25 $467.87 $0.00 $505.80 $284.51 $284.51 $0.00 $0.00 $0.00 $131.78 $469.26 $469.26 $0.00 $0.00 $131.76 $0.00 $373.98 $373.98 $0.00 $316.13 $500.74 $505.80 $0.00 $0.00 $98.95 $0.00 $0.00 $100.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.073 SUP HCPCS C1713 447.073 - PLATE CHIN 5 HOLE 2 BND 2MM SCR BONE TI 4MM NONSTRL BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 447.074 SUP HCPCS C1713 447.074 - PLATE 6MM CHIN 5 HOLE 2 BND 2MM SCR BONE TI NONSTRL BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 447.075 SUP HCPCS C1713 447.075 - PLATE CHIN 5 HOLE 2 BND 2MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 447.076 SUP HCPCS C1713 447.076 - PLATE CHIN 5 HOLE 2 BND 2MM SCR BONE TI 10MM NONSTRL BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 447.077 SUP HCPCS C1713 447.077 - PLATE CHIN 5 HOLE 1 BND 2MM SCR BONE TI 3-5MM NONSTRL BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 447.078 SUP HCPCS C1713 447.078 - PLATE CHIN 5 HOLE 1 BND 2MM SCR BONE TI 6-8MM NONSTRL BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 447.079 SUP HCPCS C1713 447.079 - PLATE CHIN 5 HOLE 1 BND 2MM SCR BONE TI 9-11MM NONSTRL BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 447.082 SUP HCPCS C1713 447.082 - PLATE MAXFACL 8 HOLE STRUT 2 MM SCR BILAT SGTL SPLT OSTMY BOTH IP/OP $942.75 $697.64 $0.00 $754.20 $424.24 $424.24 $0.00 $0.00 $0.00 $196.49 $699.71 $699.71 $0.00 $0.00 $196.47 $0.00 $557.64 $557.64 $0.00 $471.38 $746.66 $754.20 $0.00 $0.00 $147.54 $0.00 $0.00 $150.09 $0.00 $0.00 $0.00 $0.00 $0.00 447.083 SUP HCPCS C1713 447.083 - PLATE -90D 38MM MAXFACL 10 HOLE CVD SGTL SPLT CURVE 2MM SCR BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $372.60 $372.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $0.00 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.084 SUP HCPCS C1713 447.084 - PLATE 30MM MAXFACL 4 HOLE STR 2MM SCR BILAT SGTL SPLT OSTMY BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $372.60 $372.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $0.00 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.088 SUP HCPCS C1713 447.088 - PLATE MAXFACL 8 HOLE CVD 2 MM SCR BILAT SGTL SPLT OSTMY BONE BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $372.60 $372.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $0.00 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.1 SUP HCPCS C1713 447.10 - PLATE 100MM MIDFAC 20 HOLE ADOPTION 2MM SCR BONE TI NONSTRL BOTH IP/OP "$1,059.75 " $784.22 $0.00 $847.80 $476.89 $476.89 $0.00 $0.00 $0.00 $220.88 $786.55 $786.55 $0.00 $0.00 $220.85 $0.00 $626.84 $626.84 $0.00 $529.88 $839.32 $847.80 $0.00 $0.00 $165.85 $0.00 $0.00 $168.71 $0.00 $0.00 $0.00 $0.00 $0.00 447.101 SUP HCPCS C1713 447.101 - PLATE MANDIB 6 HOLE INTMD LCK 2 MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.102 SUP HCPCS C1713 447.102 - PLATE MANDIB 12 HOLE INTMD LCK 2 MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.103 SUP HCPCS C1713 447.103 - PLATE LG MANDIB 3X3 HOLE LCK STR 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.104 SUP HCPCS C1713 447.104 - PLATE LG MANDIB 6 HOLE LCK STR 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.105 SUP HCPCS C1713 447.105 - PLATE BN 8MM SPC LG 95X6.5X1.5MM NS 12 HL LCK LOPRFL TI MNDB BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.106 SUP HCPCS C1713 447.106 - PLATE LG MANDIB 20 HOLE LCK STR 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.108 SUP HCPCS C1713 447.108 - PLATE LG MANDIB 6X21 HOLE LCK RIGHT ANG 2MM SCR BONE TI BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.109 SUP HCPCS C1713 447.109 - PLATE LG MANDIB 6X21 HOLE LCK LEFT ANG 2MM SCR BONE TI BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.114 SUP HCPCS C1713 447.114 - PLATE 33MM MAXFACL 4 HOLE ADJ SLDR 2MM SCR BILAT SGTL SPLT BOTH IP/OP "$1,064.25 " $787.55 $0.00 $851.40 $478.91 $478.91 $0.00 $0.00 $0.00 $221.82 $789.89 $789.89 $0.00 $0.00 $221.79 $0.00 $629.50 $629.50 $0.00 $532.13 $842.89 $851.40 $0.00 $0.00 $166.56 $0.00 $0.00 $169.43 $0.00 $0.00 $0.00 $0.00 $0.00 447.116 SUP HCPCS C1713 447.116 - PLATE 40MM MAXFACL 4 HOLE ADJ SLDR 2MM SCR BILAT SGTL SPLT BOTH IP/OP "$1,064.25 " $787.55 $0.00 $851.40 $478.91 $478.91 $0.00 $0.00 $0.00 $221.82 $789.89 $789.89 $0.00 $0.00 $221.79 $0.00 $629.50 $629.50 $0.00 $532.13 $842.89 $851.40 $0.00 $0.00 $166.56 $0.00 $0.00 $169.43 $0.00 $0.00 $0.00 $0.00 $0.00 447.117 SUP HCPCS C1713 447.117 - PLATE LG MANDIB 3X3 HOLE LCK CRSNT 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.118 SUP HCPCS C1713 447.118 - PLATE LG MANDIB 3X3 HOLE LCK ANG 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.119 SUP HCPCS C1713 447.119 - PLATE LG MANDIB 4X4 HOLE LCK ANG 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.14 SUP HCPCS C1713 447.140 - PLATE BONE 24MM CRANFCL TI 3X3 HOLE T 2MM SCR NONSTRL BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $247.05 $247.05 $0.00 $0.00 $0.00 $114.43 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $324.73 $324.73 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $85.92 $0.00 $0.00 $87.40 $0.00 $0.00 $0.00 $0.00 $0.00 447.141 SUP HCPCS C1713 447.141 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 4MM NONSTRL BOTH IP/OP $618.75 $457.88 $0.00 $495.00 $278.44 $278.44 $0.00 $0.00 $0.00 $128.96 $459.24 $459.24 $0.00 $0.00 $128.95 $0.00 $365.99 $365.99 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 447.142 SUP HCPCS C1713 447.142 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 6MM NONSTRL BOTH IP/OP $618.75 $457.88 $0.00 $495.00 $278.44 $278.44 $0.00 $0.00 $0.00 $128.96 $459.24 $459.24 $0.00 $0.00 $128.95 $0.00 $365.99 $365.99 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 447.143 SUP HCPCS C1713 447.143 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $618.75 $457.88 $0.00 $495.00 $278.44 $278.44 $0.00 $0.00 $0.00 $128.96 $459.24 $459.24 $0.00 $0.00 $128.95 $0.00 $365.99 $365.99 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 447.144 SUP HCPCS C1713 447.144 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 10MM NONSTRL BOTH IP/OP $618.75 $457.88 $0.00 $495.00 $278.44 $278.44 $0.00 $0.00 $0.00 $128.96 $459.24 $459.24 $0.00 $0.00 $128.95 $0.00 $365.99 $365.99 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 447.145 SUP HCPCS C1713 447.145 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 12MM NONSTRL BOTH IP/OP $618.75 $457.88 $0.00 $495.00 $278.44 $278.44 $0.00 $0.00 $0.00 $128.96 $459.24 $459.24 $0.00 $0.00 $128.95 $0.00 $365.99 $365.99 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 447.146 SUP HCPCS C1713 447.146 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 6MM NONSTRL BOTH IP/OP $677.25 $501.17 $0.00 $541.80 $304.76 $304.76 $0.00 $0.00 $0.00 $141.16 $502.65 $502.65 $0.00 $0.00 $141.14 $0.00 $400.59 $400.59 $0.00 $338.63 $536.38 $541.80 $0.00 $0.00 $105.99 $0.00 $0.00 $107.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.147 SUP HCPCS C1713 447.147 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 6MM NONSTRL BOTH IP/OP $677.25 $501.17 $0.00 $541.80 $304.76 $304.76 $0.00 $0.00 $0.00 $141.16 $502.65 $502.65 $0.00 $0.00 $141.14 $0.00 $400.59 $400.59 $0.00 $338.63 $536.38 $541.80 $0.00 $0.00 $105.99 $0.00 $0.00 $107.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.148 SUP HCPCS C1713 447.148 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $677.25 $501.17 $0.00 $541.80 $304.76 $304.76 $0.00 $0.00 $0.00 $141.16 $502.65 $502.65 $0.00 $0.00 $141.14 $0.00 $400.59 $400.59 $0.00 $338.63 $536.38 $541.80 $0.00 $0.00 $105.99 $0.00 $0.00 $107.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.149 SUP HCPCS C1713 447.149 - PLATE CHIN 4 HOLE 2 BND 2MM SCR BONE TI 8MM NONSTRL BOTH IP/OP $677.25 $501.17 $0.00 $541.80 $304.76 $304.76 $0.00 $0.00 $0.00 $141.16 $502.65 $502.65 $0.00 $0.00 $141.14 $0.00 $400.59 $400.59 $0.00 $338.63 $536.38 $541.80 $0.00 $0.00 $105.99 $0.00 $0.00 $107.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.15 SUP HCPCS C1713 447.150 - PLATE RIGHT CHIN 4 HOLE 2 BND 2MM SCR BONE TI 10MM NONSTRL BOTH IP/OP $677.25 $501.17 $0.00 $541.80 $304.76 $304.76 $0.00 $0.00 $0.00 $141.16 $502.65 $502.65 $0.00 $0.00 $141.14 $0.00 $400.59 $400.59 $0.00 $338.63 $536.38 $541.80 $0.00 $0.00 $105.99 $0.00 $0.00 $107.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.151 SUP HCPCS C1713 447.151 - PLATE LEFT CHIN 4 HOLE 2 BND 2MM SCR BONE TI 10MM NONSTRL BOTH IP/OP $677.25 $501.17 $0.00 $541.80 $304.76 $304.76 $0.00 $0.00 $0.00 $141.16 $502.65 $502.65 $0.00 $0.00 $141.14 $0.00 $400.59 $400.59 $0.00 $338.63 $536.38 $541.80 $0.00 $0.00 $105.99 $0.00 $0.00 $107.82 $0.00 $0.00 $0.00 $0.00 $0.00 447.152 SUP HCPCS C1713 447.152 - PLATE BONE 24MM CRANFCL TI 4 HOLE STR 2MM SCR NONSTRL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $275.40 $275.40 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 447.153 SUP HCPCS C1713 447.153 - PLATE BONE 30MM CRANFCL TI 4 HOLE STR 2MM SCR NONSTRL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $275.40 $275.40 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 447.154 SUP HCPCS C1713 447.154 - PLATE BONE 17MM 90D RIGHT CRNMXF TI 2X2 HOLE L LP 2MM SCR BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 447.155 SUP HCPCS C1713 447.155 - PLATE BONE 17MM 90D LEFT CRNMXF TI 2X2 HOLE L LP 2MM SCR BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 447.156 SUP HCPCS C1713 447.156 - PLATE BONE 19MM 90D RIGHT CRNMXF TI 2X2 HOLE L LP 2MM SCR BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 447.157 SUP HCPCS C1713 447.157 - PLATE BONE 19MM 90D LEFT CRNMXF TI 2X2 HOLE L LP 2MM SCR BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 447.158 SUP HCPCS C1713 447.158 - PLATE BONE 23MM 90D RIGHT CRNMXF TI 2X2 HOLE L LP 2MM SCR BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 447.159 SUP HCPCS C1713 447.159 - PLATE BONE 23MM 90D LEFT CRNMXF TI 2X2 HOLE L LP 2MM SCR BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 447.18 SUP HCPCS C1713 447.18 - PLATE BONE ORBTL RIM TI 8 HOLE 2 MM SCR NONSTRL BOTH IP/OP $528.75 $391.28 $0.00 $423.00 $237.94 $237.94 $0.00 $0.00 $0.00 $110.20 $392.44 $392.44 $0.00 $0.00 $110.19 $0.00 $312.76 $312.76 $0.00 $264.38 $418.77 $423.00 $0.00 $0.00 $82.75 $0.00 $0.00 $84.18 $0.00 $0.00 $0.00 $0.00 $0.00 447.184 SUP HCPCS C1713 447.184 - 2.0MM TI SAGITTAL SPLIT PLATE STRAIGHT LOW-PROFILE/4 H/22MM BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 447.185 SUP HCPCS C1713 447.185 - 2.0MM TI SAGITTAL SPLIT PLATE STRAIGHT LOW-PROFILE/4 H/29MM BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 447.186 SUP HCPCS C1713 447.186 - 2.0MM TI SAGITTAL SPLIT PLATE STRAIGHT LOW-PROFILE/4 H/36MM BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 447.2 SUP HCPCS C1713 447.20 - PLATE BONE ORBTL RIM TI 10 HOLE 2 MM SCR NONSTRL BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 447.204 SUP HCPCS C1713 447.204 - PLATE 1.3MM MANDIB 4 HOLE INTMD LCK CMPR 2MM SCR BONE TI BOTH IP/OP $816.75 $604.40 $0.00 $653.40 $367.54 $367.54 $0.00 $0.00 $0.00 $170.23 $606.19 $606.19 $0.00 $0.00 $170.21 $0.00 $483.11 $483.11 $0.00 $408.38 $646.87 $653.40 $0.00 $0.00 $127.82 $0.00 $0.00 $130.03 $0.00 $0.00 $0.00 $0.00 $0.00 447.205 SUP HCPCS C1713 447.205 - PLATE 1.3MM MANDIB 5 HOLE INTMD LCK CMPR 2MM SCR BONE TI BOTH IP/OP $888.75 $657.68 $0.00 $711.00 $399.94 $399.94 $0.00 $0.00 $0.00 $185.24 $659.63 $659.63 $0.00 $0.00 $185.22 $0.00 $525.70 $525.70 $0.00 $444.38 $703.89 $711.00 $0.00 $0.00 $139.09 $0.00 $0.00 $141.49 $0.00 $0.00 $0.00 $0.00 $0.00 447.206 SUP HCPCS C1713 447.206 - PLATE 1.3MM MANDIB 6 HOLE INTMD LCK CMPR 2MM SCR BONE TI BOTH IP/OP $958.50 $709.29 $0.00 $766.80 $431.33 $431.33 $0.00 $0.00 $0.00 $199.78 $711.40 $711.40 $0.00 $0.00 $199.75 $0.00 $566.95 $566.95 $0.00 $479.25 $759.13 $766.80 $0.00 $0.00 $150.01 $0.00 $0.00 $152.59 $0.00 $0.00 $0.00 $0.00 $0.00 447.208 SUP HCPCS C1713 447.208 - PLATE 1.3MM MANDIB 8 HOLE INTMD LCK CMPR 2MM SCR BONE TI BOTH IP/OP "$1,084.50 " $802.53 $0.00 $867.60 $488.03 $488.03 $0.00 $0.00 $0.00 $226.04 $804.92 $804.92 $0.00 $0.00 $226.01 $0.00 $641.48 $641.48 $0.00 $542.25 $858.92 $867.60 $0.00 $0.00 $169.72 $0.00 $0.00 $172.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.21 SUP HCPCS C1713 447.210 - PLATE 1.3MM MANDIB 6 HOLE INTMD LCK ANG CMPR 2MM SCR BONE TI BOTH IP/OP "$1,208.25 " $894.11 $0.00 $966.60 $543.71 $543.71 $0.00 $0.00 $0.00 $251.83 $896.76 $896.76 $0.00 $0.00 $251.80 $0.00 $714.68 $714.68 $0.00 $604.13 $956.93 $966.60 $0.00 $0.00 $189.09 $0.00 $0.00 $192.35 $0.00 $0.00 $0.00 $0.00 $0.00 447.212 SUP HCPCS C1713 447.212 - PLATE 1.3MM MANDIB 8 HOLE INTMD LCK ANG CMPR 2MM SCR BONE TI BOTH IP/OP "$1,300.50 " $962.37 $0.00 "$1,040.40" $585.23 $585.23 $0.00 $0.00 $0.00 $271.06 $965.23 $965.23 $0.00 $0.00 $271.02 $0.00 $769.25 $769.25 $0.00 $650.25 "$1,030.00" "$1,040.40" $0.00 $0.00 $203.53 $0.00 $0.00 $207.04 $0.00 $0.00 $0.00 $0.00 $0.00 447.215 SUP HCPCS C1713 447.215 - PLATE 1.3MM MANDIB 5 HOLE INTMD LCK CRSNT 2MM SCR BONE TI BOTH IP/OP "$1,084.50 " $802.53 $0.00 $867.60 $488.03 $488.03 $0.00 $0.00 $0.00 $226.04 $804.92 $804.92 $0.00 $0.00 $226.01 $0.00 $641.48 $641.48 $0.00 $542.25 $858.92 $867.60 $0.00 $0.00 $169.72 $0.00 $0.00 $172.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.217 SUP HCPCS C1713 447.217 - PLATE 1.3MM MANDIB 7 HOLE INTMD LCK CRSNT 2MM SCR BONE TI BOTH IP/OP "$1,154.25 " $854.15 $0.00 $923.40 $519.41 $519.41 $0.00 $0.00 $0.00 $240.57 $856.68 $856.68 $0.00 $0.00 $240.55 $0.00 $682.74 $682.74 $0.00 $577.13 $914.17 $923.40 $0.00 $0.00 $180.64 $0.00 $0.00 $183.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.22 SUP HCPCS C1713 447.22 - PLATE BONE ORBTL RIM CRNMXF TI 12 HOLE CVD 2 MM SCR NONSTRL BOTH IP/OP $589.50 $436.23 $0.00 $471.60 $265.28 $265.28 $0.00 $0.00 $0.00 $122.87 $437.53 $437.53 $0.00 $0.00 $122.85 $0.00 $348.69 $348.69 $0.00 $294.75 $466.88 $471.60 $0.00 $0.00 $92.26 $0.00 $0.00 $93.85 $0.00 $0.00 $0.00 $0.00 $0.00 447.232 SUP HCPCS C1713 447.232 - PLATE BN T 53X5X1.2MM NS PRO-PK 2 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $83.00 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 447.233 SUP HCPCS C1713 447.233 - PLATE BN T 53X5X1.2MM NS PRO-PK 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 447.244 SUP HCPCS C1713 447.244 - PLATE BONE 25MM CRANFCL TI 3X4 HOLE T 2MM SCR NONSTRL BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 447.304 SUP HCPCS C1713 447.304 - PLATE MINI 1MM RIGHT MANDIB 4 HOLE LCK TNSNBND PREBNT 2MM BOTH IP/OP $987.75 $730.94 $0.00 $790.20 $444.49 $444.49 $0.00 $0.00 $0.00 $205.87 $733.11 $733.11 $0.00 $0.00 $205.85 $0.00 $584.25 $584.25 $0.00 $493.88 $782.30 $790.20 $0.00 $0.00 $154.58 $0.00 $0.00 $157.25 $0.00 $0.00 $0.00 $0.00 $0.00 447.305 SUP HCPCS C1713 447.305 - PLATE MINI 1MM LEFT MANDIB 4 HOLE LCK TNSNBND PREBNT 2MM SCR BOTH IP/OP $987.75 $730.94 $0.00 $790.20 $444.49 $444.49 $0.00 $0.00 $0.00 $205.87 $733.11 $733.11 $0.00 $0.00 $205.85 $0.00 $584.25 $584.25 $0.00 $493.88 $782.30 $790.20 $0.00 $0.00 $154.58 $0.00 $0.00 $157.25 $0.00 $0.00 $0.00 $0.00 $0.00 447.308 SUP HCPCS C1713 447.308 - PLATE 2 W MINI 1MM MANDIB 12 HOLE LCK MALBLE 2MM SCR BONE TI BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 447.309 SUP HCPCS C1713 447.309 - PLATE 2 W MINI 1MM MANDIB 9 HOLE LCK MALBLE 2MM SCR BONE TI BOTH IP/OP $949.50 $702.63 $0.00 $759.60 $427.28 $427.28 $0.00 $0.00 $0.00 $197.90 $704.72 $704.72 $0.00 $0.00 $197.88 $0.00 $561.63 $561.63 $0.00 $474.75 $752.00 $759.60 $0.00 $0.00 $148.60 $0.00 $0.00 $151.16 $0.00 $0.00 $0.00 $0.00 $0.00 447.31 SUP HCPCS C1713 447.310 - PLATE MINI 1MM MANDIB 4 HOLE LCK BOX MALBLE 2MM SCR BONE TI BOTH IP/OP $663.75 $491.18 $0.00 $531.00 $298.69 $298.69 $0.00 $0.00 $0.00 $138.34 $492.64 $492.64 $0.00 $0.00 $138.33 $0.00 $392.61 $392.61 $0.00 $331.88 $525.69 $531.00 $0.00 $0.00 $103.88 $0.00 $0.00 $105.67 $0.00 $0.00 $0.00 $0.00 $0.00 447.312 SUP HCPCS C1713 447.312 - PLATE MINI 1MM MANDIB 8 HOLE LCK STRUT MALBLE 2MM SCR BONE BOTH IP/OP "$1,300.50 " $962.37 $0.00 "$1,040.40" $585.23 $585.23 $0.00 $0.00 $0.00 $271.06 $965.23 $965.23 $0.00 $0.00 $271.02 $0.00 $769.25 $769.25 $0.00 $650.25 "$1,030.00" "$1,040.40" $0.00 $0.00 $203.53 $0.00 $0.00 $207.04 $0.00 $0.00 $0.00 $0.00 $0.00 447.315 SUP HCPCS C1713 447.315 - PLATE MINI 1MM MANDIB 8 HOLE LCK CVD STRUT MALBLE 2MM SCR BOTH IP/OP "$1,300.50 " $962.37 $0.00 "$1,040.40" $585.23 $585.23 $0.00 $0.00 $0.00 $271.06 $965.23 $965.23 $0.00 $0.00 $271.02 $0.00 $769.25 $769.25 $0.00 $650.25 "$1,030.00" "$1,040.40" $0.00 $0.00 $203.53 $0.00 $0.00 $207.04 $0.00 $0.00 $0.00 $0.00 $0.00 447.317 SUP HCPCS C1713 447.317 - PLATE MINI 1MM MANDIB 6 HOLE LCK 2Y MALBLE 2MM SCR BONE TI BOTH IP/OP $679.50 $502.83 $0.00 $543.60 $305.78 $305.78 $0.00 $0.00 $0.00 $141.62 $504.32 $504.32 $0.00 $0.00 $141.61 $0.00 $401.92 $401.92 $0.00 $339.75 $538.16 $543.60 $0.00 $0.00 $106.34 $0.00 $0.00 $108.18 $0.00 $0.00 $0.00 $0.00 $0.00 447.318 SUP HCPCS C1713 447.318 - PLATE MINI 1MM RIGHT MANDIB 5 HOLE LCK L MALBLE 2MM SCR BONE BOTH IP/OP $627.75 $464.54 $0.00 $502.20 $282.49 $282.49 $0.00 $0.00 $0.00 $130.84 $465.92 $465.92 $0.00 $0.00 $130.82 $0.00 $371.31 $371.31 $0.00 $313.88 $497.18 $502.20 $0.00 $0.00 $98.24 $0.00 $0.00 $99.94 $0.00 $0.00 $0.00 $0.00 $0.00 447.319 SUP HCPCS C1713 447.319 - PLATE MINI 1MM LEFT MANDIB 5 HOLE LCK L MALBLE 2MM SCR BONE BOTH IP/OP $627.75 $464.54 $0.00 $502.20 $282.49 $282.49 $0.00 $0.00 $0.00 $130.84 $465.92 $465.92 $0.00 $0.00 $130.82 $0.00 $371.31 $371.31 $0.00 $313.88 $497.18 $502.20 $0.00 $0.00 $98.24 $0.00 $0.00 $99.94 $0.00 $0.00 $0.00 $0.00 $0.00 447.344 SUP HCPCS C1713 447.344 - PLATE BONE 31MM 4 HOLE LP LCP TITANIUM SMALL BONE CORTICAL BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 447.345 SUP HCPCS C1713 447.345 - PLATE BONE 38MM 5 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 447.346 SUP HCPCS C1713 447.346 - PLATE BONE 45MM 6 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 447.347 SUP HCPCS C1713 447.347 - PLATE BONE 52MM 7 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 447.348 SUP HCPCS C1713 447.348 - PLATE BONE 59MM 8 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2MM BOTH IP/OP $459.65 $340.14 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $95.80 $341.15 $341.15 $0.00 $0.00 $95.79 $0.00 $271.88 $271.88 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 447.349 SUP HCPCS C1713 447.349 - PLATE BONE 7 HOLE LCP TITANIUM CONDYLE NONSTRL 2 MM SCREWS BOTH IP/OP "$1,446.45 " "$1,070.37" $0.00 "$1,123.46" $631.95 $631.95 $0.00 $0.00 $0.00 $301.48 "$1,073.56" "$1,073.56" $0.00 $0.00 $301.44 $0.00 $855.58 $855.58 $0.00 $702.16 "$1,112.23" "$1,123.46" $0.00 $0.00 $213.38 $0.00 $0.00 $223.57 $0.00 $0.00 $0.00 $0.00 $0.00 447.35 SUP HCPCS C1713 447.350 - PLATE BONE Y 55MM 3X7 HOLE LCP TITANIUM SMALL BONE NONSTRL 2 BOTH IP/OP $788.83 $583.73 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $164.41 $585.47 $585.47 $0.00 $0.00 $164.39 $0.00 $466.59 $466.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 447.351 SUP HCPCS C1713 447.351 - PLATE BONE 2 HOLE HEAD 7 HOLE SHAFT T LCP TITANIUM BOTH IP/OP $812.50 $601.25 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 447.36 SUP HCPCS C1713 447.360 - PLATE BONE 73MM 10 HOLE LCP TITANIUM SMALL BONE NONSTRL 2MM BOTH IP/OP $446.28 $330.25 $0.00 $357.02 $200.82 $200.82 $0.00 $0.00 $0.00 $93.01 $331.23 $331.23 $0.00 $0.00 $93.00 $0.00 $263.97 $263.97 $0.00 $223.14 $353.45 $357.02 $0.00 $0.00 $67.81 $0.00 $0.00 $71.05 $0.00 $0.00 $0.00 $0.00 $0.00 447.362 SUP HCPCS C1713 447.362 - PLATE BONE 81MM 12 HOLE ADAPTION LCP TITANIUM ORTHOPEDIC BOTH IP/OP $777.35 $575.24 $0.00 $603.76 $339.62 $339.62 $0.00 $0.00 $0.00 $162.02 $576.95 $576.95 $0.00 $0.00 $162.00 $0.00 $459.80 $459.80 $0.00 $377.35 $597.72 $603.76 $0.00 $0.00 $114.67 $0.00 $0.00 $120.15 $0.00 $0.00 $0.00 $0.00 $0.00 447.364 SUP HCPCS C1713 447.364 - PLATE BONE 84MM 10 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.4 BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 447.366 SUP HCPCS C1713 447.366 - PLATE BONE 88MM 12 HOLE ADAPTION LCP TITANIUM ORTHOPEDIC BOTH IP/OP $856.08 $633.50 $0.00 $664.90 $374.01 $374.01 $0.00 $0.00 $0.00 $178.43 $635.38 $635.38 $0.00 $0.00 $178.41 $0.00 $506.37 $506.37 $0.00 $415.56 $658.25 $664.90 $0.00 $0.00 $126.28 $0.00 $0.00 $132.32 $0.00 $0.00 $0.00 $0.00 $0.00 447.37 SUP HCPCS C1713 447.370 - PLATE BONE 97MM 12 HOLE ADAPTION LCP TITANIUM SMALL BONE BOTH IP/OP $831.13 $615.04 $0.00 $664.90 $374.01 $374.01 $0.00 $0.00 $0.00 $173.23 $616.86 $616.86 $0.00 $0.00 $173.21 $0.00 $491.61 $491.61 $0.00 $415.56 $658.25 $664.90 $0.00 $0.00 $126.28 $0.00 $0.00 $132.32 $0.00 $0.00 $0.00 $0.00 $0.00 447.372 SUP HCPCS C1713 447.372 - PLATE BONE 76MM 8 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.7MM BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 447.374 SUP HCPCS C1713 447.374 - PLATE BN 94MM NS LCP PRO-PK 10 HL LOPRFL CUT TO LGTH TI 2.7 BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 447.375 SUP HCPCS C1713 447.375 - PLATE BONE 44MM 5 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.4MM BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 447.377 SUP HCPCS C1713 447.377 - PLATE BONE 60MM 7 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.4MM BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 447.38 SUP HCPCS C1713 447.38 - PLATE BONE 193MM BRD SPC CRANFCL TI 30 HOLE ADP 2MM SCR BOTH IP/OP "$1,156.50 " $855.81 $0.00 $925.20 $520.43 $520.43 $0.00 $0.00 $0.00 $241.04 $858.35 $858.35 $0.00 $0.00 $241.01 $0.00 $684.07 $684.07 $0.00 $578.25 $915.95 $925.20 $0.00 $0.00 $180.99 $0.00 $0.00 $184.11 $0.00 $0.00 $0.00 $0.00 $0.00 447.404 SUP HCPCS C1713 447.404 - PLATE LG 1.5MM MANDIB 4X20X4 HOLE LCK 2 ANG 2MM SCR BONE TI BOTH IP/OP "$4,916.25 " "$3,638.03" $0.00 "$3,933.00" "$2,212.31" "$2,212.31" $0.00 $0.00 $0.00 "$1,024.67" "$3,648.84" "$3,648.84" $0.00 $0.00 "$1,024.55" $0.00 "$2,423.71" "$2,423.71" $0.00 "$2,458.13" "$3,893.67" "$3,933.00" $0.00 $0.00 $769.39 $0.00 $0.00 $782.67 $0.00 $0.00 $0.00 $0.00 $0.00 447.405 SUP HCPCS C1713 447.405 - PLATE LG 1.5MM MANDIB 5X22X5 HOLE LCK 2 ANG 2MM SCR BONE TI BOTH IP/OP "$5,190.75 " "$3,841.16" $0.00 "$4,152.60" "$2,335.84" "$2,335.84" $0.00 $0.00 $0.00 "$1,081.88" "$3,852.57" "$3,852.57" $0.00 $0.00 "$1,081.75" $0.00 "$2,559.04" "$2,559.04" $0.00 "$2,595.38" "$4,111.07" "$4,152.60" $0.00 $0.00 $812.35 $0.00 $0.00 $826.37 $0.00 $0.00 $0.00 $0.00 $0.00 447.406 SUP HCPCS C1713 447.406 - PLATE LG 1.5MM MANDIB 6X24X6 HOLE LCK 2 ANG 2MM SCR BONE TI BOTH IP/OP "$5,474.25 " "$4,050.95" $0.00 "$4,379.40" "$2,463.41" "$2,463.41" $0.00 $0.00 $0.00 "$1,140.97" "$4,062.99" "$4,062.99" $0.00 $0.00 "$1,140.83" $0.00 "$2,698.81" "$2,698.81" $0.00 "$2,737.13" "$4,335.61" "$4,379.40" $0.00 $0.00 $856.72 $0.00 $0.00 $871.50 $0.00 $0.00 $0.00 $0.00 $0.00 447.412 SUP HCPCS C1713 447.412 - PLATE 2MM MANDIB 12 HOLE X LCK STR 2MM SCR BONE TI NONSTRL BOTH IP/OP "$1,953.00 " "$1,445.22" $0.00 "$1,562.40" $878.85 $878.85 $0.00 $0.00 $0.00 $407.05 "$1,449.52" "$1,449.52" $0.00 $0.00 $407.01 $0.00 "$1,155.20" "$1,155.20" $0.00 $976.50 "$1,546.78" "$1,562.40" $0.00 $0.00 $305.64 $0.00 $0.00 $310.92 $0.00 $0.00 $0.00 $0.00 $0.00 447.42 SUP HCPCS C1713 447.420 - PLATE 2MM MANDIB 20 HOLE X LCK STR 2MM SCR BONE TI NONSTRL BOTH IP/OP "$2,697.75 " "$1,996.34" $0.00 "$2,158.20" "$1,213.99" "$1,213.99" $0.00 $0.00 $0.00 $562.28 "$2,002.27" "$2,002.27" $0.00 $0.00 $562.21 $0.00 "$1,329.99" "$1,329.99" $0.00 "$1,348.88" "$2,136.62" "$2,158.20" $0.00 $0.00 $422.20 $0.00 $0.00 $429.48 $0.00 $0.00 $0.00 $0.00 $0.00 447.422 SUP HCPCS C1713 447.422 - PLATE 2MM MANDIB 6X21 HOLE X LCK RIGHT ANG 2MM SCR BONE TI BOTH IP/OP "$4,459.50 " "$3,300.03" $0.00 "$3,567.60" "$2,006.78" "$2,006.78" $0.00 $0.00 $0.00 $929.47 "$3,309.84" "$3,309.84" $0.00 $0.00 $929.36 $0.00 "$2,198.53" "$2,198.53" $0.00 "$2,229.75" "$3,531.92" "$3,567.60" $0.00 $0.00 $697.91 $0.00 $0.00 $709.95 $0.00 $0.00 $0.00 $0.00 $0.00 447.423 SUP HCPCS C1713 447.423 - PLATE MANDIB 6X21 HOLE X LCK LEFT ANG 2 MM SCR BONE TI BOTH IP/OP "$4,459.50 " "$3,300.03" $0.00 "$3,567.60" "$2,006.78" "$2,006.78" $0.00 $0.00 $0.00 $929.47 "$3,309.84" "$3,309.84" $0.00 $0.00 $929.36 $0.00 "$2,198.53" "$2,198.53" $0.00 "$2,229.75" "$3,531.92" "$3,567.60" $0.00 $0.00 $697.91 $0.00 $0.00 $709.95 $0.00 $0.00 $0.00 $0.00 $0.00 447.424 SUP HCPCS C1713 447.424 - PLATE 2MM MANDIB 4X20X4 HOLE X LCK 2 ANG 2MM SCR BONE TI BOTH IP/OP "$5,154.75 " "$3,814.52" $0.00 "$4,123.80" "$2,319.64" "$2,319.64" $0.00 $0.00 $0.00 "$1,074.38" "$3,825.86" "$3,825.86" $0.00 $0.00 "$1,074.25" $0.00 "$2,541.29" "$2,541.29" $0.00 "$2,577.38" "$4,082.56" "$4,123.80" $0.00 $0.00 $806.72 $0.00 $0.00 $820.64 $0.00 $0.00 $0.00 $0.00 $0.00 447.425 SUP HCPCS C1713 447.425 - PLATE 2MM MANDIB 5X22X5 HOLE X LCK 2 ANG 2MM SCR BONE TI BOTH IP/OP "$5,447.25 " "$4,030.97" $0.00 "$4,357.80" "$2,451.26" "$2,451.26" $0.00 $0.00 $0.00 "$1,135.34" "$4,042.95" "$4,042.95" $0.00 $0.00 "$1,135.21" $0.00 "$2,685.49" "$2,685.49" $0.00 "$2,723.63" "$4,314.22" "$4,357.80" $0.00 $0.00 $852.49 $0.00 $0.00 $867.20 $0.00 $0.00 $0.00 $0.00 $0.00 447.426 SUP HCPCS C1713 447.426 - PLATE 2MM MANDIB 6X24X6 HOLE X LCK 2 ANG 2MM SCR BONE TI BOTH IP/OP "$5,735.25 " "$4,244.09" $0.00 "$4,588.20" "$2,580.86" "$2,580.86" $0.00 $0.00 $0.00 "$1,195.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.23" $0.00 "$2,827.48" "$2,827.48" $0.00 "$2,867.63" "$4,542.32" "$4,588.20" $0.00 $0.00 $897.57 $0.00 $0.00 $913.05 $0.00 $0.00 $0.00 $0.00 $0.00 447.5 SUP HCPCS C1713 447.50 - PLATE BN 5MM SPC OB L L 25X10X.9MM NS 4.8MM 2 HL BS 3 HL BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 447.51 SUP HCPCS C1713 447.51 - PLATE 100D TI 2MM SCR 3 HOLE RIGHT OBLQ BONE ORTH NONSTRL BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 447.515 SUP HCPCS C1713 447.515 - PLATE BONE 100D CRANFCL TI 2X3 HOLE L RIGHT OBLQ MALBLE 2MM BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $247.05 $247.05 $0.00 $0.00 $0.00 $114.43 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $324.73 $324.73 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $85.92 $0.00 $0.00 $87.40 $0.00 $0.00 $0.00 $0.00 $0.00 447.516 SUP HCPCS C1713 447.516 - PLATE BONE 100D CRANFCL TI 2X3 HOLE L LEFT OBLQ MALBLE 2MM BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $247.05 $247.05 $0.00 $0.00 $0.00 $114.43 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $324.73 $324.73 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $85.92 $0.00 $0.00 $87.40 $0.00 $0.00 $0.00 $0.00 $0.00 447.52 SUP HCPCS C1713 447.52 - PLATE BN 5MM SPC OB L L 31X15X.9MM NS 4.8MM 3 HL BS 4 HL BOTH IP/OP $587.25 $434.57 $0.00 $469.80 $264.26 $264.26 $0.00 $0.00 $0.00 $122.40 $435.86 $435.86 $0.00 $0.00 $122.38 $0.00 $347.36 $347.36 $0.00 $293.63 $465.10 $469.80 $0.00 $0.00 $91.90 $0.00 $0.00 $93.49 $0.00 $0.00 $0.00 $0.00 $0.00 447.521 SUP HCPCS C1713 447.521 - PLATE BONE 100D CRANFCL TI 4X3 HOLE L RIGHT OBLQ NO BAR 2MM BOTH IP/OP $481.50 $356.31 $0.00 $385.20 $216.68 $216.68 $0.00 $0.00 $0.00 $100.36 $357.37 $357.37 $0.00 $0.00 $100.34 $0.00 $284.81 $284.81 $0.00 $240.75 $381.35 $385.20 $0.00 $0.00 $75.35 $0.00 $0.00 $76.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.522 SUP HCPCS C1713 447.522 - PLATE BONE 100D CRANFCL TI 4X3 HOLE L LEFT OBLQ NO BAR 2MM BOTH IP/OP $481.50 $356.31 $0.00 $385.20 $216.68 $216.68 $0.00 $0.00 $0.00 $100.36 $357.37 $357.37 $0.00 $0.00 $100.34 $0.00 $284.81 $284.81 $0.00 $240.75 $381.35 $385.20 $0.00 $0.00 $75.35 $0.00 $0.00 $76.65 $0.00 $0.00 $0.00 $0.00 $0.00 447.524 SUP HCPCS C1713 447.524 - PLATE BONE 20MM 90D RIGHT CRNMXF TI 2X2 HOLE L 2MM SCR BOTH IP/OP $488.25 $361.31 $0.00 $390.60 $219.71 $219.71 $0.00 $0.00 $0.00 $101.76 $362.38 $362.38 $0.00 $0.00 $101.75 $0.00 $288.80 $288.80 $0.00 $244.13 $386.69 $390.60 $0.00 $0.00 $76.41 $0.00 $0.00 $77.73 $0.00 $0.00 $0.00 $0.00 $0.00 447.525 SUP HCPCS C1713 447.525 - PLATE BONE 20MM 90D LEFT CRNMXF TI 2X2 HOLE L 2MM SCR BOTH IP/OP $488.25 $361.31 $0.00 $390.60 $219.71 $219.71 $0.00 $0.00 $0.00 $101.76 $362.38 $362.38 $0.00 $0.00 $101.75 $0.00 $288.80 $288.80 $0.00 $244.13 $386.69 $390.60 $0.00 $0.00 $76.41 $0.00 $0.00 $77.73 $0.00 $0.00 $0.00 $0.00 $0.00 447.527 SUP HCPCS C1713 447.527 - PLATE BONE 100D CRANFCL TI 3X4 HOLE L LEFT OBLQ MALBLE 2MM BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $259.20 $259.20 $0.00 $0.00 $0.00 $120.05 $427.51 $427.51 $0.00 $0.00 $120.04 $0.00 $340.70 $340.70 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $90.14 $0.00 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $0.00 447.53 SUP HCPCS C1713 447.53 - PLATE BN 5MM SPC OB R L 31X15X.9MM NS 4.8MM 3 HL BS 4 HL BOTH IP/OP $587.25 $434.57 $0.00 $469.80 $264.26 $264.26 $0.00 $0.00 $0.00 $122.40 $435.86 $435.86 $0.00 $0.00 $122.38 $0.00 $347.36 $347.36 $0.00 $293.63 $465.10 $469.80 $0.00 $0.00 $91.90 $0.00 $0.00 $93.49 $0.00 $0.00 $0.00 $0.00 $0.00 447.537 SUP HCPCS C1713 447.537 - PLATE BONE 100D CRANFCL TI 3X4 HOLE L RIGHT OBLQ MALBLE 2MM BOTH IP/OP $576.00 $426.24 $0.00 $460.80 $259.20 $259.20 $0.00 $0.00 $0.00 $120.05 $427.51 $427.51 $0.00 $0.00 $120.04 $0.00 $340.70 $340.70 $0.00 $288.00 $456.19 $460.80 $0.00 $0.00 $90.14 $0.00 $0.00 $91.70 $0.00 $0.00 $0.00 $0.00 $0.00 447.54 SUP HCPCS C1713 447.54 - PLATE BN 5MM SPC OB L L 41X20X.9MM NS 4.8MM 4 HL BS 6 HL BOTH IP/OP $641.25 $474.53 $0.00 $513.00 $288.56 $288.56 $0.00 $0.00 $0.00 $133.65 $475.94 $475.94 $0.00 $0.00 $133.64 $0.00 $379.30 $379.30 $0.00 $320.63 $507.87 $513.00 $0.00 $0.00 $100.36 $0.00 $0.00 $102.09 $0.00 $0.00 $0.00 $0.00 $0.00 447.546 SUP HCPCS C1713 447.546 - PLATE SHRT MAXFACL 2X2 HOLE L RIGHT OBLQ MALBLE 2MM SCR BONE BOTH IP/OP $429.75 $318.02 $0.00 $343.80 $193.39 $193.39 $0.00 $0.00 $0.00 $89.57 $318.96 $318.96 $0.00 $0.00 $89.56 $0.00 $254.20 $254.20 $0.00 $214.88 $340.36 $343.80 $0.00 $0.00 $67.26 $0.00 $0.00 $68.42 $0.00 $0.00 $0.00 $0.00 $0.00 447.547 SUP HCPCS C1713 447.547 - PLATE SHRT MAXFACL 2X2 HOLE L LEFT OBLQ MALBLE 2MM SCR BONE BOTH IP/OP $429.75 $318.02 $0.00 $343.80 $193.39 $193.39 $0.00 $0.00 $0.00 $89.57 $318.96 $318.96 $0.00 $0.00 $89.56 $0.00 $254.20 $254.20 $0.00 $214.88 $340.36 $343.80 $0.00 $0.00 $67.26 $0.00 $0.00 $68.42 $0.00 $0.00 $0.00 $0.00 $0.00 447.548 SUP HCPCS C1713 447.548 - PLATE LNG MAXFACL 2X2 HOLE L RIGHT OBLQ MALBLE 2MM SCR BONE BOTH IP/OP $486.00 $359.64 $0.00 $388.80 $218.70 $218.70 $0.00 $0.00 $0.00 $101.29 $360.71 $360.71 $0.00 $0.00 $101.28 $0.00 $287.47 $287.47 $0.00 $243.00 $384.91 $388.80 $0.00 $0.00 $76.06 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $0.00 447.549 SUP HCPCS C1713 447.549 - PLATE LNG MAXFACL 2X2 HOLE L LEFT OBLQ MALBLE 2MM SCR BONE BOTH IP/OP $486.00 $359.64 $0.00 $388.80 $218.70 $218.70 $0.00 $0.00 $0.00 $101.29 $360.71 $360.71 $0.00 $0.00 $101.28 $0.00 $287.47 $287.47 $0.00 $243.00 $384.91 $388.80 $0.00 $0.00 $76.06 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $0.00 447.55 SUP HCPCS C1713 447.55 - PLATE BN 5MM SPC OB R L 41X20X.9MM NS 4.8MM 4 HL BS 6 HL BOTH IP/OP $641.25 $474.53 $0.00 $513.00 $288.56 $288.56 $0.00 $0.00 $0.00 $133.65 $475.94 $475.94 $0.00 $0.00 $133.64 $0.00 $379.30 $379.30 $0.00 $320.63 $507.87 $513.00 $0.00 $0.00 $100.36 $0.00 $0.00 $102.09 $0.00 $0.00 $0.00 $0.00 $0.00 447.556 SUP HCPCS C1713 447.556 - PLATE SHRT TI 2MM SCR L 2X2 HOLE BONE LEFT OBLQ NONSTRL BOTH IP/OP $486.00 $359.64 $0.00 $388.80 $218.70 $218.70 $0.00 $0.00 $0.00 $101.29 $360.71 $360.71 $0.00 $0.00 $101.28 $0.00 $287.47 $287.47 $0.00 $243.00 $384.91 $388.80 $0.00 $0.00 $76.06 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $0.00 447.557 SUP HCPCS C1713 447.557 - PLATE SHRT TI 2MM SCR L OBLQ 2X2 HOLE BONE LEFT NONSTRL BOTH IP/OP $486.00 $359.64 $0.00 $388.80 $218.70 $218.70 $0.00 $0.00 $0.00 $101.29 $360.71 $360.71 $0.00 $0.00 $101.28 $0.00 $287.47 $287.47 $0.00 $243.00 $384.91 $388.80 $0.00 $0.00 $76.06 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $0.00 447.558 SUP HCPCS C1713 447.558 - PLATE LNG TI 2MM SCR L OBLQ 2X2 HOLE BONE RIGHT NONSTRL BOTH IP/OP $486.00 $359.64 $0.00 $388.80 $218.70 $218.70 $0.00 $0.00 $0.00 $101.29 $360.71 $360.71 $0.00 $0.00 $101.28 $0.00 $287.47 $287.47 $0.00 $243.00 $384.91 $388.80 $0.00 $0.00 $76.06 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $0.00 447.559 SUP HCPCS C1713 447.559 - PLATE LNG TI 2MM SCR L OBLQ 2X2 HOLE BONE LEFT NONSTRL BOTH IP/OP $486.00 $359.64 $0.00 $388.80 $218.70 $218.70 $0.00 $0.00 $0.00 $101.29 $360.71 $360.71 $0.00 $0.00 $101.28 $0.00 $287.47 $287.47 $0.00 $243.00 $384.91 $388.80 $0.00 $0.00 $76.06 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $0.00 447.562 SUP HCPCS C1713 447.562 - PLATE SHRT TI 2MM SCR Z BONE RIGHT NONSTRL BOTH IP/OP $551.25 $407.93 $0.00 $441.00 $248.06 $248.06 $0.00 $0.00 $0.00 $114.89 $409.14 $409.14 $0.00 $0.00 $114.88 $0.00 $326.06 $326.06 $0.00 $275.63 $436.59 $441.00 $0.00 $0.00 $86.27 $0.00 $0.00 $87.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.563 SUP HCPCS C1713 447.563 - PLATE SHRT TI 2MM SCR Z BONE LEFT NONSTRL BOTH IP/OP $551.25 $407.93 $0.00 $441.00 $248.06 $248.06 $0.00 $0.00 $0.00 $114.89 $409.14 $409.14 $0.00 $0.00 $114.88 $0.00 $326.06 $326.06 $0.00 $275.63 $436.59 $441.00 $0.00 $0.00 $86.27 $0.00 $0.00 $87.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.564 SUP HCPCS C1713 447.564 - PLATE LNG TI 2MM SCR Z BONE RIGHT NONSTRL BOTH IP/OP $551.25 $407.93 $0.00 $441.00 $248.06 $248.06 $0.00 $0.00 $0.00 $114.89 $409.14 $409.14 $0.00 $0.00 $114.88 $0.00 $326.06 $326.06 $0.00 $275.63 $436.59 $441.00 $0.00 $0.00 $86.27 $0.00 $0.00 $87.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.565 SUP HCPCS C1713 447.565 - PLATE LNG TI 2MM SCR Z BONE LEFT NONSTRL BOTH IP/OP $551.25 $407.93 $0.00 $441.00 $248.06 $248.06 $0.00 $0.00 $0.00 $114.89 $409.14 $409.14 $0.00 $0.00 $114.88 $0.00 $326.06 $326.06 $0.00 $275.63 $436.59 $441.00 $0.00 $0.00 $86.27 $0.00 $0.00 $87.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.572 SUP HCPCS C1713 447.572 - PLATE SHRT RIGHT MAXFACL Z MALBLE 2MM SCR BONE TI NONSTRL BOTH IP/OP $551.25 $407.93 $0.00 $441.00 $248.06 $248.06 $0.00 $0.00 $0.00 $114.89 $409.14 $409.14 $0.00 $0.00 $114.88 $0.00 $326.06 $326.06 $0.00 $275.63 $436.59 $441.00 $0.00 $0.00 $86.27 $0.00 $0.00 $87.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.573 SUP HCPCS C1713 447.573 - PLATE SHRT LEFT MAXFACL Z MALBLE 2MM SCR BONE TI NONSTRL BOTH IP/OP $551.25 $407.93 $0.00 $441.00 $248.06 $248.06 $0.00 $0.00 $0.00 $114.89 $409.14 $409.14 $0.00 $0.00 $114.88 $0.00 $326.06 $326.06 $0.00 $275.63 $436.59 $441.00 $0.00 $0.00 $86.27 $0.00 $0.00 $87.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.574 SUP HCPCS C1713 447.574 - PLATE LNG RIGHT MAXFACL Z MALBLE 2MM SCR BONE TI NONSTRL BOTH IP/OP $551.25 $407.93 $0.00 $441.00 $248.06 $248.06 $0.00 $0.00 $0.00 $114.89 $409.14 $409.14 $0.00 $0.00 $114.88 $0.00 $326.06 $326.06 $0.00 $275.63 $436.59 $441.00 $0.00 $0.00 $86.27 $0.00 $0.00 $87.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.575 SUP HCPCS C1713 447.575 - PLATE LNG LEFT MAXFACL Z MALBLE 2MM SCR BONE TI NONSTRL BOTH IP/OP $551.25 $407.93 $0.00 $441.00 $248.06 $248.06 $0.00 $0.00 $0.00 $114.89 $409.14 $409.14 $0.00 $0.00 $114.88 $0.00 $326.06 $326.06 $0.00 $275.63 $436.59 $441.00 $0.00 $0.00 $86.27 $0.00 $0.00 $87.76 $0.00 $0.00 $0.00 $0.00 $0.00 447.61 SUP HCPCS C1713 447.61 - PLATE BONE CRNMXF TI 5 HOLE Y 2 MM SCR NONSTRL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 447.612 SUP HCPCS C1713 447.612 - PLATE BN Y 48X5X1.2MM NS PRO-PK 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $483.55 $357.83 $0.00 $375.58 $211.26 $211.26 $0.00 $0.00 $0.00 $100.78 $358.89 $358.89 $0.00 $0.00 $100.77 $0.00 $286.02 $286.02 $0.00 $234.74 $371.83 $375.58 $0.00 $0.00 $71.33 $0.00 $0.00 $74.74 $0.00 $0.00 $0.00 $0.00 $0.00 447.615 SUP HCPCS C1713 447.615 - PLATE BONE 3 HOLE HEAD 7 HOLE SHAFT T LCP TITANIUM BOTH IP/OP $812.50 $601.25 $0.00 $631.06 $354.97 $354.97 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $394.41 $624.75 $631.06 $0.00 $0.00 $119.86 $0.00 $0.00 $125.58 $0.00 $0.00 $0.00 $0.00 $0.00 447.62 SUP HCPCS C1713 447.62 - PLATE BN Y 32X19X.9MM NS 4.8MM 2 HLE/HD 4 HL SHFT 2 ARM TI BOTH IP/OP $580.50 $429.57 $0.00 $464.40 $261.23 $261.23 $0.00 $0.00 $0.00 $120.99 $430.85 $430.85 $0.00 $0.00 $120.98 $0.00 $343.37 $343.37 $0.00 $290.25 $459.76 $464.40 $0.00 $0.00 $90.85 $0.00 $0.00 $92.42 $0.00 $0.00 $0.00 $0.00 $0.00 447.63 SUP HCPCS C1713 447.630 - PLATE BONE CRANFCL TI 7 HOLE Y 2 MM SCR NONSTRL BOTH IP/OP $490.50 $362.97 $0.00 $392.40 $220.73 $220.73 $0.00 $0.00 $0.00 $102.23 $364.05 $364.05 $0.00 $0.00 $102.22 $0.00 $290.13 $290.13 $0.00 $245.25 $388.48 $392.40 $0.00 $0.00 $76.76 $0.00 $0.00 $78.09 $0.00 $0.00 $0.00 $0.00 $0.00 447.68 SUP HCPCS C1713 447.68 - PLATE BONE CRANFCL TI 8 HOLE 2 Y 2 MM SCR NONSTRL BOTH IP/OP $600.75 $444.56 $0.00 $480.60 $270.34 $270.34 $0.00 $0.00 $0.00 $125.21 $445.88 $445.88 $0.00 $0.00 $125.20 $0.00 $355.34 $355.34 $0.00 $300.38 $475.79 $480.60 $0.00 $0.00 $94.02 $0.00 $0.00 $95.64 $0.00 $0.00 $0.00 $0.00 $0.00 447.681 SUP HCPCS C1713 447.681 - PLATE TI 2 MM SCR 8 HOLE Y BONE NONSTRL BOTH IP/OP $600.75 $444.56 $0.00 $480.60 $270.34 $270.34 $0.00 $0.00 $0.00 $125.21 $445.88 $445.88 $0.00 $0.00 $125.20 $0.00 $355.34 $355.34 $0.00 $300.38 $475.79 $480.60 $0.00 $0.00 $94.02 $0.00 $0.00 $95.64 $0.00 $0.00 $0.00 $0.00 $0.00 447.702 SUP HCPCS C1713 447.702 - PLATE BONE SMALL 24X18MM X LOCKING TITANIUM FT NONSTRL BOTH IP/OP "$1,439.43 " "$1,065.18" $0.00 "$1,118.00" $628.88 $628.88 $0.00 $0.00 $0.00 $300.01 "$1,068.34" "$1,068.34" $0.00 $0.00 $299.98 $0.00 $851.42 $851.42 $0.00 $698.75 "$1,106.82" "$1,118.00" $0.00 $0.00 $212.34 $0.00 $0.00 $222.48 $0.00 $0.00 $0.00 $0.00 $0.00 447.704 SUP HCPCS C1713 447.704 - PLATE BONE MEDIUM 30X20MM X LOCKING TITANIUM FT NONSTRL BOTH IP/OP "$1,457.70 " "$1,078.70" $0.00 "$1,132.20" $636.86 $636.86 $0.00 $0.00 $0.00 $303.82 "$1,081.90" "$1,081.90" $0.00 $0.00 $303.78 $0.00 $862.23 $862.23 $0.00 $707.63 "$1,120.88" "$1,132.20" $0.00 $0.00 $215.03 $0.00 $0.00 $225.31 $0.00 $0.00 $0.00 $0.00 $0.00 447.706 SUP HCPCS C1713 447.706 - PLATE BONE LARGE 36X20MM X LOCKING TITANIUM FT NONSTRL BOTH IP/OP "$1,477.38 " "$1,093.26" $0.00 "$1,147.48" $645.46 $645.46 $0.00 $0.00 $0.00 $307.92 "$1,096.51" "$1,096.51" $0.00 $0.00 $307.88 $0.00 $873.87 $873.87 $0.00 $717.18 "$1,136.01" "$1,147.48" $0.00 $0.00 $217.94 $0.00 $0.00 $228.35 $0.00 $0.00 $0.00 $0.00 $0.00 447.71 SUP HCPCS C1713 447.710 - PLATE BN STRG 17X6X1.6MM NS 2 HL LCK RND THRD HL TI HND/MDFT BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $306.45 $306.45 $0.00 $0.00 $0.00 $141.94 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $402.81 $402.81 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $103.47 $0.00 $0.00 $108.42 $0.00 $0.00 $0.00 $0.00 $0.00 447.711 SUP HCPCS C1713 447.711 - PLATE BONE XS 22X14MM X LOCKING TITANIUM NONSTRL 2.4/2.7MM BOTH IP/OP "$1,460.53 " "$1,080.79" $0.00 "$1,134.38" $638.09 $638.09 $0.00 $0.00 $0.00 $304.41 "$1,084.00" "$1,084.00" $0.00 $0.00 $304.37 $0.00 $863.90 $863.90 $0.00 $708.99 "$1,123.04" "$1,134.38" $0.00 $0.00 $215.45 $0.00 $0.00 $225.74 $0.00 $0.00 $0.00 $0.00 $0.00 447.81 SUP HCPCS C1713 447.81 - PLATE BN 13MM SPC X 18X18X.9MM NS 4.8MM 4 HL TI CRNFCL 2MM BOTH IP/OP $528.75 $391.28 $0.00 $423.00 $237.94 $237.94 $0.00 $0.00 $0.00 $110.20 $392.44 $392.44 $0.00 $0.00 $110.19 $0.00 $312.76 $312.76 $0.00 $264.38 $418.77 $423.00 $0.00 $0.00 $82.75 $0.00 $0.00 $84.18 $0.00 $0.00 $0.00 $0.00 $0.00 447.811 SUP HCPCS C1713 447.811 - PLATE BONE CRANFCL TI 4 HOLE X MALBLE 2 MM SCR NONSTRL BOTH IP/OP $432.00 $319.68 $0.00 $345.60 $194.40 $194.40 $0.00 $0.00 $0.00 $90.04 $320.63 $320.63 $0.00 $0.00 $90.03 $0.00 $255.53 $255.53 $0.00 $216.00 $342.14 $345.60 $0.00 $0.00 $67.61 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 447.85 SUP HCPCS C1713 447.85 - PLATE BONE CRANFCL TI 9 HOLE H 2 MM SCR NONSTRL BOTH IP/OP $594.00 $439.56 $0.00 $475.20 $267.30 $267.30 $0.00 $0.00 $0.00 $123.80 $440.87 $440.87 $0.00 $0.00 $123.79 $0.00 $351.35 $351.35 $0.00 $297.00 $470.45 $475.20 $0.00 $0.00 $92.96 $0.00 $0.00 $94.56 $0.00 $0.00 $0.00 $0.00 $0.00 447.86 SUP HCPCS C1713 447.86 - PLATE BONE CRANFCL TI 8 HOLE H 2 MM SCR NONSTRL BOTH IP/OP $594.00 $439.56 $0.00 $475.20 $267.30 $267.30 $0.00 $0.00 $0.00 $123.80 $440.87 $440.87 $0.00 $0.00 $123.79 $0.00 $351.35 $351.35 $0.00 $297.00 $470.45 $475.20 $0.00 $0.00 $92.96 $0.00 $0.00 $94.56 $0.00 $0.00 $0.00 $0.00 $0.00 447.915 SUP HCPCS C1713 447.915 - PLATE BONE 13X13MM CRANFCL TI 4 HOLE BOX 2MM SCR NONSTRL BOTH IP/OP $474.75 $351.32 $0.00 $379.80 $213.64 $213.64 $0.00 $0.00 $0.00 $98.95 $352.36 $352.36 $0.00 $0.00 $98.94 $0.00 $280.81 $280.81 $0.00 $237.38 $376.00 $379.80 $0.00 $0.00 $74.30 $0.00 $0.00 $75.58 $0.00 $0.00 $0.00 $0.00 $0.00 449.004 SUP HCPCS C1713 449.004 - PLATE BN NAR STRG 29X4.8X1MM NS 4 HL LOPRFL TI MNDB 2MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.006 SUP HCPCS C1713 449.006 - PLATE BN NAR STRG 42X4.8X1MM NS 6 HL LOPRFL TI MNDB 2MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.008 SUP HCPCS C1713 449.008 - PLATE NAR 55MM MANDIB 8 HOLE STR 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.014 SUP HCPCS C1713 449.014 - PLATE BN CRV NAR 29X4.8X1MM NS 4 HL LOPRFL TI MNDB 2MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.016 SUP HCPCS C1713 449.016 - PLATE BN CRV NAR 41X4.8X1MM NS 6 HL LOPRFL TI MNDB 2MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.017 SUP HCPCS C1713 449.017 - PLATE NAR MANDIB 6 HOLE STRUT 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.018 SUP HCPCS C1713 449.018 - PLATE MANDIB 8 HOLE CVD STRUT 2 MM SCR BONE TI NONSTRL BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 449.02 SUP HCPCS C1713 449.020 - PLATE 119MM MANDIB 20 HOLE ADP 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.021 SUP HCPCS C1713 449.021 - PLATE BONE 100MM CRANFCL TI 2X20 HOLE 2 ADP 2MM SCR BILAT BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 449.024 SUP HCPCS C1713 449.024 - PLATE BN BRD STRG 29X4.8X1.25MM NS 4 HL LOPRFL TI MNDB 2MM BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.025 SUP HCPCS C1713 449.025 - PLATE BN BRD CRV 29X4.8X1.25MM NS 4 HL LOPRFL TI MNDB 2MM BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.026 SUP HCPCS C1713 449.026 - PLATE BN BRD STRG 42X4.8X1.25MM NS 6 HL LOPRFL TI MNDB 2MM BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.027 SUP HCPCS C1713 449.027 - PLATE BN BRD CRV 41X4.8X1.25MM NS 6 HL LOPRFL TI MNDB 2MM BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.028 SUP HCPCS C1713 449.028 - PLATE BN BRD STRG 55X4.8X1.25MM NS 8 HL LOPRFL TI MNDB 2MM BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.032 SUP HCPCS C1713 449.032 - PLATE 21MM MANDIB 4X4 HOLE ANG 2MM SCR BONE DCP TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.034 SUP HCPCS C1713 449.034 - PLATE BN 30X5X1.25MM NS DCP 4 HL LOPRFL TI MNDB 2MM SCR MDLR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.035 SUP HCPCS C1713 449.035 - PLATE BN 32X5X1.25MM NS DCP 5 HL LOPRFL TI MNDB 2MM SCR MDLR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.036 SUP HCPCS C1713 449.036 - PLATE BN 42X5X1.25MM NS DCP 6 HL LOPRFL TI MNDB 2MM SCR MDLR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.037 SUP HCPCS C1713 449.037 - PLATE 48MM MANDIB 7 HOLE 2MM SCR BONE DCP TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.038 SUP HCPCS C1713 449.038 - PLATE 54MM MANDIB 8 HOLE 2MM SCR BONE DCP TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.04 SUP HCPCS C1713 449.04 - PLATE 22MM MANDIB 4 HOLE STR TNSNBND 2MM SCR BONE TI NONSTRL BOTH IP/OP $857.25 $634.37 $0.00 $685.80 $385.76 $385.76 $0.00 $0.00 $0.00 $178.67 $636.25 $636.25 $0.00 $0.00 $178.65 $0.00 $507.06 $507.06 $0.00 $428.63 $678.94 $685.80 $0.00 $0.00 $134.16 $0.00 $0.00 $136.47 $0.00 $0.00 $0.00 $0.00 $0.00 449.05 SUP HCPCS C1713 449.05 - PLATE 25MM MANDIB 4 HOLE STR TNSNBND 2MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.06 SUP HCPCS C1713 449.06 - PLATE 35MM MANDIB 6 HOLE STR TNSNBND 2MM SCR BONE TI NONSTRL BOTH IP/OP $954.00 $705.96 $0.00 $763.20 $429.30 $429.30 $0.00 $0.00 $0.00 $198.84 $708.06 $708.06 $0.00 $0.00 $198.81 $0.00 $564.29 $564.29 $0.00 $477.00 $755.57 $763.20 $0.00 $0.00 $149.30 $0.00 $0.00 $151.88 $0.00 $0.00 $0.00 $0.00 $0.00 449.1 SUP HCPCS C1713 449.100 - PLATE 26MM MANDIB 4 HOLE CMPR TNSNBND 2.4MM SCR BONE LC DCP BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.11 SUP HCPCS C1713 449.110 - PLATE 36MM MANDIB 6 HOLE CMPR TNSNBND 2.4MM SCR BONE LC DCP BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.14 SUP HCPCS C1713 449.14 - PLATE BN 35X6.5X1.65MM NS LC DCP 4 HL TI MNDB 2.4MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.15 SUP HCPCS C1713 449.15 - PLATE BN 39X6.5X1.65MM NS LC DCP 5 HL TI MNDB 2.4MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.16 SUP HCPCS C1713 449.16 - PLATE BN 51X6.5X1.65MM NS LC DCP 6 HL TI MNDB 2.4MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.234 SUP HCPCS C1713 449.234 - PLATE 35MM MANDIB 4 HOLE ECNTRC 2.4MM SCR BONE LC DCP TI BOTH IP/OP "$1,359.00 " "$1,005.66" $0.00 "$1,087.20" $611.55 $611.55 $0.00 $0.00 $0.00 $283.25 "$1,008.65" "$1,008.65" $0.00 $0.00 $283.22 $0.00 $803.85 $803.85 $0.00 $679.50 "$1,076.33" "$1,087.20" $0.00 $0.00 $212.68 $0.00 $0.00 $216.35 $0.00 $0.00 $0.00 $0.00 $0.00 449.236 SUP HCPCS C1713 449.236 - PLATE 6 HOLE ECNTRC 2.4 MM SCR BONE LC DCP TI NONSTRL BOTH IP/OP "$1,638.00 " "$1,212.12" $0.00 "$1,310.40" $737.10 $737.10 $0.00 $0.00 $0.00 $341.40 "$1,215.72" "$1,215.72" $0.00 $0.00 $341.36 $0.00 $968.88 $968.88 $0.00 $819.00 "$1,297.30" "$1,310.40" $0.00 $0.00 $256.35 $0.00 $0.00 $260.77 $0.00 $0.00 $0.00 $0.00 $0.00 449.24 SUP HCPCS C1713 449.24 - PLATE 35X6.5X2MM MANDIB 4 HOLE CRSNT 2.4MM SCR BONE LC DCP BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.25 SUP HCPCS C1713 449.250 - PLATE 38MM MANDIB 5 HOLE CRSNT 2.4MM SCR BONE LC DCP TI BOTH IP/OP "$1,458.00 " "$1,078.92" $0.00 "$1,166.40" $656.10 $656.10 $0.00 $0.00 $0.00 $303.88 "$1,082.13" "$1,082.13" $0.00 $0.00 $303.85 $0.00 $862.41 $862.41 $0.00 $729.00 "$1,154.74" "$1,166.40" $0.00 $0.00 $228.18 $0.00 $0.00 $232.11 $0.00 $0.00 $0.00 $0.00 $0.00 449.26 SUP HCPCS C1713 449.26 - PLATE 50MM TI 2.4MM SCR 6 HOLE CRSNT LC DCP BONE MANDIB BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.38 SUP HCPCS C1713 449.38 - PLATE UNV 64MM MANDIB 8 HOLE 2.4MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.4 SUP HCPCS C1713 449.40 - PLATE UNV 80MM MANDIB 10 HOLE STR 2.4MM SCR BONE TI NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.412 SUP HCPCS C1713 449.412 - PLATE MAXFACL 12 HOLE STR MCVSC 2.4 MM SCR BONE TI NONSTRL BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $759.38 $759.38 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $264.09 $0.00 $0.00 $268.65 $0.00 $0.00 $0.00 $0.00 $0.00 449.416 SUP HCPCS C1713 449.416 - PLATE MAXFACL 16 HOLE STR MCVSC 2.4 MM SCR BONE TI NONSTRL BOTH IP/OP "$2,310.75 " "$1,709.96" $0.00 "$1,848.60" "$1,039.84" "$1,039.84" $0.00 $0.00 $0.00 $481.62 "$1,715.04" "$1,715.04" $0.00 $0.00 $481.56 $0.00 "$1,366.81" "$1,366.81" $0.00 "$1,155.38" "$1,830.11" "$1,848.60" $0.00 $0.00 $361.63 $0.00 $0.00 $367.87 $0.00 $0.00 $0.00 $0.00 $0.00 449.418 SUP HCPCS C1713 449.418 - PLATE MAXFACL 18 HOLE STR MCVSC 2.4 MM SCR BONE TI NONSTRL BOTH IP/OP "$2,623.50 " "$1,941.39" $0.00 "$2,098.80" "$1,180.58" "$1,180.58" $0.00 $0.00 $0.00 $546.80 "$1,947.16" "$1,947.16" $0.00 $0.00 $546.74 $0.00 "$1,293.39" "$1,293.39" $0.00 "$1,311.75" "$2,077.81" "$2,098.80" $0.00 $0.00 $410.58 $0.00 $0.00 $417.66 $0.00 $0.00 $0.00 $0.00 $0.00 449.42 SUP HCPCS C1713 449.420 - PLATE MAXFACL 20 HOLE STR MCVSC 2.4 MM SCR BONE TI NONSTRL BOTH IP/OP "$2,938.50 " "$2,174.49" $0.00 "$2,350.80" "$1,322.33" "$1,322.33" $0.00 $0.00 $0.00 $612.46 "$2,180.95" "$2,180.95" $0.00 $0.00 $612.38 $0.00 "$1,448.68" "$1,448.68" $0.00 "$1,469.25" "$2,327.29" "$2,350.80" $0.00 $0.00 $459.88 $0.00 $0.00 $467.81 $0.00 $0.00 $0.00 $0.00 $0.00 449.422 SUP HCPCS C1713 449.422 - PLATE MAXFACL 22 HOLE STR MCVSC 2.4 MM SCR BONE TI NONSTRL BOTH IP/OP "$2,938.50 " "$2,174.49" $0.00 "$2,350.80" "$1,322.33" "$1,322.33" $0.00 $0.00 $0.00 $612.46 "$2,180.95" "$2,180.95" $0.00 $0.00 $612.38 $0.00 "$1,448.68" "$1,448.68" $0.00 "$1,469.25" "$2,327.29" "$2,350.80" $0.00 $0.00 $459.88 $0.00 $0.00 $467.81 $0.00 $0.00 $0.00 $0.00 $0.00 449.424 SUP HCPCS C1713 449.424 - PLATE MAXFACL 24 HOLE STR MCVSC 2.4 MM SCR BONE TI NONSTRL BOTH IP/OP "$2,938.50 " "$2,174.49" $0.00 "$2,350.80" "$1,322.33" "$1,322.33" $0.00 $0.00 $0.00 $612.46 "$2,180.95" "$2,180.95" $0.00 $0.00 $612.38 $0.00 "$1,448.68" "$1,448.68" $0.00 "$1,469.25" "$2,327.29" "$2,350.80" $0.00 $0.00 $459.88 $0.00 $0.00 $467.81 $0.00 $0.00 $0.00 $0.00 $0.00 449.44 SUP HCPCS C1713 449.440 - PLATE MAXFACL 4X8 HOLE RIGHT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$2,938.50 " "$2,174.49" $0.00 "$2,350.80" "$1,322.33" "$1,322.33" $0.00 $0.00 $0.00 $612.46 "$2,180.95" "$2,180.95" $0.00 $0.00 $612.38 $0.00 "$1,448.68" "$1,448.68" $0.00 "$1,469.25" "$2,327.29" "$2,350.80" $0.00 $0.00 $459.88 $0.00 $0.00 $467.81 $0.00 $0.00 $0.00 $0.00 $0.00 449.441 SUP HCPCS C1713 449.441 - PLATE MAXFACL 4X8 HOLE LEFT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$2,938.50 " "$2,174.49" $0.00 "$2,350.80" "$1,322.33" "$1,322.33" $0.00 $0.00 $0.00 $612.46 "$2,180.95" "$2,180.95" $0.00 $0.00 $612.38 $0.00 "$1,448.68" "$1,448.68" $0.00 "$1,469.25" "$2,327.29" "$2,350.80" $0.00 $0.00 $459.88 $0.00 $0.00 $467.81 $0.00 $0.00 $0.00 $0.00 $0.00 449.442 SUP HCPCS C1713 449.442 - PLATE MAXFACL 4X16 HOLE RIGHT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$3,343.50 " "$2,474.19" $0.00 "$2,674.80" "$1,504.58" "$1,504.58" $0.00 $0.00 $0.00 $696.87 "$2,481.55" "$2,481.55" $0.00 $0.00 $696.79 $0.00 "$1,648.35" "$1,648.35" $0.00 "$1,671.75" "$2,648.05" "$2,674.80" $0.00 $0.00 $523.26 $0.00 $0.00 $532.29 $0.00 $0.00 $0.00 $0.00 $0.00 449.443 SUP HCPCS C1713 449.443 - PLATE MAXFACL 4X16 HOLE LEFT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$3,343.50 " "$2,474.19" $0.00 "$2,674.80" "$1,504.58" "$1,504.58" $0.00 $0.00 $0.00 $696.87 "$2,481.55" "$2,481.55" $0.00 $0.00 $696.79 $0.00 "$1,648.35" "$1,648.35" $0.00 "$1,671.75" "$2,648.05" "$2,674.80" $0.00 $0.00 $523.26 $0.00 $0.00 $532.29 $0.00 $0.00 $0.00 $0.00 $0.00 449.444 SUP HCPCS C1713 449.444 - PLATE MAXFACL 5X17 HOLE RIGHT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$3,660.75 " "$2,708.96" $0.00 "$2,928.60" "$1,647.34" "$1,647.34" $0.00 $0.00 $0.00 $762.99 "$2,717.01" "$2,717.01" $0.00 $0.00 $762.90 $0.00 "$1,804.75" "$1,804.75" $0.00 "$1,830.38" "$2,899.31" "$2,928.60" $0.00 $0.00 $572.91 $0.00 $0.00 $582.79 $0.00 $0.00 $0.00 $0.00 $0.00 449.445 SUP HCPCS C1713 449.445 - PLATE MAXFACL 5X17 HOLE LEFT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$3,660.75 " "$2,708.96" $0.00 "$2,928.60" "$1,647.34" "$1,647.34" $0.00 $0.00 $0.00 $762.99 "$2,717.01" "$2,717.01" $0.00 $0.00 $762.90 $0.00 "$1,804.75" "$1,804.75" $0.00 "$1,830.38" "$2,899.31" "$2,928.60" $0.00 $0.00 $572.91 $0.00 $0.00 $582.79 $0.00 $0.00 $0.00 $0.00 $0.00 449.446 SUP HCPCS C1713 449.446 - PLATE MAXFACL 6X18 HOLE RIGHT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$4,027.50 " "$2,980.35" $0.00 "$3,222.00" "$1,812.38" "$1,812.38" $0.00 $0.00 $0.00 $839.43 "$2,989.21" "$2,989.21" $0.00 $0.00 $839.33 $0.00 "$1,985.56" "$1,985.56" $0.00 "$2,013.75" "$3,189.78" "$3,222.00" $0.00 $0.00 $630.30 $0.00 $0.00 $641.18 $0.00 $0.00 $0.00 $0.00 $0.00 449.447 SUP HCPCS C1713 449.447 - PLATE MAXFACL 6X18 HOLE LEFT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$4,027.50 " "$2,980.35" $0.00 "$3,222.00" "$1,812.38" "$1,812.38" $0.00 $0.00 $0.00 $839.43 "$2,989.21" "$2,989.21" $0.00 $0.00 $839.33 $0.00 "$1,985.56" "$1,985.56" $0.00 "$2,013.75" "$3,189.78" "$3,222.00" $0.00 $0.00 $630.30 $0.00 $0.00 $641.18 $0.00 $0.00 $0.00 $0.00 $0.00 449.448 SUP HCPCS C1713 449.448 - PLATE MAXFACL 6X21 HOLE RIGHT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$4,401.00 " "$3,256.74" $0.00 "$3,520.80" "$1,980.45" "$1,980.45" $0.00 $0.00 $0.00 $917.28 "$3,266.42" "$3,266.42" $0.00 $0.00 $917.17 $0.00 "$2,169.69" "$2,169.69" $0.00 "$2,200.50" "$3,485.59" "$3,520.80" $0.00 $0.00 $688.76 $0.00 $0.00 $700.64 $0.00 $0.00 $0.00 $0.00 $0.00 449.449 SUP HCPCS C1713 449.449 - PLATE MAXFACL 6X21 HOLE LEFT ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$4,401.00 " "$3,256.74" $0.00 "$3,520.80" "$1,980.45" "$1,980.45" $0.00 $0.00 $0.00 $917.28 "$3,266.42" "$3,266.42" $0.00 $0.00 $917.17 $0.00 "$2,169.69" "$2,169.69" $0.00 "$2,200.50" "$3,485.59" "$3,520.80" $0.00 $0.00 $688.76 $0.00 $0.00 $700.64 $0.00 $0.00 $0.00 $0.00 $0.00 449.45 SUP HCPCS C1713 449.450 - PLATE MAXFACL 4X20X4 HOLE 2 ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$7,537.50 " "$5,577.75" $0.00 "$6,030.00" "$3,391.88" "$3,391.88" $0.00 $0.00 $0.00 "$1,571.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,570.82" $0.00 "$3,715.99" "$3,715.99" $0.00 "$3,768.75" "$5,969.70" "$6,030.00" $0.00 $0.00 "$1,179.62" $0.00 $0.00 "$1,199.97" $0.00 $0.00 $0.00 $0.00 $0.00 449.451 SUP HCPCS C1713 449.451 - PLATE MAXFACL 5X22X5 HOLE 2 ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$7,850.25 " "$5,809.19" $0.00 "$6,280.20" "$3,532.61" "$3,532.61" $0.00 $0.00 $0.00 "$1,636.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,635.99" $0.00 "$3,870.17" "$3,870.17" $0.00 "$3,925.13" "$6,217.40" "$6,280.20" $0.00 $0.00 "$1,228.56" $0.00 $0.00 "$1,249.76" $0.00 $0.00 $0.00 $0.00 $0.00 449.452 SUP HCPCS C1713 449.452 - PLATE MAXFACL 6X24X6 HOLE 2 ANG MCVSC 2.4 MM SCR BONE TI BOTH IP/OP "$9,411.75 " "$6,964.70" $0.00 "$7,529.40" "$4,235.29" "$4,235.29" $0.00 $0.00 $0.00 "$1,961.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.41" $0.00 "$4,639.99" "$4,639.99" $0.00 "$4,705.88" "$7,454.11" "$7,529.40" $0.00 $0.00 "$1,472.94" $0.00 $0.00 "$1,498.35" $0.00 $0.00 $0.00 $0.00 $0.00 449.612 SUP HCPCS C1713 449.612 - PLATE 96MM MANDIB 12 HOLE LCK STR RECON 2.4/3MM SCR BONE TI BOTH IP/OP "$2,301.75 " "$1,703.30" $0.00 "$1,841.40" "$1,035.79" "$1,035.79" $0.00 $0.00 $0.00 $479.74 "$1,708.36" "$1,708.36" $0.00 $0.00 $479.68 $0.00 "$1,361.49" "$1,361.49" $0.00 "$1,150.88" "$1,822.99" "$1,841.40" $0.00 $0.00 $360.22 $0.00 $0.00 $366.44 $0.00 $0.00 $0.00 $0.00 $0.00 449.615 SUP HCPCS C1713 449.615 - PLATE BONE 3 HOLE HEAD 7 HOLE SHAFT T LCP TITANIUM BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 449.62 SUP HCPCS C1713 449.62 - PLATE 95MM MANDIB 12 HOLE STR LCK RECON 2.4MM SCR BONE TI BOTH IP/OP "$2,220.75 " "$1,643.36" $0.00 "$1,776.60" $999.34 $999.34 $0.00 $0.00 $0.00 $462.86 "$1,648.24" "$1,648.24" $0.00 $0.00 $462.80 $0.00 "$1,313.57" "$1,313.57" $0.00 "$1,110.38" "$1,758.83" "$1,776.60" $0.00 $0.00 $347.55 $0.00 $0.00 $353.54 $0.00 $0.00 $0.00 $0.00 $0.00 449.621 SUP HCPCS C1713 449.621 - PLATE BN STRG 160X8X2.5MM NS 20 HL LCK RECON TI MNDB 2.4/3MM BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.632 SUP HCPCS C1713 449.632 - PLATE 214MM MANDIB 6X23 HOLE LEFT ANG LCK RECON 2.4MM SCR BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.633 SUP HCPCS C1713 449.633 - PLATE BN ANG 214X44X2.4MM NS 44MM 6 HLE/HD 23 HL SHFT LOPRFL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.636 SUP HCPCS C1713 449.636 - PLATE MANDIB 4X20X4 HOLE LCK 2 ANG RECON 2.4/3 MM SCR BONE BOTH IP/OP "$5,553.00 " "$4,109.22" $0.00 "$4,442.40" "$2,498.85" "$2,498.85" $0.00 $0.00 $0.00 "$1,157.38" "$4,121.44" "$4,121.44" $0.00 $0.00 "$1,157.25" $0.00 "$2,737.63" "$2,737.63" $0.00 "$2,776.50" "$4,397.98" "$4,442.40" $0.00 $0.00 $869.04 $0.00 $0.00 $884.04 $0.00 $0.00 $0.00 $0.00 $0.00 449.637 SUP HCPCS C1713 449.637 - PLATE MANDIB 5X22X5 HOLE LCK 2 ANG RECON 2.4/3 MM SCR BONE BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.638 SUP HCPCS C1713 449.638 - PLATE MANDIB 6X24X6 HOLE LCK 2 ANG RECON 2.4/3 MM SCR BONE BOTH IP/OP "$6,187.50 " "$4,578.75" $0.00 "$4,950.00" "$2,784.38" "$2,784.38" $0.00 $0.00 $0.00 "$1,289.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,289.48" $0.00 "$3,050.44" "$3,050.44" $0.00 "$3,093.75" "$4,900.50" "$4,950.00" $0.00 $0.00 $968.34 $0.00 $0.00 $985.05 $0.00 $0.00 $0.00 $0.00 $0.00 449.644 SUP HCPCS C1713 449.644 - PLATE RIGHT CNDYLR HEAD MANDIB 3X16 HOLE LCK RECON 2.4 MM BOTH IP/OP "$9,706.50 " "$7,182.81" $0.00 "$7,765.20" "$4,367.93" "$4,367.93" $0.00 $0.00 $0.00 "$2,023.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,022.83" $0.00 "$4,785.30" "$4,785.30" $0.00 "$4,853.25" "$7,687.55" "$7,765.20" $0.00 $0.00 "$1,519.07" $0.00 $0.00 "$1,545.27" $0.00 $0.00 $0.00 $0.00 $0.00 449.645 SUP HCPCS C1713 449.645 - PLATE LEFT CNDYLR HEAD MANDIB 3X16 HOLE LCK RECON 2.4 MM SCR BOTH IP/OP "$9,706.50 " "$7,182.81" $0.00 "$7,765.20" "$4,367.93" "$4,367.93" $0.00 $0.00 $0.00 "$2,023.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,022.83" $0.00 "$4,785.30" "$4,785.30" $0.00 "$4,853.25" "$7,687.55" "$7,765.20" $0.00 $0.00 "$1,519.07" $0.00 $0.00 "$1,545.27" $0.00 $0.00 $0.00 $0.00 $0.00 449.646 SUP HCPCS C1713 449.646 - PLATE RIGHT CNDYLR HEAD MANDIB 4X18 HOLE LCK RECON 2.4 MM BOTH IP/OP "$10,248.75 " "$7,584.08" $0.00 "$8,199.00" "$4,611.94" "$4,611.94" $0.00 $0.00 $0.00 "$2,136.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,135.84" $0.00 "$5,052.63" "$5,052.63" $0.00 "$5,124.38" "$8,117.01" "$8,199.00" $0.00 $0.00 "$1,603.93" $0.00 $0.00 "$1,631.60" $0.00 $0.00 $0.00 $0.00 $0.00 449.647 SUP HCPCS C1713 449.647 - PLATE LEFT CNDYLR HEAD MANDIB 4X18 HOLE LCK RECON 2.4 MM SCR BOTH IP/OP "$10,248.75 " "$7,584.08" $0.00 "$8,199.00" "$4,611.94" "$4,611.94" $0.00 $0.00 $0.00 "$2,136.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,135.84" $0.00 "$5,052.63" "$5,052.63" $0.00 "$5,124.38" "$8,117.01" "$8,199.00" $0.00 $0.00 "$1,603.93" $0.00 $0.00 "$1,631.60" $0.00 $0.00 $0.00 $0.00 $0.00 449.648 SUP HCPCS C1713 449.648 - PLATE TI 2.4 MM SCR 5X20 HOLE LCK RECON LCP BONE RIGHT BOTH IP/OP "$10,782.00 " "$7,978.68" $0.00 "$8,625.60" "$4,851.90" "$4,851.90" $0.00 $0.00 $0.00 "$2,247.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.97" $0.00 "$5,315.53" "$5,315.53" $0.00 "$5,391.00" "$8,539.34" "$8,625.60" $0.00 $0.00 "$1,687.38" $0.00 $0.00 "$1,716.49" $0.00 $0.00 $0.00 $0.00 $0.00 449.649 SUP HCPCS C1713 449.649 - PLATE LEFT CNDYLR HEAD MANDIB 5X20 HOLE LCK RECON 2.4 MM SCR BOTH IP/OP "$10,782.00 " "$7,978.68" $0.00 "$8,625.60" "$4,851.90" "$4,851.90" $0.00 $0.00 $0.00 "$2,247.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.97" $0.00 "$5,315.53" "$5,315.53" $0.00 "$5,391.00" "$8,539.34" "$8,625.60" $0.00 $0.00 "$1,687.38" $0.00 $0.00 "$1,716.49" $0.00 $0.00 $0.00 $0.00 $0.00 449.651 SUP HCPCS C1713 449.651 - PLATE MANDIB 3X3 HOLE LCK CRSNT ANG RECON 2.4/3 MM SCR BONE BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.652 SUP HCPCS C1713 449.652 - PLATE MANDIB 3X3 HOLE LCK ANG RECON 2.4/3 MM SCR BONE TI BOTH IP/OP "$2,756.25 " "$2,039.63" $0.00 "$2,205.00" "$1,240.31" "$1,240.31" $0.00 $0.00 $0.00 $574.47 "$2,045.69" "$2,045.69" $0.00 $0.00 $574.40 $0.00 "$1,358.83" "$1,358.83" $0.00 "$1,378.13" "$2,182.95" "$2,205.00" $0.00 $0.00 $431.35 $0.00 $0.00 $438.80 $0.00 $0.00 $0.00 $0.00 $0.00 449.653 SUP HCPCS C1713 449.653 - PLATE MANDIB 4X4 HOLE LCK ANG RECON 2.4/3 MM SCR BONE TI BOTH IP/OP "$2,972.25 " "$2,199.47" $0.00 "$2,377.80" "$1,337.51" "$1,337.51" $0.00 $0.00 $0.00 $619.49 "$2,206.00" "$2,206.00" $0.00 $0.00 $619.42 $0.00 "$1,465.32" "$1,465.32" $0.00 "$1,486.13" "$2,354.02" "$2,377.80" $0.00 $0.00 $465.16 $0.00 $0.00 $473.18 $0.00 $0.00 $0.00 $0.00 $0.00 449.654 SUP HCPCS C1713 449.654 - PLATE MANDIB 5X8 HOLE LCK LEFT ANG RECON 2.4/3 MM SCR BONE BOTH IP/OP "$3,242.25 " "$2,399.27" $0.00 "$2,593.80" "$1,459.01" "$1,459.01" $0.00 $0.00 $0.00 $675.77 "$2,406.40" "$2,406.40" $0.00 $0.00 $675.68 $0.00 "$1,598.43" "$1,598.43" $0.00 "$1,621.13" "$2,567.86" "$2,593.80" $0.00 $0.00 $507.41 $0.00 $0.00 $516.17 $0.00 $0.00 $0.00 $0.00 $0.00 449.655 SUP HCPCS C1713 449.655 - PLATE MANDIB 5X8 HOLE LCK RIGHT ANG RECON 2.4/3 MM SCR BONE BOTH IP/OP "$3,242.25 " "$2,399.27" $0.00 "$2,593.80" "$1,459.01" "$1,459.01" $0.00 $0.00 $0.00 $675.77 "$2,406.40" "$2,406.40" $0.00 $0.00 $675.68 $0.00 "$1,598.43" "$1,598.43" $0.00 "$1,621.13" "$2,567.86" "$2,593.80" $0.00 $0.00 $507.41 $0.00 $0.00 $516.17 $0.00 $0.00 $0.00 $0.00 $0.00 449.669 SUP HCPCS C1713 449.669 - PLATE BONE 3 HOLE HEAD 7 HOLE SHAFT Y LCP TITANIUM BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 449.67 SUP HCPCS C1713 449.670 - PLATE BONE T 58MM 2X7 HOLE LCP TITANIUM CONDYLE NONSTRL 2.4 BOTH IP/OP "$1,311.53 " $970.53 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $273.35 $973.41 $973.41 $0.00 $0.00 $273.32 $0.00 $775.77 $775.77 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 449.674 SUP HCPCS C1713 449.674 - PLATE BONE 36MM 4 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.4MM BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 449.676 SUP HCPCS C1713 449.676 - PLATE BONE 52MM 6 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.4MM BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 449.678 SUP HCPCS C1713 449.678 - PLATE BONE 68MM 8 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.4MM BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $321.20 $321.20 $0.00 $0.00 $0.00 $153.23 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $434.86 $434.86 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $108.45 $0.00 $0.00 $113.63 $0.00 $0.00 $0.00 $0.00 $0.00 449.679 SUP HCPCS C1713 449.679 - PLATE BONE 7 HOLE LCP TITANIUM CONDYLE NONSTRL 2.4 MM SCREW BOTH IP/OP "$1,103.48 " $816.58 $0.00 $857.06 $482.10 $482.10 $0.00 $0.00 $0.00 $229.99 $819.00 $819.00 $0.00 $0.00 $229.96 $0.00 $652.71 $652.71 $0.00 $535.66 $848.49 $857.06 $0.00 $0.00 $162.78 $0.00 $0.00 $170.55 $0.00 $0.00 $0.00 $0.00 $0.00 449.68 SUP HCPCS C1713 449.680 - PLATE BONE 40MM 4 HOLE LCP TITANIUM CONDYLE NONSTRL 2.7MM BOTH IP/OP $753.35 $557.48 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $157.02 $559.14 $559.14 $0.00 $0.00 $157.00 $0.00 $445.61 $445.61 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 449.681 SUP HCPCS C1713 449.681 - PLATE BONE 49MM 5 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.7MM BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 449.682 SUP HCPCS C1713 449.682 - PLATE BONE 6 HOLE LCP TITANIUM CONDYLE NONSTRL 2.4 MM SCREW BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 449.683 SUP HCPCS C1713 449.683 - PLATE BONE 67MM 7 HOLE LCP TITANIUM ORTHOPEDIC NONSTRL 2.7MM BOTH IP/OP $775.95 $574.20 $0.00 $602.68 $339.01 $339.01 $0.00 $0.00 $0.00 $161.73 $575.91 $575.91 $0.00 $0.00 $161.71 $0.00 $458.97 $458.97 $0.00 $376.68 $596.65 $602.68 $0.00 $0.00 $114.46 $0.00 $0.00 $119.93 $0.00 $0.00 $0.00 $0.00 $0.00 449.684 SUP HCPCS C1713 449.684 - PLATE BONE 7 HOLE LCP TITANIUM CONDYLE NONSTRL 2.7 MM SCREWS BOTH IP/OP "$1,203.28 " $890.43 $0.00 $934.58 $525.70 $525.70 $0.00 $0.00 $0.00 $250.79 $893.07 $893.07 $0.00 $0.00 $250.76 $0.00 $711.74 $711.74 $0.00 $584.11 $925.24 $934.58 $0.00 $0.00 $177.50 $0.00 $0.00 $185.98 $0.00 $0.00 $0.00 $0.00 $0.00 449.685 SUP HCPCS C1713 449.685 - PLATE BONE 2 HOLE HEAD 3 HOLE SHAFT T LCP TITANIUM BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 449.686 SUP HCPCS C1713 449.686 - PLATE BONE 2 HOLE HEAD 3 HOLE SHAFT L RIGHT OBLIQUE LCP BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 449.687 SUP HCPCS C1713 449.687 - PLATE BONE 2 HOLE HEAD 3 HOLE SHAFT L LEFT OBLIQUE LCP BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 449.688 SUP HCPCS C1713 449.688 - PLATE BONE 2 HOLE HEAD 3 HOLE SHAFT L LCP TITANIUM RIGHT BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 449.689 SUP HCPCS C1713 449.689 - PLATE BONE 2.7MM 2 HOLE HEAD 3 HOLE SHAFT LCP TITANIUM LEFT BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 449.69 SUP HCPCS C1713 449.690 - PLATE BONE 31MM 5 HOLE LOCKING TITANIUM HIND MIDFT NONSTRL BOTH IP/OP "$1,454.83 " "$1,076.57" $0.00 "$1,163.86" $654.67 $654.67 $0.00 $0.00 $0.00 $303.22 "$1,079.77" "$1,079.77" $0.00 $0.00 $303.19 $0.00 $860.53 $860.53 $0.00 $727.41 "$1,152.23" "$1,163.86" $0.00 $0.00 $221.05 $0.00 $0.00 $231.61 $0.00 $0.00 $0.00 $0.00 $0.00 449.691 SUP HCPCS C1713 449.691 - PLATE BONE 45MM 8 HOLE LOCKING TITANIUM HIND MIDFT NONSTRL BOTH IP/OP "$1,529.40 " "$1,131.76" $0.00 "$1,187.88" $668.18 $668.18 $0.00 $0.00 $0.00 $318.77 "$1,135.12" "$1,135.12" $0.00 $0.00 $318.73 $0.00 $904.64 $904.64 $0.00 $742.43 "$1,176.00" "$1,187.88" $0.00 $0.00 $225.61 $0.00 $0.00 $236.39 $0.00 $0.00 $0.00 $0.00 $0.00 449.697 SUP HCPCS C1713 449.697 - PLATE BONE 2 HOLE HEAD 4 HOLE SHAFT T LCP TITANIUM BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 449.698 SUP HCPCS C1713 449.698 - PLATE BONE 2 HOLE HEAD 4 HOLE SHAFT L RIGHT OBLIQUE LCP BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 449.699 SUP HCPCS C1713 449.699 - PLATE BONE 2 HOLE HEAD 4 HOLE SHAFT L LEFT OBLIQUE LCP BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 449.7 SUP HCPCS C1713 449.70 - PLATE MANDIB 20 HOLE STR RECON 2.4 MM SCR BONE TI NONSTRL BOTH IP/OP "$3,154.50 " "$2,334.33" $0.00 "$2,523.60" "$1,419.53" "$1,419.53" $0.00 $0.00 $0.00 $657.48 "$2,341.27" "$2,341.27" $0.00 $0.00 $657.40 $0.00 "$1,555.17" "$1,555.17" $0.00 "$1,577.25" "$2,498.36" "$2,523.60" $0.00 $0.00 $493.68 $0.00 $0.00 $502.20 $0.00 $0.00 $0.00 $0.00 $0.00 449.701 SUP HCPCS C1713 449.701 - PLATE BONE 2 HOLE HEAD 4 HOLE SHAFT L LCP TITANIUM RIGHT BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 449.702 SUP HCPCS C1713 449.702 - PLATE BONE 2 HOLE HEAD 4 HOLE SHAFT L LCP TITANIUM LEFT BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 449.82 SUP HCPCS C1713 449.82 - PLATE UNV 26MM CRNMXF 3X3 HOLE ANG 2.4MM SCR FRAC BONE TI BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.84 SUP HCPCS C1713 449.84 - PLATE UNV 32MM MANDIB 4X4 HOLE ANG FRAC 2.4MM SCR BONE TI BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 449.87 SUP HCPCS C1713 449.87 - PLATE 97X47MM MANDIB 5X13 HOLE ANG RECON 2.4MM SCR BONE TI BOTH IP/OP "$3,471.75 " "$2,569.10" $0.00 "$2,777.40" "$1,562.29" "$1,562.29" $0.00 $0.00 $0.00 $723.60 "$2,576.73" "$2,576.73" $0.00 $0.00 $723.51 $0.00 "$1,711.57" "$1,711.57" $0.00 "$1,735.88" "$2,749.63" "$2,777.40" $0.00 $0.00 $543.33 $0.00 $0.00 $552.70 $0.00 $0.00 $0.00 $0.00 $0.00 449.88 SUP HCPCS C1713 449.88 - PLATE MANDIB ANG RECON 2.4 MM SCR BONE TI NONSTRL BOTH IP/OP "$3,471.75 " "$2,569.10" $0.00 "$2,777.40" "$1,562.29" "$1,562.29" $0.00 $0.00 $0.00 $723.60 "$2,576.73" "$2,576.73" $0.00 $0.00 $723.51 $0.00 "$1,711.57" "$1,711.57" $0.00 "$1,735.88" "$2,749.63" "$2,777.40" $0.00 $0.00 $543.33 $0.00 $0.00 $552.70 $0.00 $0.00 $0.00 $0.00 $0.00 449.906 SUP HCPCS C1713 449.906 - PLATE BN STRG 36X6.3X1.25MM NS 6 HL LOPRFL PRECONTOUR CUT TO BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 449.912 SUP HCPCS C1713 449.912 - PLATE BN STRG 72X6.3X1.25MM NS 12 HL LOPRFL PRECONTOUR CUT BOTH IP/OP $522.93 $386.97 $0.00 $406.14 $228.45 $228.45 $0.00 $0.00 $0.00 $108.99 $388.11 $388.11 $0.00 $0.00 $108.98 $0.00 $309.31 $309.31 $0.00 $253.84 $402.08 $406.14 $0.00 $0.00 $77.14 $0.00 $0.00 $80.82 $0.00 $0.00 $0.00 $0.00 $0.00 449.913 SUP HCPCS C1713 449.913 - PLATE BN T 54X6.3X1.25MM NS 2 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $497.63 $368.25 $0.00 $386.50 $217.41 $217.41 $0.00 $0.00 $0.00 $103.72 $369.34 $369.34 $0.00 $0.00 $103.71 $0.00 $294.35 $294.35 $0.00 $241.56 $382.64 $386.50 $0.00 $0.00 $73.41 $0.00 $0.00 $76.91 $0.00 $0.00 $0.00 $0.00 $0.00 449.914 SUP HCPCS C1713 449.914 - PLATE BN T 54X6.3X1.25MM NS 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $531.35 $393.20 $0.00 $412.70 $232.14 $232.14 $0.00 $0.00 $0.00 $110.75 $394.37 $394.37 $0.00 $0.00 $110.73 $0.00 $314.29 $314.29 $0.00 $257.94 $408.58 $412.70 $0.00 $0.00 $78.38 $0.00 $0.00 $82.13 $0.00 $0.00 $0.00 $0.00 $0.00 449.915 SUP HCPCS C1713 449.915 - PLATE BN Y 56X6.3X1.25MM NS 3 HLE/HD 8 HL SHFT LOPRFL BOTH IP/OP $514.48 $380.72 $0.00 $399.60 $224.78 $224.78 $0.00 $0.00 $0.00 $107.23 $381.84 $381.84 $0.00 $0.00 $107.22 $0.00 $304.31 $304.31 $0.00 $249.75 $395.60 $399.60 $0.00 $0.00 $75.89 $0.00 $0.00 $79.52 $0.00 $0.00 $0.00 $0.00 $0.00 449.916 SUP HCPCS C1713 449.916 - PLATE BN 57X6.3X1.25MM NS 8 HL LOPRFL PRECONTOUR CUT TO LGTH BOTH IP/OP $580.55 $429.61 $0.00 $450.92 $253.64 $253.64 $0.00 $0.00 $0.00 $121.00 $430.88 $430.88 $0.00 $0.00 $120.99 $0.00 $343.40 $343.40 $0.00 $281.83 $446.41 $450.92 $0.00 $0.00 $85.64 $0.00 $0.00 $89.73 $0.00 $0.00 $0.00 $0.00 $0.00 449.917 SUP HCPCS C1713 449.917 - PLATE BN 57X6.3X1.25MM NS 8 HL LOPRFL PRECONTOUR CUT TO LGTH BOTH IP/OP $580.55 $429.61 $0.00 $450.92 $253.64 $253.64 $0.00 $0.00 $0.00 $121.00 $430.88 $430.88 $0.00 $0.00 $120.99 $0.00 $343.40 $343.40 $0.00 $281.83 $446.41 $450.92 $0.00 $0.00 $85.64 $0.00 $0.00 $89.73 $0.00 $0.00 $0.00 $0.00 $0.00 449.924 SUP HCPCS C1713 449.924 - PLATE BN 31X6.5X1.6MM NS LC DCP 4 HL LOPRFL PRECONTOUR CUT BOTH IP/OP $618.50 $457.69 $0.00 $480.40 $270.23 $270.23 $0.00 $0.00 $0.00 $128.91 $459.05 $459.05 $0.00 $0.00 $128.90 $0.00 $365.84 $365.84 $0.00 $300.25 $475.60 $480.40 $0.00 $0.00 $91.24 $0.00 $0.00 $95.60 $0.00 $0.00 $0.00 $0.00 $0.00 449.926 SUP HCPCS C1713 449.926 - PLATE BN 47X6.5X1.6MM NS LC DCP 6 HL LOPRFL PRECONTOUR CUT BOTH IP/OP $695.83 $514.91 $0.00 $540.44 $304.00 $304.00 $0.00 $0.00 $0.00 $145.03 $516.44 $516.44 $0.00 $0.00 $145.01 $0.00 $411.58 $411.58 $0.00 $337.78 $535.04 $540.44 $0.00 $0.00 $102.64 $0.00 $0.00 $107.55 $0.00 $0.00 $0.00 $0.00 $0.00 449.928 SUP HCPCS C1713 449.928 - PLATE BN 63X6.5X1.6MM NS LC DCP 8 HL LOPRFL PRECONTOUR CUT BOTH IP/OP $750.65 $555.48 $0.00 $583.02 $327.95 $327.95 $0.00 $0.00 $0.00 $156.45 $557.13 $557.13 $0.00 $0.00 $156.44 $0.00 $444.01 $444.01 $0.00 $364.39 $577.19 $583.02 $0.00 $0.00 $141.20 $0.00 $0.00 $116.02 $0.00 $0.00 $0.00 $0.00 $0.00 449.931 SUP HCPCS C1713 449.931 - PLATE BN 24X5.5X1.25MM NS LC DCP 4 HL LOPRFL PRECONTOUR TI BOTH IP/OP $444.20 $328.71 $0.00 $345.00 $194.06 $194.06 $0.00 $0.00 $0.00 $92.58 $329.69 $329.69 $0.00 $0.00 $92.57 $0.00 $262.74 $262.74 $0.00 $215.63 $341.55 $345.00 $0.00 $0.00 $65.53 $0.00 $0.00 $68.66 $0.00 $0.00 $0.00 $0.00 $0.00 449.936 SUP HCPCS C1713 449.936 - PLATE BN 36X5.5X1.25MM NS LC DCP 6 HL LOPRFL PRECONTOUR TI BOTH IP/OP $522.93 $386.97 $0.00 $406.14 $228.45 $228.45 $0.00 $0.00 $0.00 $108.99 $388.11 $388.11 $0.00 $0.00 $108.98 $0.00 $309.31 $309.31 $0.00 $253.84 $402.08 $406.14 $0.00 $0.00 $77.14 $0.00 $0.00 $80.82 $0.00 $0.00 $0.00 $0.00 $0.00 449.938 SUP HCPCS C1713 449.938 - PLATE BN 48X5.5X1.25MM NS LC DCP 8 HL LOPRFL PRECONTOUR TI BOTH IP/OP $594.60 $440.00 $0.00 $461.84 $259.79 $259.79 $0.00 $0.00 $0.00 $123.93 $441.31 $441.31 $0.00 $0.00 $123.91 $0.00 $351.71 $351.71 $0.00 $288.65 $457.22 $461.84 $0.00 $0.00 $87.71 $0.00 $0.00 $91.91 $0.00 $0.00 $0.00 $0.00 $0.00 450.101 SUP HCPCS C1713 450.101 - PLATE BONE 90MM CRANFCL TI 20 HOLE ADP MALBLE 1.5MM SCR BOTH IP/OP $819.00 $606.06 $0.00 $655.20 $368.55 $368.55 $0.00 $0.00 $0.00 $170.70 $607.86 $607.86 $0.00 $0.00 $170.68 $0.00 $484.44 $484.44 $0.00 $409.50 $648.65 $655.20 $0.00 $0.00 $128.17 $0.00 $0.00 $130.38 $0.00 $0.00 $0.00 $0.00 $0.00 450.611 SUP HCPCS C1713 450.611 - PLATE BONE CRANFCL TI 5 HOLE Y MALBLE 1.5 MM SCR NONSTRL BOTH IP/OP $567.00 $419.58 $0.00 $453.60 $255.15 $255.15 $0.00 $0.00 $0.00 $118.18 $420.83 $420.83 $0.00 $0.00 $118.16 $0.00 $335.38 $335.38 $0.00 $283.50 $449.06 $453.60 $0.00 $0.00 $88.74 $0.00 $0.00 $90.27 $0.00 $0.00 $0.00 $0.00 $0.00 450.861 SUP HCPCS C1713 450.861 - SCREW BONE FULTHD 6MM 45MM SELF TAP LOCKING HEXAGONAL RECESS BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.862 SUP HCPCS C1713 450.862 - SCREW BONE 6MM 50MM LOCKING HEXAGONAL RECESS AQUA TITANIUM BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.863 SUP HCPCS C1713 450.863 - SCREW BONE 6MM 55MM LOCKING HEXAGONAL RECESS AQUA TITANIUM BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.864 SUP HCPCS C1713 450.864 - SCREW BONE 6MM 60MM LOCKING HEXAGONAL RECESS AQUA TITANIUM BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.865 SUP HCPCS C1713 450.865 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 6MM 8MM 65MM 2 LEAD BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.866 SUP HCPCS C1713 450.866 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 6MM 8MM 70MM 2 LEAD BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.867 SUP HCPCS C1713 450.867 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 6MM 8MM 75MM 2 LEAD BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.868 SUP HCPCS C1713 450.868 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 6MM 8MM 80MM 2 LEAD BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.869 SUP HCPCS C1713 450.869 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 6MM 8MM 85MM 2 LEAD BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.87 SUP HCPCS C1713 450.870 - SCREW BONE 6MM 90MM LOCKING HEXAGONAL RECESS AQUA TITANIUM BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.871 SUP HCPCS C1713 450.871 - SCREW BONE 6MM 95MM LOCKING HEXAGONAL RECESS AQUA TITANIUM BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.872 SUP HCPCS C1713 450.872 - SCREW BONE 6MM 100MM LOCKING HEXAGONAL RECESS AQUA TITANIUM BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.873 SUP HCPCS C1713 450.873 - SCREW BONE 3.5MM FULTHD 6MM 8MM 30MM 2 LEAD THREAD LOCKING BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.874 SUP HCPCS C1713 450.874 - SCREW BONE FULTHD 6MM 4.8MM 35MM 2 LEAD THREAD LOCKING BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 450.875 SUP HCPCS C1713 450.875 - SCREW BONE FULTHD 6MM 4.8MM 40MM 2 LEAD THREAD LOCKING BOTH IP/OP $361.65 $267.62 $0.00 $289.32 $162.74 $162.74 $0.00 $0.00 $0.00 $75.38 $268.42 $268.42 $0.00 $0.00 $75.37 $0.00 $213.92 $213.92 $0.00 $180.83 $286.43 $289.32 $0.00 $0.00 $57.02 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 451.101 SUP HCPCS C1713 451.101 - PLATE BONE 100MM CRANFCL TI 20 HOLE ADP MALBLE 1.5MM SCR BOTH IP/OP "$1,017.00 " $752.58 $0.00 $813.60 $457.65 $457.65 $0.00 $0.00 $0.00 $211.97 $754.82 $754.82 $0.00 $0.00 $211.94 $0.00 $601.56 $601.56 $0.00 $508.50 $805.46 $813.60 $0.00 $0.00 $159.16 $0.00 $0.00 $161.91 $0.00 $0.00 $0.00 $0.00 $0.00 451.611 SUP HCPCS C1713 451.611 - PLATE BONE CRANFCL TI 5 HOLE Y MALBLE 2 MM SCR NONSTRL BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 457.07 SUP HCPCS C1713 457.070 - SCREW BONE 5MM 70MM TI FEM SLFTAP SHFT NONSTRL GOLD BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.075 SUP HCPCS C1713 457.075 - SCREW BONE 5MM 75MM TI CANC SHFT NONSTRL GOLD IM NAIL BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.08 SUP HCPCS C1713 457.080 - SCREW BONE 5MM 80MM TI FEM SHFT NONSTRL GOLD BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.085 SUP HCPCS C1713 457.085 - SCREW BONE 5MM 85MM TI FEM SHFT NONSTRL GOLD BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.09 SUP HCPCS C1713 457.090 - SCREW BONE 5MM 90MM TI FEM SHFT NONSTRL GOLD BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.095 SUP HCPCS C1713 457.095 - SCREW BONE 5MM 95MM TI FEM SHFT NONSTRL GOLD BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.1 SUP HCPCS C1713 457.100 - SCREW BONE 5MM 100MM 16MM TI FEM SLFTAP SHFT FRN CUT FLUT BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.105 SUP HCPCS C1713 457.105 - SCREW BONE 5MM 105MM TI FEM SHFT NONSTRL GOLD BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.11 SUP HCPCS C1713 457.110 - SCREW BONE 5MM 110MM TI FEM SLFTAP SHFT FRN CUT FLUT STRL BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.115 SUP HCPCS C1713 457.115 - SCREW BONE 5MM 115MM TI FEM SHFT NONSTRL GOLD BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.12 SUP HCPCS C1713 457.120 - SCREW BONE GOLD 120MM 5MM FEM TI SLFTAP SHFT FRN CUT FLUT BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 457.125 SUP HCPCS C1713 457.125 - SCREW BONE 5MM 125MM TI FEM SLFTAP SHFT FRN CUT FLUT STRL BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $233.25 $233.25 $0.00 $0.00 $0.00 $108.03 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $306.59 $306.59 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $81.12 $0.00 $0.00 $82.52 $0.00 $0.00 $0.00 $0.00 $0.00 458.818 SUP HCPCS C1713 458.818 - SCREW BONE 4MM 3.3MM 18MM SELF CUTTING TROCAR TIP LOCKING BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.82 SUP HCPCS C1713 458.820 - SCREW BONE TROCAR 4MM 8MM 20MM 2 LEAD THREAD LOCKING SLFTAP BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.822 SUP HCPCS C1713 458.822 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 22MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.824 SUP HCPCS C1713 458.824 - SCREW BONE 4MM 3.3MM 24MM SELF CUTTING TROCAR TIP LOCKING BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.826 SUP HCPCS C1713 458.826 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 26MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.828 SUP HCPCS C1713 458.828 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 28MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.83 SUP HCPCS C1713 458.830 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 30MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.832 SUP HCPCS C1713 458.832 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 32MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.834 SUP HCPCS C1713 458.834 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 34MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.836 SUP HCPCS C1713 458.836 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 36MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.838 SUP HCPCS C1713 458.838 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 38MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.84 SUP HCPCS C1713 458.840 - SCREW BONE HEXAGON TROCAR 4MM 3.3MM 40MM SELF CUT LOCK BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.842 SUP HCPCS C1713 458.842 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 42MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.844 SUP HCPCS C1713 458.844 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 44MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.846 SUP HCPCS C1713 458.846 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 46MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.848 SUP HCPCS C1713 458.848 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 48MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.85 SUP HCPCS C1713 458.850 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 50MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.852 SUP HCPCS C1713 458.852 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 52MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.854 SUP HCPCS C1713 458.854 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 54MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.856 SUP HCPCS C1713 458.856 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 56MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.858 SUP HCPCS C1713 458.858 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 58MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.86 SUP HCPCS C1713 458.860 - SCREW BONE TROCAR 4MM 8MM 60MM 2 LEAD THREAD LOCKING SLFTAP BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.862 SUP HCPCS C1713 458.862 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 62MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.864 SUP HCPCS C1713 458.864 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 64MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.866 SUP HCPCS C1713 458.866 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 66MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.868 SUP HCPCS C1713 458.868 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 68MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.87 SUP HCPCS C1713 458.870 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 70MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.872 SUP HCPCS C1713 458.872 - SCREW BONE TROCAR FULTHD 4MM 8MM 72MM 2 LEAD THREAD LOCKING BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.874 SUP HCPCS C1713 458.874 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 74MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.876 SUP HCPCS C1713 458.876 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 76MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.878 SUP HCPCS C1713 458.878 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 4MM 8MM 78MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.88 SUP HCPCS C1713 458.880 - SCREW BONE TROCAR 4MM 8MM 80MM 2 LEAD THREAD SLFTAP BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.926 SUP HCPCS C1713 458.926 - SCREW BONE 5MM 26MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.928 SUP HCPCS C1713 458.928 - SCREW BONE NONSTRL IM NAIL 5MM 28MM NLEX TI DISTAL FEM/TIB BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.93 SUP HCPCS C1713 458.930 - SCREW BONE NONSTRL 5MM 30MM NLEX TI DISTAL FEM/TIB LCK HEX BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.932 SUP HCPCS C1713 458.932 - SCREW BONE NONSTRL IM NAIL 5MM 32MM NLEX TI DISTAL FEM/TIB BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.934 SUP HCPCS C1713 458.934 - SCREW BONE NONSTRL IM NAIL 5MM 34MM NLEX TI DISTAL FEM/TIB BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.936 SUP HCPCS C1713 458.936 - SCREW BONE NONSTRL IM NAIL 5MM 36MM NLEX TI DISTAL FEM/TIB BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.938 SUP HCPCS C1713 458.938 - SCREW BONE 5MM 38MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.94 SUP HCPCS C1713 458.940 - SCREW BONE 5MM 40MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.942 SUP HCPCS C1713 458.942 - SCREW BONE 5MM 42MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.944 SUP HCPCS C1713 458.944 - SCREW BONE 5MM 44MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.946 SUP HCPCS C1713 458.946 - SCREW BONE 5MM 46MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.948 SUP HCPCS C1713 458.948 - SCREW BONE 5MM 48MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.95 SUP HCPCS C1713 458.950 - SCREW BONE 3.5MM FULTHD BLUNT HEXAGON 5MM 8MM 50MM 2 LEAD BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 458.952 SUP HCPCS C1713 458.952 - SCREW BONE 5MM 52MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $307.65 $227.66 $0.00 $316.66 $178.12 $178.12 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $197.91 $243.66 $316.66 $0.00 $0.00 $48.15 $0.00 $0.00 $63.02 $0.00 $0.00 $0.00 $0.00 $0.00 458.954 SUP HCPCS C1713 458.954 - SCREW BONE NONSTRL CANN IM NAIL 5MM 54MM NLEX TI DISTAL BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.956 SUP HCPCS C1713 458.956 - SCREW BONE NONSTRL IM NAIL 5MM 56MM NLEX TI DISTAL FEM/TIB BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.958 SUP HCPCS C1713 458.958 - SCREW BONE NONSTRL IM NAIL 5MM 58MM NLEX TI DISTAL FEM/TIB BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.96 SUP HCPCS C1713 458.960 - SCREW BONE NONSTRL IM NAIL 5MM 60MM NLEX TI DISTAL FEM/TIB BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.964 SUP HCPCS C1713 458.964 - SCREW BONE 5MM 64MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 458.968 SUP HCPCS C1713 458.968 - SCREW BONE NONSTRL CANN IM NAIL 5MM 68MM NLEX TI DISTAL BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.972 SUP HCPCS C1713 458.972 - SCREW BONE 5MM 72MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.976 SUP HCPCS C1713 458.976 - SCREW BONE 5MM 76MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.98 SUP HCPCS C1713 458.980 - SCREW BONE NONSTRL CANN IM NAIL 5MM 80MM NLEX TI DISTAL BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.985 SUP HCPCS C1713 458.985 - SCREW BONE 5MM 85MM TI ALLOY LCK SLFTAP NONSTRL BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.99 SUP HCPCS C1713 458.990 - SCREW BONE 5MM 90MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.995 SUP HCPCS C1713 458.995 - SCREW BONE 5MM 95MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 458.999 SUP HCPCS C1713 458.999 - SCREW BONE 5MM 100MM NLEX TI DISTAL FEM/TIB LCK HEX RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 459.68 SUP HCPCS C1713 459.68 - BOLT LOCKING HEXAGON 4.9MM 8MM 68MM SELF TAP SELF CUT TROCAR BOTH IP/OP $328.90 $243.39 $0.00 $263.12 $148.01 $148.01 $0.00 $0.00 $0.00 $68.55 $244.11 $244.11 $0.00 $0.00 $68.54 $0.00 $194.54 $194.54 $0.00 $164.45 $260.49 $263.12 $0.00 $0.00 $51.86 $0.00 $0.00 $52.36 $0.00 $0.00 $0.00 $0.00 $0.00 460 SUP Custom 27203010 460 - DRESSING GZE 12X12IN LF QUIKCLOT TRAUMAPAD 3 PLY NWVN FLXB BOTH IP/OP $145.58 $107.73 $0.00 $116.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.79 $115.30 $116.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.022 SUP HCPCS C1713 460.022 - PIN FIX EMERGENCY RELEASE TITANIUM STERNUM NONSTRL BOTH IP/OP $226.25 $167.43 $0.00 $181.00 $101.81 $101.81 $0.00 $0.00 $0.00 $47.16 $167.92 $167.92 $0.00 $0.00 $47.15 $0.00 $133.83 $133.83 $0.00 $113.13 $179.19 $181.00 $0.00 $0.00 $35.41 $0.00 $0.00 $36.02 $0.00 $0.00 $0.00 $0.00 $0.00 460.023 SUP HCPCS C1713 460.023 - PLATE BONE STR 20 HOLE LOCKING TITANIUM STERNUM NONSTRL 2.4 BOTH IP/OP "$5,407.50 " "$4,001.55" $0.00 "$4,326.00" "$2,433.38" "$2,433.38" $0.00 $0.00 $0.00 "$1,127.06" "$4,013.45" "$4,013.45" $0.00 $0.00 "$1,126.92" $0.00 "$2,665.90" "$2,665.90" $0.00 "$2,703.75" "$4,282.74" "$4,326.00" $0.00 $0.00 $846.27 $0.00 $0.00 $860.87 $0.00 $0.00 $0.00 $0.00 $0.00 460.027 SUP HCPCS C1713 460.027 - PLATE BONE H SMALL 8 HOLE LOCKING TITANIUM MANUBRIUM STERNUM BOTH IP/OP "$2,380.00 " "$1,761.20" $0.00 "$1,904.00" "$1,071.00" "$1,071.00" $0.00 $0.00 $0.00 $496.05 "$1,766.44" "$1,766.44" $0.00 $0.00 $495.99 $0.00 "$1,407.77" "$1,407.77" $0.00 "$1,190.00" "$1,884.96" "$1,904.00" $0.00 $0.00 $372.47 $0.00 $0.00 $378.90 $0.00 $0.00 $0.00 $0.00 $0.00 460.028 SUP HCPCS C1713 460.028 - PLATE BONE H LARGE 8 HOLE LOCKING TITANIUM MANUBRIUM STERNUM BOTH IP/OP "$2,380.00 " "$1,761.20" $0.00 "$1,904.00" "$1,071.00" "$1,071.00" $0.00 $0.00 $0.00 $496.05 "$1,766.44" "$1,766.44" $0.00 $0.00 $495.99 $0.00 "$1,407.77" "$1,407.77" $0.00 "$1,190.00" "$1,884.96" "$1,904.00" $0.00 $0.00 $372.47 $0.00 $0.00 $378.90 $0.00 $0.00 $0.00 $0.00 $0.00 460.035 SUP HCPCS C1713 460.035 - PLATE BONE STAR 6 HOLE LOCKING TITANIUM STERNUM NONSTRL BOTH IP/OP "$2,260.00 " "$1,672.40" $0.00 "$1,808.00" "$1,017.00" "$1,017.00" $0.00 $0.00 $0.00 $471.04 "$1,677.37" "$1,677.37" $0.00 $0.00 $470.98 $0.00 "$1,336.79" "$1,336.79" $0.00 "$1,130.00" "$1,789.92" "$1,808.00" $0.00 $0.00 $353.69 $0.00 $0.00 $359.79 $0.00 $0.00 $0.00 $0.00 $0.00 460.036 SUP HCPCS C1713 460.036 - PLATE BONE STAR 12 HOLE LOCKING TITANIUM STERNUM NONSTRL BOTH IP/OP "$2,827.50 " "$2,092.35" $0.00 "$2,262.00" "$1,272.38" "$1,272.38" $0.00 $0.00 $0.00 $589.32 "$2,098.57" "$2,098.57" $0.00 $0.00 $589.25 $0.00 "$1,393.96" "$1,393.96" $0.00 "$1,413.75" "$2,239.38" "$2,262.00" $0.00 $0.00 $442.50 $0.00 $0.00 $450.14 $0.00 $0.00 $0.00 $0.00 $0.00 460.037 SUP HCPCS C1713 460.037 - PLATE BONE X 10 HOLE LOCKING TITANIUM STERNUM NONSTRL BOTH IP/OP "$2,492.50 " "$1,844.45" $0.00 "$1,994.00" "$1,121.63" "$1,121.63" $0.00 $0.00 $0.00 $519.50 "$1,849.93" "$1,849.93" $0.00 $0.00 $519.44 $0.00 "$1,474.31" "$1,474.31" $0.00 "$1,246.25" "$1,974.06" "$1,994.00" $0.00 $0.00 $390.08 $0.00 $0.00 $396.81 $0.00 $0.00 $0.00 $0.00 $0.00 460.038 SUP HCPCS C1713 460.038 - PLATE BONE 2T 14 HOLE LOCKING TITANIUM STERNUM NONSTRL BOTH IP/OP "$2,825.00 " "$2,090.50" $0.00 "$2,260.00" "$1,271.25" "$1,271.25" $0.00 $0.00 $0.00 $588.80 "$2,096.72" "$2,096.72" $0.00 $0.00 $588.73 $0.00 "$1,392.73" "$1,392.73" $0.00 "$1,412.50" "$2,237.40" "$2,260.00" $0.00 $0.00 $442.11 $0.00 $0.00 $449.74 $0.00 $0.00 $0.00 $0.00 $0.00 460.039 SUP HCPCS C1713 460.039 - PLATE BONE ANGLED 12 HOLE LOCKING TITANIUM STERNUM NONSTRL BOTH IP/OP "$3,817.50 " "$2,824.95" $0.00 "$3,054.00" "$1,717.88" "$1,717.88" $0.00 $0.00 $0.00 $795.66 "$2,833.35" "$2,833.35" $0.00 $0.00 $795.57 $0.00 "$1,882.03" "$1,882.03" $0.00 "$1,908.75" "$3,023.46" "$3,054.00" $0.00 $0.00 $597.44 $0.00 $0.00 $607.75 $0.00 $0.00 $0.00 $0.00 $0.00 460.04 SUP HCPCS C1713 460.040 - PLATE BONE X 10 HOLE LOCKING TITANIUM STERNUM NONSTRL BOTH IP/OP "$2,492.50 " "$1,844.45" $0.00 "$1,994.00" "$1,121.63" "$1,121.63" $0.00 $0.00 $0.00 $519.50 "$1,849.93" "$1,849.93" $0.00 $0.00 $519.44 $0.00 "$1,474.31" "$1,474.31" $0.00 "$1,246.25" "$1,974.06" "$1,994.00" $0.00 $0.00 $390.08 $0.00 $0.00 $396.81 $0.00 $0.00 $0.00 $0.00 $0.00 460.045 SUP HCPCS C1713 460.045 - PLATE BONE STR 8 HOLE LOCKING TITANIUM STERNUM NONSTRL BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" "$1,224.00" "$1,224.00" $0.00 $0.00 $0.00 $566.92 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 "$1,340.96" "$1,340.96" $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $425.68 $0.00 $0.00 $433.02 $0.00 $0.00 $0.00 $0.00 $0.00 460.046 SUP HCPCS C1713 460.046 - PLATE BONE STR 13 HOLE LOCKING TITANIUM STERNUM NONSTRL BOTH IP/OP "$2,825.00 " "$2,090.50" $0.00 "$2,260.00" "$1,271.25" "$1,271.25" $0.00 $0.00 $0.00 $588.80 "$2,096.72" "$2,096.72" $0.00 $0.00 $588.73 $0.00 "$1,392.73" "$1,392.73" $0.00 "$1,412.50" "$2,237.40" "$2,260.00" $0.00 $0.00 $442.11 $0.00 $0.00 $449.74 $0.00 $0.00 $0.00 $0.00 $0.00 461 SUP Custom 27203010 461 - DRESSING GAUZE 4YDX3IN ROLL HEMOSTATIC QUIKCLOT BOTH IP/OP $99.72 $73.79 $0.00 $80.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.01 $74.01 $0.00 $0.00 $20.78 $0.00 $0.00 $0.00 $0.00 $50.61 $1.35 $80.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 462.64 SUP HCPCS C1713 462.640 - BLADE IM NAIL GOLD 40MM HUM TI SPRL SLD NONSTRL BOTH IP/OP "$1,253.08 " $927.28 $0.00 "$1,002.46" $563.88 $563.88 $0.00 $0.00 $0.00 $261.17 $930.03 $930.03 $0.00 $0.00 $261.14 $0.00 $741.19 $741.19 $0.00 $626.54 $992.44 "$1,002.46" $0.00 $0.00 $196.11 $0.00 $0.00 $199.49 $0.00 $0.00 $0.00 $0.00 $0.00 462.644 SUP HCPCS C1713 462.644 - BLADE IM FIX GOLD 44CM HUM TI SPRL NONSTRL BOTH IP/OP "$1,253.08 " $927.28 $0.00 "$1,002.46" $563.88 $563.88 $0.00 $0.00 $0.00 $261.17 $930.03 $930.03 $0.00 $0.00 $261.14 $0.00 $741.19 $741.19 $0.00 $626.54 $992.44 "$1,002.46" $0.00 $0.00 $196.11 $0.00 $0.00 $199.49 $0.00 $0.00 $0.00 $0.00 $0.00 476 SUP Custom 27803010 00476 - TUBE NG 45IN 10FR SDPRT WT STY FLXFL PU PED STRL BOTH IP/OP $22.88 $16.93 $0.00 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.98 $16.98 $0.00 $0.00 $4.77 $0.00 $0.00 $0.00 $0.00 $11.44 $18.12 $18.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 482.823 SUP HCPCS C1713 482.823 - PLATE BONE 17X10X.7MM 7 HOLE BUTTON OVAL TITANIUM ORTHOPEDIC BOTH IP/OP $721.13 $533.64 $0.00 $560.10 $315.06 $315.06 $0.00 $0.00 $0.00 $150.30 $535.22 $535.22 $0.00 $0.00 $150.28 $0.00 $426.55 $426.55 $0.00 $350.06 $554.50 $560.10 $0.00 $0.00 $106.38 $0.00 $0.00 $111.46 $0.00 $0.00 $0.00 $0.00 $0.00 487.931 SUP Custom 27803010 487.931 - DISTRACTOR SURG MULTI VECTOR BODY TITANIUM MANDIB NONSTRL BOTH IP/OP "$12,302.50 " "$9,103.85" $0.00 "$9,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,563.84" $0.00 $0.00 $0.00 $0.00 "$6,151.25" "$9,743.58" "$9,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.933 SUP Custom 27803010 487.933 - DISTRACTOR SURG 15MM MULTI VECTOR ARM TITANIUM MANDIB BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.934 SUP Custom 27803010 487.934 - DISTRACTOR SURG 25MM MULTI VECTOR ARM TITANIUM MANDIB BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.935 SUP Custom 27803010 487.935 - DISTRACTOR SURG 35MM MULTI VECTOR ARM TITANIUM MANDIB BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.937 SUP Custom 27803010 487.937 - DISTRACTOR SURG NUT LINEAR ACTIVATION TITANIUM MANDIB BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.938 SUP Custom 27803010 487.938 - DISTRACTOR SURG MULTI VECTOR PIN HOLDING CLMP TITANIUM BOTH IP/OP "$2,622.50 " "$1,940.65" $0.00 "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,946.42" "$1,946.42" $0.00 $0.00 $546.53 $0.00 $0.00 $0.00 $0.00 "$1,311.25" "$2,077.02" "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.939 SUP Custom 27803010 487.939 - DISTRACTOR SURG MULTI VECTOR PIN HOLDING BODY TITANIUM BOTH IP/OP "$2,622.50 " "$1,940.65" $0.00 "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,946.42" "$1,946.42" $0.00 $0.00 $546.53 $0.00 $0.00 $0.00 $0.00 "$1,311.25" "$2,077.02" "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.94 SUP Custom 27203010 487.940 - CLAMP EXFIX UNIVERSAL PIN HOLDING TITANIUM MULTI VECTOR BOTH IP/OP "$2,622.50 " "$1,940.65" $0.00 "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,946.42" "$1,946.42" $0.00 $0.00 $546.53 $0.00 $0.00 $0.00 $0.00 "$1,311.25" "$2,077.02" "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.941 SUP Custom 27203010 487.941 - CLAMP EXFIX BODY PIN HOLDING MULTIVECTOR DISTRCT BLUE BOTH IP/OP "$2,622.50 " "$1,940.65" $0.00 "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,946.42" "$1,946.42" $0.00 $0.00 $546.53 $0.00 $0.00 $0.00 $0.00 "$1,311.25" "$2,077.02" "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.942 SUP Custom 27203010 487.942 - CLAMP EXFIX RAMUS PIN HOLDING MULTIVECTOR DISTRCT GOLD BOTH IP/OP "$2,622.50 " "$1,940.65" $0.00 "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,946.42" "$1,946.42" $0.00 $0.00 $546.53 $0.00 $0.00 $0.00 $0.00 "$1,311.25" "$2,077.02" "$2,098.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.96 SUP HCPCS C1713 487.960 - PLATE 1.6MM MAXL ASMBLY BONE TI BOTH IP/OP "$1,838.25 " "$1,360.31" $0.00 "$1,470.60" $827.21 $827.21 $0.00 $0.00 $0.00 $383.14 "$1,364.35" "$1,364.35" $0.00 $0.00 $383.09 $0.00 "$1,087.32" "$1,087.32" $0.00 $919.13 "$1,455.89" "$1,470.60" $0.00 $0.00 $287.69 $0.00 $0.00 $292.65 $0.00 $0.00 $0.00 $0.00 $0.00 487.962 SUP Custom 27803010 487.962 - FOOTPLATE BONE 20MM 1 VECTOR DISTRCT BODY TITANIUM MANDIB BOTH IP/OP "$16,635.00 " "$12,309.90" $0.00 "$13,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,466.73" $0.00 $0.00 $0.00 $0.00 "$8,317.50" "$13,174.92" "$13,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.963 SUP Custom 27803010 487.963 - FOOTPLATE BONE 20MM 1 VECTOR DISTRCT BODY TITANIUM MANDIB BOTH IP/OP "$16,635.00 " "$12,309.90" $0.00 "$13,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,466.73" $0.00 $0.00 $0.00 $0.00 "$8,317.50" "$13,174.92" "$13,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.964 SUP Custom 27803010 487.964 - FOOTPLATE BONE 30MM 1 VECTOR DISTRCT BODY TITANIUM MANDIB BOTH IP/OP "$16,635.00 " "$12,309.90" $0.00 "$13,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,466.73" $0.00 $0.00 $0.00 $0.00 "$8,317.50" "$13,174.92" "$13,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.965 SUP Custom 27803010 487.965 - FOOTPLATE BONE 30MM 1 VECTOR DISTRCT BODY TITANIUM MANDIB BOTH IP/OP "$16,635.00 " "$12,309.90" $0.00 "$13,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,466.73" $0.00 $0.00 $0.00 $0.00 "$8,317.50" "$13,174.92" "$13,308.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.966 SUP Custom 27803010 487.966 - DISTRACTOR SURG MULTI VECTOR ASMBLY TITANIUM RIGHT MANDIB BOTH IP/OP "$19,727.50 " "$14,598.35" $0.00 "$15,782.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,111.21" $0.00 $0.00 $0.00 $0.00 "$9,863.75" "$15,624.18" "$15,782.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.967 SUP Custom 27803010 487.967 - DISTRACTOR SURG MULTI VECTOR ASMBLY TITANIUM MANDIB LEFT BOTH IP/OP "$19,727.50 " "$14,598.35" $0.00 "$15,782.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,111.21" $0.00 $0.00 $0.00 $0.00 "$9,863.75" "$15,624.18" "$15,782.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.971 SUP Custom 27803010 487.971 - DISTRACTOR SURG 45MM MULTI VECTOR ARM TITANIUM MANDIB BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.973 SUP Custom 27803010 487.973 - DISTRACTOR SURG 55MM MULTI VECTOR ARM TITANIUM MANDIB BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.974 SUP Custom 27803010 487.974 - DISTRACTOR SURG 1 VECTOR TITANIUM MANDIB RIGHT NONSTRL BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $512.12 $512.12 $0.00 $0.00 $143.80 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.975 SUP Custom 27803010 487.975 - DISTRACTOR SURG 1 VECTOR TITANIUM MANDIB LEFT NONSTRL BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $512.12 $512.12 $0.00 $0.00 $143.80 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.976 SUP Custom 27803010 487.976 - DISTRACTOR SURG 65MM MULTI VECTOR ARM TITANIUM MANDIB BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.977 SUP Custom 27803010 487.977 - DISTRACTOR SURG 75MM MULTI VECTOR ARM TITANIUM MANDIB BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.978 SUP Custom 27803010 487.978 - DISTRACTOR SURG 85MM MULTI VECTOR ARM TITANIUM MANDIB BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.98 SUP Custom 27803010 487.980 - DISTRACTOR SURG 7MM NUT HEXAGONAL TITANIUM MIDFAC NONSTRL BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $0.00 $0.00 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.982 SUP Custom 27803010 487.982 - DISTRACTOR SURG 40MM ASMBLY TITANIUM MIDFAC NONSTRL BOTH IP/OP "$13,747.50 " "$10,173.15" $0.00 "$10,998.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.98" $0.00 $0.00 $0.00 $0.00 "$6,873.75" "$10,888.02" "$10,998.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.984 SUP Custom 27803010 487.984 - FOOTPLATE BONE ELEVATE TITANIUM RIGHT ANTERIOR MIDFAC BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 $0.00 $0.00 $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.985 SUP Custom 27803010 487.985 - FOOTPLATE BONE ELEVATE TITANIUM LEFT ANTERIOR MIDFAC NONSTRL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 $0.00 $0.00 $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.986 SUP Custom 27803010 487.986 - FOOTPLATE BONE LP SYMMETRICAL TITANIUM ANTERIOR MIDFAC BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 $0.00 $0.00 $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.987 SUP Custom 27803010 487.987 - FOOTPLATE BONE ELEVATED SYMMETRICAL TITANIUM ANTERIOR MIDFAC BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 $0.00 $0.00 $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.988 SUP Custom 27803010 487.988 - FOOTPLATE BONE MESH TITANIUM ANTERIOR MIDFAC NONSTRL MIDFAC BOTH IP/OP "$1,542.50 " "$1,141.45" $0.00 "$1,234.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,144.84" "$1,144.84" $0.00 $0.00 $321.46 $0.00 $0.00 $0.00 $0.00 $771.25 "$1,221.66" "$1,234.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.989 SUP Custom 27803010 487.989 - FOOTPLATE BONE BUTTRESS TITANIUM ANTERIOR MIDFAC NONSTRL BOTH IP/OP "$1,542.50 " "$1,141.45" $0.00 "$1,234.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,144.84" "$1,144.84" $0.00 $0.00 $321.46 $0.00 $0.00 $0.00 $0.00 $771.25 "$1,221.66" "$1,234.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.99 SUP Custom 27803010 487.990 - FOOTPLATE BONE 1 VECTOR TITANIUM MIDFAC POSTERIOR NONSTRL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 $0.00 $0.00 $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.992 SUP Custom 27803010 487.992 - DISTRACTOR SURG 20MM RIGID EXTN TITANIUM MIDFAC NONSTRL BOTH IP/OP "$1,252.50 " $926.85 $0.00 "$1,002.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $929.61 $929.61 $0.00 $0.00 $261.02 $0.00 $0.00 $0.00 $0.00 $626.25 $991.98 "$1,002.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.993 SUP Custom 27803010 487.993 - DISTRACTOR SURG 20MM UNIVERSAL JOINT EXTN TITANIUM BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.994 SUP Custom 27803010 487.994 - DISTRACTOR SURG 40MM FLEXIBLE CABLE EXTN TITANIUM MIDFAC BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 487.995 SUP HCPCS C1713 487.995 - SCREW EXTERNAL DISTRCT EXTERNAL MIDFAC DISTRCT SYSTEM BOTH IP/OP $365.00 $270.10 $0.00 $292.00 $164.25 $164.25 $0.00 $0.00 $0.00 $76.08 $270.90 $270.90 $0.00 $0.00 $76.07 $0.00 $215.90 $215.90 $0.00 $182.50 $289.08 $292.00 $0.00 $0.00 $57.12 $0.00 $0.00 $58.11 $0.00 $0.00 $0.00 $0.00 $0.00 488.066 SUP HCPCS C1713 488.066 - SCREW BONE 1.6MM MACHINE TITANIUM CRANIAL NONSTRL BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 488.074 SUP Custom 27803010 488.074 - DISTRACTOR SURG 8MM STR PLATE TITANIUM ALVEOLAR NONSTRL BOTH IP/OP "$2,595.00 " "$1,920.30" $0.00 "$2,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,926.01" "$1,926.01" $0.00 $0.00 $540.80 $0.00 $0.00 $0.00 $0.00 "$1,297.50" "$2,055.24" "$2,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 488.075 SUP Custom 27803010 488.075 - BODY DISTRCT 12MM STR PLATE TITANIUM ALVEOLAR NONSTRL BOTH IP/OP "$2,595.00 " "$1,920.30" $0.00 "$2,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,926.01" "$1,926.01" $0.00 $0.00 $540.80 $0.00 $0.00 $0.00 $0.00 "$1,297.50" "$2,055.24" "$2,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 488.076 SUP Custom 27803010 488.076 - BODY DISTRCT 16MM STR PLATE TITANIUM ALVEOLAR NONSTRL BOTH IP/OP "$2,595.00 " "$1,920.30" $0.00 "$2,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,926.01" "$1,926.01" $0.00 $0.00 $540.80 $0.00 $0.00 $0.00 $0.00 "$1,297.50" "$2,055.24" "$2,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 488.75 SUP HCPCS C1713 488.750 - SCREW BONE 4.35MM 25MM TI CANC CERV SPN BTRS LCK XPD HEAD BOTH IP/OP $547.75 $405.34 $0.00 $438.20 $246.49 $246.49 $0.00 $0.00 $0.00 $114.16 $406.54 $406.54 $0.00 $0.00 $114.15 $0.00 $323.99 $323.99 $0.00 $273.88 $433.82 $438.20 $0.00 $0.00 $85.72 $0.00 $0.00 $87.20 $0.00 $0.00 $0.00 $0.00 $0.00 488.915 SUP HCPCS C1713 488.915 - PLATE 30MM TI 2 HOLE LCK BTRS BONE SPNL NONSTRL BOTH IP/OP "$1,232.00 " $911.68 $0.00 $985.60 $554.40 $554.40 $0.00 $0.00 $0.00 $256.78 $914.39 $914.39 $0.00 $0.00 $256.75 $0.00 $728.73 $728.73 $0.00 $616.00 $975.74 $985.60 $0.00 $0.00 $192.81 $0.00 $0.00 $196.13 $0.00 $0.00 $0.00 $0.00 $0.00 492.08 SUP Custom 27203010 492.08 - WIRE FX .8MM 70MM NS KRSH TROC PNT TI BOTH IP/OP $19.12 $14.15 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.19 $14.19 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.1 SUP Custom 27203010 492.10 - WIRE FX 1MM 150MM NS KRSH TROC PNT TI BOTH IP/OP $18.56 $13.73 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.78 $13.78 $0.00 $0.00 $3.87 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.12 SUP Custom 27203010 492.12 - WIRE FX 1.25MM 150MM NS KRSH TROC PNT TI BOTH IP/OP $19.12 $14.15 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.19 $14.19 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.16 SUP Custom 27203010 492.16 - WIRE FX 1.6MM 150MM NS KRSH TROC PNT TI BOTH IP/OP $19.12 $14.15 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.19 $14.19 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.18 SUP Custom 27203010 492.18 - WIRE FX 1.6MM 285MM NS KRSH TROC PNT TI BOTH IP/OP $23.05 $17.06 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.11 $17.11 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $11.19 $17.72 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.2 SUP Custom 27203010 492.20 - WIRE FX 2MM 150MM NS KRSH TROC PNT TI BOTH IP/OP $18.56 $13.73 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.78 $13.78 $0.00 $0.00 $3.87 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.21 SUP Custom 27203010 492.21 - WIRE FX 2MM 285MM NS KRSH TROC PNT TI BOTH IP/OP $23.05 $17.06 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.11 $17.11 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $11.19 $17.72 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.25 SUP Custom 27203010 492.25 - WIRE FX 2.5MM 150MM NS KRSH TROC PNT TI BOTH IP/OP $19.12 $14.15 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.19 $14.19 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.26 SUP Custom 27203010 492.26 - WIRE FX 2.5MM 285MM NS KRSH TROC PNT TI BOTH IP/OP $23.05 $17.06 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.11 $17.11 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $11.19 $17.72 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.3 SUP Custom 27203010 492.30 - WIRE FX 3MM 150MM NS KRSH TROC PNT TI BOTH IP/OP $18.56 $13.73 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.78 $13.78 $0.00 $0.00 $3.87 $0.00 $0.00 $0.00 $0.00 $9.28 $14.70 $14.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 492.31 SUP Custom 27203010 492.31 - WIRE FX 3MM 285MM NS KRSH TROC PNT TI BOTH IP/OP $23.05 $17.06 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.11 $17.11 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $11.19 $17.72 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 494.769 SUP HCPCS C1713 494.769 - SCREW BONE 4/2.5MM 80MM 20MM SLFDRILL REINFORCED BONE ANCHOR BOTH IP/OP $249.53 $184.65 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $52.01 $185.20 $185.20 $0.00 $0.00 $52.00 $0.00 $147.59 $147.59 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $36.81 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 494.771 SUP HCPCS C1713 494.771 - SCREW XTRNFX 4MM 3MM 80MM NS 20MM SCHNZ SLF DRL MR BOTH IP/OP $278.48 $206.08 $0.00 $216.30 $121.67 $121.67 $0.00 $0.00 $0.00 $58.04 $206.68 $206.68 $0.00 $0.00 $58.03 $0.00 $164.72 $164.72 $0.00 $135.19 $214.14 $216.30 $0.00 $0.00 $41.08 $0.00 $0.00 $43.04 $0.00 $0.00 $0.00 $0.00 $0.00 494.772 SUP HCPCS C1713 494.772 - SCREW BONE 4/3MM 100MM 20MM SLFDRILL SCHANZ TITANIUM BOTH IP/OP $278.48 $206.08 $0.00 $216.30 $121.67 $121.67 $0.00 $0.00 $0.00 $58.04 $206.68 $206.68 $0.00 $0.00 $58.03 $0.00 $164.72 $164.72 $0.00 $135.19 $214.14 $216.30 $0.00 $0.00 $41.08 $0.00 $0.00 $43.04 $0.00 $0.00 $0.00 $0.00 $0.00 494.774 SUP HCPCS C1713 494.774 - SCREW BONE 4MM 60MM 20MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $278.48 $206.08 $0.00 $216.30 $121.67 $121.67 $0.00 $0.00 $0.00 $58.04 $206.68 $206.68 $0.00 $0.00 $58.03 $0.00 $164.72 $164.72 $0.00 $135.19 $214.14 $216.30 $0.00 $0.00 $41.08 $0.00 $0.00 $43.04 $0.00 $0.00 $0.00 $0.00 $0.00 494.775 SUP HCPCS C1713 494.775 - PIN HALF 4MM 80MM 20MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $278.48 $206.08 $0.00 $216.30 $121.67 $121.67 $0.00 $0.00 $0.00 $58.04 $206.68 $206.68 $0.00 $0.00 $58.03 $0.00 $164.72 $164.72 $0.00 $135.19 $214.14 $216.30 $0.00 $0.00 $41.08 $0.00 $0.00 $43.04 $0.00 $0.00 $0.00 $0.00 $0.00 494.776 SUP HCPCS C1713 494.776 - SCREW FIX 4MM 100MM 30MM SELF DRILL REINFORCE SYMMETRICAL BOTH IP/OP $278.48 $206.08 $0.00 $216.30 $121.67 $121.67 $0.00 $0.00 $0.00 $58.04 $206.68 $206.68 $0.00 $0.00 $58.03 $0.00 $164.72 $164.72 $0.00 $135.19 $214.14 $216.30 $0.00 $0.00 $41.08 $0.00 $0.00 $43.04 $0.00 $0.00 $0.00 $0.00 $0.00 494.777 SUP HCPCS C1713 494.777 - SCREW BONE 4MM 125MM 40MM SLFDRILL SCHANZ TITANIUM BOTH IP/OP $278.48 $206.08 $0.00 $216.30 $121.67 $121.67 $0.00 $0.00 $0.00 $58.04 $206.68 $206.68 $0.00 $0.00 $58.03 $0.00 $164.72 $164.72 $0.00 $135.19 $214.14 $216.30 $0.00 $0.00 $41.08 $0.00 $0.00 $43.04 $0.00 $0.00 $0.00 $0.00 $0.00 494.778 SUP HCPCS C1713 494.778 - SCREW BONE 4MM 150MM 40MM SLFDRILL SCHANZ TITANIUM BOTH IP/OP $278.48 $206.08 $0.00 $216.30 $121.67 $121.67 $0.00 $0.00 $0.00 $58.04 $206.68 $206.68 $0.00 $0.00 $58.03 $0.00 $164.72 $164.72 $0.00 $135.19 $214.14 $216.30 $0.00 $0.00 $41.08 $0.00 $0.00 $43.04 $0.00 $0.00 $0.00 $0.00 $0.00 494.779 SUP HCPCS C1713 494.779 - PIN HALF 4MM 175MM 40MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $278.48 $206.08 $0.00 $216.30 $121.67 $121.67 $0.00 $0.00 $0.00 $58.04 $206.68 $206.68 $0.00 $0.00 $58.03 $0.00 $164.72 $164.72 $0.00 $135.19 $214.14 $216.30 $0.00 $0.00 $41.08 $0.00 $0.00 $43.04 $0.00 $0.00 $0.00 $0.00 $0.00 494.782 SUP HCPCS C1713 494.782 - PIN HALF 5MM 100MM 30MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $320.83 $237.41 $0.00 $249.18 $140.16 $140.16 $0.00 $0.00 $0.00 $66.87 $238.12 $238.12 $0.00 $0.00 $66.86 $0.00 $189.77 $189.77 $0.00 $155.74 $246.69 $249.18 $0.00 $0.00 $47.33 $0.00 $0.00 $49.59 $0.00 $0.00 $0.00 $0.00 $0.00 494.783 SUP HCPCS C1713 494.783 - PIN HALF 5MM 125MM 40MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $320.83 $237.41 $0.00 $249.18 $140.16 $140.16 $0.00 $0.00 $0.00 $66.87 $238.12 $238.12 $0.00 $0.00 $66.86 $0.00 $189.77 $189.77 $0.00 $155.74 $246.69 $249.18 $0.00 $0.00 $47.33 $0.00 $0.00 $49.59 $0.00 $0.00 $0.00 $0.00 $0.00 494.784 SUP HCPCS C1713 494.784 - SCREW XTRNFX 5MM 150MM NS 60MM SCHNZ SLF DRL TI HIP CNDYL LG BOTH IP/OP $320.83 $237.41 $0.00 $249.18 $140.16 $140.16 $0.00 $0.00 $0.00 $66.87 $238.12 $238.12 $0.00 $0.00 $66.86 $0.00 $189.77 $189.77 $0.00 $155.74 $246.69 $249.18 $0.00 $0.00 $47.33 $0.00 $0.00 $49.59 $0.00 $0.00 $0.00 $0.00 $0.00 494.785 SUP HCPCS C1713 494.785 - SCREW XTRNFX 5MM 175MM NS 60MM SCHNZ SLF DRL MR CONDITIONAL BOTH IP/OP $320.83 $237.41 $0.00 $249.18 $140.16 $140.16 $0.00 $0.00 $0.00 $66.87 $238.12 $238.12 $0.00 $0.00 $66.86 $0.00 $189.77 $189.77 $0.00 $155.74 $246.69 $249.18 $0.00 $0.00 $47.33 $0.00 $0.00 $49.59 $0.00 $0.00 $0.00 $0.00 $0.00 494.786 SUP HCPCS C1713 494.786 - SCREW XTRNFX 5MM 200MM NS 80MM SCHNZ SLF DRL TI HIP CNDYL LG BOTH IP/OP $320.83 $237.41 $0.00 $249.18 $140.16 $140.16 $0.00 $0.00 $0.00 $66.87 $238.12 $238.12 $0.00 $0.00 $66.86 $0.00 $189.77 $189.77 $0.00 $155.74 $246.69 $249.18 $0.00 $0.00 $47.33 $0.00 $0.00 $49.59 $0.00 $0.00 $0.00 $0.00 $0.00 494.788 SUP HCPCS C1713 494.788 - PIN HALF 5MM 250MM 80MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $320.83 $237.41 $0.00 $249.18 $140.16 $140.16 $0.00 $0.00 $0.00 $66.87 $238.12 $238.12 $0.00 $0.00 $66.86 $0.00 $189.77 $189.77 $0.00 $155.74 $246.69 $249.18 $0.00 $0.00 $47.33 $0.00 $0.00 $49.59 $0.00 $0.00 $0.00 $0.00 $0.00 494.792 SUP HCPCS C1713 494.792 - SCREW BONE 6MM 100MM 30MM SLFDRILL SCHANZ TITANIUM BOTH IP/OP $341.98 $253.07 $0.00 $265.62 $149.41 $149.41 $0.00 $0.00 $0.00 $71.28 $253.81 $253.81 $0.00 $0.00 $71.27 $0.00 $202.28 $202.28 $0.00 $166.01 $262.97 $265.62 $0.00 $0.00 $50.45 $0.00 $0.00 $52.86 $0.00 $0.00 $0.00 $0.00 $0.00 494.793 SUP HCPCS C1713 494.793 - PIN HALF 6MM 125MM 40MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $341.98 $253.07 $0.00 $265.62 $149.41 $149.41 $0.00 $0.00 $0.00 $71.28 $253.81 $253.81 $0.00 $0.00 $71.27 $0.00 $202.28 $202.28 $0.00 $166.01 $262.97 $265.62 $0.00 $0.00 $50.45 $0.00 $0.00 $52.86 $0.00 $0.00 $0.00 $0.00 $0.00 494.794 SUP HCPCS C1713 494.794 - SCREW BONE 6MM 150MM 60MM SLFDRILL SCHANZ TITANIUM BOTH IP/OP $341.98 $253.07 $0.00 $265.62 $149.41 $149.41 $0.00 $0.00 $0.00 $71.28 $253.81 $253.81 $0.00 $0.00 $71.27 $0.00 $202.28 $202.28 $0.00 $166.01 $262.97 $265.62 $0.00 $0.00 $50.45 $0.00 $0.00 $52.86 $0.00 $0.00 $0.00 $0.00 $0.00 494.795 SUP HCPCS C1713 494.795 - PIN HALF 6MM 175MM 60MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $341.98 $253.07 $0.00 $265.62 $149.41 $149.41 $0.00 $0.00 $0.00 $71.28 $253.81 $253.81 $0.00 $0.00 $71.27 $0.00 $202.28 $202.28 $0.00 $166.01 $262.97 $265.62 $0.00 $0.00 $50.45 $0.00 $0.00 $52.86 $0.00 $0.00 $0.00 $0.00 $0.00 494.796 SUP HCPCS C1713 494.796 - SCREW BONE 6MM 200MM 80MM SLFDRILL SCHANZ TITANIUM BOTH IP/OP $341.98 $253.07 $0.00 $265.62 $149.41 $149.41 $0.00 $0.00 $0.00 $71.28 $253.81 $253.81 $0.00 $0.00 $71.27 $0.00 $202.28 $202.28 $0.00 $166.01 $262.97 $265.62 $0.00 $0.00 $50.45 $0.00 $0.00 $52.86 $0.00 $0.00 $0.00 $0.00 $0.00 494.798 SUP HCPCS C1713 494.798 - PIN HALF 6MM 250MM 80MM SLFDRILL SCHANZ TITANIUM ORTHOPEDIC BOTH IP/OP $341.98 $253.07 $0.00 $265.62 $149.41 $149.41 $0.00 $0.00 $0.00 $71.28 $253.81 $253.81 $0.00 $0.00 $71.27 $0.00 $202.28 $202.28 $0.00 $166.01 $262.97 $265.62 $0.00 $0.00 $50.45 $0.00 $0.00 $52.86 $0.00 $0.00 $0.00 $0.00 $0.00 495.372 SUP HCPCS C1713 495.372 - CAGE SPNL OBLNG 22X17X12MM NS SNMSH TI VERT BD REPL BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 495.394 SUP HCPCS C1713 495.394 - RING SPNL 5D OBLNG 22MM 17MM 22X17MM NS SNMSH PRFT ALAT BOTH IP/OP $830.00 $614.20 $0.00 $664.00 $373.50 $373.50 $0.00 $0.00 $0.00 $172.99 $616.03 $616.03 $0.00 $0.00 $172.97 $0.00 $490.95 $490.95 $0.00 $415.00 $657.36 $664.00 $0.00 $0.00 $129.90 $0.00 $0.00 $132.14 $0.00 $0.00 $0.00 $0.00 $0.00 497.674 SUP HCPCS C1713 497.674 - SCREW TI 14MM 2.4MM MANDIB SLFTAP LCK BONE NONSTRL RECON PLT BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 497.676 SUP HCPCS C1713 497.676 - SCREW TI 16MM 2.4MM MANDIB SLFTAP LCK BONE NONSTRL RECON PLT BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 497.678 SUP HCPCS C1713 497.678 - SCREW TI 18MM 2.4MM MANDIB SLFTAP LCK BONE NONSTRL RECON PLT BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 497.78 SUP HCPCS C1713 497.78 - SCREW BN 1.8MM 5MM LCK TI SPNE BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 497.797 SUP Custom 27803010 497.797 - TRNCON ROD 35-41MM 6MM CLICKX PANGEA USS UNV SPNL TI LP BOTH IP/OP "$2,432.50 " "$1,800.05" $0.00 "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,805.40" "$1,805.40" $0.00 $0.00 $506.93 $0.00 $0.00 $0.00 $0.00 "$1,216.25" "$1,926.54" "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 498.104 SUP HCPCS C1713 498.104 - ROD SPNL 100MM 6MM USS TI HRD NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 498.105 SUP HCPCS C1713 498.105 - ROD SPNL 125MM 6MM USS TI HRD NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 498.106 SUP HCPCS C1713 498.106 - ROD SPNL 150MM 6MM USS TI HRD NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 498.108 SUP HCPCS C1713 498.108 - ROD SPNL 200MM 6MM USS TI HRD NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 498.116 SUP HCPCS C1713 498.116 - ROD SPNL 400MM 6MM USS TI HRD NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 498.12 SUP HCPCS C1713 498.120 - BAR SPNL 80MM 3.5MM USS TI CONCTR TRNSVRS NONSTRL BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 498.125 SUP HCPCS C1713 498.125 - CONNECTOR ROD STR 3.5MM 120MM SET UPPER BAR USS TITANIUM SPN BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 498.136 SUP HCPCS C1713 498.136 - ROD SPNL 40MM 3.5MM AXON TI CVD NONSTRL BOTH IP/OP $353.50 $261.59 $0.00 $282.80 $159.08 $159.08 $0.00 $0.00 $0.00 $73.68 $262.37 $262.37 $0.00 $0.00 $73.67 $0.00 $209.10 $209.10 $0.00 $176.75 $279.97 $282.80 $0.00 $0.00 $55.32 $0.00 $0.00 $56.28 $0.00 $0.00 $0.00 $0.00 $0.00 498.137 SUP HCPCS C1713 498.137 - ROD SPINAL CURVE 3.5MM 80MM PREBENT AXON TITANIUM NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 498.141 SUP HCPCS C1713 498.141 - ROD SPNL 65MM 6MM USS TI SFT CVD NONSTRL BOTH IP/OP $483.00 $357.42 $0.00 $386.40 $217.35 $217.35 $0.00 $0.00 $0.00 $100.67 $358.48 $358.48 $0.00 $0.00 $100.66 $0.00 $285.69 $285.69 $0.00 $241.50 $382.54 $386.40 $0.00 $0.00 $75.59 $0.00 $0.00 $76.89 $0.00 $0.00 $0.00 $0.00 $0.00 500 SUP Custom 27203010 LYPHOCHEK ANEMIA CONTROL BOTH IP/OP $257.50 $190.55 $0.00 $206.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.75 $203.94 $206.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 510.01 SUP HCPCS C1713 "510.010 - 4.0MM FIXED SCREW SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.012 SUP HCPCS C1713 "510.012 - 4.0MM FIXED SCREW SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.014 SUP HCPCS C1713 "510.014 - 4.0MM FIXED SCREW SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.016 SUP HCPCS C1713 "510.016 - 4.0MM FIXED SCREW SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.03 SUP HCPCS C1713 "510.030 - 4.0MM FIXED SCREW SELF-TAPPING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.032 SUP HCPCS C1713 "510.032 - 4.0MM FIXED SCREW SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.034 SUP HCPCS C1713 "510.034 - 4.0MM FIXED SCREW SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.036 SUP HCPCS C1713 "510.036 - 4.0MM FIXED SCREW SELF-TAPPING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.038 SUP HCPCS C1713 "510.038 - 4.0MM FIXED SCREW SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.04 SUP HCPCS C1713 "510.040 - 4.0MM FIXED SCREW SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.512 SUP HCPCS C1713 "510.512 - 4.5MM FIXED SCREW SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.514 SUP HCPCS C1713 "510.514 - 4.5MM FIXED SCREW SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.516 SUP HCPCS C1713 "510.516 - 4.5MM FIXED SCREW SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.53 SUP HCPCS C1713 "510.530 - 4.5MM FIXED SCREW SELF-TAPPING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.532 SUP HCPCS C1713 "510.532 - 4.5MM FIXED SCREW SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.534 SUP HCPCS C1713 "510.534 - 4.5MM FIXED SCREW SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.536 SUP HCPCS C1713 "510.536 - 4.5MM FIXED SCREW SELF-TAPPING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.538 SUP HCPCS C1713 "510.538 - 4.5MM FIXED SCREW SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.54 SUP HCPCS C1713 "510.540 - 4.5MM FIXED SCREW SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.61 SUP HCPCS C1713 "510.610 - 4.0MM STANDARD SCREW FIXED SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.612 SUP HCPCS C1713 "510.612 - 4.0MM STANDARD SCREW FIXED SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.614 SUP HCPCS C1713 "510.614 - 4.0MM STANDARD SCREW FIXED SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.616 SUP HCPCS C1713 "510.616 - 4.0MM STANDARD SCREW FIXED SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.71 SUP HCPCS C1713 "510.710 - 4.5MM STANDARD SCREW FIXED SELF-DRILLING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.712 SUP HCPCS C1713 "510.712 - 4.5MM STANDARD SCREW FIXED SELF-DRILLING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.714 SUP HCPCS C1713 "510.714 - 4.5MM STANDARD SCREW FIXED SELF-DRILLING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.716 SUP HCPCS C1713 "510.716 - 4.5MM STANDARD SCREW FIXED SELF-DRILLING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.81 SUP HCPCS C1713 "510.810 - 4.0MM STANDARD SCREW FIXED SELF-TAPPING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.812 SUP HCPCS C1713 "510.812 - 4.0MM STANDARD SCREW FIXED SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.814 SUP HCPCS C1713 "510.814 - 4.0MM STANDARD SCREW FIXED SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.816 SUP HCPCS C1713 "510.816 - 4.0MM STANDARD SCREW FIXED SELF-TAPPING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.818 SUP HCPCS C1713 "510.818 - 4.0MM STANDARD SCREW FIXED SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.82 SUP HCPCS C1713 "510.820 - 4.0MM STANDARD SCREW FIXED SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.91 SUP HCPCS C1713 "510.910 - 4.5MM STANDARD SCREW FIXED SELF-TAPPING, 10MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.912 SUP HCPCS C1713 "510.912 - 4.5MM STANDARD SCREW FIXED SELF-TAPPING, 12MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.914 SUP HCPCS C1713 "510.914 - 4.5MM STANDARD SCREW FIXED SELF-TAPPING, 14MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.916 SUP HCPCS C1713 "510.916 - 4.5MM STANDARD SCREW FIXED SELF-TAPPING, 16MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.918 SUP HCPCS C1713 "510.918 - 4.5MM STANDARD SCREW FIXED SELF-TAPPING, 18MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 510.92 SUP HCPCS C1713 "510.920 - 4.5MM STANDARD SCREW FIXED SELF-TAPPING, 20MM" BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 511.411 SUP Custom 27203010 511.411 - BIT DRILL 2MM 150MM BRAD POINT 3 FLUTED NONSTRL BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.412 SUP Custom 27203010 511.412 - BIT DRILL 2.5MM 150MM BRAD POINT 3 FLUTED NONSTRL BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.413 SUP Custom 27203010 511.413 - BIT DRILL 2.7MM 150MM QUICK COUPLING BRAD POINT 3 FLUTED BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.414 SUP Custom 27203010 511.414 - BIT DRILL 3 FLUTE 3.2MM 122MM QUICK COUPLING BRAD POINT BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.415 SUP Custom 27203010 511.415 - BIT DRILL 3.5MM 150MM QUICK COUPLING BRAD POINT 3 FLUTED BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.416 SUP Custom 27203010 511.416 - BIT DRILL 3.6MM 150MM 3 FLUTED QUICK COUPLING BRAD POINT BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.417 SUP Custom 27203010 511.417 - BIT DRILL 4MM 150MM 3 FLUTED QUICK COUPLING BRAD POINT BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.418 SUP Custom 27203010 511.418 - BIT DRILL 4.5MM 150MM QUICK COUPLING BRAD POINT 3 FLUTED BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.431 SUP Custom 27203010 511.431 - BIT DRILL 3.2MM 105MM BRAD POINT 3 FLUTE NONSTRL BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511.432 SUP Custom 27203010 511.432 - BIT DRILL 4MM 105MM BRAD POINT 3 FLUTED NONSTRL BOTH IP/OP $501.80 $371.33 $0.00 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.44 $372.44 $0.00 $0.00 $104.58 $0.00 $0.00 $0.00 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.01 SUP Custom 27203010 513.01 - BIT DRILL MINI 1.1MM 28MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.03 SUP Custom 27203010 513.03 - BIT DRILL MINI 1.1MM 45MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.05 SUP Custom 27203010 513.05 - BIT DRILL MINI 3MM 28MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.08 SUP Custom 27203010 513.08 - BIT DRILL MINI 1.5MM 52MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.1 SUP Custom 27203010 513.10 - BIT DRILL MINI 2MM 28MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.13 SUP Custom 27203010 513.13 - BIT DRILL MINI 2MM 52MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.14 SUP Custom 27203010 513.14 - BIT DRILL MINI 2MM 67MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.17 SUP Custom 27203010 513.17 - BIT DRILL MINI 2.7MM 28MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 513.19 SUP Custom 27203010 513.19 - BIT DRILL MINI 2.7MM 67MM QUICK COUPLING NONSTRL BOTH IP/OP $124.55 $92.17 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.44 $92.44 $0.00 $0.00 $25.96 $0.00 $0.00 $0.00 $0.00 $62.28 $98.64 $99.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.001 SUP Custom 27803010 "524.001 - 5.5MM STRAIGHT ROD, HEX-END, CP GRADE 4, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.002 SUP Custom 27803010 "524.002 - 5.5MM STRAIGHT ROD, HEX-END, CP GRADE 4, 400MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.003 SUP Custom 27803010 "524.003 - 5.5MM STRAIGHT ROD, HEX-END, CP GRADE 4, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.004 SUP Custom 27803010 "524.004 - 5.5MM STRAIGHT ROD, HEX-END, CP GRADE 2, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.005 SUP Custom 27803010 "524.005 - 5.5MM STRAIGHT ROD, HEX-END, CP GRADE 2, 400MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.006 SUP Custom 27803010 "524.006 - 5.5MM STRAIGHT ROD, HEX-END, CP GRADE 2, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.007 SUP Custom 27803010 "524.007 - 5.5MM STRAIGHT ROD, HEX-END W/STOP, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.008 SUP Custom 27803010 "524.008 - 5.5MM STRAIGHT ROD, HEX-END W/STOP, CP, GRADE 4, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.009 SUP Custom 27803010 "524.009 - 5.5MM STRAIGHT ROD, HEX-END W/STOP, CP, GRADE 2, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.051 SUP HCPCS C1713 "524.051 - 5.0MM REVERE REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.052 SUP HCPCS C1713 "524.052 - 5.0MM REVERE REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.053 SUP HCPCS C1713 "524.053 - 5.0MM REVERE REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.054 SUP HCPCS C1713 "524.054 - 5.0MM REVERE REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.055 SUP HCPCS C1713 "524.055 - 5.0MM REVERE REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.056 SUP HCPCS C1713 "524.056 - 5.0MM REVERE REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.057 SUP HCPCS C1713 "524.057 - 5.0MM REVERE REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.071 SUP HCPCS C1713 "524.071 - 7.5MM REVERE REDUCTION SCREW, 70MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.072 SUP HCPCS C1713 "524.072 - 7.5MM REVERE REDUCTION SCREW, 75MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.073 SUP HCPCS C1713 "524.073 - 7.5MM REVERE REDUCTION SCREW, 80MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.074 SUP HCPCS C1713 "524.074 - 7.5MM REVERE REDUCTION SCREW, 85MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.075 SUP HCPCS C1713 "524.075 - 7.5MM REVERE REDUCTION SCREW, 90MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.081 SUP HCPCS C1713 "524.081 - 8.5MM REVERE REDUCTION SCREW, 70MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.082 SUP HCPCS C1713 "524.082 - 8.5MM REVERE REDUCTION SCREW, 75MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.083 SUP HCPCS C1713 "524.083 - 8.5MM REVERE REDUCTION SCREW, 80MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.084 SUP HCPCS C1713 "524.084 - 8.5MM REVERE REDUCTION SCREW, 85MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.085 SUP HCPCS C1713 "524.085 - 8.5MM REVERE REDUCTION SCREW, 90MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.2 SUP HCPCS C1713 "524.200 - 4.0MM REVERE MONOAXIAL REDUCTION SCREW, 20MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.201 SUP HCPCS C1713 "524.201 - 4.0MM REVERE MONOAXIAL REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.202 SUP HCPCS C1713 "524.202 - 4.0MM REVERE MONOAXIAL REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.203 SUP HCPCS C1713 "524.203 - 4.0MM REVERE MONOAXIAL REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.204 SUP HCPCS C1713 "524.204 - 4.0MM REVERE MONOAXIAL REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.241 SUP HCPCS C1713 "524.241 - 4.5MM REVERE MONOAXIAL REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.242 SUP HCPCS C1713 "524.242 - 4.5MM REVERE MONOAXIAL REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.243 SUP HCPCS C1713 "524.243 - 4.5MM REVERE MONOAXIAL REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.244 SUP HCPCS C1713 "524.244 - 4.5MM REVERE MONOAXIAL REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.245 SUP HCPCS C1713 "524.245 - 4.5MM REVERE MONOAXIAL REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.252 SUP HCPCS C1713 "524.252 - 5.5MM REVERE MONOAXIAL REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.253 SUP HCPCS C1713 "524.253 - 5.5MM REVERE MONOAXIAL REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.254 SUP HCPCS C1713 "524.254 - 5.5MM REVERE MONOAXIAL REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.255 SUP HCPCS C1713 "524.255 - 5.5MM REVERE MONOAXIAL REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.256 SUP HCPCS C1713 "524.256 - 5.5MM REVERE MONOAXIAL REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.257 SUP HCPCS C1713 "524.257 - 5.5MM REVERE MONOAXIAL REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.258 SUP HCPCS C1713 "524.258 - 5.5MM REVERE MONOAXIAL REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.259 SUP HCPCS C1713 "524.259 - 5.5MM REVERE MONOAXIAL REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.262 SUP HCPCS C1713 "524.262 - 6.5MM REVERE MONOAXIAL REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.263 SUP HCPCS C1713 "524.263 - 6.5MM REVERE MONOAXIAL REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.264 SUP HCPCS C1713 "524.264 - 6.5MM REVERE MONOAXIAL REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.265 SUP HCPCS C1713 "524.265 - 6.5MM REVERE MONOAXIAL REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.266 SUP HCPCS C1713 "524.266 - 6.5MM REVERE MONOAXIAL REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.267 SUP HCPCS C1713 "524.267 - 6.5MM REVERE MONOAXIAL REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.268 SUP HCPCS C1713 "524.268 - 6.5MM REVERE MONOAXIAL REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.269 SUP HCPCS C1713 "524.269 - 6.5MM REVERE MONOAXIAL REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.272 SUP HCPCS C1713 "524.272 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.273 SUP HCPCS C1713 "524.273 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.274 SUP HCPCS C1713 "524.274 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.275 SUP HCPCS C1713 "524.275 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.276 SUP HCPCS C1713 "524.276 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.277 SUP HCPCS C1713 "524.277 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.278 SUP HCPCS C1713 "524.278 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.279 SUP HCPCS C1713 "524.279 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.282 SUP HCPCS C1713 "524.282 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.283 SUP HCPCS C1713 "524.283 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.284 SUP HCPCS C1713 "524.284 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.285 SUP HCPCS C1713 "524.285 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.286 SUP HCPCS C1713 "524.286 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.287 SUP HCPCS C1713 "524.287 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.288 SUP HCPCS C1713 "524.288 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.289 SUP HCPCS C1713 "524.289 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.341 SUP HCPCS C1713 "524.341 - REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.342 SUP HCPCS C1713 "524.342 - REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.343 SUP HCPCS C1713 "524.343 - REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.344 SUP HCPCS C1713 "524.344 - REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.345 SUP HCPCS C1713 "524.345 - REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.346 SUP HCPCS C1713 "524.346 - REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.347 SUP HCPCS C1713 "524.347 - REVERE 4.5MM UNIPLANAR REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.351 SUP HCPCS C1713 "524.351 - REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.352 SUP HCPCS C1713 "524.352 - REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.353 SUP HCPCS C1713 "524.353 - REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.354 SUP HCPCS C1713 "524.354 - REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.355 SUP HCPCS C1713 "524.355 - REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.356 SUP HCPCS C1713 "524.356 - REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.357 SUP HCPCS C1713 "524.357 - REVERE 5.0MM UNIPLANAR REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.361 SUP HCPCS C1713 "524.361 - REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.362 SUP HCPCS C1713 "524.362 - REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.363 SUP HCPCS C1713 "524.363 - REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.364 SUP HCPCS C1713 "524.364 - REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.365 SUP HCPCS C1713 "524.365 - REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.366 SUP HCPCS C1713 "524.366 - REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.367 SUP HCPCS C1713 "524.367 - REVERE 5.5MM UNIPLANAR REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.371 SUP HCPCS C1713 "524.371 - REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.372 SUP HCPCS C1713 "524.372 - REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.373 SUP HCPCS C1713 "524.373 - REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.374 SUP HCPCS C1713 "524.374 - REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.375 SUP HCPCS C1713 "524.375 - REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.376 SUP HCPCS C1713 "524.376 - REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.377 SUP HCPCS C1713 "524.377 - REVERE 6.5MM UNIPLANAR REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.441 SUP HCPCS C1713 "524.441 - 4.5MM REVERE REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.442 SUP HCPCS C1713 "524.442 - 4.5MM REVERE REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.443 SUP HCPCS C1713 "524.443 - 4.5MM REVERE REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.444 SUP HCPCS C1713 "524.444 - 4.5MM REVERE REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.445 SUP HCPCS C1713 "524.445 - 4.5MM REVERE REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.451 SUP HCPCS C1713 "524.451 - 5.5MM REVERE REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.452 SUP HCPCS C1713 "524.452 - 5.5MM REVERE REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.453 SUP HCPCS C1713 "524.453 - 5.5MM REVERE REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.454 SUP HCPCS C1713 "524.454 - 5.5MM REVERE REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.455 SUP HCPCS C1713 "524.455 - 5.5MM REVERE REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.456 SUP HCPCS C1713 "524.456 - 5.5MM REVERE REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.457 SUP HCPCS C1713 "524.457 - 5.5MM REVERE REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.461 SUP HCPCS C1713 "524.461 - 6.5MM REVERE REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.462 SUP HCPCS C1713 "524.462 - 6.5MM REVERE REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.463 SUP HCPCS C1713 "524.463 - 6.5MM REVERE REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.464 SUP HCPCS C1713 "524.464 - 6.5MM REVERE REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.465 SUP HCPCS C1713 "524.465 - 6.5MM REVERE REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.466 SUP HCPCS C1713 "524.466 - 6.5MM REVERE REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.467 SUP HCPCS C1713 "524.467 - 6.5MM REVERE REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.468 SUP HCPCS C1713 "524.468 - 6.5MM REVERE REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.469 SUP HCPCS C1713 "524.469 - 6.5MM REVERE REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.471 SUP HCPCS C1713 "524.471 - 7.5MM REVERE REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.472 SUP HCPCS C1713 "524.472 - 7.5MM REVERE REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.473 SUP HCPCS C1713 "524.473 - 7.5MM REVERE REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.474 SUP HCPCS C1713 "524.474 - 7.5MM REVERE REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.475 SUP HCPCS C1713 "524.475 - 7.5MM REVERE REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.476 SUP HCPCS C1713 "524.476 - 7.5MM REVERE REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.477 SUP HCPCS C1713 "524.477 - 7.5MM REVERE REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.478 SUP HCPCS C1713 "524.478 - 7.5MM REVERE REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.479 SUP HCPCS C1713 "524.479 - 7.5MM REVERE REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.481 SUP HCPCS C1713 "524.481 - 8.5MM REVERE REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.482 SUP HCPCS C1713 "524.482 - 8.5MM REVERE REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.483 SUP HCPCS C1713 "524.483 - 8.5MM REVERE REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.484 SUP HCPCS C1713 "524.484 - 8.5MM REVERE REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.485 SUP HCPCS C1713 "524.485 - 8.5MM REVERE REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.486 SUP HCPCS C1713 "524.486 - 8.5MM REVERE REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.487 SUP HCPCS C1713 "524.487 - 8.5MM REVERE REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.488 SUP HCPCS C1713 "524.488 - 8.5MM REVERE REDUCTION SCREW, 60MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.489 SUP HCPCS C1713 "524.489 - 8.5MM REVERE REDUCTION SCREW, 65MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.51 SUP Custom 27803010 "524.510 - 5.5MM STRAIGHT ROD, HEX-END, 100MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.512 SUP Custom 27803010 "524.512 - 5.5MM STRAIGHT ROD, HEX-END, 125MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.515 SUP Custom 27803010 "524.515 - 5.5MM STRAIGHT ROD, HEX-END, 150MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.517 SUP Custom 27803010 "524.517 - 5.5MM STRAIGHT ROD, HEX-END, 200MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.519 SUP Custom 27803010 "524.519 - 5.5MM STRAIGHT ROD, HEX-END, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.52 SUP Custom 27803010 "524.520 - 5.5MM STRAIGHT ROD, HEX-END, 400MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.521 SUP Custom 27803010 "524.521 - 5.5MM STRAIGHT ROD, HEX-END, 500MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 524.641 SUP HCPCS C1713 "524.641 - REVERE 4.5MM UNIPLANAR SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.642 SUP HCPCS C1713 "524.642 - REVERE 4.5MM UNIPLANAR SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.643 SUP HCPCS C1713 "524.643 - REVERE 4.5MM UNIPLANAR SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.644 SUP HCPCS C1713 "524.644 - REVERE 4.5MM UNIPLANAR SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.645 SUP HCPCS C1713 "524.645 - REVERE 4.5MM UNIPLANAR SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.646 SUP HCPCS C1713 "524.646 - REVERE 4.5MM UNIPLANAR SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.647 SUP HCPCS C1713 "524.647 - REVERE 4.5MM UNIPLANAR SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.651 SUP HCPCS C1713 "524.651 - REVERE 5.0MM UNIPLANAR SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.652 SUP HCPCS C1713 "524.652 - REVERE 5.0MM UNIPLANAR SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.653 SUP HCPCS C1713 "524.653 - REVERE 5.0MM UNIPLANAR SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.654 SUP HCPCS C1713 "524.654 - REVERE 5.0MM UNIPLANAR SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.655 SUP HCPCS C1713 "524.655 - REVERE 5.0MM UNIPLANAR SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.656 SUP HCPCS C1713 "524.656 - REVERE 5.0MM UNIPLANAR SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.657 SUP HCPCS C1713 "524.657 - REVERE 5.0MM UNIPLANAR SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.661 SUP HCPCS C1713 "524.661 - REVERE 5.5MM UNIPLANAR SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.662 SUP HCPCS C1713 "524.662 - REVERE 5.5MM UNIPLANAR SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.663 SUP HCPCS C1713 "524.663 - REVERE 5.5MM UNIPLANAR SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.664 SUP HCPCS C1713 "524.664 - REVERE 5.5MM UNIPLANAR SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.665 SUP HCPCS C1713 "524.665 - REVERE 5.5MM UNIPLANAR SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.666 SUP HCPCS C1713 "524.666 - REVERE 5.5MM UNIPLANAR SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.667 SUP HCPCS C1713 "524.667 - REVERE 5.5MM UNIPLANAR SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.671 SUP HCPCS C1713 "524.671 - REVERE 6.5MM UNIPLANAR SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.672 SUP HCPCS C1713 "524.672 - REVERE 6.5MM UNIPLANAR SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.673 SUP HCPCS C1713 "524.673 - REVERE 6.5MM UNIPLANAR SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.674 SUP HCPCS C1713 "524.674 - REVERE 6.5MM UNIPLANAR SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.675 SUP HCPCS C1713 "524.675 - REVERE 6.5MM UNIPLANAR SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.676 SUP HCPCS C1713 "524.676 - REVERE 6.5MM UNIPLANAR SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.677 SUP HCPCS C1713 "524.677 - REVERE 6.5MM UNIPLANAR SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.851 SUP HCPCS C1713 "524.851 - 5.0MM REVERE MONOAXIAL REDUCTION SCREW, 25MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.852 SUP HCPCS C1713 "524.852 - 5.0MM REVERE MONOAXIAL REDUCTION SCREW, 30MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.853 SUP HCPCS C1713 "524.853 - 5.0MM REVERE MONOAXIAL REDUCTION SCREW, 35MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.854 SUP HCPCS C1713 "524.854 - 5.0MM REVERE MONOAXIAL REDUCTION SCREW, 40MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.855 SUP HCPCS C1713 "524.855 - 5.0MM REVERE MONOAXIAL REDUCTION SCREW, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.856 SUP HCPCS C1713 "524.856 - 5.0MM REVERE MONOAXIAL REDUCTION SCREW, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.857 SUP HCPCS C1713 "524.857 - 5.0MM REVERE MONOAXIAL REDUCTION SCREW, 55MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.871 SUP HCPCS C1713 "524.871 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 70MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.872 SUP HCPCS C1713 "524.872 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 75MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.873 SUP HCPCS C1713 "524.873 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 80MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.874 SUP HCPCS C1713 "524.874 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 85MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.875 SUP HCPCS C1713 "524.875 - 7.5MM REVERE MONOAXIAL REDUCTION SCREW, 90MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.881 SUP HCPCS C1713 "524.881 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 70MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.882 SUP HCPCS C1713 "524.882 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 75MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.883 SUP HCPCS C1713 "524.883 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 80MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.884 SUP HCPCS C1713 "524.884 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 85MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 524.885 SUP HCPCS C1713 "524.885 - 8.5MM REVERE MONOAXIAL REDUCTION SCREW, 90MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 553 SUP Custom 27203010 CONTROL HGB A2 LYPHCHK LVL 2 1ML EPHRS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 610.514 SUP Custom 27803010 610.514 - BIT DRILL 4MM SM STOP BOTH IP/OP $672.50 $497.65 $0.00 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.13 $499.13 $0.00 $0.00 $140.15 $0.00 $0.00 $0.00 $0.00 $336.25 $532.62 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 610.712 SUP Custom 27100030 610.712 - BIT DRILL 12MM SPNL BOTH IP/OP $672.50 $497.65 $0.00 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.13 $499.13 $0.00 $0.00 $140.15 $0.00 $0.00 $0.00 $0.00 $336.25 $532.62 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 610.714 SUP Custom 27100030 610.714 - BIT DRILL 14MM SPNL BOTH IP/OP $672.50 $497.65 $0.00 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.13 $499.13 $0.00 $0.00 $140.15 $0.00 $0.00 $0.00 $0.00 $336.25 $532.62 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 615.104 SUP Custom 27100030 615.104 - BIT DRILL 2.4MM PRTX CT 3.5MM SCR NONSTRL BOTH IP/OP "$1,060.00 " $784.40 $0.00 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $786.73 $786.73 $0.00 $0.00 $220.90 $0.00 $0.00 $0.00 $0.00 $530.00 $839.52 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 615.107 SUP Custom 27100030 615.107 - TAP SPNL PRTX CT 3.5-4 MM SCR BOTH IP/OP $967.50 $715.95 $0.00 $774.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $0.00 $0.00 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 615.301 SUP HCPCS C1713 615.301 - TMPLT ROD 240MM BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 618.6 SUP Custom 27203010 618.60 - LENS OPHTHALMIC GRIESHABER MACULA ASPHERIC VITREORETINAL SUR BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $0.00 $0.00 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 624.214 SUP Custom 27100030 624.214 - TAP 4.5MM SURG SPNL REVERE BOTH IP/OP $880.00 $651.20 $0.00 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $653.14 $653.14 $0.00 $0.00 $183.39 $0.00 $0.00 $0.00 $0.00 $440.00 $696.96 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 624.215 SUP Custom 27100030 624.215 - TAP 5.5MM SURG SPNL REVERE BOTH IP/OP $880.00 $651.20 $0.00 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $653.14 $653.14 $0.00 $0.00 $183.39 $0.00 $0.00 $0.00 $0.00 $440.00 $696.96 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 624.216 SUP Custom 27100030 624.216 - TAP 6.5MM SURG SPNL REVERE BOTH IP/OP $880.00 $651.20 $0.00 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $653.14 $653.14 $0.00 $0.00 $183.39 $0.00 $0.00 $0.00 $0.00 $440.00 $696.96 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.414 SUP Custom 27803010 "632.414 - 22MM PORT, BEVELED, 40MM" BOTH IP/OP $902.50 $667.85 $0.00 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.84 $669.84 $0.00 $0.00 $188.08 $0.00 $0.00 $0.00 $0.00 $451.25 $714.78 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.415 SUP Custom 27803010 "632.415 - 22MM PORT, BEVELED, 50MM" BOTH IP/OP $902.50 $667.85 $0.00 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.84 $669.84 $0.00 $0.00 $188.08 $0.00 $0.00 $0.00 $0.00 $451.25 $714.78 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.416 SUP Custom 27803010 "632.416 - 22MM PORT, BEVELED, 60MM" BOTH IP/OP $902.50 $667.85 $0.00 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.84 $669.84 $0.00 $0.00 $188.08 $0.00 $0.00 $0.00 $0.00 $451.25 $714.78 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.417 SUP Custom 27803010 "632.417 - 22MM PORT, BEVELED, 70MM" BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.418 SUP Custom 27803010 "632.418 - 22MM PORT, BEVELED, 80MM" BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.419 SUP Custom 27803010 "632.419 - 22MM PORT, BEVELED, 90MM" BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.42 SUP Custom 27803010 "632.420 - 22MM PORT, BEVELED, 100MM" BOTH IP/OP "$1,220.00 " $902.80 $0.00 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.48 $905.48 $0.00 $0.00 $254.25 $0.00 $0.00 $0.00 $0.00 $610.00 $966.24 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.421 SUP Custom 27803010 "632.421 - 22MM PORT, BEVELED, 110MM" BOTH IP/OP "$1,220.00 " $902.80 $0.00 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.48 $905.48 $0.00 $0.00 $254.25 $0.00 $0.00 $0.00 $0.00 $610.00 $966.24 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.422 SUP Custom 27803010 "632.422 - 22MM PORT, BEVELED, 120MM" BOTH IP/OP "$1,220.00 " $902.80 $0.00 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.48 $905.48 $0.00 $0.00 $254.25 $0.00 $0.00 $0.00 $0.00 $610.00 $966.24 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.424 SUP Custom 27803010 "632.424 - 22MM PORT, STRAIGHT, 40MM" BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.74 $619.74 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $417.50 $661.32 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.425 SUP Custom 27803010 "632.425 - 22MM PORT, STRAIGHT, 50MM" BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.74 $619.74 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $417.50 $661.32 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.426 SUP Custom 27803010 "632.426 - 22MM PORT, STRAIGHT, 60MM" BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.74 $619.74 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $417.50 $661.32 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.427 SUP Custom 27803010 "632.427 - 22MM PORT, STRAIGHT, 70MM" BOTH IP/OP $942.50 $697.45 $0.00 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.52 $699.52 $0.00 $0.00 $196.42 $0.00 $0.00 $0.00 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.428 SUP Custom 27803010 "632.428 - 22MM PORT, STRAIGHT, 80MM" BOTH IP/OP $942.50 $697.45 $0.00 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.52 $699.52 $0.00 $0.00 $196.42 $0.00 $0.00 $0.00 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.429 SUP Custom 27803010 "632.429 - 22MM PORT, STRAIGHT, 90MM" BOTH IP/OP $942.50 $697.45 $0.00 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.52 $699.52 $0.00 $0.00 $196.42 $0.00 $0.00 $0.00 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.43 SUP Custom 27803010 632.430 - SET SPNL 22MM 100MM STRG PORT BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.431 SUP Custom 27803010 "632.431 - 22MM PORT, STRAIGHT, 110MM" BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.432 SUP Custom 27803010 "632.432 - 22MM PORT, STRAIGHT, 120MM" BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.434 SUP Custom 27803010 "632.434 - 19MM PORT, BEVELED, 40MM" BOTH IP/OP $902.50 $667.85 $0.00 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.84 $669.84 $0.00 $0.00 $188.08 $0.00 $0.00 $0.00 $0.00 $451.25 $714.78 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.435 SUP Custom 27803010 "632.435 - 19MM PORT, BEVELED, 50MM" BOTH IP/OP $902.50 $667.85 $0.00 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.84 $669.84 $0.00 $0.00 $188.08 $0.00 $0.00 $0.00 $0.00 $451.25 $714.78 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.436 SUP Custom 27803010 632.436 - SPACER SPNL 60MMX19MM BVL PORT PEEK INTRBD FS BOTH IP/OP $902.50 $667.85 $0.00 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.84 $669.84 $0.00 $0.00 $188.08 $0.00 $0.00 $0.00 $0.00 $451.25 $714.78 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.437 SUP Custom 27803010 632.437 - SPACER SPNL 70MMX19MM BVL PORT PEEK INTRBD FS BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.438 SUP Custom 27803010 "632.438 - 19MM PORT, BEVELED, 80MM" BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.439 SUP Custom 27803010 "632.439 - 19MM PORT, BEVELED, 90MM" BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.44 SUP Custom 27803010 "632.440 - 19MM PORT, BEVELED, 100MM" BOTH IP/OP "$1,220.00 " $902.80 $0.00 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.48 $905.48 $0.00 $0.00 $254.25 $0.00 $0.00 $0.00 $0.00 $610.00 $966.24 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.441 SUP Custom 27803010 "632.441 - 19MM PORT, BEVELED, 110MM" BOTH IP/OP "$1,220.00 " $902.80 $0.00 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.48 $905.48 $0.00 $0.00 $254.25 $0.00 $0.00 $0.00 $0.00 $610.00 $966.24 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.442 SUP Custom 27803010 "632.442 - 19MM PORT, BEVELED, 120MM" BOTH IP/OP "$1,220.00 " $902.80 $0.00 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.48 $905.48 $0.00 $0.00 $254.25 $0.00 $0.00 $0.00 $0.00 $610.00 $966.24 $976.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.444 SUP Custom 27803010 632.444 - SPACER SPNL 19MMX40MM PEEK INTRBD FS BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.74 $619.74 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $417.50 $661.32 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.445 SUP Custom 27803010 632.445 - SPACER SPNL 50MMX19MM STRG PORT PEEK INTRBD FS BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.74 $619.74 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $417.50 $661.32 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.446 SUP Custom 27803010 "632.446 - 19MM PORT, STRAIGHT, 60MM" BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.74 $619.74 $0.00 $0.00 $174.01 $0.00 $0.00 $0.00 $0.00 $417.50 $661.32 $668.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.447 SUP Custom 27803010 "632.447 - 19MM PORT, STRAIGHT, 70MM" BOTH IP/OP $942.50 $697.45 $0.00 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.52 $699.52 $0.00 $0.00 $196.42 $0.00 $0.00 $0.00 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.448 SUP Custom 27803010 "632.448 - 19MM PORT, STRAIGHT, 80MM" BOTH IP/OP $942.50 $697.45 $0.00 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.52 $699.52 $0.00 $0.00 $196.42 $0.00 $0.00 $0.00 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.449 SUP Custom 27803010 "632.449 - 19MM PORT, STRAIGHT, 90MM" BOTH IP/OP $942.50 $697.45 $0.00 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.52 $699.52 $0.00 $0.00 $196.42 $0.00 $0.00 $0.00 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.45 SUP Custom 27803010 "632.450 - 19MM PORT, STRAIGHT, 100MM" BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.451 SUP Custom 27803010 "632.451 - 19MM PORT, STRAIGHT, 110MM" BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.452 SUP Custom 27803010 "632.452 - 19MM PORT, STRAIGHT, 120MM" BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.454 SUP Custom 27803010 "632.454 - 26MM PORT, BEVELED, 40MM" BOTH IP/OP "$1,167.50 " $863.95 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $866.52 $866.52 $0.00 $0.00 $243.31 $0.00 $0.00 $0.00 $0.00 $583.75 $924.66 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.455 SUP Custom 27803010 "632.455 - 26MM PORT, BEVELED, 50MM" BOTH IP/OP "$1,167.50 " $863.95 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $866.52 $866.52 $0.00 $0.00 $243.31 $0.00 $0.00 $0.00 $0.00 $583.75 $924.66 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.456 SUP Custom 27803010 "632.456 - 26MM PORT, BEVELED, 60MM" BOTH IP/OP "$1,167.50 " $863.95 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $866.52 $866.52 $0.00 $0.00 $243.31 $0.00 $0.00 $0.00 $0.00 $583.75 $924.66 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.457 SUP Custom 27803010 "632.457 - 26MM PORT, BEVELED, 70MM" BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.458 SUP Custom 27803010 "632.458 - 26MM PORT, BEVELED, 80MM" BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.459 SUP Custom 27803010 "632.459 - 26MM PORT, BEVELED, 90MM" BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.46 SUP Custom 27803010 "632.460 - 26MM PORT, BEVELED, 100MM" BOTH IP/OP "$1,380.00 " "$1,021.20" $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.24" "$1,024.24" $0.00 $0.00 $287.59 $0.00 $0.00 $0.00 $0.00 $690.00 "$1,092.96" "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.461 SUP Custom 27803010 "632.461 - 26MM PORT, BEVELED, 110MM" BOTH IP/OP "$1,380.00 " "$1,021.20" $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.24" "$1,024.24" $0.00 $0.00 $287.59 $0.00 $0.00 $0.00 $0.00 $690.00 "$1,092.96" "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.462 SUP Custom 27803010 "632.462 - 26MM PORT, BEVELED, 120MM" BOTH IP/OP "$1,380.00 " "$1,021.20" $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.24" "$1,024.24" $0.00 $0.00 $287.59 $0.00 $0.00 $0.00 $0.00 $690.00 "$1,092.96" "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.464 SUP Custom 27803010 "632.464 - 26MM PORT, STRAIGHT, 40MM" BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.465 SUP Custom 27803010 "632.465 - 26MM PORT, STRAIGHT, 50MM" BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.466 SUP Custom 27803010 632.466 - SPACER SPNL TBLR 60MMX26MM PEEK INTRBD FS BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.467 SUP Custom 27803010 632.467 - SPACER SPNL TBLR 70MMX26MM PEEK INTRBD FS BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.468 SUP Custom 27803010 632.468 - SPACER SPNL TBLR 80MMX26MM PEEK INTRBD FS BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.469 SUP Custom 27803010 "632.469 - 26MM PORT, STRAIGHT, 90MM" BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.47 SUP Custom 27803010 "632.470 - 26MM PORT, STRAIGHT, 100MM" BOTH IP/OP "$1,380.00 " "$1,021.20" $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.24" "$1,024.24" $0.00 $0.00 $287.59 $0.00 $0.00 $0.00 $0.00 $690.00 "$1,092.96" "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.471 SUP Custom 27803010 "632.471 - 26MM PORT, STRAIGHT, 110MM" BOTH IP/OP "$1,380.00 " "$1,021.20" $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.24" "$1,024.24" $0.00 $0.00 $287.59 $0.00 $0.00 $0.00 $0.00 $690.00 "$1,092.96" "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.472 SUP Custom 27803010 "632.472 - 26MM PORT, STRAIGHT, 120MM" BOTH IP/OP "$1,380.00 " "$1,021.20" $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.24" "$1,024.24" $0.00 $0.00 $287.59 $0.00 $0.00 $0.00 $0.00 $690.00 "$1,092.96" "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 648.216 SUP Custom 27203010 648.216 - BIT DRILL FIX 2.4MM BONE CORRIDOR BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 650.012 SUP HCPCS C1713 650.012 - HOLDER IMPLANT TEMPORARY FIX SCREW SPN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 650.112 SUP Custom 27203010 650.112 - BIT DRL 12MM STRL REUSE BOTH IP/OP $672.50 $497.65 $0.00 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.13 $499.13 $0.00 $0.00 $140.15 $0.00 $0.00 $0.00 $0.00 $336.25 $532.62 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 650.114 SUP Custom 27100030 650.114 - BIT DRL 14MM STRL REUSE BOTH IP/OP $672.50 $497.65 $0.00 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.13 $499.13 $0.00 $0.00 $140.15 $0.00 $0.00 $0.00 $0.00 $336.25 $532.62 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 650.116 SUP Custom 27203010 650.116 - BIT DRL 16MM STRL REUSE BOTH IP/OP $672.50 $497.65 $0.00 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.13 $499.13 $0.00 $0.00 $140.15 $0.00 $0.00 $0.00 $0.00 $336.25 $532.62 $538.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 682.104 SUP Custom 27203010 682.104 - BIT DRILL 2.4MM 3.5MM SCR ELLI BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $0.00 $0.00 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 682.105 SUP Custom 27203010 682.105 - BIT DRILL 4 MM TITANIUM SCREW BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $0.00 $0.00 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 682.107 SUP Custom 27203010 682.107 - TAP SURG TITANIUM SPN 4 MM SCREW BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $0.00 $0.00 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 685.005 SUP HCPCS C1769 685.005 - GUIDEWIRE ORTHOPEDIC 500MM BLUNT SPN BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $156.11 $156.11 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 746 SUP Custom 27203010 REAGENT ANALY STA ST FNCT PRTN S CLOT BS ASY 1ML BOTH IP/OP $594.95 $440.26 $0.00 $475.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.48 $471.20 $475.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 751 SUP Custom 27203010 CONTROL CHM 3ML LVL 1 ASY MLANLT LQCHK BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 752 SUP Custom 27203010 CONTROL CHM 3ML LVL 2 ASY MLANLT LQCHK BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 804 SUP HCPCS C1713 804 - SCREW 804 2.2MM X-DRV 4MM 6PK BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 805 SUP HCPCS C1713 805 - SCREW 805 2.2MM X-DRV 5MM 6 BOTH IP/OP $98.10 $72.59 $0.00 $78.48 $44.15 $44.15 $0.00 $0.00 $0.00 $20.45 $72.81 $72.81 $0.00 $0.00 $20.44 $0.00 $58.03 $58.03 $0.00 $49.05 $77.70 $78.48 $0.00 $0.00 $15.35 $0.00 $0.00 $15.62 $0.00 $0.00 $0.00 $0.00 $0.00 807 SUP HCPCS C1713 807 - SCREW 807 2.2MM X-DRV 7MM 6 BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 835.105 SUP Custom 27804086 "835.105 - MAINTAIN CERVICAL ALLOGRAFT, 5MM PARALLEL" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.106 SUP Custom 27804086 "835.106 - MAINTAIN CERVICAL ALLOGRAFT, 6MM PARALLEL" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.107 SUP Custom 27804086 "835.107 - MAINTAIN CERVICAL ALLOGRAFT, 7MM PARALLEL" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.108 SUP Custom 27804086 "835.108 - MAINTAIN CERVICAL ALLOGRAFT, 8MM PARALLEL" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.109 SUP Custom 27804086 "835.109 - MAINTAIN CERVICAL ALLOGRAFT, 9MM PARALLEL" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.11 SUP Custom 27804086 "835.110 - MAINTAIN CERVICAL ALLOGRAFT, 10MM PARALLEL" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.111 SUP Custom 27804086 "835.111 - MAINTAIN CERVICAL ALLOGRAFT, 11MM PARALLEL" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.112 SUP Custom 27804086 "835.112 - MAINTAIN CERVICAL ALLOGRAFT, 12MM PARALLEL" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.205 SUP Custom 27804086 "835.205 - MAINTAIN CERVICAL ALLOGRAFT, 5MM LORDOTIC" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.206 SUP Custom 27804086 "835.206 - MAINTAIN CERVICAL ALLOGRAFT, 6MM LORDOTIC" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.207 SUP Custom 27804086 "835.207 - MAINTAIN CERVICAL ALLOGRAFT, 7MM LORDOTIC" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.208 SUP Custom 27804086 "835.208 - MAINTAIN CERVICAL ALLOGRAFT, 8MM LORDOTIC" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.209 SUP Custom 27804086 "835.209 - MAINTAIN CERVICAL ALLOGRAFT, 9MM LORDOTIC" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.21 SUP Custom 27804086 "835.210 - MAINTAIN CERVICAL ALLOGRAFT, 10MM LORDOTIC" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.211 SUP Custom 27804086 "835.211 - MAINTAIN CERVICAL ALLOGRAFT, 11MM LORDOTIC" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 835.212 SUP Custom 27804086 "835.212 - MAINTAIN CERVICAL ALLOGRAFT, 12MM LORDOTIC" BOTH IP/OP "$3,460.00 " "$2,560.40" $0.00 "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,568.01" "$2,568.01" $0.00 $0.00 $721.06 $0.00 $0.00 $0.00 $0.00 "$1,730.00" "$2,740.32" "$2,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 846 SUP Custom 27011340 846 - ELECTRODE PATIENT RETURN THK1/8IN 36X20IN 2 CORD MEGA SOFT BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,771.40" $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 876 SUP Custom 27203010 BLANKET 64X25IN MXTHR L HPR/HPO NWVN DISP WRM BOTH IP/OP $30.93 $22.89 $0.00 $24.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.95 $22.95 $0.00 $0.00 $6.44 $0.00 $0.00 $0.00 $0.00 $15.46 $24.50 $24.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 876.853 SUP HCPCS C1713 876.853 - SCREW BONE 4.5MM 13MM ATLNTS TI CANC ANT CERV SPNE SLFTAP VA BOTH IP/OP "$1,202.95 " $890.18 $0.00 $962.36 $541.33 $541.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $601.48 $952.74 $962.36 $0.00 $0.00 $188.26 $0.00 $0.00 $191.51 $0.00 $0.00 $0.00 $0.00 $0.00 900.601 SUP Custom 27203010 900.601 - GUIDEWIRE ORTHOPEDIC 1.6MM 150MM DRILL TIP NONSTRL 3.5MM BOTH IP/OP $80.83 $59.81 $0.00 $62.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $59.99 $0.00 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $39.23 $62.13 $62.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900.721 SUP HCPCS C1769 900.721 - GUIDEWIRE ORTHOPEDIC 1.25MM 150MM NONTHREADED COBALT NONSTRL BOTH IP/OP $52.35 $38.74 $0.00 $40.66 $27.60 $27.60 $0.00 $0.00 $0.00 $10.91 $38.85 $38.85 $0.00 $0.00 $10.91 $0.00 $30.97 $30.97 $0.00 $25.41 $40.26 $40.66 $0.00 $0.00 $7.72 $0.00 $0.00 $8.09 $0.00 $0.00 $0.00 $0.00 $0.00 900.722 SUP HCPCS C1769 900.722 - GUIDEWIRE ORTHOPEDIC 1.25MM 150MM THREAD NONSTRL 3.5MM CANN BOTH IP/OP $55.50 $41.07 $0.00 $43.12 $29.27 $29.27 $0.00 $0.00 $0.00 $11.57 $41.19 $41.19 $0.00 $0.00 $11.57 $0.00 $32.83 $32.83 $0.00 $26.95 $42.69 $43.12 $0.00 $0.00 $8.19 $0.00 $0.00 $8.58 $0.00 $0.00 $0.00 $0.00 $0.00 900.723 SUP HCPCS C1769 900.723 - GUIDEWIRE ORTHOPEDIC SPADE 2.5MM 230MM THREAD LCP DHHS BOTH IP/OP $90.65 $67.08 $0.00 $70.42 $47.80 $47.80 $0.00 $0.00 $0.00 $18.89 $67.28 $67.28 $0.00 $0.00 $18.89 $0.00 $53.62 $53.62 $0.00 $44.01 $69.72 $70.42 $0.00 $0.00 $13.37 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 900.726 SUP HCPCS C1769 900.726 - GUIDEWIRE ORTHOPEDIC 2.8MM 450MM 300MM TROCAR POINT THREADED BOTH IP/OP $147.60 $109.22 $0.00 $114.64 $77.81 $77.81 $0.00 $0.00 $0.00 $30.76 $109.55 $109.55 $0.00 $0.00 $30.76 $0.00 $87.31 $87.31 $0.00 $71.65 $113.49 $114.64 $0.00 $0.00 $21.77 $0.00 $0.00 $22.81 $0.00 $0.00 $0.00 $0.00 $0.00 910.011 SUP HCPCS C1713 910.011 - ASSURE SCREW RACK INSERT FOR 4.0MM STANDARD SELF-DRILLING SC BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.012 SUP HCPCS C1713 910.012 - ASSURE SCREW RACK INSERT FOR 4.5MM STANDARD SELF-DRILLING SC BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.013 SUP HCPCS C1713 910.013 - ASSURE SCREW RACK INSERT FOR 4.0MM STANDARD SELF-TAPPING SCR BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.014 SUP HCPCS C1713 910.014 - ASSURE SCREW RACK INSERT FOR 4.5MM STANDARD SELF-TAPPING SCR BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.021 SUP HCPCS C1713 910.021 - ASSURE SCREW RACK INSERT FOR 4.0MM RIGID SELF-DRILLING SCREW BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.022 SUP HCPCS C1713 910.022 - ASSURE SCREW RACK INSERT FOR 4.5MM RIGID SELF-DRILLING SCREW BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.023 SUP HCPCS C1713 910.023 - ASSURE SCREW RACK INSERT FOR 4.0MM RIGID SELF-TAPPING SCREWS BOTH IP/OP $530.00 $392.20 $0.00 $424.00 $238.50 $238.50 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $265.00 $419.76 $424.00 $0.00 $0.00 $82.95 $0.00 $0.00 $84.38 $0.00 $0.00 $0.00 $0.00 $0.00 910.024 SUP HCPCS C1713 910.024 - ASSURE SCREW RACK INSERT FOR 4.5MM RIGID SELF-TAPPING SCREWS BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.03 SUP HCPCS C1713 910.030 - ASSURE SCREW RACK INSERT FOR AUXILLARY SCREWS BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.511 SUP HCPCS C1713 910.511 - ASSURE SCREW RACK INSERT FOR 4.0MM STANDARD FIXED SELF-DRILL BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.512 SUP HCPCS C1713 910.512 - ASSURE SCREW RACK INSERT FOR 4.5MM STANDARD FIXED SELF-DRILL BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.513 SUP HCPCS C1713 910.513 - ASSURE SCREW RACK INSERT FOR 4.0MM STANDARD FIXED SELF-TAPPI BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.514 SUP HCPCS C1713 910.514 - ASSURE SCREW RACK INSERT FOR 4.5MM STANDARD FIXED SELF-TAPPI BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.521 SUP HCPCS C1713 910.521 - ASSURE SCREW RACK INSERT FOR 4.0MM FIXED SELF-DRILLING SCREW BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.522 SUP HCPCS C1713 910.522 - ASSURE SCREW RACK INSERT FOR 4.5MM FIXED SELF-DRILLING SCREW BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.523 SUP HCPCS C1713 910.523 - ASSURE SCREW RACK INSERT FOR 4.0MM FIXED SELF-TAPPING SCREWS BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.524 SUP HCPCS C1713 910.524 - ASSURE SCREW RACK INSERT FOR 4.5MM FIXED SELF-TAPPING SCREWS BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 910.525 SUP HCPCS C1713 910.525 - ASSURE SCREW RACK INSERT FOR AUXILIARY FIXED SCREWS BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 917.002 SUP HCPCS C1713 "917.002 - ASSURE TRANSLATIONAL CERVICAL PLATE IMPLANT MODULE FOR 1,2 A" BOTH IP/OP "$2,120.00 " "$1,568.80" $0.00 "$1,696.00" $954.00 $954.00 $0.00 $0.00 $0.00 $441.86 "$1,573.46" "$1,573.46" $0.00 $0.00 $441.81 $0.00 "$1,253.98" "$1,253.98" $0.00 "$1,060.00" "$1,679.04" "$1,696.00" $0.00 $0.00 $331.78 $0.00 $0.00 $337.50 $0.00 $0.00 $0.00 $0.00 $0.00 917.004 SUP HCPCS C1713 917.004 - ASSURE TRANSLATIONAL CERVICAL PLATE IMPLANT MODULE FOR 4-LEV BOTH IP/OP "$1,962.50 " "$1,452.25" $0.00 "$1,570.00" $883.13 $883.13 $0.00 $0.00 $0.00 $409.03 "$1,456.57" "$1,456.57" $0.00 $0.00 $408.99 $0.00 "$1,160.82" "$1,160.82" $0.00 $981.25 "$1,554.30" "$1,570.00" $0.00 $0.00 $307.13 $0.00 $0.00 $312.43 $0.00 $0.00 $0.00 $0.00 $0.00 929.007 SUP HCPCS C1713 929.007 - GATEWAY/CITADEL BONE SCREW MODULE BOTH IP/OP "$3,180.00 " "$2,353.20" $0.00 "$2,544.00" "$1,431.00" "$1,431.00" $0.00 $0.00 $0.00 $662.79 "$2,360.20" "$2,360.20" $0.00 $0.00 $662.71 $0.00 "$1,567.74" "$1,567.74" $0.00 "$1,590.00" "$2,518.56" "$2,544.00" $0.00 $0.00 $497.67 $0.00 $0.00 $506.26 $0.00 $0.00 $0.00 $0.00 $0.00 992 SUP HCPCS C1713 992 - KIT ARTHRO FIX TRNFX2 SCR CANN DILAT ROTR CUF STRL DISP BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 1001 SUP Custom 27203010 KIT MYCTST M TB AMPLF DIR 50 TST BOTH IP/OP "$3,090.00 " "$2,286.60" $0.00 "$2,472.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,545.00" "$2,447.28" "$2,472.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1006 SUP Custom 27203010 1006 - PROBE VITRTM LGC VRST ATIOP ANT OCCUTOME STRL DISP BOTH IP/OP $413.33 $305.86 $0.00 $330.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.77 $306.77 $0.00 $0.00 $86.14 $0.00 $0.00 $0.00 $0.00 $206.66 $327.36 $330.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1028 SUP HCPCS C2628 1028 - CATHETER BLNOCC FLOCONTROL BOTH IP/OP "$6,987.50 " "$5,170.75" $0.00 "$5,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,456.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.20" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,493.75" "$5,534.10" "$5,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1041 SUP Custom 27203010 MASK O2 VNYL ADLT ELNG UNDCHN MED CONCEN TBG 7FT BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1049 SUP Custom 27203010 01049 - MASK O2 VNYL ADLT UNDCHN STY MED CONCEN W/O TBG LATEX FREE BOTH IP/OP $1.04 $0.77 $0.00 $0.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.52 $0.82 $0.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1151 SUP Custom 27203010 1151 - MANIPULATOR SURG UT INJECTOR 4.5MM DISP BOTH IP/OP $55.70 $41.22 $0.00 $41.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.34 $41.34 $0.00 $0.00 $11.61 $0.00 $0.00 $0.00 $0.00 $25.52 $40.42 $40.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1201 SUP Custom 27803010 1201 - CLIP INTERNAL SMALL CHEVRON TRIANGLE WIDE LIGATE CROSS BOTH IP/OP $4.58 $3.39 $0.00 $3.66 $2.06 $2.06 $0.00 $0.00 $0.00 $0.95 $3.40 $3.40 $0.00 $0.00 $0.95 $0.00 $2.71 $2.71 $0.00 $2.29 $0.83 $3.66 $0.00 $0.00 $0.72 $0.00 $0.00 $0.73 $0.00 $0.00 $0.00 $0.00 $0.00 1201 SUP HCPCS C1760 001201 - CLIP SM INTNL HRZN TI ENDSCP LIGAT STRL DISP LATEX FREE BOTH IP/OP $4.58 $3.39 $0.00 $3.66 $2.06 $2.06 $0.00 $0.00 $0.00 $0.95 $3.40 $3.40 $0.00 $0.00 $0.95 $0.00 $2.71 $2.71 $0.00 $2.29 $3.63 $3.66 $0.00 $0.00 $0.72 $0.00 $0.00 $0.73 $0.00 $0.00 $0.00 $0.00 $0.00 1266 SUP Custom 27203010 REAGENT THYGL AB IMMUN BOTH IP/OP $621.35 $459.80 $0.00 $497.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.68 $492.11 $497.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1273 SUP Custom 27203010 KIT IMMUN TST THR MICROSOMAL AB BOTH IP/OP $621.35 $459.80 $0.00 $497.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.68 $492.11 $497.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1435 SUP Custom 27203010 1435 - BANDAGE COMPRESSION A TUBULAR 10MR MULTPUR ELAST COMFORTABLE BOTH IP/OP $39.80 $29.45 $0.00 $34.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.54 $29.54 $0.00 $0.00 $8.29 $0.00 $0.00 $0.00 $0.00 $21.34 $33.80 $34.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1438 SUP Custom 27203010 1438 - BANDAGE COMPRESSION F LARGE KNEE MEDIUM THIGH TUBULAR 10MR BOTH IP/OP $89.85 $66.49 $0.00 $69.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.69 $66.69 $0.00 $0.00 $18.72 $0.00 $0.00 $0.00 $0.00 $43.30 $68.60 $69.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1441 SUP Custom 27203010 1441 - BANDAGE COMPRESSION K 10MR TUBULAR MULTPUR COMFORTABLE BOTH IP/OP $136.15 $100.75 $0.00 $116.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.05 $101.05 $0.00 $0.00 $28.37 $0.00 $0.00 $0.00 $0.00 $72.99 $115.62 $116.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1443 SUP Custom 27203010 1443 - BANDAGE COMPRESSION C MEDIUM ARM SMALL ANKLE TUBULAR 10MR BOTH IP/OP $57.43 $42.50 $0.00 $49.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.62 $42.62 $0.00 $0.00 $11.97 $0.00 $0.00 $0.00 $0.00 $30.78 $48.76 $49.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1534 SUP Custom 27203010 1534 - SYSTEM GSTRC LAV 34FR NS ESLV TUBE RADOPQ STRP EASI-LOK ADPR BOTH IP/OP $365.14 $270.20 $0.00 $292.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.01 $271.01 $0.00 $0.00 $76.10 $0.00 $0.00 $0.00 $0.00 $182.57 $289.19 $292.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1537 SUP Custom 27203010 1537 - FORCEPS BIOPSY COLD BOTH IP/OP $34.78 $25.74 $0.00 $27.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.81 $25.81 $0.00 $0.00 $7.25 $0.00 $0.00 $0.00 $0.00 $17.39 $27.55 $27.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1651 SUP Custom 27203010 SENSOR NEO LNOP FNGR TOE OXM ADH OPTC PRB DISP BOTH IP/OP $641.70 $474.86 $0.00 $513.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.85 $508.23 $513.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1791 SUP Custom 27203010 REAGENT CT GC AP CMB 2 DTCT KT 1200 TST ANALY BOTH IP/OP $64.38 $47.64 $0.00 $51.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.19 $50.99 $51.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1798 SUP Custom 27203010 SENSOR NEO LNOP NEO-L OXM ADH DISP BOTH IP/OP $31.05 $22.98 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.53 $24.59 $24.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1800 SUP Custom 27203010 SENSOR INF LNOP GRT TOE THB OXM ADH STRAP INF-L BOTH IP/OP $31.05 $22.98 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.53 $24.59 $24.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1863 SUP Custom 27203010 SENSOR ADLT LNCS DCI OXM ADH CBL NSTRL LF DISP BOTH IP/OP $457.20 $338.33 $0.00 $365.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $362.10 $365.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1892 SUP Custom 27011340 1892 - SET PRSS MONITR COMBITRANS BOTH IP/OP $113.75 $84.18 $0.00 $91.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.43 $84.43 $0.00 $0.00 $23.71 $0.00 $0.00 $0.00 $0.00 $56.88 $90.09 $91.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1895 SUP Custom 27203010 SENSOR REUSABLE TIP CLIP EAR LNOP TC-I BOTH IP/OP $457.20 $338.33 $0.00 $365.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $362.10 $365.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1896 SUP Custom 27203010 SENSOR REUSABLE FOREHEAD LNOP TF-I BOTH IP/OP $572.50 $423.65 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.25 $453.42 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1904 SUP Custom 27203010 ENFACARE LIPIL POWDER 12.8OZ BOTH IP/OP $190.00 $140.60 $0.00 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.00 $150.48 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1951 SUP Custom 27203010 1951 - HEMOSTAT ABSORBABLE 14X2IN ORIGINAL FLEXIBLE SHEER WEAVE BOTH IP/OP $136.04 $100.67 $0.00 $108.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.97 $100.97 $0.00 $0.00 $28.35 $0.00 $0.00 $0.00 $0.00 $68.02 $107.74 $108.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1974 SUP Custom 27203010 1974 - SPONGE ABSORBABLE THK10MM 100 12.5X8CM HEMOSTAT SURGIFOAM BOTH IP/OP $48.96 $36.23 $0.00 $73.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.34 $36.34 $0.00 $0.00 $10.20 $0.00 $0.00 $0.00 $0.00 $45.84 $72.62 $73.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1985 SUP Custom 27203010 1985 - AGENT HMST STRL LF INSTAT ABS MCFIB CLGN 1GM DISP BOTH IP/OP $108.73 $80.46 $0.00 $86.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.00 $73.00 $0.00 $0.00 $20.50 $0.00 $0.00 $0.00 $0.00 $41.04 $86.11 $65.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2056 SUP Custom 27203010 2056 - APL BRCHTX 5-6CM VAR TRY MAMST 8MM BRST BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,432.75" $0.00 $0.00 $0.00 $0.00 "$3,437.50" "$5,445.00" "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2083 SUP Custom 27203010 2083 - HEMOSTAT ABS 4X4IN NWVN BCTRCD SRGCL SNOW CLU FBRC BOTH IP/OP $286.01 $211.65 $0.00 $228.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.28 $212.28 $0.00 $0.00 $59.60 $0.00 $0.00 $0.00 $0.00 $143.01 $226.52 $228.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2161 SUP Custom 27203010 STRIP UA MLSTX 10 SG 9 PRMTR SG REAGENT 100 TST BOTH IP/OP $81.00 $59.94 $0.00 $64.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.50 $64.15 $64.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2200 SUP Custom 27803010 2200 - CLIP INTERNAL MEDIUM CHEVRON HEART TRNSVRS GROOVE LIGATE BOTH IP/OP $6.90 $5.11 $0.00 $5.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.45 $5.46 $5.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2406 SUP Custom 27203010 STAIN DVD MRKNG 2OZ REFL BTL SET AST HISTOLGY BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2456 SUP Custom 27203010 2456 - APL BRCHTX 4-5CM VAR TRY MAMST 8MM BRST BOTH IP/OP "$1,219.18 " $902.19 $0.00 "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $904.87 $904.87 $0.00 $0.00 $254.08 $0.00 $0.00 $0.00 $0.00 "$3,437.50" "$5,445.00" "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2550 SUP Custom 27203010 2550 - BAG DRAIN INLINE SELF FILL OASIS 600ML STERILE ATRIUM ATS BOTH IP/OP $57.10 $42.25 $0.00 $45.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.38 $42.38 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $28.55 $45.22 $45.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2649 SUP Custom 27203010 CUFF CLASSIC LRG ADLT LNG 2 TB ROSE WHT SCREW CONNECTOR BOTH IP/OP $36.25 $26.83 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.13 $28.71 $29.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2816 SUP Custom 27203010 RESTRAINT XTRMT PSY LMB WRST ANKL FOAM HLDR QRLSE SGL STRAP BOTH IP/OP $35.25 $26.09 $0.00 $28.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.63 $27.92 $28.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2845 SUP Custom 27203010 KIT MYCTST ACPRB M AVIUM CULT ID 20 TST BOTH IP/OP $708.13 $524.02 $0.00 $566.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.06 $560.84 $566.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2855 SUP Custom 27203010 KIT MYCTST ACPRB MYCB KS 2 CULT ID 20 TST BOTH IP/OP $708.33 $524.16 $0.00 $566.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.16 $561.00 $566.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2860 SUP Custom 27203010 KIT MYCTST ACPRB M TB CULT ID 20 TST BOTH IP/OP $708.13 $524.02 $0.00 $566.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.06 $560.84 $566.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2910 SUP Custom 27203010 KIT MYCTST ACPRB HISTOPLASMA CAPSULATUM CULT ID 20 TST BOTH IP/OP $708.33 $524.16 $0.00 $566.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.16 $561.00 $566.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2994 SUP Custom 27203010 2994 - AGENT HMST STRL SURGIFLO KT MTRX THRMB BOTH IP/OP $650.86 $481.64 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.07 $483.07 $0.00 $0.00 $135.64 $0.00 $0.00 $0.00 $0.00 $325.43 $515.48 $520.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3037 SUP HCPCS C1787 3037 - PROGRAMMER NRSTM 5L 22X10X4CM INTSTM 240X640 PIXELS PT SLIM BOTH IP/OP "$2,975.00 " "$2,201.50" $0.00 "$2,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,487.50" "$2,356.20" "$2,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3048 SUP HCPCS C1729 CATHETER IV 14GA 1.25IN RADIOPQ SFSHLD ORNG PCTV TFLN STRL BOTH IP/OP $3.88 $2.87 $0.00 $3.10 $2.10 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.94 $3.07 $3.10 $0.00 $0.00 $0.61 $0.00 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 3050 SUP HCPCS C1729 CATHETER IV 22GA 1IN RADIOPQ SFSHLD BLUE PCTV TFLN STRL LF BOTH IP/OP $3.88 $2.87 $0.00 $3.10 $2.10 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.94 $3.07 $3.10 $0.00 $0.00 $0.61 $0.00 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 3053 SUP HCPCS C1729 CATHETER IV 24GA .75IN RADIOPQ SFSHLD YLW PCTV TFLN STRL LF BOTH IP/OP $3.88 $2.87 $0.00 $3.10 $2.10 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.94 $3.07 $3.10 $0.00 $0.00 $0.61 $0.00 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 3055 SUP HCPCS C1729 CATHETER IV 18GA 1.25IN RADIOPQ SFSHLD GRN PCTV TFLN STRL LF BOTH IP/OP $3.88 $2.87 $0.00 $3.10 $2.10 $2.10 $0.00 $0.00 $0.00 $0.81 $2.88 $2.88 $0.00 $0.00 $0.81 $0.00 $2.29 $2.29 $0.00 $1.94 $3.07 $3.10 $0.00 $0.00 $0.61 $0.00 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 3056 SUP HCPCS C1729 CATHETER IV 20GA 1.25IN RADIOPQ SFSHLD PNK PCTV+PLUS TFLN BOTH IP/OP $3.88 $2.87 $0.00 $3.10 $2.10 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.94 $3.07 $3.10 $0.00 $0.00 $0.61 $0.00 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 3057 SUP HCPCS C1729 CATHETER IV 20GA 1IN RADIOPQ SFSHLD PNK PCTV+ TFLN STRL LF BOTH IP/OP $3.88 $2.87 $0.00 $3.10 $2.10 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.94 $3.07 $3.10 $0.00 $0.00 $0.61 $0.00 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 3110 SUP Custom 27203010 03110 - WRENCH SURG 5MM ALN BOTH IP/OP $26.90 $19.91 $0.00 $254.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.97 $19.97 $0.00 $0.00 $5.61 $0.00 $0.00 $0.00 $0.00 $158.75 $251.46 $254.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3125 SUP Custom 27203010 03125 - WRENCH SURG T BONE SCR BOTH IP/OP "$1,108.70 " $820.44 $0.00 $822.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $822.88 $822.88 $0.00 $0.00 $231.05 $0.00 $0.00 $0.00 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3396 SUP HCPCS C1729 CATHETER IV 20GA 1.25IN RADIOPQ SFSHLD PNK ACV J TFLN STRL BOTH IP/OP $3.93 $2.91 $0.00 $3.14 $2.13 $2.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.96 $3.11 $3.14 $0.00 $0.00 $0.61 $0.00 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 3423 SUP Custom 27203010 3423 - DRILL SRG SM SHRT 3.5MM STRL LF EVOS AO QCK CNCT OVR DISP BOTH IP/OP $258.36 $191.19 $0.00 $254.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.35 $254.35 $0.00 $0.00 $71.42 $0.00 $0.00 $0.00 $0.00 $155.55 $204.62 $248.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3570 SUP HCPCS C1729 CATHETER URTH KNGRD 24FR FOLEY 2W SIL 5ML LTX BOTH IP/OP $2.23 $1.65 $0.00 $1.78 $1.21 $1.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.11 $1.77 $1.78 $0.00 $0.00 $0.35 $0.00 $0.00 $0.35 $0.00 $0.00 $0.00 $0.00 $0.00 3573 SUP HCPCS C1729 CATHETER URTH KNGRD 26FR FOLEY 2W SIL 5ML LTX BOTH IP/OP $2.20 $1.63 $0.00 $1.76 $1.19 $1.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.10 $1.74 $1.76 $0.00 $0.00 $0.34 $0.00 $0.00 $0.35 $0.00 $0.00 $0.00 $0.00 $0.00 3902 SUP Custom 27203010 3902 - KIT TISS CLSR 2ML EVICEL SLNT FBRN BOTH IP/OP $525.98 $389.23 $0.00 $420.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $390.38 $390.38 $0.00 $0.00 $109.61 $0.00 $0.00 $0.00 $0.00 $262.99 $416.58 $420.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4001 SUP Custom 27203010 4001 - RETAINER INTNL ORG SURGIFISH RADOPQ BOTH IP/OP $53.75 $39.78 $0.00 $43.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.89 $39.89 $0.00 $0.00 $11.20 $0.00 $0.00 $0.00 $0.00 $26.88 $42.57 $43.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4022 SUP Custom 27203010 REUSABLE CLIPS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4030 SUP Custom 27203010 4030 - DRESSING HMST 12X12IN STRL LF QUIKCLOT TRAUMAPAD CNTRL+ 3 BOTH IP/OP $145.58 $107.73 $0.00 $544.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.16 $8.16 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $544.08 $8.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4073 SUP Custom 27203010 BLADE LRNSCP 3 MCNTSH BOTH IP/OP $41.35 $30.60 $0.00 $33.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.68 $32.75 $33.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4074 SUP Custom 27203010 BLADE LRNSCP 4 MCNTSH BOTH IP/OP $41.35 $30.60 $0.00 $33.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.68 $32.75 $33.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4080 SUP Custom 27203010 BLADE LRNSCP 0 STD MLLR SS BOTH IP/OP $41.35 $30.60 $0.00 $33.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.68 $32.75 $33.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4082 SUP Custom 27203010 BLADE LRNSCP 2 STN MLLR REUSE BOTH IP/OP $37.55 $27.79 $0.00 $30.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.78 $29.74 $30.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4083 SUP Custom 27203010 BLADE LRNSCP 3 STD WINCONSIN BOTH IP/OP $41.35 $30.60 $0.00 $33.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.68 $32.75 $33.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4200 SUP Custom 27803010 004200 - CLIP INTERNAL LARGE ANGLE RIGHT RING HANDLE LIGATE BOTH IP/OP $2.36 $1.75 $0.00 $1.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.75 $1.75 $0.00 $0.00 $0.49 $0.00 $0.00 $0.00 $0.00 $1.18 $1.87 $1.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4259 SUP Custom 27203010 04259 - RESERVOIR ATF XRES B BLD COL DISP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4273 SUP Custom 27203010 04273 - KIT ATSBWL .25IN X ANCOAG ASP LN SCT ASMB TBG PVC DISP BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4275 SUP Custom 27203010 04275 - RESERVOIR ATF 120UM BTM OULET GRS FLTR BLUTSAMMEL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4350 SUP HCPCS C1765 4350 - BRR ADH ABS PLVC INTCD 4X3IN STRL BOTH IP/OP $753.34 $557.47 $0.00 $602.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $559.13 $559.13 $0.00 $0.00 $157.00 $0.00 $0.00 $0.00 $0.00 $376.67 $596.65 $602.67 $0.00 $0.00 $117.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4353 SUP Custom 27803010 4353 - IMPLANT FACIAL PATIENT SPECIFIC BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 $0.00 $0.00 $0.00 "$3,500.00" "$5,544.00" "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4400 SUP Custom 27803010 4400 - RING ANLPLS 28MM MTRL C-E CL TI BOTH IP/OP "$6,552.50 " "$4,848.85" $0.00 "$5,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.54" $0.00 $0.00 $0.00 $0.00 "$3,276.25" "$5,189.58" "$5,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4450 SUP Custom 27803010 4450 - RING ANLPLS 24-40MM MTRL C-E PH BOTH IP/OP "$3,295.00 " "$2,438.30" $0.00 "$2,609.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.51 $137.51 $0.00 $0.00 $38.61 $0.00 $0.00 $0.00 $0.00 $84.00 "$2,609.64" $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4672 SUP Custom 27803010 004672 - DEVICE VENTRICULAR ASSIST 12FR MICROAXIAL PUMP IMPELLA 2.5L BOTH IP/OP "$62,500.00 " "$46,250.00" $0.00 "$50,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$13,025.00" $0.00 $0.00 $0.00 $0.00 "$31,250.00" "$49,500.00" "$50,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4823 SUP HCPCS C1713 4823.000 - BLOCKER SPNL XIA 3 TI BOTH IP/OP $459.38 $339.94 $0.00 $367.50 $206.72 $206.72 $0.00 $0.00 $0.00 $95.75 $340.95 $340.95 $0.00 $0.00 $95.73 $0.00 $271.72 $271.72 $0.00 $229.69 $363.83 $367.50 $0.00 $0.00 $71.89 $0.00 $0.00 $73.13 $0.00 $0.00 $0.00 $0.00 $0.00 5065 SUP Custom 27203010 5065 - COVER COMPRESSION MEDIUM 12- IN RIGID SOLE VENT HOLE DORSUM BOTH IP/OP $172.30 $127.50 $0.00 $137.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.88 $127.88 $0.00 $0.00 $35.91 $0.00 $0.00 $0.00 $0.00 $86.15 $136.46 $137.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5571 SUP HCPCS C1887 5571 - HANDLE LRNSCP MED STD RUSCH DLPHN REUSE BOTH IP/OP "$1,062.50 " $786.25 $0.00 $946.00 $642.10 $642.10 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $591.25 $936.54 $946.00 $0.00 $0.00 $185.06 $0.00 $0.00 $188.25 $0.00 $0.00 $0.00 $0.00 $0.00 5897 SUP Custom 27203010 5897 - CUFF CMPR REG KDL SCD EXP BLDR FT BOTH IP/OP $80.68 $59.70 $0.00 $60.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.72 $53.72 $0.00 $0.00 $15.08 $0.00 $0.00 $0.00 $0.00 $36.73 $60.76 $58.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5898 SUP Custom 27203010 5898 - SLEEVE CMPR LG SCD EXP ANEMB CUF FT BOTH IP/OP $74.55 $55.17 $0.00 $60.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.72 $53.72 $0.00 $0.00 $15.08 $0.00 $0.00 $0.00 $0.00 $36.73 $60.76 $58.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6057 SUP HCPCS C1765 6057 - STYLET LEAD .014IN KT BALL TIP BLUE KNOB BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $15.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6081 SUP Custom 27203010 6081 - FILTER LEEP SMOKE EVACUATOR PRE BOTH IP/OP $28.90 $21.39 $0.00 $23.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.45 $22.89 $23.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6091 SUP HCPCS C1765 6091 - STYLET LEAD .014IN KT JTP BALL TIP XTD TPR GRY KNOB BOTH IP/OP $100.00 $74.00 $0.00 $79.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.72 $31.72 $0.00 $0.00 $8.91 $0.00 $0.00 $0.00 $0.00 $19.38 $79.20 $31.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6092 SUP Custom 27203010 6092 - PAPER RCD 110MM EKG THRM CARELINK BOTH IP/OP $250.00 $185.00 $0.00 $198.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $198.00 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6122 SUP Custom 27203010 6122 - MOUTHWASH ORAL 1.5OZ LF RNS ANSEP 0.05% CPC CL BOTH IP/OP $86.43 $63.96 $0.00 $69.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.15 $64.15 $0.00 $0.00 $18.01 $0.00 $0.00 $0.00 $0.00 $43.21 $68.45 $69.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6177 SUP Custom 27203010 6177 - SLEEVE PACEMAKER RADIO FREQUENCY HEAD WAND COVER STERILE BOTH IP/OP $23.75 $17.58 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.63 $17.63 $0.00 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6196 SUP HCPCS C1729 6196 - CATHETER 7FR 100CM PIGTAIL BOTH IP/OP $2.50 $1.85 $0.00 $2.00 $1.36 $1.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $1.98 $2.00 $0.00 $0.00 $0.39 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 6215 SUP Custom 27203010 6215 - CATHETER GD 6FR ATN GW PU CS VNGR BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.71 $170.71 $0.00 $0.00 $47.93 $0.00 $0.00 $0.00 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6314 SUP Custom 27803010 6314 - GRAFT SYNTH TISSUE 91X56X4MM SMOOTH EXTERIOR SURFACE BOTH IP/OP "$2,988.60 " "$2,211.56" $0.00 "$3,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,218.14" "$2,218.14" $0.00 $0.00 $622.82 $0.00 $0.00 $0.00 $0.00 "$2,371.25" "$3,756.06" "$3,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6316 SUP Custom 27803010 6316 - IMPLANT ORBTL 14MM SPHERE BIOCOMPATIBLE POROUS MEDPOR BOTH IP/OP "$1,265.18 " $936.23 $0.00 "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $939.01 $939.01 $0.00 $0.00 $263.66 $0.00 $0.00 $0.00 $0.00 $752.50 "$1,191.96" "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6317 SUP Custom 27803010 6317 - IMPLANT ORBTL 20MM SPHERE BIOCOMPATIBLE POROUS MEDPOR BOTH IP/OP "$1,265.18 " $936.23 $0.00 "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $939.01 $939.01 $0.00 $0.00 $263.66 $0.00 $0.00 $0.00 $0.00 $752.50 "$1,191.96" "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6322 SUP Custom 27803010 6322 - SPHERE EYE 22MM THK.45MM 42MMX41MMX1MM STRL PE POR MEDPOR BOTH IP/OP "$1,505.00 " "$1,113.70" $0.00 "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,117.01" "$1,117.01" $0.00 $0.00 $313.64 $0.00 $0.00 $0.00 $0.00 $752.50 "$1,191.96" "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6326 SUP Custom 27803010 6326 - IMPLANT ORBTL 16MM SPHERE BIOCOMPATIBLE POROUS MEDPOR BOTH IP/OP "$1,265.18 " $936.23 $0.00 "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $939.01 $939.01 $0.00 $0.00 $263.66 $0.00 $0.00 $0.00 $0.00 $752.50 "$1,191.96" "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6327 SUP Custom 27803010 6327 - IMPLANT ORBTL ROUND 18MM SPHERE BIOCOMPATIBLE POROUS MEDPOR BOTH IP/OP "$1,265.18 " $936.23 $0.00 "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $939.01 $939.01 $0.00 $0.00 $263.66 $0.00 $0.00 $0.00 $0.00 $752.50 "$1,191.96" "$1,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6330 SUP Custom 27803010 6330 - GRAFT SYNTH TISSUE 50X38X1.5MM SHEET POROUS MEDPOR BOTH IP/OP $911.05 $674.18 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $676.18 $676.18 $0.00 $0.00 $189.86 $0.00 $0.00 $0.00 $0.00 $651.25 "$1,031.58" "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6331 SUP Custom 27803010 6331 - GRAFT SYNTH TISSUE 76X50X1.5MM SHEET POROUS MEDPOR BOTH IP/OP "$1,224.65 " $906.24 $0.00 "$1,386.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.76 $49.76 $0.00 $0.00 $13.97 $0.00 $0.00 $0.00 $0.00 $28.50 "$1,386.00" $45.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6332 SUP Custom 27803010 6332 - GRAFT SYNTH TISSUE 38X13X3MM BLOCK POROUS MEDPOR BOTH IP/OP "$1,149.75 " $850.82 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6333 SUP Custom 27803010 6333 - GRAFT SYNTH TISSUE 38X13X6MM BLOCK POROUS MEDPOR BOTH IP/OP "$1,460.25 " "$1,080.59" $0.00 "$1,318.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,083.80" "$1,083.80" $0.00 $0.00 $304.32 $0.00 $0.00 $0.00 $0.00 $823.75 "$1,304.82" "$1,318.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6334 SUP Custom 27803010 6334 - GRAFT SYNTH TISSUE 38X13X9.5MM BLOCK POROUS MEDPOR BOTH IP/OP "$1,940.00 " "$1,435.60" $0.00 "$1,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,439.87" "$1,439.87" $0.00 $0.00 $404.30 $0.00 $0.00 $0.00 $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6335 SUP Custom 27803010 6335 - GRAFT SYNTH TISSUE 50X25X3MM BLOCK POROUS MEDPOR BOTH IP/OP "$1,730.63 " "$1,280.67" $0.00 "$1,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.47" "$1,284.47" $0.00 $0.00 $360.66 $0.00 $0.00 $0.00 $0.00 "$1,212.50" "$1,920.60" "$1,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6336 SUP Custom 27803010 6336 - GRAFT SYNTH TISSUE CNTOUR 25X50X6MM BLOCK MEDPOR BOTH IP/OP "$1,905.00 " "$1,409.70" $0.00 "$2,134.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,413.89" "$1,413.89" $0.00 $0.00 $397.00 $0.00 $0.00 $0.00 $0.00 "$1,333.75" "$2,112.66" "$2,134.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6337 SUP Custom 27803010 6337 - GRAFT SYNTH TISSUE 50X25X9.5MM BLOCK POROUS MEDPOR BOTH IP/OP "$3,155.00 " "$2,334.70" $0.00 "$2,524.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,341.64" "$2,341.64" $0.00 $0.00 $657.50 $0.00 $0.00 $0.00 $0.00 "$1,577.50" "$2,498.76" "$2,524.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6338 SUP Custom 27803010 6338 - GRAFT SYNTH TISSUE 63X38X3MM BLOCK POROUS MEDPOR POLYETHLENE BOTH IP/OP "$3,155.00 " "$2,334.70" $0.00 "$2,524.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,341.64" "$2,341.64" $0.00 $0.00 $657.50 $0.00 $0.00 $0.00 $0.00 "$1,577.50" "$2,498.76" "$2,524.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6339 SUP Custom 27803010 6339 - GRAFT SYNTH TISSUE CNTOUR 38X63X6MM BLOCK MEDPOR BOTH IP/OP "$3,395.00 " "$2,512.30" $0.00 "$2,716.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,519.77" "$2,519.77" $0.00 $0.00 $707.52 $0.00 $0.00 $0.00 $0.00 "$1,697.50" "$2,688.84" "$2,716.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6340 SUP Custom 27803010 6340 - GRAFT SNTH TISS CNTR 38X63X9.5MM STRL MDPR BLCK PE POR BOTH IP/OP "$3,642.50 " "$2,695.45" $0.00 "$2,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,703.46" "$2,703.46" $0.00 $0.00 $759.10 $0.00 $0.00 $0.00 $0.00 "$1,821.25" "$2,884.86" "$2,914.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6351 SUP Custom 27803010 6351 - GRAFT SYNTH TISSUE MEDPOR 178X127MM SHEET POROUS BOTH IP/OP "$5,350.00 " "$3,959.00" $0.00 "$4,280.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,970.77" "$3,970.77" $0.00 $0.00 "$1,114.94" $0.00 $0.00 $0.00 $0.00 "$2,675.00" "$4,237.20" "$4,280.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6550 SUP Custom 27203010 KIT OC TTHT SWB PRXMNT SOL MOIST LF BOTH IP/OP $13.45 $9.95 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.73 $10.65 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6640 SUP HCPCS C1729 6640 - SYSTEM DRN 7FR 15ML STRL LF TLS EVACUATE TUBE RADOPQ CATH BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $57.02 $57.02 $0.00 $0.00 $0.00 $21.88 $77.93 $77.93 $0.00 $0.00 $21.88 $0.00 $62.11 $62.11 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 6650 SUP HCPCS C1729 6650 - SYSTEM DRAIN 10FR EVACUATE TUBE RADIOPQ RESERVOIR LATEX FREE BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $57.02 $57.02 $0.00 $0.00 $0.00 $21.88 $77.93 $77.93 $0.00 $0.00 $21.88 $0.00 $62.11 $62.11 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 7120 SUP HCPCS C1895 7120 - LEAD DFBR 7FR DURATA ECRDL STRD ELUT TRUE BIPOL ACT FIX BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 7122 SUP HCPCS C1898 7122 - LEAD PCNG ECRDL BIPOL ACT FIX XTD-RETRAC HLX TIP DURATA BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 7207 SUP Custom 27803010 7207 - IMPLANT ORBTL CONE FLAT 16MM MULTPUR ANTERIOR SURFACE MEDPOR BOTH IP/OP "$1,153.66 " $853.71 $0.00 $922.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $856.24 $856.24 $0.00 $0.00 $240.42 $0.00 $0.00 $0.00 $0.00 $576.83 $913.70 $922.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7208 SUP Custom 27803010 7208 - SAW SURG SAGITTAL SYSTEM 7 BOTH IP/OP "$1,153.66 " $853.71 $0.00 $922.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $856.24 $856.24 $0.00 $0.00 $240.42 $0.00 $0.00 $0.00 $0.00 $576.83 $913.70 $922.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7209 SUP Custom 27803010 7209 - IMPLANT ORBTL CONE FLAT 20MM MULTPUR ANTERIOR SURFACE MEDPOR BOTH IP/OP "$1,153.66 " $853.71 $0.00 $922.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $856.24 $856.24 $0.00 $0.00 $240.42 $0.00 $0.00 $0.00 $0.00 $576.83 $913.70 $922.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7210 SUP Custom 27803010 7210 - GRAFT SYNTH TISSUE ULTRATHIN 50X38X.85MM SHEET POROUS MEDPOR BOTH IP/OP $943.40 $698.12 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $700.19 $700.19 $0.00 $0.00 $196.60 $0.00 $0.00 $0.00 $0.00 $651.25 "$1,031.58" "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7212 SUP Custom 27803010 7212 - GRAFT SYNTH TISSUE ULTRATHIN 76X50X.85MM SHEET SMOOTH BOTH IP/OP $53.20 $39.37 $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.49 $39.49 $0.00 $0.00 $11.09 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7214 SUP Custom 27803010 7214 - GRAFT SYNTH TISSUE ULTRATHIN 127X76X.85MM SHEET SMOOTH BOTH IP/OP $53.20 $39.37 $0.00 "$2,688.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.49 $39.49 $0.00 $0.00 $11.09 $0.00 $0.00 $0.00 $0.00 "$1,680.00" "$2,661.12" "$2,688.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7216 SUP Custom 27803010 7216 - MEDPOR ULTRA THIN SHEET - 127MM X 178MM X 0.85MM BOTH IP/OP "$3,710.00 " "$2,745.40" $0.00 "$2,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,753.56" "$2,753.56" $0.00 $0.00 $773.16 $0.00 $0.00 $0.00 $0.00 "$1,855.00" "$2,938.32" "$2,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7222 SUP Custom 27803010 7222 - IMPLANT ORBTL CONICAL FLAT ANTERIOR SURFACE CHANNELS POROUS BOTH IP/OP "$1,417.05 " "$1,048.62" $0.00 "$1,223.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.47 $861.47 $0.00 $0.00 $241.89 $0.00 $0.00 $0.00 $0.00 $526.69 "$1,223.64" $842.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7223 SUP Custom 27803010 7223 - IMPLANT ORBTL CONICAL FLAT ANTERIOR SURFACE CHANNELS POROUS BOTH IP/OP "$1,459.35 " "$1,079.92" $0.00 "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,083.13" "$1,083.13" $0.00 $0.00 $304.13 $0.00 $0.00 $0.00 $0.00 $796.25 "$1,261.26" "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7341 SUP Custom 27203010 STAIN BLUING SOL SGNTR 1GL HPRFR WKG SOL HMTL BOTH IP/OP $368.78 $272.90 $0.00 $295.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.39 $292.07 $295.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7511 SUP Custom 27803010 7511 - COVER BURR HOLE 5MM 15X3MM SUPERIOR FLANGE POROUS MEDPOR BOTH IP/OP $672.00 $497.28 $0.00 $856.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $498.76 $498.76 $0.00 $0.00 $140.04 $0.00 $0.00 $0.00 $0.00 $535.00 $847.44 $856.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7512 SUP Custom 27803010 7512 - COVER BURR HOLE 29X17X7MM 3PK CRANIOMAXILLOFACIAL BOTH IP/OP $672.00 $497.28 $0.00 $856.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $498.76 $498.76 $0.00 $0.00 $140.04 $0.00 $0.00 $0.00 $0.00 $535.00 $847.44 $856.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7514 SUP Custom 27803010 7514 - BURR HOLE DISC - 14MM X 16MM BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.35 $252.35 $0.00 $0.00 $70.86 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7516 SUP Custom 27803010 7516 - GRAFT SYNTH TISSUE SMALL 53X5MM DESIGN A LATEX FREE MEDPOR BOTH IP/OP $777.43 $575.30 $0.00 $862.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.00 $577.00 $0.00 $0.00 $162.02 $0.00 $0.00 $0.00 $0.00 $538.75 $853.38 $862.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7517 SUP Custom 27803010 7517 - GRAFT SYNTH TISSUE LARGE 66X8MM IMPLANT DESIGN A POROUS BOTH IP/OP $777.43 $575.30 $0.00 $862.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.00 $577.00 $0.00 $0.00 $162.02 $0.00 $0.00 $0.00 $0.00 $538.75 $853.38 $862.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7518 SUP Custom 27803010 7518 - GRAFT SYNTH TISSUE LARGE 67X6.5MM IMPLANT DESIGN B POROUS BOTH IP/OP $777.43 $575.30 $0.00 $862.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.00 $577.00 $0.00 $0.00 $162.02 $0.00 $0.00 $0.00 $0.00 $538.75 $853.38 $862.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7520 SUP Custom 27803010 7520 - GRAFT SYNTH TISSUE SMALL 65X37X5MM IMPLANT 1 PIECE DESIGN BOTH IP/OP $960.58 $710.83 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.94 $712.94 $0.00 $0.00 $200.18 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7521 SUP Custom 27803010 7521 - GRAFT SYNTH TISSUE MEDIUM 65X37X7MM IMPLANT 1 PIECE DESIGN BOTH IP/OP $960.58 $710.83 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.94 $712.94 $0.00 $0.00 $200.18 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7522 SUP Custom 27803010 7522 - GRAFT SYNTH TISSUE LARGE 65X37X10MM IMPLANT 1 PIECE DESIGN BOTH IP/OP $960.58 $710.83 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.94 $712.94 $0.00 $0.00 $200.18 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7525 SUP Custom 27803010 7525 - EAR BASE - LEFT - 28MM X 55MM X 13MM BOTH IP/OP "$2,404.00 " "$1,778.96" $0.00 "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,784.25" "$1,784.25" $0.00 $0.00 $500.99 $0.00 $0.00 $0.00 $0.00 "$1,202.00" "$1,903.97" "$1,923.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7526 SUP Custom 27803010 7526 - GRAFT SYNTH TISSUE LARGE 65X32X16MM BASE RECONSTRUCTION BOTH IP/OP "$2,454.38 " "$1,816.24" $0.00 "$2,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,821.64" "$1,821.64" $0.00 $0.00 $511.49 $0.00 $0.00 $0.00 $0.00 "$1,683.75" "$2,667.06" "$2,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7527 SUP Custom 27803010 7527 - GRAFT SYNTH TISSUE LARGE 65X32X16MM LATEX FREE EAR LEFT BOTH IP/OP "$2,454.38 " "$1,816.24" $0.00 "$2,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,821.64" "$1,821.64" $0.00 $0.00 $511.49 $0.00 $0.00 $0.00 $0.00 "$1,683.75" "$2,667.06" "$2,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7535 SUP Custom 27803010 7535 - GRAFT SYNTH TISSUE 47X37X3MM 6.5X3X3MM LATERAL AUGMENTATION BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7536 SUP Custom 27803010 7536 - GRAFT SYNTH TISSUE ANGLE 47X37X3MM AUGMENTATION ONLAY MEDPOR BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,479.06" $9.90 $9.90 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $11.00 "$1,479.06" $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7538 SUP Custom 27803010 7538 - GRAFT SYNTH TISSUE ANGLE 79X32X5MM E-5 INFERIOR RIDGE MEDPOR BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7539 SUP Custom 27803010 7539 - GRAFT SYNTH TISSUE 79X32X10MM IMPLANT RAMUS INFERIOR RIDGE BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541 SUP Custom 27803010 7541 - GRAFT SYNTH TISSUE ANGLE 79X32X4MM ES-5 INFERIOR RIDGE BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7542 SUP Custom 27803010 7542 - GRAFT SYNTH TISSUE ANGLE 5MM 5MM 79MMX32MM 4MMX5MM RAMUS BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7543 SUP Custom 27803010 7543 - GRAFT SYNTH TISSUE 79X32X10MM IMPLANT RAMUS INFERIOR RIDGE BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7544 SUP Custom 27803010 7544 - GRAFT SYNTH TISSUE 79X32X10MM IMPLANT RAMUS INFERIOR RIDGE BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7594 SUP Custom 27203010 REAGENT ANTI-FYB GMA CLN 5ML MNCLN BLOOD BANK BOTH IP/OP "$1,347.50 " $997.15 $0.00 "$1,078.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.11" "$1,000.11" $0.00 $0.00 $280.82 $0.00 $0.00 $0.00 $0.00 $673.75 "$1,067.22" "$1,078.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7730 SUP Custom 27203010 7730 - ADHESIVE OSTOMY MEDIUM SPRAY CAN REMAIN FLEXIBLE SILICONE BOTH IP/OP $607.98 $449.91 $0.00 $451.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $451.24 $451.24 $0.00 $0.00 $126.70 $0.00 $0.00 $0.00 $0.00 $19.69 $31.19 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7828 SUP HCPCS C1768 007828 - FABRIC CARDIO 4X4IN SVG THK.61MM FLMN BOTH IP/OP $254.37 $188.23 $0.00 $203.49 $114.46 $114.46 $0.00 $0.00 $0.00 $53.02 $188.79 $188.79 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.18 $201.46 $203.49 $0.00 $0.00 $39.81 $0.00 $0.00 $40.49 $0.00 $0.00 $0.00 $0.00 $0.00 7836 SUP HCPCS C1768 7836 - FELT CARDIO 10X10CM THK1.65MM PTFE BOTH IP/OP $210.00 $155.40 $0.00 $254.62 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $254.62 $254.62 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 7836 SUP HCPCS C1768 007836 - FELT CARDIO THK1.65MM 4X4IN PTFE STERILE BOTH IP/OP $210.00 $155.40 $0.00 $254.62 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $254.62 $254.62 $0.00 $105.00 $174.60 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 7837 SUP HCPCS C1768 007837 - FELT CARDIO 15X15CM THK1.65MM PTFE PTCH BOTH IP/OP $295.55 $218.71 $0.00 $236.44 $133.00 $133.00 $0.00 $0.00 $0.00 $61.60 $219.36 $219.36 $0.00 $0.00 $61.59 $0.00 $174.82 $174.82 $0.00 $147.78 $234.08 $236.44 $0.00 $0.00 $46.25 $0.00 $0.00 $47.05 $0.00 $0.00 $0.00 $0.00 $0.00 8101 SUP Custom 27203010 REAGENT METHNL ISOPRPNL FLX 100 1GL ABST DEHYDRANT BTL BOTH IP/OP $40.60 $30.04 $0.00 $32.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.30 $32.16 $32.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8185 SUP HCPCS C1769 8185 - GUIDEWIRE VASC STRG 185CM PRIMEWIRE PSTG+ PRSS BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $916.31 $916.31 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $264.09 $0.00 $0.00 $268.65 $0.00 $0.00 $0.00 $0.00 $0.00 8305 SUP Custom 27803010 8305 - GRAFT SNTH TISS TRMPT 50X38X1MM STRL MDPR BRR SHT HDPE NPOR BOTH IP/OP "$1,319.50 " $976.43 $0.00 "$1,616.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $979.33 $979.33 $0.00 $0.00 $274.98 $0.00 $0.00 $0.00 $0.00 "$1,010.00" "$1,599.84" "$1,616.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8312 SUP Custom 27803010 8312 - GRAFT SYNTH TISSUE REGULAR 76X50X1MM IMPLANT RECTANGULAR BOTH IP/OP "$1,288.00 " $953.12 $0.00 "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.95 $955.95 $0.00 $0.00 $268.42 $0.00 $0.00 $0.00 $0.00 $888.75 "$1,407.78" "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8313 SUP Custom 27803010 8313 - GRAFT SYNTH TISSUE SMALL ROUND 47X45X3MM 2 PIECE DESIGN BOTH IP/OP "$1,016.40 " $752.14 $0.00 "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $754.37 $754.37 $0.00 $0.00 $211.82 $0.00 $0.00 $0.00 $0.00 $706.25 "$1,118.70" "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8314 SUP Custom 27803010 8314 - GRAFT SYNTH TISSUE MEDIUM ROUND 47X45X5MM 2 PIECE DESIGN BOTH IP/OP "$1,016.40 " $752.14 $0.00 "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $754.37 $754.37 $0.00 $0.00 $211.82 $0.00 $0.00 $0.00 $0.00 $706.25 "$1,118.70" "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8315 SUP Custom 27803010 8315 - IMPLANT CHIN LG RND 47X45X7MM STRL MDPR RZ 2 PC DSGN NTCH BOTH IP/OP "$1,016.40 " $752.14 $0.00 "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $754.37 $754.37 $0.00 $0.00 $211.82 $0.00 $0.00 $0.00 $0.00 $706.25 "$1,118.70" "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8316 SUP Custom 27803010 8316 - GRAFT SYNTH TISSUE 3MM ROUND EXTEND RZ CHIN BOTH IP/OP "$1,016.40 " $752.14 $0.00 "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $754.37 $754.37 $0.00 $0.00 $211.82 $0.00 $0.00 $0.00 $0.00 $706.25 "$1,118.70" "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8317 SUP Custom 27803010 8317 - IMPLANT CHIN MED SQ 47X45X5MM STRL MDPR RZ 2 PC DSGN NTCH BOTH IP/OP "$1,016.40 " $752.14 $0.00 "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $754.37 $754.37 $0.00 $0.00 $211.82 $0.00 $0.00 $0.00 $0.00 $706.25 "$1,118.70" "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8318 SUP Custom 27803010 8318 - IMPLANT CHIN LG SQ 47X45X7MM STRL MDPR RZ 2 PC DSGN NTCH TAB BOTH IP/OP "$1,016.40 " $752.14 $0.00 "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $754.37 $754.37 $0.00 $0.00 $211.82 $0.00 $0.00 $0.00 $0.00 $706.25 "$1,118.70" "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8319 SUP Custom 27803010 8319 - IMPLANT CHIN 45X41X4MM MGG 2 PC BOTH IP/OP "$1,075.25 " $795.69 $0.00 $972.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $798.05 $798.05 $0.00 $0.00 $224.08 $0.00 $0.00 $0.00 $0.00 $607.50 $962.28 $972.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8320 SUP Custom 27803010 8320 - GRAFT SNTH TISS SM 56X33X5MM STRL MDPR IMPL 2 PC PRJ TPR WNG BOTH IP/OP $893.75 $661.38 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8321 SUP Custom 27803010 8321 - GRAFT SYNTH TISSUE 56X36X7MM IMPLANT 2 PIECE MEDIUM BOTH IP/OP $893.75 $661.38 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8322 SUP Custom 27803010 8322 - GRAFT SYNTH TISSUE 56X36X7MM IMPLANT 2 PIECE LARGE BOTH IP/OP $893.75 $661.38 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8328 SUP Custom 27803010 8328 - GRAFT SYNTH TISSUE 62X37MM IMPLANT HELICAL RIM POROUS MEDPOR BOTH IP/OP "$1,225.63 " $906.97 $0.00 "$1,448.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.66 $909.66 $0.00 $0.00 $255.42 $0.00 $0.00 $0.00 $0.00 $905.00 "$1,433.52" "$1,448.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8329 SUP Custom 27803010 8329 - GRAFT SYNTH TISSUE 62X37MM HELICAL RIM POROUS MEDPOR BOTH IP/OP "$1,225.63 " $906.97 $0.00 "$1,448.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.66 $909.66 $0.00 $0.00 $255.42 $0.00 $0.00 $0.00 $0.00 $905.00 "$1,433.52" "$1,448.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8330 SUP Custom 27803010 8330 - GRAFT SYNTH TISSUE 60X30MM IMPLANT EXTENDED BASE POROUS BOTH IP/OP "$2,262.60 " "$1,674.32" $0.00 "$2,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,679.30" "$1,679.30" $0.00 $0.00 $471.53 $0.00 $0.00 $0.00 $0.00 "$1,658.75" "$2,627.46" "$2,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8331 SUP Custom 27803010 8331 - GRAFT SYNTH TISSUE 60X30MM BASE EXTENDED POROUS MEDPOR BOTH IP/OP "$2,262.60 " "$1,674.32" $0.00 "$2,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,679.30" "$1,679.30" $0.00 $0.00 $471.53 $0.00 $0.00 $0.00 $0.00 "$1,658.75" "$2,627.46" "$2,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8340 SUP Custom 27803010 8340 - GRAFT SYNTH TISSUE SMALL 60X25X5MM IMPLANT GENIOPLASTY WEDGE BOTH IP/OP $984.70 $728.68 $0.00 "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $730.84 $730.84 $0.00 $0.00 $205.21 $0.00 $0.00 $0.00 $0.00 $745.00 "$1,180.08" "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8341 SUP Custom 27803010 8341 - GRAFT SYNTH TISSUE MEDIUM 60X25X7.5MM IMPLANT GENIOPLASTY BOTH IP/OP $984.70 $728.68 $0.00 "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $730.84 $730.84 $0.00 $0.00 $205.21 $0.00 $0.00 $0.00 $0.00 $745.00 "$1,180.08" "$1,192.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8342 SUP Custom 27803010 8342 - GENIOPLASTY WEDGE - LARGE - 60MM X 25MM X 10MM BOTH IP/OP "$1,096.00 " $811.04 $0.00 $876.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $813.45 $813.45 $0.00 $0.00 $228.41 $0.00 $0.00 $0.00 $0.00 $548.00 $868.03 $876.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8438 SUP Custom 27803010 8438 - GRAFT SYNTH TISSUE MICROTHIN 50X30X.4MM SHEET MEDPOR BOTH IP/OP $961.35 $711.40 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $713.51 $713.51 $0.00 $0.00 $200.35 $0.00 $0.00 $0.00 $0.00 $651.25 "$1,031.58" "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8536 SUP Custom 27203010 8536 - NEEDLE SUT ULTHN STRL HI-FI 2 ARM SS MNSCL BOTH IP/OP $116.80 $86.43 $0.00 $93.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.69 $86.69 $0.00 $0.00 $24.34 $0.00 $0.00 $0.00 $0.00 $58.40 $92.51 $93.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8570 SUP Custom 27203010 8570 - NEEDLE SUT BLU STRL ZN SPC II REPR EYLT NTNL MNSCS BOTH IP/OP $64.38 $47.64 $0.00 $51.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.78 $47.78 $0.00 $0.00 $13.42 $0.00 $0.00 $0.00 $0.00 $32.19 $50.99 $51.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8662 SUP Custom 27803010 8662 - GRAFT SYNTH TISSUE MICROTHIN 76X127MM SHEET POROUS MEDPOR BOTH IP/OP "$2,242.40 " "$1,659.38" $0.00 "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,664.31" "$1,664.31" $0.00 $0.00 $467.32 $0.00 $0.00 $0.00 $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8703 SUP Custom 27803010 8703 - SPHERE - 21MM BOTH IP/OP "$1,071.20 " $792.69 $0.00 $856.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $795.04 $795.04 $0.00 $0.00 $223.24 $0.00 $0.00 $0.00 $0.00 $535.60 $848.39 $856.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8704 SUP Custom 27803010 8704 - SPHERE - 23MM BOTH IP/OP "$1,071.20 " $792.69 $0.00 $856.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $795.04 $795.04 $0.00 $0.00 $223.24 $0.00 $0.00 $0.00 $0.00 $535.60 $848.39 $856.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8800 SUP Custom 27203010 8800 - KIT ARTHRO FIX PNACL ACL STRL DISP BOTH IP/OP $319.30 $236.28 $0.00 $255.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.98 $236.98 $0.00 $0.00 $66.54 $0.00 $0.00 $0.00 $0.00 $159.65 $252.89 $255.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8814 SUP Custom 27011340 08814 - BRACE ORTH 30.5- IN 17-27IN TSCP BRIDGETECH ROM HNG PRMR TRM BOTH IP/OP $185.10 $136.97 $0.00 $162.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.38 $137.38 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $101.60 $160.93 $162.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9019 SUP Custom 27803010 9019 - VAD 9019 18MM CONVERTIBLE BOTH IP/OP $888.25 $657.31 $0.00 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.26 $659.26 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $444.13 $703.49 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9025 SUP Custom 27803010 9025 - CATH 9025 VENT STD XTRA LENGTH MARK IMP BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.41 $264.41 $0.00 $0.00 $74.24 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9031 SUP Custom 27203010 9031 - DEVICE BRCHTX CVTY EVAL TRGT MAMST BRST BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $0.00 $0.00 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9032 SUP Custom 27803010 9032 - VENT 9032 QUICK RELEASE INTRODUCER BOTH IP/OP $270.75 $200.36 $0.00 $216.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.95 $200.95 $0.00 $0.00 $56.42 $0.00 $0.00 $0.00 $0.00 $135.38 $214.43 $216.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9041 SUP Custom 27203010 CONNECTOR TBG FMALE LUER LOCK LOCK PLG IV BOTH IP/OP $157.50 $116.55 $0.00 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9053 SUP Custom 27203010 9053 - VAD 9053 12MM CONVT W/INLET CONN BOTH IP/OP $888.25 $657.31 $0.00 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.26 $659.26 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $444.13 $703.49 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9073 SUP Custom 27203010 9073 - STOCKINETTE ORTHOPEDIC 25YDX3IN HIGH ABSORBENT KNIT LATEX BOTH IP/OP $28.80 $21.31 $0.00 $23.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.38 $21.38 $0.00 $0.00 $6.00 $0.00 $0.00 $0.00 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9094 SUP Custom 27203010 9094 - STIMULATOR NRV STRL LF CKPNT LCTR DISP BOTH IP/OP "$1,565.00 " "$1,158.10" $0.00 "$1,252.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,161.54" "$1,161.54" $0.00 $0.00 $326.15 $0.00 $0.00 $0.00 $0.00 $782.50 "$1,239.48" "$1,252.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9207 SUP HCPCS C1729 CATHETER XTRN MED XTD WR MALE BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $1.63 $1.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.47 $0.00 $0.00 $0.48 $0.00 $0.00 $0.00 $0.00 $0.00 9209 SUP HCPCS C1729 CATHETER XTRN 36MM LG XTD WR LTX MALE BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $1.63 $1.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.47 $0.00 $0.00 $0.48 $0.00 $0.00 $0.00 $0.00 $0.00 9305 SUP Custom 27803010 9305 - GRAFT SYNTH TISSUE TRUMPET 50X30X1.6MM SHEET BARRIER MEDPOR BOTH IP/OP "$1,380.00 " "$1,021.20" $0.00 "$1,616.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.24" "$1,024.24" $0.00 $0.00 $287.59 $0.00 $0.00 $0.00 $0.00 "$1,010.00" "$1,599.84" "$1,616.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9312 SUP Custom 27803010 9312 - GRAFT SYNTH TISSUE RECTANGLE 76X50X1.6MM IMPLANT NONPOROUS BOTH IP/OP "$1,277.70 " $945.50 $0.00 "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $948.31 $948.31 $0.00 $0.00 $266.27 $0.00 $0.00 $0.00 $0.00 $888.75 "$1,407.78" "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9429 SUP Custom 27803010 9429 - GRAFT SYNTH TISSUE 43X18MM FLANGE MEDPOR POLYETHYLENE POROUS BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9430 SUP Custom 27803010 9430 - GRAFT SYNTH TISSUE INFERIOR ORBTL RIM RIGHT BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,037.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $0.00 $0.00 $0.00 $3.79 "$1,037.52" $6.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9500 SUP HCPCS C1769 9500 - GUIDEWIRE VASC 3CM COMBOWIRE XT FLXB SHFT DPLR PTFE HDRPHB BOTH IP/OP $1.40 $1.04 $0.00 "$2,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 "$2,178.00" $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9501 SUP Custom 27803010 9501 - GRAFT SYNTH TISSUE SUPER PETITE 50X19X3MM IMPLANT TAPERED BOTH IP/OP $893.75 $661.38 $0.00 "$1,037.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $41.65 "$1,037.52" $66.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9502 SUP Custom 27803010 9502 - GRAFT SYNTH TISSUE SUPER PETITE 50X19X3MM IMPLANT TAPERED BOTH IP/OP $893.75 $661.38 $0.00 "$1,037.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.87 $131.87 $0.00 $0.00 $37.03 $0.00 $0.00 $0.00 $0.00 $50.40 "$1,037.52" $80.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9503 SUP Custom 27803010 9503 - GRAFT SYNTH TISSUE PETITE 50X19X5MM IMPLANT POROUS MEDPOR BOTH IP/OP $893.75 $661.38 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9504 SUP Custom 27803010 9504 - GRAFT SYNTH TISSUE PETITE 50X19X5MM IMPLANT TAPERED POROUS BOTH IP/OP $893.75 $661.38 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9513 SUP Custom 27803010 9513 - GRAFT SYNTH TISSUE SMALL CNTOUR 45X24X3MM TRIM AUGMENTATION BOTH IP/OP $935.63 $692.37 $0.00 "$1,047.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.78 $396.78 $0.00 $0.00 $111.41 $0.00 $0.00 $0.00 $0.00 $222.60 "$1,047.42" $356.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9514 SUP Custom 27803010 9514 - GRAFT SYNTH TISSUE SMALL 45X24X3MM EXTEND DESIGN MEDPOR BOTH IP/OP $935.63 $692.37 $0.00 "$1,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $694.42 $694.42 $0.00 $0.00 $194.98 $0.00 $0.00 $0.00 $0.00 $661.25 "$1,047.42" "$1,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9515 SUP Custom 27803010 9515 - GRAFT SYNTH TISSUE MEDIUM CNTOUR 50X26X4MM EXTEND MEDPOR BOTH IP/OP $935.63 $692.37 $0.00 "$1,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $694.42 $694.42 $0.00 $0.00 $194.98 $0.00 $0.00 $0.00 $0.00 $661.25 "$1,047.42" "$1,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9516 SUP Custom 27803010 9516 - GRAFT SNTH TISS MED 50X26X4MM STRL LF MDPR XTD CNTR PE POR BOTH IP/OP $935.63 $692.37 $0.00 "$1,047.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.63 $6.63 $0.00 $0.00 $1.86 $0.00 $0.00 $0.00 $0.00 $4.05 "$1,047.42" $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9517 SUP Custom 27803010 9517 - GRAFT SNTH TISS LG 55X27X5MM STRL MDPR XTD CNTR POR PE BOTH IP/OP $935.63 $692.37 $0.00 "$1,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $694.42 $694.42 $0.00 $0.00 $194.98 $0.00 $0.00 $0.00 $0.00 $661.25 "$1,047.42" "$1,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9518 SUP Custom 27803010 9518 - GRAFT SYNTH TISSUE LARGE 55X27X5MM EXTEND SHAPE MEDPOR BOTH IP/OP $935.63 $692.37 $0.00 "$1,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $694.42 $694.42 $0.00 $0.00 $194.98 $0.00 $0.00 $0.00 $0.00 $661.25 "$1,047.42" "$1,058.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9519 SUP Custom 27803010 9519 - GRAFT SYNTH TISSUE PARANASAL CRESCENT PETITE 28X26X4.5MM BOTH IP/OP $925.58 $684.93 $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $686.96 $686.96 $0.00 $0.00 $192.89 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9520 SUP Custom 27803010 9520 - GRAFT SYNTH TISSUE PARANASAL CRESCENT PETITE 28X26X4.5MM BOTH IP/OP $925.58 $684.93 $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $686.96 $686.96 $0.00 $0.00 $192.89 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9521 SUP Custom 27803010 9521 - GRAFT SYNTH TISSUE SMALL 70X70X10MM SMOOTH FLEXIBLE AUGMENT BOTH IP/OP "$2,869.60 " "$2,123.50" $0.00 "$3,644.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,129.82" "$2,129.82" $0.00 $0.00 $598.02 $0.00 $0.00 $0.00 $0.00 "$2,277.50" "$3,607.56" "$3,644.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9522 SUP Custom 27803010 9522 - GRAFT SYNTH TISSUE MEDIUM 88X86X15MM SMOOTH FLEXIBLE AUGMENT BOTH IP/OP "$2,988.60 " "$2,211.56" $0.00 "$3,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,218.14" "$2,218.14" $0.00 $0.00 $622.82 $0.00 $0.00 $0.00 $0.00 "$2,371.25" "$3,756.06" "$3,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9523 SUP Custom 27803010 9523 - GRAFT SYNTH TISSUE LARGE 98X95X18MM SMOOTH FLEXIBLE AUGMENT BOTH IP/OP "$3,102.50 " "$2,295.85" $0.00 "$3,898.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.06 $62.06 $0.00 $0.00 $17.42 $0.00 $0.00 $0.00 $0.00 $37.91 "$3,898.62" $60.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9524 SUP Custom 27803010 9524 - GRAFT SYNTH TISSUE THK6MM 107MMX97 GRID CNTOUR MEDPOR BOTH IP/OP "$7,350.80 " "$5,439.59" $0.00 "$9,542.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,531.91" $0.00 $0.00 $0.00 $0.00 "$5,963.75" "$9,446.58" "$9,542.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9525 SUP Custom 27803010 9525 - GRAFT SYNTH TISSUE PARANASAL CRESCENT LARGE 30X28X7MM BOTH IP/OP $925.58 $684.93 $0.00 "$1,077.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.43 $5.43 $0.00 $0.00 $1.53 $0.00 $0.00 $0.00 $0.00 $44.31 "$1,077.12" $70.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9526 SUP Custom 27803010 9526 - GRAFT SYNTH TISSUE PARANASAL CRESCENT LARGE 30X28X7MM BOTH IP/OP $925.58 $684.93 $0.00 "$1,077.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.14 $103.14 $0.00 $0.00 $28.96 $0.00 $0.00 $0.00 $0.00 $63.00 "$1,077.12" $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9527 SUP Custom 27803010 9527 - GRAFT SYNTH TISSUE 38X50X.85MM 1 CHANNEL SHEET MICROPLATE BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9530 SUP Custom 27203010 9530 - SLEEVE COMPRESSION MEDIUM ANTIEMBOLISM ADJUSTABLE CLOSURE BOTH IP/OP $45.71 $33.83 $0.00 $36.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.89 $36.20 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9531 SUP Custom 27803010 9531 - GRAFT SYNTH TISSUE 52X40X2.3MM IMPLANT MINIPLATE CHANNEL BOTH IP/OP "$1,766.23 " "$1,307.01" $0.00 "$2,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,310.89" "$1,310.89" $0.00 $0.00 $368.08 $0.00 $0.00 $0.00 $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9532 SUP Custom 27803010 9532 - GRAFT SNTH TISS 52X40X2.3MM BRR MDPR MCPLT CHNL SHT PE BOTH IP/OP "$1,766.23 " "$1,307.01" $0.00 "$2,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,310.89" "$1,310.89" $0.00 $0.00 $368.08 $0.00 $0.00 $0.00 $0.00 "$1,460.00" "$2,312.64" "$2,336.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9533 SUP Custom 27803010 9533 - GRAFT SYNTH TISSUE 1.1MM SMALL 70X13X2MM ONLAY ARCH SHAPE BOTH IP/OP $843.60 $624.26 $0.00 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $626.12 $626.12 $0.00 $0.00 $175.81 $0.00 $0.00 $0.00 $0.00 $588.75 $932.58 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9534 SUP Custom 27803010 9534 - GRAFT SYNTH TISSUE MEDIUM 70X15X2MM NASAL ARCH POROUS MEDPOR BOTH IP/OP $843.60 $624.26 $0.00 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $626.12 $626.12 $0.00 $0.00 $175.81 $0.00 $0.00 $0.00 $0.00 $588.75 $932.58 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9535 SUP Custom 27803010 9535 - GRAFT SYNTH TISSUE LARGE 70X17X2MM NASAL ARCH ONLAY POROUS BOTH IP/OP $843.60 $624.26 $0.00 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $626.12 $626.12 $0.00 $0.00 $175.81 $0.00 $0.00 $0.00 $0.00 $588.75 $932.58 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9536 SUP Custom 27803010 9536 - GRAFT SYNTH TISSUE 40X9X1.1MM NASAL SHEET POROUS MEDPOR BOTH IP/OP $406.00 $300.44 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.33 $301.33 $0.00 $0.00 $84.61 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9537 SUP HCPCS C1763 9537 - TISSUE SYNTH PE POR MEDPOR ORBTL RIM BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $427.50 $427.50 $0.00 $0.00 $0.00 $198.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $561.93 $561.93 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $148.68 $0.00 $0.00 $151.24 $0.00 $0.00 $0.00 $0.00 $0.00 9539 SUP Custom 27803010 9539 - GRAFT SYNTH TISSUE 47X40X6.3MM EXTEND MEDPOR POLYETHYLENE BOTH IP/OP "$1,371.58 " "$1,014.97" $0.00 "$1,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,017.98" "$1,017.98" $0.00 $0.00 $285.84 $0.00 $0.00 $0.00 $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9540 SUP Custom 27803010 9540 - GRAFT SNTH TISS 47X40X6.3MM STRL MDPR XTD PE POR CRNMXF RT BOTH IP/OP "$1,371.58 " "$1,014.97" $0.00 "$1,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,017.98" "$1,017.98" $0.00 $0.00 $285.84 $0.00 $0.00 $0.00 $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9541 SUP Custom 27803010 9541 - GRAFT SYNTH TISSUE REGULAR 31X22X7MM ENOPHTHALMOS WEDGE BOTH IP/OP "$1,215.00 " $899.10 $0.00 "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.77 $901.77 $0.00 $0.00 $253.21 $0.00 $0.00 $0.00 $0.00 $853.75 "$1,352.34" "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9542 SUP Custom 27803010 9542 - GRAFT SYNTH TISSUE REGULAR 31X22X7MM WEDGE ENOPHTHALMOS BOTH IP/OP "$1,215.00 " $899.10 $0.00 "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.77 $901.77 $0.00 $0.00 $253.21 $0.00 $0.00 $0.00 $0.00 $853.75 "$1,352.34" "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9543 SUP Custom 27803010 9543 - GRAFT SYNTH TISSUE LARGE 40X28X7.5MM ENOPHTHALMOS WEDGE BOTH IP/OP "$1,215.00 " $899.10 $0.00 "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.77 $901.77 $0.00 $0.00 $253.21 $0.00 $0.00 $0.00 $0.00 $853.75 "$1,352.34" "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9544 SUP Custom 27803010 9544 - GRAFT SYNTH TISSUE LARGE 40X28X7.5MM ENOPHTHALMOS WEDGE BOTH IP/OP "$1,215.00 " $899.10 $0.00 "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.77 $901.77 $0.00 $0.00 $253.21 $0.00 $0.00 $0.00 $0.00 $853.75 "$1,352.34" "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9545 SUP Custom 27203010 9545 - SLEEVE SMALL SCD EXPRESS THIGH LENGTH BOTH IP/OP $99.10 $73.33 $0.00 $79.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.55 $78.49 $79.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9548 SUP Custom 27803010 9548 - CONFORMER OCULAR MEDIUM 24X21X5.3MM NONVENT LATEX FREE ACRYL BOTH IP/OP $120.25 $88.99 $0.00 $142.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.25 $89.25 $0.00 $0.00 $25.06 $0.00 $0.00 $0.00 $0.00 $88.75 $140.58 $142.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9553 SUP Custom 27803010 9553 - GRAFT SYNTH TISSUE REGULAR SHELL 38X21X17MM 2 INSERT BOTH IP/OP "$1,130.00 " $836.20 $0.00 "$1,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $838.69 $838.69 $0.00 $0.00 $235.49 $0.00 $0.00 $0.00 $0.00 $776.25 "$1,229.58" "$1,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9554 SUP Custom 27803010 9554 - GRAFT SYNTH TISSUE LARGE 40X20X18MM NASAL SHELL 2 INSERTS BOTH IP/OP $190.13 $140.70 $0.00 "$1,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.11 $141.11 $0.00 $0.00 $39.62 $0.00 $0.00 $0.00 $0.00 $776.25 "$1,229.58" "$1,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9555 SUP Custom 27203010 CURETTE 4MM FLXLP ADLT EAR FLXB OVL CUP SURG POLYPRO DISP BOTH IP/OP $2.13 $1.58 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.06 $1.69 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9562 SUP Custom 27803010 9562 - SHEET SNTH 50X38X3MM MDPR NEURO BOTH IP/OP "$2,214.05 " "$1,638.40" $0.00 "$2,688.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,643.27" "$1,643.27" $0.00 $0.00 $461.41 $0.00 $0.00 $0.00 $0.00 "$1,680.00" "$2,661.12" "$2,688.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9568 SUP Custom 27803010 9568 - GRAFT SNTH TISS 108X75MM STRL MDPR IMPL INFR 2/3 ORBT POR PE BOTH IP/OP "$7,026.50 " "$5,199.61" $0.00 "$9,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,464.32" $0.00 $0.00 $0.00 $0.00 "$5,705.00" "$9,036.72" "$9,128.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9570 SUP Custom 27803010 9570 - GRAFT SNTH TISS 93X75MM STRL MDPR IMPL CMPLT POR PE CRNMXF BOTH IP/OP "$8,342.75 " "$6,173.64" $0.00 "$10,838.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,738.63" $0.00 $0.00 $0.00 $0.00 "$6,773.75" "$10,729.62" "$10,838.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9580 SUP Custom 27203010 09580 - DEVICE EXFIX OPTRM ELB TRGT DISC BOTH IP/OP $572.50 $423.65 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.91 $424.91 $0.00 $0.00 $119.31 $0.00 $0.00 $0.00 $0.00 $286.25 $453.42 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9595 SUP HCPCS C1769 09595 - WIRE .062IN KWIRE TRGT ORTH NONSTRL BOTH IP/OP $257.50 $190.55 $0.00 $206.00 $139.82 $139.82 $0.00 $0.00 $0.00 $0.00 $191.12 $191.12 $0.00 $0.00 $53.66 $0.00 $0.00 $0.00 $0.00 $128.75 $203.94 $206.00 $0.00 $0.00 $40.30 $0.00 $0.00 $40.99 $0.00 $0.00 $0.00 $0.00 $0.00 9600 SUP Custom 27203010 09600 - FXTR EXFIX OPTRM PROX ELB CMPNT BOTH IP/OP "$11,645.00 " "$8,617.30" $0.00 "$9,316.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,426.82" $0.00 $0.00 $0.00 $0.00 "$5,822.50" "$9,222.84" "$9,316.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9610 SUP Custom 27803010 09610 - CMPNT EXFIX OPTRM RIGHT DISTAL BOTH IP/OP "$5,727.50 " "$4,238.35" $0.00 "$4,536.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.25 $52.25 $0.00 $0.00 $14.67 $0.00 $0.00 $0.00 $0.00 $23.94 "$4,536.18" $38.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9780 SUP Custom 27203010 9780 - DEVICE DRN C400LB 10-24FR STRL LF INVACARE I-FIT ATCH DEV BOTH IP/OP $51.01 $37.75 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.42 $40.40 $39.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9857 SUP Custom 27803010 9857 - SHEET SNTH SM CNTR 78X61X18MM STRL FLXBLK TF2 MDPR CRNMXF LT BOTH IP/OP "$3,042.25 " "$2,251.27" $0.00 "$3,634.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,257.96" "$2,257.96" $0.00 $0.00 $634.00 $0.00 $0.00 $0.00 $0.00 "$2,271.25" "$3,597.66" "$3,634.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9858 SUP Custom 27803010 9858 - GRAFT SYNTH TISSUE SMALL CNTOUR 78X61X18MM FLEXBLOCK TF2 BOTH IP/OP "$3,042.25 " "$2,251.27" $0.00 "$3,634.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,257.96" "$2,257.96" $0.00 $0.00 $634.00 $0.00 $0.00 $0.00 $0.00 "$2,271.25" "$3,597.66" "$3,634.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9859 SUP Custom 27803010 9859 - GRAFT SYNTH TISSUE MEDIUM CNTOUR 93X74X20MM FLEXBLOCK MEDPOR BOTH IP/OP "$3,041.35 " "$2,250.60" $0.00 "$3,763.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.98 $202.98 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $124.13 "$3,763.98" $198.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9860 SUP Custom 27803010 9860 - GRAFT SYNTH TISSUE MEDIUM CNTOUR 93X74X20MM FLEXBLOCK MEDPOR BOTH IP/OP "$3,041.35 " "$2,250.60" $0.00 "$3,802.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,257.29" "$2,257.29" $0.00 $0.00 $633.82 $0.00 $0.00 $0.00 $0.00 "$2,376.25" "$3,763.98" "$3,802.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9861 SUP Custom 27803010 9861 - GRAFT SYNTH TISSUE LARGE IMPLANT CNTOUR POROUS MEDPOR BOTH IP/OP "$3,170.50 " "$2,346.17" $0.00 "$3,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,353.15" "$2,353.15" $0.00 $0.00 $660.73 $0.00 $0.00 $0.00 $0.00 "$2,486.25" "$3,938.22" "$3,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9862 SUP Custom 27803010 9862 - GRAFT SYNTH TISSUE LARGE IMPLANT POROUS MEDPOR FLEXBLOCK TF2 BOTH IP/OP "$3,170.50 " "$2,346.17" $0.00 "$3,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,353.15" "$2,353.15" $0.00 $0.00 $660.73 $0.00 $0.00 $0.00 $0.00 "$2,486.25" "$3,938.22" "$3,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9864 SUP Custom 27803010 9864 - GRAFT SYNTH TISSUE 44X43X6MM MEDPOR POLYETHYLENE POROUS BOTH IP/OP "$2,026.38 " "$1,499.52" $0.00 "$2,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,503.98" "$1,503.98" $0.00 $0.00 $422.30 $0.00 $0.00 $0.00 $0.00 "$1,757.50" "$2,783.88" "$2,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9865 SUP Custom 27803010 9865 - GRAFT SYNTH TISSUE 44X43X6MM MEDPOR POLYETHYLENE POROUS LEFT BOTH IP/OP "$2,026.38 " "$1,499.52" $0.00 "$2,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,503.98" "$1,503.98" $0.00 $0.00 $422.30 $0.00 $0.00 $0.00 $0.00 "$1,757.50" "$2,783.88" "$2,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9866 SUP Custom 27803010 9866 - IMPLANT ORBTL 16MM SMALL ROUND MOTILITY 2 CHANNEL 4 ANTERIOR BOTH IP/OP "$1,273.05 " $942.06 $0.00 "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.86 $944.86 $0.00 $0.00 $265.30 $0.00 $0.00 $0.00 $0.00 $796.25 "$1,261.26" "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9867 SUP Custom 27803010 9867 - IMPLANT ORBTL 18MM MEDIUM ROUND MOTILITY 2 CHANNEL 4 BOTH IP/OP "$1,592.50 " "$1,178.45" $0.00 "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,181.95" "$1,181.95" $0.00 $0.00 $331.88 $0.00 $0.00 $0.00 $0.00 $796.25 "$1,261.26" "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9868 SUP Custom 27803010 9868 - IMPLANT ORBTL 20MM LARGE ROUND MOTILITY 2 CHANNEL 4 ANTERIOR BOTH IP/OP "$1,592.50 " "$1,178.45" $0.00 "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,181.95" "$1,181.95" $0.00 $0.00 $331.88 $0.00 $0.00 $0.00 $0.00 $796.25 "$1,261.26" "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9952 SUP Custom 27803010 9952 - SET SZR MALAR BOTH IP/OP $521.25 $385.73 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $386.87 $386.87 $0.00 $0.00 $108.63 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9955 SUP Custom 27803010 9955 - GRAFT SYNTH TISSUE SMALL 65X35X3MM IMPLANT ANGLED WRAPAROUND BOTH IP/OP "$1,510.88 " "$1,118.05" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,121.37" "$1,121.37" $0.00 $0.00 $314.87 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9956 SUP Custom 27803010 9956 - GRAFT SYNTH TISSUE SMALL ANGLE RIGHT 65X35X3MM WRAPAROUND BOTH IP/OP "$1,420.08 " "$1,050.86" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,053.98" "$1,053.98" $0.00 $0.00 $295.94 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9957 SUP Custom 27803010 9957 - GRAFT SYNTH TISSUE MEDIUM 65X35X7MM IMPLANT ANGLED BOTH IP/OP "$1,420.08 " "$1,050.86" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,053.98" "$1,053.98" $0.00 $0.00 $295.94 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9958 SUP Custom 27803010 9958 - GRAFT SYNTH TISSUE MEDIUM 65X35X7MM IMPLANT ANGLED BOTH IP/OP "$1,420.08 " "$1,050.86" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,053.98" "$1,053.98" $0.00 $0.00 $295.94 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9959 SUP Custom 27803010 9959 - GRAFT SYNTH TISSUE LARGE 65X35X11MM IMPLANT ANGLED BOTH IP/OP "$1,420.08 " "$1,050.86" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,053.98" "$1,053.98" $0.00 $0.00 $295.94 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9960 SUP Custom 27803010 9960 - GRAFT SYNTH TISSUE LARGE 65X35X11MM IMPLANT ANGLED BOTH IP/OP "$1,420.08 " "$1,050.86" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,053.98" "$1,053.98" $0.00 $0.00 $295.94 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10004 SUP HCPCS C1713 010004 - PLATE BONE 4 HOLE UTILITY SPN BOTH IP/OP $26.25 $19.43 $0.00 $21.00 $11.81 $11.81 $0.00 $0.00 $0.00 $5.47 $19.48 $19.48 $0.00 $0.00 $5.47 $0.00 $15.53 $15.53 $0.00 $13.13 $20.79 $21.00 $0.00 $0.00 $4.11 $0.00 $0.00 $4.18 $0.00 $0.00 $0.00 $0.00 $0.00 10014 SUP HCPCS C1713 010014 - PLATE BONE 4MM STANDARD STR 14 HOLE TIMESH TITANIUM CRANIAL BOTH IP/OP $490.88 $363.25 $0.00 $388.78 $0.00 $0.00 $0.00 $0.00 $0.00 $102.31 $364.33 $364.33 $0.00 $0.00 $102.30 $0.00 $290.35 $290.35 $0.00 $86.63 $388.78 $138.60 $0.00 $0.00 $0.00 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $0.00 10015 SUP HCPCS C1713 10015 - SPACER ALLOGRAFT 8D NARROW LORDOTIC WEDGE PYRAMIDAL TEETH BOTH IP/OP "$10,725.00 " "$7,936.50" $0.00 "$8,580.00" "$4,826.25" "$4,826.25" $0.00 $0.00 $0.00 "$2,235.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,235.09" $0.00 "$5,287.43" "$5,287.43" $0.00 "$5,362.50" "$8,494.20" "$8,580.00" $0.00 $0.00 "$1,678.46" $0.00 $0.00 "$1,707.42" $0.00 $0.00 $0.00 $0.00 $0.00 10016 SUP HCPCS C1713 010016 - PLATE BONE 3MM STANDARD STR 14 HOLE TIMESH TITANIUM CRANIAL BOTH IP/OP $490.88 $363.25 $0.00 $392.70 $220.89 $220.89 $0.00 $0.00 $0.00 $102.31 $364.33 $364.33 $0.00 $0.00 $102.30 $0.00 $290.35 $290.35 $0.00 $245.44 $388.78 $392.70 $0.00 $0.00 $76.82 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $0.00 10019 SUP HCPCS C1713 10019 - SPACER ALLOGRAFT 8D NARROW PYRAMID LORDOTIC WEDGE 23-27MMX19 BOTH IP/OP "$10,725.00 " "$7,936.50" $0.00 "$8,580.00" "$4,826.25" "$4,826.25" $0.00 $0.00 $0.00 "$2,235.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,235.09" $0.00 "$5,287.43" "$5,287.43" $0.00 "$5,362.50" "$8,494.20" "$8,580.00" $0.00 $0.00 "$1,678.46" $0.00 $0.00 "$1,707.42" $0.00 $0.00 $0.00 $0.00 $0.00 10040 SUP HCPCS C1713 010040 - SCREW 010040 X-DRV 1.0MM 4MM 6 BOTH IP/OP $105.19 $77.84 $0.00 $84.15 $47.33 $47.33 $0.00 $0.00 $0.00 $21.92 $78.07 $78.07 $0.00 $0.00 $21.92 $0.00 $62.22 $62.22 $0.00 $52.59 $83.31 $84.15 $0.00 $0.00 $16.46 $0.00 $0.00 $16.75 $0.00 $0.00 $0.00 $0.00 $0.00 10060 SUP HCPCS C1713 010060 - SCREW 010060 X-DRV 1.0MM 6MM 6 BOTH IP/OP $106.60 $78.88 $0.00 $85.28 $47.97 $47.97 $0.00 $0.00 $0.00 $22.22 $79.12 $79.12 $0.00 $0.00 $22.22 $0.00 $63.06 $63.06 $0.00 $53.30 $84.43 $85.28 $0.00 $0.00 $16.68 $0.00 $0.00 $16.97 $0.00 $0.00 $0.00 $0.00 $0.00 10237 SUP Custom 27203010 10237 - KIT GASTROSTOMY 11 .035IN J LP 18FR 22FR INTROD NEEDLE FEED BOTH IP/OP $584.88 $432.81 $0.00 $467.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $434.09 $434.09 $0.00 $0.00 $121.89 $0.00 $0.00 $0.00 $0.00 $292.44 $438.37 $467.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10241 SUP HCPCS C1713 010241 - CATHETER ANGIOGRAPHIC STR PIGTAIL CURVE 6FR 110CM 6 SIDEHOLE BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 10242 SUP HCPCS C1713 010242 - CATHETER ANGIOGRAPHIC 145D VAN TASSEL ANGLED PIGTAIL CURVE 6 BOTH IP/OP $388.88 $287.77 $0.00 $311.10 $174.99 $174.99 $0.00 $0.00 $0.00 $81.05 $288.62 $288.62 $0.00 $0.00 $81.04 $0.00 $230.02 $230.02 $0.00 $194.44 $307.99 $311.10 $0.00 $0.00 $60.86 $0.00 $0.00 $61.91 $0.00 $0.00 $0.00 $0.00 $0.00 10250 SUP Custom 27203010 10250 - KIT GASTROSTOMY 12FR INTROD LAPSCOP MIC-KEY BOTH IP/OP $584.88 $432.81 $0.00 $467.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $434.09 $434.09 $0.00 $0.00 $121.89 $0.00 $0.00 $0.00 $0.00 $292.44 $463.22 $467.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10354 SUP Custom 27203010 FUNNEL CNTRF FLTR CRD SL CAP SMPL CHMBR .4ML CYFNL CYTSPN BOTH IP/OP $207.05 $153.22 $0.00 $165.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.53 $163.98 $165.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10355 SUP Custom 27203010 FUNNEL CNTRF SGL FLTR CRD SL CAP .4ML CYFNL DISP WHT BOTH IP/OP $3.00 $2.22 $0.00 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.50 $2.38 $2.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10400 SUP Custom 27203010 REAGENT NEIS HMPHLS API ID CRD ANALY BOTH IP/OP $9.80 $7.25 $0.00 $7.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.90 $7.76 $7.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12110 SUP HCPCS C1887 12110 - CATHETER PERFUSION 10IN VENT DLP PVC PEDIATRIC 10FR BOTH IP/OP $1.25 $0.93 $0.00 $919.56 $624.15 $624.15 $0.00 $0.00 $0.00 $0.00 $0.93 $0.93 $0.00 $0.00 $0.26 $0.00 $0.00 $0.00 $0.00 $574.73 $910.36 $919.56 $0.00 $0.00 $179.89 $0.00 $0.00 $182.99 $0.00 $0.00 $0.00 $0.00 $0.00 13030 SUP HCPCS C1713 013030 - SCREW 013030 X-DRV RESCUE 3MM 6PK BOTH IP/OP $99.52 $73.64 $0.00 $79.62 $44.78 $44.78 $0.00 $0.00 $0.00 $20.74 $73.86 $73.86 $0.00 $0.00 $20.74 $0.00 $58.87 $58.87 $0.00 $49.76 $78.82 $79.62 $0.00 $0.00 $15.58 $0.00 $0.00 $15.84 $0.00 $0.00 $0.00 $0.00 $0.00 13050 SUP HCPCS C1713 013050 - SCREW 013050 X-DRV RESCUE 5MM 6PK BOTH IP/OP $105.19 $77.84 $0.00 $84.15 $47.33 $47.33 $0.00 $0.00 $0.00 $21.92 $78.07 $78.07 $0.00 $0.00 $21.92 $0.00 $62.22 $62.22 $0.00 $52.59 $83.31 $84.15 $0.00 $0.00 $16.46 $0.00 $0.00 $16.75 $0.00 $0.00 $0.00 $0.00 $0.00 13186 SUP HCPCS C1713 "13186 - ENDOBUTTON FIXATION BUTTON, 4X 12MM" BOTH IP/OP $452.40 $334.78 $0.00 $361.92 $203.58 $203.58 $0.00 $0.00 $0.00 $94.29 $335.77 $335.77 $0.00 $0.00 $94.28 $0.00 $267.59 $267.59 $0.00 $226.20 $358.30 $361.92 $0.00 $0.00 $70.80 $0.00 $0.00 $72.02 $0.00 $0.00 $0.00 $0.00 $0.00 14000 SUP Custom 27203010 14000 - SET CRDPLG .25IN 15IN DLP MLT 4 LG ADPR SLIP CNCT BOTH IP/OP $49.48 $36.62 $0.00 $39.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.74 $39.19 $39.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14070 SUP Custom 27203010 14070 - SYSTEM 8 1/8-11.75IN OST C2000- ML MAXI DRAIN PORT BOTH IP/OP $42.70 $31.60 $0.00 $104.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.69 $31.69 $0.00 $0.00 $8.90 $0.00 $0.00 $0.00 $0.00 $65.01 $102.98 $104.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15030 SUP HCPCS C1713 015030 - SCREW BN 1.5MM 3MM TIMESH XDR TI CRNM BOTH IP/OP $92.44 $68.41 $0.00 $73.95 $41.60 $41.60 $0.00 $0.00 $0.00 $19.27 $68.61 $68.61 $0.00 $0.00 $19.26 $0.00 $54.68 $54.68 $0.00 $46.22 $73.21 $73.95 $0.00 $0.00 $14.47 $0.00 $0.00 $14.72 $0.00 $0.00 $0.00 $0.00 $0.00 15031 SUP HCPCS C1713 015031 - SCREW 015031 SELF TAPPING 1.5X3MM 1 BOTH IP/OP $104.13 $77.06 $0.00 $83.30 $46.86 $46.86 $0.00 $0.00 $0.00 $21.70 $77.28 $77.28 $0.00 $0.00 $21.70 $0.00 $61.59 $61.59 $0.00 $52.06 $82.47 $83.30 $0.00 $0.00 $16.30 $0.00 $0.00 $16.58 $0.00 $0.00 $0.00 $0.00 $0.00 15040 SUP HCPCS C1713 015040 - PLATE BN STRG 4MM TIMESH 1 HLE/HD 1 HL SHFT TI CRNM 1.5MM BOTH IP/OP $99.17 $73.39 $0.00 $79.33 $44.63 $44.63 $0.00 $0.00 $0.00 $20.67 $73.60 $73.60 $0.00 $0.00 $20.67 $0.00 $58.66 $58.66 $0.00 $49.58 $78.54 $79.33 $0.00 $0.00 $15.52 $0.00 $0.00 $15.79 $0.00 $0.00 $0.00 $0.00 $0.00 15041 SUP HCPCS C1713 015041 - SCREW 015041 SELF TAPPING 1.5X4MM 1 BOTH IP/OP $106.25 $78.63 $0.00 $85.00 $47.81 $47.81 $0.00 $0.00 $0.00 $22.15 $78.86 $78.86 $0.00 $0.00 $22.14 $0.00 $62.85 $62.85 $0.00 $53.13 $84.15 $85.00 $0.00 $0.00 $16.63 $0.00 $0.00 $16.92 $0.00 $0.00 $0.00 $0.00 $0.00 15050 SUP HCPCS C1713 015050 - SCREW 015050 X-DRV 1.5MM 5MM 6 BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 15051 SUP HCPCS C1713 015051 - SCREW 015051 SELF TAPPING 1.5X5MM 1 BOTH IP/OP $104.13 $77.06 $0.00 $83.30 $46.86 $46.86 $0.00 $0.00 $0.00 $21.70 $77.28 $77.28 $0.00 $0.00 $21.70 $0.00 $61.59 $61.59 $0.00 $52.06 $82.47 $83.30 $0.00 $0.00 $16.30 $0.00 $0.00 $16.58 $0.00 $0.00 $0.00 $0.00 $0.00 15060 SUP HCPCS C1713 015060 - SCREW 015060 X-DRV 1.5MM 6MM 6 BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 15070 SUP HCPCS C1713 015070 - SCREW 015070 X DRV 1.5MM 7MM 6 BOTH IP/OP $99.52 $73.64 $0.00 $79.62 $44.78 $44.78 $0.00 $0.00 $0.00 $20.74 $73.86 $73.86 $0.00 $0.00 $20.74 $0.00 $58.87 $58.87 $0.00 $49.76 $78.82 $79.62 $0.00 $0.00 $15.58 $0.00 $0.00 $15.84 $0.00 $0.00 $0.00 $0.00 $0.00 15080 SUP HCPCS C1713 015080 - SCREW 015080 X-DRV 1.5MM 8MM 6 BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 15090 SUP HCPCS C1713 015090 - SCREW BN 1.5MM 9MM XDR BOTH IP/OP $99.52 $73.64 $0.00 $79.62 $44.78 $44.78 $0.00 $0.00 $0.00 $20.74 $73.86 $73.86 $0.00 $0.00 $20.74 $0.00 $58.87 $58.87 $0.00 $49.76 $78.82 $79.62 $0.00 $0.00 $15.58 $0.00 $0.00 $15.84 $0.00 $0.00 $0.00 $0.00 $0.00 15110 SUP HCPCS C1713 015110 - SCREW 015110 X-DRV 1.5MM 11MM 6 BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 15170 SUP Custom 27203010 015170 - STAPLER INTNL 57MMX.17MM LACTOMER ABS STPL SQZ BOTH IP/OP "$1,226.30 " $907.46 $0.00 $981.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $910.16 $910.16 $0.00 $0.00 $255.56 $0.00 $0.00 $0.00 $0.00 $613.15 $971.23 $981.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15850 SUP HCPCS C1758 0015850 - BAG DRN 9.5IN 19OZ STRL LTX 2 ADJ BELT ADPR NTR RBR BILE BOTH IP/OP $253.80 $187.81 $0.00 $203.04 $137.81 $137.81 $0.00 $0.00 $0.00 $52.90 $188.37 $188.37 $0.00 $0.00 $52.89 $0.00 $150.12 $150.12 $0.00 $126.90 $201.01 $203.04 $0.00 $0.00 $39.72 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 17061 SUP Custom 27203010 PUMP BRST 1 HND FLEXSHIELD BOTH IP/OP $55.15 $40.81 $0.00 $44.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.58 $43.68 $44.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17130 SUP HCPCS C1713 017130 - PLATE BN CRV .6MM SLVR TRAUMAONE 10 HL TI ORBT FLR 1.5MM SCR BOTH IP/OP $540.00 $399.60 $0.00 $432.00 $243.00 $243.00 $0.00 $0.00 $0.00 $112.55 $400.79 $400.79 $0.00 $0.00 $112.54 $0.00 $319.41 $319.41 $0.00 $270.00 $427.68 $432.00 $0.00 $0.00 $84.51 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $0.00 17152 SUP Custom 27203010 KIT BRSTPMP 1 HND DUAL HYGIENIKIT BOTH IP/OP $92.10 $68.15 $0.00 $73.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.05 $72.94 $73.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17207 SUP HCPCS C1762 017207 - GRAFT BONE CORT CNC SPCR ANT CERV INTRBD FS 7MM BOTH IP/OP "$2,967.50 " "$2,195.95" $0.00 "$2,374.00" $0.00 $0.00 $0.00 $0.00 $0.00 $618.50 "$2,202.48" "$2,202.48" $0.00 $0.00 $618.43 $0.00 "$1,462.98" "$1,462.98" $0.00 "$1,483.75" "$2,350.26" "$2,374.00" $0.00 $0.00 $464.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17208 SUP HCPCS C1789 017208 - SPACER ALGRF 5D LRDTC OVL 12X14X8MM FRZDR MNLTH LG CNTR LUM BOTH IP/OP "$2,637.50 " "$1,951.75" $0.00 "$2,110.00" "$1,186.88" "$1,186.88" $0.00 $0.00 $0.00 $549.72 "$1,957.55" "$1,957.55" $0.00 $0.00 $549.66 $0.00 "$1,300.29" "$1,300.29" $0.00 "$1,318.75" "$2,088.90" "$2,110.00" $0.00 $0.00 $412.77 $0.00 $0.00 $419.89 $0.00 $0.00 $0.00 $0.00 $0.00 17251 SUP HCPCS C1769 17251 - PLATINUM PLUS GUIDEWIRE .014X300CM WIRE BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $190.05 $190.05 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 17614 SUP Custom 27203010 17614 - STAPLER INTNL 55X4.8MM TI ENDSCP LNR CTR SQZ HNDL STRL LF BOTH IP/OP $493.05 $364.86 $0.00 $394.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.94 $365.94 $0.00 $0.00 $102.75 $0.00 $0.00 $0.00 $0.00 $246.52 $390.50 $394.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18030 SUP HCPCS C1713 018030 - SCREW 018030 X-DRV RESCUE 3MM 6PK BOTH IP/OP $91.73 $67.88 $0.00 $73.38 $41.28 $41.28 $0.00 $0.00 $0.00 $19.12 $68.08 $68.08 $0.00 $0.00 $19.12 $0.00 $54.26 $54.26 $0.00 $45.86 $72.65 $73.38 $0.00 $0.00 $14.36 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $0.00 18031 SUP HCPCS C1713 018031 - SCREW 018031 CRUCIATE RESCUE 1.8X3MM 1 BOTH IP/OP $97.75 $72.34 $0.00 "$1,102.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.32" "$1,102.32" $0.00 $0.00 $309.52 $0.00 $57.82 $57.82 $0.00 $688.13 $77.42 "$1,101.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18050 SUP HCPCS C1713 018050 - SCREW 018050 X-DRV RESCUE 5MM 6PK BOTH IP/OP $91.73 $67.88 $0.00 $73.38 $41.28 $41.28 $0.00 $0.00 $0.00 $19.12 $68.08 $68.08 $0.00 $0.00 $19.12 $0.00 $54.26 $54.26 $0.00 $45.86 $72.65 $73.38 $0.00 $0.00 $14.36 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $0.00 18051 SUP HCPCS C1713 018051 - SCREW 018051 CRUCIATE RESCUE 1.8X5MM 1 BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 19004 SUP Custom 27203010 19004 - KIT COLOSTOMY/ILEOSTOMY 2.25- IN 2.75IN 12IN 2 PIECE DRAIN BOTH IP/OP $34.71 $25.69 $0.00 $27.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.36 $27.49 $27.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19006 SUP Custom 27203010 19006 - KIT OSTOMY 0-3.5IN 4IN 12IN 2 PIECE DRAIN LOCK N ROLL BOTH IP/OP $46.72 $34.57 $0.00 $37.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.67 $34.67 $0.00 $0.00 $9.74 $0.00 $0.00 $0.00 $0.00 $23.36 $37.00 $37.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19203 SUP Custom 27203010 19203 - KIT UROSTOMY CUT TO FIT 1.75- IN 2.25IN 9IN 2 PIECE BELT TAB BOTH IP/OP $52.03 $38.50 $0.00 $38.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.62 $38.62 $0.00 $0.00 $10.84 $0.00 $0.00 $0.00 $0.00 $4.21 $6.68 $6.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20012 SUP Custom 27203010 20012 - CANNULA PRFSN 12GA 5.5IN DLP ANTGRD STD TIP INTRO VNT LN BOTH IP/OP $2.28 $1.69 $0.00 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.69 $1.69 $0.00 $0.00 $0.48 $0.00 $0.00 $0.00 $0.00 $1.14 $1.81 $1.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20028 SUP Custom 27803010 20028 - VAD 20028 BH 12MM W/INT VENT 5.5CM BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20033 SUP HCPCS C1788 20033 - PORT 20033 3-WAY CONN W/O SILICONE BOTH IP/OP $565.25 $418.29 $0.00 $452.20 $254.36 $254.36 $0.00 $0.00 $0.00 $117.81 $419.53 $419.53 $0.00 $0.00 $117.80 $0.00 $334.35 $334.35 $0.00 $282.63 $447.68 $452.20 $0.00 $0.00 $88.46 $0.00 $0.00 $89.99 $0.00 $0.00 $0.00 $0.00 $0.00 20034 SUP Custom 27203010 20034 - KIT 20034 EDM VENTRICULAR 35CM BOTH IP/OP $712.80 $527.47 $0.00 $570.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $529.04 $529.04 $0.00 $0.00 $148.55 $0.00 $0.00 $0.00 $0.00 $356.40 $564.54 $570.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20046 SUP Custom 27803010 20046 - CATH 20046 VENT LARGE 23CM BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20116 SUP HCPCS C1758 020116 - CATH URET 6FR 70CM .038IN OP-EN BOTH IP/OP $21.38 $15.82 $0.00 $17.10 $11.61 $11.61 $0.00 $0.00 $0.00 $4.46 $15.86 $15.86 $0.00 $0.00 $4.45 $0.00 $12.64 $12.64 $0.00 $10.69 $16.93 $17.10 $0.00 $0.00 $3.35 $0.00 $0.00 $3.40 $0.00 $0.00 $0.00 $0.00 $0.00 20141 SUP Custom 27203010 20141 - DRESSING BURN 5X4IN ANTIMICROBIAL FAST ACT BARRIER CONTROL BOTH IP/OP $39.92 $29.54 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.96 $31.62 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20201 SUP Custom 27203010 20201 - DRESSING BURN ANBCTRL FAST ACT VRSTL NCRSTLN SLVR 8X4IN STRL BOTH IP/OP $121.69 $90.05 $0.00 $97.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.32 $90.32 $0.00 $0.00 $25.36 $0.00 $0.00 $0.00 $0.00 $60.85 $96.38 $97.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20230 SUP Custom 27203010 REAGENT .85% SAL API 5ML ANALY BOTH IP/OP $160.88 $119.05 $0.00 $128.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.44 $127.42 $128.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20301 SUP Custom 27203010 FORMULA ENFAMIL AR RTU BOTH IP/OP $176.40 $130.54 $0.00 $141.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.20 $139.71 $141.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20401 SUP Custom 27203010 20401 - DRESSING BRN 16X16IN STRL LF ACTCT ANBCTRL FST ACT BRR CNTRL BOTH IP/OP $156.26 $115.63 $0.00 $126.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.97 $115.97 $0.00 $0.00 $32.56 $0.00 $0.00 $0.00 $0.00 $79.30 $125.61 $126.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20421 SUP Custom 27203010 MATTRESS PT 16X10IN TRNWRMR PVC PORT NELCTR HEAT SRC INF BOTH IP/OP $57.78 $42.76 $0.00 $46.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.88 $42.88 $0.00 $0.00 $12.04 $0.00 $0.00 $0.00 $0.00 $28.89 $45.76 $46.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20934 SUP Custom 27203010 020934 - BAG OST GTCH SNTH UNV 4IN 14-14.5IN 2 PC DRAIN SRFT FLNG TPE BOTH IP/OP $81.06 $59.98 $0.00 $64.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.16 $60.16 $0.00 $0.00 $16.89 $0.00 $0.00 $0.00 $0.00 $40.53 $64.20 $64.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21004 SUP Custom 27803010 21004 - CATH 21004 PERT SML OPEN END W/SLITS BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $0.00 $0.00 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21029 SUP Custom 27803010 21029 - INLET 21029 V A D 12MM W/BOTTOM INLET BOTH IP/OP "$1,082.60 " $801.12 $0.00 $803.51 $0.00 $0.00 $0.00 $0.00 $0.00 $225.64 $803.51 $803.51 $0.00 $0.00 $225.61 $0.00 $640.36 $640.36 $0.00 $465.50 $737.35 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21038 SUP HCPCS C1769 21038 - GUIDEWIRE 21038 TEFLON COATED 100CM BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $116.07 $116.07 $0.00 $0.00 $0.00 $44.55 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $126.43 $126.43 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $33.45 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $0.00 21066 SUP Custom 27803010 21066 - CONNECTOR 21066 LUMBOPERITONEAL STRT CSF BOTH IP/OP $178.13 $131.82 $0.00 $142.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.20 $132.20 $0.00 $0.00 $37.12 $0.00 $0.00 $0.00 $0.00 $89.06 $141.08 $142.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22013 SUP Custom 27803010 22013 - CATH 22013 PER SML OPEN 90CM NO SLIT BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $0.00 $0.00 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22014 SUP Custom 27803010 22014 - CATH 22014 PER STD OPEN 96CM NO SLIT BOTH IP/OP $967.50 $715.95 $0.00 $718.08 $0.00 $0.00 $0.00 $0.00 $0.00 $201.65 $718.08 $718.08 $0.00 $0.00 $201.63 $0.00 $572.28 $572.28 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22039 SUP Custom 27803010 22039 - VAD 22039 12MM BOTH IP/OP $888.25 $657.31 $0.00 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.26 $659.26 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $444.13 $703.49 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22063 SUP Custom 27803010 22063 - CONNECTOR 22063 STEPDOWN W/TUBING STD BOTH IP/OP "$1,596.58 " "$1,181.47" $0.00 "$1,184.98" $0.00 $0.00 $0.00 $0.00 $0.00 $332.77 "$1,184.98" "$1,184.98" $0.00 $0.00 $332.73 $0.00 $944.37 $944.37 $0.00 $102.13 $161.77 $163.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22104 SUP Custom 27803010 22104 - VAD 22104 NEONATE RES W/BOTTOM INLET BOTH IP/OP $888.25 $657.31 $0.00 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.26 $659.26 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $444.13 $703.49 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22150 SUP Custom 27203010 22150 - DEVICE BLWR/MSTR STRL LF CLRVW TUBE SET N180 N185 BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $0.00 $0.00 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22355 SUP HCPCS C1713 22355 - ROD OST 64MM STRL LF LOOP DISP SFN 70MM FLNG BOTH IP/OP $3.65 $2.70 $0.00 $2.96 $1.66 $1.66 $0.00 $0.00 $0.00 $0.76 $2.71 $2.71 $0.00 $0.00 $0.76 $0.00 $2.16 $2.16 $0.00 $1.85 $2.93 $2.96 $0.00 $0.00 $0.58 $0.00 $0.00 $0.59 $0.00 $0.00 $0.00 $0.00 $0.00 22356 SUP HCPCS C1713 22356 - ROD OST 90MM STRL LF SFN CNVTC LOOP DISP 4IN FLNG SKN BRR BOTH IP/OP $37.00 $27.38 $0.00 $29.60 $16.65 $16.65 $0.00 $0.00 $0.00 $7.71 $27.46 $27.46 $0.00 $0.00 $7.71 $0.00 $21.88 $21.88 $0.00 $18.50 $29.30 $29.60 $0.00 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 23014 SUP Custom 27203010 23014 - KIT 23014 EDM VENTRICULAR BOTH IP/OP $326.40 $241.54 $0.00 $261.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.25 $242.25 $0.00 $0.00 $68.02 $0.00 $0.00 $0.00 $0.00 $163.20 $258.51 $261.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23021 SUP Custom 27803010 23021 - CONNECTOR 23021 LUERLOCK TO FIT 1.5MM ID BOTH IP/OP $153.60 $113.66 $0.00 $122.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.00 $114.00 $0.00 $0.00 $32.01 $0.00 $0.00 $0.00 $0.00 $76.80 $121.65 $122.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23045 SUP Custom 27203010 23045 - EDM 23045 PATIENT LINE 91CM W/FEM LR BOTH IP/OP $177.60 $131.42 $0.00 $142.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.81 $131.81 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $88.80 $140.66 $142.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23047 SUP Custom 27803010 23047 - CATH 23047 PERIT STD OE W/SLITS 120 BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $0.00 $0.00 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23067 SUP HCPCS C2619 23067 - ADAPTER 23067 PREIMPLANT TEST SNAP ASSY BOTH IP/OP $225.63 $166.97 $0.00 $180.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.46 $167.46 $0.00 $0.00 $47.02 $0.00 $0.00 $0.00 $0.00 $112.81 $178.70 $180.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23069 SUP Custom 27803010 23069 - SHUNT 23069 L-P K-TUBE W/PROX TIP BOTH IP/OP "$2,272.88 " "$1,681.93" $0.00 "$1,818.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,686.93" "$1,686.93" $0.00 $0.00 $473.67 $0.00 $0.00 $0.00 $0.00 "$1,136.44" "$1,800.12" "$1,818.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23075 SUP Custom 27803010 23075 - CATHETER 23075 VENTRICULAR POLYURETHANE BOTH IP/OP "$3,479.38 " "$2,574.74" $0.00 "$2,783.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,582.39" "$2,582.39" $0.00 $0.00 $725.10 $0.00 $0.00 $0.00 $0.00 "$1,739.69" "$2,755.67" "$2,783.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23076 SUP Custom 27803010 23076 - CATHETER 23076 PERITITONEAL POLYURETHANE BOTH IP/OP "$2,470.00 " "$1,827.80" $0.00 "$1,976.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,833.23" "$1,833.23" $0.00 $0.00 $514.75 $0.00 $0.00 $0.00 $0.00 "$1,235.00" "$1,956.24" "$1,976.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23092 SUP HCPCS C1750 23092 - CATHETER DLYS STD 120CM STRL BA IMPRG OP-EN WL SLT BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $188.10 $188.10 $0.00 $0.00 $0.00 $87.12 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $247.25 $247.25 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $65.42 $0.00 $0.00 $66.55 $0.00 $0.00 $0.00 $0.00 $0.00 23093 SUP Custom 27803010 23093 - VALVE 23093 CONT. REG. LOW-LOW BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24010 SUP Custom 27803010 24010 - CATHETER 24010 C/P STD 120CM BOTH IP/OP $410.88 $304.05 $0.00 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.95 $304.95 $0.00 $0.00 $85.63 $0.00 $0.00 $0.00 $0.00 $205.44 $325.42 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24048 SUP Custom 27803010 24048 - VALVE 24048 DELTA RGL PL 0.5 BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24052 SUP Custom 27203010 24052 - KIT 24052 VENTRICULOSTOMY RES 18MM BOTH IP/OP $693.50 $513.19 $0.00 $554.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $514.72 $514.72 $0.00 $0.00 $144.53 $0.00 $0.00 $0.00 $0.00 $346.75 $549.25 $554.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24053 SUP Custom 27803010 24053 - CHAMBER 24053 DELTA BOTH IP/OP "$2,690.88 " "$1,991.25" $0.00 "$5,472.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,997.17" "$1,997.17" $0.00 $0.00 $560.78 $0.00 $0.00 $0.00 $0.00 "$1,345.44" "$2,131.18" "$2,152.70" $0.00 $0.00 "$5,472.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24084 SUP Custom 27803010 24084 - RESVR 24084 12MM W INLET AND OUTLET CONN BOTH IP/OP $888.25 $657.31 $0.00 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.26 $659.26 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $444.13 $703.49 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24085 SUP Custom 27803010 24085 - DOME 24085 SNAP VENTRIC W/15CM TUBE BOTH IP/OP $605.63 $448.17 $0.00 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.49 $449.49 $0.00 $0.00 $126.21 $0.00 $0.00 $0.00 $0.00 $302.81 $479.66 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24094 SUP Custom 27803010 24094 - CATH 24094 VENT STD INCL SNAP BASE BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24114 SUP Custom 27803010 24114 - CONNECTOR SHNT .7MM CSF LL INTGR PLG BOTH IP/OP $187.20 $138.53 $0.00 $149.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.94 $138.94 $0.00 $0.00 $39.01 $0.00 $0.00 $0.00 $0.00 $93.60 $148.26 $149.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24146 SUP Custom 27203010 24146 - EDMS 24146 BECKER NO Y-SITE BOTH IP/OP $547.20 $404.93 $0.00 $437.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $406.13 $406.13 $0.00 $0.00 $114.04 $0.00 $0.00 $0.00 $0.00 $273.60 $433.38 $437.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24147 SUP Custom 27803010 24147 - VALVE 24147 DELTA SML PL 0.5 BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24148 SUP Custom 27803010 24148 - CATH 24148 C/P STD 110CM NO MARKERS BOTH IP/OP $410.88 $304.05 $0.00 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.95 $304.95 $0.00 $0.00 $85.63 $0.00 $0.00 $0.00 $0.00 $205.44 $325.42 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24154 SUP Custom 27803010 24154 - CATH 24154 VENT STD TRNS W/STRIPE BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.41 $264.41 $0.00 $0.00 $74.24 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24605 SUP HCPCS C1758 024605 - CATH URET 4.8FR 8FR 70CM CONE TIP MCK BOTH IP/OP $28.54 $21.12 $0.00 $34.38 $15.50 $15.50 $0.00 $0.00 $0.00 $5.95 $21.18 $21.18 $0.00 $0.00 $5.95 $0.00 $34.38 $34.38 $0.00 $14.27 $22.60 $22.83 $0.00 $0.00 $4.47 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 24605 SUP HCPCS C1758 24605 - CATH URET 4.8FR 8FR 70CM CONE TIP MCK BOTH IP/OP $28.54 $21.12 $0.00 $34.38 $15.50 $15.50 $0.00 $0.00 $0.00 $5.95 $21.18 $21.18 $0.00 $0.00 $5.95 $0.00 $34.38 $34.38 $0.00 $14.27 $23.44 $22.83 $0.00 $0.00 $4.47 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 24712 SUP Custom 27803010 24712 - TUBE VNT T FIRM FLNG 1.14MM 9.5MM 12MM GOODE SFT SIL EAR BOTH IP/OP $56.75 $42.00 $0.00 $45.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.12 $42.12 $0.00 $0.00 $11.83 $0.00 $0.00 $0.00 $0.00 $28.38 $44.95 $45.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25020 SUP Custom 27203010 OTOSCOPE 3.5V DX SPCLA HAL LGHT WA LEN FBROP SL SYS EXAM BOTH IP/OP $177.50 $131.35 $0.00 $142.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.75 $140.58 $142.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25024 SUP Custom 27803010 25024 - CATH 25024 PERIT STD TRNS W/STRPE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,298.85" $0.00 $0.00 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25027 SUP Custom 27803010 25027 - CONNECTOR 25027 STRT STAINLESS STEEL IMP BOTH IP/OP $204.25 $151.15 $0.00 $163.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.59 $151.59 $0.00 $0.00 $42.57 $0.00 $0.00 $0.00 $0.00 $102.13 $161.77 $163.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25030 SUP Custom 27203010 25030 - KIT 25030 EDM 46115 46124 46126 BOTH IP/OP $513.60 $380.06 $0.00 $410.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $381.19 $381.19 $0.00 $0.00 $107.03 $0.00 $0.00 $0.00 $0.00 $256.80 $406.77 $410.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25068 SUP Custom 27203010 25068 - KIT 25068 EDM 46124 46126 BOTH IP/OP $290.40 $214.90 $0.00 $232.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.53 $215.53 $0.00 $0.00 $60.52 $0.00 $0.00 $0.00 $0.00 $145.20 $230.00 $232.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25077 SUP Custom 27803010 25077 - TAB FX 1.5MM SIL BOTH IP/OP "$3,601.78 " "$2,665.32" $0.00 "$2,673.24" $0.00 $0.00 $0.00 $0.00 $0.00 $750.70 "$2,673.24" "$2,673.24" $0.00 $0.00 $750.61 $0.00 "$1,775.68" "$1,775.68" $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25104 SUP Custom 27803010 25104 - CATHETER 25104 CP STD TRANS RAD STRP 90 BOTH IP/OP $410.88 $304.05 $0.00 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.95 $304.95 $0.00 $0.00 $85.63 $0.00 $0.00 $0.00 $0.00 $205.44 $325.42 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25115 SUP Custom 27203010 REAGENT HBSAG EVOLIS BRCD ANALY BOTH IP/OP $496.25 $367.23 $0.00 $397.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.13 $393.03 $397.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25120 SUP Custom 27203010 25120 - EDMS II 25120 BECKER W/1-WAY VALVE BOTH IP/OP $628.13 $464.82 $0.00 "$2,062.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $466.19 $466.19 $0.00 $0.00 $130.90 $0.00 "$2,062.90" "$2,062.90" $0.00 $14.56 $471.40 $23.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25123 SUP HCPCS C1894 25123 - TROCAR 25123 WITH PROTECTOR SHEATH BOTH IP/OP $237.60 $175.82 $0.00 $190.08 $129.02 $129.02 $0.00 $0.00 $0.00 $49.52 $176.35 $176.35 $0.00 $0.00 $49.52 $0.00 $140.54 $140.54 $0.00 $118.80 $188.18 $190.08 $0.00 $0.00 $37.18 $0.00 $0.00 $37.83 $0.00 $0.00 $0.00 $0.00 $0.00 25173 SUP Custom 27203010 KIT IMMUN TST MCPLT EIA RBLA IGG 96 TST BOTH IP/OP $356.13 $263.54 $0.00 $284.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.06 $282.05 $284.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25175 SUP Custom 27203010 KIT IMMUN TST EIA TOXOPLASMA IGG 96 TST BOTH IP/OP $356.13 $263.54 $0.00 $284.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.06 $282.05 $284.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25177 SUP Custom 27203010 REAGENT CMV IGG AXSYM EIA 96 TST ANALY BOTH IP/OP $356.93 $264.13 $0.00 $285.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.46 $282.69 $285.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25220 SUP Custom 27203010 CONTROL ANTI HBS IGM MONOLISA EIA IMMUN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25280 SUP Custom 27203010 KIT IMMUN TST MONOLISA BRCD SEQ ANTI HBS BOTH IP/OP $552.50 $408.85 $0.00 $442.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.25 $437.58 $442.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25506 SUP Custom 27203010 025506 - STENT URET 6FR 125CM 2 PGTL CURVE URTSCP SET DRETLER BLUE BOTH IP/OP $109.68 $81.16 $0.00 $87.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.40 $81.40 $0.00 $0.00 $22.86 $0.00 $0.00 $0.00 $0.00 $54.84 $86.87 $87.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26040 SUP Custom 27203010 26040 - KIT 26040 BECKER EDMS II BOTH IP/OP $31.43 $23.26 $0.00 $660.48 $0.00 $0.00 $0.00 $0.00 $0.00 $6.55 $23.32 $23.32 $0.00 $0.00 $6.55 $0.00 $18.59 $18.59 $0.00 $412.80 $653.88 $660.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26054 SUP HCPCS C1726 26054 - DILAT VASC 4FR 20CM HYDPHI DECREASED FRCTN RADIOPQ STRL DISP BOTH IP/OP $26.25 $19.43 $0.00 $21.00 $14.25 $14.25 $0.00 $0.00 $0.00 $5.47 $19.48 $19.48 $0.00 $0.00 $5.47 $0.00 $15.53 $15.53 $0.00 $13.13 $20.79 $21.00 $0.00 $0.00 $4.11 $0.00 $0.00 $4.18 $0.00 $0.00 $0.00 $0.00 $0.00 26057 SUP Custom 27203010 26057 - EDM 26021 CATH VENT STD TRANS 25CM BOTH IP/OP $364.80 $269.95 $0.00 $291.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.75 $270.75 $0.00 $0.00 $76.02 $0.00 $0.00 $0.00 $0.00 $182.40 $288.92 $291.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26075 SUP Custom 27803010 26075 - RES 26075 VENT BH V-CATH W/7.5MM HLS BOTH IP/OP "$1,444.00 " "$1,068.56" $0.00 "$1,155.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,071.74" "$1,071.74" $0.00 $0.00 $300.93 $0.00 $0.00 $0.00 $0.00 $722.00 "$1,143.65" "$1,155.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26174 SUP Custom 27203010 CONTROL ANTI HBC IGM MONOLISA EIA IMMUN BOTH IP/OP "$1,612.50 " "$1,193.25" $0.00 "$1,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $806.25 "$1,277.10" "$1,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26186 SUP Custom 27203010 CONTROL ANTI-HBC HBV MONOLISA EIA 192 TST IMMUN BOTH IP/OP "$1,387.50 " "$1,026.75" $0.00 "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $693.75 "$1,098.90" "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26189 SUP Custom 27203010 KIT IMMUN TST MONOLISA BRCD ANTI HAV BOTH IP/OP $496.25 $367.23 $0.00 $397.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.13 $393.03 $397.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27010 SUP Custom 27803010 27010 - CATH 27010 CSF-PERIT TRANS XTRA LM BOTH IP/OP $600.88 $444.65 $0.00 $480.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.97 $445.97 $0.00 $0.00 $125.22 $0.00 $0.00 $0.00 $0.00 $300.44 $475.90 $480.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27051 SUP Custom 27803010 27051 - VAD 27051 6MM BH UNITIZED CONV. BOTH IP/OP $605.63 $448.17 $0.00 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.49 $449.49 $0.00 $0.00 $126.21 $0.00 $0.00 $0.00 $0.00 $302.81 $479.66 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27081 SUP Custom 27803010 27081 - SHUNT 27081 DELTA ASSY RGL PL 0.5 BOTH IP/OP "$3,462.75 " "$2,562.44" $0.00 "$2,770.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,570.05" "$2,570.05" $0.00 $0.00 $721.64 $0.00 $0.00 $0.00 $0.00 "$1,731.38" "$2,742.50" "$2,770.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27102 SUP Custom 27803010 27102 - VALVE 27102 CONTOURED SML LOW LOW BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27106 SUP Custom 27803010 27106 - BASE 27106 SNAP ASSY W/LARGER ID BOTH IP/OP $275.50 $203.87 $0.00 $220.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.48 $204.48 $0.00 $0.00 $57.41 $0.00 $0.00 $0.00 $0.00 $137.75 $218.20 $220.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27156 SUP Custom 27803010 27156 - CATH 27156 VENT 1.3X2.5 FXTN COLLAR BOTH IP/OP $336.00 $248.64 $0.00 $268.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.38 $249.38 $0.00 $0.00 $70.02 $0.00 $0.00 $0.00 $0.00 $168.00 $266.11 $268.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27165 SUP Custom 27803010 27165 - CATH 27165 VENT INNERVISION 1.5X2.8 BOTH IP/OP $505.88 $374.35 $0.00 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.46 $375.46 $0.00 $0.00 $105.42 $0.00 $0.00 $0.00 $0.00 $252.94 $400.66 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27211 SUP Custom 27803010 27211 - CATH 27211 VENT SLOTTED 16CM BOTH IP/OP $472.63 $349.75 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.78 $350.78 $0.00 $0.00 $98.50 $0.00 $0.00 $0.00 $0.00 $236.31 $374.32 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27240 SUP Custom 27803010 27240 - CATHETER DRN 15CM STRL LF INNERVISION DISP BOTH IP/OP $505.88 $374.35 $0.00 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.46 $375.46 $0.00 $0.00 $105.42 $0.00 $0.00 $0.00 $0.00 $252.94 $400.66 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27251 SUP Custom 27803010 27251 - CATH 27251 VENT SML 8MM OF HOLE BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.41 $264.41 $0.00 $0.00 $74.24 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27274 SUP Custom 27203010 27274 - KIT 27274 VENTRICULOSTOMY RES UNIT BOTH IP/OP $821.75 $608.10 $0.00 $657.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $609.90 $609.90 $0.00 $0.00 $171.25 $0.00 $0.00 $0.00 $0.00 $410.88 $650.83 $657.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27297 SUP Custom 27203010 27297 - KIT 27297 EDM DRAINAG VENT CATH BOTH IP/OP $806.40 $596.74 $0.00 $645.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $598.51 $598.51 $0.00 $0.00 $168.05 $0.00 $0.00 $0.00 $0.00 $403.20 $638.67 $645.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27298 SUP HCPCS C1753 27298 - V-CATH 27298 INNERVISION W/ SNAP BASE BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $361.10 $361.10 $0.00 $0.00 $0.00 $138.60 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $393.35 $393.35 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $104.07 $0.00 $0.00 $105.87 $0.00 $0.00 $0.00 $0.00 $0.00 27302 SUP Custom 27203010 27302 - DRAIN 27302 EDM LUMBAR W/120 GRAD CH BOTH IP/OP $808.80 $598.51 $0.00 $647.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.29 $600.29 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $404.40 $640.57 $647.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27303 SUP Custom 27203010 27303 - KIT 27303 EDM LUMBAR DRAINAGE OPEN BOTH IP/OP $705.60 $522.14 $0.00 $564.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.70 $523.70 $0.00 $0.00 $147.05 $0.00 $0.00 $0.00 $0.00 $352.80 $558.84 $564.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27304 SUP Custom 27203010 27304 - KIT 27304 EDM LUMBAR DRAINAGE CLOSED BOTH IP/OP $684.00 $506.16 $0.00 $547.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.66 $507.66 $0.00 $0.00 $142.55 $0.00 $0.00 $0.00 $0.00 $342.00 $541.73 $547.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27327 SUP Custom 27803010 27327 - CATH 27327 VENT STD EXTR TRANSLUC 23CM BOTH IP/OP $876.38 $648.52 $0.00 $701.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $650.45 $650.45 $0.00 $0.00 $182.64 $0.00 $0.00 $0.00 $0.00 $438.19 $694.09 $701.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27328 SUP HCPCS C1750 27328 - PCATH 27328 EXTRACTED 90 CM BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $598.50 $598.50 $0.00 $0.00 $0.00 $277.21 $987.13 $987.13 $0.00 $0.00 $277.17 $0.00 $786.70 $786.70 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $208.15 $0.00 $0.00 $211.74 $0.00 $0.00 $0.00 $0.00 $0.00 27384 SUP Custom 27803010 27384 - CATH 27384 EDM VENT 20CM W/TROCAR BOTH IP/OP $396.00 $293.04 $0.00 $316.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $293.91 $293.91 $0.00 $0.00 $82.53 $0.00 $0.00 $0.00 $0.00 $198.00 $313.63 $316.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27497 SUP Custom 27803010 27497 - SHUNT 27497 DELTA ASSY SMALL BG 0.5 BOTH IP/OP "$4,949.50 " "$3,662.63" $0.00 "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,673.52" "$3,673.52" $0.00 $0.00 "$1,031.48" $0.00 $0.00 $0.00 $0.00 "$2,474.75" "$3,920.00" "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27498 SUP Custom 27803010 27498 - SHUNT 27498 DELTA ASSY REG BG 0.5 BOTH IP/OP "$4,949.50 " "$3,662.63" $0.00 "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,673.52" "$3,673.52" $0.00 $0.00 "$1,031.48" $0.00 $0.00 $0.00 $0.00 "$2,474.75" "$3,920.00" "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27510 SUP Custom 27203010 27510 - EDMS 27510 BECKER W/ Y-SITE EURO BOTH IP/OP $520.80 $385.39 $0.00 $416.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $386.54 $386.54 $0.00 $0.00 $108.53 $0.00 $0.00 $0.00 $0.00 $260.40 $412.47 $416.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27536 SUP Custom 27803010 27536 - CATHETER 27536 PERIT W/BIOGLIDE 8 SLITS BOTH IP/OP $543.88 $402.47 $0.00 $435.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $403.66 $403.66 $0.00 $0.00 $113.34 $0.00 $0.00 $0.00 $0.00 $271.94 $430.75 $435.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27548 SUP Custom 27803010 27548 - CATH 27548 PERIT STD OE TRANS BS 120CM BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $0.00 $0.00 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27579 SUP Custom 27203010 27579 - EDMS 27579 EXACTA W/ PATIENT LINE Y-PORT BOTH IP/OP $412.80 $305.47 $0.00 $330.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.38 $306.38 $0.00 $0.00 $86.03 $0.00 $0.00 $0.00 $0.00 $206.40 $326.94 $330.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27581 SUP Custom 27203010 27581 - KIT 27581 EXACTA W/EDM VCATH 35CM BOTH IP/OP $777.60 $575.42 $0.00 $622.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.13 $577.13 $0.00 $0.00 $162.05 $0.00 $0.00 $0.00 $0.00 $388.80 $615.86 $622.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27600 SUP Custom 27803010 27600 - CATH 27600 VENT INNERVISION SLOTTED 15CM BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27613 SUP Custom 27203010 27613 - LASER 27613 EXACTA W/SCREW ASSY BOTH IP/OP "$1,024.80 " $758.35 $0.00 $819.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.61 $760.61 $0.00 $0.00 $213.57 $0.00 $0.00 $0.00 $0.00 $512.40 $811.64 $819.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27617 SUP Custom 27203010 27617 - TUBE 27617 TRANS W/STRPE STR CONN BOTH IP/OP $539.13 $398.96 $0.00 $431.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $400.14 $400.14 $0.00 $0.00 $112.35 $0.00 $0.00 $0.00 $0.00 $269.56 $426.99 $431.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27623 SUP Custom 27803010 27623 - CATH 27623 INNERV15CM XTRA HOLES 2CM BOTH IP/OP $662.63 $490.35 $0.00 $530.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $491.80 $491.80 $0.00 $0.00 $138.09 $0.00 $0.00 $0.00 $0.00 $331.31 $524.80 $530.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27628 SUP Custom 27203010 27628 - KIT 27628 CSF-VENT RES BH VCATH 15CM BOTH IP/OP $836.00 $618.64 $0.00 $668.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $620.48 $620.48 $0.00 $0.00 $174.22 $0.00 $0.00 $0.00 $0.00 $418.00 $662.11 $668.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27629 SUP HCPCS C1729 27629 - PCATH 27629 90 TRANS W/STRIPE NO SLT BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $226.97 $226.97 $0.00 $0.00 $0.00 $87.12 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $247.25 $247.25 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $65.42 $0.00 $0.00 $66.55 $0.00 $0.00 $0.00 $0.00 $0.00 27636 SUP Custom 27203010 27636 - EDM 27636 EXACTA W/BRAIDED CORD LOCK BOTH IP/OP $446.40 $330.34 $0.00 $353.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.20 $20.20 $0.00 $0.00 $5.67 $0.00 $0.00 $0.00 $0.00 $12.34 $353.55 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27637 SUP Custom 27203010 27637 - EDM 27637 VCATH TRANS OD 4.9MM W/TROC BOTH IP/OP $554.40 $410.26 $0.00 $443.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.48 $411.48 $0.00 $0.00 $115.54 $0.00 $0.00 $0.00 $0.00 $277.20 $439.08 $443.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27654 SUP Custom 27203010 27654 - BAG 27654 EXACTA W/DRAINPORT GLUED ON BOTH IP/OP $336.00 $248.64 $0.00 $268.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.38 $249.38 $0.00 $0.00 $70.02 $0.00 $0.00 $0.00 $0.00 $168.00 $266.11 $268.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27659 SUP Custom 27203010 27659 - EDM 27659 V/CATHETER 20CM LENGTH MARKER BOTH IP/OP $436.80 $323.23 $0.00 $345.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $0.00 $0.00 $1.25 $0.00 $0.00 $0.00 $0.00 $3.00 $345.95 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27664 SUP Custom 27803010 27664 - RES 27664 CSF-VENT 12MM CONV BTTM INLET BOTH IP/OP $888.25 $657.31 $0.00 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.26 $659.26 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $444.13 $703.49 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27666 SUP Custom 27203010 27666 - EDM 27666 EXCTA W GLUE STPCK GR PT LN BOTH IP/OP $400.80 $296.59 $0.00 $320.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.47 $297.47 $0.00 $0.00 $83.53 $0.00 $0.00 $0.00 $0.00 $200.40 $317.43 $320.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27673 SUP Custom 27203010 27673 - KIT 27673 EXACTA W/EDM VCATH BIOGL 35CM BOTH IP/OP $859.20 $635.81 $0.00 $687.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $637.70 $637.70 $0.00 $0.00 $179.06 $0.00 $0.00 $0.00 $0.00 $429.60 $680.49 $687.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27695 SUP Custom 27803010 27695 - CATH 27695 EDM VENT TRANS W/STRIPE 35CM BOTH IP/OP $451.20 $333.89 $0.00 $357.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.88 $334.88 $0.00 $0.00 $94.03 $0.00 $0.00 $0.00 $0.00 $3.86 $357.35 $6.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27702 SUP Custom 27203010 27702 - EDMS 27702 EURO BECKER II GR PT LN BOTH IP/OP $556.80 $412.03 $0.00 $445.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.26 $413.26 $0.00 $0.00 $116.04 $0.00 $0.00 $0.00 $0.00 $278.40 $440.99 $445.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27703 SUP HCPCS C1729 27703 - CATHETER DRN LG 35CM STRL LL CNCT LGTH MRKNG VNTRC BOTH IP/OP $424.80 $314.35 $0.00 $339.84 $230.67 $230.67 $0.00 $0.00 $0.00 $88.54 $315.29 $315.29 $0.00 $0.00 $88.53 $0.00 $251.27 $251.27 $0.00 $212.40 $336.44 $339.84 $0.00 $0.00 $66.48 $0.00 $0.00 $67.63 $0.00 $0.00 $0.00 $0.00 $0.00 27705 SUP Custom 27803010 27705 - CATH 27705 EDM NUM LNGTHMARK BIO 35CM BOTH IP/OP $460.80 $340.99 $0.00 $368.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.01 $342.01 $0.00 $0.00 $96.03 $0.00 $0.00 $0.00 $0.00 $230.40 $364.95 $368.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27710 SUP Custom 27803010 27710 - CATH 27710 EDM NUM LNGTHMRK BIO 35CM BOTH IP/OP $492.00 $364.08 $0.00 $393.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.16 $365.16 $0.00 $0.00 $102.53 $0.00 $0.00 $0.00 $0.00 $246.00 $389.66 $393.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27725 SUP Custom 27803010 27725 - CATH 27725 VENT 8MM HLS NUM LM 23CM BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.41 $264.41 $0.00 $0.00 $74.24 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27726 SUP Custom 27803010 27726 - CATH 27726 VENT 8MM HLS NUM LM 23CM BIO BOTH IP/OP $513.00 $379.62 $0.00 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.75 $380.75 $0.00 $0.00 $106.91 $0.00 $0.00 $0.00 $0.00 $256.50 $406.30 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27732 SUP Custom 27203010 27732 - EDM 27732 EXACTA W/NDL-LS INJ. ST W/CAP BOTH IP/OP $472.80 $349.87 $0.00 $378.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.91 $350.91 $0.00 $0.00 $98.53 $0.00 $0.00 $0.00 $0.00 $236.40 $374.46 $378.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27739 SUP Custom 27803010 27739 - SHUNT 27739 STRATA NSC SNAP SML 120CM BOTH IP/OP "$10,361.15 " "$7,667.25" $0.00 "$8,288.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,159.26" $0.00 $0.00 $0.00 $0.00 "$5,180.58" "$8,206.03" "$8,288.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27740 SUP Custom 27803010 27740 - SHUNT 27740 STRATA NSC SNAP REG 120CM BOTH IP/OP "$10,361.15 " "$7,667.25" $0.00 "$8,288.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,159.26" $0.00 $0.00 $0.00 $0.00 "$5,180.58" "$8,206.03" "$8,288.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27771 SUP Custom 27803010 27771 - CATH 27771 VENTR EDM STD W/L-MARKERS BOTH IP/OP $374.40 $277.06 $0.00 $299.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.88 $277.88 $0.00 $0.00 $78.02 $0.00 $0.00 $0.00 $0.00 $187.20 $296.52 $299.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27779 SUP Custom 27203010 27779 - EDMS 27779 BECKER BC NDLESS BOND CONN BOTH IP/OP $549.60 $406.70 $0.00 $439.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.91 $407.91 $0.00 $0.00 $114.54 $0.00 $0.00 $0.00 $0.00 $274.80 $435.28 $439.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27781 SUP Custom 27803010 27781 - CATH 27781 INNERV 3 SETS FLOW HLS 23CM BOTH IP/OP $840.75 $622.16 $0.00 $672.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $624.00 $624.00 $0.00 $0.00 $175.21 $0.00 $0.00 $0.00 $0.00 $420.38 $665.87 $672.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27785 SUP Custom 27203010 27785 - EDMS 27785 EXACTA 50ML BC NDLESS INJ BOTH IP/OP $475.20 $351.65 $0.00 $380.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.69 $352.69 $0.00 $0.00 $99.03 $0.00 $0.00 $0.00 $0.00 $237.60 $376.36 $380.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27786 SUP Custom 27803010 27786 - SHUNT 27786 STRATA NSC UNI-KIT SML BIOGL BOTH IP/OP "$10,114.40 " "$7,484.66" $0.00 "$8,010.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,107.84" $0.00 $0.00 $0.00 $0.00 "$1,136.00" "$8,010.60" $908.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27787 SUP Custom 27803010 27787 - SHUNT 27787 STRATA NSC UNI-KIT REG BIOGL BOTH IP/OP "$10,114.40 " "$7,484.66" $0.00 "$8,091.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,107.84" $0.00 $0.00 $0.00 $0.00 "$5,057.20" "$8,010.60" "$8,091.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27788 SUP Custom 27803010 27788 - SHUNT 27788 STRATA NSC SNAP ASSY SM BG BOTH IP/OP "$11,202.45 " "$8,289.81" $0.00 "$8,961.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,334.59" $0.00 $0.00 $0.00 $0.00 "$5,601.23" "$8,872.34" "$8,961.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27789 SUP Custom 27803010 27789 - SHUNT 27789 STRATA NSC SNAP ASSY RG BG BOTH IP/OP "$11,202.45 " "$8,289.81" $0.00 "$8,961.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,334.59" $0.00 $0.00 $0.00 $0.00 "$5,601.23" "$8,872.34" "$8,961.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27794 SUP Custom 27803010 27794 - NSC 27794 N/A STRATA SNAPSHNT NO FLANGE BOTH IP/OP "$10,361.15 " "$7,667.25" $0.00 "$8,288.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,159.26" $0.00 $0.00 $0.00 $0.00 "$5,180.58" "$8,206.03" "$8,288.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27795 SUP Custom 27203010 27795 - EDMS 27795 EXACTA 100ML CATH BOTH IP/OP $775.20 $573.65 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.35 $575.35 $0.00 $0.00 $161.55 $0.00 $0.00 $0.00 $0.00 $387.60 $613.96 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27811 SUP Custom 27203010 27811 - EDMS 27811 BECKER GRN PL VCATH BOTH IP/OP $792.00 $586.08 $0.00 $633.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $587.82 $587.82 $0.00 $0.00 $165.05 $0.00 $0.00 $0.00 $0.00 $396.00 $627.26 $633.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27812 SUP Custom 27803010 27812 - VALVE 27812 STRATA II SM EXTRACTED BOTH IP/OP "$10,144.95 " "$7,507.26" $0.00 "$8,115.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,114.21" $0.00 $0.00 $0.00 $0.00 "$5,072.48" "$8,034.80" "$8,115.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27814 SUP Custom 27803010 27814 - SHUNT 27814 STRATA II ASSY SML BOTH IP/OP "$10,770.05 " "$7,969.84" $0.00 "$8,616.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,244.48" $0.00 $0.00 $0.00 $0.00 "$5,385.03" "$8,529.88" "$8,616.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27815 SUP Custom 27803010 27815 - SHUNT 27815 STRATA II ASSY REG BOTH IP/OP "$10,770.05 " "$7,969.84" $0.00 "$8,616.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,244.48" $0.00 $0.00 $0.00 $0.00 "$5,385.03" "$8,529.88" "$8,616.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27816 SUP Custom 27803010 27816 - SHUNT 27816 SNAP STRATA II SMALL BOTH IP/OP "$11,167.20 " "$8,263.73" $0.00 "$8,933.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,327.24" $0.00 $0.00 $0.00 $0.00 "$5,583.60" "$8,844.42" "$8,933.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27817 SUP Custom 27803010 27817 - SHUNT 27817 SNAP STRATA II REG BOTH IP/OP "$11,167.20 " "$8,263.73" $0.00 "$8,933.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,327.24" $0.00 $0.00 $0.00 $0.00 "$5,583.60" "$8,844.42" "$8,933.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27818 SUP Custom 27803010 27818 - SHUNT 27818 STRATA II SML BIO BOTH IP/OP "$11,418.65 " "$8,449.80" $0.00 "$9,134.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,379.65" $0.00 $0.00 $0.00 $0.00 "$5,709.33" "$9,043.57" "$9,134.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27819 SUP Custom 27803010 27819 - SHUNT 27819 STRATA II REG BIO BOTH IP/OP "$11,418.65 " "$8,449.80" $0.00 "$9,134.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,379.65" $0.00 $0.00 $0.00 $0.00 "$5,709.33" "$9,043.57" "$9,134.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27820 SUP Custom 27203010 27820 - KIT 27820 UNI STRATA II SM V 11 PCATH90 BOTH IP/OP "$10,915.75 " "$8,077.66" $0.00 "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,274.84" $0.00 $0.00 $0.00 $0.00 "$5,457.88" "$8,645.27" "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27821 SUP Custom 27203010 27821 - KIT 27821 UNI STRATA II REG V13 PCATH90 BOTH IP/OP "$10,915.75 " "$8,077.66" $0.00 "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,274.84" $0.00 $0.00 $0.00 $0.00 "$5,457.88" "$8,645.27" "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27822 SUP Custom 27803010 27822 - SHUNT 27822 STRATA II SNP ASSY SM BIO BOTH IP/OP "$12,003.80 " "$8,882.81" $0.00 "$9,603.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,501.59" $0.00 $0.00 $0.00 $0.00 "$6,001.90" "$9,507.01" "$9,603.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27823 SUP Custom 27803010 27823 - SHUNT 27823 STRATA II ASSY SNP REG BIO BOTH IP/OP "$12,003.80 " "$8,882.81" $0.00 "$9,603.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,501.59" $0.00 $0.00 $0.00 $0.00 "$6,001.90" "$9,507.01" "$9,603.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27824 SUP Custom 27803010 27824 - SHUNT 27824 UNI STRATA II SM BIO BOTH IP/OP "$11,385.75 " "$8,425.46" $0.00 "$9,108.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,372.79" $0.00 $0.00 $0.00 $0.00 "$5,692.88" "$9,017.51" "$9,108.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27825 SUP Custom 27803010 27825 - SHUNT 27825 STRATA II UNI REG BIO BOTH IP/OP "$11,385.75 " "$8,425.46" $0.00 "$9,108.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,372.79" $0.00 $0.00 $0.00 $0.00 "$5,692.88" "$9,017.51" "$9,108.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27827 SUP Custom 27803010 27827 - VALVE 27827 STRATA II REG EXTRACTED BOTH IP/OP "$10,144.95 " "$7,507.26" $0.00 "$8,115.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,114.21" $0.00 $0.00 $0.00 $0.00 "$5,072.48" "$8,034.80" "$8,115.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27828 SUP Custom 27803010 27828 - VALVE 27828 STRATA II SML INLET BUTTON BOTH IP/OP "$10,953.35 " "$8,105.48" $0.00 "$8,762.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,282.68" $0.00 $0.00 $0.00 $0.00 "$5,476.68" "$8,675.05" "$8,762.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27829 SUP Custom 27803010 27829 - VALVE 27829 STRATA II REG INLET BUTTON BOTH IP/OP "$10,953.35 " "$8,105.48" $0.00 "$8,762.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,282.68" $0.00 $0.00 $0.00 $0.00 "$5,476.68" "$8,675.05" "$8,762.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27830 SUP Custom 27803010 27830 - SHUNT 27830 SNAP STRATA II SML BLUNT BOTH IP/OP "$11,167.20 " "$8,263.73" $0.00 "$8,933.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,327.24" $0.00 $0.00 $0.00 $0.00 "$5,583.60" "$8,844.42" "$8,933.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27831 SUP Custom 27803010 27831 - SHUNT 27831 SNAP STRATA II REG BLUNT P/C BOTH IP/OP "$11,167.20 " "$8,263.73" $0.00 "$8,933.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,327.24" $0.00 $0.00 $0.00 $0.00 "$5,583.60" "$8,844.42" "$8,933.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27832 SUP Custom 27803010 27832 - VALVE 27832 SNAP STRATA II REG BLUNT BOTH IP/OP "$10,156.70 " "$7,515.96" $0.00 "$8,125.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,116.66" $0.00 $0.00 $0.00 $0.00 "$5,078.35" "$8,044.11" "$8,125.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27842 SUP Custom 27803010 27842 - CATHETER 27842 EDMS VENTRICULAR STD 28CM BOTH IP/OP $297.60 $220.22 $0.00 $238.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.88 $220.88 $0.00 $0.00 $62.02 $0.00 $0.00 $0.00 $0.00 $148.80 $235.70 $238.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27843 SUP Custom 27803010 27843 - CATHETER 27843 VENTRICULAR STD 15CM BOTH IP/OP $410.88 $304.05 $0.00 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.95 $304.95 $0.00 $0.00 $85.63 $0.00 $0.00 $0.00 $0.00 $205.44 $325.42 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27848 SUP Custom 27203010 27848 - KIT 27848 STRATA II SHUNT SML PCATH 90CM BOTH IP/OP "$10,770.05 " "$7,969.84" $0.00 "$8,616.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,244.48" $0.00 $0.00 $0.00 $0.00 "$5,385.03" "$8,529.88" "$8,616.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27852 SUP Custom 27803010 27852 - CATHETER 27852 VENT PLIANT FIX COL 15CM BOTH IP/OP $522.50 $386.65 $0.00 $418.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $387.80 $387.80 $0.00 $0.00 $108.89 $0.00 $0.00 $0.00 $0.00 $261.25 $413.82 $418.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27853 SUP Custom 27803010 27853 - CATHETER 27853 OPUS VENT 23CM BIOGLIDE BOTH IP/OP $605.63 $448.17 $0.00 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.49 $449.49 $0.00 $0.00 $126.21 $0.00 $0.00 $0.00 $0.00 $302.81 $479.66 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27855 SUP Custom 27203010 27855 - EDMS 27855 EXACTA VCATH W/NLESS INJ/STES BOTH IP/OP $688.80 $509.71 $0.00 "$1,163.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,163.80" "$1,163.80" $0.00 $0.00 $326.78 $0.00 $0.00 $0.00 $0.00 $684.81 $545.53 "$1,095.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27857 SUP Custom 27803010 27857 - PCATH 27857 STD TRANSL NOSLIT 130CM BOTH IP/OP $418.00 $309.32 $0.00 $331.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.95 $12.95 $0.00 $0.00 $3.64 $0.00 $0.00 $0.00 $0.00 $7.92 $331.06 $12.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27861 SUP Custom 27203010 27861 - EDMS 27861 EXACTA 50ML ANTIRFLUX GRNPL BOTH IP/OP $470.40 $348.10 $0.00 $376.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.13 $349.13 $0.00 $0.00 $98.03 $0.00 $0.00 $0.00 $0.00 $235.20 $372.56 $376.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27864 SUP Custom 27803010 27864 - SHUNT 27864 STRATA II REGULAR 120CM BOTH IP/OP "$10,838.20 " "$8,020.27" $0.00 "$8,670.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,258.68" $0.00 $0.00 $0.00 $0.00 "$5,419.10" "$8,583.85" "$8,670.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27867 SUP Custom 27803010 27867 - SHUNT 27867 STRATA II SMALL PCATH 130CM BOTH IP/OP "$10,770.05 " "$7,969.84" $0.00 "$8,616.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,244.48" $0.00 $0.00 $0.00 $0.00 "$5,385.03" "$8,529.88" "$8,616.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27868 SUP Custom 27803010 27868 - SHUNT 27868 STRATA NSC SMALL PCATH 130CM BOTH IP/OP "$9,458.75 " "$6,999.48" $0.00 "$7,567.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,971.20" $0.00 $0.00 $0.00 $0.00 "$4,729.38" "$7,491.33" "$7,567.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27873 SUP Custom 27203010 27873 - EDMS 27873 BECKR W/SC BLW DC W/NLESS INJ BOTH IP/OP $496.80 $367.63 $0.00 $397.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $368.72 $368.72 $0.00 $0.00 $103.53 $0.00 $0.00 $0.00 $0.00 $248.40 $393.47 $397.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27875 SUP Custom 27803010 27875 - SHUNT 27875 CSF SNAP VCATH 15CM BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27888 SUP Custom 27803010 27888 - SHNT 27888 STRATA II SNAP ASSY REG PCATH BOTH IP/OP "$10,915.75 " "$8,077.66" $0.00 "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,274.84" $0.00 $0.00 $0.00 $0.00 "$5,457.88" "$8,645.27" "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27889 SUP Custom 27803010 27889 - RESERVOIR 27889 VENT SNAP EXT FLANGE BOTH IP/OP $731.50 $541.31 $0.00 $585.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $542.92 $542.92 $0.00 $0.00 $152.44 $0.00 $0.00 $0.00 $0.00 $365.75 $579.35 $585.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27903 SUP Custom 27803010 27903 - ASSY 27903 STRATA II SM CP CATHETER BOTH IP/OP "$9,949.90 " "$7,362.93" $0.00 "$7,959.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,073.56" $0.00 $0.00 $0.00 $0.00 "$4,974.95" "$7,880.32" "$7,959.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27922 SUP Custom 27803010 27922 - SHUNT 27922 STRATA II REG W/INTEG V/RES BOTH IP/OP "$11,432.75 " "$8,460.24" $0.00 "$9,146.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,382.59" $0.00 $0.00 $0.00 $0.00 "$5,716.38" "$9,054.74" "$9,146.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27923 SUP Custom 27803010 27923 - SHUNT 27923 STRATA II SML W/INTEG V/RES BOTH IP/OP "$11,432.75 " "$8,460.24" $0.00 "$9,146.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,382.59" $0.00 $0.00 $0.00 $0.00 "$5,716.38" "$9,054.74" "$9,146.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27924 SUP Custom 27803010 27924 - SHUNT 27924 STRATA NSC REG W/INTG V/RES BOTH IP/OP "$10,624.35 " "$7,862.02" $0.00 "$8,499.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,214.11" $0.00 $0.00 $0.00 $0.00 "$5,312.18" "$8,414.49" "$8,499.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27925 SUP Custom 27803010 27925 - SHUNT 27925 STRATA NSC SML W/INTEG V/RES BOTH IP/OP "$10,624.35 " "$7,862.02" $0.00 "$8,499.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,214.11" $0.00 $0.00 $0.00 $0.00 "$5,312.18" "$8,414.49" "$8,499.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27926 SUP Custom 27803010 27926 - SHUNT 27926 STRATA II REG W/VRES INNERVN BOTH IP/OP "$11,900.40 " "$8,806.30" $0.00 "$9,520.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,480.04" $0.00 $0.00 $0.00 $0.00 "$5,950.20" "$9,425.12" "$9,520.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27927 SUP Custom 27803010 27927 - SHUNT 27927 STRATA II SML W/VRES INNERVN BOTH IP/OP "$11,900.40 " "$8,806.30" $0.00 "$9,520.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,480.04" $0.00 $0.00 $0.00 $0.00 "$5,950.20" "$9,425.12" "$9,520.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27929 SUP Custom 27803010 27929 - CATHETER 27929 CARDIAC PERIT SML EXTRCTD BOTH IP/OP "$1,330.00 " $984.20 $0.00 "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.13 $987.13 $0.00 $0.00 $277.17 $0.00 $0.00 $0.00 $0.00 $665.00 "$1,053.36" "$1,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27930 SUP Custom 27803010 27930 - CATHETER 27930 VENTRICULAR SML EXTRACTD BOTH IP/OP $876.38 $648.52 $0.00 $701.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $650.45 $650.45 $0.00 $0.00 $182.64 $0.00 $0.00 $0.00 $0.00 $438.19 $694.09 $701.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27931 SUP Custom 27203010 27931 - EDMS 27931 BECKER GS TUBING SMARTSITES BOTH IP/OP $556.80 $412.03 $0.00 $445.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.26 $413.26 $0.00 $0.00 $116.04 $0.00 $0.00 $0.00 $0.00 $278.40 $440.99 $445.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27932 SUP Custom 27803010 27932 - VALVE 27932 STRATA NSC SML EXTRACTED BOTH IP/OP "$8,781.95 " "$6,498.64" $0.00 "$7,025.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,830.16" $0.00 $0.00 $0.00 $0.00 "$4,390.98" "$6,955.30" "$7,025.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27933 SUP Custom 27803010 27933 - VALVE 27933 STRATA NSC REG EXTRACTED BOTH IP/OP "$8,781.95 " "$6,498.64" $0.00 "$7,025.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,830.16" $0.00 $0.00 $0.00 $0.00 "$4,390.98" "$6,955.30" "$7,025.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28707 SUP Custom 27203010 SET RTRCTR OCTOBASE HLD INS SUTURE DISP BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29400 SUP Custom 27203010 STABILIZER SURG OCT4 DUAL VAC TUBE REINF ARM CARD BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30011 SUP HCPCS C1776 30011 - STEM ULNAR 41X6.2MM PLASMA SPRAY EASE OF INSERTION REDUCE BOTH IP/OP "$7,947.50 " "$5,881.15" $0.00 "$6,358.00" "$3,576.38" "$3,576.38" $0.00 $0.00 $0.00 "$1,656.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,656.26" $0.00 "$3,918.12" "$3,918.12" $0.00 "$3,973.75" "$6,294.42" "$6,358.00" $0.00 $0.00 "$1,243.78" $0.00 $0.00 "$1,265.24" $0.00 $0.00 $0.00 $0.00 $0.00 30121 SUP HCPCS C1776 30121 - STEM ULNAR LATITUDE MEDIUM STANDARD LEFT ELBOW BOTH IP/OP "$7,946.75 " "$5,880.60" $0.00 "$6,357.40" "$3,576.04" "$3,576.04" $0.00 $0.00 $0.00 "$1,656.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,656.10" $0.00 "$3,917.75" "$3,917.75" $0.00 "$3,973.38" "$6,293.83" "$6,357.40" $0.00 $0.00 "$1,243.67" $0.00 $0.00 "$1,265.12" $0.00 $0.00 $0.00 $0.00 $0.00 30303 SUP HCPCS C1776 30303 - STEM HUMERAL 90X7.7MM LATITUDE EV 6.5MM 4MM SMALL BOW BOTH IP/OP "$8,915.00 " "$6,597.10" $0.00 "$7,132.00" "$4,011.75" "$4,011.75" $0.00 $0.00 $0.00 "$1,858.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,857.89" $0.00 "$4,395.10" "$4,395.10" $0.00 "$4,457.50" "$7,060.68" "$7,132.00" $0.00 $0.00 "$1,395.20" $0.00 $0.00 "$1,419.27" $0.00 $0.00 $0.00 $0.00 $0.00 30397 SUP Custom 27203010 KIT C. DIFF A B ELISA MCBLTST 50ML 96 TST BOTH IP/OP $923.30 $683.24 $0.00 $738.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $461.65 $731.25 $738.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30405 SUP Custom 27203010 KIT PARASTST G LMBLA ELISA MCPLT POS NEG CNTRL BOTH IP/OP $910.28 $673.61 $0.00 $728.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $455.14 $720.94 $728.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30406 SUP Custom 27203010 KIT MYCTST CRPSP ELISA 96 TST BOTH IP/OP $883.75 $653.98 $0.00 $707.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $441.88 $699.93 $707.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30418 SUP Custom 27203010 030418 - RELOAD STPLR UNV STRG 12MM 30MMX2.5MM WHT STRL LF EGIA 6 ROW BOTH IP/OP $223.20 $165.17 $0.00 $178.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.66 $165.66 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $111.60 $176.77 $178.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30419 SUP Custom 27203010 030419 - RELOAD STPLR UNV STRG 12MM 30MMX3.5MM BLU STRL LF EGIA 6 ROW BOTH IP/OP $223.20 $165.17 $0.00 $178.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.66 $165.66 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $111.60 $176.77 $178.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30422 SUP Custom 27203010 030422 - RELOAD STPLR UNV STRG 12MM 45MMX3.5MM BLU STRL LF EGIA 6 ROW BOTH IP/OP $230.33 $170.44 $0.00 $184.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.16 $182.42 $184.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30423 SUP Custom 27203010 030423 - RELOAD STPLR UNV 45X4.8MM EGIA 2 TI THKTIS ENDSCP LNR CTR BOTH IP/OP $228.04 $168.75 $0.00 $182.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.25 $169.25 $0.00 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.02 $180.61 $182.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30425 SUP Custom 27203010 030425 - RELOAD STPLR UNV 45X2.5MM EGIA 2 TI VASC ENDSCP LNR CTR STRG BOTH IP/OP $228.04 $168.75 $0.00 $182.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.25 $169.25 $0.00 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $114.02 $180.61 $182.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30449 SUP Custom 27203010 030449 - RELOAD STPLR 12X4MM TI UNV LD UN STRL LATEX FREE DISP EGIA BOTH IP/OP $253.34 $187.47 $0.00 $202.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.03 $188.03 $0.00 $0.00 $52.80 $0.00 $0.00 $0.00 $0.00 $126.67 $200.65 $202.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30454 SUP Custom 27203010 030454 - RELOAD STPLR UNV 12MM 45MMX2.5MM WHT STRL LF EGIA ROTC 6 ROW BOTH IP/OP $386.78 $286.22 $0.00 $317.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.06 $287.06 $0.00 $0.00 $80.60 $0.00 $0.00 $0.00 $0.00 $198.40 $314.26 $317.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30455 SUP Custom 27203010 030455 - RELOAD STPLR UNV 12MM 45MMX3.5MM BLU STRL LF EGIA ROTC 6 ROW BOTH IP/OP $396.79 $293.62 $0.00 $317.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $294.50 $294.50 $0.00 $0.00 $82.69 $0.00 $0.00 $0.00 $0.00 $198.39 $314.26 $317.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30456 SUP Custom 27203010 RELOAD STPLR 45X4.8MM EGIA RT TI THKTIS LNR CTR LAPSCOP STRL BOTH IP/OP $425.65 $314.98 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.33 $337.11 $333.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30456 SUP Custom 27203010 030456 - RELOAD STPLR UNV 12MM 45MMX4.8MM GRN STRL LF EGIA ROTC 6 ROW BOTH IP/OP $416.66 $308.33 $0.00 $333.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.33 $329.99 $333.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30500 SUP HCPCS C1729 CATHETER SCT 5FR GRAD STRG CNTRL VLV SF-T-VAC PED STRL LF BOTH IP/OP $0.88 $0.65 $0.00 $0.70 $0.48 $0.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.44 $0.70 $0.70 $0.00 $0.00 $0.14 $0.00 $0.00 $0.14 $0.00 $0.00 $0.00 $0.00 $0.00 30688 SUP HCPCS C1729 CATHETER SCT 6FR GRAD STRG SF-T-VAC PED STRL LF BOTH IP/OP $0.88 $0.65 $0.00 $0.70 $0.48 $0.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.44 $0.70 $0.70 $0.00 $0.00 $0.14 $0.00 $0.00 $0.14 $0.00 $0.00 $0.00 $0.00 $0.00 30888 SUP HCPCS C1729 CATHETER SCT 8FR CNTRL VLV STRG SF-T-VAC STRL LF DISP BOTH IP/OP $0.80 $0.59 $0.00 $0.64 $0.43 $0.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.40 $0.63 $0.64 $0.00 $0.00 $0.13 $0.00 $0.00 $0.13 $0.00 $0.00 $0.00 $0.00 $0.00 30935 SUP Custom 25003010 ANTIBODY CD68/MACRPH MAB MRKR HAM56 LAB BOTH IP/OP $353.15 $261.33 $0.00 $282.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.58 $279.69 $282.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31000 SUP HCPCS C1729 CATHETER SCT 10FR CNTRL VLV STRG SF-T-VAC STRL LF BOTH IP/OP $0.63 $0.47 $0.00 $0.50 $0.34 $0.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.31 $0.50 $0.50 $0.00 $0.00 $0.10 $0.00 $0.00 $0.10 $0.00 $0.00 $0.00 $0.00 $0.00 31031 SUP Custom 27203010 31031 - BIT DRILL 145MM 3.2MM QC NONSTRL BOTH IP/OP $152.70 $113.00 $0.00 $122.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.33 $113.33 $0.00 $0.00 $31.82 $0.00 $0.00 $0.00 $0.00 $76.35 $120.94 $122.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31035 SUP Custom 27203010 31035 - BIT DRILL 110MM 3.5MM QC CANN NONSTRL BOTH IP/OP $149.30 $110.48 $0.00 $119.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $110.81 $110.81 $0.00 $0.00 $31.11 $0.00 $0.00 $0.00 $0.00 $74.65 $118.25 $119.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31100 SUP Custom 27203010 31100 - SHUNT CV 1MM 14MM STRL CLRVW BLB TPR TIP RADOPQ SIL INTRCOR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31113 SUP Custom 27203010 KIT ORTH HCV BRCD SEQ VIR TST 3ML BOTH IP/OP $732.50 $542.05 $0.00 $586.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $366.25 $580.14 $586.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31150 SUP Custom 27203010 31150 - SHUNT CV 1.5MM 14MM STRL CLRVW RADOPQ BLB TPR TIP SFT SIL BOTH IP/OP $207.50 $153.55 $0.00 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.01 $154.01 $0.00 $0.00 $43.24 $0.00 $0.00 $0.00 $0.00 $103.75 $164.34 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31175 SUP Custom 27203010 31175 - SHUNT CV 1.75MM 14MM STRL CLRVW BLB INTRCOR ARTMY BOTH IP/OP $207.50 $153.55 $0.00 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.01 $154.01 $0.00 $0.00 $43.24 $0.00 $0.00 $0.00 $0.00 $103.75 $164.34 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31200 SUP Custom 27203010 31200 - SHUNT CV 2MM 14MM STRL CLRVW RADOPQ BLB TPR TIP SFT SIL BOTH IP/OP $207.50 $153.55 $0.00 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.01 $154.01 $0.00 $0.00 $43.24 $0.00 $0.00 $0.00 $0.00 $103.75 $164.34 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31250 SUP Custom 27203010 31250 - SHUNT CV 2.5MM 14MM STRL 14MM CLRVW BLB TPR TIP RADOPQ SIL BOTH IP/OP $207.50 $153.55 $0.00 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.01 $154.01 $0.00 $0.00 $43.24 $0.00 $0.00 $0.00 $0.00 $103.75 $164.34 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31553.91 SUP Custom 27203010 HANDLE SCP 3FT CORD HAL LGHT ILUM SYS ANOSCP SGSCP KLNSPC BOTH IP/OP $191.73 $141.88 $0.00 $153.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.86 $151.85 $153.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31592 SUP Custom 27203010 31592 - BIT DRILL 230MM 2.5MM 3 FLT QC NONSTRL BOTH IP/OP $451.00 $333.74 $0.00 $360.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.73 $334.73 $0.00 $0.00 $93.99 $0.00 $0.00 $0.00 $0.00 $225.50 $357.19 $360.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32508 SUP Custom 27203010 KIT IMMUN TST WBLOT ANTI-HIV-1 40 TST BOTH IP/OP "$3,010.00 " "$2,227.40" $0.00 "$2,408.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,505.00" "$2,383.92" "$2,408.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32588 SUP Custom 27203010 KIT IMMUN TST EIA ANTI-HIV 1 2 BOTH IP/OP "$1,527.50 " "$1,130.35" $0.00 "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $763.75 "$1,209.78" "$1,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32591 SUP Custom 27203010 KIT GN HBSAG VIR TST 480 TST BOTH IP/OP "$1,457.50 " "$1,078.55" $0.00 "$1,166.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $728.75 "$1,154.34" "$1,166.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32594 SUP Custom 27203010 KIT IMMUN TST CNFRM ASY HBSAG 25 TST BOTH IP/OP $580.00 $429.20 $0.00 $464.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.00 $459.36 $464.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33000 SUP Custom 27203010 REAGENT VIT B2 ACCES 50ML 100 TST ANALY BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33005 SUP Custom 27203010 CALIBRATOR CHM 4ML VL VIT B2 ACCES BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33020 SUP Custom 27203010 REAGENT FRRTN ACCES 100 TST ANALY BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33025 SUP Custom 27203010 CALIBRATOR CHM 4ML VL FRRTN ACCES BOTH IP/OP $44.08 $32.62 $0.00 $35.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.04 $34.91 $35.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33138 SUP Custom 27203010 FORMULA NUTRITIONAL ENFAMIL IRON FORTIFIED POWDER BOTH IP/OP $30.30 $22.42 $0.00 $24.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.15 $24.00 $24.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33200 SUP Custom 27203010 REAGENT CEA ACCES 100 TST ANALY BOTH IP/OP $595.00 $440.30 $0.00 $476.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.50 $471.24 $476.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33205 SUP Custom 27203010 CALIBRATOR CEA ACCES 50 TST IMMUN BOTH IP/OP $161.25 $119.33 $0.00 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.63 $127.71 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33206 SUP Custom 27203010 REAGENT CEA DILU ACCES 4ML ANALY BOTH IP/OP $153.75 $113.78 $0.00 $123.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.88 $121.77 $123.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33211 SUP Custom 27203010 REAGENT AFP ACCES 300 TST ANALY BOTH IP/OP "$1,597.50 " "$1,182.15" $0.00 "$1,278.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $798.75 "$1,265.22" "$1,278.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33410 SUP Custom 27203010 REAGENT INSN ACCES SYN ULSNS 50 TST ANALY BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33415 SUP Custom 27203010 CALIBRATOR INSN ACCES SYN SET 2ML IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33500 SUP Custom 27203010 REAGENT TL BHCG ACCES 100 TST ANALY BOTH IP/OP $141.88 $104.99 $0.00 $113.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.94 $112.37 $113.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33505 SUP Custom 27203010 CALIBRATOR TL BHCG ACCES 4ML IMMUN BOTH IP/OP $26.88 $19.89 $0.00 $21.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.44 $21.29 $21.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33510 SUP Custom 27203010 REAGENT LH ACCES 50 TST ANALY BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33515 SUP Custom 27203010 CALIBRATOR LH ACCES 4ML IMMUN BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33520 SUP Custom 27203010 REAGENT FSH ACCES 50 TST ANALY BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33525 SUP Custom 27203010 CALIBRATOR FSH ACCES 4ML IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33530 SUP Custom 27203010 REAGENT PRLCTN ACCES 50 TST ANALY BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33535 SUP Custom 27203010 CALIBRATOR PRLCTN ACCES 50 TST IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33540 SUP Custom 27203010 REAGENT E2 ACCES 100 TST ANALY BOTH IP/OP $501.25 $370.93 $0.00 $401.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.63 $396.99 $401.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33545 SUP Custom 27203010 CALIBRATOR E2 ACCES 2.5ML IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33546 SUP Custom 27203010 REAGENT E2 DILU ACCES VL 4ML ANALY BOTH IP/OP $91.25 $67.53 $0.00 $73.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.63 $72.27 $73.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33560 SUP Custom 27203010 REAGENT T ACCES 50 TST ANALY BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33565 SUP Custom 27203010 CALIBRATOR T ACCES 2.5ML IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33600 SUP Custom 27203010 REAGENT CORTSL ACCES 100 TST ANALY BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33605 SUP Custom 27203010 CALIBRATOR CORTSL ACCES 50 TST IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33606 SUP Custom 27203010 CALIBRATOR CORTSL DILU ACCES 4ML IMMUN BOTH IP/OP $74.83 $55.37 $0.00 $59.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.41 $59.27 $59.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33800 SUP Custom 27203010 REAGENT TL T4 ACCES 50 TST ANALY BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33805 SUP Custom 27203010 CALIBRATOR TL T4 ACCES 4ML IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33815 SUP Custom 27203010 CALIBRATOR T UPTK ACCES 1ML IMMUN BOTH IP/OP $45.63 $33.77 $0.00 $36.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.81 $36.14 $36.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33820 SUP Custom 27203010 REAGENT TSH ACCES HYPERSENSITIVE 100 TST ANALY BOTH IP/OP $1.83 $1.35 $0.00 $1.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.91 $1.45 $1.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33821 SUP Custom 27203010 FORMULA NUTRITIONAL NUTRAMIGEN 1LB POWDER CAN BOTH IP/OP $56.68 $41.94 $0.00 $45.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.34 $44.89 $45.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33825 SUP Custom 27203010 CALIBRATOR TSH ACCES HYPERSENSITIVE VL 4ML IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33835 SUP Custom 27203010 CALIBRATOR TL T3 ACCES 50 TST IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33880 SUP Custom 27203010 REAGENT FR T4 ACCES 100 TST ANALY BOTH IP/OP $267.50 $197.95 $0.00 $214.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.75 $211.86 $214.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33885 SUP Custom 27203010 CALIBRATOR FR T4 ACCES 2.5ML IMMUN BOTH IP/OP $45.63 $33.77 $0.00 $36.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.81 $36.14 $36.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35402 SUP HCPCS C1729 CATHETER SCT 14FR CNTRL VLV 2 GLOVE WO SOL MINI TRY SF-T-VAC BOTH IP/OP $1.18 $0.87 $0.00 $0.94 $0.64 $0.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.59 $0.93 $0.94 $0.00 $0.00 $0.18 $0.00 $0.00 $0.19 $0.00 $0.00 $0.00 $0.00 $0.00 36179 SUP HCPCS C1769 36179 - NEEDLE 5CM 18GA GUIDEWIRE PRC RNL FSCA 10MM BOTH IP/OP $82.45 $61.01 $0.00 $65.96 $44.77 $44.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.23 $65.30 $65.96 $0.00 $0.00 $12.90 $0.00 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $0.00 36721 SUP Custom 27203010 FORMULA NUTRITIONAL PREGESTIMIL 1LB POWDER CAN BOTH IP/OP $42.50 $31.45 $0.00 $34.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.25 $33.66 $34.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 36826 SUP HCPCS C1729 CATHETER SCT 8FR CNTRL VLV COIL GRAD 2 GLOVE PPUP BSIN BOTH IP/OP $1.43 $1.06 $0.00 $1.14 $0.77 $0.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.71 $1.13 $1.14 $0.00 $0.00 $0.22 $0.00 $0.00 $0.23 $0.00 $0.00 $0.00 $0.00 $0.00 37024 SUP HCPCS C1729 CATHETER SCT 10FR CNTRL VLV COIL 2 GLOVE PPUP BSIN KT BOTH IP/OP $1.28 $0.95 $0.00 $1.02 $0.69 $0.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.64 $1.01 $1.02 $0.00 $0.00 $0.20 $0.00 $0.00 $0.20 $0.00 $0.00 $0.00 $0.00 $0.00 37092 SUP HCPCS C1787 37092 - PROGRAMMER NRSTM STRL ACTIVA PT ANTNA XTRN TELEM DP BRN STM BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37200 SUP Custom 27203010 REAGENT PSA ACCES HYBRITECH 100 TST ANALY BOTH IP/OP $915.00 $677.10 $0.00 $732.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.50 $724.68 $732.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37205 SUP Custom 27203010 CALIBRATOR PSA ACCES HYBRITECH VL 2.5ML IMMUN BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37206 SUP Custom 27203010 REAGENT PSA DILU ACCES HYBRITECH 14ML ANALY BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37970 SUP Custom 27203010 0037970 - DEVICE IRR EFL DISP BOTH IP/OP $96.75 $71.60 $0.00 $102.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.81 $71.81 $0.00 $0.00 $20.16 $0.00 $0.00 $0.00 $0.00 $63.75 $100.98 $102.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38005 SUP Custom 27803010 038005 - FILLER BONE VOID DBX DEMINERALIZED BONE MATRIX .5 CC ALLOGRA BOTH IP/OP $243.25 $180.01 $0.00 $194.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.54 $180.54 $0.00 $0.00 $50.69 $0.00 $0.00 $0.00 $0.00 $121.63 $192.65 $194.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38010 SUP HCPCS C1713 38010 - FILLER BONE VOID ALLOGRAFT PUTTY FREEZE DRIED DBX BOTH IP/OP $432.25 $319.87 $0.00 $345.80 $194.51 $194.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.13 $342.34 $345.80 $0.00 $0.00 $67.65 $0.00 $0.00 $68.81 $0.00 $0.00 $0.00 $0.00 $0.00 38025 SUP HCPCS C1713 038025 - FILLER BONE VOID ALLOGRAFT FREEZE DRY PUTTY DBX 2.5CC BOTH IP/OP $935.00 $691.90 $0.00 $748.00 $420.75 $420.75 $0.00 $0.00 $0.00 $194.88 $693.96 $693.96 $0.00 $0.00 $194.85 $0.00 $553.05 $553.05 $0.00 $467.50 $740.52 $748.00 $0.00 $0.00 $146.33 $0.00 $0.00 $148.85 $0.00 $0.00 $0.00 $0.00 $0.00 38050 SUP HCPCS C1713 038050 - FILLER BONE VOID ALLOGRAFT FREEZE DRY PUTTY DBX 5ML BOTH IP/OP "$1,725.50 " "$1,276.87" $0.00 "$1,380.40" $776.48 $776.48 $0.00 $0.00 $0.00 $359.64 "$1,280.67" "$1,280.67" $0.00 $0.00 $359.59 $0.00 "$1,020.63" "$1,020.63" $0.00 $862.75 "$1,366.60" "$1,380.40" $0.00 $0.00 $270.04 $0.00 $0.00 $274.70 $0.00 $0.00 $0.00 $0.00 $0.00 38100 SUP Custom 27803010 038100 - FILLER BONE VOID ALLOGRAFT FREEZE DRY PUTTY DBX 10ML BOTH IP/OP "$2,652.00 " "$1,962.48" $0.00 "$2,100.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.81 $87.81 $0.00 $0.00 $24.66 $0.00 $0.00 $0.00 $0.00 $53.64 "$2,100.38" $85.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41101 SUP HCPCS C1729 41101 - CATHETER DRN STD 4FR 23CM STRL LF INPT TS CSF IMPREGNATE BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $193.44 $193.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $55.75 $0.00 $0.00 $56.72 $0.00 $0.00 $0.00 $0.00 $0.00 41103 SUP Custom 27803010 41103 - CATH 41103 CSF-VENT STANDARD PLIANT BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.41 $264.41 $0.00 $0.00 $74.24 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41115 SUP Custom 27803010 41115 - CATH 41115 CSF-VENT STD TRANSLUCENT BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.41 $264.41 $0.00 $0.00 $74.24 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41207 SUP Custom 27803010 41207 - CATH 41207 CSF-VENT SMALL BAR IMP BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.41 $264.41 $0.00 $0.00 $74.24 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41308 SUP Custom 27803010 41308 - CATH 41308 CSF-VENT FLANGED SMALL BOTH IP/OP "$1,368.00 " "$1,012.32" $0.00 "$1,094.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,015.33" "$1,015.33" $0.00 $0.00 $285.09 $0.00 $0.00 $0.00 $0.00 $684.00 "$1,083.46" "$1,094.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41404 SUP Custom 27803010 41404 - CATHETER 41404 CSF-VENT STD W/SNAP 4CM BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41405 SUP Custom 27803010 41405 - CATHETER 41405 CSF-VENT STD W/SNAP 5CM BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41406 SUP Custom 27803010 41406 - CATHETER 41406 CSF-VENT STD W/SNAP 6CM BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41407 SUP Custom 27803010 41407 - CATHETER 41407 CSF-VENT STD W/SNAP 7CM BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41408 SUP Custom 27803010 41408 - CATHETER DRN STD 8CM STRL LF CSF SNP SHNT VNTRC DISP BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41409 SUP Custom 27803010 41409 - CATHETER DRN STD 9CM STRL LF CSF SNP SHNT VNTRC DISP BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41501 SUP Custom 27803010 41501 - CATH 41501 OPUS VENTRICULAR SM 23CM BOTH IP/OP $465.50 $344.47 $0.00 $372.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.49 $345.49 $0.00 $0.00 $97.01 $0.00 $0.00 $0.00 $0.00 $232.75 $368.68 $372.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41503 SUP Custom 27803010 41503 - CATH 41503 OPUS VENTRICULAR STD 23CM BOTH IP/OP $465.50 $344.47 $0.00 $372.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.49 $345.49 $0.00 $0.00 $97.01 $0.00 $0.00 $0.00 $0.00 $232.75 $368.68 $372.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41701 SUP Custom 27803010 41701 - CATHETER 41701 RIVULET VENTRICULAR BOTH IP/OP $619.88 $458.71 $0.00 $495.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $460.07 $460.07 $0.00 $0.00 $129.18 $0.00 $0.00 $0.00 $0.00 $309.94 $490.94 $495.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41704 SUP Custom 27803010 41704 - CATHETER 41704 RIVULET VENT SNAP 4CM BOTH IP/OP $790.88 $585.25 $0.00 $632.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.99 $586.99 $0.00 $0.00 $164.82 $0.00 $0.00 $0.00 $0.00 $395.44 $626.38 $632.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41705 SUP Custom 27803010 41705 - CATHETER 41705 RIVULET VENT SNAP 5CM BOTH IP/OP $790.88 $585.25 $0.00 $632.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.99 $586.99 $0.00 $0.00 $164.82 $0.00 $0.00 $0.00 $0.00 $395.44 $626.38 $632.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41707 SUP Custom 27803010 41707 - CATHETER 41707 RIVULET VENT SNAP 7CM BOTH IP/OP $790.88 $585.25 $0.00 $632.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.99 $586.99 $0.00 $0.00 $164.82 $0.00 $0.00 $0.00 $0.00 $395.44 $626.38 $632.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41709 SUP Custom 27803010 41709 - CATHETER 41709 RIVULET VENT SNAP 9CM BOTH IP/OP $790.88 $585.25 $0.00 $632.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.99 $586.99 $0.00 $0.00 $164.82 $0.00 $0.00 $0.00 $0.00 $395.44 $626.38 $632.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42102 SUP Custom 27803010 42102 - VALVE 42102 STANDARD LOW BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42104 SUP Custom 27803010 42104 - VALVE 42104 STANDARD MEDIUM BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42106 SUP Custom 27803010 42106 - VALVE 42106 STANDARD HIGH BOTH IP/OP "$1,655.38 " "$1,224.98" $0.00 "$1,324.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,228.62" "$1,228.62" $0.00 $0.00 $344.98 $0.00 $0.00 $0.00 $0.00 $827.69 "$1,311.06" "$1,324.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42312 SUP Custom 27803010 42312 - VALVE 42312 SM CONTOURED LOW PRES IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42314 SUP Custom 27803010 42314 - VALVE 42314 SM CONTOURED MED PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42316 SUP Custom 27803010 42316 - VALVE 42316 SM CONTOURED HIGH PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42322 SUP Custom 27803010 42322 - VALVE SHNT REG STRL DLT CNTR LP CSF BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42324 SUP Custom 27803010 42324 - VALVE SHNT REG CNTR 32X18X7.5MM STRL LF 14MM DLT PS MDCL CSF BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42326 SUP Custom 27803010 42326 - VALVE SHNT REG STRL DLT CNTR HI-PRS IMPRG CSF BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42335 SUP Custom 27803010 42335 - VALVE 42335 STRATA NSC BURR HOLE BOTH IP/OP "$9,038.10 " "$6,688.19" $0.00 "$7,230.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,883.54" $0.00 $0.00 $0.00 $0.00 "$4,519.05" "$7,158.18" "$7,230.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42355 SUP Custom 27803010 42355 - VALVE 42355 FP STRATA NSC SMALL BOTH IP/OP "$9,038.10 " "$6,688.19" $0.00 "$7,230.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,883.54" $0.00 $0.00 $0.00 $0.00 "$4,519.05" "$7,158.18" "$7,230.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42365 SUP Custom 27803010 42365 - VALVE 42365 FP STRATA NSC REGULAR BOTH IP/OP "$9,038.10 " "$6,688.19" $0.00 "$7,230.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,883.54" $0.00 $0.00 $0.00 $0.00 "$4,519.05" "$7,158.18" "$7,230.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42410 SUP Custom 27803010 42410 - VALVE 42410 ULTRA SMALL LOW-LOW BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42412 SUP Custom 27803010 42412 - VALVE 42412 ULTRA SMALL LOW PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42414 SUP Custom 27803010 42414 - VALVE 42414 ULTRA SMALL MEDIUM PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42532 SUP Custom 27803010 42532 - VALVE 42532 BURR HOLE 12MM LOW PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42534 SUP Custom 27803010 42534 - VALVE 42534 BURR HOLE 12MM MED PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42536 SUP Custom 27803010 42536 - VALVE 42536 BURR HOLE 12MM HI PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42542 SUP Custom 27803010 42542 - VALVE 42542 BURR HOLE 16 MM LOW IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42544 SUP Custom 27803010 42544 - VALVE 42544 BURR HOLE 16MM MED PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42546 SUP Custom 27803010 42546 - VALVE 42546 BURR HOLE 16MM HI PRESS IMP BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42812 SUP Custom 27803010 42812 - VALVE 42812 DELTA SMALL LEVEL I BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42813 SUP Custom 27803010 42813 - VALVE 42813 DELTA SMALL LEVEL 1.5 BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42814 SUP Custom 27803010 42814 - VALVE 42814 DELTA SMALL LEVEL II BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42822 SUP Custom 27803010 42822 - VALVE SHNT DLT REG CSF PRFRM LVL 1 STRL BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42823 SUP Custom 27803010 42823 - VALVE SHNT DLT REG CSF PRFRM LVL 1.5 CHRNC SYSTOLIC STRL BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42824 SUP HCPCS C1877 42824 - VALVE SHNT DLT REG CSF PRFRM LVL 2 STRL BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" "$1,627.71" "$1,627.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $566.08 $0.00 $0.00 $575.85 $0.00 $0.00 $0.00 $0.00 $0.00 42830 SUP Custom 27803010 42830 - VALVE 42830 DELTA BURR HOLE 12MM LEV 0.5 BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42832 SUP Custom 27803010 42832 - VALVE 42832 DELTA BURR HOLE 12MM LEVEL 1 BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42833 SUP Custom 27803010 42833 - VALVE 42833DELTA BURR HOLE 12MM LEV 1.5 BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42834 SUP Custom 27803010 42834 - VALVE 42834 DELTA BURR HOLE 12 MM LEVEL BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42836 SUP Custom 27803010 42836 - VALVE 42836 STRATA II BURR HOLE BOTH IP/OP "$9,839.45 " "$7,281.19" $0.00 "$7,871.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,050.54" $0.00 $0.00 $0.00 $0.00 "$4,919.73" "$7,792.84" "$7,871.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42840 SUP Custom 27803010 42840 - VALVE 42840 DELTA BURR HOLE 16MM LEV 0.5 BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42842 SUP Custom 27803010 42842 - VALVE 42842 DELTA BURR HOLE 16MM LEVEL 1 BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42843 SUP Custom 27803010 42843 - VALVE 42843 DELTA BURR HOLE 16 MM LEV 1. BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42844 SUP Custom 27803010 42844 - VALVE 42844 DELTA BURR HOLE 16 MM LEVEL BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42856 SUP Custom 27803010 42856 - VALVE 42856 FP-STRATA 2 SMALL BOTH IP/OP "$9,839.45 " "$7,281.19" $0.00 "$7,871.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,050.54" $0.00 $0.00 $0.00 $0.00 "$4,919.73" "$7,792.84" "$7,871.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42866 SUP Custom 27803010 42866 - VALVE 42866 FP-STRATA 2 REGULAR BOTH IP/OP "$9,839.45 " "$7,281.19" $0.00 "$7,871.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,050.54" $0.00 $0.00 $0.00 $0.00 "$4,919.73" "$7,792.84" "$7,871.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43103 SUP HCPCS C1750 43103 - CATHETER PERITONEAL STANDARD 90CM IMPREGNATE BARIUM CARDIAC BOTH IP/OP $410.88 $304.05 $0.00 $328.70 $184.89 $184.89 $0.00 $0.00 $0.00 $85.64 $304.95 $304.95 $0.00 $0.00 $85.63 $0.00 $243.03 $243.03 $0.00 $205.44 $325.42 $328.70 $0.00 $0.00 $64.30 $0.00 $0.00 $65.41 $0.00 $0.00 $0.00 $0.00 $0.00 43105 SUP HCPCS C1713 43105 - SUB BNGFT GRFTN DBM PTTY JAR 5ML BOTH IP/OP "$2,162.50 " "$1,600.25" $0.00 "$1,605.01" $630.00 $630.00 $0.00 $0.00 $0.00 $450.72 "$1,605.01" "$1,605.01" $0.00 $0.00 $450.67 $0.00 "$1,279.12" "$1,279.12" $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $219.10 $0.00 $0.00 $222.88 $0.00 $0.00 $0.00 $0.00 $0.00 43110 SUP Custom 27804086 43110 - FILLER BN VOID 10ML GRFTN ALGRF PTTY JR DBM BOTH IP/OP "$2,418.00 " "$1,789.32" $0.00 "$1,934.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,794.64" "$1,794.64" $0.00 $0.00 $503.91 $0.00 $0.00 $0.00 $0.00 "$1,209.00" "$1,915.06" "$1,934.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43111 SUP Custom 27803010 43111 - CATH 43111 C/P STANDARD TRANSLUCENT BOTH IP/OP $410.88 $304.05 $0.00 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.95 $304.95 $0.00 $0.00 $85.63 $0.00 $0.00 $0.00 $0.00 $205.44 $325.42 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43209 SUP Custom 27803010 43209 - CATH 43209 C/P SMALL BAR IMP BOTH IP/OP $410.88 $304.05 $0.00 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.95 $304.95 $0.00 $0.00 $85.63 $0.00 $0.00 $0.00 $0.00 $205.44 $325.42 $328.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43418 SUP Custom 27803010 43418 - CATH 43418 CARDIAC CATH REDUCED TIP 58CM BOTH IP/OP $534.38 $395.44 $0.00 $427.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.61 $396.61 $0.00 $0.00 $111.36 $0.00 $0.00 $0.00 $0.00 $267.19 $423.23 $427.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43522 SUP Custom 27803010 43522 - CATH 43522 C/P CATH OPEN END W/SLITS STD BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $0.00 $0.00 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43551 SUP Custom 27803010 43551 - CATH 43551 C/P STD PLIANT BAR IMP BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $0.00 $0.00 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43555 SUP Custom 27803010 43555 - CATHETER 43555 PERITONEAL SMALL LUMEN BOTH IP/OP $593.75 $439.38 $0.00 $475.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $440.68 $440.68 $0.00 $0.00 $123.74 $0.00 $0.00 $0.00 $0.00 $296.88 $470.25 $475.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11-Jan SUP HCPCS C1713 JAN-11 - PLATE BONE SM RIGHT ORBTL FLR MESH CNTOUR ANTM EZ BOTH IP/OP "$4,677.50 " "$3,461.35" $0.00 "$3,742.00" "$2,104.88" "$2,104.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,338.75" "$3,704.58" "$3,742.00" $0.00 $0.00 $732.03 $0.00 $0.00 $744.66 $0.00 $0.00 $0.00 $0.00 $0.00 44000 SUP Custom 27803010 44000 - INLET 44000 VENTRICULAR PORT BOTTOM BOTH IP/OP $959.50 $710.03 $0.00 $767.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.14 $712.14 $0.00 $0.00 $199.96 $0.00 $0.00 $0.00 $0.00 $479.75 $759.92 $767.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44010 SUP Custom 27803010 44010 - INLET 44010 VENTRICULAR PORT SIDE BOTH IP/OP $959.50 $710.03 $0.00 $767.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.14 $712.14 $0.00 $0.00 $199.96 $0.00 $0.00 $0.00 $0.00 $479.75 $759.92 $767.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44100 SUP Custom 27803010 44100 - RESERVOIR 44100 VENT. 12MM CONVERT 20MM BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44101 SUP Custom 27803010 44101 - RESERVOIR DRN SM RT ANG 2.1MM 1.2MM 3CM .1ML STRL LF 12MM BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44103 SUP Custom 27803010 44103 - RESERVOIR DRN SM 28MM 2.1MM 1.2MM 23CM 1.1ML CSF SD INLT BOTH IP/OP $931.00 $688.94 $0.00 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.99 $690.99 $0.00 $0.00 $194.02 $0.00 $0.00 $0.00 $0.00 $465.50 $737.35 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44104 SUP Custom 27803010 44104 - RESERVOIR 44104 VENT. INLET BOTTOM BOTH IP/OP $931.00 $688.94 $0.00 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.99 $690.99 $0.00 $0.00 $194.02 $0.00 $0.00 $0.00 $0.00 $465.50 $737.35 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44105 SUP Custom 27803010 44105 - SUB BNGFT GRFTN DBM CRNCH JAR 5ML BOTH IP/OP $931.00 $688.94 $0.00 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.99 $690.99 $0.00 $0.00 $194.02 $0.00 $0.00 $0.00 $0.00 $465.50 $737.35 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44108 SUP Custom 27803010 44108 - RESERVOIR DRN SM 2.1MM 1.2MM 90CM 2.4ML STRL LF 30MM CSF BOTH IP/OP "$1,503.38 " "$1,112.50" $0.00 "$1,202.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,115.80" "$1,115.80" $0.00 $0.00 $313.30 $0.00 $0.00 $0.00 $0.00 $751.69 "$1,190.68" "$1,202.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44111 SUP Custom 27803010 44111 - RESERVOIR 44111 VENT. BURR HOLE BOTH IP/OP $931.00 $688.94 $0.00 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.99 $690.99 $0.00 $0.00 $194.02 $0.00 $0.00 $0.00 $0.00 $465.50 $737.35 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44113 SUP Custom 27803010 44113 - RESERVOIR SHNT 12MM STRL DLT CSF BUR HL BOTH IP/OP $931.00 $688.94 $0.00 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.99 $690.99 $0.00 $0.00 $194.02 $0.00 $0.00 $0.00 $0.00 $465.50 $737.35 $744.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44150 SUP HCPCS C1713 44150 - SUB BNGFT GRFTN SM DFCT DBM OTHBLND JAR 10ML BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,700.00" "$1,518.75" "$1,518.75" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,687.50" "$2,673.00" "$2,700.00" $0.00 $0.00 $528.19 $0.00 $0.00 $537.30 $0.00 $0.00 $0.00 $0.00 $0.00 44200 SUP Custom 27803010 44200 - RES 44200 VENTRICULOSTOMY BH 6MM REG IMP BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $0.00 $0.00 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44201 SUP Custom 27803010 44201 - KIT VNCLSTM REG 6MM STRL BUR HL CSF BOTH IP/OP $714.88 $529.01 $0.00 $571.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $530.58 $530.58 $0.00 $0.00 $148.98 $0.00 $0.00 $0.00 $0.00 $357.44 $566.18 $571.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44210 SUP Custom 27803010 44210 - RESERVOIR VNCLSTM SHLW 6MM CSF BUR HL BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $0.00 $0.00 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44211 SUP Custom 27803010 44211 - KIT VNCLSTM REG 6MM STRL CSF BUR HL SHLW D BOTH IP/OP $714.88 $529.01 $0.00 $571.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $530.58 $530.58 $0.00 $0.00 $148.98 $0.00 $0.00 $0.00 $0.00 $357.44 $566.18 $571.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-21 SUP Custom 27803010 6-2021 - CAGE SPNL 20MM 21MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$7,813.35 " "$5,781.88" $0.00 "$6,250.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,628.30" $0.00 $0.00 $0.00 $0.00 "$3,906.68" "$6,188.17" "$6,250.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jul-21 SUP Custom 27803010 7-2021 - DEVICE FSN 20MM 21MM RYTFC BOTH IP/OP "$6,615.95 " "$4,895.80" $0.00 "$5,292.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,378.76" $0.00 $0.00 $0.00 $0.00 "$3,307.98" "$5,239.83" "$5,292.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44405 SUP Custom 27803010 44405 - CATHETER 44405 LUMBAR CLOSED TIP BOTH IP/OP "$1,472.50 " "$1,089.65" $0.00 "$1,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,092.89" "$1,092.89" $0.00 $0.00 $306.87 $0.00 $0.00 $0.00 $0.00 $736.25 "$1,166.22" "$1,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44406 SUP Custom 27803010 44406 - CATHETER 44406 LUMBAR OPEN TIP BOTH IP/OP "$1,472.50 " "$1,089.65" $0.00 "$1,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,092.89" "$1,092.89" $0.00 $0.00 $306.87 $0.00 $0.00 $0.00 $0.00 $736.25 "$1,166.22" "$1,178.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44410 SUP Custom 27803010 44410 - SYSTEM CATH C14-24CM 2O 20GA 14GA 84CM PS MDCL CNCT 3 FX TAB BOTH IP/OP "$1,686.25 " "$1,247.83" $0.00 "$1,349.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,251.53" "$1,251.53" $0.00 $0.00 $351.41 $0.00 $0.00 $0.00 $0.00 $843.13 "$1,335.51" "$1,349.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44420 SUP Custom 27803010 44420 - SHUNT 44420 STRATA KIT NSC LP BOTH IP/OP "$11,247.10 " "$8,322.85" $0.00 "$8,997.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.90" $0.00 $0.00 $0.00 $0.00 "$5,623.55" "$8,907.70" "$8,997.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44421 SUP Custom 27203010 44421 - KIT 44421 STRATA NSC LP OPEN LUMBAR BOTH IP/OP "$11,247.10 " "$8,322.85" $0.00 "$8,997.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.90" $0.00 $0.00 $0.00 $0.00 "$5,623.55" "$8,907.70" "$8,997.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44430 SUP Custom 27803010 44430 - SHUNT 44430 STRATA KIT NSC LP ASSY BOTH IP/OP "$11,646.60 " "$8,618.48" $0.00 "$9,317.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,427.15" $0.00 $0.00 $0.00 $0.00 "$5,823.30" "$9,224.11" "$9,317.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44465 SUP Custom 27803010 44465 - VALVE 44465 STRATA NSC LP BOTH IP/OP "$9,677.30 " "$7,161.20" $0.00 "$7,741.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.75" $0.00 $0.00 $0.00 $0.00 "$4,838.65" "$7,664.42" "$7,741.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44513 SUP Custom 27803010 44513 - RES 44513 CSF-LUMBOPERITONEAL 20MM BOTH IP/OP $824.13 $609.86 $0.00 $659.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.67 $611.67 $0.00 $0.00 $171.75 $0.00 $0.00 $0.00 $0.00 $412.06 $652.71 $659.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44515 SUP Custom 27803010 44515 - RES 44515 CSF-LUMBOPERITONEAL 30MM BOTH IP/OP $824.13 $609.86 $0.00 $659.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.67 $611.67 $0.00 $0.00 $171.75 $0.00 $0.00 $0.00 $0.00 $412.06 $652.71 $659.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44520 SUP Custom 27803010 44520 - SHUNT NS 87CM STRL LMBPRTNL CATH T CSF BOTH IP/OP "$1,835.88 " "$1,358.55" $0.00 "$1,468.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,362.59" "$1,362.59" $0.00 $0.00 $382.60 $0.00 $0.00 $0.00 $0.00 $917.94 "$1,454.02" "$1,468.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45001 SUP Custom 27804086 45001 - GRAFT BN 1ML GRFTN + PST SYR DBM BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45005 SUP Custom 27804086 45005 - CANNULA LAPSCP 10MM DL PK DP50-0116-006 BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45010 SUP Custom 27804086 45010 - GRAFT BN 10ML GRFTN + PST SYR DBM BOTH IP/OP "$2,170.00 " "$1,605.80" $0.00 "$1,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,610.57" "$1,610.57" $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 "$1,085.00" "$1,718.64" "$1,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45103 SUP Custom 27803010 45103 - CONNECTOR SHNT STRG STRL ACFL CSF RADOPQ CATH PLS BOTH IP/OP $178.13 $131.82 $0.00 $142.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.20 $132.20 $0.00 $0.00 $37.12 $0.00 $0.00 $0.00 $0.00 $89.06 $141.08 $142.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45104 SUP Custom 27803010 45104 - CONNECTOR SHNT RT ANG STRL ACFL CSF CATH PLS BOTH IP/OP $178.13 $131.82 $0.00 $142.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.20 $132.20 $0.00 $0.00 $37.12 $0.00 $0.00 $0.00 $0.00 $89.06 $141.08 $142.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45105 SUP Custom 27803010 45105 - CONNECTOR SHNT STRL ACFL CSF CATH 3W PLS BOTH IP/OP $565.25 $418.29 $0.00 $452.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $419.53 $419.53 $0.00 $0.00 $117.80 $0.00 $0.00 $0.00 $0.00 $282.63 $447.68 $452.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45402 SUP Custom 27203010 45402 - TOOL 45402 SNAP ASSEMBLY BOTH IP/OP $729.13 $539.56 $0.00 $583.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.16 $541.16 $0.00 $0.00 $151.95 $0.00 $0.00 $0.00 $0.00 $364.56 $577.47 $583.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45792 SUP HCPCS C1758 45792 - CATHETER URET 5FR 70CM .038IN TPR TIP OP-EN RT BOTH IP/OP $24.50 $18.13 $0.00 $19.60 $13.30 $13.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.25 $19.40 $19.60 $0.00 $0.00 $3.83 $0.00 $0.00 $3.90 $0.00 $0.00 $0.00 $0.00 $0.00 45806 SUP Custom 27203010 45806 - KIT 45806 STRATA VARIOUS BOTH IP/OP "$8,922.95 " "$6,602.98" $0.00 "$7,138.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,859.54" $0.00 $0.00 $0.00 $0.00 "$4,461.48" "$7,066.98" "$7,138.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45807 SUP Custom 27203010 45807 - CARD 45807 SMART STRATA BOTH IP/OP $169.20 $125.21 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.58 $125.58 $0.00 $0.00 $35.26 $0.00 $0.00 $0.00 $0.00 $84.60 $134.01 $135.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45808 SUP Custom 27203010 45808 - CARD 45808 SMART STRATA NSC BOTH IP/OP $232.65 $172.16 $0.00 $186.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.67 $172.67 $0.00 $0.00 $48.48 $0.00 $0.00 $0.00 $0.00 $116.33 $184.26 $186.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45809 SUP Custom 27203010 45809 - TOOL 45809 STRATAVARIUS ADJUSTMENT BOTH IP/OP $491.63 $363.81 $0.00 $393.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $364.88 $364.88 $0.00 $0.00 $102.45 $0.00 $0.00 $0.00 $0.00 $245.81 $389.37 $393.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46012 SUP Custom 27803010 46012 - KIT 46012 SHUNT UNITIZED SMALL LOW BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46014 SUP Custom 27803010 46014 - KIT 46014 SHUNT UNITIZED SMALL MED BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46016 SUP Custom 27803010 46016 - KIT 46016 SHUNT UNITIZED SMALL HIGH BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46022 SUP Custom 27803010 46022 - KIT 46022 SHUNT UNITIZED REG LOW BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46024 SUP Custom 27803010 46024 - KIT 46024 SHUNT UNITIZED REG MED BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46026 SUP Custom 27803010 46026 - KIT 46026 SHUNT UNITIZED REG HIGH BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46070 SUP Custom 27803010 46070 - SHNT 46070 FP UNI STRATA NSC SML 8CM BOTH IP/OP "$10,112.05 " "$7,482.92" $0.00 "$8,089.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,107.35" $0.00 $0.00 $0.00 $0.00 "$5,056.03" "$8,008.74" "$8,089.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46075 SUP Custom 27803010 46075 - SHNT 46075 FP UNI STRATA NSC SM 11.5 BOTH IP/OP "$10,112.05 " "$7,482.92" $0.00 "$8,089.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,107.35" $0.00 $0.00 $0.00 $0.00 "$5,056.03" "$8,008.74" "$8,089.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46080 SUP Custom 27803010 46080 - SHNT 46080 FP UNI STRATA NSC REG 11 BOTH IP/OP "$10,112.05 " "$7,482.92" $0.00 "$8,089.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,107.35" $0.00 $0.00 $0.00 $0.00 "$5,056.03" "$8,008.74" "$8,089.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46085 SUP Custom 27803010 46085 - SHNT 46085 FP UNI STRATA NSC RG 13.5 BOTH IP/OP "$10,112.05 " "$7,482.92" $0.00 "$8,089.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,107.35" $0.00 $0.00 $0.00 $0.00 "$5,056.03" "$8,008.74" "$8,089.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46115 SUP HCPCS C1729 46115 - CATHETER DRN 20CM CLR STRL LF BCKR EDMS BA IMPRG SIL VNTRC BOTH IP/OP $268.80 $198.91 $0.00 $215.04 $145.96 $145.96 $0.00 $0.00 $0.00 $56.02 $199.50 $199.50 $0.00 $0.00 $56.02 $0.00 $159.00 $159.00 $0.00 $134.40 $212.89 $215.04 $0.00 $0.00 $42.07 $0.00 $0.00 $42.79 $0.00 $0.00 $0.00 $0.00 $0.00 46118 SUP HCPCS C1729 46118 - CATHETER XTRN DRN 2.8MM 1.5MM 35CM 700ML STRL LF 15CM EDM BOTH IP/OP $403.20 $298.37 $0.00 $322.56 $218.94 $218.94 $0.00 $0.00 $0.00 $84.04 $299.26 $299.26 $0.00 $0.00 $84.03 $0.00 $238.49 $238.49 $0.00 $201.60 $319.33 $322.56 $0.00 $0.00 $63.10 $0.00 $0.00 $64.19 $0.00 $0.00 $0.00 $0.00 $0.00 46126 SUP Custom 27203010 46126 - EDMS 46126 PATIENT CONN LINE ASSY BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46129 SUP Custom 27203010 46129 - EDMS III 46129 BECKER BOTH IP/OP $508.80 $376.51 $0.00 $407.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $377.63 $377.63 $0.00 $0.00 $106.03 $0.00 $0.00 $0.00 $0.00 $254.40 $402.97 $407.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46135 SUP HCPCS C1713 46135 - CLAMP 46135 QUICK ATTACH POLE BOTH IP/OP "$1,120.80 " $829.39 $0.00 $896.64 $504.36 $504.36 $0.00 $0.00 $0.00 $233.60 $831.86 $831.86 $0.00 $0.00 $233.57 $0.00 $662.95 $662.95 $0.00 $560.40 $887.67 $896.64 $0.00 $0.00 $175.41 $0.00 $0.00 $178.43 $0.00 $0.00 $0.00 $0.00 $0.00 46137 SUP HCPCS C1713 46137 - CLMP 46137 QUICK ATTACH POLE W/LAS BOTH IP/OP "$1,293.60 " $957.26 $0.00 "$1,034.88" $582.12 $582.12 $0.00 $0.00 $0.00 $269.62 $960.11 $960.11 $0.00 $0.00 $269.59 $0.00 $765.16 $765.16 $0.00 $646.80 "$1,024.53" "$1,034.88" $0.00 $0.00 $202.45 $0.00 $0.00 $205.94 $0.00 $0.00 $0.00 $0.00 $0.00 46141 SUP Custom 27203010 46141 - KIT 46141 EDM VEN DRAINAGE 5PK BOTH IP/OP $751.20 $555.89 $0.00 $600.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $557.54 $557.54 $0.00 $0.00 $156.55 $0.00 $0.00 $0.00 $0.00 $375.60 $594.95 $600.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46154 SUP Custom 27203010 46154 - KIT 46154 VNTRC EURO BOTH IP/OP $784.80 $580.75 $0.00 $627.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $582.48 $582.48 $0.00 $0.00 $163.55 $0.00 $0.00 $0.00 $0.00 $392.40 $621.56 $627.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-26 SUP Custom 27803010 6-2026 - CAGE SPNL 20MM 26MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$7,813.35 " "$5,781.88" $0.00 "$6,250.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,628.30" $0.00 $0.00 $0.00 $0.00 "$3,906.68" "$6,188.17" "$6,250.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46220 SUP Custom 27803010 46220 - KIT 46220 SHUNT ULTRA SMALL 4CM LL BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46222 SUP Custom 27803010 46222 - KIT 46222 SHUNT ULTRA SMALL 4CM LOW BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46224 SUP Custom 27803010 46224 - SHUNT 46224 KIT ULTRA SMALL 4CM MED IMP BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46240 SUP Custom 27803010 46240 - KIT 46240 SHUNT ULTRA SMALL 6CM LL BOTH IP/OP "$3,080.38 " "$2,279.48" $0.00 "$2,464.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,286.25" "$2,286.25" $0.00 $0.00 $641.95 $0.00 $0.00 $0.00 $0.00 "$1,540.19" "$2,439.66" "$2,464.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46242 SUP Custom 27803010 46242 - KIT 46242 SHUNT ULTRA SMALL 6CM LOW BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46244 SUP Custom 27803010 46244 - KIT 46244 SHUNT ULTRA SMALL 6CM MED BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46418 SUP Custom 27803010 46418 - CATHETER 46418 EDM LUMBAR 24CM OPEN BOTH IP/OP $391.20 $289.49 $0.00 $312.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.35 $290.35 $0.00 $0.00 $81.53 $0.00 $0.00 $0.00 $0.00 $195.60 $309.83 $312.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46419 SUP HCPCS C1729 46419 - CATHETER XTRN DRN 80CM STRL EDM CLS TIP BA IMPRG SIL LMBR BOTH IP/OP $566.40 $419.14 $0.00 $453.12 $307.56 $307.56 $0.00 $0.00 $0.00 $118.05 $420.38 $420.38 $0.00 $0.00 $118.04 $0.00 $335.03 $335.03 $0.00 $283.20 $448.59 $453.12 $0.00 $0.00 $88.64 $0.00 $0.00 $90.17 $0.00 $0.00 $0.00 $0.00 $0.00 46420 SUP Custom 27803010 46420 - CATH 46420 EDM LUMBAR 80CM/OPEN TIP BOTH IP/OP $544.80 $403.15 $0.00 $435.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $404.35 $404.35 $0.00 $0.00 $113.54 $0.00 $0.00 $0.00 $0.00 $272.40 $431.48 $435.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46430 SUP Custom 27203010 46430 - BAGS 46430 EDM DRAINAGE 10-PACK BOX BOTH IP/OP $88.08 $65.18 $0.00 $70.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.37 $65.37 $0.00 $0.00 $18.36 $0.00 $0.00 $0.00 $0.00 $44.04 $69.76 $70.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46440 SUP Custom 27203010 46440 - KIT XTRN DRN 35CM 700ML BE2 MNTR LMBR BOTH IP/OP $767.52 $567.96 $0.00 $614.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $569.65 $569.65 $0.00 $0.00 $159.95 $0.00 $0.00 $0.00 $0.00 $383.76 $607.88 $614.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46441 SUP Custom 27203010 46441 - KIT 46441 EDM LUMBAR DRAINAGE 5PK BOTH IP/OP $629.76 $466.02 $0.00 $503.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $467.41 $467.41 $0.00 $0.00 $131.24 $0.00 $0.00 $0.00 $0.00 $314.88 $498.77 $503.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46442 SUP Custom 27203010 46442 - KIT 46442 EDM LUMBAR DRN CLS TIP 5PK BOTH IP/OP $629.76 $466.02 $0.00 $503.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $467.41 $467.41 $0.00 $0.00 $131.24 $0.00 $0.00 $0.00 $0.00 $314.88 $498.77 $503.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46540 SUP Custom 27803010 46540 - SHUNT 46540 CSF SNAP ASSY BUTTON LOW LOW BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46542 SUP Custom 27803010 46542 - SHUNT NS CSF ASMB SNP BTN LP BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46544 SUP Custom 27803010 46544 - SHUNT NS CSF ASMB SNP BTN MED PRSS BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46560 SUP Custom 27803010 46560 - SHUNT 46560 CSF SNAP ASSY US LOW LOW BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46562 SUP Custom 27803010 46562 - SHUNT 46562 CSF SNAP ASSY US LOW BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46564 SUP Custom 27803010 46564 - SHUNT 46564 CSF SNAP ASSY US MEDIUM BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46622 SUP Custom 27803010 46622 - SHUNT 46622 CSF ASSY SMALL LOW CONT C/P BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46624 SUP Custom 27803010 46624 - SHUNT 46624 CSF ASSY SMALL MED CONT C/P BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46626 SUP Custom 27803010 46626 - SHUNT 46626 CSF ASSY SMALL HIGH CONT C/P BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46635 SUP Custom 27803010 46635 - SHUNT 46635 STRATA NSC BURR HOLE BOTH IP/OP "$9,458.75 " "$6,999.48" $0.00 "$7,567.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,971.20" $0.00 $0.00 $0.00 $0.00 "$4,729.38" "$7,491.33" "$7,567.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46642 SUP Custom 27803010 46642 - SHUNT 46642 ASSY REG LOW C/P-90CM BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46644 SUP Custom 27803010 46644 - SHUNT 46644 ASSY REG MED C/P-90CM BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46646 SUP Custom 27803010 46646 - SHUNT 46646 ASSY REG HIGH C/P-90CM BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46655 SUP Custom 27803010 46655 - ASSY 46655 FP SHUNT STRATA NSC SMALL BOTH IP/OP "$9,458.75 " "$6,999.48" $0.00 "$7,567.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,971.20" $0.00 $0.00 $0.00 $0.00 "$4,729.38" "$7,491.33" "$7,567.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46665 SUP Custom 27803010 46665 - ASSY 46665 FP SHUNT STRATA NSC REG BOTH IP/OP "$9,458.75 " "$6,999.48" $0.00 "$7,567.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,971.20" $0.00 $0.00 $0.00 $0.00 "$4,729.38" "$7,491.33" "$7,567.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46700 SUP Custom 27203010 46700 - SYSTEM 46700 EXACTA DISP. DRAINAGE BOTH IP/OP $398.40 $294.82 $0.00 $318.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.69 $295.69 $0.00 $0.00 $83.03 $0.00 $0.00 $0.00 $0.00 $199.20 $315.53 $318.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46705 SUP Custom 27203010 46705 - SYSTEM 46705 EXACTA DRAINAGE 100ML BOTH IP/OP $432.00 $319.68 $0.00 $345.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.63 $320.63 $0.00 $0.00 $90.03 $0.00 $0.00 $0.00 $0.00 $216.00 $342.14 $345.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46710 SUP Custom 27203010 46710 - BAG 46710 EXACTA DRAINAGE BOTH IP/OP $110.40 $81.70 $0.00 $88.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.94 $81.94 $0.00 $0.00 $23.01 $0.00 $0.00 $0.00 $0.00 $55.20 $87.44 $88.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46711 SUP Custom 27203010 46711 - ASSY 46711 EXACTA POLE CLAMP W/LASER BOTH IP/OP "$1,281.60 " $948.38 $0.00 "$1,025.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.20 $951.20 $0.00 $0.00 $267.09 $0.00 $0.00 $0.00 $0.00 $640.80 "$1,015.03" "$1,025.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46712 SUP Custom 27203010 46712 - BAG 46712 EXACTA DRAINAGE 10 PK BOTH IP/OP $88.08 $65.18 $0.00 $70.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.37 $65.37 $0.00 $0.00 $18.36 $0.00 $0.00 $0.00 $0.00 $44.04 $69.76 $70.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46713 SUP Custom 27203010 46713 - ASSY 46713 EXACTA POLE CLAMP NO LASER BOTH IP/OP "$1,142.40 " $845.38 $0.00 $913.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $847.89 $847.89 $0.00 $0.00 $238.08 $0.00 $0.00 $0.00 $0.00 $571.20 $904.78 $913.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46715 SUP HCPCS C1713 46715 - CLAMP 46715 EXACTA PL NEG 25CM W/LSR BOTH IP/OP "$1,399.20 " "$1,035.41" $0.00 "$1,119.36" $629.64 $629.64 $0.00 $0.00 $0.00 $291.63 "$1,038.49" "$1,038.49" $0.00 $0.00 $291.59 $0.00 $827.63 $827.63 $0.00 $699.60 "$1,108.17" "$1,119.36" $0.00 $0.00 $218.97 $0.00 $0.00 $222.75 $0.00 $0.00 $0.00 $0.00 $0.00 46717 SUP HCPCS C1713 46717 - CLAMP 46717 EXACTA POLE -25CM W/O LSR BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 46812 SUP Custom 27803010 46812 - ASSY 46812 DELTA SHUNT SMALL PL 1 BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46813 SUP Custom 27803010 46813 - ASSY 46813 DELTA SHUNT SM LEV 1.5 BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46814 SUP Custom 27803010 46814 - ASSY 46814 DELTA SHUNT SMALL P/L 2 BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46822 SUP Custom 27803010 46822 - ASSY 46822 DELTA SHUNT REG P/L 1 BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46823 SUP Custom 27803010 46823 - ASSY 46823 DELTA SHUNT REG LEV 1.5 BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46824 SUP Custom 27803010 46824 - ASSY 46824 DELTA SHUNT REG P/L 2 BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46832 SUP Custom 27803010 46832 - SHUNT 46832 NEONATAL DELTA SNAP L 1 BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46833 SUP Custom 27803010 46833 - SHUNT 46833 NEONATAL DELTA SNAP 1.5 BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46834 SUP Custom 27803010 46834 - SHUNT 46834 NEONATAL DELTA SNAP L 2 BOTH IP/OP "$5,191.75 " "$3,841.90" $0.00 "$4,153.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,853.32" "$3,853.32" $0.00 $0.00 "$1,081.96" $0.00 $0.00 $0.00 $0.00 "$2,595.88" "$4,111.87" "$4,153.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46836 SUP Custom 27803010 46836 - SHUNT 46836 STRATA II BURR HOLE BOTH IP/OP "$10,302.40 " "$7,623.78" $0.00 "$8,241.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,147.02" $0.00 $0.00 $0.00 $0.00 "$5,151.20" "$8,159.50" "$8,241.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46856 SUP Custom 27803010 46856 - ASSY 46856 FP-STRATA 2 SHUNT SML BOTH IP/OP "$10,302.40 " "$7,623.78" $0.00 "$8,241.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,147.02" $0.00 $0.00 $0.00 $0.00 "$5,151.20" "$8,159.50" "$8,241.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46866 SUP Custom 27803010 46866 - ASSY 46866 FP-STRATA 2 SHUNT REG BOTH IP/OP "$10,302.40 " "$7,623.78" $0.00 "$8,241.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,147.02" $0.00 $0.00 $0.00 $0.00 "$5,151.20" "$8,159.50" "$8,241.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46871 SUP Custom 27803010 46871 - SHUNT 46871 FP-STRATA UNI SML 8 BOTH IP/OP "$10,915.75 " "$8,077.66" $0.00 "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,274.84" $0.00 $0.00 $0.00 $0.00 "$5,457.88" "$8,645.27" "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46876 SUP Custom 27803010 46876 - UNISHUNT 46876 FP STRATA SM 11.5 BOTH IP/OP "$10,915.75 " "$8,077.66" $0.00 "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,274.84" $0.00 $0.00 $0.00 $0.00 "$5,457.88" "$8,645.27" "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46881 SUP Custom 27803010 46881 - SHUNT 46881 FP-STRATA UNI REG 11 BOTH IP/OP "$10,915.75 " "$8,077.66" $0.00 "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,274.84" $0.00 $0.00 $0.00 $0.00 "$5,457.88" "$8,645.27" "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46886 SUP Custom 27803010 46886 - SHUNT 46886 FP-STRATA UNI REG 13.5 BOTH IP/OP "$10,915.75 " "$8,077.66" $0.00 "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,274.84" $0.00 $0.00 $0.00 $0.00 "$5,457.88" "$8,645.27" "$8,732.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46911 SUP Custom 27203010 46911 - BAG 46911 DRAINAGE DEHP-FREE 1PK BOTH IP/OP $110.40 $81.70 $0.00 $88.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.94 $81.94 $0.00 $0.00 $23.01 $0.00 $0.00 $0.00 $0.00 $55.20 $87.44 $88.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46912 SUP Custom 27203010 46912 - BAG 46912 DRAINAGE DEHP-FREE 10PK BOTH IP/OP $88.08 $65.18 $0.00 $70.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.37 $65.37 $0.00 $0.00 $18.36 $0.00 $0.00 $0.00 $0.00 $44.04 $69.76 $70.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46913 SUP Custom 27203010 46913 - EDMS 46913 DUET INTERLINK SITES BOTH IP/OP $566.40 $419.14 $0.00 $453.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.38 $420.38 $0.00 $0.00 $118.04 $0.00 $0.00 $0.00 $0.00 $283.20 $448.59 $453.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46914 SUP Custom 27203010 46914 - EDMS 46914 DUET BLUECORE SITES BOTH IP/OP $566.40 $419.14 $0.00 $453.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.38 $420.38 $0.00 $0.00 $118.04 $0.00 $0.00 $0.00 $0.00 $283.20 $448.59 $453.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46915 SUP Custom 27203010 46915 - EDMS 46915 DUET INTERLINK WITH VCATH BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46916 SUP Custom 27203010 46916 - EDMS 46916 DUET BLUECORE WITH VCATH BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46917 SUP Custom 27203010 46917 - SYSTEM XTRN DRN 60IN DUET LCATH INTLNK CLS SYS XTRN VNTRC BOTH IP/OP "$1,104.00 " $816.96 $0.00 $883.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $819.39 $819.39 $0.00 $0.00 $230.07 $0.00 $0.00 $0.00 $0.00 $552.00 $874.37 $883.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46918 SUP Custom 27203010 46918 - LEVEL LSR NS LF CLRST REUSE XTRN DRN MNTR SYS BOTH IP/OP $211.20 $156.29 $0.00 $168.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.75 $156.75 $0.00 $0.00 $44.01 $0.00 $0.00 $0.00 $0.00 $105.60 $167.27 $168.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47032 SUP Custom 27203010 47032 - NEEDLE AMNIO 15CM 20GA ECHTP SDPRT DISP BOTH IP/OP $43.13 $31.92 $0.00 $34.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.56 $34.16 $34.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48270 SUP Custom 27203010 0048270 - TUBING SCT 100FT 9/32IN PLST NCDTV ECON INTGR BLSTR CONCTR BOTH IP/OP $13.52 $10.00 $0.00 $10.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.03 $10.03 $0.00 $0.00 $2.82 $0.00 $0.00 $0.00 $0.00 $6.76 $10.71 $10.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48403 SUP Custom 27203010 48403 - PASSER 48403 L/P SUBCUT CATH 38CM BOTH IP/OP "$2,766.88 " "$2,047.49" $0.00 "$2,213.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,053.57" "$2,053.57" $0.00 $0.00 $576.62 $0.00 $0.00 $0.00 $0.00 "$1,383.44" "$2,191.37" "$2,213.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48405 SUP Custom 27203010 48405 - PASSER 48405 CATH V/P SUBCUT 60CM BOTH IP/OP "$2,914.13 " "$2,156.46" $0.00 "$2,331.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,162.86" "$2,162.86" $0.00 $0.00 $607.30 $0.00 $0.00 $0.00 $0.00 "$1,457.06" "$2,307.99" "$2,331.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48407 SUP Custom 27203010 48407 - PASSER 48407 CATHETER 38CM DISP. BOTH IP/OP $344.38 $254.84 $0.00 $275.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.60 $255.60 $0.00 $0.00 $71.77 $0.00 $0.00 $0.00 $0.00 $172.19 $272.75 $275.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48409 SUP Custom 27203010 48409 - PASSER 48409 60CM DISP. CATHETER BOTH IP/OP $368.13 $272.42 $0.00 $294.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.22 $273.22 $0.00 $0.00 $76.72 $0.00 $0.00 $0.00 $0.00 $184.06 $291.56 $294.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50120 SUP Custom 27803010 50120 - CLIP LGT MED LG VESOCCLUDE SMTR 6 CRTDG TI BOTH IP/OP $9.38 $6.94 $0.00 $7.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.96 $6.96 $0.00 $0.00 $1.95 $0.00 $0.00 $0.00 $0.00 $4.69 $7.43 $7.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50190 SUP Custom 27203010 KIT GSTRM 18FR INTROD BR-MLR TFSTNR DILAT BOTH IP/OP $414.50 $306.73 $0.00 $331.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.25 $328.28 $331.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50318 SUP Custom 27803010 50318 - CATHETER 50318 EVD ANTIBIOTIC PK 5 NCE BOTH IP/OP "$3,600.00 " "$2,664.00" $0.00 "$2,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,671.92" "$2,671.92" $0.00 $0.00 $750.24 $0.00 $0.00 $0.00 $0.00 "$1,800.00" "$2,851.20" "$2,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50823 SUP Custom 27203010 50823 - INFLATION SYSTEM BOTH IP/OP $55.15 $40.81 $0.00 $44.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.93 $40.93 $0.00 $0.00 $11.49 $0.00 $0.00 $0.00 $0.00 $27.58 $43.68 $44.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 52021 SUP HCPCS Q4108 52021 - DRESSING WND 2X2IN MTRX BVN CLGN BOTH IP/OP "$1,205.92 " $892.38 $0.00 "$1,096.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $895.03 $895.03 $0.00 $0.00 $41.87 $0.00 $0.00 $0.00 $0.00 $685.18 "$1,085.33" "$1,096.29" $0.00 $0.00 $39.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 53130 SUP Custom 27203010 53130 - RETAINER SEPRONET 3 25YDX7/8IN ELAST TBLR NT DRSG NYL RBR BOTH IP/OP $67.92 $50.26 $0.00 $54.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.96 $53.79 $54.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 53660 SUP HCPCS C1725 53660 - CATH BALDILAT .038IN 7FR 80CM 4.5CM ILC FEM POPLT ART TPR BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $20.36 $20.36 $0.00 $0.00 $0.00 $7.82 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $22.18 $22.18 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $5.87 $0.00 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 54051 SUP HCPCS Q4108 54051 - DRESSING WND 5X4IN STRL BVN CLGN GAG DISP BOTH IP/OP "$8,046.58 " "$5,954.47" $0.00 "$7,315.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,972.17" "$5,972.17" $0.00 $0.00 $41.87 $0.00 $0.00 $0.00 $0.00 "$4,571.91" "$7,241.91" "$7,315.06" $0.00 $0.00 $39.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 56030 SUP HCPCS C1729 "056030 - URETHRAL CATHETERS, BARDEX, ROBINSON MODEL, LATEX 30FR" BOTH IP/OP $7.03 $5.20 $0.00 $5.62 $3.81 $3.81 $0.00 $0.00 $0.00 $1.46 $5.21 $5.21 $0.00 $0.00 $1.46 $0.00 $4.16 $4.16 $0.00 $3.51 $5.57 $5.62 $0.00 $0.00 $1.10 $0.00 $0.00 $1.12 $0.00 $0.00 $0.00 $0.00 $0.00 57760 SUP Custom 27203010 FORMULA NUTRITIONAL SIMILAC 24 CAL IRON FORTIFIED BOTH IP/OP $26.03 $19.26 $0.00 $20.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.01 $20.62 $20.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 58025 SUP Custom 27803010 58025 - FILLER BONE VOID ALLOGRAFT FREEZE DRY MIX DBX 2.5CC BOTH IP/OP "$1,156.00 " $855.44 $0.00 $924.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.98 $857.98 $0.00 $0.00 $240.91 $0.00 $0.00 $0.00 $0.00 $578.00 $915.55 $924.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 58050 SUP HCPCS C1713 58050 - FILLER BONE VOID ALLOGRAFT FREEZE DRIED MIX DBX 5ML BOTH IP/OP "$2,091.00 " "$1,547.34" $0.00 "$1,672.80" $940.95 $940.95 $0.00 $0.00 $0.00 $435.82 "$1,551.94" "$1,551.94" $0.00 $0.00 $435.76 $0.00 "$1,236.83" "$1,236.83" $0.00 "$1,045.50" "$1,656.07" "$1,672.80" $0.00 $0.00 $327.24 $0.00 $0.00 $332.89 $0.00 $0.00 $0.00 $0.00 $0.00 58200 SUP HCPCS C1713 58200 - FILLER BONE VOID ALLOGRAFT MIX FREEZE DRIED DBX BOTH IP/OP "$9,475.00 " "$7,011.50" $0.00 "$7,580.00" "$4,263.75" "$4,263.75" $0.00 $0.00 $0.00 "$1,974.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,974.59" $0.00 "$4,671.18" "$4,671.18" $0.00 "$4,737.50" "$7,504.20" "$7,580.00" $0.00 $0.00 "$1,482.84" $0.00 $0.00 "$1,508.42" $0.00 $0.00 $0.00 $0.00 $0.00 60011 SUP HCPCS C2625 60011 - IMPLANT NASAL 370 MCG MINI 4MM 16MM STEROID RELEASE ZIP TIE BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,850.00" "$1,040.63" "$1,040.63" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,156.25" "$1,831.50" "$1,850.00" $0.00 $0.00 $361.91 $0.00 $0.00 $368.15 $0.00 $0.00 $0.00 $0.00 $0.00 61000 SUP Custom 27203010 TUBING PRSS DSPL SET STPCK 45IN REST HRT DISP BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61621 SUP Custom 27803010 61621 - CAGE SPNL 16MM 21MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$8,031.25 " "$5,943.13" $0.00 "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,673.71" $0.00 $0.00 $0.00 $0.00 "$4,015.63" "$6,360.75" "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62100 SUP Custom 27803010 62100 - PATCH DURA 2X2IN STRL DUREPAIR RSRB BVN CLGN MTRX CRNL DRPLS BOTH IP/OP $996.40 $737.34 $0.00 $797.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $739.53 $739.53 $0.00 $0.00 $207.65 $0.00 $0.00 $0.00 $0.00 $498.20 $789.15 $797.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62105 SUP Custom 27803010 62105 - PATCH DURA 3X3IN DUREPAIR CRANIAL BVN CLGN MTRX RESORB DRPLS BOTH IP/OP "$1,816.55 " "$1,344.25" $0.00 "$1,453.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,348.24" "$1,348.24" $0.00 $0.00 $378.57 $0.00 $0.00 $0.00 $0.00 $908.28 "$1,438.71" "$1,453.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62106 SUP Custom 27803010 62106 - DURA 62106 SUBSTITUTE DUREPAIR 1X3IN NCE BOTH IP/OP $822.50 $608.65 $0.00 $658.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.46 $610.46 $0.00 $0.00 $171.41 $0.00 $0.00 $0.00 $0.00 $411.25 $651.42 $658.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62110 SUP Custom 27803010 62110 - PATCH DURA 5X4IN DUREPAIR CRANIAL BVN CLGN MTRX RESORB DRPLS BOTH IP/OP "$3,520.30 " "$2,605.02" $0.00 "$2,816.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,612.77" "$2,612.77" $0.00 $0.00 $733.63 $0.00 $0.00 $0.00 $0.00 "$1,760.15" "$2,788.08" "$2,816.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62111 SUP Custom 27803010 62111 - DURA 62111 SUBSTITUTE DUREPAIR 1X1IN NCE BOTH IP/OP $392.45 $290.41 $0.00 $313.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $291.28 $291.28 $0.00 $0.00 $81.79 $0.00 $0.00 $0.00 $0.00 $196.23 $310.82 $313.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62158 SUP Custom 27803010 62158 - DURA 62158 SUBSTITUTE DUREPAIR 5X8IN NCE BOTH IP/OP "$8,742.00 " "$6,469.08" $0.00 "$6,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,821.83" $0.00 $0.00 $0.00 $0.00 "$4,371.00" "$6,923.66" "$6,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 64018 SUP HCPCS C1729 064018 - CATHETER NEPHROSTOMY 18FR 2 EYE DRAIN LATEX PEZZER STERILE BOTH IP/OP $43.23 $31.99 $0.00 $34.58 $23.47 $23.47 $0.00 $0.00 $0.00 $9.01 $32.08 $32.08 $0.00 $0.00 $9.01 $0.00 $25.57 $25.57 $0.00 $21.61 $34.24 $34.58 $0.00 $0.00 $6.76 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 64024 SUP HCPCS C1729 064024 - CATH NPHSTM 24FR PEZ DRAIN 2 EYE STRL LATEX DISP BOTH IP/OP $43.23 $31.99 $0.00 $34.58 $23.47 $23.47 $0.00 $0.00 $0.00 $9.01 $32.08 $32.08 $0.00 $0.00 $9.01 $0.00 $25.57 $25.57 $0.00 $21.61 $34.24 $34.58 $0.00 $0.00 $6.76 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 64026 SUP HCPCS C1729 064026 - CATH NPHSTM 26FR PEZ DRAIN 2 EYE STRL LATEX DISP BOTH IP/OP $43.23 $31.99 $0.00 $34.58 $23.47 $23.47 $0.00 $0.00 $0.00 $9.01 $32.08 $32.08 $0.00 $0.00 $9.01 $0.00 $25.57 $25.57 $0.00 $21.61 $34.24 $34.58 $0.00 $0.00 $6.76 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 64030 SUP HCPCS C1729 064030 - CATHETER NEPHROSTOMY 30FR 2 EYE DRAIN LATEX PEZZER STERILE BOTH IP/OP $43.23 $31.99 $0.00 $34.58 $23.47 $23.47 $0.00 $0.00 $0.00 $9.01 $32.08 $32.08 $0.00 $0.00 $9.01 $0.00 $25.57 $25.57 $0.00 $21.61 $34.24 $34.58 $0.00 $0.00 $6.76 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $0.00 64036 SUP HCPCS C1729 064036 - CATHETER URTH 36FR STRL LTX PEZ 2 EYE DRN PROPORTIONATE HD BOTH IP/OP $2.84 $2.10 $0.00 $2.27 $1.54 $1.54 $0.00 $0.00 $0.00 $0.59 $2.11 $2.11 $0.00 $0.00 $0.59 $0.00 $1.68 $1.68 $0.00 $1.42 $2.25 $2.27 $0.00 $0.00 $0.44 $0.00 $0.00 $0.45 $0.00 $0.00 $0.00 $0.00 $0.00 64331 SUP Custom 27203010 BRACE ORTH LEFT ANKL FT SWED AFO PE FRDM MALE BOTH IP/OP $76.88 $56.89 $0.00 $61.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.44 $60.89 $61.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 67910 SUP Custom 27203010 0067910 - BRUSH FEMORAL CANAL SUCTION IRRIGATION LATEX SIMPULSE PLUS BOTH IP/OP $165.48 $122.46 $0.00 $122.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.82 $122.82 $0.00 $0.00 $34.49 $0.00 $0.00 $0.00 $0.00 $46.53 $73.70 $74.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68128 SUP Custom 27203010 68128 - CANNULA PERFUSION 3/8IN CONCTR 28FR 12-15IN 1 STAGE MALBLE BOTH IP/OP $786.79 $582.22 $0.00 $717.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $583.95 $583.95 $0.00 $0.00 $163.97 $0.00 $0.00 $0.00 $0.00 $448.63 $710.62 $717.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68250 SUP Custom 27803010 68250 - GRAFT SFT TIS 1.5X1.5CM TTPLST PRICRD ALGRF PRC STRL BOTH IP/OP $637.50 $471.75 $0.00 $510.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $473.15 $473.15 $0.00 $0.00 $132.86 $0.00 $0.00 $0.00 $0.00 $318.75 $504.90 $510.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68333 SUP Custom 27803010 68333 - GRAFT SFT TIS .8X.5CM STRL TTPLST LOPRFL SCLR BOTH IP/OP $725.00 $536.50 $0.00 $580.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $0.00 $0.00 $0.00 $362.50 $574.20 $580.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70011 SUP HCPCS C2625 70011 - STENT NSL 370 MCG PROPEL MOMETASONE FUROATE BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,850.00" "$1,040.63" "$1,040.63" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,156.25" "$1,831.50" "$1,850.00" $0.00 $0.00 $361.91 $0.00 $0.00 $368.15 $0.00 $0.00 $0.00 $0.00 $0.00 71221 SUP Custom 27803010 71221 - CAGE SPNL STD 12MM 21MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$7,087.75 " "$5,244.94" $0.00 "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,477.09" $0.00 $0.00 $0.00 $0.00 "$3,543.88" "$5,613.50" "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71226 SUP Custom 27803010 71226 - CAGE SPNL STD 12MM 26MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$7,087.75 " "$5,244.94" $0.00 "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,477.09" $0.00 $0.00 $0.00 $0.00 "$3,543.88" "$5,613.50" "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71310 SUP Custom 27203010 TRAY SPCLA BLK UNV CHRGR BOTH IP/OP $69.05 $51.10 $0.00 $55.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.53 $54.69 $55.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71421 SUP Custom 27803010 71421 - CAGE SPNL STD 14MM 21MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$7,087.75 " "$5,244.94" $0.00 "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,477.09" $0.00 $0.00 $0.00 $0.00 "$3,543.88" "$5,613.50" "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71426 SUP Custom 27803010 71426 - CAGE SPNL STD 14MM 26MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$7,087.75 " "$5,244.94" $0.00 "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,477.09" $0.00 $0.00 $0.00 $0.00 "$3,543.88" "$5,613.50" "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71621 SUP Custom 27803010 71621 - CAGE SPNL STD 16MM 21MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$7,087.75 " "$5,244.94" $0.00 "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,477.09" $0.00 $0.00 $0.00 $0.00 "$3,543.88" "$5,613.50" "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71626 SUP Custom 27803010 71626 - CAGE SPNL STD 16MM 26MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$7,087.75 " "$5,244.94" $0.00 "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,477.09" $0.00 $0.00 $0.00 $0.00 "$3,543.88" "$5,613.50" "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71821 SUP Custom 27803010 71821 - CAGE SPNL STD 18MM 21MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$7,087.75 " "$5,244.94" $0.00 "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,477.09" $0.00 $0.00 $0.00 $0.00 "$3,543.88" "$5,613.50" "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71826 SUP Custom 27803010 71826 - CAGE SPNL STD 18MM 26MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$7,087.75 " "$5,244.94" $0.00 "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,477.09" $0.00 $0.00 $0.00 $0.00 "$3,543.88" "$5,613.50" "$5,670.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72026 SUP Custom 27803010 72026 - CAGE SPNL STD 20MM 26MM RYTFC THRD CNCT TI PLIF BOTH IP/OP "$6,615.95 " "$4,895.80" $0.00 "$5,292.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,378.76" $0.00 $0.00 $0.00 $0.00 "$3,307.98" "$5,239.83" "$5,292.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72228 SUP Custom 27203010 72228 - DRAIN INCISION FULL FLUTE ROUND 15FR 3/16IN CHANNEL RADIOPQ BOTH IP/OP $34.44 $25.49 $0.00 $27.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.56 $25.56 $0.00 $0.00 $7.18 $0.00 $0.00 $0.00 $0.00 $17.22 $27.28 $27.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72230 SUP Custom 27203010 072230 - DRAIN 19FR HUBLESS FULL FLUTED BOTH IP/OP $43.68 $32.32 $0.00 $34.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.42 $32.42 $0.00 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $21.84 $34.59 $34.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72335 SUP Custom 27203010 72335 - SPLINT ORTHOPEDIC LP 35X3IN PRECUT PAD WATER REPELLENT LATEX BOTH IP/OP $23.68 $17.52 $0.00 $32.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.57 $17.57 $0.00 $0.00 $4.93 $0.00 $0.00 $0.00 $0.00 $12.02 $32.08 $19.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72430 SUP Custom 27203010 72430 - SPLINT ORTH 30X4IN CNFRM PCUT FELT PD HPOAL H2O RPLNT FBGLS BOTH IP/OP $26.74 $19.79 $0.00 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.37 $21.18 $21.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72495 SUP Custom 27203010 CONTROL ANTI HAV IGM MONOLISA EIA IMMUN BOTH IP/OP "$1,612.50 " "$1,193.25" $0.00 "$1,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $806.25 "$1,277.10" "$1,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72496 SUP Custom 27203010 CONTROL ANTI-HAV IGM IGG HAV MONOLISA EIA 192 TST IMMUN BOTH IP/OP "$1,387.50 " "$1,026.75" $0.00 "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $693.75 "$1,098.90" "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72530 SUP Custom 27203010 72530 - SPLINT ORTH 30X5IN PCUT FELT PD FBGLS SCTCHCST CNFRM BOTH IP/OP $31.37 $23.21 $0.00 $25.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.28 $23.28 $0.00 $0.00 $6.54 $0.00 $0.00 $0.00 $0.00 $15.69 $24.85 $25.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75000 SUP HCPCS C1726 075000 - SET DILAT 30CM 6-30FR AMPTZ RNL TFE 16CM BOTH IP/OP $495.85 $366.93 $0.00 $396.68 $269.25 $269.25 $0.00 $0.00 $0.00 $103.35 $368.02 $368.02 $0.00 $0.00 $103.34 $0.00 $293.30 $293.30 $0.00 $247.93 $392.71 $396.68 $0.00 $0.00 $77.60 $0.00 $0.00 $78.94 $0.00 $0.00 $0.00 $0.00 $0.00 76430 SUP Custom 27203010 76430 - SPLINT ORTHOPEDIC 30X4IN CONFORMABLE MOLDABLE LIGHTWEIGHT 3M BOTH IP/OP $72.14 $53.38 $0.00 $53.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.54 $53.54 $0.00 $0.00 $15.03 $0.00 $0.00 $0.00 $0.00 $14.11 $37.46 $22.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 78710 SUP HCPCS C1713 SPACER MDI ARCHB+ MED VLV HLD CHMBR HNDHLD CMFSL MASK PED BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $18.81 $18.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 78810 SUP Custom 27203010 TRANSILLUMINATOR EXAM TRNSFM ON/OFF SWH LF DISP KLNSPC VAG BOTH IP/OP $326.83 $241.85 $0.00 $261.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.41 $258.85 $261.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79910 SUP Custom 27203010 TRANSILLUMINATOR EXAM CRDLS CHRG STTN DISP KLNSPC VAG SPCLM BOTH IP/OP $461.70 $341.66 $0.00 $369.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.85 $365.67 $369.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80010 SUP Custom 27803010 80010 - IMPLANT ORBTL 18MM SPHERE SMOOTH SUTURE TUNNELS POROUS BOTH IP/OP "$1,630.13 " "$1,206.30" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,209.88" "$1,209.88" $0.00 $0.00 $339.72 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80018 SUP Custom 27203010 80018 - IMPLANT ORBTL 18MM CONICAL MULTPUR SMOOTH SUTURE TUNNELS BOTH IP/OP "$1,912.50 " "$1,415.25" $0.00 "$1,530.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,419.46" "$1,419.46" $0.00 $0.00 $398.57 $0.00 $0.00 $0.00 $0.00 $956.25 "$1,514.70" "$1,530.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80022 SUP Custom 27803010 80022 - QUAD MOTILITY IMPLANT - EXTRA LARGE (APPROX. 22MM VOLUME) BOTH IP/OP "$1,188.06 " $879.16 $0.00 $950.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.78 $881.78 $0.00 $0.00 $247.59 $0.00 $0.00 $0.00 $0.00 $594.03 $940.94 $950.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80026 SUP Custom 27803010 80026 - IMPLANT ORBTL CONICAL CONICAL FLAT ANTERIOR SURFACE CHANNELS BOTH IP/OP "$1,188.06 " $879.16 $0.00 $950.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.78 $881.78 $0.00 $0.00 $247.59 $0.00 $0.00 $0.00 $0.00 $594.03 $940.94 $950.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80036 SUP Custom 27803010 80036 - SPHERE EYE 16MM MDPR+ BOTH IP/OP "$1,277.20 " $945.13 $0.00 "$1,021.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $947.94 $947.94 $0.00 $0.00 $266.17 $0.00 $0.00 $0.00 $0.00 $638.60 "$1,011.54" "$1,021.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80038 SUP Custom 27803010 80038 - IMPLANT ORBTL STANDARD SPHERE 18MM MEDPOR PLUS BIOACTIVE BOTH IP/OP "$1,742.50 " "$1,289.45" $0.00 "$1,394.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,293.28" "$1,293.28" $0.00 $0.00 $363.14 $0.00 $0.00 $0.00 $0.00 $871.25 "$1,380.06" "$1,394.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80040 SUP Custom 27803010 80040 - SPHERE EYE 20MM MDPR+ BOTH IP/OP "$1,277.20 " $945.13 $0.00 "$1,021.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $947.94 $947.94 $0.00 $0.00 $266.17 $0.00 $0.00 $0.00 $0.00 $638.60 "$1,011.54" "$1,021.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80042 SUP Custom 27803010 80042 - MEDPOR PLUS - 22MM BOTH IP/OP "$1,277.20 " $945.13 $0.00 "$1,021.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $947.94 $947.94 $0.00 $0.00 $266.17 $0.00 $0.00 $0.00 $0.00 $638.60 "$1,011.54" "$1,021.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80046 SUP Custom 27803010 80046 - MEDPOR PLUS SST - 16MM BOTH IP/OP "$1,483.20 " "$1,097.57" $0.00 "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,100.83" "$1,100.83" $0.00 $0.00 $309.10 $0.00 $0.00 $0.00 $0.00 $741.60 "$1,174.69" "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80048 SUP Custom 27803010 80048 - MEDPOR PLUS SST - 18MM BOTH IP/OP $26.00 $19.24 $0.00 "$1,174.69" $15.07 $15.07 $8.46 $8.46 $4.23 $4.23 $12.85 $12.85 $12.36 $8.46 $12.52 $5.50 $0.00 $0.00 $8.88 $23.66 "$1,174.69" $24.00 $12.27 $12.27 $0.00 $8.46 $8.46 $9.34 $8.46 $0.00 $0.00 $0.00 $0.00 80050 SUP Custom 27803010 80050 - MEDPOR PLUS SST - 20MM BOTH IP/OP "$1,483.20 " "$1,097.57" $0.00 "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,100.83" "$1,100.83" $0.00 $0.00 $309.10 $0.00 $0.00 $0.00 $0.00 $741.60 "$1,174.69" "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80052 SUP Custom 27803010 80052 - KIT RETRIEVER 18MM 20X4MM 32MM MICROCATHETER FLEXCELL TREVO BOTH IP/OP "$13,641.25 " "$10,094.53" $0.00 "$10,913.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,842.84" $0.00 $0.00 $0.00 $0.00 "$6,820.63" "$10,803.87" "$10,913.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80056 SUP Custom 27803010 80056 - MEDPOR PLUS SST EZ - 16MM BOTH IP/OP "$1,483.20 " "$1,097.57" $0.00 "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,100.83" "$1,100.83" $0.00 $0.00 $309.10 $0.00 $0.00 $0.00 $0.00 $741.60 "$1,174.69" "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80058 SUP Custom 27803010 80058 - SPHERE EYE 18MM SST EZ BOTH IP/OP "$1,483.20 " "$1,097.57" $0.00 "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,100.83" "$1,100.83" $0.00 $0.00 $309.10 $0.00 $0.00 $0.00 $0.00 $741.60 "$1,174.69" "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80060 SUP Custom 27803010 80060 - MEDPOR PLUS SST EZ - 20MM BOTH IP/OP "$1,483.20 " "$1,097.57" $0.00 "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,100.83" "$1,100.83" $0.00 $0.00 $309.10 $0.00 $0.00 $0.00 $0.00 $741.60 "$1,174.69" "$1,186.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80062 SUP Custom 27803010 80062 - IMPLANT ORBTL ROUND 22MM SPHERE SMOOTH SURFACE SUTURE BOTH IP/OP "$2,052.50 " "$1,518.85" $0.00 "$1,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,523.37" "$1,523.37" $0.00 $0.00 $427.74 $0.00 $0.00 $0.00 $0.00 "$1,026.25" "$1,625.58" "$1,642.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80400 SUP HCPCS C1751 0080400 - DRAIN INCISION 15X5/8IN 3 LUMEN ANTIBACTERIAL FILTER SUMP BOTH IP/OP $55.90 $41.37 $0.00 $44.72 $30.35 $30.35 $0.00 $0.00 $0.00 $11.65 $41.49 $41.49 $0.00 $0.00 $11.65 $0.00 $33.06 $33.06 $0.00 $27.95 $44.27 $44.72 $0.00 $0.00 $8.75 $0.00 $0.00 $8.90 $0.00 $0.00 $0.00 $0.00 $0.00 80710 SUP HCPCS C1713 SPACER MDI ARCHB+ LG VLV HLD CHMBR HNDHLD CMFSL MASK PED BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $14.63 $14.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $5.09 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 81001 SUP Custom 27803010 81001 - IMPLANT ORBT 40X40X8.45MM STRL MDPR ONLAY PE POR LT CRNMXF BOTH IP/OP $10.00 $7.40 $0.00 "$1,536.48" $5.65 $5.65 $3.17 $3.17 $1.59 $1.58 $4.82 $4.82 $4.63 $3.17 $4.68 $2.06 $0.00 $0.00 $3.33 $8.86 "$1,536.48" $8.80 $4.60 $4.60 $4.99 $3.17 $3.17 $3.49 $3.17 $0.00 $0.00 $0.00 $0.00 81002 SUP Custom 27803010 81002 - GRAFT SYNTH TISSUE 40X40MM ONLAY MEDPOR POLYETHYLENE POROUS BOTH IP/OP "$1,371.58 " "$1,014.97" $0.00 "$1,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,017.98" "$1,017.98" $0.00 $0.00 $285.84 $0.00 $0.00 $0.00 $0.00 $970.00 "$1,536.48" "$1,552.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81007 SUP Custom 27803010 81007 - GRAFT SYNTH TISSUE 33X45MM IMPLANT POROUS MEDPOR BOTH IP/OP "$1,387.50 " "$1,026.75" $0.00 "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,029.80" "$1,029.80" $0.00 $0.00 $289.16 $0.00 $0.00 $0.00 $0.00 $693.75 "$1,098.90" "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81008 SUP Custom 27803010 81008 - GRAFT SYNTH TISSUE 45X33MM IMPLANT POROUS MEDPOR BOTH IP/OP "$1,387.50 " "$1,026.75" $0.00 "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,029.80" "$1,029.80" $0.00 $0.00 $289.16 $0.00 $0.00 $0.00 $0.00 $693.75 "$1,098.90" "$1,110.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81013 SUP Custom 27803010 81013 - GRAFT SYNTH TISSUE 30MM 38X33X.8MM IMPLANT ORBITO-ZYGOMATIC BOTH IP/OP "$1,984.15 " "$1,468.27" $0.00 "$2,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,472.64" "$1,472.64" $0.00 $0.00 $413.50 $0.00 $0.00 $0.00 $0.00 "$1,520.00" "$2,407.68" "$2,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81014 SUP Custom 27803010 81014 - IMPLANT ORBT 38X33X.8MM TRM OFF THE SHLF MDPR RT BOTH IP/OP "$1,984.15 " "$1,468.27" $0.00 "$2,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,472.64" "$1,472.64" $0.00 $0.00 $413.50 $0.00 $0.00 $0.00 $0.00 "$1,520.00" "$2,407.68" "$2,432.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81020 SUP Custom 27803010 81020 - MESH CRANIAL 76X50X.85MM EMBED SHEET MEDPOR TITAN MEDPOR BOTH IP/OP "$2,677.50 " "$1,981.35" $0.00 "$2,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,987.24" "$1,987.24" $0.00 $0.00 $557.99 $0.00 $0.00 $0.00 $0.00 "$1,851.25" "$2,932.38" "$2,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81021 SUP Custom 27803010 81021 - PLATE BONE 38X50X.85MM MESH EMBEDDED POROUS MEDPOR TITAN MTM BOTH IP/OP "$1,958.10 " "$1,448.99" $0.00 "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,453.30" "$1,453.30" $0.00 $0.00 $408.07 $0.00 $0.00 $0.00 $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81022 SUP Custom 27803010 81022 - PLATE BONE 38X50X1.5MM MESH EMBEDDED POROUS MEDPOR TITAN MTM BOTH IP/OP "$1,958.10 " "$1,448.99" $0.00 "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,453.30" "$1,453.30" $0.00 $0.00 $408.07 $0.00 $0.00 $0.00 $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81023 SUP Custom 27803010 81023 - PLATE BONE 76X50X1.5MM MESH EMBEDDED POROUS MEDPOR TITAN MTM BOTH IP/OP "$2,447.23 " "$1,810.95" $0.00 "$2,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.33" "$1,816.33" $0.00 $0.00 $510.00 $0.00 $0.00 $0.00 $0.00 "$1,851.25" "$2,932.38" "$2,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81024 SUP Custom 27803010 81024 - PLATE BONE 38X50X.6MM MESH EMBEDDED NONPOROUS BARRIER BOTH IP/OP "$2,301.50 " "$1,703.11" $0.00 "$2,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.17" "$1,708.17" $0.00 $0.00 $479.63 $0.00 $0.00 $0.00 $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81025 SUP Custom 27803010 81025 - MESH CRANIAL 76X50X.6MM EMBED SHEET MEDPOR TITAN BARRIER BOTH IP/OP $26.00 $19.24 $0.00 "$3,346.20" $11.26 $11.26 $8.61 $8.61 $4.31 $3.87 $9.61 $9.61 $9.24 $8.61 $9.36 $5.60 $0.00 $0.00 $9.04 $17.68 "$3,346.20" $24.00 $12.48 $12.48 $9.97 $8.61 $8.61 $6.98 $8.61 $0.00 $0.00 $0.00 $0.00 81026 SUP Custom 27803010 81026 - MESH CRANIAL 38X50X1MM EMBED SHEET SOLID MEDPOR TITAN DOUBLE BOTH IP/OP "$2,301.50 " "$1,703.11" $0.00 "$2,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.17" "$1,708.17" $0.00 $0.00 $479.63 $0.00 $0.00 $0.00 $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81027 SUP Custom 27803010 81027 - MESH CRANIAL 76X50X1MM EMBED SHEET SOLID MEDPOR TITAN DOUBLE BOTH IP/OP "$2,790.63 " "$2,065.07" $0.00 "$3,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,071.20" "$2,071.20" $0.00 $0.00 $581.57 $0.00 $0.00 $0.00 $0.00 "$2,112.50" "$3,346.20" "$3,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81028 SUP Custom 27803010 81028 - PLATE BONE 50X38X1.6MM SHEET SOLID SURFACE MTB POLYETHYLENE BOTH IP/OP "$2,301.50 " "$1,703.11" $0.00 "$2,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.17" "$1,708.17" $0.00 $0.00 $479.63 $0.00 $0.00 $0.00 $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81029 SUP Custom 27803010 81029 - PLATE BONE 76X50X1.6MM MESH EMBEDDED NONPOROUS BARRIER BOTH IP/OP "$2,790.63 " "$2,065.07" $0.00 "$3,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,071.20" "$2,071.20" $0.00 $0.00 $581.57 $0.00 $0.00 $0.00 $0.00 "$2,112.50" "$3,346.20" "$3,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81030 SUP Custom 27803010 81030 - GRAFT SYNTH TISSUE 41X42X.85MM MESH EMBED MEDPOR TITAN BOTH IP/OP "$2,099.93 " "$1,553.95" $0.00 "$2,324.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,558.56" "$1,558.56" $0.00 $0.00 $437.62 $0.00 $0.00 $0.00 $0.00 "$1,452.50" "$2,300.76" "$2,324.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81031 SUP Custom 27803010 81031 - PLATE BN 42X41X1MM STRL MDPR TN MTB MESH EMBED XTN TI PE BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 $0.00 $0.00 $0.00 "$1,708.75" "$2,706.66" "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81032 SUP Custom 27803010 81032 - PLATE BONE 42X41X1MM MESH EMBED EXTN MEDPOR TITAN MTB BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 $0.00 $0.00 $0.00 "$1,708.75" "$2,706.66" "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81033 SUP Custom 27803010 81033 - PLATE BONE 42X41X.6MM MESH EMBED EXTN MEDPOR TITAN DOUBLE BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 $0.00 $0.00 $0.00 "$1,708.75" "$2,706.66" "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81034 SUP Custom 27803010 81034 - GRAFT SYNTH TISSUE 41X42X.85MM MESH EMBED MEDPOR TITAN MAX BOTH IP/OP "$2,099.93 " "$1,553.95" $0.00 "$2,324.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,558.56" "$1,558.56" $0.00 $0.00 $437.62 $0.00 $0.00 $0.00 $0.00 "$1,452.50" "$2,300.76" "$2,324.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81035 SUP Custom 27803010 81035 - PLATE BONE 42X41X1MM MESH EMBED EXTN MEDPOR TITAN BARRIER BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 $0.00 $0.00 $0.00 "$1,708.75" "$2,706.66" "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81036 SUP Custom 27803010 81036 - PLATE BONE THK1MM 42X41X1MM MESH EMBEDDED EXTENSIONS POROUS BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 $0.00 $0.00 $0.00 "$1,708.75" "$2,706.66" "$2,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81037 SUP Custom 27803010 81037 - PLATE BONE THIN PROFILE 130X130X3MM RADIOPQ MEDPOR TITANIUM BOTH IP/OP "$15,775.50 " "$11,673.87" $0.00 "$20,298.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,287.61" $0.00 $0.00 $0.00 $0.00 "$12,686.25" "$20,095.02" "$20,298.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81038 SUP Custom 27803010 81038 - PLATE BONE 130X130X3MM MESH EMBEDDED POROUS MEDPOR TITAN BOTH IP/OP "$15,775.50 " "$11,673.87" $0.00 "$20,298.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,287.61" $0.00 $0.00 $0.00 $0.00 "$12,686.25" "$20,095.02" "$20,298.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81040 SUP Custom 27803010 81040 - PLATE BONE 76X100X1.5MM MESH EMBEDDED SHEET POROUS MEDPOR BOTH IP/OP "$5,756.90 " "$4,260.11" $0.00 "$6,514.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,199.74" $0.00 $0.00 $0.00 $0.00 "$4,071.25" "$6,448.86" "$6,514.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81050 SUP HCPCS C1713 81050 - PLATE BONE FAN MTB CRANFCL BOTH IP/OP "$2,546.25 " "$1,884.23" $0.00 "$2,874.00" "$1,616.63" "$1,616.63" $0.00 $0.00 $0.00 $530.70 "$1,889.83" "$1,889.83" $0.00 $0.00 $530.64 $0.00 "$1,255.30" "$1,255.30" $0.00 "$1,796.25" "$2,845.26" "$2,874.00" $0.00 $0.00 $562.23 $0.00 $0.00 $571.93 $0.00 $0.00 $0.00 $0.00 $0.00 81060 SUP Custom 27803010 81060 - IMPLANT MANDIB 30X15X.25MM BIOCOMPATIBLE SPACE MAINTENANCE BOTH IP/OP $477.50 $353.35 $0.00 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.40 $354.40 $0.00 $0.00 $99.51 $0.00 $0.00 $0.00 $0.00 $238.75 $378.18 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81061 SUP Custom 27803010 81061 - IMPLANT MANDIB 30X25X.25MM BIOCOMPATIBLE SPACE MAINTENANCE BOTH IP/OP $720.00 $532.80 $0.00 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $534.38 $534.38 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $360.00 $570.24 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81062 SUP Custom 27803010 81062 - GRAFT SYNTH TISSUE ULTRATHIN 35X45X.25IN SHEET CONTAINMENT BOTH IP/OP $957.50 $708.55 $0.00 $766.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $710.66 $710.66 $0.00 $0.00 $199.54 $0.00 $0.00 $0.00 $0.00 $478.75 $758.34 $766.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81063 SUP Custom 27803010 81063 - IMPLANT MANDIB 30X15X.35MM BIOCOMPATIBLE SPACE MAINTENANCE BOTH IP/OP $348.43 $257.84 $0.00 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.60 $258.60 $0.00 $0.00 $72.61 $0.00 $0.00 $0.00 $0.00 $238.75 $378.18 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81064 SUP Custom 27803010 81064 - IMPLANT MANDIB 30X25X.35MM BIOCOMPATIBLE SPACE MAINTENANCE BOTH IP/OP $527.45 $390.31 $0.00 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $391.47 $391.47 $0.00 $0.00 $109.92 $0.00 $0.00 $0.00 $0.00 $360.00 $570.24 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81065 SUP Custom 27803010 81065 - IMPLANT MANDIB 45X35X.35MM BIOCOMPATIBLE SPACE MAINTENANCE BOTH IP/OP $702.63 $519.95 $0.00 $766.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $521.49 $521.49 $0.00 $0.00 $146.43 $0.00 $0.00 $0.00 $0.00 $478.75 $758.34 $766.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81066 SUP Custom 27803010 81066 - IMPLANT MANDIB 30X15X.45MM BIOCOMPATIBLE SPACE MAINTENANCE BOTH IP/OP $477.50 $353.35 $0.00 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.40 $354.40 $0.00 $0.00 $99.51 $0.00 $0.00 $0.00 $0.00 $238.75 $378.18 $382.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81067 SUP Custom 27803010 81067 - IMPLANT MANDIB 30X25X.45MM BIOCOMPATIBLE SPACE MAINTENANCE BOTH IP/OP $526.88 $389.89 $0.00 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $391.05 $391.05 $0.00 $0.00 $109.80 $0.00 $0.00 $0.00 $0.00 $360.00 $570.24 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81068 SUP Custom 27803010 81068 - IMPLANT MANDIB 35X45X.45MM BIOCOMPATIBLE SPACE MAINTENANCE BOTH IP/OP $701.25 $518.93 $0.00 $766.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $520.47 $520.47 $0.00 $0.00 $146.14 $0.00 $0.00 $0.00 $0.00 $478.75 $758.34 $766.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81200 SUP Custom 27803010 81200 - ROD SPNL 5.5MM 50MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81201 SUP Custom 27803010 81201 - ROD SPNL 5.5MM 60MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81202 SUP Custom 27803010 81202 - ROD SPNL 5.5MM 70MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81203 SUP Custom 27803010 81203 - ROD SPNL 5.5MM 80MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81204 SUP Custom 27803010 81204 - ROD SPNL 5.5MM 90MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81205 SUP Custom 27803010 81205 - ROD SPNL 5.5MM 100MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81206 SUP Custom 27803010 81206 - ROD SPNL 5.5MM 110MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81207 SUP Custom 27803010 81207 - ROD SPNL 5.5MM 120MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81208 SUP Custom 27803010 81208 - ROD SPNL 5.5MM 140MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81210 SUP Custom 27803010 81210 - ROD SPNL 5.5MM 160MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81211 SUP Custom 27803010 81211 - ROD SPNL 5.5MM 180MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81212 SUP Custom 27803010 81212 - ROD SPNL 5.5MM 220MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81213 SUP Custom 27803010 81213 - ROD SPNL 5.5MM 240MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81214 SUP Custom 27803010 81214 - ROD SPNL 5.5MM 260MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81215 SUP Custom 27803010 81215 - ROD SPNL 5.5MM 280MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81216 SUP Custom 27803010 81216 - ROD SPNL 5.5MM 300MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81217 SUP Custom 27803010 81217 - ROD SPNL 5.5MM 320MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81218 SUP Custom 27803010 81218 - ROD SPNL 5.5MM 340MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81219 SUP Custom 27803010 81219 - ROD SPNL 5.5MM 360MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81220 SUP Custom 27803010 81220 - ROD SPNL 5.5MM 380MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81906 SUP Custom 27203010 REAGENT SBSTR ACCES 130ML ANALY BOTH IP/OP $461.25 $341.33 $0.00 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.63 $365.31 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81908 SUP Custom 27203010 REAGENT SMPL DILU A ANALY BOTH IP/OP $74.83 $55.37 $0.00 $59.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.41 $59.27 $59.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81910 SUP Custom 27203010 REAGENT SYS CHK SOL ACCES 4ML ANALY BOTH IP/OP $95.33 $70.54 $0.00 $76.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.66 $75.50 $76.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82000 SUP Custom 27803010 82000 - GRAFT SYNTH TISSUE THK4MM HEMISPHERE CNTOUR POROUS MEDPOR BOTH IP/OP "$14,542.50 " "$10,761.45" $0.00 "$11,634.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,271.25" "$11,517.66" "$11,634.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82001 SUP Custom 27803010 82001 - GRAFT SYNTH TISSUE HEMISPHERE 170X124X4.5MM OFF THE SHELF BOTH IP/OP "$8,921.60 " "$6,601.98" $0.00 "$11,634.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,859.26" $0.00 $0.00 $0.00 $0.00 "$7,271.25" "$11,517.66" "$11,634.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82006 SUP Custom 27803010 82006 - GRAFT SYNTH TISSUE DOME 180X150X6MM PRESHAPED POROUS MEDPOR BOTH IP/OP "$15,460.00 " "$11,440.40" $0.00 "$12,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,221.86" $0.00 $0.00 $0.00 $0.00 "$7,730.00" "$12,244.32" "$12,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82007 SUP Custom 27803010 82007 - GRAFT SNTH TISS LG 20X2.5X2.5MM STRL MDPR TSI TAB NPOR POST BOTH IP/OP "$1,108.25 " $820.11 $0.00 "$1,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $822.54 $822.54 $0.00 $0.00 $230.96 $0.00 $0.00 $0.00 $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82008 SUP Custom 27803010 82008 - GRAFT SYNTH TISSUE LARGE 40X40X2.5MM .73MM 3 TABS NONPOROUS BOTH IP/OP "$1,268.75 " $938.88 $0.00 "$1,578.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $941.67 $941.67 $0.00 $0.00 $264.41 $0.00 $0.00 $0.00 $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82011 SUP Custom 27803010 82011 - GRAFT SYNTH TISSUE TRIANGLE 102X3.6X4MM 102X10X6MM IMPLANT BOTH IP/OP $672.00 $497.28 $0.00 $810.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $498.76 $498.76 $0.00 $0.00 $140.04 $0.00 $0.00 $0.00 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82013 SUP Custom 27803010 82013 - GRAFT SYNTH TISSUE .6MM V SHAPE 30X10X6MM IMPLANT CRANIOTOMY BOTH IP/OP $880.00 $651.20 $0.00 $810.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $653.14 $653.14 $0.00 $0.00 $183.39 $0.00 $0.00 $0.00 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82014 SUP Custom 27803010 82014 - GRAFT SYNTH TISSUE SMALL 36X45X1MM IMPLANT POROUS MEDPOR BOTH IP/OP "$1,521.50 " "$1,125.91" $0.00 "$1,856.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,129.26" "$1,129.26" $0.00 $0.00 $317.08 $0.00 $0.00 $0.00 $0.00 "$1,160.00" "$1,837.44" "$1,856.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82015 SUP Custom 27803010 82015 - GRAFT SYNTH TISSUE 58X56X1.5MM IMPLANT POROUS MEDPOR BOTH IP/OP "$1,974.38 " "$1,461.04" $0.00 "$2,566.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,465.38" "$1,465.38" $0.00 $0.00 $411.46 $0.00 $0.00 $0.00 $0.00 "$1,603.75" "$2,540.34" "$2,566.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82016 SUP Custom 27803010 82016 - GRAFT SYNTH TISSUE 58X56X1.5MM IMPLANT POROUS MEDPOR BOTH IP/OP "$1,974.38 " "$1,461.04" $0.00 "$2,566.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,465.38" "$1,465.38" $0.00 $0.00 $411.46 $0.00 $0.00 $0.00 $0.00 "$1,603.75" "$2,540.34" "$2,566.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82019 SUP Custom 27803010 82019 - PLATE BONE CURVE 48X38X.85MM MESH EMBED PRESHAPE MEDPOR BOTH IP/OP "$2,728.38 " "$2,019.00" $0.00 "$3,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,025.00" "$2,025.00" $0.00 $0.00 $568.59 $0.00 $0.00 $0.00 $0.00 "$2,215.00" "$3,508.56" "$3,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82020 SUP Custom 27803010 82020 - PLATE BONE CURVE 48X38X1MM MESH EMBEDDED PCVD NONPOROUS BOTH IP/OP "$2,859.75 " "$2,116.22" $0.00 "$4,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,122.51" "$2,122.51" $0.00 $0.00 $595.97 $0.00 $0.00 $0.00 $0.00 "$2,507.50" "$3,971.88" "$4,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82022 SUP Custom 27803010 82022 - FLEXBLOCK IMPLANT - BARRIER 56MM X 91MM X 4MM BOTH IP/OP "$3,712.00 " "$2,746.88" $0.00 "$2,969.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,755.05" "$2,755.05" $0.00 $0.00 $773.58 $0.00 $0.00 $0.00 $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82030 SUP Custom 27803010 82030 - PLATE BONE 96X61X1.5MM IMPLANT POROUS MEDPOR TITAN TITANIUM BOTH IP/OP "$5,756.83 " "$4,260.05" $0.00 "$6,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,199.72" $0.00 $0.00 $0.00 $0.00 "$4,351.25" "$6,892.38" "$6,962.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82301 SUP HCPCS B4088 082301 - TUBE JJNSTM 60IN 9-18FR PU COMPAT STPT FEED NSL STRL BOTH IP/OP $466.09 $344.91 $0.00 $369.14 $9.90 $9.90 $0.00 $0.00 $0.00 $7.07 $16.33 $16.33 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $11.00 $369.14 $17.60 $13.20 $13.20 $3.29 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $0.00 83003 SUP Custom 27803010 83003 - GRAFT SYNTH TISSUE 47X28X3MM MEDPOR POLYETHYLENE POROUS BOTH IP/OP "$1,025.43 " $758.82 $0.00 "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $761.07 $761.07 $0.00 $0.00 $213.70 $0.00 $0.00 $0.00 $0.00 $703.75 "$1,114.74" "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83004 SUP Custom 27803010 83004 - GRAFT SYNTH TISSUE 47X28X3MM MEDPOR POLYETHYLENE POROUS BOTH IP/OP "$1,025.43 " $758.82 $0.00 "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $761.07 $761.07 $0.00 $0.00 $213.70 $0.00 $0.00 $0.00 $0.00 $703.75 "$1,114.74" "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83007 SUP Custom 27803010 83007 - GRAFT SNTH TISS 60X40X4MM STRL MDPR IMPL CNTR SHL-TY DSGN BOTH IP/OP "$1,025.43 " $758.82 $0.00 "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $761.07 $761.07 $0.00 $0.00 $213.70 $0.00 $0.00 $0.00 $0.00 $703.75 "$1,114.74" "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83008 SUP Custom 27803010 83008 - GRAFT SNTH TISS 60X40MM STRL MDPR IMPL CNTR SHL-TY DSGN POR BOTH IP/OP "$1,025.43 " $758.82 $0.00 "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $761.07 $761.07 $0.00 $0.00 $213.70 $0.00 $0.00 $0.00 $0.00 $703.75 "$1,114.74" "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83020 SUP Custom 27803010 83020 - GRAFT SYNTH TISSUE MICROTHIN 38X50X.25MM SHEET POROUS MEDPOR BOTH IP/OP $961.35 $711.40 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $713.51 $713.51 $0.00 $0.00 $200.35 $0.00 $0.00 $0.00 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83021 SUP Custom 27803010 83021 - GRAFT SYNTH TISSUE MICROTHIN 76X50X.25MM SHEET POROUS MEDPOR BOTH IP/OP "$1,777.50 " "$1,315.35" $0.00 "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,319.26" "$1,319.26" $0.00 $0.00 $370.43 $0.00 $0.00 $0.00 $0.00 $888.75 "$1,407.78" "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83022 SUP Custom 27803010 83022 - GRAFT SNTH 38X50X.35MM STRL OFF THE SHLF FTHR EDG SMTH TRNS BOTH IP/OP $949.03 $702.28 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $704.37 $704.37 $0.00 $0.00 $197.78 $0.00 $0.00 $0.00 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83023 SUP Custom 27803010 83023 - GRAFT SYNTH TISSUE MICROTHIN 76X50X.35MM SHEET POROUS MEDPOR BOTH IP/OP "$1,777.50 " "$1,315.35" $0.00 "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,319.26" "$1,319.26" $0.00 $0.00 $370.43 $0.00 $0.00 $0.00 $0.00 $888.75 "$1,407.78" "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83029 SUP Custom 27803010 83029 - GRAFT SYNTH TISSUE MICROTHIN 50X38X.45MM SHEET POROUS MEDPOR BOTH IP/OP $949.03 $702.28 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $704.37 $704.37 $0.00 $0.00 $197.78 $0.00 $0.00 $0.00 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83030 SUP Custom 27803010 83030 - GRAFT SYNTH TISSUE MICROTHIN 76X50X.45MM SHEET MEDPOR POROUS BOTH IP/OP "$1,276.28 " $944.45 $0.00 "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $947.25 $947.25 $0.00 $0.00 $265.98 $0.00 $0.00 $0.00 $0.00 $888.75 "$1,407.78" "$1,422.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84000 SUP Custom 27803010 84000 - GRAFT SYNTH TISSUE PETITE 45X4X4MM IMPLANT TAPERED PROFILE BOTH IP/OP $650.63 $481.47 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.89 $482.89 $0.00 $0.00 $135.59 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84001 SUP Custom 27803010 84001 - GRAFT SYNTH TISSUE PETITE 55X4X4MM IMPLANT TAPERED PROFILE BOTH IP/OP $650.63 $481.47 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.89 $482.89 $0.00 $0.00 $135.59 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84002 SUP Custom 27803010 84002 - GRAFT SYNTH TISSUE PETITE 45X5X5MM IMPLANT TAPERED PROFILE BOTH IP/OP $650.63 $481.47 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.89 $482.89 $0.00 $0.00 $135.59 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84003 SUP Custom 27803010 84003 - GRAFT SYNTH TISSUE PETITE 55X5X5MM IMPLANT TAPERED PROFILE BOTH IP/OP $650.63 $481.47 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.89 $482.89 $0.00 $0.00 $135.59 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84004 SUP Custom 27803010 84004 - GRAFT SYNTH TISSUE PETITE 55X9X6MM IMPLANT TAPERED PROFILE BOTH IP/OP $650.63 $481.47 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.89 $482.89 $0.00 $0.00 $135.59 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84006 SUP Custom 27803010 84006 - IMPLANT FACIAL THIN SHELL NASAL DORSAL BOTH IP/OP "$1,130.00 " $836.20 $0.00 "$1,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $838.69 $838.69 $0.00 $0.00 $235.49 $0.00 $0.00 $0.00 $0.00 $776.25 "$1,229.58" "$1,242.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84008 SUP Custom 27803010 84008 - NASAL DARTT IMPLANT - 40M X 4MM X 1.4MM BOTH IP/OP $884.00 $654.16 $0.00 $707.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $656.10 $656.10 $0.00 $0.00 $184.23 $0.00 $0.00 $0.00 $0.00 $442.00 $700.13 $707.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84010 SUP Custom 27803010 84010 - IMPLANT FACIAL 37X22X.5MM TIP TOP MEDPOR NASAL BOTH IP/OP $900.90 $666.67 $0.00 $982.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $668.65 $668.65 $0.00 $0.00 $187.75 $0.00 $0.00 $0.00 $0.00 $613.75 $972.18 $982.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84012 SUP Custom 27803010 84012 - GRAFT SYNTH TISSUE 41X9X3MM ONLAY POROUS MEDPOR POLYETHYLENE BOTH IP/OP $777.43 $575.30 $0.00 $862.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.00 $577.00 $0.00 $0.00 $162.02 $0.00 $0.00 $0.00 $0.00 $538.75 $853.38 $862.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84129 SUP Custom 27803010 84129 - GRAFT SYNTH TISSUE SMALL 59X34X19.5MM IMPLANT S-SHAPE 1 BOTH IP/OP "$4,354.13 " "$3,222.06" $0.00 "$4,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,231.63" "$3,231.63" $0.00 $0.00 $907.40 $0.00 $0.00 $0.00 $0.00 "$2,638.75" "$4,179.78" "$4,222.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84130 SUP Custom 27803010 84130 - S EAR - SMALL - RIGHT - 59MM X 34MM X 19.5 BOTH IP/OP "$3,886.00 " "$2,875.64" $0.00 "$3,108.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,884.19" "$2,884.19" $0.00 $0.00 $809.84 $0.00 $0.00 $0.00 $0.00 "$1,943.00" "$3,077.71" "$3,108.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84131 SUP Custom 27803010 84131 - PROS OSS MED 62X36X20.5MM LEFT EAR S BOTH IP/OP "$3,886.00 " "$2,875.64" $0.00 "$3,108.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,884.19" "$2,884.19" $0.00 $0.00 $809.84 $0.00 $0.00 $0.00 $0.00 "$1,943.00" "$3,077.71" "$3,108.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84132 SUP Custom 27803010 84132 - S EAR - MEDIUM - RIGHT - 62MM X 36MM X 20.5MM BOTH IP/OP $15.00 $11.10 $0.00 "$3,108.80" $0.00 $0.00 $4.76 $4.76 $2.38 $2.30 $6.97 $6.97 $0.00 $4.76 $6.79 $3.09 $0.00 $0.00 $0.00 "$1,943.00" "$3,077.71" "$3,108.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84133 SUP Custom 27803010 84133 - S EAR - LARGE - LEFT - 65MM X 37MM X 21.5MM BOTH IP/OP "$3,886.00 " "$2,875.64" $0.00 "$3,108.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,884.19" "$2,884.19" $0.00 $0.00 $809.84 $0.00 $0.00 $0.00 $0.00 "$1,943.00" "$3,077.71" "$3,108.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84134 SUP Custom 27803010 84134 - S EAR - LARGE - RIGHT - 65MM X 37MM X 21.5MM BOTH IP/OP "$4,004.00 " "$2,962.96" $0.00 "$3,203.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,971.77" "$2,971.77" $0.00 $0.00 $834.43 $0.00 $0.00 $0.00 $0.00 "$2,002.00" "$3,171.17" "$3,203.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84505 SUP Custom 27803010 84505 - CONNECTOR 84505 CD CL DOM 7.7MM BOTH IP/OP "$1,991.25 " "$1,473.53" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,477.91" "$1,477.91" $0.00 $0.00 $414.98 $0.00 $0.00 $0.00 $0.00 $995.63 "$1,577.07" "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 85040 SUP Custom 27203010 85040 - APPLICATOR FBRTP 6IN FOAM CTTN POLYPRO CSTM OVR 1IN 3/8IN BOTH IP/OP $151.63 $112.21 $0.00 $121.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.54 $112.54 $0.00 $0.00 $31.60 $0.00 $0.00 $0.00 $0.00 $75.81 $120.09 $121.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 85201 SUP HCPCS C1768 85201 - GRAFT HEMASHIELD GRAFT? 20X10MM X 40L962.45 BOTH IP/OP "$1,688.05 " "$1,249.16" $0.00 "$1,350.44" $759.62 $759.62 $0.00 $0.00 $0.00 $351.83 "$1,252.87" "$1,252.87" $0.00 $0.00 $351.79 $0.00 $998.48 $998.48 $0.00 $844.03 "$1,336.94" "$1,350.44" $0.00 $0.00 $264.18 $0.00 $0.00 $268.74 $0.00 $0.00 $0.00 $0.00 $0.00 85412 SUP HCPCS C1876 85412 - STENT TRCHBR 6MM 7FR 38MM STRL 120CM ICAST CVR CATH INTRO BOTH IP/OP "$6,125.00 " "$4,532.50" $0.00 "$4,900.00" "$2,756.25" "$2,756.25" $0.00 $0.00 $0.00 "$1,276.60" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,276.45" $0.00 "$3,019.63" "$3,019.63" $0.00 "$3,062.50" "$4,851.00" "$4,900.00" $0.00 $0.00 $958.56 $0.00 $0.00 $975.10 $0.00 $0.00 $0.00 $0.00 $0.00 85414 SUP HCPCS C1876 85414 - STENT TRCHBR 7MM 7FR 38MM STRL 120CM ICAST CVR CATH INTRO BOTH IP/OP "$6,115.63 " "$4,525.57" $0.00 "$4,892.50" "$2,752.03" "$2,752.03" $0.00 $0.00 $0.00 "$1,274.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,274.50" $0.00 "$3,015.00" "$3,015.00" $0.00 "$3,057.81" "$4,843.58" "$4,892.50" $0.00 $0.00 $957.10 $0.00 $0.00 $973.61 $0.00 $0.00 $0.00 $0.00 $0.00 85415 SUP HCPCS C1876 85415 - STENT TRCHBR 7MM 7FR 59MM STRL 120CM ICAST CVR CATH INTRO SS BOTH IP/OP "$6,590.63 " "$4,877.07" $0.00 "$5,272.50" "$2,965.78" "$2,965.78" $0.00 $0.00 $0.00 "$1,373.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.49" $0.00 "$3,249.18" "$3,249.18" $0.00 "$3,295.31" "$5,219.78" "$5,272.50" $0.00 $0.00 "$1,031.43" $0.00 $0.00 "$1,049.23" $0.00 $0.00 $0.00 $0.00 $0.00 85416 SUP HCPCS C1876 85416 - STENT TRCHBR 8MM 7FR 38MM STRL 120CM ICAST CVR CATH INTRO SS BOTH IP/OP "$6,115.63 " "$4,525.57" $0.00 "$4,892.50" "$2,752.03" "$2,752.03" $0.00 $0.00 $0.00 "$1,274.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,274.50" $0.00 "$3,015.00" "$3,015.00" $0.00 "$3,057.81" "$4,843.58" "$4,892.50" $0.00 $0.00 $957.10 $0.00 $0.00 $973.61 $0.00 $0.00 $0.00 $0.00 $0.00 85417 SUP HCPCS C1876 85417 - STENT TRCHBR 8MM 7FR 59MM STRL 120CM ICAST CVR CATH INTRO SS BOTH IP/OP "$6,590.63 " "$4,877.07" $0.00 "$5,272.50" "$2,965.78" "$2,965.78" $0.00 $0.00 $0.00 "$1,373.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.49" $0.00 "$3,249.18" "$3,249.18" $0.00 "$3,295.31" "$5,219.78" "$5,272.50" $0.00 $0.00 "$1,031.43" $0.00 $0.00 "$1,049.23" $0.00 $0.00 $0.00 $0.00 $0.00 85418 SUP HCPCS C1876 85418 - STENT TRCHBR 9MM 7FR 38MM STRL 120CM ICAST CVR CATH INTRO BOTH IP/OP "$6,115.63 " "$4,525.57" $0.00 "$4,892.50" "$2,752.03" "$2,752.03" $0.00 $0.00 $0.00 "$1,274.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,274.50" $0.00 "$3,015.00" "$3,015.00" $0.00 "$3,057.81" "$4,843.58" "$4,892.50" $0.00 $0.00 $957.10 $0.00 $0.00 $973.61 $0.00 $0.00 $0.00 $0.00 $0.00 85419 SUP HCPCS C1876 85419 - STENT TRCHBR 9MM 7FR 59MM STRL 120CM ICAST CVR CATH INTRO SS BOTH IP/OP "$6,590.63 " "$4,877.07" $0.00 "$5,272.50" "$2,965.78" "$2,965.78" $0.00 $0.00 $0.00 "$1,373.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.49" $0.00 "$3,249.18" "$3,249.18" $0.00 "$3,295.31" "$5,219.78" "$5,272.50" $0.00 $0.00 "$1,031.43" $0.00 $0.00 "$1,049.23" $0.00 $0.00 $0.00 $0.00 $0.00 85424 SUP HCPCS C1876 85424 - STENT TRCHBR 10MM 7FR 38MM STRL 120CM ICAST CVR CATH INTRO BOTH IP/OP "$6,115.63 " "$4,525.57" $0.00 "$4,892.50" "$2,752.03" "$2,752.03" $0.00 $0.00 $0.00 "$1,274.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,274.50" $0.00 "$3,015.00" "$3,015.00" $0.00 "$3,057.81" "$4,843.58" "$4,892.50" $0.00 $0.00 $957.10 $0.00 $0.00 $973.61 $0.00 $0.00 $0.00 $0.00 $0.00 85426 SUP HCPCS C1768 85426 - STENT COVERED 12MMX38MMX120CM BOTH IP/OP "$6,125.00 " "$4,532.50" $0.00 "$4,900.00" "$2,756.25" "$2,756.25" $0.00 $0.00 $0.00 "$1,276.60" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,276.45" $0.00 "$3,019.63" "$3,019.63" $0.00 "$3,062.50" "$4,851.00" "$4,900.00" $0.00 $0.00 $958.56 $0.00 $0.00 $975.10 $0.00 $0.00 $0.00 $0.00 $0.00 85450 SUP HCPCS C1876 85450 - STENT TRCHBR 5MM 6FR 16MM 120CM ICAST CVR ULT LO CX PRFL PWR BOTH IP/OP "$5,723.75 " "$4,235.58" $0.00 "$4,579.00" "$2,575.69" "$2,575.69" $0.00 $0.00 $0.00 "$1,192.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,192.83" $0.00 "$2,821.81" "$2,821.81" $0.00 "$2,861.88" "$4,533.21" "$4,579.00" $0.00 $0.00 $895.77 $0.00 $0.00 $911.22 $0.00 $0.00 $0.00 $0.00 $0.00 85451 SUP HCPCS C1876 85451 - STENT TRCHBR 5MM 6FR 22MM STRL 120CM ICAST CVR CATH INTRO SS BOTH IP/OP "$6,287.50 " "$4,652.75" $0.00 "$5,030.00" "$2,829.38" "$2,829.38" $0.00 $0.00 $0.00 "$1,310.47" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,310.32" $0.00 "$3,099.74" "$3,099.74" $0.00 "$3,143.75" "$4,979.70" "$5,030.00" $0.00 $0.00 $983.99 $0.00 $0.00 "$1,000.97" $0.00 $0.00 $0.00 $0.00 $0.00 85785 SUP HCPCS C1733 85785 - SET TBG 260CM CL PNT 2W CMUNC IRR PMP CATH BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 86000 SUP Custom 27803010 86000 - IMPLANT CHIN CNTR LF 2 PC BOTH IP/OP "$1,005.00 " $743.70 $0.00 "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $745.91 $745.91 $0.00 $0.00 $209.44 $0.00 $0.00 $0.00 $0.00 $703.75 "$1,114.74" "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86001 SUP Custom 27803010 86001 - GRAFT SYNTH TISSUE CNTOUR CONCAVE TAPER 74X42X5MM 2 PIECE BOTH IP/OP "$1,005.00 " $743.70 $0.00 "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $745.91 $745.91 $0.00 $0.00 $209.44 $0.00 $0.00 $0.00 $0.00 $703.75 "$1,114.74" "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86002 SUP Custom 27803010 86002 - IMPLANT CHIN CNTR TPR 78X50X7MM STRL MDPR 2 PC PE POR BOTH IP/OP "$1,005.00 " $743.70 $0.00 "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $745.91 $745.91 $0.00 $0.00 $209.44 $0.00 $0.00 $0.00 $0.00 $703.75 "$1,114.74" "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86003 SUP Custom 27803010 86003 - GRAFT SYNTH TISSUE CNTOUR TAPER 80X55X9MM 2 PIECE GRADUAL BOTH IP/OP "$1,005.00 " $743.70 $0.00 "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $745.91 $745.91 $0.00 $0.00 $209.44 $0.00 $0.00 $0.00 $0.00 $703.75 "$1,114.74" "$1,126.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86010 SUP Custom 27803010 86010 - GRAFT SNTH TISS SM 3D 40X25X4MM STRL MDPR BTN MXLFCL CHIN BOTH IP/OP $848.00 $627.52 $0.00 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $629.39 $629.39 $0.00 $0.00 $176.72 $0.00 $0.00 $0.00 $0.00 $588.75 $932.58 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86011 SUP Custom 27803010 86011 - GRAFT SNTH TISS MED 3D 47.5X37.5X5.5MM STRL MDPR BTN MXLFCL BOTH IP/OP $848.00 $627.52 $0.00 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $629.39 $629.39 $0.00 $0.00 $176.72 $0.00 $0.00 $0.00 $0.00 $588.75 $932.58 $942.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86012 SUP HCPCS C2627 CATHETER SPBC MLCT 12FR 4 WNG DRAIN STRL LTX DISP AMBR BOTH IP/OP $165.15 $122.21 $0.00 $122.57 $20.73 $20.73 $0.00 $0.00 $0.00 $34.42 $122.57 $122.57 $0.00 $0.00 $34.42 $0.00 $97.69 $97.69 $0.00 $19.09 $30.25 $30.55 $0.00 $0.00 $5.98 $0.00 $0.00 $6.08 $0.00 $0.00 $0.00 $0.00 $0.00 86014 SUP HCPCS C1729 086014 - CATHETER SUPRAPUBIC 14FR 4 WING DRAIN LATEX MALECOT STERILE BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86016 SUP HCPCS C1729 086016 - CATHETER NPHSTM 16FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86018 SUP HCPCS C1751 086018 - CATHETER NPHSTM 18FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86020 SUP HCPCS C1729 086020 - CATH NPHSTM AMBR 20FR MLCT DRAIN 4 WNG STRL LATEX DISP BOTH IP/OP $284.70 $210.68 $0.00 $294.48 $199.88 $199.88 $0.00 $0.00 $0.00 $59.34 $211.30 $211.30 $0.00 $0.00 $59.33 $0.00 $168.40 $168.40 $0.00 $184.05 $291.54 $294.48 $0.00 $0.00 $57.61 $0.00 $0.00 $58.60 $0.00 $0.00 $0.00 $0.00 $0.00 86022 SUP HCPCS C1729 086022 - CATHETER NPHSTM 22FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86024 SUP HCPCS C1729 086024 - CATHETER NPHSTM 24FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86026 SUP HCPCS C1729 086026 - CATHETER NPHSTM 26FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86028 SUP HCPCS C1729 086028 - CATHETER NPHSTM 28FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86030 SUP HCPCS C1729 086030 - CATHETER NPHSTM 30FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86032 SUP HCPCS C1729 086032 - CATHETER NPHSTM 32FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86034 SUP HCPCS C1729 086034 - CATHETER NPHSTM 34FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $19.92 $13.52 $13.52 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $12.45 $19.72 $19.92 $0.00 $0.00 $3.90 $0.00 $0.00 $3.96 $0.00 $0.00 $0.00 $0.00 $0.00 86036 SUP HCPCS C1729 086036 - CATHETER NPHSTM 36FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $4.15 $3.07 $0.00 $3.32 $2.25 $2.25 $0.00 $0.00 $0.00 $0.86 $3.08 $3.08 $0.00 $0.00 $0.86 $0.00 $2.45 $2.45 $0.00 $2.08 $3.29 $3.32 $0.00 $0.00 $0.65 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 86038 SUP HCPCS C1751 086038 - CATHETER NPHSTM 38FR STRL LTX MLCT 4 WNG DRN NTR RBR DISP BOTH IP/OP $24.90 $18.43 $0.00 $49.08 $33.31 $33.31 $0.00 $0.00 $0.00 $5.19 $18.48 $18.48 $0.00 $0.00 $5.19 $0.00 $14.73 $14.73 $0.00 $30.68 $48.59 $49.08 $0.00 $0.00 $9.60 $0.00 $0.00 $9.77 $0.00 $0.00 $0.00 $0.00 $0.00 86202 SUP Custom 27203010 86202 - TUBE ENDOTRAC 6MM CUF MRPH EYE OR R STRL LATEX FREE DISP BOTH IP/OP $41.37 $30.61 $0.00 $30.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.71 $30.71 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $6.13 $9.71 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86203 SUP Custom 27203010 86203 - TUBE ENDOTRAC 6.5MM CUF MRPH EYE PREFRM CURVE OR R STRL BOTH IP/OP $12.26 $9.07 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.10 $9.10 $0.00 $0.00 $2.55 $0.00 $0.00 $0.00 $0.00 $6.13 $9.71 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86207 SUP Custom 27203010 86207 - TUBE ORAL/TRACHEAL RAE 8.5MM CUFFED MURPHY TIP PREFORMED PVC BOTH IP/OP $14.41 $10.66 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.70 $10.70 $0.00 $0.00 $3.00 $0.00 $0.00 $0.00 $0.00 $7.21 $11.41 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86207 SUP Custom 27203010 086207 - TUBE ORAL/TRACHEAL RAE 8.5MM CUFFED MURPHY TIP PREFORMED PVC BOTH IP/OP $14.41 $10.66 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.70 $10.70 $0.00 $0.00 $3.00 $0.00 $0.00 $0.00 $0.00 $7.21 $11.41 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86228 SUP Custom 27203010 86228 - TUBE ENDOTRAC 22FR 5.5MM STD NSL/ORL UNCUF MRPH EYE RADIOPQ BOTH IP/OP $25.12 $18.59 $0.00 $26.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.65 $18.65 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $16.33 $25.87 $26.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86266 SUP Custom 27203010 86266 - TUBE ENDOTRAC 4.5MM UNCUF MRPH EYE OR R BOTH IP/OP $87.85 $65.01 $0.00 $70.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.20 $65.20 $0.00 $0.00 $18.31 $0.00 $0.00 $0.00 $0.00 $43.92 $69.58 $70.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86287 SUP Custom 27203010 86287 - TUBE NASOTRACHEAL RAE 21FR 5MM UNCUFFED MURPHY EYE BOTH IP/OP $6.57 $4.86 $0.00 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.88 $4.88 $0.00 $0.00 $1.37 $0.00 $0.00 $0.00 $0.00 $4.24 $6.72 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86311 SUP HCPCS C1757 86311 - CATHETER THROMBECTOMY PROGREAT PRELUMEN BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86395 SUP Custom 27203010 86395 - TUBE ET 7.9MM 5.5MM STRL SHLY LSRFLX 2 CUF MRPH EYE SS BOTH IP/OP $114.75 $84.92 $0.00 $91.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.17 $85.17 $0.00 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $57.38 $90.88 $91.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86397 SUP Custom 27203010 86397 - TUBE ET MGL CRV 7MM 4.5MM STRL LF LSRFLX MALLINCKRODT 2 CUF BOTH IP/OP $114.75 $84.92 $0.00 $91.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.17 $85.17 $0.00 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $57.38 $90.88 $91.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86548 SUP Custom 27203010 86548 - TUBE ENDOTRAC 6MM CUFF REINFORCE MURPHY EYE PVC SILICONE BOTH IP/OP $45.30 $33.52 $0.00 $36.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.65 $35.88 $36.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86551 SUP Custom 27203010 86551 - TUBE ENDOTRAC 7.5MM NSL/ORL CUF MRPH EYE REINF SIL SS STRL BOTH IP/OP $44.63 $33.03 $0.00 $40.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.12 $33.12 $0.00 $0.00 $9.30 $0.00 $0.00 $0.00 $0.00 $25.29 $40.07 $40.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86552 SUP Custom 27203010 86552 - TUBE ENDOTRAC 8MM CUF REINF STRL BOTH IP/OP $44.63 $33.03 $0.00 $250.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.12 $33.12 $0.00 $0.00 $9.30 $0.00 $0.00 $0.00 $0.00 $156.47 $247.84 $250.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 86700 SUP HCPCS C1753 86700 - CATH US .018IN 3.4FR 135CM INTVASC NONUNIFORM ROT DSTRTN VSN BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $916.31 $916.31 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $264.09 $0.00 $0.00 $268.65 $0.00 $0.00 $0.00 $0.00 $0.00 87003 SUP Custom 27803010 87003 - GRAFT SYNTH TISSUE 26X25X2.5MM IMPLANT POROUS MEDPOR IMORI BOTH IP/OP $935.63 $692.37 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $694.42 $694.42 $0.00 $0.00 $194.98 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87004 SUP Custom 27803010 87004 - GRAFT SYNTH TISSUE 26X25X2.5MM IMPLANT POROUS MEDPOR IMORI BOTH IP/OP $935.63 $692.37 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $694.42 $694.42 $0.00 $0.00 $194.98 $0.00 $0.00 $0.00 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87118 SUP Custom 27203010 SLIDE KOVA 2 GLSTC 4 WELL WO GRID UA BOTH IP/OP $241.95 $179.04 $0.00 $193.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.98 $191.62 $193.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88000 SUP HCPCS B4088 88000 - TUBE JJNSTM 55IN 28FR 12FR SIL CMPCT BLN RADIOPQ STRP ADPR BOTH IP/OP $263.90 $195.29 $0.00 $211.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.87 $195.87 $0.00 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $131.95 $209.01 $211.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88037 SUP Custom 27803010 88037 - GRAFT SYNTH TISSUE 59X29X7MM IMPLANT CNTOUR ANGLED POROUS BOTH IP/OP "$1,353.75 " "$1,001.78" $0.00 "$1,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,004.75" "$1,004.75" $0.00 $0.00 $282.12 $0.00 $0.00 $0.00 $0.00 $948.75 "$1,502.82" "$1,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88038 SUP Custom 27803010 88038 - GRAFT SYNTH TISSUE 59X29X7MM IMPLANT CNTOUR ANGLED POROUS BOTH IP/OP "$1,353.75 " "$1,001.78" $0.00 "$1,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,004.75" "$1,004.75" $0.00 $0.00 $282.12 $0.00 $0.00 $0.00 $0.00 $948.75 "$1,502.82" "$1,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88051 SUP Custom 27803010 88051 - GRAFT SYNTH TISSUE 79X37X5MM IMPLANT RAMUS INFERIOR RIDGE BOTH IP/OP "$1,867.50 " "$1,381.95" $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.06" "$1,386.06" $0.00 $0.00 $389.19 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88052 SUP Custom 27803010 88052 - GRAFT SYNTH TISSUE 79X37X5MM IMPLANT RAMUS INFERIOR RIDGE BOTH IP/OP "$1,867.50 " "$1,381.95" $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.06" "$1,386.06" $0.00 $0.00 $389.19 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88053 SUP Custom 27803010 88053 - GRAFT SYNTH TISSUE ANGLE LARGE 57X40X4MM AUGMENTATION BOTH IP/OP "$1,333.13 " $986.52 $0.00 "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $989.45 $989.45 $0.00 $0.00 $277.82 $0.00 $0.00 $0.00 $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88054 SUP Custom 27803010 88054 - MANDIBLE ANGLE LARGE - RIGHT-57MM X 40MM X 4MM X 10MM X 4MM BOTH IP/OP "$1,380.00 " "$1,021.20" $0.00 "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.24" "$1,024.24" $0.00 $0.00 $287.59 $0.00 $0.00 $0.00 $0.00 $690.00 "$1,092.96" "$1,104.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88710 SUP HCPCS C1713 SPACER MDI ARCHB+ SM VLV HLD CHMBR HNDHLD CMFSL MASK PED BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $18.81 $18.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 88900 SUP HCPCS C1725 88900 - CATH US .038IN 8.2FR 90CM INTVASC PULBCK SLED REV BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" "$1,153.88" "$1,153.88" $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 88901 SUP HCPCS C1753 88901 - CATHETER ULTRASOUND .035IN 8.5FR 90CM 100CM OTW RADIOPQ BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,357.50" "$1,357.50" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 89007 SUP HCPCS C2617 089007 - STENT URETERAL 7FR 90CM LUBRICIOUS GWIRE LATEX FREE STERILE BOTH IP/OP $213.05 $157.66 $0.00 $170.44 $95.87 $95.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.53 $168.74 $170.44 $0.00 $0.00 $33.34 $0.00 $0.00 $33.92 $0.00 $0.00 $0.00 $0.00 $0.00 89008 SUP HCPCS C2617 089008 - STENT URETERAL 8FR 90CM LUBRICIOUS GWIRE LATEX FREE STERILE BOTH IP/OP $213.05 $157.66 $0.00 $170.44 $95.87 $95.87 $0.00 $0.00 $0.00 $44.40 $158.13 $158.13 $0.00 $0.00 $44.40 $0.00 $126.02 $126.02 $0.00 $106.53 $168.74 $170.44 $0.00 $0.00 $33.34 $0.00 $0.00 $33.92 $0.00 $0.00 $0.00 $0.00 $0.00 89020 SUP HCPCS C1763 89020 - TISSUE SYNTH PE POR MEDPOR IMPL CSTM CRANIAL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 89104 SUP HCPCS C1713 89104 - SCREW 89104 CD THR PLUG BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 89223 SUP Custom 27803010 89223 - IMPLANT SOFT TISSUE FLAT 4X1X1CM MOIST TOUGH FLEXIBLE SHEET BOTH IP/OP $861.00 $637.14 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $639.03 $639.03 $0.00 $0.00 $179.43 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89224 SUP Custom 27803010 89224 - IMPLANT SOFT TISSUE THK1MM FLAT 5X2CM MOIST TOUGH FLEXIBLE BOTH IP/OP "$1,742.50 " "$1,289.45" $0.00 "$1,814.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,293.28" "$1,293.28" $0.00 $0.00 $363.14 $0.00 $0.00 $0.00 $0.00 "$1,133.75" "$1,795.86" "$1,814.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89225 SUP Custom 27803010 89225 - IMPLANT SOFT TISSUE 8X3X1CM MOIST TOUGH FLEXIBLE FLAT SHEET BOTH IP/OP "$2,109.45 " "$1,560.99" $0.00 "$2,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,565.63" "$1,565.63" $0.00 $0.00 $439.61 $0.00 $0.00 $0.00 $0.00 "$1,371.25" "$2,172.06" "$2,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89612 SUP Custom 27203010 TIP PIP 1100UL EPNDF CNDCT BOTH IP/OP "$3,545.00 " "$2,623.30" $0.00 "$2,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,772.50" "$2,807.64" "$2,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89894 SUP Custom 27203010 WASHER PIP KT BOTH IP/OP $547.50 $405.15 $0.00 $438.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.75 $433.62 $438.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90001 SUP Custom 27203010 090001 - NEEDLE ENDSCP 35CM 23GA 8MM URTH CSCP INJEC PRC WMS BOTH IP/OP $48.50 $35.89 $0.00 $38.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $36.00 $0.00 $0.00 $10.11 $0.00 $0.00 $0.00 $0.00 $24.25 $38.41 $38.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90044 SUP HCPCS C1887 90044 - CATHETER ANGIO 3-2.4FR 150CM MRC 1 LUM RADOPQ BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $644.81 $644.81 $0.00 $0.00 $0.00 $247.50 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $702.41 $702.41 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $185.84 $0.00 $0.00 $189.05 $0.00 $0.00 $0.00 $0.00 $0.00 90051 SUP Custom 27203010 90051 - CATHETER URETHRAL 16FR FOLEY TEMPERATURE SENSOR LATEX FREE BOTH IP/OP $3.93 $2.91 $0.00 $20.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.91 $2.91 $0.00 $0.00 $0.82 $0.00 $0.00 $0.00 $0.00 $12.88 $3.11 $20.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90071 SUP Custom 27203010 090071 - NEEDLE FASCIAL INCISING 10MM BOTH IP/OP $76.95 $56.94 $0.00 $61.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.11 $57.11 $0.00 $0.00 $16.04 $0.00 $0.00 $0.00 $0.00 $38.48 $60.94 $61.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90071 SUP Custom 27203010 90071 - NEEDLE 5CM 18GA GWIRE PRC RNL FSCA 10MM BOTH IP/OP $76.95 $56.94 $0.00 $65.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.11 $57.11 $0.00 $0.00 $16.04 $0.00 $0.00 $0.00 $0.00 $38.48 $65.30 $61.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90073 SUP HCPCS C1887 CATHETER GUID .038IN 8FR 5.9FR 95CM BLN SIL MRC BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" "$1,187.81" "$1,187.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 90074 SUP HCPCS C1887 CATHETER BALLOON GUIDE CONCENTRIC 9F 95CM BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" "$1,187.81" "$1,187.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 90076 SUP HCPCS C1887 CATHETER BALLOON GUIDE CONCENTRIC 8F 80CM BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" "$1,187.81" "$1,187.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 90077 SUP HCPCS C1887 CATHETER BALLOON GUIDE 9F 80CM BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" "$1,187.81" "$1,187.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 90110 SUP HCPCS C1757 90110 - CATHETER THRMB CRKSCR 2MM 180CM 5MM MRC V RTRV V2 FIRM NTNL BOTH IP/OP "$7,987.50 " "$5,910.75" $0.00 "$6,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,664.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,664.60" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,993.75" "$6,326.10" "$6,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90111 SUP HCPCS C1757 90111 - CATHETER THRMB CRKSCR 2.5MM 180CM 6MM MRC V RETREIEVER V2.5 BOTH IP/OP "$7,987.50 " "$5,910.75" $0.00 "$6,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,664.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,664.60" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,993.75" "$6,326.10" "$6,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90112 SUP HCPCS C1757 90112 - CATHETER THRMB CRKSCR 2.5MM 180CM 6MM MRC V RETREIVER V2.5 BOTH IP/OP "$7,987.50 " "$5,910.75" $0.00 "$6,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,664.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,664.60" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,993.75" "$6,326.10" "$6,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90113 SUP HCPCS C1757 90113 - CATHETER THRMB CRKSCR 3MM 180CM 7MM MRC V RTRV V3 SFT NTNL BOTH IP/OP "$7,987.50 " "$5,910.75" $0.00 "$6,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,664.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,664.60" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,993.75" "$6,326.10" "$6,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90120 SUP HCPCS C1757 90120 - CATHETER THRMB 3.9FR .038IN 125CM DAC 1 LUM BRAID RADOPQ LL BOTH IP/OP "$2,700.15 " "$1,998.11" $0.00 "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $562.78 "$2,004.05" "$2,004.05" $0.00 $0.00 $562.71 $0.00 "$1,597.14" "$1,597.14" $0.00 "$1,350.08" "$2,138.52" "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90121 SUP HCPCS C1887 CATHETER THROMBECTOMY DAC 038 - 136CM BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,350.71" "$1,350.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 90131 SUP HCPCS C1887 CATHETER DISTAL ACCESS DAC 057 - 125CM BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,350.71" "$1,350.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 90160 SUP HCPCS C1757 90160 - CATHETER THRMB 4.3FR .044IN 115CM DAC 1 LUM BRAID RADOPQ LL BOTH IP/OP "$2,700.15 " "$1,998.11" $0.00 "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $562.78 "$2,004.05" "$2,004.05" $0.00 $0.00 $562.71 $0.00 "$1,597.14" "$1,597.14" $0.00 "$1,350.08" "$2,138.52" "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90161 SUP HCPCS C1757 90161 - CATHETER THROMBECTOMY DAC® 044 0.044IN / 130CM RADIOPQ SHAFT BOTH IP/OP "$2,573.25 " "$1,904.21" $0.00 "$2,058.60" $0.00 $0.00 $0.00 $0.00 $0.00 $536.33 "$1,909.87" "$1,909.87" $0.00 $0.00 $536.27 $0.00 "$1,522.08" "$1,522.08" $0.00 "$1,286.63" "$2,038.01" "$2,058.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90162 SUP HCPCS C1757 90162 - CATHETER THRMB 4.3FR .044IN 136CM DAC 1 LUM BRAID RADOPQ LL BOTH IP/OP "$2,700.15 " "$1,998.11" $0.00 "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $562.78 "$2,004.05" "$2,004.05" $0.00 $0.00 $562.71 $0.00 "$1,597.14" "$1,597.14" $0.00 "$1,350.08" "$2,138.52" "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90170 SUP HCPCS C1757 90170 - CATHETER THRMB 6.3FR .07IN 105CM DAC 1 LUM BRD RADOPQ LL HUB BOTH IP/OP "$2,700.15 " "$1,998.11" $0.00 "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $562.78 "$2,004.05" "$2,004.05" $0.00 $0.00 $562.71 $0.00 "$1,597.14" "$1,597.14" $0.00 "$1,350.08" "$2,138.52" "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90171 SUP HCPCS C1757 90171 - CATHETER THRMB 6.3FR .07IN 120CM DAC 1 LUM BRD RADOPQ LL HUB BOTH IP/OP "$2,700.15 " "$1,998.11" $0.00 "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,350.08" "$2,138.52" "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90182 SUP Custom 27203010 90182 - RETRIEVER ESCP 4MM 20MM TREVO XP PROVUE BOTH IP/OP "$13,116.25 " "$9,706.03" $0.00 "$10,493.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,733.43" $0.00 $0.00 $0.00 $0.00 "$6,558.13" "$10,388.07" "$10,493.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90183 SUP Custom 27203010 90183 - RETRIEVER ESCP 3MM 20MM TREVO XP PROVUE BOTH IP/OP "$13,116.25 " "$9,706.03" $0.00 "$10,493.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,733.43" $0.00 $0.00 $0.00 $0.00 "$6,558.13" "$10,388.07" "$10,493.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90231 SUP HCPCS C1757 90231 - CATHETER INFS MIC 18FR TREVO PRO NRVSC BOTH IP/OP "$1,703.75 " "$1,260.78" $0.00 "$1,363.00" $0.00 $0.00 $0.00 $0.00 $0.00 $355.10 "$1,264.52" "$1,264.52" $0.00 $0.00 $355.06 $0.00 "$1,007.77" "$1,007.77" $0.00 $851.88 "$1,349.37" "$1,363.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90603 SUP Custom 27203010 90603 - DRESSING TRANSPARENT 8X8IN ABSORBENT NONADHESIVE BOTH IP/OP $28.88 $21.37 $0.00 $23.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.44 $21.44 $0.00 $0.00 $6.02 $0.00 $0.00 $0.00 $0.00 $14.44 $22.87 $23.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90605 SUP Custom 27203010 90605 - DRESSING FOAM 24X4IN NONADHESIVE HIGH FLUID HANDLE BOTH IP/OP $49.61 $36.71 $0.00 $39.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.82 $36.82 $0.00 $0.00 $10.34 $0.00 $0.00 $0.00 $0.00 $24.80 $39.29 $39.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90730 SUP HCPCS C1757 90730 - CATHETER THRMB 5.2FR .057IN 115CM DAC 1 LUM BRAID RADOPQ LL BOTH IP/OP "$2,700.15 " "$1,998.11" $0.00 "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $562.78 "$2,004.05" "$2,004.05" $0.00 $0.00 $562.71 $0.00 "$1,597.14" "$1,597.14" $0.00 "$1,350.08" "$2,138.52" "$2,160.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90760 SUP HCPCS C1757 90760 - CATHETER THRMB 4.3FR .044IN 130CM DAC 1 LUM BRAID RADOPQ LL BOTH IP/OP "$2,573.25 " "$1,904.21" $0.00 "$2,058.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,286.63" "$2,038.01" "$2,058.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90805 SUP Custom 27203010 90805 - DRESSING TRANSPARENT LARGE SQUARE 8INX7 7/8IN 6INX5 7/8IN BOTH IP/OP $24.44 $18.09 $0.00 $19.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.14 $18.14 $0.00 $0.00 $5.09 $0.00 $0.00 $0.00 $0.00 $12.22 $19.36 $19.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91101 SUP Custom 27203010 91101 - CATHETER NEUROSURGICAL ANTIBIOTIC IMPREGNATED ARES VENTRICLE BOTH IP/OP $770.00 $569.80 $0.00 $616.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $571.49 $571.49 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $385.00 $609.84 $616.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91265 SUP Custom 27203010 91265 - FLAT VENOUS 2 STAGE CANNULA MC2 BOTH IP/OP $78.68 $58.22 $0.00 $68.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.40 $58.40 $0.00 $0.00 $16.40 $0.00 $0.00 $0.00 $0.00 $43.04 $68.18 $68.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91503 SUP Custom 27803010 91503 - CATH 91503 BIOGLIDE VENT 23CM CLOSED IMP BOTH IP/OP $513.00 $379.62 $0.00 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.75 $380.75 $0.00 $0.00 $106.91 $0.00 $0.00 $0.00 $0.00 $256.50 $406.30 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92001 SUP Custom 27203010 092001 - CLIP INTNL ANG RT 15MM STRL LF LDS LNR CTR PWR SF LKOUT BOTH IP/OP $387.15 $286.49 $0.00 $309.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.34 $287.34 $0.00 $0.00 $80.68 $0.00 $0.00 $0.00 $0.00 $193.58 $306.62 $309.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100 SUP Custom 27203010 0092100 - TUBE ESPH 20FR 8IN NS LTX 1.5IN BLKMR BLN SPCL NTR RBR ADLT BOTH IP/OP $758.28 $561.13 $0.00 $562.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.79 $562.79 $0.00 $0.00 $158.02 $0.00 $0.00 $0.00 $0.00 $182.94 $289.78 $292.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92100 SUP Custom 27203010 TUBE NG 8IN 20FR 3 LUM BLN RADIOPQ STRP BLKMR ADLT NSTRL LTX BOTH IP/OP $758.28 $561.13 $0.00 $704.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.79 $562.79 $0.00 $0.00 $158.02 $0.00 $0.00 $0.00 $0.00 $182.94 $704.23 $292.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92312 SUP Custom 27803010 92312 - VALVE 92312 CSF CONTRD SML LOW BIO BOTH IP/OP "$2,681.38 " "$1,984.22" $0.00 "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,990.12" "$1,990.12" $0.00 $0.00 $558.80 $0.00 $0.00 $0.00 $0.00 "$1,340.69" "$2,123.65" "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92314 SUP Custom 27803010 92314 - VALVE 92314 CSF CONT SML MED BIO BOTH IP/OP "$2,681.38 " "$1,984.22" $0.00 "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,990.12" "$1,990.12" $0.00 $0.00 $558.80 $0.00 $0.00 $0.00 $0.00 "$1,340.69" "$2,123.65" "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92316 SUP Custom 27803010 92316 - VALVE 92316 CSF CONT SML HIGH BIO BOTH IP/OP "$3,018.63 " "$2,233.79" $0.00 "$2,414.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,240.42" "$2,240.42" $0.00 $0.00 $629.08 $0.00 $0.00 $0.00 $0.00 "$1,509.31" "$2,390.75" "$2,414.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92322 SUP Custom 27803010 92322 - VALVE 92322 CSF CONT REG LOW BIO BOTH IP/OP "$2,681.38 " "$1,984.22" $0.00 "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,990.12" "$1,990.12" $0.00 $0.00 $558.80 $0.00 $0.00 $0.00 $0.00 "$1,340.69" "$2,123.65" "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92324 SUP Custom 27803010 92324 - VALVE 92324 CSF CONT REG MED BIO BOTH IP/OP "$2,681.38 " "$1,984.22" $0.00 "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,990.12" "$1,990.12" $0.00 $0.00 $558.80 $0.00 $0.00 $0.00 $0.00 "$1,340.69" "$2,123.65" "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92326 SUP Custom 27803010 92326 - VALVE 92326 CSF CONT REG HIGH BIO BOTH IP/OP "$2,681.38 " "$1,984.22" $0.00 "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,990.12" "$1,990.12" $0.00 $0.00 $558.80 $0.00 $0.00 $0.00 $0.00 "$1,340.69" "$2,123.65" "$2,145.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92355 SUP Custom 27803010 92355 - VALVE 92355 STRATA NSC SML BIOGLIDE BOTH IP/OP "$9,501.05 " "$7,030.78" $0.00 "$7,600.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,980.02" $0.00 $0.00 $0.00 $0.00 "$4,750.53" "$7,524.83" "$7,600.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92365 SUP Custom 27803010 92365 - VALVE 92365 STRATA NSC REG BIOGLIDE BOTH IP/OP "$9,501.05 " "$7,030.78" $0.00 "$7,600.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,980.02" $0.00 $0.00 $0.00 $0.00 "$4,750.53" "$7,524.83" "$7,600.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92812 SUP Custom 27803010 92812 - VALVE 92812 BIOGLIDE DELTA SM 1.0 BOTH IP/OP "$4,358.13 " "$3,225.02" $0.00 "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,234.60" "$3,234.60" $0.00 $0.00 $908.23 $0.00 $0.00 $0.00 $0.00 "$2,179.06" "$3,451.64" "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92813 SUP Custom 27803010 92813 - VALVE 92813 BIOGLIDE DELTA SM 1.5 BOTH IP/OP "$4,358.13 " "$3,225.02" $0.00 "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,234.60" "$3,234.60" $0.00 $0.00 $908.23 $0.00 $0.00 $0.00 $0.00 "$2,179.06" "$3,451.64" "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92814 SUP Custom 27803010 92814 - VALVE 92814 BIOGLIDE DELTA SM 2.0 BOTH IP/OP "$4,358.13 " "$3,225.02" $0.00 "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,234.60" "$3,234.60" $0.00 $0.00 $908.23 $0.00 $0.00 $0.00 $0.00 "$2,179.06" "$3,451.64" "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92822 SUP Custom 27803010 92822 - VALVE 92822 BIOGLIDE DELTA REG. 1.0 BOTH IP/OP "$4,358.13 " "$3,225.02" $0.00 "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,234.60" "$3,234.60" $0.00 $0.00 $908.23 $0.00 $0.00 $0.00 $0.00 "$2,179.06" "$3,451.64" "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92823 SUP Custom 27803010 92823 - VALVE 92823 BIOGLIDE DELTA REG. 1.5 BOTH IP/OP "$4,358.13 " "$3,225.02" $0.00 "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,234.60" "$3,234.60" $0.00 $0.00 $908.23 $0.00 $0.00 $0.00 $0.00 "$2,179.06" "$3,451.64" "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92824 SUP Custom 27803010 92824 - VALVE 92824 BIOGLIDE DELTA REG. 2.0 BOTH IP/OP "$4,358.13 " "$3,225.02" $0.00 "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,234.60" "$3,234.60" $0.00 $0.00 $908.23 $0.00 $0.00 $0.00 $0.00 "$2,179.06" "$3,451.64" "$3,486.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92830 SUP Custom 27803010 92830 - VALVE 92830 DELTA BH 12MM PL 0.5 BIOGLID BOTH IP/OP "$4,612.25 " "$3,413.07" $0.00 "$3,689.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,423.21" "$3,423.21" $0.00 $0.00 $961.19 $0.00 $0.00 $0.00 $0.00 "$2,306.13" "$3,652.90" "$3,689.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92833 SUP Custom 27803010 92833 - VALVE 92833 BIOGLIDE DELTA BH 12 1.5 BOTH IP/OP "$3,904.50 " "$2,889.33" $0.00 "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,897.92" "$2,897.92" $0.00 $0.00 $813.70 $0.00 $0.00 $0.00 $0.00 "$1,952.25" "$3,092.36" "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92834 SUP Custom 27803010 92834 - VALVE 92834 BIOGLIDE DELTA BH 12 2.0 BOTH IP/OP "$4,612.25 " "$3,413.07" $0.00 "$3,689.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,423.21" "$3,423.21" $0.00 $0.00 $961.19 $0.00 $0.00 $0.00 $0.00 "$2,306.13" "$3,652.90" "$3,689.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92840 SUP Custom 27803010 92840 - VALVE 92840 DELTA BH 16MM PL 0.5 BIOGLID BOTH IP/OP "$3,904.50 " "$2,889.33" $0.00 "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,897.92" "$2,897.92" $0.00 $0.00 $813.70 $0.00 $0.00 $0.00 $0.00 "$1,952.25" "$3,092.36" "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92842 SUP Custom 27803010 92842 - VALVE 92842 BIOGLIDE DELTA BH 16 1.0 BOTH IP/OP "$3,904.50 " "$2,889.33" $0.00 "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,897.92" "$2,897.92" $0.00 $0.00 $813.70 $0.00 $0.00 $0.00 $0.00 "$1,952.25" "$3,092.36" "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92843 SUP Custom 27803010 92843 - VALVE 92843 BIOGLIDE DELTA BH 16 1.5 BOTH IP/OP "$3,904.50 " "$2,889.33" $0.00 "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,897.92" "$2,897.92" $0.00 $0.00 $813.70 $0.00 $0.00 $0.00 $0.00 "$1,952.25" "$3,092.36" "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92844 SUP Custom 27803010 92844 - VALVE 92844 BIOGLIDE DELTA BH 16 2.0 BOTH IP/OP "$3,904.50 " "$2,889.33" $0.00 "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,897.92" "$2,897.92" $0.00 $0.00 $813.70 $0.00 $0.00 $0.00 $0.00 "$1,952.25" "$3,092.36" "$3,123.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92856 SUP Custom 27803010 92856 - VALVE 92856 FP STRATA 2 SML BG BOTH IP/OP "$10,337.65 " "$7,649.86" $0.00 "$8,270.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,154.37" $0.00 $0.00 $0.00 $0.00 "$5,168.83" "$8,187.42" "$8,270.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92866 SUP Custom 27803010 92866 - VALVE 92866 FP STRATA 2 REG BG BOTH IP/OP "$10,337.65 " "$7,649.86" $0.00 "$8,270.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,154.37" $0.00 $0.00 $0.00 $0.00 "$5,168.83" "$8,187.42" "$8,270.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93092 SUP Custom 27203010 93092 - CATHETER NEUROSURGICAL 120CM ANTIBIOTIC IMPREGNATED ARES BOTH IP/OP $770.00 $569.80 $0.00 $616.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $571.49 $571.49 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $385.00 $609.84 $616.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93320 SUP HCPCS C1769 93320 - WIRE 35-180 COONS BOTH IP/OP $60.75 $44.96 $0.00 $48.60 $32.99 $32.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.38 $48.11 $48.60 $0.00 $0.00 $9.51 $0.00 $0.00 $9.67 $0.00 $0.00 $0.00 $0.00 $0.00 93522 SUP Custom 27803010 93522 - CATHETER 93522 BIOGLIDE PERITONEAL BOTH IP/OP $543.88 $402.47 $0.00 $435.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $403.66 $403.66 $0.00 $0.00 $113.34 $0.00 $0.00 $0.00 $0.00 $271.94 $430.75 $435.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94965 SUP Custom 27203010 94965 - DLP RETROGRADE CORONARY PERFUSION CANNULA 15 FR BOTH IP/OP $199.49 $147.62 $0.00 $174.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.06 $148.06 $0.00 $0.00 $41.57 $0.00 $0.00 $0.00 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95001 SUP Custom 27203010 95001 - KIT CATH STRL LF ARES ANBTC BOTH IP/OP $336.88 $249.29 $0.00 "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.03 $250.03 $0.00 $0.00 $70.20 $0.00 $0.00 $0.00 $0.00 $675.00 "$1,069.20" "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95201 SUP Custom 27203010 PUMP CNTRF BPMP BPX80 STRL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96115 SUP Custom 27803010 96115 - CATH 96115 BIOGLIDE EDM VENT 20 CM BOTH IP/OP $458.40 $339.22 $0.00 $366.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.22 $340.22 $0.00 $0.00 $95.53 $0.00 $0.00 $0.00 $0.00 $229.20 $363.05 $366.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96118 SUP Custom 27803010 96118 - CATH 96118 BIOGLIDE EDM VENT 35 CM BOTH IP/OP $549.60 $406.70 $0.00 $439.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.91 $407.91 $0.00 $0.00 $114.54 $0.00 $0.00 $0.00 $0.00 $274.80 $435.28 $439.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96655 SUP Custom 27803010 96655 - SHUNT 96655 STRATA NSC ASSY SML BIOGLIDE BOTH IP/OP "$9,921.70 " "$7,342.06" $0.00 "$7,937.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,067.68" $0.00 $0.00 $0.00 $0.00 "$4,960.85" "$7,857.99" "$7,937.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96665 SUP Custom 27803010 96665 - SHUNT 96665 STRATA NSC ASSY REG BIOGLIDE BOTH IP/OP "$9,921.70 " "$7,342.06" $0.00 "$7,937.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,067.68" $0.00 $0.00 $0.00 $0.00 "$4,960.85" "$7,857.99" "$7,937.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96812 SUP Custom 27803010 96812 - SHUNT 96812 DELTA ASSY SMALL P/L 1.0 BIO BOTH IP/OP "$4,949.50 " "$3,662.63" $0.00 "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,673.52" "$3,673.52" $0.00 $0.00 "$1,031.48" $0.00 $0.00 $0.00 $0.00 "$2,474.75" "$3,920.00" "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96813 SUP Custom 27803010 96813 - SHUNT 96813 DELTA ASSY SMALL P/L 1.5 BIO BOTH IP/OP "$4,949.50 " "$3,662.63" $0.00 "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,673.52" "$3,673.52" $0.00 $0.00 "$1,031.48" $0.00 $0.00 $0.00 $0.00 "$2,474.75" "$3,920.00" "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96814 SUP Custom 27803010 96814 - SHUNT 96814 DELTA ASSY SMALL P/L 2.0 BIO BOTH IP/OP "$4,949.50 " "$3,662.63" $0.00 "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,673.52" "$3,673.52" $0.00 $0.00 "$1,031.48" $0.00 $0.00 $0.00 $0.00 "$2,474.75" "$3,920.00" "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96822 SUP Custom 27803010 96822 - SHUNT 96822 DELTA ASSY REG P/L 1.0 BIO BOTH IP/OP "$4,949.50 " "$3,662.63" $0.00 "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,673.52" "$3,673.52" $0.00 $0.00 "$1,031.48" $0.00 $0.00 $0.00 $0.00 "$2,474.75" "$3,920.00" "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96823 SUP Custom 27803010 96823 - SHUNT 96823 DELTA ASSY REG P/L 1.5 BIO BOTH IP/OP "$4,949.50 " "$3,662.63" $0.00 "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,673.52" "$3,673.52" $0.00 $0.00 "$1,031.48" $0.00 $0.00 $0.00 $0.00 "$2,474.75" "$3,920.00" "$3,959.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96824 SUP Custom 27803010 96824 - SHUNT 96824 DELTA ASSY REG P/L 2.0 BIO BOTH IP/OP "$5,569.38 " "$4,121.34" $0.00 "$4,455.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,133.59" "$4,133.59" $0.00 $0.00 "$1,160.66" $0.00 $0.00 $0.00 $0.00 "$2,784.69" "$4,410.95" "$4,455.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97021 SUP Custom 27203010 KIT OC KIMVENT SLF CLEAN Y CONNCTR SCT HNDL BOTH IP/OP $38.04 $28.15 $0.00 $30.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.02 $30.13 $30.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98200 SUP Custom 27203010 TRIAGE BIOSITE BNP REAGENT 2/PK BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98201 SUP Custom 27203010 CONTROL BNP TRG BKMN SYS IMMUN BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98202 SUP Custom 27203010 CALIBRATOR CHM BKMN SYS VRFR BNP TRG 98202 BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 98433 SUP HCPCS C1894 98433 - KIT GASTROSTOMY 22FR 18GA DILAT INTROD NEEDLE HEMOSTAT LATEX BOTH IP/OP $531.70 $393.46 $0.00 $425.36 $288.71 $288.71 $0.00 $0.00 $0.00 $110.82 $394.63 $394.63 $0.00 $0.00 $110.81 $0.00 $314.50 $314.50 $0.00 $265.85 $421.11 $425.36 $0.00 $0.00 $83.21 $0.00 $0.00 $84.65 $0.00 $0.00 $0.00 $0.00 $0.00 99102 SUP Custom 27803010 99102 - CATH 99102 INNERVISION BIOGLIDE BOTH IP/OP $729.13 $539.56 $0.00 $583.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.16 $541.16 $0.00 $0.00 $151.95 $0.00 $0.00 $0.00 $0.00 $364.56 $577.47 $583.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99800 SUP Custom 27203010 0099800 - DRAIN INCS 10FR 12IN DEAVER RBR BIL 5IN T-TB STM XBAR GRVTY BOTH IP/OP $34.88 $25.81 $0.00 $27.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.88 $25.88 $0.00 $0.00 $7.27 $0.00 $0.00 $0.00 $0.00 $17.44 $27.62 $27.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99810 SUP HCPCS C1729 0099810 - DRAIN INCS 12FR 12IN DEAVER RBR BIL 5IN T-TB STM XBAR GRVTY BOTH IP/OP $28.78 $21.30 $0.00 $23.02 $15.62 $15.62 $0.00 $0.00 $0.00 $6.00 $21.36 $21.36 $0.00 $0.00 $6.00 $0.00 $17.02 $17.02 $0.00 $14.39 $22.79 $23.02 $0.00 $0.00 $4.50 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 99820 SUP Custom 27203010 99820 - TUBES T 14FR BOTH IP/OP $31.68 $23.44 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.51 $23.51 $0.00 $0.00 $6.60 $0.00 $0.00 $0.00 $0.00 $15.84 $25.09 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99830 SUP Custom 27203010 99830 - DRAIN INCS 16FR 12IN DEAVER RBR BIL 5IN T-TB STM XBAR GRVTY BOTH IP/OP $173.25 $128.21 $0.00 $138.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99840 SUP HCPCS C1729 0099840 - DRAIN INCS 18FR 12IN DEAVER RBR BIL 5IN T-TB STM XBAR GRVTY BOTH IP/OP $28.78 $21.30 $0.00 $23.02 $15.62 $15.62 $0.00 $0.00 $0.00 $6.00 $21.36 $21.36 $0.00 $0.00 $6.00 $0.00 $17.02 $17.02 $0.00 $14.39 $22.79 $23.02 $0.00 $0.00 $4.50 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 100100 SUP Custom 27011340 100100 - ROD XTRNFX LG 100MM ILZ TLSCP BSC SET SS AL PED FEM BOTH IP/OP "$1,686.40 " "$1,247.94" $0.00 "$1,349.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,251.65" "$1,251.65" $0.00 $0.00 $351.45 $0.00 $0.00 $0.00 $0.00 $843.20 "$1,335.63" "$1,349.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100101 SUP Custom 27011340 100101 - ROD XTRNFX LG 150MM ILZ TLSCP SYS BOTH IP/OP "$1,686.40 " "$1,247.94" $0.00 "$1,349.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,251.65" "$1,251.65" $0.00 $0.00 $351.45 $0.00 $0.00 $0.00 $0.00 $843.20 "$1,335.63" "$1,349.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100102 SUP Custom 27011340 100102 - ROD XTRNFX LG 200MM ILZ TLSCP BOTH IP/OP "$2,048.50 " "$1,515.89" $0.00 "$1,638.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,520.40" "$1,520.40" $0.00 $0.00 $426.91 $0.00 $0.00 $0.00 $0.00 "$1,024.25" "$1,622.41" "$1,638.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100103 SUP Custom 27011340 100103 - ROD XTRNFX LG 250MM ILZ CIRC TLSCP SS AL BOTH IP/OP "$2,048.50 " "$1,515.89" $0.00 "$1,638.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,520.40" "$1,520.40" $0.00 $0.00 $426.91 $0.00 $0.00 $0.00 $0.00 "$1,024.25" "$1,622.41" "$1,638.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100104 SUP Custom 27011340 100104 - ROD XTRNFX 60MM ILZ GRAD TLSCP SYS SS AL BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,516.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 $0.00 $0.00 $0.00 "$1,572.50" "$2,490.84" "$2,516.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100105 SUP Custom 27011340 100105 - ROD XTRNFX LG 100MM ILZ TLSCP GRAD DLX SET ADLT TIB BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,516.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 $0.00 $0.00 $0.00 "$1,572.50" "$2,490.84" "$2,516.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100106 SUP Custom 27011340 100106 - ROD XTRNFX 150MM ILZ GRAD TLSCP SYS SS AL BOTH IP/OP "$4,615.50 " "$3,415.47" $0.00 "$3,692.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,425.62" "$3,425.62" $0.00 $0.00 $961.87 $0.00 $0.00 $0.00 $0.00 "$2,307.75" "$3,655.48" "$3,692.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100107 SUP Custom 27011340 100107 - ROD XTRNFX 200MM ILZ GRAD TLSCP SYS SS AL BOTH IP/OP "$4,615.50 " "$3,415.47" $0.00 "$3,692.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,425.62" "$3,425.62" $0.00 $0.00 $961.87 $0.00 $0.00 $0.00 $0.00 "$2,307.75" "$3,655.48" "$3,692.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100108 SUP Custom 27011340 100108 - ROD XTRNFX 250MM ILZ GRAD TLSCP AL SS BOTH IP/OP "$4,615.50 " "$3,415.47" $0.00 "$3,692.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,425.62" "$3,425.62" $0.00 $0.00 $961.87 $0.00 $0.00 $0.00 $0.00 "$2,307.75" "$3,655.48" "$3,692.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100200 SUP Custom 27011340 100200 - WIRE XTRNFX ILZ BSC SET BCKL DTCH ADLT FEM SS RING BOTH IP/OP $826.20 $611.39 $0.00 $660.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $613.21 $613.21 $0.00 $0.00 $172.18 $0.00 $0.00 $0.00 $0.00 $413.10 $654.35 $660.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100241 SUP Custom 27011340 100241 - DEVICE XTRNFX ILZ WRE FX BCKL CIRC SM BN FXTR BOTH IP/OP "$1,768.00 " "$1,308.32" $0.00 "$1,414.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,312.21" "$1,312.21" $0.00 $0.00 $368.45 $0.00 $0.00 $0.00 $0.00 $884.00 "$1,400.26" "$1,414.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100250 SUP Custom 27203010 100250 - DEVICE XTRNFX ILZ WRE FX BCKL CIRC COMP RING BOTH IP/OP $911.20 $674.29 $0.00 $728.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $676.29 $676.29 $0.00 $0.00 $189.89 $0.00 $0.00 $0.00 $0.00 $455.60 $721.67 $728.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100301 SUP Custom 27011340 100301 - CLAMP XTRNFX ILZ 1 HL PIN BOTH IP/OP $892.50 $660.45 $0.00 $714.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.41 $662.41 $0.00 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $446.25 $706.86 $714.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100302 SUP Custom 27011340 100302 - CLAMP XTRNFX ILZ 2 HL PIN BOTH IP/OP $892.50 $660.45 $0.00 $714.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.41 $662.41 $0.00 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $446.25 $706.86 $714.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100303 SUP Custom 27011340 100303 - CLAMP XTRNFX ILZ 3 HL PIN BOTH IP/OP $892.50 $660.45 $0.00 $714.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.41 $662.41 $0.00 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $446.25 $706.86 $714.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100304 SUP Custom 27011340 100304 - CLAMP XTRNFX ILZ 4 HL PIN BOTH IP/OP "$1,251.20 " $925.89 $0.00 "$1,000.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $928.64 $928.64 $0.00 $0.00 $260.75 $0.00 $0.00 $0.00 $0.00 $625.60 $990.95 "$1,000.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100305 SUP Custom 27011340 100305 - CLAMP XTRNFX ILZ 5 HL PIN BOTH IP/OP "$1,251.20 " $925.89 $0.00 "$1,000.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.60 $990.95 "$1,000.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100400 SUP Custom 27011340 100400 - PLATE XTRNFX LNG 155MM 8 HL CNCT BOTH IP/OP $974.10 $720.83 $0.00 $779.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $722.98 $722.98 $0.00 $0.00 $203.00 $0.00 $0.00 $0.00 $0.00 $487.05 $771.49 $779.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100401 SUP Custom 27011340 100401 - PLATE XTRNFX LNG 235MM ILZ 12 HL CNCT BOTH IP/OP $974.10 $720.83 $0.00 $779.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $722.98 $722.98 $0.00 $0.00 $203.00 $0.00 $0.00 $0.00 $0.00 $487.05 $771.49 $779.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100402 SUP Custom 27011340 100402 - PLATE XTRNFX LNG 355MM ILZ 17 HL CNCT SYS BOTH IP/OP "$1,184.90 " $876.83 $0.00 $947.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.43 $879.43 $0.00 $0.00 $246.93 $0.00 $0.00 $0.00 $0.00 $592.45 $938.44 $947.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100409 SUP Custom 27011340 100409 - PLATE XTRNFX LNG 72MM ILZ 5 HL SM BN FXTR SET BOTH IP/OP $873.80 $646.61 $0.00 $699.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $648.53 $648.53 $0.00 $0.00 $182.10 $0.00 $0.00 $0.00 $0.00 $436.90 $692.05 $699.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100412 SUP Custom 27011340 100412 - PLATE XTRNFX LNG 102MM ILZ 7 HL SM BN FXTR SET BOTH IP/OP $958.80 $709.51 $0.00 $767.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $711.62 $711.62 $0.00 $0.00 $199.81 $0.00 $0.00 $0.00 $0.00 $479.40 $759.37 $767.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100415 SUP Custom 27011340 100415 - PLATE XTRNFX LNG 72MM ILZ 9 HL SM BN FXTR SET BOTH IP/OP "$1,014.90 " $751.03 $0.00 $811.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.26 $753.26 $0.00 $0.00 $211.51 $0.00 $0.00 $0.00 $0.00 $507.45 $803.80 $811.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100418 SUP Custom 27011340 100418 - PLATE XTRNFX LNG 162MM ILZ 11 HL SM BN FXTR SET BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $0.00 $0.00 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100420 SUP Custom 27011340 100420 - PLATE XTRNFX LNG 155MM ILZ 8 HL CNCT CIRC COMP CFBR EPOXY BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100421 SUP Custom 27011340 100421 - PLATE XTRNFX LNG 235MM ILZ 12 HL CNCT CIRC COMP CFBR EPOXY BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100422 SUP Custom 27011340 100422 - PLATE XTRNFX LNG 335MM ILZ 17 HL CNCT CIRC COMP CFBR EPOXY BOTH IP/OP "$1,354.00 " "$1,001.96" $0.00 "$1,083.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,004.94" "$1,004.94" $0.00 $0.00 $282.17 $0.00 $0.00 $0.00 $0.00 $677.00 "$1,072.37" "$1,083.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100500 SUP Custom 27011340 100500 - PLATE XTRNFX 135MM ILZ 5 HL CNCT THRD END BOTH IP/OP "$1,079.50 " $798.83 $0.00 $863.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $801.20 $801.20 $0.00 $0.00 $224.97 $0.00 $0.00 $0.00 $0.00 $539.75 $854.96 $863.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100501 SUP Custom 27011340 100501 - PLATE XTRNFX 175MM ILZ 7 HL CNCT SYS THRD END BOTH IP/OP "$1,079.50 " $798.83 $0.00 $863.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $801.20 $801.20 $0.00 $0.00 $224.97 $0.00 $0.00 $0.00 $0.00 $539.75 $854.96 $863.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100502 SUP Custom 27011340 100502 - PLATE XTRNFX 215MM ILZ 9 HL CNCT CIRC THRD END BOTH IP/OP "$1,380.40 " "$1,021.50" $0.00 "$1,104.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.53" "$1,024.53" $0.00 $0.00 $287.68 $0.00 $0.00 $0.00 $0.00 $690.20 "$1,093.28" "$1,104.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100503 SUP Custom 27011340 100503 - PLATE XTRNFX 255MM ILZ 11 HL CNCT THRD END SS ADLT TIB BOTH IP/OP "$1,416.00 " "$1,047.84" $0.00 "$1,132.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.00 "$1,121.47" "$1,132.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100550 SUP HCPCS C1713 100550 - BOLT XTRNFX 8MM ILZ CNCT SS ADLT BOTH IP/OP $16.15 $11.95 $0.00 $12.92 $7.27 $7.27 $0.00 $0.00 $0.00 $3.37 $11.99 $11.99 $0.00 $0.00 $3.37 $0.00 $9.55 $9.55 $0.00 $8.08 $12.79 $12.92 $0.00 $0.00 $2.53 $0.00 $0.00 $2.57 $0.00 $0.00 $0.00 $0.00 $0.00 100600 SUP Custom 27203010 100600 - BOLT XTRNFX ILZ CNN WRE FEM BOTH IP/OP $143.83 $106.43 $0.00 $115.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.75 $106.75 $0.00 $0.00 $29.97 $0.00 $0.00 $0.00 $0.00 $71.91 $113.91 $115.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100601 SUP Custom 27011340 100601 - BOLT XTRNFX ILZ CNN WRE CIRC THRD HD BOTH IP/OP $223.20 $165.17 $0.00 $178.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.66 $165.66 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $111.60 $176.77 $178.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100613 SUP Custom 27011340 100613 - BOLT XTRNFX 3MM ILZ .5 PIN CIRC BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.23 $549.23 $0.00 $0.00 $154.22 $0.00 $0.00 $0.00 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100614 SUP Custom 27011340 100614 - BOLT XTRNFX 4MM ILZ .5 PIN CIRC BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.23 $549.23 $0.00 $0.00 $154.22 $0.00 $0.00 $0.00 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100615 SUP Custom 27011340 100615 - BOLT XTRNFX CRC 5MM ILZ HLF PIN BOTH IP/OP $672.00 $497.28 $0.00 $537.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $498.76 $498.76 $0.00 $0.00 $140.04 $0.00 $0.00 $0.00 $0.00 $336.00 $532.22 $537.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100616 SUP Custom 27011340 100616 - BOLT XTRNFX CRC 6MM ILZ HLF PIN BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 100700 SUP HCPCS C1713 100700 - BOLT XTRNFX ILZ SLOT WRE BSC SET FEM BOTH IP/OP $161.85 $119.77 $0.00 $129.48 $72.83 $72.83 $0.00 $0.00 $0.00 $33.73 $120.13 $120.13 $0.00 $0.00 $33.73 $0.00 $95.73 $95.73 $0.00 $80.93 $128.19 $129.48 $0.00 $0.00 $25.33 $0.00 $0.00 $25.77 $0.00 $0.00 $0.00 $0.00 $0.00 100819 SUP HCPCS C1713 100819 - PLATE XTRNFX SHRT 27MM 2 HL CNCT CIRC SM BN BOTH IP/OP $484.50 $358.53 $0.00 $387.60 $218.03 $218.03 $0.00 $0.00 $0.00 $100.98 $359.60 $359.60 $0.00 $0.00 $100.97 $0.00 $286.58 $286.58 $0.00 $242.25 $383.72 $387.60 $0.00 $0.00 $75.82 $0.00 $0.00 $77.13 $0.00 $0.00 $0.00 $0.00 $0.00 100822 SUP HCPCS C1713 100822 - PLATE XTRNFX SHRT 37MM 3 HL CNCT CIRC SM BN BOTH IP/OP $564.40 $417.66 $0.00 $451.52 $253.98 $253.98 $0.00 $0.00 $0.00 $117.64 $418.90 $418.90 $0.00 $0.00 $117.62 $0.00 $333.84 $333.84 $0.00 $282.20 $447.00 $451.52 $0.00 $0.00 $88.33 $0.00 $0.00 $89.85 $0.00 $0.00 $0.00 $0.00 $0.00 100825 SUP HCPCS C1713 100825 - PLATE XTRNFX SHRT 47MM 4 HL CNCT CIRC SM BN BOTH IP/OP $600.10 $444.07 $0.00 $480.08 $270.05 $270.05 $0.00 $0.00 $0.00 $125.08 $445.39 $445.39 $0.00 $0.00 $125.06 $0.00 $354.96 $354.96 $0.00 $300.05 $475.28 $480.08 $0.00 $0.00 $93.92 $0.00 $0.00 $95.54 $0.00 $0.00 $0.00 $0.00 $0.00 100882 SUP HCPCS C1713 100882 - SPACER XTRNFX 20MM SM BN FXTR BOTH IP/OP $511.70 $378.66 $0.00 $409.36 $230.27 $230.27 $0.00 $0.00 $0.00 $106.65 $379.78 $379.78 $0.00 $0.00 $106.64 $0.00 $302.67 $302.67 $0.00 $255.85 $405.27 $409.36 $0.00 $0.00 $80.08 $0.00 $0.00 $81.46 $0.00 $0.00 $0.00 $0.00 $0.00 100883 SUP HCPCS C1713 100883 - SPACER XTRNFX 30MM SM BN FXTR BOTH IP/OP $511.70 $378.66 $0.00 $409.36 $230.27 $230.27 $0.00 $0.00 $0.00 $106.65 $379.78 $379.78 $0.00 $0.00 $106.64 $0.00 $302.67 $302.67 $0.00 $255.85 $405.27 $409.36 $0.00 $0.00 $80.08 $0.00 $0.00 $81.46 $0.00 $0.00 $0.00 $0.00 $0.00 101010 SUP HCPCS Q4116 101010 - GRAFT SKIN 14X5CM ALLOGRAFT NON MESHED ALLODERM ACELLULAR BOTH IP/OP $1.39 $1.03 $0.00 $1.11 $0.63 $0.63 $0.00 $0.00 $0.00 $0.29 $1.03 $1.03 $0.00 $0.00 $0.29 $0.00 $0.82 $0.82 $0.00 $0.70 $1.10 $1.11 $0.00 $0.00 $0.22 $0.00 $0.00 $0.22 $0.00 $0.00 $0.00 $0.00 $0.00 101020 SUP HCPCS Q4116 101020 - GRAFT SKIN 12X5CM ALLOGRAFT NON MESHED ALLODERM ACELLULAR BOTH IP/OP $1.63 $1.21 $0.00 $1.30 $0.73 $0.73 $0.00 $0.00 $0.00 $0.34 $1.21 $1.21 $0.00 $0.00 $0.34 $0.00 $0.96 $0.96 $0.00 $0.81 $1.29 $1.30 $0.00 $0.00 $0.25 $0.00 $0.00 $0.26 $0.00 $0.00 $0.00 $0.00 $0.00 101400 SUP Custom 27011340 101400 - POST EXFIX ILZ SS 2 HOLE MALE BOTH IP/OP $409.70 $303.18 $0.00 $327.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.08 $304.08 $0.00 $0.00 $85.38 $0.00 $0.00 $0.00 $0.00 $204.85 $324.48 $327.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101401 SUP Custom 27011340 101401 - POST EXFIX ILZ TIB 3 HOLE MALE PED BOTH IP/OP $428.40 $317.02 $0.00 $342.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.96 $317.96 $0.00 $0.00 $89.28 $0.00 $0.00 $0.00 $0.00 $214.20 $339.29 $342.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101510 SUP HCPCS Q4116 101510 - GRAFT SKIN 36X5MM ALLOGRAFT MESHED ALLODERM ACELLULAR DERMIS BOTH IP/OP $0.54 $0.40 $0.00 $0.43 $0.24 $0.24 $0.00 $0.00 $0.00 $0.11 $0.40 $0.40 $0.00 $0.00 $0.11 $0.00 $0.32 $0.32 $0.00 $0.27 $0.43 $0.43 $0.00 $0.00 $0.08 $0.00 $0.00 $0.09 $0.00 $0.00 $0.00 $0.00 $0.00 101520 SUP HCPCS Q4116 101520 - GRAFT SKIN 14.5X4CM ALLOGRAFT MESHED ALLODERM ACELLULAR BOTH IP/OP $1.68 $1.24 $0.00 $1.34 $0.76 $0.76 $0.00 $0.00 $0.00 $0.35 $1.25 $1.25 $0.00 $0.00 $0.35 $0.00 $0.99 $0.99 $0.00 $0.84 $1.33 $1.34 $0.00 $0.00 $0.26 $0.00 $0.00 $0.27 $0.00 $0.00 $0.00 $0.00 $0.00 101602 SUP Custom 27011340 101602 - HINGE XTRNFX ILZ M CNCT LOPRFL SS TIB BOTH IP/OP $367.20 $271.73 $0.00 $293.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.54 $272.54 $0.00 $0.00 $76.52 $0.00 $0.00 $0.00 $0.00 $183.60 $290.82 $293.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 101804 SUP HCPCS C1713 101804 - PLATE XTRNFX SHRT 85MM ILZ 7 HL CNCT TIB BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 101805 SUP HCPCS C1713 101805 - PLATE XTRNFX SHRT 95MM ILZ 8 HL CNCT TIB BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 101806 SUP HCPCS C1713 101806 - PLATE XTRNFX SHRT 105MM ILZ 9 HL CNCT TIB BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 101807 SUP HCPCS C1713 101807 - PLATE XTRNFX SHRT 115MM ILZ 10 HL CNCT CIRC BOTH IP/OP $642.60 $475.52 $0.00 $514.08 $289.17 $289.17 $0.00 $0.00 $0.00 $133.93 $476.94 $476.94 $0.00 $0.00 $133.92 $0.00 $380.10 $380.10 $0.00 $321.30 $508.94 $514.08 $0.00 $0.00 $100.57 $0.00 $0.00 $102.30 $0.00 $0.00 $0.00 $0.00 $0.00 101900 SUP HCPCS C1713 101900 - PLATE BN 45MM 2 HL TWST ORTH BOTH IP/OP $364.00 $269.36 $0.00 $291.20 $163.80 $163.80 $0.00 $0.00 $0.00 $75.87 $270.16 $270.16 $0.00 $0.00 $75.86 $0.00 $215.31 $215.31 $0.00 $182.00 $288.29 $291.20 $0.00 $0.00 $56.97 $0.00 $0.00 $57.95 $0.00 $0.00 $0.00 $0.00 $0.00 101901 SUP HCPCS C1713 101901 - PLATE XTRNFX 65MM ILZ 3 HL TWST DLX SET ADLT TIB BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 101902 SUP HCPCS C1713 101902 - PLATE XTRNFX 85MM ILZ 3 HL TWST DLX SET ADLT BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 102000 SUP HCPCS C1713 102000 - PLATE XTRNFX ILZ 3 HL CRV CIRC BOTH IP/OP $623.90 $461.69 $0.00 $499.12 $280.76 $280.76 $0.00 $0.00 $0.00 $130.04 $463.06 $463.06 $0.00 $0.00 $130.02 $0.00 $369.04 $369.04 $0.00 $311.95 $494.13 $499.12 $0.00 $0.00 $97.64 $0.00 $0.00 $99.32 $0.00 $0.00 $0.00 $0.00 $0.00 102003 SUP HCPCS Q4116 102003 - MATRIX TISSUE THICK 2X1CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $177.50 $131.35 $0.00 $219.00 $123.19 $123.19 $0.00 $0.00 $0.00 $37.00 $131.74 $131.74 $0.00 $0.00 $36.99 $0.00 $104.99 $104.99 $0.00 $136.88 $216.81 $219.00 $0.00 $0.00 $42.84 $0.00 $0.00 $43.58 $0.00 $0.00 $0.00 $0.00 $0.00 102007 SUP HCPCS Q4116 102007 - MATRIX TISSUE THIN 4X1CM ALLOGRAFT REGENERATIVE FREEZE DRIED BOTH IP/OP $148.13 $109.62 $0.00 $184.00 $103.50 $103.50 $0.00 $0.00 $0.00 $30.87 $109.94 $109.94 $0.00 $0.00 $30.87 $0.00 $87.62 $87.62 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 102009 SUP HCPCS Q4116 102009 - GRAFT SKIN 4X2CM ALLOGRAFT ALLODERM ACELLULAR DERMIS BOTH IP/OP $65.00 $48.10 $0.00 $80.75 $45.42 $45.42 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $50.47 $79.94 $80.75 $0.00 $0.00 $15.80 $0.00 $0.00 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 102010 SUP HCPCS Q4116 102010 - MATRIX TISSUE THIN 4X2CM ALLOGRAFT REGENERATIVE FREEZE DRIED BOTH IP/OP "$1,030.00 " $762.20 $0.00 "$1,280.00" $720.00 $720.00 $0.00 $0.00 $0.00 $214.68 $764.47 $764.47 $0.00 $0.00 $214.65 $0.00 $609.25 $609.25 $0.00 $800.00 "$1,267.20" "$1,280.00" $0.00 $0.00 $250.40 $0.00 $0.00 $254.72 $0.00 $0.00 $0.00 $0.00 $0.00 102012 SUP HCPCS Q4116 102012 - MATRIX TISSUE THICK 4X2CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $128.75 $95.28 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $26.83 $95.56 $95.56 $0.00 $0.00 $26.83 $0.00 $76.16 $76.16 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 102016 SUP HCPCS Q4116 102016 - ALLODERM IMPLANTABLE BOTH IP/OP "$12,497.50 " "$9,248.15" $0.00 "$9,998.00" "$5,623.88" "$5,623.88" $0.00 $0.00 $0.00 "$2,604.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,604.48" $0.00 "$6,161.27" "$6,161.27" $0.00 "$6,248.75" "$9,898.02" "$9,998.00" $0.00 $0.00 "$1,955.86" $0.00 $0.00 "$1,989.60" $0.00 $0.00 $0.00 $0.00 $0.00 102020 SUP HCPCS Q4116 102020 - MATRIX TISSUE MEDIUM 7X3CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $83.45 $61.75 $0.00 $103.52 $58.23 $58.23 $0.00 $0.00 $0.00 $17.39 $61.94 $61.94 $0.00 $0.00 $17.39 $0.00 $49.36 $49.36 $0.00 $64.70 $102.48 $103.52 $0.00 $0.00 $20.25 $0.00 $0.00 $20.60 $0.00 $0.00 $0.00 $0.00 $0.00 102021 SUP HCPCS Q4116 102021 - MATRIX TISSUE THICK 7X3CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $83.45 $61.75 $0.00 $103.52 $58.23 $58.23 $0.00 $0.00 $0.00 $17.39 $61.94 $61.94 $0.00 $0.00 $17.39 $0.00 $49.36 $49.36 $0.00 $64.70 $102.48 $103.52 $0.00 $0.00 $20.25 $0.00 $0.00 $20.60 $0.00 $0.00 $0.00 $0.00 $0.00 102031 SUP HCPCS Q4116 102031 - MATRIX TISSUE THIN 7X4CM ALLOGRAFT REGENERATIVE FREEZE DRIED BOTH IP/OP $32.59 $24.12 $0.00 $40.50 $22.78 $22.78 $0.00 $0.00 $0.00 $6.79 $24.19 $24.19 $0.00 $0.00 $6.79 $0.00 $19.28 $19.28 $0.00 $25.31 $40.10 $40.50 $0.00 $0.00 $7.92 $0.00 $0.00 $8.06 $0.00 $0.00 $0.00 $0.00 $0.00 102033 SUP HCPCS Q4116 102033 - MATRIX TISSUE MEDIUM 7X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $64.73 $47.90 $0.00 $80.43 $45.24 $45.24 $0.00 $0.00 $0.00 $13.49 $48.04 $48.04 $0.00 $0.00 $13.49 $0.00 $38.29 $38.29 $0.00 $50.27 $79.63 $80.43 $0.00 $0.00 $15.73 $0.00 $0.00 $16.01 $0.00 $0.00 $0.00 $0.00 $0.00 102034 SUP HCPCS Q4116 102034 - MATRIX TISSUE THICK 7X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $64.73 $47.90 $0.00 $80.43 $45.24 $45.24 $0.00 $0.00 $0.00 $13.49 $48.04 $48.04 $0.00 $0.00 $13.49 $0.00 $38.29 $38.29 $0.00 $50.27 $79.63 $80.43 $0.00 $0.00 $15.73 $0.00 $0.00 $16.01 $0.00 $0.00 $0.00 $0.00 $0.00 102049 SUP HCPCS Q4116 102049 - MATRIX TISSUE MEDIUM 12X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $104.11 $77.04 $0.00 $83.29 $46.85 $46.85 $0.00 $0.00 $0.00 $21.70 $77.27 $77.27 $0.00 $0.00 $21.70 $0.00 $61.58 $61.58 $0.00 $52.06 $82.46 $83.29 $0.00 $0.00 $16.29 $0.00 $0.00 $16.58 $0.00 $0.00 $0.00 $0.00 $0.00 102050 SUP HCPCS Q4116 102050 - MATRIX TISSUE THICK 12X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 102061 SUP HCPCS Q4116 102061 - MATRIX TISSUE MEDIUM 10X5CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $64.55 $47.77 $0.00 $80.16 $45.09 $45.09 $0.00 $0.00 $0.00 $13.45 $47.91 $47.91 $0.00 $0.00 $13.45 $0.00 $38.18 $38.18 $0.00 $50.10 $79.36 $80.16 $0.00 $0.00 $15.68 $0.00 $0.00 $15.95 $0.00 $0.00 $0.00 $0.00 $0.00 102062 SUP HCPCS Q4116 102062 - MATRIX TISSUE THICK 10X5CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP "$3,227.50 " "$2,388.35" $0.00 "$4,008.00" "$2,254.50" "$2,254.50" $0.00 $0.00 $0.00 $672.69 "$2,395.45" "$2,395.45" $0.00 $0.00 $672.61 $0.00 "$1,591.16" "$1,591.16" $0.00 "$2,505.00" "$3,967.92" "$4,008.00" $0.00 $0.00 $784.07 $0.00 $0.00 $797.59 $0.00 $0.00 $0.00 $0.00 $0.00 102071 SUP HCPCS Q4116 102071 - MATRIX TISSUE MEDIUM 12X6CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $70.80 $52.39 $0.00 $56.64 $31.86 $31.86 $0.00 $0.00 $0.00 $14.76 $52.55 $52.55 $0.00 $0.00 $14.75 $0.00 $41.88 $41.88 $0.00 $35.40 $56.07 $56.64 $0.00 $0.00 $11.08 $0.00 $0.00 $11.27 $0.00 $0.00 $0.00 $0.00 $0.00 102072 SUP HCPCS Q4116 102072 - MATRIX TISSUE THICK 12X6CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $188.80 $139.71 $0.00 $140.13 $31.86 $31.86 $0.00 $0.00 $0.00 $0.00 $140.13 $140.13 $0.00 $0.00 $39.35 $0.00 $41.88 $41.88 $0.00 $35.40 $56.07 $56.64 $0.00 $0.00 $11.08 $0.00 $0.00 $11.27 $0.00 $0.00 $0.00 $0.00 $0.00 102081 SUP HCPCS Q4116 102081 - MATRIX TISSUE MEDIUM 16X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.09 $57.79 $0.00 $62.47 $35.14 $35.14 $0.00 $0.00 $0.00 $16.28 $57.96 $57.96 $0.00 $0.00 $16.27 $0.00 $46.19 $46.19 $0.00 $39.04 $61.85 $62.47 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 102082 SUP HCPCS Q4116 102082 - MATRIX TISSUE THICK 16X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $867.50 $641.95 $0.00 $643.86 $35.14 $35.14 $0.00 $0.00 $0.00 $0.00 $643.86 $643.86 $0.00 $0.00 $180.79 $0.00 $46.19 $46.19 $0.00 $39.04 $61.85 $62.47 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 102096 SUP HCPCS Q4116 102096 - MATRIX TISSUE THICK 12X8CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.10 $57.79 $0.00 $62.48 $35.14 $35.14 $0.00 $0.00 $0.00 $16.28 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $46.20 $46.20 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 102102 SUP Custom 27203010 102102 - WIRE XTRNFX 1.8MM 370MM NS ILZ BYNT PNT DLX SET SS TIB BOTH IP/OP $208.50 $154.29 $0.00 $166.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.75 $154.75 $0.00 $0.00 $43.45 $0.00 $0.00 $0.00 $0.00 $104.25 $165.13 $166.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 102128 SUP HCPCS Q4116 102128 - MATRIX TISSUE THICK 16X8CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.11 $57.80 $0.00 $62.48 $35.15 $35.15 $0.00 $0.00 $0.00 $16.28 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $46.20 $46.20 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 102132 SUP HCPCS C1760 CLIP HLF PIN CIRC DISC ILZ EXFIXA 4 BOTH IP/OP $4.65 $3.44 $0.00 $3.72 $2.09 $2.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.33 $3.68 $3.72 $0.00 $0.00 $0.73 $0.00 $0.00 $0.74 $0.00 $0.00 $0.00 $0.00 $0.00 102144 SUP HCPCS Q4116 102144 - MATRIX TISSUE THICK 12X12CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $68.23 $50.49 $0.00 $84.69 $47.64 $47.64 $0.00 $0.00 $0.00 $14.22 $50.64 $50.64 $0.00 $0.00 $14.22 $0.00 $40.36 $40.36 $0.00 $52.93 $83.85 $84.69 $0.00 $0.00 $16.57 $0.00 $0.00 $16.85 $0.00 $0.00 $0.00 $0.00 $0.00 102196 SUP HCPCS Q4116 102196 - MATRIX TISSUE THICK 16X6CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.10 $57.79 $0.00 $62.48 $35.14 $35.14 $0.00 $0.00 $0.00 $16.28 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $46.20 $46.20 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 102302 SUP HCPCS C1713 102302 - SET XTRNFX 100MM ILZ THRD ROD ADLT TIB BOTH IP/OP $109.60 $81.10 $0.00 $87.68 $49.32 $49.32 $0.00 $0.00 $0.00 $22.84 $81.35 $81.35 $0.00 $0.00 $22.84 $0.00 $64.83 $64.83 $0.00 $54.80 $86.80 $87.68 $0.00 $0.00 $17.15 $0.00 $0.00 $17.45 $0.00 $0.00 $0.00 $0.00 $0.00 102303 SUP HCPCS C1713 102303 - ROD EXFIX 120MM ILZ TIB THRD DLX SET ADLT BOTH IP/OP $109.60 $81.10 $0.00 $87.68 $49.32 $49.32 $0.00 $0.00 $0.00 $22.84 $81.35 $81.35 $0.00 $0.00 $22.84 $0.00 $64.83 $64.83 $0.00 $54.80 $86.80 $87.68 $0.00 $0.00 $17.15 $0.00 $0.00 $17.45 $0.00 $0.00 $0.00 $0.00 $0.00 102304 SUP HCPCS C1713 102304 - ROD XTRNFX 150MM ILZ THRD DLX SET SS ADLT TIB BOTH IP/OP $109.60 $81.10 $0.00 $87.68 $49.32 $49.32 $0.00 $0.00 $0.00 $22.84 $81.35 $81.35 $0.00 $0.00 $22.84 $0.00 $64.83 $64.83 $0.00 $54.80 $86.80 $87.68 $0.00 $0.00 $17.15 $0.00 $0.00 $17.45 $0.00 $0.00 $0.00 $0.00 $0.00 102320 SUP HCPCS Q4116 102320 - MATRIX TISSUE THICK 20X16CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.12 $57.81 $0.00 $62.49 $35.15 $35.15 $0.00 $0.00 $0.00 $16.28 $57.98 $57.98 $0.00 $0.00 $16.28 $0.00 $46.21 $46.21 $0.00 $39.06 $61.87 $62.49 $0.00 $0.00 $12.23 $0.00 $0.00 $12.44 $0.00 $0.00 $0.00 $0.00 $0.00 102600 SUP HCPCS C1713 102600 - WASHER XTRNFX THK3MM 14MM ILZ SLT BSC SET ADLT FEM BOTH IP/OP $65.40 $48.40 $0.00 $52.32 $29.43 $29.43 $0.00 $0.00 $0.00 $13.63 $48.54 $48.54 $0.00 $0.00 $13.63 $0.00 $38.68 $38.68 $0.00 $32.70 $51.80 $52.32 $0.00 $0.00 $10.24 $0.00 $0.00 $10.41 $0.00 $0.00 $0.00 $0.00 $0.00 102701 SUP HCPCS C1713 102701 - WASHER XTRNFX 2MM 14MM ILZ BSC SET ADLT TIB BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $13.50 $13.50 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 102706 SUP HCPCS C1713 102706 - WASHER XTRNFX THK2MM ILZ BOLT BOTH IP/OP $65.40 $48.40 $0.00 $52.32 $29.43 $29.43 $0.00 $0.00 $0.00 $13.63 $48.54 $48.54 $0.00 $0.00 $13.63 $0.00 $38.68 $38.68 $0.00 $32.70 $51.80 $52.32 $0.00 $0.00 $10.24 $0.00 $0.00 $10.41 $0.00 $0.00 $0.00 $0.00 $0.00 102707 SUP HCPCS C1713 102707 - WASHER XTRNFX THK4MM ILZ BOLT BOTH IP/OP $65.40 $48.40 $0.00 $52.32 $29.43 $29.43 $0.00 $0.00 $0.00 $13.63 $48.54 $48.54 $0.00 $0.00 $13.63 $0.00 $38.68 $38.68 $0.00 $32.70 $51.80 $52.32 $0.00 $0.00 $10.24 $0.00 $0.00 $10.41 $0.00 $0.00 $0.00 $0.00 $0.00 102715 SUP HCPCS C1713 102715 - WASHER XTRNFX THK1MM 1MM CIRC SM BN FXTR BOTH IP/OP $45.90 $33.97 $0.00 $36.72 $20.66 $20.66 $0.00 $0.00 $0.00 $9.57 $34.07 $34.07 $0.00 $0.00 $9.57 $0.00 $27.15 $27.15 $0.00 $22.95 $36.35 $36.72 $0.00 $0.00 $7.18 $0.00 $0.00 $7.31 $0.00 $0.00 $0.00 $0.00 $0.00 102718 SUP HCPCS C1713 102718 - WASHER XTRNFX THK1.5MM 1.5MM CIRC SM BN FXTR BOTH IP/OP $45.90 $33.97 $0.00 $36.72 $20.66 $20.66 $0.00 $0.00 $0.00 $9.57 $34.07 $34.07 $0.00 $0.00 $9.57 $0.00 $27.15 $27.15 $0.00 $22.95 $36.35 $36.72 $0.00 $0.00 $7.18 $0.00 $0.00 $7.31 $0.00 $0.00 $0.00 $0.00 $0.00 102721 SUP HCPCS C1713 102721 - WASHER XTRNFX THK3MM SLT SM BN FXTR BOTH IP/OP $86.30 $63.86 $0.00 $69.04 $38.84 $38.84 $0.00 $0.00 $0.00 $17.99 $64.05 $64.05 $0.00 $0.00 $17.98 $0.00 $51.05 $51.05 $0.00 $43.15 $68.35 $69.04 $0.00 $0.00 $13.51 $0.00 $0.00 $13.74 $0.00 $0.00 $0.00 $0.00 $0.00 103044 SUP Custom 27203010 103044 - BIT DRL 2.7MM STRL ILZ SHNK CMPNT SET DISP RNCH SYS BOTH IP/OP "$1,023.40 " $757.32 $0.00 $818.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $759.57 $759.57 $0.00 $0.00 $213.28 $0.00 $0.00 $0.00 $0.00 $511.70 $810.53 $818.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103045 SUP Custom 27203010 103045 - BIT DRL 3.8MM STRL ILZ SHNK CMPNT SET DISP RNCH SYS BOTH IP/OP "$1,023.40 " $757.32 $0.00 $818.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $759.57 $759.57 $0.00 $0.00 $213.28 $0.00 $0.00 $0.00 $0.00 $511.70 $810.53 $818.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103201 SUP HCPCS C1713 103201 - BOLT XTRNFX UNV 16MM ILZ CMPS BSC SET CIRC CNCT HNG SS ADLT BOTH IP/OP $0.81 $0.60 $0.00 $12.92 $7.27 $7.27 $0.00 $0.00 $0.00 $0.17 $0.60 $0.60 $0.00 $0.00 $0.17 $0.00 $0.48 $0.48 $0.00 $8.08 $12.79 $12.92 $0.00 $0.00 $2.53 $0.00 $0.00 $2.57 $0.00 $0.00 $0.00 $0.00 $0.00 103301 SUP HCPCS C1713 103301 - NUT XTRNFX THK5MM 10MM 6MM ILZ THRD INS HEX SS NYL BOTH IP/OP $77.20 $57.13 $0.00 $61.76 $34.74 $34.74 $0.00 $0.00 $0.00 $16.09 $57.30 $57.30 $0.00 $0.00 $16.09 $0.00 $45.66 $45.66 $0.00 $38.60 $61.14 $61.76 $0.00 $0.00 $12.08 $0.00 $0.00 $12.29 $0.00 $0.00 $0.00 $0.00 $0.00 103313 SUP HCPCS C1713 103313 - NUT XTRNFX 3ANG SM BN FXTR BOTH IP/OP $409.70 $303.18 $0.00 $327.76 $184.37 $184.37 $0.00 $0.00 $0.00 $85.39 $304.08 $304.08 $0.00 $0.00 $85.38 $0.00 $242.34 $242.34 $0.00 $204.85 $324.48 $327.76 $0.00 $0.00 $64.12 $0.00 $0.00 $65.22 $0.00 $0.00 $0.00 $0.00 $0.00 103406 SUP HCPCS C1776 103406 - SLEEVE XTRNFX 6MM ILZ CENTERING BOTH IP/OP $406.30 $300.66 $0.00 $325.04 $182.84 $182.84 $0.00 $0.00 $0.00 $84.68 $301.56 $301.56 $0.00 $0.00 $84.67 $0.00 $240.33 $240.33 $0.00 $203.15 $321.79 $325.04 $0.00 $0.00 $63.59 $0.00 $0.00 $64.68 $0.00 $0.00 $0.00 $0.00 $0.00 103452 SUP HCPCS C1713 103452 - CUBE XTRNFX ILZ 2 HL SS RNCH SYS BOTH IP/OP $578.00 $427.72 $0.00 $462.40 $260.10 $260.10 $0.00 $0.00 $0.00 $120.47 $428.99 $428.99 $0.00 $0.00 $120.46 $0.00 $341.89 $341.89 $0.00 $289.00 $457.78 $462.40 $0.00 $0.00 $90.46 $0.00 $0.00 $92.02 $0.00 $0.00 $0.00 $0.00 $0.00 103453 SUP HCPCS C1713 103453 - CUBE EXFIX UNIVERSAL 3 HOLE COMPONENT SET HINGE COMPASS BOTH IP/OP $668.00 $494.32 $0.00 $534.40 $300.60 $300.60 $0.00 $0.00 $0.00 $139.23 $495.79 $495.79 $0.00 $0.00 $139.21 $0.00 $395.12 $395.12 $0.00 $334.00 $529.06 $534.40 $0.00 $0.00 $104.54 $0.00 $0.00 $106.35 $0.00 $0.00 $0.00 $0.00 $0.00 103454 SUP Custom 27203010 103454 - CUBE XTRNFX ILZ 4 HL SS RNCH SYS BOTH IP/OP $686.80 $508.23 $0.00 $549.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.74 $509.74 $0.00 $0.00 $143.13 $0.00 $0.00 $0.00 $0.00 $343.40 $543.95 $549.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103455 SUP HCPCS C1713 CUBE 5 HOLE CIRC EXFIXA RNCH SYS BOTH IP/OP $758.20 $561.07 $0.00 $562.74 $217.09 $217.09 $0.00 $0.00 $0.00 $0.00 $562.74 $562.74 $0.00 $0.00 $158.01 $0.00 $0.00 $0.00 $0.00 $241.21 $382.08 $385.94 $0.00 $0.00 $75.50 $0.00 $0.00 $76.80 $0.00 $0.00 $0.00 $0.00 $0.00 106132 SUP HCPCS C1713 106132 - BLADE SW DMD 800X.64X.54MM BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 106133 SUP HCPCS C1713 106133 - SAW 0106133 DIAMOND 0.81 0.91MM X 800MM BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 108280 SUP Custom 27203010 108280 - DOPPLER VASC 8MHZ STRL PRB DISP BOTH IP/OP $374.38 $277.04 $0.00 $299.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.86 $277.86 $0.00 $0.00 $78.02 $0.00 $0.00 $0.00 $0.00 $187.19 $296.51 $299.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-00 SUP Custom 27803010 01-2200 - HEAD FEMORAL MORSE TAPER LFIT HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-00 SUP Custom 27803010 06-2200 - HEAD FEM +0MM OFST CTPR 22MM STRL LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110021 SUP Custom 27203010 110021 - BIT DRL 6.3MM AMBI PRFR BOTH IP/OP $200.55 $148.41 $0.00 $160.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.85 $148.85 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $100.28 $158.84 $160.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110107 SUP HCPCS C1713 110107 - SCREW SET CLLS FRM BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $49.95 $49.95 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 110242 SUP Custom 27203010 110242 - BIT DRL 2.7MM STRL COLE TWST RDLCNT BOTH IP/OP $635.63 $470.37 $0.00 $508.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.76 $471.76 $0.00 $0.00 $132.46 $0.00 $0.00 $0.00 $0.00 $317.81 $503.42 $508.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110244 SUP Custom 27203010 110244 - BIT DRL 3.5MM STRL COLE TWST RDLCNT BOTH IP/OP $635.63 $470.37 $0.00 $508.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.76 $471.76 $0.00 $0.00 $132.46 $0.00 $0.00 $0.00 $0.00 $317.81 $503.42 $508.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110245 SUP Custom 27203010 110245 - BIT DRL 4MM COLE RDLCNT BOTH IP/OP $635.63 $470.37 $0.00 $508.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.76 $471.76 $0.00 $0.00 $132.46 $0.00 $0.00 $0.00 $0.00 $317.81 $503.42 $508.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110246 SUP Custom 27203010 110246 - BIT DRL 4.8MM COLE RDLCNT BOTH IP/OP $635.63 $470.37 $0.00 $508.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.76 $471.76 $0.00 $0.00 $132.46 $0.00 $0.00 $0.00 $0.00 $317.81 $503.42 $508.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110300 SUP HCPCS C1713 110300 - SCREW 110300 BABY CD SELF BRKNG BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 110675 SUP Custom 27203010 110675 - PASSER SUT 6.1IN BLK STRL LF 3.6CM SWNSN WIRELOOP ATCL SS BOTH IP/OP $199.70 $147.78 $0.00 $159.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.22 $148.22 $0.00 $0.00 $41.62 $0.00 $0.00 $0.00 $0.00 $99.85 $158.16 $159.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111250 SUP HCPCS C1762 111250 - GRAFT SOFT TISSUE 1-2MM 50MM ALLOGRAFT AXONAL REGENERATION BOTH IP/OP "$11,165.00 " "$8,262.10" $0.00 "$8,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,327.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,326.79" $0.00 "$5,504.35" "$5,504.35" $0.00 "$5,062.50" "$8,019.00" "$8,100.00" $0.00 $0.00 "$1,584.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-05 SUP Custom 27803010 01-2205 - HEAD FEMORAL +5MM 22MM MORSE TAPERED LFIT COCR HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-05 SUP Custom 27803010 06-2205 - HEAD FEM +5MM OFST CTPR 22MM STRL LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 111630 SUP HCPCS C1713 111630 - PIN FX SM DUNN-DAUTREY STRPR UNCMP BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 111640 SUP HCPCS C1713 111640 - PIN FX 4MM 170MM STRL KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 111650 SUP HCPCS C1776 111650 - KIT THR STRL FEM/TIB CKPNT KT KN BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $174.38 $174.38 $0.00 $0.00 $0.00 $80.76 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $229.21 $229.21 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $60.64 $0.00 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $0.00 111651 SUP HCPCS C1776 111651 - COMPONENT FEM STRL TIB CKPNT KN BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $54.00 $54.00 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 111652 SUP HCPCS C1776 111652 - COMPONENT FEM STRL FEM CKPNT KN BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $92.25 $92.25 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 111655 SUP HCPCS C1713 111655 - SCREW BN STRL VA CORT BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $298.13 $298.13 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 111670 SUP HCPCS C1713 111670 - PIN ORTH 3.2MM 80MM STRL KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 111680 SUP HCPCS C1713 111680 - PIN FX 4MM 80MM STRL KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-06 SUP HCPCS C1713 1-2206 - SPACER SPNL 6MM X-STP TI LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$7,632.00 " "$5,647.68" $0.00 "$6,105.60" "$3,434.40" "$3,434.40" $0.00 $0.00 $0.00 "$1,590.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,590.51" $0.00 "$3,762.58" "$3,762.58" $0.00 "$3,816.00" "$6,044.54" "$6,105.60" $0.00 $0.00 "$1,194.41" $0.00 $0.00 "$1,215.01" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-08 SUP HCPCS C1713 1-2208 - SPACER SPNL 8MM X-STP TI LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$7,632.00 " "$5,647.68" $0.00 "$6,105.60" "$3,434.40" "$3,434.40" $0.00 $0.00 $0.00 "$1,590.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,590.51" $0.00 "$3,762.58" "$3,762.58" $0.00 "$3,816.00" "$6,044.54" "$6,105.60" $0.00 $0.00 "$1,194.41" $0.00 $0.00 "$1,215.01" $0.00 $0.00 $0.00 $0.00 $0.00 112640 SUP HCPCS C1781 0112640 - MESH SURG 4X1IN PATCH FLAT SHEET KNIT MARLEX GROIN HERN BOTH IP/OP $118.25 $87.51 $0.00 $94.60 $53.21 $53.21 $0.00 $0.00 $0.00 $24.65 $87.77 $87.77 $0.00 $0.00 $24.64 $0.00 $69.94 $69.94 $0.00 $59.13 $93.65 $94.60 $0.00 $0.00 $18.51 $0.00 $0.00 $18.83 $0.00 $0.00 $0.00 $0.00 $0.00 112660 SUP HCPCS C1781 112660 - MESH HERN GROIN POLYPRO 14X10IN FLAT PTCH KNTD MRLX STRL BOTH IP/OP "$1,350.00 " $999.00 $0.00 "$1,080.00" $607.50 $607.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $675.00 "$1,069.20" "$1,080.00" $0.00 $0.00 $211.28 $0.00 $0.00 $214.92 $0.00 $0.00 $0.00 $0.00 $0.00 112727 SUP Custom 27203010 112727 - SCREW XTRNFX SPTL FRM HXFX SET SS BOTH IP/OP $33.83 $25.03 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.10 $25.10 $0.00 $0.00 $7.05 $0.00 $0.00 $0.00 $0.00 $16.91 $26.79 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 112960 SUP HCPCS C1781 0112960 - PLUG SURG MEDIUM TAPER 1.55X1.3IN MONOFILAMENT NONABSORBABLE BOTH IP/OP $725.75 $537.06 $0.00 $589.31 $331.49 $331.49 $0.00 $0.00 $0.00 $151.26 $538.65 $538.65 $0.00 $0.00 $151.25 $0.00 $429.28 $429.28 $0.00 $368.32 $583.42 $589.31 $0.00 $0.00 $115.28 $0.00 $0.00 $117.27 $0.00 $0.00 $0.00 $0.00 $0.00 112970 SUP HCPCS C1781 0112970 - MESH SRG LG 1.9IN 1.6IN STRL BARD PRFX PLG MFL PLT EDG PP BOTH IP/OP $732.25 $541.87 $0.00 "$2,118.08" $334.46 $334.46 $0.00 $0.00 $0.00 $152.62 $543.48 $543.48 $0.00 $0.00 $152.60 $0.00 "$2,118.08" "$2,118.08" $0.00 $371.62 $588.64 $594.59 $0.00 $0.00 $116.32 $0.00 $0.00 $118.32 $0.00 $0.00 $0.00 $0.00 $0.00 112970 SUP HCPCS C1781 112970 - MESH SURG LARGE 1.9IN 1.6IN PLUG MONOFILAMENT PERFIX POLYPRO BOTH IP/OP $732.25 $541.87 $0.00 "$2,706.86" $334.46 $334.46 $0.00 $0.00 $0.00 $152.62 $543.48 $543.48 $0.00 $0.00 $152.60 $0.00 "$2,118.08" "$2,118.08" $0.00 $371.62 "$2,706.86" $594.59 $0.00 $0.00 $116.32 $0.00 $0.00 $118.32 $0.00 $0.00 $0.00 $0.00 $0.00 112980 SUP HCPCS C1781 0112980 - MESH SURG XL 2X1.6IN NONABSORBABLE PLUG TAPERED MARLEX BOTH IP/OP $849.25 $628.45 $0.00 $679.40 $382.16 $382.16 $0.00 $0.00 $0.00 $177.00 $630.31 $630.31 $0.00 $0.00 $176.98 $0.00 $502.33 $502.33 $0.00 $424.63 $672.61 $679.40 $0.00 $0.00 $132.91 $0.00 $0.00 $135.20 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-10 SUP HCPCS C1713 1-2210 - SPACER SPNL 10MM X-STP TI LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$7,632.00 " "$5,647.68" $0.00 "$6,105.60" "$3,434.40" "$3,434.40" $0.00 $0.00 $0.00 "$1,590.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,590.51" $0.00 "$3,762.58" "$3,762.58" $0.00 "$3,816.00" "$6,044.54" "$6,105.60" $0.00 $0.00 "$1,194.41" $0.00 $0.00 "$1,215.01" $0.00 $0.00 $0.00 $0.00 $0.00 Jun-10 SUP Custom 27803010 06-2210 - HEAD FEM +10MM OFST CTPR 22MM STRL LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-12 SUP HCPCS C1713 1-2212 - SPACER SPNL 12MM X-STP TI LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$7,632.00 " "$5,647.68" $0.00 "$6,105.60" "$3,434.40" "$3,434.40" $0.00 $0.00 $0.00 "$1,590.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,590.51" $0.00 "$3,762.58" "$3,762.58" $0.00 "$3,816.00" "$6,044.54" "$6,105.60" $0.00 $0.00 "$1,194.41" $0.00 $0.00 "$1,215.01" $0.00 $0.00 $0.00 $0.00 $0.00 114153 SUP HCPCS C1880 114153 - CATHETER SCT KT 2 LUM COIL XTD LGTH BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 114156 SUP HCPCS C1788 114156 - SET HMDIAL 33ML LF AQDX BLD CRCT UF-500 BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-14 SUP HCPCS C1713 1-2214 - SPACER SPNL 14MM X-STP TI LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$7,632.00 " "$5,647.68" $0.00 "$6,105.60" "$3,434.40" "$3,434.40" $0.00 $0.00 $0.00 "$1,590.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,590.51" $0.00 "$3,762.58" "$3,762.58" $0.00 "$3,816.00" "$6,044.54" "$6,105.60" $0.00 $0.00 "$1,194.41" $0.00 $0.00 "$1,215.01" $0.00 $0.00 $0.00 $0.00 $0.00 116240 SUP HCPCS C1713 116240 - SCREW BN STRL CORT BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $298.13 $298.13 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 120019 SUP HCPCS C1713 120019 - BUTTON SUT 19MM STRL LF HWSN 4 HL HD PE LGMNT DISP BOTH IP/OP $310.40 $229.70 $0.00 $248.32 $139.68 $139.68 $0.00 $0.00 $0.00 $64.70 $230.38 $230.38 $0.00 $0.00 $64.69 $0.00 $183.60 $183.60 $0.00 $155.20 $245.84 $248.32 $0.00 $0.00 $48.58 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $0.00 121100 SUP HCPCS C1713 121100 - SCREW BN STD 12.7MM 9MM 55MM STRL 21MM AMBI CLS LG CMPR SS BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121101 SUP HCPCS C1713 121101 - SCREW BN STD 9MM .5MM 60MM CLS AMBI IMHS LG THRD HIP BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121102 SUP HCPCS C1713 121102 - SCREW BN STD 12.7MM 9MM 65MM STRL 21MM AMBI CLS LG CMPR SS BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121103 SUP HCPCS C1713 121103 - SCREW BN STD 9MM .5MM 70MM CLS AMBI IMHS LG THRD HIP BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121104 SUP HCPCS C1713 121104 - SCREW BN STD 12.7MM 9MM 75MM STRL 21MM AMBI IMHS CLS LG CMPR BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121105 SUP HCPCS C1713 121105 - SCREW BN STD 12.7MM 9MM 80MM STRL 21MM AMBI IMHS CLS LG CMPR BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121106 SUP HCPCS C1713 121106 - SCREW BN P/T 12.7MM 9MM 85MM 21MM AMBI CHS IMHS STD LG HIP BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121107 SUP HCPCS C1713 121107 - SCREW BN P/T 12.7MM 9MM 90MM 21MM AMBI CHS IMHS STD LG HIP BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121108 SUP HCPCS C1713 121108 - SCREW BN 12.7MM 9MM 95MM 21MM AMBI CHS STD LG SS HIP BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121109 SUP HCPCS C1713 121109 - SCREW BN STD 12.7MM 9MM 100MM STRL 21MM AMBI IMHS CLS LG BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121110 SUP HCPCS C1713 121110 - SCREW BN 12.7MM 9MM 105MM 21MM AMBI CHS STD LG SS HIP BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121111 SUP HCPCS C1713 121111 - SCREW BN STD .5IN 9MM 110MM 21MM IMHS LG HIP SP CNDL PLT BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121112 SUP HCPCS C1713 121112 - SCREW BN STD .5IN 9MM 115MM 21MM AMBI CLS IMHS LG BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121116 SUP HCPCS C1713 121116 - SCREW BN HEX 3.5MM 19MM AMBI IMHS CLS CMPR SS HIP SP CNDL IM BOTH IP/OP $199.40 $147.56 $0.00 $159.52 $89.73 $89.73 $0.00 $0.00 $0.00 $41.56 $147.99 $147.99 $0.00 $0.00 $41.55 $0.00 $117.95 $117.95 $0.00 $99.70 $157.92 $159.52 $0.00 $0.00 $31.21 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 121117 SUP HCPCS C1713 121117 - SCREW BN HEX 3.5MM 28.5MM AMBI IMHS CLS CMPR SS HIP SP CNDL BOTH IP/OP $199.40 $147.56 $0.00 $159.52 $89.73 $89.73 $0.00 $0.00 $0.00 $41.56 $147.99 $147.99 $0.00 $0.00 $41.55 $0.00 $117.95 $117.95 $0.00 $99.70 $157.92 $159.52 $0.00 $0.00 $31.21 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 121120 SUP HCPCS C1713 121120 - PLATE BN 130D STD BRL 60MM 38.1MM AMBI 2 HL SS HIP BOTH IP/OP "$1,081.50 " $800.31 $0.00 $865.20 $486.68 $486.68 $0.00 $0.00 $0.00 $225.41 $802.69 $802.69 $0.00 $0.00 $225.38 $0.00 $639.71 $639.71 $0.00 $540.75 $856.55 $865.20 $0.00 $0.00 $169.25 $0.00 $0.00 $172.17 $0.00 $0.00 $0.00 $0.00 $0.00 121121 SUP HCPCS C1713 121121 - PLATE BN 135D STD BRL 60MM 38.1MM AMBI 2 HL CMPR SS HIP BOTH IP/OP "$1,081.50 " $800.31 $0.00 $865.20 $486.68 $486.68 $0.00 $0.00 $0.00 $225.41 $802.69 $802.69 $0.00 $0.00 $225.38 $0.00 $639.71 $639.71 $0.00 $540.75 $856.55 $865.20 $0.00 $0.00 $169.25 $0.00 $0.00 $172.17 $0.00 $0.00 $0.00 $0.00 $0.00 121122 SUP HCPCS C1713 121122 - PLATE BN 140D STD BRL 60MM 38.1MM AMBI 2 HL CMPR SS HIP BOTH IP/OP "$1,081.50 " $800.31 $0.00 $865.20 $486.68 $486.68 $0.00 $0.00 $0.00 $225.41 $802.69 $802.69 $0.00 $0.00 $225.38 $0.00 $639.71 $639.71 $0.00 $540.75 $856.55 $865.20 $0.00 $0.00 $169.25 $0.00 $0.00 $172.17 $0.00 $0.00 $0.00 $0.00 $0.00 121123 SUP HCPCS C1713 121123 - PLATE BN 145D STD BRL 60MM 38.1MM AMBI 2 HL SS HIP BOTH IP/OP "$1,081.50 " $800.31 $0.00 $865.20 $486.68 $486.68 $0.00 $0.00 $0.00 $225.41 $802.69 $802.69 $0.00 $0.00 $225.38 $0.00 $639.71 $639.71 $0.00 $540.75 $856.55 $865.20 $0.00 $0.00 $169.25 $0.00 $0.00 $172.17 $0.00 $0.00 $0.00 $0.00 $0.00 121124 SUP HCPCS C1713 121124 - PLATE BN 150D STD BRL 60MM 38.1MM AMBI 2 HL CMPR SS HIP BOTH IP/OP "$1,081.50 " $800.31 $0.00 $865.20 $486.68 $486.68 $0.00 $0.00 $0.00 $225.41 $802.69 $802.69 $0.00 $0.00 $225.38 $0.00 $639.71 $639.71 $0.00 $540.75 $856.55 $865.20 $0.00 $0.00 $169.25 $0.00 $0.00 $172.17 $0.00 $0.00 $0.00 $0.00 $0.00 121125 SUP HCPCS C1713 121125 - PLATE BN 130D STD BRL 80MM 38.1MM AMBI 3 HL CMPR SS HIP BOTH IP/OP "$1,113.00 " $823.62 $0.00 $890.40 $500.85 $500.85 $0.00 $0.00 $0.00 $231.98 $826.07 $826.07 $0.00 $0.00 $231.95 $0.00 $658.34 $658.34 $0.00 $556.50 $881.50 $890.40 $0.00 $0.00 $174.18 $0.00 $0.00 $177.19 $0.00 $0.00 $0.00 $0.00 $0.00 121126 SUP HCPCS C1713 121126 - PLATE BN 135D STD BRL 80MM 38.1MM AMBI 3 HL CMPR SS HIP BOTH IP/OP "$1,113.00 " $823.62 $0.00 $890.40 $500.85 $500.85 $0.00 $0.00 $0.00 $231.98 $826.07 $826.07 $0.00 $0.00 $231.95 $0.00 $658.34 $658.34 $0.00 $556.50 $881.50 $890.40 $0.00 $0.00 $174.18 $0.00 $0.00 $177.19 $0.00 $0.00 $0.00 $0.00 $0.00 121127 SUP HCPCS C1713 121127 - PLATE BN 140D STD BRL 80MM 38.1MM AMBI 3 HL CMPR HIP BOTH IP/OP "$1,113.00 " $823.62 $0.00 $890.40 $500.85 $500.85 $0.00 $0.00 $0.00 $231.98 $826.07 $826.07 $0.00 $0.00 $231.95 $0.00 $658.34 $658.34 $0.00 $556.50 $881.50 $890.40 $0.00 $0.00 $174.18 $0.00 $0.00 $177.19 $0.00 $0.00 $0.00 $0.00 $0.00 121128 SUP HCPCS C1713 121128 - PLATE BN 145D STD BRL 80MM 38.1MM AMBI 3 HL CMPR HIP BOTH IP/OP "$1,113.00 " $823.62 $0.00 $890.40 $500.85 $500.85 $0.00 $0.00 $0.00 $231.98 $826.07 $826.07 $0.00 $0.00 $231.95 $0.00 $658.34 $658.34 $0.00 $556.50 $881.50 $890.40 $0.00 $0.00 $174.18 $0.00 $0.00 $177.19 $0.00 $0.00 $0.00 $0.00 $0.00 121130 SUP HCPCS C1713 121130 - PLATE BN 130D STD BRL 100MM 38.1MM AMBI 4 HL CMPR SS HIP BOTH IP/OP "$1,113.00 " $823.62 $0.00 $890.40 $500.85 $500.85 $0.00 $0.00 $0.00 $231.98 $826.07 $826.07 $0.00 $0.00 $231.95 $0.00 $658.34 $658.34 $0.00 $556.50 $881.50 $890.40 $0.00 $0.00 $174.18 $0.00 $0.00 $177.19 $0.00 $0.00 $0.00 $0.00 $0.00 121131 SUP HCPCS C1713 121131 - PLATE BN 135D STD BRL 135MM 38.1MM AMBI 4 HL CMPR SS HIP BOTH IP/OP "$1,113.00 " $823.62 $0.00 $890.40 $500.85 $500.85 $0.00 $0.00 $0.00 $231.98 $826.07 $826.07 $0.00 $0.00 $231.95 $0.00 $658.34 $658.34 $0.00 $556.50 $881.50 $890.40 $0.00 $0.00 $174.18 $0.00 $0.00 $177.19 $0.00 $0.00 $0.00 $0.00 $0.00 121135 SUP HCPCS C1713 121135 - PLATE BN 130D STD BRL 120MM 38.1MM AMBI CHS 5 HL SS HIP BOTH IP/OP "$1,191.75 " $881.90 $0.00 $953.40 $536.29 $536.29 $0.00 $0.00 $0.00 $248.39 $884.52 $884.52 $0.00 $0.00 $248.36 $0.00 $704.92 $704.92 $0.00 $595.88 $943.87 $953.40 $0.00 $0.00 $186.51 $0.00 $0.00 $189.73 $0.00 $0.00 $0.00 $0.00 $0.00 121137 SUP HCPCS C1713 121137 - PLATE BN 140D STD BRL 120MM 38.1MM AMBI 5 HL HIP BOTH IP/OP "$1,191.75 " $881.90 $0.00 $953.40 $536.29 $536.29 $0.00 $0.00 $0.00 $248.39 $884.52 $884.52 $0.00 $0.00 $248.36 $0.00 $704.92 $704.92 $0.00 $595.88 $943.87 $953.40 $0.00 $0.00 $186.51 $0.00 $0.00 $189.73 $0.00 $0.00 $0.00 $0.00 $0.00 121138 SUP HCPCS C1713 121138 - PLATE BN 145D STD BRL 120MM 38.1MM AMBI 5 HL CMPR SS HIP BOTH IP/OP "$1,191.75 " $881.90 $0.00 $953.40 $536.29 $536.29 $0.00 $0.00 $0.00 $248.39 $884.52 $884.52 $0.00 $0.00 $248.36 $0.00 $704.92 $704.92 $0.00 $595.88 $943.87 $953.40 $0.00 $0.00 $186.51 $0.00 $0.00 $189.73 $0.00 $0.00 $0.00 $0.00 $0.00 121139 SUP HCPCS C1713 121139 - PLATE BN 150D STD BRL 120MM 38.1MM AMBI 5 HL CMPR SS HIP BOTH IP/OP "$1,191.75 " $881.90 $0.00 $953.40 $536.29 $536.29 $0.00 $0.00 $0.00 $248.39 $884.52 $884.52 $0.00 $0.00 $248.36 $0.00 $704.92 $704.92 $0.00 $595.88 $943.87 $953.40 $0.00 $0.00 $186.51 $0.00 $0.00 $189.73 $0.00 $0.00 $0.00 $0.00 $0.00 121141 SUP HCPCS C1713 121141 - PLATE BN 135D STD BRL 140MM 38.1MM AMBI 6 HL CMPR SS HIP BOTH IP/OP "$1,239.00 " $916.86 $0.00 $991.20 $557.55 $557.55 $0.00 $0.00 $0.00 $258.24 $919.59 $919.59 $0.00 $0.00 $258.21 $0.00 $732.87 $732.87 $0.00 $619.50 $981.29 $991.20 $0.00 $0.00 $193.90 $0.00 $0.00 $197.25 $0.00 $0.00 $0.00 $0.00 $0.00 121143 SUP HCPCS C1713 121143 - PLATE BN 145D STD BRL 140MM 38.1MM AMBI 6 HL CMPR SS HIP BOTH IP/OP "$1,239.00 " $916.86 $0.00 $991.20 $557.55 $557.55 $0.00 $0.00 $0.00 $258.24 $919.59 $919.59 $0.00 $0.00 $258.21 $0.00 $732.87 $732.87 $0.00 $619.50 $981.29 $991.20 $0.00 $0.00 $193.90 $0.00 $0.00 $197.25 $0.00 $0.00 $0.00 $0.00 $0.00 121144 SUP HCPCS C1713 121144 - PLATE BN 150D STD BRL 140MM 38.1MM AMBI 6 HL CMPR SS HIP BOTH IP/OP "$1,239.00 " $916.86 $0.00 $991.20 $557.55 $557.55 $0.00 $0.00 $0.00 $258.24 $919.59 $919.59 $0.00 $0.00 $258.21 $0.00 $732.87 $732.87 $0.00 $619.50 $981.29 $991.20 $0.00 $0.00 $193.90 $0.00 $0.00 $197.25 $0.00 $0.00 $0.00 $0.00 $0.00 121145 SUP HCPCS C1713 121145 - PLATE BN 130D STD BRL 180MM 38.1MM AMBI 8 HL CMPR SS HIP BOTH IP/OP "$1,501.50 " "$1,111.11" $0.00 "$1,201.20" $675.68 $675.68 $0.00 $0.00 $0.00 $312.95 "$1,114.41" "$1,114.41" $0.00 $0.00 $312.91 $0.00 $888.14 $888.14 $0.00 $750.75 "$1,189.19" "$1,201.20" $0.00 $0.00 $234.98 $0.00 $0.00 $239.04 $0.00 $0.00 $0.00 $0.00 $0.00 121147 SUP HCPCS C1713 121147 - PLATE BN 140D STD BRL 180MM 38.1MM AMBI 8 HL CMPR SS HIP BOTH IP/OP "$1,501.50 " "$1,111.11" $0.00 "$1,201.20" $675.68 $675.68 $0.00 $0.00 $0.00 $312.95 "$1,114.41" "$1,114.41" $0.00 $0.00 $312.91 $0.00 $888.14 $888.14 $0.00 $750.75 "$1,189.19" "$1,201.20" $0.00 $0.00 $234.98 $0.00 $0.00 $239.04 $0.00 $0.00 $0.00 $0.00 $0.00 121148 SUP HCPCS C1713 121148 - PLATE BN 145D STD BRL 180MM 38.1MM AMBI 8 HL CMPR SS HIP BOTH IP/OP "$1,501.50 " "$1,111.11" $0.00 "$1,201.20" $675.68 $675.68 $0.00 $0.00 $0.00 $312.95 "$1,114.41" "$1,114.41" $0.00 $0.00 $312.91 $0.00 $888.14 $888.14 $0.00 $750.75 "$1,189.19" "$1,201.20" $0.00 $0.00 $234.98 $0.00 $0.00 $239.04 $0.00 $0.00 $0.00 $0.00 $0.00 121149 SUP HCPCS C1713 121149 - PLATE BN 150D STD BRL 180MM 38.1MM AMBI 8 HL CMPR SS HIP BOTH IP/OP "$1,501.50 " "$1,111.11" $0.00 "$1,201.20" $675.68 $675.68 $0.00 $0.00 $0.00 $312.95 "$1,114.41" "$1,114.41" $0.00 $0.00 $312.91 $0.00 $888.14 $888.14 $0.00 $750.75 "$1,189.19" "$1,201.20" $0.00 $0.00 $234.98 $0.00 $0.00 $239.04 $0.00 $0.00 $0.00 $0.00 $0.00 121150 SUP HCPCS C1713 121150 - PLATE BN 130D STD BRL 220MM 38.1MM AMBI 10 HL SS HIP BOTH IP/OP "$1,758.75 " "$1,301.48" $0.00 "$1,407.00" $791.44 $791.44 $0.00 $0.00 $0.00 $366.57 "$1,305.34" "$1,305.34" $0.00 $0.00 $366.52 $0.00 "$1,040.30" "$1,040.30" $0.00 $879.38 "$1,392.93" "$1,407.00" $0.00 $0.00 $275.24 $0.00 $0.00 $279.99 $0.00 $0.00 $0.00 $0.00 $0.00 121152 SUP HCPCS C1713 121152 - PLATE BN 140D STD BRL 220MM 1.5IN AMBI 10 HL SS HIP BOTH IP/OP "$1,758.75 " "$1,301.48" $0.00 "$1,407.00" $791.44 $791.44 $0.00 $0.00 $0.00 $366.57 "$1,305.34" "$1,305.34" $0.00 $0.00 $366.52 $0.00 "$1,040.30" "$1,040.30" $0.00 $879.38 "$1,392.93" "$1,407.00" $0.00 $0.00 $275.24 $0.00 $0.00 $279.99 $0.00 $0.00 $0.00 $0.00 $0.00 121153 SUP HCPCS C1713 121153 - PLATE BN 145D STD BRL 180MM 38.1MM AMBI 10 HL CMPR SS HIP BOTH IP/OP "$1,758.75 " "$1,301.48" $0.00 "$1,407.00" $791.44 $791.44 $0.00 $0.00 $0.00 $366.57 "$1,305.34" "$1,305.34" $0.00 $0.00 $366.52 $0.00 "$1,040.30" "$1,040.30" $0.00 $879.38 "$1,392.93" "$1,407.00" $0.00 $0.00 $275.24 $0.00 $0.00 $279.99 $0.00 $0.00 $0.00 $0.00 $0.00 121154 SUP HCPCS C1713 121154 - PLATE BN 150D STD BRL 220MM 38.1MM AMBI 10 HL CMPR SS HIP BOTH IP/OP "$1,758.75 " "$1,301.48" $0.00 "$1,407.00" $791.44 $791.44 $0.00 $0.00 $0.00 $366.57 "$1,305.34" "$1,305.34" $0.00 $0.00 $366.52 $0.00 "$1,040.30" "$1,040.30" $0.00 $879.38 "$1,392.93" "$1,407.00" $0.00 $0.00 $275.24 $0.00 $0.00 $279.99 $0.00 $0.00 $0.00 $0.00 $0.00 121156 SUP HCPCS C1713 121156 - PLATE BN 135D STD BRL 260MM 38.1MM AMBI 12 HL CMPR SS HIP BOTH IP/OP "$1,879.50 " "$1,390.83" $0.00 "$1,503.60" $845.78 $845.78 $0.00 $0.00 $0.00 $391.73 "$1,394.96" "$1,394.96" $0.00 $0.00 $391.69 $0.00 "$1,111.72" "$1,111.72" $0.00 $939.75 "$1,488.56" "$1,503.60" $0.00 $0.00 $294.14 $0.00 $0.00 $299.22 $0.00 $0.00 $0.00 $0.00 $0.00 121158 SUP HCPCS C1713 121158 - PLATE BN 145D STD BRL 260MM 38.1MM AMBI 12 HL CMPR SS HIP BOTH IP/OP "$1,879.50 " "$1,390.83" $0.00 "$1,503.60" $845.78 $845.78 $0.00 $0.00 $0.00 $391.73 "$1,394.96" "$1,394.96" $0.00 $0.00 $391.69 $0.00 "$1,111.72" "$1,111.72" $0.00 $939.75 "$1,488.56" "$1,503.60" $0.00 $0.00 $294.14 $0.00 $0.00 $299.22 $0.00 $0.00 $0.00 $0.00 $0.00 121159 SUP HCPCS C1713 121159 - PLATE BN 150D STD BRL 260MM 38.1MM AMBI 12 HL CMPR HIP BOTH IP/OP $889.35 $658.12 $0.00 $711.48 $400.21 $400.21 $0.00 $0.00 $0.00 $185.36 $660.08 $660.08 $0.00 $0.00 $185.34 $0.00 $526.05 $526.05 $0.00 $444.68 $704.37 $711.48 $0.00 $0.00 $139.18 $0.00 $0.00 $141.58 $0.00 $0.00 $0.00 $0.00 $0.00 121161 SUP HCPCS C1713 121161 - PLATE BN 135D STD BRL 300MM 38.1MM AMBI 14 SLOT SS HIP BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 121165 SUP HCPCS C1713 121165 - PLATE BN 130D SHRT BRL 120MM 25.4MM AMBI CHS 5 HL SS HIP BOTH IP/OP "$1,212.75 " $897.44 $0.00 $970.20 $545.74 $545.74 $0.00 $0.00 $0.00 $252.77 $900.10 $900.10 $0.00 $0.00 $252.74 $0.00 $717.34 $717.34 $0.00 $606.38 $960.50 $970.20 $0.00 $0.00 $189.80 $0.00 $0.00 $193.07 $0.00 $0.00 $0.00 $0.00 $0.00 121166 SUP HCPCS C1713 121166 - PLATE BN 135D SHRT BRL 120MM 25.4MM AMBI CHS 5 HL SS HIP BOTH IP/OP "$1,212.75 " $897.44 $0.00 $970.20 $545.74 $545.74 $0.00 $0.00 $0.00 $252.77 $900.10 $900.10 $0.00 $0.00 $252.74 $0.00 $717.34 $717.34 $0.00 $606.38 $960.50 $970.20 $0.00 $0.00 $189.80 $0.00 $0.00 $193.07 $0.00 $0.00 $0.00 $0.00 $0.00 121167 SUP HCPCS C1713 121167 - PLATE BN 140D SHRT BRL 120MM 25.4MM AMBI CHS 5 HL SS HIP BOTH IP/OP "$1,212.75 " $897.44 $0.00 $970.20 $545.74 $545.74 $0.00 $0.00 $0.00 $252.77 $900.10 $900.10 $0.00 $0.00 $252.74 $0.00 $717.34 $717.34 $0.00 $606.38 $960.50 $970.20 $0.00 $0.00 $189.80 $0.00 $0.00 $193.07 $0.00 $0.00 $0.00 $0.00 $0.00 121168 SUP HCPCS C1713 121168 - PLATE BN 145D SHRT BRL 120MM 25.4MM AMBI CHS 5 HL SS HIP BOTH IP/OP "$1,212.75 " $897.44 $0.00 $970.20 $545.74 $545.74 $0.00 $0.00 $0.00 $252.77 $900.10 $900.10 $0.00 $0.00 $252.74 $0.00 $717.34 $717.34 $0.00 $606.38 $960.50 $970.20 $0.00 $0.00 $189.80 $0.00 $0.00 $193.07 $0.00 $0.00 $0.00 $0.00 $0.00 121169 SUP HCPCS C1713 121169 - PLATE BN 150D SHRT BRL 120MM 25.4MM AMBI CHS 5 HL SS HIP BOTH IP/OP "$1,212.75 " $897.44 $0.00 $970.20 $545.74 $545.74 $0.00 $0.00 $0.00 $252.77 $900.10 $900.10 $0.00 $0.00 $252.74 $0.00 $717.34 $717.34 $0.00 $606.38 $960.50 $970.20 $0.00 $0.00 $189.80 $0.00 $0.00 $193.07 $0.00 $0.00 $0.00 $0.00 $0.00 121176 SUP HCPCS C1713 121176 - SCREW BN STD .5IN 9MM 130MM 21MM AMBI CLS IMHS LG BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121177 SUP HCPCS C1713 121177 - SCREW BN 12.7MM 9MM 135MM 21MM IMHS CP STD LG SS HIP IM NL BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121178 SUP HCPCS C1713 121178 - SCREW BN 12.7MM 9MM 140MM 21MM IMHS CP STD LG SS HIP IM NL BOTH IP/OP $726.60 $537.68 $0.00 $581.28 $326.97 $326.97 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $363.30 $575.47 $581.28 $0.00 $0.00 $113.71 $0.00 $0.00 $115.67 $0.00 $0.00 $0.00 $0.00 $0.00 121181 SUP HCPCS C1713 121181 - SCREW BN 14.3MM 9MM 60MM 21MM SPLG HIP BOTH IP/OP $774.90 $573.43 $0.00 $619.92 $348.71 $348.71 $0.00 $0.00 $0.00 $161.51 $575.13 $575.13 $0.00 $0.00 $161.49 $0.00 $458.35 $458.35 $0.00 $387.45 $613.72 $619.92 $0.00 $0.00 $121.27 $0.00 $0.00 $123.36 $0.00 $0.00 $0.00 $0.00 $0.00 121191 SUP HCPCS C1713 121191 - SCREW BN 9/16IN 9MM 110MM 21MM AMBI CLS SPLG BOTH IP/OP $774.90 $573.43 $0.00 $619.92 $348.71 $348.71 $0.00 $0.00 $0.00 $161.51 $575.13 $575.13 $0.00 $0.00 $161.49 $0.00 $458.35 $458.35 $0.00 $387.45 $613.72 $619.92 $0.00 $0.00 $121.27 $0.00 $0.00 $123.36 $0.00 $0.00 $0.00 $0.00 $0.00 121192 SUP HCPCS C1713 121192 - SCREW BN 14.3MM 9MM 115MM STRL 21MM AMBI CLS SPLG CMPR SS BOTH IP/OP $774.90 $573.43 $0.00 $619.92 $348.71 $348.71 $0.00 $0.00 $0.00 $161.51 $575.13 $575.13 $0.00 $0.00 $161.49 $0.00 $458.35 $458.35 $0.00 $387.45 $613.72 $619.92 $0.00 $0.00 $121.27 $0.00 $0.00 $123.36 $0.00 $0.00 $0.00 $0.00 $0.00 121193 SUP HCPCS C1713 121193 - SCREW BN 14.3MM 9MM 120MM STRL 21MM AMBI CLS SPLG CMPR SS BOTH IP/OP $774.90 $573.43 $0.00 $619.92 $348.71 $348.71 $0.00 $0.00 $0.00 $161.51 $575.13 $575.13 $0.00 $0.00 $161.49 $0.00 $458.35 $458.35 $0.00 $387.45 $613.72 $619.92 $0.00 $0.00 $121.27 $0.00 $0.00 $123.36 $0.00 $0.00 $0.00 $0.00 $0.00 121194 SUP HCPCS C1713 121194 - SCREW BN 14.3MM 9MM 125MM STRL 21MM AMBI CLS SPLG CMPR SS BOTH IP/OP $774.90 $573.43 $0.00 $619.92 $348.71 $348.71 $0.00 $0.00 $0.00 $161.51 $575.13 $575.13 $0.00 $0.00 $161.49 $0.00 $458.35 $458.35 $0.00 $387.45 $613.72 $619.92 $0.00 $0.00 $121.27 $0.00 $0.00 $123.36 $0.00 $0.00 $0.00 $0.00 $0.00 121195 SUP HCPCS C1713 121195 - SCREW BN 14.3MM 9MM 130MM 21MM CHS SPLG SS HIP BOTH IP/OP $774.90 $573.43 $0.00 $619.92 $348.71 $348.71 $0.00 $0.00 $0.00 $161.51 $575.13 $575.13 $0.00 $0.00 $161.49 $0.00 $458.35 $458.35 $0.00 $387.45 $613.72 $619.92 $0.00 $0.00 $121.27 $0.00 $0.00 $123.36 $0.00 $0.00 $0.00 $0.00 $0.00 121196 SUP HCPCS C1713 121196 - SCREW BN 14.3MM 9MM 135MM 21MM CHS SPLG SS HIP BOTH IP/OP $774.90 $573.43 $0.00 $619.92 $348.71 $348.71 $0.00 $0.00 $0.00 $161.51 $575.13 $575.13 $0.00 $0.00 $161.49 $0.00 $458.35 $458.35 $0.00 $387.45 $613.72 $619.92 $0.00 $0.00 $121.27 $0.00 $0.00 $123.36 $0.00 $0.00 $0.00 $0.00 $0.00 121197 SUP HCPCS C1713 121197 - SCREW BN 14.3MM 9MM 140MM 21MM CHS SPLG SS HIP BOTH IP/OP $774.90 $573.43 $0.00 $619.92 $348.71 $348.71 $0.00 $0.00 $0.00 $161.51 $575.13 $575.13 $0.00 $0.00 $161.49 $0.00 $458.35 $458.35 $0.00 $387.45 $613.72 $619.92 $0.00 $0.00 $121.27 $0.00 $0.00 $123.36 $0.00 $0.00 $0.00 $0.00 $0.00 121198 SUP HCPCS C1713 121198 - PLATE BN 130D SHRT BRL 100MM 25.4MM AMBI CHS 4 HL SS HIP BOTH IP/OP "$1,165.50 " $862.47 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $242.92 $865.03 $865.03 $0.00 $0.00 $242.89 $0.00 $689.39 $689.39 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $182.40 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 121199 SUP HCPCS C1713 121199 - PLATE BN 135D SHRT BRL 100MM 25.4MM AMBI CHS 4 HL SS HIP BOTH IP/OP "$1,165.50 " $862.47 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $242.92 $865.03 $865.03 $0.00 $0.00 $242.89 $0.00 $689.39 $689.39 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $182.40 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 121200 SUP HCPCS C1713 121200 - PLATE BN 140D SHRT BRL 100MM 25.4MM AMBI CHS 4 HL SS HIP BOTH IP/OP "$1,165.50 " $862.47 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $242.92 $865.03 $865.03 $0.00 $0.00 $242.89 $0.00 $689.39 $689.39 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $182.40 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 121201 SUP HCPCS C1713 121201 - PLATE BN 145D SHRT BRL 100MM 25.4MM AMBI CHS 4 HL SS HIP BOTH IP/OP "$1,165.50 " $862.47 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $242.92 $865.03 $865.03 $0.00 $0.00 $242.89 $0.00 $689.39 $689.39 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $182.40 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 121202 SUP HCPCS C1713 121202 - PLATE BN 150D SHRT BRL 100MM 25.4MM AMBI CHS 4 HL SS HIP BOTH IP/OP "$1,165.50 " $862.47 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $242.92 $865.03 $865.03 $0.00 $0.00 $242.89 $0.00 $689.39 $689.39 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $182.40 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 121410 SUP Custom 27203010 121410 - DEVICE BIOP 10CM 14GA MNPTY 22MM INSTR AUTO STRL DISP BOTH IP/OP $176.32 $130.48 $0.00 $141.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.16 $139.65 $141.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121625 SUP HCPCS C1713 121625 - SCREW BN 6.5MM 25MM STRL 16MM IMSC CNN SS SP CNDL BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121626 SUP HCPCS C1713 121626 - SCREW BN UNV 6.5MM 30MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121627 SUP HCPCS C1713 121627 - SCREW BN UNV 6.5MM 35MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121628 SUP HCPCS C1713 121628 - SCREW BN UNV 6.5MM 40MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121629 SUP HCPCS C1713 121629 - SCREW BN UNV 6.5MM 45MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121630 SUP HCPCS C1713 121630 - SCREW BN UNV 6.5MM 50MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121631 SUP HCPCS C1713 121631 - SCREW BN UNV 6.5MM 55MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121632 SUP HCPCS C1713 121632 - SCREW BN UNV 6.5MM 60MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121633 SUP HCPCS C1713 121633 - SCREW BN UNV 6.5MM 65MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121634 SUP HCPCS C1713 121634 - SCREW BN UNV 6.5MM 70MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121635 SUP HCPCS C1713 121635 - SCREW BN UNV 6.5MM 75MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121636 SUP HCPCS C1713 121636 - SCREW BN P/T 6.5MM 4.5MM 80MM STRL 20MM CNN SS HIP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121637 SUP HCPCS C1713 121637 - SCREW BN UNV 6.5MM 85MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121638 SUP HCPCS C1713 121638 - SCREW BN 6.5MM 90MM CNN MTPHSL BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121639 SUP HCPCS C1713 121639 - SCREW BN UNV 6.5MM 95MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121640 SUP HCPCS C1713 121640 - SCREW BN 6.5MM 100MM CNN SP CNDL BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121641 SUP HCPCS C1713 121641 - SCREW BN UNV 6.5MM 105MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121642 SUP HCPCS C1713 121642 - SCREW BN UNV 6.5MM 110MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121643 SUP HCPCS C1713 121643 - SCREW BN UNV 6.5MM 115MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121644 SUP HCPCS C1713 121644 - SCREW BN UNV 6.5MM 120MM STRL 20MM IMSC CNN CMPR SS HIP SP BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 121654 SUP HCPCS C1713 121654 - PIN FX 30MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121655 SUP HCPCS C1713 121655 - PIN FX 35MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121656 SUP HCPCS C1713 121656 - PIN FX 40MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121657 SUP HCPCS C1713 121657 - PIN FX 45MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121658 SUP HCPCS C1713 121658 - PIN FX 50MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121659 SUP HCPCS C1713 121659 - PIN FX 55MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121660 SUP HCPCS C1713 121660 - PIN FX 60MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121661 SUP HCPCS C1713 121661 - PIN FX 65MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121662 SUP HCPCS C1713 121662 - PIN FX 6.35MM 70MM 16MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121663 SUP HCPCS C1713 121663 - PIN FX 75MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121664 SUP HCPCS C1713 121664 - PIN FX 6.35MM 80MM 16MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121665 SUP HCPCS C1713 121665 - PIN FX 6.35MM 85MM 16MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121666 SUP HCPCS C1713 121666 - PIN FX 6.35MM 90MM 16MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121667 SUP HCPCS C1713 121667 - PIN FX 6.35MM 95MM 16MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121668 SUP HCPCS C1713 121668 - PIN FX 6.35MM 100MM 16MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121669 SUP HCPCS C1713 121669 - PIN FX 105MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121670 SUP HCPCS C1713 121670 - PIN FX 6.35MM 110MM 16MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121671 SUP HCPCS C1713 121671 - PIN FX 6.35MM 115MM 16MM CNN HIP BOTH IP/OP $700.35 $518.26 $0.00 $560.28 $315.16 $315.16 $0.00 $0.00 $0.00 $145.97 $519.80 $519.80 $0.00 $0.00 $145.95 $0.00 $414.26 $414.26 $0.00 $350.18 $554.68 $560.28 $0.00 $0.00 $109.60 $0.00 $0.00 $111.50 $0.00 $0.00 $0.00 $0.00 $0.00 121672 SUP HCPCS C1713 121672 - PIN FX 6.86MM 115MM STRL 16MM CNN HEX HD SS HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121673 SUP HCPCS C1713 121673 - PIN FX 125MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121674 SUP HCPCS C1713 121674 - PIN FX 130MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121675 SUP HCPCS C1713 121675 - PIN FX 135MM CNN HIP BOTH IP/OP $761.25 $563.33 $0.00 $609.00 $342.56 $342.56 $0.00 $0.00 $0.00 $158.66 $565.00 $565.00 $0.00 $0.00 $158.64 $0.00 $450.28 $450.28 $0.00 $380.63 $602.91 $609.00 $0.00 $0.00 $119.14 $0.00 $0.00 $121.19 $0.00 $0.00 $0.00 $0.00 $0.00 121680 SUP HCPCS C1713 121680 - WASHER ORTH UNV 12.7MM 6.5MM 1MM STRL SET SS 6.5MM CNN SCR BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $71.10 $71.10 $0.00 $0.00 $0.00 $32.93 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $93.46 $93.46 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $24.73 $0.00 $0.00 $25.15 $0.00 $0.00 $0.00 $0.00 $0.00 121810 SUP HCPCS C1713 121810 - SCREW BN 2.5MM FLUT 4MM 6MM 10MM STRL 5MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121812 SUP HCPCS C1713 121812 - SCREW BN 2.5MM FLUT 4MM 6MM 12MM STRL 5MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121814 SUP HCPCS C1713 121814 - SCREW BN 2.5MM FLUT 4MM 6MM 14MM STRL 5MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121816 SUP HCPCS C1713 121816 - SCREW BN 2.5MM FLUT 4MM 6MM 16MM STRL 6MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121818 SUP HCPCS C1713 121818 - SCREW BN 2.5MM FLUT 4MM 6MM 18MM STRL 7MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121820 SUP HCPCS C1713 121820 - SCREW BN 2.5MM FLUT 4MM 6MM 20MM STRL 8MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121822 SUP HCPCS C1713 121822 - SCREW BN 2.5MM FLUT 4MM 6MM 22MM STRL 9MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121824 SUP HCPCS C1713 121824 - SCREW BN 2.5MM FLUT 4MM 6MM 24MM STRL 10MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121826 SUP HCPCS C1713 121826 - SCREW BN 2.5MM FLUT 4MM 6MM 26MM STRL 12MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121828 SUP HCPCS C1713 121828 - SCREW BN 2.5MM FLUT 4MM 6MM 28MM STRL 14MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121830 SUP HCPCS C1713 121830 - SCREW BN 2.5MM FLUT 4MM 6MM 30MM STRL 14MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121832 SUP HCPCS C1713 121832 - SCREW BN 2.5MM FLUT 4MM 6MM 32MM STRL 14MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121834 SUP HCPCS C1713 121834 - SCREW BN 2.5MM FLUT 4MM 6MM 34MM STRL 14MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121836 SUP HCPCS C1713 121836 - SCREW BN 2.5MM FLUT 4MM 6MM 36MM STRL 14MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121838 SUP HCPCS C1713 121838 - SCREW BN 2.5MM FLUT 4MM 6MM 38MM STRL 14MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121840 SUP HCPCS C1713 121840 - SCREW BN 2.5MM FLUT 4MM 6MM 40MM STRL 14MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121842 SUP HCPCS C1713 121842 - SCREW BN 2.5MM FLUT 4MM 6MM 42MM STRL 14MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121844 SUP HCPCS C1713 121844 - SCREW BN P/T 4MM 6MM 1.3MM 44MM STRL 2.9MM CNN ST SLF DRL BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121846 SUP HCPCS C1713 121846 - SCREW BN 2.5MM FLUT 4MM 6MM 46MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121848 SUP HCPCS C1713 121848 - SCREW BN 2.5MM FLUT P/T 4MM 6MM 48MM STRL 15MM PRLC ST CNN BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121850 SUP HCPCS C1713 121850 - SCREW BN 2.5MM FLUT 4MM 6MM 50MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121852 SUP HCPCS C1713 121852 - SCREW BN 2.5MM FLUT 4MM 6MM 52MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121854 SUP HCPCS C1713 121854 - SCREW BN 2.5MM FLUT 4MM 6MM 54MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $316.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.15 $146.15 $0.00 $0.00 $41.04 $0.00 $236.01 $236.01 $0.00 $80.86 $316.01 $129.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 121856 SUP HCPCS C1713 121856 - SCREW BN 2.5MM FLUT 4MM 6MM 56MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121858 SUP HCPCS C1713 121858 - SCREW BN 2.5MM FLUT 4MM 6MM 58MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121860 SUP HCPCS C1713 121860 - SCREW BN 2.5MM FLUT 4MM 6MM 60MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121865 SUP HCPCS C1713 121865 - SCREW BN 2.5MM FLUT 4MM 6MM 65MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121870 SUP HCPCS C1713 121870 - SCREW BN 2.5MM FLUT 4MM 6MM 70MM STRL 15MM PRLC ST CNN TROC BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 121905 SUP HCPCS C1713 121905 - NAIL IM 8MM 32CM RUS-TYLR DLT SS FEM BOTH IP/OP "$1,704.38 " "$1,261.24" $0.00 "$1,363.50" $766.97 $766.97 $0.00 $0.00 $0.00 $355.23 "$1,264.99" "$1,264.99" $0.00 $0.00 $355.19 $0.00 "$1,008.14" "$1,008.14" $0.00 $852.19 "$1,349.87" "$1,363.50" $0.00 $0.00 $266.73 $0.00 $0.00 $271.34 $0.00 $0.00 $0.00 $0.00 $0.00 121906 SUP HCPCS C1713 121906 - NAIL IM 8MM 34CM RUS-TYLR DLT II FEM BOTH IP/OP "$1,704.38 " "$1,261.24" $0.00 "$1,363.50" $766.97 $766.97 $0.00 $0.00 $0.00 $355.23 "$1,264.99" "$1,264.99" $0.00 $0.00 $355.19 $0.00 "$1,008.14" "$1,008.14" $0.00 $852.19 "$1,349.87" "$1,363.50" $0.00 $0.00 $266.73 $0.00 $0.00 $271.34 $0.00 $0.00 $0.00 $0.00 $0.00 121907 SUP HCPCS C1713 121907 - NAIL IM 8MM 36CM RUS-TYLR DLT II FEM BOTH IP/OP "$1,704.38 " "$1,261.24" $0.00 "$1,363.50" $766.97 $766.97 $0.00 $0.00 $0.00 $355.23 "$1,264.99" "$1,264.99" $0.00 $0.00 $355.19 $0.00 "$1,008.14" "$1,008.14" $0.00 $852.19 "$1,349.87" "$1,363.50" $0.00 $0.00 $266.73 $0.00 $0.00 $271.34 $0.00 $0.00 $0.00 $0.00 $0.00 122034 SUP HCPCS C1713 122034 - NAIL IM 11MM 44CM RUS-TYLR DLT SS FEM BOTH IP/OP "$1,563.75 " "$1,157.18" $0.00 "$1,251.00" $703.69 $703.69 $0.00 $0.00 $0.00 $325.92 "$1,160.62" "$1,160.62" $0.00 $0.00 $325.89 $0.00 $924.96 $924.96 $0.00 $781.88 "$1,238.49" "$1,251.00" $0.00 $0.00 $244.73 $0.00 $0.00 $248.95 $0.00 $0.00 $0.00 $0.00 $0.00 122153 SUP HCPCS C1713 122153 - NAIL IM 15MM 42CM RUS-TYLR INTLK SS FEM BOTH IP/OP "$2,711.25 " "$2,006.33" $0.00 "$2,169.00" "$1,220.06" "$1,220.06" $0.00 $0.00 $0.00 $565.09 "$2,012.29" "$2,012.29" $0.00 $0.00 $565.02 $0.00 "$1,336.65" "$1,336.65" $0.00 "$1,355.63" "$2,147.31" "$2,169.00" $0.00 $0.00 $424.31 $0.00 $0.00 $431.63 $0.00 $0.00 $0.00 $0.00 $0.00 122159 SUP HCPCS C1713 122159 - NAIL IM 16MM 40CM RUS-TYLR INTLK SS FEM BOTH IP/OP "$2,711.25 " "$2,006.33" $0.00 "$2,169.00" "$1,220.06" "$1,220.06" $0.00 $0.00 $0.00 $565.09 "$2,012.29" "$2,012.29" $0.00 $0.00 $565.02 $0.00 "$1,336.65" "$1,336.65" $0.00 "$1,355.63" "$2,147.31" "$2,169.00" $0.00 $0.00 $424.31 $0.00 $0.00 $431.63 $0.00 $0.00 $0.00 $0.00 $0.00 122202 SUP HCPCS C1713 122202 - NAIL IM 13MM 36CM RUS-TYLR INTLK SS TIB BOTH IP/OP "$3,150.00 " "$2,331.00" $0.00 "$2,520.00" "$1,417.50" "$1,417.50" $0.00 $0.00 $0.00 $656.54 "$2,337.93" "$2,337.93" $0.00 $0.00 $656.46 $0.00 "$1,552.95" "$1,552.95" $0.00 "$1,575.00" "$2,494.80" "$2,520.00" $0.00 $0.00 $492.98 $0.00 $0.00 $501.48 $0.00 $0.00 $0.00 $0.00 $0.00 122341 SUP HCPCS C1713 122341 - NAIL IM 10MM 38CM RUS-TYLR DLT INTLK RECON SS FEM RT BOTH IP/OP "$8,375.63 " "$6,197.97" $0.00 "$6,700.50" "$3,769.03" "$3,769.03" $0.00 $0.00 $0.00 "$1,745.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,745.48" $0.00 "$4,129.18" "$4,129.18" $0.00 "$4,187.81" "$6,633.50" "$6,700.50" $0.00 $0.00 "$1,310.79" $0.00 $0.00 "$1,333.40" $0.00 $0.00 $0.00 $0.00 $0.00 122466 SUP HCPCS C1713 122466 - NAIL IM 8MM 30CM RUS-TYLR INTLK SS HUM BOTH IP/OP "$6,519.38 " "$4,824.34" $0.00 "$5,215.50" "$2,933.72" "$2,933.72" $0.00 $0.00 $0.00 "$1,358.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,358.64" $0.00 "$3,214.05" "$3,214.05" $0.00 "$3,259.69" "$5,163.35" "$5,215.50" $0.00 $0.00 "$1,020.28" $0.00 $0.00 "$1,037.88" $0.00 $0.00 $0.00 $0.00 $0.00 122670 SUP HCPCS C1713 122670 - CAP END RECON FEM BOTH IP/OP $70.10 $51.87 $0.00 $56.08 $31.55 $31.55 $0.00 $0.00 $0.00 $14.61 $52.03 $52.03 $0.00 $0.00 $14.61 $0.00 $41.46 $41.46 $0.00 $35.05 $55.52 $56.08 $0.00 $0.00 $10.97 $0.00 $0.00 $11.16 $0.00 $0.00 $0.00 $0.00 $0.00 122671 SUP HCPCS C1713 122671 - CAP END RUS-TYLR RUS-TYLR RECON NL BOTH IP/OP $66.83 $49.45 $0.00 $53.46 $30.07 $30.07 $0.00 $0.00 $0.00 $13.93 $49.60 $49.60 $0.00 $0.00 $13.93 $0.00 $39.53 $39.53 $0.00 $33.41 $52.93 $53.46 $0.00 $0.00 $10.46 $0.00 $0.00 $10.64 $0.00 $0.00 $0.00 $0.00 $0.00 122700 SUP HCPCS C1713 122700 - PIN HLF UNV 4MM 20MM 20MM HXFX RN HNG KT CMPS TI ORTH XTRNFX BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122701 SUP HCPCS C1713 122701 - PIN HLF 4MM 25MM HXFX RN UNLAT TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122703 SUP HCPCS C1713 122703 - PIN HLF 4MM 35MM HXFX TI ORTH BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122704 SUP HCPCS C1713 122704 - PIN HLF 4MM 40MM HXFX RN UNLAT TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122705 SUP HCPCS C1713 122705 - PIN HLF 4MM 45MM HXFX TI ORTH BOTH IP/OP $469.20 $347.21 $0.00 $375.36 $211.14 $211.14 $0.00 $0.00 $0.00 $97.79 $348.24 $348.24 $0.00 $0.00 $97.78 $0.00 $277.53 $277.53 $0.00 $234.60 $371.61 $375.36 $0.00 $0.00 $73.43 $0.00 $0.00 $74.70 $0.00 $0.00 $0.00 $0.00 $0.00 122706 SUP HCPCS C1713 122706 - PIN HLF 4MM 50MM HXFX TI BOTH IP/OP $561.00 $415.14 $0.00 $448.80 $252.45 $252.45 $0.00 $0.00 $0.00 $116.93 $416.37 $416.37 $0.00 $0.00 $116.91 $0.00 $331.83 $331.83 $0.00 $280.50 $444.31 $448.80 $0.00 $0.00 $87.80 $0.00 $0.00 $89.31 $0.00 $0.00 $0.00 $0.00 $0.00 122707 SUP HCPCS C1713 122707 - PIN HLF P/T 5MM 20MM HXFX SET TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122708 SUP HCPCS C1713 122708 - PIN HLF P/T 5MM 25MM 25MM HXFX TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122709 SUP HCPCS C1713 122709 - PIN HLF P/T 5MM 30MM HXFX TI BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122710 SUP HCPCS C1713 122710 - PIN HLF P/T 5MM 35MM HXFX TI XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122711 SUP HCPCS C1713 122711 - PIN HLF P/T 5MM 40MM HXFX TI XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122712 SUP HCPCS C1713 122712 - PIN HLF 5MM 45MM HXFX RN TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122714 SUP HCPCS C1713 122714 - PIN HLF 5MM 55MM HXFX RN UNLAT TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122715 SUP HCPCS C1713 122715 - PIN HLF 5MM 60MM HXFX RN UNLAT TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122716 SUP HCPCS C1713 122716 - PIN HLF 5MM 65MM HXFX RN UNLAT TI ORTH XTRNFX SYS BOTH IP/OP $533.80 $395.01 $0.00 $427.04 $240.21 $240.21 $0.00 $0.00 $0.00 $111.26 $396.19 $396.19 $0.00 $0.00 $111.24 $0.00 $315.74 $315.74 $0.00 $266.90 $422.77 $427.04 $0.00 $0.00 $83.54 $0.00 $0.00 $84.98 $0.00 $0.00 $0.00 $0.00 $0.00 122717 SUP HCPCS C1713 122717 - PIN HLF 5MM 70MM HXFX TI ORTH BOTH IP/OP $394.40 $291.86 $0.00 $315.52 $177.48 $177.48 $0.00 $0.00 $0.00 $82.20 $292.72 $292.72 $0.00 $0.00 $82.19 $0.00 $233.29 $233.29 $0.00 $197.20 $312.36 $315.52 $0.00 $0.00 $61.72 $0.00 $0.00 $62.79 $0.00 $0.00 $0.00 $0.00 $0.00 122718 SUP HCPCS C1713 122718 - PIN HLF 5MM 75MM HXFX TI ORTH BOTH IP/OP $561.00 $415.14 $0.00 $448.80 $252.45 $252.45 $0.00 $0.00 $0.00 $116.93 $416.37 $416.37 $0.00 $0.00 $116.91 $0.00 $331.83 $331.83 $0.00 $280.50 $444.31 $448.80 $0.00 $0.00 $87.80 $0.00 $0.00 $89.31 $0.00 $0.00 $0.00 $0.00 $0.00 122719 SUP HCPCS C1713 122719 - PIN HLF 5MM 80MM HXFX TI BOTH IP/OP $561.00 $415.14 $0.00 $448.80 $252.45 $252.45 $0.00 $0.00 $0.00 $116.93 $416.37 $416.37 $0.00 $0.00 $116.91 $0.00 $331.83 $331.83 $0.00 $280.50 $444.31 $448.80 $0.00 $0.00 $87.80 $0.00 $0.00 $89.31 $0.00 $0.00 $0.00 $0.00 $0.00 122720 SUP HCPCS C1713 122720 - PIN HLF 5MM 85MM HXFX TI ORTH BOTH IP/OP $472.60 $349.72 $0.00 $378.08 $212.67 $212.67 $0.00 $0.00 $0.00 $98.50 $350.76 $350.76 $0.00 $0.00 $98.49 $0.00 $279.54 $279.54 $0.00 $236.30 $374.30 $378.08 $0.00 $0.00 $73.96 $0.00 $0.00 $75.24 $0.00 $0.00 $0.00 $0.00 $0.00 122721 SUP HCPCS C1713 122721 - PIN HLF 5MM 90MM HXFX TI ORTH BOTH IP/OP $561.00 $415.14 $0.00 $448.80 $252.45 $252.45 $0.00 $0.00 $0.00 $116.93 $416.37 $416.37 $0.00 $0.00 $116.91 $0.00 $331.83 $331.83 $0.00 $280.50 $444.31 $448.80 $0.00 $0.00 $87.80 $0.00 $0.00 $89.31 $0.00 $0.00 $0.00 $0.00 $0.00 122725 SUP HCPCS C1713 122725 - PIN HLF 6MM 40MM 40MM HXFX RN UNLAT THRD TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122727 SUP HCPCS C1713 122727 - PIN HLF 6MM 50MM HXFX RN UNLAT TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122729 SUP HCPCS C1713 122729 - PIN HLF 6MM 60MM HXFX RN UNLAT TI ORTH XTRNFX SYS BOTH IP/OP $780.30 $577.42 $0.00 $624.24 $351.14 $351.14 $0.00 $0.00 $0.00 $162.63 $579.14 $579.14 $0.00 $0.00 $162.61 $0.00 $461.55 $461.55 $0.00 $390.15 $618.00 $624.24 $0.00 $0.00 $122.12 $0.00 $0.00 $124.22 $0.00 $0.00 $0.00 $0.00 $0.00 122733 SUP HCPCS C1713 122733 - PIN HLF 6MM 80MM HXFX TI BOTH IP/OP $472.60 $349.72 $0.00 $378.08 $212.67 $212.67 $0.00 $0.00 $0.00 $98.50 $350.76 $350.76 $0.00 $0.00 $98.49 $0.00 $279.54 $279.54 $0.00 $236.30 $374.30 $378.08 $0.00 $0.00 $73.96 $0.00 $0.00 $75.24 $0.00 $0.00 $0.00 $0.00 $0.00 122735 SUP HCPCS C1713 122735 - PIN FX HLF 6MM 90MM BOTH IP/OP $561.00 $415.14 $0.00 $448.80 $252.45 $252.45 $0.00 $0.00 $0.00 $116.93 $416.37 $416.37 $0.00 $0.00 $116.91 $0.00 $331.83 $331.83 $0.00 $280.50 $444.31 $448.80 $0.00 $0.00 $87.80 $0.00 $0.00 $89.31 $0.00 $0.00 $0.00 $0.00 $0.00 122741 SUP HCPCS C1713 122741 - PIN HLF 4MM 25MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $499.80 $369.85 $0.00 $399.84 $224.91 $224.91 $0.00 $0.00 $0.00 $104.17 $370.95 $370.95 $0.00 $0.00 $104.16 $0.00 $295.63 $295.63 $0.00 $249.90 $395.84 $399.84 $0.00 $0.00 $78.22 $0.00 $0.00 $79.57 $0.00 $0.00 $0.00 $0.00 $0.00 122742 SUP HCPCS C1713 122742 - PIN HLF 4MM 30MM HXFX SS ORTH BOTH IP/OP $282.20 $208.83 $0.00 $225.76 $126.99 $126.99 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $141.10 $223.50 $225.76 $0.00 $0.00 $44.16 $0.00 $0.00 $44.93 $0.00 $0.00 $0.00 $0.00 $0.00 122743 SUP HCPCS C1713 122743 - PIN HLF 4MM 35MM HXFX SS ORTH BOTH IP/OP $282.20 $208.83 $0.00 $225.76 $126.99 $126.99 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $141.10 $223.50 $225.76 $0.00 $0.00 $44.16 $0.00 $0.00 $44.93 $0.00 $0.00 $0.00 $0.00 $0.00 122744 SUP HCPCS C1713 122744 - PIN HLF 4MM 40MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $499.80 $369.85 $0.00 $399.84 $224.91 $224.91 $0.00 $0.00 $0.00 $104.17 $370.95 $370.95 $0.00 $0.00 $104.16 $0.00 $295.63 $295.63 $0.00 $249.90 $395.84 $399.84 $0.00 $0.00 $78.22 $0.00 $0.00 $79.57 $0.00 $0.00 $0.00 $0.00 $0.00 122745 SUP HCPCS C1713 122745 - PIN HLF 4MM 45MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $499.80 $369.85 $0.00 $399.84 $224.91 $224.91 $0.00 $0.00 $0.00 $104.17 $370.95 $370.95 $0.00 $0.00 $104.16 $0.00 $295.63 $295.63 $0.00 $249.90 $395.84 $399.84 $0.00 $0.00 $78.22 $0.00 $0.00 $79.57 $0.00 $0.00 $0.00 $0.00 $0.00 122746 SUP HCPCS C1713 122746 - PIN HLF 4MM 50MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $499.80 $369.85 $0.00 $399.84 $224.91 $224.91 $0.00 $0.00 $0.00 $104.17 $370.95 $370.95 $0.00 $0.00 $104.16 $0.00 $295.63 $295.63 $0.00 $249.90 $395.84 $399.84 $0.00 $0.00 $78.22 $0.00 $0.00 $79.57 $0.00 $0.00 $0.00 $0.00 $0.00 122747 SUP HCPCS C1713 122747 - PIN HLF 5MM 20MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122748 SUP HCPCS C1713 122748 - PIN HLF 5MM 25MM 25MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122749 SUP HCPCS C1713 122749 - PIN HLF 5MM 30MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122750 SUP HCPCS C1713 122750 - PIN HLF 5MM 35MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122751 SUP HCPCS C1713 122751 - PIN HLF 5MM 40MM 40MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122752 SUP HCPCS C1713 122752 - PIN HLF 5MM 45MM 45MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122753 SUP HCPCS C1713 122753 - PIN HLF 5MM 50MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122754 SUP HCPCS C1713 122754 - PIN HLF 5MM 55MM HXFX SS ORTH BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $153.00 $153.00 $0.00 $0.00 $0.00 $70.86 $252.35 $252.35 $0.00 $0.00 $70.86 $0.00 $201.11 $201.11 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $53.21 $0.00 $0.00 $54.13 $0.00 $0.00 $0.00 $0.00 $0.00 122755 SUP HCPCS C1713 122755 - PIN HLF 5MM 60MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $209.10 $154.73 $0.00 $167.28 $94.10 $94.10 $0.00 $0.00 $0.00 $43.58 $155.19 $155.19 $0.00 $0.00 $43.58 $0.00 $123.68 $123.68 $0.00 $104.55 $165.61 $167.28 $0.00 $0.00 $32.72 $0.00 $0.00 $33.29 $0.00 $0.00 $0.00 $0.00 $0.00 122756 SUP HCPCS C1713 122756 - PIN HLF 5MM 65MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $499.80 $369.85 $0.00 $399.84 $224.91 $224.91 $0.00 $0.00 $0.00 $104.17 $370.95 $370.95 $0.00 $0.00 $104.16 $0.00 $295.63 $295.63 $0.00 $249.90 $395.84 $399.84 $0.00 $0.00 $78.22 $0.00 $0.00 $79.57 $0.00 $0.00 $0.00 $0.00 $0.00 122757 SUP HCPCS C1713 122757 - PIN HLF 5MM 70MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $209.10 $154.73 $0.00 $167.28 $94.10 $94.10 $0.00 $0.00 $0.00 $43.58 $155.19 $155.19 $0.00 $0.00 $43.58 $0.00 $123.68 $123.68 $0.00 $104.55 $165.61 $167.28 $0.00 $0.00 $32.72 $0.00 $0.00 $33.29 $0.00 $0.00 $0.00 $0.00 $0.00 122758 SUP HCPCS C1713 122758 - PIN HLF 5MM 75MM HXFX SS ORTH BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $153.00 $153.00 $0.00 $0.00 $0.00 $70.86 $252.35 $252.35 $0.00 $0.00 $70.86 $0.00 $201.11 $201.11 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $53.21 $0.00 $0.00 $54.13 $0.00 $0.00 $0.00 $0.00 $0.00 122759 SUP HCPCS C1713 122759 - PIN HLF 5MM 80MM HXFX SS ORTH BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $153.00 $153.00 $0.00 $0.00 $0.00 $70.86 $252.35 $252.35 $0.00 $0.00 $70.86 $0.00 $201.11 $201.11 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $53.21 $0.00 $0.00 $54.13 $0.00 $0.00 $0.00 $0.00 $0.00 122760 SUP HCPCS C1713 122760 - PIN HLF 5MM 85MM HXFX SS ORTH BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $153.00 $153.00 $0.00 $0.00 $0.00 $70.86 $252.35 $252.35 $0.00 $0.00 $70.86 $0.00 $201.11 $201.11 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $53.21 $0.00 $0.00 $54.13 $0.00 $0.00 $0.00 $0.00 $0.00 122761 SUP HCPCS C1713 122761 - PIN HLF 5MM 90MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $209.10 $154.73 $0.00 $167.28 $94.10 $94.10 $0.00 $0.00 $0.00 $43.58 $155.19 $155.19 $0.00 $0.00 $43.58 $0.00 $123.68 $123.68 $0.00 $104.55 $165.61 $167.28 $0.00 $0.00 $32.72 $0.00 $0.00 $33.29 $0.00 $0.00 $0.00 $0.00 $0.00 122765 SUP HCPCS C1713 122765 - PIN HLF 6MM 40MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122767 SUP HCPCS C1713 122767 - PIN HLF 6MM 50MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122769 SUP HCPCS C1713 122769 - PIN HLF 6MM 60MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $567.80 $420.17 $0.00 $454.24 $255.51 $255.51 $0.00 $0.00 $0.00 $118.34 $421.42 $421.42 $0.00 $0.00 $118.33 $0.00 $335.85 $335.85 $0.00 $283.90 $449.70 $454.24 $0.00 $0.00 $88.86 $0.00 $0.00 $90.39 $0.00 $0.00 $0.00 $0.00 $0.00 122771 SUP HCPCS C1713 122771 - PIN HLF 6MM 70MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $499.80 $369.85 $0.00 $399.84 $224.91 $224.91 $0.00 $0.00 $0.00 $104.17 $370.95 $370.95 $0.00 $0.00 $104.16 $0.00 $295.63 $295.63 $0.00 $249.90 $395.84 $399.84 $0.00 $0.00 $78.22 $0.00 $0.00 $79.57 $0.00 $0.00 $0.00 $0.00 $0.00 122773 SUP HCPCS C1713 122773 - PIN HLF 6MM 80MM HXFX SS ORTH BOTH IP/OP $282.20 $208.83 $0.00 $225.76 $126.99 $126.99 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $141.10 $223.50 $225.76 $0.00 $0.00 $44.16 $0.00 $0.00 $44.93 $0.00 $0.00 $0.00 $0.00 $0.00 122775 SUP HCPCS C1713 122775 - PIN HLF 6MM 90MM HXFX UNLAT SS ORTH XTRNFX SYS BOTH IP/OP $499.80 $369.85 $0.00 $399.84 $224.91 $224.91 $0.00 $0.00 $0.00 $104.17 $370.95 $370.95 $0.00 $0.00 $104.16 $0.00 $295.63 $295.63 $0.00 $249.90 $395.84 $399.84 $0.00 $0.00 $78.22 $0.00 $0.00 $79.57 $0.00 $0.00 $0.00 $0.00 $0.00 124120 SUP HCPCS C1713 124120 - PLATE BN 130D STD BRL 60MM 38.1MM CLS CHS 2 HL SS HIP BOTH IP/OP "$1,107.75 " $819.74 $0.00 $886.20 $498.49 $498.49 $0.00 $0.00 $0.00 $230.88 $822.17 $822.17 $0.00 $0.00 $230.86 $0.00 $655.23 $655.23 $0.00 $553.88 $877.34 $886.20 $0.00 $0.00 $173.36 $0.00 $0.00 $176.35 $0.00 $0.00 $0.00 $0.00 $0.00 124121 SUP HCPCS C1713 124121 - PLATE BN 135D STD BRL 60MM 38.1MM CLS CHS 2 HL CMPR HIP BOTH IP/OP "$1,107.75 " $819.74 $0.00 $886.20 $498.49 $498.49 $0.00 $0.00 $0.00 $230.88 $822.17 $822.17 $0.00 $0.00 $230.86 $0.00 $655.23 $655.23 $0.00 $553.88 $877.34 $886.20 $0.00 $0.00 $173.36 $0.00 $0.00 $176.35 $0.00 $0.00 $0.00 $0.00 $0.00 124122 SUP HCPCS C1713 124122 - PLATE BN 140D STD BRL 60MM 38.1MM CLS CHS 2 HL CMPR HIP BOTH IP/OP "$1,107.75 " $819.74 $0.00 $886.20 $498.49 $498.49 $0.00 $0.00 $0.00 $230.88 $822.17 $822.17 $0.00 $0.00 $230.86 $0.00 $655.23 $655.23 $0.00 $553.88 $877.34 $886.20 $0.00 $0.00 $173.36 $0.00 $0.00 $176.35 $0.00 $0.00 $0.00 $0.00 $0.00 124123 SUP HCPCS C1713 124123 - PLATE BN 145D STD BRL 60MM 38.1MM CLS CHS 2 HL CMPR HIP BOTH IP/OP "$1,107.75 " $819.74 $0.00 $886.20 $498.49 $498.49 $0.00 $0.00 $0.00 $230.88 $822.17 $822.17 $0.00 $0.00 $230.86 $0.00 $655.23 $655.23 $0.00 $553.88 $877.34 $886.20 $0.00 $0.00 $173.36 $0.00 $0.00 $176.35 $0.00 $0.00 $0.00 $0.00 $0.00 124124 SUP HCPCS C1713 124124 - PLATE BN 150D STD BRL 60MM 38.1MM CLS CHS 2 HL CMPR HIP BOTH IP/OP "$1,107.75 " $819.74 $0.00 $886.20 $498.49 $498.49 $0.00 $0.00 $0.00 $230.88 $822.17 $822.17 $0.00 $0.00 $230.86 $0.00 $655.23 $655.23 $0.00 $553.88 $877.34 $886.20 $0.00 $0.00 $173.36 $0.00 $0.00 $176.35 $0.00 $0.00 $0.00 $0.00 $0.00 124125 SUP HCPCS C1713 124125 - PLATE BN 130D STD BRL 80MM 38.1MM CLS CHS 3 HL CMPR HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124126 SUP HCPCS C1713 124126 - PLATE BN 135D STD BRL 80MM 38.1MM CLS CHS 3 HL CMPR SS HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124127 SUP HCPCS C1713 124127 - PLATE BN 140D STD BRL 80MM 38.1MM CLS CHS 3 HL CMPR SS HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124128 SUP HCPCS C1713 124128 - PLATE BN 145D STD BRL 80MM 38.1MM CLS CHS 3 HL SS HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124129 SUP HCPCS C1713 124129 - PLATE BN 150D STD BRL 80MM 38.1MM CLS CHS 3 HL SS HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124130 SUP HCPCS C1713 124130 - PLATE BN 130D STD BRL 100MM 38.1MM CLS CHS 4 HL CMPR HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124131 SUP HCPCS C1713 124131 - PLATE BN 135D STD BRL 100MM 1.5MM CLS 4 HL HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124132 SUP HCPCS C1713 124132 - PLATE BN 140D STD BRL 100MM 38.1MM CLS CHS 4 HL CMPR HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124133 SUP HCPCS C1713 124133 - PLATE BN 145D STD BRL 100MM 38.1MM CLS CHS 4 HL CMPR HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124134 SUP HCPCS C1713 124134 - PLATE BN 150D STD BRL 100MM 38.1MM CLS CHS 4 HL SS HIP BOTH IP/OP "$1,144.50 " $846.93 $0.00 $915.60 $515.03 $515.03 $0.00 $0.00 $0.00 $238.54 $849.45 $849.45 $0.00 $0.00 $238.51 $0.00 $676.97 $676.97 $0.00 $572.25 $906.44 $915.60 $0.00 $0.00 $179.11 $0.00 $0.00 $182.20 $0.00 $0.00 $0.00 $0.00 $0.00 124135 SUP HCPCS C1713 124135 - PLATE BN 130D STD BRL 120MM 38.1MM CLS CHS 5 HL CMPR SS HIP BOTH IP/OP "$1,223.25 " $905.21 $0.00 $978.60 $550.46 $550.46 $0.00 $0.00 $0.00 $254.96 $907.90 $907.90 $0.00 $0.00 $254.93 $0.00 $723.55 $723.55 $0.00 $611.63 $968.81 $978.60 $0.00 $0.00 $191.44 $0.00 $0.00 $194.74 $0.00 $0.00 $0.00 $0.00 $0.00 124136 SUP HCPCS C1713 124136 - PLATE BN 135D STD BRL 120MM 1.5MM CLS 5 HL HIP BOTH IP/OP "$1,223.25 " $905.21 $0.00 $978.60 $550.46 $550.46 $0.00 $0.00 $0.00 $254.96 $907.90 $907.90 $0.00 $0.00 $254.93 $0.00 $723.55 $723.55 $0.00 $611.63 $968.81 $978.60 $0.00 $0.00 $191.44 $0.00 $0.00 $194.74 $0.00 $0.00 $0.00 $0.00 $0.00 124137 SUP HCPCS C1713 124137 - PLATE BN 140D STD BRL 120MM 38.1MM CHS 5 HL CMPR SS HIP BOTH IP/OP "$1,223.25 " $905.21 $0.00 $978.60 $550.46 $550.46 $0.00 $0.00 $0.00 $254.96 $907.90 $907.90 $0.00 $0.00 $254.93 $0.00 $723.55 $723.55 $0.00 $611.63 $968.81 $978.60 $0.00 $0.00 $191.44 $0.00 $0.00 $194.74 $0.00 $0.00 $0.00 $0.00 $0.00 124138 SUP HCPCS C1713 124138 - PLATE BN 145D STD BRL 120MM 38.1MM CLS CHS 5 HL SS HIP BOTH IP/OP "$1,223.25 " $905.21 $0.00 $978.60 $550.46 $550.46 $0.00 $0.00 $0.00 $254.96 $907.90 $907.90 $0.00 $0.00 $254.93 $0.00 $723.55 $723.55 $0.00 $611.63 $968.81 $978.60 $0.00 $0.00 $191.44 $0.00 $0.00 $194.74 $0.00 $0.00 $0.00 $0.00 $0.00 124139 SUP HCPCS C1713 124139 - PLATE BN 150D STD BRL 120MM 38.1MM CLS CHS 5 HL SS HIP BOTH IP/OP "$1,223.25 " $905.21 $0.00 $978.60 $550.46 $550.46 $0.00 $0.00 $0.00 $254.96 $907.90 $907.90 $0.00 $0.00 $254.93 $0.00 $723.55 $723.55 $0.00 $611.63 $968.81 $978.60 $0.00 $0.00 $191.44 $0.00 $0.00 $194.74 $0.00 $0.00 $0.00 $0.00 $0.00 124140 SUP HCPCS C1713 124140 - PLATE BN 130D STD BRL 140MM 38.1MM CLS CHS 6 HL SS HIP BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 124141 SUP HCPCS C1713 124141 - PLATE BN 135D STD BRL 140MM 38.1MM CLS CHS 6 HL SS HIP BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 124142 SUP HCPCS C1713 124142 - PLATE BN 140D STD BRL 140MM 38.1MM CLS CHS 6 HL SS HIP BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 124143 SUP HCPCS C1713 124143 - PLATE BN 145D STD BRL 140MM 38.1MM CLS CHS 6 HL SS HIP BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 124144 SUP HCPCS C1713 124144 - PLATE BN 150D STD BRL 140MM 38.1MM CLS CHS 6 HL SS HIP BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 124145 SUP HCPCS C1713 124145 - PLATE BN 130D STD BRL 180MM 38.1MM CLS CHS 8 HL CMPR HIP BOTH IP/OP "$1,554.00 " "$1,149.96" $0.00 "$1,243.20" $699.30 $699.30 $0.00 $0.00 $0.00 $323.89 "$1,153.38" "$1,153.38" $0.00 $0.00 $323.85 $0.00 $919.19 $919.19 $0.00 $777.00 "$1,230.77" "$1,243.20" $0.00 $0.00 $243.20 $0.00 $0.00 $247.40 $0.00 $0.00 $0.00 $0.00 $0.00 124146 SUP HCPCS C1713 124146 - PLATE BN 135D STD BRL 180MM 38.1MM CLS CHS 8 HL CMPR HIP BOTH IP/OP "$1,554.00 " "$1,149.96" $0.00 "$1,243.20" $699.30 $699.30 $0.00 $0.00 $0.00 $323.89 "$1,153.38" "$1,153.38" $0.00 $0.00 $323.85 $0.00 $919.19 $919.19 $0.00 $777.00 "$1,230.77" "$1,243.20" $0.00 $0.00 $243.20 $0.00 $0.00 $247.40 $0.00 $0.00 $0.00 $0.00 $0.00 124147 SUP HCPCS C1713 124147 - PLATE BN 140D STD BRL 180MM 38.1MM CLS CHS 8 HL CMPR HIP BOTH IP/OP "$1,554.00 " "$1,149.96" $0.00 "$1,243.20" $699.30 $699.30 $0.00 $0.00 $0.00 $323.89 "$1,153.38" "$1,153.38" $0.00 $0.00 $323.85 $0.00 $919.19 $919.19 $0.00 $777.00 "$1,230.77" "$1,243.20" $0.00 $0.00 $243.20 $0.00 $0.00 $247.40 $0.00 $0.00 $0.00 $0.00 $0.00 124148 SUP HCPCS C1713 124148 - PLATE BN 145D STD BRL 180MM 38.1MM CLS CHS 8 HL CMPR HIP BOTH IP/OP "$1,554.00 " "$1,149.96" $0.00 "$1,243.20" $699.30 $699.30 $0.00 $0.00 $0.00 $323.89 "$1,153.38" "$1,153.38" $0.00 $0.00 $323.85 $0.00 $919.19 $919.19 $0.00 $777.00 "$1,230.77" "$1,243.20" $0.00 $0.00 $243.20 $0.00 $0.00 $247.40 $0.00 $0.00 $0.00 $0.00 $0.00 124149 SUP HCPCS C1713 124149 - PLATE BN 150D STD BRL 180MM 38.1MM CLS CHS 8 HL CMPR HIP BOTH IP/OP "$1,554.00 " "$1,149.96" $0.00 "$1,243.20" $699.30 $699.30 $0.00 $0.00 $0.00 $323.89 "$1,153.38" "$1,153.38" $0.00 $0.00 $323.85 $0.00 $919.19 $919.19 $0.00 $777.00 "$1,230.77" "$1,243.20" $0.00 $0.00 $243.20 $0.00 $0.00 $247.40 $0.00 $0.00 $0.00 $0.00 $0.00 124150 SUP HCPCS C1713 124150 - PLATE BN 130D STD BRL 220MM 38.1MM CLS CHS 10 HL CMPR HIP BOTH IP/OP "$1,811.25 " "$1,340.33" $0.00 "$1,449.00" $815.06 $815.06 $0.00 $0.00 $0.00 $377.51 "$1,344.31" "$1,344.31" $0.00 $0.00 $377.46 $0.00 "$1,071.35" "$1,071.35" $0.00 $905.63 "$1,434.51" "$1,449.00" $0.00 $0.00 $283.46 $0.00 $0.00 $288.35 $0.00 $0.00 $0.00 $0.00 $0.00 124151 SUP HCPCS C1713 124151 - PLATE BN 135D STD BRL 220MM 38.1MM CHS 10 HL SS HIP BOTH IP/OP "$1,811.25 " "$1,340.33" $0.00 "$1,449.00" $815.06 $815.06 $0.00 $0.00 $0.00 $377.51 "$1,344.31" "$1,344.31" $0.00 $0.00 $377.46 $0.00 "$1,071.35" "$1,071.35" $0.00 $905.63 "$1,434.51" "$1,449.00" $0.00 $0.00 $283.46 $0.00 $0.00 $288.35 $0.00 $0.00 $0.00 $0.00 $0.00 124152 SUP HCPCS C1713 124152 - PLATE BN 140D STD BRL 220MM 38.1MM CLS CHS 10 HL CMPR HIP BOTH IP/OP "$1,811.25 " "$1,340.33" $0.00 "$1,449.00" $815.06 $815.06 $0.00 $0.00 $0.00 $377.51 "$1,344.31" "$1,344.31" $0.00 $0.00 $377.46 $0.00 "$1,071.35" "$1,071.35" $0.00 $905.63 "$1,434.51" "$1,449.00" $0.00 $0.00 $283.46 $0.00 $0.00 $288.35 $0.00 $0.00 $0.00 $0.00 $0.00 124153 SUP HCPCS C1713 124153 - PLATE BN 145D STD BRL 220MM 38.1MM CLS CHS 10 HL CMPR HIP BOTH IP/OP "$1,811.25 " "$1,340.33" $0.00 "$1,449.00" $815.06 $815.06 $0.00 $0.00 $0.00 $377.51 "$1,344.31" "$1,344.31" $0.00 $0.00 $377.46 $0.00 "$1,071.35" "$1,071.35" $0.00 $905.63 "$1,434.51" "$1,449.00" $0.00 $0.00 $283.46 $0.00 $0.00 $288.35 $0.00 $0.00 $0.00 $0.00 $0.00 124154 SUP HCPCS C1713 124154 - PLATE BN 150D STD BRL 220MM 38.1MM CLS CHS 10 HL CMPR HIP BOTH IP/OP "$1,811.25 " "$1,340.33" $0.00 "$1,449.00" $815.06 $815.06 $0.00 $0.00 $0.00 $377.51 "$1,344.31" "$1,344.31" $0.00 $0.00 $377.46 $0.00 "$1,071.35" "$1,071.35" $0.00 $905.63 "$1,434.51" "$1,449.00" $0.00 $0.00 $283.46 $0.00 $0.00 $288.35 $0.00 $0.00 $0.00 $0.00 $0.00 124156 SUP HCPCS C1713 124156 - PLATE BN 135D STD BRL 260MM 38.1MM CLS CHS 12 HL CMPR HIP BOTH IP/OP "$1,937.25 " "$1,433.57" $0.00 "$1,549.80" $871.76 $871.76 $0.00 $0.00 $0.00 $403.77 "$1,437.83" "$1,437.83" $0.00 $0.00 $403.72 $0.00 "$1,145.88" "$1,145.88" $0.00 $968.63 "$1,534.30" "$1,549.80" $0.00 $0.00 $303.18 $0.00 $0.00 $308.41 $0.00 $0.00 $0.00 $0.00 $0.00 124158 SUP HCPCS C1713 124158 - PLATE BN 145D STD BRL 260MM 38.1MM CLS CHS 12 HL SS HIP BOTH IP/OP "$1,937.25 " "$1,433.57" $0.00 "$1,549.80" $871.76 $871.76 $0.00 $0.00 $0.00 $403.77 "$1,437.83" "$1,437.83" $0.00 $0.00 $403.72 $0.00 "$1,145.88" "$1,145.88" $0.00 $968.63 "$1,534.30" "$1,549.80" $0.00 $0.00 $303.18 $0.00 $0.00 $308.41 $0.00 $0.00 $0.00 $0.00 $0.00 124161 SUP HCPCS C1713 124161 - PLATE BN 135D STD BRL 300MM 38.1MM CLS CHS 14 HL CMPR HIP BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" "$1,032.41" "$1,032.41" $0.00 $0.00 $0.00 $478.18 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 "$1,357.05" "$1,357.05" $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $359.05 $0.00 $0.00 $365.24 $0.00 $0.00 $0.00 $0.00 $0.00 124162 SUP HCPCS C1713 124162 - PLATE BN 140D STD BRL 300MM 38.1MM CLS CHS 14 HL SS HIP BOTH IP/OP "$2,160.00 " "$1,598.40" $0.00 "$1,728.00" $972.00 $972.00 $0.00 $0.00 $0.00 $450.20 "$1,603.15" "$1,603.15" $0.00 $0.00 $450.14 $0.00 "$1,277.64" "$1,277.64" $0.00 "$1,080.00" "$1,710.72" "$1,728.00" $0.00 $0.00 $338.04 $0.00 $0.00 $343.87 $0.00 $0.00 $0.00 $0.00 $0.00 124163 SUP HCPCS C1713 124163 - PLATE BN 145D STD BRL 300MM 38.1MM CLS CHS 14 HL SS HIP BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" "$1,032.41" "$1,032.41" $0.00 $0.00 $0.00 $478.18 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 "$1,357.05" "$1,357.05" $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $359.05 $0.00 $0.00 $365.24 $0.00 $0.00 $0.00 $0.00 $0.00 124164 SUP HCPCS C1713 124164 - PLATE BN 150D STD BRL 300MM 38.1MM CLS CHS 14 HL SS HIP BOTH IP/OP "$1,386.00 " "$1,025.64" $0.00 "$1,108.80" $623.70 $623.70 $0.00 $0.00 $0.00 $288.88 "$1,028.69" "$1,028.69" $0.00 $0.00 $288.84 $0.00 $819.82 $819.82 $0.00 $693.00 "$1,097.71" "$1,108.80" $0.00 $0.00 $216.91 $0.00 $0.00 $220.65 $0.00 $0.00 $0.00 $0.00 $0.00 124165 SUP HCPCS C1713 124165 - PLATE BN 130D SHRT BRL 120MM 25.4MM CLS CHS 5 HL CMPR SS HIP BOTH IP/OP "$1,249.50 " $924.63 $0.00 $999.60 $562.28 $562.28 $0.00 $0.00 $0.00 $260.43 $927.38 $927.38 $0.00 $0.00 $260.40 $0.00 $739.08 $739.08 $0.00 $624.75 $989.60 $999.60 $0.00 $0.00 $195.55 $0.00 $0.00 $198.92 $0.00 $0.00 $0.00 $0.00 $0.00 124166 SUP HCPCS C1713 124166 - PLATE BN 135D SHRT BRL 120MM 25.9MM CLS CHS 5 HL CMPR SS HIP BOTH IP/OP "$1,249.50 " $924.63 $0.00 $999.60 $562.28 $562.28 $0.00 $0.00 $0.00 $260.43 $927.38 $927.38 $0.00 $0.00 $260.40 $0.00 $739.08 $739.08 $0.00 $624.75 $989.60 $999.60 $0.00 $0.00 $195.55 $0.00 $0.00 $198.92 $0.00 $0.00 $0.00 $0.00 $0.00 124167 SUP HCPCS C1713 124167 - PLATE BN 140D SHRT BRL 120MM 25.4MM CLS CHS 5 HL CMPR SS HIP BOTH IP/OP "$1,249.50 " $924.63 $0.00 $999.60 $562.28 $562.28 $0.00 $0.00 $0.00 $260.43 $927.38 $927.38 $0.00 $0.00 $260.40 $0.00 $739.08 $739.08 $0.00 $624.75 $989.60 $999.60 $0.00 $0.00 $195.55 $0.00 $0.00 $198.92 $0.00 $0.00 $0.00 $0.00 $0.00 124168 SUP HCPCS C1713 124168 - PLATE BN 145D SHRT BRL 120MM 25.4MM CLS CHS 5 HL CMPR SS HIP BOTH IP/OP "$1,249.50 " $924.63 $0.00 $999.60 $562.28 $562.28 $0.00 $0.00 $0.00 $260.43 $927.38 $927.38 $0.00 $0.00 $260.40 $0.00 $739.08 $739.08 $0.00 $624.75 $989.60 $999.60 $0.00 $0.00 $195.55 $0.00 $0.00 $198.92 $0.00 $0.00 $0.00 $0.00 $0.00 124169 SUP HCPCS C1713 124169 - PLATE BN 150D SHRT BRL 120MM 25.4MM CLS CHS 5 HL CMPR SS HIP BOTH IP/OP "$1,249.50 " $924.63 $0.00 $999.60 $562.28 $562.28 $0.00 $0.00 $0.00 $260.43 $927.38 $927.38 $0.00 $0.00 $260.40 $0.00 $739.08 $739.08 $0.00 $624.75 $989.60 $999.60 $0.00 $0.00 $195.55 $0.00 $0.00 $198.92 $0.00 $0.00 $0.00 $0.00 $0.00 124176 SUP HCPCS C1713 124176 - PLATE BN 130D SHRT BRL 100MM 25.4MM CLS CHS 4 HL CMPR HIP SP BOTH IP/OP "$1,197.00 " $885.78 $0.00 $957.60 $538.65 $538.65 $0.00 $0.00 $0.00 $249.48 $888.41 $888.41 $0.00 $0.00 $249.45 $0.00 $708.03 $708.03 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $187.33 $0.00 $0.00 $190.56 $0.00 $0.00 $0.00 $0.00 $0.00 124177 SUP HCPCS C1713 124177 - PLATE BN 135D SHRT BRL 100MM 1MM CLS 4 HL HIP BOTH IP/OP "$1,197.00 " $885.78 $0.00 $957.60 $538.65 $538.65 $0.00 $0.00 $0.00 $249.48 $888.41 $888.41 $0.00 $0.00 $249.45 $0.00 $708.03 $708.03 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $187.33 $0.00 $0.00 $190.56 $0.00 $0.00 $0.00 $0.00 $0.00 124178 SUP HCPCS C1713 124178 - PLATE BN 140D SHRT BRL 100MM CLS 4 SLOT CMPR BOTH IP/OP "$1,197.00 " $885.78 $0.00 $957.60 $538.65 $538.65 $0.00 $0.00 $0.00 $249.48 $888.41 $888.41 $0.00 $0.00 $249.45 $0.00 $708.03 $708.03 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $187.33 $0.00 $0.00 $190.56 $0.00 $0.00 $0.00 $0.00 $0.00 124179 SUP HCPCS C1713 124179 - PLATE BN 145D SHRT BRL 100MM 25.4MM CLS CHS 4 HL CMPR HIP SP BOTH IP/OP "$1,197.00 " $885.78 $0.00 $957.60 $538.65 $538.65 $0.00 $0.00 $0.00 $249.48 $888.41 $888.41 $0.00 $0.00 $249.45 $0.00 $708.03 $708.03 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $187.33 $0.00 $0.00 $190.56 $0.00 $0.00 $0.00 $0.00 $0.00 124180 SUP HCPCS C1713 124180 - PLATE BN 150D SHRT BRL 100MM 25.4MM CLS CHS 4 HL CMPR HIP SP BOTH IP/OP "$1,197.00 " $885.78 $0.00 $957.60 $538.65 $538.65 $0.00 $0.00 $0.00 $249.48 $888.41 $888.41 $0.00 $0.00 $249.45 $0.00 $708.03 $708.03 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $187.33 $0.00 $0.00 $190.56 $0.00 $0.00 $0.00 $0.00 $0.00 124810 SUP HCPCS C1713 124810 - PIN TRC 4MM 250MM 50MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $708.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.45 $4.45 $0.00 $0.00 $1.25 $0.00 $529.10 $529.10 $0.00 $3.00 $708.44 $4.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 124811 SUP HCPCS C1713 124811 - PIN TRC 4MM 150MM 60MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 124820 SUP HCPCS C1713 124820 - PIN TRC 4MM 250MM 40MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 124823 SUP HCPCS C1713 124823 - PIN TRC 4MM 300MM 40MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 124824 SUP HCPCS C1713 124824 - PIN TRC 4MM 300MM 50MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 124825 SUP HCPCS C1713 124825 - PIN TRC 4MM 250MM 40MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 124826 SUP HCPCS C1713 124826 - PIN TRC 5MM 250MM 50MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 124827 SUP HCPCS C1713 124827 - PIN TRC 5MM 250MM 60MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 124828 SUP HCPCS C1713 124828 - PIN TRC 3MM 60MM 16MM HLF COVE PNT ORTH BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 124829 SUP HCPCS C1713 124829 - PIN TRC 3MM 60MM 22MM HLF COVE PNT BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 124830 SUP HCPCS C1713 124830 - PIN TRC 3MM 75MM 28MM HLF COVE PNT ORTH BOTH IP/OP $558.00 $412.92 $0.00 $446.40 $251.10 $251.10 $0.00 $0.00 $0.00 $116.30 $414.15 $414.15 $0.00 $0.00 $116.29 $0.00 $330.06 $330.06 $0.00 $279.00 $441.94 $446.40 $0.00 $0.00 $87.33 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $0.00 124831 SUP HCPCS C1713 124831 - PIN TRC 4MM 150MM 50MM HLF COVE PNT ORTH BOTH IP/OP $770.00 $569.80 $0.00 $616.00 $346.50 $346.50 $0.00 $0.00 $0.00 $160.49 $571.49 $571.49 $0.00 $0.00 $160.47 $0.00 $455.46 $455.46 $0.00 $385.00 $609.84 $616.00 $0.00 $0.00 $120.51 $0.00 $0.00 $122.58 $0.00 $0.00 $0.00 $0.00 $0.00 124833 SUP HCPCS C1713 124833 - PIN TRC 5MM 150MM 50MM HLF COVE PNT ORTH BOTH IP/OP $770.00 $569.80 $0.00 $616.00 $346.50 $346.50 $0.00 $0.00 $0.00 $160.49 $571.49 $571.49 $0.00 $0.00 $160.47 $0.00 $455.46 $455.46 $0.00 $385.00 $609.84 $616.00 $0.00 $0.00 $120.51 $0.00 $0.00 $122.58 $0.00 $0.00 $0.00 $0.00 $0.00 124834 SUP HCPCS C1713 124834 - PIN TRC 5MM 200MM 35MM HLF COVE PNT ORTH BOTH IP/OP $614.00 $454.36 $0.00 $491.20 $276.30 $276.30 $0.00 $0.00 $0.00 $127.97 $455.71 $455.71 $0.00 $0.00 $127.96 $0.00 $363.18 $363.18 $0.00 $307.00 $486.29 $491.20 $0.00 $0.00 $96.09 $0.00 $0.00 $97.75 $0.00 $0.00 $0.00 $0.00 $0.00 124835 SUP HCPCS C1713 124835 - PIN TRC 3MM 250MM 50MM HLF COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 124839 SUP HCPCS C1713 124839 - PIN HLF 5MM 150MM 40MM PDRLL ORTH BOTH IP/OP $614.00 $454.36 $0.00 $491.20 $276.30 $276.30 $0.00 $0.00 $0.00 $127.97 $455.71 $455.71 $0.00 $0.00 $127.96 $0.00 $363.18 $363.18 $0.00 $307.00 $486.29 $491.20 $0.00 $0.00 $96.09 $0.00 $0.00 $97.75 $0.00 $0.00 $0.00 $0.00 $0.00 124840 SUP HCPCS C1713 124840 - PIN HLF 5MM 150MM 45MM PDRLL ORTH BOTH IP/OP $493.00 $364.82 $0.00 $394.40 $221.85 $221.85 $0.00 $0.00 $0.00 $102.75 $365.90 $365.90 $0.00 $0.00 $102.74 $0.00 $291.61 $291.61 $0.00 $246.50 $390.46 $394.40 $0.00 $0.00 $77.15 $0.00 $0.00 $78.49 $0.00 $0.00 $0.00 $0.00 $0.00 124841 SUP HCPCS C1713 124841 - PIN HLF 5MM 150MM 50MM PDRLL ORTH BOTH IP/OP $493.00 $364.82 $0.00 $394.40 $221.85 $221.85 $0.00 $0.00 $0.00 $102.75 $365.90 $365.90 $0.00 $0.00 $102.74 $0.00 $291.61 $291.61 $0.00 $246.50 $390.46 $394.40 $0.00 $0.00 $77.15 $0.00 $0.00 $78.49 $0.00 $0.00 $0.00 $0.00 $0.00 125037 SUP Custom 27203010 125037 - TUBE ENDBR 37FR 5.1MM BLU CLR SHLY B-CTH LT CUF RADOPQ SLT BOTH IP/OP $124.95 $92.46 $0.00 $101.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $0.00 $0.00 $0.00 $63.41 $100.45 $101.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 125039 SUP Custom 27203010 125039 - TUBE ENDBR 39FR 5.3MM BLU CLR SHLY B-CTH LT CUF RADOPQ SLT BOTH IP/OP $298.25 $220.71 $0.00 $101.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $0.00 $0.00 $0.00 $63.41 $100.45 $101.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 125195 SUP HCPCS C1713 125195 - SCREW BN SLT HD CMPR PED BOTH IP/OP $183.75 $135.98 $0.00 $147.00 $82.69 $82.69 $0.00 $0.00 $0.00 $38.30 $136.38 $136.38 $0.00 $0.00 $38.29 $0.00 $108.69 $108.69 $0.00 $91.88 $145.53 $147.00 $0.00 $0.00 $28.76 $0.00 $0.00 $29.25 $0.00 $0.00 $0.00 $0.00 $0.00 125292 SUP HCPCS C1713 125292 - PLATE BN 100D 3 HL BRL INTMD SS HIP BOTH IP/OP $601.65 $445.22 $0.00 $481.32 $270.74 $270.74 $0.00 $0.00 $0.00 $125.40 $446.54 $446.54 $0.00 $0.00 $125.38 $0.00 $355.88 $355.88 $0.00 $300.83 $476.51 $481.32 $0.00 $0.00 $94.16 $0.00 $0.00 $95.78 $0.00 $0.00 $0.00 $0.00 $0.00 125294 SUP HCPCS C1713 125294 - PLATE BN 130D 76.2MM 3 HL BRL INTMD SS HIP KY-LOK BOTH IP/OP $558.60 $413.36 $0.00 $446.88 $251.37 $251.37 $0.00 $0.00 $0.00 $116.43 $414.59 $414.59 $0.00 $0.00 $116.41 $0.00 $330.41 $330.41 $0.00 $279.30 $442.41 $446.88 $0.00 $0.00 $87.42 $0.00 $0.00 $88.93 $0.00 $0.00 $0.00 $0.00 $0.00 125800 SUP HCPCS C1713 125800 - PIN HLF 4MM 150MM 35MM SKL TRX COVE PNT BOTH IP/OP $383.50 $283.79 $0.00 $306.80 $172.58 $172.58 $0.00 $0.00 $0.00 $79.93 $284.63 $284.63 $0.00 $0.00 $79.92 $0.00 $226.84 $226.84 $0.00 $191.75 $303.73 $306.80 $0.00 $0.00 $60.02 $0.00 $0.00 $61.05 $0.00 $0.00 $0.00 $0.00 $0.00 125900 SUP HCPCS C1713 125900 - PIN TRC 4MM 300MM 60MM FULL COVE PNT ORTH BOTH IP/OP $894.50 $661.93 $0.00 $715.60 $402.53 $402.53 $0.00 $0.00 $0.00 $186.44 $663.90 $663.90 $0.00 $0.00 $186.41 $0.00 $529.10 $529.10 $0.00 $447.25 $708.44 $715.60 $0.00 $0.00 $139.99 $0.00 $0.00 $142.40 $0.00 $0.00 $0.00 $0.00 $0.00 127016 SUP HCPCS C1713 127016 - SCREW BN 4.5MM 16MM IMHS ST HIP BOTH IP/OP $36.50 $27.01 $0.00 $29.20 $16.43 $16.43 $0.00 $0.00 $0.00 $7.61 $27.09 $27.09 $0.00 $0.00 $7.61 $0.00 $21.59 $21.59 $0.00 $18.25 $28.91 $29.20 $0.00 $0.00 $5.71 $0.00 $0.00 $5.81 $0.00 $0.00 $0.00 $0.00 $0.00 127018 SUP HCPCS C1713 127018 - SCREW BN 4.5MM 18MM IMHS ST HIP BOTH IP/OP $36.50 $27.01 $0.00 $29.20 $16.43 $16.43 $0.00 $0.00 $0.00 $7.61 $27.09 $27.09 $0.00 $0.00 $7.61 $0.00 $21.59 $21.59 $0.00 $18.25 $28.91 $29.20 $0.00 $0.00 $5.71 $0.00 $0.00 $5.81 $0.00 $0.00 $0.00 $0.00 $0.00 127020 SUP HCPCS C1713 127020 - SCREW BN 4.5MM 20MM IMHS ST HIP BOTH IP/OP $36.50 $27.01 $0.00 $29.20 $16.43 $16.43 $0.00 $0.00 $0.00 $7.61 $27.09 $27.09 $0.00 $0.00 $7.61 $0.00 $21.59 $21.59 $0.00 $18.25 $28.91 $29.20 $0.00 $0.00 $5.71 $0.00 $0.00 $5.81 $0.00 $0.00 $0.00 $0.00 $0.00 127026 SUP HCPCS C1713 127026 - SCREW BN 4.5MM 26MM IMHS ST HIP BOTH IP/OP $36.50 $27.01 $0.00 $29.20 $16.43 $16.43 $0.00 $0.00 $0.00 $7.61 $27.09 $27.09 $0.00 $0.00 $7.61 $0.00 $21.59 $21.59 $0.00 $18.25 $28.91 $29.20 $0.00 $0.00 $5.71 $0.00 $0.00 $5.81 $0.00 $0.00 $0.00 $0.00 $0.00 127032 SUP HCPCS C1713 127032 - SCREW BN 4.5MM 32MM IMHS ST HIP BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $17.55 $17.55 $0.00 $0.00 $0.00 $8.13 $28.95 $28.95 $0.00 $0.00 $8.13 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $6.10 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 127042 SUP HCPCS C1713 127042 - SCREW BN 4.5MM 8MM 42MM IMHS ST THRD HD CORT BOTH IP/OP $32.10 $23.75 $0.00 $25.68 $14.45 $14.45 $0.00 $0.00 $0.00 $6.69 $23.82 $23.82 $0.00 $0.00 $6.69 $0.00 $18.99 $18.99 $0.00 $16.05 $25.42 $25.68 $0.00 $0.00 $5.02 $0.00 $0.00 $5.11 $0.00 $0.00 $0.00 $0.00 $0.00 127056 SUP HCPCS C1713 127056 - SCREW BN 4.5MM 56MM IMHS ST HIP BOTH IP/OP $39.00 $28.86 $0.00 $31.20 $17.55 $17.55 $0.00 $0.00 $0.00 $8.13 $28.95 $28.95 $0.00 $0.00 $8.13 $0.00 $23.07 $23.07 $0.00 $19.50 $30.89 $31.20 $0.00 $0.00 $6.10 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $0.00 127060 SUP HCPCS C1713 127060 - SCREW BN 4.5MM 60MM IMHS ST SS HIP BOTH IP/OP $36.50 $27.01 $0.00 $29.20 $16.43 $16.43 $0.00 $0.00 $0.00 $7.61 $27.09 $27.09 $0.00 $0.00 $7.61 $0.00 $21.59 $21.59 $0.00 $18.25 $28.91 $29.20 $0.00 $0.00 $5.71 $0.00 $0.00 $5.81 $0.00 $0.00 $0.00 $0.00 $0.00 127062 SUP HCPCS C1713 127062 - SCREW BN 4.5MM 62MM ST CORT BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $18.81 $18.81 $0.00 $0.00 $0.00 $8.71 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $24.72 $24.72 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 127820 SUP HCPCS C1769 127820 - WIRE FX .85MM 9IN NS KRSH THRD DMD PT 1 END RND TY E SS ORTH BOTH IP/OP $164.70 $121.88 $0.00 $131.76 $89.43 $89.43 $0.00 $0.00 $0.00 $34.33 $122.24 $122.24 $0.00 $0.00 $34.32 $0.00 $97.42 $97.42 $0.00 $82.35 $130.44 $131.76 $0.00 $0.00 $25.78 $0.00 $0.00 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 127821 SUP HCPCS C1769 127821 - WIRE FX .035MM 9IN NS KRSH THRD DMD PT BOTH ENDS TY F SS BOTH IP/OP $164.70 $121.88 $0.00 $131.76 $89.43 $89.43 $0.00 $0.00 $0.00 $34.33 $122.24 $122.24 $0.00 $0.00 $34.32 $0.00 $97.42 $97.42 $0.00 $82.35 $130.44 $131.76 $0.00 $0.00 $25.78 $0.00 $0.00 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 127840 SUP HCPCS C1769 127840 - WIRE FX 1.1MM 9IN NS KRSH THRD DMD PT 1 END RND TY E SS ORTH BOTH IP/OP $164.70 $121.88 $0.00 $131.76 $89.43 $89.43 $0.00 $0.00 $0.00 $34.33 $122.24 $122.24 $0.00 $0.00 $34.32 $0.00 $97.42 $97.42 $0.00 $82.35 $130.44 $131.76 $0.00 $0.00 $25.78 $0.00 $0.00 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 127841 SUP HCPCS C1769 127841 - WIRE FX 1.1MM 9IN NS KRSH THRD DMD PT BOTH ENDS TY F SS BOTH IP/OP $164.70 $121.88 $0.00 $131.76 $89.43 $89.43 $0.00 $0.00 $0.00 $34.33 $122.24 $122.24 $0.00 $0.00 $34.32 $0.00 $97.42 $97.42 $0.00 $82.35 $130.44 $131.76 $0.00 $0.00 $25.78 $0.00 $0.00 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 127860 SUP HCPCS C1769 127860 - WIRE FX 1.5MM 9IN NS KRSH THRD DMD PT 1 END RND TY E SS ORTH BOTH IP/OP $164.70 $121.88 $0.00 $131.76 $89.43 $89.43 $0.00 $0.00 $0.00 $34.33 $122.24 $122.24 $0.00 $0.00 $34.32 $0.00 $97.42 $97.42 $0.00 $82.35 $130.44 $131.76 $0.00 $0.00 $25.78 $0.00 $0.00 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 127861 SUP HCPCS C1769 127861 - WIRE FX 1.5IN 9IN NS KRSH THRD F TY PNT SS ORTH BOTH IP/OP $164.70 $121.88 $0.00 $131.76 $89.43 $89.43 $0.00 $0.00 $0.00 $34.33 $122.24 $122.24 $0.00 $0.00 $34.32 $0.00 $97.42 $97.42 $0.00 $82.35 $130.44 $131.76 $0.00 $0.00 $25.78 $0.00 $0.00 $26.22 $0.00 $0.00 $0.00 $0.00 $0.00 127874 SUP HCPCS C1713 127874 - PIN FX 1.9MM 9IN NS STNM THRD TROC PNT BOTH ENDS TY A SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127877 SUP HCPCS C1713 127877 - PIN FX 1.9IN 9IN NS STNM SMTH TY D THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127880 SUP HCPCS C1713 127880 - PIN FX 5/64IN 9IN NS STNM THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127881 SUP HCPCS C1713 127881 - PIN FX 1.9IN 9IN NS STNM F PLN THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127894 SUP HCPCS C1713 127894 - PIN FX 2.3MM 9IN NS STNM THRD TROC PNT BOTH ENDS TY A SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127900 SUP HCPCS C1713 127900 - PIN FX 2.3IN 9IN NS STNM THRD TY E SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127901 SUP HCPCS C1713 127901 - PIN FX 2.3MM 9IN NS STNM 2 END DMD PT TY F SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127914 SUP HCPCS C1713 127914 - PIN FX 2.7MM 9IN NS STNM THRD TROC PNT BOTH ENDS TY A SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127917 SUP HCPCS C1713 127917 - PIN FX 2.7MM 9IN NS STNM THRD TROC PNT 1 END RND TY D SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127920 SUP HCPCS C1713 127920 - PIN FX 7/64IN 9IN NS STNM THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127921 SUP HCPCS C1713 127921 - PIN FX 2.7IN 9IN NS STNM F PLN THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127934 SUP HCPCS C1713 127934 - PIN FX 3.1MM 9IN NS STNM THRD TROC PNT BOTH ENDS TY A SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127937 SUP HCPCS C1713 127937 - PIN FX 3.1MM 9IN NS STNM THRD TROC PNT 1 END RND TY D SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127940 SUP HCPCS C1713 127940 - PIN FX 1/8IN 9IN NS STNM THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127941 SUP HCPCS C1713 127941 - PIN FX 3.1IN 9IN NS STNM F PLN THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127954 SUP HCPCS C1713 127954 - PIN FX 3.5MM 9IN NS STNM THRD TROC PNT BOTH ENDS TY A SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127957 SUP HCPCS C1713 127957 - PIN FX 3.5MM 9IN NS STNM THRD TROC PNT 1 END RND TY D SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127960 SUP HCPCS C1713 127960 - PIN FX 9/64IN 9IN NS STNM THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127961 SUP HCPCS C1713 127961 - PIN FX 3.5MM 9IN NS STNM THRD DMD PT BOTH ENDS TY F SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127974 SUP HCPCS C1713 127974 - PIN FX 3.9MM 9IN NS STNM THRD TROC PNT BOTH ENDS TY A SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127977 SUP HCPCS C1713 127977 - PIN FX 3.9MM 9IN NS STNM THRD TROC PNT 1 END RND TY D SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127980 SUP HCPCS C1713 127980 - PIN FX 5/32IN 9IN NS STNM THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127981 SUP HCPCS C1713 127981 - PIN FX 3.9IN 9IN NS STNM THRD TY F SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127994 SUP HCPCS C1713 127994 - PIN FX 4.7MM 9IN NS STNM THRD TROC PNT BOTH ENDS TY A SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 127997 SUP HCPCS C1713 127997 - PIN FX 4.7MM 9IN NS STNM THRD TROC PNT 1 END RND TY D SS BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 128000 SUP HCPCS C1713 128000 - PIN FX 3/16IN 9IN NS STNM THRD SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 128001 SUP HCPCS C1713 128001 - PIN FX 4.7MM 9IN NS STNM THRD DMD PT BOTH ENDS TY F SS ORTH BOTH IP/OP $170.40 $126.10 $0.00 $136.32 $76.68 $76.68 $0.00 $0.00 $0.00 $35.52 $126.47 $126.47 $0.00 $0.00 $35.51 $0.00 $100.79 $100.79 $0.00 $85.20 $134.96 $136.32 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 128005 SUP HCPCS C1769 128005 - WIRE FX .028MM 4MM NS KRSH SMTH TROC PNT BOTH END TY A SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128007 SUP HCPCS C1769 128007 - WIRE FX .76IN 4IN NS KRSH PLN PNT TY A SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128010 SUP HCPCS C1769 128010 - WIRE FX .035IN 4IN STRL KRSH PLN 2 PNT TY A TROC SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128011 SUP HCPCS C1769 128011 - WIRE FX .85MM 4IN NS KRSH SMTH TROC PNT 1 END RND TY D SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128012 SUP HCPCS C1769 128012 - WIRE FX .035IN 9IN NS KRSH 1 DMD PT SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128017 SUP HCPCS C1769 128017 - WIRE FX .85IN 4IN NS KRSH PLN PNT TY A SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128020 SUP HCPCS C1769 128020 - WIRE FX .85MM 5IN NS KRSH SMTH DMD PT BOTH ENDS TY F SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128021 SUP HCPCS C1769 128021 - WIRE FX .035IN 7IN NS KRSH PLN PNT TY F SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128022 SUP HCPCS C1769 128022 - WIRE FX .85IN 9IN NS KRSH PLN PNT TY F SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128030 SUP HCPCS C1769 128030 - WIRE FX .045MM 4MM STRL KRSH TROC PNT BOTH END TY A SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128031 SUP HCPCS C1769 128031 - WIRE FX 1.1MM 4IN NS KRSH SMTH TROC PNT 1 END RND TY D SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128032 SUP HCPCS C1769 128032 - WIRE FX .045IN 9IN NS KRSH PLN PNT TY E SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128034 SUP HCPCS C1769 128034 - WIRE FX 1.1MM 12IN NS KRSH SMTH DMD PT 1 END RND TY E SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128037 SUP HCPCS C1769 128037 - WIRE FX .045IN 4IN NS KRSH SMTH TY A SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128040 SUP HCPCS C1769 128040 - WIRE FX 1.1MM 5IN NS KRSH SMTH DMD PT BOTH ENDS TY F SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128041 SUP HCPCS C1769 128041 - WIRE FX .045IN 7IN NS KRSH PLN PNT TY F SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128042 SUP HCPCS C1769 128042 - WIRE FX .045IN 9IN NS KRSH DMD PT 2 END SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128044 SUP HCPCS C1769 128044 - WIRE FX 1.1MM 12IN NS KRSH SMTH DMD PT BOTH ENDS TY F SS BOTH IP/OP $49.40 $36.56 $0.00 $39.52 $26.82 $26.82 $0.00 $0.00 $0.00 $10.30 $36.66 $36.66 $0.00 $0.00 $10.29 $0.00 $29.22 $29.22 $0.00 $24.70 $39.12 $39.52 $0.00 $0.00 $7.73 $0.00 $0.00 $7.86 $0.00 $0.00 $0.00 $0.00 $0.00 128050 SUP HCPCS C1769 128050 - WIRE FX .062IN 4IN NS KRSH PLN 2 PNT TY A TROC SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128051 SUP HCPCS C1769 128051 - WIRE FX 1.5MM 4IN NS KRSH SMTH TROC PNT 1 END RND TY D SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128052 SUP HCPCS C1769 128052 - WIRE FX .062IN 9IN NS KRSH PLN PNT TY E SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128054 SUP HCPCS C1769 128054 - WIRE FX 1.5MM 12IN NS KRSH SMTH DMD PT 1 END RND TY E SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128057 SUP HCPCS C1769 128057 - WIRE FX 1.5IN 4IN NS KRSH PLN PNT TY A SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128060 SUP HCPCS C1769 128060 - WIRE FX 1.5MM 5IN NS KRSH SMTH DMD PT BOTH ENDS TY F SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128061 SUP HCPCS C1769 128061 - WIRE FX .062IN 7IN NS KRSH PLN PNT TY F SS ORTH BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128062 SUP HCPCS C1769 128062 - WIRE FX 1.5IN 9IN NS KRSH PLN TY F SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128064 SUP HCPCS C1769 128064 - WIRE FX 1.5MM 12IN NS KRSH SMTH DMD PT BOTH ENDS TY F SS BOTH IP/OP $78.70 $58.24 $0.00 $62.96 $42.73 $42.73 $0.00 $0.00 $0.00 $16.40 $58.41 $58.41 $0.00 $0.00 $16.40 $0.00 $46.55 $46.55 $0.00 $39.35 $62.33 $62.96 $0.00 $0.00 $12.32 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $0.00 128076 SUP HCPCS C1713 128076 - PIN FX 1.9IN 9IN NS STNM 2 END DMD PT PLN TY A SS ORTH BOTH IP/OP $87.40 $64.68 $0.00 $69.92 $39.33 $39.33 $0.00 $0.00 $0.00 $18.22 $64.87 $64.87 $0.00 $0.00 $18.21 $0.00 $51.70 $51.70 $0.00 $43.70 $69.22 $69.92 $0.00 $0.00 $13.68 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 128077 SUP HCPCS C1713 128077 - PIN FX 1.9MM 9IN NS STNM SMTH TROC PNT 1 END CHK TY B SS BOTH IP/OP $87.40 $64.68 $0.00 $69.92 $39.33 $39.33 $0.00 $0.00 $0.00 $18.22 $64.87 $64.87 $0.00 $0.00 $18.21 $0.00 $51.70 $51.70 $0.00 $43.70 $69.22 $69.92 $0.00 $0.00 $13.68 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 128078 SUP HCPCS C1713 128078 - PIN FX 1.9MM 9IN NS STNM SMTH DMD PT 1 END CHK TY C SS ORTH BOTH IP/OP $87.40 $64.68 $0.00 $69.92 $39.33 $39.33 $0.00 $0.00 $0.00 $18.22 $64.87 $64.87 $0.00 $0.00 $18.21 $0.00 $51.70 $51.70 $0.00 $43.70 $69.22 $69.92 $0.00 $0.00 $13.68 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 128079 SUP HCPCS C1713 128079 - PIN FX 1.9MM 9IN NS STNM SMTH TROC PNT 1 END RND TY D SS BOTH IP/OP $87.40 $64.68 $0.00 $69.92 $39.33 $39.33 $0.00 $0.00 $0.00 $18.22 $64.87 $64.87 $0.00 $0.00 $18.21 $0.00 $51.70 $51.70 $0.00 $43.70 $69.22 $69.92 $0.00 $0.00 $13.68 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 128080 SUP HCPCS C1713 128080 - PIN FX 1.9IN 9IN NS STNM SMTH TY E SS ORTH BOTH IP/OP $87.40 $64.68 $0.00 $69.92 $39.33 $39.33 $0.00 $0.00 $0.00 $18.22 $64.87 $64.87 $0.00 $0.00 $18.21 $0.00 $51.70 $51.70 $0.00 $43.70 $69.22 $69.92 $0.00 $0.00 $13.68 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 128081 SUP HCPCS C1713 128081 - PIN FX 1.9IN 9IN NS STNM 2 END DMD PT TY F SS BOTH IP/OP $87.40 $64.68 $0.00 $69.92 $39.33 $39.33 $0.00 $0.00 $0.00 $18.22 $64.87 $64.87 $0.00 $0.00 $18.21 $0.00 $51.70 $51.70 $0.00 $43.70 $69.22 $69.92 $0.00 $0.00 $13.68 $0.00 $0.00 $13.91 $0.00 $0.00 $0.00 $0.00 $0.00 128086 SUP HCPCS C1713 128086 - PIN FX 2.3IN 9IN NS STNM A PLN SS ORTH BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128087 SUP HCPCS C1713 128087 - PIN FX 2.3MM 9IN NS STNM SMTH TROC PNT 1 END CHK TY B SS BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128088 SUP HCPCS C1713 128088 - PIN FX 2.3MM 9IN NS STNM SMTH DMD PT 1 END CHK TY C SS ORTH BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128089 SUP HCPCS C1713 128089 - PIN FX 3/32IN 9IN NS STNM TY D SS ORTH BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128090 SUP HCPCS C1713 128090 - PIN FX 2.3IN 9IN NS STNM SMTH TY E SS ORTH BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128091 SUP HCPCS C1713 128091 - PIN FX 2.3MM 9IN NS STNM 2 END DMD PT SMTH TY F SS BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128097 SUP HCPCS C1713 128097 - PIN FX 2.7MM 9IN NS STNM SMTH TROC PNT 1 END CHK TY B SS BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128098 SUP HCPCS C1713 128098 - PIN FX 2.7MM 9IN NS STNM SMTH DMD PT 1 END CHK TY C SS ORTH BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128099 SUP HCPCS C1713 128099 - PIN FX 2.7MM 9IN NS STNM SMTH TROC PNT 1 END RND TY D SS BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128100 SUP HCPCS C1713 128100 - PIN FX 2.7IN 9IN NS STNM SMTH DMD PT RND END TY E SS ORTH BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128101 SUP HCPCS C1713 128101 - PIN FX 7/64IN 9IN NS STNM SMTH DMD PT BOTH ENDS TY F SS BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128106 SUP HCPCS C1713 128106 - PIN FX 3.1IN 9IN NS STNM A PLN SS ORTH BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $42.75 $42.75 $0.00 $0.00 $0.00 $19.80 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $56.19 $56.19 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 128107 SUP HCPCS C1713 128107 - PIN FX 3.1MM 9IN NS STNM SMTH TROC PNT 1 END CHK TY B SS BOTH IP/OP $102.70 $76.00 $0.00 $82.16 $46.22 $46.22 $0.00 $0.00 $0.00 $21.41 $76.22 $76.22 $0.00 $0.00 $21.40 $0.00 $60.75 $60.75 $0.00 $51.35 $81.34 $82.16 $0.00 $0.00 $16.07 $0.00 $0.00 $16.35 $0.00 $0.00 $0.00 $0.00 $0.00 128108 SUP HCPCS C1713 128108 - PIN FX 3.1MM 9IN NS STNM SMTH DMD PT 1 END CHK TY C SS ORTH BOTH IP/OP $102.70 $76.00 $0.00 $82.16 $46.22 $46.22 $0.00 $0.00 $0.00 $21.41 $76.22 $76.22 $0.00 $0.00 $21.40 $0.00 $60.75 $60.75 $0.00 $51.35 $81.34 $82.16 $0.00 $0.00 $16.07 $0.00 $0.00 $16.35 $0.00 $0.00 $0.00 $0.00 $0.00 128109 SUP HCPCS C1713 128109 - PIN FX 3.1IN 9IN NS STNM PLN PNT TY D TROC RND END SS BOTH IP/OP $102.70 $76.00 $0.00 $82.16 $46.22 $46.22 $0.00 $0.00 $0.00 $21.41 $76.22 $76.22 $0.00 $0.00 $21.40 $0.00 $60.75 $60.75 $0.00 $51.35 $81.34 $82.16 $0.00 $0.00 $16.07 $0.00 $0.00 $16.35 $0.00 $0.00 $0.00 $0.00 $0.00 128110 SUP HCPCS C1713 128110 - PIN FX 3.1IN 9IN NS STNM SMTH TY E SS ORTH BOTH IP/OP $102.70 $76.00 $0.00 $82.16 $46.22 $46.22 $0.00 $0.00 $0.00 $21.41 $76.22 $76.22 $0.00 $0.00 $21.40 $0.00 $60.75 $60.75 $0.00 $51.35 $81.34 $82.16 $0.00 $0.00 $16.07 $0.00 $0.00 $16.35 $0.00 $0.00 $0.00 $0.00 $0.00 128111 SUP HCPCS C1713 128111 - PIN FX 3.1IN 9IN NS STNM F PLN SS BOTH IP/OP $102.70 $76.00 $0.00 $82.16 $46.22 $46.22 $0.00 $0.00 $0.00 $21.41 $76.22 $76.22 $0.00 $0.00 $21.40 $0.00 $60.75 $60.75 $0.00 $51.35 $81.34 $82.16 $0.00 $0.00 $16.07 $0.00 $0.00 $16.35 $0.00 $0.00 $0.00 $0.00 $0.00 128116 SUP HCPCS C1713 128116 - PIN FX 3.5IN 9IN NS STNM A PLN SS ORTH BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $49.95 $49.95 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 128117 SUP HCPCS C1713 128117 - PIN FX 3.5IN 9IN NS STNM PLN PNT TY A SS BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $49.95 $49.95 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 128118 SUP HCPCS C1713 128118 - PIN FX 3.5MM 9IN NS STNM SMTH DMD PT 1 END CHK TY C SS ORTH BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $49.95 $49.95 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 128119 SUP HCPCS C1713 128119 - PIN FX 3.5IN 9IN NS STNM PLN PNT TY D TROC RND END SS BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $49.95 $49.95 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 128120 SUP HCPCS C1713 128120 - PIN FX 3.5MM 9IN NS STNM SMTH DMD PT 1 END RND TY E SS ORTH BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $49.95 $49.95 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 128121 SUP HCPCS C1713 128121 - PIN FX 3.5IN 9IN NS STNM F PLN SS BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $49.95 $49.95 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 128126 SUP HCPCS C1713 128126 - PIN FX 3.9IN 9IN NS STNM A PLN SS ORTH BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128127 SUP HCPCS C1713 128127 - PIN FX 3.9MM 9IN NS STNM SMTH TROC PNT 1 END CHK TY B SS BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128128 SUP HCPCS C1713 128128 - PIN FX 3.9MM 9IN NS STNM SMTH DMD PT 1 END CHK TY C SS ORTH BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128129 SUP HCPCS C1713 128129 - PIN FX 5/32IN 9IN NS STNM TY D SS ORTH BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128130 SUP HCPCS C1713 128130 - PIN FX 3.9MM 9IN NS STNM SMTH DMD PT 1 END RND TY E SS ORTH BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128131 SUP HCPCS C1713 128131 - PIN FX 3.9IN 9IN NS STNM F PLN SS BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128136 SUP HCPCS C1713 128136 - PIN FX 4.7IN 9IN NS STNM PLN TY A SS ORTH BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128137 SUP HCPCS C1713 128137 - PIN FX 4.7IN 9IN NS STNM SMTH TROC PNT 1 END TY B SS ORTH BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128138 SUP HCPCS C1713 128138 - PIN FX 4.7MM 9IN NS STNM SMTH DMD PT 1 END CHK TY C SS ORTH BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128139 SUP HCPCS C1713 128139 - PIN FX 4.7MM 9IN NS STNM SMTH TROC PNT 1 END RND TY D SS BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128140 SUP HCPCS C1713 128140 - PIN FX 4.7IN 9IN NS STNM SMTH DMD PT BOTH ENDS TY E SS ORTH BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128141 SUP HCPCS C1713 128141 - PIN FX 4.7IN 9IN NS STNM F PLN SS BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128146 SUP HCPCS C1713 128146 - PIN FX 1.14MM 5IN SWNSN SS FNGR XTRNFX SYS BOTH IP/OP $76.00 $56.24 $0.00 $60.80 $34.20 $34.20 $0.00 $0.00 $0.00 $15.84 $56.41 $56.41 $0.00 $0.00 $15.84 $0.00 $44.95 $44.95 $0.00 $38.00 $60.19 $60.80 $0.00 $0.00 $11.89 $0.00 $0.00 $12.10 $0.00 $0.00 $0.00 $0.00 $0.00 128162 SUP HCPCS C1713 128162 - PIN FX 5/32IN 11.5IN THRD ORTH K-DONK BOTH IP/OP $452.20 $334.63 $0.00 $361.76 $203.49 $203.49 $0.00 $0.00 $0.00 $94.25 $335.62 $335.62 $0.00 $0.00 $94.24 $0.00 $267.48 $267.48 $0.00 $226.10 $358.14 $361.76 $0.00 $0.00 $70.77 $0.00 $0.00 $71.99 $0.00 $0.00 $0.00 $0.00 $0.00 128175 SUP HCPCS C1713 128175 - PIN FX TROC PNT 1 END ORTH K-DONK BOTH IP/OP $452.20 $334.63 $0.00 $361.76 $203.49 $203.49 $0.00 $0.00 $0.00 $94.25 $335.62 $335.62 $0.00 $0.00 $94.24 $0.00 $267.48 $267.48 $0.00 $226.10 $358.14 $361.76 $0.00 $0.00 $70.77 $0.00 $0.00 $71.99 $0.00 $0.00 $0.00 $0.00 $0.00 128177 SUP HCPCS C1713 128177 - PIN FX 7/64IN 9IN TROC PNT 1 END ORTH K-DONK BOTH IP/OP $598.40 $442.82 $0.00 $478.72 $269.28 $269.28 $0.00 $0.00 $0.00 $124.72 $444.13 $444.13 $0.00 $0.00 $124.71 $0.00 $353.95 $353.95 $0.00 $299.20 $473.93 $478.72 $0.00 $0.00 $93.65 $0.00 $0.00 $95.27 $0.00 $0.00 $0.00 $0.00 $0.00 128307 SUP HCPCS C1713 128307 - PIN FX .15IN 2.25IN KNWL SS ORTH BOTH IP/OP $418.95 $310.02 $0.00 $335.16 $188.53 $188.53 $0.00 $0.00 $0.00 $87.32 $310.94 $310.94 $0.00 $0.00 $87.31 $0.00 $247.81 $247.81 $0.00 $209.48 $331.81 $335.16 $0.00 $0.00 $65.57 $0.00 $0.00 $66.70 $0.00 $0.00 $0.00 $0.00 $0.00 128310 SUP HCPCS C1713 128310 - PIN FX 5/32IN 3IN KNWL SS BOTH IP/OP $418.95 $310.02 $0.00 $335.16 $188.53 $188.53 $0.00 $0.00 $0.00 $87.32 $310.94 $310.94 $0.00 $0.00 $87.31 $0.00 $247.81 $247.81 $0.00 $209.48 $331.81 $335.16 $0.00 $0.00 $65.57 $0.00 $0.00 $66.70 $0.00 $0.00 $0.00 $0.00 $0.00 128314 SUP HCPCS C1713 128314 - PIN FX 5/32IN 4IN KNWL SS BOTH IP/OP $418.95 $310.02 $0.00 $335.16 $188.53 $188.53 $0.00 $0.00 $0.00 $87.32 $310.94 $310.94 $0.00 $0.00 $87.31 $0.00 $247.81 $247.81 $0.00 $209.48 $331.81 $335.16 $0.00 $0.00 $65.57 $0.00 $0.00 $66.70 $0.00 $0.00 $0.00 $0.00 $0.00 128408 SUP HCPCS C1713 128408 - PIN FX 5/32IN 6IN 1.5IN HAGIE ORTH BOTH IP/OP $319.20 $236.21 $0.00 $255.36 $143.64 $143.64 $0.00 $0.00 $0.00 $66.53 $236.91 $236.91 $0.00 $0.00 $66.52 $0.00 $188.81 $188.81 $0.00 $159.60 $252.81 $255.36 $0.00 $0.00 $49.95 $0.00 $0.00 $50.82 $0.00 $0.00 $0.00 $0.00 $0.00 128416 SUP HCPCS C1713 128416 - PIN FX 3/16IN 6IN 1.25IN HAGIE ORTH BOTH IP/OP $319.20 $236.21 $0.00 $255.36 $143.64 $143.64 $0.00 $0.00 $0.00 $66.53 $236.91 $236.91 $0.00 $0.00 $66.52 $0.00 $188.81 $188.81 $0.00 $159.60 $252.81 $255.36 $0.00 $0.00 $49.95 $0.00 $0.00 $50.82 $0.00 $0.00 $0.00 $0.00 $0.00 128418 SUP HCPCS C1713 128418 - PIN FX 3/16IN 6IN 1.5IN HAGIE ORTH BOTH IP/OP $319.20 $236.21 $0.00 $255.36 $143.64 $143.64 $0.00 $0.00 $0.00 $66.53 $236.91 $236.91 $0.00 $0.00 $66.52 $0.00 $188.81 $188.81 $0.00 $159.60 $252.81 $255.36 $0.00 $0.00 $49.95 $0.00 $0.00 $50.82 $0.00 $0.00 $0.00 $0.00 $0.00 128436 SUP HCPCS C1713 128436 - PIN FX .25IN 6IN 1.25IN HAGIE ORTH BOTH IP/OP $319.20 $236.21 $0.00 $255.36 $143.64 $143.64 $0.00 $0.00 $0.00 $66.53 $236.91 $236.91 $0.00 $0.00 $66.52 $0.00 $188.81 $188.81 $0.00 $159.60 $252.81 $255.36 $0.00 $0.00 $49.95 $0.00 $0.00 $50.82 $0.00 $0.00 $0.00 $0.00 $0.00 128518 SUP HCPCS C1713 128518 - PIN FX .89MM 2IN STRL INSTR ORTH XTRNFX SYS BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128520 SUP HCPCS C1713 128520 - PIN FX 1.1MM 2IN STRL INSTR ORTH XTRNFX SYS BOTH IP/OP $102.70 $76.00 $0.00 $82.16 $46.22 $46.22 $0.00 $0.00 $0.00 $21.41 $76.22 $76.22 $0.00 $0.00 $21.40 $0.00 $60.75 $60.75 $0.00 $51.35 $81.34 $82.16 $0.00 $0.00 $16.07 $0.00 $0.00 $16.35 $0.00 $0.00 $0.00 $0.00 $0.00 128522 SUP HCPCS C1713 128522 - PIN FX 1.5MM 2IN STRL INSTR ORTH XTRNFX SYS BOTH IP/OP $124.00 $91.76 $0.00 $99.20 $55.80 $55.80 $0.00 $0.00 $0.00 $25.84 $92.03 $92.03 $0.00 $0.00 $25.84 $0.00 $73.35 $73.35 $0.00 $62.00 $98.21 $99.20 $0.00 $0.00 $19.41 $0.00 $0.00 $19.74 $0.00 $0.00 $0.00 $0.00 $0.00 128551 SUP HCPCS C1713 128551 - PIN FX .062IN 5.8IN SML SS ORTH BOTH IP/OP $149.00 $110.26 $0.00 $119.20 $67.05 $67.05 $0.00 $0.00 $0.00 $31.06 $110.59 $110.59 $0.00 $0.00 $31.05 $0.00 $88.13 $88.13 $0.00 $74.50 $118.01 $119.20 $0.00 $0.00 $23.32 $0.00 $0.00 $23.72 $0.00 $0.00 $0.00 $0.00 $0.00 128552 SUP HCPCS C1713 128552 - PIN FX .062IN 7.8IN SML SS ORTH BOTH IP/OP $119.00 $88.06 $0.00 $95.20 $53.55 $53.55 $0.00 $0.00 $0.00 $24.80 $88.32 $88.32 $0.00 $0.00 $24.80 $0.00 $70.39 $70.39 $0.00 $59.50 $94.25 $95.20 $0.00 $0.00 $18.62 $0.00 $0.00 $18.94 $0.00 $0.00 $0.00 $0.00 $0.00 128553 SUP HCPCS C1713 128553 - PIN FX .062IN 1IN SML SS ORTH BOTH IP/OP $119.00 $88.06 $0.00 $95.20 $53.55 $53.55 $0.00 $0.00 $0.00 $24.80 $88.32 $88.32 $0.00 $0.00 $24.80 $0.00 $70.39 $70.39 $0.00 $59.50 $94.25 $95.20 $0.00 $0.00 $18.62 $0.00 $0.00 $18.94 $0.00 $0.00 $0.00 $0.00 $0.00 128555 SUP HCPCS C1713 128555 - PIN FX .062IN 1.25IN SML SS ORTH BOTH IP/OP $119.00 $88.06 $0.00 $95.20 $53.55 $53.55 $0.00 $0.00 $0.00 $24.80 $88.32 $88.32 $0.00 $0.00 $24.80 $0.00 $70.39 $70.39 $0.00 $59.50 $94.25 $95.20 $0.00 $0.00 $18.62 $0.00 $0.00 $18.94 $0.00 $0.00 $0.00 $0.00 $0.00 128607 SUP HCPCS C1713 128607 - STAPLE BN 12MM 12MM KRCKW HTO OFST COCR TIB LAT BLDE BOTH IP/OP $852.60 $630.92 $0.00 $682.08 $383.67 $383.67 $0.00 $0.00 $0.00 $177.70 $632.80 $632.80 $0.00 $0.00 $177.68 $0.00 $504.31 $504.31 $0.00 $426.30 $675.26 $682.08 $0.00 $0.00 $133.43 $0.00 $0.00 $135.73 $0.00 $0.00 $0.00 $0.00 $0.00 128608 SUP HCPCS C1713 128608 - STAPLE BN 14MM 14MM KRCKW HTO OFST COCR TIB LAT BLDE BOTH IP/OP $852.60 $630.92 $0.00 $682.08 $383.67 $383.67 $0.00 $0.00 $0.00 $177.70 $632.80 $632.80 $0.00 $0.00 $177.68 $0.00 $504.31 $504.31 $0.00 $426.30 $675.26 $682.08 $0.00 $0.00 $133.43 $0.00 $0.00 $135.73 $0.00 $0.00 $0.00 $0.00 $0.00 128609 SUP HCPCS C1713 128609 - STAPLE BN 16MM 16MM KRCKW HTO OFST COCR TIB LAT BLDE BOTH IP/OP $852.60 $630.92 $0.00 $682.08 $383.67 $383.67 $0.00 $0.00 $0.00 $177.70 $632.80 $632.80 $0.00 $0.00 $177.68 $0.00 $504.31 $504.31 $0.00 $426.30 $675.26 $682.08 $0.00 $0.00 $133.43 $0.00 $0.00 $135.73 $0.00 $0.00 $0.00 $0.00 $0.00 128610 SUP HCPCS C1713 128610 - STAPLE BN 25X25MM BLK KRCKW HTO COCR TIB MDL MEDAL BOTH IP/OP $852.60 $630.92 $0.00 $682.08 $383.67 $383.67 $0.00 $0.00 $0.00 $177.70 $632.80 $632.80 $0.00 $0.00 $177.68 $0.00 $504.31 $504.31 $0.00 $426.30 $675.26 $682.08 $0.00 $0.00 $133.43 $0.00 $0.00 $135.73 $0.00 $0.00 $0.00 $0.00 $0.00 128673 SUP HCPCS C1713 128673 - STAPLE BN 5MM OFST 26.5X23MM FX COCR OSTM BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 128674 SUP HCPCS C1713 128674 - STAPLE BN 10MM 21.5X23MM FX OFST COCR ORTH OSTM BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 128675 SUP HCPCS C1713 128675 - STAPLE BN 14MM 17.5X23MM FX COCR ORTH OSTM BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 128690 SUP HCPCS C1713 128690 - STAPLE BN XS 23.22X6.35MM SPK FX COCR BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128691 SUP HCPCS C1713 128691 - STAPLE BN XS 23.22X6.35MM WO SPK COCR ORTH BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128692 SUP HCPCS C1713 128692 - STAPLE BN SM SPK 23X12MM FX COCR BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128693 SUP HCPCS C1713 128693 - STAPLE BN SM REG 23.22X7.94MM FX COCR OSTM BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128695 SUP HCPCS C1713 128695 - STAPLE BN MED 23.22X11.11MM SPK COCR ORTH BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128696 SUP HCPCS C1713 128696 - STAPLE BN LG REG 23.22X14.29MM SPK COCR ORTH OSTM BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128697 SUP HCPCS C1713 128697 - STAPLE BN LG 23.22X14.29MM FX COCR OSTM BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128698 SUP HCPCS C1713 128698 - STAPLE BN SM 16X13MM TBL FX COCR BOTH IP/OP $655.20 $484.85 $0.00 $524.16 $294.84 $294.84 $0.00 $0.00 $0.00 $136.56 $486.29 $486.29 $0.00 $0.00 $136.54 $0.00 $387.55 $387.55 $0.00 $327.60 $518.92 $524.16 $0.00 $0.00 $102.54 $0.00 $0.00 $104.31 $0.00 $0.00 $0.00 $0.00 $0.00 128699 SUP HCPCS C1713 128699 - STAPLE BN 16 MED 22X16MM TBL FX RTRCT COCR ORTH BOTH IP/OP $655.20 $484.85 $0.00 $524.16 $294.84 $294.84 $0.00 $0.00 $0.00 $136.56 $486.29 $486.29 $0.00 $0.00 $136.54 $0.00 $387.55 $387.55 $0.00 $327.60 $518.92 $524.16 $0.00 $0.00 $102.54 $0.00 $0.00 $104.31 $0.00 $0.00 $0.00 $0.00 $0.00 128720 SUP HCPCS C1713 128720 - STAPLE BN XS 15X6.35MM FX SPK SHRT LG COCR BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128721 SUP HCPCS C1713 128721 - STAPLE BN XS 15X6.35MM WO SPK SHRT LG COCR ORTH BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128722 SUP HCPCS C1713 128722 - STAPLE BN SM 15X7.94MM SPK SHRT LG FX COCR BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128723 SUP HCPCS C1713 128723 - STAPLE BN SM 15X7.94MM WO SPK SHRT LG COCR ORTH BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128724 SUP HCPCS C1713 128724 - STAPLE BN MED 15X11.11MM SPK SHRT LG FX COCR BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128725 SUP HCPCS C1713 128725 - STAPLE BN MED 15X11.11MM WO SPK SHRT LG COCR ORTH BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128726 SUP HCPCS C1713 128726 - STAPLE BN LG 15X14.29MM SPK SHRT LG FX COCR BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 128727 SUP HCPCS C1713 128727 - STAPLE BN LG 15X14.29MM WO SPK SHRT LG COCR ORTH BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 131710 SUP HCPCS Q4130 131710 - DRESSING BIO 48X3IN EZ DERM MSH PRFR PRCN XENOGRAFT BOTH IP/OP $890.29 $658.81 $0.00 $779.16 $0.00 $0.00 $0.00 $0.00 $0.00 $185.56 $660.77 $660.77 $0.00 $0.00 $185.54 $0.00 $526.61 $526.61 $0.00 $486.97 $771.37 $779.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 140100 SUP Custom 27203010 KIT IMMUN TST AGLT SYS CRPTCOC NFRMNS AG LTX BOTH IP/OP $950.70 $703.52 $0.00 $760.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $475.35 $752.95 $760.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 143080 SUP HCPCS C1713 143080 - PIN FX 3.2MM 80MM STRL BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 143090 SUP HCPCS C1713 143090 - PIN FX 3.2MM 90MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 143100 SUP HCPCS C1713 143100 - PIN FX 3.2MM 100MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 143110 SUP HCPCS C1713 143110 - PIN FX 3.2MM 110MM STRL BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 143120 SUP HCPCS C1713 143120 - PIN FX 3.2MM 120MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 "$1,082.34" $0.00 $0.00 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $676.47 $239.58 "$1,082.34" $0.00 $0.00 $0.00 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 143130 SUP HCPCS C1713 143130 - PIN FX 3.2MM 130MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 143140 SUP HCPCS C1713 143140 - PIN FX 3.2MM 140MM STRL BOTH IP/OP $302.50 $223.85 $0.00 $239.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.33 $16.33 $0.00 $0.00 $4.58 $0.00 $178.93 $178.93 $0.00 $11.00 $239.58 $17.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 144080 SUP HCPCS C1713 144080 - PIN FX 4MM 80MM NS KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144090 SUP HCPCS C1713 144090 - PIN FX 4MM 90MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144100 SUP HCPCS C1713 144100 - PIN FX 4MM 100MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144110 SUP HCPCS C1713 144110 - PIN FX 4MM 110MM STRL BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144120 SUP HCPCS C1713 144120 - PIN FX 4MM 1200MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144130 SUP HCPCS C1713 144130 - PIN FX 4MM 130MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144140 SUP HCPCS C1713 144140 - PIN FX 4MM 140MM STRL KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144150 SUP HCPCS C1713 144150 - PIN FX 4MM 150MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144160 SUP HCPCS C1713 144160 - PIN FX 4MM 160MM STRL PRM KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 144170 SUP HCPCS C1713 144170 - PIN FX 4MM 170MM STRL KN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 151435 SUP Custom 27203010 RETAINER TBGRP A 33FTX1.5IN NTR ELAST TBLR DRSG LTX BOTH IP/OP $40.13 $29.70 $0.00 $32.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.06 $31.78 $32.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151436 SUP Custom 27203010 151436 - RETAINER TBGRP B 33FTX2.5IN NTR ELAST TBLR DRSG LF BOTH IP/OP $52.92 $39.16 $0.00 $42.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.27 $39.27 $0.00 $0.00 $11.03 $0.00 $0.00 $0.00 $0.00 $26.46 $41.91 $42.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151437 SUP Custom 27203010 151437 - RETAINER DRSG D 33FTX3IN NTR LF TBGRP ELC TBLR BOTH IP/OP $73.13 $54.12 $0.00 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.28 $54.28 $0.00 $0.00 $15.24 $0.00 $0.00 $0.00 $0.00 $36.57 $57.92 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151440 SUP Custom 27203010 151440 - RETAINER TBGRP J 33FTX6.75IN NTR ELAST TBLR DRSG LTX BOTH IP/OP $55.61 $41.15 $0.00 $44.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.27 $41.27 $0.00 $0.00 $11.59 $0.00 $0.00 $0.00 $0.00 $27.80 $44.04 $44.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151442 SUP Custom 27203010 151442 - RTNR TBGRP LG 10MR NTR ELAST TBLR DRSG LATEX BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.03 $449.03 $0.00 $0.00 $126.08 $0.00 $0.00 $0.00 $0.00 $302.50 $479.16 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 160821 SUP Custom 27203010 160821 - BURR SURG MICRO 14 FLUTE BARREL .24IN 2.13IN .41IN STAINLESS BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 163663 SUP HCPCS C1776 163663 - HEAD FEMORAL +3MM 28MM MODULAR TYPE 1 COCR HIP BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 165808 SUP Custom 27203010 165808 - CATHETER URETHRAL 8FR 2 WAY FOLEY LATEX FREE BARD SILICONE 3 BOTH IP/OP $8.13 $6.02 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.03 $6.03 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $4.06 $6.44 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 165810 SUP Custom 27203010 165810 - CATHETER URETHRAL 10FR 2 WAY FOLEY LATEX FREE BARD SILICONE BOTH IP/OP $8.13 $6.02 $0.00 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.03 $6.03 $0.00 $0.00 $1.69 $0.00 $0.00 $0.00 $0.00 $4.06 $6.44 $6.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 165814 SUP Custom 27203010 165814 - CATHETER URTH 14FR 5CC STRL LF BARD 2W FL BLN UNCOAT SIL BOTH IP/OP $7.83 $5.79 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.81 $5.81 $0.00 $0.00 $1.63 $0.00 $0.00 $0.00 $0.00 $3.91 $6.20 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 165816 SUP Custom 27203010 165816 - CATHETER URTH 16FR 5CC STRL LF BARD 2W FL BLN UNCOAT SIL BOTH IP/OP $7.83 $5.79 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.81 $5.81 $0.00 $0.00 $1.63 $0.00 $0.00 $0.00 $0.00 $3.91 $6.20 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 165818 SUP Custom 27203010 165818 - CATHETER URTH 18FR 5CC STRL LF BARD 2W FL BLN UNCOAT SIL BOTH IP/OP $7.83 $5.79 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.81 $5.81 $0.00 $0.00 $1.63 $0.00 $0.00 $0.00 $0.00 $3.91 $6.20 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 165822 SUP Custom 27203010 165822 - CATHETER URETHRAL 22FR 2 WAY FOLEY LATEX FREE BARD SILICONE BOTH IP/OP $7.83 $5.79 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.81 $5.81 $0.00 $0.00 $1.63 $0.00 $0.00 $0.00 $0.00 $3.91 $6.20 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 170057 SUP Custom 27803010 170057 - RELOAD SUT AS 2-0 ES-9 48IN UD E STCH PLSRB 1 STCH LACTOMER BOTH IP/OP $620.10 $458.87 $0.00 $496.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $460.24 $460.24 $0.00 $0.00 $129.23 $0.00 $0.00 $0.00 $0.00 $310.05 $491.12 $496.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 173016 SUP Custom 27203010 173016 - DEVICE SUTURING 10MM 15IN PUSH BUTTON GRIP HANDLE LATEX FREE BOTH IP/OP $284.40 $210.46 $0.00 $230.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.08 $211.08 $0.00 $0.00 $59.27 $0.00 $0.00 $0.00 $0.00 $144.33 $228.63 $230.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 173019 SUP Custom 27203010 173019 - RETRACTOR LAPSCOP STANDARD LENGTH 5MM 45CM TROCAR ADAPTER BOTH IP/OP $50.43 $37.32 $0.00 $40.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.43 $37.43 $0.00 $0.00 $10.51 $0.00 $0.00 $0.00 $0.00 $25.59 $40.53 $40.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 174001 SUP Custom 27203010 174001 - CLAMP LAPSCP STD 10MM 31CM GRN STRL E-BBCK ON OFF SWH RCHT BOTH IP/OP $176.91 $130.91 $0.00 $141.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.46 $140.11 $141.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 174006 SUP Custom 27203010 174006 - STAPLER INTERNAL 35.5X5MM 30 HELICAL FASTENER LATEX FREE BOTH IP/OP $584.95 $432.86 $0.00 $474.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $434.15 $434.15 $0.00 $0.00 $121.90 $0.00 $0.00 $0.00 $0.00 $296.86 $470.23 $474.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 175424 SUP HCPCS C1768 175424 - GRAFT CV 24MM 30CM HMSH PL WVN STRG BOTH IP/OP "$1,236.58 " $915.07 $0.00 $989.26 $556.46 $556.46 $0.00 $0.00 $0.00 $257.73 $917.79 $917.79 $0.00 $0.00 $257.70 $0.00 $731.43 $731.43 $0.00 $618.29 $979.37 $989.26 $0.00 $0.00 $193.52 $0.00 $0.00 $196.86 $0.00 $0.00 $0.00 $0.00 $0.00 175428 SUP HCPCS C1768 175428 - GRAFT VASC 30CM 28MM HMSH GMCVL WVN STR BOTH IP/OP "$1,317.40 " $974.88 $0.00 "$1,053.92" $592.83 $592.83 $0.00 $0.00 $0.00 $274.58 $977.77 $977.77 $0.00 $0.00 $274.55 $0.00 $779.24 $779.24 $0.00 $658.70 "$1,043.38" "$1,053.92" $0.00 $0.00 $206.17 $0.00 $0.00 $209.73 $0.00 $0.00 $0.00 $0.00 $0.00 175432 SUP HCPCS C1768 175432 - GRAFT CV 32MM 30CM HMSH GMCVL WVN STRG BOTH IP/OP "$1,317.40 " $974.88 $0.00 "$1,053.92" $592.83 $592.83 $0.00 $0.00 $0.00 $274.58 $977.77 $977.77 $0.00 $0.00 $274.55 $0.00 $779.24 $779.24 $0.00 $658.70 "$1,043.38" "$1,053.92" $0.00 $0.00 $206.17 $0.00 $0.00 $209.73 $0.00 $0.00 $0.00 $0.00 $0.00 176605 SUP Custom 27203010 176605 - SCISSORS LAPSCP 5MM 31CM E SCZ MNPLR CAUT ADPR HK CRV JAW BOTH IP/OP $187.02 $138.39 $0.00 $149.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.80 $138.80 $0.00 $0.00 $38.97 $0.00 $0.00 $0.00 $0.00 $93.51 $148.12 $149.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 176620 SUP Custom 27203010 176620 - APPLIER INTERNAL CLIP LARGE 5MM 11IN TROCAR SLEEVE ENDO CLIP BOTH IP/OP $373.88 $276.67 $0.00 $299.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.49 $277.49 $0.00 $0.00 $77.92 $0.00 $0.00 $0.00 $0.00 $186.94 $296.11 $299.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 176643 SUP Custom 27203010 176643 - SHEARS MONOPOLAR STANDARD CURVE 5MM 31CM MONOPOLAR CAUTERY BOTH IP/OP $151.10 $111.81 $0.00 $122.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.15 $112.15 $0.00 $0.00 $31.49 $0.00 $0.00 $0.00 $0.00 $76.68 $121.47 $122.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 176657 SUP Custom 27203010 176657 - APPLIER INTERNAL CLIP MEDIUM LARGE 10MM 10MM PISTOL GRIP BOTH IP/OP $206.08 $152.50 $0.00 $167.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.95 $152.95 $0.00 $0.00 $42.95 $0.00 $0.00 $0.00 $0.00 $104.58 $165.66 $167.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 176816 SUP Custom 27203010 176816 - CATHETER URTH 16FR 30ML STRL LF BARD LBRSL 2W FL BLN SIL BOTH IP/OP $18.70 $13.84 $0.00 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.88 $13.88 $0.00 $0.00 $3.90 $0.00 $0.00 $0.00 $0.00 $9.35 $14.81 $14.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 177017 SUP Custom 27203010 REAGENT ANALY QUICKCOMP FLUOROCHROME MNCLN LQ 50 TST BOTH IP/OP "$1,849.53 " "$1,368.65" $0.00 "$1,479.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.76 "$1,464.83" "$1,479.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179301 SUP Custom 27203010 179301 - TROCAR ENDSCP 10.5MM NONCONDUCTIVE SLEEVE THORACOPORT TEAL BOTH IP/OP $38.25 $28.31 $0.00 $31.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.39 $28.39 $0.00 $0.00 $7.97 $0.00 $0.00 $0.00 $0.00 $19.41 $30.75 $31.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179309 SUP Custom 27203010 179309 - TROCAR ENDSCP 12MM SOFT CONDUCTIVE SLEEVE OBTURATOR BOTH IP/OP $38.25 $28.31 $0.00 $31.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.39 $28.39 $0.00 $0.00 $7.97 $0.00 $0.00 $0.00 $0.00 $19.41 $30.75 $31.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 180402 SUP HCPCS C1776 180402 - COMPONENT FEM 2 KN LT PTLFEM MULTICOMPARTMENTAL KN SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180403 SUP HCPCS C1776 180403 - COMPONENT FEM 3 KN PTLFEM LT MCK SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180404 SUP HCPCS C1776 180404 - COMPONENT FEM 4 KN PTLFEM LT MCK SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180405 SUP HCPCS C1776 180405 - COMPONENT FEM 5 KN PTLFEM LT MCK SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180406 SUP HCPCS C1776 180406 - COMPONENT FEM 6 KN LT PTLFEM MULTICOMPARTMENTAL KN SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180407 SUP HCPCS C1776 180407 - COMPONENT FEM 7 KN PTLFEM LT MCK SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180412 SUP HCPCS C1776 180412 - COMPONENT FEM 2 KN PTLFEM RT MCK SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180413 SUP HCPCS C1776 180413 - COMPONENT FEM 3 KN RT PTLFEM MULTICOMPARTMENTAL KN SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180414 SUP HCPCS C1776 180414 - COMPONENT FEM 4 KN PTLFEM RT MCK SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180415 SUP HCPCS C1776 180415 - COMPONENT FEM 5 KN PTLFEM RT MCK SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180416 SUP HCPCS C1776 180416 - COMPONENT FEM 6 KN PTLFEM RT MCK SYS BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180417 SUP HCPCS C1776 180417 - COMPONENT FEM 7 STD KN PTLFEM RT BOTH IP/OP "$9,780.00 " "$7,237.20" $0.00 "$7,824.00" "$4,401.00" "$4,401.00" $0.00 $0.00 $0.00 "$2,038.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,038.15" $0.00 "$4,821.54" "$4,821.54" $0.00 "$4,890.00" "$7,745.76" "$7,824.00" $0.00 $0.00 "$1,530.57" $0.00 $0.00 "$1,556.98" $0.00 $0.00 $0.00 $0.00 $0.00 180502 SUP HCPCS C1776 180502 - COMPONENT FEM 2 KN LT MDL RL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180503 SUP HCPCS C1776 180503 - COMPONENT FEM 3 KN LT MDL RL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180504 SUP HCPCS C1776 180504 - COMPONENT FEM 4 KN LT MDL RL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180505 SUP HCPCS C1776 180505 - COMPONENT FEM 5 KN LT MDL RL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180506 SUP HCPCS C1776 180506 - COMPONENT FEM 6 KN LT MDL RL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180507 SUP HCPCS C1776 180507 - COMPONENT FEM 7 KN LT MDL RL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180512 SUP HCPCS C1776 180512 - COMPONENT FEM 2 KN RMLL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180513 SUP HCPCS C1776 180513 - COMPONENT FEM 3 KN RMLL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180514 SUP HCPCS C1776 180514 - COMPONENT FEM 4 KN RMLL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180515 SUP HCPCS C1776 180515 - COMPONENT FEM 5 KN RMLL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180516 SUP HCPCS C1776 180516 - COMPONENT FEM 6 KN RMLL MCK SYS BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180517 SUP HCPCS C1776 180517 - COMPONENT FEM 7 STRL RESTORIS MULTICOMPARTMENTAL KN RMLL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180518 SUP HCPCS C1776 180518 - COMPONENT FEM 8 STRL RESTORIS MULTICOMPARTMENTAL KN RMLL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 180601 SUP HCPCS C1776 180601 - BASEPLATE TIB 1 STRL RESTORIS ONLAY MULTICOMPARTMENTAL KN LT BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180602 SUP HCPCS C1776 180602 - BASEPLATE TIB 2 KN LT MDL RL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180603 SUP HCPCS C1776 180603 - BASEPLATE TIB 3 KN LT MDL RL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180604 SUP HCPCS C1776 180604 - BASEPLATE TIB 4 KN LT MDL RL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180605 SUP HCPCS C1776 180605 - BASEPLATE TIB 5 KN LT MDL RL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180606 SUP HCPCS C1776 180606 - BASEPLATE TIB 6 KN LT MDL RL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180607 SUP HCPCS C1776 180607 - BASEPLATE TIB 7 KN LT MDL RL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180608 SUP HCPCS C1776 180608 - BASEPLATE TIB 8 STRL RESTORIS ONLAY MULTICOMPARTMENTAL KN LT BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180612 SUP HCPCS C1776 180612 - BASEPLATE TIB 2 KN RMLL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180613 SUP HCPCS C1776 180613 - BASEPLATE TIB 3 KN RMLL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180614 SUP HCPCS C1776 180614 - BASEPLATE TIB 4 STRL RESTORIS KN RMLL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180615 SUP HCPCS C1776 180615 - BASEPLATE TIB 5 STRL RESTORIS KN RMLL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180616 SUP HCPCS C1776 180616 - BASEPLATE TIB 6 KN RMLL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180617 SUP HCPCS C1776 180617 - BASEPLATE TIB 7 KN RMLL MCK SYS BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 180618 SUP HCPCS C1776 180618 - BASEPLATE TIB 8 STRL RESTORIS ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 186140 SUP HCPCS C1776 186140 - LINER ACTB NTRL RESTORIS XLVE HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186240 SUP HCPCS C1776 186240 - LINER ACTB RESTORIS HW XLVE HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 200641 SUP Custom 27805411 200641 - GRAFT BONE CORNERSTONE CORTICAL L14 MM X W11 MM X H6 MM BLOC BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 $0.00 $0.00 $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200741 SUP HCPCS C1713 200741 - GRAFT BONE CRSTN SR CORT BLCK 14X11X7MM CERV SPNE BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 200744 SUP Custom 27804086 200744 - GRAFT BONE 14X14X7MM BLOCK CORNERSTONE SR CORTICAL CERV SPN BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 $0.00 $0.00 $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 200841 SUP HCPCS C1713 200841 - GRAFT BONE CRSTN PSR CORT BLOCK 14X11X8MM CERV SPN BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 200941 SUP Custom 27804086 200941 - GRAFT BONE 14X11X9MM BLOCK FREEZE DRIED CORNERSTONE CORTICAL BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 $0.00 $0.00 $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201400 SUP HCPCS C1713 201400 - PIN HLF 4MM 120MM 30MM ILZ THRD ORTH BOTH IP/OP $422.00 $312.28 $0.00 $337.60 $189.90 $189.90 $0.00 $0.00 $0.00 $87.96 $313.21 $313.21 $0.00 $0.00 $87.94 $0.00 $249.61 $249.61 $0.00 $211.00 $334.22 $337.60 $0.00 $0.00 $66.04 $0.00 $0.00 $67.18 $0.00 $0.00 $0.00 $0.00 $0.00 201401 SUP HCPCS C1713 201401 - PIN HLF 4MM 150MM 35MM ILZ THRD ORTH BOTH IP/OP $428.00 $316.72 $0.00 $342.40 $192.60 $192.60 $0.00 $0.00 $0.00 $89.21 $317.66 $317.66 $0.00 $0.00 $89.20 $0.00 $253.16 $253.16 $0.00 $214.00 $338.98 $342.40 $0.00 $0.00 $66.98 $0.00 $0.00 $68.14 $0.00 $0.00 $0.00 $0.00 $0.00 201402 SUP HCPCS C1713 201402 - PIN HLF 4MM 180MM 40MM ILZ THRD ORTH BOTH IP/OP $448.00 $331.52 $0.00 $358.40 $201.60 $201.60 $0.00 $0.00 $0.00 $93.37 $332.51 $332.51 $0.00 $0.00 $93.36 $0.00 $264.99 $264.99 $0.00 $224.00 $354.82 $358.40 $0.00 $0.00 $70.11 $0.00 $0.00 $71.32 $0.00 $0.00 $0.00 $0.00 $0.00 201502 SUP HCPCS C1713 201502 - PIN HLF 5MM 180MM 50MM ILZ THRD CNCL ORTH BOTH IP/OP $480.00 $355.20 $0.00 $384.00 $216.00 $216.00 $0.00 $0.00 $0.00 $100.04 $356.26 $356.26 $0.00 $0.00 $100.03 $0.00 $283.92 $283.92 $0.00 $240.00 $380.16 $384.00 $0.00 $0.00 $75.12 $0.00 $0.00 $76.42 $0.00 $0.00 $0.00 $0.00 $0.00 201700 SUP HCPCS C1713 201700 - WASHER ORTH ILZ CNCL CPL BOTH IP/OP $128.80 $95.31 $0.00 $103.04 $57.96 $57.96 $0.00 $0.00 $0.00 $26.85 $95.60 $95.60 $0.00 $0.00 $26.84 $0.00 $76.19 $76.19 $0.00 $64.40 $102.01 $103.04 $0.00 $0.00 $20.16 $0.00 $0.00 $20.50 $0.00 $0.00 $0.00 $0.00 $0.00 202050 SUP Custom 27203010 202050 - SEALANT DURA 5ML DURASEAL PG TRILYSINE AMINE BOTH IP/OP "$2,732.63 " "$2,022.15" $0.00 "$2,208.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,028.15" "$2,028.15" $0.00 $0.00 $569.48 $0.00 $0.00 $0.00 $0.00 "$1,380.47" "$2,186.66" "$2,208.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 204002 SUP HCPCS Q4116 204002 - GRAFT SKN STRATTICE 20 X 40 BOTH IP/OP "$50,720.00 " "$37,532.80" $0.00 "$40,576.00" "$22,824.00" "$22,824.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,570.05" $0.00 "$25,004.96" "$25,004.96" $0.00 "$25,360.00" "$40,170.24" "$40,576.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,074.62" $0.00 $0.00 $0.00 $0.00 $0.00 205108 SUP Custom 27203010 205108 - DEVICE TISSUE CLOSURE 8CM EXTEND TIP APPLICATOR BOTH IP/OP "$2,830.10 " "$2,094.27" $0.00 "$2,264.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,100.50" "$2,100.50" $0.00 $0.00 $589.79 $0.00 $0.00 $0.00 $0.00 "$1,415.05" "$2,241.44" "$2,264.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 206010 SUP Custom 27203010 206010 - STONE BREAKER BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $0.00 $0.00 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 206020 SUP Custom 27203010 206020 - STONE BRAKER PROBE 20 MM BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $0.00 $0.00 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 206520 SUP Custom 27203010 206520 - SEALANT TISS CLSR 5ML STRL LF DURASEAL EXACT SPNE DISP BOTH IP/OP "$14,296.10 " "$10,579.11" $0.00 "$11,436.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,979.31" $0.00 $0.00 $0.00 $0.00 "$7,148.05" "$11,322.51" "$11,436.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 208058 SUP Custom 27203010 FORMULA 1QT MCT OIL SUPPL GLS BTL ADLT 7.7 CAL BOTH IP/OP $375.20 $277.65 $0.00 $300.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.60 $297.16 $300.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210439 SUP Custom 27203010 210439 - BIT DRL LNG 2MM 127MM STRL TWST SS BOTH IP/OP $175.40 $129.80 $0.00 $140.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.18 $130.18 $0.00 $0.00 $36.55 $0.00 $0.00 $0.00 $0.00 $87.70 $138.92 $140.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210440 SUP Custom 27203010 210440 - BIT DRL LNG 2.4MM 127MM STRL CUT SS BOTH IP/OP $175.40 $129.80 $0.00 $140.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.18 $130.18 $0.00 $0.00 $36.55 $0.00 $0.00 $0.00 $0.00 $87.70 $138.92 $140.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210441 SUP Custom 27203010 210441 - BIT DRL LNG 2.7MM 127MM STRL TWST SS BOTH IP/OP $175.40 $129.80 $0.00 $140.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.18 $130.18 $0.00 $0.00 $36.55 $0.00 $0.00 $0.00 $0.00 $87.70 $138.92 $140.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210442 SUP Custom 27203010 210442 - BIT DRL 3.2MM 127MM STRL TWST SS BOTH IP/OP $175.40 $129.80 $0.00 $140.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.18 $130.18 $0.00 $0.00 $36.55 $0.00 $0.00 $0.00 $0.00 $87.70 $138.92 $140.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210444 SUP Custom 27203010 210444 - BIT DRL LNG 4MM 127MM STRL TWST SS BOTH IP/OP $132.30 $97.90 $0.00 $105.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $0.00 $0.00 $0.00 $66.15 $104.78 $105.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210445 SUP Custom 27203010 210445 - BIT DRL LNG 4.3MM 127MM STRL CUT SS BOTH IP/OP $132.30 $97.90 $0.00 $105.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $0.00 $0.00 $0.00 $66.15 $104.78 $105.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210446 SUP Custom 27203010 210446 - BIT DRL LNG 4.7MM 127MM TWST SS BOTH IP/OP $132.30 $97.90 $0.00 $105.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $0.00 $0.00 $0.00 $66.15 $104.78 $105.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210447 SUP Custom 27203010 210447 - BIT DRL 5.5MM 127MM STRL TWST SS BOTH IP/OP $140.70 $104.12 $0.00 $112.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $0.00 $0.00 $0.00 $70.35 $111.43 $112.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210448 SUP Custom 27203010 210448 - BIT DRL LNG 6.4MM 127MM STRL CUT SS BOTH IP/OP $132.30 $97.90 $0.00 $105.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $0.00 $0.00 $0.00 $66.15 $104.78 $105.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210450 SUP Custom 27203010 210450 - BIT DRL 2.7MM 152.4MM STRL TWST SS BOTH IP/OP $157.50 $116.55 $0.00 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.90 $116.90 $0.00 $0.00 $32.82 $0.00 $0.00 $0.00 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210451 SUP Custom 27203010 210451 - BIT DRL LNG 3.5MM 152.4MM STRL TWST SS BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.71 $170.71 $0.00 $0.00 $47.93 $0.00 $0.00 $0.00 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210454 SUP Custom 27203010 210454 - BIT DRL 5/16MM STRL TWST SS BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $0.00 $0.00 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210455 SUP Custom 27203010 210455 - BIT DRL LG 9.5MM 127MM STRL TWST SS BOTH IP/OP $632.10 $467.75 $0.00 $505.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.14 $469.14 $0.00 $0.00 $131.73 $0.00 $0.00 $0.00 $0.00 $316.05 $500.62 $505.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210458 SUP Custom 27203010 210458 - BIT DRL LG 11.1MM 127MM STRL TWST SS BOTH IP/OP $679.35 $502.72 $0.00 $543.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $504.21 $504.21 $0.00 $0.00 $141.58 $0.00 $0.00 $0.00 $0.00 $339.68 $538.05 $543.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210461 SUP Custom 27203010 210461 - BIT DRL LG 12.7MM 127MM TWST BOTH IP/OP $679.35 $502.72 $0.00 $543.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $504.21 $504.21 $0.00 $0.00 $141.58 $0.00 $0.00 $0.00 $0.00 $339.68 $538.05 $543.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210465 SUP Custom 27203010 210465 - BIT DRL 3.6MM 152.4MM STRL TWST SS BOTH IP/OP $217.35 $160.84 $0.00 $173.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.32 $161.32 $0.00 $0.00 $45.30 $0.00 $0.00 $0.00 $0.00 $108.68 $172.14 $173.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210521 SUP Custom 27203010 210521 - FORCEP SPEC RTRVL 65CM 5.2FR 1 JAW ALGTR TOOTH FLXB SHFT BOTH IP/OP $707.35 $523.44 $0.00 $565.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $353.68 $560.22 $565.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210550 SUP Custom 27203010 210550 - BIT DRL 2.4MM 127MM STRL TWST SUT HL SS BOTH IP/OP $166.95 $123.54 $0.00 $133.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.91 $123.91 $0.00 $0.00 $34.79 $0.00 $0.00 $0.00 $0.00 $83.48 $132.22 $133.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210551 SUP Custom 27203010 210551 - BIT DRL 2.7MM 127MM STRL TWST SUT HL SS BOTH IP/OP $166.95 $123.54 $0.00 $133.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.91 $123.91 $0.00 $0.00 $34.79 $0.00 $0.00 $0.00 $0.00 $83.48 $132.22 $133.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210552 SUP Custom 27203010 210552 - BIT DRL 3.1MM 127MM STRL TWST SUT HL SS BOTH IP/OP $164.85 $121.99 $0.00 $131.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.35 $122.35 $0.00 $0.00 $34.35 $0.00 $0.00 $0.00 $0.00 $82.43 $130.56 $131.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 210554 SUP Custom 27203010 210554 - BIT DRL 3.9MM 127MM STRL TWST SUT HL BOTH IP/OP $164.85 $121.99 $0.00 $131.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.35 $122.35 $0.00 $0.00 $34.35 $0.00 $0.00 $0.00 $0.00 $82.43 $130.56 $131.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 211250 SUP HCPCS C1763 211250 - GRAFT SOFT TISSUE 2-3MM 50MM ALLOGRAFT MULTIPLE CLEAN AVANCE BOTH IP/OP "$11,165.00 " "$8,262.10" $0.00 "$8,100.00" "$4,556.25" "$4,556.25" $0.00 $0.00 $0.00 "$2,327.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,326.79" $0.00 "$5,504.35" "$5,504.35" $0.00 "$5,062.50" "$8,019.00" "$8,100.00" $0.00 $0.00 "$1,584.56" $0.00 $0.00 "$1,611.90" $0.00 $0.00 $0.00 $0.00 $0.00 212038 SUP HCPCS C1713 212038 - ANCHOR SUTURE OTHCRD BOTH IP/OP "$1,027.50 " $760.35 $0.00 $822.00 $462.38 $462.38 $0.00 $0.00 $0.00 $214.16 $762.61 $762.61 $0.00 $0.00 $214.13 $0.00 $607.77 $607.77 $0.00 $513.75 $813.78 $822.00 $0.00 $0.00 $160.80 $0.00 $0.00 $163.58 $0.00 $0.00 $0.00 $0.00 $0.00 212133 SUP HCPCS C1713 212133 - ANCHOR SUTURE 0 OS-2 MINI QANCHR+ SFT TIS SHLDR ARTHRO TI BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 212525 SUP Custom 27203010 STAIN MCBL GM CRYS VIOL WKG SOL BBL 250ML BOTH IP/OP $17.55 $12.99 $0.00 $14.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.78 $13.90 $14.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 212843 SUP HCPCS C1713 212843 - ANCHOR SUT 3-0 V-4 MIC 1.3MM STRL LF QANCHR+ OTHCRD BABSR BOTH IP/OP "$1,480.00 " "$1,095.20" $0.00 "$1,098.46" $450.00 $450.00 $0.00 $0.00 $0.00 $308.47 "$1,098.46" "$1,098.46" $0.00 $0.00 $308.43 $0.00 $875.42 $875.42 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 212865 SUP HCPCS C1713 212865 - ANCHOR SUT 3-0 V-4 MIC QAN+ ETH BIT BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $333.00 $333.00 $0.00 $0.00 $0.00 $154.23 $549.23 $549.23 $0.00 $0.00 $154.22 $0.00 $437.71 $437.71 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $115.81 $0.00 $0.00 $117.81 $0.00 $0.00 $0.00 $0.00 $0.00 213352 SUP Custom 27203010 REAGENT FLW CYMTR CTCHX FIXAT TRNSPT STOR 1ML BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 213524 SUP HCPCS C1713 213524 - PIN FX 3.2MM 110MM STRL LF BN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 213527 SUP HCPCS C1713 213527 - PIN FX 3.2MM 140MM STRL LF BN BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 219791 SUP Custom 27203010 219791 - MONTEFIORE 7FR X 100CM BOTH IP/OP $39.38 $29.14 $0.00 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.22 $29.22 $0.00 $0.00 $8.21 $0.00 $0.00 $0.00 $0.00 $19.69 $31.19 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 221716 SUP Custom 27203010 MEDIA CULT TSB TUBE MCFLS 5ML BOTH IP/OP $75.88 $56.15 $0.00 $60.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.94 $60.10 $60.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 222000 SUP Custom 27203010 222000 - IMMOBILIZER ORTH UNV 18-24IN KNEE 2 CUF SLD TO ADJ EXOFORM BOTH IP/OP $47.13 $34.88 $0.00 $34.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.98 $34.98 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $21.29 $33.73 $34.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 222228 SUP Custom 27203010 MEDIA CULT C DFC SLCT AGAR PLT BBL BOTH IP/OP $26.43 $19.56 $0.00 $21.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.21 $20.93 $21.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 222820 SUP HCPCS C1713 222820 - SCREW BN 6MM FT 4MM 2.7MM 1.3MM 20MM STRL EXCEL ST FLUT CNN BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222822 SUP HCPCS C1713 222822 - SCREW BN FT FLUT 4MM 22MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222824 SUP HCPCS C1713 222824 - SCREW BN 6MM FT 4MM 2.7MM 1.3MM 24MM STRL EXCEL ST FLUT CNN BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222826 SUP HCPCS C1713 222826 - SCREW BN FT FLUT 4MM 26MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222828 SUP HCPCS C1713 222828 - SCREW BN FT FLUT 4MM 28MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222830 SUP HCPCS C1713 222830 - SCREW BN FT FLUT 4MM 30MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222835 SUP HCPCS C1713 222835 - SCREW BN FT FLUT 4MM 35MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222840 SUP HCPCS C1713 222840 - SCREW BN 6MM FT 4MM 2.7MM 1.3MM 40MM STRL EXCEL ST FLUT CNN BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222845 SUP HCPCS C1713 222845 - SCREW BN FT FLUT 4MM 45MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222850 SUP HCPCS C1713 222850 - SCREW BN FT FLUT 4MM 50MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222855 SUP HCPCS C1713 222855 - SCREW BN FT FLUT 4MM 55MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222860 SUP HCPCS C1713 222860 - SCREW BN FT FLUT 4MM 60MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222865 SUP HCPCS C1713 222865 - SCREW BN FT FLUT 4MM 65MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222870 SUP HCPCS C1713 222870 - SCREW BN FT FLUT 4MM 70MM STRL EXCEL ST CNN TROC SS HIP BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 222983 SUP HCPCS C1713 222983 - ANCHOR SUT 2 CP-2 2.4MM 8.8MM STRL G2QKAN + OTHCRD NDL NTNL BOTH IP/OP "$1,030.00 " $762.20 $0.00 $824.00 $463.50 $463.50 $0.00 $0.00 $0.00 $214.68 $764.47 $764.47 $0.00 $0.00 $214.65 $0.00 $609.25 $609.25 $0.00 $515.00 $815.76 $824.00 $0.00 $0.00 $161.20 $0.00 $0.00 $163.98 $0.00 $0.00 $0.00 $0.00 $0.00 222984 SUP HCPCS C1713 222984 - ANCHOR SUT 2 CP-2 2.8MM 11.4MM STRL QANCHR+ OTHCRD NDL NTNL BOTH IP/OP "$1,712.50 " "$1,267.25" $0.00 "$1,271.02" $470.25 $470.25 $0.00 $0.00 $0.00 $356.93 "$1,271.02" "$1,271.02" $0.00 $0.00 $356.89 $0.00 "$1,012.94" "$1,012.94" $0.00 $522.50 $827.64 $836.00 $0.00 $0.00 $163.54 $0.00 $0.00 $166.36 $0.00 $0.00 $0.00 $0.00 $0.00 223522 SUP HCPCS C1713 223522 - NAIL IM 3.5MM 22CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223524 SUP HCPCS C1713 223524 - NAIL IM 3.5MM 24CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223525 SUP HCPCS C1713 223525 - NAIL IM 3.5MM 25CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223526 SUP HCPCS C1713 223526 - NAIL IM 3.5MM 26CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223527 SUP HCPCS C1713 223527 - NAIL IM 3.5MM 27CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223528 SUP HCPCS C1713 223528 - NAIL IM 3.5MM 28CM ENDR ORTH BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223529 SUP HCPCS C1713 223529 - NAIL IM 3.5MM 29CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223530 SUP HCPCS C1713 223530 - NAIL IM 3.5MM 30CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223531 SUP HCPCS C1713 223531 - NAIL IM 3.5MM 31CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223532 SUP HCPCS C1713 223532 - NAIL IM 3.5MM 32CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223533 SUP HCPCS C1713 223533 - NAIL IM 3.5MM 33CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223534 SUP HCPCS C1713 223534 - NAIL IM 3.5MM 34CM ENDR ADLT ORTH BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223535 SUP HCPCS C1713 223535 - NAIL IM 3.5MM 35CM ENDR ORTH BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223536 SUP HCPCS C1713 223536 - NAIL IM 3.5MM 36CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223537 SUP HCPCS C1713 223537 - NAIL IM 3.5MM 37CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 223538 SUP HCPCS C1713 223538 - NAIL IM 3.5MM 38CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224022 SUP HCPCS C1713 224022 - NAIL IM 4MM 22CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224023 SUP HCPCS C1713 224023 - NAIL IM 4MM 23CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224024 SUP HCPCS C1713 224024 - NAIL IM 4MM 24CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224025 SUP HCPCS C1713 224025 - NAIL IM 4MM 25CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224026 SUP HCPCS C1713 224026 - NAIL IM 4MM 26CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224027 SUP HCPCS C1713 224027 - NAIL IM 4MM 27CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224028 SUP HCPCS C1713 224028 - NAIL IM 4MM 28CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224029 SUP HCPCS C1713 224029 - NAIL IM 4MM 29CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224030 SUP HCPCS C1713 224030 - NAIL IM 4MM 30CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224031 SUP HCPCS C1713 224031 - NAIL IM 4MM 31CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224032 SUP HCPCS C1713 224032 - NAIL IM 4MM 32CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224033 SUP HCPCS C1713 224033 - NAIL IM 4MM 33CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224034 SUP HCPCS C1713 224034 - NAIL IM 4MM 34CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224035 SUP HCPCS C1713 224035 - NAIL IM 4MM 35CM ENDR SS HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224037 SUP HCPCS C1713 224037 - NAIL IM 4MM 37CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224527 SUP HCPCS C1713 224527 - NAIL IM 4.5MM 27CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224532 SUP HCPCS C1713 224532 - NAIL IM 4.5MM 32CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224533 SUP HCPCS C1713 224533 - NAIL IM 4.5MM 33CM ENDR BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224534 SUP HCPCS C1713 224534 - NAIL IM 4.5MM 34CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224535 SUP HCPCS C1713 224535 - NAIL IM 4.5MM 35CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224536 SUP HCPCS C1713 224536 - NAIL IM 4.5MM 36CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224537 SUP HCPCS C1713 224537 - NAIL IM 4.5MM 37CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224538 SUP HCPCS C1713 224538 - NAIL IM 4.5MM 38CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224539 SUP HCPCS C1713 224539 - NAIL IM 4.5MM 39CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224540 SUP HCPCS C1713 224540 - NAIL IM 4.5MM 40CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224541 SUP HCPCS C1713 224541 - NAIL IM 4.5MM 41CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224542 SUP HCPCS C1713 224542 - NAIL IM 4.5MM 42CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224543 SUP HCPCS C1713 224543 - NAIL IM 4.5MM 43CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224544 SUP HCPCS C1713 224544 - NAIL IM 4.5MM 44CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224545 SUP HCPCS C1713 224545 - NAIL IM 4.5MM 45CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224546 SUP HCPCS C1713 224546 - NAIL IM 4.5MM 46CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224547 SUP HCPCS C1713 224547 - NAIL IM 4.5MM 47CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224548 SUP HCPCS C1713 224548 - NAIL IM 4.5MM 48CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 224549 SUP HCPCS C1713 224549 - NAIL IM 4.5MM 49CM ENDR HUM TIB BOTH IP/OP "$1,092.38 " $808.36 $0.00 $873.90 $491.57 $491.57 $0.00 $0.00 $0.00 $227.68 $810.76 $810.76 $0.00 $0.00 $227.65 $0.00 $646.14 $646.14 $0.00 $546.19 $865.16 $873.90 $0.00 $0.00 $170.96 $0.00 $0.00 $173.91 $0.00 $0.00 $0.00 $0.00 $0.00 231554 SUP Custom 25003010 DISK OPTOCHIN PNMC DIFF BD TXO SNS BOTH IP/OP $91.08 $67.40 $0.00 $72.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.54 $72.14 $72.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 232447 SUP HCPCS C1713 232447 - SYSTEM FX STD RIGIDLOOP ADJ CORT BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 240765 SUP Custom 27203010 REAGENT VDRL CRDLPN AG BUFF SAL DFC .5ML 60ML NTRPN VL SERO BOTH IP/OP $127.95 $94.68 $0.00 $102.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.98 $101.34 $102.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-00 SUP Custom 27803010 01-2600 - HEAD FEMORAL MORSE TAPERED LFIT HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-00 SUP Custom 27803010 06-2600 - HEAD FEMORAL 0 26MM C TAPER LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-05 SUP Custom 27803010 01-2605 - HEAD FEMORAL +5MM 26MM MORSE TAPERED LFIT COCR HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-05 SUP Custom 27803010 06-2605 - HEAD FEMORAL +5MM 26MM C TAPER OFFST LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 258962 SUP HCPCS C1769 258962 - INTROD TUBE 24-28FR CGL BRHN 8 PERC HYDPHI INTROD SHLY DILAT BOTH IP/OP $843.75 $624.38 $0.00 $675.00 $458.16 $458.16 $0.00 $0.00 $0.00 $175.86 $626.23 $626.23 $0.00 $0.00 $175.84 $0.00 $499.08 $499.08 $0.00 $421.88 $668.25 $675.00 $0.00 $0.00 $132.05 $0.00 $0.00 $134.33 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-10 SUP Custom 27803010 01-2610 - HEAD FEMORAL +10MM 26MM MORSE TAPERED LFIT COCR BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-10 SUP Custom 27803010 06-2610 - HEAD FEMORAL +10MM 26MM C TAPER LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 261187 SUP Custom 27203010 REAGENT MCBL DMACA INDL DRPR BBL .5ML BOTH IP/OP $1.33 $0.98 $0.00 $1.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.66 $1.05 $1.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 261221 SUP Custom 27203010 261221 - PERFORATOR SURG 14MM 11MM 14X11MM CRANIUM ADULT STERILE BOTH IP/OP $735.05 $543.94 $0.00 $588.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.55 $545.55 $0.00 $0.00 $153.18 $0.00 $0.00 $0.00 $0.00 $367.53 $582.16 $588.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 263567 SUP HCPCS C1769 263567 - SET INTROD 24-26-28FR CGL BRHN 6 PERC EZ-PASS HYDPHI COAT BOTH IP/OP $905.05 $669.74 $0.00 $724.04 $491.44 $491.44 $0.00 $0.00 $0.00 $188.64 $671.73 $671.73 $0.00 $0.00 $188.61 $0.00 $535.34 $535.34 $0.00 $452.53 $716.80 $724.04 $0.00 $0.00 $141.64 $0.00 $0.00 $144.08 $0.00 $0.00 $0.00 $0.00 $0.00 265724 SUP Custom 27203010 265724 - CATHETER FOLEY 5CC 24FR BOTH IP/OP $4.60 $3.40 $0.00 $3.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.41 $3.41 $0.00 $0.00 $0.96 $0.00 $0.00 $0.00 $0.00 $2.45 $3.87 $3.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 266720 SUP Custom 27203010 266720 - CATHETER URTH 20FR 30CC STRL LTX BARD 2W FL 2 OPPS EYE BOTH IP/OP $5.73 $4.24 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.25 $4.25 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $2.86 $4.54 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 266722 SUP Custom 27203010 266722 - CATHETER URTH 22FR 30CC STRL LTX BARD 2W FL 2 OPPS EYE BOTH IP/OP $5.73 $4.24 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.25 $4.25 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $2.86 $4.54 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 266728 SUP Custom 27203010 266728 - CATH URTH 28FR 2W 2 OPPS EYE FOLEY RND TIP SIL-EL 30ML STRL BOTH IP/OP $0.48 $0.36 $0.00 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.35 $0.35 $0.00 $0.00 $0.10 $0.00 $0.00 $0.00 $0.00 $3.09 $4.89 $4.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 268877 SUP Custom 27203010 TUBE ACD SOL B 3ML YLW VCTNR CNV CLSR COLLECT BOTH IP/OP $0.65 $0.48 $0.00 $0.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.33 $0.51 $0.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 272905 SUP Custom 27203010 DEVICE MACV DISPENSTIRS RPR VDRL KT SERTST .05ML BOTH IP/OP $183.63 $135.89 $0.00 $146.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.81 $145.43 $146.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276081 SUP Custom 27803010 276081 - SHUNT 276081 UNI DSM VCATH23CM PCTH120CM BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276082 SUP Custom 27803010 276082 - SHUNT 276082 UNI DSM VCATH23CM PCTH120CM BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276084 SUP Custom 27803010 276084 - SHUNT 276084 UNI DSM VCATH23CM PCTH120CM BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276085 SUP Custom 27803010 276085 - SHUNT 276085 UNI DSM VCATH23CM PCTH120CM BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276124 SUP Custom 27803010 276124 - SHUNT 276124 UNIDLTA VCATH11 PCATH90 38+ BOTH IP/OP "$4,251.25 " "$3,145.93" $0.00 "$3,401.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,155.28" "$3,155.28" $0.00 $0.00 $885.96 $0.00 $0.00 $0.00 $0.00 "$2,125.63" "$3,366.99" "$3,401.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276125 SUP Custom 27803010 276125 - SHUNT 276125 UNIDLTA VCATH11 PCATH90 38+ BOTH IP/OP "$4,251.25 " "$3,145.93" $0.00 "$3,401.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,155.28" "$3,155.28" $0.00 $0.00 $885.96 $0.00 $0.00 $0.00 $0.00 "$2,125.63" "$3,366.99" "$3,401.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276201 SUP Custom 27203010 276201 - KIT 276201 SHNT SM BIO PCATH 90 VCATH 15 BOTH IP/OP "$5,804.50 " "$4,295.33" $0.00 "$4,643.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,209.66" $0.00 $0.00 $0.00 $0.00 "$2,902.25" "$4,597.16" "$4,643.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276391 SUP Custom 27203010 276391 - KIT 276391 DREG VRES PCATH120 VCATH15 BOTH IP/OP "$4,970.88 " "$3,678.45" $0.00 "$3,976.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,689.38" "$3,689.38" $0.00 $0.00 "$1,035.93" $0.00 $0.00 $0.00 $0.00 "$2,485.44" "$3,936.94" "$3,976.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276412 SUP Custom 27803010 276412 - SHUNT 276412 DSM PCATH130 STRP NOSLT BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276421 SUP Custom 27803010 276421 - SHUNT 276421 DREG PCATH130 STRP P/L 1.0 BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 276709 SUP Custom 27203010 CONTROL RPR BBL MACV CRD 1.5ML IMMUN BOTH IP/OP $105.93 $78.39 $0.00 $84.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.96 $83.90 $84.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 278801 SUP Custom 27803010 278801 - SHUNT 278801 DELTA SNP ASY BG SML PL 1.0 BOTH IP/OP "$2,983.00 " "$2,207.42" $0.00 "$2,386.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,213.98" "$2,213.98" $0.00 $0.00 $621.66 $0.00 $0.00 $0.00 $0.00 "$1,491.50" "$2,362.54" "$2,386.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 278802 SUP Custom 27803010 278802 - SHUNT 278802 DELTA SNP ASY BG SML PL 2.0 BOTH IP/OP "$2,983.00 " "$2,207.42" $0.00 "$2,386.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,213.98" "$2,213.98" $0.00 $0.00 $621.66 $0.00 $0.00 $0.00 $0.00 "$1,491.50" "$2,362.54" "$2,386.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 278805 SUP Custom 27803010 278805 - SHUNT 278805 DELTA SNP ASY BG SML PL 1.5 BOTH IP/OP "$2,983.00 " "$2,207.42" $0.00 "$2,386.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,213.98" "$2,213.98" $0.00 $0.00 $621.66 $0.00 $0.00 $0.00 $0.00 "$1,491.50" "$2,362.54" "$2,386.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 281000 SUP Custom 27203010 281000 - DRESSING FOAM THIN 2X1.6IN SELF ADHERENT MOISTURE PROOF BOTH IP/OP $221.83 $164.15 $0.00 $213.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.64 $164.64 $0.00 $0.00 $46.23 $0.00 $0.00 $0.00 $0.00 $133.36 $211.24 $213.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282400 SUP Custom 27203010 282400 - DRESSING FM 9.2X9.2IN MPLX BR ADH SAFETAC SIL SCRM BOTH IP/OP $26.69 $19.75 $0.00 $21.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.81 $19.81 $0.00 $0.00 $5.56 $0.00 $0.00 $0.00 $0.00 $13.34 $21.14 $21.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 287300 SUP Custom 27203010 287300 - DRESSING FOAM 6X6IN ABSORBENT SELF ADHERENT WATERPROOF BOTH IP/OP $39.20 $29.01 $0.00 $33.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.10 $29.10 $0.00 $0.00 $8.17 $0.00 $0.00 $0.00 $0.00 $21.24 $33.64 $33.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 287500 SUP Custom 27203010 287500 - DRESSING FOAM 20X8IN GENTLE ADHERENCE POLYURETHANE FOAM PAD BOTH IP/OP $154.14 $114.06 $0.00 $133.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.41 $114.41 $0.00 $0.00 $32.12 $0.00 $0.00 $0.00 $0.00 $83.52 $132.30 $133.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-91 SUP HCPCS C1713 01-2691 - PLATE BONE RECONSTRUCTION ADD ON LEFT CNDYLR HEAD MANDIB 2.4 BOTH IP/OP "$7,577.50 " "$5,607.35" $0.00 "$6,062.00" "$3,409.88" "$3,409.88" $0.00 $0.00 $0.00 "$1,579.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,579.15" $0.00 "$3,735.71" "$3,735.71" $0.00 "$3,788.75" "$6,001.38" "$6,062.00" $0.00 $0.00 "$1,185.88" $0.00 $0.00 "$1,206.34" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-92 SUP HCPCS C1713 01-2692 - PLATE BONE RECONSTRUCTION ADD ON RIGHT CNDYLR HEAD MANDIB BOTH IP/OP "$7,577.50 " "$5,607.35" $0.00 "$6,062.00" "$3,409.88" "$3,409.88" $0.00 $0.00 $0.00 "$1,579.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,579.15" $0.00 "$3,735.71" "$3,735.71" $0.00 "$3,788.75" "$6,001.38" "$6,062.00" $0.00 $0.00 "$1,185.88" $0.00 $0.00 "$1,206.34" $0.00 $0.00 $0.00 $0.00 $0.00 290058 SUP HCPCS C1713 290058 - CAP PCTV 4MM RD STRL BOTH IP/OP $84.30 $62.38 $0.00 $67.44 $37.94 $37.94 $0.00 $0.00 $0.00 $17.57 $62.57 $62.57 $0.00 $0.00 $17.57 $0.00 $49.86 $49.86 $0.00 $42.15 $66.77 $67.44 $0.00 $0.00 $13.19 $0.00 $0.00 $13.42 $0.00 $0.00 $0.00 $0.00 $0.00 290060 SUP HCPCS C1713 290060 - CAP PCTV 3MM GRN STRL BOTH IP/OP $83.70 $61.94 $0.00 $66.96 $37.67 $37.67 $0.00 $0.00 $0.00 $17.45 $62.12 $62.12 $0.00 $0.00 $17.44 $0.00 $49.51 $49.51 $0.00 $41.85 $66.29 $66.96 $0.00 $0.00 $13.10 $0.00 $0.00 $13.33 $0.00 $0.00 $0.00 $0.00 $0.00 290061 SUP HCPCS C1713 290061 - CAP PROTECTIVE 5MM BLACK STERILE BOTH IP/OP $78.20 $57.87 $0.00 $62.56 $35.19 $35.19 $0.00 $0.00 $0.00 $16.30 $58.04 $58.04 $0.00 $0.00 $16.30 $0.00 $46.26 $46.26 $0.00 $39.10 $61.93 $62.56 $0.00 $0.00 $12.24 $0.00 $0.00 $12.45 $0.00 $0.00 $0.00 $0.00 $0.00 293400 SUP Custom 27203010 293400 - DRESSING MPFRM THN 7X4IN ADH FLXB WTPRF SAFETAC TCH WND SIL BOTH IP/OP $17.62 $13.04 $0.00 $14.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.81 $13.96 $14.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 295900 SUP Custom 27203010 295900 - DRESSING FOAM 12X4IN ABSORBENT NONADHERENT WATERPROOF BOTH IP/OP $376.13 $278.34 $0.00 $300.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.17 $279.17 $0.00 $0.00 $78.39 $0.00 $0.00 $0.00 $0.00 $188.07 $297.89 $300.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 296348 SUP Custom 27203010 MEDIA MYCL SAB-DEX EMNS AGAR GNTA BBL PLT DP FILL BOTH IP/OP $57.80 $42.77 $0.00 $46.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.90 $45.78 $46.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 304206 SUP HCPCS C1729 CATHETER IV 16GA 1.25IN RADIOPQ SFSHLD GRY PCTV TFLN STRL LF BOTH IP/OP $3.88 $2.87 $0.00 $3.10 $2.10 $2.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.94 $3.07 $3.10 $0.00 $0.00 $0.61 $0.00 $0.00 $0.62 $0.00 $0.00 $0.00 $0.00 $0.00 310431 SUP Custom 27203010 310431 - BIT DRILL 180MM 4.3MM QC 5MM LCK SCR NONSTRL BOTH IP/OP $260.10 $192.47 $0.00 $208.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.05 $193.05 $0.00 $0.00 $54.20 $0.00 $0.00 $0.00 $0.00 $130.05 $206.00 $208.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311270 SUP HCPCS C1768 "311270 - GRAFT, AVANCE NERVE, 3-4MM X 70MM" BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$11,800.00" "$6,637.50" "$6,637.50" $0.00 $0.00 $0.00 "$3,356.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 "$7,939.77" "$7,939.77" $0.00 "$7,375.00" "$11,682.00" "$11,800.00" $0.00 $0.00 "$2,308.38" $0.00 $0.00 "$2,348.20" $0.00 $0.00 $0.00 $0.00 $0.00 315804 SUP Custom 27203010 315804 - CANNU PRFSN 11.4IN 4MM CORON ART STR SLF INFL BLN LATEX FREE BOTH IP/OP $163.75 $121.18 $0.00 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.54 $121.54 $0.00 $0.00 $34.13 $0.00 $0.00 $0.00 $0.00 $81.88 $129.69 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315805 SUP Custom 27203010 315805 - CANNULA PERFUSION 2.1MM STR 5MM 11.4IN SELF INFLATING BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315806 SUP Custom 27203010 315806 - CANNU PRFSN 11.4IN 6MM CORON ART 3MM STR SLF INFL BLN FMALE BOTH IP/OP $196.50 $145.41 $0.00 $157.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.84 $145.84 $0.00 $0.00 $40.95 $0.00 $0.00 $0.00 $0.00 $98.25 $155.63 $157.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315807 SUP Custom 27203010 315807 - CANNU PRFSN 11.4IN 7MM CORON ART 3MM STR SLF INFL BLN FMALE BOTH IP/OP $163.75 $121.18 $0.00 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.54 $121.54 $0.00 $0.00 $34.13 $0.00 $0.00 $0.00 $0.00 $81.88 $129.69 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 323020 SUP Custom 27803010 323020 - STENT LARYNGEAL SMALL 2 SUTURE BUTTON FLEXIBLE NONADHERENT BOTH IP/OP $300.00 $222.00 $0.00 $222.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 323025 SUP Custom 27803010 323025 - STENT LARYNGEAL MEDIUM FLEXIBLE NONADHERENT INTEGRAL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 323030 SUP Custom 27803010 323030 - STENT LARYNGEAL LARGE FLEXIBLE NONADHERENT INTEGRAL BOTH IP/OP $300.00 $222.00 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 325014 SUP HCPCS C1713 325014 - SCREW BN 4MM 14MM NS ASNS III P/T CNN SS BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325016 SUP HCPCS C1713 325016 - SCREW BONE 4MM 16MM ASNS 3 SS PTHRD FRARM CANN NONSTRL BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $86.63 $86.63 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $30.13 $0.00 $0.00 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 325018 SUP HCPCS C1713 325018 - SCREW BN 4MM 18MM STRL ASNS III P/T IMPL SS BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325020 SUP HCPCS C1713 325020 - SCREW BONE 4MM 20MM ASNS 3 SS CANN NONSTRL BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325022 SUP HCPCS C1713 325022 - SCREW BONE 4MM 22MM ASNS 3 SS CANN NONSTRL BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325024 SUP HCPCS C1713 325024 - SCREW BONE 4MM 24MM ASNS 3 SS PTHRD FRARM CANN NONSTRL BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $86.63 $86.63 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $30.13 $0.00 $0.00 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 325026 SUP HCPCS C1713 325026 - SCREW BN P/T 4MM 26MM STRL 9MM ASNS III ST SLF DRL CNN SS BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325028 SUP HCPCS C1713 325028 - SCREW BN 4MM 28MM STRL 9.5MM ASNS III CNN SS BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325030 SUP HCPCS C1713 325030 - SCREW BN P/T 4MM 30MM STRL ASNS III ST SLF DRL CNN SS HIP BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325032 SUP HCPCS C1713 325032 - SCREW BONE 4MM 32MM SS PTTHRD IMPL STRL BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325034 SUP HCPCS C1713 325034 - SCREW BONE 4MM 34MM SS PTTHRD IMPL STRL BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325036 SUP HCPCS C1713 325036 - SCREW BONE 4MM 36MM ASNS 3 SS PTHRD FEM HIP STRL BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325038 SUP HCPCS C1713 325038 - SCREW BN P/T 4MM 38MM NS ASNS III ST SLF DRL LOPRFL HD CNN BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325040 SUP HCPCS C1713 325040 - SCREW BONE 4MM 40MM ASNS 3 SS PTHRD HIP CANN SYS SLFTAP CUT BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325042 SUP HCPCS C1713 325042 - SCREW BONE 4MM 42MM ASNS 3 SS ORTH CANN BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325044 SUP HCPCS C1713 325044 - SCREW BONE 4MM 44MM ASNS 3 SS HIP SLFTAP SLFDRILL CANN PTHRD BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 325046 SUP HCPCS C1713 325046 - SCREW BONE 4MM 46MM ASNS 3 SS HIP SLFTAP SLFDRILL CANN PTHRD BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325048 SUP HCPCS C1713 325048 - SCREW BN P/T 4MM 48MM NS ASNS III ST SLF DRL LOPRFL HD CNN BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325050 SUP HCPCS C1713 325050 - SCREW BONE 4MM 50MM ASNS 3 SS PTHRD HIP CANN SLFTAP SLFDRILL BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325055 SUP HCPCS C1713 325055 - SCREW BONE 4MM 55MM ASNS 3 SS PTHRD HIP CANN SLFTAP CUT STRL BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325060 SUP HCPCS C1713 325060 - SCREW BONE 4MM 60MM ASNS 3 SS CANN NONSTRL BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 325065 SUP HCPCS C1713 325065 - SCREW BONE 4MM 65MM ASNS 3 SS HIP CANN NONSTRL BOTH IP/OP $274.55 $203.17 $0.00 $228.80 $128.70 $128.70 $0.00 $0.00 $0.00 $57.22 $203.77 $203.77 $0.00 $0.00 $57.22 $0.00 $162.40 $162.40 $0.00 $143.00 $226.51 $228.80 $0.00 $0.00 $44.76 $0.00 $0.00 $45.53 $0.00 $0.00 $0.00 $0.00 $0.00 325070 SUP HCPCS C1713 325070 - SCREW BONE 4MM 70MM ASNS 3 SS PTHRD HIP CANN STRL BOTH IP/OP $274.55 $203.17 $0.00 $228.80 $128.70 $128.70 $0.00 $0.00 $0.00 $57.22 $203.77 $203.77 $0.00 $0.00 $57.22 $0.00 $162.40 $162.40 $0.00 $143.00 $226.51 $228.80 $0.00 $0.00 $44.76 $0.00 $0.00 $45.53 $0.00 $0.00 $0.00 $0.00 $0.00 325420 SUP HCPCS C1713 325420 - SCREW BONE 5MM 20MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $266.25 $197.03 $0.00 $197.61 $74.87 $74.87 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $26.04 $0.00 $0.00 $26.49 $0.00 $0.00 $0.00 $0.00 $0.00 326260 SUP HCPCS C1713 326260 - SCREW BONE 6.5MM 60MM 40MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-00 SUP Custom 27803010 01-2800 - HEAD FEM +0MM OFST MRS TPR 28MM STRL HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-00 SUP Custom 27803010 06-2800 - HEAD FEM +0MM OFST CTPR 28MM LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 330046 SUP Custom 27203010 ADAPTER TBG Y 2 FMALE SCR TO 1 MALE BYNT BOTH IP/OP $29.70 $21.98 $0.00 $23.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.85 $23.52 $23.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-05 SUP HCPCS C1776 01-2805 - HEAD FEM +5MM 28MM LFIT MRS TPR COCR HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $807.75 $807.75 $0.00 $0.00 $0.00 $374.12 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 "$1,061.74" "$1,061.74" $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $280.92 $0.00 $0.00 $285.76 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-05 SUP Custom 27803010 06-2805 - HEAD FEM +5MM OFST CTPR 28MM LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 331822 SUP HCPCS C1729 CATHETER CONTAMINATING GUARD AG-2000 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 332079 SUP Custom 27203010 TRAY EPDRL 17GA 3.5IN NDL MTL TIP SYR FLTR PRFX TH SCHF BOTH IP/OP $720.00 $532.80 $0.00 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $534.38 $534.38 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $360.00 $570.24 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-10 SUP Custom 27803010 01-2810 - HEAD FEM LFIT MRS TPR BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-10 SUP Custom 27803010 06-2810 - HEAD FEM +10MM OFST CTPR 28MM LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 333676 SUP Custom 27203010 NEEDLE NS STPLX D BVL INSL EXTN SET 15D 4.75IN 22GA BOTH IP/OP $127.50 $94.35 $0.00 $102.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.75 $100.98 $102.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 333690 SUP Custom 27203010 NEEDLE NS STPLX A INSL EXTN SET BVL 30D DIG/HNS11 STM 2IN 22 BOTH IP/OP $23.45 $17.35 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.73 $18.57 $18.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 334050 SUP HCPCS C1900 334050 - PHILOS DR SYSTEM BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,771.61" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,771.40" $0.00 "$4,190.50" "$4,190.50" $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 "$1,330.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 335903 SUP HCPCS C1729 CATHETER IV 20GA 1.75IN RADIOPQ SFSHLD PNK ACV+ OCRILON STRL BOTH IP/OP $3.98 $2.95 $0.00 $3.18 $2.16 $2.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $3.15 $3.18 $0.00 $0.00 $0.62 $0.00 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $0.00 338001 SUP HCPCS C1729 CATHETER IV 22GA 1IN RADIOPQ SFSHLD BLUE ACV J TFLN STRL LF BOTH IP/OP $3.80 $2.81 $0.00 $3.04 $2.06 $2.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.90 $3.01 $3.04 $0.00 $0.00 $0.59 $0.00 $0.00 $0.60 $0.00 $0.00 $0.00 $0.00 $0.00 338610 SUP HCPCS C1713 338610 - SCREW BONE 3.5MM 10MM AXSOS SS FULTHD CORT SLFTAP BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338612 SUP HCPCS C1713 338612 - SCREW BONE 3.5MM 12MM SS CORT SLFTAP BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338614 SUP HCPCS C1713 338614 - SCREW BONE 3.5MM 14MM AXSOS SS FULTHD CORT HUM HEX DRV BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338616 SUP HCPCS C1713 338616 - SCREW BONE 3.5MM 16MM SS CORT SLFTAP BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338618 SUP HCPCS C1713 338618 - SCREW BONE 3.5MM 2.5MM 18MM AXSOS SS CORT PROX HUM HEX DRV BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338620 SUP HCPCS C1713 338620 - SCREW BN 2.5MM 3.5MM 20MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338622 SUP HCPCS C1713 338622 - SCREW BN 2.5MM 3.5MM 22MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338624 SUP HCPCS C1713 338624 - SCREW BN 2.5MM 3.5MM 24MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338626 SUP HCPCS C1713 338626 - SCREW BN 2.5MM 3.5MM 26MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338628 SUP HCPCS C1713 338628 - SCREW BN 2.5MM 3.5MM 28MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338630 SUP HCPCS C1713 338630 - SCREW BN 2.5MM 3.5MM 30MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338632 SUP HCPCS C1713 338632 - SCREW BONE 3.5MM 32MM AXSOS SS 2.5MM PROX CORT HUM SLFTAP BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338634 SUP HCPCS C1713 338634 - SCREW BN 2.5MM 3.5MM 34MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338636 SUP HCPCS C1713 338636 - SCREW BONE 3.5MM 36MM AXSOS SS FULTHD CORT HUM HEX DRV BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338638 SUP HCPCS C1713 338638 - SCREW BN 2.5MM 3.5MM 38MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338640 SUP HCPCS C1713 338640 - SCREW BN 2.5MM 3.5MM 40MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338642 SUP HCPCS C1713 338642 - SCREW BONE 3.5MM 40MM AXSOS SS FULTHD CORT SLFTAP BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338644 SUP HCPCS C1713 338644 - SCREW BONE 3.5MM 44MM AXSOS SS FULTHD CORT HUM HEX DRV BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338645 SUP HCPCS C1713 338645 - SCREW BN 2.5MM 3.5MM 45MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338646 SUP HCPCS C1713 338646 - SCREW BONE 3.5MM 46MM SS CORT SLFTAP BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338648 SUP HCPCS C1713 338648 - SCREW BONE 3.5MM 48MM AXSOS SS FULTHD CORT HUM HEX DRV BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338650 SUP HCPCS C1713 338650 - SCREW BN 2.5MM 3.5MM 50MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338655 SUP HCPCS C1713 338655 - SCREW BN 2.5MM 3.5MM 55MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338660 SUP HCPCS C1713 338660 - SCREW BN 2.5MM 3.5MM 60MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338665 SUP HCPCS C1713 338665 - SCREW BN 2.5MM 3.5MM 65MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338670 SUP HCPCS C1713 338670 - SCREW BN 2.5MM 3.5MM 70MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $14.23 $14.23 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338675 SUP HCPCS C1713 338675 - SCREW BN 2.5MM 3.5MM 75MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338680 SUP HCPCS C1713 338680 - SCREW BN 2.5MM 3.5MM 80MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338685 SUP HCPCS C1713 338685 - SCREW BN 2.5MM 3.5MM 85MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338690 SUP HCPCS C1713 338690 - SCREW BN 2.5MM 3.5MM 90MM NS ST HEX SS CORT AXSOS SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338695 SUP HCPCS C1713 338695 - SCREW BONE 3.5MM 95MM CORT SLFTAP BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 338700 SUP HCPCS C1713 338700 - SCREW BN FT 3.5MM 100MM ST HEX SS CORT AXSOS SM FRAG SET BOTH IP/OP $43.20 $31.97 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $9.00 $32.06 $32.06 $0.00 $0.00 $9.00 $0.00 $25.55 $25.55 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 338705 SUP HCPCS C1713 338705 - SCREW BONE 3.5MM 105MM CORT SLFTAP BOTH IP/OP $43.20 $31.97 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $9.00 $32.06 $32.06 $0.00 $0.00 $9.00 $0.00 $25.55 $25.55 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 338710 SUP HCPCS C1713 338710 - SCREW BONE 3.5MM 110MM CORT SLFTAP BOTH IP/OP $43.20 $31.97 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $9.00 $32.06 $32.06 $0.00 $0.00 $9.00 $0.00 $25.55 $25.55 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 338715 SUP HCPCS C1713 338715 - SCREW BONE 3.5MM 115MM SS CORT SLFTAP BOTH IP/OP $43.20 $31.97 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $9.00 $32.06 $32.06 $0.00 $0.00 $9.00 $0.00 $25.55 $25.55 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 338720 SUP HCPCS C1713 338720 - SCREW BONE 3.5MM 120MM SS CORT SLFTAP BOTH IP/OP $43.20 $31.97 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $9.00 $32.06 $32.06 $0.00 $0.00 $9.00 $0.00 $25.55 $25.55 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 340612 SUP HCPCS C1713 340612 - SCREW BONE 4.5MM 12MM CORT SLFTAP BOTH IP/OP $28.88 $21.37 $0.00 $23.10 $12.99 $12.99 $0.00 $0.00 $0.00 $6.02 $21.43 $21.43 $0.00 $0.00 $6.02 $0.00 $17.08 $17.08 $0.00 $14.44 $22.87 $23.10 $0.00 $0.00 $4.52 $0.00 $0.00 $4.60 $0.00 $0.00 $0.00 $0.00 $0.00 340614 SUP HCPCS C1713 340614 - SCREW BONE 4.5MM 14MM CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340616 SUP HCPCS C1713 340616 - SCREW BONE 4.5MM 16MM ISO SS FULTHD CORT SLFTAP NONSTRL BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340618 SUP HCPCS C1713 340618 - SCREW BONE 4.5MM 18MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340620 SUP HCPCS C1713 340620 - SCREW BONE 4.5MM 20MM SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340622 SUP HCPCS C1713 340622 - SCREW BONE 4.5MM 22MM SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340624 SUP HCPCS C1713 340624 - SCREW BONE 4.5MM 24MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340626 SUP HCPCS C1713 340626 - SCREW BONE 4.5MM 26MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340628 SUP HCPCS C1713 340628 - SCREW BONE 4.5MM 28MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340630 SUP HCPCS C1713 340630 - SCREW BONE 4.5MM 30MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340632 SUP HCPCS C1713 340632 - SCREW BONE 4.5MM 32MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340634 SUP HCPCS C1713 340634 - SCREW BONE 4.5MM 34MM SPS SS CORT SLFTAP BASIC FRAG SET BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340636 SUP HCPCS C1713 340636 - SCREW BONE 4.5MM 36MM AXSOS SS 3.5MM LAT DISTAL CORT FEM BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340638 SUP HCPCS C1713 340638 - SCREW BONE 4.5MM 38MM AXSOS SS 3.5MM LAT DISTAL CORT FEM BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340640 SUP HCPCS C1713 340640 - SCREW BONE 4.5MM 40MM AXSOS SS 3.5MM LAT DISTAL CORT FEM BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340642 SUP HCPCS C1713 340642 - SCREW BONE 4.5MM 42MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340644 SUP HCPCS C1713 340644 - SCREW BONE 4.5MM 44MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340646 SUP HCPCS C1713 340646 - SCREW BONE 4.5MM 46MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340648 SUP HCPCS C1713 340648 - SCREW BONE 4.5MM 48MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340650 SUP HCPCS C1713 340650 - SCREW BONE 4.5MM 50MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340652 SUP HCPCS C1713 340652 - SCREW BONE 4.5MM 52MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340654 SUP HCPCS C1713 340654 - SCREW BONE 4.5MM 54MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340656 SUP HCPCS C1713 340656 - SCREW BONE 4.5MM 56MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340658 SUP HCPCS C1713 340658 - SCREW BONE 4.5MM 58MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340660 SUP HCPCS C1713 340660 - SCREW BONE 4.5MM 60MM AXSOS SS CORT SLFTAP LCK HEX DRV BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340665 SUP HCPCS C1713 340665 - SCREW BONE 4.5MM 3.5MM 65MM AXSOS SS CORT HEX DRV SLFTAP LCK BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340670 SUP HCPCS C1713 340670 - SCREW BONE 4.5MM 70MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340675 SUP HCPCS C1713 340675 - SCREW BONE 4.5MM 75MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340680 SUP HCPCS C1713 340680 - SCREW BONE 4.5MM 80MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340685 SUP HCPCS C1713 340685 - SCREW BONE 4.5MM 85MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340690 SUP HCPCS C1713 340690 - SCREW BONE 4.5MM 90MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340695 SUP HCPCS C1713 340695 - SCREW BONE 4.5MM 95MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $36.18 $14.85 $14.85 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $5.16 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $0.00 340700 SUP HCPCS C1713 340700 - SCREW BONE 4.5MM 100MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340705 SUP HCPCS C1713 340705 - SCREW BONE 4.5MM 105MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340710 SUP HCPCS C1713 340710 - SCREW BONE 4.5MM 100MM AXSOS SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340715 SUP HCPCS C1713 340715 - SCREW BONE 4.5MM 115MM SS CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340720 SUP HCPCS C1713 340720 - SCREW BONE 4.5MM 120MM CORT BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340725 SUP HCPCS C1713 340725 - SCREW BONE 4.5MM 125MM ISO SS FULTHD CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340730 SUP HCPCS C1713 340730 - SCREW BONE 4.5MM 130MM ISO SS FULTHD CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340735 SUP HCPCS C1713 340735 - SCREW BONE 4.5MM 135MM ISO SS FULTHD CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340740 SUP HCPCS C1713 340740 - SCREW BONE 4.5MM 140MM ISO SS FULTHD CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340745 SUP HCPCS C1713 340745 - SCREW BONE 4.5MM 145MM ISO SS FULTHD CORT SLFTAP BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 340750 SUP HCPCS C1713 340750 - SCREW BONE 4.5MM 150MM ISO SS CORT SLFTAP FULTHD BOTH IP/OP $48.75 $36.08 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.16 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $28.84 $28.84 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 341025 SUP HCPCS C1713 341025 - SCREW BN 6.5MM 25MM 16MM P/T CANC BOTH IP/OP $52.25 $38.67 $0.00 $41.80 $23.51 $23.51 $0.00 $0.00 $0.00 $10.89 $38.78 $38.78 $0.00 $0.00 $10.89 $0.00 $30.91 $30.91 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341030 SUP HCPCS C1713 341030 - SCREW BONE 6.5MM 30MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341035 SUP HCPCS C1713 341035 - SCREW BONE 6.5MM 35MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341040 SUP HCPCS C1713 341040 - SCREW BONE 6.5MM 40MM 16MM CANC PTHRD BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341045 SUP HCPCS C1713 341045 - SCREW BONE 6.5MM 45MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341050 SUP HCPCS C1713 341050 - SCREW BONE 6.5MM 50MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341055 SUP HCPCS C1713 341055 - SCREW BONE 6.5MM 55MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341060 SUP HCPCS C1713 341060 - SCREW BONE 6.5MM 60MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341065 SUP HCPCS C1713 341065 - SCREW BONE 6.5MM 65MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341070 SUP HCPCS C1713 341070 - SCREW BONE 6.5MM 70MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341075 SUP HCPCS C1713 341075 - SCREW BONE 6.5MM 75MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341080 SUP HCPCS C1713 341080 - SCREW BONE 6.5MM 80MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341085 SUP HCPCS C1713 341085 - SCREW BONE 6.5MM 85MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341090 SUP HCPCS C1713 341090 - SCREW BONE 6.5MM 90MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341095 SUP HCPCS C1713 341095 - SCREW BONE 6.5MM 95MM 16MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 341100 SUP HCPCS C1713 341100 - SCREW BONE 6.5MM 100MM 16MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 341105 SUP HCPCS C1713 341105 - SCREW BONE 6.5MM 105MM 16MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 341110 SUP HCPCS C1713 341110 - SCREW BONE 6.5MM 110MM 16MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 341115 SUP HCPCS C1713 341115 - SCREW BONE 6.5MM 115MM 16MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 341120 SUP HCPCS C1713 341120 - SCREW BONE 6.5MM 120MM 16MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 341125 SUP HCPCS C1713 341125 - SCREW BONE 6.5MM 125MM 16MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 341130 SUP HCPCS C1713 341130 - SCREW BONE 6.5MM 130MM 16MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 341140 SUP HCPCS C1713 341140 - SCREW BONE 6.5MM 140MM 16MM SS CANC SLFTAP FULTHD ISO BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 341824 SUP HCPCS C1786 341824 - PACEMAKER CRD THK6MM 53X39MM 11ML PH2 SR IMPL 1 CHMBR RR BOTH IP/OP "$8,000.00 " "$5,920.00" $0.00 "$6,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,667.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,667.20" $0.00 "$3,944.00" "$3,944.00" $0.00 "$4,000.00" "$6,336.00" "$6,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 342040 SUP HCPCS C1713 342040 - SCREW BONE 6.5MM 40MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342045 SUP HCPCS C1713 342045 - SCREW BONE 6.5MM 45MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342050 SUP HCPCS C1713 342050 - SCREW BONE 6.5MM 50MM SS CANC PTTHRD BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342055 SUP HCPCS C1713 342055 - SCREW BONE 6.5MM 55MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342060 SUP HCPCS C1713 342060 - SCREW BONE 6.5MM 60MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342065 SUP HCPCS C1713 342065 - SCREW BONE 6.5MM 65MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342070 SUP HCPCS C1713 342070 - SCREW BONE 6.5MM 70MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342075 SUP HCPCS C1713 342075 - SCREW BONE 6.5MM 75MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342080 SUP HCPCS C1713 342080 - SCREW BONE 6.5MM 80MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342085 SUP HCPCS C1713 342085 - SCREW BONE 6.5MM 85MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342090 SUP HCPCS C1713 342090 - SCREW BONE 6.5MM 90MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342095 SUP HCPCS C1713 342095 - SCREW BONE 6.5MM 95MM 32MM SS CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 342100 SUP HCPCS C1713 342100 - SCREW BONE 6.5MM 100MM 32MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 342105 SUP HCPCS C1713 342105 - SCREW BONE 6.5MM 105MM 32MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 342110 SUP HCPCS C1713 342110 - SCREW BONE 6.5MM 110MM 32MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 342115 SUP HCPCS C1713 342115 - SCREW BONE 6.5MM 115MM 32MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 342120 SUP HCPCS C1713 342120 - SCREW BONE 6.5MM 120MM 32MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 342125 SUP HCPCS C1713 342125 - SCREW BONE 6.5MM 125MM 32MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 342130 SUP HCPCS C1713 342130 - SCREW BONE 6.5MM 130MM 32MM SS CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 342140 SUP HCPCS C1713 342140 - SCREW BONE 6.5MM 140MM 32MM SS CANC BOTH IP/OP $61.88 $45.79 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.90 $45.92 $45.92 $0.00 $0.00 $12.89 $0.00 $36.60 $36.60 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 343020 SUP HCPCS C1713 343020 - SCREW BONE 6.5MM 20MM SS FULTHD CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 343025 SUP HCPCS C1713 343025 - SCREW BONE 6.5MM 25MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343030 SUP HCPCS C1713 343030 - SCREW BONE 6.5MM 30MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343035 SUP HCPCS C1713 343035 - SCREW BONE 6.5MM 35MM SS FULTHD CANC LCK HEX DRV BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343040 SUP HCPCS C1713 343040 - SCREW BONE 6.5MM 40MM ISO TI FULTHD CANC NONSTRL BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343045 SUP HCPCS C1713 343045 - SCREW BONE 6.5MM 45MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343050 SUP HCPCS C1713 343050 - SCREW BONE 6.5MM 50MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343055 SUP HCPCS C1713 343055 - SCREW BONE 6.5MM 55MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343060 SUP HCPCS C1713 343060 - SCREW BONE 6.5MM 60MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343065 SUP HCPCS C1713 343065 - SCREW BONE 6.5MM 65MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343070 SUP HCPCS C1713 343070 - SCREW BONE 6.5MM 70MM SS FULTHD CANC LCK HEX DRV BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343075 SUP HCPCS C1713 343075 - SCREW BONE 6.5MM 75MM SS FULTHD CANC LCK HEX DRV BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343080 SUP HCPCS C1713 343080 - SCREW BONE 6.5MM 80MM SS FULTHD CANC LCK HEX DRV BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343085 SUP HCPCS C1713 343085 - SCREW BONE 6.5MM 85MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343090 SUP HCPCS C1713 343090 - SCREW BONE 6.5MM 90MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343095 SUP HCPCS C1713 343095 - SCREW BONE 6.5MM 95MM SS FULTHD CANC BOTH IP/OP $57.00 $42.18 $0.00 $42.31 $23.51 $23.51 $0.00 $0.00 $0.00 $11.88 $42.31 $42.31 $0.00 $0.00 $11.88 $0.00 $33.72 $33.72 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 343100 SUP HCPCS C1713 343100 - SCREW BONE 6.5MM 100MM SS FULTHD CANC BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 343105 SUP HCPCS C1713 343105 - SCREW BONE 6.5MM 105MM SS CANC FULTHRD BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 343110 SUP HCPCS C1713 343110 - SCREW BONE 6.5MM 110MM SS CANC FULTHRD BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 343115 SUP HCPCS C1713 343115 - SCREW BONE 6.5MM 115MM SS CANC FULTHRD BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 343120 SUP HCPCS C1713 343120 - SCREW BONE 6.5MM 120MM ISO SS CANC FULTHRD BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 343125 SUP HCPCS C1713 343125 - SCREW BONE 6.5MM 125MM ISO SS FULTHD CANC HIP NONSTRL BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 343130 SUP HCPCS C1713 343130 - SCREW BONE 6.5MM 130MM ISO SS FULTHD CANC HIP NONSTRL BOTH IP/OP $60.80 $44.99 $0.00 $49.50 $27.84 $27.84 $0.00 $0.00 $0.00 $12.67 $45.13 $45.13 $0.00 $0.00 $12.67 $0.00 $35.96 $35.96 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 345410 SUP HCPCS C1713 345410 - SCREW BONE 4MM 10MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345412 SUP HCPCS C1713 345412 - SCREW BONE 4MM 12MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345414 SUP HCPCS C1713 345414 - SCREW BONE 4MM 14MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345416 SUP HCPCS C1713 345416 - SCREW BONE 4MM 16MM SS FULTHD CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345418 SUP HCPCS C1713 345418 - SCREW BONE 4MM 18MM SS FULTHD CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345420 SUP HCPCS C1713 345420 - SCREW BONE 4MM 20MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345422 SUP HCPCS C1713 345422 - SCREW BONE 4MM 22MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345424 SUP HCPCS C1713 345424 - SCREW BONE 4MM 24MM UNIFLEX SS FULTHD CANC IM NAIL BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345426 SUP HCPCS C1713 345426 - SCREW BONE 4MM 26MM UNIFLEX SS FULTHD CANC IM NAIL BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345428 SUP HCPCS C1713 345428 - SCREW BONE 4MM 28MM ISO SS FULTHD CANC NONSTRL BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345430 SUP HCPCS C1713 345430 - SCREW BONE 4MM 30MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345432 SUP HCPCS C1713 345432 - SCREW BONE 4MM 32MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345434 SUP HCPCS C1713 345434 - SCREW BONE 4MM 34MM UNIFLEX SS FULTHD CANC IM NAIL BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345436 SUP HCPCS C1713 345436 - SCREW BONE 4MM 36MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345438 SUP HCPCS C1713 345438 - SCREW BONE 4MM 38MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345440 SUP HCPCS C1713 345440 - SCREW BONE 4MM 40MM SS FULTHD CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345445 SUP HCPCS C1713 345445 - SCREW BONE 4MM 45MM AXSOS SS 2.5MM FULTHD PROX CANC HUM LCK BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345450 SUP HCPCS C1713 345450 - SCREW BONE 4MM 50MM SS FULTHD CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345455 SUP HCPCS C1713 345455 - SCREW BONE 4MM 55MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345460 SUP HCPCS C1713 345460 - SCREW BONE 4MM 60MM UNIFLEX SS FULTHD CANC IM NAIL BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345465 SUP HCPCS C1713 345465 - SCREW BONE 4MM 65MM AXSOS SS FULTHD CANC HEX DRV LCK BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345470 SUP HCPCS C1713 345470 - SCREW BONE 4MM 70MM ISO SS FULTHD CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345475 SUP HCPCS C1713 345475 - SCREW BONE 4MM 75MM SS FULTHD CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345480 SUP HCPCS C1713 345480 - SCREW BONE 4MM 80MM UNIFLEX SS FULTHD CANC PROX HUM HEX DRV BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345485 SUP HCPCS C1713 345485 - SCREW BONE 4MM 85MM SS FULTHD CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345490 SUP HCPCS C1713 345490 - SCREW BONE 4MM 90MM SS FULTHD CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345495 SUP HCPCS C1713 345495 - SCREW BONE 4MM 95MM ISO SS FULTHD CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345500 SUP HCPCS C1713 345500 - SCREW BONE 4MM 100MM ISO SS FULTHD CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345510 SUP HCPCS C1713 345510 - SCREW BONE 4MM 10MM 5MM SS CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345512 SUP HCPCS C1713 345512 - SCREW BONE 4MM 12MM AXSOS SS PTHRD CANC HUM HEX DRV SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345514 SUP HCPCS C1713 345514 - SCREW BONE 4MM 14MM AXSOS SS PTHRD CANC HUM HEX DRV SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345516 SUP HCPCS C1713 345516 - SCREW BONE 4MM 16MM AXSOS SS PTHRD CANC HUM HEX DRV SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345518 SUP HCPCS C1758 345518 - SCREW BONE 4MM 18MM UNIFLEX SS CANC PTTHRD IM NAIL BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $17.17 $17.17 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345520 SUP HCPCS C1713 345520 - SCREW BONE 4MM 20MM AXSOS SS PTHRD CANC HUM HEX DRV SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345522 SUP HCPCS C1713 345522 - SCREW BONE 4MM 22MM AXSOS SS PTHRD CANC HUM HEX DRV SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345524 SUP HCPCS C1713 345524 - SCREW BONE 4MM 24MM ISO SS PTHRD CANC PARTIL THRD SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345526 SUP HCPCS C1713 345526 - SCREW BONE 4MM 26MM SS CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345528 SUP HCPCS C1713 345528 - SCREW BONE 4MM 28MM UNIFLEX SS CANC PTHRD IM NAIL BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345530 SUP HCPCS C1713 345530 - SCREW BONE 4MM 30MM AXSOS SS PTHRD CANC PTHRD SM FRAG SET BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345532 SUP HCPCS C1713 345532 - SCREW BONE 4MM 32MM 14MM SS CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345534 SUP HCPCS C1713 345534 - SCREW BONE 4MM 34MM 14MM SS CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345536 SUP HCPCS C1713 345536 - SCREW BONE 4MM 36MM 14MM SS CANC PTHRD BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345538 SUP HCPCS C1713 345538 - SCREW BONE 4MM 38MM 14MM SS CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345540 SUP HCPCS C1713 345540 - SCREW BONE 4MM 40MM AXSOS SS PTHRD CANC HUM HEX DRV SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345545 SUP HCPCS C1713 345545 - SCREW BN 2.5MM P/T 4MM 45MM NS HEX SS CANC AXSOS SM FRAG SET BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345550 SUP HCPCS C1713 345550 - SCREW BONE 4MM 50MM AXSOS SS PTHRD CANC PTHRD SM FRAG SET BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345555 SUP HCPCS C1713 345555 - SCREW BONE 4MM 55MM AXSOS SS PTHRD CANC HUM HEX DRV SM FRAG BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345560 SUP HCPCS C1713 345560 - SCREW BONE 4MM 60MM 16MM SS CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345565 SUP HCPCS C1713 345565 - SCREW BONE 4MM 65MM SS CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345570 SUP HCPCS C1713 345570 - SCREW BONE 4MM 70MM 14MM SS CANC BOTH IP/OP $40.50 $29.97 $0.00 $30.06 $14.23 $14.23 $0.00 $0.00 $0.00 $8.44 $30.06 $30.06 $0.00 $0.00 $8.44 $0.00 $23.96 $23.96 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345575 SUP HCPCS C1713 345575 - SCREW BONE 4MM 75MM SS CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345580 SUP HCPCS C1713 345580 - SCREW BONE 4MM 80MM SS CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345585 SUP HCPCS C1713 345585 - SCREW BONE 4MM 85MM 16MM ISO SS CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345590 SUP HCPCS C1713 345590 - SCREW BONE 4MM 90MM 16MM ISO SS CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345595 SUP HCPCS C1713 345595 - SCREW BONE 4MM 95MM AXSOS SS CANC LCK PTHRD BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 345600 SUP HCPCS C1713 345600 - SCREW BONE 4MM 100MM 16MM ISO SS CANC BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $14.23 $14.23 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 348446 SUP HCPCS C1900 348446 - PHILOS II DR SYSTEM BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 350974 SUP HCPCS C1895 350974 - SETROX S 53 LEAD BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 353440 SUP Custom 27203010 PUNCH 7IN 4MM STD TIP STRL LF DISP AOR BOTH IP/OP $335.90 $248.57 $0.00 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.30 $249.30 $0.00 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $232.50 $368.28 $372.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 355149 SUP HCPCS C1900 355149 - COROX OTW 85 BP-S LEAD BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 356053 SUP HCPCS C1900 356053 - CYLOS VR SYSTEM WITH CLS AUTONOMIC RESPONSE BOTH IP/OP "$9,500.00 " "$7,030.00" $0.00 "$7,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,980.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,979.80" $0.00 "$4,683.50" "$4,683.50" $0.00 "$4,750.00" "$7,524.00" "$7,600.00" $0.00 $0.00 "$1,486.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 359654 SUP HCPCS C1721 359654 - LUMAX 340 DR-T HIGH ENERGY WITH HM MOBILE GSM BOTH IP/OP "$46,450.00 " "$34,373.00" $0.00 "$37,160.00" "$20,902.50" "$20,902.50" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,680.18" $0.00 "$22,899.85" "$22,899.85" $0.00 "$23,225.00" "$36,788.40" "$37,160.00" $0.00 $0.00 "$7,269.43" $0.00 $0.00 "$7,394.84" $0.00 $0.00 $0.00 $0.00 $0.00 359655 SUP HCPCS C1721 359655 - LUMAX 340 DR-T HIGH ENERGY SYSTEM WITH HM MOBILE GSM BOTH IP/OP "$56,450.00 " "$41,773.00" $0.00 "$45,160.00" "$25,402.50" "$25,402.50" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$11,764.18" $0.00 "$27,829.85" "$27,829.85" $0.00 "$28,225.00" "$44,708.40" "$45,160.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 359656 SUP HCPCS C1721 359656 - LUMAX 340 DR-T HIGH ENERGY SYSTEM WITH HM LANDLINE BOTH IP/OP "$51,450.00 " "$38,073.00" $0.00 "$41,160.00" "$23,152.50" "$23,152.50" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,722.18" $0.00 "$25,364.85" "$25,364.85" $0.00 "$25,725.00" "$40,748.40" "$41,160.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 359659 SUP HCPCS C1882 359659 - LUMAX 340 HF-T HIGH ENERGY SYSTEM WITH HM MOBILE GSM BOTH IP/OP "$72,600.00 " "$53,724.00" $0.00 "$58,080.00" "$32,670.00" "$32,670.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$15,129.84" $0.00 "$35,791.80" "$35,791.80" $0.00 "$36,300.00" "$57,499.20" "$58,080.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 359662 SUP HCPCS C1882 359662 - LUMAX 340 HF-T HIGH ENERGY SYSTEM WITH HM LANDLINE BOTH IP/OP "$67,600.00 " "$50,024.00" $0.00 "$54,080.00" "$30,420.00" "$30,420.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$14,087.84" $0.00 "$33,326.80" "$33,326.80" $0.00 "$33,800.00" "$53,539.20" "$54,080.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 359664 SUP HCPCS C1786 359664 - LUMAX 340 VR-T HIGH ENERGY WITH HM MOBILE GSM BOTH IP/OP "$42,700.00 " "$31,598.00" $0.00 "$34,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$8,899.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,898.68" $0.00 "$21,051.10" "$21,051.10" $0.00 "$21,350.00" "$33,818.40" "$34,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 359665 SUP HCPCS C1786 359665 - LUMAX 340 VR-T HIGH ENERGY SYSTEM WITH HM MOBILE GSM BOTH IP/OP "$52,700.00 " "$38,998.00" $0.00 "$42,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,982.68" $0.00 "$25,981.10" "$25,981.10" $0.00 "$26,350.00" "$41,738.40" "$42,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 359666 SUP HCPCS C1874 359666 - DFBR CRD LUMAX 340 VR-T AV 1 CHMBR RSYN THRP IMPLTABLE BOTH IP/OP "$47,700.00 " "$35,298.00" $0.00 "$38,160.00" "$21,465.00" "$21,465.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,940.68" $0.00 "$23,516.10" "$23,516.10" $0.00 "$23,850.00" "$37,778.40" "$38,160.00" $0.00 $0.00 "$7,465.05" $0.00 $0.00 "$7,593.84" $0.00 $0.00 $0.00 $0.00 $0.00 360101 SUP Custom 27203010 360101 - DEVICE SPEC RTRVL .018IN 10MM 10CM INTLK DTCH COIL BOTH IP/OP $455.50 $337.07 $0.00 $364.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $338.07 $338.07 $0.00 $0.00 $94.93 $0.00 $0.00 $0.00 $0.00 $227.75 $360.76 $364.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-98 SUP Custom 27803010 06-2898 - HEAD FEM -3MM OFST CTPR 28MM LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 370001 SUP Custom 27803010 370001 - INSERT ACETAB 3MM HIP LCK BOTH IP/OP $71.20 $52.69 $0.00 $59.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.84 $52.84 $0.00 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $37.13 $58.81 $59.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 370002 SUP Custom 27803010 370002 - INSERT ACETAB 4MM SM BONE SS AXSOS PLT SYS BOTH IP/OP $78.40 $58.02 $0.00 $59.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.19 $58.19 $0.00 $0.00 $16.34 $0.00 $0.00 $0.00 $0.00 $37.13 $58.81 $59.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 370003 SUP Custom 27803010 370003 - INSERT TIB LAT DISTAL FEM SS LCK AXSOS 5MM NONSTRL BASIC BOTH IP/OP $96.25 $71.23 $0.00 $77.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.44 $71.44 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 370004 SUP HCPCS C1713 370004 - PLUG CABLE 4MM AXSOS SS SM FRAG BOTH IP/OP $78.40 $58.02 $0.00 $59.40 $33.41 $33.41 $0.00 $0.00 $0.00 $16.34 $58.19 $58.19 $0.00 $0.00 $16.34 $0.00 $46.37 $46.37 $0.00 $37.13 $58.81 $59.40 $0.00 $0.00 $11.62 $0.00 $0.00 $11.82 $0.00 $0.00 $0.00 $0.00 $0.00 370005 SUP HCPCS C1713 370005 - PLUG CABLE 5MM AXSOS LAT DISTAL FEM SS NONSTRL BOTH IP/OP $102.40 $75.78 $0.00 $76.00 $40.22 $40.22 $0.00 $0.00 $0.00 $21.34 $76.00 $76.00 $0.00 $0.00 $21.34 $0.00 $60.57 $60.57 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 370008 SUP HCPCS C1713 370008 - SCREW BONE 3MM 8MM ORTH LCK BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370010 SUP HCPCS C1713 370010 - SCREW BONE 3MM 10MM ORTH LCK BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370012 SUP HCPCS C1713 370012 - SCREW BONE 3MM 12MM AXSOS SS CORT T8 DRV LCK SLFTAP BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370014 SUP HCPCS C1713 370014 - SCREW BONE 3MM 14MM AXSOS SS CORT T8 DRV LCK SLFTAP BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370016 SUP HCPCS C1713 370016 - SCREW BONE 3MM 16MM AXSOS SS CORT T8 DRV LCK SLFTAP BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370018 SUP HCPCS C1713 370018 - SCREW BONE 3MM 18MM AXSOS SS HUM FEM/TIB T8 DRV LCK SLFTAP BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370020 SUP HCPCS C1713 370020 - SCREW BONE 3MM 20MM ORTH LCK BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370022 SUP HCPCS C1713 370022 - SCREW BONE 3MM 22MM ORTH LCK BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370024 SUP HCPCS C1713 370024 - SCREW BONE 3MM 24MM AXSOS SS CORT T8 DRV LCK SLFTAP BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370026 SUP HCPCS C1713 370026 - SCREW BONE 3MM 26MM ORTH LCK BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370028 SUP HCPCS C1713 370028 - SCREW BONE 3MM 28MM ORTH LCK BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370030 SUP HCPCS C1713 370030 - SCREW BONE 3MM 30MM AXSOS SS CORT T8 DRV LCK SLFTAP BOTH IP/OP $132.00 $97.68 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $27.51 $97.97 $97.97 $0.00 $0.00 $27.51 $0.00 $78.08 $78.08 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 370110 SUP HCPCS C1713 370110 - SCREW BONE 5MM 10MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $260.80 $192.99 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.36 $193.57 $193.57 $0.00 $0.00 $54.35 $0.00 $154.26 $154.26 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 370112 SUP HCPCS C1713 370112 - SCREW BONE 5MM 12MM AXSOS SS HUM FEM/TIB SLFTAP LCK T15 DRV BOTH IP/OP $260.80 $192.99 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.36 $193.57 $193.57 $0.00 $0.00 $54.35 $0.00 $154.26 $154.26 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 370114 SUP HCPCS C1713 370114 - SCREW BONE 5MM 14MM AXSOS DISTAL LAT FEM SLFTAP LCK T20 DRV BOTH IP/OP $260.80 $192.99 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.36 $193.57 $193.57 $0.00 $0.00 $54.35 $0.00 $154.26 $154.26 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 370116 SUP HCPCS C1713 370116 - SCREW BONE 5MM 16MM AXSOS SS HUM FEM/TIB SLFTAP LCK T20 DRV BOTH IP/OP $260.80 $192.99 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.36 $193.57 $193.57 $0.00 $0.00 $54.35 $0.00 $154.26 $154.26 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 370118 SUP HCPCS C1713 370118 - SCREW BONE 5MM 18MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $260.80 $192.99 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.36 $193.57 $193.57 $0.00 $0.00 $54.35 $0.00 $154.26 $154.26 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 370120 SUP HCPCS C1713 370120 - SCREW BONE 5MM 20MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $260.80 $192.99 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.36 $193.57 $193.57 $0.00 $0.00 $54.35 $0.00 $154.26 $154.26 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 370314 SUP HCPCS C1713 370314 - SCREW BONE 5MM 14MM ORTH LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370316 SUP HCPCS C1713 370316 - SCREW BONE 5MM 16MM ORTH LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370318 SUP HCPCS C1713 370318 - SCREW BONE 5MM 18MM AXSOS SS HUM FEM/TIB SLFTAP LCK T20 DRV BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370320 SUP HCPCS C1713 370320 - SCREW BONE 5MM 20MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370322 SUP HCPCS C1713 370322 - SCREW BONE 5MM 22MM ORTH LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370324 SUP HCPCS C1713 370324 - SCREW BONE 5MM 24MM ORTH LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370326 SUP HCPCS C1713 370326 - SCREW BONE 5MM 26MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370328 SUP HCPCS C1713 370328 - SCREW BONE 5MM 28MM AXSOS SS LCK SLFTAP T20 DRV PLT SYS BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370330 SUP HCPCS C1713 370330 - SCREW BONE 5MM 30MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370332 SUP HCPCS C1713 370332 - SCREW BONE 5MM 32MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370334 SUP HCPCS C1713 370334 - SCREW BONE 5MM 34MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370336 SUP HCPCS C1713 370336 - SCREW BONE 5MM 36MM AXSOS SS HUM FEM/TIB T20 DRV SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370338 SUP HCPCS C1713 370338 - SCREW BONE 5MM 38MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370340 SUP HCPCS C1713 370340 - SCREW BONE 5MM 40MM AXSOS SS DISTAL LAT FEM LCK SLFTAP T20 BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370342 SUP HCPCS C1713 370342 - SCREW BONE 5MM 42MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370344 SUP HCPCS C1713 370344 - SCREW BONE 5MM 44MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370346 SUP HCPCS C1713 370346 - SCREW BONE 5MM 46MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370348 SUP HCPCS C1713 370348 - SCREW BONE 5MM 48MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370350 SUP HCPCS C1713 370350 - SCREW BONE 5MM 50MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370355 SUP HCPCS C1713 370355 - SCREW BONE 5MM 55MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370360 SUP HCPCS C1713 370360 - SCREW BONE 5MM 60MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370365 SUP HCPCS C1713 370365 - SCREW BONE 5MM 65MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370370 SUP HCPCS C1713 370370 - SCREW BONE 5MM 70MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370375 SUP HCPCS C1713 370375 - SCREW BONE 5MM 75MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370380 SUP HCPCS C1713 370380 - SCREW BONE 5MM 80MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370385 SUP HCPCS C1713 370385 - SCREW BONE 5MM 85MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370390 SUP HCPCS C1713 370390 - SCREW BONE 5MM 90MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370395 SUP HCPCS C1713 370395 - SCREW BONE 5MM 95MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 370400 SUP HCPCS C1713 370400 - SCREW BONE 5MM 100MM ORTH LCK BOTH IP/OP $196.63 $145.51 $0.00 $157.30 $88.48 $88.48 $0.00 $0.00 $0.00 $40.98 $145.94 $145.94 $0.00 $0.00 $40.98 $0.00 $116.30 $116.30 $0.00 $98.31 $155.73 $157.30 $0.00 $0.00 $30.77 $0.00 $0.00 $31.30 $0.00 $0.00 $0.00 $0.00 $0.00 370405 SUP HCPCS C1713 370405 - SCREW BONE 5MM 105MM ORTH LCK BOTH IP/OP $196.63 $145.51 $0.00 $157.30 $88.48 $88.48 $0.00 $0.00 $0.00 $40.98 $145.94 $145.94 $0.00 $0.00 $40.98 $0.00 $116.30 $116.30 $0.00 $98.31 $155.73 $157.30 $0.00 $0.00 $30.77 $0.00 $0.00 $31.30 $0.00 $0.00 $0.00 $0.00 $0.00 370410 SUP HCPCS C1713 370410 - SCREW BONE 5MM 110MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $196.63 $145.51 $0.00 $157.30 $88.48 $88.48 $0.00 $0.00 $0.00 $40.98 $145.94 $145.94 $0.00 $0.00 $40.98 $0.00 $116.30 $116.30 $0.00 $98.31 $155.73 $157.30 $0.00 $0.00 $30.77 $0.00 $0.00 $31.30 $0.00 $0.00 $0.00 $0.00 $0.00 370415 SUP HCPCS C1713 370415 - SCREW BONE 5MM 115MM ORTH LCK BOTH IP/OP $196.63 $145.51 $0.00 $157.30 $88.48 $88.48 $0.00 $0.00 $0.00 $40.98 $145.94 $145.94 $0.00 $0.00 $40.98 $0.00 $116.30 $116.30 $0.00 $98.31 $155.73 $157.30 $0.00 $0.00 $30.77 $0.00 $0.00 $31.30 $0.00 $0.00 $0.00 $0.00 $0.00 370420 SUP HCPCS C1713 370420 - SCREW BONE 5MM 120MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $196.63 $145.51 $0.00 $157.30 $88.48 $88.48 $0.00 $0.00 $0.00 $40.98 $145.94 $145.94 $0.00 $0.00 $40.98 $0.00 $116.30 $116.30 $0.00 $98.31 $155.73 $157.30 $0.00 $0.00 $30.77 $0.00 $0.00 $31.30 $0.00 $0.00 $0.00 $0.00 $0.00 370514 SUP HCPCS C1713 370514 - SCREW BONE 4MM 14MM AXSOS SS HUM FEM/TIB T15 DRV LCK SLFTAP BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370516 SUP HCPCS C1713 370516 - SCREW BONE 4MM 16MM AXSOS SS HUM FEM/TIB T15 DRV LCK SLFTAP BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370518 SUP HCPCS C1713 370518 - SCREW BONE 4MM 18MM AXSOS SS HUM FEM/TIB T15 DRV LCK SLFTAP BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370520 SUP HCPCS C1713 370520 - SCREW BONE 4MM 20MM AXSOS SS HUM FEM/TIB T15 DRV LCK SLFTAP BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370522 SUP HCPCS C1713 370522 - SCREW BONE 4MM 22MM AXSOS SS HUM FEM/TIB T15 DRV LCK SLFTAP BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370524 SUP HCPCS C1713 370524 - SCREW BONE 4MM 24MM AXSOS SS HUM FEM/TIB SLFTAP LCK T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370526 SUP HCPCS C1713 370526 - SCREW BONE 4MM 26MM AXSOS SS HUM FEM/TIB SLFTAP LCK T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370528 SUP HCPCS C1713 370528 - SCREW BONE 4MM 28MM AXSOS SS LCK SLFTAP T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370530 SUP HCPCS C1713 370530 - SCREW BONE 4MM 30MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370532 SUP HCPCS C1713 370532 - SCREW BONE 4MM 32MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370534 SUP HCPCS C1713 370534 - SCREW BONE 4MM 34MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370536 SUP HCPCS C1713 370536 - SCREW BONE 4MM 36MM AXSOS SS HUM FEM/TIB SLFTAP LCK T20 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370538 SUP HCPCS C1713 370538 - SCREW BONE 4MM 38MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370540 SUP HCPCS C1713 370540 - SCREW BONE 4MM 40MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370542 SUP HCPCS C1713 370542 - SCREW BONE 4MM 42MM AXSOS SS LCK SLFTAP T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370544 SUP HCPCS C1713 370544 - SCREW BONE 4MM 44MM AXSOS SS HUM FEM/TIB SLFTAP LCK T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370546 SUP HCPCS C1713 370546 - SCREW BONE 4MM 46MM AXSOS SS LCK SLFTAP T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370548 SUP HCPCS C1713 370548 - SCREW BONE 4MM 48MM AXSOS SS HUM FEM/TIB LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370550 SUP HCPCS C1713 370550 - SCREW BONE 4MM 50MM AXSOS SS LCK SLFTAP T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370555 SUP HCPCS C1713 370555 - SCREW BONE 4MM 55MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370560 SUP HCPCS C1713 370560 - SCREW BONE 4MM 60MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370565 SUP HCPCS C1713 370565 - SCREW BONE 4MM 65MM AXSOS SS HUM FEM/TIB SLFTAP LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370570 SUP HCPCS C1713 370570 - SCREW BONE 4MM 70MM AXSOS SS SLFTAP LCK T15 DRV NONSTRL BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370575 SUP HCPCS C1713 370575 - SCREW BONE 4MM 75MM AXSOS SS HUM FEM/TIB SLFTAP LCK T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370580 SUP HCPCS C1713 370580 - SCREW BONE 4MM 80MM AXSOS SS HUM FEM/TIB SLFTAP LCK T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370585 SUP HCPCS C1713 370585 - SCREW BONE 4MM 85MM AXSOS SS HUM FEM/TIB SLFTAP LCK T20 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370590 SUP HCPCS C1713 370590 - SCREW BONE 4MM 90MM AXSOS SS HUM FEM/TIB SLFTAP LCK T15 DRV BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370595 SUP HCPCS C1713 370595 - SCREW BONE 3.5MM 95MM AXSOS SS HUM FEM/TIB ST LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370600 SUP HCPCS C1713 370600 - SCREW BONE 4MM 100MM ORTH LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370605 SUP HCPCS C1713 370605 - SCREW BONE 4MM 105MM ORTH LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370610 SUP HCPCS C1713 370610 - SCREW BONE 4MM 110MM ORTH LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370615 SUP HCPCS C1713 370615 - SCREW BONE 4MM 115MM ORTH LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 370620 SUP HCPCS C1713 370620 - SCREW BONE 4MM 120MM ORTH LCK BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 371008 SUP HCPCS C1713 371008 - SCREW BONE 3MM 8MM AXSOS T8 DRV LCK SLFTAP BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371010 SUP HCPCS C1713 371010 - SCREW BONE 3MM 10MM AXSOS SS LCK SLFTAP T8 DRV BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371012 SUP HCPCS C1713 371012 - SCREW BONE 3MM 12MM AXSOS LCK BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371014 SUP HCPCS C1713 371014 - SCREW BONE 3MM 14MM AXSOS SS PERIART LCK SLFTAP T8 DRV BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371016 SUP HCPCS C1713 371016 - SCREW BONE 3MM 16MM AXSOS SS PERIART LCK SLFTAP T8 DRV BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371018 SUP HCPCS C1713 371018 - SCREW BONE 3MM 18MM AXSOS SS PERIART LCK SLFTAP T8 DRV BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371020 SUP HCPCS C1713 371020 - SCREW BONE 3MM 20MM AXSOS SS PERIART T8 DRV LCK SLFTAP BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371022 SUP HCPCS C1713 371022 - SCREW BONE 3MM 22MM AXSOS SS LCK SLFTAP T8 DRV BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371024 SUP HCPCS C1713 371024 - SCREW BONE 3MM 24MM AXSOS T8 DRV LCK SLFTAP BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371026 SUP HCPCS C1713 371026 - SCREW BONE 3MM 26MM AXSOS T8 DRV LCK SLFTAP BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371028 SUP HCPCS C1713 371028 - SCREW BONE 3MM 28MM AXSOS T8 DRV LCK SLFTAP BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371030 SUP HCPCS C1713 371030 - SCREW BONE 3MM 30MM AXSOS SS PERIART LCK SLFTAP T8 DRV BOTH IP/OP $123.20 $91.17 $0.00 $105.60 $59.40 $59.40 $0.00 $0.00 $0.00 $25.68 $91.44 $91.44 $0.00 $0.00 $25.67 $0.00 $72.87 $72.87 $0.00 $66.00 $104.54 $105.60 $0.00 $0.00 $20.66 $0.00 $0.00 $21.01 $0.00 $0.00 $0.00 $0.00 $0.00 371314 SUP HCPCS C1713 371314 - LOCKING SCREW AXSOS 5.0MM / L14MM BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371316 SUP HCPCS C1713 371316 - LOCKING SCREW AXSOS 5.0MM / L16MM BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371318 SUP HCPCS C1713 371318 - SCREW BONE 5MM 18MM AXSOS SS LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371320 SUP HCPCS C1713 371320 - SCREW BONE 5MM 20MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371322 SUP HCPCS C1713 371322 - LOCKING SCREW AXSOS 5.0MM / L22MM BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371324 SUP HCPCS C1713 371324 - SCREW BONE 5MM 24MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371326 SUP HCPCS C1713 371326 - SCREW BONE 5MM 26MM AXSOS SS LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371328 SUP HCPCS C1713 371328 - SCREW BONE 5MM 28MM AXOS SS T20 DRV LCK SLFTAP NONSTRL BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371330 SUP HCPCS C1713 371330 - SCREW BONE 5MM 30MM AXSOS SS HUM FEM/TIB LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371332 SUP HCPCS C1713 371332 - SCREW BONE 5MM 32MM AXSOS SS HUM FEM/TIB LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371334 SUP HCPCS C1713 371334 - SCREW BONE 5MM 34MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371336 SUP HCPCS C1713 371336 - LOCKING SCREW AXSOS 5.0MM / L36MM BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371338 SUP HCPCS C1713 371338 - SCREW BONE 5MM 38MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371340 SUP HCPCS C1713 371340 - SCREW BONE 5MM 40MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371342 SUP HCPCS C1713 371342 - SCREW BONE 5MM 42MM AXSOS SS HUM FEM/TIB LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371344 SUP HCPCS C1713 371344 - SCREW BONE 5MM 44MM AXSOS SS LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371346 SUP HCPCS C1713 371346 - SCREW BONE 5MM 46MM AXSOS SS LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371348 SUP HCPCS C1713 371348 - SCREW BONE 5MM 48MM AXSOS SS LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371350 SUP HCPCS C1713 371350 - SCREW BONE 5MM 50MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371355 SUP HCPCS C1713 371355 - SCREW BONE 5MM 55MM AXSOS SS LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371360 SUP HCPCS C1713 371360 - SCREW BONE 5MM 60MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371365 SUP HCPCS C1713 371365 - SCREW BONE 5MM 65MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371370 SUP HCPCS C1713 371370 - SCREW BONE 5MM 70MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371375 SUP HCPCS C1713 371375 - SCREW BONE 5MM 75MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371380 SUP HCPCS C1713 371380 - SCREW BONE 5MM 80MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371385 SUP HCPCS C1713 371385 - SCREW BONE 5MM 85MM AXSOS SS LCK BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371390 SUP HCPCS C1713 371390 - SCREW BONE 5MM 90MM AXSOS SS LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371395 SUP HCPCS C1713 371395 - SCREW BONE 5MM 95MM AXSOS SS PERIART LCK SLFTAP T20 DRV BOTH IP/OP $228.00 $168.72 $0.00 $169.22 $94.05 $94.05 $0.00 $0.00 $0.00 $47.52 $169.22 $169.22 $0.00 $0.00 $47.52 $0.00 $134.86 $134.86 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 371514 SUP HCPCS C1713 371514 - SCREW BONE 4MM 14MM SS T15 SLFTAP LCK DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371516 SUP HCPCS C1713 371516 - SCREW BONE 4MM 16MM SS LCK SLFTAP T15 DRV NONSTRL BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371518 SUP HCPCS C1713 371518 - SCREW BONE 4MM 18MM AXSOS SS LCK SLFTAP T15 DRV NONSTRL BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371520 SUP HCPCS C1713 371520 - SCREW BN T15 4MM 20MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371522 SUP HCPCS C1713 371522 - SCREW BN T15 4MM 22MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371524 SUP HCPCS C1713 371524 - SCREW BN T15 4MM 24MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371526 SUP HCPCS C1713 371526 - SCREW BN T15 4MM 26MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371528 SUP HCPCS C1713 371528 - SCREW BN T15 4MM 28MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371530 SUP HCPCS C1713 371530 - SCREW BN T15 4MM 30MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371532 SUP HCPCS C1713 371532 - SCREW BN T15 4MM 32MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371534 SUP HCPCS C1713 371534 - SCREW BN T15 4MM 34MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371536 SUP HCPCS C1713 371536 - SCREW BN T15 4MM 36MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371538 SUP HCPCS C1713 371538 - SCREW BN T15 4MM 38MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371540 SUP HCPCS C1713 371540 - SCREW BONE 4MM 40MM AXSOS SS PERIART LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371542 SUP HCPCS C1713 371542 - SCREW BONE 4MM 42MM AXSOS SS PERIART LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371544 SUP HCPCS C1713 371544 - SCREW BONE 4MM 44MM AXSOS SS PERIART LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371546 SUP HCPCS C1713 371546 - SCREW BONE 4MM 46MM AXSOS SS PERIART LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371548 SUP HCPCS C1713 371548 - SCREW BN T15 4MM 48MM NS ST LCK SS AXSOS SM FRAG SET XTRMT BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371550 SUP HCPCS C1713 371550 - SCREW BONE 4MM 50MM AXSOS SS HUM FEM/TIB LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371555 SUP HCPCS C1713 371555 - SCREW BONE 4MM 55MM AXSOS SS PERIART LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371560 SUP HCPCS C1713 371560 - SCREW BONE 4MM 60MM AXSOS SS PERIART LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371565 SUP HCPCS C1713 371565 - SCREW BONE 4MM 65MM AXSOS SS LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371570 SUP HCPCS C1713 371570 - SCREW BONE T15 4MM 70MM SELF TAP LOCK AXSOS STAINLESS STEEL BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371575 SUP HCPCS C1713 371575 - SCREW BONE 4MM 75MM AXSOS SS LCK SLFTAP T15 DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371580 SUP HCPCS C1713 371580 - SCREW BONE 4MM 80MM AXSOS LCK BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371585 SUP HCPCS C1713 371585 - SCREW BONE 4MM 85MM AXSOS SS T15 SLFTAP LCK DRV BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371590 SUP HCPCS C1713 371590 - SCREW BONE 4MM 90MM AXSOS SS T15 DRV SLFTAP LCK BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 371595 SUP HCPCS C1713 371595 - LOCKING SCREW AXSOS 4.0MM / L95MM BOTH IP/OP $204.80 $151.55 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $42.69 $152.00 $152.00 $0.00 $0.00 $42.68 $0.00 $121.14 $121.14 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 372615 SUP HCPCS C1713 372615 - SCALPEL SURG 15 1 HAND ACTIVATION LOCK RETRACTABLE SHIELD BOTH IP/OP $36.48 $27.00 $0.00 $29.62 $16.66 $16.66 $0.00 $0.00 $0.00 $7.60 $27.07 $27.07 $0.00 $0.00 $7.60 $0.00 $21.57 $21.57 $0.00 $18.51 $29.32 $29.62 $0.00 $0.00 $5.79 $0.00 $0.00 $5.89 $0.00 $0.00 $0.00 $0.00 $0.00 373741 SUP Custom 27203010 373741 - KNIFE OPHTHALMIC 45D ANGLED 4.1MM BEVEL UP PHACO SLIT MATTE BOTH IP/OP $30.07 $22.25 $0.00 $24.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.32 $22.32 $0.00 $0.00 $6.27 $0.00 $0.00 $0.00 $0.00 $15.03 $23.82 $24.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 373808 SUP Custom 27203010 373808 - SCALPEL SURG 2.5MM 2.5MM STR ROUND TIP CRESCENT OPHTHALMIC BOTH IP/OP $34.30 $25.38 $0.00 $69.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.46 $25.46 $0.00 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $16.90 $69.44 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 378227 SUP Custom 27203010 378227 - KNIFE OPHTHALMIC 45D BEVEL 2.75MM BLADE MATTE FINISH SLIT BD BOTH IP/OP $35.63 $26.37 $0.00 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.44 $26.44 $0.00 $0.00 $7.42 $0.00 $0.00 $0.00 $0.00 $17.81 $28.22 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 378230 SUP Custom 27203010 378230 - KNIFE OPHTHALMIC 45D BEVEL 3MM PHACO SLIT SAFETY MATTE BOTH IP/OP $35.63 $26.37 $0.00 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.44 $26.44 $0.00 $0.00 $7.42 $0.00 $0.00 $0.00 $0.00 $17.81 $28.22 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 378231 SUP Custom 27203010 378231 - KNIFE OPHTHALMIC 20D .9MM 3MM SAFETY SIDEPORT RETRACTABLE BOTH IP/OP $48.69 $36.03 $0.00 $103.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.13 $36.13 $0.00 $0.00 $10.15 $0.00 $0.00 $0.00 $0.00 $64.44 $102.07 $103.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 381112 SUP HCPCS C1729 CATHETER IV 24GA .75IN RADIOPQ YLW ANGCTH TFLN STRL LF BOTH IP/OP $4.45 $3.29 $0.00 $3.56 $2.42 $2.42 $0.00 $0.00 $0.00 $0.93 $3.30 $3.30 $0.00 $0.00 $0.93 $0.00 $2.63 $2.63 $0.00 $2.23 $3.52 $3.56 $0.00 $0.00 $0.70 $0.00 $0.00 $0.71 $0.00 $0.00 $0.00 $0.00 $0.00 381137 SUP HCPCS C1729 CATHETER IV 20GA 1.88IN RADIOPQ PNK ANGCTH TFLN STRL LF BOTH IP/OP $9.18 $6.79 $0.00 $7.34 $4.98 $4.98 $0.00 $0.00 $0.00 $1.91 $6.81 $6.81 $0.00 $0.00 $1.91 $0.00 $5.43 $5.43 $0.00 $4.59 $7.27 $7.34 $0.00 $0.00 $1.44 $0.00 $0.00 $1.46 $0.00 $0.00 $0.00 $0.00 $0.00 381144 SUP HCPCS C1729 CATHETER IV 18GA 1.16IN RADIOPQ GRN ANGCTH TFLN STRL LF BOTH IP/OP $9.93 $7.35 $0.00 $7.94 $5.39 $5.39 $0.00 $0.00 $0.00 $2.07 $7.37 $7.37 $0.00 $0.00 $2.07 $0.00 $5.87 $5.87 $0.00 $4.96 $7.86 $7.94 $0.00 $0.00 $1.55 $0.00 $0.00 $1.58 $0.00 $0.00 $0.00 $0.00 $0.00 381511 SUP HCPCS C1729 CATHETER IV 24GA .56IN RADIOPQ SFSHLD WNG YLW INST-N ATGRD BOTH IP/OP $6.65 $4.92 $0.00 $5.32 $3.61 $3.61 $0.00 $0.00 $0.00 $1.39 $4.94 $4.94 $0.00 $0.00 $1.39 $0.00 $3.93 $3.93 $0.00 $3.33 $5.27 $5.32 $0.00 $0.00 $1.04 $0.00 $0.00 $1.06 $0.00 $0.00 $0.00 $0.00 $0.00 381512 SUP HCPCS C1729 CATHETER IV 24GA .75IN RADIOPQ SFSHLD WNG YLW INST-N ATGRD BOTH IP/OP $4.93 $3.65 $0.00 $3.94 $2.67 $2.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.46 $3.90 $3.94 $0.00 $0.00 $0.77 $0.00 $0.00 $0.78 $0.00 $0.00 $0.00 $0.00 $0.00 381523 SUP HCPCS C1729 CATHETER IV 22GA 1IN RADIOPQ SFSHLD WNG BLUE INST-N ATGRD BOTH IP/OP $4.78 $3.54 $0.00 $3.82 $2.59 $2.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.39 $3.79 $3.82 $0.00 $0.00 $0.75 $0.00 $0.00 $0.76 $0.00 $0.00 $0.00 $0.00 $0.00 381533 SUP HCPCS C1729 CATHETER IV 20GA 1IN RADIOPQ SFSHLD WNG PNK INST AGRD VLN BOTH IP/OP $4.53 $3.35 $0.00 $3.62 $2.46 $2.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.26 $3.59 $3.62 $0.00 $0.00 $0.71 $0.00 $0.00 $0.72 $0.00 $0.00 $0.00 $0.00 $0.00 382259 SUP HCPCS C1729 CATHETER IV 16GA 5.25IN RADIOPQ YLW ANGCTH TFLN STRL LF BOTH IP/OP $33.00 $24.42 $0.00 $36.36 $15.46 $15.46 $0.00 $0.00 $0.00 $6.88 $24.49 $24.49 $0.00 $0.00 $6.88 $0.00 $36.36 $36.36 $0.00 $14.24 $22.56 $22.78 $0.00 $0.00 $4.46 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 382269 SUP HCPCS C1729 CATHETER IV 14GA 5.25IN RADIOPQ SFSHLD ORNG ANGCTH TFLN STRL BOTH IP/OP $33.00 $24.42 $0.00 $36.36 $15.46 $15.46 $0.00 $0.00 $0.00 $6.88 $24.49 $24.49 $0.00 $0.00 $6.88 $0.00 $36.36 $36.36 $0.00 $14.24 $22.56 $22.78 $0.00 $0.00 $4.46 $0.00 $0.00 $4.53 $0.00 $0.00 $0.00 $0.00 $0.00 382861 SUP HCPCS C1898 "382861 - PASSIVE FIXATION PACING LEAD, J-SHAPE, SILICONE INSULATION," BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 382866 SUP HCPCS C1898 "382866 - PASSIVE FIXATION PACING LEAD, J-SHAPE, SILICONE INSULATION," BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 382872 SUP HCPCS C1898 "382872 - PASSIVE FIXATION PACING LEAD, STRAIGHT, SILICONE INSULATION," BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 382878 SUP HCPCS C1898 "382878 - PASSIVE FIXATION PACING LEAD, STRAIGHT, SILICONE INSULATION," BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 382884 SUP HCPCS C1898 382884 - LEAD PCNG HLX 45CM SIL ATR TILDA BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 382889 SUP HCPCS C1895 382889 - LEAD PCNG HLX 53CM SIL ATR TILDA BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 382895 SUP HCPCS C1895 382895 - LEAD PCNG HLX 60CM SIL VNTRC TILDA BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 382903 SUP HCPCS C1777 382903 - LEAD PCNG 65CM VIGILA BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 382918 SUP HCPCS C1721 "382918 - PASSIVE FIXATION, DUAL COIL, SILICONE INSULATION, 65 CM, 18" BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 382924 SUP HCPCS C1721 "382924 - ACTIVE FIXATION, DUAL COIL, SILICONE INSULATION, 60 CM, 16 C" BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 382936 SUP HCPCS C1721 "382936 - ACTIVE FIXATION, DUAL COIL, SILICONE INSULATION, 65 CM, 18 C" BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 382961 SUP HCPCS C1900 382961 - LEFT VENTRICULAR LEAD WITH 3D PRE-SHAPED HELIX AT DISTAL END BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 382972 SUP HCPCS C1900 382972 - LEFT VENTRICULAR LEAD WITH PRE-SHAPED BEND AND THREAD FIXATI BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 383395 SUP HCPCS C1900 "383395 - LEFT VENTRICULAR LEAD WITH 2D PRE-SHAPED BEND AT DISTAL END," BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 384021 SUP HCPCS C1887 INTRODUCER CATH 26GA 1.9FR INTRST-N NEO BOTH IP/OP $96.18 $71.17 $0.00 $76.94 $52.22 $52.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.09 $76.17 $76.94 $0.00 $0.00 $15.05 $0.00 $0.00 $15.31 $0.00 $0.00 $0.00 $0.00 $0.00 384232 SUP HCPCS C1729 CATHETER CEN VEN 1.9FR 50CM 1 LUM PICC 1ST PICC SIL BOTH IP/OP $143.63 $106.29 $0.00 $114.90 $77.99 $77.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.81 $113.75 $114.90 $0.00 $0.00 $22.48 $0.00 $0.00 $22.87 $0.00 $0.00 $0.00 $0.00 $0.00 384825 SUP Custom 27203010 TRAY PRC DRSG SCSR TRNQT NEO BOTH IP/OP $110.10 $81.47 $0.00 $88.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.05 $87.20 $88.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 386358 SUP Custom 27203010 CALIBRATOR CA 125 ACCES OV MONITR VL 2.5ML IMMUN BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 386371 SUP Custom 27203010 REAGENT CKMB ACCES 100 TST ANALY BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 386372 SUP Custom 27203010 CALIBRATOR CHM SET CK-MB ACCES 6X2ML BOTH IP/OP $264.45 $195.69 $0.00 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.23 $209.44 $211.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 390016 SUP HCPCS C1713 390016 - WASHER 6.6MM CANN ASNS 3 ORTH SS 8IN 6.5/8MM SCR BOTH IP/OP $59.13 $43.76 $0.00 $47.30 $26.61 $26.61 $0.00 $0.00 $0.00 $12.32 $43.88 $43.88 $0.00 $0.00 $12.32 $0.00 $34.97 $34.97 $0.00 $29.56 $46.83 $47.30 $0.00 $0.00 $9.25 $0.00 $0.00 $9.41 $0.00 $0.00 $0.00 $0.00 $0.00 390017 SUP HCPCS C1713 390017 - WASHER 5MM ASNS 3 ORTH SS 7MM CANN SCR BOTH IP/OP $46.75 $34.60 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $9.74 $34.70 $34.70 $0.00 $0.00 $9.74 $0.00 $27.65 $27.65 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 390018 SUP HCPCS C1713 390018 - WASHER 8MM ASNS 3 ORTH SS 7MM CANN SCR BOTH IP/OP $46.75 $34.60 $0.00 $39.60 $22.28 $22.28 $0.00 $0.00 $0.00 $9.74 $34.70 $34.70 $0.00 $0.00 $9.74 $0.00 $27.65 $27.65 $0.00 $24.75 $39.20 $39.60 $0.00 $0.00 $7.75 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $0.00 390019 SUP HCPCS C1713 390019 - WASHER 9MM ASNS 3 ORTH SS 8IN 3.5MM CANN SCR BOTH IP/OP $50.88 $37.65 $0.00 $40.70 $22.89 $22.89 $0.00 $0.00 $0.00 $10.60 $37.76 $37.76 $0.00 $0.00 $10.60 $0.00 $30.09 $30.09 $0.00 $25.44 $40.30 $40.70 $0.00 $0.00 $7.96 $0.00 $0.00 $8.10 $0.00 $0.00 $0.00 $0.00 $0.00 390083 SUP HCPCS C1713 390083 - PIN HLD 5MM ORTH REDX 150MM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 390084 SUP HCPCS C1713 390084 - PIN HLD 5MM ORTH REDX SS 180MM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 390086 SUP HCPCS C1713 390086 - PIN HALF 150MM 6MM PLVC SS SLF CUT REDX BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 390087 SUP HCPCS C1713 390087 - PIN HLD 6MM ORTH REDX 180MM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 390181 SUP HCPCS C1713 390181 - WIRE FX 2.5MM 285MM NS KRSH TROC PNT SS BOTH IP/OP $136.00 $100.64 $0.00 $112.20 $63.11 $63.11 $0.00 $0.00 $0.00 $28.35 $100.94 $100.94 $0.00 $0.00 $28.34 $0.00 $80.44 $80.44 $0.00 $70.13 $111.08 $112.20 $0.00 $0.00 $21.95 $0.00 $0.00 $22.33 $0.00 $0.00 $0.00 $0.00 $0.00 390195 SUP HCPCS C1713 390195 - WIRE FX 3MM 285MM NS KRSH TROC PNT SS BOTH IP/OP $129.25 $95.65 $0.00 $103.40 $58.16 $58.16 $0.00 $0.00 $0.00 $26.94 $95.93 $95.93 $0.00 $0.00 $26.94 $0.00 $76.45 $76.45 $0.00 $64.63 $102.37 $103.40 $0.00 $0.00 $20.23 $0.00 $0.00 $20.58 $0.00 $0.00 $0.00 $0.00 $0.00 397003 SUP HCPCS C1713 397003 - CEMENT BONE SLF SET INJ OSTCNDC HYDROSET BONE SUB VOID FILR BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$2,018.10" "$1,135.18" "$1,135.18" $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,261.31" "$1,997.92" "$2,018.10" $0.00 $0.00 $394.79 $0.00 $0.00 $401.60 $0.00 $0.00 $0.00 $0.00 $0.00 397005 SUP HCPCS C1713 397005 - CEMENT BONE HYDROSET CALCIUM PHOS 5ML INJ SLF SET VOID FILR BOTH IP/OP "$3,285.00 " "$2,430.90" $0.00 "$3,236.40" "$1,820.48" "$1,820.48" $0.00 $0.00 $0.00 $684.68 "$2,438.13" "$2,438.13" $0.00 $0.00 $684.59 $0.00 "$1,619.51" "$1,619.51" $0.00 "$2,022.75" "$3,204.04" "$3,236.40" $0.00 $0.00 $633.12 $0.00 $0.00 $644.04 $0.00 $0.00 $0.00 $0.00 $0.00 397010 SUP HCPCS C1713 397010 - CEMENT BONE SLF SET INJ OSTCNDC HYDROSET BONE SUB VOID FILR BOTH IP/OP "$6,252.50 " "$4,626.85" $0.00 "$6,221.70" "$3,499.71" "$3,499.71" $0.00 $0.00 $0.00 "$1,303.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,303.02" $0.00 "$3,082.48" "$3,082.48" $0.00 "$3,888.56" "$6,159.49" "$6,221.70" $0.00 $0.00 "$1,217.12" $0.00 $0.00 "$1,238.12" $0.00 $0.00 $0.00 $0.00 $0.00 397015 SUP HCPCS C1713 397015 - CEMENT BONE HYDROSET BONE SUB VOID FILR CALCIUM PHOS 15ML BOTH IP/OP "$8,970.94 " "$6,638.50" $0.00 "$8,928.00" "$5,022.00" "$5,022.00" $0.00 $0.00 $0.00 "$1,869.77" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,869.54" $0.00 "$4,422.67" "$4,422.67" $0.00 "$5,580.00" "$8,838.72" "$8,928.00" $0.00 $0.00 "$1,746.54" $0.00 $0.00 "$1,776.67" $0.00 $0.00 $0.00 $0.00 $0.00 400077 SUP Custom 27203010 400077 - SEAL CNN 8MM DVNC EWRST DISP BOTH IP/OP $3.75 $2.78 $0.00 $3.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.78 $2.78 $0.00 $0.00 $0.78 $0.00 $0.00 $0.00 $0.00 $1.88 $2.97 $3.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400180 SUP Custom 27203010 400180 - COVER ESCP TIP 8MM STD HOT SHR DVNC EWRST CAUT MNPLR DISP BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400427 SUP Custom 27203010 400427 - PACKING NSL 2.5X.9X2CM MRCL BRN SIN-PK STNG SLIM PRFL BOTH IP/OP $18.98 $14.05 $0.00 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.08 $14.08 $0.00 $0.00 $3.95 $0.00 $0.00 $0.00 $0.00 $9.49 $15.03 $15.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401531 SUP Custom 27203010 401531 - BAG OST SFN MINI 1.75IN 5IN 2 SIDE COROVIN LATEX FREE DISP BOTH IP/OP $1.50 $1.11 $0.00 $1.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.12 $1.12 $0.00 $0.00 $0.31 $0.00 $0.00 $0.00 $0.00 $0.75 $1.19 $1.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401552 SUP Custom 27203010 KIT 1.5IN UROS STD SRFT BOTH IP/OP $4.00 $2.96 $0.00 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.97 $2.97 $0.00 $0.00 $0.83 $0.00 $0.00 $0.00 $0.00 $2.00 $3.17 $3.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 402025 SUP HCPCS Q4116 402025 - MATRIX TISSUE THIN 7X4CM ALLOGRAFT REGENERATIVE FREEZE DRIED BOTH IP/OP $64.73 $47.90 $0.00 $80.43 $45.24 $45.24 $0.00 $0.00 $0.00 $13.49 $48.04 $48.04 $0.00 $0.00 $13.49 $0.00 $38.29 $38.29 $0.00 $50.27 $79.63 $80.43 $0.00 $0.00 $15.73 $0.00 $0.00 $16.01 $0.00 $0.00 $0.00 $0.00 $0.00 402045 SUP HCPCS Q4116 402045 - MATRIX TISSUE THIN 12X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $64.58 $47.79 $0.00 $80.13 $45.07 $45.07 $0.00 $0.00 $0.00 $13.46 $47.93 $47.93 $0.00 $0.00 $13.46 $0.00 $38.20 $38.20 $0.00 $50.08 $79.33 $80.13 $0.00 $0.00 $15.67 $0.00 $0.00 $15.94 $0.00 $0.00 $0.00 $0.00 $0.00 402432 SUP Custom 27803010 402432 - CEMENT BONE CO HV LG 40GM HVISC STRL BOTH IP/OP $292.50 $216.45 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.09 $217.09 $0.00 $0.00 $60.96 $0.00 $0.00 $0.00 $0.00 $146.25 $231.66 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 402433 SUP Custom 27803010 402433 - CEMENT BONE CBLT G-HV 40GM HVISC GNTA STRL BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $0.00 $0.00 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 403326 SUP Custom 27203010 DRESSING DUODERM 4X4 SIGNAL BOTH IP/OP $6.60 $4.88 $0.00 $5.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.90 $4.90 $0.00 $0.00 $1.38 $0.00 $0.00 $0.00 $0.00 $3.30 $5.23 $5.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 403711 SUP Custom 27203010 403711 - DRESSING WOUND RECTANGLE 10X8IN STRONGER GREATER ABSORBENCY BOTH IP/OP $82.33 $60.92 $0.00 $65.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.10 $61.10 $0.00 $0.00 $17.16 $0.00 $0.00 $0.00 $0.00 $41.16 $65.21 $65.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 403771 SUP Custom 27203010 403771 - DRESSING HYDROCOLLOID RIBBON 18X.75IN STITCHBOND LATEX FREE BOTH IP/OP $29.96 $22.17 $0.00 $23.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.98 $23.73 $23.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 405416 SUP HCPCS C1892 405416 - INTROD SHTH 9FR 14CM HMSTS GWIRE PLWY .038IN TRNSPT BOTH IP/OP "$9,500.00 " "$7,030.00" $0.00 "$4,688.23" $4.34 $4.34 $0.00 $0.00 $0.00 "$1,980.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,979.80" $0.00 "$4,688.23" "$4,688.23" $0.00 $4.00 $6.34 $6.40 $0.00 $0.00 $1.25 $0.00 $0.00 $1.27 $0.00 $0.00 $0.00 $0.00 $0.00 406136 SUP HCPCS C1894 406136 - INTROD CATH 12CM 14FR .038IN TRNSPT FSTCTH HMSTS BOTH IP/OP $42.75 $31.64 $0.00 $34.20 $23.21 $23.21 $0.00 $0.00 $0.00 $8.91 $31.73 $31.73 $0.00 $0.00 $8.91 $0.00 $25.29 $25.29 $0.00 $21.38 $33.86 $34.20 $0.00 $0.00 $6.69 $0.00 $0.00 $6.81 $0.00 $0.00 $0.00 $0.00 $0.00 406701 SUP HCPCS C1894 406701 - INTRODUCER SHEATH .038IN STANDARD 6FR 12CM 50CM 2 DISTAL BOTH IP/OP $2.75 $2.04 $0.00 $2.20 $1.49 $1.49 $0.00 $0.00 $0.00 $0.57 $2.04 $2.04 $0.00 $0.00 $0.57 $0.00 $1.63 $1.63 $0.00 $1.38 $2.18 $2.20 $0.00 $0.00 $0.43 $0.00 $0.00 $0.44 $0.00 $0.00 $0.00 $0.00 $0.00 407145 SUP HCPCS C1785 407145 - PACEMAKER CRD SM 48X40X6.5MM 10CC EDORA PROMRI 1 CHMBR RT BOTH IP/OP "$15,250.00 " "$11,285.00" $0.00 "$12,200.00" "$6,862.50" "$6,862.50" $0.00 $0.00 $0.00 "$3,178.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,178.10" $0.00 "$7,518.25" "$7,518.25" $0.00 "$7,625.00" "$12,078.00" "$12,200.00" $0.00 $0.00 "$2,386.63" $0.00 $0.00 "$2,427.80" $0.00 $0.00 $0.00 $0.00 $0.00 407157 SUP HCPCS C1786 407157 - PACEMAKER CRD SM 48X40X6.5MM 10CC EDORA PROMRI 1 CHMBR RT BOTH IP/OP "$13,375.00 " "$9,897.50" $0.00 "$10,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,787.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,787.35" $0.00 "$6,593.88" "$6,593.88" $0.00 "$6,687.50" "$10,593.00" "$10,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 410298 SUP Custom 27803010 410298 - STAPLER INTNL 14MM 45MM NS LF DVNC SI EWRST RPSB 50 FRNG BOTH IP/OP "$17,500.00 " "$12,950.00" $0.00 "$14,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,647.00" $0.00 $0.00 $0.00 $0.00 "$8,750.00" "$13,860.00" "$14,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 410322 SUP Custom 27203010 410322 - TIP CAUT 8MM 1 DVNC SI EWRST VSL SLR DISP BOTH IP/OP "$8,925.00 " "$6,604.50" $0.00 "$7,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,859.97" $0.00 $0.00 $0.00 $0.00 "$4,462.50" "$7,068.60" "$7,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 410370 SUP Custom 27203010 410370 - SHEATH LAPSCP 45MM STPLR BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 410500 SUP Custom 27203010 410500 - DRESSING HYDROCOLLOID TAPER 7.8X7.5IN ABSORBENT FLEXIBLE BOTH IP/OP $29.32 $21.70 $0.00 $23.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.76 $21.76 $0.00 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $14.88 $23.56 $23.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 410501 SUP Custom 27203010 SACRAL DUODERM SIGNAL 7.8X8.77 BOTH IP/OP $28.28 $20.93 $0.00 $22.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.14 $22.40 $22.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 410614 SUP Custom 27203010 410614 - DRESSING FOAM 8X8IN GELLING LATEX FREE VERSIVA XC BOTH IP/OP $33.99 $25.15 $0.00 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.23 $25.23 $0.00 $0.00 $7.08 $0.00 $0.00 $0.00 $0.00 $16.99 $26.92 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 411250 SUP HCPCS C1762 411250 - GRAFT SOFT TISSUE 4-5MM 50MM ALLOGRAFT NATURAL CONNECT BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 411270 SUP HCPCS C1768 "411270 - GRAFT, AVANCE NERVE, 4-5MM X 70MM" BOTH IP/OP "$16,105.00 " "$11,917.70" $0.00 "$11,800.00" "$6,637.50" "$6,637.50" $0.00 $0.00 $0.00 "$3,356.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,356.28" $0.00 "$7,939.77" "$7,939.77" $0.00 "$7,375.00" "$11,682.00" "$11,800.00" $0.00 $0.00 "$2,308.38" $0.00 $0.00 "$2,348.20" $0.00 $0.00 $0.00 $0.00 $0.00 415807 SUP Custom 27203010 415807 - CANNULA PERFUSION 7MM 3MM 11.4IN BALLOON RIGHT ANGLED LATEX BOTH IP/OP $982.50 $727.05 $0.00 $786.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $729.21 $729.21 $0.00 $0.00 $204.75 $0.00 $0.00 $0.00 $0.00 $491.25 $778.14 $786.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 417300 SUP Custom 27803010 417300 - SYSTEM BONE CMNT TRPL MX KIT 120GM OPTVC BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 419588 SUP HCPCS C1898 419588 - LEAD PACING 5FR 88CM UNIPOLAR DEPLOYABLE LOBES FIX IS-1 BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,850.00" "$1,603.13" "$1,603.13" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $567.15 $0.00 $0.00 $0.00 $0.00 $0.00 419678 SUP HCPCS C1898 419678 - LEAD PACING 2 CURVE 4FR 78CM BIPOL IS-1 ATTAIN ABILITY BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,850.00" "$1,603.13" "$1,603.13" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $567.15 $0.00 $0.00 $0.00 $0.00 $0.00 419688 SUP HCPCS C1898 419688 - LEAD PACING 4FR 88CM OTW TRACKABILITY STEERABLE BIPOL BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,850.00" "$1,603.13" "$1,603.13" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $567.15 $0.00 $0.00 $0.00 $0.00 $0.00 420006 SUP Custom 27203010 420006 - DRIVER NDL 0-30D LG 8MM 54.4CM 1CM S/SI EWRST BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 420024 SUP Custom 27203010 420024 - OBTURATOR LAPSCP LNG 8MM STRL DVNC S/SI EWRST DISP BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 420206 SUP Custom 27203010 420206 - SEAL ENDSCP INSTR 8.5-13MM S/SI EWRST CANNU HD SD BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 420290 SUP Custom 27203010 420290 - KIT ACC 8MM DVNC SI 3 ARM CAM CNN SL INST DRP DISP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 420291 SUP Custom 27203010 420291 - KIT 8MM 4 ARM CAM CANNU SL INSTR DRP ACC DVNC SI BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 $0.00 $0.00 $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 425304 SUP HCPCS C1713 425304 - PLATE PELVIS 108MM RADIUS BOTH IP/OP $284.63 $210.63 $0.00 $227.70 $128.08 $128.08 $0.00 $0.00 $0.00 $59.32 $211.25 $211.25 $0.00 $0.00 $59.32 $0.00 $168.36 $168.36 $0.00 $142.31 $225.43 $227.70 $0.00 $0.00 $44.54 $0.00 $0.00 $45.31 $0.00 $0.00 $0.00 $0.00 $0.00 425306 SUP HCPCS C1713 425306 - PLATE PELVIS 108MM RADIUS BOTH IP/OP $361.63 $267.61 $0.00 $289.30 $162.73 $162.73 $0.00 $0.00 $0.00 $75.37 $268.40 $268.40 $0.00 $0.00 $75.36 $0.00 $213.90 $213.90 $0.00 $180.81 $286.41 $289.30 $0.00 $0.00 $56.59 $0.00 $0.00 $57.57 $0.00 $0.00 $0.00 $0.00 $0.00 425308 SUP HCPCS C1713 425308 - PLATE PELVIS 108MM RADIUS BOTH IP/OP $354.75 $262.52 $0.00 $283.80 $159.64 $159.64 $0.00 $0.00 $0.00 $73.94 $263.30 $263.30 $0.00 $0.00 $73.93 $0.00 $209.83 $209.83 $0.00 $177.38 $280.96 $283.80 $0.00 $0.00 $55.52 $0.00 $0.00 $56.48 $0.00 $0.00 $0.00 $0.00 $0.00 425310 SUP HCPCS C1713 425310 - PLATE PELVIS 108MM RADIUS BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 425312 SUP HCPCS C1713 425312 - PLATE PELVIS 108MM RADIUS BOTH IP/OP $419.38 $310.34 $0.00 $335.50 $188.72 $188.72 $0.00 $0.00 $0.00 $87.41 $311.26 $311.26 $0.00 $0.00 $87.40 $0.00 $248.06 $248.06 $0.00 $209.69 $332.15 $335.50 $0.00 $0.00 $65.63 $0.00 $0.00 $66.76 $0.00 $0.00 $0.00 $0.00 $0.00 425406 SUP HCPCS C1713 425406 - PLATE PELVIS 88MM RADIUS BOTH IP/OP $328.63 $243.19 $0.00 $262.90 $147.88 $147.88 $0.00 $0.00 $0.00 $68.49 $243.91 $243.91 $0.00 $0.00 $68.49 $0.00 $194.38 $194.38 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 425408 SUP HCPCS C1713 425408 - PLATE PELVIS 88MM RADIUS BOTH IP/OP $349.25 $258.45 $0.00 $279.40 $157.16 $157.16 $0.00 $0.00 $0.00 $72.79 $259.21 $259.21 $0.00 $0.00 $72.78 $0.00 $206.58 $206.58 $0.00 $174.63 $276.61 $279.40 $0.00 $0.00 $54.66 $0.00 $0.00 $55.60 $0.00 $0.00 $0.00 $0.00 $0.00 425410 SUP HCPCS C1713 425410 - PLATE PELVIS 88MM RADIUS BOTH IP/OP $389.13 $287.96 $0.00 $311.30 $175.11 $175.11 $0.00 $0.00 $0.00 $81.10 $288.81 $288.81 $0.00 $0.00 $81.09 $0.00 $230.17 $230.17 $0.00 $194.56 $308.19 $311.30 $0.00 $0.00 $60.90 $0.00 $0.00 $61.95 $0.00 $0.00 $0.00 $0.00 $0.00 425412 SUP HCPCS C1713 425412 - PLATE PELVIS 88MM RADIUS BOTH IP/OP $419.38 $310.34 $0.00 $335.50 $188.72 $188.72 $0.00 $0.00 $0.00 $87.41 $311.26 $311.26 $0.00 $0.00 $87.40 $0.00 $248.06 $248.06 $0.00 $209.69 $332.15 $335.50 $0.00 $0.00 $65.63 $0.00 $0.00 $66.76 $0.00 $0.00 $0.00 $0.00 $0.00 425504 SUP HCPCS C1713 425504 - PELVIC PLATE STRAIGHT 4H/64MM BOTH IP/OP $233.75 $172.98 $0.00 $187.00 $105.19 $105.19 $0.00 $0.00 $0.00 $48.72 $173.49 $173.49 $0.00 $0.00 $48.71 $0.00 $138.26 $138.26 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $36.58 $0.00 $0.00 $37.21 $0.00 $0.00 $0.00 $0.00 $0.00 425506 SUP HCPCS C1713 425506 - PLATE PELVIS STRAIGHT BOTH IP/OP $268.13 $198.42 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $55.88 $199.00 $199.00 $0.00 $0.00 $55.88 $0.00 $158.60 $158.60 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 425509 SUP HCPCS C1713 425509 - PELVIC PLATE STRAIGHT 9H/154MM BOTH IP/OP $338.25 $250.31 $0.00 $270.60 $152.21 $152.21 $0.00 $0.00 $0.00 $70.50 $251.05 $251.05 $0.00 $0.00 $70.49 $0.00 $200.07 $200.07 $0.00 $169.13 $267.89 $270.60 $0.00 $0.00 $52.94 $0.00 $0.00 $53.85 $0.00 $0.00 $0.00 $0.00 $0.00 425512 SUP HCPCS C1713 425512 - PLATE. PELVIS. STRAIGHT BOTH IP/OP $398.75 $295.08 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $83.11 $295.95 $295.95 $0.00 $0.00 $83.10 $0.00 $235.86 $235.86 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 425602 SUP HCPCS C1713 425602 - PLATE 108MM RAD 26.5MM 2 HOLE CVD MATTA BONE PLVC BOTH IP/OP $383.63 $283.89 $0.00 $306.90 $172.63 $172.63 $0.00 $0.00 $0.00 $79.96 $284.73 $284.73 $0.00 $0.00 $79.95 $0.00 $226.91 $226.91 $0.00 $191.81 $303.83 $306.90 $0.00 $0.00 $60.04 $0.00 $0.00 $61.07 $0.00 $0.00 $0.00 $0.00 $0.00 425603 SUP HCPCS C1713 425603 - PLATE 108MM RAD 42.5MM 3 HOLE CVD MATTA BONE PLVC BOTH IP/OP $426.25 $315.43 $0.00 $341.00 $191.81 $191.81 $0.00 $0.00 $0.00 $88.84 $316.36 $316.36 $0.00 $0.00 $88.83 $0.00 $252.13 $252.13 $0.00 $213.13 $337.59 $341.00 $0.00 $0.00 $66.71 $0.00 $0.00 $67.86 $0.00 $0.00 $0.00 $0.00 $0.00 425604 SUP HCPCS C1713 425604 - PLATE 108MM RAD 58.5MM SS R108 4 HOLE CVD MATTA BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $210.99 $210.99 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $234.44 $371.35 $375.10 $0.00 $0.00 $73.38 $0.00 $0.00 $74.64 $0.00 $0.00 $0.00 $0.00 $0.00 425605 SUP HCPCS C1713 425605 - PLATE 108MM 74.5MM 5 HOLE CVD BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $230.79 $230.79 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $256.44 $406.20 $410.30 $0.00 $0.00 $80.26 $0.00 $0.00 $81.65 $0.00 $0.00 $0.00 $0.00 $0.00 425606 SUP HCPCS C1713 425606 - PLATE 108MM RAD 90.5MM SS 6 HOLE CVD MPS BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $249.36 $249.36 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $277.06 $438.87 $443.30 $0.00 $0.00 $86.72 $0.00 $0.00 $88.22 $0.00 $0.00 $0.00 $0.00 $0.00 425607 SUP HCPCS C1713 425607 - PLATE 108MM 106.5MM 5 HOLE CVD BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $259.88 $259.88 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 425608 SUP HCPCS C1713 425608 - PLATE 108MM RAD 122.5MM SS 8 HOLE CVD MPS BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $273.49 $273.49 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $303.88 $481.34 $486.20 $0.00 $0.00 $95.11 $0.00 $0.00 $96.75 $0.00 $0.00 $0.00 $0.00 $0.00 425609 SUP HCPCS C1713 425609 - PLATE 108MM RAD 138.5X10.5X2.5MM 9 HL SHFT CVD MATTA BONE BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $278.44 $278.44 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 425610 SUP HCPCS C1713 425610 - PLATE BN CRV 154.5MM MPS 10 HL SS R108 BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $288.34 $288.34 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $320.38 $507.47 $512.60 $0.00 $0.00 $100.28 $0.00 $0.00 $102.01 $0.00 $0.00 $0.00 $0.00 $0.00 425611 SUP HCPCS C1713 425611 - PLATE 108MM RAD 170.5X10.5X2.5MM 11 HL SHFT CVD MATTA BONE BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $292.05 $292.05 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $324.50 $514.01 $519.20 $0.00 $0.00 $101.57 $0.00 $0.00 $103.32 $0.00 $0.00 $0.00 $0.00 $0.00 425612 SUP HCPCS C1713 425612 - PLATE 186.5MM SS 12 HOLE CVD MPS BONE 108MM PLVC BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $301.95 $301.95 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $335.50 $531.43 $536.80 $0.00 $0.00 $105.01 $0.00 $0.00 $106.82 $0.00 $0.00 $0.00 $0.00 $0.00 425613 SUP HCPCS C1713 425613 - PLATE 108MM RAD 202.5X10.5X2.5MM 13 HL SHFT CVD MATTA BONE BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $312.47 $312.47 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $347.19 $549.95 $555.50 $0.00 $0.00 $108.67 $0.00 $0.00 $110.54 $0.00 $0.00 $0.00 $0.00 $0.00 425614 SUP HCPCS C1713 425614 - PLATE 218.5MM SS 14 HOLE CVD MPS BONE 108MM PLVC BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $335.98 $335.98 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $373.31 $591.33 $597.30 $0.00 $0.00 $116.85 $0.00 $0.00 $118.86 $0.00 $0.00 $0.00 $0.00 $0.00 425615 SUP HCPCS C1713 425615 - PLATE 108MM RAD 234.5X10.5X2.5MM 15 HL SHFT CVD MATTA BONE BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $350.21 $350.21 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $389.13 $616.37 $622.60 $0.00 $0.00 $121.80 $0.00 $0.00 $123.90 $0.00 $0.00 $0.00 $0.00 $0.00 425616 SUP HCPCS C1713 425616 - PLATE 108MM RAD 250.5MM 16 HOLE CVD MATTA BONE PLVC BOTH IP/OP $966.70 $715.36 $0.00 $717.48 $360.11 $360.11 $0.00 $0.00 $0.00 $201.48 $717.48 $717.48 $0.00 $0.00 $201.46 $0.00 $571.80 $571.80 $0.00 $400.13 $633.80 $640.20 $0.00 $0.00 $125.24 $0.00 $0.00 $127.40 $0.00 $0.00 $0.00 $0.00 $0.00 425618 SUP HCPCS C1713 425618 - PLATE 108MM RAD 282.5X10.5X2.5MM 18 HL SHFT CVD MATTA BONE BOTH IP/OP $966.70 $715.36 $0.00 $717.48 $389.19 $389.19 $0.00 $0.00 $0.00 $201.48 $717.48 $717.48 $0.00 $0.00 $201.46 $0.00 $571.80 $571.80 $0.00 $432.44 $684.98 $691.90 $0.00 $0.00 $135.35 $0.00 $0.00 $137.69 $0.00 $0.00 $0.00 $0.00 $0.00 425620 SUP HCPCS C1713 425620 - PLATE 108MM RAD 314.5X10.5X2.5MM 20 HL SHFT CVD MATTA BONE BOTH IP/OP "$1,012.00 " $748.88 $0.00 $809.60 $455.40 $455.40 $0.00 $0.00 $0.00 $210.93 $751.11 $751.11 $0.00 $0.00 $210.90 $0.00 $598.60 $598.60 $0.00 $506.00 $801.50 $809.60 $0.00 $0.00 $158.38 $0.00 $0.00 $161.11 $0.00 $0.00 $0.00 $0.00 $0.00 425653 SUP HCPCS C1713 425653 - PLATE 88MM RAD 42.5MM 3 HOLE CVD MATTA BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $191.81 $191.81 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $213.13 $337.59 $341.00 $0.00 $0.00 $66.71 $0.00 $0.00 $67.86 $0.00 $0.00 $0.00 $0.00 $0.00 425654 SUP HCPCS C1713 425654 - PLATE 88MM RAD 58.8MM SS 4 HOLE CVD MPS BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $210.99 $210.99 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $234.44 $371.35 $375.10 $0.00 $0.00 $73.38 $0.00 $0.00 $74.64 $0.00 $0.00 $0.00 $0.00 $0.00 425655 SUP HCPCS C1713 425655 - PLATE BN 88MM RDS CRV 74.5MM NS MATTA 5 HL SS PLV BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $230.79 $230.79 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $256.44 $406.20 $410.30 $0.00 $0.00 $80.26 $0.00 $0.00 $81.65 $0.00 $0.00 $0.00 $0.00 $0.00 425656 SUP HCPCS C1713 425656 - PLATE 88MM RAD 90.5MM SS 6 HOLE CVD MPS BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $249.36 $249.36 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $277.06 $438.87 $443.30 $0.00 $0.00 $86.72 $0.00 $0.00 $88.22 $0.00 $0.00 $0.00 $0.00 $0.00 425657 SUP HCPCS C1713 425657 - PLATE 88MM 106.5MM 7 HOLE CVD BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $259.88 $259.88 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 425658 SUP HCPCS C1713 425658 - PLATE 122.5MM SS 8 HOLE CVD BONE 88MM PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $273.49 $273.49 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $303.88 $481.34 $486.20 $0.00 $0.00 $95.11 $0.00 $0.00 $96.75 $0.00 $0.00 $0.00 $0.00 $0.00 425659 SUP HCPCS C1713 425659 - PLATE 88MM RAD 138.5MM 9 HOLE CVD MATTA BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $278.44 $278.44 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 425660 SUP HCPCS C1713 425660 - PLATE 154.5MM SS 10 HOLE CVD MPS BONE 88MM PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $288.34 $288.34 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $320.38 $507.47 $512.60 $0.00 $0.00 $100.28 $0.00 $0.00 $102.01 $0.00 $0.00 $0.00 $0.00 $0.00 425661 SUP HCPCS C1713 425661 - PLATE 88MM RAD 170.5MM 11 HOLE CVD MATTA BONE PLVC BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $292.05 $292.05 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $324.50 $514.01 $519.20 $0.00 $0.00 $101.57 $0.00 $0.00 $103.32 $0.00 $0.00 $0.00 $0.00 $0.00 425662 SUP HCPCS C1713 425662 - PLATE 186.5MM SS 12 HOLE CVD MPS BONE 88MM PLVC BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $301.95 $301.95 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $335.50 $531.43 $536.80 $0.00 $0.00 $105.01 $0.00 $0.00 $106.82 $0.00 $0.00 $0.00 $0.00 $0.00 425663 SUP HCPCS C1713 425663 - PLATE 88MM RAD 202.5MM 13 HOLE CVD MATTA BONE PLVC BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $312.47 $312.47 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $347.19 $549.95 $555.50 $0.00 $0.00 $108.67 $0.00 $0.00 $110.54 $0.00 $0.00 $0.00 $0.00 $0.00 425664 SUP HCPCS C1713 425664 - PLATE 218.5MM SS 14 HOLE CVD MPS BONE 88MM PLVC BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $335.98 $335.98 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $373.31 $591.33 $597.30 $0.00 $0.00 $116.85 $0.00 $0.00 $118.86 $0.00 $0.00 $0.00 $0.00 $0.00 425665 SUP HCPCS C1713 425665 - PLATE 88MM RAD 234.5MM 15 HOLE CVD MATTA BONE PLVC BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $350.21 $350.21 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $389.13 $616.37 $622.60 $0.00 $0.00 $121.80 $0.00 $0.00 $123.90 $0.00 $0.00 $0.00 $0.00 $0.00 425666 SUP HCPCS C1713 425666 - PLATE 88MM RAD 250.5MM 16 HOLE CVD MATTA BONE PLVC BOTH IP/OP $880.60 $651.64 $0.00 $653.58 $360.11 $360.11 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $400.13 $633.80 $640.20 $0.00 $0.00 $125.24 $0.00 $0.00 $127.40 $0.00 $0.00 $0.00 $0.00 $0.00 425667 SUP HCPCS C1713 425667 - PLATE 88MM RAD 266.5MM 17 HOLE CVD MATTA BONE PLVC BOTH IP/OP $833.25 $616.61 $0.00 $666.60 $374.96 $374.96 $0.00 $0.00 $0.00 $173.67 $618.44 $618.44 $0.00 $0.00 $173.65 $0.00 $492.87 $492.87 $0.00 $416.63 $659.93 $666.60 $0.00 $0.00 $130.40 $0.00 $0.00 $132.65 $0.00 $0.00 $0.00 $0.00 $0.00 425668 SUP HCPCS C1713 425668 - PLATE 88MM RAD 282.5MM 18 HOLE CVD MATTA BONE PLVC BOTH IP/OP $880.60 $651.64 $0.00 $691.90 $389.19 $389.19 $0.00 $0.00 $0.00 $183.54 $653.58 $653.58 $0.00 $0.00 $183.52 $0.00 $520.87 $520.87 $0.00 $432.44 $684.98 $691.90 $0.00 $0.00 $135.35 $0.00 $0.00 $137.69 $0.00 $0.00 $0.00 $0.00 $0.00 425670 SUP HCPCS C1713 425670 - PLATE 88MM RAD 314.5MM 20 HOLE CVD MATTA BONE PLVC BOTH IP/OP $974.95 $721.46 $0.00 $809.60 $455.40 $455.40 $0.00 $0.00 $0.00 $203.20 $723.61 $723.61 $0.00 $0.00 $203.18 $0.00 $576.68 $576.68 $0.00 $506.00 $801.50 $809.60 $0.00 $0.00 $158.38 $0.00 $0.00 $161.11 $0.00 $0.00 $0.00 $0.00 $0.00 425672 SUP HCPCS C1713 425672 - PLATE 88MM RAD 346.5MM 22 HOLE CVD MATTA BONE PLVC BOTH IP/OP "$1,012.00 " $748.88 $0.00 $809.60 $455.40 $455.40 $0.00 $0.00 $0.00 $210.93 $751.11 $751.11 $0.00 $0.00 $210.90 $0.00 $598.60 $598.60 $0.00 $506.00 $801.50 $809.60 $0.00 $0.00 $158.38 $0.00 $0.00 $161.11 $0.00 $0.00 $0.00 $0.00 $0.00 425674 SUP HCPCS C1713 425674 - PLATE 88MM RAD 378.5MM 24 HOLE CVD MATTA BONE PLVC BOTH IP/OP "$1,012.00 " $748.88 $0.00 $809.60 $455.40 $455.40 $0.00 $0.00 $0.00 $210.93 $751.11 $751.11 $0.00 $0.00 $210.90 $0.00 $598.60 $598.60 $0.00 $506.00 $801.50 $809.60 $0.00 $0.00 $158.38 $0.00 $0.00 $161.11 $0.00 $0.00 $0.00 $0.00 $0.00 425676 SUP HCPCS C1713 425676 - PLATE 88MM RAD 410.5MM 26 HOLE CVD MATTA BONE PLVC BOTH IP/OP "$1,067.00 " $789.58 $0.00 $853.60 $480.15 $480.15 $0.00 $0.00 $0.00 $222.39 $791.93 $791.93 $0.00 $0.00 $222.36 $0.00 $631.13 $631.13 $0.00 $533.50 $845.06 $853.60 $0.00 $0.00 $166.99 $0.00 $0.00 $169.87 $0.00 $0.00 $0.00 $0.00 $0.00 425678 SUP HCPCS C1713 425678 - PLATE 442.5MM 28 HOLE CVD BONE 88MM PLVC BOTH IP/OP "$1,067.00 " $789.58 $0.00 $853.60 $480.15 $480.15 $0.00 $0.00 $0.00 $222.39 $791.93 $791.93 $0.00 $0.00 $222.36 $0.00 $631.13 $631.13 $0.00 $533.50 $845.06 $853.60 $0.00 $0.00 $166.99 $0.00 $0.00 $169.87 $0.00 $0.00 $0.00 $0.00 $0.00 425680 SUP HCPCS C1713 425680 - PLATE 88MM RAD 474.5MM 30 HOLE CVD MATTA BONE PLVC BOTH IP/OP "$1,067.00 " $789.58 $0.00 $853.60 $480.15 $480.15 $0.00 $0.00 $0.00 $222.39 $791.93 $791.93 $0.00 $0.00 $222.36 $0.00 $631.13 $631.13 $0.00 $533.50 $845.06 $853.60 $0.00 $0.00 $166.99 $0.00 $0.00 $169.87 $0.00 $0.00 $0.00 $0.00 $0.00 425702 SUP HCPCS C1713 425702 - PLATE 26.5MMX10.5MMX2.5M SS 2 HOLE STR MATTA BONE PLVC BOTH IP/OP $659.40 $487.96 $0.00 $489.41 $157.16 $157.16 $0.00 $0.00 $0.00 $137.44 $489.41 $489.41 $0.00 $0.00 $137.42 $0.00 $390.04 $390.04 $0.00 $174.63 $276.61 $279.40 $0.00 $0.00 $54.66 $0.00 $0.00 $55.60 $0.00 $0.00 $0.00 $0.00 $0.00 425703 SUP HCPCS C1713 425703 - PLATE 42.5MM SS 3 HOLE STR BONE PLVC BOTH IP/OP $659.40 $487.96 $0.00 $489.41 $180.68 $180.68 $0.00 $0.00 $0.00 $137.44 $489.41 $489.41 $0.00 $0.00 $137.42 $0.00 $390.04 $390.04 $0.00 $200.75 $317.99 $321.20 $0.00 $0.00 $62.83 $0.00 $0.00 $63.92 $0.00 $0.00 $0.00 $0.00 $0.00 425704 SUP HCPCS C1713 425704 - PLATE 58.5MM SS 4 HOLE STR MPS BONE PLVC BOTH IP/OP $659.40 $487.96 $0.00 $489.41 $189.96 $189.96 $0.00 $0.00 $0.00 $137.44 $489.41 $489.41 $0.00 $0.00 $137.42 $0.00 $390.04 $390.04 $0.00 $211.06 $334.33 $337.70 $0.00 $0.00 $66.06 $0.00 $0.00 $67.20 $0.00 $0.00 $0.00 $0.00 $0.00 425705 SUP HCPCS C1713 425705 - PLATE 74.5MM 5 HL SHFT STR MATTA BONE PLVC BOTH IP/OP $659.40 $487.96 $0.00 $489.41 $198.62 $198.62 $0.00 $0.00 $0.00 $137.44 $489.41 $489.41 $0.00 $0.00 $137.42 $0.00 $390.04 $390.04 $0.00 $220.69 $349.57 $353.10 $0.00 $0.00 $69.08 $0.00 $0.00 $70.27 $0.00 $0.00 $0.00 $0.00 $0.00 425706 SUP HCPCS C1713 425706 - PLATE 90.5MM SS 6 HOLE STR MPS BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $215.94 $215.94 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $239.94 $380.06 $383.90 $0.00 $0.00 $75.10 $0.00 $0.00 $76.40 $0.00 $0.00 $0.00 $0.00 $0.00 425707 SUP HCPCS C1713 425707 - PLATE 106.5MM 7 HL SHFT STR MATTA BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $229.56 $229.56 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $255.06 $404.02 $408.10 $0.00 $0.00 $79.83 $0.00 $0.00 $81.21 $0.00 $0.00 $0.00 $0.00 $0.00 425708 SUP HCPCS C1713 425708 - PLATE 122.5MM SS 8 HOLE STR MPS BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $243.79 $243.79 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $270.88 $429.07 $433.40 $0.00 $0.00 $84.78 $0.00 $0.00 $86.25 $0.00 $0.00 $0.00 $0.00 $0.00 425709 SUP HCPCS C1713 425709 - PLATE 138.5MM 9 HL SHFT STR MATTA BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $252.45 $252.45 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $280.50 $444.31 $448.80 $0.00 $0.00 $87.80 $0.00 $0.00 $89.31 $0.00 $0.00 $0.00 $0.00 $0.00 425710 SUP HCPCS C1713 425710 - PLATE 154.5MM SS 10 HOLE STR MPS BONE PLVC BOTH IP/OP $726.60 $537.68 $0.00 $539.28 $261.11 $261.11 $0.00 $0.00 $0.00 $151.44 $539.28 $539.28 $0.00 $0.00 $151.42 $0.00 $429.78 $429.78 $0.00 $290.13 $459.56 $464.20 $0.00 $0.00 $90.81 $0.00 $0.00 $92.38 $0.00 $0.00 $0.00 $0.00 $0.00 425711 SUP HCPCS C1713 425711 - PLATE 170.5MM 11 HL SHFT STR MATTA BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $270.39 $270.39 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $300.44 $475.90 $480.70 $0.00 $0.00 $94.04 $0.00 $0.00 $95.66 $0.00 $0.00 $0.00 $0.00 $0.00 425712 SUP HCPCS C1713 425712 - PLATE 186.5MM SS 12 HOLE STR MATTA MPS BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $279.68 $279.68 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $310.75 $492.23 $497.20 $0.00 $0.00 $97.26 $0.00 $0.00 $98.94 $0.00 $0.00 $0.00 $0.00 $0.00 425713 SUP HCPCS C1713 425713 - PLATE 202.5MM 13 HL SHFT STR MATTA BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $288.96 $288.96 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $321.06 $508.57 $513.70 $0.00 $0.00 $100.49 $0.00 $0.00 $102.23 $0.00 $0.00 $0.00 $0.00 $0.00 425714 SUP HCPCS C1713 425714 - PLATE 218.5MM SS 14 HOLE STR MATTA BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $297.62 $297.62 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $330.69 $523.81 $529.10 $0.00 $0.00 $103.51 $0.00 $0.00 $105.29 $0.00 $0.00 $0.00 $0.00 $0.00 425715 SUP HCPCS C1713 425715 - PLATE 234.5MM 15 HL SHFT STR MATTA BONE PLVC BOTH IP/OP $799.40 $591.56 $0.00 $593.31 $306.28 $306.28 $0.00 $0.00 $0.00 $166.61 $593.31 $593.31 $0.00 $0.00 $166.59 $0.00 $472.85 $472.85 $0.00 $340.31 $539.06 $544.50 $0.00 $0.00 $106.52 $0.00 $0.00 $108.36 $0.00 $0.00 $0.00 $0.00 $0.00 425716 SUP HCPCS C1713 425716 - PLATE 250.5MMX10.5MMX2.5M SS 16 HOLE STR MATTA BONE PLVC BOTH IP/OP $877.80 $649.57 $0.00 $651.50 $324.23 $324.23 $0.00 $0.00 $0.00 $182.96 $651.50 $651.50 $0.00 $0.00 $182.93 $0.00 $519.22 $519.22 $0.00 $360.25 $570.64 $576.40 $0.00 $0.00 $112.76 $0.00 $0.00 $114.70 $0.00 $0.00 $0.00 $0.00 $0.00 425718 SUP HCPCS C1713 425718 - PLATE 282.5MM 18 HL SHFT STR MATTA BONE PLVC BOTH IP/OP $877.80 $649.57 $0.00 $651.50 $360.73 $360.73 $0.00 $0.00 $0.00 $182.96 $651.50 $651.50 $0.00 $0.00 $182.93 $0.00 $519.22 $519.22 $0.00 $400.81 $634.89 $641.30 $0.00 $0.00 $125.45 $0.00 $0.00 $127.62 $0.00 $0.00 $0.00 $0.00 $0.00 425720 SUP HCPCS C1713 425720 - PLATE 314.5MM 20 HL SHFT STR MATTA BONE PLVC BOTH IP/OP $902.00 $667.48 $0.00 $721.60 $405.90 $405.90 $0.00 $0.00 $0.00 $188.00 $669.46 $669.46 $0.00 $0.00 $187.98 $0.00 $533.53 $533.53 $0.00 $451.00 $714.38 $721.60 $0.00 $0.00 $141.16 $0.00 $0.00 $143.60 $0.00 $0.00 $0.00 $0.00 $0.00 425752 SUP HCPCS C1713 425752 - PLATE 22.5MM 2 HOLE STR BONE ACETAB BOTH IP/OP $374.00 $276.76 $0.00 $299.20 $168.30 $168.30 $0.00 $0.00 $0.00 $77.95 $277.58 $277.58 $0.00 $0.00 $77.94 $0.00 $221.22 $221.22 $0.00 $187.00 $296.21 $299.20 $0.00 $0.00 $58.53 $0.00 $0.00 $59.54 $0.00 $0.00 $0.00 $0.00 $0.00 425753 SUP HCPCS C1713 425753 - PLATE 34.5MM 3 HOLE STR BONE ACETAB BOTH IP/OP $762.30 $564.10 $0.00 $565.78 $191.81 $191.81 $0.00 $0.00 $0.00 $158.88 $565.78 $565.78 $0.00 $0.00 $158.86 $0.00 $450.90 $450.90 $0.00 $213.13 $337.59 $341.00 $0.00 $0.00 $66.71 $0.00 $0.00 $67.86 $0.00 $0.00 $0.00 $0.00 $0.00 425754 SUP HCPCS C1713 425754 - PLATE 46.5MM SS 4 HOLE STR MPS BONE ACETAB BOTH IP/OP $762.30 $564.10 $0.00 $565.78 $201.71 $201.71 $0.00 $0.00 $0.00 $158.88 $565.78 $565.78 $0.00 $0.00 $158.86 $0.00 $450.90 $450.90 $0.00 $224.13 $355.01 $358.60 $0.00 $0.00 $70.15 $0.00 $0.00 $71.36 $0.00 $0.00 $0.00 $0.00 $0.00 425755 SUP HCPCS C1713 425755 - PLATE 58.5MM 5 HOLE STR BONE ACETAB BOTH IP/OP $762.30 $564.10 $0.00 $565.78 $210.99 $210.99 $0.00 $0.00 $0.00 $158.88 $565.78 $565.78 $0.00 $0.00 $158.86 $0.00 $450.90 $450.90 $0.00 $234.44 $371.35 $375.10 $0.00 $0.00 $73.38 $0.00 $0.00 $74.64 $0.00 $0.00 $0.00 $0.00 $0.00 425756 SUP HCPCS C1713 425756 - PLATE 70.5MM SS 6 HOLE STR MPS BONE ACETAB BOTH IP/OP $837.90 $620.05 $0.00 $621.89 $230.79 $230.79 $0.00 $0.00 $0.00 $174.64 $621.89 $621.89 $0.00 $0.00 $174.62 $0.00 $495.62 $495.62 $0.00 $256.44 $406.20 $410.30 $0.00 $0.00 $80.26 $0.00 $0.00 $81.65 $0.00 $0.00 $0.00 $0.00 $0.00 425757 SUP HCPCS C1713 425757 - PLATE 82.5MM 7 HOLE STR BONE ACETAB BOTH IP/OP $837.90 $620.05 $0.00 $621.89 $244.41 $244.41 $0.00 $0.00 $0.00 $174.64 $621.89 $621.89 $0.00 $0.00 $174.62 $0.00 $495.62 $495.62 $0.00 $271.56 $430.16 $434.50 $0.00 $0.00 $85.00 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 425758 SUP HCPCS C1713 425758 - PLATE 94.5MM SS 8 HOLE STR MPS BONE ACETAB BOTH IP/OP $837.90 $620.05 $0.00 $621.89 $259.88 $259.88 $0.00 $0.00 $0.00 $174.64 $621.89 $621.89 $0.00 $0.00 $174.62 $0.00 $495.62 $495.62 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 425759 SUP HCPCS C1713 425759 - PLATE 106.5MM 9 HOLE STR BONE ACETAB BOTH IP/OP $837.90 $620.05 $0.00 $621.89 $269.16 $269.16 $0.00 $0.00 $0.00 $174.64 $621.89 $621.89 $0.00 $0.00 $174.62 $0.00 $495.62 $495.62 $0.00 $299.06 $473.72 $478.50 $0.00 $0.00 $93.61 $0.00 $0.00 $95.22 $0.00 $0.00 $0.00 $0.00 $0.00 425760 SUP HCPCS C1713 425760 - PLATE 118.5MM SS 10 HOLE STR MPS BONE ACETAB BOTH IP/OP $837.90 $620.05 $0.00 $621.89 $278.44 $278.44 $0.00 $0.00 $0.00 $174.64 $621.89 $621.89 $0.00 $0.00 $174.62 $0.00 $495.62 $495.62 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 425761 SUP HCPCS C1713 425761 - PLATE 130.5MM 11 HOLE STR BONE ACETAB BOTH IP/OP $924.70 $684.28 $0.00 $686.31 $288.34 $288.34 $0.00 $0.00 $0.00 $192.73 $686.31 $686.31 $0.00 $0.00 $192.71 $0.00 $546.96 $546.96 $0.00 $320.38 $507.47 $512.60 $0.00 $0.00 $100.28 $0.00 $0.00 $102.01 $0.00 $0.00 $0.00 $0.00 $0.00 425762 SUP HCPCS C1713 425762 - PLATE 142.5MM SS 12 HOLE STR MATTA MPS BONE ACETAB BOTH IP/OP $924.70 $684.28 $0.00 $686.31 $298.24 $298.24 $0.00 $0.00 $0.00 $192.73 $686.31 $686.31 $0.00 $0.00 $192.71 $0.00 $546.96 $546.96 $0.00 $331.38 $524.90 $530.20 $0.00 $0.00 $103.72 $0.00 $0.00 $105.51 $0.00 $0.00 $0.00 $0.00 $0.00 425763 SUP HCPCS C1713 425763 - PLATE 154.5MM 13 HOLE STR BONE ACETAB BOTH IP/OP $924.70 $684.28 $0.00 $686.31 $306.90 $306.90 $0.00 $0.00 $0.00 $192.73 $686.31 $686.31 $0.00 $0.00 $192.71 $0.00 $546.96 $546.96 $0.00 $341.00 $540.14 $545.60 $0.00 $0.00 $106.73 $0.00 $0.00 $108.57 $0.00 $0.00 $0.00 $0.00 $0.00 425764 SUP HCPCS C1713 425764 - PLATE 166.5MM SS 14 HOLE STR MATTA MPS BONE ACETAB BOTH IP/OP $924.70 $684.28 $0.00 $686.31 $316.80 $316.80 $0.00 $0.00 $0.00 $192.73 $686.31 $686.31 $0.00 $0.00 $192.71 $0.00 $546.96 $546.96 $0.00 $352.00 $557.57 $563.20 $0.00 $0.00 $110.18 $0.00 $0.00 $112.08 $0.00 $0.00 $0.00 $0.00 $0.00 425765 SUP HCPCS C1713 425765 - PLATE 178.5MM 15 HOLE STR BONE ACETAB BOTH IP/OP $924.70 $684.28 $0.00 $686.31 $326.70 $326.70 $0.00 $0.00 $0.00 $192.73 $686.31 $686.31 $0.00 $0.00 $192.71 $0.00 $546.96 $546.96 $0.00 $363.00 $574.99 $580.80 $0.00 $0.00 $113.62 $0.00 $0.00 $115.58 $0.00 $0.00 $0.00 $0.00 $0.00 425766 SUP HCPCS C1713 425766 - PLATE 190.5MM SS 16 HOLE STR BONE ACETAB BOTH IP/OP "$1,014.30 " $750.58 $0.00 $752.81 $345.26 $345.26 $0.00 $0.00 $0.00 $211.41 $752.81 $752.81 $0.00 $0.00 $211.38 $0.00 $599.96 $599.96 $0.00 $383.63 $607.66 $613.80 $0.00 $0.00 $120.07 $0.00 $0.00 $122.15 $0.00 $0.00 $0.00 $0.00 $0.00 425767 SUP HCPCS C1713 425767 - PLATE 202.5MM 17 HOLE STR BONE ACETAB BOTH IP/OP "$1,014.30 " $750.58 $0.00 $752.81 $364.44 $364.44 $0.00 $0.00 $0.00 $211.41 $752.81 $752.81 $0.00 $0.00 $211.38 $0.00 $599.96 $599.96 $0.00 $404.94 $641.42 $647.90 $0.00 $0.00 $126.75 $0.00 $0.00 $128.93 $0.00 $0.00 $0.00 $0.00 $0.00 425768 SUP HCPCS C1713 425768 - PLATE 214.5MM 18 HOLE STR BONE ACETAB BOTH IP/OP "$1,014.30 " $750.58 $0.00 $752.81 $383.01 $383.01 $0.00 $0.00 $0.00 $211.41 $752.81 $752.81 $0.00 $0.00 $211.38 $0.00 $599.96 $599.96 $0.00 $425.56 $674.09 $680.90 $0.00 $0.00 $133.20 $0.00 $0.00 $135.50 $0.00 $0.00 $0.00 $0.00 $0.00 425769 SUP HCPCS C1713 425769 - PLATE 226.5MM 19 HOLE STR BONE ACETAB BOTH IP/OP $961.13 $711.24 $0.00 $768.90 $432.51 $432.51 $0.00 $0.00 $0.00 $200.32 $713.35 $713.35 $0.00 $0.00 $200.30 $0.00 $568.51 $568.51 $0.00 $480.56 $761.21 $768.90 $0.00 $0.00 $150.42 $0.00 $0.00 $153.01 $0.00 $0.00 $0.00 $0.00 $0.00 425770 SUP HCPCS C1713 425770 - PLATE 238.5MM 20 HOLE STR BONE ACETAB BOTH IP/OP "$1,014.30 " $750.58 $0.00 $768.90 $432.51 $432.51 $0.00 $0.00 $0.00 $211.41 $752.81 $752.81 $0.00 $0.00 $211.38 $0.00 $599.96 $599.96 $0.00 $480.56 $761.21 $768.90 $0.00 $0.00 $150.42 $0.00 $0.00 $153.01 $0.00 $0.00 $0.00 $0.00 $0.00 425772 SUP HCPCS C1713 425772 - PLATE 262.5MM 22 HOLE STR BONE ACETAB BOTH IP/OP "$1,014.30 " $750.58 $0.00 $768.90 $432.51 $432.51 $0.00 $0.00 $0.00 $211.41 $752.81 $752.81 $0.00 $0.00 $211.38 $0.00 $599.96 $599.96 $0.00 $480.56 $761.21 $768.90 $0.00 $0.00 $150.42 $0.00 $0.00 $153.01 $0.00 $0.00 $0.00 $0.00 $0.00 425774 SUP HCPCS C1713 425774 - PLATE 286.5MM 24 HOLE STR BONE ACETAB BOTH IP/OP $961.13 $711.24 $0.00 $768.90 $432.51 $432.51 $0.00 $0.00 $0.00 $200.32 $713.35 $713.35 $0.00 $0.00 $200.30 $0.00 $568.51 $568.51 $0.00 $480.56 $761.21 $768.90 $0.00 $0.00 $150.42 $0.00 $0.00 $153.01 $0.00 $0.00 $0.00 $0.00 $0.00 425776 SUP HCPCS C1713 425776 - PLATE 310.5MM 26 HOLE STR BONE ACETAB BOTH IP/OP $961.13 $711.24 $0.00 $768.90 $432.51 $432.51 $0.00 $0.00 $0.00 $200.32 $713.35 $713.35 $0.00 $0.00 $200.30 $0.00 $568.51 $568.51 $0.00 $480.56 $761.21 $768.90 $0.00 $0.00 $150.42 $0.00 $0.00 $153.01 $0.00 $0.00 $0.00 $0.00 $0.00 425778 SUP HCPCS C1713 425778 - PLATE 334.5MM 28 HOLE STR BONE ACETAB BOTH IP/OP $961.13 $711.24 $0.00 $768.90 $432.51 $432.51 $0.00 $0.00 $0.00 $200.32 $713.35 $713.35 $0.00 $0.00 $200.30 $0.00 $568.51 $568.51 $0.00 $480.56 $761.21 $768.90 $0.00 $0.00 $150.42 $0.00 $0.00 $153.01 $0.00 $0.00 $0.00 $0.00 $0.00 425780 SUP HCPCS C1713 425780 - PLATE 358.5MM 30 HOLE STR BONE ACETAB BOTH IP/OP "$1,014.30 " $750.58 $0.00 $768.90 $432.51 $432.51 $0.00 $0.00 $0.00 $211.41 $752.81 $752.81 $0.00 $0.00 $211.38 $0.00 $599.96 $599.96 $0.00 $480.56 $761.21 $768.90 $0.00 $0.00 $150.42 $0.00 $0.00 $153.01 $0.00 $0.00 $0.00 $0.00 $0.00 425794 SUP HCPCS C1713 425794 - PLATE BN 60.5MM MPS 4 HL SS R75 BOTH IP/OP "$1,120.00 " $828.80 $0.00 $831.26 $458.49 $458.49 $0.00 $0.00 $0.00 $233.44 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $662.48 $662.48 $0.00 $509.44 $806.95 $815.10 $0.00 $0.00 $159.45 $0.00 $0.00 $162.20 $0.00 $0.00 $0.00 $0.00 $0.00 425796 SUP HCPCS C1713 425796 - PLATE BN 92.5MM MPS 6 HL SS R75 BOTH IP/OP "$1,187.20 " $878.53 $0.00 $881.14 $482.01 $482.01 $0.00 $0.00 $0.00 $247.44 $881.14 $881.14 $0.00 $0.00 $247.41 $0.00 $702.23 $702.23 $0.00 $535.56 $848.33 $856.90 $0.00 $0.00 $167.63 $0.00 $0.00 $170.52 $0.00 $0.00 $0.00 $0.00 $0.00 425798 SUP HCPCS C1713 425798 - PLATE 75MM RAD 124.5MM 8 HOLE BONE PUBIS SYMPHYSIS BOTH IP/OP "$1,122.00 " $830.28 $0.00 $897.60 $504.90 $504.90 $0.00 $0.00 $0.00 $233.85 $832.75 $832.75 $0.00 $0.00 $233.82 $0.00 $663.66 $663.66 $0.00 $561.00 $888.62 $897.60 $0.00 $0.00 $175.59 $0.00 $0.00 $178.62 $0.00 $0.00 $0.00 $0.00 $0.00 427002 SUP HCPCS C1713 427002 - PLATE 32MM SS 4MM SCR SM FRAG 2 HOLE WST CMPR LCK AXSOS BONE BOTH IP/OP $182.40 $134.98 $0.00 $143.00 $80.44 $80.44 $0.00 $0.00 $0.00 $38.02 $135.38 $135.38 $0.00 $0.00 $38.01 $0.00 $107.89 $107.89 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $27.97 $0.00 $0.00 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 427003 SUP HCPCS C1713 427003 - PLATE 45MM SS 3 HOLE WST CMPR SM FRAG IMPL AXSOS BONE 4MM BOTH IP/OP $182.40 $134.98 $0.00 $143.00 $80.44 $80.44 $0.00 $0.00 $0.00 $38.02 $135.38 $135.38 $0.00 $0.00 $38.01 $0.00 $107.89 $107.89 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $27.97 $0.00 $0.00 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 427004 SUP HCPCS C1713 427004 - PLATE 58MM SS 4MM SCR SM FRAG 4 HOLE WST CMPR LCK AXSOS BONE BOTH IP/OP $182.40 $134.98 $0.00 $154.00 $86.63 $86.63 $0.00 $0.00 $0.00 $38.02 $135.38 $135.38 $0.00 $0.00 $38.01 $0.00 $107.89 $107.89 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $30.13 $0.00 $0.00 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 427005 SUP HCPCS C1713 427005 - PLATE BN 71MM NS AXSOS 5 HL LCK CMPR SS WST 4MM SCR SM FRAG BOTH IP/OP $233.60 $172.86 $0.00 $181.50 $102.09 $102.09 $0.00 $0.00 $0.00 $48.69 $173.38 $173.38 $0.00 $0.00 $48.68 $0.00 $138.17 $138.17 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $35.51 $0.00 $0.00 $36.12 $0.00 $0.00 $0.00 $0.00 $0.00 427006 SUP HCPCS C1713 427006 - PLATE BN 84MM NS AXSOS 6 HL LCK CMPR SS WST 4MM SCR SM FRAG BOTH IP/OP $233.60 $172.86 $0.00 $181.50 $102.09 $102.09 $0.00 $0.00 $0.00 $48.69 $173.38 $173.38 $0.00 $0.00 $48.68 $0.00 $138.17 $138.17 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $35.51 $0.00 $0.00 $36.12 $0.00 $0.00 $0.00 $0.00 $0.00 427007 SUP HCPCS C1713 427007 - PLATE BN 97MM NS AXSOS 7 HL LCK CMPR SS WST 4MM SCR SM FRAG BOTH IP/OP $233.60 $172.86 $0.00 $181.50 $102.09 $102.09 $0.00 $0.00 $0.00 $48.69 $173.38 $173.38 $0.00 $0.00 $48.68 $0.00 $138.17 $138.17 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $35.51 $0.00 $0.00 $36.12 $0.00 $0.00 $0.00 $0.00 $0.00 427008 SUP HCPCS C1713 427008 - PLATE 110MM SS 4MM SCR 8 HOLE WST CMPR SM FRAG IMPL AXSOS BOTH IP/OP $260.00 $192.40 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $0.00 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 427009 SUP HCPCS C1713 427009 - PLATE 123MM SS 4MM SCR SM FRAG 29 HOLE WST CMPR LCK AXSOS BOTH IP/OP $260.00 $192.40 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $0.00 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 427010 SUP HCPCS C1713 427010 - PLATE 4MM SCR NONSTRL 136MM SS 10 HOLE LCK CMPR WST SM FRAG BOTH IP/OP $260.00 $192.40 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $0.00 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 427011 SUP HCPCS C1713 427011 - PLATE 149MM SS 4MM SCR SM FRAG 11 HOLE WST CMPR LCK AXSOS BOTH IP/OP $260.00 $192.40 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $0.00 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 427012 SUP HCPCS C1713 427012 - PLATE BN 162MM NS AXSOS 12 HL LCK CMPR SS WST 4MM SCR SM BOTH IP/OP $260.00 $192.40 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $0.00 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 427014 SUP HCPCS C1713 427014 - PLATE 188MM 14 HOLE CMPR WST LCK AXSOS BONE 4MM BOTH IP/OP $311.20 $230.29 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $64.86 $230.97 $230.97 $0.00 $0.00 $64.85 $0.00 $184.07 $184.07 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 427016 SUP HCPCS C1713 427016 - PLATE 241MM SS 16 HOLE WST CMPR BONE 4MM STRL BOTH IP/OP $311.20 $230.29 $0.00 $269.50 $151.59 $151.59 $0.00 $0.00 $0.00 $64.86 $230.97 $230.97 $0.00 $0.00 $64.85 $0.00 $184.07 $184.07 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $52.72 $0.00 $0.00 $53.63 $0.00 $0.00 $0.00 $0.00 $0.00 427018 SUP HCPCS C1713 427018 - PLATE 240MM SS 4MM SCR SM FRAG 18 HOLE WST CMPR LCK AXSOS BOTH IP/OP $363.20 $268.77 $0.00 $302.50 $170.16 $170.16 $0.00 $0.00 $0.00 $75.70 $269.57 $269.57 $0.00 $0.00 $75.69 $0.00 $214.83 $214.83 $0.00 $189.06 $299.48 $302.50 $0.00 $0.00 $59.18 $0.00 $0.00 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 427020 SUP HCPCS C1713 427020 - PLATE 266MM SS 4MM SCR SM FRAG 20 HOLE WST CMPR LCK AXSOS BOTH IP/OP $363.20 $268.77 $0.00 $302.50 $170.16 $170.16 $0.00 $0.00 $0.00 $75.70 $269.57 $269.57 $0.00 $0.00 $75.69 $0.00 $214.83 $214.83 $0.00 $189.06 $299.48 $302.50 $0.00 $0.00 $59.18 $0.00 $0.00 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 427062 SUP HCPCS C1713 427062 - PLATE 24MM SS 3MM SCR SM FRAG 2 HOLE 1/3 TBLR LCK SYS AXSOS BOTH IP/OP $179.20 $132.61 $0.00 $144.10 $81.06 $81.06 $0.00 $0.00 $0.00 $37.35 $133.00 $133.00 $0.00 $0.00 $37.35 $0.00 $106.00 $106.00 $0.00 $90.06 $142.66 $144.10 $0.00 $0.00 $28.19 $0.00 $0.00 $28.68 $0.00 $0.00 $0.00 $0.00 $0.00 427063 SUP HCPCS C1713 427063 - PLATE 37MM SS 3 HOLE 1/3 TBLR BONE 3MM BOTH IP/OP $190.40 $140.90 $0.00 $151.80 $85.39 $85.39 $0.00 $0.00 $0.00 $39.68 $141.31 $141.31 $0.00 $0.00 $39.68 $0.00 $112.62 $112.62 $0.00 $94.88 $150.28 $151.80 $0.00 $0.00 $29.70 $0.00 $0.00 $30.21 $0.00 $0.00 $0.00 $0.00 $0.00 427064 SUP HCPCS C1713 427064 - PLATE 50MM SS 3MM SCR SM FRAG SET 4 HOLE 1/3 TBLR LCK AXSOS BOTH IP/OP $218.40 $161.62 $0.00 $174.90 $98.38 $98.38 $0.00 $0.00 $0.00 $45.52 $162.10 $162.10 $0.00 $0.00 $45.51 $0.00 $129.18 $129.18 $0.00 $109.31 $173.15 $174.90 $0.00 $0.00 $34.21 $0.00 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 427065 SUP HCPCS C1713 427065 - PLATE 3MM 63MM SS 5 HOLE 1/3 TBLR SM FRAG AXSOS BONE BOTH IP/OP $218.40 $161.62 $0.00 $174.90 $98.38 $98.38 $0.00 $0.00 $0.00 $45.52 $162.10 $162.10 $0.00 $0.00 $45.51 $0.00 $129.18 $129.18 $0.00 $109.31 $173.15 $174.90 $0.00 $0.00 $34.21 $0.00 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 427066 SUP HCPCS C1713 427066 - PLATE BN 1/3 TBLR 76MM NS AXSOS 6 HL LCK SS 3MM SCR SM FRAG BOTH IP/OP $218.40 $161.62 $0.00 $162.10 $39.60 $39.60 $0.00 $0.00 $0.00 $45.52 $162.10 $162.10 $0.00 $0.00 $45.51 $0.00 $129.18 $129.18 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 427067 SUP HCPCS C1713 427067 - PLATE 89MM SS 3MM SCR SM FRAG 7 HOLE 1/3 TBLR LCK AXSOS BONE BOTH IP/OP $223.20 $165.17 $0.00 $179.30 $100.86 $100.86 $0.00 $0.00 $0.00 $46.52 $165.66 $165.66 $0.00 $0.00 $46.51 $0.00 $132.02 $132.02 $0.00 $112.06 $177.51 $179.30 $0.00 $0.00 $35.08 $0.00 $0.00 $35.68 $0.00 $0.00 $0.00 $0.00 $0.00 427068 SUP HCPCS C1713 427068 - PLATE BN 1/3 TBLR 102MM NS AXSOS 8 HL LCK SS 3MM SCR SM FRAG BOTH IP/OP $236.80 $175.23 $0.00 $189.20 $106.43 $106.43 $0.00 $0.00 $0.00 $49.36 $175.75 $175.75 $0.00 $0.00 $49.35 $0.00 $140.07 $140.07 $0.00 $118.25 $187.31 $189.20 $0.00 $0.00 $37.01 $0.00 $0.00 $37.65 $0.00 $0.00 $0.00 $0.00 $0.00 427070 SUP HCPCS C1713 427070 - PLATE 3MM 128MM SS 10 HOLE 1/3 TBLR SM FRAG IMPL AXSOS BONE BOTH IP/OP $236.80 $175.23 $0.00 $189.20 $106.43 $106.43 $0.00 $0.00 $0.00 $49.36 $175.75 $175.75 $0.00 $0.00 $49.35 $0.00 $140.07 $140.07 $0.00 $118.25 $187.31 $189.20 $0.00 $0.00 $37.01 $0.00 $0.00 $37.65 $0.00 $0.00 $0.00 $0.00 $0.00 427072 SUP HCPCS C1713 427072 - PLATE 154MM SS 3MM SCR SM FRAG 12 HOLE 1/3 TBLR LCK AXSOS BOTH IP/OP $243.20 $179.97 $0.00 $194.70 $109.52 $109.52 $0.00 $0.00 $0.00 $50.69 $180.50 $180.50 $0.00 $0.00 $50.68 $0.00 $143.85 $143.85 $0.00 $121.69 $192.76 $194.70 $0.00 $0.00 $38.09 $0.00 $0.00 $38.75 $0.00 $0.00 $0.00 $0.00 $0.00 427074 SUP HCPCS C1713 427074 - PLATE 180MM SS 3MM SCR SM FRAG 14 HOLE 1/3 TBLR LCK AXSOS BOTH IP/OP $247.20 $182.93 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.52 $183.47 $183.47 $0.00 $0.00 $51.52 $0.00 $146.22 $146.22 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 427102 SUP HCPCS C1713 427102 - PLATE NAR 43MM SS 5MM SCR BASIC FRAG 2 HOLE WST CMPR LCK BOTH IP/OP $245.60 $181.74 $0.00 $182.28 $89.72 $89.72 $0.00 $0.00 $0.00 $51.19 $182.28 $182.28 $0.00 $0.00 $51.18 $0.00 $145.27 $145.27 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 427103 SUP HCPCS C1713 427103 - PLATE NAR 61MM SS 5MM SCR BASIC FRAG 3 HOLE WST CMPR LCK BOTH IP/OP $245.60 $181.74 $0.00 $182.28 $89.72 $89.72 $0.00 $0.00 $0.00 $51.19 $182.28 $182.28 $0.00 $0.00 $51.18 $0.00 $145.27 $145.27 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 427104 SUP HCPCS C1713 427104 - PLATE NAR 79MM SS 5MM SCR BASIC FRAG 4 HOLE WST CMPR LCK BOTH IP/OP $245.60 $181.74 $0.00 $182.28 $89.72 $89.72 $0.00 $0.00 $0.00 $51.19 $182.28 $182.28 $0.00 $0.00 $51.18 $0.00 $145.27 $145.27 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 427105 SUP HCPCS C1713 427105 - PLATE NAR 97MM SS 5MM SCR BASIC FRAG 5 HOLE WST CMPR LCK BOTH IP/OP $245.60 $181.74 $0.00 $182.28 $89.72 $89.72 $0.00 $0.00 $0.00 $51.19 $182.28 $182.28 $0.00 $0.00 $51.18 $0.00 $145.27 $145.27 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 427106 SUP HCPCS C1713 427106 - PLATE NAR 115MM SS WST CMPR 6 HOLE BONE 5MM BOTH IP/OP $245.60 $181.74 $0.00 $182.28 $89.72 $89.72 $0.00 $0.00 $0.00 $51.19 $182.28 $182.28 $0.00 $0.00 $51.18 $0.00 $145.27 $145.27 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 427107 SUP HCPCS C1713 427107 - PLATE NAR 133MM SS 7 HL SHFT CMPR WST BONE 5MM BOTH IP/OP $293.60 $217.26 $0.00 $217.91 $114.47 $114.47 $0.00 $0.00 $0.00 $61.19 $217.91 $217.91 $0.00 $0.00 $61.19 $0.00 $173.66 $173.66 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 427108 SUP HCPCS C1713 427108 - PLATE BN NAR 151MM NS AXSOS 8 HL LCK CMPR SS WST 5MM SCR BSC BOTH IP/OP $293.60 $217.26 $0.00 $217.91 $114.47 $114.47 $0.00 $0.00 $0.00 $61.19 $217.91 $217.91 $0.00 $0.00 $61.19 $0.00 $173.66 $173.66 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 427109 SUP HCPCS C1713 427109 - PLATE NAR 169MM SS BASIC FRAG SET 9 HOLE LCK CMPR AXSOS BONE BOTH IP/OP $293.60 $217.26 $0.00 $217.91 $114.47 $114.47 $0.00 $0.00 $0.00 $61.19 $217.91 $217.91 $0.00 $0.00 $61.19 $0.00 $173.66 $173.66 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 427110 SUP HCPCS C1713 427110 - PLATE NAR 187MM SS 5MM SCR BASIC FRAG 10 HOLE WST CMPR LCK BOTH IP/OP $293.60 $217.26 $0.00 $217.91 $114.47 $114.47 $0.00 $0.00 $0.00 $61.19 $217.91 $217.91 $0.00 $0.00 $61.19 $0.00 $173.66 $173.66 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 427112 SUP HCPCS C1713 427112 - PLATE NAR 223MM SS 5MM SCR BASIC FRAG 12 HOLE WST CMPR LCK BOTH IP/OP $351.20 $259.89 $0.00 $260.66 $142.31 $142.31 $0.00 $0.00 $0.00 $73.20 $260.66 $260.66 $0.00 $0.00 $73.19 $0.00 $207.73 $207.73 $0.00 $158.13 $250.47 $253.00 $0.00 $0.00 $49.49 $0.00 $0.00 $50.35 $0.00 $0.00 $0.00 $0.00 $0.00 427114 SUP HCPCS C1713 427114 - PLATE BN NAR 259MM NS AXSOS 14 HL LCK CMPR SS WST 5MM SCR BOTH IP/OP $351.20 $259.89 $0.00 $260.66 $142.31 $142.31 $0.00 $0.00 $0.00 $73.20 $260.66 $260.66 $0.00 $0.00 $73.19 $0.00 $207.73 $207.73 $0.00 $158.13 $250.47 $253.00 $0.00 $0.00 $49.49 $0.00 $0.00 $50.35 $0.00 $0.00 $0.00 $0.00 $0.00 427116 SUP HCPCS C1713 427116 - PLATE NAR NONSTRL 295MM SS 5MM SCR BASIC FRAG 16 HOLE WST BOTH IP/OP $378.40 $280.02 $0.00 $297.00 $167.06 $167.06 $0.00 $0.00 $0.00 $78.87 $280.85 $280.85 $0.00 $0.00 $78.86 $0.00 $223.82 $223.82 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 427118 SUP HCPCS C1713 427118 - PLATE NAR NONSTRL 331MM SS 5MM SCR BASIC FRAG 18 HOLE WST BOTH IP/OP $418.40 $309.62 $0.00 $357.50 $201.09 $201.09 $0.00 $0.00 $0.00 $87.21 $310.54 $310.54 $0.00 $0.00 $87.19 $0.00 $247.48 $247.48 $0.00 $223.44 $353.93 $357.50 $0.00 $0.00 $69.94 $0.00 $0.00 $71.14 $0.00 $0.00 $0.00 $0.00 $0.00 427120 SUP HCPCS C1713 427120 - PLATE NAR 367MM SS 5MM SCR BASIC FRAG 20 HOLE WST CMPR LCK BOTH IP/OP $636.00 $470.64 $0.00 $472.04 $225.84 $225.84 $0.00 $0.00 $0.00 $132.56 $472.04 $472.04 $0.00 $0.00 $132.54 $0.00 $376.19 $376.19 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 427122 SUP HCPCS C1713 427122 - PLATE NAR NONSTRL 403MM SS 5MM SCR BASIC FRAG 22 HOLE WST BOTH IP/OP $636.00 $470.64 $0.00 $472.04 $253.69 $253.69 $0.00 $0.00 $0.00 $132.56 $472.04 $472.04 $0.00 $0.00 $132.54 $0.00 $376.19 $376.19 $0.00 $281.88 $446.49 $451.00 $0.00 $0.00 $88.23 $0.00 $0.00 $89.75 $0.00 $0.00 $0.00 $0.00 $0.00 427136 SUP HCPCS C1713 427136 - PLATE BRD 119MM SS 5MM SCR BASIC FRAG SET 6 HOLE LCK CMPR BOTH IP/OP $340.80 $252.19 $0.00 $252.94 $133.65 $133.65 $0.00 $0.00 $0.00 $71.03 $252.94 $252.94 $0.00 $0.00 $71.02 $0.00 $201.58 $201.58 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 427137 SUP HCPCS C1713 427137 - PLATE BRD 137MM SS 7 HL SHFT CMPR WST BONE 5MM BOTH IP/OP $358.40 $265.22 $0.00 $266.20 $149.74 $149.74 $0.00 $0.00 $0.00 $74.70 $266.00 $266.00 $0.00 $0.00 $74.69 $0.00 $211.99 $211.99 $0.00 $166.38 $263.54 $266.20 $0.00 $0.00 $52.08 $0.00 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $0.00 427138 SUP HCPCS C1713 427138 - PLATE BN BRD 155MM NS AXSOS 8 HL LCK CMPR SS WST 5MM SCR BSC BOTH IP/OP $380.80 $281.79 $0.00 $282.63 $149.74 $149.74 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $166.38 $263.54 $266.20 $0.00 $0.00 $52.08 $0.00 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $0.00 427139 SUP HCPCS C1713 427139 - PLATE BRD 173MM SS 5MM SCR BASIC FRAG 9 HOLE WST CMPR LCK BOTH IP/OP $380.80 $281.79 $0.00 $282.63 $149.74 $149.74 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $166.38 $263.54 $266.20 $0.00 $0.00 $52.08 $0.00 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $0.00 427140 SUP HCPCS C1713 427140 - PLATE BN BRD 191MM NS AXSOS 10 HL LCK CMPR SS WST 5MM SCR BOTH IP/OP $380.80 $281.79 $0.00 $282.63 $149.74 $149.74 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $166.38 $263.54 $266.20 $0.00 $0.00 $52.08 $0.00 $0.00 $52.97 $0.00 $0.00 $0.00 $0.00 $0.00 427141 SUP HCPCS C1713 427141 - PLATE BRD 209MM SS 5MM SCR BASIC FRAG 11 HOLE WST CMPR LCK BOTH IP/OP $416.80 $308.43 $0.00 $309.35 $167.06 $167.06 $0.00 $0.00 $0.00 $86.87 $309.35 $309.35 $0.00 $0.00 $86.86 $0.00 $246.54 $246.54 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 427142 SUP HCPCS C1713 427142 - PLATE BRD 227MM SS BASIC FRAG SET 12 HOLE LCK CMPR AXSOS BOTH IP/OP $416.80 $308.43 $0.00 $309.35 $167.06 $167.06 $0.00 $0.00 $0.00 $86.87 $309.35 $309.35 $0.00 $0.00 $86.86 $0.00 $246.54 $246.54 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 427143 SUP HCPCS C1713 427143 - PLATE BRD 245MM SS 5MM SCR BASIC FRAG 13 HOLE WST CMPR LCK BOTH IP/OP $416.80 $308.43 $0.00 $309.35 $167.06 $167.06 $0.00 $0.00 $0.00 $86.87 $309.35 $309.35 $0.00 $0.00 $86.86 $0.00 $246.54 $246.54 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 427144 SUP HCPCS C1713 427144 - PLATE BRD 263MM SS 5MM SCR BASIC FRAG 14 HOLE WST CMPR LCK BOTH IP/OP $416.80 $308.43 $0.00 $309.35 $167.06 $167.06 $0.00 $0.00 $0.00 $86.87 $309.35 $309.35 $0.00 $0.00 $86.86 $0.00 $246.54 $246.54 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 427146 SUP HCPCS C1713 427146 - PLATE BRD 299MM SS 5MM SCR BASIC FRAG 16 HOLE WST CMPR LCK BOTH IP/OP $446.40 $330.34 $0.00 $331.32 $183.15 $183.15 $0.00 $0.00 $0.00 $93.04 $331.32 $331.32 $0.00 $0.00 $93.03 $0.00 $264.05 $264.05 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 427148 SUP HCPCS C1713 427148 - PLATE BRD 335MM SS 5MM SCR BASIC FRAG 18 HOLE WST CMPR LCK BOTH IP/OP $446.40 $330.34 $0.00 $400.40 $225.23 $225.23 $0.00 $0.00 $0.00 $93.04 $331.32 $331.32 $0.00 $0.00 $93.03 $0.00 $264.05 $264.05 $0.00 $250.25 $396.40 $400.40 $0.00 $0.00 $78.33 $0.00 $0.00 $79.68 $0.00 $0.00 $0.00 $0.00 $0.00 427150 SUP HCPCS C1713 427150 - PLATE BRD 371MM SS 5MM SCR BASIC FRAG 20 HOLE WST CMPR LCK BOTH IP/OP $597.60 $442.22 $0.00 $447.70 $251.83 $251.83 $0.00 $0.00 $0.00 $124.55 $443.54 $443.54 $0.00 $0.00 $124.54 $0.00 $353.48 $353.48 $0.00 $279.81 $443.23 $447.70 $0.00 $0.00 $87.58 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $0.00 427152 SUP HCPCS C1713 427152 - PLATE BRD 407MM SS 5MM SCR BASIC FRAG 22 HOLE WST CMPR LCK BOTH IP/OP $597.60 $442.22 $0.00 $495.00 $278.44 $278.44 $0.00 $0.00 $0.00 $124.55 $443.54 $443.54 $0.00 $0.00 $124.54 $0.00 $353.48 $353.48 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 429688 SUP HCPCS C1900 429688 - LEAD PACING 2 CURVE 5.3FR 88CM BIPOL 2 ELECTRODE 2 FIX IS-1 BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 430009 SUP HCPCS C1713 430009 - PLATE 117MM SS SM FRAG SET 9 HOLE WST CMPR SPS BONE ORTH BOTH IP/OP $204.00 $150.96 $0.00 $180.40 $101.48 $101.48 $0.00 $0.00 $0.00 $42.52 $151.41 $151.41 $0.00 $0.00 $42.51 $0.00 $120.67 $120.67 $0.00 $112.75 $178.60 $180.40 $0.00 $0.00 $35.29 $0.00 $0.00 $35.90 $0.00 $0.00 $0.00 $0.00 $0.00 430012 SUP HCPCS C1713 430012 - PLATE 156X10.3X3.2MM SS 12 HOLE CMPR WST BONE ORTH BOTH IP/OP $287.25 $212.57 $0.00 $213.20 $109.52 $109.52 $0.00 $0.00 $0.00 $59.87 $213.20 $213.20 $0.00 $0.00 $59.86 $0.00 $169.91 $169.91 $0.00 $121.69 $192.76 $194.70 $0.00 $0.00 $38.09 $0.00 $0.00 $38.75 $0.00 $0.00 $0.00 $0.00 $0.00 430014 SUP HCPCS C1713 430014 - PLATE 182MM SS SM FRAG SET 14 HOLE WST CMPR SPS BONE ORTH BOTH IP/OP $306.40 $226.74 $0.00 $311.30 $175.11 $175.11 $0.00 $0.00 $0.00 $63.86 $227.41 $227.41 $0.00 $0.00 $63.85 $0.00 $181.24 $181.24 $0.00 $194.56 $308.19 $311.30 $0.00 $0.00 $60.90 $0.00 $0.00 $61.95 $0.00 $0.00 $0.00 $0.00 $0.00 430016 SUP HCPCS C1713 430016 - PLATE 208MM SS SM FRAG SET 16 HOLE WST CMPR SPS BONE ORTH BOTH IP/OP $509.60 $377.10 $0.00 $485.10 $272.87 $272.87 $0.00 $0.00 $0.00 $106.21 $378.23 $378.23 $0.00 $0.00 $106.20 $0.00 $301.43 $301.43 $0.00 $303.19 $480.25 $485.10 $0.00 $0.00 $94.90 $0.00 $0.00 $96.53 $0.00 $0.00 $0.00 $0.00 $0.00 430018 SUP HCPCS C1713 430018 - PLATE 234X10.3X3.2MM SS 18 HOLE CMPR WST BONE ORTH BOTH IP/OP $612.00 $452.88 $0.00 $553.30 $311.23 $311.23 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $345.81 $547.77 $553.30 $0.00 $0.00 $108.24 $0.00 $0.00 $110.11 $0.00 $0.00 $0.00 $0.00 $0.00 430055 SUP HCPCS C1713 430055 - PLATE STD 65MM SS 5 HOLE CMPR SPS BONE DISTAL ULN NONSTRL BOTH IP/OP $191.13 $141.44 $0.00 $152.90 $86.01 $86.01 $0.00 $0.00 $0.00 $39.84 $141.85 $141.85 $0.00 $0.00 $39.83 $0.00 $113.05 $113.05 $0.00 $95.56 $151.37 $152.90 $0.00 $0.00 $29.91 $0.00 $0.00 $30.43 $0.00 $0.00 $0.00 $0.00 $0.00 430056 SUP HCPCS C1713 430056 - PLATE STD 78MM SS 6 HOLE CMPR BONE BOTH IP/OP $191.25 $141.53 $0.00 $141.95 $71.78 $71.78 $0.00 $0.00 $0.00 $39.86 $141.95 $141.95 $0.00 $0.00 $39.86 $0.00 $113.12 $113.12 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $24.96 $0.00 $0.00 $25.39 $0.00 $0.00 $0.00 $0.00 $0.00 430060 SUP HCPCS C1713 430060 - PLATE STD 130MM SS 10 HOLE CMPR SPS BONE DISTAL ULN NONSTRL BOTH IP/OP $191.25 $141.53 $0.00 $141.95 $74.25 $74.25 $0.00 $0.00 $0.00 $39.86 $141.95 $141.95 $0.00 $0.00 $39.86 $0.00 $113.12 $113.12 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 431748 SUP HCPCS C1785 431748 - PACEMAKER CRD EDORA PROMRI CLS HOME MNTR DR-T BOTH IP/OP "$17,750.00 " "$13,135.00" $0.00 "$14,200.00" "$7,987.50" "$7,987.50" $0.00 $0.00 $0.00 "$3,699.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,699.10" $0.00 "$8,750.75" "$8,750.75" $0.00 "$8,875.00" "$14,058.00" "$14,200.00" $0.00 $0.00 "$2,777.88" $0.00 $0.00 "$2,825.80" $0.00 $0.00 $0.00 $0.00 $0.00 431749 SUP HCPCS C1786 431749 - PACEMAKER CRD EDORA PROMRI CLS HOME MNTR SR-T BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 432203 SUP HCPCS C1713 432203 - PLATE 46MM SS 4.5MM SCR 3 HOLE RECON SPS BONE DISTAL TIB BOTH IP/OP $312.80 $231.47 $0.00 $259.60 $146.03 $146.03 $0.00 $0.00 $0.00 $65.20 $232.16 $232.16 $0.00 $0.00 $65.19 $0.00 $185.02 $185.02 $0.00 $162.25 $257.00 $259.60 $0.00 $0.00 $50.78 $0.00 $0.00 $51.66 $0.00 $0.00 $0.00 $0.00 $0.00 432204 SUP HCPCS C1713 432204 - PLATE 62MM SS 4.5MM SCR 4 HL SHFT RECON BONE BOTH IP/OP $358.40 $265.22 $0.00 $299.20 $168.30 $168.30 $0.00 $0.00 $0.00 $74.70 $266.00 $266.00 $0.00 $0.00 $74.69 $0.00 $211.99 $211.99 $0.00 $187.00 $296.21 $299.20 $0.00 $0.00 $58.53 $0.00 $0.00 $59.54 $0.00 $0.00 $0.00 $0.00 $0.00 432205 SUP HCPCS C1713 432205 - PLATE 78MM SS 4.5MM SCR 5 HOLE RECON SPS BONE DISTAL TIB BOTH IP/OP $392.80 $290.67 $0.00 $327.80 $184.39 $184.39 $0.00 $0.00 $0.00 $81.87 $291.54 $291.54 $0.00 $0.00 $81.86 $0.00 $232.34 $232.34 $0.00 $204.88 $324.52 $327.80 $0.00 $0.00 $64.13 $0.00 $0.00 $65.23 $0.00 $0.00 $0.00 $0.00 $0.00 432206 SUP HCPCS C1713 432206 - PLATE 94MM SS 4.5MM SCR 6 HL SHFT RECON BONE BOTH IP/OP $419.20 $310.21 $0.00 $349.80 $196.76 $196.76 $0.00 $0.00 $0.00 $87.37 $311.13 $311.13 $0.00 $0.00 $87.36 $0.00 $247.96 $247.96 $0.00 $218.63 $346.30 $349.80 $0.00 $0.00 $68.43 $0.00 $0.00 $69.61 $0.00 $0.00 $0.00 $0.00 $0.00 432207 SUP HCPCS C1713 432207 - PLATE 110MM SS 4.5MM SCR 7 HOLE RECON SPS BONE DISTAL TIB BOTH IP/OP $436.00 $322.64 $0.00 $364.10 $204.81 $204.81 $0.00 $0.00 $0.00 $90.87 $323.60 $323.60 $0.00 $0.00 $90.86 $0.00 $257.89 $257.89 $0.00 $227.56 $360.46 $364.10 $0.00 $0.00 $71.23 $0.00 $0.00 $72.46 $0.00 $0.00 $0.00 $0.00 $0.00 432208 SUP HCPCS C1713 432208 - PLATE 126MM SS 4.5MM SCR 8 HL SHFT RECON BONE BOTH IP/OP $454.40 $336.26 $0.00 $385.00 $216.56 $216.56 $0.00 $0.00 $0.00 $94.71 $337.26 $337.26 $0.00 $0.00 $94.70 $0.00 $268.78 $268.78 $0.00 $240.63 $381.15 $385.00 $0.00 $0.00 $75.32 $0.00 $0.00 $76.62 $0.00 $0.00 $0.00 $0.00 $0.00 432209 SUP HCPCS C1713 432209 - PLATE 142MM SS 4.5MM SCR 9 HOLE RECON SPS BONE DISTAL TIB BOTH IP/OP $485.60 $359.34 $0.00 $413.60 $232.65 $232.65 $0.00 $0.00 $0.00 $101.21 $360.41 $360.41 $0.00 $0.00 $101.20 $0.00 $287.23 $287.23 $0.00 $258.50 $409.46 $413.60 $0.00 $0.00 $80.91 $0.00 $0.00 $82.31 $0.00 $0.00 $0.00 $0.00 $0.00 432210 SUP HCPCS C1713 432210 - PLATE 158MM SS 4.5MM SCR 10 HOLE RECON BONE BOTH IP/OP $503.20 $372.37 $0.00 $427.90 $240.69 $240.69 $0.00 $0.00 $0.00 $104.88 $373.48 $373.48 $0.00 $0.00 $104.87 $0.00 $297.64 $297.64 $0.00 $267.44 $423.62 $427.90 $0.00 $0.00 $83.71 $0.00 $0.00 $85.15 $0.00 $0.00 $0.00 $0.00 $0.00 432211 SUP HCPCS C1713 432211 - PLATE 174MM SS 4.5MM SCR 11 HOLE RECON SPS BONE DISTAL TIB BOTH IP/OP $529.50 $391.83 $0.00 $409.20 $230.18 $230.18 $0.00 $0.00 $0.00 $110.36 $392.99 $392.99 $0.00 $0.00 $110.35 $0.00 $313.20 $313.20 $0.00 $255.75 $405.11 $409.20 $0.00 $0.00 $80.05 $0.00 $0.00 $81.43 $0.00 $0.00 $0.00 $0.00 $0.00 432212 SUP HCPCS C1713 432212 - PLATE 190MM SS 4.5MM SCR 12 HOLE RECON BONE BOTH IP/OP $566.40 $419.14 $0.00 $469.70 $264.21 $264.21 $0.00 $0.00 $0.00 $118.05 $420.38 $420.38 $0.00 $0.00 $118.04 $0.00 $335.03 $335.03 $0.00 $293.56 $465.01 $469.70 $0.00 $0.00 $91.89 $0.00 $0.00 $93.47 $0.00 $0.00 $0.00 $0.00 $0.00 432213 SUP HCPCS C1713 432213 - PLATE 206MM SS 4.5MM SCR 13 HOLE RECON SPS BONE DISTAL TIB BOTH IP/OP $587.20 $434.53 $0.00 $499.40 $280.91 $280.91 $0.00 $0.00 $0.00 $122.39 $435.82 $435.82 $0.00 $0.00 $122.37 $0.00 $347.33 $347.33 $0.00 $312.13 $494.41 $499.40 $0.00 $0.00 $97.70 $0.00 $0.00 $99.38 $0.00 $0.00 $0.00 $0.00 $0.00 432214 SUP HCPCS C1713 432214 - PLATE 222MM SS 4.5MM SCR 14 HL SHFT RECON BONE BOTH IP/OP $591.20 $437.49 $0.00 $513.70 $288.96 $288.96 $0.00 $0.00 $0.00 $123.22 $438.79 $438.79 $0.00 $0.00 $123.21 $0.00 $349.69 $349.69 $0.00 $321.06 $508.57 $513.70 $0.00 $0.00 $100.49 $0.00 $0.00 $102.23 $0.00 $0.00 $0.00 $0.00 $0.00 432215 SUP HCPCS C1713 432215 - PLATE 238MM SS 4.5MM SCR 15 HOLE RECON SPS BONE DISTAL TIB BOTH IP/OP $592.00 $438.08 $0.00 $486.20 $273.49 $273.49 $0.00 $0.00 $0.00 $123.39 $439.38 $439.38 $0.00 $0.00 $123.37 $0.00 $350.17 $350.17 $0.00 $303.88 $481.34 $486.20 $0.00 $0.00 $95.11 $0.00 $0.00 $96.75 $0.00 $0.00 $0.00 $0.00 $0.00 432216 SUP HCPCS C1713 432216 - PLATE 254MM SS 4.5MM SCR 16 HL SHFT RECON BONE BOTH IP/OP $625.60 $462.94 $0.00 $548.90 $308.76 $308.76 $0.00 $0.00 $0.00 $130.39 $464.32 $464.32 $0.00 $0.00 $130.38 $0.00 $370.04 $370.04 $0.00 $343.06 $543.41 $548.90 $0.00 $0.00 $107.38 $0.00 $0.00 $109.23 $0.00 $0.00 $0.00 $0.00 $0.00 433165 SUP Custom 27803010 433165 - CEMENT BONE SIL 65MM 40GM TIB KNEE SPCR MLD STRL DISP BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 $0.00 $0.00 $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 436003 SUP HCPCS C1713 436003 - PLATE 3 HOLE BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,174.40 " $869.06 $0.00 $871.64 $464.06 $464.06 $0.00 $0.00 $0.00 $244.77 $871.64 $871.64 $0.00 $0.00 $244.74 $0.00 $694.66 $694.66 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436004 SUP HCPCS C1713 436004 - PLATE 4 HOLE BONE LEFT DISTAL VOLR RAD BOTH IP/OP "$1,174.40 " $869.06 $0.00 $871.64 $464.06 $464.06 $0.00 $0.00 $0.00 $244.77 $871.64 $871.64 $0.00 $0.00 $244.74 $0.00 $694.66 $694.66 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436006 SUP HCPCS C1713 436006 - PLATE 6 HOLE BONE LEFT DISTAL VOLR RAD BOTH IP/OP "$1,031.25 " $763.13 $0.00 $825.00 $464.06 $464.06 $0.00 $0.00 $0.00 $214.94 $765.39 $765.39 $0.00 $0.00 $214.91 $0.00 $609.98 $609.98 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436008 SUP HCPCS C1713 436008 - DISTAL VOLAR RADIUS 8 HOLE LT BOTH IP/OP "$1,031.25 " $763.13 $0.00 $825.00 $464.06 $464.06 $0.00 $0.00 $0.00 $214.94 $765.39 $765.39 $0.00 $0.00 $214.91 $0.00 $609.98 $609.98 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436010 SUP HCPCS C1713 436010 - PLATE 10 HOLE BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,031.25 " $763.13 $0.00 $825.00 $464.06 $464.06 $0.00 $0.00 $0.00 $214.94 $765.39 $765.39 $0.00 $0.00 $214.91 $0.00 $609.98 $609.98 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436023 SUP HCPCS C1713 436023 - PLATE 3 HOLE BONE RIGHT DISTAL VOLR RAD BOTH IP/OP "$1,174.40 " $869.06 $0.00 $871.64 $464.06 $464.06 $0.00 $0.00 $0.00 $244.77 $871.64 $871.64 $0.00 $0.00 $244.74 $0.00 $694.66 $694.66 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436024 SUP HCPCS C1713 436024 - PLATE 4 HOLE BONE RIGHT DISTAL VOLR RAD BOTH IP/OP "$1,174.40 " $869.06 $0.00 $871.64 $464.06 $464.06 $0.00 $0.00 $0.00 $244.77 $871.64 $871.64 $0.00 $0.00 $244.74 $0.00 $694.66 $694.66 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436026 SUP HCPCS C1713 436026 - PLATE 6 HOLE BONE RIGHT DISTAL VOLR RAD BOTH IP/OP "$1,031.25 " $763.13 $0.00 $825.00 $464.06 $464.06 $0.00 $0.00 $0.00 $214.94 $765.39 $765.39 $0.00 $0.00 $214.91 $0.00 $609.98 $609.98 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436028 SUP HCPCS C1713 436028 - PLATE 8 HOLE BONE RIGHT DISTAL VOLR RADL BOTH IP/OP "$1,031.25 " $763.13 $0.00 $825.00 $464.06 $464.06 $0.00 $0.00 $0.00 $214.94 $765.39 $765.39 $0.00 $0.00 $214.91 $0.00 $609.98 $609.98 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436030 SUP HCPCS C1713 436030 - PLATE 10 HOLE BONE RIGHT DISTAL VOLR RADL BOTH IP/OP "$1,031.25 " $763.13 $0.00 $825.00 $464.06 $464.06 $0.00 $0.00 $0.00 $214.94 $765.39 $765.39 $0.00 $0.00 $214.91 $0.00 $609.98 $609.98 $0.00 $515.63 $816.75 $825.00 $0.00 $0.00 $161.39 $0.00 $0.00 $164.18 $0.00 $0.00 $0.00 $0.00 $0.00 436103 SUP HCPCS C1713 436103 - PLATE 86MM SS 5 HOLE BONE LEFT PROX LAT HUM BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 436105 SUP HCPCS C1713 436105 - PLATE 5 HOLE BONE LEFT PROX LAT HUM BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 436108 SUP HCPCS C1713 436108 - PLATE 150MM SS 8 HOLE BONE LEFT PROX LAT HUM BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 436123 SUP HCPCS C1713 436123 - PLATE 86MM SS 5 HOLE BONE RIGHT PROX LAT HUM BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 436125 SUP HCPCS C1713 436125 - PLATE 112MM SS 5 HOLE BONE RIGHT PROX LAT HUM BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 436128 SUP HCPCS C1713 436128 - PLATE 112MM 8 HOLE LCK BONE 4MM RIGHT PROX HUM PERIART TIB BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 436204 SUP HCPCS C1713 436204 - PLATE 94MM SS 4MM 3.5MM STD LCK SCR 4 SHFT HOLE AXSOS BONE BOTH IP/OP "$1,813.63 " "$1,342.09" $0.00 "$1,450.90" $816.13 $816.13 $0.00 $0.00 $0.00 $378.00 "$1,346.07" "$1,346.07" $0.00 $0.00 $377.96 $0.00 "$1,072.76" "$1,072.76" $0.00 $906.81 "$1,436.39" "$1,450.90" $0.00 $0.00 $283.83 $0.00 $0.00 $288.73 $0.00 $0.00 $0.00 $0.00 $0.00 436206 SUP HCPCS C1713 436206 - PLATE 6 HOLE BONE LEFT DISTAL MDL TIB BOTH IP/OP "$1,813.63 " "$1,342.09" $0.00 "$1,450.90" $816.13 $816.13 $0.00 $0.00 $0.00 $378.00 "$1,346.07" "$1,346.07" $0.00 $0.00 $377.96 $0.00 "$1,072.76" "$1,072.76" $0.00 $906.81 "$1,436.39" "$1,450.90" $0.00 $0.00 $283.83 $0.00 $0.00 $288.73 $0.00 $0.00 $0.00 $0.00 $0.00 436208 SUP HCPCS C1713 436208 - PLATE 8 HOLE BONE LEFT DISTAL MDL TIB BOTH IP/OP "$1,813.63 " "$1,342.09" $0.00 "$1,450.90" $816.13 $816.13 $0.00 $0.00 $0.00 $378.00 "$1,346.07" "$1,346.07" $0.00 $0.00 $377.96 $0.00 "$1,072.76" "$1,072.76" $0.00 $906.81 "$1,436.39" "$1,450.90" $0.00 $0.00 $283.83 $0.00 $0.00 $288.73 $0.00 $0.00 $0.00 $0.00 $0.00 436210 SUP HCPCS C1713 436210 - PLATE 172MM SS 10 HOLE BONE LEFT DISTAL MDL TIB BOTH IP/OP "$1,813.63 " "$1,342.09" $0.00 "$1,450.90" $816.13 $816.13 $0.00 $0.00 $0.00 $378.00 "$1,346.07" "$1,346.07" $0.00 $0.00 $377.96 $0.00 "$1,072.76" "$1,072.76" $0.00 $906.81 "$1,436.39" "$1,450.90" $0.00 $0.00 $283.83 $0.00 $0.00 $288.73 $0.00 $0.00 $0.00 $0.00 $0.00 436212 SUP HCPCS C1713 436212 - PLATE 198MM SS 12 HOLE BONE LEFT DISTAL MDL TIB BOTH IP/OP "$2,143.63 " "$1,586.29" $0.00 "$1,714.90" $964.63 $964.63 $0.00 $0.00 $0.00 $446.79 "$1,591.00" "$1,591.00" $0.00 $0.00 $446.73 $0.00 "$1,267.95" "$1,267.95" $0.00 "$1,071.81" "$1,697.75" "$1,714.90" $0.00 $0.00 $335.48 $0.00 $0.00 $341.27 $0.00 $0.00 $0.00 $0.00 $0.00 436214 SUP HCPCS C1713 436214 - PLATE 224MM SS 14 SHFT HOLE LCK BONE 4MM 3.5MM DISTAL MDL BOTH IP/OP "$2,143.63 " "$1,586.29" $0.00 "$1,714.90" $964.63 $964.63 $0.00 $0.00 $0.00 $446.79 "$1,591.00" "$1,591.00" $0.00 $0.00 $446.73 $0.00 "$1,267.95" "$1,267.95" $0.00 "$1,071.81" "$1,697.75" "$1,714.90" $0.00 $0.00 $335.48 $0.00 $0.00 $341.27 $0.00 $0.00 $0.00 $0.00 $0.00 436216 SUP HCPCS C1713 436216 - PLATE 250MM SS 16 HOLE BONE LEFT DISTAL MDL TIB BOTH IP/OP "$2,143.63 " "$1,586.29" $0.00 "$1,714.90" $964.63 $964.63 $0.00 $0.00 $0.00 $446.79 "$1,591.00" "$1,591.00" $0.00 $0.00 $446.73 $0.00 "$1,267.95" "$1,267.95" $0.00 "$1,071.81" "$1,697.75" "$1,714.90" $0.00 $0.00 $335.48 $0.00 $0.00 $341.27 $0.00 $0.00 $0.00 $0.00 $0.00 436224 SUP HCPCS C1713 436224 - PLATE 4 HOLE BONE RIGHT DISTAL MDL TIB BOTH IP/OP "$1,813.63 " "$1,342.09" $0.00 "$1,450.90" $816.13 $816.13 $0.00 $0.00 $0.00 $378.00 "$1,346.07" "$1,346.07" $0.00 $0.00 $377.96 $0.00 "$1,072.76" "$1,072.76" $0.00 $906.81 "$1,436.39" "$1,450.90" $0.00 $0.00 $283.83 $0.00 $0.00 $288.73 $0.00 $0.00 $0.00 $0.00 $0.00 436226 SUP HCPCS C1713 436226 - PLATE 120MM SS 4MM 3.5MM STD LCK SCR 6 SHFT HOLE AXSOS BONE BOTH IP/OP "$1,813.63 " "$1,342.09" $0.00 "$1,450.90" $816.13 $816.13 $0.00 $0.00 $0.00 $378.00 "$1,346.07" "$1,346.07" $0.00 $0.00 $377.96 $0.00 "$1,072.76" "$1,072.76" $0.00 $906.81 "$1,436.39" "$1,450.90" $0.00 $0.00 $283.83 $0.00 $0.00 $288.73 $0.00 $0.00 $0.00 $0.00 $0.00 436228 SUP HCPCS C1713 436228 - PLATE 8 HOLE BONE RIGHT DISTAL MDL TIB BOTH IP/OP "$1,813.63 " "$1,342.09" $0.00 "$1,450.90" $816.13 $816.13 $0.00 $0.00 $0.00 $378.00 "$1,346.07" "$1,346.07" $0.00 $0.00 $377.96 $0.00 "$1,072.76" "$1,072.76" $0.00 $906.81 "$1,436.39" "$1,450.90" $0.00 $0.00 $283.83 $0.00 $0.00 $288.73 $0.00 $0.00 $0.00 $0.00 $0.00 436230 SUP HCPCS C1713 436230 - PLATE 172MM SS 10 HOLE BONE RIGHT DISTAL MDL TIB BOTH IP/OP "$1,813.63 " "$1,342.09" $0.00 "$1,450.90" $816.13 $816.13 $0.00 $0.00 $0.00 $378.00 "$1,346.07" "$1,346.07" $0.00 $0.00 $377.96 $0.00 "$1,072.76" "$1,072.76" $0.00 $906.81 "$1,436.39" "$1,450.90" $0.00 $0.00 $283.83 $0.00 $0.00 $288.73 $0.00 $0.00 $0.00 $0.00 $0.00 436232 SUP HCPCS C1713 436232 - PLATE 198MM SS 12 SHFT HOLE LCK BONE 4MM 3.5MM DISTAL MDL BOTH IP/OP "$2,143.63 " "$1,586.29" $0.00 "$1,714.90" $964.63 $964.63 $0.00 $0.00 $0.00 $446.79 "$1,591.00" "$1,591.00" $0.00 $0.00 $446.73 $0.00 "$1,267.95" "$1,267.95" $0.00 "$1,071.81" "$1,697.75" "$1,714.90" $0.00 $0.00 $335.48 $0.00 $0.00 $341.27 $0.00 $0.00 $0.00 $0.00 $0.00 436234 SUP HCPCS C1713 436234 - PLATE 224MM SS 14 HL SHFT LCK IMPL AXSOS BONE RIGHT DISTAL BOTH IP/OP "$2,143.63 " "$1,586.29" $0.00 "$1,714.90" $964.63 $964.63 $0.00 $0.00 $0.00 $446.79 "$1,591.00" "$1,591.00" $0.00 $0.00 $446.73 $0.00 "$1,267.95" "$1,267.95" $0.00 "$1,071.81" "$1,697.75" "$1,714.90" $0.00 $0.00 $335.48 $0.00 $0.00 $341.27 $0.00 $0.00 $0.00 $0.00 $0.00 436236 SUP HCPCS C1713 436236 - PLATE 250MM SS 16 HL SHFT LCK IMPL AXSOS BONE RIGHT DISTAL BOTH IP/OP "$2,143.63 " "$1,586.29" $0.00 "$1,714.90" $964.63 $964.63 $0.00 $0.00 $0.00 $446.79 "$1,591.00" "$1,591.00" $0.00 $0.00 $446.73 $0.00 "$1,267.95" "$1,267.95" $0.00 "$1,071.81" "$1,697.75" "$1,714.90" $0.00 $0.00 $335.48 $0.00 $0.00 $341.27 $0.00 $0.00 $0.00 $0.00 $0.00 436302 SUP HCPCS C1713 436302 - PLATE 2 HOLE BONE LEFT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436304 SUP HCPCS C1713 436304 - PLATE 4 HOLE BONE LEFT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436306 SUP HCPCS C1713 436306 - PLATE 6 HOLE BONE LEFT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436308 SUP HCPCS C1713 436308 - PLATE 8 HOLE BONE LEFT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436310 SUP HCPCS C1713 436310 - PLATE 10 HOLE BONE LEFT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436312 SUP HCPCS C1713 436312 - PLATE 12 HOLE BONE LEFT PROX LAT TIB BOTH IP/OP "$1,874.13 " "$1,386.86" $0.00 "$1,499.30" $843.36 $843.36 $0.00 $0.00 $0.00 $390.61 "$1,390.98" "$1,390.98" $0.00 $0.00 $390.57 $0.00 "$1,108.54" "$1,108.54" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 436314 SUP HCPCS C1713 436314 - PLATE 14 HOLE BONE LEFT PROX LAT TIB BOTH IP/OP "$2,061.13 " "$1,525.24" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $429.59 "$1,529.77" "$1,529.77" $0.00 $0.00 $429.54 $0.00 "$1,219.16" "$1,219.16" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 436322 SUP HCPCS C1713 436322 - PLATE 2 HOLE BONE RIGHT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436324 SUP HCPCS C1713 436324 - PLATE 4 HOLE BONE RIGHT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436326 SUP HCPCS C1713 436326 - PLATE 6 HOLE BONE RIGHT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436328 SUP HCPCS C1713 436328 - PLATE 8 HOLE BONE RIGHT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436330 SUP HCPCS C1713 436330 - PLATE 10 HOLE BONE RIGHT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436332 SUP HCPCS C1713 436332 - PLATE 12 HOLE BONE RIGHT PROX LAT TIB BOTH IP/OP "$2,061.13 " "$1,525.24" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $429.59 "$1,529.77" "$1,529.77" $0.00 $0.00 $429.54 $0.00 "$1,219.16" "$1,219.16" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 436334 SUP HCPCS C1713 436334 - PLATE 14 HOLE BONE RIGHT PROX LAT TIB BOTH IP/OP "$1,874.13 " "$1,386.86" $0.00 "$1,499.30" $843.36 $843.36 $0.00 $0.00 $0.00 $390.61 "$1,390.98" "$1,390.98" $0.00 $0.00 $390.57 $0.00 "$1,108.54" "$1,108.54" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 436342 SUP HCPCS C1713 436342 - PLATE 95MM SS 3.5MM 4MM STD SCR 2 SHFT HOLE 5 LCK HOLE BONE BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436344 SUP HCPCS C1713 436344 - PLATE 121MM 4MM SCR 4 HOLE LCK AXSOS BONE LEFT PROX LAT BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436346 SUP HCPCS C1713 436346 - PLATE 147MM 6 HL SHFT LCK BONE LEFT PROX LAT TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436348 SUP HCPCS C1713 436348 - PLATE 173MM SS 3.5MM 4MM STD SCR 8 SHFT HOLE 5 LCK HOLE BONE BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436350 SUP HCPCS C1713 436350 - PLATE 199MM 4MM SCR 10X5 HOLE LCK AXSOS BONE LEFT PROX LAT BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436352 SUP HCPCS C1713 436352 - PLATE 225MM 4MM SCR 12X5 HOLE LCK AXSOS BONE LEFT PROX LAT BOTH IP/OP "$2,061.13 " "$1,525.24" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $429.59 "$1,529.77" "$1,529.77" $0.00 $0.00 $429.54 $0.00 "$1,219.16" "$1,219.16" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 436354 SUP HCPCS C1713 436354 - PLATE 251MM 15 HOLE LCK BONE 4MM RIGHT PROX LAT PERIART TIB BOTH IP/OP "$1,874.13 " "$1,386.86" $0.00 "$1,499.30" $843.36 $843.36 $0.00 $0.00 $0.00 $390.61 "$1,390.98" "$1,390.98" $0.00 $0.00 $390.57 $0.00 "$1,108.54" "$1,108.54" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 436362 SUP HCPCS C1713 436362 - PLATE 2 HOLE BONE RIGHT PROX TIB BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436364 SUP HCPCS C1713 436364 - PLATE 121MM 4MM SCR 4X5 HOLE LCK AXSOS BONE RIGHT PROX LAT BOTH IP/OP "$1,574.38 " "$1,165.04" $0.00 "$1,259.50" $708.47 $708.47 $0.00 $0.00 $0.00 $328.14 "$1,168.50" "$1,168.50" $0.00 $0.00 $328.10 $0.00 $931.24 $931.24 $0.00 $787.19 "$1,246.91" "$1,259.50" $0.00 $0.00 $246.39 $0.00 $0.00 $250.64 $0.00 $0.00 $0.00 $0.00 $0.00 436366 SUP HCPCS C1713 436366 - PLATE 147MM 4MM SCR 6X5 HOLE LCK AXSOS BONE RIGHT PROX LAT BOTH IP/OP "$1,731.13 " "$1,281.04" $0.00 "$1,384.90" $779.01 $779.01 $0.00 $0.00 $0.00 $360.81 "$1,284.84" "$1,284.84" $0.00 $0.00 $360.77 $0.00 "$1,023.96" "$1,023.96" $0.00 $865.56 "$1,371.05" "$1,384.90" $0.00 $0.00 $270.92 $0.00 $0.00 $275.60 $0.00 $0.00 $0.00 $0.00 $0.00 436368 SUP HCPCS C1713 436368 - PLATE 173MM 4MM SCR 8X5 HOLE LCK AXSOS BONE RIGHT PROX LAT BOTH IP/OP "$1,574.38 " "$1,165.04" $0.00 "$1,259.50" $708.47 $708.47 $0.00 $0.00 $0.00 $328.14 "$1,168.50" "$1,168.50" $0.00 $0.00 $328.10 $0.00 $931.24 $931.24 $0.00 $787.19 "$1,246.91" "$1,259.50" $0.00 $0.00 $246.39 $0.00 $0.00 $250.64 $0.00 $0.00 $0.00 $0.00 $0.00 436370 SUP HCPCS C1713 436370 - PLATE 199MM 4MM SCR 10X5 HOLE LCK AXSOS BONE RIGHT PROX LAT BOTH IP/OP "$1,574.38 " "$1,165.04" $0.00 "$1,259.50" $708.47 $708.47 $0.00 $0.00 $0.00 $328.14 "$1,168.50" "$1,168.50" $0.00 $0.00 $328.10 $0.00 $931.24 $931.24 $0.00 $787.19 "$1,246.91" "$1,259.50" $0.00 $0.00 $246.39 $0.00 $0.00 $250.64 $0.00 $0.00 $0.00 $0.00 $0.00 436372 SUP HCPCS C1713 436372 - PLATE 225MM 4MM SCR 12X5 HOLE LCK AXSOS BONE RIGHT PROX LAT BOTH IP/OP "$1,874.13 " "$1,386.86" $0.00 "$1,499.30" $843.36 $843.36 $0.00 $0.00 $0.00 $390.61 "$1,390.98" "$1,390.98" $0.00 $0.00 $390.57 $0.00 "$1,108.54" "$1,108.54" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 436374 SUP HCPCS C1713 436374 - PLATE 251MM 14 HL SHFT LCK BONE RIGHT PROX LAT MTPHSL TIB BOTH IP/OP "$1,874.13 " "$1,386.86" $0.00 "$1,499.30" $843.36 $843.36 $0.00 $0.00 $0.00 $390.61 "$1,390.98" "$1,390.98" $0.00 $0.00 $390.57 $0.00 "$1,108.54" "$1,108.54" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 436404 SUP HCPCS C1713 436404 - PLATE 4 HOLE BONE LEFT DISTAL ANT LAT TIB BOTH IP/OP "$2,308.63 " "$1,708.39" $0.00 "$1,846.90" "$1,038.88" "$1,038.88" $0.00 $0.00 $0.00 $481.18 "$1,713.46" "$1,713.46" $0.00 $0.00 $481.12 $0.00 "$1,365.55" "$1,365.55" $0.00 "$1,154.31" "$1,828.43" "$1,846.90" $0.00 $0.00 $361.30 $0.00 $0.00 $367.53 $0.00 $0.00 $0.00 $0.00 $0.00 436406 SUP HCPCS C1713 436406 - PLATE 123MM SS 6 HL SHFT LCK IMPL AXSOS BONE LEFT DISTAL BOTH IP/OP "$2,308.63 " "$1,708.39" $0.00 "$1,846.90" "$1,038.88" "$1,038.88" $0.00 $0.00 $0.00 $481.18 "$1,713.46" "$1,713.46" $0.00 $0.00 $481.12 $0.00 "$1,365.55" "$1,365.55" $0.00 "$1,154.31" "$1,828.43" "$1,846.90" $0.00 $0.00 $361.30 $0.00 $0.00 $367.53 $0.00 $0.00 $0.00 $0.00 $0.00 436408 SUP HCPCS C1713 436408 - PLATE 149MM SS 8 HL SHFT LCK IMPL AXSOS BONE LEFT DISTAL BOTH IP/OP "$2,308.63 " "$1,708.39" $0.00 "$1,846.90" "$1,038.88" "$1,038.88" $0.00 $0.00 $0.00 $481.18 "$1,713.46" "$1,713.46" $0.00 $0.00 $481.12 $0.00 "$1,365.55" "$1,365.55" $0.00 "$1,154.31" "$1,828.43" "$1,846.90" $0.00 $0.00 $361.30 $0.00 $0.00 $367.53 $0.00 $0.00 $0.00 $0.00 $0.00 436410 SUP HCPCS C1713 436410 - PLATE 10 HOLE BONE LEFT DISTAL ANTLAT TIB BOTH IP/OP "$2,308.63 " "$1,708.39" $0.00 "$1,846.90" "$1,038.88" "$1,038.88" $0.00 $0.00 $0.00 $481.18 "$1,713.46" "$1,713.46" $0.00 $0.00 $481.12 $0.00 "$1,365.55" "$1,365.55" $0.00 "$1,154.31" "$1,828.43" "$1,846.90" $0.00 $0.00 $361.30 $0.00 $0.00 $367.53 $0.00 $0.00 $0.00 $0.00 $0.00 436412 SUP HCPCS C1713 436412 - PLATE 12 HOLE BONE LEFT DISTAL ANTLAT TIB BOTH IP/OP "$2,638.63 " "$1,952.59" $0.00 "$2,110.90" "$1,187.38" "$1,187.38" $0.00 $0.00 $0.00 $549.96 "$1,958.39" "$1,958.39" $0.00 $0.00 $549.89 $0.00 "$1,300.84" "$1,300.84" $0.00 "$1,319.31" "$2,089.79" "$2,110.90" $0.00 $0.00 $412.94 $0.00 $0.00 $420.07 $0.00 $0.00 $0.00 $0.00 $0.00 436414 SUP HCPCS C1713 436414 - PLATE 14 HOLE BONE LEFT DISTAL ANT LAT TIB BOTH IP/OP "$2,638.63 " "$1,952.59" $0.00 "$2,110.90" "$1,187.38" "$1,187.38" $0.00 $0.00 $0.00 $549.96 "$1,958.39" "$1,958.39" $0.00 $0.00 $549.89 $0.00 "$1,300.84" "$1,300.84" $0.00 "$1,319.31" "$2,089.79" "$2,110.90" $0.00 $0.00 $412.94 $0.00 $0.00 $420.07 $0.00 $0.00 $0.00 $0.00 $0.00 436416 SUP HCPCS C1713 436416 - PLATE 16 HOLE BONE LEFT DISTAL ANTLAT TIB BOTH IP/OP "$2,638.63 " "$1,952.59" $0.00 "$2,110.90" "$1,187.38" "$1,187.38" $0.00 $0.00 $0.00 $549.96 "$1,958.39" "$1,958.39" $0.00 $0.00 $549.89 $0.00 "$1,300.84" "$1,300.84" $0.00 "$1,319.31" "$2,089.79" "$2,110.90" $0.00 $0.00 $412.94 $0.00 $0.00 $420.07 $0.00 $0.00 $0.00 $0.00 $0.00 436424 SUP HCPCS C1713 436424 - PLATE 4 HOLE BONE RIGHT DISTAL ANT LAT TIB BOTH IP/OP "$2,308.63 " "$1,708.39" $0.00 "$1,846.90" "$1,038.88" "$1,038.88" $0.00 $0.00 $0.00 $481.18 "$1,713.46" "$1,713.46" $0.00 $0.00 $481.12 $0.00 "$1,365.55" "$1,365.55" $0.00 "$1,154.31" "$1,828.43" "$1,846.90" $0.00 $0.00 $361.30 $0.00 $0.00 $367.53 $0.00 $0.00 $0.00 $0.00 $0.00 436426 SUP HCPCS C1713 436426 - PLATE 123MM SS 6 HL SHFT LCK IMPL AXSOS BONE RIGHT DISTAL BOTH IP/OP "$2,308.63 " "$1,708.39" $0.00 "$1,846.90" "$1,038.88" "$1,038.88" $0.00 $0.00 $0.00 $481.18 "$1,713.46" "$1,713.46" $0.00 $0.00 $481.12 $0.00 "$1,365.55" "$1,365.55" $0.00 "$1,154.31" "$1,828.43" "$1,846.90" $0.00 $0.00 $361.30 $0.00 $0.00 $367.53 $0.00 $0.00 $0.00 $0.00 $0.00 436428 SUP HCPCS C1713 436428 - PLATE 149MM SS 8 HL SHFT LCK IMPL AXSOS BONE RIGHT DISTAL BOTH IP/OP "$2,308.63 " "$1,708.39" $0.00 "$1,846.90" "$1,038.88" "$1,038.88" $0.00 $0.00 $0.00 $481.18 "$1,713.46" "$1,713.46" $0.00 $0.00 $481.12 $0.00 "$1,365.55" "$1,365.55" $0.00 "$1,154.31" "$1,828.43" "$1,846.90" $0.00 $0.00 $361.30 $0.00 $0.00 $367.53 $0.00 $0.00 $0.00 $0.00 $0.00 436430 SUP HCPCS C1713 436430 - PLATE 4 HOLE BONE RIGHT DISTAL ANT LAT TIB BOTH IP/OP "$2,308.63 " "$1,708.39" $0.00 "$1,846.90" "$1,038.88" "$1,038.88" $0.00 $0.00 $0.00 $481.18 "$1,713.46" "$1,713.46" $0.00 $0.00 $481.12 $0.00 "$1,365.55" "$1,365.55" $0.00 "$1,154.31" "$1,828.43" "$1,846.90" $0.00 $0.00 $361.30 $0.00 $0.00 $367.53 $0.00 $0.00 $0.00 $0.00 $0.00 436432 SUP HCPCS C1713 436432 - PLATE 12 HOLE BONE RIGHT DISTAL ANT LAT TIB BOTH IP/OP "$2,638.63 " "$1,952.59" $0.00 "$2,110.90" "$1,187.38" "$1,187.38" $0.00 $0.00 $0.00 $549.96 "$1,958.39" "$1,958.39" $0.00 $0.00 $549.89 $0.00 "$1,300.84" "$1,300.84" $0.00 "$1,319.31" "$2,089.79" "$2,110.90" $0.00 $0.00 $412.94 $0.00 $0.00 $420.07 $0.00 $0.00 $0.00 $0.00 $0.00 436434 SUP HCPCS C1713 436434 - PLATE 14 HOLE BONE RIGHT DISTAL ANT LAT TIB BOTH IP/OP "$2,638.63 " "$1,952.59" $0.00 "$2,110.90" "$1,187.38" "$1,187.38" $0.00 $0.00 $0.00 $549.96 "$1,958.39" "$1,958.39" $0.00 $0.00 $549.89 $0.00 "$1,300.84" "$1,300.84" $0.00 "$1,319.31" "$2,089.79" "$2,110.90" $0.00 $0.00 $412.94 $0.00 $0.00 $420.07 $0.00 $0.00 $0.00 $0.00 $0.00 436436 SUP HCPCS C1713 436436 - PLATE 16 HOLE BONE RIGHT DISTAL ANT LAT TIB BOTH IP/OP "$2,638.63 " "$1,952.59" $0.00 "$2,110.90" "$1,187.38" "$1,187.38" $0.00 $0.00 $0.00 $549.96 "$1,958.39" "$1,958.39" $0.00 $0.00 $549.89 $0.00 "$1,300.84" "$1,300.84" $0.00 "$1,319.31" "$2,089.79" "$2,110.90" $0.00 $0.00 $412.94 $0.00 $0.00 $420.07 $0.00 $0.00 $0.00 $0.00 $0.00 436504 SUP HCPCS C1713 436504 - PLATE 130MM SS 5MM SCR 4 HOLE LCK AXSOS BONE LEFT DISTAL LAT BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436506 SUP HCPCS C1713 436506 - PLATE 6 HOLE BONE LEFT DISTAL LAT FEM BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436508 SUP HCPCS C1713 436508 - PLATE 202MM SS 8 HL SHFT LCK IMPL AXSOS BONE LEFT DISTAL LAT BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436510 SUP HCPCS C1713 436510 - PLATE 238MM SS 5MM SCR 10 HOLE LCK AXSOS BONE LEFT DISTAL BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436512 SUP HCPCS C1713 436512 - PLATE 274MM SS 12 HL SHFT LCK AXSOS BONE LEFT DISTAL LAT FEM BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436514 SUP HCPCS C1713 436514 - PLATE 310MM SS 14 HL SHFT LCK IMPL AXSOS BONE LEFT DISTAL BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436516 SUP HCPCS C1713 436516 - PLATE 343MM SS 16 HL SHFT LCK AXSOS BONE LEFT DISTAL LAT FEM BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436524 SUP HCPCS C1713 436524 - PLATE 130MM SS 5MM/4.5MM/6.5MM SCR 4X5 HOLE LCK AXSOS BONE BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436526 SUP HCPCS C1713 436526 - PLATE 166MM SS 5MM/4.5MM/6.5MM SCR 6X5 HOLE LCK AXSOS BONE BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436528 SUP HCPCS C1713 436528 - PLATE 8 HOLE BONE RIGHT DISTAL LAT FEM BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436530 SUP HCPCS C1713 436530 - PLATE SS 10 SHFT HOLE 5 LCK HOLE BONE BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436532 SUP HCPCS C1713 436532 - PLATE 274MM SS 12X5 HOLE LCK AXSOS BONE RIGHT DISTAL LAT FEM BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436534 SUP HCPCS C1713 436534 - PLATE 14 HOLE BONE RIGHT DISTAL LAT FEM BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 436536 SUP HCPCS C1713 436536 - PLATE 343MM SS 16X5 HOLE LCK AXSOS BONE RIGHT DISTAL LAT FEM BOTH IP/OP "$1,930.50 " "$1,428.57" $0.00 "$1,544.40" $868.73 $868.73 $0.00 $0.00 $0.00 $402.36 "$1,432.82" "$1,432.82" $0.00 $0.00 $402.32 $0.00 "$1,141.89" "$1,141.89" $0.00 $965.25 "$1,528.96" "$1,544.40" $0.00 $0.00 $302.12 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 437103 SUP HCPCS C1713 437103 - PLATE BN 86MM NS AXSOS 3X7X 1 HL LCK SS HUM LT PROX 3.5/4MM BOTH IP/OP "$2,319.20 " "$1,716.21" $0.00 "$1,721.31" $965.25 $965.25 $0.00 $0.00 $0.00 $483.38 "$1,721.31" "$1,721.31" $0.00 $0.00 $483.32 $0.00 "$1,371.81" "$1,371.81" $0.00 "$1,072.50" "$1,698.84" "$1,716.00" $0.00 $0.00 $335.69 $0.00 $0.00 $341.48 $0.00 $0.00 $0.00 $0.00 $0.00 437105 SUP HCPCS C1713 437105 - PLATE BN 112MM NS AXSOS 5X7X 2 HL LCK SS HUM LT PROX 3.5/4MM BOTH IP/OP "$2,319.20 " "$1,716.21" $0.00 "$1,721.31" $965.25 $965.25 $0.00 $0.00 $0.00 $483.38 "$1,721.31" "$1,721.31" $0.00 $0.00 $483.32 $0.00 "$1,371.81" "$1,371.81" $0.00 "$1,072.50" "$1,698.84" "$1,716.00" $0.00 $0.00 $335.69 $0.00 $0.00 $341.48 $0.00 $0.00 $0.00 $0.00 $0.00 437108 SUP HCPCS C1713 437108 - PLATE 150MM 4MM SCR 8 SHFT HOLE LCK THRD BONE LEFT PROX BOTH IP/OP "$2,319.20 " "$1,716.21" $0.00 "$1,721.31" $965.25 $965.25 $0.00 $0.00 $0.00 $483.38 "$1,721.31" "$1,721.31" $0.00 $0.00 $483.32 $0.00 "$1,371.81" "$1,371.81" $0.00 "$1,072.50" "$1,698.84" "$1,716.00" $0.00 $0.00 $335.69 $0.00 $0.00 $341.48 $0.00 $0.00 $0.00 $0.00 $0.00 437123 SUP HCPCS C1713 437123 - PLATE BN 86MM NS AXSOS 3X7X 1 HL LCK SS HUM RT PROX 3.5/4MM BOTH IP/OP "$2,319.20 " "$1,716.21" $0.00 "$1,721.31" $965.25 $965.25 $0.00 $0.00 $0.00 $483.38 "$1,721.31" "$1,721.31" $0.00 $0.00 $483.32 $0.00 "$1,371.81" "$1,371.81" $0.00 "$1,072.50" "$1,698.84" "$1,716.00" $0.00 $0.00 $335.69 $0.00 $0.00 $341.48 $0.00 $0.00 $0.00 $0.00 $0.00 437125 SUP HCPCS C1713 437125 - PLATE BN 112MM NS AXSOS 5X7X 2 HL LCK SS HUM RT PROX 3.5/4MM BOTH IP/OP "$2,319.20 " "$1,716.21" $0.00 "$1,721.31" $965.25 $965.25 $0.00 $0.00 $0.00 $483.38 "$1,721.31" "$1,721.31" $0.00 $0.00 $483.32 $0.00 "$1,371.81" "$1,371.81" $0.00 "$1,072.50" "$1,698.84" "$1,716.00" $0.00 $0.00 $335.69 $0.00 $0.00 $341.48 $0.00 $0.00 $0.00 $0.00 $0.00 437128 SUP HCPCS C1713 437128 - PLATE BN 150MM NS AXSOS 8X7X 4 HL LCK SS HUM RT PROX 3.5/4MM BOTH IP/OP "$2,319.20 " "$1,716.21" $0.00 "$1,721.31" $965.25 $965.25 $0.00 $0.00 $0.00 $483.38 "$1,721.31" "$1,721.31" $0.00 $0.00 $483.32 $0.00 "$1,371.81" "$1,371.81" $0.00 "$1,072.50" "$1,698.84" "$1,716.00" $0.00 $0.00 $335.69 $0.00 $0.00 $341.48 $0.00 $0.00 $0.00 $0.00 $0.00 437204 SUP HCPCS C1713 437204 - PLATE BN 94MM NS AXSOS 4X4X 2 HL LCK SS TIB LT DIST MDL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437206 SUP HCPCS C1713 437206 - PLATE BN 120MM NS AXSOS 6X4X 3 HL LCK SS TIB LT DIST MDL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437208 SUP HCPCS C1713 437208 - PLATE BN 146MM NS AXSOS 8X4X 4 HL LCK SS TIB LT DIST MDL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437210 SUP HCPCS C1713 437210 - PLATE 172MM 10X4X 5 HOLE LCK THRD SHFT HOLE SYS AXSOS BONE BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437212 SUP HCPCS C1713 437212 - PLATE 198MM 4MM SCR 12 SHFT HOLE LCK THRD BONE LEFT DISTAL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437214 SUP HCPCS C1713 437214 - PLATE BN 224MM NS AXSOS 14X4X 7 HL LCK SS TIB LT DIST MDL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437216 SUP HCPCS C1713 437216 - PLATE 16 HL SHFT BONE DISTAL MDL TIB BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437224 SUP HCPCS C1713 437224 - PLATE BN 94MM NS AXSOS 4X4X 2 HL LCK SS TIB RT DIST MDL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437226 SUP HCPCS C1713 437226 - PLATE BN 120MM NS AXSOS 6X4X 3 HL LCK SS TIB RT DIST MDL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437228 SUP HCPCS C1713 437228 - PLATE BN 146MM NS AXSOS 8X4X 4 HL SS TIB RT DIST MDL 4/3.5MM BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437230 SUP HCPCS C1713 437230 - PLATE BN 172MM NS AXSOS 10X4X 5 HL LCK SS TIB RT DIST MDL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437232 SUP HCPCS C1713 437232 - PLATE BN 198MM NS AXSOS 12X4X 6 HL LCK SS TIB RT DIST MDL BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437234 SUP HCPCS C1713 437234 - PLATE SS 14 HOLE TOT STAB AXSOS BONE DISTAL MDL TIB BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437236 SUP HCPCS C1713 437236 - PLATE 250MM BONE RIGHT DISTAL MDL TIB BOTH IP/OP "$2,049.60 " "$1,516.70" $0.00 "$1,651.10" $928.74 $928.74 $0.00 $0.00 $0.00 $427.19 "$1,521.21" "$1,521.21" $0.00 $0.00 $427.14 $0.00 "$1,212.34" "$1,212.34" $0.00 "$1,031.94" "$1,634.59" "$1,651.10" $0.00 $0.00 $323.00 $0.00 $0.00 $328.57 $0.00 $0.00 $0.00 $0.00 $0.00 437302 SUP HCPCS C1713 437302 - PLATE BN 95MM NS AXSOS 2X5X 1 HL SS TIB LT PROX LAT 3.5/4MM BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437304 SUP HCPCS C1713 437304 - PLATE BN 121MM NS AXSOS 4X5X 2 HL SS TIB LT PROX LAT 3.5/4MM BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437306 SUP HCPCS C1713 437306 - PLATE BN 147MM NS AXSOS 6X5X 3 HL SS TIB LT PROX LAT 3.5/4MM BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437308 SUP HCPCS C1713 437308 - PLATE BN 173MM NS AXSOS 8X5X 4 HL SS TIB LT PROX LAT 3.5/4MM BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437310 SUP HCPCS C1713 437310 - PLATE BN 199MM NS AXSOS 10X5X 5 HL SS TIB LT PROX LAT 3.5/4 BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437312 SUP HCPCS C1713 437312 - PLATE BN 225MM NS AXSOS 12X5X 6 HL SS TIB LT PROX LAT 3.5/4 BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437314 SUP HCPCS C1713 437314 - PLATE 251MM 4MM SCR 14 SHFT HOLE LCK THRD BONE LEFT PROX LAT BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437322 SUP HCPCS C1713 437322 - PLATE BN 95MM NS AXSOS 2X5X 1 HL SS TIB RT PROX LAT 3.5/4MM BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437324 SUP HCPCS C1713 437324 - PLATE BN 121MM NS AXSOS 4X5X 2 HL SS TIB RT PROX LAT 3.5/4MM BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437326 SUP HCPCS C1713 437326 - PLATE BN 147MM NS AXSOS 6X5X 3 HL SS TIB RT PROX LAT 3.5/4MM BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437328 SUP HCPCS C1713 437328 - PLATE BN 173MM NS AXSOS 8X5X 4 HL SS TIB RT PROX LAT 3.5/4MM BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437330 SUP HCPCS C1713 437330 - PLATE BN 199MM NS AXSOS 10X5X 5 HL SS TIB RT PROX LAT 3.5/4 BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437332 SUP HCPCS C1713 437332 - PLATE BN 225MM NS AXSOS 12X5X 6 HL SS TIB RT PROX LAT 3.5/4 BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437334 SUP HCPCS C1713 437334 - PLATE 251MM 4MM SCR 14 SHFT HOLE LCK THRD BONE RIGHT PROX BOTH IP/OP "$2,025.60 " "$1,498.94" $0.00 "$1,503.40" $843.36 $843.36 $0.00 $0.00 $0.00 $422.19 "$1,503.40" "$1,503.40" $0.00 $0.00 $422.14 $0.00 "$1,198.14" "$1,198.14" $0.00 $937.06 "$1,484.31" "$1,499.30" $0.00 $0.00 $293.30 $0.00 $0.00 $298.36 $0.00 $0.00 $0.00 $0.00 $0.00 437404 SUP HCPCS C1713 437404 - PLATE BN 95MM NS AXSOS 4X3X 2 HL SS TIB LT DIST ALAT 3.5/4MM BOTH IP/OP "$2,126.40 " "$1,573.54" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $443.19 "$1,578.21" "$1,578.21" $0.00 $0.00 $443.14 $0.00 "$1,257.77" "$1,257.77" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 437406 SUP HCPCS C1713 437406 - PLATE BN 123MM NS AXSOS 6X3X 3 HL SS TIB LT DIST ALAT 3.5/4 BOTH IP/OP "$2,126.40 " "$1,573.54" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $443.19 "$1,578.21" "$1,578.21" $0.00 $0.00 $443.14 $0.00 "$1,257.77" "$1,257.77" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 437408 SUP HCPCS C1713 437408 - PLATE BN 149MM NS AXSOS 8X3X 4 HL SS TIB LT DIST ALAT 3.5/4 BOTH IP/OP "$2,126.40 " "$1,573.54" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $443.19 "$1,578.21" "$1,578.21" $0.00 $0.00 $443.14 $0.00 "$1,257.77" "$1,257.77" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 437410 SUP HCPCS C1713 437410 - PLATE BN 175MM NS AXSOS 10X3X 5 HL SS TIB LT DIST ALAT 3.5/4 BOTH IP/OP "$2,126.40 " "$1,573.54" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $443.19 "$1,578.21" "$1,578.21" $0.00 $0.00 $443.14 $0.00 "$1,257.77" "$1,257.77" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 437412 SUP HCPCS C1713 437412 - PLATE 12 HL SHFT BONE DISTAL ANTLAT TIB BOTH IP/OP "$2,232.00 " "$1,651.68" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $465.20 "$1,656.59" "$1,656.59" $0.00 $0.00 $465.15 $0.00 "$1,320.23" "$1,320.23" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437414 SUP HCPCS C1713 437414 - PLATE 14 HL SHFT BONE DISTAL ANTLAT TIB BOTH IP/OP "$2,232.00 " "$1,651.68" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $465.20 "$1,656.59" "$1,656.59" $0.00 $0.00 $465.15 $0.00 "$1,320.23" "$1,320.23" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437416 SUP HCPCS C1713 437416 - PLATE 16 HL SHFT BONE DISTAL ANTLAT TIB BOTH IP/OP "$2,232.00 " "$1,651.68" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $465.20 "$1,656.59" "$1,656.59" $0.00 $0.00 $465.15 $0.00 "$1,320.23" "$1,320.23" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437424 SUP HCPCS C1713 437424 - PLATE BN 95MM NS AXSOS 4X3X 2 HL SS TIB RT DIST ALAT 3.5/4MM BOTH IP/OP "$2,126.40 " "$1,573.54" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $443.19 "$1,578.21" "$1,578.21" $0.00 $0.00 $443.14 $0.00 "$1,257.77" "$1,257.77" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 437426 SUP HCPCS C1713 437426 - PLATE 123MM SS RFLX BONE RIGHT ANTLAT TIB BOTH IP/OP "$2,126.40 " "$1,573.54" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $443.19 "$1,578.21" "$1,578.21" $0.00 $0.00 $443.14 $0.00 "$1,257.77" "$1,257.77" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 437428 SUP HCPCS C1713 437428 - PLATE BN 149MM NS AXSOS 8X3X 4 HL SS TIB RT DIST ALAT 4/3.5 BOTH IP/OP "$2,126.40 " "$1,573.54" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $443.19 "$1,578.21" "$1,578.21" $0.00 $0.00 $443.14 $0.00 "$1,257.77" "$1,257.77" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 437430 SUP HCPCS C1713 437430 - PLATE 10 HL SHFT BONE DISTAL ANTLAT TIB BOTH IP/OP "$2,126.40 " "$1,573.54" $0.00 "$1,648.90" $927.51 $927.51 $0.00 $0.00 $0.00 $443.19 "$1,578.21" "$1,578.21" $0.00 $0.00 $443.14 $0.00 "$1,257.77" "$1,257.77" $0.00 "$1,030.56" "$1,632.41" "$1,648.90" $0.00 $0.00 $322.57 $0.00 $0.00 $328.13 $0.00 $0.00 $0.00 $0.00 $0.00 437432 SUP HCPCS C1713 437432 - PLATE 12 HL SHFT BONE DISTAL ANTLAT TIB BOTH IP/OP "$2,232.00 " "$1,651.68" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $465.20 "$1,656.59" "$1,656.59" $0.00 $0.00 $465.15 $0.00 "$1,320.23" "$1,320.23" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437434 SUP HCPCS C1713 437434 - PLATE BN 14 HL SHFT TIB RT ALAT DIST BOTH IP/OP "$2,232.00 " "$1,651.68" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $465.20 "$1,656.59" "$1,656.59" $0.00 $0.00 $465.15 $0.00 "$1,320.23" "$1,320.23" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437436 SUP HCPCS C1713 437436 - PLATE 16 HL SHFT BONE DISTAL ANTLAT TIB BOTH IP/OP "$2,232.00 " "$1,651.68" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $465.20 "$1,656.59" "$1,656.59" $0.00 $0.00 $465.15 $0.00 "$1,320.23" "$1,320.23" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437504 SUP HCPCS C1713 437504 - PLATE BN 130MM NS AXSOS 4X5X 2 HL SS FEM LT DIST LAT BOTH IP/OP "$2,439.20 " "$1,805.01" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $508.39 "$1,810.37" "$1,810.37" $0.00 $0.00 $508.33 $0.00 "$1,442.79" "$1,442.79" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437506 SUP HCPCS C1713 437506 - PLATE BN 166MM NS AXSOS 6X5X 3 HL SS FEM LT DIST LAT BOTH IP/OP "$2,439.20 " "$1,805.01" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $508.39 "$1,810.37" "$1,810.37" $0.00 $0.00 $508.33 $0.00 "$1,442.79" "$1,442.79" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437508 SUP HCPCS C1713 437508 - PLATE BN 202MM NS AXSOS 8X5X 4 HL SS FEM LT DIST LAT BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437510 SUP HCPCS C1713 437510 - PLATE BN 238MM NS AXSOS 10X5X 5 HL SS FEM LT DIST LAT BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437512 SUP HCPCS C1713 437512 - PLATE 12 HL SHFT BONE DISTAL LAT FEM BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437514 SUP HCPCS C1713 437514 - PLATE BN 310MM NS AXSOS 10X5X 7 HL SS FEM LT DIST LAT BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437516 SUP HCPCS C1713 437516 - PLATE BN 343MM NS AXSOS 16X5X 8 HL SS FEM LT DIST LAT BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437524 SUP HCPCS C1713 437524 - PLATE BN 130MM NS AXSOS 4X5X 2 HL SS FEM RT DIST LAT BOTH IP/OP "$2,439.20 " "$1,805.01" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $508.39 "$1,810.37" "$1,810.37" $0.00 $0.00 $508.33 $0.00 "$1,442.79" "$1,442.79" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437526 SUP HCPCS C1713 437526 - PLATE BN 166MM NS AXSOS 6X5X 3 HL SS FEM RT DIST LAT BOTH IP/OP "$2,439.20 " "$1,805.01" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $508.39 "$1,810.37" "$1,810.37" $0.00 $0.00 $508.33 $0.00 "$1,442.79" "$1,442.79" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437528 SUP HCPCS C1713 437528 - PLATE BN 202MM NS AXSOS 8X5X 4 HL SS FEM RT DIST LAT BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437530 SUP HCPCS C1713 437530 - PLATE BN 238MM NS AXSOS 10X5X 5 HL SS FEM RT DIST LAT BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437532 SUP HCPCS C1713 437532 - PLATE BN 274MM NS AXSOS 12X5X 6 HL SS FEM RT DIST LAT BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437534 SUP HCPCS C1713 437534 - PLATE 310MM 14 HL SHFT BONE RIGHT DISTAL LAT PERIART FEM BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 437536 SUP HCPCS C1713 437536 - PLATE BN 343MM NS AXSOS 16X5X 8 HL SS FEM RT DIST LAT BOTH IP/OP "$2,449.60 " "$1,812.70" $0.00 "$1,885.40" "$1,060.54" "$1,060.54" $0.00 $0.00 $0.00 $510.56 "$1,818.09" "$1,818.09" $0.00 $0.00 $510.50 $0.00 "$1,448.94" "$1,448.94" $0.00 "$1,178.38" "$1,866.55" "$1,885.40" $0.00 $0.00 $368.83 $0.00 $0.00 $375.19 $0.00 $0.00 $0.00 $0.00 $0.00 439678 SUP HCPCS C1900 439678 - LEAD PACING STR 4FR 78CM 2 ELECTRODE TINES IS-1 ATTAIN BOTH IP/OP "$3,562.50 " "$2,636.25" $0.00 "$2,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 439688 SUP HCPCS C1900 439688 - LEAD PACING STR 4FR 88CM 2 ELECTRODE TINES IS-1 ATTAIN BOTH IP/OP "$3,562.50 " "$2,636.25" $0.00 "$2,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 440400 SUP Custom 27203010 440400 - DRESSING NSL THK1.5CM STD 4.5CM WHT STRL LF MRCL TMPN SPT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 446400 SUP Custom 27203010 REAGENT IGG IMMAGE 300 TST ANALY BOTH IP/OP "$1,608.75 " "$1,190.48" $0.00 "$1,287.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.38 "$1,274.13" "$1,287.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 447060 SUP Custom 27203010 REAGENT WSH SOL IMMAGE 10L ANALY BOTH IP/OP $318.75 $235.88 $0.00 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.38 $252.45 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 447600 SUP Custom 27203010 REAGENT ALBM IMMAGE 150 TST ANALY BOTH IP/OP $811.25 $600.33 $0.00 $649.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $405.63 $642.51 $649.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 447640 SUP Custom 27203010 REAGENT DILU 1 IMMAGE 120ML ANALY BOTH IP/OP $328.13 $242.82 $0.00 $262.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.06 $259.88 $262.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 447650 SUP Custom 27203010 REAGENT BUFF 1 IMMAGE 120ML ANALY BOTH IP/OP $328.13 $242.82 $0.00 $262.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.06 $259.88 $262.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 449560 SUP Custom 27203010 CALIBRATOR ARY CHM SYS IMMUN BOTH IP/OP $806.25 $596.63 $0.00 $645.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $403.13 $638.55 $645.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 449730 SUP Custom 27203010 CALIBRATOR TRNFRN IMMAGE ARY LVL 3 3ML 360 SER IMMUN BOTH IP/OP $534.38 $395.44 $0.00 $427.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $267.19 $423.23 $427.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 453547 SUP HCPCS C1751 453547 - CATHETER IV 26GA .75IN STRL LF ABCTH-T ISO CLR CD TFLN BOTH IP/OP $8.68 $6.42 $0.00 $6.94 $3.90 $3.90 $0.00 $0.00 $0.00 $1.81 $6.44 $6.44 $0.00 $0.00 $1.81 $0.00 $5.13 $5.13 $0.00 $4.34 $6.87 $6.94 $0.00 $0.00 $1.36 $0.00 $0.00 $1.38 $0.00 $0.00 $0.00 $0.00 $0.00 465990 SUP Custom 27203010 CONTROL NH3 ALC SYN LVL 1 4ML CX7/LX SER TOX BOTH IP/OP $107.50 $79.55 $0.00 $86.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.75 $85.14 $86.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 465993 SUP Custom 27203010 CONTROL NH3 ALC SYN LVL 2 4ML CX7/LX SER TOX BOTH IP/OP $107.50 $79.55 $0.00 $86.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.75 $85.14 $86.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 465996 SUP Custom 27203010 CONTROL NH3 ALC SYN LVL 3 4ML CX7/LX SER TOX BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 472620 SUP CPT® Q4128 472620 - GRAFT SKIN THK1.8+ MM ULTRATHICK 20X16CM ALLOGRAFT HYDRATE BOTH IP/OP "$21,021.00 " "$15,555.54" $0.00 "$16,816.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,380.78" $0.00 $0.00 $0.00 $0.00 "$10,510.50" "$16,648.63" "$16,816.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-00 SUP Custom 27803010 01-3200 - HEAD FEMORAL +0MM 32MM MORSE TAPER LFIT COCR HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-00 SUP Custom 27803010 06-3200 - HEAD FEMORAL 0 32MM C TAPER LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 474976 SUP Custom 27203010 CONTROL MUL-DRUG SYN LOW 10ML CX/LX SER TOX BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-05 SUP Custom 27803010 01-3205 - HEAD FEMORAL +5MM MORSE TAPER 32MM LFIT COCR HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-06 SUP HCPCS C1713 1-3206 - SPACER SPNL 6MM X-STP PEEK LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-08 SUP HCPCS C1713 1-3208 - SPACER SPNL 8MM X-STP PEEK LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-10 SUP Custom 27803010 01-3210 - HEAD FEMORAL 10MM MORSE TAPER 32MM MORSE TAPER LFIT HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$4,144.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 "$4,144.90" "$4,144.90" $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-10 SUP HCPCS C1713 1-3210 - SPACER SPNL 10MM X-STP PEEK LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$6,658.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 "$4,144.90" "$4,144.90" $0.00 $897.50 "$6,658.74" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-10 SUP Custom 27803010 06-3210 - HEAD FEM +10MM OFST CTPR 32MM STRL LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-12 SUP HCPCS C1713 1-3212 - SPACER SPNL 12MM X-STP PEEK LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-14 SUP HCPCS C1713 1-3214 - SPACER SPNL 14MM X-STP PEEK LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-16 SUP HCPCS C1713 1-3216 - SPACER SPNL 16MM X-STP PEEK LMBR INTERSPINOUS PRC DCMPRS BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 482047 SUP HCPCS C1763 482047 - IMPL URO PLVCL BCMPT VERSATILITY DRBLTY STRTH ACLR CLGN MTRX BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 502452 SUP HCPCS C1769 502452 - GUIDEWIRE VASC 3MM RDS J .025IN 260CM STRL LF 7CM CRDS EMRLD BOTH IP/OP $25.08 $18.56 $0.00 $18.61 $12.26 $12.26 $0.00 $0.00 $0.00 $5.23 $18.61 $18.61 $0.00 $0.00 $5.23 $0.00 $14.83 $14.83 $0.00 $11.29 $17.88 $18.06 $0.00 $0.00 $3.53 $0.00 $0.00 $3.59 $0.00 $0.00 $0.00 $0.00 $0.00 502455 SUP HCPCS C1769 502455 - GUIDEWIRE VASC 3MM RDS J .035IN 260CM STRL LF 7CM CRDS EMRLD BOTH IP/OP $25.08 $18.56 $0.00 $18.61 $12.26 $12.26 $0.00 $0.00 $0.00 $5.23 $18.61 $18.61 $0.00 $0.00 $5.23 $0.00 $14.83 $14.83 $0.00 $11.29 $17.88 $18.06 $0.00 $0.00 $3.53 $0.00 $0.00 $3.59 $0.00 $0.00 $0.00 $0.00 $0.00 502521 SUP HCPCS C1769 502521 - GUIDEWIRE VASC 3MM RDS J .035IN 150CM STRL LF 7CM CRDS EMRLD BOTH IP/OP $16.25 $12.03 $0.00 $12.06 $7.85 $7.85 $0.00 $0.00 $0.00 $3.39 $12.06 $12.06 $0.00 $0.00 $3.39 $0.00 $9.61 $9.61 $0.00 $7.23 $11.44 $11.56 $0.00 $0.00 $2.26 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 502542 SUP HCPCS C1769 502542 - GUIDEWIRE VASC STRG .035IN 150CM STRL LF 7CM CRDS EMRLD FLXB BOTH IP/OP $16.25 $12.03 $0.00 $12.06 $7.85 $7.85 $0.00 $0.00 $0.00 $3.39 $12.06 $12.06 $0.00 $0.00 $3.39 $0.00 $9.61 $9.61 $0.00 $7.23 $11.44 $11.56 $0.00 $0.00 $2.26 $0.00 $0.00 $2.30 $0.00 $0.00 $0.00 $0.00 $0.00 509748 SUP Custom 27203010 DRUG ANBTC VITEK2 ETST DXYCL DC 256 B100 BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 510422 SUP HCPCS A4351 510422 - CATHETER URETHRAL 22FR 16IN 2 STAGGERED EYE RADIOPQ LATEX BOTH IP/OP $10.58 $7.83 $0.00 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $7.85 $7.85 $0.00 $0.00 $2.20 $0.00 $6.26 $6.26 $0.00 $5.29 $8.38 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 510426 SUP HCPCS C1729 510426 - CATHETER URTH RBNSN 26FR RBR STRL LTX RD BOTH IP/OP $105.75 $78.26 $0.00 $162.76 $110.47 $110.47 $0.00 $0.00 $0.00 $0.00 $78.49 $78.49 $0.00 $0.00 $22.04 $0.00 $0.00 $0.00 $0.00 $101.73 $161.13 $162.76 $0.00 $0.00 $31.84 $0.00 $0.00 $32.39 $0.00 $0.00 $0.00 $0.00 $0.00 510428 SUP HCPCS C1758 510428 - CATHETER URTH 28FR 16IN RD STRL LTX 2 STGR EYE RADOPQ RBR BOTH IP/OP $10.58 $7.83 $0.00 $8.46 $5.74 $5.74 $0.00 $0.00 $0.00 $2.20 $7.85 $7.85 $0.00 $0.00 $2.20 $0.00 $6.26 $6.26 $0.00 $5.29 $8.38 $8.46 $0.00 $0.00 $1.65 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-99 SUP Custom 27803010 01-3299 - HEAD FEMORAL -5MM 32MM MORSE TAPER LFIT COCR HIP BOTH IP/OP "$1,795.00 " "$1,328.30" $0.00 "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,332.25" "$1,332.25" $0.00 $0.00 $374.08 $0.00 $0.00 $0.00 $0.00 $897.50 "$1,421.64" "$1,436.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-99 SUP Custom 27203010 06-3299 - HEAD FEM -5MM OFST CTPR 32MM STRL LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 511212 SUP HCPCS C1898 "511212 - IS-1, SILICONE, 54CM, V PLACEMENT" BOTH IP/OP $680.00 $503.20 $0.00 "$1,067.66" $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 "$1,067.66" "$1,067.66" $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 513658 SUP Custom 27203010 STRIP IMPNM .002-32 MCG SNS BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 516001 SUP HCPCS Q4130 0516001 - MATRIX TISSUE 16X5CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP "$24,997.50 " "$18,498.15" $0.00 "$19,998.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$5,210.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,209.48" $0.00 "$12,323.77" "$12,323.77" $0.00 "$12,498.75" "$19,798.02" "$19,998.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 520368 SUP HCPCS C1713 520368 - SCREW BN 2MM CMPR HEX SCKT BOTH IP/OP $38.40 $28.42 $0.00 $30.72 $17.28 $17.28 $0.00 $0.00 $0.00 $8.00 $28.50 $28.50 $0.00 $0.00 $8.00 $0.00 $22.71 $22.71 $0.00 $19.20 $30.41 $30.72 $0.00 $0.00 $6.01 $0.00 $0.00 $6.11 $0.00 $0.00 $0.00 $0.00 $0.00 522022 SUP HCPCS C1776 522022 - HEAD FEM +0MM 11/13 TPR 22MM STRL SR COCR HIP MDLR SYS BOTH IP/OP "$3,187.50 " "$2,358.75" $0.00 "$2,550.00" "$1,434.38" "$1,434.38" $0.00 $0.00 $0.00 $664.35 "$2,365.76" "$2,365.76" $0.00 $0.00 $664.28 $0.00 "$1,571.44" "$1,571.44" $0.00 "$1,593.75" "$2,524.50" "$2,550.00" $0.00 $0.00 $498.84 $0.00 $0.00 $507.45 $0.00 $0.00 $0.00 $0.00 $0.00 525558 SUP Custom 27203010 STRIP VNCMCN ETST SNS BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 528341 SUP Custom 27203010 528341 - PILLING SURGILUX H/L VAR. 10-75 MM BOTH IP/OP "$2,400.00 " "$1,776.00" $0.00 "$1,920.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,781.28" "$1,781.28" $0.00 $0.00 $500.16 $0.00 $0.00 $0.00 $0.00 "$1,200.00" "$1,900.80" "$1,920.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 531658 SUP Custom 27203010 DISK ERTAPENEM SNS BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 532644 SUP HCPCS C1725 532644 - CATHETER ANGIO MP A2 CRV 6FR 125CM ST BRD ATRM SLCT 2 SH PU BOTH IP/OP $21.13 $15.64 $0.00 $16.90 $11.47 $11.47 $0.00 $0.00 $0.00 $4.40 $15.68 $15.68 $0.00 $0.00 $4.40 $0.00 $12.50 $12.50 $0.00 $10.56 $16.73 $16.90 $0.00 $0.00 $3.31 $0.00 $0.00 $3.36 $0.00 $0.00 $0.00 $0.00 $0.00 533448 SUP Custom 27203010 STRIP PLMXN ETST SNS BOTH IP/OP $785.00 $580.90 $0.00 $628.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $392.50 $621.72 $628.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 533558 SUP Custom 27203010 STRIP TIGECYCLINE 256 MCG ETST VK2 SNS F100 BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 535058 SUP Custom 27203010 STRIP DAPTOMYCIN .016-256 MCG ETST SNS BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 535070 SUP Custom 27203010 535070 - KIT TRACHEOSTOMY 9.6MM 7MM 82MM 2 DECK TRAY DILAT OBTURATOR BOTH IP/OP $677.00 $500.98 $0.00 $502.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.47 $502.47 $0.00 $0.00 $141.09 $0.00 $0.00 $0.00 $0.00 $313.81 $497.08 $502.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 535080 SUP Custom 27203010 535080 - KIT TRCH 10.9MM 8MM 86MM STRL LTX PRFT PRTX 2 DECK TRY DIL BOTH IP/OP $677.00 $500.98 $0.00 $502.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.47 $502.47 $0.00 $0.00 $141.09 $0.00 $0.00 $0.00 $0.00 $313.81 $497.08 $502.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 535090 SUP Custom 27203010 535090 - KIT TRACHEOSTOMY 12.3MM 9MM COMPLETE SET INNER CANNU BOTH IP/OP $677.00 $500.98 $0.00 $502.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.47 $502.47 $0.00 $0.00 $141.09 $0.00 $0.00 $0.00 $0.00 $313.81 $497.08 $502.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540015 SUP Custom 27203010 540015 - DRILL SURG MICRO CORE BOTH IP/OP "$13,025.75 " "$9,639.06" $0.00 "$10,420.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,714.57" $0.00 $0.00 $0.00 $0.00 "$6,512.88" "$10,316.39" "$10,420.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 544230 SUP Custom 27803010 544230 - CLIP INTNL MED LG CHEVRON HRT GRN STRL LF WECK HEM-O-LOK LGT BOTH IP/OP $86.61 $64.09 $0.00 $69.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.28 $64.28 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $43.30 $68.60 $69.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 544240 SUP Custom 27803010 544240 - CLIP INTERNAL LARGE LIGATE CARTRIDGE LATEX FREE WECK BOTH IP/OP $86.61 $64.09 $0.00 $69.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.28 $64.28 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $43.30 $68.60 $69.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 544250 SUP Custom 27803010 544250 - CLIP XL INTNL HEM-O-LOK PLMR LAPSCOP STRL DISP LATEX FREE BOTH IP/OP $81.75 $60.50 $0.00 $65.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.67 $60.67 $0.00 $0.00 $17.04 $0.00 $0.00 $0.00 $0.00 $40.88 $64.75 $65.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 570624 SUP HCPCS C1729 570624 - CATH URTH SMPLS 24FR 16IN FOLEY 3W CVLR TIP 30ML STRL LATEX BOTH IP/OP $84.50 $62.53 $0.00 $67.60 $45.88 $45.88 $0.00 $0.00 $0.00 $17.61 $62.72 $62.72 $0.00 $0.00 $17.61 $0.00 $49.98 $49.98 $0.00 $42.25 $66.92 $67.60 $0.00 $0.00 $13.22 $0.00 $0.00 $13.45 $0.00 $0.00 $0.00 $0.00 $0.00 573030 SUP HCPCS C1725 573030 - CATH BALDILAT .014IN 3MM 145CM 10MM OTW NC DRLN NC RPTR BOTH IP/OP $597.55 $442.19 $0.00 $478.04 $324.47 $324.47 $0.00 $0.00 $0.00 $124.54 $443.50 $443.50 $0.00 $0.00 $124.53 $0.00 $353.45 $353.45 $0.00 $298.78 $473.26 $478.04 $0.00 $0.00 $93.52 $0.00 $0.00 $95.13 $0.00 $0.00 $0.00 $0.00 $0.00 585040 SUP Custom 27203010 585040 - CANNULA OPHTHALMIC 40D 1.1MM 25MM 8MM SMOOTH TIP AIR INJEC BOTH IP/OP $198.83 $147.13 $0.00 $154.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.57 $147.57 $0.00 $0.00 $41.44 $0.00 $0.00 $0.00 $0.00 $96.51 $152.88 $154.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 585047 SUP Custom 27203010 585047 - CANNULA IRR 23GA .8IN .4IN .3MM STRL LF SMC ASP PORT THNWL BOTH IP/OP $172.77 $127.85 $0.00 $128.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.23 $128.23 $0.00 $0.00 $36.01 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 585119 SUP Custom 27203010 585119 - CANNULA OPHTHALMIC 45D ULTRATHIN WALL BEVEL 20GA 4MM INFUS BOTH IP/OP $256.00 $189.44 $0.00 $204.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.00 $190.00 $0.00 $0.00 $53.35 $0.00 $0.00 $0.00 $0.00 $128.00 $202.75 $204.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 585233 SUP Custom 27203010 585233 - UNIT IRRIGATION 14MM SQUEEGEE LASIK FLAP ROLLER SLEEVE BD BOTH IP/OP $59.80 $44.25 $0.00 $47.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.90 $47.36 $47.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600040 SUP HCPCS C1751 0600040 - CATHETER CV 2 BRCH 2.7FR .9MM .5MM 71CM STRL LTX BRVC 1 LUM BOTH IP/OP $195.50 $144.67 $0.00 $154.84 $0.00 $0.00 $0.00 $0.00 $0.00 $38.71 $137.85 $137.85 $0.00 $0.00 $9.33 $0.00 $115.64 $115.64 $0.00 $84.91 $154.84 $135.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600125 SUP Custom 27203010 0600125 - APPLICATOR ENDSCP FLSL BXTR NRFL COMP CANNU COMP BOTH IP/OP $133.00 $98.42 $0.00 $133.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.72 $98.72 $0.00 $0.00 $27.72 $0.00 $0.00 $0.00 $0.00 $83.17 $131.73 $133.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600160 SUP HCPCS C1751 0600160 - CATHETER 9FR SINGLE LUMEN HICKMAN BOTH IP/OP $61.35 $45.40 $0.00 $49.08 $33.31 $33.31 $0.00 $0.00 $0.00 $12.79 $45.53 $45.53 $0.00 $0.00 $12.79 $0.00 $36.29 $36.29 $0.00 $30.68 $48.59 $49.08 $0.00 $0.00 $9.60 $0.00 $0.00 $9.77 $0.00 $0.00 $0.00 $0.00 $0.00 600544 SUP HCPCS C1751 0600544 - KIT CATH 6.6FR 57CM STRL LF BRVC 1 LUM LOPRFL ADPR SIL PED BOTH IP/OP $371.13 $274.64 $0.00 $293.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.24 $15.24 $0.00 $0.00 $4.28 $0.00 $219.52 $219.52 $0.00 $9.31 $293.93 $14.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600560 SUP HCPCS C1751 0600560 - CATHETER CEN VEN 9.6FR 3.2MM 1.6MM 90CM 1 LUMEN TISSUE BOTH IP/OP $395.00 $292.30 $0.00 $312.84 $23.40 $23.40 $0.00 $0.00 $0.00 $1.05 $38.59 $38.59 $0.00 $0.00 $4.30 $0.00 $0.00 $0.00 $0.00 $26.00 $312.84 $41.60 $0.00 $0.00 $3.91 $0.00 $0.00 $3.73 $0.00 $0.00 $0.00 $0.00 $0.00 600600 SUP HCPCS C1751 0600600 - KIT CATH 9FR 54CM STRL LF HKMN PEEL-APART 2 LUM LOPRFL ADPR BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $192.77 $192.77 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 601600 SUP HCPCS C1751 0601600 - KIT CATH REPR 2.7FR .9MM .5MM 71CM .15ML WHT STRL LTX BRVC 1 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 601610 SUP HCPCS C1751 0601610 - KIT CATH REPR 4.2FR 1.4MM .7MM 71CM .3ML WHT STRL LF BRVC 1 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 601648 SUP HCPCS C1713 601648 - SCREW BONE PTHRD 5MM 48MM CANN LP HEAD REVERSE CUTTING FLUTE BOTH IP/OP $299.75 $221.82 $0.00 $408.18 $229.60 $229.60 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $255.11 $404.10 $408.18 $0.00 $0.00 $79.85 $0.00 $0.00 $81.23 $0.00 $0.00 $0.00 $0.00 $0.00 602230 SUP HCPCS C1788 0602230 - PORT IMPLTABLE INFUS SBQ TI 9.6FR 1 LUM ATCH CATH PLAPRT BOTH IP/OP "$2,108.70 " "$1,560.44" $0.00 "$1,686.96" $948.92 $948.92 $0.00 $0.00 $0.00 $439.51 "$1,565.08" "$1,565.08" $0.00 $0.00 $439.45 $0.00 "$1,247.30" "$1,247.30" $0.00 "$1,054.35" "$1,670.09" "$1,686.96" $0.00 $0.00 $330.01 $0.00 $0.00 $335.71 $0.00 $0.00 $0.00 $0.00 $0.00 602645 SUP HCPCS C1713 602645 - SCREW BN 6.5MM 45MM STRL 20MM ASNS III ST SLFDRL CNN TI ORTH BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 602650 SUP HCPCS C1713 602650 - SCREW BN 6.5MM 50MM STRL 20MM ASNS III ST SLF DRL CNN TI HIP BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 602660 SUP HCPCS C1713 602660 - SCREW BN 6.5MM 60MM STRL 20MM ASNS III SLF DRL ST CNN TI LNG BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 602885 SUP HCPCS C1713 602885 - SCREW BN LOPRFL REVCT FLUT 6.5MM 85MM NS 40MM ASNS III CNN BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 603020 SUP HCPCS Q4116 603020 - MATRIX TISSUE INJECTABLE CYMETRA MAT ACELLULAR DERMIS 2ML BOTH IP/OP $373.75 $276.58 $0.00 $299.00 $168.19 $168.19 $0.00 $0.00 $0.00 $77.90 $277.40 $277.40 $0.00 $0.00 $77.89 $0.00 $221.07 $221.07 $0.00 $186.88 $296.01 $299.00 $0.00 $0.00 $58.49 $0.00 $0.00 $59.50 $0.00 $0.00 $0.00 $0.00 $0.00 606008 SUP HCPCS Q4130 0606008 - MESH SURG 6X6MM STMA TISS HERN PTCH BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" $0.00 $0.00 $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 606096 SUP Custom 27203010 KIT IMMUN TST PRMR POS NEG CNTRL H PYLR IGG 96 TST BOTH IP/OP "$1,619.25 " "$1,198.25" $0.00 "$1,295.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $809.63 "$1,282.45" "$1,295.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 606560 SUP HCPCS C1751 0606560 - KIT CATH 10FR 59CM STRL LF HKMN 3 LUM LOPRFL ADPR PLAPRT BOTH IP/OP $455.05 $336.74 $0.00 $364.04 $247.09 $247.09 $0.00 $0.00 $0.00 $94.84 $337.74 $337.74 $0.00 $0.00 $94.83 $0.00 $269.16 $269.16 $0.00 $227.53 $360.40 $364.04 $0.00 $0.00 $71.22 $0.00 $0.00 $72.44 $0.00 $0.00 $0.00 $0.00 $0.00 608001 SUP HCPCS Q4130 0608001 - MATRIX TISS 8X6CM STRL STRATTICE RECON PRCN DERM BOTH IP/OP "$2,825.00 " "$2,090.50" $0.00 "$3,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $588.80 "$2,096.72" "$2,096.72" $0.00 $0.00 $588.73 $0.00 "$1,392.73" "$1,392.73" $0.00 "$2,135.00" "$3,381.84" "$3,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 609002 SUP Custom 27803010 609002 - TISSUE 609002 2MM FACET SHIM BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 609003 SUP Custom 27803010 609003 - TISSUE 609003 3MM FACET SHIM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 609004 SUP HCPCS C1763 609004 - GRAFT SFT SHIM 4 MM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 609404 SUP HCPCS C1763 609404 - GRAFT SFT TIS 10X8X4MM FACET BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 609604 SUP HCPCS C1763 609604 - GRAFT SFT TIS WDG 8X8X4MM LF BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 610008 SUP HCPCS Q4130 0610008 - MATRIX TISSUE 10X6CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP "$3,785.00 " "$2,800.90" $0.00 "$4,576.00" $0.00 $0.00 $0.00 $0.00 $0.00 $788.89 "$2,809.23" "$2,809.23" $0.00 $0.00 $788.79 $0.00 "$1,866.01" "$1,866.01" $0.00 "$2,860.00" "$4,530.24" "$4,576.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 610102 SUP HCPCS C1894 INTRODUCER SHTH 6FR 16CM TRAW ADPR DILAT SET INDN SPNLK .038 BOTH IP/OP $67.10 $49.65 $0.00 $53.68 $36.44 $36.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.55 $53.14 $53.68 $0.00 $0.00 $10.50 $0.00 $0.00 $10.68 $0.00 $0.00 $0.00 $0.00 $0.00 610104 SUP HCPCS C1894 INTRODUCER 8 FR TEAR AWAY BOTH IP/OP $70.40 $52.10 $0.00 $56.32 $38.23 $38.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.20 $55.76 $56.32 $0.00 $0.00 $11.02 $0.00 $0.00 $11.21 $0.00 $0.00 $0.00 $0.00 $0.00 610106 SUP HCPCS C1892 INTRODUCER SHTH 10FR 16CM TRAW DILAT SET ADPR INTRDN .038IN BOTH IP/OP $69.35 $51.32 $0.00 $55.48 $37.66 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.68 $54.93 $55.48 $0.00 $0.00 $10.85 $0.00 $0.00 $11.04 $0.00 $0.00 $0.00 $0.00 $0.00 610130 SUP HCPCS C1760 610130 - DEVICE CLSR 6FR .035IN 70CM STRL LF ANGSL VIP BONDEK-+ HMST BOTH IP/OP $840.00 $621.60 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 610131 SUP HCPCS C1760 610131 - DEVICE CLSR 8FR ANGSL VIP VASC HMST STRL LATEX FREE DISP BOTH IP/OP $840.00 $621.60 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 610400 SUP Custom 27203010 CONNECTOR CATH 9.5FR Y SWVL LUER LOCK SDPRT SGL BOTH IP/OP $65.65 $48.58 $0.00 $52.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.83 $51.99 $52.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 611125 SUP HCPCS C1713 611125 - SCREW BONE 8MM 125MM 25MM ASNS 3 TI ORTH SLFTAP SLFDRILL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 611130 SUP HCPCS C1713 611130 - SCREW BONE 8MM 130MM 25MM ASNS 3 TI ORTH SLFTAP SLFDRILL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 611335 SUP HCPCS C1713 611335 - SCREW BONE 8MM 135MM ASNS 3 TI FULTHRD CANN NONSTRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 611340 SUP HCPCS C1713 611340 - SCREW BONE 8MM 140MM ASNS 3 TI FULTHRD CANN NONSTRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 611345 SUP HCPCS C1713 611345 - SCREW BONE 8MM 145MM ASNS 3 TI FULTHRD CANN NONSTRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 611350 SUP HCPCS C1713 611350 - SCREW BONE 8MM 150MM ASNS 3 TI FULTHRD CANN NONSTRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 612601 SUP HCPCS C1892 612601 - INTRODUCER SHTH 5FR 19CM 16CM TRAW ADPR DILAT SET INDN SPNLK BOTH IP/OP $60.88 $45.05 $0.00 $48.70 $33.06 $33.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.44 $48.22 $48.70 $0.00 $0.00 $9.53 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 614508 SUP HCPCS C1713 614508 - SCREW BONE 2.7MM 8MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614510 SUP HCPCS C1713 614510 - SCREW BONE 2.7MM 10MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614512 SUP HCPCS C1713 614512 - SCREW BONE 2.7MM 12MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614514 SUP HCPCS C1713 614514 - SCREW BONE 2.7MM 14MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614516 SUP HCPCS C1713 614516 - SCREW BONE 2.7MM 16MM LCK STRL BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614518 SUP HCPCS C1713 614518 - SCREW BONE 2.7MM 18MM LCK STRL BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614520 SUP HCPCS C1713 614520 - SCREW BONE 2.7MM 20MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614522 SUP HCPCS C1713 614522 - SCREW BONE 2.7MM 22MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614524 SUP HCPCS C1713 614524 - SCREW BONE 2.7MM 24MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614526 SUP HCPCS C1713 614526 - SCREW BONE 2.7MM 26MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614528 SUP HCPCS C1713 614528 - SCREW BONE 2.7MM 28MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614530 SUP HCPCS C1713 614530 - SCREW BONE 2.7MM 30MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614532 SUP HCPCS C1713 614532 - SCREW BONE 2.7MM 32MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614534 SUP HCPCS C1713 614534 - SCREW BONE 2.7MM 34MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614536 SUP HCPCS C1713 614536 - SCREW BONE 2.7MM 36MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614538 SUP HCPCS C1713 614538 - SCREW BONE 2.7MM 38MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614540 SUP HCPCS C1713 614540 - SCREW BONE 2.7MM 40MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614542 SUP HCPCS C1713 614542 - SCREW BONE 2.7MM 42MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $964.83 $713.97 $0.00 $717.09 $111.38 $111.38 $0.00 $0.00 $0.00 $201.09 $716.09 $716.09 $0.00 $0.00 $201.07 $0.00 $717.09 $717.09 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614544 SUP HCPCS C1713 614544 - SCREW BONE 2.7MM 44MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614546 SUP HCPCS C1713 614546 - SCREW BONE 2.7MM 46MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614548 SUP HCPCS C1713 614548 - SCREW BONE 2.7MM 48MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614550 SUP HCPCS C1713 614550 - SCREW BONE 2.7MM 50MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614555 SUP HCPCS C1713 614555 - SCREW BONE 2.7MM 55MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614560 SUP HCPCS C1713 614560 - SCREW BONE 2.7MM 60MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614565 SUP HCPCS C1713 614565 - SCREW BONE 2.7MM 65MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614570 SUP HCPCS C1713 614570 - SCREW BONE 2.7MM 70MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 614608 SUP HCPCS C1713 614608 - SCREW BONE 3.5MM 8MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614610 SUP HCPCS C1713 614610 - SCREW BONE 3.5MM 10MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614612 SUP HCPCS C1713 614612 - SCREW BONE 3.5MM 12MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614614 SUP HCPCS C1713 614614 - SCREW BONE 3.5MM 14MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614616 SUP HCPCS C1713 614616 - SCREW BONE 3.5MM 16MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614618 SUP HCPCS C1713 614618 - SCREW BONE 3.5MM 18MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614620 SUP HCPCS C1713 614620 - SCREW BONE 3.5MM 20MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614622 SUP HCPCS C1713 614622 - SCREW BONE 3.5MM 22MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614624 SUP HCPCS C1713 614624 - SCREW BONE 3.5MM 24MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614626 SUP HCPCS C1713 614626 - SCREW BONE 3.5MM 26MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614628 SUP HCPCS C1713 614628 - SCREW BONE 3.5MM 28MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614630 SUP HCPCS C1713 614630 - SCREW BONE 3.5MM 30MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614632 SUP HCPCS C1713 614632 - SCREW BONE 3.5MM 32MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614634 SUP HCPCS C1713 614634 - SCREW BONE 3.5MM 42MM VARIAX TI ELB SLFTAP LCK NONSTRL BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614636 SUP HCPCS C1713 614636 - SCREW BONE 3.5MM 36MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614638 SUP HCPCS C1713 614638 - SCREW BONE 3.5MM 38MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614640 SUP HCPCS C1713 614640 - SCREW BONE 3.5MM 40MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614642 SUP HCPCS C1713 614642 - SCREW BONE 3.5MM 42MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614644 SUP HCPCS C1713 614644 - SCREW BONE 3.5MM 44MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614646 SUP HCPCS C1713 614646 - SCREW BONE 3.5MM 46MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614648 SUP HCPCS C1713 614648 - SCREW BONE 3.5MM 48MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614650 SUP HCPCS C1713 614650 - SCREW BONE 3.5MM 50MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614655 SUP HCPCS C1713 614655 - SCREW BONE 3.5MM 55MM VARIAX LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614660 SUP HCPCS C1713 614660 - SCREW BONE 3.5MM 60MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614665 SUP HCPCS C1713 614665 - SCREW BONE 3.5MM 65MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614670 SUP HCPCS C1713 614670 - SCREW BONE 3.5MM 70MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 614708 SUP HCPCS C1713 614708 - SCREW BONE 2.7MM 8MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614710 SUP HCPCS C1713 614710 - SCREW BONE 2.7MM 10MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614712 SUP HCPCS C1713 614712 - SCREW BONE 2.7MM 12MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614714 SUP HCPCS C1713 614714 - SCREW BONE 2.7MM 14MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614716 SUP HCPCS C1713 614716 - SCREW BONE 2.7MM 16MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614718 SUP HCPCS C1713 614718 - SCREW BONE 2.7MM 18MM VARIAX SLFTAP BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614720 SUP HCPCS C1713 614720 - SCREW BONE 2.7MM 20MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614722 SUP HCPCS C1713 614722 - SCREW BONE 2.7MM 22MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614724 SUP HCPCS C1713 614724 - SCREW BONE 2.7MM 24MM VARIAX SLFTAP BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614726 SUP HCPCS C1713 614726 - SCREW BONE 2.7MM 26MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614728 SUP HCPCS C1713 614728 - SCREW BONE 2.7MM 28MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614730 SUP HCPCS C1713 614730 - SCREW BONE 2.7MM 30MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614732 SUP HCPCS C1713 614732 - SCREW BONE 2.7MM 32MM VARIAX TI ELB SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614734 SUP HCPCS C1713 614734 - SCREW BONE 2.7MM 34MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614736 SUP HCPCS C1713 614736 - SCREW BONE 2.7MM 36MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614738 SUP HCPCS C1713 614738 - SCREW BONE 2.7MM 38MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614740 SUP HCPCS C1713 614740 - SCREW BONE 2.7MM 40MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614742 SUP HCPCS C1713 614742 - SCREW BONE 2.7MM 42MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614744 SUP HCPCS C1713 614744 - SCREW BONE 2.7MM 44MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614746 SUP HCPCS C1713 614746 - SCREW BONE 2.7MM 46MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614748 SUP HCPCS C1713 614748 - SCREW BONE 2.7MM 48MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614750 SUP HCPCS C1713 614750 - SCREW BONE 2.7MM 50MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614755 SUP HCPCS C1713 614755 - SCREW BONE 2.7MM 55MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614760 SUP HCPCS C1713 614760 - SCREW BONE 2.7MM 60MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614765 SUP HCPCS C1713 614765 - SCREW BONE 2.7MM 65MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614770 SUP HCPCS C1713 614770 - SCREW BONE 2.7MM 70MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $111.30 $82.36 $0.00 $85.80 $48.26 $48.26 $0.00 $0.00 $0.00 $23.20 $82.61 $82.61 $0.00 $0.00 $23.19 $0.00 $65.83 $65.83 $0.00 $53.63 $84.94 $85.80 $0.00 $0.00 $16.78 $0.00 $0.00 $17.07 $0.00 $0.00 $0.00 $0.00 $0.00 614808 SUP HCPCS C1713 614808 - SCREW BONE 3.5MM 8MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614810 SUP HCPCS C1713 614810 - SCREW BONE 3.5MM 10MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614812 SUP HCPCS C1713 614812 - SCREW BONE 3.5MM 12MM VARIAX TI ELB LCK SLFTAP PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614814 SUP HCPCS C1713 614814 - SCREW BONE 3.5MM 14MM VARIAX SS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614816 SUP HCPCS C1713 614816 - SCREW BONE 3.5MM 16MM VARIAX SS NLCKG BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614818 SUP HCPCS C1713 614818 - SCREW BONE 3.5MM 18MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614820 SUP HCPCS C1713 614820 - SCREW BONE 3.5MM 20MM VARIAX SS ELB SLFTAP LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614822 SUP HCPCS C1713 614822 - SCREW BONE 3.5MM 22MM VARIAX TI ELB SLFTAP LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614824 SUP HCPCS C1713 614824 - SCREW BONE 3.5MM 24MM VARIAX TI ELB SLFTAP LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614826 SUP HCPCS C1713 614826 - SCREW BONE 3.5MM 26MM VARIAX TI BOTH IP/OP "$1,941.50 " "$1,436.71" $0.00 "$1,553.20" $873.68 $873.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 614828 SUP HCPCS C1713 614828 - SCREW BONE 3.5MM 28MM VARIAX TI BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614830 SUP HCPCS C1713 614830 - SCREW BONE 3.5MM 30MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614832 SUP HCPCS C1713 614832 - SCREW BONE 3.5MM 32MM VARIAX TI ELB SLFTAP LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614834 SUP HCPCS C1713 614834 - SCREW BONE 3.5MM 34MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614836 SUP HCPCS C1713 614836 - SCREW BONE 3.5MM 36MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614838 SUP HCPCS C1713 614838 - SCREW BONE 3.5MM 38MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614840 SUP HCPCS C1713 614840 - SCREW BONE 3.5MM 40MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614842 SUP HCPCS C1713 614842 - SCREW BONE 3.5MM 42MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614844 SUP HCPCS C1713 614844 - SCREW BONE 3.5MM 44MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614846 SUP HCPCS C1713 614846 - SCREW BONE 3.5MM 46MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614848 SUP HCPCS C1713 614848 - SCREW BONE 3.5MM 48MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614850 SUP HCPCS C1713 614850 - SCREW BONE 3.5MM 50MM VARIAX NLCKG BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614855 SUP HCPCS C1713 614855 - SCREW BONE 3.5MM 55MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614860 SUP HCPCS C1713 614860 - SCREW BONE 3.5MM 60MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614865 SUP HCPCS C1713 614865 - SCREW BONE 3.5MM 65MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 614870 SUP HCPCS C1713 614870 - SCREW BONE 3.5MM 70MM VARIAX TI ELB SLFTAP LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 616002 SUP HCPCS Q4130 0616002 - MATRIX TISSUE 16X6CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP $58.88 $43.57 $0.00 $71.19 $0.00 $0.00 $0.00 $0.00 $0.00 $12.27 $43.70 $43.70 $0.00 $0.00 $12.27 $0.00 $34.83 $34.83 $0.00 $44.49 $70.47 $71.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-00 SUP Custom 27803010 06-3600 - HEAD FEM +0MM OFST CTPR 36MM STRL LFIT ANTM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621552 SUP HCPCS C1713 621552 - PLATE LNG 50MM TI BONE CALCANEUS BOTH IP/OP $705.38 $521.98 $0.00 $564.30 $317.42 $317.42 $0.00 $0.00 $0.00 $147.02 $523.53 $523.53 $0.00 $0.00 $147.00 $0.00 $417.23 $417.23 $0.00 $352.69 $558.66 $564.30 $0.00 $0.00 $110.39 $0.00 $0.00 $112.30 $0.00 $0.00 $0.00 $0.00 $0.00 621553 SUP HCPCS C1713 621553 - PLATE LNG 60MM TI BONE CALCANEUS BOTH IP/OP $705.38 $521.98 $0.00 $564.30 $317.42 $317.42 $0.00 $0.00 $0.00 $147.02 $523.53 $523.53 $0.00 $0.00 $147.00 $0.00 $417.23 $417.23 $0.00 $352.69 $558.66 $564.30 $0.00 $0.00 $110.39 $0.00 $0.00 $112.30 $0.00 $0.00 $0.00 $0.00 $0.00 621554 SUP HCPCS C1713 621554 - PLATE LNG 70MM TI BONE CALCANEUS BOTH IP/OP $705.38 $521.98 $0.00 $564.30 $317.42 $317.42 $0.00 $0.00 $0.00 $147.02 $523.53 $523.53 $0.00 $0.00 $147.00 $0.00 $417.23 $417.23 $0.00 $352.69 $558.66 $564.30 $0.00 $0.00 $110.39 $0.00 $0.00 $112.30 $0.00 $0.00 $0.00 $0.00 $0.00 621555 SUP HCPCS C1713 621555 - PLATE LNG 80MM TI BONE CALCANEUS BOTH IP/OP $541.75 $400.90 $0.00 $433.40 $243.79 $243.79 $0.00 $0.00 $0.00 $112.91 $402.09 $402.09 $0.00 $0.00 $112.90 $0.00 $320.45 $320.45 $0.00 $270.88 $429.07 $433.40 $0.00 $0.00 $84.78 $0.00 $0.00 $86.25 $0.00 $0.00 $0.00 $0.00 $0.00 624519 SUP Custom 27203010 CALIBRATOR CL S-CL KT 4.2ML HMTL BOTH IP/OP $78.85 $58.35 $0.00 $63.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.43 $62.45 $63.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 626001 SUP HCPCS C1713 626001 - PLATE LNG 1 LVL RPS BONE SPNL BOTH IP/OP "$2,830.60 " "$2,094.64" $0.00 "$2,264.48" "$1,273.77" "$1,273.77" $0.00 $0.00 $0.00 $589.97 "$2,100.87" "$2,100.87" $0.00 $0.00 $589.90 $0.00 "$1,395.49" "$1,395.49" $0.00 "$1,415.30" "$2,241.84" "$2,264.48" $0.00 $0.00 $442.99 $0.00 $0.00 $450.63 $0.00 $0.00 $0.00 $0.00 $0.00 626002 SUP HCPCS C1713 626002 - PLATE LNG TI 2 LVL BONE ORTH BOTH IP/OP "$3,124.90 " "$2,312.43" $0.00 "$2,499.92" "$1,406.21" "$1,406.21" $0.00 $0.00 $0.00 $651.31 "$2,319.30" "$2,319.30" $0.00 $0.00 $651.23 $0.00 "$1,540.58" "$1,540.58" $0.00 "$1,562.45" "$2,474.92" "$2,499.92" $0.00 $0.00 $489.05 $0.00 $0.00 $497.48 $0.00 $0.00 $0.00 $0.00 $0.00 626011 SUP HCPCS C1713 626011 - PLATE SHRT 1 LVL RPS BONE SPNL BOTH IP/OP "$2,830.60 " "$2,094.64" $0.00 "$2,264.48" "$1,273.77" "$1,273.77" $0.00 $0.00 $0.00 $589.97 "$2,100.87" "$2,100.87" $0.00 $0.00 $589.90 $0.00 "$1,395.49" "$1,395.49" $0.00 "$1,415.30" "$2,241.84" "$2,264.48" $0.00 $0.00 $442.99 $0.00 $0.00 $450.63 $0.00 $0.00 $0.00 $0.00 $0.00 626300 SUP Custom 27803010 626300 - CONCTR ROD RPS FIX SPNL BOTH IP/OP "$2,122.93 " "$1,570.97" $0.00 "$1,698.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,575.63" "$1,575.63" $0.00 $0.00 $442.42 $0.00 $0.00 $0.00 $0.00 "$1,061.46" "$1,681.36" "$1,698.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 629004 SUP HCPCS C1713 629004 - PLATE BN 4 HL HUM DIST LAT BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629006 SUP HCPCS C1713 629006 - PLATE BN 6 HL HUM LT DIST LAT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629008 SUP HCPCS C1713 629008 - PLATE BN 8 HL HUM LT DIST LAT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 629024 SUP HCPCS C1713 629024 - PLATE BN 4 HL HUM RT DIST LAT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $668.25 $668.25 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629026 SUP HCPCS C1713 629026 - PLATE BN 6 HL HUM RT DIST LAT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629028 SUP HCPCS C1713 629028 - PLATE BN 8 HL HUM RT DIST LAT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 629044 SUP HCPCS C1713 629044 - PLATE BN 4 HL HUM DP LAT BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629046 SUP HCPCS C1713 629046 - PLATE BN 6 HL HUM L/L POST DIST BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629048 SUP HCPCS C1713 629048 - PLATE BN 8 HL HUM L/L POST DIST BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $816.75 $816.75 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 629064 SUP HCPCS C1713 629064 - PLATE BN 4 HL HUM RL POST DIST BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629066 SUP HCPCS C1713 629066 - PLATE BN 6 HL HUM RL POST DIST BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629068 SUP HCPCS C1713 629068 - PLATE BN 8 HL HUM DP LAT BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 629084 SUP HCPCS C1713 629084 - PLATE BN XTD HUM DIST MDL BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629086 SUP HCPCS C1713 629086 - PLATE BN 6 HL XTD HUM DIST MDL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629088 SUP HCPCS C1713 629088 - PLATE BN XTD HUM DIST MDL BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 629104 SUP HCPCS C1713 629104 - PLATE BN 4 HL HUM MDL POST DIST BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629106 SUP HCPCS C1713 629106 - DIST. POST. MED. HUM. PL. 6 HOLE / LEFT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629108 SUP HCPCS C1713 629108 - PLATE BN 8 HL HUM MDL POST DIST BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 629124 SUP HCPCS C1713 629124 - PLATE BN 4 HL HUM MDL POST DIST BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629126 SUP HCPCS C1713 629126 - PLATE BN 6 HL HUM MDL POST DIST BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629128 SUP HCPCS C1713 629128 - PLATE BN 8 HL HUM MDL POST DIST BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 629144 SUP HCPCS C1713 629144 - PLATE BN 4 HL LT OLCRN BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629146 SUP HCPCS C1713 629146 - PLATE BN 6 HL LT OLCRN BOTH IP/OP "$1,567.50 " "$1,159.95" $0.00 "$1,254.00" $705.38 $705.38 $0.00 $0.00 $0.00 $326.71 "$1,163.40" "$1,163.40" $0.00 $0.00 $326.67 $0.00 $927.18 $927.18 $0.00 $783.75 "$1,241.46" "$1,254.00" $0.00 $0.00 $245.31 $0.00 $0.00 $249.55 $0.00 $0.00 $0.00 $0.00 $0.00 629148 SUP HCPCS C1713 629148 - PLATE BN 8 HL LT OLCRN BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629164 SUP HCPCS C1713 629164 - OLECRANON PLATE 4 HOLE / RIGHT BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629166 SUP HCPCS C1713 629166 - PLATE SS 6 HOLE LCK BONE OLCRN BOTH IP/OP "$1,567.50 " "$1,159.95" $0.00 "$1,254.00" $705.38 $705.38 $0.00 $0.00 $0.00 $326.71 "$1,163.40" "$1,163.40" $0.00 $0.00 $326.67 $0.00 $927.18 $927.18 $0.00 $783.75 "$1,241.46" "$1,254.00" $0.00 $0.00 $245.31 $0.00 $0.00 $249.55 $0.00 $0.00 $0.00 $0.00 $0.00 629168 SUP HCPCS C1713 629168 - PLATE BN 8 HL RT OLCRN BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629184 SUP HCPCS C1713 629184 - PLATE BN 4 HL HUM DIST MDL BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 629186 SUP HCPCS C1713 629186 - DIST. MED. HUM. PLATE 6 HOLE BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 629188 SUP HCPCS C1713 629188 - PLATE BN 8 HL HUM DIST MDL BOTH IP/OP "$1,815.00 " "$1,343.10" $0.00 "$1,452.00" $816.75 $816.75 $0.00 $0.00 $0.00 $378.29 "$1,347.09" "$1,347.09" $0.00 $0.00 $378.25 $0.00 "$1,073.57" "$1,073.57" $0.00 $907.50 "$1,437.48" "$1,452.00" $0.00 $0.00 $284.05 $0.00 $0.00 $288.95 $0.00 $0.00 $0.00 $0.00 $0.00 629204 SUP HCPCS C1713 629204 - PLATE BN 109MM NS VARIAX 4 HL TI HUM LT DIST LAT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629206 SUP HCPCS C1713 629206 - PLATE BN 132MM NS VARIAX 6 HL TI HUM LT DIST LAT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,412.40" $794.48 $794.48 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629208 SUP HCPCS C1713 629208 - PLATE BN 156MM NS VARIAX 8 HL TI HUM LT DIST LAT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $873.68 $873.68 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 629224 SUP HCPCS C1713 629224 - PLATE BN 109MM NS VARIAX 4 HL TI HUM RT DIST LAT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629226 SUP HCPCS C1713 629226 - PLATE BN 132MM NS VARIAX 6 HL TI HUM RT DIST LAT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,412.40" $794.48 $794.48 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629228 SUP HCPCS C1713 629228 - PLATE BN 156MM NS VARIAX 8 HL TI HUM RT DIST LAT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $873.68 $873.68 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 629244 SUP HCPCS C1713 629244 - PLATE BN 105MM NS VARIAX 4 HL TI HUM LT P/L BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629246 SUP HCPCS C1713 629246 - PLATE BN 128MM NS VARIAX 6 HL TI HUM LT P/L BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,412.40" $794.48 $794.48 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629248 SUP HCPCS C1713 629248 - PLATE BN 150MM NS VARIAX 8 HL TI HUM LT P/L BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $873.68 $873.68 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 629264 SUP HCPCS C1713 629264 - PLATE BN 105MM NS VARIAX 4 HL TI HUM RT P/L BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629266 SUP HCPCS C1713 629266 - PLATE BN 128MM NS VARIAX 6 HL TI HUM RT P/L BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,412.40" $794.48 $794.48 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629268 SUP HCPCS C1713 629268 - PLATE BN 150MM NS VARIAX 8 HL TI HUM RT P/L BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $873.68 $873.68 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 629284 SUP HCPCS C1713 629284 - PLATE BN 96MM NS VARIAX 4 HL XTD TI HUM DIST MDL BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629286 SUP HCPCS C1713 629286 - PLATE BN 120MM NS VARIAX 6 HL XTD TI HUM DIST MDL BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,412.40" $794.48 $794.48 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629288 SUP HCPCS C1713 629288 - PLATE BN 143MM NS VARIAX 8 HL XTD TI HUM DIST MDL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $873.68 $873.68 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 629304 SUP HCPCS C1713 629304 - PLATE 104MM TI 4 SHFT HOLE VARIAX BONE LEFT POST MDL ELB BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629306 SUP HCPCS C1713 629306 - PLATE 128MM TI 6 SHFT HOLE VARIAX BONE LEFT POST MDL ELB BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,412.40" $794.48 $794.48 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629308 SUP HCPCS C1713 629308 - PLATE 151MM TI 8 SHFT HOLE VARIAX BONE LEFT POST MDL ELB BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $873.68 $873.68 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 629324 SUP HCPCS C1713 629324 - PLATE 104MM TI 4 SHFT HOLE VARIAX BONE RIGHT POST MDL ELB BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629326 SUP HCPCS C1713 629326 - PLATE 128MM TI 6 SHFT HOLE VARIAX BONE RIGHT POST MDL ELB BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,412.40" $794.48 $794.48 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629328 SUP HCPCS C1713 629328 - PLATE 151MM TI 8 SHFT HOLE VARIAX BONE RIGHT POST MDL ELB BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $873.68 $873.68 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 629344 SUP HCPCS C1713 629344 - PLATE BN 89MM NS VARIAX 4 HL TI OLCRN LT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629346 SUP HCPCS C1713 629346 - PLATE BN 113MM NS VARIAX 6 HL TI OLCRN LT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $754.88 $754.88 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $838.75 "$1,328.58" "$1,342.00" $0.00 $0.00 $262.53 $0.00 $0.00 $267.06 $0.00 $0.00 $0.00 $0.00 $0.00 629348 SUP HCPCS C1713 629348 - PLATE BN 137MM NS VARIAX 8 HL TI OLCRN LT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $794.48 $794.48 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629364 SUP HCPCS C1713 629364 - PLATE BN 89MM NS VARIAX 4 HL TI OLCRN RT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629366 SUP HCPCS C1713 629366 - PLATE BN 113MM NS VARIAX 6 HL TI OLCRN RT BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $754.88 $754.88 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $838.75 "$1,328.58" "$1,342.00" $0.00 $0.00 $262.53 $0.00 $0.00 $267.06 $0.00 $0.00 $0.00 $0.00 $0.00 629368 SUP HCPCS C1713 629368 - PLATE BN 137MM NS VARIAX 8 HL TI OLCRN RT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $794.48 $794.48 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629384 SUP HCPCS C1713 629384 - PLATE BN 92MM NS VARIAX 4 HL TI HUM DIST MDL BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,387.17" $715.28 $715.28 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $794.75 "$1,258.88" "$1,271.60" $0.00 $0.00 $248.76 $0.00 $0.00 $253.05 $0.00 $0.00 $0.00 $0.00 $0.00 629385 SUP Custom 27203010 629385 - STYLET LEAD STR BALL TAPER .016IN 85CM KIT EXTEND KNOB BOTH IP/OP $16.00 $11.84 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $11.88 $0.00 $0.00 $3.33 $0.00 $0.00 $0.00 $0.00 $8.00 $12.67 $12.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 629386 SUP HCPCS C1713 629386 - PLATE BN 116MM NS VARIAX 6 HL TI HUM DIST MDL BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,412.40" $794.48 $794.48 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $882.75 "$1,398.28" "$1,412.40" $0.00 $0.00 $276.30 $0.00 $0.00 $281.07 $0.00 $0.00 $0.00 $0.00 $0.00 629388 SUP HCPCS C1713 629388 - PLATE BN 139MM NS VARIAX 8 HL TI HUM DIST MDL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $873.68 $873.68 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $970.75 "$1,537.67" "$1,553.20" $0.00 $0.00 $303.84 $0.00 $0.00 $309.09 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-25 SUP Custom 27803010 06-3625 - HEAD FEM +2.5MM OFST CTPR 36MM STRL LFIT ANTM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 631400 SUP Custom 27203010 631400 - PARTICLES EMBL TRFL KT LQ SYS NBCA 2GM BOTH IP/OP "$10,375.00 " "$7,677.50" $0.00 "$8,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,162.15" $0.00 $0.00 $0.00 $0.00 "$5,187.50" "$8,217.00" "$8,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 631500 SUP Custom 27203010 631500 - PARTICLES EMBL TRFL KT LQ SYS NBCA 1GM BOTH IP/OP "$8,099.68 " "$5,993.76" $0.00 "$6,479.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,687.97" $0.00 $0.00 $0.00 $0.00 "$4,049.84" "$6,414.95" "$6,479.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 633000 SUP HCPCS C1884 COIL EMBL 2MM .014IN TRFL STRG PSH 2CM PLTN NRVSC BOTH IP/OP $172.50 $127.65 $0.00 $138.00 $77.63 $77.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.25 $136.62 $138.00 $0.00 $0.00 $27.00 $0.00 $0.00 $27.46 $0.00 $0.00 $0.00 $0.00 $0.00 633340 SUP HCPCS C1884 COIL EMBL 5MM TRFL PSH CMPLX SHP BOTH IP/OP $389.50 $288.23 $0.00 $311.60 $175.28 $175.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.75 $308.48 $311.60 $0.00 $0.00 $60.96 $0.00 $0.00 $62.01 $0.00 $0.00 $0.00 $0.00 $0.00 633360 SUP HCPCS C1884 COIL EMBL 60MM 7MM TRFL OCL PSH CMPLX SHP NYL BOTH IP/OP $389.50 $288.23 $0.00 $311.60 $175.28 $175.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.75 $308.48 $311.60 $0.00 $0.00 $60.96 $0.00 $0.00 $62.01 $0.00 $0.00 $0.00 $0.00 $0.00 635002 SUP Custom 27803010 635002 - SYRINGE INFLAT/DEFLATION INDEFLATOR TRUFILL DCS II PLATINUM BOTH IP/OP $674.40 $499.06 $0.00 $539.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.54 $500.54 $0.00 $0.00 $140.54 $0.00 $0.00 $0.00 $0.00 $337.20 $534.12 $539.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 636032 SUP HCPCS C1713 636032 - SPACER 636032 PERIMETER XS 10X13X12MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636053 SUP HCPCS C1713 636053 - SPACER 636053 PERIMETER XS 10X15X13MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636132 SUP HCPCS C1713 636132 - SPACER 636132 PERIMETER XS 11X13X12MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636153 SUP HCPCS C1713 636153 - SPACER 636153 PERIMETER XS 11X15X13MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636232 SUP HCPCS C1713 636232 - SPACER 636232 PERIMETER XS 12X13X12MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636253 SUP HCPCS C1713 636253 - SPACER 636253 PERIMETER XS 12X15X13MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636532 SUP HCPCS C1713 636532 - SPACER 636532 PERIMETER XS 5X13X12MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636553 SUP HCPCS C1713 636553 - SPACER 636553 PERIMETER XS 5X15X13MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636632 SUP HCPCS C1713 636632 - SPACER 636632 PERIMETER XS 6X13X12MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636653 SUP HCPCS C1713 636653 - SPACER 636653 PERIMETER XS 6X15X13MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636732 SUP HCPCS C1713 636732 - SPACER 636732 PERIMETER XS 7X13X12MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636753 SUP HCPCS C1713 636753 - SPACER 636753 PERIMETER XS 7X15X13MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636832 SUP HCPCS C1713 636832 - SPACER 636832 PERIMETER XS 8X13X12MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636853 SUP HCPCS C1713 636853 - SPACER 636853 PERIMETER XS 8X15X13MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636932 SUP HCPCS C1713 636932 - SPACER 636932 PERIMETER XS 9X13X12MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 636953 SUP HCPCS C1713 636953 - SPACER SPNL XS 15X13X9MM PRIMTR PEEK-OPTM LMBR INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-75 SUP Custom 27803010 06-3675 - HEAD FEM +7.5MM OFST CTPR 36MM STRL LFIT ANTM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 650038 SUP Custom 27203010 CONTROL CHM LX SER LVL 1 2 HBA1C SYN VIGIL BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 653050 SUP HCPCS C1762 653050 - GRAFT BONE SHORT 5X2.5CM DEMINERALIZED BONE MATRIX BOTH IP/OP "$6,800.00 " "$5,032.00" $0.00 "$5,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,417.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,417.12" $0.00 "$3,352.40" "$3,352.40" $0.00 "$3,400.00" "$5,385.60" "$5,440.00" $0.00 $0.00 "$1,064.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 653100 SUP HCPCS C1762 653100 - GRAFT BONE BIO BOAT ALLOGRAFT DEMINERALIZED BONE MATRIX 20ML BOTH IP/OP "$10,975.00 " "$8,121.50" $0.00 "$8,780.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,287.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,287.19" $0.00 "$5,410.68" "$5,410.68" $0.00 "$5,487.50" "$8,692.20" "$8,780.00" $0.00 $0.00 "$1,717.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-97 SUP Custom 27803010 06-3697 - HEAD FEMORAL C TAPER LOW FRICTION HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-99 SUP Custom 27803010 06-3699 - HEAD FEMORAL -5 36MM C TAPER ANATOMIC LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663940 SUP Custom 27203010 CALIBRATOR MLANLT IMMAGE ARY 1ML IMMUN BOTH IP/OP $543.75 $402.38 $0.00 $435.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.88 $430.65 $435.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665040 SUP Custom 27803010 665040 - ROD SPINAL 6MM 40MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665050 SUP Custom 27803010 665050 - ROD SPINAL 6MM 50MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665060 SUP Custom 27803010 665060 - ROD SPINAL 6MM 60MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665070 SUP Custom 27803010 665070 - ROD SPINAL 6MM 70MM UNION TRIO THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665080 SUP Custom 27803010 665080 - ROD SPINAL 6MM 80MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665090 SUP Custom 27803010 665090 - ROD SPINAL 6MM 90MM UNION TRIO THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665100 SUP Custom 27803010 665100 - ROD SPINAL 6MM 100MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665110 SUP Custom 27803010 665110 - ROD SPINAL 6MM 110MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665120 SUP Custom 27803010 665120 - ROD SPINAL 6MM 120MM UNION DIAPASON OSS TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665130 SUP Custom 27803010 665130 - ROD SPINAL 6MM 130MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665140 SUP Custom 27803010 665140 - ROD SPINAL 6MM 140MM UNION TOP LOADING TRIO THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665150 SUP Custom 27803010 665150 - ROD SPINAL 6MM 150MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665160 SUP Custom 27803010 665160 - ROD SPINAL 6MM 160MM UNION DIAPASON OSS TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665170 SUP Custom 27803010 665170 - ROD SPINAL 6MM 170MM UNION DIAPASON TITANIUM THORACOLUMBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665180 SUP Custom 27803010 665180 - ROD SPINAL 6MM 180MM UNION DIAPASON OSS TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665190 SUP Custom 27803010 665190 - ROD SPINAL 190MM UNION DIAPASON TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665200 SUP Custom 27803010 665200 - ROD SPINAL 6MM 200MM UNION DIAPASON TITANIUM PEDICLE BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665210 SUP Custom 27803010 665210 - ROD SPINAL 210MM UNION DIAPASON OSS TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665250 SUP Custom 27803010 665250 - ROD SPINAL 250MM UNION DIAPASON OSS TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665270 SUP Custom 27803010 665270 - ROD SPINAL 270MM UNION DIAPASON OSS TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665300 SUP Custom 27803010 665300 - ROD SPINAL 300MM UNION DIAPASON OSS TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665350 SUP Custom 27803010 665350 - ROD SPINAL 6MM 350MM UNION TRIO THORACOLUMBAR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665400 SUP Custom 27803010 665400 - ROD SPINAL 6MM 400MM UNION DIAPASON TITANIUM PEDICLE BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 665480 SUP Custom 27803010 665480 - ROD SPINAL 6MM 480MM UNION DIAPASON TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 670001 SUP HCPCS C1713 670001 - SCREW BONE 6.7MM 35MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670002 SUP HCPCS C1713 670002 - SCREW BONE 6.7MM 40MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670003 SUP HCPCS C1713 670003 - SCREW BONE 6.7MM 45MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670004 SUP HCPCS C1713 670004 - SCREW BONE 6.5MM 50MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670005 SUP HCPCS C1713 670005 - SCREW BONE 7.5MM 35MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670006 SUP HCPCS C1713 670006 - SCREW BONE 7.5MM 40MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670007 SUP HCPCS C1713 670007 - SCREW BONE 7.5MM 45MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670008 SUP HCPCS C1713 670008 - SCREW BONE 7.5MM 50MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670009 SUP HCPCS C1713 670009 - SCREW BONE 7.5MM 55MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670015 SUP HCPCS C1713 670015 - SCREW BONE 6.5MM 55MM OPUS SPNL CYLND BOTH IP/OP "$1,505.15 " "$1,113.81" $0.00 "$1,204.12" $677.32 $677.32 $0.00 $0.00 $0.00 $313.71 "$1,117.12" "$1,117.12" $0.00 $0.00 $313.67 $0.00 $890.30 $890.30 $0.00 $752.58 "$1,192.08" "$1,204.12" $0.00 $0.00 $235.56 $0.00 $0.00 $239.62 $0.00 $0.00 $0.00 $0.00 $0.00 670062 SUP HCPCS C1713 670062 - SCREW BONE 5.5MM 35MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670063 SUP HCPCS C1713 670063 - SCREW BONE 5.5MM 40MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670071 SUP HCPCS C1713 670071 - SCREW BONE 6.5MM 35MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670072 SUP HCPCS C1713 670072 - SCREW BONE 6.5MM 40MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670073 SUP HCPCS C1713 670073 - SCREW BONE 6.5MM 45MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,644.45 " "$1,216.89" $0.00 "$1,315.56" $740.00 $740.00 $0.00 $0.00 $0.00 $342.74 "$1,220.51" "$1,220.51" $0.00 $0.00 $342.70 $0.00 $972.69 $972.69 $0.00 $822.23 "$1,302.40" "$1,315.56" $0.00 $0.00 $257.36 $0.00 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 670074 SUP HCPCS C1713 670074 - SCREW BONE 6.5MM 50MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670075 SUP HCPCS C1713 670075 - SCREW BONE 6.5MM 55MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670081 SUP HCPCS C1713 670081 - SCREW BONE 7.5MM 35MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670082 SUP HCPCS C1713 670082 - SCREW BONE 7.5MM 40MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670083 SUP HCPCS C1713 670083 - SCREW BONE 7.5MM 45MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670084 SUP HCPCS C1713 670084 - SCREW BONE 7.5MM 50MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670086 SUP HCPCS C1713 670086 - SCREW BONE 7.5MM 55MM OPUS LNG SPNL HEX CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670102 SUP HCPCS C1713 670102 - SCREW BONE 8MM 40MM OPUS SPNL CONICAL BOTH IP/OP "$1,026.65 " $759.72 $0.00 $821.32 $461.99 $461.99 $0.00 $0.00 $0.00 $213.98 $761.98 $761.98 $0.00 $0.00 $213.95 $0.00 $607.26 $607.26 $0.00 $513.33 $813.11 $821.32 $0.00 $0.00 $160.67 $0.00 $0.00 $163.44 $0.00 $0.00 $0.00 $0.00 $0.00 670103 SUP HCPCS C1713 670103 - SCREW BONE 8MM 45MM OPUS SPNL CONICAL BOTH IP/OP "$1,026.65 " $759.72 $0.00 $821.32 $461.99 $461.99 $0.00 $0.00 $0.00 $213.98 $761.98 $761.98 $0.00 $0.00 $213.95 $0.00 $607.26 $607.26 $0.00 $513.33 $813.11 $821.32 $0.00 $0.00 $160.67 $0.00 $0.00 $163.44 $0.00 $0.00 $0.00 $0.00 $0.00 670111 SUP HCPCS C1713 670111 - SCREW BONE 9MM 35MM OPUS SPNL CONICAL BOTH IP/OP "$1,062.58 " $786.31 $0.00 $850.06 $478.16 $478.16 $0.00 $0.00 $0.00 $221.47 $788.64 $788.64 $0.00 $0.00 $221.44 $0.00 $628.51 $628.51 $0.00 $531.29 $841.56 $850.06 $0.00 $0.00 $166.29 $0.00 $0.00 $169.16 $0.00 $0.00 $0.00 $0.00 $0.00 670112 SUP HCPCS C1713 670112 - SCREW BONE 9MM 40MM OPUS SPNL CONICAL BOTH IP/OP "$1,062.58 " $786.31 $0.00 $850.06 $478.16 $478.16 $0.00 $0.00 $0.00 $221.47 $788.64 $788.64 $0.00 $0.00 $221.44 $0.00 $628.51 $628.51 $0.00 $531.29 $841.56 $850.06 $0.00 $0.00 $166.29 $0.00 $0.00 $169.16 $0.00 $0.00 $0.00 $0.00 $0.00 670113 SUP HCPCS C1713 670113 - SCREW BONE 9MM 45MM OPUS SPNL CONICAL BOTH IP/OP "$1,062.58 " $786.31 $0.00 $850.06 $478.16 $478.16 $0.00 $0.00 $0.00 $221.47 $788.64 $788.64 $0.00 $0.00 $221.44 $0.00 $628.51 $628.51 $0.00 $531.29 $841.56 $850.06 $0.00 $0.00 $166.29 $0.00 $0.00 $169.16 $0.00 $0.00 $0.00 $0.00 $0.00 670114 SUP HCPCS C1713 670114 - SCREW BONE 9MM 50MM OPUS SPNL CONICAL BOTH IP/OP "$1,062.58 " $786.31 $0.00 $850.06 $478.16 $478.16 $0.00 $0.00 $0.00 $221.47 $788.64 $788.64 $0.00 $0.00 $221.44 $0.00 $628.51 $628.51 $0.00 $531.29 $841.56 $850.06 $0.00 $0.00 $166.29 $0.00 $0.00 $169.16 $0.00 $0.00 $0.00 $0.00 $0.00 670115 SUP HCPCS C1713 670115 - SCREW BONE 9MM 55MM OPUS SPNL CONICAL BOTH IP/OP "$1,062.58 " $786.31 $0.00 $850.06 $478.16 $478.16 $0.00 $0.00 $0.00 $221.47 $788.64 $788.64 $0.00 $0.00 $221.44 $0.00 $628.51 $628.51 $0.00 $531.29 $841.56 $850.06 $0.00 $0.00 $166.29 $0.00 $0.00 $169.16 $0.00 $0.00 $0.00 $0.00 $0.00 670213 SUP HCPCS C1713 670213 - SCREW BONE 5.5MM 35MM OPUS SPNL SGTL DUAL CUT BOTH IP/OP "$1,505.15 " "$1,113.81" $0.00 "$1,204.12" $677.32 $677.32 $0.00 $0.00 $0.00 $313.71 "$1,117.12" "$1,117.12" $0.00 $0.00 $313.67 $0.00 $890.30 $890.30 $0.00 $752.58 "$1,192.08" "$1,204.12" $0.00 $0.00 $235.56 $0.00 $0.00 $239.62 $0.00 $0.00 $0.00 $0.00 $0.00 670214 SUP HCPCS C1713 670214 - SCREW BONE 5.5MM 40MM OPUS SPNL CONICAL BOTH IP/OP "$1,675.90 " "$1,240.17" $0.00 "$1,340.72" $754.16 $754.16 $0.00 $0.00 $0.00 $349.30 "$1,243.85" "$1,243.85" $0.00 $0.00 $349.26 $0.00 $991.29 $991.29 $0.00 $837.95 "$1,327.31" "$1,340.72" $0.00 $0.00 $262.28 $0.00 $0.00 $266.80 $0.00 $0.00 $0.00 $0.00 $0.00 670221 SUP HCPCS C1713 670221 - PLATE LNG 35MM 2 HOLE OPUS BONE SPNL BOTH IP/OP "$2,619.45 " "$1,938.39" $0.00 "$2,095.56" "$1,178.75" "$1,178.75" $0.00 $0.00 $0.00 $545.96 "$1,944.16" "$1,944.16" $0.00 $0.00 $545.89 $0.00 "$1,291.39" "$1,291.39" $0.00 "$1,309.73" "$2,074.60" "$2,095.56" $0.00 $0.00 $409.94 $0.00 $0.00 $417.02 $0.00 $0.00 $0.00 $0.00 $0.00 670222 SUP HCPCS C1713 670222 - PLATE SHRT 2 HOLE OPUS BONE SPNL BOTH IP/OP "$2,619.45 " "$1,938.39" $0.00 "$2,095.56" "$1,178.75" "$1,178.75" $0.00 $0.00 $0.00 $545.96 "$1,944.16" "$1,944.16" $0.00 $0.00 $545.89 $0.00 "$1,291.39" "$1,291.39" $0.00 "$1,309.73" "$2,074.60" "$2,095.56" $0.00 $0.00 $409.94 $0.00 $0.00 $417.02 $0.00 $0.00 $0.00 $0.00 $0.00 670223 SUP HCPCS C1713 670223 - PLATE LNG 3 HOLE OPUS BONE SPNL BOTH IP/OP "$2,772.18 " "$2,051.41" $0.00 "$2,217.74" "$1,247.48" "$1,247.48" $0.00 $0.00 $0.00 $577.79 "$2,057.51" "$2,057.51" $0.00 $0.00 $577.72 $0.00 "$1,366.68" "$1,366.68" $0.00 "$1,386.09" "$2,195.57" "$2,217.74" $0.00 $0.00 $433.85 $0.00 $0.00 $441.33 $0.00 $0.00 $0.00 $0.00 $0.00 670224 SUP HCPCS C1713 670224 - PLATE 90MM OPUS BONE SPNL BOTH IP/OP "$2,621.70 " "$1,940.06" $0.00 "$2,097.36" "$1,179.77" "$1,179.77" $0.00 $0.00 $0.00 $546.43 "$1,945.83" "$1,945.83" $0.00 $0.00 $546.36 $0.00 "$1,292.50" "$1,292.50" $0.00 "$1,310.85" "$2,076.39" "$2,097.36" $0.00 $0.00 $410.30 $0.00 $0.00 $417.37 $0.00 $0.00 $0.00 $0.00 $0.00 670225 SUP HCPCS C1713 670225 - PLATE 105MM OPUS BONE SPNL BOTH IP/OP "$2,495.88 " "$1,846.95" $0.00 "$1,996.70" "$1,123.14" "$1,123.14" $0.00 $0.00 $0.00 $520.20 "$1,852.44" "$1,852.44" $0.00 $0.00 $520.14 $0.00 "$1,476.31" "$1,476.31" $0.00 "$1,247.94" "$1,976.74" "$1,996.70" $0.00 $0.00 $390.60 $0.00 $0.00 $397.34 $0.00 $0.00 $0.00 $0.00 $0.00 670226 SUP HCPCS C1713 670226 - PLATE 120MM OPUS BONE SPNL BOTH IP/OP "$2,495.88 " "$1,846.95" $0.00 "$1,996.70" "$1,123.14" "$1,123.14" $0.00 $0.00 $0.00 $520.20 "$1,852.44" "$1,852.44" $0.00 $0.00 $520.14 $0.00 "$1,476.31" "$1,476.31" $0.00 "$1,247.94" "$1,976.74" "$1,996.70" $0.00 $0.00 $390.60 $0.00 $0.00 $397.34 $0.00 $0.00 $0.00 $0.00 $0.00 670282 SUP Custom 27803010 670282 - CONCTR ROD 35MM 5.5MM OPUS LONGTOP SPNL BOTH IP/OP "$1,121.03 " $829.56 $0.00 $896.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $832.02 $832.02 $0.00 $0.00 $233.62 $0.00 $0.00 $0.00 $0.00 $560.51 $887.86 $896.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 670283 SUP Custom 27803010 670283 - CONCTR ROD 40MM 5.5MM OPUS LONGTOP SPNL BOTH IP/OP "$1,121.03 " $829.56 $0.00 $896.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $832.02 $832.02 $0.00 $0.00 $233.62 $0.00 $0.00 $0.00 $0.00 $560.51 $887.86 $896.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 670301 SUP HCPCS C1713 670301 - SCREW BONE 6.5MM 35MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670302 SUP HCPCS C1713 670302 - SCREW BONE 6.5MM 40MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670303 SUP HCPCS C1713 670303 - SCREW BONE 6.5MM 45MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,644.45 " "$1,216.89" $0.00 "$1,315.56" $740.00 $740.00 $0.00 $0.00 $0.00 $342.74 "$1,220.51" "$1,220.51" $0.00 $0.00 $342.70 $0.00 $972.69 $972.69 $0.00 $822.23 "$1,302.40" "$1,315.56" $0.00 $0.00 $257.36 $0.00 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 670304 SUP HCPCS C1713 670304 - SCREW BONE 6.5MM 50MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670305 SUP HCPCS C1713 670305 - SCREW BONE 6.5MM 55MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670311 SUP HCPCS C1713 670311 - SCREW BONE 7.5MM 35MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670312 SUP HCPCS C1713 670312 - SCREW BONE 7.5MM 40MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670313 SUP HCPCS C1713 670313 - SCREW BONE 7.5MM 45MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670314 SUP HCPCS C1713 670314 - SCREW BONE 7.5MM 50MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670315 SUP HCPCS C1713 670315 - SCREW BONE 7.5MM 55MM OPUS SPNL LNG TOP CONICAL BOTH IP/OP "$1,565.80 " "$1,158.69" $0.00 "$1,252.64" $704.61 $704.61 $0.00 $0.00 $0.00 $326.35 "$1,162.14" "$1,162.14" $0.00 $0.00 $326.31 $0.00 $926.17 $926.17 $0.00 $782.90 "$1,240.11" "$1,252.64" $0.00 $0.00 $245.05 $0.00 $0.00 $249.28 $0.00 $0.00 $0.00 $0.00 $0.00 670371 SUP HCPCS C1713 670371 - SCREW BONE 6.5MM 35MM OPUS SPNL LNG TOP LNG HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670372 SUP HCPCS C1713 670372 - SCREW BONE 6.5MM 40MM OPUS SPNL LNG TOP LNG HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670373 SUP HCPCS C1713 670373 - SCREW BONE 6.5MM 45MM OPUS SPNL LNG TOP LNG HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670374 SUP HCPCS C1713 670374 - SCREW BONE 6.5MM 50MM OPUS SPNL LNG TOP LNG HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670381 SUP HCPCS C1713 670381 - SCREW BONE 7.5MM 35MM OPUS SPNL LNG TOP LNG HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670382 SUP HCPCS C1713 670382 - SCREW BONE 7.5MM 40MM OPUS SPNL LNG TOP LNG HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670383 SUP HCPCS C1713 670383 - SCREW BONE 7.5MM 45MM OPUS SPNL LNG TOP LNG HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670384 SUP HCPCS C1713 670384 - SCREW BONE 7.5MM 50MM OPUS SPNL LNG TOP LNG HEX CONICAL BOTH IP/OP "$1,073.85 " $794.65 $0.00 $859.08 $483.23 $483.23 $0.00 $0.00 $0.00 $223.82 $797.01 $797.01 $0.00 $0.00 $223.79 $0.00 $635.18 $635.18 $0.00 $536.93 $850.49 $859.08 $0.00 $0.00 $168.06 $0.00 $0.00 $170.96 $0.00 $0.00 $0.00 $0.00 $0.00 670501 SUP HCPCS C1713 670501 - OPUS WASHER BOTH IP/OP $141.55 $104.75 $0.00 $113.24 $63.70 $63.70 $0.00 $0.00 $0.00 $29.50 $105.06 $105.06 $0.00 $0.00 $29.50 $0.00 $83.73 $83.73 $0.00 $70.78 $112.11 $113.24 $0.00 $0.00 $22.15 $0.00 $0.00 $22.53 $0.00 $0.00 $0.00 $0.00 $0.00 670504 SUP HCPCS C1713 670504 - OPUS PLATE NUT BOTH IP/OP $141.55 $104.75 $0.00 $113.24 $63.70 $63.70 $0.00 $0.00 $0.00 $29.50 $105.06 $105.06 $0.00 $0.00 $29.50 $0.00 $83.73 $83.73 $0.00 $70.78 $112.11 $113.24 $0.00 $0.00 $22.15 $0.00 $0.00 $22.53 $0.00 $0.00 $0.00 $0.00 $0.00 670600 SUP Custom 27803010 670600 - CONCTR ROD OPUS SPNL BOTH IP/OP "$1,062.58 " $786.31 $0.00 $850.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.64 $788.64 $0.00 $0.00 $221.44 $0.00 $0.00 $0.00 $0.00 $531.29 $841.56 $850.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 670604 SUP HCPCS C1713 670604 - OPUS ROD NUT BOTH IP/OP $199.95 $147.96 $0.00 $159.96 $89.98 $89.98 $0.00 $0.00 $0.00 $41.67 $148.40 $148.40 $0.00 $0.00 $41.67 $0.00 $118.27 $118.27 $0.00 $99.98 $158.36 $159.96 $0.00 $0.00 $31.29 $0.00 $0.00 $31.83 $0.00 $0.00 $0.00 $0.00 $0.00 670610 SUP Custom 27803010 670610 - CONCTR ROD OPUS OFFST SPNL BOTH IP/OP "$1,251.28 " $925.95 $0.00 "$1,001.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $928.70 $928.70 $0.00 $0.00 $260.77 $0.00 $0.00 $0.00 $0.00 $625.64 $991.01 "$1,001.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671040 SUP Custom 27803010 671040 - ROD SPNL 40MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671050 SUP Custom 27803010 671050 - ROD SPNL 50MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671060 SUP Custom 27803010 671060 - ROD SPNL 60MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671070 SUP Custom 27803010 671070 - ROD SPNL 70MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671080 SUP Custom 27803010 671080 - ROD SPNL 80MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671090 SUP Custom 27803010 671090 - ROD SPNL 90MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671100 SUP Custom 27803010 671100 - ROD SPNL 100MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671110 SUP Custom 27803010 671110 - ROD SPNL 110MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671120 SUP Custom 27803010 671120 - ROD SPNL 120MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671140 SUP Custom 27803010 671140 - ROD SPNL 140MM OPUS BOTH IP/OP $458.30 $339.14 $0.00 $366.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.15 $340.15 $0.00 $0.00 $95.51 $0.00 $0.00 $0.00 $0.00 $229.15 $362.97 $366.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671150 SUP Custom 27803010 671150 - ROD SPNL 150MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671180 SUP Custom 27803010 671180 - ROD SPNL 180MM OPUS BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671190 SUP Custom 27803010 671190 - ROD SPNL 190MM OPUS TI BOTH IP/OP $707.65 $523.66 $0.00 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.22 $525.22 $0.00 $0.00 $147.47 $0.00 $0.00 $0.00 $0.00 $353.83 $560.46 $566.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671210 SUP Custom 27803010 671210 - ROD SPNL 210MM OPUS BOTH IP/OP $669.48 $495.42 $0.00 $535.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $496.88 $496.88 $0.00 $0.00 $139.52 $0.00 $0.00 $0.00 $0.00 $334.74 $530.23 $535.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671240 SUP Custom 27803010 671240 - ROD SPNL 240MM OPUS BOTH IP/OP $638.03 $472.14 $0.00 $510.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $473.54 $473.54 $0.00 $0.00 $132.96 $0.00 $0.00 $0.00 $0.00 $319.01 $505.32 $510.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671270 SUP Custom 27803010 671270 - ROD SPNL 270MM OPUS BOTH IP/OP $638.03 $472.14 $0.00 $510.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $473.54 $473.54 $0.00 $0.00 $132.96 $0.00 $0.00 $0.00 $0.00 $319.01 $505.32 $510.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671300 SUP Custom 27803010 671300 - ROD SPNL 300MM OPUS BOTH IP/OP $638.03 $472.14 $0.00 $510.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $473.54 $473.54 $0.00 $0.00 $132.96 $0.00 $0.00 $0.00 $0.00 $319.01 $505.32 $510.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 671600 SUP Custom 27803010 671600 - ROD SPNL 600MM OPUS BOTH IP/OP $435.83 $322.51 $0.00 $348.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $323.47 $323.47 $0.00 $0.00 $90.83 $0.00 $0.00 $0.00 $0.00 $217.91 $345.18 $348.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 695305 SUP Custom 27803010 695305 - CONCTR ROD DIAPASON OSS OFFST SPNL BOTH IP/OP $660.48 $488.76 $0.00 $528.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $490.20 $490.20 $0.00 $0.00 $137.64 $0.00 $0.00 $0.00 $0.00 $330.24 $523.10 $528.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700351 SUP Custom 27203010 700351 - BIT DRILL 180MM 2.5MM CLBRT AO FIT STRL BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $0.00 $0.00 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700353 SUP Custom 27203010 700353 - BIT DRILL 195MM 3.5MM SPS TWST CLBRT AO FIT NONSTRL BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $0.00 $0.00 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700354 SUP Custom 27203010 700354 - DRILL TWST LNG 4.5MM 195MM STRL AO FIT BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $0.00 $0.00 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700355 SUP Custom 27203010 700355 - BIT DRILL 230MM 2.5MM SPS TWST CLBRT AO FIT NONSTRL BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $0.00 $0.00 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700356 SUP Custom 27203010 700356 - BIT DRILL 180MM 3.2MM CLBRT AO FIT NONSTRL BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $0.00 $0.00 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700357 SUP Custom 27203010 700357 - BIT DRILL 230MM 3.2MM AXSOS STD TWST CLBRT AO FIT STRL BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $0.00 $0.00 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700371 SUP Custom 27203010 700371 - BIT DRILL 2MM TWST AO FIT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700373 SUP Custom 27203010 700373 - BIT DRL 2.7MM OSTN TWST AO FIT BOTH IP/OP $196.63 $145.51 $0.00 $157.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.94 $145.94 $0.00 $0.00 $40.98 $0.00 $0.00 $0.00 $0.00 $98.31 $155.73 $157.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700374 SUP Custom 27203010 700374 - 3.2MM AO FIT.TWIST DRILL BIT BOTH IP/OP $162.25 $120.07 $0.00 $129.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.42 $120.42 $0.00 $0.00 $33.81 $0.00 $0.00 $0.00 $0.00 $81.13 $128.50 $129.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700375 SUP Custom 27203010 700375 - BIT DRILL 3.5MM TWST AO FIT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700436 SUP Custom 27203010 700436 - TAP SRG OD2.7 MM CORT SCR BOTH IP/OP $178.75 $132.28 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $0.00 $0.00 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700438 SUP Custom 27203010 700438 - TAP SRG OD4.5 MM CANC SCR BOTH IP/OP $178.75 $132.28 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $0.00 $0.00 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700443 SUP Custom 27203010 700443 - TAP SRG OSTEO FIT OD4.5 MM SCR BOTH IP/OP $342.38 $253.36 $0.00 $273.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.11 $254.11 $0.00 $0.00 $71.35 $0.00 $0.00 $0.00 $0.00 $171.19 $271.16 $273.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700447 SUP Custom 27203010 700447 - TAP FIT SURG 6.5 MM SCR BOTH IP/OP $515.63 $381.57 $0.00 $412.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.70 $382.70 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $257.81 $408.38 $412.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700448 SUP Custom 27203010 700448 - TAP FIT SURG 6.5 MM SCR BOTH IP/OP $618.75 $457.88 $0.00 $495.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $459.24 $459.24 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700708 SUP Custom 27203010 700708 - TAP LAG SCR SURG HIP OHS BOTH IP/OP "$2,014.38 " "$1,490.64" $0.00 "$1,611.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.07" "$1,495.07" $0.00 $0.00 $419.80 $0.00 $0.00 $0.00 $0.00 "$1,007.19" "$1,595.39" "$1,611.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 700721 SUP Custom 27203010 700721 - TAP SURG OCS LAG SCR BOTH IP/OP "$1,560.63 " "$1,154.87" $0.00 "$1,248.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,158.30" "$1,158.30" $0.00 $0.00 $325.23 $0.00 $0.00 $0.00 $0.00 $780.31 "$1,236.02" "$1,248.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702346 SUP Custom 27203010 702346 - BIT DRL 3.5MM BOTH IP/OP $243.38 $180.10 $0.00 $194.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.63 $180.63 $0.00 $0.00 $50.72 $0.00 $0.00 $0.00 $0.00 $121.69 $192.76 $194.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702347 SUP Custom 27203010 702347 - BIT DRILL 220MM 5MM TWST AO FIT STRL BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.45 $171.45 $0.00 $0.00 $48.14 $0.00 $0.00 $0.00 $0.00 $115.50 $182.95 $184.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702348 SUP Custom 27203010 702348 - DRILL TWST 1.5MM 3.5MM AO FIT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702350 SUP Custom 27203010 702350 - BIT DRILL 235MM 4.2MM STRL BOTH IP/OP $243.38 $180.10 $0.00 $194.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.63 $180.63 $0.00 $0.00 $50.72 $0.00 $0.00 $0.00 $0.00 $121.69 $192.76 $194.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702446 SUP Custom 27203010 702446 - DRILL SRG 4MM NS CNN AO CPLNG TWST BOTH IP/OP $507.45 $375.51 $0.00 $410.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $376.63 $376.63 $0.00 $0.00 $105.75 $0.00 $0.00 $0.00 $0.00 $256.44 $406.20 $410.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702447 SUP Custom 27203010 702447 - BIT DRILL 5MM CANN TWST AO BOTH IP/OP $551.38 $408.02 $0.00 $441.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $409.23 $409.23 $0.00 $0.00 $114.91 $0.00 $0.00 $0.00 $0.00 $275.69 $436.69 $441.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702448 SUP Custom 27203010 702448 - BIT DRILL 150MM 1.4MM NONSTRL DISP BOTH IP/OP $305.25 $225.89 $0.00 $244.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $226.56 $226.56 $0.00 $0.00 $63.61 $0.00 $0.00 $0.00 $0.00 $152.63 $241.76 $244.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702453 SUP Custom 27203010 702453 - BIT DRILL 150MM 2MM ASNS CANN STRL BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $0.00 $0.00 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702459 SUP HCPCS C1769 702459 - GWIRE ORTH 150MM 1.4MM ASNS 3 FEM HIP THRD STRL BOTH IP/OP $109.50 $81.03 $0.00 $81.27 $34.34 $34.34 $0.00 $0.00 $0.00 $22.82 $81.27 $81.27 $0.00 $0.00 $22.82 $0.00 $64.77 $64.77 $0.00 $31.63 $50.09 $50.60 $0.00 $0.00 $9.90 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 702460 SUP HCPCS C1769 702460 - GWIRE ORTH 150MM 2MM ASNS 3 FEM HIP THRD 5MM NONSTRL DISP BOTH IP/OP $109.50 $81.03 $0.00 $81.27 $33.60 $33.60 $0.00 $0.00 $0.00 $22.82 $81.27 $81.27 $0.00 $0.00 $22.82 $0.00 $64.77 $64.77 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 702461 SUP HCPCS C1769 702461 - GWIRE ORTH 300MM 3MM ASNS 3 FEM HIP THRD DISP BOTH IP/OP $61.88 $45.79 $0.00 $49.50 $33.60 $33.60 $0.00 $0.00 $0.00 $12.90 $45.92 $45.92 $0.00 $0.00 $12.89 $0.00 $36.60 $36.60 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 702462 SUP HCPCS C1769 702462 - GWIRE ORTH 300MM 3.2MM ASNS 3 FEM HIP THRD CANN SCR SYS STRL BOTH IP/OP $75.63 $55.97 $0.00 $60.50 $41.06 $41.06 $0.00 $0.00 $0.00 $15.76 $56.13 $56.13 $0.00 $0.00 $15.76 $0.00 $44.73 $44.73 $0.00 $37.81 $59.90 $60.50 $0.00 $0.00 $11.84 $0.00 $0.00 $12.04 $0.00 $0.00 $0.00 $0.00 $0.00 702463 SUP HCPCS C1769 702463 - GWIRE ORTH 300MM 3.2MM ASNS 3 FEM HIP THRD 5MM STRL DISP BOTH IP/OP $75.63 $55.97 $0.00 $60.50 $41.06 $41.06 $0.00 $0.00 $0.00 $15.76 $56.13 $56.13 $0.00 $0.00 $15.76 $0.00 $44.73 $44.73 $0.00 $37.81 $59.90 $60.50 $0.00 $0.00 $11.84 $0.00 $0.00 $12.04 $0.00 $0.00 $0.00 $0.00 $0.00 702739 SUP Custom 27203010 702739 - BIT DRL 4MM 180MM AO FIT BOTH IP/OP $728.75 $539.28 $0.00 $583.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $540.88 $540.88 $0.00 $0.00 $151.87 $0.00 $0.00 $0.00 $0.00 $364.38 $577.17 $583.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702741 SUP Custom 27203010 702741 - BIT DRILL 125MM 2.3MM AXSOS CLBRT NONSTRL BOTH IP/OP $174.63 $129.23 $0.00 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.61 $129.61 $0.00 $0.00 $36.39 $0.00 $0.00 $0.00 $0.00 $87.31 $138.31 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702742 SUP Custom 27203010 702742 - BIT DRILL 289MM 4.3MM AXSOS CLBRT NONSTRL BOTH IP/OP $205.50 $152.07 $0.00 $152.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.52 $152.52 $0.00 $0.00 $42.83 $0.00 $0.00 $0.00 $0.00 $83.88 $132.86 $134.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702743 SUP Custom 27203010 702743 - BIT DRILL 289MM 4.3MM AXSOS CLBRT STRL BOTH IP/OP $222.75 $164.84 $0.00 $171.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $0.00 $0.00 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702771 SUP Custom 27803010 702771 - TAP 3MM 130MM SURG BOTH IP/OP $172.55 $127.69 $0.00 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.07 $128.07 $0.00 $0.00 $35.96 $0.00 $0.00 $0.00 $0.00 $87.31 $138.31 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702772 SUP Custom 27803010 702772 - TAP 4MM 140MM LCK SURG BOTH IP/OP $207.63 $153.65 $0.00 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.10 $154.10 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $103.81 $164.44 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702773 SUP Custom 27803010 702773 - TAP 5MM 140MM LCK SURG AXSOS BOTH IP/OP $236.50 $175.01 $0.00 $189.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.53 $175.53 $0.00 $0.00 $49.29 $0.00 $0.00 $0.00 $0.00 $118.25 $187.31 $189.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702804 SUP Custom 27803010 702804 - TAP 3.5MM SURG AXSOS BOTH IP/OP $642.00 $475.08 $0.00 $476.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $476.49 $476.49 $0.00 $0.00 $133.79 $0.00 $0.00 $0.00 $0.00 $140.25 $222.16 $224.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702806 SUP Custom 27803010 702806 - TAP 4.5MM 180MM AO FIT SURG BOTH IP/OP $730.50 $540.57 $0.00 $542.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $542.18 $542.18 $0.00 $0.00 $152.24 $0.00 $0.00 $0.00 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702807 SUP Custom 27803010 702807 - TAP 6.5MM 180MM AO FIT SURG CORT BOTH IP/OP $819.00 $606.06 $0.00 $607.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.86 $607.86 $0.00 $0.00 $170.68 $0.00 $0.00 $0.00 $0.00 $140.25 $222.16 $224.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702808 SUP Custom 27803010 702808 - TAP 4.5MM SHRT 145MM AO FIT SURG CORT BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702809 SUP Custom 27803010 702809 - TAP 6.5MM SHRT 145MM AO FIT SURG CANC BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $0.00 $0.00 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702930 SUP Custom 27203010 702930 - FORCEP SURG PLVC REPST 2X1 JAW BOTH IP/OP "$2,457.13 " "$1,818.28" $0.00 "$1,965.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,823.68" "$1,823.68" $0.00 $0.00 $512.06 $0.00 $0.00 $0.00 $0.00 "$1,228.56" "$1,946.05" "$1,965.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702996 SUP Custom 27203010 702996 - BIT DRL 2.5MM 285MM AO CLBRT BOTH IP/OP $152.63 $112.95 $0.00 $122.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.28 $113.28 $0.00 $0.00 $31.81 $0.00 $0.00 $0.00 $0.00 $76.31 $120.88 $122.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702997 SUP Custom 27203010 702997 - BIT DRILL 285MM 3.1MM CLBRT BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $0.00 $0.00 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703176 SUP Custom 27203010 703176 - BIT DRILL 325MM 4.2MM AO STRL BOTH IP/OP $243.38 $180.10 $0.00 $194.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.63 $180.63 $0.00 $0.00 $50.72 $0.00 $0.00 $0.00 $0.00 $121.69 $192.76 $194.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703178 SUP Custom 27203010 703178 - BIT DRILL 4.2MM TROCAR PNT AO STRL BOTH IP/OP $243.38 $180.10 $0.00 $194.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.63 $180.63 $0.00 $0.00 $50.72 $0.00 $0.00 $0.00 $0.00 $121.69 $192.76 $194.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703541 SUP Custom 27203010 703541 - BIT DRILL 310MM 4.3MM CLBRT AO FIT BOTH IP/OP $331.38 $245.22 $0.00 $265.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $245.95 $245.95 $0.00 $0.00 $69.06 $0.00 $0.00 $0.00 $0.00 $165.69 $262.45 $265.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703542 SUP Custom 27203010 703542 - BIT DRILL 310MM 3.2MM CLBRT AO FIT BOTH IP/OP $320.38 $237.08 $0.00 $256.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.78 $237.78 $0.00 $0.00 $66.77 $0.00 $0.00 $0.00 $0.00 $160.19 $253.74 $256.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703543 SUP Custom 27203010 703543 - SET ORTH 4.5MM AO BOTH IP/OP $336.88 $249.29 $0.00 $269.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.03 $250.03 $0.00 $0.00 $70.20 $0.00 $0.00 $0.00 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703551 SUP Custom 27803010 703551 - TAP 4.5MM 295MM AO FIT SURG CORT AXSOS BOTH IP/OP $475.75 $352.06 $0.00 $380.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $353.10 $353.10 $0.00 $0.00 $99.15 $0.00 $0.00 $0.00 $0.00 $237.88 $376.79 $380.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703553 SUP Custom 27803010 703553 - TAP 6.5MM 295MM AO FIT SURG CANC AXSOS BOTH IP/OP $490.45 $362.93 $0.00 $392.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $364.01 $364.01 $0.00 $0.00 $102.21 $0.00 $0.00 $0.00 $0.00 $245.44 $388.78 $392.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703554 SUP Custom 27803010 703554 - TAP 5MM 295MM LCK SURG BOTH IP/OP $489.50 $362.23 $0.00 $391.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $363.31 $363.31 $0.00 $0.00 $102.01 $0.00 $0.00 $0.00 $0.00 $244.75 $387.68 $391.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703561 SUP HCPCS C1713 703561 - WIRE FX 2MM 315MM KRSH DRL TIP BOTH IP/OP $108.63 $80.39 $0.00 $86.90 $48.88 $48.88 $0.00 $0.00 $0.00 $22.64 $80.62 $80.62 $0.00 $0.00 $22.64 $0.00 $64.25 $64.25 $0.00 $54.31 $86.03 $86.90 $0.00 $0.00 $17.00 $0.00 $0.00 $17.29 $0.00 $0.00 $0.00 $0.00 $0.00 703574 SUP HCPCS C1713 703574 - TAP BN LCK SPHRCL TIP 4 MM SCR BOTH IP/OP $606.38 $448.72 $0.00 $485.10 $272.87 $272.87 $0.00 $0.00 $0.00 $126.38 $450.05 $450.05 $0.00 $0.00 $126.37 $0.00 $358.67 $358.67 $0.00 $303.19 $480.25 $485.10 $0.00 $0.00 $94.90 $0.00 $0.00 $96.53 $0.00 $0.00 $0.00 $0.00 $0.00 703583 SUP HCPCS C1713 703583 - WIRE FX 2MM 285MM KRSH DRL TIP BOTH IP/OP $167.45 $123.91 $0.00 $138.60 $77.96 $77.96 $0.00 $0.00 $0.00 $34.90 $124.28 $124.28 $0.00 $0.00 $34.90 $0.00 $99.05 $99.05 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $27.11 $0.00 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 703585 SUP Custom 27203010 703585 - BIT DRILL 3.1MM BOTH IP/OP $323.13 $239.12 $0.00 $258.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.82 $239.82 $0.00 $0.00 $67.34 $0.00 $0.00 $0.00 $0.00 $161.56 $255.92 $258.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703586 SUP Custom 27203010 703586 - BIT DRL 2.5MM CLBRT AO BOTH IP/OP $323.13 $239.12 $0.00 $258.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.82 $239.82 $0.00 $0.00 $67.34 $0.00 $0.00 $0.00 $0.00 $161.56 $255.92 $258.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703588 SUP Custom 27803010 703588 - TAP 3.5MM SURG CORT AXSOS BOTH IP/OP $575.45 $425.83 $0.00 $460.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.10 $427.10 $0.00 $0.00 $119.92 $0.00 $0.00 $0.00 $0.00 $288.06 $456.29 $460.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703589 SUP Custom 27803010 703589 - TAP SURG AXSOS 4 MM CANC SCR BOTH IP/OP $575.45 $425.83 $0.00 $460.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.10 $427.10 $0.00 $0.00 $119.92 $0.00 $0.00 $0.00 $0.00 $288.06 $456.29 $460.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703590 SUP Custom 27203010 703590 - DRILL SURG SM AO 3.5MM BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703615 SUP Custom 27203010 703615 - BIT DRL 4.3MM 264MM CLBRT BOTH IP/OP $277.50 $205.35 $0.00 $205.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703616 SUP Custom 27203010 703616 - BIT DRL 3.1MM 205MM CLBRT BOTH IP/OP $259.50 $192.03 $0.00 $192.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.60 $192.60 $0.00 $0.00 $54.08 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703617 SUP Custom 27203010 703617 - CALIBRATED DRILL BIT 03.1 X 285MM BOTH IP/OP $279.75 $207.02 $0.00 $207.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.63 $207.63 $0.00 $0.00 $58.30 $0.00 $0.00 $0.00 $0.00 $103.81 $164.44 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703618 SUP Custom 27203010 703618 - CALIBRATED DRILL BIT 04.3 X 315MM BOTH IP/OP $363.80 $269.21 $0.00 $311.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.01 $270.01 $0.00 $0.00 $75.82 $0.00 $0.00 $0.00 $0.00 $194.56 $308.19 $311.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703701 SUP Custom 27203010 703701 - DRILL SURG AO CONNECT 2MM 2.7MM SCR BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703702 SUP Custom 27203010 703702 - DRILL SURG AO CONNECT 2.6MM 3.5MM SCR BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703703 SUP Custom 27203010 703703 - DRILL SURG OVR AO CONNECT 2.7 MM SCR BOTH IP/OP $232.90 $172.35 $0.00 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.86 $172.86 $0.00 $0.00 $48.54 $0.00 $0.00 $0.00 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703704 SUP Custom 27203010 703704 - BIT DRL 3.5MM STRL DISP BOTH IP/OP $232.90 $172.35 $0.00 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.86 $172.86 $0.00 $0.00 $48.54 $0.00 $0.00 $0.00 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703705 SUP Custom 27803010 703705 - TAP AO CONNECT SURG VARIAX 2.7 MM SCR NONSTRL BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703706 SUP Custom 27803010 703706 - TAP AO CONNECT SURG 3.5 MM SCR BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 704501 SUP Custom 27203010 704501 - DRILL SURG SHRT 246MM CANN JCB FIT HANSSON ADLT 6.7MM BOTH IP/OP $680.63 $503.67 $0.00 $544.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.16 $505.16 $0.00 $0.00 $141.84 $0.00 $0.00 $0.00 $0.00 $340.31 $539.06 $544.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 704502 SUP Custom 27203010 704502 - DRILL SURG LNG 276MM CANN JCB FIT HANSSON ADLT 6.7MM BOTH IP/OP $680.63 $503.67 $0.00 $544.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.16 $505.16 $0.00 $0.00 $141.84 $0.00 $0.00 $0.00 $0.00 $340.31 $539.06 $544.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 711050 SUP Custom 27203010 00711050 - DEVICE SPECIMEN RETRIEVAL STANDARD 2.5MM 230CM 6X3CM STRONG BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $0.00 $0.00 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 712001 SUP Custom 27203010 712001 - CLIP PMP IRR MDNXT BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.91 $103.91 $0.00 $0.00 $29.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 714080 SUP Custom 27203010 REAGENT ANTI-LTTL C RH 4 BCLN 5ML MNCLN TUBE MCPLT BLOOD BOTH IP/OP $470.23 $347.97 $0.00 $376.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.11 $372.42 $376.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 719101 SUP Custom 27203010 REAGENT .8% RBC SRGSCRN 10ML AB SCRN BLOOD BANK BOTH IP/OP $80.35 $59.46 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.18 $63.64 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 721543 SUP Custom 27203010 REAGENT ANALY CLTR CLEAN SOL 10L LH SER BOTH IP/OP $106.15 $78.55 $0.00 $84.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.08 $84.07 $84.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 725230 SUP Custom 27203010 REAGENT ANTI-FY LTTL B BLOOD BANK BOTH IP/OP "$1,350.63 " $999.47 $0.00 "$1,080.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $675.31 "$1,069.70" "$1,080.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 732420 SUP HCPCS C1713 732420 - SCREW BN 2.4MM 20MM AU STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 733008 SUP HCPCS C1768 733008 - GRAFT CARDIO STR 8MM 30CM SUTURE RETENTION UNIQUE BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 733010 SUP HCPCS C1768 733010 - GRAFT CV STRG 10MM 30CM GLWV SUT RTNT UNQ HYDROLYZABLE GELTN BOTH IP/OP "$1,202.25 " $889.67 $0.00 $961.80 $541.01 $541.01 $0.00 $0.00 $0.00 $250.58 $892.31 $892.31 $0.00 $0.00 $250.55 $0.00 $711.13 $711.13 $0.00 $601.13 $952.18 $961.80 $0.00 $0.00 $188.15 $0.00 $0.00 $191.40 $0.00 $0.00 $0.00 $0.00 $0.00 733026 SUP HCPCS C1768 733026 - GRAFT CARDIO STR 26MM 30CM WOVEN VASCUTEK GELWEAVE THORAX BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 733028 SUP HCPCS C1768 733028 - GRAFT CARDIO STR 28MM 30CM SUTURE RETENTION UNIQUE BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 733030 SUP HCPCS C1768 733030 - GRAFT CARDIO STR 30MM 30CM SUTURE RETENTION UNIQUE BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 733032 SUP HCPCS C1768 733032 - GRAFT CARDIO STR 32MM 30CM SUTURE RETENTION UNIQUE BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 740026 SUP Custom 27203010 740026 - DEVICE PSTN STRL THE SEC AST 2 ADJ CLP BT FTBRD PLS KN DISP BOTH IP/OP $497.50 $368.15 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $369.24 $369.24 $0.00 $0.00 $103.68 $0.00 $0.00 $0.00 $0.00 $248.75 $394.02 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-00 SUP Custom 27803010 06-4000 - HEAD FEM +0MM OFST CTPR 40MM STRL LFIT ANTM COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-05 SUP Custom 27803010 06-4005 - HEAD FEM +5MM OFST CTPR 40MM STRL LFIT ANTM COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4010 SUP HCPCS C1713 03-11-4010 - SCREW BONE 4MM 10MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4010 SUP HCPCS C1713 03-12-4010 - SCREW BONE 4MM 10MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-10 SUP Custom 27803010 06-4010 - HEAD FEMORAL +10 40MM C TAPER ANATOMIC OFFST LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4011 SUP HCPCS C1713 03-11-4011 - SCREW BONE 4MM 11MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4011 SUP HCPCS C1713 03-12-4011 - SCREW BONE 4MM 11MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4012 SUP HCPCS C1713 03-11-4012 - SCREW BONE 4MM 12MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4012 SUP HCPCS C1713 03-12-4012 - SCREW BONE 4MM 12MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4013 SUP HCPCS C1713 03-11-4013 - SCREW BONE 4MM 13MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4013 SUP HCPCS C1713 03-12-4013 - SCREW BONE 4MM 13MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4014 SUP HCPCS C1713 03-11-4014 - SCREW BONE 4MM 14MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4014 SUP HCPCS C1713 03-12-4014 - SCREW BONE 4MM 14MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4015 SUP HCPCS C1713 03-11-4015 - SCREW BONE 4MM 15MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4015 SUP HCPCS C1713 03-12-4015 - SCREW BONE 4MM 15MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4016 SUP HCPCS C1713 03-11-4016 - SCREW BONE 4MM 16MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4016 SUP HCPCS C1713 03-12-4016 - SCREW BONE 4MM 16MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4017 SUP HCPCS C1713 03-11-4017 - SCREW BONE 4MM 17MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4017 SUP HCPCS C1713 03-12-4017 - SCREW BONE 4MM 17MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4018 SUP HCPCS C1713 03-11-4018 - SCREW BONE 4MM 18MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4018 SUP HCPCS C1713 03-12-4018 - SCREW BONE 4MM 18MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 773997 SUP Custom 27203010 CIRCUIT BRTHG HEAT WIRE 38IN BOTH IP/OP $299.35 $221.52 $0.00 $239.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.68 $237.09 $239.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4019 SUP HCPCS C1713 03-11-4019 - SCREW BONE 4MM 19MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4019 SUP HCPCS C1713 03-12-4019 - SCREW BONE 4MM 19MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4020 SUP HCPCS C1713 03-11-4020 - SCREW BONE 4MM 20MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4020 SUP HCPCS C1713 03-12-4020 - SCREW BONE 4MM 20MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 775856 SUP Custom 27203010 CIRCUIT BRTHG 3100B F AND P 850 VIASYS BOTH IP/OP $329.58 $243.89 $0.00 $263.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.79 $261.03 $263.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-25 SUP Custom 27803010 06-4025 - HEAD FEM +2.5MM OFST CTPR 40MM STRL LFIT ANTM COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-75 SUP Custom 27803010 06-4075 - HEAD FEM +7.5MM OFST CTPR 40MM STRL LFIT ANTM COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 800070 SUP Custom 27203010 800070 - SLIDE INSTRUCTIONAL HMRHD THD SYS BOTH IP/OP "$1,307.50 " $967.55 $0.00 "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.43 $970.43 $0.00 $0.00 $272.48 $0.00 $0.00 $0.00 $0.00 $653.75 "$1,035.54" "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 800257 SUP Custom 27203010 TIP ANALY PIP ALQ BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-97 SUP Custom 27803010 06-4097 - HEAD FEM -2.5MM OFST CTPR 40MM STRL LFIT ANTM COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-99 SUP Custom 27803010 06-4099 - HEAD FEM -5MM OFST CTPR 40MM STRL LFIT ANTM COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 807603 SUP Custom 27203010 807603 - FORCEPS BIPOL .5MM SMALL 8IN IRRIGATION DISPOSABLE BOTH IP/OP "$1,088.00 " $805.12 $0.00 $870.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $807.51 $807.51 $0.00 $0.00 $226.74 $0.00 $0.00 $0.00 $0.00 $544.00 $861.70 $870.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 808006 SUP HCPCS Q4130 0808006 - MATRIX TISSUE 8X8CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$3,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $636.74 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 "$1,506.12" "$1,506.12" $0.00 "$2,308.75" "$3,657.06" "$3,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 810051 SUP HCPCS C1771 810051 - SLING GYN GNCR TVT OBT INTROD SYS DEV FMALE STRS URN INCNT BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $613.13 $613.13 $0.00 $0.00 $0.00 $283.98 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $805.92 $805.92 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $213.23 $0.00 $0.00 $216.91 $0.00 $0.00 $0.00 $0.00 $0.00 810061 SUP HCPCS C1769 810061 - GUIDE CATHETER 7FR 100CM RIGID TAPE TVT FMALE VAGINA BOTH IP/OP $347.63 $257.25 $0.00 $278.10 $188.76 $188.76 $0.00 $0.00 $0.00 $72.45 $258.01 $258.01 $0.00 $0.00 $72.45 $0.00 $205.62 $205.62 $0.00 $173.81 $275.32 $278.10 $0.00 $0.00 $54.40 $0.00 $0.00 $55.34 $0.00 $0.00 $0.00 $0.00 $0.00 811558 SUP Custom 27803010 811558 - X-10 CROSSLINK BOTH IP/OP "$4,640.30 " "$3,433.82" $0.00 "$3,712.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,444.03" "$3,444.03" $0.00 $0.00 $967.04 $0.00 $0.00 $0.00 $0.00 "$2,320.15" "$3,675.12" "$3,712.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 815009 SUP HCPCS Q4130 815009 - MATRIX TISSUE 15X8CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP "$7,235.00 " "$5,353.90" $0.00 "$5,788.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,507.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,507.77" $0.00 "$3,566.86" "$3,566.86" $0.00 "$3,617.50" "$5,730.12" "$5,788.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 816001 SUP HCPCS Q4130 0816001 - MATRIX TISSUE 16X8CM RECONSTRUCTIVE PLIABLE STRATTICE PIG BOTH IP/OP "$8,120.00 " "$6,008.80" $0.00 "$6,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,692.41" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,692.21" $0.00 "$4,003.16" "$4,003.16" $0.00 "$4,060.00" "$6,431.04" "$6,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 816458 SUP HCPCS C1713 816458 - CROSSLINK X-10/58MM BOTH IP/OP "$4,640.30 " "$3,433.82" $0.00 "$3,712.24" "$2,088.14" "$2,088.14" $0.00 $0.00 $0.00 $967.15 "$3,444.03" "$3,444.03" $0.00 $0.00 $967.04 $0.00 "$2,287.67" "$2,287.67" $0.00 "$2,320.15" "$3,675.12" "$3,712.24" $0.00 $0.00 $726.21 $0.00 $0.00 $738.74 $0.00 $0.00 $0.00 $0.00 $0.00 821707 SUP Custom 27203010 821707 - KIT XTRN DRN CDMN CATH LMBR BOTH IP/OP $527.05 $390.02 $0.00 $421.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $391.18 $391.18 $0.00 $0.00 $109.84 $0.00 $0.00 $0.00 $0.00 $263.53 $417.42 $421.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 821739 SUP Custom 27803010 821739 - SET VENTRICULAR DRAINAGE TRAUMACATH L35 CM OD10 FR ODSEC3.3 BOTH IP/OP $271.95 $201.24 $0.00 $217.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.98 $215.38 $217.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 821750 SUP HCPCS C1729 821750 - CATHETER EXTERNAL DRAIN LARGE 1.9MM LATEX FREE BACTISEAL EVD BOTH IP/OP "$1,241.73 " $918.88 $0.00 $983.08 $667.27 $667.27 $0.00 $0.00 $0.00 $258.81 $921.61 $921.61 $0.00 $0.00 $258.78 $0.00 $734.48 $734.48 $0.00 $614.43 $973.25 $983.08 $0.00 $0.00 $192.32 $0.00 $0.00 $195.63 $0.00 $0.00 $0.00 $0.00 $0.00 858445 SUP HCPCS C1713 858445 - SCREW BONE 4.5MM 45MM FIX ANGLE CD HORIZON M8 STAINLESS BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858450 SUP HCPCS C1713 858450 - SCREW BONE 4.5MM 50MM FIX ANGLE CD HORIZON M8 STAINLESS BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 862309 SUP Custom 27203010 862309 - ELECTRODE MONOPOLAR 24.5FR 26FR HOOK BIPOL BOTH IP/OP $721.13 $533.64 $0.00 $579.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $535.22 $535.22 $0.00 $0.00 $150.28 $0.00 $0.00 $0.00 $0.00 $362.38 $574.00 $579.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 873011 SUP Custom 27203010 873011 - SPRDR SURG DURA MATER BOTH IP/OP $398.08 $294.58 $0.00 $318.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.45 $295.45 $0.00 $0.00 $82.96 $0.00 $0.00 $0.00 $0.00 $199.04 $315.28 $318.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 874002 SUP Custom 27803010 874002 - PIN DISTRACTION 10MM RELIANCE STERILE C BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $0.00 $0.00 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 898716 SUP Custom 27203010 898716 - TRAY CATH 16FR 350ML FOLEY URMTR LATEX BOTH IP/OP $40.06 $29.64 $0.00 $32.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.73 $29.73 $0.00 $0.00 $8.35 $0.00 $0.00 $0.00 $0.00 $20.03 $31.73 $32.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900284 SUP Custom 27203010 900284 - SUTURE NABSB 2 KHC-5 BLU MXBRD BRAID BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900334 SUP Custom 27203010 900334 - SUTURE NABSB 2 C-2 BLU MXBRD BRAID BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900339 SUP Custom 27203010 900339 - DEVICE FX MAXFIRE REPR ZIPLOOP TCH MNSCS BOTH IP/OP "$1,085.00 " $802.90 $0.00 $868.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $805.29 $805.29 $0.00 $0.00 $226.11 $0.00 $0.00 $0.00 $0.00 $542.50 $859.32 $868.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 901124 SUP HCPCS C1894 901124 - INTRO SHTH PRTNL BOTH IP/OP $777.50 $575.35 $0.00 $622.00 $422.18 $422.18 $0.00 $0.00 $0.00 $162.05 $577.06 $577.06 $0.00 $0.00 $162.03 $0.00 $459.89 $459.89 $0.00 $388.75 $615.78 $622.00 $0.00 $0.00 $121.68 $0.00 $0.00 $123.78 $0.00 $0.00 $0.00 $0.00 $0.00 902916 SUP Custom 27203010 902916 - TRAY CATHETERIZATION 16FR URINE METER FOLEY STATLOCK LATEX BOTH IP/OP $38.29 $28.33 $0.00 $30.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.15 $30.33 $30.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 904754 SUP Custom 27803010 904754 - DEVICE FX 7 50IN TOGGLELOC ZIPLOOP LNG LOOP XTD PE FEM BOTH IP/OP "$1,452.50 " "$1,074.85" $0.00 "$1,162.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,078.05" "$1,078.05" $0.00 $0.00 $302.70 $0.00 $0.00 $0.00 $0.00 $726.25 "$1,150.38" "$1,162.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905256 SUP HCPCS C1713 905256 - SCREW INTFR 9MM 25MM COMPOSITCP RND HD BOTH IP/OP "$1,122.50 " $830.65 $0.00 $898.00 $505.13 $505.13 $0.00 $0.00 $0.00 $233.96 $833.12 $833.12 $0.00 $0.00 $233.93 $0.00 $663.96 $663.96 $0.00 $561.25 $889.02 $898.00 $0.00 $0.00 $175.67 $0.00 $0.00 $178.70 $0.00 $0.00 $0.00 $0.00 $0.00 905257 SUP HCPCS C1713 905257 - SCREW BABSR 9MM 30MM COMPOSITCP RND HD BOTH IP/OP "$1,122.50 " $830.65 $0.00 $898.00 $505.13 $505.13 $0.00 $0.00 $0.00 $233.96 $833.12 $833.12 $0.00 $0.00 $233.93 $0.00 $663.96 $663.96 $0.00 $561.25 $889.02 $898.00 $0.00 $0.00 $175.67 $0.00 $0.00 $178.70 $0.00 $0.00 $0.00 $0.00 $0.00 905261 SUP HCPCS C1713 905261 - SCREW INTFR FT 10MM 30MM COMPOSITCP BOTH IP/OP "$1,122.50 " $830.65 $0.00 $898.00 $505.13 $505.13 $0.00 $0.00 $0.00 $233.96 $833.12 $833.12 $0.00 $0.00 $233.93 $0.00 $663.96 $663.96 $0.00 $561.25 $889.02 $898.00 $0.00 $0.00 $175.67 $0.00 $0.00 $178.70 $0.00 $0.00 $0.00 $0.00 $0.00 905263 SUP HCPCS C1713 905263 - SCREW INTFR FT 11MM 30MM COMPOSITCP BOTH IP/OP "$1,122.50 " $830.65 $0.00 $898.00 $505.13 $505.13 $0.00 $0.00 $0.00 $233.96 $833.12 $833.12 $0.00 $0.00 $233.93 $0.00 $663.96 $663.96 $0.00 $561.25 $889.02 $898.00 $0.00 $0.00 $175.67 $0.00 $0.00 $178.70 $0.00 $0.00 $0.00 $0.00 $0.00 905732 SUP Custom 27203010 905732 - CUTTER SRG 203MM MAXFIRE DISP BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 906520 SUP Custom 27203010 BAG PPR THK1/6IN C50LB LG KRAFT BRL BOTH IP/OP $0.35 $0.26 $0.00 $0.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.18 $0.28 $0.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 908469 SUP HCPCS C1713 908469 - WASHER ORTH SPK 16MM WSHRLC XTD TIP TI TIB BOTH IP/OP "$1,450.00 " "$1,073.00" $0.00 "$1,160.00" $652.50 $652.50 $0.00 $0.00 $0.00 $302.22 "$1,076.19" "$1,076.19" $0.00 $0.00 $302.18 $0.00 $857.68 $857.68 $0.00 $725.00 "$1,148.40" "$1,160.00" $0.00 $0.00 $226.93 $0.00 $0.00 $230.84 $0.00 $0.00 $0.00 $0.00 $0.00 908846 SUP HCPCS C1713 908846 - SCREW BN 6MM 46MM STRL WSHRLC TI ACL/PCL CANC ASCP BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $226.13 $226.13 $0.00 $0.00 $0.00 $104.73 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $297.23 $297.23 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $78.64 $0.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 908850 SUP HCPCS C1713 908850 - SCREW BN 6MM 50MM STRL WSHRLC TI ACL/PCL CANC ASCP BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $226.13 $226.13 $0.00 $0.00 $0.00 $104.73 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $297.23 $297.23 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $78.64 $0.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 908860 SUP HCPCS C1713 908860 - SCREW BN 6MM 60MM STRL WSHRLC TI ACL/PCL CANC ASCP BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $226.13 $226.13 $0.00 $0.00 $0.00 $104.73 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $297.23 $297.23 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $78.64 $0.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 909848 SUP Custom 27203010 909848 - KIT ASCP FX TOGGLELOC ZIPLOOP BOTH IP/OP "$3,657.50 " "$2,706.55" $0.00 "$2,926.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,714.60" "$2,714.60" $0.00 $0.00 $762.22 $0.00 $0.00 $0.00 $0.00 "$1,828.75" "$2,896.74" "$2,926.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 912076 SUP HCPCS C1713 912076 - ANCHOR SUT JUGGERKNOT SFT TIS BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-00 SUP Custom 27803010 06-4400 - HEAD FEM +0MM OFST CTPR 44MM STRL LFIT ANTM COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-05 SUP Custom 27803010 06-4405 - HEAD FEM +5MM OFST CTPR 44MM STRL LFIT ANTM COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-10 SUP Custom 27803010 06-4410 - HEAD FEMORAL +10MM 44MM C TAPER LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 921031 SUP HCPCS C9250 921031 - SET SPRY 2 SPRY TIP CONCTR HOSE STRL FLTR TSMT DISP BOTH IP/OP $111.69 $82.65 $0.00 $173.09 $59.25 $59.25 $156.84 $156.84 $111.69 $23.28 $82.90 $82.90 $0.00 $156.84 $23.28 $101.95 $66.07 $66.07 $173.09 $65.83 $104.27 $105.33 $131.66 $131.66 $20.60 $0.00 $0.00 $20.96 $164.85 $0.00 $0.00 $0.00 $0.00 Jun-25 SUP Custom 27803010 06-4425 - HEAD FEMORAL +2.5MM 44MM C TAPER LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 928950 SUP HCPCS C1894 0928950 - MICROMICROINTRUDUCER 7CM 5.0FR FLECURA GUIDEWIRE BOTH IP/OP $78.50 $58.09 $0.00 $62.80 $42.63 $42.63 $0.00 $0.00 $0.00 $16.36 $58.26 $58.26 $0.00 $0.00 $16.36 $0.00 $46.43 $46.43 $0.00 $39.25 $62.17 $62.80 $0.00 $0.00 $12.29 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 930740 SUP Custom 27203010 KIT IMMUN TST ELISA ANTI-HCV 480 TST BOTH IP/OP "$7,582.50 " "$5,611.05" $0.00 "$6,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,791.25" "$6,005.34" "$6,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 933040 SUP Custom 27203010 REAGENT ANTI-HCV ELISA STOP SOL 500ML ANALY BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-75 SUP Custom 27803010 06-4475 - HEAD FEMORAL +7.5MM 44MM C TAPER LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-97 SUP Custom 27803010 06-4497 - HEAD FEMORAL -2.5MM 44MM C TAPER LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jun-99 SUP Custom 27803010 06-4499 - HEAD FEMORAL -5MM 44MM C TAPER ANATOMIC LFIT V40 COCR BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4513 SUP HCPCS C1713 03-11-4513 - SCREW BONE 4.5MM 13MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4513 SUP HCPCS C1713 03-12-4513 - SCREW BONE 4.5MM 13MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4515 SUP HCPCS C1713 03-11-4515 - SCREW BONE 4.5MM 15MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4515 SUP HCPCS C1713 03-12-4515 - SCREW BONE 4.5MM 15MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/11/4517 SUP HCPCS C1713 03-11-4517 - SCREW BONE 4.5MM 17MM FIX ANGLE TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3/12/4517 SUP HCPCS C1713 03-12-4517 - SCREW BONE 4.5MM 17MM VAR ANG TITANIUM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 982001 SUP HCPCS Q4116 982001 - GRAFT SKN XTHICK 1X1CM ALDRM BOTH IP/OP $140.00 $103.60 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $29.18 $103.91 $103.91 $0.00 $0.00 $29.18 $0.00 $82.81 $82.81 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 982003 SUP HCPCS Q4116 982003 - GRAFT SKN 2X1CM ALDRM RGNRT ACLR DRML MTRX BOTH IP/OP $355.00 $262.70 $0.00 $438.00 $246.38 $246.38 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $273.75 $433.62 $438.00 $0.00 $0.00 $85.68 $0.00 $0.00 $87.16 $0.00 $0.00 $0.00 $0.00 $0.00 982007 SUP HCPCS Q4116 982007 - MATRIX TISSUE XTHICK 4X1CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $148.13 $109.62 $0.00 $184.00 $103.50 $103.50 $0.00 $0.00 $0.00 $30.87 $109.94 $109.94 $0.00 $0.00 $30.87 $0.00 $87.62 $87.62 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 982011 SUP HCPCS Q4116 982011 - MATRIX TISSUE XTHICK 4X2CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP "$1,030.00 " $762.20 $0.00 "$1,280.00" $720.00 $720.00 $0.00 $0.00 $0.00 $214.68 $764.47 $764.47 $0.00 $0.00 $214.65 $0.00 $609.25 $609.25 $0.00 $800.00 "$1,267.20" "$1,280.00" $0.00 $0.00 $250.40 $0.00 $0.00 $254.72 $0.00 $0.00 $0.00 $0.00 $0.00 982021 SUP HCPCS Q4116 982021 - MATRIX TISSUE XTHICK 7X3CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $83.45 $61.75 $0.00 $103.52 $58.23 $58.23 $0.00 $0.00 $0.00 $17.39 $61.94 $61.94 $0.00 $0.00 $17.39 $0.00 $49.36 $49.36 $0.00 $64.70 $102.48 $103.52 $0.00 $0.00 $20.25 $0.00 $0.00 $20.60 $0.00 $0.00 $0.00 $0.00 $0.00 982024 SUP HCPCS Q4116 982024 - GRAFT SKN XTHICK 12X2CM ALDRM BOTH IP/OP "$1,507.50 " "$1,115.55" $0.00 "$1,870.00" "$1,051.88" "$1,051.88" $0.00 $0.00 $0.00 $314.20 "$1,118.87" "$1,118.87" $0.00 $0.00 $314.16 $0.00 $891.69 $891.69 $0.00 "$1,168.75" "$1,851.30" "$1,870.00" $0.00 $0.00 $365.82 $0.00 $0.00 $372.13 $0.00 $0.00 $0.00 $0.00 $0.00 982028 SUP HCPCS Q4116 982028 - MATRIX TISSUE XTHICK 7X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $64.73 $47.90 $0.00 $80.43 $45.24 $45.24 $0.00 $0.00 $0.00 $13.49 $48.04 $48.04 $0.00 $0.00 $13.49 $0.00 $38.29 $38.29 $0.00 $50.27 $79.63 $80.43 $0.00 $0.00 $15.73 $0.00 $0.00 $16.01 $0.00 $0.00 $0.00 $0.00 $0.00 982048 SUP HCPCS Q4116 982048 - MATRIX TISSUE XTHICK 12X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 982060 SUP HCPCS Q4116 982060 - MATRIX TISSUE XTHICK 10CMX5CMX2.3-3.3MM ALLOGRAFT BOTH IP/OP $64.55 $47.77 $0.00 $80.16 $45.09 $45.09 $0.00 $0.00 $0.00 $13.45 $47.91 $47.91 $0.00 $0.00 $13.45 $0.00 $38.18 $38.18 $0.00 $50.10 $79.36 $80.16 $0.00 $0.00 $15.68 $0.00 $0.00 $15.95 $0.00 $0.00 $0.00 $0.00 $0.00 982070 SUP HCPCS Q4116 982070 - MATRIX TISSUE XTHICK 12X6CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $70.80 $52.39 $0.00 $56.64 $31.86 $31.86 $0.00 $0.00 $0.00 $14.76 $52.55 $52.55 $0.00 $0.00 $14.75 $0.00 $41.88 $41.88 $0.00 $35.40 $56.07 $56.64 $0.00 $0.00 $11.08 $0.00 $0.00 $11.27 $0.00 $0.00 $0.00 $0.00 $0.00 982080 SUP HCPCS Q4116 982080 - MATRIX TISSUE XTHICK 16X4CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.09 $57.79 $0.00 $62.47 $35.14 $35.14 $0.00 $0.00 $0.00 $16.28 $57.96 $57.96 $0.00 $0.00 $16.27 $0.00 $46.19 $46.19 $0.00 $39.04 $61.85 $62.47 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 982096 SUP HCPCS Q4116 982096 - MATRIX TISSUE XTHICK 12X8CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.10 $57.79 $0.00 $62.48 $35.14 $35.14 $0.00 $0.00 $0.00 $16.28 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $46.20 $46.20 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 982108 SUP HCPCS Q4116 982108 - MATRIX TISSUE XTHICK 18X6CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $92.57 $68.50 $0.00 $74.06 $41.66 $41.66 $0.00 $0.00 $0.00 $19.29 $68.71 $68.71 $0.00 $0.00 $19.29 $0.00 $54.75 $54.75 $0.00 $46.28 $73.32 $74.06 $0.00 $0.00 $14.49 $0.00 $0.00 $14.74 $0.00 $0.00 $0.00 $0.00 $0.00 982128 SUP HCPCS Q4116 982128 - MATRIX TISSUE XTHICK 16X8CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.11 $57.80 $0.00 $62.48 $35.15 $35.15 $0.00 $0.00 $0.00 $16.28 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $46.20 $46.20 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 982144 SUP HCPCS Q4116 982144 - MATRIX TISSUE XTHICK 12X12CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $68.23 $50.49 $0.00 $84.69 $47.64 $47.64 $0.00 $0.00 $0.00 $14.22 $50.64 $50.64 $0.00 $0.00 $14.22 $0.00 $40.36 $40.36 $0.00 $52.93 $83.85 $84.69 $0.00 $0.00 $16.57 $0.00 $0.00 $16.85 $0.00 $0.00 $0.00 $0.00 $0.00 982196 SUP HCPCS Q4116 982196 - MATRIX TISSUE XTHICK 16X6CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.10 $57.79 $0.00 $62.48 $35.14 $35.14 $0.00 $0.00 $0.00 $16.28 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $46.20 $46.20 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 982320 SUP HCPCS Q4116 982320 - MATRIX TISSUE XTHICK 20X16CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.12 $57.81 $0.00 $62.49 $35.15 $35.15 $0.00 $0.00 $0.00 $16.28 $57.98 $57.98 $0.00 $0.00 $16.28 $0.00 $46.21 $46.21 $0.00 $39.06 $61.87 $62.49 $0.00 $0.00 $12.23 $0.00 $0.00 $12.44 $0.00 $0.00 $0.00 $0.00 $0.00 983102 SUP Custom 27203010 983102 - COLLAR CERV CHLD SHRT CHIN REST TRCH OPN ADJ STRAP CNTCT BOTH IP/OP $67.45 $49.91 $0.00 $53.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.73 $53.42 $53.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 983104 SUP Custom 27203010 983104 - COLLAR CERV CHLD REG ASPN CHIN REST TRCH OPN ADJ STRAP CNTCT BOTH IP/OP $70.54 $52.20 $0.00 $60.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.36 $52.36 $0.00 $0.00 $14.70 $0.00 $0.00 $0.00 $0.00 $37.98 $60.17 $60.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 983106 SUP Custom 27203010 983106 - COLLAR CERV CHLD TOT CHIN REST TRCH OPN ADJ STRAP CNTCT CLSR BOTH IP/OP $81.85 $60.57 $0.00 $60.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.75 $60.75 $0.00 $0.00 $17.06 $0.00 $0.00 $0.00 $0.00 $36.31 $57.52 $58.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 983112 SUP Custom 27203010 983112 - COLLAR CERV ADLT TLL CHIN REST TRCH OPN ADJ STRAP CNTCT CLSR BOTH IP/OP $65.80 $48.69 $0.00 $52.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.90 $52.11 $52.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 983114 SUP Custom 27203010 983114 - COLLAR CERV ADLT XTALL CHIN REST TRCH OPN ADJ STRAP CNTCT BOTH IP/OP $69.50 $51.43 $0.00 $112.86 $0.00 $0.00 $0.00 $0.00 $0.00 $112.86 $51.58 $51.58 $0.00 $0.00 $14.48 $0.00 $41.11 $41.11 $0.00 $32.90 $52.11 $52.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 983119 SUP Custom 27203010 983119 - COLLAR CERV ADLT LG BACK PNL PLST BOTH IP/OP $27.50 $20.35 $0.00 $112.86 $0.00 $0.00 $0.00 $0.00 $0.00 $112.86 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $16.27 $16.27 $0.00 $18.42 $29.19 $29.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 983190 SUP Custom 27203010 983190 - COLLAR IMMOB CERVICAL INFANT FOAM PAD TRACH OPEN FLEXIBLE TA BOTH IP/OP $65.80 $48.69 $0.00 $52.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.90 $52.11 $52.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 983195 SUP Custom 27203010 983195 - COLLAR CERV INF REG CHIN REST TRCH OPN ADJ STRAP CNTCT CLSR BOTH IP/OP $81.85 $60.57 $0.00 $112.86 $0.00 $0.00 $0.00 $0.00 $0.00 $112.86 $60.75 $60.75 $0.00 $0.00 $17.06 $0.00 $48.41 $48.41 $0.00 $36.14 $57.25 $57.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 992003 SUP HCPCS Q4116 992003 - MATRIX TISSUE THIN 2X1CM ALLOGRAFT REGENERATIVE FREEZE DRIED BOTH IP/OP $170.00 $125.80 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 992128 SUP HCPCS Q4116 992128 - MATRIX TISSUE MEDIUM 16X8CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.11 $57.80 $0.00 $62.48 $35.15 $35.15 $0.00 $0.00 $0.00 $16.28 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $46.20 $46.20 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 992196 SUP HCPCS Q4116 992196 - MATRIX TISSUE THIN 16X6CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP $78.10 $57.79 $0.00 $62.48 $35.14 $35.14 $0.00 $0.00 $0.00 $16.28 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $46.20 $46.20 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $12.22 $0.00 $0.00 $12.43 $0.00 $0.00 $0.00 $0.00 $0.00 1001740 SUP HCPCS C1769 1001740 - GUIDEWIRE VASCULAR STR .014IN 190CM 3CM RADIOPQ HI-TORQUE BOTH IP/OP $177.50 $131.35 $0.00 $142.00 $96.38 $96.38 $0.00 $0.00 $0.00 $37.00 $131.74 $131.74 $0.00 $0.00 $36.99 $0.00 $104.99 $104.99 $0.00 $88.75 $140.58 $142.00 $0.00 $0.00 $27.78 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $0.00 1001741 SUP HCPCS C1769 1001741 - GUIDEWIRE VASCULAR STR .014IN 300CM 3CM HI-TORQUE ALL STAR BOTH IP/OP $177.50 $131.35 $0.00 $142.00 $96.38 $96.38 $0.00 $0.00 $0.00 $37.00 $131.74 $131.74 $0.00 $0.00 $36.99 $0.00 $104.99 $104.99 $0.00 $88.75 $140.58 $142.00 $0.00 $0.00 $27.78 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $0.00 1002005 SUP Custom 27203010 1002005 - NON STERILE DISPOSABLE DRILL BIT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004722 SUP Custom 27804086 1004722 - GRAFT BN 11X11X5MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004723 SUP Custom 27804086 1004723 - GRAFT BN 11X11X6MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004724 SUP Custom 27804086 1004724 - GRAFT BN 11X11X7MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004725 SUP Custom 27804086 1004725 - GRAFT BN 11X11X8MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004726 SUP Custom 27804086 1004726 - GRAFT BN 11X11X9MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004727 SUP Custom 27804086 1004727 - GRAFT BN 11X11X10MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004728 SUP Custom 27804086 1004728 - GRAFT BN 11X11X11IN ALGRF SPNE BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004732 SUP Custom 27804086 1004732 - GRAFT BN 14X11X5MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004733 SUP Custom 27804086 1004733 - GRAFT BN 14X11X6MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004734 SUP Custom 27804086 1004734 - GRAFT BN 7X11X14MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004735 SUP Custom 27804086 1004735 - GRAFT BN 14X11X8MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004736 SUP Custom 27804086 1004736 - GRAFT BN 14X11X9MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004737 SUP Custom 27804086 1004737 - GRAFT BN 14X11X10MM TRD CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004772 SUP Custom 27804086 1004772 - GRAFT BN 20X9X8MM TRD PLIF BOTH IP/OP "$5,257.50 " "$3,890.55" $0.00 "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,902.12" "$3,902.12" $0.00 $0.00 "$1,095.66" $0.00 $0.00 $0.00 $0.00 "$2,628.75" "$4,163.94" "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004773 SUP Custom 27804086 1004773 - GRAFT BN 20X9X10MM TRD PLIF ALGRF BOTH IP/OP "$5,257.50 " "$3,890.55" $0.00 "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,902.12" "$3,902.12" $0.00 $0.00 "$1,095.66" $0.00 $0.00 $0.00 $0.00 "$2,628.75" "$4,163.94" "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004774 SUP Custom 27804086 1004774 - GRAFT BN 20X9X12MM TRD PLIF ALGRF BOTH IP/OP "$5,257.50 " "$3,890.55" $0.00 "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,902.12" "$3,902.12" $0.00 $0.00 "$1,095.66" $0.00 $0.00 $0.00 $0.00 "$2,628.75" "$4,163.94" "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004775 SUP Custom 27804086 1004775 - GRAFT BN 20X9X14MM TRD PLIF BOTH IP/OP "$5,257.50 " "$3,890.55" $0.00 "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,902.12" "$3,902.12" $0.00 $0.00 "$1,095.66" $0.00 $0.00 $0.00 $0.00 "$2,628.75" "$4,163.94" "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004782 SUP Custom 27804086 1004782 - GRAFT BN 20X11X8MM TRD TLIF BOTH IP/OP "$7,017.50 " "$5,192.95" $0.00 "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,462.45" $0.00 $0.00 $0.00 $0.00 "$3,508.75" "$5,557.86" "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004783 SUP Custom 27804086 1004783 - GRAFT BN 20X11X10MM TRD TLIF BOTH IP/OP "$7,017.50 " "$5,192.95" $0.00 "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,462.45" $0.00 $0.00 $0.00 $0.00 "$3,508.75" "$5,557.86" "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004784 SUP Custom 27804086 1004784 - GRAFT BN 20X11X12MM TRD TLIF BOTH IP/OP "$7,017.50 " "$5,192.95" $0.00 "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,462.45" $0.00 $0.00 $0.00 $0.00 "$3,508.75" "$5,557.86" "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004785 SUP Custom 27804086 1004785 - GRAFT BN 20X11X14MM TRD TLIF BOTH IP/OP "$7,017.50 " "$5,192.95" $0.00 "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,462.45" $0.00 $0.00 $0.00 $0.00 "$3,508.75" "$5,557.86" "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004792 SUP Custom 27804086 1004792 - GRAFT BN 25X9X8MM TRD PLIF ALGRF BOTH IP/OP "$5,257.50 " "$3,890.55" $0.00 "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,902.12" "$3,902.12" $0.00 $0.00 "$1,095.66" $0.00 $0.00 $0.00 $0.00 "$2,628.75" "$4,163.94" "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004793 SUP Custom 27804086 1004793 - GRAFT BN 25X9X10MM TRD PLIF ALGRF BOTH IP/OP "$5,257.50 " "$3,890.55" $0.00 "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,902.12" "$3,902.12" $0.00 $0.00 "$1,095.66" $0.00 $0.00 $0.00 $0.00 "$2,628.75" "$4,163.94" "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004794 SUP Custom 27804086 1004794 - GRAFT BN 25X9X12MM TRD PLIF BOTH IP/OP "$5,257.50 " "$3,890.55" $0.00 "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,902.12" "$3,902.12" $0.00 $0.00 "$1,095.66" $0.00 $0.00 $0.00 $0.00 "$2,628.75" "$4,163.94" "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004795 SUP Custom 27804086 1004795 - GRAFT BN 25X9X14MM TRD PLIF BOTH IP/OP "$5,257.50 " "$3,890.55" $0.00 "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,902.12" "$3,902.12" $0.00 $0.00 "$1,095.66" $0.00 $0.00 $0.00 $0.00 "$2,628.75" "$4,163.94" "$4,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004802 SUP Custom 27804086 1004802 - GRAFT BN 25X11X8MM TRD TLIF BOTH IP/OP "$7,017.50 " "$5,192.95" $0.00 "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,462.45" $0.00 $0.00 $0.00 $0.00 "$3,508.75" "$5,557.86" "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004803 SUP Custom 27804086 1004803 - GRAFT BN 25X11X10MM TLIF BOTH IP/OP "$7,017.50 " "$5,192.95" $0.00 "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,462.45" $0.00 $0.00 $0.00 $0.00 "$3,508.75" "$5,557.86" "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004804 SUP Custom 27804086 1004804 - GRAFT BN 25X11X12MM TRD TLIF ALGRF BOTH IP/OP "$7,017.50 " "$5,192.95" $0.00 "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,462.45" $0.00 $0.00 $0.00 $0.00 "$3,508.75" "$5,557.86" "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1004805 SUP Custom 27804086 1004805 - GRAFT BN 25X11X14MM TLIF BOTH IP/OP "$7,017.50 " "$5,192.95" $0.00 "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,462.45" $0.00 $0.00 $0.00 $0.00 "$3,508.75" "$5,557.86" "$5,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1005203 SUP HCPCS C1769 1005203 - GUIDEWIRE VASCULAR STR .014IN 300CM 5CM STEERABLE CORE TO BOTH IP/OP $207.50 $153.55 $0.00 $166.00 $112.67 $112.67 $0.00 $0.00 $0.00 $43.25 $154.01 $154.01 $0.00 $0.00 $43.24 $0.00 $122.74 $122.74 $0.00 $103.75 $164.34 $166.00 $0.00 $0.00 $32.47 $0.00 $0.00 $33.03 $0.00 $0.00 $0.00 $0.00 $0.00 1005987 SUP Custom 27203010 MASK F/F DISP W/HEADSTRP PED BOTH IP/OP $58.40 $43.22 $0.00 $46.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.20 $46.25 $46.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007633 SUP HCPCS C1713 1007633 - MESH SRG 10X6MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007634 SUP HCPCS C1713 1007634 - MESH SRG 10X7MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007635 SUP HCPCS C1713 1007635 - MESH SRG 10X8MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007636 SUP HCPCS C1713 1007636 - MESH SRG 10X9MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007637 SUP HCPCS C1713 1007637 - MESH SRG 10X10MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007639 SUP HCPCS C1713 1007639 - MESH SRG 12X10MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007640 SUP HCPCS C1713 1007640 - MESH SRG 10X14MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007643 SUP HCPCS C1713 1007643 - MESH SRG 50X10MM SPNE BOTH IP/OP "$6,322.50 " "$4,678.65" $0.00 "$5,058.00" "$2,845.13" "$2,845.13" $0.00 $0.00 $0.00 "$1,317.77" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,317.61" $0.00 "$3,116.99" "$3,116.99" $0.00 "$3,161.25" "$5,007.42" "$5,058.00" $0.00 $0.00 $989.47 $0.00 $0.00 "$1,006.54" $0.00 $0.00 $0.00 $0.00 $0.00 1007653 SUP HCPCS C1713 1007653 - MESH SRG 12X6MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007654 SUP HCPCS C1713 1007654 - MESH SRG 12X7MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007655 SUP HCPCS C1713 1007655 - MESH SRG 12X8MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007656 SUP HCPCS C1713 1007656 - MESH SRG 12X9MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007657 SUP HCPCS C1713 1007657 - MESH SRG 10X12MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007659 SUP HCPCS C1713 1007659 - MESH SRG 12X12MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007660 SUP HCPCS C1713 1007660 - MESH SRG 12X14MM SPNE BOTH IP/OP "$2,617.50 " "$1,936.95" $0.00 "$2,094.00" "$1,177.88" "$1,177.88" $0.00 $0.00 $0.00 $545.55 "$1,942.71" "$1,942.71" $0.00 $0.00 $545.49 $0.00 "$1,290.43" "$1,290.43" $0.00 "$1,308.75" "$2,073.06" "$2,094.00" $0.00 $0.00 $409.64 $0.00 $0.00 $416.71 $0.00 $0.00 $0.00 $0.00 $0.00 1007663 SUP HCPCS C1713 1007663 - MESH SRG 50X12MM SPNE BOTH IP/OP "$7,227.50 " "$5,348.35" $0.00 "$5,782.00" "$3,252.38" "$3,252.38" $0.00 $0.00 $0.00 "$1,506.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,506.21" $0.00 "$3,563.16" "$3,563.16" $0.00 "$3,613.75" "$5,724.18" "$5,782.00" $0.00 $0.00 "$1,131.10" $0.00 $0.00 "$1,150.62" $0.00 $0.00 $0.00 $0.00 $0.00 1007673 SUP HCPCS C1713 1007673 - MESH SRG 14X6MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007674 SUP HCPCS C1713 1007674 - MESH SRG 14X7MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007675 SUP HCPCS C1713 1007675 - MESH SRG 14X8MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007676 SUP HCPCS C1713 1007676 - MESH SRG 14X9MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007677 SUP HCPCS C1713 1007677 - MESH SRG 14X10MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007679 SUP HCPCS C1713 1007679 - MESH SRG 14X12MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007680 SUP HCPCS C1713 1007680 - MESH SRG 14X14MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007683 SUP HCPCS C1713 1007683 - MESH SRG 50X14MM TI SPNE BOTH IP/OP "$8,132.50 " "$6,018.05" $0.00 "$6,506.00" "$3,659.63" "$3,659.63" $0.00 $0.00 $0.00 "$1,695.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,694.81" $0.00 "$4,009.32" "$4,009.32" $0.00 "$4,066.25" "$6,440.94" "$6,506.00" $0.00 $0.00 "$1,272.74" $0.00 $0.00 "$1,294.69" $0.00 $0.00 $0.00 $0.00 $0.00 1007693 SUP HCPCS C1713 1007693 - MESH SRG 16X6MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007694 SUP HCPCS C1713 1007694 - MESH SRG 16X7MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007695 SUP HCPCS C1713 1007695 - MESH SRG 16X8MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007696 SUP HCPCS C1713 1007696 - MESH SRG 16X9MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007697 SUP HCPCS C1713 1007697 - MESH SRG 16X10MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007699 SUP HCPCS C1713 1007699 - MESH SRG 16X12MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007700 SUP HCPCS C1713 1007700 - MESH SRG 16X14MM SPNE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 1007703 SUP HCPCS C1713 1007703 - CAGE SPNL 16MM 50MM MESH BOTH IP/OP "$8,132.50 " "$6,018.05" $0.00 "$6,506.00" "$3,659.63" "$3,659.63" $0.00 $0.00 $0.00 "$1,695.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,694.81" $0.00 "$4,009.32" "$4,009.32" $0.00 "$4,066.25" "$6,440.94" "$6,506.00" $0.00 $0.00 "$1,272.74" $0.00 $0.00 "$1,294.69" $0.00 $0.00 $0.00 $0.00 $0.00 1007704 SUP HCPCS C1713 1007704 - MESH SRG 90X16MM SPNE BOTH IP/OP "$10,122.50 " "$7,490.65" $0.00 "$8,098.00" "$4,555.13" "$4,555.13" $0.00 $0.00 $0.00 "$2,109.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,109.53" $0.00 "$4,990.39" "$4,990.39" $0.00 "$5,061.25" "$8,017.02" "$8,098.00" $0.00 $0.00 "$1,584.17" $0.00 $0.00 "$1,611.50" $0.00 $0.00 $0.00 $0.00 $0.00 1010008 SUP HCPCS Q4130 1010008 - SUBSTITUTE TISS 10X10CM STRATTICE MESH RECON TISS MTRX PRCN BOTH IP/OP "$6,825.00 " "$5,050.50" $0.00 "$5,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,422.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,422.33" $0.00 "$3,364.73" "$3,364.73" $0.00 "$3,412.50" "$5,405.40" "$5,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1010020 SUP Custom 27203010 1010020 - AGENT HMST AVTN CLGN MCFIB FLUR 1GM STRL LATEX FREE DISP BOTH IP/OP $256.15 $189.55 $0.00 $204.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.11 $190.11 $0.00 $0.00 $53.38 $0.00 $0.00 $0.00 $0.00 $128.08 $202.87 $204.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1010150 SUP Custom 27203010 1010150 - AGENT HEMOSTATIC 10MM 42CM 50X15X1MM PRELOAD APPLICATOR BOTH IP/OP $245.25 $181.49 $0.00 $196.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.02 $182.02 $0.00 $0.00 $51.11 $0.00 $0.00 $0.00 $0.00 $122.63 $194.24 $196.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1011132 SUP HCPCS C1713 1011132 - MESH SRG 30X20MM SPNE BOTH IP/OP "$6,012.50 " "$4,449.25" $0.00 "$4,810.00" "$2,705.63" "$2,705.63" $0.00 $0.00 $0.00 "$1,253.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.01" $0.00 "$2,964.16" "$2,964.16" $0.00 "$3,006.25" "$4,761.90" "$4,810.00" $0.00 $0.00 $940.96 $0.00 $0.00 $957.19 $0.00 $0.00 $0.00 $0.00 $0.00 1011134 SUP HCPCS C1713 1011134 - MESH SRG 60X20MM SPNE BOTH IP/OP "$8,495.00 " "$6,286.30" $0.00 "$6,796.00" "$3,822.75" "$3,822.75" $0.00 $0.00 $0.00 "$1,770.57" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,770.36" $0.00 "$4,188.04" "$4,188.04" $0.00 "$4,247.50" "$6,728.04" "$6,796.00" $0.00 $0.00 "$1,329.47" $0.00 $0.00 "$1,352.40" $0.00 $0.00 $0.00 $0.00 $0.00 1011135 SUP HCPCS C1713 1011135 - MESH SRG 90X20MM SPNE BOTH IP/OP "$10,662.50 " "$7,890.25" $0.00 "$8,530.00" "$4,798.13" "$4,798.13" $0.00 $0.00 $0.00 "$2,222.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,222.07" $0.00 "$5,256.61" "$5,256.61" $0.00 "$5,331.25" "$8,444.70" "$8,530.00" $0.00 $0.00 "$1,668.68" $0.00 $0.00 "$1,697.47" $0.00 $0.00 $0.00 $0.00 $0.00 1011152 SUP HCPCS C1713 1011152 - MESH SRG 30X24MM SPNE BOTH IP/OP "$6,012.50 " "$4,449.25" $0.00 "$4,810.00" "$2,705.63" "$2,705.63" $0.00 $0.00 $0.00 "$1,253.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.01" $0.00 "$2,964.16" "$2,964.16" $0.00 "$3,006.25" "$4,761.90" "$4,810.00" $0.00 $0.00 $940.96 $0.00 $0.00 $957.19 $0.00 $0.00 $0.00 $0.00 $0.00 1011154 SUP HCPCS C1713 1011154 - MESH SRG 60X24MM SPNE BOTH IP/OP "$9,035.00 " "$6,685.90" $0.00 "$7,228.00" "$4,065.75" "$4,065.75" $0.00 $0.00 $0.00 "$1,883.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,882.89" $0.00 "$4,454.26" "$4,454.26" $0.00 "$4,517.50" "$7,155.72" "$7,228.00" $0.00 $0.00 "$1,413.98" $0.00 $0.00 "$1,438.37" $0.00 $0.00 $0.00 $0.00 $0.00 1011155 SUP HCPCS C1713 1011155 - MESH SRG 90X24MM SPNE BOTH IP/OP "$11,207.50 " "$8,293.55" $0.00 "$8,966.00" "$5,043.38" "$5,043.38" $0.00 $0.00 $0.00 "$2,335.92" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,335.64" $0.00 "$5,525.30" "$5,525.30" $0.00 "$5,603.75" "$8,876.34" "$8,966.00" $0.00 $0.00 "$1,753.97" $0.00 $0.00 "$1,784.23" $0.00 $0.00 $0.00 $0.00 $0.00 1012572 SUP Custom 27203010 MASK CPAP LG ADLT HDGR FULL ADJ STRAP FRHD CLIP PRFMTRK LF BOTH IP/OP $65.20 $48.25 $0.00 $52.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.60 $51.64 $52.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1012624 SUP Custom 27203010 MASK CPAP MED ADLT HDGR FULL ADJ STRAP FRHD CLIP PRFMTRK LF BOTH IP/OP $65.20 $48.25 $0.00 $52.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.60 $51.64 $52.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1016002 SUP HCPCS Q4130 1016002 - MATRIX TISSUE 16X10CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP $58.88 $43.57 $0.00 $71.19 $0.00 $0.00 $0.00 $0.00 $0.00 $12.27 $43.70 $43.70 $0.00 $0.00 $12.27 $0.00 $34.82 $34.82 $0.00 $44.49 $70.47 $71.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1016692 SUP Custom 27203010 MASK CPAP MED LG 2 FLP CSHN HDSTRP SIL CNTOUR DLX LF DISP BOTH IP/OP $37.53 $27.77 $0.00 $30.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.76 $29.72 $30.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1025002 SUP HCPCS Q4130 1025002 - MATRIX TISSUE 25X10CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP "$14,720.00 " "$10,892.80" $0.00 "$17,796.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,067.65" $0.00 "$7,256.96" "$7,256.96" $0.00 "$11,122.50" "$17,618.04" "$17,796.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1040014 SUP Custom 27803010 1040014 - TUBE VNT 1.14MM 3.6MM 1.3MM GRN POPE GRMT BVL FLRPLAS EAR BOTH IP/OP $44.25 $32.75 $0.00 $35.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $0.00 $0.00 $0.00 $22.13 $35.05 $35.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1046742 SUP Custom 27203010 PACIFIER NBN WTHMB PRMTR PUR BOTH IP/OP $7.40 $5.48 $0.00 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.70 $5.86 $5.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1050044 SUP Custom 27203010 1050044 - HYSTOCRYL BLUE FOIL POUCH 10X0.5ML BOTH IP/OP $487.50 $360.75 $0.00 $361.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $24.38 $38.61 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1112095 SUP HCPCS C1713 1112095 - PROSTHESIS OSS 90D RND 4MM 1.1MM 5MM FULL CNN SHFT OFF CNTR BOTH IP/OP $442.50 $327.45 $0.00 $354.00 $199.13 $199.13 $0.00 $0.00 $0.00 $92.23 $328.42 $328.42 $0.00 $0.00 $92.22 $0.00 $261.74 $261.74 $0.00 $221.25 $350.46 $354.00 $0.00 $0.00 $69.25 $0.00 $0.00 $70.45 $0.00 $0.00 $0.00 $0.00 $0.00 1135510 SUP HCPCS C1713 "1135510 - RELINE MAS ROD, 100MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1151015 SUP HCPCS C1781 1151015 - GRAFT PRCN RECT 5.9X3.9IN STRL XENMATRIX AB NONCROSSLINK BOTH IP/OP "$11,445.00 " "$8,469.30" $0.00 "$9,156.00" "$5,150.25" "$5,150.25" $0.00 $0.00 $0.00 "$2,385.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,385.14" $0.00 "$5,642.39" "$5,642.39" $0.00 "$5,722.50" "$9,064.44" "$9,156.00" $0.00 $0.00 "$1,791.14" $0.00 $0.00 "$1,822.04" $0.00 $0.00 $0.00 $0.00 $0.00 1151928 SUP HCPCS C1781 1151928 - GRAFT PRCN RECT 11X7.5IN STRL XENMATRIX AB RGNRT BOTH IP/OP "$22,877.00 " "$16,928.98" $0.00 "$18,301.60" "$10,294.65" "$10,294.65" $0.00 $0.00 $0.00 "$4,768.14" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,767.57" $0.00 "$11,278.36" "$11,278.36" $0.00 "$11,438.50" "$18,118.58" "$18,301.60" $0.00 $0.00 "$3,580.25" $0.00 $0.00 "$3,642.02" $0.00 $0.00 $0.00 $0.00 $0.00 1161015 SUP HCPCS C1781 1161015 - GRAFT PIG THK1.8-2.5MM 5.9X3.9IN REGENERATIVE XENMATRIX BOTH IP/OP "$10,374.00 " "$7,676.76" $0.00 "$8,299.20" "$4,668.30" "$4,668.30" $0.00 $0.00 $0.00 "$2,162.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,161.94" $0.00 "$5,114.38" "$5,114.38" $0.00 "$5,187.00" "$8,216.21" "$8,299.20" $0.00 $0.00 "$1,623.53" $0.00 $0.00 "$1,651.54" $0.00 $0.00 $0.00 $0.00 $0.00 1161520 SUP HCPCS C1781 1161520 - GRAFT PIG THK1.8-2.5MM 7.9X5.9IN REGENERATIVE XENMATRIX BOTH IP/OP "$20,748.00 " "$15,353.52" $0.00 "$16,598.40" "$9,336.60" "$9,336.60" $0.00 $0.00 $0.00 "$4,324.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,323.88" $0.00 "$10,228.76" "$10,228.76" $0.00 "$10,374.00" "$16,432.42" "$16,598.40" $0.00 $0.00 "$3,247.06" $0.00 $0.00 "$3,303.08" $0.00 $0.00 $0.00 $0.00 $0.00 1161928 SUP HCPCS C1781 1161928 - GRAFT SURG 11X7.5IN REGENERATIVE XENMATRIX COLLAGEN MATRIX BOTH IP/OP "$35,479.60 " "$26,254.90" $0.00 "$28,383.68" "$15,965.82" "$15,965.82" $0.00 $0.00 $0.00 "$7,394.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,393.95" $0.00 "$17,491.44" "$17,491.44" $0.00 "$17,739.80" "$28,099.84" "$28,383.68" $0.00 $0.00 "$5,552.56" $0.00 $0.00 "$5,648.35" $0.00 $0.00 $0.00 $0.00 $0.00 1190602 SUP HCPCS C1781 1190602 - PLUG SURG LARGE 1.9X1.5IN MONOFILAMENT MESH PLEATED EDGE BOTH IP/OP "$1,572.25 " "$1,163.47" $0.00 "$1,257.80" $707.51 $707.51 $0.00 $0.00 $0.00 $327.70 "$1,166.92" "$1,166.92" $0.00 $0.00 $327.66 $0.00 $929.99 $929.99 $0.00 $786.13 "$1,245.22" "$1,257.80" $0.00 $0.00 $246.06 $0.00 $0.00 $250.30 $0.00 $0.00 $0.00 $0.00 $0.00 1190603 SUP HCPCS C1781 1190603 - PLUG SURG XL 1.6X1.3IN MESH MULTILAYER PHASIX BOTH IP/OP "$1,585.75 " "$1,173.46" $0.00 "$1,268.60" $713.59 $713.59 $0.00 $0.00 $0.00 $330.51 "$1,176.94" "$1,176.94" $0.00 $0.00 $330.47 $0.00 $937.97 $937.97 $0.00 $792.88 "$1,255.91" "$1,268.60" $0.00 $0.00 $248.17 $0.00 $0.00 $252.45 $0.00 $0.00 $0.00 $0.00 $0.00 1203105 SUP Custom 27203010 1203105 - TUBE ENDBR 9FR STRL UNIBLOCKER ADLT BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $0.00 $0.00 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1303346 SUP Custom 27203010 1303346 - SPONGE ABS HMST AGNT PWDR GELTN GLFM 50 STRL BOTH IP/OP $421.96 $312.25 $0.00 $313.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.18 $313.18 $0.00 $0.00 $87.94 $0.00 $0.00 $0.00 $0.00 $144.21 $228.44 $230.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Oct-10 SUP Custom 27203010 10-5510 - DRESSING GZE 36X36IN STRL LF 1-+ 17 PLY W MESH 1 LYR BOTH IP/OP $37.32 $27.62 $0.00 $27.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.70 $27.70 $0.00 $0.00 $7.78 $0.00 $0.00 $0.00 $0.00 $16.85 $26.68 $26.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6/11/5537 SUP HCPCS C1776 5537-6/11 - STEM HUMERAL 6 135MM PRESS FIT ANATOMIC TITANIUM NONSTRL BOTH IP/OP "$6,566.70 " "$4,859.36" $0.00 "$5,253.36" "$2,955.02" "$2,955.02" $0.00 $0.00 $0.00 "$1,368.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,368.50" $0.00 "$3,237.38" "$3,237.38" $0.00 "$3,283.35" "$5,200.83" "$5,253.36" $0.00 $0.00 "$1,027.69" $0.00 $0.00 "$1,045.42" $0.00 $0.00 $0.00 $0.00 $0.00 8/12/5537 SUP HCPCS C1776 5537-8/12 - STEM HUMERAL 8 120MM PRESS FIT ANATOMIC SELF CENTERING EPOCA BOTH IP/OP "$6,566.70 " "$4,859.36" $0.00 "$5,253.36" "$2,955.02" "$2,955.02" $0.00 $0.00 $0.00 "$1,368.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,368.50" $0.00 "$3,237.38" "$3,237.38" $0.00 "$3,283.35" "$5,200.83" "$5,253.36" $0.00 $0.00 "$1,027.69" $0.00 $0.00 "$1,045.42" $0.00 $0.00 $0.00 $0.00 $0.00 10/12/5537 SUP HCPCS C1776 5537-10/12 - STEM HUMERAL 10 125MM PRESS FIT ANATOMIC SELF CENTERING BOTH IP/OP "$6,566.70 " "$4,859.36" $0.00 "$5,253.36" "$2,955.02" "$2,955.02" $0.00 $0.00 $0.00 "$1,368.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,368.50" $0.00 "$3,237.38" "$3,237.38" $0.00 "$3,283.35" "$5,200.83" "$5,253.36" $0.00 $0.00 "$1,027.69" $0.00 $0.00 "$1,045.42" $0.00 $0.00 $0.00 $0.00 $0.00 12/13/5537 SUP HCPCS C1776 5537-12/13 - STEM HUMERAL 12MM 130MM PRESS FIT TITANIUM NONSTRL BOTH IP/OP "$6,566.70 " "$4,859.36" $0.00 "$5,253.36" "$2,955.02" "$2,955.02" $0.00 $0.00 $0.00 "$1,368.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,368.50" $0.00 "$3,237.38" "$3,237.38" $0.00 "$3,283.35" "$5,200.83" "$5,253.36" $0.00 $0.00 "$1,027.69" $0.00 $0.00 "$1,045.42" $0.00 $0.00 $0.00 $0.00 $0.00 6/11/5540 SUP HCPCS C1776 5540-6/11 - STEM HUMERAL 6MM 115MM PRESS FIT TITANIUM HA STERILE BOTH IP/OP "$6,943.00 " "$5,137.82" $0.00 "$5,554.40" "$3,124.35" "$3,124.35" $0.00 $0.00 $0.00 "$1,447.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,446.92" $0.00 "$3,422.90" "$3,422.90" $0.00 "$3,471.50" "$5,498.86" "$5,554.40" $0.00 $0.00 "$1,086.58" $0.00 $0.00 "$1,105.33" $0.00 $0.00 $0.00 $0.00 $0.00 8/12/5540 SUP HCPCS C1776 5540-8/12 - STEM HUMERAL 8MM 120MM PRESS FIT EPOCA TITANIUM HA SHOULDER BOTH IP/OP "$6,943.00 " "$5,137.82" $0.00 "$5,554.40" "$3,124.35" "$3,124.35" $0.00 $0.00 $0.00 "$1,447.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,446.92" $0.00 "$3,422.90" "$3,422.90" $0.00 "$3,471.50" "$5,498.86" "$5,554.40" $0.00 $0.00 "$1,086.58" $0.00 $0.00 "$1,105.33" $0.00 $0.00 $0.00 $0.00 $0.00 10/12/5540 SUP HCPCS C1776 5540-10/12 - STEM HUMERAL 10 125MM PRESS FIT IMPLANT TITANIUM HA SHOULDER BOTH IP/OP "$6,943.00 " "$5,137.82" $0.00 "$5,554.40" "$3,124.35" "$3,124.35" $0.00 $0.00 $0.00 "$1,447.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,446.92" $0.00 "$3,422.90" "$3,422.90" $0.00 "$3,471.50" "$5,498.86" "$5,554.40" $0.00 $0.00 "$1,086.58" $0.00 $0.00 "$1,105.33" $0.00 $0.00 $0.00 $0.00 $0.00 12/13/5540 SUP HCPCS C1776 5540-12/13 - STEM HUMERAL 12MM 130MM PRESS FIT TITANIUM HA STERILE BOTH IP/OP "$6,943.00 " "$5,137.82" $0.00 "$5,554.40" "$3,124.35" "$3,124.35" $0.00 $0.00 $0.00 "$1,447.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,446.92" $0.00 "$3,422.90" "$3,422.90" $0.00 "$3,471.50" "$5,498.86" "$5,554.40" $0.00 $0.00 "$1,086.58" $0.00 $0.00 "$1,105.33" $0.00 $0.00 $0.00 $0.00 $0.00 6/11/5624 SUP HCPCS C1776 5624-6/11 - STEM HUMERAL 8MM 115MM CEMENT EPOCA COCR SHOULDER STERILE BOTH IP/OP "$5,769.05 " "$4,269.10" $0.00 "$4,615.24" "$2,596.07" "$2,596.07" $0.00 $0.00 $0.00 "$1,202.41" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,202.27" $0.00 "$2,844.14" "$2,844.14" $0.00 "$2,884.53" "$4,569.09" "$4,615.24" $0.00 $0.00 $902.86 $0.00 $0.00 $918.43 $0.00 $0.00 $0.00 $0.00 $0.00 8/12/5624 SUP HCPCS C1776 5624-8/12 - STEM HUMERAL 8MM 120MM CEMENTED ANATOMIC SELF CENTERING BOTH IP/OP "$5,769.05 " "$4,269.10" $0.00 "$4,615.24" "$2,596.07" "$2,596.07" $0.00 $0.00 $0.00 "$1,202.41" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,202.27" $0.00 "$2,844.14" "$2,844.14" $0.00 "$2,884.53" "$4,569.09" "$4,615.24" $0.00 $0.00 $902.86 $0.00 $0.00 $918.43 $0.00 $0.00 $0.00 $0.00 $0.00 10/12/5624 SUP HCPCS C1776 5624-10/12 - STEM HUMERAL 10 125MM CEMENTED ANATOMIC COCR STERILE BOTH IP/OP "$5,769.05 " "$4,269.10" $0.00 "$4,615.24" "$2,596.07" "$2,596.07" $0.00 $0.00 $0.00 "$1,202.41" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,202.27" $0.00 "$2,844.14" "$2,844.14" $0.00 "$2,884.53" "$4,569.09" "$4,615.24" $0.00 $0.00 $902.86 $0.00 $0.00 $918.43 $0.00 $0.00 $0.00 $0.00 $0.00 12/13/5624 SUP HCPCS C1776 5624-12/13 - STEM HUMERAL 12 130MM CEMENTED ANATOMIC COCR STERILE BOTH IP/OP "$5,769.05 " "$4,269.10" $0.00 "$4,615.24" "$2,596.07" "$2,596.07" $0.00 $0.00 $0.00 "$1,202.41" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,202.27" $0.00 "$2,844.14" "$2,844.14" $0.00 "$2,884.53" "$4,569.09" "$4,615.24" $0.00 $0.00 $902.86 $0.00 $0.00 $918.43 $0.00 $0.00 $0.00 $0.00 $0.00 1371120 SUP Custom 27203010 PIPETTE TRNSF PE 6IN 5.8ML GRAD STRL BOTH IP/OP $0.30 $0.22 $0.00 $0.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.15 $0.24 $0.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1372301 SUP Custom 27203010 1372301 - SET ADM 110IN 0.2 MH NVNT ADON BOTH IP/OP $38.38 $28.40 $0.00 $30.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.48 $28.48 $0.00 $0.00 $8.00 $0.00 $0.00 $0.00 $0.00 $19.19 $30.40 $30.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1424571 SUP HCPCS C1713 PLATE MCWL 96 WELL UBTM RGD PS DISP BOTH IP/OP $4.48 $3.32 $0.00 $3.58 $2.01 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.24 $3.55 $3.58 $0.00 $0.00 $0.70 $0.00 $0.00 $0.71 $0.00 $0.00 $0.00 $0.00 $0.00 1437374 SUP Custom 27203010 BLADE HISTOLGY 130MM ACED SHRT SS TRM DISP BOTH IP/OP $539.75 $399.42 $0.00 $431.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.88 $427.48 $431.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1500181 SUP Custom 27203010 1500181 - APL ENDSCP FLSL STRL DISP BOTH IP/OP $147.78 $109.36 $0.00 $118.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.68 $109.68 $0.00 $0.00 $30.80 $0.00 $0.00 $0.00 $0.00 $73.89 $117.04 $118.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1501262 SUP HCPCS C9250 1501262 - KIT TISSUE CLOSURE 1 PREFILL SYRINGE PLUNGER 2 PULL STRAP BOTH IP/OP $385.60 $285.34 $0.00 $481.28 $270.72 $270.72 $156.84 $156.84 $156.84 $80.37 $286.19 $286.19 $0.00 $156.84 $80.36 $101.95 $228.08 $228.08 $173.09 $300.80 $476.47 $481.28 $239.03 $239.03 $94.15 $0.00 $0.00 $95.77 $164.85 $0.00 $0.00 $0.00 $0.00 1501263 SUP HCPCS C9250 1501263 - KIT TISS CLSR 10ML 2 PCH FRZN SLNT SYRPLNG Y PC CONCTR TSSL BOTH IP/OP $946.28 $700.25 $0.00 "$1,113.26" $626.21 $626.21 $156.84 $156.84 $156.84 $197.23 $702.33 $702.33 $0.00 $156.84 $197.20 $101.95 $559.72 $559.72 $173.09 $695.79 "$1,102.13" "$1,113.26" $239.03 $239.03 $217.78 $0.00 $0.00 $221.54 $164.85 $0.00 $0.00 $0.00 $0.00 1518128 SUP HCPCS Q4116 1518128 - MATRIX TISS THK.4-1.6MM 128SQ CM MED RECT 16X8CM ALDRM SLCT BOTH IP/OP "$8,732.50 " "$6,462.05" $0.00 "$10,840.00" "$6,097.50" "$6,097.50" $0.00 $0.00 $0.00 "$1,820.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,819.85" $0.00 "$4,305.12" "$4,305.12" $0.00 "$6,775.00" "$10,731.60" "$10,840.00" $0.00 $0.00 "$2,120.58" $0.00 $0.00 "$2,157.16" $0.00 $0.00 $0.00 $0.00 $0.00 1518320 SUP HCPCS Q4116 1518320 - MATRIX TISS THK.4-1.6MM 320SQ CM MED RECT 20X16CM ALDRM SLCT BOTH IP/OP "$21,832.50 " "$16,156.05" $0.00 "$27,100.00" "$15,243.75" "$15,243.75" $0.00 $0.00 $0.00 "$4,550.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,549.89" $0.00 "$10,763.42" "$10,763.42" $0.00 "$16,937.50" "$26,829.00" "$27,100.00" $0.00 $0.00 "$5,301.44" $0.00 $0.00 "$5,392.90" $0.00 $0.00 $0.00 $0.00 $0.00 1518616 SUP HCPCS Q4116 1518616 - MATRIX TISSUE THICK 16X6CM ALLOGRAFT REGENERATIVE FREEZE BOTH IP/OP "$7,497.50 " "$5,548.15" $0.00 "$5,998.00" "$3,373.88" "$3,373.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,748.75" "$5,938.02" "$5,998.00" $0.00 $0.00 "$1,173.36" $0.00 $0.00 "$1,193.60" $0.00 $0.00 $0.00 $0.00 $0.00 1520616 SUP HCPCS Q4116 1520616 - MATRIX TISS THK.4-1.6MM MED 16X6CM ALDRM SLCT ALGRF RGNRT BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$8,130.00" "$4,573.13" "$4,573.13" $0.00 $0.00 $0.00 "$1,365.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 "$3,229.15" "$3,229.15" $0.00 "$5,081.25" "$8,048.70" "$8,130.00" $0.00 $0.00 "$1,590.43" $0.00 $0.00 "$1,617.87" $0.00 $0.00 $0.00 $0.00 $0.00 1523901 SUP Custom 27203010 1523901 - SET IRRIGATION .28IN 85IN 4 LEAD 3Y CONCTR SIGHT CHAMBER BOTH IP/OP $385.75 $285.46 $0.00 $308.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.30 $286.30 $0.00 $0.00 $80.39 $0.00 $0.00 $0.00 $0.00 $192.88 $305.51 $308.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1524055 SUP Custom 27203010 1524055 - SPLINT NSL WHT STRL LF DYLE II CMPR ANT TIP INTGR ARWY SIL BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $0.00 $0.00 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1525002 SUP HCPCS Q4130 1525002 - MATRIX TISSUE 25X15CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP "$22,080.00 " "$16,339.20" $0.00 "$26,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,602.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,601.47" $0.00 "$10,885.44" "$10,885.44" $0.00 "$16,683.75" "$26,427.06" "$26,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1527005 SUP Custom 27803010 1527005 - SPLINT NSL THK.5MM STD REUT PREPUNCH HL FLRPLAS SPT BOTH IP/OP $74.50 $55.13 $0.00 $59.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.29 $55.29 $0.00 $0.00 $15.53 $0.00 $0.00 $0.00 $0.00 $37.25 $59.00 $59.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1527010 SUP HCPCS C1713 1527010 - SPLINT 1527010 10PK PAIR REUTER LRG THIN BOTH IP/OP $100.00 $74.00 $0.00 $74.22 $33.53 $33.53 $0.00 $0.00 $0.00 $20.84 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $37.25 $59.00 $59.60 $0.00 $0.00 $11.66 $0.00 $0.00 $11.86 $0.00 $0.00 $0.00 $0.00 $0.00 1527020 SUP Custom 27803010 1527020 - SPLINT 1527020 10PK PAIR REUTER LRG THK BOTH IP/OP $100.00 $74.00 $0.00 $74.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $37.25 $59.00 $59.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1528120 SUP Custom 27203010 1528120 - SPLINT NASAL MEDIUM REGULAR 2.38X1.53IN EXTERNAL RUBBER FOAM BOTH IP/OP "$2,912.50 " "$2,155.25" $0.00 "$2,330.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,161.66" "$2,161.66" $0.00 $0.00 $606.97 $0.00 $0.00 $0.00 $0.00 "$1,456.25" "$2,306.70" "$2,330.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1528126 SUP Custom 27203010 1528126 - SPLINT NSL MED 2.38X1.53IN WHT STRL LF XTRN KT FM RBR SPT BOTH IP/OP $93.50 $69.19 $0.00 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.40 $69.40 $0.00 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1528136 SUP Custom 27203010 1528136 - SPLINT NSL LG KT XTRN LTWT STRNG WTR RS ADH FM AL SPT BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1528137 SUP Custom 27203010 1528137 - SPLINT NASAL LARGE 2.63INX1.73IN ADHERENT EXTERNAL STRONG BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1529010 SUP Custom 27803010 1529010 - SPLINT NSL MED 2.38X1.53IN WHT STRL LF THRMSPLNT KT XTRN BOTH IP/OP $7.80 $5.77 $0.00 $462.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.79 $5.79 $0.00 $0.00 $1.63 $0.00 $0.00 $0.00 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1529020 SUP Custom 27203010 1529020 - SPLINT NSL LG 2.63INX1.73IN WHT STRL LF THRMSPLNT KT XTRN BOTH IP/OP $56.75 $42.00 $0.00 $45.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.12 $42.12 $0.00 $0.00 $11.83 $0.00 $0.00 $0.00 $0.00 $28.38 $44.95 $45.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1608695 SUP Custom 27203010 1608695 - BURR SURG ROUND .157MM 2.13IN DIAMOND MEDIUM GRIT BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $0.00 $0.00 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1620002 SUP HCPCS Q4130 1620002 - MATRIX TISSUE 20X16CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP $58.88 $43.57 $0.00 $71.19 $0.00 $0.00 $0.00 $0.00 $0.00 $12.27 $43.70 $43.70 $0.00 $0.00 $12.27 $0.00 $34.83 $34.83 $0.00 $44.49 $70.47 $71.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1664017 SUP HCPCS C1713 1664017 - SET SCREW 1664017 4.75 SOL PERC MULTI S BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 1677545 SUP HCPCS C1713 1677545 - SCREW BN 7.5MM 45MM NS PRCPT PA CR SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 1677550 SUP HCPCS C1713 1677550 - SCREW BN 7.5MM 50MM NS PRCPT PA CR SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 1801303 SUP HCPCS C1713 1801303 - ENDPLATE SPNL 3D MED NS INFIX TI THORLMBR ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 1801306 SUP HCPCS C1713 1801306 - ENDPLATE SPNL 6D MED NS INFIX TI THORLMBR ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 1803205 SUP HCPCS C1776 1803205 - DOME PTLR RND 38MM RSRFC KN MCK SYS BOTH IP/OP "$2,192.50 " "$1,622.45" $0.00 "$1,754.00" $986.63 $986.63 $0.00 $0.00 $0.00 $456.97 "$1,627.27" "$1,627.27" $0.00 $0.00 $456.92 $0.00 "$1,296.86" "$1,296.86" $0.00 "$1,096.25" "$1,736.46" "$1,754.00" $0.00 $0.00 $343.13 $0.00 $0.00 $349.05 $0.00 $0.00 $0.00 $0.00 $0.00 1804308 SUP HCPCS C1713 1804308 - STRUT SPNL MED 8MM BLU NS INFIX TI THORLMBR ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 1807052 SUP HCPCS C1776 1807052 - INSERT TIB 5 9MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 1807081 SUP HCPCS C1776 1807081 - INSERT TIB 8 8MM STRL RESTORIS ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 1850300 SUP HCPCS C1894 1850300 - SHEATH ENDSCP CLEAN 170MM 4MM ESCRB 25D SIN LEN SYS STRL BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $272.86 $272.86 $0.00 $0.00 $0.00 $104.73 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $297.23 $297.23 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $78.64 $0.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-33 SUP HCPCS C1713 01-7033 - PLATE 100D MED RIGHT MIDFAC 3X3 HOLE L 1.5MM SCR BONE TI BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $210.38 $210.38 $0.00 $0.00 $0.00 $97.44 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $276.53 $276.53 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $73.16 $0.00 $0.00 $74.43 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-38 SUP HCPCS C1713 01-7038 - PLATE BONE 1.5MM REGULAR L SILVER LEFT MIDFAC BOTH IP/OP $910.00 $673.40 $0.00 $728.00 $409.50 $409.50 $0.00 $0.00 $0.00 $189.67 $675.40 $675.40 $0.00 $0.00 $189.64 $0.00 $538.27 $538.27 $0.00 $455.00 $720.72 $728.00 $0.00 $0.00 $142.42 $0.00 $0.00 $144.87 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-40 SUP HCPCS C1713 01-7040 - PLATE BONE REGULAR STR 16MMX.6MM 4 HOLE TRAUMAONE LORENZ BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-45 SUP HCPCS C1713 01-7045 - PLATE BONE MEDIUM STR 17MMX.6MM 4 HOLE SILVER TITANIUM BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-47 SUP HCPCS C1713 01-7047 - PLATE BONE LONG STR 4 HOLE GRADE II TRAUMAONE LORENZ SILVER BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-50 SUP HCPCS C1713 01-7050 - PLATE BONE REGULAR STR 6 HOLE TRAUMAONE LORENZ SILVER BOTH IP/OP $447.50 $331.15 $0.00 $358.00 $201.38 $201.38 $0.00 $0.00 $0.00 $93.27 $332.13 $332.13 $0.00 $0.00 $93.26 $0.00 $264.70 $264.70 $0.00 $223.75 $354.42 $358.00 $0.00 $0.00 $70.03 $0.00 $0.00 $71.24 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-65 SUP HCPCS C1713 01-7065 - PLATE BONE MESH SIDE PROFILE PRECONTOUR 163X115X.3MM ULTRA BOTH IP/OP "$10,742.50 " "$7,949.45" $0.00 "$8,594.00" "$4,834.13" "$4,834.13" $0.00 $0.00 $0.00 "$2,239.01" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,238.74" $0.00 "$5,296.05" "$5,296.05" $0.00 "$5,371.25" "$8,508.06" "$8,594.00" $0.00 $0.00 "$1,681.20" $0.00 $0.00 "$1,710.21" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-66 SUP HCPCS C1713 01-7066 - PLATE BONE 16 HOLE STR LORENZ TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-92 SUP HCPCS C1713 01-7092 - PLATE BONE MED 2T CRNMXF TI 1.5MM SCR BOTH IP/OP $710.00 $525.40 $0.00 $568.00 $319.50 $319.50 $0.00 $0.00 $0.00 $147.98 $526.96 $526.96 $0.00 $0.00 $147.96 $0.00 $419.97 $419.97 $0.00 $355.00 $562.32 $568.00 $0.00 $0.00 $111.12 $0.00 $0.00 $113.03 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-02 SUP HCPCS C1713 01-7102 - PLATE BONE LONG REGULAR Y 5 HOLE TRAUMAONE LORENZ SILVER BOTH IP/OP $840.00 $621.60 $0.00 $672.00 $378.00 $378.00 $0.00 $0.00 $0.00 $175.08 $623.45 $623.45 $0.00 $0.00 $175.06 $0.00 $496.86 $496.86 $0.00 $420.00 $665.28 $672.00 $0.00 $0.00 $131.46 $0.00 $0.00 $133.73 $0.00 $0.00 $0.00 $0.00 $0.00 1900233 SUP Custom 27203010 REAGENT XYLN SHDN 120ML SUB MOUNTANT HISTOLGY BOTH IP/OP $54.45 $40.29 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.23 $43.12 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-04 SUP HCPCS C1713 01-7104 - PLATE BONE XL Y 19MMX.6MM 5 HOLE LORENZ SILVER TITANIUM BOTH IP/OP $710.00 $525.40 $0.00 $568.00 $319.50 $319.50 $0.00 $0.00 $0.00 $147.98 $526.96 $526.96 $0.00 $0.00 $147.96 $0.00 $419.97 $419.97 $0.00 $355.00 $562.32 $568.00 $0.00 $0.00 $111.12 $0.00 $0.00 $113.03 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-06 SUP HCPCS C1713 01-7106 - PLATE BONE SMALL PREFORM TITANIUM ORBTL FLOOR BOTH IP/OP "$3,112.50 " "$2,303.25" $0.00 "$2,490.00" "$1,400.63" "$1,400.63" $0.00 $0.00 $0.00 $648.72 "$2,310.10" "$2,310.10" $0.00 $0.00 $648.65 $0.00 "$1,534.46" "$1,534.46" $0.00 "$1,556.25" "$2,465.10" "$2,490.00" $0.00 $0.00 $487.11 $0.00 $0.00 $495.51 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-07 SUP HCPCS C1713 01-7107 - PLATE BONE MEDIUM .3MM PREFORM TRAUMAONE LORENZ GOLD BOTH IP/OP "$3,112.50 " "$2,303.25" $0.00 "$1,232,500.00" "$1,400.63" "$1,400.63" $0.00 $0.00 $0.00 $648.72 "$2,310.10" "$2,310.10" $0.00 $0.00 $648.65 $0.00 "$1,232,500.00" "$1,232,500.00" $0.00 "$1,556.25" "$2,465.10" "$2,490.00" $0.00 $0.00 $487.11 $0.00 $0.00 $495.51 $0.00 $0.00 $0.00 $0.00 $0.00 1901819 SUP HCPCS C1713 1901819 - PLATE BONE MED ORBTL FLR TI MESH BOTH IP/OP "$3,112.50 " "$2,303.25" $0.00 "$1,980,000.00" "$1,400.63" "$1,400.63" $0.00 $0.00 $0.00 $648.72 "$2,310.10" "$2,310.10" $0.00 $0.00 $648.65 $0.00 "$1,232,500.00" "$1,232,500.00" $0.00 "$1,556.25" "$1,980,000.00" "$2,490.00" $0.00 $0.00 $487.11 $0.00 $0.00 $495.51 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-08 SUP HCPCS C1713 01-7108 - PLATE BONE LARGE .3MM PREFORM TITANIUM ORBTL FLOOR STERILE BOTH IP/OP "$3,242.50 " "$2,399.45" $0.00 "$2,594.00" "$1,459.13" "$1,459.13" $0.00 $0.00 $0.00 $675.82 "$2,406.58" "$2,406.58" $0.00 $0.00 $675.74 $0.00 "$1,598.55" "$1,598.55" $0.00 "$1,621.25" "$2,568.06" "$2,594.00" $0.00 $0.00 $507.45 $0.00 $0.00 $516.21 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-09 SUP HCPCS C1713 01-7109 - PLATE BONE .3MM GRADE IV PREFORME TRAUMAONE LORENZ GOLD BOTH IP/OP "$2,835.00 " "$2,097.90" $0.00 "$2,268.00" "$1,275.75" "$1,275.75" $0.00 $0.00 $0.00 $590.88 "$2,104.14" "$2,104.14" $0.00 $0.00 $590.81 $0.00 "$1,397.66" "$1,397.66" $0.00 "$1,417.50" "$2,245.32" "$2,268.00" $0.00 $0.00 $443.68 $0.00 $0.00 $451.33 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-10 SUP HCPCS C1713 01-7110 - PLATE BN REG 2Y 6 HL TI MDFC 1.5MM SCR BOTH IP/OP $760.00 $562.40 $0.00 $608.00 $342.00 $342.00 $0.00 $0.00 $0.00 $158.40 $564.07 $564.07 $0.00 $0.00 $158.38 $0.00 $449.54 $449.54 $0.00 $380.00 $601.92 $608.00 $0.00 $0.00 $118.94 $0.00 $0.00 $120.99 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-12 SUP HCPCS C1713 01-7112 - PLATE BONE LONG 6 HOLE 2Y TITANIUM MIDFAC 1.5MM SCREWS BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $382.50 $382.50 $0.00 $0.00 $0.00 $177.16 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $502.78 $502.78 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $133.03 $0.00 $0.00 $135.32 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-14 SUP HCPCS C1713 01-7114 - PLATE BONE XLONG 2Y TITANIUM CRANIOMAXILLOFACIAL 1.5MM SCREW BOTH IP/OP $745.00 $551.30 $0.00 $596.00 $335.25 $335.25 $0.00 $0.00 $0.00 $155.28 $552.94 $552.94 $0.00 $0.00 $155.26 $0.00 $440.67 $440.67 $0.00 $372.50 $590.04 $596.00 $0.00 $0.00 $116.59 $0.00 $0.00 $118.60 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-20 SUP HCPCS C1713 01-7120 - PLATE BONE REGULAR X TITANIUM CRANIOMAXILLOFACIAL STERILE BOTH IP/OP $840.00 $621.60 $0.00 $672.00 $378.00 $378.00 $0.00 $0.00 $0.00 $175.08 $623.45 $623.45 $0.00 $0.00 $175.06 $0.00 $496.86 $496.86 $0.00 $420.00 $665.28 $672.00 $0.00 $0.00 $131.46 $0.00 $0.00 $133.73 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-21 SUP HCPCS C1713 01-7121 - PLATE BONE 6 HOLE CVD TRAUMAONE GREEN ORBTL MIDFAC BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-22 SUP HCPCS C1713 01-7122 - PLATE BONE 18 HOLE CVD TRAUMAONE GREEN ORBTL MIDFAC BOTH IP/OP "$1,570.00 " "$1,161.80" $0.00 "$1,256.00" $706.50 $706.50 $0.00 $0.00 $0.00 $327.23 "$1,165.25" "$1,165.25" $0.00 $0.00 $327.19 $0.00 $928.66 $928.66 $0.00 $785.00 "$1,243.44" "$1,256.00" $0.00 $0.00 $245.71 $0.00 $0.00 $249.94 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-23 SUP HCPCS C1713 01-7123 - PLATE BONE 4 HOLE CVD TRAUMAONE GREEN ORBTL MIDFAC BOTH IP/OP $932.50 $690.05 $0.00 $746.00 $419.63 $419.63 $0.00 $0.00 $0.00 $194.36 $692.10 $692.10 $0.00 $0.00 $194.33 $0.00 $551.57 $551.57 $0.00 $466.25 $738.54 $746.00 $0.00 $0.00 $145.94 $0.00 $0.00 $148.45 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-26 SUP HCPCS C1713 01-7126 - PLATE BONE REGULAR CURVE 6 HOLE GRADE II TRAUMAONE LORENZ BOTH IP/OP $857.50 $634.55 $0.00 $686.00 $385.88 $385.88 $0.00 $0.00 $0.00 $178.72 $636.44 $636.44 $0.00 $0.00 $178.70 $0.00 $507.21 $507.21 $0.00 $428.75 $679.14 $686.00 $0.00 $0.00 $134.20 $0.00 $0.00 $136.51 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-28 SUP HCPCS C1713 01-7128 - PLATE BONE REGULAR CURVE .6MM 8 HOLE TRAUMAONE LORENZ SILVER BOTH IP/OP $540.00 $399.60 $0.00 $432.00 $243.00 $243.00 $0.00 $0.00 $0.00 $112.55 $400.79 $400.79 $0.00 $0.00 $112.54 $0.00 $319.41 $319.41 $0.00 $270.00 $427.68 $432.00 $0.00 $0.00 $84.51 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-30 SUP HCPCS C1713 01-7130 - PLATE BN CRV .6MM SLVR TRAUMAONE 10 HL TI ORBT FLR 1.5MM SCR BOTH IP/OP $540.00 $399.60 $0.00 $432.00 $243.00 $243.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.00 $427.68 $432.00 $0.00 $0.00 $84.51 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-31 SUP HCPCS C1713 01-7131 - PLATE BN SQ 12MM LORENZ 4 HL NEURO 1.5MM SCR BOTH IP/OP $760.00 $562.40 $0.00 $608.00 $342.00 $342.00 $0.00 $0.00 $0.00 $158.40 $564.07 $564.07 $0.00 $0.00 $158.38 $0.00 $449.54 $449.54 $0.00 $380.00 $601.92 $608.00 $0.00 $0.00 $118.94 $0.00 $0.00 $120.99 $0.00 $0.00 $0.00 $0.00 $0.00 1912000 SUP HCPCS C1894 1912000 - SHEATH ENDSCP CLEAN 0D 4MM LENS SOFTWARE CONTROL ENDO-SCRUB BOTH IP/OP $32.80 $24.27 $0.00 $26.24 $17.81 $17.81 $0.00 $0.00 $0.00 $6.84 $24.34 $24.34 $0.00 $0.00 $6.84 $0.00 $19.40 $19.40 $0.00 $16.40 $25.98 $26.24 $0.00 $0.00 $5.13 $0.00 $0.00 $5.22 $0.00 $0.00 $0.00 $0.00 $0.00 1912010 SUP HCPCS C1892 1912010 - SHEATH ENDSCP CLEAN 4MM ESCRB2 30D SIN LEN STRL LATEX FREE BOTH IP/OP $27.50 $20.35 $0.00 $22.00 $14.93 $14.93 $0.00 $0.00 $0.00 $5.73 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $16.27 $16.27 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $4.30 $0.00 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-36 SUP HCPCS C1713 01-7136 - PLATE BONE RECTANGLE 2X3 HOLE TRAUMAONE MATRIX SILVER BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $427.50 $427.50 $0.00 $0.00 $0.00 $198.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $561.93 $561.93 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $148.68 $0.00 $0.00 $151.24 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-37 SUP HCPCS C1713 01-7137 - PLATE BONE 2X4 HOLE RECTANGULAR LORENZ TITANIUM BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $427.50 $427.50 $0.00 $0.00 $0.00 $198.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $561.93 $561.93 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $148.68 $0.00 $0.00 $151.24 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-42 SUP Custom 27203010 01-7142 - DRILL TWIST 5MM STOP 1MM 50MM LORENZ MANDIB BOTH IP/OP $447.50 $331.15 $0.00 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $332.13 $332.13 $0.00 $0.00 $93.26 $0.00 $0.00 $0.00 $0.00 $223.75 $354.42 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-44 SUP Custom 27203010 01-7144 - DRILL TWIST 1.1MM 50MM 7MM STOP LORENZ 1.5MM SCREW MIDAS REX BOTH IP/OP $447.50 $331.15 $0.00 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $332.13 $332.13 $0.00 $0.00 $93.26 $0.00 $0.00 $0.00 $0.00 $223.75 $354.42 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-46 SUP Custom 27203010 01-7146 - DRILL TWIST 1.1MM 50MM 9MM STOP BOTH IP/OP $447.50 $331.15 $0.00 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $332.13 $332.13 $0.00 $0.00 $93.26 $0.00 $0.00 $0.00 $0.00 $223.75 $354.42 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-48 SUP Custom 27203010 01-7148 - DRILL TWIST 1.1MM 50MM 15MM STOP BOTH IP/OP $447.50 $331.15 $0.00 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $332.13 $332.13 $0.00 $0.00 $93.26 $0.00 $0.00 $0.00 $0.00 $223.75 $354.42 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924542 SUP Custom 27803010 1924542 - ROD SPNL 5.5MM 200MM SPRL R90D HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924543 SUP Custom 27803010 1924543 - ROD SPNL 5.5MM 400MM SPRL R90D HEX END BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924547 SUP HCPCS C1713 1924547 - SCREW BN 6.75MM 30MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,345.68 " $995.80 $0.00 "$1,076.54" $605.55 $605.55 $0.00 $0.00 $0.00 $280.47 $998.76 $998.76 $0.00 $0.00 $280.44 $0.00 $795.97 $795.97 $0.00 $672.84 "$1,065.78" "$1,076.54" $0.00 $0.00 $210.60 $0.00 $0.00 $214.23 $0.00 $0.00 $0.00 $0.00 $0.00 1924548 SUP HCPCS C1713 1924548 - SCREW BN 6.75MM 35MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,345.68 " $995.80 $0.00 "$1,076.54" $605.55 $605.55 $0.00 $0.00 $0.00 $280.47 $998.76 $998.76 $0.00 $0.00 $280.44 $0.00 $795.97 $795.97 $0.00 $672.84 "$1,065.78" "$1,076.54" $0.00 $0.00 $210.60 $0.00 $0.00 $214.23 $0.00 $0.00 $0.00 $0.00 $0.00 1924549 SUP HCPCS C1713 1924549 - SCREW BN 6.75MM 40MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,345.68 " $995.80 $0.00 "$1,076.54" $605.55 $605.55 $0.00 $0.00 $0.00 $280.47 $998.76 $998.76 $0.00 $0.00 $280.44 $0.00 $795.97 $795.97 $0.00 $672.84 "$1,065.78" "$1,076.54" $0.00 $0.00 $210.60 $0.00 $0.00 $214.23 $0.00 $0.00 $0.00 $0.00 $0.00 1924550 SUP HCPCS C1713 1924550 - SCREW BN 6.75MM 45MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,345.68 " $995.80 $0.00 "$1,076.54" $605.55 $605.55 $0.00 $0.00 $0.00 $280.47 $998.76 $998.76 $0.00 $0.00 $280.44 $0.00 $795.97 $795.97 $0.00 $672.84 "$1,065.78" "$1,076.54" $0.00 $0.00 $210.60 $0.00 $0.00 $214.23 $0.00 $0.00 $0.00 $0.00 $0.00 1924551 SUP HCPCS C1713 1924551 - SCREW BN 6.75MM 50MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,345.68 " $995.80 $0.00 "$1,076.54" $605.55 $605.55 $0.00 $0.00 $0.00 $280.47 $998.76 $998.76 $0.00 $0.00 $280.44 $0.00 $795.97 $795.97 $0.00 $672.84 "$1,065.78" "$1,076.54" $0.00 $0.00 $210.60 $0.00 $0.00 $214.23 $0.00 $0.00 $0.00 $0.00 $0.00 1924552 SUP Custom 27803010 1924552 - ROD SPNL 5.5MM 200MM SPRL R90D SCRL EYE TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924553 SUP Custom 27803010 1924553 - ROD SPNL 5.5MM 400MM SPRL R90D SCRL EYE TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924900 SUP Custom 27803010 1924900 - ROD SPNL 5.5MM 40MM SPRL R90D NONHEXAGONAL TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924901 SUP Custom 27803010 1924901 - ROD SPNL 5.5MM 50MM SPRL R90D NONHEXAGONAL TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924902 SUP Custom 27803010 1924902 - ROD SPNL 5.5MM 60MM SPRL R90D TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924903 SUP Custom 27803010 1924903 - ROD SPNL 5.5MM 70MM SPRL R90D NONHEXAGONAL TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924904 SUP Custom 27803010 1924904 - ROD SPNL 5.5MM 80MM SPRL R90D NONHEXAGONAL TI SPNE BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924905 SUP Custom 27803010 1924905 - ROD SPNL 5.5MM 90MM SPRL R90D NONHEXAGONAL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924906 SUP Custom 27803010 1924906 - ROD SPNL 5.5MM 100MM SPRL R90D NONHEXAGONAL TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924907 SUP Custom 27803010 1924907 - ROD SPNL 5.5MM 110MM SPRL R90D NONHEXAGONAL TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924908 SUP Custom 27803010 1924908 - ROD SPNL 5.5MM 120MM SPRL R90D NONHEXAGONAL TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924909 SUP Custom 27803010 1924909 - ROD SPNL 5.5MM 600MM SPRL R90D HEX TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-80 SUP HCPCS C1713 01-7180 - PLATE BN REG 80X53X.6MM SLVR LORENZ GRID MESH PNL TI CRNMXF BOTH IP/OP "$4,182.50 " "$3,095.05" $0.00 "$3,346.00" "$1,882.13" "$1,882.13" $0.00 $0.00 $0.00 $871.74 "$3,104.25" "$3,104.25" $0.00 $0.00 $871.63 $0.00 "$2,061.97" "$2,061.97" $0.00 "$2,091.25" "$3,312.54" "$3,346.00" $0.00 $0.00 $654.56 $0.00 $0.00 $665.85 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-82 SUP HCPCS C1713 01-7182 - PLATE BONE SMALL 85X53X.6MM GRID MESH PANEL LORENZ SILVER BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-85 SUP HCPCS C1713 01-7185 - PLATE BONE SMALL 85X53X.3MM GRID MESH PANEL LORENZ SILVER BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-49 SUP HCPCS C1713 01-7249 - PLATE BONE 100X100X.6MM CONTUR MESH LORENZ STERILE 1.5MM BOTH IP/OP "$6,692.50 " "$4,952.45" $0.00 "$5,354.00" "$3,011.63" "$3,011.63" $0.00 $0.00 $0.00 "$1,394.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,394.72" $0.00 "$3,299.40" "$3,299.40" $0.00 "$3,346.25" "$5,300.46" "$5,354.00" $0.00 $0.00 "$1,047.38" $0.00 $0.00 "$1,065.45" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-05 SUP HCPCS C1713 01-7305 - PLATE BONE LORENZ TITANIUM H.5 MM OD18.5 MM CRANIOMAXILLOFAC BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-06 SUP HCPCS C1713 01-7306 - PLATE BONE 18.5MM .5MM BURR HOLE LORENZ TITANIUM BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-08 SUP HCPCS C1713 01-7308 - PLATE BONE 18.5MM BURR HOLE TITANIUM MIDFAC 1.5MM SCREWS BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-09 SUP HCPCS C1713 01-7309 - PLATE BONE 22MM .5MM BURR HOLE LORENZ TITANIUM BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-40 SUP HCPCS C1713 01-7340 - PLATE BONE 1/1.5MM 85X50X.2MM HEXAGONAL PANEL LORENZ BOTH IP/OP "$4,022.50 " "$2,976.65" $0.00 "$3,218.00" "$1,810.13" "$1,810.13" $0.00 $0.00 $0.00 $838.39 "$2,985.50" "$2,985.50" $0.00 $0.00 $838.29 $0.00 "$1,983.09" "$1,983.09" $0.00 "$2,011.25" "$3,185.82" "$3,218.00" $0.00 $0.00 $629.52 $0.00 $0.00 $640.38 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-45 SUP HCPCS C1713 01-7345 - PLATE BONE MEDIUM 2 HOLE STR TITANIUM MIDFAC 1.5MM SCREWS BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-47 SUP HCPCS C1713 01-7347 - PLATE BONE LONG STR .6MM 2 HOLE TRAUMAONE LORENZ SILVER BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-51 SUP HCPCS C1713 01-7351 - PLATE BN 25MM LORENZ 6 HL GAP NEURO 1.5MM SCR BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-53 SUP HCPCS C1713 01-7353 - PLATE BONE MEDIUM 35MMX.5MM 6 HOLE GAP LORENZ TITANIUM BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-55 SUP HCPCS C1713 01-7355 - PLATE BN 45MMX.5MM LORENZ 6 HL GAP TI CRNM 1.5MM SCR BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 2010027 SUP Custom 27203010 2010027 - ELECTRODE EMG DMD STRL LF I-PAS III SPRINGLESS DISP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2010028 SUP Custom 27203010 2010028 - SET SPINAL INSULATED PEDICLE ACCES SYSTEM DIAMOND TIP I-PAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2010029 SUP Custom 27203010 2010029 - SET SPINAL INSULATED PEDICLE ACCES SYSTEM BEVELED TIP I-PAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2010036 SUP Custom 27011340 2010036 - STIMULATOR NRV STRL LF NVJJB DYNMC DISP BOTH IP/OP $182.50 $135.05 $0.00 $146.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.45 $135.45 $0.00 $0.00 $38.03 $0.00 $0.00 $0.00 $0.00 $91.25 $144.54 $146.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2010037 SUP Custom 27203010 2010037 - ELECTRODE EMG BVL STRL LF I-PAS III SPRINGLESS DISP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2011202 SUP Custom 27203010 2011202 - RETRACTOR SRG SHTH NRV ROOT BOTH IP/OP "$1,205.00 " $891.70 $0.00 $964.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $894.35 $894.35 $0.00 $0.00 $251.12 $0.00 $0.00 $0.00 $0.00 $602.50 $954.36 $964.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2012021 SUP Custom 27011340 2012021 - PROBE EMG STM HNDPC NV M5 BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Oct-08 SUP Custom 27203010 10-7408 - BANDAGE COMPRESSION 7 TUBULAR 42-52IN 10YD ELAST DRESSING BOTH IP/OP $107.89 $79.84 $0.00 $80.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.08 $80.08 $0.00 $0.00 $22.48 $0.00 $0.00 $0.00 $0.00 $14.65 $23.21 $23.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Oct-09 SUP Custom 27203010 10-7409 - RETAINER DRESSING 8 TUBULAR 52-58IN 10YD ELAST LATEX SAFE BOTH IP/OP $157.99 $116.91 $0.00 $117.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.26 $117.26 $0.00 $0.00 $32.92 $0.00 $0.00 $0.00 $0.00 $19.98 $31.66 $31.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Oct-13 SUP Custom 27203010 10-7413 - RETAINER DRESSING 12 10YD ELAST LATEX SAFE STRETCHED TUBULAR BOTH IP/OP $65.24 $48.28 $0.00 $52.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.42 $48.42 $0.00 $0.00 $13.60 $0.00 $0.00 $0.00 $0.00 $32.62 $51.67 $52.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2020000 SUP HCPCS Q4130 2020000 - SUB TISS 20X20CM STRATTICE PIG DRML MTRX FIRM PTCH RECON BOTH IP/OP $65.23 $48.27 $0.00 $52.18 $0.00 $0.00 $0.00 $0.00 $0.00 $13.59 $48.41 $48.41 $0.00 $0.00 $13.59 $0.00 $38.58 $38.58 $0.00 $32.61 $51.66 $52.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2020002 SUP HCPCS Q4130 2020002 - MATRIX TISSUE 20X20CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP "$23,552.50 " "$17,428.85" $0.00 "$28,474.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,908.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,908.34" $0.00 "$11,611.38" "$11,611.38" $0.00 "$17,796.25" "$28,189.26" "$28,474.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2025002 SUP HCPCS Q4130 2025002 - MATRIX TISSUE 25X20CM RECONSTRUCTIVE STRATTICE PIG DERMIS BOTH IP/OP "$29,440.00 " "$21,785.60" $0.00 "$35,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$6,136.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,135.30" $0.00 "$14,513.92" "$14,513.92" $0.00 "$22,245.00" "$35,236.08" "$35,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2029950 SUP Custom 27803010 2029950 - KIT SPINAL DILAT XLIF NEUROVISION DISPOSABLE M5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2030365 SUP Custom 27203010 STRIP ACCK CMFCRV GLUC CHMTEST BOTH IP/OP $60.20 $44.55 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.10 $47.68 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2040001 SUP HCPCS C1713 2040001 - DIGITIZER INST BENDINI ROD BNDRG ARY BOTH IP/OP "$5,660.00 " "$4,188.40" $0.00 "$4,528.00" "$2,547.00" "$2,547.00" $0.00 $0.00 $0.00 "$1,179.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,179.54" $0.00 "$2,790.38" "$2,790.38" $0.00 "$2,830.00" "$4,482.72" "$4,528.00" $0.00 $0.00 $885.79 $0.00 $0.00 $901.07 $0.00 $0.00 $0.00 $0.00 $0.00 2078175 SUP HCPCS C1769 2078175 - GUIDEWIRE VASCULAR .014IN 300CM 3CM SHAPEABLE TIP STEERABLE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $203.63 $203.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 2110140 SUP HCPCS C1713 2110140 - SPACER SPNL 0D 40X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110145 SUP HCPCS C1713 2110145 - SPACER SPNL 0D 45X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110150 SUP HCPCS C1713 2110150 - SPACER SPNL 0D 50X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110155 SUP HCPCS C1713 2110155 - SPACER SPNL 0D 55X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110160 SUP HCPCS C1713 2110160 - SPACER SPNL 0D 60X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110240 SUP HCPCS C1713 2110240 - SPACER SPNL 0D 40X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110245 SUP HCPCS C1713 2110245 - SPACER SPNL 0D 45X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110250 SUP HCPCS C1713 2110250 - SPACER SPNL 0D 50X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110255 SUP HCPCS C1713 2110255 - SPACER SPNL 0D 55X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110260 SUP HCPCS C1713 2110260 - SPACER SPNL 0D 60X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110340 SUP HCPCS C1713 2110340 - SPACER SPNL 0D 40X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110345 SUP HCPCS C1713 2110345 - SPACER SPNL 0D 45X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110350 SUP HCPCS C1713 2110350 - SPACER SPNL 0D 50X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110355 SUP HCPCS C1713 2110355 - SPACER SPNL 0D 55X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110360 SUP HCPCS C1713 2110360 - SPACER SPNL 0D 60X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110440 SUP HCPCS C1713 2110440 - SPACER SPNL 0D 40X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110445 SUP HCPCS C1713 2110445 - SPACER SPNL 0D 45X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110450 SUP HCPCS C1713 2110450 - SPACER SPNL 0D 50X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110455 SUP HCPCS C1713 2110455 - SPACER SPNL 0D 55X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110460 SUP HCPCS C1713 2110460 - SPACER SPNL 0D 60X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110540 SUP HCPCS C1713 2110540 - SPACER SPNL 0D 40X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110545 SUP HCPCS C1713 2110545 - SPACER SPNL 0D 45X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110550 SUP HCPCS C1713 2110550 - SPACER SPNL 0D 50X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110555 SUP HCPCS C1713 2110555 - SPACER SPNL 0D 55X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2110560 SUP HCPCS C1713 2110560 - SPACER SPNL 0D 60X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111140 SUP HCPCS C1713 2111140 - SPACER SPNL 6D 40X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111145 SUP HCPCS C1713 2111145 - SPACER SPNL 6D 45X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111150 SUP HCPCS C1713 2111150 - SPACER SPNL 6D 50X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111155 SUP HCPCS C1713 2111155 - SPACER SPNL 6D 55X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111160 SUP HCPCS C1713 2111160 - SPACER SPNL 6D 60X20X8MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111240 SUP HCPCS C1713 2111240 - SPACER SPNL 6D 40X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111245 SUP HCPCS C1713 2111245 - SPACER SPNL 6D 45X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111250 SUP HCPCS C1713 2111250 - SPACER SPNL 6D 50X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111255 SUP HCPCS C1713 2111255 - SPACER SPNL 6D 55X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111260 SUP HCPCS C1713 2111260 - SPACER SPNL 6D 60X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111340 SUP HCPCS C1713 2111340 - SPACER SPNL 6D 40X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111345 SUP HCPCS C1713 2111345 - SPACER SPNL 6D 45X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111350 SUP HCPCS C1713 2111350 - SPACER SPNL 6D 50X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111355 SUP HCPCS C1713 2111355 - SPACER SPNL 6D 55X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111360 SUP HCPCS C1713 2111360 - SPACER SPNL 6D 60X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111440 SUP HCPCS C1713 2111440 - SPACER SPNL 6D 40X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111445 SUP HCPCS C1713 2111445 - SPACER SPNL 6D 45X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111450 SUP HCPCS C1713 2111450 - SPACER SPNL 6D 50X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111455 SUP HCPCS C1713 2111455 - SPACER SPNL 6D 55X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111460 SUP HCPCS C1713 2111460 - SPACER SPNL 6D 60X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111540 SUP HCPCS C1713 2111540 - SPACER SPNL 6D 40X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111545 SUP HCPCS C1713 2111545 - SPACER SPNL 6D 45X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111550 SUP HCPCS C1713 2111550 - SPACER SPNL 6D 50X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111555 SUP HCPCS C1713 2111555 - SPACER SPNL 6D 55X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2111560 SUP HCPCS C1713 2111560 - SPACER SPNL 6D 60X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112240 SUP HCPCS C1713 2112240 - SPACER SPNL 12D 40X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112245 SUP HCPCS C1713 2112245 - SPACER SPNL 12D 45X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112250 SUP HCPCS C1713 2112250 - SPACER SPNL 12D 50X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112255 SUP HCPCS C1713 2112255 - SPACER SPNL 12D 55X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112260 SUP HCPCS C1713 2112260 - SPACER SPNL 12D 60X20X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112340 SUP HCPCS C1713 2112340 - SPACER SPNL 12D 40X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112345 SUP HCPCS C1713 2112345 - SPACER SPNL 12D 45X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112350 SUP HCPCS C1713 2112350 - SPACER SPNL 12D 50X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112355 SUP HCPCS C1713 2112355 - SPACER SPNL 12D 55X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112360 SUP HCPCS C1713 2112360 - SPACER SPNL 12D 60X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112440 SUP HCPCS C1713 2112440 - SPACER SPNL 12D 40X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112445 SUP HCPCS C1713 2112445 - SPACER SPNL 12D 45X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112450 SUP HCPCS C1713 2112450 - SPACER SPNL 12D 50X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112455 SUP HCPCS C1713 2112455 - SPACER SPNL 12D 55X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112460 SUP HCPCS C1713 2112460 - SPACER SPNL 12D 60X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112540 SUP HCPCS C1713 2112540 - SPACER SPNL 12D 40X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112545 SUP HCPCS C1713 2112545 - SPACER SPNL 12D 45X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112550 SUP HCPCS C1713 2112550 - SPACER SPNL 12D 50X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112555 SUP HCPCS C1713 2112555 - SPACER SPNL 12D 55X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112560 SUP HCPCS C1713 2112560 - SPACER SPNL 12D 60X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112640 SUP HCPCS C1713 2112640 - SPACER SPNL 12D 40X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112645 SUP HCPCS C1713 2112645 - SPACER SPNL 12D 45X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112650 SUP HCPCS C1713 2112650 - SPACER SPNL 12D 50X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112655 SUP HCPCS C1713 2112655 - SPACER SPNL 12D 55X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2112660 SUP HCPCS C1713 2112660 - SPACER SPNL 12D 60X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113340 SUP HCPCS C1713 2113340 - SPACER SPNL 18D 40X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113345 SUP HCPCS C1713 2113345 - SPACER SPNL 18D 45X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113350 SUP HCPCS C1713 2113350 - SPACER SPNL 18D 50X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113355 SUP HCPCS C1713 2113355 - SPACER SPNL 18D 55X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113360 SUP HCPCS C1713 2113360 - SPACER SPNL 18D 60X20X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113440 SUP HCPCS C1713 2113440 - SPACER SPNL 18D 40X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113445 SUP HCPCS C1713 2113445 - SPACER SPNL 18D 45X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113450 SUP HCPCS C1713 2113450 - SPACER SPNL 18D 50X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113455 SUP HCPCS C1713 2113455 - SPACER SPNL 18D 55X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113460 SUP HCPCS C1713 2113460 - SPACER SPNL 18D 60X20X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113540 SUP HCPCS C1713 2113540 - SPACER SPNL 18D 40X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113545 SUP HCPCS C1713 2113545 - SPACER SPNL 18D 45X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113550 SUP HCPCS C1713 2113550 - SPACER SPNL 18D 50X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113555 SUP HCPCS C1713 2113555 - SPACER SPNL 18D 55X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113560 SUP HCPCS C1713 2113560 - SPACER SPNL 18D 60X20X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113640 SUP HCPCS C1713 2113640 - SPACER SPNL 18D 40X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113645 SUP HCPCS C1713 2113645 - SPACER SPNL 18D 45X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113650 SUP HCPCS C1713 2113650 - SPACER SPNL 18D 50X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113655 SUP HCPCS C1713 2113655 - SPACER SPNL 18D 55X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2113660 SUP HCPCS C1713 2113660 - SPACER SPNL 18D 60X20X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131240 SUP HCPCS C1713 2131240 - SPACER SPNL 6D 40X27X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131245 SUP HCPCS C1713 2131245 - SPACER SPNL 6D 45X27X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131250 SUP HCPCS C1713 2131250 - SPACER SPNL 6D 50X27X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131255 SUP HCPCS C1713 2131255 - SPACER SPNL 6D 55X27X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131260 SUP HCPCS C1713 2131260 - SPACER SPNL 6D 60X27X10MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131340 SUP HCPCS C1713 2131340 - SPACER SPNL 6D 40X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131345 SUP HCPCS C1713 2131345 - SPACER SPNL 6D 45X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131350 SUP HCPCS C1713 2131350 - SPACER SPNL 6D 50X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131355 SUP HCPCS C1713 2131355 - SPACER SPNL 6D 55X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131360 SUP HCPCS C1713 2131360 - SPACER SPNL 6D 60X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131440 SUP HCPCS C1713 2131440 - SPACER SPNL 6D 40X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131445 SUP HCPCS C1713 2131445 - SPACER SPNL 6D 45X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131450 SUP HCPCS C1713 2131450 - SPACER SPNL 6D 50X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131455 SUP HCPCS C1713 2131455 - SPACER SPNL 6D 55X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131460 SUP HCPCS C1713 2131460 - SPACER SPNL 6D 60X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131540 SUP HCPCS C1713 2131540 - SPACER SPNL 6D 40X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131545 SUP HCPCS C1713 2131545 - SPACER SPNL 6D 45X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131550 SUP HCPCS C1713 2131550 - SPACER SPNL 6D 50X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131555 SUP HCPCS C1713 2131555 - SPACER SPNL 6D 55X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2131560 SUP HCPCS C1713 2131560 - SPACER SPNL 6D 60X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132340 SUP HCPCS C1713 2132340 - SPACER SPNL 12D 40X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132345 SUP HCPCS C1713 2132345 - SPACER SPNL 12D 45X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132350 SUP HCPCS C1713 2132350 - SPACER SPNL 12D 50X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132355 SUP HCPCS C1713 2132355 - SPACER SPNL 12D 55X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132360 SUP HCPCS C1713 2132360 - SPACER SPNL 12D 60X27X12MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132440 SUP HCPCS C1713 2132440 - SPACER SPNL 12D 40X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132445 SUP HCPCS C1713 2132445 - SPACER SPNL 12D 45X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132450 SUP HCPCS C1713 2132450 - SPACER SPNL 12D 50X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132455 SUP HCPCS C1713 2132455 - SPACER SPNL 12D 55X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132460 SUP HCPCS C1713 2132460 - SPACER SPNL 12D 60X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132540 SUP HCPCS C1713 2132540 - SPACER SPNL 12D 40X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132545 SUP HCPCS C1713 2132545 - SPACER SPNL 12D 45X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132550 SUP HCPCS C1713 2132550 - SPACER SPNL 12D 50X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132555 SUP HCPCS C1713 2132555 - SPACER SPNL 12D 55X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132560 SUP HCPCS C1713 2132560 - SPACER SPNL 12D 60X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132640 SUP HCPCS C1713 2132640 - SPACER SPNL 12D 40X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132645 SUP HCPCS C1713 2132645 - SPACER SPNL 12D 45X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132650 SUP HCPCS C1713 2132650 - SPACER SPNL 12D 50X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132655 SUP HCPCS C1713 2132655 - SPACER SPNL 12D 55X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2132660 SUP HCPCS C1713 2132660 - SPACER SPNL 12D 60X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133440 SUP HCPCS C1713 2133440 - SPACER SPNL 18D 40X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133445 SUP HCPCS C1713 2133445 - SPACER SPNL 18D 45X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133450 SUP HCPCS C1713 2133450 - SPACER SPNL 18D 50X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133455 SUP HCPCS C1713 2133455 - SPACER SPNL 18D 55X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133460 SUP HCPCS C1713 2133460 - SPACER SPNL 18D 60X27X14MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133540 SUP HCPCS C1713 2133540 - SPACER SPNL 18D 40X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133545 SUP HCPCS C1713 2133545 - SPACER SPNL 18D 45X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133550 SUP HCPCS C1713 2133550 - SPACER SPNL 18D 50X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133555 SUP HCPCS C1713 2133555 - SPACER SPNL 18D 55X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133560 SUP HCPCS C1713 2133560 - SPACER SPNL 18D 60X27X16MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133640 SUP HCPCS C1713 2133640 - SPACER SPNL 18D 40X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133645 SUP HCPCS C1713 2133645 - SPACER SPNL 18D 45X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133650 SUP HCPCS C1713 2133650 - SPACER SPNL 18D 50X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133655 SUP HCPCS C1713 2133655 - SPACER SPNL 18D 55X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2133660 SUP HCPCS C1713 2133660 - SPACER SPNL 18D 60X27X18MM PIVOX LAT OLIF25 BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2140001 SUP HCPCS C1713 2140001 - PLATE SPNL SM 2 HOLE OLIF25 STRL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2140002 SUP HCPCS C1713 2140002 - PLATE SPNL LG 2 HOLE OLIF25 STRL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2140120 SUP HCPCS C1713 2140120 - SCREW BONE 5.5MM 20MM LMBR SPN STRL BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2140125 SUP HCPCS C1713 2140125 - SCREW BONE 5.5MM 25MM LMBR SPN STRL BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2140130 SUP HCPCS C1713 2140130 - SCREW BONE 5.5MM 30MM LMBR SPN STRL BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2140135 SUP HCPCS C1713 2140135 - SCREW BONE 5.5MM 35MM LMBR SPN STRL BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2140140 SUP HCPCS C1713 2140140 - SCREW BONE 5.5MM 40MM LMBR SPN STRL BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2140145 SUP HCPCS C1713 2140145 - SCREW BONE 5.5MM 45MM LMBR SPN STRL BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2140150 SUP HCPCS C1713 2140150 - SCREW BONE 5.5MM 50MM LMBR SPN STRL BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2150010 SUP HCPCS C1713 2150010 - PLATE SPNL 10MM DIVERGENCE-L OLIF51 BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2150012 SUP HCPCS C1713 2150012 - PLATE SPNL 12MM DIVERGENCE-L OLIF51 BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2150014 SUP HCPCS C1713 2150014 - PLATE SPNL 14MM DIVERGENCE-L OLIF51 BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2150016 SUP HCPCS C1713 2150016 - PLATE SPNL 16MM DIVERGENCE-L OLIF51 BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2150018 SUP HCPCS C1713 2150018 - PLATE SPNL 18MM DIVERGENCE-L OLIF51 BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2150020 SUP HCPCS C1713 2150020 - PLATE SPNL 20MM DIVERGENCE-L OLIF51 BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2150120 SUP HCPCS C1713 2150120 - SCREW BONE 20MM DIVERGENCE-L SPN BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2150125 SUP HCPCS C1713 2150125 - SCREW BONE 25MM DIVERGENCE-L SPN BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2150130 SUP HCPCS C1713 2150130 - SCREW BONE 6.5MM 30MM DIVERGENCE-L SPN BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2150135 SUP HCPCS C1713 2150135 - SCREW BONE 6.5MM 35MM DIVERGENCE-L SPN BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2150140 SUP HCPCS C1713 2150140 - SCREW BONE 6.5MM 40MM DIVERGENCE-L SPN BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 2151110 SUP HCPCS C1713 2151110 - CAGE SPNL 6D SM 32X25X10MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151112 SUP HCPCS C1713 2151112 - CAGE SPNL 32X25X12MM DIVERGENCE-L 6D SM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151114 SUP HCPCS C1713 2151114 - CAGE SPNL 6D SM 32X25X14MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151116 SUP HCPCS C1713 2151116 - CAGE SPNL 6D SM 32X25X16MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151118 SUP HCPCS C1713 2151118 - CAGE SPNL 6D SM 32X25X18MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151120 SUP HCPCS C1713 2151120 - CAGE SPNL 6D SM 32X25X20MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151210 SUP HCPCS C1713 2151210 - CAGE SPNL 6D MED 37X29X10MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151212 SUP HCPCS C1713 2151212 - CAGE SPNL 6D MED 37X29X12MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151214 SUP HCPCS C1713 2151214 - CAGE SPNL 6D MED 37X29X14MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151216 SUP HCPCS C1713 2151216 - CAGE SPNL 6D MED 37X29X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151218 SUP HCPCS C1713 2151218 - CAGE SPNL 6D MED 37X29X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151220 SUP HCPCS C1713 2151220 - CAGE SPNL 6D MED 37X29X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151310 SUP HCPCS C1713 2151310 - CAGE SPNL 6D LG 42X32X10MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151312 SUP HCPCS C1713 2151312 - CAGE SPNL 6D LG 42X32X12MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151314 SUP HCPCS C1713 2151314 - CAGE SPNL 6D LG 42X32X14MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151316 SUP HCPCS C1713 2151316 - CAGE SPNL 6D LG 42X32X16MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151318 SUP HCPCS C1713 2151318 - CAGE SPNL 6D LG 42X32X18MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2151320 SUP HCPCS C1713 2151320 - CAGE SPNL 6D LG 42X32X20MM DIVERGENCE-L ANT OBLQ LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152110 SUP HCPCS C1713 2152110 - CAGE SPNL 12D SM 32X25X10MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152112 SUP HCPCS C1713 2152112 - CAGE SPNL 12D SM 32X25X12MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152114 SUP HCPCS C1713 2152114 - CAGE SPNL 12D SM 32X25X14MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152116 SUP HCPCS C1713 2152116 - CAGE SPNL 12D SM 32X25X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152118 SUP HCPCS C1713 2152118 - CAGE SPNL 12D SM 32X25X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152120 SUP HCPCS C1713 2152120 - CAGE SPNL 12D SM 32X25X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152210 SUP HCPCS C1713 2152210 - CAGE SPNL 12D MED 37X29X10MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152212 SUP HCPCS C1713 2152212 - CAGE SPNL 12D MED 37X29X12MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152214 SUP HCPCS C1713 2152214 - CAGE SPNL 12D MED 37X29X14MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152216 SUP HCPCS C1713 2152216 - CAGE SPNL 12D MED 37X29X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152218 SUP HCPCS C1713 2152218 - CAGE SPNL 12D MED 37X29X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152220 SUP HCPCS C1713 2152220 - CAGE SPNL 12D MED 37X29X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152312 SUP HCPCS C1713 2152312 - CAGE SPNL 12D LG 42X32X12MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152314 SUP HCPCS C1713 2152314 - CAGE SPNL 12D LG 42X32X14MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152316 SUP HCPCS C1713 2152316 - CAGE SPNL 12D LG 42X32X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152318 SUP HCPCS C1713 2152318 - CAGE SPNL 12D LG 42X32X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2152320 SUP HCPCS C1713 2152320 - CAGE SPNL 12D LG 42X32X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153112 SUP HCPCS C1713 2153112 - CAGE SPNL 18D SM 32X25X12MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153114 SUP HCPCS C1713 2153114 - CAGE SPNL 18D SM 32X25X14MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153116 SUP HCPCS C1713 2153116 - CAGE SPNL 18D SM 32X25X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153118 SUP HCPCS C1713 2153118 - CAGE SPNL 18D SM 32X25X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153120 SUP HCPCS C1713 2153120 - CAGE SPNL 18D SM 32X25X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153214 SUP HCPCS C1713 2153214 - CAGE SPNL 18D MED 37X29X14MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153216 SUP HCPCS C1713 2153216 - CAGE SPNL 18D MED 37X29X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153218 SUP HCPCS C1713 2153218 - CAGE SPNL 18D MED 37X29X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153220 SUP HCPCS C1713 2153220 - CAGE SPNL 18D MED 37X29X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153316 SUP HCPCS C1713 2153316 - CAGE SPNL 18D LG 42X32X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153318 SUP HCPCS C1713 2153318 - CAGE SPNL 18D LG 42X32X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2153320 SUP HCPCS C1713 2153320 - CAGE SPNL 18D LG 42X32X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2154116 SUP HCPCS C1713 2154116 - CAGE SPNL 24D SM 32X25X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2154118 SUP HCPCS C1713 2154118 - CAGE SPNL 24D SM 32X25X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2154120 SUP HCPCS C1713 2154120 - CAGE SPNL 24D SM 32X25X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2154216 SUP HCPCS C1713 2154216 - CAGE SPNL 24D MED 37X29X16MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2154218 SUP HCPCS C1713 2154218 - CAGE SPNL 24D MED 37X29X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2154220 SUP HCPCS C1713 2154220 - CAGE SPNL 24D MED 37X29X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2154318 SUP HCPCS C1713 2154318 - CAGE SPNL 24D LG 42X32X18MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2154320 SUP HCPCS C1713 2154320 - CAGE SPNL 24D LG 42X32X20MM DIVERGENCE-L ANT OBLQ LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2160010 SUP HCPCS C1713 2160010 - PLATE SPNL 10MM DIVERGENCE-L ALIF BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 2160012 SUP HCPCS C1713 2160012 - PLATE SPNL 12MM DIVERGENCE-L ALIF BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-11 SUP HCPCS C1713 01-8611 - PLATE BN SM MESH CNTR ANTM EZ MODIFICATION MN SHRP EDG RT BOTH IP/OP "$4,677.50 " "$3,461.35" $0.00 "$3,742.00" "$2,104.88" "$2,104.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,338.75" "$3,704.58" "$3,742.00" $0.00 $0.00 $732.03 $0.00 $0.00 $744.66 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-12 SUP HCPCS C1713 01-8612 - PLATE BN LG MESH CNTR ANTM EZ MODIFICATION MN SHRP EDG LT BOTH IP/OP "$4,837.50 " "$3,579.75" $0.00 "$3,870.00" "$2,176.88" "$2,176.88" $0.00 $0.00 $0.00 "$1,008.26" "$3,590.39" "$3,590.39" $0.00 $0.00 "$1,008.14" $0.00 "$2,384.89" "$2,384.89" $0.00 "$2,418.75" "$3,831.30" "$3,870.00" $0.00 $0.00 $757.07 $0.00 $0.00 $770.13 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-36 SUP HCPCS C1713 01-8636 - PLATE BONE LONG 3X3 HOLE L RIGID DELTA GOLD LEFT BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-62 SUP HCPCS C1713 01-8662 - PLATE BONE 8 HOLE STR RIGID TRAUMAONE GOLD TITANIUM MIDFAC BOTH IP/OP $872.50 $645.65 $0.00 $698.00 $392.63 $392.63 $0.00 $0.00 $0.00 $181.85 $647.57 $647.57 $0.00 $0.00 $181.83 $0.00 $516.08 $516.08 $0.00 $436.25 $691.02 $698.00 $0.00 $0.00 $136.55 $0.00 $0.00 $138.90 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-64 SUP HCPCS C1713 01-8664 - PLATE BONE 4 HOLE STR RIGID TRAUMAONE GOLD TITANIUM MIDFAC BOTH IP/OP $872.50 $645.65 $0.00 $698.00 $392.63 $392.63 $0.00 $0.00 $0.00 $181.85 $647.57 $647.57 $0.00 $0.00 $181.83 $0.00 $516.08 $516.08 $0.00 $436.25 $691.02 $698.00 $0.00 $0.00 $136.55 $0.00 $0.00 $138.90 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-70 SUP HCPCS C1713 01-8670 - PLATE BONE LONG STR 20 HOLE RIGID SYSTEM LORENZ TRAUMAONE BOTH IP/OP "$1,510.00 " "$1,117.40" $0.00 "$1,208.00" $679.50 $679.50 $0.00 $0.00 $0.00 $314.72 "$1,120.72" "$1,120.72" $0.00 $0.00 $314.68 $0.00 $893.17 $893.17 $0.00 $755.00 "$1,195.92" "$1,208.00" $0.00 $0.00 $236.32 $0.00 $0.00 $240.39 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-78 SUP HCPCS C1713 01-8678 - PLATE LEFT MIDFAC 2X2 HOLE L RGD 1.5MM SCR BONE LORENZ BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-79 SUP HCPCS C1713 01-8679 - PLATE RIGHT MIDFAC 2X2 HOLE L RGD 1.5MM SCR BONE LORENZ BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-80 SUP HCPCS C1713 01-8680 - PLATE BONE LONG 4X6 HOLE L RIGID TRAUMAONE GOLD TITANIUM BOTH IP/OP "$1,015.00 " $751.10 $0.00 $812.00 $456.75 $456.75 $0.00 $0.00 $0.00 $211.55 $753.33 $753.33 $0.00 $0.00 $211.53 $0.00 $600.37 $600.37 $0.00 $507.50 $803.88 $812.00 $0.00 $0.00 $158.85 $0.00 $0.00 $161.59 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-81 SUP HCPCS C1713 01-8681 - PLATE BONE LONG 4X6 HOLE L RIGID TRAUMAONE GOLD TITANIUM BOTH IP/OP "$1,015.00 " $751.10 $0.00 $812.00 $456.75 $456.75 $0.00 $0.00 $0.00 $211.55 $753.33 $753.33 $0.00 $0.00 $211.53 $0.00 $600.37 $600.37 $0.00 $507.50 $803.88 $812.00 $0.00 $0.00 $158.85 $0.00 $0.00 $161.59 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-89 SUP HCPCS C1713 01-8689 - PLATE BONE LONG 14 HOLE CVD RIGID TRAUMAONE GOLD TITANIUM BOTH IP/OP "$1,102.50 " $815.85 $0.00 $882.00 $496.13 $496.13 $0.00 $0.00 $0.00 $229.79 $818.28 $818.28 $0.00 $0.00 $229.76 $0.00 $652.13 $652.13 $0.00 $551.25 $873.18 $882.00 $0.00 $0.00 $172.54 $0.00 $0.00 $175.52 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-92 SUP Custom 27203010 01-9192 - TW DRILL 1.5X50MM 5MM STP W/NT BOTH IP/OP $435.00 $321.90 $0.00 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.86 $322.86 $0.00 $0.00 $90.65 $0.00 $0.00 $0.00 $0.00 $217.50 $344.52 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-93 SUP Custom 27203010 01-9193 - DRILL TWIST 1.5MM 50MM 7MM STOP TRAUMAONE BOTH IP/OP $435.00 $321.90 $0.00 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.86 $322.86 $0.00 $0.00 $90.65 $0.00 $0.00 $0.00 $0.00 $217.50 $344.52 $348.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Jan-20 SUP HCPCS C1781 01-9520 - MESH SURG SMALL .6MM ETCHED LABEL ANATOMIC AESTHETIC BOTH IP/OP "$16,200.00 " "$11,988.00" $0.00 "$12,960.00" "$7,290.00" "$7,290.00" $0.00 $0.00 $0.00 "$3,376.49" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,376.08" $0.00 "$7,986.60" "$7,986.60" $0.00 "$8,100.00" "$12,830.40" "$12,960.00" $0.00 $0.00 "$2,535.30" $0.00 $0.00 "$2,579.04" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-21 SUP HCPCS C1781 01-9521 - MESH SURG SMALL .6MM ETCHED LABEL ANATOMIC AESTHETIC BOTH IP/OP "$18,900.00 " "$13,986.00" $0.00 "$15,120.00" "$8,505.00" "$8,505.00" $0.00 $0.00 $0.00 "$3,939.23" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,938.76" $0.00 "$9,317.70" "$9,317.70" $0.00 "$9,450.00" "$14,968.80" "$15,120.00" $0.00 $0.00 "$2,957.85" $0.00 $0.00 "$3,008.88" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-22 SUP HCPCS C1781 01-9522 - MESH SURG SMALL .6MM ETCHED LABEL ANATOMIC AESTHETIC BOTH IP/OP "$18,900.00 " "$13,986.00" $0.00 "$15,120.00" "$8,505.00" "$8,505.00" $0.00 $0.00 $0.00 "$3,939.23" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,938.76" $0.00 "$9,317.70" "$9,317.70" $0.00 "$9,450.00" "$14,968.80" "$15,120.00" $0.00 $0.00 "$2,957.85" $0.00 $0.00 "$3,008.88" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-23 SUP HCPCS C1781 01-9523 - MESH SURG LARGE .6MM ETCHED LABEL ANATOMIC AESTHETIC BOTH IP/OP "$21,060.00 " "$15,584.40" $0.00 "$16,848.00" "$9,477.00" "$9,477.00" $0.00 $0.00 $0.00 "$4,389.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,388.90" $0.00 "$10,382.58" "$10,382.58" $0.00 "$10,530.00" "$16,679.52" "$16,848.00" $0.00 $0.00 "$3,295.89" $0.00 $0.00 "$3,352.75" $0.00 $0.00 $0.00 $0.00 $0.00 Jan-24 SUP HCPCS C1781 01-9524 - MESH SURG LARGE .6MM ETCHED LABEL ANATOMIC AESTHETIC BOTH IP/OP "$21,060.00 " "$15,584.40" $0.00 "$16,848.00" "$9,477.00" "$9,477.00" $0.00 $0.00 $0.00 "$4,389.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,388.90" $0.00 "$10,382.58" "$10,382.58" $0.00 "$10,530.00" "$16,679.52" "$16,848.00" $0.00 $0.00 "$3,295.89" $0.00 $0.00 "$3,352.75" $0.00 $0.00 $0.00 $0.00 $0.00 2800724 SUP HCPCS C1713 2800724 - CAGE SPNL 0D 24MMX7MM STRL FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2800824 SUP HCPCS C1713 2800824 - CAGE SPNL 0D 24MMX8MM STRL FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2840924 SUP HCPCS C1713 2840924 - CAGE SPNL 4D 24MMX9MM STRL FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2841024 SUP HCPCS C1713 2841024 - CAGE SPNL 4D 24MMX10MM STRL FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2841124 SUP HCPCS C1713 2841124 - CAGE SPNL 4D 24MMX11MM STRL FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2841224 SUP HCPCS C1713 2841224 - CAGE SPNL 4D 24MMX12MM STRL FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2841324 SUP HCPCS C1713 2841324 - CAGE SPNL 4D 24MMX13MM STRL FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2841424 SUP HCPCS C1713 2841424 - CAGE SPNL 4D 24MMX14MM STRL FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2880924 SUP HCPCS C1713 2880924 - CAGE SPNL 8D 24MMX9MM FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2881024 SUP HCPCS C1713 2881024 - CAGE SPNL 8D 24MMX10MM FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2881124 SUP HCPCS C1713 2881124 - CAGE SPNL 8D 24MMX11MM FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2881224 SUP HCPCS C1713 2881224 - CAGE SPNL 8D 24MMX12MM FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2881324 SUP HCPCS C1713 2881324 - CAGE SPNL 8D 24MMX13MM FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2881424 SUP HCPCS C1713 2881424 - CAGE SPNL 8D 24MMX14MM FUSE TI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 2920040 SUP Custom 27803010 2920040 - CAGE SPNL 0D 40X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920045 SUP Custom 27803010 2920045 - CAGE SPNL 0D 45X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920050 SUP Custom 27803010 2920050 - CAGE SPNL 0D 50X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920055 SUP Custom 27803010 2920055 - CAGE SPNL 0D 55X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920060 SUP Custom 27803010 2920060 - CAGE SPNL 0D 60X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920240 SUP Custom 27803010 2920240 - CAGE SPNL 0D 40X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920245 SUP Custom 27803010 2920245 - CAGE SPNL 0D 45X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920250 SUP Custom 27803010 2920250 - CAGE SPNL 0D 50X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920255 SUP Custom 27803010 2920255 - CAGE SPNL 0D 55X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920260 SUP Custom 27803010 2920260 - CAGE SPNL 0D 60X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920440 SUP Custom 27803010 2920440 - CAGE SPNL 0D 40X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920445 SUP Custom 27803010 2920445 - CAGE SPNL 0D 45X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920450 SUP Custom 27803010 2920450 - CAGE SPNL 0D 50X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920455 SUP Custom 27803010 2920455 - CAGE SPNL 0D 55X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920460 SUP Custom 27803010 2920460 - CAGE SPNL 0D 60X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920640 SUP Custom 27803010 2920640 - CAGE SPNL 0D 40X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920645 SUP Custom 27803010 2920645 - CAGE SPNL 0D 45X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920650 SUP Custom 27803010 2920650 - CAGE SPNL 0D 50X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920655 SUP Custom 27803010 2920655 - CAGE SPNL 0D 55X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920660 SUP Custom 27803010 2920660 - CAGE SPNL 0D 60X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920840 SUP Custom 27803010 2920840 - CAGE SPNL 0D 40X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920845 SUP Custom 27803010 2920845 - CAGE SPNL 0D 45X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920850 SUP Custom 27803010 2920850 - CAGE SPNL 0D 50X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920855 SUP Custom 27803010 2920855 - CAGE SPNL 0D 55X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2920860 SUP Custom 27803010 2920860 - CAGE SPNL 0D 60X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922040 SUP Custom 27803010 2922040 - CAGE SPNL 12D 40X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922045 SUP Custom 27803010 2922045 - CAGE SPNL 12D 45X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922050 SUP Custom 27803010 2922050 - CAGE SPNL 12D 50X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922055 SUP Custom 27803010 2922055 - CAGE SPNL 12D 55X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922060 SUP Custom 27803010 2922060 - CAGE SPNL 12D 60X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922240 SUP Custom 27803010 2922240 - CAGE SPNL 12D 40X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922245 SUP Custom 27803010 2922245 - CAGE SPNL 12D 45X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922250 SUP Custom 27803010 2922250 - CAGE SPNL 12D 50X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922255 SUP Custom 27803010 2922255 - CAGE SPNL 12D 55X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922260 SUP Custom 27803010 2922260 - CAGE SPNL 12D 60X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922440 SUP Custom 27803010 2922440 - CAGE SPNL 12D 40X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922445 SUP Custom 27803010 2922445 - CAGE SPNL 12D 45X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922450 SUP Custom 27803010 2922450 - CAGE SPNL 12D 50X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922455 SUP Custom 27803010 2922455 - CAGE SPNL 12D 55X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922460 SUP Custom 27803010 2922460 - CAGE SPNL 12D 60X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922640 SUP Custom 27803010 2922640 - CAGE SPNL 12D 40X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922645 SUP Custom 27803010 2922645 - CAGE SPNL 12D 45X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922650 SUP Custom 27803010 2922650 - CAGE SPNL 12D 50X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922655 SUP Custom 27803010 2922655 - CAGE SPNL 12D 55X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2922660 SUP Custom 27803010 2922660 - CAGE SPNL 12D 60X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926040 SUP Custom 27803010 2926040 - CAGE SPNL 6D 40X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926045 SUP Custom 27803010 2926045 - CAGE SPNL 6D 45X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926050 SUP Custom 27803010 2926050 - CAGE SPNL 6D 50X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926055 SUP Custom 27803010 2926055 - CAGE SPNL 6D 55X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926060 SUP Custom 27803010 2926060 - CAGE SPNL 6D 60X22X10MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926240 SUP Custom 27803010 2926240 - CAGE SPNL 6D 40X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926245 SUP Custom 27803010 2926245 - CAGE SPNL 6D 45X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926250 SUP Custom 27803010 2926250 - CAGE SPNL 6D 50X22X12MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926255 SUP Custom 27803010 2926255 - CAGE SPNL 6D 22X12X55MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926260 SUP Custom 27803010 2926260 - CAGE SPNL 6D 60X12X22MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926440 SUP Custom 27803010 2926440 - CAGE SPNL 6D 40X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926445 SUP Custom 27803010 2926445 - CAGE SPNL 6D 45X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926450 SUP Custom 27803010 2926450 - CAGE SPNL 6D 50X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926455 SUP Custom 27803010 2926455 - CAGE SPNL 6D 55X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926460 SUP Custom 27803010 2926460 - CAGE SPNL 6D 60X22X14MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926640 SUP Custom 27803010 2926640 - CAGE SPNL 6D 40X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926645 SUP Custom 27803010 2926645 - CAGE SPNL 6D 45X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926650 SUP Custom 27803010 2926650 - CAGE SPNL 6D 50X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926655 SUP Custom 27803010 2926655 - CAGE SPNL 6D 55X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926660 SUP Custom 27803010 2926660 - CAGE SPNL 6D 60X22X16MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926840 SUP Custom 27803010 2926840 - CAGE SPNL 6D 40X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926845 SUP Custom 27803010 2926845 - CAGE SPNL 6D 45X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926850 SUP Custom 27803010 2926850 - CAGE SPNL 6D 50X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926855 SUP Custom 27803010 2926855 - CAGE SPNL 6D 55X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2926860 SUP Custom 27803010 2926860 - CAGE SPNL 6D 60X22X8MM STRL CLYDESDALE RADOPQ PEEK LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2960822 SUP Custom 27803010 2960822 - SPACER SPNL 22MMX8MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2960826 SUP HCPCS C1713 2960826 - SPACER SPNL 26MMX8MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2960832 SUP Custom 27803010 2960832 - SPACER SPNL 32MMX8MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2960836 SUP Custom 27803010 2960836 - SPACER SPNL 36MMX8MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961022 SUP Custom 27803010 2961022 - SPACER SPNL 22MMX10MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961026 SUP HCPCS C1713 2961026 - SPACER SPNL 26MMX10MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961032 SUP Custom 27803010 2961032 - SPACER SPNL 32MMX10MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961036 SUP Custom 27803010 2961036 - SPACER SPNL 36MMX10MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961222 SUP Custom 27803010 2961222 - SPACER SPNL 22MMX12MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961226 SUP Custom 27803010 2961226 - SPACER SPNL 26MMX12MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961232 SUP Custom 27803010 2961232 - SPACER SPNL 32MMX12MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961236 SUP Custom 27803010 2961236 - SPACER SPNL 36MMX12MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961422 SUP Custom 27803010 2961422 - SPACER SPNL 22MMX14MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961426 SUP Custom 27803010 2961426 - SPACER SPNL 26X14MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961432 SUP Custom 27803010 2961432 - SPACER SPNL 32MMX14MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2961436 SUP Custom 27803010 2961436 - SPACER SPNL 36X14MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2962036 SUP HCPCS C1713 2962036 - SPACER SPNL 36MMX10MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962040 SUP HCPCS C1713 2962040 - SPACER SPNL 40MMX10MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962044 SUP HCPCS C1713 2962044 - SPACER SPNL 44MMX10MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962236 SUP HCPCS C1713 2962236 - SPACER SPNL 36MMX12MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962240 SUP HCPCS C1713 2962240 - SPACER SPNL 40MMX12MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962244 SUP HCPCS C1713 2962244 - SPACER SPNL 44MMX12MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962436 SUP HCPCS C1713 2962436 - SPACER SPNL 36MMX14MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962440 SUP HCPCS C1713 2962440 - SPACER SPNL 40MMX14MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962444 SUP HCPCS C1713 2962444 - SPACER SPNL 44MMX14MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962836 SUP HCPCS C1713 2962836 - SPACER SPNL 36MMX8MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962840 SUP HCPCS C1713 2962840 - SPACER SPNL 40MMX8MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2962844 SUP HCPCS C1713 2962844 - SPACER SPNL 44MMX8MM VRTSTCK CPSTN END PC PEEK-OPTM LMBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 2968040 SUP Custom 27803010 2968040 - CAGE SPNL 6D 40MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968045 SUP Custom 27803010 2968045 - CAGE SPNL 6D 45MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968050 SUP Custom 27803010 2968050 - CAGE SPNL 6D 50MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968055 SUP Custom 27803010 2968055 - CAGE SPNL 6D 55MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968060 SUP Custom 27803010 2968060 - CAGE SPNL 6D 60MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968240 SUP Custom 27803010 2968240 - CAGE SPNL 6D 40MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968245 SUP Custom 27803010 2968245 - CAGE SPNL 6D 45MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968250 SUP Custom 27803010 2968250 - CAGE SPNL 6D 50MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968255 SUP Custom 27803010 2968255 - CAGE SPNL 6D 55MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968260 SUP Custom 27803010 2968260 - CAGE SPNL 6D 60MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968440 SUP Custom 27803010 2968440 - CAGE SPNL 6D 40MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968445 SUP Custom 27803010 2968445 - CAGE SPNL 6D 45MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968450 SUP Custom 27803010 2968450 - CAGE SPNL 6D 50MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968455 SUP Custom 27803010 2968455 - CAGE SPNL 6D 55MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968460 SUP Custom 27803010 2968460 - CAGE SPNL 6D 60MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968640 SUP Custom 27803010 2968640 - CAGE SPNL 6D 40MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968645 SUP Custom 27803010 2968645 - CAGE SPNL 6D 45MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968650 SUP Custom 27803010 2968650 - CAGE SPNL 6D 50MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968655 SUP Custom 27803010 2968655 - CAGE SPNL 6D 55MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968660 SUP Custom 27803010 2968660 - CAGE SPNL 6D 60MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968840 SUP Custom 27803010 2968840 - CAGE SPNL 6D 40MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968845 SUP Custom 27803010 2968845 - CAGE SPNL 6D 45MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968850 SUP Custom 27803010 2968850 - CAGE SPNL 6D 50MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968855 SUP Custom 27803010 2968855 - CAGE SPNL 6D 55MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2968860 SUP Custom 27803010 2968860 - CAGE SPNL 6D 60MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969040 SUP Custom 27803010 2969040 - CAGE SPNL 0D 40MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969045 SUP Custom 27803010 2969045 - CAGE SPNL 0D 45MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969050 SUP Custom 27803010 2969050 - CAGE SPNL 0D 50MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969055 SUP Custom 27803010 2969055 - CAGE SPNL 0D 55MMX10MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969240 SUP Custom 27803010 2969240 - CAGE SPNL 0D 40MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969245 SUP Custom 27803010 2969245 - CAGE SPNL 0D 45MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969250 SUP Custom 27803010 2969250 - CAGE SPNL 0D 50MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969255 SUP Custom 27803010 2969255 - CAGE SPNL 0D 55MMX12MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969440 SUP Custom 27803010 2969440 - CAGE SPNL 0D 40MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969445 SUP Custom 27803010 2969445 - CAGE SPNL 0D 45MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969450 SUP Custom 27803010 2969450 - CAGE SPNL 0D 50MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969455 SUP Custom 27803010 2969455 - CAGE SPNL 0D 55MMX14MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969640 SUP Custom 27803010 2969640 - CAGE SPNL 0D 40MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969645 SUP Custom 27803010 2969645 - CAGE SPNL 0D 45MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969650 SUP Custom 27803010 2969650 - CAGE SPNL 0D 50MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969655 SUP Custom 27803010 2969655 - CAGE SPNL 0D 55MMX16MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969840 SUP Custom 27803010 2969840 - CAGE SPNL 0D 40MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969845 SUP Custom 27803010 2969845 - CAGE SPNL 0D 45MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969850 SUP Custom 27803010 2969850 - CAGE SPNL 0D 50MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2969855 SUP Custom 27803010 2969855 - CAGE SPNL 0D 55MMX8MM LF CLYDESDALE RADOPQ HLW PEEK-OPTM BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990622 SUP HCPCS C1713 2990622 - SPACER SPNL 22MMX6MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990626 SUP HCPCS C1713 2990626 - SPACER SPNL 26MMX6MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990722 SUP HCPCS C1713 2990722 - SPACER SPNL 22MMX7MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990726 SUP HCPCS C1713 2990726 - SPACER SPNL 26MMX7MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990732 SUP HCPCS C1713 2990732 - SPACER SPNL 32MMX7MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990736 SUP HCPCS C1713 2990736 - SPACER SPNL 36MMX7MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990822 SUP Custom 27803010 2990822 - SPACER SPNL 22MMX8MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990826 SUP Custom 27803010 2990826 - SPACER SPNL 26MMX8MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990832 SUP Custom 27803010 2990832 - SPACER SPNL 32MMX8MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990836 SUP Custom 27803010 2990836 - SPACER SPNL 36MMX8MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990922 SUP HCPCS C1713 2990922 - SPACER SPNL 22MMX9MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990926 SUP HCPCS C1713 2990926 - SPACER SPNL 26MMX9MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990932 SUP HCPCS C1713 2990932 - SPACER SPNL 32MMX9MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2990936 SUP HCPCS C1713 2990936 - SPACER SPNL 36MMX9MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM LMBR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991022 SUP Custom 27803010 2991022 - SPACER SPNL 22MMX10MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991026 SUP Custom 27803010 2991026 - SPACER SPNL 26MMX10MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991032 SUP Custom 27803010 2991032 - SPACER SPNL 32MMX10MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991036 SUP Custom 27803010 2991036 - SPACER SPNL 36MMX10MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991122 SUP HCPCS C1713 2991122 - SPACER SPNL 22MMX11MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991126 SUP HCPCS C1713 2991126 - SPACER SPNL 26MMX11MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991132 SUP HCPCS C1713 2991132 - SPACER SPNL 32MMX11MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991136 SUP HCPCS C1713 2991136 - SPACER SPNL 36MMX11MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991222 SUP Custom 27803010 2991222 - SPACER SPNL 22MMX12MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991226 SUP Custom 27803010 2991226 - SPACER SPNL 26MMX12MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991232 SUP Custom 27803010 2991232 - SPACER SPNL 32MMX12MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991236 SUP Custom 27803010 2991236 - SPACER SPNL 36MMX12MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991322 SUP HCPCS C1713 2991322 - SPACER SPNL 22MMX13MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991326 SUP HCPCS C1713 2991326 - SPACER SPNL 26MMX13MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991332 SUP HCPCS C1713 2991332 - SPACER SPNL 32MMX13MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991336 SUP HCPCS C1713 2991336 - SPACER SPNL 36MMX13MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991422 SUP Custom 27803010 2991422 - SPACER SPNL 22MMX14MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991426 SUP Custom 27803010 2991426 - SPACER SPNL 26MMX14MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991432 SUP Custom 27803010 2991432 - SPACER SPNL 32MMX14MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991436 SUP Custom 27803010 2991436 - SPACER SPNL 36MMX14MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991522 SUP HCPCS C1713 2991522 - SPACER SPNL 22MMX15MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991526 SUP HCPCS C1713 2991526 - SPACER SPNL 26MMX15MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991532 SUP HCPCS C1713 2991532 - SPACER SPNL 32MMX15MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991536 SUP HCPCS C1713 2991536 - SPACER SPNL 36MMX15MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991622 SUP Custom 27803010 2991622 - SPACER SPNL 22MMX16MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991626 SUP Custom 27803010 2991626 - SPACER SPNL 26MMX16MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991632 SUP Custom 27803010 2991632 - SPACER SPNL 32MMX16MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2991636 SUP Custom 27803010 2991636 - SPACER SPNL 36MMX16MM STRL LF CPSTN SLF DSTRCT PEEK-OPTM BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3001015 SUP HCPCS C1713 3001015 - PLATE BN 15MM ZEVO 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3001017 SUP HCPCS C1713 3001017 - PLATE BN 17MM ZEVO 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3001019 SUP HCPCS C1713 3001019 - PLATE BN 19MM ZEVO 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3001021 SUP HCPCS C1713 3001021 - PLATE BN 21MM ZEVO 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3001023 SUP HCPCS C1713 3001023 - PLATE BN 23MM ZEVO 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3001027 SUP HCPCS C1713 3001027 - PLATE 27MM TI LVL 1 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3001029 SUP HCPCS C1713 3001029 - PLATE 29MM TI LVL 1 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3001031 SUP HCPCS C1713 3001031 - PLATE 31MM TI LVL 1 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3002035 SUP HCPCS C1713 3002035 - PLATE BN 35MM ZEVO 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3002039 SUP HCPCS C1713 3002039 - PLATE BN 39MM ZEVO 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3002043 SUP HCPCS C1713 3002043 - PLATE 43MM TI LVL 2 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 3002045 SUP HCPCS C1713 3002045 - PLATE BN 45MM ZEVO 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 3002047 SUP HCPCS C1713 3002047 - PLATE 47MM TI LVL 2 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 3002048 SUP HCPCS C1713 3002048 - PLATE BN 48MM ZEVO 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 3002049 SUP HCPCS C1713 3002049 - PLATE 49MM TI LVL 2 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 3002051 SUP HCPCS C1713 3002051 - PLATE BN 51MM ZEVO 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 3002053 SUP HCPCS C1713 3002053 - PLATE 53MM TI LVL 2 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 3003047 SUP HCPCS C1713 3003047 - PLATE BN 47MM ZEVO 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003049 SUP HCPCS C1713 3003049 - PLATE 49MM TI LVL 3 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003055 SUP HCPCS C1713 3003055 - PLATE BN 55MM ZEVO LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003063 SUP HCPCS C1713 3003063 - PLATE BN 63MM ZEVO LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003065 SUP HCPCS C1713 3003065 - PLATE 65MM TI LVL 3 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003067 SUP HCPCS C1713 3003067 - PLATE 67MM TI LVL 3 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003068 SUP HCPCS C1713 3003068 - PLATE 68MM TI LVL 3 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003069 SUP HCPCS C1713 3003069 - PLATE 69MM TI LVL 3 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003071 SUP HCPCS C1713 3003071 - PLATE 71MM TI LVL 3 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 3003248 SUP Custom 27203010 REAGENT PCR HOT SRT REAC MX LTCYCLR 96 TST BOTH IP/OP $597.50 $442.15 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.75 $473.22 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3004071 SUP HCPCS C1713 3004071 - PLATE 71MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004073 SUP HCPCS C1713 3004073 - PLATE BN 73MM ZEVO 4 LVL TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004075 SUP HCPCS C1713 3004075 - PLATE BN 75MM ZEVO 4 LVL TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004077 SUP HCPCS C1713 3004077 - PLATE 77MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004078 SUP HCPCS C1713 3004078 - PLATE BN 78MM ZEVO 4 LVL TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004079 SUP HCPCS C1713 3004079 - PLATE 79MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004081 SUP HCPCS C1713 3004081 - PLATE 81MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004083 SUP HCPCS C1713 3004083 - PLATE 83MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004085 SUP HCPCS C1713 3004085 - PLATE 85MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004086 SUP HCPCS C1713 3004086 - PLATE 86MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004087 SUP HCPCS C1713 3004087 - PLATE 87MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3004089 SUP HCPCS C1713 3004089 - PLATE 89MM TI LVL 4 ZEVO BONE SPN CERV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 3005075 SUP HCPCS C1713 3005075 - PLATE 75MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005077 SUP HCPCS C1713 3005077 - PLATE 77MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005079 SUP HCPCS C1713 3005079 - PLATE 79MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005081 SUP HCPCS C1713 3005081 - PLATE 81MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005085 SUP HCPCS C1713 3005085 - PLATE 85MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005090 SUP HCPCS C1713 3005090 - PLATE 90MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005095 SUP HCPCS C1713 3005095 - PLATE 95MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005100 SUP HCPCS C1713 3005100 - PLATE 100MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005105 SUP HCPCS C1713 3005105 - PLATE 105MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3005108 SUP HCPCS C1713 3005108 - PLATE 108MM TI LVL 5 ZEVO BONE SPN CERV ANT BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 3034001 SUP Custom 27203010 3034001 - DRILL BIT 3034001 ADJUSTABLE STERILE BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $0.00 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3101001 SUP Custom 27203010 EARPLUG FOAM EAR NSE RDC BRL SHP PCTV EAR BOTH IP/OP $0.18 $0.13 $0.00 $0.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.09 $0.14 $0.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3120211 SUP HCPCS C1713 3120211 - SCREW BN 4MM 11MM NS ATLNTS ST FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120212 SUP HCPCS C1713 3120212 - SCREW 3120212 4.0 X 12 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120213 SUP HCPCS C1713 3120213 - SCREW 3120213 4.0 X 13 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120214 SUP HCPCS C1713 3120214 - SCREW BONE 4MM 14MM ATLNTS TI ANT CERV SPN SLFTAP FIXANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120215 SUP HCPCS C1713 3120215 - SCREW BN 4MM 15MM NS ATLNTS ST FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120216 SUP HCPCS C1713 3120216 - SCREW 3120216 4.0 X 16 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120217 SUP HCPCS C1713 3120217 - SCREW BN 4MM 17MM NS ATLNTS ST FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120218 SUP HCPCS C1713 3120218 - SCREW 3120218 4.0 X 18 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120219 SUP HCPCS C1713 3120219 - SCREW 3120219 4.0 X 19 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120220 SUP HCPCS C1713 3120220 - SCREW 3120220 4.0 X 20 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120311 SUP HCPCS C1713 3120311 - SCREW BN 4MM 11MM NS ATLNTS ST VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120312 SUP HCPCS C1713 3120312 - SCREW 3120312 4.0 X 12 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120313 SUP HCPCS C1713 3120313 - SCREW 3120313 4.0 X 13 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120314 SUP HCPCS C1713 3120314 - SCREW BN 4MM 14MM NS ATLNTS ST VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120315 SUP HCPCS C1713 3120315 - SCREW BN 4MM 15MM NS ATLNTS ST VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120316 SUP HCPCS C1713 3120316 - SCREW BN 4MM 16MM NS ATLNTS ST VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120317 SUP HCPCS C1713 3120317 - SCREW BN 4MM 17MM NS ATLNTS ST VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120318 SUP HCPCS C1713 3120318 - SCREW 3120318 4.0 X 18 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120319 SUP HCPCS C1713 3120319 - SCREW 3120319 4.0 X 19 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120320 SUP HCPCS C1713 3120320 - SCREW 3120320 4.0 X 20 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120411 SUP HCPCS C1713 3120411 - SCREW 3120411 4.0 X 11 SELF DRILL FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120412 SUP HCPCS C1713 3120412 - SCREW BN 4MM 12MM NS ATLNTS SLF DRL FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120413 SUP HCPCS C1713 3120413 - SCREW BN 4MM 13MM NS ATLNTS SLF DRL FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120414 SUP HCPCS C1713 3120414 - SCREW BN 4MM 14MM NS ATLNTS SLF DRL FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120415 SUP HCPCS C1713 3120415 - SCREW BN 4MM 15MM NS ATLNTS SLF DRL FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120416 SUP HCPCS C1713 3120416 - SCREW BN 4MM 16MM NS ATLNTS SLF DRL FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120417 SUP HCPCS C1713 3120417 - SCREW 3120417 4.0 X 17 SELF DRILL FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120419 SUP HCPCS C1713 3120419 - SCREW 3120419 4.0 X 19 SELF DRILL FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120420 SUP HCPCS C1713 3120420 - SCREW 3120420 4.0 X 20 SELF DRILL FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120511 SUP HCPCS C1713 3120511 - SCREW BN 4MM 11MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120512 SUP HCPCS C1713 3120512 - SCREW BN 4MM 12MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120513 SUP HCPCS C1713 3120513 - SCREW BN 4MM 13MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120514 SUP HCPCS C1713 3120514 - SCREW BN 4MM 14MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120515 SUP HCPCS C1713 3120515 - SCREW BN 4MM 15MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120516 SUP HCPCS C1713 3120516 - SCREW BN 4MM 16MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120517 SUP HCPCS C1713 3120517 - SCREW BN 4MM 17MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120518 SUP HCPCS C1713 3120518 - SCREW 3120518 4.0 X 18 SELF DRILL VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120519 SUP HCPCS C1713 3120519 - SCREW 3120519 4.0 X 19 SELF DRILL VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3120520 SUP HCPCS C1713 3120520 - SCREW 3120520 4.0 X 20 SELF DRILL VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125211 SUP HCPCS C1713 3125211 - SCREW 3125211 4.5 X 11 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125213 SUP HCPCS C1713 3125213 - SCREW 3125213 4.5 X 13 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125215 SUP HCPCS C1713 3125215 - SCREW 3125215 4.5 X 15 SELF TAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125217 SUP HCPCS C1713 3125217 - SCREW BN 4.5MM 17MM NS ATLNTS ST FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125311 SUP HCPCS C1713 3125311 - SCREW 3125311 4.5 X 11 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125313 SUP HCPCS C1713 3125313 - SCREW 3125313 4.5 X 13 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125315 SUP HCPCS C1713 3125315 - SCREW 3125315 4.5 X 15 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125317 SUP HCPCS C1713 3125317 - SCREW 3125317 4.5 X 17 SELF TAP VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125411 SUP HCPCS C1713 3125411 - SCREW 3125411 4.5 X 11 SELF DRILL FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125413 SUP HCPCS C1713 3125413 - SCREW BN 4.5MM 13MM NS ATLNTS SLF DRL FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125415 SUP HCPCS C1713 3125415 - SCREW BN 4.5MM 15MM NS ATLNTS SLF DRL FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125417 SUP HCPCS C1713 3125417 - SCREW BN 4.5MM 17MM NS ATLNTS SLF DRL FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125511 SUP HCPCS C1713 3125511 - SCREW 3125511 4.5 X 11 SELF DRILL VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125513 SUP HCPCS C1713 3125513 - SCREW BN 4.5MM 13MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125515 SUP HCPCS C1713 3125515 - SCREW BN 4.5MM 15MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125517 SUP HCPCS C1713 3125517 - SCREW BN 4.5MM 17MM NS ATLNTS SLF DRL VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3125520 SUP HCPCS C1713 3125520 - SCREW 3125520 4.5 X 20 SELF DRILL VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 3155648 SUP Custom 27203010 3155648 - BURR SURG .8MM LOW FRICTION SLEEVE BEARING OTO-FLEX SKEETER BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $0.00 $0.00 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3200028 SUP Custom 27203010 3200028 - KIT SPNL MAXCESS SHIM FX BOTH IP/OP $920.00 $680.80 $0.00 $736.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $682.82 $682.82 $0.00 $0.00 $191.73 $0.00 $0.00 $0.00 $0.00 $460.00 $728.64 $736.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3200060 SUP Custom 27203010 3200060 - KIT SPNL MAXCESS MOD STRL DISP BOTH IP/OP "$3,765.00 " "$2,786.10" $0.00 "$3,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,794.38" "$2,794.38" $0.00 $0.00 $784.63 $0.00 $0.00 $0.00 $0.00 "$1,882.50" "$2,981.88" "$3,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3230101 SUP HCPCS C1713 3230101 - WIRE FIX 13.5IN KWIRE SPN BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 3240060 SUP Custom 27803010 3240060 - RETRACTOR SURG MAXCESS 4 DISPOSABLE BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 $0.00 $0.00 $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3240061 SUP Custom 27203010 3240061 - KIT SPNL MAXCESS4 SHIM DISP BOTH IP/OP "$2,957.50 " "$2,188.55" $0.00 "$2,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,195.06" "$2,195.06" $0.00 $0.00 $616.34 $0.00 $0.00 $0.00 $0.00 "$1,478.75" "$2,342.34" "$2,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3391208 SUP HCPCS C1713 3391208 - SPACER SPNL 4D SM 8MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3391210 SUP HCPCS C1713 3391210 - SPACER SPNL 4D SM 10MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3391212 SUP HCPCS C1713 3391212 - SPACER SPNL 4D SM 12MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3391214 SUP HCPCS C1713 3391214 - SPACER SPNL 4D SM 14MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3392308 SUP Custom 27803010 3392308 - SPACER SPNL 8D MED 8MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3392310 SUP Custom 27803010 3392310 - SPACER SPNL 8D MED 10MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3392312 SUP Custom 27803010 3392312 - SPACER SPNL 8D MED 12MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3392314 SUP Custom 27803010 3392314 - SPACER SPNL 8D MED 14MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3392316 SUP Custom 27803010 3392316 - SPACER SPNL 8D MED 16MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3392318 SUP HCPCS C1713 3392318 - SPACER SPNL 8D MED 18MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3392320 SUP HCPCS C1713 3392320 - SPACER SPNL 8D MED 20MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3393308 SUP Custom 27803010 3393308 - SPACER SPNL 8D LG 8MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3393310 SUP Custom 27803010 3393310 - SPACER SPNL 8D LG 10MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3393312 SUP Custom 27803010 3393312 - SPACER SPNL 8D LG 12MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3393314 SUP Custom 27803010 3393314 - SPACER SPNL 8D LG 14MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3393316 SUP Custom 27803010 3393316 - SPACER SPNL 8D LG 16MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3393318 SUP HCPCS C1713 3393318 - SPACER SPNL 8D LG 18MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3393320 SUP HCPCS C1713 3393320 - SPACER SPNL 8D LG 20MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3393412 SUP Custom 27803010 3393412 - SPACER SPNL 12D LG 12MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3393414 SUP Custom 27803010 3393414 - SPACER SPNL 12D LG 14MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3393416 SUP Custom 27803010 3393416 - SPACER SPNL 12D LG 16MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3393418 SUP HCPCS C1713 3393418 - SPACER SPNL 12D LG 18MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3393420 SUP HCPCS C1713 3393420 - SPACER SPNL 12D LG 20MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3394310 SUP HCPCS C1713 3394310 - SPACER SPNL 8D XL 8MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3394312 SUP HCPCS C1713 3394312 - SPACER SPNL 8D XL 12MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3394314 SUP HCPCS C1713 3394314 - SPACER SPNL 8D XL 14MM PRIMTR ADON PEEK-OPTM ALIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3400014 SUP HCPCS C1713 3400014 - SPACER SPNL TLIF HOOD SHIM BOTH IP/OP $920.00 $680.80 $0.00 $736.00 $414.00 $414.00 $0.00 $0.00 $0.00 $191.75 $682.82 $682.82 $0.00 $0.00 $191.73 $0.00 $544.18 $544.18 $0.00 $460.00 $728.64 $736.00 $0.00 $0.00 $143.98 $0.00 $0.00 $146.46 $0.00 $0.00 $0.00 $0.00 $0.00 3400033 SUP Custom 27203010 3400033 - KIT SPNL MAS LGHT CBL SLFRET TLIF BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $0.00 $0.00 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3491208 SUP HCPCS C1713 3491208 - SPACER SPNL 4D LRDTC SM 8MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3491210 SUP HCPCS C1713 3491210 - SPACER SPNL 4D LRDTC SM 10MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3491212 SUP HCPCS C1713 3491212 - SPACER SPNL 4D LRDTC SM 12MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3491214 SUP HCPCS C1713 3491214 - SPACER SPNL 4D LRDTC SM 14MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3491216 SUP HCPCS C1713 3491216 - SPACER SPNL 4D LRDTC SM 16MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3491218 SUP HCPCS C1713 3491218 - SPACER SPNL 4D LRDTC SM 18MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3491220 SUP HCPCS C1713 3491220 - SPACER SPNL 4D LRDTC SM 20MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3492308 SUP HCPCS C1713 3492308 - SPACER SPNL 8D LRDTC MED 8MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3492310 SUP HCPCS C1713 3492310 - SPACER SPNL 8D LRDTC MED 10MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3492312 SUP HCPCS C1713 3492312 - SPACER SPNL 8D LRDTC MED 12MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3492314 SUP HCPCS C1713 3492314 - SPACER SPNL 8D LRDTC MED 14MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3492316 SUP HCPCS C1713 3492316 - SPACER SPNL 8D LRDTC MED 16MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3492318 SUP HCPCS C1713 3492318 - SPACER SPNL 8D LRDTC MED 18MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3492320 SUP HCPCS C1713 3492320 - SPACER SPNL 8D LRDTC MED 20MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493308 SUP HCPCS C1713 3493308 - SPACER SPNL 8D LRDTC LG 8MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493310 SUP HCPCS C1713 3493310 - SPACER SPNL 8D LRDTC LG 10MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493312 SUP HCPCS C1713 3493312 - SPACER SPNL 8D LRDTC LG 12MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493314 SUP HCPCS C1713 3493314 - SPACER SPNL 8D LRDTC LG 14MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493316 SUP HCPCS C1713 3493316 - SPACER SPNL 8D LRDTC LG 16MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493318 SUP HCPCS C1713 3493318 - SPACER SPNL 8D LRDTC LG 18MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493320 SUP HCPCS C1713 3493320 - SPACER SPNL 8D LRDTC LG 20MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493412 SUP HCPCS C1713 3493412 - SPACER SPNL 12D LRDTC LG 12MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493414 SUP HCPCS C1713 3493414 - SPACER SPNL 12D LRDTC LG 14MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493416 SUP HCPCS C1713 3493416 - SPACER SPNL 12D LRDTC LG 16MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493418 SUP HCPCS C1713 3493418 - SPACER SPNL 12D LRDTC LG 18MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493420 SUP HCPCS C1713 3493420 - SPACER SPNL 12D LRDTC LG 20MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493512 SUP HCPCS C1713 3493512 - SPACER SPNL 15D LRDTC LG 12MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493514 SUP HCPCS C1713 3493514 - SPACER SPNL 15D LRDTC LG 14MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493516 SUP HCPCS C1713 3493516 - SPACER SPNL 15D LRDTC LG 16MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493518 SUP HCPCS C1713 3493518 - SPACER SPNL 15D LRDTC LG 18MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3493520 SUP HCPCS C1713 3493520 - SPACER SPNL 15D LRDTC LG 20MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3494310 SUP HCPCS C1713 3494310 - SPACER SPNL 8D LRDTC XL 10MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3494312 SUP HCPCS C1713 3494312 - SPACER SPNL 8D LRDTC XL 12MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3494314 SUP HCPCS C1713 3494314 - SPACER SPNL 8D LRDTC XL 14MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3494316 SUP HCPCS C1713 3494316 - SPACER SPNL 8D LRDTC XL 16MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3494318 SUP HCPCS C1713 3494318 - SPACER SPNL 8D LRDTC XL 18MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3494320 SUP HCPCS C1713 3494320 - SPACER SPNL 8D LRDTC XL 20MM PRIMTR VERT BD REPL BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3547213 SUP HCPCS C1789 3547213 - EXPANDER TISS 450ML TAB MED HT STY 7200 CPX3 SLTX CNTOUR BOTH IP/OP "$3,312.50 " "$2,451.25" $0.00 "$2,650.00" "$1,490.63" "$1,490.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,656.25" "$2,623.50" "$2,650.00" $0.00 $0.00 $518.41 $0.00 $0.00 $527.35 $0.00 $0.00 $0.00 $0.00 $0.00 3549213 SUP HCPCS C1789 3549213 - EXPANDER TISS P7CM CNTR PRFL MED HT 12.7X10.8CM 450ML CPX4 BOTH IP/OP "$2,937.50 " "$2,173.75" $0.00 "$2,350.00" "$1,321.88" "$1,321.88" $0.00 $0.00 $0.00 $612.25 "$2,180.21" "$2,180.21" $0.00 $0.00 $612.18 $0.00 "$1,448.19" "$1,448.19" $0.00 "$1,468.75" "$2,326.50" "$2,350.00" $0.00 $0.00 $459.72 $0.00 $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 $0.00 3549214 SUP HCPCS C1789 3549214 - EXPANDER TISS P7.4CM CNTR PRFL MED HT 13.5X11.7CM 550ML CPX4 BOTH IP/OP "$2,937.50 " "$2,173.75" $0.00 "$2,350.00" "$1,321.88" "$1,321.88" $0.00 $0.00 $0.00 $612.25 "$2,180.21" "$2,180.21" $0.00 $0.00 $612.18 $0.00 "$1,448.19" "$1,448.19" $0.00 "$1,468.75" "$2,326.50" "$2,350.00" $0.00 $0.00 $459.72 $0.00 $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 $0.00 3549215 SUP HCPCS C1789 3549215 - EXPANDER TISS P7.6CM CNTR PRFL MED HT 14.6X12.6CM 650ML CPX4 BOTH IP/OP "$2,937.50 " "$2,173.75" $0.00 "$2,350.00" "$1,321.88" "$1,321.88" $0.00 $0.00 $0.00 $612.25 "$2,180.21" "$2,180.21" $0.00 $0.00 $612.18 $0.00 "$1,448.19" "$1,448.19" $0.00 "$1,468.75" "$2,326.50" "$2,350.00" $0.00 $0.00 $459.72 $0.00 $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 $0.00 3549216 SUP HCPCS C1789 3549216 - EXPANDER TISS P8CM CNTR PRFL MED HT 15.6X13.3CM 800ML CPX4 BOTH IP/OP "$2,937.50 " "$2,173.75" $0.00 "$2,350.00" "$1,321.88" "$1,321.88" $0.00 $0.00 $0.00 $612.25 "$2,180.21" "$2,180.21" $0.00 $0.00 $612.18 $0.00 "$1,448.19" "$1,448.19" $0.00 "$1,468.75" "$2,326.50" "$2,350.00" $0.00 $0.00 $459.72 $0.00 $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 $0.00 3712039 SUP Custom 27203010 PUNCH SURG 3.5MM UP BITE ANG CIRC CUT 160MM 45D BOTH IP/OP "$2,515.00 " "$1,861.10" $0.00 "$2,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,257.50" "$1,991.88" "$2,012.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3714231 SUP Custom 27203010 PROBE SURG 208MM FRNTL OSTM SKR RT ANG 2 END BALL TIP BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3714284 SUP Custom 27203010 CURETTE 5MM 2MM 75D CURVE CUP SURG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3756230 SUP HCPCS C1713 03756230 - SCREW SET BUTTRESS BLOCKER XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 3800750 SUP HCPCS C1713 03800750 - SCREW BONE 7.5MM 50MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801530 SUP HCPCS C1713 03801530 - SCREW BONE 5.5MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801535 SUP HCPCS C1713 03801535 - SCREW BONE 5.5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801540 SUP HCPCS C1713 03801540 - SCREW BONE 5.5MM 40MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801545 SUP HCPCS C1713 03801545 - SCREW BONE 5.5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801550 SUP HCPCS C1713 03801550 - SCREW BONE 5.5MM 50MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801555 SUP HCPCS C1713 03801555 - SCREW BONE 5.5MM 55MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801630 SUP HCPCS C1713 03801630 - SCREW BONE 6.5MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801635 SUP HCPCS C1713 03801635 - SCREW BONE 6.5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801640 SUP HCPCS C1713 03801640 - SCREW BONE 6.5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801645 SUP HCPCS C1713 03801645 - SCREW BONE 6.5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801650 SUP HCPCS C1713 03801650 - SCREW BONE 6.5MM 50MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801655 SUP HCPCS C1713 03801655 - SCREW BONE 6.5MM 55MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801660 SUP HCPCS C1713 03801660 - SCREW BONE 6.5MM 60MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801730 SUP HCPCS C1713 03801730 - SCREW BONE 7.5MM 30MM POLYAX XIA SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801735 SUP HCPCS C1713 03801735 - SCREW BONE 7.5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801740 SUP HCPCS C1713 03801740 - SCREW BONE 7.5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801745 SUP HCPCS C1713 03801745 - SCREW BONE 7.5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801750 SUP HCPCS C1713 03801750 - SCREW BONE 7.5MM 50MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801755 SUP HCPCS C1713 03801755 - SCREW BONE 7.5MM 55MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801760 SUP HCPCS C1713 03801760 - SCREW BONE 7.5MM 60MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3801800 SUP HCPCS C1713 03801800 - SCREW BONE 8.5MM 100MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801830 SUP HCPCS C1713 03801830 - SCREW BONE 8.5MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801835 SUP HCPCS C1713 03801835 - SCREW BONE 8.5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801840 SUP HCPCS C1713 03801840 - SCREW BONE 8.5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801845 SUP HCPCS C1713 03801845 - SCREW BONE 8.5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801850 SUP HCPCS C1713 03801850 - SCREW BONE 8.5MM 50MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801855 SUP HCPCS C1713 03801855 - SCREW BONE 8.5MM 55MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801860 SUP HCPCS C1713 03801860 - SCREW BONE 8.5MM 60MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801870 SUP HCPCS C1713 03801870 - SCREW BONE 8.5MM 70MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801880 SUP HCPCS C1713 03801880 - SCREW BONE 8.5MM 80MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801890 SUP HCPCS C1713 03801890 - SCREW BONE 8.5MM 90MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3801900 SUP HCPCS C1713 03801900 - SCREW BONE 9.5MM 100MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,162.50 " $860.25 $0.00 $930.00 $523.13 $523.13 $0.00 $0.00 $0.00 $242.29 $862.81 $862.81 $0.00 $0.00 $242.27 $0.00 $687.62 $687.62 $0.00 $581.25 $920.70 $930.00 $0.00 $0.00 $181.93 $0.00 $0.00 $185.07 $0.00 $0.00 $0.00 $0.00 $0.00 3801960 SUP HCPCS C1713 03801960 - SCREW BONE 9.5MM 60MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,162.50 " $860.25 $0.00 $930.00 $523.13 $523.13 $0.00 $0.00 $0.00 $242.29 $862.81 $862.81 $0.00 $0.00 $242.27 $0.00 $687.62 $687.62 $0.00 $581.25 $920.70 $930.00 $0.00 $0.00 $181.93 $0.00 $0.00 $185.07 $0.00 $0.00 $0.00 $0.00 $0.00 3801970 SUP HCPCS C1713 03801970 - SCREW BONE 9.5MM 70MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 3801980 SUP HCPCS C1713 03801980 - SCREW BONE 9.5MM 80MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$4,437.50 " "$3,283.75" $0.00 "$3,550.00" "$1,996.88" "$1,996.88" $0.00 $0.00 $0.00 $924.89 "$3,293.51" "$3,293.51" $0.00 $0.00 $924.78 $0.00 "$2,187.69" "$2,187.69" $0.00 "$2,218.75" "$3,514.50" "$3,550.00" $0.00 $0.00 $694.47 $0.00 $0.00 $706.45 $0.00 $0.00 $0.00 $0.00 $0.00 3801990 SUP HCPCS C1713 03801990 - SCREW BONE 9.5MM 90MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3802070 SUP Custom 27803010 03802070 - ROD SPNL 70MM 6MM XIA TI CENTRL POST BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3802110 SUP Custom 27803010 03802110 - ROD SPNL 110MM 6MM XIA TI CENTRL POST BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3802480 SUP Custom 27803010 03802480 - ROD SPNL 480MM 6MM XIA TI CENTRL POST BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3804025 SUP Custom 27803010 03804025 - CONNECTOR ROD XIA SPN I BOTH IP/OP $991.68 $733.84 $0.00 $793.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $736.02 $736.02 $0.00 $0.00 $206.67 $0.00 $0.00 $0.00 $0.00 $495.84 $785.41 $793.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3804120 SUP Custom 27803010 03804120 - CONNECTOR ROD ADAPTER XIA SPN BOTH IP/OP $991.68 $733.84 $0.00 $793.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $736.02 $736.02 $0.00 $0.00 $206.67 $0.00 $0.00 $0.00 $0.00 $495.84 $785.41 $793.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3805000 SUP Custom 27803010 03805000 - BLOCK SPINAL XIA TITANIUM SACRAL BOTH IP/OP "$4,082.50 " "$3,021.05" $0.00 "$3,266.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,030.03" "$3,030.03" $0.00 $0.00 $850.79 $0.00 $0.00 $0.00 $0.00 "$2,041.25" "$3,233.34" "$3,266.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3805001 SUP Custom 27803010 03805001 - CLAMP SPINAL ROD TO ROD PARALLEL XIA TITANIUM BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3805002 SUP Custom 27803010 03805002 - CLAMP SPINAL AXIAL XIA TITANIUM BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3805025 SUP HCPCS C1713 03805025 - SCREW BONE 6.5MM 25MM XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,400.00 " "$1,776.00" $0.00 "$1,920.00" "$1,080.00" "$1,080.00" $0.00 $0.00 $0.00 $500.22 "$1,781.28" "$1,781.28" $0.00 $0.00 $500.16 $0.00 "$1,419.60" "$1,419.60" $0.00 "$1,200.00" "$1,900.80" "$1,920.00" $0.00 $0.00 $375.60 $0.00 $0.00 $382.08 $0.00 $0.00 $0.00 $0.00 $0.00 3805030 SUP HCPCS C1713 03805030 - SCREW BONE 6.5MM 30MM XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,400.00 " "$1,776.00" $0.00 "$1,920.00" "$1,080.00" "$1,080.00" $0.00 $0.00 $0.00 $500.22 "$1,781.28" "$1,781.28" $0.00 $0.00 $500.16 $0.00 "$1,419.60" "$1,419.60" $0.00 "$1,200.00" "$1,900.80" "$1,920.00" $0.00 $0.00 $375.60 $0.00 $0.00 $382.08 $0.00 $0.00 $0.00 $0.00 $0.00 3805035 SUP HCPCS C1713 03805035 - SCREW BONE 6.5MM 35MM XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3806001 SUP Custom 27803010 03806001 - HOOK SPINAL LARGE XIA TITANIUM LAMINA BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3806002 SUP Custom 27803010 03806002 - HOOK SPINAL MEDIUM XIA TITANIUM LAMINA BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3806003 SUP Custom 27803010 03806003 - HOOK SPINAL SMALL XIA TITANIUM LMNR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3806006 SUP Custom 27803010 03806006 - HOOK SPINAL LEFT EXTEND BODY XIA TITANIUM LAMINA BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3806007 SUP Custom 27803010 03806007 - HOOK SPINAL RIGHT EXTEND BODY XIA TITANIUM LAMINA BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3806009 SUP Custom 27803010 03806009 - HOOK SPINAL LARGE ANGLE LEFT XIA TITANIUM LAMINA BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3806012 SUP Custom 27803010 03806012 - HOOK SPINAL SMALL XIA GOLD TITANIUM PEDICLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820100 SUP HCPCS C1713 03820100 - WASHER SPINAL LP XIA II TITANIUM BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 3820101 SUP Custom 27803010 03820101 - CONCTR ROD XIA OFFST SCR TI THORLMBR SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820104 SUP HCPCS C1713 03820104 - STAPLE BONE 1 HOLE XIA TITANIUM SPN ANTERIOR BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 3820110 SUP HCPCS C1713 03820110 - STAPLE BONE SMALL 2 DIAPASON OSS XIA TITANIUM SPN CAUDAL BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3820111 SUP HCPCS C1713 03820111 - STAPLE BONE SMALL 2 DIAPASON OSS XIA TITANIUM SPN ROSTRAL BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3820112 SUP HCPCS C1713 03820112 - STAPLE BONE MEDIUM 2 DIAPASON OSS XIA TITANIUM SPN CAUDAL BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3820113 SUP HCPCS C1713 03820113 - STAPLE BONE MEDIUM 2 DIAPASON OSS XIA TITANIUM SPN ROSTRAL BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3820114 SUP HCPCS C1713 03820114 - STAPLE BONE LARGE 2 DIAPASON OSS XIA TITANIUM SPN CAUDAL BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3820115 SUP HCPCS C1713 03820115 - STAPLE BONE LARGE 2 DIAPASON OSS XIA TITANIUM SPN ROSTRAL BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3820120 SUP HCPCS C1713 03820120 - WASHER SPINAL 4.5MM LP XIA TITANIUM BOTH IP/OP $223.38 $165.30 $0.00 $178.70 $100.52 $100.52 $0.00 $0.00 $0.00 $46.56 $165.79 $165.79 $0.00 $0.00 $46.55 $0.00 $132.13 $132.13 $0.00 $111.69 $176.92 $178.70 $0.00 $0.00 $34.96 $0.00 $0.00 $35.56 $0.00 $0.00 $0.00 $0.00 $0.00 3820124 SUP HCPCS C1713 03820124 - WASHER SPINAL 8.5MM LP XIA TITANIUM BOTH IP/OP $223.38 $165.30 $0.00 $178.70 $100.52 $100.52 $0.00 $0.00 $0.00 $46.56 $165.79 $165.79 $0.00 $0.00 $46.55 $0.00 $132.13 $132.13 $0.00 $111.69 $176.92 $178.70 $0.00 $0.00 $34.96 $0.00 $0.00 $35.56 $0.00 $0.00 $0.00 $0.00 $0.00 3820130 SUP Custom 27803010 03820130 - CONNECTOR ROD 75D XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820131 SUP Custom 27803010 03820131 - CONNECTOR ROD 0D PLATE XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820132 SUP Custom 27803010 03820132 - CONNECTOR ROD 105D OFFST PLATE XIA TITANIUM SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820133 SUP Custom 27803010 03820133 - CONNECTOR ROD NEUTRAL 80MM OFFST XIA 3 TITANIUM STAINLESS BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820134 SUP Custom 27803010 03820134 - CONNECTOR ROD 0D SMALL XIA TITANIUM SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820135 SUP Custom 27803010 03820135 - CONNECTOR ROD 30D SMALL XIA TITANIUM SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820136 SUP Custom 27803010 03820136 - CONNECTOR ROD 0D LARGE XIA TITANIUM SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820137 SUP Custom 27803010 03820137 - CONNECTOR ROD 30D LARGE XIA TITANIUM SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820200 SUP Custom 27803010 03820200 - HOOK SPINAL SMALL STANDARD BLADE XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820201 SUP Custom 27803010 03820201 - HOOK SPINAL SMALL NARROW XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820202 SUP Custom 27803010 03820202 - HOOK SPINAL LARGE STANDARD BLADE XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820203 SUP Custom 27803010 03820203 - HOOK SPINAL LARGE LEGENDARY BLADE XIA II TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820204 SUP Custom 27803010 03820204 - HOOK SPINAL EXTEND XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820206 SUP Custom 27803010 03820206 - HOOK SPINAL RIGHT OFFST XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820207 SUP Custom 27803010 03820207 - HOOK SPINAL LEFT OFFST XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820208 SUP Custom 27803010 03820208 - HOOK SPINAL ANGLE BLADE XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820210 SUP Custom 27803010 03820210 - HOOK SPINAL STANDARD BLADE XIA TITANIUM LMNR THORACIC BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820211 SUP Custom 27803010 03820211 - HOOK SPINAL SMALL NARROW BLADE XIA TITANIUM THORAX LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820212 SUP Custom 27803010 03820212 - HOOK SPINAL SMALL RIGHT OFFST XIA TITANIUM THORACOLUMBAR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820213 SUP Custom 27803010 03820213 - HOOK SPINAL SMALL LEFT OFFST XIA TITANIUM THORACOLUMBAR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820214 SUP Custom 27803010 03820214 - HOOK SPINAL LARGE RIGHT OFFST XIA TITANIUM THORAX LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820215 SUP Custom 27803010 03820215 - HOOK SPINAL LARGE LEFT OFFST XIA TITANIUM THORAX LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820220 SUP Custom 27803010 03820220 - HOOK SPINAL SMALL LOCK XIA TITANIUM PEDICLE BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820221 SUP Custom 27803010 03820221 - HOOK SPINAL LARGE XIA TITANIUM PEDICLE BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820230 SUP Custom 27803010 03820230 - HOOK SPINAL RIGHT OFFST XIA TITANIUM TRNSVRS PROCESS BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820231 SUP Custom 27803010 03820231 - HOOK SPINAL LEFT OFFST XIA II TITANIUM TRNSVRS PROCESS BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820240 SUP Custom 27803010 03820240 - HOOK SPINAL NARROW ANGLE REDUCE BLADE XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820241 SUP Custom 27803010 03820241 - HOOK SPINAL WIDE ANGLE REDUCE BLADE XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820242 SUP Custom 27803010 03820242 - HOOK SPINAL ANGLE REDUCE XIA TITANIUM LAMINA BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820243 SUP Custom 27803010 03820243 - HOOK SPINAL NARROW ANGLE REDUCE BLADE XIA TITANIUM THORAX BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820244 SUP Custom 27803010 03820244 - HOOK SPINAL LP RED BLADE XIA TITANIUM PEDIATRIC PEDICLE BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820425 SUP HCPCS C1713 03820425 - SCREW BONE 4.5MM 25MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820430 SUP HCPCS C1713 03820430 - SCREW BONE 4.5MM 30MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820435 SUP HCPCS C1713 03820435 - SCREW BONE 4.5MM 35MM MNOAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820440 SUP HCPCS C1713 03820440 - SCREW BONE 4.5MM 40MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820445 SUP HCPCS C1713 03820445 - SCREW BONE 4.5MM 45MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820525 SUP HCPCS C1713 03820525 - SCREW BONE 5.5MM 25MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820530 SUP HCPCS C1713 03820530 - SCREW BONE 5.5MM 30MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820535 SUP HCPCS C1713 03820535 - SCREW BONE 5.5MM 35MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820540 SUP HCPCS C1713 03820540 - SCREW BONE 5.5MM 40MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820545 SUP HCPCS C1713 03820545 - SCREW BONE 5.5MM 45MM XIA SPNL MNOAX BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820550 SUP HCPCS C1713 03820550 - SCREW BONE 5.5MM 50MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820555 SUP HCPCS C1713 03820555 - SCREW BONE 5.5MM 55MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820600 SUP HCPCS C1713 03820600 - SCREW BONE 6.5MM 100MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820630 SUP HCPCS C1713 03820630 - SCREW BONE 6.5MM 30MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820635 SUP HCPCS C1713 03820635 - SCREW BONE 6.5MM 35MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820640 SUP HCPCS C1713 03820640 - SCREW BONE 6.5MM 40MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820645 SUP HCPCS C1713 03820645 - SCREW BONE 6.5MM 45MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820650 SUP HCPCS C1713 03820650 - SCREW BONE 6.5MM 50MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820655 SUP HCPCS C1713 03820655 - SCREW BONE 6.5MM 55MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820660 SUP HCPCS C1713 03820660 - SCREW BONE 6.5MM 60MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820670 SUP HCPCS C1713 03820670 - SCREW BONE 6.5MM 70MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820680 SUP HCPCS C1713 03820680 - SCREW BONE 6.5MM 80MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820690 SUP HCPCS C1713 03820690 - SCREW BONE 6.5MM 90MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820700 SUP HCPCS C1713 03820700 - SCREW BONE 7.5MM 100MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820730 SUP HCPCS C1713 03820730 - SCREW BONE 7.5MM 30MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820735 SUP HCPCS C1713 03820735 - SCREW BONE 7.5MM 35MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820740 SUP HCPCS C1713 03820740 - SCREW BONE 7.5MM 40MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820745 SUP HCPCS C1713 03820745 - SCREW BONE 7.5MM 45MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820750 SUP HCPCS C1713 03820750 - SCREW BONE 7.5MM 50MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820755 SUP HCPCS C1713 03820755 - SCREW BONE 7.5MM 55MM XIA TI SPNL MNOAX BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820760 SUP HCPCS C1713 03820760 - SCREW BONE 7.5MM 60MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820770 SUP HCPCS C1713 03820770 - SCREW BONE 7.5MM 70MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820780 SUP HCPCS C1713 03820780 - SCREW BONE 7.5MM 80MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820790 SUP HCPCS C1713 03820790 - SCREW BONE 7.5MM 90MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820800 SUP HCPCS C1713 03820800 - SCREW BONE 8.5MM 100MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820830 SUP HCPCS C1713 03820830 - SCREW BONE 8.5MM 30MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820835 SUP HCPCS C1713 03820835 - SCREW BONE 8.5MM 35MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820840 SUP HCPCS C1713 03820840 - SCREW BONE 8.5MM 40MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820845 SUP HCPCS C1713 03820845 - SCREW BONE 8.5MM 45MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820850 SUP HCPCS C1713 03820850 - SCREW BONE 8.5MM 50MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820855 SUP HCPCS C1713 03820855 - SCREW BONE 8.5MM 55MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820860 SUP HCPCS C1713 03820860 - SCREW BONE 8.5MM 60MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820870 SUP HCPCS C1713 03820870 - SCREW BONE 8.5MM 70MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3820880 SUP HCPCS C1713 03820880 - SCREW BONE 8.5MM 80MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 3820890 SUP HCPCS C1713 03820890 - SCREW BONE 8.5MM 90MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820900 SUP HCPCS C1713 03820900 - SCREW BONE 9.5MM 100MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820960 SUP HCPCS C1713 03820960 - SCREW BONE 9.5MM 60MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820970 SUP HCPCS C1713 03820970 - SCREW BONE 9.5MM 70MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820980 SUP HCPCS C1713 03820980 - SCREW BONE 9.5MM 80MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3820990 SUP HCPCS C1713 03820990 - SCREW BONE 9.5MM 90MM MNOAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3821015 SUP Custom 27803010 03821015 - CONNECTOR ROD 15MM CROSSLINK XIA MAC TITANIUM THORACOLUMBAR BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 $0.00 $0.00 $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3821016 SUP Custom 27803010 03821016 - CONNECTOR ROD 16MM MULTIAX CROSSLINK XIA MAC TITANIUM BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 $0.00 $0.00 $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3821017 SUP Custom 27803010 03821017 - CONNECTOR ROD 17MM MULTIAX CROSSLINK XIA MAC TITANIUM BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 $0.00 $0.00 $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3821018 SUP Custom 27803010 03821018 - CONNECTOR ROD 18MM MULTIAX CROSSLINK XIA MAC TITANIUM BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 $0.00 $0.00 $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3821019 SUP Custom 27803010 03821019 - CONNECTOR ROD 19MM MULTIAX CROSSLINK XIA MAC TITANIUM BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 $0.00 $0.00 $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3821020 SUP Custom 27803010 03821020 - CONNECTOR ROD 20MM MULTIAX CROSSLINK XIA MAC TITANIUM BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 $0.00 $0.00 $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3821425 SUP HCPCS C1713 03821425 - SCREW BONE 4.5MM 25MM XIA TI THORLMBR SPN POLYAX BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 3821430 SUP HCPCS C1713 03821430 - SCREW BONE 4.5MM 30MM XIA TI THORLMBR SPN POLYAX BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 3821435 SUP HCPCS C1713 03821435 - SCREW BONE 4.5MM 35MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821440 SUP HCPCS C1713 03821440 - SCREW BONE 4.5MM 40MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821445 SUP HCPCS C1713 03821445 - SCREW BONE 4.5MM 45MM FIX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821525 SUP HCPCS C1713 03821525 - SCREW BONE 5.5MM 25MM XIA TI SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 3821530 SUP HCPCS C1713 03821530 - SCREW BONE 5.5MM 30MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821535 SUP HCPCS C1713 03821535 - SCREW BONE 5.5MM 30MM XIA TI SPNL POLYAX LP BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 3821540 SUP HCPCS C1713 03821540 - SCREW BONE 5.5MM 40MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821545 SUP HCPCS C1713 03821545 - SCREW BONE 5.5MM 45MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821550 SUP HCPCS C1713 03821550 - SCREW BONE 5.5MM 50MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821555 SUP HCPCS C1713 03821555 - SCREW BONE 5.5MM 55MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821600 SUP HCPCS C1713 03821600 - SCREW BONE 6.5MM 100MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821630 SUP HCPCS C1713 03821630 - SCREW BONE 6.5MM 30MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821635 SUP HCPCS C1713 03821635 - SCREW BONE 6.5MM 35MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821640 SUP HCPCS C1713 03821640 - SCREW BONE 6.5MM 40MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821645 SUP HCPCS C1713 03821645 - SCREW BONE 6.5MM 45MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821650 SUP HCPCS C1713 03821650 - SCREW BONE 6.5MM 50MM XIA TI THORLMBR SPN POLYAX BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 3821650 SUP HCPCS C1713 03821650 - SCREW BONE 6.5MM 50MM XIA TI THORLMBR SPN POLYAX BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 3821655 SUP HCPCS C1713 03821655 - SCREW BONE 6.5MM 55MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821660 SUP HCPCS C1713 03821660 - SCREW BONE 6.5MM 60MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821670 SUP HCPCS C1713 03821670 - SCREW BONE 6.5MM 70MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3821680 SUP HCPCS C1713 03821680 - SCREW BONE 6.5MM 80MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821690 SUP HCPCS C1713 03821690 - SCREW BONE 6.5MM 90MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821700 SUP HCPCS C1713 03821700 - SCREW BONE 7.5MM 100MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821730 SUP HCPCS C1713 03821730 - SCREW BONE 7.5MM 30MM POLYAX XIA SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821735 SUP HCPCS C1713 03821735 - SCREW BONE 7.5MM 35MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821740 SUP HCPCS C1713 03821740 - SCREW BONE 7.5MM 40MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821745 SUP HCPCS C1713 03821745 - SCREW BONE 7.5MM 45MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821750 SUP HCPCS C1713 03821750 - SCREW BONE 7.5MM 50MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821755 SUP HCPCS C1713 03821755 - SCREW BONE 7.5MM 55MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821760 SUP HCPCS C1713 03821760 - SCREW BONE 7.5MM 60MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821770 SUP HCPCS C1713 03821770 - SCREW BONE 7.5MM 70MM POLYAX XIA II SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821780 SUP HCPCS C1713 03821780 - SCREW BONE 7.5MM 80MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3821790 SUP HCPCS C1713 03821790 - SCREW BONE 7.5MM 90MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3822601 SUP Custom 27803010 03822601 - ROD SPINAL 6MM 600MM XIA VITALLIUM BOTH IP/OP "$2,356.58 " "$1,743.87" $0.00 "$1,885.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,749.05" "$1,749.05" $0.00 $0.00 $491.11 $0.00 $0.00 $0.00 $0.00 "$1,178.29" "$1,866.41" "$1,885.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3827201 SUP Custom 27803010 03827201 - HOOK SPINAL SMALL NARROW BLADE LMNR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3827202 SUP Custom 27803010 03827202 - HOOK SPINAL LARGE STANDARD BLADE LMNR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3827203 SUP Custom 27803010 03827203 - HOOK SPINAL LARGE NARROW BLADE LMNR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3827211 SUP Custom 27803010 03827211 - HOOK SPINAL STANDARD BLADE LMNR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3827220 SUP Custom 27803010 03827220 - HOOK SPINAL SMALL LONG ARM PEDICLE BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3828425 SUP HCPCS C1713 03828425 - SCREW BONE LONG ARM 4.5MM 25MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828430 SUP HCPCS C1713 03828430 - SCREW BONE LONG ARM 4.5MM 30MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828435 SUP HCPCS C1713 03828435 - SCREW BONE LONG ARM 4.5MM 35MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828440 SUP HCPCS C1713 03828440 - SCREW BONE LONG ARM 4.5MM 40MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828445 SUP HCPCS C1713 03828445 - SCREW BONE LONG ARM 4.5MM 45MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828530 SUP HCPCS C1713 03828530 - SCREW BONE 5.5MM 30MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828535 SUP HCPCS C1713 03828535 - SCREW BONE 5.5MM 35MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828540 SUP HCPCS C1713 03828540 - SCREW BONE 5.5MM 40MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828545 SUP HCPCS C1713 03828545 - SCREW BONE 5.5MM 45MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828550 SUP HCPCS C1713 03828550 - SCREW BONE LONG ARM 5.5MM 50MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828555 SUP HCPCS C1713 03828555 - SCREW BONE LONG ARM 5.5MM 55MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828630 SUP HCPCS C1713 03828630 - SCREW BONE 6.5MM 30MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828635 SUP HCPCS C1713 03828635 - SCREW BONE 6.5MM 35MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828640 SUP HCPCS C1713 03828640 - SCREW BONE 6.5MM 40MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828645 SUP HCPCS C1713 03828645 - SCREW BONE 6.5MM 45MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828650 SUP HCPCS C1713 03828650 - SCREW BONE 6.5MM 50MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828655 SUP HCPCS C1713 03828655 - SCREW BONE 6.5MM 55MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828660 SUP HCPCS C1713 03828660 - SCREW BONE LONG ARM 6.5MM 60MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828730 SUP HCPCS C1713 03828730 - SCREW BONE 7.5MM 30MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828735 SUP HCPCS C1713 03828735 - SCREW BONE 7.5MM 35MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828740 SUP HCPCS C1713 03828740 - SCREW BONE 7.5MM 40MM MNOAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828745 SUP HCPCS C1713 03828745 - SCREW BONE 7.5MM 45MM MNOAX REDX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828750 SUP HCPCS C1713 03828750 - SCREW BONE 7.5MM 50MM MULTIAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828755 SUP HCPCS C1713 03828755 - SCREW BONE LONG ARM 7.5MM 55MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3828760 SUP HCPCS C1713 03828760 - SCREW BONE LONG ARM 7.5MM 60MM MNOAX XIA TITANIUM SPN BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 3829425 SUP HCPCS C1713 03829425 - SCREW BONE LONG ARM 4.5MM 25MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3829430 SUP HCPCS C1713 03829430 - SCREW BONE LONG ARM 4.5MM 30MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3829435 SUP HCPCS C1713 03829435 - SCREW BONE LONG ARM 4.5MM 35MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3829440 SUP HCPCS C1713 03829440 - SCREW BONE LONG ARM 4.5MM 40MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 3829445 SUP HCPCS C1713 03829445 - SCREW BONE LONG ARM 4.5MM 45MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 3829530 SUP HCPCS C1713 03829530 - SCREW BONE 5.5MM 30MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 3829535 SUP HCPCS C1713 03829535 - SCREW BONE 5.5MM 35MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $371.25 $371.25 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 3829540 SUP HCPCS C1713 03829540 - SCREW BONE 5.5MM 40MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829550 SUP HCPCS C1713 03829550 - SCREW BONE 5.5MM 50MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829555 SUP HCPCS C1713 03829555 - SCREW BONE LONG ARM 5.5MM 55MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829630 SUP HCPCS C1713 03829630 - SCREW BONE 6.5MM 30MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829635 SUP HCPCS C1713 03829635 - SCREW BONE 6.5MM 35MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829640 SUP HCPCS C1713 03829640 - SCREW BONE 6.5MM 40MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829645 SUP HCPCS C1713 03829645 - SCREW BONE 6.5MM 45MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829650 SUP HCPCS C1713 03829650 - SCREW BONE 6.5MM 50MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829655 SUP HCPCS C1713 03829655 - SCREW BONE 6.5MM 55MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829660 SUP HCPCS C1713 03829660 - SCREW BONE LONG ARM 6.5MM 60MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829730 SUP HCPCS C1713 03829730 - SCREW BONE 7.5MM 30MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829735 SUP HCPCS C1713 03829735 - SCREW BONE 7.5MM 35MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829740 SUP HCPCS C1713 03829740 - SCREW BONE 7.5MM 40MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829745 SUP HCPCS C1713 03829745 - SCREW BONE 7.5MM 45MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829750 SUP HCPCS C1713 03829750 - SCREW BONE 7.5MM 50MM POLYAX LONG ARM XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829755 SUP HCPCS C1713 03829755 - SCREW BONE LONG ARM 7.5MM 55MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3829760 SUP HCPCS C1713 03829760 - SCREW BONE LONG ARM 7.5MM 60MM POLYAX XIA TITANIUM SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 3992206 SUP HCPCS C1713 3992206 - SPACER SPNL 0D 27MMX6MM STRL LF CPSTN CNTRL PEEK INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992207 SUP HCPCS C1713 3992207 - SPACER SPNL 22MMX7MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992208 SUP HCPCS C1713 3992208 - SPACER SPNL 22MMX8MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992209 SUP HCPCS C1713 3992209 - SPACER SPNL 22MMX9MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992210 SUP HCPCS C1713 3992210 - SPACER SPNL 22MMX10MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992211 SUP HCPCS C1713 3992211 - SPACER SPNL 22MMX11MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992212 SUP HCPCS C1713 3992212 - SPACER SPNL 22MMX12MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992213 SUP HCPCS C1713 3992213 - SPACER SPNL 22MMX13MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992214 SUP HCPCS C1713 3992214 - SPACER SPNL 22MMX14MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992215 SUP HCPCS C1713 3992215 - SPACER SPNL 22MMX15MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992216 SUP HCPCS C1713 3992216 - SPACER SPNL 22MMX16MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 3992606 SUP HCPCS C1713 3992606 - SPACER SPNL 26MMX6MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992607 SUP HCPCS C1713 3992607 - SPACER SPNL 26MMX7MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992608 SUP HCPCS C1713 3992608 - SPACER SPNL 26MMX8MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992609 SUP HCPCS C1713 3992609 - SPACER SPNL 26MMX9MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992610 SUP HCPCS C1713 3992610 - SPACER SPNL 26MMX10MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992611 SUP HCPCS C1713 3992611 - SPACER SPNL 26MMX11MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992612 SUP HCPCS C1713 3992612 - SPACER SPNL 26MMX12MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992613 SUP HCPCS C1713 3992613 - SPACER SPNL 26MMX13MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992614 SUP HCPCS C1713 3992614 - SPACER SPNL 26X14MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992615 SUP HCPCS C1713 3992615 - SPACER SPNL 26MMX15MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3992616 SUP HCPCS C1713 3992616 - SPACER SPNL 26MMX16MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993207 SUP HCPCS C1713 3993207 - SPACER SPNL 32MMX7MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993208 SUP HCPCS C1713 3993208 - SPACER SPNL 32MMX8MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993209 SUP HCPCS C1713 3993209 - SPACER SPNL 32MMX9MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993210 SUP HCPCS C1713 3993210 - SPACER SPNL 32MMX10MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993211 SUP HCPCS C1713 3993211 - SPACER SPNL 32MMX11MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993212 SUP HCPCS C1713 3993212 - SPACER SPNL 32MMX12MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993213 SUP HCPCS C1713 3993213 - SPACER SPNL 32MMX13MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993214 SUP HCPCS C1713 3993214 - SPACER SPNL 32MMX14MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993215 SUP HCPCS C1713 3993215 - SPACER SPNL 32MMX15MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993216 SUP HCPCS C1713 3993216 - SPACER SPNL 32MMX16MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 3993616 SUP HCPCS C1713 3993616 - SPACER SPNL 36MMX16MM STRL LF CPSTN PTC PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 4001122 SUP HCPCS C1713 4001122 - SPACER SPNL 6D 22MMX11MM STRL LF CPSTN CNTRL PEEK INTRBD FS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4001227 SUP HCPCS C1713 4001227 - SPACER SPNL 6D 27MMX12MM STRL LF CPSTN CNTRL PEEK INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 4001322 SUP HCPCS C1713 4001322 - SPACER SPNL 6D 22MMX13MM STRL LF CPSTN CNTRL PEEK INTRBD FS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4011022 SUP HCPCS C1713 4011022 - SPACER SPNL 12D 22MMX10MM STRL LF CPSTN CNTRL PEEK INTRBD FS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4011222 SUP HCPCS C1713 4011222 - SPACER SPNL 12D 22MMX12MM CPSTN CNTRL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4025900 SUP Custom 27203010 VIAL ANALY CODA POLYPRO 5 REAGENT 23ML BOTH IP/OP $25.75 $19.06 $0.00 $20.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.88 $20.39 $20.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4098545 SUP HCPCS C1713 4098545 - SCREW BONE CYLINDER 8.5MM 45MM OSS SPN BOTH IP/OP "$1,213.13 " $897.72 $0.00 $970.50 $545.91 $545.91 $0.00 $0.00 $0.00 $252.85 $900.38 $900.38 $0.00 $0.00 $252.82 $0.00 $717.56 $717.56 $0.00 $606.56 $960.80 $970.50 $0.00 $0.00 $189.85 $0.00 $0.00 $193.13 $0.00 $0.00 $0.00 $0.00 $0.00 4098550 SUP HCPCS C1713 4098550 - SCREW BONE CYLINDER 8.5MM 50MM OSS SPN BOTH IP/OP "$1,213.13 " $897.72 $0.00 $970.50 $545.91 $545.91 $0.00 $0.00 $0.00 $252.85 $900.38 $900.38 $0.00 $0.00 $252.82 $0.00 $717.56 $717.56 $0.00 $606.56 $960.80 $970.50 $0.00 $0.00 $189.85 $0.00 $0.00 $193.13 $0.00 $0.00 $0.00 $0.00 $0.00 4105535 SUP HCPCS C1713 4105535 - SCREW BONE 5.5MM 35MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4105540 SUP HCPCS C1713 4105540 - SCREW BONE 5.5MM 40MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4105545 SUP HCPCS C1713 4105545 - SCREW BONE 5.5MM 45MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4106535 SUP HCPCS C1713 4106535 - SCREW BONE 6.5MM 35MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4106540 SUP HCPCS C1713 4106540 - SCREW BONE 6.5MM 40MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4106550 SUP HCPCS C1713 4106550 - SCREW BONE 6.5MM 50MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4106555 SUP HCPCS C1713 4106555 - SCREW BONE 6.5MM 55MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4106560 SUP HCPCS C1713 4106560 - SCREW BONE 6.5MM 60MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4107017 SUP Custom 27803010 4107017 - CONNECTOR ROD 17MM MULTIAX CROSS XIA CROSSLINK TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107020 SUP Custom 27803010 4107020 - CONNECTOR ROD 20MM MULTIAX CROSS XIA CROSSLINK TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107023 SUP Custom 27803010 4107023 - CONNECTOR ROD 23MM CROSSLINK XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107026 SUP Custom 27803010 4107026 - CONNECTOR ROD 26MM CROSSLINK XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107029 SUP Custom 27803010 4107029 - CONNECTOR ROD 29-31MM MULTIAX CROSS XIA SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107031 SUP Custom 27803010 4107031 - CONNECTOR ROD 31-34MM MULTIAX MAC CROSSLINK TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107035 SUP Custom 27803010 4107035 - CONNECTOR ROD 35MM CROSSLINK XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107038 SUP Custom 27803010 4107038 - CONNECTOR ROD 38-43MM MULTIAX CROSSLINK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107042 SUP Custom 27803010 4107042 - CONNECTOR ROD 42-51MM MULTIAX CROSSLINK MAC SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107050 SUP Custom 27803010 4107050 - CONNECTOR ROD 50-67MM MULTIAX CROSSLINK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107066 SUP Custom 27803010 4107066 - CONNECTOR ROD 66-99MM MULTIAX CROSS XIA MAC TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4107535 SUP HCPCS C1713 4107535 - SCREW BONE 7.5MM 35MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4107545 SUP HCPCS C1713 4107545 - SCREW BONE 7.5MM 45MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4107555 SUP HCPCS C1713 4107555 - SCREW BONE 7.5MM 55MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4107560 SUP HCPCS C1713 4107560 - SCREW BONE 7.5MM 60MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4108535 SUP HCPCS C1713 4108535 - SCREW BONE 8.5MM 35MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4108540 SUP HCPCS C1713 4108540 - SCREW BONE 8.5MM 40MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4108560 SUP HCPCS C1713 4108560 - SCREW BONE 8.5MM 60MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4109040 SUP HCPCS C1713 4109040 - SCREW BONE 9MM 40MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4109045 SUP HCPCS C1713 4109045 - SCREW BONE 9MM 45MM OSS SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 4110101 SUP Custom 27803010 4110101 - HOOK SPINAL OSS LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110102 SUP Custom 27803010 4110102 - HOOK SPINAL LONG OSS LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110113 SUP Custom 27803010 4110113 - HOOK SPINAL SMALL OSS LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110118 SUP Custom 27803010 4110118 - HOOK SPINAL LARGE OSS LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110201 SUP Custom 27803010 4110201 - HOOK SPINAL CENTERED OSS TITANIUM LMNR LUMBAR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110202 SUP Custom 27803010 4110202 - HOOK SPINAL LARGE OSS LMNR LUMBAR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110203 SUP Custom 27803010 4110203 - HOOK SPINAL OSS RIGHT LMNR LUMBAR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110204 SUP Custom 27803010 4110204 - HOOK SPINAL CENTERING OSS LEFT LMNR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110223 SUP Custom 27803010 4110223 - HOOK SPINAL OSS RIGHT INFERIOR LMNR LUMBAR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110224 SUP Custom 27803010 4110224 - HOOK SPINAL OSS LEFT INFERIOR LMNR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110231 SUP Custom 27803010 4110231 - HOOK SPINAL SMALL LOWER RIGHT OFFST OSS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110232 SUP Custom 27803010 4110232 - HOOK SPINAL SMALL LOWER LEFT OFFST OSS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4110302 SUP Custom 27803010 4110302 - HOOK SPINAL LONG BLADE OSS TITANIUM PEDICLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4123010 SUP Custom 27803010 4123010 - RING SPNL OSS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4123021 SUP HCPCS C1713 4123021 - CAP SCR SPNL OSS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 4125303 SUP Custom 27803010 4125303 - RING SPNL OSS XL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4195103 SUP HCPCS C1898 4195103 - LEAD PACING 5FR 103CM UNIPOLAR DEPLOYABLE LOBES FIX IS-1 BOTH IP/OP "$3,562.50 " "$2,636.25" $0.00 "$2,850.00" "$1,603.13" "$1,603.13" $0.00 $0.00 $0.00 $742.51 "$2,644.09" "$2,644.09" $0.00 $0.00 $742.43 $0.00 "$1,756.31" "$1,756.31" $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $567.15 $0.00 $0.00 $0.00 $0.00 $0.00 4200015 SUP HCPCS C1762 4200015 - GRAFT SOFT TISSUE DELIVERY UNCRIMPED BOTH IP/OP "$1,415.30 " "$1,047.32" $0.00 "$1,132.24" $0.00 $0.00 $0.00 $0.00 $0.00 $294.98 "$1,050.44" "$1,050.44" $0.00 $0.00 $294.95 $0.00 $837.15 $837.15 $0.00 $707.65 "$1,120.92" "$1,132.24" $0.00 $0.00 $221.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4210564 SUP Custom 27803010 4210564 - SPACER SPNL 14MM 16X5MM STRL PRVL STNDALN PEEK-OPTM CRV BOTH IP/OP "$5,775.00 " "$4,273.50" $0.00 "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.51" $0.00 $0.00 $0.00 $0.00 "$2,887.50" "$4,573.80" "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4210664 SUP Custom 27803010 4210664 - SPACER SPNL 14MM 16X6MM STRL PRVL STNDALN PEEK-OPTM CRV BOTH IP/OP "$5,775.00 " "$4,273.50" $0.00 "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.51" $0.00 $0.00 $0.00 $0.00 "$2,887.50" "$4,573.80" "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4210764 SUP Custom 27803010 4210764 - SPACER SPNL 14MM 16X7MM STRL PRVL STNDALN PEEK-OPTM CRV BOTH IP/OP "$5,775.00 " "$4,273.50" $0.00 "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.51" $0.00 $0.00 $0.00 $0.00 "$2,887.50" "$4,573.80" "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4210864 SUP Custom 27803010 4210864 - SPACER SPNL 14MM 16X8MM STRL PRVL STNDALN PEEK-OPTM CRV BOTH IP/OP "$5,775.00 " "$4,273.50" $0.00 "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.51" $0.00 $0.00 $0.00 $0.00 "$2,887.50" "$4,573.80" "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4210964 SUP Custom 27803010 4210964 - SPACER SPNL 14MM 16X9MM STRL PRVL STNDALN PEEK-OPTM CRV BOTH IP/OP "$5,775.00 " "$4,273.50" $0.00 "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.51" $0.00 $0.00 $0.00 $0.00 "$2,887.50" "$4,573.80" "$4,620.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240041 SUP Custom 27803010 4240041 - CAGE SPNL 11MM 14X10MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240064 SUP Custom 27803010 4240064 - CAGE SPNL 14MM 16X10MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240086 SUP Custom 27803010 4240086 - CAGE SPNL 16MM 18X10MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240141 SUP Custom 27803010 4240141 - CAGE SPNL 11MM 14X11MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240164 SUP Custom 27803010 4240164 - CAGE SPNL 14MM 16X11MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240186 SUP Custom 27803010 4240186 - CAGE SPNL 16MM 18X11MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240241 SUP Custom 27803010 4240241 - CAGE SPNL 11MM 14X12MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240264 SUP Custom 27803010 4240264 - CAGE SPNL 14MM 16X12MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240286 SUP Custom 27803010 4240286 - CAGE SPNL 16MM 18X12MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240341 SUP Custom 27803010 4240341 - CAGE SPNL 11MM 14X13MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240364 SUP Custom 27803010 4240364 - CAGE SPNL 14MM 16X13MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240386 SUP Custom 27803010 4240386 - CAGE SPNL 16MM 18X13MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240441 SUP Custom 27803010 4240441 - CAGE SPNL 11MM 14X14MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240464 SUP Custom 27803010 4240464 - CAGE SPNL 14MM 16X14MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240486 SUP Custom 27803010 4240486 - CAGE SPNL 16MM 18X14MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240541 SUP Custom 27803010 4240541 - CAGE SPNL 11MM 14X5MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240564 SUP Custom 27803010 4240564 - CAGE SPNL 14MM 16X5MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240586 SUP Custom 27803010 4240586 - CAGE SPNL 16MM 18X5MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240641 SUP Custom 27803010 4240641 - CAGE SPNL 11MM 14X6MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240664 SUP Custom 27803010 4240664 - CAGE SPNL 14MM 16X6MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240686 SUP Custom 27803010 4240686 - CAGE SPNL 16MM 18X6MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240741 SUP Custom 27803010 4240741 - CAGE SPNL 11MM 14X7MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240764 SUP Custom 27803010 4240764 - CAGE SPNL 14MM 16X7MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240786 SUP Custom 27803010 4240786 - CAGE SPNL 16MM 18X7MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240841 SUP Custom 27803010 4240841 - CAGE SPNL 11MM 14X8MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240864 SUP Custom 27803010 4240864 - CAGE SPNL 14MM 16X8MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240886 SUP Custom 27803010 4240886 - CAGE SPNL 16MM 18X8MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240941 SUP Custom 27803010 4240941 - CAGE SPNL 11MM 14X9MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240964 SUP Custom 27803010 4240964 - CAGE SPNL 14MM 16X9MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4240986 SUP Custom 27803010 4240986 - CAGE SPNL 16MM 18X9MM STRL ANTM RADOPQ PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4264606 SUP Custom 27203010 4264606 - KIT PRSS MONITR 84IN SFST 2 INLN BLD SMPL PORT TRNDCR KIT AN BOTH IP/OP $41.40 $30.64 $0.00 $33.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.70 $32.79 $33.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4302208 SUP HCPCS C1713 4302208 - SPACER 4302208 TELAMON P VBS 0 22X8MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4302210 SUP HCPCS C1713 4302210 - SPACER 4302210 TELAMON P VBS 0 22X10MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4302212 SUP HCPCS C1713 4302212 - SPACER 4302212 TELAMON P VBS 0 22X12MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4302214 SUP HCPCS C1713 4302214 - SPACER 4302214 TELAMON P VBS 0 22X14MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4302608 SUP HCPCS C1713 4302608 - SPACER 4302608 TELAMON P VBS 0 26X8MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4302610 SUP HCPCS C1713 4302610 - SPACER 4302610 TELAMON P VBS 0 26X10MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4302612 SUP HCPCS C1713 4302612 - SPACER 4302612 TELAMON P VBS 0 26X12MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4302614 SUP Custom 27803010 4302614 - TELAMON-P 4302614 VBS 0 26 X 14MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4312513 SUP Custom 27203010 STAIN MYCL DFC TB KMNO4 PK 250ML BOTH IP/OP $79.45 $58.79 $0.00 $63.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.73 $62.92 $63.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4312514 SUP Custom 27203010 STAIN MYCL DFC TB ARMN M BTL 250ML BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4312518 SUP Custom 27203010 STAIN MYCL BBL TB CRBL FCHSN WKG SOL 250ML BOTH IP/OP $224.40 $166.06 $0.00 $179.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.20 $177.72 $179.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4312526 SUP Custom 27203010 STAIN MCBL GM CRYS VIOL WKG SOL BBL 1GL BOTH IP/OP $132.05 $97.72 $0.00 $105.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.03 $104.58 $105.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4312531 SUP Custom 27203010 STAIN MCBL GM SFRN WKG SOL DFC 250ML BOTH IP/OP $53.95 $39.92 $0.00 $43.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.98 $42.73 $43.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4312532 SUP Custom 27203010 STAIN MCBL GM SFRN REPL REAGENT BBL 1GL BOTH IP/OP $122.30 $90.50 $0.00 $97.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.15 $96.86 $97.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4312542 SUP Custom 27203010 STAIN MCBL GM IOD STAB DFC 250ML BOTH IP/OP $60.45 $44.73 $0.00 $48.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.23 $47.88 $48.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4321039 SUP Custom 27203010 MEDIA CULT TSI SLANT MCFLS BOTH IP/OP $121.63 $90.01 $0.00 $97.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.81 $96.33 $97.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4321087 SUP Custom 27203010 MEDIA CULT TSA SLANT BBL BOTH IP/OP $115.03 $85.12 $0.00 $92.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.51 $91.10 $92.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4321283 SUP Custom 27203010 MEDIA CULT TSA PLT BBL BOTH IP/OP $104.93 $77.65 $0.00 $83.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.46 $83.10 $83.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4321326 SUP Custom 27203010 MEDIA CULT OF BSL MED TUBE BBL 5ML BOTH IP/OP $39.93 $29.55 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.96 $31.62 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4321328 SUP Custom 27203010 MEDIA CULT OF MED DEX TUBE BBL 5ML BOTH IP/OP $39.93 $29.55 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.96 $31.62 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4321388 SUP Custom 27203010 MEDIA MYCL L-J MED BBL SLANT BOTH IP/OP $156.83 $116.05 $0.00 $125.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.41 $124.21 $125.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4321739 SUP Custom 27203010 MEDIA CULT CDC ANAER AGAR PEA 5% SB PLT BBL BOTH IP/OP $25.93 $19.19 $0.00 $20.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.96 $20.54 $20.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4321826 SUP Custom 27203010 MEDIA MYCL SAB EMNS DEX AGAR BBL SLANT BOTH IP/OP $1.78 $1.32 $0.00 $1.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.89 $1.41 $1.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4328351 SUP Custom 27203010 REAGENT MCBL ANSR SHIG FLEXNERI GRP B TYPE 1-6 LYPH 3ML BOTH IP/OP $272.00 $201.28 $0.00 $217.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.00 $215.42 $217.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331107 SUP Custom 27203010 STRIP X FCTR HMPHLS DIFF TAXO ID BOTH IP/OP $314.40 $232.66 $0.00 $251.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.20 $249.00 $251.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331109 SUP Custom 27203010 STRIP FCTR 5 DIFF TAXO ID BOTH IP/OP $278.90 $206.39 $0.00 $223.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.45 $220.89 $223.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331264 SUP Custom 25003010 DISK AMPCLN 10 MCG BD SNS DS SNS BOTH IP/OP $6.80 $5.03 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.40 $5.39 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331275 SUP Custom 25003010 DISK CLNDMCN 2 MCG BD SNS DS SNS BOTH IP/OP $66.78 $49.42 $0.00 $53.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.39 $52.89 $53.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331286 SUP Custom 25003010 DISK DXYCL 30 MCG BD SNS DS SNS BOTH IP/OP $1.58 $1.17 $0.00 $1.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.79 $1.25 $1.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331290 SUP Custom 25003010 DISK EMYCIN 15 MCG SNSDC SNS BOTH IP/OP $6.80 $5.03 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.40 $5.39 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331299 SUP Custom 25003010 DISK GNTA 10 MCG BD SNS DS SNS BOTH IP/OP $0.68 $0.50 $0.00 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.34 $0.54 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331321 SUP Custom 25003010 DISK PEN 10 UN SNSDC SNS BOTH IP/OP $6.80 $5.03 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.40 $5.39 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331344 SUP Custom 25003010 DISK TTRCLN 30 MCG SNSDC SNS BOTH IP/OP $64.70 $47.88 $0.00 $51.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.35 $51.24 $51.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331539 SUP Custom 25003010 DISK SXT 23.75 MCG 1.25 MCG SNSDC SNS BOTH IP/OP $6.80 $5.03 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.40 $5.39 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331569 SUP Custom 25003010 DISK TBR 10 MCG BD SNS DS SNS BOTH IP/OP $6.80 $5.03 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.40 $5.39 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331593 SUP Custom 25003010 DISK CFZLN 30 MCG SNSDC SNS BOTH IP/OP $67.93 $50.27 $0.00 $54.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.96 $53.80 $54.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331597 SUP Custom 27203010 DISK AMK 30 MCG BD SNS DS SNS BOTH IP/OP $67.93 $50.27 $0.00 $54.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.96 $53.80 $54.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331609 SUP Custom 25003010 DISK PIPRCLN 100 MCG SNSDC SNS BOTH IP/OP $60.13 $44.50 $0.00 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.06 $47.62 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331621 SUP Custom 25003010 DISK CEFRXM 30 MCG BD SNS DS SNS BOTH IP/OP $60.13 $44.50 $0.00 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.06 $47.62 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331633 SUP Custom 25003010 DISK CFTZDM 30 MCG BD SNS DS SNS BOTH IP/OP $6.55 $4.85 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.28 $5.19 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331635 SUP Custom 25003010 DISK CEFTRXN 30 MCG SNSDC SNS BOTH IP/OP $60.13 $44.50 $0.00 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.06 $47.62 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331649 SUP Custom 25003010 DISK TCR CLVLN 75 10 MCG SNSDC SNS BOTH IP/OP $66.78 $49.42 $0.00 $53.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.39 $52.89 $53.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331658 SUP Custom 25003010 DISK CIPRO 5 MCG BD SNS DS SNS BOTH IP/OP $6.80 $5.03 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.40 $5.39 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331696 SUP Custom 25003010 DISK CEFEPIME 30 MCG BD SNS DS SNS BOTH IP/OP $6.80 $5.03 $0.00 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.40 $5.39 $5.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331704 SUP Custom 25003010 DISK MRPNM 10 MCG BD SNS DS SNS BOTH IP/OP $0.68 $0.50 $0.00 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.34 $0.54 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331752 SUP Custom 25003010 DISK CFTXM CLVLN 30 10 MCG BD SNS DS SNS BOTH IP/OP $216.88 $160.49 $0.00 $173.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.44 $171.77 $173.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4331754 SUP Custom 25003010 DISK CFTZDM CLVLN 30 10 MCG BD SNS DS SNS BOTH IP/OP $56.13 $41.54 $0.00 $44.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.06 $44.45 $44.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4332208 SUP HCPCS C1713 4332208 - SPACER SPNL 3D 22MMX8MM TLMN-PPEEK-OPTM END PC VERT BD REPL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4332210 SUP HCPCS C1713 4332210 - SPACER SPNL 3D 22MMX10MM TLMN-PPEEK-OPTM END PC VERT BD REPL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4332212 SUP HCPCS C1713 4332212 - SPACER 4332212 TELAMON P VBS 3 22X12MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4332214 SUP HCPCS C1713 4332214 - SPACER 4332214 TELAMON P VBS 3 22X14MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4332608 SUP HCPCS C1713 4332608 - SPACER 4332608 TELAMON P VBS 3 26X8MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4332610 SUP HCPCS C1713 4332610 - SPACER 4332610 TELAMON P VBS 3 26X10MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4332612 SUP HCPCS C1713 4332612 - SPACER SPNL 3D 26MMX12MM TLMN-PPEEK-OPTM END PC VERT BD REPL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4332614 SUP HCPCS C1713 4332614 - SPACER 4332614 TELAMON P VBS 3 26X14MM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340765 SUP Custom 27203010 REAGENT VDRL AG BUFF SAL BBL .5ML 60ML SERO BOTH IP/OP $183.70 $135.94 $0.00 $146.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $145.49 $146.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340826 SUP Custom 27203010 REAGENT MCBL COAG PLSM EDTA LYPH RBT BBL 15ML BOTH IP/OP $301.25 $222.93 $0.00 $241.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.63 $238.59 $241.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340983 SUP Custom 27203010 REAGENT MCBL ANSR SLMNLA O GRP A GLYCERINATED DFC 3ML BOTH IP/OP $291.48 $215.70 $0.00 $233.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.74 $230.85 $233.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340984 SUP Custom 27203010 REAGENT MCBL ANSR SLMNLA O GRP B GLYCERINATED DFC 3ML BOTH IP/OP $194.85 $144.19 $0.00 $155.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.43 $154.32 $155.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340985 SUP Custom 27203010 REAGENT MCBL ANSR SLMNLA O GRP C1 GLYCERINATED DFC 3ML BOTH IP/OP $363.13 $268.72 $0.00 $290.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.56 $287.60 $290.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340986 SUP Custom 27203010 REAGENT MCBL ANSR SLMNLA O GRP C2 GLYCERINATED DFC 3ML BOTH IP/OP $306.63 $226.91 $0.00 $245.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.31 $242.85 $245.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340987 SUP Custom 27203010 REAGENT MCBL ANSR SLMNLA O GRP D GLYCERINATED DFC 3ML BOTH IP/OP $133.28 $98.63 $0.00 $106.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.64 $105.56 $106.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340988 SUP Custom 27203010 REAGENT MCBL ANSR SLMNLA O GRP E GLYCERINATED DFC 3ML BOTH IP/OP $240.65 $178.08 $0.00 $192.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.33 $190.59 $192.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340993 SUP Custom 27203010 REAGENT MCBL ANSR SLMNLA O PLVLNT A-1 6 GLYCERINATED DFC 3ML BOTH IP/OP $234.25 $173.35 $0.00 $187.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.13 $185.53 $187.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4340994 SUP Custom 27203010 REAGENT MCBL ANSR SLMNLA 6 GLYCERINATED DFC 3ML BOTH IP/OP $228.23 $168.89 $0.00 $182.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.11 $180.76 $182.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4360130 SUP HCPCS C1713 4360130 - ENDCAP 4360130 13MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360135 SUP HCPCS C1713 4360135 - ENDCAP 4360135 13MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360138 SUP HCPCS C1713 4360138 - ENDCAP 4360138 13MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360160 SUP HCPCS C1713 4360160 - ENDCAP 4360160 16MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360165 SUP HCPCS C1713 4360165 - ENDCAP 4360165 16MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360168 SUP HCPCS C1713 4360168 - ENDCAP 4360168 16MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360200 SUP HCPCS C1713 4360200 - ENDCAP 4360200 20MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360205 SUP HCPCS C1713 4360205 - ENDCAP 4360205 20MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360208 SUP HCPCS C1713 4360208 - ENDCAP 4360208 20MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360220 SUP HCPCS C1713 4360220 - ENDCAP 4360220 22MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360225 SUP HCPCS C1713 4360225 - ENDCAP 4360225 22MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360228 SUP HCPCS C1713 4360228 - ENDCAP 4360228 22MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360250 SUP HCPCS C1713 4360250 - ENDCAP 4360250 25MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360255 SUP HCPCS C1713 4360255 - ENDCAP 4360255 25MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360258 SUP HCPCS C1713 4360258 - ENDCAP 4360258 25MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360300 SUP HCPCS C1713 4360300 - ENDCAP 4360300 30MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360305 SUP HCPCS C1713 4360305 - ENDCAP 4360305 30MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360308 SUP HCPCS C1713 4360308 - ENDCAP 4360308 30MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4360678 SUP Custom 27203010 4360678 - SYSTEM CULT SCHT GSPK EZ BOTH IP/OP $82.23 $60.85 $0.00 $65.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.12 $65.13 $65.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4361130 SUP HCPCS C1713 4361130 - ENDCAP 4361130 13MM 0 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361135 SUP HCPCS C1713 4361135 - ENDCAP 4361135 13MM 15 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361138 SUP HCPCS C1713 4361138 - ENDCAP 4361138 13MM 8 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361160 SUP HCPCS C1713 4361160 - ENDCAP 4361160 16MM 0 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361165 SUP HCPCS C1713 4361165 - ENDCAP 4361165 16MM 15 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361168 SUP HCPCS C1713 4361168 - ENDCAP 4361168 16MM 8 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361200 SUP HCPCS C1713 4361200 - ENDCAP 4361200 20MM 0 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361205 SUP HCPCS C1713 4361205 - ENDCAP 4361205 20MM 15 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361208 SUP HCPCS C1713 4361208 - ENDCAP 4361208 20MM 8 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361220 SUP HCPCS C1713 4361220 - ENDCAP 4361220 22MM 0 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361225 SUP HCPCS C1713 4361225 - ENDCAP 4361225 22MM 15 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361228 SUP HCPCS C1713 4361228 - ENDCAP 4361228 22MM 8 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361250 SUP HCPCS C1713 4361250 - ENDCAP 4361250 25MM 0 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361255 SUP HCPCS C1713 4361255 - ENDCAP 4361255 25MM 15 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361258 SUP HCPCS C1713 4361258 - ENDCAP 4361258 25MM 8 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361300 SUP HCPCS C1713 4361300 - ENDCAP 4361300 30MM 0 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361305 SUP HCPCS C1713 4361305 - ENDCAP 4361305 30MM 15 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4361308 SUP HCPCS C1713 4361308 - ENDCAP 4361308 30MM 8 DEGREE STERILE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 4395872 SUP Custom 27203010 MEDIA CULT CHOC AGAR SLANT MCFLS BOTH IP/OP $49.63 $36.73 $0.00 $39.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.81 $39.31 $39.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4396266 SUP Custom 27203010 MEDIA CULT T-H BROTH TUBE MYCFLS 5ML BOTH IP/OP $176.30 $130.46 $0.00 $141.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.15 $139.63 $141.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4396348 SUP Custom 27203010 MEDIA MYCL SAB-DEX EMNS AGAR GNTA BBL PLT DP FILL BOTH IP/OP $62.88 $46.53 $0.00 $50.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.44 $49.80 $50.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397222 SUP Custom 27203010 MEDIA CULT TRSN AGAR PR TUBE BBL 20ML BOTH IP/OP $55.08 $40.76 $0.00 $44.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.54 $43.62 $44.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397224 SUP Custom 27203010 MEDIA CULT XANTHINE AGAR PR TUBE BBL 20ML BOTH IP/OP $55.08 $40.76 $0.00 $44.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.54 $43.62 $44.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397231 SUP Custom 27203010 MEDIA CULT LYSOZYME BROTH TUBE MCFLS 5ML BOTH IP/OP $62.83 $46.49 $0.00 $50.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.41 $49.76 $50.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397232 SUP Custom 27203010 MEDIA CULT LYSOZYME CNTRL BROTH TUBE MCFLS 5ML BOTH IP/OP $56.98 $42.17 $0.00 $45.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.49 $45.13 $45.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397448 SUP Custom 27203010 MEDIA MYCL MDBRK COHN 7H10 AGAR MCFLS SLANT BOTH IP/OP $53.98 $39.95 $0.00 $43.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.99 $42.75 $43.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397770 SUP Custom 27203010 MEDIA MYCL SAB EMNS DEX AGAR GNTA SLANT BOTH IP/OP $759.05 $561.70 $0.00 $607.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.53 $601.17 $607.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397793 SUP Custom 27203010 MEDIA CULT SKIRROWS MED PLT BBL BOTH IP/OP $60.70 $44.92 $0.00 $48.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.35 $48.07 $48.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397875 SUP Custom 27203010 MEDIA MYCL BIRD SEED AGAR BBL PLT BOTH IP/OP $45.85 $33.93 $0.00 $36.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.93 $36.31 $36.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397880 SUP Custom 27203010 MEDIA CULT BCYE SLCT AGAR PAV PLT BBL BOTH IP/OP $37.03 $27.40 $0.00 $29.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.51 $29.33 $29.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4397886 SUP Custom 27203010 MEDIA MYCL YST XTRT PHOS AGAR BBL PLT DP FILL BOTH IP/OP $26.43 $19.56 $0.00 $21.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.21 $20.93 $21.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4484525 SUP HCPCS C1713 4484525 - SCREW BN 4.5MM 25MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484530 SUP HCPCS C1713 4484530 - SCREW BN 4.5MM 30MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484535 SUP HCPCS C1713 4484535 - SCREW BN 4.5MM 35MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484540 SUP HCPCS C1713 4484540 - SCREW BN 4.5MM 40MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484545 SUP HCPCS C1713 4484545 - SCREW BN 4.5MM 45MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484550 SUP HCPCS C1713 4484550 - SCREW BN 4.5MM 50MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484555 SUP HCPCS C1713 4484555 - SCREW BN 4.5MM 55MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484560 SUP HCPCS C1713 4484560 - SCREW BN 4.5MM 60MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484565 SUP HCPCS C1713 4484565 - SCREW BN 4.5MM 65MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484570 SUP HCPCS C1713 4484570 - SCREW BN 4.5MM 70MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484575 SUP HCPCS C1713 4484575 - SCREW BN 4.5MM 75MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4484580 SUP HCPCS C1713 4484580 - SCREW BN 4.5MM 80MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485525 SUP HCPCS C1713 4485525 - SCREW BN 5.5MM 25MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485530 SUP HCPCS C1713 4485530 - SCREW BN 5.5MM 30MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485535 SUP HCPCS C1713 4485535 - SCREW BN 5.5MM 35MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485540 SUP HCPCS C1713 4485540 - SCREW BN 5.5MM 40MM NS DBR III SPHERX CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485545 SUP HCPCS C1713 4485545 - SCREW BN 5.5MM 45MM NS DBR III SPHERX CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485550 SUP HCPCS C1713 4485550 - SCREW BN 5.5MM 50MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485555 SUP HCPCS C1713 4485555 - SCREW BN 5.5MM 55MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485560 SUP HCPCS C1713 4485560 - SCREW BN 5.5MM 60MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485565 SUP HCPCS C1713 4485565 - SCREW BN 5.5MM 65MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485570 SUP HCPCS C1713 4485570 - SCREW BN 5.5MM 70MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485575 SUP HCPCS C1713 4485575 - SCREW BN 5.5MM 75MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4485580 SUP HCPCS C1713 4485580 - SCREW BN 5.5MM 80MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486510 SUP HCPCS C1713 4486510 - SCREW BN 6.5MM 100MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486511 SUP HCPCS C1713 4486511 - SCREW BN 6.5MM 105MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486512 SUP HCPCS C1713 4486512 - SCREW BN 6.5MM 110MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486513 SUP HCPCS C1713 4486513 - SCREW BN 6.5MM 115MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486514 SUP HCPCS C1713 4486514 - SCREW BN 6.5MM 120MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486525 SUP HCPCS C1713 4486525 - SCREW BN 6.5MM 25MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486530 SUP HCPCS C1713 4486530 - SCREW BN 6.5MM 30MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486535 SUP HCPCS C1713 4486535 - SCREW BN 6.5MM 35MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486540 SUP HCPCS C1713 4486540 - SCREW BN 6.5MM 40MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486545 SUP HCPCS C1713 4486545 - SCREW BN 6.5MM 45MM NS DBR III SPHERX CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486550 SUP HCPCS C1713 4486550 - SCREW BN 6.5MM 50MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486555 SUP HCPCS C1713 4486555 - SCREW BN 6.5MM 55MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486560 SUP HCPCS C1713 4486560 - SCREW BN 6.5MM 60MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486565 SUP HCPCS C1713 4486565 - SCREW BN 6.5MM 65MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486570 SUP HCPCS C1713 4486570 - SCREW BN 6.5MM 70MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486575 SUP HCPCS C1713 4486575 - SCREW BN 6.5MM 75MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486580 SUP HCPCS C1713 4486580 - SCREW BN 6.5MM 80MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486585 SUP HCPCS C1713 4486585 - SCREW BN 6.5MM 85MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486590 SUP HCPCS C1713 4486590 - SCREW BN 6.5MM 90MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4486595 SUP HCPCS C1713 4486595 - SCREW BN 6.5MM 95MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487510 SUP HCPCS C1713 4487510 - SCREW BN 7.5MM 100MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487511 SUP HCPCS C1713 4487511 - SCREW BN 7.5MM 105MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487512 SUP HCPCS C1713 4487512 - SCREW BN 7.5MM 110MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487513 SUP HCPCS C1713 4487513 - SCREW BN 7.5MM 115MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487514 SUP HCPCS C1713 4487514 - SCREW BN 7.5MM 120MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487525 SUP HCPCS C1713 4487525 - SCREW BN 7.5MM 25MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487530 SUP HCPCS C1713 4487530 - SCREW BN 7.5MM 30MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487535 SUP HCPCS C1713 4487535 - SCREW BN 7.5MM 35MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487540 SUP HCPCS C1713 4487540 - SCREW BN 7.5MM 40MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487545 SUP HCPCS C1713 4487545 - SCREW BN 7.5MM 45MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487550 SUP HCPCS C1713 4487550 - SCREW BN 7.5MM 50MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487555 SUP HCPCS C1713 4487555 - SCREW BN 7.5MM 55MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487560 SUP HCPCS C1713 4487560 - SCREW BN 7.5MM 60MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487565 SUP HCPCS C1713 4487565 - SCREW BN 7.5MM 65MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487570 SUP HCPCS C1713 4487570 - SCREW BN 7.5MM 70MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487575 SUP HCPCS C1713 4487575 - SCREW BN 7.5MM 75MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487580 SUP HCPCS C1713 4487580 - SCREW BN 7.5MM 80MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487585 SUP HCPCS C1713 4487585 - SCREW BN 7.5MM 85MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487590 SUP HCPCS C1713 4487590 - SCREW BN 7.5MM 90MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4487595 SUP HCPCS C1713 4487595 - SCREW BN 7.5MM 95MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488510 SUP HCPCS C1713 4488510 - SCREW BN 8.5MM 100MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488511 SUP HCPCS C1713 4488511 - SCREW BN 8.5MM 105MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488512 SUP HCPCS C1713 4488512 - SCREW BN 8.5MM 110MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488513 SUP HCPCS C1713 4488513 - SCREW BN 8.5MM 115MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488514 SUP HCPCS C1713 4488514 - SCREW BN 8.5MM 120MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488525 SUP HCPCS C1713 4488525 - SCREW BN 8.5MM 25MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488530 SUP HCPCS C1713 4488530 - SCREW BN 8.5MM 30MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488535 SUP HCPCS C1713 4488535 - SCREW BN 8.5MM 35MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488540 SUP HCPCS C1713 4488540 - SCREW BN 8.5MM 40MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488545 SUP HCPCS C1713 4488545 - SCREW BN 8.5MM 45MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488550 SUP HCPCS C1713 4488550 - SCREW BN 8.5MM 50MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488555 SUP HCPCS C1713 4488555 - SCREW BN 8.5MM 55MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488560 SUP HCPCS C1713 4488560 - SCREW BN 8.5MM 60MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488565 SUP HCPCS C1713 4488565 - SCREW BN 8.5MM 65MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488570 SUP HCPCS C1713 4488570 - SCREW BN 8.5MM 70MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488575 SUP HCPCS C1713 4488575 - SCREW BN 8.5MM 75MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488580 SUP HCPCS C1713 4488580 - SCREW BN 8.5MM 80MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488585 SUP HCPCS C1713 4488585 - SCREW BN 8.5MM 85MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488590 SUP HCPCS C1713 4488590 - SCREW BN 8.5MM 90MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4488595 SUP HCPCS C1713 4488595 - SCREW BN 8.5MM 95MM DBR III CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 4527020 SUP Custom 27203010 4527020 - BIT DRILL 2MM 102MM AO SHAFT BOTH IP/OP $306.30 $226.66 $0.00 $245.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.34 $227.34 $0.00 $0.00 $63.83 $0.00 $0.00 $0.00 $0.00 $153.15 $242.59 $245.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4535020 SUP Custom 27203010 4535020 - BIT DRL 3.6MM RD YLW AO FIT 3.5MM VARIAX LCK PLT SYSTE BOTH IP/OP $306.30 $226.66 $0.00 $245.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.34 $227.34 $0.00 $0.00 $63.83 $0.00 $0.00 $0.00 $0.00 $153.15 $242.59 $245.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4622801 SUP Custom 27203010 MATTRESS HEAD SECTION /FA BOTH IP/OP "$1,264.83 " $935.97 $0.00 "$1,011.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.41 "$1,001.75" "$1,011.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4623002 SUP Custom 27203010 MATTRESS FOOT SECTION /FA BOTH IP/OP "$1,015.35 " $751.36 $0.00 $812.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.68 $804.16 $812.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920040 SUP HCPCS C1713 4920040 - CAGE SPNL 0D 40X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920045 SUP HCPCS C1713 4920045 - CAGE SPNL 0D 45X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920050 SUP HCPCS C1713 4920050 - CAGE SPNL 0D 50X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920055 SUP HCPCS C1713 4920055 - CAGE SPNL 0D 55X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920060 SUP HCPCS C1713 4920060 - CAGE SPNL 0D 60X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920240 SUP HCPCS C1713 4920240 - CAGE SPNL 0D 40X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920245 SUP HCPCS C1713 4920245 - CAGE SPNL 0D 45X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920250 SUP HCPCS C1713 4920250 - CAGE SPNL 0D 50X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920255 SUP HCPCS C1713 4920255 - CAGE SPNL 0D 55X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920260 SUP HCPCS C1713 4920260 - CAGE SPNL 0D 60X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920440 SUP HCPCS C1713 4920440 - CAGE SPNL 0D 40X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920445 SUP HCPCS C1713 4920445 - CAGE SPNL 0D 45X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920450 SUP HCPCS C1713 4920450 - CAGE SPNL 0D 50X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920455 SUP HCPCS C1713 4920455 - CAGE SPNL 0D 55X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920460 SUP HCPCS C1713 4920460 - CAGE SPNL 0D 60X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920640 SUP HCPCS C1713 4920640 - CAGE SPNL 0D 40X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920645 SUP HCPCS C1713 4920645 - CAGE SPNL 0D 45X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920650 SUP HCPCS C1713 4920650 - CAGE SPNL 0D 50X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920655 SUP HCPCS C1713 4920655 - CAGE SPNL 0D 55X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920660 SUP HCPCS C1713 4920660 - CAGE SPNL 0D 60X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920840 SUP HCPCS C1713 4920840 - CAGE SPNL 0D 40X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920845 SUP HCPCS C1713 4920845 - CAGE SPNL 0D 45X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920850 SUP HCPCS C1713 4920850 - CAGE SPNL 0D 50X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920855 SUP HCPCS C1713 4920855 - CAGE SPNL 0D 55X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4920860 SUP HCPCS C1713 4920860 - CAGE SPNL 0D 60X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922040 SUP HCPCS C1713 4922040 - CAGE SPNL 12D 40X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922045 SUP HCPCS C1713 4922045 - CAGE SPNL 12D 45X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922050 SUP HCPCS C1713 4922050 - CAGE SPNL 12D 50X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922055 SUP HCPCS C1713 4922055 - CAGE SPNL 12D 55X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922060 SUP HCPCS C1713 4922060 - CAGE SPNL 12D 60X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922240 SUP HCPCS C1713 4922240 - CAGE SPNL 12D 40X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922245 SUP HCPCS C1713 4922245 - CAGE SPNL 12D 45X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922250 SUP HCPCS C1713 4922250 - CAGE SPNL 12D 50X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922255 SUP HCPCS C1713 4922255 - CAGE SPNL 12D 55X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922260 SUP HCPCS C1713 4922260 - CAGE SPNL 12D 60X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922440 SUP HCPCS C1713 4922440 - CAGE SPNL 12D 40X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922445 SUP HCPCS C1713 4922445 - CAGE SPNL 12D 45X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922450 SUP HCPCS C1713 4922450 - CAGE SPNL 12D 50X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922455 SUP HCPCS C1713 4922455 - CAGE SPNL 12D 55X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922460 SUP HCPCS C1713 4922460 - CAGE SPNL 12D 60X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922640 SUP HCPCS C1713 4922640 - CAGE SPNL 12D 40X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922645 SUP HCPCS C1713 4922645 - CAGE SPNL 12D 45X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922650 SUP HCPCS C1713 4922650 - CAGE SPNL 12D 50X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922655 SUP HCPCS C1713 4922655 - CAGE SPNL 12D 55X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4922660 SUP HCPCS C1713 4922660 - CAGE SPNL 12D 60X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926040 SUP HCPCS C1713 4926040 - CAGE SPNL 6D 40X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926045 SUP HCPCS C1713 4926045 - CAGE SPNL 6D 45X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926050 SUP HCPCS C1713 4926050 - CAGE SPNL 6D 50X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926055 SUP HCPCS C1713 4926055 - CAGE SPNL 6D 55X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926060 SUP HCPCS C1713 4926060 - CAGE SPNL 6D 60X22X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926240 SUP HCPCS C1713 4926240 - CAGE SPNL 6D 40X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926245 SUP HCPCS C1713 4926245 - CAGE SPNL 6D 45X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926250 SUP HCPCS C1713 4926250 - CAGE SPNL 6D 50X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926255 SUP HCPCS C1713 4926255 - CAGE SPNL 6D 55X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926260 SUP HCPCS C1713 4926260 - CAGE SPNL 6D 60X22X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926440 SUP HCPCS C1713 4926440 - CAGE SPNL 6D 40X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926445 SUP HCPCS C1713 4926445 - CAGE SPNL 6D 45X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926450 SUP HCPCS C1713 4926450 - CAGE SPNL 6D 50X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926455 SUP HCPCS C1713 4926455 - CAGE SPNL 6D 55X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926460 SUP HCPCS C1713 4926460 - CAGE SPNL 6D 60X22X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926640 SUP HCPCS C1713 4926640 - CAGE SPNL 6D 40X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926645 SUP HCPCS C1713 4926645 - CAGE SPNL 6D 45X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926650 SUP HCPCS C1713 4926650 - CAGE SPNL 6D 50X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926655 SUP HCPCS C1713 4926655 - CAGE SPNL 6D 55X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926660 SUP HCPCS C1713 4926660 - CAGE SPNL 6D 60X22X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926840 SUP HCPCS C1713 4926840 - CAGE SPNL 6D 40X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926845 SUP HCPCS C1713 4926845 - CAGE SPNL 6D 45X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926850 SUP HCPCS C1713 4926850 - CAGE SPNL 6D 50X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926855 SUP HCPCS C1713 4926855 - CAGE SPNL 6D 55X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4926860 SUP HCPCS C1713 4926860 - CAGE SPNL 6D 60X22X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980040 SUP HCPCS C1713 4980040 - CAGE SPNL 0D 40X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980045 SUP HCPCS C1713 4980045 - CAGE SPNL 0D 45X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980050 SUP HCPCS C1713 4980050 - CAGE SPNL 0D 50X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980055 SUP HCPCS C1713 4980055 - CAGE SPNL 0D 55X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980240 SUP HCPCS C1713 4980240 - CAGE SPNL 0D 40X12X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980245 SUP HCPCS C1713 4980245 - CAGE SPNL 0D 45X12X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980250 SUP HCPCS C1713 4980250 - CAGE SPNL 0D 50X12X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980255 SUP HCPCS C1713 4980255 - CAGE SPNL 0D 55X12X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980440 SUP HCPCS C1713 4980440 - CAGE SPNL 0D 40X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980445 SUP HCPCS C1713 4980445 - CAGE SPNL 0D 45X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980450 SUP HCPCS C1713 4980450 - CAGE SPNL 0D 50X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980455 SUP HCPCS C1713 4980455 - CAGE SPNL 0D 55X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980640 SUP HCPCS C1713 4980640 - CAGE SPNL 0D 40X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980645 SUP HCPCS C1713 4980645 - CAGE SPNL 0D 45X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980650 SUP HCPCS C1713 4980650 - CAGE SPNL 0D 50X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980655 SUP HCPCS C1713 4980655 - CAGE SPNL 0D 55X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980840 SUP HCPCS C1713 4980840 - CAGE SPNL 0D 40X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980845 SUP HCPCS C1713 4980845 - CAGE SPNL 0D 45X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980850 SUP HCPCS C1713 4980850 - CAGE SPNL 0D 50X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4980855 SUP HCPCS C1713 4980855 - CAGE SPNL 0D 55X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986040 SUP HCPCS C1713 4986040 - CAGE SPNL 6D 40X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986045 SUP HCPCS C1713 4986045 - CAGE SPNL 6D 45X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986050 SUP HCPCS C1713 4986050 - CAGE SPNL 6D 50X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986055 SUP HCPCS C1713 4986055 - CAGE SPNL 6D 55X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986060 SUP HCPCS C1713 4986060 - CAGE SPNL 6D 60X18X10MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986240 SUP HCPCS C1713 4986240 - CAGE SPNL 6D 40X18X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986245 SUP HCPCS C1713 4986245 - CAGE SPNL 6D 45X18X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986250 SUP HCPCS C1713 4986250 - CAGE SPNL 6D 50X18X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986255 SUP HCPCS C1713 4986255 - CAGE SPNL 6D 55X18X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986260 SUP HCPCS C1713 4986260 - CAGE SPNL 6D 60X18X12MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986440 SUP HCPCS C1713 4986440 - CAGE SPNL 6D 40X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986445 SUP HCPCS C1713 4986445 - CAGE SPNL 6D 45X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986450 SUP HCPCS C1713 4986450 - CAGE SPNL 6D 50X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986455 SUP HCPCS C1713 4986455 - CAGE SPNL 6D 55X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986460 SUP HCPCS C1713 4986460 - CAGE SPNL 6D 60X18X14MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986640 SUP HCPCS C1713 4986640 - CAGE SPNL 6D 40X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986645 SUP HCPCS C1713 4986645 - CAGE SPNL 6D 45X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986650 SUP HCPCS C1713 4986650 - CAGE SPNL 6D 50X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986655 SUP HCPCS C1713 4986655 - CAGE SPNL 6D 55X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986660 SUP HCPCS C1713 4986660 - CAGE SPNL 6D 60X18X16MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986840 SUP HCPCS C1713 4986840 - CAGE SPNL 6D 40X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986845 SUP HCPCS C1713 4986845 - CAGE SPNL 6D 45X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986850 SUP HCPCS C1713 4986850 - CAGE SPNL 6D 50X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986855 SUP HCPCS C1713 4986855 - CAGE SPNL 6D 55X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 4986860 SUP HCPCS C1713 4986860 - CAGE SPNL 6D 60X18X8MM CLYDESDALE PTC RADOPQ PEEK TI LMBR BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 5010001 SUP HCPCS C1788 5010001 - DEVICE BX 6 PORT ASP BN MRW BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $156.38 $156.38 $0.00 $0.00 $0.00 $72.43 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $205.55 $205.55 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $54.38 $0.00 $0.00 $55.32 $0.00 $0.00 $0.00 $0.00 $0.00 5010005 SUP Custom 27804086 5010005 - SUBSTITUTE BNGF 5ML STRL FORMAGRAFT GRNL BVN CLGN MTRX TCP BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 $0.00 $0.00 $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5010008 SUP Custom 27203010 5010008 - NEEDLE SPNL 8IN ASP PORT BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $0.00 $0.00 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5010010 SUP Custom 27804086 5010010 - SUBSTITUTE BNGF 10ML STRL FORMAGRAFT GRNL BVN CLGN MTRX BOTH IP/OP "$3,505.00 " "$2,593.70" $0.00 "$2,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,601.41" "$2,601.41" $0.00 $0.00 $730.44 $0.00 $0.00 $0.00 $0.00 "$1,752.50" "$2,775.96" "$2,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5010020 SUP Custom 27804086 5010020 - SUBSTITUTE BNGF 20ML STRL FORMAGRAFT GRNL BVN CLGN MTRX TCP BOTH IP/OP "$3,505.00 " "$2,593.70" $0.00 "$2,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,601.41" "$2,601.41" $0.00 $0.00 $730.44 $0.00 $0.00 $0.00 $0.00 "$1,752.50" "$2,775.96" "$2,804.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5010024 SUP HCPCS C1884 5010024 - FILTER CV .035IN LOPRFL CONE 9FR 70CM VNTC LP PROVEN DSGN BOTH IP/OP "$2,925.60 " "$2,164.94" $0.00 "$2,340.48" "$1,316.52" "$1,316.52" $0.00 $0.00 $0.00 $609.77 "$2,171.38" "$2,171.38" $0.00 $0.00 $609.70 $0.00 "$1,442.32" "$1,442.32" $0.00 "$1,462.80" "$2,317.08" "$2,340.48" $0.00 $0.00 $457.86 $0.00 $0.00 $465.76 $0.00 $0.00 $0.00 $0.00 $0.00 5010085 SUP Custom 27804086 5010085 - SUBSTITUTE BNGF SM STRL FORMAGRAFT BLCK BVN CLGN MTRX TCP BOTH IP/OP "$4,130.00 " "$3,056.20" $0.00 "$3,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,065.29" "$3,065.29" $0.00 $0.00 $860.69 $0.00 $0.00 $0.00 $0.00 "$2,065.00" "$3,270.96" "$3,304.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5010125 SUP HCPCS C1713 5010125 - SUBSTITUTE BNGF LG STRL FORMAGRAFT BLCK BVN CLGN MTRX TCP BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" "$2,008.13" "$2,008.13" $0.00 $0.00 $0.00 $930.10 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 "$2,200.01" "$2,200.01" $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $698.38 $0.00 $0.00 $710.43 $0.00 $0.00 $0.00 $0.00 $0.00 5010205 SUP Custom 27804086 5010205 - SUBSTITUTE BNGF 5ML STRL FORMAGRAFT STRP BVN CLGN MTRX TCP BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 $0.00 $0.00 $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5013001 SUP HCPCS C1762 5013001 - GRAFT BONE OSTEOCEL PLUS CLLR BONE MTRX 1ML BOTH IP/OP "$1,222.50 " $904.65 $0.00 $978.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.25 $968.22 $978.00 $0.00 $0.00 $191.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5013005 SUP HCPCS C1762 5013005 - GRAFT BONE OSTEOCEL PLUS CLLR BONE MTRX 5ML BOTH IP/OP "$5,632.50 " "$4,168.05" $0.00 "$4,506.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,816.25" "$4,460.94" "$4,506.00" $0.00 $0.00 $881.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5013010 SUP Custom 27804086 5013010 - GRAFT BN 10ML OSTEOCEL + CLLR BN MTRX BOTH IP/OP "$9,625.00 " "$7,122.50" $0.00 "$7,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,005.85" $0.00 $0.00 $0.00 $0.00 "$4,812.50" "$7,623.00" "$7,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5013015 SUP HCPCS C1762 5013015 - GRAFT BONE OSTEOCEL PLUS CLLR BONE MTRX 15ML BOTH IP/OP "$11,475.00 " "$8,491.50" $0.00 "$9,180.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,391.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,391.39" $0.00 "$5,657.18" "$5,657.18" $0.00 "$5,737.50" "$9,088.20" "$9,180.00" $0.00 $0.00 "$1,795.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016001 SUP HCPCS C1762 5016001 - GRAFT BONE OSTEOCEL CLLR BONE MTRX 1ML BOTH IP/OP "$1,345.00 " $995.30 $0.00 "$1,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $672.50 "$1,065.24" "$1,076.00" $0.00 $0.00 $210.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016005 SUP HCPCS C1762 5016005 - GRAFT BONE OSTEOCEL CLLR BONE MTRX 5ML BOTH IP/OP "$6,195.00 " "$4,584.30" $0.00 "$4,956.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,097.50" "$4,906.44" "$4,956.00" $0.00 $0.00 $969.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5016010 SUP HCPCS C1762 5016010 - GRAFT BONE OSTEOCEL CLLR BONE MTRX 10ML BOTH IP/OP "$10,652.50 " "$7,882.85" $0.00 "$8,522.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,326.25" "$8,436.78" "$8,522.00" $0.00 $0.00 "$1,667.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5017905 SUP HCPCS C1713 5017905 - SCREW BN 1.7MM 5MM NS LEIBINGER UNV 2 SLF DRL XPN TI MDFC BOTH IP/OP $103.40 $76.52 $0.00 $118.32 $66.56 $66.56 $0.00 $0.00 $0.00 $21.55 $76.74 $76.74 $0.00 $0.00 $21.55 $0.00 $61.16 $61.16 $0.00 $73.95 $117.14 $118.32 $0.00 $0.00 $23.15 $0.00 $0.00 $23.55 $0.00 $0.00 $0.00 $0.00 $0.00 5020001 SUP HCPCS C1713 5020001 - GRAFT BN SM STRL LF PROPEL ALGRF PTTY BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 5020005 SUP HCPCS C1713 5020005 - GRAFT BN MED STRL LF PROPEL ALGRF PTTY BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020010 SUP HCPCS C1713 5020010 - GRAFT BN LG STRL LF PROPEL ALGRF PTTY BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5020404 SUP HCPCS C1713 5020404 - SCREW BN 2MM 4MM AU NS LEIBINGER UNV 2 ST XPN TI MXLFCL BOTH IP/OP $87.40 $64.68 $0.00 $100.74 $56.67 $56.67 $0.00 $0.00 $0.00 $18.22 $64.87 $64.87 $0.00 $0.00 $18.21 $0.00 $51.70 $51.70 $0.00 $62.96 $99.74 $100.74 $0.00 $0.00 $19.71 $0.00 $0.00 $20.05 $0.00 $0.00 $0.00 $0.00 $0.00 5022105 SUP HCPCS C1713 5022105 - GRAFT BN MED PROPEL ALGRF DBM FBR BOTH IP/OP "$1,450.00 " "$1,073.00" $0.00 "$1,160.00" $652.50 $652.50 $0.00 $0.00 $0.00 $302.22 "$1,076.19" "$1,076.19" $0.00 $0.00 $302.18 $0.00 $857.68 $857.68 $0.00 $725.00 "$1,148.40" "$1,160.00" $0.00 $0.00 $226.93 $0.00 $0.00 $230.84 $0.00 $0.00 $0.00 $0.00 $0.00 5022112 SUP HCPCS C1713 5022112 - GRAFT BN SM BOAT PROPEL ALGRF DBM FBR BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 5022113 SUP HCPCS C1713 5022113 - GRAFT BN LG BOAT PROPEL ALGRF DBM FBR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030641 SUP HCPCS C1713 5030641 - CAGE SPNL 11MM 14MMX6MM STRL ANTM RADOPQ PTC CRV INTRBD FS BOTH IP/OP "$5,940.00 " "$4,395.60" $0.00 "$4,752.00" "$2,673.00" "$2,673.00" $0.00 $0.00 $0.00 "$1,238.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,237.90" $0.00 "$2,928.42" "$2,928.42" $0.00 "$2,970.00" "$4,704.48" "$4,752.00" $0.00 $0.00 $929.61 $0.00 $0.00 $945.65 $0.00 $0.00 $0.00 $0.00 $0.00 5101302 SUP HCPCS C1713 5101302 - CAGE SPNL 12D 30X11X10MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5101308 SUP HCPCS C1713 5101308 - CAGE SPNL 8D 30X11X10MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5104308 SUP HCPCS C1713 5104308 - CAGE SPNL 8D 30MMX14MMX10 NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5109308 SUP HCPCS C1713 5109308 - CAGE SPNL 8D 30X10X9MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5111308 SUP HCPCS C1713 5111308 - CAGE SPNL 8D 30X11X11MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5119308 SUP HCPCS C1713 5119308 - CAGE SPNL 8D 30X11X9MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5121308 SUP HCPCS C1713 5121308 - CAGE SPNL 8D 30X12X11MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5129308 SUP HCPCS C1713 5129308 - CAGE SPNL 8D 30X12X9MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5149308 SUP HCPCS C1713 5149308 - CAGE SPNL 8D 30X14X9MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5161600 SUP Custom 27803010 5161600 - ENDCAP 16MM RND 0 DEG OD16 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5161604 SUP Custom 27803010 5161604 - ENDCAP 16MM RND 4 DEG OD16 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5161608 SUP Custom 27803010 5161608 - ENDCAP 16MM RND 8 DEG OD16 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5161612 SUP Custom 27803010 5161612 - ENDCAP 16MM RND 12 DEG XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5163000 SUP Custom 27803010 5163000 - ENDCAP OD16X16X30MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5163004 SUP Custom 27803010 5163004 - ENDCAP˙ OD16X16X30MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5163014 SUP Custom 27803010 5163014 - ENDCAP OD16X16X30MM -4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5164000 SUP Custom 27803010 5164000 - ENDCAP OD16X16X40MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5164004 SUP Custom 27803010 5164004 - ENDCAP OD16X16X40MM 4 DEG TI XCORE TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5164014 SUP Custom 27803010 5164014 - ENDCAP OD16X16X40MM -4 DEG TI OD16 TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5181308 SUP HCPCS C1713 5181308 - CAGE SPNL 8D 30X11X8MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5181800 SUP Custom 27803010 5181800 - ENDCAP 18MM RND 0 DEG OD16 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5181804 SUP Custom 27803010 5181804 - ENDCAP 18MM RND 4 DEG OD16 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5181808 SUP Custom 27803010 5181808 - ENDCAP 18MM RND 8 DEG OD16 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5181812 SUP Custom 27803010 5181812 - ENDCAP 18MM RND 12 DEG OD18 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5189300 SUP HCPCS C1713 5189300 - CAGE SPNL 0D 30X9X8MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5189302 SUP HCPCS C1713 5189302 - CAGE SPNL 12D 30X9X8MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5191302 SUP HCPCS C1713 5191302 - CAGE SPNL 12D 30X11X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5191308 SUP HCPCS C1713 5191308 - CAGE SPNL 8D 30X11X9MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5199300 SUP HCPCS C1713 5199300 - CAGE SPNL 0D 30X9X9MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5199302 SUP HCPCS C1713 5199302 - CAGE SPNL 12D 30X9X9MM NS LF CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5289308 SUP HCPCS C1713 5289308 - CAGE SPNL 8D 30X9X8MM NS LF TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5300252 SUP HCPCS C1713 5300252 - CAGE SPNL 12D OBLQ 25X10X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5300254 SUP HCPCS C1713 5300254 - CAGE SPNL 4D OBLQ 25X10X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5300302 SUP HCPCS C1713 5300302 - CAGE SPNL 12D OBLQ 30X10X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5300304 SUP HCPCS C1713 5300304 - CAGE SPNL 4D OBLQ 30X10X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5300354 SUP HCPCS C1713 5300354 - CAGE SPNL 4D OBLQ 35X10X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5304252 SUP HCPCS C1713 5304252 - CAGE SPNL 12D OBLQ 25X10X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5304254 SUP HCPCS C1713 5304254 - CAGE SPNL 4D OBLQ 25X10X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5304302 SUP HCPCS C1713 5304302 - CAGE SPNL 12D OBLQ 30X10X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5304304 SUP HCPCS C1713 5304304 - CAGE SPNL 4D OBLQ 30X10X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5320252 SUP HCPCS C1713 5320252 - CAGE SPNL 12D OBLQ 25X12X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5320254 SUP HCPCS C1713 5320254 - CAGE SPNL 4D OBLQ 25X12X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5320302 SUP HCPCS C1713 5320302 - CAGE SPNL 12D OBLQ 30X12X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5320304 SUP HCPCS C1713 5320304 - CAGE SPNL 4D OBLQ 30X12X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5320354 SUP HCPCS C1713 5320354 - CAGE SPNL 4D OBLQ 35X12X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5324252 SUP HCPCS C1713 5324252 - CAGE SPNL 12D OBLQ 25X12X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5324254 SUP HCPCS C1713 5324254 - CAGE SPNL 4D OBLQ 25X12X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5324302 SUP HCPCS C1713 5324302 - CAGE SPNL 12D OBLQ 30X12X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5324304 SUP HCPCS C1713 5324304 - CAGE SPNL 4D OBLQ 30X12X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5340252 SUP HCPCS C1713 5340252 - CAGE SPNL 12D OBLQ 25X14X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5340254 SUP HCPCS C1713 5340254 - CAGE SPNL 4D OBLQ 25X14X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5340302 SUP HCPCS C1713 5340302 - CAGE SPNL 12D OBLQ 30X14X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5340304 SUP HCPCS C1713 5340304 - CAGE SPNL 4D OBLQ 30X14X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5340354 SUP HCPCS C1713 5340354 - CAGE SPNL 4D OBLQ 35X14X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5380252 SUP HCPCS C1713 5380252 - CAGE SPNL 12D OBLQ 25X8X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5380254 SUP HCPCS C1713 5380254 - CAGE SPNL 4D OBLQ 25X8X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5380302 SUP HCPCS C1713 5380302 - CAGE SPNL 12D OBLQ 30X8X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5380304 SUP HCPCS C1713 5380304 - CAGE SPNL 4D OBLQ 30X8X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5380354 SUP HCPCS C1713 5380354 - CAGE SPNL 4D OBLQ 35X8X10MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5384252 SUP HCPCS C1713 5384252 - CAGE SPNL 12D OBLQ 25X8X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5384254 SUP HCPCS C1713 5384254 - CAGE SPNL 4D OBLQ 25X8X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5384302 SUP HCPCS C1713 5384302 - CAGE SPNL 12D OBLQ 30X8X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5384304 SUP HCPCS C1713 5384304 - CAGE SPNL 4D OBLQ 30X8X14MM TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400250 SUP HCPCS C1713 5400250 - CAGE SPNL 0D OBLQ 25X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5400252 SUP HCPCS C1713 5400252 - CAGE SPNL 12D OBLQ 25X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5400254 SUP HCPCS C1713 5400254 - CAGE SPNL 4D OBLQ 25X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5400255 SUP HCPCS C1713 5400255 - CAGE SPNL 15D OBLQ 25X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400258 SUP HCPCS C1713 5400258 - CAGE SPNL 8D OBLQ 25X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400300 SUP HCPCS C1713 5400300 - CAGE SPNL 0D OBLQ 30X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5400302 SUP HCPCS C1713 5400302 - CAGE SPNL 12D OBLQ 30X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5400304 SUP HCPCS C1713 5400304 - CAGE SPNL 4D OBLQ 30X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5400305 SUP HCPCS C1713 5400305 - CAGE SPNL 15D OBLQ 30X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400308 SUP HCPCS C1713 5400308 - CAGE SPNL 8D OBLQ 30X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400350 SUP HCPCS C1713 5400350 - CAGE SPNL 0D OBLQ 35X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400352 SUP HCPCS C1713 5400352 - CAGE SPNL 12D OBLQ 35X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400354 SUP HCPCS C1713 5400354 - CAGE SPNL 4D OBLQ 35X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5400355 SUP HCPCS C1713 5400355 - CAGE SPNL 15D OBLQ 35X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400358 SUP HCPCS C1713 5400358 - CAGE SPNL 8D OBLQ 35X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400400 SUP HCPCS C1713 5400400 - CAGE SPNL 0D OBLQ 40X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400402 SUP HCPCS C1713 5400402 - CAGE SPNL 12D OBLQ 40X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400404 SUP HCPCS C1713 5400404 - CAGE SPNL 4D OBLQ 40X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400405 SUP HCPCS C1713 5400405 - CAGE SPNL 15D OBLQ 40X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5400408 SUP HCPCS C1713 5400408 - CAGE SPNL 8D OBLQ 40X10X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404250 SUP HCPCS C1713 5404250 - CAGE SPNL 0D OBLQ 25X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404252 SUP HCPCS C1713 5404252 - CAGE SPNL 12D OBLQ 25X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5404254 SUP HCPCS C1713 5404254 - CAGE SPNL 4D OBLQ 25X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5404255 SUP HCPCS C1713 5404255 - CAGE SPNL 15D OBLQ 25X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404258 SUP HCPCS C1713 5404258 - CAGE SPNL 8D OBLQ 25X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404300 SUP HCPCS C1713 5404300 - CAGE SPNL 0D OBLQ 30X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404302 SUP HCPCS C1713 5404302 - CAGE SPNL 12D OBLQ 30X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404304 SUP HCPCS C1713 5404304 - CAGE SPNL 4D OBLQ 30X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5404305 SUP HCPCS C1713 5404305 - CAGE SPNL 15D OBLQ 30X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404308 SUP HCPCS C1713 5404308 - CAGE SPNL 8D OBLQ 30X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404350 SUP HCPCS C1713 5404350 - CAGE SPNL 0D OBLQ 35X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404352 SUP HCPCS C1713 5404352 - CAGE SPNL 12D OBLQ 35X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404354 SUP HCPCS C1713 5404354 - CAGE SPNL 4D OBLQ 35X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404355 SUP HCPCS C1713 5404355 - CAGE SPNL 15D OBLQ 35X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404358 SUP HCPCS C1713 5404358 - CAGE SPNL 8D OBLQ 35X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404400 SUP HCPCS C1713 5404400 - CAGE SPNL 0D OBLQ 40X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404402 SUP HCPCS C1713 5404402 - CAGE SPNL 12D OBLQ 40X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404404 SUP HCPCS C1713 5404404 - CAGE SPNL 4D OBLQ 40X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404405 SUP HCPCS C1713 5404405 - CAGE SPNL 15D OBLQ 40X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5404408 SUP HCPCS C1713 5404408 - CAGE SPNL 8D OBLQ 40X14X10MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410250 SUP HCPCS C1713 5410250 - CAGE SPNL 0D OBLQ 25X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410252 SUP HCPCS C1713 5410252 - CAGE SPNL 12D OBLQ 25X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410254 SUP HCPCS C1713 5410254 - CAGE SPNL 4D OBLQ 25X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410255 SUP HCPCS C1713 5410255 - CAGE SPNL 15D OBLQ 25X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410258 SUP HCPCS C1713 5410258 - CAGE SPNL 8D OBLQ 25X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410300 SUP HCPCS C1713 5410300 - CAGE SPNL 0D OBLQ 30X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410302 SUP HCPCS C1713 5410302 - CAGE SPNL 12D OBLQ 30X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410304 SUP HCPCS C1713 5410304 - CAGE SPNL 4D OBLQ 30X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410305 SUP HCPCS C1713 5410305 - CAGE SPNL 15D OBLQ 30X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410308 SUP HCPCS C1713 5410308 - CAGE SPNL 8D OBLQ 30X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410350 SUP HCPCS C1713 5410350 - CAGE SPNL 0D OBLQ 35X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410352 SUP HCPCS C1713 5410352 - CAGE SPNL 12D OBLQ 35X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410354 SUP HCPCS C1713 5410354 - CAGE SPNL 4D OBLQ 35X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410355 SUP HCPCS C1713 5410355 - CAGE SPNL 15D OBLQ 35X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410358 SUP HCPCS C1713 5410358 - CAGE SPNL 8D OBLQ 35X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410400 SUP HCPCS C1713 5410400 - CAGE SPNL 0D OBLQ 40X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410402 SUP HCPCS C1713 5410402 - CAGE SPNL 12D OBLQ 40X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410404 SUP HCPCS C1713 5410404 - CAGE SPNL 4D OBLQ 40X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410405 SUP HCPCS C1713 5410405 - CAGE SPNL 15D OBLQ 40X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5410408 SUP HCPCS C1713 5410408 - CAGE SPNL 8D OBLQ 40X10X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414250 SUP HCPCS C1713 5414250 - CAGE SPNL 0D OBLQ 25X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414252 SUP HCPCS C1713 5414252 - CAGE SPNL 12D OBLQ 25X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414254 SUP HCPCS C1713 5414254 - CAGE SPNL 4D OBLQ 25X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414255 SUP HCPCS C1713 5414255 - CAGE SPNL 15D OBLQ 25X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414258 SUP HCPCS C1713 5414258 - CAGE SPNL 8D OBLQ 25X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414300 SUP HCPCS C1713 5414300 - CAGE SPNL 0D OBLQ 30X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414302 SUP HCPCS C1713 5414302 - CAGE SPNL 12D OBLQ 30X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414304 SUP HCPCS C1713 5414304 - CAGE SPNL 4D OBLQ 30X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414305 SUP HCPCS C1713 5414305 - CAGE SPNL 15D OBLQ 30X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414308 SUP HCPCS C1713 5414308 - CAGE SPNL 8D OBLQ 30X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414350 SUP HCPCS C1713 5414350 - CAGE SPNL 0D OBLQ 35X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414352 SUP HCPCS C1713 5414352 - CAGE SPNL 12D OBLQ 35X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414355 SUP HCPCS C1713 5414355 - CAGE SPNL 15D OBLQ 35X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414358 SUP HCPCS C1713 5414358 - CAGE SPNL 8D OBLQ 35X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414400 SUP HCPCS C1713 5414400 - CAGE SPNL 0D OBLQ 40X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414402 SUP HCPCS C1713 5414402 - CAGE SPNL 12D OBLQ 40X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414404 SUP HCPCS C1713 5414404 - CAGE SPNL 4D OBLQ 40X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414405 SUP HCPCS C1713 5414405 - CAGE SPNL 15D OBLQ 40X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5414408 SUP HCPCS C1713 5414408 - CAGE SPNL 8D OBLQ 40X14X11MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420250 SUP HCPCS C1713 5420250 - CAGE SPNL 0D OBLQ 25X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420252 SUP HCPCS C1713 5420252 - CAGE SPNL 12D OBLQ 25X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5420254 SUP HCPCS C1713 5420254 - CAGE SPNL 4D OBLQ 25X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5420255 SUP HCPCS C1713 5420255 - CAGE SPNL 15D OBLQ 25X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420258 SUP HCPCS C1713 5420258 - CAGE SPNL 8D OBLQ 25X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420300 SUP HCPCS C1713 5420300 - CAGE SPNL 0D OBLQ 30X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420302 SUP HCPCS C1713 5420302 - CAGE SPNL 12D OBLQ 30X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5420304 SUP HCPCS C1713 5420304 - CAGE SPNL 4D OBLQ 30X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5420305 SUP HCPCS C1713 5420305 - CAGE SPNL 15D OBLQ 30X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420308 SUP HCPCS C1713 5420308 - CAGE SPNL 8D OBLQ 30X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420350 SUP HCPCS C1713 5420350 - CAGE SPNL 0D OBLQ 35X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420352 SUP HCPCS C1713 5420352 - CAGE SPNL 12D OBLQ 35X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420354 SUP HCPCS C1713 5420354 - CAGE SPNL 4D OBLQ 35X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5420355 SUP HCPCS C1713 5420355 - CAGE SPNL 15D OBLQ 35X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420358 SUP HCPCS C1713 5420358 - CAGE SPNL 8D OBLQ 35X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420400 SUP HCPCS C1713 5420400 - CAGE SPNL 0D OBLQ 40X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420402 SUP HCPCS C1713 5420402 - CAGE SPNL 12D OBLQ 40X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420404 SUP HCPCS C1713 5420404 - CAGE SPNL 4D OBLQ 40X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420405 SUP HCPCS C1713 5420405 - CAGE SPNL 15D OBLQ 40X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5420408 SUP HCPCS C1713 5420408 - CAGE SPNL 8D OBLQ 40X10X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424250 SUP HCPCS C1713 5424250 - CAGE SPNL 0D OBLQ 25X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424252 SUP HCPCS C1713 5424252 - CAGE SPNL 12D OBLQ 25X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5424254 SUP HCPCS C1713 5424254 - CAGE SPNL 4D OBLQ 25X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5424255 SUP HCPCS C1713 5424255 - CAGE SPNL 15D OBLQ 25X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424258 SUP HCPCS C1713 5424258 - CAGE SPNL 8D OBLQ 25X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424300 SUP HCPCS C1713 5424300 - CAGE SPNL 0D OBLQ 30X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424302 SUP HCPCS C1713 5424302 - CAGE SPNL 12D OBLQ 30X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424304 SUP HCPCS C1713 5424304 - CAGE SPNL 4D OBLQ 30X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5424305 SUP HCPCS C1713 5424305 - CAGE SPNL 15D OBLQ 30X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424308 SUP HCPCS C1713 5424308 - CAGE SPNL 8D OBLQ 30X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424350 SUP HCPCS C1713 5424350 - CAGE SPNL 0D OBLQ 35X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424352 SUP HCPCS C1713 5424352 - CAGE SPNL 12D OBLQ 35X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424354 SUP HCPCS C1713 5424354 - CAGE SPNL 4D OBLQ 35X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424355 SUP HCPCS C1713 5424355 - CAGE SPNL 15D OBLQ 35X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424358 SUP HCPCS C1713 5424358 - CAGE SPNL 8D OBLQ 35X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424400 SUP HCPCS C1713 5424400 - CAGE SPNL 0D OBLQ 40X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424402 SUP HCPCS C1713 5424402 - CAGE SPNL 12D OBLQ 40X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424404 SUP HCPCS C1713 5424404 - CAGE SPNL 4D OBLQ 40X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424405 SUP HCPCS C1713 5424405 - CAGE SPNL 15D OBLQ 40X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5424408 SUP HCPCS C1713 5424408 - CAGE SPNL 8D OBLQ 40X14X12MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430250 SUP HCPCS C1713 5430250 - CAGE SPNL 0D OBLQ 25X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430252 SUP HCPCS C1713 5430252 - CAGE SPNL 12D OBLQ 25X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430254 SUP HCPCS C1713 5430254 - CAGE SPNL 4D OBLQ 25X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430255 SUP HCPCS C1713 5430255 - CAGE SPNL 15D OBLQ 25X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430258 SUP HCPCS C1713 5430258 - CAGE SPNL 8D OBLQ 25X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430300 SUP HCPCS C1713 5430300 - CAGE SPNL 0D OBLQ 30X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430302 SUP HCPCS C1713 5430302 - CAGE SPNL 12D OBLQ 30X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430304 SUP HCPCS C1713 5430304 - CAGE SPNL 4D OBLQ 30X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430305 SUP HCPCS C1713 5430305 - CAGE SPNL 15D OBLQ 30X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430308 SUP HCPCS C1713 5430308 - CAGE SPNL 8D OBLQ 30X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430350 SUP HCPCS C1713 5430350 - CAGE SPNL 0D OBLQ 35X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430352 SUP HCPCS C1713 5430352 - CAGE SPNL 12D OBLQ 35X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430354 SUP HCPCS C1713 5430354 - CAGE SPNL 4D OBLQ 35X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430355 SUP HCPCS C1713 5430355 - CAGE SPNL 15D OBLQ 35X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430358 SUP HCPCS C1713 5430358 - CAGE SPNL 8D OBLQ 35X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430400 SUP HCPCS C1713 5430400 - CAGE SPNL 0D OBLQ 40X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430402 SUP HCPCS C1713 5430402 - CAGE SPNL 12D OBLQ 40X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430404 SUP HCPCS C1713 5430404 - CAGE SPNL 4D OBLQ 40X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430405 SUP HCPCS C1713 5430405 - CAGE SPNL 15D OBLQ 40X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5430408 SUP HCPCS C1713 5430408 - CAGE SPNL 8D OBLQ 40X10X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434250 SUP HCPCS C1713 5434250 - CAGE SPNL 0D OBLQ 25X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434252 SUP HCPCS C1713 5434252 - CAGE SPNL 12D OBLQ 25X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434254 SUP HCPCS C1713 5434254 - CAGE SPNL 4D OBLQ 25X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434255 SUP HCPCS C1713 5434255 - CAGE SPNL 15D OBLQ 25X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434258 SUP HCPCS C1713 5434258 - CAGE SPNL 8D OBLQ 25X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434300 SUP HCPCS C1713 5434300 - CAGE SPNL 0D OBLQ 30X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434302 SUP HCPCS C1713 5434302 - CAGE SPNL 12D OBLQ 30X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434304 SUP HCPCS C1713 5434304 - CAGE SPNL 4D OBLQ 30X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434305 SUP HCPCS C1713 5434305 - CAGE SPNL 15D OBLQ 30X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434308 SUP HCPCS C1713 5434308 - CAGE SPNL 8D OBLQ 30X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434350 SUP HCPCS C1713 5434350 - CAGE SPNL 0D OBLQ 35X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434352 SUP HCPCS C1713 5434352 - CAGE SPNL 12D OBLQ 35X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434354 SUP HCPCS C1713 5434354 - CAGE SPNL 4D OBLQ 35X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434355 SUP HCPCS C1713 5434355 - CAGE SPNL 15D OBLQ 35X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434358 SUP HCPCS C1713 5434358 - CAGE SPNL 8D OBLQ 35X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434400 SUP HCPCS C1713 5434400 - CAGE SPNL 0D OBLQ 40X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434402 SUP HCPCS C1713 5434402 - CAGE SPNL 12D OBLQ 40X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434404 SUP HCPCS C1713 5434404 - CAGE SPNL 4D OBLQ 40X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434405 SUP HCPCS C1713 5434405 - CAGE SPNL 15D OBLQ 40X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5434408 SUP HCPCS C1713 5434408 - CAGE SPNL 8D OBLQ 40X14X13MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440030 SUP HCPCS C1713 5440030 - SET SCREW 5440030 4.75 TI NS BRK OFF BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5440130 SUP HCPCS C1713 5440130 - SET SCREW 5440130 4.75 TI NS NON BRK OFF BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5440230 SUP HCPCS C1713 5440230 - SET SCREW 5440230 4.75 TI NS RED BRK OFF BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5440250 SUP HCPCS C1713 5440250 - CAGE SPNL 0D OBLQ 25X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440252 SUP HCPCS C1713 5440252 - CAGE SPNL 12D OBLQ 25X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5440254 SUP HCPCS C1713 5440254 - CAGE SPNL 4D OBLQ 25X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5440255 SUP HCPCS C1713 5440255 - CAGE SPNL 15D OBLQ 25X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440258 SUP HCPCS C1713 5440258 - CAGE SPNL 8D OBLQ 25X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440300 SUP HCPCS C1713 5440300 - CAGE SPNL 0D OBLQ 30X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440302 SUP HCPCS C1713 5440302 - CAGE SPNL 12D OBLQ 30X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5440304 SUP HCPCS C1713 5440304 - CAGE SPNL 4D OBLQ 30X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5440305 SUP HCPCS C1713 5440305 - CAGE SPNL 15D OBLQ 30X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440308 SUP HCPCS C1713 5440308 - CAGE SPNL 8D OBLQ 30X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440350 SUP HCPCS C1713 5440350 - CAGE SPNL 0D OBLQ 35X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440352 SUP HCPCS C1713 5440352 - CAGE SPNL 12D OBLQ 35X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440355 SUP HCPCS C1713 5440355 - CAGE SPNL 15D OBLQ 35X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440358 SUP HCPCS C1713 5440358 - CAGE SPNL 8D OBLQ 35X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440400 SUP HCPCS C1713 5440400 - CAGE SPNL 0D OBLQ 40X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440402 SUP HCPCS C1713 5440402 - CAGE SPNL 12D OBLQ 40X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440404 SUP HCPCS C1713 5440404 - CAGE SPNL 4D OBLQ 40X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440405 SUP HCPCS C1713 5440405 - CAGE SPNL 15D OBLQ 40X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440408 SUP HCPCS C1713 5440408 - CAGE SPNL 8D OBLQ 40X10X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5440430 SUP HCPCS C1713 5440430 - SCREW SET BREAKOFF SOLERA SEXTANT CD HORIZON TITANIUM SPN BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5441101 SUP HCPCS C1713 5441101 - HOOK 5441101 4.75 TI NS PEDICLE XSML BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441102 SUP HCPCS C1713 5441102 - HOOK 5441102 PEDICLE 4.75 SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441103 SUP HCPCS C1713 5441103 - HOOK 5441103 PEDICLE 4.75 MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441104 SUP HCPCS C1713 5441104 - HOOK 5441104 PEDICLE 4.75 LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441112 SUP HCPCS C1713 5441112 - HOOK 5441112 WIDE BLADE 4.75 SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441113 SUP HCPCS C1713 5441113 - HOOK 5441113 WIDE BLADE 4.75 MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441114 SUP HCPCS C1713 5441114 - HOOK 5441114 WIDE BLADE 4.75 LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441122 SUP HCPCS C1713 5441122 - HOOK 5441122 NARROW BLADE 4.75 SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441123 SUP HCPCS C1713 5441123 - HOOK 5441123 NARROW BLADE 4.75 MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441124 SUP HCPCS C1713 5441124 - HOOK 5441124 NARROW BLADE 4.75 LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441133 SUP HCPCS C1713 5441133 - HOOK 5441133 RAMP WIDE BLADE 4.75 MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441142 SUP HCPCS C1713 5441142 - HOOK 5441142 RMP NRW BLADE 4.75 SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441143 SUP HCPCS C1713 5441143 - HOOK 5441143 RMP NRW BLADE 4.75 MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441172 SUP HCPCS C1713 5441172 - HOOK 5441172 EXTENDED BODY 4.75 SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441173 SUP HCPCS C1713 5441173 - HOOK 5441173 EXTENDED BODY 4.75 MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441174 SUP HCPCS C1713 5441174 - HOOK 5441174 EXTENDED BODY 4.75 LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441196 SUP HCPCS C1713 5441196 - HOOK 5441196 4.75 TI NS OFFSET SML RT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441197 SUP HCPCS C1713 5441197 - HOOK 5441197 4.75 TI NS OFFSET SML LEFT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441198 SUP HCPCS C1713 5441198 - HOOK 5441198 OFFSET 4.75 RIGHT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441199 SUP HCPCS C1713 5441199 - HOOK 5441199 OFFSET 4.75 LEFT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441302 SUP HCPCS C1713 5441302 - HOOK 5441302 4.75 TI NS TAH PEDICLE SML BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441303 SUP HCPCS C1713 5441303 - HOOK 5441303 4.75 TI NS TAH PEDICLE MED BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441342 SUP HCPCS C1713 5441342 - HOOK 5441342 4.75 TI NS TAH TRAN PRO SML BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5441343 SUP HCPCS C1713 5441343 - HOOK 5441343 4.75 TI NS TAH TRAN PRO MED BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 5442016 SUP HCPCS C1713 5442016 - CROSSLINK 5442016 4.75 TI NS FIXED 16MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442019 SUP HCPCS C1713 5442019 - CROSSLINK 5442019 4.75 TI NS FIXED 19MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442022 SUP HCPCS C1713 5442022 - CROSSLINK 5442022 4.75 TI NS FIXED 22MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442025 SUP HCPCS C1713 5442025 - CROSSLINK 5442025 4.75 TI NS FIXED 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442028 SUP HCPCS C1713 5442028 - CROSSLINK 5442028 4.75 TI NS FIXED 28MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442031 SUP HCPCS C1713 5442031 - CROSSLINK 5442031 4.75 TI NS FIXED 31MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442034 SUP HCPCS C1713 5442034 - CROSSLINK 5442034 4.75 TI NS FIXED 34MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442037 SUP HCPCS C1713 5442037 - CROSSLINK 5442037 4.75 TI NS FIXED 37MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442130 SUP HCPCS C1713 5442130 - PLATE BN 30-32MM NS SOLERA X10 XLNK CD HZN MLSPN TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442132 SUP HCPCS C1713 5442132 - PLATE BN 32-37MM NS SOLERA X10 XLNK CD HZN MLSPN TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442136 SUP HCPCS C1713 5442136 - PLATE BN 36-38MM NS SOLERA X10 XLNK CD HZN MLSPN TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442138 SUP HCPCS C1713 5442138 - PLATE BN 38-42MM NS SOLERA X10 XLNK CD HZN MLSPN TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442141 SUP HCPCS C1713 5442141 - PLATE BN 41-48MM NS SOLERA X10 XLNK CD HZN MLSPN TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442144 SUP HCPCS C1713 5442144 - CROSSLINK 5442144 4.75X10 MLTSPN 44-54MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442147 SUP HCPCS C1713 5442147 - PLATE BN 47-60MM NS SOLERA X10 XLNK CD HZN MLSPN TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442152 SUP HCPCS C1713 5442152 - CROSSLINK 5442152 4.75X10 MLTSPN 52-70MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5442160 SUP HCPCS C1713 5442160 - CROSSLINK 5442160 4.75X10 MLTSPN 60-86MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 5443110 SUP Custom 27803010 5443110 - CONNECTOR 5443110 475/635 TI CL ILC 10MM BOTH IP/OP "$1,929.00 " "$1,427.46" $0.00 "$1,543.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,431.70" "$1,431.70" $0.00 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $964.50 "$1,527.77" "$1,543.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5443120 SUP Custom 27803010 5443120 - CONNECTOR 5443120 475/635 TI CL ILC 20MM BOTH IP/OP "$1,929.00 " "$1,427.46" $0.00 "$1,543.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,431.70" "$1,431.70" $0.00 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $964.50 "$1,527.77" "$1,543.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5443130 SUP Custom 27803010 5443130 - CONNECTOR 5443130 475/635 TI CL ILC 30MM BOTH IP/OP "$1,929.00 " "$1,427.46" $0.00 "$1,543.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,431.70" "$1,431.70" $0.00 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $964.50 "$1,527.77" "$1,543.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5443160 SUP Custom 27803010 5443160 - CONNECTOR 5443160 475/635 TI CL ILC 60MM BOTH IP/OP "$1,929.00 " "$1,427.46" $0.00 "$1,543.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,431.70" "$1,431.70" $0.00 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $964.50 "$1,527.77" "$1,543.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5444250 SUP HCPCS C1713 5444250 - CAGE SPNL 0D OBLQ 25X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444252 SUP HCPCS C1713 5444252 - CAGE SPNL 12D OBLQ 25X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444254 SUP HCPCS C1713 5444254 - CAGE SPNL 4D OBLQ 25X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444255 SUP HCPCS C1713 5444255 - CAGE SPNL 15D OBLQ 25X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444258 SUP HCPCS C1713 5444258 - CAGE SPNL 8D OBLQ 25X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444300 SUP HCPCS C1713 5444300 - CAGE SPNL 0D OBLQ 30X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444302 SUP HCPCS C1713 5444302 - CAGE SPNL 12D OBLQ 30X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444304 SUP HCPCS C1713 5444304 - CAGE SPNL 4D OBLQ 30X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444305 SUP HCPCS C1713 5444305 - CAGE SPNL 15D OBLQ 30X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444308 SUP HCPCS C1713 5444308 - CAGE SPNL 8D OBLQ 30X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444350 SUP HCPCS C1713 5444350 - CAGE SPNL 0D OBLQ 35X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444352 SUP HCPCS C1713 5444352 - CAGE SPNL 12D OBLQ 35X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444354 SUP HCPCS C1713 5444354 - CAGE SPNL 4D OBLQ 35X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444355 SUP HCPCS C1713 5444355 - CAGE SPNL 15D OBLQ 35X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444358 SUP HCPCS C1713 5444358 - CAGE SPNL 8D OBLQ 35X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444400 SUP HCPCS C1713 5444400 - CAGE SPNL 0D OBLQ 40X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444402 SUP HCPCS C1713 5444402 - CAGE SPNL 12D OBLQ 40X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444404 SUP HCPCS C1713 5444404 - CAGE SPNL 4D OBLQ 40X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444405 SUP HCPCS C1713 5444405 - CAGE SPNL 15D OBLQ 40X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5444408 SUP HCPCS C1713 5444408 - CAGE SPNL 8D OBLQ 40X14X14MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460250 SUP HCPCS C1713 5460250 - CAGE SPNL 0D OBLQ 25X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5460252 SUP HCPCS C1713 5460252 - CAGE SPNL 12D OBLQ 25X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460254 SUP HCPCS C1713 5460254 - CAGE SPNL 4D OBLQ 25X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5460255 SUP HCPCS C1713 5460255 - CAGE SPNL 15D OBLQ 25X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460258 SUP HCPCS C1713 5460258 - CAGE SPNL 8D OBLQ 25X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460300 SUP HCPCS C1713 5460300 - CAGE SPNL 0D OBLQ 30X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5460302 SUP HCPCS C1713 5460302 - CAGE SPNL 12D OBLQ 30X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460304 SUP HCPCS C1713 5460304 - CAGE SPNL 4D OBLQ 30X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5460305 SUP HCPCS C1713 5460305 - CAGE SPNL 15D OBLQ 30X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460308 SUP HCPCS C1713 5460308 - CAGE SPNL 8D OBLQ 30X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460350 SUP HCPCS C1713 5460350 - CAGE SPNL 0D OBLQ 35X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460352 SUP HCPCS C1713 5460352 - CAGE SPNL 12D OBLQ 35X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460354 SUP HCPCS C1713 5460354 - CAGE SPNL 4D OBLQ 35X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460355 SUP HCPCS C1713 5460355 - CAGE SPNL 15D OBLQ 35X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460358 SUP HCPCS C1713 5460358 - CAGE SPNL 8D OBLQ 35X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460400 SUP HCPCS C1713 5460400 - CAGE SPNL 0D OBLQ 40X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460402 SUP HCPCS C1713 5460402 - CAGE SPNL 12D OBLQ 40X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460404 SUP HCPCS C1713 5460404 - CAGE SPNL 4D OBLQ 40X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460405 SUP HCPCS C1713 5460405 - CAGE SPNL 15D OBLQ 40X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5460408 SUP HCPCS C1713 5460408 - CAGE SPNL 8D OBLQ 40X10X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464250 SUP HCPCS C1713 5464250 - CAGE SPNL 0D OBLQ 25X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464252 SUP HCPCS C1713 5464252 - CAGE SPNL 12D OBLQ 25X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464254 SUP HCPCS C1713 5464254 - CAGE SPNL 4D OBLQ 25X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464255 SUP HCPCS C1713 5464255 - CAGE SPNL 15D OBLQ 25X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464258 SUP HCPCS C1713 5464258 - CAGE SPNL 8D OBLQ 25X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464300 SUP HCPCS C1713 5464300 - CAGE SPNL 0D OBLQ 30X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464302 SUP HCPCS C1713 5464302 - CAGE SPNL 12D OBLQ 30X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464304 SUP HCPCS C1713 5464304 - CAGE SPNL 4D OBLQ 30X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464305 SUP HCPCS C1713 5464305 - CAGE SPNL 15D OBLQ 30X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464308 SUP HCPCS C1713 5464308 - CAGE SPNL 8D OBLQ 30X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464350 SUP HCPCS C1713 5464350 - CAGE SPNL 0D OBLQ 35X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464352 SUP HCPCS C1713 5464352 - CAGE SPNL 12D OBLQ 35X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464354 SUP HCPCS C1713 5464354 - CAGE SPNL 4D OBLQ 35X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464355 SUP HCPCS C1713 5464355 - CAGE SPNL 15D OBLQ 35X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464358 SUP HCPCS C1713 5464358 - CAGE SPNL 8D OBLQ 35X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464400 SUP HCPCS C1713 5464400 - CAGE SPNL 0D OBLQ 40X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464402 SUP HCPCS C1713 5464402 - CAGE SPNL 12D OBLQ 40X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464404 SUP HCPCS C1713 5464404 - CAGE SPNL 4D OBLQ 40X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464405 SUP HCPCS C1713 5464405 - CAGE SPNL 15D OBLQ 40X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5464408 SUP HCPCS C1713 5464408 - CAGE SPNL 8D OBLQ 40X14X6MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470250 SUP HCPCS C1713 5470250 - CAGE SPNL 0D OBLQ 25X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5470252 SUP HCPCS C1713 5470252 - CAGE SPNL 12D OBLQ 25X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470254 SUP HCPCS C1713 5470254 - CAGE SPNL 4D OBLQ 25X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470255 SUP HCPCS C1713 5470255 - CAGE SPNL 15D OBLQ 25X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470258 SUP HCPCS C1713 5470258 - CAGE SPNL 8D OBLQ 25X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470300 SUP HCPCS C1713 5470300 - CAGE SPNL 0D OBLQ 30X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5470302 SUP HCPCS C1713 5470302 - CAGE SPNL 12D OBLQ 30X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470304 SUP HCPCS C1713 5470304 - CAGE SPNL 4D OBLQ 30X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470305 SUP HCPCS C1713 5470305 - CAGE SPNL 15D OBLQ 30X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470308 SUP HCPCS C1713 5470308 - CAGE SPNL 8D OBLQ 30X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470350 SUP HCPCS C1713 5470350 - CAGE SPNL 0D OBLQ 35X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470352 SUP HCPCS C1713 5470352 - CAGE SPNL 12D OBLQ 35X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470354 SUP HCPCS C1713 5470354 - CAGE SPNL 4D OBLQ 35X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470355 SUP HCPCS C1713 5470355 - CAGE SPNL 15D OBLQ 35X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470358 SUP HCPCS C1713 5470358 - CAGE SPNL 8D OBLQ 35X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470400 SUP HCPCS C1713 5470400 - CAGE SPNL 0D OBLQ 40X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470402 SUP HCPCS C1713 5470402 - CAGE SPNL 12D OBLQ 40X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470404 SUP HCPCS C1713 5470404 - CAGE SPNL 4D OBLQ 40X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470405 SUP HCPCS C1713 5470405 - CAGE SPNL 15D OBLQ 40X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5470408 SUP HCPCS C1713 5470408 - CAGE SPNL 8D OBLQ 40X10X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474250 SUP HCPCS C1713 5474250 - CAGE SPNL 0D OBLQ 25X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474252 SUP HCPCS C1713 5474252 - CAGE SPNL 12D OBLQ 25X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474254 SUP HCPCS C1713 5474254 - CAGE SPNL 4D OBLQ 25X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474255 SUP HCPCS C1713 5474255 - CAGE SPNL 15D OBLQ 25X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474258 SUP HCPCS C1713 5474258 - CAGE SPNL 8D OBLQ 25X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474300 SUP HCPCS C1713 5474300 - CAGE SPNL 0D OBLQ 30X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474302 SUP HCPCS C1713 5474302 - CAGE SPNL 12D OBLQ 30X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474304 SUP HCPCS C1713 5474304 - CAGE SPNL 4D OBLQ 30X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474305 SUP HCPCS C1713 5474305 - CAGE SPNL 15D OBLQ 30X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474308 SUP HCPCS C1713 5474308 - CAGE SPNL 8D OBLQ 30X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474350 SUP HCPCS C1713 5474350 - CAGE SPNL 0D OBLQ 35X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474352 SUP HCPCS C1713 5474352 - CAGE SPNL 12D OBLQ 35X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474355 SUP HCPCS C1713 5474355 - CAGE SPNL 15D OBLQ 35X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474358 SUP HCPCS C1713 5474358 - CAGE SPNL 8D OBLQ 35X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474400 SUP HCPCS C1713 5474400 - CAGE SPNL 0D OBLQ 40X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474402 SUP HCPCS C1713 5474402 - CAGE SPNL 12D OBLQ 40X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474404 SUP HCPCS C1713 5474404 - CAGE SPNL 4D OBLQ 40X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474405 SUP HCPCS C1713 5474405 - CAGE SPNL 15D OBLQ 40X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5474408 SUP HCPCS C1713 5474408 - CAGE SPNL 8D OBLQ 40X14X7MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5475525 SUP HCPCS C1713 5475525 - SCREW BN 5.5MM 25MM NS CRNT FX ANG SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5475540 SUP HCPCS C1713 5475540 - SCREW BN 5.5MM 40MM NS CRNT FX ANG SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5475545 SUP HCPCS C1713 5475545 - SCREW BN 5.5MM 45MM NS CRNT FX ANG SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5475550 SUP HCPCS C1713 5475550 - SCREW BN 5.5MM 50MM NS CRNT FX ANG SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5475555 SUP HCPCS C1713 5475555 - SCREW BN 5.5MM 55MM NS CRNT FX ANG SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5475560 SUP HCPCS C1713 5475560 - SCREW BN 5.5MM 60MM NS CRNT FX ANG SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5475565 SUP HCPCS C1713 5475565 - SCREW BN 5.5MM 65MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5475570 SUP HCPCS C1713 5475570 - SCREW BN 5.5MM 70MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5476525 SUP HCPCS C1713 5476525 - SCREW BN 6.5MM 25MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5476540 SUP HCPCS C1713 5476540 - SCREW BN 6.5MM 40MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5476545 SUP HCPCS C1713 5476545 - SCREW BN 6.5MM 45MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5476550 SUP HCPCS C1713 5476550 - SCREW BN 6.5MM 50MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5476555 SUP HCPCS C1713 5476555 - SCREW BN 6.5MM 55MM FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5476560 SUP HCPCS C1713 5476560 - SCREW BN 6.5MM 60MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5476565 SUP HCPCS C1713 5476565 - SCREW BN 6.5MM 65MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5476570 SUP HCPCS C1713 5476570 - SCREW BN 6.5MM 70MM CRNT XLIF FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5480250 SUP HCPCS C1713 5480250 - CAGE SPNL 0D OBLQ 25X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5480252 SUP HCPCS C1713 5480252 - CAGE SPNL 12D OBLQ 25X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5480254 SUP HCPCS C1713 5480254 - CAGE SPNL 4D OBLQ 25X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5480255 SUP HCPCS C1713 5480255 - CAGE SPNL 15D OBLQ 25X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480258 SUP HCPCS C1713 5480258 - CAGE SPNL 8D OBLQ 25X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480300 SUP HCPCS C1713 5480300 - CAGE SPNL 0D OBLQ 30X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5480302 SUP HCPCS C1713 5480302 - CAGE SPNL 12D OBLQ 30X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5480304 SUP HCPCS C1713 5480304 - CAGE SPNL 4D OBLQ 30X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5480305 SUP HCPCS C1713 5480305 - CAGE SPNL 15D OBLQ 30X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480308 SUP HCPCS C1713 5480308 - CAGE SPNL 8D OBLQ 30X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480350 SUP HCPCS C1713 5480350 - CAGE SPNL 0D OBLQ 35X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480352 SUP HCPCS C1713 5480352 - CAGE SPNL 12D OBLQ 35X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480354 SUP HCPCS C1713 5480354 - CAGE SPNL 4D OBLQ 35X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5480355 SUP HCPCS C1713 5480355 - CAGE SPNL 15D OBLQ 35X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480358 SUP HCPCS C1713 5480358 - CAGE SPNL 8D OBLQ 35X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480400 SUP HCPCS C1713 5480400 - CAGE SPNL 0D OBLQ 40X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480402 SUP HCPCS C1713 5480402 - CAGE SPNL 12D OBLQ 40X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480404 SUP HCPCS C1713 5480404 - CAGE SPNL 4D OBLQ 40X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480405 SUP HCPCS C1713 5480405 - CAGE SPNL 15D OBLQ 40X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5480408 SUP HCPCS C1713 5480408 - CAGE SPNL 8D OBLQ 40X10X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484250 SUP HCPCS C1713 5484250 - CAGE SPNL 0D OBLQ 25X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484252 SUP HCPCS C1713 5484252 - CAGE SPNL 12D OBLQ 25X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5484254 SUP HCPCS C1713 5484254 - CAGE SPNL 4D OBLQ 25X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5484258 SUP HCPCS C1713 5484258 - CAGE SPNL 8D OBLQ 25X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484300 SUP HCPCS C1713 5484300 - CAGE SPNL 0D OBLQ 30X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484350 SUP HCPCS C1713 5484350 - CAGE SPNL 0D OBLQ 35X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484352 SUP HCPCS C1713 5484352 - CAGE SPNL 12D OBLQ 35X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484354 SUP HCPCS C1713 5484354 - CAGE SPNL 4D OBLQ 35X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484355 SUP HCPCS C1713 5484355 - CAGE SPNL 15D OBLQ 35X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484358 SUP HCPCS C1713 5484358 - CAGE SPNL 8D OBLQ 35X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484400 SUP HCPCS C1713 5484400 - CAGE SPNL 0D OBLQ 40X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484402 SUP HCPCS C1713 5484402 - CAGE SPNL 12D OBLQ 40X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484404 SUP HCPCS C1713 5484404 - CAGE SPNL 4D OBLQ 40X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484405 SUP HCPCS C1713 5484405 - CAGE SPNL 15D OBLQ 40X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5484408 SUP HCPCS C1713 5484408 - CAGE SPNL 8D OBLQ 40X14X8MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5485525 SUP HCPCS C1713 5485525 - SCREW BONE 5.5MM 25MM VARIABLE COROENT XLF SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5485540 SUP HCPCS C1713 5485540 - SCREW BN 5.5MM 40MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5485545 SUP HCPCS C1713 5485545 - SCREW BN 5.5MM 45MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5485550 SUP HCPCS C1713 5485550 - SCREW BN 5.5MM 50MM CRNT XLF VA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5485555 SUP HCPCS C1713 5485555 - SCREW BN 5.5MM 55MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5485560 SUP HCPCS C1713 5485560 - SCREW BN 5.5MM 60MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5485565 SUP HCPCS C1713 5485565 - SCREW BN 5.5MM 65MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5485570 SUP HCPCS C1713 5485570 - SCREW BN 5.5MM 70MM CRNT XLF VAR SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5486525 SUP HCPCS C1713 5486525 - SCREW BN 6.5MM 25MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5486540 SUP HCPCS C1713 5486540 - SCREW BN 6.5MM 40MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5486545 SUP HCPCS C1713 5486545 - SCREW BN 6.5MM 45MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5486550 SUP HCPCS C1713 5486550 - SCREW BN 6.5MM 50MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5486555 SUP HCPCS C1713 5486555 - SCREW BN 6.5MM 55MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5486560 SUP HCPCS C1713 5486560 - SCREW BN 6.5MM 60MM NS CRNT VA SPNE XLF SYS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5486565 SUP HCPCS C1713 5486565 - SCREW BN 6.5MM 65MM CRNT XLF VAR SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5486570 SUP HCPCS C1713 5486570 - SCREW BN 6.5MM 70MM CRNT XLF VAR SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5490250 SUP HCPCS C1713 5490250 - CAGE SPNL 0D OBLQ 25X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5490252 SUP HCPCS C1713 5490252 - CAGE SPNL 12D OBLQ 25X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490254 SUP HCPCS C1713 5490254 - CAGE SPNL 4D OBLQ 25X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490255 SUP HCPCS C1713 5490255 - CAGE SPNL 15D OBLQ 25X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490258 SUP HCPCS C1713 5490258 - CAGE SPNL 8D OBLQ 25X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490300 SUP HCPCS C1713 5490300 - CAGE SPNL 0D OBLQ 30X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5490302 SUP HCPCS C1713 5490302 - CAGE SPNL 12D OBLQ 30X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490304 SUP HCPCS C1713 5490304 - CAGE SPNL 4D OBLQ 30X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490305 SUP HCPCS C1713 5490305 - CAGE SPNL 15D OBLQ 30X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490308 SUP HCPCS C1713 5490308 - CAGE SPNL 8D OBLQ 30X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490350 SUP HCPCS C1713 5490350 - CAGE SPNL 0D OBLQ 35X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490352 SUP HCPCS C1713 5490352 - CAGE SPNL 12D OBLQ 35X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490354 SUP HCPCS C1713 5490354 - CAGE SPNL 4D OBLQ 35X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490355 SUP HCPCS C1713 5490355 - CAGE SPNL 15D OBLQ 35X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490358 SUP HCPCS C1713 5490358 - CAGE SPNL 8D OBLQ 35X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490400 SUP HCPCS C1713 5490400 - CAGE SPNL 0D OBLQ 40X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490402 SUP HCPCS C1713 5490402 - CAGE SPNL 12D OBLQ 40X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490404 SUP HCPCS C1713 5490404 - CAGE SPNL 4D OBLQ 40X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490405 SUP HCPCS C1713 5490405 - CAGE SPNL 15D OBLQ 40X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5490408 SUP HCPCS C1713 5490408 - CAGE SPNL 8D OBLQ 40X10X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494250 SUP HCPCS C1713 5494250 - CAGE SPNL 0D OBLQ 25X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494252 SUP HCPCS C1713 5494252 - CAGE SPNL 12D OBLQ 25X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494254 SUP HCPCS C1713 5494254 - CAGE SPNL 4D OBLQ 25X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494255 SUP HCPCS C1713 5494255 - CAGE SPNL 15D OBLQ 25X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494258 SUP HCPCS C1713 5494258 - CAGE SPNL 8D OBLQ 25X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494300 SUP HCPCS C1713 5494300 - CAGE SPNL 0D OBLQ 30X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494302 SUP HCPCS C1713 5494302 - CAGE SPNL 12D OBLQ 30X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494304 SUP HCPCS C1713 5494304 - CAGE SPNL 4D OBLQ 30X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494305 SUP HCPCS C1713 5494305 - CAGE SPNL 15D OBLQ 30X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494308 SUP HCPCS C1713 5494308 - CAGE SPNL 8D OBLQ 30X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494350 SUP HCPCS C1713 5494350 - CAGE SPNL 0D OBLQ 35X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494352 SUP HCPCS C1713 5494352 - CAGE SPNL 12D OBLQ 35X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494354 SUP HCPCS C1713 5494354 - CAGE SPNL 4D OBLQ 35X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494355 SUP HCPCS C1713 5494355 - CAGE SPNL 15D OBLQ 35X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494358 SUP HCPCS C1713 5494358 - CAGE SPNL 8D OBLQ 35X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494400 SUP HCPCS C1713 5494400 - CAGE SPNL 0D OBLQ 40X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494402 SUP HCPCS C1713 5494402 - CAGE SPNL 12D OBLQ 40X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494404 SUP HCPCS C1713 5494404 - CAGE SPNL 4D OBLQ 40X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494405 SUP HCPCS C1713 5494405 - CAGE SPNL 15D OBLQ 40X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5494408 SUP HCPCS C1713 5494408 - CAGE SPNL 8D OBLQ 40X14X9MM NS LF CRNT TI TLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 5500302 SUP HCPCS C1769 GUIDEWIRE VASC .035IN 150CM 3MM JTP FIX CORE PTFE BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $17.65 $17.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $5.09 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 5500801 SUP HCPCS C1769 GUIDEWIRE VASC .035IN 150CM BNTSN STRG FIX CORE PTFE BOTH IP/OP $22.50 $16.65 $0.00 $18.00 $12.22 $12.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.25 $17.82 $18.00 $0.00 $0.00 $3.52 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 5500803 SUP Custom 27203010 GUIDEWIRE BENTSON .038 150CM BOTH IP/OP $30.00 $22.20 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5501701 SUP HCPCS C1769 GUIDEWIRE VASC .035IN 150CM 1.5MM RSN CURVE JTP FIX CORE BOTH IP/OP $22.50 $16.65 $0.00 $18.00 $12.22 $12.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.25 $17.82 $18.00 $0.00 $0.00 $3.52 $0.00 $0.00 $3.58 $0.00 $0.00 $0.00 $0.00 $0.00 5513150 SUP HCPCS C1894 5513150 - INTRODUCER CATH 15FR 13CM ARGD VLV HMDIAL BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $133.04 $133.04 $0.00 $0.00 $0.00 $51.06 $181.84 $181.84 $0.00 $0.00 $51.06 $0.00 $144.92 $144.92 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534010 SUP HCPCS C1713 5534010 - SPACER ALGRF 30X10X2MM EXTENSURE SPNE BOTH IP/OP "$5,577.50 " "$4,127.35" $0.00 "$4,462.00" "$2,509.88" "$2,509.88" $0.00 $0.00 $0.00 "$1,162.49" "$4,139.62" "$4,139.62" $0.00 $0.00 "$1,162.35" $0.00 "$2,749.71" "$2,749.71" $0.00 "$2,788.75" "$4,417.38" "$4,462.00" $0.00 $0.00 $872.88 $0.00 $0.00 $887.94 $0.00 $0.00 $0.00 $0.00 $0.00 5534012 SUP HCPCS C1713 5534012 - SPACER ALGRF 30X12X2MM EXTENSURE SPNE BOTH IP/OP "$5,577.50 " "$4,127.35" $0.00 "$4,462.00" "$2,509.88" "$2,509.88" $0.00 $0.00 $0.00 "$1,162.49" "$4,139.62" "$4,139.62" $0.00 $0.00 "$1,162.35" $0.00 "$2,749.71" "$2,749.71" $0.00 "$2,788.75" "$4,417.38" "$4,462.00" $0.00 $0.00 $872.88 $0.00 $0.00 $887.94 $0.00 $0.00 $0.00 $0.00 $0.00 5534014 SUP HCPCS C1713 5534014 - SPACER ALGRF 30X14X2MM EXTENSURE SPNE BOTH IP/OP "$5,577.50 " "$4,127.35" $0.00 "$4,462.00" "$2,509.88" "$2,509.88" $0.00 $0.00 $0.00 "$1,162.49" "$4,139.62" "$4,139.62" $0.00 $0.00 "$1,162.35" $0.00 "$2,749.71" "$2,749.71" $0.00 "$2,788.75" "$4,417.38" "$4,462.00" $0.00 $0.00 $872.88 $0.00 $0.00 $887.94 $0.00 $0.00 $0.00 $0.00 $0.00 5534018 SUP HCPCS C1713 5534018 - SPACER SPNL 30X18X2MM EXTENSURE ALGRF BOTH IP/OP "$5,577.50 " "$4,127.35" $0.00 "$4,462.00" "$2,509.88" "$2,509.88" $0.00 $0.00 $0.00 "$1,162.49" "$4,139.62" "$4,139.62" $0.00 $0.00 "$1,162.35" $0.00 "$2,749.71" "$2,749.71" $0.00 "$2,788.75" "$4,417.38" "$4,462.00" $0.00 $0.00 $872.88 $0.00 $0.00 $887.94 $0.00 $0.00 $0.00 $0.00 $0.00 5540030 SUP HCPCS C1713 5540030 - SCREW SET BREAK OFF CD HORIZON TITANIUM SPINAL NONSTRL 5.5 BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5540130 SUP HCPCS C1713 5540130 - SET SCREW 5540130 5.5/6.0 TI NS NON BO BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5540230 SUP HCPCS C1713 5540230 - SET SCREW 5540230 5.5/6.0 TI NS RED BO BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5540430 SUP HCPCS C1713 5540430 - SCREW SET SOLERA SEXTANT CD HORIZON TITANIUM 5.5-6MM NONSTRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5560001 SUP Custom 27804086 5560001 - GRAFT BN 13MMX5MM FACET DWL SPNE BOTH IP/OP "$3,177.50 " "$2,351.35" $0.00 "$2,542.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,358.34" "$2,358.34" $0.00 $0.00 $662.19 $0.00 $0.00 $0.00 $0.00 "$1,588.75" "$2,516.58" "$2,542.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5587000 SUP HCPCS C1750 5587000 - KIT CATH REPR REPL CNCT PU HMDIAL BOTH IP/OP $325.28 $240.71 $0.00 $260.22 $146.37 $146.37 $0.00 $0.00 $0.00 $67.80 $241.42 $241.42 $0.00 $0.00 $67.79 $0.00 $192.40 $192.40 $0.00 $162.64 $257.62 $260.22 $0.00 $0.00 $50.91 $0.00 $0.00 $51.78 $0.00 $0.00 $0.00 $0.00 $0.00 5688000 SUP Custom 27203010 5688000 - TUNNELER SRG 30MM 8IN HMSPLT HMSPLT XK MLBL TPR BOTH IP/OP $61.25 $45.33 $0.00 $49.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.46 $45.46 $0.00 $0.00 $12.76 $0.00 $0.00 $0.00 $0.00 $30.63 $48.51 $49.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5740105 SUP Custom 27804086 5740105 - GRAFT BN LRDTC 14X11X5MM SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5740106 SUP Custom 27804086 5740106 - GRAFT BONE 14X11X6MM ALLOGRAFT TRIAD CANCELLOUS CORTICAL SPN BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5740107 SUP Custom 27804086 5740107 - GRAFT BONE LORDOSIS 14X7X11MM ALLOGRAFT TRAID CANCELLOUS BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5740109 SUP Custom 27804086 5740109 - GRAFT BN LRDTC 14X11X9MM TRD ALGRF CORT CNC BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5740110 SUP Custom 27804086 5740110 - GRAFT BN LRDTC 14X11X10MM ALGRF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5750005 SUP Custom 27804086 5750005 - GRAFT BN 14X11X5MM TRD ALGRF SPNE CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5750007 SUP HCPCS C1713 "5750007 - TRIAD CR ALLOGRAFT, 7X 11X 14MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 5750010 SUP Custom 27804086 5750010 - GRAFT BN 14X11X10MM TRD ALGRF SPNE CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5950007 SUP HCPCS C1781 5950007 - PATCH SURG SMALL CIR 1.7IN STRAP VENTRALEX ST SEPRA BOTH IP/OP "$1,769.50 " "$1,309.43" $0.00 "$1,415.60" $796.28 $796.28 $0.00 $0.00 $0.00 $368.81 "$1,313.32" "$1,313.32" $0.00 $0.00 $368.76 $0.00 "$1,046.66" "$1,046.66" $0.00 $884.75 "$1,401.44" "$1,415.60" $0.00 $0.00 $276.93 $0.00 $0.00 $281.70 $0.00 $0.00 $0.00 $0.00 $0.00 5950008 SUP HCPCS C1781 5950008 - PATCH SURG MEDIUM CIR 2.5IN STRAP VENTRALEX ST SEPRA BOTH IP/OP "$2,117.00 " "$1,566.58" $0.00 "$1,693.60" $952.65 $952.65 $0.00 $0.00 $0.00 $441.24 "$1,571.24" "$1,571.24" $0.00 $0.00 $441.18 $0.00 "$1,252.21" "$1,252.21" $0.00 "$1,058.50" "$1,676.66" "$1,693.60" $0.00 $0.00 $331.31 $0.00 $0.00 $337.03 $0.00 $0.00 $0.00 $0.00 $0.00 5950009 SUP HCPCS C1781 5950009 - PATCH SRG LG CRC 3.2IN STRL VNTRLX ST SEPRA SORBAFLEX SPRG BOTH IP/OP "$2,405.50 " "$1,780.07" $0.00 "$1,924.40" "$1,082.48" "$1,082.48" $0.00 $0.00 $0.00 $501.37 "$1,785.36" "$1,785.36" $0.00 $0.00 $501.31 $0.00 "$1,422.85" "$1,422.85" $0.00 "$1,202.75" "$1,905.16" "$1,924.40" $0.00 $0.00 $376.46 $0.00 $0.00 $382.96 $0.00 $0.00 $0.00 $0.00 $0.00 5950020 SUP HCPCS C1781 5950020 - PATCH SURG LARGE CIR 4.5IN SELF EXPAND VENTRIO ST SORBAFLEX BOTH IP/OP "$2,760.75 " "$2,042.96" $0.00 "$2,208.60" "$1,242.34" "$1,242.34" $0.00 $0.00 $0.00 $575.41 "$2,049.03" "$2,049.03" $0.00 $0.00 $575.34 $0.00 "$1,361.05" "$1,361.05" $0.00 "$1,380.38" "$2,186.51" "$2,208.60" $0.00 $0.00 $432.06 $0.00 $0.00 $439.51 $0.00 $0.00 $0.00 $0.00 $0.00 5950030 SUP HCPCS C1781 5950030 - PATCH SURG SMALL OVAL 4.7X3.1IN SELF EXPAND VENTRIO ST BOTH IP/OP "$1,213.38 " $897.90 $0.00 $970.70 $546.02 $546.02 $0.00 $0.00 $0.00 $252.90 $900.57 $900.57 $0.00 $0.00 $252.87 $0.00 $717.71 $717.71 $0.00 $606.69 $961.00 $970.70 $0.00 $0.00 $189.89 $0.00 $0.00 $193.17 $0.00 $0.00 $0.00 $0.00 $0.00 5950040 SUP HCPCS C1781 5950040 - PATCH SURG MEDIUM OVAL 5.5X4.3IN SELF EXPAND VENTRIO ST BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 5950050 SUP HCPCS C1781 5950050 - PATCH SURG LARGE OVAL 7X5.4IN SELF EXPAND VENTRIO ST BOTH IP/OP "$4,550.25 " "$3,367.19" $0.00 "$3,640.20" "$2,047.61" "$2,047.61" $0.00 $0.00 $0.00 $948.39 "$3,377.20" "$3,377.20" $0.00 $0.00 $948.27 $0.00 "$2,243.27" "$2,243.27" $0.00 "$2,275.13" "$3,603.80" "$3,640.20" $0.00 $0.00 $712.11 $0.00 $0.00 $724.40 $0.00 $0.00 $0.00 $0.00 $0.00 5950070 SUP HCPCS C1781 5950070 - PATCH SURG XL CIR 9.7X7.7IN SELF EXPAND VENTRIO ST SORBAFLEX BOTH IP/OP "$6,143.00 " "$4,545.82" $0.00 "$4,914.40" "$2,764.35" "$2,764.35" $0.00 $0.00 $0.00 "$1,280.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,280.20" $0.00 "$3,028.50" "$3,028.50" $0.00 "$3,071.50" "$4,865.26" "$4,914.40" $0.00 $0.00 $961.38 $0.00 $0.00 $977.97 $0.00 $0.00 $0.00 $0.00 $0.00 5950080 SUP HCPCS C1781 5950080 - PATCH SURG XL CIR 10.7X8.7IN SELF EXPAND VENTRIO ST BOTH IP/OP "$7,356.25 " "$5,443.63" $0.00 "$5,885.00" "$3,310.31" "$3,310.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,678.13" "$5,826.15" "$5,885.00" $0.00 $0.00 "$1,151.25" $0.00 $0.00 "$1,171.12" $0.00 $0.00 $0.00 $0.00 $0.00 5960011 SUP HCPCS C1713 5960011 - SCREW SET UNIVERSAL END CAP SPN BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5960033 SUP HCPCS C1713 5960033 - SCREW BN 12MM X-COR MN VBR LCK TI SPNE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5960034 SUP HCPCS C1713 5960034 - SCREW BONE 14MM X-CORE MINI VBR TI SPN LOCK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 5960200 SUP HCPCS C1713 5960200 - END CAP SPNL PRLL 12MM 14MM NS X-COR MN BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5960400 SUP HCPCS C1713 5960400 - END CAP SPNL 16MM PRLL 14MM CORE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5962152 SUP HCPCS C1713 5962152 - CAGE SPNL 12MM 15-20MM NS LF X-COR MN XPD VERT BD REPL BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5962172 SUP Custom 27803010 5962172 - CAGE SPNL 12MM 17-24MM NS LF X-COR MN XPD VERT BD REPL BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 $0.00 $0.00 $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5962223 SUP HCPCS C1713 5962223 - CAGE SPNL 12MM 22-34MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5962253 SUP HCPCS C1713 5962253 - CAGE SPNL 12MM 25-40MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5962294 SUP HCPCS C1713 5962294 - CAGE SPNL 12MM 29-48MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5962366 SUP HCPCS C1713 5962366 - CAGE SPNL 12MM 36-62MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5962427 SUP HCPCS C1713 5962427 - CAGE SPNL 12MM 42-74MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5962520 SUP Custom 27803010 5962520 - ENDCAP SPINAL 12MM 15MM PARALLEL TITANIUM 12MM CORE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 $0.00 $0.00 $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5962521 SUP Custom 27803010 5962521 - ENDCAP SPINAL CONVEX 12MM 15X12MM TOP X-CORE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 $0.00 $0.00 $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5962526 SUP Custom 27803010 5962526 - ENDCAP SPINAL 7D 12MM 15MM BOTTOM TITANIUM 12MM CORE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 $0.00 $0.00 $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5962527 SUP Custom 27803010 5962527 - ENDCAP SPINAL 7D 12MM 15MM TOP TITANIUM 12MM CORE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 $0.00 $0.00 $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5962740 SUP HCPCS C1713 5962740 - END CAP SPNL PRLL 12MM 17MM NS 14MM X-COR MN TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5962741 SUP HCPCS C1713 5962741 - END CAP SPNL 12MM 17MM NS 14MM X-COR MN CNTR TOP TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5962746 SUP HCPCS C1713 5962746 - END CAP SPNL 7D 12MM 17MM NS 14MM X-COR MN LRDTC BTM TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5962747 SUP HCPCS C1713 5962747 - END CAP SPNL 7D 12MM 17MM NS 14MM X-COR MN LRDTC TOP TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5963740 SUP HCPCS C1713 5963740 - END CAP SPNL ANG 14MM 17MM PRLL TOP TI 14MM COR BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5963745 SUP HCPCS C1713 5963745 - END CAP SPNL ANG 14MM 17MM PRLL BTM TI 14MM COR BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5963746 SUP HCPCS C1713 5963746 - END CAP SPNL 4D KYPHOTIC 14MM 17X14MM X-COR BTM BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5963747 SUP HCPCS C1713 5963747 - END CAP SPNL 4D KYPHOTIC 14MM 17X14MM X-COR TOP BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5963960 SUP HCPCS C1713 5963960 - END CAP SPNL ANG 16MM 19MM PRLL TOP TI 14MM COR BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5963965 SUP HCPCS C1713 5963965 - END CAP SPNL ANG 16MM 19MM PRLL BTM TI 14MM COR BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5963966 SUP HCPCS C1713 5963966 - END CAP SPNL 4D KYPHOTIC 14MM 19X16MM X-COR BTM BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5963967 SUP HCPCS C1713 5963967 - END CAP SPNL 4D KYPHOTIC 14MM 19X16MM X-COR TOP BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5964152 SUP HCPCS C1713 5964152 - CAGE SPNL 14MM 15-20MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5964172 SUP Custom 27803010 5964172 - CAGE SPNL 14MM 17-24MM NS LF X-COR MN XPD VERT BD REPL BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 $0.00 $0.00 $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5964223 SUP HCPCS C1713 5964223 - CAGE SPNL 14MM 22-34MM NS LF X-COR MN XPD VERT BD REPL BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5964253 SUP HCPCS C1713 5964253 - CAGE SPNL 14MM 25-40MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5964294 SUP HCPCS C1713 5964294 - CAGE SPNL 14MM 29-48MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5964366 SUP HCPCS C1713 5964366 - CAGE SPNL 14MM 36-62MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5964427 SUP HCPCS C1713 5964427 - CAGE SPNL 14MM 42-74MM NS LF X-COR MN BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 5964740 SUP HCPCS C1713 5964740 - END CAP SPNL PRLL 14MM 17MM NS 14MM X-COR MN TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5964741 SUP HCPCS C1713 5964741 - END CAP SPNL 14MM 17MM NS 14MM X-COR MN CNTR TOP TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5964746 SUP HCPCS C1713 5964746 - END CAP SPNL 7D LRDTC 14MM 17MM NS 14MM X-COR MN TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5964747 SUP HCPCS C1713 5964747 - END CAP SPNL 7D LRDTC 14MM 17MM NS 14MM X-COR MN TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5964960 SUP HCPCS C1713 5964960 - END CAP SPNL PRLL 14MM 19MM NS 14MM X-COR MN TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5964966 SUP HCPCS C1713 5964966 - END CAP SPNL 7D LRDTC 14MM 19MM NS 16MM X-COR MN TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5964967 SUP HCPCS C1713 5964967 - END CAP SPNL 7D LRDTC 14MM 19MM NS 16MM X-COR MN TI BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 5975730 SUP HCPCS C1713 5975730 - VUE POINT 435 X 30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6014908 SUP Custom 27203010 6014908 - DRILL TWST 1.4MM 18MM 8MM WL BOTH IP/OP $760.00 $562.40 $0.00 $608.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $564.07 $564.07 $0.00 $0.00 $158.38 $0.00 $0.00 $0.00 $0.00 $380.00 $601.92 $608.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6019135 SUP Custom 27203010 6019135 - DRILL TWST 1.9MM 115MM LF BOTH IP/OP $617.05 $456.62 $0.00 $640.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.97 $457.97 $0.00 $0.00 $128.59 $0.00 $0.00 $0.00 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6046385 SUP HCPCS C1713 "6046385 - 4.0 CANNULATED, 38MM" BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 6101045 SUP HCPCS C1713 6101045 - SPACER SPNL XL STD 45X18X10CM C-THRU PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101050 SUP HCPCS C1713 6101050 - CAGE SPNL XL 50X18X10MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101055 SUP HCPCS C1713 6101055 - CAGE SPNL XL STD 55X18X10MM CRNT CT4 BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101060 SUP HCPCS C1713 6101060 - CAGE SPNL XL STD 60X18X10MM CRNT CT4 BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101245 SUP HCPCS C1713 6101245 - SPACER SPNL 45X18X12MM CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101250 SUP HCPCS C1713 6101250 - CAGE SPNL XL CRNL TPR 50X18X12MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101255 SUP HCPCS C1713 6101255 - CAGE SPNL XL CRNL TPR 55X18X12MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101260 SUP HCPCS C1713 6101260 - CAGE SPNL XL CRNL TPR 60X18X12MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101445 SUP HCPCS C1713 6101445 - CAGE SPNL XL CRNL TPR 45X18X14MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101450 SUP HCPCS C1713 6101450 - CAGE SPNL XL CRNL TPR 50X18X14MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101455 SUP HCPCS C1713 6101455 - CAGE SPNL XL CRNL TPR 55X18X14MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101460 SUP HCPCS C1713 6101460 - CAGE SPNL XL CRNL TPR 60X18X14MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101645 SUP HCPCS C1713 6101645 - CAGE SPNL XL CRNL TPR 45X18X16MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101650 SUP HCPCS C1713 6101650 - CAGE SPNL XL CRNL TPR 50X18X16MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101655 SUP HCPCS C1713 6101655 - CAGE SPNL XL CRNL TPR 55X18X16MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6101660 SUP HCPCS C1713 6101660 - CAGE SPNL XL CRNL TPR 60X18X16MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111045 SUP HCPCS C1713 6111045 - CAGE SPNL 10D LRDTC 45X18X10MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111050 SUP HCPCS C1713 6111050 - CAGE SPNL 10D LRDTC 50X18X10MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111055 SUP HCPCS C1713 6111055 - CAGE SPNL 10D LRDTC 55X18X10MM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111060 SUP HCPCS C1713 6111060 - CAGE SPNL 10D LRDTC 60X18X10MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111245 SUP HCPCS C1713 6111245 - CAGE SPNL 10D LRDTC 45X18X12MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111250 SUP HCPCS C1713 6111250 - CAGE SPNL XL 10D 50X18X12MM CRNT COALITION PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111255 SUP HCPCS C1713 6111255 - CAGE SPNL 10D XL CRNL TPR 55X18X12MM CRNT PEEK-OPTM IM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111260 SUP HCPCS C1713 6111260 - SPACER SPNL 10D XL 60X18X12MM PEEK BCK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111445 SUP HCPCS C1713 6111445 - CAGE SPNL 10D XL CRNL TPR 45X18X14MM CRNT PEEK-OPTM IM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111450 SUP HCPCS C1713 6111450 - CAGE SPNL 10D XL CRNL TPR 50X18X14MM CRNT PEEK-OPTM IM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111455 SUP HCPCS C1713 6111455 - CAGE SPNL XL CRNL TPR 55X18X14MM CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111460 SUP HCPCS C1713 6111460 - CAGE SPNL 10D XL CRNL TPR 60X18X14MM CRNT PEEK-OPTM IM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111645 SUP HCPCS C1713 6111645 - CAGE SPNL 10D XL CRNL TPR 45X18X16MM CRNT PEEK-OPTM IM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111650 SUP HCPCS C1713 6111650 - CAGE SPNL 10D XL CRNL TPR 50X18X16MM CRNT PEEK-OPTM IM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111655 SUP HCPCS C1713 6111655 - CAGE SPNL 10D XL CRNL TPR 55X18X16MM CRNT PEEK-OPTM IM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6111660 SUP HCPCS C1713 6111660 - CAGE SPNL 10D XL CRNL TPR 60X18X16MM CRNT PEEK-OPTM IM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6160850 SUP HCPCS C1713 6160850 - CAGE SPNL XL W 50X22X8MM CRNT FX BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6160855 SUP HCPCS C1713 6160855 - CAGE SPNL XL W 55X22X8MM CRNT FX BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6160860 SUP HCPCS C1713 6160860 - CAGE SPNL XL W 60X22X8MM CRNT FX BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161045 SUP HCPCS C1713 6161045 - CAGE SPNL XL 45X22X10MM NS LF CRNT W FTPRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161050 SUP HCPCS C1713 6161050 - CAGE SPNL XL W 50X22X10MM CRNT FX BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161055 SUP HCPCS C1713 6161055 - CAGE SPNL XL W 55X22X10MM CRNT FX BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161060 SUP HCPCS C1713 6161060 - CAGE SPNL XL W 60X22X10MM CRNT FX BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161255 SUP HCPCS C1713 6161255 - CAGE SPNL XL W 55X22X12MM CRNT FSN BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161260 SUP HCPCS C1713 6161260 - CAGE SPNL XL W 60X22X12MM CRNT FSN BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161450 SUP HCPCS C1713 6161450 - CAGE SPNL XL W 50X22X14MM CRNT FSN BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161455 SUP HCPCS C1713 6161455 - CAGE SPNL XL W 55X22X14MM CRNT FSN BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6161460 SUP HCPCS C1713 6161460 - CAGE SPNL XL W 60X22X14MM CRNT FSN BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6170850 SUP HCPCS C1713 6170850 - CAGE SPNL XL W LRDTC 50X22X8MM CRNT FSN BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6170855 SUP HCPCS C1713 6170855 - CAGE SPNL XL LRDTC 55X22X8MM NS LF CRNT W FTPRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6170860 SUP HCPCS C1713 6170860 - CAGE SPNL XL LRDTC 60X22X8MM NS LF CRNT W FTPRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171050 SUP HCPCS C1713 6171050 - SPACER SPNL XL W LRDTC 50X22X10MM CRNT FSN BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171055 SUP HCPCS C1713 6171055 - CAGE SPNL XL LRDTC 55X22X10MM NS LF CRNT W FTPRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171060 SUP HCPCS C1713 6171060 - CAGE SPNL XL LRDTC 60X22X10MM NS LF CRNT W FTPRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171250 SUP HCPCS C1713 6171250 - CAGE SPNL XL W LRDTC 50X22X12MM CRNT FSN BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171255 SUP HCPCS C1713 6171255 - CAGE SPNL XL LRDTC 55X22X12MM NS LF CRNT W FTPRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171260 SUP HCPCS C1713 6171260 - CAGE SPNL XL LRDTC 60X22X12MM NS LF CRNT W FTPRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171450 SUP HCPCS C1713 6171450 - CAGE SPNL XL W LRDTC 50X22X14MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171455 SUP HCPCS C1713 6171455 - CAGE SPNL XL W LRDTC 55X22X14MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6171460 SUP HCPCS C1713 6171460 - CAGE SPNL XL W LRDTC 60X22X14MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6181800 SUP Custom 27803010 6181800 - ENDCAP 18MM RND 0 DEG OD18 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6181804 SUP Custom 27803010 6181804 - ENDCAP 18MM RND 4 DEG OD18 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6181808 SUP Custom 27803010 6181808 - ENDCAP 18MM RND 8 DEG XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183000 SUP Custom 27803010 6183000 - ENDCAP OD18X18X30MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183004 SUP Custom 27803010 6183004 - ENDCAP OD18X18X30MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183008 SUP Custom 27803010 6183008 - ENDCAP OD18X18X30MM 8 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183014 SUP Custom 27803010 6183014 - ENDCAP OD18X18X30MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6184000 SUP Custom 27803010 6184000 - ENDCAP OD18X18X40MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6184004 SUP Custom 27803010 6184004 - ENDCAP OD18X18X40MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6184008 SUP Custom 27803010 6184008 - ENDCAP OD18X18X40MM 8 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6184014 SUP Custom 27803010 6184014 - ENDCAP OD18X18X40MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6185000 SUP Custom 27803010 6185000 - ENDCAP OD18X18X50MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6185004 SUP Custom 27803010 6185004 - ENDCAP OD18X18X50MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6185008 SUP Custom 27803010 6185008 - ENDCAP OD18X18X50MM 8 DEG TI XCORE TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6185014 SUP Custom 27803010 6185014 - ENDCAP OD18X18X50MM 4 DEG TI OD18 TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6200240 SUP HCPCS C1713 6200240 - CAGE SPNL 20D XL HYPERLORDOTIC 40X22X2MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200245 SUP HCPCS C1713 6200245 - CAGE SPNL 20D XL 45X22X2MM CRNT PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200250 SUP HCPCS C1713 6200250 - CAGE SPNL 20D XL 50X22X2MM CRNT PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200255 SUP HCPCS C1713 6200255 - CAGE SPNL 20D XL 55X22X2MM CRNT PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200260 SUP HCPCS C1713 6200260 - CAGE SPNL 20D XL 60X22X2MM CRNT PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200265 SUP HCPCS C1713 6200265 - CAGE SPNL 20D XL HYPERLORDOTIC 65X22X2MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200440 SUP HCPCS C1713 6200440 - CAGE SPNL 20D XL HYPERLORDOTIC 40X22X4MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200445 SUP HCPCS C1713 6200445 - CAGE SPNL 20D XL 45X22X4MM CRNT PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200450 SUP HCPCS C1713 6200450 - CAGE SPNL 20D XL 50X22X4MM PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200455 SUP HCPCS C1713 6200455 - CAGE SPNL 20D XL 55X22X4MM PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200460 SUP HCPCS C1713 6200460 - CAGE SPNL 20D XL 60X22X4MM CRNT PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200465 SUP HCPCS C1713 6200465 - CAGE SPNL 20D XL HYPERLORDOTIC 65X22X4MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200640 SUP HCPCS C1713 6200640 - CAGE SPNL 20D XL HYPERLORDOTIC 40X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200645 SUP HCPCS C1713 6200645 - CAGE SPNL 20D XL 45X22X6MM CRNT PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200650 SUP HCPCS C1713 6200650 - CAGE SPNL 20D XL 50X22X6MM CRNT PEEK BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200655 SUP HCPCS C1713 6200655 - CAGE SPNL 20D XL HYPERLORDOTIC 55X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200660 SUP HCPCS C1713 6200660 - CAGE SPNL 20D XL HYPERLORDOTIC 60X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200665 SUP HCPCS C1713 6200665 - CAGE SPNL 20D XL HYPERLORDOTIC 65X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200840 SUP HCPCS C1713 6200840 - CAGE SPNL 20D XL HYPERLORDOTIC 40X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200845 SUP HCPCS C1713 6200845 - CAGE SPNL 20D XL HYPERLORDOTIC 45X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200850 SUP HCPCS C1713 6200850 - CAGE SPNL 20D XL HYPERLORDOTIC 50X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200855 SUP HCPCS C1713 6200855 - CAGE SPNL 20D XL HYPERLORDOTIC 55X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200860 SUP HCPCS C1713 6200860 - CAGE SPNL 20D XL HYPERLORDOTIC 60X22X8MM NS LF CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6200865 SUP HCPCS C1713 6200865 - CAGE SPNL 20D XL HYPERLORDOTIC 65X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6201040 SUP HCPCS C1713 6201040 - CAGE SPNL 20D XL HYPERLORDOTIC 40X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6201045 SUP HCPCS C1713 6201045 - CAGE SPNL 20D XL HYPERLORDOTIC 45X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6201050 SUP HCPCS C1713 6201050 - CAGE SPNL 20D XL HYPERLORDOTIC 50X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6201055 SUP HCPCS C1713 6201055 - CAGE SPNL 20D XL HYPERLORDOTIC 55X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6201060 SUP HCPCS C1713 6201060 - CAGE SPNL 20D XL HYPERLORDOTIC 60X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6201065 SUP HCPCS C1713 6201065 - CAGE SPNL 20D XL HYPERLORDOTIC 65X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6208045 SUP HCPCS C1713 6208045 - CAGE SPNL XL XW 45X26X8MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6208050 SUP HCPCS C1713 6208050 - CAGE SPNL XL XW 50X26X8MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6208055 SUP HCPCS C1713 6208055 - CAGE SPNL XL XW 55X26X8MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6208060 SUP HCPCS C1713 6208060 - CAGE SPNL XL XW 60X26X8MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6208145 SUP HCPCS C1713 6208145 - CAGE SPNL 10D XL XW 45X26X8MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6208150 SUP HCPCS C1713 6208150 - CAGE SPNL 10D XL XW 50X26X8MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6208155 SUP HCPCS C1713 6208155 - CAGE SPNL 10D XL XW 55X26X8MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6208160 SUP HCPCS C1713 6208160 - CAGE SPNL 10D XL XW 60X26X8MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6210045 SUP HCPCS C1713 6210045 - CAGE SPNL XL XW 45X26X10MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6210050 SUP HCPCS C1713 6210050 - CAGE SPNL XL XW 50X26X10MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6210055 SUP HCPCS C1713 6210055 - CAGE SPNL XL XW 55X26X10MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6210060 SUP HCPCS C1713 6210060 - CAGE SPNL XL XW 60X26X10MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6210145 SUP HCPCS C1713 6210145 - CAGE SPNL 10D XL XW 45X26X10MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6210150 SUP HCPCS C1713 6210150 - CAGE SPNL 10D XL XW 50X26X10MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6210155 SUP HCPCS C1713 6210155 - CAGE SPNL 10D XL XW 55X26X10MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6212045 SUP HCPCS C1713 6212045 - CAGE SPNL XL XW 45X26X12MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6212050 SUP HCPCS C1713 6212050 - CAGE SPNL XL XW 50X26X12MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6212055 SUP HCPCS C1713 6212055 - CAGE SPNL XL XW 55X26X12MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6212060 SUP HCPCS C1713 6212060 - CAGE SPNL XL XW 60X26X12MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6212145 SUP HCPCS C1713 6212145 - CAGE SPNL 10D XL XW 45X26X12MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6212150 SUP HCPCS C1713 6212150 - CAGE SPNL 10D XL XW LRDTC 50X26X12MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6212155 SUP HCPCS C1713 6212155 - CAGE SPNL 10D XL XW LRDTC 55X26X12MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6212160 SUP HCPCS C1713 6212160 - CAGE SPNL 10D XL XW 60X26X12MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6214045 SUP HCPCS C1713 6214045 - CAGE SPNL XL XW 45X26X14MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6214050 SUP HCPCS C1713 6214050 - CAGE SPNL XL XW 50X26X14MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6214055 SUP HCPCS C1713 6214055 - CAGE SPNL XL XW 55X26X14MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6214060 SUP HCPCS C1713 6214060 - CAGE SPNL XL XW 60X26X14MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6214145 SUP HCPCS C1713 6214145 - CAGE SPNL 10D XL XW 45X26X14MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6214150 SUP HCPCS C1713 6214150 - CAGE SPNL 10D XL XW 50X26X14MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6214155 SUP HCPCS C1713 6214155 - CAGE SPNL 10D XL XW 55X26X14MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6214160 SUP HCPCS C1713 6214160 - CAGE SPNL 10D XL XW 60X26X14MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6216045 SUP HCPCS C1713 6216045 - CAGE SPNL XL XW 45X26X16MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6216050 SUP HCPCS C1713 6216050 - CAGE SPNL XL XW 50X26X16MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6216055 SUP HCPCS C1713 6216055 - CAGE SPNL XL XW 55X26X16MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6216060 SUP HCPCS C1713 6216060 - CAGE SPNL XL XW 60X26X16MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6216145 SUP HCPCS C1713 6216145 - CAGE SPNL 10D XL XW 45X26X16MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6216150 SUP HCPCS C1713 6216150 - CAGE SPNL 10D XL XW 50X26X16MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6216155 SUP HCPCS C1713 6216155 - CAGE SPNL 10D XL XW 55X26X16MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6216160 SUP HCPCS C1713 6216160 - CAGE SPNL 10D XL XW 60X26X16MM CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6222200 SUP Custom 27803010 6222200 - ENDCAP 22MM RND 0 DEG OD18 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6222204 SUP Custom 27803010 6222204 - ENDCAP 22MM RND 4 DEG OD18 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6222208 SUP Custom 27803010 6222208 - ENDCAP 22MM RND 8 DEG XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6223000 SUP Custom 27803010 6223000 - ENDCAP OD18X22X30MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6223004 SUP HCPCS C1713 6223004 - END CAP SPNL 4D 18MM 30MM NS 22MM X-COR 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" "$1,420.88" "$1,420.88" $0.00 $0.00 $0.00 $658.10 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 "$1,556.65" "$1,556.65" $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $494.15 $0.00 $0.00 $502.67 $0.00 $0.00 $0.00 $0.00 $0.00 6223008 SUP Custom 27803010 6223008 - ENDCAP OD18X22X30MM 8 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6223012 SUP Custom 27803010 6223012 - ENDCAP OD18X22X30MM 12 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6224000 SUP Custom 27803010 6224000 - ENDCAP OD18X22X40MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6224004 SUP Custom 27803010 6224004 - ENDCAP OD18X22X40MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6224008 SUP Custom 27803010 6224008 - ENDCAP OD18X22X40MM 8 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6224012 SUP Custom 27803010 6224012 - ENDCAP OD18X22X40MM 12 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6225000 SUP Custom 27803010 6225000 - ENDCAP OD18X22X50MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6225004 SUP Custom 27803010 6225004 - ENDCAP OD18X22X50MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6225008 SUP Custom 27803010 6225008 - ENDCAP OD18X22X50MM 8 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6225012 SUP Custom 27803010 6225012 - ENDCAP OD18X22X50MM 12 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6226000 SUP Custom 27803010 6226000 - ENDCAP OD18X22X60MM 0 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6226004 SUP Custom 27803010 6226004 - ENDCAP OD18X22X60MM 4 DEG TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6226008 SUP Custom 27803010 6226008 - ENDCAP OD18X22X60MM 8 DEG TI XCORE TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6226012 SUP Custom 27803010 6226012 - ENDCAP OD18X22X60MM 12 DEG TI OD18 TI XCORE 2 BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240041 SUP Custom 27803010 6240041 - SPACER SPNL 11MM 14X10MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240064 SUP Custom 27803010 6240064 - SPACER SPNL 6MM 14X16MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240086 SUP Custom 27803010 6240086 - SPACER SPNL 16MM 18X10MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240141 SUP Custom 27803010 6240141 - SPACER SPNL 11MM 14X11MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240164 SUP Custom 27803010 6240164 - SPACER SPNL 14MM 16X11MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240186 SUP Custom 27803010 6240186 - SPACER SPNL 16MM 18X11MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240241 SUP Custom 27803010 6240241 - SPACER SPNL 12MM 11X14MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240264 SUP Custom 27803010 6240264 - SPACER SPNL 14MM 16X12MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240286 SUP Custom 27803010 6240286 - SPACER SPNL 16MM 18X12MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240341 SUP Custom 27803010 6240341 - SPACER SPNL 13MM 11X14MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240364 SUP Custom 27803010 6240364 - SPACER SPNL 14MM 16X13MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240386 SUP Custom 27803010 6240386 - SPACER SPNL 16MM 18X13MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240441 SUP Custom 27803010 6240441 - SPACER SPNL 14MM 11X14MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240464 SUP Custom 27803010 6240464 - SPACER SPNL 14MM 16X14MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240486 SUP Custom 27803010 6240486 - SPACER SPNL 16MM 18X14MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240541 SUP Custom 27803010 6240541 - SPACER SPNL 11MM 14X5MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240564 SUP Custom 27803010 6240564 - SPACER SPNL 5MM 14X16MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240586 SUP Custom 27803010 6240586 - SPACER SPNL 16MM 18X5MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240641 SUP Custom 27803010 6240641 - SPACER SPNL 11MM 14X6MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240664 SUP Custom 27803010 6240664 - SPACER SPNL 6MM 14X16MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240686 SUP Custom 27803010 6240686 - SPACER SPNL 16MM 18X6MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240741 SUP Custom 27803010 6240741 - SPACER SPNL 11MM 14X7MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240764 SUP Custom 27803010 6240764 - SPACER SPNL 7MM 14X16MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240786 SUP Custom 27803010 6240786 - SPACER SPNL 16MM 18X7MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240841 SUP HCPCS C1713 6240841 - SPACER SPNL 11MM 14X8MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6240864 SUP Custom 27803010 6240864 - SPACER SPNL 8MM 14X16MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240886 SUP Custom 27803010 6240886 - SPACER SPNL 16MM 18X8MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240941 SUP Custom 27803010 6240941 - SPACER SPNL 11MM 14X9MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240964 SUP Custom 27803010 6240964 - SPACER SPNL 9MM 14X16MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6240986 SUP Custom 27803010 6240986 - SPACER SPNL 16MM 18X9MM VRTSTCK CRSTN PSR PEEK-OPTM CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6241041 SUP HCPCS C1713 6241041 - STRUT SPNL 11MM 14X5MM VRTSTCK HDRSRB PEEK-OPTM CRV BOTH IP/OP "$5,445.00 " "$4,029.30" $0.00 "$4,356.00" "$2,450.25" "$2,450.25" $0.00 $0.00 $0.00 "$1,134.87" "$4,041.28" "$4,041.28" $0.00 $0.00 "$1,134.74" $0.00 "$2,684.39" "$2,684.39" $0.00 "$2,722.50" "$4,312.44" "$4,356.00" $0.00 $0.00 $852.14 $0.00 $0.00 $866.84 $0.00 $0.00 $0.00 $0.00 $0.00 6241064 SUP HCPCS C1713 6241064 - STRUT SPNL 14MM 16X5MM VRTSTCK HDRSRB PEEK-OPTM CRV BOTH IP/OP "$5,445.00 " "$4,029.30" $0.00 "$4,356.00" "$2,450.25" "$2,450.25" $0.00 $0.00 $0.00 "$1,134.87" "$4,041.28" "$4,041.28" $0.00 $0.00 "$1,134.74" $0.00 "$2,684.39" "$2,684.39" $0.00 "$2,722.50" "$4,312.44" "$4,356.00" $0.00 $0.00 $852.14 $0.00 $0.00 $866.84 $0.00 $0.00 $0.00 $0.00 $0.00 6241086 SUP HCPCS C1713 6241086 - STRUT SPNL 16MM 18X5MM VRTSTCK HDRSRB PEEK-OPTM CRV BOTH IP/OP "$5,445.00 " "$4,029.30" $0.00 "$4,356.00" "$2,450.25" "$2,450.25" $0.00 $0.00 $0.00 "$1,134.87" "$4,041.28" "$4,041.28" $0.00 $0.00 "$1,134.74" $0.00 "$2,684.39" "$2,684.39" $0.00 "$2,722.50" "$4,312.44" "$4,356.00" $0.00 $0.00 $852.14 $0.00 $0.00 $866.84 $0.00 $0.00 $0.00 $0.00 $0.00 6242041 SUP HCPCS C1713 6242041 - STRUT SPNL 11MM 14X24MM VRTSTCK HDRSRB PEEK-OPTM CRV BOTH IP/OP "$5,445.00 " "$4,029.30" $0.00 "$4,356.00" "$2,450.25" "$2,450.25" $0.00 $0.00 $0.00 "$1,134.87" "$4,041.28" "$4,041.28" $0.00 $0.00 "$1,134.74" $0.00 "$2,684.39" "$2,684.39" $0.00 "$2,722.50" "$4,312.44" "$4,356.00" $0.00 $0.00 $852.14 $0.00 $0.00 $866.84 $0.00 $0.00 $0.00 $0.00 $0.00 6242064 SUP HCPCS C1713 6242064 - STRUT SPNL 14MM 16X24MM VRTSTCK HDRSRB PEEK-OPTM CRV BOTH IP/OP "$5,445.00 " "$4,029.30" $0.00 "$4,356.00" "$2,450.25" "$2,450.25" $0.00 $0.00 $0.00 "$1,134.87" "$4,041.28" "$4,041.28" $0.00 $0.00 "$1,134.74" $0.00 "$2,684.39" "$2,684.39" $0.00 "$2,722.50" "$4,312.44" "$4,356.00" $0.00 $0.00 $852.14 $0.00 $0.00 $866.84 $0.00 $0.00 $0.00 $0.00 $0.00 6242086 SUP HCPCS C1713 6242086 - STRUT SPNL 16MM 18X24MM VRTSTCK HDRSRB PEEK-OPTM CRV BOTH IP/OP "$5,445.00 " "$4,029.30" $0.00 "$4,356.00" "$2,450.25" "$2,450.25" $0.00 $0.00 $0.00 "$1,134.87" "$4,041.28" "$4,041.28" $0.00 $0.00 "$1,134.74" $0.00 "$2,684.39" "$2,684.39" $0.00 "$2,722.50" "$4,312.44" "$4,356.00" $0.00 $0.00 $852.14 $0.00 $0.00 $866.84 $0.00 $0.00 $0.00 $0.00 $0.00 6260535 SUP HCPCS C1713 6260535 - SCREW BONE 5MM 35MM RPS SPNL FIX BOTH IP/OP "$2,122.93 " "$1,570.97" $0.00 "$1,698.34" $955.32 $955.32 $0.00 $0.00 $0.00 $442.47 "$1,575.63" "$1,575.63" $0.00 $0.00 $442.42 $0.00 "$1,255.71" "$1,255.71" $0.00 "$1,061.46" "$1,681.36" "$1,698.34" $0.00 $0.00 $332.24 $0.00 $0.00 $337.97 $0.00 $0.00 $0.00 $0.00 $0.00 6260540 SUP HCPCS C1713 6260540 - SCREW BONE 5MM 40MM RPS SPNL FIX BOTH IP/OP "$2,122.93 " "$1,570.97" $0.00 "$1,698.34" $955.32 $955.32 $0.00 $0.00 $0.00 $442.47 "$1,575.63" "$1,575.63" $0.00 $0.00 $442.42 $0.00 "$1,255.71" "$1,255.71" $0.00 "$1,061.46" "$1,681.36" "$1,698.34" $0.00 $0.00 $332.24 $0.00 $0.00 $337.97 $0.00 $0.00 $0.00 $0.00 $0.00 6260555 SUP HCPCS C1713 6260555 - SCREW BONE 5MM 55MM RPS SPNL FIX BOTH IP/OP "$2,122.93 " "$1,570.97" $0.00 "$1,698.34" $955.32 $955.32 $0.00 $0.00 $0.00 $442.47 "$1,575.63" "$1,575.63" $0.00 $0.00 $442.42 $0.00 "$1,255.71" "$1,255.71" $0.00 "$1,061.46" "$1,681.36" "$1,698.34" $0.00 $0.00 $332.24 $0.00 $0.00 $337.97 $0.00 $0.00 $0.00 $0.00 $0.00 6260560 SUP HCPCS C1713 6260560 - SCREW BONE 5MM 60MM RPS SPNL FIX BOTH IP/OP "$2,122.93 " "$1,570.97" $0.00 "$1,698.34" $955.32 $955.32 $0.00 $0.00 $0.00 $442.47 "$1,575.63" "$1,575.63" $0.00 $0.00 $442.42 $0.00 "$1,255.71" "$1,255.71" $0.00 "$1,061.46" "$1,681.36" "$1,698.34" $0.00 $0.00 $332.24 $0.00 $0.00 $337.97 $0.00 $0.00 $0.00 $0.00 $0.00 6260625 SUP HCPCS C1713 6260625 - SCREW BONE 6MM 25MM TECHTONIX TI SPNL BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6260630 SUP HCPCS C1713 6260630 - SCREW BONE 6MM 30MM TECHTONIX SPNL BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6260635 SUP HCPCS C1713 6260635 - SCREW BONE 6MM 35MM TECHTONIX TI SPNL LP BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6260640 SUP HCPCS C1713 6260640 - SCREW BONE 6MM 40MM TECHTONIX TI SPNL LP BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6260645 SUP HCPCS C1713 6260645 - SCREW BONE 6MM 44MM TECHTONIX TI SPNL LP BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6260650 SUP HCPCS C1713 6260650 - SCREW BONE 6MM 50MM TECHTONIX TI SPNL LP BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6260655 SUP HCPCS C1713 6260655 - SCREW BONE 6MM 55MM TECHTONIX BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6260660 SUP HCPCS C1713 6260660 - SCREW BONE 6MM 60MM TECHTONIX BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262525 SUP HCPCS C1713 6262525 - SCREW BONE 5MM 25MM TECHTONIX TI SPNL BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262530 SUP HCPCS C1713 6262530 - SCREW BONE 5MM 30MM TECHTONIX BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262535 SUP HCPCS C1713 6262535 - SCREW BONE 5MM 35MM TECHTONIX TI SPNL BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262540 SUP HCPCS C1713 6262540 - SCREW BONE 5MM 40MM TECHTONIX SPNL BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262545 SUP HCPCS C1713 6262545 - SCREW BONE 5MM 45MM TECHTONIX SPNL BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262550 SUP HCPCS C1713 6262550 - SCREW BONE 5MM 50MM TECHTONIX SPNL BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262555 SUP HCPCS C1713 6262555 - SCREW BONE 5MM 55MM TECHTONIX BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262560 SUP HCPCS C1713 6262560 - SCREW BONE 5MM 60MM TECHTONIX BOTH IP/OP "$3,232.75 " "$2,392.24" $0.00 "$2,586.20" "$1,454.74" "$1,454.74" $0.00 $0.00 $0.00 $673.79 "$2,399.35" "$2,399.35" $0.00 $0.00 $673.71 $0.00 "$1,593.75" "$1,593.75" $0.00 "$1,616.38" "$2,560.34" "$2,586.20" $0.00 $0.00 $505.93 $0.00 $0.00 $514.65 $0.00 $0.00 $0.00 $0.00 $0.00 6262600 SUP Custom 27803010 6262600 - ENDCAP 26MM RND 0 DEG OD18 TI XCORE 2 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6262604 SUP Custom 27803010 6262604 - ENDCAP 26MM RND 4 DEG OD18 BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6262608 SUP Custom 27803010 6262608 - ENDCAP 26MM RND 8 DEG BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6271044 SUP HCPCS C1713 6271044 - SPACER SPNL 11MM 11X44MM STRL LF VRTSTCK CRSTN PSR STRUT BOTH IP/OP "$4,992.00 " "$3,694.08" $0.00 "$3,993.60" "$2,246.40" "$2,246.40" $0.00 $0.00 $0.00 "$1,040.46" "$3,705.06" "$3,705.06" $0.00 $0.00 "$1,040.33" $0.00 "$2,461.06" "$2,461.06" $0.00 "$2,496.00" "$3,953.66" "$3,993.60" $0.00 $0.00 $781.25 $0.00 $0.00 $794.73 $0.00 $0.00 $0.00 $0.00 $0.00 6272044 SUP Custom 27803010 6272044 - SPACER SPNL 11MM 14X44MM STRL LF VRTSTCK CRSTN PSR STRUT BOTH IP/OP "$4,992.00 " "$3,694.08" $0.00 "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,705.06" "$3,705.06" $0.00 $0.00 "$1,040.33" $0.00 $0.00 $0.00 $0.00 "$2,496.00" "$3,953.66" "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6273044 SUP Custom 27803010 6273044 - SPACER SPNL 14MM 14X44MM STRL LF VRTSTCK CRSTN PSR STRUT BOTH IP/OP "$4,992.00 " "$3,694.08" $0.00 "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,705.06" "$3,705.06" $0.00 $0.00 "$1,040.33" $0.00 $0.00 $0.00 $0.00 "$2,496.00" "$3,953.66" "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6276011 SUP HCPCS C1713 6276011 - SPACER SPNL 11MM 11X10MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276025 SUP HCPCS C1713 6276025 - SPACER SPNL 11MM 11X25MM STRL LF VRTSTCK CRSTN PSR STRUT BOTH IP/OP "$4,992.00 " "$3,694.08" $0.00 "$3,993.60" "$2,246.40" "$2,246.40" $0.00 $0.00 $0.00 "$1,040.46" "$3,705.06" "$3,705.06" $0.00 $0.00 "$1,040.33" $0.00 "$2,461.06" "$2,461.06" $0.00 "$2,496.00" "$3,953.66" "$3,993.60" $0.00 $0.00 $781.25 $0.00 $0.00 $794.73 $0.00 $0.00 $0.00 $0.00 $0.00 6276111 SUP HCPCS C1713 6276111 - SPACER SPNL 11MM 11X11MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276211 SUP HCPCS C1713 6276211 - SPACER SPNL 12MM 11X12MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276311 SUP HCPCS C1713 6276311 - SPACER SPNL 11MM 11X13MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276411 SUP HCPCS C1713 6276411 - SPACER SPNL 11MM 11X4MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276511 SUP HCPCS C1713 6276511 - SPACER SPNL 11MM 11X5MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276611 SUP HCPCS C1713 6276611 - SPACER SPNL 11MM 11X6MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276711 SUP HCPCS C1713 6276711 - SPACER SPNL 11MM 11X7MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276811 SUP HCPCS C1713 6276811 - SPACER SPNL 11MM 11X8MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6276911 SUP HCPCS C1713 6276911 - SPACER SPNL 11MM 11X9MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6277006 SUP HCPCS C1713 6277006 - SPACER SPNL 11MM 14X6MM STRL LF VRTSTCK CRSTN PSR STRUT BOTH IP/OP "$4,992.00 " "$3,694.08" $0.00 "$3,993.60" "$2,246.40" "$2,246.40" $0.00 $0.00 $0.00 "$1,040.46" "$3,705.06" "$3,705.06" $0.00 $0.00 "$1,040.33" $0.00 "$2,461.06" "$2,461.06" $0.00 "$2,496.00" "$3,953.66" "$3,993.60" $0.00 $0.00 $781.25 $0.00 $0.00 $794.73 $0.00 $0.00 $0.00 $0.00 $0.00 6277025 SUP Custom 27803010 6277025 - SPACER SPNL 11MM 14X25MM STRL LF VRTSTCK CRSTN PSR STRUT BOTH IP/OP "$4,992.00 " "$3,694.08" $0.00 "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,705.06" "$3,705.06" $0.00 $0.00 "$1,040.33" $0.00 $0.00 $0.00 $0.00 "$2,496.00" "$3,953.66" "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6277041 SUP HCPCS C1713 6277041 - SPACER SPNL 11MM 14X10MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6277141 SUP HCPCS C1713 6277141 - SPACER SPNL 11MM 14X10MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6277241 SUP Custom 27803010 6277241 - SPACER SPNL 11MM 14X12MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6277341 SUP Custom 27803010 6277341 - SPACER SPNL 11MM 14X13MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6277441 SUP Custom 27803010 6277441 - SPACER SPNL 11MM 14X4MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6277541 SUP HCPCS C1713 6277541 - SPACER SPNL 11MM 14X5MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6277641 SUP HCPCS C1713 6277641 - SPACER SPNL 11MM 14X6MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6277741 SUP HCPCS C1713 6277741 - SPACER SPNL 11MM 14X7MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6277841 SUP HCPCS C1713 6277841 - SPACER SPNL 11MM 14X8MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6277941 SUP HCPCS C1713 6277941 - SPACER SPNL 11MM 14X9MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6278006 SUP Custom 27803010 6278006 - SPACER SPNL 14MM 14X6MM STRL LF VRTSTCK CRSTN PSR STRUT BOTH IP/OP "$4,992.00 " "$3,694.08" $0.00 "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,705.06" "$3,705.06" $0.00 $0.00 "$1,040.33" $0.00 $0.00 $0.00 $0.00 "$2,496.00" "$3,953.66" "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278025 SUP Custom 27803010 6278025 - SPACER SPNL 14MM 14X25MM STRL LF VRTSTCK CRSTN PSR STRUT BOTH IP/OP "$4,992.00 " "$3,694.08" $0.00 "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,705.06" "$3,705.06" $0.00 $0.00 "$1,040.33" $0.00 $0.00 $0.00 $0.00 "$2,496.00" "$3,953.66" "$3,993.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278044 SUP Custom 27803010 6278044 - SPACER SPNL 14MM 14X10MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278144 SUP Custom 27803010 6278144 - SPACER SPNL 14MM 14X11MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278244 SUP Custom 27803010 6278244 - SPACER SPNL 14MM 14X12MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278344 SUP Custom 27803010 6278344 - SPACER SPNL 14MM 14X13MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278444 SUP Custom 27803010 6278444 - SPACER SPNL 14MM 14X4MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278544 SUP Custom 27803010 6278544 - SPACER SPNL 14MM 14X5MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278644 SUP Custom 27803010 6278644 - SPACER SPNL 14MM 14X6MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278744 SUP Custom 27803010 6278744 - SPACER SPNL 14MM 14X7MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278844 SUP Custom 27803010 6278844 - SPACER SPNL 14MM 14X8MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6278944 SUP Custom 27803010 6278944 - SPACER SPNL 14MM 14X9MM STRL LF VRTSTCK CRSTN PSR PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6284011 SUP HCPCS C1713 6284011 - SPACER SPNL 11MM 11X10MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284041 SUP HCPCS C1713 6284041 - SPACER SPNL 11MM 14X10MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284044 SUP HCPCS C1713 6284044 - SPACER SPNL 14MM 14X10MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284111 SUP HCPCS C1713 6284111 - SPACER SPNL 11MM 11X11MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284141 SUP HCPCS C1713 6284141 - SPACER SPNL 11MM 14X11MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284144 SUP HCPCS C1713 6284144 - SPACER SPNL 14MM 14X11MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284211 SUP HCPCS C1713 6284211 - SPACER SPNL 11MM 11X12MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284241 SUP HCPCS C1713 6284241 - SPACER SPNL 11MM 14X12MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284244 SUP HCPCS C1713 6284244 - SPACER SPNL 14MM 14X12MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284311 SUP HCPCS C1713 6284311 - SPACER SPNL 11MM 11X13MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284511 SUP HCPCS C1713 6284511 - SPACER SPNL 11MM 11X5MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284541 SUP HCPCS C1713 6284541 - SPACER SPNL 11MM 14X5MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284544 SUP HCPCS C1713 6284544 - SPACER SPNL 14MM 14X5MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284611 SUP HCPCS C1713 6284611 - SPACER SPNL 11MM 11X6MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284641 SUP HCPCS C1713 6284641 - SPACER SPNL 11MM 14X6MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284644 SUP HCPCS C1713 6284644 - SPACER SPNL 14MM 14X6MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284711 SUP HCPCS C1713 6284711 - SPACER SPNL 11MM 11X7MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284741 SUP HCPCS C1713 6284741 - SPACER SPNL 11MM 14X7MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284744 SUP HCPCS C1713 6284744 - SPACER SPNL 14MM 14X7MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284811 SUP HCPCS C1713 6284811 - SPACER SPNL 11MM 11X8MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284841 SUP HCPCS C1713 6284841 - SPACER SPNL 11MM 14X8MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284844 SUP HCPCS C1713 6284844 - SPACER SPNL 14MM 14X8MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284911 SUP HCPCS C1713 6284911 - SPACER SPNL 11MM 11X9MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284941 SUP HCPCS C1713 6284941 - SPACER SPNL 11MM 14X9MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6284944 SUP HCPCS C1713 6284944 - SPACER SPNL 14MM 14X9MM CRSTN PSR PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286011 SUP HCPCS C1713 6286011 - SPACER SPNL 11MM 11X10MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286111 SUP HCPCS C1713 6286111 - SPACER SPNL 11MM 11X11MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286211 SUP HCPCS C1713 6286211 - SPACER SPNL 11MM 11X12MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286311 SUP HCPCS C1713 6286311 - SPACER SPNL 11MM 11X13MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286511 SUP HCPCS C1713 6286511 - SPACER SPNL 11MM 11X5MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286611 SUP HCPCS C1713 6286611 - SPACER SPNL 11MM 11X6MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286711 SUP HCPCS C1713 6286711 - SPACER SPNL 11MM 11X7MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286811 SUP HCPCS C1713 6286811 - SPACER SPNL 11MM 11X8MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6286911 SUP HCPCS C1713 6286911 - SPACER SPNL 11MM 11X9MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287041 SUP HCPCS C1713 6287041 - SPACER SPNL 11MM 14X10MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287141 SUP HCPCS C1713 6287141 - SPACER SPNL 11MM 14X11MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287241 SUP HCPCS C1713 6287241 - SPACER SPNL 11MM 14X12MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287341 SUP HCPCS C1713 6287341 - SPACER SPNL 11MM 14X13MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287541 SUP HCPCS C1713 6287541 - SPACER SPNL 11MM 14X5MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287641 SUP HCPCS C1713 6287641 - SPACER SPNL 11MM 14X6MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287741 SUP HCPCS C1713 6287741 - SPACER SPNL 11MM 14X7MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287841 SUP HCPCS C1713 6287841 - SPACER SPNL 11MM 14X8MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6287941 SUP HCPCS C1713 6287941 - SPACER SPNL 11MM 14X9MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288044 SUP HCPCS C1713 6288044 - SPACER SPNL 14MM 14X10MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288144 SUP HCPCS C1713 6288144 - SPACER SPNL 14MM 14X11MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288244 SUP HCPCS C1713 6288244 - SPACER SPNL 14MM 14X12MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288344 SUP HCPCS C1713 6288344 - SPACER SPNL 14MM 14X13MM VRTSTCK CRSTN PSR LAT PORT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288544 SUP HCPCS C1713 6288544 - SPACER SPNL 14MM 14X5MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288644 SUP HCPCS C1713 6288644 - SPACER SPNL 14MM 14X6MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288744 SUP HCPCS C1713 6288744 - SPACER SPNL 14MM 14X7MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288844 SUP HCPCS C1713 6288844 - SPACER SPNL 14MM 14X8MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6288944 SUP HCPCS C1713 6288944 - SPACER SPNL 14MM 14X9MM VRTSTCK CRSTN PSR LAT PORT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6300240 SUP HCPCS C1713 6300240 - CAGE SPNL 30D XL HYPERLORDOTIC 40X22X2MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300245 SUP HCPCS C1713 6300245 - CAGE SPNL 30D XL HYPERLORDOTIC 45X22X2MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300250 SUP HCPCS C1713 6300250 - CAGE SPNL 30D XL HYPERLORDOTIC 50X22X2MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300255 SUP HCPCS C1713 6300255 - CAGE SPNL 30D XL HYPERLORDOTIC 55X22X2MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300260 SUP HCPCS C1713 6300260 - CAGE SPNL 30D XL HYPERLORDOTIC 60X22X2MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300265 SUP HCPCS C1713 6300265 - CAGE SPNL 30D XL HYPERLORDOTIC 65X22X2MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300440 SUP HCPCS C1713 6300440 - CAGE SPNL 30D XL HYPERLORDOTIC 40X22X4MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300445 SUP HCPCS C1713 6300445 - CAGE SPNL 30D XL HYPERLORDOTIC 45X22X4MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300450 SUP HCPCS C1713 6300450 - CAGE SPNL 30D XL HYPERLORDOTIC 50X22X4MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300455 SUP HCPCS C1713 6300455 - CAGE SPNL 30D XL HYPERLORDOTIC 55X22X4MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300460 SUP HCPCS C1713 6300460 - CAGE SPNL 30D XL HYPERLORDOTIC 60X22X4MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300465 SUP HCPCS C1713 6300465 - CAGE SPNL 30D XL HYPERLORDOTIC 65X22X4MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300640 SUP HCPCS C1713 6300640 - CAGE SPNL 30D XL HYPERLORDOTIC 40X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300645 SUP HCPCS C1713 6300645 - CAGE SPNL 30D XL HYPERLORDOTIC 45X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300650 SUP HCPCS C1713 6300650 - CAGE SPNL 30D XL HYPERLORDOTIC 50X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300655 SUP HCPCS C1713 6300655 - CAGE SPNL 30D LRDTC HI BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300660 SUP HCPCS C1713 6300660 - CAGE SPNL 30D XL HYPERLORDOTIC 60X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300665 SUP HCPCS C1713 6300665 - CAGE SPNL 30D XL HYPERLORDOTIC 65X22X6MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300840 SUP HCPCS C1713 6300840 - CAGE SPNL 30D XL HYPERLORDOTIC 40X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300845 SUP HCPCS C1713 6300845 - CAGE SPNL 30D XL HYPERLORDOTIC 45X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300850 SUP HCPCS C1713 6300850 - CAGE SPNL 30D XL HYPERLORDOTIC 50X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300855 SUP HCPCS C1713 6300855 - CAGE SPNL 30D XL HYPERLORDOTIC 55X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300860 SUP HCPCS C1713 6300860 - CAGE SPNL 30D XL HYPERLORDOTIC 60X22X8MM NS LF CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6300865 SUP HCPCS C1713 6300865 - CAGE SPNL 30D XL HYPERLORDOTIC 65X22X8MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6301040 SUP HCPCS C1713 6301040 - CAGE SPNL 30D XL HYPERLORDOTIC 40X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6301045 SUP HCPCS C1713 6301045 - CAGE SPNL 30D XL HYPERLORDOTIC 45X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6301050 SUP HCPCS C1713 6301050 - CAGE SPNL 30D XL HYPERLORDOTIC 50X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6301055 SUP HCPCS C1713 6301055 - CAGE SPNL 30D XL HYPERLORDOTIC 55X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6301060 SUP HCPCS C1713 6301060 - CAGE SPNL 30D XL HYPERLORDOTIC 60X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6301065 SUP HCPCS C1713 6301065 - CAGE SPNL 30D XL HYPERLORDOTIC 65X22X10MM CRNT BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 6360032 SUP HCPCS C1713 6360032 - SPACER SPNL XS 13X12X10MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360053 SUP HCPCS C1713 6360053 - SPACER SPNL XS 15X13X10MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360132 SUP HCPCS C1713 6360132 - SPACER SPNL XS 13X12X11MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360153 SUP HCPCS C1713 6360153 - SPACER SPNL XS 15X13X11MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360232 SUP HCPCS C1713 6360232 - SPACER SPNL XS 13X12X12MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360253 SUP HCPCS C1713 6360253 - SPACER SPNL XS 15X13X12MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360532 SUP HCPCS C1713 6360532 - SPACER SPNL XS 13X12X5MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360553 SUP HCPCS C1713 6360553 - SPACER SPNL XS 15X13X5MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360632 SUP HCPCS C1713 6360632 - SPACER SPNL XS 13X12X6MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360653 SUP HCPCS C1713 6360653 - SPACER SPNL XS 15X6X3MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360732 SUP HCPCS C1713 6360732 - SPACER SPNL XS 13X12X7MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360753 SUP HCPCS C1713 6360753 - SPACER SPNL XS 15X13X7MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360832 SUP HCPCS C1713 6360832 - SPACER SPNL XS 13X12X8MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360853 SUP HCPCS C1713 6360853 - SPACER SPNL XS 15X13X8MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360932 SUP HCPCS C1713 6360932 - SPACER SPNL XS 13X12X9MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6360953 SUP HCPCS C1713 6360953 - SPACER SPNL XS 15X13X9MM PRIMTR C PEEK-OPTM CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6390206 SUP Custom 27803010 6390206 - CAGE SPNL CYL LRDTC TPR 6MM 12MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390207 SUP Custom 27803010 6390207 - CAGE SPNL CYL LRDTC TPR 7MM 12MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390208 SUP Custom 27803010 6390208 - CAGE SPNL CYL LRDTC TPR 8MM 12MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390209 SUP Custom 27803010 6390209 - CAGE SPNL CYL LRDTC TPR 9MM 12MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390210 SUP Custom 27803010 6390210 - CAGE SPNL CYL LRDTC TPR 10MM 12MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390211 SUP Custom 27803010 6390211 - CAGE SPNL CYL LRDTC TPR 11MM 12MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390212 SUP Custom 27803010 6390212 - CAGE SPNL CYL LRDTC TPR 12MM 12MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390406 SUP Custom 27803010 6390406 - CAGE SPNL CYL LRDTC TPR 6MM 14MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390407 SUP Custom 27803010 6390407 - CAGE SPNL CYL LRDTC TPR 7MM 14MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390408 SUP Custom 27803010 6390408 - CAGE SPNL CYL LRDTC TPR 8MM 14MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390409 SUP Custom 27803010 6390409 - CAGE SPNL CYL LRDTC TPR 9MM 14MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390410 SUP Custom 27803010 6390410 - CAGE SPNL CYL LRDTC TPR 10MM 14MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390411 SUP Custom 27803010 6390411 - CAGE SPNL CYL LRDTC TPR 11MM 14MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6390412 SUP Custom 27803010 6390412 - CAGE SPNL CYL LRDTC TPR 12MM 14MM AFF CLS CHMFR EDG MLT THR BOTH IP/OP "$6,988.50 " "$5,171.49" $0.00 "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,456.40" $0.00 $0.00 $0.00 $0.00 "$3,494.25" "$5,534.89" "$5,590.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6430530 SUP HCPCS C1713 6430530 - SCREW SET TI 4.75MM SPN PERC SOLERA CD HZN STRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 6440530 SUP HCPCS C1713 6440530 - SET SCREW 6440530 4.75 SOLERA PERC TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 6470314 SUP Custom 27203010 "6470314 - BRYAN CERVICAL DISC, 14MM" BOTH IP/OP "$8,850.00 " "$6,549.00" $0.00 "$7,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,844.34" $0.00 $0.00 $0.00 $0.00 "$4,425.00" "$7,009.20" "$7,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6470315 SUP Custom 27803010 6470315 - DISK SPINAL MOTION BRYAN 15MM CERV BOTH IP/OP "$8,850.00 " "$6,549.00" $0.00 "$7,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,844.34" $0.00 $0.00 $0.00 $0.00 "$4,425.00" "$7,009.20" "$7,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6474024 SUP HCPCS C1713 6474024 - PIN DISTRACTION 14MM 3.5MM REUSABLE BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 6474176 SUP Custom 27203010 6474176 - BIT DRILL SPN BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6474524 SUP Custom 27203010 6474524 - BRYAN DISC CUTTER 14MM BOTH IP/OP "$1,350.00 " $999.00 $0.00 "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,001.97" "$1,001.97" $0.00 $0.00 $281.34 $0.00 $0.00 $0.00 $0.00 $675.00 "$1,069.20" "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6533131 SUP HCPCS C1713 6533131 - END CAP SPNL 0D 30X18MM VBR EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533141 SUP HCPCS C1713 6533141 - END CAP SPNL 0D 40X18MM VBR EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533151 SUP HCPCS C1713 6533151 - CAGE SPNL 0D 50X18MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533231 SUP HCPCS C1713 6533231 - END CAP SPNL 4D 30X18MM VBR EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533241 SUP HCPCS C1713 6533241 - CAGE SPNL 4D 40X18MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533251 SUP HCPCS C1713 6533251 - END CAP SPNL 4D 50X18MM VBR EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533331 SUP HCPCS C1713 6533331 - CAGE SPNL 8D 30X18MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533341 SUP HCPCS C1713 6533341 - CAGE SPNL 8D 40X18MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533351 SUP HCPCS C1713 6533351 - CAGE SPNL 8D 50X18MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533431 SUP HCPCS C1713 6533431 - END CAP SPNL -4D 30X18MM VBR EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533441 SUP HCPCS C1713 6533441 - CAGE SPNL -4D 40X18MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6533451 SUP HCPCS C1713 6533451 - CAGE SPNL -4D 50X18MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535241 SUP HCPCS C1713 6535241 - CAGE SPNL 0D 40X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535251 SUP HCPCS C1713 6535251 - CAGE SPNL 0D 50X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535261 SUP HCPCS C1713 6535261 - CAGE SPNL 0D 60X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535341 SUP HCPCS C1713 6535341 - CAGE SPNL 4D 40X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535351 SUP HCPCS C1713 6535351 - CAGE SPNL 4D 50X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535361 SUP HCPCS C1713 6535361 - CAGE SPNL 4D 60X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535441 SUP HCPCS C1713 6535441 - CAGE SPNL 8D 40X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535451 SUP HCPCS C1713 6535451 - CAGE SPNL 8D 50X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535461 SUP HCPCS C1713 6535461 - CAGE SPNL 8D 60X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535541 SUP HCPCS C1713 6535541 - CAGE SPNL 12D 40X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535551 SUP HCPCS C1713 6535551 - CAGE SPNL 12D 50X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6535561 SUP HCPCS C1713 6535561 - CAGE SPNL 12D 60X22MM VBR ENDCP EXPANDABLE BOTH IP/OP "$3,740.00 " "$2,767.60" $0.00 "$2,992.00" "$1,683.00" "$1,683.00" $0.00 $0.00 $0.00 $779.51 "$2,775.83" "$2,775.83" $0.00 $0.00 $779.42 $0.00 "$1,843.82" "$1,843.82" $0.00 "$1,870.00" "$2,962.08" "$2,992.00" $0.00 $0.00 $585.31 $0.00 $0.00 $595.41 $0.00 $0.00 $0.00 $0.00 $0.00 6537124 SUP HCPCS C1713 6537124 - END CAP SPNL 0D RND 18MM 22MM VBR EXPANDABLE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $490.32 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 "$1,391.50" "$1,391.50" $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 6537125 SUP HCPCS C1713 6537125 - CAGE SPNL 0D RND 18MM 26MM VBR ENDCP EXPANDABLE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $490.32 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 "$1,391.50" "$1,391.50" $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 6537134 SUP HCPCS C1713 6537134 - END CAP SPNL 8D RND 18MM 22MM VBR EXPANDABLE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $490.32 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 "$1,391.50" "$1,391.50" $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 6537135 SUP HCPCS C1713 6537135 - CAGE SPNL 8D RND 18MM 26MM VBR ENDCP EXPANDABLE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $490.32 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 "$1,391.50" "$1,391.50" $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 6537225 SUP HCPCS C1713 6537225 - CAGE SPNL 0D RND 22MM 26MM VBR ENDCP EXPANDABLE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $490.32 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 "$1,391.50" "$1,391.50" $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 6537226 SUP HCPCS C1713 6537226 - CAGE SPNL 0D RND 22MM 30MM VBR ENDCP EXPANDABLE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $490.32 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 "$1,391.50" "$1,391.50" $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 6537235 SUP HCPCS C1713 6537235 - CAGE SPNL 8D RND 18MM 26MM VBR ENDCP EXPANDABLE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $490.32 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 "$1,391.50" "$1,391.50" $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 6537236 SUP HCPCS C1713 6537236 - CAGE SPNL 8D RND 22MM 30MM VBR ENDCP EXPANDABLE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $490.32 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 "$1,391.50" "$1,391.50" $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 6539001 SUP HCPCS C1713 6539001 - SCREW BN SM VBR EXPANDABLE LCK SPNE BOTH IP/OP $620.00 $458.80 $0.00 $496.00 $279.00 $279.00 $0.00 $0.00 $0.00 $129.22 $460.16 $460.16 $0.00 $0.00 $129.21 $0.00 $366.73 $366.73 $0.00 $310.00 $491.04 $496.00 $0.00 $0.00 $97.03 $0.00 $0.00 $98.70 $0.00 $0.00 $0.00 $0.00 $0.00 6539002 SUP HCPCS C1713 6539002 - SCREW BN LG VBR LCK EXPANDABLE SPNE BOTH IP/OP $620.00 $458.80 $0.00 $496.00 $279.00 $279.00 $0.00 $0.00 $0.00 $129.22 $460.16 $460.16 $0.00 $0.00 $129.21 $0.00 $366.73 $366.73 $0.00 $310.00 $491.04 $496.00 $0.00 $0.00 $97.03 $0.00 $0.00 $98.70 $0.00 $0.00 $0.00 $0.00 $0.00 6540530 SUP HCPCS C1713 6540530 - SCREW SET 5.5/6MM NS LF CD HZN SOLERAL VYGR BOTH IP/OP $912.50 $675.25 $0.00 $730.00 $410.63 $410.63 $0.00 $0.00 $0.00 $190.19 $677.26 $677.26 $0.00 $0.00 $190.17 $0.00 $539.74 $539.74 $0.00 $456.25 $722.70 $730.00 $0.00 $0.00 $142.81 $0.00 $0.00 $145.27 $0.00 $0.00 $0.00 $0.00 $0.00 6541019 SUP HCPCS C1713 6541019 - STAPLE 6541019 19MM ROSTRAL BOTH IP/OP "$2,932.13 " "$2,169.78" $0.00 "$2,345.70" "$1,319.46" "$1,319.46" $0.00 $0.00 $0.00 $611.13 "$2,176.22" "$2,176.22" $0.00 $0.00 $611.05 $0.00 "$1,445.54" "$1,445.54" $0.00 "$1,466.06" "$2,322.25" "$2,345.70" $0.00 $0.00 $458.88 $0.00 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 6541021 SUP HCPCS C1713 6541021 - STAPLE 6541021 21MM ROSTRAL BOTH IP/OP "$2,932.13 " "$2,169.78" $0.00 "$2,345.70" "$1,319.46" "$1,319.46" $0.00 $0.00 $0.00 $611.13 "$2,176.22" "$2,176.22" $0.00 $0.00 $611.05 $0.00 "$1,445.54" "$1,445.54" $0.00 "$1,466.06" "$2,322.25" "$2,345.70" $0.00 $0.00 $458.88 $0.00 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 6541023 SUP HCPCS C1713 6541023 - STAPLE 6541023 23MM ROSTRAL BOTH IP/OP "$2,932.13 " "$2,169.78" $0.00 "$2,345.70" "$1,319.46" "$1,319.46" $0.00 $0.00 $0.00 $611.13 "$2,176.22" "$2,176.22" $0.00 $0.00 $611.05 $0.00 "$1,445.54" "$1,445.54" $0.00 "$1,466.06" "$2,322.25" "$2,345.70" $0.00 $0.00 $458.88 $0.00 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 6541025 SUP HCPCS C1713 6541025 - STAPLE 6541025 25MM ROSTRAL BOTH IP/OP "$2,932.13 " "$2,169.78" $0.00 "$2,345.70" "$1,319.46" "$1,319.46" $0.00 $0.00 $0.00 $611.13 "$2,176.22" "$2,176.22" $0.00 $0.00 $611.05 $0.00 "$1,445.54" "$1,445.54" $0.00 "$1,466.06" "$2,322.25" "$2,345.70" $0.00 $0.00 $458.88 $0.00 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 6541119 SUP HCPCS C1713 6541119 - STAPLE 6541119 19MM CAUDAL BOTH IP/OP "$2,932.13 " "$2,169.78" $0.00 "$2,345.70" "$1,319.46" "$1,319.46" $0.00 $0.00 $0.00 $611.13 "$2,176.22" "$2,176.22" $0.00 $0.00 $611.05 $0.00 "$1,445.54" "$1,445.54" $0.00 "$1,466.06" "$2,322.25" "$2,345.70" $0.00 $0.00 $458.88 $0.00 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 6541121 SUP HCPCS C1713 6541121 - STAPLE 6541121 21MM CAUDAL BOTH IP/OP "$2,932.13 " "$2,169.78" $0.00 "$2,345.70" "$1,319.46" "$1,319.46" $0.00 $0.00 $0.00 $611.13 "$2,176.22" "$2,176.22" $0.00 $0.00 $611.05 $0.00 "$1,445.54" "$1,445.54" $0.00 "$1,466.06" "$2,322.25" "$2,345.70" $0.00 $0.00 $458.88 $0.00 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 6541123 SUP HCPCS C1713 6541123 - STAPLE 6541123 23MM CAUDAL BOTH IP/OP "$2,932.13 " "$2,169.78" $0.00 "$2,345.70" "$1,319.46" "$1,319.46" $0.00 $0.00 $0.00 $611.13 "$2,176.22" "$2,176.22" $0.00 $0.00 $611.05 $0.00 "$1,445.54" "$1,445.54" $0.00 "$1,466.06" "$2,322.25" "$2,345.70" $0.00 $0.00 $458.88 $0.00 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 6541125 SUP HCPCS C1713 6541125 - STAPLE 6541125 25MM CAUDAL BOTH IP/OP "$2,932.13 " "$2,169.78" $0.00 "$2,345.70" "$1,319.46" "$1,319.46" $0.00 $0.00 $0.00 $611.13 "$2,176.22" "$2,176.22" $0.00 $0.00 $611.05 $0.00 "$1,445.54" "$1,445.54" $0.00 "$1,466.06" "$2,322.25" "$2,345.70" $0.00 $0.00 $458.88 $0.00 $0.00 $466.79 $0.00 $0.00 $0.00 $0.00 $0.00 6541213 SUP HCPCS C1713 6541213 - STAPLE 6541213 SINGLE 13MM BOTH IP/OP "$1,465.50 " "$1,084.47" $0.00 "$1,172.40" $659.48 $659.48 $0.00 $0.00 $0.00 $305.45 "$1,087.69" "$1,087.69" $0.00 $0.00 $305.41 $0.00 $866.84 $866.84 $0.00 $732.75 "$1,160.68" "$1,172.40" $0.00 $0.00 $229.35 $0.00 $0.00 $233.31 $0.00 $0.00 $0.00 $0.00 $0.00 6541215 SUP HCPCS C1713 6541215 - STAPLE 6541215 SINGLE 15MM BOTH IP/OP "$1,465.50 " "$1,084.47" $0.00 "$1,172.40" $659.48 $659.48 $0.00 $0.00 $0.00 $305.45 "$1,087.69" "$1,087.69" $0.00 $0.00 $305.41 $0.00 $866.84 $866.84 $0.00 $732.75 "$1,160.68" "$1,172.40" $0.00 $0.00 $229.35 $0.00 $0.00 $233.31 $0.00 $0.00 $0.00 $0.00 $0.00 6541217 SUP HCPCS C1713 6541217 - STAPLE 6541217 SINGLE 17MM BOTH IP/OP "$1,465.50 " "$1,084.47" $0.00 "$1,172.40" $659.48 $659.48 $0.00 $0.00 $0.00 $305.45 "$1,087.69" "$1,087.69" $0.00 $0.00 $305.41 $0.00 $866.84 $866.84 $0.00 $732.75 "$1,160.68" "$1,172.40" $0.00 $0.00 $229.35 $0.00 $0.00 $233.31 $0.00 $0.00 $0.00 $0.00 $0.00 6543420 SUP HCPCS C1713 6543420 - SCREW 6543420 4.5MM FAS FOR 5.5 20MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543425 SUP HCPCS C1713 6543425 - SCREW 6543425 4.5MM FAS FOR 5.5 25MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543430 SUP HCPCS C1713 6543430 - SCREW 6543430 4.5MM FAS FOR 5.5 30MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543435 SUP HCPCS C1713 6543435 - SCREW 6543435 4.5MM FAS FOR 5.5 35MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 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FAS FOR 5.5 25MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543630 SUP HCPCS C1713 6543630 - SCREW 6543630 6.5MM FAS FOR 5.5 30MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543635 SUP HCPCS C1713 6543635 - SCREW 6543635 6.5MM FAS FOR 5.5 35MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543640 SUP HCPCS C1713 6543640 - SCREW 6543640 6.5MM FAS FOR 5.5 40MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543645 SUP HCPCS C1713 6543645 - SCREW 6543645 6.5MM FAS FOR 5.5 45MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543650 SUP HCPCS C1713 6543650 - SCREW 6543650 6.5MM FAS FOR 5.5 50MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 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FAS FOR 5.5 20MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543825 SUP HCPCS C1713 6543825 - SCREW 6543825 8.5MM FAS FOR 5.5 25MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543830 SUP HCPCS C1713 6543830 - SCREW 6543830 8.5MM FAS FOR 5.5 30MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543835 SUP HCPCS C1713 6543835 - SCREW 6543835 8.5MM FAS FOR 5.5 35MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543840 SUP HCPCS C1713 6543840 - SCREW 6543840 8.5MM FAS FOR 5.5 40MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543845 SUP HCPCS C1713 6543845 - SCREW 6543845 8.5MM FAS FOR 5.5 45MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543850 SUP HCPCS C1713 6543850 - SCREW 6543850 8.5MM FAS FOR 5.5 50MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543855 SUP HCPCS C1713 6543855 - SCREW 6543855 8.5MM FAS FOR 5.5 55MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6543860 SUP HCPCS C1713 6543860 - SCREW 6543860 8.5MM FAS FOR 5.5 60MM LG BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 6591011 SUP HCPCS C1713 6591011 - CAGE SPNL 18MM 20-22MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591012 SUP HCPCS C1713 6591012 - CAGE SPNL 18MM 21-25MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591013 SUP HCPCS C1713 6591013 - CAGE SPNL 18MM 24-31MM VBR COR XPD BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591014 SUP HCPCS C1713 6591014 - CAGE SPNL 18MM 28-40MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591015 SUP HCPCS C1713 6591015 - CAGE SPNL 18MM 35-52MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591016 SUP HCPCS C1713 6591016 - CAGE SPNL 18MM 41-65MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591017 SUP HCPCS C1713 6591017 - CAGE SPNL 18MM 47-75MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591021 SUP HCPCS C1713 6591021 - CAGE SPNL 22MM 20-22MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591022 SUP HCPCS C1713 6591022 - CAGE SPNL 22MM 21-25MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591023 SUP HCPCS C1713 6591023 - CAGE SPNL 22MM 24-31MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591024 SUP HCPCS C1713 6591024 - CAGE SPNL 22MM 28-40MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591025 SUP HCPCS C1713 6591025 - CAGE SPNL 22MM 35-52MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591026 SUP HCPCS C1713 6591026 - CAGE SPNL 22MM 41-65MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6591027 SUP HCPCS C1713 6591027 - CAGE SPNL 22MM 47-75MM VBR EXPANDABLE BOTH IP/OP "$11,245.00 " "$8,321.30" $0.00 "$8,996.00" "$5,060.25" "$5,060.25" $0.00 $0.00 $0.00 "$2,343.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,343.46" $0.00 "$5,543.79" "$5,543.79" $0.00 "$5,622.50" "$8,906.04" "$8,996.00" $0.00 $0.00 "$1,759.84" $0.00 $0.00 "$1,790.20" $0.00 $0.00 $0.00 $0.00 $0.00 6605359 SUP Custom 27203010 CALIBRATOR FLW CYMTR FLW-CHK FLUOROSPHERES 10ML BOTH IP/OP $458.68 $339.42 $0.00 $366.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.34 $363.27 $366.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6607007 SUP Custom 27203010 CALIBRATOR FLW CYMTR FLW-SET FLUOROSPHERES 10ML BOTH IP/OP $458.68 $339.42 $0.00 $366.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.34 $363.27 $366.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6607013 SUP Custom 27203010 ANTIBODY CD45 CD4 CD8 CD3 CLONE B3821F4A SFCI12T4D11 SFCI21 BOTH IP/OP $722.10 $534.35 $0.00 $577.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.05 $571.90 $577.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6607023 SUP Custom 27203010 CALIBRATOR FLW CYMTR CYTO-COMP HMN LYMPH LYPH 250 TST BOTH IP/OP $285.35 $211.16 $0.00 $228.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.68 $226.00 $228.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6607077 SUP Custom 27203010 CONTROL FLW CYMTR IMTRL POS 3ML 60 TST BOTH IP/OP $403.73 $298.76 $0.00 $322.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.86 $319.75 $322.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6607098 SUP Custom 27203010 CONTROL FLW CYMTR IMTRL LOW 3ML 60 TST BOTH IP/OP $403.73 $298.76 $0.00 $322.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.86 $319.75 $322.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6608125 SUP HCPCS C1713 6608125 - CAGE SPNL 8D LG CNTR 25X11X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6608925 SUP HCPCS C1713 6608925 - CAGE SPNL 8D LG CNTR 25X9X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6609125 SUP HCPCS C1713 6609125 - CAGE SPNL LG 25X11X9MM CNTR PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6609925 SUP HCPCS C1713 6609925 - CAGE SPNL 8 25X9X9MM PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6610125 SUP HCPCS C1713 6610125 - CAGE SPNL 8D LG CNTR 25X11X10MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6610925 SUP HCPCS C1713 6610925 - CAGE SPNL 8D LG CNTR 25X10X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6611125 SUP HCPCS C1713 6611125 - SPACER SPNL LG 25X11X11MM CNTR PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6611925 SUP Custom 27803010 6611925 - CAGE SPNL 8D LG CNTR 25X9X11MM NS LF CRNT PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6612125 SUP HCPCS C1713 6612125 - CAGE SPNL 8D LG CNTR 25X12X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6612925 SUP HCPCS C1713 6612925 - CAGE SPNL 8D LG CNTR 25X12X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6613125 SUP HCPCS C1713 6613125 - SPACER SPNL 25X11X13MM PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6613925 SUP HCPCS C1713 6613925 - CAGE SPNL 8D LG CNTR 25X9X13MM NS LF CRNT PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6614125 SUP HCPCS C1713 6614125 - CAGE SPNL 8D LG CNTR 25X14X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6614925 SUP HCPCS C1713 6614925 - CAGE SPNL 8D LG CNTR 25X14X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6615125 SUP HCPCS C1713 6615125 - SPACER SPNL LG 25X11X15MM CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6615925 SUP HCPCS C1713 6615925 - CAGE SPNL 8D LG 25X9X15MM PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6616125 SUP HCPCS C1713 6616125 - CAGE SPNL LG 25X11X16MM PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6616925 SUP HCPCS C1713 6616925 - CAGE SPNL 8D LG 25X9X16MM PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6660725 SUP HCPCS C1713 6660725 - SPACER SPNL 6D 25X10X7MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660730 SUP HCPCS C1713 6660730 - SPACER SPNL 6D 30X10X7MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660736 SUP HCPCS C1713 6660736 - SPACER SPNL 6D 36X10X7MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660825 SUP HCPCS C1713 6660825 - SPACER SPNL 6D 25X10X8MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660830 SUP HCPCS C1713 6660830 - SPACER SPNL 6D 30X10X8MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660836 SUP HCPCS C1713 6660836 - SPACER SPNL 6D 36X10X8MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660925 SUP HCPCS C1713 6660925 - SPACER SPNL 6D 25X10X9MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660930 SUP HCPCS C1713 6660930 - SPACER SPNL 6D 30X10X9MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6660936 SUP HCPCS C1713 6660936 - SPACER SPNL 6D 36X10X9MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661025 SUP HCPCS C1713 6661025 - SPACER SPNL 6D 25X10X10MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661030 SUP HCPCS C1713 6661030 - SPACER SPNL 6D 30X10X10MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661036 SUP HCPCS C1713 6661036 - SPACER SPNL 6D 36X10X10MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661125 SUP HCPCS C1713 6661125 - SPACER SPNL 6D 25X10X11MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661130 SUP HCPCS C1713 6661130 - SPACER SPNL 6D 30X10X11MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661136 SUP HCPCS C1713 6661136 - SPACER SPNL 6D 36X10X11MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661225 SUP HCPCS C1713 6661225 - SPACER SPNL 6D 25X10X12MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661230 SUP HCPCS C1713 6661230 - SPACER SPNL 6D 30X10X12MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661236 SUP HCPCS C1713 6661236 - SPACER SPNL 6D 36X10X12MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661325 SUP HCPCS C1713 6661325 - SPACER SPNL 6D 25X10X13MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661330 SUP HCPCS C1713 6661330 - SPACER SPNL 6D 30X10X13MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661336 SUP HCPCS C1713 6661336 - SPACER SPNL 6D 36X10X13MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661425 SUP HCPCS C1713 6661425 - SPACER SPNL 6D 25X10X14MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661430 SUP HCPCS C1713 6661430 - SPACER SPNL 6D 30X10X14MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661436 SUP HCPCS C1713 6661436 - SPACER SPNL 6D 36X10X14MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661525 SUP HCPCS C1713 6661525 - SPACER SPNL 6D 25X10X15MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661530 SUP HCPCS C1713 6661530 - SPACER SPNL 6D 30X10X15MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661536 SUP HCPCS C1713 6661536 - SPACER SPNL 6D 36X10X15MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661625 SUP HCPCS C1713 6661625 - SPACER SPNL 6D 25X10X16MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661630 SUP HCPCS C1713 6661630 - SPACER SPNL 6D 30X10X16MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6661636 SUP HCPCS C1713 6661636 - SPACER SPNL 6D 36X10X16MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670725 SUP HCPCS C1713 6670725 - SPACER SPNL W 25X10X7MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670730 SUP HCPCS C1713 6670730 - SPACER SPNL W 30X10X7MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670736 SUP HCPCS C1713 6670736 - SPACER SPNL W 36X10X7MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670825 SUP HCPCS C1713 6670825 - SPACER SPNL W 25X10X8MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670830 SUP HCPCS C1713 6670830 - SPACER SPNL W 30X10X8MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670836 SUP HCPCS C1713 6670836 - SPACER SPNL W 36X10X8MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670925 SUP HCPCS C1713 6670925 - SPACER SPNL W 25X10X9MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670930 SUP HCPCS C1713 6670930 - SPACER SPNL W 30X10X9MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6670936 SUP HCPCS C1713 6670936 - SPACER SPNL W 36X10X9MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671025 SUP HCPCS C1713 6671025 - SPACER SPNL W 25X10X10MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671030 SUP HCPCS C1713 6671030 - SPACER SPNL W 30X10X10MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671036 SUP HCPCS C1713 6671036 - SPACER SPNL W 36X10X10MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671125 SUP HCPCS C1713 6671125 - SPACER SPNL W 25X10X11MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671130 SUP HCPCS C1713 6671130 - SPACER SPNL W 30X10X11MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671136 SUP HCPCS C1713 6671136 - SPACER SPNL W 36X10X11MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671225 SUP HCPCS C1713 6671225 - SPACER SPNL W 25X10X12MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671230 SUP HCPCS C1713 6671230 - SPACER SPNL W 30X10X12MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671236 SUP HCPCS C1713 6671236 - SPACER SPNL W 36X10X12MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671325 SUP HCPCS C1713 6671325 - SPACER SPNL W 25X10X13MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671330 SUP HCPCS C1713 6671330 - SPACER SPNL W 30X10X13MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671336 SUP HCPCS C1713 6671336 - SPACER SPNL W 36X10X13MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671425 SUP HCPCS C1713 6671425 - SPACER SPNL W 25X10X14MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671430 SUP HCPCS C1713 6671430 - SPACER SPNL W 30X10X14MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671436 SUP HCPCS C1713 6671436 - SPACER SPNL W 36X10X14MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671525 SUP HCPCS C1713 6671525 - SPACER SPNL W 25X10X15MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671530 SUP HCPCS C1713 6671530 - SPACER SPNL W 30X10X15MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671536 SUP HCPCS C1713 6671536 - SPACER SPNL W 36X10X15MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671625 SUP HCPCS C1713 6671625 - SPACER SPNL W 25X10X16MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671630 SUP HCPCS C1713 6671630 - SPACER SPNL W 30X10X16MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6671636 SUP HCPCS C1713 6671636 - SPACER SPNL W 36X10X16MM STRL CRSNT TI BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 6708120 SUP HCPCS C1713 6708120 - CAGE SPNL 4D LG IMPCT 20X11X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708126 SUP Custom 27803010 6708126 - CAGE SPNL 4D LG IMPCT 26X11X8MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6708132 SUP HCPCS C1713 6708132 - CAGE SPNL 4D LG IMPCT 32X11X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708520 SUP HCPCS C1713 6708520 - SPACER SPNL 20X9X8MM CRNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708820 SUP HCPCS C1713 6708820 - SPACER SPNL 8D LG 20X9X8MM CRNT THORLMBR INTRBD FS TPR PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708926 SUP Custom 27803010 6708926 - CAGE SPNL 4D LG IMPCT 26X9X8MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6708932 SUP HCPCS C1713 6708932 - CAGE SPNL 4D LG IMPCT 32X9X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6709120 SUP HCPCS C1713 6709120 - CAGE SPNL 4D LG IMPCT 20X11X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6709126 SUP HCPCS C1713 6709126 - CAGE SPNL 4D LG IMPCT 26X11X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6709132 SUP HCPCS C1713 6709132 - CAGE SPNL 4D LG IMPCT 32X11X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6709920 SUP HCPCS C1713 6709920 - CAGE SPNL 4D LG IMPCT 20X9X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6709926 SUP Custom 27803010 6709926 - CAGE SPNL 4D LG IMPCT 26X9X9MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6709932 SUP Custom 27803010 6709932 - CAGE SPNL 4D LG IMPCT 32X9X9MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6710120 SUP HCPCS C1713 6710120 - CAGE SPNL 4D LG IMPCT 20X11X10MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710126 SUP HCPCS C1713 6710126 - CAGE SPNL 4D LG IMPCT 26X11X10MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710132 SUP HCPCS C1713 6710132 - CAGE SPNL 4D LG IMPCT 32X11X10MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710520 SUP HCPCS C1713 6710520 - SPACER SPNL 20X10X9MM PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710820 SUP HCPCS C1713 6710820 - SPACER SPNL 20X10X8MM CRNT THORLMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710920 SUP HCPCS C1713 6710920 - CAGE SPNL 20X10X9MM CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710926 SUP Custom 27803010 6710926 - CAGE SPNL 4D LG IMPCT 26X9X10MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6710932 SUP HCPCS C1713 6710932 - CAGE SPNL 4D LG IMPCT 32X9X10MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711120 SUP HCPCS C1713 6711120 - CAGE SPNL 4D LG IMPCT 20X11X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711126 SUP HCPCS C1713 6711126 - CAGE SPNL 4D LG IMPCT 26X11X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711132 SUP HCPCS C1713 6711132 - CAGE SPNL 4D LG IMPCT 32X11X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711920 SUP HCPCS C1713 6711920 - CAGE SPNL 4D LG IMPCT 20X11X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711926 SUP HCPCS C1713 6711926 - CAGE SPNL 4D LG IMPCT 26X11X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711932 SUP HCPCS C1713 6711932 - CAGE SPNL 4D LG IMPCT 32X11X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712120 SUP HCPCS C1713 6712120 - CAGE SPNL 4D LG IMPCT 20X12X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712126 SUP HCPCS C1713 6712126 - CAGE SPNL 4D LG IMPCT 26X12X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712132 SUP HCPCS C1713 6712132 - CAGE SPNL 4D LG IMPCT 32X12X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712520 SUP HCPCS C1713 6712520 - SPACER SPNL 12MM 15MM INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712820 SUP HCPCS C1713 6712820 - CAGE SPNL 8D LG 20X9X12MM CRNT TPR PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712920 SUP HCPCS C1713 6712920 - CAGE SPNL 4D LG IMPCT 20X12X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712926 SUP HCPCS C1713 6712926 - CAGE SPNL 4D LG IMPCT 26X12X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712932 SUP HCPCS C1713 6712932 - CAGE SPNL 4D LG IMPCT 32X12X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713120 SUP HCPCS C1713 6713120 - CAGE SPNL 4D LG IMPCT 20X13X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713126 SUP HCPCS C1713 6713126 - CAGE SPNL 4D LG IMPCT 26X13X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713132 SUP HCPCS C1713 6713132 - CAGE SPNL 4D LG IMPCT 32X13X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713920 SUP HCPCS C1713 6713920 - CAGE SPNL 4D LG IMPCT 20X13X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713926 SUP HCPCS C1713 6713926 - CAGE SPNL 4D LG IMPCT 26X13X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713932 SUP HCPCS C1713 6713932 - CAGE SPNL 4D LG IMPCT 32X13X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714120 SUP HCPCS C1713 6714120 - CAGE SPNL 4D LG IMPCT 20X14X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714126 SUP HCPCS C1713 6714126 - CAGE SPNL 4D LG IMPCT 26X14X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714132 SUP HCPCS C1713 6714132 - CAGE SPNL 4D LG IMPCT 32X14X11MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714820 SUP HCPCS C1713 6714820 - SPACER SPNL 20X14X9MM INTRBD FS TPR PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714920 SUP HCPCS C1713 6714920 - CAGE SPNL 4D LG IMPCT 20X14X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714926 SUP HCPCS C1713 6714926 - CAGE SPNL 4D LG IMPCT 26X14X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714932 SUP HCPCS C1713 6714932 - CAGE SPNL 4D LG IMPCT 32X14X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6733206 SUP HCPCS C1713 6733206 - CAGE SPNL 10D SM 16X19X6MM NS LF CRNT ACR RADOPQ BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 6733209 SUP HCPCS C1713 6733209 - CAGE SPNL 10D SM 16X19X9MM NS LF CRNT ACR RADOPQ BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 6736207 SUP HCPCS C1713 6736207 - CAGE SPNL 10D 7X17X14MM NS CRNT ACR TA SM INTLK RADOPQ BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 6790151 SUP Custom 27203010 6790151 - BIT DRL SM 12-16MM INTLK DISP B BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $0.00 $0.00 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6790152 SUP Custom 27203010 6790152 - TAP SRG 12MM TEMP SPNE DISP BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $0.00 $0.00 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6790225 SUP HCPCS C1713 6790225 - CAGE SPNL 5MM CRNT INTLK CRV BOTH IP/OP "$4,832.50 " "$3,576.05" $0.00 "$3,866.00" "$2,174.63" "$2,174.63" $0.00 $0.00 $0.00 "$1,007.21" "$3,586.68" "$3,586.68" $0.00 $0.00 "$1,007.09" $0.00 "$2,382.42" "$2,382.42" $0.00 "$2,416.25" "$3,827.34" "$3,866.00" $0.00 $0.00 $756.29 $0.00 $0.00 $769.33 $0.00 $0.00 $0.00 $0.00 $0.00 6790228 SUP HCPCS C1713 6790228 - CAGE SPNL 7D SM 17X14X8MM NS LF CRNT INTLK CRV BOTH IP/OP "$4,832.50 " "$3,576.05" $0.00 "$3,866.00" "$2,174.63" "$2,174.63" $0.00 $0.00 $0.00 "$1,007.21" "$3,586.68" "$3,586.68" $0.00 $0.00 "$1,007.09" $0.00 "$2,382.42" "$2,382.42" $0.00 "$2,416.25" "$3,827.34" "$3,866.00" $0.00 $0.00 $756.29 $0.00 $0.00 $769.33 $0.00 $0.00 $0.00 $0.00 $0.00 6790229 SUP HCPCS C1713 6790229 - CAGE SPNL 9MM CRNT INTLK CRV BOTH IP/OP "$4,832.50 " "$3,576.05" $0.00 "$3,866.00" "$2,174.63" "$2,174.63" $0.00 $0.00 $0.00 "$1,007.21" "$3,586.68" "$3,586.68" $0.00 $0.00 "$1,007.09" $0.00 "$2,382.42" "$2,382.42" $0.00 "$2,416.25" "$3,827.34" "$3,866.00" $0.00 $0.00 $756.29 $0.00 $0.00 $769.33 $0.00 $0.00 $0.00 $0.00 $0.00 6790230 SUP HCPCS C1713 6790230 - CAGE SPNL 10MM CRNT INTLK CRV BOTH IP/OP "$4,832.50 " "$3,576.05" $0.00 "$3,866.00" "$2,174.63" "$2,174.63" $0.00 $0.00 $0.00 "$1,007.21" "$3,586.68" "$3,586.68" $0.00 $0.00 "$1,007.09" $0.00 "$2,382.42" "$2,382.42" $0.00 "$2,416.25" "$3,827.34" "$3,866.00" $0.00 $0.00 $756.29 $0.00 $0.00 $769.33 $0.00 $0.00 $0.00 $0.00 $0.00 6790231 SUP HCPCS C1713 6790231 - CAGE SPNL 11MM CRNT INTLK CRV BOTH IP/OP "$4,832.50 " "$3,576.05" $0.00 "$3,866.00" "$2,174.63" "$2,174.63" $0.00 $0.00 $0.00 "$1,007.21" "$3,586.68" "$3,586.68" $0.00 $0.00 "$1,007.09" $0.00 "$2,382.42" "$2,382.42" $0.00 "$2,416.25" "$3,827.34" "$3,866.00" $0.00 $0.00 $756.29 $0.00 $0.00 $769.33 $0.00 $0.00 $0.00 $0.00 $0.00 6790232 SUP HCPCS C1713 6790232 - CAGE SPNL 12MM CRNT INTLK CRV BOTH IP/OP "$4,832.50 " "$3,576.05" $0.00 "$3,866.00" "$2,174.63" "$2,174.63" $0.00 $0.00 $0.00 "$1,007.21" "$3,586.68" "$3,586.68" $0.00 $0.00 "$1,007.09" $0.00 "$2,382.42" "$2,382.42" $0.00 "$2,416.25" "$3,827.34" "$3,866.00" $0.00 $0.00 $756.29 $0.00 $0.00 $769.33 $0.00 $0.00 $0.00 $0.00 $0.00 6791512 SUP HCPCS C1713 6791512 - SCREW BN 4MM 12MM CRNT SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791513 SUP HCPCS C1713 6791513 - SCREW BN 4MM 13MM CRNT SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791514 SUP HCPCS C1713 6791514 - SCREW BN 4MM 14MM CRNT SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791515 SUP HCPCS C1713 6791515 - SCREW BN 4MM 15MM CRNT SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791516 SUP HCPCS C1713 6791516 - SCREW BN 4MM 16MM CRNT SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791612 SUP HCPCS C1713 6791612 - SCREW BN 4.5MM 12MM CRNT SM INTLK SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791613 SUP HCPCS C1713 6791613 - SCREW BN 4.5MM 13MM CRNT SM INTLK SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791614 SUP HCPCS C1713 6791614 - SCREW BN 4.5MM 14MM CRNT SM INTLK SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791615 SUP HCPCS C1713 6791615 - SCREW BN 4.5MM 15MM CRNT SM INTLK SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791616 SUP HCPCS C1713 6791616 - SCREW BN 4.5MM 16MM CRNT SM INTLK SLF DRL SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791712 SUP HCPCS C1713 6791712 - SCREW BN 4MM 12MM SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791713 SUP HCPCS C1713 6791713 - SCREW BN 4MM 13MM RSC SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791714 SUP HCPCS C1713 6791714 - SCREW BN 4MM 14MM RSC SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791715 SUP HCPCS C1713 6791715 - SCREW BN 4MM 15MM SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791716 SUP HCPCS C1713 6791716 - SCREW BN 4MM 16MM SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791812 SUP HCPCS C1713 6791812 - SCREW BN 4.5MM 12MM RSC SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791813 SUP HCPCS C1713 6791813 - SCREW BN 4.5MM 13MM RSC SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791814 SUP HCPCS C1713 6791814 - SCREW BN 4.5MM 14MM RSC SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6791816 SUP HCPCS C1713 6791816 - SCREW BN 4.5MM 16MM RSC SPNE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 6805115 SUP HCPCS C1713 6805115 - CAGE SPNL SM 14X11X5MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6805714 SUP HCPCS C1713 6805714 - CAGE SPNL 5D SM LRDTC 14X11X5MM NS LF CRNT RDLCNT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6805815 SUP HCPCS C1713 6805815 - CAGE SPNL SM LRDTC + 15X13X5MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6806115 SUP HCPCS C1713 6806115 - CAGE SPNL SM 14X11X6MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6806714 SUP HCPCS C1713 6806714 - CAGE SPNL 5D SM LRDTC 14X11X6MM NS LF CRNT RDLCNT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6806815 SUP Custom 27803010 6806815 - CAGE SPNL SM LRDTC + 15X13X6MM NS LF CRNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6807115 SUP HCPCS C1713 6807115 - CAGE SPNL SM 14X11X7MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6807714 SUP HCPCS C1713 6807714 - CAGE SPNL 5D SM LRDTC 14X11X7MM NS LF CRNT RDLCNT PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6807815 SUP HCPCS C1713 6807815 - CAGE SPNL 5D SM LRDTC + 15X13X7MM NS LF CRNT RDLCNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6808115 SUP HCPCS C1713 6808115 - CAGE SPNL SM 14X11X8MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6808125 SUP HCPCS C1713 6808125 - SPACER SPNL 25X11X8MM CRNT THORLMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6808130 SUP HCPCS C1713 6808130 - RESTRICTOR CMNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6808240 SUP HCPCS C1713 6808240 - SPACER SPNL XL W 40X22X8MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6808340 SUP HCPCS C1713 6808340 - SPACER SPNL XL 10 40X22X8MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6808815 SUP Custom 27803010 6808815 - CAGE SPNL SM LRDTC + 15X13X8MM NS LF CRNT PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6808925 SUP HCPCS C1713 6808925 - SPACER SPNL 25X9X8MM INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6808930 SUP HCPCS C1713 6808930 - SPACER SPNL 30X9X8MM INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6809115 SUP HCPCS C1713 6809115 - CAGE SPNL SM 14X11X9MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6809714 SUP HCPCS C1713 6809714 - CAGE SPNL 5D SM LRDTC 14X11X9MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6809925 SUP HCPCS C1713 6809925 - SPACER SPNL 25X9X9MM STRL CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6810115 SUP HCPCS C1713 6810115 - CAGE SPNL SM 14X11X10MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6810125 SUP HCPCS C1713 6810125 - SPACER SPNL 25X11X10MM STRL CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6810130 SUP HCPCS C1713 6810130 - SPACER SPNL 30INX11INX10MM STRL CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6810240 SUP HCPCS C1713 6810240 - SPACER SPNL XL W 40X22X10MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6810340 SUP HCPCS C1713 6810340 - SPACER SPNL 10D XL W LRDTC 40X22X10MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6810714 SUP HCPCS C1713 6810714 - CAGE SPNL 5D SM LRDTC 14X11X10MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6810815 SUP HCPCS C1713 6810815 - CAGE SPNL SM LRDTC + 15X13X10MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6810925 SUP HCPCS C1713 6810925 - SPACER SPNL NAR 25X10X9MM INTRBD FS PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6810930 SUP HCPCS C1713 6810930 - SPACER SPNL NAR 30X10X9MM INTRBD FS PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6811115 SUP HCPCS C1713 6811115 - CAGE SPNL SM 14X11X11MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6811714 SUP HCPCS C1713 6811714 - CAGE SPNL 5D SM LRDTC 14X11X11MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6811815 SUP HCPCS C1713 6811815 - CAGE SPNL SM LRDTC + 15X13X11MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6811925 SUP HCPCS C1713 6811925 - SPACER SPNL 25X11X9MM STRL CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6812115 SUP HCPCS C1713 6812115 - CAGE SPNL SM 14X11X11MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6812125 SUP HCPCS C1713 6812125 - SPACER SPNL LG 25X12X11MM CRNT THORLMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6812130 SUP HCPCS C1713 6812130 - CAGE SPNL LG 30X12X10MM CRNT THORLMBR INTRBD FS RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6812240 SUP HCPCS C1713 6812240 - SPACER SPNL XL W 40X22X12MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6812340 SUP HCPCS C1713 6812340 - SPACER SPNL 10 XL W LRDTC 40X22X12MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6812714 SUP HCPCS C1713 6812714 - CAGE SPNL 5D SM LRDTC 14X11X11MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6812815 SUP HCPCS C1713 6812815 - CAGE SPNL SM LRDTC + 15X13X10MM NS LF CRNT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6812925 SUP HCPCS C1713 6812925 - SPACER SPNL 25X12X9MM CRNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6812930 SUP HCPCS C1713 6812930 - SPACER SPNL 30X12X9MM STRL CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6813815 SUP HCPCS C1713 6813815 - SPACER SPNL SM 15X13X13MM LOPRFL PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6813925 SUP HCPCS C1713 6813925 - SPACER SPNL LG NAR 25X13X9MM CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6814125 SUP HCPCS C1713 6814125 - SPACER SPNL LG 25X14X11MM CRNT THORLMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6814130 SUP HCPCS C1713 6814130 - SPACER SPNL LG W 14X11X30MM CRNT LMBR INTRBD FS RDLCNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6814240 SUP HCPCS C1713 6814240 - SPACER SPNL XL W 40X22X14MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6814340 SUP HCPCS C1713 6814340 - SPACER SPNL 10D XL W LRDTC 40X22X14MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6814815 SUP HCPCS C1713 6814815 - SPACER SPNL SM 15X14X13MM LOPRFL PEEK-OPTM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6814925 SUP HCPCS C1713 6814925 - SPACER SPNL 25X14X9MM CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6814930 SUP HCPCS C1713 6814930 - CAGE SPNL LG NAR 30X9X14MM CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6816240 SUP HCPCS C1713 6816240 - SPACER SPNL XL W 40X22X16MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6816340 SUP HCPCS C1713 6816340 - SPACER SPNL 10D XL W LRDTC 40X22X16MM PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6850810 SUP HCPCS C1713 6850810 - SPACER SPNL GRN CRNT LMBR OBLQ BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6850811 SUP HCPCS C1713 6850811 - CAGE SPNL 5D LG 30X10X8MM CRNT OBLQ PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6850813 SUP HCPCS C1713 6850813 - CAGE SPNL LG 40X10X8MM GRN OBLQ PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6851012 SUP HCPCS C1713 6851012 - CAGE SPNL 5D LG 35X10X10MM CRNT OBLQ PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6851013 SUP HCPCS C1713 6851013 - CAGE SPNL 5D LG 40X10X10MM CRNT OBLQ PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6851211 SUP HCPCS C1713 6851211 - CAGE SPNL 30X12X10MM CRNT PEEK LRDTC 5 BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6851212 SUP HCPCS C1713 6851212 - SPACER SPNL 5D LG 35X12X10MM CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6851213 SUP HCPCS C1713 6851213 - CAGE SPNL 5D LG 40X10X12MM CRNT OBLQ PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6851411 SUP HCPCS C1713 6851411 - SPACER SPNL 5D LG 30X14X10MM CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6851412 SUP HCPCS C1713 6851412 - CAGE SPNL 5D LG OBLQ 35X14X10MM CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6851413 SUP Custom 27804086 6851413 - GRAFT BN LG CRNT PEEK SPNE 5DE BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6860010 SUP HCPCS C1713 6860010 - SCREW BN 4MM 10MM PRMR ST TI CANC ANT CSPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860011 SUP HCPCS C1713 6860011 - SCREW BN 4MM 11MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860012 SUP HCPCS C1713 6860012 - SCREW BN 4MM 12MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860013 SUP HCPCS C1713 6860013 - SCREW BN 4MM 13MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860014 SUP HCPCS C1713 6860014 - SCREW BN 4MM 14MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860015 SUP HCPCS C1713 6860015 - SCREW BN 4MM 15MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860016 SUP HCPCS C1713 6860016 - SCREW BN 4MM 16MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860017 SUP HCPCS C1713 6860017 - SCREW BN 4MM 17MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860018 SUP HCPCS C1713 6860018 - SCREW BN 4MM 18MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860019 SUP HCPCS C1713 6860019 - SCREW BN 4MM 19MM STRL PRMR ST TI CANC ANT CSPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860020 SUP HCPCS C1713 6860020 - SCREW BN 4MM 20MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860053 SUP HCPCS C1713 6860053 - SCREW BN 4.5MM 13MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860055 SUP HCPCS C1713 6860055 - SCREW BN 4.5MM 15MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860057 SUP HCPCS C1713 6860057 - SCREW BN 4.5MM 17MM NS PRMR VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 6860123 SUP HCPCS C1713 6860123 - PLATE 6860123 23 MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6860125 SUP HCPCS C1713 6860125 - PLATE 6860125 25 MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6860127 SUP HCPCS C1713 6860127 - PLATE 6860127 27.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6860130 SUP HCPCS C1713 6860130 - PLATE 6860130 30 MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6860132 SUP HCPCS C1713 6860132 - PLATE 6860132 32.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6860135 SUP HCPCS C1713 6860135 - PLATE 6860135 35 MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6860137 SUP HCPCS C1713 6860137 - PLATE 6860137 37.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6860140 SUP HCPCS C1713 6860140 - PLATE 6860140 40 MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6860142 SUP HCPCS C1713 6860142 - PLATE 6860142 42.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6860145 SUP HCPCS C1713 6860145 - PLATE 6860145 45 MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6860147 SUP HCPCS C1713 6860147 - PLATE 6860147 47.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6860150 SUP HCPCS C1713 6860150 - PLATE 6860150 50 MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6860152 SUP HCPCS C1713 6860152 - PLATE 6860152 52.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6860155 SUP HCPCS C1713 6860155 - PLATE 6860155 55 MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6860157 SUP HCPCS C1713 6860157 - PLATE 6860157 57.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6860160 SUP HCPCS C1713 6860160 - PLATE 6860160 60 MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6860162 SUP HCPCS C1713 6860162 - PLATE 6860162 62.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6860165 SUP HCPCS C1713 6860165 - PLATE 6860165 65 MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6860167 SUP HCPCS C1713 6860167 - PLATE 6860167 67.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6860170 SUP HCPCS C1713 6860170 - PLATE 6860170 70 MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6860172 SUP HCPCS C1713 6860172 - PLATE 6860172 72.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6860175 SUP HCPCS C1713 6860175 - PLATE 6860175 75 MM ANT CERV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6860177 SUP HCPCS C1713 6860177 - PLATE 6860177 77 5MM ANT CERV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6860180 SUP HCPCS C1713 6860180 - PLATE 6860180 80 MM ANT CERV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6860182 SUP HCPCS C1713 6860182 - PLATE 6860182 82 5MM ANT CERV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6860185 SUP HCPCS C1713 6860185 - PLATE 6860185 85 MM ANT CERV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6860187 SUP HCPCS C1713 6860187 - PLATE 6860187 87 5MM ANT CERV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6860190 SUP HCPCS C1713 6860190 - PLATE 6860190 90 MM ANT CERV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6860195 SUP HCPCS C1713 6860195 - PLATE 6860195 95 MM ANT CERV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6860200 SUP HCPCS C1713 6860200 - PLATE 6860200 100 MM ANT CERV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6860205 SUP HCPCS C1713 6860205 - PLATE 6860205 105 MM ANT CERV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6860210 SUP HCPCS C1713 6860210 - PLATE 6860210 110 MM ANT CERV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6860405 SUP Custom 27803010 6860405 - PIN 6860405 PREMIER MIDLINE FIXATION BOTH IP/OP $177.00 $130.98 $0.00 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $88.50 $140.18 $141.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861130 SUP HCPCS C1713 6861130 - PLATE 6861130 30MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6861137 SUP HCPCS C1713 6861137 - PLATE 6861137 37.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6861150 SUP HCPCS C1713 6861150 - PLATE 6861150 50 MM ANT CERV PLATE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6861157 SUP HCPCS C1713 6861157 - PLATE 6861157 57.5 MM ANT CERV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861165 SUP HCPCS C1713 6861165 - PLATE 6861165 65 MM ANT CERV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861167 SUP HCPCS C1713 6861167 - PLATE 6861167 67.5 MM ANT CERV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861175 SUP HCPCS C1713 6861175 - PLATE 6861175 75 MM ANT CERV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861177 SUP HCPCS C1713 6861177 - PLATE 6861177 77.5 MM ANT CERV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861182 SUP HCPCS C1713 6861182 - PLATE 6861182 82.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861185 SUP HCPCS C1713 6861185 - PLATE 6861185 85MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861200 SUP HCPCS C1713 6861200 - PLATE 6861200 100MM ANTERIOR CERVICAL BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6861223 SUP HCPCS C1713 6861223 - PLATE 6861223 23MM FSP ANTERIOR CRV BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6861225 SUP HCPCS C1713 6861225 - PLATE 6861225 25MM FSP ANTERIOR CRV BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6861227 SUP HCPCS C1713 6861227 - PLATE 6861227 27.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6861230 SUP HCPCS C1713 6861230 - PLATE 6861230 30MM FSP ANTERIOR CRV BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6861232 SUP HCPCS C1713 6861232 - PLATE 6861232 32.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6861235 SUP HCPCS C1713 6861235 - PLATE 6861235 35MM FSP ANTERIOR CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6861237 SUP HCPCS C1713 6861237 - PLATE 6861237 37.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6861240 SUP HCPCS C1713 6861240 - PLATE 6861240 40 MM FSP ANTERIOR CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6861242 SUP HCPCS C1713 6861242 - PLATE 6861242 42.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6861245 SUP HCPCS C1713 6861245 - PLATE 6861245 45MM FSP ANTERIOR CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6861247 SUP HCPCS C1713 6861247 - PLATE 6861247 47.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6861250 SUP HCPCS C1713 6861250 - PLATE 6861250 50MM FSP ANTERIOR CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861252 SUP HCPCS C1713 6861252 - PLATE 6861252 52.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861255 SUP HCPCS C1713 6861255 - PLATE 6861255 55MM FSP ANTERIOR CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861257 SUP HCPCS C1713 6861257 - PLATE 6861257 57.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861260 SUP HCPCS C1713 6861260 - PLATE 6861260 60MM FSP ANTERIOR CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861262 SUP HCPCS C1713 6861262 - PLATE 6861262 62.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861265 SUP HCPCS C1713 6861265 - PLATE 6861265 65MM FSP ANTERIOR CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861267 SUP HCPCS C1713 6861267 - PLATE 6861267 67.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 6861270 SUP HCPCS C1713 6861270 - PLATE 6861270 70MM FSP ANTERIOR CRV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861272 SUP HCPCS C1713 6861272 - PLATE 6861272 72.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861275 SUP HCPCS C1713 6861275 - PLATE 6861275 75MM FSP ANTERIOR CRV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861277 SUP HCPCS C1713 6861277 - PLATE 6861277 77.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861280 SUP HCPCS C1713 6861280 - PLATE 6861280 80MM FSP ANTERIOR CRV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861282 SUP HCPCS C1713 6861282 - PLATE 6861282 82.5MM FSP ANTERIOR CRV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861285 SUP HCPCS C1713 6861285 - PLATE 6861285 85MM FSP ANTERIOR CRV BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 6861287 SUP HCPCS C1713 6861287 - PLATE 6861287 87.5MM FSP ANTERIOR CRV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6861290 SUP HCPCS C1713 6861290 - PLATE 6861290 90MM FSP ANTERIOR CRV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6861295 SUP HCPCS C1713 6861295 - PLATE 6861295 95MM FSP ANTERIOR CRV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6861300 SUP HCPCS C1713 6861300 - PLATE 6861300 100MM FSP ANTERIOR CRV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6861305 SUP HCPCS C1713 6861305 - PLATE 6861305 105MM FSP ANTERIOR CRV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6861310 SUP HCPCS C1713 6861310 - PLATE 6861310 110MM FSP ANTERIOR CRV BOTH IP/OP "$4,266.00 " "$3,156.84" $0.00 "$3,412.80" "$1,919.70" "$1,919.70" $0.00 $0.00 $0.00 $889.14 "$3,166.23" "$3,166.23" $0.00 $0.00 $889.03 $0.00 "$2,103.14" "$2,103.14" $0.00 "$2,133.00" "$3,378.67" "$3,412.80" $0.00 $0.00 $667.63 $0.00 $0.00 $679.15 $0.00 $0.00 $0.00 $0.00 $0.00 6900120 SUP HCPCS C1713 6900120 - ROD SPNL SHRT 3.2MM 120MM VRTX MX CNCT PNT TI RECON SYS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 6900240 SUP HCPCS C1713 6900240 - ROD SPNL 240MM 3.2MM VRTX STD TI PCVD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 6900241 SUP Custom 27203010 6900241 - INSTRUMENT 6900241 3.2MMX240MM ROD TMPLT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6900270 SUP HCPCS C1713 6900270 - ROD SPNL 100MM 3.2MM VRTX STD OCCPTL TI PCVD OCCPTL PLT BOTH IP/OP "$4,216.50 " "$3,120.21" $0.00 "$3,373.20" "$1,897.43" "$1,897.43" $0.00 $0.00 $0.00 $878.82 "$3,129.49" "$3,129.49" $0.00 $0.00 $878.72 $0.00 "$2,078.73" "$2,078.73" $0.00 "$2,108.25" "$3,339.47" "$3,373.20" $0.00 $0.00 $659.88 $0.00 $0.00 $671.27 $0.00 $0.00 $0.00 $0.00 $0.00 6900280 SUP HCPCS C1713 6900280 - ROD SPNL 200MM 3.2MM VRTX STD OCCPTL TI PCVD OCCPTL PLT BOTH IP/OP "$4,216.50 " "$3,120.21" $0.00 "$3,373.20" "$1,897.43" "$1,897.43" $0.00 $0.00 $0.00 $878.82 "$3,129.49" "$3,129.49" $0.00 $0.00 $878.72 $0.00 "$2,078.73" "$2,078.73" $0.00 "$2,108.25" "$3,339.47" "$3,373.20" $0.00 $0.00 $659.88 $0.00 $0.00 $671.27 $0.00 $0.00 $0.00 $0.00 $0.00 6900506 SUP HCPCS C1713 6900506 - SCREW BN 3.5MM 6MM NTR STRL VRTX MA VA TI SPNE THOR CANC BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900508 SUP HCPCS C1713 6900508 - SCREW BN 3.5MM 8MM NTR STRL VRTX MA VA TI SPNE THOR CANC BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900510 SUP HCPCS C1713 6900510 - SCREW BN 3.5MM 10MM NTR STRL VRTX MA VA TI SPNE THOR CANC BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900512 SUP HCPCS C1713 6900512 - SCREW 6900512 VAS CANCELLOUS 3.5X12MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900514 SUP HCPCS C1713 6900514 - SCREW 6900514 VAS CANCELLOUS 3.5X14MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900516 SUP HCPCS C1713 6900516 - SCREW 6900516 VAS CANCELLOUS 3.5X16MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900518 SUP HCPCS C1713 6900518 - SCREW 6900518 VAS CANCELLOUS 3.5X18MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900520 SUP HCPCS C1713 6900520 - SCREW 6900520 VAS CANCELLOUS 3.5X20MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900522 SUP HCPCS C1713 6900522 - SCREW BONE 3.5MM 22MM VRTX TI CANC THOR SPN MULTIAX STRL BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900524 SUP HCPCS C1713 6900524 - SCREW 6900524 CANCELLOUS 3.5MMX24MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900606 SUP HCPCS C1713 6900606 - SCREW BN 4MM 6MM NTR STRL VRTX MA VA TI SPNE THOR CANC BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900608 SUP HCPCS C1713 6900608 - SCREW BN 4MM 8MM NTR STRL VRTX MA VA TI SPNE THOR CANC BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900610 SUP HCPCS C1713 6900610 - SCREW BN 4MM 10MM NTR STRL VRTX MA VA TI SPNE THOR CANC BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900612 SUP HCPCS C1713 6900612 - SCREW 6900612 VAS CANCELLOUS 4.0X12MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900614 SUP HCPCS C1713 6900614 - SCREW 6900614 VAS CANCELLOUS 4.0X14MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900616 SUP HCPCS C1713 6900616 - SCREW 6900616 VAS CANCELLOUS 4.0X16MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900618 SUP HCPCS C1713 6900618 - SCREW 6900618 VAS CANCELLOUS 4.0X18MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900620 SUP HCPCS C1713 6900620 - SCREW 6900620 VAS CANCELLOUS 4.0X20MM TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900622 SUP HCPCS C1713 6900622 - BONE SCREW 6900622 4.0MMX22MM CANC TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900624 SUP HCPCS C1713 6900624 - BONE SCREW 6900624 4.0MMX24MM CANC TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900626 SUP HCPCS C1713 6900626 - BONE SCREW 6900626 4.0MMX26MM CORT TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6900628 SUP HCPCS C1713 6900628 - BONE SCREW 6900628 4.0MMX28MM CORT TI BOTH IP/OP $696.00 $515.04 $0.00 $556.80 $313.20 $313.20 $0.00 $0.00 $0.00 $145.06 $516.57 $516.57 $0.00 $0.00 $145.05 $0.00 $411.68 $411.68 $0.00 $348.00 $551.23 $556.80 $0.00 $0.00 $108.92 $0.00 $0.00 $110.80 $0.00 $0.00 $0.00 $0.00 $0.00 6901000 SUP Custom 27803010 6901000 - CONNECTOR 6901000 SCREW BOTH IP/OP $963.38 $712.90 $0.00 $770.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $715.02 $715.02 $0.00 $0.00 $200.77 $0.00 $0.00 $0.00 $0.00 $481.69 $763.00 $770.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6902130 SUP Custom 27803010 6902130 - CONNECTOR 6902130 LATERAL CLOSED 10MM BOTH IP/OP $963.38 $712.90 $0.00 $770.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $715.02 $715.02 $0.00 $0.00 $200.77 $0.00 $0.00 $0.00 $0.00 $481.69 $763.00 $770.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6902131 SUP Custom 27803010 6902131 - CONNECTOR 6902131 13MM LATRL CONCTR CLSE BOTH IP/OP $963.38 $712.90 $0.00 $770.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $715.02 $715.02 $0.00 $0.00 $200.77 $0.00 $0.00 $0.00 $0.00 $481.69 $763.00 $770.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6902135 SUP Custom 27803010 6902135 - CONNECTOR 6902135 LATERAL OPEN 10MM BOTH IP/OP $963.38 $712.90 $0.00 $770.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $715.02 $715.02 $0.00 $0.00 $200.77 $0.00 $0.00 $0.00 $0.00 $481.69 $763.00 $770.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6902200 SUP Custom 27803010 6902200 - CONNECTOR 6902200 ROD 3.2-5.5 TI BOTH IP/OP "$1,389.00 " "$1,027.86" $0.00 "$1,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,030.92" "$1,030.92" $0.00 $0.00 $289.47 $0.00 $0.00 $0.00 $0.00 $694.50 "$1,100.09" "$1,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6902220 SUP Custom 27803010 6902220 - CONNECTOR 6902220 ROD 3.2-4.5 TI BOTH IP/OP "$1,389.00 " "$1,027.86" $0.00 "$1,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,030.92" "$1,030.92" $0.00 $0.00 $289.47 $0.00 $0.00 $0.00 $0.00 $694.50 "$1,100.09" "$1,111.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6902525 SUP HCPCS C1713 6902525 - CROSSLINK 6902525 CRSSLNK CONNECTOR CLIP BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6902530 SUP HCPCS C1713 6902530 - CROSSLINK 6902530 CRSSLNK CONNECTOR BAR BOTH IP/OP $276.00 $204.24 $0.00 $220.80 $124.20 $124.20 $0.00 $0.00 $0.00 $57.53 $204.85 $204.85 $0.00 $0.00 $57.52 $0.00 $163.25 $163.25 $0.00 $138.00 $218.59 $220.80 $0.00 $0.00 $43.19 $0.00 $0.00 $43.94 $0.00 $0.00 $0.00 $0.00 $0.00 6904045 SUP HCPCS C1713 6904045 - HOOK 6904045 LAMINAR 4.5MM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6904060 SUP HCPCS C1713 6904060 - HOOK 6904060 LAMINAR 6.0MM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6904075 SUP HCPCS C1713 6904075 - HOOK 6904075 LAMINAR 7.5MM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6904090 SUP HCPCS C1713 6904090 - HOOK 6904090 LAMINAR 9.0MM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6908245 SUP HCPCS C1713 6908245 - CAGE SPNL XL W 45X22X8MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6908250 SUP HCPCS C1713 6908250 - CAGE SPNL XL W 50X22X8MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6908255 SUP HCPCS C1713 6908255 - CAGE SPNL XL W 55X22X8MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6908260 SUP HCPCS C1713 6908260 - CAGE SPNL XL W 60X22X8MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6908840 SUP HCPCS C1713 6908840 - SPACER SPNL XL 40X18X8MM CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6908845 SUP HCPCS C1713 6908845 - CAGE SPNL XL 45X18X8MM NS LF CRNT PEEK LMBR INTRBD FS BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6908850 SUP HCPCS C1713 6908850 - CAGE SPNL XL 50X18X8MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6908855 SUP HCPCS C1713 6908855 - CAGE SPNL XL 55X18X8MM NS LF CRNT PEEK LMBR INTRBD FS BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6908860 SUP HCPCS C1713 6908860 - CAGE SPNL XL 60X18X8MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6910245 SUP HCPCS C1713 6910245 - CAGE SPNL XL W 45X22X10MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6910250 SUP HCPCS C1713 6910250 - CAGE SPNL XL W 50X22X10MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6910255 SUP Custom 27803010 6910255 - CAGE SPNL XL W 55X22X10MM NS LF CRNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 $0.00 $0.00 $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6910260 SUP HCPCS C1713 6910260 - CAGE SPNL XL W 60X22X10MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6910840 SUP HCPCS C1713 6910840 - SPACER SPNL XL 40X18X10MM CRNT THORLMBR INTRBD FS RDLCNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6910845 SUP HCPCS C1713 6910845 - CAGE SPNL XL 45X18X10MM NS LF CRNT RADOPQ PEEK TLIF BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6910850 SUP HCPCS C1713 6910850 - CAGE SPNL XL 50X18X10MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6910855 SUP HCPCS C1713 6910855 - CAGE SPNL XL 55X18X10MM NS LF CRNT RADOPQ PEEK TLIF BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6910860 SUP HCPCS C1713 6910860 - CAGE SPNL XL 60X18X10MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6912245 SUP HCPCS C1713 6912245 - CAGE SPNL XL W 45X22X12MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6912250 SUP HCPCS C1713 6912250 - CAGE SPNL XL W 50X22X12MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6912255 SUP HCPCS C1713 6912255 - CAGE SPNL XL W 55X22X12MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6912260 SUP HCPCS C1713 6912260 - CAGE SPNL XL W 60X22X12MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6912840 SUP HCPCS C1713 6912840 - SPACER SPNL XL 40X18X12MM CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6912845 SUP HCPCS C1713 6912845 - CAGE SPNL XL 45X18X12MM NS LF CRNT RADOPQ PEEK LMBR INTRBD BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6912850 SUP HCPCS C1713 6912850 - CAGE SPNL XL 50X18X12MM NS LF CRNT RADOPQ PEEK LMBR INTRBD BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6912855 SUP Custom 27803010 6912855 - CAGE SPNL XL 55X18X12MM NS LF CRNT RADOPQ PEEK LMBR INTRBD BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6912860 SUP HCPCS C1713 6912860 - CAGE SPNL XL 60X18X12MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6914245 SUP HCPCS C1713 6914245 - SPACER SPNL XL W 45X22X14MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6914250 SUP HCPCS C1713 6914250 - CAGE SPNL XL W 50X22X14MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6914255 SUP HCPCS C1713 6914255 - SPACER SPNL XL W 55X22X14MM CRNT LMBR INTRBD FS RDLCNT PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6914260 SUP HCPCS C1713 6914260 - CAGE SPNL XL 60X22X14MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6914840 SUP HCPCS C1713 6914840 - SPACER SPNL 40X18X14MM INTRBD FS GFT RSTRC BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6914845 SUP HCPCS C1713 6914845 - SPACER SPNL XL 45X18X14MM STRL CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6914850 SUP HCPCS C1713 6914850 - CAGE SPNL XL 50X18X14MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6914855 SUP HCPCS C1713 6914855 - CAGE SPNL XL 55X18X14MM NS LF CRNT PEEK LMBR INTRBD FS BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6914860 SUP HCPCS C1713 6914860 - CAGE SPNL 10D XL 60X18X14MM XLIF CRNT PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6916245 SUP HCPCS C1713 6916245 - SPACER SPNL XL W 45X22X16MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6916250 SUP HCPCS C1713 6916250 - CAGE SPNL XL W 50X22X16MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6916255 SUP HCPCS C1713 6916255 - SPACER SPNL XL W 55X22X16MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6916260 SUP HCPCS C1713 6916260 - SPACER SPNL XL W 60X22X16MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6916840 SUP HCPCS C1713 6916840 - SPACER SPNL XL 40X18X16MM CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6916845 SUP HCPCS C1713 6916845 - SPACER SPNL XL 45X18X16MM CRNT THORLMBR INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6916850 SUP HCPCS C1713 6916850 - CAGE SPNL XL 50X18X16MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6916855 SUP HCPCS C1713 6916855 - SPACER SPNL XL 55X18X16MM CRNT THORLMBR INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6916860 SUP HCPCS C1713 6916860 - SPACER SPNL 10D XL 60X18X16MM XLIF CRNT PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6920845 SUP HCPCS C1713 6920845 - CAGE SPNL XL W LRDTC 45X22X8MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6920855 SUP HCPCS C1713 6920855 - CAGE SPNL XL W LRDTC 55X22X8MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6920860 SUP HCPCS C1713 6920860 - CAGE SPNL XL W LRDTC 60X22X8MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921044 SUP HCPCS C1713 6921044 - CAGE SPNL 8D XL 24X34X10MM CRNT RND PEEK-OPTM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921045 SUP HCPCS C1713 6921045 - CAGE SPNL XL W LRDTC 45X22X10MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921050 SUP HCPCS C1713 6921050 - CAGE SPNL XL W LRDTC 50X22X10MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921055 SUP HCPCS C1713 6921055 - CAGE SPNL XL W LRDTC 55X22X10MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921088 SUP HCPCS C1713 6921088 - SPACER SPNL 8D XL 38X28X10MM CRNT PEEK-OPTM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921244 SUP HCPCS C1713 6921244 - SPACER SPNL XL 12X34X24MM CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921245 SUP HCPCS C1713 6921245 - CAGE SPNL XL W LRDTC 45X22X12MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921255 SUP HCPCS C1713 6921255 - CAGE SPNL XL W LRDTC 55X22X12MM NS LF CRNT PEEK LMBR INTRBD BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921260 SUP HCPCS C1713 6921260 - CAGE SPNL XL W LRDTC 60X22X12MM NS LF CRNT BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921288 SUP HCPCS C1713 6921288 - CAGE SPNL 8D XL 28X38X12MM CRNT RND PEEK-OPTM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921444 SUP HCPCS C1713 6921444 - CAGE SPNL 8D XL 24X34X14MM CRNT RND PEEK-OPTM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921445 SUP HCPCS C1713 6921445 - SPACER SPNL 10D LRDTC XL W 45X22X14MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921450 SUP HCPCS C1713 6921450 - SPACER SPNL 10D LRDTC XL W 50X22X14MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921455 SUP HCPCS C1713 6921455 - SPACER SPNL 10D LRDTC XL W 55X22X14MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921460 SUP HCPCS C1713 6921460 - SPACER SPNL 10D LRDTC XL W 60X22X14MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921488 SUP HCPCS C1713 6921488 - SPACER SPNL 8D XL 38X28X114MM LMBR INTRBD FS RDLCNT PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921644 SUP HCPCS C1713 6921644 - SPACER SPNL 8D XL 34X24X16MM CRNT PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921645 SUP HCPCS C1713 6921645 - SPACER SPNL 10D LRDTC XL W 45X22X16MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921650 SUP HCPCS C1713 6921650 - SPACER SPNL 10D LRDTC XL W 50X22X16MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921655 SUP HCPCS C1713 6921655 - SPACER SPNL 10D LRDTC XL W 55X22X16MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921660 SUP HCPCS C1713 6921660 - SPACER SPNL 10D LRDTC XL W 60X22X16MM PEEK BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6921688 SUP HCPCS C1713 6921688 - SPACER SPNL 8D XL 38X28X16MM CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921844 SUP HCPCS C1713 6921844 - SPACER SPNL 8D XL 34X24X18MM LMBR INTRBD FS RDLCNT PEEK-OPTM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6921888 SUP HCPCS C1713 6921888 - SPACER SPNL 8D XL 38X28X18MM LMBR INTRBD FS RDLCNT PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6922044 SUP HCPCS C1713 6922044 - SPACER SPNL 8D XL 34X24X20MM LMBR INTRBD FS RDLCNT PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6922088 SUP HCPCS C1713 6922088 - SPACER SPNL 8D XL 38X28X20MM LMBR INTRBD FS RDLCNT PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6931288 SUP HCPCS C1713 6931288 - CAGE SPNL 15D XL 28X38X12MM CRNT RND PEEK-OPTM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6931488 SUP HCPCS C1713 6931488 - CAGE SPNL 15D XL 28X38X14MM CRNT RND PEEK-OPTM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6931688 SUP HCPCS C1713 6931688 - SPACER SPNL XL 38X28X16MM CRNT INTRBD FS PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6931888 SUP HCPCS C1713 6931888 - SPACER SPNL 15D XL 38X28X18MM CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6932088 SUP HCPCS C1713 6932088 - SPACER SPNL 15D XL 38X28X20MM TLIF RDLCNT PEEK-OPTM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" "$6,750.00" "$6,750.00" $0.00 $0.00 $0.00 "$3,126.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 "$7,395.00" "$7,395.00" $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 "$2,347.50" $0.00 $0.00 "$2,388.00" $0.00 $0.00 $0.00 $0.00 $0.00 6940664 SUP HCPCS C1713 6940664 - GRAFT BN 16X14X6MM SPCR ANTM SPNE CRV BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 6940764 SUP HCPCS C1713 6940764 - SPACER ALGRF 16X14X7MM SPNE CRV BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 6940864 SUP HCPCS C1713 6940864 - SPACER ALGRF 16X14X8MM SPNE CRV BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 6940964 SUP HCPCS C1713 6940964 - SPACER ALGRF 16X14X9MM SPNE CRV BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 6941034 SUP HCPCS C1713 6941034 - CAGE SPNL 8D 34X24X10MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941038 SUP HCPCS C1713 6941038 - CAGE SPNL 8D 38X28X10MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941042 SUP HCPCS C1713 6941042 - CAGE SPNL 8D 42X30X10MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941234 SUP HCPCS C1713 6941234 - CAGE SPNL 8D 34X24X12MM NS LF BRIGADE TI BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941238 SUP HCPCS C1713 6941238 - CAGE SPNL 8D 38X28X12MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941242 SUP HCPCS C1713 6941242 - CAGE SPNL 8D 42X30X12MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941434 SUP HCPCS C1713 6941434 - CAGE SPNL 8D 34X24X14MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941438 SUP HCPCS C1713 6941438 - CAGE SPNL 8D 38X28X14MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941442 SUP HCPCS C1713 6941442 - CAGE SPNL 8D 42X30X14MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941634 SUP HCPCS C1713 6941634 - CAGE SPNL 8D 34X24X16MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941638 SUP HCPCS C1713 6941638 - CAGE SPNL 8D 38X28X16MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941642 SUP HCPCS C1713 6941642 - CAGE SPNL 8D 42X30X16MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941834 SUP HCPCS C1713 6941834 - CAGE SPNL 8D 34X24X18MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941838 SUP HCPCS C1713 6941838 - CAGE SPNL 8D 38X28X18MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6941842 SUP HCPCS C1713 6941842 - CAGE SPNL 8D 42X30X18MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6942034 SUP HCPCS C1713 6942034 - CAGE SPNL 8D 34X24X20MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6942038 SUP HCPCS C1713 6942038 - CAGE SPNL 8D 38X28X20MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6942042 SUP HCPCS C1713 6942042 - CAGE SPNL 8D 42X30X20MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6950305 SUP HCPCS C1713 6950305 - SCREW BN 3.5MM 5MM LGHT BLU NS VRTX MX 3 RLF NTCH ST TOP LD BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 6950315 SUP HCPCS C1713 6950315 - SCREW SET TI 15MM 3.5MM POST SPN M6 VRTX BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 6951034 SUP HCPCS C1713 6951034 - CAGE SPNL 12D 34X24X10MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951234 SUP HCPCS C1713 6951234 - CAGE SPNL 12D 34X24X12MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951238 SUP HCPCS C1713 6951238 - CAGE SPNL 12D 38X28X12MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951242 SUP HCPCS C1713 6951242 - CAGE SPNL 12D 42X30X12MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951434 SUP HCPCS C1713 6951434 - CAGE SPNL 12D 34X24X14MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951438 SUP HCPCS C1713 6951438 - CAGE SPNL 12D 38X28X14MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951442 SUP HCPCS C1713 6951442 - CAGE SPNL 12D 42X30X14MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951634 SUP HCPCS C1713 6951634 - CAGE SPNL 12D 34X24X16MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951638 SUP HCPCS C1713 6951638 - CAGE SPNL 12D 38X28X16MM NS LF BRIGADE TI BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951642 SUP HCPCS C1713 6951642 - CAGE SPNL 12D 42X30X16MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951834 SUP HCPCS C1713 6951834 - CAGE SPNL 12D 34X24X18MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951838 SUP HCPCS C1713 6951838 - CAGE SPNL 12D 38X28X18MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6951842 SUP HCPCS C1713 6951842 - CAGE SPNL 12D 42X30X18MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6952034 SUP HCPCS C1713 6952034 - CAGE SPNL 12D 34X24X20MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6952038 SUP HCPCS C1713 6952038 - CAGE SPNL 12D 38X28X20MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6952042 SUP HCPCS C1713 6952042 - CAGE SPNL 12D 42X30X20MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6955240 SUP Custom 27803010 6955240 - CONCTR ROD 240MM 3.2MM VRTX MX THRD TI SPNL RECON SYS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6955245 SUP HCPCS C1713 6955245 - ROD SPNL 4.5MM 360MM VRTX MX THRD TI RECON SYS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 6955255 SUP HCPCS C1713 6955255 - ROD SPNL 5.5MM 360MM VRTX MX THRD TI OCPTL RECON SYS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 6955260 SUP HCPCS C1713 6955260 - ROD 6955260 3.2 X 100 PRECURVED OC TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 6955270 SUP HCPCS C1713 6955270 - ROD 6955270 3.2 X 200 PRECURVED OC TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 6955273 SUP HCPCS C1713 6955273 - PLATE 6955273 OCCIPITAL KEEL SMALL BOTH IP/OP "$6,735.00 " "$4,983.90" $0.00 "$5,388.00" "$3,030.75" "$3,030.75" $0.00 $0.00 $0.00 "$1,403.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,403.57" $0.00 "$3,320.36" "$3,320.36" $0.00 "$3,367.50" "$5,334.12" "$5,388.00" $0.00 $0.00 "$1,054.03" $0.00 $0.00 "$1,072.21" $0.00 $0.00 $0.00 $0.00 $0.00 6955274 SUP HCPCS C1713 6955274 - PLATE 6955274 OCCIPITAL KEEL MEDIUM BOTH IP/OP "$6,735.00 " "$4,983.90" $0.00 "$5,388.00" "$3,030.75" "$3,030.75" $0.00 $0.00 $0.00 "$1,403.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,403.57" $0.00 "$3,320.36" "$3,320.36" $0.00 "$3,367.50" "$5,334.12" "$5,388.00" $0.00 $0.00 "$1,054.03" $0.00 $0.00 "$1,072.21" $0.00 $0.00 $0.00 $0.00 $0.00 6955275 SUP HCPCS C1713 6955275 - PLATE 6955275 OCCIPITAL KEEL LARGE BOTH IP/OP "$6,735.00 " "$4,983.90" $0.00 "$5,388.00" "$3,030.75" "$3,030.75" $0.00 $0.00 $0.00 "$1,403.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,403.57" $0.00 "$3,320.36" "$3,320.36" $0.00 "$3,367.50" "$5,334.12" "$5,388.00" $0.00 $0.00 "$1,054.03" $0.00 $0.00 "$1,072.21" $0.00 $0.00 $0.00 $0.00 $0.00 6955406 SUP HCPCS C1713 6955406 - BONE SCREW 6955406 4.0 X 6MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955408 SUP HCPCS C1713 6955408 - BONE SCREW 6955408 4.0 X 8MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955410 SUP HCPCS C1713 6955410 - BONE SCREW 6955410 4.0 X 10MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955412 SUP HCPCS C1713 6955412 - BONE SCREW 6955412 4.0 X 12MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955414 SUP HCPCS C1713 6955414 - BONE SCREW 6955414 4.0 X 14MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955416 SUP HCPCS C1713 6955416 - BONE SCREW 6955416 4.0 X 16MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955418 SUP HCPCS C1713 6955418 - BONE SCREW 6955418 4.0 X 18MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955506 SUP HCPCS C1713 6955506 - BONE SCREW 6955506 4.5 X 6MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955508 SUP HCPCS C1713 6955508 - BONE SCREW 6955508 4.5 X 8MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955510 SUP HCPCS C1713 6955510 - BONE SCREW 6955510 4.5 X 10MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955512 SUP HCPCS C1713 6955512 - BONE SCREW 6955512 4.5 X 12MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955514 SUP HCPCS C1713 6955514 - BONE SCREW 6955514 4.5 X 14MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955516 SUP HCPCS C1713 6955516 - BONE SCREW 6955516 4.5 X 16MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955518 SUP HCPCS C1713 6955518 - BONE SCREW 6955518 4.5 X 18MM CORTICAL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955520 SUP HCPCS C1713 6955520 - SCREW BONE 4.5MM 20MM TI CORT SPNL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955524 SUP HCPCS C1713 6955524 - SCREW BONE 4.5MM 24MM CORT SPNL BOTH IP/OP $694.88 $514.21 $0.00 $555.90 $312.69 $312.69 $0.00 $0.00 $0.00 $144.83 $515.74 $515.74 $0.00 $0.00 $144.81 $0.00 $411.02 $411.02 $0.00 $347.44 $550.34 $555.90 $0.00 $0.00 $108.75 $0.00 $0.00 $110.62 $0.00 $0.00 $0.00 $0.00 $0.00 6955710 SUP HCPCS C1713 6955710 - SCREW BN 3.5MM 10MM GRN VRTX MX MA ST ROT SDL TI THOR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6955712 SUP HCPCS C1713 6955712 - SCREW BN 3.5MM 12MM STRL VRTX MA TI THOR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6955714 SUP HCPCS C1713 6955714 - SCREW BN 3.5MM 14MM GRN VRTX MX MA ST ROT SDL TI THOR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6955718 SUP HCPCS C1713 6955718 - SCREW BN 3.5MM 18MM GRN VRTX MX MA ST ROT SDL TI THOR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6955826 SUP HCPCS C1713 6955826 - SCREW BN 4MM 26MM BLU VRTX MX MA ST ROT SDL TI THOR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6955830 SUP HCPCS C1713 6955830 - SCREW BN 4MM 30MM AU VRTX MX MA ST ROT SDL TI THOR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6955926 SUP HCPCS C1713 6955926 - SCREW BN 4.5MM 26MM MAG VRTX MX MA ST ROT SDL TI THOR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6955960 SUP Custom 27803010 6955960 - CONNECTOR 6955960 10MM LAT OFFSET OPEN BOTH IP/OP $970.50 $718.17 $0.00 $776.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $720.31 $720.31 $0.00 $0.00 $202.25 $0.00 $0.00 $0.00 $0.00 $485.25 $768.64 $776.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6955965 SUP Custom 27803010 6955965 - CONNECTOR 6955965 13MM LAT OFFSET OPEN BOTH IP/OP $970.50 $718.17 $0.00 $776.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $720.31 $720.31 $0.00 $0.00 $202.25 $0.00 $0.00 $0.00 $0.00 $485.25 $768.64 $776.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6955973 SUP HCPCS C1713 6955973 - HOOK SPNL 4.5MM NS VRTX MX TI LMN RECON SYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6955974 SUP HCPCS C1713 6955974 - HOOK SPNL 6MM VRTX MX LMNR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6956010 SUP Custom 27203010 6956010 - BIT DRL 2.4MM STRL VRTX DISP BOTH IP/OP $649.50 $480.63 $0.00 $519.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.06 $482.06 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $324.75 $514.40 $519.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6956011 SUP Custom 27203010 6956011 - BIT DRILL 26-52MM 2.9MM VRTX MX STRL DISP BOTH IP/OP $649.50 $480.63 $0.00 $519.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.06 $482.06 $0.00 $0.00 $135.36 $0.00 $0.00 $0.00 $0.00 $324.75 $514.40 $519.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6956035 SUP HCPCS C1713 6956035 - TAP 3.5MM 10-24MM SURG VRTX MX BOTH IP/OP $385.50 $285.27 $0.00 $308.40 $173.48 $173.48 $0.00 $0.00 $0.00 $80.35 $286.12 $286.12 $0.00 $0.00 $80.34 $0.00 $228.02 $228.02 $0.00 $192.75 $305.32 $308.40 $0.00 $0.00 $60.33 $0.00 $0.00 $61.37 $0.00 $0.00 $0.00 $0.00 $0.00 6957314 SUP HCPCS C1769 6957314 - GWIRE ORTH 720MM SPN THRD BOTH IP/OP $261.00 $193.14 $0.00 $208.80 $141.72 $141.72 $0.00 $0.00 $0.00 $54.40 $193.71 $193.71 $0.00 $0.00 $54.39 $0.00 $154.38 $154.38 $0.00 $130.50 $206.71 $208.80 $0.00 $0.00 $40.85 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $0.00 6957315 SUP HCPCS C1769 6957315 - GWIRE ORTH 3MM CANN BOTH IP/OP $261.00 $193.14 $0.00 $208.80 $141.72 $141.72 $0.00 $0.00 $0.00 $54.40 $193.71 $193.71 $0.00 $0.00 $54.39 $0.00 $154.38 $154.38 $0.00 $130.50 $206.71 $208.80 $0.00 $0.00 $40.85 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $0.00 6958710 SUP HCPCS C1713 6958710 - SCREW BN 3.5MM 10MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958712 SUP HCPCS C1713 6958712 - SCREW BN 3.5MM 12MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958714 SUP HCPCS C1713 6958714 - SCREW BN 3.5MM 14MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958716 SUP HCPCS C1713 6958716 - SCREW BN 3.5MM 16MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958718 SUP HCPCS C1713 6958718 - SCREW BN 3.5MM 18MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958720 SUP HCPCS C1713 6958720 - SCREW BN 3.5MM 20MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958722 SUP HCPCS C1713 6958722 - SCREW BN 3.5MM 22MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958724 SUP HCPCS C1713 6958724 - SCREW BN 3.5MM 24MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958726 SUP HCPCS C1713 6958726 - SCREW BN 3.5MM 26MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958728 SUP HCPCS C1713 6958728 - SCREW BN 3.5MM 28MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958730 SUP HCPCS C1713 6958730 - SCREW BN 3.5MM 30MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958732 SUP HCPCS C1713 6958732 - SCREW BN 3.5MM 32MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958734 SUP HCPCS C1713 6958734 - SCREW BN 3.5MM 34MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958736 SUP HCPCS C1713 6958736 - SCREW BN 3.5MM 36MM GRN NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958738 SUP HCPCS C1713 6958738 - SCREW BN 3.5MM 38MM GRN NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958740 SUP HCPCS C1713 6958740 - SCREW BN 3.5MM 40MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958742 SUP HCPCS C1713 6958742 - SCREW BN 3.5MM 42MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958744 SUP HCPCS C1713 6958744 - SCREW BN 3.5MM 44MM GRN VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958746 SUP HCPCS C1713 6958746 - SCREW BN 3.5MM 46MM GRN VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958748 SUP HCPCS C1713 6958748 - SCREW BN 3.5MM 48MM GRN VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958750 SUP HCPCS C1713 6958750 - SCREW BN 3.5MM 50MM GRN VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958752 SUP HCPCS C1713 6958752 - SCREW BN 3.5MM 52MM GRN VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958810 SUP HCPCS C1713 6958810 - SCREW BN 4MM 10MM BLU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958812 SUP HCPCS C1713 6958812 - SCREW 6958812 4.0 X 12MM MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958814 SUP HCPCS C1713 6958814 - SCREW BN 4MM 14MM BLU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958816 SUP HCPCS C1713 6958816 - SCREW BN 4MM 16MM BLU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958818 SUP HCPCS C1713 6958818 - SCREW BN 4MM 18MM BLU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958820 SUP HCPCS C1713 6958820 - SCREW BN 4MM 20MM BLU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958822 SUP HCPCS C1713 6958822 - SCREW BN 4MM 22MM BLU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958824 SUP HCPCS C1713 6958824 - SCREW BN 4MM 24MM BLU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958826 SUP HCPCS C1713 6958826 - SCREW BN 4MM 26MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958828 SUP HCPCS C1713 6958828 - SCREW BN 4MM 28MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958830 SUP HCPCS C1713 6958830 - SCREW BN 4MM 30MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958832 SUP HCPCS C1713 6958832 - SCREW BN 4MM 32MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958834 SUP HCPCS C1713 6958834 - SCREW BN 4MM 34MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958836 SUP HCPCS C1713 6958836 - SCREW BN 4MM 36MM AU VRTX MX MA ST ROT SDL TI THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958838 SUP HCPCS C1713 6958838 - SCREW BN 4MM 38MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958840 SUP HCPCS C1713 6958840 - SCREW BN 4MM 40MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958842 SUP HCPCS C1713 6958842 - SCREW BN 4MM 42MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958844 SUP HCPCS C1713 6958844 - SCREW BN 4MM 44MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958846 SUP HCPCS C1713 6958846 - SCREW BN 4MM 46MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958848 SUP HCPCS C1713 6958848 - SCREW BN 4MM 48MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958850 SUP HCPCS C1713 6958850 - SCREW BN 4MM 50MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958852 SUP HCPCS C1713 6958852 - SCREW BN 4MM 52MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958910 SUP HCPCS C1713 6958910 - SCREW BN 4.5MM 10MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958912 SUP HCPCS C1713 6958912 - SCREW BN 4.5MM 12MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958914 SUP HCPCS C1713 6958914 - SCREW BN 4.5MM 14MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958916 SUP HCPCS C1713 6958916 - SCREW BN 4.5MM 16MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958918 SUP HCPCS C1713 6958918 - SCREW BN 4.5MM 18MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958920 SUP HCPCS C1713 6958920 - SCREW BN 4.5MM 20MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958922 SUP HCPCS C1713 6958922 - SCREW BN 4.5MM 22MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958924 SUP HCPCS C1713 6958924 - SCREW BN 4.5MM 24MM MAG NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958926 SUP HCPCS C1713 6958926 - SCREW BN 4.5MM 26MM MAG NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958928 SUP HCPCS C1713 6958928 - SCREW BN 4.5MM 28MM MAG NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958930 SUP HCPCS C1713 6958930 - SCREW BN 4.5MM 30MM MAG NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958932 SUP HCPCS C1713 6958932 - SCREW BN 4.5MM 32MM MAG NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958934 SUP HCPCS C1713 6958934 - SCREW BN 4.5MM 34MM MAG NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958936 SUP HCPCS C1713 6958936 - SCREW BN 4.5MM 36MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958938 SUP HCPCS C1713 6958938 - SCREW BN 4.5MM 38MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958940 SUP HCPCS C1713 6958940 - SCREW BN 4.5MM 40MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958942 SUP HCPCS C1713 6958942 - SCREW BN 4.5MM 42MM MAG NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958944 SUP HCPCS C1713 6958944 - SCREW 6958944 4.5 X 44MM MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958946 SUP HCPCS C1713 6958946 - SCREW 6958946 4.5 X 46MM MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958948 SUP HCPCS C1713 6958948 - SCREW 6958948 4.5 X 48MM MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958950 SUP HCPCS C1713 6958950 - SCREW 6958950 4.5 X 50MM MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958952 SUP HCPCS C1713 6958952 - SCREW 6958952 4.5 X 52MM MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6959418 SUP HCPCS C1713 6959418 - SCREW BN 4MM 18MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959420 SUP HCPCS C1713 6959420 - SCREW BN 4MM 20MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959422 SUP HCPCS C1713 6959422 - SCREW BN 4MM 22MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959424 SUP HCPCS C1713 6959424 - SCREW BN 4MM 24MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959426 SUP HCPCS C1713 6959426 - SCREW BN 4MM 26MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959430 SUP HCPCS C1713 6959430 - SCREW BN 4MM 30MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959432 SUP HCPCS C1713 6959432 - SCREW BN 4MM 32MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959434 SUP HCPCS C1713 6959434 - SCREW BN 4MM 34MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959436 SUP HCPCS C1713 6959436 - SCREW BN 4MM 36MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959438 SUP HCPCS C1713 6959438 - SCREW BN 4MM 38MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959440 SUP HCPCS C1713 6959440 - SCREW BN 4MM 40MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959442 SUP HCPCS C1713 6959442 - SCREW BN 4MM 42MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959444 SUP HCPCS C1713 6959444 - SCREW BN 4MM 44MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959446 SUP HCPCS C1713 6959446 - SCREW BN 4MM 46MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959448 SUP HCPCS C1713 6959448 - SCREW BN 4MM 48MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959450 SUP HCPCS C1713 6959450 - SCREW BN 4MM 50MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959452 SUP HCPCS C1713 6959452 - SCREW BN 4MM 52MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959510 SUP HCPCS C1713 6959510 - SCREW BN 4.5MM 10MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959512 SUP HCPCS C1713 6959512 - SCREW BN 4.5MM 12MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959514 SUP HCPCS C1713 6959514 - SCREW BN 4.5MM 14MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959516 SUP HCPCS C1713 6959516 - SCREW BN 4.5MM 16MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959518 SUP HCPCS C1713 6959518 - SCREW BN 4.5MM 18MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959520 SUP HCPCS C1713 6959520 - SCREW BN 4.5MM 20MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959522 SUP HCPCS C1713 6959522 - SCREW BN 4.5MM 22MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959524 SUP HCPCS C1713 6959524 - SCREW BN 4.5MM 24MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959526 SUP HCPCS C1713 6959526 - SCREW BN 4.5MM 26MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959528 SUP HCPCS C1713 6959528 - SCREW BN 4.5MM 28MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959530 SUP HCPCS C1713 6959530 - SCREW BN 4.5MM 30MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959532 SUP HCPCS C1713 6959532 - SCREW BN 4.5MM 32MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959534 SUP HCPCS C1713 6959534 - SCREW BN 4.5MM 34MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959536 SUP HCPCS C1713 6959536 - SCREW BN 4.5MM 36MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959538 SUP HCPCS C1713 6959538 - SCREW BN 4.5MM 38MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959540 SUP HCPCS C1713 6959540 - SCREW BN 4.5MM 40MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959542 SUP HCPCS C1713 6959542 - SCREW BN 4.5MM 42MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959544 SUP HCPCS C1713 6959544 - SCREW BN 4.5MM 44MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959546 SUP HCPCS C1713 6959546 - SCREW BN 4.5MM 46MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959548 SUP HCPCS C1713 6959548 - SCREW BN 4.5MM 48MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959550 SUP HCPCS C1713 6959550 - SCREW BN 4.5MM 50MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959552 SUP HCPCS C1713 6959552 - SCREW BN 4.5MM 52MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959970 SUP HCPCS C1713 6959970 - PLATE 6959970 LP OC KEEL SMALL BOTH IP/OP "$7,095.00 " "$5,250.30" $0.00 "$5,676.00" "$3,192.75" "$3,192.75" $0.00 $0.00 $0.00 "$1,478.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,478.60" $0.00 "$3,497.84" "$3,497.84" $0.00 "$3,547.50" "$5,619.24" "$5,676.00" $0.00 $0.00 "$1,110.37" $0.00 $0.00 "$1,129.52" $0.00 $0.00 $0.00 $0.00 $0.00 6959971 SUP HCPCS C1713 6959971 - PLATE 6959971 LP OC KEEL MEDIUM BOTH IP/OP "$7,095.00 " "$5,250.30" $0.00 "$5,676.00" "$3,192.75" "$3,192.75" $0.00 $0.00 $0.00 "$1,478.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,478.60" $0.00 "$3,497.84" "$3,497.84" $0.00 "$3,547.50" "$5,619.24" "$5,676.00" $0.00 $0.00 "$1,110.37" $0.00 $0.00 "$1,129.52" $0.00 $0.00 $0.00 $0.00 $0.00 6959972 SUP HCPCS C1713 6959972 - PLATE 6959972 LP OC KEEL LARGE BOTH IP/OP "$7,095.00 " "$5,250.30" $0.00 "$5,676.00" "$3,192.75" "$3,192.75" $0.00 $0.00 $0.00 "$1,478.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,478.60" $0.00 "$3,497.84" "$3,497.84" $0.00 "$3,547.50" "$5,619.24" "$5,676.00" $0.00 $0.00 "$1,110.37" $0.00 $0.00 "$1,129.52" $0.00 $0.00 $0.00 $0.00 $0.00 6960013 SUP HCPCS C1713 6960013 - SCREW 6960013 PRSTG BON FAST 4.0X13MM BOTH IP/OP $633.00 $468.42 $0.00 $506.40 $284.85 $284.85 $0.00 $0.00 $0.00 $131.93 $469.81 $469.81 $0.00 $0.00 $131.92 $0.00 $374.42 $374.42 $0.00 $316.50 $501.34 $506.40 $0.00 $0.00 $99.06 $0.00 $0.00 $100.77 $0.00 $0.00 $0.00 $0.00 $0.00 6960015 SUP HCPCS C1713 6960015 - SCREW 6960015 PRSTG BONE FAST 4.0X15MM BOTH IP/OP $633.00 $468.42 $0.00 $506.40 $284.85 $284.85 $0.00 $0.00 $0.00 $131.93 $469.81 $469.81 $0.00 $0.00 $131.92 $0.00 $374.42 $374.42 $0.00 $316.50 $501.34 $506.40 $0.00 $0.00 $99.06 $0.00 $0.00 $100.77 $0.00 $0.00 $0.00 $0.00 $0.00 6960113 SUP HCPCS C1713 6960113 - SCREW 6960113 PRSTG BONE FAST 4.5X13MM BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 6960120 SUP HCPCS C1713 6960120 - SCREW 6960120 LOCK BOTH IP/OP $268.50 $198.69 $0.00 $214.80 $120.83 $120.83 $0.00 $0.00 $0.00 $55.96 $199.28 $199.28 $0.00 $0.00 $55.96 $0.00 $158.82 $158.82 $0.00 $134.25 $212.65 $214.80 $0.00 $0.00 $42.02 $0.00 $0.00 $42.75 $0.00 $0.00 $0.00 $0.00 $0.00 6961038 SUP HCPCS C1713 6961038 - CAGE SPNL 8D 38X32X10MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6961238 SUP HCPCS C1713 6961238 - CAGE SPNL 8D 38X32X12MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6961260 SUP Custom 27803010 6961260 - PRESTIGE ARTIFICIAL DISC 6X12MM BOTH IP/OP "$7,342.50 " "$5,433.45" $0.00 "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,530.18" $0.00 $0.00 $0.00 $0.00 "$3,671.25" "$5,815.26" "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6961438 SUP HCPCS C1713 6961438 - CAGE SPNL 8D 38X32X14MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6961460 SUP Custom 27203010 6961460 - DISC 6961460 CERVICAL DISC 6MM X 14MM BOTH IP/OP "$7,342.50 " "$5,433.45" $0.00 "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,530.18" $0.00 $0.00 $0.00 $0.00 "$3,671.25" "$5,815.26" "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6961470 SUP Custom 27203010 6961470 - DISC 6961470 PRESTIGE ARTIFICIAL 7X14MM BOTH IP/OP "$7,342.50 " "$5,433.45" $0.00 "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,530.18" $0.00 $0.00 $0.00 $0.00 "$3,671.25" "$5,815.26" "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6961638 SUP HCPCS C1713 6961638 - CAGE SPNL 8D 38X32X16MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6961660 SUP Custom 27203010 6961660 - DISC 6961660 CERVICAL DISC 6MM X 16MM BOTH IP/OP "$7,342.50 " "$5,433.45" $0.00 "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,530.18" $0.00 $0.00 $0.00 $0.00 "$3,671.25" "$5,815.26" "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6961670 SUP Custom 27203010 6961670 - DISC 6961670 CERVICAL DISC 7MM X 16MM BOTH IP/OP "$7,342.50 " "$5,433.45" $0.00 "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,530.18" $0.00 $0.00 $0.00 $0.00 "$3,671.25" "$5,815.26" "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6961838 SUP HCPCS C1713 6961838 - CAGE SPNL 8D 38X32X18MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6961870 SUP Custom 27203010 6961870 - DISC 6961870 CERVICAL DISC 7MM X 18MM BOTH IP/OP "$7,342.50 " "$5,433.45" $0.00 "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,530.18" $0.00 $0.00 $0.00 $0.00 "$3,671.25" "$5,815.26" "$5,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6962038 SUP HCPCS C1713 6962038 - CAGE SPNL 8D 38X32X20MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6971238 SUP HCPCS C1713 6971238 - CAGE SPNL 12D 38X32X12MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6971250 SUP HCPCS C1713 6971250 - DISC ARTF 12MM 5MM CERV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971260 SUP HCPCS C1713 6971260 - DISC ARTF 12MM 6MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971270 SUP HCPCS C1713 6971270 - DISC ARTF 12MM 7MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971438 SUP HCPCS C1713 6971438 - CAGE SPNL 12D 38X32X14MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6971450 SUP HCPCS C1713 6971450 - DISC ARTF 14MM 5MM CERV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971460 SUP HCPCS C1713 6971460 - DISC ARTF 14MM 6MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971470 SUP HCPCS C1713 6971470 - DISC ARTF 14MM 7MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971480 SUP HCPCS C1713 6971480 - DISC ARTF 14MM 8MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971638 SUP HCPCS C1713 6971638 - CAGE SPNL 12D 38X32X16MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6971650 SUP HCPCS C1713 6971650 - DISC 6971650 CERVICAL 5MM X 16MM BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971660 SUP HCPCS C1713 6971660 - DISC ARTF 16MM 6MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971670 SUP HCPCS C1713 6971670 - DISC ARTF 16MM 7MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971680 SUP HCPCS C1713 6971680 - DISC ARTF 16MM 8MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971838 SUP HCPCS C1713 6971838 - CAGE SPNL 12D 38X32X18MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6971870 SUP HCPCS C1713 6971870 - DISC ARTF 18MM 7MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971880 SUP HCPCS C1713 6971880 - DISC ARTF 18MM 8MM CERV MTN BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972038 SUP HCPCS C1713 6972038 - CAGE SPNL 12D 38X32X20MM NS LF BRIGADE BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 6972118 SUP Custom 27203010 6972118 - BIT DRL DMD 1.5MM STRL RAIL CTR DISP BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6972250 SUP HCPCS C1713 6972250 - DISC 6972250 PRESTIGE BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972260 SUP HCPCS C1713 6972260 - DISC INTVRTB 12MM 6MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972270 SUP HCPCS C1713 6972270 - DISC INTVRTB 12MM 7MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972450 SUP HCPCS C1713 6972450 - DISC INTVRTB 14MM 4MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972460 SUP HCPCS C1713 6972460 - DISC INTVRTB 14MM 6MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972470 SUP HCPCS C1713 6972470 - DISC INTVRTB 14MM 7MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972480 SUP HCPCS C1713 6972480 - DISC INTVRTB 14MM 8MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972650 SUP HCPCS C1713 6972650 - DISC INTVRTB 16MM 5MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972660 SUP HCPCS C1713 6972660 - DISC INTVRTB 16MM 6MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972670 SUP HCPCS C1713 6972670 - DISC INTVRTB 16MM 7MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972680 SUP HCPCS C1713 6972680 - DISC INTVRTB 16MM 8MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972860 SUP HCPCS C1713 6972860 - DISC INTVRTB 18MM 6MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972870 SUP HCPCS C1713 6972870 - DISC INTVRTB 18MM 7MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6972880 SUP HCPCS C1713 6972880 - DISC INTVRTB 18MM 8MM PSTG LP CERV SPN TI BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6980840 SUP HCPCS C1713 6980840 - SPACER SPNL 40X18X8MM LMBR INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6980850 SUP HCPCS C1713 6980850 - CAGE SPNL 10D XL 50X18X8MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6980855 SUP HCPCS C1713 6980855 - CAGE SPNL 10D XL 55X18X8MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6980860 SUP HCPCS C1713 6980860 - CAGE SPNL 10D XL 60X18X8MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981040 SUP HCPCS C1713 6981040 - CAGE SPNL 40X18X10MM PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981045 SUP Custom 27803010 6981045 - CAGE SPNL 10D XL 45X18X10MM NS LF CRNT PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6981050 SUP HCPCS C1713 6981050 - CAGE SPNL 10D XL 50X18X10MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981055 SUP HCPCS C1713 6981055 - CAGE SPNL 10D XL 55X18X10MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981060 SUP HCPCS C1713 6981060 - CAGE SPNL 10D XL 60X18X10MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981240 SUP HCPCS C1713 6981240 - SPACER SPNL LRDTC XL 40X18X12MM CRNT PEEK LMBR INTRBD FS BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981245 SUP Custom 27803010 6981245 - CAGE SPNL 10D XL 45X18X12MM NS LF CRNT PEEK LMBR INTRBD FS BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6981250 SUP HCPCS C1713 6981250 - CAGE SPNL 10D XL 50X18X12MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981255 SUP Custom 27803010 6981255 - CAGE SPNL 10D XL 55X18X12MM NS LF CRNT PEEK LMBR INTRBD FS BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6981260 SUP HCPCS C1713 6981260 - CAGE SPNL 10D XL 60X18X12MM NS LF CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981440 SUP HCPCS C1713 6981440 - SPACER SPNL XL 40X18X14MM CRNT LMBR INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981445 SUP HCPCS C1713 6981445 - CAGE SPNL 10D XL 45X18X14MM CRNT PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981455 SUP HCPCS C1713 6981455 - CAGE SPNL 55X18X14MM CRNT THORLMBR INTRBD FS RDLCNT PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981460 SUP HCPCS C1713 6981460 - CAGE SPNL 10D XL 60X18X14MM CRNT PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981640 SUP HCPCS C1713 6981640 - SPACER SPNL XL 40X18X16MM INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981645 SUP HCPCS C1713 6981645 - CAGE SPNL 10D XL 45X18X16MM CRNT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981650 SUP HCPCS C1713 6981650 - CAGE SPNL 10D XL 50X18X16MM CRNT PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981655 SUP HCPCS C1713 6981655 - CAGE SPNL 55X18X16MM CRNT THORLMBR INTRBD FS PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6981660 SUP HCPCS C1713 6981660 - CAGE SPNL XL LRDTC 60X18X14MM CRNT PEEK BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 6990625 SUP HCPCS C1713 6990625 - CAGE SPNL XL 25X16X6MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6990630 SUP HCPCS C1713 6990630 - CAGE SPNL XL 30X16X6MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6990635 SUP HCPCS C1713 6990635 - CAGE SPNL XL 35X16X6MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6990640 SUP HCPCS C1713 6990640 - CAGE SPNL XL 40X16X6MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6990825 SUP HCPCS C1713 6990825 - CAGE SPNL XL 25X16X8MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6990830 SUP HCPCS C1713 6990830 - CAGE SPNL XL 30X16X8MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6990835 SUP HCPCS C1713 6990835 - CAGE SPNL XL 35X16X8MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6990840 SUP HCPCS C1713 6990840 - CAGE SPNL XL 40X16X8MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6991025 SUP HCPCS C1713 6991025 - CAGE SPNL XL 25X16X10MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6991030 SUP HCPCS C1713 6991030 - CAGE SPNL XL 30X16X10MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6991035 SUP HCPCS C1713 6991035 - CAGE SPNL XL 35X16X10MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6991040 SUP HCPCS C1713 6991040 - CAGE SPNL XL 40X16X10MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6991225 SUP HCPCS C1713 6991225 - CAGE SPNL XL 25X16X12MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6991230 SUP HCPCS C1713 6991230 - CAGE SPNL XL 30X16X12MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6991235 SUP HCPCS C1713 6991235 - CAGE SPNL XL 35X16X12MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 6991240 SUP HCPCS C1713 6991240 - CAGE SPNL XL 40X16X12MM NS LF CRNT THOR BOTH IP/OP "$13,000.00 " "$9,620.00" $0.00 "$10,400.00" "$5,850.00" "$5,850.00" $0.00 $0.00 $0.00 "$2,709.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,709.20" $0.00 "$6,409.00" "$6,409.00" $0.00 "$6,500.00" "$10,296.00" "$10,400.00" $0.00 $0.00 "$2,034.50" $0.00 $0.00 "$2,069.60" $0.00 $0.00 $0.00 $0.00 $0.00 7002500 SUP HCPCS C1713 7002500 - CROSSLINK SET SCREW BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7002525 SUP HCPCS C1713 7002525 - LINK SPNL XLNK VRTX SM TI PLT RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7002526 SUP HCPCS C1713 7002526 - PLATE BONE XLNK MED SPNL TI PLT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7002527 SUP Custom 27803010 7002527 - CONCTR ROD LG VRTX MX XLNK PLT TI SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7020500 SUP HCPCS C1713 7020500 - BONE SCREW 7020500 ILIAC 5.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020535 SUP HCPCS C1713 7020535 - BONE SCREW 7020535 ILIAC 5.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020540 SUP HCPCS C1713 7020540 - BONE SCREW 7020540 ILIAC 5.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020545 SUP HCPCS C1713 7020545 - BONE SCREW 7020545 ILIAC 5.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020550 SUP HCPCS C1713 7020550 - BONE SCREW 7020550 ILIAC 5.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020555 SUP HCPCS C1713 7020555 - BONE SCREW 7020555 ILIAC 5.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020560 SUP HCPCS C1713 7020560 - BONE SCREW 7020560 ILIAC 5.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020570 SUP HCPCS C1713 7020570 - BONE SCREW 7020570 ILIAC 5.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020580 SUP HCPCS C1713 7020580 - BONE SCREW 7020580 ILIAC 5.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020590 SUP HCPCS C1713 7020590 - BONE SCREW 7020590 ILIAC 5.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020600 SUP HCPCS C1713 7020600 - BONE SCREW 7020600 ILIAC 6.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020635 SUP HCPCS C1713 7020635 - BONE SCREW 7020635 ILIAC 6.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020640 SUP HCPCS C1713 7020640 - BONE SCREW 7020640 ILIAC 6.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020645 SUP HCPCS C1713 7020645 - BONE SCREW 7020645 ILIAC 6.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020650 SUP HCPCS C1713 7020650 - BONE SCREW 7020650 ILIAC 6.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020655 SUP HCPCS C1713 7020655 - BONE SCREW 7020655 ILIAC 6.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020660 SUP HCPCS C1713 7020660 - BONE SCREW 7020660 ILIAC 6.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020670 SUP HCPCS C1713 7020670 - BONE SCREW 7020670 ILIAC 6.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020680 SUP HCPCS C1713 7020680 - BONE SCREW 7020680 ILIAC 6.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020690 SUP HCPCS C1713 7020690 - BONE SCREW 7020690 ILIAC 6.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020700 SUP HCPCS C1713 7020700 - BONE SCREW 7020700 ILIAC 7.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020735 SUP HCPCS C1713 7020735 - BONE SCREW 7020735 ILIAC 7.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020740 SUP HCPCS C1713 7020740 - BONE SCREW 7020740 ILIAC 7.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020745 SUP HCPCS C1713 7020745 - BONE SCREW 7020745 ILIAC 7.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020750 SUP HCPCS C1713 7020750 - BONE SCREW 7020750 ILIAC 7.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020755 SUP HCPCS C1713 7020755 - BONE SCREW 7020755 ILIAC 7.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020760 SUP HCPCS C1713 7020760 - BONE SCREW 7020760 ILIAC 7.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020770 SUP HCPCS C1713 7020770 - BONE SCREW 7020770 ILIAC 7.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020780 SUP HCPCS C1713 7020780 - BONE SCREW 7020780 ILIAC 7.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020790 SUP HCPCS C1713 7020790 - BONE SCREW 7020790 ILIAC 7.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020800 SUP HCPCS C1713 7020800 - BONE SCREW 7020800 ILIAC 8.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020835 SUP HCPCS C1713 7020835 - BONE SCREW 7020835 ILIAC 8.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020840 SUP HCPCS C1713 7020840 - BONE SCREW 7020840 ILIAC 8.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020845 SUP HCPCS C1713 7020845 - BONE SCREW 7020845 ILIAC 8.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020850 SUP HCPCS C1713 7020850 - BONE SCREW 7020850 ILIAC 8.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020860 SUP HCPCS C1713 7020860 - BONE SCREW 7020860 ILIAC 8.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020870 SUP HCPCS C1713 7020870 - BONE SCREW 7020870 ILIAC 8.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020880 SUP HCPCS C1713 7020880 - BONE SCREW 7020880 ILIAC 8.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7020890 SUP HCPCS C1713 7020890 - BONE SCREW 7020890 ILIAC 8.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021210 SUP Custom 27803010 7021210 - CONCTR ROD 10MM 4.5/6.35MM CD HZN LGC CLOSE OFFST SS SPNL BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021220 SUP Custom 27803010 7021220 - CONCTR ROD 20MM 4.5/6.35MM CD HZN LGC CLOSE OFFST SS SPNL BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021230 SUP Custom 27803010 7021230 - CONCTR ROD 30MM 4.5/6.35MM CD HZN LGC CLOSE OFFST SS SPNL BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021310 SUP Custom 27803010 7021310 - CONNECTOR 7021310 5.5 6.35 CLS LAT 10 SS BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021320 SUP Custom 27803010 7021320 - CONNECTOR 7021320 5.5 6.35 CLS LAT 20 SS BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021330 SUP Custom 27803010 7021330 - CONNECTOR 7021330 5.5 6.35 CLS LAT 30 SS BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021360 SUP Custom 27803010 7021360 - CONCTR ROD 60MM 5.5/6.35MM CD HZN LGC CLOSE OFFST SS SPNL BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021410 SUP Custom 27803010 7021410 - CONNECTOR 7021410 6.35 6.35 CLS LT 10 SS BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021420 SUP Custom 27803010 7021420 - CONNECTOR 7021420 6.35 6.35 CLS LT 20 SS BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021430 SUP Custom 27803010 7021430 - CONNECTOR 7021430 6.35 6.35 CLS LT 30 SS BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021460 SUP Custom 27803010 7021460 - CONCTR ROD 60MM 6.35MM CD HZN LGC CLOSE OFFST SS SPNL LAT BOTH IP/OP "$1,730.18 " "$1,280.33" $0.00 "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.14" "$1,284.14" $0.00 $0.00 $360.57 $0.00 $0.00 $0.00 $0.00 $865.09 "$1,370.30" "$1,384.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7021600 SUP HCPCS C1713 7021600 - BONE SCREW 7021600 10 DEG ILC 6.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021635 SUP HCPCS C1713 7021635 - BONE SCREW 7021635 10 DEG ILC 6.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021640 SUP HCPCS C1713 7021640 - BONE SCREW 7021640 10 DEG ILC 6.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021645 SUP HCPCS C1713 7021645 - BONE SCREW 7021645 10 DEG ILC 6.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021650 SUP HCPCS C1713 7021650 - BONE SCREW 7021650 10 DEG ILC 6.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021655 SUP HCPCS C1713 7021655 - BONE SCREW 7021655 10 DEG ILC 6.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021660 SUP HCPCS C1713 7021660 - BONE SCREW 7021660 10 DEG ILC 6.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021670 SUP HCPCS C1713 7021670 - BONE SCREW 7021670 10 DEG ILC 6.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021680 SUP HCPCS C1713 7021680 - BONE SCREW 7021680 10 DEG ILC 6.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021690 SUP HCPCS C1713 7021690 - BONE SCREW 7021690 10 DEG ILC 6.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021700 SUP HCPCS C1713 7021700 - BONE SCREW 7021700 10 DEG ILC 7.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021735 SUP HCPCS C1713 7021735 - BONE SCREW 7021735 10 DEG ILC 7.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021740 SUP HCPCS C1713 7021740 - BONE SCREW 7021740 10 DEG ILC 7.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021745 SUP HCPCS C1713 7021745 - BONE SCREW 7021745 10 DEG ILC 7.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021750 SUP HCPCS C1713 7021750 - BONE SCREW 7021750 10 DEG ILC 7.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021755 SUP HCPCS C1713 7021755 - BONE SCREW 7021755 10 DEG ILC 7.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021760 SUP HCPCS C1713 7021760 - BONE SCREW 7021760 10 DEG ILC 7.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021770 SUP HCPCS C1713 7021770 - BONE SCREW 7021770 10 DEG ILC 7.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021780 SUP HCPCS C1713 7021780 - BONE SCREW 7021780 10 DEG ILC 7.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021790 SUP HCPCS C1713 7021790 - BONE SCREW 7021790 10 DEG ILC 7.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021800 SUP HCPCS C1713 7021800 - BONE SCREW 7021800 10 DEG ILC 8.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021835 SUP HCPCS C1713 7021835 - BONE SCREW 7021835 10 DEG ILC 8.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021840 SUP HCPCS C1713 7021840 - BONE SCREW 7021840 10 DEG ILC 8.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021845 SUP HCPCS C1713 7021845 - BONE SCREW 7021845 10 DEG ILC 8.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021850 SUP HCPCS C1713 7021850 - BONE SCREW 7021850 10 DEG ILC 8.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021855 SUP HCPCS C1713 7021855 - BONE SCREW 7021855 10 DEG ILC 8.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021860 SUP HCPCS C1713 7021860 - BONE SCREW 7021860 10 DEG ILC 8.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021870 SUP HCPCS C1713 7021870 - BONE SCREW 7021870 10 DEG ILC 8.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021880 SUP HCPCS C1713 7021880 - BONE SCREW 7021880 10 DEG ILC 8.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7021890 SUP HCPCS C1713 7021890 - BONE SCREW 7021890 10 DEG ILC 8.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022210 SUP Custom 27803010 7022210 - CONNECTOR 7022210 LAT CONN SS 4.5 12MM BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7022230 SUP Custom 27803010 7022230 - CONNECTOR 7022230 LAT CONN SS 4.5 32MM BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7022310 SUP Custom 27803010 7022310 - CONNECTOR 7022310 LAT CONN SS 5.5 12MM BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7022330 SUP Custom 27803010 7022330 - CONNECTOR 7022330 LAT CONN SS 5.5 32MM BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7022410 SUP Custom 27803010 7022410 - CONNECTOR 7022410 LAT CONN SS 6.35 12MM BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7022430 SUP Custom 27803010 7022430 - CONNECTOR 7022430 LAT CONN SS 6.35 32MM BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7022600 SUP HCPCS C1713 7022600 - BONE SCREW 7022600 20 DEG ILC 6.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022635 SUP HCPCS C1713 7022635 - BONE SCREW 7022635 20 DEG ILC 6.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022640 SUP HCPCS C1713 7022640 - BONE SCREW 7022640 20 DEG ILC 6.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022645 SUP HCPCS C1713 7022645 - BONE SCREW 7022645 20 DEG ILC 6.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022650 SUP HCPCS C1713 7022650 - BONE SCREW 7022650 20 DEG ILC 6.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022655 SUP HCPCS C1713 7022655 - BONE SCREW 7022655 20 DEG ILC 6.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022660 SUP HCPCS C1713 7022660 - BONE SCREW 7022660 20 DEG ILC 6.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022670 SUP HCPCS C1713 7022670 - BONE SCREW 7022670 20 DEG ILC 6.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022680 SUP HCPCS C1713 7022680 - BONE SCREW 7022680 20 DEG ILC 6.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022690 SUP HCPCS C1713 7022690 - BONE SCREW 7022690 20 DEG ILC 6.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022700 SUP HCPCS C1713 7022700 - BONE SCREW 7022700 20 DEG ILC 7.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022735 SUP HCPCS C1713 7022735 - BONE SCREW 7022735 20 DEG ILC 7.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022740 SUP HCPCS C1713 7022740 - BONE SCREW 7022740 20 DEG ILC 7.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022750 SUP HCPCS C1713 7022750 - BONE SCREW 7022750 20 DEG ILC 7.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022755 SUP HCPCS C1713 7022755 - BONE SCREW 7022755 20 DEG ILC 7.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022760 SUP HCPCS C1713 7022760 - BONE SCREW 7022760 20 DEG ILC 7.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022770 SUP HCPCS C1713 7022770 - BONE SCREW 7022770 20 DEG ILC 7.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022780 SUP HCPCS C1713 7022780 - BONE SCREW 7022780 20 DEG ILC 7.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022790 SUP HCPCS C1713 7022790 - BONE SCREW 7022790 20 DEG ILC 7.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022800 SUP HCPCS C1713 7022800 - BONE SCREW 7022800 20 DEG ILC 8.5X100 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022835 SUP HCPCS C1713 7022835 - BONE SCREW 7022835 20 DEG ILC 8.5X35 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022840 SUP HCPCS C1713 7022840 - BONE SCREW 7022840 20 DEG ILC 8.5X40 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022845 SUP HCPCS C1713 7022845 - BONE SCREW 7022845 20 DEG ILC 8.5X45 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022850 SUP HCPCS C1713 7022850 - BONE SCREW 7022850 20 DEG ILC 8.5X50 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022855 SUP HCPCS C1713 7022855 - BONE SCREW 7022855 20 DEG ILC 8.5X55 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022860 SUP HCPCS C1713 7022860 - BONE SCREW 7022860 20 DEG ILC 8.5X60 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022870 SUP HCPCS C1713 7022870 - BONE SCREW 7022870 20 DEG ILC 8.5X70 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022880 SUP HCPCS C1713 7022880 - BONE SCREW 7022880 20 DEG ILC 8.5X80 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7022890 SUP HCPCS C1713 7022890 - BONE SCREW 7022890 20 DEG ILC 8.5X90 SS BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7023130 SUP Custom 27203010 7023130 - CASE STERILIZATION ILIAC SCREW SET BOTH IP/OP $409.50 $303.03 $0.00 $327.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $303.93 $303.93 $0.00 $0.00 $85.34 $0.00 $0.00 $0.00 $0.00 $204.75 $324.32 $327.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7024855 SUP HCPCS C1713 7024855 - SCREW SET SS .25IN 32 THRD SPN PDCL BRKOF CD HZN LGC 6.35MM BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7025855 SUP HCPCS C1713 7025855 - SET SCREW 7025855 1 4 32 BREAK OFF SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7030500 SUP HCPCS C1713 "7030500 - PROXIMAL SCREW 5.5 X 100, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030550 SUP HCPCS C1713 "7030550 - PROXIMAL SCREW 5.5 X 50, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030555 SUP HCPCS C1713 "7030555 - PROXIMAL SCREW 5.5 X 55, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030560 SUP HCPCS C1713 "7030560 - PROXIMAL SCREW 5.5 X 60, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030570 SUP HCPCS C1713 "7030570 - PROXIMAL SCREW 5.5 X 70, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030580 SUP HCPCS C1713 "7030580 - PROXIMAL SCREW 5.5 X 80, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030590 SUP HCPCS C1713 "7030590 - PROXIMAL SCREW 5.5 X 90, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030600 SUP HCPCS C1713 "7030600 - PROXIMAL SCREW 6.5 X 100, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030655 SUP HCPCS C1713 "7030655 - PROXIMAL SCREW 6.5 X 55, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030680 SUP HCPCS C1713 "7030680 - PROXIMAL SCREW 6.5 X 80, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030690 SUP HCPCS C1713 "7030690 - PROXIMAL SCREW 6.5 X 90, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030750 SUP HCPCS C1713 "7030750 - PROXIMAL SCREW 7.5 X 50, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030755 SUP HCPCS C1713 "7030755 - PROXIMAL SCREW 7.5 X 55, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030850 SUP HCPCS C1713 "7030850 - PROXIMAL SCREW 8.5 X 50, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030855 SUP HCPCS C1713 "7030855 - PROXIMAL SCREW 8.5 X 55, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7030860 SUP HCPCS C1713 "7030860 - PROXIMAL SCREW 8.5 X 60, SS" BOTH IP/OP "$2,134.10 " "$1,579.23" $0.00 "$1,707.28" $960.35 $960.35 $0.00 $0.00 $0.00 $444.80 "$1,583.93" "$1,583.93" $0.00 $0.00 $444.75 $0.00 "$1,262.32" "$1,262.32" $0.00 "$1,067.05" "$1,690.21" "$1,707.28" $0.00 $0.00 $333.99 $0.00 $0.00 $339.75 $0.00 $0.00 $0.00 $0.00 $0.00 7040500 SUP HCPCS C1713 7040500 - BONE SCREW 7040500 ILIAC 5.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040535 SUP HCPCS C1713 7040535 - BONE SCREW 7040535 ILIAC 5.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040540 SUP HCPCS C1713 7040540 - BONE SCREW 7040540 ILIAC 5.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040545 SUP HCPCS C1713 7040545 - BONE SCREW 7040545 ILIAC 5.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040550 SUP HCPCS C1713 7040550 - BONE SCREW 7040550 ILIAC 5.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040555 SUP HCPCS C1713 7040555 - BONE SCREW 7040555 ILIAC 5.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040570 SUP HCPCS C1713 7040570 - BONE SCREW 7040570 ILIAC 5.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040580 SUP HCPCS C1713 7040580 - BONE SCREW 7040580 ILIAC 5.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040590 SUP HCPCS C1713 7040590 - BONE SCREW 7040590 ILIAC 5.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040600 SUP HCPCS C1713 7040600 - BONE SCREW 7040600 ILIAC 6.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040635 SUP HCPCS C1713 7040635 - BONE SCREW 7040635 ILIAC 6.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040640 SUP HCPCS C1713 7040640 - BONE SCREW 7040640 ILIAC 6.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040645 SUP HCPCS C1713 7040645 - BONE SCREW 7040645 ILIAC 6.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040650 SUP HCPCS C1713 7040650 - BONE SCREW 7040650 ILIAC 6.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040655 SUP HCPCS C1713 7040655 - BONE SCREW 7040655 ILIAC 6.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040660 SUP HCPCS C1713 7040660 - BONE SCREW 7040660 ILIAC 6.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040670 SUP HCPCS C1713 7040670 - BONE SCREW 7040670 ILIAC 6.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040680 SUP HCPCS C1713 7040680 - BONE SCREW 7040680 ILIAC 6.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040690 SUP HCPCS C1713 7040690 - BONE SCREW 7040690 ILIAC 6.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040700 SUP HCPCS C1713 7040700 - BONE SCREW 7040700 ILIAC 7.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040740 SUP HCPCS C1713 7040740 - BONE SCREW 7040740 ILIAC 7.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040745 SUP HCPCS C1713 7040745 - BONE SCREW 7040745 ILIAC 7.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040750 SUP HCPCS C1713 7040750 - BONE SCREW 7040750 ILIAC 7.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040755 SUP HCPCS C1713 7040755 - BONE SCREW 7040755 ILIAC 7.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040760 SUP HCPCS C1713 7040760 - BONE SCREW 7040760 ILIAC 7.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040770 SUP HCPCS C1713 7040770 - BONE SCREW 7040770 ILIAC 7.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040780 SUP HCPCS C1713 7040780 - BONE SCREW 7040780 ILIAC 7.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040790 SUP HCPCS C1713 7040790 - BONE SCREW 7040790 ILIAC 7.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040800 SUP HCPCS C1713 7040800 - BONE SCREW 7040800 ILIAC 8.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040835 SUP HCPCS C1713 7040835 - BONE SCREW 7040835 ILIAC 8.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040840 SUP HCPCS C1713 7040840 - BONE SCREW 7040840 ILIAC 8.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040845 SUP HCPCS C1713 7040845 - BONE SCREW 7040845 ILIAC 8.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040850 SUP HCPCS C1713 7040850 - BONE SCREW 7040850 ILIAC 8.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040860 SUP HCPCS C1713 7040860 - BONE SCREW 7040860 ILIAC 8.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040870 SUP HCPCS C1713 7040870 - BONE SCREW 7040870 ILIAC 8.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040880 SUP HCPCS C1713 7040880 - BONE SCREW 7040880 ILIAC 8.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7040890 SUP HCPCS C1713 7040890 - BONE SCREW 7040890 ILIAC 8.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041210 SUP Custom 27803010 7041210 - CONCTR ROD 10MM CD HZN LGC CLOSE OFFST TI LAT SPNL 4.5/6.35 BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041220 SUP Custom 27803010 7041220 - CONECTOR 7041220 CLSLAT 20MM TI 4.5/6.35 BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041230 SUP Custom 27803010 7041230 - CONECTOR 7041230 CLSLAT 30MM TI 4.5/6.35 BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041310 SUP Custom 27803010 7041310 - CONNECTOR 7041310 5.5 6.35 CLS LAT 10 TI BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041320 SUP Custom 27803010 7041320 - CONCTR ROD 20MM CD HZN LGC CLOSE OFFST TI LAT SPNL 5.5/6.35 BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041330 SUP Custom 27803010 7041330 - CONNECTOR 7041330 5.5 6.35 CLS LAT 30 TI BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041360 SUP Custom 27803010 7041360 - CONECTR 7041360 5.5/6.35 CLS LAT 60MM TI BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041410 SUP Custom 27803010 7041410 - CONNECTOR 7041410 6.35 6.35 CLS LT 10 TI BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041420 SUP Custom 27803010 7041420 - CONNECTOR 7041420 6.35 6.35 CLS LT 20 TI BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041430 SUP Custom 27803010 7041430 - CONNECTOR 7041430 6.35 6.35 CLS LT 30 TI BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041460 SUP Custom 27803010 7041460 - CONECTR 7041460 6.35/6.35 CLS LAT 60MMTI BOTH IP/OP "$1,843.63 " "$1,364.29" $0.00 "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.34" "$1,368.34" $0.00 $0.00 $384.21 $0.00 $0.00 $0.00 $0.00 $921.81 "$1,460.15" "$1,474.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7041600 SUP HCPCS C1713 7041600 - BONE SCREW 7041600 10 DEG ILC 6.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041635 SUP HCPCS C1713 7041635 - BONE SCREW 7041635 10 DEG ILC 6.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041640 SUP HCPCS C1713 7041640 - BONE SCREW 7041640 10 DEG ILC 6.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041645 SUP HCPCS C1713 7041645 - BONE SCREW 7041645 10 DEG ILC 6.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041650 SUP HCPCS C1713 7041650 - BONE SCREW 7041650 10 DEG ILC 6.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041655 SUP HCPCS C1713 7041655 - BONE SCREW 7041655 10 DEG ILC 6.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041660 SUP HCPCS C1713 7041660 - BONE SCREW 7041660 10 DEG ILC 6.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041670 SUP HCPCS C1713 7041670 - BONE SCREW 7041670 10 DEG ILC 6.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041680 SUP HCPCS C1713 7041680 - BONE SCREW 7041680 10 DEG ILC 6.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041690 SUP HCPCS C1713 7041690 - BONE SCREW 7041690 10 DEG ILC 6.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041700 SUP HCPCS C1713 7041700 - BONE SCREW 7041700 10 DEG ILC 7.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041735 SUP HCPCS C1713 7041735 - BONE SCREW 7041735 10 DEG ILC 7.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041740 SUP HCPCS C1713 7041740 - BONE SCREW 7041740 10 DEG ILC 7.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041745 SUP HCPCS C1713 7041745 - BONE SCREW 7041745 10 DEG ILC 7.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041750 SUP HCPCS C1713 7041750 - BONE SCREW 7041750 10 DEG ILC 7.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041755 SUP HCPCS C1713 7041755 - BONE SCREW 7041755 10 DEG ILC 7.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041760 SUP HCPCS C1713 7041760 - BONE SCREW 7041760 10 DEG ILC 7.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041770 SUP HCPCS C1713 7041770 - BONE SCREW 7041770 10 DEG ILC 7.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041780 SUP HCPCS C1713 7041780 - BONE SCREW 7041780 10 DEG ILC 7.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041790 SUP HCPCS C1713 7041790 - BONE SCREW 7041790 10 DEG ILC 7.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041800 SUP HCPCS C1713 7041800 - BONE SCREW 7041800 10 DEG ILC 8.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041835 SUP HCPCS C1713 7041835 - BONE SCREW 7041835 10 DEG ILC 8.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041840 SUP HCPCS C1713 7041840 - BONE SCREW 7041840 10 DEG ILC 8.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041845 SUP HCPCS C1713 7041845 - BONE SCREW 7041845 10 DEG ILC 8.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041850 SUP HCPCS C1713 7041850 - BONE SCREW 7041850 10 DEG ILC 8.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041855 SUP HCPCS C1713 7041855 - BONE SCREW 7041855 10 DEG ILC 8.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041860 SUP HCPCS C1713 7041860 - BONE SCREW 7041860 10 DEG ILC 8.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041870 SUP HCPCS C1713 7041870 - BONE SCREW 7041870 10 DEG ILC 8.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041880 SUP HCPCS C1713 7041880 - BONE SCREW 7041880 10 DEG ILC 8.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7041890 SUP HCPCS C1713 7041890 - BONE SCREW 7041890 10 DEG ILC 8.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042210 SUP Custom 27803010 7042210 - CONNECTOR 7042210 LAT CONN TI 4.5 12MM BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7042230 SUP Custom 27803010 7042230 - CONNECTOR 7042230 LAT CONN TI 4.5 32MM BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7042310 SUP Custom 27803010 7042310 - CONNECTOR 7042310 LAT CONN TI 5.5 12MM BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7042320 SUP Custom 27803010 7042320 - CONNECTOR 7042320 LAT CONN TI 5.5 22MM BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7042330 SUP Custom 27803010 7042330 - CONNECTOR 7042330 LAT CONN TI 5.5 32MM BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7042410 SUP Custom 27803010 7042410 - CONNECTOR 7042410 LAT CONN TI 6.35 12MM BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7042430 SUP Custom 27803010 7042430 - CONNECTOR 7042430 LAT CONN TI 6.35 32MM BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7042600 SUP HCPCS C1713 7042600 - BONE SCREW 7042600 20 DEG ILC 6.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042635 SUP HCPCS C1713 7042635 - BONE SCREW 7042635 20 DEG ILC 6.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042640 SUP HCPCS C1713 7042640 - BONE SCREW 7042640 20 DEG ILC 6.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042645 SUP HCPCS C1713 7042645 - BONE SCREW 7042645 20 DEG ILC 6.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042650 SUP HCPCS C1713 7042650 - BONE SCREW 7042650 20 DEG ILC 6.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042655 SUP HCPCS C1713 7042655 - BONE SCREW 7042655 20 DEG ILC 6.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042660 SUP HCPCS C1713 7042660 - BONE SCREW 7042660 20 DEG ILC 6.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042670 SUP HCPCS C1713 7042670 - BONE SCREW 7042670 20 DEG ILC 6.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042680 SUP HCPCS C1713 7042680 - BONE SCREW 7042680 20 DEG ILC 6.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042690 SUP HCPCS C1713 7042690 - BONE SCREW 7042690 20 DEG ILC 6.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042700 SUP HCPCS C1713 7042700 - BONE SCREW 7042700 20 DEG ILC 7.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042735 SUP HCPCS C1713 7042735 - BONE SCREW 7042735 20 DEG ILC 7.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042740 SUP HCPCS C1713 7042740 - BONE SCREW 7042740 20 DEG ILC 7.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042745 SUP HCPCS C1713 7042745 - BONE SCREW 7042745 20 DEG ILC 7.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042750 SUP HCPCS C1713 7042750 - BONE SCREW 7042750 20 DEG ILC 7.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042755 SUP HCPCS C1713 7042755 - BONE SCREW 7042755 20 DEG ILC 7.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042760 SUP HCPCS C1713 7042760 - BONE SCREW 7042760 20 DEG ILC 7.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042770 SUP HCPCS C1713 7042770 - BONE SCREW 7042770 20 DEG ILC 7.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042780 SUP HCPCS C1713 7042780 - BONE SCREW 7042780 20 DEG ILC 7.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042790 SUP HCPCS C1713 7042790 - BONE SCREW 7042790 20 DEG ILC 7.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042800 SUP HCPCS C1713 7042800 - BONE SCREW 7042800 20 DEG ILC 8.5X100 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042835 SUP HCPCS C1713 7042835 - BONE SCREW 7042835 20 DEG ILC 8.5X35 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042840 SUP HCPCS C1713 7042840 - BONE SCREW 7042840 20 DEG ILC 8.5X40 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042845 SUP HCPCS C1713 7042845 - BONE SCREW 7042845 20 DEG ILC 8.5X45 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042850 SUP HCPCS C1713 7042850 - BONE SCREW 7042850 20 DEG ILC 8.5X50 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042855 SUP HCPCS C1713 7042855 - BONE SCREW 7042855 20 DEG ILC 8.5X55 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042860 SUP HCPCS C1713 7042860 - BONE SCREW 7042860 20 DEG ILC 8.5X60 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042870 SUP HCPCS C1713 7042870 - BONE SCREW 7042870 20 DEG ILC 8.5X70 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042880 SUP HCPCS C1713 7042880 - BONE SCREW 7042880 20 DEG ILC 8.5X80 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7042890 SUP HCPCS C1713 7042890 - BONE SCREW 7042890 20 DEG ILC 8.5X90 TI BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7045855 SUP HCPCS C1713 7045855 - SET SCREW 7045855 1 4 32 BREAK OFF TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7049855 SUP HCPCS C1713 7049855 - SCREW 7049855 HEX BREAK OFF TI .25 32 BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7050500 SUP HCPCS C1713 "7050500 - PROXIMAL SCREW 5.5 X 100, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050550 SUP HCPCS C1713 "7050550 - PROXIMAL SCREW 5.5 X 50, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050555 SUP HCPCS C1713 "7050555 - PROXIMAL SCREW 5.5 X 55, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050560 SUP HCPCS C1713 "7050560 - PROXIMAL SCREW 5.5 X 60, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050570 SUP HCPCS C1713 "7050570 - PROXIMAL SCREW 5.5 X 70, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050580 SUP HCPCS C1713 "7050580 - PROXIMAL SCREW 5.5 X 80, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050590 SUP HCPCS C1713 "7050590 - PROXIMAL SCREW 5.5 X 90, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050600 SUP HCPCS C1713 "7050600 - PROXIMAL SCREW 6.5 X 100, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050655 SUP HCPCS C1713 "7050655 - PROXIMAL SCREW 6.5 X 55, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050680 SUP HCPCS C1713 "7050680 - PROXIMAL SCREW 6.5 X 80, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050690 SUP HCPCS C1713 "7050690 - PROXIMAL SCREW 6.5 X 90, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050750 SUP HCPCS C1713 "7050750 - PROXIMAL SCREW 7.5 X 50, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050755 SUP HCPCS C1713 "7050755 - PROXIMAL SCREW 7.5 X 55, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050850 SUP HCPCS C1713 "7050850 - PROXIMAL SCREW 8.5 X 50, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050855 SUP HCPCS C1713 "7050855 - PROXIMAL SCREW 8.5 X 55, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7050860 SUP HCPCS C1713 "7050860 - PROXIMAL SCREW 8.5 X 60, TI" BOTH IP/OP "$2,273.50 " "$1,682.39" $0.00 "$1,818.80" "$1,023.08" "$1,023.08" $0.00 $0.00 $0.00 $473.85 "$1,687.39" "$1,687.39" $0.00 $0.00 $473.80 $0.00 "$1,344.78" "$1,344.78" $0.00 "$1,136.75" "$1,800.61" "$1,818.80" $0.00 $0.00 $355.80 $0.00 $0.00 $361.94 $0.00 $0.00 $0.00 $0.00 $0.00 7060300 SUP Custom 27803010 7060300 - TUBE ET 9MM 6MM STRL LSRSHLD II CUF WRP REFLC SIL AL FLRPLAS BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $0.00 $0.00 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7060400 SUP Custom 27803010 7060400 - TUBE ET 10.5MM 7MM STRL LSRSHLD II CUF WRP REFLC SIL AL BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $0.00 $0.00 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7060500 SUP Custom 27803010 7060500 - TUBE ET 11.5MM 8MM STRL LF LSRSHLD II DISP BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $0.00 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7070501 SUP Custom 27203010 7070501 - DRILL SRG 4.5MM NS LF DISP MAS PLIF BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7070502 SUP Custom 27203010 7070502 - DRILL SRG 5MM DISP MAS PLIF BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7070503 SUP Custom 27203010 7070503 - DRILL SRG 5.5MM DISP MAS PLIF BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7080510 SUP Custom 27203010 7080510 - BIT DRL 11MM STRL DISP BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $0.00 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7080513 SUP Custom 27203010 7080513 - BIT DRL 13MM STRL DISP BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $0.00 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7096530 SUP HCPCS C1713 7096530 - SCREW BN 6.5MM 30MM MAS PLIF BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7110001 SUP HCPCS C1713 7110001 - SCREW LOCK DIA 16 CORE VBR 2 BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 7110003 SUP HCPCS C1713 7110003 - SCREW LOCK CORE DIA 18 DIA 22 XCORE 2 TI BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 7124540 SUP HCPCS C1713 7124540 - SCREW BN 4.5MM 40MM SPNE MAS PLIF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7125025 SUP HCPCS C1713 7125025 - SCREW BN 5MM 25MM NS MAS PA SPNE 3Z PLIF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7125035 SUP HCPCS C1713 7125035 - SCREW BN 5MM 35MM SPNE MAS PLIF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7125525 SUP HCPCS C1713 7125525 - SCREW BN 5.5MM 25MM SPNE MAS PLIF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7125535 SUP HCPCS C1713 7125535 - SCREW BN 5.5MM 35MM SPNE MAS PLIF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7135100 SUP Custom 27203010 7135100 - KIT AUTOTRANSFUSION BOWL SMALL ASMBLY LOW VOLUME CENTRIFUGE BOTH IP/OP "$1,378.93 " "$1,020.41" $0.00 "$1,103.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,023.44" "$1,023.44" $0.00 $0.00 $287.37 $0.00 $0.00 $0.00 $0.00 $689.46 "$1,092.11" "$1,103.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7140208 SUP HCPCS C1713 7140208 - PLATE BN 8 NS DECADE 2 HL SPNE XLIF BOTH IP/OP "$9,005.00 " "$6,663.70" $0.00 "$7,204.00" "$4,052.25" "$4,052.25" $0.00 $0.00 $0.00 "$1,876.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,876.64" $0.00 "$4,439.47" "$4,439.47" $0.00 "$4,502.50" "$7,131.96" "$7,204.00" $0.00 $0.00 "$1,409.28" $0.00 $0.00 "$1,433.60" $0.00 $0.00 $0.00 $0.00 $0.00 7140210 SUP HCPCS C1713 7140210 - PLATE BN 10 NS DECADE 2 HL SPNE XLIF BOTH IP/OP "$9,005.00 " "$6,663.70" $0.00 "$7,204.00" "$4,052.25" "$4,052.25" $0.00 $0.00 $0.00 "$1,876.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,876.64" $0.00 "$4,439.47" "$4,439.47" $0.00 "$4,502.50" "$7,131.96" "$7,204.00" $0.00 $0.00 "$1,409.28" $0.00 $0.00 "$1,433.60" $0.00 $0.00 $0.00 $0.00 $0.00 7140212 SUP HCPCS C1713 7140212 - PLATE BN 12 NS DECADE 2 HL SPNE XLIF BOTH IP/OP "$9,005.00 " "$6,663.70" $0.00 "$7,204.00" "$4,052.25" "$4,052.25" $0.00 $0.00 $0.00 "$1,876.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,876.64" $0.00 "$4,439.47" "$4,439.47" $0.00 "$4,502.50" "$7,131.96" "$7,204.00" $0.00 $0.00 "$1,409.28" $0.00 $0.00 "$1,433.60" $0.00 $0.00 $0.00 $0.00 $0.00 7140214 SUP HCPCS C1713 7140214 - PLATE BN 14 NS DECADE 2 HL SPNE XLIF BOTH IP/OP "$9,005.00 " "$6,663.70" $0.00 "$7,204.00" "$4,052.25" "$4,052.25" $0.00 $0.00 $0.00 "$1,876.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,876.64" $0.00 "$4,439.47" "$4,439.47" $0.00 "$4,502.50" "$7,131.96" "$7,204.00" $0.00 $0.00 "$1,409.28" $0.00 $0.00 "$1,433.60" $0.00 $0.00 $0.00 $0.00 $0.00 7140216 SUP HCPCS C1713 7140216 - PLATE BN 16 NS DECADE 2 HL SPNE XLIF BOTH IP/OP "$9,005.00 " "$6,663.70" $0.00 "$7,204.00" "$4,052.25" "$4,052.25" $0.00 $0.00 $0.00 "$1,876.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,876.64" $0.00 "$4,439.47" "$4,439.47" $0.00 "$4,502.50" "$7,131.96" "$7,204.00" $0.00 $0.00 "$1,409.28" $0.00 $0.00 "$1,433.60" $0.00 $0.00 $0.00 $0.00 $0.00 7140218 SUP HCPCS C1713 7140218 - PLATE BN 18 NS DECADE 2 HL SPNE XLIF BOTH IP/OP "$9,005.00 " "$6,663.70" $0.00 "$7,204.00" "$4,052.25" "$4,052.25" $0.00 $0.00 $0.00 "$1,876.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,876.64" $0.00 "$4,439.47" "$4,439.47" $0.00 "$4,502.50" "$7,131.96" "$7,204.00" $0.00 $0.00 "$1,409.28" $0.00 $0.00 "$1,433.60" $0.00 $0.00 $0.00 $0.00 $0.00 7140408 SUP HCPCS C1713 7140408 - PLATE BN 8 NS DECADE 4 HL SPNE XLIF BOTH IP/OP "$9,642.50 " "$7,135.45" $0.00 "$7,714.00" "$4,339.13" "$4,339.13" $0.00 $0.00 $0.00 "$2,009.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,009.50" $0.00 "$4,753.75" "$4,753.75" $0.00 "$4,821.25" "$7,636.86" "$7,714.00" $0.00 $0.00 "$1,509.05" $0.00 $0.00 "$1,535.09" $0.00 $0.00 $0.00 $0.00 $0.00 7140410 SUP HCPCS C1713 7140410 - PLATE BN 10 NS DECADE 4 HL SPNE XLIF BOTH IP/OP "$9,642.50 " "$7,135.45" $0.00 "$7,714.00" "$4,339.13" "$4,339.13" $0.00 $0.00 $0.00 "$2,009.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,009.50" $0.00 "$4,753.75" "$4,753.75" $0.00 "$4,821.25" "$7,636.86" "$7,714.00" $0.00 $0.00 "$1,509.05" $0.00 $0.00 "$1,535.09" $0.00 $0.00 $0.00 $0.00 $0.00 7140412 SUP HCPCS C1713 7140412 - PLATE BN 12 NS DECADE 4 HL SPNE XLIF BOTH IP/OP "$9,642.50 " "$7,135.45" $0.00 "$7,714.00" "$4,339.13" "$4,339.13" $0.00 $0.00 $0.00 "$2,009.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,009.50" $0.00 "$4,753.75" "$4,753.75" $0.00 "$4,821.25" "$7,636.86" "$7,714.00" $0.00 $0.00 "$1,509.05" $0.00 $0.00 "$1,535.09" $0.00 $0.00 $0.00 $0.00 $0.00 7140414 SUP HCPCS C1713 7140414 - PLATE BN 14 NS DECADE 4 HL SPNE XLIF BOTH IP/OP "$9,642.50 " "$7,135.45" $0.00 "$7,714.00" "$4,339.13" "$4,339.13" $0.00 $0.00 $0.00 "$2,009.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,009.50" $0.00 "$4,753.75" "$4,753.75" $0.00 "$4,821.25" "$7,636.86" "$7,714.00" $0.00 $0.00 "$1,509.05" $0.00 $0.00 "$1,535.09" $0.00 $0.00 $0.00 $0.00 $0.00 7140416 SUP HCPCS C1713 7140416 - PLATE BN 16 NS DECADE 4 HL SPNE XLIF BOTH IP/OP "$9,642.50 " "$7,135.45" $0.00 "$7,714.00" "$4,339.13" "$4,339.13" $0.00 $0.00 $0.00 "$2,009.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,009.50" $0.00 "$4,753.75" "$4,753.75" $0.00 "$4,821.25" "$7,636.86" "$7,714.00" $0.00 $0.00 "$1,509.05" $0.00 $0.00 "$1,535.09" $0.00 $0.00 $0.00 $0.00 $0.00 7140418 SUP HCPCS C1713 7140418 - PLATE BN 18 NS DECADE 4 HL SPNE XLIF BOTH IP/OP "$9,642.50 " "$7,135.45" $0.00 "$7,714.00" "$4,339.13" "$4,339.13" $0.00 $0.00 $0.00 "$2,009.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,009.50" $0.00 "$4,753.75" "$4,753.75" $0.00 "$4,821.25" "$7,636.86" "$7,714.00" $0.00 $0.00 "$1,509.05" $0.00 $0.00 "$1,535.09" $0.00 $0.00 $0.00 $0.00 $0.00 7141112 SUP Custom 27203010 7141112 - GUIDE PIN ORTH 100MM DECADE SPNE XLIF BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7141113 SUP HCPCS C1713 7141113 - PIN FX DECADE SCR XLIF BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 7141230 SUP HCPCS C1713 7141230 - BOLT SPNL SM 5MM 30MM DECADE IMPACTABLE XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7141240 SUP HCPCS C1713 7141240 - BOLT SPNL SM 5MM 40MM DECADE IMPACTABLE XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7141250 SUP HCPCS C1713 7141250 - BOLT SPNL SM 5MM 50MM DECADE IMPACTABLE XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145030 SUP HCPCS C1713 7145030 - BOLT SPNL SM 5MM 30MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145035 SUP HCPCS C1713 7145035 - BOLT SPNL SM 5MM 35MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145040 SUP HCPCS C1713 7145040 - BOLT SPNL SM 5MM 40MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145045 SUP HCPCS C1713 7145045 - BOLT SPNL SM 5MM 45MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145050 SUP HCPCS C1713 7145050 - BOLT SPNL SM 5MM 50MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145055 SUP HCPCS C1713 7145055 - BOLT SPNL SM 5MM 55MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145060 SUP HCPCS C1713 7145060 - BOLT SPNL SM 5MM 60MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145130 SUP HCPCS C1713 7145130 - BOLT SPNL SM 5.5MM 30MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145140 SUP HCPCS C1713 7145140 - BOLT SPNL SM 5.5MM 40MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145150 SUP HCPCS C1713 7145150 - BOLT SPNL SM 5.5MM 50MM NS DECADE THRD PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145525 SUP HCPCS C1713 7145525 - BOLT SPNL LG 5.5MM 25MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145530 SUP HCPCS C1713 7145530 - BOLT SPNL LG 5.5MM 30MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145535 SUP HCPCS C1713 7145535 - BOLT SPNL LG 5.5MM 35MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145540 SUP HCPCS C1713 7145540 - BOLT SPNL LG 5.5MM 40MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145545 SUP HCPCS C1713 7145545 - BOLT SPNL LG 5.5MM 45MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145550 SUP HCPCS C1713 7145550 - BOLT SPNL LG 5.5MM 50MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145555 SUP HCPCS C1713 7145555 - BOLT SPNL LG 5.5MM 55MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7145560 SUP HCPCS C1713 7145560 - BOLT SPNL LG 5.5MM 60MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7146525 SUP HCPCS C1713 7146525 - BOLT SPNL LG 6.5MM 25MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7146530 SUP HCPCS C1713 7146530 - BOLT SPNL LG 6.5MM 30MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7146535 SUP HCPCS C1713 7146535 - BOLT SPNL LG 6.5MM 35MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7146540 SUP HCPCS C1713 7146540 - BOLT SPNL LG 6.5MM 40MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7146545 SUP HCPCS C1713 7146545 - BOLT SPNL LG 6.5MM 45MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7146550 SUP HCPCS C1713 7146550 - BOLT SPNL LG 6.5MM 50MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7146555 SUP HCPCS C1713 7146555 - BOLT SPNL LG 6.5MM 55MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7146560 SUP HCPCS C1713 7146560 - BOLT SPNL LG 6.5MM 60MM NS DECADE PLT XLIF BOTH IP/OP "$2,407.50 " "$1,781.55" $0.00 "$1,926.00" "$1,083.38" "$1,083.38" $0.00 $0.00 $0.00 $501.78 "$1,786.85" "$1,786.85" $0.00 $0.00 $501.72 $0.00 "$1,424.04" "$1,424.04" $0.00 "$1,203.75" "$1,906.74" "$1,926.00" $0.00 $0.00 $376.77 $0.00 $0.00 $383.27 $0.00 $0.00 $0.00 $0.00 $0.00 7160012 SUP Custom 27803010 7160012 - CAGE SPNL 16MM 12MM NS LF X-COR 2 STC FTPRNT TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160014 SUP Custom 27803010 7160014 - CAGE SPNL 16MM 14MM NS LF X-COR 2 STC FTPRNT TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160022 SUP Custom 27803010 7160022 - CAGE SPNL 16MM 16-22MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160025 SUP Custom 27803010 7160025 - CAGE SPNL 16MM 18-25MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160035 SUP Custom 27803010 7160035 - CAGE SPNL 16MM 23-35MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160041 SUP Custom 27803010 7160041 - CAGE SPNL 16MM 26-41MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160049 SUP Custom 27803010 7160049 - CAGE SPNL 16MM 30-49MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160063 SUP Custom 27803010 7160063 - CAGE SPNL 16MM 37-63MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160075 SUP Custom 27803010 7160075 - CAGE SPNL 16MM 43-75MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7162000 SUP HCPCS C1713 7162000 - SCREW LOCK ENDCAP XCORE 2 TI BOTH IP/OP $620.00 $458.80 $0.00 $496.00 $279.00 $279.00 $0.00 $0.00 $0.00 $129.22 $460.16 $460.16 $0.00 $0.00 $129.21 $0.00 $366.73 $366.73 $0.00 $310.00 $491.04 $496.00 $0.00 $0.00 $97.03 $0.00 $0.00 $98.70 $0.00 $0.00 $0.00 $0.00 $0.00 7164565 SUP HCPCS C1713 7164565 - 5.0X 65MM SCREW BOTH IP/OP $648.00 $479.52 $0.00 $518.40 $291.60 $291.60 $0.00 $0.00 $0.00 $135.06 $480.95 $480.95 $0.00 $0.00 $135.04 $0.00 $383.29 $383.29 $0.00 $324.00 $513.22 $518.40 $0.00 $0.00 $101.41 $0.00 $0.00 $103.16 $0.00 $0.00 $0.00 $0.00 $0.00 7180016 SUP Custom 27803010 7180016 - CAGE SPNL 18MM 16MM NS LF X-COR 2 STC FTPRNT TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180018 SUP Custom 27803010 7180018 - CAGE SPNL 18MM 18MM NS LF X-COR 2 STC FTPRNT TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180025 SUP Custom 27803010 7180025 - CAGE SPNL 18MM 20-25MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180027 SUP Custom 27803010 7180027 - CAGE SPNL 18MM 21-27MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180033 SUP Custom 27803010 7180033 - CAGE SPNL 18MM 24-33MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180041 SUP Custom 27803010 7180041 - CAGE SPNL 18MM 28-41MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180055 SUP Custom 27803010 7180055 - CAGE SPINAL 18X35-55MM X-CORE 2 TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180067 SUP Custom 27803010 7180067 - CAGE SPNL 18MM 41-67MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180079 SUP Custom 27803010 7180079 - CAGE SPNL 18MM 47-79MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180121 SUP Custom 27803010 7180121 - CAGE SPNL 18MM 68-121MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7191525 SUP HCPCS C1713 7191525 - CDH 7191525 HA COATED 5.5X25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191530 SUP HCPCS C1713 7191530 - CDH 7191530 HA COATED 5.5X30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191535 SUP HCPCS C1713 7191535 - SCREW BN 5.5MM 35MM STRL CD HZN LGC MA HA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191540 SUP HCPCS C1713 7191540 - SCREW BN 5.5MM 40MM STRL CD HZN LGC MA HA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191545 SUP HCPCS C1713 7191545 - CDH 7191545 HA COATED 5.5X45 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191550 SUP HCPCS C1713 7191550 - CDH HA COATED MAS 5.5X50 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191555 SUP HCPCS C1713 7191555 - CDH HA COATED MAS 5.5X55 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191560 SUP HCPCS C1713 7191560 - CDH HA COATED MAS 5.5X60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191625 SUP HCPCS C1713 7191625 - CDH HA COATED MAS 6.5X25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191630 SUP HCPCS C1713 7191630 - CDH HA COATED MAS 6.5X30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191635 SUP HCPCS C1713 7191635 - SCREW BN 6.5MM 35MM STRL CD HZN LGC MA HA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191640 SUP HCPCS C1713 7191640 - SCREW BN 6.5MM 40MM STRL CD HZN LGC MA HA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191645 SUP HCPCS C1713 7191645 - SCREW BN 6.5MM 45MM STRL CD HZN LGC MA HA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191650 SUP HCPCS C1713 7191650 - CDH HA COATED MAS 6.5X50 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191655 SUP HCPCS C1713 7191655 - CDH HA COATED MAS 6.5X55 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191660 SUP HCPCS C1713 7191660 - CDH HA COATED MAS 6.5X60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191665 SUP HCPCS C1713 7191665 - CDH HA COATED MAS 6.5X65 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191725 SUP HCPCS C1713 7191725 - CDH HA COATED MAS 7.5X25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191730 SUP HCPCS C1713 7191730 - CDH HA COATED MAS 7.5X30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191735 SUP HCPCS C1713 7191735 - CDH 7191735 HA COATED 7.5X35 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191740 SUP HCPCS C1713 7191740 - SCREW BN 7.5MM 40MM STRL CD HZN LGC MA HA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191745 SUP HCPCS C1713 7191745 - SCREW 7191745 MULTI-AXIAL HA COATED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191750 SUP HCPCS C1713 7191750 - CDH HA COATED MAS 7.5X50 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191755 SUP HCPCS C1713 7191755 - CDH HA COATED MAS 7.5X55 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191760 SUP HCPCS C1713 7191760 - CDH HA COATED MAS 7.5X60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191765 SUP HCPCS C1713 7191765 - SCREW 7191765 CDH HA COATED MA 7.5X65 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191770 SUP HCPCS C1713 7191770 - CDH HA COATED MAS 7.5X70 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191825 SUP HCPCS C1713 7191825 - CDH HA COATED MAS 8.5X25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191830 SUP HCPCS C1713 7191830 - CDH HA COATED MAS 8.5X30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191835 SUP HCPCS C1713 7191835 - CDH 7191835 HA COATED 8.5X35 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191840 SUP HCPCS C1713 7191840 - SCREW 7191840 MULTI-AXIAL HA COATED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191845 SUP HCPCS C1713 7191845 - SCREW 7191845 MULTI-AXIAL HA COATED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191850 SUP HCPCS C1713 7191850 - CDH HA COATED MAS 8.5X50 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191855 SUP HCPCS C1713 7191855 - CDH 7191855 HA COATED 8.5X55 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191860 SUP HCPCS C1713 7191860 - CDH HA COATED MAS 8.5X60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7191865 SUP HCPCS C1713 7191865 - CDH HA COATED MAS 8.5X65 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7195535 SUP HCPCS C1713 7195535 - SCREW BN 5.5MM 35MM SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7195540 SUP HCPCS C1713 7195540 - SCREW BN 5.5MM 40MM 2 LD CNN SPNE PDCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7195545 SUP HCPCS C1713 7195545 - SCREW BN 5.5MM 45MM SPHERX II 2 LCK SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7195550 SUP HCPCS C1713 7195550 - SCREW BN 5.5MM 50MM 2 LD CNN SPNE PDCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7195555 SUP HCPCS C1713 7195555 - SCREW BN 5.5MM 55MM 2 LD CNN SPNE PDCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7196535 SUP HCPCS C1713 7196535 - SCREW BN 6.5MM 35MM SPHERX II SPNE DLS BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7196540 SUP HCPCS C1713 7196540 - SCREW BN 6.5MM 40MM SPHERX II 2 LCK SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7196545 SUP HCPCS C1713 7196545 - SCREW BN 6.5MM 45MM SPHERX II 2 SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7196550 SUP HCPCS C1713 7196550 - SCREW BN 6.5MM 50MM SPHERX II 2 LCK SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7196555 SUP HCPCS C1713 7196555 - SCREW BN 6.5MM 55MM SPHERX II 2 LCK SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7197535 SUP HCPCS C1713 7197535 - SCREW BN 7.5MM 40MM SPHERX II 2 LCK SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7197540 SUP HCPCS C1713 7197540 - SCREW BN 7.5MM 40MM SPHERX II 2 LCK SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7197545 SUP HCPCS C1713 7197545 - SCREW BN 7.5MM 45MM 2 LD SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7197550 SUP HCPCS C1713 7197550 - SCREW BN 7.5MM 50MM 2 LD SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7197555 SUP HCPCS C1713 7197555 - SCREW BN 7.5MM 55MM SPHERX II PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7200019 SUP HCPCS C1713 7200019 - PLATE BN 19MM NS ATL VS ELT 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7200021 SUP HCPCS C1713 7200021 - PLATE BN 21MM NS ATL VS ELT 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7200023 SUP HCPCS C1713 7200023 - PLATE BN 23MM NS ATL VS ELT 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7200025 SUP HCPCS C1713 7200025 - PLATE BN 25MM NS ATL VS ELT 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7200027 SUP HCPCS C1713 7200027 - PLATE BN 27.5MM NS ATL VS ELT 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7200030 SUP HCPCS C1713 7200030 - PLATE BN 30MM NS ATL VS ELT 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7200032 SUP HCPCS C1713 7200032 - PLATE 7200032 ATL VISION ELITE 32.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200035 SUP HCPCS C1713 7200035 - PLATE BN 35MM NS ATL VS ELT 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200037 SUP HCPCS C1713 7200037 - PLATE BN 37.5MM NS ATL VS ELT 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200040 SUP HCPCS C1713 7200040 - PLATE BN 40MM NS ATL VS ELT 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200042 SUP HCPCS C1713 7200042 - PLATE BN 42.5MM NS ATL VS ELT 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200045 SUP HCPCS C1713 7200045 - PLATE BN 45MM NS ATL VS ELT 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200047 SUP HCPCS C1713 7200047 - PLATE BN 47.5MM NS ATL VS ELT 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200050 SUP HCPCS C1713 7200050 - PLATE 7200050 ATL VISION ELITE 50MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200052 SUP HCPCS C1713 7200052 - PLATE BN 52.5MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200055 SUP HCPCS C1713 7200055 - PLATE BN 55MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200057 SUP HCPCS C1713 7200057 - PLATE BN 57.5MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200060 SUP HCPCS C1713 7200060 - PLATE BN 60MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200062 SUP HCPCS C1713 7200062 - PLATE BN 62.5MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200065 SUP HCPCS C1713 7200065 - PLATE BN 65MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200067 SUP HCPCS C1713 7200067 - PLATE BN 67.5MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200070 SUP HCPCS C1713 7200070 - PLATE 7200070 ATL VISION ELITE 70MM BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200072 SUP HCPCS C1713 7200072 - PLATE 7200072 ATL VISION ELITE 72.5MM BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200075 SUP HCPCS C1713 7200075 - PLATE 7200075 ATL VISION ELITE 75MM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7200077 SUP HCPCS C1713 7200077 - PLATE 7200077 ATL VISION ELITE 77.5MM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7200080 SUP HCPCS C1713 7200080 - PLATE BN 80MM NS ATL VS ELT 4 LVL TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7200082 SUP HCPCS C1713 7200082 - PLATE BN 82.5MM NS ATL VS ELT 4 LVL TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7200085 SUP HCPCS C1713 7200085 - PLATE 7200085 ATL VISION ELITE 85MM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7200087 SUP HCPCS C1713 7200087 - PLATE 7200087 ATL VISION ELITE 87.5MM BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200090 SUP HCPCS C1713 7200090 - PLATE 7200090 ATL VISION ELITE 90MM BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200095 SUP HCPCS C1713 7200095 - PLATE BN 95MM NS ATL VS ELT 5 LVL TI SPNE CRV ANT BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200100 SUP HCPCS C1713 7200100 - PLATE 7200100 ATL VISION ELITE 100MM BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200105 SUP HCPCS C1713 7200105 - PLATE 7200105 ATL VISION ELITE 105MM BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200110 SUP HCPCS C1713 7200110 - PLATE 7200110 ATL VISION ELITE 110MM BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200127 SUP Custom 27203010 RESERVOIR REAGENT NTR CSTR PS MT CHNL PIPETTER 50ML STRL BOTH IP/OP $1.48 $1.10 $0.00 $1.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $1.17 $1.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200130 SUP HCPCS C1713 7200130 - PLATE 7200130 ATL VISION ELITE 30MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200132 SUP HCPCS C1713 7200132 - PLATE BN 32.5MM NS ATL VS ELT 1 LVL TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7200145 SUP HCPCS C1713 7200145 - PLATE BN 45MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200147 SUP HCPCS C1713 7200147 - PLATE 7200147 ATL VISION ELITE 47.5MM BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200150 SUP HCPCS C1713 7200150 - PLATE BN 50MM NS ATL VS ELT 3 LVL TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200152 SUP HCPCS C1713 7200152 - PLATE BN 52.5MM NS ATL VS ELT 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200155 SUP HCPCS C1713 7200155 - PLATE BN 55MM NS ATL VS ELT 2 LVL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7200167 SUP HCPCS C1713 7200167 - PLATE 7200167 ATL VISION ELITE 67.5MM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7200170 SUP HCPCS C1713 7200170 - PLATE BN 70MM NS ATL VS ELT 4 LVL TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7200172 SUP HCPCS C1713 7200172 - PLATE BN 72.5MM NS ATL VS ELT 4 LVL TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7200180 SUP HCPCS C1713 7200180 - PLATE BN 80MM NS ATL VS ELT 5 LVL TI SPNE CRV ANT BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200182 SUP HCPCS C1713 7200182 - PLATE 7200182 ATL VISION ELITE 82.5MM BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200185 SUP HCPCS C1713 7200185 - PLATE BN 85MM NS ATL VS ELT 5 LVL TI SPNE CRV ANT BOTH IP/OP "$4,492.00 " "$3,324.08" $0.00 "$3,593.60" "$2,021.40" "$2,021.40" $0.00 $0.00 $0.00 $936.25 "$3,333.96" "$3,333.96" $0.00 $0.00 $936.13 $0.00 "$2,214.56" "$2,214.56" $0.00 "$2,246.00" "$3,557.66" "$3,593.60" $0.00 $0.00 $703.00 $0.00 $0.00 $715.13 $0.00 $0.00 $0.00 $0.00 $0.00 7200300 SUP Custom 27203010 TIP PIP 1-200UL POLYPRO GRAD BVL RK NTR NSTRL BOTH IP/OP $0.13 $0.10 $0.00 $0.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.06 $0.10 $0.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7200502 SUP HCPCS C1713 7200502 - WIRE FX LNG KRSH SS ORTH BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $88.88 $88.88 $0.00 $0.00 $0.00 $41.16 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $116.82 $116.82 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $30.91 $0.00 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $0.00 7205345 SUP Custom 27203010 7205345 - DYONICS 4.5MM INCISOR PLUS BLSDE BX/6 BOTH IP/OP $56.10 $41.51 $0.00 $44.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.05 $44.43 $44.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7209984 SUP Custom 27203010 7209984 - CANNU ARTHRO 72MM OBT THRD CL-TRC STRL DISP 8.5MM LATEX FREE BOTH IP/OP $61.26 $45.33 $0.00 $49.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.47 $45.47 $0.00 $0.00 $12.77 $0.00 $0.00 $0.00 $0.00 $30.63 $48.52 $49.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7209985 SUP Custom 27203010 7209985 - CANNU ENDSCP GRY 72MM OBT THRD CL-TRC CMPLT STRL DISP 7MM BOTH IP/OP $61.26 $45.33 $0.00 $49.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.47 $45.47 $0.00 $0.00 $12.77 $0.00 $0.00 $0.00 $0.00 $30.63 $48.52 $49.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7217020 SUP HCPCS C1713 7217020 - ROD SPNL PREBNT 20MM BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217025 SUP HCPCS C1713 7217025 - ROD SPNL PREBNT 6MM 25MM SPHERX TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217030 SUP HCPCS C1713 7217030 - ROD SPNL PREBNT 6MM 30MM SPHERX DBR II TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217035 SUP HCPCS C1713 7217035 - ROD SPNL PREBNT 6MM 35MM TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217040 SUP HCPCS C1713 7217040 - ROD SPNL PREBNT 40MM SPHERX DBR II TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217045 SUP HCPCS C1713 7217045 - ROD SPNL PREBNT 45MM BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217050 SUP HCPCS C1713 7217050 - ROD SPNL PREBNT 6MM 50MM TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217055 SUP HCPCS C1713 7217055 - ROD SPNL PREBNT 55MM NS SPHERX DBR II TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217060 SUP HCPCS C1713 7217060 - ROD SPNL PREBNT 60MM SPHERX DBR II TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217065 SUP HCPCS C1713 7217065 - ROD SPNL PREBNT 65MM SPHERX DBR II TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217070 SUP HCPCS C1713 7217070 - ROD SPNL PREBNT 70MM SPHERX DBR II TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217075 SUP HCPCS C1713 7217075 - ROD SPNL PREBNT 75MM SPHERX DBR II TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217080 SUP HCPCS C1713 7217080 - ROD SPNL PREBNT 80MM SPHERX DBR II TI BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 7217085 SUP HCPCS C1713 7217085 - ROD SPNL PREBNT 85MM SPHERX DBR II BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217090 SUP HCPCS C1713 7217090 - ROD SPNL PREBNT 90MM SPHERX DBR II BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217095 SUP HCPCS C1713 7217095 - ROD SPNL PREBNT 95MM SPHERX DBR II BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217100 SUP HCPCS C1713 7217100 - ROD SPNL PREBNT 100MM SPHERX DBR II BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217105 SUP HCPCS C1713 7217105 - ROD SPNL PREBNT 105MM SPHERX DBR II BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217110 SUP HCPCS C1713 7217110 - ROD SPNL PREBNT 110MM SPHERX DBR II TI BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217120 SUP HCPCS C1713 7217120 - ROD SPNL PREBNT 120MM SPHERX DBR II TI BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217130 SUP HCPCS C1713 7217130 - ROD SPNL PREBNT 130MM SPHERX DBR II BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217140 SUP HCPCS C1713 7217140 - ROD SPNL PREBNT 140MM SPHERX II DBR BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7217150 SUP HCPCS C1713 7217150 - ROD SPNL PREBNT 150MM SPHERX DBR II BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $641.25 $641.25 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $223.01 $0.00 $0.00 $226.86 $0.00 $0.00 $0.00 $0.00 $0.00 7220016 SUP Custom 27803010 7220016 - CAGE SPNL 22MM 16MM NS LF X-COR 2 STC FTPRNT TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220018 SUP Custom 27803010 7220018 - CAGE SPNL 22MM 18MM NS LF X-COR 2 STC FTPRNT TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220025 SUP Custom 27803010 7220025 - CAGE SPNL 22MM 20-25MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220027 SUP Custom 27803010 7220027 - CAGE SPINAL 22X21-27MM X-CORE 2 TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220033 SUP Custom 27803010 7220033 - CAGE SPNL 22MM 24-33MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220041 SUP Custom 27803010 7220041 - CAGE SPNL 22MM 28-41MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220055 SUP Custom 27803010 7220055 - CAGE SPNL 22MM 35-55MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220067 SUP Custom 27803010 7220067 - CAGE SPNL 22MM 41-67MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220079 SUP Custom 27803010 7220079 - CAGE SPNL 22MM 47-79MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220121 SUP Custom 27803010 7220121 - CAGE SPNL 22MM 68-121MM NS LF X-COR 2 XPD TI VERT BD REPL BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 $0.00 $0.00 $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220850 SUP HCPCS C1713 7220850 - SCREW SET 50MM 8.5MM SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7222200 SUP Custom 27803010 7222200 - ENDCAP SPNL 22MM RND 0 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7222204 SUP Custom 27803010 7222204 - ENDCAP SPNL 22MM RND 4 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7222208 SUP Custom 27803010 7222208 - ENDCAP SPNL 22MM RND 8 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7222212 SUP Custom 27803010 7222212 - ENDCAP SPNL 22MM RND 12 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224000 SUP Custom 27803010 7224000 - ENDCAP SPNL OD 22X22X40MM 0 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224004 SUP Custom 27803010 7224004 - ENDCAP SPNL OD 22X22X40MM 4 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224008 SUP Custom 27803010 7224008 - ENDCAP SPNL OD 22X22X40MM 8 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7224012 SUP Custom 27803010 7224012 - ENDCAP SPNL OD 22X22X40MM 12 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7225000 SUP Custom 27803010 7225000 - ENDCAP SPNL OD 22X22X50MM 0 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7225004 SUP Custom 27803010 7225004 - ENDCAP SPNL OD 22X22X50MM 4 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7225008 SUP Custom 27803010 7225008 - ENDCAP SPNL OD 22X22X50MM 8 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7225012 SUP Custom 27803010 7225012 - ENDCAP SPNL OD 22X22X50MM 12 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7226000 SUP Custom 27803010 7226000 - ENDCAP SPNL OD 22X22X60MM 0 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7226004 SUP Custom 27803010 7226004 - ENDCAP SPNL OD 22X22X60MM 4 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7226008 SUP Custom 27803010 7226008 - ENDCAP SPNL OD 22X22X60MM 8 DEG XCORE 2 TI BOTH IP/OP "$3,157.50 " "$2,336.55" $0.00 "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,343.50" "$2,343.50" $0.00 $0.00 $658.02 $0.00 $0.00 $0.00 $0.00 "$1,578.75" "$2,500.74" "$2,526.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7240033 SUP HCPCS C1713 7240033 - TMPLT ROD 250MM BOTH IP/OP "$1,012.50 " $749.25 $0.00 $810.00 $455.63 $455.63 $0.00 $0.00 $0.00 $211.03 $751.48 $751.48 $0.00 $0.00 $211.01 $0.00 $598.89 $598.89 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $158.46 $0.00 $0.00 $161.19 $0.00 $0.00 $0.00 $0.00 $0.00 7240034 SUP HCPCS C1713 7240034 - TMPLT ROD 500MM SPHERX 2 TI BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $534.38 $534.38 $0.00 $0.00 $0.00 $247.50 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $702.41 $702.41 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $185.84 $0.00 $0.00 $189.05 $0.00 $0.00 $0.00 $0.00 $0.00 7241045 SUP HCPCS C1713 7241045 - CONNECTOR ROD 45-60MM SPHERX II TRNSV TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241055 SUP HCPCS C1713 7241055 - CONNECTOR ROD 55-81MM SPHERX II TRNSV TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241075 SUP HCPCS C1713 7241075 - CONNECTOR ROD 74-85MM SPHERX II TRNSV TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241100 SUP HCPCS C1713 7241100 - SCREW BN SM 1.5MM 10MM SPHERX DBR II LCK TI SPNE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7241102 SUP HCPCS C1713 7241102 - HOOK SPNL SM SPHERX II TI PDCL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241103 SUP HCPCS C1713 7241103 - HOOK SPNL MED SPHERX II TI PDCL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241104 SUP HCPCS C1713 7241104 - HOOK SPNL 6MM SPHERX II NAR BLDE TI LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241105 SUP HCPCS C1713 7241105 - HOOK SPNL 8MM SPHERX II NAR BLDE TI LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241106 SUP HCPCS C1713 7241106 - HOOK SPNL 10MM SPHERX II NAR BLDE TI LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241107 SUP HCPCS C1713 7241107 - HOOK SPNL 6MM SPHERX II W BLDE ANG LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241108 SUP HCPCS C1713 7241108 - HOOK SPNL 8MM SPHERX II W BLDE ANG LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241109 SUP HCPCS C1713 7241109 - HOOK SPNL 10MM SPHERX II W BLDE ANG LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241110 SUP HCPCS C1713 7241110 - HOOK SPNL 6MM SPHERX II NAR BLDE ANG RDC TIP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241111 SUP HCPCS C1713 7241111 - HOOK SPNL 8MM SPHERX II NAR BLDE ANG RDC TIP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241112 SUP HCPCS C1713 7241112 - HOOK SPNL 10MM SPHERX II NAR BLDE ANG RDC TIP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241113 SUP HCPCS C1713 7241113 - HOOK SPNL 6MM SPHERX II WA RDC TIP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241114 SUP HCPCS C1713 7241114 - HOOK SPNL 8MM SPHERX II W BLDE ANG RDC TIP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241115 SUP HCPCS C1713 7241115 - HOOK SPNL 10MM SPHERX II W BLDE ANG RDC TIP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241116 SUP HCPCS C1713 7241116 - HOOK SPNL 6MM SPHERX II NAR BLDE DN ANG LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241117 SUP HCPCS C1713 7241117 - HOOK SPNL 8MM SPHERX II NAR BLDE DN ANG LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241118 SUP HCPCS C1713 7241118 - HOOK SPNL 10MM SPHERX II NAR BLDE DN ANG LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241119 SUP HCPCS C1713 7241119 - HOOK SPNL 6MM SPHERX II NAR BLDE ANG XTD LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241120 SUP HCPCS C1713 7241120 - HOOK SPNL 8MM SPHERX II NAR BLDE ANG XTD LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241121 SUP HCPCS C1713 7241121 - HOOK SPNL 45D SPHERX II NAR BLDE ANG BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241122 SUP HCPCS C1713 7241122 - HOOK SPNL SPHERX II NAR BLDE ANG RT OFST BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241123 SUP HCPCS C1713 7241123 - HOOK SPNL SPHERX II NAR BLDE ANG LT OFST BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241124 SUP HCPCS C1713 7241124 - HOOK SPNL SPHERX II NAR BLDE ANG RT OFST BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241125 SUP HCPCS C1713 7241125 - HOOK SPNL SPHERX II NAR BLDE ANG LT OFST BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241131 SUP HCPCS C1713 7241131 - HOOK SPNL 6MM SPHERX II ANG UP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241132 SUP HCPCS C1713 7241132 - HOOK SPNL 8MM SPHERX II ANG UP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241133 SUP HCPCS C1713 7241133 - HOOK SPNL 10MM SPHERX II ANG UP LMR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 7241200 SUP HCPCS C1713 7241200 - CONNECTOR ROD 20MM SPHERX II TRNSV FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241225 SUP HCPCS C1713 7241225 - CONNECTOR ROD 22MM SPHERX II TRNSV FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241250 SUP HCPCS C1713 7241250 - CONNECTOR ROD 25MM SPHERX II TRNSV FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241275 SUP HCPCS C1713 7241275 - CONNECTOR ROD 27MM SPHERX II TRNSV FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241300 SUP HCPCS C1713 7241300 - CONNECTOR ROD 30MM TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241325 SUP HCPCS C1713 7241325 - CONNECTOR ROD 32.5MM TRNSV FX SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241350 SUP HCPCS C1713 7241350 - CONNECTOR ROD 35MM SPHERX II TRNSV FA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241375 SUP HCPCS C1713 7241375 - CONNECTOR ROD 37.5MM SPHERX II TRNSV FA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241400 SUP HCPCS C1713 7241400 - CONNECTOR ROD 40MM SPHERX II TRNSV FA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241450 SUP HCPCS C1713 7241450 - CONNECTOR ROD 45MM SPHERX II TRNSV FA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241500 SUP HCPCS C1713 7241500 - CONNECTOR ROD 50MM SPHERX II TRNSV FA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241550 SUP HCPCS C1713 7241550 - CONNECTOR ROD 55MM SPHERX II TRNSV FA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7241600 SUP HCPCS C1713 7241600 - CONNECTOR ROD 60MM SPHERX II TRNSV FA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7242020 SUP HCPCS C1713 7242020 - ROD SPNL PREBNT 20MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242030 SUP HCPCS C1713 7242030 - ROD SPNL PREBNT 30MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242035 SUP HCPCS C1713 7242035 - ROD SPNL PREBNT 35MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242040 SUP HCPCS C1713 7242040 - ROD SPINAL 40MM PREBENT CONVENTIONAL SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242050 SUP HCPCS C1713 7242050 - ROD SPNL PREBNT 50MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242055 SUP HCPCS C1713 7242055 - ROD SPNL PREBNT 55MM NS SPHERX II MAS PLIF BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242060 SUP HCPCS C1713 7242060 - ROD SPNL PREBNT 60MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242065 SUP HCPCS C1713 7242065 - ROD SPNL PREBNT 65MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242070 SUP HCPCS C1713 7242070 - ROD SPNL PREBNT 70MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242075 SUP HCPCS C1713 7242075 - ROD SPINAL 75MM PREBENT CONVENTIONAL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242080 SUP HCPCS C1713 7242080 - ROD SPNL PREBNT 80MM NS SPHERX II MAS PLIF BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242085 SUP HCPCS C1713 7242085 - ROD SPNL PREBNT 85MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242095 SUP HCPCS C1713 7242095 - ROD SPNL PREBNT 95MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7242110 SUP HCPCS C1713 7242110 - ROD SPNL PREBNT 110MM SPHERX II BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7243045 SUP HCPCS C1713 7243045 - TRANSCONNECTOR ROD PREBNT 45-50MM ADJ ARCH SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7243050 SUP HCPCS C1713 7243050 - CONNECTOR ROD 50-60MM TRNSV SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7243060 SUP HCPCS C1713 7243060 - TRANSCONNECTOR ROD 60-70MM ADJ ARCH VAR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7243070 SUP HCPCS C1713 7243070 - CONNECTOR ROD 70-85MM VAR ADJ TRANSVRS BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7245525 SUP HCPCS C1713 7245525 - SCREW BN 5.5MM 25MM SPHERX DBR II PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7245530 SUP HCPCS C1713 7245530 - SCREW BN 5.5MM 30MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7245535 SUP HCPCS C1713 7245535 - SCREW BN 5.5MM 35MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7245540 SUP HCPCS C1713 7245540 - SCREW BN 5.5MM 40MM PA SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7245545 SUP HCPCS C1713 7245545 - SCREW BN 5.5MM 45MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7245550 SUP HCPCS C1713 7245550 - SCREW BN 5.5MM 50MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7245555 SUP HCPCS C1713 7245555 - SCREW BN 5.5MM 55MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7245560 SUP HCPCS C1713 7245560 - SCREW BN 5.5MM 60MM SPHERX II PA SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246510 SUP HCPCS C1713 7246510 - SCREW BN 6.5MM 100MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246525 SUP HCPCS C1713 7246525 - SCREW BN 6.5MM 25MM SPHERX II PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246530 SUP HCPCS C1713 7246530 - SCREW BN 6.5MM 30MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246535 SUP HCPCS C1713 7246535 - SCREW BN 6.5MM 35MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246540 SUP HCPCS C1713 7246540 - SCREW BN 6.5MM 40MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246545 SUP HCPCS C1713 7246545 - SCREW BN 6.5MM 45MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246550 SUP HCPCS C1713 7246550 - SCREW BN 6.5MM 50MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246555 SUP HCPCS C1713 7246555 - SCREW BN 6.5MM 55MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246560 SUP HCPCS C1713 7246560 - SCREW BN 6.5MM 60MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246565 SUP HCPCS C1713 7246565 - SCREW BN 6.5MM 65MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246570 SUP HCPCS C1713 7246570 - SCREW BN 6.5MM 70MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246575 SUP HCPCS C1713 7246575 - SCREW BN 6.5MM 75MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246580 SUP HCPCS C1713 7246580 - SCREW BN 6.5MM 80MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246585 SUP HCPCS C1713 7246585 - SCREW BN 6.5MM 85MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246590 SUP HCPCS C1713 7246590 - SCREW BN 6.5MM 90MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7246595 SUP HCPCS C1713 7246595 - SCREW BN 6.5MM 95MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247510 SUP HCPCS C1713 7247510 - SCREW BN 7.5MM 100MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247525 SUP HCPCS C1713 7247525 - SCREW BN 7.5MM 25MM SPHERX II PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247530 SUP HCPCS C1713 7247530 - SCREW BN 7.5MM 30MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247535 SUP HCPCS C1713 7247535 - SCREW BN 7.5MM 35MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247540 SUP HCPCS C1713 7247540 - SCREW BN 7.5MM 40MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247545 SUP HCPCS C1713 7247545 - SCREW BN 7.5MM 45MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247550 SUP HCPCS C1713 7247550 - SCREW BN 7.5MM 50MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247555 SUP HCPCS C1713 7247555 - SCREW BN 7.5MM 55MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247560 SUP HCPCS C1713 7247560 - SCREW BN 7.5MM 60MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247565 SUP HCPCS C1713 7247565 - SCREW BN 7.5MM 65MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247570 SUP HCPCS C1713 7247570 - SCREW BN 7.5MM 70MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247575 SUP HCPCS C1713 7247575 - SCREW BN 7.5MM 75MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247580 SUP HCPCS C1713 7247580 - SCREW BN 7.5MM 80MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247585 SUP HCPCS C1713 7247585 - SCREW BN 7.5MM 85MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247590 SUP HCPCS C1713 7247590 - SCREW BN 7.5MM 90MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7247595 SUP HCPCS C1713 7247595 - SCREW BN 7.5MM 95MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248025 SUP HCPCS C1713 7248025 - ROD SPNL 25MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248030 SUP HCPCS C1713 7248030 - ROD SPNL 30MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248035 SUP HCPCS C1713 7248035 - ROD SPNL 35MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248040 SUP HCPCS C1713 7248040 - ROD SPNL 40MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248045 SUP HCPCS C1713 7248045 - ROD SPNL 45MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248050 SUP HCPCS C1713 7248050 - ROD SPNL 50MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248055 SUP HCPCS C1713 7248055 - ROD SPNL 55MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248060 SUP HCPCS C1713 7248060 - ROD SPNL 60MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248065 SUP HCPCS C1713 7248065 - ROD SPNL 65MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248070 SUP HCPCS C1713 7248070 - ROD SPNL 70MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248075 SUP HCPCS C1713 7248075 - ROD SPNL 75MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248080 SUP HCPCS C1713 7248080 - ROD SPNL 80MM SPHERX DBR II THOR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248085 SUP HCPCS C1713 7248085 - ROD SPNL 85MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248090 SUP HCPCS C1713 7248090 - ROD SPNL 90MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248095 SUP HCPCS C1713 7248095 - ROD SPNL 95MM SPHERX II CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7248100 SUP HCPCS C1713 7248100 - ROD SPNL 100MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248105 SUP HCPCS C1713 7248105 - ROD SPNL 105MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248110 SUP HCPCS C1713 7248110 - ROD SPNL 110MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248115 SUP HCPCS C1713 7248115 - ROD SPNL 115MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248120 SUP HCPCS C1713 7248120 - ROD SPNL 120MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248125 SUP HCPCS C1713 7248125 - ROD SPNL 125MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248130 SUP HCPCS C1713 7248130 - ROD SPNL 130MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248135 SUP HCPCS C1713 7248135 - ROD SPNL 135MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248140 SUP HCPCS C1713 7248140 - ROD SPNL 140MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248145 SUP HCPCS C1713 7248145 - ROD SPNL 145MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248150 SUP HCPCS C1713 7248150 - ROD SPNL 150MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248300 SUP HCPCS C1713 7248300 - ROD SPNL 300MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248500 SUP HCPCS C1713 7248500 - ROD SPNL 500MM SPHERX II CNV BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7248510 SUP HCPCS C1713 7248510 - SCREW BN 8.5MM 100MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248525 SUP HCPCS C1713 7248525 - SCREW BN 8.5MM 25MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248530 SUP HCPCS C1713 7248530 - SCREW BN 8.5MM 30MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248535 SUP HCPCS C1713 7248535 - SCREW BN 8.5MM 35MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248540 SUP HCPCS C1713 7248540 - SCREW BN 8.5MM 40MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248545 SUP HCPCS C1713 7248545 - SCREW BN 8.5MM 45MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248550 SUP HCPCS C1713 7248550 - SCREW BN 8.5MM 50MM SPHERX DBR II PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248555 SUP HCPCS C1713 7248555 - SCREW BN 8.5MM 55MM PA SPNE PDCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248560 SUP HCPCS C1713 7248560 - SCREW BN 8.5MM 60MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248565 SUP HCPCS C1713 7248565 - SCREW BN 8.5MM 65MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248570 SUP HCPCS C1713 7248570 - SCREW BN 8.5MM 70MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248575 SUP HCPCS C1713 7248575 - SCREW BN 8.5MM 75MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248580 SUP HCPCS C1713 7248580 - SCREW BN 8.5MM 80MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248585 SUP HCPCS C1713 7248585 - SCREW BN 8.5MM 85MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248590 SUP HCPCS C1713 7248590 - SCREW BN 8.5MM 90MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7248595 SUP HCPCS C1713 7248595 - SCREW BN 8.5MM 95MM PA ILIUM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7249310 SUP HCPCS C1713 7249310 - CONNECTOR ROD OFST 100MM SPNE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 7249335 SUP HCPCS C1713 7249335 - CONNECTOR ROD OFST 35MM SPHERX II SPNE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 7249350 SUP HCPCS C1713 7249350 - CONNECTOR ROD OFST 50MM SPNE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 7251526 SUP HCPCS C1713 7251526 - STAPLE BN SM INFR ANT THOR SPNL BOTH IP/OP "$2,162.50 " "$1,600.25" $0.00 "$1,730.00" $973.13 $973.13 $0.00 $0.00 $0.00 $450.72 "$1,605.01" "$1,605.01" $0.00 $0.00 $450.67 $0.00 "$1,279.12" "$1,279.12" $0.00 "$1,081.25" "$1,712.70" "$1,730.00" $0.00 $0.00 $338.43 $0.00 $0.00 $344.27 $0.00 $0.00 $0.00 $0.00 $0.00 7251528 SUP HCPCS C1713 7251528 - STAPLE BN MED INFR ANT THOR SPNL BOTH IP/OP "$2,162.50 " "$1,600.25" $0.00 "$1,730.00" $973.13 $973.13 $0.00 $0.00 $0.00 $450.72 "$1,605.01" "$1,605.01" $0.00 $0.00 $450.67 $0.00 "$1,279.12" "$1,279.12" $0.00 "$1,081.25" "$1,712.70" "$1,730.00" $0.00 $0.00 $338.43 $0.00 $0.00 $344.27 $0.00 $0.00 $0.00 $0.00 $0.00 7251530 SUP HCPCS C1713 7251530 - STAPLE BN LG INFR ANT THOR SPNL BOTH IP/OP "$2,162.50 " "$1,600.25" $0.00 "$1,730.00" $973.13 $973.13 $0.00 $0.00 $0.00 $450.72 "$1,605.01" "$1,605.01" $0.00 $0.00 $450.67 $0.00 "$1,279.12" "$1,279.12" $0.00 "$1,081.25" "$1,712.70" "$1,730.00" $0.00 $0.00 $338.43 $0.00 $0.00 $344.27 $0.00 $0.00 $0.00 $0.00 $0.00 7251626 SUP HCPCS C1713 7251626 - STAPLE BN SM SUP ANT THOR SPNL BOTH IP/OP "$2,162.50 " "$1,600.25" $0.00 "$1,730.00" $973.13 $973.13 $0.00 $0.00 $0.00 $450.72 "$1,605.01" "$1,605.01" $0.00 $0.00 $450.67 $0.00 "$1,279.12" "$1,279.12" $0.00 "$1,081.25" "$1,712.70" "$1,730.00" $0.00 $0.00 $338.43 $0.00 $0.00 $344.27 $0.00 $0.00 $0.00 $0.00 $0.00 7251628 SUP HCPCS C1713 7251628 - STAPLE BN MED SUP ANT THOR SPNL BOTH IP/OP "$2,162.50 " "$1,600.25" $0.00 "$1,730.00" $973.13 $973.13 $0.00 $0.00 $0.00 $450.72 "$1,605.01" "$1,605.01" $0.00 $0.00 $450.67 $0.00 "$1,279.12" "$1,279.12" $0.00 "$1,081.25" "$1,712.70" "$1,730.00" $0.00 $0.00 $338.43 $0.00 $0.00 $344.27 $0.00 $0.00 $0.00 $0.00 $0.00 7251630 SUP HCPCS C1713 7251630 - STAPLE BN LG SUP ANT THOR SPNL BOTH IP/OP "$2,162.50 " "$1,600.25" $0.00 "$1,730.00" $973.13 $973.13 $0.00 $0.00 $0.00 $450.72 "$1,605.01" "$1,605.01" $0.00 $0.00 $450.67 $0.00 "$1,279.12" "$1,279.12" $0.00 "$1,081.25" "$1,712.70" "$1,730.00" $0.00 $0.00 $338.43 $0.00 $0.00 $344.27 $0.00 $0.00 $0.00 $0.00 $0.00 7253012 SUP HCPCS C1713 7253012 - STAPLE BN SM 1 HL BOTH IP/OP $947.50 $701.15 $0.00 $758.00 $426.38 $426.38 $0.00 $0.00 $0.00 $197.48 $703.23 $703.23 $0.00 $0.00 $197.46 $0.00 $560.45 $560.45 $0.00 $473.75 $750.42 $758.00 $0.00 $0.00 $148.28 $0.00 $0.00 $150.84 $0.00 $0.00 $0.00 $0.00 $0.00 7253014 SUP HCPCS C1713 7253014 - STAPLE BN MED 1 HL BOTH IP/OP $947.50 $701.15 $0.00 $758.00 $426.38 $426.38 $0.00 $0.00 $0.00 $197.48 $703.23 $703.23 $0.00 $0.00 $197.46 $0.00 $560.45 $560.45 $0.00 $473.75 $750.42 $758.00 $0.00 $0.00 $148.28 $0.00 $0.00 $150.84 $0.00 $0.00 $0.00 $0.00 $0.00 7253016 SUP HCPCS C1713 7253016 - STAPLE BN LG 1 HL BOTH IP/OP $947.50 $701.15 $0.00 $758.00 $426.38 $426.38 $0.00 $0.00 $0.00 $197.48 $703.23 $703.23 $0.00 $0.00 $197.46 $0.00 $560.45 $560.45 $0.00 $473.75 $750.42 $758.00 $0.00 $0.00 $148.28 $0.00 $0.00 $150.84 $0.00 $0.00 $0.00 $0.00 $0.00 7253112 SUP HCPCS C1713 7253112 - WASHER SPNL SM BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $174.38 $174.38 $0.00 $0.00 $0.00 $80.76 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $229.21 $229.21 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $60.64 $0.00 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $0.00 7253114 SUP HCPCS C1713 7253114 - WASHER SPNL MED BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $174.38 $174.38 $0.00 $0.00 $0.00 $80.76 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $229.21 $229.21 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $60.64 $0.00 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $0.00 7253116 SUP HCPCS C1713 7253116 - WASHER SPNL LG BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $174.38 $174.38 $0.00 $0.00 $0.00 $80.76 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $229.21 $229.21 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $60.64 $0.00 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $0.00 7254022 SUP HCPCS C1713 7254022 - CONNECTOR ROD 22MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7254525 SUP HCPCS C1713 7254525 - SCREW BN 4.5MM 25MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7254530 SUP HCPCS C1713 7254530 - SCREW BN 4.5MM 30MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7254535 SUP HCPCS C1713 7254535 - SCREW BN 4.5MM 35MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7254540 SUP HCPCS C1713 7254540 - SCREW BN 4.5MM 40MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7254545 SUP HCPCS C1713 7254545 - SCREW BN 4.5MM 45MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7254550 SUP HCPCS C1713 7254550 - SCREW BN 4.5MM 50MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7255525 SUP HCPCS C1713 7255525 - SCREW BN 5.5MM 25MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7255530 SUP HCPCS C1713 7255530 - SCREW BN 5.5MM 30MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7255535 SUP HCPCS C1713 7255535 - SCREW BN 5.5MM 35MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7255540 SUP HCPCS C1713 7255540 - SCREW BN 5.5MM 40MM SPHERX DBR II FX ANG TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7255545 SUP HCPCS C1713 7255545 - SCREW BN 5.5MM 45MM SPHERX DBR II FX ANG TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7255550 SUP HCPCS C1713 7255550 - SCREW BN 5.5MM 50MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7255555 SUP HCPCS C1713 7255555 - SCREW BN 5.5MM 55MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7255560 SUP HCPCS C1713 7255560 - SCREW BN 5.5MM 60MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256012 SUP HCPCS C1713 7256012 - CONNECTOR ROD 12MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256013 SUP HCPCS C1713 7256013 - CONNECTOR ROD 13MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256014 SUP HCPCS C1713 7256014 - CONNECTOR ROD 14MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256015 SUP HCPCS C1713 7256015 - CONNECTOR ROD 15MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256016 SUP HCPCS C1713 7256016 - CONNECTOR ROD 16MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256017 SUP HCPCS C1713 7256017 - CONNECTOR ROD 17MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256018 SUP HCPCS C1713 7256018 - CONNECTOR ROD 18MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256019 SUP HCPCS C1713 7256019 - CONNECTOR ROD 19MM TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256020 SUP HCPCS C1713 7256020 - CONNECTOR ROD 20MM TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256021 SUP HCPCS C1713 7256021 - CONNECTOR ROD 21MM SPHERX II FX SPNE ANT BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256530 SUP HCPCS C1713 7256530 - SCREW BN 6.5MM 30MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256535 SUP HCPCS C1713 7256535 - SCREW BN 6.5MM 35MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256540 SUP HCPCS C1713 7256540 - SCREW BN 6.5MM 40MM SPHERX DBR II FX ANG TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256545 SUP HCPCS C1713 7256545 - SCREW BN 6.5MM 45MM SPHERX II FX BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256550 SUP HCPCS C1713 7256550 - SCREW BN 6.5MM 50MM SPHERX DBR II FX ANG TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256555 SUP HCPCS C1713 7256555 - SCREW BN 6.5MM 55MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7256560 SUP HCPCS C1713 7256560 - SCREW BN 6.5MM 60MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7257530 SUP HCPCS C1713 7257530 - SCREW BN 7.5MM 30MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7257535 SUP HCPCS C1713 7257535 - SCREW BN 7.5MM 35MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7257540 SUP HCPCS C1713 7257540 - SCREW BN 7.5IN 40MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7257545 SUP HCPCS C1713 7257545 - SCREW BN 7.5MM 45MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7257550 SUP HCPCS C1713 7257550 - SCREW BN 7.5MM 50MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7257555 SUP HCPCS C1713 7257555 - SCREW BN 7.5MM 55MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7257560 SUP HCPCS C1713 7257560 - SCREW BN 7.5MM 60MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7258530 SUP HCPCS C1713 7258530 - SCREW BN 8.5MM 30MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7258535 SUP HCPCS C1713 7258535 - SCREW BN 8.5MM 35MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7258540 SUP HCPCS C1713 7258540 - SCREW BN 8.5MM 40MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7258545 SUP HCPCS C1713 7258545 - SCREW BN 8.5MM 45MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7258550 SUP HCPCS C1713 7258550 - SCREW BN 8.5MM 50MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7258555 SUP HCPCS C1713 7258555 - SCREW BN 8.5MM 55MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7258560 SUP HCPCS C1713 7258560 - SCREW BN 8.5MM 60MM SPHERX II FA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7262600 SUP Custom 27803010 7262600 - ENDCAP SPNL 26MM RND 0 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7262604 SUP Custom 27803010 7262604 - ENDCAP SPNL 26MM RND 4 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7262608 SUP Custom 27803010 7262608 - ENDCAP SPNL 26MM RND 8 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7262612 SUP Custom 27803010 7262612 - ENDCAP SPNL 26MM RND 12 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7265535 SUP HCPCS C1713 7265535 - SCREW BN 5.5MM 35MM RDC PA SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7265540 SUP HCPCS C1713 7265540 - SCREW BN 5.5MM 40MM PA RDC SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7265545 SUP HCPCS C1713 7265545 - SCREW BN 5.5MM 45MM PA RDC SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7265550 SUP HCPCS C1713 7265550 - SCREW BN 5.5MM 50MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7265555 SUP HCPCS C1713 7265555 - SCREW BN 5.5MM 55MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7266535 SUP HCPCS C1713 7266535 - SCREW BN 6.5MM 35MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7266540 SUP HCPCS C1713 7266540 - SCREW BN 6.5MM 40MM SPHERX RDC SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7266545 SUP HCPCS C1713 7266545 - SCREW BN 6.5MM 45MM SPHERX II RDC PA SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7266550 SUP HCPCS C1713 7266550 - SCREW BN 6.5MM 50MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7266555 SUP HCPCS C1713 7266555 - SCREW BN 6.5MM 55MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7267535 SUP HCPCS C1713 7267535 - SCREW BN 7.5MM 35MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7267540 SUP HCPCS C1713 7267540 - SCREW BN 7.5MM 40MM RDC PA SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7267545 SUP HCPCS C1713 7267545 - SCREW BN 7.5MM 45MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7267550 SUP HCPCS C1713 7267550 - SCREW BN 7.5MM 50MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7267555 SUP HCPCS C1713 7267555 - SCREW BN 7.5MM 55MM SPHERX PA SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7270100 SUP HCPCS C1713 7270100 - WIRE FX KRSH BVL TIP BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 7270200 SUP HCPCS C1713 7270200 - WIRE FX KRSH THRD BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 7270300 SUP HCPCS C1713 7270300 - WIRE FX XLNG KRSH THRD TIP BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 7270411 SUP HCPCS C1713 7270411 - SPACER SPNL 11MM 11X4MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270441 SUP HCPCS C1713 7270441 - SPACER SPNL 11MM 14X4MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270444 SUP HCPCS C1713 7270444 - SPACER SPNL 14MM 14X4MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270511 SUP HCPCS C1713 7270511 - SPACER SPNL 11MM 11X5MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270541 SUP HCPCS C1713 7270541 - SPACER SPNL 11MM 14X5MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270544 SUP HCPCS C1713 7270544 - SPACER SPNL 14MM 14X5MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270611 SUP HCPCS C1713 7270611 - SPACER SPNL 11MM 11X6MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270641 SUP HCPCS C1713 7270641 - SPACER SPNL 11MM 14X6MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270644 SUP HCPCS C1713 7270644 - SPACER SPNL 14MM 14X6MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270711 SUP HCPCS C1713 7270711 - SPACER SPNL 11MM 11X7MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270741 SUP HCPCS C1713 7270741 - SPACER SPNL 11MM 14X7MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270744 SUP HCPCS C1713 7270744 - SPACER SPNL 14MM 14X7MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270811 SUP HCPCS C1713 7270811 - SPACER SPNL 11MM 11X8MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270841 SUP HCPCS C1713 7270841 - SPACER SPNL 11MM 14X8MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270844 SUP HCPCS C1713 7270844 - SPACER SPNL 14MM 14X8MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270911 SUP HCPCS C1713 7270911 - SPACER SPNL 11MM 11X9MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270941 SUP HCPCS C1713 7270941 - SPACER SPNL 11MM 14X9MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7270944 SUP HCPCS C1713 7270944 - SPACER SPNL 14MM 14X9MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271011 SUP HCPCS C1713 7271011 - SPACER SPNL 11MM 11X10MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271041 SUP HCPCS C1713 7271041 - SPACER SPNL 11MM 14X10MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271044 SUP HCPCS C1713 7271044 - SPACER SPNL 14MM 14X10MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271111 SUP HCPCS C1713 7271111 - SPACER SPNL 11MM 11X11MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271141 SUP HCPCS C1713 7271141 - SPACER SPNL 11MM 14X11MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271144 SUP HCPCS C1713 7271144 - SPACER SPNL 14MM 14X11MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271211 SUP HCPCS C1713 7271211 - SPACER SPNL 11MM 11X12MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271241 SUP HCPCS C1713 7271241 - SPACER SPNL 11MM 14X12MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271244 SUP HCPCS C1713 7271244 - SPACER SPNL 14MM 14X12MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271311 SUP HCPCS C1713 7271311 - SPACER SPNL 11MM 11X13MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271341 SUP HCPCS C1713 7271341 - SPACER SPNL 11MM 14X13MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7271344 SUP HCPCS C1713 7271344 - SPACER SPNL 14MM 14X13MM STRL VRTSTCK CRSTN PSR RADOPQ PEEK BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7284525 SUP HCPCS C1713 7284525 - SCREW BN 4.5MM 25MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7284530 SUP HCPCS C1713 7284530 - SCREW BN 4.5MM 30MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7284535 SUP HCPCS C1713 7284535 - SCREW BN 4.5MM 35MM PA SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7284540 SUP HCPCS C1713 7284540 - SCREW BN 4.5MM 40MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7284545 SUP HCPCS C1713 7284545 - SCREW BN 4.5MM 45MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7284550 SUP HCPCS C1713 7284550 - SCREW BN 4.5MM 50MM SPHERX II PA TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7291025 SUP HCPCS C1713 7291025 - ROD SPNL 5.5MM 25MM SPHERX II TI BOTH IP/OP $782.50 $579.05 $0.00 $626.00 $352.13 $352.13 $0.00 $0.00 $0.00 $163.09 $580.77 $580.77 $0.00 $0.00 $163.07 $0.00 $462.85 $462.85 $0.00 $391.25 $619.74 $626.00 $0.00 $0.00 $122.46 $0.00 $0.00 $124.57 $0.00 $0.00 $0.00 $0.00 $0.00 7291030 SUP HCPCS C1713 7291030 - ROD SPNL 5.5MM 30MM SPHERX II TI BOTH IP/OP $782.50 $579.05 $0.00 $626.00 $352.13 $352.13 $0.00 $0.00 $0.00 $163.09 $580.77 $580.77 $0.00 $0.00 $163.07 $0.00 $462.85 $462.85 $0.00 $391.25 $619.74 $626.00 $0.00 $0.00 $122.46 $0.00 $0.00 $124.57 $0.00 $0.00 $0.00 $0.00 $0.00 7291035 SUP HCPCS C1713 7291035 - ROD SPNL 5.5MM 35MM 1 BALL BOTH IP/OP $782.50 $579.05 $0.00 $626.00 $352.13 $352.13 $0.00 $0.00 $0.00 $163.09 $580.77 $580.77 $0.00 $0.00 $163.07 $0.00 $462.85 $462.85 $0.00 $391.25 $619.74 $626.00 $0.00 $0.00 $122.46 $0.00 $0.00 $124.57 $0.00 $0.00 $0.00 $0.00 $0.00 7291040 SUP HCPCS C1713 7291040 - ROD SPNL PREBNT 5.5MM 40MM SPHERX II 1 BALL BOTH IP/OP $782.50 $579.05 $0.00 $626.00 $352.13 $352.13 $0.00 $0.00 $0.00 $163.09 $580.77 $580.77 $0.00 $0.00 $163.07 $0.00 $462.85 $462.85 $0.00 $391.25 $619.74 $626.00 $0.00 $0.00 $122.46 $0.00 $0.00 $124.57 $0.00 $0.00 $0.00 $0.00 $0.00 7291045 SUP HCPCS C1713 7291045 - ROD SPNL 5.5MM 45MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291050 SUP HCPCS C1713 7291050 - ROD SPNL 5.5MM 50MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291055 SUP HCPCS C1713 7291055 - ROD SPNL 5.5MM 55MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291060 SUP HCPCS C1713 7291060 - ROD SPNL 5.5MM 60MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291065 SUP HCPCS C1713 7291065 - ROD SPNL 5.5MM 65MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291070 SUP HCPCS C1713 7291070 - ROD SPNL 5.5MM 70MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291075 SUP HCPCS C1713 7291075 - ROD SPNL 5.5MM 75MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291080 SUP HCPCS C1713 7291080 - ROD SPNL 5.5MM 80MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291085 SUP HCPCS C1713 7291085 - ROD SPNL 5.5MM 85MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291090 SUP HCPCS C1713 7291090 - ROD SPNL 5.5MM 90MM SPHERX II TI BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $387.00 $387.00 $0.00 $0.00 $0.00 $179.25 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $508.69 $508.69 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $134.59 $0.00 $0.00 $136.91 $0.00 $0.00 $0.00 $0.00 $0.00 7291095 SUP HCPCS C1713 7291095 - ROD SPNL 5.5MM 95MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291100 SUP HCPCS C1713 7291100 - ROD SPNL 5.5MM 100MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291110 SUP HCPCS C1713 7291110 - ROD SPNL 5.5MM 110MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291120 SUP HCPCS C1713 7291120 - ROD SPNL PREBNT 5.5MM 120MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291130 SUP HCPCS C1713 7291130 - ROD SPNL 5.5MM 400MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291140 SUP HCPCS C1713 7291140 - ROD SPNL PREBNT 5.5MM 140MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291150 SUP HCPCS C1713 7291150 - ROD SPNL 150MM MAS PLIF BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291160 SUP HCPCS C1713 7291160 - ROD SPNL PREBNT 5.5MM 160MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291180 SUP HCPCS C1713 7291180 - ROD SPNL PREBNT 5.5MM 180MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291200 SUP HCPCS C1713 7291200 - ROD SPNL PREBNT 5.5MM 200MM SPHERX II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291300 SUP HCPCS C1713 7291300 - ROD SPNL PREBNT 5.5MM 300MM SPHERX DBR II TI BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $191.23 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $542.70 $542.70 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 7291500 SUP HCPCS C1713 7291500 - ROD SPNL PREBNT 5.5MM 500MM SPHERX II TI BOTH IP/OP "$1,052.50 " $778.85 $0.00 $842.00 $473.63 $473.63 $0.00 $0.00 $0.00 $219.37 $781.17 $781.17 $0.00 $0.00 $219.34 $0.00 $622.55 $622.55 $0.00 $526.25 $833.58 $842.00 $0.00 $0.00 $164.72 $0.00 $0.00 $167.56 $0.00 $0.00 $0.00 $0.00 $0.00 7292025 SUP HCPCS C1713 7292025 - ROD SPNL PREBNT 5.5MM 25MM SPHERX II TI BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292030 SUP HCPCS C1713 7292030 - ROD SPNL PREBNT 5.5MM 30MM SPHERX II BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292040 SUP HCPCS C1713 7292040 - ROD SPNL PREBNT 5.5MM 40MM SPHERX II TI BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292050 SUP HCPCS C1713 7292050 - ROD SPNL PREBNT 5.5MM 50MM SPHERX II TI BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292060 SUP HCPCS C1713 7292060 - ROD SPNL PREBNT 5.5MM 60MM SPHERX II TI BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292065 SUP HCPCS C1713 7292065 - ROD SPNL PREBNT 5.5MM 65MM SPHERX II TI BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292070 SUP HCPCS C1713 7292070 - ROD SPNL PREBNT 5.5MM 70MM SPHERX II BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292080 SUP HCPCS C1713 7292080 - ROD SPNL PREBNT 5.5MM 80MM BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292085 SUP HCPCS C1713 7292085 - ROD SPNL PREBNT 5.5MM 85MM BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292090 SUP HCPCS C1713 7292090 - ROD SPNL PREBNT 5.5MM 90MM BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292095 SUP HCPCS C1713 7292095 - ROD SPNL PREBNT 5.5MM 95MM BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292100 SUP HCPCS C1713 7292100 - ROD SPNL PREBNT 5.5MM 100MM SPHERX II TI BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7292120 SUP HCPCS C1713 7292120 - ROD SPNL PREBNT 120MM SPHERX BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 7303000 SUP Custom 27803010 7303000 - ENDCAP SPNL 30MM RND 0 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7303004 SUP Custom 27803010 7303004 - ENDCAP SPNL 30MM RND 4 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7303008 SUP Custom 27803010 7303008 - ENDCAP SPNL 30MM RND 8 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7303012 SUP Custom 27803010 7303012 - ENDCAP SPNL 30MM RND 12 DEG OD 22 XCORE 2 TI BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7340000 SUP HCPCS C1713 7340000 - SET SCREW 7340000 BREAKOFF M6XI BUTTRESS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7340300 SUP HCPCS C1713 7340300 - ROD 7340300 3.5MM TI 300MM LENGTH BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7340500 SUP HCPCS C1713 7340500 - ROD 7340500 3.5MM TI 500MM LENGTH BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7341101 SUP HCPCS C1713 7341101 - HOOK 7341101 PEDICLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7341111 SUP HCPCS C1713 7341111 - HOOK 7341111 SMALL LAMINIAR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7341112 SUP HCPCS C1713 7341112 - HOOK 7341112 MEDIUM LAMINIAR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7341113 SUP HCPCS C1713 7341113 - HOOK 7341113 LARGE LAMINIAR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7341142 SUP HCPCS C1713 7341142 - HOOK 7341142 RAMPED NARROW BLADE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7341171 SUP HCPCS C1713 7341171 - HOOK 7341171 EXTENDED BODY BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7342410 SUP HCPCS C1713 7342410 - SCREW 7342410 FAS 4.0 X 10MM FOR 3.5 ROD BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7342415 SUP HCPCS C1713 7342415 - SCREW 7342415 FAS 4.0 X 15MM FOR 3.5 ROD BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7342420 SUP HCPCS C1713 7342420 - SCREW 7342420 FAS 4.0 X 20MM FOR 3.5 ROD BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7342425 SUP HCPCS C1713 7342425 - SCREW 7342425 FAS 4.0 X 25MM FOR 3.5 ROD BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7342430 SUP HCPCS C1713 7342430 - SCREW 7342430 FAS 4.0 X 30MM FOR 3.5 ROD BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7342435 SUP HCPCS C1713 7342435 - FAS 4.0 X 35MM FOR 3.5 ROD BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7342440 SUP HCPCS C1713 7342440 - FAS 4.0 X 40MM FOR 3.5 ROD BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343310 SUP HCPCS C1713 7343310 - SCREW 7343310 3.5 X 10 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343315 SUP HCPCS C1713 7343315 - SCREW 7343315 3.5 X 15 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343320 SUP HCPCS C1713 7343320 - SCREW 7343320 3.5 X 20 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343325 SUP HCPCS C1713 7343325 - SCREW 7343325 3.5 X 25 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343330 SUP HCPCS C1713 7343330 - SCREW 7343330 3.5 X 30 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343415 SUP HCPCS C1713 7343415 - SCREW 7343415 4.5 X 15 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343420 SUP HCPCS C1713 7343420 - SCREW 7343420 4.5 X 20 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343425 SUP HCPCS C1713 7343425 - SCREW 7343425 4.5 X 25 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343430 SUP HCPCS C1713 7343430 - SCREW 7343430 4.5 X 30 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343435 SUP HCPCS C1713 7343435 - SCREW 7343435 4.5 X 35 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343440 SUP HCPCS C1713 7343440 - SCREW 7343440 4.5 X 40 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343520 SUP HCPCS C1713 7343520 - SCREW 7343520 5.5 X 20 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343525 SUP HCPCS C1713 7343525 - SCREW 7343525 5.5 X 25 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343530 SUP HCPCS C1713 7343530 - SCREW 7343530 5.5 X 30 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343535 SUP HCPCS C1713 7343535 - SCREW 7343535 5.5 X 35 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343540 SUP HCPCS C1713 7343540 - SCREW 7343540 5.5 X 40 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7343545 SUP HCPCS C1713 7343545 - SCREW 7343545 5.5 X 45 BOTH IP/OP "$1,959.00 " "$1,449.66" $0.00 "$1,567.20" $881.55 $881.55 $0.00 $0.00 $0.00 $408.30 "$1,453.97" "$1,453.97" $0.00 $0.00 $408.26 $0.00 "$1,158.75" "$1,158.75" $0.00 $979.50 "$1,551.53" "$1,567.20" $0.00 $0.00 $306.58 $0.00 $0.00 $311.87 $0.00 $0.00 $0.00 $0.00 $0.00 7360000 SUP HCPCS C1713 7360000 - SET SCREW 7360000 BRK OFF M6 BUTR PLG SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7360300 SUP HCPCS C1713 7360300 - ROD 7360300 ROD 3.5MM DIA SS L 300 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7360500 SUP HCPCS C1713 7360500 - ROD 7360500 ROD 3.5MM DIA SS L 500 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7361101 SUP HCPCS C1713 7361101 - HOOK 7361101 PEDICLE HOOK 3.5MM DIA SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7361111 SUP HCPCS C1713 7361111 - HOOK 7361111 S LAMINAR HOOK 3.5MM DIA SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7361112 SUP HCPCS C1713 7361112 - HOOK 7361112 M LAMINAR HOOK 3.5MM DIA SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7361113 SUP HCPCS C1713 7361113 - HOOK 7361113 L LAMINAR HOOK 3.5MM DIA SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7361142 SUP HCPCS C1713 7361142 - HOOK 7361142 RMP NAR BLD HK 3.5MM DIA SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7361171 SUP HCPCS C1713 7361171 - HOOK 7361171 EXTD BODY HOOK 3.5MM DIA SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7362410 SUP HCPCS C1713 "7362410 - FAS 4.0 X 10MM FOR 3.5 ROD, SS" BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7362415 SUP HCPCS C1713 "7362415 - FAS 4.0 X 15MM FOR 3.5 ROD, SS" BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7362420 SUP HCPCS C1713 "7362420 - FAS 4.0 X 20MM FOR 3.5 ROD, SS" BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7362425 SUP HCPCS C1713 "7362425 - FAS 4.0 X 25MM FOR 3.5 ROD, SS" BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7362430 SUP HCPCS C1713 "7362430 - FAS 4.0 X 30MM FOR 3.5 ROD, SS" BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7362435 SUP HCPCS C1713 "7362435 - FAS 4.0 X 35MM FOR 3.5 ROD, SS" BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7362440 SUP HCPCS C1713 "7362440 - FAS 4.0 X 40MM FOR 3.5 ROD, SS" BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363310 SUP HCPCS C1713 7363310 - BONE SCREW 7363310 FAS 3.5 X 10 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363315 SUP HCPCS C1713 7363315 - BONE SCREW 7363315 FAS 3.5 X 15 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363320 SUP HCPCS C1713 7363320 - BONE SCREW 7363320 FAS 3.5 X 20 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363325 SUP HCPCS C1713 7363325 - BONE SCREW 7363325 FAS 3.5 X 25 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363330 SUP HCPCS C1713 7363330 - BONE SCREW 7363330 FAS 3.5 X 30 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363415 SUP HCPCS C1713 7363415 - BONE SCREW 7363415 FAS 4.5 X 15 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363420 SUP HCPCS C1713 7363420 - BONE SCREW 7363420 FAS 4.5 X 20 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363425 SUP HCPCS C1713 7363425 - BONE SCREW 7363425 FAS 4.5 X 25 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363430 SUP HCPCS C1713 7363430 - BONE SCREW 7363430 FAS 4.5 X 30 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363435 SUP HCPCS C1713 7363435 - BONE SCREW 7363435 FAS 4.5 X 35 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363440 SUP HCPCS C1713 7363440 - BONE SCREW 7363440 FAS 4.5 X 40 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363520 SUP HCPCS C1713 7363520 - BONE SCREW 7363520 FAS 5.5 X 20 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363525 SUP HCPCS C1713 7363525 - BONE SCREW 7363525 FAS 5.5 X 25 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363530 SUP HCPCS C1713 7363530 - BONE SCREW 7363530 FAS 5.5 X 30 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363535 SUP HCPCS C1713 7363535 - BONE SCREW 7363535 FAS 5.5 X 35 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363540 SUP HCPCS C1713 7363540 - BONE SCREW 7363540 FAS 5.5 X 40 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7363545 SUP HCPCS C1713 7363545 - BONE SCREW 7363545 FAS 5.5 X 45 SS BOTH IP/OP "$1,825.50 " "$1,350.87" $0.00 "$1,460.40" $821.48 $821.48 $0.00 $0.00 $0.00 $380.48 "$1,354.89" "$1,354.89" $0.00 $0.00 $380.43 $0.00 "$1,079.78" "$1,079.78" $0.00 $912.75 "$1,445.80" "$1,460.40" $0.00 $0.00 $285.69 $0.00 $0.00 $290.62 $0.00 $0.00 $0.00 $0.00 $0.00 7370100 SUP HCPCS C1713 7370100 - SCREW BONE .5MM 10MM SPHERX DBR 2 TI SPNL LCK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7375530 SUP HCPCS C1713 7375530 - SCREW BN 5.5MM 30MM SPHERX II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7375535 SUP HCPCS C1713 7375535 - SCREW BN 5.5MM 35MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7375540 SUP HCPCS C1713 7375540 - SCREW BN 5.5MM 40MM PA CNN CANC SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7375545 SUP HCPCS C1713 7375545 - SCREW BN 5.5MM 45MM PA CNN CANC SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7375550 SUP HCPCS C1713 7375550 - SCREW BN 5.5MM 50MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7375555 SUP HCPCS C1713 7375555 - SCREW BN 5.5MM 55MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7376530 SUP HCPCS C1713 7376530 - SCREW BN 6.5MM 30MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7376535 SUP HCPCS C1713 7376535 - SCREW BN 6.5MM 35MM PA CANC SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7376540 SUP HCPCS C1713 7376540 - SCREW BN 6.5MM 40MM SPHERX DBR II PA CNN TI SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7376550 SUP HCPCS C1713 7376550 - SCREW BN 6.5MM 50MM SPHERX DBR II PA CNN TI SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7376555 SUP HCPCS C1713 7376555 - SCREW BN 6.5MM 55MM SPHERX DBR II PA CNN TI SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7377530 SUP HCPCS C1713 7377530 - SCREW BN 7.5MM 30MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7377535 SUP HCPCS C1713 7377535 - SCREW BN 7.5MM 35MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7377540 SUP HCPCS C1713 7377540 - SCREW BN 7.5MM 40MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7377545 SUP HCPCS C1713 7377545 - SCREW BN 7.5MM 45MM SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7377550 SUP HCPCS C1713 7377550 - SCREW BN 7.5MM 50MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7377555 SUP HCPCS C1713 7377555 - SCREW BN 7.5MM 55MM SPHERX DBR II PA CNN SPNE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 7401151 SUP Custom 27203010 KIT CYTOBLOCK REPL REAGENT TISS FRAG CELL PREP CYTO BOTH IP/OP $65.18 $48.23 $0.00 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.59 $51.62 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440020 SUP HCPCS C1713 7440020 - SET SCREW 7440020 BREAKOFF TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7440030 SUP HCPCS C1713 7440030 - SET SCREW 7440030 L 4.5 G4 TI BRK OFF BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7440100 SUP HCPCS C1713 "7440100 - SET SCREW, NON BREAK-OFF, TI" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7440120 SUP HCPCS C1713 "7440120 - SET SCREW, NON BREAK-OFF, TI" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7440122 SUP HCPCS C1713 7440122 - PLATE BN 22MM NS GRDNT + 1 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440124 SUP HCPCS C1713 7440124 - PLATE BN 24MM NS GRDNT + 1 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440126 SUP HCPCS C1713 7440126 - PLATE BN 26MM NS GRDNT + 1 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440128 SUP HCPCS C1713 7440128 - PLATE BN 28MM NS GRDNT + 1 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440130 SUP HCPCS C1713 7440130 - PLATE BN 30MM NS GRDNT + 1 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440132 SUP HCPCS C1713 7440132 - PLATE BN 32MM NS GRDNT + 1 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440134 SUP HCPCS C1713 7440134 - PLATE BN 34MM NS GRDNT + 1 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440136 SUP HCPCS C1713 7440136 - PLATE BN 36MM NS GRDNT + 1 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440236 SUP HCPCS C1713 7440236 - PLATE BN 36MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440238 SUP HCPCS C1713 7440238 - PLATE BN 38MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440240 SUP HCPCS C1713 7440240 - PLATE BN 40MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440242 SUP HCPCS C1713 7440242 - PLATE BN 42MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440244 SUP HCPCS C1713 7440244 - PLATE BN 44MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440246 SUP HCPCS C1713 7440246 - PLATE BN 46MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440248 SUP HCPCS C1713 7440248 - PLATE BN 48MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440250 SUP HCPCS C1713 7440250 - PLATE BN 50MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440252 SUP HCPCS C1713 7440252 - PLATE BN 52MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440254 SUP HCPCS C1713 7440254 - PLATE BN 54MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440354 SUP HCPCS C1713 7440354 - PLATE BN 54MM NS GRDNT + 3 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440356 SUP HCPCS C1713 7440356 - PLATE BN 56MM NS GRDNT + 3 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440358 SUP HCPCS C1713 7440358 - PLATE BN 58MM NS GRDNT + 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440360 SUP HCPCS C1713 7440360 - PLATE BN 60MM NS GRDNT + 3 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440362 SUP HCPCS C1713 7440362 - PLATE BN 62MM NS GRDNT + 3 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440364 SUP HCPCS C1713 7440364 - PLATE BN 64MM NS GRDNT + 3 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440366 SUP HCPCS C1713 7440366 - PLATE BN 66MM NS GRDNT + 3 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440368 SUP HCPCS C1713 7440368 - PLATE BN 68MM NS GRDNT + 3 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440468 SUP HCPCS C1713 7440468 - PLATE BN 68MM NS GRDNT + 4 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440470 SUP HCPCS C1713 7440470 - PLATE BN 70MM NS GRDNT + 4 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440474 SUP HCPCS C1713 7440474 - PLATE BN 74MM NS GRDNT + 4 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440478 SUP HCPCS C1713 7440478 - PLATE BN 78MM NS GRDNT + 4 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440482 SUP HCPCS C1713 7440482 - PLATE BN 82MM NS GRDNT + 4 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440486 SUP HCPCS C1713 7440486 - PLATE BN 86MM NS GRDNT + 4 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440490 SUP HCPCS C1713 7440490 - PLATE BN 90MM NS GRDNT + 4 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7440500 SUP HCPCS C1713 7440500 - PLATE BN RND HL CVR TI SPNE CRV ANT BOTH IP/OP $377.50 $279.35 $0.00 $302.00 $169.88 $169.88 $0.00 $0.00 $0.00 $78.68 $280.18 $280.18 $0.00 $0.00 $78.67 $0.00 $223.29 $223.29 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 7440918 SUP Custom 27203010 7440918 - BIT DRL MN 10MM HLX ACP SPNE BOTH IP/OP $570.00 $421.80 $0.00 $456.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $423.05 $423.05 $0.00 $0.00 $118.79 $0.00 $0.00 $0.00 $0.00 $285.00 $451.44 $456.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441102 SUP HCPCS C1713 7441102 - HOOK 7441102 PEDICLE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441112 SUP HCPCS C1713 7441112 - HOOK 7441112 WIDE BLADE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441113 SUP HCPCS C1713 7441113 - HOOK 7441113 WIDE BLADE MED TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441114 SUP HCPCS C1713 7441114 - HOOK 7441114 WIDE BLADE LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441122 SUP HCPCS C1713 7441122 - HOOK 7441122 NARROW BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441142 SUP HCPCS C1713 7441142 - HOOK 7441142 RAMPED THORACIC TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441162 SUP HCPCS C1713 7441162 - HOOK 7441162 LUMBAR ANGLED BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441172 SUP HCPCS C1713 7441172 - HOOK 7441172 EXTENDED BODY TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441198 SUP HCPCS C1713 7441198 - HOOK 7441198 OFFSET RT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7441199 SUP HCPCS C1713 7441199 - HOOK 7441199 OFFSET LT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7442420 SUP HCPCS C1713 7442420 - BONE SCREW 7442420 FXD ANGLE 4.0X20 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442425 SUP HCPCS C1713 7442425 - BONE SCREW 7442425 FXD ANGLE 4.0X25 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442430 SUP HCPCS C1713 7442430 - BONE SCREW 7442430 FXD ANGLE 4.0X30 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442435 SUP HCPCS C1713 7442435 - BONE SCREW 7442435 FXD ANGLE 4.0X35 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442440 SUP HCPCS C1713 7442440 - BONE SCREW 7442440 FXD ANGLE 4.0X40 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442525 SUP HCPCS C1713 7442525 - BONE SCREW 7442525 FXD ANGLE 5.0X25 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442528 SUP HCPCS C1713 "7442528 - SCREW, FIXED ANGLE,5.0X27.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442530 SUP HCPCS C1713 7442530 - BONE SCREW 7442530 FXD ANGLE 5.0X30 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442533 SUP HCPCS C1713 "7442533 - SCREW, FIXED ANGLE,5.0X32.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442535 SUP HCPCS C1713 7442535 - BONE SCREW 7442535 FXD ANGLE 5.0X35 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442538 SUP HCPCS C1713 "7442538 - SCREW, FIXED ANGLE,5.0X37.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442540 SUP HCPCS C1713 7442540 - BONE SCREW 7442540 FXD ANGLE 5.0X40 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442545 SUP HCPCS C1713 7442545 - BONE SCREW 7442545 FXD ANGLE 5.0X45 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442550 SUP HCPCS C1713 7442550 - BONE SCREW 7442550 FXD ANGLE 5.0X50 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442625 SUP HCPCS C1713 7442625 - BONE SCREW 7442625 FXD ANGLE6.0X25TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442628 SUP HCPCS C1713 "7442628 - SCREW, FIXED ANGLE,6.0X27.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442630 SUP HCPCS C1713 7442630 - BONE SCREW 7442630 FXD ANGLE6.0X30TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442633 SUP HCPCS C1713 "7442633 - SCREW, FIXED ANGLE,6.0X32.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442635 SUP HCPCS C1713 7442635 - BONE SCREW 7442635 FXD ANGLE6.0X35TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442638 SUP HCPCS C1713 "7442638 - SCREW, FIXED ANGLE,6.0X37.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442640 SUP HCPCS C1713 7442640 - BONE SCREW 7442640 FXD ANGLE6.0X40TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442645 SUP HCPCS C1713 7442645 - BONE SCREW 7442645 FXD ANGLE6.0X45TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7442650 SUP HCPCS C1713 7442650 - BONE SCREW 7442650 FXD ANGLE6.0X50TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443425 SUP HCPCS C1713 7443425 - BONE SCREW 7443425 FXD ANGLE 4.5X25 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443428 SUP HCPCS C1713 "7443428 - SCREW, FIXED ANGLE,4.5X27.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443430 SUP HCPCS C1713 7443430 - BONE SCREW 7443430 FXD ANGLE 4.5X30 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443433 SUP HCPCS C1713 "7443433 - SCREW, FIXED ANGLE,4.5X32.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443435 SUP HCPCS C1713 7443435 - BONE SCREW 7443435 FXD ANGLE 4.5X35 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443438 SUP HCPCS C1713 "7443438 - SCREW, FIXED ANGLE,4.5X37.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443440 SUP HCPCS C1713 7443440 - BONE SCREW 7443440 FXD ANGLE 4.5X40 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443445 SUP HCPCS C1713 "7443445 - SCREW, FIXED ANGLE, 4.5X45, TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443450 SUP HCPCS C1713 "7443450 - SCREW, FIXED ANGLE, 4.5X50, TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443525 SUP HCPCS C1713 7443525 - BONE SCREW 7443525 FXD ANGLE 5.5X25 TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443528 SUP HCPCS C1713 "7443528 - SCREW, FIXED ANGLE,5.5X27.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443530 SUP HCPCS C1713 7443530 - BONE SCREW 7443530 FXD ANGLE5.5X30TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443533 SUP HCPCS C1713 "7443533 - SCREW, FIXED ANGLE,5.5X32.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443535 SUP HCPCS C1713 7443535 - BONE SCREW 7443535 FXD ANGLE5.5X35TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443538 SUP HCPCS C1713 "7443538 - SCREW, FIXED ANGLE,5.5X37.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443540 SUP HCPCS C1713 7443540 - BONE SCREW 7443540 FXD ANGLE5.5X40TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443545 SUP HCPCS C1713 7443545 - BONE SCREW 7443545 FXD ANGLE5.5X45TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443550 SUP HCPCS C1713 7443550 - BONE SCREW 7443550 FXD ANGLE5.5X50TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443625 SUP HCPCS C1713 7443625 - BONE SCREW 7443625 FXD ANGLE6.5X25TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443628 SUP HCPCS C1713 "7443628 - SCREW, FIXED ANGLE,6.5X27.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443630 SUP HCPCS C1713 7443630 - BONE SCREW 7443630 FXD ANGLE6.5X30TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443633 SUP HCPCS C1713 "7443633 - SCREW, FIXED ANGLE,6.5X32.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443635 SUP HCPCS C1713 7443635 - BONE SCREW 7443635 FXD ANGLE6.5X35TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443638 SUP HCPCS C1713 "7443638 - SCREW, FIXED ANGLE,6.5X37.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443640 SUP HCPCS C1713 7443640 - BONE SCREW 7443640 FXD ANGLE6.5X40TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443645 SUP HCPCS C1713 7443645 - BONE SCREW 7443645 FXD ANGLE6.5X45TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443650 SUP HCPCS C1713 7443650 - BONE SCREW 7443650 FXD ANGLE6.5X50TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443655 SUP HCPCS C1713 7443655 - BONE SCREW 7443655 FXD ANGLE6.5X55TI BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443725 SUP HCPCS C1713 "7443725 - SCREW, FIXED ANGLE,7.5X25,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443728 SUP HCPCS C1713 "7443728 - SCREW, FIXED ANGLE,7.5X27.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443730 SUP HCPCS C1713 "7443730 - SCREW, FIXED ANGLE,7.5X30,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443733 SUP HCPCS C1713 "7443733 - SCREW, FIXED ANGLE,7.5X32.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443735 SUP HCPCS C1713 "7443735 - SCREW, FIXED ANGLE,7.5X35,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443738 SUP HCPCS C1713 "7443738 - SCREW, FIXED ANGLE,7.5X37.5,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443740 SUP HCPCS C1713 "7443740 - SCREW, FIXED ANGLE,7.5X40,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443745 SUP HCPCS C1713 "7443745 - SCREW, FIXED ANGLE,7.5X45,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443750 SUP HCPCS C1713 "7443750 - SCREW, FIXED ANGLE,7.5X50,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7443755 SUP HCPCS C1713 "7443755 - SCREW, FIXED ANGLE,7.5X55,TI" BOTH IP/OP "$1,864.50 " "$1,379.73" $0.00 "$1,491.60" $839.03 $839.03 $0.00 $0.00 $0.00 $388.61 "$1,383.83" "$1,383.83" $0.00 $0.00 $388.56 $0.00 "$1,102.85" "$1,102.85" $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $291.79 $0.00 $0.00 $296.83 $0.00 $0.00 $0.00 $0.00 $0.00 7450122 SUP HCPCS C1713 7450122 - PLATE BN 22MM GRDNT + 1 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450124 SUP HCPCS C1713 7450124 - PLATE BN 24MM GRDNT + 1 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450126 SUP HCPCS C1713 7450126 - PLATE BN 26MM GRDNT + 1 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450128 SUP HCPCS C1713 7450128 - PLATE BN 28MM GRDNT + 1 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450130 SUP HCPCS C1713 7450130 - PLATE BN 30MM GRDNT + 1 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450132 SUP HCPCS C1713 7450132 - PLATE BN 32MM GRDNT + 1 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450134 SUP HCPCS C1713 7450134 - PLATE BN 34MM GRDNT + 1 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450136 SUP HCPCS C1713 7450136 - PLATE BN 36MM GRDNT + 1 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450236 SUP HCPCS C1713 7450236 - PLATE BN 36MM GRDNT + 2 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450238 SUP HCPCS C1713 7450238 - PLATE BN 38MM GRDNT + 2 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450240 SUP HCPCS C1713 7450240 - PLATE BN 40MM GRDNT + 2 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450242 SUP HCPCS C1713 7450242 - PLATE BN 42MM GRDNT + 2 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450244 SUP HCPCS C1713 7450244 - PLATE BN 44MM GRDNT + 2 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450246 SUP HCPCS C1713 7450246 - PLATE BN 46MM GRDNT + 2 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450248 SUP HCPCS C1713 7450248 - PLATE BN 48MM GRDNT + 2 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450250 SUP HCPCS C1713 7450250 - PLATE BN 50MM GRDNT + LVL 2 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450252 SUP HCPCS C1713 7450252 - PLATE BN 52MM GRDNT + LVL 2 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450254 SUP HCPCS C1713 7450254 - PLATE BN 54MM GRDNT + 2 LVL FX SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7450354 SUP HCPCS C1713 7450354 - PLATE BN 54MM GRDNT + 3 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450356 SUP HCPCS C1713 7450356 - PLATE BN 56MM GRDNT + LVL 3 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450358 SUP HCPCS C1713 7450358 - PLATE BN 58MM GRDNT + 3 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450360 SUP HCPCS C1713 7450360 - PLATE BN 60MM GRDNT + 3 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450362 SUP HCPCS C1713 7450362 - PLATE BN 62MM GRDNT + 3 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450364 SUP HCPCS C1713 7450364 - PLATE BN 64MM GRDNT + 3 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450366 SUP HCPCS C1713 7450366 - PLATE BN 66MM GRDNT + 3 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450368 SUP HCPCS C1713 7450368 - PLATE BN 68MM GRDNT + 3 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450468 SUP HCPCS C1713 7450468 - PLATE BN 68MM GRDNT + 4 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450470 SUP HCPCS C1713 7450470 - PLATE BN 70MM GRDNT + 4 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450474 SUP HCPCS C1713 7450474 - PLATE BN 74MM GRDNT + 4 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450478 SUP HCPCS C1713 7450478 - PLATE BN 78MM GRDNT + 4 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450482 SUP HCPCS C1713 7450482 - PLATE BN 82MM GRDNT + 4 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450486 SUP HCPCS C1713 7450486 - PLATE BN 86MM GRDNT + 4 LVL FX SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450490 SUP HCPCS C1713 7450490 - PLATE BN 90MM GRDNT + LVL 4 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450500 SUP HCPCS C1713 7450500 - PLATE BN 100MM GRDNT + LVL 5 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450505 SUP HCPCS C1713 7450505 - PLATE BN 105MM GRDNT + LVL 5 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450510 SUP HCPCS C1713 7450510 - PLATE BN 110MM GRDNT + LVL 5 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450595 SUP HCPCS C1713 7450595 - PLATE BN 95MM GRDNT + LVL 5 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7450610 SUP HCPCS C1713 7450610 - SCREW BN 4MM 10MM NS GRDNT + FX ANG SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7450612 SUP HCPCS C1713 7450612 - SCREW BN 4MM 12MM NS GRDNT + FX ANG SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7450614 SUP HCPCS C1713 7450614 - SCREW BN 4MM 14MM NS GRDNT + FX ANG SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7450616 SUP HCPCS C1713 7450616 - SCREW BN 4MM FA ANT CSPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7450710 SUP HCPCS C1713 7450710 - SCREW BN 4.5MM 10MM NS GRDNT + FX ANG SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7450712 SUP HCPCS C1713 7450712 - SCREW BN 4.5MM 12MM NS GRDNT + FX ANG SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7450714 SUP HCPCS C1713 7450714 - SCREW BN 4.5MM 14MM NS GRDNT + FX ANG SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7450716 SUP HCPCS C1713 7450716 - SCREW BN 4.5MM 16MM GRDNT + FA ANT CSPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7450800 SUP Custom 27803010 7450800 - HOLDER IMPL VLCK TEMP FX TACK BOTH IP/OP $377.50 $279.35 $0.00 $302.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.18 $280.18 $0.00 $0.00 $78.67 $0.00 $0.00 $0.00 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7451500 SUP HCPCS C1713 7451500 - PLATE BN NS GRDNT + SLOT HL CVR TI SPNE BOTH IP/OP $377.50 $279.35 $0.00 $302.00 $169.88 $169.88 $0.00 $0.00 $0.00 $78.68 $280.18 $280.18 $0.00 $0.00 $78.67 $0.00 $223.29 $223.29 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 7451501 SUP HCPCS C1713 7451501 - PLATE BN NS GRDNT + RND HL CVR TI SPNE BOTH IP/OP $377.50 $279.35 $0.00 $302.00 $169.88 $169.88 $0.00 $0.00 $0.00 $78.68 $280.18 $280.18 $0.00 $0.00 $78.67 $0.00 $223.29 $223.29 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 7460020 SUP HCPCS C1713 7460020 - SET SCREW 7460020 BREAK OFF SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7460120 SUP HCPCS C1713 "7460120 - SET SCREW, NON BREAK-OFF, SS" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7460500 SUP HCPCS C1713 7460500 - PLATE BN 100MM GRDNT + LVL 5 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7460505 SUP HCPCS C1713 7460505 - PLATE BN 105MM GRDNT + LVL 5 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7460510 SUP HCPCS C1713 7460510 - PLATE BN 110MM GRDNT + LVL 5 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7460595 SUP HCPCS C1713 7460595 - PLATE BN 95MM GRDNT + LVL 5 FX ANG TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7460610 SUP HCPCS C1713 7460610 - SCREW BN 4MM 10MM NS GRDNT + SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7460612 SUP HCPCS C1713 7460612 - SCREW BN 4MM 12MM NS GRDNT + SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7460614 SUP HCPCS C1713 7460614 - SCREW BN 4MM 14MM NS GRDNT + SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7460616 SUP HCPCS C1713 7460616 - SCREW BN 4MM 16MM GRDNT + VA TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7460710 SUP HCPCS C1713 7460710 - SCREW BN 4.5MM 10MM NS GRDNT + SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7460712 SUP HCPCS C1713 7460712 - SCREW BN 4.5MM 12MM NS GRDNT + SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7460714 SUP HCPCS C1713 7460714 - SCREW BN 4.5MM 14MM NS GRDNT + SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7460716 SUP HCPCS C1713 7460716 - SCREW BN 4.5MM 16MM GRDNT + VA ANT CSPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7461102 SUP HCPCS C1713 7461102 - HOOK 7461102 PEDICLE SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461112 SUP HCPCS C1713 7461112 - HOOK 7461112 WIDE BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461113 SUP HCPCS C1713 7461113 - HOOK 7461113 WIDE BLADE MED SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461114 SUP HCPCS C1713 7461114 - HOOK 7461114 WIDE BLADE LGE SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461122 SUP HCPCS C1713 7461122 - HOOK 7461122 NARROW BLADE SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461142 SUP HCPCS C1713 7461142 - HOOK 7461142 RAMPED THORACIC SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461162 SUP HCPCS C1713 7461162 - HOOK 7461162 LUMBAR ANGLED BLADE SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461172 SUP HCPCS C1713 7461172 - HOOK 7461172 EXTENDED BODY SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461198 SUP HCPCS C1713 7461198 - HOOK 7461198 OFFSET RIGHT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461199 SUP HCPCS C1713 7461199 - HOOK 7461199 OFFSET LEFT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7461500 SUP HCPCS C1713 7461500 - PLATE BN NS GRDNT + SLOT HL CVR TI SPNE BOTH IP/OP $377.50 $279.35 $0.00 $302.00 $169.88 $169.88 $0.00 $0.00 $0.00 $78.68 $280.18 $280.18 $0.00 $0.00 $78.67 $0.00 $223.29 $223.29 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 7461501 SUP HCPCS C1713 7461501 - PLATE BN NS GRDNT + RND HL CVR TI SPNE BOTH IP/OP $377.50 $279.35 $0.00 $302.00 $169.88 $169.88 $0.00 $0.00 $0.00 $78.68 $280.18 $280.18 $0.00 $0.00 $78.67 $0.00 $223.29 $223.29 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 7462420 SUP HCPCS C1713 7462420 - SCREW 7462420 FIXED ANGLE 4.0X20 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462425 SUP HCPCS C1713 7462425 - SCREW 7462425 FIXED ANGLE 4.0X25 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462430 SUP HCPCS C1713 7462430 - SCREW 7462430 FIXED ANGLE 4.0X30 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462435 SUP HCPCS C1713 7462435 - SCREW 7462435 FIXED ANGLE 4.0X35 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462440 SUP HCPCS C1713 7462440 - SCREW 7462440 FIXED ANGLE 4.0X40 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462525 SUP HCPCS C1713 7462525 - SCREW 7462525 FIXED ANGLE 5.0X25 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462528 SUP HCPCS C1713 "7462528 - SCREW, FIXED ANGLE,5.0X27.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462530 SUP HCPCS C1713 7462530 - SCREW 7462530 FIXED ANGLE 5.0X30 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462533 SUP HCPCS C1713 "7462533 - SCREW, FIXED ANGLE,5.0X32.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462535 SUP HCPCS C1713 7462535 - SCREW 7462535 FIXED ANGLE 5.0X35 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462538 SUP HCPCS C1713 "7462538 - SCREW, FIXED ANGLE,5.0X37.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462540 SUP HCPCS C1713 7462540 - SCREW 7462540 FIXED ANGLE 5.0X40 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462545 SUP HCPCS C1713 7462545 - SCREW 7462545 FIXED ANGLE 5.0X45 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462550 SUP HCPCS C1713 7462550 - SCREW 7462550 FIXED ANGLE 5.0X50 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462625 SUP HCPCS C1713 7462625 - SCREW 7462625 FIXED ANGLE 6.0X25 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462628 SUP HCPCS C1713 "7462628 - SCREW, FIXED ANGLE,6.0X27.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462630 SUP HCPCS C1713 7462630 - SCREW 7462630 FIXED ANGLE 6.0X30 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462633 SUP HCPCS C1713 "7462633 - SCREW, FIXED ANGLE,6.0X32.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462635 SUP HCPCS C1713 7462635 - SCREW 7462635 FIXED ANGLE 6.0X35 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462638 SUP HCPCS C1713 "7462638 - SCREW, FIXED ANGLE,6.0X37.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462640 SUP HCPCS C1713 7462640 - SCREW 7462640 FIXED ANGLE 6.0X40 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462645 SUP HCPCS C1713 7462645 - SCREW 7462645 FIXED ANGLE 6.0X45 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7462650 SUP HCPCS C1713 7462650 - SCREW 7462650 FIXED ANGLE 6.0X50 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463425 SUP HCPCS C1713 7463425 - SCREW 7463425 FIXED ANGLE 4.5X25 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463428 SUP HCPCS C1713 "7463428 - SCREW, FIXED ANGLE,4.5X27.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463430 SUP HCPCS C1713 7463430 - SCREW 7463430 FIXED ANGLE 4.5X30 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463433 SUP HCPCS C1713 "7463433 - SCREW, FIXED ANGLE,4.5X32.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463435 SUP HCPCS C1713 7463435 - SCREW 7463435 FIXED ANGLE 4.5X35 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463438 SUP HCPCS C1713 "7463438 - SCREW, FIXED ANGLE,4.5X37.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463440 SUP HCPCS C1713 7463440 - SCREW 7463440 FIXED ANGLE 4.5X40 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463445 SUP HCPCS C1713 "7463445 - SCREW, FIXED ANGLE, 4.5X45, SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463450 SUP HCPCS C1713 "7463450 - SCREW, FIXED ANGLE, 4.5X50, SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463525 SUP HCPCS C1713 7463525 - SCREW 7463525 FIXED ANGLE 5.5X25 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463528 SUP HCPCS C1713 "7463528 - SCREW, FIXED ANGLE,5.5X27.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463530 SUP HCPCS C1713 7463530 - SCREW 7463530 FIXED ANGLE 5.5X30 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463533 SUP HCPCS C1713 "7463533 - SCREW, FIXED ANGLE,5.5X32.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463535 SUP HCPCS C1713 7463535 - SCREW 7463535 FIXED ANGLE 5.5X35 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463538 SUP HCPCS C1713 "7463538 - SCREW, FIXED ANGLE,5.5X37.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463540 SUP HCPCS C1713 7463540 - SCREW 7463540 FIXED ANGLE 5.5X40 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463545 SUP HCPCS C1713 7463545 - SCREW 7463545 FIXED ANGLE 5.5X45 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463550 SUP HCPCS C1713 7463550 - SCREW 7463550 FIXED ANGLE 5.5X50 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463625 SUP HCPCS C1713 7463625 - SCREW 7463625 FIXED ANGLE 6.5X25 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463628 SUP HCPCS C1713 "7463628 - SCREW, FIXED ANGLE,6.5X27.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463630 SUP HCPCS C1713 7463630 - SCREW 7463630 FIXED ANGLE 6.5X30 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463633 SUP HCPCS C1713 "7463633 - SCREW, FIXED ANGLE,6.5X32.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463635 SUP HCPCS C1713 7463635 - SCREW 7463635 FIXED ANGLE 6.5X35 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463638 SUP HCPCS C1713 "7463638 - SCREW, FIXED ANGLE,6.5X37.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463640 SUP HCPCS C1713 7463640 - SCREW 7463640 FIXED ANGLE 6.5X40 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463645 SUP HCPCS C1713 7463645 - SCREW 7463645 FIXED ANGLE 6.5X45 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463650 SUP HCPCS C1713 7463650 - SCREW 7463650 FIXED ANGLE 6.5X50 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463655 SUP HCPCS C1713 7463655 - SCREW 7463655 FIXED ANGLE 6.5X55 SS BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463725 SUP HCPCS C1713 "7463725 - SCREW, FIXED ANGLE,7.5X25,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463728 SUP HCPCS C1713 "7463728 - SCREW, FIXED ANGLE,7.5X27.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463730 SUP HCPCS C1713 "7463730 - SCREW, FIXED ANGLE,7.5X30,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463733 SUP HCPCS C1713 "7463733 - SCREW, FIXED ANGLE,7.5X32.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463735 SUP HCPCS C1713 "7463735 - SCREW, FIXED ANGLE,7.5X35,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463738 SUP HCPCS C1713 "7463738 - SCREW, FIXED ANGLE,7.5X37.5,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463740 SUP HCPCS C1713 "7463740 - SCREW, FIXED ANGLE,7.5X40,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463745 SUP HCPCS C1713 "7463745 - SCREW, FIXED ANGLE,7.5X45,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463750 SUP HCPCS C1713 "7463750 - SCREW, FIXED ANGLE,7.5X50,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7463755 SUP HCPCS C1713 "7463755 - SCREW, FIXED ANGLE,7.5X55,SS" BOTH IP/OP "$1,666.50 " "$1,233.21" $0.00 "$1,333.20" $749.93 $749.93 $0.00 $0.00 $0.00 $347.34 "$1,236.88" "$1,236.88" $0.00 $0.00 $347.30 $0.00 $985.73 $985.73 $0.00 $833.25 "$1,319.87" "$1,333.20" $0.00 $0.00 $260.81 $0.00 $0.00 $265.31 $0.00 $0.00 $0.00 $0.00 $0.00 7490122 SUP HCPCS C1713 7490122 - PLATE BN 22MM GRDNT + 1 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490124 SUP HCPCS C1713 7490124 - PLATE BN 24MM GRDNT + 1 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490126 SUP HCPCS C1713 7490126 - PLATE BN 26MM GRDNT + 1 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490128 SUP HCPCS C1713 7490128 - PLATE BN 28MM GRDNT + 1 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490236 SUP HCPCS C1713 7490236 - PLATE BN 36MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490238 SUP HCPCS C1713 7490238 - PLATE BN 38MM NS GRDNT + 2 LVL SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490240 SUP HCPCS C1713 7490240 - PLATE BN 40MM GRDNT + 2 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490242 SUP HCPCS C1713 7490242 - PLATE BN 42MM GRDNT + 2 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490244 SUP HCPCS C1713 7490244 - PLATE BN 44MM GRDNT + 2 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490246 SUP HCPCS C1713 7490246 - PLATE BN 46MM GRDNT + 2 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490248 SUP HCPCS C1713 7490248 - PLATE BN 48MM GRDNT + 2 LVL FX SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7490354 SUP HCPCS C1713 7490354 - PLATE BN 54MM GRDNT + 3 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490356 SUP HCPCS C1713 7490356 - PLATE BN 56MM GRDNT + 3 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490358 SUP HCPCS C1713 7490358 - PLATE BN 58MM GRDNT + 3 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490360 SUP HCPCS C1713 7490360 - PLATE BN 60MM GRDNT + 3 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490362 SUP HCPCS C1713 7490362 - PLATE BN 62MM GRDNT + 3 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490364 SUP HCPCS C1713 7490364 - PLATE BN 64MM GRDNT + 3 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490366 SUP HCPCS C1713 7490366 - PLATE BN 66MM GRDNT + 3 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490468 SUP HCPCS C1713 7490468 - PLATE BN 68MM GRDNT + 4 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490470 SUP HCPCS C1713 7490470 - PLATE BN 70MM GRDNT + 4 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490474 SUP HCPCS C1713 7490474 - PLATE BN 74MM GRDNT + 4 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490478 SUP HCPCS C1713 7490478 - PLATE BN 78MM GRDNT + 4 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490482 SUP HCPCS C1713 7490482 - PLATE BN 82MM GRDNT + 4 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7490486 SUP HCPCS C1713 7490486 - PLATE BN 86MM GRDNT + 4 LVL FX SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7502073 SUP HCPCS C1713 7502073 - CAGE SPNL 20D HYPERLORDOTIC 34X6X24MM CRNT BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502077 SUP HCPCS C1713 7502077 - CAGE SPNL 20D HYPERLORDOTIC 34X10X24MM NS BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502100 SUP HCPCS C1713 7502100 - CAGE SPNL 20D HYPERLORDOTIC 38X28X6MM NS LF BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502102 SUP HCPCS C1713 7502102 - CAGE SPNL 20D HYPERLORDOTIC 38X28X8MM NS LF BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502104 SUP HCPCS C1713 7502104 - CAGE SPNL 20D HYPERLORDOTIC 38X28X10MM NS LF BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502219 SUP HCPCS C1713 7502219 - CAGE SPNL 20D HYPERLORDOTIC 34X8X24MM CRNT BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502221 SUP HCPCS C1713 7502221 - CAGE SPNL 30D HYPERLORDOTIC 34X10X24MM CRNT BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502244 SUP HCPCS C1713 7502244 - CAGE SPNL 30D HYPERLORDOTIC 38X6X28MM CRNT BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502246 SUP HCPCS C1713 7502246 - CAGE SPNL 30D HYPERLORDOTIC 38X28X8MM NS LF BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7502248 SUP HCPCS C1713 7502248 - CAGE SPNL 30D HYPERLORDOTIC 38X28X10MM NS LF BRIGADE BOTH IP/OP "$18,375.00 " "$13,597.50" $0.00 "$14,700.00" "$8,268.75" "$8,268.75" $0.00 $0.00 $0.00 "$3,829.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,829.35" $0.00 "$9,058.88" "$9,058.88" $0.00 "$9,187.50" "$14,553.00" "$14,700.00" $0.00 $0.00 "$2,875.69" $0.00 $0.00 "$2,925.30" $0.00 $0.00 $0.00 $0.00 $0.00 7509145 SUP Custom 27804086 7509145 - GRAFT BN 5X1.75CM MAGNIFUSE DBM BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,432.75" $0.00 $0.00 $0.00 $0.00 "$3,437.50" "$5,445.00" "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7509211 SUP Custom 27804086 7509211 - GRAFT BN 10X1CM MAGNIFUSE DBM BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,354.60" $0.00 $0.00 $0.00 $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7509215 SUP Custom 27804086 7509215 - GRAFT BN 5X1CM MAGNIFUSE DBM SPNE CRV POST BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 $0.00 $0.00 $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7510001 SUP HCPCS C1713 7510001 - NUT LCK 5.5MM LAT PLT SPNE BOTH IP/OP $317.50 $234.95 $0.00 $254.00 $142.88 $142.88 $0.00 $0.00 $0.00 $66.17 $235.65 $235.65 $0.00 $0.00 $66.17 $0.00 $187.80 $187.80 $0.00 $158.75 $251.46 $254.00 $0.00 $0.00 $49.69 $0.00 $0.00 $50.55 $0.00 $0.00 $0.00 $0.00 $0.00 7510050 SUP HCPCS C1713 7510050 - GRAFT BONE 2XS 12MM 20MM ABSORBABLE SPONGE STERILE WATER BOTH IP/OP "$2,387.50 " "$1,766.75" $0.00 "$1,910.00" "$1,074.38" "$1,074.38" $0.00 $0.00 $0.00 $497.61 "$1,772.00" "$1,772.00" $0.00 $0.00 $497.56 $0.00 "$1,412.21" "$1,412.21" $0.00 "$1,193.75" "$1,890.90" "$1,910.00" $0.00 $0.00 $373.64 $0.00 $0.00 $380.09 $0.00 $0.00 $0.00 $0.00 $0.00 7510100 SUP HCPCS C1713 7510100 - GRAFT BONE XS KIT INFUSE BOVINE COLLAGEN RHBMP-2 LUMBAR BOTH IP/OP "$4,762.50 " "$3,524.25" $0.00 "$3,810.00" "$2,143.13" "$2,143.13" $0.00 $0.00 $0.00 $992.62 "$3,534.73" "$3,534.73" $0.00 $0.00 $992.51 $0.00 "$2,347.91" "$2,347.91" $0.00 "$2,381.25" "$3,771.90" "$3,810.00" $0.00 $0.00 $745.33 $0.00 $0.00 $758.19 $0.00 $0.00 $0.00 $0.00 $0.00 7510200 SUP HCPCS C1713 7510200 - GRAFT BONE SMALL 14MM 23MM ABSORBABLE SPONGE STERILE WATER BOTH IP/OP "$9,512.50 " "$7,039.25" $0.00 "$7,610.00" "$4,280.63" "$4,280.63" $0.00 $0.00 $0.00 "$1,982.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,982.41" $0.00 "$4,689.66" "$4,689.66" $0.00 "$4,756.25" "$7,533.90" "$7,610.00" $0.00 $0.00 "$1,488.71" $0.00 $0.00 "$1,514.39" $0.00 $0.00 $0.00 $0.00 $0.00 7510400 SUP HCPCS C1713 7510400 - GRAFT BONE MEDIUM 20GA 2X1IN VIAL ABSORBABLE COLLAGEN SPONGE BOTH IP/OP "$13,250.00 " "$9,805.00" $0.00 "$10,600.00" "$5,962.50" "$5,962.50" $0.00 $0.00 $0.00 "$2,761.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,761.30" $0.00 "$6,532.25" "$6,532.25" $0.00 "$6,625.00" "$10,494.00" "$10,600.00" $0.00 $0.00 "$2,073.63" $0.00 $0.00 "$2,109.40" $0.00 $0.00 $0.00 $0.00 $0.00 7510800 SUP HCPCS C1713 7510800 - GRAFT BONE LARGE II 18MM 26MM ABSORBABLE SPONGE STERILE BOTH IP/OP "$14,775.00 " "$10,933.50" $0.00 "$11,820.00" "$6,648.75" "$6,648.75" $0.00 $0.00 $0.00 "$3,079.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,079.11" $0.00 "$7,284.08" "$7,284.08" $0.00 "$7,387.50" "$11,701.80" "$11,820.00" $0.00 $0.00 "$2,312.29" $0.00 $0.00 "$2,352.18" $0.00 $0.00 $0.00 $0.00 $0.00 7521006 SUP HCPCS C1713 7521006 - PLATE BN 6MM XLP 2 HL TI SPNE LAT BOTH IP/OP "$7,022.50 " "$5,196.65" $0.00 "$5,618.00" "$3,160.13" "$3,160.13" $0.00 $0.00 $0.00 "$1,463.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,463.49" $0.00 "$3,462.09" "$3,462.09" $0.00 "$3,511.25" "$5,561.82" "$5,618.00" $0.00 $0.00 "$1,099.02" $0.00 $0.00 "$1,117.98" $0.00 $0.00 $0.00 $0.00 $0.00 7521008 SUP HCPCS C1713 7521008 - PLATE BN 8MM XLP 2 HL TI SPNE LAT BOTH IP/OP "$7,022.50 " "$5,196.65" $0.00 "$5,618.00" "$3,160.13" "$3,160.13" $0.00 $0.00 $0.00 "$1,463.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,463.49" $0.00 "$3,462.09" "$3,462.09" $0.00 "$3,511.25" "$5,561.82" "$5,618.00" $0.00 $0.00 "$1,099.02" $0.00 $0.00 "$1,117.98" $0.00 $0.00 $0.00 $0.00 $0.00 7521012 SUP HCPCS C1713 7521012 - PLATE BN 12MM XLP 2 HL TI SPNE LAT BOTH IP/OP "$7,022.50 " "$5,196.65" $0.00 "$5,618.00" "$3,160.13" "$3,160.13" $0.00 $0.00 $0.00 "$1,463.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,463.49" $0.00 "$3,462.09" "$3,462.09" $0.00 "$3,511.25" "$5,561.82" "$5,618.00" $0.00 $0.00 "$1,099.02" $0.00 $0.00 "$1,117.98" $0.00 $0.00 $0.00 $0.00 $0.00 7521014 SUP HCPCS C1713 7521014 - PLATE BN 14MM XLP 2 HL TI SPNE LAT BOTH IP/OP "$7,022.50 " "$5,196.65" $0.00 "$5,618.00" "$3,160.13" "$3,160.13" $0.00 $0.00 $0.00 "$1,463.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,463.49" $0.00 "$3,462.09" "$3,462.09" $0.00 "$3,511.25" "$5,561.82" "$5,618.00" $0.00 $0.00 "$1,099.02" $0.00 $0.00 "$1,117.98" $0.00 $0.00 $0.00 $0.00 $0.00 7521016 SUP HCPCS C1713 7521016 - PLATE BN 16MM XLP 2 HL TI SPNE LAT BOTH IP/OP "$7,022.50 " "$5,196.65" $0.00 "$5,618.00" "$3,160.13" "$3,160.13" $0.00 $0.00 $0.00 "$1,463.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,463.49" $0.00 "$3,462.09" "$3,462.09" $0.00 "$3,511.25" "$5,561.82" "$5,618.00" $0.00 $0.00 "$1,099.02" $0.00 $0.00 "$1,117.98" $0.00 $0.00 $0.00 $0.00 $0.00 7533006 SUP HCPCS C1713 7533006 - PLATE BN 6MM XLP + 4 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7533008 SUP HCPCS C1713 7533008 - PLATE BN 8MM XLP + 4 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7533010 SUP HCPCS C1713 7533010 - PLATE BN 10MM XLP + 4 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7533012 SUP HCPCS C1713 7533012 - PLATE BN 12MM XLP + 4 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7533014 SUP HCPCS C1713 7533014 - PLATE BN 14MM XLP + 4 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7533016 SUP HCPCS C1713 7533016 - PLATE BN 16MM XLP + 4 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7534006 SUP HCPCS C1713 7534006 - PLATE BN 6MM XLP + 2X2 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7534008 SUP HCPCS C1713 7534008 - PLATE BN 8MM XLP + 2X2 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7534010 SUP HCPCS C1713 7534010 - PLATE BN 10MM XLP + 2X2 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7534012 SUP HCPCS C1713 7534012 - PLATE BN 12MM XLP + 2X2 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7534014 SUP HCPCS C1713 7534014 - PLATE BN 14MM XLP + 2X2 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7534016 SUP HCPCS C1713 7534016 - PLATE BN 16MM XLP + 2X2 HL SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7539006 SUP HCPCS C1713 7539006 - PLATE BN ANG FAVORED 6MM XLP + SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7539008 SUP HCPCS C1713 7539008 - PLATE BN ANG FAVORED 8MM XLP + SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7539010 SUP HCPCS C1713 7539010 - PLATE BN ANG FAVORED 10MM XLP + SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7539012 SUP HCPCS C1713 7539012 - PLATE BN ANG FAVORED 12MM XLP + SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7539014 SUP HCPCS C1713 7539014 - PLATE BN ANG FAVORED 14MM XLP + SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7539016 SUP HCPCS C1713 7539016 - PLATE BN ANG FAVORED 16MM XLP + SPNE BOTH IP/OP "$7,887.50 " "$5,836.75" $0.00 "$6,310.00" "$3,549.38" "$3,549.38" $0.00 $0.00 $0.00 "$1,643.95" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,643.76" $0.00 "$3,888.54" "$3,888.54" $0.00 "$3,943.75" "$6,246.90" "$6,310.00" $0.00 $0.00 "$1,234.39" $0.00 $0.00 "$1,255.69" $0.00 $0.00 $0.00 $0.00 $0.00 7540020 SUP HCPCS C1713 7540020 - SCREW BONE 20MM SPNL TI BRKOF BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7540120 SUP HCPCS C1713 7540120 - SET SCREW 7540120 NON BREAK OFF TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7540220 SUP HCPCS C1713 7540220 - SET SCREW 7540220 LEGACY 5.5 RED PLUG TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7541102 SUP HCPCS C1713 7541102 - HOOK 7541102 PEDICLE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541103 SUP HCPCS C1713 7541103 - HOOK 7541103 PEDICLE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541104 SUP HCPCS C1713 7541104 - HOOK 7541104 PEDICLE LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541112 SUP HCPCS C1713 7541112 - HOOK 7541112 WIDE BLADE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541113 SUP HCPCS C1713 7541113 - HOOK 7541113 WIDE BLADE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541114 SUP HCPCS C1713 7541114 - HOOK 7541114 WIDE BLADE LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541122 SUP HCPCS C1713 7541122 - HOOK 7541122 NARROW BLADE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541123 SUP HCPCS C1713 7541123 - HOOK 7541123 NARROW BLADE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541124 SUP HCPCS C1713 7541124 - HOOK 7541124 NARROW BLADE LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541133 SUP HCPCS C1713 7541133 - HOOK 7541133 RAMP WIDE BLADE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541142 SUP HCPCS C1713 7541142 - HOOK 7541142 RAMP NARROW BLADE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541143 SUP HCPCS C1713 7541143 - HOOK 7541143 RAMP NARROW BLADE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541153 SUP HCPCS C1713 7541153 - HOOK 7541153 SUPRA LAM LUMBAR MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541162 SUP HCPCS C1713 7541162 - HOOK 7541162 LUMBAR ANG BLADE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541163 SUP HCPCS C1713 7541163 - HOOK 7541163 LUMBAR ANG BLADE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541172 SUP HCPCS C1713 7541172 - HOOK 7541172 EXTENDED BODY SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541173 SUP HCPCS C1713 7541173 - HOOK 7541173 EXTENDED BODY MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541174 SUP HCPCS C1713 7541174 - HOOK 7541174 EXTENDED BODY LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541188 SUP HCPCS C1713 7541188 - HOOK 7541188 THORACIC ANG BLADE RT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541189 SUP HCPCS C1713 7541189 - HOOK 7541189 THORACIC ANG BLADE LT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541198 SUP HCPCS C1713 7541198 - HOOK 7541198 OFFSET RT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541199 SUP HCPCS C1713 7541199 - HOOK 7541199 OFFSET LT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541203 SUP HCPCS C1713 7541203 - HOOK 7541203 PEDICLE WITH LIP MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541213 SUP HCPCS C1713 7541213 - HOOK 7541213 WIDE BLADEW LIP MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541223 SUP HCPCS C1713 7541223 - HOOK 7541223 NARROW BLADEW LIP MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541302 SUP HCPCS C1713 "7541302 - TAH PEDICLE HOOK - SMALL, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541303 SUP HCPCS C1713 "7541303 - TAH PEDICLE HOOK - MEDIUM, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541304 SUP HCPCS C1713 "7541304 - TAH PEDICLE HOOK - LARGE,TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541312 SUP HCPCS C1713 "7541312 - TAH SUPRA-LAMINAR HOOK -SM, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541313 SUP HCPCS C1713 "7541313 - TAH SUPRA-LAMINAR HOOK -MD, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541314 SUP HCPCS C1713 "7541314 - TAH SUPRA-LAMINAR HOOK-LG, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541322 SUP HCPCS C1713 "7541322 - TAH INFRA-LAMINAR HOOK-SM, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541323 SUP HCPCS C1713 "7541323 - TAH INFRA-LAMINAR HOOK-MD, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541324 SUP HCPCS C1713 "7541324 - TAH INFRA-LAMINAR HOOK-LG, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541342 SUP HCPCS C1713 7541342 - TAH TRANSVERSE PROCESS HOOK-SM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541343 SUP HCPCS C1713 7541343 - TAH TRANSVERSE PROCESS HOOK-MD BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7541344 SUP HCPCS C1713 7541344 - TAH TRANSVERSE PROCESS HOOK-TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7542420 SUP HCPCS C1713 "7542420 - SCREW, FIXED ANGLE, 4.0X20, TI" BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542425 SUP HCPCS C1713 7542425 - SCREW 7542425 FIXED ANGLE 4.0X25 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542430 SUP HCPCS C1713 "7542430 - SCREW, FIXED ANGLE, 4.0X30, TI" BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542435 SUP HCPCS C1713 "7542435 - SCREW, FIXED ANGLE, 4.0X35, TI" BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542440 SUP HCPCS C1713 "7542440 - SCREW, FIXED ANGLE, 4.0X40, TI" BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542445 SUP HCPCS C1713 "7542445 - SCREW, FIXED ANGLE, 4.0X45, TI" BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542450 SUP HCPCS C1713 "7542450 - SCREW, FIXED ANGLE, 4.0X50, TI" BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542455 SUP HCPCS C1713 "7542455 - SCREW, FIXED ANGLE, 4.0X55, TI" BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542520 SUP HCPCS C1713 7542520 - SCREW 7542520 FIXED ANGLE 5.0X20 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542525 SUP HCPCS C1713 7542525 - SCREW BN 5MM 25MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM ROD BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542530 SUP HCPCS C1713 7542530 - SCREW BN 5MM 30MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM ROD BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542535 SUP HCPCS C1713 7542535 - SCREW BN 5MM 35MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM ROD BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542540 SUP HCPCS C1713 7542540 - SCREW BN 5MM 40MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM ROD BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542545 SUP HCPCS C1713 7542545 - SCREW BN 5MM 45MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM ROD BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542550 SUP HCPCS C1713 7542550 - SCREW 7542550 FIXED ANGLE 5.0X50 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542555 SUP HCPCS C1713 7542555 - SCREW 7542555 FIXED ANGLE 5.0X55 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542625 SUP HCPCS C1713 7542625 - SCREW 7542625 FIXED ANGLE 6.0X25 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542630 SUP HCPCS C1713 7542630 - SCREW 7542630 FIXED ANGLE 6.0X30 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542635 SUP HCPCS C1713 7542635 - SCREW 7542635 FIXED ANGLE 6.0X35 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542640 SUP HCPCS C1713 7542640 - SCREW 7542640 FIXED ANGLE 6.0X40 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542645 SUP HCPCS C1713 7542645 - BONE SCREW 7542645 FIXED ANGLE 6.0X45 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542650 SUP HCPCS C1713 7542650 - SCREW 7542650 FIXED ANGLE 6.0X50 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542655 SUP HCPCS C1713 7542655 - SCREW 7542655 FIXED ANGLE 6.0X55 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7542660 SUP HCPCS C1713 7542660 - SCREW 7542660 FIXED ANGLE 6.0X60 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543420 SUP HCPCS C1713 7543420 - SCREW 7543420 FIXED ANGLE 4.5X20 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543425 SUP HCPCS C1713 7543425 - SCREW BN 4.5MM 25MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543430 SUP HCPCS C1713 7543430 - SCREW BN 4.5MM 30MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543435 SUP HCPCS C1713 7543435 - SCREW BN 4.5MM 35MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543440 SUP HCPCS C1713 7543440 - SCREW BN 4.5MM 40MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543445 SUP HCPCS C1713 7543445 - SCREW BN 4.5MM 45MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543450 SUP HCPCS C1713 7543450 - SCREW 7543450 FIXED ANGLE 4.5X50 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543455 SUP HCPCS C1713 7543455 - SCREW 7543455 FIXED ANGLE 4.5X55 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543525 SUP HCPCS C1713 7543525 - SCREW BN 5.5MM 25MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543530 SUP HCPCS C1713 7543530 - SCREW BN 5.5MM 30MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543535 SUP HCPCS C1713 7543535 - SCREW BN 5.5MM 35MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543540 SUP HCPCS C1713 7543540 - SCREW BN 5.5MM 40MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543545 SUP HCPCS C1713 7543545 - SCREW BN 5.5MM 45MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543550 SUP HCPCS C1713 7543550 - SCREW BN 5.5MM 50MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543555 SUP HCPCS C1713 7543555 - SCREW 7543555 FIXED ANGLE 5.5X55 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543560 SUP HCPCS C1713 7543560 - SCREW 7543560 FIXED ANGLE 5.5X60 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543625 SUP HCPCS C1713 7543625 - SCREW 7543625 FIXED ANGLE 6.5X25 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543630 SUP HCPCS C1713 7543630 - SCREW BN 6.5MM 30MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543635 SUP HCPCS C1713 7543635 - SCREW BN 6.5MM 35MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543640 SUP HCPCS C1713 7543640 - SCREW BN 6.5MM 40MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543645 SUP HCPCS C1713 7543645 - SCREW BN 6.5MM 45MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543650 SUP HCPCS C1713 7543650 - SCREW BN 6.5MM 50MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543655 SUP HCPCS C1713 7543655 - SCREW BN 6.5MM 55MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543660 SUP HCPCS C1713 7543660 - SCREW 7543660 FIXED ANGLE 6.5X60 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543725 SUP HCPCS C1713 7543725 - SCREW 7543725 FIXED ANGLE 7.5X25 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543730 SUP HCPCS C1713 7543730 - SCREW BN 7.5MM 30MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543735 SUP HCPCS C1713 7543735 - SCREW BN 7.5MM 35MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543740 SUP HCPCS C1713 7543740 - SCREW BN 7.5MM 40MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543745 SUP HCPCS C1713 7543745 - SCREW BN 7.5MM 45MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543750 SUP HCPCS C1713 7543750 - SCREW BN 7.5MM 50MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543755 SUP HCPCS C1713 7543755 - SCREW BN 7.5MM 55MM CD HZN LGC FX ANG CLR CD TI SPNE 5.5MM BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543760 SUP HCPCS C1713 7543760 - SCREW 7543760 FIXED ANGLE 7.5X60 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7543765 SUP HCPCS C1713 7543765 - SCREW 7543765 FIXED ANGLE 7.5X65 TI BOTH IP/OP "$1,896.00 " "$1,403.04" $0.00 "$1,516.80" $853.20 $853.20 $0.00 $0.00 $0.00 $395.17 "$1,407.21" "$1,407.21" $0.00 $0.00 $395.13 $0.00 "$1,121.48" "$1,121.48" $0.00 $948.00 "$1,501.63" "$1,516.80" $0.00 $0.00 $296.72 $0.00 $0.00 $301.84 $0.00 $0.00 $0.00 $0.00 $0.00 7544035 SUP HCPCS C1713 7544035 - SCREW BN 4MM 35MM CD HZN LGC MA TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7546999 SUP Custom 27203010 REAGENT SOL A B C IMPRP KT 300 TST ANALY BOTH IP/OP $559.15 $413.77 $0.00 $447.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.58 $442.85 $447.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7547053 SUP Custom 27203010 CONTROL FLW CYMTR FLWCNT FLUOROSPHERES 20ML BOTH IP/OP $686.15 $507.75 $0.00 $548.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.08 $543.43 $548.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7547116 SUP Custom 27203010 CONTROL CLTR 5C 3PK DISK 3.3ML HMTL BOTH IP/OP $40.83 $30.21 $0.00 $32.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.41 $32.34 $32.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7547125 SUP Custom 27203010 CONTROL RETCYT CLTR RTC C GNS 3PK 3.3ML LH SER HMTL BOTH IP/OP $38.73 $28.66 $0.00 $30.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.36 $30.67 $30.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7547178 SUP Custom 27203010 STAIN WRTS GMS TRUCOLOR 2L SLD LH SER HMTL BOTH IP/OP $517.38 $382.86 $0.00 $413.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.69 $409.76 $413.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7547181 SUP Custom 27203010 STAIN WRTS GMS TRUCOLOR 2L SLD BUFF LH SER HMTL BOTH IP/OP $316.25 $234.03 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.13 $250.47 $253.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7555025 SUP HCPCS C1713 7555025 - BOLT SPNL 5.5MM 25MM PLT BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7555030 SUP HCPCS C1713 7555030 - BOLT SPNL 5.5MM 30MM TI BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7555035 SUP HCPCS C1713 7555035 - BOLT SPNL 5MM 35MM TI BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7555040 SUP HCPCS C1713 7555040 - BOLT SPNL 5.5MM 40MM TI BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7555050 SUP HCPCS C1713 7555050 - BOLT SPNL 5.5MM 50MM TI BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7555055 SUP HCPCS C1713 7555055 - BOLT SPNL 5.5MM 55MM XLP BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7555060 SUP HCPCS C1713 7555060 - BOLT SPNL 5.5MM 60MM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7555065 SUP HCPCS C1713 7555065 - BOLT SPNL 5.5MM 65MM TI BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7560020 SUP HCPCS C1713 7560020 - SET SCREW 7560020 BREAK OFF SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7560120 SUP HCPCS C1713 7560120 - SET SCREW 7560120 NON BREAK OFF SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7560220 SUP HCPCS C1713 7560220 - SET SCREW 7560220 LEGACY 5.5 RED PLUG SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7561102 SUP HCPCS C1713 7561102 - HOOK 7561102 PEDICLE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561103 SUP HCPCS C1713 7561103 - HOOK 7561103 PEDICLE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561104 SUP HCPCS C1713 7561104 - HOOK 7561104 PEDICLE LG SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561112 SUP HCPCS C1713 7561112 - HOOK 7561112 WIDE BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561113 SUP HCPCS C1713 7561113 - HOOK 7561113 WIDE BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561114 SUP HCPCS C1713 7561114 - HOOK 7561114 WIDE BLADE LG SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561122 SUP HCPCS C1713 7561122 - HOOK 7561122 NARROW BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561123 SUP HCPCS C1713 7561123 - HOOK 7561123 NARROW BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561124 SUP HCPCS C1713 7561124 - HOOK 7561124 NARROW BLADE LG SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561133 SUP HCPCS C1713 7561133 - HOOK SPNL MED CD HZN LGC RAMP W BLDE SS THOR 5.5MM ROD BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561142 SUP HCPCS C1713 7561142 - HOOK 7561142 RAMP NARROW BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561143 SUP HCPCS C1713 7561143 - HOOK 7561143 RAMP NARROW BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561153 SUP HCPCS C1713 7561153 - HOOK 7561153 SUPRA LAM LUMBAR MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561162 SUP HCPCS C1713 7561162 - HOOK 7561162 LUMBAR ANG BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561163 SUP HCPCS C1713 7561163 - HOOK 7561163 LUMBAR ANG BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561172 SUP HCPCS C1713 7561172 - HOOK 7561172 EXTENDED BODY SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561173 SUP HCPCS C1713 7561173 - HOOK 7561173 EXTENDED BODY MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561174 SUP HCPCS C1713 7561174 - HOOK 7561174 EXTENDED BODY LG SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561188 SUP HCPCS C1713 7561188 - HOOK 7561188 THORACIC ANG BLADE RT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561189 SUP HCPCS C1713 7561189 - HOOK 7561189 THORACIC ANG BLADE LT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561198 SUP HCPCS C1713 7561198 - HOOK 7561198 OFFSET RT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561199 SUP HCPCS C1713 7561199 - HOOK 7561199 OFFSET LT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561203 SUP HCPCS C1713 7561203 - HOOK 7561203 PEDICLE WITH LIP MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561213 SUP HCPCS C1713 7561213 - HOOK 7561213 WIDE BLADE W LIP MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7561223 SUP HCPCS C1713 7561223 - HOOK 7561223 NARROW BLADE W LIP MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7562420 SUP HCPCS C1713 "7562420 - SCREW, FIXED ANGLE, 4.0X20, SS" BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562425 SUP HCPCS C1713 "7562425 - SCREW, FIXED ANGLE, 4.0X25, SS" BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562430 SUP HCPCS C1713 "7562430 - SCREW, FIXED ANGLE, 4.0X30, SS" BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562435 SUP HCPCS C1713 "7562435 - SCREW, FIXED ANGLE, 4.0X35, SS" BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562440 SUP HCPCS C1713 "7562440 - SCREW, FIXED ANGLE, 4.0X40, SS" BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562445 SUP HCPCS C1713 "7562445 - SCREW, FIXED ANGLE, 4.0X45, SS" BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562450 SUP HCPCS C1713 "7562450 - SCREW, FIXED ANGLE, 4.0X50, SS" BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562455 SUP HCPCS C1713 "7562455 - SCREW, FIXED ANGLE, 4.0X55, SS" BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562520 SUP HCPCS C1713 7562520 - SCREW 7562520 FIXED ANGLE 5.0X20 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562525 SUP HCPCS C1713 7562525 - SCREW 7562525 FIXED ANGLE 5.0X25 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562530 SUP HCPCS C1713 7562530 - BONE SCREW 7562530 FIXED ANGLE 5X30 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562535 SUP HCPCS C1713 7562535 - SCREW 7562535 FIXED ANGLE 5.0X35 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562540 SUP HCPCS C1713 7562540 - SCREW 7562540 FIXED ANGLE 5.0X40 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562545 SUP HCPCS C1713 7562545 - SCREW 7562545 FIXED ANGLE 5.0X45 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562550 SUP HCPCS C1713 7562550 - SCREW 7562550 FIXED ANGLE 5.0X50 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562555 SUP HCPCS C1713 7562555 - SCREW 7562555 FIXED ANGLE 5.0X55 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562625 SUP HCPCS C1713 7562625 - SCREW 7562625 FIXED ANGLE 6.0X25 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562630 SUP HCPCS C1713 7562630 - SCREW 7562630 FIXED ANGLE 6.0X30 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562635 SUP HCPCS C1713 7562635 - SCREW 7562635 FIXED ANGLE 6.0X35 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562640 SUP HCPCS C1713 7562640 - SCREW 7562640 FIXED ANGLE 6.0X40 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562645 SUP HCPCS C1713 7562645 - SCREW 7562645 FIXED ANGLE 6.0X45 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562650 SUP HCPCS C1713 7562650 - SCREW 7562650 FIXED ANGLE 6.0X50 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562655 SUP HCPCS C1713 7562655 - SCREW 7562655 FIXED ANGLE 6.0X55 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7562660 SUP HCPCS C1713 7562660 - SCREW 7562660 FIXED ANGLE 6.0X60 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563420 SUP HCPCS C1713 7563420 - SCREW 7563420 FIXED ANGLE 4.5X20 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563425 SUP HCPCS C1713 7563425 - SCREW 7563425 FIXED ANGLE 4.5X25 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563430 SUP HCPCS C1713 7563430 - SCREW 7563430 FIXED ANGLE 4.5X30 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563435 SUP HCPCS C1713 7563435 - SCREW 7563435 FIXED ANGLE 4.5X35 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563440 SUP HCPCS C1713 7563440 - SCREW 7563440 FIXED ANGLE 4.5X40 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563445 SUP HCPCS C1713 7563445 - SCREW 7563445 FIXED ANGLE 4.5X45 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563450 SUP HCPCS C1713 7563450 - SCREW 7563450 FIXED ANGLE 4.5X50 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563455 SUP HCPCS C1713 7563455 - SCREW 7563455 FIXED ANGLE 4.5X55 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563525 SUP HCPCS C1713 7563525 - SCREW 7563525 FIXED ANGLE 5.5X25 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563530 SUP HCPCS C1713 7563530 - SCREW 7563530 FIXED ANGLE 5.5X30 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563535 SUP HCPCS C1713 7563535 - SCREW 7563535 FIXED ANGLE 5.5X35 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563540 SUP HCPCS C1713 7563540 - SCREW 7563540 FIXED ANGLE 5.5X40 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563545 SUP HCPCS C1713 7563545 - SCREW 7563545 FIXED ANGLE 5.5X45 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563550 SUP HCPCS C1713 7563550 - SCREW 7563550 FIXED ANGLE 5.5X50 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563555 SUP HCPCS C1713 7563555 - SCREW 7563555 FIXED ANGLE 5.5X55 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563560 SUP HCPCS C1713 7563560 - SCREW 7563560 FIXED ANGLE 5.5X60 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563625 SUP HCPCS C1713 7563625 - SCREW 7563625 FIXED ANGLE 6.5X25 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563630 SUP HCPCS C1713 7563630 - SCREW 7563630 FIXED ANGLE 6.5X30 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563635 SUP HCPCS C1713 7563635 - SCREW 7563635 FIXED ANGLE 6.5X35 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563640 SUP HCPCS C1713 7563640 - SCREW 7563640 FIXED ANGLE 6.5X40 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563645 SUP HCPCS C1713 7563645 - SCREW 7563645 FIXED ANGLE 6.5X45 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563650 SUP HCPCS C1713 7563650 - SCREW 7563650 FIXED ANGLE 6.5X50 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563655 SUP HCPCS C1713 7563655 - SCREW 7563655 FIXED ANGLE 6.5X55 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563660 SUP HCPCS C1713 7563660 - SCREW 7563660 FIXED ANGLE 6.5X60 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563725 SUP HCPCS C1713 7563725 - SCREW 7563725 FIXED ANGLE 7.5X25 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563730 SUP HCPCS C1713 7563730 - SCREW 7563730 FIXED ANGLE 7.5X30 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563735 SUP HCPCS C1713 7563735 - SCREW 7563735 FIXED ANGLE 7.5X35 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563740 SUP HCPCS C1713 7563740 - SCREW 7563740 FIXED ANGLE 7.5X40 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563745 SUP HCPCS C1713 7563745 - SCREW 7563745 FIXED ANGLE 7.5X45 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563750 SUP HCPCS C1713 7563750 - SCREW 7563750 FIXED ANGLE 7.5X50 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563755 SUP HCPCS C1713 7563755 - SCREW 7563755 FIXED ANGLE 7.5X55 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563760 SUP HCPCS C1713 7563760 - SCREW 7563760 FIXED ANGLE 7.5X60 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7563765 SUP HCPCS C1713 7563765 - SCREW 7563765 FIXED ANGLE 7.5X65 SS BOTH IP/OP "$2,036.15 " "$1,506.75" $0.00 "$1,628.92" $916.27 $916.27 $0.00 $0.00 $0.00 $424.38 "$1,511.23" "$1,511.23" $0.00 $0.00 $424.33 $0.00 "$1,204.38" "$1,204.38" $0.00 "$1,018.08" "$1,612.63" "$1,628.92" $0.00 $0.00 $318.66 $0.00 $0.00 $324.16 $0.00 $0.00 $0.00 $0.00 $0.00 7565025 SUP HCPCS C1713 7565025 - BOLT SPNL 6.5MM 25MM PLT BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7565030 SUP HCPCS C1713 7565030 - BOLT SPNL 6.5MM 30MM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7565035 SUP HCPCS C1713 7565035 - BOLT SPNL 6.5MM 35MM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7565040 SUP HCPCS C1713 7565040 - BOLT SPNL 6.5MM 40MM XLP BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7565045 SUP HCPCS C1713 7565045 - BOLT SPNL 6.5MM 45MM TI BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7565050 SUP HCPCS C1713 7565050 - BOLT SPNL 6.5MM 50MM TI BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7565055 SUP HCPCS C1713 7565055 - BOLT SPNL 6.5MM 55MM TI BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7565060 SUP HCPCS C1713 7565060 - BOLT SPNL 6.5MM 60MM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7565065 SUP HCPCS C1713 7565065 - BOLT SPNL 6.5MM 65MM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7570955 SUP HCPCS C1713 7570955 - SCREW SET CD HZN SXTNT II BRKOF SS SPNE PDCL ROD INS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7571030 SUP HCPCS C1713 7571030 - ROD 7571030 5.5MM STRAIGHT 30MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571035 SUP HCPCS C1713 7571035 - PLATE BN 35MM AFFIX II SPNE SPINOUS PRC BOTH IP/OP "$8,730.00 " "$6,460.20" $0.00 "$6,984.00" "$3,928.50" "$3,928.50" $0.00 $0.00 $0.00 "$1,819.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,819.33" $0.00 "$4,303.89" "$4,303.89" $0.00 "$4,365.00" "$6,914.16" "$6,984.00" $0.00 $0.00 "$1,366.25" $0.00 $0.00 "$1,389.82" $0.00 $0.00 $0.00 $0.00 $0.00 7571040 SUP HCPCS C1713 7571040 - ROD 7571040 5.5MM STRAIGHT 40MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571045 SUP HCPCS C1713 7571045 - PLATE BN 45MM XLIF AFFIX XTRM SPNE BOTH IP/OP "$8,730.00 " "$6,460.20" $0.00 "$6,984.00" "$3,928.50" "$3,928.50" $0.00 $0.00 $0.00 "$1,819.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,819.33" $0.00 "$4,303.89" "$4,303.89" $0.00 "$4,365.00" "$6,914.16" "$6,984.00" $0.00 $0.00 "$1,366.25" $0.00 $0.00 "$1,389.82" $0.00 $0.00 $0.00 $0.00 $0.00 7571050 SUP HCPCS C1713 7571050 - ROD 7571050 5.5MM STRAIGHT 50MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571055 SUP HCPCS C1713 7571055 - PLATE BN 55MM AFFIX II SPNE SPINOUS PRC BOTH IP/OP "$8,730.00 " "$6,460.20" $0.00 "$6,984.00" "$3,928.50" "$3,928.50" $0.00 $0.00 $0.00 "$1,819.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,819.33" $0.00 "$4,303.89" "$4,303.89" $0.00 "$4,365.00" "$6,914.16" "$6,984.00" $0.00 $0.00 "$1,366.25" $0.00 $0.00 "$1,389.82" $0.00 $0.00 $0.00 $0.00 $0.00 7571060 SUP HCPCS C1713 7571060 - ROD 7571060 5.5MM STRAIGHT 60MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571070 SUP HCPCS C1713 7571070 - ROD 7571070 5.5MM STRAIGHT 70MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571080 SUP HCPCS C1713 7571080 - ROD 7571080 5.5MM STRAIGHT 80MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571090 SUP HCPCS C1713 7571090 - ROD 7571090 5.5MM STRAIGHT 90MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571100 SUP HCPCS C1713 7571100 - ROD 7571100 5.5MM STRAIGHT 100MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571110 SUP HCPCS C1713 7571110 - ROD 7571110 5.5MM STRAIGHT 110MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571120 SUP HCPCS C1713 7571120 - ROD 7571120 5.5MM STRAIGHT 120MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571130 SUP HCPCS C1713 7571130 - ROD 7571130 5.5MM STRAIGHT 130MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571140 SUP HCPCS C1713 7571140 - ROD 7571140 5.5MM STRAIGHT 140MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571150 SUP HCPCS C1713 7571150 - ROD 7571150 5.5MM STRAIGHT 150MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571160 SUP HCPCS C1713 7571160 - ROD 7571160 5.5MM STRAIGHT 160MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571170 SUP HCPCS C1713 7571170 - ROD 7571170 5.5MM STRAIGHT 170MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571180 SUP HCPCS C1713 7571180 - ROD 7571180 5.5MM STRAIGHT 180MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571190 SUP HCPCS C1713 7571190 - ROD 7571190 5.5MM STRAIGHT 190MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571200 SUP HCPCS C1713 7571200 - ROD 7571200 5.5MM STRAIGHT 200MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571210 SUP HCPCS C1713 7571210 - ROD 7571210 5.5MM STRAIGHT 210MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571220 SUP HCPCS C1713 7571220 - ROD 7571220 5.5MM STRAIGHT 220MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571230 SUP HCPCS C1713 7571230 - ROD 7571230 5.5MM STRAIGHT 230MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571240 SUP HCPCS C1713 7571240 - ROD 7571240 5.5MM STRAIGHT 240MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571250 SUP HCPCS C1713 7571250 - ROD 7571250 5.5MM STRAIGHT 250MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571260 SUP HCPCS C1713 7571260 - ROD 7571260 5.5MM STRAIGHT 260MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571270 SUP HCPCS C1713 7571270 - ROD 7571270 5.5MM STRAIGHT 270MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571280 SUP HCPCS C1713 7571280 - ROD 7571280 5.5MM STRAIGHT 280MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571290 SUP HCPCS C1713 7571290 - ROD 7571290 5.5MM STRAIGHT 290MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571300 SUP HCPCS C1713 7571300 - ROD 7571300 5.5MM STRAIGHT 300MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571310 SUP HCPCS C1713 7571310 - ROD 7571310 5.5MM STRAIGHT 310MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571320 SUP HCPCS C1713 7571320 - ROD 7571320 5.5MM STRAIGHT 320MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571330 SUP HCPCS C1713 7571330 - ROD 7571330 5.5MM STRAIGHT 330MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571340 SUP HCPCS C1713 7571340 - ROD 7571340 5.5MM STRAIGHT 340MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571350 SUP HCPCS C1713 7571350 - ROD 7571350 5.5MM STRAIGHT 350MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571360 SUP HCPCS C1713 7571360 - ROD 7571360 5.5MM STRAIGHT 360MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571370 SUP HCPCS C1713 7571370 - ROD 7571370 5.5MM STRAIGHT 370MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571380 SUP HCPCS C1713 7571380 - ROD 7571380 5.5MM STRAIGHT 380MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571390 SUP HCPCS C1713 7571390 - ROD 7571390 5.5MM STRAIGHT 390MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571400 SUP HCPCS C1713 7571400 - ROD 7571400 5.5MM STRAIGHT 400MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571410 SUP HCPCS C1713 7571410 - ROD 7571410 5.5MM STRAIGHT 410MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571420 SUP HCPCS C1713 7571420 - ROD 7571420 5.5MM STRAIGHT 420MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571430 SUP HCPCS C1713 7571430 - ROD 7571430 5.5MM STRAIGHT 430MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571440 SUP HCPCS C1713 7571440 - ROD 7571440 5.5MM STRAIGHT 440MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571450 SUP HCPCS C1713 7571450 - ROD 7571450 5.5MM STRAIGHT 450MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571460 SUP HCPCS C1713 7571460 - ROD 7571460 5.5MM STRAIGHT 460MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571470 SUP HCPCS C1713 7571470 - ROD 7571470 5.5MM STRAIGHT 470MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571480 SUP HCPCS C1713 7571480 - ROD 7571480 5.5MM STRAIGHT 480MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571490 SUP HCPCS C1713 7571490 - ROD 7571490 5.5MM STRAIGHT 490MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7571500 SUP HCPCS C1713 7571500 - ROD 7571500 5.5MM STRAIGHT 500MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7575535 SUP HCPCS C1713 7575535 - SCREW BN 5.5MM 35MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7575540 SUP HCPCS C1713 7575540 - SCREW BN 5.5MM 40MM CD HZN LGC MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7575545 SUP HCPCS C1713 7575545 - SCREW BN 5.5MM 45MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7575550 SUP HCPCS C1713 7575550 - SCREW BN 5.5MM 50MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7576309 SUP Custom 27203010 7576309 - INSTRUMENT 7576309 TALL REDUX NUT DR BOTH IP/OP $726.00 $537.24 $0.00 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $538.84 $538.84 $0.00 $0.00 $151.30 $0.00 $0.00 $0.00 $0.00 $363.00 $574.99 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7576535 SUP HCPCS C1713 7576535 - SCREW BN 6.5MM 35MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7576540 SUP HCPCS C1713 7576540 - SCREW BN 6.5MM 40MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7576545 SUP HCPCS C1713 7576545 - SCREW BN 6.5MM 45MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7576550 SUP HCPCS C1713 7576550 - SCREW BN 6.5MM 50MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7576555 SUP HCPCS C1713 7576555 - SCREW BN 6.5MM 55MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7577025 SUP HCPCS C1713 7577025 - PLATE BN MN 25MM NS AFFIX II SPNE LMBR BOTH IP/OP "$9,162.50 " "$6,780.25" $0.00 "$7,330.00" "$4,123.13" "$4,123.13" $0.00 $0.00 $0.00 "$1,909.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,909.47" $0.00 "$4,517.11" "$4,517.11" $0.00 "$4,581.25" "$7,256.70" "$7,330.00" $0.00 $0.00 "$1,433.93" $0.00 $0.00 "$1,458.67" $0.00 $0.00 $0.00 $0.00 $0.00 7577035 SUP HCPCS C1713 7577035 - PLATE BN 35MM NS AFFIX II SPNE LMBR BOTH IP/OP "$9,162.50 " "$6,780.25" $0.00 "$7,330.00" "$4,123.13" "$4,123.13" $0.00 $0.00 $0.00 "$1,909.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,909.47" $0.00 "$4,517.11" "$4,517.11" $0.00 "$4,581.25" "$7,256.70" "$7,330.00" $0.00 $0.00 "$1,433.93" $0.00 $0.00 "$1,458.67" $0.00 $0.00 $0.00 $0.00 $0.00 7577045 SUP HCPCS C1713 7577045 - PLATE BN 45MM NS AFFIX II SPNE LMBR BOTH IP/OP "$9,162.50 " "$6,780.25" $0.00 "$7,330.00" "$4,123.13" "$4,123.13" $0.00 $0.00 $0.00 "$1,909.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,909.47" $0.00 "$4,517.11" "$4,517.11" $0.00 "$4,581.25" "$7,256.70" "$7,330.00" $0.00 $0.00 "$1,433.93" $0.00 $0.00 "$1,458.67" $0.00 $0.00 $0.00 $0.00 $0.00 7577055 SUP HCPCS C1713 7577055 - PLATE BN 55MM NS AFFIX II SPNE LMBR BOTH IP/OP "$9,162.50 " "$6,780.25" $0.00 "$7,330.00" "$4,123.13" "$4,123.13" $0.00 $0.00 $0.00 "$1,909.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,909.47" $0.00 "$4,517.11" "$4,517.11" $0.00 "$4,581.25" "$7,256.70" "$7,330.00" $0.00 $0.00 "$1,433.93" $0.00 $0.00 "$1,458.67" $0.00 $0.00 $0.00 $0.00 $0.00 7577530 SUP HCPCS C1713 7577530 - SCREW BN 7.5MM 30MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7577535 SUP HCPCS C1713 7577535 - SCREW BN 7.5MM 35MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7577540 SUP HCPCS C1713 7577540 - SCREW BN 7.5MM 40MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7577545 SUP HCPCS C1713 7577545 - SCREW BN 7.5MM 45MM LGC CD HZN MA CNN TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$6,185.00 " "$4,576.90" $0.00 "$4,948.00" "$2,783.25" "$2,783.25" $0.00 $0.00 $0.00 "$1,289.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,288.95" $0.00 "$3,049.21" "$3,049.21" $0.00 "$3,092.50" "$4,898.52" "$4,948.00" $0.00 $0.00 $967.95 $0.00 $0.00 $984.65 $0.00 $0.00 $0.00 $0.00 $0.00 7600320 SUP HCPCS C1713 7600320 - SUB BNGFT CALCIUM PHOS CLGN 20ML MS GRFT VOID FILR MTRX BOTH IP/OP "$3,575.00 " "$2,645.50" $0.00 "$2,860.00" "$1,608.75" "$1,608.75" $0.00 $0.00 $0.00 $745.12 "$2,653.37" "$2,653.37" $0.00 $0.00 $745.03 $0.00 "$1,762.48" "$1,762.48" $0.00 "$1,787.50" "$2,831.40" "$2,860.00" $0.00 $0.00 $559.49 $0.00 $0.00 $569.14 $0.00 $0.00 $0.00 $0.00 $0.00 7640120 SUP HCPCS C1713 7640120 - SET SCREW 7640120 NON BREAK OFF TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7640220 SUP HCPCS C1713 7640220 - SET SCREW 7640220 REDUCTION PLUG TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7641102 SUP HCPCS C1713 7641102 - HOOK 7641102 L6.35 PEDICLE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641103 SUP HCPCS C1713 7641103 - HOOK 7641103 L6.35 PEDICLE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641104 SUP HCPCS C1713 7641104 - HOOK 7641104 L6.35 PEDICLE LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641112 SUP HCPCS C1713 7641112 - HOOK 7641112 L6.35 WIDE BLADE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641113 SUP HCPCS C1713 7641113 - HOOK 7641113 L6.35 WIDE BLADE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641114 SUP HCPCS C1713 7641114 - HOOK 7641114 L6.35 WIDE BLADE LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641122 SUP HCPCS C1713 7641122 - HOOK 7641122 L6.35 NARRW BLDE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641123 SUP HCPCS C1713 7641123 - HOOK 7641123 L6.35 NARRW BLDE MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641124 SUP HCPCS C1713 7641124 - HOOK 7641124 L6.35 NARRW BLDE LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641133 SUP HCPCS C1713 7641133 - HOOK 7641133 RAMP WIDE BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641142 SUP HCPCS C1713 7641142 - HOOK 7641142 RAMP NARROW BLADE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641143 SUP HCPCS C1713 7641143 - HOOK 7641143 RAMP NARROW BLADE MED TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641162 SUP HCPCS C1713 7641162 - HOOK 7641162 LUMBAR ANG BLADE SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641163 SUP HCPCS C1713 7641163 - HOOK 7641163 LUMBAR ANG BLADE MED TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641173 SUP HCPCS C1713 7641173 - HOOK 7641173 EXTENDED BODY MED TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641174 SUP HCPCS C1713 7641174 - HOOK 7641174 EXTENDED BODY LARGE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641188 SUP HCPCS C1713 7641188 - HOOK 7641188 THORACIC ANG BLADE RT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641189 SUP HCPCS C1713 7641189 - HOOK 7641189 THORACIC ANG BLADE LT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641198 SUP HCPCS C1713 7641198 - HOOK 7641198 OFFSET RIGHT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641199 SUP HCPCS C1713 7641199 - HOOK 7641199 OFFSET LEFT TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641202 SUP HCPCS C1713 7641202 - HOOK 7641202 PEDICLE WITH LIP SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641203 SUP HCPCS C1713 7641203 - HOOK 7641203 PEDICLE WITH LIP MED TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641204 SUP HCPCS C1713 7641204 - HOOK 7641204 PEDICLE WITH LIP LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641212 SUP HCPCS C1713 7641212 - HOOK 7641212 WIDE BLADE W SHELF SM T BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641213 SUP HCPCS C1713 7641213 - HOOK 7641213 WIDE BLADE W SHELF MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641214 SUP HCPCS C1713 7641214 - HOOK 7641214 WIDE BLADE W SHELF LG TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641222 SUP HCPCS C1713 7641222 - HOOK 7641222 NARROW BLADE W SHELF SM TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641223 SUP HCPCS C1713 7641223 - HOOK 7641223 NARROW BLADE W SHELF MD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7641224 SUP HCPCS C1713 7641224 - HOOK 7641224 NARROW BLADE W SHELF LG T BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7642420 SUP HCPCS C1713 "7642420 - SCREW, FIXED ANGLE, 4.0X20, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642425 SUP HCPCS C1713 "7642425 - SCREW, FIXED ANGLE, 4.0X25, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642430 SUP HCPCS C1713 "7642430 - SCREW, FIXED ANGLE, 4.0X30, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642435 SUP HCPCS C1713 "7642435 - SCREW, FIXED ANGLE, 4.0X35, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642440 SUP HCPCS C1713 "7642440 - SCREW, FIXED ANGLE, 4.0X40, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642445 SUP HCPCS C1713 "7642445 - SCREW, FIXED ANGLE, 4.0X45, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642450 SUP HCPCS C1713 "7642450 - SCREW, FIXED ANGLE, 4.0X50, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642455 SUP HCPCS C1713 "7642455 - SCREW, FIXED ANGLE, 4.0X55, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642520 SUP HCPCS C1713 "7642520 - SCREW, FIXED ANGLE, 5.0X20, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642525 SUP HCPCS C1713 "7642525 - SCREW, FIXED ANGLE, 5.0X25, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642530 SUP HCPCS C1713 "7642530 - SCREW, FIXED ANGLE, 5.0X30, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642535 SUP HCPCS C1713 "7642535 - SCREW, FIXED ANGLE, 5.0X35, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642540 SUP HCPCS C1713 "7642540 - SCREW, FIXED ANGLE, 5.0X40, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642545 SUP HCPCS C1713 "7642545 - SCREW, FIXED ANGLE, 5.0X45, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642550 SUP HCPCS C1713 "7642550 - SCREW, FIXED ANGLE, 5.0X50, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642555 SUP HCPCS C1713 7642555 - FIXED ANGLE 5.0X55 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642625 SUP HCPCS C1713 "7642625 - SCREW, FIXED ANGLE, 6.0X25, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642630 SUP HCPCS C1713 "7642630 - SCREW, FIXED ANGLE, 6.0X30, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642635 SUP HCPCS C1713 "7642635 - SCREW, FIXED ANGLE, 6.0X35, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642640 SUP HCPCS C1713 "7642640 - SCREW, FIXED ANGLE, 6.0X40, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642645 SUP HCPCS C1713 "7642645 - SCREW, FIXED ANGLE, 6.0X45, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642650 SUP HCPCS C1713 "7642650 - SCREW, FIXED ANGLE, 6.0X50, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642655 SUP HCPCS C1713 "7642655 - SCREW, FIXED ANGLE, 6.0X55, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7642660 SUP HCPCS C1713 "7642660 - SCREW, FIXED ANGLE, 6.0X60, TI" BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643420 SUP HCPCS C1713 7643420 - BONE SCREW 7643420 FXD ANGLE 4.5X20 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643425 SUP HCPCS C1713 7643425 - BONE SCREW 7643425 FXD ANGLE 4.5X25 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643430 SUP HCPCS C1713 7643430 - BONE SCREW 7643430 FXD ANGLE 4.5X30 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643435 SUP HCPCS C1713 7643435 - BONE SCREW 7643435 FXD ANGLE 4.5X35 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643440 SUP HCPCS C1713 7643440 - BONE SCREW 7643440 FXD ANGLE 4.5X40 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643445 SUP HCPCS C1713 7643445 - BONE SCREW 7643445 FXD ANGLE 4.5X45 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643450 SUP HCPCS C1713 7643450 - BONE SCREW 7643450 FXD ANGLE 4.5X50 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643455 SUP HCPCS C1713 7643455 - BONE SCREW 7643455 FXD ANGLE 4.5X55 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643525 SUP HCPCS C1713 7643525 - BONE SCREW 7643525 FXD ANGLE 5.5X25 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643530 SUP HCPCS C1713 7643530 - BONE SCREW 7643530 FXD ANGLE 5.5X30 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643535 SUP HCPCS C1713 7643535 - BONE SCREW 7643535 FXD ANGLE 5.5X35 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643540 SUP HCPCS C1713 7643540 - BONE SCREW 7643540 FXD ANGLE 5.5X40 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643545 SUP HCPCS C1713 7643545 - BONE SCREW 7643545 FXD ANGLE 5.5X45 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643550 SUP HCPCS C1713 7643550 - BONE SCREW 7643550 FXD ANGLE 5.5X50 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643555 SUP HCPCS C1713 7643555 - BONE SCREW 7643555 FXD ANGLE 5.5X55 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643560 SUP HCPCS C1713 7643560 - BONE SCREW 7643560 FXD ANGLE 5.5X60 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643625 SUP HCPCS C1713 7643625 - SCREW 7643625 FIXED ANGLE 6.5X25 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643630 SUP HCPCS C1713 7643630 - SCREW 7643630 FIXED ANGLE 6.5X30 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643635 SUP HCPCS C1713 7643635 - BONE SCREW 7643635 FXD ANGLE 6.5X35 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643640 SUP HCPCS C1713 7643640 - BONE SCREW 7643640 FXD ANGLE 6.5X40 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643645 SUP HCPCS C1713 7643645 - BONE SCREW 7643645 FXD ANGLE 6.5X45 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643650 SUP HCPCS C1713 7643650 - BONE SCREW 7643650 FXD ANGLE 6.5X50 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643655 SUP HCPCS C1713 7643655 - BONE SCREW 7643655 FXD ANGLE 6.5X55 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643660 SUP HCPCS C1713 7643660 - BONE SCREW 7643660 FXD ANGLE 6.5X60 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643665 SUP HCPCS C1713 7643665 - BONE SCREW 7643665 FXD ANGLE 6.5X65 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643670 SUP HCPCS C1713 7643670 - BONE SCREW 7643670 FXD ANGLE 6.5X70 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643725 SUP HCPCS C1713 7643725 - BONE SCREW 7643725 FXD ANGLE 7.5X25 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643730 SUP HCPCS C1713 7643730 - BONE SCREW 7643730 FXD ANGLE 7.5X30 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643735 SUP HCPCS C1713 7643735 - BONE SCREW 7643735 FXD ANGLE 7.5X35 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643740 SUP HCPCS C1713 7643740 - BONE SCREW 7643740 FXD ANGLE 7.5X40 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643745 SUP HCPCS C1713 7643745 - BONE SCREW 7643745 FXD ANGLE 7.5X45 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643750 SUP HCPCS C1713 7643750 - BONE SCREW 7643750 FXD ANGLE 7.5X50 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643755 SUP HCPCS C1713 7643755 - BONE SCREW 7643755 FXD ANGLE 7.5X55 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643760 SUP HCPCS C1713 7643760 - BONE SCREW 7643760 FXD ANGLE 7.5X60 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7643765 SUP HCPCS C1713 7643765 - BONE SCREW 7643765 FXD ANGLE 7.5X65 TI BOTH IP/OP "$1,933.50 " "$1,430.79" $0.00 "$1,546.80" $870.08 $870.08 $0.00 $0.00 $0.00 $402.99 "$1,435.04" "$1,435.04" $0.00 $0.00 $402.94 $0.00 "$1,143.67" "$1,143.67" $0.00 $966.75 "$1,531.33" "$1,546.80" $0.00 $0.00 $302.59 $0.00 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 7650008 SUP HCPCS C1713 7650008 - PLATE BONE SMALL 8MM TRADITIONAL SPN CERV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650009 SUP HCPCS C1713 7650009 - PLATE BONE MEDIUM 9.5MM TRADITIONAL SPN CERV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650011 SUP HCPCS C1713 7650011 - PLATE BONE LARGE 11MM TRADITIONAL SPN CERV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650012 SUP HCPCS C1713 7650012 - PLATE BN XL 12.5MM NS LVRG TRD SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650108 SUP HCPCS C1713 7650108 - PLATE BN SM 8MM NS LVRG TRD SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650109 SUP HCPCS C1713 7650109 - PLATE MED 9.5MM TRD BONE SPN CERV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650111 SUP HCPCS C1713 7650111 - PLATE BN LG 11MM NS LVRG TRD SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650112 SUP HCPCS C1713 7650112 - PLATE BN XL 12.5MM NS LVRG TRD SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650208 SUP HCPCS C1713 7650208 - PLATE BONE SMALL 8MM GRAFT SPN CERV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650209 SUP HCPCS C1713 7650209 - PLATE BONE MEDIUM 9.5MM GRAFT SPN CERV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650211 SUP HCPCS C1713 7650211 - PLATE BN LG 11MM NS LVRG GFT SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650212 SUP HCPCS C1713 7650212 - PLATE BN XL 12.5MM GFT SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650308 SUP HCPCS C1713 7650308 - PLATE BN SM 8MM NS LVRG GFT SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650309 SUP HCPCS C1713 7650309 - PLATE BN MED 9.5MM NS LVRG GFT SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650311 SUP HCPCS C1713 7650311 - PLATE BN LG 11MM NS LVRG GFT SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650312 SUP HCPCS C1713 7650312 - PLATE BN XL 12.5MM NS LVRG GFT SPNE CRV BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650408 SUP HCPCS C1713 7650408 - PLATE BN SM 8MM NS LVRG SPNE CRV LMN BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650409 SUP HCPCS C1713 7650409 - PLATE BN MED 9.5MM NS LVRG SPNE CRV LMN BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650411 SUP HCPCS C1713 7650411 - PLATE BN LG 11MM NS LVRG SPNE CRV LMN BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650412 SUP HCPCS C1713 7650412 - PLATE BN XL 12.5MM NS LVRG SPNE CRV LMN BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 7650505 SUP HCPCS C1713 7650505 - SCREW BONE 2.6MM 5MM LATERAL MASS CERV BOTH IP/OP $410.00 $303.40 $0.00 $328.00 $184.50 $184.50 $0.00 $0.00 $0.00 $85.45 $304.30 $304.30 $0.00 $0.00 $85.44 $0.00 $242.52 $242.52 $0.00 $205.00 $324.72 $328.00 $0.00 $0.00 $64.17 $0.00 $0.00 $65.27 $0.00 $0.00 $0.00 $0.00 $0.00 7650506 SUP HCPCS C1713 7650506 - SCREW BONE 2.6MM 6MM LATERAL MASS SPN CERV BOTH IP/OP $410.00 $303.40 $0.00 $328.00 $184.50 $184.50 $0.00 $0.00 $0.00 $85.45 $304.30 $304.30 $0.00 $0.00 $85.44 $0.00 $242.52 $242.52 $0.00 $205.00 $324.72 $328.00 $0.00 $0.00 $64.17 $0.00 $0.00 $65.27 $0.00 $0.00 $0.00 $0.00 $0.00 7650507 SUP HCPCS C1713 7650507 - SCREW BONE 2.6MM 7MM LATERAL MASS SPN CERV BOTH IP/OP $410.00 $303.40 $0.00 $328.00 $184.50 $184.50 $0.00 $0.00 $0.00 $85.45 $304.30 $304.30 $0.00 $0.00 $85.44 $0.00 $242.52 $242.52 $0.00 $205.00 $324.72 $328.00 $0.00 $0.00 $64.17 $0.00 $0.00 $65.27 $0.00 $0.00 $0.00 $0.00 $0.00 7650508 SUP HCPCS C1713 "7650508 - LATERAL MASS SCREW, 2.6X8MM" BOTH IP/OP $410.00 $303.40 $0.00 $328.00 $184.50 $184.50 $0.00 $0.00 $0.00 $85.45 $304.30 $304.30 $0.00 $0.00 $85.44 $0.00 $242.52 $242.52 $0.00 $205.00 $324.72 $328.00 $0.00 $0.00 $64.17 $0.00 $0.00 $65.27 $0.00 $0.00 $0.00 $0.00 $0.00 7650605 SUP HCPCS C1713 7650605 - SCREW BONE 3MM 5MM LATERAL MASS CERV BOTH IP/OP $410.00 $303.40 $0.00 $328.00 $184.50 $184.50 $0.00 $0.00 $0.00 $85.45 $304.30 $304.30 $0.00 $0.00 $85.44 $0.00 $242.52 $242.52 $0.00 $205.00 $324.72 $328.00 $0.00 $0.00 $64.17 $0.00 $0.00 $65.27 $0.00 $0.00 $0.00 $0.00 $0.00 7650607 SUP HCPCS C1713 7650607 - SCREW BONE 3MM 7MM LATERAL MASS SPN CERV BOTH IP/OP $410.00 $303.40 $0.00 $328.00 $184.50 $184.50 $0.00 $0.00 $0.00 $85.45 $304.30 $304.30 $0.00 $0.00 $85.44 $0.00 $242.52 $242.52 $0.00 $205.00 $324.72 $328.00 $0.00 $0.00 $64.17 $0.00 $0.00 $65.27 $0.00 $0.00 $0.00 $0.00 $0.00 7650608 SUP HCPCS C1713 7650608 - SCREW BN 3MM 8MM NS LVRG LAT MASS SPNE CRV BOTH IP/OP $410.00 $303.40 $0.00 $328.00 $184.50 $184.50 $0.00 $0.00 $0.00 $85.45 $304.30 $304.30 $0.00 $0.00 $85.44 $0.00 $242.52 $242.52 $0.00 $205.00 $324.72 $328.00 $0.00 $0.00 $64.17 $0.00 $0.00 $65.27 $0.00 $0.00 $0.00 $0.00 $0.00 7650705 SUP HCPCS C1713 7650705 - SCREW BONE 2.6MM 5MM SPN CERV LAMINA BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $258.75 $258.75 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 7650753 SUP Custom 27203010 7650753 - BIT DRILL 3MM SHAFT SPN DISPOSABLE BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $456.45 $456.45 $0.00 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $307.50 $487.08 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7650755 SUP Custom 27203010 7650755 - BIT DRILL 5MM SHAFT SPN DISPOSABLE BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $456.45 $456.45 $0.00 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $307.50 $487.08 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7650756 SUP Custom 27203010 7650756 - BIT DRILL 6MM SHAFT SPN DISPOSABLE BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $456.45 $456.45 $0.00 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $307.50 $487.08 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7650757 SUP Custom 27203010 7650757 - BIT DRILL 7MM SHAFT DISPOSABLE LVG LFS BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $456.45 $456.45 $0.00 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $307.50 $487.08 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7650758 SUP Custom 27203010 "7650758 - LAMINOPLASTY DRILL BIT, 8MM" BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $456.45 $456.45 $0.00 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $307.50 $487.08 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7650805 SUP HCPCS C1713 7650805 - SCREW BONE 3MM 5MM LAMINA CERV SPN BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $258.75 $258.75 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 7650811 SUP HCPCS C1713 7650811 - CAGE SPNL 11MM ALGRF XLIF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7650812 SUP HCPCS C1713 7650812 - CAGE SPNL 12.5MM ALGRF XLIF BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7660020 SUP HCPCS C1713 7660020 - SET SCREW 7660020 BREAK OFF SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7660120 SUP HCPCS C1713 7660120 - SET SCREW 7660120 NON BREAK OFF SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7660220 SUP HCPCS C1713 7660220 - SET SCREW 7660220 REDUCTION PLUG SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7661102 SUP HCPCS C1713 7661102 - HOOK 7661102 PEDICLE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661103 SUP HCPCS C1713 7661103 - HOOK 7661103 PEDICLE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661104 SUP HCPCS C1713 7661104 - HOOK 7661104 PEDICLE LG SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661112 SUP HCPCS C1713 7661112 - HOOK 7661112 WIDE BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661113 SUP HCPCS C1713 7661113 - HOOK 7661113 WIDE BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661114 SUP HCPCS C1713 7661114 - HOOK 7661114 WIDE BLADE LG SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661122 SUP HCPCS C1713 7661122 - HOOK 7661122 NARROW BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661123 SUP HCPCS C1713 7661123 - HOOK 7661123 NARROW BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661124 SUP HCPCS C1713 7661124 - HOOK 7661124 NARROW BLADE LG SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661133 SUP HCPCS C1713 7661133 - HOOK 7661133 RAMP WIDE BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661142 SUP HCPCS C1713 7661142 - HOOK 7661142 RAMP NARROW BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661143 SUP HCPCS C1713 7661143 - HOOK 7661143 RAMP NARROW BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661162 SUP HCPCS C1713 7661162 - HOOK 7661162 LUMBAR ANG BLADE SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661163 SUP HCPCS C1713 7661163 - HOOK 7661163 LUMBAR ANG BLADE MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661173 SUP HCPCS C1713 7661173 - HOOK 7661173 EXTENDED BODY MD SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661174 SUP HCPCS C1713 7661174 - HOOK 7661174 EXTENDED BODY LG SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661188 SUP HCPCS C1713 7661188 - HOOK 7661188 THORACIC ANG BLADE RT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661189 SUP HCPCS C1713 7661189 - HOOK 7661189 THORACIC ANG BLADE LT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661198 SUP HCPCS C1713 7661198 - HOOK 7661198 OFFSET RT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661199 SUP HCPCS C1713 7661199 - HOOK 7661199 OFFSET LT SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661202 SUP HCPCS C1713 7661202 - HOOK 7661202 PEDICLE WITH LIP SM SS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661203 SUP HCPCS C1713 "7661203 - HOOK, PEDICLE WITH LIP, MD,SS" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661204 SUP HCPCS C1713 "7661204 - HOOK, PEDICLE WITH LIP, LG,SS" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661212 SUP HCPCS C1713 "7661212 - HOOK, WIDE BLADE W/LIP,SM,SS" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661213 SUP HCPCS C1713 "7661213 - HOOK, WIDE BLADE W/LIP,MD,SS" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661214 SUP HCPCS C1713 "7661214 - HOOK, WIDE BLADE W/LIP,LG,SS" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661222 SUP HCPCS C1713 "7661222 - HOOK, NARROW BLADE W/LIP,SM,SS" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661223 SUP HCPCS C1713 "7661223 - HOOK, NARROW BLADE W/LIP,MD,SS" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7661224 SUP HCPCS C1713 "7661224 - HOOK, NARROW BLADE W/LIP,LG,SS" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7662420 SUP HCPCS C1713 "7662420 - SCREW, FIXED ANGLE, 4.0X20, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662425 SUP HCPCS C1713 "7662425 - SCREW, FIXED ANGLE, 4.0X25, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662430 SUP HCPCS C1713 "7662430 - SCREW, FIXED ANGLE, 4.0X30, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662435 SUP HCPCS C1713 "7662435 - SCREW, FIXED ANGLE, 4.0X35, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662440 SUP HCPCS C1713 "7662440 - SCREW, FIXED ANGLE, 4.0X40, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662445 SUP HCPCS C1713 "7662445 - SCREW, FIXED ANGLE, 4.0X45, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662450 SUP HCPCS C1713 "7662450 - SCREW, FIXED ANGLE, 4.0X50, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662455 SUP HCPCS C1713 "7662455 - SCREW, FIXED ANGLE, 4.0X55, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662520 SUP HCPCS C1713 "7662520 - SCREW, FIXED ANGLE, 5.0X20, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662525 SUP HCPCS C1713 "7662525 - SCREW, FIXED ANGLE, 5.0X25, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662530 SUP HCPCS C1713 "7662530 - SCREW, FIXED ANGLE, 5.0X30, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662535 SUP HCPCS C1713 "7662535 - SCREW, FIXED ANGLE, 5.0X35, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662540 SUP HCPCS C1713 "7662540 - SCREW, FIXED ANGLE, 5.0X40, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662545 SUP HCPCS C1713 "7662545 - SCREW, FIXED ANGLE, 5.0X45, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662550 SUP HCPCS C1713 "7662550 - SCREW, FIXED ANGLE, 5.0X50, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662555 SUP HCPCS C1713 "7662555 - SCREW, FIXED ANGLE, 5.0X55, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662625 SUP HCPCS C1713 "7662625 - SCREW, FIXED ANGLE, 6.0X25, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662630 SUP HCPCS C1713 "7662630 - SCREW, FIXED ANGLE, 6.0X30, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662635 SUP HCPCS C1713 "7662635 - SCREW, FIXED ANGLE, 6.0X35, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662640 SUP HCPCS C1713 "7662640 - SCREW, FIXED ANGLE, 6.0X40, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662645 SUP HCPCS C1713 "7662645 - SCREW, FIXED ANGLE, 6.0X45, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662650 SUP HCPCS C1713 "7662650 - SCREW, FIXED ANGLE, 6.0X50, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662655 SUP HCPCS C1713 "7662655 - SCREW, FIXED ANGLE, 6.0X55, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7662660 SUP HCPCS C1713 "7662660 - SCREW, FIXED ANGLE, 6.0X60, SS" BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663420 SUP HCPCS C1713 7663420 - SCREW 7663420 FIXED ANGLE 4.5X20 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663425 SUP HCPCS C1713 7663425 - SCREW 7663425 FIXED ANGLE 4.5X25 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663430 SUP HCPCS C1713 7663430 - SCREW 7663430 FIXED ANGLE 4.5X30 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663435 SUP HCPCS C1713 7663435 - SCREW 7663435 FIXED ANGLE 4.5X35 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663440 SUP HCPCS C1713 7663440 - SCREW 7663440 FIXED ANGLE 4.5X40 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663445 SUP HCPCS C1713 7663445 - SCREW 7663445 FIXED ANGLE 4.5X45 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663450 SUP HCPCS C1713 7663450 - SCREW 7663450 FIXED ANGLE 4.5X50 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663455 SUP HCPCS C1713 7663455 - SCREW 7663455 FIXED ANGLE 4.5X55 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663525 SUP HCPCS C1713 7663525 - SCREW 7663525 FIXED ANGLE 5.5X25 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663530 SUP HCPCS C1713 7663530 - SCREW 7663530 FIXED ANGLE 5.5X30 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663535 SUP HCPCS C1713 7663535 - SCREW 7663535 FIXED ANGLE 5.5X35 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663540 SUP HCPCS C1713 7663540 - SCREW 7663540 FIXED ANGLE 5.5X40 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663545 SUP HCPCS C1713 7663545 - SCREW 7663545 FIXED ANGLE 5.5X45 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663550 SUP HCPCS C1713 7663550 - SCREW 7663550 FIXED ANGLE 5.5X50 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663555 SUP HCPCS C1713 7663555 - SCREW 7663555 FIXED ANGLE 5.5X55 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663560 SUP HCPCS C1713 7663560 - SCREW 7663560 FIXED ANGLE 5.5X60 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663625 SUP HCPCS C1713 7663625 - SCREW 7663625 FIXED ANGLE 6.5X25 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663630 SUP HCPCS C1713 7663630 - SCREW 7663630 FIXED ANGLE 6.5X30 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663635 SUP HCPCS C1713 7663635 - SCREW 7663635 FIXED ANGLE 6.5X35 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663640 SUP HCPCS C1713 7663640 - SCREW 7663640 FIXED ANGLE 6.5X40 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663645 SUP HCPCS C1713 7663645 - SCREW 7663645 FIXED ANGLE 6.5X45 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663650 SUP HCPCS C1713 7663650 - SCREW 7663650 FIXED ANGLE 6.5X50 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663655 SUP HCPCS C1713 7663655 - BONE SCREW 7663655 FIXED ANGLE 6.5X55 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663660 SUP HCPCS C1713 7663660 - SCREW 7663660 FIXED ANGLE 6.5X60 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663665 SUP HCPCS C1713 7663665 - SCREW 7663665 FIXED ANGLE 6.5X65 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663670 SUP HCPCS C1713 7663670 - SCREW 7663670 FIXED ANGLE 6.5X70 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663725 SUP HCPCS C1713 7663725 - SCREW 7663725 FIXED ANGLE 7.5X25 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663730 SUP HCPCS C1713 7663730 - SCREW 7663730 FIXED ANGLE 7.5X30 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663735 SUP HCPCS C1713 7663735 - SCREW 7663735 FIXED ANGLE 7.5X35 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663740 SUP HCPCS C1713 7663740 - SCREW 7663740 FIXED ANGLE 7.5X40 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663745 SUP HCPCS C1713 7663745 - SCREW 7663745 FIXED ANGLE 7.5X45 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663750 SUP HCPCS C1713 7663750 - SCREW 7663750 FIXED ANGLE 7.5X50 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663755 SUP HCPCS C1713 7663755 - SCREW 7663755 FIXED ANGLE 7.5X55 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663760 SUP HCPCS C1713 7663760 - SCREW 7663760 FIXED ANGLE 7.5X60 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7663765 SUP HCPCS C1713 7663765 - SCREW 7663765 FIXED ANGLE 7.5X65 SS BOTH IP/OP "$1,762.50 " "$1,304.25" $0.00 "$1,410.00" $793.13 $793.13 $0.00 $0.00 $0.00 $367.35 "$1,308.13" "$1,308.13" $0.00 $0.00 $367.31 $0.00 "$1,042.52" "$1,042.52" $0.00 $881.25 "$1,395.90" "$1,410.00" $0.00 $0.00 $275.83 $0.00 $0.00 $280.59 $0.00 $0.00 $0.00 $0.00 $0.00 7670212 SUP HCPCS C1713 7670212 - 12MM CASPAR PINS BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 7670214 SUP HCPCS C1713 7670214 - SCREW DSTRCT 14MM PCM SPNE BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 7680265 SUP Custom 27803010 7680265 - DISK SPNL SM 6.5MM PCM CRV BOTH IP/OP "$13,077.50 " "$9,677.35" $0.00 "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,725.35" $0.00 $0.00 $0.00 $0.00 "$6,538.75" "$10,357.38" "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7680272 SUP Custom 27803010 7680272 - DISC INTVRTB 14MM SM 17X7.2MM STRL LF PCM ARTF SPNE CRV BOTH IP/OP "$13,077.50 " "$9,677.35" $0.00 "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,725.35" $0.00 $0.00 $0.00 $0.00 "$6,538.75" "$10,357.38" "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7680280 SUP Custom 27803010 7680280 - DISK SPNL SM 8MM PCM CRV BOTH IP/OP "$13,077.50 " "$9,677.35" $0.00 "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,725.35" $0.00 $0.00 $0.00 $0.00 "$6,538.75" "$10,357.38" "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7680372 SUP Custom 27803010 7680372 - DISK SPNL MED 7.2MM PCM CRV BOTH IP/OP "$13,077.50 " "$9,677.35" $0.00 "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,725.35" $0.00 $0.00 $0.00 $0.00 "$6,538.75" "$10,357.38" "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7680380 SUP Custom 27803010 7680380 - DISK SPNL MED 8MM PCM CRV BOTH IP/OP "$13,077.50 " "$9,677.35" $0.00 "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,725.35" $0.00 $0.00 $0.00 $0.00 "$6,538.75" "$10,357.38" "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7680465 SUP Custom 27803010 7680465 - DISK SPNL LG 6.5MM PCM CRV BOTH IP/OP "$13,077.50 " "$9,677.35" $0.00 "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,725.35" $0.00 $0.00 $0.00 $0.00 "$6,538.75" "$10,357.38" "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7680472 SUP Custom 27803010 7680472 - DISK SPNL LG 7.2MM PCM CRV BOTH IP/OP "$13,077.50 " "$9,677.35" $0.00 "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,725.35" $0.00 $0.00 $0.00 $0.00 "$6,538.75" "$10,357.38" "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7680480 SUP Custom 27803010 7680480 - DISK SPNL LG 8MM PCM CRV BOTH IP/OP "$13,077.50 " "$9,677.35" $0.00 "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,725.35" $0.00 $0.00 $0.00 $0.00 "$6,538.75" "$10,357.38" "$10,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7710635 SUP HCPCS C1713 7710635 - CAGE SPNL 6MM CRNT LO CX PRFL PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 7710835 SUP HCPCS C1713 7710835 - CAGE SPNL 8MM CRNT LO CX PRFL PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 7711055 SUP HCPCS C1713 7711055 - CAGE SPNL 10MM CRNT LO CX PRFL PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 7711275 SUP HCPCS C1713 7711275 - CAGE SPNL 12MM CRNT LX BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 7711495 SUP HCPCS C1713 7711495 - SPACER SPNL 14MM CRNT LX EXTENSURE BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 7711615 SUP HCPCS C1713 7711615 - SPACER SPNL 16MM CRNT LX EXTENSURE BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 7711835 SUP HCPCS C1713 7711835 - SPACER SPNL 18MM CRNT LX EXTENSURE BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 7712055 SUP HCPCS C1713 7712055 - SPACER SPNL 20MM CRNT LX EXTENSURE LMBR INTRBD FS PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 7713510 SUP HCPCS C1713 7713510 - SCREW BONE 3.5MM 10MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713511 SUP HCPCS C1713 7713511 - SCREW BONE 3.5MM 11MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713512 SUP HCPCS C1713 7713512 - SCREW BONE 3.5MM 12MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713514 SUP HCPCS C1713 7713514 - SCREW BONE 3.5MM 14MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713515 SUP HCPCS C1713 7713515 - SCREW BONE 3.5MM 15MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713516 SUP HCPCS C1713 7713516 - SCREW BONE 3.5MM 16MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713517 SUP HCPCS C1713 7713517 - SCREW BONE 3.5MM 17MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713518 SUP HCPCS C1713 7713518 - SCREW BONE 3.5MM 18MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713519 SUP HCPCS C1713 7713519 - SCREW BONE 3.5MM 19MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713520 SUP HCPCS C1713 7713520 - SCREW BONE 3.5MM 20MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713521 SUP HCPCS C1713 7713521 - SCREW BONE 3.5MM 21MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713522 SUP HCPCS C1713 7713522 - SCREW BONE 3.5MM 22MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713523 SUP HCPCS C1713 7713523 - SCREW BONE 3.5MM 23MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7713524 SUP HCPCS C1713 7713524 - SCREW BONE 3.5MM 24MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714010 SUP HCPCS C1713 7714010 - SCREW BONE 4MM 10MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714011 SUP HCPCS C1713 7714011 - SCREW BONE 4MM 11MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714012 SUP HCPCS C1713 7714012 - SCREW BONE 4MM 12MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714014 SUP HCPCS C1713 7714014 - SCREW BONE 4MM 14MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714016 SUP HCPCS C1713 7714016 - SCREW BONE 4MM 16MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714018 SUP HCPCS C1713 7714018 - SCREW BONE 4MM 18MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714019 SUP HCPCS C1713 7714019 - SCREW BONE 4MM 19MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714020 SUP HCPCS C1713 7714020 - SCREW BONE 4MM 20MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714021 SUP HCPCS C1713 7714021 - SCREW BONE 4MM 21MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714022 SUP HCPCS C1713 7714022 - SCREW BONE 4MM 22MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714023 SUP HCPCS C1713 7714023 - SCREW BONE 4MM 23MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7714024 SUP HCPCS C1713 7714024 - SCREW BONE 4MM 24MM ZEVO TI SPN CERV ANT VAR SLF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723510 SUP HCPCS C1713 7723510 - SCREW BONE 3.5MM 10MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723511 SUP HCPCS C1713 7723511 - SCREW BONE 3.5MM 11MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723512 SUP HCPCS C1713 7723512 - SCREW BONE 3.5MM 12MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723514 SUP HCPCS C1713 7723514 - SCREW BN 3.5MM 14MM ZEVO VAR ST TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723515 SUP HCPCS C1713 7723515 - SCREW BN 3.5MM 15MM ZEVO VAR ST TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723516 SUP HCPCS C1713 7723516 - SCREW BONE 3.5MM 16MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723517 SUP HCPCS C1713 7723517 - SCREW BONE 3.5MM 17MM VARIABLE SELF TAP ZEVO TITANIUM SPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723518 SUP HCPCS C1713 7723518 - SCREW BONE 3.5MM 18MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723519 SUP HCPCS C1713 7723519 - SCREW BONE 3.5MM 19MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723520 SUP HCPCS C1713 7723520 - SCREW BONE 3.5MM 20MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723521 SUP HCPCS C1713 7723521 - SCREW BONE 3.5MM 21MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723522 SUP HCPCS C1713 7723522 - SCREW BONE 3.5MM 22MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723523 SUP HCPCS C1713 7723523 - SCREW BONE 3.5MM 23MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7723524 SUP HCPCS C1713 7723524 - SCREW BONE 3.5MM 24MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724010 SUP HCPCS C1713 7724010 - SCREW BONE 4MM 10MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724011 SUP HCPCS C1713 7724011 - SCREW BONE 4MM 11MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724012 SUP HCPCS C1713 7724012 - SCREW BONE 4MM 12MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724014 SUP HCPCS C1713 7724014 - SCREW BONE 4MM 14MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724016 SUP HCPCS C1713 7724016 - SCREW BONE 4MM 16MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724017 SUP HCPCS C1713 7724017 - SCREW BN 4MM 17MM ZEVO VAR ST TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724018 SUP HCPCS C1713 7724018 - SCREW BONE 4MM 18MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724019 SUP HCPCS C1713 7724019 - SCREW BONE 4MM 19MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724020 SUP HCPCS C1713 7724020 - SCREW BONE 4MM 20MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724021 SUP HCPCS C1713 7724021 - SCREW BONE 4MM 21MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724022 SUP HCPCS C1713 7724022 - SCREW BONE 4MM 22MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724023 SUP HCPCS C1713 7724023 - SCREW BONE 4MM 23MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7724024 SUP HCPCS C1713 7724024 - SCREW BONE 4MM 24MM ZEVO TI SPN CERV ANT VAR ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7730016 SUP Custom 27203010 7730016 - BIT DRL 13MM STRL HLX ACP SPNE BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $0.00 $0.00 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7732111 SUP HCPCS C1713 7732111 - SCREW BN 4MM 11MM NS HLX ACP SLF DRL FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7732113 SUP HCPCS C1713 7732113 - SCREW BN 4MM 13MM NS HLX-T SLF DRL FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7732115 SUP HCPCS C1713 7732115 - SCREW BN 4MM 15MM NS HLX-T SLF DRL FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7733111 SUP HCPCS C1713 7733111 - SCREW BN 4MM 11MM NS HLX ACP ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7733119 SUP HCPCS C1713 7733119 - SCREW BN 4MM 19MM NS HLX ACP ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7734111 SUP HCPCS C1713 7734111 - SCREW BN 4MM 11MM NS HLX-T ACP ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7734113 SUP HCPCS C1713 7734113 - SCREW BN 4MM 13MM NS HLX-T ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7734115 SUP HCPCS C1713 7734115 - SCREW BN 4MM 15MM NS HLX-T ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7734117 SUP HCPCS C1713 7734117 - SCREW BN 4MM 17MM NS HLX-T ACP ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7734119 SUP HCPCS C1713 7734119 - SCREW BN 4MM 19MM NS HLX-T ACP ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7735111 SUP HCPCS C1713 7735111 - SCREW BN 4.5MM 11MM HLX ACP VA ST SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7735113 SUP HCPCS C1713 7735113 - SCREW BN 4.5MM 13MM NS HLX-T ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7735115 SUP HCPCS C1713 7735115 - SCREW BN 4.5MM 15MM NS HLX-T ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7735117 SUP HCPCS C1713 7735117 - SCREW BN 4.5MM 17MM NS HLX ACP ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7735119 SUP HCPCS C1713 7735119 - SCREW BN 4.5MM 19MM NS HLX ACP ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7736113 SUP HCPCS C1713 7736113 - SCREW BN 4.5MM 13MM NS HLX-T ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7736115 SUP HCPCS C1713 7736115 - SCREW BN 4.5MM 15MM NS HLX-T ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7736117 SUP HCPCS C1713 7736117 - SCREW BN 4.5MM 17MM NS HLX ACP ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7737110 SUP Custom 27203010 7737110 - HOLDER IMPL NS HLX ACP TEMP TACK SPNE BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $0.00 $0.00 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738120 SUP HCPCS C1713 7738120 - PLATE BN 20MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738122 SUP HCPCS C1713 7738122 - PLATE BN 22MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738124 SUP HCPCS C1713 7738124 - PLATE BN 24MM HLX ACP 1 LVL TI ANT CSPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738126 SUP HCPCS C1713 7738126 - PLATE BN 26MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738128 SUP HCPCS C1713 7738128 - PLATE BN 28MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738130 SUP HCPCS C1713 7738130 - PLATE BN 30MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738132 SUP HCPCS C1713 7738132 - PLATE BN 32MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738134 SUP HCPCS C1713 7738134 - PLATE BN 34MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738236 SUP HCPCS C1713 7738236 - PLATE BN 36MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738238 SUP HCPCS C1713 7738238 - PLATE BN 38MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738240 SUP HCPCS C1713 7738240 - PLATE BN 40MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738242 SUP HCPCS C1713 7738242 - PLATE BN 42MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738244 SUP HCPCS C1713 7738244 - PLATE BN 44MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738246 SUP HCPCS C1713 7738246 - PLATE BN 46MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738248 SUP HCPCS C1713 7738248 - PLATE BN 48MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738250 SUP HCPCS C1713 7738250 - PLATE BN 50MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738252 SUP HCPCS C1713 7738252 - PLATE BN 52MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738254 SUP HCPCS C1713 7738254 - PLATE BN 54MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7738356 SUP HCPCS C1713 7738356 - PLATE BN 56MM HLX LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738358 SUP HCPCS C1713 7738358 - PLATE BN 58MM HLX LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738360 SUP HCPCS C1713 7738360 - PLATE BN 60MM HLX LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738362 SUP HCPCS C1713 7738362 - PLATE BN 62MM HLX LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738364 SUP HCPCS C1713 7738364 - PLATE BN 64MM HLX LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738366 SUP HCPCS C1713 7738366 - PLATE BN 66MM HLX LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738368 SUP HCPCS C1713 7738368 - PLATE BN 68MM HLX LVL 3 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738470 SUP HCPCS C1713 7738470 - PLATE BN 70MM HLX LVL 4 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738474 SUP HCPCS C1713 7738474 - PLATE BN 74MM HLX LVL 4 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738478 SUP HCPCS C1713 7738478 - PLATE BN 78MM HLX LVL 4 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738482 SUP HCPCS C1713 7738482 - PLATE BN 82MM HLX LVL 4 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738486 SUP HCPCS C1713 7738486 - PLATE BN 86MM HLX LVL 4 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738490 SUP HCPCS C1713 7738490 - PLATE BN 90MM HLX LVL 4 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738500 SUP HCPCS C1713 7738500 - PLATE BN 100MM HLX LVL 5 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738505 SUP HCPCS C1713 7738505 - PLATE BN 105MM HLX LVL 5 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738510 SUP HCPCS C1713 7738510 - PLATE BN 110MM HLX LVL 5 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7738595 SUP HCPCS C1713 7738595 - PLATE BN 95MM HLX LVL 5 TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7739111 SUP HCPCS C1713 7739111 - SCREW BN 4MM 11MM NS HLX ACP SLF DRL VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7739113 SUP HCPCS C1713 7739113 - SCREW BN 4MM 13MM NS HLX-T SLF DRL VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7739115 SUP HCPCS C1713 7739115 - SCREW BN 4MM 15MM NS HLX-T SLF DRL VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7739213 SUP HCPCS C1713 7739213 - SCREW BN 4MM 13MM NS HLX-T ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7739215 SUP HCPCS C1713 7739215 - SCREW BN 4MM 15MM NS HLX-T ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7739217 SUP HCPCS C1713 7739217 - SCREW BN 4MM 17MM NS HLX ACP ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7740120 SUP HCPCS C1713 7740120 - PLATE BN MN 20MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7740122 SUP HCPCS C1713 7740122 - PLATE BN MN 22MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7740124 SUP HCPCS C1713 7740124 - PLATE BN MN 24MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7740126 SUP HCPCS C1713 7740126 - PLATE BN MN 26MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7740128 SUP HCPCS C1713 7740128 - PLATE BN MN 28MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7740130 SUP HCPCS C1713 7740130 - PLATE BN MN 30MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7740132 SUP HCPCS C1713 7740132 - PLATE BN MN 32MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7740134 SUP HCPCS C1713 7740134 - PLATE BN MN 34MM HLX LVL 1 TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7740236 SUP HCPCS C1713 7740236 - PLATE BN MN 36MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7740238 SUP HCPCS C1713 7740238 - PLATE BN MN 38MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7740240 SUP HCPCS C1713 7740240 - PLATE BONE 40MM LEVEL 2 HELIX MINI TITANIUM SPN CERV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7740242 SUP HCPCS C1713 7740242 - PLATE BN MN 42MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7740244 SUP HCPCS C1713 7740244 - PLATE BN MN 44MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7740246 SUP HCPCS C1713 7740246 - PLATE BN MN 46MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7740248 SUP HCPCS C1713 7740248 - PLATE BN MN 48MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7740250 SUP HCPCS C1713 7740250 - PLATE BN MN 50MM HLX LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7741111 SUP HCPCS C1713 7741111 - SCREW BN HEX 4MM 11MM VA SLF DRL SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7741113 SUP HCPCS C1713 7741113 - SCREW BN HEX 4MM 13MM VA SLF DRL SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7741115 SUP HCPCS C1713 7741115 - SCREW BN HEX 4MM 15MM VA SLF DRL SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7742111 SUP HCPCS C1713 7742111 - SCREW BN 4MM 11MM FX ANG SLF DRL SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7742113 SUP HCPCS C1713 7742113 - SCREW BN 4MM 13MM FX ANG SLF DRL SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7742115 SUP HCPCS C1713 7742115 - SCREW BN 4MM 15MM FX ANG SLF DRL SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7746111 SUP HCPCS C1713 7746111 - SCREW BN 4.5MM 11MM FX ANG ST SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7746113 SUP HCPCS C1713 7746113 - SCREW BN 4.5MM 13MM FX ANG ST SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7746115 SUP HCPCS C1713 7746115 - SCREW BN 4.5MM 15MM FX ANG ST SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7747111 SUP HCPCS C1713 7747111 - SCREW BN 4MM 11MM FX ANG ST SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7747113 SUP HCPCS C1713 7747113 - SCREW BONE 13MM FIX ANGLE SELF TAP 4MM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7747115 SUP HCPCS C1713 7747115 - SCREW BN 4MM 15MM FX ANG ST SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7748111 SUP HCPCS C1713 7748111 - SCREW BN 4MM 11MM VA ST SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7748113 SUP HCPCS C1713 7748113 - SCREW BONE 13MM VAR ANG SELF TAP 4MM SPN CERV ANTERIOR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7748115 SUP HCPCS C1713 7748115 - SCREW BN 4MM 15MM VA ST SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7750010 SUP HCPCS C1713 7750010 - ROD 7750010 3.5MM ROD 120MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7750015 SUP HCPCS C1713 7750015 - ROD 7750015 3.5MM ROD 240MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7750020 SUP HCPCS C1713 7750020 - ROD 7750020 3.5MM ROD 300MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7750086 SUP HCPCS C1713 7750086 - ROD 7750086 3.5MM CHROMALOY PLUS 120MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7750087 SUP HCPCS C1713 7750087 - ROD 7750087 3.5MM CHROMALOY PLUS 240MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7750088 SUP HCPCS C1713 7750088 - ROD 7750088 3.5MM CHROMALOY PLUS 300MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7750346 SUP Custom 27803010 7750346 - CONNECTOR 7750346 DMNO3.5 4.0 TO 3.5 4.0 BOTH IP/OP "$1,458.00 " "$1,078.92" $0.00 "$1,166.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,082.13" "$1,082.13" $0.00 $0.00 $303.85 $0.00 $0.00 $0.00 $0.00 $729.00 "$1,154.74" "$1,166.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7750347 SUP Custom 27803010 7750347 - CONNECTOR 7750347 AX DOMNO3.5 4.0 TO 4.5 BOTH IP/OP "$1,458.00 " "$1,078.92" $0.00 "$1,166.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,082.13" "$1,082.13" $0.00 $0.00 $303.85 $0.00 $0.00 $0.00 $0.00 $729.00 "$1,154.74" "$1,166.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7750348 SUP Custom 27803010 7750348 - CONNECTOR 7750348 AX DOMNO3.5 4.0 TO 5.5 BOTH IP/OP "$1,458.00 " "$1,078.92" $0.00 "$1,166.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,082.13" "$1,082.13" $0.00 $0.00 $303.85 $0.00 $0.00 $0.00 $0.00 $729.00 "$1,154.74" "$1,166.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7750443 SUP HCPCS C1713 "7750443 - DOMINO 7750443 OFFSET 3.2,3.5 TO 3.2,3.5" BOTH IP/OP "$1,458.00 " "$1,078.92" $0.00 "$1,166.40" $656.10 $656.10 $0.00 $0.00 $0.00 $303.88 "$1,082.13" "$1,082.13" $0.00 $0.00 $303.85 $0.00 $862.41 $862.41 $0.00 $729.00 "$1,154.74" "$1,166.40" $0.00 $0.00 $228.18 $0.00 $0.00 $232.11 $0.00 $0.00 $0.00 $0.00 $0.00 7750444 SUP HCPCS C1713 7750444 - DOMINO 7750444 OFSET 3.2-3.5 TO 4.5-4.75 BOTH IP/OP "$1,458.00 " "$1,078.92" $0.00 "$1,166.40" $656.10 $656.10 $0.00 $0.00 $0.00 $303.88 "$1,082.13" "$1,082.13" $0.00 $0.00 $303.85 $0.00 $862.41 $862.41 $0.00 $729.00 "$1,154.74" "$1,166.40" $0.00 $0.00 $228.18 $0.00 $0.00 $232.11 $0.00 $0.00 $0.00 $0.00 $0.00 7750445 SUP HCPCS C1713 "7750445 - DOMINO 7750445 OFFSET 3.2, 3.5 TO 5.5" BOTH IP/OP "$1,458.00 " "$1,078.92" $0.00 "$1,166.40" $656.10 $656.10 $0.00 $0.00 $0.00 $303.88 "$1,082.13" "$1,082.13" $0.00 $0.00 $303.85 $0.00 $862.41 $862.41 $0.00 $729.00 "$1,154.74" "$1,166.40" $0.00 $0.00 $228.18 $0.00 $0.00 $232.11 $0.00 $0.00 $0.00 $0.00 $0.00 7750506 SUP HCPCS C1713 7750506 - SCREW BN 4.5MM 6MM VRTX SLCT TI SPNE OCPTL BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750508 SUP HCPCS C1713 7750508 - SCREW BN 4.5MM 8MM VRTX SLCT TI SPNE OCPTL BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750510 SUP HCPCS C1713 7750510 - SCREW BN 4.5MM 10MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750512 SUP HCPCS C1713 7750512 - SCREW BN 4.5MM 12MM VRTX SLCT TI SPNE OCPTL BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750514 SUP HCPCS C1713 7750514 - SCREW BN 4.5MM 14MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750516 SUP HCPCS C1713 7750516 - SCREW BN 4.5MM 16MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750518 SUP HCPCS C1713 7750518 - SCREW BN 4.5MM 18MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750606 SUP HCPCS C1713 7750606 - SCREW BN 5MM 6MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750608 SUP HCPCS C1713 7750608 - SCREW BONE 4MM 8MM CORT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750610 SUP HCPCS C1713 7750610 - SCREW BN 5MM 10MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750612 SUP HCPCS C1713 7750612 - SCREW BN 5MM 12MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750614 SUP HCPCS C1713 7750614 - SCREW BN 5MM 14MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750616 SUP HCPCS C1713 7750616 - SCREW BN 5MM 16MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7750618 SUP HCPCS C1713 7750618 - SCREW BN 5MM 18MM VRTX TI SPNE CRV OCPTL CORT ANT BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $323.55 $323.55 $0.00 $0.00 $0.00 $149.86 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $425.29 $425.29 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $112.52 $0.00 $0.00 $114.46 $0.00 $0.00 $0.00 $0.00 $0.00 7751101 SUP HCPCS C1713 7751101 - POSTED SCREW CONNECTOR 7751101 SMALL BOTH IP/OP "$1,794.00 " "$1,327.56" $0.00 "$1,435.20" $807.30 $807.30 $0.00 $0.00 $0.00 $373.91 "$1,331.51" "$1,331.51" $0.00 $0.00 $373.87 $0.00 "$1,061.15" "$1,061.15" $0.00 $897.00 "$1,420.85" "$1,435.20" $0.00 $0.00 $280.76 $0.00 $0.00 $285.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751103 SUP HCPCS C1713 7751103 - POSTED SCREW CONNECTOR 7751103 MEDIUM BOTH IP/OP "$1,794.00 " "$1,327.56" $0.00 "$1,435.20" $807.30 $807.30 $0.00 $0.00 $0.00 $373.91 "$1,331.51" "$1,331.51" $0.00 $0.00 $373.87 $0.00 "$1,061.15" "$1,061.15" $0.00 $897.00 "$1,420.85" "$1,435.20" $0.00 $0.00 $280.76 $0.00 $0.00 $285.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751105 SUP HCPCS C1713 7751105 - POSTED SCREW CONNECTOR 7751105 LARGE BOTH IP/OP "$1,794.00 " "$1,327.56" $0.00 "$1,435.20" $807.30 $807.30 $0.00 $0.00 $0.00 $373.91 "$1,331.51" "$1,331.51" $0.00 $0.00 $373.87 $0.00 "$1,061.15" "$1,061.15" $0.00 $897.00 "$1,420.85" "$1,435.20" $0.00 $0.00 $280.76 $0.00 $0.00 $285.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751110 SUP Custom 27803010 7751110 - CONNECTOR 7751110 OPEN CABLE CONN BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7751710 SUP HCPCS C1713 7751710 - SCREW 7751710 3.5 X 10MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751712 SUP HCPCS C1713 7751712 - SCREW 7751712 3.5 X 12MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751714 SUP HCPCS C1713 7751714 - SCREW 7751714 3.5 X 14MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751716 SUP HCPCS C1713 7751716 - SCREW 7751716 3.5 X 16MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751718 SUP HCPCS C1713 7751718 - SCREW 7751718 3.5 X 18MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751720 SUP HCPCS C1713 7751720 - SCREW 7751720 3.5 X 20MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751722 SUP HCPCS C1713 7751722 - SCREW 7751722 3.5 X 22MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751724 SUP HCPCS C1713 7751724 - SCREW 7751724 3.5 X 24MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751726 SUP HCPCS C1713 7751726 - SCREW 7751726 3.5 X 26MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751728 SUP HCPCS C1713 7751728 - SCREW 7751728 3.5 X 28MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751730 SUP HCPCS C1713 7751730 - SCREW 7751730 3.5 X 30MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751732 SUP HCPCS C1713 7751732 - SCREW 7751732 3.5 X 32MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751734 SUP HCPCS C1713 7751734 - SCREW 7751734 3.5 X 34MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751810 SUP HCPCS C1713 7751810 - SCREW 7751810 4.0 X 10MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751812 SUP HCPCS C1713 7751812 - SCREW 7751812 4.0 X 12MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751814 SUP HCPCS C1713 7751814 - SCREW 7751814 4.0 X 14MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751816 SUP HCPCS C1713 7751816 - SCREW 7751816 4.0 X 16MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751818 SUP HCPCS C1713 7751818 - SCREW 7751818 4.0 X 18MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751820 SUP HCPCS C1713 7751820 - SCREW 7751820 4.0 X 20MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751822 SUP HCPCS C1713 7751822 - SCREW 7751822 4.0 X 22MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751824 SUP HCPCS C1713 7751824 - SCREW 7751824 4.0 X 24MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751826 SUP HCPCS C1713 7751826 - SCREW 7751826 4.0 X 26MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751828 SUP HCPCS C1713 7751828 - SCREW 7751828 4.0 X 28MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751830 SUP HCPCS C1713 7751830 - SCREW 7751830 4.0 X 30MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751832 SUP HCPCS C1713 7751832 - SCREW 7751832 4.0 X 32MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751834 SUP HCPCS C1713 7751834 - SCREW 7751834 4.0 X 34MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751924 SUP HCPCS C1713 7751924 - SCREW 7751924 4.5 X 24MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751926 SUP HCPCS C1713 7751926 - SCREW 7751926 4.5 X 26MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751928 SUP HCPCS C1713 7751928 - SCREW 7751928 4.5 X 28MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751930 SUP HCPCS C1713 7751930 - SCREW 7751930 4.5 X 30MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751932 SUP HCPCS C1713 7751932 - SCREW 7751932 4.5 X 32MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751934 SUP HCPCS C1713 7751934 - SCREW 7751934 4.5 X 34MM POSTED BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7752510 SUP HCPCS C1713 7752510 - SET SCREW 7752510 CROSSLINK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7752515 SUP HCPCS C1713 7752515 - SCREW 7752515 FLAT CONNECTOR SETSCREW BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7752525 SUP HCPCS C1713 7752525 - CROSSLINK 7752525 SMALL MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7752526 SUP HCPCS C1713 7752526 - CROSSLINK 7752526 MEDIUM MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7752527 SUP HCPCS C1713 7752527 - CROSSLINK 7752527 LARGE MAS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7752528 SUP Custom 27803010 7752528 - CONNECTOR 7752528 MAS CROSSLINK ROD BOTH IP/OP $719.00 $532.06 $0.00 $575.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $533.64 $533.64 $0.00 $0.00 $149.84 $0.00 $0.00 $0.00 $0.00 $359.50 $569.45 $575.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7752529 SUP HCPCS C1713 7752529 - SCREW 7752529 MAS CROSSLINK LOCKING BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7752535 SUP HCPCS C1713 7752535 - CROSSLINK 7752535 SMALL ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7752536 SUP HCPCS C1713 7752536 - CROSSLINK 7752536 MEDIUM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7752537 SUP HCPCS C1713 7752537 - CROSSLINK 7752537 LARGE ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7753500 SUP HCPCS C1713 7753500 - SET SCREW 7753500 MAS CONNECTOR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7753520 SUP HCPCS C1713 "7753520 - SET SCREW 7753520 MAS EXT., LAT. CONN" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7753730 SUP HCPCS C1713 7753730 - ROD SPINAL 30MM PRECUT VERTEX 3.5MM NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7753740 SUP HCPCS C1713 7753740 - ROD SPNL 40MM 3.5MM VRTX PCUT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7753750 SUP HCPCS C1713 7753750 - ROD SPINAL 3.5MM 50MM PRECUT VERTEX NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7753760 SUP HCPCS C1713 7753760 - ROD SPINAL 3.5MM 60MM PRECUT VERTEX SELECT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7753770 SUP HCPCS C1713 7753770 - ROD SPINAL 70MM PRECUT CCM PLUS 3.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7753780 SUP HCPCS C1713 7753780 - ROD SPINAL 80MM PRECUT TITANIUM 3.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7753806 SUP HCPCS C1713 7753806 - ROD SPINAL 420MM CCM PLUS STAINLESS STEEL 4.75MM 3.5MM BOTH IP/OP "$2,362.50 " "$1,748.25" $0.00 "$1,890.00" "$1,063.13" "$1,063.13" $0.00 $0.00 $0.00 $492.40 "$1,753.45" "$1,753.45" $0.00 $0.00 $492.35 $0.00 "$1,397.42" "$1,397.42" $0.00 "$1,181.25" "$1,871.10" "$1,890.00" $0.00 $0.00 $369.73 $0.00 $0.00 $376.11 $0.00 $0.00 $0.00 $0.00 $0.00 7753880 SUP HCPCS C1713 7753880 - ROD SPINAL 80MM PRECUT CCM PLUS 3.5MM BOTH IP/OP "$1,252.50 " $926.85 $0.00 "$1,002.00" $563.63 $563.63 $0.00 $0.00 $0.00 $261.05 $929.61 $929.61 $0.00 $0.00 $261.02 $0.00 $740.85 $740.85 $0.00 $626.25 $991.98 "$1,002.00" $0.00 $0.00 $196.02 $0.00 $0.00 $199.40 $0.00 $0.00 $0.00 $0.00 $0.00 7753890 SUP HCPCS C1713 7753890 - ROD SPINAL 90MM PRECUT CCM PLUS 3.5MM BOTH IP/OP "$1,252.50 " $926.85 $0.00 "$1,002.00" $563.63 $563.63 $0.00 $0.00 $0.00 $261.05 $929.61 $929.61 $0.00 $0.00 $261.02 $0.00 $740.85 $740.85 $0.00 $626.25 $991.98 "$1,002.00" $0.00 $0.00 $196.02 $0.00 $0.00 $199.40 $0.00 $0.00 $0.00 $0.00 $0.00 7753900 SUP HCPCS C1713 7753900 - ROD SPINAL 100MM PRECUT CCM PLUS 3.5MM BOTH IP/OP "$1,252.50 " $926.85 $0.00 "$1,002.00" $563.63 $563.63 $0.00 $0.00 $0.00 $261.05 $929.61 $929.61 $0.00 $0.00 $261.02 $0.00 $740.85 $740.85 $0.00 $626.25 $991.98 "$1,002.00" $0.00 $0.00 $196.02 $0.00 $0.00 $199.40 $0.00 $0.00 $0.00 $0.00 $0.00 7754525 SUP HCPCS C1713 7754525 - SCREW BN 4.5MM 25MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7754530 SUP HCPCS C1713 7754530 - SCREW BN 4.5MM 35MM SHNK PPS SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7754535 SUP HCPCS C1713 7754535 - SCREW BN 4.5MM 35MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7754540 SUP HCPCS C1713 7754540 - SCREW BN 4.5MM 40MM HLX-REV ACP SHNK PLYP-PHENYLENE SLF SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7754545 SUP HCPCS C1713 7754545 - SCREW BN 4.5MM 45MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7754550 SUP HCPCS C1713 7754550 - SCREW BN 4.5MM 50MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7755120 SUP HCPCS C1713 7755120 - ROD SPNL 3.5MM HNG BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755122 SUP HCPCS C1713 7755122 - ROD SPNL 3.2/3.5MM 120MM HNG ADJ OCPTL BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 7755123 SUP HCPCS C1713 7755123 - ROD SPNL 3.5MM 3.2MM 220MM ADJ OCPTL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755124 SUP HCPCS C1713 7755124 - ROD SPNL 3.5MM 220MM STRL VRTX ADJ TI OCPTL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755217 SUP HCPCS C1713 7755217 - VERTEX SELECT PRE-CURVED OC ROD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755231 SUP HCPCS C1713 7755231 - ROD SPNL 3.5MM 100MM OCPTL PLT BOTH IP/OP "$4,426.50 " "$3,275.61" $0.00 "$3,541.20" "$1,991.93" "$1,991.93" $0.00 $0.00 $0.00 $922.59 "$3,285.35" "$3,285.35" $0.00 $0.00 $922.48 $0.00 "$2,182.26" "$2,182.26" $0.00 "$2,213.25" "$3,505.79" "$3,541.20" $0.00 $0.00 $692.75 $0.00 $0.00 $704.70 $0.00 $0.00 $0.00 $0.00 $0.00 7755232 SUP HCPCS C1713 7755232 - ROD SPNL 3.5MM 200MM PCRV PLT OCPTL BOTH IP/OP "$4,426.50 " "$3,275.61" $0.00 "$3,541.20" "$1,991.93" "$1,991.93" $0.00 $0.00 $0.00 $922.59 "$3,285.35" "$3,285.35" $0.00 $0.00 $922.48 $0.00 "$2,182.26" "$2,182.26" $0.00 "$2,213.25" "$3,505.79" "$3,541.20" $0.00 $0.00 $692.75 $0.00 $0.00 $704.70 $0.00 $0.00 $0.00 $0.00 $0.00 7755240 SUP HCPCS C1713 7755240 - ROD SPNL 3.5MM 240MM VRTX THRD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755245 SUP HCPCS C1713 7755245 - ROD THRD 4.5MM 360MM SPNE BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755247 SUP HCPCS C1713 7755247 - ROD SPNL 5.5MM 360MM VRTX THRD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755266 SUP HCPCS C1713 7755266 - ROD SPNL P/T 4.75MM 360MM CIRC BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755270 SUP HCPCS C1713 7755270 - ROD SPNL 3.5MM 100MM PCRV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755271 SUP HCPCS C1713 7755271 - ROD SPNL 3.5MM 200MM VRTX PCRV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755274 SUP HCPCS C1713 7755274 - ROD 7755274 3.5 PRECURV CHROMALOY PL 100 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755275 SUP HCPCS C1713 7755275 - ROD SPNL CRV 3.5MM 200MM NS CHROMALOY + BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755278 SUP HCPCS C1713 7755278 - PLATE BN 50MM NS VRTX SLCT ADJ SPNE OCPTL RECON SYS BOTH IP/OP "$8,085.00 " "$5,982.90" $0.00 "$6,468.00" "$3,638.25" "$3,638.25" $0.00 $0.00 $0.00 "$1,685.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,684.91" $0.00 "$3,985.91" "$3,985.91" $0.00 "$4,042.50" "$6,403.32" "$6,468.00" $0.00 $0.00 "$1,265.30" $0.00 $0.00 "$1,287.13" $0.00 $0.00 $0.00 $0.00 $0.00 7755325 SUP HCPCS C1713 7755325 - CONNECTOR ROD SM LOPRFL SCR OCPTL SPNE BOTH IP/OP "$1,794.00 " "$1,327.56" $0.00 "$1,435.20" $807.30 $807.30 $0.00 $0.00 $0.00 $373.91 "$1,331.51" "$1,331.51" $0.00 $0.00 $373.87 $0.00 "$1,061.15" "$1,061.15" $0.00 $897.00 "$1,420.85" "$1,435.20" $0.00 $0.00 $280.76 $0.00 $0.00 $285.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755327 SUP HCPCS C1713 7755327 - SCREW BN OFST 27MM CNCT SPNE OCPTL BOTH IP/OP "$1,794.00 " "$1,327.56" $0.00 "$1,435.20" $807.30 $807.30 $0.00 $0.00 $0.00 $373.91 "$1,331.51" "$1,331.51" $0.00 $0.00 $373.87 $0.00 "$1,061.15" "$1,061.15" $0.00 $897.00 "$1,420.85" "$1,435.20" $0.00 $0.00 $280.76 $0.00 $0.00 $285.60 $0.00 $0.00 $0.00 $0.00 $0.00 7755530 SUP HCPCS C1713 7755530 - SCREW BN 5.5MM 30MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7755535 SUP HCPCS C1713 7755535 - SCREW BN 5.5MM 35MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7755540 SUP HCPCS C1713 7755540 - SCREW BN 5.5MM 40MM CNN TI SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7755545 SUP HCPCS C1713 7755545 - SCREW BN 5.5MM 45MM CNN TI SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7755550 SUP HCPCS C1713 7755550 - SCREW BN 5.5MM 50MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7755555 SUP HCPCS C1713 7755555 - SCREW BN 5.5MM 55MM HLX-REV ACP SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7756007 SUP Custom 27203010 7756007 - BIT DRILL 2.4MM BOTH IP/OP $660.00 $488.40 $0.00 $528.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.85 $489.85 $0.00 $0.00 $137.54 $0.00 $0.00 $0.00 $0.00 $330.00 $522.72 $528.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756010 SUP Custom 27203010 7756010 - BIT DRL 2.4MM STRL VRTX SLCT DISP BOTH IP/OP $660.00 $488.40 $0.00 $528.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.85 $489.85 $0.00 $0.00 $137.54 $0.00 $0.00 $0.00 $0.00 $330.00 $522.72 $528.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756035 SUP Custom 27203010 7756035 - TAP SURG INSTR 3.5MM BOTH IP/OP "$1,038.00 " $768.12 $0.00 $830.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $770.40 $770.40 $0.00 $0.00 $216.32 $0.00 $0.00 $0.00 $0.00 $519.00 $822.10 $830.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756064 SUP Custom 27803010 "7756064 - LATERAL CONNECTOR 7756064 OPEN, 10MM" BOTH IP/OP "$1,077.00 " $796.98 $0.00 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $799.35 $799.35 $0.00 $0.00 $224.45 $0.00 $0.00 $0.00 $0.00 $538.50 $852.98 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756066 SUP Custom 27803010 "7756066 - LATERAL CONNECTOR 7756066 OPEN, 13MM" BOTH IP/OP "$1,077.00 " $796.98 $0.00 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $799.35 $799.35 $0.00 $0.00 $224.45 $0.00 $0.00 $0.00 $0.00 $538.50 $852.98 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756067 SUP Custom 27803010 "7756067 - LATERAL CONNECTOR 7756067 CLOSED, 10MM" BOTH IP/OP "$1,018.50 " $753.69 $0.00 $814.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $755.93 $755.93 $0.00 $0.00 $212.26 $0.00 $0.00 $0.00 $0.00 $509.25 $806.65 $814.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756068 SUP Custom 27803010 "7756068 - LATERAL CONNECTOR 7756068 CLOSED, 13MM" BOTH IP/OP "$1,018.50 " $753.69 $0.00 $814.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $755.93 $755.93 $0.00 $0.00 $212.26 $0.00 $0.00 $0.00 $0.00 $509.25 $806.65 $814.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756069 SUP Custom 27803010 "7756069 - MAS EXTENSION CONN. 7756069 3.2, 3.5MM" BOTH IP/OP "$1,077.00 " $796.98 $0.00 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $799.35 $799.35 $0.00 $0.00 $224.45 $0.00 $0.00 $0.00 $0.00 $538.50 $852.98 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756071 SUP Custom 27803010 7756071 - CONNECTOR MAS EXT 7756071 4.5-4.75MM BOTH IP/OP "$1,077.00 " $796.98 $0.00 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $799.35 $799.35 $0.00 $0.00 $224.45 $0.00 $0.00 $0.00 $0.00 $538.50 $852.98 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756072 SUP Custom 27803010 7756072 - MAS EXTENSION CONN. 7756072 5.5MM BOTH IP/OP "$1,077.00 " $796.98 $0.00 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $799.35 $799.35 $0.00 $0.00 $224.45 $0.00 $0.00 $0.00 $0.00 $538.50 $852.98 $861.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756073 SUP HCPCS C1713 "7756073 - HOOK 7756073 LAMINAR, 4.5MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756074 SUP HCPCS C1713 "7756074 - HOOK 7756074 LAMINAR, 6.0MM" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756131 SUP Custom 27203010 7756131 - DRILL BIT 7756131 3.2MM DRILL BIT BOTH IP/OP $676.50 $500.61 $0.00 $541.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.10 $502.10 $0.00 $0.00 $140.98 $0.00 $0.00 $0.00 $0.00 $338.25 $535.79 $541.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756133 SUP Custom 27203010 7756133 - DRILL BIT 7756133 3.2MM DRILL BIT BOTH IP/OP $676.50 $500.61 $0.00 $541.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.10 $502.10 $0.00 $0.00 $140.98 $0.00 $0.00 $0.00 $0.00 $338.25 $535.79 $541.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756300 SUP Custom 27203010 7756300 - TAP SPINAL VERTEX SELECT 3MM BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756530 SUP HCPCS C1713 7756530 - SCREW BN 6.5MM 30MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7756535 SUP HCPCS C1713 7756535 - SCREW BN 6.5MM 35MM CNN TI SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7756540 SUP HCPCS C1713 7756540 - SCREW BN 6.5MM 40MM CNN TI SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7756545 SUP HCPCS C1713 7756545 - SCREW BN 6.5MM 45MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7756550 SUP HCPCS C1713 7756550 - SCREW BN 6.5MM 50MM CNN TI SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7756555 SUP HCPCS C1713 7756555 - SCREW BN 6.5MM 55MM NEURO SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7757530 SUP HCPCS C1713 7757530 - SCREW BN 7.5MM 30MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7757535 SUP HCPCS C1713 7757535 - SCREW BN 7.5MM 35MM SHNK CNN SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7757540 SUP HCPCS C1713 7757540 - SCREW BN 7.5MM 40MM CNN TI SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7757545 SUP HCPCS C1713 7757545 - SCREW BN 7.5MM 45MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7757550 SUP HCPCS C1713 7757550 - SCREW BN 7.5MM 50MM SPHERX PPS CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7757555 SUP HCPCS C1713 7757555 - SCREW BN 7.5MM 55MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7758535 SUP HCPCS C1713 7758535 - SCREW BN 8.5MM 35MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7758540 SUP HCPCS C1713 7758540 - SCREW BN 8.5MM 40MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7758545 SUP HCPCS C1713 7758545 - SCREW BN 8.5MM 45MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7758550 SUP HCPCS C1713 7758550 - SCREW BN 8.5MM 50MM CNN SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7759970 SUP HCPCS C1713 7759970 - PLATE BN SM LOPRFL VRTX SLCT LCK SLCT SPNE OC BOTH IP/OP "$7,095.00 " "$5,250.30" $0.00 "$5,676.00" "$3,192.75" "$3,192.75" $0.00 $0.00 $0.00 "$1,478.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,478.60" $0.00 "$3,497.84" "$3,497.84" $0.00 "$3,547.50" "$5,619.24" "$5,676.00" $0.00 $0.00 "$1,110.37" $0.00 $0.00 "$1,129.52" $0.00 $0.00 $0.00 $0.00 $0.00 7759971 SUP HCPCS C1713 7759971 - PLATE BN MED LOPRFL VRTX SLCT LCK SLCT SPNE OC BOTH IP/OP "$7,095.00 " "$5,250.30" $0.00 "$5,676.00" "$3,192.75" "$3,192.75" $0.00 $0.00 $0.00 "$1,478.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,478.60" $0.00 "$3,497.84" "$3,497.84" $0.00 "$3,547.50" "$5,619.24" "$5,676.00" $0.00 $0.00 "$1,110.37" $0.00 $0.00 "$1,129.52" $0.00 $0.00 $0.00 $0.00 $0.00 7759972 SUP HCPCS C1713 7759972 - PLATE BN LG LOPRFL VRTX SLCT LCK SLCT SPNE OC BOTH IP/OP "$7,095.00 " "$5,250.30" $0.00 "$5,676.00" "$3,192.75" "$3,192.75" $0.00 $0.00 $0.00 "$1,478.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,478.60" $0.00 "$3,497.84" "$3,497.84" $0.00 "$3,547.50" "$5,619.24" "$5,676.00" $0.00 $0.00 "$1,110.37" $0.00 $0.00 "$1,129.52" $0.00 $0.00 $0.00 $0.00 $0.00 7764525 SUP HCPCS C1713 7764525 - SCREW BN 4.5MM 25MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7764530 SUP HCPCS C1713 7764530 - SCREW BN 4.5MM 30MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7764535 SUP HCPCS C1713 7764535 - SCREW BN 4.5MM 35MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7764540 SUP HCPCS C1713 7764540 - SCREW BN 4.5MM 40MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7764545 SUP HCPCS C1713 7764545 - SCREW BN 4.5MM 45MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7765530 SUP HCPCS C1713 7765530 - SCREW BN 5.5MM 30MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7765535 SUP HCPCS C1713 7765535 - SCREW BN 5.5MM 35MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7765540 SUP HCPCS C1713 7765540 - SCREW BN 5.5MM 40MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7765545 SUP HCPCS C1713 7765545 - SCREW BN 5.5MM 45MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7765550 SUP HCPCS C1713 7765550 - SCREW BN 5.5MM 50MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7765555 SUP HCPCS C1713 7765555 - SCREW BN 5.5MM 55MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7765560 SUP HCPCS C1713 7765560 - SCREW BN 5.5MM 60MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7766530 SUP HCPCS C1713 7766530 - SCREW BN 6.5MM 30MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7766535 SUP HCPCS C1713 7766535 - SCREW BN 6.5MM 35MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7766540 SUP HCPCS C1713 7766540 - SCREW BN 6.5MM 40MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7766545 SUP HCPCS C1713 7766545 - SCREW BN 6.5MM 45MM TI SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7766550 SUP HCPCS C1713 7766550 - SCREW BN 6.5MM 50MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7766555 SUP HCPCS C1713 7766555 - SCREW BN 6.5MM 55MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7766560 SUP HCPCS C1713 7766560 - SCREW BN 6.5MM 60MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7767530 SUP HCPCS C1713 7767530 - SCREW BN 7.5MM 30MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7767535 SUP HCPCS C1713 7767535 - SCREW BN 7.5MM 35MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7767540 SUP HCPCS C1713 7767540 - SCREW BN 7.5MM 40MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7767545 SUP HCPCS C1713 7767545 - SCREW BN 7.5MM 45MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7767550 SUP HCPCS C1713 7767550 - SCREW BN 7.5MM 50MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7767555 SUP HCPCS C1713 7767555 - SCREW BN 7.5MM 55MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7767560 SUP HCPCS C1713 7767560 - SCREW BN 7.5MM 60MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7768535 SUP HCPCS C1713 7768535 - SCREW BN 8.5MM 35MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7768540 SUP HCPCS C1713 7768540 - SCREW BN 8.5MM 40MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7768545 SUP HCPCS C1713 7768545 - SCREW BN 8.5MM 45MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7768550 SUP HCPCS C1713 7768550 - SCREW BN 8.5MM 50MM NCLNLT SHNK SPNE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 7770723 SUP HCPCS C1713 7770723 - SPACER SPNL XLORDOTIC 23MMX7MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7770728 SUP HCPCS C1713 7770728 - SPACER SPNL XLORDOTIC 28MMX7MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7770732 SUP HCPCS C1713 7770732 - SPACER SPNL XLORDOTIC 32MMX7MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7770823 SUP HCPCS C1713 7770823 - SPACER SPNL STD 23MMX8MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7770828 SUP HCPCS C1713 7770828 - SPACER SPNL STD 28MMX8MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7770832 SUP HCPCS C1713 7770832 - SPACER SPNL STD 32MMX8MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7770923 SUP HCPCS C1713 7770923 - SPACER SPNL STD 23MMX9MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7770928 SUP HCPCS C1713 7770928 - SPACER SPNL STD 28MMX9MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7770932 SUP HCPCS C1713 7770932 - SPACER SPNL STD 32MMX9MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7771023 SUP HCPCS C1713 7771023 - SPACER SPNL STD 23MMX10MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7771028 SUP HCPCS C1713 7771028 - SPACER SPNL STD 28MMX10MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7771032 SUP HCPCS C1713 7771032 - SPACER SPNL STD 32MMX10MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7771123 SUP HCPCS C1713 7771123 - SPACER SPNL STD 23MMX11MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7771128 SUP HCPCS C1713 7771128 - SPACER SPNL STD 28MMX11MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7771132 SUP HCPCS C1713 7771132 - SPACER SPNL STD 32MMX11MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 7771174 SUP Custom 27203010 7771174 - SLEEVE SPNL SPHERX PRODUCTIVE PPS BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7772001 SUP HCPCS C1713 7772001 - SCREW BN TULIP LCK SPNE 6.25 MM ROD BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7781120 SUP HCPCS C1713 7781120 - PLATE BN 20MM NS HLX-T 1 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781122 SUP HCPCS C1713 7781122 - PLATE BN 22MM NS HLX-T 1 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781124 SUP HCPCS C1713 7781124 - PLATE BN 24MM NS HLX-T 1 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781126 SUP HCPCS C1713 7781126 - PLATE BN 26MM NS HLX-T 1 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781128 SUP HCPCS C1713 7781128 - PLATE BN 28MM NS HLX-T 1 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781130 SUP HCPCS C1713 7781130 - PLATE BN 30MM NS HLX-T 1 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781132 SUP HCPCS C1713 7781132 - PLATE BN 32MM NS HLX-T 1 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781134 SUP HCPCS C1713 7781134 - PLATE BN 34MM NS HLX-T 1 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781234 SUP HCPCS C1713 7781234 - PLATE BN 34MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781236 SUP HCPCS C1713 7781236 - PLATE BN 36MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781238 SUP HCPCS C1713 7781238 - PLATE BN 38MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781240 SUP HCPCS C1713 7781240 - PLATE BN 40MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781242 SUP HCPCS C1713 7781242 - PLATE BN 42MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781244 SUP HCPCS C1713 7781244 - PLATE BN 44MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781246 SUP HCPCS C1713 7781246 - PLATE BN 46MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781248 SUP HCPCS C1713 7781248 - PLATE BN 48MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781250 SUP HCPCS C1713 7781250 - PLATE BN 50MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781252 SUP HCPCS C1713 7781252 - PLATE BN 52MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781254 SUP HCPCS C1713 7781254 - PLATE BN 54MM NS HLX-T 2 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781354 SUP HCPCS C1713 7781354 - PLATE BN 54MM NS HLX-T 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781356 SUP HCPCS C1713 7781356 - PLATE BN 56MM NS HLX-T 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781358 SUP HCPCS C1713 7781358 - PLATE BN 58MM NS HLX-T 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781360 SUP HCPCS C1713 7781360 - PLATE BN 60MM NS HLX-T 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781362 SUP HCPCS C1713 7781362 - PLATE BN 62MM NS HLX-T 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781364 SUP HCPCS C1713 7781364 - PLATE BN 64MM NS HLX-T 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781366 SUP HCPCS C1713 7781366 - PLATE BN 66MM NS HLX-T 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781368 SUP HCPCS C1713 7781368 - PLATE BN 68MM NS HLX-T 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781470 SUP HCPCS C1713 7781470 - PLATE BN 70MM NS HLX-T 4 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781474 SUP HCPCS C1713 7781474 - PLATE BN 74MM NS HLX-T 4 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781478 SUP HCPCS C1713 7781478 - PLATE BN 78MM NS HLX-T 4 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781482 SUP HCPCS C1713 7781482 - PLATE BN 82MM NS HLX-T 4 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781486 SUP HCPCS C1713 7781486 - PLATE BN 86MM NS HLX-T 4 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781490 SUP HCPCS C1713 7781490 - PLATE BN 90MM NS HLX-T 4 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781501 SUP HCPCS C1713 7781501 - PLATE BN T 100MM HLX LVL 5 TRANSLATIONAL SS SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781505 SUP HCPCS C1713 7781505 - PLATE BN T 105MM HLX LVL 5 TRANSLATIONAL SS SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781510 SUP HCPCS C1713 7781510 - PLATE BN T 110MM HLX LVL 5 TRANSLATIONAL SS SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7781595 SUP HCPCS C1713 7781595 - PLATE BN T 95MM HLX LVL 5 TRANSLATIONAL SS SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7782001 SUP HCPCS C1713 7782001 - SCREW LCK 5.5MM SPHERX PPS SPNE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7782300 SUP HCPCS C1713 7782300 - ROD SPNL 5.5MM 300MM STRL SPHERX XTN BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $693.00 $693.00 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 7782500 SUP HCPCS C1713 7782500 - ROD SPNL 5.5MM 500MM SPHERX XTN BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $693.00 $693.00 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 7783025 SUP HCPCS C1713 7783025 - ROD SPNL PREBNT 5.5MM 25MM SPHERX XTN BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 7783030 SUP HCPCS C1713 7783030 - ROD SPNL PREBNT 5.5MM 30MM SPHERX XTN BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 7783035 SUP HCPCS C1713 7783035 - ROD SPNL PREBNT 5.5MM 35MM SPHERX XTN BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 7783040 SUP HCPCS C1713 7783040 - ROD SPNL PREBNT 5.5MM 40MM SPHERX XTN BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 7783045 SUP HCPCS C1713 7783045 - ROD SPNL PREBNT 5.5MM 45MM SPHERX XTN BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 7783050 SUP HCPCS C1713 7783050 - ROD SPNL PREBNT 5.5MM 50MM SPHERX XTN BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 7783055 SUP HCPCS C1713 7783055 - ROD SPNL PREBNT 5.5MM 55MM SPHERX XTN BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 7783060 SUP HCPCS C1713 7783060 - ROD SPNL PREBNT 5.5MM 60MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783065 SUP HCPCS C1713 7783065 - ROD SPNL PREBNT 5.5MM 65MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783070 SUP HCPCS C1713 7783070 - ROD SPNL PREBNT 5.5MM 70MM SPHERX PPS XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783075 SUP HCPCS C1713 7783075 - ROD SPNL PREBNT 5.5MM 75MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783080 SUP HCPCS C1713 7783080 - ROD SPNL PREBNT 5.5MM 90MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783085 SUP HCPCS C1713 7783085 - ROD SPNL PREBNT 5.5MM 85MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783090 SUP HCPCS C1713 7783090 - ROD SPNL PREBNT 5.5MM 90MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783095 SUP HCPCS C1713 7783095 - ROD SPNL PREBNT 5.5MM 95MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783100 SUP HCPCS C1713 7783100 - ROD SPNL PREBNT 5.5MM 100MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783110 SUP HCPCS C1713 7783110 - ROD SPNL PREBNT 5.5MM 110MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783120 SUP HCPCS C1713 7783120 - ROD SPNL PREBNT 5.5MM 120MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783150 SUP HCPCS C1713 7783150 - ROD SPNL PREBNT 5.5MM 150MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783300 SUP HCPCS C1713 7783300 - ROD SPNL PREBNT 5.5MM 300MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7783500 SUP HCPCS C1713 7783500 - ROD SPNL PREBNT 5.5MM 500MM SPHERX XTN BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 7800015 SUP HCPCS C1713 7800015 - PIN FX HLX TEMP SLFCNTR TACK SPNE BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $240.75 $240.75 $0.00 $0.00 $0.00 $111.51 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $316.45 $316.45 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $83.73 $0.00 $0.00 $85.17 $0.00 $0.00 $0.00 $0.00 $0.00 7800120 SUP HCPCS C1713 7800120 - PLATE BONE 20MM LEVEL 1 HELIX T STAINLESS STEEL SPN CERV BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7800122 SUP HCPCS C1713 7800122 - PLATE BONE 22MM LEVEL 1 HELIX T STAINLESS STEEL SPN CERV BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7800124 SUP HCPCS C1713 7800124 - PLATE BN 24MM NS HLX R 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7800126 SUP HCPCS C1713 7800126 - PLATE BN 26MM NS HLX R 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7800128 SUP HCPCS C1713 7800128 - PLATE BN 28MM NS HLX R 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7800130 SUP HCPCS C1713 7800130 - PLATE BN 30MM NS HLX R 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7800132 SUP HCPCS C1713 7800132 - PLATE BN 32MM NS HLX R 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7800134 SUP HCPCS C1713 7800134 - PLATE BN 34MM NS HLX R 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7800232 SUP HCPCS C1713 7800232 - PLATE BN 32MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800234 SUP HCPCS C1713 7800234 - PLATE BN 34MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800236 SUP HCPCS C1713 7800236 - PLATE BN 36MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800238 SUP HCPCS C1713 7800238 - PLATE BONE 38MM LEVEL 2 HELIX-REVOLUTION SPN CERV ANTERIOR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800240 SUP HCPCS C1713 7800240 - PLATE BONE 40MM LEVEL 1 HELIX-REVOLUTION SPN CERV ANTERIOR BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800242 SUP HCPCS C1713 7800242 - PLATE BN 42MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800244 SUP HCPCS C1713 7800244 - PLATE BN 44MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800246 SUP HCPCS C1713 7800246 - PLATE BN 46MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800248 SUP HCPCS C1713 7800248 - PLATE BN 48MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800250 SUP HCPCS C1713 7800250 - PLATE BN 50MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800252 SUP HCPCS C1713 7800252 - PLATE BN 52MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800254 SUP HCPCS C1713 7800254 - PLATE BN 54MM NS HLX R 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 7800350 SUP HCPCS C1713 7800350 - PLATE BN 50MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800352 SUP HCPCS C1713 7800352 - PLATE BN 52MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800354 SUP HCPCS C1713 7800354 - PLATE BN 54MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800356 SUP HCPCS C1713 7800356 - PLATE BN 56MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800358 SUP HCPCS C1713 7800358 - PLATE BN 58MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800360 SUP HCPCS C1713 7800360 - PLATE BN 60MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800362 SUP HCPCS C1713 7800362 - PLATE BN 62MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800364 SUP HCPCS C1713 7800364 - PLATE BN 64MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800366 SUP HCPCS C1713 7800366 - PLATE BN 66MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800368 SUP HCPCS C1713 7800368 - PLATE BN 68MM NS HLX R 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 7800466 SUP HCPCS C1713 7800466 - PLATE BN 66MM NS HLX R 4 LVL SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800468 SUP HCPCS C1713 7800468 - PLATE BN 68MM NS HLX R 4 LVL SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800470 SUP HCPCS C1713 7800470 - PLATE BN 70MM NS HLX R 4 LVL SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800474 SUP HCPCS C1713 7800474 - PLATE BN 74MM NS HLX R 4 LVL SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800478 SUP HCPCS C1713 7800478 - PLATE BN 78MM NS HLX R 4 LVL SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800482 SUP HCPCS C1713 7800482 - PLATE BN 82MM NS HLX R 4 LVL SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800486 SUP HCPCS C1713 7800486 - PLATE BN 86MM NS HLX R 4 LVL SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800490 SUP HCPCS C1713 7800490 - PLATE BN 90MM NS HLX R 4 LVL SPNE BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800500 SUP HCPCS C1713 7800500 - PLATE BN 100MM HLX-REV LVL 5 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800505 SUP HCPCS C1713 7800505 - PLATE BN 105MM HLX-REV LVL 5 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800510 SUP HCPCS C1713 7800510 - PLATE BN 110MM HLX-REV LVL 5 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800590 SUP HCPCS C1713 7800590 - PLATE BN 90MM HLX-REV LVL 5 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7800595 SUP HCPCS C1713 7800595 - PLATE BN 95MM HLX-REV LVL 5 SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 7801111 SUP HCPCS C1713 7801111 - SCREW BN 4MM 11MM NS HLX R SLF DRL VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7801113 SUP HCPCS C1713 7801113 - SCREW BONE 13MM VAR ANG SELF DRILL HELIX-REVOLUTION ACP 4MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7801115 SUP HCPCS C1713 7801115 - SCREW BONE 15MM VAR ANG SELF DRILL HELIX-REVOLUTION ACP 4MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7801117 SUP HCPCS C1713 7801117 - SCREW BN 4MM 17MM HLX REV ACP SLF DRL VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7802211 SUP HCPCS C1713 7802211 - SCREW BN 4MM 11MM NS HLX R SLF DRL FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7802213 SUP HCPCS C1713 7802213 - SCREW BONE 13MM FIX ANGLE SELF DRILL HELIX-REVOLUTION ACP 4 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7802215 SUP HCPCS C1713 7802215 - SCREW BONE 15MM FIX ANGLE SELF DRILL HELIX-REVOLUTION ACP 4 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7803111 SUP HCPCS C1713 7803111 - SCREW BN 4MM 11MM NS HLX R ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7803113 SUP HCPCS C1713 7803113 - SCREW BONE 13MM VAR ANG SELF TAP HELIX-REVOLUTION ACP 4MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7803115 SUP HCPCS C1713 7803115 - SCREW BONE 15MM VAR ANG SELF TAP HELIX-REVOLUTION ACP 4MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7803117 SUP HCPCS C1713 7803117 - SCREW BN 4MM 17MM NS HLX R ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7803119 SUP HCPCS C1713 7803119 - SCREW BN 4MM 19MM NS HLX R ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7804211 SUP HCPCS C1713 7804211 - SCREW BN 4MM 11MM NS HLX R ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7804213 SUP HCPCS C1713 7804213 - SCREW BONE 13MM FIX ANGLE SELF TAP HELIX-REVOLUTION ACP 4MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7804215 SUP HCPCS C1713 7804215 - SCREW BN 4MM 15MM NS HLX R ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7804217 SUP HCPCS C1713 7804217 - SCREW BN 4MM 17MM NS HLX R ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7804219 SUP HCPCS C1713 7804219 - SCREW BN 4MM 19MM NS HLX R ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7805111 SUP HCPCS C1713 7805111 - SCREW BN 4.5MM 11MM NS HLX R ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7805113 SUP HCPCS C1713 7805113 - SCREW BN 4.5MM 13MM NS HLX R ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7805114 SUP HCPCS C1713 7805114 - SCREW BN 4.5MM 14MM VAR ST SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7805115 SUP HCPCS C1713 7805115 - SCREW BN 4.5MM 15MM NS HLX R ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7805117 SUP HCPCS C1713 7805117 - SCREW BN 4.5MM 17MM NS HLX R ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7805119 SUP HCPCS C1713 7805119 - SCREW BN 4.5MM 19MM NS HLX R ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7806211 SUP HCPCS C1713 7806211 - SCREW BN 4.5MM 11MM NS HLX R ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7806213 SUP HCPCS C1713 7806213 - SCREW BN 4.5MM 13MM NS HLX R ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7806215 SUP HCPCS C1713 7806215 - SCREW BONE 15MM FIX ANGLE SELF TAP HELIX-REVOLUTION ACP 4.5 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7806217 SUP HCPCS C1713 7806217 - SCREW BN 4.5MM 17MM NS HLX R ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7806219 SUP HCPCS C1713 7806219 - SCREW BN 4.5MM 19MM NS HLX R ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 7807110 SUP Custom 27203010 7807110 - PIN FIX TEMPORARY HELIX BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $0.00 $0.00 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7812025 SUP Custom 27203010 7812025 - BIT DRILL 10MM BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $0.00 $0.00 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7820015 SUP HCPCS C1713 7820015 - PLATE BONE 15MM FIX TRAVERSE SPN BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820020 SUP HCPCS C1713 7820020 - PLATE BN 20MM FX TRAVERSE SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820025 SUP HCPCS C1713 7820025 - PLATE BN 25MM FX TRAVERSE SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820030 SUP HCPCS C1713 7820030 - PLATE BONE 30MM FIX TRAVERSE SPN BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820040 SUP HCPCS C1713 7820040 - PLATE BONE 40MM FIX TRAVERSE SPN BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820045 SUP HCPCS C1713 7820045 - PLATE BN 45MM NS TRAVERSE FX SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820050 SUP HCPCS C1713 7820050 - PLATE BN 50MM NS TRAVERSE FX SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820055 SUP HCPCS C1713 7820055 - PLATE BN 55MM NS TRAVERSE FX SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820060 SUP HCPCS C1713 7820060 - PLATE BN 60MM NS TRAVERSE FX SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820065 SUP HCPCS C1713 7820065 - PLATE BN 65MM NS TRAVERSE FX SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820070 SUP HCPCS C1713 7820070 - PLATE BN 70MM NS TRAVERSE FX SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820080 SUP HCPCS C1713 7820080 - PLATE BN 80MM NS TRAVERSE FX SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7820090 SUP HCPCS C1713 7820090 - PLATE BN 90MM NS TRAVERSE FX SPNE BOTH IP/OP "$10,232.50 " "$7,572.05" $0.00 "$8,186.00" "$4,604.63" "$4,604.63" $0.00 $0.00 $0.00 "$2,132.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,132.45" $0.00 "$5,044.62" "$5,044.62" $0.00 "$5,116.25" "$8,104.14" "$8,186.00" $0.00 $0.00 "$1,601.39" $0.00 $0.00 "$1,629.01" $0.00 $0.00 $0.00 $0.00 $0.00 7821045 SUP HCPCS C1713 7821045 - PLATE BN 45MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821050 SUP HCPCS C1713 7821050 - PLATE BN 50MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821055 SUP HCPCS C1713 7821055 - PLATE BN 55MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821060 SUP HCPCS C1713 7821060 - PLATE BN 60MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821065 SUP HCPCS C1713 7821065 - PLATE BN 65MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821070 SUP HCPCS C1713 7821070 - PLATE BN 70MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821075 SUP HCPCS C1713 7821075 - PLATE BN 75MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821080 SUP HCPCS C1713 7821080 - PLATE BN 80MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821085 SUP HCPCS C1713 7821085 - PLATE BN 85MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821095 SUP HCPCS C1713 7821095 - PLATE BN 95MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7821105 SUP HCPCS C1713 7821105 - PLATE BN 105MM NS TRAVERSE CMPR SPNE BOTH IP/OP "$11,560.00 " "$8,554.40" $0.00 "$9,248.00" "$5,202.00" "$5,202.00" $0.00 $0.00 $0.00 "$2,409.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,409.10" $0.00 "$5,699.08" "$5,699.08" $0.00 "$5,780.00" "$9,155.52" "$9,248.00" $0.00 $0.00 "$1,809.14" $0.00 $0.00 "$1,840.35" $0.00 $0.00 $0.00 $0.00 $0.00 7822035 SUP HCPCS C1713 7822035 - PLATE BN 35MM NS TRAVERSE 2 BOLT SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822040 SUP HCPCS C1713 7822040 - PLATE BN 40MM NS TRAVERSE 2 BOLT SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822045 SUP HCPCS C1713 7822045 - PLATE BN 45MM NS TRAVERSE 2 BOLT SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822050 SUP HCPCS C1713 7822050 - PLATE BN 50MM NS TRAVERSE 2 BOLT SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822055 SUP HCPCS C1713 7822055 - PLATE BN 55MM NS TRAVERSE 2 BOLT SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822060 SUP HCPCS C1713 7822060 - PLATE BONE 60MM 2 BOLT TRAVERSE SPN BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822065 SUP HCPCS C1713 7822065 - PLATE BONE 65MM 2 BOLT TRAVERSE SPN BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822070 SUP HCPCS C1713 7822070 - PLATE BN 70MM 2 BOLT TRAVERSE SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822075 SUP HCPCS C1713 7822075 - PLATE BN 75MM 2 BOLT TRAVERSE SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822080 SUP HCPCS C1713 7822080 - PLATE BN 80MM 2 BOLT TRAVERSE SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822085 SUP HCPCS C1713 7822085 - PLATE BN 85MM 2 BOLT TRAVERSE SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822095 SUP HCPCS C1713 7822095 - PLATE BN 95MM 2 BOLT TRAVERSE SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7822105 SUP HCPCS C1713 7822105 - PLATE BN 105MM 2 BOLT TRAVERSE SPNE BOTH IP/OP "$9,747.50 " "$7,213.15" $0.00 "$7,798.00" "$4,386.38" "$4,386.38" $0.00 $0.00 $0.00 "$2,031.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.38" $0.00 "$4,805.52" "$4,805.52" $0.00 "$4,873.75" "$7,720.02" "$7,798.00" $0.00 $0.00 "$1,525.48" $0.00 $0.00 "$1,551.80" $0.00 $0.00 $0.00 $0.00 $0.00 7830002 SUP HCPCS C1713 7830002 - SCREW BONE NUT LOCKING TITANIUM SPN BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 7835525 SUP HCPCS C1713 7835525 - SCREW BONE 5.5MM 25MM ASMBLY TRAVERSE SPN BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7835530 SUP HCPCS C1713 7835530 - SCREW BONE 5.5MM 30MM TRAVERSE SPN BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7835535 SUP HCPCS C1713 7835535 - SCREW BONE 35MM TRAVERSE 5.5MM SPN BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7835540 SUP HCPCS C1713 7835540 - SCREW BN 5.5MM 40MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7835545 SUP HCPCS C1713 7835545 - SCREW BN 5.5MM 45MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7835550 SUP HCPCS C1713 7835550 - SCREW BONE 5.5MM 50MM TRAVERSE SPN BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7835555 SUP HCPCS C1713 7835555 - SCREW BN 5.5MM 55MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7835560 SUP HCPCS C1713 7835560 - SCREW BN 5.5MM 60MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7835565 SUP HCPCS C1713 7835565 - SCREW BN 5.5MM 65MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846525 SUP HCPCS C1713 7846525 - SCREW BN 6.5MM 25MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846530 SUP HCPCS C1713 7846530 - SCREW BONE 6.5MM 30MM TRAVERSE SPN BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846535 SUP HCPCS C1713 7846535 - SCREW BN 6.5MM 35MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846540 SUP HCPCS C1713 7846540 - SCREW BN 6.5MM 40MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846545 SUP HCPCS C1713 7846545 - TRAVERSE 6.5X 45MM VARIABLE SCREW BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846550 SUP HCPCS C1713 7846550 - TRAVERSE 6.5X 50MM VARIABLE SCREW BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846555 SUP HCPCS C1713 7846555 - SCREW BN 6.5MM 55MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846560 SUP HCPCS C1713 7846560 - SCREW BN 6.5MM 60MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7846565 SUP HCPCS C1713 7846565 - SCREW BN 6.5MM 65MM NS TRAVERSE SPNE BOTH IP/OP "$1,007.50 " $745.55 $0.00 $806.00 $453.38 $453.38 $0.00 $0.00 $0.00 $209.99 $747.77 $747.77 $0.00 $0.00 $209.96 $0.00 $595.94 $595.94 $0.00 $503.75 $797.94 $806.00 $0.00 $0.00 $157.67 $0.00 $0.00 $160.39 $0.00 $0.00 $0.00 $0.00 $0.00 7856525 SUP HCPCS C1713 7856525 - BOLT SPNL 6.5MM 25MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7856530 SUP HCPCS C1713 7856530 - BOLT SPINAL 6.5MM 30MM BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7856535 SUP HCPCS C1713 7856535 - BOLT SPINAL 6.5MM 35MM BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7856540 SUP HCPCS C1713 7856540 - BOLT SPNL 6.5MM 40MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7856545 SUP HCPCS C1713 7856545 - BOLT SPINAL 6.5MM 45MM TITANIUM BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7856550 SUP HCPCS C1713 7856550 - BOLT SPINAL 6.5MM 50MM BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7856555 SUP HCPCS C1713 7856555 - BOLT SPNL 6.5MM 55MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7856560 SUP HCPCS C1713 7856560 - BOLT SPNL 6.5MM 60MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7856565 SUP HCPCS C1713 7856565 - BOLT SPNL 6.5MM 65MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7860845 SUP HCPCS C1713 7860845 - CAGE SPNL 45X18X8MM CRNT XLIF BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7860850 SUP HCPCS C1713 7860850 - CAGE SPNL XL 50X18X8MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7860855 SUP HCPCS C1713 7860855 - CAGE SPNL XL 55X18X8MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7860860 SUP HCPCS C1713 7860860 - CAGE SPNL 10D LRDTC 60X18X8MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861045 SUP HCPCS C1713 7861045 - SPACER SPNL 45X18X10MM CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861050 SUP HCPCS C1713 7861050 - CAGE SPNL XL 50X18X10MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861055 SUP HCPCS C1713 7861055 - CAGE SPNL XL 55X18X10MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861060 SUP HCPCS C1713 7861060 - CAGE SPNL STD XL 60X10MM PLT FSN PEEK BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861245 SUP HCPCS C1713 7861245 - SPACER SPNL XL 45X18X12MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861250 SUP HCPCS C1713 7861250 - CAGE SPNL XL 50X12X12MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861255 SUP HCPCS C1713 7861255 - CAGE SPNL XL 55X12X12MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861260 SUP HCPCS C1713 7861260 - SPACER SPNL XL 60X18X12MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861445 SUP HCPCS C1713 7861445 - SPACER SPNL XL 45X18X14MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861450 SUP HCPCS C1713 7861450 - SPACER SPNL XL 50X18X14MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861455 SUP HCPCS C1713 7861455 - IMPLANT SPNL 55X18X14MM XLIF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861460 SUP HCPCS C1713 7861460 - SPACER SPNL XL 60X18X14MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861645 SUP HCPCS C1713 7861645 - SPACER SPNL XL 45X18X16MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861650 SUP HCPCS C1713 7861650 - SPACER SPNL XL 50X18X16MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861655 SUP HCPCS C1713 7861655 - SPACER SPNL XL 55X18X16MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861660 SUP HCPCS C1713 7861660 - SPACER SPNL XL 60X18X16MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861845 SUP HCPCS C1713 7861845 - CAGE SPNL XL 45X18X18MM NS LF CRNT PEEK-OPTM 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861850 SUP HCPCS C1713 7861850 - CAGE SPNL 10D LRDTC 50X18X10MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861855 SUP HCPCS C1713 7861855 - SPACER SPNL XL 55X18X18MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7861860 SUP HCPCS C1713 7861860 - CAGE SPNL 10D LRDTC 60X18X8MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7867525 SUP HCPCS C1713 7867525 - BOLT SPNL 7.5MM 25MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7867530 SUP HCPCS C1713 7867530 - BOLT SPNL 7.5MM 30MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7867535 SUP HCPCS C1713 7867535 - BOLT SPNL 7.5MM 35MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7867540 SUP HCPCS C1713 7867540 - BOLT SPNL 7.5MM 40MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7867545 SUP HCPCS C1713 7867545 - BOLT SPNL 7.5MM 45MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7867550 SUP HCPCS C1713 7867550 - BOLT SPNL 7.5MM 50MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7867555 SUP HCPCS C1713 7867555 - BOLT SPNL 7.5MM 55MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7867560 SUP HCPCS C1713 7867560 - BOLT SPNL 7.5MM 60MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7867565 SUP HCPCS C1713 7867565 - BOLT SPNL 7.5MM 65MM NS TRAVERSE PLT BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 7870845 SUP HCPCS C1713 7870845 - SPACER SPNL 10D XL 45X18X8MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7870850 SUP HCPCS C1713 7870850 - CAGE SPNL 10D XL 50X18X8MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7870855 SUP HCPCS C1713 7870855 - CAGE SPNL 10D XL 55X18X8MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7870860 SUP HCPCS C1713 7870860 - CAGE SPNL 10D LRDTC 60X18X8MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871055 SUP HCPCS C1713 7871055 - CAGE SPNL 10D XL 55X18X10MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871060 SUP HCPCS C1713 7871060 - CAGE SPNL 10D LRDTC 60X18X10MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871245 SUP HCPCS C1713 7871245 - SPACER SPNL XL 45X18X12MM CRNT FSN BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871250 SUP HCPCS C1713 7871250 - CAGE SPNL 10D XL 50X18X10MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871255 SUP HCPCS C1713 7871255 - CAGE SPNL 10D XL 55X18X12MM NS LF CRNT BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871260 SUP HCPCS C1713 7871260 - CAGE SPNL 10D LRDTC 60X18X12MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871445 SUP HCPCS C1713 7871445 - SPACER SPNL 10D XL 45X18X14MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871450 SUP HCPCS C1713 7871450 - SPACER SPNL 10D XL 50X18X14MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871455 SUP HCPCS C1713 7871455 - CAGE SPNL 10D LRDTC 55X18X14MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871460 SUP HCPCS C1713 7871460 - CAGE SPNL 10D LRDTC 60X18X14MM CRNT XLIF PEEK-OPTM BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871645 SUP HCPCS C1713 7871645 - SPACER SPNL 10D XL 45X18X16MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871650 SUP HCPCS C1713 7871650 - SPACER SPNL 10D XL 50X18X16MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871655 SUP HCPCS C1713 7871655 - SPACER SPNL 10D XL 55X18X16MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871660 SUP HCPCS C1713 7871660 - SPACER SPNL 10D XL 60X18X16MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871845 SUP HCPCS C1713 7871845 - SPACER SPNL 10D XL 45X18X18MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871850 SUP HCPCS C1713 7871850 - SPACER SPNL 10D XL 50X18X18MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871855 SUP HCPCS C1713 7871855 - SPACER SPNL 10D XL 55X18X18MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7871860 SUP HCPCS C1713 7871860 - SPACER SPNL 10D XL 60X18X18MM CRNT 1ST LAT APRCH BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 7875520 SUP HCPCS C1713 7875520 - SCREW BN 5.5MM 20MM HALO SPNE BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7875522 SUP HCPCS C1713 7875522 - SCREW BN 5.5MM 22MM HALO SPNE BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7875524 SUP HCPCS C1713 7875524 - SCREW BN 5.5MM 24MM HALO SPNE BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7875526 SUP HCPCS C1713 7875526 - SCREW BN 5.5MM 26MM HALO SPNE BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7875528 SUP HCPCS C1713 7875528 - SCREW BN 5.5MM 28MM HALO SPNE BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7875530 SUP HCPCS C1713 7875530 - SCREW BN 5.5MM 30MM HALO SPNE LMBR ANT BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7875532 SUP HCPCS C1713 7875532 - SCREW BN 5.5MM 32MM HALO SPNE LMBR ANT BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7875534 SUP HCPCS C1713 7875534 - SCREW BN 5.5MM 34MM HALO SPNE LMBR ANT BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7876520 SUP HCPCS C1713 7876520 - SCREW BN 6.5MM 20MM HALO SPNE LMBR ANT BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7876522 SUP HCPCS C1713 7876522 - SCREW BN 6.5MM 22MM HALO SPNE BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7876526 SUP HCPCS C1713 7876526 - SCREW BN 6.5MM 26MM HALO ANT LMBR SPNE PLT BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7876528 SUP HCPCS C1713 7876528 - SCREW BN 6.5MM 28MM HALO PLT ANT LMBR SPNE BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7876530 SUP HCPCS C1713 7876530 - SCREW BN 6.5MM 30MM HALO SPNE LMBR ANT BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7876532 SUP HCPCS C1713 7876532 - SCREW BN 6.5MM 32MM HALO SPNE LMBR ANT BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7876534 SUP HCPCS C1713 7876534 - SCREW BN 6.5MM 34MM HALO SPNE LMBR ANT BOTH IP/OP "$1,057.50 " $782.55 $0.00 $846.00 $475.88 $475.88 $0.00 $0.00 $0.00 $220.41 $784.88 $784.88 $0.00 $0.00 $220.38 $0.00 $625.51 $625.51 $0.00 $528.75 $837.54 $846.00 $0.00 $0.00 $165.50 $0.00 $0.00 $168.35 $0.00 $0.00 $0.00 $0.00 $0.00 7890030 SUP HCPCS C1713 7890030 - PIN SKL HALO SLV ANT LMBR SPNE BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 7891032 SUP HCPCS C1713 7891032 - PLATE BN 32MM HALO TI SPNE LMBR ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7891034 SUP HCPCS C1713 7891034 - PLATE BN 34MM HALO TI SPNE LMBR ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7891036 SUP HCPCS C1713 7891036 - PLATE BN 36MM HALO TI SPNE LMBR ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7891038 SUP HCPCS C1713 7891038 - PLATE BN 38MM HALO TI SPNE LMBR ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7891040 SUP HCPCS C1713 7891040 - PLATE BN 40MM HALO TI SPNE LMBR ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7891042 SUP HCPCS C1713 7891042 - PLATE BN 42MM HALO TI SPNE LMBR ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7891044 SUP HCPCS C1713 7891044 - PLATE BN 44MM HALO TI SPNE LMBR ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7891046 SUP HCPCS C1713 7891046 - PLATE BN 46MM HALO TI SPNE LMBR ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7892032 SUP HCPCS C1713 7892032 - PLATE BN 32MM HALO TI SPNE SCRM ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7892034 SUP HCPCS C1713 7892034 - PLATE BN 34MM HALO TI SPNE SCRM ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7892038 SUP HCPCS C1713 7892038 - PLATE BN 38MM HALO TI SPNE SCRM ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7892042 SUP HCPCS C1713 7892042 - PLATE BN 42MM HALO TI SPNE SCRM ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7892044 SUP HCPCS C1713 7892044 - PLATE BN 44MM HALO TI SPNE SCRM ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7892046 SUP HCPCS C1713 7892046 - PLATE BN 46MM HALO TI SPNE SCRM ANT BOTH IP/OP "$8,407.50 " "$6,221.55" $0.00 "$6,726.00" "$3,783.38" "$3,783.38" $0.00 $0.00 $0.00 "$1,752.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,752.12" $0.00 "$4,144.90" "$4,144.90" $0.00 "$4,203.75" "$6,658.74" "$6,726.00" $0.00 $0.00 "$1,315.77" $0.00 $0.00 "$1,338.47" $0.00 $0.00 $0.00 $0.00 $0.00 7892525 SUP HCPCS C1713 7892525 - SCREW 7892525 HA COATED NONCAN 5.5 X 25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892530 SUP HCPCS C1713 7892530 - SCREW 7892530 HA COATED NONCAN 5.5 X 30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892535 SUP HCPCS C1713 7892535 - SCREW 7892535 HA COATED NONCAN 5.5 X 35 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892540 SUP HCPCS C1713 7892540 - SCREW 7892540 HA COATED NONCAN 5.5 X 40 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892545 SUP HCPCS C1713 7892545 - SCREW 7892545 HA COATED NONCAN 5.5 X 45 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892550 SUP HCPCS C1713 7892550 - SCREW 7892550 HA COATED NONCAN 5.5 X 50 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892555 SUP HCPCS C1713 7892555 - SCREW 7892555 HA COATED NONCAN 5.5 X 55 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892560 SUP HCPCS C1713 7892560 - SCREW 7892560 HA COATED NONCANN 5.5X60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892625 SUP HCPCS C1713 7892625 - SCREW 7892625 HA COATED NONCAN 6.5 X 25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892630 SUP HCPCS C1713 7892630 - SCREW 7892630 HA COATED NONCAN 6.5 X 30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892635 SUP HCPCS C1713 7892635 - SCREW 7892635 HA COATED NONCAN 6.5 X 35 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892640 SUP HCPCS C1713 7892640 - SCREW 7892640 HA COATED NONCAN 6.5 X 40 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892645 SUP HCPCS C1713 7892645 - SCREW 7892645 HA COATED NONCAN 6.5 X 45 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892650 SUP HCPCS C1713 7892650 - SCREW 7892650 HA COATED NONCAN 6.5 X 50 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892655 SUP HCPCS C1713 7892655 - SCREW 7892655 HA COATED NONCAN 6.5 X 55 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892660 SUP HCPCS C1713 7892660 - SCREW 7892660 HA COATED NONCAN 6.5 X 60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892665 SUP HCPCS C1713 7892665 - SCREW 7892665 HA COATED NONCAN 6.5 X 65 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892725 SUP HCPCS C1713 7892725 - SCREW 7892725 HA COATED NONCAN 7.5 X 25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892730 SUP HCPCS C1713 7892730 - SCREW 7892730 HA COATED NONCAN 7.5 X 30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892735 SUP HCPCS C1713 7892735 - SCREW 7892735 HA COATED NONCAN 7.5 X 35 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892740 SUP HCPCS C1713 7892740 - SCREW BN 7.5MM 40MM STRL CD HZN LGC MA PEEK HA SPNE PDCL 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892745 SUP HCPCS C1713 7892745 - SCREW BN 7.5MM 45MM STRL CD HZN LGC MA PEEK HA SPNE PDCL 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892750 SUP HCPCS C1713 7892750 - SCREW 7892750 HA COATED NONCAN 7.5 X 50 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892755 SUP HCPCS C1713 7892755 - SCREW 7892755 HA COATED NONCAN 7.5 X 55 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892760 SUP HCPCS C1713 7892760 - SCREW 7892760 HA COATED NONCAN 7.5 X 60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892765 SUP HCPCS C1713 7892765 - SCREW 7892765 HA COATED NONCAN 7.5 X 65 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892770 SUP HCPCS C1713 7892770 - SCREW 7892770 HA COATED NONCAN 7.5 X 70 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892825 SUP HCPCS C1713 7892825 - SCREW 7892825 HA COATED NONCAN 8.5 X 25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892830 SUP HCPCS C1713 7892830 - SCREW 7892830 HA COATED NONCAN 8.5 X 30 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892835 SUP HCPCS C1713 7892835 - SCREW 7892835 HA COATED NONCAN 8.5 X 35 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892840 SUP HCPCS C1713 7892840 - SCREW 7892840 HA COATED NONCAN 8.5 X 40 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892845 SUP HCPCS C1713 7892845 - SCREW 7892845 HA COATED NONCAN 8.5 X 45 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892850 SUP HCPCS C1713 7892850 - SCREW 7892850 HA COATED NONCAN 8.5 X 50 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892855 SUP HCPCS C1713 7892855 - SCREW 7892855 HA COATED NONCAN 8.5 X 55 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892860 SUP HCPCS C1713 7892860 - SCREW 7892860 HA COATED NONCAN 8.5 X 60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7892865 SUP HCPCS C1713 7892865 - SCREW 7892865 HA COATED NONCAN 8.5 X 65 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893025 SUP HCPCS C1713 7893025 - ROD 7893025 6.35MM X 25MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893030 SUP HCPCS C1713 7893030 - ROD 7893030 6.35MM X 30MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893035 SUP HCPCS C1713 7893035 - ROD 7893035 6.35MM X 35MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893040 SUP HCPCS C1713 7893040 - ROD 7893040 6.35MM X 40MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893045 SUP HCPCS C1713 7893045 - ROD 7893045 6.35MM X 45MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893050 SUP HCPCS C1713 7893050 - ROD 7893050 6.35MM X 50MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893055 SUP HCPCS C1713 7893055 - ROD 7893055 6.35MM X 55MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893060 SUP HCPCS C1713 7893060 - ROD SPNL 60MM 6.35MM PEEK BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893065 SUP HCPCS C1713 7893065 - ROD 7893065 6.35MM X 65MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893070 SUP HCPCS C1713 7893070 - ROD 7893070 6.35MM X 70MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893075 SUP HCPCS C1713 7893075 - ROD 7893075 6.35MM X 75MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893076 SUP HCPCS C1713 7893076 - PLATE BN 76MM HALO LVL 2 TI SPNE LMBR ANT BOTH IP/OP "$11,927.50 " "$8,826.35" $0.00 "$9,542.00" "$5,367.38" "$5,367.38" $0.00 $0.00 $0.00 "$2,485.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,485.69" $0.00 "$5,880.26" "$5,880.26" $0.00 "$5,963.75" "$9,446.58" "$9,542.00" $0.00 $0.00 "$1,866.65" $0.00 $0.00 "$1,898.86" $0.00 $0.00 $0.00 $0.00 $0.00 7893080 SUP HCPCS C1713 7893080 - PLATE BN 80MM HALO LVL 2 TI SPNE LMBR ANT BOTH IP/OP "$11,927.50 " "$8,826.35" $0.00 "$9,542.00" "$5,367.38" "$5,367.38" $0.00 $0.00 $0.00 "$2,485.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,485.69" $0.00 "$5,880.26" "$5,880.26" $0.00 "$5,963.75" "$9,446.58" "$9,542.00" $0.00 $0.00 "$1,866.65" $0.00 $0.00 "$1,898.86" $0.00 $0.00 $0.00 $0.00 $0.00 7893084 SUP HCPCS C1713 7893084 - PLATE BN 84MM HALO LVL 2 TI SPNE LMBR ANT BOTH IP/OP "$11,927.50 " "$8,826.35" $0.00 "$9,542.00" "$5,367.38" "$5,367.38" $0.00 $0.00 $0.00 "$2,485.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,485.69" $0.00 "$5,880.26" "$5,880.26" $0.00 "$5,963.75" "$9,446.58" "$9,542.00" $0.00 $0.00 "$1,866.65" $0.00 $0.00 "$1,898.86" $0.00 $0.00 $0.00 $0.00 $0.00 7893085 SUP HCPCS C1713 7893085 - ROD 7893085 6.35MM X 85MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893088 SUP HCPCS C1713 7893088 - PLATE BN 88MM HALO LVL 2 TI SPNE LMBR ANT BOTH IP/OP "$11,927.50 " "$8,826.35" $0.00 "$9,542.00" "$5,367.38" "$5,367.38" $0.00 $0.00 $0.00 "$2,485.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,485.69" $0.00 "$5,880.26" "$5,880.26" $0.00 "$5,963.75" "$9,446.58" "$9,542.00" $0.00 $0.00 "$1,866.65" $0.00 $0.00 "$1,898.86" $0.00 $0.00 $0.00 $0.00 $0.00 7893090 SUP HCPCS C1713 7893090 - ROD 7893090 6.35MM X 90MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893092 SUP HCPCS C1713 7893092 - PLATE BN 92MM HALO LVL 2 TI SPNE LMBR ANT BOTH IP/OP "$11,927.50 " "$8,826.35" $0.00 "$9,542.00" "$5,367.38" "$5,367.38" $0.00 $0.00 $0.00 "$2,485.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,485.69" $0.00 "$5,880.26" "$5,880.26" $0.00 "$5,963.75" "$9,446.58" "$9,542.00" $0.00 $0.00 "$1,866.65" $0.00 $0.00 "$1,898.86" $0.00 $0.00 $0.00 $0.00 $0.00 7893095 SUP HCPCS C1713 7893095 - ROD 7893095 6.35MM X 95MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893096 SUP HCPCS C1713 7893096 - PLATE BN 96MM HALO LVL 2 TI SPNE LMBR ANT BOTH IP/OP "$11,927.50 " "$8,826.35" $0.00 "$9,542.00" "$5,367.38" "$5,367.38" $0.00 $0.00 $0.00 "$2,485.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,485.69" $0.00 "$5,880.26" "$5,880.26" $0.00 "$5,963.75" "$9,446.58" "$9,542.00" $0.00 $0.00 "$1,866.65" $0.00 $0.00 "$1,898.86" $0.00 $0.00 $0.00 $0.00 $0.00 7893100 SUP HCPCS C1713 7893100 - PLATE BN 100MM HALO LVL 2 TI SPNE LMBR ANT BOTH IP/OP "$11,927.50 " "$8,826.35" $0.00 "$9,542.00" "$5,367.38" "$5,367.38" $0.00 $0.00 $0.00 "$2,485.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,485.69" $0.00 "$5,880.26" "$5,880.26" $0.00 "$5,963.75" "$9,446.58" "$9,542.00" $0.00 $0.00 "$1,866.65" $0.00 $0.00 "$1,898.86" $0.00 $0.00 $0.00 $0.00 $0.00 7893105 SUP HCPCS C1713 7893105 - ROD 7893105 6.35MM X 105MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893110 SUP HCPCS C1713 7893110 - ROD 7893110 6.35MM X 110MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893115 SUP HCPCS C1713 7893115 - ROD 7893115 6.35MM X 115MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893120 SUP HCPCS C1713 7893120 - ROD 7893120 6.35MM X 120MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893125 SUP HCPCS C1713 7893125 - ROD 7893125 6.35MM X 125MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7893130 SUP HCPCS C1713 7893130 - ROD 7893130 6.35MM X 130MM PEEK ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 7894525 SUP HCPCS C1713 7894525 - SCREW 7894525 CDH PEEK 4.5X25 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7894530 SUP HCPCS C1713 7894530 - SCREW 7894530 CDH PEEK 4.5X30 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7894535 SUP HCPCS C1713 7894535 - SCREW 7894535 CDH PEEK 4.5X35 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7894540 SUP HCPCS C1713 7894540 - SCREW 7894540 CDH PEEK 4.5X40 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7894545 SUP HCPCS C1713 7894545 - SCREW 7894545 CDH PEEK 4.5X45 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7894550 SUP HCPCS C1713 7894550 - SCREW 7894550 CDH PEEK 4.5X50 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7895525 SUP HCPCS C1713 7895525 - SCREW 7895525 CDH PEEK 5.5X25 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7895530 SUP HCPCS C1713 7895530 - SCREW 7895530 CDH PEEK 5.5X30 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7895535 SUP HCPCS C1713 7895535 - SCREW 7895535 CDH PEEK 5.5X35 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7895540 SUP HCPCS C1713 7895540 - SCREW 7895540 CDH PEEK 5.5X40 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7895545 SUP HCPCS C1713 7895545 - SCREW BN 5.5MM 45MM STRL CD HZN LGC MA PEEK SPNE PDCL 5.5MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7895550 SUP HCPCS C1713 7895550 - SCREW 7895550 CDH PEEK 5.5X50 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7895555 SUP HCPCS C1713 7895555 - SCREW 7895555 CDH PEEK 5.5X55 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7895560 SUP HCPCS C1713 7895560 - SCREW 7895560 CDH PEEK 5.5X60 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896525 SUP HCPCS C1713 7896525 - SCREW 7896525 CDH PEEK 6.5X25 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896530 SUP HCPCS C1713 7896530 - SCREW 7896530 CDH PEEK 6.5X30 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896535 SUP HCPCS C1713 7896535 - SCREW BN 6.5MM 35MM STRL CD HZN LGC MA PEEK SPNE PDCL 5.5MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896540 SUP HCPCS C1713 7896540 - SCREW BN 6.5MM 40MM STRL CD HZN LGC MA PEEK SPNE PDCL 5.5MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896545 SUP HCPCS C1713 7896545 - SCREW BN 6.5MM 45MM STRL CD HZN LGC MA PEEK SPNE PDCL 5.5MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896550 SUP HCPCS C1713 7896550 - SCREW BN 6.5MM 50MM STRL CD HZN LGC MA PEEK SPNE PDCL 5.5MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896555 SUP HCPCS C1713 7896555 - SCREW 7896555 CDH PEEK 6.5X55 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896560 SUP HCPCS C1713 7896560 - SCREW 7896560 CDH PEEK 6.5X60 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7896565 SUP HCPCS C1713 7896565 - SCREW 7896565 CDH PEEK 6.5X65 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897530 SUP HCPCS C1713 7897530 - SCREW 7897530 CDH PEEK 7.5X30 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897535 SUP HCPCS C1713 7897535 - SCREW 7897535 CDH PEEK 7.5X35 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897540 SUP HCPCS C1713 7897540 - SCREW BONE 7.5MM 40MM CD HZN LGC PEEK SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897545 SUP HCPCS C1713 7897545 - SCREW 7897545 CDH PEEK 7.5X45 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897550 SUP HCPCS C1713 7897550 - SCREW 7897550 CDH PEEK 7.5X50 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897555 SUP HCPCS C1713 7897555 - SCREW 7897555 CDH PEEK 7.5X55 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897560 SUP HCPCS C1713 7897560 - SCREW 7897560 CDH PEEK 7.5X60 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897565 SUP HCPCS C1713 7897565 - SCREW 7897565 CDH PEEK 7.5X65 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7897570 SUP HCPCS C1713 7897570 - SCREW 7897570 CDH PEEK 7.5X70 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7898530 SUP HCPCS C1713 7898530 - SCREW 7898530 CDH PEEK 8.5X30 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7898535 SUP HCPCS C1713 7898535 - SCREW 7898535 CDH PEEK 8.5X35 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7898540 SUP HCPCS C1713 7898540 - SCREW 7898540 CDH PEEK 8.5X40 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7898545 SUP HCPCS C1713 7898545 - SCREW 7898545 CDH PEEK 8.5X45 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7898550 SUP HCPCS C1713 7898550 - SCREW 7898550 CDH PEEK 8.5X50 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7898555 SUP HCPCS C1713 7898555 - SCREW 7898555 CDH PEEK 8.5X55 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7898560 SUP HCPCS C1713 7898560 - SCREW 7898560 CDH PEEK 8.5X60 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7898565 SUP HCPCS C1713 7898565 - SCREW 7898565 CDH PEEK 8.5X65 NON CANN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905310 SUP HCPCS C1713 7905310 - SCREW BONE 3.5MM 10MM TI SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905312 SUP HCPCS C1713 7905312 - SCREW BONE 3.5MM 12MM VUEPOINT POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905314 SUP HCPCS C1713 7905314 - SCREW BONE 3.5MM 14MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905316 SUP HCPCS C1713 7905316 - SCREW BONE 3.5MM 16MM VUEPOINT POST CERV SPN MULTIAX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905318 SUP HCPCS C1713 7905318 - SCREW BONE 3.5MM 18MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905320 SUP HCPCS C1713 7905320 - SCREW BONE 3.5MM 20MM VUEPOINT POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905322 SUP HCPCS C1713 7905322 - SCREW BONE 3.5MM 22MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905324 SUP HCPCS C1713 7905324 - SCREW BONE 3.5MM 24MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905326 SUP HCPCS C1713 7905326 - SCREW BONE 3.5MM 26MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905328 SUP HCPCS C1713 7905328 - SCREW BONE 3.5MM 28MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905330 SUP HCPCS C1713 7905330 - SCREW BONE 3.5MM 30MM VUEPOINT POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905332 SUP HCPCS C1713 7905332 - SCREW BONE 3.5MM 32MM VUEPOINT POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905334 SUP HCPCS C1713 7905334 - SCREW BONE 34MM 3.5MM VUEPOINT POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905410 SUP HCPCS C1713 7905410 - SCREW BONE 4MM 10MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905412 SUP HCPCS C1713 7905412 - SCREW BONE 4MM 12MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905414 SUP HCPCS C1713 7905414 - SCREW BONE 4MM 14MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905416 SUP HCPCS C1713 7905416 - SCREW BONE 16MM 40MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905418 SUP HCPCS C1713 7905418 - SCREW BONE 4MM 18MM VUEPOINT TI POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905420 SUP HCPCS C1713 7905420 - SCREW BONE 24MM 40MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905422 SUP HCPCS C1713 7905422 - SCREW BONE 4MM 22MM POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905424 SUP HCPCS C1713 7905424 - SCREW BONE 4MM 24MM VUEPOINT POST CERV SPN MULTIAX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905426 SUP HCPCS C1713 7905426 - SCREW BONE 4MM 26MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905428 SUP HCPCS C1713 7905428 - SCREW BONE 4MM 28MM VUEPOINT POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905430 SUP HCPCS C1713 7905430 - SCREW BONE 4MM 30MM VUEPOINT POST CERV SPN MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905432 SUP HCPCS C1713 7905432 - SCREW BONE 4MM 32MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905434 SUP HCPCS C1713 7905434 - SCREW BONE 4MM 34MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905436 SUP HCPCS C1713 7905436 - SCREW BONE 4MM 36MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905438 SUP HCPCS C1713 7905438 - SCREW BONE 4MM 38MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905440 SUP HCPCS C1713 7905440 - SCREW BONE 4MM 40MM VUEPOINT POST CERV SPN MULTIAX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905510 SUP HCPCS C1713 7905510 - SCREW BONE 3.5MM 10MM VUEPOINT POST CERV SPN MULTIAX FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905512 SUP HCPCS C1713 7905512 - SCREW BONE 3.5MM 12MM TI SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905514 SUP HCPCS C1713 7905514 - SCREW BONE 3.5MM 14MM VUEPOINT POST CERV SPN MULTIAX FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905516 SUP HCPCS C1713 7905516 - SCREW BONE 3.5MM 16MM VUEPOINT POST CERV SPN MULTIAX FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905518 SUP HCPCS C1713 7905518 - SCREW BONE 3.5MM 18MM VUEPOINT POST CERV SPN MULTIAX FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905520 SUP HCPCS C1713 7905520 - SCREW BONE 3.5MM 20MM VUEPOINT POST CERV SPN MULTIAX FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905522 SUP HCPCS C1713 7905522 - SCREW BONE 22MM 35MM SPNL FAVORED ANG FULTHRD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905524 SUP HCPCS C1713 7905524 - SCREW BONE 3.5MM 24MM VUEPOINT POST CERV SPN MULTIAX FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905526 SUP HCPCS C1713 7905526 - SCREW BONE 3.5MM 26MM VUEPOINT POST CERV SPN MULTIAX FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905528 SUP HCPCS C1713 7905528 - SCREW BONE 3.5MM 28MM SPNL MULTIAX FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905530 SUP HCPCS C1713 7905530 - SCREW BONE 3.5MM 30MM SPNL MULTIAX FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905532 SUP HCPCS C1713 7905532 - SCREW BONE 3.5MM 32MM SPNL MULTIAX FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905534 SUP HCPCS C1713 7905534 - SCREW BONE 3.5MM 34MM VUEPOINT POST CERV SPN MULTIAX FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905610 SUP HCPCS C1713 7905610 - SCREW BONE 4MM 10MM TULIP SPNL ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905612 SUP HCPCS C1713 7905612 - SCREW BONE 4MM 12MM TI SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905614 SUP HCPCS C1713 7905614 - SCREW BONE 4MM 14MM TULIP SPNL ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905616 SUP HCPCS C1713 7905616 - SCREW BONE 4MM 20MM TULIP SPNL ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905618 SUP HCPCS C1713 7905618 - SCREW BONE 4MM 18MM TULIP SPNL ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905620 SUP HCPCS C1713 7905620 - SCREW BONE 4MM 20MM TULIP SPNL ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905622 SUP HCPCS C1713 7905622 - SCREW BONE 4MM 22MM TULIP SPNL ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905624 SUP HCPCS C1713 7905624 - SCREW BONE 4MM 24MM TULIP SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905626 SUP HCPCS C1713 7905626 - SCREW BONE 4MM 26MM TULIP SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905628 SUP HCPCS C1713 7905628 - SCREW BONE 4MM 28MM TULIP SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905630 SUP HCPCS C1713 7905630 - SCREW BONE 4MM 30MM VUEPOINT TULIP POST CERV SPN FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905632 SUP HCPCS C1713 7905632 - SCREW BONE 4MM 32MM TULIP SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905634 SUP HCPCS C1713 7905634 - SCREW BONE 4MM 34MM TULIP SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905636 SUP HCPCS C1713 7905636 - SCREW BONE 4MM 36MM TULIP SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905638 SUP HCPCS C1713 7905638 - SCREW BONE 4MM 38MM TULIP SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905640 SUP HCPCS C1713 7905640 - SCREW BONE 4MM 40MM TULIP SPNL FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905710 SUP HCPCS C1713 7905710 - SCREW BONE 4.5MM 10MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905712 SUP HCPCS C1713 7905712 - SCREW BONE 4.5MM 12MM VUEPOINT SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905714 SUP HCPCS C1713 7905714 - SCREW BONE 4.5MM 14MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905716 SUP HCPCS C1713 7905716 - SCREW BONE 4.5MM 16MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905718 SUP HCPCS C1713 7905718 - SCREW BONE 4.5MM 18MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905720 SUP HCPCS C1713 7905720 - SCREW BONE 4.5MM 20MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905722 SUP HCPCS C1713 7905722 - SCREW BONE 4.5MM 22MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905724 SUP HCPCS C1713 7905724 - SCREW BONE 4.5MM 24MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905726 SUP HCPCS C1713 7905726 - SCREW BONE 4.5MM 26MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905728 SUP HCPCS C1713 7905728 - SCREW BONE 4.5MM 28MM VUEPOINT POST CERV SPN SYS MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905730 SUP HCPCS C1713 7905730 - SCREW BONE 4.5MM 30MM VUEPOINT POST CERV SPN SYS MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905732 SUP HCPCS C1713 7905732 - SCREW BONE 4.5MM 32MM VUEPOINT POST CERV SPN SYS MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905734 SUP HCPCS C1713 7905734 - SCREW BONE 4.5MM 34MM VUEPOINT POST CERV SPN SYS MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905736 SUP HCPCS C1713 7905736 - SCREW BONE 4.5MM 36MM VUEPOINT POST CERV SPN SYS MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905738 SUP HCPCS C1713 7905738 - SCREW BONE 4.5MM 38MM VUEPOINT POST CERV SPN SYS MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905740 SUP HCPCS C1713 7905740 - SCREW BONE 4.5MM 40MM SPNL MULTIAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905824 SUP HCPCS C1713 7905824 - SCREW BONE 3.5MM 24MM SPNL FAVORED ANG PTTHRD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905826 SUP HCPCS C1713 7905826 - SCREW BONE 3.5MM 26MM SPNL PTTHRD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905828 SUP HCPCS C1713 7905828 - SCREW BONE 3.5MM 28MM VUEPOINT POST CERV SPN SYS FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905830 SUP HCPCS C1713 7905830 - SCREW BONE 3.5MM 30MM VUEPOINT TI POST CERV SPN FAVORED ANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905832 SUP HCPCS C1713 7905832 - SCREW BONE 3.5MM 32MM SPNL FAVORED ANG PTTHRD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905834 SUP HCPCS C1713 7905834 - SCREW BONE 3.5MM 14MM VUEPOINT POST CERV SPN FAVORED ANG SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7905836 SUP HCPCS C1713 7905836 - SCREW BONE 3.5MM 36MM VUEPOINT PTHRD POST CERV SPN FAVORED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906000 SUP HCPCS C1713 7906000 - SCREW SET 3.5MM POST CERV SPN LMNR HOOK TULIP SYS VUEPOINT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 7906005 SUP Custom 27803010 7906005 - HOOK SPNL 5MM LMNR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7906007 SUP Custom 27803010 7906007 - HOOK SPNL 7MM LMNR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7906008 SUP HCPCS C1713 7906008 - SCREW BONE 11MM VUEPOINT POST CERV SPN SYS OFFST CONCTR OPN BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 7906022 SUP HCPCS C1713 7906022 - SCREW BONE 25MM VUEPOINT LG POST CERV SPN SYS OFFST CONCTR BOTH IP/OP "$1,240.00 " $917.60 $0.00 $992.00 $558.00 $558.00 $0.00 $0.00 $0.00 $258.45 $920.33 $920.33 $0.00 $0.00 $258.42 $0.00 $733.46 $733.46 $0.00 $620.00 $982.08 $992.00 $0.00 $0.00 $194.06 $0.00 $0.00 $197.41 $0.00 $0.00 $0.00 $0.00 $0.00 7906025 SUP HCPCS C1713 7906025 - CONCTR ROD ACUTE ANG OFFST BOTH IP/OP "$1,240.00 " $917.60 $0.00 $992.00 $558.00 $558.00 $0.00 $0.00 $0.00 $258.45 $920.33 $920.33 $0.00 $0.00 $258.42 $0.00 $733.46 $733.46 $0.00 $620.00 $982.08 $992.00 $0.00 $0.00 $194.06 $0.00 $0.00 $197.41 $0.00 $0.00 $0.00 $0.00 $0.00 7906035 SUP HCPCS C1713 7906035 - CONCTR ROD 3.5MM INLN BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7906045 SUP HCPCS C1713 7906045 - CONCTR ROD 3.5-4.5MM INLN BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7906055 SUP HCPCS C1713 7906055 - CONCTR ROD 5.5MM 3.5MM INLN BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7906065 SUP HCPCS C1713 7906065 - CONCTR ROD 6.5MM 3.5MM INLN BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7906120 SUP HCPCS C1713 7906120 - CONCTR ROD 120MM 3.5MM VUEPOINT SYS POST CERV SPN BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7906126 SUP HCPCS C1713 7906126 - CONCTR ROD 26MM FIX CX SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906128 SUP HCPCS C1713 7906128 - CONCTR ROD 28MM CX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906130 SUP HCPCS C1713 7906130 - CONCTR ROD 30MM FIX CX SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906132 SUP HCPCS C1713 7906132 - CONCTR ROD 32MM FIX CX TI SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906134 SUP HCPCS C1713 7906134 - CONCTR ROD 34MM CX FIX SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906136 SUP HCPCS C1713 7906136 - CONCTR ROD 36MM CX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906138 SUP HCPCS C1713 7906138 - CONCTR ROD 38MM VUEPOINT FIX CX SYS POST CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906140 SUP HCPCS C1713 7906140 - CONCTR ROD 40MM CX FIX SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906142 SUP HCPCS C1713 7906142 - CONCTR ROD 42MM XLNK SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906144 SUP HCPCS C1713 7906144 - CONCTR ROD 44MM VUEPOINT FIX CX SYS POST CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906146 SUP HCPCS C1713 7906146 - CONCTR ROD 46MM VUEPOINT FIX CX SYS POST CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906148 SUP HCPCS C1713 7906148 - CONCTR ROD 48MM VUEPOINT FIX CX SYS POST CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906150 SUP HCPCS C1713 7906150 - CONCTR ROD 50MM VUEPOINT FIX CX SYS POST CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 7906160 SUP HCPCS C1713 7906160 - CONCTR ROD 60MM 3.5MM VUEPOINT SYS POST CERV SPN BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7906240 SUP HCPCS C1713 7906240 - ROD SPNL 240MM 3.5MM BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 7906300 SUP HCPCS C1713 7906300 - ROD SPNL 45D PCVD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 7906302 SUP Custom 27203010 7906302 - CONCTR CORD EYLT OCCPTL BOTH IP/OP "$1,277.50 " $945.35 $0.00 "$1,022.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $948.16 $948.16 $0.00 $0.00 $266.23 $0.00 $0.00 $0.00 $0.00 $638.75 "$1,011.78" "$1,022.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7906306 SUP HCPCS C1713 7906306 - SCREW BONE 4.5MM 6MM VUEPOINT POST CERV SPN OCCPTL CORT SYS BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906308 SUP HCPCS C1713 7906308 - SCREW BONE 4.5MM 8MM VUEPOINT POST CERV SPN OCCPTL CORT SYS BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906310 SUP HCPCS C1713 7906310 - SCREW BONE 4.5MM 10MM VUEPOINT POST CERV SPN CORT OCCPTL SYS BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906312 SUP HCPCS C1713 7906312 - SCREW BONE 4.5MM 12MM VUEPOINT POST CERV SPN CORT OCCPTL SYS BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906314 SUP HCPCS C1713 7906314 - SCREW BONE 4.5MM 14MM VUEPOINT POST CERV SPN CORT OCCPTL SYS BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906335 SUP HCPCS C1713 7906335 - PLATE 35MM KLD POST CERV SYS VUEPOINT BONE BOTH IP/OP "$6,355.00 " "$4,702.70" $0.00 "$5,084.00" "$2,859.75" "$2,859.75" $0.00 $0.00 $0.00 "$1,324.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,324.38" $0.00 "$3,133.02" "$3,133.02" $0.00 "$3,177.50" "$5,033.16" "$5,084.00" $0.00 $0.00 $994.56 $0.00 $0.00 "$1,011.72" $0.00 $0.00 $0.00 $0.00 $0.00 7906340 SUP HCPCS C1713 7906340 - PLATE 40MM KLD SYS VUEPOINT BONE POST CERV SPN BOTH IP/OP "$6,355.00 " "$4,702.70" $0.00 "$5,084.00" "$2,859.75" "$2,859.75" $0.00 $0.00 $0.00 "$1,324.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,324.38" $0.00 "$3,133.02" "$3,133.02" $0.00 "$3,177.50" "$5,033.16" "$5,084.00" $0.00 $0.00 $994.56 $0.00 $0.00 "$1,011.72" $0.00 $0.00 $0.00 $0.00 $0.00 7906345 SUP HCPCS C1713 7906345 - PLATE 45MM KLD BONE BOTH IP/OP "$6,355.00 " "$4,702.70" $0.00 "$5,084.00" "$2,859.75" "$2,859.75" $0.00 $0.00 $0.00 "$1,324.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,324.38" $0.00 "$3,133.02" "$3,133.02" $0.00 "$3,177.50" "$5,033.16" "$5,084.00" $0.00 $0.00 $994.56 $0.00 $0.00 "$1,011.72" $0.00 $0.00 $0.00 $0.00 $0.00 7906355 SUP HCPCS C1713 7906355 - ROD SPNL 3.5-5.5MM VUEPOINT TRNS BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7906356 SUP HCPCS C1713 7906356 - SCREW BONE 5MM 6MM VUEPOINT POST CERV SPN OCCPTL CORT SYS BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906358 SUP HCPCS C1713 7906358 - SCREW BONE 5MM 8MM VUEPOINT POST CERV SPN OCCPTL CORT SYS BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906360 SUP HCPCS C1713 7906360 - SCREW BONE 5MM 10MM LEFT OCCPTL CORT BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906362 SUP HCPCS C1713 7906362 - SCREW BONE 5MM 12MM VUEPOINT POST CERV SPN CORT OCCPTL SYS BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906364 SUP HCPCS C1713 7906364 - SCREW BONE 5MM 14MM CORT OCCPTL BOTH IP/OP $680.00 $503.20 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 7906435 SUP HCPCS C1713 7906435 - CONCTR ROD 35MM OFFST BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7906445 SUP HCPCS C1713 7906445 - CONCTR ROD 4.5MM 3.5MM OFFST BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7906455 SUP HCPCS C1713 7906455 - CONCTR ROD 5.5MM 3.5MM OFFST BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7906465 SUP HCPCS C1713 7906465 - CONCTR ROD 6.25MM 3.5MM OFFST BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 7907010 SUP Custom 27203010 7907010 - BIT DRILL 2.05MM SYSTEM VUEPOINT POSTERIOR CERV SPN BOTH IP/OP $647.50 $479.15 $0.00 $518.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $480.57 $480.57 $0.00 $0.00 $134.94 $0.00 $0.00 $0.00 $0.00 $323.75 $512.82 $518.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7907012 SUP Custom 27203010 7907012 - BIT DRILL 2.5MM BOTH IP/OP $647.50 $479.15 $0.00 $518.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $480.57 $480.57 $0.00 $0.00 $134.94 $0.00 $0.00 $0.00 $0.00 $323.75 $512.82 $518.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7907220 SUP HCPCS C1713 7907220 - TEMPLATE SZ 120MM ROD BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $61.88 $61.88 $0.00 $0.00 $0.00 $28.66 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $81.33 $81.33 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $21.52 $0.00 $0.00 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 7907240 SUP HCPCS C1713 7907240 - TMPLT ROD 240MM VUEPOINT POST CERV SPN BOTH IP/OP $157.50 $116.55 $0.00 $126.00 $70.88 $70.88 $0.00 $0.00 $0.00 $32.83 $116.90 $116.90 $0.00 $0.00 $32.82 $0.00 $93.16 $93.16 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $24.65 $0.00 $0.00 $25.07 $0.00 $0.00 $0.00 $0.00 $0.00 7908300 SUP HCPCS C1713 7908300 - ROD SPNL VUEPOINT 45D COCR BNT BOTH IP/OP "$1,680.00 " "$1,243.20" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $350.15 "$1,246.90" "$1,246.90" $0.00 $0.00 $350.11 $0.00 $993.72 $993.72 $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $262.92 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 7908355 SUP HCPCS C1713 7908355 - ROD TRANSITION COCR 5.5 MM BOTH IP/OP "$3,150.00 " "$2,331.00" $0.00 "$2,520.00" "$1,417.50" "$1,417.50" $0.00 $0.00 $0.00 $656.54 "$2,337.93" "$2,337.93" $0.00 $0.00 $656.46 $0.00 "$1,552.95" "$1,552.95" $0.00 "$1,575.00" "$2,494.80" "$2,520.00" $0.00 $0.00 $492.98 $0.00 $0.00 $501.48 $0.00 $0.00 $0.00 $0.00 $0.00 7965520 SUP HCPCS C1713 7965520 - SCREW 7965520 5.5MM X 20MM SELF TAP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7965525 SUP HCPCS C1713 7965525 - SCREW 7965525 5.5MM X 25MM SELF TAP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7965530 SUP HCPCS C1713 7965530 - SCREW 7965530 5.5MM X 30MM SELF TAP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7965535 SUP HCPCS C1713 7965535 - SCREW 7965535 5.5MM X 35MM SELF TAP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7966020 SUP HCPCS C1713 7966020 - SCREW 7966020 6.0MM X 20MM SELF TAP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7966025 SUP HCPCS C1713 7966025 - SCREW 7966025 6.0MM X 25MM SELF TAP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7966030 SUP HCPCS C1713 7966030 - SCREW 7966030 6.0MM X 30MM SELF TAP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7966035 SUP HCPCS C1713 7966035 - SCREW 7966035 6.0MM X 35MM SELF TAP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7967210 SUP HCPCS C1713 7967210 - SPACER SPNL 12D SM 32X23X10MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967212 SUP HCPCS C1713 7967212 - SPACER SPNL 12D SM 32X23X12MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967214 SUP HCPCS C1713 7967214 - SPACER SPNL 12D SM 32X23X14MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967216 SUP HCPCS C1713 7967216 - SPACER SPNL 12D SM 32X23X16MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967218 SUP HCPCS C1713 7967218 - SPACER SPNL 12D SM 32X23X18MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967220 SUP HCPCS C1713 7967220 - SPACER SPNL 12D SM 32X23X20MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967810 SUP HCPCS C1713 7967810 - SPACER SPNL 8D SM 32X23X10MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967812 SUP HCPCS C1713 7967812 - SPACER SPNL 8D SM 32X23X12MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967814 SUP HCPCS C1713 7967814 - SPACER SPNL 8D SM 32X23X14MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967816 SUP HCPCS C1713 7967816 - SPACER SPNL 8D SM 32X23X16MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967818 SUP HCPCS C1713 7967818 - SPACER SPNL 8D SM 32X23X18MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7967820 SUP HCPCS C1713 7967820 - SPACER SPNL 8D SM 32X23X20MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968210 SUP HCPCS C1713 7968210 - SPACER SPNL 12D MED 37X27X10MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968212 SUP HCPCS C1713 7968212 - SPACER SPNL 12D MED 37X27X12MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968214 SUP HCPCS C1713 7968214 - SPACER SPNL 12D MED 37X27X14MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968216 SUP HCPCS C1713 7968216 - SPACER SPNL 12D MED 37X27X16MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968218 SUP HCPCS C1713 7968218 - SPACER SPNL 12D MED 37X27X18MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968220 SUP HCPCS C1713 7968220 - SPACER SPNL 12D MED 37X27X20MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968810 SUP HCPCS C1713 7968810 - SPACER SPNL 8D MED 37X27X10MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968812 SUP HCPCS C1713 7968812 - SPACER SPNL 8D MED 37X27X12MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968814 SUP HCPCS C1713 7968814 - SPACER SPNL 8D MED 37X27X14MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968816 SUP HCPCS C1713 7968816 - SPACER SPNL 8D MED 37X27X16MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968818 SUP HCPCS C1713 7968818 - SPACER SPNL 8D MED 37X27X18MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7968820 SUP HCPCS C1713 7968820 - SPACER SPNL 8D MED 37X27X20MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969210 SUP HCPCS C1713 7969210 - SPACER SPNL 12D LG 42X30X10MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969212 SUP HCPCS C1713 7969212 - SPACER SPNL 12D LG 42X30X12MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969214 SUP HCPCS C1713 7969214 - SPACER SPNL 12D LG 42X30X14MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969216 SUP HCPCS C1713 7969216 - SPACER SPNL 12D LG 42X30X16MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969218 SUP HCPCS C1713 7969218 - SPACER SPNL 12D LG 42X30X18MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969220 SUP HCPCS C1713 7969220 - SPACER SPNL 12D LG 42X30X20MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969810 SUP HCPCS C1713 7969810 - SPACER SPNL 8D LG 42X30X10MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969812 SUP HCPCS C1713 7969812 - SPACER SPNL 8D LG 42X30X12MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969814 SUP HCPCS C1713 7969814 - SPACER SPNL 8D LG 42X30X14MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969816 SUP HCPCS C1713 7969816 - SPACER SPNL 8D LG 42X30X16MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969818 SUP HCPCS C1713 7969818 - SPACER SPNL 8D LG 42X30X18MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7969820 SUP HCPCS C1713 7969820 - SPACER SPNL 8D LG 42X30X20MM STRL CRSNT SVRGN CVR PLT PEEK BOTH IP/OP "$14,190.00 " "$10,500.60" $0.00 "$11,352.00" "$6,385.50" "$6,385.50" $0.00 $0.00 $0.00 "$2,957.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.20" $0.00 "$6,995.67" "$6,995.67" $0.00 "$7,095.00" "$11,238.48" "$11,352.00" $0.00 $0.00 "$2,220.74" $0.00 $0.00 "$2,259.05" $0.00 $0.00 $0.00 $0.00 $0.00 7975520 SUP HCPCS C1713 7975520 - SCREW 7975520 SOVEREIGN FA 5.5 X 20MM BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7975525 SUP HCPCS C1713 7975525 - SCREW 7975525 SOVEREIGN FA 5.5 X 25MM BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7975530 SUP HCPCS C1713 7975530 - SCREW 7975530 SOVEREIGN FA 5.5 X 30MM BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7975535 SUP HCPCS C1713 7975535 - SCREW 7975535 SOVEREIGN FA 5.5 X 35MM BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7976020 SUP HCPCS C1713 7976020 - SCREW 7976020 SOVEREIGN FA 6.0 X 20MM BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7976025 SUP HCPCS C1713 7976025 - SCREW 7976025 SOVEREIGN FA 6.0 X 25MM BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7976030 SUP HCPCS C1713 7976030 - SCREW 7976030 SOVEREIGN FA 6.0 X 30MM BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 7976035 SUP HCPCS C1713 7976035 - SCREW 7976035 SOVEREIGN FA 6.0 X 35MM BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 8001501 SUP Custom 27203010 8001501 - TRAY 8001501 CRANI FIX 1.5 MM ST BOTH IP/OP "$4,636.75 " "$3,431.20" $0.00 "$3,709.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,441.40" "$3,441.40" $0.00 $0.00 $966.30 $0.00 $0.00 $0.00 $0.00 "$2,318.38" "$3,672.31" "$3,709.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8001505 SUP HCPCS C1713 8001505 - CADDY 8001505 SCREW CRANI FIX 1.5MM ST BOTH IP/OP "$1,177.25 " $871.17 $0.00 $941.80 $529.76 $529.76 $0.00 $0.00 $0.00 $245.37 $873.75 $873.75 $0.00 $0.00 $245.34 $0.00 $696.34 $696.34 $0.00 $588.63 $932.38 $941.80 $0.00 $0.00 $184.24 $0.00 $0.00 $187.42 $0.00 $0.00 $0.00 $0.00 $0.00 8001601 SUP HCPCS C1713 8001601 - CADDY 8001601 SCREW 1.6 SDS BOTH IP/OP $930.75 $688.76 $0.00 $744.60 $418.84 $418.84 $0.00 $0.00 $0.00 $193.99 $690.80 $690.80 $0.00 $0.00 $193.97 $0.00 $550.54 $550.54 $0.00 $465.38 $737.15 $744.60 $0.00 $0.00 $145.66 $0.00 $0.00 $148.18 $0.00 $0.00 $0.00 $0.00 $0.00 8001602 SUP Custom 27203010 8001602 - TRAY 8001602 CRANI FIX 1.6MM SD BOTH IP/OP "$4,636.75 " "$3,431.20" $0.00 "$3,709.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,441.40" "$3,441.40" $0.00 $0.00 $966.30 $0.00 $0.00 $0.00 $0.00 "$2,318.38" "$3,672.31" "$3,709.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8001605 SUP HCPCS C1713 8001605 - CADDY 8001605 CRANI FIX SCRW 1.6MM SD BOTH IP/OP "$1,247.38 " $923.06 $0.00 $997.90 $561.32 $561.32 $0.00 $0.00 $0.00 $259.98 $925.80 $925.80 $0.00 $0.00 $259.95 $0.00 $737.82 $737.82 $0.00 $623.69 $987.92 $997.90 $0.00 $0.00 $195.21 $0.00 $0.00 $198.58 $0.00 $0.00 $0.00 $0.00 $0.00 8001830 SUP HCPCS C1713 8001830 - SCREW BONE 1.8MM 3MM RSC TI SPNL BOTH IP/OP $119.35 $88.32 $0.00 $95.48 $53.71 $53.71 $0.00 $0.00 $0.00 $24.88 $88.58 $88.58 $0.00 $0.00 $24.87 $0.00 $70.60 $70.60 $0.00 $59.68 $94.53 $95.48 $0.00 $0.00 $18.68 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 8002635 SUP HCPCS C1713 8002635 - SCREW BONE 1.6MM 3.5MM TIMESH TI CRANIAL SLFDRILL STRL BOTH IP/OP $126.08 $93.30 $0.00 $100.87 $56.74 $56.74 $0.00 $0.00 $0.00 $26.28 $93.58 $93.58 $0.00 $0.00 $26.28 $0.00 $74.58 $74.58 $0.00 $63.04 $99.86 $100.87 $0.00 $0.00 $19.73 $0.00 $0.00 $20.07 $0.00 $0.00 $0.00 $0.00 $0.00 8004200 SUP Custom 27203010 8004200 - BPD TRAY BOTH IP/OP $896.75 $663.60 $0.00 $717.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $665.57 $665.57 $0.00 $0.00 $186.88 $0.00 $0.00 $0.00 $0.00 $448.38 $710.23 $717.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8009000 SUP Custom 27803010 8009000 - BASE 8009000 TRAY CRANI FIX 1.5/1.6MM BOTH IP/OP "$1,544.88 " "$1,143.21" $0.00 "$1,235.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,146.61" "$1,146.61" $0.00 $0.00 $321.95 $0.00 $0.00 $0.00 $0.00 $772.44 "$1,223.54" "$1,235.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8009002 SUP HCPCS C1713 8009002 - CADDY 8009002 PLATE CRANI FIX 1.5/1.6MM BOTH IP/OP $773.50 $572.39 $0.00 $618.80 $348.08 $348.08 $0.00 $0.00 $0.00 $161.22 $574.09 $574.09 $0.00 $0.00 $161.20 $0.00 $457.53 $457.53 $0.00 $386.75 $612.61 $618.80 $0.00 $0.00 $121.05 $0.00 $0.00 $123.14 $0.00 $0.00 $0.00 $0.00 $0.00 8009220 SUP Custom 27803010 8009220 - BASE 8009220 TRAY COMBO CRANI FIX SYS BOTH IP/OP $809.63 $599.13 $0.00 $647.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.90 $600.90 $0.00 $0.00 $168.73 $0.00 $0.00 $0.00 $0.00 $404.81 $641.23 $647.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8010050 SUP Custom 27203010 8010050 - ELECTRODE EEG 2 NDL MNTR PK SPNE BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8011830 SUP HCPCS C1713 8011830 - SCREW 8011830 RESCUE SDS 1.8X3MM 1 BOTH IP/OP $140.25 $103.79 $0.00 $112.20 $63.11 $63.11 $0.00 $0.00 $0.00 $29.23 $104.09 $104.09 $0.00 $0.00 $29.23 $0.00 $82.96 $82.96 $0.00 $70.13 $111.08 $112.20 $0.00 $0.00 $21.95 $0.00 $0.00 $22.33 $0.00 $0.00 $0.00 $0.00 $0.00 8011850 SUP HCPCS C1713 8011850 - SCREW 8011850 RESCUE SDS 1.8X5MM 1 BOTH IP/OP $140.25 $103.79 $0.00 $112.20 $63.11 $63.11 $0.00 $0.00 $0.00 $29.23 $104.09 $104.09 $0.00 $0.00 $29.23 $0.00 $82.96 $82.96 $0.00 $70.13 $111.08 $112.20 $0.00 $0.00 $21.95 $0.00 $0.00 $22.33 $0.00 $0.00 $0.00 $0.00 $0.00 8012635 SUP HCPCS C1713 8012635 - SCREW 8012635 CRUCIATE SDS 1.6X3.5MM 1 BOTH IP/OP $142.38 $105.36 $0.00 $113.90 $64.07 $64.07 $0.00 $0.00 $0.00 $29.67 $105.67 $105.67 $0.00 $0.00 $29.67 $0.00 $84.21 $84.21 $0.00 $71.19 $112.76 $113.90 $0.00 $0.00 $22.28 $0.00 $0.00 $22.67 $0.00 $0.00 $0.00 $0.00 $0.00 8012640 SUP HCPCS C1713 8012640 - SCREW 8012640 CRUCIATE SDS 1.6X4MM 1 BOTH IP/OP $142.38 $105.36 $0.00 $113.90 $64.07 $64.07 $0.00 $0.00 $0.00 $29.67 $105.67 $105.67 $0.00 $0.00 $29.67 $0.00 $84.21 $84.21 $0.00 $71.19 $112.76 $113.90 $0.00 $0.00 $22.28 $0.00 $0.00 $22.67 $0.00 $0.00 $0.00 $0.00 $0.00 8020016 SUP Custom 27011340 8020016 - PROBE EMG M5 MOD BOTH IP/OP "$3,377.50 " "$2,499.35" $0.00 "$2,702.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,506.78" "$2,506.78" $0.00 $0.00 $703.87 $0.00 $0.00 $0.00 $0.00 "$1,688.75" "$2,674.98" "$2,702.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8020018 SUP Custom 27203010 8020018 - ELECTRODE EMG SRFC MOD CLIP NVM5 BOTH IP/OP "$3,377.50 " "$2,499.35" $0.00 "$2,702.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,506.78" "$2,506.78" $0.00 $0.00 $703.87 $0.00 $0.00 $0.00 $0.00 "$1,688.75" "$2,674.98" "$2,702.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8020020 SUP Custom 27203010 8020020 - ELECTRODE EMG NRVSN MOD CLIP PRB BOTH IP/OP "$4,140.00 " "$3,063.60" $0.00 "$3,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,072.71" "$3,072.71" $0.00 $0.00 $862.78 $0.00 $0.00 $0.00 $0.00 "$2,070.00" "$3,278.88" "$3,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8020021 SUP Custom 27203010 8020021 - ELECTRODE EMG MOD CLIP SHTH NVM5 BOTH IP/OP "$3,367.50 " "$2,491.95" $0.00 "$2,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,499.36" "$2,499.36" $0.00 $0.00 $701.79 $0.00 $0.00 $0.00 $0.00 "$1,683.75" "$2,667.06" "$2,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8020029 SUP Custom 27203010 8020029 - KIT EMG XLIF NVM5 BOTH IP/OP "$4,442.50 " "$3,287.45" $0.00 "$3,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,297.22" "$3,297.22" $0.00 $0.00 $925.82 $0.00 $0.00 $0.00 $0.00 "$2,221.25" "$3,518.46" "$3,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8020215 SUP Custom 27203010 8020215 - ELTRD EMG NRVSN MOD M5 BOTH IP/OP "$3,572.50 " "$2,643.65" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,651.51" "$2,651.51" $0.00 $0.00 $744.51 $0.00 $0.00 $0.00 $0.00 "$1,786.25" "$2,829.42" "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8050015 SUP Custom 27203010 8050015 - ELECTRODE EMG 15MM NEEDLE MODULE PROBE NEUROVISION M5 BOTH IP/OP "$2,687.50 " "$1,988.75" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,994.66" "$1,994.66" $0.00 $0.00 $560.08 $0.00 $0.00 $0.00 $0.00 "$1,343.75" "$2,128.50" "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8050016 SUP Custom 27203010 8050016 - MODULE EMG NDL PRB M5 BOTH IP/OP "$3,377.50 " "$2,499.35" $0.00 "$2,702.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,506.78" "$2,506.78" $0.00 $0.00 $703.87 $0.00 $0.00 $0.00 $0.00 "$1,688.75" "$2,674.98" "$2,702.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8050018 SUP Custom 27203010 8050018 - MODULE SPNL M5 NDL EMG CLIP BOTH IP/OP "$3,377.50 " "$2,499.35" $0.00 "$2,702.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,506.78" "$2,506.78" $0.00 $0.00 $703.87 $0.00 $0.00 $0.00 $0.00 "$1,688.75" "$2,674.98" "$2,702.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8050020 SUP Custom 27203010 8050020 - ELECTRODE EMG 20MM NRVSN M5 NDL MOD PRB BOTH IP/OP "$4,140.00 " "$3,063.60" $0.00 "$3,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,072.71" "$3,072.71" $0.00 $0.00 $862.78 $0.00 $0.00 $0.00 $0.00 "$2,070.00" "$3,278.88" "$3,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8050021 SUP Custom 27203010 8050021 - MODULE SPNL M5 NDL EMG CLIP SHTH BOTH IP/OP "$3,367.50 " "$2,491.95" $0.00 "$2,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,499.36" "$2,499.36" $0.00 $0.00 $701.79 $0.00 $0.00 $0.00 $0.00 "$1,683.75" "$2,667.06" "$2,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8050029 SUP Custom 27203010 8050029 - MODULE SPNL M5 NDL EMG XLIF KT BOTH IP/OP "$4,442.50 " "$3,287.45" $0.00 "$3,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,297.22" "$3,297.22" $0.00 $0.00 $925.82 $0.00 $0.00 $0.00 $0.00 "$2,221.25" "$3,518.46" "$3,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8050215 SUP Custom 27011340 8050215 - ELECTRODE EMG 15MM NEEDLE MODULE PROBE NEUROVISION M5 BOTH IP/OP "$3,572.50 " "$2,643.65" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,651.51" "$2,651.51" $0.00 $0.00 $744.51 $0.00 $0.00 $0.00 $0.00 "$1,786.25" "$2,829.42" "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8051100 SUP HCPCS C1713 8051100 - SCREW BONE 100MM TULIP TI LOCK CLOSE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8052025 SUP HCPCS C1713 8052025 - ROD SPNL 25MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052030 SUP HCPCS C1713 8052030 - ROD SPNL 30MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052035 SUP HCPCS C1713 8052035 - ROD SPNL 35MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052040 SUP HCPCS C1713 8052040 - ROD SPNL 40MM 5.5MM ARMADA TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052045 SUP HCPCS C1713 8052045 - ROD SPNL 45MM 5.5MM ARMADA TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052050 SUP HCPCS C1713 8052050 - ROD SPNL 50MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052055 SUP HCPCS C1713 8052055 - ROD SPNL 55MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052060 SUP HCPCS C1713 8052060 - ROD SPNL 60MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052065 SUP HCPCS C1713 8052065 - ROD SPNL 65MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052070 SUP HCPCS C1713 8052070 - ROD SPNL 70MM 5.5MM PREBNT ARM15 CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052075 SUP HCPCS C1713 8052075 - ROD SPNL 75MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052080 SUP HCPCS C1713 8052080 - ROD SPNL 80MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052085 SUP HCPCS C1713 8052085 - ROD SPNL 85MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052090 SUP HCPCS C1713 8052090 - ROD SPNL 90MM 5.5MM PREBNT ARM15 CNV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052095 SUP HCPCS C1713 8052095 - ROD SPNL 95MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052100 SUP HCPCS C1713 8052100 - ROD SPNL 100MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052110 SUP HCPCS C1713 8052110 - ROD SPNL 110MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052120 SUP HCPCS C1713 8052120 - ROD SPNL 120MM 5.5MM TI PREBNT ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8052200 SUP HCPCS C1713 8052200 - ROD SPNL PREBNT 5.5MM 200MM ARMADA TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8060040 SUP Custom 27011340 8060040 - PLANER SRG NUVAMAP BOTH IP/OP "$2,990.00 " "$2,212.60" $0.00 "$2,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,219.18" "$2,219.18" $0.00 $0.00 $623.12 $0.00 $0.00 $0.00 $0.00 "$1,495.00" "$2,368.08" "$2,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8100845 SUP HCPCS C1713 8100845 - SCREW 8100845 BREAKOFF SET SCRW 10-32 BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8100855 SUP HCPCS C1713 8100855 - SCREW 8100855 BREAKOFF SET 12 32 BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8103500 SUP HCPCS C1713 "8103500 - SETSCREW, SS, FOR 3.5MM X10" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8103513 SUP HCPCS C1713 8103513 - CROSSLINK 8103513 X10 FOR 3.5ROD L 13 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8103517 SUP HCPCS C1713 8103517 - CROSSLINK 8103517 X10 FOR 3.5ROD L 17 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8103521 SUP HCPCS C1713 8103521 - CROSSLINK 8103521 X10 FOR 3.5ROD L 21 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8103525 SUP HCPCS C1713 8103525 - CROSSLINK 8103525 X10 FOR 3.5ROD L 25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8103529 SUP HCPCS C1713 8103529 - CROSSLINK 8103529 X10 FOR 3.5ROD L 29 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8103533 SUP HCPCS C1713 8103533 - CROSSLINK 8103533 X10 FOR 3.5ROD L 33 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8103537 SUP HCPCS C1713 8103537 - CROSSLINK 8103537 X10 FOR 3.5ROD L 37 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104516 SUP HCPCS C1713 8104516 - CROSSLINK 8104516 16MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104519 SUP HCPCS C1713 8104519 - CROSSLINK 8104519 19MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104522 SUP HCPCS C1713 8104522 - CROSSLINK 8104522 22MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104525 SUP HCPCS C1713 8104525 - CROSSLINK 8104525 25MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104528 SUP HCPCS C1713 8104528 - CROSSLINK 8104528 28MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104531 SUP HCPCS C1713 8104531 - CROSSLINK 8104531 31MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104534 SUP HCPCS C1713 8104534 - CROSSLINK 8104534 34MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104537 SUP HCPCS C1713 8104537 - CROSSLINK 8104537 37MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104540 SUP HCPCS C1713 8104540 - CROSSLINK 8104540 40MM X10 PLATE 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105516 SUP HCPCS C1713 8105516 - CROSSLINK 8105516 16MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105519 SUP HCPCS C1713 8105519 - CROSSLINK 8105519 19MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105522 SUP HCPCS C1713 8105522 - CROSSLINK 8105522 22MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105525 SUP HCPCS C1713 8105525 - CROSSLINK 8105525 25MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105527 SUP HCPCS C1713 8105527 - CROSSLINK 8105527 28MM FXD LP 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105528 SUP HCPCS C1713 8105528 - CROSSLINK 8105528 28TO30MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105530 SUP HCPCS C1713 8105530 - CROSSLINK 8105530 30TO34MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105531 SUP HCPCS C1713 8105531 - CROSSLINK 8105531 31MM FXD LP 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105534 SUP HCPCS C1713 8105534 - CROSSLINK 8105534 34TO36MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105536 SUP HCPCS C1713 8105536 - CROSSLINK 8105536 36TO39MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105539 SUP HCPCS C1713 8105539 - CROSSLINK 8105539 39TO45MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105545 SUP HCPCS C1713 8105545 - CROSSLINK 8105545 45TO58MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8105558 SUP HCPCS C1713 8105558 - CROSSLINK 8105558 58TO80MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106416 SUP HCPCS C1713 8106416 - CROSSLINK 8106416 16MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106419 SUP HCPCS C1713 8106419 - CROSSLINK 8106419 19MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106422 SUP HCPCS C1713 8106422 - CROSSLINK 8106422 22MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106425 SUP HCPCS C1713 8106425 - CROSSLINK 8106425 25MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106427 SUP HCPCS C1713 8106427 - CROSSLINK 8106427 28MM FXD LP 6.35 SS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106428 SUP HCPCS C1713 8106428 - CROSSLINK 8106428 28TO30MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106430 SUP HCPCS C1713 8106430 - CROSSLINK 8106430 30TO34MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106431 SUP HCPCS C1713 8106431 - CROSSLINK 8106431 31MM FXD LP 6.35 SS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106434 SUP HCPCS C1713 8106434 - CROSSLINK 8106434 34TO36MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106436 SUP HCPCS C1713 8106436 - CROSSLINK 8106436 36TO39MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106439 SUP HCPCS C1713 8106439 - CROSSLINK 8106439 39TO45MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106445 SUP HCPCS C1713 8106445 - CROSSLINK 8106445 45TO58MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8106458 SUP HCPCS C1713 8106458 - CROSSLINK 8106458 58TO80MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8110450 SUP HCPCS C1713 8110450 - SCREW 8110450 NA LP CROSSLINK SET TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8110614 SUP HCPCS C1713 8110614 - PLATE 14MM TI FIX CD HZN ANTARES XLNK BONE SPNL BOTH IP/OP "$4,155.00 " "$3,074.70" $0.00 "$3,324.00" "$1,869.75" "$1,869.75" $0.00 $0.00 $0.00 $866.01 "$3,083.84" "$3,083.84" $0.00 $0.00 $865.90 $0.00 "$2,048.42" "$2,048.42" $0.00 "$2,077.50" "$3,290.76" "$3,324.00" $0.00 $0.00 $650.26 $0.00 $0.00 $661.48 $0.00 $0.00 $0.00 $0.00 $0.00 8110713 SUP HCPCS C1713 8110713 - CROSSLINK 8110713 ANTERIOR 13MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8110714 SUP HCPCS C1713 8110714 - CROSSLINK 8110714 ANTERIOR 14MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8110715 SUP HCPCS C1713 8110715 - CROSSLINK 8110715 ANTERIOR 15MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8110716 SUP HCPCS C1713 8110716 - CROSSLINK 8110716 ANTERIOR 16MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8110717 SUP HCPCS C1713 8110717 - CROSSLINK 8110717 ANTERIOR 17MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8110718 SUP HCPCS C1713 8110718 - CROSSLINK 8110718 ANTERIOR 18MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8110719 SUP HCPCS C1713 8110719 - CROSSLINK 8110719 ANTERIOR 19MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8110845 SUP HCPCS C1713 8110845 - SCREW 8110845 BREAKOFF SET SCREW 10-32TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8110855 SUP HCPCS C1713 8110855 - SCREW SET TI 12-32MM 5.5MM SPNL BRKOF X10 XLNK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8113500 SUP HCPCS C1713 "8113500 - SETSCREW, TI, FOR 3.5MM X10" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8113513 SUP HCPCS C1713 8113513 - CROSSLINK 8113513 X10 FOR 3.5ROD L 13 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8113517 SUP HCPCS C1713 8113517 - CROSSLINK 8113517 X10 FOR 3.5ROD L 17 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8113521 SUP HCPCS C1713 8113521 - CROSSLINK 8113521 X10 FOR 3.5ROD L 21 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8113525 SUP HCPCS C1713 8113525 - CROSSLINK 8113525 X10 FOR 3.5ROD L 25 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8113529 SUP HCPCS C1713 8113529 - CROSSLINK 8113529 X10 FOR 3.5ROD L 29 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8113533 SUP HCPCS C1713 8113533 - CROSSLINK 8113533 X10 FOR 3.5ROD L 33 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8113537 SUP HCPCS C1713 8113537 - CROSSLINK 8113537 X10 FOR 3.5ROD L 37 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114516 SUP HCPCS C1713 8114516 - CROSSLINK 8114516 16MM X10 PLATE 4.5 TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114519 SUP HCPCS C1713 8114519 - CROSSLINK 8114519 19MM X10 PLATE 4.5 TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114522 SUP HCPCS C1713 8114522 - CROSSLINK 8114522 22MM X10 PLATE 4.5 TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114525 SUP HCPCS C1713 8114525 - CROSSLINK 8114525 25MM X10 PLT 4.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114528 SUP HCPCS C1713 8114528 - CROSSLINK 8114528 28MM X10 PLATE 4.5 TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114531 SUP HCPCS C1713 8114531 - CROSSLINK 8114531 31MM X10 PLATE 4.5 TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114534 SUP HCPCS C1713 8114534 - CROSSLINK 8114534 34MM X10 PLATE 4.5 TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114537 SUP HCPCS C1713 8114537 - CROSSLINK 8114537 37MM X10 PLATE 4.5 TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114540 SUP HCPCS C1713 8114540 - CROSSLINK 8114540 40MM X10 PLATE 4.5 TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115516 SUP HCPCS C1713 8115516 - PLATE BN 16MM STRL LG X10 XLNK CD HZN LOPRFL FX TI SPNE 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115519 SUP HCPCS C1713 8115519 - PLATE BN 19MM STRL LG X10 XLNK CD HZN LOPRFL FX TI SPNE 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115522 SUP HCPCS C1713 8115522 - CROSSLINK 8115522 22MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115525 SUP HCPCS C1713 8115525 - PLATE BN 25MM STRL LG X10 XLNK CD HZN LOPRFL FX TI SPNE 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115527 SUP HCPCS C1713 8115527 - CROSSLINK 8115527 28MM FXD LP TI 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115528 SUP HCPCS C1713 8115528 - PLATE BN 28-30MM STRL LGC MLSPN X10 XLNK CD HZN LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115530 SUP HCPCS C1713 8115530 - PLATE BN 30-34MM STRL LGC MLSPN X10 XLNK CD HZN LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115531 SUP HCPCS C1713 8115531 - CROSSLINK 8115531 31MM FXD LP TI 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115534 SUP HCPCS C1713 8115534 - PLATE BN 34-36MM STRL LGC MLSPN X10 XLNK CD HZN LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115536 SUP HCPCS C1713 8115536 - PLATE BN 36-39MM STRL LGC MLSPN X10 XLNK CD HZN LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115539 SUP HCPCS C1713 8115539 - PLATE BN 39-45MM STRL LGC MLSPN X10 XLNK CD HZN LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115545 SUP HCPCS C1713 8115545 - PLATE BN 45-58MM STRL LGC MLSPN X10 XLNK CD HZN LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8115558 SUP HCPCS C1713 8115558 - PLATE BN 58-81MM STRL LGC MLSPN X10 XLNK CD HZN LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116416 SUP HCPCS C1713 8116416 - CROSSLINK 8116416 16MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116419 SUP HCPCS C1713 8116419 - CROSSLINK 8116419 19MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116422 SUP HCPCS C1713 8116422 - CROSSLINK 8116422 22MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116425 SUP HCPCS C1713 8116425 - CROSSLINK 8116425 25MM X10 FIXED BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116427 SUP HCPCS C1713 8116427 - CROSSLINK 8116427 28MM FXD L P 6 35TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116428 SUP HCPCS C1713 8116428 - CROSSLINK 8116428 28 30MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116430 SUP HCPCS C1713 8116430 - CROSSLINK 8116430 30 34MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116431 SUP HCPCS C1713 8116431 - CROSSLINK 8116431 31MM FXD LP TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116434 SUP HCPCS C1713 8116434 - PLATE 34-36MM TI 6.35MM ROD MLSPN X10 XLNK BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116436 SUP HCPCS C1713 8116436 - CROSSLINK 8116436 36 39MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116439 SUP HCPCS C1713 8116439 - CROSSLINK 8116439 39 45MM X10 MULTI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116445 SUP HCPCS C1713 8116445 - PLATE 45-57MM TI 6.35MM ROD MLSPN X10 XLNK BONE SPNL STRL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8116458 SUP HCPCS C1713 8116458 - PLATE 58-80MM TI 6.35MM SCR MULTIAX X10 XLNK BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8151100 SUP HCPCS C1713 8151100 - SCREW BONE SS SPNL LCK CLOSE HEAD BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $340.88 $340.88 $0.00 $0.00 $0.00 $157.88 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $448.06 $448.06 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $118.55 $0.00 $0.00 $120.59 $0.00 $0.00 $0.00 $0.00 $0.00 8162102 SUP HCPCS C1713 8162102 - STAPLE 8162102 2MM X 9MM TWO PRONG SMA BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 8162103 SUP HCPCS C1713 8162103 - STAPLE 8162103 3MM X 9MM TWO PRONG SMA BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 8162104 SUP HCPCS C1713 8162104 - STAPLE 8162104 4MM X 10MM 2PRONG SMA BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 8162106 SUP HCPCS C1713 8162106 - STAPLE 8162106 6MM X 11MM 2PRONG SMA BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 8162108 SUP HCPCS C1713 8162108 - STAPLE 8162108 8MM X 12MM 2PRONG SMA BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 8162110 SUP HCPCS C1713 8162110 - STAPLE 8162110 10MM X 13MM 2PRONG SMA BOTH IP/OP "$1,972.50 " "$1,459.65" $0.00 "$1,578.00" $887.63 $887.63 $0.00 $0.00 $0.00 $411.12 "$1,463.99" "$1,463.99" $0.00 $0.00 $411.07 $0.00 "$1,166.73" "$1,166.73" $0.00 $986.25 "$1,562.22" "$1,578.00" $0.00 $0.00 $308.70 $0.00 $0.00 $314.02 $0.00 $0.00 $0.00 $0.00 $0.00 8164604 SUP HCPCS C1713 8164604 - STAPLE 8164604 4MM X 10MM 4 PRONG SMA BOTH IP/OP "$6,300.65 " "$4,662.48" $0.00 "$5,040.52" "$2,835.29" "$2,835.29" $0.00 $0.00 $0.00 "$1,313.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,313.06" $0.00 "$3,106.22" "$3,106.22" $0.00 "$3,150.33" "$4,990.11" "$5,040.52" $0.00 $0.00 $986.05 $0.00 $0.00 "$1,003.06" $0.00 $0.00 $0.00 $0.00 $0.00 8164605 SUP HCPCS C1713 8164605 - STAPLE BONE 4 PR 10X5MM SPNL SMA BOTH IP/OP "$6,300.65 " "$4,662.48" $0.00 "$5,040.52" "$2,835.29" "$2,835.29" $0.00 $0.00 $0.00 "$1,313.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,313.06" $0.00 "$3,106.22" "$3,106.22" $0.00 "$3,150.33" "$4,990.11" "$5,040.52" $0.00 $0.00 $986.05 $0.00 $0.00 "$1,003.06" $0.00 $0.00 $0.00 $0.00 $0.00 8164606 SUP HCPCS C1713 8164606 - STAPLE 8164606 6MM X 11MM 4 PRONG SMA BOTH IP/OP "$6,300.65 " "$4,662.48" $0.00 "$5,040.52" "$2,835.29" "$2,835.29" $0.00 $0.00 $0.00 "$1,313.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,313.06" $0.00 "$3,106.22" "$3,106.22" $0.00 "$3,150.33" "$4,990.11" "$5,040.52" $0.00 $0.00 $986.05 $0.00 $0.00 "$1,003.06" $0.00 $0.00 $0.00 $0.00 $0.00 8164608 SUP HCPCS C1713 8164608 - STAPLE 8164608 8MM X 12MM 4 PRONG SMA BOTH IP/OP "$6,300.65 " "$4,662.48" $0.00 "$5,040.52" "$2,835.29" "$2,835.29" $0.00 $0.00 $0.00 "$1,313.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,313.06" $0.00 "$3,106.22" "$3,106.22" $0.00 "$3,150.33" "$4,990.11" "$5,040.52" $0.00 $0.00 $986.05 $0.00 $0.00 "$1,003.06" $0.00 $0.00 $0.00 $0.00 $0.00 8164610 SUP HCPCS C1713 8164610 - STAPLE 8164610 10MM X 13MM 4 PRONG SMA BOTH IP/OP "$6,300.65 " "$4,662.48" $0.00 "$5,040.52" "$2,835.29" "$2,835.29" $0.00 $0.00 $0.00 "$1,313.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,313.06" $0.00 "$3,106.22" "$3,106.22" $0.00 "$3,150.33" "$4,990.11" "$5,040.52" $0.00 $0.00 $986.05 $0.00 $0.00 "$1,003.06" $0.00 $0.00 $0.00 $0.00 $0.00 8164612 SUP HCPCS C1713 8164612 - STAPLE 8164612 12MMX14MM 4PRNG SMA BOTH IP/OP "$6,300.65 " "$4,662.48" $0.00 "$5,040.52" "$2,835.29" "$2,835.29" $0.00 $0.00 $0.00 "$1,313.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,313.06" $0.00 "$3,106.22" "$3,106.22" $0.00 "$3,150.33" "$4,990.11" "$5,040.52" $0.00 $0.00 $986.05 $0.00 $0.00 "$1,003.06" $0.00 $0.00 $0.00 $0.00 $0.00 8164614 SUP HCPCS C1713 8164614 - STAPLE 8164614 14MMX15MM 4PRNG SMA BOTH IP/OP "$6,300.65 " "$4,662.48" $0.00 "$5,040.52" "$2,835.29" "$2,835.29" $0.00 $0.00 $0.00 "$1,313.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,313.06" $0.00 "$3,106.22" "$3,106.22" $0.00 "$3,150.33" "$4,990.11" "$5,040.52" $0.00 $0.00 $986.05 $0.00 $0.00 "$1,003.06" $0.00 $0.00 $0.00 $0.00 $0.00 8200001 SUP HCPCS C1713 8200001 - CLIP SPNL LG NUVASIVE INC BOTH IP/OP "$2,282.50 " "$1,689.05" $0.00 "$1,826.00" "$1,027.13" "$1,027.13" $0.00 $0.00 $0.00 $475.73 "$1,694.07" "$1,694.07" $0.00 $0.00 $475.67 $0.00 "$1,350.10" "$1,350.10" $0.00 "$1,141.25" "$1,807.74" "$1,826.00" $0.00 $0.00 $357.21 $0.00 $0.00 $363.37 $0.00 $0.00 $0.00 $0.00 $0.00 8200003 SUP HCPCS C1769 8200003 - WIRE FX KRSH MAXCESS MOD BOTH IP/OP "$1,857.50 " "$1,374.55" $0.00 "$1,486.00" "$1,008.62" "$1,008.62" $0.00 $0.00 $0.00 $387.15 "$1,378.64" "$1,378.64" $0.00 $0.00 $387.10 $0.00 "$1,098.71" "$1,098.71" $0.00 $928.75 "$1,471.14" "$1,486.00" $0.00 $0.00 $290.70 $0.00 $0.00 $295.71 $0.00 $0.00 $0.00 $0.00 $0.00 8200010 SUP Custom 27203010 8200010 - KIT SPNL STRL MAXCESS SHIM DISP BOTH IP/OP "$3,572.50 " "$2,643.65" $0.00 "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,651.51" "$2,651.51" $0.00 $0.00 $744.51 $0.00 $0.00 $0.00 $0.00 "$1,786.25" "$2,829.42" "$2,858.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8200011 SUP Custom 27203010 8200011 - KIT SPNL STRL MAXCESS MOD DISP BOTH IP/OP "$5,115.00 " "$3,785.10" $0.00 "$4,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,796.35" "$3,796.35" $0.00 $0.00 "$1,065.97" $0.00 $0.00 $0.00 $0.00 "$2,557.50" "$4,051.08" "$4,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8200200 SUP HCPCS C1713 8200200 - SCREW BN MA MOD TLIF SPNE DISP BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 8200201 SUP HCPCS C1713 8200201 - SCREW BN MA HP SHIM LGHT CBL SPNE TLIF BOTH IP/OP "$4,662.50 " "$3,450.25" $0.00 "$3,730.00" "$2,098.13" "$2,098.13" $0.00 $0.00 $0.00 $971.78 "$3,460.51" "$3,460.51" $0.00 $0.00 $971.67 $0.00 "$2,298.61" "$2,298.61" $0.00 "$2,331.25" "$3,692.70" "$3,730.00" $0.00 $0.00 $729.68 $0.00 $0.00 $742.27 $0.00 $0.00 $0.00 $0.00 $0.00 8200202 SUP HCPCS C1713 8200202 - SCREW BN MA MOD TLIF HP SHIM SPNE BOTH IP/OP "$3,575.00 " "$2,645.50" $0.00 "$2,860.00" "$1,608.75" "$1,608.75" $0.00 $0.00 $0.00 $745.12 "$2,653.37" "$2,653.37" $0.00 $0.00 $745.03 $0.00 "$1,762.48" "$1,762.48" $0.00 "$1,787.50" "$2,831.40" "$2,860.00" $0.00 $0.00 $559.49 $0.00 $0.00 $569.14 $0.00 $0.00 $0.00 $0.00 $0.00 8203030 SUP Custom 27203010 8203030 - AIRWAY PHARYNGEAL 3 SMALL 15MM CONCTR NONINFLATABLE CUFF BOTH IP/OP $23.05 $17.06 $0.00 $28.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.11 $17.11 $0.00 $0.00 $4.80 $0.00 $0.00 $0.00 $0.00 $17.54 $27.78 $28.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8227103 SUP HCPCS C1898 8227103 - ELECTRODE EMG 4MM 12MM 2MM 2 CHANNEL NEEDLE LANCET TIP BOTH IP/OP $227.50 $168.35 $0.00 $182.00 $102.38 $102.38 $0.00 $0.00 $0.00 $47.42 $168.85 $168.85 $0.00 $0.00 $47.41 $0.00 $134.57 $134.57 $0.00 $113.75 $180.18 $182.00 $0.00 $0.00 $35.60 $0.00 $0.00 $36.22 $0.00 $0.00 $0.00 $0.00 $0.00 8229507 SUP Custom 27203010 8229507 - TUBE ENDOTRACHEAL NIM STAINLESS STEEL PVC OD10.5 MM ID7.0 MM BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8229706 SUP Custom 27803010 8229706 - TUBE ENDOTRAC STANDARD LP 8.2MM 6MM DEPH FREE NONREINFORCED BOTH IP/OP "$1,014.13 " $750.46 $0.00 $739.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.70 $685.70 $0.00 $0.00 $192.54 $0.00 $0.00 $0.00 $0.00 $461.94 $731.71 $739.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8229707 SUP Custom 27803010 8229707 - TUBE ENDOTRAC STANDARD LP 8.2MM 6MM DEPH FREE NONREINFORCED BOTH IP/OP "$1,014.13 " $750.46 $0.00 $739.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.70 $685.70 $0.00 $0.00 $192.54 $0.00 $0.00 $0.00 $0.00 $461.94 $731.71 $739.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8229708 SUP Custom 27803010 8229708 - TUBE ENDOTRAC STANDARD LP 10.7MM 8MM DEPH FREE NONREINFORCED BOTH IP/OP $852.63 $630.95 $0.00 $682.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.82 $632.82 $0.00 $0.00 $177.69 $0.00 $0.00 $0.00 $0.00 $426.31 $675.28 $682.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8240001 SUP Custom 27203010 8240001 - KIT SPINAL 4 MAXCESS BOTH IP/OP "$2,385.00 " "$1,764.90" $0.00 "$1,908.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,770.15" "$1,770.15" $0.00 $0.00 $497.03 $0.00 $0.00 $0.00 $0.00 "$1,192.50" "$1,888.92" "$1,908.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8240060 SUP Custom 27203010 8240060 - MODULE SPNL 4 MAXCESS BOTH IP/OP "$5,850.25 " "$4,329.19" $0.00 "$4,680.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,219.19" $0.00 $0.00 $0.00 $0.00 "$2,925.13" "$4,633.40" "$4,680.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8240061 SUP Custom 27203010 8240061 - MODULE SPNL 4 MAXCESS SHIM BOTH IP/OP "$4,695.25 " "$3,474.49" $0.00 "$3,756.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,484.81" "$3,484.81" $0.00 $0.00 $978.49 $0.00 $0.00 $0.00 $0.00 "$2,347.63" "$3,718.64" "$3,756.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8275525 SUP HCPCS C1713 8275525 - SCREW BN 5.5MM 25MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8275530 SUP HCPCS C1713 8275530 - SCREW BN 5.5MM 30MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8275535 SUP HCPCS C1713 8275535 - SCREW BN 5.5MM 35MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8275540 SUP HCPCS C1713 8275540 - SCREW BONE 5.5MM 40MM REDX TITANIUM SPN 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8275545 SUP HCPCS C1713 8275545 - SCREW BN 5.5MM 45MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8275550 SUP HCPCS C1713 8275550 - SCREW BN 5.5MM 50MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8275555 SUP HCPCS C1713 8275555 - SCREW BN 5.5MM 55MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8276530 SUP HCPCS C1713 8276530 - SCREW BN 6.5MM 30MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8276535 SUP HCPCS C1713 8276535 - SCREW BN 6.5MM 35MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8276545 SUP HCPCS C1713 8276545 - SCREW BN 6.5MM 45MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8276555 SUP HCPCS C1713 8276555 - SCREW BN 6.5MM 55MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8277530 SUP HCPCS C1713 8277530 - SCREW BN 7.5MM 30MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8277535 SUP HCPCS C1713 8277535 - SCREW BN 7.5MM 35MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8277540 SUP HCPCS C1713 8277540 - SCREW BN 7.5MM 40MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8277550 SUP HCPCS C1713 8277550 - SCREW BN 7.5MM 50MM RDC TI SPNE 5.5MM ROD BOTH IP/OP "$3,257.50 " "$2,410.55" $0.00 "$2,606.00" "$1,465.88" "$1,465.88" $0.00 $0.00 $0.00 $678.94 "$2,417.72" "$2,417.72" $0.00 $0.00 $678.86 $0.00 "$1,605.95" "$1,605.95" $0.00 "$1,628.75" "$2,579.94" "$2,606.00" $0.00 $0.00 $509.80 $0.00 $0.00 $518.59 $0.00 $0.00 $0.00 $0.00 $0.00 8281190 SUP HCPCS C1713 8281190 - SCREW 8281190 TSRH .25 32 LOCK NON BREAK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8281246 SUP HCPCS C1713 8281246 - SCREW 8281246 SET 3BDL HEX TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8281248 SUP HCPCS C1713 8281248 - SET SCREW 8281248 0.25 32 FLSH BRK LK TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8350424 SUP Custom 27203010 8350424 - TAP SURG OSTEOGRIP 5.5MM BOTH IP/OP $790.50 $584.97 $0.00 $632.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.71 $586.71 $0.00 $0.00 $164.74 $0.00 $0.00 $0.00 $0.00 $395.25 $626.08 $632.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8350426 SUP Custom 27203010 8350426 - TAP SURG OSTEOGRIP 6.5MM BOTH IP/OP $790.50 $584.97 $0.00 $632.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.71 $586.71 $0.00 $0.00 $164.74 $0.00 $0.00 $0.00 $0.00 $395.25 $626.08 $632.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8351500 SUP HCPCS C1713 8351500 - SET SCREW 8351500 TSRH 3DX FLUSH BREAK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8351502 SUP HCPCS C1713 8351502 - SET SCREW 8351502 TSRH 3DX NON-BREAK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8351520 SUP Custom 27803010 8351520 - CONNECTOR 8351520 TSRH 3DX SMALL BOTH IP/OP "$2,316.75 " "$1,714.40" $0.00 "$1,853.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,719.49" "$1,719.49" $0.00 $0.00 $482.81 $0.00 $0.00 $0.00 $0.00 "$1,158.38" "$1,834.87" "$1,853.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8351521 SUP Custom 27803010 8351521 - CONNECTOR 8351521 TSRH 3DX MEDIUM BOTH IP/OP "$2,316.75 " "$1,714.40" $0.00 "$1,853.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,719.49" "$1,719.49" $0.00 $0.00 $482.81 $0.00 $0.00 $0.00 $0.00 "$1,158.38" "$1,834.87" "$1,853.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8351522 SUP Custom 27803010 8351522 - CONNECTOR 8351522 TSRH 3DX LARGE BOTH IP/OP "$2,316.75 " "$1,714.40" $0.00 "$1,853.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,719.49" "$1,719.49" $0.00 $0.00 $482.81 $0.00 $0.00 $0.00 $0.00 "$1,158.38" "$1,834.87" "$1,853.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8351523 SUP Custom 27803010 8351523 - CONNECTOR 8351523 TSRH 3DX 90 DEG OFFSET BOTH IP/OP "$2,316.75 " "$1,714.40" $0.00 "$1,853.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,719.49" "$1,719.49" $0.00 $0.00 $482.81 $0.00 $0.00 $0.00 $0.00 "$1,158.38" "$1,834.87" "$1,853.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8352200 SUP HCPCS C1713 8352200 - ROD 5.5MM USS 200MM BOTH IP/OP "$2,017.50 " "$1,492.95" $0.00 "$1,614.00" $907.88 $907.88 $0.00 $0.00 $0.00 $420.50 "$1,497.39" "$1,497.39" $0.00 $0.00 $420.45 $0.00 "$1,193.35" "$1,193.35" $0.00 "$1,008.75" "$1,597.86" "$1,614.00" $0.00 $0.00 $315.74 $0.00 $0.00 $321.19 $0.00 $0.00 $0.00 $0.00 $0.00 8352300 SUP HCPCS C1713 8352300 - ROD 5.5MM USS 300MM BOTH IP/OP "$2,275.00 " "$1,683.50" $0.00 "$1,820.00" "$1,023.75" "$1,023.75" $0.00 $0.00 $0.00 $474.17 "$1,688.51" "$1,688.51" $0.00 $0.00 $474.11 $0.00 "$1,345.66" "$1,345.66" $0.00 "$1,137.50" "$1,801.80" "$1,820.00" $0.00 $0.00 $356.04 $0.00 $0.00 $362.18 $0.00 $0.00 $0.00 $0.00 $0.00 8352500 SUP HCPCS C1713 8352500 - ROD 5.5MM USS 500MM BOTH IP/OP "$2,502.50 " "$1,851.85" $0.00 "$2,002.00" "$1,126.13" "$1,126.13" $0.00 $0.00 $0.00 $521.58 "$1,857.36" "$1,857.36" $0.00 $0.00 $521.52 $0.00 "$1,233.73" "$1,233.73" $0.00 "$1,251.25" "$1,981.98" "$2,002.00" $0.00 $0.00 $391.64 $0.00 $0.00 $398.40 $0.00 $0.00 $0.00 $0.00 $0.00 8352510 SUP Custom 27803010 8352510 - CONNECTOR 8352510 5.5 SLOTTED TI BOTH IP/OP "$2,031.00 " "$1,502.94" $0.00 "$1,624.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,507.41" "$1,507.41" $0.00 $0.00 $423.26 $0.00 $0.00 $0.00 $0.00 "$1,015.50" "$1,608.55" "$1,624.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8354525 SUP HCPCS C1713 8354525 - SCREW BONE 4.5MM 25MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8354530 SUP HCPCS C1713 8354530 - SCREW BONE 4.5MM 30MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8354535 SUP HCPCS C1713 8354535 - SCREW BONE 4.5MM 35MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8354540 SUP HCPCS C1713 8354540 - SCREW BONE 4.5MM 40MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8355530 SUP HCPCS C1713 8355530 - SCREW BONE 5.5MM 30MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8355535 SUP HCPCS C1713 8355535 - SCREW BONE 5.5MM 35MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8355540 SUP HCPCS C1713 8355540 - SCREW BONE 5.5MM 40MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8355545 SUP HCPCS C1713 8355545 - SCREW BONE 5.5MM 45MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8356535 SUP HCPCS C1713 8356535 - SCREW BONE 6.5MM 35MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8356540 SUP HCPCS C1713 8356540 - SCREW BONE 6.5MM 40MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8356545 SUP HCPCS C1713 8356545 - SCREW BONE 6.5MM 45MM SS SPNL LCK 5.5MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8364525 SUP HCPCS C1713 8364525 - SCREW BONE 4.5MM 25MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8364530 SUP HCPCS C1713 8364530 - SCREW BONE 4.5MM 30MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8364535 SUP HCPCS C1713 8364535 - SCREW BONE 4.5MM 35MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8364540 SUP HCPCS C1713 8364540 - SCREW BONE 4.5MM 40MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8364545 SUP HCPCS C1713 8364545 - SCREW BONE 4.5MM 45MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8365530 SUP HCPCS C1713 8365530 - SCREW BONE 5.5MM 30MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8365535 SUP HCPCS C1713 8365535 - SCREW BONE 5.5MM 35MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8365540 SUP HCPCS C1713 8365540 - SCREW BONE 5.5MM 40MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8365545 SUP HCPCS C1713 8365545 - SCREW BONE 5.5MM 45MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8366535 SUP HCPCS C1713 8366535 - SCREW BONE 6.5MM 35MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8366540 SUP HCPCS C1713 8366540 - SCREW BONE 6.5MM 40MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8366545 SUP HCPCS C1713 8366545 - SCREW BONE 6.5MM 45MM SPNL LCK 6.35MM ROD BOTH IP/OP "$5,507.50 " "$4,075.55" $0.00 "$4,406.00" "$2,478.38" "$2,478.38" $0.00 $0.00 $0.00 "$1,147.90" "$4,087.67" "$4,087.67" $0.00 $0.00 "$1,147.76" $0.00 "$2,715.20" "$2,715.20" $0.00 "$2,753.75" "$4,361.94" "$4,406.00" $0.00 $0.00 $861.92 $0.00 $0.00 $876.79 $0.00 $0.00 $0.00 $0.00 $0.00 8367645 SUP HCPCS C1713 8367645 - BONE SCREW 8367645 EXTRACTOR 4.5MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367650 SUP HCPCS C1713 8367650 - BONE SCREW 8367650 EXTRACTPR 5.0MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367655 SUP HCPCS C1713 8367655 - BONE SCREW 8367655 EXTRACTOR 5.5MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367660 SUP HCPCS C1713 8367660 - BONE SCREW 8367660 EXTRACTOR 6.0MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367665 SUP HCPCS C1713 8367665 - BONE SCREW 8367665 EXTRACTOR 6.5MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367670 SUP HCPCS C1713 8367670 - BONE SCREW 8367670 EXTRACTOR 7.0MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367675 SUP HCPCS C1713 8367675 - BONE SCREW 8367675 EXTRACTOR 7.5MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367680 SUP HCPCS C1713 8367680 - BONE SCREW 8367680 EXTRACTOR 8.0MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367745 SUP HCPCS C1713 8367745 - BONE SCREW 8367745 TREPHINE 4.5MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367750 SUP HCPCS C1713 8367750 - BONE SCREW 8367750 TREPHINE 5.0MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367755 SUP HCPCS C1713 8367755 - BONE SCREW 8367755 TREPHINE 5.5MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367760 SUP HCPCS C1713 8367760 - BONE SCREW 8367760 TREPHINE 6.0MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367765 SUP HCPCS C1713 8367765 - BONE SCREW 8367765 TREPHINE 6.5MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367770 SUP HCPCS C1713 8367770 - BONE SCREW 8367770 TREPHINE 7.0MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367775 SUP HCPCS C1713 8367775 - BONE SCREW 8367775 TREPHINE 7.5MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8367780 SUP HCPCS C1713 8367780 - BONE SCREW 8367780 TREPHINE 8.0MM BOTH IP/OP "$1,138.50 " $842.49 $0.00 $910.80 $512.33 $512.33 $0.00 $0.00 $0.00 $237.29 $844.99 $844.99 $0.00 $0.00 $237.26 $0.00 $673.42 $673.42 $0.00 $569.25 $901.69 $910.80 $0.00 $0.00 $178.18 $0.00 $0.00 $181.25 $0.00 $0.00 $0.00 $0.00 $0.00 8370030 SUP HCPCS C1713 8370030 - ROD 8370030 TSR2D PCUT BENT 3.0CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370035 SUP HCPCS C1713 8370035 - ROD 8370035 TSR2D PCUT BENT 3.5CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370040 SUP HCPCS C1713 8370040 - ROD 8370040 TSR2D PCUT BENT 4.0CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370045 SUP HCPCS C1713 8370045 - ROD SPNL 450MM 5.5MM TSRH3D TI PREBNT PCUT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370050 SUP HCPCS C1713 8370050 - ROD 8370050 TSR2D PCUT BENT 5.0CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370055 SUP HCPCS C1713 8370055 - ROD SPNL 550MM 5.5MM TSRH3D TI PREBNT PCUT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370060 SUP HCPCS C1713 8370060 - ROD 8370060 TSR2D PCUT BENT 6.0CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370065 SUP HCPCS C1713 8370065 - ROD 8370065 6.5CM X 5.5MM PRE-CUT/BENT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370070 SUP HCPCS C1713 8370070 - ROD 8370070 TSR2D PCUT BENT 7.0CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370080 SUP HCPCS C1713 8370080 - ROD 8370080 TSR2D PCUT BENT8.0CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370090 SUP HCPCS C1713 8370090 - ROD 8370090 TSR2D PCUT BENT 9.0CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370095 SUP HCPCS C1713 8370095 - ROD SPNL 950MM 5.5MM TSRH3D TI PREBNT PCUT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370100 SUP HCPCS C1713 8370100 - ROD 8370100 TSR2D PCUT BENT 10CMX5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8370420 SUP HCPCS C1713 8370420 - SCREW 8370420 TSRH SHORT POST4.5X20 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8370425 SUP HCPCS C1713 8370425 - SCREW 8370425 TSRH SHORT POST4.5X25 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8370430 SUP HCPCS C1713 8370430 - SCREW 8370430 TSRH SHORT POST4.5X30 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8370435 SUP HCPCS C1713 8370435 - SCREW 8370435 TSRH SHORT POST4.5X35 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8370440 SUP HCPCS C1713 8370440 - SCREW 8370440 TSRH SHORT POST4.5X40 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8370445 SUP HCPCS C1713 8370445 - SCREW 8370445 TSRH SHORT POST4.5X45 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8370450 SUP HCPCS C1713 8370450 - SCREW 8370450 TSRH SHORT POST4.5X50 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8370455 SUP HCPCS C1713 8370455 - SCREW 8370455 TSRH SHORT POST4.5X55 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8371030 SUP HCPCS C1713 8371030 - ROD 8371030 TSR2D PCUT BENT 3.0CMX6.35 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371035 SUP HCPCS C1713 8371035 - ROD 8371035 3.5CMX6.35 PRE CUT BENT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371040 SUP HCPCS C1713 8371040 - ROD 8371040 TSR2D PCUT BENT 4.0CMX6.35 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371050 SUP HCPCS C1713 8371050 - ROD 8371050 TSR2D PCUT BENT 5.0CMX6.35 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371060 SUP HCPCS C1713 8371060 - ROD 8371060 TSR2D PCUT BENT 6.0CMX6.35 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371070 SUP HCPCS C1713 8371070 - ROD 8371070 TSR2D PCUT BENT 7.0CMX6.35 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371080 SUP HCPCS C1713 8371080 - ROD 8371080 TSR2D PCUT BENT 8.0CMX6.35 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371090 SUP HCPCS C1713 8371090 - ROD 8371090 TSR2D PCUT BENT 9.0CMX6.35 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371100 SUP HCPCS C1713 8371100 - ROD 8371100 TSR2D PCUT BENT 10.0CMX6.35 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8371530 SUP HCPCS C1713 8371530 - SCREW 8371530 TSR3D THRD 5.5X30MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371535 SUP HCPCS C1713 8371535 - SCREW 8371535 TSR3D THRD 5.5X35MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371540 SUP HCPCS C1713 8371540 - SCREW 8371540 TSR3D THRD 5.5X40MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371545 SUP HCPCS C1713 8371545 - SCREW 8371545 TSR3D THRD 5.5X45MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371550 SUP HCPCS C1713 8371550 - SCREW 8371550 TSR3D THRD 5.5X50MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371630 SUP HCPCS C1713 8371630 - SCREW 8371630 TSR3D THRD 6.5X30MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371635 SUP HCPCS C1713 8371635 - SCREW 8371635 TSR3D THRD 6.5X35MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371640 SUP HCPCS C1713 8371640 - SCREW 8371640 TSR3D THRD 6.5X40MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371645 SUP HCPCS C1713 8371645 - SCREW 8371645 TSR3D THRD 6.5X45MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371650 SUP HCPCS C1713 8371650 - SCREW 8371650 TSR3D THRD 6.5X50MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371655 SUP HCPCS C1713 8371655 - SCREW 8371655 TSR3D THRD 6.5X55MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371660 SUP HCPCS C1713 8371660 - SCREW 8371660 TSR3D THRD 6.5X60MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371730 SUP HCPCS C1713 8371730 - SCREW 8371730 TSR3D THRD 7.5X30MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371735 SUP HCPCS C1713 8371735 - SCREW 8371735 TSR3D THRD 7.5X35MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371740 SUP HCPCS C1713 8371740 - SCREW 8371740 TSR3D THRD 7.5X40MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371745 SUP HCPCS C1713 8371745 - SCREW 8371745 TSR3D THRD 7.5X45MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371750 SUP HCPCS C1713 8371750 - SCREW 8371750 TSR3D THRD 7.5X50MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371755 SUP HCPCS C1713 8371755 - SCREW 8371755 TSR3D THRD 7.5X55MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371760 SUP HCPCS C1713 8371760 - SCREW 8371760 TSR3D THRD 7.5X60MM TI BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371830 SUP HCPCS C1713 8371830 - SCREW 8371830 TSRH 3D 8 5MMX30MM THR PST BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371835 SUP HCPCS C1713 8371835 - SCREW 8371835 TSRH 3D 8 5MMX35MM THR PST BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371840 SUP HCPCS C1713 8371840 - SCREW 8371840 TSRH 3D 8 5MMX40MM THR PST BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371845 SUP HCPCS C1713 8371845 - SCREW 8371845 TSRH 3D 8 5MMX45MM THR PST BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371850 SUP HCPCS C1713 8371850 - SCREW 8371850 TSRH 3D 8 5MMX50MM THR PST BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371855 SUP HCPCS C1713 8371855 - SCREW 8371855 TSRH 3D 8 5MMX55MM THR PST BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8371860 SUP HCPCS C1713 8371860 - SCREW 8371860 TSRH 3D 8 5MMX60MM THR PST BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $535.95 $535.95 $0.00 $0.00 $0.00 $248.23 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $704.48 $704.48 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $186.39 $0.00 $0.00 $189.61 $0.00 $0.00 $0.00 $0.00 $0.00 8372520 SUP HCPCS C1713 8372520 - SCREW 8372520 TSR3D SHORT POST 5.5X20 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372525 SUP HCPCS C1713 8372525 - SCREW 8372525 TSR3D SHORT POST 5.5X25 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372530 SUP HCPCS C1713 8372530 - SCREW 8372530 TSR3D SHORT POST 5.5X30 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372535 SUP HCPCS C1713 8372535 - SCREW 8372535 TSR3D SHORT POST 5.5X35 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372540 SUP HCPCS C1713 8372540 - SCREW 8372540 TSR3D SHORT POST 5.5X40 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372545 SUP HCPCS C1713 8372545 - SCREW 8372545 TSR3D SHORT POST 5.5X45 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372550 SUP HCPCS C1713 8372550 - SCREW 8372550 TSR3D SHORT POST 5.5X50 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372555 SUP HCPCS C1713 8372555 - SCREW 8372555 TSR3D SHORT POST 5.5X55 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372620 SUP HCPCS C1713 8372620 - SCREW 8372620 TSR3D SHORT POST 6.5X20 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372625 SUP HCPCS C1713 8372625 - SCREW 8372625 TSR3D SHORT POST 6.5X25 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372630 SUP HCPCS C1713 8372630 - SCREW 8372630 TSR3D SHORT POST 6.5X30 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372635 SUP HCPCS C1713 8372635 - SCREW 8372635 TSR3D SHORT POST 6.5X35 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372640 SUP HCPCS C1713 8372640 - SCREW 8372640 TSR3D SHORT POST 6.5X40 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372645 SUP HCPCS C1713 8372645 - SCREW 8372645 TSR3D SHORT POST 6.5X45 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372650 SUP HCPCS C1713 8372650 - SCREW 8372650 TSR3D SHORT POST 6.5X50 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372655 SUP HCPCS C1713 8372655 - SCREW 8372655 TSR3D SHORT POST 6.5X55 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372660 SUP HCPCS C1713 8372660 - SCREW 8372660 TSR3D SHORT POST 6.5X60 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372720 SUP HCPCS C1713 8372720 - SCREW 8372720 TSR3D SHORT POST 7.5X20 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372725 SUP HCPCS C1713 8372725 - SCREW 8372725 TSR3D SHORT POST 7.5X25 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372730 SUP HCPCS C1713 8372730 - SCREW 8372730 TSR3D SHORT POST 7.5X30 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372735 SUP HCPCS C1713 8372735 - SCREW 8372735 TSR3D SHORT POST 7.5X35 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372740 SUP HCPCS C1713 8372740 - SCREW 8372740 TSR3D SHORT POST 7.5X40 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372745 SUP HCPCS C1713 8372745 - SCREW 8372745 TSR3D SHORT POST 7.5X45 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372750 SUP HCPCS C1713 8372750 - SCREW 8372750 TSR3D SHORT POST 7.5X50 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372755 SUP HCPCS C1713 8372755 - SCREW 8372755 TSR3D SHORT POST 7.5X55 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372760 SUP HCPCS C1713 8372760 - SCREW 8372760 TSR3D SHORT POST 7.5X60 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372820 SUP HCPCS C1713 8372820 - SCREW 8372820 TSR3D SHORT POST 8.5X20 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372825 SUP HCPCS C1713 8372825 - SCREW 8372825 TSR3D SHORT POST 8.5X25 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372830 SUP HCPCS C1713 8372830 - SCREW 8372830 TSR3D SHORT POST 8.5X30 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372835 SUP HCPCS C1713 8372835 - SCREW 8372835 TSR3D SHORT POST 8.5X35 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372840 SUP HCPCS C1713 8372840 - SCREW 8372840 TSR3D SHORT POST 8.5X40 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372845 SUP HCPCS C1713 8372845 - SCREW 8372845 TSR3D SHORT POST 8.5X45 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372850 SUP HCPCS C1713 8372850 - SCREW 8372850 TSR3D SHORT POST 8.5X50 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372855 SUP HCPCS C1713 8372855 - SCREW 8372855 TSR3D SHORT POST 8.5X55 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8372860 SUP HCPCS C1713 8372860 - SCREW 8372860 TSR3D SHORT POST 8.5X60 TI BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8373745 SUP HCPCS C1713 8373745 - SCREW BONE 7.5MM 45MM SCRL BOTH IP/OP "$1,122.00 " $830.28 $0.00 $897.60 $504.90 $504.90 $0.00 $0.00 $0.00 $233.85 $832.75 $832.75 $0.00 $0.00 $233.82 $0.00 $663.66 $663.66 $0.00 $561.00 $888.62 $897.60 $0.00 $0.00 $175.59 $0.00 $0.00 $178.62 $0.00 $0.00 $0.00 $0.00 $0.00 8374535 SUP HCPCS C1713 8374535 - SCREW BONE 4.5MM 35MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8374540 SUP HCPCS C1713 8374540 - SCREW BONE 4.5MM 40MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8374545 SUP HCPCS C1713 8374545 - SCREW BONE 4.5MM 45MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8375530 SUP HCPCS C1713 8375530 - SCREW BONE 5.5MM 30MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8375535 SUP HCPCS C1713 8375535 - SCREW BONE 5.5MM 35MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8375540 SUP HCPCS C1713 8375540 - SCREW BONE 5.5MM 40MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8375545 SUP HCPCS C1713 8375545 - SCREW BONE 5.5MM 45MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8375550 SUP HCPCS C1713 8375550 - SCREW BONE 5.5MM 50MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8376520 SUP HCPCS C1713 "8376520 - MPA SHRT SCREW, 5.5MMX20MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376525 SUP HCPCS C1713 "8376525 - MPA SHRT SCREW, 5.5MMX25MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376530 SUP HCPCS C1713 "8376530 - MPA SHRT SCREW, 5.5MMX30MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376535 SUP HCPCS C1713 8376535 - SCREW 8376535 MPA SHRT 5 5MMX35MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376540 SUP HCPCS C1713 8376540 - SCREW BONE 6.5MM 40MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8376545 SUP HCPCS C1713 8376545 - SCREW BONE 6.5MM 45MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8376550 SUP HCPCS C1713 8376550 - SCREW BONE 6.5MM 50MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8376555 SUP HCPCS C1713 8376555 - SCREW BONE 6.5MM 55MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8376620 SUP HCPCS C1713 "8376620 - MPA SHRT SCREW, 6.5MMX20MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376625 SUP HCPCS C1713 "8376625 - MPA SHRT SCREW, 6.5MMX25MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376630 SUP HCPCS C1713 "8376630 - MPA SHRT SCREW, 6.5MMX30MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376635 SUP HCPCS C1713 8376635 - BONE SCREW 8376635 MPA SHRT 6.5MMX35MM BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376640 SUP HCPCS C1713 8376640 - SCREW 8376640 MPA SHRT 6 5MMX40MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376645 SUP HCPCS C1713 8376645 - SCREW 8376645 MPA SHRT 6 5MMX45MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376650 SUP HCPCS C1713 8376650 - SCREW 8376650 MPA SHRT 6 5MMX50MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376655 SUP HCPCS C1713 "8376655 - MPA SHRT SCREW, 6.5MMX55MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376660 SUP HCPCS C1713 "8376660 - MPA SHRT SCREW, 6.5MMX60MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376720 SUP HCPCS C1713 "8376720 - MPA SHRT SCREW, 7.5MMX20MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376725 SUP HCPCS C1713 "8376725 - MPA SHRT SCREW, 7.5MMX25MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376730 SUP HCPCS C1713 "8376730 - MPA SHRT SCREW, 7.5MMX30MM, TI" BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376735 SUP HCPCS C1713 8376735 - SCREW 8376735 MPA SHRT 7 5MMX35MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376740 SUP HCPCS C1713 8376740 - SCREW 8376740 MPA SHRT 7 5MMX40MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376745 SUP HCPCS C1713 8376745 - SCREW 8376745 MPA SHRT 7 5MMX45MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376750 SUP HCPCS C1713 8376750 - SCREW 8376750 MPA SHRT 7 5MMX50MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376755 SUP HCPCS C1713 8376755 - SCREW 8376755 MPA SHRT 7 5MMX55MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8376760 SUP HCPCS C1713 8376760 - SCREW 8376760 MPA SHRT 7 5MMX60MM TI BOTH IP/OP "$1,279.50 " $946.83 $0.00 "$1,023.60" $575.78 $575.78 $0.00 $0.00 $0.00 $266.68 $949.64 $949.64 $0.00 $0.00 $266.65 $0.00 $756.82 $756.82 $0.00 $639.75 "$1,013.36" "$1,023.60" $0.00 $0.00 $200.24 $0.00 $0.00 $203.70 $0.00 $0.00 $0.00 $0.00 $0.00 8377530 SUP HCPCS C1713 8377530 - BONE SCREW 8377530 MPA THRD 5.5X30 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377535 SUP HCPCS C1713 8377535 - BONE SCREW 8377535 MPA THRD 5.5X35 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377540 SUP HCPCS C1713 8377540 - SCREW BONE 7.5MM 40MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8377545 SUP HCPCS C1713 8377545 - SCREW BONE 7.5MM 45MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8377550 SUP HCPCS C1713 8377550 - SCREW BONE 7.5MM 50MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8377555 SUP HCPCS C1713 8377555 - SCREW BONE 7.5MM 55MM SPNL REDX 5.5MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8377630 SUP HCPCS C1713 8377630 - BONE SCREW 8377630 MPA THRD 6.5X30 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377635 SUP HCPCS C1713 8377635 - BONE SCREW 8377635 MPA THRD 6.5X35 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377640 SUP HCPCS C1713 8377640 - BONE SCREW 8377640 MPA THRD 6.5X40 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377645 SUP HCPCS C1713 8377645 - BONE SCREW 8377645 MPA THRD 6.5X45 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377650 SUP HCPCS C1713 8377650 - BONE SCREW 8377650 MPA THRD 6.5X50 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377655 SUP HCPCS C1713 8377655 - BONE SCREW 8377655 MPA THRD 6.5X55 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377660 SUP HCPCS C1713 8377660 - BONE SCREW 8377660 MPA THRD 6.5X60 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377730 SUP HCPCS C1713 8377730 - BONE SCREW 8377730 MPA THRD 7.5X30 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377735 SUP HCPCS C1713 8377735 - BONE SCREW 8377735 MPA THRD 7.5X35 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377740 SUP HCPCS C1713 8377740 - BONE SCREW 8377740 MPA THRD 7.5X40 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377745 SUP HCPCS C1713 8377745 - BONE SCREW 8377745 MPA THRD 7.5X45 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377750 SUP HCPCS C1713 8377750 - BONE SCREW 8377750 MPA THRD 7.5X50 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377755 SUP HCPCS C1713 8377755 - BONE SCREW 8377755 MPA THRD 7.5X55 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8377760 SUP HCPCS C1713 8377760 - BONE SCREW 8377760 MPA THRD 7.5X60 TI BOTH IP/OP "$1,549.50 " "$1,146.63" $0.00 "$1,239.60" $697.28 $697.28 $0.00 $0.00 $0.00 $322.95 "$1,150.04" "$1,150.04" $0.00 $0.00 $322.92 $0.00 $916.53 $916.53 $0.00 $774.75 "$1,227.20" "$1,239.60" $0.00 $0.00 $242.50 $0.00 $0.00 $246.68 $0.00 $0.00 $0.00 $0.00 $0.00 8379120 SUP Custom 27803010 8379120 - CONNECTOR 8379120 5.5 TSRH 3D SML TI BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379121 SUP Custom 27803010 8379121 - CONNECTOR 8379121 5.5 TSRH 3D MED TI BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379122 SUP Custom 27803010 8379122 - CONNECTOR 8379122 5.5 TSRH 3D LRG TI BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379124 SUP Custom 27803010 8379124 - CONNECTOR 8379124 90 DEG OFFSET 5.5 TI BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379130 SUP Custom 27803010 8379130 - CONNECTOR ROD 8379130 6.35 TSRH 3D SM BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379131 SUP Custom 27803010 8379131 - CONNECTOR 8379131 6.35 TSRH 3D MED TI BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379132 SUP Custom 27803010 8379132 - CONNECTOR 8379132 6.35 TSRH 3D LRG TI BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379134 SUP Custom 27803010 8379134 - CONNECTOR 8379134 90 DEG OSET 6.35 TI BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379140 SUP Custom 27803010 8379140 - CONNECTOR 8379140 SM TRSH-3D 6.35MM TI BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379141 SUP Custom 27803010 8379141 - CONNECTOR 8379141 6.35 TSRH-3D MED BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379142 SUP Custom 27803010 8379142 - CONCTR ROD LG 6.35MM TSRH3D CLOSE OFFST TI POST PDCL BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8384535 SUP HCPCS C1713 8384535 - SCREW BONE 4.5MM 35MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8384540 SUP HCPCS C1713 8384540 - SCREW BONE 4.5MM 40MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8384545 SUP HCPCS C1713 8384545 - SCREW BONE 4.5MM 45MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8385040 SUP HCPCS C1713 8385040 - SCREW BONE 5MM 40MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8385045 SUP HCPCS C1713 8385045 - SCREW BONE 5MM 45MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8385050 SUP HCPCS C1713 8385050 - SCREW BONE 5MM 50MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8386535 SUP HCPCS C1713 8386535 - SCREW BONE 6.5MM 35MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8386540 SUP HCPCS C1713 8386540 - SCREW BONE 6.5MM 40MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8386545 SUP HCPCS C1713 8386545 - SCREW BONE 6.5MM 45MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8386550 SUP HCPCS C1713 8386550 - SCREW BONE 6.5MM 50MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8387540 SUP HCPCS C1713 8387540 - SCREW BONE 7.5MM 40MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8387545 SUP HCPCS C1713 8387545 - SCREW BONE 7.5MM 45MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8387550 SUP HCPCS C1713 8387550 - SCREW BONE 7.5MM 50MM SPNL REDX 6.35MM ROD BOTH IP/OP "$5,220.00 " "$3,862.80" $0.00 "$4,176.00" "$2,349.00" "$2,349.00" $0.00 $0.00 $0.00 "$1,087.98" "$3,874.28" "$3,874.28" $0.00 $0.00 "$1,087.85" $0.00 "$2,573.46" "$2,573.46" $0.00 "$2,610.00" "$4,134.24" "$4,176.00" $0.00 $0.00 $816.93 $0.00 $0.00 $831.02 $0.00 $0.00 $0.00 $0.00 $0.00 8436510 SUP HCPCS C1713 8436510 - SCREW BN 6.5MM 100MM SACROILIAC 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8436560 SUP HCPCS C1713 8436560 - SCREW BN 6.5MM 60MM SACROILIAC 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8436570 SUP HCPCS C1713 8436570 - SCREW BN 6.5MM 70MM SACROILIAC 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8436580 SUP HCPCS C1713 8436580 - SCREW BN 6.5MM 80MM SACROILIAC 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8436590 SUP HCPCS C1713 8436590 - SCREW BN 6.5MM 90MM SACROILIAC 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8437510 SUP HCPCS C1713 8437510 - SCREW BONE 7.5MM 100MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8437560 SUP HCPCS C1713 8437560 - SCREW BONE 7.5MM 60MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8437570 SUP HCPCS C1713 8437570 - SCREW BONE 7.5MM 70MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8437580 SUP HCPCS C1713 8437580 - SCREW BONE 7.5MM 80MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8437590 SUP HCPCS C1713 8437590 - SCREW BONE 7.5MM 90MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8438510 SUP HCPCS C1713 8438510 - SCREW BONE 8.5MM 100MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8438560 SUP HCPCS C1713 8438560 - SCREW BONE 8.5MM 60MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8438570 SUP HCPCS C1713 8438570 - SCREW BONE 8.5MM 70MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8438580 SUP HCPCS C1713 8438580 - SCREW BONE 8.5MM 80MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8438590 SUP HCPCS C1713 8438590 - SCREW BONE 8.5MM 90MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8439510 SUP HCPCS C1713 8439510 - SCREW BONE 9.5MM 100MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8439560 SUP HCPCS C1713 8439560 - SCREW BONE 9.5MM 60MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8439570 SUP HCPCS C1713 8439570 - SCREW BONE 9.5MM 70MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8439580 SUP HCPCS C1713 8439580 - SCREW BONE 9.5MM 80MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8439590 SUP HCPCS C1713 8439590 - SCREW BONE 9.5MM 90MM ILC 5.5MM ROD SLC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8446510 SUP HCPCS C1713 8446510 - SCREW BONE 6.5MM 100MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8446560 SUP HCPCS C1713 8446560 - SCREW BONE 6.5MM 60MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8446570 SUP HCPCS C1713 8446570 - SCREW BONE 6.5MM 70MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8446580 SUP HCPCS C1713 8446580 - SCREW BONE 6.5MM 80MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8446590 SUP HCPCS C1713 8446590 - SCREW BONE 6.5MM 90MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8447510 SUP HCPCS C1713 8447510 - SCREW BONE 7.5MM 100MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8447560 SUP HCPCS C1713 8447560 - SCREW BONE 7.5MM 60MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8447570 SUP HCPCS C1713 8447570 - SCREW BONE 7.5MM 70MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8447580 SUP HCPCS C1713 8447580 - SCREW BONE 7.5MM 80MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8447590 SUP HCPCS C1713 8447590 - SCREW BONE 7.5MM 90MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8448510 SUP HCPCS C1713 8448510 - SCREW BONE 8.5MM 100MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8448560 SUP HCPCS C1713 8448560 - SCREW BONE 8.5MM 60MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8448570 SUP HCPCS C1713 8448570 - SCREW BONE 8.5MM 70MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8448580 SUP HCPCS C1713 8448580 - SCREW BONE 8.5MM 80MM SPNL ILC BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8448590 SUP HCPCS C1713 8448590 - SCREW BONE 8.5MM 90MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8449510 SUP HCPCS C1713 8449510 - SCREW BONE 9.5MM 100MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8449560 SUP HCPCS C1713 8449560 - SCREW BONE 9.5MM 60MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8449570 SUP HCPCS C1713 8449570 - SCREW BONE 9.5MM 70MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8449580 SUP HCPCS C1713 8449580 - SCREW BONE 9.5MM 80MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8449590 SUP HCPCS C1713 8449590 - SCREW BONE 9.5MM 90MM ILC SLT 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8450120 SUP HCPCS C1713 8450120 - CONCTR ROD 20MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450122 SUP HCPCS C1713 8450122 - CONCTR ROD 22MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450125 SUP HCPCS C1713 8450125 - CONCTR ROD 25MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450127 SUP HCPCS C1713 8450127 - CONCTR ROD 27.5MM BCN CX BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450130 SUP HCPCS C1713 8450130 - CONCTR ROD 30MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450132 SUP HCPCS C1713 8450132 - CONCTR ROD 32.5MM 5.5MM ARMADA CX SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450135 SUP HCPCS C1713 8450135 - CONCTR ROD 35MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450137 SUP HCPCS C1713 8450137 - CONCTR ROD 37MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450140 SUP HCPCS C1713 8450140 - CONCTR ROD 40MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450145 SUP HCPCS C1713 8450145 - CONCTR ROD 45MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450150 SUP HCPCS C1713 8450150 - CONCTR ROD 50MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450155 SUP HCPCS C1713 8450155 - CONCTR ROD 55MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450160 SUP HCPCS C1713 8450160 - CONCTR ROD 60MM 5.5MM FIX CX TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450245 SUP HCPCS C1713 8450245 - TRNCON ROD 45-50MM ADJ ARCH BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450250 SUP HCPCS C1713 8450250 - CONCTR ROD 50-60MM ADJ TRNSVRS SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8450260 SUP HCPCS C1713 8450260 - TRNCON ROD 60-70MM ADJ ARCH BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8451188 SUP HCPCS C1713 8451188 - POSITIONING CLIP 8451188 5.5MM ROD BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $16.88 $16.88 $0.00 $0.00 $0.00 $7.82 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $22.18 $22.18 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $5.87 $0.00 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 8451302 SUP HCPCS C1713 8451302 - CONNECTOR ROD 5.5MM INLN TI BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8451402 SUP HCPCS C1713 8451402 - CONCTR ROD 5.5MM T PRLL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8451530 SUP HCPCS C1713 8451530 - SCREW BONE 10.5MM 30MM POLYAX˙ 5.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8451535 SUP HCPCS C1713 8451535 - SCREW BONE 10.5MM 35MM POLYAX˙ 5.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8451540 SUP HCPCS C1713 8451540 - SCREW BONE 10.5MM 40MM POLYAX˙ 5.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8451545 SUP HCPCS C1713 8451545 - SCREW BONE 10.5MM 45MM POLYAX˙ 5.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8451550 SUP HCPCS C1713 8451550 - SCREW BONE 10.5MM 50MM POLYAX˙ 5.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8451555 SUP HCPCS C1713 8451555 - SCREW BONE 10.5MM 55MM POLYAX˙ 5.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8451602 SUP HCPCS C1713 8451602 - CONCTR ROD 5.5MM 4 HOLE TI ARM15 BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8452004 SUP HCPCS C1713 8452004 - ROD LATERAL OFFSET BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" "$1,057.50" "$1,057.50" $0.00 $0.00 $0.00 $489.80 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 "$1,390.03" "$1,390.03" $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $367.78 $0.00 $0.00 $374.12 $0.00 $0.00 $0.00 $0.00 $0.00 8452025 SUP HCPCS C1713 8452025 - ROD SPNL 25MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452030 SUP HCPCS C1713 8452030 - ROD SPNL 30MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452035 SUP HCPCS C1713 8452035 - ROD SPNL 35MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452040 SUP HCPCS C1713 8452040 - ROD SPNL 40MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452045 SUP HCPCS C1713 8452045 - ROD SPNL 45MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452050 SUP HCPCS C1713 8452050 - ROD SPNL 50MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452055 SUP HCPCS C1713 8452055 - ROD SPNL 55MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452060 SUP HCPCS C1713 8452060 - ROD SPNL 60MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452065 SUP HCPCS C1713 8452065 - ROD SPNL 65MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452070 SUP HCPCS C1713 8452070 - ROD SPNL 70MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452075 SUP HCPCS C1713 8452075 - ROD SPNL 5.5MM 75MM TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452080 SUP HCPCS C1713 8452080 - ROD SPNL 80MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452090 SUP HCPCS C1713 8452090 - ROD SPNL 90MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452100 SUP HCPCS C1713 8452100 - ROD SPNL 100MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452120 SUP HCPCS C1713 8452120 - ROD SPNL 120MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452140 SUP HCPCS C1713 8452140 - ROD SPNL 140MM 5.5MM TI ARM15 BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452152 SUP HCPCS C1713 8452152 - ROD-ROD 5.5MM O -5.5MM O BOTH IP/OP "$3,530.00 " "$2,612.20" $0.00 "$2,824.00" "$1,588.50" "$1,588.50" $0.00 $0.00 $0.00 $735.74 "$2,619.97" "$2,619.97" $0.00 $0.00 $735.65 $0.00 "$1,740.29" "$1,740.29" $0.00 "$1,765.00" "$2,795.76" "$2,824.00" $0.00 $0.00 $552.45 $0.00 $0.00 $561.98 $0.00 $0.00 $0.00 $0.00 $0.00 8452156 SUP HCPCS C1713 8452156 - ROD-ROD 5.5MM O-6.35MM O BOTH IP/OP "$3,530.00 " "$2,612.20" $0.00 "$2,824.00" "$1,588.50" "$1,588.50" $0.00 $0.00 $0.00 $735.74 "$2,619.97" "$2,619.97" $0.00 $0.00 $735.65 $0.00 "$1,740.29" "$1,740.29" $0.00 "$1,765.00" "$2,795.76" "$2,824.00" $0.00 $0.00 $552.45 $0.00 $0.00 $561.98 $0.00 $0.00 $0.00 $0.00 $0.00 8452160 SUP HCPCS C1713 8452160 - ROD SPNL 160MM 5.5MM TI ARM15T BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452166 SUP HCPCS C1713 8452166 - ROD-ROD 6.35MM O-6.35MM O BOTH IP/OP "$3,530.00 " "$2,612.20" $0.00 "$2,824.00" "$1,588.50" "$1,588.50" $0.00 $0.00 $0.00 $735.74 "$2,619.97" "$2,619.97" $0.00 $0.00 $735.65 $0.00 "$1,740.29" "$1,740.29" $0.00 "$1,765.00" "$2,795.76" "$2,824.00" $0.00 $0.00 $552.45 $0.00 $0.00 $561.98 $0.00 $0.00 $0.00 $0.00 $0.00 8452200 SUP HCPCS C1713 8452200 - ROD SPNL 200MM 5.5MM ARMADA TI ARM15T BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452255 SUP HCPCS C1713 8452255 - ROD-ROD 5.5MM O-5.5MM OW BOTH IP/OP "$3,530.00 " "$2,612.20" $0.00 "$2,824.00" "$1,588.50" "$1,588.50" $0.00 $0.00 $0.00 $735.74 "$2,619.97" "$2,619.97" $0.00 $0.00 $735.65 $0.00 "$1,740.29" "$1,740.29" $0.00 "$1,765.00" "$2,795.76" "$2,824.00" $0.00 $0.00 $552.45 $0.00 $0.00 $561.98 $0.00 $0.00 $0.00 $0.00 $0.00 8452256 SUP HCPCS C1713 8452256 - ROD-ROD 5.5MM O-6.35MM OW BOTH IP/OP "$3,530.00 " "$2,612.20" $0.00 "$2,824.00" "$1,588.50" "$1,588.50" $0.00 $0.00 $0.00 $735.74 "$2,619.97" "$2,619.97" $0.00 $0.00 $735.65 $0.00 "$1,740.29" "$1,740.29" $0.00 "$1,765.00" "$2,795.76" "$2,824.00" $0.00 $0.00 $552.45 $0.00 $0.00 $561.98 $0.00 $0.00 $0.00 $0.00 $0.00 8452266 SUP HCPCS C1713 8452266 - ROD-ROD 6.35MM O-6.35MM OW BOTH IP/OP "$3,530.00 " "$2,612.20" $0.00 "$2,824.00" "$1,588.50" "$1,588.50" $0.00 $0.00 $0.00 $735.74 "$2,619.97" "$2,619.97" $0.00 $0.00 $735.65 $0.00 "$1,740.29" "$1,740.29" $0.00 "$1,765.00" "$2,795.76" "$2,824.00" $0.00 $0.00 $552.45 $0.00 $0.00 $561.98 $0.00 $0.00 $0.00 $0.00 $0.00 8452300 SUP HCPCS C1713 8452300 - ROD SPNL 300MM NS ARMADA ARM15T BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8452355 SUP HCPCS C1713 8452355 - ROD-ROD 90 DEG 5.5MM O-5.5MM C BOTH IP/OP "$3,845.00 " "$2,845.30" $0.00 "$3,076.00" "$1,730.25" "$1,730.25" $0.00 $0.00 $0.00 $801.39 "$2,853.76" "$2,853.76" $0.00 $0.00 $801.30 $0.00 "$1,895.59" "$1,895.59" $0.00 "$1,922.50" "$3,045.24" "$3,076.00" $0.00 $0.00 $601.74 $0.00 $0.00 $612.12 $0.00 $0.00 $0.00 $0.00 $0.00 8452356 SUP HCPCS C1713 8452356 - ROD-ROD 90 DEG 5.5MM O 6.35MM C BOTH IP/OP "$3,845.00 " "$2,845.30" $0.00 "$3,076.00" "$1,730.25" "$1,730.25" $0.00 $0.00 $0.00 $801.39 "$2,853.76" "$2,853.76" $0.00 $0.00 $801.30 $0.00 "$1,895.59" "$1,895.59" $0.00 "$1,922.50" "$3,045.24" "$3,076.00" $0.00 $0.00 $601.74 $0.00 $0.00 $612.12 $0.00 $0.00 $0.00 $0.00 $0.00 8452365 SUP HCPCS C1713 8452365 - ROD-ROD 90 DEG 6.35MM O 5.5MM C BOTH IP/OP "$3,845.00 " "$2,845.30" $0.00 "$3,076.00" "$1,730.25" "$1,730.25" $0.00 $0.00 $0.00 $801.39 "$2,853.76" "$2,853.76" $0.00 $0.00 $801.30 $0.00 "$1,895.59" "$1,895.59" $0.00 "$1,922.50" "$3,045.24" "$3,076.00" $0.00 $0.00 $601.74 $0.00 $0.00 $612.12 $0.00 $0.00 $0.00 $0.00 $0.00 8452366 SUP HCPCS C1713 8452366 - ROD-ROD 90 DEG 6.35MM O 6.35MM C BOTH IP/OP "$3,845.00 " "$2,845.30" $0.00 "$3,076.00" "$1,730.25" "$1,730.25" $0.00 $0.00 $0.00 $801.39 "$2,853.76" "$2,853.76" $0.00 $0.00 $801.30 $0.00 "$1,895.59" "$1,895.59" $0.00 "$1,922.50" "$3,045.24" "$3,076.00" $0.00 $0.00 $601.74 $0.00 $0.00 $612.12 $0.00 $0.00 $0.00 $0.00 $0.00 8452412 SUP HCPCS C1713 8452412 - ROD CONNECTOR LH 5.5MM 15 X 200MM BOTH IP/OP "$5,105.00 " "$3,777.70" $0.00 "$4,084.00" "$2,297.25" "$2,297.25" $0.00 $0.00 $0.00 "$1,064.01" "$3,788.93" "$3,788.93" $0.00 $0.00 "$1,063.88" $0.00 "$2,516.77" "$2,516.77" $0.00 "$2,552.50" "$4,043.16" "$4,084.00" $0.00 $0.00 $798.93 $0.00 $0.00 $812.72 $0.00 $0.00 $0.00 $0.00 $0.00 8452422 SUP HCPCS C1713 8452422 - ROD CONNECTOR LH 5.5MM 25 X 200MM BOTH IP/OP "$5,105.00 " "$3,777.70" $0.00 "$4,084.00" "$2,297.25" "$2,297.25" $0.00 $0.00 $0.00 "$1,064.01" "$3,788.93" "$3,788.93" $0.00 $0.00 "$1,063.88" $0.00 "$2,516.77" "$2,516.77" $0.00 "$2,552.50" "$4,043.16" "$4,084.00" $0.00 $0.00 $798.93 $0.00 $0.00 $812.72 $0.00 $0.00 $0.00 $0.00 $0.00 8452432 SUP HCPCS C1713 8452432 - ROD CONNECTOR LH 5.5MM 35 X 200MM BOTH IP/OP "$5,105.00 " "$3,777.70" $0.00 "$4,084.00" "$2,297.25" "$2,297.25" $0.00 $0.00 $0.00 "$1,064.01" "$3,788.93" "$3,788.93" $0.00 $0.00 "$1,063.88" $0.00 "$2,516.77" "$2,516.77" $0.00 "$2,552.50" "$4,043.16" "$4,084.00" $0.00 $0.00 $798.93 $0.00 $0.00 $812.72 $0.00 $0.00 $0.00 $0.00 $0.00 8452442 SUP HCPCS C1713 8452442 - ROD CONNECTOR LH 5.5MM 40 X 200MM BOTH IP/OP "$5,105.00 " "$3,777.70" $0.00 "$4,084.00" "$2,297.25" "$2,297.25" $0.00 $0.00 $0.00 "$1,064.01" "$3,788.93" "$3,788.93" $0.00 $0.00 "$1,063.88" $0.00 "$2,516.77" "$2,516.77" $0.00 "$2,552.50" "$4,043.16" "$4,084.00" $0.00 $0.00 $798.93 $0.00 $0.00 $812.72 $0.00 $0.00 $0.00 $0.00 $0.00 8452500 SUP HCPCS C1713 8452500 - ROD SPNL 500MM 5.5MM TI BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 8452512 SUP HCPCS C1713 8452512 - ROD CONNECTOR RH 5.5MM 15 X 200MM BOTH IP/OP "$5,105.00 " "$3,777.70" $0.00 "$4,084.00" "$2,297.25" "$2,297.25" $0.00 $0.00 $0.00 "$1,064.01" "$3,788.93" "$3,788.93" $0.00 $0.00 "$1,063.88" $0.00 "$2,516.77" "$2,516.77" $0.00 "$2,552.50" "$4,043.16" "$4,084.00" $0.00 $0.00 $798.93 $0.00 $0.00 $812.72 $0.00 $0.00 $0.00 $0.00 $0.00 8452522 SUP HCPCS C1713 8452522 - ROD CONNECTOR RH 5.5MM 25 X 200MM BOTH IP/OP "$5,105.00 " "$3,777.70" $0.00 "$4,084.00" "$2,297.25" "$2,297.25" $0.00 $0.00 $0.00 "$1,064.01" "$3,788.93" "$3,788.93" $0.00 $0.00 "$1,063.88" $0.00 "$2,516.77" "$2,516.77" $0.00 "$2,552.50" "$4,043.16" "$4,084.00" $0.00 $0.00 $798.93 $0.00 $0.00 $812.72 $0.00 $0.00 $0.00 $0.00 $0.00 8452532 SUP HCPCS C1713 8452532 - ROD CONNECTOR RH 5.5MM 35 X 200MM BOTH IP/OP "$5,105.00 " "$3,777.70" $0.00 "$4,084.00" "$2,297.25" "$2,297.25" $0.00 $0.00 $0.00 "$1,064.01" "$3,788.93" "$3,788.93" $0.00 $0.00 "$1,063.88" $0.00 "$2,516.77" "$2,516.77" $0.00 "$2,552.50" "$4,043.16" "$4,084.00" $0.00 $0.00 $798.93 $0.00 $0.00 $812.72 $0.00 $0.00 $0.00 $0.00 $0.00 8452542 SUP HCPCS C1713 8452542 - ROD CONNECTOR RH 5.5MM 40 X 200MM BOTH IP/OP "$5,105.00 " "$3,777.70" $0.00 "$4,084.00" "$2,297.25" "$2,297.25" $0.00 $0.00 $0.00 "$1,064.01" "$3,788.93" "$3,788.93" $0.00 $0.00 "$1,063.88" $0.00 "$2,516.77" "$2,516.77" $0.00 "$2,552.50" "$4,043.16" "$4,084.00" $0.00 $0.00 $798.93 $0.00 $0.00 $812.72 $0.00 $0.00 $0.00 $0.00 $0.00 8453101 SUP Custom 27803010 8453101 - HOOK SPNL 5.5MM SM PDCL TI BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8453102 SUP Custom 27803010 8453102 - HOOK SPNL 5.5MM MED PDCL TI BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8453112 SUP Custom 27803010 8453112 - HOOK SPNL 6MM 5.5MM LMNR TI RED BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8453113 SUP Custom 27803010 8453113 - HOOK SPNL 8MM 5.5MM LMNR TI RED BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8453114 SUP Custom 27803010 8453114 - HOOK SPNL 10MM 5.5MM LMNR RED BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8453121 SUP Custom 27803010 8453121 - HOOK SPNL 5.5MM RIGHT TI ANG BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8453122 SUP Custom 27803010 8453122 - HOOK SPNL 5.5MM LEFT TI ANG BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8453123 SUP Custom 27803010 8453123 - HOOK SPNL 5.5MM TI RIGHT OFFST BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8453124 SUP Custom 27803010 8453124 - HOOK SPNL 5.5MM TI LEFT OFFST BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8454025 SUP HCPCS C1713 8454025 - SCREW BONE 4MM 25MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454030 SUP HCPCS C1713 8454030 - SCREW BONE 4MM 30MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454035 SUP HCPCS C1713 8454035 - SCREW BONE 4MM 35MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454040 SUP HCPCS C1713 8454040 - SCREW BONE 4MM 40MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454045 SUP HCPCS C1713 8454045 - SCREW BONE 4MM 45MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454402 SUP HCPCS C1713 8454402 - CONNECTOR ROD PARALLEL 5.5MM CLOSE TITANIUM SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8454404 SUP HCPCS C1713 8454404 - CONNECTOR ROD 5.5MM NS ARMADA PRLL SPNE ASF25T BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8454525 SUP HCPCS C1713 8454525 - SCREW BONE 4.5MM 25MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454530 SUP HCPCS C1713 8454530 - SCREW BONE 4.5MM 30MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454535 SUP HCPCS C1713 8454535 - SCREW BONE 4.5MM 35MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454540 SUP HCPCS C1713 8454540 - SCREW BONE 40MM 4.5MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454545 SUP HCPCS C1713 8454545 - SCREW BONE 45MM 4.5MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8454602 SUP HCPCS C1713 8454602 - CONNECTOR ROD 5.5MM 4 HOLE TITANIUM SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8454604 SUP HCPCS C1713 8454604 - CONNECTOR ROD 5.5MM NS ARMADA 4 HL PRLL SPNE ASF25T BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8455025 SUP HCPCS C1713 8455025 - SCREW BONE 5MM 25MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455030 SUP HCPCS C1713 8455030 - SCREW BONE 5MM 30MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455035 SUP HCPCS C1713 8455035 - SCREW BONE 5MM 35MM SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455040 SUP HCPCS C1713 8455040 - SCREW BONE 5MM 40MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455045 SUP HCPCS C1713 8455045 - SCREW BONE 5MM 45MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455050 SUP HCPCS C1713 8455050 - SCREW BONE 5MM 50MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455525 SUP HCPCS C1713 8455525 - SCREW BONE 5.5MM 25MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455530 SUP HCPCS C1713 8455530 - SCREW BONE 5.5MM 30MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455535 SUP HCPCS C1713 8455535 - SCREW BONE 5.5MM 35MM SPNL POLYAX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455540 SUP HCPCS C1713 8455540 - SCREW BONE 5.5MM 40MM SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455545 SUP HCPCS C1713 8455545 - SCREW BONE 5.5MM 45MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455550 SUP HCPCS C1713 8455550 - SCREW BONE 5.5MM 50MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8455555 SUP HCPCS C1713 8455555 - SCREW BONE 5.5MM 55MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8456530 SUP HCPCS C1713 8456530 - SCREW BONE 6.5MM 30MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8456535 SUP HCPCS C1713 8456535 - SCREW BONE 6.5MM 35MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8456540 SUP HCPCS C1713 8456540 - SCREW BN 6.5MM 40MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8456545 SUP HCPCS C1713 8456545 - SCREW BN 6.5MM 45MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8456550 SUP HCPCS C1713 8456550 - SCREW BN 6.5MM 50MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8456555 SUP HCPCS C1713 8456555 - SCREW BN 6.5MM 55MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8456560 SUP HCPCS C1713 8456560 - SCREW BONE 6.5MM 60MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8457530 SUP HCPCS C1713 8457530 - SCREW BONE 7.5MM 30MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8457535 SUP HCPCS C1713 8457535 - SCREW BONE 7.5MM 35MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8457540 SUP HCPCS C1713 8457540 - SCREW BN 7.5MM 40MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8457545 SUP HCPCS C1713 8457545 - SCREW BN 7.5MM 45MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8457550 SUP HCPCS C1713 8457550 - SCREW BN 7.5MM 50MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8457555 SUP HCPCS C1713 8457555 - SCREW BN 7.5MM 55MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8457560 SUP HCPCS C1713 8457560 - SCREW BN 7.5MM 60MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8458530 SUP HCPCS C1713 8458530 - SCREW BONE 8.5MM 30MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8458535 SUP HCPCS C1713 8458535 - SCREW BONE 8.5MM 35MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8458540 SUP HCPCS C1713 8458540 - SCREW BONE 8.5MM 40MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8458545 SUP HCPCS C1713 8458545 - SCREW BONE 8.5MM 45MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8458550 SUP HCPCS C1713 8458550 - SCREW BN 8.5MM 50MM NS ARMADA PA TI SPNE ARM15T BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8459530 SUP HCPCS C1713 8459530 - SCREW BONE 9.5MM 30MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8459535 SUP HCPCS C1713 8459535 - SCREW BONE 9.5MM 35MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8459540 SUP HCPCS C1713 8459540 - SCREW BONE 9.5MM 40MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8459545 SUP HCPCS C1713 8459545 - SCREW BONE 9.5MM 45MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8459550 SUP HCPCS C1713 8459550 - SCREW BONE 9.5MM 50MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8459555 SUP HCPCS C1713 8459555 - SCREW BONE 9.5MM 55MM POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8461100 SUP HCPCS C1713 8461100 - SCREW BN 5.5MM 100MM NS ARMADA LCK OPN TULIP TI SPNE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8461302 SUP HCPCS C1713 8461302 - CONNECTOR ROD 5.5MM 6.25MM INLN TI BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8461402 SUP HCPCS C1713 8461402 - CONCTR ROD 6.5/5.5MM PRLL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8461602 SUP HCPCS C1713 8461602 - CONCTR ROD 6.25/5.5MM 4 HOLE TI BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8464402 SUP HCPCS C1713 8464402 - CONNECTOR ROD PARALLEL 5.5MM 6.35MM CLOSE TITANIUM SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8464404 SUP HCPCS C1713 8464404 - CONNECTOR ROD 5.5-6.35MM NS ARMADA PRLL SPNE ASF26T BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8464602 SUP HCPCS C1713 8464602 - CONNECTOR ROD PARALLEL 5.5MM 6.35MM 4 HOLE TITANIUM SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8464604 SUP HCPCS C1713 8464604 - CONNECTOR ROD 5.5-6.35MM NS ARMADA 4 HL PRLL SPNE ASF26T BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8480511 SUP HCPCS C1713 8480511 - STAPLE 8480511 3 PRONG 12MM TI BOTH IP/OP $579.00 $428.46 $0.00 $463.20 $260.55 $260.55 $0.00 $0.00 $0.00 $120.68 $429.73 $429.73 $0.00 $0.00 $120.66 $0.00 $342.48 $342.48 $0.00 $289.50 $458.57 $463.20 $0.00 $0.00 $90.61 $0.00 $0.00 $92.18 $0.00 $0.00 $0.00 $0.00 $0.00 8480512 SUP HCPCS C1713 8480512 - STAPLE 8480512 12MM TI BOTH IP/OP $579.00 $428.46 $0.00 $463.20 $260.55 $260.55 $0.00 $0.00 $0.00 $120.68 $429.73 $429.73 $0.00 $0.00 $120.66 $0.00 $342.48 $342.48 $0.00 $289.50 $458.57 $463.20 $0.00 $0.00 $90.61 $0.00 $0.00 $92.18 $0.00 $0.00 $0.00 $0.00 $0.00 8481623 SUP HCPCS C1713 8481623 - SCREW 8481623 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481625 SUP HCPCS C1713 8481625 - SCREW 8481625 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481628 SUP HCPCS C1713 8481628 - SCREW 8481628 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481630 SUP HCPCS C1713 8481630 - SCREW 8481630 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481633 SUP HCPCS C1713 8481633 - SCREW 8481633 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481635 SUP HCPCS C1713 8481635 - SCREW 8481635 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481638 SUP HCPCS C1713 8481638 - SCREW 8481638 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481640 SUP HCPCS C1713 8481640 - SCREW 8481640 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481643 SUP HCPCS C1713 8481643 - SCREW 8481643 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481645 SUP HCPCS C1713 8481645 - SCREW 8481645 CANNULATED BONE 6.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481648 SUP HCPCS C1713 8481648 - BONE SCREW 8481648 6.5MM TI CANNULATED BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481650 SUP HCPCS C1713 8481650 - SCREW BONE 6.5MM 50MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481653 SUP HCPCS C1713 8481653 - SCREW BONE 6.5MM 53MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481655 SUP HCPCS C1713 8481655 - SCREW BONE 6.5MM 55MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481723 SUP HCPCS C1713 8481723 - SCREW BONE 7.5MM 48MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481725 SUP HCPCS C1713 8481725 - SCREW BONE 7.5MM 50MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481728 SUP HCPCS C1713 8481728 - SCREW BONE 7.5MM 53MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481730 SUP HCPCS C1713 8481730 - SCREW BONE 7.5MM 55MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481733 SUP HCPCS C1713 8481733 - SCREW 8481733 CANNULATED BONE 7.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481735 SUP HCPCS C1713 8481735 - SCREW 8481735 CANNULATED BONE 7.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481738 SUP HCPCS C1713 8481738 - SCREW 8481738 CANNULATED BONE 7.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481743 SUP HCPCS C1713 8481743 - SCREW 8481743 CANNULATED BONE 7.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481745 SUP HCPCS C1713 8481745 - SCREW 8481745 CANNULATED BONE 7.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481748 SUP HCPCS C1713 8481748 - SCREW BONE 7.5MM 48MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481750 SUP HCPCS C1713 8481750 - SCREW BONE 7.5MM 50MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481753 SUP HCPCS C1713 8481753 - SCREW BONE 7.5MM 53MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481755 SUP HCPCS C1713 8481755 - SCREW BONE 7.5MM 55MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481823 SUP HCPCS C1713 8481823 - SCREW BONE 8.5MM 23MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481825 SUP HCPCS C1713 8481825 - SCREW 8481825 CANNULATED BONE 8.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481828 SUP HCPCS C1713 8481828 - SCREW BONE 8.5MM 28MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481830 SUP HCPCS C1713 8481830 - SCREW 8481830 CANNULATED BONE 8.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481833 SUP HCPCS C1713 8481833 - SCREW BONE 8.5MM 33MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481835 SUP HCPCS C1713 8481835 - SCREW 8481835 CANNULATED BONE 8.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481838 SUP HCPCS C1713 8481838 - SCREW BONE 8.5MM 38MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481840 SUP HCPCS C1713 8481840 - SCREW 8481840 CANNULATED BONE 8.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481843 SUP HCPCS C1713 8481843 - SCREW BONE 8.5MM 43MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481845 SUP HCPCS C1713 8481845 - SCREW 8481845 CANNULATED BONE 8.5MM TI BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481848 SUP HCPCS C1713 8481848 - SCREW BONE 8.5MM 48MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481850 SUP HCPCS C1713 8481850 - SCREW BONE 8.5MM 50MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481853 SUP HCPCS C1713 8481853 - SCREW BONE 8.5MM 53MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481855 SUP HCPCS C1713 8481855 - SCREW BONE 8.5MM 55MM TI SPNL CANN BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 8481910 SUP Custom 27203010 8481910 - INSTRUMENT 8481910 6.5MM RM CAN TAP BOTH IP/OP $945.00 $699.30 $0.00 $756.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $701.38 $701.38 $0.00 $0.00 $196.94 $0.00 $0.00 $0.00 $0.00 $472.50 $748.44 $756.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8481912 SUP Custom 27203010 8481912 - INSTRUMENT 8481912 7.5MM RM TP HNDL GRN BOTH IP/OP $945.00 $699.30 $0.00 $756.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $701.38 $701.38 $0.00 $0.00 $196.94 $0.00 $0.00 $0.00 $0.00 $472.50 $748.44 $756.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8482623 SUP HCPCS C1713 8482623 - SCREW 8482623 CDH ECLIPSE 6.5X22.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482625 SUP HCPCS C1713 8482625 - SCREW 8482625 CDH ECLIPSE 6.5X25MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482628 SUP HCPCS C1713 8482628 - SCREW 8482628 CDH ECLIPSE 6.5X27.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482630 SUP HCPCS C1713 8482630 - SCREW 8482630 CDH ECLIPSE 6.5X30MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482633 SUP HCPCS C1713 8482633 - SCREW 8482633 CDH ECLIPSE 6.5X32.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482635 SUP HCPCS C1713 8482635 - SCREW 8482635 CDH ECLIPSE 6.5X35MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482638 SUP HCPCS C1713 8482638 - SCREW 8482638 CDH ECLIPSE 6.5X37.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482640 SUP HCPCS C1713 8482640 - SCREW 8482640 CDH ECLIPSE 6.5X40MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482643 SUP HCPCS C1713 8482643 - SCREW 8482643 CDH ECLIPSE 6.5X42.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482645 SUP HCPCS C1713 8482645 - SCREW 8482645 CDH ECLIPSE 6.5X45MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482648 SUP HCPCS C1713 8482648 - SCREW BONE 6.5MM 47.5MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482650 SUP HCPCS C1713 8482650 - SCREW BONE 6.5MM 50MM ECLPS DBL HEX BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482653 SUP HCPCS C1713 8482653 - SCREW BONE 6.5MM 52.5MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482655 SUP HCPCS C1713 8482655 - SCREW BONE 6.5MM 55MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482723 SUP HCPCS C1713 8482723 - SCREW 8482723 CDH ECLIPSE 7.5X22.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482725 SUP HCPCS C1713 8482725 - SCREW 8482725 CDH ECLIPSE 7.5X25MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482728 SUP HCPCS C1713 8482728 - SCREW 8482728 CDH ECLIPSE 7.5X27.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482730 SUP HCPCS C1713 8482730 - SCREW 8482730 CDH ECLIPSE 7.5X30MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482733 SUP HCPCS C1713 8482733 - SCREW 8482733 CDH ECLIPSE 7.5X32.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482735 SUP HCPCS C1713 8482735 - SCREW 8482735 CDH ECLIPSE 7.5X35MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482738 SUP HCPCS C1713 8482738 - SCREW 8482738 CDH ECLIPSE 7.5X37.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482740 SUP HCPCS C1713 8482740 - SCREW 8482740 CDH ECLIPSE 7.5X40MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482743 SUP HCPCS C1713 8482743 - SCREW 8482743 CDH ECLIPSE 7.5X42.5MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482745 SUP HCPCS C1713 8482745 - SCREW 8482745 CDH ECLIPSE 7.5X45MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482748 SUP HCPCS C1713 8482748 - SCREW BONE 7.5MM 47.5MM ECLPS DBL HEX BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482750 SUP HCPCS C1713 8482750 - SCREW BONE 7.5MM 50MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482753 SUP HCPCS C1713 8482753 - SCREW BONE 7.5MM 52.5MM ECLPS DBL HEX BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482755 SUP HCPCS C1713 8482755 - SCREW BONE 7.5MM 55MM ECLPS DBL HEX BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482823 SUP HCPCS C1713 8482823 - SCREW BONE 8.5MM 22.5MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482825 SUP HCPCS C1713 8482825 - SCREW 8482825 CDH ECLIPSE 8.5X25MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482828 SUP HCPCS C1713 8482828 - SCREW BONE 8.5MM 27.5MM ECLPS DBL HEX BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482830 SUP HCPCS C1713 8482830 - SCREW 8482830 CDH ECLIPSE 8.5X30MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482833 SUP HCPCS C1713 8482833 - SCREW BONE 8.5MM 32.5MM ECLPS DBL HEX BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482835 SUP HCPCS C1713 8482835 - SCREW 8482835 CDH ECLIPSE 8.5X35MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482838 SUP HCPCS C1713 8482838 - SCREW BONE 8.5MM 37.5MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482840 SUP HCPCS C1713 8482840 - SCREW 8482840 CDH ECLIPSE 8.5X40MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482843 SUP HCPCS C1713 8482843 - SCREW BONE 8.5MM 42.5MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482845 SUP HCPCS C1713 8482845 - SCREW 8482845 CDH ECLIPSE 8.5X45MM BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482848 SUP HCPCS C1713 8482848 - SCREW BONE 8.5MM 47.5MM ECLPS DBL HEX BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482850 SUP HCPCS C1713 8482850 - SCREW BONE 8.5MM 50MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482853 SUP HCPCS C1713 8482853 - SCREW BONE 8.5MM 52.5MM ECLPS SPNL BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8482855 SUP HCPCS C1713 8482855 - SCREW BONE 8.5MM 55MM ECLPS DBL HEX BOTH IP/OP "$2,890.50 " "$2,138.97" $0.00 "$2,312.40" "$1,300.73" "$1,300.73" $0.00 $0.00 $0.00 $602.45 "$2,145.33" "$2,145.33" $0.00 $0.00 $602.38 $0.00 "$1,425.02" "$1,425.02" $0.00 "$1,445.25" "$2,289.28" "$2,312.40" $0.00 $0.00 $452.36 $0.00 $0.00 $460.17 $0.00 $0.00 $0.00 $0.00 $0.00 8530000 SUP HCPCS C1713 8530000 - PLATE 8530000 TROUGH PLATE BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 8530008 SUP HCPCS C1713 8530008 - PLATE 8MM BONE SPN BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 8530408 SUP HCPCS C1713 8530408 - PLATE BN 8MM NS CENTERPIECE GFT SPNE BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 8530605 SUP Custom 27203010 8530605 - BIT DRL 1.9MM STRL 3 FLT DISP BOTH IP/OP $349.50 $258.63 $0.00 $279.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.40 $259.40 $0.00 $0.00 $72.84 $0.00 $0.00 $0.00 $0.00 $174.75 $276.80 $279.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8536510 SUP HCPCS C1713 8536510 - SCREW ILIAC 6.5MM 100MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8536560 SUP HCPCS C1713 8536560 - SCREW ILIAC 6.5MM 60MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8536570 SUP HCPCS C1713 8536570 - SCREW ILIAC 6.5MM 70MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8536580 SUP HCPCS C1713 8536580 - SCREW ILIAC 6.5MM 80MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8536590 SUP HCPCS C1713 8536590 - SCREW ILIAC 6.5MM 90MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8537510 SUP HCPCS C1713 8537510 - SCREW ILIAC 7.5MM 100MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8537570 SUP HCPCS C1713 8537570 - SCREW ILIAC 7.5MM 70MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8537580 SUP HCPCS C1713 8537580 - SCREW ILIAC 7.5MM 80MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8537590 SUP HCPCS C1713 8537590 - SCREW ILIAC 7.5MM 90MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8538510 SUP HCPCS C1713 8538510 - SCREW ILIAC 8.5MM 100MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8538570 SUP HCPCS C1713 8538570 - SCREW ILIAC 8.5MM 70MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8538580 SUP HCPCS C1713 8538580 - SCREW ILIAC 8.5MM 80MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8538590 SUP HCPCS C1713 8538590 - SCREW ILIAC 8.5MM 90MM SC 5.5MM SS BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8540611 SUP HCPCS C1713 8540611 - CROSSLINK 8540611 11 MM ANTERIOR LPC TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8540612 SUP HCPCS C1713 8540612 - CROSSLINK 8540612 12 MM ANTERIOR LPC TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8540613 SUP HCPCS C1713 8540613 - CROSSLINK 8540613 13 MM ANTERIOR LPC TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8540614 SUP HCPCS C1713 8540614 - CROSSLINK 8540614 14 MM ANTERIOR LPC TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8540615 SUP HCPCS C1713 8540615 - CROSSLINK 8540615 15 MM ANTERIOR LPC TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8540616 SUP HCPCS C1713 8540616 - CROSSLINK 8540616 16 MM ANTERIOR LPC TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8540617 SUP HCPCS C1713 8540617 - CROSSLINK 8540617 17 MM ANTERIOR LPC TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8546796 SUP Custom 27203010 REAGENT LYS SOL CLTR LYS S 5L MAXM/HMX/LH SER ANALY BOTH IP/OP $815.20 $603.25 $0.00 $652.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.60 $645.64 $652.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8547008 SUP Custom 27203010 REAGENT SHTH FLUID ISFLW 1.8L ANALY BOTH IP/OP $38.05 $28.16 $0.00 $30.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.03 $30.14 $30.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8547194 SUP Custom 27203010 REAGENT DILU CLTR ISOT CARBOY 20L LH700 SER ANALY BOTH IP/OP $64.33 $47.60 $0.00 $51.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.16 $50.95 $51.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8547195 SUP Custom 27203010 REAGENT DILU CLTR SCTR PK 20L LH700 SER ANALY BOTH IP/OP $354.18 $262.09 $0.00 $283.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.09 $280.51 $283.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8547196 SUP Custom 27203010 REAGENT RETCYT CLTR 20L LH700 SER ANALY BOTH IP/OP $419.10 $310.13 $0.00 $335.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $209.55 $331.93 $335.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8548498 SUP HCPCS C1713 8548498 - STAPLE 8548498 19MM CAUDAL TI BOTH IP/OP "$2,518.50 " "$1,863.69" $0.00 "$2,014.80" "$1,133.33" "$1,133.33" $0.00 $0.00 $0.00 $524.92 "$1,869.23" "$1,869.23" $0.00 $0.00 $524.86 $0.00 "$1,241.62" "$1,241.62" $0.00 "$1,259.25" "$1,994.65" "$2,014.80" $0.00 $0.00 $394.15 $0.00 $0.00 $400.95 $0.00 $0.00 $0.00 $0.00 $0.00 8548499 SUP HCPCS C1713 8548499 - STAPLE 8548499 19MM ROSTRAL TI BOTH IP/OP "$2,518.50 " "$1,863.69" $0.00 "$2,014.80" "$1,133.33" "$1,133.33" $0.00 $0.00 $0.00 $524.92 "$1,869.23" "$1,869.23" $0.00 $0.00 $524.86 $0.00 "$1,241.62" "$1,241.62" $0.00 "$1,259.25" "$1,994.65" "$2,014.80" $0.00 $0.00 $394.15 $0.00 $0.00 $400.95 $0.00 $0.00 $0.00 $0.00 $0.00 8548500 SUP HCPCS C1713 8548500 - STAPLE 8548500 21 MM CAUDAL TI BOTH IP/OP "$2,518.50 " "$1,863.69" $0.00 "$2,014.80" "$1,133.33" "$1,133.33" $0.00 $0.00 $0.00 $524.92 "$1,869.23" "$1,869.23" $0.00 $0.00 $524.86 $0.00 "$1,241.62" "$1,241.62" $0.00 "$1,259.25" "$1,994.65" "$2,014.80" $0.00 $0.00 $394.15 $0.00 $0.00 $400.95 $0.00 $0.00 $0.00 $0.00 $0.00 8548501 SUP HCPCS C1713 8548501 - STAPLE 8548501 21 MM ROSTRAL TI BOTH IP/OP "$2,518.50 " "$1,863.69" $0.00 "$2,014.80" "$1,133.33" "$1,133.33" $0.00 $0.00 $0.00 $524.92 "$1,869.23" "$1,869.23" $0.00 $0.00 $524.86 $0.00 "$1,241.62" "$1,241.62" $0.00 "$1,259.25" "$1,994.65" "$2,014.80" $0.00 $0.00 $394.15 $0.00 $0.00 $400.95 $0.00 $0.00 $0.00 $0.00 $0.00 8549008 SUP HCPCS C1713 8549008 - CROSSLINK 8549008 16TI LPC FOR 4.5ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549009 SUP HCPCS C1713 8549009 - CROSSLINK 8549009 19TI LPC FOR 4.5ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549010 SUP HCPCS C1713 8549010 - CROSSLINK 8549010 22TI LPC FOR 4.5ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549011 SUP HCPCS C1713 8549011 - CROSSLINK 8549011 25TI LPC FOR 4.5ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549012 SUP HCPCS C1713 8549012 - CROSSLINK 8549012 29TI LPC FOR 4.5ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549013 SUP HCPCS C1713 8549013 - CROSSLINK 8549013 32TI LPC FOR 4.5ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549014 SUP HCPCS C1713 8549014 - CROSSLINK 8549014 35TI LPC FOR 4.5ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549015 SUP HCPCS C1713 8549015 - CROSSLINK 8549015 38TI LPC FOR 4.5ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549016 SUP HCPCS C1713 8549016 - CROSSLINK 8549016 4.5MM MLTSPAN LPC SM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549017 SUP HCPCS C1713 8549017 - CROSSLINK 8549017 4.5MM MLTSPAN LPC MD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549018 SUP HCPCS C1713 8549018 - CROSSLINK 8549018 4.5MM MLTSPAN LPC LG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8549300 SUP Custom 27803010 8549300 - CONNECTOR 8549300 4.5 4.5 OPEN DOMINO TI BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8549301 SUP Custom 27803010 8549301 - CONNECTOR 8549301 4.5 5.5 OPEN DOMINO TI BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8549305 SUP Custom 27803010 8549305 - CONNECTOR 8549305 4.5 MM DOMINO BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8549306 SUP Custom 27803010 8549306 - CONNECTOR 8549306 4.5 MM 5.5MM DOMINO BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8550120 SUP HCPCS C1713 8550120 - CONCTR ROD 20MM 5.5MM CX FIX SS BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550122 SUP HCPCS C1713 8550122 - CONCTR ROD 22.5MM 5.5MM CX FIX SS BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550125 SUP HCPCS C1713 8550125 - CONCTR ROD 25MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550127 SUP HCPCS C1713 8550127 - CONCTR ROD 27.5MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550130 SUP HCPCS C1713 8550130 - CONCTR ROD 30MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550132 SUP HCPCS C1713 8550132 - CONCTR ROD 32.5MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550135 SUP HCPCS C1713 8550135 - CONCTR ROD 35MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550137 SUP HCPCS C1713 8550137 - CONCTR ROD 37.5MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550140 SUP HCPCS C1713 8550140 - CONCTR ROD 40MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550145 SUP HCPCS C1713 8550145 - CONCTR ROD 45MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550150 SUP HCPCS C1713 8550150 - CONCTR ROD 50MM 5.5MM SS CX FIX BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 8550245 SUP HCPCS C1713 8550245 - CONCTR ROD 45-50MM 5.5MM SS CX BOTH IP/OP "$4,905.00 " "$3,629.70" $0.00 "$3,924.00" "$2,207.25" "$2,207.25" $0.00 $0.00 $0.00 "$1,022.32" "$3,640.49" "$3,640.49" $0.00 $0.00 "$1,022.20" $0.00 "$2,418.17" "$2,418.17" $0.00 "$2,452.50" "$3,884.76" "$3,924.00" $0.00 $0.00 $767.63 $0.00 $0.00 $780.88 $0.00 $0.00 $0.00 $0.00 $0.00 8550250 SUP HCPCS C1713 8550250 - CONCTR ROD 50-60MM 5.5MM SS CX BOTH IP/OP "$4,905.00 " "$3,629.70" $0.00 "$3,924.00" "$2,207.25" "$2,207.25" $0.00 $0.00 $0.00 "$1,022.32" "$3,640.49" "$3,640.49" $0.00 $0.00 "$1,022.20" $0.00 "$2,418.17" "$2,418.17" $0.00 "$2,452.50" "$3,884.76" "$3,924.00" $0.00 $0.00 $767.63 $0.00 $0.00 $780.88 $0.00 $0.00 $0.00 $0.00 $0.00 8550260 SUP HCPCS C1713 8550260 - CONCTR ROD 60-70MM 5.5MM SS CX BOTH IP/OP "$4,905.00 " "$3,629.70" $0.00 "$3,924.00" "$2,207.25" "$2,207.25" $0.00 $0.00 $0.00 "$1,022.32" "$3,640.49" "$3,640.49" $0.00 $0.00 "$1,022.20" $0.00 "$2,418.17" "$2,418.17" $0.00 "$2,452.50" "$3,884.76" "$3,924.00" $0.00 $0.00 $767.63 $0.00 $0.00 $780.88 $0.00 $0.00 $0.00 $0.00 $0.00 8550270 SUP HCPCS C1713 8550270 - CONCTR ROD 70-85MM 5.5MM SS CX BOTH IP/OP "$4,905.00 " "$3,629.70" $0.00 "$3,924.00" "$2,207.25" "$2,207.25" $0.00 $0.00 $0.00 "$1,022.32" "$3,640.49" "$3,640.49" $0.00 $0.00 "$1,022.20" $0.00 "$2,418.17" "$2,418.17" $0.00 "$2,452.50" "$3,884.76" "$3,924.00" $0.00 $0.00 $767.63 $0.00 $0.00 $780.88 $0.00 $0.00 $0.00 $0.00 $0.00 8550302 SUP HCPCS C1713 8550302 - CONCTR ROD 5.5MM SS INLN BOTH IP/OP "$2,880.00 " "$2,131.20" $0.00 "$2,304.00" "$1,296.00" "$1,296.00" $0.00 $0.00 $0.00 $600.26 "$2,137.54" "$2,137.54" $0.00 $0.00 $600.19 $0.00 "$1,419.84" "$1,419.84" $0.00 "$1,440.00" "$2,280.96" "$2,304.00" $0.00 $0.00 $450.72 $0.00 $0.00 $458.50 $0.00 $0.00 $0.00 $0.00 $0.00 8550402 SUP HCPCS C1713 8550402 - CONCTR ROD 5.5MM SS PRLL BOTH IP/OP "$2,880.00 " "$2,131.20" $0.00 "$2,304.00" "$1,296.00" "$1,296.00" $0.00 $0.00 $0.00 $600.26 "$2,137.54" "$2,137.54" $0.00 $0.00 $600.19 $0.00 "$1,419.84" "$1,419.84" $0.00 "$1,440.00" "$2,280.96" "$2,304.00" $0.00 $0.00 $450.72 $0.00 $0.00 $458.50 $0.00 $0.00 $0.00 $0.00 $0.00 8550602 SUP HCPCS C1713 8550602 - CONCTR ROD 5.5MM SS 4 HOLE BOTH IP/OP "$3,617.50 " "$2,676.95" $0.00 "$2,894.00" "$1,627.88" "$1,627.88" $0.00 $0.00 $0.00 $753.98 "$2,684.91" "$2,684.91" $0.00 $0.00 $753.89 $0.00 "$1,783.43" "$1,783.43" $0.00 "$1,808.75" "$2,865.06" "$2,894.00" $0.00 $0.00 $566.14 $0.00 $0.00 $575.91 $0.00 $0.00 $0.00 $0.00 $0.00 8552200 SUP HCPCS C1713 8552200 - ROD 5.5MM 200MM SS BOTH IP/OP "$1,295.00 " $958.30 $0.00 "$1,036.00" $582.75 $582.75 $0.00 $0.00 $0.00 $269.91 $961.15 $961.15 $0.00 $0.00 $269.88 $0.00 $765.99 $765.99 $0.00 $647.50 "$1,025.64" "$1,036.00" $0.00 $0.00 $202.67 $0.00 $0.00 $206.16 $0.00 $0.00 $0.00 $0.00 $0.00 8552300 SUP HCPCS C1713 8552300 - ROD 5.5MM 300MM SS BOTH IP/OP "$1,860.00 " "$1,376.40" $0.00 "$1,488.00" $837.00 $837.00 $0.00 $0.00 $0.00 $387.67 "$1,380.49" "$1,380.49" $0.00 $0.00 $387.62 $0.00 "$1,100.19" "$1,100.19" $0.00 $930.00 "$1,473.12" "$1,488.00" $0.00 $0.00 $291.09 $0.00 $0.00 $296.11 $0.00 $0.00 $0.00 $0.00 $0.00 8552500 SUP HCPCS C1713 8552500 - ROD SPNL 500MM 5.5MM SS BOTH IP/OP "$1,922.50 " "$1,422.65" $0.00 "$1,538.00" $865.13 $865.13 $0.00 $0.00 $0.00 $400.70 "$1,426.88" "$1,426.88" $0.00 $0.00 $400.65 $0.00 "$1,137.16" "$1,137.16" $0.00 $961.25 "$1,522.62" "$1,538.00" $0.00 $0.00 $300.87 $0.00 $0.00 $306.06 $0.00 $0.00 $0.00 $0.00 $0.00 8553101 SUP Custom 27803010 8553101 - HOOK SPNL 5.5MM SM PDCL SS BOTH IP/OP "$3,115.00 " "$2,305.10" $0.00 "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,311.95" "$2,311.95" $0.00 $0.00 $649.17 $0.00 $0.00 $0.00 $0.00 "$1,557.50" "$2,467.08" "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8553102 SUP Custom 27803010 8553102 - HOOK SPNL 5.5MM MED PDCL SS BOTH IP/OP "$3,115.00 " "$2,305.10" $0.00 "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,311.95" "$2,311.95" $0.00 $0.00 $649.17 $0.00 $0.00 $0.00 $0.00 "$1,557.50" "$2,467.08" "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8553112 SUP Custom 27803010 8553112 - HOOK SPNL 6MM LMNR SS RED 5.5MM ROD BOTH IP/OP "$3,115.00 " "$2,305.10" $0.00 "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,311.95" "$2,311.95" $0.00 $0.00 $649.17 $0.00 $0.00 $0.00 $0.00 "$1,557.50" "$2,467.08" "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8553113 SUP Custom 27803010 8553113 - HOOK SPNL 8MM LMNR SS RED 5.5MM ROD BOTH IP/OP "$3,115.00 " "$2,305.10" $0.00 "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,311.95" "$2,311.95" $0.00 $0.00 $649.17 $0.00 $0.00 $0.00 $0.00 "$1,557.50" "$2,467.08" "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8553114 SUP Custom 27803010 8553114 - HOOK SPNL 10MM LMNR SS RED 5.5MM ROD BOTH IP/OP "$3,115.00 " "$2,305.10" $0.00 "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,311.95" "$2,311.95" $0.00 $0.00 $649.17 $0.00 $0.00 $0.00 $0.00 "$1,557.50" "$2,467.08" "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8553121 SUP Custom 27803010 8553121 - HOOK SPNL SS RIGHT ANG 5.5 MM ROD BOTH IP/OP "$3,950.00 " "$2,923.00" $0.00 "$3,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,931.69" "$2,931.69" $0.00 $0.00 $823.18 $0.00 $0.00 $0.00 $0.00 "$1,975.00" "$3,128.40" "$3,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8553122 SUP Custom 27803010 8553122 - HOOK SPNL SS LEFT ANG 5.5 MM ROD BOTH IP/OP "$3,950.00 " "$2,923.00" $0.00 "$3,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,931.69" "$2,931.69" $0.00 $0.00 $823.18 $0.00 $0.00 $0.00 $0.00 "$1,975.00" "$3,128.40" "$3,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8553123 SUP Custom 27803010 8553123 - HOOK SPNL SS RIGHT OFFST 5.5 MM ROD BOTH IP/OP "$3,950.00 " "$2,923.00" $0.00 "$3,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,931.69" "$2,931.69" $0.00 $0.00 $823.18 $0.00 $0.00 $0.00 $0.00 "$1,975.00" "$3,128.40" "$3,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8553124 SUP Custom 27803010 8553124 - HOOK SPNL SS LEFT OFFST 5.5 MM ROD BOTH IP/OP "$3,950.00 " "$2,923.00" $0.00 "$3,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,931.69" "$2,931.69" $0.00 $0.00 $823.18 $0.00 $0.00 $0.00 $0.00 "$1,975.00" "$3,128.40" "$3,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8554025 SUP HCPCS C1713 8554025 - SCREW BONE 4MM 25MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8554030 SUP HCPCS C1713 8554030 - SCREW BONE 4MM 30MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8554035 SUP HCPCS C1713 8554035 - SCREW BONE 4MM 35MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8554040 SUP HCPCS C1713 8554040 - SCREW BONE 4MM 40MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8554525 SUP HCPCS C1713 8554525 - SCREW BONE 4.5MM 25MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8554530 SUP HCPCS C1713 8554530 - SCREW BONE 4.5MM 30MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8554535 SUP HCPCS C1713 8554535 - SCREW BONE 4.5MM 35MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8554540 SUP HCPCS C1713 8554540 - SCREW BONE 4.5MM 40MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8554545 SUP HCPCS C1713 8554545 - SCREW BONE 4.5MM 45MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555025 SUP HCPCS C1713 8555025 - SCREW BONE 5MM 25MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555030 SUP HCPCS C1713 8555030 - SCREW BONE 5MM 30MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555035 SUP HCPCS C1713 8555035 - SCREW BONE 5MM 35MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555040 SUP HCPCS C1713 8555040 - SCREW BONE 5MM 40MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555045 SUP HCPCS C1713 8555045 - SCREW BONE 5MM 45MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555530 SUP HCPCS C1713 8555530 - SCREW BONE 5.5MM 30MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555535 SUP HCPCS C1713 8555535 - SCREW BONE 5.5MM 35MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555540 SUP HCPCS C1713 8555540 - SCREW BONE 5.5MM 40MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555545 SUP HCPCS C1713 8555545 - SCREW BONE 5.5MM 45MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555550 SUP HCPCS C1713 8555550 - SCREW BONE 5.5MM 50MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8555555 SUP HCPCS C1713 8555555 - SCREW BONE 5.5MM 55MM SS SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8556535 SUP HCPCS C1713 8556535 - SCREW BONE 6.5MM 35MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8556540 SUP HCPCS C1713 8556540 - SCREW BONE 6.5MM 40MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8556545 SUP HCPCS C1713 8556545 - SCREW BONE 6.5MM 45MM SS SPNL BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8556550 SUP HCPCS C1713 8556550 - SCREW BONE 6.5MM 50MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8556555 SUP HCPCS C1713 8556555 - SCREW BONE 6.5MM 55MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8557535 SUP HCPCS C1713 8557535 - SCREW BONE 7.5MM 35MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8557540 SUP HCPCS C1713 8557540 - SCREW BONE 7.5MM 40MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8557545 SUP HCPCS C1713 8557545 - SCREW BONE 7.5MM 45MM SS SPNL BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8557550 SUP HCPCS C1713 8557550 - SCREW BONE 7.5MM 50MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8557555 SUP HCPCS C1713 8557555 - SCREW BONE 7.5MM 55MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8558540 SUP HCPCS C1713 8558540 - SCREW BONE 8.5MM 40MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8558545 SUP HCPCS C1713 8558545 - SCREW BONE 8.5MM 45MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8558550 SUP HCPCS C1713 8558550 - SCREW BONE 8.5MM 50MM SPNL POLYAX 5.5MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8560302 SUP HCPCS C1713 8560302 - CONCTR ROD 6.35/5.5MM SS INLN BOTH IP/OP "$2,880.00 " "$2,131.20" $0.00 "$2,304.00" "$1,296.00" "$1,296.00" $0.00 $0.00 $0.00 $600.26 "$2,137.54" "$2,137.54" $0.00 $0.00 $600.19 $0.00 "$1,419.84" "$1,419.84" $0.00 "$1,440.00" "$2,280.96" "$2,304.00" $0.00 $0.00 $450.72 $0.00 $0.00 $458.50 $0.00 $0.00 $0.00 $0.00 $0.00 8560402 SUP HCPCS C1713 8560402 - CONCTR ROD 6.35/5.5MM SS PRLL BOTH IP/OP "$2,880.00 " "$2,131.20" $0.00 "$2,304.00" "$1,296.00" "$1,296.00" $0.00 $0.00 $0.00 $600.26 "$2,137.54" "$2,137.54" $0.00 $0.00 $600.19 $0.00 "$1,419.84" "$1,419.84" $0.00 "$1,440.00" "$2,280.96" "$2,304.00" $0.00 $0.00 $450.72 $0.00 $0.00 $458.50 $0.00 $0.00 $0.00 $0.00 $0.00 8560602 SUP HCPCS C1713 8560602 - CONCTR ROD 6.35/5.5MM SS 4 HOLE BOTH IP/OP "$3,617.50 " "$2,676.95" $0.00 "$2,894.00" "$1,627.88" "$1,627.88" $0.00 $0.00 $0.00 $753.98 "$2,684.91" "$2,684.91" $0.00 $0.00 $753.89 $0.00 "$1,783.43" "$1,783.43" $0.00 "$1,808.75" "$2,865.06" "$2,894.00" $0.00 $0.00 $566.14 $0.00 $0.00 $575.91 $0.00 $0.00 $0.00 $0.00 $0.00 8561100 SUP HCPCS C1713 8561100 - SCREW BONE ARMADA SPNL LCK BOTH IP/OP $910.00 $673.40 $0.00 $728.00 $409.50 $409.50 $0.00 $0.00 $0.00 $189.67 $675.40 $675.40 $0.00 $0.00 $189.64 $0.00 $538.27 $538.27 $0.00 $455.00 $720.72 $728.00 $0.00 $0.00 $142.42 $0.00 $0.00 $144.87 $0.00 $0.00 $0.00 $0.00 $0.00 8561300 SUP HCPCS C1713 8561300 - CONCTR ROD ROD TO ROD LCK SCR SIDE SPNL BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $340.88 $340.88 $0.00 $0.00 $0.00 $157.88 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $448.06 $448.06 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $118.55 $0.00 $0.00 $120.59 $0.00 $0.00 $0.00 $0.00 $0.00 8562010 SUP Custom 27203010 8562010 - STIMULATOR NRV STD VRSTIM3 HNDHLD LCTR SUBDERMIS BOTH IP/OP $204.75 $151.52 $0.00 $151.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.97 $151.97 $0.00 $0.00 $42.67 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8562250 SUP HCPCS C1713 8562250 - ROD SPNL 250MM 6.35MM SS BOTH IP/OP "$1,860.00 " "$1,376.40" $0.00 "$1,488.00" $837.00 $837.00 $0.00 $0.00 $0.00 $387.67 "$1,380.49" "$1,380.49" $0.00 $0.00 $387.62 $0.00 "$1,100.19" "$1,100.19" $0.00 $930.00 "$1,473.12" "$1,488.00" $0.00 $0.00 $291.09 $0.00 $0.00 $296.11 $0.00 $0.00 $0.00 $0.00 $0.00 8562500 SUP HCPCS C1713 8562500 - ROD SPNL 500MM 6.35MM SS BOTH IP/OP "$2,017.50 " "$1,492.95" $0.00 "$1,614.00" $907.88 $907.88 $0.00 $0.00 $0.00 $420.50 "$1,497.39" "$1,497.39" $0.00 $0.00 $420.45 $0.00 "$1,193.35" "$1,193.35" $0.00 "$1,008.75" "$1,597.86" "$1,614.00" $0.00 $0.00 $315.74 $0.00 $0.00 $321.19 $0.00 $0.00 $0.00 $0.00 $0.00 8564525 SUP HCPCS C1713 8564525 - SCREW BONE 4.5MM 25MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8564530 SUP HCPCS C1713 8564530 - SCREW BONE 4.5MM 30MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8564535 SUP HCPCS C1713 8564535 - SCREW BONE 4.5MM 35MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8564540 SUP HCPCS C1713 8564540 - SCREW BONE 4.5MM 40MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8564545 SUP HCPCS C1713 8564545 - SCREW BONE 4.5MM 45MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8565530 SUP HCPCS C1713 8565530 - SCREW BONE 5.5MM 30MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8565535 SUP HCPCS C1713 8565535 - SCREW BONE 5.5MM 35MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8565540 SUP HCPCS C1713 8565540 - SCREW BONE 5.5MM 40MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8565545 SUP HCPCS C1713 8565545 - SCREW BONE 5.5MM 45MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8565550 SUP HCPCS C1713 8565550 - SCREW BONE 5.5MM 50MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8565555 SUP HCPCS C1713 8565555 - SCREW BONE 5.5MM 55MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8566530 SUP HCPCS C1713 8566530 - SCREW BONE 6.5MM 30MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8566535 SUP HCPCS C1713 8566535 - SCREW BONE 6.5MM 35MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8566540 SUP HCPCS C1713 8566540 - SCREW BONE 6.5MM 40MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8566545 SUP HCPCS C1713 8566545 - SCREW BONE 6.5MM 45MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8566550 SUP HCPCS C1713 8566550 - SCREW BONE 6.5MM 50MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8566555 SUP HCPCS C1713 8566555 - SCREW BONE 6.5MM 55MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8567535 SUP HCPCS C1713 8567535 - SCREW BONE 7.5MM 35MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8567540 SUP HCPCS C1713 8567540 - SCREW BONE 7.5MM 40MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8567545 SUP HCPCS C1713 8567545 - SCREW BONE 7.5MM 45MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8567550 SUP HCPCS C1713 8567550 - SCREW BONE 7.5MM 50MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8567555 SUP HCPCS C1713 8567555 - SCREW BONE 7.5MM 55MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8568535 SUP HCPCS C1713 8568535 - SCREW BONE 8.5MM 35MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8568540 SUP HCPCS C1713 8568540 - SCREW BONE 8.5MM 40MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8568545 SUP HCPCS C1713 8568545 - SCREW BONE 8.5MM 45MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8568550 SUP HCPCS C1713 8568550 - SCREW BONE 8.5MM 50MM SPNL POLYAX 6.35MM ROD BOTH IP/OP "$4,607.50 " "$3,409.55" $0.00 "$3,686.00" "$2,073.38" "$2,073.38" $0.00 $0.00 $0.00 $960.32 "$3,419.69" "$3,419.69" $0.00 $0.00 $960.20 $0.00 "$2,271.50" "$2,271.50" $0.00 "$2,303.75" "$3,649.14" "$3,686.00" $0.00 $0.00 $721.07 $0.00 $0.00 $733.51 $0.00 $0.00 $0.00 $0.00 $0.00 8570611 SUP HCPCS C1713 8570611 - CROSSLINK 8570611 4.5MM DUAL ROD 11MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8570612 SUP HCPCS C1713 8570612 - CROSSLINK 8570612 4.5MM DUAL ROD 12MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8570613 SUP HCPCS C1713 8570613 - CROSSLINK 8570613 4.5MM DUAL ROD 13MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8570614 SUP HCPCS C1713 8570614 - CROSSLINK 8570614 4.5MM DUAL ROD 14MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8570615 SUP HCPCS C1713 8570615 - CROSSLINK 8570615 4.5MM DUAL ROD 15MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8570616 SUP HCPCS C1713 8570616 - CROSSLINK 8570616 4.5MM DUAL ROD 16MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8570617 SUP HCPCS C1713 8570617 - CROSSLINK 8570617 4.5MM DUAL ROD 17MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8576510 SUP HCPCS C1713 8576510 - SCREW BONE 6.5MM 80MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8576570 SUP HCPCS C1713 8576570 - SCREW BONE 6.5MM 70MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8576580 SUP HCPCS C1713 8576580 - SCREW BONE 6.5MM 80MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8576590 SUP HCPCS C1713 8576590 - SCREW BONE 6.5MM 90MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8577510 SUP HCPCS C1713 8577510 - SCREW BONE 7.5MM 100MM ILC SPNL 6.3MM BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8577570 SUP HCPCS C1713 8577570 - SCREW BONE 7.5MM 70MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8577580 SUP HCPCS C1713 8577580 - SCREW BONE 7.5MM 80MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8577590 SUP HCPCS C1713 8577590 - SCREW BONE 7.5MM 90MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8578510 SUP HCPCS C1713 8578510 - SCREW BONE 8.5MM 100MM ILC SPNL 6.3MM BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8578570 SUP HCPCS C1713 8578570 - SCREW BONE 8.5MM 70MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8578580 SUP HCPCS C1713 8578580 - SCREW BONE 8.5MM 80MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8578590 SUP HCPCS C1713 8578590 - SCREW BONE 8.5MM 90MM ILC SPNL 6.35MM ROD BOTH IP/OP "$5,602.50 " "$4,145.85" $0.00 "$4,482.00" "$2,521.13" "$2,521.13" $0.00 $0.00 $0.00 "$1,167.70" "$4,158.18" "$4,158.18" $0.00 $0.00 "$1,167.56" $0.00 "$2,762.03" "$2,762.03" $0.00 "$2,801.25" "$4,437.18" "$4,482.00" $0.00 $0.00 $876.79 $0.00 $0.00 $891.92 $0.00 $0.00 $0.00 $0.00 $0.00 8579008 SUP HCPCS C1713 8579008 - CROSSLINK 8579008 4.5 LP .625 16MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579009 SUP HCPCS C1713 8579009 - CROSSLINK 8579009 4.5 LP .750 19MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579010 SUP HCPCS C1713 8579010 - CROSSLINK 8579010 4.5 LP .875 22MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579011 SUP HCPCS C1713 8579011 - CROSSLINK 8579011 4.5 LP 1.00 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579012 SUP HCPCS C1713 8579012 - CROSSLINK 8579012 4.5 LP 1.12529MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579013 SUP HCPCS C1713 8579013 - CROSSLINK 8579013 4.5 LP 1.25032MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579014 SUP HCPCS C1713 8579014 - CROSSLINK 8579014 4.5 LP 1.37535MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579015 SUP HCPCS C1713 8579015 - CROSSLINK 8579015 4.5 LP 1.50038MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579016 SUP HCPCS C1713 8579016 - CROSSLINK 8579016 4.5 LP 1.55 1.75 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579017 SUP HCPCS C1713 8579017 - CROSSLINK 8579017 4.5 LP 1.75 2.15 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579018 SUP HCPCS C1713 8579018 - CROSSLINK 8579018 4.5 LP 2.15 2.95 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8579300 SUP Custom 27803010 8579300 - CONNECTOR 8579300 4.5 TO 4.5MM DOMINO BOTH IP/OP "$1,796.58 " "$1,329.47" $0.00 "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.42" "$1,333.42" $0.00 $0.00 $374.41 $0.00 $0.00 $0.00 $0.00 $898.29 "$1,422.89" "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8579301 SUP Custom 27803010 8579301 - CONNECTOR 8579301 4.5 TO 5.5MM DOMINO BOTH IP/OP "$1,796.58 " "$1,329.47" $0.00 "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.42" "$1,333.42" $0.00 $0.00 $374.41 $0.00 $0.00 $0.00 $0.00 $898.29 "$1,422.89" "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8580858 SUP HCPCS C1713 "8580858 - SET SCREW, BREAK-OFF, M8, SS" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8590855 SUP HCPCS C1713 8590855 - SCREW SET TI 55MM SPNL BRKOF CLOSE HZNM8 5.5MM ROD BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8590858 SUP HCPCS C1713 "8590858 - SET SCREW, BREAK-OFF, M8, TI" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8594520 SUP HCPCS C1713 8594520 - SCREW BN 4.5MM 20MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8594522 SUP HCPCS C1713 8594522 - SCREW BN 4.5MM 22.5MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8594525 SUP HCPCS C1713 8594525 - SCREW BONE 4.5MM 25MM POLYAX BRIGADE SPN BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8594527 SUP HCPCS C1713 8594527 - SCREW BN 4.5MM 27.5MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8594530 SUP HCPCS C1713 8594530 - SCREW BN 4.5MM 30MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8594535 SUP HCPCS C1713 8594535 - SCREW BN 4.5MM 35MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8595520 SUP HCPCS C1713 8595520 - SCREW BN 5.5MM 20MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8595522 SUP HCPCS C1713 8595522 - SCREW BN 5.5MM 22.5MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8595525 SUP HCPCS C1713 8595525 - SCREW BN 5.5MM 25MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8595527 SUP HCPCS C1713 8595527 - SCREW BN 5.5MM 27.5MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8595530 SUP HCPCS C1713 8595530 - SCREW BN 5.5MM 30MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8595535 SUP HCPCS C1713 8595535 - SCREW BN 5.5MM 35MM NS BRIGADE CRNT SPNE XLRF SYS BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 8610425 SUP HCPCS C1713 8610425 - SCREW 8610425 CLRD 4.5MMX25MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610430 SUP HCPCS C1713 8610430 - SCREW 8610430 CLRD 4.5MMX30MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610435 SUP HCPCS C1713 8610435 - SCREW 8610435 CLRD 4.5MMX35MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610440 SUP HCPCS C1713 8610440 - SCREW 8610440 CLRD 4.5MMX40MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610445 SUP HCPCS C1713 8610445 - SCREW 8610445 CLRD 4.5MMX45MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610525 SUP HCPCS C1713 8610525 - SCREW 8610525 CLRD 5.5MMX25MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610530 SUP HCPCS C1713 8610530 - SCREW 8610530 CLRD 5.5MMX30MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610535 SUP HCPCS C1713 8610535 - SCREW 8610535 CLRD 5.5MMX35MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610540 SUP HCPCS C1713 8610540 - SCREW 8610540 CLRD 5.5MMX40MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610545 SUP HCPCS C1713 8610545 - SCREW 8610545 CLRD 5.5MMX45MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610550 SUP HCPCS C1713 8610550 - SCREW 8610550 CLRD 5.5MMX50MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610555 SUP HCPCS C1713 8610555 - SCREW 8610555 CLRD 5.5MMX55MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610630 SUP HCPCS C1713 8610630 - SCREW 8610630 CLRD 6.5MMX30MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610635 SUP HCPCS C1713 8610635 - SCREW 8610635 CLRD 6.5MMX35MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610640 SUP HCPCS C1713 8610640 - SCREW 8610640 CLRD 6.5MMX40MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610645 SUP HCPCS C1713 8610645 - SCREW 8610645 CLRD 6.5MMX45MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610650 SUP HCPCS C1713 8610650 - SCREW 8610650 CLRD 6.5MMX50MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610655 SUP HCPCS C1713 8610655 - SCREW 8610655 CLRD 6.5MMX55MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610735 SUP HCPCS C1713 8610735 - SCREW 8610735 CLRD 7.5MMX35MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610740 SUP HCPCS C1713 8610740 - SCREW 8610740 CLRD 7.5MMX40MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610745 SUP HCPCS C1713 8610745 - SCREW 8610745 CLRD 7.5MMX45MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8610750 SUP HCPCS C1713 8610750 - SCREW 8610750 CLRD 7.5MMX50MM BOTH IP/OP "$2,517.00 " "$1,862.58" $0.00 "$2,013.60" "$1,132.65" "$1,132.65" $0.00 $0.00 $0.00 $524.61 "$1,868.12" "$1,868.12" $0.00 $0.00 $524.54 $0.00 "$1,240.88" "$1,240.88" $0.00 "$1,258.50" "$1,993.46" "$2,013.60" $0.00 $0.00 $393.91 $0.00 $0.00 $400.71 $0.00 $0.00 $0.00 $0.00 $0.00 8611102 SUP HCPCS C1713 8611102 - HOOK 8611102 PEDICULAR SM GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8611104 SUP HCPCS C1713 8611104 - HOOK 8611104 PEDICULAR LG GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8611202 SUP HCPCS C1713 8611202 - HOOK 8611202 LAMINAR SM GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8611203 SUP HCPCS C1713 8611203 - HOOK 8611203 LAM MEDIUM GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8611204 SUP HCPCS C1713 8611204 - HOOK 8611204 LAMINAR LG GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8611300 SUP HCPCS C1713 8611300 - STAPLE 8611300 PEDICULAR HK BOTH IP/OP $873.00 $646.02 $0.00 $698.40 $392.85 $392.85 $0.00 $0.00 $0.00 $181.96 $647.94 $647.94 $0.00 $0.00 $181.93 $0.00 $516.38 $516.38 $0.00 $436.50 $691.42 $698.40 $0.00 $0.00 $136.62 $0.00 $0.00 $138.98 $0.00 $0.00 $0.00 $0.00 $0.00 8611402 SUP HCPCS C1713 8611402 - HOOK 8611402 CLOSED LAM THOR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8612055 SUP HCPCS C1713 8612055 - SCREW 8612055 CLRD ILIO SCARAL 7.0X55MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612060 SUP HCPCS C1713 8612060 - SCREW 8612060 CLRD ILIO SCARAL 7.0X60MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612065 SUP HCPCS C1713 8612065 - SCREW 8612065 CLRD ILIO SCARAL 7.0X65MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612070 SUP HCPCS C1713 8612070 - SCREW 8612070 CLRD ILIO SCARAL 7.0X70MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612075 SUP HCPCS C1713 8612075 - SCREW 8612075 CLRD ILIO SCARAL 7.0X75MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612080 SUP HCPCS C1713 8612080 - SCREW 8612080 CLRD ILIO SCARAL 7.0X80MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612230 SUP HCPCS C1713 8612230 - SCREW 8612230 CLRD SACRAL 6.5X30MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612235 SUP HCPCS C1713 8612235 - SCREW 8612235 CLRD SACRAL 6.5X35MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612240 SUP HCPCS C1713 8612240 - SCREW 8612240 CLRD SACRAL 6.5X40MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612245 SUP HCPCS C1713 8612245 - SCREW 8612245 CLRD SACRAL 6.5X45MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612250 SUP HCPCS C1713 8612250 - SCREW 8612250 CLRD SACRAL 6.5X50MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612255 SUP HCPCS C1713 8612255 - SCREW 8612255 CLRD SACRAL 6.5X55MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612260 SUP HCPCS C1713 8612260 - SCREW 8612260 CLRD SACRAL 6.5X60MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612265 SUP HCPCS C1713 8612265 - SCREW 8612265 CLRD SACRAL 6.5X65MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8612270 SUP HCPCS C1713 8612270 - SCREW 8612270 CLRD SACRAL 6.5X70MM BOTH IP/OP "$1,594.50 " "$1,179.93" $0.00 "$1,275.60" $717.53 $717.53 $0.00 $0.00 $0.00 $332.33 "$1,183.44" "$1,183.44" $0.00 $0.00 $332.29 $0.00 $943.15 $943.15 $0.00 $797.25 "$1,262.84" "$1,275.60" $0.00 $0.00 $249.54 $0.00 $0.00 $253.84 $0.00 $0.00 $0.00 $0.00 $0.00 8613505 SUP HCPCS C1713 8613505 - ROD 8613505 CLRD 5.0X50MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613506 SUP HCPCS C1713 8613506 - ROD 8613506 CLRD 5.0X60MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613507 SUP HCPCS C1713 8613507 - ROD 8613507 CLRD 5.0X70MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613508 SUP HCPCS C1713 8613508 - ROD 8613508 CLRD 5.0X80MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613509 SUP HCPCS C1713 8613509 - ROD 8613509 CLRD 5.0X90MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613510 SUP HCPCS C1713 8613510 - ROD 8613510 CLRD 5.0X100MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613511 SUP HCPCS C1713 8613511 - ROD 8613511 CLRD 5.0X110MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613512 SUP HCPCS C1713 8613512 - ROD 8613512 CLRD 5.0X120MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613514 SUP HCPCS C1713 8613514 - ROD 8613514 CLRD 5.0X140MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613516 SUP HCPCS C1713 8613516 - ROD 8613516 CLRD 5.0X160MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613518 SUP HCPCS C1713 8613518 - ROD 8613518 CLRD 5.0X180MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613520 SUP HCPCS C1713 8613520 - ROD 8613520 CLRD 5.0X200MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613522 SUP HCPCS C1713 8613522 - ROD 8613522 CLRD 5.0X220MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613524 SUP HCPCS C1713 8613524 - ROD 8613524 CLRD 5.0X240MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613526 SUP HCPCS C1713 8613526 - ROD 8613526 CLRD 5.0X260MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613528 SUP HCPCS C1713 8613528 - ROD 8613528 CLRD 5.0X280MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613530 SUP HCPCS C1713 8613530 - ROD 8613530 CLRD 5.0X300MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613532 SUP HCPCS C1713 8613532 - ROD 8613532 CLRD 5.0X320MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613534 SUP HCPCS C1713 8613534 - ROD 8613534 CLRD 5.0X340MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613536 SUP HCPCS C1713 8613536 - ROD 8613536 CLRD 5.0X360MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613538 SUP HCPCS C1713 8613538 - ROD 8613538 CLRD 5.0X380MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613544 SUP HCPCS C1713 8613544 - ROD 8613544 CLRD 5.0X440MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8613560 SUP HCPCS C1713 8613560 - ROD 8613560 CLRD 5MM X 600MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8614100 SUP Custom 27803010 8614100 - CONNECTOR 8614100 CLAMP FOR 5MM ROD BOTH IP/OP "$1,255.50 " $929.07 $0.00 "$1,004.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $931.83 $931.83 $0.00 $0.00 $261.65 $0.00 $0.00 $0.00 $0.00 $627.75 $994.36 "$1,004.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8614110 SUP Custom 27803010 8614110 - CONNECTOR 8614110 SACRAL ILIO PLATE BOTH IP/OP "$1,710.00 " "$1,265.40" $0.00 "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,269.16" "$1,269.16" $0.00 $0.00 $356.36 $0.00 $0.00 $0.00 $0.00 $855.00 "$1,354.32" "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8614111 SUP HCPCS C1713 8614111 - SCREW 8614111 BREAK OFF NUT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8614120 SUP HCPCS C1713 8614120 - SCREW 8614120 BREAK OFF SET XLINK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8614200 SUP Custom 27803010 8614200 - CONNECTOR 8614200 OFFSET BOTH IP/OP "$1,870.50 " "$1,384.17" $0.00 "$1,496.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,388.29" "$1,388.29" $0.00 $0.00 $389.81 $0.00 $0.00 $0.00 $0.00 $935.25 "$1,481.44" "$1,496.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8615400 SUP Custom 27803010 8615400 - CONNECTOR 8615400 5MM X 5MM AXIAL BOTH IP/OP "$2,631.50 " "$1,947.31" $0.00 "$2,105.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,953.10" "$1,953.10" $0.00 $0.00 $548.40 $0.00 $0.00 $0.00 $0.00 "$1,315.75" "$2,084.15" "$2,105.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8615405 SUP HCPCS C1713 8615405 - SCREW 8615405 BK OFF AXIALLAT CLSD HK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8615410 SUP Custom 27803010 8615410 - CONNECTOR 8615410 5MM X 5MM LATERAL BOTH IP/OP "$2,631.50 " "$1,947.31" $0.00 "$2,105.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,953.10" "$1,953.10" $0.00 $0.00 $548.40 $0.00 $0.00 $0.00 $0.00 "$1,315.75" "$2,084.15" "$2,105.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8615420 SUP Custom 27803010 8615420 - CONNECTOR 8615420 5MM X 5.5MM AXIAL BOTH IP/OP "$2,833.50 " "$2,096.79" $0.00 "$2,266.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,103.02" "$2,103.02" $0.00 $0.00 $590.50 $0.00 $0.00 $0.00 $0.00 "$1,416.75" "$2,244.13" "$2,266.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8615440 SUP Custom 27803010 8615440 - CONNECTOR 8615440 5MM X 7MM AXIAL BOTH IP/OP "$2,631.50 " "$1,947.31" $0.00 "$2,105.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,953.10" "$1,953.10" $0.00 $0.00 $548.40 $0.00 $0.00 $0.00 $0.00 "$1,315.75" "$2,084.15" "$2,105.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8616100 SUP Custom 27203010 BLADE LRNSCP 1 MLLR IMRSB REUSE BOTH IP/OP $60.80 $44.99 $0.00 $48.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.40 $48.15 $48.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8619110 SUP HCPCS C1713 8619110 - PLATE 8619110 RIGHT SACRAL BOTH IP/OP "$3,873.00 " "$2,866.02" $0.00 "$3,098.40" "$1,742.85" "$1,742.85" $0.00 $0.00 $0.00 $807.23 "$2,874.54" "$2,874.54" $0.00 $0.00 $807.13 $0.00 "$1,909.39" "$1,909.39" $0.00 "$1,936.50" "$3,067.42" "$3,098.40" $0.00 $0.00 $606.12 $0.00 $0.00 $616.58 $0.00 $0.00 $0.00 $0.00 $0.00 8619120 SUP HCPCS C1713 8619120 - PLATE 8619120 LEFT SACRAL BOTH IP/OP "$3,873.00 " "$2,866.02" $0.00 "$3,098.40" "$1,742.85" "$1,742.85" $0.00 $0.00 $0.00 $807.23 "$2,874.54" "$2,874.54" $0.00 $0.00 $807.13 $0.00 "$1,909.39" "$1,909.39" $0.00 "$1,936.50" "$3,067.42" "$3,098.40" $0.00 $0.00 $606.12 $0.00 $0.00 $616.58 $0.00 $0.00 $0.00 $0.00 $0.00 8619210 SUP HCPCS C1713 8619210 - PLATE 8619210 RIGHT ILLIO SACRAL BOTH IP/OP "$4,800.00 " "$3,552.00" $0.00 "$3,840.00" "$2,160.00" "$2,160.00" $0.00 $0.00 $0.00 "$1,000.44" "$3,562.56" "$3,562.56" $0.00 $0.00 "$1,000.32" $0.00 "$2,366.40" "$2,366.40" $0.00 "$2,400.00" "$3,801.60" "$3,840.00" $0.00 $0.00 $751.20 $0.00 $0.00 $764.16 $0.00 $0.00 $0.00 $0.00 $0.00 8619220 SUP HCPCS C1713 8619220 - PLATE 8619220 LEFT ILLIO SACRAL BOTH IP/OP "$4,800.00 " "$3,552.00" $0.00 "$3,840.00" "$2,160.00" "$2,160.00" $0.00 $0.00 $0.00 "$1,000.44" "$3,562.56" "$3,562.56" $0.00 $0.00 "$1,000.32" $0.00 "$2,366.40" "$2,366.40" $0.00 "$2,400.00" "$3,801.60" "$3,840.00" $0.00 $0.00 $751.20 $0.00 $0.00 $764.16 $0.00 $0.00 $0.00 $0.00 $0.00 8619300 SUP HCPCS C1713 8619300 - SCREW 8619300 SET SAC LLIO SAC PLATE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8619400 SUP HCPCS C1713 8619400 - STAPLE 8619400 ANTERIOR BOTH IP/OP $873.00 $646.02 $0.00 $698.40 $392.85 $392.85 $0.00 $0.00 $0.00 $181.96 $647.94 $647.94 $0.00 $0.00 $181.93 $0.00 $516.38 $516.38 $0.00 $436.50 $691.42 $698.40 $0.00 $0.00 $136.62 $0.00 $0.00 $138.98 $0.00 $0.00 $0.00 $0.00 $0.00 8619654 SUP HCPCS C1713 8619654 - PLATE 8619654 INTERPEDICULAR 54MM BOTH IP/OP "$2,187.00 " "$1,618.38" $0.00 "$1,749.60" $984.15 $984.15 $0.00 $0.00 $0.00 $455.83 "$1,623.19" "$1,623.19" $0.00 $0.00 $455.77 $0.00 "$1,293.61" "$1,293.61" $0.00 "$1,093.50" "$1,732.10" "$1,749.60" $0.00 $0.00 $342.27 $0.00 $0.00 $348.17 $0.00 $0.00 $0.00 $0.00 $0.00 8624110 SUP Custom 27803010 8624110 - CONNECTOR 8624110 5.5MM ILIO SAC PLT BOTH IP/OP "$1,710.00 " "$1,265.40" $0.00 "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,269.16" "$1,269.16" $0.00 $0.00 $356.36 $0.00 $0.00 $0.00 $0.00 $855.00 "$1,354.32" "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8630540 SUP HCPCS C1713 8630540 - SCREW 8630540 CLRD 5.5MMX40MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8630550 SUP HCPCS C1713 8630550 - SCREW 8630550 CLRD 5.5MMX50MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8630645 SUP HCPCS C1713 8630645 - SCREW 8630645 CLRD 6.5MMX45MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8630650 SUP HCPCS C1713 8630650 - SCREW 8630650 CLRD 6.5MMX50MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8631203 SUP HCPCS C1713 8631203 - HOOK 8631203 MEDIUM LAMINAR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8631300 SUP HCPCS C1713 8631300 - STAPLE 8631300 BOTH IP/OP $988.50 $731.49 $0.00 $790.80 $444.83 $444.83 $0.00 $0.00 $0.00 $206.03 $733.66 $733.66 $0.00 $0.00 $206.00 $0.00 $584.70 $584.70 $0.00 $494.25 $782.89 $790.80 $0.00 $0.00 $154.70 $0.00 $0.00 $157.37 $0.00 $0.00 $0.00 $0.00 $0.00 8631402 SUP HCPCS C1713 8631402 - HOOK 8631402 CLOSED LAMINAR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8632050 SUP HCPCS C1713 8632050 - SCREW 8632050 CLRD ILIO SACRAL 7.0X50MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632055 SUP HCPCS C1713 8632055 - SCREW 8632055 CLRD ILIO SACRAL 7.0X55MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632060 SUP HCPCS C1713 8632060 - SCREW 8632060 CLRD ILIO SACRAL 7.0X60MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632065 SUP HCPCS C1713 8632065 - SCREW 8632065 CLRD ILIO SACRAL 7.0X65MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632070 SUP HCPCS C1713 8632070 - SCREW 8632070 CLRD ILIO SACRAL 7.0X70MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632075 SUP HCPCS C1713 8632075 - SCREW 8632075 CLRD ILIO SACRAL 7.0X75MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632080 SUP HCPCS C1713 8632080 - SCREW 8632080 CLRD ILIO SACRAL 7.0X80MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632230 SUP HCPCS C1713 8632230 - SCREW 8632230 CLRD SACRAL 6.5X30MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632235 SUP HCPCS C1713 8632235 - SCREW 8632235 CLRD SACRAL 6.5X35MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632240 SUP HCPCS C1713 8632240 - SCREW 8632240 CLRD SACRAL 6.5X40MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632245 SUP HCPCS C1713 8632245 - SCREW 8632245 CLRD SACRAL 6.5X45MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632250 SUP HCPCS C1713 8632250 - SCREW 8632250 CLRD SACRAL 6.5X50MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632255 SUP HCPCS C1713 8632255 - SCREW 8632255 CLRD SACRAL 6.5X55MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632260 SUP HCPCS C1713 8632260 - SCREW 8632260 CLRD SACRAL 6.5X60MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632265 SUP HCPCS C1713 8632265 - SCREW 8632265 CLRD SACRAL 6.5X65MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632270 SUP HCPCS C1713 8632270 - SCREW 8632270 CLRD SACRAL 6.5X70MM BOTH IP/OP "$1,821.23 " "$1,347.71" $0.00 "$1,456.98" $819.55 $819.55 $0.00 $0.00 $0.00 $379.59 "$1,351.71" "$1,351.71" $0.00 $0.00 $379.54 $0.00 "$1,077.25" "$1,077.25" $0.00 $910.61 "$1,442.41" "$1,456.98" $0.00 $0.00 $285.02 $0.00 $0.00 $289.94 $0.00 $0.00 $0.00 $0.00 $0.00 8632330 SUP HCPCS C1713 8632330 - SCREW 8632330 CLRD SACRAL 7.0X30MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632335 SUP HCPCS C1713 8632335 - SCREW 8632335 CLRD SACRAL 7.0X35MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632340 SUP HCPCS C1713 8632340 - SCREW 8632340 CLRD SACRAL 7.0X40MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632345 SUP HCPCS C1713 8632345 - SCREW 8632345 CLRD SACRAL 7.0X45MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632350 SUP HCPCS C1713 8632350 - SCREW 8632350 CLRD SACRAL 7.0X50MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632355 SUP HCPCS C1713 8632355 - SCREW 8632355 CLRD SACRAL 7.0X55MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632360 SUP HCPCS C1713 8632360 - SCREW 8632360 CLRD SACRAL 7.0X60MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632365 SUP HCPCS C1713 8632365 - SCREW 8632365 CLRD SACRAL 7.0X65MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8632370 SUP HCPCS C1713 8632370 - SCREW 8632370 CLRD SACRAL 7.0X70MM BOTH IP/OP "$1,811.63 " "$1,340.61" $0.00 "$1,449.30" $815.23 $815.23 $0.00 $0.00 $0.00 $377.59 "$1,344.59" "$1,344.59" $0.00 $0.00 $377.54 $0.00 "$1,071.58" "$1,071.58" $0.00 $905.81 "$1,434.81" "$1,449.30" $0.00 $0.00 $283.52 $0.00 $0.00 $288.41 $0.00 $0.00 $0.00 $0.00 $0.00 8634100 SUP Custom 27803010 8634100 - CONNECTOR 8634100 CLAMP FOR 5MM ROD BOTH IP/OP "$1,453.50 " "$1,075.59" $0.00 "$1,162.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,078.79" "$1,078.79" $0.00 $0.00 $302.91 $0.00 $0.00 $0.00 $0.00 $726.75 "$1,151.17" "$1,162.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8634110 SUP Custom 27803010 8634110 - CONNECTOR 8634110 SACRAL ILIO PLATE BOTH IP/OP "$1,935.50 " "$1,432.27" $0.00 "$1,548.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,436.53" "$1,436.53" $0.00 $0.00 $403.36 $0.00 $0.00 $0.00 $0.00 $967.75 "$1,532.92" "$1,548.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8634111 SUP HCPCS C1713 8634111 - SCREW 8634111 BREAK OFF NUT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8634200 SUP Custom 27803010 8634200 - CONNECTOR 8634200 OFFSET CLAMP BOTH IP/OP "$1,935.50 " "$1,432.27" $0.00 "$1,548.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,436.53" "$1,436.53" $0.00 $0.00 $403.36 $0.00 $0.00 $0.00 $0.00 $967.75 "$1,532.92" "$1,548.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8635400 SUP Custom 27803010 8635400 - CONNECTOR 8635400 5.5X5.5 LAT CLOSE CLMP BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 $0.00 $0.00 $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8635405 SUP HCPCS C1713 8635405 - SCREW 8635405 BREAK OFF LOCKING BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8635430 SUP Custom 27803010 8635430 - CONNECTOR 8635430 LATERAL CLOSED BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 $0.00 $0.00 $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8638102 SUP HCPCS C1713 8638102 - HOOK 8638102 PED SMALL GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8638104 SUP HCPCS C1713 8638104 - HOOK 8638104 PED LARGE GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8638110 SUP HCPCS C1713 8638110 - PLATE 8638110 RIGHT SACRAL BOTH IP/OP "$3,873.00 " "$2,866.02" $0.00 "$3,098.40" "$1,742.85" "$1,742.85" $0.00 $0.00 $0.00 $807.23 "$2,874.54" "$2,874.54" $0.00 $0.00 $807.13 $0.00 "$1,909.39" "$1,909.39" $0.00 "$1,936.50" "$3,067.42" "$3,098.40" $0.00 $0.00 $606.12 $0.00 $0.00 $616.58 $0.00 $0.00 $0.00 $0.00 $0.00 8638120 SUP HCPCS C1713 8638120 - PLATE 8638120 LEFT SACRAL BOTH IP/OP "$3,873.00 " "$2,866.02" $0.00 "$3,098.40" "$1,742.85" "$1,742.85" $0.00 $0.00 $0.00 $807.23 "$2,874.54" "$2,874.54" $0.00 $0.00 $807.13 $0.00 "$1,909.39" "$1,909.39" $0.00 "$1,936.50" "$3,067.42" "$3,098.40" $0.00 $0.00 $606.12 $0.00 $0.00 $616.58 $0.00 $0.00 $0.00 $0.00 $0.00 8638203 SUP HCPCS C1713 8638203 - HOOK 8638203 LAM MEDIUM GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8638210 SUP HCPCS C1713 8638210 - PLATE 8638210 RIGHT LLIO SACRAL BOTH IP/OP "$4,938.00 " "$3,654.12" $0.00 "$3,950.40" "$2,222.10" "$2,222.10" $0.00 $0.00 $0.00 "$1,029.20" "$3,664.98" "$3,664.98" $0.00 $0.00 "$1,029.08" $0.00 "$2,434.43" "$2,434.43" $0.00 "$2,469.00" "$3,910.90" "$3,950.40" $0.00 $0.00 $772.80 $0.00 $0.00 $786.13 $0.00 $0.00 $0.00 $0.00 $0.00 8638220 SUP HCPCS C1713 8638220 - PLATE 8638220 LEFT ILIO SACRAL BOTH IP/OP "$4,938.00 " "$3,654.12" $0.00 "$3,950.40" "$2,222.10" "$2,222.10" $0.00 $0.00 $0.00 "$1,029.20" "$3,664.98" "$3,664.98" $0.00 $0.00 "$1,029.08" $0.00 "$2,434.43" "$2,434.43" $0.00 "$2,469.00" "$3,910.90" "$3,950.40" $0.00 $0.00 $772.80 $0.00 $0.00 $786.13 $0.00 $0.00 $0.00 $0.00 $0.00 8638425 SUP HCPCS C1713 8638425 - SCREW 8638425 PED D4.5MM L25MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638430 SUP HCPCS C1713 8638430 - SCREW 8638430 CLRD PED 4.5X30MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638435 SUP HCPCS C1713 8638435 - SCREW 8638435 CLRD PED 4.5X35MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638440 SUP HCPCS C1713 8638440 - BONE SCREW 8638440 PED D4.5MM L40MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638445 SUP HCPCS C1713 8638445 - SCREW 8638445 CLRD PED 4.5X45MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638525 SUP HCPCS C1713 8638525 - SCREW 8638525 CLRD PED 5.5X25MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638530 SUP HCPCS C1713 8638530 - SCREW 8638530 CLRD PED 5.5X30MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638535 SUP HCPCS C1713 8638535 - SCREW 8638535 CLRD PED 5.5X35MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638540 SUP HCPCS C1713 8638540 - SCREW 8638540 CLRD PED 5.5X40MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638545 SUP HCPCS C1713 8638545 - SCREW 8638545 CLRD PED 5.5X45MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638550 SUP HCPCS C1713 8638550 - SCREW 8638550 CLRD PED 5.5X50MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638555 SUP HCPCS C1713 8638555 - SCREW 8638555 CLRD PED 5.5X55MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638625 SUP HCPCS C1713 8638625 - SCREW 8638625 PED D6.5MM L25MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638630 SUP HCPCS C1713 8638630 - SCREW 8638630 CLRD PED 6.5X30MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638635 SUP HCPCS C1713 8638635 - SCREW BN 6.5MM 35MM CO2 SPNE PDCL BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638640 SUP HCPCS C1713 8638640 - SCREW BN 6.5MM 35MM CO2 SPNE PDCL BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638645 SUP HCPCS C1713 8638645 - SCREW 8638645 CLRD PED 6.5X45MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638650 SUP HCPCS C1713 8638650 - SCREW 8638650 CLRD PED 6.5X50MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638655 SUP HCPCS C1713 8638655 - SCREW 8638655 CLRD PED 6.5X55MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638660 SUP HCPCS C1713 8638660 - SCREW 8638660 PED D6.5MM L60MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638665 SUP HCPCS C1713 8638665 - SCREW 8638665 PED D6.5MM L65MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638725 SUP HCPCS C1713 8638725 - SCREW 8638725 PED D7.5MM L25MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638730 SUP HCPCS C1713 8638730 - BONE SCREW 8638730 PED D7.5MM L30MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638735 SUP HCPCS C1713 8638735 - SCREW 8638735 CLRD PED 7.5X35MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638740 SUP HCPCS C1713 8638740 - SCREW 8638740 CLRD PED 7.5X40MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638745 SUP HCPCS C1713 8638745 - SCREW 8638745 CLRD PED 7.5X45MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638750 SUP HCPCS C1713 8638750 - SCREW 8638750 CLRD PED 7.5X50MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638755 SUP HCPCS C1713 8638755 - BONE SCREW 8638755 PED SCRW D7.5MM L55MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638760 SUP HCPCS C1713 8638760 - SCREW 8638760 PED D7.5MM L60MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8638765 SUP HCPCS C1713 8638765 - SCREW 8638765 PED D7.5MM L65MM BOTH IP/OP "$2,818.50 " "$2,085.69" $0.00 "$2,254.80" "$1,268.33" "$1,268.33" $0.00 $0.00 $0.00 $587.45 "$2,091.89" "$2,091.89" $0.00 $0.00 $587.38 $0.00 "$1,389.52" "$1,389.52" $0.00 "$1,409.25" "$2,232.25" "$2,254.80" $0.00 $0.00 $441.10 $0.00 $0.00 $448.71 $0.00 $0.00 $0.00 $0.00 $0.00 8639300 SUP HCPCS C1713 8639300 - SCREW 8639300 L AND ILIO L SET BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8639400 SUP HCPCS C1713 8639400 - STAPLE 8639400 ANTERIOR BOTH IP/OP $988.50 $731.49 $0.00 $790.80 $444.83 $444.83 $0.00 $0.00 $0.00 $206.03 $733.66 $733.66 $0.00 $0.00 $206.00 $0.00 $584.70 $584.70 $0.00 $494.25 $782.89 $790.80 $0.00 $0.00 $154.70 $0.00 $0.00 $157.37 $0.00 $0.00 $0.00 $0.00 $0.00 8644525 SUP HCPCS C1713 8644525 - SCREW BN 4.5MM 25MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8644530 SUP HCPCS C1713 8644530 - SCREW BN 4.5MM 30MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8644535 SUP HCPCS C1713 8644535 - SCREW BN 4.5MM 35MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8644540 SUP HCPCS C1713 8644540 - SCREW BN 4.5MM 40MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8644545 SUP HCPCS C1713 8644545 - SCREW BN 4.5MM 45MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8645025 SUP HCPCS C1713 8645025 - SCREW BN 5MM 25MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8645030 SUP HCPCS C1713 8645030 - SCREW BN 5MM 30MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8645035 SUP HCPCS C1713 8645035 - SCREW BN 5MM 35MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8645040 SUP HCPCS C1713 8645040 - SCREW BN 5MM 40MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8645045 SUP HCPCS C1713 8645045 - SCREW BN 5MM 45MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8645050 SUP HCPCS C1713 8645050 - SCREW BN 6MM 55MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8646030 SUP HCPCS C1713 8646030 - SCREW BN 5MM 50MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8646035 SUP HCPCS C1713 8646035 - SCREW BN 6MM 30MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8646040 SUP HCPCS C1713 8646040 - SCREW BN 6MM 35MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8646045 SUP HCPCS C1713 8646045 - SCREW BN 6MM 40MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8646050 SUP HCPCS C1713 8646050 - SCREW BN 6MM 45MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8646055 SUP HCPCS C1713 8646055 - SCREW BN 6MM 50MM UNIPLANAR TI SPNE 5.5MM ROD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 8650520 SUP HCPCS C1713 8650520 - CONCTR ROD 20MM 5.5MM OFFST TI SPNL BOTH IP/OP "$1,655.00 " "$1,224.70" $0.00 "$1,324.00" $744.75 $744.75 $0.00 $0.00 $0.00 $344.94 "$1,228.34" "$1,228.34" $0.00 $0.00 $344.90 $0.00 $978.93 $978.93 $0.00 $827.50 "$1,310.76" "$1,324.00" $0.00 $0.00 $259.01 $0.00 $0.00 $263.48 $0.00 $0.00 $0.00 $0.00 $0.00 8650530 SUP HCPCS C1713 8650530 - CONCTR ROD 30MM 4.5MM OFFST TI BOTH IP/OP "$1,655.00 " "$1,224.70" $0.00 "$1,324.00" $744.75 $744.75 $0.00 $0.00 $0.00 $344.94 "$1,228.34" "$1,228.34" $0.00 $0.00 $344.90 $0.00 $978.93 $978.93 $0.00 $827.50 "$1,310.76" "$1,324.00" $0.00 $0.00 $259.01 $0.00 $0.00 $263.48 $0.00 $0.00 $0.00 $0.00 $0.00 8650560 SUP HCPCS C1713 8650560 - CONCTR ROD 60MM 4.5MM OFFST TI BOTH IP/OP "$1,655.00 " "$1,224.70" $0.00 "$1,324.00" $744.75 $744.75 $0.00 $0.00 $0.00 $344.94 "$1,228.34" "$1,228.34" $0.00 $0.00 $344.90 $0.00 $978.93 $978.93 $0.00 $827.50 "$1,310.76" "$1,324.00" $0.00 $0.00 $259.01 $0.00 $0.00 $263.48 $0.00 $0.00 $0.00 $0.00 $0.00 8651520 SUP HCPCS C1713 8651520 - CONCTR ROD 5.5MM OFFST CLOSE TI BOTH IP/OP "$1,655.00 " "$1,224.70" $0.00 "$1,324.00" $744.75 $744.75 $0.00 $0.00 $0.00 $344.94 "$1,228.34" "$1,228.34" $0.00 $0.00 $344.90 $0.00 $978.93 $978.93 $0.00 $827.50 "$1,310.76" "$1,324.00" $0.00 $0.00 $259.01 $0.00 $0.00 $263.48 $0.00 $0.00 $0.00 $0.00 $0.00 8651530 SUP HCPCS C1713 8651530 - CONCTR ROD 5.5MM OFFST CLOSE TI BOTH IP/OP "$1,655.00 " "$1,224.70" $0.00 "$1,324.00" $744.75 $744.75 $0.00 $0.00 $0.00 $344.94 "$1,228.34" "$1,228.34" $0.00 $0.00 $344.90 $0.00 $978.93 $978.93 $0.00 $827.50 "$1,310.76" "$1,324.00" $0.00 $0.00 $259.01 $0.00 $0.00 $263.48 $0.00 $0.00 $0.00 $0.00 $0.00 8651560 SUP HCPCS C1713 8651560 - CONCTR ROD 5.5MM OFFST CLOSE TI BOTH IP/OP "$1,655.00 " "$1,224.70" $0.00 "$1,324.00" $744.75 $744.75 $0.00 $0.00 $0.00 $344.94 "$1,228.34" "$1,228.34" $0.00 $0.00 $344.90 $0.00 $978.93 $978.93 $0.00 $827.50 "$1,310.76" "$1,324.00" $0.00 $0.00 $259.01 $0.00 $0.00 $263.48 $0.00 $0.00 $0.00 $0.00 $0.00 8664110 SUP Custom 27803010 8664110 - CONNECTOR 8664110 6.35MM SACRAL SS BOTH IP/OP "$1,710.00 " "$1,265.40" $0.00 "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,269.16" "$1,269.16" $0.00 $0.00 $356.36 $0.00 $0.00 $0.00 $0.00 $855.00 "$1,354.32" "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8664111 SUP HCPCS C1713 8664111 - SET SCREW 8664111 FOR 6.35MM CONN SS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8670001 SUP HCPCS C1769 8670001 - GUIDEWIRE ORTHOPEDIC BLUNT INSTR SEXTANT TITANIUM SPN BOTH IP/OP $151.50 $112.11 $0.00 $121.20 $82.26 $82.26 $0.00 $0.00 $0.00 $31.58 $112.44 $112.44 $0.00 $0.00 $31.57 $0.00 $89.61 $89.61 $0.00 $75.75 $119.99 $121.20 $0.00 $0.00 $23.71 $0.00 $0.00 $24.12 $0.00 $0.00 $0.00 $0.00 $0.00 8670002 SUP HCPCS C1769 8670002 - GUIDEWIRE ORTHOPEDIC SHARP CD HORIZON TITANIUM SPN BOTH IP/OP $151.50 $112.11 $0.00 $121.20 $82.26 $82.26 $0.00 $0.00 $0.00 $31.58 $112.44 $112.44 $0.00 $0.00 $31.57 $0.00 $89.61 $89.61 $0.00 $75.75 $119.99 $121.20 $0.00 $0.00 $23.71 $0.00 $0.00 $24.12 $0.00 $0.00 $0.00 $0.00 $0.00 8672030 SUP HCPCS C1713 8672030 - ROD SPNL STD PREBNT CNTR 5.5MM 30MM SXTNT CD HZN TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672035 SUP HCPCS C1713 8672035 - ROD SPNL PREBNT 5.5MM 35MM SXTNT CD HZN TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672040 SUP HCPCS C1713 8672040 - ROD SPNL STD CNTR PREBNT 5.5MM 40MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672045 SUP HCPCS C1713 8672045 - ROD SPNL STD CNTR PREBNT 5.5MM 45MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672050 SUP HCPCS C1713 8672050 - ROD SPNL STD CNTR PREBNT 5.5MM 50MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672055 SUP HCPCS C1713 8672055 - ROD SPNL STD PREBNT PCUT CNTR 5.5MM 55MM SXTNT CD HZN TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672060 SUP HCPCS C1713 8672060 - ROD SPNL STD CNTR PREBNT 5.5MM 60MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672065 SUP HCPCS C1713 8672065 - ROD SPNL STD CNTR PREBNT 5.5MM 65MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672070 SUP HCPCS C1713 8672070 - ROD SPNL STD CNTR PREBNT 5.5MM 70MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672075 SUP HCPCS C1713 8672075 - ROD SPNL STD CNTR PREBNT 5.5MM 75MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672080 SUP HCPCS C1713 8672080 - ROD SPNL STD CNTR PREBNT 5.5MM 80MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672085 SUP HCPCS C1713 8672085 - ROD SPNL STD PREBNT PCUT CNTR 5.5MM 85MM SXTNT CD HZN TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672090 SUP HCPCS C1713 8672090 - ROD SPNL STD PREBNT CNTR 5.5MM 90MM SXTNT CD HZN TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672095 SUP HCPCS C1713 8672095 - ROD SPNL STD CNTR PREBNT 5.5MM 95MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8672100 SUP HCPCS C1713 8672100 - ROD SPNL STD CNTR PREBNT 5.5MM 100MM CD HZN SXTNT PCUT TI BOTH IP/OP "$2,072.50 " "$1,533.65" $0.00 "$1,658.00" $932.63 $932.63 $0.00 $0.00 $0.00 $431.96 "$1,538.21" "$1,538.21" $0.00 $0.00 $431.91 $0.00 "$1,225.88" "$1,225.88" $0.00 "$1,036.25" "$1,641.42" "$1,658.00" $0.00 $0.00 $324.35 $0.00 $0.00 $329.94 $0.00 $0.00 $0.00 $0.00 $0.00 8674110 SUP Custom 27803010 8674110 - CONNECTOR 8674110 6.35MM SACRAL TI BOTH IP/OP "$1,935.50 " "$1,432.27" $0.00 "$1,548.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,436.53" "$1,436.53" $0.00 $0.00 $403.36 $0.00 $0.00 $0.00 $0.00 $967.75 "$1,532.92" "$1,548.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8674111 SUP HCPCS C1713 8674111 - SCREW 8674111 SET FOR 6.35MM CONN TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8680853 SUP HCPCS C1713 "8680853 - M8 REDUCTION SCREW PLUG, SS" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8688498 SUP HCPCS C1713 8688498 - STAPLE 8688498 19MM CAUDAL SS BOTH IP/OP "$2,173.50 " "$1,608.39" $0.00 "$1,738.80" $978.08 $978.08 $0.00 $0.00 $0.00 $453.01 "$1,613.17" "$1,613.17" $0.00 $0.00 $452.96 $0.00 "$1,285.63" "$1,285.63" $0.00 "$1,086.75" "$1,721.41" "$1,738.80" $0.00 $0.00 $340.15 $0.00 $0.00 $346.02 $0.00 $0.00 $0.00 $0.00 $0.00 8688499 SUP HCPCS C1713 8688499 - STAPLE 8688499 19MM ROSTRAL SS BOTH IP/OP "$2,173.50 " "$1,608.39" $0.00 "$1,738.80" $978.08 $978.08 $0.00 $0.00 $0.00 $453.01 "$1,613.17" "$1,613.17" $0.00 $0.00 $452.96 $0.00 "$1,285.63" "$1,285.63" $0.00 "$1,086.75" "$1,721.41" "$1,738.80" $0.00 $0.00 $340.15 $0.00 $0.00 $346.02 $0.00 $0.00 $0.00 $0.00 $0.00 8688500 SUP HCPCS C1713 8688500 - STAPLE 8688500 21MM CAUDAL SS BOTH IP/OP "$2,173.50 " "$1,608.39" $0.00 "$1,738.80" $978.08 $978.08 $0.00 $0.00 $0.00 $453.01 "$1,613.17" "$1,613.17" $0.00 $0.00 $452.96 $0.00 "$1,285.63" "$1,285.63" $0.00 "$1,086.75" "$1,721.41" "$1,738.80" $0.00 $0.00 $340.15 $0.00 $0.00 $346.02 $0.00 $0.00 $0.00 $0.00 $0.00 8688501 SUP HCPCS C1713 8688501 - STAPLE 8688501 21MM ROSTRAL SS BOTH IP/OP "$2,173.50 " "$1,608.39" $0.00 "$1,738.80" $978.08 $978.08 $0.00 $0.00 $0.00 $453.01 "$1,613.17" "$1,613.17" $0.00 $0.00 $452.96 $0.00 "$1,285.63" "$1,285.63" $0.00 "$1,086.75" "$1,721.41" "$1,738.80" $0.00 $0.00 $340.15 $0.00 $0.00 $346.02 $0.00 $0.00 $0.00 $0.00 $0.00 8690024 SUP HCPCS C1713 8690024 - ROD 8690024 5.5MM CCM ROD L 500MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8690030 SUP HCPCS C1713 8690030 - ROD SPNL PREBNT 5.5MM 30MM CD HZN TI CP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690035 SUP HCPCS C1713 "8690035 - PRE-BENT ROD, 5.5X35, TI" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690040 SUP HCPCS C1713 8690040 - ROD SPNL PREBNT 5.5MM 40MM LGC CD HZN TI CP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690045 SUP HCPCS C1713 "8690045 - PRE-BENT ROD, 5.5X45, TI" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690050 SUP HCPCS C1713 8690050 - ROD SPNL PCUT PREBNT 5.5MM 50MM LGC CD HZN TI CP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690055 SUP HCPCS C1713 8690055 - ROD 8690055 PRE-BENT 5.5X55 TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690060 SUP HCPCS C1713 8690060 - ROD SPNL PREBNT 5.5MM 60MM CD HZN LGC CNTR POST TI THRX BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690065 SUP HCPCS C1713 "8690065 - PRE-BENT ROD, 5.5X65, TI" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690070 SUP HCPCS C1713 8690070 - ROD SPNL PREBNT 5.5MM 70MM CD HZN LGC CNTR POST TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690075 SUP HCPCS C1713 "8690075 - PRE-BENT ROD, 5.5X75, TI" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690080 SUP HCPCS C1713 8690080 - ROD SPNL 80MM 5.5MM CD HZN LGC TI PREBNT CP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690085 SUP HCPCS C1713 "8690085 - PRE-BENT ROD, 5.5X85, TI" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690090 SUP HCPCS C1713 8690090 - ROD SPNL PREBNT 5.5MM 90MM CD HZN LGC CNTR POST TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690095 SUP HCPCS C1713 "8690095 - ROD 8690095, PRE-BENT 5.5X95, TI" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690100 SUP HCPCS C1713 8690100 - ROD SPNL PREBNT 5.5MM 100MM LGC CD HZN TI CP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690105 SUP HCPCS C1713 "8690105 - PRE-BENT ROD, 5.5X105, TI" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690110 SUP HCPCS C1713 8690110 - ROD 8690110 CDH PBNT 5.5X110 TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690115 SUP HCPCS C1713 "8690115 - PRE-BENT ROD, 5.5X115, TI" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690120 SUP HCPCS C1713 8690120 - ROD 8690120 CDH PBNT 5.5X120 TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8690853 SUP HCPCS C1713 8690853 - SCREW 8690853 M8 REDUCTION PLUG TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8690878 SUP HCPCS C1713 "8690878 - SET SCREW, REDUCTION, M8, TI" BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8691530 SUP HCPCS C1713 8691530 - CDH M8 5.5 X 30 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691535 SUP HCPCS C1713 8691535 - CDH M8 5.5 X 35 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691540 SUP HCPCS C1713 8691540 - CDH M8 5.5 X 40 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691545 SUP HCPCS C1713 8691545 - CDH M8 5.5 X 45 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691550 SUP HCPCS C1713 8691550 - CDH M8 5.5 X 50 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691630 SUP HCPCS C1713 8691630 - CDH M8 6.5 X 30 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691635 SUP HCPCS C1713 8691635 - CDH M8 6.5 X 35 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691640 SUP HCPCS C1713 8691640 - CDH M8 6.5 X 40 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691645 SUP HCPCS C1713 8691645 - CDH M8 6.5 X 45 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691650 SUP HCPCS C1713 8691650 - CDH M8 6.5 X 50 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691655 SUP HCPCS C1713 8691655 - CDH M8 6.5 X 55 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691730 SUP HCPCS C1713 8691730 - CDH M8 7.5 X 30 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691735 SUP HCPCS C1713 8691735 - CDH M8 7.5 X 35 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691745 SUP HCPCS C1713 8691745 - CDH M8 7.5 X 45 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8691750 SUP HCPCS C1713 8691750 - CDH M8 7.5 X 50 RED FAS 5.5 TI BOTH IP/OP "$2,362.40 " "$1,748.18" $0.00 "$1,889.92" "$1,063.08" "$1,063.08" $0.00 $0.00 $0.00 $492.38 "$1,753.37" "$1,753.37" $0.00 $0.00 $492.32 $0.00 "$1,397.36" "$1,397.36" $0.00 "$1,181.20" "$1,871.02" "$1,889.92" $0.00 $0.00 $369.72 $0.00 $0.00 $376.09 $0.00 $0.00 $0.00 $0.00 $0.00 8692150 SUP HCPCS C1713 "8692150 - M8 RED. STD. RAMPED HOOK, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8692152 SUP HCPCS C1713 "8692152 - M8 RED. NARROW RAMP HOOK, TI" BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8698501 SUP HCPCS C1713 8698501 - STAPLE BONE SM 2 ROD 21MM TI RSTRL SPN CD HZN ANTARES STRL BOTH IP/OP "$4,240.00 " "$3,137.60" $0.00 "$3,392.00" "$1,908.00" "$1,908.00" $0.00 $0.00 $0.00 $883.72 "$3,146.93" "$3,146.93" $0.00 $0.00 $883.62 $0.00 "$2,090.32" "$2,090.32" $0.00 "$2,120.00" "$3,358.08" "$3,392.00" $0.00 $0.00 $663.56 $0.00 $0.00 $675.01 $0.00 $0.00 $0.00 $0.00 $0.00 8698502 SUP HCPCS C1713 8698502 - STAPLE BONE MED 2 ROD TI CDL SPN CD HZN ANTARES BOTH IP/OP "$4,240.00 " "$3,137.60" $0.00 "$3,392.00" "$1,908.00" "$1,908.00" $0.00 $0.00 $0.00 $883.72 "$3,146.93" "$3,146.93" $0.00 $0.00 $883.62 $0.00 "$2,090.32" "$2,090.32" $0.00 "$2,120.00" "$3,358.08" "$3,392.00" $0.00 $0.00 $663.56 $0.00 $0.00 $675.01 $0.00 $0.00 $0.00 $0.00 $0.00 8699050 SUP HCPCS C1713 "8699050 - CDH 5.5X50 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699055 SUP HCPCS C1713 "8699055 - CDH 5.5X55 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699060 SUP HCPCS C1713 "8699060 - CDH 5.5X60 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699065 SUP HCPCS C1713 "8699065 - CDH 5.5X65 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699070 SUP HCPCS C1713 "8699070 - CDH 5.5X70 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699075 SUP HCPCS C1713 "8699075 - CDH 5.5X75 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699080 SUP HCPCS C1713 "8699080 - CDH 5.5X80 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699085 SUP HCPCS C1713 "8699085 - CDH 5.5X85 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699090 SUP HCPCS C1713 "8699090 - CDH 5.5X90 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699095 SUP HCPCS C1713 "8699095 - CDH 5.5X95 STRAIGHT ROD, TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8699100 SUP HCPCS C1713 "8699100 - CDH 5.5X100 STRAIGHT ROD,TI CP" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8730006 SUP Custom 27203010 "8730006 - UCSS CANNULATED DRILL BIT, STERILE" BOTH IP/OP "$1,099.50 " $813.63 $0.00 $879.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $816.05 $816.05 $0.00 $0.00 $229.14 $0.00 $0.00 $0.00 $0.00 $549.75 $870.80 $879.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8750520 SUP HCPCS C1713 8750520 - CONCTR ROD 20MM 5.5MM SS OFFST BOTH IP/OP "$2,482.50 " "$1,837.05" $0.00 "$1,986.00" "$1,117.13" "$1,117.13" $0.00 $0.00 $0.00 $517.42 "$1,842.51" "$1,842.51" $0.00 $0.00 $517.35 $0.00 "$1,468.40" "$1,468.40" $0.00 "$1,241.25" "$1,966.14" "$1,986.00" $0.00 $0.00 $388.51 $0.00 $0.00 $395.21 $0.00 $0.00 $0.00 $0.00 $0.00 8750530 SUP HCPCS C1713 8750530 - CONCTR ROD 30MM 5.5MM SS OFFST BOTH IP/OP "$2,482.50 " "$1,837.05" $0.00 "$1,986.00" "$1,117.13" "$1,117.13" $0.00 $0.00 $0.00 $517.42 "$1,842.51" "$1,842.51" $0.00 $0.00 $517.35 $0.00 "$1,468.40" "$1,468.40" $0.00 "$1,241.25" "$1,966.14" "$1,986.00" $0.00 $0.00 $388.51 $0.00 $0.00 $395.21 $0.00 $0.00 $0.00 $0.00 $0.00 8750560 SUP HCPCS C1713 8750560 - CONCTR ROD 60MM 5.5MM SS OFFST BOTH IP/OP "$2,482.50 " "$1,837.05" $0.00 "$1,986.00" "$1,117.13" "$1,117.13" $0.00 $0.00 $0.00 $517.42 "$1,842.51" "$1,842.51" $0.00 $0.00 $517.35 $0.00 "$1,468.40" "$1,468.40" $0.00 "$1,241.25" "$1,966.14" "$1,986.00" $0.00 $0.00 $388.51 $0.00 $0.00 $395.21 $0.00 $0.00 $0.00 $0.00 $0.00 8754025 SUP HCPCS C1713 8754025 - SCREW UNIPLANER 4.0MM 25MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754030 SUP HCPCS C1713 8754030 - SCREW UNIPLANER 4.0MM 30MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754035 SUP HCPCS C1713 8754035 - SCREW UNIPLANER 4.0MM 35MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754040 SUP HCPCS C1713 8754040 - SCREW UNIPLANER 4.0MM 40MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754045 SUP HCPCS C1713 8754045 - SCREW UNIPLANER 4.0MM 45MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754525 SUP HCPCS C1713 8754525 - SCREW UNIPLANER 4.5MM 25MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754530 SUP HCPCS C1713 8754530 - SCREW UNIPLANER 4.5MM 30MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754535 SUP HCPCS C1713 8754535 - SCREW UNIPLANER 4.5MM 35MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754540 SUP HCPCS C1713 8754540 - SCREW UNIPLANER 4.5MM 40MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754545 SUP HCPCS C1713 8754545 - SCREW UNIPLANER 4.5MM 45MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8754550 SUP HCPCS C1713 8754550 - SCREW UNIPLANER 4.5MM 50MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755025 SUP HCPCS C1713 8755025 - SCREW UNIPLANER 5.0MM 25MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755030 SUP HCPCS C1713 8755030 - SCREW UNIPLANER 5.0MM 30MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755035 SUP HCPCS C1713 8755035 - SCREW UNIPLANER 5.0MM 35MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755040 SUP HCPCS C1713 8755040 - SCREW UNIPLANER 5.0MM 40MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755045 SUP HCPCS C1713 8755045 - SCREW UNIPLANER 5.0MM 45MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755050 SUP HCPCS C1713 8755050 - SCREW UNIPLANER 5.0MM 50MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755525 SUP HCPCS C1713 8755525 - SCREW UNIPLANER 5.5MM 25MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755530 SUP HCPCS C1713 8755530 - SCREW UNIPLANER 5.5MM 30MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755535 SUP HCPCS C1713 8755535 - SCREW UNIPLANER 5.5MM 35MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755540 SUP HCPCS C1713 8755540 - SCREW UNIPLANER 5.5MM 40MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755545 SUP HCPCS C1713 8755545 - SCREW UNIPLANER 5.5MM 45MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755550 SUP HCPCS C1713 8755550 - SCREW UNIPLANER 5.5MM 50MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755555 SUP HCPCS C1713 8755555 - SCREW UNIPLANER 5.5MM 55MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755560 SUP HCPCS C1713 8755560 - SCREW UNIPLANER 5.5MM 60MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8755565 SUP HCPCS C1713 8755565 - SCREW UNIPLANER 5.5MM 65MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756025 SUP HCPCS C1713 8756025 - SCREW UNIPLANER 6.0MM 25MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756030 SUP HCPCS C1713 8756030 - SCREW UNIPLANER 6.0MM 30MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756035 SUP HCPCS C1713 8756035 - SCREW UNIPLANER 6.0MM 35MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756040 SUP HCPCS C1713 8756040 - SCREW UNIPLANER 6.0MM 40MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756045 SUP HCPCS C1713 8756045 - SCREW UNIPLANER 6.0MM 45MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756050 SUP HCPCS C1713 8756050 - SCREW UNIPLANER 6.0MM 50MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756055 SUP HCPCS C1713 8756055 - SCREW UNIPLANER 6.0MM 55MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756060 SUP HCPCS C1713 8756060 - SCREW UNIPLANER 6.0MM 60MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8756065 SUP HCPCS C1713 8756065 - SCREW UNIPLANER 6.0MM 65MM 5.5MM SS BOTH IP/OP "$5,192.50 " "$3,842.45" $0.00 "$4,154.00" "$2,336.63" "$2,336.63" $0.00 $0.00 $0.00 "$1,082.25" "$3,853.87" "$3,853.87" $0.00 $0.00 "$1,082.12" $0.00 "$2,559.90" "$2,559.90" $0.00 "$2,596.25" "$4,112.46" "$4,154.00" $0.00 $0.00 $812.63 $0.00 $0.00 $826.65 $0.00 $0.00 $0.00 $0.00 $0.00 8780111 SUP HCPCS C1713 8780111 - SCREW BN 4MM 11MM ARCHON SLF DRL FX ANG SPNE DEGENERATIVE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780113 SUP HCPCS C1713 8780113 - SCREW BN 4MM 13MM ARCHON SLF DRL FX ANG SPNE DEGENERATIVE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780115 SUP HCPCS C1713 8780115 - SCREW BN 4MM 15MM ARCHON SLF DRL FX ANG SPNE DEGENERATIVE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780211 SUP HCPCS C1713 8780211 - SCREW BN 4MM 11MM NS ARCHON SLF DRL VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780213 SUP HCPCS C1713 8780213 - SCREW BN 4MM 13MM ARCHON SLF DRL VA SPNE DEGENERATIVE DISC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780215 SUP HCPCS C1713 8780215 - SCREW BN 4MM 15MM NS ARCHON SLF DRL VA SPNE DEGENERATIVE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780216 SUP HCPCS C1713 8780216 - SCREW BN 4MM 16MM SLF DRL VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780311 SUP HCPCS C1713 8780311 - SCREW BN 4MM 11MM ARCHON ST FX ANG SPNE DEGENERATIVE DISC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780313 SUP HCPCS C1713 8780313 - SCREW BN 4MM 13MM ARCHON ST FX ANG SPNE DEGENERATIVE DISC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780319 SUP HCPCS C1713 8780319 - SCREW BN 4MM 19MM ARCHON ST FX ANG SPNE DEGENERATIVE DISC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780411 SUP HCPCS C1713 8780411 - SCREW BN 4MM 11MM NS ARCHON SLF DRL VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780511 SUP HCPCS C1713 8780511 - SCREW BN 4.5MM 11MM ARCHON ST FX ANG SPNE DEGENERATIVE DISC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780515 SUP HCPCS C1713 8780515 - SCREW BN 4.5MM 15MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780517 SUP HCPCS C1713 8780517 - SCREW BN 4.5MM 17MM ARCHON ST FX ANG SPNE DEGENERATIVE DISC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780519 SUP HCPCS C1713 8780519 - SCREW BN 4.5MM 19MM ARCHON ST FX ANG SPNE DEGENERATIVE DISC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780613 SUP HCPCS C1713 8780613 - SCREW BN 4.5MM 13MM NS ARCHON ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780617 SUP HCPCS C1713 8780617 - SCREW BN 4.5MM 17MM NS ARCHON SLF DRL VA SPNE DEGENERATIVE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780619 SUP HCPCS C1713 8780619 - SCREW BN 4.5MM 19MM NS ARCHON ST VA SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780711 SUP HCPCS C1713 8780711 - SCREW BN 4MM 11MM NS ARCHON SLF DRL FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780715 SUP HCPCS C1713 8780715 - SCREW BN 4MM 15MM NS ARCHON SLF DRL FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780811 SUP HCPCS C1713 8780811 - SCREW BN 4MM 11MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780813 SUP HCPCS C1713 8780813 - SCREW BN 4MM 13MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780815 SUP HCPCS C1713 8780815 - SCREW BN 4MM 15MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780817 SUP HCPCS C1713 8780817 - SCREW BN 4MM 17MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780819 SUP HCPCS C1713 8780819 - SCREW BN 4MM 19MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780911 SUP HCPCS C1713 8780911 - SCREW BN 4.5MM 11MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780913 SUP HCPCS C1713 8780913 - SCREW BN 4.5MM 13MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780915 SUP HCPCS C1713 8780915 - SCREW BN 4.5MM 15MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780917 SUP HCPCS C1713 8780917 - SCREW BN 4.5MM 17MM NS ARCHON SLF DRL FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8780919 SUP HCPCS C1713 8780919 - SCREW BN 4.5MM 19MM NS ARCHON ST FX ANG SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8787118 SUP HCPCS C1713 8787118 - ARCHON 18MM PLATE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8787120 SUP HCPCS C1713 8787120 - PLATE BN 20MM ARCHON 1 LVL SPNE DEGENERATIVE DISC BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8787128 SUP HCPCS C1713 8787128 - PLATE BN 28MM NS ARCHON 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8787130 SUP HCPCS C1713 8787130 - PLATE BN 30MM NS ARCHON 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8787132 SUP HCPCS C1713 8787132 - PLATE BN 32MM NS ARCHON 1 LVL SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8787234 SUP HCPCS C1713 8787234 - PLATE BN 34MM NS ARCHON 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787236 SUP HCPCS C1713 8787236 - PLATE BN 36MM NS ARCHON 2 LVL SPNE DEGENERATIVE DISC BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787238 SUP HCPCS C1713 8787238 - ARCHON 2 LEVEL PLATE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787240 SUP HCPCS C1713 "8787240 - ARCHON LEVEL2, CERVICAL PLATE" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787242 SUP HCPCS C1713 8787242 - PLATE BN 42MM ARCHON 2 LVL SPNE DEGENERATIVE DISC BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787244 SUP HCPCS C1713 "8787244 - ARCHON PLATE, 2 LEVEL, 44MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787246 SUP HCPCS C1713 8787246 - PLATE BN 46MM NS ARCHON 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787248 SUP HCPCS C1713 8787248 - PLATE BN 48MM NS ARCHON 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787250 SUP HCPCS C1713 8787250 - PLATE BN 50MM NS ARCHON 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787252 SUP HCPCS C1713 8787252 - PLATE BN 52MM NS ARCHON 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787254 SUP HCPCS C1713 8787254 - PLATE BN 54MM NS ARCHON 2 LVL SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8787350 SUP HCPCS C1713 8787350 - PLATE BN 50MM NS ARCHON 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8787352 SUP HCPCS C1713 8787352 - PLATE BN 52MM NS ARCHON 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8787356 SUP HCPCS C1713 8787356 - PLATE BN 56MM NS ARCHON 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8787364 SUP HCPCS C1713 8787364 - PLATE BN 64MM NS ARCHON 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8787366 SUP HCPCS C1713 8787366 - PLATE BN 66MM NS ARCHON 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8787368 SUP HCPCS C1713 8787368 - PLATE BN 68MM NS ARCHON 3 LVL SPNE BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8787468 SUP HCPCS C1713 8787468 - PLATE BN 68MM ARCHON 4 LVL SPNE DEGENERATIVE DISC BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 8787474 SUP HCPCS C1713 8787474 - PLATE BN 74MM ARCHON 4 LVL SPNE DEGENERATIVE DISC BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 8787486 SUP HCPCS C1713 8787486 - PLATE BN 86MM ARCHON 4 LVL SPNE DEGENERATIVE DISC BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 8787500 SUP HCPCS C1713 8787500 - PLATE BN 100MM ARCHON 5 LVL SPNE DEGENERATIVE DISC BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 8787510 SUP HCPCS C1713 8787510 - PLATE BN 110MM ARCHON 5 LVL SPNE DEGENERATIVE DISC BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 8792111 SUP HCPCS C1713 8792111 - SCREW 8792111 VAST CNCLLS 3.5X11MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792113 SUP HCPCS C1713 8792113 - SCREW 8792113 ZEPHIR VAST 3.5X13 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792115 SUP HCPCS C1713 8792115 - SCREW 8792115 ZEPHIR VAST 3.5X15 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792117 SUP HCPCS C1713 8792117 - SCREW 8792117 ZEPHIR VAST 3.5X17 BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792711 SUP HCPCS C1713 8792711 - SCREW 8792711 VAST CNCLLS 4.0X11MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792713 SUP HCPCS C1713 8792713 - SCREW 8792713 VAST CNCLLS 4.0X13MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792715 SUP HCPCS C1713 8792715 - SCREW 8792715 VAST CNCLLS 4.0X15MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792717 SUP HCPCS C1713 8792717 - SCREW 8792717 VASD CNCLLS 4.0X17MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792811 SUP HCPCS C1713 8792811 - SCREW 8792811 VA SELF DRILLING 3.5X11MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792813 SUP HCPCS C1713 8792813 - SCREW 8792813 VA SELF DRILLING 3.5X13MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792815 SUP HCPCS C1713 8792815 - SCREW BN 3.5MM 15MM NS ZPHR VA SLF DRL TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792817 SUP HCPCS C1713 8792817 - SCREW 8792817 VA SELF DRILLING 3.5X17MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792911 SUP HCPCS C1713 8792911 - SCREW 8792911 VA SELF DRILLING 4.0X11MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792913 SUP HCPCS C1713 8792913 - SCREW 8792913 VA SELF DRILLING 4.0X13MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792915 SUP HCPCS C1713 8792915 - SCREW BN 4MM 15MM NS ZPHR VA SLF DRL TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8792917 SUP HCPCS C1713 8792917 - SCREW 8792917 VA SELF DRILLING 4.0X17MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 8799022 SUP HCPCS C1713 8799022 - PLATE 8799022 ANT CERV 22.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799025 SUP HCPCS C1713 8799025 - PLATE 8799025 ANT CERV 25MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799027 SUP HCPCS C1713 8799027 - PLATE 8799027 ANT CERV 27.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799130 SUP HCPCS C1713 8799130 - PLATE 8799130 ZEPHIR 30MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799132 SUP HCPCS C1713 8799132 - PLATE 8799132 ZEPHIR 32.5MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799135 SUP HCPCS C1713 8799135 - PLATE 8799135 ZEPHIR 35MM TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799137 SUP HCPCS C1713 8799137 - PLATE 8799137 ZEPHIR 37.5MM TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799140 SUP HCPCS C1713 8799140 - PLATE 8799140 ZEPHIR 40MM TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799142 SUP HCPCS C1713 8799142 - PLATE 8799142 ZEPHIR 42.5MM TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799145 SUP HCPCS C1713 8799145 - PLATE 8799145 ZEPHIR 45MM TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799147 SUP HCPCS C1713 8799147 - PLATE 8799147ZEPHIR 47.5MM TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799150 SUP HCPCS C1713 8799150 - PLATE 8799150 ZEPHIR 50MM TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799152 SUP HCPCS C1713 8799152 - PLATE 8799152 ZEPHIR 52.5MM TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799155 SUP HCPCS C1713 8799155 - PLATE 8799155 ZEPHIR 55MM TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799157 SUP HCPCS C1713 8799157 - PLATE 8799157 ZEPHIR 57.5MM TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799160 SUP HCPCS C1713 8799160 - PLATE 8799160 ZEPHIR 60MM TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799162 SUP HCPCS C1713 8799162 - PLATE 8799162 ZEPHIR 62.5MM TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799165 SUP HCPCS C1713 8799165 - PLATE 8799165 ZEPHIR 65MM TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799167 SUP HCPCS C1713 8799167 - PLATE 8799167 ZEPHIR 67.5MM TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799170 SUP HCPCS C1713 8799170 - PLATE 8799170 ZEPHIR 70MM TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799180 SUP HCPCS C1713 8799180 - PLATE 8799180 ZEPHIR KIT 22MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799190 SUP HCPCS C1713 8799190 - PLATE 8799190 ZEPHIR KIT 25MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799200 SUP HCPCS C1713 8799200 - PLATE 8799200 ZEPHIR KIT 27MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799230 SUP HCPCS C1713 "8799230 - ZEPHIR DUAL SLOT PLATE, 30MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799232 SUP HCPCS C1713 "8799232 - ZEPHIR DUAL SLOT PLATE, 32.5MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799235 SUP HCPCS C1713 "8799235 - ZEPHIR DUAL SLOT PLATE, 35MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8799237 SUP HCPCS C1713 "8799237 - ZEPHIR DUAL SLOT PLATE, 37.5MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799245 SUP HCPCS C1713 "8799245 - ZEPHIR DUAL SLOT PLATE, 45MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799247 SUP HCPCS C1713 "8799247 - ZEPHIR DUAL SLOT PLATE, 47.5MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799250 SUP HCPCS C1713 "8799250 - ZEPHIR DUAL SLOT PLATE, 50MM" BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8799252 SUP HCPCS C1713 "8799252 - ZEPHIR DUAL SLOT PLATE, 52.5MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799255 SUP HCPCS C1713 "8799255 - ZEPHIR DUAL SLOT PLATE, 55MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799257 SUP HCPCS C1713 "8799257 - ZEPHIR DUAL SLOT PLATE, 57.5MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799260 SUP HCPCS C1713 "8799260 - ZEPHIR DUAL SLOT PLATE, 60MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799262 SUP HCPCS C1713 "8799262 - ZEPHIR DUAL SLOT PLATE, 62.5MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799265 SUP HCPCS C1713 "8799265 - ZEPHIR DUAL SLOT PLATE, 65MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799267 SUP HCPCS C1713 "8799267 - ZEPHIR DUAL SLOT PLATE, 67.5MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8799270 SUP HCPCS C1713 "8799270 - ZEPHIR DUAL SLOT PLATE, 70MM" BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 8800000 SUP HCPCS C1713 8800000 - SCREW BONE SPNL MULTIAX LCK BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8801054 SUP Custom 27203010 8801054 - MARKER SRG STRL NDI 4 SPHR IN TRY STD MNT POST DISP BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8801068 SUP HCPCS C1769 8801068 - WIRE KWIRE SPNL THRD BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 8801269 SUP HCPCS C1713 8801269 - WIRE FX LNG PRCPT GSB MAS KRSH BVL TIP NTNL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 8804525 SUP HCPCS C1713 8804525 - SCREW BONE 4.5MM 25MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804530 SUP HCPCS C1713 8804530 - SCREW BONE 4.5MM 30MM SPNL POLYAX BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804535 SUP HCPCS C1713 8804535 - SCREW BONE 4.5MM 35MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804540 SUP HCPCS C1713 8804540 - SCREW BONE 4.5MM 40MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804545 SUP HCPCS C1713 8804545 - SCREW BONE 4.5MM 45MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805530 SUP HCPCS C1713 8805530 - SCREW BONE 5.5MM 30MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805535 SUP HCPCS C1713 8805535 - SCREW BONE 5.5MM 35MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805540 SUP HCPCS C1713 8805540 - SCREW BONE 5.5MM 40MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805545 SUP HCPCS C1713 8805545 - SCREW BONE 5.5MM 45MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805550 SUP HCPCS C1713 8805550 - SCREW BONE 5.5MM 50MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805555 SUP HCPCS C1713 8805555 - SCREW BONE 5.5MM 55MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806530 SUP HCPCS C1713 8806530 - SCREW BONE 6.5MM 30MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806535 SUP HCPCS C1713 8806535 - SCREW BONE 6.5MM 35MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806540 SUP HCPCS C1713 8806540 - SCREW BONE 6.5MM 40MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806545 SUP HCPCS C1713 8806545 - SCREW BONE 6.5MM 45MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806550 SUP HCPCS C1713 8806550 - SCREW BONE 6.5MM 50MM MULTIAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806555 SUP HCPCS C1713 8806555 - SCREW BONE 6.5MM 55MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807500 SUP HCPCS C1713 8807500 - SCREW BONE 7.5MM 50MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807530 SUP HCPCS C1713 8807530 - SCREW BONE 7.5MM 30MM SPNL POLYAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807535 SUP HCPCS C1713 8807535 - SCREW BONE 7.5MM 35MM SPNL POLYAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807540 SUP HCPCS C1713 8807540 - SCREW BONE 7.5MM 40MM SPNL POLYAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807545 SUP HCPCS C1713 8807545 - SCREW BONE 7.5MM 45MM SPNL POLYAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807550 SUP HCPCS C1713 8807550 - SCREW BONE 7.5MM 50MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807555 SUP HCPCS C1713 8807555 - SCREW BONE 7.5MM 55MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807560 SUP HCPCS C1713 8807560 - SCREW BONE 7.5MM 60MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807570 SUP HCPCS C1713 8807570 - SCREW BONE 7.5MM 70MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807580 SUP HCPCS C1713 8807580 - SCREW BONE 7.5MM 80MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807590 SUP HCPCS C1713 8807590 - SCREW BONE 7.5MM 90MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808500 SUP HCPCS C1713 8808500 - SCREW BONE 8.5MM 100MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808535 SUP HCPCS C1713 8808535 - SCREW BONE 8.5MM 35MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808540 SUP HCPCS C1713 8808540 - SCREW BONE 8.5MM 40MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808545 SUP HCPCS C1713 8808545 - SCREW BONE 8.5MM 45MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808550 SUP HCPCS C1713 8808550 - SCREW BONE 8.5MM 50MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808555 SUP HCPCS C1713 8808555 - SCREW BONE 8.5MM 55MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808560 SUP HCPCS C1713 8808560 - SCREW BONE 8.5MM 60MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808570 SUP HCPCS C1713 8808570 - SCREW BONE 8.5MM 70MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808580 SUP HCPCS C1713 8808580 - SCREW BONE 8.5MM 80MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808590 SUP HCPCS C1713 8808590 - SCREW BONE 8.5MM 90MM SPNL MULTIAX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8824525 SUP HCPCS C1713 8824525 - SCREW BN 4.5MM 25MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8824530 SUP HCPCS C1713 8824530 - SCREW BN 4.5MM 30MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8824535 SUP HCPCS C1713 8824535 - SCREW BN 4.5MM 35MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8824540 SUP HCPCS C1713 8824540 - SCREW BN 4.5MM 40MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8824545 SUP HCPCS C1713 8824545 - SCREW BN 4.5MM 45MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8825530 SUP HCPCS C1713 8825530 - SCREW BN 7.5MM 35MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8825545 SUP HCPCS C1713 8825545 - SCREW BN 7.5MM 50MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8825550 SUP HCPCS C1713 8825550 - SCREW BN 7.5MM 55MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8825555 SUP HCPCS C1713 8825555 - SCREW BN 6.5MM 40MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8826530 SUP HCPCS C1713 8826530 - SCREW BN 6.5MM 45MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8826540 SUP HCPCS C1713 8826540 - SCREW BN 6.5MM 40MM NS PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8826550 SUP HCPCS C1713 8826550 - SCREW BN 5.5MM 30MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8826555 SUP HCPCS C1713 8826555 - SCREW BN 5.5MM 35MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827500 SUP HCPCS C1713 8827500 - SCREW BN 7.5MM 100MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827530 SUP HCPCS C1713 8827530 - SCREW BN 5.5MM 40MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827535 SUP HCPCS C1713 8827535 - SCREW BN 5.5MM 45MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827550 SUP HCPCS C1713 8827550 - SCREW BN 6.5MM 30MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827555 SUP HCPCS C1713 8827555 - SCREW BN 6.5MM 35MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827560 SUP HCPCS C1713 8827560 - SCREW BN 7.5MM 60MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827570 SUP HCPCS C1713 8827570 - SCREW BN 7.5MM 70MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827580 SUP HCPCS C1713 8827580 - SCREW BN 7.5MM 80MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8827590 SUP HCPCS C1713 8827590 - SCREW BN 7.5MM 90MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828500 SUP HCPCS C1713 8828500 - SCREW BN 8.5MM 100MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828535 SUP HCPCS C1713 8828535 - SCREW BN 8.5MM 35MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828540 SUP HCPCS C1713 8828540 - SCREW BN 8.5MM 40MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828545 SUP HCPCS C1713 8828545 - SCREW BN 8.5MM 45MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828550 SUP HCPCS C1713 8828550 - SCREW BN 8.5MM 50MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828555 SUP HCPCS C1713 8828555 - SCREW BN 8.5MM 55MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828560 SUP HCPCS C1713 8828560 - SCREW BN 8.5MM 60MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828570 SUP HCPCS C1713 8828570 - SCREW BN 8.5MM 70MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828580 SUP HCPCS C1713 8828580 - SCREW BN 8.5MM 80MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8828590 SUP HCPCS C1713 8828590 - SCREW BN 8.5MM 90MM PRCPT RDC SPNE BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 8847020 SUP HCPCS C1713 8847020 - ROD SPNL 20MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847025 SUP HCPCS C1713 8847025 - ROD SPNL 25MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847030 SUP HCPCS C1713 8847030 - ROD SPNL 30MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847035 SUP HCPCS C1713 8847035 - ROD SPNL 35MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847040 SUP HCPCS C1713 8847040 - ROD SPNL 540MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847045 SUP HCPCS C1713 8847045 - ROD SPNL 45MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847050 SUP HCPCS C1713 8847050 - ROD SPNL 50MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847055 SUP HCPCS C1713 8847055 - ROD SPNL 55MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847060 SUP HCPCS C1713 8847060 - ROD SPNL 60MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847065 SUP HCPCS C1713 8847065 - ROD SPNL 65MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847070 SUP HCPCS C1713 8847070 - ROD SPNL 70MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847075 SUP HCPCS C1713 8847075 - ROD SPNL 75MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847080 SUP HCPCS C1713 8847080 - ROD SPNL 80MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847085 SUP HCPCS C1713 8847085 - ROD SPNL 85MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847090 SUP HCPCS C1713 8847090 - ROD SPNL 90MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847095 SUP HCPCS C1713 8847095 - ROD SPNL 95MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847100 SUP HCPCS C1713 8847100 - ROD SPNL 100MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847110 SUP HCPCS C1713 8847110 - ROD SPNL 110MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847120 SUP HCPCS C1713 8847120 - ROD SPNL 120MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847130 SUP HCPCS C1713 8847130 - ROD SPNL 130MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847140 SUP HCPCS C1713 8847140 - ROD SPNL 140MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847150 SUP HCPCS C1713 8847150 - ROD SPNL 150MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8847160 SUP HCPCS C1713 8847160 - ROD SPNL 160MM PRCPT PREBNT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848160 SUP HCPCS C1713 8848160 - ROD SPNL 160MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848170 SUP HCPCS C1713 8848170 - ROD SPNL 170MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848180 SUP HCPCS C1713 8848180 - ROD SPNL 180MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848190 SUP HCPCS C1713 8848190 - ROD SPNL 190MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848200 SUP HCPCS C1713 8848200 - ROD SPNL 200MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848210 SUP HCPCS C1713 8848210 - ROD SPNL 210MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848220 SUP HCPCS C1713 8848220 - ROD SPNL 220MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848230 SUP HCPCS C1713 8848230 - ROD SPNL 230MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848240 SUP HCPCS C1713 8848240 - ROD SPNL 240MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848250 SUP HCPCS C1713 8848250 - ROD SPNL 250MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848300 SUP HCPCS C1713 8848300 - ROD SPNL 300MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848500 SUP HCPCS C1713 8848500 - ROD SPNL 500MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8848600 SUP HCPCS C1713 8848600 - ROD SPNL 600MM PRCPT STRAIGHT TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8880823 SUP HCPCS C1713 8880823 - SPACER SPNL XLORDOTIC 23MMX8MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8880828 SUP HCPCS C1713 8880828 - SPACER SPNL XLORDOTIC 28MMX8MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8880832 SUP HCPCS C1713 8880832 - SPACER SPNL XLORDOTIC 32MMX8MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8880923 SUP HCPCS C1713 8880923 - SPACER SPNL XLORDOTIC 23MMX9MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8880928 SUP HCPCS C1713 8880928 - SPACER SPNL 28MMX9MM ELEV XLORDOTIC PEEK TI STRL BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8880932 SUP HCPCS C1713 8880932 - SPACER SPNL XLORDOTIC 32MMX9MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8881023 SUP HCPCS C1713 8881023 - SPACER SPNL XLORDOTIC 23MMX10MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8881028 SUP HCPCS C1713 8881028 - SPACER SPNL XLORDOTIC 28MMX10MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8881032 SUP HCPCS C1713 8881032 - SPACER SPNL XLORDOTIC 32MMX10MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8881123 SUP HCPCS C1713 8881123 - SPACER SPNL XLORDOTIC 23MMX11MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8881128 SUP HCPCS C1713 8881128 - SPACER SPNL XLORDOTIC 28MMX11MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8881132 SUP HCPCS C1713 8881132 - SPACER SPNL XLORDOTIC 32MMX11MM STRL ELEV PEEK TI BOTH IP/OP "$11,698.50 " "$8,656.89" $0.00 "$9,358.80" "$5,264.33" "$5,264.33" $0.00 $0.00 $0.00 "$2,438.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,437.97" $0.00 "$5,767.36" "$5,767.36" $0.00 "$5,849.25" "$9,265.21" "$9,358.80" $0.00 $0.00 "$1,830.82" $0.00 $0.00 "$1,862.40" $0.00 $0.00 $0.00 $0.00 $0.00 8896555 SUP HCPCS C1713 8896555 - SCREW BONE 6.5MM 55MM GSB PRCPT SPN MDLR CANN SHNK BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 8914000 SUP HCPCS C1713 8914000 - M4 BREAK-OFF SCREW BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8915008 SUP HCPCS C1713 8915008 - SPACER SPNL SM FLT 8MM STRL VRTSTCK ADON PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915010 SUP HCPCS C1713 8915010 - SPACER SPNL SM FLT 10MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915012 SUP HCPCS C1713 8915012 - SPACER SPNL SM FLT 12MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915014 SUP HCPCS C1713 8915014 - SPACER SPNL SM FLT 14MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915016 SUP HCPCS C1713 8915016 - SPACER SPNL SM FLT 16MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915018 SUP HCPCS C1713 8915018 - SPACER SPNL SM FLT 18MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915020 SUP HCPCS C1713 8915020 - SPACER SPNL SM FLT 20MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915408 SUP HCPCS C1713 8915408 - SPACER SPNL SM LRDTC 8MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915410 SUP HCPCS C1713 8915410 - SPACER SPNL SM LRDTC 10MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915412 SUP HCPCS C1713 8915412 - SPACER SPNL SM LRDTC 12MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915414 SUP HCPCS C1713 8915414 - SPACER SPNL SM LRDTC 14MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915416 SUP HCPCS C1713 8915416 - SPACER SPNL SM LRDTC 16MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915418 SUP HCPCS C1713 8915418 - SPACER SPNL SM LRDTC 18MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915420 SUP HCPCS C1713 8915420 - SPACER SPNL SM LRDTC 20MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915805 SUP HCPCS C1713 8915805 - SPACER SPNL SM 5MM STRL VRTSTCK CENTERPIECE PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915810 SUP HCPCS C1713 8915810 - SPACER SPNL SM 10MM STRL VRTSTCK CENTERPIECE PEEK LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915820 SUP HCPCS C1713 8915820 - SPACER SPNL SM 20MM STRL VRTSTCK CENTERPIECE PEEK LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915830 SUP HCPCS C1713 8915830 - SPACER SPNL SM 30MM STRL VRTSTCK CENTERPIECE PEEK LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8915840 SUP HCPCS C1713 8915840 - SPACER SPNL SM 40MM STRL VRTSTCK CENTERPIECE PEEK LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916008 SUP HCPCS C1713 8916008 - SPACER SPNL LG FLT 8MM STRL VRTSTCK ADON PEEK LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916010 SUP HCPCS C1713 8916010 - SPACER SPNL LG FLT 10MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916012 SUP HCPCS C1713 8916012 - SPACER SPNL LG FLT 12MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916014 SUP HCPCS C1713 8916014 - SPACER SPNL LG FLT 14MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916016 SUP HCPCS C1713 8916016 - SPACER SPNL LG FLT 16MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916018 SUP HCPCS C1713 8916018 - SPACER SPNL LG FLT 18MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916020 SUP HCPCS C1713 8916020 - SPACER SPNL LG FLT 20MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916408 SUP HCPCS C1713 8916408 - SPACER SPNL LG LRDTC 8MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916410 SUP HCPCS C1713 8916410 - SPACER SPNL LG LRDTC 10MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916412 SUP HCPCS C1713 8916412 - SPACER SPNL LG LRDTC 12MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916414 SUP HCPCS C1713 8916414 - SPACER SPNL LG LRDTC 14MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916416 SUP HCPCS C1713 8916416 - SPACER SPNL LG LRDTC 16MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916418 SUP HCPCS C1713 8916418 - SPACER SPNL LG LRDTC 18MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916420 SUP HCPCS C1713 8916420 - SPACER SPNL LG LRDTC 20MM STRL VRTSTCK ADON PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916805 SUP HCPCS C1713 8916805 - SPACER SPNL LG 5MM STRL VRTSTCK CENTERPIECE PEEK LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916810 SUP HCPCS C1713 8916810 - SPACER SPNL LG 10MM STRL VRTSTCK CENTERPIECE PEEK LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916820 SUP HCPCS C1713 8916820 - SPACER SPNL LG 20MM STRL VRTSTCK CENTERPIECE PEEK LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916830 SUP HCPCS C1713 8916830 - SPACER SPNL LG 30MM STRL VRTSTCK CENTERPIECE PEEK LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8916840 SUP HCPCS C1713 8916840 - SPACER SPNL LG 40MM STRL VRTSTCK CENTERPIECE PEEK LMBR BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 8941420 SUP Custom 27803010 8941420 - CAGE SPNL 14MM 20X17MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,226.25 " "$5,347.43" $0.00 "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.95" $0.00 $0.00 $0.00 $0.00 "$3,613.13" "$5,723.19" "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941423 SUP Custom 27803010 8941423 - CAGE SPNL 14MM 23X17.5MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,226.25 " "$5,347.43" $0.00 "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.95" $0.00 $0.00 $0.00 $0.00 "$3,613.13" "$5,723.19" "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941620 SUP Custom 27803010 8941620 - CAGE SPNL 16MM 20X19MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,226.25 " "$5,347.43" $0.00 "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.95" $0.00 $0.00 $0.00 $0.00 "$3,613.13" "$5,723.19" "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941623 SUP Custom 27803010 8941623 - CAGE SPNL 16MM 23X19MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,226.25 " "$5,347.43" $0.00 "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.95" $0.00 $0.00 $0.00 $0.00 "$3,613.13" "$5,723.19" "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941626 SUP Custom 27803010 8941626 - CAGE SPNL 16MM 26X20MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,226.25 " "$5,347.43" $0.00 "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.95" $0.00 $0.00 $0.00 $0.00 "$3,613.13" "$5,723.19" "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941823 SUP Custom 27803010 8941823 - CAGE SPNL 18MM 23X21.5MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,226.25 " "$5,347.43" $0.00 "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.95" $0.00 $0.00 $0.00 $0.00 "$3,613.13" "$5,723.19" "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941826 SUP Custom 27803010 8941826 - CAGE SPNL 18MM 26X22MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,226.25 " "$5,347.43" $0.00 "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.95" $0.00 $0.00 $0.00 $0.00 "$3,613.13" "$5,723.19" "$5,781.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8954025 SUP HCPCS C1713 8954025 - SCREW BONE 25MM 4MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8954030 SUP HCPCS C1713 8954030 - SCREW BONE 30MM 4MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8954035 SUP HCPCS C1713 8954035 - SCREW BONE 35MM 4MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8954525 SUP HCPCS C1713 8954525 - SCREW BONE 25MM 4.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8954530 SUP HCPCS C1713 8954530 - SCREW BONE 30MM 4.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8954535 SUP HCPCS C1713 8954535 - SCREW BONE 35MM 4.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8954540 SUP HCPCS C1713 8954540 - SCREW BONE 40MM 4.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8954545 SUP HCPCS C1713 8954545 - SCREW BONE 45MM 4.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8955530 SUP HCPCS C1713 8955530 - SCREW BONE 30MM 5.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8955535 SUP HCPCS C1713 8955535 - SCREW BONE 35MM 5.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8955540 SUP HCPCS C1713 8955540 - SCREW BONE 40MM 5.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8955545 SUP HCPCS C1713 8955545 - SCREW BONE 45MM 5.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8956535 SUP HCPCS C1713 8956535 - SCREW BONE 35MM 6.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8956540 SUP HCPCS C1713 8956540 - SCREW BONE 40MM 6.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8956545 SUP HCPCS C1713 8956545 - SCREW BONE 45MM 6.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8956550 SUP HCPCS C1713 8956550 - SCREW BONE 50MM 6.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8957535 SUP HCPCS C1713 8957535 - SCREW BONE 35MM 7.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8957540 SUP HCPCS C1713 8957540 - SCREW BONE 40MM 7.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8957545 SUP HCPCS C1713 8957545 - SCREW BONE 45MM 7.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8957550 SUP HCPCS C1713 8957550 - SCREW BONE 50MM 7.5MM SS FIX 5.5MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8964525 SUP HCPCS C1713 8964525 - SCREW BONE 4.5MM 25MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8964530 SUP HCPCS C1713 8964530 - SCREW BONE 4.5MM 30MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8964535 SUP HCPCS C1713 8964535 - SCREW BONE 4.5MM 35MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8964540 SUP HCPCS C1713 8964540 - SCREW BONE 4.5MM 40MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8964545 SUP HCPCS C1713 8964545 - SCREW BONE 4.5MM 45MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8965530 SUP HCPCS C1713 8965530 - SCREW BONE 5.5MM 30MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8965535 SUP HCPCS C1713 8965535 - SCREW BONE 5.5MM 35MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8965540 SUP HCPCS C1713 8965540 - SCREW BONE 5.5MM 40MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8965545 SUP HCPCS C1713 8965545 - SCREW BONE 5.5MM 45MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8966535 SUP HCPCS C1713 8966535 - SCREW BONE 6.5MM 35MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8966540 SUP HCPCS C1713 8966540 - SCREW BONE 6.5MM 40MM SS SPNL FIX 6.35MM ROD BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8966545 SUP HCPCS C1713 8966545 - SCREW BONE 6.5MM 6.35MM 45MM SS SPNL FIX BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8966550 SUP HCPCS C1713 8966550 - SCREW BONE 6.5MM 6.35MM 50MM SS SPNL FIX BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8967535 SUP HCPCS C1713 8967535 - SCREW BONE 7.5MM 6.35MM 35MM SS SPNL FIX BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8967540 SUP HCPCS C1713 8967540 - SCREW BONE 7.5MM 6.35MM 40MM SS SPNL FIX BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8967545 SUP HCPCS C1713 8967545 - SCREW BONE 7.5MM 6.35MM 45MM SS SPNL FIX BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8967550 SUP HCPCS C1713 8967550 - SCREW BONE 7.5MM 6.35MM 50MM SS SPNL FIX BOTH IP/OP "$2,802.50 " "$2,073.85" $0.00 "$2,242.00" "$1,261.13" "$1,261.13" $0.00 $0.00 $0.00 $584.11 "$2,080.02" "$2,080.02" $0.00 $0.00 $584.04 $0.00 "$1,381.63" "$1,381.63" $0.00 "$1,401.25" "$2,219.58" "$2,242.00" $0.00 $0.00 $438.59 $0.00 $0.00 $446.16 $0.00 $0.00 $0.00 $0.00 $0.00 8968625 SUP HCPCS C1713 8968625 - SCREW 8968625 PYRMD BONE FAS 6.5X25MM BOTH IP/OP $880.50 $651.57 $0.00 $704.40 $396.23 $396.23 $0.00 $0.00 $0.00 $183.52 $653.51 $653.51 $0.00 $0.00 $183.50 $0.00 $520.82 $520.82 $0.00 $440.25 $697.36 $704.40 $0.00 $0.00 $137.80 $0.00 $0.00 $140.18 $0.00 $0.00 $0.00 $0.00 $0.00 8968630 SUP HCPCS C1713 8968630 - SCREW 8968630 PYRMD BONE FAS 6.5X30MM BOTH IP/OP $880.50 $651.57 $0.00 $704.40 $396.23 $396.23 $0.00 $0.00 $0.00 $183.52 $653.51 $653.51 $0.00 $0.00 $183.50 $0.00 $520.82 $520.82 $0.00 $440.25 $697.36 $704.40 $0.00 $0.00 $137.80 $0.00 $0.00 $140.18 $0.00 $0.00 $0.00 $0.00 $0.00 8968635 SUP HCPCS C1713 8968635 - SCREW 8968635 PYRMD BONE FAS 6.5X35MM BOTH IP/OP $880.50 $651.57 $0.00 $704.40 $396.23 $396.23 $0.00 $0.00 $0.00 $183.52 $653.51 $653.51 $0.00 $0.00 $183.50 $0.00 $520.82 $520.82 $0.00 $440.25 $697.36 $704.40 $0.00 $0.00 $137.80 $0.00 $0.00 $140.18 $0.00 $0.00 $0.00 $0.00 $0.00 8969117 SUP HCPCS C1713 8969117 - PLATE 8969117 PLATE 17MM BOTH IP/OP "$8,377.50 " "$6,199.35" $0.00 "$6,702.00" "$3,769.88" "$3,769.88" $0.00 $0.00 $0.00 "$1,746.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,745.87" $0.00 "$4,130.11" "$4,130.11" $0.00 "$4,188.75" "$6,634.98" "$6,702.00" $0.00 $0.00 "$1,311.08" $0.00 $0.00 "$1,333.70" $0.00 $0.00 $0.00 $0.00 $0.00 8969119 SUP HCPCS C1713 8969119 - PLATE 8969119 PLATE 19MM BOTH IP/OP "$8,377.50 " "$6,199.35" $0.00 "$6,702.00" "$3,769.88" "$3,769.88" $0.00 $0.00 $0.00 "$1,746.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,745.87" $0.00 "$4,130.11" "$4,130.11" $0.00 "$4,188.75" "$6,634.98" "$6,702.00" $0.00 $0.00 "$1,311.08" $0.00 $0.00 "$1,333.70" $0.00 $0.00 $0.00 $0.00 $0.00 8969121 SUP HCPCS C1713 8969121 - PLATE 8969121 PLATE 21MM BOTH IP/OP "$8,377.50 " "$6,199.35" $0.00 "$6,702.00" "$3,769.88" "$3,769.88" $0.00 $0.00 $0.00 "$1,746.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,745.87" $0.00 "$4,130.11" "$4,130.11" $0.00 "$4,188.75" "$6,634.98" "$6,702.00" $0.00 $0.00 "$1,311.08" $0.00 $0.00 "$1,333.70" $0.00 $0.00 $0.00 $0.00 $0.00 8969123 SUP HCPCS C1713 8969123 - PLATE 8969123 PLATE 23MM BOTH IP/OP "$8,377.50 " "$6,199.35" $0.00 "$6,702.00" "$3,769.88" "$3,769.88" $0.00 $0.00 $0.00 "$1,746.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,745.87" $0.00 "$4,130.11" "$4,130.11" $0.00 "$4,188.75" "$6,634.98" "$6,702.00" $0.00 $0.00 "$1,311.08" $0.00 $0.00 "$1,333.70" $0.00 $0.00 $0.00 $0.00 $0.00 8969125 SUP HCPCS C1713 8969125 - PLATE 8969125 PLATE 25MM BOTH IP/OP "$8,377.50 " "$6,199.35" $0.00 "$6,702.00" "$3,769.88" "$3,769.88" $0.00 $0.00 $0.00 "$1,746.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,745.87" $0.00 "$4,130.11" "$4,130.11" $0.00 "$4,188.75" "$6,634.98" "$6,702.00" $0.00 $0.00 "$1,311.08" $0.00 $0.00 "$1,333.70" $0.00 $0.00 $0.00 $0.00 $0.00 8969127 SUP HCPCS C1713 8969127 - PLATE 8969127 PLATE 27MM BOTH IP/OP "$8,377.50 " "$6,199.35" $0.00 "$6,702.00" "$3,769.88" "$3,769.88" $0.00 $0.00 $0.00 "$1,746.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,745.87" $0.00 "$4,130.11" "$4,130.11" $0.00 "$4,188.75" "$6,634.98" "$6,702.00" $0.00 $0.00 "$1,311.08" $0.00 $0.00 "$1,333.70" $0.00 $0.00 $0.00 $0.00 $0.00 8969201 SUP HCPCS C1713 8969201 - SET SCREW 8969201 LOCKING PLATE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8969217 SUP HCPCS C1713 8969217 - PLATE 8969217 COVER PLATE 17MM BOTH IP/OP "$1,105.50 " $818.07 $0.00 $884.40 $497.48 $497.48 $0.00 $0.00 $0.00 $230.41 $820.50 $820.50 $0.00 $0.00 $230.39 $0.00 $653.90 $653.90 $0.00 $552.75 $875.56 $884.40 $0.00 $0.00 $173.01 $0.00 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 8969219 SUP HCPCS C1713 8969219 - PLATE 8969219 COVER PLATE 19MM BOTH IP/OP "$1,105.50 " $818.07 $0.00 $884.40 $497.48 $497.48 $0.00 $0.00 $0.00 $230.41 $820.50 $820.50 $0.00 $0.00 $230.39 $0.00 $653.90 $653.90 $0.00 $552.75 $875.56 $884.40 $0.00 $0.00 $173.01 $0.00 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 8969221 SUP HCPCS C1713 8969221 - PLATE 8969221 COVER PLATE 21MM BOTH IP/OP "$1,105.50 " $818.07 $0.00 $884.40 $497.48 $497.48 $0.00 $0.00 $0.00 $230.41 $820.50 $820.50 $0.00 $0.00 $230.39 $0.00 $653.90 $653.90 $0.00 $552.75 $875.56 $884.40 $0.00 $0.00 $173.01 $0.00 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 8969223 SUP HCPCS C1713 8969223 - PLATE 8969223 COVER PLATE 23MM BOTH IP/OP "$1,105.50 " $818.07 $0.00 $884.40 $497.48 $497.48 $0.00 $0.00 $0.00 $230.41 $820.50 $820.50 $0.00 $0.00 $230.39 $0.00 $653.90 $653.90 $0.00 $552.75 $875.56 $884.40 $0.00 $0.00 $173.01 $0.00 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 8969225 SUP HCPCS C1713 8969225 - PLATE 8969225 COVER PLATE 25MM BOTH IP/OP "$1,105.50 " $818.07 $0.00 $884.40 $497.48 $497.48 $0.00 $0.00 $0.00 $230.41 $820.50 $820.50 $0.00 $0.00 $230.39 $0.00 $653.90 $653.90 $0.00 $552.75 $875.56 $884.40 $0.00 $0.00 $173.01 $0.00 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 8969227 SUP HCPCS C1713 8969227 - PLATE 8969227 COVER PLATE 27MM BOTH IP/OP "$1,105.50 " $818.07 $0.00 $884.40 $497.48 $497.48 $0.00 $0.00 $0.00 $230.41 $820.50 $820.50 $0.00 $0.00 $230.39 $0.00 $653.90 $653.90 $0.00 $552.75 $875.56 $884.40 $0.00 $0.00 $173.01 $0.00 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 8970000 SUP HCPCS C1713 8970000 - SCREW LOCK 2 VUE POINT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8970240 SUP HCPCS C1713 "8970240 - VUE POINT II, ROD TEMPLATE" BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 8975310 SUP HCPCS C1713 8975310 - SCREW BN 3.5MM 10MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975312 SUP HCPCS C1713 8975312 - SCREW BN 3.5MM 12MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975314 SUP HCPCS C1713 8975314 - SCREW BN 3.5MM 14MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975318 SUP HCPCS C1713 8975318 - SCREW BN 3.5MM 18MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975320 SUP HCPCS C1713 8975320 - SCREW BN 3.5MM 20MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975322 SUP HCPCS C1713 8975322 - SCREW BN 3.5MM 22MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975324 SUP HCPCS C1713 8975324 - SCREW BN 3.5MM 24MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975326 SUP HCPCS C1713 8975326 - SCREW BN 3.5MM 26MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975328 SUP HCPCS C1713 8975328 - SCREW BN 3.5MM 28MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975330 SUP HCPCS C1713 8975330 - SCREW BN 3.5MM 30MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975332 SUP HCPCS C1713 8975332 - SCREW BN 3.5MM 32MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975334 SUP HCPCS C1713 8975334 - SCREW BN 3.5MM 34MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975410 SUP HCPCS C1713 8975410 - SCREW BN 4MM 10MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975412 SUP HCPCS C1713 8975412 - SCREW BN 4MM 12MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975414 SUP HCPCS C1713 8975414 - SCREW BN 4MM 14MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975416 SUP HCPCS C1713 8975416 - SCREW BN 4MM 16MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975418 SUP HCPCS C1713 8975418 - SCREW BN 4MM 18MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975420 SUP HCPCS C1713 8975420 - SCREW BN 4MM 20MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975422 SUP HCPCS C1713 8975422 - SCREW BN 4MM 22MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975424 SUP HCPCS C1713 8975424 - SCREW BN 4MM 24MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975426 SUP HCPCS C1713 8975426 - SCREW BN 4MM 26MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975428 SUP HCPCS C1713 8975428 - SCREW BN 4MM 28MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975430 SUP HCPCS C1713 8975430 - SCREW BN 4MM 30MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975432 SUP HCPCS C1713 8975432 - SCREW BN 4MM 32MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975434 SUP HCPCS C1713 8975434 - SCREW BN 4MM 34MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975436 SUP HCPCS C1713 8975436 - SCREW BN 4MM 36MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975438 SUP HCPCS C1713 8975438 - SCREW BN 4MM 38MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975440 SUP HCPCS C1713 8975440 - SCREW BN 4MM 40MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975510 SUP HCPCS C1713 8975510 - SCREW BONE 3.5MM 10MM FAVORED ANGLE SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975512 SUP HCPCS C1713 8975512 - SCREW BONE 2MM 12MM VUEPOINT POSTERIOR CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975514 SUP HCPCS C1713 8975514 - SCREW BONE 3.5MM 14MM VUEPOINT SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975516 SUP HCPCS C1713 8975516 - SCREW BN 3.5MM 16MM VUEPOINT II FAVOR ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975518 SUP HCPCS C1713 8975518 - SCREW BN 3.5MM 18MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975526 SUP HCPCS C1713 8975526 - SCREW BN 3.5MM 26MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975528 SUP HCPCS C1713 8975528 - SCREW BN 3.5MM 28MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975530 SUP HCPCS C1713 8975530 - SCREW BN 3.5MM 30MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975532 SUP HCPCS C1713 8975532 - SCREW BN 3.5MM 32MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975534 SUP HCPCS C1713 8975534 - SCREW BN 3.5MM 34MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975618 SUP HCPCS C1713 8975618 - SCREW BN 4MM 18MM VUEPOINT II FAVOR ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975622 SUP HCPCS C1713 "8975622 - VUE POINT 2, 4.0X 22MM, FAVORED ANGLE" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975624 SUP HCPCS C1713 8975624 - VUE POINT 2 4.0X 24MM SCREW BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975636 SUP HCPCS C1713 8975636 - SCREW BN 4MM 36MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975638 SUP HCPCS C1713 8975638 - SCREW BN 4MM 38MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975640 SUP HCPCS C1713 8975640 - SCREW BN 4MM 40MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975710 SUP HCPCS C1713 8975710 - SCREW BN 4.5MM 10MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975712 SUP HCPCS C1713 8975712 - SCREW BN 4.5MM 12MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975716 SUP HCPCS C1713 8975716 - SCREW BN 4.5MM 16MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975718 SUP HCPCS C1713 8975718 - SCREW BN 4.5MM 18MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975720 SUP HCPCS C1713 8975720 - VUE POINT 435 X 20 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975722 SUP HCPCS C1713 8975722 - SCREW BN 4.5MM 22MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975724 SUP HCPCS C1713 8975724 - SCREW BONE MULTIAX TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975726 SUP HCPCS C1713 8975726 - SCREW BN 4.5MM 26MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975728 SUP HCPCS C1713 8975728 - VUEPOINT 2 MULTI-AXIAL SCREW 4.5 X28 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975732 SUP HCPCS C1713 "8975732 - VUE POINT II, SCREW 4.5X32MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975734 SUP HCPCS C1713 "8975734 - VUE POINT II, SCREW 4.5X34MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975736 SUP HCPCS C1713 "8975736 - VUE POINT II, SCREW 4.5X36MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975738 SUP HCPCS C1713 "8975738 - VUE POINT II, SCREW 4.5X38MM" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975740 SUP HCPCS C1713 8975740 - SCREW BN 4.5MM 40MM NS VUEPOINT II MA SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975824 SUP HCPCS C1713 8975824 - SCREW BN P/T 3.5MM 24MM NS VUEPOINT II FAVORED ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975834 SUP HCPCS C1713 8975834 - SCREW BN P/T 3.5MM 34MM VUEPOINT II FAVOR ANG SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8975838 SUP HCPCS C1713 "8975838 - VUE POINT II, FA/PT SCREW 3.5X38" BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976006 SUP HCPCS C1713 8976006 - HOOK SPNL 6MM NS VUEPOINT II LMN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976008 SUP HCPCS C1713 8976008 - HOOK SPNL 8MM NS VUEPOINT II LMN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976011 SUP HCPCS C1713 8976011 - CONNECTOR ROD 11MM OFST VUEPOINT II OPN SPNE BOTH IP/OP "$1,095.00 " $810.30 $0.00 $876.00 $492.75 $492.75 $0.00 $0.00 $0.00 $228.23 $812.71 $812.71 $0.00 $0.00 $228.20 $0.00 $647.69 $647.69 $0.00 $547.50 $867.24 $876.00 $0.00 $0.00 $171.37 $0.00 $0.00 $174.32 $0.00 $0.00 $0.00 $0.00 $0.00 8976025 SUP HCPCS C1713 8976025 - CONNECTOR ROD 25MM LNG OFST NS VUEPOINT II OPN SPNE BOTH IP/OP "$1,222.50 " $904.65 $0.00 $978.00 $550.13 $550.13 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $611.25 $968.22 $978.00 $0.00 $0.00 $191.32 $0.00 $0.00 $194.62 $0.00 $0.00 $0.00 $0.00 $0.00 8976030 SUP HCPCS C1713 8976030 - CONNECTOR ROD 45D OFST NS VUEPOINT II SPNE BOTH IP/OP "$1,222.50 " $904.65 $0.00 $978.00 $550.13 $550.13 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $611.25 $968.22 $978.00 $0.00 $0.00 $191.32 $0.00 $0.00 $194.62 $0.00 $0.00 $0.00 $0.00 $0.00 8976035 SUP HCPCS C1713 8976035 - CONNECTOR ROD 3.5MM NS VUEPOINT II INLN SPNE BOTH IP/OP "$1,867.50 " "$1,381.95" $0.00 "$1,494.00" $840.38 $840.38 $0.00 $0.00 $0.00 $389.23 "$1,386.06" "$1,386.06" $0.00 $0.00 $389.19 $0.00 "$1,104.63" "$1,104.63" $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $292.26 $0.00 $0.00 $297.31 $0.00 $0.00 $0.00 $0.00 $0.00 8976055 SUP HCPCS C1713 8976055 - CONNECTOR ROD 3.5-5.5MM NS VUEPOINT II INLN SPNE BOTH IP/OP "$1,867.50 " "$1,381.95" $0.00 "$1,494.00" $840.38 $840.38 $0.00 $0.00 $0.00 $389.23 "$1,386.06" "$1,386.06" $0.00 $0.00 $389.19 $0.00 "$1,104.63" "$1,104.63" $0.00 $933.75 "$1,479.06" "$1,494.00" $0.00 $0.00 $292.26 $0.00 $0.00 $297.31 $0.00 $0.00 $0.00 $0.00 $0.00 8976112 SUP HCPCS C1713 8976112 - ROD SPNL 3.5MM 120MM VUEPOINT II BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8976124 SUP HCPCS C1713 8976124 - ROD 240MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8976128 SUP HCPCS C1713 8976128 - CONNECTOR ROD 28MM NS VUEPOINT II FX CX SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976130 SUP HCPCS C1713 8976130 - CONNECTOR ROD 30MM NS VUEPOINT II FX CX SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976132 SUP HCPCS C1713 8976132 - VUE POINT 2 32MM FIXED CROSS CONN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976136 SUP HCPCS C1713 8976136 - CONNECTOR ROD 36MM NS VUEPOINT II FX CX SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976138 SUP HCPCS C1713 8976138 - CONNECTOR ROD 38MM VUEPOINT II CX STC SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976160 SUP HCPCS C1713 8976160 - VUE POINT II ROD 60MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976165 SUP HCPCS C1713 8976165 - CONNECTOR ROD NS VUEPOINT II X SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976180 SUP HCPCS C1713 8976180 - ROD SPNL 80MM NS VUEPOINT II PRECONTOUR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976240 SUP HCPCS C1713 8976240 - ROD SPNL 45D 240MM NS VUEPOINT II PRECURVE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976355 SUP HCPCS C1713 "8976355 - TRANSITION ROD, 3.5X 5.5MM" BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 8976406 SUP HCPCS C1713 8976406 - SCREW BN 4.5MM 6MM VUEPOINT II SPNE OCPTL CORT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 8976412 SUP HCPCS C1713 8976412 - SCREW BN 4.5MM 12MM NS VUEPOINT II SPNE OCPTL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 8976414 SUP HCPCS C1713 8976414 - SCREW BN 4.5MM 14MM VUEPOINT II SPNE OCPTL CORT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 8976435 SUP HCPCS C1713 8976435 - CONNECTOR ROD OFST 3.5MM NS VUEPOINT II SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976455 SUP HCPCS C1713 8976455 - CONNECTOR ROD OFST 3.5-5.5MM NS VUEPOINT II SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8976506 SUP HCPCS C1713 8976506 - SCREW BN 5MM 6MM VUEPOINT II SPNE OCPTL CORT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 8976508 SUP HCPCS C1713 8976508 - SCREW BN 5MM 8MM VUEPOINT II SPNE OCPTL CORT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 8976510 SUP HCPCS C1713 8976510 - SCREW BN 5MM 10MM VUEPOINT II SPNE OCPTL CORT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 8976512 SUP HCPCS C1713 8976512 - SCREW BN 5MM 12MM VUEPOINT II SPNE OCPTL CORT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 8976514 SUP HCPCS C1713 8976514 - SCREW BN 5MM 14MM VUEPOINT II SPNE OCPTL CORT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 8977010 SUP Custom 27203010 8977010 - DRILL BIT VUE POINT 2 2.4MM BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8977035 SUP HCPCS C1713 8977035 - SCREW TAP VUE POINT 3.5MM BOTH IP/OP "$1,200.00 " $888.00 $0.00 $890.64 $320.63 $320.63 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 8977040 SUP HCPCS C1713 8977040 - SCREW TAP VUE POINT 4.0MM BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 9000027 SUP Custom 27203010 9000027 - SPIDER FLEX SERRATED GRASPER BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9000028 SUP Custom 27203010 9000028 - SPIDER FLEX MARYLAND DISSECTOR BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9000031 SUP Custom 27203010 9000031 - SPIDER FLEX MONOPOLAR HOOK BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9000240 SUP HCPCS C1713 9000240 - SCREW BONE 40MM CANN TITANIUM 12MM SACROILIAC BOTH IP/OP "$11,000.00 " "$8,140.00" $0.00 "$8,800.00" "$4,950.00" "$4,950.00" $0.00 $0.00 $0.00 "$2,292.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,292.40" $0.00 "$5,423.00" "$5,423.00" $0.00 "$5,500.00" "$8,712.00" "$8,800.00" $0.00 $0.00 "$1,721.50" $0.00 $0.00 "$1,751.20" $0.00 $0.00 $0.00 $0.00 $0.00 9000250 SUP HCPCS C1713 9000250 - SCREW BONE 12MM 50MM TI SACROILIAC CANN BOTH IP/OP "$11,000.00 " "$8,140.00" $0.00 "$8,800.00" "$4,950.00" "$4,950.00" $0.00 $0.00 $0.00 "$2,292.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,292.40" $0.00 "$5,423.00" "$5,423.00" $0.00 "$5,500.00" "$8,712.00" "$8,800.00" $0.00 $0.00 "$1,721.50" $0.00 $0.00 "$1,751.20" $0.00 $0.00 $0.00 $0.00 $0.00 9001635 SUP HCPCS C1713 9001635 - SCREW BONE 1.6MM 35MM TIMESH TI SPNL BOTH IP/OP $146.20 $108.19 $0.00 $116.96 $65.79 $65.79 $0.00 $0.00 $0.00 $30.47 $108.51 $108.51 $0.00 $0.00 $30.47 $0.00 $86.48 $86.48 $0.00 $73.10 $115.79 $116.96 $0.00 $0.00 $22.88 $0.00 $0.00 $23.28 $0.00 $0.00 $0.00 $0.00 $0.00 9001640 SUP HCPCS C1713 9001640 - SCREW BONE 1.6MM 4MM TI SPNL SLFDRILL STRL BOTH IP/OP $731.00 $540.94 $0.00 $584.80 $328.95 $328.95 $0.00 $0.00 $0.00 $152.36 $542.55 $542.55 $0.00 $0.00 $152.34 $0.00 $432.39 $432.39 $0.00 $365.50 $578.95 $584.80 $0.00 $0.00 $114.40 $0.00 $0.00 $116.38 $0.00 $0.00 $0.00 $0.00 $0.00 9002196 SUP Custom 27203010 9002196 - KIT NDL GD 21GA 96IN STRT US BOTH IP/OP $68.43 $50.64 $0.00 $50.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.79 $50.79 $0.00 $0.00 $14.26 $0.00 $0.00 $0.00 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011221 SUP Custom 27803010 9011221 - CAGE SPNL 12MM 20MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011225 SUP Custom 27803010 9011225 - CAGE SPNL 12MM 25MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011420 SUP Custom 27803010 9011420 - CAGE SPNL 14MM 20MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011423 SUP Custom 27803010 9011423 - CAGE SPNL 14MM 23MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011426 SUP Custom 27803010 9011426 - CAGE SPNL 14MM 26MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011429 SUP Custom 27803010 9011429 - CAGE SPNL 14MM 29MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011620 SUP Custom 27803010 9011620 - CAGE SPNL 16MM 20MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011623 SUP Custom 27803010 9011623 - CAGE SPNL 16MM 23MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011626 SUP Custom 27803010 9011626 - CAGE SPNL 16MM 26MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011629 SUP Custom 27803010 9011629 - CAGE SPNL 16MM 29MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011635 SUP HCPCS C1713 9011635 - SCREW 9011635 TIMESH 1.6X3.5MM SDS OPT 1 BOTH IP/OP $127.50 $94.35 $0.00 $102.00 $57.38 $57.38 $0.00 $0.00 $0.00 $26.57 $94.63 $94.63 $0.00 $0.00 $26.57 $0.00 $75.42 $75.42 $0.00 $63.75 $100.98 $102.00 $0.00 $0.00 $19.95 $0.00 $0.00 $20.30 $0.00 $0.00 $0.00 $0.00 $0.00 9011640 SUP HCPCS C1713 9011640 - SCREW 9011640 TIMESH 1.6X4.0MM SDS OPT 1 BOTH IP/OP $129.63 $95.93 $0.00 $103.70 $58.33 $58.33 $0.00 $0.00 $0.00 $27.02 $96.21 $96.21 $0.00 $0.00 $27.01 $0.00 $76.67 $76.67 $0.00 $64.81 $102.67 $103.70 $0.00 $0.00 $20.29 $0.00 $0.00 $20.64 $0.00 $0.00 $0.00 $0.00 $0.00 9011820 SUP Custom 27803010 9011820 - CAGE SPNL 18MM 20MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011823 SUP Custom 27803010 9011823 - CAGE SPNL 18MM 23MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011826 SUP Custom 27803010 9011826 - CAGE SPNL 18MM 26MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9011829 SUP Custom 27803010 9011829 - CAGE SPNL 18MM 29MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012020 SUP Custom 27803010 9012020 - CAGE SPNL 20MM 20MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012023 SUP Custom 27803010 9012023 - CAGE SPNL 20MM 23MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012026 SUP Custom 27803010 9012026 - CAGE SPNL 20MM 26MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012029 SUP Custom 27803010 9012029 - CAGE SPNL 20MM 29MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012220 SUP Custom 27803010 9012220 - CAGE SPNL 22MM 20MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012223 SUP Custom 27803010 9012223 - CAGE SPNL 22MM 23MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012226 SUP Custom 27803010 9012226 - CAGE SPNL 22MM 26MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012229 SUP Custom 27803010 9012229 - CAGE SPNL 22MM 29MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012420 SUP Custom 27803010 9012420 - CAGE SPNL 24MM 20MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012423 SUP Custom 27803010 9012423 - CAGE SPNL 24MM 23MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012426 SUP Custom 27803010 9012426 - CAGE SPNL 24MM 26MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9012429 SUP Custom 27803010 9012429 - CAGE SPNL 24MM 29MM LF INTRFX RP THRD CNCT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9050012 SUP HCPCS C1781 9050012 - CAGE SPNL 12MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050014 SUP HCPCS C1781 9050014 - CAGE SPNL 14MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050016 SUP HCPCS C1781 9050016 - CAGE SPNL 16MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050018 SUP HCPCS C1781 9050018 - CAGE SPNL 18MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050020 SUP HCPCS C1781 9050020 - CAGE SPNL 20MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050413 SUP HCPCS C1781 9050413 - CAGE SPNL OVOID 14X13X10MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050414 SUP HCPCS C1781 9050414 - CAGE SPNL OVOID 14X14X10MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050450 SUP HCPCS C1781 9050450 - MESH 9050450 PYRAMESH IMP 10MMX14MMX50MM BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9050513 SUP HCPCS C1781 9050513 - CAGE SPNL OVOID 17X13X13MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050514 SUP HCPCS C1781 9050514 - CAGE SPNL OVOID 17X13X14MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9050700 SUP Custom 27203010 9050700 - INSTRUMENT 9050700 PYMSH END CAP INSERT BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 $0.00 $0.00 $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9050713 SUP HCPCS C1781 9050713 - MESH 9050713 PYMSH IMPL 13MM END CAP BOTH IP/OP $858.00 $634.92 $0.00 $686.40 $386.10 $386.10 $0.00 $0.00 $0.00 $178.83 $636.81 $636.81 $0.00 $0.00 $178.81 $0.00 $507.51 $507.51 $0.00 $429.00 $679.54 $686.40 $0.00 $0.00 $134.28 $0.00 $0.00 $136.59 $0.00 $0.00 $0.00 $0.00 $0.00 9050716 SUP HCPCS C1781 9050716 - MESH 9050716 PYMSH IMPL 16MM END CAP BOTH IP/OP $858.00 $634.92 $0.00 $686.40 $386.10 $386.10 $0.00 $0.00 $0.00 $178.83 $636.81 $636.81 $0.00 $0.00 $178.81 $0.00 $507.51 $507.51 $0.00 $429.00 $679.54 $686.40 $0.00 $0.00 $134.28 $0.00 $0.00 $136.59 $0.00 $0.00 $0.00 $0.00 $0.00 9050719 SUP HCPCS C1781 9050719 - MESH 9050719 PYMSH IMPL 19MM END CAP BOTH IP/OP $858.00 $634.92 $0.00 $686.40 $386.10 $386.10 $0.00 $0.00 $0.00 $178.83 $636.81 $636.81 $0.00 $0.00 $178.81 $0.00 $507.51 $507.51 $0.00 $429.00 $679.54 $686.40 $0.00 $0.00 $134.28 $0.00 $0.00 $136.59 $0.00 $0.00 $0.00 $0.00 $0.00 9050722 SUP HCPCS C1781 9050722 - MESH 9050722 PYMSH IMPL 22MM END CAP BOTH IP/OP $858.00 $634.92 $0.00 $686.40 $386.10 $386.10 $0.00 $0.00 $0.00 $178.83 $636.81 $636.81 $0.00 $0.00 $178.81 $0.00 $507.51 $507.51 $0.00 $429.00 $679.54 $686.40 $0.00 $0.00 $134.28 $0.00 $0.00 $136.59 $0.00 $0.00 $0.00 $0.00 $0.00 9050725 SUP HCPCS C1781 9050725 - MESH 9050725 PYMSH IMPL 25MM END CAP BOTH IP/OP $858.00 $634.92 $0.00 $686.40 $386.10 $386.10 $0.00 $0.00 $0.00 $178.83 $636.81 $636.81 $0.00 $0.00 $178.81 $0.00 $507.51 $507.51 $0.00 $429.00 $679.54 $686.40 $0.00 $0.00 $134.28 $0.00 $0.00 $136.59 $0.00 $0.00 $0.00 $0.00 $0.00 9050823 SUP HCPCS C1781 9050823 - CAGE SPNL OVOID 24X10X8MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9051009 SUP HCPCS C1781 9051009 - CAGE SPNL RND 10MM 9MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 9051011 SUP HCPCS C1781 9051011 - CAGE SPNL RND 10MM 10MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 9051013 SUP HCPCS C1781 9051013 - CAGE SPNL 13MMX10MM PRMSH LMBR INTRBD FS RND TI BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 9051014 SUP HCPCS C1781 9051014 - CAGE SPNL RND 10MM 14MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 9051023 SUP HCPCS C1781 9051023 - CAGE SPNL RND 10MM 23MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9051050 SUP HCPCS C1781 9051050 - CAGE SPNL RND 10MM 50MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9051223 SUP HCPCS C1781 9051223 - CAGE SPNL RND 12MM 23MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9051314 SUP HCPCS C1781 9051314 - CAGE SPNL RND 13MM 14MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 9051315 SUP HCPCS C1781 9051315 - CAGE SPNL RND 13MM 15MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 9051350 SUP HCPCS C1781 9051350 - MESH 9051350 PYRAMESH IMP 13MMX50MM RND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9051423 SUP HCPCS C1781 9051423 - CAGE SPNL RND 14MM 23MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9051690 SUP HCPCS C1781 9051690 - CAGE SPNL RND 16MM 90MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9051710 SUP HCPCS C1781 9051710 - CAGE SPNL OVOID 22X17X10MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9051715 SUP HCPCS C1781 9051715 - CAGE SPNL OVOID 22X17X15MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9051730 SUP HCPCS C1781 9051730 - CAGE SPNL RND 22MM 30MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9051750 SUP HCPCS C1781 9051750 - CAGE SPNL OVOID 22X17X50MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9051770 SUP HCPCS C1781 9051770 - CAGE SPNL OVOID 22X17X70MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9051790 SUP HCPCS C1781 9051790 - CAGE SPNL OVOID 22X17X90MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9051915 SUP HCPCS C1781 9051915 - CAGE SPNL RND 15MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9051918 SUP HCPCS C1781 9051918 - CAGE SPNL RND 18MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052205 SUP HCPCS C1781 9052205 - CAGE SPNL RND 22MM 15MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052208 SUP HCPCS C1781 9052208 - MESH 9052208 PYRMSH IMPL 22MM AGL 13X18 BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052215 SUP HCPCS C1781 9052215 - MESH 9052215 PYRAMESH IMPLT 22MMX15MM RD BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052230 SUP HCPCS C1781 9052230 - MESH 9052230 PYRAMESH IMPLT 22MMX30MM RD BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052250 SUP HCPCS C1781 9052250 - CAGE SPNL RND 22MM 50MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9052270 SUP HCPCS C1781 9052270 - MESH 9052270 PYRM IMPLANT 22MMX70MM RND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9052290 SUP HCPCS C1781 9052290 - MESH 9052290 PYRAMESH IMP 22MMX90MM RND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9052315 SUP HCPCS C1781 9052315 - MESH 9052315 PYMSH IMPL 23X27 AGL 10X15 BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052318 SUP HCPCS C1781 9052318 - MESH 9052318 PYMSH IMPL 25X27 AGL 13X18 BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052518 SUP HCPCS C1781 9052518 - MESH 9052518 PYRMSH IMPL 25MM AGL 13X18 BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052815 SUP HCPCS C1781 9052815 - MESH 9052815 PYRAMESH IMP 22MMX28MMX15MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 9052830 SUP HCPCS C1781 9052830 - MESH 9052830 PYRAMESH IMP 22MMX28MMX30MM BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9052850 SUP HCPCS C1781 9052850 - MESH SRG OVOID 50X28X22MM NS PRMSH CG TI BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9052870 SUP HCPCS C1781 9052870 - PYRAMESH IMPL 22MMX28MMX70MM BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 9052890 SUP HCPCS C1781 9052890 - CAGE SPNL OVOID 28X22X90MM PRMSH HLW CNTR OP-EN TI LMBR BOTH IP/OP "$16,827.60 " "$12,452.42" $0.00 "$13,462.08" "$7,572.42" "$7,572.42" $0.00 $0.00 $0.00 "$3,507.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,506.87" $0.00 "$8,296.01" "$8,296.01" $0.00 "$8,413.80" "$13,327.46" "$13,462.08" $0.00 $0.00 "$2,633.52" $0.00 $0.00 "$2,678.95" $0.00 $0.00 $0.00 $0.00 $0.00 9059104 SUP Custom 27203010 9059104 - DISPOSABLE 9059104 MESH CUTTER BLADE BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9098526 SUP HCPCS C1713 9098526 - SCREW BONE 4MM 26MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098530 SUP HCPCS C1713 9098530 - SCREW BONE 4MM 30MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098534 SUP HCPCS C1713 9098534 - SCREW BONE 4MM 34MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098538 SUP HCPCS C1713 9098538 - SCREW BONE 4MM 38MM CORTEX SPN BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098540 SUP HCPCS C1713 9098540 - SCREW BONE 4MM 40MM CORTEX SPN BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098542 SUP HCPCS C1713 9098542 - SCREW BONE 4MM 42MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098544 SUP HCPCS C1713 9098544 - SCREW BONE 4MM 44MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098546 SUP HCPCS C1713 9098546 - SCREW BONE 4MM 46MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098548 SUP HCPCS C1713 9098548 - SCREW BONE 4MM 48MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098550 SUP HCPCS C1713 9098550 - SCREW BONE 4MM 50MM CORTEX SPN BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098552 SUP HCPCS C1713 9098552 - SCREW BONE 4MM 52MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098554 SUP HCPCS C1713 9098554 - SCREW BONE 4MM 54MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098556 SUP HCPCS C1713 9098556 - SCREW BONE 4MM 56MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098558 SUP HCPCS C1713 9098558 - SCREW BONE 4MM 58MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9098560 SUP HCPCS C1713 9098560 - SCREW BONE 4MM 60MM CORT SPNL BOTH IP/OP "$1,384.50 " "$1,024.53" $0.00 "$1,107.60" $623.03 $623.03 $0.00 $0.00 $0.00 $288.56 "$1,027.58" "$1,027.58" $0.00 $0.00 $288.53 $0.00 $818.93 $818.93 $0.00 $692.25 "$1,096.52" "$1,107.60" $0.00 $0.00 $216.67 $0.00 $0.00 $220.41 $0.00 $0.00 $0.00 $0.00 $0.00 9164400 SUP Custom 27803010 9164400 - CONNECTOR 9164400 CDH 4.5 DOMINO BOTH IP/OP "$1,506.00 " "$1,114.44" $0.00 "$1,204.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,117.75" "$1,117.75" $0.00 $0.00 $313.85 $0.00 $0.00 $0.00 $0.00 $753.00 "$1,192.75" "$1,204.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192507 SUP HCPCS C1713 9192507 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X7MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192508 SUP HCPCS C1713 9192508 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X8MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192509 SUP HCPCS C1713 9192509 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X9MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192510 SUP HCPCS C1713 9192510 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X10MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192511 SUP HCPCS C1713 9192511 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X11MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192512 SUP HCPCS C1713 9192512 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X12MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192513 SUP HCPCS C1713 9192513 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X13MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192514 SUP HCPCS C1713 9192514 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X14MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9192515 SUP HCPCS C1713 9192515 - SPACER SPNL 6D LRDTC STRG BLT NOSE 25X10X15MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193007 SUP HCPCS C1713 9193007 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X7MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193008 SUP HCPCS C1713 9193008 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X8MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193009 SUP HCPCS C1713 9193009 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X9MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193010 SUP HCPCS C1713 9193010 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X10MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193011 SUP HCPCS C1713 9193011 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X11MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193012 SUP HCPCS C1713 9193012 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X12MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193013 SUP HCPCS C1713 9193013 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X13MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193014 SUP HCPCS C1713 9193014 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X14MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193015 SUP HCPCS C1713 9193015 - SPACER SPNL 6D LRDTC STRG BLT NOSE 30X10X15MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193607 SUP HCPCS C1713 9193607 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X7MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193608 SUP HCPCS C1713 9193608 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X8MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193609 SUP HCPCS C1713 9193609 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X9MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193610 SUP HCPCS C1713 9193610 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X10MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193611 SUP HCPCS C1713 9193611 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X11MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193612 SUP HCPCS C1713 9193612 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X12MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193613 SUP HCPCS C1713 9193613 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X13MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193614 SUP HCPCS C1713 9193614 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X14MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9193615 SUP HCPCS C1713 9193615 - SPACER SPNL 6D LRDTC STRG BLT NOSE 36X10X15MM VRTSTCK CRSNT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9206768 SUP HCPCS C1713 9206768 - PLATE BN 90D STD L 4MM 9 HL BAR CRNMXF LT BOTH IP/OP "$1,315.00 " $973.10 $0.00 "$1,052.00" $591.75 $591.75 $0.00 $0.00 $0.00 $274.08 $975.99 $975.99 $0.00 $0.00 $274.05 $0.00 $777.82 $777.82 $0.00 $657.50 "$1,041.48" "$1,052.00" $0.00 $0.00 $205.80 $0.00 $0.00 $209.35 $0.00 $0.00 $0.00 $0.00 $0.00 9240100 SUP HCPCS C1713 9240100 - PLATE 9240100 SPINOUS PROCESS BOTH IP/OP "$8,608.50 " "$6,370.29" $0.00 "$6,886.80" "$3,873.83" "$3,873.83" $0.00 $0.00 $0.00 "$1,794.23" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,794.01" $0.00 "$4,243.99" "$4,243.99" $0.00 "$4,304.25" "$6,817.93" "$6,886.80" $0.00 $0.00 "$1,347.23" $0.00 $0.00 "$1,370.47" $0.00 $0.00 $0.00 $0.00 $0.00 9240150 SUP HCPCS C1713 9240150 - SCREW 9240150 M4 BREAKOFFS BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 9240200 SUP HCPCS C1713 9240200 - PLATE 9240200 35MM SPIRE BOTH IP/OP "$8,608.50 " "$6,370.29" $0.00 "$6,886.80" "$3,873.83" "$3,873.83" $0.00 $0.00 $0.00 "$1,794.23" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,794.01" $0.00 "$4,243.99" "$4,243.99" $0.00 "$4,304.25" "$6,817.93" "$6,886.80" $0.00 $0.00 "$1,347.23" $0.00 $0.00 "$1,370.47" $0.00 $0.00 $0.00 $0.00 $0.00 9255562 SUP HCPCS C1713 9255562 - PLATE BN 3D CRV 1.5MM 6X2 HL CRNMXF BOTH IP/OP "$1,965.00 " "$1,454.10" $0.00 "$1,572.00" $884.25 $884.25 $0.00 $0.00 $0.00 $409.56 "$1,458.42" "$1,458.42" $0.00 $0.00 $409.51 $0.00 "$1,162.30" "$1,162.30" $0.00 $982.50 "$1,556.28" "$1,572.00" $0.00 $0.00 $307.52 $0.00 $0.00 $312.83 $0.00 $0.00 $0.00 $0.00 $0.00 9330000 SUP HCPCS C1713 9330000 - NUT LOCK VNTG SPNL TI LCK SCR SET STRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 9330001 SUP HCPCS C1713 9330001 - STAPLE BONE 2 HOLE TI RSTRL VNTG STRL BOTH IP/OP "$2,805.00 " "$2,075.70" $0.00 "$2,244.00" "$1,262.25" "$1,262.25" $0.00 $0.00 $0.00 $584.63 "$2,081.87" "$2,081.87" $0.00 $0.00 $584.56 $0.00 "$1,382.87" "$1,382.87" $0.00 "$1,402.50" "$2,221.56" "$2,244.00" $0.00 $0.00 $438.98 $0.00 $0.00 $446.56 $0.00 $0.00 $0.00 $0.00 $0.00 9330002 SUP HCPCS C1713 9330002 - STAPLE BONE 2 HOLE TI CDL VNTG STRL BOTH IP/OP "$2,805.00 " "$2,075.70" $0.00 "$2,244.00" "$1,262.25" "$1,262.25" $0.00 $0.00 $0.00 $584.63 "$2,081.87" "$2,081.87" $0.00 $0.00 $584.56 $0.00 "$1,382.87" "$1,382.87" $0.00 "$1,402.50" "$2,221.56" "$2,244.00" $0.00 $0.00 $438.98 $0.00 $0.00 $446.56 $0.00 $0.00 $0.00 $0.00 $0.00 9330003 SUP HCPCS C1713 9330003 - STAPLE BONE 2 HOLE TI RSTRL VNTG STRL BOTH IP/OP "$2,805.00 " "$2,075.70" $0.00 "$2,244.00" "$1,262.25" "$1,262.25" $0.00 $0.00 $0.00 $584.63 "$2,081.87" "$2,081.87" $0.00 $0.00 $584.56 $0.00 "$1,382.87" "$1,382.87" $0.00 "$1,402.50" "$2,221.56" "$2,244.00" $0.00 $0.00 $438.98 $0.00 $0.00 $446.56 $0.00 $0.00 $0.00 $0.00 $0.00 9330004 SUP HCPCS C1713 9330004 - STAPLE BONE 2 HOLE TI CDL VNTG STRL BOTH IP/OP "$2,805.00 " "$2,075.70" $0.00 "$2,244.00" "$1,262.25" "$1,262.25" $0.00 $0.00 $0.00 $584.63 "$2,081.87" "$2,081.87" $0.00 $0.00 $584.56 $0.00 "$1,382.87" "$1,382.87" $0.00 "$1,402.50" "$2,221.56" "$2,244.00" $0.00 $0.00 $438.98 $0.00 $0.00 $446.56 $0.00 $0.00 $0.00 $0.00 $0.00 9330040 SUP HCPCS C1713 9330040 - PLATE 9330040 4CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330045 SUP HCPCS C1713 9330045 - PLATE 9330045 4 5CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330050 SUP HCPCS C1713 9330050 - PLATE 9330050 5CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330055 SUP HCPCS C1713 9330055 - PLATE 9330055 5 5CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330060 SUP HCPCS C1713 9330060 - PLATE BN 6CM VNTG SMTH TI SPNE THORLMBR ANT BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330065 SUP HCPCS C1713 9330065 - PLATE 65MM TI LCK ATLNTS BONE ANT CERV SPN BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330070 SUP HCPCS C1713 9330070 - PLATE 7CM TI LCK VNTG BONE LAT LMBR BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330075 SUP HCPCS C1713 9330075 - PLATE 9330075 7 5CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330080 SUP HCPCS C1713 9330080 - PLATE 9330080 8CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330085 SUP HCPCS C1713 9330085 - PLATE 9330085 8 5CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330090 SUP HCPCS C1713 9330090 - PLATE 9330090 9CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330095 SUP HCPCS C1713 9330095 - PLATE 9330095 9 5CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9330100 SUP HCPCS C1713 9330100 - PLATE 9330100 10CM ATL TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331025 SUP Custom 27803010 9331025 - PLATE 25MM TI VNTG BONE ANT THORLMBR SPN STRL BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 $0.00 $0.00 $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9331030 SUP HCPCS C1713 9331030 - PLATE 9331030 3CM THORACIC TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331035 SUP HCPCS C1713 9331035 - PLATE 9331035 3 5CM THORACIC TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331040 SUP HCPCS C1713 9331040 - PLATE 9331040 4CM THORACIC TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331045 SUP HCPCS C1713 9331045 - PLATE 9331045 4 5CM THORACIC TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331050 SUP HCPCS C1713 9331050 - PLATE 9331050 5CM THORACIC TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331055 SUP HCPCS C1713 9331055 - PLATE BN 5.5CM VNTG SMTH TI SPNE THOR ANT BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331060 SUP HCPCS C1713 9331060 - PLATE BN 6CM VNTG SMTH TI SPNE THOR ANT BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331065 SUP HCPCS C1713 9331065 - PLATE 9331065 6 5CM THORACIC TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331070 SUP HCPCS C1713 9331070 - PLATE 9331070 7CM THORACIC TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331075 SUP HCPCS C1713 9331075 - PLATE 9331075 7CM THORACIC TI 5 BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9331080 SUP HCPCS C1713 9331080 - PLATE 9331080 8CM THORACIC TI BOTH IP/OP "$6,778.50 " "$5,016.09" $0.00 "$5,422.80" "$3,050.33" "$3,050.33" $0.00 $0.00 $0.00 "$1,412.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,412.64" $0.00 "$3,341.80" "$3,341.80" $0.00 "$3,389.25" "$5,368.57" "$5,422.80" $0.00 $0.00 "$1,060.84" $0.00 $0.00 "$1,079.14" $0.00 $0.00 $0.00 $0.00 $0.00 9335515 SUP HCPCS C1713 9335515 - SCREW 9335515 THORACIC 5.5X15MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9335520 SUP HCPCS C1713 9335520 - SCREW 9335520 THORACIC 5.5X20MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9335525 SUP HCPCS C1713 9335525 - SCREW 9335525 THORACIC 5.5X25MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9335530 SUP HCPCS C1713 9335530 - SCREW 9335530 THORACIC 5.5X30MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9335535 SUP HCPCS C1713 9335535 - SCREW BN 5.5MM 35MM NS VNTG ST INTNL HEX CLR CD CUT TI SPNE BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9335540 SUP HCPCS C1713 9335540 - SCREW BN 5.5MM 40MM NS VNTG ST INTNL HEX CLR CD CUT TI SPNE BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9335545 SUP HCPCS C1713 9335545 - SCREW 9335545 THORACIC 5.5X45MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9335550 SUP HCPCS C1713 9335550 - SCREW 9335550 THORACIC 5.5X50MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9336525 SUP HCPCS C1713 9336525 - SCREW BONE 6.5MM 25MM ATLNTS TI ANT CERV SPN BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9336530 SUP HCPCS C1713 9336530 - SCREW 9336530 FAST ATL 6.5X30MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9336535 SUP HCPCS C1713 9336535 - SCREW BONE 6.5MM 35MM ATLNTS TI ANT CERV SPN BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9336540 SUP HCPCS C1713 9336540 - SCREW BN 6.5MM 40MM NS ATLNTS VNTG FST CLSR TI SPNE CRV ANT BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9336545 SUP HCPCS C1713 9336545 - SCREW 9336545 FAST ATL 6.5X45MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9336550 SUP HCPCS C1713 9336550 - SCREW 9336550 FAST ATL 6.5X50MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9336555 SUP HCPCS C1713 9336555 - SCREW 9336555 FAST ATL 6.5X55MM TI BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9336560 SUP HCPCS C1713 9336560 - SCREW BONE 6.5MM 60MM ATLNTS TI ANT CERV SPN BOTH IP/OP "$1,305.00 " $965.70 $0.00 "$1,044.00" $587.25 $587.25 $0.00 $0.00 $0.00 $271.99 $968.57 $968.57 $0.00 $0.00 $271.96 $0.00 $771.91 $771.91 $0.00 $652.50 "$1,033.56" "$1,044.00" $0.00 $0.00 $204.23 $0.00 $0.00 $207.76 $0.00 $0.00 $0.00 $0.00 $0.00 9338020 SUP HCPCS C1713 9338020 - BOLT SPNL 20MM 8MM ANT BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338025 SUP HCPCS C1713 9338025 - BOLT SPNL 25MM 8MM VNTG TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338030 SUP HCPCS C1713 9338030 - BOLT SPNL 30MM 8MM ANT TI SGL BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338035 SUP HCPCS C1713 9338035 - SCREW BONE 8MM 35MM TI ANT SPN BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338040 SUP HCPCS C1713 9338040 - BOLT SPNL 40MM 8MM VNTG TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338045 SUP HCPCS C1713 9338045 - SCREW BONE 8MM 45MM TI ANT SPN BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338050 SUP HCPCS C1713 9338050 - BOLT SPNL 50MM 8MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338055 SUP HCPCS C1713 9338055 - BOLT SPNL 55MM 8MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338920 SUP HCPCS C1713 9338920 - BOLT SPNL 20MM 9MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338925 SUP HCPCS C1713 9338925 - BOLT SPNL 25MM 9MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338930 SUP HCPCS C1713 9338930 - BOLT SPNL 30MM 9MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338935 SUP HCPCS C1713 9338935 - BOLT SPNL 35MM 6MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338940 SUP HCPCS C1713 9338940 - BOLT SPNL 40MM 9MM SGL BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338945 SUP HCPCS C1713 9338945 - BOLT SPNL 45MM 9MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338950 SUP HCPCS C1713 9338950 - BOLT SPNL 50MM 9MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9338955 SUP HCPCS C1713 9338955 - BOLT SPNL 55MM 9MM TI BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9391316 SUP HCPCS C1713 9391316 - CAGE SPNL 13MM 16MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$9,968.75 " "$7,376.88" $0.00 "$7,975.00" "$4,485.94" "$4,485.94" $0.00 $0.00 $0.00 "$2,077.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,077.49" $0.00 "$4,914.59" "$4,914.59" $0.00 "$4,984.38" "$7,895.25" "$7,975.00" $0.00 $0.00 "$1,560.11" $0.00 $0.00 "$1,587.03" $0.00 $0.00 $0.00 $0.00 $0.00 9391319 SUP HCPCS C1713 9391319 - CAGE SPNL 13MM 19MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$9,968.75 " "$7,376.88" $0.00 "$7,975.00" "$4,485.94" "$4,485.94" $0.00 $0.00 $0.00 "$2,077.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,077.49" $0.00 "$4,914.59" "$4,914.59" $0.00 "$4,984.38" "$7,895.25" "$7,975.00" $0.00 $0.00 "$1,560.11" $0.00 $0.00 "$1,587.03" $0.00 $0.00 $0.00 $0.00 $0.00 9391322 SUP HCPCS C1713 9391322 - CAGE SPNL 13MM 22MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$9,968.75 " "$7,376.88" $0.00 "$7,975.00" "$4,485.94" "$4,485.94" $0.00 $0.00 $0.00 "$2,077.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,077.49" $0.00 "$4,914.59" "$4,914.59" $0.00 "$4,984.38" "$7,895.25" "$7,975.00" $0.00 $0.00 "$1,560.11" $0.00 $0.00 "$1,587.03" $0.00 $0.00 $0.00 $0.00 $0.00 9391326 SUP HCPCS C1713 9391326 - CAGE SPNL 13MM 26MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$9,968.75 " "$7,376.88" $0.00 "$7,975.00" "$4,485.94" "$4,485.94" $0.00 $0.00 $0.00 "$2,077.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,077.49" $0.00 "$4,914.59" "$4,914.59" $0.00 "$4,984.38" "$7,895.25" "$7,975.00" $0.00 $0.00 "$1,560.11" $0.00 $0.00 "$1,587.03" $0.00 $0.00 $0.00 $0.00 $0.00 9391332 SUP HCPCS C1713 9391332 - CAGE SPNL 13MM 32MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9391341 SUP HCPCS C1713 9391341 - CAGE SPNL 13MM 41MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9391617 SUP HCPCS C1713 9391617 - CAGE SPNL 16MM 17MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$9,968.75 " "$7,376.88" $0.00 "$7,975.00" "$4,485.94" "$4,485.94" $0.00 $0.00 $0.00 "$2,077.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,077.49" $0.00 "$4,914.59" "$4,914.59" $0.00 "$4,984.38" "$7,895.25" "$7,975.00" $0.00 $0.00 "$1,560.11" $0.00 $0.00 "$1,587.03" $0.00 $0.00 $0.00 $0.00 $0.00 9391620 SUP HCPCS C1713 9391620 - CENTERPIECE 9391620 16 X 20MM 16B BOTH IP/OP "$9,968.75 " "$7,376.88" $0.00 "$7,975.00" "$4,485.94" "$4,485.94" $0.00 $0.00 $0.00 "$2,077.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,077.49" $0.00 "$4,914.59" "$4,914.59" $0.00 "$4,984.38" "$7,895.25" "$7,975.00" $0.00 $0.00 "$1,560.11" $0.00 $0.00 "$1,587.03" $0.00 $0.00 $0.00 $0.00 $0.00 9391623 SUP HCPCS C1713 9391623 - CAGE SPNL 16MM 23MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$9,968.75 " "$7,376.88" $0.00 "$7,975.00" "$4,485.94" "$4,485.94" $0.00 $0.00 $0.00 "$2,077.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,077.49" $0.00 "$4,914.59" "$4,914.59" $0.00 "$4,984.38" "$7,895.25" "$7,975.00" $0.00 $0.00 "$1,560.11" $0.00 $0.00 "$1,587.03" $0.00 $0.00 $0.00 $0.00 $0.00 9391628 SUP HCPCS C1713 9391628 - CAGE SPNL 16MM 28MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$9,968.75 " "$7,376.88" $0.00 "$7,975.00" "$4,485.94" "$4,485.94" $0.00 $0.00 $0.00 "$2,077.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,077.49" $0.00 "$4,914.59" "$4,914.59" $0.00 "$4,984.38" "$7,895.25" "$7,975.00" $0.00 $0.00 "$1,560.11" $0.00 $0.00 "$1,587.03" $0.00 $0.00 $0.00 $0.00 $0.00 9391633 SUP HCPCS C1713 9391633 - CAGE SPNL 16MM 33MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9391641 SUP HCPCS C1713 9391641 - CAGE SPNL 16MM 41MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9391919 SUP HCPCS C1713 9391919 - CAGE SPNL 19MM 19MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9391923 SUP HCPCS C1713 9391923 - CAGE SPNL 19MM 23MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9391928 SUP HCPCS C1713 9391928 - CAGE SPNL 19MM 28MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9391936 SUP HCPCS C1713 9391936 - CAGE SPNL 19MM 36MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9391947 SUP HCPCS C1713 9391947 - CAGE SPNL 19MM 47MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$13,406.25 " "$9,920.63" $0.00 "$10,725.00" "$6,032.81" "$6,032.81" $0.00 $0.00 $0.00 "$2,794.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,793.86" $0.00 "$6,609.28" "$6,609.28" $0.00 "$6,703.13" "$10,617.75" "$10,725.00" $0.00 $0.00 "$2,098.08" $0.00 $0.00 "$2,134.28" $0.00 $0.00 $0.00 $0.00 $0.00 9391969 SUP HCPCS C1713 9391969 - CAGE SPNL 19MM 69MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$13,406.25 " "$9,920.63" $0.00 "$10,725.00" "$6,032.81" "$6,032.81" $0.00 $0.00 $0.00 "$2,794.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,793.86" $0.00 "$6,609.28" "$6,609.28" $0.00 "$6,703.13" "$10,617.75" "$10,725.00" $0.00 $0.00 "$2,098.08" $0.00 $0.00 "$2,134.28" $0.00 $0.00 $0.00 $0.00 $0.00 9392221 SUP HCPCS C1713 9392221 - CAGE SPNL 22MM 21MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9392225 SUP HCPCS C1713 9392225 - CAGE SPNL 22MM 25MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9392231 SUP HCPCS C1713 9392231 - CAGE SPNL 22MM 31MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9392237 SUP HCPCS C1713 9392237 - CAGE SPNL 22MM 37MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9392248 SUP HCPCS C1713 9392248 - CAGE SPNL 22MM 48MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$13,406.25 " "$9,920.63" $0.00 "$10,725.00" "$6,032.81" "$6,032.81" $0.00 $0.00 $0.00 "$2,794.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,793.86" $0.00 "$6,609.28" "$6,609.28" $0.00 "$6,703.13" "$10,617.75" "$10,725.00" $0.00 $0.00 "$2,098.08" $0.00 $0.00 "$2,134.28" $0.00 $0.00 $0.00 $0.00 $0.00 9392268 SUP HCPCS C1713 9392268 - CAGE SPNL 22MM 68MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$13,406.25 " "$9,920.63" $0.00 "$10,725.00" "$6,032.81" "$6,032.81" $0.00 $0.00 $0.00 "$2,794.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,793.86" $0.00 "$6,609.28" "$6,609.28" $0.00 "$6,703.13" "$10,617.75" "$10,725.00" $0.00 $0.00 "$2,098.08" $0.00 $0.00 "$2,134.28" $0.00 $0.00 $0.00 $0.00 $0.00 9392507 SUP HCPCS C1713 9392507 - SPACER SPNL 25MMX7MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392508 SUP HCPCS C1713 9392508 - SPACER SPNL 25MMX8MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392509 SUP HCPCS C1713 9392509 - SPACER SPNL 25MMX9MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392510 SUP HCPCS C1713 9392510 - SPACER SPNL 25MMX10MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392511 SUP HCPCS C1713 9392511 - SPACER SPNL 25MMX11MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392512 SUP HCPCS C1713 9392512 - SPACER SPNL 25MMX12MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392513 SUP HCPCS C1713 9392513 - SPACER SPNL 25MMX13MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392514 SUP HCPCS C1713 9392514 - SPACER SPNL 25MMX14MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392515 SUP HCPCS C1713 9392515 - SPACER SPNL 25MMX15MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9392521 SUP HCPCS C1713 9392521 - CAGE SPNL 25MM 21MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9392525 SUP HCPCS C1713 9392525 - CAGE SPNL 25MM 25MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9392531 SUP HCPCS C1713 9392531 - CAGE SPNL 25MM 31MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9392537 SUP HCPCS C1713 9392537 - CAGE SPNL 25MM 37MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$11,687.50 " "$8,648.75" $0.00 "$9,350.00" "$5,259.38" "$5,259.38" $0.00 $0.00 $0.00 "$2,435.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,435.68" $0.00 "$5,761.94" "$5,761.94" $0.00 "$5,843.75" "$9,256.50" "$9,350.00" $0.00 $0.00 "$1,829.09" $0.00 $0.00 "$1,860.65" $0.00 $0.00 $0.00 $0.00 $0.00 9392548 SUP HCPCS C1713 9392548 - CAGE SPNL 25MM 48MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$13,406.25 " "$9,920.63" $0.00 "$10,725.00" "$6,032.81" "$6,032.81" $0.00 $0.00 $0.00 "$2,794.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,793.86" $0.00 "$6,609.28" "$6,609.28" $0.00 "$6,703.13" "$10,617.75" "$10,725.00" $0.00 $0.00 "$2,098.08" $0.00 $0.00 "$2,134.28" $0.00 $0.00 $0.00 $0.00 $0.00 9392568 SUP HCPCS C1713 9392568 - CAGE SPNL 25MM 68MM LF T2 ALTD CENTERPIECE TI COCR NTNL THOR BOTH IP/OP "$13,406.25 " "$9,920.63" $0.00 "$10,725.00" "$6,032.81" "$6,032.81" $0.00 $0.00 $0.00 "$2,794.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,793.86" $0.00 "$6,609.28" "$6,609.28" $0.00 "$6,703.13" "$10,617.75" "$10,725.00" $0.00 $0.00 "$2,098.08" $0.00 $0.00 "$2,134.28" $0.00 $0.00 $0.00 $0.00 $0.00 9393007 SUP HCPCS C1713 9393007 - SPACER SPNL 30MMX7MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393008 SUP HCPCS C1713 9393008 - SPACER SPNL 30MMX8MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393009 SUP HCPCS C1713 9393009 - SPACER SPNL 30MMX9MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393010 SUP HCPCS C1713 9393010 - SPACER SPNL 30MMX10MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393011 SUP HCPCS C1713 9393011 - SPACER SPNL 30MMX11MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393012 SUP HCPCS C1713 9393012 - SPACER SPNL 30MMX12MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393013 SUP HCPCS C1713 9393013 - SPACER SPNL 30MMX13MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393014 SUP HCPCS C1713 9393014 - SPACER SPNL 30MMX14MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393015 SUP HCPCS C1713 9393015 - SPACER SPNL 30MMX15MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393607 SUP HCPCS C1713 9393607 - SPACER SPNL 36MMX7MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393608 SUP HCPCS C1713 9393608 - SPACER SPNL 36MMX8MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393609 SUP HCPCS C1713 9393609 - SPACER SPNL 36MMX9MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393610 SUP HCPCS C1713 9393610 - SPACER SPNL 36MMX10MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393611 SUP HCPCS C1713 9393611 - SPACER SPNL 36MMX11MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393612 SUP HCPCS C1713 9393612 - SPACER SPNL 36MMX12MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393613 SUP HCPCS C1713 9393613 - SPACER SPNL 36MMX13MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393614 SUP HCPCS C1713 9393614 - SPACER SPNL 36MMX14MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9393615 SUP HCPCS C1713 9393615 - SPACER SPNL 36MMX15MM LF CRSNT PEEK-OPTM VERT BD REPL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 9401300 SUP HCPCS C1713 9401300 - END CAP 9401300 13MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401304 SUP HCPCS C1713 9401304 - END CAP 9401304 13MM 4 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401308 SUP HCPCS C1713 9401308 - END CAP 9401308 13MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401315 SUP HCPCS C1713 9401315 - END CAP 9401315 13MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401600 SUP HCPCS C1713 9401600 - END CAP 9401600 16MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401604 SUP HCPCS C1713 9401604 - END CAP 9401604 16MM 4 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401608 SUP HCPCS C1713 9401608 - END CAP 9401608 16MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401615 SUP HCPCS C1713 9401615 - END CAP 9401615 16MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401900 SUP HCPCS C1713 9401900 - END CAP 9401900 19MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401904 SUP HCPCS C1713 9401904 - END CAP 9401904 19MM 4 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401908 SUP HCPCS C1713 9401908 - END CAP 9401908 19MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9401915 SUP HCPCS C1713 9401915 - END CAP 9401915 19MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9402200 SUP HCPCS C1713 9402200 - END CAP 9402200 22MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9402204 SUP HCPCS C1713 9402204 - CAGE SPNL 4D 22MM T2 XVBR CENTERPIECE END CAP TI COCR NTNL BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9402208 SUP HCPCS C1713 9402208 - END CAP 9402208 22MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9402215 SUP HCPCS C1713 9402215 - END CAP 9402215 22MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9402500 SUP HCPCS C1713 9402500 - END CAP 9402500 25MM 0 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9402504 SUP HCPCS C1713 9402504 - CAGE SPNL 4D 25MM T2 XVBR CENTERPIECE END CAP TI COCR NTNL BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9402508 SUP HCPCS C1713 9402508 - END CAP 9402508 25MM 8 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9402515 SUP HCPCS C1713 9402515 - END CAP 9402515 25MM 15 DEGREE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 9450002 SUP Custom 27203010 9450002 - DISPOSABLE 9450002 ELECTRO LOW IMPED22MM BOTH IP/OP $669.00 $495.06 $0.00 $535.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $496.53 $496.53 $0.00 $0.00 $139.42 $0.00 $0.00 $0.00 $0.00 $334.50 $529.85 $535.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9450003 SUP Custom 27203010 9450003 - DISPOSABLE 9450003 ELECTRO TWST PAIR 8CH BOTH IP/OP $936.00 $692.64 $0.00 $748.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $694.70 $694.70 $0.00 $0.00 $195.06 $0.00 $0.00 $0.00 $0.00 $468.00 $741.31 $748.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9450019 SUP Custom 27203010 9450019 - DISPOSABLE 9450019 NIM PED PROBE THORAC BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9450020 SUP Custom 27203010 9450020 - NEEDLE SPNL STRL LF NIM-SPNE ACC PDCL DISP BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9450047 SUP Custom 27203010 9450047 - DISPOSABLE 9450047 NEW PED PROBE LMBR BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9450051 SUP Custom 27203010 9450051 - DISPOSABLE 9450051 NIM 2.3MM BLL TIP PRB BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560551 SUP Custom 27203010 9560551 - INSTRUMENT 9560551 METRX SHTHD KNF BLDE BOTH IP/OP $645.00 $477.30 $0.00 $516.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.72 $478.72 $0.00 $0.00 $134.42 $0.00 $0.00 $0.00 $0.00 $322.50 $510.84 $516.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560658 SUP Custom 27203010 9560658 - INSTRUMENT 9560658 QUADRANT ILLUMIN SYS BOTH IP/OP "$1,207.50 " $893.55 $0.00 $966.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $896.21 $896.21 $0.00 $0.00 $251.64 $0.00 $0.00 $0.00 $0.00 $603.75 $956.34 $966.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560659 SUP Custom 27203010 9560659 - KNIFE SRG BYNT STRL MTRX SPNE CRV ANT DISP DSCTMY BOTH IP/OP $781.50 $578.31 $0.00 $625.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $580.03 $580.03 $0.00 $0.00 $162.86 $0.00 $0.00 $0.00 $0.00 $390.75 $618.95 $625.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560702 SUP Custom 27203010 9560702 - INSTRUMENT 9560702 RADIANCE ILLUMIN SYS BOTH IP/OP "$1,062.00 " $785.88 $0.00 $849.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.22 $788.22 $0.00 $0.00 $221.32 $0.00 $0.00 $0.00 $0.00 $531.00 $841.10 $849.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560703 SUP Custom 27203010 9560703 - INSTRUMENT 9560703 DISP 22MMX3CM RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560704 SUP Custom 27203010 9560704 - INSTRUMENT 9560704 DISP 22MMX4CM RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560705 SUP Custom 27203010 9560705 - INSTRUMENT 9560705 DISP 22MMX5CM RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560706 SUP Custom 27203010 9560706 - INSTRUMENT 9560706 DISP 22MMX6CM RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560707 SUP Custom 27203010 9560707 - INSTRUMENT 9560707 DISP 22MMX7CM RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560708 SUP Custom 27203010 9560708 - INSTRUMENT 9560708 DISP 22MMX8CM RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560709 SUP Custom 27203010 9560709 - INSTRUMENT 9560709 DISP 22MMX9CM RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560757 SUP Custom 27203010 9560757 - INSTRUMENT 9560757 RDINCEXILLUMIN SYS BOTH IP/OP "$1,290.00 " $954.60 $0.00 "$1,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $957.44 $957.44 $0.00 $0.00 $268.84 $0.00 $0.00 $0.00 $0.00 $645.00 "$1,021.68" "$1,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9560802 SUP Custom 27803010 9560802 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $958.50 $709.29 $0.00 $766.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $711.40 $711.40 $0.00 $0.00 $199.75 $0.00 $0.00 $0.00 $0.00 $479.25 $759.13 $766.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561424 SUP Custom 27203010 9561424 - PLATE 18MM TI BONE SPNL BOTH IP/OP $921.00 $681.54 $0.00 $736.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $683.57 $683.57 $0.00 $0.00 $191.94 $0.00 $0.00 $0.00 $0.00 $460.50 $729.43 $736.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561426 SUP Custom 27203010 9561426 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $0.00 $0.00 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561427 SUP Custom 27203010 9561427 - PLATE 18MM TI BONE SPNL BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $0.00 $0.00 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561428 SUP Custom 27203010 9561428 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $0.00 $0.00 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561523 SUP Custom 27203010 9561523 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$5,940.00 " "$4,395.60" $0.00 "$4,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,237.90" $0.00 $0.00 $0.00 $0.00 "$2,970.00" "$4,704.48" "$4,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561524 SUP Custom 27203010 9561524 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$8,920.50 " "$6,601.17" $0.00 "$7,136.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,859.03" $0.00 $0.00 $0.00 $0.00 "$4,460.25" "$7,065.04" "$7,136.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561525 SUP Custom 27203010 9561525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,314.50 " "$1,712.73" $0.00 "$1,851.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,717.82" "$1,717.82" $0.00 $0.00 $482.34 $0.00 $0.00 $0.00 $0.00 "$1,157.25" "$1,833.08" "$1,851.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561526 SUP Custom 27203010 9561526 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.03 $187.03 $0.00 $0.00 $52.52 $0.00 $0.00 $0.00 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561813 SUP Custom 27203010 9561813 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561814 SUP Custom 27203010 9561814 - PLATE 18MM TI BONE SPNL BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561815 SUP Custom 27203010 9561815 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561816 SUP Custom 27203010 9561816 - PLATE 18MM TI BONE SPNL BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561817 SUP Custom 27203010 9561817 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561818 SUP Custom 27203010 9561818 - PLATE 18MM TI BONE SPNL BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9561819 SUP Custom 27203010 9561819 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9562613 SUP Custom 27203010 9562613 - PLATE 18MM TI BONE SPNL BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9562614 SUP Custom 27203010 9562614 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $631.50 $467.31 $0.00 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.70 $468.70 $0.00 $0.00 $131.60 $0.00 $0.00 $0.00 $0.00 $315.75 $500.15 $505.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9562615 SUP Custom 27203010 9562615 - PLATE 18MM TI BONE SPNL BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9562616 SUP Custom 27203010 9562616 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9562617 SUP Custom 27203010 9562617 - PLATE 18MM TI BONE SPNL BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9562618 SUP Custom 27203010 9562618 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9562619 SUP Custom 27203010 9562619 - PLATE 18MM TI BONE SPNL BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9569575 SUP Custom 27203010 9569575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.64 $153.64 $0.00 $0.00 $43.14 $0.00 $0.00 $0.00 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9569813 SUP Custom 27203010 9569813 - PLATE 18MM TI BONE SPNL BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9569814 SUP Custom 27203010 9569814 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9569815 SUP Custom 27203010 9569815 - PLATE 18MM TI BONE SPNL BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9569816 SUP Custom 27203010 9569816 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9569817 SUP Custom 27203010 9569817 - PLATE 18MM TI BONE SPNL BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9569818 SUP Custom 27203010 9569818 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9569819 SUP Custom 27203010 9569819 - PLATE 18MM TI BONE SPNL BOTH IP/OP $681.00 $503.94 $0.00 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.44 $505.44 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $340.50 $539.35 $544.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9680050 SUP Custom 27203010 9680050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,451.00 " "$1,813.74" $0.00 "$1,960.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,819.13" "$1,819.13" $0.00 $0.00 $510.79 $0.00 $0.00 $0.00 $0.00 "$1,225.50" "$1,941.19" "$1,960.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9680853 SUP HCPCS C1713 9680853 - PLATE 18MM TI BONE SPNL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $153.90 $153.90 $0.00 $0.00 $0.00 $71.28 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $202.29 $202.29 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $53.52 $0.00 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 9680854 SUP HCPCS C1713 9680854 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 9680855 SUP HCPCS C1713 9680855 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 9690030 SUP HCPCS C1713 9690030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690040 SUP HCPCS C1713 9690040 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690050 SUP HCPCS C1713 9690050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690060 SUP HCPCS C1713 9690060 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690070 SUP HCPCS C1713 9690070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690080 SUP HCPCS C1713 9690080 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690090 SUP HCPCS C1713 9690090 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690100 SUP HCPCS C1713 9690100 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690110 SUP HCPCS C1713 9690110 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 9690853 SUP HCPCS C1713 9690853 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 9690854 SUP HCPCS C1713 9690854 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 9690855 SUP HCPCS C1713 9690855 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 9733065 SUP Custom 27203010 9733065 - SYSTEM GUIDANCE EXTERNAL TRAJECTORY KIT NAVIGUS BOTH IP/OP "$2,937.50 " "$2,173.75" $0.00 "$2,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,180.21" "$2,180.21" $0.00 $0.00 $612.18 $0.00 $0.00 $0.00 $0.00 "$1,468.75" "$2,326.50" "$2,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9733068 SUP Custom 27203010 9733068 - KIT BIOP NEEDLE PASSIVE NAVIGUS BOTH IP/OP "$1,562.50 " "$1,156.25" $0.00 "$1,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,159.69" "$1,159.69" $0.00 $0.00 $325.63 $0.00 $0.00 $0.00 $0.00 $781.25 "$1,237.50" "$1,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9733497 SUP Custom 27203010 9733497 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,642.50 " "$1,215.45" $0.00 "$1,314.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,219.06" "$1,219.06" $0.00 $0.00 $342.30 $0.00 $0.00 $0.00 $0.00 $821.25 "$1,300.86" "$1,314.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9733498 SUP Custom 27203010 9733498 - KIT STRTC STRL LF NAVIGATE ACC SPNE PDCL DISP BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $0.00 $0.00 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9734887 SUP Custom 27203010 9734887 - TRACKER NVG STRL LF NINVS DISP BOTH IP/OP $542.50 $401.45 $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $402.64 $402.64 $0.00 $0.00 $113.06 $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9735428 SUP Custom 27203010 9735428 - STYLET NVG STRL LF 2 COIL DISP BOTH IP/OP "$1,420.00 " "$1,050.80" $0.00 "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,053.92" "$1,053.92" $0.00 $0.00 $295.93 $0.00 $0.00 $0.00 $0.00 $682.50 "$1,081.08" "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790019 SUP HCPCS C1713 9790019 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 9790021 SUP HCPCS C1713 9790021 - PLATE 21MM TI LCK VNTR BONE ANT CERV SPN STRL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 9790023 SUP HCPCS C1713 9790023 - PLATE BN 23MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 9790025 SUP HCPCS C1713 9790025 - PLATE BN 25MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 9790027 SUP HCPCS C1713 9790027 - PLATE BN 27.5MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 9790030 SUP HCPCS C1713 9790030 - PLATE BN 30MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 9790032 SUP HCPCS C1713 9790032 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9790035 SUP HCPCS C1713 9790035 - PLATE 35MM TI LCK VNTR BONE ANT CERV SPN STRL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9790037 SUP HCPCS C1713 9790037 - PLATE 37.5MM TI LCK VNTR BONE ANT CERV SPN STRL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9790040 SUP HCPCS C1713 9790040 - PLATE BN 40MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9790042 SUP HCPCS C1713 9790042 - PLATE 42.5MM TI LCK VNTR BONE ANT CERV SPN STRL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9790045 SUP HCPCS C1713 9790045 - PLATE BN 45MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9790047 SUP HCPCS C1713 9790047 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9790050 SUP HCPCS C1713 9790050 - PLATE BN 50MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9790052 SUP HCPCS C1713 9790052 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790055 SUP HCPCS C1713 9790055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790057 SUP HCPCS C1713 9790057 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790060 SUP HCPCS C1713 9790060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790062 SUP HCPCS C1713 9790062 - PLATE BN 62.5MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790065 SUP HCPCS C1713 9790065 - PLATE BN 65MM STRL VNTR INTGR LCK MDLN ALGN NTCH LOPRFL TI BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790067 SUP HCPCS C1713 9790067 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790070 SUP HCPCS C1713 9790070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790072 SUP HCPCS C1713 9790072 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 9790075 SUP HCPCS C1713 9790075 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 9790077 SUP HCPCS C1713 9790077 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 9790080 SUP HCPCS C1713 9790080 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 9790082 SUP HCPCS C1713 9790082 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 9790085 SUP HCPCS C1713 9790085 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 9790087 SUP HCPCS C1713 9790087 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9790090 SUP HCPCS C1713 9790090 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9790095 SUP HCPCS C1713 9790095 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9790100 SUP HCPCS C1713 9790100 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9790105 SUP HCPCS C1713 9790105 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9790110 SUP HCPCS C1713 9790110 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,525.50 " "$3,348.87" $0.00 "$3,620.40" "$2,036.48" "$2,036.48" $0.00 $0.00 $0.00 $943.23 "$3,358.83" "$3,358.83" $0.00 $0.00 $943.11 $0.00 "$2,231.07" "$2,231.07" $0.00 "$2,262.75" "$3,584.20" "$3,620.40" $0.00 $0.00 $708.24 $0.00 $0.00 $720.46 $0.00 $0.00 $0.00 $0.00 $0.00 9790211 SUP HCPCS C1713 9790211 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790213 SUP HCPCS C1713 9790213 - SCREW BONE 4MM 13MM VNTR TI ANT CERV SPN SLFTAP FIXANG STRL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790215 SUP HCPCS C1713 9790215 - SCREW BN 4MM 15MM NS VNTR ST FX ANG TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790217 SUP HCPCS C1713 9790217 - SCREW BONE 4MM 17MM VNTR TI ANT CERV SPN SLFTAP FIXANG STRL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790219 SUP HCPCS C1713 9790219 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790221 SUP HCPCS C1713 9790221 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790223 SUP HCPCS C1713 9790223 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790311 SUP HCPCS C1713 9790311 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790312 SUP HCPCS C1713 9790312 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790313 SUP HCPCS C1713 9790313 - SCREW BONE 4MM 13MM VNTR TI ANT CERV SPN SLFTAP VAR ANG STRL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790315 SUP HCPCS C1713 9790315 - SCREW BONE 4MM 15MM VNTR TI ANT CERV SPN SLFTAP VAR ANG STRL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790317 SUP HCPCS C1713 9790317 - SCREW BONE 4MM 15MM TI SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790319 SUP HCPCS C1713 9790319 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790325 SUP HCPCS C1713 9790325 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9790904 SUP HCPCS C1713 9790904 - PIN FIX PREFIXATION SPNL BOTH IP/OP $291.00 $215.34 $0.00 $232.80 $130.95 $130.95 $0.00 $0.00 $0.00 $60.65 $215.98 $215.98 $0.00 $0.00 $60.64 $0.00 $172.13 $172.13 $0.00 $145.50 $230.47 $232.80 $0.00 $0.00 $45.54 $0.00 $0.00 $46.33 $0.00 $0.00 $0.00 $0.00 $0.00 9790915 SUP Custom 27203010 9790915 - BIT DRL 11MM STRL DISP BOTH IP/OP $718.50 $531.69 $0.00 $574.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $533.27 $533.27 $0.00 $0.00 $149.74 $0.00 $0.00 $0.00 $0.00 $359.25 $569.05 $574.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9791030 SUP HCPCS C1713 9791030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 9791150 SUP HCPCS C1713 9791150 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 9791221 SUP HCPCS C1713 9791221 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791222 SUP HCPCS C1713 9791222 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791223 SUP HCPCS C1713 9791223 - SCREW BN 4MM 13MM NS VNTR SLF DRL FX ANG INTGR LCK TI SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791224 SUP HCPCS C1713 9791224 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791225 SUP HCPCS C1713 9791225 - SCREW BN 4MM 15MM NS VNTR SLF DRL FX ANG INTGR LCK TI SPNE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791226 SUP HCPCS C1713 9791226 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791227 SUP HCPCS C1713 9791227 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791321 SUP HCPCS C1713 9791321 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791322 SUP HCPCS C1713 9791322 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791323 SUP HCPCS C1713 9791323 - SCREW BN 4MM 13MM NS VNTR SLF DRL VA INTGR LCK TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791324 SUP HCPCS C1713 9791324 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791325 SUP HCPCS C1713 9791325 - SCREW BN 4MM 15MM NS VNTR SLF DRL VA INTGR LCK TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791326 SUP HCPCS C1713 9791326 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9791327 SUP HCPCS C1713 9791327 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795211 SUP HCPCS C1713 9795211 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795213 SUP HCPCS C1713 9795213 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795215 SUP HCPCS C1713 9795215 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795217 SUP HCPCS C1713 9795217 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795219 SUP HCPCS C1713 9795219 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795221 SUP HCPCS C1713 9795221 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795223 SUP HCPCS C1713 9795223 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795225 SUP HCPCS C1713 9795225 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795227 SUP HCPCS C1713 9795227 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795229 SUP HCPCS C1713 9795229 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795311 SUP HCPCS C1713 9795311 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795313 SUP HCPCS C1713 9795313 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795315 SUP HCPCS C1713 9795315 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795317 SUP HCPCS C1713 9795317 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795319 SUP HCPCS C1713 9795319 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795321 SUP HCPCS C1713 9795321 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795323 SUP HCPCS C1713 9795323 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795325 SUP HCPCS C1713 9795325 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795327 SUP HCPCS C1713 9795327 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9795329 SUP HCPCS C1713 9795329 - PLATE 18MM TI BONE SPNL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9873033 SUP HCPCS C1713 9873033 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873035 SUP HCPCS C1713 9873035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873037 SUP HCPCS C1713 9873037 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873039 SUP HCPCS C1713 9873039 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873041 SUP HCPCS C1713 9873041 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873133 SUP HCPCS C1713 9873133 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873135 SUP HCPCS C1713 9873135 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873137 SUP HCPCS C1713 9873137 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873139 SUP HCPCS C1713 9873139 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9873141 SUP HCPCS C1713 9873141 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9874035 SUP HCPCS C1713 9874035 - PLATE BN 35MM PRMD 4 HL SPNE LMBR ANT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9874037 SUP HCPCS C1713 9874037 - PLATE BN 37MM PRMD 4 HL SPNE LMBR ANT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9874039 SUP HCPCS C1713 9874039 - PLATE BN 39MM PRMD 4 HL SPNE LMBR ANT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9874041 SUP HCPCS C1713 9874041 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9874043 SUP HCPCS C1713 9874043 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9874045 SUP HCPCS C1713 9874045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$9,487.50 " "$7,020.75" $0.00 "$7,590.00" "$4,269.38" "$4,269.38" $0.00 $0.00 $0.00 "$1,977.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,977.20" $0.00 "$4,677.34" "$4,677.34" $0.00 "$4,743.75" "$7,514.10" "$7,590.00" $0.00 $0.00 "$1,484.79" $0.00 $0.00 "$1,510.41" $0.00 $0.00 $0.00 $0.00 $0.00 9990700 SUP Custom 27203010 KWIQ DIP BOTH IP/OP $223.78 $165.60 $0.00 $179.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.89 $177.23 $179.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10000607 SUP HCPCS C1713 10000607 - WIRE FX RELINE MAS BLNT THRD NTNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 10004354 SUP Custom 27203010 MAX-FAST FOREHEAD SENSOR WITH HEADBAND BOTH IP/OP $117.73 $87.12 $0.00 $94.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.87 $93.24 $94.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10055332 SUP HCPCS C1713 10055332 - RELINE FIXED CROSS CONN. 37.5MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 10055425 SUP HCPCS C1713 10055425 - CONNECTOR ROD 5.5MM 25-30MM RELINE CX ADJ LOPRFL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 10056425 SUP HCPCS C1713 10056425 - CONNECTOR ROD 5.5-6MM 25-30MM RELINE CX ADJ LOPRFL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 10612513 SUP Custom 27203010 TIP PIP 1000UL DISP BLK BOTH IP/OP "$1,844.75 " "$1,365.12" $0.00 "$1,475.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $922.38 "$1,461.04" "$1,475.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10719701 SUP HCPCS C1725 CATHETER ANGIO .035IN 5FR 65CM C1 CURVE NBRD SFT RADIOPQ TIP BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $4.89 $4.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $1.41 $0.00 $0.00 $1.43 $0.00 $0.00 $0.00 $0.00 $0.00 10719702 SUP HCPCS C1725 CATHETER ANGIO .035IN C2 CURVE 5FR 65CM 2 SH NBRD SFT BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $4.89 $4.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $1.41 $0.00 $0.00 $1.43 $0.00 $0.00 $0.00 $0.00 $0.00 10720401 SUP HCPCS C1725 CATHETER ANGIO .038IN SOS OMNI1 CURVE 5FR 80CM NBRD SFT BOTH IP/OP $35.00 $25.90 $0.00 $25.98 $12.76 $12.76 $0.00 $0.00 $0.00 $7.29 $25.98 $25.98 $0.00 $0.00 $7.29 $0.00 $20.70 $20.70 $0.00 $11.75 $18.61 $18.80 $0.00 $0.00 $3.68 $0.00 $0.00 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 10720405 SUP HCPCS C1725 CATHETER ANGIO .038IN SOS OMNI2 CURVE 5FR 80CM NBRD SFT BOTH IP/OP $23.75 $17.58 $0.00 $19.00 $12.90 $12.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $3.72 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $0.00 10722102 SUP HCPCS C1725 CATHETER ANGIO .038IN BERN CURVE 5FR 100CM NBRD SFT RADIOPQ BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 10732101 SUP HCPCS C1725 CATHETER ANGIO .038IN MIK CURVE 5FR 80CM NBRD SFT RADIOPQ BOTH IP/OP $23.75 $17.58 $0.00 $19.00 $12.90 $12.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $3.72 $0.00 $0.00 $3.78 $0.00 $0.00 $0.00 $0.00 $0.00 10800702 SUP HCPCS C1769 SET CATH 20CM .035IN SCHN XL GUIDEWIRE INTROD NDL HMDIAL BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $133.04 $133.04 $0.00 $0.00 $0.00 $51.06 $181.84 $181.84 $0.00 $0.00 $51.06 $0.00 $144.92 $144.92 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 10802701 SUP HCPCS C1769 SET CATH 15CM .035IN SIL SCHN XL GUIDEWIRE INTROD NDL FULL BOTH IP/OP $355.00 $262.70 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $0.00 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 10802702 SUP HCPCS C1769 SET CATH 20CM .035IN SIL SCHN XL GUIDEWIRE INTROD NDL FULL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 10802703 SUP HCPCS C1752 10802703 - SET CATH 24CM SCHN XL FULL HMDIAL BOTH IP/OP $355.00 $262.70 $0.00 $654.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $0.00 $0.00 $0.00 $409.17 $648.13 $654.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11221000 SUP Custom 27203010 11221000 - COLLAR XTRIC MN PRFT AC SM CERV PLST ADJ PED BOTH IP/OP $74.37 $55.03 $0.00 $59.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.18 $58.90 $59.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11355025 SUP HCPCS C1713 11355025 - ROD SPNL LRDTC 5.5MM 25MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355030 SUP HCPCS C1713 11355030 - ROD SPNL LRDTC 5.5MM 30MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355035 SUP HCPCS C1713 11355035 - ROD SPNL LRDTC 5.5MM 35MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355045 SUP HCPCS C1713 11355045 - ROD SPNL LRDTC 5.5MM 45MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355050 SUP HCPCS C1713 11355050 - ROD SPNL LRDTC 5.5MM 50MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355055 SUP HCPCS C1713 11355055 - ROD SPNL LRDTC 5.5MM 55MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355060 SUP HCPCS C1713 11355060 - ROD SPNL LRDTC 5.5MM 60MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355070 SUP HCPCS C1713 11355070 - ROD SPNL LRDTC 5.5MM 70MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355085 SUP HCPCS C1713 11355085 - RELINE ROD 85MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355090 SUP HCPCS C1713 "11355090 - RELINE ROD, 90MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355095 SUP HCPCS C1713 11355095 - ROD SPNL LRDTC 5.5MM 95MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355110 SUP HCPCS C1713 11355110 - ROD SPNL LRDTC 5.5MM 110MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355150 SUP HCPCS C1713 11355150 - ROD SPNL LRDTC 5.5MM 150MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11355160 SUP HCPCS C1713 11355160 - ROD SPNL LRDTC 5.5MM 160MM NS RELINE TI MAS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 11403002 SUP Custom 27203010 11403002 - KIT PROCEDURE .035IN 21GA 65CM LONG ACCES GWIRE NEEDLE GOLD BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12401812 SUP HCPCS C1757 12401812 - CATHETER THROMBECTOMY 5FR 135CM 10CM OCCLUDING BALL WIRE BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12401813 SUP HCPCS C1729 CATHETER INFUS 5FR 25MM 20CM SLT DSGN FLW THRU HUB OCL WIRE BOTH IP/OP $412.50 $305.25 $0.00 $502.77 $223.99 $223.99 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $502.77 $502.77 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 12401816 SUP HCPCS C1729 CATHETER INFUS 5FR 25MM 50CM CORON SLT DSGN FLW THRU HUB OCL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $223.99 $223.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 13010545 SUP HCPCS C1713 13010545 - SCREW BN 2S 10.5MM 45MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13014030 SUP HCPCS C1713 13014030 - SCREW BN 2S 4MM 30MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13014040 SUP HCPCS C1713 13014040 - SCREW BN 2S 4MM 40MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13014530 SUP HCPCS C1713 13014530 - SCREW BN 2S 4.5MM 30MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13014540 SUP HCPCS C1713 13014540 - SCREW BN 2S 4.5MM 40MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015035 SUP HCPCS C1713 13015035 - SCREW BN 2S 5MM 35MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015045 SUP HCPCS C1713 13015045 - SCREW BN 2S 5MM 45MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015050 SUP HCPCS C1713 13015050 - SCREW BN 2S 5MM 50MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015055 SUP HCPCS C1713 13015055 - SCREW BN 2S 5MM 55MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015525 SUP HCPCS C1713 13015525 - SCREW BN 2S 5.5MM 25MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015530 SUP HCPCS C1713 13015530 - SCREW BN 2S 5.5MM 30MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015535 SUP HCPCS C1713 13015535 - SCREW BN 2S 5.5MM 35MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015540 SUP HCPCS C1713 13015540 - SCREW BN 2S 5.5MM 40MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015545 SUP HCPCS C1713 13015545 - SCREW BN 2S 5.5MM 45MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015550 SUP HCPCS C1713 13015550 - SCREW BN 2S 5.5MM 50MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13015555 SUP HCPCS C1713 13015555 - SCREW BN 2S 5.5MM 55MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13016535 SUP HCPCS C1713 13016535 - SCREW BN 2S 6.5MM 35MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13016540 SUP HCPCS C1713 13016540 - SCREW BN 2S 6.5MM 40MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13016545 SUP HCPCS C1713 13016545 - SCREW BN 2S 6.5MM 45MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13016550 SUP HCPCS C1713 13016550 - SCREW BN 2S 6.5MM 50MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13016555 SUP HCPCS C1713 13016555 - SCREW BN 2S 6.5MM 55MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13017535 SUP HCPCS C1713 13017535 - SCREW BN 2S 7.5MM 35MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13017540 SUP HCPCS C1713 13017540 - SCREW BN 2S 7.5MM 40MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13017545 SUP HCPCS C1713 13017545 - SCREW BN 2S 7.5MM 45MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13017550 SUP HCPCS C1713 13017550 - SCREW BN 2S 7.5MM 50MM NS LF RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13017555 SUP HCPCS C1713 13017555 - SCREW BN 2S 7.5MM 55MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13018535 SUP HCPCS C1713 13018535 - SCREW BN 2S 8.5MM 35MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13018540 SUP HCPCS C1713 13018540 - SCREW BN 2S 8.5MM 40MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13018545 SUP HCPCS C1713 13018545 - SCREW BN 2S 8.5MM 45MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13018550 SUP HCPCS C1713 13018550 - SCREW BN 2S 8.5MM 50MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13018555 SUP HCPCS C1713 13018555 - SCREW BN 2S 8.5MM 55MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13018560 SUP HCPCS C1713 13018560 - SCREW BN 2S 8.5MM 60MM NS LF RELINE-O PA SPNE LLIAC BOTH IP/OP "$3,450.00 " "$2,553.00" $0.00 "$2,760.00" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $719.07 "$2,560.59" "$2,560.59" $0.00 $0.00 $718.98 $0.00 "$1,700.85" "$1,700.85" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $549.24 $0.00 $0.00 $0.00 $0.00 $0.00 13018580 SUP HCPCS C1713 13018580 - SCREW BN 2S 8.5MM 80MM NS RELINE-O PA SPNE LLIAC BOTH IP/OP "$3,450.00 " "$2,553.00" $0.00 "$2,760.00" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $719.07 "$2,560.59" "$2,560.59" $0.00 $0.00 $718.98 $0.00 "$1,700.85" "$1,700.85" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $549.24 $0.00 $0.00 $0.00 $0.00 $0.00 13019545 SUP HCPCS C1713 13019545 - SCREW BN 2S 9.5MM 45MM NS RELINE-O PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13025545 SUP HCPCS C1713 13025545 - SCREW BN 2S 5.5MM 45MM NS RELINE RELINEO RDC SPNE BOTH IP/OP "$3,580.00 " "$2,649.20" $0.00 "$2,864.00" "$1,611.00" "$1,611.00" $0.00 $0.00 $0.00 $746.16 "$2,657.08" "$2,657.08" $0.00 $0.00 $746.07 $0.00 "$1,764.94" "$1,764.94" $0.00 "$1,790.00" "$2,835.36" "$2,864.00" $0.00 $0.00 $560.27 $0.00 $0.00 $569.94 $0.00 $0.00 $0.00 $0.00 $0.00 13025555 SUP HCPCS C1713 13025555 - SCREW BN 2S 5.5MM 55MM NS RELINE RELINEO RDC SPNE BOTH IP/OP "$3,580.00 " "$2,649.20" $0.00 "$2,864.00" "$1,611.00" "$1,611.00" $0.00 $0.00 $0.00 $746.16 "$2,657.08" "$2,657.08" $0.00 $0.00 $746.07 $0.00 "$1,764.94" "$1,764.94" $0.00 "$1,790.00" "$2,835.36" "$2,864.00" $0.00 $0.00 $560.27 $0.00 $0.00 $569.94 $0.00 $0.00 $0.00 $0.00 $0.00 13026545 SUP HCPCS C1713 13026545 - SCREW BN 2S 6.5MM 45MM NS RELINE-O RDC SPNE BOTH IP/OP "$3,580.00 " "$2,649.20" $0.00 "$2,864.00" "$1,611.00" "$1,611.00" $0.00 $0.00 $0.00 $746.16 "$2,657.08" "$2,657.08" $0.00 $0.00 $746.07 $0.00 "$1,764.94" "$1,764.94" $0.00 "$1,790.00" "$2,835.36" "$2,864.00" $0.00 $0.00 $560.27 $0.00 $0.00 $569.94 $0.00 $0.00 $0.00 $0.00 $0.00 13037590 SUP HCPCS C1713 13037590 - SCREW BN 2S 7.5MM 90MM NS RELINE-O CLS PA SPNE ILC BOTH IP/OP "$3,450.00 " "$2,553.00" $0.00 "$2,760.00" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $719.07 "$2,560.59" "$2,560.59" $0.00 $0.00 $718.98 $0.00 "$1,700.85" "$1,700.85" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $549.24 $0.00 $0.00 $0.00 $0.00 $0.00 13038560 SUP HCPCS C1713 13038560 - SCREW BN 2S 8.5MM 60MM NS RELINE-O CLS SPNE ILC BOTH IP/OP "$3,450.00 " "$2,553.00" $0.00 "$2,760.00" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $719.07 "$2,560.59" "$2,560.59" $0.00 $0.00 $718.98 $0.00 "$1,700.85" "$1,700.85" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $549.24 $0.00 $0.00 $0.00 $0.00 $0.00 13038580 SUP HCPCS C1713 13038580 - SCREW BN 2S 8.5MM 80MM NS RELINE-O CLS SPNE ILC BOTH IP/OP "$3,450.00 " "$2,553.00" $0.00 "$2,760.00" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $719.07 "$2,560.59" "$2,560.59" $0.00 $0.00 $718.98 $0.00 "$1,700.85" "$1,700.85" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $549.24 $0.00 $0.00 $0.00 $0.00 $0.00 13039510 SUP HCPCS C1713 13039510 - SCREW BN 2S 9.5MM 100MM NS RELINE-O CLS SPNE ILC BOTH IP/OP "$3,450.00 " "$2,553.00" $0.00 "$2,760.00" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $719.07 "$2,560.59" "$2,560.59" $0.00 $0.00 $718.98 $0.00 "$1,700.85" "$1,700.85" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $549.24 $0.00 $0.00 $0.00 $0.00 $0.00 13114540 SUP HCPCS C1713 13114540 - SCREW BN 4.5MM 40MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13115540 SUP HCPCS C1713 13115540 - SCREW BN 5.5MM 40MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13115545 SUP HCPCS C1713 13115545 - SCREW BN 5.5MM 45MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13115550 SUP HCPCS C1713 13115550 - SCREW BN 5.5MM 50MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13115555 SUP HCPCS C1713 13115555 - SCREW BN 5.5MM 55MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13116545 SUP HCPCS C1713 13116545 - SCREW BN 6.5MM 45MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13116550 SUP HCPCS C1713 13116550 - SCREW BN 6.5MM 50MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13117550 SUP HCPCS C1713 13117550 - SCREW BN 7.5MM 50MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13117555 SUP HCPCS C1713 13117555 - SCREW BN 7.5MM 55MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13118555 SUP HCPCS C1713 13118555 - SCREW BN 8.5MM 55MM NS RELINE-O PA TRC SPNE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 13210510 SUP HCPCS C1713 13210510 - SCREW BN 10.5MM 100MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210511 SUP HCPCS C1713 13210511 - SCREW BN 10.5MM 110MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210512 SUP HCPCS C1713 13210512 - SCREW BN 10.5MM 120MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210525 SUP HCPCS C1713 13210525 - SCREW BN 10.5MM 25MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210530 SUP HCPCS C1713 13210530 - SCREW BN 10.5MM 30MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210535 SUP HCPCS C1713 13210535 - SCREW BN 10.5MM 35MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210540 SUP HCPCS C1713 13210540 - SCREW BN 10.5MM 40MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210545 SUP HCPCS C1713 13210545 - SCREW BN 10.5MM 45MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210550 SUP HCPCS C1713 13210550 - SCREW BN 10.5MM 50MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210555 SUP HCPCS C1713 13210555 - SCREW BN 10.5MM 55MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210560 SUP HCPCS C1713 13210560 - SCREW BN 10.5MM 60MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210565 SUP HCPCS C1713 13210565 - SCREW BN 10.5MM 65MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210570 SUP HCPCS C1713 13210570 - SCREW BN 10.5MM 70MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210575 SUP HCPCS C1713 13210575 - SCREW BN 10.5MM 75MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210580 SUP HCPCS C1713 13210580 - SCREW BN 10.5MM 80MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210585 SUP HCPCS C1713 13210585 - SCREW BN 10.5MM 85MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210590 SUP HCPCS C1713 13210590 - SCREW BN 10.5MM 90MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13210595 SUP HCPCS C1713 13210595 - SCREW BN 10.5MM 95MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13211010 SUP HCPCS C1713 13211010 - SCREW BN 10MM 100MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13219545 SUP HCPCS C1713 13219545 - SCREW BN 9.5MM 45MM NS RELINE PA 2 FENESTRATE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13550000 SUP HCPCS C1713 13550000 - RELINE LOCK SCREW BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 13600000 SUP HCPCS C1713 13600000 - SCREW BN 6MM NS RELINE LCK OPN TULIP SPNE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 14355030 SUP HCPCS C1713 14355030 - ROD SPNL LRDTC 5.5MM 30MM NS RELINE-O TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 14355035 SUP HCPCS C1713 14355035 - ROD SPNL LRDTC 5.5MM 35MM NS RELINE-O TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 14355045 SUP HCPCS C1713 "14355045 - RELINE ROD, 45MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 14355050 SUP HCPCS C1713 14355050 - ROD SPNL LRDTC 5.5MM 50MM NS RELINE-O TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 14355055 SUP HCPCS C1713 14355055 - ROD SPNL LRDTC 5.5MM 55MM NS RELINE-O TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 14355060 SUP HCPCS C1713 14355060 - ROD SPNL LRDTC 5.5MM 60MM NS RELINE-O TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 14910164 SUP Custom 27203010 KIT IMMUN TST PRMR POS NEG CNTRL H PYLR IGG 96 TST BOTH IP/OP "$1,619.25 " "$1,198.25" $0.00 "$1,295.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $809.63 "$1,282.45" "$1,295.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15355300 SUP HCPCS C1713 "15355300 - RELINE ROD, 300MM" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 16014520 SUP HCPCS C1713 16014520 - SCREW BN 4.5MM 20MM NS RELINE MAS PA SPNL 2C BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16015520 SUP HCPCS C1713 16015520 - SCREW BN 5.5MM 20MM NS RELINE MAS PA SPNL 2C BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16015540 SUP HCPCS C1713 16015540 - SCREW BN 2C 5.5MM 40MM NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16016520 SUP HCPCS C1713 16016520 - SCREW BN 6.5MM 20MM NS RELINE MAS PA SPNL 2C BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16016535 SUP HCPCS C1713 16016535 - SCREW BN 2C 6.5MM 35MM NS LF RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16016550 SUP HCPCS C1713 16016550 - SCREW BN 6.5MM 50MM RELINE POLYAX MA SPNE 2C BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16017540 SUP HCPCS C1713 16017540 - SCREW BN 2C 7.5MM 40MM NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16017545 SUP HCPCS C1713 16017545 - SCREW BN 2C 7.5MM 45MM NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16018510 SUP HCPCS C1713 16018510 - SCREW BN 2C 8.5MM 100MM NS RELINE PA SPNE ILC MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16018580 SUP HCPCS C1713 16018580 - SCREW BN 2C 8.5MM 80MM NS LF RELINE PA SPNE LLIAC MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16018590 SUP HCPCS C1713 16018590 - RELINE MAS SCREW 8.5X 90 BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16024530 SUP HCPCS C1713 16024530 - SCREW BN 2C 4.5MM 30MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16024535 SUP HCPCS C1713 16024535 - SCREW BN 2C 4.5MM 35MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16024540 SUP HCPCS C1713 16024540 - SCREW BN 2C 4.5MM 40MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16024545 SUP HCPCS C1713 16024545 - SCREW BN 2C 4.5MM 45MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16025535 SUP HCPCS C1713 16025535 - SCREW BN 2C 5.5MM 35MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16026540 SUP HCPCS C1713 16026540 - SCREW BN 2C 6.5MM 40MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16026545 SUP HCPCS C1713 "16026545 - RELINE REDUCTIONSCREW, 6.5 X 45" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16026550 SUP HCPCS C1713 "16026550 - RELINE MAS REDUCTION SCREW, 6.5X 50" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16026555 SUP HCPCS C1713 "16026555 - RELINE MAS REDUCTION SCREW, 6.5X 55" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16027535 SUP HCPCS C1713 16027535 - SCREW BN 2C 7.5MM 35MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16027555 SUP HCPCS C1713 "16027555 - RELINE REDUCTION SCREW, 7.5X 55" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16028535 SUP HCPCS C1713 16028535 - SCREW BN 2C 8.5MM 35MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16028540 SUP HCPCS C1713 16028540 - SCREW BN 2C 8.5MM 40MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16028545 SUP HCPCS C1713 16028545 - SCREW BN 2C 8.5MM 45MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16028550 SUP HCPCS C1713 16028550 - SCREW BN 2C 8.5MM 50MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16028555 SUP HCPCS C1713 16028555 - SCREW BN 2C 8.5MM 55MM RD NS RELINE PA SPNE MAS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16084520 SUP HCPCS C1713 16084520 - SCREW BN T 4.5MM 20MM NS RELINE MAS MA SPNL 2C BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16085520 SUP HCPCS C1713 16085520 - SCREW BN T 5.5MM 20MM NS RELINE MAS MA SPNL 2C BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16086520 SUP HCPCS C1713 16086520 - SCREW BN T 5.5MM 20MM RELINE MAS MA SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 16500311 SUP HCPCS C1876 BALLOON WORKHOUSE 7-2/5/75 BOTH IP/OP $2.50 $1.85 $0.00 $2.00 $1.13 $1.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.25 $1.98 $2.00 $0.00 $0.00 $0.39 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 16500317 SUP HCPCS C1725 CATHETER BALDILAT 5MM 100CM 2CM NC LOW PROFILE HI-PRS BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 16500412 SUP HCPCS C1725 CATHETER BALDILAT 6FR 8MM 75CM 2CM NC LOW PROFILE HI-PRS BOTH IP/OP $320.00 $236.80 $0.00 $256.00 $173.76 $173.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.00 $253.44 $256.00 $0.00 $0.00 $50.08 $0.00 $0.00 $50.94 $0.00 $0.00 $0.00 $0.00 $0.00 16500414 SUP HCPCS C1725 CATHETER BALDILAT 6FR 6MM 75CM 4CM NC LOW PROFILE HI-PRS BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $169.69 $169.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 16500416 SUP HCPCS C1725 CATHETER BALDILAT 6FR 8MM 75CM 4CM NC LOW PROFILE HI-PRS BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $169.69 $169.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 16500446 SUP HCPCS C1725 CATHETER BALDILAT 7FR 10MM 75CM 4CM NC LOW PROFILE HI-PRS BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 16500448 SUP HCPCS C1725 CATHETER BALDILAT 7FR 10MM 100CM 4CM NC LOW PROFILE HI-PRS BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 16701001 SUP HCPCS C1876 STENT BILIARY OMNIFLEX 6FR X 75CM X 5MM X 15MM BALLOON EXPAN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 18600545 SUP HCPCS C1713 18600545 - SCREW ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 18600550 SUP HCPCS C1713 18600550 - SCREW ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 18600555 SUP HCPCS C1713 18600555 - SCREW ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 18600560 SUP HCPCS C1713 18600560 - SCREW ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 20585507 SUP Custom 27203010 HEMOCONCENTRATOR PK RINSELESS TBG CONNCTR WST BAG PRFSN 1400 BOTH IP/OP $655.10 $484.77 $0.00 $524.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $327.55 $518.84 $524.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21074025 SUP Custom 27203010 21074025 - BIT DRILL 4MM 25MM STERILE BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $0.00 $0.00 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21381338 SUP Custom 27203010 TIP PIP 2.5ML EPNDF CMBTP PLUS 25UL INCR GRAD PLNG CYL STRL BOTH IP/OP $3.15 $2.33 $0.00 $2.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.58 $2.49 $2.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22046341 SUP Custom 27203010 REAGENT CLRT 3 1GL CLR AGNT HISTOLGY BOTH IP/OP $68.75 $50.88 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.38 $54.45 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22046344 SUP Custom 27203010 REAGENT METHNL ISOPRPNL FLX 100 1GL ABST DEHYDRANT BTL BOTH IP/OP $40.60 $30.04 $0.00 $32.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.30 $32.16 $32.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22046346 SUP Custom 27203010 REAGENT METHNL ISOPRPNL FLX 95 1GL DEHYDRANT BTL HISTOLGY BOTH IP/OP $158.90 $117.59 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.45 $125.85 $127.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22046348 SUP Custom 27203010 REAGENT METHNL ISOPRPNL FLX 80 1GL DEHYDRANT BTL HISTOLGY BOTH IP/OP $169.55 $125.47 $0.00 $135.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.78 $134.28 $135.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22046619 SUP Custom 27203010 CONTROL OSMTR ACCUREF 2ML 290 SER BOTH IP/OP $116.03 $85.86 $0.00 $92.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.01 $91.90 $92.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22266306 SUP Custom 27203010 TIP PIP 5ML CMBTP PLUS EPPPENDORF INCRM NSTRL BOTH IP/OP $273.28 $202.23 $0.00 $218.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.64 $216.44 $218.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22610135 SUP Custom 27203010 CAP TUBE 12MM FLNG BOTH IP/OP $0.08 $0.06 $0.00 $0.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.04 $0.06 $0.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23022523 SUP Custom 27203010 AIR CMPR AERS DSTR EXTN TUBE O3 SAFE TRPL FLTR 11OZ 5IN SUP BOTH IP/OP $43.33 $32.06 $0.00 $34.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.66 $34.32 $34.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23022524 SUP Custom 27203010 FREEZER CRYGN SUP FRND FRZ-IT AERS TISS SPRY PE SNORKEL 11OZ BOTH IP/OP $35.83 $26.51 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.91 $28.38 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23030817 SUP HCPCS C1783 23030817 - DRAIN GLAUCOMA IMNPLANT BAERVELDT SILICONE ANTER CHAM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 23038384 SUP Custom 27203010 CONTROL MLANLT MAS NRM VL 60ML UA BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23046581 SUP Custom 27203010 CONTROL ESR ESRCHX LVL 1 2 9ML HMTL BOTH IP/OP $780.00 $577.20 $0.00 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $390.00 $617.76 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23046595 SUP Custom 27203010 KIT IMMUN TST CLRVW COMBO 2 CLIA COMPLEXITY WVD SER URN HCG BOTH IP/OP $108.25 $80.11 $0.00 $86.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.13 $85.73 $86.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23255961 SUP Custom 27203010 STAIN MCBL GM IOD PRTCL 500ML BOTH IP/OP $66.35 $49.10 $0.00 $53.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.18 $52.55 $53.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23270181 SUP Custom 27203010 STAIN MCBL GM IOD UNSTBL PRTCL 1GL BOTH IP/OP $324.78 $240.34 $0.00 $259.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.39 $257.23 $259.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23285625 SUP Custom 27203010 REAGENT SCKL SCRN SCKCHX BUFF PWDR HMTL BOTH IP/OP $8.53 $6.31 $0.00 $6.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.26 $6.76 $6.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100101 SUP Custom 27203010 30100101 - BIT DRILL 16-24MM BIOTRAK STD CANN BIOTRACK BOTH IP/OP $650.00 $481.00 $0.00 $525.60 $29.07 $29.07 $16.30 $16.30 $8.15 $8.15 $24.76 $24.76 $23.81 $16.30 $24.09 $10.60 $0.00 $0.00 $17.12 $45.56 $429.66 $525.60 $23.64 $23.64 $25.67 $16.30 $16.30 $17.97 $16.30 $0.00 $0.00 $0.00 $0.00 30100102 SUP Custom 27203010 30100102 - BIT DRILL BIOTRAK STD TAP BOTH IP/OP $791.00 $585.34 $0.00 $625.60 $32.19 $32.19 $24.09 $24.09 $12.05 $10.84 $9.12 $9.12 $8.77 $24.09 $8.87 $15.66 $0.00 $0.00 $25.29 $16.78 $429.66 $625.60 $34.93 $34.93 $9.45 $24.09 $24.09 $6.62 $24.09 $0.00 $0.00 $0.00 $0.00 30100151 SUP Custom 27203010 30100151 - BIT DRL MN BIOTRAK BOTH IP/OP $510.00 $377.40 $0.00 $429.66 $34.50 $34.50 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $28.25 $26.07 $28.59 $16.95 $0.00 $0.00 $27.37 $54.08 $429.66 $371.20 $37.80 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100152 SUP Custom 27203010 30100152 - BIT DRL BIOTRAK TAP BOTH IP/OP $462.00 $341.88 $0.00 $429.66 $34.50 $34.50 $26.07 $26.07 $13.04 $11.73 $29.38 $29.38 $28.25 $26.07 $28.59 $16.95 $0.00 $0.00 $27.37 $54.08 $429.66 $371.20 $37.80 $37.80 $30.46 $26.07 $26.07 $21.33 $26.07 $0.00 $0.00 $0.00 $0.00 30100153 SUP Custom 27203010 30100153 - DRIVER MINI BIOTRAK SURG BOTH IP/OP $176.00 $130.24 $0.00 $429.66 $27.63 $27.63 $21.09 $21.09 $10.55 $9.49 $23.52 $23.52 $22.62 $21.09 $22.90 $13.71 $0.00 $0.00 $22.14 $43.30 $429.66 $140.80 $30.58 $30.58 $24.40 $21.09 $21.09 $17.08 $21.09 $0.00 $0.00 $0.00 $0.00 30100154 SUP Custom 27203010 30100154 - EJTR MINI BLADE BIOTRAK INDIV SET NONSTRL BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $0.00 $0.00 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30100351 SUP Custom 27203010 30100351 - DRILL SRG BIOTRAK BOTH IP/OP $276.00 $204.24 $0.00 $429.66 $37.85 $37.85 $21.23 $21.23 $10.62 $10.62 $32.25 $32.25 $31.01 $21.23 $31.36 $13.80 $0.00 $0.00 $22.29 $59.34 $429.66 $220.80 $30.78 $30.78 $33.42 $21.23 $21.23 $23.39 $21.23 $0.00 $0.00 $0.00 $0.00 31002701 SUP Custom 27803010 31002701 - VALVE MTRL 27MM 35MM 24MM 19MM 14MM MSC CNCH FLXB STNT BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 37129000 SUP Custom 27203010 FORMULA 237ML PTMN SUPPL CHOC BOTH IP/OP $7.28 $5.39 $0.00 $5.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.64 $5.77 $5.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38204020 SUP HCPCS C1713 038204020 - SCREW BONE 4MM 20MM MULTIAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38204025 SUP HCPCS C1713 038204025 - SCREW BONE 4MM 25MM MULTIAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38204030 SUP HCPCS C1713 038204030 - SCREW BONE 4MM 30MM MULTIAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38204035 SUP HCPCS C1713 038204035 - SCREW BONE 4MM 35MM MNOAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38204040 SUP HCPCS C1713 038204040 - SCREW BONE 4MM 40MM MULTIAX XIA II TITANIUM SPN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38205025 SUP HCPCS C1713 038205025 - SCREW BONE 5MM 25MM MNOAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38205030 SUP HCPCS C1713 038205030 - SCREW BONE 5MM 30MM MNOAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38205035 SUP HCPCS C1713 038205035 - SCREW BONE 5MM 35MM MNOAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38205040 SUP HCPCS C1713 038205040 - SCREW BONE 5MM 40MM MNOAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 38205045 SUP HCPCS C1713 038205045 - SCREW BONE 5MM 45MM MNOAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 38214020 SUP HCPCS C1713 038214020 - SCREW BONE 4MM 20MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 38214025 SUP HCPCS C1713 038214025 - SCREW BONE 4MM 25MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 38214030 SUP HCPCS C1713 038214030 - SCREW BONE 4MM 30MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 38214035 SUP HCPCS C1713 038214035 - SCREW BONE 4MM 35MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 38214040 SUP HCPCS C1713 038214040 - SCREW BONE 4MM 40MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 38215025 SUP HCPCS C1713 038215025 - SCREW BONE 5MM 25MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 38215030 SUP HCPCS C1713 038215030 - SCREW BONE 5MM 30MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 38215035 SUP HCPCS C1713 038215035 - SCREW BONE 5MM 35MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 38215040 SUP HCPCS C1713 038215040 - SCREW BONE 5MM 40MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 38215045 SUP HCPCS C1713 038215045 - SCREW BONE 5MM 45MM POLYAX XIA II TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 40036170 SUP Custom 27803010 61421 - SPACER SPNL 21MMX14MM RYTFC UNT BOTH IP/OP "$8,031.25 " "$5,943.13" $0.00 "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,673.71" $0.00 $0.00 $0.00 $0.00 "$4,015.63" "$6,360.75" "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48030022 SUP HCPCS C1713 48030022 - PLATE BONE 22MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$8,793.48 " "$6,507.18" $0.00 "$7,034.78" "$3,957.06" "$3,957.06" $0.00 $0.00 $0.00 "$1,832.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,832.56" $0.00 "$4,335.18" "$4,335.18" $0.00 "$4,396.74" "$6,964.44" "$7,034.78" $0.00 $0.00 "$1,376.18" $0.00 $0.00 "$1,399.92" $0.00 $0.00 $0.00 $0.00 $0.00 48030025 SUP HCPCS C1713 48030025 - PLATE BONE 25MM NONCOMPRESSION 1 LEVEL THORACIC BOTH IP/OP "$8,793.48 " "$6,507.18" $0.00 "$7,034.78" "$3,957.06" "$3,957.06" $0.00 $0.00 $0.00 "$1,832.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,832.56" $0.00 "$4,335.18" "$4,335.18" $0.00 "$4,396.74" "$6,964.44" "$7,034.78" $0.00 $0.00 "$1,376.18" $0.00 $0.00 "$1,399.92" $0.00 $0.00 $0.00 $0.00 $0.00 48030028 SUP HCPCS C1713 48030028 - PLATE BONE 28MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$8,793.48 " "$6,507.18" $0.00 "$7,034.78" "$3,957.06" "$3,957.06" $0.00 $0.00 $0.00 "$1,832.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,832.56" $0.00 "$4,335.18" "$4,335.18" $0.00 "$4,396.74" "$6,964.44" "$7,034.78" $0.00 $0.00 "$1,376.18" $0.00 $0.00 "$1,399.92" $0.00 $0.00 $0.00 $0.00 $0.00 48030031 SUP HCPCS C1713 48030031 - PLATE BONE 31MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$8,793.48 " "$6,507.18" $0.00 "$7,034.78" "$3,957.06" "$3,957.06" $0.00 $0.00 $0.00 "$1,832.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,832.56" $0.00 "$4,335.18" "$4,335.18" $0.00 "$4,396.74" "$6,964.44" "$7,034.78" $0.00 $0.00 "$1,376.18" $0.00 $0.00 "$1,399.92" $0.00 $0.00 $0.00 $0.00 $0.00 48030034 SUP HCPCS C1713 48030034 - PLATE BONE 34MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$8,793.48 " "$6,507.18" $0.00 "$7,034.78" "$3,957.06" "$3,957.06" $0.00 $0.00 $0.00 "$1,832.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,832.56" $0.00 "$4,335.18" "$4,335.18" $0.00 "$4,396.74" "$6,964.44" "$7,034.78" $0.00 $0.00 "$1,376.18" $0.00 $0.00 "$1,399.92" $0.00 $0.00 $0.00 $0.00 $0.00 48030037 SUP HCPCS C1713 48030037 - PLATE BONE 37MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$8,793.48 " "$6,507.18" $0.00 "$7,034.78" "$3,957.06" "$3,957.06" $0.00 $0.00 $0.00 "$1,832.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,832.56" $0.00 "$4,335.18" "$4,335.18" $0.00 "$4,396.74" "$6,964.44" "$7,034.78" $0.00 $0.00 "$1,376.18" $0.00 $0.00 "$1,399.92" $0.00 $0.00 $0.00 $0.00 $0.00 48030040 SUP HCPCS C1713 48030040 - PLATE BONE 40MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$8,793.48 " "$6,507.18" $0.00 "$7,034.78" "$3,957.06" "$3,957.06" $0.00 $0.00 $0.00 "$1,832.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,832.56" $0.00 "$4,335.18" "$4,335.18" $0.00 "$4,396.74" "$6,964.44" "$7,034.78" $0.00 $0.00 "$1,376.18" $0.00 $0.00 "$1,399.92" $0.00 $0.00 $0.00 $0.00 $0.00 48030225 SUP HCPCS C1713 48030225 - SCREW BONE 6.5MM 22MM COMPRESSION SPN THORACIC BOTH IP/OP "$1,008.65 " $746.40 $0.00 $806.92 $453.89 $453.89 $0.00 $0.00 $0.00 $210.23 $748.62 $748.62 $0.00 $0.00 $210.20 $0.00 $596.62 $596.62 $0.00 $504.33 $798.85 $806.92 $0.00 $0.00 $157.85 $0.00 $0.00 $160.58 $0.00 $0.00 $0.00 $0.00 $0.00 48030265 SUP HCPCS C1713 48030265 - PLATE BONE 65MM LEVEL 2 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48030271 SUP HCPCS C1713 48030271 - PLATE BONE 71MM LEVEL 2 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48030277 SUP HCPCS C1713 48030277 - PLATE BONE 77MM LEVEL 2 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48030283 SUP HCPCS C1713 48030283 - PLATE BONE 83MM LEVEL 2 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48030289 SUP HCPCS C1713 48030289 - PLATE BONE 89MM LEVEL 2 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48030350 SUP HCPCS C1713 48030350 - SCREW BONE 6MM 35MM COMPRESSION SPN THORACIC BOTH IP/OP "$1,008.65 " $746.40 $0.00 $806.92 $453.89 $453.89 $0.00 $0.00 $0.00 $210.23 $748.62 $748.62 $0.00 $0.00 $210.20 $0.00 $596.62 $596.62 $0.00 $504.33 $798.85 $806.92 $0.00 $0.00 $157.85 $0.00 $0.00 $160.58 $0.00 $0.00 $0.00 $0.00 $0.00 48032040 SUP HCPCS C1713 48032040 - PLATE BONE 40MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032044 SUP HCPCS C1713 48032044 - PLATE BONE 44MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032048 SUP HCPCS C1713 48032048 - PLATE BONE 48MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032052 SUP HCPCS C1713 48032052 - PLATE BONE 52MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032056 SUP HCPCS C1713 48032056 - PLATE BONE 56MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032060 SUP HCPCS C1713 48032060 - PLATE BONE 60MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032064 SUP HCPCS C1713 48032064 - PLATE BONE 64MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032068 SUP HCPCS C1713 48032068 - PLATE BONE 68MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032072 SUP HCPCS C1713 48032072 - PLATE BONE 72MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032076 SUP HCPCS C1713 48032076 - PLATE BONE 76MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$12,217.15 " "$9,040.69" $0.00 "$9,773.72" "$5,497.72" "$5,497.72" $0.00 $0.00 $0.00 "$2,546.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,546.05" $0.00 "$6,023.05" "$6,023.05" $0.00 "$6,108.58" "$9,675.98" "$9,773.72" $0.00 $0.00 "$1,911.98" $0.00 $0.00 "$1,944.97" $0.00 $0.00 $0.00 $0.00 $0.00 48032080 SUP HCPCS C1713 48032080 - PLATE BONE 80MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$13,963.70 " "$10,333.14" $0.00 "$11,170.96" "$6,283.67" "$6,283.67" $0.00 $0.00 $0.00 "$2,910.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.04" $0.00 "$6,884.10" "$6,884.10" $0.00 "$6,981.85" "$11,059.25" "$11,170.96" $0.00 $0.00 "$2,185.32" $0.00 $0.00 "$2,223.02" $0.00 $0.00 $0.00 $0.00 $0.00 48032084 SUP HCPCS C1713 48032084 - PLATE BONE 84MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$13,963.70 " "$10,333.14" $0.00 "$11,170.96" "$6,283.67" "$6,283.67" $0.00 $0.00 $0.00 "$2,910.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.04" $0.00 "$6,884.10" "$6,884.10" $0.00 "$6,981.85" "$11,059.25" "$11,170.96" $0.00 $0.00 "$2,185.32" $0.00 $0.00 "$2,223.02" $0.00 $0.00 $0.00 $0.00 $0.00 48032088 SUP HCPCS C1713 48032088 - PLATE BONE 88MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$13,963.70 " "$10,333.14" $0.00 "$11,170.96" "$6,283.67" "$6,283.67" $0.00 $0.00 $0.00 "$2,910.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.04" $0.00 "$6,884.10" "$6,884.10" $0.00 "$6,981.85" "$11,059.25" "$11,170.96" $0.00 $0.00 "$2,185.32" $0.00 $0.00 "$2,223.02" $0.00 $0.00 $0.00 $0.00 $0.00 48032092 SUP HCPCS C1713 48032092 - PLATE BONE 92MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$13,963.70 " "$10,333.14" $0.00 "$11,170.96" "$6,283.67" "$6,283.67" $0.00 $0.00 $0.00 "$2,910.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.04" $0.00 "$6,884.10" "$6,884.10" $0.00 "$6,981.85" "$11,059.25" "$11,170.96" $0.00 $0.00 "$2,185.32" $0.00 $0.00 "$2,223.02" $0.00 $0.00 $0.00 $0.00 $0.00 48032096 SUP HCPCS C1713 48032096 - PLATE BONE 96MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$13,963.70 " "$10,333.14" $0.00 "$11,170.96" "$6,283.67" "$6,283.67" $0.00 $0.00 $0.00 "$2,910.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.04" $0.00 "$6,884.10" "$6,884.10" $0.00 "$6,981.85" "$11,059.25" "$11,170.96" $0.00 $0.00 "$2,185.32" $0.00 $0.00 "$2,223.02" $0.00 $0.00 $0.00 $0.00 $0.00 48032100 SUP HCPCS C1713 48032100 - PLATE BONE 100MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$13,963.70 " "$10,333.14" $0.00 "$11,170.96" "$6,283.67" "$6,283.67" $0.00 $0.00 $0.00 "$2,910.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.04" $0.00 "$6,884.10" "$6,884.10" $0.00 "$6,981.85" "$11,059.25" "$11,170.96" $0.00 $0.00 "$2,185.32" $0.00 $0.00 "$2,223.02" $0.00 $0.00 $0.00 $0.00 $0.00 48034525 SUP HCPCS C1713 48034525 - PLATE BONE 25MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48034528 SUP HCPCS C1713 48034528 - PLATE BONE 28MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48034531 SUP HCPCS C1713 48034531 - PLATE BONE 31MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48034534 SUP HCPCS C1713 48034534 - PLATE BONE 34MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48034537 SUP HCPCS C1713 48034537 - PLATE BONE 37MM LEVEL 1 COMPRESSION SPN THORACOLUMBAR BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48035125 SUP HCPCS C1713 48035125 - PLATE BONE 25MM LEVEL 1 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48035128 SUP HCPCS C1713 48035128 - PLATE BONE 28MM LEVEL 1 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48035131 SUP HCPCS C1713 48035131 - PLATE BONE 31MM LEVEL 1 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48035134 SUP HCPCS C1713 48035134 - PLATE BONE 34MM LEVEL 1 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48035137 SUP HCPCS C1713 48035137 - PLATE BONE 37MM LEVEL 1 COMPRESSION SPN THORACIC SACRUM BOTH IP/OP "$9,160.23 " "$6,778.57" $0.00 "$7,328.18" "$4,122.10" "$4,122.10" $0.00 $0.00 $0.00 "$1,909.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,908.99" $0.00 "$4,515.99" "$4,515.99" $0.00 "$4,580.11" "$7,254.90" "$7,328.18" $0.00 $0.00 "$1,433.58" $0.00 $0.00 "$1,458.31" $0.00 $0.00 $0.00 $0.00 $0.00 48035225 SUP HCPCS C1713 48035225 - SCREW BONE 6.5MM 22MM COMPRESSION THORACIC SPN BOTH IP/OP "$1,008.65 " $746.40 $0.00 $806.92 $453.89 $453.89 $0.00 $0.00 $0.00 $210.23 $748.62 $748.62 $0.00 $0.00 $210.20 $0.00 $596.62 $596.62 $0.00 $504.33 $798.85 $806.92 $0.00 $0.00 $157.85 $0.00 $0.00 $160.58 $0.00 $0.00 $0.00 $0.00 $0.00 48035350 SUP HCPCS C1713 48035350 - SCREW BONE 6.5MM 35MM COMPRESSION THORACIC SPN BOTH IP/OP "$1,008.65 " $746.40 $0.00 $806.92 $453.89 $453.89 $0.00 $0.00 $0.00 $210.23 $748.62 $748.62 $0.00 $0.00 $210.20 $0.00 $596.62 $596.62 $0.00 $504.33 $798.85 $806.92 $0.00 $0.00 $157.85 $0.00 $0.00 $160.58 $0.00 $0.00 $0.00 $0.00 $0.00 48130000 SUP Custom 27803010 48130000 - SCREW SET BLOCKER XIA TITANIUM SPN 4.5 MM ROD BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130110 SUP HCPCS C1713 48130110 - STAPLE BONE SMALL 4.5MM 2 XIA TITANIUM SPN CAUDAL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130111 SUP HCPCS C1713 48130111 - STAPLE BONE SMALL 4.5MM 2 XIA TITANIUM SPN ROSTRAL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130112 SUP HCPCS C1713 48130112 - STAPLE BONE LARGE 4.5MM 2 XIA TITANIUM SPN CAUDAL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130113 SUP HCPCS C1713 48130113 - STAPLE BONE LARGE 4.5MM 2 XIA TITANIUM SPN ROSTRAL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130201 SUP Custom 27803010 48130201 - HOOK SPINAL SMALL XIA TITANIUM LMNR 4.5MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130202 SUP Custom 27803010 48130202 - HOOK SPINAL MEDIUM XIA TITANIUM LMNR 4.5MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130203 SUP Custom 27803010 48130203 - HOOK SPINAL LARGE XIA TITANIUM LMNR 4.5MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130204 SUP Custom 27803010 48130204 - HOOK SPINAL EXTEND XIA TITANIUM LMNR 4.5 MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130208 SUP Custom 27803010 48130208 - HOOK SPINAL ANGLED BLADE XIA TITANIUM LMNR 4.5 MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130210 SUP Custom 27803010 48130210 - HOOK SPINAL XIA TITANIUM LMNR THORACIC 4.5 MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130212 SUP Custom 27803010 48130212 - HOOK SPINAL RIGHT OFFST XIA TITANIUM LMNR THORACIC 4.5 MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130213 SUP Custom 27803010 48130213 - HOOK SPINAL LEFT OFFST XIA TITANIUM LMNR THORACIC 4.5 MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130214 SUP Custom 27803010 48130214 - HOOK SPINAL RIGHT OFFST XIA TITANIUM SUPRA LMNR 4.5 MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130215 SUP Custom 27803010 48130215 - HOOK SPINAL LEFT OFFST XIA TITANIUM SUPRA LMNR 4.5 MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130220 SUP Custom 27803010 48130220 - HOOK SPINAL SMALL XIA TITANIUM PEDICLE 4.5MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130221 SUP Custom 27803010 48130221 - HOOK SPINAL LARGE XIA TITANIUM PEDICLE 4.5MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130230 SUP Custom 27803010 48130230 - HOOK SPINAL RIGHT OFFST TRNSVRS PROCESS XIA TITANIUM 4.5 MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48130231 SUP Custom 27803010 48130231 - HOOK SPINAL LEFT OFFST TRNSVRS PROCESS XIA TITANIUM 4.5 MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48132040 SUP HCPCS C1713 48132040 - ROD SPNL STRG 4.5MM 40MM XIA HEX VIT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 48132090 SUP HCPCS C1713 48132090 - ROD SPNL STRG 4.5MM 90MM XIA HEX VIT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 48132100 SUP HCPCS C1713 48132100 - ROD SPNL STRG 4.5MM 100MM XIA HEX VIT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 48132601 SUP HCPCS C1713 48132601 - ROD SPINAL 4.5MM 600MM XIA VITALLIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 48133012 SUP HCPCS C1713 48133012 - SCREW BONE 4.5MM 12MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133013 SUP HCPCS C1713 48133013 - SCREW BONE 4.5MM 13MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133014 SUP HCPCS C1713 48133014 - SCREW BONE 4.5MM 14MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133015 SUP Custom 27803010 48133015 - CROSSLINK SPINAL 15MM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133016 SUP HCPCS C1713 48133016 - SCREW BONE 4.5MM 16MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133017 SUP HCPCS C1713 48133017 - SCREW BONE 4.5MM 17MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133018 SUP HCPCS C1713 48133018 - SCREW BONE 4.5MM 18MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133019 SUP HCPCS C1713 48133019 - CONNECTOR ROD 4.5MM 19MM MONOBLOCK CROSSLINK XIA SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133021 SUP HCPCS C1713 48133021 - SCREW BONE 4.5MM 21MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133023 SUP HCPCS C1713 48133023 - SCREW BONE 4.5MM 23MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133024 SUP HCPCS C1713 48133024 - SCREW BONE 4.5MM 24MM CONCTR MONOBLOCK XIA TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133200 SUP Custom 27803010 48133200 - ROD SPINAL 5.5MM 40MM XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133224 SUP Custom 27803010 48133224 - CONNECTOR ROD SMALL 24-30MM POLYAX CROSS XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133230 SUP Custom 27803010 48133230 - CONNECTOR ROD MEDIUM 30-36MM POLYAX CROSS XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133236 SUP Custom 27803010 48133236 - CONNECTOR ROD LARGE 36-45MM CROSSLINK XIA TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133245 SUP Custom 27803010 48133245 - CONNECTOR ROD LARGE 45-60MM POLYAX CROSS XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48133480 SUP Custom 27803010 48133480 - ROD SPINAL 4.5MM 480MM XIA TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48134020 SUP HCPCS C1713 48134020 - SCREW BONE 4MM 20MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134025 SUP HCPCS C1713 48134025 - SCREW BONE 4MM 25MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134030 SUP HCPCS C1713 48134030 - SCREW BONE 4MM 30MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134035 SUP HCPCS C1713 48134035 - SCREW BONE 4MM 35MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134040 SUP HCPCS C1713 48134040 - SCREW BONE 4MM 40MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134520 SUP HCPCS C1713 48134520 - SCREW BONE 4.5MM 20MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134525 SUP HCPCS C1713 48134525 - SCREW BONE 4.5MM 25MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134530 SUP HCPCS C1713 48134530 - SCREW BONE 4.5MM 30MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134535 SUP HCPCS C1713 48134535 - SCREW BONE 4.5MM 35MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134540 SUP HCPCS C1713 48134540 - SCREW BONE 4.5MM 40MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48134545 SUP HCPCS C1713 48134545 - SCREW BONE 4.5MM 45MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135000 SUP Custom 27803010 48135000 - CONNECTOR ROD 4.5MM 30MM ROD TO ROD XIA TITANIUM SPN BOTH IP/OP "$1,819.65 " "$1,346.54" $0.00 "$1,455.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,350.54" "$1,350.54" $0.00 $0.00 $379.22 $0.00 $0.00 $0.00 $0.00 $909.83 "$1,441.16" "$1,455.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135000 SUP Custom 27803010 0048135000 - CONNECTOR ROD 4.5MM 30MM ROD TO ROD XIA TITANIUM SPN BOTH IP/OP "$1,819.65 " "$1,346.54" $0.00 "$1,455.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,350.54" "$1,350.54" $0.00 $0.00 $379.22 $0.00 $0.00 $0.00 $0.00 $909.83 "$1,441.16" "$1,455.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135001 SUP Custom 27803010 48135001 - CONNECTOR ROD 4.5MM 60MM XIA SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135003 SUP Custom 27803010 48135003 - CONNECTOR ROD 4.5-5.5/6MM ROD TO ROD PARALLEL XIA SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135004 SUP Custom 27803010 48135004 - CONNECTOR ROD 4.5-6MM ROD TO ROD XIA SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135005 SUP Custom 27803010 48135005 - CONNECTOR ROD SMALL 4.5MM ROD TO ROD PARALLEL XIA SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135006 SUP Custom 27803010 48135006 - CONNECTOR ROD LARGE 4.5MM ROD TO ROD PARALLEL XIA SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135008 SUP Custom 27803010 48135008 - CONNECTOR ROD 4.5-5.5/6MM ROD TO ROD PARALLEL XIA SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135020 SUP HCPCS C1713 48135020 - SCREW BONE 5MM 20MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135025 SUP HCPCS C1713 48135025 - SCREW BONE 5MM 25MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135030 SUP HCPCS C1713 48135030 - SCREW BONE 5MM 30MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135035 SUP HCPCS C1713 48135035 - SCREW BONE 5MM 35MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135040 SUP HCPCS C1713 48135040 - SCREW BONE 5MM 40MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135045 SUP HCPCS C1713 48135045 - SCREW BONE 5MM 45MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135050 SUP HCPCS C1713 48135050 - SCREW BONE 5MM 50MM MNOAX XIA TITANIUM SPN THORACOLUMBAR 4.5 BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135055 SUP HCPCS C1713 48135055 - SCREW BONE 5MM 55MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135060 SUP HCPCS C1713 48135060 - SCREW BONE 5MM 60MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135070 SUP HCPCS C1713 48135070 - SCREW BONE 5MM 70MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135080 SUP HCPCS C1713 48135080 - SCREW BONE 5MM 80MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135101 SUP Custom 27803010 48135101 - CONNECTOR ROD 4.5MM 30MM OFFST XIA TITANIUM SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135102 SUP Custom 27803010 48135102 - CONNECTOR ROD 4.5MM 70MM OFFST XIA SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135103 SUP Custom 27803010 48135103 - CONNECTOR ROD SMALL EXTEND XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$3,032.78 " "$2,244.26" $0.00 "$2,426.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,250.93" "$2,250.93" $0.00 $0.00 $632.03 $0.00 $0.00 $0.00 $0.00 "$1,516.39" "$2,401.96" "$2,426.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135104 SUP Custom 27803010 48135104 - CONNECTOR ROD LONG 4.5MM EXTEND XIA SPN BOTH IP/OP "$3,032.78 " "$2,244.26" $0.00 "$2,426.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,250.93" "$2,250.93" $0.00 $0.00 $632.03 $0.00 $0.00 $0.00 $0.00 "$1,516.39" "$2,401.96" "$2,426.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135105 SUP Custom 27803010 48135105 - CONNECTOR ROD STR XIA TITANIUM ILIAC SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135106 SUP Custom 27803010 48135106 - CONNECTOR ROD 15D 4.5MM STR XIA SPN ILIAC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135107 SUP Custom 27803010 48135107 - CONNECTOR ROD 25D 4.5MM STR XIA SPN ILIAC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135108 SUP Custom 27803010 48135108 - CONNECTOR ROD 35D 4.5MM STR XIA SPN ILIAC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135109 SUP Custom 27803010 48135109 - CONNECTOR ROD 45D 4.5MM STR XIA SPN ILIAC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48135520 SUP HCPCS C1713 48135520 - SCREW BONE 5.5MM 20MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135525 SUP HCPCS C1713 48135525 - SCREW BONE 5.5MM 25MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135530 SUP HCPCS C1713 48135530 - SCREW BONE 5.5MM 30MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135535 SUP HCPCS C1713 48135535 - SCREW BONE 5.5MM 35MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135540 SUP HCPCS C1713 48135540 - SCREW BONE 5.5MM 40MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135545 SUP HCPCS C1713 48135545 - SCREW BONE 5.5MM 45MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135550 SUP HCPCS C1713 48135550 - SCREW BONE 5.5MM 50MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135555 SUP HCPCS C1713 48135555 - SCREW BONE 5.5MM 55MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135560 SUP HCPCS C1713 48135560 - SCREW BONE 5.5MM 60MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135570 SUP HCPCS C1713 48135570 - SCREW BONE 5.5MM 70MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48135580 SUP HCPCS C1713 48135580 - SCREW BONE 5.5MM 80MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136025 SUP HCPCS C1713 48136025 - SCREW BONE 6MM 25MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136030 SUP HCPCS C1713 48136030 - SCREW BONE 6MM 30MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136035 SUP HCPCS C1713 48136035 - SCREW BONE 6MM 35MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136040 SUP HCPCS C1713 48136040 - SCREW BONE 6MM 40MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136045 SUP HCPCS C1713 48136045 - SCREW BONE 6MM 45MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136050 SUP HCPCS C1713 48136050 - SCREW BONE 6MM 50MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136055 SUP HCPCS C1713 48136055 - SCREW BONE 6MM 55MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136060 SUP HCPCS C1713 48136060 - SCREW BONE 6MM 60MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136070 SUP HCPCS C1713 48136070 - SCREW BONE 6MM 70MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136080 SUP HCPCS C1713 48136080 - SCREW BONE 6MM 80MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136530 SUP HCPCS C1713 48136530 - SCREW BONE 6.5MM 30MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136535 SUP HCPCS C1713 48136535 - SCREW BONE 6.5MM 35MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136540 SUP HCPCS C1713 48136540 - SCREW BONE 6.5MM 40MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136545 SUP HCPCS C1713 48136545 - SCREW BONE 6.5MM 45MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136550 SUP HCPCS C1713 48136550 - SCREW BONE 6.5MM 50MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136555 SUP HCPCS C1713 48136555 - SCREW BONE 6.5MM 55MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136560 SUP HCPCS C1713 48136560 - SCREW BONE 6.5MM 60MM MNOAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136570 SUP HCPCS C1713 48136570 - SCREW BONE 6.5MM 70MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48136580 SUP HCPCS C1713 48136580 - SCREW BONE 6.5MM 80MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137030 SUP HCPCS C1713 48137030 - SCREW BONE 7MM 30MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137035 SUP HCPCS C1713 48137035 - SCREW BONE 7MM 35MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137040 SUP HCPCS C1713 48137040 - SCREW BONE 7MM 40MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137045 SUP HCPCS C1713 48137045 - SCREW BONE 7MM 45MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137050 SUP HCPCS C1713 48137050 - SCREW BONE 7MM 50MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137060 SUP HCPCS C1713 48137060 - SCREW BONE 7MM 60MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137070 SUP HCPCS C1713 48137070 - SCREW BONE 7MM 70MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137080 SUP HCPCS C1713 48137080 - SCREW BONE 7MM 80MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137530 SUP HCPCS C1713 48137530 - SCREW BONE 7.5MM 30MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137535 SUP HCPCS C1713 48137535 - SCREW BONE 7.5MM 35MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137540 SUP HCPCS C1713 48137540 - SCREW BONE 7.5MM 40MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137545 SUP HCPCS C1713 48137545 - SCREW BONE 7.5MM 45MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137550 SUP HCPCS C1713 48137550 - SCREW BONE 7.5MM 50MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137555 SUP HCPCS C1713 48137555 - SCREW BONE 7.5MM 55MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137560 SUP HCPCS C1713 48137560 - SCREW BONE 7.5MM 60MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137570 SUP HCPCS C1713 48137570 - SCREW BONE 7.5MM 70MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48137580 SUP HCPCS C1713 48137580 - SCREW BONE 7.5MM 80MM MNOAX XIA SPN 4.5MM ROD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 48144020 SUP HCPCS C1713 48144020 - SCREW BONE 4MM 20MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144025 SUP HCPCS C1713 48144025 - SCREW BONE 4MM 25MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144030 SUP HCPCS C1713 48144030 - SCREW BONE 4MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144035 SUP HCPCS C1713 48144035 - SCREW BONE 4MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144040 SUP HCPCS C1713 48144040 - SCREW BONE 4MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144520 SUP HCPCS C1713 48144520 - SCREW BONE 4.5MM 20MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144525 SUP HCPCS C1713 48144525 - SCREW BONE 4.5MM 25MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144530 SUP HCPCS C1713 48144530 - SCREW BONE 4.5MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144535 SUP HCPCS C1713 48144535 - SCREW BONE 4.5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144540 SUP HCPCS C1713 48144540 - SCREW BONE 4.5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144545 SUP HCPCS C1713 48144545 - SCREW BONE 4.5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144560 SUP HCPCS C1713 48144560 - SCREW BONE 4.5MM 60MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48144570 SUP HCPCS C1713 48144570 - SCREW BONE 4.5MM 70MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145020 SUP HCPCS C1713 48145020 - SCREW BONE 5MM 20MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145025 SUP HCPCS C1713 48145025 - SCREW BONE 5MM 25MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145030 SUP HCPCS C1713 48145030 - SCREW BONE 5MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145035 SUP HCPCS C1713 48145035 - SCREW BONE 5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145040 SUP HCPCS C1713 48145040 - SCREW BONE 5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145045 SUP HCPCS C1713 48145045 - SCREW BONE 5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145050 SUP HCPCS C1713 48145050 - SCREW BONE 5MM 50MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145055 SUP HCPCS C1713 48145055 - SCREW BONE 5MM 55MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145060 SUP HCPCS C1713 48145060 - SCREW BONE 5MM 60MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145070 SUP HCPCS C1713 48145070 - SCREW BONE 5MM 70MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145080 SUP HCPCS C1713 48145080 - SCREW BONE 5MM 80MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145520 SUP HCPCS C1713 48145520 - SCREW BONE 5.5MM 20MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145525 SUP HCPCS C1713 48145525 - SCREW BONE 5.5MM 25MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145530 SUP HCPCS C1713 48145530 - SCREW BONE 5.5MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145535 SUP HCPCS C1713 48145535 - SCREW BONE 5.5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145540 SUP HCPCS C1713 48145540 - SCREW BONE 5.5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145545 SUP HCPCS C1713 48145545 - SCREW BONE 5.5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145550 SUP HCPCS C1713 48145550 - SCREW BONE 5.5MM 50MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145555 SUP HCPCS C1713 48145555 - SCREW BONE 5.5MM 55MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145560 SUP HCPCS C1713 48145560 - SCREW BONE 5.5MM 60MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145570 SUP HCPCS C1713 48145570 - SCREW BONE 5.5MM 70MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48145580 SUP HCPCS C1713 48145580 - SCREW BONE 5.5MM 80MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146025 SUP HCPCS C1713 48146025 - SCREW BONE 6MM 25MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146030 SUP HCPCS C1713 48146030 - SCREW BONE 6MM 30MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146035 SUP HCPCS C1713 48146035 - SCREW BONE 6MM 35MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146040 SUP HCPCS C1713 48146040 - SCREW BONE 6MM 40MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146045 SUP HCPCS C1713 48146045 - SCREW BONE 6MM 45MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146050 SUP HCPCS C1713 48146050 - SCREW BONE 6MM 50MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146055 SUP HCPCS C1713 48146055 - SCREW BONE 6MM 55MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146060 SUP HCPCS C1713 48146060 - SCREW BONE 6MM 60MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146070 SUP HCPCS C1713 48146070 - SCREW BONE 6MM 70MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146080 SUP HCPCS C1713 48146080 - SCREW BONE 6MM 80MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146530 SUP HCPCS C1713 48146530 - SCREW BONE 6.5MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146535 SUP HCPCS C1713 48146535 - SCREW BONE 6.5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146540 SUP HCPCS C1713 48146540 - SCREW BONE 6.5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146545 SUP HCPCS C1713 48146545 - SCREW BONE 6.5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146550 SUP HCPCS C1713 48146550 - SCREW BONE 6.5MM 50MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146555 SUP HCPCS C1713 48146555 - SCREW BONE 6.5MM 55MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146560 SUP HCPCS C1713 48146560 - SCREW BONE 6.5MM 60MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146570 SUP HCPCS C1713 48146570 - SCREW BONE 6.5MM 70MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48146580 SUP HCPCS C1713 48146580 - SCREW BONE 6.5MM 80MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147030 SUP HCPCS C1713 48147030 - SCREW BONE 7MM 30MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147035 SUP HCPCS C1713 48147035 - SCREW BONE 7MM 35MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147040 SUP HCPCS C1713 48147040 - SCREW BONE 7MM 40MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147045 SUP HCPCS C1713 48147045 - SCREW BONE 7MM 45MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147050 SUP HCPCS C1713 48147050 - SCREW BONE 7MM 50MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147055 SUP HCPCS C1713 48147055 - SCREW BONE 7MM 55MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147060 SUP HCPCS C1713 48147060 - SCREW BONE 7MM 60MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147070 SUP HCPCS C1713 48147070 - SCREW BONE 7MM 70MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147080 SUP HCPCS C1713 48147080 - SCREW BONE 7MM 80MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147530 SUP HCPCS C1713 48147530 - SCREW BONE 7.5MM 30MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147535 SUP HCPCS C1713 48147535 - SCREW BONE 7.5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147540 SUP HCPCS C1713 48147540 - SCREW BONE 7.5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147545 SUP HCPCS C1713 48147545 - SCREW BONE 7.5MM 45MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147550 SUP HCPCS C1713 48147550 - SCREW BONE 7.5MM 50MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147555 SUP HCPCS C1713 48147555 - SCREW BONE 7.5MM 55MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147560 SUP HCPCS C1713 48147560 - SCREW BONE 7.5MM 60MM POLYAX XIA TITANIUM THORACOLUMBAR SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147570 SUP HCPCS C1713 48147570 - SCREW BONE 7.5MM 70MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48147580 SUP HCPCS C1713 48147580 - SCREW BONE 7.5MM 80MM POLYAX XIA SPN 4.5MM ROD BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48200000 SUP HCPCS C1713 48200000 - BLOCKER SPINAL BLOCKER TECHTONIX LUMBAR SACRAL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 48200005 SUP Custom 27803010 48200005 - BLOCKER SPINAL 4.5MM BLOCKER TECHTONIX LUMBAR SACRAL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48200022 SUP HCPCS C1713 48200022 - PLATE BONE 22MM LEVEL 2 TECHTONIX TITANIUM SPN BOTH IP/OP "$3,306.20 " "$2,446.59" $0.00 "$2,644.96" "$1,487.79" "$1,487.79" $0.00 $0.00 $0.00 $689.09 "$2,453.86" "$2,453.86" $0.00 $0.00 $689.01 $0.00 "$1,629.96" "$1,629.96" $0.00 "$1,653.10" "$2,618.51" "$2,644.96" $0.00 $0.00 $517.42 $0.00 $0.00 $526.35 $0.00 $0.00 $0.00 $0.00 $0.00 48202234 SUP HCPCS C1713 48202234 - PLATE BONE 22-34MM LEVEL 2 TECHTONIX TITANIUM SPN BOTH IP/OP "$3,306.20 " "$2,446.59" $0.00 "$2,644.96" "$1,487.79" "$1,487.79" $0.00 $0.00 $0.00 $689.09 "$2,453.86" "$2,453.86" $0.00 $0.00 $689.01 $0.00 "$1,629.96" "$1,629.96" $0.00 "$1,653.10" "$2,618.51" "$2,644.96" $0.00 $0.00 $517.42 $0.00 $0.00 $526.35 $0.00 $0.00 $0.00 $0.00 $0.00 48202840 SUP HCPCS C1713 48202840 - PLATE BONE 28-40MM LEVEL 2 TECHTONIX TITANIUM SPN BOTH IP/OP "$3,306.20 " "$2,446.59" $0.00 "$2,644.96" "$1,487.79" "$1,487.79" $0.00 $0.00 $0.00 $689.09 "$2,453.86" "$2,453.86" $0.00 $0.00 $689.01 $0.00 "$1,629.96" "$1,629.96" $0.00 "$1,653.10" "$2,618.51" "$2,644.96" $0.00 $0.00 $517.42 $0.00 $0.00 $526.35 $0.00 $0.00 $0.00 $0.00 $0.00 48204658 SUP HCPCS C1713 48204658 - PLATE BONE 46-58MM LEVEL 2 TECHTONIX TITANIUM SPN BOTH IP/OP "$3,729.85 " "$2,760.09" $0.00 "$2,983.88" "$1,678.43" "$1,678.43" $0.00 $0.00 $0.00 $777.39 "$2,768.29" "$2,768.29" $0.00 $0.00 $777.30 $0.00 "$1,838.82" "$1,838.82" $0.00 "$1,864.93" "$2,954.04" "$2,983.88" $0.00 $0.00 $583.72 $0.00 $0.00 $593.79 $0.00 $0.00 $0.00 $0.00 $0.00 48213017 SUP Custom 27803010 48213017 - CONNECTOR ROD 17MM MONOBLOCK MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213020 SUP Custom 27803010 48213020 - CONNECTOR ROD 20MM MONOBLOCK MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213023 SUP Custom 27803010 48213023 - CONNECTOR ROD 23MM MULTIAX CROSS XIA MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213026 SUP Custom 27803010 48213026 - CONNECTOR ROD 26MM MULTIAX CROSS XIA MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213029 SUP Custom 27803010 48213029 - CONNECTOR ROD 29-31MM CROSS MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213031 SUP Custom 27803010 48213031 - CONNECTOR ROD SMALL 31-35MM MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213035 SUP Custom 27803010 48213035 - CONNECTOR ROD SMALL 35-40MM MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213038 SUP Custom 27803010 48213038 - CONNECTOR ROD STANDARD 39-43MM MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213042 SUP Custom 27803010 48213042 - CONNECTOR ROD 42MM MULTIAX CROSSLINK MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213050 SUP Custom 27803010 48213050 - CONNECTOR ROD 50MM MULTIAX CROSSLINK MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48213066 SUP Custom 27803010 48213066 - CONNECTOR ROD 67-99MM MULTIAX CROSS XIA MAC TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218030 SUP Custom 27803010 48218030 - ROD SPINAL 3.5IN RAD PREBENT 30MM XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218035 SUP Custom 27803010 48218035 - ROD SPINAL 6MM 35MM RAD XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218040 SUP Custom 27803010 48218040 - ROD SPINAL 3.5IN 40MM XIA RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218045 SUP Custom 27803010 48218045 - ROD SPINAL 4.25IN RAD 6MM 45MM RAD XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218050 SUP Custom 27803010 48218050 - ROD SPINAL 4.25IN RAD 6MM 50MM CVD XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218060 SUP Custom 27803010 48218060 - ROD SPINAL 4.25IN RAD 6MM 60MM CVD XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218070 SUP Custom 27803010 48218070 - ROD SPINAL 6MM 70MM RAD XIA RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218080 SUP Custom 27803010 48218080 - ROD SPINAL 5IN RAD 5IN 80MM XIA BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48218090 SUP Custom 27803010 48218090 - ROD SPINAL 5IN RAD PREBENT 90MM XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48219050 SUP Custom 27803010 48219050 - ROD SPNL 50MM 6MM XIA TI RAD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48219060 SUP Custom 27803010 48219060 - ROD SPNL 60MM XIA TI 2 RAD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48219070 SUP Custom 27803010 48219070 - ROD SPNL 70MM XIA MXTI 2 RAD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48219080 SUP Custom 27803010 48219080 - ROD SPNL 80MM XIA TI 2 RAD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220000 SUP Custom 27803010 48220000 - SCREW SET BUTTRESS THREAD BLOCKER XIA STAINLESS STEEL BOTH IP/OP "$2,400.00 " "$1,776.00" $0.00 "$1,920.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,781.28" "$1,781.28" $0.00 $0.00 $500.16 $0.00 $0.00 $0.00 $0.00 "$1,200.00" "$1,900.80" "$1,920.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220100 SUP HCPCS C1713 48220100 - WASHER SPINAL XIA STAINLESS STEEL THORACOLUMBAR SPN SCOLIOS BOTH IP/OP $202.18 $149.61 $0.00 $161.74 $90.98 $90.98 $0.00 $0.00 $0.00 $42.14 $150.05 $150.05 $0.00 $0.00 $42.13 $0.00 $119.59 $119.59 $0.00 $101.09 $160.13 $161.74 $0.00 $0.00 $31.64 $0.00 $0.00 $32.19 $0.00 $0.00 $0.00 $0.00 $0.00 48220101 SUP Custom 27803010 48220101 - CONNECTOR ROD OFFST XIA STAINLESS STEEL SCOLIOS BOTH IP/OP $556.50 $411.81 $0.00 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.03 $413.03 $0.00 $0.00 $115.97 $0.00 $0.00 $0.00 $0.00 $278.25 $440.75 $445.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220102 SUP Custom 27803010 48220102 - CONNECTOR ROD AXIAL OFFST XIA STAINLESS STEEL THORACOLUMBAR BOTH IP/OP "$1,001.30 " $740.96 $0.00 $801.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $743.16 $743.16 $0.00 $0.00 $208.67 $0.00 $0.00 $0.00 $0.00 $500.65 $793.03 $801.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220103 SUP Custom 27803010 48220103 - CONNECTOR ROD AXIAL OFFST XIA STAINLESS STEEL THORACOLUMBAR BOTH IP/OP "$1,001.30 " $740.96 $0.00 $801.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $743.16 $743.16 $0.00 $0.00 $208.67 $0.00 $0.00 $0.00 $0.00 $500.65 $793.03 $801.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220104 SUP HCPCS C1713 48220104 - STAPLE BONE XIA STAINLESS STEEL THORACOLUMBAR SPN SCOLIOS BOTH IP/OP $223.38 $165.30 $0.00 $178.70 $100.52 $100.52 $0.00 $0.00 $0.00 $46.56 $165.79 $165.79 $0.00 $0.00 $46.55 $0.00 $132.13 $132.13 $0.00 $111.69 $176.92 $178.70 $0.00 $0.00 $34.96 $0.00 $0.00 $35.56 $0.00 $0.00 $0.00 $0.00 $0.00 48220110 SUP HCPCS C1713 48220110 - STAPLE BONE SMALL 2 HOLE XIA STAINLESS STEEL ANTERIOR CAUDAL BOTH IP/OP "$2,133.55 " "$1,578.83" $0.00 "$1,706.84" $960.10 $960.10 $0.00 $0.00 $0.00 $444.69 "$1,583.52" "$1,583.52" $0.00 $0.00 $444.63 $0.00 "$1,261.99" "$1,261.99" $0.00 "$1,066.78" "$1,689.77" "$1,706.84" $0.00 $0.00 $333.90 $0.00 $0.00 $339.66 $0.00 $0.00 $0.00 $0.00 $0.00 48220111 SUP HCPCS C1713 48220111 - STAPLE BONE SMALL 2 HOLE XIA STAINLESS STEEL ANTERIOR BOTH IP/OP "$2,133.55 " "$1,578.83" $0.00 "$1,706.84" $960.10 $960.10 $0.00 $0.00 $0.00 $444.69 "$1,583.52" "$1,583.52" $0.00 $0.00 $444.63 $0.00 "$1,261.99" "$1,261.99" $0.00 "$1,066.78" "$1,689.77" "$1,706.84" $0.00 $0.00 $333.90 $0.00 $0.00 $339.66 $0.00 $0.00 $0.00 $0.00 $0.00 48220112 SUP HCPCS C1713 48220112 - STAPLE BONE MEDIUM 2 HOLE XIA STAINLESS STEEL ANTERIOR BOTH IP/OP "$2,133.55 " "$1,578.83" $0.00 "$1,706.84" $960.10 $960.10 $0.00 $0.00 $0.00 $444.69 "$1,583.52" "$1,583.52" $0.00 $0.00 $444.63 $0.00 "$1,261.99" "$1,261.99" $0.00 "$1,066.78" "$1,689.77" "$1,706.84" $0.00 $0.00 $333.90 $0.00 $0.00 $339.66 $0.00 $0.00 $0.00 $0.00 $0.00 48220113 SUP HCPCS C1713 48220113 - STAPLE BONE MEDIUM 2 HOLE XIA STAINLESS STEEL ANTERIOR BOTH IP/OP "$2,133.55 " "$1,578.83" $0.00 "$1,706.84" $960.10 $960.10 $0.00 $0.00 $0.00 $444.69 "$1,583.52" "$1,583.52" $0.00 $0.00 $444.63 $0.00 "$1,261.99" "$1,261.99" $0.00 "$1,066.78" "$1,689.77" "$1,706.84" $0.00 $0.00 $333.90 $0.00 $0.00 $339.66 $0.00 $0.00 $0.00 $0.00 $0.00 48220114 SUP HCPCS C1713 48220114 - STAPLE BONE LARGE 2 HOLE XIA STAINLESS STEEL ANTERIOR CAUDAL BOTH IP/OP "$2,133.55 " "$1,578.83" $0.00 "$1,706.84" $960.10 $960.10 $0.00 $0.00 $0.00 $444.69 "$1,583.52" "$1,583.52" $0.00 $0.00 $444.63 $0.00 "$1,261.99" "$1,261.99" $0.00 "$1,066.78" "$1,689.77" "$1,706.84" $0.00 $0.00 $333.90 $0.00 $0.00 $339.66 $0.00 $0.00 $0.00 $0.00 $0.00 48220115 SUP HCPCS C1713 48220115 - STAPLE BONE LARGE 2 HOLE XIA STAINLESS STEEL ANTERIOR BOTH IP/OP "$2,133.55 " "$1,578.83" $0.00 "$1,706.84" $960.10 $960.10 $0.00 $0.00 $0.00 $444.69 "$1,583.52" "$1,583.52" $0.00 $0.00 $444.63 $0.00 "$1,261.99" "$1,261.99" $0.00 "$1,066.78" "$1,689.77" "$1,706.84" $0.00 $0.00 $333.90 $0.00 $0.00 $339.66 $0.00 $0.00 $0.00 $0.00 $0.00 48220130 SUP Custom 27803010 48220130 - CONNECTOR ROD 75D OFFST XIA STAINLESS STEEL SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220131 SUP Custom 27803010 48220131 - CONNECTOR ROD OFFST STAINLESS STEEL SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220132 SUP Custom 27803010 48220132 - CONNECTOR ROD 105D OFFST XIA STAINLESS STEEL SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220133 SUP Custom 27803010 48220133 - CONNECTOR ROD NEUTRAL LONG OFFST XIA STAINLESS STEEL SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220134 SUP Custom 27803010 48220134 - CONNECTOR ROD 0D SMALL PARALLEL XIA STAINLESS STEEL SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220135 SUP Custom 27803010 48220135 - CONNECTOR ROD 30D SMALL ROD TO ROD XIA STAINLESS STEEL SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220136 SUP Custom 27803010 48220136 - CONNECTOR ROD 0D LARGE ROD TO ROD XIA STAINLESS STEEL SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220137 SUP Custom 27803010 48220137 - CONNECTOR ROD 30D LARGE ROD TO ROD XIA STAINLESS STEEL SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220200 SUP Custom 27803010 48220200 - HOOK SPINAL SMALL STANDARD LAMINATE XIA STAINLESS STEEL LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220201 SUP Custom 27803010 48220201 - HOOK SPINAL SMALL NARROW XIA STAINLESS STEEL LMNR SCOLIOS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220202 SUP Custom 27803010 48220202 - HOOK SPINAL LARGE STANDARD BLADE XIA STAINLESS STEEL LAMINA BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220203 SUP Custom 27203010 48220203 - HOOK SURG LARGE NARROW BLADE XIA STAINLESS STEEL SPINAL LMNR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220204 SUP Custom 27803010 48220204 - HOOK SPINAL EXTENDED BODY XIA STAINLESS STEEL LMNR SCOLIOS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220205 SUP Custom 27803010 48220205 - HOOK SPINAL ANGLED BLADE XIA STAINLESS STEEL LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220206 SUP Custom 27803010 48220206 - HOOK SPINAL OFFST XIA STAINLESS STEEL RIGHT LMNR SCOLIOS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220207 SUP Custom 27803010 48220207 - HOOK SPINAL OFFST XIA LEFT LMNR SCOLIOS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220208 SUP Custom 27803010 48220208 - HOOK SPINAL ANGLED BLADE XIA STAINLESS STEEL LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220210 SUP Custom 27803010 48220210 - HOOK SPINAL STANDARD BLADE XIA STAINLESS STEEL LMNR SCOLIOS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220211 SUP Custom 27803010 48220211 - HOOK SPINAL NARROW BLADE XIA STAINLESS STEEL LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220212 SUP Custom 27803010 48220212 - HOOK SPINAL SMALL RIGHT OFFST XIA STAINLESS STEEL LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220213 SUP Custom 27803010 48220213 - HOOK SPINAL SMALL LEFT OFFST XIA STAINLESS STEEL LMNR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220214 SUP Custom 27803010 48220214 - HOOK SPINAL LARGE STANDARD RIGHT OFFST XIA STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220215 SUP Custom 27803010 48220215 - HOOK SPINAL LARGE LEFT OFFST XIA STAINLESS STEEL LMNR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220220 SUP Custom 27803010 48220220 - HOOK SPINAL SMALL XIA PEDICLE SCOLIOS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220221 SUP Custom 27803010 48220221 - HOOK SPINAL LARGE XIA PEDICLE SCOLIOS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220230 SUP Custom 27803010 48220230 - HOOK SPINAL STANDARD TRNSVRS PROCESS XIA STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220231 SUP Custom 27803010 48220231 - HOOK SPINAL LEFT OFFST TRNSVRS PROCESS XIA STAINLESS STEEL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220240 SUP Custom 27203010 48220240 - HOOK RETRACTION WIDE LAMINA RBH BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220241 SUP Custom 27803010 48220241 - HOOK SPINAL WIDE BLADE RED XIA STAINLESS STEEL LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220242 SUP Custom 27203010 48220242 - HOOK RETRACTION ANGLED LP BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220243 SUP Custom 27803010 48220243 - HOOK SPINAL RED NARROW BLADE XIA TITANIUM LMNR THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220244 SUP Custom 27803010 48220244 - HOOK SPINAL RED BLADE XIA STAINLESS STEEL PEDICLE SCOLIOS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220317 SUP Custom 27803010 48220317 - CONNECTOR ROD 17MM CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220319 SUP Custom 27803010 48220319 - CONNECTOR ROD 19MM MULTIAX CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220321 SUP Custom 27803010 48220321 - CONNECTOR ROD 21MM MOMO TYPE XIA MAC STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220323 SUP Custom 27803010 48220323 - CONNECTOR ROD 23MM MULTIAX CROSS XIA STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220326 SUP Custom 27803010 48220326 - CONNECTOR ROD 26MM MOMO TYPE XIA MAC STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220329 SUP Custom 27803010 48220329 - CONNECTOR ROD 29MM MULTIAX MONO XIA STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220331 SUP Custom 27803010 48220331 - CROSSLINK SPINAL 31-34MM MULTIAX XIA STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220335 SUP Custom 27803010 48220335 - CONNECTOR ROD SMALL 35-37MM MULTIAX CROSS XIA STAINLESS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220338 SUP Custom 27803010 48220338 - CROSSLINK SPINAL 38-43MM MULTIAX XIA STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220342 SUP Custom 27803010 48220342 - CONNECTOR ROD 42-51MM MULTIAX CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220350 SUP Custom 27803010 48220350 - CONNECTOR ROD 50-67MM CROSSLINK XIA SPN SCOLIOS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48220425 SUP HCPCS C1713 48220425 - SCREW BONE 4.5MM 25MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220430 SUP HCPCS C1713 48220430 - SCREW BONE 4.5MM 30MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220435 SUP HCPCS C1713 48220435 - SCREW BONE 4.5MM 35MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220440 SUP HCPCS C1713 48220440 - SCREW BONE 4.5MM 40MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220445 SUP HCPCS C1713 48220445 - SCREW BONE 4.5MM 45MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220525 SUP HCPCS C1713 48220525 - SCREW BONE 5.5MM 25MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220530 SUP HCPCS C1713 48220530 - SCREW BONE 5.5MM 30MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48220535 SUP HCPCS C1713 48220535 - SCREW BONE 5.5MM 35MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48220540 SUP HCPCS C1713 48220540 - SCREW BONE 5.5MM 40MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48220545 SUP HCPCS C1713 48220545 - SCREW BONE 5.5MM 45MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220550 SUP HCPCS C1713 48220550 - SCREW BONE 5.5MM 50MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220555 SUP HCPCS C1713 48220555 - SCREW BONE 5.5MM 55MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220600 SUP HCPCS C1713 48220600 - SCREW BONE 6.5MM 100MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220630 SUP HCPCS C1713 48220630 - SCREW BONE 6.5MM 30MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220635 SUP HCPCS C1713 48220635 - SCREW BONE 6.5MM 35MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48220640 SUP HCPCS C1713 48220640 - SCREW BONE 6.5MM 40MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48220645 SUP HCPCS C1713 48220645 - SCREW BONE 6.5MM 45MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48220650 SUP HCPCS C1713 48220650 - SCREW BONE 6.5MM 50MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220655 SUP HCPCS C1713 48220655 - SCREW BONE 6.5MM 55MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220660 SUP HCPCS C1713 48220660 - SCREW BONE 6.5MM 60MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220670 SUP HCPCS C1713 48220670 - SCREW BONE 6.5MM 70MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220680 SUP HCPCS C1713 48220680 - SCREW BONE 6.5MM 80MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220690 SUP HCPCS C1713 48220690 - SCREW BONE 6.5MM 90MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220700 SUP HCPCS C1713 48220700 - SCREW BONE 7.5MM 100MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220730 SUP HCPCS C1713 48220730 - SCREW BONE 7.5MM 30MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220735 SUP HCPCS C1713 48220735 - SCREW BONE 7.5MM 35MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220740 SUP HCPCS C1713 48220740 - SCREW BONE 7.5MM 40MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48220745 SUP HCPCS C1713 48220745 - SCREW BONE 7.5MM 45MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48220750 SUP HCPCS C1713 48220750 - SCREW BONE 7.5MM 50MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220755 SUP HCPCS C1713 48220755 - SCREW BONE 7.5MM 55MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220760 SUP HCPCS C1713 48220760 - SCREW BONE 7.5MM 60MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220770 SUP HCPCS C1713 48220770 - SCREW BONE 7.5MM 70MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220780 SUP HCPCS C1713 48220780 - SCREW BONE 7.5MM 80MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220790 SUP HCPCS C1713 48220790 - SCREW BONE 7.5MM 90MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220800 SUP HCPCS C1713 48220800 - SCREW BONE 8.5MM 100MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220830 SUP HCPCS C1713 48220830 - SCREW BONE 8.5MM 30MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220835 SUP HCPCS C1713 48220835 - SCREW BONE 8.5MM 35MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220840 SUP HCPCS C1713 48220840 - SCREW BONE 8.5MM 40MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220845 SUP HCPCS C1713 48220845 - SCREW BONE 8.5MM 45MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220850 SUP HCPCS C1713 48220850 - SCREW BONE 8.5MM 50MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220855 SUP HCPCS C1713 48220855 - SCREW BONE 8.5MM 55MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220860 SUP HCPCS C1713 48220860 - SCREW BONE 8.5MM 60MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220870 SUP HCPCS C1713 48220870 - SCREW BONE 8.5MM 70MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220880 SUP HCPCS C1713 48220880 - SCREW BONE 8.5MM 80MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220890 SUP HCPCS C1713 48220890 - SCREW BONE 8.5MM 90MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220900 SUP HCPCS C1713 48220900 - SCREW BONE 9.5MM 100MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220960 SUP HCPCS C1713 48220960 - SCREW BONE 9.5MM 60MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220970 SUP HCPCS C1713 48220970 - SCREW BONE 9.5MM 70MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220980 SUP HCPCS C1713 48220980 - SCREW BONE 9.5MM 80MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48220990 SUP HCPCS C1713 48220990 - SCREW BONE 9.5MM 90MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 48221015 SUP Custom 27803010 48221015 - CONNECTOR ROD 15MM MULTIAX CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48221016 SUP Custom 27803010 48221016 - CONNECTOR ROD 16MM MULTIAX CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48221017 SUP Custom 27803010 48221017 - CONNECTOR ROD 17MM MULTIAX CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48221018 SUP Custom 27803010 48221018 - CONNECTOR ROD 18MM MULTIAX CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48221019 SUP Custom 27803010 48221019 - CONNECTOR ROD 19MM MULTIAX CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48221020 SUP Custom 27803010 48221020 - CONNECTOR ROD 20MM MULTIAX CROSS XIA MAC STAINLESS STEEL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48221425 SUP HCPCS C1713 48221425 - SCREW BONE 4.5MM 25MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 48221430 SUP HCPCS C1713 48221430 - SCREW BONE 4.5MM 30MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 48221435 SUP HCPCS C1713 48221435 - SCREW BONE 4.5MM 35MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 48221440 SUP HCPCS C1713 48221440 - SCREW BONE 4.5MM 40MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 48221445 SUP HCPCS C1713 48221445 - SCREW BONE 4.5MM 45MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 48221525 SUP HCPCS C1713 48221525 - SCREW BONE 5.5MM 25MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 48221530 SUP HCPCS C1713 48221530 - SCREW BONE 5.5MM 30MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 48221535 SUP HCPCS C1713 48221535 - SCREW BONE 5.5MM 35MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 48221540 SUP HCPCS C1713 48221540 - SCREW BONE 5.5MM 40MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 48221545 SUP HCPCS C1713 48221545 - SCREW BONE 5.5MM 45MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221550 SUP HCPCS C1713 48221550 - SCREW BONE 5.5MM 50MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221555 SUP HCPCS C1713 48221555 - SCREW BONE 5.5MM 55MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221600 SUP HCPCS C1713 48221600 - SCREW BONE 6.5MM 100MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221630 SUP HCPCS C1713 48221630 - SCREW BONE 6.5MM 30MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221635 SUP HCPCS C1713 48221635 - SCREW BONE 6.5MM 35MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221640 SUP HCPCS C1713 48221640 - SCREW BONE 6.5MM 40MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221645 SUP HCPCS C1713 48221645 - SCREW BONE 6.5MM 45MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221650 SUP HCPCS C1713 48221650 - SCREW BONE 6.5MM 50MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221655 SUP HCPCS C1713 48221655 - SCREW BONE 6.5MM 55MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221660 SUP HCPCS C1713 48221660 - SCREW BONE 6.5MM 60MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221670 SUP HCPCS C1713 48221670 - SCREW BONE 6.5MM 70MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221680 SUP HCPCS C1713 48221680 - SCREW BONE 6.5MM 80MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221690 SUP HCPCS C1713 48221690 - SCREW BONE 6.5MM 90MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221700 SUP HCPCS C1713 48221700 - SCREW BONE 7.5MM 100MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221730 SUP HCPCS C1713 48221730 - SCREW BONE 7.5MM 30MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221735 SUP HCPCS C1713 48221735 - SCREW BONE 7.5MM 35MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221740 SUP HCPCS C1713 48221740 - SCREW BONE 7.5MM 40MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221745 SUP HCPCS C1713 48221745 - SCREW BONE 7.5MM 45MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221750 SUP HCPCS C1713 48221750 - SCREW BONE 7.5MM 50MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221755 SUP HCPCS C1713 48221755 - SCREW BONE 7.5MM 55MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221760 SUP HCPCS C1713 48221760 - SCREW BONE 7.5MM 60MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221770 SUP HCPCS C1713 48221770 - SCREW BONE 7.5MM 70MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221780 SUP HCPCS C1713 48221780 - SCREW BONE 7.5MM 80MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48221790 SUP HCPCS C1713 48221790 - SCREW BONE 7.5MM 90MM POLYAX XIA STAINLESS STEEL SPN BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 48222000 SUP Custom 27803010 48222000 - ROD SPINAL STANDARD 5.5MM 480MM XIA STAINLESS STEEL SCOLIOS BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48222001 SUP Custom 27803010 48222001 - ROD SPINAL STANDARD 5.5MM 480MM STIFF XIA STAINLESS STEEL BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48222003 SUP Custom 27803010 48222003 - ROD SPNL 5.5MM 480MM NS XIA STF HEX SS BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48222600 SUP Custom 27803010 48222600 - ROD SPINAL STANDARD 600MM XIA STAINLESS STEEL SCOLIOS BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48222601 SUP Custom 27803010 48222601 - ROD SPINAL 600MM STIFF XIA STAINLESS STEEL SCOLIOS BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48222603 SUP Custom 27803010 48222603 - ROD SPNL 5.5MM 600MM NS XIA STF HEX SS BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48223425 SUP HCPCS C1713 48223425 - SCREW BONE 4.5MM 25MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$6,800.00 " "$5,032.00" $0.00 "$5,440.00" "$3,060.00" "$3,060.00" $0.00 $0.00 $0.00 "$1,417.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,417.12" $0.00 "$3,352.40" "$3,352.40" $0.00 "$3,400.00" "$5,385.60" "$5,440.00" $0.00 $0.00 "$1,064.20" $0.00 $0.00 "$1,082.56" $0.00 $0.00 $0.00 $0.00 $0.00 48223430 SUP HCPCS C1713 48223430 - SCREW BONE 4.5MM 30MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$10,975.00 " "$8,121.50" $0.00 "$8,780.00" "$4,938.75" "$4,938.75" $0.00 $0.00 $0.00 "$2,287.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,287.19" $0.00 "$5,410.68" "$5,410.68" $0.00 "$5,487.50" "$8,692.20" "$8,780.00" $0.00 $0.00 "$1,717.59" $0.00 $0.00 "$1,747.22" $0.00 $0.00 $0.00 $0.00 $0.00 48223435 SUP HCPCS C1713 48223435 - SCREW BONE 4.5MM 35MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223440 SUP HCPCS C1713 48223440 - SCREW BONE 4.5MM 40MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223445 SUP HCPCS C1713 48223445 - SCREW BONE 4.5MM 45MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223530 SUP HCPCS C1713 48223530 - SCREW BONE 5.5MM 30MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223535 SUP HCPCS C1713 48223535 - SCREW BONE 5.5MM 35MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223540 SUP HCPCS C1713 48223540 - SCREW BONE 5.5MM 40MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223545 SUP HCPCS C1713 48223545 - SCREW BONE 5.5MM 45MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223550 SUP HCPCS C1713 48223550 - SCREW BONE 5.5MM 50MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223630 SUP HCPCS C1713 48223630 - SCREW BONE 6.5MM 30MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223635 SUP HCPCS C1713 48223635 - SCREW BONE 6.5MM 35MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223640 SUP HCPCS C1713 48223640 - SCREW BONE 6.5MM 40MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223645 SUP HCPCS C1713 48223645 - SCREW BONE 6.5MM 45MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48223650 SUP HCPCS C1713 48223650 - SCREW BONE 6.5MM 50MM UNIPLNR XIA STAINLESS STEEL SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48227201 SUP Custom 27803010 48227201 - HOOK SPINAL LONG ARM REDX STAINLESS STEEL LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48227202 SUP Custom 27803010 48227202 - HOOK SPINAL LONG ARM REDX STAINLESS STEEL LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48227203 SUP Custom 27803010 48227203 - HOOK SPINAL LONG ARM REDX STAINLESS STEEL LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48227211 SUP Custom 27803010 48227211 - HOOK SPINAL LONG ARM REDX STAINLESS STEEL LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48227220 SUP Custom 27803010 48227220 - HOOK SPINAL REDX LONG ARM STAINLESS STEEL PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48228425 SUP HCPCS C1713 48228425 - SCREW BONE 4.5MM 25MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228430 SUP HCPCS C1713 48228430 - SCREW BONE 4.5MM 30MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228435 SUP HCPCS C1713 48228435 - SCREW BONE 4.5MM 35MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228440 SUP HCPCS C1713 48228440 - SCREW BONE 4.5MM 40MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228445 SUP HCPCS C1713 48228445 - SCREW BONE 4.5MM 45MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228530 SUP HCPCS C1713 48228530 - SCREW BONE 5.5MM 30MM REDX MNOAX LONG ARM STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228535 SUP HCPCS C1713 48228535 - SCREW BONE 5.5MM 35MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228540 SUP HCPCS C1713 48228540 - SCREW BONE 5.5MM 40MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228545 SUP HCPCS C1713 48228545 - SCREW BONE 5.5MM 45MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228550 SUP HCPCS C1713 48228550 - SCREW BONE 5.5MM 50MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228555 SUP HCPCS C1713 48228555 - SCREW BONE 5.5MM 55MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228630 SUP HCPCS C1713 48228630 - SCREW BONE 6.5MM 30MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228635 SUP HCPCS C1713 48228635 - SCREW BONE 6.5MM 35MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228640 SUP HCPCS C1713 48228640 - SCREW BONE 6.5MM 40MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228645 SUP HCPCS C1713 48228645 - SCREW BONE 6.5MM 45MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228650 SUP HCPCS C1713 48228650 - SCREW BONE 6.5MM 50MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 "$1,313.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 "$3,105.90" "$3,105.90" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 48228655 SUP HCPCS C1713 48228655 - SCREW BONE 6.5MM 55MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48228660 SUP HCPCS C1713 48228660 - SCREW BONE 6.5MM 60MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48228730 SUP HCPCS C1713 48228730 - SCREW BONE 7.5MM 30MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48228735 SUP HCPCS C1713 48228735 - SCREW BONE 7.5MM 35MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48228740 SUP HCPCS C1713 48228740 - SCREW BONE 7.5MM 40MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48228745 SUP HCPCS C1713 48228745 - SCREW BONE 7.5MM 45MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48228750 SUP HCPCS C1713 48228750 - SCREW BONE 7.5MM 50MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48228755 SUP HCPCS C1713 48228755 - SCREW BONE 7.5MM 55MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48228760 SUP HCPCS C1713 48228760 - SCREW BONE 7.5MM 60MM REDX LONG ARM MNOAX STAINLESS STEEL BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 48229425 SUP HCPCS C1713 48229425 - SCREW BONE LONG ARM 4.5MM 25MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48229430 SUP HCPCS C1713 48229430 - SCREW BONE 4.5MM 30MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229435 SUP HCPCS C1713 48229435 - SCREW BONE 4.5MM 35MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229440 SUP HCPCS C1713 48229440 - SCREW BONE 4.5MM 40MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229445 SUP HCPCS C1713 48229445 - SCREW BONE LONG ARM 4.5MM 45MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229530 SUP HCPCS C1713 48229530 - SCREW BONE 5.5MM 30MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229535 SUP HCPCS C1713 48229535 - SCREW BONE 5.5MM 35MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229540 SUP HCPCS C1713 48229540 - SCREW BONE 5.5MM 40MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229545 SUP HCPCS C1713 48229545 - SCREW BONE LONG ARM 5.5MM 45MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229550 SUP HCPCS C1713 48229550 - SCREW BONE LONG ARM 5.5MM 50MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229555 SUP HCPCS C1713 48229555 - SCREW BONE LONG ARM 5.5MM 55MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229630 SUP HCPCS C1713 48229630 - SCREW BONE 6.5MM 30MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229635 SUP HCPCS C1713 48229635 - SCREW BONE 6.5MM 35MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229640 SUP HCPCS C1713 48229640 - SCREW BONE 6.5MM 40MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229645 SUP HCPCS C1713 48229645 - SCREW BONE 6.5MM 45MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229650 SUP HCPCS C1713 48229650 - SCREW BONE 6.5MM 50MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229655 SUP HCPCS C1713 48229655 - SCREW BONE 6.5MM 55MM REDX LONG ARM POLYAX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229660 SUP HCPCS C1713 48229660 - SCREW BONE LONG ARM 6.5MM 60MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229730 SUP HCPCS C1713 48229730 - SCREW BONE LONG ARM 7.5MM 30MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229735 SUP HCPCS C1713 48229735 - SCREW BONE LONG ARM 7.5MM 35MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229740 SUP HCPCS C1713 48229740 - SCREW BONE LONG ARM 7.5MM 40MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229745 SUP HCPCS C1713 48229745 - SCREW BONE LONG ARM 7.5MM 45MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229750 SUP HCPCS C1713 48229750 - SCREW BONE LONG ARM 7.5MM 50MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229755 SUP HCPCS C1713 48229755 - SCREW BONE LONG ARM 7.5MM 55MM POLYAX REDX XIA STAINLESS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48229760 SUP HCPCS C1713 48229760 - BLOCKER SPNL XIA 3 TI SPNE BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 48230000 SUP Custom 27803010 48230000 - SCREW SET BLOCKER XIA 3 TITANIUM SPN BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230133 SUP Custom 27803010 48230133 - CONNECTOR ROD LARGE OFFST ILIAC PELVIC BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230138 SUP Custom 27803010 48230138 - CONNECTOR ROD SMALL REVISION OFFST ILIOSACRAL SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230139 SUP Custom 27803010 48230139 - CONNECTOR ROD LONG REVISION OFFST XIA 3 ILIOSACRAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230141 SUP Custom 27803010 48230141 - CONNECTOR ROD SMALL 7MM REVISION ROD TO ROD PARALLEL XIA 3 BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230143 SUP Custom 27803010 48230143 - CONNECTOR ROD REVISION J HOOK OFFST ILIOSACRAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230144 SUP Custom 27803010 48230144 - CONNECTOR ROD REVISION OFFST ILIOSACRAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230201 SUP Custom 27803010 48230201 - HOOK SPINAL NARROW BLADE XIA TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230202 SUP Custom 27803010 48230202 - HOOK SPINAL LARGE XIA TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230203 SUP Custom 27803010 48230203 - HOOK SPINAL NARROW BLADE XIA TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230204 SUP Custom 27803010 48230204 - HOOK SPINAL EXTENDED BODY XIA TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230205 SUP Custom 27803010 48230205 - HOOK SPINAL EXTENDED BODY XIA 3 TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230206 SUP Custom 27803010 48230206 - HOOK SPINAL RIGHT OFFST XIA LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230207 SUP Custom 27803010 48230207 - HOOK SPINAL LEFT OFFST XIA LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230208 SUP Custom 27803010 48230208 - HOOK SPINAL ANGLED BLADE XIA TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230209 SUP Custom 27803010 48230209 - HOOK SPINAL ANGLED BLADE XIA TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230210 SUP Custom 27803010 48230210 - HOOK SPINAL OPEN XIA THORACIC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230211 SUP Custom 27803010 48230211 - HOOK SPINAL NARROW BLADE XIA TITANIUM LMNR THORACIC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230212 SUP Custom 27803010 48230212 - HOOK SPINAL XIA RIGHT LMNR THORACIC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230213 SUP Custom 27803010 48230213 - HOOK SPINAL XIA LEFT LMNR THORACIC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230214 SUP Custom 27803010 48230214 - HOOK SPINAL LARGE OFFST XIA 3 TITANIUM RIGHT LMNR THORACIC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230215 SUP Custom 27803010 48230215 - HOOK SPINAL LARGE OFFST XIA 3 TITANIUM LEFT LMNR THORACIC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230216 SUP Custom 27803010 48230216 - HOOK SPINAL SMALL XIA TITANIUM LMNR THORACIC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230217 SUP Custom 27803010 48230217 - HOOK SPNL XIA LG TI RIGHT OFFST BOTH IP/OP "$2,687.35 " "$1,988.64" $0.00 "$2,149.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,994.55" "$1,994.55" $0.00 $0.00 $560.04 $0.00 $0.00 $0.00 $0.00 "$1,343.68" "$2,128.38" "$2,149.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230218 SUP Custom 27803010 48230218 - HOOK SPNL XIA LG TI LEFT OFFST BOTH IP/OP "$2,687.35 " "$1,988.64" $0.00 "$2,149.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,994.55" "$1,994.55" $0.00 $0.00 $560.04 $0.00 $0.00 $0.00 $0.00 "$1,343.68" "$2,128.38" "$2,149.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230220 SUP Custom 27803010 48230220 - HOOK SPINAL SMALL XIA TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230221 SUP Custom 27803010 48230221 - HOOK SPINAL MEDIUM XIA TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230222 SUP Custom 27803010 48230222 - HOOK SPINAL LARGE XIA TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230230 SUP HCPCS C1713 48230230 - WIRE FIX SHARP CANN KWIRE SPN BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48230231 SUP HCPCS C1713 48230231 - WIRE FIX BLUNT KWIRE BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48230232 SUP Custom 27803010 48230232 - HOOK SPINAL TRNSVRS PROCESS XIA TITANIUM RIGHT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230233 SUP Custom 27803010 48230233 - HOOK SPINAL TRNSVRS PROCESS XIA TITANIUM LEFT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230240 SUP Custom 27803010 48230240 - HOOK SPINAL NARROW BLADE XIA TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230241 SUP Custom 27803010 48230241 - HOOK SPINAL XIA TITANIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230250 SUP Custom 27803010 48230250 - HOOK SPINAL MEDIUM LMNR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230260 SUP Custom 27803010 48230260 - HOOK SPINAL REVISION ILIOSACRAL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48231535 SUP HCPCS C1713 48231535 - SCREW BONE 5.5MM 35MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231540 SUP HCPCS C1713 48231540 - SCREW BONE 5.5MM 40MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231545 SUP HCPCS C1713 48231545 - SCREW BONE 5.5MM 45MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231550 SUP HCPCS C1713 48231550 - SCREW BONE 5.5MM 50MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231630 SUP HCPCS C1713 48231630 - SCREW BONE 6.5MM 30MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231635 SUP HCPCS C1713 48231635 - SCREW BONE 6.5MM 35MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231640 SUP HCPCS C1713 48231640 - SCREW BONE 6.5MM 40MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231645 SUP HCPCS C1713 48231645 - SCREW BONE 6.5MM 45MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231650 SUP HCPCS C1713 48231650 - SCREW BONE 6.5MM 50MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231655 SUP HCPCS C1713 48231655 - SCREW BN 6.5MM 50MM XIA 3 PA TI SPNE THORLMBR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231730 SUP HCPCS C1713 48231730 - SCREW BONE 7.5MM 30MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231735 SUP HCPCS C1713 48231735 - SCREW BONE 7.5MM 35MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231740 SUP HCPCS C1713 48231740 - SCREW BONE 7.5MM 40MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231745 SUP HCPCS C1713 48231745 - SCREW BN 7.5MM 45MM XIA 3 PA TI SPNE THORLMBR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231750 SUP HCPCS C1713 48231750 - SCREW BONE 7.5MM 50MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48231755 SUP HCPCS C1713 48231755 - SCREW BN 7.5MM 50MM XIA CNN TI SPNE THORLMBR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 48232030 SUP Custom 27803010 48232030 - ROD SPINAL 6MM 30MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232040 SUP Custom 27803010 48232040 - ROD SPINAL 40MM XIA BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232050 SUP Custom 27803010 48232050 - ROD SPINAL 6MM 50MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232060 SUP Custom 27803010 48232060 - ROD SPINAL 6MM 60MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232070 SUP Custom 27803010 48232070 - ROD SPINAL 6MM 70MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232080 SUP Custom 27803010 48232080 - ROD SPINAL 6MM 80MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232090 SUP Custom 27803010 48232090 - ROD SPINAL 6MM 90MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232100 SUP Custom 27803010 48232100 - ROD SPINAL 6MM 100MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232110 SUP Custom 27803010 48232110 - ROD SPINAL 6MM 110MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232120 SUP Custom 27803010 48232120 - ROD SPINAL 6MM 120MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232130 SUP Custom 27803010 48232130 - ROD SPINAL 6MM 130MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232140 SUP Custom 27803010 48232140 - ROD SPINAL 6MM 140MM COMPRESSION XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232150 SUP Custom 27803010 48232150 - ROD SPINAL 6MM 30MM XIA 3 TITANIUM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232480 SUP Custom 27803010 48232480 - ROD SPINAL 6MM 480MM COMPRESSION XIA TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48232600 SUP Custom 27803010 48232600 - ROD SPINAL 6MM 600MM COMPRESSION XIA TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233030 SUP Custom 27803010 48233030 - ROD SPINAL 6MM 30MM XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233040 SUP Custom 27803010 48233040 - ROD SPINAL 6MM 40MM XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233050 SUP Custom 27803010 48233050 - ROD SPINAL 6MM 50MM XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233060 SUP Custom 27803010 48233060 - ROD SPINAL 6MM 60MM XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233070 SUP Custom 27803010 48233070 - ROD SPINAL 6MM 70MM XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233080 SUP Custom 27803010 48233080 - ROD SPINAL 6MM 80MM XIA TITANIUM ALLOY BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233090 SUP Custom 27803010 48233090 - ROD SPINAL 6MM 90MM XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233100 SUP Custom 27803010 48233100 - ROD SPINAL 100MM STR DIAPASON XIA BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233110 SUP Custom 27803010 48233110 - ROD SPINAL 110MM STR DIAPASON XIA BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233120 SUP Custom 27803010 48233120 - ROD SPINAL 6MM 120MM XIA TITANIUM ALLOY BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233130 SUP Custom 27803010 48233130 - ROD SPINAL 6MM 13MM XIA TITANIUM ALLOY BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233140 SUP Custom 27803010 48233140 - ROD SPINAL 6MM 14MM XIA TITANIUM ALLOY BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233150 SUP Custom 27803010 48233150 - ROD SPINAL 6MM 15MM XIA TITANIUM ALLOY BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233420 SUP HCPCS C1713 48233420 - SCREW BONE 4.5MM 20MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233425 SUP HCPCS C1713 48233425 - SCREW BONE 4.5MM 25MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233430 SUP HCPCS C1713 48233430 - SCREW BONE 4.5MM 30MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233435 SUP HCPCS C1713 48233435 - SCREW BONE 4.5MM 35MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233440 SUP HCPCS C1713 48233440 - SCREW BONE 4.5MM 40MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233445 SUP HCPCS C1713 48233445 - SCREW BONE 4.5MM 45MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233480 SUP HCPCS C1713 48233480 - ROD SPINAL 6MM 480MM XIA 3 BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 48233500 SUP HCPCS C1713 48233500 - SCREW SET M6 NS XIA 3 SPNE BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233520 SUP HCPCS C1713 48233520 - SCREW BONE 5.5MM 20MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233525 SUP HCPCS C1713 48233525 - SCREW BONE 5.5MM 25MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233530 SUP HCPCS C1713 48233530 - SCREW BONE 5.5MM 30MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233535 SUP HCPCS C1713 48233535 - SCREW BONE 5.5MM 35MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233540 SUP HCPCS C1713 48233540 - SCREW BONE 5.5MM 40MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233545 SUP HCPCS C1713 48233545 - SCREW BONE 5.5MM 45MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233550 SUP HCPCS C1713 48233550 - SCREW BONE 5.5MM 50MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233555 SUP HCPCS C1713 48233555 - SCREW BONE 5.5MM 55MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233600 SUP Custom 27803010 48233600 - ROD SPINAL 6MM 60MM XIA TITANIUM ALLOY BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48233625 SUP HCPCS C1713 48233625 - SCREW BONE 6.5MM 25MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233630 SUP HCPCS C1713 48233630 - SCREW BONE 6.5MM 30MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233635 SUP HCPCS C1713 48233635 - SCREW BONE 6.5MM 35MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233640 SUP HCPCS C1713 48233640 - SCREW BONE 6.5MM 40MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233645 SUP HCPCS C1713 48233645 - SCREW BONE 6.5MM 45MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233650 SUP HCPCS C1713 48233650 - SCREW BONE 6.5MM 50MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233655 SUP HCPCS C1713 48233655 - SCREW BONE 6.5MM 55MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233660 SUP HCPCS C1713 48233660 - SCREW BONE 6.5MM 60MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233730 SUP HCPCS C1713 48233730 - SCREW BONE 7.5MM 30MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233735 SUP HCPCS C1713 48233735 - SCREW BONE 7.5MM 35MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233740 SUP HCPCS C1713 48233740 - SCREW BONE 7.5MM 40MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233745 SUP HCPCS C1713 48233745 - SCREW BONE 7.5MM 45MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233750 SUP HCPCS C1713 48233750 - SCREW BONE 7.5MM 50MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233755 SUP HCPCS C1713 48233755 - SCREW BONE 7.5MM 55MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48233760 SUP HCPCS C1713 48233760 - SCREW BONE 7.5MM 60MM 2 MACHINE GROOVE UNIPLNR POLYAX XIA 3 BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48235007 SUP HCPCS C1713 48235007 - SCREW BONE REVISION SPN ILIOSACRAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 48235008 SUP Custom 27803010 48235008 - CONNECTOR ROD REVISION ILIOSACRAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48235009 SUP Custom 27803010 48235009 - CONNECTOR ROD LARGE PARALLEL 11MM XIA 3 TITANIUM SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48235010 SUP HCPCS C1713 48235010 - SCREW BONE REVISION PARALLEL ILIOSACRAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 48235011 SUP Custom 27803010 48235011 - CONNECTOR ROD REVISION ROD TO ROD PARALLEL ILIOSACRAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48235012 SUP Custom 27803010 48235012 - CONNECTOR ROD REVISION ROD TO ROD ILIOSACRAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236014 SUP Custom 27803010 48236014 - CROSSLINK SPINAL 14MM MONOBLOCK XIA TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236015 SUP Custom 27803010 48236015 - CROSSLINK SPINAL 15MM MONOBLOCK XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236016 SUP Custom 27803010 48236016 - CROSSLINK SPINAL 16MM MONOBLOCK XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236017 SUP Custom 27803010 48236017 - CROSSLINK SPINAL 17MM MONOBLOCK XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236018 SUP Custom 27803010 48236018 - CROSSLINK SPINAL 18MM MONOBLOCK XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236019 SUP Custom 27803010 48236019 - CROSSLINK SPINAL 19MM MONOBLOCK XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236020 SUP Custom 27803010 48236020 - CROSSLINK SPINAL 20MM MONOBLOCK XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236022 SUP Custom 27803010 48236022 - CROSSLINK SPINAL 22MM MONOBLOCK XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236024 SUP Custom 27803010 48236024 - CROSSLINK SPINAL 24MM MONOBLOCK XIA TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236026 SUP HCPCS C1713 48236026 - SCREW BONE 26MM MONOBLOCK SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236028 SUP Custom 27803010 48236028 - CONNECTOR ROD 28-31MM MULTIAX CROSS XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236030 SUP Custom 27803010 48236030 - CONNECTOR ROD 35-44MM XIA 3 MA CX TI THORLMBR SPNE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236035 SUP Custom 27803010 48236035 - CONNECTOR ROD 35-44MM MULTIAX CROSS XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236043 SUP Custom 27803010 48236043 - CONNECTOR ROD 70-99MM XIA 3 MA CX TI THORLMBR SPNE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236053 SUP Custom 27803010 48236053 - CONNECTOR ROD 53-73MM MULTIAX CROSS XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236070 SUP HCPCS C1713 48236070 - CONNECTOR ROD 70-99MM MULTIAX CROSS XIA 3 TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48236540 SUP HCPCS C1713 48236540 - SCREW BONE 6.5MM 40MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48236550 SUP HCPCS C1713 48236550 - SCREW BONE 6.5MM 50MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48236560 SUP HCPCS C1713 48236560 - SCREW BONE 6.5MM 60MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48237105 SUP Custom 27203010 48237105 - NEEDLE BIOP 10GA 5IN JAMSHIDI BOTH IP/OP $73.55 $54.43 $0.00 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.59 $54.59 $0.00 $0.00 $15.33 $0.00 $0.00 $0.00 $0.00 $36.78 $58.25 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48237110 SUP Custom 27203010 48237110 - BLADE SURG 10GA 9IN JAMSHIDI BOTH IP/OP $73.55 $54.43 $0.00 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.59 $54.59 $0.00 $0.00 $15.33 $0.00 $0.00 $0.00 $0.00 $36.78 $58.25 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48237115 SUP HCPCS C1713 48237115 - WIRE FIX JAMSHIDI SPN BOTH IP/OP $73.55 $54.43 $0.00 $58.84 $33.10 $33.10 $0.00 $0.00 $0.00 $15.33 $54.59 $54.59 $0.00 $0.00 $15.33 $0.00 $43.50 $43.50 $0.00 $36.78 $58.25 $58.84 $0.00 $0.00 $11.51 $0.00 $0.00 $11.71 $0.00 $0.00 $0.00 $0.00 $0.00 48237135 SUP Custom 27203010 48237135 - NEEDLE BIOP 13GA 5IN BOTH IP/OP $73.55 $54.43 $0.00 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.59 $54.59 $0.00 $0.00 $15.33 $0.00 $0.00 $0.00 $0.00 $36.78 $58.25 $58.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48237540 SUP HCPCS C1713 48237540 - SCREW BONE 7.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48237550 SUP HCPCS C1713 48237550 - SCREW BONE 7.5MM 50MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48237560 SUP HCPCS C1713 48237560 - SCREW BONE 7.5MM 60MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48238030 SUP Custom 27803010 48238030 - ROD SPINAL 6MM 30MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238035 SUP Custom 27803010 48238035 - ROD SPINAL 6MM 35MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238040 SUP Custom 27803010 48238040 - ROD SPINAL 6MM 40MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238045 SUP Custom 27803010 48238045 - ROD SPINAL 6MM 45MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238050 SUP Custom 27803010 48238050 - ROD SPINAL 6MM 50MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238060 SUP Custom 27803010 48238060 - ROD SPINAL 6MM 60MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238070 SUP Custom 27803010 48238070 - ROD SPINAL 6MM 70MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238080 SUP Custom 27803010 48238080 - ROD SPINAL 6MM 80MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238090 SUP Custom 27803010 48238090 - ROD SPINAL 6MM 90MM RADIOLUCENT XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238100 SUP Custom 27803010 48238100 - ROD SPINAL 6MM 100MM XIA 3 TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238110 SUP Custom 27803010 48238110 - ROD SPINAL 6MM 110MM XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238120 SUP Custom 27803010 48238120 - ROD SPINAL 6MM 120MM XIA TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48238540 SUP HCPCS C1713 48238540 - SCREW BONE 8.5MM 40MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48238550 SUP HCPCS C1713 48238550 - SCREW BONE 8.5MM 50MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48238560 SUP HCPCS C1713 48238560 - SCREW BONE 8.5MM 60MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48239050 SUP Custom 27803010 48239050 - ROD SPNL 50MM XIA 2 BND BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48239060 SUP Custom 27803010 48239060 - ROD SPINAL 60MM MAX XIA BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48239070 SUP Custom 27803010 48239070 - ROD SPINAL 70MM XIA MAX BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48239080 SUP Custom 27803010 48239080 - ROD SPINAL 80MM XIA MAXL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48239090 SUP Custom 27803010 48239090 - ROD SPINAL 90MM RAD MAX BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48239100 SUP Custom 27803010 48239100 - ROD SPINAL 100MM RAD XIA BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48239110 SUP Custom 27803010 48239110 - ROD SPINAL 110MM RAD XIA BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48239120 SUP Custom 27803010 48239120 - ROD SPINAL 120MM RAD XIA BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48239540 SUP HCPCS C1713 48239540 - SCREW BONE 9.5MM 40MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48239550 SUP HCPCS C1713 48239550 - SCREW BONE 9.5MM 50MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48239560 SUP HCPCS C1713 48239560 - SCREW BONE 9.5MM 60MM REVISION ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48250210 SUP Custom 27203010 48250210 - RETRACTOR FIBER OPTIC LUXOR BOTH IP/OP $597.13 $441.88 $0.00 $477.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.19 $443.19 $0.00 $0.00 $124.44 $0.00 $0.00 $0.00 $0.00 $298.56 $472.93 $477.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48251040 SUP Custom 27803010 48251040 - SLEEVE RB 40MM LUXOR SIL BOTH IP/OP $906.95 $671.14 $0.00 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.14 $673.14 $0.00 $0.00 $189.01 $0.00 $0.00 $0.00 $0.00 $453.48 $718.30 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48251050 SUP Custom 27803010 48251050 - SLEEVE RB 50MM LUXOR SIL BOTH IP/OP $906.95 $671.14 $0.00 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.14 $673.14 $0.00 $0.00 $189.01 $0.00 $0.00 $0.00 $0.00 $453.48 $718.30 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48251060 SUP Custom 27803010 48251060 - SPREADER SURG OVAL 60MM SLEEVE LUXOR SILICONE THORACOLUMBAR BOTH IP/OP $906.95 $671.14 $0.00 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.14 $673.14 $0.00 $0.00 $189.01 $0.00 $0.00 $0.00 $0.00 $453.48 $718.30 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48251070 SUP Custom 27803010 48251070 - SPREADER SURG OVAL 70MM SLEEVE LUXOR SILICONE SPN BOTH IP/OP $906.95 $671.14 $0.00 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.14 $673.14 $0.00 $0.00 $189.01 $0.00 $0.00 $0.00 $0.00 $453.48 $718.30 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48251080 SUP Custom 27803010 48251080 - SPREADER SURG OVAL 80MM SLEEVE LUXOR SILICONE SPN BOTH IP/OP $906.95 $671.14 $0.00 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.14 $673.14 $0.00 $0.00 $189.01 $0.00 $0.00 $0.00 $0.00 $453.48 $718.30 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48251090 SUP Custom 27803010 48251090 - SLEEVE RB 90MM LUXOR SIL BOTH IP/OP $906.95 $671.14 $0.00 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.14 $673.14 $0.00 $0.00 $189.01 $0.00 $0.00 $0.00 $0.00 $453.48 $718.30 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48251105 SUP Custom 27803010 48251105 - SLEEVE RB 105MM LUXOR SIL BOTH IP/OP $906.95 $671.14 $0.00 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.14 $673.14 $0.00 $0.00 $189.01 $0.00 $0.00 $0.00 $0.00 $453.48 $718.30 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48251120 SUP Custom 27803010 48251120 - SLEEVE RB 120MM LUXOR SIL BOTH IP/OP $906.95 $671.14 $0.00 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.14 $673.14 $0.00 $0.00 $189.01 $0.00 $0.00 $0.00 $0.00 $453.48 $718.30 $725.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48285425 SUP HCPCS C1713 48285425 - SCREW BONE 4.5MM 25MM CANN MANTIS SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285430 SUP HCPCS C1713 48285430 - SCREW BONE 4.5MM 30MM CANN MANTIS SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285435 SUP HCPCS C1713 48285435 - SCREW BONE 4.5MM 35MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285440 SUP HCPCS C1713 48285440 - SCREW BONE 4.5MM 40MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285445 SUP HCPCS C1713 48285445 - SCREW BONE 4.5MM 45MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285530 SUP HCPCS C1713 48285530 - SCREW BONE 5.5MM 30MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285535 SUP HCPCS C1713 48285535 - SCREW BONE 5.5MM 35MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285540 SUP HCPCS C1713 48285540 - SCREW BONE 5.5MM 40MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285545 SUP HCPCS C1713 48285545 - SCREW BONE 5.5MM 45MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285550 SUP HCPCS C1713 48285550 - SCREW BONE 5.5MM 50MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285555 SUP HCPCS C1713 48285555 - SCREW BONE 5.5MM 55MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285630 SUP HCPCS C1713 48285630 - SCREW BONE 6.5MM 30MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285635 SUP HCPCS C1713 48285635 - SCREW BONE 6.5MM 35MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285640 SUP HCPCS C1713 48285640 - SCREW BONE 6.5MM 40MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285645 SUP HCPCS C1713 48285645 - SCREW BONE 6.5MM 45MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285650 SUP HCPCS C1713 48285650 - SCREW BONE 6.5MM 50MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285655 SUP HCPCS C1713 48285655 - SCREW BONE 6.5MM 55MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285660 SUP HCPCS C1713 48285660 - SCREW BONE 6.5MM 60MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285730 SUP HCPCS C1713 48285730 - SCREW BONE 7.5MM 30MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285735 SUP HCPCS C1713 48285735 - SCREW BONE 7.5MM 35MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285740 SUP HCPCS C1713 48285740 - SCREW BONE 7.5MM 40MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285745 SUP HCPCS C1713 48285745 - SCREW BONE 7.5MM 45MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285750 SUP HCPCS C1713 48285750 - SCREW BONE 7.5MM 50MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285755 SUP HCPCS C1713 48285755 - SCREW BONE 7.5MM 55MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48285760 SUP HCPCS C1713 48285760 - SCREW BONE 7.5MM 60MM POLYAX CANN XIA MANTIS SPN PEDICLE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 48286030 SUP Custom 27803010 48286030 - ROD SPINAL 6MM 30MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286035 SUP Custom 27803010 48286035 - ROD SPINAL 6MM 35MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286040 SUP Custom 27803010 48286040 - ROD SPINAL 6MM 40MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286045 SUP Custom 27803010 48286045 - ROD SPINAL 6MM 45MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286050 SUP Custom 27803010 48286050 - ROD SPINAL 6MM 50MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286060 SUP Custom 27803010 48286060 - ROD SPINAL 6MM 60MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286070 SUP Custom 27803010 48286070 - ROD SPINAL 6MM 70MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286080 SUP Custom 27803010 48286080 - ROD SPINAL 6MM 80MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286090 SUP Custom 27803010 48286090 - ROD SPINAL 6MM 90MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286100 SUP Custom 27803010 48286100 - ROD SPINAL 6MM 100MM RAD MANTIS TITANIUM PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286110 SUP Custom 27803010 48286110 - ROD SPINAL 6MM 110MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286120 SUP Custom 27803010 48286120 - ROD SPINAL 120MM CVD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48286130 SUP Custom 27803010 48286130 - ROD SPINAL 6MM 130MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287050 SUP Custom 27803010 48287050 - ROD SPINAL 6MM 50MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287060 SUP Custom 27803010 48287060 - ROD SPINAL 6MM 60MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287070 SUP Custom 27803010 48287070 - ROD SPINAL 6MM 70MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287080 SUP Custom 27803010 48287080 - ROD SPINAL 6MM 80MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287090 SUP Custom 27803010 48287090 - ROD SPINAL 6MM 90MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287100 SUP Custom 27803010 48287100 - ROD SPINAL 6MM 100MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287110 SUP Custom 27803010 48287110 - ROD SPINAL 6MM 110MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287120 SUP Custom 27803010 48287120 - ROD SPINAL 6MM 120MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287130 SUP Custom 27803010 48287130 - ROD SPINAL 6MM 130MM RADIOPQ MANTIS PEDICLE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48287200 SUP Custom 27803010 48287200 - ROD SPINAL 6MM 200MM STR MANTIS PEDICLE BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288030 SUP Custom 27803010 48288030 - ROD SPINAL STR 6MM 30MM MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288040 SUP Custom 27803010 48288040 - ROD SPINAL STR 6MM 40MM MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288050 SUP Custom 27803010 48288050 - ROD SPINAL 6MM 50MM STR MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288060 SUP Custom 27803010 48288060 - ROD SPINAL 6MM 60MM STR MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288070 SUP Custom 27803010 48288070 - ROD SPINAL STR 6MM 70MM MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288080 SUP Custom 27803010 48288080 - ROD SPINAL STR 6MM 80MM MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288090 SUP Custom 27803010 48288090 - ROD SPINAL 6MM 90MM STR MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288100 SUP Custom 27803010 48288100 - ROD SPINAL 6MM 100MM STR MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288110 SUP Custom 27803010 48288110 - ROD SPINAL STR 6MM 110MM MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288120 SUP Custom 27803010 48288120 - ROD SPINAL 6MM 120MM STR MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288130 SUP Custom 27803010 48288130 - ROD SPINAL 6MM 130MM STR MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48288480 SUP Custom 27803010 48288480 - ROD SPINAL 6MM 480MM STR MANTIS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48290220 SUP Custom 27803010 48290220 - END CAP SPNL 20D 22MM 18MM NS VLIFT TI LMBR INTRBD FS BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48290225 SUP Custom 27803010 48290225 - ENDCAP SPINAL 25D 22MM CLOSE BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48290230 SUP Custom 27803010 48290230 - ENDCAP SPINAL 30D 22MM CLOSE BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291180 SUP Custom 27803010 48291180 - ENDCAP SPINAL 0D 18MM MODULAR OPEN SNAP EXTERIOR METAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291183 SUP Custom 27803010 48291183 - ENDCAP SPINAL 3D 18MM MODULAR OPEN SNAP EXTERIOR METAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291188 SUP Custom 27803010 48291188 - ENDCAP SPINAL 8D 18MM 118MM VLIFT BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291220 SUP Custom 27803010 48291220 - ENDCAP SPINAL 0D 22MM MODULAR OPEN SNAP EXTERIOR METAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291223 SUP Custom 27803010 48291223 - ENDCAP SPINAL 3D 22MM MODULAR OPEN SNAP EXTERIOR METAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291228 SUP Custom 27803010 48291228 - ENDCAP SPINAL 8D 22MM MODULAR OPEN SNAP EXTERIOR METAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291800 SUP HCPCS C1781 48291800 - EXTENSION STEM 18MM VLIFT BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 48291820 SUP Custom 27803010 48291820 - CAGE SPNL 18MM 20MM NS LF VLIFT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291825 SUP Custom 27803010 48291825 - CAGE SPNL 18MM 25MM NS LF VLIFT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48291832 SUP Custom 27803010 48291832 - CAGE SPNL 18MM 32MM NS LF VLIFT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48292200 SUP Custom 27803010 48292200 - EXTENSION SPNL 22MM NS LF VLIFT TI LMBR INTRBD FS BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48292215 SUP Custom 27803010 48292215 - ENDCAP SPINAL 15D 22MM MODULAR OPEN SNAP EXTERIOR METAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48292225 SUP Custom 27803010 48292225 - CAGE SPNL 22MM 25MM NS LF VLIFT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48292232 SUP Custom 27803010 48292232 - CAGE SPNL 22MM 32MM NS LF VLIFT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48292237 SUP Custom 27803010 48292237 - CAGE SPNL 22MM 37MM NS LF VLIFT TI LMBR INTRBD FS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321060 SUP Custom 27803010 48321060 - CAGE SPNL 0D 12MM RECT 14X6MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321064 SUP Custom 27803010 48321064 - CAGE SPNL 4D 12MM RECT 14X6MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321068 SUP Custom 27803010 48321068 - CAGE SPNL 8D 12MM RECT 14X6MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321070 SUP Custom 27803010 48321070 - CAGE SPNL 0D 12MM RECT 14X7MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321074 SUP Custom 27803010 48321074 - CAGE SPNL 4D 12MM RECT 14X7MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321078 SUP Custom 27803010 48321078 - CAGE SPNL 8D 12MM RECT 14X7MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321080 SUP Custom 27803010 48321080 - CAGE SPNL 0D 12MM RECT 14X8MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321084 SUP Custom 27803010 48321084 - CAGE SPNL 4D 12MM RECT 14X8MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321088 SUP Custom 27803010 48321088 - CAGE SPNL 8D 12MM RECT 14X8MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321090 SUP Custom 27803010 48321090 - CAGE SPNL 0D 12MM RECT 14X9MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321094 SUP Custom 27803010 48321094 - CAGE SPNL 4D 12MM RECT 14X9MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321098 SUP Custom 27803010 48321098 - CAGE SPNL 8D 12MM RECT 14X9MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321100 SUP Custom 27803010 48321100 - CAGE SPNL 0D 12MM RECT 14X10MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321104 SUP Custom 27803010 48321104 - CAGE SPNL 4D 12MM RECT 14X10MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321108 SUP Custom 27803010 48321108 - CAGE SPNL 8D 12MM RECT 14X10MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321110 SUP Custom 27803010 48321110 - CAGE SPNL 0D 12MM RECT 14X11MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321114 SUP Custom 27803010 48321114 - CAGE SPNL 4D 12MM RECT 14X11MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321118 SUP Custom 27803010 48321118 - CAGE SPNL 8D 12MM RECT 14X11MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321120 SUP Custom 27803010 48321120 - CAGE SPNL 0D 12MM RECT 14X12MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321124 SUP Custom 27803010 48321124 - CAGE SPNL 4D 12MM RECT 14X12MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48321128 SUP Custom 27803010 48321128 - CAGE SPNL 8D 12MM RECT 14X12MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322040 SUP Custom 27803010 48322040 - SPACER SPNL 0D 12MM 14X4MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322044 SUP Custom 27803010 48322044 - SPACER SPNL 4D 12MM 14X4MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322050 SUP Custom 27803010 48322050 - SPACER SPNL 0D 12MM 14X5MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322054 SUP Custom 27803010 48322054 - SPACER SPNL 4D 12MM 14X5MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322060 SUP Custom 27803010 48322060 - SPACER SPNL 0D 12MM 14X6MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322064 SUP Custom 27803010 48322064 - SPACER SPNL 4D 12MM 14X6MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322070 SUP Custom 27803010 48322070 - SPACER SPNL 0D 12MM 14X7MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322074 SUP Custom 27803010 48322074 - SPACER SPNL 4D 12MM 14X7MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322080 SUP Custom 27803010 48322080 - SPACER SPNL 0D 12MM 14X8MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322084 SUP Custom 27803010 48322084 - SPACER SPNL 4D 12MM 14X8MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322090 SUP Custom 27803010 48322090 - SPACER SPNL 0D 12MM 14X9MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322094 SUP Custom 27803010 48322094 - SPACER SPNL 4D 12MM 14X9MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322100 SUP Custom 27803010 48322100 - SPACER SPNL 0D 12MM 14X10MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322104 SUP Custom 27803010 48322104 - SPACER SPNL 4D 12MM 14X10MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322110 SUP Custom 27803010 48322110 - SPACER SPNL 0D 12MM 14X11MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322114 SUP Custom 27803010 48322114 - SPACER SPNL 4D 12MM 14X11MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322120 SUP Custom 27803010 48322120 - SPACER SPNL 0D 12MM 14X12MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322124 SUP Custom 27803010 48322124 - SPACER SPNL 4D 12MM 14X12MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48322204 SUP Custom 27803010 48322204 - SPACER SPNL 4D 12MM 14X20MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323060 SUP Custom 27803010 48323060 - CAGE SPNL 0D 14MM RECT 16X6MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323064 SUP Custom 27803010 48323064 - CAGE SPNL 4D 14MM RECT 16X6MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323068 SUP Custom 27803010 48323068 - CAGE SPNL 8D 14MM RECT 16X6MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323070 SUP Custom 27803010 48323070 - CAGE SPNL 0D 14MM RECT 16X7MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323074 SUP Custom 27803010 48323074 - CAGE SPNL 4D 14MM RECT 16X7MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323078 SUP Custom 27803010 48323078 - CAGE SPNL 8D 14MM RECT 16X7MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323080 SUP Custom 27803010 48323080 - CAGE SPNL 0D 14MM RECT 16X8MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323084 SUP Custom 27803010 48323084 - CAGE SPNL 4D 14MM RECT 16X8MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323088 SUP Custom 27803010 48323088 - CAGE SPNL 8D 14MM RECT 16X8MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323090 SUP Custom 27803010 48323090 - CAGE SPNL 0D 14MM RECT 16X9MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323094 SUP Custom 27803010 48323094 - CAGE SPNL 4D 14MM RECT 16X9MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323098 SUP Custom 27803010 48323098 - CAGE SPNL 8D 14MM RECT 16X9MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323100 SUP Custom 27803010 48323100 - CAGE SPNL 0D 14MM RECT 16X10MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323104 SUP Custom 27803010 48323104 - CAGE SPNL 4D 14MM RECT 16X10MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323108 SUP Custom 27803010 48323108 - CAGE SPNL 8D 14MM RECT 16X10MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323110 SUP Custom 27803010 48323110 - CAGE SPNL 0D 14MM RECT 16X11MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323114 SUP Custom 27803010 48323114 - CAGE SPNL 4D 14MM RECT 16X11MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323118 SUP Custom 27803010 48323118 - CAGE SPNL 8D 14MM RECT 16X11MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323120 SUP Custom 27803010 48323120 - CAGE SPNL 0D 14MM RECT 16X12MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323124 SUP Custom 27803010 48323124 - CAGE SPNL 4D 14MM RECT 16X12MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48323128 SUP Custom 27803010 48323128 - CAGE SPNL 8D 14MM RECT 16X12MM NS LF AVS ANCH-C RADOPQ HLW BOTH IP/OP "$3,875.00 " "$2,867.50" $0.00 "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,876.03" "$2,876.03" $0.00 $0.00 $807.55 $0.00 $0.00 $0.00 $0.00 "$1,937.50" "$3,069.00" "$3,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324040 SUP Custom 27803010 48324040 - SPACER SPNL 0D 14MM 16X4MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324044 SUP Custom 27803010 48324044 - SPACER SPNL 4D 14MM 16X4MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324050 SUP Custom 27803010 48324050 - SPACER SPNL 0D 14MM 16X5MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324054 SUP Custom 27803010 48324054 - SPACER SPNL 4D 14MM 16X5MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324060 SUP Custom 27803010 48324060 - SPACER SPNL 0D 14MM 16X6MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324064 SUP Custom 27803010 48324064 - SPACER SPNL 4D 14MM 16X6MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324070 SUP Custom 27803010 48324070 - SPACER SPNL 0D 14MM 16X7MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324074 SUP Custom 27803010 48324074 - SPACER SPNL 4D 14MM 16X7MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324080 SUP Custom 27803010 48324080 - SPACER SPNL 0D 14MM 16X8MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324084 SUP Custom 27803010 48324084 - SPACER SPNL 4D 14MM 16X8MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324090 SUP Custom 27803010 48324090 - SPACER SPNL 0D 14MM 16X9MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324094 SUP Custom 27803010 48324094 - SPACER SPNL 4D 14MM 16X9MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324100 SUP Custom 27803010 48324100 - SPACER SPNL 0D 14MM 16X10MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324104 SUP Custom 27803010 48324104 - SPACER SPNL 4D 14MM 16X10MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324110 SUP Custom 27803010 48324110 - SPACER SPNL 0D 14MM 16X11MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324114 SUP Custom 27803010 48324114 - SPACER SPNL 4D 14MM 16X11MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324120 SUP Custom 27803010 48324120 - SPACER SPNL 0D 14MM 16X12MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48324124 SUP Custom 27803010 48324124 - SPACER SPNL 4D 14MM 16X12MM AVS AS PEEK CRV INTRBD FS BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48325308 SUP HCPCS C1713 48325308 - SCREW BONE 3.5MM 8MM SPNL SLFTAP BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48325310 SUP HCPCS C1713 48325310 - SCREW BONE 3.5MM 10MM SELF TAP AVS ANCHOR-C TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48325312 SUP HCPCS C1713 48325312 - SCREW BONE 3.5MM 12MM SELF TAP AVS ANCHOR-C TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48325314 SUP HCPCS C1713 48325314 - SCREW BONE 3.5MM 14MM SPNL SLFTAP BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48325408 SUP HCPCS C1713 48325408 - SCREW BONE 4MM 8MM SPNL SLFTAP BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48325410 SUP HCPCS C1713 48325410 - SCREW BONE 4MM 10MM SELF TAP AVS ANCHOR-C TITANIUM SPN CERV BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48325412 SUP HCPCS C1713 48325412 - SCREW BONE 4MM 12MM SELF TAP AVS ANCHOR-C TITANIUM SPN CERV BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48325414 SUP HCPCS C1713 48325414 - ANCHOR-C 4.0 X 14MM SELF TAPPING SCREW BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48326084 SUP Custom 27803010 48326084 - SPACER SPNL 4D 28X22X8MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326088 SUP Custom 27803010 48326088 - SPACER SPNL 8D 28X22X8MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326104 SUP Custom 27803010 48326104 - SPACER SPNL 4D 28X22X10MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326108 SUP Custom 27803010 48326108 - SPACER SPNL 8D 28X22X10MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326122 SUP Custom 27803010 48326122 - SPACER SPNL 12D 28X22X12MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326124 SUP Custom 27803010 48326124 - SPACER SPNL 4D 28X22X12MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326126 SUP Custom 27803010 48326126 - SPACER SPNL 16D 28X22X12MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326128 SUP Custom 27803010 48326128 - SPACER SPNL 8D 28X22X12MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326142 SUP Custom 27803010 48326142 - SPACER SPNL 12D 28X22X14MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326144 SUP Custom 27803010 48326144 - SPACER SPNL 4D 28X22X14MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326146 SUP Custom 27803010 48326146 - SPACER SPNL 16D 28X22X14MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326148 SUP Custom 27803010 48326148 - SPACER SPNL 8D 28X22X14MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326162 SUP Custom 27803010 48326162 - SPACER SPNL 12D 28X22X16MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326164 SUP Custom 27803010 48326164 - SPACER SPNL 4D 28X22X16MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326166 SUP Custom 27803010 48326166 - SPACER SPNL 16D 28X22X16MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326168 SUP Custom 27803010 48326168 - SPACER SPNL 8D 28X22X16MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326182 SUP Custom 27803010 48326182 - SPACER SPNL 12D 28X22X18MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326184 SUP Custom 27803010 48326184 - SPACER SPNL 4D 28X22X18MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326186 SUP Custom 27803010 48326186 - SPACER SPNL 16D 28X22X18MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326188 SUP Custom 27803010 48326188 - SPACER SPNL 8D 28X22X18MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326202 SUP Custom 27803010 48326202 - SPACER SPNL 12D 28X22X20MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326204 SUP Custom 27803010 48326204 - SPACER SPNL 4D 28X22X20MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326206 SUP Custom 27803010 48326206 - SPACER SPNL 16D 22X28X20MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48326208 SUP Custom 27803010 48326208 - SPACER SPNL 8D 28X22X20MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328084 SUP Custom 27803010 48328084 - SPACER SPNL 4D 28X33X8MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328088 SUP Custom 27803010 48328088 - SPACER SPNL 8D 28X33X8MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328104 SUP Custom 27803010 48328104 - SPACER SPNL 4D 28X33X10MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328108 SUP Custom 27803010 48328108 - SPACER SPNL 8D 28X33X10MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328122 SUP Custom 27803010 48328122 - SPACER SPNL 12D 28X33X12MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328124 SUP Custom 27803010 48328124 - SPACER SPNL 4D 28X33X12MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328126 SUP Custom 27803010 48328126 - SPACER SPNL 16D 28X33X12MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328128 SUP Custom 27803010 48328128 - SPACER SPNL 8D 28X33X12MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328142 SUP Custom 27803010 48328142 - SPACER SPNL 12D 28X33X14MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328144 SUP Custom 27803010 48328144 - SPACER SPNL 4D 28X33X14MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328146 SUP Custom 27803010 48328146 - SPACER SPNL 16D 28X33X14MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328148 SUP Custom 27803010 48328148 - SPACER SPNL 8D 28X33X14MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328162 SUP Custom 27803010 48328162 - SPACER SPNL 12D 28X33X16MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328164 SUP Custom 27803010 48328164 - SPACER SPNL 4D 28X33X16MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328166 SUP Custom 27803010 48328166 - SPACER SPNL 16D 28X33X16MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328168 SUP Custom 27803010 48328168 - SPACER SPNL 8D 28X33X16MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328182 SUP Custom 27803010 48328182 - SPACER SPNL 12D 28X33X18MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328184 SUP Custom 27803010 48328184 - SPACER SPNL 4D 28X33X18MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328186 SUP Custom 27803010 48328186 - SPACER SPNL 16D 28X33X18MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328188 SUP Custom 27803010 48328188 - SPACER SPNL 8D 28X33X18MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328202 SUP Custom 27803010 48328202 - SPACER SPNL 12D 28X33X20MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328204 SUP Custom 27803010 48328204 - SPACER SPNL 4D 28X33X20MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328206 SUP Custom 27803010 48328206 - SPACER SPNL 16D 33X28X20MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328208 SUP Custom 27803010 48328208 - SPACER SPNL 8D 28X33X20MM AVS AL PEEK ALIF BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328908 SUP Custom 27203010 48328908 - BIT DRILL 2.3MM 8MM AVS ANCHOR-C BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328910 SUP Custom 27203010 48328910 - BIT DRILL 2.3MM 10MM AVS ANCHOR-C BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48328912 SUP Custom 27203010 48328912 - BIT DRILL 2.3MM 12MM AVS ANCHOR-C BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48335308 SUP HCPCS C1713 48335308 - ANCHOR-C 3.5 X 8MM SELF DRILLING SCREW BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48335310 SUP HCPCS C1713 48335310 - ANCHOR-C 3.5 X 10MM SELF DRILLING SCREW BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48335312 SUP HCPCS C1713 48335312 - SCREW BONE 3.5MM 12MM SPNL SLFDRILL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48335314 SUP HCPCS C1713 48335314 - SCREW BONE 3.5MM 14MM SPNL SLFDRILL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48335408 SUP HCPCS C1713 48335408 - SCREW BONE 4MM 8MM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48335410 SUP HCPCS C1713 48335410 - ANCHOR-C 4.0 X 10MM SELF DRILLING SCREW BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48335412 SUP HCPCS C1713 48335412 - SCREW BONE 4MM 12MM SPNL SLFDRILL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48335414 SUP HCPCS C1713 48335414 - SCREW BONE 4MM 14MM SPNL SLFDRILL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48340074 SUP Custom 27803010 48340074 - SPACER SPNL 4D WDG 20X9X7MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340084 SUP Custom 27803010 48340084 - SPACER SPNL 4D WDG 20X9X8MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340090 SUP Custom 27803010 48340090 - SPACER SPNL 0D RECT 20X9X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340094 SUP Custom 27803010 48340094 - SPACER SPNL 4D WDG 20X9X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340098 SUP Custom 27803010 48340098 - SPACER SPNL 8D WDG 20X9X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340100 SUP Custom 27803010 48340100 - SPACER SPNL 0D RECT 20X9X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340104 SUP Custom 27803010 48340104 - SPACER SPNL 4D WDG 20X9X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340108 SUP Custom 27803010 48340108 - SPACER SPNL 8D WDG 20X9X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340110 SUP Custom 27803010 48340110 - SPACER SPNL 0D RECT 20X9X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340114 SUP Custom 27803010 48340114 - SPACER SPNL 4D WDG 20X9X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340118 SUP Custom 27803010 48340118 - SPACER SPNL 8D WDG 20X9X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340120 SUP Custom 27803010 48340120 - SPACER SPNL 0D RECT 20X9X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340124 SUP Custom 27803010 48340124 - SPACER SPNL 4D WDG 20X9X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340128 SUP Custom 27803010 48340128 - SPACER SPNL 8D WDG 20X9X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340130 SUP Custom 27803010 48340130 - SPACER SPNL 0D RECT 20X9X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340134 SUP Custom 27803010 48340134 - SPACER SPNL 4D WDG 20X9X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340138 SUP Custom 27803010 48340138 - SPACER SPNL 8D WDG 20X9X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340140 SUP Custom 27803010 48340140 - SPACER SPNL 0D RECT 20X9X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340144 SUP Custom 27803010 48340144 - SPACER SPNL 4D WDG 20X9X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340148 SUP Custom 27803010 48340148 - SPACER SPNL 8D WDG 20X9X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340150 SUP Custom 27803010 48340150 - SPACER SPNL 0D RECT 20X9X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340154 SUP Custom 27803010 48340154 - SPACER SPNL 4D WDG 20X9X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340158 SUP Custom 27803010 48340158 - SPACER SPNL 8D WDG 20X9X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340160 SUP Custom 27803010 48340160 - SPACER SPNL 0D RECT 20X9X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340164 SUP Custom 27803010 48340164 - SPACER SPNL 4D WDG 20X9X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48340168 SUP Custom 27803010 48340168 - SPACER SPNL 8D WDG 20X9X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345074 SUP Custom 27803010 48345074 - SPACER SPNL 4D WDG 25X8X7MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345084 SUP Custom 27803010 48345084 - SPACER SPNL 4D WDG 25X8X8MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345090 SUP Custom 27803010 48345090 - SPACER SPNL 0D RECT 25X8X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345094 SUP Custom 27803010 48345094 - SPACER SPNL 4D WDG 25X8X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345098 SUP Custom 27803010 48345098 - SPACER SPNL 8D WDG 25X8X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345100 SUP Custom 27803010 48345100 - SPACER SPNL 0D RECT 25X8X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345104 SUP Custom 27803010 48345104 - SPACER SPNL 4D WDG 25X8X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345108 SUP Custom 27803010 48345108 - SPACER SPNL 8D WDG 25X8X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345110 SUP Custom 27803010 48345110 - SPACER SPNL 0D RECT 25X8X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345114 SUP Custom 27803010 48345114 - SPACER SPNL 4D WDG 25X8X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345118 SUP Custom 27803010 48345118 - SPACER SPNL 8D WDG 25X8X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345120 SUP Custom 27803010 48345120 - SPACER SPNL 0D RECT 25X8X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345124 SUP Custom 27803010 48345124 - SPACER SPNL 4D WDG 25X8X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345128 SUP Custom 27803010 48345128 - SPACER SPNL 8D WDG 25X8X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345130 SUP Custom 27803010 48345130 - SPACER SPNL 0D RECT 25X8X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345134 SUP Custom 27803010 48345134 - SPACER SPNL 4D WDG 25X8X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345138 SUP Custom 27803010 48345138 - SPACER SPNL 8D WDG 25X8X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345140 SUP Custom 27803010 48345140 - SPACER SPNL 0D RECT 25X8X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345144 SUP Custom 27803010 48345144 - SPACER SPNL 4D WDG 25X8X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345148 SUP Custom 27803010 48345148 - SPACER SPNL 8D WDG 25X8X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345150 SUP Custom 27803010 48345150 - SPACER SPNL 0D RECT 25X8X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345154 SUP Custom 27803010 48345154 - SPACER SPNL 4D WDG 25X8X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345158 SUP Custom 27803010 48345158 - SPACER SPNL 8D WDG 25X8X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345160 SUP Custom 27803010 48345160 - SPACER SPNL 0D RECT 25X8X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345164 SUP Custom 27803010 48345164 - SPACER SPNL 4D WDG 25X8X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48345168 SUP Custom 27803010 48345168 - SPACER SPNL 8D WDG 25X8X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350060 SUP Custom 27803010 48350060 - SPACER SPNL 0D WDG NOSE 20X11X6MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350064 SUP Custom 27803010 48350064 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X6MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350070 SUP Custom 27803010 48350070 - SPACER SPNL 0D WDG NOSE 20X11X7MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350074 SUP Custom 27803010 48350074 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X7MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350080 SUP Custom 27803010 48350080 - SPACER SPNL 0D WDG NOSE 20X11X8MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350084 SUP Custom 27803010 48350084 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X8MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350090 SUP Custom 27803010 48350090 - SPACER SPNL 0D RECT 20X11X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350094 SUP Custom 27803010 48350094 - SPACER SPNL 4D WDG 20X11X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350100 SUP Custom 27803010 48350100 - SPACER SPNL 0D RECT 20X11X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350104 SUP Custom 27803010 48350104 - SPACER SPNL 4D WDG 20X11X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350110 SUP Custom 27803010 48350110 - SPACER SPNL 0D RECT 20X11X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350114 SUP Custom 27803010 48350114 - SPACER SPNL 4D WDG 20X11X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350120 SUP Custom 27803010 48350120 - SPACER SPNL 0D RECT 20X11X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350124 SUP Custom 27803010 48350124 - SPACER SPNL 4D WDG 20X11X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350130 SUP Custom 27803010 48350130 - SPACER SPNL 0D RECT 20X11X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350134 SUP Custom 27803010 48350134 - SPACER SPNL 4D WDG 20X11X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350160 SUP Custom 27803010 48350160 - SPACER SPNL 0D RECT 20X11X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350164 SUP Custom 27803010 48350164 - SPACER SPNL 4D WDG 20X11X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350180 SUP Custom 27803010 48350180 - SPACER SPNL 0D RECT 20X11X18MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48350184 SUP Custom 27803010 48350184 - SPACER SPNL 4D WDG 20X11X18MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351060 SUP Custom 27803010 48351060 - SPACER SPNL 0D WDG NOSE 30X11X6MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351064 SUP Custom 27803010 48351064 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X6MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351070 SUP Custom 27803010 48351070 - SPACER SPNL 0D WDG NOSE 30X11X7MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351074 SUP Custom 27803010 48351074 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X7MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351080 SUP Custom 27803010 48351080 - SPACER SPNL 0D WDG NOSE 30X11X8MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351084 SUP Custom 27803010 48351084 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X8MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351090 SUP Custom 27803010 48351090 - SPACER SPNL 0D WDG NOSE 30X11X9MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351094 SUP Custom 27803010 48351094 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X9MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351100 SUP Custom 27803010 48351100 - SPACER SPNL 0D WDG NOSE 30X11X10MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351104 SUP Custom 27803010 48351104 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X10MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351110 SUP Custom 27803010 48351110 - SPACER SPNL 0D WDG NOSE 30X11X11MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351114 SUP Custom 27803010 48351114 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X11MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351120 SUP Custom 27803010 48351120 - SPACER SPNL 0D WDG NOSE 30X11X12MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351124 SUP Custom 27803010 48351124 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X12MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351130 SUP Custom 27803010 48351130 - SPACER SPNL 0D WDG NOSE 30X11X13MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351134 SUP Custom 27803010 48351134 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X13MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351140 SUP Custom 27803010 48351140 - SPACER SPNL 0D WDG NOSE 30X11X14MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48351144 SUP Custom 27803010 48351144 - SPACER SPNL 4D LRDTC WDG NOSE 30X11X14MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353060 SUP HCPCS C1713 48353060 - SPACER SPNL 0D WDG NOSE 33X11X6MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" "$2,475.00" "$2,475.00" $0.00 $0.00 $0.00 "$1,146.34" "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 "$2,711.50" "$2,711.50" $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $860.75 $0.00 $0.00 $875.60 $0.00 $0.00 $0.00 $0.00 $0.00 48353064 SUP Custom 27803010 48353064 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X6MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353070 SUP Custom 27803010 48353070 - SPACER SPNL 0D WDG NOSE 33X11X7MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353074 SUP Custom 27803010 48353074 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X7MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353080 SUP Custom 27803010 48353080 - SPACER SPNL 0D WDG NOSE 33X11X8MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353084 SUP Custom 27803010 48353084 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X8MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353090 SUP Custom 27803010 48353090 - SPACER SPNL 0D WDG NOSE 33X11X9MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353094 SUP Custom 27803010 48353094 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X9MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353100 SUP Custom 27803010 48353100 - SPACER SPNL 0D WDG NOSE 33X11X10MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353104 SUP Custom 27803010 48353104 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X10MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353110 SUP Custom 27803010 48353110 - SPACER SPNL 0D WDG NOSE 33X11X11MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353114 SUP Custom 27803010 48353114 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X11MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353120 SUP Custom 27803010 48353120 - SPACER SPNL 0D WDG NOSE 33X11X12MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353124 SUP Custom 27803010 48353124 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X12MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353130 SUP Custom 27803010 48353130 - SPACER SPNL 0D WDG NOSE 33X11X13MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353134 SUP Custom 27803010 48353134 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X13MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353140 SUP Custom 27803010 48353140 - SPACER SPNL 0D WDG NOSE 33X11X14MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48353144 SUP Custom 27803010 48353144 - SPACER SPNL 4D LRDTC WDG NOSE 33X11X14MM AVS UNILIF HLW BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355060 SUP Custom 27803010 48355060 - SPACER SPNL 0D WDG NOSE 25X11X6MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355064 SUP Custom 27803010 48355064 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X6MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355070 SUP Custom 27803010 48355070 - SPACER SPNL 0D WDG NOSE 25X11X7MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355074 SUP Custom 27803010 48355074 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X7MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355080 SUP Custom 27803010 48355080 - SPACER SPNL 0D WDG NOSE 25X11X8MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355084 SUP Custom 27803010 48355084 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X8MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355090 SUP Custom 27803010 48355090 - SPACER SPNL 0D RECT 25X11X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355094 SUP Custom 27803010 48355094 - SPACER SPNL 4D WDG 25X11X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355100 SUP Custom 27803010 48355100 - SPACER SPNL 0D RECT 25X11X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355104 SUP Custom 27803010 48355104 - SPACER SPNL 4D WDG 25X11X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355110 SUP Custom 27803010 48355110 - SPACER SPNL 0D RECT 25X11X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355114 SUP Custom 27803010 48355114 - SPACER SPNL 4D WDG 25X11X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355120 SUP Custom 27803010 48355120 - SPACER SPNL 0D RECT 25X11X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355124 SUP Custom 27803010 48355124 - SPACER SPNL 4D WDG 25X11X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355130 SUP Custom 27803010 48355130 - SPACER SPNL 0D RECT 25X11X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355134 SUP Custom 27803010 48355134 - SPACER SPNL 4D WDG 25X11X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355164 SUP Custom 27803010 48355164 - SPACER SPNL 4D WDG 25X11X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355180 SUP Custom 27803010 48355180 - SPACER SPNL 0D RECT 25X11X18MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48355184 SUP Custom 27803010 48355184 - SPACER SPNL 4D WDG 25X11X18MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370090 SUP Custom 27803010 48370090 - SPACER SPNL 0D PRLL 30X9MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370094 SUP Custom 27803010 48370094 - SPACER SPNL 4D WDG 30X9MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370100 SUP Custom 27803010 48370100 - SPACER SPNL 0D PRLL 30X10MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370104 SUP Custom 27803010 48370104 - SPACER SPNL 4D WDG 30X10MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370110 SUP Custom 27803010 48370110 - SPACER SPNL 0D PRLL 30X11MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370114 SUP Custom 27803010 48370114 - SPACER SPNL 4D WDG 30X11MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370120 SUP Custom 27803010 48370120 - SPACER SPNL 0D PRLL 30X12MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370124 SUP Custom 27803010 48370124 - SPACER SPNL 4D WDG 30X12MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370130 SUP Custom 27803010 48370130 - SPACER SPNL 0D PRLL 30X13MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370134 SUP Custom 27803010 48370134 - SPACER SPNL 4D WDG 30X13MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370140 SUP Custom 27803010 48370140 - SPACER SPNL 0D PRLL 30X14MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370144 SUP Custom 27803010 48370144 - SPACER SPNL 4D WDG 30X14MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370150 SUP Custom 27803010 48370150 - SPACER SPNL 0D PRLL 30X15MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370154 SUP Custom 27803010 48370154 - SPACER SPNL 4D WDG 30X15MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370160 SUP Custom 27803010 48370160 - SPACER SPNL 0D PRLL 30X16MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370164 SUP Custom 27803010 48370164 - SPACER SPNL 4D WDG 30X16MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370170 SUP Custom 27803010 48370170 - SPACER SPNL 0D PRLL 30X17MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370174 SUP Custom 27803010 48370174 - SPACER SPNL 4D WDG 30X17MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370180 SUP Custom 27803010 48370180 - SPACER SPNL 0D PRLL 30X18MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48370184 SUP Custom 27803010 48370184 - SPACER SPNL 4D WDG 30X18MM AVS TL HLW PEEK TLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375070 SUP Custom 27803010 48375070 - SPACER SPNL 0D PRLL 25X7MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375074 SUP Custom 27803010 48375074 - SPACER SPNL 4D WDG 25X7MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375080 SUP Custom 27803010 48375080 - SPACER SPNL 0D PRLL 25X8MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375084 SUP Custom 27803010 48375084 - SPACER SPNL 4D WDG 25X8MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375090 SUP Custom 27803010 48375090 - SPACER SPNL 0D PRLL 25X9MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375094 SUP Custom 27803010 48375094 - SPACER SPNL 4D WDG 25X9MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375100 SUP Custom 27803010 48375100 - SPACER SPNL 0D PRLL 25X10MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375104 SUP Custom 27803010 48375104 - SPACER SPNL 4D WDG 25X10MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375110 SUP Custom 27803010 48375110 - SPACER SPNL 0D PRLL 25X11MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375114 SUP Custom 27803010 48375114 - SPACER SPNL 4D WDG 25X11MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375120 SUP Custom 27803010 48375120 - SPACER SPNL 0D PRLL 25X12MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375124 SUP Custom 27803010 48375124 - SPACER SPNL 4D WDG 25X12MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375130 SUP Custom 27803010 48375130 - SPACER SPNL 0D PRLL 25X13MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375134 SUP Custom 27803010 48375134 - SPACER SPNL 4D WDG 25X13MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375140 SUP Custom 27803010 48375140 - SPACER SPNL 0D PRLL 25X14MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48375144 SUP Custom 27803010 48375144 - SPACER SPNL 4D WDG 25X14MM AVS TL HLW PEEK TLIF BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390090 SUP Custom 27803010 48390090 - SPACER SPNL 0D WDG NOSE 20X11X9MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390094 SUP Custom 27803010 48390094 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X9MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390101 SUP Custom 27803010 48390101 - SPACER SPNL 0D WDG NOSE 20X11X10MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390104 SUP Custom 27803010 48390104 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X10MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390111 SUP Custom 27803010 48390111 - SPACER SPNL 0D WDG NOSE 20X11X11MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390114 SUP Custom 27803010 48390114 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X11MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390120 SUP Custom 27803010 48390120 - SPACER SPNL 0D WDG NOSE 20X11X12MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390124 SUP Custom 27803010 48390124 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X12MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390130 SUP Custom 27803010 48390130 - SPACER SPNL 0D WDG NOSE 20X11X13MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390134 SUP Custom 27803010 48390134 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X13MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390140 SUP Custom 27803010 48390140 - SPACER SPNL 0D WDG NOSE 20X11X14MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390144 SUP Custom 27803010 48390144 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X14MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390150 SUP Custom 27803010 48390150 - SPACER SPNL 0D WDG NOSE 20X11X15MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390154 SUP Custom 27803010 48390154 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X15MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390160 SUP Custom 27803010 48390160 - SPACER SPNL 0D WDG NOSE 20X11X16MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390164 SUP Custom 27803010 48390164 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X16MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48390180 SUP Custom 27803010 48390180 - SPACER SPNL 0D WDG NOSE 20X11X18MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395090 SUP Custom 27803010 48395090 - SPACER SPNL 0D WDG NOSE 25X11X9MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395094 SUP Custom 27803010 48395094 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X9MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395100 SUP Custom 27803010 48395100 - SPACER SPNL 0D WDG NOSE 25X11X10MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395104 SUP Custom 27803010 48395104 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X10MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395110 SUP Custom 27803010 48395110 - SPACER SPNL 0D WDG NOSE 25X11X11MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395114 SUP Custom 27803010 48395114 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X11MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395120 SUP Custom 27803010 48395120 - SPACER SPNL 0D WDG NOSE 25X11X12MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395124 SUP Custom 27803010 48395124 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X12MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395130 SUP Custom 27803010 48395130 - SPACER SPNL 0D WDG NOSE 25X11X13MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395134 SUP Custom 27803010 48395134 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X13MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395140 SUP Custom 27803010 48395140 - SPACER SPNL 0D WDG NOSE 25X11X14MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395144 SUP Custom 27803010 48395144 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X14MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395150 SUP Custom 27803010 48395150 - SPACER SPNL 0D WDG NOSE 25X11X15MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395154 SUP Custom 27803010 48395154 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X15MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395160 SUP Custom 27803010 48395160 - SPACER SPNL 0D WDG NOSE 25X11X16MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395164 SUP Custom 27803010 48395164 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X16MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395180 SUP Custom 27803010 48395180 - SPACER SPNL 0D WDG NOSE 25X11X18MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48395184 SUP Custom 27803010 48395184 - SPACER SPNL 4D LRDTC WDG NOSE 25X11X18MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480074 SUP Custom 27803010 48480074 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X7MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480084 SUP Custom 27803010 48480084 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X8MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480090 SUP Custom 27803010 48480090 - SPACER SPNL 0D WDG NOSE 20X9X9MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480094 SUP Custom 27803010 48480094 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X9MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480100 SUP Custom 27803010 48480100 - SPACER SPNL 0D WDG NOSE 20X9X10MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480104 SUP Custom 27803010 48480104 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X10MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480110 SUP Custom 27803010 48480110 - SPACER SPNL 0D WDG NOSE 20X9X11MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480114 SUP Custom 27803010 48480114 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X11MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480120 SUP Custom 27803010 48480120 - SPACER SPNL 0D WDG NOSE 20X9X12MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480124 SUP Custom 27803010 48480124 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X12MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480130 SUP Custom 27803010 48480130 - SPACER SPNL 0D WDG NOSE 20X9X13MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480134 SUP Custom 27803010 48480134 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X13MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480140 SUP Custom 27803010 48480140 - SPACER SPNL 0D WDG NOSE 20X9X14MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480144 SUP Custom 27803010 48480144 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X14MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480150 SUP Custom 27803010 48480150 - SPACER SPNL 0D WDG NOSE 20X9X15MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480154 SUP Custom 27803010 48480154 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X15MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480160 SUP Custom 27803010 48480160 - SPACER SPNL 0D WDG NOSE 20X9X16MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48480164 SUP Custom 27803010 48480164 - SPACER SPNL 4D LRDTC WDG NOSE 20X9X16MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48482001 SUP HCPCS C1713 48482001 - SCREW BONE DIAPASON OSS LMBR SPN COMBO BOTH IP/OP $271.83 $201.15 $0.00 $217.46 $122.32 $122.32 $0.00 $0.00 $0.00 $56.66 $201.75 $201.75 $0.00 $0.00 $56.65 $0.00 $160.78 $160.78 $0.00 $135.91 $215.29 $217.46 $0.00 $0.00 $42.54 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $0.00 48482010 SUP HCPCS C1713 48482010 - CAP IMPL DIAPASON OSS BLOCKER SPNE BOTH IP/OP $271.83 $201.15 $0.00 $217.46 $122.32 $122.32 $0.00 $0.00 $0.00 $56.66 $201.75 $201.75 $0.00 $0.00 $56.65 $0.00 $160.78 $160.78 $0.00 $135.91 $215.29 $217.46 $0.00 $0.00 $42.54 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $0.00 48482020 SUP HCPCS C1713 48482020 - RING IMPL DIAPASON OSS BLOCKER SPNE BOTH IP/OP $271.83 $201.15 $0.00 $217.46 $122.32 $122.32 $0.00 $0.00 $0.00 $56.66 $201.75 $201.75 $0.00 $0.00 $56.65 $0.00 $160.78 $160.78 $0.00 $135.91 $215.29 $217.46 $0.00 $0.00 $42.54 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $0.00 48485074 SUP Custom 27803010 48485074 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X7MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485084 SUP Custom 27803010 48485084 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X8MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485090 SUP Custom 27803010 48485090 - SPACER SPNL 0D WDG NOSE 25X8X9MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485094 SUP Custom 27803010 48485094 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X9MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485100 SUP Custom 27803010 48485100 - SPACER SPNL 0D WDG NOSE 25X8X10MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485104 SUP Custom 27803010 48485104 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X10MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485110 SUP Custom 27803010 48485110 - SPACER SPNL 0D WDG NOSE 25X8X11MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485114 SUP Custom 27803010 48485114 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X11MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485120 SUP Custom 27803010 48485120 - SPACER SPNL 0D WDG NOSE 25X8X12MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485124 SUP Custom 27803010 48485124 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X12MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485130 SUP Custom 27803010 48485130 - SPACER SPNL 0D WDG NOSE 25X8X13MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485134 SUP Custom 27803010 48485134 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X13MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485140 SUP Custom 27803010 48485140 - SPACER SPNL 0D WDG NOSE 25X8X14MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485144 SUP Custom 27803010 48485144 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X14MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485150 SUP Custom 27803010 48485150 - SPACER SPNL 0D WDG NOSE 25X8X15MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485154 SUP Custom 27803010 48485154 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X15MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485160 SUP Custom 27803010 48485160 - SPACER SPNL 0D WDG NOSE 25X8X16MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485164 SUP Custom 27803010 48485164 - SPACER SPNL 4D LRDTC WDG NOSE 25X8X16MM AVS UNILIF HLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48485530 SUP HCPCS C1713 48485530 - SCREW BONE 5.5MM 30MM DIAPASON OSS THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48485535 SUP HCPCS C1713 48485535 - SCREW BONE 5.5MM 35MM DIAPASON OSS THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48485540 SUP HCPCS C1713 48485540 - SCREW BONE 5.5MM 40MM DIAPASON OSS THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48485545 SUP HCPCS C1713 48485545 - SCREW BONE 5.5MM 45MM DIAPASON OSS THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48485550 SUP HCPCS C1713 48485550 - SCREW BONE 5.5MM 50MM DIAPASON OSS THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48485555 SUP HCPCS C1713 48485555 - SCREW BONE 5.5MM 55MM DIAPASON OSS THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486730 SUP HCPCS C1713 48486730 - SCREW BONE 6.7MM 30MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486735 SUP HCPCS C1713 48486735 - SCREW BONE 6.7MM 35MM DIAPASON OSS THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486740 SUP HCPCS C1713 48486740 - SCREW BONE 6.7MM 40MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486745 SUP HCPCS C1713 48486745 - SCREW BONE 6.7MM 45MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486750 SUP HCPCS C1713 48486750 - SCREW BONE 6.7MM 50MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486755 SUP HCPCS C1713 48486755 - SCREW BONE 6.7MM 55MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486760 SUP HCPCS C1713 48486760 - SCREW BONE 6.7MM 60MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487730 SUP HCPCS C1713 48487730 - SCREW BONE 7.7MM 30MM DIAPASON OSS TI LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487735 SUP HCPCS C1713 48487735 - SCREW BONE 7.7MM 35MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487740 SUP HCPCS C1713 48487740 - SCREW BONE 7.7MM 40MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487745 SUP HCPCS C1713 48487745 - SCREW BONE 7.7MM 45MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487750 SUP HCPCS C1713 48487750 - SCREW BONE 7.7MM 50MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487755 SUP HCPCS C1713 48487755 - SCREW BONE 7.7MM 55MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487760 SUP HCPCS C1713 48487760 - SCREW BONE 7.7MM 60MM DIAPASON OSS LMBR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48488035 SUP HCPCS C1713 48488035 - SCREW BONE 8MM 35MM DIAPASON OSS SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48488040 SUP HCPCS C1713 48488040 - SCREW BONE 8MM 40MM DIAPASON OSS SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48488045 SUP HCPCS C1713 48488045 - SCREW BONE 8MM 45MM DIAPASON OSS SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48488050 SUP HCPCS C1713 48488050 - SCREW BONE 8MM 50MM DIAPASON OSS SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48488055 SUP HCPCS C1713 48488055 - SCREW BONE 8MM 55MM DIAPASON OSS SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48489040 SUP HCPCS C1713 48489040 - SCREW BONE 9MM 40MM DIAPASON OSS SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48489045 SUP HCPCS C1713 48489045 - SCREW BONE 9MM 45MM DIAPASON OSS SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48489050 SUP HCPCS C1713 48489050 - SCREW BONE 9MM 50MM DIAPASON OSS SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48489055 SUP HCPCS C1713 48489055 - SCREW BONE 9MM 55MM DIAPASON OSS TI SCRL SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48510410 SUP Custom 27203010 48510410 - PIN FIX STANDARD TEMPORARY NAIL REFLEX SPN BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48510420 SUP Custom 27203010 48510420 - PIN FIX LONG REFLEX HYBRID BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48510610 SUP HCPCS C1729 48510610 - BIT DRILL 10MM REFLEX HYBRID STERILE BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48510612 SUP Custom 27203010 48510612 - BIT DRILL 12MM REFLEX HYBRID SPN CERV ANTERIOR STERILE BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48510614 SUP Custom 27203010 48510614 - BIT DRILL 14MM REFLEX HYBRID SPN CERV ANTERIOR STERILE BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48510616 SUP Custom 27203010 48510616 - BIT DRILL 16MM REFLEX HYBRID SPN CERV ANTERIOR STERILE BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48510618 SUP HCPCS C1729 48510618 - BIT DRILL 18MM REFLEX HYBRID SPN CERV ANTERIOR STERILE BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48510620 SUP HCPCS C1729 48510620 - BIT DRILL 20MM BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $142.54 $142.54 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 48550260 SUP HCPCS C1713 48550260 - ROD SPNL 60MM 3.5MM OASYS TI BOTH IP/OP $480.48 $355.56 $0.00 $384.38 $216.21 $216.21 $0.00 $0.00 $0.00 $100.14 $356.61 $356.61 $0.00 $0.00 $100.13 $0.00 $284.20 $284.20 $0.00 $240.24 $380.54 $384.38 $0.00 $0.00 $75.19 $0.00 $0.00 $76.49 $0.00 $0.00 $0.00 $0.00 $0.00 48551000 SUP Custom 27803010 48551000 - SCREW SET BUTTRESS THREAD BLOCKER OASYS TITANIUM BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551006 SUP HCPCS C1713 48551006 - SCREW SET OASYS SPN CONCTR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48551040 SUP HCPCS C1713 48551040 - PLATE BONE 130D STR OASYS TITANIUM SPN THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551042 SUP HCPCS C1713 48551042 - PLATE BONE 100D STR OASYS TITANIUM SPN THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551044 SUP HCPCS C1713 48551044 - PLATE BONE SMALL OASYS TITANIUM SPN THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551045 SUP HCPCS C1713 48551045 - PLATE BONE MEDIUM OASYS TITANIUM SPN THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551046 SUP HCPCS C1713 48551046 - PLATE BONE LARGE OASYS TITANIUM SPN THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551047 SUP HCPCS C1713 48551047 - PLATE BONE LARGE LONG OASYS TITANIUM SPN THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551048 SUP HCPCS C1713 48551048 - PLATE BONE MINI OASYS TITANIUM SPN THORACIC OCCIPITOCERVICAL BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551049 SUP Custom 27803010 48551049 - HOOK SPINAL 3.5MM OASYS TITANIUM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551050 SUP Custom 27803010 48551050 - HOOK SPINAL SHORT 5MM OASYS TITANIUM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551053 SUP Custom 27803010 48551053 - HOOK SPINAL 6.5MM OASYS TITANIUM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551055 SUP Custom 27803010 48551055 - HOOK SPINAL STANDARD 8MM TALL OASYS TITANIUM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551060 SUP Custom 27803010 48551060 - HOOK SPINAL RIGHT OFFST OASYS TITANIUM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551065 SUP Custom 27803010 48551065 - HOOK SPINAL LEFT OFFST OASYS TITANIUM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551070 SUP Custom 27803010 48551070 - CONNECTOR ROD TRNSVRS POLYAX OASYS CROSSLINK SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551071 SUP Custom 27803010 48551071 - CONNECTOR ROD 60MM TRNSVRS SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551072 SUP Custom 27803010 48551072 - CONNECTOR ROD 40MM TRNSVRS SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551073 SUP HCPCS C1713 48551073 - PLATE BONE SMALL CROSS CONCTR OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551074 SUP Custom 27203010 48551074 - CONNECTOR ROD MEDIUM 32MM CROSS PLATE OASYS SPN NONSTRL 91 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551075 SUP HCPCS C1713 48551075 - PLATE BONE CROSS CONCTR OASYS TITANIUM SPN THORACIC BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551080 SUP Custom 27803010 48551080 - CONNECTOR ROD OFFST OASYS SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551081 SUP Custom 27803010 48551081 - CONNECTOR ROD 12MM CROSS PLATE OASYS CERV SPN NONSTRL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551084 SUP Custom 27803010 48551084 - CONNECTOR ROD 3.5-4.5MM AXIAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551085 SUP Custom 27803010 48551085 - CONNECTOR ROD 3.5/3.5MM AXIAL OASYS SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551086 SUP Custom 27803010 48551086 - CONNECTOR ROD 3.5/5.5MM AXIAL OASYS SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551087 SUP Custom 27803010 48551087 - CONNECTOR ROD 3.5/6MM AXIAL OASYS SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551088 SUP Custom 27803010 48551088 - CONNECTOR ROD 3.5/3.5MM ROD TO ROD OASYS SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551089 SUP Custom 27803010 48551089 - CONNECTOR ROD 3.5/5.5MM ROD TO ROD OASYS SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551090 SUP Custom 27803010 48551090 - CONNECTOR ROD 3.5MM 90MM POLYAX ROD TO ROD OASYS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551091 SUP Custom 27803010 48551091 - CONNECTOR ROD 3.5/4.5MM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551094 SUP Custom 27803010 48551094 - CONNECTOR ROD SADDLE SCREW OASYS SPN 3.5 MM ROD BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551240 SUP Custom 27803010 48551240 - ROD SPINAL 3.5MM 240MM OASYS BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48551350 SUP Custom 27803010 48551350 - ROD SPINAL 3.5MM 350MM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552025 SUP Custom 27803010 48552025 - ROD SPINAL 3.5MM 25MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552030 SUP Custom 27803010 48552030 - ROD SPINAL 3.5MM 30MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552040 SUP Custom 27803010 48552040 - ROD SPINAL 3.5MM 40MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552050 SUP Custom 27803010 48552050 - ROD SPINAL 3.5MM 50MM OASYS TITANIUM OCCIPITO CERVICO BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552060 SUP Custom 27803010 48552060 - ROD SPINAL 3.5MM 60MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552070 SUP Custom 27803010 48552070 - ROD SPINAL 3.5MM 70MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552080 SUP Custom 27803010 48552080 - ROD SPINAL 3.5MM 80MM OASYS TITANIUM OCCIPITOCERVICOTHORACIC BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552120 SUP Custom 27803010 48552120 - ROD SPINAL 3.5MM 120MM OASYS TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552240 SUP Custom 27803010 48552240 - ROD SPINAL 3.5MM 240MM OASYS TITANIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552310 SUP HCPCS C1713 48552310 - SCREW BONE 3.5MM 10MM BIAS ANGLE POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552312 SUP HCPCS C1713 48552312 - SCREW BONE LP 3.5MM 12MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552314 SUP HCPCS C1713 48552314 - SCREW BONE LP 3.5MM 14MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552316 SUP HCPCS C1713 48552316 - SCREW BONE LP 3.5MM 16MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552318 SUP HCPCS C1713 48552318 - SCREW BONE LP 3.5MM 18MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552320 SUP HCPCS C1713 48552320 - SCREW BONE LP 3.5MM 20MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552322 SUP HCPCS C1713 48552322 - SCREW BONE LP 3.5MM 22MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552324 SUP HCPCS C1713 48552324 - SCREW BONE LP 3.5MM 24MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552326 SUP HCPCS C1713 48552326 - SCREW BONE LP 3.5MM 26MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552328 SUP HCPCS C1713 48552328 - SCREW BONE LP 3.5MM 28MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552330 SUP HCPCS C1713 48552330 - SCREW BONE LP 3.5MM 30MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552332 SUP HCPCS C1713 48552332 - SCREW BONE LP 3.5MM 32MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552334 SUP HCPCS C1713 48552334 - SCREW BONE LP 3.5MM 34MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552336 SUP HCPCS C1713 48552336 - SCREW BONE 3.5MM 36MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552338 SUP HCPCS C1713 48552338 - SCREW BONE 3.5MM 38MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552340 SUP HCPCS C1713 48552340 - SCREW BONE 3.5MM 40MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552342 SUP HCPCS C1713 48552342 - SCREW BONE 3.5MM 42MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552344 SUP HCPCS C1713 48552344 - SCREW BONE 3.5MM 44MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552346 SUP HCPCS C1713 48552346 - SCREW BONE 3.5MM 46MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552348 SUP HCPCS C1713 48552348 - SCREW BONE 3.5MM 48MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552350 SUP HCPCS C1713 48552350 - SCREW BONE 3.5MM 50MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552352 SUP HCPCS C1713 48552352 - SCREW BONE 3.5MM 52MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552354 SUP HCPCS C1713 48552354 - SCREW BONE 3.5MM 54MM POLYAX OASYS SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552410 SUP HCPCS C1713 48552410 - SCREW BONE LP 4MM 10MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552412 SUP HCPCS C1713 48552412 - SCREW BONE LP 4MM 12MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552414 SUP HCPCS C1713 48552414 - SCREW BONE LP 4MM 14MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552416 SUP HCPCS C1713 48552416 - SCREW BONE LP 4MM 16MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552418 SUP HCPCS C1713 48552418 - SCREW BONE LP 4MM 18MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552420 SUP HCPCS C1713 48552420 - SCREW BONE LP 4MM 20MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552422 SUP HCPCS C1713 48552422 - SCREW BONE LP 4MM 22MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552424 SUP HCPCS C1713 48552424 - SCREW BONE LP 4MM 24MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552426 SUP HCPCS C1713 48552426 - SCREW BONE LP 4MM 26MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552428 SUP HCPCS C1713 48552428 - SCREW BONE LP 4MM 28MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552430 SUP HCPCS C1713 48552430 - SCREW BONE LP 4MM 30MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552432 SUP HCPCS C1713 48552432 - SCREW BONE LP 4MM 32MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552434 SUP HCPCS C1713 48552434 - SCREW BONE LP 4MM 34MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552436 SUP HCPCS C1713 48552436 - SCREW BONE LP 4MM 36MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552438 SUP HCPCS C1713 48552438 - SCREW BONE LP 4MM 38MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552440 SUP HCPCS C1713 48552440 - SCREW BONE LP 4MM 40MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552442 SUP HCPCS C1713 48552442 - SCREW BONE LP 4MM 42MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552446 SUP HCPCS C1713 48552446 - SCREW BONE LP 4MM 46MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48552450 SUP HCPCS C1713 48552450 - SCREW BONE LP 4MM 50MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48553600 SUP Custom 27803010 48553600 - ROD SPINAL 3.5-4.5MM 600MM TRANSITION OASYS TITANIUM BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48553602 SUP Custom 27803010 48553602 - ROD SPNL 3.5-4.5MM 600MM NS LF OASYS TRNS VIT BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48553604 SUP Custom 27803010 48553604 - ROD SPNL 3.5-5.5MM 600MM NS OASYS TRNS TI BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48553606 SUP Custom 27803010 48553606 - ROD SPINAL 3.5-5.5MM TRANSITION OASYS VITALLIUM BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48553608 SUP Custom 27803010 48553608 - ROD SPNL 3.5-6MM 600MM NS OASYS TRNS TI BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48553610 SUP Custom 27803010 48553610 - ROD SPINAL 3.5-6MM TRANSITION OASYS VITALLIUM BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48554306 SUP HCPCS C1713 48554306 - SCREW BONE LP 3.5MM 6MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554308 SUP HCPCS C1713 48554308 - SCREW BONE LP 3.5MM 8MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554310 SUP HCPCS C1713 48554310 - SCREW BONE LP 3.5MM 10MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554312 SUP HCPCS C1713 48554312 - SCREW BONE LP 3.5MM 12MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554314 SUP HCPCS C1713 48554314 - SCREW BONE LP 3.5MM 14MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554316 SUP HCPCS C1713 48554316 - SCREW BONE LP 3.5MM 16MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554406 SUP HCPCS C1713 48554406 - SCREW BONE LP 4MM 6MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554408 SUP HCPCS C1713 48554408 - SCREW BONE LP 4MM 8MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554410 SUP HCPCS C1713 48554410 - SCREW BONE LP 4MM 10MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554412 SUP HCPCS C1713 48554412 - SCREW BONE LP 4MM 12MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554414 SUP HCPCS C1713 48554414 - SCREW BONE LP 4MM 14MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554416 SUP HCPCS C1713 48554416 - SCREW BONE LP 4MM 16MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554506 SUP HCPCS C1713 48554506 - SCREW BONE LP 4.5MM 6MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554508 SUP HCPCS C1713 48554508 - SCREW BONE LP 4.5MM 8MM OASYS TITANIUM SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554510 SUP HCPCS C1713 48554510 - SCREW BONE 4.5MM 10MM OASYS SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554512 SUP HCPCS C1713 48554512 - SCREW BONE 4.5MM 12MM OASYS SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554514 SUP HCPCS C1713 48554514 - SCREW BONE 4.5MM 14MM OASYS SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48554516 SUP HCPCS C1713 48554516 - SCREW BONE 4.5MM 16MM OASYS SPN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 48555320 SUP HCPCS C1713 48555320 - SCREW BONE LP 3.5MM 20MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555322 SUP HCPCS C1713 48555322 - SCREW BONE LP 3.5MM 22MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555324 SUP HCPCS C1713 48555324 - SCREW BONE LP 3.5MM 24MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555328 SUP HCPCS C1713 48555328 - SCREW BONE LP 3.5MM 28MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555332 SUP HCPCS C1713 48555332 - SCREW BONE LP 3.5MM 32MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555336 SUP HCPCS C1713 48555336 - SCREW BONE LP 3.5MM 36MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555340 SUP HCPCS C1713 48555340 - SCREW BONE LP 3.5MM 40MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555420 SUP HCPCS C1713 48555420 - SCREW BONE LP 4MM 20MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555422 SUP HCPCS C1713 48555422 - SCREW BONE LP 4MM 22MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555424 SUP HCPCS C1713 48555424 - SCREW BONE LP 4MM 24MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555428 SUP HCPCS C1713 48555428 - SCREW BONE LP 4MM 28MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555432 SUP HCPCS C1713 48555432 - SCREW BONE LP 4MM 32MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555436 SUP HCPCS C1713 48555436 - SCREW BONE LP 4MM 36MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555440 SUP HCPCS C1713 48555440 - SCREW BONE LP 4MM 40MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555444 SUP HCPCS C1713 48555444 - SCREW BONE LP 4MM 44MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555448 SUP HCPCS C1713 48555448 - SCREW BONE LP 4MM 48MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48555452 SUP HCPCS C1713 48555452 - SCREW BONE LP 4MM 52MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556322 SUP HCPCS C1713 48556322 - SCREW BONE LP 3.5MM 22MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556324 SUP HCPCS C1713 48556324 - SCREW BONE LP 3.5MM 24MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556326 SUP HCPCS C1713 48556326 - SCREW BONE LP 3.5MM 26MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556328 SUP HCPCS C1713 48556328 - SCREW BONE LP 3.5MM 28MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556330 SUP HCPCS C1713 48556330 - SCREW BONE LP 3.5MM 30MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556332 SUP HCPCS C1713 48556332 - SCREW BONE LP 3.5MM 32MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556334 SUP HCPCS C1713 48556334 - SCREW BONE LP 3.5MM 34MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556336 SUP HCPCS C1713 48556336 - SCREW BONE LP 3.5MM 36MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556338 SUP HCPCS C1713 48556338 - SCREW BONE LP 3.5MM 38MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48556340 SUP HCPCS C1713 48556340 - SCREW BONE LP 3.5MM 40MM BIAS ANGLE SMOOTH SHANK OASYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557310 SUP HCPCS C1713 48557310 - SCREW BONE LP 3.5MM 10MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557312 SUP HCPCS C1713 48557312 - SCREW BONE LP 3.5MM 12MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557314 SUP HCPCS C1713 48557314 - SCREW BONE LP 3.5MM 14MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557316 SUP HCPCS C1713 48557316 - SCREW BONE LP 3.5MM 16MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557318 SUP HCPCS C1713 48557318 - SCREW BONE LP 3.5MM 18MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557320 SUP HCPCS C1713 48557320 - SCREW BONE LP 3.5MM 20MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557322 SUP HCPCS C1713 48557322 - SCREW BONE LP 3.5MM 22MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557324 SUP HCPCS C1713 48557324 - SCREW BONE LP 3.5MM 24MM BIAS ANGLE POLYAX OASYS TITANIUM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557410 SUP HCPCS C1713 48557410 - SCREW BONE LP 4MM 10MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557412 SUP HCPCS C1713 48557412 - SCREW BONE LP 4MM 12MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557414 SUP HCPCS C1713 48557414 - SCREW BONE LP 4MM 14MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557416 SUP HCPCS C1713 48557416 - SCREW BONE LP 4MM 16MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557418 SUP HCPCS C1713 48557418 - SCREW BONE LP 4MM 18MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557420 SUP HCPCS C1713 48557420 - SCREW BONE LP 4MM 20MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557422 SUP HCPCS C1713 48557422 - SCREW BONE LP 4MM 22MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48557424 SUP HCPCS C1713 48557424 - SCREW BONE LP 4MM 24MM BIAS ANGLE POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558310 SUP HCPCS C1713 48558310 - SCREW BONE LP 3.5MM 10MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558312 SUP HCPCS C1713 48558312 - SCREW BN 3.5MM 12MM FCHSA NS OASYS PA NONBIAS ANG TULIP HD BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558314 SUP HCPCS C1713 48558314 - SCREW BN 3.5MM 14MM FCHSA NS OASYS PA NONBIAS ANG TULIP HD BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558316 SUP HCPCS C1713 48558316 - SCREW BONE LP 3.5MM 16MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558318 SUP HCPCS C1713 48558318 - SCREW BONE LP 3.5MM 18MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558320 SUP HCPCS C1713 48558320 - SCREW BONE LP 3.5MM 20MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558410 SUP HCPCS C1713 48558410 - SCREW BONE LP 4MM 10MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558412 SUP HCPCS C1713 48558412 - SCREW BONE LP 4MM 12MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558414 SUP HCPCS C1713 48558414 - SCREW BONE LP 4MM 14MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558416 SUP HCPCS C1713 48558416 - SCREW BONE LP 4MM 16MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558418 SUP HCPCS C1713 48558418 - SCREW BONE LP 4MM 18MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558420 SUP HCPCS C1713 48558420 - SCREW BONE LP 4MM 20MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558520 SUP HCPCS C1713 48558520 - SCREW BONE LP 4.5MM 20MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558524 SUP HCPCS C1713 48558524 - SCREW BN 4.5MM 24MM FCHSA NS OASYS PA NONBIAS ANG TULIP HD BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558528 SUP HCPCS C1713 48558528 - SCREW BONE LP 4.5MM 28MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558532 SUP HCPCS C1713 48558532 - SCREW BONE LP 4.5MM 32MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558536 SUP HCPCS C1713 48558536 - SCREW BONE LP 4.5MM 36MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558540 SUP HCPCS C1713 48558540 - SCREW BONE LP 4.5MM 40MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558544 SUP HCPCS C1713 48558544 - SCREW BONE LP 4.5MM 44MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558548 SUP HCPCS C1713 48558548 - SCREW BONE LP 4.5MM 48MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48558552 SUP HCPCS C1713 48558552 - SCREW BONE LP 4.5MM 52MM POLYAX OASYS TITANIUM SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 48560314 SUP Custom 27803010 48560314 - TAP SPINAL 3.5MM DRILL BIT OASYS BOTH IP/OP $490.83 $363.21 $0.00 $392.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $364.29 $364.29 $0.00 $0.00 $102.29 $0.00 $0.00 $0.00 $0.00 $245.41 $388.74 $392.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48560323 SUP Custom 27203010 48560323 - BIT DRL 2.5MM 3.5MM PA SCR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48560414 SUP HCPCS C1713 48560414 - TAP SURG 4MM OASYS SPN 4MM SCREW BOTH IP/OP $490.83 $363.21 $0.00 $392.66 $220.87 $220.87 $0.00 $0.00 $0.00 $102.30 $364.29 $364.29 $0.00 $0.00 $102.29 $0.00 $290.32 $290.32 $0.00 $245.41 $388.74 $392.66 $0.00 $0.00 $76.81 $0.00 $0.00 $78.14 $0.00 $0.00 $0.00 $0.00 $0.00 48560423 SUP Custom 27203010 48560423 - DRILL SURG 3MM OASYS SPN STERILE 4MM SCREW BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48560514 SUP HCPCS C1713 48560514 - TAP SPINAL 3.5MM OASYS SPN BOTH IP/OP $425.30 $314.72 $0.00 $340.24 $191.39 $191.39 $0.00 $0.00 $0.00 $88.64 $315.66 $315.66 $0.00 $0.00 $88.63 $0.00 $251.56 $251.56 $0.00 $212.65 $336.84 $340.24 $0.00 $0.00 $66.56 $0.00 $0.00 $67.71 $0.00 $0.00 $0.00 $0.00 $0.00 48570114 SUP Custom 27203010 48570114 - BIT DRL 4MM ESCALATE LAMINOPLASTY BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48570116 SUP Custom 27203010 48570116 - DRILL SURG 6MM ESCALATE NONSTRL LAMINOPLASTY BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48570118 SUP Custom 27203010 48570118 - DRILL SURG 8MM ESCALATE NONSTRL LAMINOPLASTY BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48570204 SUP HCPCS C1713 48570204 - SCREW BONE 2MM 4MM SELF DRILL ESCALATE MAGENTA SPN CERV BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48570206 SUP HCPCS C1713 48570206 - SCREW BONE 2MM 6MM SELF DRILL ESCALATE MAGENTA SPN CERV BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48570208 SUP HCPCS C1713 48570208 - SCREW BONE 2MM 8MM SELF DRILL ESCALATE MAGENTA SPN CERV BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48570210 SUP HCPCS C1713 48570210 - ESCALATE 2.0 X 10MM SELF DRILLING SCREW BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48570240 SUP HCPCS C1713 48570240 - ESCALATE 2.4 X 10MM SELF TAPPING SCREW BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48570244 SUP HCPCS C1713 48570244 - ESCALATE 2.4 X 4MM SELF TAPPING SCREW BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48570246 SUP HCPCS C1713 48570246 - ESCALATE 2.4 X 6MM SELF TAPPING SCREW BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48570248 SUP HCPCS C1713 48570248 - ESCALATE 2.4 X 8MM SELF TAPPING SCREW BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48570300 SUP HCPCS C1713 48570300 - PLATE BONE 5MM EXPANDABLE ESCALATE TITANIUM SPN CERV NONSTRL BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 48570301 SUP HCPCS C1713 48570301 - PLATE BONE 5MM 2 HOLE BASE ESCALATE TITANIUM SPN CERV BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610112 SUP HCPCS C1713 48610112 - PLATE 12MM TI 1 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610114 SUP HCPCS C1713 48610114 - PLATE 14MM TI 1 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610116 SUP HCPCS C1713 48610116 - PLATE 16MM TI 1 LVL RFLX HB BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610118 SUP HCPCS C1713 48610118 - PLATE 18MM TI 1 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610120 SUP HCPCS C1713 48610120 - PLATE 20MM TI 1 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610122 SUP HCPCS C1713 48610122 - PLATE 22MM TI 1 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610224 SUP HCPCS C1713 48610224 - PLATE 24MM TI 2 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610226 SUP HCPCS C1713 48610226 - PLATE 26MM TI 2 LVL RFLX HB BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610228 SUP HCPCS C1713 48610228 - PLATE 28MM TI 2 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610230 SUP HCPCS C1713 48610230 - PLATE 30MM TI 2 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610232 SUP HCPCS C1713 48610232 - PLATE 32MM TI 2 LVL RFLX BONE ANT CERV BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610234 SUP HCPCS C1713 48610234 - PLATE 34MM TI 2 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610237 SUP HCPCS C1713 48610237 - PLATE 37MM TI 2 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610240 SUP HCPCS C1713 48610240 - PLATE 40MM TI 2 LVL RFLX HB BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610243 SUP HCPCS C1713 48610243 - PLATE 43MM TI 2 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610246 SUP HCPCS C1713 48610246 - PLATE 46MM 2 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48610339 SUP HCPCS C1713 48610339 - PLATE 39MM TI 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610342 SUP HCPCS C1713 48610342 - PLATE 42MM TI 3 LVL RFLX BONE ANT CERV BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610345 SUP HCPCS C1713 48610345 - PLATE 45MM TI 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610348 SUP HCPCS C1713 48610348 - PLATE 48MM 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610351 SUP HCPCS C1713 48610351 - PLATE 51MM TI 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610354 SUP HCPCS C1713 48610354 - PLATE 54MM TI 3 LVL RFLX HB BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610357 SUP HCPCS C1713 48610357 - PLATE 57MM TI 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610360 SUP HCPCS C1713 48610360 - PLATE 60MM TI 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610363 SUP HCPCS C1713 48610363 - PLATE 63MM TI 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610366 SUP HCPCS C1713 48610366 - PLATE 66MM TI 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610369 SUP HCPCS C1713 48610369 - PLATE 69MM TI 3 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610460 SUP HCPCS C1713 48610460 - PLATE 60MM TI 4 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610464 SUP HCPCS C1713 48610464 - PLATE 64MM TI 4 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610468 SUP HCPCS C1713 48610468 - PLATE 68MM TI 4 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610472 SUP HCPCS C1713 48610472 - PLATE 72MM TI 4 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610476 SUP HCPCS C1713 48610476 - PLATE 76MM TI 4 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610480 SUP HCPCS C1713 48610480 - PLATE 80MM TI 4 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48610484 SUP HCPCS C1713 48610484 - PLATE 84MM TI 4 LVL RFLX BONE ANT CERV SPN BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 48624010 SUP HCPCS C1713 48624010 - SCREW BONE 4MM 10MM RFLX HB TI ANT CERV SPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624012 SUP HCPCS C1713 48624012 - SCREW BONE 4MM 12MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624014 SUP HCPCS C1713 48624014 - SCREW BONE 4MM 14MM RFLX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624016 SUP HCPCS C1713 48624016 - SCREW BONE 4MM 16MM RFLX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624018 SUP HCPCS C1713 48624018 - SCREW BONE 4MM 18MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624020 SUP HCPCS C1713 48624020 - SCREW BONE 4MM 20MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624022 SUP HCPCS C1713 48624022 - SCREW BONE 4MM 22MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624512 SUP HCPCS C1713 48624512 - SCREW BONE 4.5MM 12MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624514 SUP HCPCS C1713 48624514 - SCREW BONE 4.5MM 14MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624516 SUP HCPCS C1713 48624516 - SCREW BONE 4.5MM 16MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624518 SUP HCPCS C1713 48624518 - SCREW BONE 4.5MM 18MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624520 SUP HCPCS C1713 48624520 - SCREW BONE 4.5MM 20MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48624522 SUP HCPCS C1713 48624522 - SCREW BONE 4.5MM 22MM RFLX TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48644010 SUP HCPCS C1713 48644010 - SCREW BONE 4MM 10MM RFLX HB TI SPNL SLFDRILL VAR ANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 48644012 SUP HCPCS C1713 48644012 - SCREW BONE 4MM 12MM VAR ANG SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48644014 SUP HCPCS C1713 48644014 - SCREW BONE 4MM 14MM VAR ANG SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48644016 SUP HCPCS C1713 48644016 - SCREW BONE 4MM 16MM VAR ANG SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48644018 SUP HCPCS C1713 48644018 - SCREW BONE 4MM 18MM VAR ANG SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48650228 SUP HCPCS C1713 48650228 - PLATE BN 28MM RFLX HB LVL 2 TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 48651112 SUP HCPCS C1713 48651112 - PLATE BONE 12MM LEVEL 1 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651114 SUP HCPCS C1713 48651114 - PLATE BN 14MM NS RFLX HB LVL 1 TI SPNE CRV ANT BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651116 SUP HCPCS C1713 48651116 - PLATE BONE 16MM LEVEL 1 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651118 SUP HCPCS C1713 48651118 - PLATE BONE 18MM LEVEL 1 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651120 SUP HCPCS C1713 48651120 - PLATE BONE 20MM LEVEL 1 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651122 SUP HCPCS C1713 48651122 - PLATE BONE 22MM LEVEL 1 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651224 SUP HCPCS C1713 48651224 - PLATE BONE 24MM LEVEL 2 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651226 SUP HCPCS C1713 48651226 - PLATE BONE 26MM LEVEL 2 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651228 SUP HCPCS C1713 48651228 - PLATE BN 28MM NS RFLX HB LVL 2 TI SPNE CRV ANT BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651230 SUP HCPCS C1713 48651230 - PLATE BONE 30MM LEVEL 2 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651232 SUP HCPCS C1713 48651232 - PLATE BN 32MM NS RFLX HB LVL 2 TI SPNE CRV ANT BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651234 SUP HCPCS C1713 48651234 - PLATE BONE 34MM LEVEL 2 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651237 SUP HCPCS C1713 48651237 - PLATE BONE 37MM 6 HOLE LEVEL 2 REFLEX HYBRID TITANIUM SPN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651240 SUP HCPCS C1713 48651240 - PLATE BONE 40MM LEVEL 2 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651243 SUP HCPCS C1713 48651243 - PLATE BONE 43MM LEVEL 2 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651246 SUP HCPCS C1713 48651246 - PLATE BONE 46MM LEVEL 2 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48651339 SUP HCPCS C1713 48651339 - PLATE BONE 39MM LEVEL 3 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651342 SUP HCPCS C1713 48651342 - PLATE BONE 42MM LEVEL 3 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651345 SUP HCPCS C1713 48651345 - PLATE BONE 45MM LEVEL 3 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651348 SUP HCPCS C1713 48651348 - PLATE BN 48MM NS RFLX HB LVL 3 TI SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651351 SUP HCPCS C1713 48651351 - PLATE BONE 51MM LEVEL 3 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651354 SUP HCPCS C1713 48651354 - PLATE BONE 54MM LEVEL 3 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651357 SUP HCPCS C1713 48651357 - PLATE BONE 57MM LEVEL 3 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651360 SUP HCPCS C1713 48651360 - PLATE BN 60MM NS RFLX HB LVL 3 TI SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651363 SUP HCPCS C1713 48651363 - PLATE BN 63MM RFLX HB LVL 3 TI SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651366 SUP HCPCS C1713 48651366 - PLATE BN 66MM RFLX HB LVL 3 TI SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651369 SUP HCPCS C1713 48651369 - PLATE BN 69MM RFLX HB LVL 3 TI SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651460 SUP HCPCS C1713 48651460 - PLATE BN 60MM NS RFLX HB LVL 4 TI SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651464 SUP HCPCS C1713 48651464 - PLATE BONE 64MM LEVEL 4 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651468 SUP HCPCS C1713 48651468 - PLATE BONE 68MM LEVEL 4 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651472 SUP HCPCS C1713 48651472 - PLATE BONE 72MM LEVEL 4 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651476 SUP HCPCS C1713 48651476 - PLATE BN 76MM RFLX HB LVL 4 TI SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651480 SUP HCPCS C1713 48651480 - PLATE BN 80MM RFLX HB LVL 4 TI SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651484 SUP HCPCS C1713 48651484 - PLATE BONE 84MM LEVEL 4 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651488 SUP HCPCS C1713 48651488 - PLATE BONE 88MM LEVEL 4 REFLEX HYBRID TITANIUM SPN CERV BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651492 SUP HCPCS C1713 48651492 - PLATE BN 92MM LVL 4 SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48651496 SUP HCPCS C1713 48651496 - PLATE BN 96MM LVL 4 SPNE CRV ANT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48654010 SUP HCPCS C1713 48654010 - SCREW BONE 4MM 10MM FIX ANGLE SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48654012 SUP HCPCS C1713 48654012 - SCREW BONE 4MM 12MM FIX ANGLE SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48654014 SUP HCPCS C1713 48654014 - SCREW BONE 4MM 14MM FIX ANGLE SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48654016 SUP HCPCS C1713 48654016 - SCREW BONE 4MM 16MM FIX ANGLE SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48654018 SUP HCPCS C1713 48654018 - SCREW BONE 4MM 18MM FIX ANGLE SELF DRILL DYNATRAN REFLEX BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48660112 SUP HCPCS C1713 48660112 - PLATE 12MM 1 LVL ZERO PRFL ACP BONE ANT CERV SPN BOTH IP/OP "$4,263.88 " "$3,155.27" $0.00 "$3,411.10" "$1,918.74" "$1,918.74" $0.00 $0.00 $0.00 $888.70 "$3,164.65" "$3,164.65" $0.00 $0.00 $888.59 $0.00 "$2,102.09" "$2,102.09" $0.00 "$2,131.94" "$3,376.99" "$3,411.10" $0.00 $0.00 $667.30 $0.00 $0.00 $678.81 $0.00 $0.00 $0.00 $0.00 $0.00 48660114 SUP HCPCS C1713 48660114 - PLATE 14MM 1 LVL BONE BOTH IP/OP "$4,263.88 " "$3,155.27" $0.00 "$3,411.10" "$1,918.74" "$1,918.74" $0.00 $0.00 $0.00 $888.70 "$3,164.65" "$3,164.65" $0.00 $0.00 $888.59 $0.00 "$2,102.09" "$2,102.09" $0.00 "$2,131.94" "$3,376.99" "$3,411.10" $0.00 $0.00 $667.30 $0.00 $0.00 $678.81 $0.00 $0.00 $0.00 $0.00 $0.00 48660116 SUP HCPCS C1713 48660116 - PLATE 16MM ZERO PRFL ACP BONE ANT CERV SPN BOTH IP/OP "$4,263.88 " "$3,155.27" $0.00 "$3,411.10" "$1,918.74" "$1,918.74" $0.00 $0.00 $0.00 $888.70 "$3,164.65" "$3,164.65" $0.00 $0.00 $888.59 $0.00 "$2,102.09" "$2,102.09" $0.00 "$2,131.94" "$3,376.99" "$3,411.10" $0.00 $0.00 $667.30 $0.00 $0.00 $678.81 $0.00 $0.00 $0.00 $0.00 $0.00 48660118 SUP HCPCS C1713 48660118 - PLATE 18MM 1 LVL BONE ANT CERV SPN BOTH IP/OP "$4,263.88 " "$3,155.27" $0.00 "$3,411.10" "$1,918.74" "$1,918.74" $0.00 $0.00 $0.00 $888.70 "$3,164.65" "$3,164.65" $0.00 $0.00 $888.59 $0.00 "$2,102.09" "$2,102.09" $0.00 "$2,131.94" "$3,376.99" "$3,411.10" $0.00 $0.00 $667.30 $0.00 $0.00 $678.81 $0.00 $0.00 $0.00 $0.00 $0.00 48660120 SUP HCPCS C1713 48660120 - PLATE 20MM 1 LVL ZERO PRFL ACP BONE BOTH IP/OP "$4,263.88 " "$3,155.27" $0.00 "$3,411.10" "$1,918.74" "$1,918.74" $0.00 $0.00 $0.00 $888.70 "$3,164.65" "$3,164.65" $0.00 $0.00 $888.59 $0.00 "$2,102.09" "$2,102.09" $0.00 "$2,131.94" "$3,376.99" "$3,411.10" $0.00 $0.00 $667.30 $0.00 $0.00 $678.81 $0.00 $0.00 $0.00 $0.00 $0.00 48660122 SUP HCPCS C1713 48660122 - PLATE 22MM 1 LVL ACP BONE ANT CERV SPN BOTH IP/OP "$4,263.88 " "$3,155.27" $0.00 "$3,411.10" "$1,918.74" "$1,918.74" $0.00 $0.00 $0.00 $888.70 "$3,164.65" "$3,164.65" $0.00 $0.00 $888.59 $0.00 "$2,102.09" "$2,102.09" $0.00 "$2,131.94" "$3,376.99" "$3,411.10" $0.00 $0.00 $667.30 $0.00 $0.00 $678.81 $0.00 $0.00 $0.00 $0.00 $0.00 48660124 SUP HCPCS C1713 48660124 - PLATE 24MM 1 LVL ACP BONE ANT CERV SPN BOTH IP/OP "$4,263.88 " "$3,155.27" $0.00 "$3,411.10" "$1,918.74" "$1,918.74" $0.00 $0.00 $0.00 $888.70 "$3,164.65" "$3,164.65" $0.00 $0.00 $888.59 $0.00 "$2,102.09" "$2,102.09" $0.00 "$2,131.94" "$3,376.99" "$3,411.10" $0.00 $0.00 $667.30 $0.00 $0.00 $678.81 $0.00 $0.00 $0.00 $0.00 $0.00 48660224 SUP HCPCS C1713 48660224 - PLATE 24MM 2 LVL ACP BONE ANT CERV SPN BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660226 SUP HCPCS C1713 48660226 - PLATE 26MM 2 LVL ACP BONE ANT CERV SPN BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660228 SUP HCPCS C1713 48660228 - PLATE 28MM 2 LVL ACP BONE ANT CERV SPN BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660230 SUP HCPCS C1713 48660230 - PLATE 30MM 2 LVL BONE SPNL BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660232 SUP HCPCS C1713 48660232 - PLATE 32MM 2 LVL ACP BONE BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660234 SUP HCPCS C1713 48660234 - PLATE 34MM 2 LVL BONE ANT CERV SPN BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660236 SUP HCPCS C1713 48660236 - PLATE 36MM 2 LVL ACP BONE BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660238 SUP HCPCS C1713 48660238 - PLATE 38MM 2 LVL ACP BONE ANT CERV SPN BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660240 SUP HCPCS C1713 48660240 - PLATE 40MM 2 LVL ACP BONE ANT CERV SPN BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48660242 SUP HCPCS C1713 48660242 - PLATE 42MM 2 LVL ACP BONE ANT CERV SPN BOTH IP/OP "$4,477.28 " "$3,313.19" $0.00 "$3,581.82" "$2,014.77" "$2,014.77" $0.00 $0.00 $0.00 $933.18 "$3,323.03" "$3,323.03" $0.00 $0.00 $933.06 $0.00 "$2,207.30" "$2,207.30" $0.00 "$2,238.64" "$3,546.01" "$3,581.82" $0.00 $0.00 $700.69 $0.00 $0.00 $712.78 $0.00 $0.00 $0.00 $0.00 $0.00 48665030 SUP HCPCS C1713 48665030 - SCREW BN 5MM 30MM AVS ANCH-L ST SLF DRL 2 THRD LD CUT FLUT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 48667000 SUP HCPCS C1713 48667000 - ANCHOR-L LOCKING PLATE BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 48668142 SUP HCPCS C1713 48668142 - SPACER SPNL 12D RECT 28X40X14MM NS LF AVS ANCH-L RADOPQ HLW BOTH IP/OP "$9,375.00 " "$6,937.50" $0.00 "$7,500.00" "$4,218.75" "$4,218.75" $0.00 $0.00 $0.00 "$1,953.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,953.75" $0.00 "$4,621.88" "$4,621.88" $0.00 "$4,687.50" "$7,425.00" "$7,500.00" $0.00 $0.00 "$1,467.19" $0.00 $0.00 "$1,492.50" $0.00 $0.00 $0.00 $0.00 $0.00 48674010 SUP HCPCS C1713 48674010 - SCREW BONE FLUTE 4MM 10MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674012 SUP HCPCS C1713 48674012 - SCREW BONE FLUTE 4MM 12MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674014 SUP HCPCS C1713 48674014 - SCREW BONE FLUTE 4MM 14MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674016 SUP HCPCS C1713 48674016 - SCREW BONE FLUTE 4MM 16MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674018 SUP HCPCS C1713 48674018 - SCREW BONE FLUTE 4MM 18MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674020 SUP HCPCS C1713 48674020 - SCREW BONE FLUTE 4MM 20MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674512 SUP HCPCS C1713 48674512 - SCREW BONE FLUTE 4.5MM 12MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674514 SUP HCPCS C1713 48674514 - SCREW BONE FLUTE 4.5MM 14MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674516 SUP HCPCS C1713 48674516 - SCREW BONE FLUTE 4.5MM 16MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674518 SUP HCPCS C1713 48674518 - SCREW BONE FLUTE 4.5MM 18MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48674520 SUP HCPCS C1713 48674520 - SCREW BONE FLUTE 4.5MM 20MM FIX ANGLE SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694010 SUP HCPCS C1713 48694010 - SCREW BONE FLUTE 4MM 10MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694012 SUP HCPCS C1713 48694012 - SCREW BONE FLUTE 4MM 12MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694014 SUP HCPCS C1713 48694014 - SCREW BONE FLUTE 4MM 14MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694016 SUP HCPCS C1713 48694016 - SCREW BONE FLUTE 4MM 16MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694018 SUP HCPCS C1713 48694018 - SCREW BONE FLUTE 4MM 18MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694020 SUP HCPCS C1713 48694020 - SCREW BONE FLUTE 4MM 20MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694512 SUP HCPCS C1713 48694512 - SCREW BONE FLUTE 4.5MM 12MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694514 SUP HCPCS C1713 48694514 - SCREW BONE FLUTE 4.5MM 14MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694516 SUP HCPCS C1713 48694516 - SCREW BONE FLUTE 4.5MM 16MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694518 SUP HCPCS C1713 48694518 - SCREW BONE FLUTE 4.5MM 18MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48694520 SUP HCPCS C1713 48694520 - SCREW BONE FLUTE 4.5MM 20MM VAR ANG SELF TAP COLOR CODED BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48770410 SUP Custom 27203010 48770410 - PIN FIX TEMPORARY AVIATOR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48770610 SUP Custom 27203010 48770610 - BIT DRILL 10MM AVTR BOTH IP/OP $656.90 $486.11 $0.00 $525.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $487.55 $487.55 $0.00 $0.00 $136.90 $0.00 $0.00 $0.00 $0.00 $328.45 $520.26 $525.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48770612 SUP Custom 27203010 48770612 - BIT DRILL 12MM AVTR BOTH IP/OP $656.90 $486.11 $0.00 $525.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $487.55 $487.55 $0.00 $0.00 $136.90 $0.00 $0.00 $0.00 $0.00 $328.45 $520.26 $525.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48770614 SUP Custom 27203010 48770614 - BIT DRILL 14MM AVTR BOTH IP/OP $656.90 $486.11 $0.00 $525.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $487.55 $487.55 $0.00 $0.00 $136.90 $0.00 $0.00 $0.00 $0.00 $328.45 $520.26 $525.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48770616 SUP Custom 27203010 48770616 - BIT DRILL 16MM AVTR BOTH IP/OP $656.90 $486.11 $0.00 $525.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $487.55 $487.55 $0.00 $0.00 $136.90 $0.00 $0.00 $0.00 $0.00 $328.45 $520.26 $525.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48771610 SUP Custom 27203010 48771610 - BIT DRILL 2.5MM 10MM AVIATOR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48771612 SUP Custom 27203010 48771612 - BIT DRILL 2.5MM 12MM AVIATOR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48771614 SUP Custom 27203010 48771614 - BIT DRILL 2.5MM 14MM AVIATOR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48771616 SUP Custom 27203010 48771616 - BIT DRILL 2.5MM 16MM AVIATOR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48811112 SUP HCPCS C1713 48811112 - PLATE BONE 12X17.4X2.5MM LEVEL 1 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811114 SUP HCPCS C1713 48811114 - PLATE BONE 14X17.4X2.5MM LEVEL 1 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811116 SUP HCPCS C1713 48811116 - PLATE BONE 16X17.4X2.5MM LEVEL 1 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811118 SUP HCPCS C1713 48811118 - PLATE BONE 18X17.4X2.5MM LEVEL 1 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811120 SUP HCPCS C1713 48811120 - PLATE BONE 20X17.4X2.5MM LEVEL 1 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811122 SUP HCPCS C1713 48811122 - PLATE BONE 22X17.4X2.5MM LEVEL 1 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811224 SUP HCPCS C1713 48811224 - PLATE BONE 24X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811226 SUP HCPCS C1713 48811226 - PLATE BONE 26X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811228 SUP HCPCS C1713 48811228 - PLATE BONE 28X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811230 SUP HCPCS C1713 48811230 - PLATE BONE 30X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811232 SUP HCPCS C1713 48811232 - PLATE BONE 32X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811234 SUP HCPCS C1713 48811234 - PLATE BONE 34X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811237 SUP HCPCS C1713 48811237 - PLATE BONE 37X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811240 SUP HCPCS C1713 48811240 - PLATE BONE 40X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811243 SUP HCPCS C1713 48811243 - PLATE BONE 43X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811246 SUP HCPCS C1713 48811246 - PLATE BONE 46X17.4X2.5MM LEVEL 2 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 48811339 SUP HCPCS C1713 48811339 - PLATE BONE 39X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811342 SUP HCPCS C1713 48811342 - PLATE BONE 42X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811345 SUP HCPCS C1713 48811345 - PLATE BONE 45X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811348 SUP HCPCS C1713 48811348 - PLATE BONE 48X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811351 SUP HCPCS C1713 48811351 - PLATE BONE 51X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811354 SUP HCPCS C1713 48811354 - PLATE BONE 54X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811357 SUP HCPCS C1713 48811357 - PLATE BONE 57X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811360 SUP HCPCS C1713 48811360 - PLATE BONE 60X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811363 SUP HCPCS C1713 48811363 - PLATE BONE 63X17.4X2.5MM LEVEL 3 AUTO LOCK SYSTEM SPRING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811366 SUP HCPCS C1713 48811366 - PLATE BONE 66MM LEVEL 3 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811369 SUP HCPCS C1713 48811369 - PLATE BONE 69MM LEVEL 3 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811456 SUP HCPCS C1713 48811456 - PLATE BONE 56MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811460 SUP HCPCS C1713 48811460 - PLATE BONE 60MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811464 SUP HCPCS C1713 48811464 - PLATE BONE 64MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811468 SUP HCPCS C1713 48811468 - PLATE BONE 68MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811472 SUP HCPCS C1713 48811472 - PLATE BONE 72MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811476 SUP HCPCS C1713 48811476 - PLATE BONE 76MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811480 SUP HCPCS C1713 48811480 - PLATE BONE 80MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811484 SUP HCPCS C1713 48811484 - PLATE BONE 84MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811488 SUP HCPCS C1713 48811488 - PLATE BONE 88MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811492 SUP HCPCS C1713 48811492 - PLATE BONE 92MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48811496 SUP HCPCS C1713 48811496 - PLATE BONE 96MM LEVEL 4 AVIATOR SPN CERV ANTERIOR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 48814010 SUP HCPCS C1713 48814010 - SCREW BONE 4MM 10MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814012 SUP HCPCS C1713 48814012 - SCREW BONE 4MM 12MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814014 SUP HCPCS C1713 48814014 - SCREW BONE 4MM 14MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814016 SUP HCPCS C1713 48814016 - SCREW BONE 4MM 16MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814018 SUP HCPCS C1713 48814018 - SCREW BONE 4MM 18MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814512 SUP HCPCS C1713 48814512 - SCREW BONE 4.35MM 12MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814514 SUP HCPCS C1713 48814514 - SCREW BONE 4.35MM 14MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814516 SUP HCPCS C1713 48814516 - SCREW BONE 4.35MM 16MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814518 SUP HCPCS C1713 48814518 - SCREW BONE 4.35MM 18MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48814520 SUP HCPCS C1713 48814520 - SCREW BONE 4.35MM 20MM VAR ANG SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48815540 SUP HCPCS C1713 48815540 - SCREW POLYAXIAL 5.5X40MM XIA CT BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 48824010 SUP HCPCS C1713 48824010 - SCREW BONE 4MM 10MM VAR ANG SELF DRILL AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48824012 SUP HCPCS C1713 48824012 - SCREW BONE 4MM 12MM VAR ANG SELF DRILL AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48824014 SUP HCPCS C1713 48824014 - SCREW BONE 4MM 14MM VAR ANG SELF DRILL AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48824016 SUP HCPCS C1713 48824016 - SCREW BONE 4MM 16MM VAR ANG SELF DRILL AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48824018 SUP HCPCS C1713 48824018 - SCREW BONE 4MM 18MM VAR ANG SELF DRILL AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834010 SUP HCPCS C1713 48834010 - SCREW BONE 4MM 10MM FIX ANGLE SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834012 SUP HCPCS C1713 48834012 - SCREW BONE 4MM 12MM FIX ANGLE SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834014 SUP HCPCS C1713 48834014 - SCREW BONE 4MM 14MM FIX ANGLE SELF TAP AVIATOR SPN CERV BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834016 SUP HCPCS C1713 48834016 - SCREW BONE 4MM 16MM FIX ANGLE SELF TAP AVIATOR TITANIUM SPN BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834018 SUP HCPCS C1713 48834018 - SCREW BONE 4MM 18MM SPNL FIX SLFDRILL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834512 SUP HCPCS C1713 48834512 - SCREW BONE 4.35MM 12MM FIX ANGLE SELF TAP AVIATOR TITANIUM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834514 SUP HCPCS C1713 48834514 - SCREW BN 4.35MM 14MM AVTR ST FA SPNE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834516 SUP HCPCS C1713 48834516 - SCREW BONE 4.35MM 16MM FIX ANGLE SELF TAP AVIATOR TITANIUM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834518 SUP HCPCS C1713 48834518 - SCREW BONE 4.35MM 18MM SELF TAP FIX ANGLE AVIATOR SPN CERV BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48834520 SUP HCPCS C1713 48834520 - SCREW BONE 4.35MM 20MM SELF TAP FIX ANGLE AVIATOR SPN CERV BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48844010 SUP HCPCS C1713 48844010 - SCREW BONE 4MM 10MM FIX ANGLE SELF DRILL AVIATOR TITANIUM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48844012 SUP HCPCS C1713 48844012 - SCREW BONE 4MM 12MM FIX ANGLE SELF DRILL AVIATOR TITANIUM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48844014 SUP HCPCS C1713 48844014 - SCREW BONE 4MM 14MM FIX ANGLE SELF DRILL AVIATOR TITANIUM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48844016 SUP HCPCS C1713 48844016 - SCREW BONE 4MM 16MM FIX ANGLE SELF DRILL AVIATOR TITANIUM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48844018 SUP HCPCS C1713 48844018 - SCREW BONE 4MM 18MM SELF DRILL FIX ANGLE AVIATOR SPN CERV BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 48850000 SUP HCPCS C1713 48850000 - BLOCKER SPNL CORT XIA BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 48857535 SUP Custom 27203010 48857535 - XIA CT 05.0mmX35mm TAP MARKER BOTH IP/OP $406.58 $300.87 $0.00 $325.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.76 $301.76 $0.00 $0.00 $84.73 $0.00 $0.00 $0.00 $0.00 $203.29 $322.01 $325.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48858435 SUP Custom 27203010 48858435 - XIA CT 04.5mmX35mm TAP MARKER BOTH IP/OP $406.58 $300.87 $0.00 $325.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.76 $301.76 $0.00 $0.00 $84.73 $0.00 $0.00 $0.00 $0.00 $203.29 $322.01 $325.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48858535 SUP Custom 27203010 48858535 - XIA CT 05.5mmX35mm TAP MARKER BOTH IP/OP $406.58 $300.87 $0.00 $325.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.76 $301.76 $0.00 $0.00 $84.73 $0.00 $0.00 $0.00 $0.00 $203.29 $322.01 $325.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48900425 SUP HCPCS C1713 48900425 - SCREW BONE STANDARD POST 4.5MM 25MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900430 SUP HCPCS C1713 48900430 - SCREW BONE STANDARD POST 4.5MM 30MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900435 SUP HCPCS C1713 48900435 - SCREW BONE STANDARD POST 4.5MM 35MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900440 SUP HCPCS C1713 48900440 - SCREW BONE STANDARD POST 4.5MM 40MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900445 SUP HCPCS C1713 48900445 - SCREW BONE 4.5MM 45MM STANDARD POST TRIO SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48900450 SUP HCPCS C1713 48900450 - SCREW BONE 4.5MM 50MM STANDARD POST TRIO SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48900455 SUP HCPCS C1713 48900455 - SCREW BONE 4.5MM 55MM STANDARD POST TRIO SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48900525 SUP HCPCS C1713 48900525 - SCREW BONE STANDARD POST 5.5MM 25MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900530 SUP HCPCS C1713 48900530 - SCREW BONE STANDARD POST 5.5MM 30MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900535 SUP HCPCS C1713 48900535 - SCREW BONE STANDARD POST 5.5MM 35MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900540 SUP HCPCS C1713 48900540 - SCREW BONE STANDARD POST 5.5MM 40MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900545 SUP HCPCS C1713 48900545 - SCREW BONE STANDARD POST 5.5MM 45MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900550 SUP HCPCS C1713 48900550 - SCREW BONE STANDARD POST 5.5MM 50MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900555 SUP HCPCS C1713 48900555 - SCREW BONE 5.5MM 55MM STANDARD POST TRIO SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48900560 SUP HCPCS C1713 48900560 - SCREW BONE 5.5MM 60MM STANDARD POST TRIO SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 48900630 SUP HCPCS C1713 48900630 - SCREW BONE STANDARD POST 6.5MM 30MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900635 SUP HCPCS C1713 48900635 - SCREW BONE STANDARD POST 6.5MM 35MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900640 SUP HCPCS C1713 48900640 - SCREW BONE STANDARD POST 6.5MM 40MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900645 SUP HCPCS C1713 48900645 - SCREW BONE STANDARD POST 6.5MM 45MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900650 SUP HCPCS C1713 48900650 - SCREW BONE STANDARD POST 6.5MM 50MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900655 SUP HCPCS C1713 48900655 - SCREW BONE STANDARD POST 6.5MM 55MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900660 SUP HCPCS C1713 48900660 - SCREW BONE STANDARD POST 6.5MM 60MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900730 SUP HCPCS C1713 48900730 - SCREW BONE STANDARD POST 7.5MM 30MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900735 SUP HCPCS C1713 48900735 - SCREW BONE STANDARD POST 7.5MM 35MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900740 SUP HCPCS C1713 48900740 - SCREW BONE STANDARD POST 7.5MM 40MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900745 SUP HCPCS C1713 48900745 - SCREW BONE STANDARD POST 7.5MM 45MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900750 SUP HCPCS C1713 48900750 - SCREW BONE STANDARD POST 7.5MM 50MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900755 SUP HCPCS C1713 48900755 - SCREW BONE STANDARD POST 7.5MM 55MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900760 SUP HCPCS C1713 48900760 - SCREW BONE STANDARD POST 7.5MM 60MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900830 SUP HCPCS C1713 48900830 - SCREW BONE STANDARD POST 8.5MM 30MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900835 SUP HCPCS C1713 48900835 - SCREW BONE STANDARD POST 8.5MM 35MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900840 SUP HCPCS C1713 48900840 - SCREW BONE STANDARD POST 8.5MM 40MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900845 SUP HCPCS C1713 48900845 - SCREW BONE STANDARD POST 8.5MM 45MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900850 SUP HCPCS C1713 48900850 - SCREW BONE STANDARD POST 8.5MM 50MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900855 SUP HCPCS C1713 48900855 - SCREW BONE STANDARD POST 8.5MM 55MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48900860 SUP HCPCS C1713 48900860 - SCREW BONE STANDARD POST 8.5MM 60MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48901640 SUP HCPCS C1713 48901640 - SCREW BONE LONG POST 6.5MM 40MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48901645 SUP HCPCS C1713 48901645 - SCREW BONE LONG POST 6.5MM 45MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48901650 SUP HCPCS C1713 48901650 - SCREW BONE LONG POST 6.5MM 50MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48901740 SUP HCPCS C1713 48901740 - SCREW BONE LONG POST 7.5MM 40MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48901745 SUP HCPCS C1713 48901745 - SCREW BONE LONG POST 7.5MM 45MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48901750 SUP HCPCS C1713 48901750 - SCREW BONE LONG POST 7.5MM 50MM TITANIUM SPN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 48902015 SUP Custom 27803010 48902015 - CONNECTOR ROD SMALL OFFST UPGRADE TRIO SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48902025 SUP Custom 27803010 48902025 - CONNECTOR ROD MEDIUM LP SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48902035 SUP Custom 27803010 48902035 - CONNECTOR ROD LARGE LP OFFST SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48902040 SUP Custom 27803010 48902040 - CONNECTOR ROD 2 STEP LOCKING TITANIUM SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48902060 SUP Custom 27803010 48902060 - CONNECTOR ROD RIGHT OFFST BIASED SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48902070 SUP Custom 27803010 48902070 - CONNECTOR ROD LEFT BIASED OFFST TITANIUM SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48910530 SUP HCPCS C1713 48910530 - SCREW BONE 5.5MM 30MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910535 SUP HCPCS C1713 48910535 - SCREW BONE 5.5MM 35MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910540 SUP HCPCS C1713 48910540 - SCREW BONE 5.5MM 40MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910545 SUP HCPCS C1713 48910545 - SCREW BONE 5.5MM 45MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910550 SUP HCPCS C1713 48910550 - SCREW BONE 5.5MM 50MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910635 SUP HCPCS C1713 48910635 - SCREW BONE 6.5MM 35MM TI STD POST SPNL PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910640 SUP HCPCS C1713 48910640 - SCREW BONE 6.5MM 40MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910645 SUP HCPCS C1713 48910645 - SCREW BONE 6.5MM 45MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910655 SUP HCPCS C1713 48910655 - SCREW BONE 6.5MM 55MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910660 SUP HCPCS C1713 48910660 - SCREW BONE 6.5MM 60MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910730 SUP HCPCS C1713 48910730 - SCREW BONE 7.5MM 30MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910735 SUP HCPCS C1713 48910735 - SCREW BONE 7.5MM 35MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910740 SUP HCPCS C1713 48910740 - SCREW BONE 7.5MM 40MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910745 SUP HCPCS C1713 48910745 - SCREW BONE 7.5MM 45MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910755 SUP HCPCS C1713 48910755 - SCREW BONE 7.5MM 55MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910760 SUP HCPCS C1713 48910760 - SCREW BONE 7.5MM 60MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910830 SUP HCPCS C1713 48910830 - SCREW BONE 8.5MM 30MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910835 SUP HCPCS C1713 48910835 - SCREW BONE 8.5MM 35MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910840 SUP HCPCS C1713 48910840 - SCREW BONE 8.5MM 40MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910855 SUP HCPCS C1713 48910855 - SCREW BONE 8.5MM 55MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48910860 SUP HCPCS C1713 48910860 - SCREW BONE 8.5MM 60MM STD POST PS BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 48911640 SUP HCPCS C1713 48911640 - SCREW BONE 6.5MM 40MM LNG POST PS BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 48911645 SUP HCPCS C1713 48911645 - SCREW BONE 6.5MM 45MM LNG POST PS BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 48911650 SUP HCPCS C1713 48911650 - SCREW BONE 6.5MM 50MM LNG POST PS BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 48911740 SUP HCPCS C1713 48911740 - SCREW BONE 7.5MM 40MM LNG POST PS BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 48911745 SUP HCPCS C1713 48911745 - SCREW BONE 7.5MM 45MM LNG POST PS BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 48911750 SUP HCPCS C1713 48911750 - SCREW BONE 7.5MM 50MM LNG POST PS BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 48912035 SUP HCPCS C1713 48912035 - PLATE 35MM LRDTC STAB BONE POST BOTH IP/OP "$2,866.53 " "$2,121.23" $0.00 "$2,293.22" "$1,289.94" "$1,289.94" $0.00 $0.00 $0.00 $597.46 "$2,127.53" "$2,127.53" $0.00 $0.00 $597.38 $0.00 "$1,413.20" "$1,413.20" $0.00 "$1,433.26" "$2,270.29" "$2,293.22" $0.00 $0.00 $448.61 $0.00 $0.00 $456.35 $0.00 $0.00 $0.00 $0.00 $0.00 48912040 SUP HCPCS C1713 48912040 - PLATE 40MM LRDTC STAB BONE POST BOTH IP/OP "$2,866.53 " "$2,121.23" $0.00 "$2,293.22" "$1,289.94" "$1,289.94" $0.00 $0.00 $0.00 $597.46 "$2,127.53" "$2,127.53" $0.00 $0.00 $597.38 $0.00 "$1,413.20" "$1,413.20" $0.00 "$1,433.26" "$2,270.29" "$2,293.22" $0.00 $0.00 $448.61 $0.00 $0.00 $456.35 $0.00 $0.00 $0.00 $0.00 $0.00 48912060 SUP HCPCS C1713 48912060 - PLATE 60MM LRDTC STAB BONE POST BOTH IP/OP "$3,102.43 " "$2,295.80" $0.00 "$2,481.94" "$1,396.09" "$1,396.09" $0.00 $0.00 $0.00 $646.62 "$2,302.62" "$2,302.62" $0.00 $0.00 $646.55 $0.00 "$1,529.50" "$1,529.50" $0.00 "$1,551.21" "$2,457.12" "$2,481.94" $0.00 $0.00 $485.53 $0.00 $0.00 $493.91 $0.00 $0.00 $0.00 $0.00 $0.00 48912070 SUP HCPCS C1713 48912070 - PLATE 70MM POST STAB LRDTC BONE SPNL BOTH IP/OP "$3,102.43 " "$2,295.80" $0.00 "$2,481.94" "$1,396.09" "$1,396.09" $0.00 $0.00 $0.00 $646.62 "$2,302.62" "$2,302.62" $0.00 $0.00 $646.55 $0.00 "$1,529.50" "$1,529.50" $0.00 "$1,551.21" "$2,457.12" "$2,481.94" $0.00 $0.00 $485.53 $0.00 $0.00 $493.91 $0.00 $0.00 $0.00 $0.00 $0.00 48912080 SUP HCPCS C1713 48912080 - PLATE 80MM POST STAB LRDTC BONE SPNL BOTH IP/OP "$3,102.43 " "$2,295.80" $0.00 "$2,481.94" "$1,396.09" "$1,396.09" $0.00 $0.00 $0.00 $646.62 "$2,302.62" "$2,302.62" $0.00 $0.00 $646.55 $0.00 "$1,529.50" "$1,529.50" $0.00 "$1,551.21" "$2,457.12" "$2,481.94" $0.00 $0.00 $485.53 $0.00 $0.00 $493.91 $0.00 $0.00 $0.00 $0.00 $0.00 48912090 SUP HCPCS C1713 48912090 - PLATE 90MM POST STAB LRDTC BONE SPNL BOTH IP/OP "$3,102.43 " "$2,295.80" $0.00 "$2,481.94" "$1,396.09" "$1,396.09" $0.00 $0.00 $0.00 $646.62 "$2,302.62" "$2,302.62" $0.00 $0.00 $646.55 $0.00 "$1,529.50" "$1,529.50" $0.00 "$1,551.21" "$2,457.12" "$2,481.94" $0.00 $0.00 $485.53 $0.00 $0.00 $493.91 $0.00 $0.00 $0.00 $0.00 $0.00 48912105 SUP HCPCS C1713 48912105 - PLATE 105MM POST STAB LRDTC BONE SPNL BOTH IP/OP "$3,338.33 " "$2,470.36" $0.00 "$2,670.66" "$1,502.25" "$1,502.25" $0.00 $0.00 $0.00 $695.79 "$2,477.70" "$2,477.70" $0.00 $0.00 $695.71 $0.00 "$1,645.79" "$1,645.79" $0.00 "$1,669.16" "$2,643.96" "$2,670.66" $0.00 $0.00 $522.45 $0.00 $0.00 $531.46 $0.00 $0.00 $0.00 $0.00 $0.00 48912120 SUP HCPCS C1713 48912120 - PLATE 120MM POST STAB LRDTC BONE SPNL BOTH IP/OP "$3,338.33 " "$2,470.36" $0.00 "$2,670.66" "$1,502.25" "$1,502.25" $0.00 $0.00 $0.00 $695.79 "$2,477.70" "$2,477.70" $0.00 $0.00 $695.71 $0.00 "$1,645.79" "$1,645.79" $0.00 "$1,669.16" "$2,643.96" "$2,670.66" $0.00 $0.00 $522.45 $0.00 $0.00 $531.46 $0.00 $0.00 $0.00 $0.00 $0.00 48912510 SUP Custom 27803010 48912510 - NUT LOCK 9MM POST TI HEX STAB POST STAB BOTH IP/OP $294.28 $217.77 $0.00 $235.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.41 $218.41 $0.00 $0.00 $61.33 $0.00 $0.00 $0.00 $0.00 $147.14 $233.07 $235.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48912520 SUP HCPCS C1713 48912520 - PLATE 20MM POST STAB POLYAX DOME BONE SPNL BOTH IP/OP $224.65 $166.24 $0.00 $179.72 $101.09 $101.09 $0.00 $0.00 $0.00 $46.82 $166.74 $166.74 $0.00 $0.00 $46.82 $0.00 $132.88 $132.88 $0.00 $112.33 $177.92 $179.72 $0.00 $0.00 $35.16 $0.00 $0.00 $35.76 $0.00 $0.00 $0.00 $0.00 $0.00 48953112 SUP Custom 27803010 48953112 - CAGE SPNL 12D LRDTC 28X11X11MM STRL LF TRITANIUM PLIF BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48955106 SUP Custom 27203010 48955106 - CAGE SPNL 6D LRDTC 28X11X10MM STRL LF TRITANIUM PLIF BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 $0.00 $0.00 $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48955126 SUP HCPCS C1713 48955126 - POSTERIOR LUMBAR CAGE 12MM X 28MM X 6 - 11MM BOTH IP/OP "$5,500.00 " "$4,070.00" $0.00 "$4,400.00" "$2,475.00" "$2,475.00" $0.00 $0.00 $0.00 "$1,146.34" "$4,082.10" "$4,082.10" $0.00 $0.00 "$1,146.20" $0.00 "$2,711.50" "$2,711.50" $0.00 "$2,750.00" "$4,356.00" "$4,400.00" $0.00 $0.00 $860.75 $0.00 $0.00 $875.60 $0.00 $0.00 $0.00 $0.00 $0.00 50506000 SUP Custom 27011340 050506000 - CONCTR PRFSN STR EQL 3/8INX3/8IN 3/8INX3/8IN STRL BOTH IP/OP $248.78 $184.10 $0.00 $199.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.64 $184.64 $0.00 $0.00 $51.84 $0.00 $0.00 $0.00 $0.00 $124.39 $197.03 $199.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50516000 SUP Custom 27011340 050516000 - CONNECTOR PRFSN .25IN 3/8IN STRL RDCR BOTH IP/OP $281.50 $208.31 $0.00 $225.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.93 $208.93 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $140.75 $222.95 $225.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50524000 SUP Custom 27011340 050524000 - CONNECTOR PRFSN .25IN X .25IN X .25IN STRL Y EQL BOTH IP/OP $11.28 $8.35 $0.00 $9.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.37 $8.37 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.64 $8.93 $9.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50524000 SUP Custom 27011340 50524000 - CONNECTOR PERFUSION EQUAL Y STER 1/4 X 1/4IN BOTH IP/OP $11.28 $8.35 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.37 $8.37 $0.00 $0.00 $2.35 $0.00 $0.00 $0.00 $0.00 $5.64 $10.10 $9.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50526000 SUP Custom 27203010 CONNECTOR PRFSN Y EQL 3/8INX3/8INX3/8IN BOTH IP/OP $10.95 $8.10 $0.00 $8.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.48 $8.67 $8.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50529000 SUP Custom 27011340 050529000 - CONCTR PRFSN RDC WYE .5X3/8IN STRL BOTH IP/OP $13.33 $9.86 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.89 $9.89 $0.00 $0.00 $2.78 $0.00 $0.00 $0.00 $0.00 $11.19 $17.73 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60060083 SUP Custom 27203010 60060083 - KIT PRSS MNTR CSTM TRNDCR RT HRT BOTH IP/OP $35.57 $26.32 $0.00 $28.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.40 $26.40 $0.00 $0.00 $7.41 $0.00 $0.00 $0.00 $0.00 $17.78 $28.17 $28.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65305001 SUP HCPCS C1762 65305001 - GRAFT BONE DBM 10ML SPNL BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 66020016 SUP Custom 27203010 66020016 - BANDAGE COMPRESSION 7.25+ IN 4IN MULTILAYER HIGH WOUND BOTH IP/OP $21.65 $16.02 $0.00 $17.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.07 $16.07 $0.00 $0.00 $4.51 $0.00 $0.00 $0.00 $0.00 $10.99 $17.40 $17.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 66800433 SUP Custom 27203010 66800433 - DRESSING BRN 16X16IN STRL LF ACTCT FLX 3 ANMC BRR FLXB SFT BOTH IP/OP $150.59 $111.44 $0.00 $122.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.77 $111.77 $0.00 $0.00 $31.38 $0.00 $0.00 $0.00 $0.00 $76.42 $121.06 $122.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 66800434 SUP Custom 27203010 66800434 - DRESSING BURN 16X16IN ANTIBACTERIAL FAST ACT BARRIER CONTROL BOTH IP/OP $179.20 $132.61 $0.00 $140.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.00 $133.00 $0.00 $0.00 $37.35 $0.00 $0.00 $0.00 $0.00 $87.81 $139.08 $140.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 67005200 SUP HCPCS C1887 CATHETER GUID XB3 CURVE 6FR .070IN 100CM PTFE VSBR BLUE YLW BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 67005300 SUP HCPCS C1887 CATHETER GUID XB3 CURVE 6FR .070IN 100CM SH PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 67005500 SUP HCPCS C1887 CATHETER GUID XB3.5 CURVE 6FR .070IN 100CM SH PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 67011200 SUP HCPCS C1887 CATHETER GUID AR2 CURVE 6FR .070IN 100CM PTFE VSBR BLUE YLW BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 68304060 SUP Custom 27803010 68304060 - ROD SPNL 60MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304070 SUP Custom 27803010 68304070 - ROD SPNL 70MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304080 SUP Custom 27803010 68304080 - ROD SPNL 80MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304090 SUP Custom 27803010 68304090 - ROD SPNL 90MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304100 SUP Custom 27803010 68304100 - ROD SPNL 100MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304110 SUP Custom 27803010 68304110 - ROD SPNL 110MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304120 SUP Custom 27803010 68304120 - ROD SPNL 120MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304130 SUP Custom 27803010 68304130 - ROD SPNL 130MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304140 SUP Custom 27803010 68304140 - ROD SPNL 140MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304150 SUP Custom 27803010 68304150 - ROD SPNL 150MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68304160 SUP Custom 27803010 68304160 - ROD SPNL 160MM 4MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306060 SUP Custom 27803010 68306060 - ROD SPNL 60MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306070 SUP Custom 27803010 68306070 - ROD SPNL 70MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306080 SUP Custom 27803010 68306080 - ROD SPNL 80MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306090 SUP Custom 27803010 68306090 - ROD SPNL 90MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306100 SUP Custom 27803010 68306100 - ROD SPNL 100MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306110 SUP Custom 27803010 68306110 - ROD SPNL 110MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306120 SUP Custom 27803010 68306120 - ROD SPNL 120MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306130 SUP Custom 27803010 68306130 - ROD SPNL 130MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306140 SUP Custom 27803010 68306140 - ROD SPNL 140MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306150 SUP Custom 27803010 68306150 - ROD SPNL 150MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68306160 SUP Custom 27803010 68306160 - ROD SPNL 160MM 6MM CENTAUR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68415525 SUP HCPCS C1713 68415525 - SCREW BONE 5.5MM 25MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68415530 SUP HCPCS C1713 68415530 - SCREW BONE 5.5MM 30MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68415535 SUP HCPCS C1713 68415535 - SCREW BONE 5.5MM 35MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68415540 SUP HCPCS C1713 68415540 - SCREW BONE 5.5MM 40MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68415545 SUP HCPCS C1713 68415545 - SCREW BONE 5.5MM 45MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68415550 SUP HCPCS C1713 68415550 - SCREW BONE 5.5MM 50MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68415555 SUP HCPCS C1713 68415555 - SCREW BONE 5.5MM 55MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68417025 SUP HCPCS C1713 68417025 - SCREW BONE 7MM 25MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68417030 SUP HCPCS C1713 68417030 - SCREW BONE 30MM 7MM CENTAUR PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68417035 SUP HCPCS C1713 68417035 - SCREW BONE 7MM 35MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68417040 SUP HCPCS C1713 68417040 - SCREW BONE 7MM 40MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68417045 SUP HCPCS C1713 68417045 - SCREW BONE 7MM 45MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68417050 SUP HCPCS C1713 68417050 - SCREW BONE 7MM 50MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68417055 SUP HCPCS C1713 68417055 - SCREW BONE 7MM 55MM CENTAUR SPNL PLT BOTH IP/OP "$1,204.15 " $891.07 $0.00 $963.32 $541.87 $541.87 $0.00 $0.00 $0.00 $250.97 $893.72 $893.72 $0.00 $0.00 $250.94 $0.00 $712.25 $712.25 $0.00 $602.08 $953.69 $963.32 $0.00 $0.00 $188.45 $0.00 $0.00 $191.70 $0.00 $0.00 $0.00 $0.00 $0.00 68420000 SUP HCPCS C1713 68420000 - PLATE SPRT CENTAUR BONE SPNL BOTH IP/OP $354.95 $262.66 $0.00 $283.96 $159.73 $159.73 $0.00 $0.00 $0.00 $73.98 $263.44 $263.44 $0.00 $0.00 $73.97 $0.00 $209.95 $209.95 $0.00 $177.48 $281.12 $283.96 $0.00 $0.00 $55.55 $0.00 $0.00 $56.51 $0.00 $0.00 $0.00 $0.00 $0.00 68425525 SUP HCPCS C1713 68425525 - BOLT SPNL 25MM 5.5MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68425530 SUP HCPCS C1713 68425530 - BOLT SPNL 30MM 5.5MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68425535 SUP HCPCS C1713 68425535 - BOLT SPNL 35MM 5.5MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68425540 SUP HCPCS C1713 68425540 - BOLT SPNL 40MM 5.5MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68425545 SUP HCPCS C1713 68425545 - BOLT SPNL 45MM 5.5MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68425550 SUP HCPCS C1713 68425550 - BOLT SPNL 50MM 5.5MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68425555 SUP HCPCS C1713 68425555 - BOLT SPNL 55MM 5.5MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68427025 SUP HCPCS C1713 68427025 - BOLT SPNL 25MM 7MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68427030 SUP HCPCS C1713 68427030 - BOLT SPNL 30MM 7MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68427035 SUP HCPCS C1713 68427035 - BOLT SPNL 35MM 7MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68427040 SUP HCPCS C1713 68427040 - BOLT SPNL 40MM 7MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68427045 SUP HCPCS C1713 68427045 - BOLT SPNL 45MM 7MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68427050 SUP HCPCS C1713 68427050 - BOLT SPNL 50MM 7MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68427055 SUP HCPCS C1713 68427055 - BOLT SPNL 55MM 7MM CENTAUR BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $626.78 $626.78 $0.00 $0.00 $0.00 $290.30 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $823.87 $823.87 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $217.98 $0.00 $0.00 $221.74 $0.00 $0.00 $0.00 $0.00 $0.00 68430000 SUP Custom 27803010 68430000 - CONCTR ROD CENTAUR SET SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68435525 SUP Custom 27803010 68435525 - BOLT SPNL 25MM 5.5MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68435530 SUP Custom 27803010 68435530 - BOLT SPNL 30MM 5.5MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68435535 SUP Custom 27803010 68435535 - BOLT SPNL 35MM 5.5MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68435540 SUP Custom 27803010 68435540 - BOLT SPNL 40MM 5.5MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68435545 SUP Custom 27803010 68435545 - BOLT SPNL 45MM 5.5MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68435550 SUP Custom 27803010 68435550 - BOLT SPNL 50MM 5.5MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68435555 SUP Custom 27803010 68435555 - BOLT SPNL 55MM 5.5MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68437025 SUP Custom 27803010 68437025 - BOLT SPNL 25MM 7MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68437030 SUP Custom 27803010 68437030 - BOLT SPNL 30MM 7MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68437035 SUP Custom 27803010 68437035 - BOLT SPNL 35MM 7MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68437040 SUP Custom 27803010 68437040 - BOLT SPNL 40MM 7MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68437045 SUP Custom 27803010 68437045 - BOLT SPNL 45MM 7MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68437050 SUP Custom 27803010 68437050 - BOLT SPNL 50MM 7MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68437055 SUP Custom 27803010 68437055 - BOLT SPNL 55MM 7MM CENTAUR ROD BOTH IP/OP "$1,392.85 " "$1,030.71" $0.00 "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.77" "$1,033.77" $0.00 $0.00 $290.27 $0.00 $0.00 $0.00 $0.00 $696.43 "$1,103.14" "$1,114.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68470030 SUP HCPCS C1713 68470030 - PLATE 30MM STR CENTAUR BONE SPNL BOTH IP/OP "$6,274.48 " "$4,643.12" $0.00 "$5,019.58" "$2,823.51" "$2,823.51" $0.00 $0.00 $0.00 "$1,307.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,307.60" $0.00 "$3,093.32" "$3,093.32" $0.00 "$3,137.24" "$4,969.39" "$5,019.58" $0.00 $0.00 $981.96 $0.00 $0.00 $998.90 $0.00 $0.00 $0.00 $0.00 $0.00 68470040 SUP HCPCS C1713 68470040 - PLATE 40MM STR CENTAUR BONE SPNL BOTH IP/OP "$6,274.48 " "$4,643.12" $0.00 "$5,019.58" "$2,823.51" "$2,823.51" $0.00 $0.00 $0.00 "$1,307.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,307.60" $0.00 "$3,093.32" "$3,093.32" $0.00 "$3,137.24" "$4,969.39" "$5,019.58" $0.00 $0.00 $981.96 $0.00 $0.00 $998.90 $0.00 $0.00 $0.00 $0.00 $0.00 68470050 SUP HCPCS C1713 68470050 - PLATE 50MM STR CENTAUR BONE SPNL BOTH IP/OP "$6,723.78 " "$4,975.60" $0.00 "$5,379.02" "$3,025.70" "$3,025.70" $0.00 $0.00 $0.00 "$1,401.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,401.23" $0.00 "$3,314.82" "$3,314.82" $0.00 "$3,361.89" "$5,325.23" "$5,379.02" $0.00 $0.00 "$1,052.27" $0.00 $0.00 "$1,070.42" $0.00 $0.00 $0.00 $0.00 $0.00 68470060 SUP HCPCS C1713 68470060 - PLATE 60MM STR CENTAUR BONE SPNL BOTH IP/OP "$6,723.78 " "$4,975.60" $0.00 "$5,379.02" "$3,025.70" "$3,025.70" $0.00 $0.00 $0.00 "$1,401.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,401.23" $0.00 "$3,314.82" "$3,314.82" $0.00 "$3,361.89" "$5,325.23" "$5,379.02" $0.00 $0.00 "$1,052.27" $0.00 $0.00 "$1,070.42" $0.00 $0.00 $0.00 $0.00 $0.00 68470070 SUP HCPCS C1713 68470070 - PLATE 70MM STR CENTAUR BONE SPNL BOTH IP/OP "$7,006.85 " "$5,185.07" $0.00 "$5,605.48" "$3,153.08" "$3,153.08" $0.00 $0.00 $0.00 "$1,460.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.23" $0.00 "$3,454.38" "$3,454.38" $0.00 "$3,503.43" "$5,549.43" "$5,605.48" $0.00 $0.00 "$1,096.57" $0.00 $0.00 "$1,115.49" $0.00 $0.00 $0.00 $0.00 $0.00 68470080 SUP HCPCS C1713 68470080 - PLATE 80MM STR CENTAUR BONE SPNL BOTH IP/OP "$7,006.85 " "$5,185.07" $0.00 "$5,605.48" "$3,153.08" "$3,153.08" $0.00 $0.00 $0.00 "$1,460.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.23" $0.00 "$3,454.38" "$3,454.38" $0.00 "$3,503.43" "$5,549.43" "$5,605.48" $0.00 $0.00 "$1,096.57" $0.00 $0.00 "$1,115.49" $0.00 $0.00 $0.00 $0.00 $0.00 68470090 SUP HCPCS C1713 68470090 - PLATE 90MM STR CENTAUR BONE SPNL BOTH IP/OP "$7,465.13 " "$5,524.20" $0.00 "$5,972.10" "$3,359.31" "$3,359.31" $0.00 $0.00 $0.00 "$1,555.92" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,555.73" $0.00 "$3,680.31" "$3,680.31" $0.00 "$3,732.56" "$5,912.38" "$5,972.10" $0.00 $0.00 "$1,168.29" $0.00 $0.00 "$1,188.45" $0.00 $0.00 $0.00 $0.00 $0.00 68480060 SUP HCPCS C1713 68480060 - PLATE 60MM LRDTC CENTAUR BONE SPNL BOTH IP/OP "$4,953.53 " "$3,665.61" $0.00 "$3,962.82" "$2,229.09" "$2,229.09" $0.00 $0.00 $0.00 "$1,032.44" "$3,676.51" "$3,676.51" $0.00 $0.00 "$1,032.31" $0.00 "$2,442.09" "$2,442.09" $0.00 "$2,476.76" "$3,923.20" "$3,962.82" $0.00 $0.00 $775.23 $0.00 $0.00 $788.60 $0.00 $0.00 $0.00 $0.00 $0.00 68480070 SUP HCPCS C1713 68480070 - PLATE 70MM LRDTC CENTAUR BONE SPNL BOTH IP/OP "$5,166.98 " "$3,823.57" $0.00 "$4,133.58" "$2,325.14" "$2,325.14" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.93" "$3,834.93" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.32" "$2,547.32" $0.00 "$2,583.49" "$4,092.25" "$4,133.58" $0.00 $0.00 $808.63 $0.00 $0.00 $822.58 $0.00 $0.00 $0.00 $0.00 $0.00 68480080 SUP HCPCS C1713 68480080 - PLATE 80MM LRDTC CENTAUR BONE SPNL BOTH IP/OP "$5,366.88 " "$3,971.49" $0.00 "$4,293.50" "$2,415.09" "$2,415.09" $0.00 $0.00 $0.00 "$1,118.59" "$3,983.29" "$3,983.29" $0.00 $0.00 "$1,118.46" $0.00 "$2,645.87" "$2,645.87" $0.00 "$2,683.44" "$4,250.57" "$4,293.50" $0.00 $0.00 $839.92 $0.00 $0.00 $854.41 $0.00 $0.00 $0.00 $0.00 $0.00 68480090 SUP HCPCS C1713 68480090 - PLATE 90MM LRDTC CENTAUR BONE SPNL BOTH IP/OP "$5,366.88 " "$3,971.49" $0.00 "$4,293.50" "$2,415.09" "$2,415.09" $0.00 $0.00 $0.00 "$1,118.59" "$3,983.29" "$3,983.29" $0.00 $0.00 "$1,118.46" $0.00 "$2,645.87" "$2,645.87" $0.00 "$2,683.44" "$4,250.57" "$4,293.50" $0.00 $0.00 $839.92 $0.00 $0.00 $854.41 $0.00 $0.00 $0.00 $0.00 $0.00 68490050 SUP HCPCS C1713 68490050 - PLATE 50MM KYPHOTIC CENTAUR BONE SPNL BOTH IP/OP "$6,818.15 " "$5,045.43" $0.00 "$5,454.52" "$3,068.17" "$3,068.17" $0.00 $0.00 $0.00 "$1,421.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,420.90" $0.00 "$3,361.35" "$3,361.35" $0.00 "$3,409.08" "$5,399.97" "$5,454.52" $0.00 $0.00 "$1,067.04" $0.00 $0.00 "$1,085.45" $0.00 $0.00 $0.00 $0.00 $0.00 68490060 SUP HCPCS C1713 68490060 - PLATE 60MM KYPHOTIC CENTAUR BONE SPNL BOTH IP/OP "$7,112.45 " "$5,263.21" $0.00 "$5,689.96" "$3,200.60" "$3,200.60" $0.00 $0.00 $0.00 "$1,482.41" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,482.23" $0.00 "$3,506.44" "$3,506.44" $0.00 "$3,556.23" "$5,633.06" "$5,689.96" $0.00 $0.00 "$1,113.10" $0.00 $0.00 "$1,132.30" $0.00 $0.00 $0.00 $0.00 $0.00 68490070 SUP HCPCS C1713 68490070 - PLATE 70MM KYPHOTIC CENTAUR BONE SPNL BOTH IP/OP "$7,395.48 " "$5,472.66" $0.00 "$5,916.38" "$3,327.96" "$3,327.96" $0.00 $0.00 $0.00 "$1,541.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,541.22" $0.00 "$3,645.97" "$3,645.97" $0.00 "$3,697.74" "$5,857.22" "$5,916.38" $0.00 $0.00 "$1,157.39" $0.00 $0.00 "$1,177.36" $0.00 $0.00 $0.00 $0.00 $0.00 68490080 SUP HCPCS C1713 68490080 - PLATE 80MM KYPHOTIC CENTAUR BONE SPNL BOTH IP/OP "$7,831.35 " "$5,795.20" $0.00 "$6,265.08" "$3,524.11" "$3,524.11" $0.00 $0.00 $0.00 "$1,632.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,632.05" $0.00 "$3,860.86" "$3,860.86" $0.00 "$3,915.68" "$6,202.43" "$6,265.08" $0.00 $0.00 "$1,225.61" $0.00 $0.00 "$1,246.75" $0.00 $0.00 $0.00 $0.00 $0.00 68490090 SUP HCPCS C1713 68490090 - PLATE 90MM KYPHOTIC CENTAUR BONE SPNL BOTH IP/OP "$8,386.20 " "$6,205.79" $0.00 "$6,708.96" "$3,773.79" "$3,773.79" $0.00 $0.00 $0.00 "$1,747.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,747.68" $0.00 "$4,134.40" "$4,134.40" $0.00 "$4,193.10" "$6,641.87" "$6,708.96" $0.00 $0.00 "$1,312.44" $0.00 $0.00 "$1,335.08" $0.00 $0.00 $0.00 $0.00 $0.00 70000267 SUP HCPCS C1894 612606 - INTRODUCER SHTH 9FR 16CM TRAW ADPR DILAT SET INDN SPNLK .035 BOTH IP/OP $67.10 $49.65 $0.00 $53.68 $36.44 $36.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.55 $53.14 $53.68 $0.00 $0.00 $10.50 $0.00 $0.00 $10.68 $0.00 $0.00 $0.00 $0.00 $0.00 70035009 SUP Custom 27203010 70035009 - STOPCOCK ANGIO 400 PSI NAMIC 3W ROT ADPR RT PORT BOTH IP/OP $2.80 $2.07 $0.00 $2.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.08 $2.08 $0.00 $0.00 $0.58 $0.00 $0.00 $0.00 $0.00 $1.40 $2.22 $2.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70055017 SUP Custom 27203010 70055017 - STOPCOCK ANGIO 1050 PSI NAMIC 1 WY FX M LL BOTH IP/OP $161.28 $119.35 $0.00 $129.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.70 $119.70 $0.00 $0.00 $33.61 $0.00 $0.00 $0.00 $0.00 $80.64 $127.73 $129.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70245550 SUP HCPCS C1713 70245550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70245560 SUP HCPCS C1713 70245560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70260500 SUP HCPCS C1713 70260500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70260511 SUP HCPCS C1713 70260511 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70260580 SUP HCPCS C1713 70260580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70260590 SUP HCPCS C1713 70260590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70265530 SUP HCPCS C1713 70265530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70265535 SUP HCPCS C1713 70265535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70265540 SUP HCPCS C1713 70265540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70265545 SUP HCPCS C1713 70265545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70265550 SUP HCPCS C1713 70265550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70265555 SUP HCPCS C1713 70265555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70265560 SUP HCPCS C1713 70265560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70266535 SUP HCPCS C1713 70266535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70266540 SUP HCPCS C1713 70266540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70266545 SUP HCPCS C1713 70266545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70266550 SUP HCPCS C1713 70266550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70266555 SUP HCPCS C1713 70266555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70266560 SUP HCPCS C1713 70266560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70266570 SUP HCPCS C1713 70266570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267500 SUP HCPCS C1713 70267500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267540 SUP HCPCS C1713 70267540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267545 SUP HCPCS C1713 70267545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267550 SUP HCPCS C1713 70267550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267555 SUP HCPCS C1713 70267555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267560 SUP HCPCS C1713 70267560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267570 SUP HCPCS C1713 70267570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267580 SUP HCPCS C1713 70267580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70267590 SUP HCPCS C1713 70267590 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268500 SUP HCPCS C1713 70268500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268540 SUP HCPCS C1713 70268540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268545 SUP HCPCS C1713 70268545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268550 SUP HCPCS C1713 70268550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268555 SUP HCPCS C1713 70268555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268560 SUP HCPCS C1713 70268560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268570 SUP HCPCS C1713 70268570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268580 SUP HCPCS C1713 70268580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70268590 SUP HCPCS C1713 70268590 - SCREW BN 8.5MM 90MM SOLERA CD HZN LGC MA CLS SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70269500 SUP HCPCS C1713 70269500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70269511 SUP HCPCS C1713 70269511 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70269580 SUP HCPCS C1713 70269580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70269590 SUP HCPCS C1713 70269590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 70460500 SUP HCPCS C1713 70460500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70460511 SUP HCPCS C1713 70460511 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70460580 SUP HCPCS C1713 70460580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70460590 SUP HCPCS C1713 70460590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70465530 SUP HCPCS C1713 70465530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70465535 SUP HCPCS C1713 70465535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70465540 SUP HCPCS C1713 70465540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70465545 SUP HCPCS C1713 70465545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70465550 SUP HCPCS C1713 70465550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70465555 SUP HCPCS C1713 70465555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70465560 SUP HCPCS C1713 70465560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70466535 SUP HCPCS C1713 70466535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70466540 SUP HCPCS C1713 70466540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70466545 SUP HCPCS C1713 70466545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70466550 SUP HCPCS C1713 70466550 - SCREW BN 6.5MM 50MM SOLERA CD HZN LGC MA CLS TI SPNE BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70466555 SUP HCPCS C1713 70466555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70466560 SUP HCPCS C1713 70466560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70466570 SUP HCPCS C1713 70466570 - SCREW BN 6.5MM 70MM SOLERA CD HZN LGC MA CLS TI SPNE BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467500 SUP HCPCS C1713 70467500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467540 SUP HCPCS C1713 70467540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467545 SUP HCPCS C1713 70467545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467550 SUP HCPCS C1713 70467550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467555 SUP HCPCS C1713 70467555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467560 SUP HCPCS C1713 70467560 - SCREW BN 7.5MM 60MM SOLERA CD HZN LGC MA CLS TI SPNE BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467570 SUP HCPCS C1713 70467570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467580 SUP HCPCS C1713 70467580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70467590 SUP HCPCS C1713 70467590 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468500 SUP HCPCS C1713 70468500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468540 SUP HCPCS C1713 70468540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468545 SUP HCPCS C1713 70468545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468550 SUP HCPCS C1713 70468550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468555 SUP HCPCS C1713 70468555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468560 SUP HCPCS C1713 70468560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468570 SUP HCPCS C1713 70468570 - SCREW BN 8.5MM 70MM SOLERA CD HZN LGC MA CLS TI SPNE BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468580 SUP HCPCS C1713 70468580 - SCREW BN 8.5MM 80MM SOLERA CD HZN LGC MA CLS TI SPNE BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70468590 SUP HCPCS C1713 70468590 - SCREW BN 8.5MM 90MM SOLERA CD HZN LGC MA CLS TI SPNE BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70469500 SUP HCPCS C1713 70469500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70469511 SUP HCPCS C1713 70469511 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70469580 SUP HCPCS C1713 70469580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 70469590 SUP HCPCS C1713 70469590 - SCREW BN 9.5MM 90MM SOLERA CD HZN LGC MA CLS TI SPNE BOTH IP/OP "$3,091.50 " "$2,287.71" $0.00 "$2,473.20" "$1,391.18" "$1,391.18" $0.00 $0.00 $0.00 $644.35 "$2,294.51" "$2,294.51" $0.00 $0.00 $644.27 $0.00 "$1,524.11" "$1,524.11" $0.00 "$1,545.75" "$2,448.47" "$2,473.20" $0.00 $0.00 $483.82 $0.00 $0.00 $492.17 $0.00 $0.00 $0.00 $0.00 $0.00 71010705 SUP HCPCS C1713 71010705 - BOLT EXFIX ILZ RSN WIRE BOTH IP/OP $147.60 $109.22 $0.00 $118.08 $66.42 $66.42 $0.00 $0.00 $0.00 $30.76 $109.55 $109.55 $0.00 $0.00 $30.76 $0.00 $87.31 $87.31 $0.00 $73.80 $116.90 $118.08 $0.00 $0.00 $23.10 $0.00 $0.00 $23.50 $0.00 $0.00 $0.00 $0.00 $0.00 71011002 SUP HCPCS C1713 71011002 - NUT XTRNFX ILZ QCK CNCT CIRC BOTH IP/OP $175.10 $129.57 $0.00 $140.08 $78.80 $78.80 $0.00 $0.00 $0.00 $36.50 $129.96 $129.96 $0.00 $0.00 $36.49 $0.00 $103.57 $103.57 $0.00 $87.55 $138.68 $140.08 $0.00 $0.00 $27.40 $0.00 $0.00 $27.88 $0.00 $0.00 $0.00 $0.00 $0.00 71011550 SUP HCPCS C1713 71011550 - WASHER ORTH 7MM TI BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 71012000 SUP HCPCS C1713 71012000 - WASHER XTRNFX CNCL CPL SM BN FXTR BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $86.40 $86.40 $0.00 $0.00 $0.00 $40.02 $142.50 $142.50 $0.00 $0.00 $40.01 $0.00 $113.57 $113.57 $0.00 $96.00 $152.06 $153.60 $0.00 $0.00 $30.05 $0.00 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $0.00 71012005 SUP HCPCS C1713 71012005 - NUT XTRNFX CIRC NYL SM BN FXTR BOTH IP/OP $29.70 $21.98 $0.00 $23.76 $13.37 $13.37 $0.00 $0.00 $0.00 $6.19 $22.04 $22.04 $0.00 $0.00 $6.19 $0.00 $17.57 $17.57 $0.00 $14.85 $23.52 $23.76 $0.00 $0.00 $4.65 $0.00 $0.00 $4.73 $0.00 $0.00 $0.00 $0.00 $0.00 71012502 SUP HCPCS C1713 71012502 - PIN HLF 5MM 180MM ILZ SS ANKL/FT XTRNFXTR BOTH IP/OP $627.30 $464.20 $0.00 $501.84 $282.29 $282.29 $0.00 $0.00 $0.00 $130.75 $465.58 $465.58 $0.00 $0.00 $130.73 $0.00 $371.05 $371.05 $0.00 $313.65 $496.82 $501.84 $0.00 $0.00 $98.17 $0.00 $0.00 $99.87 $0.00 $0.00 $0.00 $0.00 $0.00 71013000 SUP Custom 27203010 71013000 - BOLT XTRNFX LNG ILZ SLOT WRE BOTH IP/OP $178.50 $132.09 $0.00 $142.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.48 $132.48 $0.00 $0.00 $37.20 $0.00 $0.00 $0.00 $0.00 $89.25 $141.37 $142.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71013204 SUP HCPCS C1713 71013204 - BOLT EXFIX ILIZAROV BOTH IP/OP $148.33 $109.76 $0.00 $118.66 $66.75 $66.75 $0.00 $0.00 $0.00 $30.91 $110.09 $110.09 $0.00 $0.00 $30.91 $0.00 $87.73 $87.73 $0.00 $74.16 $117.48 $118.66 $0.00 $0.00 $23.21 $0.00 $0.00 $23.61 $0.00 $0.00 $0.00 $0.00 $0.00 71021027 SUP HCPCS C1713 71021027 - PIN HLF 6MM 45MM HXFX TI BOTH IP/OP $472.60 $349.72 $0.00 $378.08 $212.67 $212.67 $0.00 $0.00 $0.00 $98.50 $350.76 $350.76 $0.00 $0.00 $98.49 $0.00 $279.54 $279.54 $0.00 $236.30 $374.30 $378.08 $0.00 $0.00 $73.96 $0.00 $0.00 $75.24 $0.00 $0.00 $0.00 $0.00 $0.00 71021029 SUP HCPCS C1713 71021029 - PIN HLF 6MM 55MM HXFX TI BOTH IP/OP $472.60 $349.72 $0.00 $378.08 $212.67 $212.67 $0.00 $0.00 $0.00 $98.50 $350.76 $350.76 $0.00 $0.00 $98.49 $0.00 $279.54 $279.54 $0.00 $236.30 $374.30 $378.08 $0.00 $0.00 $73.96 $0.00 $0.00 $75.24 $0.00 $0.00 $0.00 $0.00 $0.00 71021031 SUP HCPCS C1713 71021031 - PIN HLF 6MM 65MM HXFX TI ORTH XTRNFX SYS BOTH IP/OP $719.10 $532.13 $0.00 $575.28 $323.60 $323.60 $0.00 $0.00 $0.00 $149.88 $533.72 $533.72 $0.00 $0.00 $149.86 $0.00 $425.35 $425.35 $0.00 $359.55 $569.53 $575.28 $0.00 $0.00 $112.54 $0.00 $0.00 $114.48 $0.00 $0.00 $0.00 $0.00 $0.00 71021033 SUP HCPCS C1713 71021033 - PIN HLF 6MM 75MM HXFX TI ORTH XTRNFX SYS BOTH IP/OP $719.10 $532.13 $0.00 $575.28 $323.60 $323.60 $0.00 $0.00 $0.00 $149.88 $533.72 $533.72 $0.00 $0.00 $149.86 $0.00 $425.35 $425.35 $0.00 $359.55 $569.53 $575.28 $0.00 $0.00 $112.54 $0.00 $0.00 $114.48 $0.00 $0.00 $0.00 $0.00 $0.00 71021035 SUP HCPCS C1713 71021035 - PIN HLF 6MM 85MM HXFX TI ORTH XTRNFX SYS BOTH IP/OP $719.10 $532.13 $0.00 $575.28 $323.60 $323.60 $0.00 $0.00 $0.00 $149.88 $533.72 $533.72 $0.00 $0.00 $149.86 $0.00 $425.35 $425.35 $0.00 $359.55 $569.53 $575.28 $0.00 $0.00 $112.54 $0.00 $0.00 $114.48 $0.00 $0.00 $0.00 $0.00 $0.00 71021072 SUP HCPCS C1713 71021072 - PIN HLF 6MM 20MM HXFX SS ORTH XTRNFX SYS BOTH IP/OP $719.10 $532.13 $0.00 $575.28 $323.60 $323.60 $0.00 $0.00 $0.00 $149.88 $533.72 $533.72 $0.00 $0.00 $149.86 $0.00 $425.35 $425.35 $0.00 $359.55 $569.53 $575.28 $0.00 $0.00 $112.54 $0.00 $0.00 $114.48 $0.00 $0.00 $0.00 $0.00 $0.00 71021073 SUP HCPCS C1713 71021073 - PIN HLF 6MM 25MM HXFX SS BOTH IP/OP $248.20 $183.67 $0.00 $198.56 $111.69 $111.69 $0.00 $0.00 $0.00 $51.73 $184.21 $184.21 $0.00 $0.00 $51.72 $0.00 $146.81 $146.81 $0.00 $124.10 $196.57 $198.56 $0.00 $0.00 $38.84 $0.00 $0.00 $39.51 $0.00 $0.00 $0.00 $0.00 $0.00 71021074 SUP HCPCS C1713 71021074 - PIN HLF 6MM 30MM HXFX SS BOTH IP/OP $496.40 $367.34 $0.00 $397.12 $223.38 $223.38 $0.00 $0.00 $0.00 $103.46 $368.43 $368.43 $0.00 $0.00 $103.45 $0.00 $293.62 $293.62 $0.00 $248.20 $393.15 $397.12 $0.00 $0.00 $77.69 $0.00 $0.00 $79.03 $0.00 $0.00 $0.00 $0.00 $0.00 71021075 SUP HCPCS C1713 71021075 - PIN HLF 6MM 35MM HXFX SS BOTH IP/OP $282.20 $208.83 $0.00 $225.76 $126.99 $126.99 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $141.10 $223.50 $225.76 $0.00 $0.00 $44.16 $0.00 $0.00 $44.93 $0.00 $0.00 $0.00 $0.00 $0.00 71021077 SUP HCPCS C1713 71021077 - PIN HLF 6MM 45MM HXFX SS ORTH XTRNFX SYS BOTH IP/OP $719.10 $532.13 $0.00 $575.28 $323.60 $323.60 $0.00 $0.00 $0.00 $149.88 $533.72 $533.72 $0.00 $0.00 $149.86 $0.00 $425.35 $425.35 $0.00 $359.55 $569.53 $575.28 $0.00 $0.00 $112.54 $0.00 $0.00 $114.48 $0.00 $0.00 $0.00 $0.00 $0.00 71021079 SUP HCPCS C1713 71021079 - PIN HLF 6MM 55MM HXFX SS BOTH IP/OP $282.20 $208.83 $0.00 $225.76 $126.99 $126.99 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $141.10 $223.50 $225.76 $0.00 $0.00 $44.16 $0.00 $0.00 $44.93 $0.00 $0.00 $0.00 $0.00 $0.00 71021081 SUP HCPCS C1713 71021081 - PIN HLF 6MM 65MM HXFX SS ORTH XTRNFX SYS BOTH IP/OP $409.70 $303.18 $0.00 $327.76 $184.37 $184.37 $0.00 $0.00 $0.00 $85.39 $304.08 $304.08 $0.00 $0.00 $85.38 $0.00 $242.34 $242.34 $0.00 $204.85 $324.48 $327.76 $0.00 $0.00 $64.12 $0.00 $0.00 $65.22 $0.00 $0.00 $0.00 $0.00 $0.00 71021083 SUP HCPCS C1713 71021083 - PIN HLF 6MM 75MM HXFX SS ORTH XTRNFX SYS BOTH IP/OP $409.70 $303.18 $0.00 $327.76 $184.37 $184.37 $0.00 $0.00 $0.00 $85.39 $304.08 $304.08 $0.00 $0.00 $85.38 $0.00 $242.34 $242.34 $0.00 $204.85 $324.48 $327.76 $0.00 $0.00 $64.12 $0.00 $0.00 $65.22 $0.00 $0.00 $0.00 $0.00 $0.00 71021085 SUP HCPCS C1713 71021085 - PIN HLF 6MM 85MM HXFX SS ORTH XTRNFX SYS BOTH IP/OP $409.70 $303.18 $0.00 $327.76 $184.37 $184.37 $0.00 $0.00 $0.00 $85.39 $304.08 $304.08 $0.00 $0.00 $85.38 $0.00 $242.34 $242.34 $0.00 $204.85 $324.48 $327.76 $0.00 $0.00 $64.12 $0.00 $0.00 $65.22 $0.00 $0.00 $0.00 $0.00 $0.00 71022001 SUP HCPCS C1713 71022001 - PIN FX 3MM 120MM 16MM COVE PNT ORTH BOTH IP/OP $533.80 $395.01 $0.00 $427.04 $240.21 $240.21 $0.00 $0.00 $0.00 $111.26 $396.19 $396.19 $0.00 $0.00 $111.24 $0.00 $315.74 $315.74 $0.00 $266.90 $422.77 $427.04 $0.00 $0.00 $83.54 $0.00 $0.00 $84.98 $0.00 $0.00 $0.00 $0.00 $0.00 71022002 SUP HCPCS C1713 71022002 - PIN FX 3MM 120MM 22MM COVE PNT ORTH BOTH IP/OP $533.80 $395.01 $0.00 $427.04 $240.21 $240.21 $0.00 $0.00 $0.00 $111.26 $396.19 $396.19 $0.00 $0.00 $111.24 $0.00 $315.74 $315.74 $0.00 $266.90 $422.77 $427.04 $0.00 $0.00 $83.54 $0.00 $0.00 $84.98 $0.00 $0.00 $0.00 $0.00 $0.00 71022003 SUP HCPCS C1713 71022003 - PIN HLF 3MM 28MM 28MM COVE PNT DIST RADL BOTH IP/OP $533.80 $395.01 $0.00 $427.04 $240.21 $240.21 $0.00 $0.00 $0.00 $111.26 $396.19 $396.19 $0.00 $0.00 $111.24 $0.00 $315.74 $315.74 $0.00 $266.90 $422.77 $427.04 $0.00 $0.00 $83.54 $0.00 $0.00 $84.98 $0.00 $0.00 $0.00 $0.00 $0.00 71031033 SUP HCPCS C1713 71031033 - POSITIONER SRG 5MM HXFX CENTERING SLV PIN BOTH IP/OP $691.90 $512.01 $0.00 $553.52 $311.36 $311.36 $0.00 $0.00 $0.00 $144.21 $513.53 $513.53 $0.00 $0.00 $144.19 $0.00 $409.26 $409.26 $0.00 $345.95 $547.98 $553.52 $0.00 $0.00 $108.28 $0.00 $0.00 $110.15 $0.00 $0.00 $0.00 $0.00 $0.00 71031034 SUP HCPCS C1713 71031034 - POSITIONER SRG 6MM HXFX CENTERING SLV PIN BOTH IP/OP $691.90 $512.01 $0.00 $553.52 $311.36 $311.36 $0.00 $0.00 $0.00 $144.21 $513.53 $513.53 $0.00 $0.00 $144.19 $0.00 $409.26 $409.26 $0.00 $345.95 $547.98 $553.52 $0.00 $0.00 $108.28 $0.00 $0.00 $110.15 $0.00 $0.00 $0.00 $0.00 $0.00 71031040 SUP Custom 27203010 71031040 - GUIDE HXFX TROCAR SURG BOTH IP/OP "$5,262.50 " "$3,894.25" $0.00 "$4,210.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,905.83" "$3,905.83" $0.00 $0.00 "$1,096.71" $0.00 $0.00 $0.00 $0.00 "$2,631.25" "$4,167.90" "$4,210.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71033019 SUP Custom 27203010 71033019 - BIT DRL 2MM DIST RDS SYS BOTH IP/OP $914.60 $676.80 $0.00 $731.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $678.82 $678.82 $0.00 $0.00 $190.60 $0.00 $0.00 $0.00 $0.00 $457.30 $724.36 $731.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71053002 SUP Custom 27203010 71053002 - BIT DRL 2.8MM BOTH IP/OP "$1,106.70 " $818.96 $0.00 $885.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $821.39 $821.39 $0.00 $0.00 $230.64 $0.00 $0.00 $0.00 $0.00 $553.35 $876.51 $885.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71053004 SUP Custom 27203010 71053004 - BIT DRL 4.8MM BOTH IP/OP "$1,106.70 " $818.96 $0.00 $885.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $821.39 $821.39 $0.00 $0.00 $230.64 $0.00 $0.00 $0.00 $0.00 $553.35 $876.51 $885.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71053033 SUP HCPCS C1713 71053033 - WASHER XTRNFX 8MM CNTR BD LCK BOLT BOTH IP/OP $265.20 $196.25 $0.00 $212.16 $119.34 $119.34 $0.00 $0.00 $0.00 $55.27 $196.83 $196.83 $0.00 $0.00 $55.27 $0.00 $156.87 $156.87 $0.00 $132.60 $210.04 $212.16 $0.00 $0.00 $41.50 $0.00 $0.00 $42.22 $0.00 $0.00 $0.00 $0.00 $0.00 71053101 SUP HCPCS C1713 71053101 - PIN HLF 3MM 10MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $218.75 $161.88 $0.00 $175.00 $98.44 $98.44 $0.00 $0.00 $0.00 $45.59 $162.36 $162.36 $0.00 $0.00 $45.59 $0.00 $129.39 $129.39 $0.00 $109.38 $173.25 $175.00 $0.00 $0.00 $34.23 $0.00 $0.00 $34.83 $0.00 $0.00 $0.00 $0.00 $0.00 71053151 SUP HCPCS C1713 71053151 - PIN HLF 3MM 15MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $218.75 $161.88 $0.00 $175.00 $98.44 $98.44 $0.00 $0.00 $0.00 $45.59 $162.36 $162.36 $0.00 $0.00 $45.59 $0.00 $129.39 $129.39 $0.00 $109.38 $173.25 $175.00 $0.00 $0.00 $34.23 $0.00 $0.00 $34.83 $0.00 $0.00 $0.00 $0.00 $0.00 71053201 SUP HCPCS C1713 71053201 - PIN HLF 3MM 20MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $218.75 $161.88 $0.00 $175.00 $98.44 $98.44 $0.00 $0.00 $0.00 $45.59 $162.36 $162.36 $0.00 $0.00 $45.59 $0.00 $129.39 $129.39 $0.00 $109.38 $173.25 $175.00 $0.00 $0.00 $34.23 $0.00 $0.00 $34.83 $0.00 $0.00 $0.00 $0.00 $0.00 71053251 SUP HCPCS C1713 71053251 - PIN HLF 3MM 25MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $218.75 $161.88 $0.00 $175.00 $98.44 $98.44 $0.00 $0.00 $0.00 $45.59 $162.36 $162.36 $0.00 $0.00 $45.59 $0.00 $129.39 $129.39 $0.00 $109.38 $173.25 $175.00 $0.00 $0.00 $34.23 $0.00 $0.00 $34.83 $0.00 $0.00 $0.00 $0.00 $0.00 71054151 SUP HCPCS C1713 71054151 - PIN HLF 4MM 15MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $231.88 $171.59 $0.00 $185.50 $104.34 $104.34 $0.00 $0.00 $0.00 $48.33 $172.10 $172.10 $0.00 $0.00 $48.32 $0.00 $137.15 $137.15 $0.00 $115.94 $183.65 $185.50 $0.00 $0.00 $36.29 $0.00 $0.00 $36.91 $0.00 $0.00 $0.00 $0.00 $0.00 71054201 SUP HCPCS C1713 71054201 - PIN HLF 4MM 20MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $231.88 $171.59 $0.00 $185.50 $104.34 $104.34 $0.00 $0.00 $0.00 $48.33 $172.10 $172.10 $0.00 $0.00 $48.32 $0.00 $137.15 $137.15 $0.00 $115.94 $183.65 $185.50 $0.00 $0.00 $36.29 $0.00 $0.00 $36.91 $0.00 $0.00 $0.00 $0.00 $0.00 71054251 SUP HCPCS C1713 71054251 - PIN HLF 4MM 25MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $231.88 $171.59 $0.00 $185.50 $104.34 $104.34 $0.00 $0.00 $0.00 $48.33 $172.10 $172.10 $0.00 $0.00 $48.32 $0.00 $137.15 $137.15 $0.00 $115.94 $183.65 $185.50 $0.00 $0.00 $36.29 $0.00 $0.00 $36.91 $0.00 $0.00 $0.00 $0.00 $0.00 71054301 SUP HCPCS C1713 71054301 - PIN HLF 4MM 30MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $231.88 $171.59 $0.00 $185.50 $104.34 $104.34 $0.00 $0.00 $0.00 $48.33 $172.10 $172.10 $0.00 $0.00 $48.32 $0.00 $137.15 $137.15 $0.00 $115.94 $183.65 $185.50 $0.00 $0.00 $36.29 $0.00 $0.00 $36.91 $0.00 $0.00 $0.00 $0.00 $0.00 71054351 SUP HCPCS C1713 71054351 - PIN HLF 4MM 35MM JTX TI ORTH XTRNFX SYS BOTH IP/OP $231.88 $171.59 $0.00 $185.50 $104.34 $104.34 $0.00 $0.00 $0.00 $48.33 $172.10 $172.10 $0.00 $0.00 $48.32 $0.00 $137.15 $137.15 $0.00 $115.94 $183.65 $185.50 $0.00 $0.00 $36.29 $0.00 $0.00 $36.91 $0.00 $0.00 $0.00 $0.00 $0.00 71055020 SUP HCPCS C1713 71055020 - PIN HLF 5MM 20MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $121.13 $89.64 $0.00 $96.90 $54.51 $54.51 $0.00 $0.00 $0.00 $25.25 $89.90 $89.90 $0.00 $0.00 $25.24 $0.00 $71.65 $71.65 $0.00 $60.56 $95.93 $96.90 $0.00 $0.00 $18.96 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $0.00 71055201 SUP HCPCS C1713 71055201 - PIN HLF SHRT 5MM 20MM JTX TI NTRD BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055251 SUP HCPCS C1713 71055251 - PIN HLF SHRT 5MM 25MM JTX TI NTRD BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055301 SUP HCPCS C1713 71055301 - PIN HLF SHRT 5MM 30MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055351 SUP HCPCS C1713 71055351 - PIN HLF SHRT 5MM 35MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055401 SUP HCPCS C1713 71055401 - PIN HLF SHRT 5MM 40MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055451 SUP HCPCS C1713 71055451 - PIN HLF SHRT 5MM 45MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055501 SUP HCPCS C1713 71055501 - PIN HLF SHRT 5MM 50MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055502 SUP HCPCS C1713 71055502 - PIN HLF LNG 5MM 50MM TI BOTH IP/OP $234.50 $173.53 $0.00 $187.60 $105.53 $105.53 $0.00 $0.00 $0.00 $48.88 $174.05 $174.05 $0.00 $0.00 $48.87 $0.00 $138.71 $138.71 $0.00 $117.25 $185.72 $187.60 $0.00 $0.00 $36.70 $0.00 $0.00 $37.33 $0.00 $0.00 $0.00 $0.00 $0.00 71055503 SUP HCPCS C1713 71055503 - PIN HLF 5MM 50MM STRL TI BOTH IP/OP $718.38 $531.60 $0.00 $574.70 $323.27 $323.27 $0.00 $0.00 $0.00 $149.73 $533.18 $533.18 $0.00 $0.00 $149.71 $0.00 $424.92 $424.92 $0.00 $359.19 $568.96 $574.70 $0.00 $0.00 $112.43 $0.00 $0.00 $114.37 $0.00 $0.00 $0.00 $0.00 $0.00 71055551 SUP HCPCS C1713 71055551 - PIN HLF SHRT 5MM 55MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055552 SUP HCPCS C1713 71055552 - PIN HLF LNG 5MM 55MM TI BOTH IP/OP $234.50 $173.53 $0.00 $187.60 $105.53 $105.53 $0.00 $0.00 $0.00 $48.88 $174.05 $174.05 $0.00 $0.00 $48.87 $0.00 $138.71 $138.71 $0.00 $117.25 $185.72 $187.60 $0.00 $0.00 $36.70 $0.00 $0.00 $37.33 $0.00 $0.00 $0.00 $0.00 $0.00 71055601 SUP HCPCS C1713 71055601 - PIN HLF SHRT 5MM 60MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055602 SUP HCPCS C1713 71055602 - PIN HLF LNG 5MM 60MM TI BOTH IP/OP $234.50 $173.53 $0.00 $187.60 $105.53 $105.53 $0.00 $0.00 $0.00 $48.88 $174.05 $174.05 $0.00 $0.00 $48.87 $0.00 $138.71 $138.71 $0.00 $117.25 $185.72 $187.60 $0.00 $0.00 $36.70 $0.00 $0.00 $37.33 $0.00 $0.00 $0.00 $0.00 $0.00 71055651 SUP HCPCS C1713 71055651 - PIN HLF SHRT 5MM 65MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055701 SUP HCPCS C1713 71055701 - PIN HLF SHRT 5MM 70MM TI BOTH IP/OP $253.75 $187.78 $0.00 $203.00 $114.19 $114.19 $0.00 $0.00 $0.00 $52.89 $188.33 $188.33 $0.00 $0.00 $52.88 $0.00 $150.09 $150.09 $0.00 $126.88 $200.97 $203.00 $0.00 $0.00 $39.71 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 71055702 SUP HCPCS C1713 71055702 - PIN HLF LNG 5MM 70MM TI BOTH IP/OP $234.50 $173.53 $0.00 $187.60 $105.53 $105.53 $0.00 $0.00 $0.00 $48.88 $174.05 $174.05 $0.00 $0.00 $48.87 $0.00 $138.71 $138.71 $0.00 $117.25 $185.72 $187.60 $0.00 $0.00 $36.70 $0.00 $0.00 $37.33 $0.00 $0.00 $0.00 $0.00 $0.00 71056208 SUP HCPCS C1713 71056208 - PIN HLF SHRT 6MM 20MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056209 SUP HCPCS C1713 71056209 - PIN HLF LNG 20MM JTX TI ORTH BOTH IP/OP $248.50 $183.89 $0.00 $198.80 $111.83 $111.83 $0.00 $0.00 $0.00 $51.79 $184.44 $184.44 $0.00 $0.00 $51.79 $0.00 $146.99 $146.99 $0.00 $124.25 $196.81 $198.80 $0.00 $0.00 $38.89 $0.00 $0.00 $39.56 $0.00 $0.00 $0.00 $0.00 $0.00 71056258 SUP HCPCS C1713 71056258 - PIN HLF SHRT 6MM 25MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056308 SUP HCPCS C1713 71056308 - PIN HLF SHRT 6MM 30MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056309 SUP HCPCS C1713 71056309 - PIN HLF LNG 30MM JTX TI ORTH BOTH IP/OP $248.50 $183.89 $0.00 $198.80 $111.83 $111.83 $0.00 $0.00 $0.00 $51.79 $184.44 $184.44 $0.00 $0.00 $51.79 $0.00 $146.99 $146.99 $0.00 $124.25 $196.81 $198.80 $0.00 $0.00 $38.89 $0.00 $0.00 $39.56 $0.00 $0.00 $0.00 $0.00 $0.00 71056358 SUP HCPCS C1713 71056358 - PIN HLF SHRT 6MM 35MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056408 SUP HCPCS C1713 71056408 - PIN HLF SHRT 6MM 40MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056409 SUP HCPCS C1713 71056409 - PIN HLF LNG 40MM JTX TI ORTH BOTH IP/OP $248.50 $183.89 $0.00 $198.80 $111.83 $111.83 $0.00 $0.00 $0.00 $51.79 $184.44 $184.44 $0.00 $0.00 $51.79 $0.00 $146.99 $146.99 $0.00 $124.25 $196.81 $198.80 $0.00 $0.00 $38.89 $0.00 $0.00 $39.56 $0.00 $0.00 $0.00 $0.00 $0.00 71056458 SUP HCPCS C1713 71056458 - PIN HLF SHRT 6MM 45MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056459 SUP HCPCS C1713 71056459 - PIN HLF LNG 45MM JTX TI ORTH BOTH IP/OP $248.50 $183.89 $0.00 $198.80 $111.83 $111.83 $0.00 $0.00 $0.00 $51.79 $184.44 $184.44 $0.00 $0.00 $51.79 $0.00 $146.99 $146.99 $0.00 $124.25 $196.81 $198.80 $0.00 $0.00 $38.89 $0.00 $0.00 $39.56 $0.00 $0.00 $0.00 $0.00 $0.00 71056508 SUP HCPCS C1713 71056508 - PIN HLF SHRT 6MM 50MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056509 SUP HCPCS C1713 71056509 - PIN HLF LNG 50MM JTX TI ORTH BOTH IP/OP $260.75 $192.96 $0.00 $208.60 $117.34 $117.34 $0.00 $0.00 $0.00 $54.35 $193.53 $193.53 $0.00 $0.00 $54.34 $0.00 $154.23 $154.23 $0.00 $130.38 $206.51 $208.60 $0.00 $0.00 $40.81 $0.00 $0.00 $41.51 $0.00 $0.00 $0.00 $0.00 $0.00 71056558 SUP HCPCS C1713 71056558 - PIN HLF SHRT 6MM 55MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056608 SUP HCPCS C1713 71056608 - PIN HLF SHRT 6MM 60MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056609 SUP HCPCS C1713 71056609 - PIN HLF 60MM JTX TI ORTH BOTH IP/OP $260.75 $192.96 $0.00 $208.60 $117.34 $117.34 $0.00 $0.00 $0.00 $54.35 $193.53 $193.53 $0.00 $0.00 $54.34 $0.00 $154.23 $154.23 $0.00 $130.38 $206.51 $208.60 $0.00 $0.00 $40.81 $0.00 $0.00 $41.51 $0.00 $0.00 $0.00 $0.00 $0.00 71056658 SUP HCPCS C1713 71056658 - PIN HLF SHRT 6MM 65MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056708 SUP HCPCS C1713 71056708 - PIN HLF SHRT 6MM 70MM JTX TI NTRD BOTH IP/OP $259.00 $191.66 $0.00 $207.20 $116.55 $116.55 $0.00 $0.00 $0.00 $53.98 $192.23 $192.23 $0.00 $0.00 $53.98 $0.00 $153.20 $153.20 $0.00 $129.50 $205.13 $207.20 $0.00 $0.00 $40.53 $0.00 $0.00 $41.23 $0.00 $0.00 $0.00 $0.00 $0.00 71056709 SUP HCPCS C1713 71056709 - PIN HLF LNG 60MM JTX TI ORTH BOTH IP/OP $260.75 $192.96 $0.00 $208.60 $117.34 $117.34 $0.00 $0.00 $0.00 $54.35 $193.53 $193.53 $0.00 $0.00 $54.34 $0.00 $154.23 $154.23 $0.00 $130.38 $206.51 $208.60 $0.00 $0.00 $40.81 $0.00 $0.00 $41.51 $0.00 $0.00 $0.00 $0.00 $0.00 71061001 SUP HCPCS C1713 71061001 - PIN FX 3.2MM 86MM TROC PNT 1 END ORTH BOTH IP/OP $494.00 $365.56 $0.00 $395.20 $222.30 $222.30 $0.00 $0.00 $0.00 $102.96 $366.65 $366.65 $0.00 $0.00 $102.95 $0.00 $292.20 $292.20 $0.00 $247.00 $391.25 $395.20 $0.00 $0.00 $77.31 $0.00 $0.00 $78.64 $0.00 $0.00 $0.00 $0.00 $0.00 71062007 SUP HCPCS C1713 71062007 - CAP PCTV 5MM BOTH IP/OP $60.30 $44.62 $0.00 $48.24 $27.14 $27.14 $0.00 $0.00 $0.00 $12.57 $44.75 $44.75 $0.00 $0.00 $12.57 $0.00 $35.67 $35.67 $0.00 $30.15 $47.76 $48.24 $0.00 $0.00 $9.44 $0.00 $0.00 $9.60 $0.00 $0.00 $0.00 $0.00 $0.00 71062008 SUP HCPCS C1713 71062008 - BAR XTRNFX JTX CAP BOTH IP/OP $69.10 $51.13 $0.00 $55.28 $31.10 $31.10 $0.00 $0.00 $0.00 $14.40 $51.29 $51.29 $0.00 $0.00 $14.40 $0.00 $40.87 $40.87 $0.00 $34.55 $54.73 $55.28 $0.00 $0.00 $10.81 $0.00 $0.00 $11.00 $0.00 $0.00 $0.00 $0.00 $0.00 71062017 SUP HCPCS C1713 71062017 - CAP END 4MM JTX PIN ORTH XTRNFX SYS BOTH IP/OP $115.50 $85.47 $0.00 $92.40 $51.98 $51.98 $0.00 $0.00 $0.00 $24.07 $85.72 $85.72 $0.00 $0.00 $24.07 $0.00 $68.32 $68.32 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $18.08 $0.00 $0.00 $18.39 $0.00 $0.00 $0.00 $0.00 $0.00 71062200 SUP HCPCS C1713 71062200 - BAR XTRNFX 200MM NS JTX CFBR DISP BOTH IP/OP $400.75 $296.56 $0.00 $320.60 $180.34 $180.34 $0.00 $0.00 $0.00 $83.53 $297.44 $297.44 $0.00 $0.00 $83.52 $0.00 $237.04 $237.04 $0.00 $200.38 $317.39 $320.60 $0.00 $0.00 $62.72 $0.00 $0.00 $63.80 $0.00 $0.00 $0.00 $0.00 $0.00 71062250 SUP Custom 27203010 71062250 - BAR XTRNFX 250MM NS JTX CFBR DISP BOTH IP/OP $430.50 $318.57 $0.00 $344.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.52 $319.52 $0.00 $0.00 $89.72 $0.00 $0.00 $0.00 $0.00 $215.25 $340.96 $344.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71062300 SUP HCPCS C1713 71062300 - BAR XTRNFX 300MM NS JTX CFBR DISP BOTH IP/OP $430.50 $318.57 $0.00 $344.40 $193.73 $193.73 $0.00 $0.00 $0.00 $89.73 $319.52 $319.52 $0.00 $0.00 $89.72 $0.00 $254.64 $254.64 $0.00 $215.25 $340.96 $344.40 $0.00 $0.00 $67.37 $0.00 $0.00 $68.54 $0.00 $0.00 $0.00 $0.00 $0.00 71062350 SUP HCPCS C1713 71062350 - BAR XTRNFX 350MM NS JTX CFBR DISP BOTH IP/OP $430.50 $318.57 $0.00 $344.40 $193.73 $193.73 $0.00 $0.00 $0.00 $89.73 $319.52 $319.52 $0.00 $0.00 $89.72 $0.00 $254.64 $254.64 $0.00 $215.25 $340.96 $344.40 $0.00 $0.00 $67.37 $0.00 $0.00 $68.54 $0.00 $0.00 $0.00 $0.00 $0.00 71062400 SUP HCPCS C1713 71062400 - BAR XTRNFX 400MM NS JTX CFBR DISP BOTH IP/OP $474.25 $350.95 $0.00 $379.40 $213.41 $213.41 $0.00 $0.00 $0.00 $98.85 $351.99 $351.99 $0.00 $0.00 $98.83 $0.00 $280.52 $280.52 $0.00 $237.13 $375.61 $379.40 $0.00 $0.00 $74.22 $0.00 $0.00 $75.50 $0.00 $0.00 $0.00 $0.00 $0.00 71063006 SUP Custom 27203010 71063006 - BIT DRL 3.5MM STRL JTX AO CNCT BOTH IP/OP $470.75 $348.36 $0.00 $376.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.39 $349.39 $0.00 $0.00 $98.10 $0.00 $0.00 $0.00 $0.00 $235.38 $372.83 $376.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71063011 SUP HCPCS C1769 71063011 - GUIDEWIRE ESCP 1.6MM BOTH IP/OP "$1,876.88 " "$1,388.89" $0.00 "$1,501.50" "$1,019.14" "$1,019.14" $0.00 $0.00 $0.00 $391.19 "$1,393.02" "$1,393.02" $0.00 $0.00 $391.14 $0.00 "$1,110.17" "$1,110.17" $0.00 $938.44 "$1,486.49" "$1,501.50" $0.00 $0.00 $293.73 $0.00 $0.00 $298.80 $0.00 $0.00 $0.00 $0.00 $0.00 71063028 SUP Custom 27203010 71063028 - BIT DRL 3.5MM STRL JTX GRAD STP SHRT HLF PIN BOTH IP/OP $413.88 $306.27 $0.00 $331.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.18 $307.18 $0.00 $0.00 $86.25 $0.00 $0.00 $0.00 $0.00 $206.94 $327.79 $331.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71063152 SUP HCPCS C1713 71063152 - PIN XTRNFX SHRT 3MM 15MM JTX TI NTRD DIST RDS XTRNFX SYS BOTH IP/OP $317.63 $235.05 $0.00 $254.10 $142.93 $142.93 $0.00 $0.00 $0.00 $66.20 $235.74 $235.74 $0.00 $0.00 $66.19 $0.00 $187.88 $187.88 $0.00 $158.81 $251.56 $254.10 $0.00 $0.00 $49.71 $0.00 $0.00 $50.57 $0.00 $0.00 $0.00 $0.00 $0.00 71063202 SUP HCPCS C1713 71063202 - PIN XTRNFX SHRT 3MM 20MM JTX TI NTRD DIST RDS XTRNFX SYS BOTH IP/OP $317.63 $235.05 $0.00 $254.10 $142.93 $142.93 $0.00 $0.00 $0.00 $66.20 $235.74 $235.74 $0.00 $0.00 $66.19 $0.00 $187.88 $187.88 $0.00 $158.81 $251.56 $254.10 $0.00 $0.00 $49.71 $0.00 $0.00 $50.57 $0.00 $0.00 $0.00 $0.00 $0.00 71063203 SUP Custom 27203010 71063203 - BIT DRL SHRT 3MM STRL GRAD HLF PIN BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $0.00 $0.00 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71064151 SUP HCPCS C1713 71064151 - PIN HLF 4MM 95MM 15MM JTX SS DIST RDS FT XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064158 SUP HCPCS C1713 71064158 - PIN HLF SHRT 4MM 15MM JTX TI NTRD XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064201 SUP HCPCS C1713 71064201 - PIN HLF 4MM 20MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064208 SUP HCPCS C1713 71064208 - PIN HLF SHRT 4MM 20MM JTX TI NTRD XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064251 SUP HCPCS C1713 71064251 - PIN HLF 4MM 25MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064258 SUP HCPCS C1713 71064258 - PIN HLF SHRT 4MM 25MM JTX TI NTRD XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064301 SUP HCPCS C1713 71064301 - PIN HLF SHRT 4MM 30MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064308 SUP HCPCS C1713 71064308 - PIN HALF SHORT 4MM 30MM JET-X TITANIUM NITRIDE ORTHOPEDIC BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064351 SUP HCPCS C1713 71064351 - PIN HLF 4MM 35MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71064358 SUP HCPCS C1713 71064358 - PIN HLF SHRT 4MM 35MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $219.63 $162.53 $0.00 $175.70 $98.83 $98.83 $0.00 $0.00 $0.00 $45.78 $163.01 $163.01 $0.00 $0.00 $45.77 $0.00 $129.91 $129.91 $0.00 $109.81 $173.95 $175.70 $0.00 $0.00 $34.37 $0.00 $0.00 $34.96 $0.00 $0.00 $0.00 $0.00 $0.00 71065301 SUP HCPCS C1713 71065301 - PIN HLF 5MM 17.5CM 30MM JTX SS XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065302 SUP HCPCS C1713 71065302 - PIN HLF LNG 5MM 255MM 30MM JTX SS XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065304 SUP HCPCS C1713 71065304 - PIN HLF XSH 5MM 30MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065309 SUP HCPCS C1713 71065309 - PIN HLF LNG 5MM 30MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71065351 SUP HCPCS C1713 71065351 - PIN HLF 5MM 17.5CM 35MM JTX SS XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065352 SUP HCPCS C1713 71065352 - PIN HLF LNG 5MM 255MM 35MM JTX SS XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065354 SUP HCPCS C1713 71065354 - PIN HLF XSH 5MM 35MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065358 SUP HCPCS C1713 71065358 - PIN HLF SHRT 5MM 35MM JTX TI NTRD XTRNFX SYS BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71065359 SUP HCPCS C1713 71065359 - PIN HLF LNG 5MM 35MM JTX TI NTRD XTRNFX SYS BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71065400 SUP HCPCS C1713 71065400 - PIN HLF 5MM 40MM JTX CNN TI NTRD ORTH XTRNFX SYS BOTH IP/OP $392.00 $290.08 $0.00 $313.60 $176.40 $176.40 $0.00 $0.00 $0.00 $81.70 $290.94 $290.94 $0.00 $0.00 $81.69 $0.00 $231.87 $231.87 $0.00 $196.00 $310.46 $313.60 $0.00 $0.00 $61.35 $0.00 $0.00 $62.41 $0.00 $0.00 $0.00 $0.00 $0.00 71065401 SUP HCPCS C1713 71065401 - PIN HLF 5MM 17.5CM 40MM JTX SS XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065402 SUP HCPCS C1713 71065402 - PIN HLF LNG 5MM 225MM 40MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065404 SUP HCPCS C1713 71065404 - PIN HLF XSH 5MM 40MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065407 SUP HCPCS C1713 71065407 - PIN HLF XSH 1.6MM 40MM 40MM JTX CNN TI NTRD ORTH XTRNFX SYS BOTH IP/OP $392.00 $290.08 $0.00 $313.60 $176.40 $176.40 $0.00 $0.00 $0.00 $81.70 $290.94 $290.94 $0.00 $0.00 $81.69 $0.00 $231.87 $231.87 $0.00 $196.00 $310.46 $313.60 $0.00 $0.00 $61.35 $0.00 $0.00 $62.41 $0.00 $0.00 $0.00 $0.00 $0.00 71065408 SUP HCPCS C1713 71065408 - PIN HLF SHRT 5MM 40MM JTX TI NTRD XTRNFX SYS BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71065409 SUP HCPCS C1713 71065409 - PIN HLF LNG 5MM 40MM JTX TI NTRD XTRNFX SYS BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71065451 SUP HCPCS C1713 71065451 - PIN HLF 5MM 17.5CM 45MM JTX SS XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065452 SUP HCPCS C1713 71065452 - PIN HLF LNG 5MM 255MM 45MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065454 SUP HCPCS C1713 71065454 - PIN HLF XSH 5MM 45MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065458 SUP HCPCS C1713 71065458 - PIN HLF SHRT 5MM 45MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71065459 SUP HCPCS C1713 71065459 - PIN HLF LNG 5MM 45MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71065501 SUP HCPCS C1713 71065501 - PIN HLF SHRT 5MM 175MM 50MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065502 SUP HCPCS C1713 71065502 - PIN HLF LNG 5MM 255MM 50MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065508 SUP HCPCS C1713 71065508 - PIN HLF SHRT 5MM 50MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71065509 SUP HCPCS C1713 71065509 - PIN HLF LNG 5MM 50MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71065551 SUP HCPCS C1713 71065551 - PIN HLF SHRT 5MM 175MM 55MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065552 SUP HCPCS C1713 71065552 - PIN HLF LNG 5MM 255MM 55MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065558 SUP HCPCS C1713 71065558 - PIN HLF SHRT 5MM 55MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71065559 SUP HCPCS C1713 71065559 - PIN HLF LNG 5MM 55MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71065601 SUP HCPCS C1713 71065601 - PIN HLF SHRT 5MM 60MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065602 SUP HCPCS C1713 71065602 - PIN HLF LNG 5MM 60MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065608 SUP HCPCS C1713 71065608 - PIN HLF SHRT 5MM 60MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71065609 SUP HCPCS C1713 71065609 - PIN HLF LNG 5MM 60MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71065651 SUP HCPCS C1713 71065651 - PIN HLF SHRT 5MM 65MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065652 SUP HCPCS C1713 71065652 - PIN HLF LNG 5MM 65MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065658 SUP HCPCS C1713 71065658 - PIN HLF SHRT 5MM 65MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71065659 SUP HCPCS C1713 71065659 - PIN HLF LNG 5MM 65MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $230.13 $170.30 $0.00 $184.10 $103.56 $103.56 $0.00 $0.00 $0.00 $47.96 $170.80 $170.80 $0.00 $0.00 $47.96 $0.00 $136.12 $136.12 $0.00 $115.06 $182.26 $184.10 $0.00 $0.00 $36.01 $0.00 $0.00 $36.64 $0.00 $0.00 $0.00 $0.00 $0.00 71065701 SUP HCPCS C1713 71065701 - PIN HLF SHRT 5MM 70MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065702 SUP HCPCS C1713 71065702 - PIN HLF LNG 5MM 70MM JTX SS ORTH XTRNFX SYS BOTH IP/OP $278.25 $205.91 $0.00 $222.60 $125.21 $125.21 $0.00 $0.00 $0.00 $57.99 $206.52 $206.52 $0.00 $0.00 $57.99 $0.00 $164.58 $164.58 $0.00 $139.13 $220.37 $222.60 $0.00 $0.00 $43.55 $0.00 $0.00 $44.30 $0.00 $0.00 $0.00 $0.00 $0.00 71065708 SUP HCPCS C1713 71065708 - PIN HLF SHRT 5MM 70MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71065709 SUP HCPCS C1713 71065709 - PIN HLF LNG 5MM 70MM JTX TI NTRD ORTH XTRNFX SYS BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71066409 SUP HCPCS C1713 71066409 - PIN FX LNG 6MM 40MM NS 160MM JTX SLF DRL ST TI NTRD BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71066459 SUP HCPCS C1713 71066459 - PIN HLF LNG 6MM 45MM JTX TI NTRD BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71066509 SUP HCPCS C1713 71066509 - PIN HALF 50MM 6MM JTX LNG TI NTRD BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $138.60 $138.60 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 71066559 SUP HCPCS C1713 71066559 - PIN HLF LNG 6MM 55MM JTX TI NTRD BOTH IP/OP $233.63 $172.89 $0.00 $186.90 $105.13 $105.13 $0.00 $0.00 $0.00 $48.69 $173.40 $173.40 $0.00 $0.00 $48.69 $0.00 $138.19 $138.19 $0.00 $116.81 $185.03 $186.90 $0.00 $0.00 $36.56 $0.00 $0.00 $37.19 $0.00 $0.00 $0.00 $0.00 $0.00 71067315 SUP Custom 27203010 71067315 - BIT DRL 2MM 3MM HLF PIN BOTH IP/OP $569.63 $421.53 $0.00 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $422.78 $422.78 $0.00 $0.00 $118.71 $0.00 $0.00 $0.00 $0.00 $284.81 $451.15 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71067319 SUP Custom 27203010 71067319 - BIT DRILL LNG 5MM HALF PIN BOTH IP/OP $569.63 $421.53 $0.00 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $422.78 $422.78 $0.00 $0.00 $118.71 $0.00 $0.00 $0.00 $0.00 $284.81 $451.15 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71067321 SUP Custom 27203010 71067321 - BIT DRILL 6 MM HALF PIN BOTH IP/OP $569.63 $421.53 $0.00 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $422.78 $422.78 $0.00 $0.00 $118.71 $0.00 $0.00 $0.00 $0.00 $284.81 $451.15 $455.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71067374 SUP HCPCS C1713 71067374 - CLAMP EXFIX 10.5MM 10.5MM QUICK CONNECT BAR TO BAR JET-X BOTH IP/OP "$1,015.00 " $751.10 $0.00 $812.00 $456.75 $456.75 $0.00 $0.00 $0.00 $211.55 $753.33 $753.33 $0.00 $0.00 $211.53 $0.00 $600.37 $600.37 $0.00 $507.50 $803.88 $812.00 $0.00 $0.00 $158.85 $0.00 $0.00 $161.59 $0.00 $0.00 $0.00 $0.00 $0.00 71070113 SUP HCPCS C1713 71070113 - RING EXFIX CIR FULL 130MM TAYLOR SPATIAL FRAME BOTH IP/OP "$3,230.00 " "$2,390.20" $0.00 "$2,584.00" "$1,453.50" "$1,453.50" $0.00 $0.00 $0.00 $673.21 "$2,397.31" "$2,397.31" $0.00 $0.00 $673.13 $0.00 "$1,592.39" "$1,592.39" $0.00 "$1,615.00" "$2,558.16" "$2,584.00" $0.00 $0.00 $505.50 $0.00 $0.00 $514.22 $0.00 $0.00 $0.00 $0.00 $0.00 71070116 SUP HCPCS C1713 71070116 - RING EXFIX FULL 205MM ALUMINUM TAYLOR SPATIAL FRAME BOTH IP/OP "$3,230.00 " "$2,390.20" $0.00 "$2,584.00" "$1,453.50" "$1,453.50" $0.00 $0.00 $0.00 $673.21 "$2,397.31" "$2,397.31" $0.00 $0.00 $673.13 $0.00 "$1,592.39" "$1,592.39" $0.00 "$1,615.00" "$2,558.16" "$2,584.00" $0.00 $0.00 $505.50 $0.00 $0.00 $514.22 $0.00 $0.00 $0.00 $0.00 $0.00 71070117 SUP Custom 27203010 71070117 - RING EXFIX 230MM FULL RING CIRCULAR TAYLOR SPATIAL FRAME BOTH IP/OP "$3,230.00 " "$2,390.20" $0.00 "$2,584.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,397.31" "$2,397.31" $0.00 $0.00 $673.13 $0.00 $0.00 $0.00 $0.00 "$1,615.00" "$2,558.16" "$2,584.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070124 SUP Custom 27011340 71070124 - RING EXFIX 155MM CIR HALF TLT SP BOTH IP/OP "$3,459.50 " "$2,560.03" $0.00 "$2,767.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,567.64" "$2,567.64" $0.00 $0.00 $720.96 $0.00 $0.00 $0.00 $0.00 "$1,729.75" "$2,739.92" "$2,767.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070144 SUP Custom 27011340 71070144 - RING EXFIX 155MM LNG CIR FT TLT SP BOTH IP/OP "$4,080.00 " "$3,019.20" $0.00 "$3,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,028.18" "$3,028.18" $0.00 $0.00 $850.27 $0.00 $0.00 $0.00 $0.00 "$2,040.00" "$3,231.36" "$3,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070272 SUP HCPCS C1776 71070272 - SLEEVE CENTERING 6MM BOTH IP/OP $406.30 $300.66 $0.00 $325.04 $182.84 $182.84 $0.00 $0.00 $0.00 $84.68 $301.56 $301.56 $0.00 $0.00 $84.67 $0.00 $240.33 $240.33 $0.00 $203.15 $321.79 $325.04 $0.00 $0.00 $63.59 $0.00 $0.00 $64.68 $0.00 $0.00 $0.00 $0.00 $0.00 71070273 SUP Custom 27011340 71070273 - CUBE XTRNFX ILZ 1 HL POST RNCH SYS BOTH IP/OP $527.00 $389.98 $0.00 $421.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $391.14 $391.14 $0.00 $0.00 $109.83 $0.00 $0.00 $0.00 $0.00 $263.50 $417.38 $421.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070282 SUP Custom 27011340 71070282 - CONNECTOR EXFIX 30MM SHRT XTD BOTH IP/OP $406.30 $300.66 $0.00 $325.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.56 $301.56 $0.00 $0.00 $84.67 $0.00 $0.00 $0.00 $0.00 $203.15 $321.79 $325.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070283 SUP Custom 27011340 71070283 - CONNECTOR ROD 50MM LNG XTD BOTH IP/OP $406.30 $300.66 $0.00 $325.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.56 $301.56 $0.00 $0.00 $84.67 $0.00 $0.00 $0.00 $0.00 $203.15 $321.79 $325.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070284 SUP HCPCS C1713 71070284 - BOLT XTRNFX ILZ CMBN WRE BOTH IP/OP $191.20 $141.49 $0.00 $152.96 $86.04 $86.04 $0.00 $0.00 $0.00 $39.85 $141.91 $141.91 $0.00 $0.00 $39.85 $0.00 $113.09 $113.09 $0.00 $95.60 $151.43 $152.96 $0.00 $0.00 $29.92 $0.00 $0.00 $30.44 $0.00 $0.00 $0.00 $0.00 $0.00 71070285 SUP HCPCS C1713 71070285 - NUT ORTH LNG RSN BOTH IP/OP $32.80 $24.27 $0.00 $26.24 $14.76 $14.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.40 $25.98 $26.24 $0.00 $0.00 $5.13 $0.00 $0.00 $5.22 $0.00 $0.00 $0.00 $0.00 $0.00 71070286 SUP HCPCS C1713 71070286 - NUT ORTH 10MM BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $49.05 $49.05 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $0.00 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 71070290 SUP HCPCS C1713 71070290 - CAP PIN 6MM HALF HALF ORANGE BOTH IP/OP $80.33 $59.44 $0.00 $64.26 $36.15 $36.15 $0.00 $0.00 $0.00 $16.74 $59.62 $59.62 $0.00 $0.00 $16.74 $0.00 $47.51 $47.51 $0.00 $40.16 $63.62 $64.26 $0.00 $0.00 $12.57 $0.00 $0.00 $12.79 $0.00 $0.00 $0.00 $0.00 $0.00 71070340 SUP HCPCS C1713 71070340 - KIT XTRNFX FST FX ID BAND STD STRUT BOTH IP/OP "$1,057.40 " $782.48 $0.00 $845.92 $475.83 $475.83 $0.00 $0.00 $0.00 $220.39 $784.80 $784.80 $0.00 $0.00 $220.36 $0.00 $625.45 $625.45 $0.00 $528.70 $837.46 $845.92 $0.00 $0.00 $165.48 $0.00 $0.00 $168.34 $0.00 $0.00 $0.00 $0.00 $0.00 71070345 SUP Custom 27203010 71070345 - DRILL SURG SHORT 3.8MM STEP BOTH IP/OP "$1,072.70 " $793.80 $0.00 $858.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $796.16 $796.16 $0.00 $0.00 $223.55 $0.00 $0.00 $0.00 $0.00 $536.35 $849.58 $858.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070348 SUP Custom 27203010 71070348 - DRILL SURG LONG 3.8MM STEP BOTH IP/OP "$1,072.70 " $793.80 $0.00 $858.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $796.16 $796.16 $0.00 $0.00 $223.55 $0.00 $0.00 $0.00 $0.00 $536.35 $849.58 $858.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070365 SUP Custom 27011340 71070365 - RING EXFIX 180MM 155MM RCKR BOTH IP/OP "$2,592.50 " "$1,918.45" $0.00 "$2,074.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,924.15" "$1,924.15" $0.00 $0.00 $540.28 $0.00 $0.00 $0.00 $0.00 "$1,296.25" "$2,053.26" "$2,074.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070515 SUP HCPCS C1713 71070515 - BOLT CNCT 12MM TLT SP BOTH IP/OP $25.00 $18.50 $0.00 $20.00 $11.25 $11.25 $0.00 $0.00 $0.00 $5.21 $18.56 $18.56 $0.00 $0.00 $5.21 $0.00 $14.79 $14.79 $0.00 $12.50 $19.80 $20.00 $0.00 $0.00 $3.91 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $0.00 71070720 SUP HCPCS C1713 71070720 - STRUT EXFIX MEDIUM CIR 143-205MM FAST-FIX TAYLOR SPATIAL BOTH IP/OP "$3,332.00 " "$2,465.68" $0.00 "$2,665.60" "$1,499.40" "$1,499.40" $0.00 $0.00 $0.00 $694.47 "$2,473.01" "$2,473.01" $0.00 $0.00 $694.39 $0.00 "$1,642.68" "$1,642.68" $0.00 "$1,666.00" "$2,638.94" "$2,665.60" $0.00 $0.00 $521.46 $0.00 $0.00 $530.45 $0.00 $0.00 $0.00 $0.00 $0.00 71070730 SUP HCPCS C1713 71070730 - STRUT XTRNFX LNG 195-311MM FST FX TLT SP BOTH IP/OP "$3,332.00 " "$2,465.68" $0.00 "$2,665.60" "$1,499.40" "$1,499.40" $0.00 $0.00 $0.00 $694.47 "$2,473.01" "$2,473.01" $0.00 $0.00 $694.39 $0.00 "$1,642.68" "$1,642.68" $0.00 "$1,666.00" "$2,638.94" "$2,665.60" $0.00 $0.00 $521.46 $0.00 $0.00 $530.45 $0.00 $0.00 $0.00 $0.00 $0.00 71070800 SUP HCPCS C1713 71070800 - PIN HLF 6MM 150MM 20MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070801 SUP HCPCS C1713 71070801 - PIN HLF 6MM 200MM 20MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070802 SUP HCPCS C1713 71070802 - PIN HALF 6MM 150MM 25MM HA EXFIX SYSTEM BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070803 SUP HCPCS C1713 71070803 - PIN HALF 6MM 200MM 25MM HA ORTHOPEDIC EXFIX SYSTEM BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070804 SUP HCPCS C1713 71070804 - PIN HALF 6MM 150MM 30MM HA EXFIX SYSTEM BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070805 SUP HCPCS C1713 71070805 - PIN HLF 6MM 200MM 30MM HA ORTH XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070806 SUP HCPCS C1713 71070806 - PIN HALF 6MM 150MM 35MM HA EXFIX SYSTEM BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070808 SUP HCPCS C1713 71070808 - PIN HALF 6MM 150MM 40MM HA EXFIX SYSTEM BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070809 SUP HCPCS C1713 71070809 - PIN HALF 200MM 6MM HA 40MM EXFIX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070812 SUP HCPCS C1713 71070812 - PIN HLF 6MM 150MM 55MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070814 SUP HCPCS C1713 71070814 - PIN HLF 6MM 150MM 60MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070815 SUP HCPCS C1713 71070815 - PIN HLF 6MM 200MM 60MM HAP XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070816 SUP HCPCS C1713 71070816 - PIN HLF 6MM 150MM 65MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070817 SUP HCPCS C1713 71070817 - PIN HLF 6MM 200MM 65MM HAP XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070818 SUP HCPCS C1713 71070818 - PIN HLF 6MM 150MM 70MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070819 SUP HCPCS C1713 71070819 - PIN HLF 6MM 200MM 70MM HAP ORTH XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070820 SUP HCPCS C1713 71070820 - PIN HLF 6MM 200MM 80MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070821 SUP HCPCS C1713 71070821 - PIN HLF 6MM 200MM 90MM HAP ORTH XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070822 SUP HCPCS C1713 71070822 - PIN HLF 6MM 150MM 20MM HAP ORTH XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070823 SUP HCPCS C1713 71070823 - PIN HLF 4.5MM 150MM 10MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070824 SUP HCPCS C1713 71070824 - PIN HLF 4.5MM 150MM 20MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070825 SUP HCPCS C1713 71070825 - PIN HALF 4.5MM 150MM 30MM THREAD HA ORTHOPEDIC EXFIX SYSTEM BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070826 SUP HCPCS C1713 71070826 - PIN HALF 4.5MM 150MM 40MM THREAD HA ORTHOPEDIC EXFIX SYSTEM BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070827 SUP HCPCS C1713 71070827 - PIN HLF 4.5MM 150MM 50MM THRD HA ORTH XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070828 SUP HCPCS C1713 71070828 - PIN HLF 6MM 150MM 15MM HA ORTH XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070829 SUP HCPCS C1713 71070829 - PIN HLF 6MM 200MM 15MM HAP ORTH XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070835 SUP HCPCS C1713 71070835 - PIN HLF 6MM 150MM 45MM HA XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070836 SUP HCPCS C1713 71070836 - PIN HLF 6MM 200MM 45MM HAP XTRNFX SYS BOTH IP/OP $586.50 $434.01 $0.00 $469.20 $263.93 $263.93 $0.00 $0.00 $0.00 $122.24 $435.30 $435.30 $0.00 $0.00 $122.23 $0.00 $346.91 $346.91 $0.00 $293.25 $464.51 $469.20 $0.00 $0.00 $91.79 $0.00 $0.00 $93.37 $0.00 $0.00 $0.00 $0.00 $0.00 71070844 SUP Custom 27203010 71070844 - BIT DRL LNG 4.8MM HA PIN BOTH IP/OP "$1,237.60 " $915.82 $0.00 $990.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.55 $918.55 $0.00 $0.00 $257.92 $0.00 $0.00 $0.00 $0.00 $618.80 $980.18 $990.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070845 SUP Custom 27203010 71070845 - BIT DRL 1.8MM 4.8MM CNN HA PIN BOTH IP/OP "$1,603.10 " "$1,186.29" $0.00 "$1,282.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,189.82" "$1,189.82" $0.00 $0.00 $334.09 $0.00 $0.00 $0.00 $0.00 $801.55 "$1,269.66" "$1,282.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71070846 SUP Custom 27203010 71070846 - BIT DRL 1.5MM 3.8MM CNN HA PIN BOTH IP/OP "$1,603.10 " "$1,186.29" $0.00 "$1,282.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,189.82" "$1,189.82" $0.00 $0.00 $334.09 $0.00 $0.00 $0.00 $0.00 $801.55 "$1,269.66" "$1,282.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71100045 SUP HCPCS C1713 71100045 - SCREW BN 6.5MM 45MM STRL 32MM CNN ORTH BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100050 SUP HCPCS C1713 71100050 - SCREW BN 6.5MM 8MM 3.5MM 50MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100055 SUP HCPCS C1713 71100055 - SCREW BN 6.5MM 8MM 3.5MM 55MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100060 SUP HCPCS C1713 71100060 - SCREW BN 6.5MM 8MM 3.5MM 60MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100065 SUP HCPCS C1713 71100065 - SCREW BN 6.5MM 8MM 3.5MM 65MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100070 SUP HCPCS C1713 71100070 - SCREW BN 6.5MM 8MM 3.5MM 70MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100075 SUP HCPCS C1713 71100075 - SCREW BN 6.5MM 8MM 3.5MM 75MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100080 SUP HCPCS C1713 71100080 - SCREW BN 6.5MM 8MM 3.5MM 80MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100085 SUP HCPCS C1713 71100085 - SCREW BN 6.5MM 8MM 3.5MM 85MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100090 SUP HCPCS C1713 71100090 - SCREW BN 6.5MM 8MM 3.5MM 90MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100095 SUP HCPCS C1713 71100095 - SCREW BN 6.5MM 8MM 3.5MM 95MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100100 SUP HCPCS C1713 71100100 - SCREW BN 6.5MM 8MM 3.5MM 100MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100105 SUP HCPCS C1713 71100105 - SCREW BN 6.5MM 105MM STRL 32MM CNN ORTH BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100110 SUP HCPCS C1713 71100110 - SCREW BN 6.5MM 8MM 3.5MM 110MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100115 SUP HCPCS C1713 71100115 - SCREW BN 6.5MM 115MM STRL 32MM CNN ORTH BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100120 SUP HCPCS C1713 71100120 - SCREW BN 6.5MM 8MM 3.5MM 120MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100125 SUP HCPCS C1713 71100125 - SCREW BN 6.5MM 125MM STRL 32MM CNN ORTH BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71100130 SUP HCPCS C1713 71100130 - SCREW BN 6.5MM 8MM 3.5MM 130MM STRL 32MM CNN SS HIP ACPT 2.4 BOTH IP/OP $531.30 $393.16 $0.00 $425.04 $239.09 $239.09 $0.00 $0.00 $0.00 $110.74 $394.33 $394.33 $0.00 $0.00 $110.72 $0.00 $314.26 $314.26 $0.00 $265.65 $420.79 $425.04 $0.00 $0.00 $83.15 $0.00 $0.00 $84.58 $0.00 $0.00 $0.00 $0.00 $0.00 71101000 SUP HCPCS C1713 71101000 - WASHER ORTH 8MM 4MM STRL TI BOTH IP/OP $187.70 $138.90 $0.00 $150.16 $84.47 $84.47 $0.00 $0.00 $0.00 $39.12 $139.31 $139.31 $0.00 $0.00 $39.12 $0.00 $111.02 $111.02 $0.00 $93.85 $148.66 $150.16 $0.00 $0.00 $29.38 $0.00 $0.00 $29.88 $0.00 $0.00 $0.00 $0.00 $0.00 71101020 SUP HCPCS C1713 71101020 - SCREW BN 4MM 20MM STRL 8MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101022 SUP HCPCS C1713 71101022 - SCREW BN 4MM 22MM STRL 10MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101024 SUP HCPCS C1713 71101024 - SCREW BN 4MM 24MM STRL 12MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101026 SUP HCPCS C1713 71101026 - SCREW BN 4MM 26MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101028 SUP HCPCS C1713 71101028 - SCREW BN 4MM 28MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101030 SUP HCPCS C1713 71101030 - SCREW BN 4MM 30MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101032 SUP HCPCS C1713 71101032 - SCREW BN 4MM 32MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101034 SUP HCPCS C1713 71101034 - SCREW BN 4MM 34MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101036 SUP HCPCS C1713 71101036 - SCREW BN 4MM 36MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101038 SUP HCPCS C1713 71101038 - SCREW BN 4MM 38MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101040 SUP HCPCS C1713 71101040 - SCREW BN 4MM 40MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101042 SUP HCPCS C1713 71101042 - SCREW BN 4MM 42MM STRL 14MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101044 SUP HCPCS C1713 71101044 - SCREW BN 4MM 44MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101046 SUP HCPCS C1713 71101046 - SCREW BN 4MM 46MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101048 SUP HCPCS C1713 71101048 - SCREW BN 4MM 48MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101050 SUP HCPCS C1713 71101050 - SCREW BN 4MM 50MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101052 SUP HCPCS C1713 71101052 - SCREW BN 4MM 52MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101054 SUP HCPCS C1713 71101054 - SCREW BN 4MM 54MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101056 SUP HCPCS C1713 71101056 - SCREW BN 4MM 56MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101058 SUP HCPCS C1713 71101058 - SCREW BN 4MM 58MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101060 SUP HCPCS C1713 71101060 - SCREW BN 4MM 60MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101065 SUP HCPCS C1713 71101065 - SCREW BN 4MM 65MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101070 SUP HCPCS C1713 71101070 - SCREW BN 4MM 70MM STRL 15MM CNN TI ORTH BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71101401 SUP HCPCS C1713 71101401 - CAP PCTV 1.1 MM WRE BOTH IP/OP $30.70 $22.72 $0.00 $24.56 $13.82 $13.82 $0.00 $0.00 $0.00 $6.40 $22.79 $22.79 $0.00 $0.00 $6.40 $0.00 $18.16 $18.16 $0.00 $15.35 $24.31 $24.56 $0.00 $0.00 $4.80 $0.00 $0.00 $4.89 $0.00 $0.00 $0.00 $0.00 $0.00 71101402 SUP HCPCS C1713 71101402 - CAP PCTV 1.25 MM WRE BOTH IP/OP $30.70 $22.72 $0.00 $24.56 $13.82 $13.82 $0.00 $0.00 $0.00 $6.40 $22.79 $22.79 $0.00 $0.00 $6.40 $0.00 $18.16 $18.16 $0.00 $15.35 $24.31 $24.56 $0.00 $0.00 $4.80 $0.00 $0.00 $4.89 $0.00 $0.00 $0.00 $0.00 $0.00 71101403 SUP HCPCS C1713 71101403 - CAP PCTV 1.6 MM WRE BOTH IP/OP $30.70 $22.72 $0.00 $24.56 $13.82 $13.82 $0.00 $0.00 $0.00 $6.40 $22.79 $22.79 $0.00 $0.00 $6.40 $0.00 $18.16 $18.16 $0.00 $15.35 $24.31 $24.56 $0.00 $0.00 $4.80 $0.00 $0.00 $4.89 $0.00 $0.00 $0.00 $0.00 $0.00 71101404 SUP HCPCS C1713 71101404 - CAP PCTV 2 MM WRE BOTH IP/OP $30.70 $22.72 $0.00 $24.56 $13.82 $13.82 $0.00 $0.00 $0.00 $6.40 $22.79 $22.79 $0.00 $0.00 $6.40 $0.00 $18.16 $18.16 $0.00 $15.35 $24.31 $24.56 $0.00 $0.00 $4.80 $0.00 $0.00 $4.89 $0.00 $0.00 $0.00 $0.00 $0.00 71101501 SUP Custom 27203010 71101501 - WIRE FX 2MM 150MM DRL TIP BOTH IP/OP $145.50 $107.67 $0.00 $116.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.99 $107.99 $0.00 $0.00 $30.32 $0.00 $0.00 $0.00 $0.00 $72.75 $115.24 $116.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71101502 SUP Custom 27203010 71101502 - WIRE FX FLUT 1.6MM 150MM VLP DRL TIP COCR BOTH IP/OP $105.63 $78.17 $0.00 $84.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.39 $78.39 $0.00 $0.00 $22.01 $0.00 $0.00 $0.00 $0.00 $52.81 $83.66 $84.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71101691 SUP HCPCS C1713 71101691 - WASHER ORTH 21.7MM 12.7MM OBLNG SS BOTH IP/OP $109.20 $80.81 $0.00 $87.36 $49.14 $49.14 $0.00 $0.00 $0.00 $22.76 $81.05 $81.05 $0.00 $0.00 $22.76 $0.00 $64.59 $64.59 $0.00 $54.60 $86.49 $87.36 $0.00 $0.00 $17.09 $0.00 $0.00 $17.38 $0.00 $0.00 $0.00 $0.00 $0.00 71101693 SUP HCPCS C1713 71101693 - WASHER ORTH 21.7MM BTRFLY SS BOTH IP/OP $103.33 $76.46 $0.00 $82.66 $46.50 $46.50 $0.00 $0.00 $0.00 $21.54 $76.69 $76.69 $0.00 $0.00 $21.53 $0.00 $61.12 $61.12 $0.00 $51.66 $81.84 $82.66 $0.00 $0.00 $16.17 $0.00 $0.00 $16.45 $0.00 $0.00 $0.00 $0.00 $0.00 71102000 SUP HCPCS C1713 71102000 - WASHER ORTH 12.7MM 6.5MM 1MM TI BOTH IP/OP $242.40 $179.38 $0.00 $193.92 $109.08 $109.08 $0.00 $0.00 $0.00 $50.52 $179.91 $179.91 $0.00 $0.00 $50.52 $0.00 $143.38 $143.38 $0.00 $121.20 $191.98 $193.92 $0.00 $0.00 $37.94 $0.00 $0.00 $38.59 $0.00 $0.00 $0.00 $0.00 $0.00 71102030 SUP HCPCS C1713 71102030 - PIN FX 30MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102035 SUP HCPCS C1713 71102035 - PIN FX 35MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102040 SUP HCPCS C1713 71102040 - PIN FX 40MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102045 SUP HCPCS C1713 71102045 - PIN FX 45MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102050 SUP HCPCS C1713 71102050 - PIN FX 50MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102055 SUP HCPCS C1713 71102055 - PIN FX 55MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102060 SUP HCPCS C1713 71102060 - PIN FX 60MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102065 SUP HCPCS C1713 71102065 - PIN FX 65MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102070 SUP HCPCS C1713 71102070 - PIN FX 70MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102075 SUP HCPCS C1713 71102075 - PIN FX 75MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102080 SUP HCPCS C1713 71102080 - PIN FX 80MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102085 SUP HCPCS C1713 71102085 - PIN FX 85MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102090 SUP HCPCS C1713 71102090 - PIN FX 90MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102095 SUP HCPCS C1713 71102095 - PIN FX 95MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102100 SUP HCPCS C1713 71102100 - PIN FX 100MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102105 SUP HCPCS C1713 71102105 - PIN FX 105MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102110 SUP HCPCS C1713 71102110 - PIN FX 110MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102115 SUP HCPCS C1713 71102115 - PIN FX 115MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102120 SUP HCPCS C1713 71102120 - PIN FX 120MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102125 SUP HCPCS C1713 71102125 - PIN FX 125MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102130 SUP HCPCS C1713 71102130 - PIN FX 130MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71102135 SUP HCPCS C1713 71102135 - PIN FX 135MM 16MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71103045 SUP HCPCS C1713 71103045 - PIN FX 45MM 32MM CNN TI HIP BOTH IP/OP $741.30 $548.56 $0.00 $593.04 $333.59 $333.59 $0.00 $0.00 $0.00 $154.51 $550.19 $550.19 $0.00 $0.00 $154.49 $0.00 $438.48 $438.48 $0.00 $370.65 $587.11 $593.04 $0.00 $0.00 $116.01 $0.00 $0.00 $118.01 $0.00 $0.00 $0.00 $0.00 $0.00 71107030 SUP HCPCS C1713 71107030 - SCREW BN 7MM 30MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107035 SUP HCPCS C1713 71107035 - SCREW BN 7MM 35MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107040 SUP HCPCS C1713 71107040 - SCREW BN 7MM 40MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107045 SUP HCPCS C1713 71107045 - SCREW BN 7MM 45MM 16MM CNN P/T TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107050 SUP HCPCS C1713 71107050 - SCREW BN 7MM 50MM 16MM CNN P/T TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107055 SUP HCPCS C1713 71107055 - SCREW BN 7MM 55MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107060 SUP HCPCS C1713 71107060 - SCREW BN 7MM 60MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107065 SUP HCPCS C1713 71107065 - SCREW BN P/T 7MM 65MM STRL 16MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107070 SUP HCPCS C1713 71107070 - SCREW BN P/T 7MM 70MM STRL 16MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107075 SUP HCPCS C1713 71107075 - SCREW BN P/T 7MM 75MM STRL 16MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107080 SUP HCPCS C1713 71107080 - SCREW BN P/T 7MM 80MM STRL 16MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107085 SUP HCPCS C1713 71107085 - SCREW BN P/T 7MM 85MM STRL 16MM CNN TI SM BN LNG BN BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107090 SUP HCPCS C1713 71107090 - SCREW BN P/T 7MM 90MM STRL 16MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107095 SUP HCPCS C1713 71107095 - SCREW BN P/T 7MM 95MM STRL 16MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107100 SUP HCPCS C1713 71107100 - SCREW BN P/T 7MM 100MM STRL 16MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107105 SUP HCPCS C1713 71107105 - SCREW BN P/T 7MM 105MM STRL 16MM CNN TI SM BN LNG BN BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107110 SUP HCPCS C1713 71107110 - SCREW BN 7MM 110MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107115 SUP HCPCS C1713 71107115 - SCREW BN 7MM 115MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107120 SUP HCPCS C1713 71107120 - SCREW BN 7MM 120MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107125 SUP HCPCS C1713 71107125 - SCREW BN 7MM 125MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107130 SUP HCPCS C1713 71107130 - SCREW BN 7MM 130MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107135 SUP HCPCS C1713 71107135 - SCREW BN 7MM 135MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107140 SUP HCPCS C1713 71107140 - SCREW BN 7MM 140MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107145 SUP HCPCS C1713 71107145 - SCREW BN 7MM 145MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71107150 SUP HCPCS C1713 71107150 - SCREW BN 7MM 150MM STRL 16MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108045 SUP HCPCS C1713 71108045 - SCREW BN 7MM 45MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108050 SUP HCPCS C1713 71108050 - SCREW BN 7MM 50MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108055 SUP HCPCS C1713 71108055 - SCREW BN 7MM 55MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108060 SUP HCPCS C1713 71108060 - SCREW BN 7MM 60MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108065 SUP HCPCS C1713 71108065 - SCREW BN 7MM 65MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108070 SUP HCPCS C1713 71108070 - SCREW BN 7MM 70MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108075 SUP HCPCS C1713 71108075 - SCREW BN P/T 7MM 75MM STRL 32MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108080 SUP HCPCS C1713 71108080 - SCREW BN P/T 7MM 80MM STRL 32MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108085 SUP HCPCS C1713 71108085 - SCREW BN 7MM 85MM 32MM CNN P/T TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108090 SUP HCPCS C1713 71108090 - SCREW BN P/T 7MM 90MM STRL 32MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108095 SUP HCPCS C1713 71108095 - SCREW BN P/T 7MM 95MM STRL 32MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108100 SUP HCPCS C1713 71108100 - SCREW BN P/T 7MM 100MM STRL 32MM CNN TI BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108105 SUP HCPCS C1713 71108105 - SCREW BN 7MM 105MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108110 SUP HCPCS C1713 71108110 - SCREW BN 7MM 110MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108115 SUP HCPCS C1713 71108115 - SCREW BN 7MM 115MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108120 SUP HCPCS C1713 71108120 - SCREW BN 7MM 120MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108125 SUP HCPCS C1713 71108125 - SCREW BN 7MM 125MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108130 SUP HCPCS C1713 71108130 - SCREW BN 7MM 130MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108135 SUP HCPCS C1713 71108135 - SCREW BN 7MM 135MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108140 SUP HCPCS C1713 71108140 - SCREW BN 7MM 140MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108145 SUP HCPCS C1713 71108145 - SCREW BN 7MM 145MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108150 SUP HCPCS C1713 71108150 - SCREW BN 7MM 150MM STRL 32MM CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71108670 SUP HCPCS C1713 71108670 - SCREW BN P/T 8MM 170MM 24MM CNN SS CANC BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 71109030 SUP HCPCS C1713 71109030 - SCREW BN FT 7MM 30MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109035 SUP HCPCS C1713 71109035 - SCREW BN FT 7MM 35MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109040 SUP HCPCS C1713 71109040 - SCREW BN FT 7MM 40MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109045 SUP HCPCS C1713 71109045 - SCREW BN FT 7MM 45MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109050 SUP HCPCS C1713 71109050 - SCREW BN FT 7MM 50MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109055 SUP HCPCS C1713 71109055 - SCREW BN FT 7MM 55MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109060 SUP HCPCS C1713 71109060 - SCREW BN FT 7MM 60MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109065 SUP HCPCS C1713 71109065 - SCREW BN FT 7MM 65MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109070 SUP HCPCS C1713 71109070 - SCREW BN FT 7MM 70MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109075 SUP HCPCS C1713 71109075 - SCREW BN FT 7MM 75MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109080 SUP HCPCS C1713 71109080 - SCREW BN FT 7MM 80MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109085 SUP HCPCS C1713 71109085 - SCREW BN FT 7MM 85MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109090 SUP HCPCS C1713 71109090 - SCREW BN FT 7MM 90MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109095 SUP HCPCS C1713 71109095 - SCREW BN FT 7MM 95MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109100 SUP HCPCS C1713 71109100 - SCREW BN FT 7MM 100MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109105 SUP HCPCS C1713 71109105 - SCREW BN FT 7MM 105MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109110 SUP HCPCS C1713 71109110 - SCREW BN FT 7MM 110MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109115 SUP HCPCS C1713 71109115 - SCREW BN 7MM 115MM STRL CNN FT TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109120 SUP HCPCS C1713 71109120 - SCREW BN 7MM 120MM STRL CNN FT TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109125 SUP HCPCS C1713 71109125 - SCREW BN FT 7MM 125MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109130 SUP HCPCS C1713 71109130 - SCREW BN FT 7MM 130MM STRL CNN TI ORTH BOTH IP/OP $519.75 $384.62 $0.00 $415.80 $233.89 $233.89 $0.00 $0.00 $0.00 $108.33 $385.76 $385.76 $0.00 $0.00 $108.32 $0.00 $307.43 $307.43 $0.00 $259.88 $411.64 $415.80 $0.00 $0.00 $81.34 $0.00 $0.00 $82.74 $0.00 $0.00 $0.00 $0.00 $0.00 71110027 SUP Custom 27203010 71110027 - BIT DRL 4.5MM TWST BOTH IP/OP $143.85 $106.45 $0.00 $115.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.77 $106.77 $0.00 $0.00 $29.98 $0.00 $0.00 $0.00 $0.00 $71.93 $113.93 $115.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71110045 SUP Custom 27203010 71110045 - BIT DRL 3.5MM TWST BOTH IP/OP $114.45 $84.69 $0.00 $91.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.94 $84.94 $0.00 $0.00 $23.85 $0.00 $0.00 $0.00 $0.00 $57.23 $90.64 $91.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71116060 SUP HCPCS C1713 71116060 - PIN FX 3IN ORTH BOTH IP/OP "$1,459.50 " "$1,080.03" $0.00 "$1,167.60" $656.78 $656.78 $0.00 $0.00 $0.00 $304.20 "$1,083.24" "$1,083.24" $0.00 $0.00 $304.16 $0.00 $863.29 $863.29 $0.00 $729.75 "$1,155.92" "$1,167.60" $0.00 $0.00 $228.41 $0.00 $0.00 $232.35 $0.00 $0.00 $0.00 $0.00 $0.00 71119005 SUP HCPCS C1713 71119005 - WASHER XTRNFX 12.7MM SLV 7MM CNN SCR BOTH IP/OP $308.70 $228.44 $0.00 $246.96 $138.92 $138.92 $0.00 $0.00 $0.00 $64.34 $229.12 $229.12 $0.00 $0.00 $64.33 $0.00 $182.60 $182.60 $0.00 $154.35 $244.49 $246.96 $0.00 $0.00 $48.31 $0.00 $0.00 $49.15 $0.00 $0.00 $0.00 $0.00 $0.00 71119007 SUP Custom 27203010 71119007 - BIT DRL 4MM STRL CNN BOTH IP/OP $807.45 $597.51 $0.00 $645.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.29 $599.29 $0.00 $0.00 $168.27 $0.00 $0.00 $0.00 $0.00 $403.73 $639.50 $645.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71119106 SUP Custom 27203010 71119106 - BIT DRL 5.2MM STRL CNN 7MM SCR BOTH IP/OP $940.80 $696.19 $0.00 $752.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $698.26 $698.26 $0.00 $0.00 $196.06 $0.00 $0.00 $0.00 $0.00 $470.40 $745.11 $752.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71120006 SUP HCPCS C1713 71120006 - WASHER ORTH THK1MM 8MM 4MM STRL CNN SS 4MM CNN SCR BOTH IP/OP $121.90 $90.21 $0.00 $97.52 $54.86 $54.86 $0.00 $0.00 $0.00 $25.41 $90.47 $90.47 $0.00 $0.00 $25.40 $0.00 $72.10 $72.10 $0.00 $60.95 $96.54 $97.52 $0.00 $0.00 $19.08 $0.00 $0.00 $19.41 $0.00 $0.00 $0.00 $0.00 $0.00 71123122 SUP HCPCS C1713 71123122 - PLATE BN 90D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123124 SUP HCPCS C1713 71123124 - PLATE BN 100D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123126 SUP HCPCS C1713 71123126 - PLATE BN 110D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123128 SUP HCPCS C1713 71123128 - PLATE BN 120D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123130 SUP HCPCS C1713 71123130 - PLATE BN 130D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123132 SUP HCPCS C1713 71123132 - PLATE BN 135D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123134 SUP HCPCS C1713 71123134 - PLATE BN 140D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123136 SUP HCPCS C1713 71123136 - PLATE BN 145D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123138 SUP HCPCS C1713 71123138 - PLATE BN 150D 55MM CHS 3 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123140 SUP HCPCS C1713 71123140 - PLATE BN 90D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123142 SUP HCPCS C1713 71123142 - PLATE BN 100D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123144 SUP HCPCS C1713 71123144 - PLATE BN 110D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123146 SUP HCPCS C1713 71123146 - PLATE BN 120D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123148 SUP HCPCS C1713 71123148 - PLATE BN 130D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123150 SUP HCPCS C1713 71123150 - PLATE BN 135D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123152 SUP HCPCS C1713 71123152 - PLATE BN 140D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123154 SUP HCPCS C1713 71123154 - PLATE BN 145D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123156 SUP HCPCS C1713 71123156 - PLATE BN 150D 76MM CHS 4 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123158 SUP HCPCS C1713 71123158 - PLATE BN 90D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123160 SUP HCPCS C1713 71123160 - PLATE BN 100D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123162 SUP HCPCS C1713 71123162 - PLATE BN 110D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123164 SUP HCPCS C1713 71123164 - PLATE BN 120D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123166 SUP HCPCS C1713 71123166 - PLATE BN 130D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123168 SUP HCPCS C1713 71123168 - PLATE BN 135D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123170 SUP HCPCS C1713 71123170 - PLATE BN 140D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123172 SUP HCPCS C1713 71123172 - PLATE BN 145D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123174 SUP HCPCS C1713 71123174 - PLATE BN 150D 102MM CHS 6 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123176 SUP HCPCS C1713 71123176 - PLATE BN 130D 127MM CHS 8 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123178 SUP HCPCS C1713 71123178 - PLATE BN 135D 127MM CHS 8 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123180 SUP HCPCS C1713 71123180 - PLATE BN 140D 127MM CHS 8 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123182 SUP HCPCS C1713 71123182 - PLATE BN 145D 127MM CHS 8 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123184 SUP HCPCS C1713 71123184 - PLATE BN 150D 127MM CHS 8 HL INTMD SS PED HIP BOTH IP/OP "$1,832.25 " "$1,355.87" $0.00 "$1,465.80" $824.51 $824.51 $0.00 $0.00 $0.00 $381.89 "$1,359.90" "$1,359.90" $0.00 $0.00 $381.84 $0.00 "$1,083.78" "$1,083.78" $0.00 $916.13 "$1,451.14" "$1,465.80" $0.00 $0.00 $286.75 $0.00 $0.00 $291.69 $0.00 $0.00 $0.00 $0.00 $0.00 71123186 SUP HCPCS C1713 71123186 - SCREW BN 35MM CHS INTMD LG SS PED HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123187 SUP HCPCS C1713 71123187 - SCREW BN 40MM CHS INTMD LG SS PED HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123188 SUP HCPCS C1713 71123188 - SCREW BN 45MM CHS INTMD LG SS PED HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123189 SUP HCPCS C1713 71123189 - SCREW BN 50MM CHS INTMD LG SS PED HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123190 SUP HCPCS C1713 71123190 - SCREW BN 55MM CHS INTMD LG SS HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123191 SUP HCPCS C1713 71123191 - SCREW BN 60MM CHS INTMD LG SS HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123192 SUP HCPCS C1713 71123192 - SCREW BN 65MM CHS INTMD LG SS HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123193 SUP HCPCS C1713 71123193 - SCREW BN 70MM CHS INTMD LG SS PED HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123194 SUP HCPCS C1713 71123194 - SCREW BN 75MM CHS INTMD LG SS HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123195 SUP HCPCS C1713 71123195 - SCREW BN 80MM CHS INTMD LG SS HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123196 SUP HCPCS C1713 71123196 - SCREW BN 85MM CHS INTMD LG SS HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123197 SUP HCPCS C1713 71123197 - SCREW BN 90MM CHS INTMD LG SS HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123198 SUP HCPCS C1713 71123198 - SCREW BN 95MM CHS INTMD LG SS HIP BOTH IP/OP "$1,307.25 " $967.37 $0.00 "$1,045.80" $588.26 $588.26 $0.00 $0.00 $0.00 $272.46 $970.24 $970.24 $0.00 $0.00 $272.43 $0.00 $773.24 $773.24 $0.00 $653.63 "$1,035.34" "$1,045.80" $0.00 $0.00 $204.58 $0.00 $0.00 $208.11 $0.00 $0.00 $0.00 $0.00 $0.00 71123199 SUP HCPCS C1713 71123199 - SCREW BN 2.5MM CHS INTMD CMPR HEX HD SS PED HIP BOTH IP/OP $216.30 $160.06 $0.00 $173.04 $97.34 $97.34 $0.00 $0.00 $0.00 $45.08 $160.54 $160.54 $0.00 $0.00 $45.08 $0.00 $127.94 $127.94 $0.00 $108.15 $171.31 $173.04 $0.00 $0.00 $33.85 $0.00 $0.00 $34.43 $0.00 $0.00 $0.00 $0.00 $0.00 71123228 SUP HCPCS C1713 71123228 - SCREW BN FT 2.7MM 28MM ST PED HIP BOTH IP/OP $40.70 $30.12 $0.00 $32.56 $18.32 $18.32 $0.00 $0.00 $0.00 $8.48 $30.21 $30.21 $0.00 $0.00 $8.48 $0.00 $24.07 $24.07 $0.00 $20.35 $32.23 $32.56 $0.00 $0.00 $6.37 $0.00 $0.00 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 71123232 SUP HCPCS C1713 71123232 - SCREW BN 2.7MM 32MM ST HEX HD BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $18.81 $18.81 $0.00 $0.00 $0.00 $8.71 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $24.72 $24.72 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 71123234 SUP HCPCS C1713 71123234 - SCREW BN 2.7MM 34MM ST HEX HD BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $18.81 $18.81 $0.00 $0.00 $0.00 $8.71 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $24.72 $24.72 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 71123236 SUP HCPCS C1713 71123236 - SCREW BN 2.7MM 36MM ST HEX HD BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $18.81 $18.81 $0.00 $0.00 $0.00 $8.71 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $24.72 $24.72 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 71123238 SUP HCPCS C1713 71123238 - SCREW BN 2.7MM 38MM ST HEX HD BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $18.81 $18.81 $0.00 $0.00 $0.00 $8.71 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $24.72 $24.72 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 71123242 SUP HCPCS C1713 71123242 - PLATE BN 90D 50MM CHS 4 PROX HL SS PED HIP BOTH IP/OP "$2,394.00 " "$1,771.56" $0.00 "$1,915.20" "$1,077.30" "$1,077.30" $0.00 $0.00 $0.00 $498.97 "$1,776.83" "$1,776.83" $0.00 $0.00 $498.91 $0.00 "$1,416.05" "$1,416.05" $0.00 "$1,197.00" "$1,896.05" "$1,915.20" $0.00 $0.00 $374.66 $0.00 $0.00 $381.12 $0.00 $0.00 $0.00 $0.00 $0.00 71123244 SUP HCPCS C1713 71123244 - PLATE BN 100D .385IN CHS 4 PROX HL SS PED HIP BOTH IP/OP "$2,394.00 " "$1,771.56" $0.00 "$1,915.20" "$1,077.30" "$1,077.30" $0.00 $0.00 $0.00 $498.97 "$1,776.83" "$1,776.83" $0.00 $0.00 $498.91 $0.00 "$1,416.05" "$1,416.05" $0.00 "$1,197.00" "$1,896.05" "$1,915.20" $0.00 $0.00 $374.66 $0.00 $0.00 $381.12 $0.00 $0.00 $0.00 $0.00 $0.00 71123246 SUP HCPCS C1713 71123246 - PLATE BN 110D 50MM CHS 4 PROX HL SS PED HIP BOTH IP/OP "$2,394.00 " "$1,771.56" $0.00 "$1,915.20" "$1,077.30" "$1,077.30" $0.00 $0.00 $0.00 $498.97 "$1,776.83" "$1,776.83" $0.00 $0.00 $498.91 $0.00 "$1,416.05" "$1,416.05" $0.00 "$1,197.00" "$1,896.05" "$1,915.20" $0.00 $0.00 $374.66 $0.00 $0.00 $381.12 $0.00 $0.00 $0.00 $0.00 $0.00 71123248 SUP HCPCS C1713 71123248 - PLATE BN 120D 50MM CHS 4 PROX HL SS PED HIP BOTH IP/OP "$2,394.00 " "$1,771.56" $0.00 "$1,915.20" "$1,077.30" "$1,077.30" $0.00 $0.00 $0.00 $498.97 "$1,776.83" "$1,776.83" $0.00 $0.00 $498.91 $0.00 "$1,416.05" "$1,416.05" $0.00 "$1,197.00" "$1,896.05" "$1,915.20" $0.00 $0.00 $374.66 $0.00 $0.00 $381.12 $0.00 $0.00 $0.00 $0.00 $0.00 71123250 SUP HCPCS C1713 71123250 - PLATE BN 130D 50MM CHS 4 PROX HL SS PED HIP BOTH IP/OP "$2,394.00 " "$1,771.56" $0.00 "$1,915.20" "$1,077.30" "$1,077.30" $0.00 $0.00 $0.00 $498.97 "$1,776.83" "$1,776.83" $0.00 $0.00 $498.91 $0.00 "$1,416.05" "$1,416.05" $0.00 "$1,197.00" "$1,896.05" "$1,915.20" $0.00 $0.00 $374.66 $0.00 $0.00 $381.12 $0.00 $0.00 $0.00 $0.00 $0.00 71123252 SUP HCPCS C1713 71123252 - PLATE BN 140D 50MM CHS 4 PROX HL SS PED HIP BOTH IP/OP "$2,394.00 " "$1,771.56" $0.00 "$1,915.20" "$1,077.30" "$1,077.30" $0.00 $0.00 $0.00 $498.97 "$1,776.83" "$1,776.83" $0.00 $0.00 $498.91 $0.00 "$1,416.05" "$1,416.05" $0.00 "$1,197.00" "$1,896.05" "$1,915.20" $0.00 $0.00 $374.66 $0.00 $0.00 $381.12 $0.00 $0.00 $0.00 $0.00 $0.00 71123254 SUP HCPCS C1713 71123254 - SCREW BN 22MM CHS LG SS PED HIP BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71123256 SUP HCPCS C1713 71123256 - SCREW BN 25MM CHS LG SS PED HIP BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71123258 SUP HCPCS C1713 71123258 - SCREW BN 28MM CHS LG SS PED HIP BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71123260 SUP HCPCS C1713 71123260 - SCREW BN 31MM CHS LG SS PED HIP BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71123262 SUP HCPCS C1713 71123262 - SCREW BN 34MM CHS LG SS PED HIP BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71123264 SUP HCPCS C1713 71123264 - SCREW BN 37MM CHS LG SS PED HIP BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71123266 SUP HCPCS C1713 71123266 - SCREW BN 40MM CHS LG SS PED HIP BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71124002 SUP HCPCS C1713 71124002 - NAIL IM 4MM 22CM FRSGHT SET FRARM BOTH IP/OP "$6,380.00 " "$4,721.20" $0.00 "$5,104.00" "$2,871.00" "$2,871.00" $0.00 $0.00 $0.00 "$1,329.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,329.59" $0.00 "$3,145.34" "$3,145.34" $0.00 "$3,190.00" "$5,052.96" "$5,104.00" $0.00 $0.00 $998.47 $0.00 $0.00 "$1,015.70" $0.00 $0.00 $0.00 $0.00 $0.00 71124010 SUP HCPCS C1713 71124010 - SCREW BN 2.7MM 10MM UNICORTICAL BOTH IP/OP $373.40 $276.32 $0.00 $298.72 $168.03 $168.03 $0.00 $0.00 $0.00 $77.83 $277.14 $277.14 $0.00 $0.00 $77.82 $0.00 $220.87 $220.87 $0.00 $186.70 $295.73 $298.72 $0.00 $0.00 $58.44 $0.00 $0.00 $59.45 $0.00 $0.00 $0.00 $0.00 $0.00 71126130 SUP HCPCS C1713 71126130 - PLATE BN 130D CLS 4 HL CMPR LOPRFL HIP BOTH IP/OP $715.05 $529.14 $0.00 $572.04 $321.77 $321.77 $0.00 $0.00 $0.00 $149.03 $530.71 $530.71 $0.00 $0.00 $149.02 $0.00 $422.95 $422.95 $0.00 $357.53 $566.32 $572.04 $0.00 $0.00 $111.91 $0.00 $0.00 $113.84 $0.00 $0.00 $0.00 $0.00 $0.00 71126131 SUP HCPCS C1713 71126131 - PLATE BN 135D CLS LP 4 HL BOTH IP/OP $532.35 $393.94 $0.00 $425.88 $239.56 $239.56 $0.00 $0.00 $0.00 $110.96 $395.11 $395.11 $0.00 $0.00 $110.94 $0.00 $314.89 $314.89 $0.00 $266.18 $421.62 $425.88 $0.00 $0.00 $83.31 $0.00 $0.00 $84.75 $0.00 $0.00 $0.00 $0.00 $0.00 71127030 SUP HCPCS C1713 71127030 - SCREW BN 7MM 30MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127035 SUP HCPCS C1713 71127035 - SCREW BN 7MM 35MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127040 SUP HCPCS C1713 71127040 - SCREW BN 7MM 40MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127045 SUP HCPCS C1713 71127045 - SCREW BN 7MM 45MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127050 SUP HCPCS C1713 71127050 - SCREW BN 7MM 50MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127055 SUP HCPCS C1713 71127055 - SCREW BN 7MM 55MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127060 SUP HCPCS C1713 71127060 - SCREW BN 7MM 60MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127065 SUP HCPCS C1713 71127065 - SCREW BN 7MM 65MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127070 SUP HCPCS C1713 71127070 - SCREW BN P/T TROC SPHR 7MM 5.2MM 70MM 16MM CNN SLFDRL ST HD BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127075 SUP HCPCS C1713 71127075 - SCREW BN 7MM 75MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127080 SUP HCPCS C1713 71127080 - SCREW BN 7MM 80MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127085 SUP HCPCS C1713 71127085 - SCREW BN 7MM 85MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127090 SUP HCPCS C1713 71127090 - SCREW BN 7MM 90MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127095 SUP HCPCS C1713 71127095 - SCREW BN 7MM 95MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127100 SUP HCPCS C1713 71127100 - SCREW BN 7MM 100MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127105 SUP HCPCS C1713 71127105 - SCREW BN 7MM 105MM STRL 16MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127110 SUP HCPCS C1713 71127110 - SCREW BN 7MM 110MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127115 SUP HCPCS C1713 71127115 - SCREW BN 7MM 115MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127120 SUP HCPCS C1713 71127120 - SCREW BN 7MM 120MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127125 SUP HCPCS C1713 71127125 - SCREW BN 7MM 125MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127130 SUP HCPCS C1713 71127130 - SCREW BN 7MM 130MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127135 SUP HCPCS C1713 71127135 - SCREW BN 7MM 135MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127140 SUP HCPCS C1713 71127140 - SCREW BN 7MM 140MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127145 SUP HCPCS C1713 71127145 - SCREW BN 7MM 145MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71127150 SUP HCPCS C1713 71127150 - SCREW BN 7MM 150MM STRL 16MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128045 SUP HCPCS C1713 71128045 - SCREW BN 7MM 45MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128050 SUP HCPCS C1713 71128050 - SCREW BN 7MM 50MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128055 SUP HCPCS C1713 71128055 - SCREW BN 7MM 55MM STRL 32MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128060 SUP HCPCS C1713 71128060 - SCREW BN 7MM 60MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128065 SUP HCPCS C1713 71128065 - SCREW BN 7MM 65MM STRL 32MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128070 SUP HCPCS C1713 71128070 - SCREW BN 7MM 70MM STRL 32MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128075 SUP HCPCS C1713 71128075 - SCREW BN 7MM 75MM STRL 32MM CNN SET SS ORTH IMPL BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128080 SUP HCPCS C1713 71128080 - SCREW BN 7MM 80MM STRL 32MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128085 SUP HCPCS C1713 71128085 - SCREW BN 7MM 85MM STRL 32MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128090 SUP HCPCS C1713 71128090 - SCREW BN 7MM 90MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128095 SUP HCPCS C1713 71128095 - SCREW BN 7MM 95MM STRL 32MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128100 SUP HCPCS C1713 71128100 - SCREW BN 7MM 100MM STRL 32MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128105 SUP HCPCS C1713 71128105 - SCREW BN 7MM 105MM STRL 32MM CNN SS CORT BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128110 SUP HCPCS C1713 71128110 - SCREW BN 7MM 110MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128115 SUP HCPCS C1713 71128115 - SCREW BN 7MM 115MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128120 SUP HCPCS C1713 71128120 - SCREW BN 7MM 120MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128125 SUP HCPCS C1713 71128125 - SCREW BN 7MM 125MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128130 SUP HCPCS C1713 71128130 - SCREW BN 7MM 130MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128135 SUP HCPCS C1713 71128135 - SCREW BN 7MM 135MM STRL 32MM CNN SS ORTH BOTH IP/OP $467.25 $345.77 $0.00 $373.80 $210.26 $210.26 $0.00 $0.00 $0.00 $97.39 $346.79 $346.79 $0.00 $0.00 $97.37 $0.00 $276.38 $276.38 $0.00 $233.63 $370.06 $373.80 $0.00 $0.00 $73.12 $0.00 $0.00 $74.39 $0.00 $0.00 $0.00 $0.00 $0.00 71128140 SUP HCPCS C1713 71128140 - SCREW BN 7MM 140MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128145 SUP HCPCS C1713 71128145 - SCREW BN 7MM 145MM STRL 32MM CNN SS ORTH BOTH IP/OP $467.25 $345.77 $0.00 $373.80 $210.26 $210.26 $0.00 $0.00 $0.00 $97.39 $346.79 $346.79 $0.00 $0.00 $97.37 $0.00 $276.38 $276.38 $0.00 $233.63 $370.06 $373.80 $0.00 $0.00 $73.12 $0.00 $0.00 $74.39 $0.00 $0.00 $0.00 $0.00 $0.00 71128150 SUP HCPCS C1713 71128150 - SCREW BN 7MM 150MM STRL 32MM CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71128690 SUP HCPCS C1713 71128690 - STAPLE BN SM 23X10.8MM SPK FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128691 SUP HCPCS C1713 71128691 - STAPLE BN SM 23X10.8MM FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128692 SUP HCPCS C1713 71128692 - STAPLE BN SM 23X12MM SPK FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128693 SUP HCPCS C1713 71128693 - STAPLE BN SM 23X12MM FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128694 SUP HCPCS C1713 71128694 - STAPLE BN MED 23X15MM SPK FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128695 SUP HCPCS C1713 71128695 - STAPLE BN MED 23X15MM FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128696 SUP HCPCS C1713 71128696 - STAPLE BN LG 23X18MM SPK FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128697 SUP HCPCS C1713 71128697 - STAPLE BN LG 23X18MM FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128698 SUP HCPCS C1713 71128698 - STAPLE BN SM 16X13MM TBL FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128699 SUP HCPCS C1713 71128699 - STAPLE BN MED 22X16MM TBL FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128720 SUP HCPCS C1713 71128720 - STAPLE BN SM 15X11MM SPK FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128721 SUP HCPCS C1713 71128721 - STAPLE BN SM 15X11MM FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128722 SUP HCPCS C1713 71128722 - STAPLE BN SM 15X12.5MM SPK FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128723 SUP HCPCS C1713 71128723 - STAPLE BN SM 23X12.5MM FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128724 SUP HCPCS C1713 71128724 - STAPLE BN SM 16X15MM SPK FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128725 SUP HCPCS C1713 71128725 - STAPLE BN SM 16X15MM FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128726 SUP HCPCS C1713 71128726 - STAPLE BN LG 19X15MM SPK FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71128727 SUP HCPCS C1713 71128727 - STAPLE BN LG 19X15MM FX BOTH IP/OP $507.15 $375.29 $0.00 $405.72 $228.22 $228.22 $0.00 $0.00 $0.00 $105.70 $376.41 $376.41 $0.00 $0.00 $105.69 $0.00 $299.98 $299.98 $0.00 $253.58 $401.66 $405.72 $0.00 $0.00 $79.37 $0.00 $0.00 $80.74 $0.00 $0.00 $0.00 $0.00 $0.00 71129030 SUP HCPCS C1713 71129030 - SCREW BN FT 7MM 30MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129035 SUP HCPCS C1713 71129035 - SCREW BN FT 7MM 35MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129040 SUP HCPCS C1713 71129040 - SCREW BN FT 7MM 40MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129045 SUP HCPCS C1713 71129045 - SCREW BN FT 7MM 45MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129050 SUP HCPCS C1713 71129050 - SCREW BN FT 7MM 50MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129055 SUP HCPCS C1713 71129055 - SCREW BN FT 7MM 55MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129060 SUP HCPCS C1713 71129060 - SCREW BN FT 7MM 60MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129065 SUP HCPCS C1713 71129065 - SCREW BN FT 7MM 65MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129070 SUP HCPCS C1713 71129070 - SCREW BN FT 7MM 70MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129075 SUP HCPCS C1713 71129075 - SCREW BN FT 7MM 75MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129080 SUP HCPCS C1713 71129080 - SCREW BN FT 7MM 80MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129085 SUP HCPCS C1713 71129085 - SCREW BN FT 7MM 85MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129090 SUP HCPCS C1713 71129090 - SCREW BN FT 7MM 90MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129095 SUP HCPCS C1713 71129095 - SCREW BN FT 7MM 95MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129100 SUP HCPCS C1713 71129100 - SCREW BN FT 7MM 100MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129105 SUP HCPCS C1713 71129105 - SCREW BN FT 7MM 105MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129110 SUP HCPCS C1713 71129110 - SCREW BN FT 7MM 110MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129115 SUP HCPCS C1713 71129115 - SCREW BN FT 7MM 115MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129120 SUP HCPCS C1713 71129120 - SCREW BN FT 7MM 120MM STRL CNN SS ORTH BOTH IP/OP $467.25 $345.77 $0.00 $373.80 $210.26 $210.26 $0.00 $0.00 $0.00 $97.39 $346.79 $346.79 $0.00 $0.00 $97.37 $0.00 $276.38 $276.38 $0.00 $233.63 $370.06 $373.80 $0.00 $0.00 $73.12 $0.00 $0.00 $74.39 $0.00 $0.00 $0.00 $0.00 $0.00 71129125 SUP HCPCS C1713 71129125 - SCREW BN FT 7MM 125MM STRL CNN SS ORTH BOTH IP/OP $467.25 $345.77 $0.00 $373.80 $210.26 $210.26 $0.00 $0.00 $0.00 $97.39 $346.79 $346.79 $0.00 $0.00 $97.37 $0.00 $276.38 $276.38 $0.00 $233.63 $370.06 $373.80 $0.00 $0.00 $73.12 $0.00 $0.00 $74.39 $0.00 $0.00 $0.00 $0.00 $0.00 71129130 SUP HCPCS C1713 71129130 - SCREW BN FT 7MM 130MM STRL CNN SS ORTH BOTH IP/OP $487.20 $360.53 $0.00 $389.76 $219.24 $219.24 $0.00 $0.00 $0.00 $101.54 $361.60 $361.60 $0.00 $0.00 $101.53 $0.00 $288.18 $288.18 $0.00 $243.60 $385.86 $389.76 $0.00 $0.00 $76.25 $0.00 $0.00 $77.56 $0.00 $0.00 $0.00 $0.00 $0.00 71129212 SUP HCPCS C1713 71129212 - SCREW BN 4.5MM 12MM AMBI CLS ST CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129214 SUP HCPCS C1713 71129214 - SCREW BN 4.5MM 3.2MM 14MM AMBI CLS ST SS CORT HIP PLT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129216 SUP HCPCS C1713 71129216 - SCREW BN 4.5MM 8MM 16MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129218 SUP HCPCS C1713 71129218 - SCREW BN 4.5MM 8MM 18MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129220 SUP HCPCS C1713 71129220 - SCREW BN 4.5MM 8MM 20MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129222 SUP HCPCS C1713 71129222 - SCREW BN 4.5MM 8MM 22MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129224 SUP HCPCS C1713 71129224 - SCREW BN 4.5MM 24MM CHS ST SS CORT HIP PLT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129226 SUP HCPCS C1713 71129226 - SCREW BN 4.5MM 26MM AMBI CLS ST SS CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129228 SUP HCPCS C1713 71129228 - SCREW BN 4.5MM 8MM 28MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129230 SUP HCPCS C1713 71129230 - SCREW BN 4.5MM 3.2MM 30MM ST SS CORT SP CNDL PLT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129232 SUP HCPCS C1713 71129232 - SCREW BN 4.5MM 8MM 32MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129234 SUP HCPCS C1713 71129234 - SCREW BN 4.5MM 34MM IMHS ST SS CORT IM NL BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129236 SUP HCPCS C1713 71129236 - SCREW BN 4.5MM 8MM 36MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129238 SUP HCPCS C1713 71129238 - SCREW BN 4.5MM 8MM 38MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129240 SUP HCPCS C1713 71129240 - SCREW BN 4.5MM 8MM 40MM ST HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129242 SUP HCPCS C1713 71129242 - SCREW BN 4.5MM 8MM 42MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129244 SUP HCPCS C1713 71129244 - SCREW BN 4.5MM 8MM 44MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129246 SUP HCPCS C1713 71129246 - SCREW BN 4.5MM 8MM 46MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129248 SUP HCPCS C1713 71129248 - SCREW BN 4.5MM 8MM 48MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129250 SUP HCPCS C1713 71129250 - SCREW BN 4.5MM 8MM 50MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129252 SUP HCPCS C1713 71129252 - SCREW BN 4.5MM 8MM 52MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129254 SUP HCPCS C1713 71129254 - SCREW BN 4.5MM 8MM 54MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129256 SUP HCPCS C1713 71129256 - SCREW BN 4.5MM 8MM 56MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129258 SUP HCPCS C1713 71129258 - SCREW BN 4.5MM 3.2MM 58MM AMBI CLS ST SS CORT HIP PLT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129260 SUP HCPCS C1713 71129260 - SCREW BN 4.5MM 8MM 60MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129262 SUP HCPCS C1713 71129262 - SCREW BN 4.5MM 3.2MM 62MM AMBI CLS ST SS CORT HIP PLT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71129264 SUP HCPCS C1713 71129264 - SCREW BN 4.5MM 8MM 64MM AMBI CLS ST SS HIP CORT BOTH IP/OP $54.13 $40.06 $0.00 $43.30 $24.36 $24.36 $0.00 $0.00 $0.00 $11.28 $40.17 $40.17 $0.00 $0.00 $11.28 $0.00 $32.01 $32.01 $0.00 $27.06 $42.87 $43.30 $0.00 $0.00 $8.47 $0.00 $0.00 $8.62 $0.00 $0.00 $0.00 $0.00 $0.00 71130205 SUP HCPCS C1713 71130205 - PLATE BN 3.5MM 5 HL CMPR PRV FX 3.5MM SCR SM FRAG SET BOTH IP/OP $359.10 $265.73 $0.00 $287.28 $161.60 $161.60 $0.00 $0.00 $0.00 $74.85 $266.52 $266.52 $0.00 $0.00 $74.84 $0.00 $212.41 $212.41 $0.00 $179.55 $284.41 $287.28 $0.00 $0.00 $56.20 $0.00 $0.00 $57.17 $0.00 $0.00 $0.00 $0.00 $0.00 71130206 SUP HCPCS C1713 71130206 - PLATE BN 3.5MM 6 HL CMPR PRV FX 3.5MM SCR SM FRAG SET BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $170.10 $170.10 $0.00 $0.00 $0.00 $78.78 $280.55 $280.55 $0.00 $0.00 $78.78 $0.00 $223.59 $223.59 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $59.16 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 71130207 SUP HCPCS C1713 71130207 - PLATE BN 3.5MM 7 HL CMPR PRV FX 3.5MM SCR SM FRAG SET BOTH IP/OP $389.55 $288.27 $0.00 $311.64 $175.30 $175.30 $0.00 $0.00 $0.00 $81.19 $289.12 $289.12 $0.00 $0.00 $81.18 $0.00 $230.42 $230.42 $0.00 $194.78 $308.52 $311.64 $0.00 $0.00 $60.96 $0.00 $0.00 $62.02 $0.00 $0.00 $0.00 $0.00 $0.00 71130208 SUP HCPCS C1713 71130208 - PLATE BN 3.5MM 8 HL CMPR PRV FX 3.5MM SCR SM FRAG SET BOTH IP/OP $411.60 $304.58 $0.00 $329.28 $185.22 $185.22 $0.00 $0.00 $0.00 $85.79 $305.49 $305.49 $0.00 $0.00 $85.78 $0.00 $243.46 $243.46 $0.00 $205.80 $325.99 $329.28 $0.00 $0.00 $64.42 $0.00 $0.00 $65.53 $0.00 $0.00 $0.00 $0.00 $0.00 71130209 SUP HCPCS C1713 71130209 - PLATE BN 3.5MM 9 HL CMPR PRV FX 3.5MM SCR SM FRAG SET BOTH IP/OP $434.70 $321.68 $0.00 $347.76 $195.62 $195.62 $0.00 $0.00 $0.00 $90.60 $322.63 $322.63 $0.00 $0.00 $90.59 $0.00 $257.13 $257.13 $0.00 $217.35 $344.28 $347.76 $0.00 $0.00 $68.03 $0.00 $0.00 $69.20 $0.00 $0.00 $0.00 $0.00 $0.00 71130210 SUP HCPCS C1713 71130210 - PLATE BN 3.5MM 10 HL CMPR PRV FX 3.5MM SCR SM FRAG SET BOTH IP/OP $442.05 $327.12 $0.00 $353.64 $198.92 $198.92 $0.00 $0.00 $0.00 $92.13 $328.09 $328.09 $0.00 $0.00 $92.12 $0.00 $261.47 $261.47 $0.00 $221.03 $350.10 $353.64 $0.00 $0.00 $69.18 $0.00 $0.00 $70.37 $0.00 $0.00 $0.00 $0.00 $0.00 71130303 SUP HCPCS C1713 71130303 - PLATE BN 1/3 TBLR 3 HL COLR PRV FX SM FRAG SET BOTH IP/OP $190.05 $140.64 $0.00 $152.04 $85.52 $85.52 $0.00 $0.00 $0.00 $39.61 $141.06 $141.06 $0.00 $0.00 $39.61 $0.00 $112.41 $112.41 $0.00 $95.03 $150.52 $152.04 $0.00 $0.00 $29.74 $0.00 $0.00 $30.26 $0.00 $0.00 $0.00 $0.00 $0.00 71130304 SUP HCPCS C1713 71130304 - PLATE BN 1/3 TBLR 4 HL COLR PRV FX SM FRAG SET BOTH IP/OP $204.75 $151.52 $0.00 $163.80 $92.14 $92.14 $0.00 $0.00 $0.00 $42.68 $151.97 $151.97 $0.00 $0.00 $42.67 $0.00 $121.11 $121.11 $0.00 $102.38 $162.16 $163.80 $0.00 $0.00 $32.04 $0.00 $0.00 $32.60 $0.00 $0.00 $0.00 $0.00 $0.00 71130305 SUP HCPCS C1713 71130305 - PLATE BN 1/3 TBLR 5 HL COLR PRV FX SM FRAG SET BOTH IP/OP $218.40 $161.62 $0.00 $174.72 $98.28 $98.28 $0.00 $0.00 $0.00 $45.52 $162.10 $162.10 $0.00 $0.00 $45.51 $0.00 $129.18 $129.18 $0.00 $109.20 $172.97 $174.72 $0.00 $0.00 $34.18 $0.00 $0.00 $34.77 $0.00 $0.00 $0.00 $0.00 $0.00 71130306 SUP HCPCS C1713 71130306 - PLATE BN 1/3 TBLR 6 HL COLR PRV FX SM FRAG SET BOTH IP/OP $211.05 $156.18 $0.00 $168.84 $94.97 $94.97 $0.00 $0.00 $0.00 $43.99 $156.64 $156.64 $0.00 $0.00 $43.98 $0.00 $124.84 $124.84 $0.00 $105.53 $167.15 $168.84 $0.00 $0.00 $33.03 $0.00 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 71130307 SUP HCPCS C1713 71130307 - PLATE BN 1/3 TBLR 7 HL COLR PRV FX SM FRAG SET BOTH IP/OP $227.85 $168.61 $0.00 $182.28 $102.53 $102.53 $0.00 $0.00 $0.00 $47.49 $169.11 $169.11 $0.00 $0.00 $47.48 $0.00 $134.77 $134.77 $0.00 $113.93 $180.46 $182.28 $0.00 $0.00 $35.66 $0.00 $0.00 $36.27 $0.00 $0.00 $0.00 $0.00 $0.00 71130308 SUP HCPCS C1713 71130308 - PLATE BN 1/3 TBLR 8 HL COLR PRV FX SM FRAG SET BOTH IP/OP $235.20 $174.05 $0.00 $188.16 $105.84 $105.84 $0.00 $0.00 $0.00 $49.02 $174.57 $174.57 $0.00 $0.00 $49.02 $0.00 $139.12 $139.12 $0.00 $117.60 $186.28 $188.16 $0.00 $0.00 $36.81 $0.00 $0.00 $37.44 $0.00 $0.00 $0.00 $0.00 $0.00 71130310 SUP HCPCS C1713 71130310 - PLATE BN 1/3 TBLR 10 HL COLR PRV FX SM FRAG SET BOTH IP/OP $246.75 $182.60 $0.00 $197.40 $111.04 $111.04 $0.00 $0.00 $0.00 $51.43 $183.14 $183.14 $0.00 $0.00 $51.42 $0.00 $145.95 $145.95 $0.00 $123.38 $195.43 $197.40 $0.00 $0.00 $38.62 $0.00 $0.00 $39.28 $0.00 $0.00 $0.00 $0.00 $0.00 71130403 SUP HCPCS C1713 71130403 - PLATE BN T SM 3 HL PRV FX SM FRAG SET BOTH IP/OP $352.80 $261.07 $0.00 $282.24 $158.76 $158.76 $0.00 $0.00 $0.00 $73.53 $261.85 $261.85 $0.00 $0.00 $73.52 $0.00 $208.68 $208.68 $0.00 $176.40 $279.42 $282.24 $0.00 $0.00 $55.21 $0.00 $0.00 $56.17 $0.00 $0.00 $0.00 $0.00 $0.00 71130404 SUP HCPCS C1713 71130404 - PLATE BN T SM 4 HL PRV FX SM FRAG SET BOTH IP/OP $360.15 $266.51 $0.00 $288.12 $162.07 $162.07 $0.00 $0.00 $0.00 $75.06 $267.30 $267.30 $0.00 $0.00 $75.06 $0.00 $213.03 $213.03 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $56.36 $0.00 $0.00 $57.34 $0.00 $0.00 $0.00 $0.00 $0.00 71130405 SUP HCPCS C1713 71130405 - PLATE BN T SM 5 HL PRV FX SM FRAG SET BOTH IP/OP $456.75 $338.00 $0.00 $365.40 $205.54 $205.54 $0.00 $0.00 $0.00 $95.20 $339.00 $339.00 $0.00 $0.00 $95.19 $0.00 $270.17 $270.17 $0.00 $228.38 $361.75 $365.40 $0.00 $0.00 $71.48 $0.00 $0.00 $72.71 $0.00 $0.00 $0.00 $0.00 $0.00 71130503 SUP HCPCS C1713 71130503 - PLATE BN T OBLQ 3 HL PRV FX SM FRAG SET BOTH IP/OP $581.70 $430.46 $0.00 $465.36 $261.77 $261.77 $0.00 $0.00 $0.00 $121.24 $431.74 $431.74 $0.00 $0.00 $121.23 $0.00 $344.08 $344.08 $0.00 $290.85 $460.71 $465.36 $0.00 $0.00 $91.04 $0.00 $0.00 $92.61 $0.00 $0.00 $0.00 $0.00 $0.00 71130504 SUP HCPCS C1713 71130504 - PLATE BN T OBLQ 4 HL PRV FX SM FRAG SET BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71130505 SUP HCPCS C1713 71130505 - PLATE BN T OBLQ 5 HL PRV FX SM FRAG SET BOTH IP/OP $640.50 $473.97 $0.00 $512.40 $288.23 $288.23 $0.00 $0.00 $0.00 $133.50 $475.38 $475.38 $0.00 $0.00 $133.48 $0.00 $378.86 $378.86 $0.00 $320.25 $507.28 $512.40 $0.00 $0.00 $100.24 $0.00 $0.00 $101.97 $0.00 $0.00 $0.00 $0.00 $0.00 71130603 SUP HCPCS C1713 71130603 - PLATE BN CLVRLF 3 HL PRV FX SM FRAG SET BOTH IP/OP $819.00 $606.06 $0.00 $655.20 $368.55 $368.55 $0.00 $0.00 $0.00 $170.70 $607.86 $607.86 $0.00 $0.00 $170.68 $0.00 $484.44 $484.44 $0.00 $409.50 $648.65 $655.20 $0.00 $0.00 $128.17 $0.00 $0.00 $130.38 $0.00 $0.00 $0.00 $0.00 $0.00 71130804 SUP HCPCS C1713 71130804 - PLATE BN L BTRS 4 HL PRV FX LT LG FRAG SET BOTH IP/OP $922.95 $682.98 $0.00 $738.36 $415.33 $415.33 $0.00 $0.00 $0.00 $192.37 $685.01 $685.01 $0.00 $0.00 $192.34 $0.00 $545.92 $545.92 $0.00 $461.48 $730.98 $738.36 $0.00 $0.00 $144.44 $0.00 $0.00 $146.93 $0.00 $0.00 $0.00 $0.00 $0.00 71130904 SUP HCPCS C1713 71130904 - PLATE BN L BTRS 4 HL PRV FX RT LG FRAG SET BOTH IP/OP $922.95 $682.98 $0.00 $738.36 $415.33 $415.33 $0.00 $0.00 $0.00 $192.37 $685.01 $685.01 $0.00 $0.00 $192.34 $0.00 $545.92 $545.92 $0.00 $461.48 $730.98 $738.36 $0.00 $0.00 $144.44 $0.00 $0.00 $146.93 $0.00 $0.00 $0.00 $0.00 $0.00 71131007 SUP HCPCS C1713 71131007 - PLATE BN BTRS 7 HL PRV FX TIBHD RL LG FRAG SET BOTH IP/OP "$1,974.00 " "$1,460.76" $0.00 "$1,579.20" $888.30 $888.30 $0.00 $0.00 $0.00 $411.43 "$1,465.10" "$1,465.10" $0.00 $0.00 $411.38 $0.00 "$1,167.62" "$1,167.62" $0.00 $987.00 "$1,563.41" "$1,579.20" $0.00 $0.00 $308.93 $0.00 $0.00 $314.26 $0.00 $0.00 $0.00 $0.00 $0.00 71131009 SUP HCPCS C1713 71131009 - PLATE BN BTRS 9 HL PRV FX TIBHD RL LG FRAG SET BOTH IP/OP "$2,110.50 " "$1,561.77" $0.00 "$1,688.40" $949.73 $949.73 $0.00 $0.00 $0.00 $439.88 "$1,566.41" "$1,566.41" $0.00 $0.00 $439.83 $0.00 "$1,248.36" "$1,248.36" $0.00 "$1,055.25" "$1,671.52" "$1,688.40" $0.00 $0.00 $330.29 $0.00 $0.00 $335.99 $0.00 $0.00 $0.00 $0.00 $0.00 71131107 SUP HCPCS C1713 71131107 - PLATE BN BTRS 7 HL PRV FX TIBHD L/L LG FRAG SET BOTH IP/OP "$1,974.00 " "$1,460.76" $0.00 "$1,579.20" $888.30 $888.30 $0.00 $0.00 $0.00 $411.43 "$1,465.10" "$1,465.10" $0.00 $0.00 $411.38 $0.00 "$1,167.62" "$1,167.62" $0.00 $987.00 "$1,563.41" "$1,579.20" $0.00 $0.00 $308.93 $0.00 $0.00 $314.26 $0.00 $0.00 $0.00 $0.00 $0.00 71131109 SUP HCPCS C1713 71131109 - PLATE BN BTRS 9 HL PRV FX TIBHD L/L LG FRAG SET BOTH IP/OP "$2,110.50 " "$1,561.77" $0.00 "$1,688.40" $949.73 $949.73 $0.00 $0.00 $0.00 $439.88 "$1,566.41" "$1,566.41" $0.00 $0.00 $439.83 $0.00 "$1,248.36" "$1,248.36" $0.00 "$1,055.25" "$1,671.52" "$1,688.40" $0.00 $0.00 $330.29 $0.00 $0.00 $335.99 $0.00 $0.00 $0.00 $0.00 $0.00 71131206 SUP HCPCS C1713 71131206 - PLATE BN 4.5MM BRD 6 HL PRV FX PERIART MTPHSL 4.5MM SCR LG BOTH IP/OP $703.50 $520.59 $0.00 $562.80 $316.58 $316.58 $0.00 $0.00 $0.00 $146.63 $522.14 $522.14 $0.00 $0.00 $146.61 $0.00 $416.12 $416.12 $0.00 $351.75 $557.17 $562.80 $0.00 $0.00 $110.10 $0.00 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 71131207 SUP HCPCS C1713 71131207 - PLATE BN 4.5MM BRD 7 HL PRV FX PERIART MTPHSL 4.5MM SCR LG BOTH IP/OP $703.50 $520.59 $0.00 $562.80 $316.58 $316.58 $0.00 $0.00 $0.00 $146.63 $522.14 $522.14 $0.00 $0.00 $146.61 $0.00 $416.12 $416.12 $0.00 $351.75 $557.17 $562.80 $0.00 $0.00 $110.10 $0.00 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 71131208 SUP HCPCS C1713 71131208 - PLATE BN 4.5MM BRD 8 HL PRV FX PERIART MTPHSL 4.5MM SCR LG BOTH IP/OP $875.70 $648.02 $0.00 $700.56 $394.07 $394.07 $0.00 $0.00 $0.00 $182.52 $649.94 $649.94 $0.00 $0.00 $182.50 $0.00 $517.98 $517.98 $0.00 $437.85 $693.55 $700.56 $0.00 $0.00 $137.05 $0.00 $0.00 $139.41 $0.00 $0.00 $0.00 $0.00 $0.00 71131209 SUP HCPCS C1713 71131209 - PLATE BN 4.5MM BRD 9 HL PRV FX PERIART MTPHSL 4.5MM SCR LG BOTH IP/OP $875.70 $648.02 $0.00 $700.56 $394.07 $394.07 $0.00 $0.00 $0.00 $182.52 $649.94 $649.94 $0.00 $0.00 $182.50 $0.00 $517.98 $517.98 $0.00 $437.85 $693.55 $700.56 $0.00 $0.00 $137.05 $0.00 $0.00 $139.41 $0.00 $0.00 $0.00 $0.00 $0.00 71131210 SUP HCPCS C1713 71131210 - PLATE BN 4.5MM BRD 10 HL PRV FX PERIART MTPHSL 4.5MM SCR LG BOTH IP/OP $875.70 $648.02 $0.00 $700.56 $394.07 $394.07 $0.00 $0.00 $0.00 $182.52 $649.94 $649.94 $0.00 $0.00 $182.50 $0.00 $517.98 $517.98 $0.00 $437.85 $693.55 $700.56 $0.00 $0.00 $137.05 $0.00 $0.00 $139.41 $0.00 $0.00 $0.00 $0.00 $0.00 71131212 SUP HCPCS C1713 71131212 - PLATE BN 4.5MM BRD 12 HL PRV FX PERIART MTPHSL 4.5MM SCR LG BOTH IP/OP $939.75 $695.42 $0.00 $751.80 $422.89 $422.89 $0.00 $0.00 $0.00 $195.87 $697.48 $697.48 $0.00 $0.00 $195.84 $0.00 $555.86 $555.86 $0.00 $469.88 $744.28 $751.80 $0.00 $0.00 $147.07 $0.00 $0.00 $149.61 $0.00 $0.00 $0.00 $0.00 $0.00 71131214 SUP HCPCS C1713 71131214 - PLATE BN 4.5MM BRD 14 HL PRV FX PERIART MTPHSL 4.5MM SCR LG BOTH IP/OP $939.75 $695.42 $0.00 $751.80 $422.89 $422.89 $0.00 $0.00 $0.00 $195.87 $697.48 $697.48 $0.00 $0.00 $195.84 $0.00 $555.86 $555.86 $0.00 $469.88 $744.28 $751.80 $0.00 $0.00 $147.07 $0.00 $0.00 $149.61 $0.00 $0.00 $0.00 $0.00 $0.00 71131304 SUP HCPCS C1713 71131304 - PLATE BN SMTB 4 HL PRV FX LG FRAG SET BOTH IP/OP $190.05 $140.64 $0.00 $152.04 $85.52 $85.52 $0.00 $0.00 $0.00 $39.61 $141.06 $141.06 $0.00 $0.00 $39.61 $0.00 $112.41 $112.41 $0.00 $95.03 $150.52 $152.04 $0.00 $0.00 $29.74 $0.00 $0.00 $30.26 $0.00 $0.00 $0.00 $0.00 $0.00 71131305 SUP HCPCS C1713 71131305 - PLATE BN SMTB 5 HL PRV FX LG FRAG SET BOTH IP/OP $192.15 $142.19 $0.00 $153.72 $86.47 $86.47 $0.00 $0.00 $0.00 $40.05 $142.61 $142.61 $0.00 $0.00 $40.04 $0.00 $113.66 $113.66 $0.00 $96.08 $152.18 $153.72 $0.00 $0.00 $30.07 $0.00 $0.00 $30.59 $0.00 $0.00 $0.00 $0.00 $0.00 71131306 SUP HCPCS C1713 71131306 - PLATE BN SMTB 6 HL PRV FX LG FRAG SET BOTH IP/OP $211.05 $156.18 $0.00 $168.84 $94.97 $94.97 $0.00 $0.00 $0.00 $43.99 $156.64 $156.64 $0.00 $0.00 $43.98 $0.00 $124.84 $124.84 $0.00 $105.53 $167.15 $168.84 $0.00 $0.00 $33.03 $0.00 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 71131307 SUP HCPCS C1713 71131307 - PLATE BN SMTB 7 HL PRV FX LG FRAG SET BOTH IP/OP $223.65 $165.50 $0.00 $178.92 $100.64 $100.64 $0.00 $0.00 $0.00 $46.61 $165.99 $165.99 $0.00 $0.00 $46.61 $0.00 $132.29 $132.29 $0.00 $111.83 $177.13 $178.92 $0.00 $0.00 $35.00 $0.00 $0.00 $35.61 $0.00 $0.00 $0.00 $0.00 $0.00 71131403 SUP HCPCS C1713 71131403 - PLATE BN NAR 3 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $473.55 $350.43 $0.00 $378.84 $213.10 $213.10 $0.00 $0.00 $0.00 $98.70 $351.47 $351.47 $0.00 $0.00 $98.69 $0.00 $280.10 $280.10 $0.00 $236.78 $375.05 $378.84 $0.00 $0.00 $74.11 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 71131404 SUP HCPCS C1713 71131404 - PLATE BN NAR 4 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $473.55 $350.43 $0.00 $378.84 $213.10 $213.10 $0.00 $0.00 $0.00 $98.70 $351.47 $351.47 $0.00 $0.00 $98.69 $0.00 $280.10 $280.10 $0.00 $236.78 $375.05 $378.84 $0.00 $0.00 $74.11 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 71131405 SUP HCPCS C1713 71131405 - PLATE BN NAR 5 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $473.55 $350.43 $0.00 $378.84 $213.10 $213.10 $0.00 $0.00 $0.00 $98.70 $351.47 $351.47 $0.00 $0.00 $98.69 $0.00 $280.10 $280.10 $0.00 $236.78 $375.05 $378.84 $0.00 $0.00 $74.11 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 71131406 SUP HCPCS C1713 71131406 - PLATE BN NAR 6 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $198.45 $198.45 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $220.50 $349.27 $352.80 $0.00 $0.00 $69.02 $0.00 $0.00 $70.21 $0.00 $0.00 $0.00 $0.00 $0.00 71131407 SUP HCPCS C1713 71131407 - PLATE BN NAR 7 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $526.05 $389.28 $0.00 $420.84 $236.72 $236.72 $0.00 $0.00 $0.00 $109.64 $390.43 $390.43 $0.00 $0.00 $109.63 $0.00 $311.16 $311.16 $0.00 $263.03 $416.63 $420.84 $0.00 $0.00 $82.33 $0.00 $0.00 $83.75 $0.00 $0.00 $0.00 $0.00 $0.00 71131408 SUP HCPCS C1713 71131408 - PLATE BN NAR 8 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $198.45 $198.45 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $220.50 $349.27 $352.80 $0.00 $0.00 $69.02 $0.00 $0.00 $70.21 $0.00 $0.00 $0.00 $0.00 $0.00 71131409 SUP HCPCS C1713 71131409 - PLATE BN NAR 9 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $198.45 $198.45 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $220.50 $349.27 $352.80 $0.00 $0.00 $69.02 $0.00 $0.00 $70.21 $0.00 $0.00 $0.00 $0.00 $0.00 71131410 SUP HCPCS C1713 71131410 - PLATE BN NAR 10 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $570.15 $421.91 $0.00 $456.12 $256.57 $256.57 $0.00 $0.00 $0.00 $118.83 $423.17 $423.17 $0.00 $0.00 $118.82 $0.00 $337.24 $337.24 $0.00 $285.08 $451.56 $456.12 $0.00 $0.00 $89.23 $0.00 $0.00 $90.77 $0.00 $0.00 $0.00 $0.00 $0.00 71131411 SUP HCPCS C1713 71131411 - PLATE BN NAR 11 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $696.15 $515.15 $0.00 $556.92 $313.27 $313.27 $0.00 $0.00 $0.00 $145.10 $516.68 $516.68 $0.00 $0.00 $145.08 $0.00 $411.77 $411.77 $0.00 $348.08 $551.35 $556.92 $0.00 $0.00 $108.95 $0.00 $0.00 $110.83 $0.00 $0.00 $0.00 $0.00 $0.00 71131412 SUP HCPCS C1713 71131412 - PLATE BN NAR 12 HL PRV FX PERIART MTPHSL 4.5MM SCR LG FRAG BOTH IP/OP $696.15 $515.15 $0.00 $556.92 $313.27 $313.27 $0.00 $0.00 $0.00 $145.10 $516.68 $516.68 $0.00 $0.00 $145.08 $0.00 $411.77 $411.77 $0.00 $348.08 $551.35 $556.92 $0.00 $0.00 $108.95 $0.00 $0.00 $110.83 $0.00 $0.00 $0.00 $0.00 $0.00 71131510 SUP HCPCS C1713 71131510 - PIN FX LG ST 2MM 61MM 10MM TRL SS BOTH IP/OP $221.55 $163.95 $0.00 $177.24 $99.70 $99.70 $0.00 $0.00 $0.00 $46.18 $164.43 $164.43 $0.00 $0.00 $46.17 $0.00 $131.05 $131.05 $0.00 $110.78 $175.47 $177.24 $0.00 $0.00 $34.67 $0.00 $0.00 $35.27 $0.00 $0.00 $0.00 $0.00 $0.00 71131511 SUP HCPCS C1713 71131511 - PIN FX LG MED THRD 2MM 38MM 13MM TRL SS BOTH IP/OP $221.55 $163.95 $0.00 $177.24 $99.70 $99.70 $0.00 $0.00 $0.00 $46.18 $164.43 $164.43 $0.00 $0.00 $46.17 $0.00 $131.05 $131.05 $0.00 $110.78 $175.47 $177.24 $0.00 $0.00 $34.67 $0.00 $0.00 $35.27 $0.00 $0.00 $0.00 $0.00 $0.00 71131512 SUP HCPCS C1713 71131512 - PIN FX LG L/T 2MM 61MM 23MM TRL SS BOTH IP/OP $235.20 $174.05 $0.00 $188.16 $105.84 $105.84 $0.00 $0.00 $0.00 $49.02 $174.57 $174.57 $0.00 $0.00 $49.02 $0.00 $139.12 $139.12 $0.00 $117.60 $186.28 $188.16 $0.00 $0.00 $36.81 $0.00 $0.00 $37.44 $0.00 $0.00 $0.00 $0.00 $0.00 71131604 SUP HCPCS C1713 71131604 - PLATE BN T 4 HL PRV FX LG FRAG SET BOTH IP/OP $340.20 $251.75 $0.00 $272.16 $153.09 $153.09 $0.00 $0.00 $0.00 $70.91 $252.50 $252.50 $0.00 $0.00 $70.90 $0.00 $201.23 $201.23 $0.00 $170.10 $269.44 $272.16 $0.00 $0.00 $53.24 $0.00 $0.00 $54.16 $0.00 $0.00 $0.00 $0.00 $0.00 71131606 SUP HCPCS C1713 71131606 - PLATE BN T 6 HL PRV FX LG FRAG SET BOTH IP/OP $376.95 $278.94 $0.00 $301.56 $169.63 $169.63 $0.00 $0.00 $0.00 $78.57 $279.77 $279.77 $0.00 $0.00 $78.56 $0.00 $222.97 $222.97 $0.00 $188.48 $298.54 $301.56 $0.00 $0.00 $58.99 $0.00 $0.00 $60.01 $0.00 $0.00 $0.00 $0.00 $0.00 71131608 SUP HCPCS C1713 71131608 - PLATE BN T 8 HL PRV FX LG FRAG SET BOTH IP/OP "$1,118.25 " $827.51 $0.00 $894.60 $503.21 $503.21 $0.00 $0.00 $0.00 $233.07 $829.97 $829.97 $0.00 $0.00 $233.04 $0.00 $661.44 $661.44 $0.00 $559.13 $885.65 $894.60 $0.00 $0.00 $175.01 $0.00 $0.00 $178.03 $0.00 $0.00 $0.00 $0.00 $0.00 71134016 SUP Custom 27203010 71134016 - BIT DRL 2MM TWST PED BOTH IP/OP $91.40 $67.64 $0.00 $73.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.84 $67.84 $0.00 $0.00 $19.05 $0.00 $0.00 $0.00 $0.00 $45.70 $72.39 $73.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71134064 SUP Custom 27203010 71134064 - BIT DRL 2.7MM TWST PED BOTH IP/OP $95.70 $70.82 $0.00 $76.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.03 $71.03 $0.00 $0.00 $19.94 $0.00 $0.00 $0.00 $0.00 $47.85 $75.79 $76.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71140003 SUP HCPCS C1713 71140003 - PLATE BN 45MM TC100 3 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP $798.00 $590.52 $0.00 $638.40 $359.10 $359.10 $0.00 $0.00 $0.00 $166.32 $592.28 $592.28 $0.00 $0.00 $166.30 $0.00 $472.02 $472.02 $0.00 $399.00 $632.02 $638.40 $0.00 $0.00 $124.89 $0.00 $0.00 $127.04 $0.00 $0.00 $0.00 $0.00 $0.00 71140004 SUP HCPCS C1713 71140004 - PLATE BN 61MM TC100 4 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP $846.30 $626.26 $0.00 $677.04 $380.84 $380.84 $0.00 $0.00 $0.00 $176.39 $628.12 $628.12 $0.00 $0.00 $176.37 $0.00 $500.59 $500.59 $0.00 $423.15 $670.27 $677.04 $0.00 $0.00 $132.45 $0.00 $0.00 $134.73 $0.00 $0.00 $0.00 $0.00 $0.00 71140005 SUP HCPCS C1713 71140005 - PLATE BN 77MM TC100 5 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP $910.35 $673.66 $0.00 $728.28 $409.66 $409.66 $0.00 $0.00 $0.00 $189.74 $675.66 $675.66 $0.00 $0.00 $189.72 $0.00 $538.47 $538.47 $0.00 $455.18 $721.00 $728.28 $0.00 $0.00 $142.47 $0.00 $0.00 $144.93 $0.00 $0.00 $0.00 $0.00 $0.00 71140006 SUP HCPCS C1713 71140006 - PLATE BN 93MM TC100 6 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP $972.30 $719.50 $0.00 $777.84 $437.54 $437.54 $0.00 $0.00 $0.00 $202.65 $721.64 $721.64 $0.00 $0.00 $202.63 $0.00 $575.12 $575.12 $0.00 $486.15 $770.06 $777.84 $0.00 $0.00 $152.16 $0.00 $0.00 $154.79 $0.00 $0.00 $0.00 $0.00 $0.00 71140007 SUP HCPCS C1713 71140007 - PLATE BN 109MM TC100 7 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,025.85 " $759.13 $0.00 $820.68 $461.63 $461.63 $0.00 $0.00 $0.00 $213.81 $761.39 $761.39 $0.00 $0.00 $213.79 $0.00 $606.79 $606.79 $0.00 $512.93 $812.47 $820.68 $0.00 $0.00 $160.55 $0.00 $0.00 $163.32 $0.00 $0.00 $0.00 $0.00 $0.00 71140008 SUP HCPCS C1713 71140008 - PLATE BN 125MM TC100 8 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 71140009 SUP HCPCS C1713 71140009 - PLATE BN 141MM TC100 9 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,391.25 " "$1,029.53" $0.00 "$1,113.00" $626.06 $626.06 $0.00 $0.00 $0.00 $289.97 "$1,032.59" "$1,032.59" $0.00 $0.00 $289.94 $0.00 $822.92 $822.92 $0.00 $695.63 "$1,101.87" "$1,113.00" $0.00 $0.00 $217.73 $0.00 $0.00 $221.49 $0.00 $0.00 $0.00 $0.00 $0.00 71140010 SUP HCPCS C1713 71140010 - PLATE BN 157MM TC100 10 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,464.75 " "$1,083.92" $0.00 "$1,171.80" $659.14 $659.14 $0.00 $0.00 $0.00 $305.29 "$1,087.14" "$1,087.14" $0.00 $0.00 $305.25 $0.00 $866.40 $866.40 $0.00 $732.38 "$1,160.08" "$1,171.80" $0.00 $0.00 $229.23 $0.00 $0.00 $233.19 $0.00 $0.00 $0.00 $0.00 $0.00 71140011 SUP HCPCS C1713 71140011 - PLATE BN 173MM TC100 11 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,506.75 " "$1,115.00" $0.00 "$1,205.40" $678.04 $678.04 $0.00 $0.00 $0.00 $314.04 "$1,118.31" "$1,118.31" $0.00 $0.00 $314.01 $0.00 $891.24 $891.24 $0.00 $753.38 "$1,193.35" "$1,205.40" $0.00 $0.00 $235.81 $0.00 $0.00 $239.87 $0.00 $0.00 $0.00 $0.00 $0.00 71140012 SUP HCPCS C1713 71140012 - PLATE BN 189MM TC100 12 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 71140013 SUP HCPCS C1713 71140013 - PLATE BN 205MM TC100 13 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,701.00 " "$1,258.74" $0.00 "$1,360.80" $765.45 $765.45 $0.00 $0.00 $0.00 $354.53 "$1,262.48" "$1,262.48" $0.00 $0.00 $354.49 $0.00 "$1,006.14" "$1,006.14" $0.00 $850.50 "$1,347.19" "$1,360.80" $0.00 $0.00 $266.21 $0.00 $0.00 $270.80 $0.00 $0.00 $0.00 $0.00 $0.00 71140014 SUP HCPCS C1713 71140014 - PLATE BN 221MM TC100 14 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71140015 SUP HCPCS C1713 71140015 - PLATE BN 237MM TC100 15 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,806.00 " "$1,336.44" $0.00 "$1,444.80" $812.70 $812.70 $0.00 $0.00 $0.00 $376.42 "$1,340.41" "$1,340.41" $0.00 $0.00 $376.37 $0.00 "$1,068.25" "$1,068.25" $0.00 $903.00 "$1,430.35" "$1,444.80" $0.00 $0.00 $282.64 $0.00 $0.00 $287.52 $0.00 $0.00 $0.00 $0.00 $0.00 71140016 SUP HCPCS C1713 71140016 - PLATE BN 253MM TC100 16 HL RECON SS PLVC 4.5MM SCR BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,495.20" $841.05 $841.05 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $934.50 "$1,480.25" "$1,495.20" $0.00 $0.00 $292.50 $0.00 $0.00 $297.54 $0.00 $0.00 $0.00 $0.00 $0.00 71140104 SUP HCPCS C1713 71140104 - PLATE BN 46MM TC100 4 HL RECON SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $875.70 $648.02 $0.00 $700.56 $394.07 $394.07 $0.00 $0.00 $0.00 $182.52 $649.94 $649.94 $0.00 $0.00 $182.50 $0.00 $517.98 $517.98 $0.00 $437.85 $693.55 $700.56 $0.00 $0.00 $137.05 $0.00 $0.00 $139.41 $0.00 $0.00 $0.00 $0.00 $0.00 71140105 SUP HCPCS C1713 71140105 - PLATE BN 58MM TC100 5 HL RECON SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $812.70 $601.40 $0.00 $650.16 $365.72 $365.72 $0.00 $0.00 $0.00 $169.39 $603.19 $603.19 $0.00 $0.00 $169.37 $0.00 $480.71 $480.71 $0.00 $406.35 $643.66 $650.16 $0.00 $0.00 $127.19 $0.00 $0.00 $129.38 $0.00 $0.00 $0.00 $0.00 $0.00 71140106 SUP HCPCS C1713 71140106 - PLATE BN 70MM TC100 6 HL RECON SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP "$1,022.70 " $756.80 $0.00 $818.16 $460.22 $460.22 $0.00 $0.00 $0.00 $213.16 $759.05 $759.05 $0.00 $0.00 $213.13 $0.00 $604.93 $604.93 $0.00 $511.35 $809.98 $818.16 $0.00 $0.00 $160.05 $0.00 $0.00 $162.81 $0.00 $0.00 $0.00 $0.00 $0.00 71140107 SUP HCPCS C1713 71140107 - PLATE BN 82MM TC100 7 HL RECON SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $974.40 $721.06 $0.00 $779.52 $438.48 $438.48 $0.00 $0.00 $0.00 $203.09 $723.20 $723.20 $0.00 $0.00 $203.06 $0.00 $576.36 $576.36 $0.00 $487.20 $771.72 $779.52 $0.00 $0.00 $152.49 $0.00 $0.00 $155.12 $0.00 $0.00 $0.00 $0.00 $0.00 71140108 SUP HCPCS C1713 71140108 - PLATE BN 94MM TC100 8 HL RECON SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP "$1,118.25 " $827.51 $0.00 $894.60 $503.21 $503.21 $0.00 $0.00 $0.00 $233.07 $829.97 $829.97 $0.00 $0.00 $233.04 $0.00 $661.44 $661.44 $0.00 $559.13 $885.65 $894.60 $0.00 $0.00 $175.01 $0.00 $0.00 $178.03 $0.00 $0.00 $0.00 $0.00 $0.00 71140109 SUP HCPCS C1713 71140109 - PLATE BN 106MM TC100 9 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,050.00 " $777.00 $0.00 $840.00 $472.50 $472.50 $0.00 $0.00 $0.00 $218.85 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $621.08 $621.08 $0.00 $525.00 $831.60 $840.00 $0.00 $0.00 $164.33 $0.00 $0.00 $167.16 $0.00 $0.00 $0.00 $0.00 $0.00 71140110 SUP HCPCS C1713 71140110 - PLATE BN 118MM TC100 10 HL RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71140111 SUP HCPCS C1713 71140111 - PLATE BN 130MM TC100 11 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,118.25 " $827.51 $0.00 $894.60 $503.21 $503.21 $0.00 $0.00 $0.00 $233.07 $829.97 $829.97 $0.00 $0.00 $233.04 $0.00 $661.44 $661.44 $0.00 $559.13 $885.65 $894.60 $0.00 $0.00 $175.01 $0.00 $0.00 $178.03 $0.00 $0.00 $0.00 $0.00 $0.00 71140112 SUP HCPCS C1713 71140112 - PLATE BN 142MM TC100 12 HL RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71140113 SUP HCPCS C1713 71140113 - PLATE BN 154MM TC100 13 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 71140114 SUP HCPCS C1713 71140114 - PLATE BN 166MM TC100 14 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,380.75 " "$1,021.76" $0.00 "$1,104.60" $621.34 $621.34 $0.00 $0.00 $0.00 $287.78 "$1,024.79" "$1,024.79" $0.00 $0.00 $287.75 $0.00 $816.71 $816.71 $0.00 $690.38 "$1,093.55" "$1,104.60" $0.00 $0.00 $216.09 $0.00 $0.00 $219.82 $0.00 $0.00 $0.00 $0.00 $0.00 71140115 SUP HCPCS C1713 71140115 - PLATE BN 178MM TC100 15 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,648.50 " "$1,219.89" $0.00 "$1,318.80" $741.83 $741.83 $0.00 $0.00 $0.00 $343.59 "$1,223.52" "$1,223.52" $0.00 $0.00 $343.55 $0.00 $975.09 $975.09 $0.00 $824.25 "$1,305.61" "$1,318.80" $0.00 $0.00 $257.99 $0.00 $0.00 $262.44 $0.00 $0.00 $0.00 $0.00 $0.00 71140116 SUP HCPCS C1713 71140116 - PLATE BN 190MM TC100 16 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,407.00 " "$1,041.18" $0.00 "$1,125.60" $633.15 $633.15 $0.00 $0.00 $0.00 $293.25 "$1,044.28" "$1,044.28" $0.00 $0.00 $293.22 $0.00 $832.24 $832.24 $0.00 $703.50 "$1,114.34" "$1,125.60" $0.00 $0.00 $220.20 $0.00 $0.00 $223.99 $0.00 $0.00 $0.00 $0.00 $0.00 71140118 SUP HCPCS C1713 71140118 - PLATE BN 214MM TC100 18 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,480.50 " "$1,095.57" $0.00 "$1,184.40" $666.23 $666.23 $0.00 $0.00 $0.00 $308.57 "$1,098.83" "$1,098.83" $0.00 $0.00 $308.54 $0.00 $875.72 $875.72 $0.00 $740.25 "$1,172.56" "$1,184.40" $0.00 $0.00 $231.70 $0.00 $0.00 $235.70 $0.00 $0.00 $0.00 $0.00 $0.00 71140120 SUP HCPCS C1713 71140120 - PLATE BN 238MM TC100 20 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,800.75 " "$1,332.56" $0.00 "$1,440.60" $810.34 $810.34 $0.00 $0.00 $0.00 $375.32 "$1,336.52" "$1,336.52" $0.00 $0.00 $375.28 $0.00 "$1,065.14" "$1,065.14" $0.00 $900.38 "$1,426.19" "$1,440.60" $0.00 $0.00 $281.82 $0.00 $0.00 $286.68 $0.00 $0.00 $0.00 $0.00 $0.00 71140122 SUP HCPCS C1713 71140122 - PLATE BN 263MM TC100 22 HL RECON SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,827.00" "$1,027.69" "$1,027.69" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,141.88" "$1,808.73" "$1,827.00" $0.00 $0.00 $357.41 $0.00 $0.00 $363.57 $0.00 $0.00 $0.00 $0.00 $0.00 71140202 SUP HCPCS C1713 71140202 - PLATE BN 25MM TC100 2 HL CMPR SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $296.10 $219.11 $0.00 $236.88 $133.25 $133.25 $0.00 $0.00 $0.00 $61.71 $219.77 $219.77 $0.00 $0.00 $61.71 $0.00 $175.14 $175.14 $0.00 $148.05 $234.51 $236.88 $0.00 $0.00 $46.34 $0.00 $0.00 $47.14 $0.00 $0.00 $0.00 $0.00 $0.00 71140203 SUP HCPCS C1713 71140203 - PLATE BN 37MM TC100 3 HL CMPR SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $309.75 $229.22 $0.00 $247.80 $139.39 $139.39 $0.00 $0.00 $0.00 $64.56 $229.90 $229.90 $0.00 $0.00 $64.55 $0.00 $183.22 $183.22 $0.00 $154.88 $245.32 $247.80 $0.00 $0.00 $48.48 $0.00 $0.00 $49.31 $0.00 $0.00 $0.00 $0.00 $0.00 71140204 SUP HCPCS C1713 71140204 - PLATE BN 49MM TC100 4 HL CMPR SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $316.05 $233.88 $0.00 $252.84 $142.22 $142.22 $0.00 $0.00 $0.00 $65.87 $234.57 $234.57 $0.00 $0.00 $65.86 $0.00 $186.94 $186.94 $0.00 $158.03 $250.31 $252.84 $0.00 $0.00 $49.46 $0.00 $0.00 $50.32 $0.00 $0.00 $0.00 $0.00 $0.00 71140205 SUP HCPCS C1713 71140205 - PLATE BN 61MM TC100 5 HL CMPR SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $345.45 $255.63 $0.00 $276.36 $155.45 $155.45 $0.00 $0.00 $0.00 $72.00 $256.39 $256.39 $0.00 $0.00 $71.99 $0.00 $204.33 $204.33 $0.00 $172.73 $273.60 $276.36 $0.00 $0.00 $54.06 $0.00 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 71140206 SUP HCPCS C1713 71140206 - PLATE BN 73MM TC100 6 HL CMPR SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $361.20 $267.29 $0.00 $288.96 $162.54 $162.54 $0.00 $0.00 $0.00 $75.28 $268.08 $268.08 $0.00 $0.00 $75.27 $0.00 $213.65 $213.65 $0.00 $180.60 $286.07 $288.96 $0.00 $0.00 $56.53 $0.00 $0.00 $57.50 $0.00 $0.00 $0.00 $0.00 $0.00 71140207 SUP HCPCS C1713 71140207 - PLATE BN 85MM TC100 7 HL CMPR SS PLVC 3.5MM SCR BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $170.10 $170.10 $0.00 $0.00 $0.00 $78.78 $280.55 $280.55 $0.00 $0.00 $78.78 $0.00 $223.59 $223.59 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $59.16 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 71140208 SUP HCPCS C1713 71140208 - PLATE BN 97MM 8 HL HIP 3.5MM SCR SM FRAG SET BOTH IP/OP $405.30 $299.92 $0.00 $324.24 $182.39 $182.39 $0.00 $0.00 $0.00 $84.47 $300.81 $300.81 $0.00 $0.00 $84.46 $0.00 $239.73 $239.73 $0.00 $202.65 $321.00 $324.24 $0.00 $0.00 $63.43 $0.00 $0.00 $64.52 $0.00 $0.00 $0.00 $0.00 $0.00 71140209 SUP HCPCS C1713 71140209 - PLATE BN 109MM TC100 9 HL CMPR SS PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $414.75 $306.92 $0.00 $331.80 $186.64 $186.64 $0.00 $0.00 $0.00 $86.44 $307.83 $307.83 $0.00 $0.00 $86.43 $0.00 $245.32 $245.32 $0.00 $207.38 $328.48 $331.80 $0.00 $0.00 $64.91 $0.00 $0.00 $66.03 $0.00 $0.00 $0.00 $0.00 $0.00 71140210 SUP HCPCS C1713 71140210 - PLATE BN 121MM TC100 10 HL CMPR SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP $426.30 $315.46 $0.00 $341.04 $191.84 $191.84 $0.00 $0.00 $0.00 $88.85 $316.40 $316.40 $0.00 $0.00 $88.84 $0.00 $252.16 $252.16 $0.00 $213.15 $337.63 $341.04 $0.00 $0.00 $66.72 $0.00 $0.00 $67.87 $0.00 $0.00 $0.00 $0.00 $0.00 71140212 SUP HCPCS C1713 71140212 - PLATE BN 145MM TC100 12 HL CMPR SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP $473.55 $350.43 $0.00 $378.84 $213.10 $213.10 $0.00 $0.00 $0.00 $98.70 $351.47 $351.47 $0.00 $0.00 $98.69 $0.00 $280.10 $280.10 $0.00 $236.78 $375.05 $378.84 $0.00 $0.00 $74.11 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 71140214 SUP HCPCS C1713 71140214 - PLATE BN 169MM TC100 14 HL CMPR SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP $889.35 $658.12 $0.00 $711.48 $400.21 $400.21 $0.00 $0.00 $0.00 $185.36 $660.08 $660.08 $0.00 $0.00 $185.34 $0.00 $526.05 $526.05 $0.00 $444.68 $704.37 $711.48 $0.00 $0.00 $139.18 $0.00 $0.00 $141.58 $0.00 $0.00 $0.00 $0.00 $0.00 71140216 SUP HCPCS C1713 71140216 - PLATE BN 194MM TC100 16 HL CMPR SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,025.85 " $759.13 $0.00 $820.68 $461.63 $461.63 $0.00 $0.00 $0.00 $213.81 $761.39 $761.39 $0.00 $0.00 $213.79 $0.00 $606.79 $606.79 $0.00 $512.93 $812.47 $820.68 $0.00 $0.00 $160.55 $0.00 $0.00 $163.32 $0.00 $0.00 $0.00 $0.00 $0.00 71140218 SUP HCPCS C1713 71140218 - PLATE BN 217MM TC100 18 HL CMPR SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,380.75 " "$1,021.76" $0.00 "$1,104.60" $621.34 $621.34 $0.00 $0.00 $0.00 $287.78 "$1,024.79" "$1,024.79" $0.00 $0.00 $287.75 $0.00 $816.71 $816.71 $0.00 $690.38 "$1,093.55" "$1,104.60" $0.00 $0.00 $216.09 $0.00 $0.00 $219.82 $0.00 $0.00 $0.00 $0.00 $0.00 71140220 SUP HCPCS C1713 71140220 - PLATE BN 242MM TC100 20 HL CMPR SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,270.50 " $940.17 $0.00 "$1,016.40" $571.73 $571.73 $0.00 $0.00 $0.00 $264.80 $942.97 $942.97 $0.00 $0.00 $264.77 $0.00 $751.50 $751.50 $0.00 $635.25 "$1,006.24" "$1,016.40" $0.00 $0.00 $198.83 $0.00 $0.00 $202.26 $0.00 $0.00 $0.00 $0.00 $0.00 71140222 SUP HCPCS C1713 71140222 - PLATE BN 265MM TC100 22 HL CMPR SS PLVC 3.5MM SCR SM FRAG BOTH IP/OP "$1,701.00 " "$1,258.74" $0.00 "$1,360.80" $765.45 $765.45 $0.00 $0.00 $0.00 $354.53 "$1,262.48" "$1,262.48" $0.00 $0.00 $354.49 $0.00 "$1,006.14" "$1,006.14" $0.00 $850.50 "$1,347.19" "$1,360.80" $0.00 $0.00 $266.21 $0.00 $0.00 $270.80 $0.00 $0.00 $0.00 $0.00 $0.00 71140302 SUP HCPCS C1713 71140302 - PLATE BN 25MM TC100 2 HL 1/3 TBLR COLR SS PLVC 3.5MM SCR SM BOTH IP/OP $169.05 $125.10 $0.00 $135.24 $76.07 $76.07 $0.00 $0.00 $0.00 $35.23 $125.47 $125.47 $0.00 $0.00 $35.23 $0.00 $99.99 $99.99 $0.00 $84.53 $133.89 $135.24 $0.00 $0.00 $26.46 $0.00 $0.00 $26.91 $0.00 $0.00 $0.00 $0.00 $0.00 71140303 SUP HCPCS C1713 71140303 - PLATE BN 37MM TC100 3 HL 1/3 TBLR COLR SS PLVC 3.5MM SCR SM BOTH IP/OP $143.85 $106.45 $0.00 $115.08 $64.73 $64.73 $0.00 $0.00 $0.00 $29.98 $106.77 $106.77 $0.00 $0.00 $29.98 $0.00 $85.09 $85.09 $0.00 $71.93 $113.93 $115.08 $0.00 $0.00 $22.51 $0.00 $0.00 $22.90 $0.00 $0.00 $0.00 $0.00 $0.00 71140304 SUP HCPCS C1713 71140304 - PLATE BN 49MM TC100 4 HL 1/3 TBLR COLR SS PLVC 3.5MM SCR SM BOTH IP/OP $169.05 $125.10 $0.00 $135.24 $76.07 $76.07 $0.00 $0.00 $0.00 $35.23 $125.47 $125.47 $0.00 $0.00 $35.23 $0.00 $99.99 $99.99 $0.00 $84.53 $133.89 $135.24 $0.00 $0.00 $26.46 $0.00 $0.00 $26.91 $0.00 $0.00 $0.00 $0.00 $0.00 71140305 SUP HCPCS C1713 71140305 - PLATE BN 61MM TC100 5 HL 1/3 TBLR COLR SS PLVC 3.5MM SCR SM BOTH IP/OP $211.05 $156.18 $0.00 $168.84 $94.97 $94.97 $0.00 $0.00 $0.00 $43.99 $156.64 $156.64 $0.00 $0.00 $43.98 $0.00 $124.84 $124.84 $0.00 $105.53 $167.15 $168.84 $0.00 $0.00 $33.03 $0.00 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 71140306 SUP HCPCS C1713 71140306 - PLATE BN 73MM TC100 6 HL 1/3 TBLR COLR SS PLVC 3.5MM SCR SM BOTH IP/OP $175.35 $129.76 $0.00 $140.28 $78.91 $78.91 $0.00 $0.00 $0.00 $36.55 $130.14 $130.14 $0.00 $0.00 $36.54 $0.00 $103.72 $103.72 $0.00 $87.68 $138.88 $140.28 $0.00 $0.00 $27.44 $0.00 $0.00 $27.92 $0.00 $0.00 $0.00 $0.00 $0.00 71140307 SUP HCPCS C1713 71140307 - PLATE BN 1/3 TBLR 85MM NS TC100 7 HL COLR SS PLVC 3.5MM SCR BOTH IP/OP $175.35 $129.76 $0.00 $140.28 $78.91 $78.91 $0.00 $0.00 $0.00 $36.55 $130.14 $130.14 $0.00 $0.00 $36.54 $0.00 $103.72 $103.72 $0.00 $87.68 $138.88 $140.28 $0.00 $0.00 $27.44 $0.00 $0.00 $27.92 $0.00 $0.00 $0.00 $0.00 $0.00 71140308 SUP HCPCS C1713 71140308 - PLATE BN 97MM TC100 8 HL 1/3 TBLR COLR SS PLVC 3.5MM SCR SM BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 71140309 SUP HCPCS C1713 71140309 - PLATE BN 109MM TC100 9 HL 1/3 TBLR COLR SS PLVC 3.5MM SCR SM BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 71140310 SUP HCPCS C1713 71140310 - PLATE BN 121MM TC100 10 HL 1/3 TBLR COLR SS PLVC 3.5MM SCR BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 71140312 SUP HCPCS C1713 71140312 - PLATE BN 145MM TC100 12 HL 1/3 TBLR COLR SS ORTH SM FRAG SET BOTH IP/OP $181.65 $134.42 $0.00 $145.32 $81.74 $81.74 $0.00 $0.00 $0.00 $37.86 $134.82 $134.82 $0.00 $0.00 $37.86 $0.00 $107.45 $107.45 $0.00 $90.83 $143.87 $145.32 $0.00 $0.00 $28.43 $0.00 $0.00 $28.92 $0.00 $0.00 $0.00 $0.00 $0.00 71140403 SUP HCPCS C1713 71140403 - PLATE BN SM T RT ANG 50MM TC100 3X3 HL SS PLVC SM FRAG SET BOTH IP/OP $313.95 $232.32 $0.00 $251.16 $141.28 $141.28 $0.00 $0.00 $0.00 $65.44 $233.01 $233.01 $0.00 $0.00 $65.43 $0.00 $185.70 $185.70 $0.00 $156.98 $248.65 $251.16 $0.00 $0.00 $49.13 $0.00 $0.00 $49.98 $0.00 $0.00 $0.00 $0.00 $0.00 71140404 SUP HCPCS C1713 71140404 - PLATE BN SM T RT ANG 50MM TC100 4X4 HL SS PLVC SM FRAG SET BOTH IP/OP $320.25 $236.99 $0.00 $256.20 $144.11 $144.11 $0.00 $0.00 $0.00 $66.75 $237.69 $237.69 $0.00 $0.00 $66.74 $0.00 $189.43 $189.43 $0.00 $160.13 $253.64 $256.20 $0.00 $0.00 $50.12 $0.00 $0.00 $50.98 $0.00 $0.00 $0.00 $0.00 $0.00 71140405 SUP HCPCS C1713 71140405 - PLATE BN SM T RT ANG 50MM TC100 3X5 HL SS PLVC SM FRAG SET BOTH IP/OP $360.15 $266.51 $0.00 $288.12 $162.07 $162.07 $0.00 $0.00 $0.00 $75.06 $267.30 $267.30 $0.00 $0.00 $75.06 $0.00 $213.03 $213.03 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $56.36 $0.00 $0.00 $57.34 $0.00 $0.00 $0.00 $0.00 $0.00 71140406 SUP HCPCS C1713 71140406 - PLATE BN 78MM TC100 4 HLE/HD 6 HL SHFT T RT ANG SS ORTH SM BOTH IP/OP $414.75 $306.92 $0.00 $331.80 $186.64 $186.64 $0.00 $0.00 $0.00 $86.44 $307.83 $307.83 $0.00 $0.00 $86.43 $0.00 $245.32 $245.32 $0.00 $207.38 $328.48 $331.80 $0.00 $0.00 $64.91 $0.00 $0.00 $66.03 $0.00 $0.00 $0.00 $0.00 $0.00 71140503 SUP HCPCS C1713 71140503 - PLATE BN SM T OBLQ 53MM TC100 3X3 HL SS PLVC SM FRAG SET BOTH IP/OP $563.85 $417.25 $0.00 $451.08 $253.73 $253.73 $0.00 $0.00 $0.00 $117.52 $418.49 $418.49 $0.00 $0.00 $117.51 $0.00 $333.52 $333.52 $0.00 $281.93 $446.57 $451.08 $0.00 $0.00 $88.24 $0.00 $0.00 $89.76 $0.00 $0.00 $0.00 $0.00 $0.00 71140504 SUP HCPCS C1713 71140504 - PLATE BN SM T OBLQ 53MM TC100 3X4 HL SS PLVC SM FRAG SET BOTH IP/OP $588.00 $435.12 $0.00 $470.40 $264.60 $264.60 $0.00 $0.00 $0.00 $122.55 $436.41 $436.41 $0.00 $0.00 $122.54 $0.00 $347.80 $347.80 $0.00 $294.00 $465.70 $470.40 $0.00 $0.00 $92.02 $0.00 $0.00 $93.61 $0.00 $0.00 $0.00 $0.00 $0.00 71140505 SUP HCPCS C1713 71140505 - PLATE BN SM T OBLQ 53MM TC100 3X5 HL SS PLVC SM FRAG SET BOTH IP/OP $609.00 $450.66 $0.00 $487.20 $274.05 $274.05 $0.00 $0.00 $0.00 $126.93 $452.00 $452.00 $0.00 $0.00 $126.92 $0.00 $360.22 $360.22 $0.00 $304.50 $482.33 $487.20 $0.00 $0.00 $95.31 $0.00 $0.00 $96.95 $0.00 $0.00 $0.00 $0.00 $0.00 71140603 SUP HCPCS C1713 71140603 - PLATE BN 88MM TC100 3 HL CLVRLF SS ORTH SM FRAG SET BOTH IP/OP $744.45 $550.89 $0.00 $595.56 $335.00 $335.00 $0.00 $0.00 $0.00 $155.16 $552.53 $552.53 $0.00 $0.00 $155.14 $0.00 $440.34 $440.34 $0.00 $372.23 $589.60 $595.56 $0.00 $0.00 $116.51 $0.00 $0.00 $118.52 $0.00 $0.00 $0.00 $0.00 $0.00 71140604 SUP HCPCS C1713 71140604 - PLATE BN 104MM TC100 4 HL CLVRLF SS ORTH SM FRAG SET BOTH IP/OP $798.00 $590.52 $0.00 $638.40 $359.10 $359.10 $0.00 $0.00 $0.00 $166.32 $592.28 $592.28 $0.00 $0.00 $166.30 $0.00 $472.02 $472.02 $0.00 $399.00 $632.02 $638.40 $0.00 $0.00 $124.89 $0.00 $0.00 $127.04 $0.00 $0.00 $0.00 $0.00 $0.00 71140606 SUP HCPCS C1713 71140606 - PLATE BN 70MM TC100 6 HL CRV RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,039.50 " $769.23 $0.00 $831.60 $467.78 $467.78 $0.00 $0.00 $0.00 $216.66 $771.52 $771.52 $0.00 $0.00 $216.63 $0.00 $614.86 $614.86 $0.00 $519.75 $823.28 $831.60 $0.00 $0.00 $162.68 $0.00 $0.00 $165.49 $0.00 $0.00 $0.00 $0.00 $0.00 71140608 SUP HCPCS C1713 71140608 - PLATE BN 94MM TC100 8 HL CRV RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,134.00 " $839.16 $0.00 $907.20 $510.30 $510.30 $0.00 $0.00 $0.00 $236.35 $841.65 $841.65 $0.00 $0.00 $236.33 $0.00 $670.76 $670.76 $0.00 $567.00 $898.13 $907.20 $0.00 $0.00 $177.47 $0.00 $0.00 $180.53 $0.00 $0.00 $0.00 $0.00 $0.00 71140610 SUP HCPCS C1713 71140610 - PLATE BN 118MM TC100 10 HL CRV RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,186.50 " $878.01 $0.00 $949.20 $533.93 $533.93 $0.00 $0.00 $0.00 $247.30 $880.62 $880.62 $0.00 $0.00 $247.27 $0.00 $701.81 $701.81 $0.00 $593.25 $939.71 $949.20 $0.00 $0.00 $185.69 $0.00 $0.00 $188.89 $0.00 $0.00 $0.00 $0.00 $0.00 71140612 SUP HCPCS C1713 71140612 - PLATE BN 142MM TC100 12 HL CRV RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,244.25 " $920.75 $0.00 $995.40 $559.91 $559.91 $0.00 $0.00 $0.00 $259.33 $923.48 $923.48 $0.00 $0.00 $259.30 $0.00 $735.97 $735.97 $0.00 $622.13 $985.45 $995.40 $0.00 $0.00 $194.73 $0.00 $0.00 $198.08 $0.00 $0.00 $0.00 $0.00 $0.00 71140614 SUP HCPCS C1713 71140614 - PLATE BN 166MM TC100 14 HL CRV RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,401.75 " "$1,037.30" $0.00 "$1,121.40" $630.79 $630.79 $0.00 $0.00 $0.00 $292.16 "$1,040.38" "$1,040.38" $0.00 $0.00 $292.12 $0.00 $829.14 $829.14 $0.00 $700.88 "$1,110.19" "$1,121.40" $0.00 $0.00 $219.37 $0.00 $0.00 $223.16 $0.00 $0.00 $0.00 $0.00 $0.00 71140616 SUP HCPCS C1713 71140616 - PLATE BN 190MM TC100 16 HL CRV RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,485.75 " "$1,099.46" $0.00 "$1,188.60" $668.59 $668.59 $0.00 $0.00 $0.00 $309.67 "$1,102.72" "$1,102.72" $0.00 $0.00 $309.63 $0.00 $878.82 $878.82 $0.00 $742.88 "$1,176.71" "$1,188.60" $0.00 $0.00 $232.52 $0.00 $0.00 $236.53 $0.00 $0.00 $0.00 $0.00 $0.00 71140618 SUP HCPCS C1713 71140618 - PLATE BN 214MM TC100 18 HL CRV RECON SS PLVC 3.5MM SCR BOTH IP/OP "$1,601.25 " "$1,184.93" $0.00 "$1,281.00" $720.56 $720.56 $0.00 $0.00 $0.00 $333.74 "$1,188.45" "$1,188.45" $0.00 $0.00 $333.70 $0.00 $947.14 $947.14 $0.00 $800.63 "$1,268.19" "$1,281.00" $0.00 $0.00 $250.60 $0.00 $0.00 $254.92 $0.00 $0.00 $0.00 $0.00 $0.00 71140625 SUP HCPCS C1713 71140625 - PLATE BN 120MM TC100 5 HL CLVRLF SS ORTH SM FRAG SET BOTH IP/OP "$1,013.25 " $749.81 $0.00 $810.60 $455.96 $455.96 $0.00 $0.00 $0.00 $211.19 $752.03 $752.03 $0.00 $0.00 $211.16 $0.00 $599.34 $599.34 $0.00 $506.63 $802.49 $810.60 $0.00 $0.00 $158.57 $0.00 $0.00 $161.31 $0.00 $0.00 $0.00 $0.00 $0.00 71140626 SUP HCPCS C1713 71140626 - PLATE BN 136MM TC100 6 HL CLVRLF SS ORTH SM FRAG SET BOTH IP/OP "$1,113.00 " $823.62 $0.00 $890.40 $500.85 $500.85 $0.00 $0.00 $0.00 $231.98 $826.07 $826.07 $0.00 $0.00 $231.95 $0.00 $658.34 $658.34 $0.00 $556.50 $881.50 $890.40 $0.00 $0.00 $174.18 $0.00 $0.00 $177.19 $0.00 $0.00 $0.00 $0.00 $0.00 71140627 SUP HCPCS C1713 71140627 - PLATE BN 152MM TC100 7 HL CLVRLF SS ORTH SM FRAG SET BOTH IP/OP "$1,186.50 " $878.01 $0.00 $949.20 $533.93 $533.93 $0.00 $0.00 $0.00 $247.30 $880.62 $880.62 $0.00 $0.00 $247.27 $0.00 $701.81 $701.81 $0.00 $593.25 $939.71 $949.20 $0.00 $0.00 $185.69 $0.00 $0.00 $188.89 $0.00 $0.00 $0.00 $0.00 $0.00 71140628 SUP HCPCS C1713 71140628 - PLATE BN 168MM TC100 8 HL CLVRLF SS ORTH SM FRAG SET BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71140629 SUP HCPCS C1713 71140629 - PLATE BN 184MM TC100 9 HL CLVRLF SS ORTH SM FRAG SET BOTH IP/OP "$1,365.00 " "$1,010.10" $0.00 "$1,092.00" $614.25 $614.25 $0.00 $0.00 $0.00 $284.50 "$1,013.10" "$1,013.10" $0.00 $0.00 $284.47 $0.00 $807.40 $807.40 $0.00 $682.50 "$1,081.08" "$1,092.00" $0.00 $0.00 $213.62 $0.00 $0.00 $217.31 $0.00 $0.00 $0.00 $0.00 $0.00 71140704 SUP HCPCS C1713 71140704 - PLATE BN 80MM TC100 4 HL T BTRS SS ORTH LG FRAG SET BOTH IP/OP $926.10 $685.31 $0.00 $740.88 $416.75 $416.75 $0.00 $0.00 $0.00 $193.02 $687.35 $687.35 $0.00 $0.00 $193.00 $0.00 $547.79 $547.79 $0.00 $463.05 $733.47 $740.88 $0.00 $0.00 $144.93 $0.00 $0.00 $147.44 $0.00 $0.00 $0.00 $0.00 $0.00 71140705 SUP HCPCS C1713 71140705 - PLATE BN 96MM TC100 5 HL T BTRS SS ORTH LG FRAG SET BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71140706 SUP HCPCS C1713 71140706 - PLATE BN 112MM TC100 6 HL T BTRS SS ORTH LG FRAG SET BOTH IP/OP "$1,249.50 " $924.63 $0.00 $999.60 $562.28 $562.28 $0.00 $0.00 $0.00 $260.43 $927.38 $927.38 $0.00 $0.00 $260.40 $0.00 $739.08 $739.08 $0.00 $624.75 $989.60 $999.60 $0.00 $0.00 $195.55 $0.00 $0.00 $198.92 $0.00 $0.00 $0.00 $0.00 $0.00 71140804 SUP HCPCS C1713 71140804 - PLATE BN 86MM TC100 4 HL L BTRS RT ANG SS TIB LT LG FRAG SET BOTH IP/OP $828.45 $613.05 $0.00 $662.76 $372.80 $372.80 $0.00 $0.00 $0.00 $172.67 $614.88 $614.88 $0.00 $0.00 $172.65 $0.00 $490.03 $490.03 $0.00 $414.23 $656.13 $662.76 $0.00 $0.00 $129.65 $0.00 $0.00 $131.89 $0.00 $0.00 $0.00 $0.00 $0.00 71140904 SUP HCPCS C1713 71140904 - PLATE BN 86MM TC100 4 HL L BTRS LT ANG SS TIB RT LG FRAG SET BOTH IP/OP $828.45 $613.05 $0.00 $662.76 $372.80 $372.80 $0.00 $0.00 $0.00 $172.67 $614.88 $614.88 $0.00 $0.00 $172.65 $0.00 $490.03 $490.03 $0.00 $414.23 $656.13 $662.76 $0.00 $0.00 $129.65 $0.00 $0.00 $131.89 $0.00 $0.00 $0.00 $0.00 $0.00 71141003 SUP HCPCS C1713 71141003 - PLATE BN 86.5MM TC100 3 HL BTRS SS TIBHD RL LG FRAG SET BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71141005 SUP HCPCS C1713 71141005 - PLATE BN 188MM TC100 5 HL BTRS SS TIBHD RL LG FRAG SET BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71141007 SUP HCPCS C1713 71141007 - PLATE BN 149MM TC100 7 HL BTRS SS TIBHD RL LG FRAG SET BOTH IP/OP "$1,785.00 " "$1,320.90" $0.00 "$1,428.00" $803.25 $803.25 $0.00 $0.00 $0.00 $372.04 "$1,324.83" "$1,324.83" $0.00 $0.00 $371.99 $0.00 "$1,055.83" "$1,055.83" $0.00 $892.50 "$1,413.72" "$1,428.00" $0.00 $0.00 $279.35 $0.00 $0.00 $284.17 $0.00 $0.00 $0.00 $0.00 $0.00 71141009 SUP HCPCS C1713 71141009 - PLATE BN 181MM TC100 9 HL BTRS SS TIBHD RL LG FRAG SET BOTH IP/OP "$1,905.75 " "$1,410.26" $0.00 "$1,524.60" $857.59 $857.59 $0.00 $0.00 $0.00 $397.21 "$1,414.45" "$1,414.45" $0.00 $0.00 $397.16 $0.00 "$1,127.25" "$1,127.25" $0.00 $952.88 "$1,509.35" "$1,524.60" $0.00 $0.00 $298.25 $0.00 $0.00 $303.40 $0.00 $0.00 $0.00 $0.00 $0.00 71141011 SUP HCPCS C1713 71141011 - PLATE BN 214MM TC100 11 HL BTRS SS TIBHD RL LG FRAG SET BOTH IP/OP "$2,499.00 " "$1,849.26" $0.00 "$1,999.20" "$1,124.55" "$1,124.55" $0.00 $0.00 $0.00 $520.85 "$1,854.76" "$1,854.76" $0.00 $0.00 $520.79 $0.00 "$1,478.16" "$1,478.16" $0.00 "$1,249.50" "$1,979.21" "$1,999.20" $0.00 $0.00 $391.09 $0.00 $0.00 $397.84 $0.00 $0.00 $0.00 $0.00 $0.00 71141013 SUP HCPCS C1713 71141013 - PLATE BN 246MM TC100 13 HL BTRS SS TIBHD RL LG FRAG SET BOTH IP/OP "$2,593.50 " "$1,919.19" $0.00 "$2,074.80" "$1,167.08" "$1,167.08" $0.00 $0.00 $0.00 $540.55 "$1,924.90" "$1,924.90" $0.00 $0.00 $540.49 $0.00 "$1,278.60" "$1,278.60" $0.00 "$1,296.75" "$2,054.05" "$2,074.80" $0.00 $0.00 $405.88 $0.00 $0.00 $412.89 $0.00 $0.00 $0.00 $0.00 $0.00 71141103 SUP HCPCS C1713 71141103 - PLATE BN 86.5MM TC100 3 HL BTRS SS TIBHD L/L LG FRAG SET BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71141105 SUP HCPCS C1713 71141105 - PLATE BN 188MM TC100 5 HL BTRS SS TIBHD L/L LG FRAG SET BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71141107 SUP HCPCS C1713 71141107 - PLATE BN 149MM TC100 7 HL BTRS SS TIBHD L/L LG FRAG SET BOTH IP/OP "$1,785.00 " "$1,320.90" $0.00 "$1,428.00" $803.25 $803.25 $0.00 $0.00 $0.00 $372.04 "$1,324.83" "$1,324.83" $0.00 $0.00 $371.99 $0.00 "$1,055.83" "$1,055.83" $0.00 $892.50 "$1,413.72" "$1,428.00" $0.00 $0.00 $279.35 $0.00 $0.00 $284.17 $0.00 $0.00 $0.00 $0.00 $0.00 71141109 SUP HCPCS C1713 71141109 - PLATE BN 181MM TC100 9 HL BTRS SS TIBHD L/L LG FRAG SET BOTH IP/OP "$1,905.75 " "$1,410.26" $0.00 "$1,524.60" $857.59 $857.59 $0.00 $0.00 $0.00 $397.21 "$1,414.45" "$1,414.45" $0.00 $0.00 $397.16 $0.00 "$1,127.25" "$1,127.25" $0.00 $952.88 "$1,509.35" "$1,524.60" $0.00 $0.00 $298.25 $0.00 $0.00 $303.40 $0.00 $0.00 $0.00 $0.00 $0.00 71141111 SUP HCPCS C1713 71141111 - PLATE BN 214MM TC100 11 HL BTRS SS TIBHD L/L LG FRAG SET BOTH IP/OP "$2,499.00 " "$1,849.26" $0.00 "$1,999.20" "$1,124.55" "$1,124.55" $0.00 $0.00 $0.00 $520.85 "$1,854.76" "$1,854.76" $0.00 $0.00 $520.79 $0.00 "$1,478.16" "$1,478.16" $0.00 "$1,249.50" "$1,979.21" "$1,999.20" $0.00 $0.00 $391.09 $0.00 $0.00 $397.84 $0.00 $0.00 $0.00 $0.00 $0.00 71141113 SUP HCPCS C1713 71141113 - PLATE BN 246MM TC100 13 HL BTRS SS TIBHD L/L LG FRAG SET BOTH IP/OP "$2,593.50 " "$1,919.19" $0.00 "$2,074.80" "$1,167.08" "$1,167.08" $0.00 $0.00 $0.00 $540.55 "$1,924.90" "$1,924.90" $0.00 $0.00 $540.49 $0.00 "$1,278.60" "$1,278.60" $0.00 "$1,296.75" "$2,054.05" "$2,074.80" $0.00 $0.00 $405.88 $0.00 $0.00 $412.89 $0.00 $0.00 $0.00 $0.00 $0.00 71141206 SUP HCPCS C1713 71141206 - PLATE BN BRD 103MM TC100 6 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $245.70 $245.70 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 71141207 SUP HCPCS C1713 71141207 - PLATE BN BRD 119MM TC100 7 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $245.70 $245.70 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 71141208 SUP HCPCS C1713 71141208 - PLATE BN BRD 135MM TC100 8 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 71141209 SUP HCPCS C1713 71141209 - PLATE BN BRD 151MM TC100 9 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 71141210 SUP HCPCS C1713 71141210 - PLATE BN BRD 167MM TC100 10 HL CMPR SS 4.5MM SCR LG FRAG SET BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 71141212 SUP HCPCS C1713 71141212 - PLATE BN BRD 199MM TC100 12 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $731.85 $541.57 $0.00 $585.48 $329.33 $329.33 $0.00 $0.00 $0.00 $152.54 $543.18 $543.18 $0.00 $0.00 $152.52 $0.00 $432.89 $432.89 $0.00 $365.93 $579.63 $585.48 $0.00 $0.00 $114.53 $0.00 $0.00 $116.51 $0.00 $0.00 $0.00 $0.00 $0.00 71141214 SUP HCPCS C1713 71141214 - PLATE BN BRD 231MM TC100 14 HL CMPR SS 4.5MM SCR LG FRAG SET BOTH IP/OP $731.85 $541.57 $0.00 $585.48 $329.33 $329.33 $0.00 $0.00 $0.00 $152.54 $543.18 $543.18 $0.00 $0.00 $152.52 $0.00 $432.89 $432.89 $0.00 $365.93 $579.63 $585.48 $0.00 $0.00 $114.53 $0.00 $0.00 $116.51 $0.00 $0.00 $0.00 $0.00 $0.00 71141216 SUP HCPCS C1713 71141216 - PLATE BN BRD 263MM TC100 16 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $926.10 $685.31 $0.00 $740.88 $416.75 $416.75 $0.00 $0.00 $0.00 $193.02 $687.35 $687.35 $0.00 $0.00 $193.00 $0.00 $547.79 $547.79 $0.00 $463.05 $733.47 $740.88 $0.00 $0.00 $144.93 $0.00 $0.00 $147.44 $0.00 $0.00 $0.00 $0.00 $0.00 71141218 SUP HCPCS C1713 71141218 - PLATE BN BRD 295MM TC100 18 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,022.70 " $756.80 $0.00 $818.16 $460.22 $460.22 $0.00 $0.00 $0.00 $213.16 $759.05 $759.05 $0.00 $0.00 $213.13 $0.00 $604.93 $604.93 $0.00 $511.35 $809.98 $818.16 $0.00 $0.00 $160.05 $0.00 $0.00 $162.81 $0.00 $0.00 $0.00 $0.00 $0.00 71141220 SUP HCPCS C1713 71141220 - PLATE BN BRD 326MM TC100 20 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,459.50 " "$1,080.03" $0.00 "$1,167.60" $656.78 $656.78 $0.00 $0.00 $0.00 $304.20 "$1,083.24" "$1,083.24" $0.00 $0.00 $304.16 $0.00 $863.29 $863.29 $0.00 $729.75 "$1,155.92" "$1,167.60" $0.00 $0.00 $228.41 $0.00 $0.00 $232.35 $0.00 $0.00 $0.00 $0.00 $0.00 71141222 SUP HCPCS C1713 71141222 - PLATE BN BRD 358MM TC100 22 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,543.50 " "$1,142.19" $0.00 "$1,234.80" $694.58 $694.58 $0.00 $0.00 $0.00 $321.70 "$1,145.59" "$1,145.59" $0.00 $0.00 $321.67 $0.00 $912.98 $912.98 $0.00 $771.75 "$1,222.45" "$1,234.80" $0.00 $0.00 $241.56 $0.00 $0.00 $245.73 $0.00 $0.00 $0.00 $0.00 $0.00 71141224 SUP HCPCS C1713 71141224 - PLATE BN BRD 390MM TC100 24 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,711.50 " "$1,266.51" $0.00 "$1,369.20" $770.18 $770.18 $0.00 $0.00 $0.00 $356.72 "$1,270.28" "$1,270.28" $0.00 $0.00 $356.68 $0.00 "$1,012.35" "$1,012.35" $0.00 $855.75 "$1,355.51" "$1,369.20" $0.00 $0.00 $267.85 $0.00 $0.00 $272.47 $0.00 $0.00 $0.00 $0.00 $0.00 71141226 SUP HCPCS C1713 71141226 - PLATE BN BRD 423MM TC100 26 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,811.25 " "$1,340.33" $0.00 "$1,449.00" $815.06 $815.06 $0.00 $0.00 $0.00 $377.51 "$1,344.31" "$1,344.31" $0.00 $0.00 $377.46 $0.00 "$1,071.35" "$1,071.35" $0.00 $905.63 "$1,434.51" "$1,449.00" $0.00 $0.00 $283.46 $0.00 $0.00 $288.35 $0.00 $0.00 $0.00 $0.00 $0.00 71141302 SUP HCPCS C1713 71141302 - PLATE BN 39MM TC100 2 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 71141303 SUP HCPCS C1713 71141303 - PLATE BN 55MM TC100 3 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $147.00 $108.78 $0.00 $117.60 $66.15 $66.15 $0.00 $0.00 $0.00 $30.64 $109.10 $109.10 $0.00 $0.00 $30.63 $0.00 $86.95 $86.95 $0.00 $73.50 $116.42 $117.60 $0.00 $0.00 $23.01 $0.00 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 71141304 SUP HCPCS C1713 71141304 - PLATE BN 71MM TC100 4 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $159.60 $118.10 $0.00 $127.68 $71.82 $71.82 $0.00 $0.00 $0.00 $33.26 $118.46 $118.46 $0.00 $0.00 $33.26 $0.00 $94.40 $94.40 $0.00 $79.80 $126.40 $127.68 $0.00 $0.00 $24.98 $0.00 $0.00 $25.41 $0.00 $0.00 $0.00 $0.00 $0.00 71141305 SUP HCPCS C1713 71141305 - PLATE BN 87MM TC100 5 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $166.95 $123.54 $0.00 $133.56 $75.13 $75.13 $0.00 $0.00 $0.00 $34.80 $123.91 $123.91 $0.00 $0.00 $34.79 $0.00 $98.75 $98.75 $0.00 $83.48 $132.22 $133.56 $0.00 $0.00 $26.13 $0.00 $0.00 $26.58 $0.00 $0.00 $0.00 $0.00 $0.00 71141306 SUP HCPCS C1713 71141306 - PLATE BN 103MM TC100 6 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 71141307 SUP HCPCS C1713 71141307 - PLATE BN 119MM TC100 7 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $192.15 $142.19 $0.00 $153.72 $86.47 $86.47 $0.00 $0.00 $0.00 $40.05 $142.61 $142.61 $0.00 $0.00 $40.04 $0.00 $113.66 $113.66 $0.00 $96.08 $152.18 $153.72 $0.00 $0.00 $30.07 $0.00 $0.00 $30.59 $0.00 $0.00 $0.00 $0.00 $0.00 71141308 SUP HCPCS C1713 71141308 - PLATE BN 135MM TC100 8 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $246.75 $182.60 $0.00 $197.40 $111.04 $111.04 $0.00 $0.00 $0.00 $51.43 $183.14 $183.14 $0.00 $0.00 $51.42 $0.00 $145.95 $145.95 $0.00 $123.38 $195.43 $197.40 $0.00 $0.00 $38.62 $0.00 $0.00 $39.28 $0.00 $0.00 $0.00 $0.00 $0.00 71141309 SUP HCPCS C1713 71141309 - PLATE BN 151MM TC100 9 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $218.40 $161.62 $0.00 $174.72 $98.28 $98.28 $0.00 $0.00 $0.00 $45.52 $162.10 $162.10 $0.00 $0.00 $45.51 $0.00 $129.18 $129.18 $0.00 $109.20 $172.97 $174.72 $0.00 $0.00 $34.18 $0.00 $0.00 $34.77 $0.00 $0.00 $0.00 $0.00 $0.00 71141310 SUP HCPCS C1713 71141310 - PLATE BN 167MM TC100 10 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $270.90 $200.47 $0.00 $216.72 $121.91 $121.91 $0.00 $0.00 $0.00 $56.46 $201.06 $201.06 $0.00 $0.00 $56.46 $0.00 $160.24 $160.24 $0.00 $135.45 $214.55 $216.72 $0.00 $0.00 $42.40 $0.00 $0.00 $43.13 $0.00 $0.00 $0.00 $0.00 $0.00 71141311 SUP HCPCS C1713 71141311 - PLATE BN 183MM TC100 11 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $282.45 $209.01 $0.00 $225.96 $127.10 $127.10 $0.00 $0.00 $0.00 $58.87 $209.63 $209.63 $0.00 $0.00 $58.86 $0.00 $167.07 $167.07 $0.00 $141.23 $223.70 $225.96 $0.00 $0.00 $44.20 $0.00 $0.00 $44.97 $0.00 $0.00 $0.00 $0.00 $0.00 71141312 SUP HCPCS C1713 71141312 - PLATE BN 199MM TC100 12 HL SMTB SS ORTH LG FRAG SET BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 71141402 SUP HCPCS C1713 71141402 - PLATE BN NAR 39MM TC100 2 HL CMPR SS ORTH 4.5MM SCR BOTH IP/OP $352.80 $261.07 $0.00 $282.24 $158.76 $158.76 $0.00 $0.00 $0.00 $73.53 $261.85 $261.85 $0.00 $0.00 $73.52 $0.00 $208.68 $208.68 $0.00 $176.40 $279.42 $282.24 $0.00 $0.00 $55.21 $0.00 $0.00 $56.17 $0.00 $0.00 $0.00 $0.00 $0.00 71141403 SUP HCPCS C1713 71141403 - PLATE BN NAR 55MM TC100 3 HL CMPR SS 4.5MM SCR LG FRAG SET BOTH IP/OP $368.55 $272.73 $0.00 $294.84 $165.85 $165.85 $0.00 $0.00 $0.00 $76.82 $273.54 $273.54 $0.00 $0.00 $76.81 $0.00 $218.00 $218.00 $0.00 $184.28 $291.89 $294.84 $0.00 $0.00 $57.68 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 71141404 SUP HCPCS C1713 71141404 - PLATE BN NAR 71MM TC100 4 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $368.55 $272.73 $0.00 $294.84 $165.85 $165.85 $0.00 $0.00 $0.00 $76.82 $273.54 $273.54 $0.00 $0.00 $76.81 $0.00 $218.00 $218.00 $0.00 $184.28 $291.89 $294.84 $0.00 $0.00 $57.68 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 71141405 SUP HCPCS C1713 71141405 - PLATE BN NAR 87MM TC100 5 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $368.55 $272.73 $0.00 $294.84 $165.85 $165.85 $0.00 $0.00 $0.00 $76.82 $273.54 $273.54 $0.00 $0.00 $76.81 $0.00 $218.00 $218.00 $0.00 $184.28 $291.89 $294.84 $0.00 $0.00 $57.68 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 71141406 SUP HCPCS C1713 71141406 - PLATE BN NAR 103MM TC100 6 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 71141407 SUP HCPCS C1713 71141407 - PLATE BN NAR 119MM TC100 7 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 71141408 SUP HCPCS C1713 71141408 - PLATE BN NAR 135MM TC100 8 HL CMPR SS ORTH 4.5MM SCR BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 71141409 SUP HCPCS C1713 71141409 - PLATE BN NAR 151MM TC100 9 HL CMPR SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 71141410 SUP HCPCS C1713 71141410 - PLATE BN NAR 167MM TC100 10 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71141411 SUP HCPCS C1713 71141411 - PLATE BN NAR 183MM TC100 11 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71141412 SUP HCPCS C1713 71141412 - PLATE BN NAR 199MM TC100 12 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71141413 SUP HCPCS C1713 71141413 - PLATE BN NAR 215MM TC100 13 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71141414 SUP HCPCS C1713 71141414 - PLATE BN NAR 231MM TC100 14 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $763.35 $564.88 $0.00 $610.68 $343.51 $343.51 $0.00 $0.00 $0.00 $159.10 $566.56 $566.56 $0.00 $0.00 $159.08 $0.00 $451.52 $451.52 $0.00 $381.68 $604.57 $610.68 $0.00 $0.00 $119.46 $0.00 $0.00 $121.53 $0.00 $0.00 $0.00 $0.00 $0.00 71141415 SUP HCPCS C1713 71141415 - PLATE BN NAR 247MM TC100 15 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $805.35 $595.96 $0.00 $644.28 $362.41 $362.41 $0.00 $0.00 $0.00 $167.86 $597.73 $597.73 $0.00 $0.00 $167.83 $0.00 $476.36 $476.36 $0.00 $402.68 $637.84 $644.28 $0.00 $0.00 $126.04 $0.00 $0.00 $128.21 $0.00 $0.00 $0.00 $0.00 $0.00 71141416 SUP HCPCS C1713 71141416 - PLATE BN NAR 263MM TC100 16 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP $805.35 $595.96 $0.00 $644.28 $362.41 $362.41 $0.00 $0.00 $0.00 $167.86 $597.73 $597.73 $0.00 $0.00 $167.83 $0.00 $476.36 $476.36 $0.00 $402.68 $637.84 $644.28 $0.00 $0.00 $126.04 $0.00 $0.00 $128.21 $0.00 $0.00 $0.00 $0.00 $0.00 71141418 SUP HCPCS C1713 71141418 - PLATE BN NAR 295MM TC100 18 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71141420 SUP HCPCS C1713 71141420 - PLATE BN NAR 326MM TC100 20 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,038.45 " $768.45 $0.00 $830.76 $467.30 $467.30 $0.00 $0.00 $0.00 $216.44 $770.74 $770.74 $0.00 $0.00 $216.41 $0.00 $614.24 $614.24 $0.00 $519.23 $822.45 $830.76 $0.00 $0.00 $162.52 $0.00 $0.00 $165.32 $0.00 $0.00 $0.00 $0.00 $0.00 71141422 SUP HCPCS C1713 71141422 - PLATE BN NAR 358MM TC100 22 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,401.75 " "$1,037.30" $0.00 "$1,121.40" $630.79 $630.79 $0.00 $0.00 $0.00 $292.16 "$1,040.38" "$1,040.38" $0.00 $0.00 $292.12 $0.00 $829.14 $829.14 $0.00 $700.88 "$1,110.19" "$1,121.40" $0.00 $0.00 $219.37 $0.00 $0.00 $223.16 $0.00 $0.00 $0.00 $0.00 $0.00 71141424 SUP HCPCS C1713 71141424 - PLATE BN NAR 390MM TC100 24 HL CMPR SS ORTH 4.5MM SCR LG BOTH IP/OP "$1,517.25 " "$1,122.77" $0.00 "$1,213.80" $682.76 $682.76 $0.00 $0.00 $0.00 $316.23 "$1,126.10" "$1,126.10" $0.00 $0.00 $316.19 $0.00 $897.45 $897.45 $0.00 $758.63 "$1,201.66" "$1,213.80" $0.00 $0.00 $237.45 $0.00 $0.00 $241.55 $0.00 $0.00 $0.00 $0.00 $0.00 71141505 SUP HCPCS C1713 71141505 - PLATE BN 100MM TC100 5 HL SPN SS ORTH 4.5MM SCR LG FRAG SET BOTH IP/OP $866.25 $641.03 $0.00 $693.00 $389.81 $389.81 $0.00 $0.00 $0.00 $180.55 $642.93 $642.93 $0.00 $0.00 $180.53 $0.00 $512.39 $512.39 $0.00 $433.13 $686.07 $693.00 $0.00 $0.00 $135.57 $0.00 $0.00 $137.91 $0.00 $0.00 $0.00 $0.00 $0.00 71141506 SUP HCPCS C1713 71141506 - PLATE BN 120MM TC100 6 HL SPN SS ORTH 4.5MM SCR LG FRAG SET BOTH IP/OP $753.90 $557.89 $0.00 $603.12 $339.26 $339.26 $0.00 $0.00 $0.00 $157.13 $559.54 $559.54 $0.00 $0.00 $157.11 $0.00 $445.93 $445.93 $0.00 $376.95 $597.09 $603.12 $0.00 $0.00 $117.99 $0.00 $0.00 $120.02 $0.00 $0.00 $0.00 $0.00 $0.00 71141603 SUP HCPCS C1713 71141603 - PLATE BN 68MM TC100 3 HL T SS ORTH 4.5MM SCR LG FRAG SET BOTH IP/OP $568.05 $420.36 $0.00 $454.44 $255.62 $255.62 $0.00 $0.00 $0.00 $118.40 $421.61 $421.61 $0.00 $0.00 $118.38 $0.00 $336.00 $336.00 $0.00 $284.03 $449.90 $454.44 $0.00 $0.00 $88.90 $0.00 $0.00 $90.43 $0.00 $0.00 $0.00 $0.00 $0.00 71141604 SUP HCPCS C1713 71141604 - PLATE BN 84MM TC100 4 HL T SS ORTH 4.5MM SCR LG FRAG SET BOTH IP/OP $631.05 $466.98 $0.00 $504.84 $283.97 $283.97 $0.00 $0.00 $0.00 $131.53 $468.37 $468.37 $0.00 $0.00 $131.51 $0.00 $373.27 $373.27 $0.00 $315.53 $499.79 $504.84 $0.00 $0.00 $98.76 $0.00 $0.00 $100.46 $0.00 $0.00 $0.00 $0.00 $0.00 71141605 SUP HCPCS C1713 71141605 - PLATE BN 100MM TC100 5 HL T SS ORTH 4.5MM SCR LG FRAG SET BOTH IP/OP $670.95 $496.50 $0.00 $536.76 $301.93 $301.93 $0.00 $0.00 $0.00 $139.84 $497.98 $497.98 $0.00 $0.00 $139.83 $0.00 $396.87 $396.87 $0.00 $335.48 $531.39 $536.76 $0.00 $0.00 $105.00 $0.00 $0.00 $106.82 $0.00 $0.00 $0.00 $0.00 $0.00 71141606 SUP HCPCS C1713 71141606 - PLATE BN 116MM TC100 6 HL T SS ORTH 4.5MM SCR LG FRAG SET BOTH IP/OP $742.35 $549.34 $0.00 $593.88 $334.06 $334.06 $0.00 $0.00 $0.00 $154.72 $550.97 $550.97 $0.00 $0.00 $154.71 $0.00 $439.10 $439.10 $0.00 $371.18 $587.94 $593.88 $0.00 $0.00 $116.18 $0.00 $0.00 $118.18 $0.00 $0.00 $0.00 $0.00 $0.00 71141608 SUP HCPCS C1713 71141608 - PLATE BN 148MM TC100 8 HL T SS ORTH 4.5MM SCR LG FRAG SET BOTH IP/OP "$1,025.85 " $759.13 $0.00 $820.68 $461.63 $461.63 $0.00 $0.00 $0.00 $213.81 $761.39 $761.39 $0.00 $0.00 $213.79 $0.00 $606.79 $606.79 $0.00 $512.93 $812.47 $820.68 $0.00 $0.00 $160.55 $0.00 $0.00 $163.32 $0.00 $0.00 $0.00 $0.00 $0.00 71141704 SUP HCPCS C1713 71141704 - PLATE BN 123MM TC100 4 HL HK SS ORTH 4.5MM SCR LG FRAG SET BOTH IP/OP "$2,084.25 " "$1,542.35" $0.00 "$1,667.40" $937.91 $937.91 $0.00 $0.00 $0.00 $434.41 "$1,546.93" "$1,546.93" $0.00 $0.00 $434.36 $0.00 "$1,232.83" "$1,232.83" $0.00 "$1,042.13" "$1,650.73" "$1,667.40" $0.00 $0.00 $326.19 $0.00 $0.00 $331.81 $0.00 $0.00 $0.00 $0.00 $0.00 71141809 SUP HCPCS C1713 71141809 - PLATE BN 188MM TC100 9 HL CBR HD SS ORTH 4.5MM SCR LG FRAG BOTH IP/OP $945.00 $699.30 $0.00 $756.00 $425.25 $425.25 $0.00 $0.00 $0.00 $196.96 $701.38 $701.38 $0.00 $0.00 $196.94 $0.00 $558.97 $558.97 $0.00 $472.50 $748.44 $756.00 $0.00 $0.00 $147.89 $0.00 $0.00 $150.44 $0.00 $0.00 $0.00 $0.00 $0.00 71141900 SUP HCPCS C1713 71141900 - PLATE BN 20MM TC100 2 HL CMPR SS ORTH 2.7MM SCR SM FRAG SET BOTH IP/OP $345.45 $255.63 $0.00 $276.36 $155.45 $155.45 $0.00 $0.00 $0.00 $72.00 $256.39 $256.39 $0.00 $0.00 $71.99 $0.00 $204.33 $204.33 $0.00 $172.73 $273.60 $276.36 $0.00 $0.00 $54.06 $0.00 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 71141902 SUP HCPCS C1713 71141902 - PLATE BN 26MM TC100 2 HL CMPR SS ORTH 2.7MM SCR SM FRAG SET BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 71141904 SUP HCPCS C1713 71141904 - PLATE BN 36MM TC100 4 HL CMPR SS ORTH 2.7MM SCR SM FRAG SET BOTH IP/OP $316.05 $233.88 $0.00 $252.84 $142.22 $142.22 $0.00 $0.00 $0.00 $65.87 $234.57 $234.57 $0.00 $0.00 $65.86 $0.00 $186.94 $186.94 $0.00 $158.03 $250.31 $252.84 $0.00 $0.00 $49.46 $0.00 $0.00 $50.32 $0.00 $0.00 $0.00 $0.00 $0.00 71141905 SUP HCPCS C1713 71141905 - PLATE BN 44MM TC100 5 HL CMPR SS ORTH 2.7MM SCR SM FRAG SET BOTH IP/OP $375.90 $278.17 $0.00 $300.72 $169.16 $169.16 $0.00 $0.00 $0.00 $78.35 $278.99 $278.99 $0.00 $0.00 $78.34 $0.00 $222.34 $222.34 $0.00 $187.95 $297.71 $300.72 $0.00 $0.00 $58.83 $0.00 $0.00 $59.84 $0.00 $0.00 $0.00 $0.00 $0.00 71141906 SUP HCPCS C1713 71141906 - PLATE BN 52MM 6 HL 2.7MM SCR BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71141907 SUP HCPCS C1713 71141907 - PLATE BN 60MM TC100 7 HL CMPR SS ORTH 2.7MM SCR SM FRAG SET BOTH IP/OP $452.55 $334.89 $0.00 $362.04 $203.65 $203.65 $0.00 $0.00 $0.00 $94.32 $335.88 $335.88 $0.00 $0.00 $94.31 $0.00 $267.68 $267.68 $0.00 $226.28 $358.42 $362.04 $0.00 $0.00 $70.82 $0.00 $0.00 $72.05 $0.00 $0.00 $0.00 $0.00 $0.00 71141908 SUP HCPCS C1713 71141908 - PLATE BN 68MM TC100 8 HL CMPR SS ORTH 2.7MM SCR SM FRAG SET BOTH IP/OP $495.60 $366.74 $0.00 $396.48 $223.02 $223.02 $0.00 $0.00 $0.00 $103.30 $367.83 $367.83 $0.00 $0.00 $103.28 $0.00 $293.15 $293.15 $0.00 $247.80 $392.52 $396.48 $0.00 $0.00 $77.56 $0.00 $0.00 $78.90 $0.00 $0.00 $0.00 $0.00 $0.00 71141909 SUP HCPCS C1713 71141909 - PLATE BN 76MM TC100 9 HL CMPR SS ORTH 2.7MM SCR SM FRAG SET BOTH IP/OP $639.45 $473.19 $0.00 $511.56 $287.75 $287.75 $0.00 $0.00 $0.00 $133.28 $474.60 $474.60 $0.00 $0.00 $133.26 $0.00 $378.23 $378.23 $0.00 $319.73 $506.44 $511.56 $0.00 $0.00 $100.07 $0.00 $0.00 $101.80 $0.00 $0.00 $0.00 $0.00 $0.00 71141910 SUP HCPCS C1713 71141910 - PLATE BN 84MM TC100 10 HL CMPR SS ORTH 2.7MM SCR SM FRAG SET BOTH IP/OP $701.40 $519.04 $0.00 $561.12 $315.63 $315.63 $0.00 $0.00 $0.00 $146.19 $520.58 $520.58 $0.00 $0.00 $146.17 $0.00 $414.88 $414.88 $0.00 $350.70 $555.51 $561.12 $0.00 $0.00 $109.77 $0.00 $0.00 $111.66 $0.00 $0.00 $0.00 $0.00 $0.00 71141912 SUP HCPCS C1713 71141912 - PLATE BN 100MM TC100 12 HL CMPR SS ORTH 2.7MM SCR SM FRAG BOTH IP/OP $777.00 $574.98 $0.00 $621.60 $349.65 $349.65 $0.00 $0.00 $0.00 $161.95 $576.69 $576.69 $0.00 $0.00 $161.93 $0.00 $459.60 $459.60 $0.00 $388.50 $615.38 $621.60 $0.00 $0.00 $121.60 $0.00 $0.00 $123.70 $0.00 $0.00 $0.00 $0.00 $0.00 71142007 SUP HCPCS C1713 71142007 - PLATE BN 158MM TC100 7 HL BTRS SS CNDYL LT 4.5MM SCR LG FRAG BOTH IP/OP "$1,953.00 " "$1,445.22" $0.00 "$1,562.40" $878.85 $878.85 $0.00 $0.00 $0.00 $407.05 "$1,449.52" "$1,449.52" $0.00 $0.00 $407.01 $0.00 "$1,155.20" "$1,155.20" $0.00 $976.50 "$1,546.78" "$1,562.40" $0.00 $0.00 $305.64 $0.00 $0.00 $310.92 $0.00 $0.00 $0.00 $0.00 $0.00 71142009 SUP HCPCS C1713 71142009 - PLATE BN 190MM TC100 9 HL BTRS SS CNDYL LT 4.5MM SCR LG FRAG BOTH IP/OP "$2,026.50 " "$1,499.61" $0.00 "$1,621.20" $911.93 $911.93 $0.00 $0.00 $0.00 $422.37 "$1,504.07" "$1,504.07" $0.00 $0.00 $422.32 $0.00 "$1,198.67" "$1,198.67" $0.00 "$1,013.25" "$1,604.99" "$1,621.20" $0.00 $0.00 $317.15 $0.00 $0.00 $322.62 $0.00 $0.00 $0.00 $0.00 $0.00 71142011 SUP HCPCS C1713 71142011 - PLATE BN 221MM TC100 11 HL BTRS SS CNDYL LT 4.5MM SCR LG BOTH IP/OP "$2,541.00 " "$1,880.34" $0.00 "$2,032.80" "$1,143.45" "$1,143.45" $0.00 $0.00 $0.00 $529.61 "$1,885.93" "$1,885.93" $0.00 $0.00 $529.54 $0.00 "$1,252.71" "$1,252.71" $0.00 "$1,270.50" "$2,012.47" "$2,032.80" $0.00 $0.00 $397.67 $0.00 $0.00 $404.53 $0.00 $0.00 $0.00 $0.00 $0.00 71142013 SUP HCPCS C1713 71142013 - PLATE BN 253MM TC100 13 HL BTRS SS CNDYL LT 4.5MM SCR LG BOTH IP/OP "$2,136.75 " "$1,581.20" $0.00 "$1,709.40" $961.54 $961.54 $0.00 $0.00 $0.00 $445.35 "$1,585.90" "$1,585.90" $0.00 $0.00 $445.30 $0.00 "$1,263.89" "$1,263.89" $0.00 "$1,068.38" "$1,692.31" "$1,709.40" $0.00 $0.00 $334.40 $0.00 $0.00 $340.17 $0.00 $0.00 $0.00 $0.00 $0.00 71142015 SUP HCPCS C1713 71142015 - PLATE BN 285MM TC100 15 HL BTRS SS CNDYL LT 4.5MM SCR LG BOTH IP/OP "$2,682.75 " "$1,985.24" $0.00 "$2,146.20" "$1,207.24" "$1,207.24" $0.00 $0.00 $0.00 $559.15 "$1,991.14" "$1,991.14" $0.00 $0.00 $559.09 $0.00 "$1,322.60" "$1,322.60" $0.00 "$1,341.38" "$2,124.74" "$2,146.20" $0.00 $0.00 $419.85 $0.00 $0.00 $427.09 $0.00 $0.00 $0.00 $0.00 $0.00 71142107 SUP HCPCS C1713 71142107 - PLATE BN 158MM TC100 7 HL BTRS SS CNDYL RT 4.5MM SCR LG FRAG BOTH IP/OP "$2,367.75 " "$1,752.14" $0.00 "$1,894.20" "$1,065.49" "$1,065.49" $0.00 $0.00 $0.00 $493.50 "$1,757.34" "$1,757.34" $0.00 $0.00 $493.44 $0.00 "$1,400.52" "$1,400.52" $0.00 "$1,183.88" "$1,875.26" "$1,894.20" $0.00 $0.00 $370.55 $0.00 $0.00 $376.95 $0.00 $0.00 $0.00 $0.00 $0.00 71142109 SUP HCPCS C1713 71142109 - PLATE BN 190MM TC100 9 HL BTRS SS CNDYL RT 4.5MM SCR LG FRAG BOTH IP/OP "$2,026.50 " "$1,499.61" $0.00 "$1,621.20" $911.93 $911.93 $0.00 $0.00 $0.00 $422.37 "$1,504.07" "$1,504.07" $0.00 $0.00 $422.32 $0.00 "$1,198.67" "$1,198.67" $0.00 "$1,013.25" "$1,604.99" "$1,621.20" $0.00 $0.00 $317.15 $0.00 $0.00 $322.62 $0.00 $0.00 $0.00 $0.00 $0.00 71142111 SUP HCPCS C1713 71142111 - PLATE BN 221MM TC100 11 HL BTRS SS CNDYL RT 4.5MM SCR LG BOTH IP/OP "$2,541.00 " "$1,880.34" $0.00 "$2,032.80" "$1,143.45" "$1,143.45" $0.00 $0.00 $0.00 $529.61 "$1,885.93" "$1,885.93" $0.00 $0.00 $529.54 $0.00 "$1,252.71" "$1,252.71" $0.00 "$1,270.50" "$2,012.47" "$2,032.80" $0.00 $0.00 $397.67 $0.00 $0.00 $404.53 $0.00 $0.00 $0.00 $0.00 $0.00 71142113 SUP HCPCS C1713 71142113 - PLATE BN 253MM TC100 13 HL BTRS SS CNDYL RT 4.5MM SCR LG BOTH IP/OP "$2,604.00 " "$1,926.96" $0.00 "$2,083.20" "$1,171.80" "$1,171.80" $0.00 $0.00 $0.00 $542.74 "$1,932.69" "$1,932.69" $0.00 $0.00 $542.67 $0.00 "$1,283.77" "$1,283.77" $0.00 "$1,302.00" "$2,062.37" "$2,083.20" $0.00 $0.00 $407.53 $0.00 $0.00 $414.56 $0.00 $0.00 $0.00 $0.00 $0.00 71142115 SUP HCPCS C1713 71142115 - PLATE BN 285MM TC100 15 HL BTRS SS CNDYL RT 4.5MM SCR LG BOTH IP/OP "$2,682.75 " "$1,985.24" $0.00 "$2,146.20" "$1,207.24" "$1,207.24" $0.00 $0.00 $0.00 $559.15 "$1,991.14" "$1,991.14" $0.00 $0.00 $559.09 $0.00 "$1,322.60" "$1,322.60" $0.00 "$1,341.38" "$2,124.74" "$2,146.20" $0.00 $0.00 $419.85 $0.00 $0.00 $427.09 $0.00 $0.00 $0.00 $0.00 $0.00 71143004 SUP HCPCS C1713 71143004 - WASHER ORTH 4.5MM 2.2MM STRL TC100 SS BOTH IP/OP $94.40 $69.86 $0.00 $75.52 $42.48 $42.48 $0.00 $0.00 $0.00 $19.68 $70.06 $70.06 $0.00 $0.00 $19.67 $0.00 $55.84 $55.84 $0.00 $47.20 $74.76 $75.52 $0.00 $0.00 $14.77 $0.00 $0.00 $15.03 $0.00 $0.00 $0.00 $0.00 $0.00 71143007 SUP HCPCS C1713 71143007 - WASHER ORTH 7MM 3.7MM STRL TC100 SS BOTH IP/OP $94.40 $69.86 $0.00 $75.52 $42.48 $42.48 $0.00 $0.00 $0.00 $19.68 $70.06 $70.06 $0.00 $0.00 $19.67 $0.00 $55.84 $55.84 $0.00 $47.20 $74.76 $75.52 $0.00 $0.00 $14.77 $0.00 $0.00 $15.03 $0.00 $0.00 $0.00 $0.00 $0.00 71143010 SUP HCPCS C1713 71143010 - WASHER ORTH THK2MM 10MM ILZ SPC CIRC BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $49.05 $49.05 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $0.00 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 71143013 SUP HCPCS C1713 71143013 - WASHER ORTH 13MM 6.6MM STRL TC100 SS BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $54.00 $54.00 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 71143045 SUP HCPCS C1713 71143045 - NUT ORTH STRL TC100 SS 4.5 MM CORT SCR BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71143104 SUP HCPCS C1713 71143104 - WASHER ORTH 4.5MM 2.2MM NS TC100 SS BOTH IP/OP $94.40 $69.86 $0.00 $75.52 $42.48 $42.48 $0.00 $0.00 $0.00 $19.68 $70.06 $70.06 $0.00 $0.00 $19.67 $0.00 $55.84 $55.84 $0.00 $47.20 $74.76 $75.52 $0.00 $0.00 $14.77 $0.00 $0.00 $15.03 $0.00 $0.00 $0.00 $0.00 $0.00 71143107 SUP HCPCS C1713 71143107 - WASHER ORTH HEX 7MM NS TC100 BOTH IP/OP $94.40 $69.86 $0.00 $75.52 $42.48 $42.48 $0.00 $0.00 $0.00 $19.68 $70.06 $70.06 $0.00 $0.00 $19.67 $0.00 $55.84 $55.84 $0.00 $47.20 $74.76 $75.52 $0.00 $0.00 $14.77 $0.00 $0.00 $15.03 $0.00 $0.00 $0.00 $0.00 $0.00 71143110 SUP HCPCS C1713 71143110 - WASHER ORTH 10MM NS TC100 BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $49.05 $49.05 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $0.00 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 71143113 SUP HCPCS C1713 71143113 - WASHER ORTH 13MM NS TC100 SS BOTH IP/OP $94.40 $69.86 $0.00 $75.52 $42.48 $42.48 $0.00 $0.00 $0.00 $19.68 $70.06 $70.06 $0.00 $0.00 $19.67 $0.00 $55.84 $55.84 $0.00 $47.20 $74.76 $75.52 $0.00 $0.00 $14.77 $0.00 $0.00 $15.03 $0.00 $0.00 $0.00 $0.00 $0.00 71144010 SUP HCPCS C1713 71144010 - PLATE BN 60MM STRL TC100 TMPLT SS CALCANEUS 3.5MM CORT SCR 4 BOTH IP/OP "$1,338.75 " $990.68 $0.00 "$1,071.00" $602.44 $602.44 $0.00 $0.00 $0.00 $279.03 $993.62 $993.62 $0.00 $0.00 $279.00 $0.00 $791.87 $791.87 $0.00 $669.38 "$1,060.29" "$1,071.00" $0.00 $0.00 $209.51 $0.00 $0.00 $213.13 $0.00 $0.00 $0.00 $0.00 $0.00 71144011 SUP HCPCS C1713 71144011 - PLATE BN 70MM STRL TC100 TMPLT SS CALCANEUS 3.5MM CORT SCR 4 BOTH IP/OP "$1,354.50 " "$1,002.33" $0.00 "$1,083.60" $609.53 $609.53 $0.00 $0.00 $0.00 $282.31 "$1,005.31" "$1,005.31" $0.00 $0.00 $282.28 $0.00 $801.19 $801.19 $0.00 $677.25 "$1,072.76" "$1,083.60" $0.00 $0.00 $211.98 $0.00 $0.00 $215.64 $0.00 $0.00 $0.00 $0.00 $0.00 71144012 SUP HCPCS C1713 71144012 - PLATE BN STRL TC100 9 HL BNDRG TMPLT SS CALCANEUS 3.5 MM SCR BOTH IP/OP "$1,559.25 " "$1,153.85" $0.00 "$1,247.40" $701.66 $701.66 $0.00 $0.00 $0.00 $324.99 "$1,157.28" "$1,157.28" $0.00 $0.00 $324.95 $0.00 $922.30 $922.30 $0.00 $779.63 "$1,234.93" "$1,247.40" $0.00 $0.00 $244.02 $0.00 $0.00 $248.23 $0.00 $0.00 $0.00 $0.00 $0.00 71145020 SUP HCPCS C1713 71145020 - PLATE BN 100MM TC100 20 HL STRG SS ORTH 1.5MM SCR MN FRAG BOTH IP/OP $570.15 $421.91 $0.00 $456.12 $256.57 $256.57 $0.00 $0.00 $0.00 $118.83 $423.17 $423.17 $0.00 $0.00 $118.82 $0.00 $337.24 $337.24 $0.00 $285.08 $451.56 $456.12 $0.00 $0.00 $89.23 $0.00 $0.00 $90.77 $0.00 $0.00 $0.00 $0.00 $0.00 71145022 SUP HCPCS C1713 71145022 - PLATE BN TC100 3 HLE/HD 9 HL SHFT T SS ORTH 1.5 MM SCR MN BOTH IP/OP $504.00 $372.96 $0.00 $403.20 $226.80 $226.80 $0.00 $0.00 $0.00 $105.05 $374.07 $374.07 $0.00 $0.00 $105.03 $0.00 $298.12 $298.12 $0.00 $252.00 $399.17 $403.20 $0.00 $0.00 $78.88 $0.00 $0.00 $80.24 $0.00 $0.00 $0.00 $0.00 $0.00 71145024 SUP HCPCS C1713 71145024 - PLATE BN TC100 4 HLE/HD 9 HL SHFT T SS ORTH 1.5 MM SCR MN BOTH IP/OP $534.45 $395.49 $0.00 $427.56 $240.50 $240.50 $0.00 $0.00 $0.00 $111.39 $396.67 $396.67 $0.00 $0.00 $111.38 $0.00 $316.13 $316.13 $0.00 $267.23 $423.28 $427.56 $0.00 $0.00 $83.64 $0.00 $0.00 $85.08 $0.00 $0.00 $0.00 $0.00 $0.00 71145026 SUP HCPCS C1713 71145026 - PLATE BN TC100 7 HL SS CNDYL LT 1.5 MM SCR MN FRAG SET BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 71145028 SUP HCPCS C1713 71145028 - PLATE BN TC100 7 HL SS CNDYL RT 1.5 MM SCR MN FRAG SET BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 71145030 SUP HCPCS C1713 71145030 - PLATE BN TC100 4 HL H SS ORTH 1.5 MM SCR MN FRAG SET BOTH IP/OP $406.35 $300.70 $0.00 $325.08 $182.86 $182.86 $0.00 $0.00 $0.00 $84.69 $301.59 $301.59 $0.00 $0.00 $84.68 $0.00 $240.36 $240.36 $0.00 $203.18 $321.83 $325.08 $0.00 $0.00 $63.59 $0.00 $0.00 $64.69 $0.00 $0.00 $0.00 $0.00 $0.00 71146020 SUP HCPCS C1713 71146020 - PLATE BN 20MM TC100 3 HL STRG SS CNDYL 2MM SCR MN FRAG SET BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 71146022 SUP HCPCS C1713 71146022 - PLATE BN 22MM TC100 4 HL STRG SS CNDYL 2MM SCR MN FRAG SET BOTH IP/OP $148.05 $109.56 $0.00 $118.44 $66.62 $66.62 $0.00 $0.00 $0.00 $30.86 $109.88 $109.88 $0.00 $0.00 $30.85 $0.00 $87.57 $87.57 $0.00 $74.03 $117.26 $118.44 $0.00 $0.00 $23.17 $0.00 $0.00 $23.57 $0.00 $0.00 $0.00 $0.00 $0.00 71146024 SUP HCPCS C1713 71146024 - PLATE BN 24MM TC100 5 HL STRG SS CNDYL 2MM SCR MN FRAG SET BOTH IP/OP $159.60 $118.10 $0.00 $127.68 $71.82 $71.82 $0.00 $0.00 $0.00 $33.26 $118.46 $118.46 $0.00 $0.00 $33.26 $0.00 $94.40 $94.40 $0.00 $79.80 $126.40 $127.68 $0.00 $0.00 $24.98 $0.00 $0.00 $25.41 $0.00 $0.00 $0.00 $0.00 $0.00 71146026 SUP HCPCS C1713 71146026 - PLATE BN 35MM TC100 6 HL STRG SS ORTH 2MM SCR MN FRAG SET BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 71146028 SUP HCPCS C1713 71146028 - PLATE BN 28MM TC100 20 HL STRG SS CNDYL 2MM SCR MN FRAG SET BOTH IP/OP $568.05 $420.36 $0.00 $454.44 $255.62 $255.62 $0.00 $0.00 $0.00 $118.40 $421.61 $421.61 $0.00 $0.00 $118.38 $0.00 $336.00 $336.00 $0.00 $284.03 $449.90 $454.44 $0.00 $0.00 $88.90 $0.00 $0.00 $90.43 $0.00 $0.00 $0.00 $0.00 $0.00 71146030 SUP HCPCS C1713 71146030 - PLATE BN 5X1.2MM TC100 3 HLE/HD 9 HL SHFT T SS CNDYL 2MM SCR BOTH IP/OP $504.00 $372.96 $0.00 $403.20 $226.80 $226.80 $0.00 $0.00 $0.00 $105.05 $374.07 $374.07 $0.00 $0.00 $105.03 $0.00 $298.12 $298.12 $0.00 $252.00 $399.17 $403.20 $0.00 $0.00 $78.88 $0.00 $0.00 $80.24 $0.00 $0.00 $0.00 $0.00 $0.00 71146032 SUP HCPCS C1713 71146032 - PLATE BN 5X1.2MM TC100 4 HLE/HD 9 HL SHFT T SS CNDYL 2MM SCR BOTH IP/OP $534.45 $395.49 $0.00 $427.56 $240.50 $240.50 $0.00 $0.00 $0.00 $111.39 $396.67 $396.67 $0.00 $0.00 $111.38 $0.00 $316.13 $316.13 $0.00 $267.23 $423.28 $427.56 $0.00 $0.00 $83.64 $0.00 $0.00 $85.08 $0.00 $0.00 $0.00 $0.00 $0.00 71146034 SUP HCPCS C1713 71146034 - PLATE BN 5X.9MM TC100 2 HLE/HD 2 HL SHFT T SS CNDYL 2MM SCR BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 71146036 SUP HCPCS C1713 71146036 - PLATE BN 5X.9MM TC100 2 HL SHFT L RT OBLQ SS CNDYL 2MM SCR BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 71146038 SUP HCPCS C1713 71146038 - PLATE BN 5X.9MM TC100 2 HL SHFT L LT OBLQ SS CNDYL 2MM SCR BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 71146040 SUP HCPCS C1713 71146040 - PLATE BN TC100 7 HL SS CNDYL LT 2 MM SCR MN FRAG SET BOTH IP/OP $678.30 $501.94 $0.00 $542.64 $305.24 $305.24 $0.00 $0.00 $0.00 $141.37 $503.43 $503.43 $0.00 $0.00 $141.36 $0.00 $401.21 $401.21 $0.00 $339.15 $537.21 $542.64 $0.00 $0.00 $106.15 $0.00 $0.00 $107.99 $0.00 $0.00 $0.00 $0.00 $0.00 71146042 SUP HCPCS C1713 71146042 - PLATE BN 39X5X12MM TC100 7 HL SS CNDYL RT 2MM SCR MN FRAG BOTH IP/OP $678.30 $501.94 $0.00 $542.64 $305.24 $305.24 $0.00 $0.00 $0.00 $141.37 $503.43 $503.43 $0.00 $0.00 $141.36 $0.00 $401.21 $401.21 $0.00 $339.15 $537.21 $542.64 $0.00 $0.00 $106.15 $0.00 $0.00 $107.99 $0.00 $0.00 $0.00 $0.00 $0.00 71146044 SUP HCPCS C1713 71146044 - PLATE BN TC100 L SS RT ORTH 2 MM SCR MN FRAG SET BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 71146046 SUP HCPCS C1713 71146046 - PLATE BN TC100 L SS LT ORTH 2 MM SCR MN FRAG SET BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 71146048 SUP HCPCS C1713 71146048 - PLATE BN TC100 4 HL H SS ORTH 2 MM SCR MN FRAG SET BOTH IP/OP $406.35 $300.70 $0.00 $325.08 $182.86 $182.86 $0.00 $0.00 $0.00 $84.69 $301.59 $301.59 $0.00 $0.00 $84.68 $0.00 $240.36 $240.36 $0.00 $203.18 $321.83 $325.08 $0.00 $0.00 $63.59 $0.00 $0.00 $64.69 $0.00 $0.00 $0.00 $0.00 $0.00 71147001 SUP HCPCS C1713 71147001 - PLATE BN TC100 L SS RT ORTH 2.7 MM SCR MN FRAG SET BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 71147002 SUP HCPCS C1713 71147002 - PLATE BN 35X7X1.2MM TC100 L LT OBLQ SS CNDYL 2.7MM SCR MN BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 71147003 SUP HCPCS C1713 71147003 - PLATE BN TC100 L SS LT ORTH 2.7 MM SCR MN FRAG SET BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 71147004 SUP HCPCS C1713 71147004 - PLATE BN 35X7X1.2MM TC100 L RT OBLQ SS CNDYL 2.7MM SCR MN BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 71147006 SUP HCPCS C1713 71147006 - PLATE BN 32X7X1.2MM TC100 3 HL T SS CNDYL 2.7MM SCR MN FRAG BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 71147008 SUP HCPCS C1713 71147008 - PLATE BN 57X7X1.4MM TC100 7 HL SS CNDYL LT 2.7MM SCR MN FRAG BOTH IP/OP $720.30 $533.02 $0.00 $576.24 $324.14 $324.14 $0.00 $0.00 $0.00 $150.13 $534.61 $534.61 $0.00 $0.00 $150.11 $0.00 $426.06 $426.06 $0.00 $360.15 $570.48 $576.24 $0.00 $0.00 $112.73 $0.00 $0.00 $114.67 $0.00 $0.00 $0.00 $0.00 $0.00 71147010 SUP HCPCS C1713 71147010 - PLATE BN 57X7X1.4MM TC100 7 HL SS CNDYL RT 2.7MM SCR MN FRAG BOTH IP/OP $720.30 $533.02 $0.00 $576.24 $324.14 $324.14 $0.00 $0.00 $0.00 $150.13 $534.61 $534.61 $0.00 $0.00 $150.11 $0.00 $426.06 $426.06 $0.00 $360.15 $570.48 $576.24 $0.00 $0.00 $112.73 $0.00 $0.00 $114.67 $0.00 $0.00 $0.00 $0.00 $0.00 71147012 SUP HCPCS C1713 71147012 - PLATE BN TC100 7 HL MULTIFRAGMENT SS ORTH 2.7 MM SCR MN FRAG BOTH IP/OP $169.05 $125.10 $0.00 $135.24 $76.07 $76.07 $0.00 $0.00 $0.00 $35.23 $125.47 $125.47 $0.00 $0.00 $35.23 $0.00 $99.99 $99.99 $0.00 $84.53 $133.89 $135.24 $0.00 $0.00 $26.46 $0.00 $0.00 $26.91 $0.00 $0.00 $0.00 $0.00 $0.00 71148003 SUP HCPCS C1713 71148003 - PLATE BN 23MM TC100 3 HL .25 TBLR SS ORTH 2.7MM SCR MN FRAG BOTH IP/OP $159.60 $118.10 $0.00 $127.68 $71.82 $71.82 $0.00 $0.00 $0.00 $33.26 $118.46 $118.46 $0.00 $0.00 $33.26 $0.00 $94.40 $94.40 $0.00 $79.80 $126.40 $127.68 $0.00 $0.00 $24.98 $0.00 $0.00 $25.41 $0.00 $0.00 $0.00 $0.00 $0.00 71148004 SUP HCPCS C1713 71148004 - PLATE BN 31MM TC100 4 HL .25 TBLR SS CNDYL 2.7MM SCR MN FRAG BOTH IP/OP $175.35 $129.76 $0.00 $140.28 $78.91 $78.91 $0.00 $0.00 $0.00 $36.55 $130.14 $130.14 $0.00 $0.00 $36.54 $0.00 $103.72 $103.72 $0.00 $87.68 $138.88 $140.28 $0.00 $0.00 $27.44 $0.00 $0.00 $27.92 $0.00 $0.00 $0.00 $0.00 $0.00 71148005 SUP HCPCS C1713 71148005 - PLATE BN 39MM TC100 5 HL .25 TBLR SS CNDYL 2.7MM SCR MN FRAG BOTH IP/OP $185.85 $137.53 $0.00 $148.68 $83.63 $83.63 $0.00 $0.00 $0.00 $38.74 $137.94 $137.94 $0.00 $0.00 $38.73 $0.00 $109.93 $109.93 $0.00 $92.93 $147.19 $148.68 $0.00 $0.00 $29.09 $0.00 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $0.00 71148006 SUP HCPCS C1713 71148006 - PLATE BN 47MM TC100 6 HL .25 TBLR SS CNDYL 2.7MM SCR MN FRAG BOTH IP/OP $205.80 $152.29 $0.00 $164.64 $92.61 $92.61 $0.00 $0.00 $0.00 $42.89 $152.74 $152.74 $0.00 $0.00 $42.89 $0.00 $121.73 $121.73 $0.00 $102.90 $162.99 $164.64 $0.00 $0.00 $32.21 $0.00 $0.00 $32.76 $0.00 $0.00 $0.00 $0.00 $0.00 71148007 SUP HCPCS C1713 71148007 - PLATE BN 55MM TC100 7 HL .25 TBLR SS ORTH 2.7MM SCR MN FRAG BOTH IP/OP $214.20 $158.51 $0.00 $171.36 $96.39 $96.39 $0.00 $0.00 $0.00 $44.64 $158.98 $158.98 $0.00 $0.00 $44.64 $0.00 $126.70 $126.70 $0.00 $107.10 $169.65 $171.36 $0.00 $0.00 $33.52 $0.00 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $0.00 71148008 SUP HCPCS C1713 71148008 - PLATE BN 63MM TC100 QT TBLR SS ORTH 2.7MM SCR MN FRAG SET BOTH IP/OP $227.85 $168.61 $0.00 $182.28 $102.53 $102.53 $0.00 $0.00 $0.00 $47.49 $169.11 $169.11 $0.00 $0.00 $47.48 $0.00 $134.77 $134.77 $0.00 $113.93 $180.46 $182.28 $0.00 $0.00 $35.66 $0.00 $0.00 $36.27 $0.00 $0.00 $0.00 $0.00 $0.00 71149006 SUP HCPCS C1713 71149006 - SCREW BN 1.5MM 6MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149007 SUP HCPCS C1713 71149007 - SCREW BN 1.5MM 7MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149008 SUP HCPCS C1713 71149008 - SCREW BN 1.5MM 8MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149009 SUP HCPCS C1713 71149009 - SCREW BN 1.5MM 9MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149010 SUP HCPCS C1713 71149010 - SCREW BN 1.5MM 10MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149011 SUP HCPCS C1713 71149011 - SCREW BN 1.5MM 11MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149012 SUP HCPCS C1713 71149012 - SCREW BN 1.5MM 12MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149014 SUP HCPCS C1713 71149014 - SCREW BN 1.5MM 14MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149016 SUP HCPCS C1713 71149016 - SCREW BN 1.5MM 16MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149018 SUP HCPCS C1713 71149018 - SCREW BN 1.5MM 18MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149020 SUP HCPCS C1713 71149020 - SCREW BN 1.5MM 20MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149022 SUP HCPCS C1713 71149022 - SCREW BN 1.5MM 22MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149024 SUP HCPCS C1713 71149024 - SCREW BN 1.5MM 24MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149106 SUP HCPCS C1713 71149106 - SCREW BN 1.5MM 6MM TC100 ST HEX SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149107 SUP HCPCS C1713 71149107 - SCREW BN 1.5MM 7MM TC100 ST HEX SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149108 SUP HCPCS C1713 71149108 - SCREW BN 1.5MM 8MM TC100 ST HEX SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149109 SUP HCPCS C1713 71149109 - SCREW BN 1.5MM 9MM TC100 ST HEX SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149110 SUP HCPCS C1713 71149110 - SCREW BN 1.5MM 10MM TC100 ST HEX SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149111 SUP HCPCS C1713 71149111 - SCREW BN 1.5MM 11MM TC100 ST HEX SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149112 SUP HCPCS C1713 71149112 - SCREW BN 1.5MM 12MM TC100 ST HEX SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149114 SUP HCPCS C1713 71149114 - SCREW BN 1.5MM 14MM TC100 ST HEX SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149116 SUP HCPCS C1713 71149116 - SCREW BN 1.5MM 16MM TC100 ST HEX SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149118 SUP HCPCS C1713 71149118 - SCREW BN 1.5MM 3MM 18MM TC100 HEX HD ST SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149120 SUP HCPCS C1713 71149120 - SCREW BN 1.5MM 3MM 20MM TC100 HEX HD ST SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149122 SUP HCPCS C1713 71149122 - SCREW BN 1.5MM 3MM 22MM TC100 HEX HD ST SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149124 SUP HCPCS C1713 71149124 - SCREW BN 1.5MM 3MM 24MM TC100 HEX HD ST SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149206 SUP HCPCS C1713 71149206 - SCREW BN 2MM 6MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149208 SUP HCPCS C1713 71149208 - SCREW BN 2MM 8MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149210 SUP HCPCS C1713 71149210 - SCREW BN 2MM 10MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149212 SUP HCPCS C1713 71149212 - SCREW BN 2MM 12MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149214 SUP HCPCS C1713 71149214 - SCREW BN 2MM 14MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149216 SUP HCPCS C1713 71149216 - SCREW BN 2MM 16MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149218 SUP HCPCS C1713 71149218 - SCREW BN 2MM 18MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149220 SUP HCPCS C1713 71149220 - SCREW BN 2MM 20MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149222 SUP HCPCS C1713 71149222 - SCREW BN 2MM 22MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149224 SUP HCPCS C1713 71149224 - SCREW BN 2MM 24MM TC100 ST LTWT MDLR CRCTE HD SS CORT MN BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149226 SUP HCPCS C1713 71149226 - SCREW BN 2MM 26MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149228 SUP HCPCS C1713 71149228 - SCREW BN 2MM 28MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149230 SUP HCPCS C1713 71149230 - SCREW BN 2MM 30MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149232 SUP HCPCS C1713 71149232 - SCREW BN 2MM 32MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149234 SUP HCPCS C1713 71149234 - SCREW BN 2MM 34MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149236 SUP HCPCS C1713 71149236 - SCREW BN 2MM 36MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149238 SUP HCPCS C1713 71149238 - SCREW BN 2MM 38MM TC100 ST CRCTE HD SS CORT MN FRAG SET BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 71149306 SUP HCPCS C1713 71149306 - SCREW BN MN 2MM 4MM 6MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149308 SUP HCPCS C1713 71149308 - SCREW BN 2MM 4MM 8MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149310 SUP HCPCS C1713 71149310 - SCREW BN 2MM 4MM 10MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149312 SUP HCPCS C1713 71149312 - SCREW BN 2MM 4MM 12MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149314 SUP HCPCS C1713 71149314 - SCREW BN 2MM 4MM 14MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149316 SUP HCPCS C1713 71149316 - SCREW BN 2MM 4MM 16MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149318 SUP HCPCS C1713 71149318 - SCREW BN 2MM 4MM 18MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149320 SUP HCPCS C1713 71149320 - SCREW BN 2MM 4MM 20MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149322 SUP HCPCS C1713 71149322 - SCREW BN 2MM 4MM 22MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149324 SUP HCPCS C1713 71149324 - SCREW BN 2MM 4MM 24MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149326 SUP HCPCS C1713 71149326 - SCREW BN 2MM 26MM TC100 ST CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149328 SUP HCPCS C1713 71149328 - SCREW BN 2MM 28MM TC100 ST CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149330 SUP HCPCS C1713 71149330 - SCREW BN 2MM 30MM TC100 ST CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149332 SUP HCPCS C1713 71149332 - SCREW BN 2MM 32MM TC100 ST CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149334 SUP HCPCS C1713 71149334 - SCREW BN 2MM 34MM TC100 ST CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149336 SUP HCPCS C1713 71149336 - SCREW BN 2MM 36MM TC100 ST CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149338 SUP HCPCS C1713 71149338 - SCREW BN 2MM 38MM TC100 ST CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 71149406 SUP HCPCS C1713 71149406 - SCREW BN 2.7MM 5MM 6MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149408 SUP HCPCS C1713 71149408 - SCREW BN 2.7MM 5MM 8MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149410 SUP HCPCS C1713 71149410 - SCREW BN 2.7MM 5MM 10MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149412 SUP HCPCS C1713 71149412 - SCREW BN 2.7MM 5MM 12MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149414 SUP HCPCS C1713 71149414 - SCREW BN 2.7MM 5MM 14MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149416 SUP HCPCS C1713 71149416 - SCREW BN 2.7MM 5MM 16MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149418 SUP HCPCS C1713 71149418 - SCREW BN 2.7MM 18MM TC100 ST CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149420 SUP HCPCS C1713 71149420 - SCREW BN 2.7MM 5MM 20MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149422 SUP HCPCS C1713 71149422 - SCREW BN 2.7MM 5MM 22MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149424 SUP HCPCS C1713 71149424 - SCREW BN 2.7MM 5MM 24MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149426 SUP HCPCS C1713 71149426 - SCREW BN 2.7MM 5MM 26MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149428 SUP HCPCS C1713 71149428 - SCREW BN 2.7MM 5MM 28MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149430 SUP HCPCS C1713 71149430 - SCREW BN 2.7MM 5MM 30MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149432 SUP HCPCS C1713 71149432 - SCREW BN 2.7MM 5MM 32MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149434 SUP HCPCS C1713 71149434 - SCREW BN 2.7MM 5MM 34MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149436 SUP HCPCS C1713 71149436 - SCREW BN 2.7MM 5MM 36MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149438 SUP HCPCS C1713 71149438 - SCREW BN 2.7MM 5MM 38MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149440 SUP HCPCS C1713 71149440 - SCREW BN 2.7MM 5MM 40MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149445 SUP HCPCS C1713 71149445 - SCREW BN 2.7MM 5MM 45MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149450 SUP HCPCS C1713 71149450 - SCREW BN 2.7MM 5MM 50MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149455 SUP HCPCS C1713 71149455 - SCREW BN 2.7MM 5MM 55MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149460 SUP HCPCS C1713 71149460 - SCREW BN 2.7MM 5MM 60MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149465 SUP HCPCS C1713 71149465 - SCREW BN 2.7MM 5MM 65MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149470 SUP HCPCS C1713 71149470 - SCREW BN 2.7MM 5MM 70MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71149510 SUP HCPCS C1713 71149510 - SCREW BN 3.5MM 6MM 10MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149512 SUP HCPCS C1713 71149512 - SCREW BN 3.5MM 6MM 12MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149514 SUP HCPCS C1713 71149514 - SCREW BN 3.5MM 14MM ST DIST CORT VOLR RDS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149516 SUP HCPCS C1713 71149516 - SCREW BN HEX 3.5MM 16MM ST DIST CORT VOLR RDS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149518 SUP HCPCS C1713 71149518 - SCREW BN 3.5MM 6MM 18MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149520 SUP HCPCS C1713 71149520 - SCREW BN 3.5MM 6MM 20MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149522 SUP HCPCS C1713 71149522 - SCREW BN 3.5MM 6MM 22MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149524 SUP HCPCS C1713 71149524 - SCREW BN 3.5MM 6MM 24MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149526 SUP HCPCS C1713 71149526 - SCREW BN 3.5MM 6MM 26MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149528 SUP HCPCS C1713 71149528 - SCREW BN 3.5MM 6MM 28MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149530 SUP HCPCS C1713 71149530 - SCREW BN 3.5MM 6MM 30MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149532 SUP HCPCS C1713 71149532 - SCREW BN 3.5MM 6MM 32MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149534 SUP HCPCS C1713 71149534 - SCREW BN 3.5MM 6MM 34MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149536 SUP HCPCS C1713 71149536 - SCREW BN 3.5MM 6MM 36MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149538 SUP HCPCS C1713 71149538 - SCREW BN 3.5MM 6MM 38MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149540 SUP HCPCS C1713 71149540 - SCREW BN 3.5MM 6MM 40MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149545 SUP HCPCS C1713 71149545 - SCREW BN 3.5MM 6MM 45MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149550 SUP HCPCS C1713 71149550 - SCREW BN 3.5MM 6MM 50MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149555 SUP HCPCS C1713 71149555 - SCREW BN 3.5MM 6MM 55MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149560 SUP HCPCS C1713 71149560 - SCREW BN 3.5MM 6MM 60MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149565 SUP HCPCS C1713 71149565 - SCREW BN 3.5MM 6MM 65MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149570 SUP HCPCS C1713 71149570 - SCREW BN 3.5MM 6MM 70MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149575 SUP HCPCS C1713 71149575 - SCREW BN 3.5MM 6MM 75MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149580 SUP HCPCS C1713 71149580 - SCREW BN 3.5MM 6MM 80MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149585 SUP HCPCS C1713 71149585 - SCREW BN 3.5MM 6MM 85MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149590 SUP HCPCS C1713 71149590 - SCREW BN 3.5MM 6MM 90MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149595 SUP HCPCS C1713 71149595 - SCREW BN 3.5MM 6MM 95MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149600 SUP HCPCS C1713 71149600 - SCREW BN 3.5MM 100MM TC100 ST DP HEX HD SS CORT SM FRAG SET BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149605 SUP HCPCS C1713 71149605 - SCREW BN 3.5MM 105MM TC100 ST DP HEX HD SS CORT SM FRAG SET BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149610 SUP HCPCS C1713 71149610 - SCREW BN 3.5MM 110MM TC100 ST DP HEX HD SS CORT SM FRAG SET BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 71149615 SUP HCPCS C1713 71149615 - SCREW BN 3.5MM 115MM STRL TC100 ST DP HEX HD SS CORT SM FRAG BOTH IP/OP $93.35 $69.08 $0.00 $74.68 $42.01 $42.01 $0.00 $0.00 $0.00 $19.46 $69.28 $69.28 $0.00 $0.00 $19.45 $0.00 $55.22 $55.22 $0.00 $46.68 $73.93 $74.68 $0.00 $0.00 $14.61 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 71149620 SUP HCPCS C1713 71149620 - SCREW BN 3.5MM 120MM STRL TC100 ST DP HEX HD SS CORT SM FRAG BOTH IP/OP $93.35 $69.08 $0.00 $74.68 $42.01 $42.01 $0.00 $0.00 $0.00 $19.46 $69.28 $69.28 $0.00 $0.00 $19.45 $0.00 $55.22 $55.22 $0.00 $46.68 $73.93 $74.68 $0.00 $0.00 $14.61 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 71149625 SUP HCPCS C1713 71149625 - SCREW BN 3.5MM 125MM STRL TC100 ST DP HEX HD SS CORT SM FRAG BOTH IP/OP $93.35 $69.08 $0.00 $74.68 $42.01 $42.01 $0.00 $0.00 $0.00 $19.46 $69.28 $69.28 $0.00 $0.00 $19.45 $0.00 $55.22 $55.22 $0.00 $46.68 $73.93 $74.68 $0.00 $0.00 $14.61 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 71149630 SUP HCPCS C1713 71149630 - SCREW BN 3.5MM 130MM STRL TC100 ST DP HEX HD SS CORT SM FRAG BOTH IP/OP $93.35 $69.08 $0.00 $74.68 $42.01 $42.01 $0.00 $0.00 $0.00 $19.46 $69.28 $69.28 $0.00 $0.00 $19.45 $0.00 $55.22 $55.22 $0.00 $46.68 $73.93 $74.68 $0.00 $0.00 $14.61 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 71149714 SUP HCPCS C1713 71149714 - SCREW BN 4.5MM 14MM TC100 ST HEX SCKT SS CORT LG SCR SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149716 SUP HCPCS C1713 71149716 - SCREW BN 4.5MM 16MM TC100 ST HEX SCKT SS CORT LG FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149718 SUP HCPCS C1713 71149718 - SCREW BN 4.5MM 18MM TC100 ST HEX SCKT SS CORT LG SCR SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149720 SUP HCPCS C1713 71149720 - SCREW BN 4.5MM 20MM TC100 ST HEX SCKT SS CORT LG SCR SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149722 SUP HCPCS C1713 71149722 - SCREW BN 4.5MM 22MM TC100 ST HEX SCKT SS CORT LG FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149724 SUP HCPCS C1713 71149724 - SCREW BN 4.5MM 24MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149726 SUP HCPCS C1713 71149726 - SCREW BN 4.5MM 26MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149728 SUP HCPCS C1713 71149728 - SCREW BN 4.5MM 28MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149730 SUP HCPCS C1713 71149730 - SCREW BN 4.5MM 30MM TC100 ST HEX SCKT SS CORT LG FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149732 SUP HCPCS C1713 71149732 - SCREW BN 4.5MM 32MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149734 SUP HCPCS C1713 71149734 - SCREW BN 4.5MM 34MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149736 SUP HCPCS C1713 71149736 - SCREW BN 4.5MM 36MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149738 SUP HCPCS C1713 71149738 - SCREW BN 4.5MM 38MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149740 SUP HCPCS C1713 71149740 - SCREW BN 4.5MM 40MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149742 SUP HCPCS C1713 71149742 - SCREW BN HEX 4.5MM 42MM TC100 ST SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149744 SUP HCPCS C1713 71149744 - SCREW BN HEX 4.5MM 44MM TC100 ST SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149746 SUP HCPCS C1713 71149746 - SCREW BN 4.5MM 46MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149748 SUP HCPCS C1713 71149748 - SCREW BN 4.5MM 48MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149750 SUP HCPCS C1713 71149750 - SCREW BN 4.5MM 50MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149752 SUP HCPCS C1713 71149752 - SCREW BN 4.5MM 52MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149754 SUP HCPCS C1713 71149754 - SCREW BN 4.5MM 54MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149756 SUP HCPCS C1713 71149756 - SCREW BN 4.5MM 56MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149758 SUP HCPCS C1713 71149758 - SCREW BN 4.5MM 58MM TC100 ST HEX SCKT SS CORT LG FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149760 SUP HCPCS C1713 71149760 - SCREW BN 4.5MM 60MM TC100 ST HEX SCKT SS CORT LG SCR SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149762 SUP HCPCS C1713 71149762 - SCREW BN 4.5MM 62MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149764 SUP HCPCS C1713 71149764 - SCREW BN 4.5MM 64MM TC100 ST HEX SCKT SS CORT LG FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149766 SUP HCPCS C1713 71149766 - SCREW BN 4.5MM 66MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149768 SUP HCPCS C1713 71149768 - SCREW BN 4.5MM 68MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149770 SUP HCPCS C1713 71149770 - SCREW BN 4.5MM 70MM TC100 ST HEX SCKT SS CORT LG FRAG SET BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71149772 SUP HCPCS C1713 71149772 - SCREW BN 4.5MM 72MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149776 SUP HCPCS C1713 71149776 - SCREW BN 4.5MM 76MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149785 SUP HCPCS C1713 71149785 - SCREW BN 4.5MM 85MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149795 SUP HCPCS C1713 71149795 - SCREW BN 4.5MM 95MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149800 SUP HCPCS C1713 71149800 - SCREW BN 4.5MM 100MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149805 SUP HCPCS C1713 71149805 - SCREW BN 4.5MM 105MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149810 SUP HCPCS C1713 71149810 - SCREW BN 4.5MM 110MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149815 SUP HCPCS C1713 71149815 - SCREW BN 4.5MM 115MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149820 SUP HCPCS C1713 71149820 - SCREW BN 4.5MM 120MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149825 SUP HCPCS C1713 71149825 - SCREW BN 4.5MM 125MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149830 SUP HCPCS C1713 71149830 - SCREW BN 4.5MM 130MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149835 SUP HCPCS C1713 71149835 - SCREW BN 4.5MM 135MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149840 SUP HCPCS C1713 71149840 - SCREW BN 4.5MM 140MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71149845 SUP HCPCS C1713 71149845 - SCREW BN 4.5MM 145MM TC100 ST HEX HD SS CORT LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71160095 SUP HCPCS C1713 71160095 - SCREW BN 95MM LG TI ORTH BOTH IP/OP $689.85 $510.49 $0.00 $551.88 $310.43 $310.43 $0.00 $0.00 $0.00 $143.78 $512.01 $512.01 $0.00 $0.00 $143.76 $0.00 $408.05 $408.05 $0.00 $344.93 $546.36 $551.88 $0.00 $0.00 $107.96 $0.00 $0.00 $109.82 $0.00 $0.00 $0.00 $0.00 $0.00 71161008 SUP HCPCS C1769 71161008 - WIRE FX .8MM 70MM STRL KRSH TROC PNT 1 END SS ORTH BOTH IP/OP $47.70 $35.30 $0.00 $38.16 $25.90 $25.90 $0.00 $0.00 $0.00 $9.94 $35.40 $35.40 $0.00 $0.00 $9.94 $0.00 $28.21 $28.21 $0.00 $23.85 $37.78 $38.16 $0.00 $0.00 $7.47 $0.00 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 71161010 SUP HCPCS C1769 71161010 - WIRE FX 1MM 150MM STRL KRSH TROC PNT 1 END SS ORTH BOTH IP/OP $47.70 $35.30 $0.00 $38.16 $25.90 $25.90 $0.00 $0.00 $0.00 $9.94 $35.40 $35.40 $0.00 $0.00 $9.94 $0.00 $28.21 $28.21 $0.00 $23.85 $37.78 $38.16 $0.00 $0.00 $7.47 $0.00 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 71161020 SUP Custom 27203010 71161020 - WIRE FX 2MM 150MM STRL KRSH TROC PNT SS ORTH DISP BOTH IP/OP $67.20 $49.73 $0.00 $53.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.88 $49.88 $0.00 $0.00 $14.00 $0.00 $0.00 $0.00 $0.00 $33.60 $53.22 $53.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71161040 SUP HCPCS C1713 71161040 - SCREW BN P/T 6.5MM 40MM NS 20MM CNN TI BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161045 SUP HCPCS C1713 71161045 - SCREW BN P/T 6.5MM 45MM NS 20MM CNN TI BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161050 SUP HCPCS C1713 71161050 - SCREW BN P/T 6.5MM 50MM NS 20MM CNN TI BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161055 SUP HCPCS C1713 71161055 - SCREW BN P/T 6.5MM 55MM NS 20MM CNN TI BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161060 SUP HCPCS C1713 71161060 - SCREW BN P/T 6.5MM 60MM NS 20MM CNN TI BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161065 SUP HCPCS C1713 71161065 - SCREW BN P/T 6.5MM 65MM NS 20MM CNN TI BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161066 SUP HCPCS C1769 71161066 - WIRE FX .6MM STRL KRSH BOTH IP/OP $47.70 $35.30 $0.00 $38.16 $25.90 $25.90 $0.00 $0.00 $0.00 $9.94 $35.40 $35.40 $0.00 $0.00 $9.94 $0.00 $28.21 $28.21 $0.00 $23.85 $37.78 $38.16 $0.00 $0.00 $7.47 $0.00 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $0.00 71161070 SUP HCPCS C1713 71161070 - SCREW BN 6.5MM 70MM NS 20MM CNN P/T TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161075 SUP HCPCS C1713 71161075 - SCREW BN 6.5MM 75MM NS 20MM CNN P/T TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161080 SUP HCPCS C1713 71161080 - SCREW BN LG 6.5MM 80MM STRL 20MM CNN THRD TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161085 SUP HCPCS C1713 71161085 - SCREW BN 6.5MM 85MM NS 20MM CNN P/T TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161090 SUP HCPCS C1713 71161090 - SCREW BN 6.5MM 90MM NS 20MM CNN P/T TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161095 SUP HCPCS C1713 71161095 - SCREW BN 6.5MM 95MM NS 20MM CNN P/T TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161100 SUP HCPCS C1713 71161100 - SCREW BN 6.5MM 100MM NS 20MM CNN P/T TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161105 SUP HCPCS C1713 71161105 - SCREW BN 6.5MM 105MM NS 20MM CNN P/T TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161110 SUP HCPCS C1713 71161110 - SCREW BN 6.5MM 110MM NS 20MM CNN P/T TI ORTH BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 71161303 SUP HCPCS C1713 71161303 - PLATE BN 130D CLS 3 HL CMPR TI HIP BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71161352 SUP HCPCS C1713 71161352 - PLATE BN 135D CLS 2 HL CMPR TI HIP BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71161354 SUP HCPCS C1713 71161354 - PLATE BN 135D CLS 4 HL CMPR TI HIP BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71161355 SUP HCPCS C1713 71161355 - PLATE BN 135D CLS 5 HL CMPR TI HIP BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71161404 SUP HCPCS C1713 71161404 - PLATE BN 140D CLS 4 HL CMPR TI HIP BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71161405 SUP HCPCS C1713 71161405 - PLATE BN 140D CLS 5 HL CMPR TI HIP BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 71161506 SUP HCPCS C1713 71161506 - SCREW BN 1.5MM 6MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161507 SUP HCPCS C1713 71161507 - SCREW BN 1.5MM 7MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161508 SUP HCPCS C1713 71161508 - SCREW BN 1.5MM 8MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161509 SUP HCPCS C1713 71161509 - SCREW BN 1.5MM 9MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161510 SUP HCPCS C1713 71161510 - SCREW BN 1.5MM 10MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161511 SUP HCPCS C1713 71161511 - SCREW BN 1.5MM 11MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161512 SUP HCPCS C1713 71161512 - SCREW BN 1.5MM 12MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161514 SUP HCPCS C1713 71161514 - SCREW BN 1.5MM 14MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161516 SUP HCPCS C1713 71161516 - SCREW BN 1.5MM 16MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161518 SUP HCPCS C1713 71161518 - SCREW BN 1.5MM 18MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161520 SUP HCPCS C1713 71161520 - SCREW BN 1.5MM 20MM TC100 HEX SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161606 SUP HCPCS C1713 71161606 - SCREW BN MN 1.5MM 6MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161607 SUP HCPCS C1713 71161607 - SCREW BN MN 1.5MM 7MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161608 SUP HCPCS C1713 71161608 - SCREW BN MN 1.5MM 8MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161609 SUP HCPCS C1713 71161609 - SCREW BN MN 1.5MM 9MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161610 SUP HCPCS C1713 71161610 - SCREW BN 1.5MM 10MM TC100 CRCTE SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161611 SUP HCPCS C1713 71161611 - SCREW BN MN 1.5MM 11MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161612 SUP HCPCS C1713 71161612 - SCREW BN 1.5MM 12MM TC100 CRCTE SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161614 SUP HCPCS C1713 71161614 - SCREW BN 1.5MM 14MM TC100 CRCTE SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161616 SUP HCPCS C1713 71161616 - SCREW BN 1.5MM 16MM TC100 CRCTE SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161618 SUP HCPCS C1713 71161618 - SCREW BN 1.5MM 18MM TC100 CRCTE SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71161620 SUP HCPCS C1713 71161620 - SCREW BN 1.5MM 20MM TC100 CRCTE SCKT SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162008 SUP HCPCS C1713 71162008 - SCREW BN 2MM 8MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162010 SUP HCPCS C1713 71162010 - SCREW BN 2MM 10MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162012 SUP HCPCS C1713 71162012 - SCREW BN 2MM 12MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162014 SUP HCPCS C1713 71162014 - SCREW BN 2MM 14MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162016 SUP HCPCS C1713 71162016 - SCREW BN 2MM 16MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162018 SUP HCPCS C1713 71162018 - SCREW BN 2MM 18MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162020 SUP HCPCS C1713 71162020 - SCREW BN 2MM 20MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162022 SUP HCPCS C1713 71162022 - SCREW BN 2MM 22MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162024 SUP HCPCS C1713 71162024 - SCREW BN 2MM 24MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162026 SUP HCPCS C1713 71162026 - SCREW BN 2MM 26MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162028 SUP HCPCS C1713 71162028 - SCREW BN 2MM 28MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162030 SUP HCPCS C1713 71162030 - SCREW BN 2MM 30MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162032 SUP HCPCS C1713 71162032 - SCREW BN 2MM 32MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162036 SUP HCPCS C1713 71162036 - SCREW BN 2MM 36MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162038 SUP HCPCS C1713 71162038 - SCREW BN 2MM 38MM TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162106 SUP HCPCS C1713 71162106 - SCREW BN 2MM 6MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162108 SUP HCPCS C1713 71162108 - SCREW BN 2MM 8MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162110 SUP HCPCS C1713 71162110 - SCREW BN 2MM 10MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162112 SUP HCPCS C1713 71162112 - SCREW BN 2MM 12MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162114 SUP HCPCS C1713 71162114 - SCREW BN 2MM 14MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162116 SUP HCPCS C1713 71162116 - SCREW BN 2MM 16MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162118 SUP HCPCS C1713 71162118 - SCREW BN 2MM 18MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162120 SUP HCPCS C1713 71162120 - SCREW BN 2MM 20MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162122 SUP HCPCS C1713 71162122 - SCREW BN 2MM 22MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162124 SUP HCPCS C1713 71162124 - SCREW BN 2MM 24MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162126 SUP HCPCS C1713 71162126 - SCREW BN 2MM 26MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162128 SUP HCPCS C1713 71162128 - SCREW BN 2MM 28MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162130 SUP HCPCS C1713 71162130 - SCREW BN 2MM 30MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162132 SUP HCPCS C1713 71162132 - SCREW BN 2MM 32MM TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162134 SUP HCPCS C1713 71162134 - SCREW BN 2MM 34MM STRL TC100 CRCTE HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71162206 SUP HCPCS C1713 71162206 - SCREW BN 2MM 6MM STRL TC100 HEX HD SS CORT BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71163006 SUP HCPCS C1769 71163006 - WIRE FX .6MM 175MM STRL KRSH CRLGE SS ORTH BOTH IP/OP $50.40 $37.30 $0.00 $40.32 $27.37 $27.37 $0.00 $0.00 $0.00 $10.50 $37.41 $37.41 $0.00 $0.00 $10.50 $0.00 $29.81 $29.81 $0.00 $25.20 $39.92 $40.32 $0.00 $0.00 $7.89 $0.00 $0.00 $8.02 $0.00 $0.00 $0.00 $0.00 $0.00 71163008 SUP HCPCS C1769 71163008 - WIRE FX .8MM 200MM STRL KRSH CRLGE SS ORTH BOTH IP/OP $50.40 $37.30 $0.00 $40.32 $27.37 $27.37 $0.00 $0.00 $0.00 $10.50 $37.41 $37.41 $0.00 $0.00 $10.50 $0.00 $29.81 $29.81 $0.00 $25.20 $39.92 $40.32 $0.00 $0.00 $7.89 $0.00 $0.00 $8.02 $0.00 $0.00 $0.00 $0.00 $0.00 71164026 SUP HCPCS C1713 71164026 - SCREW BN 4.5MM 26MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164028 SUP HCPCS C1713 71164028 - SCREW BN 4.5MM 28MM ST CMPR TI CORT BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164030 SUP HCPCS C1713 71164030 - SCREW BN 4.5MM 30MM ST TI ORTH BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164032 SUP HCPCS C1713 71164032 - SCREW BN 4.5MM 32MM ST CMPR TI CORT BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164034 SUP HCPCS C1713 71164034 - SCREW BN 4.5MM 34MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164036 SUP HCPCS C1713 71164036 - SCREW BN 4.5MM 36MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164038 SUP HCPCS C1713 71164038 - SCREW BN 4.5MM 38MM ST CMPR TI CORT BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164040 SUP HCPCS C1713 71164040 - SCREW BN 4.5MM 40MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164042 SUP HCPCS C1713 71164042 - SCREW BN 4.5MM 42MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164044 SUP HCPCS C1713 71164044 - SCREW BN 4.5MM 44MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164046 SUP HCPCS C1713 71164046 - SCREW BN 4.5MM 46MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164048 SUP HCPCS C1713 71164048 - SCREW BN 4.5MM 48MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164050 SUP HCPCS C1713 71164050 - SCREW BN 4.5MM 50MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71164052 SUP HCPCS C1713 71164052 - SCREW BN 4.5MM 52MM ST CMPR TI CORT HIP BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $27.17 $27.17 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 71170001 SUP Custom 27203010 71170001 - BIT DRL 1.1MM QC BOTH IP/OP $163.80 $121.21 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.57 $121.57 $0.00 $0.00 $34.14 $0.00 $0.00 $0.00 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170003 SUP Custom 27203010 71170003 - BIT DRL 1.5MM 85MM STRL 60MM TC100 QC BOTH IP/OP $163.80 $121.21 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.57 $121.57 $0.00 $0.00 $34.14 $0.00 $0.00 $0.00 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170005 SUP Custom 27203010 71170005 - BIT DRL 2MM STRL GLD HL BOTH IP/OP $163.80 $121.21 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.57 $121.57 $0.00 $0.00 $34.14 $0.00 $0.00 $0.00 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170007 SUP Custom 27203010 71170007 - BIT DRL 2.7MM QC BOTH IP/OP $163.80 $121.21 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.57 $121.57 $0.00 $0.00 $34.14 $0.00 $0.00 $0.00 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170071 SUP Custom 27203010 71170071 - BIT DRL 2.5MM 110MM AU STRL QC BOTH IP/OP $270.90 $200.47 $0.00 $216.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.06 $201.06 $0.00 $0.00 $56.46 $0.00 $0.00 $0.00 $0.00 $135.45 $214.55 $216.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170073 SUP Custom 27203010 71170073 - BIT DRL 3.5MM 110MM STRL QC BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $0.00 $0.00 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170111 SUP Custom 27203010 71170111 - BIT DRL 3.2MM 145MM STRL QC BOTH IP/OP $163.80 $121.21 $0.00 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.57 $121.57 $0.00 $0.00 $34.14 $0.00 $0.00 $0.00 $0.00 $81.90 $129.73 $131.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170113 SUP Custom 27203010 71170113 - BIT DRL 4.5MM 145MM STRL QC BOTH IP/OP $204.75 $151.52 $0.00 $163.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.97 $151.97 $0.00 $0.00 $42.67 $0.00 $0.00 $0.00 $0.00 $102.38 $162.16 $163.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170147 SUP Custom 27203010 71170147 - BIT DRL LNG 3.5MM 195MM STRL QC BOTH IP/OP $279.30 $206.68 $0.00 $223.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.30 $207.30 $0.00 $0.00 $58.21 $0.00 $0.00 $0.00 $0.00 $139.65 $221.21 $223.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170149 SUP Custom 27203010 71170149 - BIT DRL LNG 4.5MM 195MM STRL QC BOTH IP/OP $279.30 $206.68 $0.00 $223.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.30 $207.30 $0.00 $0.00 $58.21 $0.00 $0.00 $0.00 $0.00 $139.65 $221.21 $223.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170151 SUP Custom 27203010 71170151 - BIT DRL 4.5MM 196MM STRL QC 3 FLT BOTH IP/OP $433.65 $320.90 $0.00 $346.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.86 $321.86 $0.00 $0.00 $90.37 $0.00 $0.00 $0.00 $0.00 $216.83 $343.45 $346.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170153 SUP Custom 27203010 71170153 - BIT DRL 2.5MM 230MM STRL QC 3 FLT BOTH IP/OP $576.45 $426.57 $0.00 $461.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.84 $427.84 $0.00 $0.00 $120.13 $0.00 $0.00 $0.00 $0.00 $288.23 $456.55 $461.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170155 SUP Custom 27203010 71170155 - BIT DRL 3.2MM 230MM STRL QC 3 FLT BOTH IP/OP $576.45 $426.57 $0.00 $461.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.84 $427.84 $0.00 $0.00 $120.13 $0.00 $0.00 $0.00 $0.00 $288.23 $456.55 $461.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71170315 SUP HCPCS C1713 71170315 - SCREW BN 6MM 190MM TC100 SCHNZ DMD PT SS ORTH BOTH IP/OP "$1,000.65 " $740.48 $0.00 $800.52 $450.29 $450.29 $0.00 $0.00 $0.00 $208.56 $742.68 $742.68 $0.00 $0.00 $208.54 $0.00 $591.88 $591.88 $0.00 $500.33 $792.51 $800.52 $0.00 $0.00 $156.60 $0.00 $0.00 $159.30 $0.00 $0.00 $0.00 $0.00 $0.00 71173501 SUP Custom 27203010 71173501 - BIT DRILL 2MM 190MM QUICK CONNECT PERI-LOC DISPOSABLE BOTH IP/OP $180.60 $133.64 $0.00 $144.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.04 $134.04 $0.00 $0.00 $37.64 $0.00 $0.00 $0.00 $0.00 $90.30 $143.04 $144.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71173505 SUP Custom 27203010 71173505 - BIT DRL 3.5MM 220MM STRL PRLC AO QCK CNCT CLBRT DISP BOTH IP/OP $280.35 $207.46 $0.00 $224.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.08 $208.08 $0.00 $0.00 $58.42 $0.00 $0.00 $0.00 $0.00 $140.18 $222.04 $224.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71173581 SUP Custom 27203010 71173581 - BIT DRL 2.7MM 155MM CNN DISP BOTH IP/OP $743.40 $550.12 $0.00 $594.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $551.75 $551.75 $0.00 $0.00 $154.92 $0.00 $0.00 $0.00 $0.00 $371.70 $588.77 $594.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71173807 SUP HCPCS C1713 71173807 - PIN FX 2MM 14MM VLP BOTH IP/OP $307.50 $227.55 $0.00 $246.00 $138.38 $138.38 $0.00 $0.00 $0.00 $64.09 $228.23 $228.23 $0.00 $0.00 $64.08 $0.00 $181.89 $181.89 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $48.12 $0.00 $0.00 $48.95 $0.00 $0.00 $0.00 $0.00 $0.00 71173808 SUP HCPCS C1713 71173808 - PIN FIX 2MM 25MM TRIAL BOTH IP/OP $332.50 $246.05 $0.00 $266.00 $149.63 $149.63 $0.00 $0.00 $0.00 $69.30 $246.78 $246.78 $0.00 $0.00 $69.29 $0.00 $196.67 $196.67 $0.00 $166.25 $263.34 $266.00 $0.00 $0.00 $52.04 $0.00 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $0.00 71174904 SUP HCPCS C1713 71174904 - PIN FX 1.5MM BOTH IP/OP $343.75 $254.38 $0.00 $275.00 $154.69 $154.69 $0.00 $0.00 $0.00 $71.65 $255.13 $255.13 $0.00 $0.00 $71.64 $0.00 $203.33 $203.33 $0.00 $171.88 $272.25 $275.00 $0.00 $0.00 $53.80 $0.00 $0.00 $54.73 $0.00 $0.00 $0.00 $0.00 $0.00 71174909 SUP HCPCS C1713 71174909 - PIN FX 1.8MM BOTH IP/OP $343.75 $254.38 $0.00 $275.00 $154.69 $154.69 $0.00 $0.00 $0.00 $71.65 $255.13 $255.13 $0.00 $0.00 $71.64 $0.00 $203.33 $203.33 $0.00 $171.88 $272.25 $275.00 $0.00 $0.00 $53.80 $0.00 $0.00 $54.73 $0.00 $0.00 $0.00 $0.00 $0.00 71174914 SUP HCPCS C1713 71174914 - PIN FX 2MM 30MM EVOS MN BOTH IP/OP $343.75 $254.38 $0.00 $275.00 $154.69 $154.69 $0.00 $0.00 $0.00 $71.65 $255.13 $255.13 $0.00 $0.00 $71.64 $0.00 $203.33 $203.33 $0.00 $171.88 $272.25 $275.00 $0.00 $0.00 $53.80 $0.00 $0.00 $54.73 $0.00 $0.00 $0.00 $0.00 $0.00 71175022 SUP Custom 27203010 71175022 - DRILL SRG SM LNG 2.5MM STRL LF EVOS AO QCK CNCT REUSE BOTH IP/OP $270.88 $200.45 $0.00 $216.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.04 $201.04 $0.00 $0.00 $56.45 $0.00 $0.00 $0.00 $0.00 $135.44 $214.54 $216.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71175023 SUP Custom 27203010 71175023 - DRILL SRG SM SHRT 2.5MM STRL LF EVOS AO QCK CNCT REUSE BOTH IP/OP $225.50 $166.87 $0.00 $180.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.37 $167.37 $0.00 $0.00 $46.99 $0.00 $0.00 $0.00 $0.00 $112.75 $178.60 $180.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71175027 SUP Custom 27203010 71175027 - SCREW BN 3.5MM 14MM STRL EVOS ST CORT BOTH IP/OP $312.13 $230.98 $0.00 $249.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.66 $231.66 $0.00 $0.00 $65.05 $0.00 $0.00 $0.00 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71175029 SUP Custom 27203010 71175029 - TAP BN 4.7MM STRL LF EVOS AO QCK CNCT DISP BOTH IP/OP $309.38 $228.94 $0.00 $247.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.62 $229.62 $0.00 $0.00 $64.47 $0.00 $0.00 $0.00 $0.00 $154.69 $245.03 $247.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71175701 SUP HCPCS C1713 71175701 - PIN DRL 3.2MM 358MM DRL TIP BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $56.19 $56.19 $0.00 $0.00 $0.00 $26.03 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $73.86 $73.86 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $19.54 $0.00 $0.00 $19.88 $0.00 $0.00 $0.00 $0.00 $0.00 71175702 SUP HCPCS C1713 71175702 - PIN FX 4.5MM 80MM PRLC TRL TARGETER DRL TIP BOTH IP/OP $348.75 $258.08 $0.00 $279.00 $156.94 $156.94 $0.00 $0.00 $0.00 $72.69 $258.84 $258.84 $0.00 $0.00 $72.68 $0.00 $206.29 $206.29 $0.00 $174.38 $276.21 $279.00 $0.00 $0.00 $54.58 $0.00 $0.00 $55.52 $0.00 $0.00 $0.00 $0.00 $0.00 71175703 SUP HCPCS C1713 71175703 - PIN FX 3.5MM 18MM TARGETER BOTH IP/OP $348.75 $258.08 $0.00 $279.00 $156.94 $156.94 $0.00 $0.00 $0.00 $72.69 $258.84 $258.84 $0.00 $0.00 $72.68 $0.00 $206.29 $206.29 $0.00 $174.38 $276.21 $279.00 $0.00 $0.00 $54.58 $0.00 $0.00 $55.52 $0.00 $0.00 $0.00 $0.00 $0.00 71175705 SUP HCPCS C1713 71175705 - PIN FX SHRT 4.5MM 80MM PRLC TRL DRL TIP BOTH IP/OP $348.75 $258.08 $0.00 $279.00 $156.94 $156.94 $0.00 $0.00 $0.00 $72.69 $258.84 $258.84 $0.00 $0.00 $72.68 $0.00 $206.29 $206.29 $0.00 $174.38 $276.21 $279.00 $0.00 $0.00 $54.58 $0.00 $0.00 $55.52 $0.00 $0.00 $0.00 $0.00 $0.00 71175706 SUP HCPCS C1713 71175706 - PIN FX SHRT 3.5MM 18MM PRLC TRL DRL TIP BOTH IP/OP $348.75 $258.08 $0.00 $279.00 $156.94 $156.94 $0.00 $0.00 $0.00 $72.69 $258.84 $258.84 $0.00 $0.00 $72.68 $0.00 $206.29 $206.29 $0.00 $174.38 $276.21 $279.00 $0.00 $0.00 $54.58 $0.00 $0.00 $55.52 $0.00 $0.00 $0.00 $0.00 $0.00 71176011 SUP Custom 27203010 71176011 - BIT DRL 1.1MM 30MM QC BOTH IP/OP $244.65 $181.04 $0.00 $195.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.58 $181.58 $0.00 $0.00 $50.99 $0.00 $0.00 $0.00 $0.00 $122.33 $193.76 $195.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176015 SUP Custom 27203010 71176015 - BIT DRL 1.5MM 85MM QC BOTH IP/OP $244.65 $181.04 $0.00 $195.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.58 $181.58 $0.00 $0.00 $50.99 $0.00 $0.00 $0.00 $0.00 $122.33 $193.76 $195.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176016 SUP Custom 27203010 71176016 - BIT DRL 1.5MM 110MM STRL 85MM TC100 QC BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176020 SUP Custom 27203010 71176020 - BIT DRL 2MM 100MM QC BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $0.00 $0.00 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176021 SUP Custom 27203010 71176021 - BIT DRL 2MM 125MM QC BOTH IP/OP $257.25 $190.37 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.93 $190.93 $0.00 $0.00 $53.61 $0.00 $0.00 $0.00 $0.00 $128.63 $203.74 $205.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176025 SUP Custom 27203010 71176025 - BIT DRL 2.5MM 110MM AU QC BOTH IP/OP $273.00 $202.02 $0.00 $218.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.62 $202.62 $0.00 $0.00 $56.89 $0.00 $0.00 $0.00 $0.00 $136.50 $216.22 $218.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176026 SUP Custom 27203010 71176026 - BIT DRL 2.5MM 180MM AU QC BOTH IP/OP $354.90 $262.63 $0.00 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.41 $263.41 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.45 $281.08 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176027 SUP Custom 27203010 71176027 - BIT DRL 2.7MM 100MM QC BOTH IP/OP $244.65 $181.04 $0.00 $195.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.58 $181.58 $0.00 $0.00 $50.99 $0.00 $0.00 $0.00 $0.00 $122.33 $193.76 $195.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176028 SUP Custom 27203010 71176028 - BIT DRL 2.7MM 125MM STRL QC BOTH IP/OP $267.75 $198.14 $0.00 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.72 $198.72 $0.00 $0.00 $55.80 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176032 SUP Custom 27203010 71176032 - BIT DRL 3.2MM 145MM STRL QC BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $0.00 $0.00 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176033 SUP Custom 27203010 71176033 - BIT DRL 3.2MM 195MM QC BOTH IP/OP $354.90 $262.63 $0.00 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.41 $263.41 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.45 $281.08 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176035 SUP Custom 27203010 71176035 - BIT DRL 3.5MM 110MM QC BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $0.00 $0.00 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176037 SUP Custom 27203010 71176037 - BIT DRL 3.5MM 195MM QC BOTH IP/OP $354.90 $262.63 $0.00 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.41 $263.41 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.45 $281.08 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176045 SUP Custom 27203010 71176045 - BIT DRL 4.5MM 145MM QC BOTH IP/OP $354.90 $262.63 $0.00 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.41 $263.41 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.45 $281.08 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176047 SUP Custom 27203010 71176047 - BIT DRL 4.5MM 195MM QC BOTH IP/OP $354.90 $262.63 $0.00 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.41 $263.41 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.45 $281.08 $283.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176125 SUP Custom 27203010 71176125 - BIT DRL 2.5MM 230MM QC 3 FLT BOTH IP/OP $606.90 $449.11 $0.00 $485.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $450.44 $450.44 $0.00 $0.00 $126.48 $0.00 $0.00 $0.00 $0.00 $303.45 $480.66 $485.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176132 SUP Custom 27203010 71176132 - BIT DRL LNG 3.2MM 230MM QC 3 FLT BOTH IP/OP $606.90 $449.11 $0.00 $485.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $450.44 $450.44 $0.00 $0.00 $126.48 $0.00 $0.00 $0.00 $0.00 $303.45 $480.66 $485.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176145 SUP Custom 27203010 71176145 - BIT DRL 4.5MM 196MM STRL QC 3 FLT BOTH IP/OP $470.40 $348.10 $0.00 $376.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.13 $349.13 $0.00 $0.00 $98.03 $0.00 $0.00 $0.00 $0.00 $235.20 $372.56 $376.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176511 SUP Custom 27203010 71176511 - BIT DRL 1.1MM 45MM STRL NQCK CPLNG BOTH IP/OP $233.10 $172.49 $0.00 $186.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.01 $173.01 $0.00 $0.00 $48.58 $0.00 $0.00 $0.00 $0.00 $116.55 $184.62 $186.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176516 SUP Custom 27203010 71176516 - BIT DRL 1.5MM 95MM STRL NQCK CPLNG BOTH IP/OP $241.50 $178.71 $0.00 $193.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.24 $179.24 $0.00 $0.00 $50.33 $0.00 $0.00 $0.00 $0.00 $120.75 $191.27 $193.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176521 SUP Custom 27203010 71176521 - BIT DRL 2MM 110MM NQCK CPLNG BOTH IP/OP $281.40 $208.24 $0.00 $225.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.86 $208.86 $0.00 $0.00 $58.64 $0.00 $0.00 $0.00 $0.00 $140.70 $222.87 $225.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176525 SUP Custom 27203010 71176525 - BIT DRL 2.5MM 95MM AU NQCK CPLNG BOTH IP/OP $296.10 $219.11 $0.00 $236.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.77 $219.77 $0.00 $0.00 $61.71 $0.00 $0.00 $0.00 $0.00 $148.05 $234.51 $236.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176528 SUP Custom 27203010 71176528 - BIT DRL 2.7MM 110MM NQCK CPLNG BOTH IP/OP $255.15 $188.81 $0.00 $204.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.37 $189.37 $0.00 $0.00 $53.17 $0.00 $0.00 $0.00 $0.00 $127.58 $202.08 $204.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176532 SUP Custom 27203010 71176532 - BIT DRL 3.2MM 130MM NQCK CPLNG BOTH IP/OP $224.70 $166.28 $0.00 $179.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.77 $166.77 $0.00 $0.00 $46.83 $0.00 $0.00 $0.00 $0.00 $112.35 $177.96 $179.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176533 SUP Custom 27203010 71176533 - BIT DRL 3.2MM 180MM NQCK CPLNG BOTH IP/OP $352.80 $261.07 $0.00 $282.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $261.85 $261.85 $0.00 $0.00 $73.52 $0.00 $0.00 $0.00 $0.00 $176.40 $279.42 $282.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176535 SUP Custom 27203010 71176535 - BIT DRL 3.5MM 95MM NQCK CPLNG BOTH IP/OP $270.90 $200.47 $0.00 $216.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.06 $201.06 $0.00 $0.00 $56.46 $0.00 $0.00 $0.00 $0.00 $135.45 $214.55 $216.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176537 SUP Custom 27203010 71176537 - BIT DRL 3.5MM 180MM NQCK CPLNG BOTH IP/OP $281.40 $208.24 $0.00 $225.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.86 $208.86 $0.00 $0.00 $58.64 $0.00 $0.00 $0.00 $0.00 $140.70 $222.87 $225.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176545 SUP Custom 27203010 71176545 - BIT DRL 4.5MM 130MM STRL NQCK CPLNG BOTH IP/OP $270.90 $200.47 $0.00 $216.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.06 $201.06 $0.00 $0.00 $56.46 $0.00 $0.00 $0.00 $0.00 $135.45 $214.55 $216.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71176547 SUP Custom 27203010 71176547 - BIT DRL 4.5MM 180MM NQCK CPLNG BOTH IP/OP $303.45 $224.55 $0.00 $242.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.22 $225.22 $0.00 $0.00 $63.24 $0.00 $0.00 $0.00 $0.00 $151.73 $240.33 $242.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71177134 SUP Custom 27203010 71177134 - BIT DRL 5MM CNN BOTH IP/OP $918.75 $679.88 $0.00 $735.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $681.90 $681.90 $0.00 $0.00 $191.47 $0.00 $0.00 $0.00 $0.00 $459.38 $727.65 $735.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71177135 SUP Custom 27203010 71177135 - BIT DRL 5.5MM CNN 8MM SCR BOTH IP/OP $918.75 $679.88 $0.00 $735.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $681.90 $681.90 $0.00 $0.00 $191.47 $0.00 $0.00 $0.00 $0.00 $459.38 $727.65 $735.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71177197 SUP Custom 27203010 71177197 - BIT DRL SHRT 2MM VLP MN-MOD AO QC OVR BOTH IP/OP $242.00 $179.08 $0.00 $193.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.61 $179.61 $0.00 $0.00 $50.43 $0.00 $0.00 $0.00 $0.00 $121.00 $191.66 $193.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71177201 SUP HCPCS C1713 71177201 - PIN GD 3.2MM 300MM THRD BOTH IP/OP $170.80 $126.39 $0.00 $136.64 $76.86 $76.86 $0.00 $0.00 $0.00 $35.60 $126.77 $126.77 $0.00 $0.00 $35.59 $0.00 $101.03 $101.03 $0.00 $85.40 $135.27 $136.64 $0.00 $0.00 $26.73 $0.00 $0.00 $27.19 $0.00 $0.00 $0.00 $0.00 $0.00 71177202 SUP Custom 27203010 71177202 - BIT DRL 3.2MM 300MM QC BOTH IP/OP $361.20 $267.29 $0.00 $288.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.08 $268.08 $0.00 $0.00 $75.27 $0.00 $0.00 $0.00 $0.00 $180.60 $286.07 $288.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71190808 SUP HCPCS C1713 71190808 - PIN HLF 6MM HAP ORTH BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $38.25 $38.25 $0.00 $0.00 $0.00 $17.72 $63.09 $63.09 $0.00 $0.00 $17.71 $0.00 $50.28 $50.28 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $13.30 $0.00 $0.00 $13.53 $0.00 $0.00 $0.00 $0.00 $0.00 71191010 SUP HCPCS C1713 71191010 - TRIAL SRG 3.5MM SMPL LCK PLT HUM LT PROX BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 71191019 SUP HCPCS C1713 71191019 - TRIAL SRG SMPL LCK PLT RT OLCRN BOTH IP/OP $500.85 $370.63 $0.00 $400.68 $225.38 $225.38 $0.00 $0.00 $0.00 $104.39 $371.73 $371.73 $0.00 $0.00 $104.38 $0.00 $296.25 $296.25 $0.00 $250.43 $396.67 $400.68 $0.00 $0.00 $78.38 $0.00 $0.00 $79.74 $0.00 $0.00 $0.00 $0.00 $0.00 71191025 SUP HCPCS C1713 71191025 - TRIAL SRG 10 HL SMPL LCK PLT INFR MDL CLVCL BOTH IP/OP $465.15 $344.21 $0.00 $372.12 $209.32 $209.32 $0.00 $0.00 $0.00 $96.95 $345.23 $345.23 $0.00 $0.00 $96.94 $0.00 $275.14 $275.14 $0.00 $232.58 $368.40 $372.12 $0.00 $0.00 $72.80 $0.00 $0.00 $74.05 $0.00 $0.00 $0.00 $0.00 $0.00 71192010 SUP HCPCS C1713 71192010 - TRIAL SRG 2.7MM 55MM SMPL LCK SCR CORT BOTH IP/OP $18.23 $13.49 $0.00 $14.58 $8.20 $8.20 $0.00 $0.00 $0.00 $3.80 $13.53 $13.53 $0.00 $0.00 $3.80 $0.00 $10.78 $10.78 $0.00 $9.11 $14.44 $14.58 $0.00 $0.00 $2.85 $0.00 $0.00 $2.90 $0.00 $0.00 $0.00 $0.00 $0.00 71192011 SUP HCPCS C1713 71192011 - TRIAL SRG 2.7MM 20MM SMPL SCR CORT BOTH IP/OP $17.65 $13.06 $0.00 $14.12 $7.94 $7.94 $0.00 $0.00 $0.00 $3.68 $13.10 $13.10 $0.00 $0.00 $3.68 $0.00 $10.44 $10.44 $0.00 $8.83 $13.98 $14.12 $0.00 $0.00 $2.76 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $0.00 71192012 SUP HCPCS C1713 71192012 - TRIAL SRG 2.7MM 55MM SMPL SCR CORT BOTH IP/OP $19.53 $14.45 $0.00 $15.62 $8.79 $8.79 $0.00 $0.00 $0.00 $4.07 $14.49 $14.49 $0.00 $0.00 $4.07 $0.00 $11.55 $11.55 $0.00 $9.76 $15.47 $15.62 $0.00 $0.00 $3.06 $0.00 $0.00 $3.11 $0.00 $0.00 $0.00 $0.00 $0.00 71192016 SUP HCPCS C1713 71192016 - TRIAL SRG 2.5MM 20MM SMPL SCR CORT BOTH IP/OP $17.65 $13.06 $0.00 $14.12 $7.94 $7.94 $0.00 $0.00 $0.00 $3.68 $13.10 $13.10 $0.00 $0.00 $3.68 $0.00 $10.44 $10.44 $0.00 $8.83 $13.98 $14.12 $0.00 $0.00 $2.76 $0.00 $0.00 $2.81 $0.00 $0.00 $0.00 $0.00 $0.00 71192535 SUP HCPCS C1713 71192535 - TRIAL SRG 5MM 35MM HEX SCR ORTH SMPL BOTH IP/OP $26.78 $19.82 $0.00 $21.42 $12.05 $12.05 $0.00 $0.00 $0.00 $5.58 $19.87 $19.87 $0.00 $0.00 $5.58 $0.00 $15.84 $15.84 $0.00 $13.39 $21.21 $21.42 $0.00 $0.00 $4.19 $0.00 $0.00 $4.26 $0.00 $0.00 $0.00 $0.00 $0.00 71192570 SUP HCPCS C1713 71192570 - TRIAL SRG 5MM 70MM HEX SCR ORTH SMPL BOTH IP/OP $39.33 $29.10 $0.00 $31.46 $17.70 $17.70 $0.00 $0.00 $0.00 $8.20 $29.19 $29.19 $0.00 $0.00 $8.20 $0.00 $23.26 $23.26 $0.00 $19.66 $31.15 $31.46 $0.00 $0.00 $6.15 $0.00 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 71193006 SUP HCPCS C1713 71193006 - SCREW SET ASIAN SMPL HIP IM NL BOTH IP/OP $65.30 $48.32 $0.00 $52.24 $29.39 $29.39 $0.00 $0.00 $0.00 $13.61 $48.47 $48.47 $0.00 $0.00 $13.61 $0.00 $38.62 $38.62 $0.00 $32.65 $51.72 $52.24 $0.00 $0.00 $10.22 $0.00 $0.00 $10.40 $0.00 $0.00 $0.00 $0.00 $0.00 71193039 SUP HCPCS C1713 71193039 - NAIL IM 11.5MM 40CM TRGN RTRGD TI FEM BOTH IP/OP $178.88 $132.37 $0.00 $143.10 $80.49 $80.49 $0.00 $0.00 $0.00 $37.28 $132.76 $132.76 $0.00 $0.00 $37.28 $0.00 $105.80 $105.80 $0.00 $89.44 $141.67 $143.10 $0.00 $0.00 $27.99 $0.00 $0.00 $28.48 $0.00 $0.00 $0.00 $0.00 $0.00 71193111 SUP HCPCS C1713 71193111 - TRIAL SRG MT-NL SMPL CAP NL BOTH IP/OP $29.35 $21.72 $0.00 $23.48 $13.21 $13.21 $0.00 $0.00 $0.00 $6.12 $21.78 $21.78 $0.00 $0.00 $6.12 $0.00 $17.36 $17.36 $0.00 $14.68 $23.25 $23.48 $0.00 $0.00 $4.59 $0.00 $0.00 $4.67 $0.00 $0.00 $0.00 $0.00 $0.00 71193125 SUP HCPCS C1713 71193125 - NAIL IM 11.5MM 25CM TRGN TI FEM BOTH IP/OP $176.40 $130.54 $0.00 $141.12 $79.38 $79.38 $0.00 $0.00 $0.00 $36.77 $130.92 $130.92 $0.00 $0.00 $36.76 $0.00 $104.34 $104.34 $0.00 $88.20 $139.71 $141.12 $0.00 $0.00 $27.61 $0.00 $0.00 $28.08 $0.00 $0.00 $0.00 $0.00 $0.00 71193632 SUP HCPCS C1713 71193632 - NAIL IM 10MM 32CM TRGN TI TIB DIST BOTH IP/OP $239.63 $177.33 $0.00 $191.70 $107.83 $107.83 $0.00 $0.00 $0.00 $49.94 $177.85 $177.85 $0.00 $0.00 $49.94 $0.00 $141.74 $141.74 $0.00 $119.81 $189.79 $191.70 $0.00 $0.00 $37.50 $0.00 $0.00 $38.15 $0.00 $0.00 $0.00 $0.00 $0.00 71194828 SUP HCPCS C1713 71194828 - NAIL IM 10/8.5MM 28CM TRGN BNT TI HUM BOTH IP/OP $339.75 $251.42 $0.00 $271.80 $152.89 $152.89 $0.00 $0.00 $0.00 $70.81 $252.16 $252.16 $0.00 $0.00 $70.80 $0.00 $200.96 $200.96 $0.00 $169.88 $269.08 $271.80 $0.00 $0.00 $53.17 $0.00 $0.00 $54.09 $0.00 $0.00 $0.00 $0.00 $0.00 71220006 SUP HCPCS C1713 71220006 - SCREW BN 2.7MM 6MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220008 SUP HCPCS C1713 71220008 - SCREW BN 2.7MM 8MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220010 SUP HCPCS C1713 71220010 - SCREW BN MN 2.7MM 10MM TC100 SS CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220012 SUP HCPCS C1713 71220012 - SCREW BN MN 2.7MM 12MM TC100 SS CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220014 SUP HCPCS C1713 71220014 - SCREW BN MN 2.7MM 14MM TC100 SS CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220016 SUP HCPCS C1713 71220016 - SCREW BN MN 2.7MM 16MM TC100 SS CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220018 SUP HCPCS C1713 71220018 - SCREW BN 2.7MM 18MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220020 SUP HCPCS C1713 71220020 - SCREW BN 2.7MM 20MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220022 SUP HCPCS C1713 71220022 - SCREW BN 2.7MM 22MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220024 SUP HCPCS C1713 71220024 - SCREW BN 2.7MM 24MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220026 SUP HCPCS C1713 71220026 - SCREW BN 2.7MM 26MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220028 SUP HCPCS C1713 71220028 - SCREW BN 2.7MM 28MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220030 SUP HCPCS C1713 71220030 - SCREW BN 2.7MM 30MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220032 SUP HCPCS C1713 71220032 - SCREW BN 2.7MM 32MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220034 SUP HCPCS C1713 71220034 - SCREW BN MN 2.7MM 34MM TC100 SS CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220036 SUP HCPCS C1713 71220036 - SCREW BN 2.7MM 36MM TC100 ST HEX HD SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220038 SUP HCPCS C1713 71220038 - SCREW BN 2.7MM 38MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220040 SUP HCPCS C1713 71220040 - SCREW BN 2.7MM 40MM TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220045 SUP HCPCS C1713 71220045 - SCREW BN MN 2.7MM 45MM TC100 SS CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71220050 SUP HCPCS C1713 71220050 - SCREW BN 2.7MM 50MM STRL TC100 SS CORT MN FRAG SET BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222010 SUP HCPCS C1713 71222010 - SCREW BN 3.5MM 6MM 10MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222012 SUP HCPCS C1713 71222012 - SCREW BN 3.5MM 6MM 12MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222014 SUP HCPCS C1713 71222014 - SCREW BN 3.5MM 6MM 14MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222016 SUP HCPCS C1713 71222016 - SCREW BN 3.5MM 6MM 16MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222018 SUP HCPCS C1713 71222018 - SCREW BN 3.5MM 6MM 18MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222020 SUP HCPCS C1713 71222020 - SCREW BN 3.5MM 6MM 20MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222022 SUP HCPCS C1713 71222022 - SCREW BN 3.5MM 6MM 22MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222024 SUP HCPCS C1713 71222024 - SCREW BN 3.5MM 6MM 24MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222026 SUP HCPCS C1713 71222026 - SCREW BN 3.5MM 6MM 26MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222028 SUP HCPCS C1713 71222028 - SCREW BN 3.5MM 6MM 28MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222030 SUP HCPCS C1713 71222030 - SCREW BN 3.5MM 6MM 30MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222032 SUP HCPCS C1713 71222032 - SCREW BN 3.5MM 6MM 32MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222034 SUP HCPCS C1713 71222034 - SCREW BN 3.5MM 6MM 34MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222036 SUP HCPCS C1713 71222036 - SCREW BN 3.5MM 6MM 36MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222038 SUP HCPCS C1713 71222038 - SCREW BN 3.5MM 6MM 38MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222040 SUP HCPCS C1713 71222040 - SCREW BN 3.5MM 6MM 40MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222045 SUP HCPCS C1713 71222045 - SCREW BN 3.5MM 6MM 45MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222050 SUP HCPCS C1713 71222050 - SCREW BN 3.5MM 6MM 50MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222055 SUP HCPCS C1713 71222055 - SCREW BN 3.5MM 6MM 55MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71222060 SUP HCPCS C1713 71222060 - SCREW BN 3.5MM 6MM 60MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222065 SUP HCPCS C1713 71222065 - SCREW BN 3.5MM 6MM 65MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222070 SUP HCPCS C1713 71222070 - SCREW BN 3.5MM 6MM 70MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222075 SUP HCPCS C1713 71222075 - SCREW BN 3.5MM 6MM 75MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222080 SUP HCPCS C1713 71222080 - SCREW BN 3.5MM 6MM 80MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222085 SUP HCPCS C1713 71222085 - SCREW BN 3.5MM 6MM 85MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222090 SUP HCPCS C1713 71222090 - SCREW BN 3.5MM 6MM 90MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222095 SUP HCPCS C1713 71222095 - SCREW BN 3.5MM 6MM 95MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222100 SUP HCPCS C1713 71222100 - SCREW BN 3.5MM 100MM TC100 SS CORT SM FRAG SET BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222105 SUP HCPCS C1713 71222105 - SCREW BN 3.5MM 105MM TC100 SS CORT SM FRAG SET BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222110 SUP HCPCS C1713 71222110 - SCREW BN SM 3.5MM 110MM TC100 SS CORT BOTH IP/OP $89.40 $66.16 $0.00 $71.52 $40.23 $40.23 $0.00 $0.00 $0.00 $18.63 $66.35 $66.35 $0.00 $0.00 $18.63 $0.00 $52.88 $52.88 $0.00 $44.70 $70.80 $71.52 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222115 SUP HCPCS C1713 71222115 - SCREW BN 3.5MM 115MM TC100 SS CORT SM FRAG SET BOTH IP/OP $101.48 $75.10 $0.00 $81.18 $45.66 $45.66 $0.00 $0.00 $0.00 $21.15 $75.31 $75.31 $0.00 $0.00 $21.15 $0.00 $60.02 $60.02 $0.00 $50.74 $80.37 $81.18 $0.00 $0.00 $15.88 $0.00 $0.00 $16.15 $0.00 $0.00 $0.00 $0.00 $0.00 71222120 SUP HCPCS C1713 71222120 - SCREW BN 3.5MM 120MM TC100 SS CORT SM FRAG SET BOTH IP/OP $101.48 $75.10 $0.00 $81.18 $45.66 $45.66 $0.00 $0.00 $0.00 $21.15 $75.31 $75.31 $0.00 $0.00 $21.15 $0.00 $60.02 $60.02 $0.00 $50.74 $80.37 $81.18 $0.00 $0.00 $15.88 $0.00 $0.00 $16.15 $0.00 $0.00 $0.00 $0.00 $0.00 71222130 SUP HCPCS C1713 71222130 - SCREW BN 3.5MM 130MM TC100 SS CORT SM FRAG SET BOTH IP/OP $101.48 $75.10 $0.00 $81.18 $45.66 $45.66 $0.00 $0.00 $0.00 $21.15 $75.31 $75.31 $0.00 $0.00 $21.15 $0.00 $60.02 $60.02 $0.00 $50.74 $80.37 $81.18 $0.00 $0.00 $15.88 $0.00 $0.00 $16.15 $0.00 $0.00 $0.00 $0.00 $0.00 71223010 SUP HCPCS C1713 71223010 - SCREW BN FT 4MM 6MM 10MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223012 SUP HCPCS C1713 71223012 - SCREW BN FT 4MM 6MM 12MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223014 SUP HCPCS C1713 71223014 - SCREW BN FT 4MM 6MM 14MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223016 SUP HCPCS C1713 71223016 - SCREW BN FT 4MM 6MM 16MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223018 SUP HCPCS C1713 71223018 - SCREW BN FT 4MM 6MM 18MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223020 SUP HCPCS C1713 71223020 - SCREW BN FT 4MM 6MM 20MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223022 SUP HCPCS C1713 71223022 - SCREW BN FT 4MM 6MM 22MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223024 SUP HCPCS C1713 71223024 - SCREW BN FT 4MM 6MM 24MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223026 SUP HCPCS C1713 71223026 - SCREW BN FT 4MM 6MM 26MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223028 SUP HCPCS C1713 71223028 - SCREW BN FT 4MM 6MM 28MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223030 SUP HCPCS C1713 71223030 - SCREW BN FT 4MM 6MM 30MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223032 SUP HCPCS C1713 71223032 - SCREW BN FT 4MM 6MM 32MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223035 SUP HCPCS C1713 71223035 - SCREW BN FT 4MM 6MM 35MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223036 SUP HCPCS C1713 71223036 - SCREW BN FT 4MM 6MM 36MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223040 SUP HCPCS C1713 71223040 - SCREW BN FT 4MM 6MM 40MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223045 SUP HCPCS C1713 71223045 - SCREW BN FT 4MM 6MM 45MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223050 SUP HCPCS C1713 71223050 - SCREW BN FT 4MM 6MM 50MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223055 SUP HCPCS C1713 71223055 - SCREW BN FT 4MM 6MM 55MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223060 SUP HCPCS C1713 71223060 - SCREW BN FT 4MM 6MM 60MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $61.70 $45.66 $0.00 $49.36 $27.77 $27.77 $0.00 $0.00 $0.00 $12.86 $45.79 $45.79 $0.00 $0.00 $12.86 $0.00 $36.50 $36.50 $0.00 $30.85 $48.87 $49.36 $0.00 $0.00 $9.66 $0.00 $0.00 $9.82 $0.00 $0.00 $0.00 $0.00 $0.00 71223065 SUP HCPCS C1713 71223065 - SCREW BN FT 4MM 6MM 65MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71223070 SUP HCPCS C1713 71223070 - SCREW BN FT 4MM 6MM 70MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71223075 SUP HCPCS C1713 71223075 - SCREW BN FT 4MM 6MM 75MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71223080 SUP HCPCS C1713 71223080 - SCREW BN FT 4MM 6MM 80MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71223085 SUP HCPCS C1713 71223085 - SCREW BN FT 4MM 6MM 85MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $81.53 $60.33 $0.00 $65.22 $36.69 $36.69 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $40.76 $64.57 $65.22 $0.00 $0.00 $12.76 $0.00 $0.00 $12.98 $0.00 $0.00 $0.00 $0.00 $0.00 71223090 SUP HCPCS C1713 71223090 - SCREW BN FT 4MM 6MM 90MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $81.53 $60.33 $0.00 $65.22 $36.69 $36.69 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $40.76 $64.57 $65.22 $0.00 $0.00 $12.76 $0.00 $0.00 $12.98 $0.00 $0.00 $0.00 $0.00 $0.00 71223095 SUP HCPCS C1713 71223095 - SCREW BN FT 4MM 6MM 95MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $81.53 $60.33 $0.00 $65.22 $36.69 $36.69 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $40.76 $64.57 $65.22 $0.00 $0.00 $12.76 $0.00 $0.00 $12.98 $0.00 $0.00 $0.00 $0.00 $0.00 71223100 SUP HCPCS C1713 71223100 - SCREW BN FT 4MM 100MM TC100 SS CANC SM FRAG SET BOTH IP/OP $81.53 $60.33 $0.00 $65.22 $36.69 $36.69 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $40.76 $64.57 $65.22 $0.00 $0.00 $12.76 $0.00 $0.00 $12.98 $0.00 $0.00 $0.00 $0.00 $0.00 71223210 SUP HCPCS C1713 71223210 - SCREW BN P/T 4MM 6MM 10MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223212 SUP HCPCS C1713 71223212 - SCREW BN P/T 4MM 6MM 12MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223214 SUP HCPCS C1713 71223214 - SCREW BN P/T 4MM 6MM 14MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223216 SUP HCPCS C1713 71223216 - SCREW BN P/T 4MM 6MM 16MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223218 SUP HCPCS C1713 71223218 - SCREW BN P/T 4MM 6MM 18MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223220 SUP HCPCS C1713 71223220 - SCREW BN P/T 4MM 6MM 20MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223222 SUP HCPCS C1713 71223222 - SCREW BN P/T 4MM 6MM 22MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223224 SUP HCPCS C1713 71223224 - SCREW BN P/T 4MM 6MM 24MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223226 SUP HCPCS C1713 71223226 - SCREW BN P/T 4MM 6MM 26MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223228 SUP HCPCS C1713 71223228 - SCREW BN P/T 4MM 6MM 28MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223230 SUP HCPCS C1713 71223230 - SCREW BN P/T 4MM 6MM 30MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223235 SUP HCPCS C1713 71223235 - SCREW BN P/T 4MM 6MM 35MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223240 SUP HCPCS C1713 71223240 - SCREW BN P/T 4MM 6MM 40MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223245 SUP HCPCS C1713 71223245 - SCREW BN P/T 4MM 6MM 45MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223250 SUP HCPCS C1713 71223250 - SCREW BN P/T 4MM 6MM 50MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223255 SUP HCPCS C1713 71223255 - SCREW BN P/T 4MM 6MM 55MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223260 SUP HCPCS C1713 71223260 - SCREW BN P/T 4MM 6MM 60MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $59.53 $44.05 $0.00 $47.62 $26.79 $26.79 $0.00 $0.00 $0.00 $12.41 $44.18 $44.18 $0.00 $0.00 $12.41 $0.00 $35.21 $35.21 $0.00 $29.76 $47.15 $47.62 $0.00 $0.00 $9.32 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $0.00 71223265 SUP HCPCS C1713 71223265 - SCREW BN P/T 4MM 6MM 65MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71223270 SUP HCPCS C1713 71223270 - SCREW BN P/T 4MM 6MM 70MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71223275 SUP HCPCS C1713 71223275 - SCREW BN P/T 4MM 6MM 75MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71223280 SUP HCPCS C1713 71223280 - SCREW BN P/T 4MM 6MM 80MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71223285 SUP HCPCS C1713 71223285 - SCREW BN P/T 4MM 6MM 85MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71223290 SUP HCPCS C1713 71223290 - SCREW BN P/T 4MM 6MM 90MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71223295 SUP HCPCS C1713 71223295 - SCREW BN P/T 4MM 6MM 95MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71223300 SUP HCPCS C1713 71223300 - SCREW BN 4MM 100MM TC100 P/T SS CANC BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225014 SUP HCPCS C1713 71225014 - SCREW BN 4.5MM 14MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225016 SUP HCPCS C1713 71225016 - SCREW BN 4.5MM 16MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225018 SUP HCPCS C1713 71225018 - SCREW BN 4.5MM 18MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225020 SUP HCPCS C1713 71225020 - SCREW BN 4.5MM 20MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225022 SUP HCPCS C1713 71225022 - SCREW BN 4.5MM 22MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225024 SUP HCPCS C1713 71225024 - SCREW BN 4.5MM 24MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225026 SUP HCPCS C1713 71225026 - SCREW BN 4.5MM 26MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225028 SUP HCPCS C1713 71225028 - SCREW BN 4.5MM 28MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225030 SUP HCPCS C1713 71225030 - SCREW BN 4.5MM 30MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225032 SUP HCPCS C1713 71225032 - SCREW BN 4.5MM 32MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225034 SUP HCPCS C1713 71225034 - SCREW BN 4.5MM 34MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225036 SUP HCPCS C1713 71225036 - SCREW BN 4.5MM 36MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225038 SUP HCPCS C1713 71225038 - SCREW BN 4.5MM 38MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225040 SUP HCPCS C1713 71225040 - SCREW BN 4.5MM 40MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225042 SUP HCPCS C1713 71225042 - SCREW BN 4.5MM 42MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225044 SUP HCPCS C1713 71225044 - SCREW BN 4.5MM 44MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225046 SUP HCPCS C1713 71225046 - SCREW BN 4.5MM 46MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225048 SUP HCPCS C1713 71225048 - SCREW BN 4.5MM 48MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225050 SUP HCPCS C1713 71225050 - SCREW BN 4.5MM 50MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225052 SUP HCPCS C1713 71225052 - SCREW BN 4.5MM 52MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225054 SUP HCPCS C1713 71225054 - SCREW BN 4.5MM 54MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225056 SUP HCPCS C1713 71225056 - SCREW BN 4.5MM 56MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225058 SUP HCPCS C1713 71225058 - SCREW BN 4.5MM 58MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225060 SUP HCPCS C1713 71225060 - SCREW BN 4.5MM 8MM 60MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225062 SUP HCPCS C1713 71225062 - SCREW BN 4.5MM 62MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225064 SUP HCPCS C1713 71225064 - SCREW BN 4.5MM 64MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225066 SUP HCPCS C1713 71225066 - SCREW BN 4.5MM 66MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225068 SUP HCPCS C1713 71225068 - SCREW BN 4.5MM 68MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225070 SUP HCPCS C1713 71225070 - SCREW BN 4.5MM 70MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225072 SUP HCPCS C1713 71225072 - SCREW BN 4.5MM 72MM TC100 CORT BOTH IP/OP $57.60 $42.62 $0.00 $46.08 $25.92 $25.92 $0.00 $0.00 $0.00 $12.01 $42.75 $42.75 $0.00 $0.00 $12.00 $0.00 $34.07 $34.07 $0.00 $28.80 $45.62 $46.08 $0.00 $0.00 $9.01 $0.00 $0.00 $9.17 $0.00 $0.00 $0.00 $0.00 $0.00 71225076 SUP HCPCS C1713 71225076 - SCREW BN 4.5MM 8MM 76MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $99.33 $73.50 $0.00 $79.46 $44.70 $44.70 $0.00 $0.00 $0.00 $20.70 $73.72 $73.72 $0.00 $0.00 $20.70 $0.00 $58.75 $58.75 $0.00 $49.66 $78.67 $79.46 $0.00 $0.00 $15.54 $0.00 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 71225080 SUP HCPCS C1713 71225080 - SCREW BN 4.5MM 8MM 80MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $99.33 $73.50 $0.00 $79.46 $44.70 $44.70 $0.00 $0.00 $0.00 $20.70 $73.72 $73.72 $0.00 $0.00 $20.70 $0.00 $58.75 $58.75 $0.00 $49.66 $78.67 $79.46 $0.00 $0.00 $15.54 $0.00 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 71225085 SUP HCPCS C1713 71225085 - SCREW BN 4.5MM 8MM 85MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $99.33 $73.50 $0.00 $79.46 $44.70 $44.70 $0.00 $0.00 $0.00 $20.70 $73.72 $73.72 $0.00 $0.00 $20.70 $0.00 $58.75 $58.75 $0.00 $49.66 $78.67 $79.46 $0.00 $0.00 $15.54 $0.00 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 71225090 SUP HCPCS C1713 71225090 - SCREW BN 4.5MM 8MM 90MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $99.33 $73.50 $0.00 $79.46 $44.70 $44.70 $0.00 $0.00 $0.00 $20.70 $73.72 $73.72 $0.00 $0.00 $20.70 $0.00 $58.75 $58.75 $0.00 $49.66 $78.67 $79.46 $0.00 $0.00 $15.54 $0.00 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 71225095 SUP HCPCS C1713 71225095 - SCREW BN 4.5MM 8MM 95MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $99.33 $73.50 $0.00 $79.46 $44.70 $44.70 $0.00 $0.00 $0.00 $20.70 $73.72 $73.72 $0.00 $0.00 $20.70 $0.00 $58.75 $58.75 $0.00 $49.66 $78.67 $79.46 $0.00 $0.00 $15.54 $0.00 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 71225100 SUP HCPCS C1713 71225100 - SCREW BN 4.5MM 100MM TC100 SS CORT LG FRAG SET BOTH IP/OP $99.33 $73.50 $0.00 $79.46 $44.70 $44.70 $0.00 $0.00 $0.00 $20.70 $73.72 $73.72 $0.00 $0.00 $20.70 $0.00 $58.75 $58.75 $0.00 $49.66 $78.67 $79.46 $0.00 $0.00 $15.54 $0.00 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 71225105 SUP HCPCS C1713 71225105 - SCREW BN 4.5MM 105MM TC100 SS CORT LG FRAG SET BOTH IP/OP $99.33 $73.50 $0.00 $79.46 $44.70 $44.70 $0.00 $0.00 $0.00 $20.70 $73.72 $73.72 $0.00 $0.00 $20.70 $0.00 $58.75 $58.75 $0.00 $49.66 $78.67 $79.46 $0.00 $0.00 $15.54 $0.00 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 71225110 SUP HCPCS C1713 71225110 - SCREW BN LG 4.5MM 110MM TC100 SS CORT BOTH IP/OP $108.15 $80.03 $0.00 $86.52 $48.67 $48.67 $0.00 $0.00 $0.00 $22.54 $80.27 $80.27 $0.00 $0.00 $22.54 $0.00 $63.97 $63.97 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $16.93 $0.00 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $0.00 71225115 SUP HCPCS C1713 71225115 - SCREW BN 4.5MM 115MM TC100 SS CORT LG FRAG SET BOTH IP/OP $108.15 $80.03 $0.00 $86.52 $48.67 $48.67 $0.00 $0.00 $0.00 $22.54 $80.27 $80.27 $0.00 $0.00 $22.54 $0.00 $63.97 $63.97 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $16.93 $0.00 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $0.00 71225120 SUP HCPCS C1713 71225120 - SCREW BN 4.5MM 120MM TC100 SS CORT LG FRAG SET BOTH IP/OP $108.15 $80.03 $0.00 $86.52 $48.67 $48.67 $0.00 $0.00 $0.00 $22.54 $80.27 $80.27 $0.00 $0.00 $22.54 $0.00 $63.97 $63.97 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $16.93 $0.00 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $0.00 71225125 SUP HCPCS C1713 71225125 - SCREW BN 4.5MM 125MM TC100 SS CORT LG FRAG SET BOTH IP/OP $108.15 $80.03 $0.00 $86.52 $48.67 $48.67 $0.00 $0.00 $0.00 $22.54 $80.27 $80.27 $0.00 $0.00 $22.54 $0.00 $63.97 $63.97 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $16.93 $0.00 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $0.00 71225130 SUP HCPCS C1713 71225130 - SCREW BN 4.5MM 130MM TC100 SS CORT LG FRAG SET BOTH IP/OP $108.15 $80.03 $0.00 $86.52 $48.67 $48.67 $0.00 $0.00 $0.00 $22.54 $80.27 $80.27 $0.00 $0.00 $22.54 $0.00 $63.97 $63.97 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $16.93 $0.00 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $0.00 71225135 SUP HCPCS C1713 71225135 - SCREW BN 4.5MM 135MM TC100 SS CORT LG FRAG SET BOTH IP/OP $108.15 $80.03 $0.00 $86.52 $48.67 $48.67 $0.00 $0.00 $0.00 $22.54 $80.27 $80.27 $0.00 $0.00 $22.54 $0.00 $63.97 $63.97 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $16.93 $0.00 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $0.00 71225140 SUP HCPCS C1713 71225140 - SCREW BN 4.5MM 140MM TC100 SS CORT LG FRAG SET BOTH IP/OP $108.15 $80.03 $0.00 $86.52 $48.67 $48.67 $0.00 $0.00 $0.00 $22.54 $80.27 $80.27 $0.00 $0.00 $22.54 $0.00 $63.97 $63.97 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $16.93 $0.00 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $0.00 71225145 SUP HCPCS C1713 71225145 - SCREW BN 4.5MM 145MM TC100 SS CORT LG FRAG SET BOTH IP/OP $108.15 $80.03 $0.00 $86.52 $48.67 $48.67 $0.00 $0.00 $0.00 $22.54 $80.27 $80.27 $0.00 $0.00 $22.54 $0.00 $63.97 $63.97 $0.00 $54.08 $85.65 $86.52 $0.00 $0.00 $16.93 $0.00 $0.00 $17.22 $0.00 $0.00 $0.00 $0.00 $0.00 71225225 SUP HCPCS C1713 71225225 - SCREW BN 4.5MM 25MM STRL 12MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225230 SUP HCPCS C1713 71225230 - SCREW BN 4.5MM 30MM STRL 15MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225235 SUP HCPCS C1713 71225235 - SCREW BN 4.5MM 35MM STRL 18MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225240 SUP HCPCS C1713 71225240 - SCREW BN 4.5MM 40MM STRL 20MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225245 SUP HCPCS C1713 71225245 - SCREW BN 4.5MM 45MM STRL 22MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225250 SUP HCPCS C1713 71225250 - SCREW BN 4.5MM 50MM STRL 24MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225255 SUP HCPCS C1713 71225255 - SCREW BN 4.5MM 55MM STRL 26MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225260 SUP HCPCS C1713 71225260 - SCREW BN 4.5MM 60MM STRL 28MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225265 SUP HCPCS C1713 71225265 - SCREW BN 4.5MM 65MM STRL 30MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225270 SUP HCPCS C1713 71225270 - SCREW BN 4.5MM 70MM STRL 32MM TC100 SS MLR LG FRAG SET BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 71225320 SUP HCPCS C1713 71225320 - PLATE BN 90D 10MM DSPL 40MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225321 SUP HCPCS C1713 71225321 - PLATE BN 90D 10MM DSPL 50MM TC100 4 HL OSTM SS ADLT PROX FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225322 SUP HCPCS C1713 71225322 - PLATE BN 90D 10MM DSPL 55MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225323 SUP HCPCS C1713 71225323 - PLATE BN 90D 10MM DSPL 60MM TC100 4 HL OSTM SS ADLT PROX FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225324 SUP HCPCS C1713 71225324 - PLATE BN 90D 10MM DSPL 65MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225325 SUP HCPCS C1713 71225325 - PLATE BN 90D 10MM DSPL 70MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225326 SUP HCPCS C1713 71225326 - PLATE BN 90D 10MM DSPL 80MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225327 SUP HCPCS C1713 71225327 - PLATE BN 90D 15MM DSPL 40MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225328 SUP HCPCS C1713 71225328 - PLATE BN 90D 15MM DSPL 50MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225329 SUP HCPCS C1713 71225329 - PLATE BN 90D 15MM DSPL 55MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225330 SUP HCPCS C1713 71225330 - PLATE BN 90D 15MM DSPL 60MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225331 SUP HCPCS C1713 71225331 - PLATE BN 90D 15MM DSPL 65MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225332 SUP HCPCS C1713 71225332 - PLATE BN 90D 15MM DSPL 70MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225333 SUP HCPCS C1713 71225333 - PLATE BN 90D 15MM DSPL 75MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225334 SUP HCPCS C1713 71225334 - PLATE BN 90D 15MM DSPL 80MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225335 SUP HCPCS C1713 71225335 - PLATE BN 90D 20MM DSPL 50MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225336 SUP HCPCS C1713 71225336 - PLATE BN 90D 20MM DSPL 60MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225337 SUP HCPCS C1713 71225337 - PLATE BN 90D 20MM DSPL 70MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225338 SUP HCPCS C1713 71225338 - PLATE BN 90D 20MM DSPL 75MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225339 SUP HCPCS C1713 71225339 - PLATE BN 100D 10MM DSPL 50MM TC100 4 HL OSTM SS ADLT FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225340 SUP HCPCS C1713 71225340 - PLATE BN 100D 10MM DSPL 60MM TC100 4 HL OSTM SS ADLT FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225341 SUP HCPCS C1713 71225341 - PLATE BN 110D 65MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225342 SUP HCPCS C1713 71225342 - PLATE BN 110D 75MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225343 SUP HCPCS C1713 71225343 - PLATE BN 110D 85MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225344 SUP HCPCS C1713 71225344 - PLATE BN 120D 65MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225345 SUP HCPCS C1713 71225345 - PLATE BN 120D 75MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225346 SUP HCPCS C1713 71225346 - PLATE BN 120D 85MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225347 SUP HCPCS C1713 71225347 - PLATE BN 130D 65MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225348 SUP HCPCS C1713 71225348 - PLATE BN 130D 70MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225349 SUP HCPCS C1713 71225349 - PLATE BN 130D 75MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225350 SUP HCPCS C1713 71225350 - PLATE BN 130D 80MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225351 SUP HCPCS C1713 71225351 - PLATE BN 130D 85MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225352 SUP HCPCS C1713 71225352 - PLATE BN 130D 90MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225353 SUP HCPCS C1713 71225353 - PLATE BN 130D 95MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225354 SUP HCPCS C1713 71225354 - PLATE BN 130D 100MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225355 SUP HCPCS C1713 71225355 - PLATE BN 130D 105MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225356 SUP HCPCS C1713 71225356 - PLATE BN 130D 110MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5MM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225400 SUP HCPCS C1713 71225400 - PLATE BN 95D 92MM 50MM TC100 5 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225401 SUP HCPCS C1713 71225401 - PLATE BN 95D 92MM 60MM TC100 5 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225402 SUP HCPCS C1713 71225402 - PLATE BN 95D 92MM 70MM TC100 5 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225403 SUP HCPCS C1713 71225403 - PLATE BN 95D 92MM 80MM TC100 5 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225404 SUP HCPCS C1713 71225404 - PLATE BN 95D 124MM 50MM TC100 7 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225405 SUP HCPCS C1713 71225405 - PLATE BN 95D 124MM 60MM TC100 7 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225406 SUP HCPCS C1713 71225406 - PLATE BN 95D 124MM 70MM TC100 7 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225407 SUP HCPCS C1713 71225407 - PLATE BN 95D 124MM 80MM TC100 7 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225408 SUP HCPCS C1713 71225408 - PLATE BN 95D 156MM 50MM TC100 9 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225409 SUP HCPCS C1713 71225409 - PLATE BN 95D 156MM 60MM TC100 9 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225410 SUP HCPCS C1713 71225410 - PLATE BN 95D 156MM 70MM TC100 9 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225411 SUP HCPCS C1713 71225411 - PLATE BN 95D 156MM 80MM TC100 9 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225412 SUP HCPCS C1713 71225412 - PLATE BN 95D 204MM 50MM TC100 12 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225413 SUP HCPCS C1713 71225413 - PLATE BN 95D 204MM 60MM TC100 12 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225414 SUP HCPCS C1713 71225414 - PLATE BN 95D 204MM 70MM TC100 12 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225415 SUP HCPCS C1713 71225415 - PLATE BN 95D 204MM 80MM TC100 12 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225416 SUP HCPCS C1713 71225416 - PLATE BN 95D 235MM 50MM TC100 14 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225417 SUP HCPCS C1713 71225417 - PLATE BN 95D 235MM 60MM TC100 14 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225418 SUP HCPCS C1713 71225418 - PLATE BN 95D 235MM 70MM TC100 14 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225419 SUP HCPCS C1713 71225419 - PLATE BN 95D 235MM 80MM TC100 14 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225420 SUP HCPCS C1713 71225420 - PLATE BN 95D 267MM 60MM TC100 16 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225421 SUP HCPCS C1713 71225421 - PLATE BN 95D 267MM 70MM TC100 16 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225422 SUP HCPCS C1713 71225422 - PLATE BN 95D 267MM 80MM TC100 16 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225423 SUP HCPCS C1713 71225423 - PLATE BN 95D 299MM 60MM TC100 18 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225424 SUP HCPCS C1713 71225424 - PLATE BN 95D 299MM 70MM TC100 18 HL OSTM SS ADLT CNDYL FEM BOTH IP/OP "$2,955.75 " "$2,187.26" $0.00 "$2,364.60" "$1,330.09" "$1,330.09" $0.00 $0.00 $0.00 $616.05 "$2,193.76" "$2,193.76" $0.00 $0.00 $615.98 $0.00 "$1,457.18" "$1,457.18" $0.00 "$1,477.88" "$2,340.95" "$2,364.60" $0.00 $0.00 $462.57 $0.00 $0.00 $470.56 $0.00 $0.00 $0.00 $0.00 $0.00 71225430 SUP HCPCS C1713 71225430 - PLATE BN 95D SM STAT 92MM 40MM TC100 5 HL OSTM SS CNDYL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71225431 SUP HCPCS C1713 71225431 - PLATE BN 95D SM STAT 92MM 50MM TC100 5 HL OSTM SS CNDYL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71225432 SUP HCPCS C1713 71225432 - PLATE BN 95D SM STAT 92MM 60MM TC100 5 HL OSTM SS CNDYL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71225433 SUP HCPCS C1713 71225433 - PLATE BN 95D SM STAT 92MM 70MM TC100 5 HL OSTM SS CNDYL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71225434 SUP HCPCS C1713 71225434 - PLATE BN 95D SM STAT 124MM 40MM TC100 7 HL OSTM SS CNDYL BOTH IP/OP "$1,580.25 " "$1,169.39" $0.00 "$1,264.20" $711.11 $711.11 $0.00 $0.00 $0.00 $329.36 "$1,172.86" "$1,172.86" $0.00 $0.00 $329.32 $0.00 $934.72 $934.72 $0.00 $790.13 "$1,251.56" "$1,264.20" $0.00 $0.00 $247.31 $0.00 $0.00 $251.58 $0.00 $0.00 $0.00 $0.00 $0.00 71225435 SUP HCPCS C1713 71225435 - PLATE BN 95D SM STAT 124MM 50MM TC100 7 HL OSTM SS CNDYL BOTH IP/OP "$1,580.25 " "$1,169.39" $0.00 "$1,264.20" $711.11 $711.11 $0.00 $0.00 $0.00 $329.36 "$1,172.86" "$1,172.86" $0.00 $0.00 $329.32 $0.00 $934.72 $934.72 $0.00 $790.13 "$1,251.56" "$1,264.20" $0.00 $0.00 $247.31 $0.00 $0.00 $251.58 $0.00 $0.00 $0.00 $0.00 $0.00 71225436 SUP HCPCS C1713 71225436 - PLATE BN 95D SM STAT 124MM 60MM TC100 7 HL OSTM SS CNDYL BOTH IP/OP "$1,580.25 " "$1,169.39" $0.00 "$1,264.20" $711.11 $711.11 $0.00 $0.00 $0.00 $329.36 "$1,172.86" "$1,172.86" $0.00 $0.00 $329.32 $0.00 $934.72 $934.72 $0.00 $790.13 "$1,251.56" "$1,264.20" $0.00 $0.00 $247.31 $0.00 $0.00 $251.58 $0.00 $0.00 $0.00 $0.00 $0.00 71225437 SUP HCPCS C1713 71225437 - PLATE BN 95D SM STAT 124MM 70MM TC100 7 HL OSTM SS CNDYL BOTH IP/OP "$1,580.25 " "$1,169.39" $0.00 "$1,264.20" $711.11 $711.11 $0.00 $0.00 $0.00 $329.36 "$1,172.86" "$1,172.86" $0.00 $0.00 $329.32 $0.00 $934.72 $934.72 $0.00 $790.13 "$1,251.56" "$1,264.20" $0.00 $0.00 $247.31 $0.00 $0.00 $251.58 $0.00 $0.00 $0.00 $0.00 $0.00 71225438 SUP HCPCS C1713 71225438 - PLATE BN 95D SM STAT 156MM 40MM TC100 9 HL OSTM SS CNDYL BOTH IP/OP "$1,711.50 " "$1,266.51" $0.00 "$1,369.20" $770.18 $770.18 $0.00 $0.00 $0.00 $356.72 "$1,270.28" "$1,270.28" $0.00 $0.00 $356.68 $0.00 "$1,012.35" "$1,012.35" $0.00 $855.75 "$1,355.51" "$1,369.20" $0.00 $0.00 $267.85 $0.00 $0.00 $272.47 $0.00 $0.00 $0.00 $0.00 $0.00 71225439 SUP HCPCS C1713 71225439 - PLATE BN 95D SM STAT 156MM 50MM TC100 9 HL OSTM SS CNDYL BOTH IP/OP "$1,711.50 " "$1,266.51" $0.00 "$1,369.20" $770.18 $770.18 $0.00 $0.00 $0.00 $356.72 "$1,270.28" "$1,270.28" $0.00 $0.00 $356.68 $0.00 "$1,012.35" "$1,012.35" $0.00 $855.75 "$1,355.51" "$1,369.20" $0.00 $0.00 $267.85 $0.00 $0.00 $272.47 $0.00 $0.00 $0.00 $0.00 $0.00 71225440 SUP HCPCS C1713 71225440 - PLATE BN 95D SM STAT 156MM 60MM TC100 9 HL OSTM SS CNDYL BOTH IP/OP "$1,711.50 " "$1,266.51" $0.00 "$1,369.20" $770.18 $770.18 $0.00 $0.00 $0.00 $356.72 "$1,270.28" "$1,270.28" $0.00 $0.00 $356.68 $0.00 "$1,012.35" "$1,012.35" $0.00 $855.75 "$1,355.51" "$1,369.20" $0.00 $0.00 $267.85 $0.00 $0.00 $272.47 $0.00 $0.00 $0.00 $0.00 $0.00 71225441 SUP HCPCS C1713 71225441 - PLATE BN 95D SM STAT 156MM 70MM TC100 9 HL OSTM SS CNDYL BOTH IP/OP "$1,711.50 " "$1,266.51" $0.00 "$1,369.20" $770.18 $770.18 $0.00 $0.00 $0.00 $356.72 "$1,270.28" "$1,270.28" $0.00 $0.00 $356.68 $0.00 "$1,012.35" "$1,012.35" $0.00 $855.75 "$1,355.51" "$1,369.20" $0.00 $0.00 $267.85 $0.00 $0.00 $272.47 $0.00 $0.00 $0.00 $0.00 $0.00 71225500 SUP HCPCS C1713 71225500 - PLATE BN 130D 50MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5 BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225501 SUP HCPCS C1713 71225501 - PLATE BN 130D 60MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5 BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225502 SUP HCPCS C1713 71225502 - PLATE BN 130D 70MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5 BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225503 SUP HCPCS C1713 71225503 - PLATE BN 130D 75MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5 BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225504 SUP HCPCS C1713 71225504 - PLATE BN 130D 80MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5 BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225505 SUP HCPCS C1713 71225505 - PLATE BN 130D 85MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5 BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225506 SUP HCPCS C1713 71225506 - PLATE BN 130D 90MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5 BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225507 SUP HCPCS C1713 71225507 - PLATE BN 130D 95MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX 4.5 BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225508 SUP HCPCS C1713 71225508 - PLATE BN 130D 100MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225509 SUP HCPCS C1713 71225509 - PLATE BN 130D 105MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225510 SUP HCPCS C1713 71225510 - PLATE BN 130D 110MM 60MM TC100 4 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,412.25 " "$1,045.07" $0.00 "$1,129.80" $635.51 $635.51 $0.00 $0.00 $0.00 $294.35 "$1,048.17" "$1,048.17" $0.00 $0.00 $294.31 $0.00 $835.35 $835.35 $0.00 $706.13 "$1,118.50" "$1,129.80" $0.00 $0.00 $221.02 $0.00 $0.00 $224.83 $0.00 $0.00 $0.00 $0.00 $0.00 71225511 SUP HCPCS C1713 71225511 - PLATE BN 130D 50MM 104MM TC100 6 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 71225512 SUP HCPCS C1713 71225512 - PLATE BN 130D 60MM 104MM TC100 6 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 71225513 SUP HCPCS C1713 71225513 - PLATE BN 130D 70MM 104MM TC100 6 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 71225514 SUP HCPCS C1713 71225514 - PLATE BN 130D 80MM 104MM TC100 6 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 71225515 SUP HCPCS C1713 71225515 - PLATE BN 130D 90MM 104MM TC100 6 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 71225516 SUP HCPCS C1713 71225516 - PLATE BN 130D 70MM 152MM TC100 9 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225517 SUP HCPCS C1713 71225517 - PLATE BN 130D 80MM 152MM TC100 9 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225518 SUP HCPCS C1713 71225518 - PLATE BN 130D 90MM 152MM TC100 9 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 71225519 SUP HCPCS C1713 71225519 - PLATE BN 130D 70MM 200MM TC100 12 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,911.00 " "$1,414.14" $0.00 "$1,528.80" $859.95 $859.95 $0.00 $0.00 $0.00 $398.30 "$1,418.34" "$1,418.34" $0.00 $0.00 $398.25 $0.00 "$1,130.36" "$1,130.36" $0.00 $955.50 "$1,513.51" "$1,528.80" $0.00 $0.00 $299.07 $0.00 $0.00 $304.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225520 SUP HCPCS C1713 71225520 - PLATE BN 130D 80MM 200MM TC100 12 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,911.00 " "$1,414.14" $0.00 "$1,528.80" $859.95 $859.95 $0.00 $0.00 $0.00 $398.30 "$1,418.34" "$1,418.34" $0.00 $0.00 $398.25 $0.00 "$1,130.36" "$1,130.36" $0.00 $955.50 "$1,513.51" "$1,528.80" $0.00 $0.00 $299.07 $0.00 $0.00 $304.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225521 SUP HCPCS C1713 71225521 - PLATE BN 130D 90MM 200MM TC100 12 HL OSTM SS ADLT FEM PROX BOTH IP/OP "$1,911.00 " "$1,414.14" $0.00 "$1,528.80" $859.95 $859.95 $0.00 $0.00 $0.00 $398.30 "$1,418.34" "$1,418.34" $0.00 $0.00 $398.25 $0.00 "$1,130.36" "$1,130.36" $0.00 $955.50 "$1,513.51" "$1,528.80" $0.00 $0.00 $299.07 $0.00 $0.00 $304.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225530 SUP HCPCS C1713 71225530 - PLATE BN 130D SM STAT 50MM 60MM TC100 4 HL OSTM SS FEM PROX BOTH IP/OP "$1,580.25 " "$1,169.39" $0.00 "$1,264.20" $711.11 $711.11 $0.00 $0.00 $0.00 $329.36 "$1,172.86" "$1,172.86" $0.00 $0.00 $329.32 $0.00 $934.72 $934.72 $0.00 $790.13 "$1,251.56" "$1,264.20" $0.00 $0.00 $247.31 $0.00 $0.00 $251.58 $0.00 $0.00 $0.00 $0.00 $0.00 71225531 SUP HCPCS C1713 71225531 - PLATE BN 130D SM STAT 60MM 60MM TC100 4 HL OSTM SS FEM PROX BOTH IP/OP "$1,580.25 " "$1,169.39" $0.00 "$1,264.20" $711.11 $711.11 $0.00 $0.00 $0.00 $329.36 "$1,172.86" "$1,172.86" $0.00 $0.00 $329.32 $0.00 $934.72 $934.72 $0.00 $790.13 "$1,251.56" "$1,264.20" $0.00 $0.00 $247.31 $0.00 $0.00 $251.58 $0.00 $0.00 $0.00 $0.00 $0.00 71225532 SUP HCPCS C1713 71225532 - PLATE BN 130D SM STAT 70MM 60MM TC100 4 HL OSTM SS FEM PROX BOTH IP/OP "$1,580.25 " "$1,169.39" $0.00 "$1,264.20" $711.11 $711.11 $0.00 $0.00 $0.00 $329.36 "$1,172.86" "$1,172.86" $0.00 $0.00 $329.32 $0.00 $934.72 $934.72 $0.00 $790.13 "$1,251.56" "$1,264.20" $0.00 $0.00 $247.31 $0.00 $0.00 $251.58 $0.00 $0.00 $0.00 $0.00 $0.00 71225533 SUP HCPCS C1713 71225533 - PLATE BN 130D SM STAT 80MM 60MM TC100 4 HL OSTM SS FEM PROX BOTH IP/OP "$1,580.25 " "$1,169.39" $0.00 "$1,264.20" $711.11 $711.11 $0.00 $0.00 $0.00 $329.36 "$1,172.86" "$1,172.86" $0.00 $0.00 $329.32 $0.00 $934.72 $934.72 $0.00 $790.13 "$1,251.56" "$1,264.20" $0.00 $0.00 $247.31 $0.00 $0.00 $251.58 $0.00 $0.00 $0.00 $0.00 $0.00 71225534 SUP HCPCS C1713 71225534 - PLATE BN 130D SM STAT 50MM 104MM TC100 6 HL OSTM SS FEM PROX BOTH IP/OP "$1,680.00 " "$1,243.20" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $350.15 "$1,246.90" "$1,246.90" $0.00 $0.00 $350.11 $0.00 $993.72 $993.72 $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $262.92 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 71225535 SUP HCPCS C1713 71225535 - PLATE BN 130D SM STAT 104MM 70MM TC100 6 HL ANG SS FEM PROX BOTH IP/OP "$1,680.00 " "$1,243.20" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $350.15 "$1,246.90" "$1,246.90" $0.00 $0.00 $350.11 $0.00 $993.72 $993.72 $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $262.92 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 71225536 SUP HCPCS C1713 71225536 - PLATE BN 130D SM STAT 104MM 60MM TC100 6 HL ANG SS FEM PROX BOTH IP/OP "$1,680.00 " "$1,243.20" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $350.15 "$1,246.90" "$1,246.90" $0.00 $0.00 $350.11 $0.00 $993.72 $993.72 $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $262.92 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 71225537 SUP HCPCS C1713 71225537 - PLATE BN 130D SM STAT 104MM 80MM TC100 6 HL ANG SS FEM PROX BOTH IP/OP "$1,680.00 " "$1,243.20" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $350.15 "$1,246.90" "$1,246.90" $0.00 $0.00 $350.11 $0.00 $993.72 $993.72 $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $262.92 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 71225539 SUP HCPCS C1713 71225539 - PLATE BN 130D SM STAT 152MM 60MM TC100 9 HL ANG SS FEM PROX BOTH IP/OP "$1,853.25 " "$1,371.41" $0.00 "$1,482.60" $833.96 $833.96 $0.00 $0.00 $0.00 $386.26 "$1,375.48" "$1,375.48" $0.00 $0.00 $386.22 $0.00 "$1,096.20" "$1,096.20" $0.00 $926.63 "$1,467.77" "$1,482.60" $0.00 $0.00 $290.03 $0.00 $0.00 $295.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225540 SUP HCPCS C1713 71225540 - PLATE BN 130D SM STAT 152MM 72MM TC100 9 HL ANG SS FEM PROX BOTH IP/OP "$1,853.25 " "$1,371.41" $0.00 "$1,482.60" $833.96 $833.96 $0.00 $0.00 $0.00 $386.26 "$1,375.48" "$1,375.48" $0.00 $0.00 $386.22 $0.00 "$1,096.20" "$1,096.20" $0.00 $926.63 "$1,467.77" "$1,482.60" $0.00 $0.00 $290.03 $0.00 $0.00 $295.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225541 SUP HCPCS C1713 71225541 - PLATE BN 130D SM STAT 152MM 80MM TC100 9 HL ANG SS FEM PROX BOTH IP/OP "$1,853.25 " "$1,371.41" $0.00 "$1,482.60" $833.96 $833.96 $0.00 $0.00 $0.00 $386.26 "$1,375.48" "$1,375.48" $0.00 $0.00 $386.22 $0.00 "$1,096.20" "$1,096.20" $0.00 $926.63 "$1,467.77" "$1,482.60" $0.00 $0.00 $290.03 $0.00 $0.00 $295.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225600 SUP HCPCS C1713 71225600 - PLATE BN 90D 7MM 25MM TC100 3 HL ANG SS PED PROX FEM 3.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225601 SUP HCPCS C1713 71225601 - PLATE BN 90D 12MM 25MM TC100 3 HL ANG SS PED PROX FEM 3.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225602 SUP HCPCS C1713 71225602 - PLATE BN 90D 7MM 32MM TC100 3 HL ANG SS PED PROX FEM 3.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225603 SUP HCPCS C1713 71225603 - PLATE BN 90D 12MM 32MM TC100 3 HL ANG SS PED PROX FEM 3.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225610 SUP HCPCS C1713 71225610 - PLATE BN 115D 5MM 30MM TC100 BFUR ANG SS PED FEM PROX 3.5MM BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 71225611 SUP HCPCS C1713 71225611 - PLATE BN 115D 5MM 35MM TC100 BFUR ANG SS PED FEM PROX 3.5MM BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 71225620 SUP HCPCS C1713 71225620 - PLATE BN 80D 8MM 35MM TC100 3 HL ANG SS PED PROX FEM 4.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225621 SUP HCPCS C1713 71225621 - PLATE BN 80D 8MM 45MM TC100 3 HL ANG SS PED PROX FEM 4.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225622 SUP HCPCS C1713 71225622 - PLATE BN 90D 8MM 35MM TC100 3 HL ANG SS PED PROX FEM 4.5MM BOTH IP/OP $951.30 $703.96 $0.00 $761.04 $428.09 $428.09 $0.00 $0.00 $0.00 $198.27 $706.05 $706.05 $0.00 $0.00 $198.25 $0.00 $562.69 $562.69 $0.00 $475.65 $753.43 $761.04 $0.00 $0.00 $148.88 $0.00 $0.00 $151.45 $0.00 $0.00 $0.00 $0.00 $0.00 71225623 SUP HCPCS C1713 71225623 - PLATE BN 90D 8MM 45MM TC100 3 HL ANG SS PED PROX FEM 4.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225624 SUP HCPCS C1713 71225624 - PLATE BN 100D 8MM 35MM TC100 3 HL ANG SS PED PROX FEM 4.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225625 SUP HCPCS C1713 71225625 - PLATE BN 100D 8MM 45MM TC100 3 HL ANG SS PED PROX FEM 4.5MM BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 71225640 SUP HCPCS C1713 71225640 - PLATE BN 90D 10MM 40MM TC100 3 HL ANG SS PED PROX FEM 4.5MM BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 71225641 SUP HCPCS C1713 71225641 - PLATE BN 90D 15MM 40MM TC100 3 HL ANG SS PED PROX FEM 4.5MM BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 71225642 SUP HCPCS C1713 71225642 - PLATE BN 90D 10MM 50MM TC100 3 HL ANG SS PED FEM PROX 4.5MM BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 71225643 SUP HCPCS C1713 71225643 - PLATE BN 90D 15MM 50MM TC100 3 HL ANG SS PED FEM PROX 4.5MM BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 71225644 SUP HCPCS C1713 71225644 - PLATE BN 90D 15MM 60MM TC100 3 HL ANG SS PED FEM PROX 4.5MM BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 71225716 SUP HCPCS C1713 71225716 - SCREW BN 3.5MM 16MM STRL 6MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225718 SUP HCPCS C1713 71225718 - SCREW BN 3.5MM 18MM STRL 6MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225720 SUP HCPCS C1713 71225720 - SCREW BN 3.5MM 20MM STRL 6MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225722 SUP HCPCS C1713 71225722 - SCREW BN 3.5MM 22MM STRL 6MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225724 SUP HCPCS C1713 71225724 - SCREW BN 3.5MM 24MM STRL 10MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225726 SUP HCPCS C1713 71225726 - SCREW BN 3.5MM 26MM STRL 10MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225728 SUP HCPCS C1713 71225728 - SCREW BN 3.5MM 28MM STRL 10MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225730 SUP HCPCS C1713 71225730 - SCREW BN 3.5MM 30MM STRL 10MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225732 SUP HCPCS C1713 71225732 - SCREW BN 3.5MM 32MM STRL 12MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225734 SUP HCPCS C1713 71225734 - SCREW BN 3.5MM 34MM STRL 12MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225736 SUP HCPCS C1713 71225736 - SCREW BN 3.5MM 36MM STRL 12MM TC100 ST SS ORTH BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225738 SUP HCPCS C1713 71225738 - SCREW BN 3.5MM 38MM STRL 12MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225740 SUP HCPCS C1713 71225740 - SCREW BN 3.5MM 40MM STRL 12MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225745 SUP HCPCS C1713 71225745 - SCREW BN 3.5MM 45MM STRL 15MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225750 SUP HCPCS C1713 71225750 - SCREW BN 3.5MM 50MM STRL 15MM TC100 ST SHFT SS ORTH SM FRAG BOTH IP/OP $65.53 $48.49 $0.00 $52.42 $29.49 $29.49 $0.00 $0.00 $0.00 $13.66 $48.63 $48.63 $0.00 $0.00 $13.66 $0.00 $38.76 $38.76 $0.00 $32.76 $51.90 $52.42 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 71225822 SUP HCPCS C1713 71225822 - SCREW BN 4.5MM 22MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225824 SUP HCPCS C1713 71225824 - SCREW BN 4.5MM 24MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225826 SUP HCPCS C1713 71225826 - SCREW BN 4.5MM 26MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225828 SUP HCPCS C1713 71225828 - SCREW BN 4.5MM 28MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225830 SUP HCPCS C1713 71225830 - SCREW BN 4.5MM 30MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225832 SUP HCPCS C1713 71225832 - SCREW BN 4.5MM 32MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225834 SUP HCPCS C1713 71225834 - SCREW BN 4.5MM 34MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225836 SUP HCPCS C1713 71225836 - SCREW BN 4.5MM 36MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225838 SUP HCPCS C1713 71225838 - SCREW BN 4.5MM 38MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225840 SUP HCPCS C1713 71225840 - SCREW BN 4.5MM 40MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $67.53 $49.97 $0.00 $54.02 $30.39 $30.39 $0.00 $0.00 $0.00 $14.07 $50.12 $50.12 $0.00 $0.00 $14.07 $0.00 $39.94 $39.94 $0.00 $33.76 $53.48 $54.02 $0.00 $0.00 $10.57 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 71225842 SUP HCPCS C1713 71225842 - SCREW BN 4.5MM 42MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225844 SUP HCPCS C1713 71225844 - SCREW BN 4.5MM 44MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225846 SUP HCPCS C1713 71225846 - SCREW BN 4.5MM 46MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225848 SUP HCPCS C1713 71225848 - SCREW BN 4.5MM 48MM STRL 12MM TC100 ST SS ORTH BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225850 SUP HCPCS C1713 71225850 - SCREW BN 4.5MM 50MM STRL 12MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225852 SUP HCPCS C1713 71225852 - SCREW BN 4.5MM 52MM STRL 15MM TC100 ST SS ORTH BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225854 SUP HCPCS C1713 71225854 - SCREW BN 4.5MM 54MM STRL 15MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225856 SUP HCPCS C1713 71225856 - SCREW BN 4.5MM 56MM STRL 15MM TC100 ST SS ORTH BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225858 SUP HCPCS C1713 71225858 - SCREW BN 4.5MM 58MM STRL 15MM TC100 ST SS ORTH BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225860 SUP HCPCS C1713 71225860 - SCREW BN 4.5MM 60MM STRL 15MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225864 SUP HCPCS C1713 71225864 - SCREW BN 4.5MM 64MM STRL 18MM TC100 ST SS ORTH BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225868 SUP HCPCS C1713 71225868 - SCREW BN 4.5MM 68MM STRL 18MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225872 SUP HCPCS C1713 71225872 - SCREW BN 4.5MM 72MM STRL 18MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 71225876 SUP HCPCS C1713 71225876 - SCREW BN 4.5MM 76MM STRL 18MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71225880 SUP HCPCS C1713 71225880 - SCREW BN 4.5MM 80MM STRL 18MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71225885 SUP HCPCS C1713 71225885 - SCREW BN 4.5MM 85MM STRL 22MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71225890 SUP HCPCS C1713 71225890 - SCREW BN 4.5MM 90MM STRL 22MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71225895 SUP HCPCS C1713 71225895 - SCREW BN 4.5MM 95MM STRL 26MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71225900 SUP HCPCS C1713 71225900 - SCREW BN 4.5MM 100MM STRL 26MM TC100 ST SHFT SS ORTH LG FRAG BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 71226030 SUP HCPCS C1713 71226030 - SCREW BN P/T 6.5MM 8MM 30MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226035 SUP HCPCS C1713 71226035 - SCREW BN P/T 6.5MM 8MM 35MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226040 SUP HCPCS C1713 71226040 - SCREW BN P/T 6.5MM 8MM 40MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226045 SUP HCPCS C1713 71226045 - SCREW BN P/T 6.5MM 8MM 45MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226050 SUP HCPCS C1713 71226050 - SCREW BN P/T 6.5MM 8MM 50MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226055 SUP HCPCS C1713 71226055 - SCREW BN P/T 6.5MM 8MM 55MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226060 SUP HCPCS C1713 71226060 - SCREW BN P/T 6.5MM 8MM 60MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226065 SUP HCPCS C1713 71226065 - SCREW BN P/T 6.5MM 8MM 65MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226070 SUP HCPCS C1713 71226070 - SCREW BN P/T 6.5MM 8MM 70MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226075 SUP HCPCS C1713 71226075 - SCREW BN P/T 6.5MM 8MM 75MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226080 SUP HCPCS C1713 71226080 - SCREW BN P/T 6.5MM 8MM 80MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71226085 SUP HCPCS C1713 71226085 - SCREW BN P/T 6.5MM 8MM 85MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71226090 SUP HCPCS C1713 71226090 - SCREW BN P/T 6.5MM 8MM 90MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71226095 SUP HCPCS C1713 71226095 - SCREW BN P/T 6.5MM 8MM 95MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71226100 SUP HCPCS C1713 71226100 - SCREW BN 6.5MM 100MM 16MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71226105 SUP HCPCS C1713 71226105 - SCREW BN 6.5MM 105MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71226110 SUP HCPCS C1713 71226110 - SCREW BN 6.5MM 110MM 16MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71226115 SUP HCPCS C1713 71226115 - SCREW BN 6.5MM 115MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71226120 SUP HCPCS C1713 71226120 - SCREW BN 6.5MM 120MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71226125 SUP HCPCS C1713 71226125 - SCREW BN 6.5MM 125MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71226130 SUP HCPCS C1713 71226130 - SCREW BN 6.5MM 130MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71226135 SUP HCPCS C1713 71226135 - SCREW BN 6.5MM 135MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71226140 SUP HCPCS C1713 71226140 - SCREW BN 6.5MM 140MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71226145 SUP HCPCS C1713 71226145 - SCREW BN 6.5MM 145MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71226150 SUP HCPCS C1713 71226150 - SCREW BN 6.5MM 150MM 16MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71228045 SUP HCPCS C1713 71228045 - SCREW BN 6.5MM 45MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71228050 SUP HCPCS C1713 71228050 - SCREW BN 6.5MM 50MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71228055 SUP HCPCS C1713 71228055 - SCREW BN 6.5MM 55MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71228060 SUP HCPCS C1713 71228060 - SCREW BN 6.5MM 60MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71228065 SUP HCPCS C1713 71228065 - SCREW BN 6.5MM 65MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71228070 SUP HCPCS C1713 71228070 - SCREW BN 6.5MM 70MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71228075 SUP HCPCS C1713 71228075 - SCREW BN 6.5MM 75MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71228080 SUP HCPCS C1713 71228080 - SCREW BN 6.5MM 80MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71228085 SUP HCPCS C1713 71228085 - SCREW BN 6.5MM 85MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $143.85 $106.45 $0.00 $115.08 $64.73 $64.73 $0.00 $0.00 $0.00 $29.98 $106.77 $106.77 $0.00 $0.00 $29.98 $0.00 $85.09 $85.09 $0.00 $71.93 $113.93 $115.08 $0.00 $0.00 $22.51 $0.00 $0.00 $22.90 $0.00 $0.00 $0.00 $0.00 $0.00 71228090 SUP HCPCS C1713 71228090 - SCREW BN 6.5MM 90MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71228095 SUP HCPCS C1713 71228095 - SCREW BN 6.5MM 95MM 32MM TC100 THRD SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71228100 SUP HCPCS C1713 71228100 - SCREW BN 6.5MM 100MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71228105 SUP HCPCS C1713 71228105 - SCREW BN 6.5MM 105MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71228110 SUP HCPCS C1713 71228110 - SCREW BN 6.5MM 110MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71228115 SUP HCPCS C1713 71228115 - SCREW BN 6.5MM 115MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71228120 SUP HCPCS C1713 71228120 - SCREW BN 6.5MM 120MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71228125 SUP HCPCS C1713 71228125 - SCREW BN 6.5MM 125MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71228130 SUP HCPCS C1713 71228130 - SCREW BN 6.5MM 130MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71228135 SUP HCPCS C1713 71228135 - SCREW BN 6.5MM 135MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71228140 SUP HCPCS C1713 71228140 - SCREW BN 6.5MM 140MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71228145 SUP HCPCS C1713 71228145 - SCREW BN 6.5MM 145MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71228150 SUP HCPCS C1713 71228150 - SCREW BN 6.5MM 150MM 32MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71229025 SUP HCPCS C1713 71229025 - SCREW BN FT 6.5MM 8MM 25MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229030 SUP HCPCS C1713 71229030 - SCREW BN FT 6.5MM 8MM 30MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229035 SUP HCPCS C1713 71229035 - SCREW BN FT 6.5MM 8MM 35MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229040 SUP HCPCS C1713 71229040 - SCREW BN FT 6.5MM 8MM 40MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229045 SUP HCPCS C1713 71229045 - SCREW BN FT 6.5MM 8MM 45MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229050 SUP HCPCS C1713 71229050 - SCREW BN FT 6.5MM 8MM 50MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229055 SUP HCPCS C1713 71229055 - SCREW BN FT 6.5MM 8MM 55MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229060 SUP HCPCS C1713 71229060 - SCREW BN FT 6.5MM 8MM 60MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229065 SUP HCPCS C1713 71229065 - SCREW BN FT 6.5MM 8MM 65MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229070 SUP HCPCS C1713 71229070 - SCREW BN FT 6.5MM 8MM 70MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229075 SUP HCPCS C1713 71229075 - SCREW BN FT 6.5MM 75MM TC100 CANC BOTH IP/OP $123.90 $91.69 $0.00 $99.12 $55.76 $55.76 $0.00 $0.00 $0.00 $25.82 $91.96 $91.96 $0.00 $0.00 $25.82 $0.00 $73.29 $73.29 $0.00 $61.95 $98.13 $99.12 $0.00 $0.00 $19.39 $0.00 $0.00 $19.72 $0.00 $0.00 $0.00 $0.00 $0.00 71229080 SUP HCPCS C1713 71229080 - SCREW BN FT 6.5MM 80MM TC100 CANC BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71229085 SUP HCPCS C1713 71229085 - SCREW BN FT 6.5MM 85MM TC100 CANC BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71229090 SUP HCPCS C1713 71229090 - SCREW BN FT 6.5MM 90MM TC100 CANC BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71229095 SUP HCPCS C1713 71229095 - SCREW BN FT 6.5MM 8MM 95MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71229100 SUP HCPCS C1713 71229100 - SCREW BN FT 6.5MM 100MM TC100 SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71229105 SUP HCPCS C1713 71229105 - SCREW BN FT 6.5MM 105MM TC100 SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71229110 SUP HCPCS C1713 71229110 - SCREW BN FT 6.5MM 110MM TC100 SS CANC LG FRAG SET BOTH IP/OP $135.45 $100.23 $0.00 $108.36 $60.95 $60.95 $0.00 $0.00 $0.00 $28.23 $100.53 $100.53 $0.00 $0.00 $28.23 $0.00 $80.12 $80.12 $0.00 $67.73 $107.28 $108.36 $0.00 $0.00 $21.20 $0.00 $0.00 $21.56 $0.00 $0.00 $0.00 $0.00 $0.00 71229115 SUP HCPCS C1713 71229115 - SCREW BN FT 6.5MM 115MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71229120 SUP HCPCS C1713 71229120 - SCREW BN FT 6.5MM 120MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71229125 SUP HCPCS C1713 71229125 - SCREW BN FT 6.5MM 125MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71229130 SUP HCPCS C1713 71229130 - SCREW BN FT 6.5MM 130MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71229135 SUP HCPCS C1713 71229135 - SCREW BN FT 6.5MM 135MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71229140 SUP HCPCS C1713 71229140 - SCREW BN FT 6.5MM 140MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71229145 SUP HCPCS C1713 71229145 - SCREW BN FT 6.5MM 145MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71229150 SUP HCPCS C1713 71229150 - SCREW BN FT 6.5MM 150MM TC100 SS CANC LG FRAG SET BOTH IP/OP $174.30 $128.98 $0.00 $139.44 $78.44 $78.44 $0.00 $0.00 $0.00 $36.33 $129.37 $129.37 $0.00 $0.00 $36.32 $0.00 $103.10 $103.10 $0.00 $87.15 $138.05 $139.44 $0.00 $0.00 $27.28 $0.00 $0.00 $27.75 $0.00 $0.00 $0.00 $0.00 $0.00 71453122 SUP HCPCS C1776 71453122 - INSERT TIB 5-6 11MM LEGION CR HI FLXN XLPE KN BOTH IP/OP "$10,175.00 " "$7,529.50" $0.00 "$8,140.00" "$4,578.75" "$4,578.75" $0.00 $0.00 $0.00 "$2,120.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,120.47" $0.00 "$5,016.28" "$5,016.28" $0.00 "$5,087.50" "$8,058.60" "$8,140.00" $0.00 $0.00 "$1,592.39" $0.00 $0.00 "$1,619.86" $0.00 $0.00 $0.00 $0.00 $0.00 71525986 SUP HCPCS C1713 71525986 - SCREW BN 5MM 55MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71525989 SUP HCPCS C1713 71525989 - SCREW BN 5MM 70MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71525990 SUP HCPCS C1713 71525990 - SCREW BN 5MM 75MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71525991 SUP HCPCS C1713 71525991 - SCREW BN 5MM 80MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71525993 SUP HCPCS C1713 71525993 - SCREW BN 5MM 90MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71525994 SUP HCPCS C1713 71525994 - SCREW BN 5MM 95MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71525995 SUP HCPCS C1713 71525995 - SCREW BN 5MM 100MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71525996 SUP HCPCS C1713 71525996 - SCREW BN 5MM 105MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71525997 SUP HCPCS C1713 71525997 - SCREW BN 5MM 110MM ORTH BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $137.70 $137.70 $0.00 $0.00 $0.00 $63.78 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $181.00 $181.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $47.89 $0.00 $0.00 $48.72 $0.00 $0.00 $0.00 $0.00 $0.00 71631035 SUP Custom 27203010 71631035 - DRILL SURG 6.4MM STERILE BOTH IP/OP $587.25 $434.57 $0.00 $469.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $435.86 $435.86 $0.00 $0.00 $122.38 $0.00 $0.00 $0.00 $0.00 $293.63 $465.10 $469.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71631110 SUP Custom 27203010 71631110 - BIT DRILL LONG 4MM PILOT TRIGEN GOLD STERILE DISPOSABLE BOTH IP/OP $504.00 $372.96 $0.00 $403.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.07 $374.07 $0.00 $0.00 $105.03 $0.00 $0.00 $0.00 $0.00 $252.00 $399.17 $403.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71631112 SUP Custom 27203010 71631112 - BIT DRL SHRT 3.2MM STRL TRGN PILT BOTH IP/OP $148.50 $109.89 $0.00 $118.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $110.22 $110.22 $0.00 $0.00 $30.95 $0.00 $0.00 $0.00 $0.00 $74.25 $117.61 $118.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71631117 SUP Custom 27203010 71631117 - BIT DRILL 4MM TRGN SHRT PILT STRL DISP BOTH IP/OP $340.88 $252.25 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.00 $253.00 $0.00 $0.00 $71.04 $0.00 $0.00 $0.00 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71631626 SUP HCPCS C1769 71631626 - GUIDE ROD ORTH BALL 3MM 1000MM STRL TRGN BALL TIP SS DISP BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $235.19 $235.19 $0.00 $0.00 $0.00 $90.27 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $256.19 $256.19 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $67.78 $0.00 $0.00 $68.95 $0.00 $0.00 $0.00 $0.00 $0.00 71631690 SUP Custom 27203010 71631690 - GUIDEWIRE ORTHOPEDIC THREAD 3.2MM TRIGEN DISTAL FEMUR BOTH IP/OP $209.25 $154.85 $0.00 $167.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $104.63 $165.73 $167.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71632001 SUP HCPCS C1713 71632001 - NUT ORTH 5MM STRL TRGN STBLK LCK STAB 5MM SCR BOTH IP/OP $585.00 $432.90 $0.00 $468.00 $263.25 $263.25 $0.00 $0.00 $0.00 $121.93 $434.19 $434.19 $0.00 $0.00 $121.91 $0.00 $346.03 $346.03 $0.00 $292.50 $463.32 $468.00 $0.00 $0.00 $91.55 $0.00 $0.00 $93.13 $0.00 $0.00 $0.00 $0.00 $0.00 71632002 SUP HCPCS C1713 71632002 - NUT ORTH 4.5MM STBLK WSHR BOTH IP/OP $303.75 $224.78 $0.00 $243.00 $136.69 $136.69 $0.00 $0.00 $0.00 $63.31 $225.44 $225.44 $0.00 $0.00 $63.30 $0.00 $179.67 $179.67 $0.00 $151.88 $240.57 $243.00 $0.00 $0.00 $47.54 $0.00 $0.00 $48.36 $0.00 $0.00 $0.00 $0.00 $0.00 71632125 SUP HCPCS C1713 71632125 - SCREW BN 4.5MM 25MM GRY TRGN ST SLFDRL FLUT TIP CPTR TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632130 SUP HCPCS C1713 71632130 - SCREW BN 4.5MM 30MM GRY TRGN ST SLFDRL CPTR FLUT TIP TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632135 SUP HCPCS C1713 71632135 - SCREW BN 4.5MM 35MM GRY TRGN ST SLFDRL CPTR FLUT TIP TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632140 SUP HCPCS C1713 71632140 - SCREW BN 4.5MM 40MM GRY TRGN ST SLFDRL FLUT TIP CPTR TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632150 SUP HCPCS C1713 71632150 - SCREW BN 4.5MM 50MM GRY TRGN ST SLFDRL FLUT TIP CPTR TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632200 SUP HCPCS C1713 71632200 - SCREW BN 5MM 100MM AU TRGN ST SLFDRL FLUT TIP CPTR TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632205 SUP HCPCS C1713 71632205 - SCREW BN 5MM 105MM AU TRGN ST SLFDRL FLUT TIP CPTR TI KN IM BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632210 SUP HCPCS C1713 71632210 - SCREW BN 5MM 110MM AU TRGN ST SLFDRL FLUT TIP CPTR TI KN IM BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632220 SUP HCPCS C1713 71632220 - SCREW BN 5MM 20MM AU TRGN ST SLFDRL CPTR FLUT TIP THRD TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632230 SUP HCPCS C1713 71632230 - SCREW BN 5MM 30MM AU TRGN FLUT TIP ST DRL CPTR TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632260 SUP HCPCS C1713 71632260 - SCREW BN 5MM 60MM AU TRGN CPTR SLF DRL ST TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632275 SUP HCPCS C1713 71632275 - SCREW BN 5MM 75MM AU TRGN ST SLF DRL FLUT TIP CPTR TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632280 SUP HCPCS C1713 71632280 - SCREW BN 5MM 80MM AU TRGN ST SLF DRL FLUT TIP CPTR TI KN BOTH IP/OP $407.25 $301.37 $0.00 $325.80 $183.26 $183.26 $0.00 $0.00 $0.00 $84.88 $302.26 $302.26 $0.00 $0.00 $84.87 $0.00 $240.89 $240.89 $0.00 $203.63 $322.54 $325.80 $0.00 $0.00 $63.73 $0.00 $0.00 $64.83 $0.00 $0.00 $0.00 $0.00 $0.00 71632300 SUP HCPCS C1713 71632300 - SCREW BN 6.4MM 100MM BLU TRGN SLF DRL ST CPTR RECON TI KN IM BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71632305 SUP HCPCS C1713 71632305 - SCREW BN 6.4MM 105MM BLU TRGN ST SLFDRL CPTR RECON TI KN IM BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71632316 SUP HCPCS C1713 71632316 - SCREW BN 6.4MM 115MM BLU TRGN SLF DRL ST CPTR RECON TI KN IM BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71632325 SUP HCPCS C1713 71632325 - SCREW BN 6.4MM 125MM BLU TRGN CPTR RECON TI KN IM NL BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71632375 SUP HCPCS C1713 71632375 - SCREW BN 6.4MM 75MM BLU TRGN SLF DRL ST CPTR RECON TI KN IM BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71632380 SUP HCPCS C1713 71632380 - SCREW BN 6.4MM 80MM BLU TRGN SLF DRL ST CPTR RECON TI KN IM BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71632385 SUP HCPCS C1713 71632385 - SCREW BN 6.4MM 85MM BLU TRGN CPTR RECON TI KN IM NL BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71632390 SUP HCPCS C1713 71632390 - SCREW BN 6.4MM 90MM BLU TRGN SLF DRL ST CPTR RECON TI KN IM BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71632395 SUP HCPCS C1713 71632395 - SCREW BN 6.4MM 95MM BLU TRGN ST SLFDRL CPTR RECON TI KN IM BOTH IP/OP $685.13 $507.00 $0.00 $548.10 $308.31 $308.31 $0.00 $0.00 $0.00 $142.80 $508.50 $508.50 $0.00 $0.00 $142.78 $0.00 $405.25 $405.25 $0.00 $342.56 $542.62 $548.10 $0.00 $0.00 $107.22 $0.00 $0.00 $109.07 $0.00 $0.00 $0.00 $0.00 $0.00 71633005 SUP HCPCS C1713 71633005 - CAP END 5MM 5MM TRGN XTD TI FEM IM NL BOTH IP/OP $418.50 $309.69 $0.00 $334.80 $188.33 $188.33 $0.00 $0.00 $0.00 $87.23 $310.61 $310.61 $0.00 $0.00 $87.22 $0.00 $247.54 $247.54 $0.00 $209.25 $331.45 $334.80 $0.00 $0.00 $65.50 $0.00 $0.00 $66.63 $0.00 $0.00 $0.00 $0.00 $0.00 71633010 SUP HCPCS C1713 71633010 - CAP END 10MM 10MM TRGN XTD TI FEM IM NL BOTH IP/OP $418.50 $309.69 $0.00 $334.80 $188.33 $188.33 $0.00 $0.00 $0.00 $87.23 $310.61 $310.61 $0.00 $0.00 $87.22 $0.00 $247.54 $247.54 $0.00 $209.25 $331.45 $334.80 $0.00 $0.00 $65.50 $0.00 $0.00 $66.63 $0.00 $0.00 $0.00 $0.00 $0.00 71633015 SUP HCPCS C1713 71633015 - CAP END 15MM TRGN TI ORTH IM NL BOTH IP/OP $418.50 $309.69 $0.00 $334.80 $188.33 $188.33 $0.00 $0.00 $0.00 $87.23 $310.61 $310.61 $0.00 $0.00 $87.22 $0.00 $247.54 $247.54 $0.00 $209.25 $331.45 $334.80 $0.00 $0.00 $65.50 $0.00 $0.00 $66.63 $0.00 $0.00 $0.00 $0.00 $0.00 71633020 SUP HCPCS C1713 71633020 - CAP END 20MM TRGN TI ORTH IM NL BOTH IP/OP $418.50 $309.69 $0.00 $334.80 $188.33 $188.33 $0.00 $0.00 $0.00 $87.23 $310.61 $310.61 $0.00 $0.00 $87.22 $0.00 $247.54 $247.54 $0.00 $209.25 $331.45 $334.80 $0.00 $0.00 $65.50 $0.00 $0.00 $66.63 $0.00 $0.00 $0.00 $0.00 $0.00 71633315 SUP HCPCS C1713 71633315 - NAIL IM 11.5MM 15CM AU TRGN SET TI KN SP CNDL BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 71633320 SUP HCPCS C1713 71633320 - NAIL IM 11.5MM 20CM AU TRGN TI KN TIB BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 71633325 SUP HCPCS C1713 71633325 - NAIL IM 11.5MM 25CM AU TRGN SET TI KN SP CNDL BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 71633415 SUP HCPCS C1713 71633415 - NAIL IM 13MM 15CM AU TRGN SET TI KN SP CNDL BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 71633420 SUP HCPCS C1713 71633420 - NAIL IM 13MM 20CM AU TRGN SET TI KN SP CNDL BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 71633425 SUP HCPCS C1713 71633425 - NAIL IM 13MM 25CM AU TRGN SET TI KN SP CNDL BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 71633448 SUP HCPCS C1713 71633448 - NAIL IM 13MM 48CM AU TRGN RTRGD ANTGRD TI FEM TIB BOTH IP/OP "$6,490.00 " "$4,802.60" $0.00 "$5,192.00" "$2,920.50" "$2,920.50" $0.00 $0.00 $0.00 "$1,352.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,352.52" $0.00 "$3,199.57" "$3,199.57" $0.00 "$3,245.00" "$5,140.08" "$5,192.00" $0.00 $0.00 "$1,015.69" $0.00 $0.00 "$1,033.21" $0.00 $0.00 $0.00 $0.00 $0.00 71634000 SUP HCPCS C1713 71634000 - CAP END 0MM TRGN SET TI DISP INTNL HEX IM NL BOTH IP/OP $420.75 $311.36 $0.00 $336.60 $189.34 $189.34 $0.00 $0.00 $0.00 $87.69 $312.28 $312.28 $0.00 $0.00 $87.68 $0.00 $248.87 $248.87 $0.00 $210.38 $333.23 $336.60 $0.00 $0.00 $65.85 $0.00 $0.00 $66.98 $0.00 $0.00 $0.00 $0.00 $0.00 71634005 SUP HCPCS C1713 71634005 - CAP END 5MM TRGN SET TI DISP INTNL HEX IM NL BOTH IP/OP $420.75 $311.36 $0.00 $336.60 $189.34 $189.34 $0.00 $0.00 $0.00 $87.69 $312.28 $312.28 $0.00 $0.00 $87.68 $0.00 $248.87 $248.87 $0.00 $210.38 $333.23 $336.60 $0.00 $0.00 $65.85 $0.00 $0.00 $66.98 $0.00 $0.00 $0.00 $0.00 $0.00 71634010 SUP HCPCS C1713 71634010 - CAP END 10MM 10MM TRGN TI ORTH IM NL BOTH IP/OP $420.75 $311.36 $0.00 $336.60 $189.34 $189.34 $0.00 $0.00 $0.00 $87.69 $312.28 $312.28 $0.00 $0.00 $87.68 $0.00 $248.87 $248.87 $0.00 $210.38 $333.23 $336.60 $0.00 $0.00 $65.85 $0.00 $0.00 $66.98 $0.00 $0.00 $0.00 $0.00 $0.00 71634015 SUP HCPCS C1713 71634015 - CAP END 15MM 15MM TRGN ORTH IM NL BOTH IP/OP $420.75 $311.36 $0.00 $336.60 $189.34 $189.34 $0.00 $0.00 $0.00 $87.69 $312.28 $312.28 $0.00 $0.00 $87.68 $0.00 $248.87 $248.87 $0.00 $210.38 $333.23 $336.60 $0.00 $0.00 $65.85 $0.00 $0.00 $66.98 $0.00 $0.00 $0.00 $0.00 $0.00 71634020 SUP HCPCS C1713 71634020 - CAP END 20MM TRGN TI INTNL HEX IM NL BOTH IP/OP $420.75 $311.36 $0.00 $336.60 $189.34 $189.34 $0.00 $0.00 $0.00 $87.69 $312.28 $312.28 $0.00 $0.00 $87.68 $0.00 $248.87 $248.87 $0.00 $210.38 $333.23 $336.60 $0.00 $0.00 $65.85 $0.00 $0.00 $66.98 $0.00 $0.00 $0.00 $0.00 $0.00 71634230 SUP HCPCS C1713 71634230 - NAIL IM STD 10MM 30CM LIME TRGN ANTGRD FAN TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634232 SUP HCPCS C1713 71634232 - NAIL IM STD 10MM 32CM LIME TRGN ANTGRD FAN TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634234 SUP HCPCS C1713 71634234 - NAIL IM STD 10MM 34CM LIME TRGN ANTGRD FAN TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634236 SUP HCPCS C1713 71634236 - NAIL IM STD 10MM 36CM LIME TRGN ANTGRD FAN TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634238 SUP HCPCS C1713 71634238 - NAIL IM STD 10MM 38CM LIME TRGN ANTGRD FAN TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634240 SUP HCPCS C1713 71634240 - NAIL IM STD 10MM 40CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634242 SUP HCPCS C1713 71634242 - NAIL IM STD 10MM 42CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634244 SUP HCPCS C1713 71634244 - NAIL IM STD 10MM 44CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634246 SUP HCPCS C1713 71634246 - NAIL IM STD 10MM 46CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634248 SUP HCPCS C1713 71634248 - NAIL IM STD 10MM 48CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634250 SUP HCPCS C1713 71634250 - NAIL IM 10MM 50CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634330 SUP HCPCS C1713 71634330 - NAIL IM 11.5MM 30CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634332 SUP HCPCS C1713 71634332 - NAIL IM STD 11.5MM 32CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634334 SUP HCPCS C1713 71634334 - NAIL IM STD 11.5MM 34CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634336 SUP HCPCS C1713 71634336 - NAIL IM STD 11.5MM 36CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634338 SUP HCPCS C1713 71634338 - NAIL IM STD 11.5MM 38CM FAN LIME TRGN ANTGRD RECON TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634340 SUP HCPCS C1713 71634340 - NAIL IM STD 11.5MM 40CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634342 SUP HCPCS C1713 71634342 - NAIL IM STD 11.5MM 42CM FAN LIME TRGN ANTGRD TI LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634344 SUP HCPCS C1713 71634344 - NAIL IM STD 11.5MM 44CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634346 SUP HCPCS C1713 71634346 - NAIL IM STD 11.5MM 46CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634348 SUP HCPCS C1713 71634348 - NAIL IM STD 11.5MM 48CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634350 SUP HCPCS C1713 71634350 - NAIL IM 11.5MM 50CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634430 SUP HCPCS C1713 71634430 - NAIL IM 13MM 30CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634432 SUP HCPCS C1713 71634432 - NAIL IM STD 13MM 32CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634434 SUP HCPCS C1713 71634434 - NAIL IM STD 13MM 34CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634436 SUP HCPCS C1713 71634436 - NAIL IM STD 13MM 36CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634438 SUP HCPCS C1713 71634438 - NAIL IM STD 13MM 38CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634440 SUP HCPCS C1713 71634440 - NAIL IM STD 13MM 40CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634442 SUP HCPCS C1713 71634442 - NAIL IM STD 13MM 42CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71634444 SUP HCPCS C1713 71634444 - NAIL IM STD 13MM 44CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634446 SUP HCPCS C1713 71634446 - NAIL IM STD 13MM 46CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634448 SUP HCPCS C1713 71634448 - NAIL IM STD 13MM 48CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634450 SUP HCPCS C1713 71634450 - NAIL IM 13MM 50CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71634830 SUP HCPCS C1713 71634830 - NAIL IM 130D 8.5MM 30CM ROSE TN RT BOTH IP/OP "$3,971.25 " "$2,938.73" $0.00 "$3,177.00" "$1,787.06" "$1,787.06" $0.00 $0.00 $0.00 $827.71 "$2,947.46" "$2,947.46" $0.00 $0.00 $827.61 $0.00 "$1,957.83" "$1,957.83" $0.00 "$1,985.63" "$3,145.23" "$3,177.00" $0.00 $0.00 $621.50 $0.00 $0.00 $632.22 $0.00 $0.00 $0.00 $0.00 $0.00 71635230 SUP HCPCS C1713 71635230 - NAIL IM 10MM 30CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635232 SUP HCPCS C1713 71635232 - NAIL IM STD 10MM 32CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635234 SUP HCPCS C1713 71635234 - NAIL IM STD 10MM 34CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635236 SUP HCPCS C1713 71635236 - NAIL IM 130D STD 10MM 36CM ROSE TRGN ANTGRD RND XSECT CNN TI BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635238 SUP HCPCS C1713 71635238 - NAIL IM STD 10MM 38CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635240 SUP HCPCS C1713 71635240 - NAIL IM STD 10MM 40CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635242 SUP HCPCS C1713 71635242 - NAIL IM STD 10MM 42CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635244 SUP HCPCS C1713 71635244 - NAIL IM STD 10MM 44CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635246 SUP HCPCS C1713 71635246 - NAIL IM STD 10MM 46CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635248 SUP HCPCS C1713 71635248 - NAIL IM STD 10MM 48CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635250 SUP HCPCS C1713 71635250 - NAIL IM 10MM 50CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635330 SUP HCPCS C1713 71635330 - NAIL IM 11.5MM 30CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635332 SUP HCPCS C1713 71635332 - NAIL IM STD 11.5MM 32CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635334 SUP HCPCS C1713 71635334 - NAIL IM STD 11.5MM 34CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635336 SUP HCPCS C1713 71635336 - NAIL IM STD 11.5MM 36CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635338 SUP HCPCS C1713 71635338 - NAIL IM STD 11.5MM 38CM FAN ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635340 SUP HCPCS C1713 71635340 - NAIL IM STD 11.5MM 40CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635342 SUP HCPCS C1713 71635342 - NAIL IM STD 11.5MM 42CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635344 SUP HCPCS C1713 71635344 - NAIL IM STD 11.5MM 44CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635346 SUP HCPCS C1713 71635346 - NAIL IM STD 11.5MM 46CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635348 SUP HCPCS C1713 71635348 - NAIL IM STD 11.5MM 48CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635350 SUP HCPCS C1713 71635350 - NAIL IM 11.5MM 50CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635430 SUP HCPCS C1713 71635430 - NAIL IM 13MM 30CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635432 SUP HCPCS C1713 71635432 - NAIL IM STD 13MM 32CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635434 SUP HCPCS C1713 71635434 - NAIL IM STD 13MM 34CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635436 SUP HCPCS C1713 71635436 - NAIL IM STD 13MM 36CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635438 SUP HCPCS C1713 71635438 - NAIL IM STD 13MM 38CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635440 SUP HCPCS C1713 71635440 - NAIL IM STD 13MM 40CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635442 SUP HCPCS C1713 71635442 - NAIL IM STD 13MM 42CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71635444 SUP HCPCS C1713 71635444 - NAIL IM STD 13MM 44CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635446 SUP HCPCS C1713 71635446 - NAIL IM STD 13MM 46CM ROSE TRGN ANTGRD TI FEM LT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635448 SUP HCPCS C1713 71635448 - NAIL IM STD 13MM 48CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71635450 SUP HCPCS C1713 71635450 - NAIL IM 13MM 50CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71636126 SUP HCPCS C1713 71636126 - NAIL IM 8.5IN 26IN GRY TRGN ANTGRD TI FEM BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71636128 SUP HCPCS C1713 71636128 - NAIL IM 8.5MM 28CM GRY TRGN ANTGRD TI FEM BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71636130 SUP HCPCS C1713 71636130 - NAIL IM 10MM 30CM GRY TRGN ANTGRD TI FEM BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71636132 SUP HCPCS C1713 71636132 - NAIL IM 8.5MM 32CM GRY TRGN ANTGRD TI KN FEM BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71636134 SUP HCPCS C1713 71636134 - NAIL IM 8.5MM 34CM GRY TRGN CNN ANTGRD TI FEM BOTH IP/OP "$4,044.38 " "$2,992.84" $0.00 "$3,235.50" "$1,819.97" "$1,819.97" $0.00 $0.00 $0.00 $842.95 "$3,001.74" "$3,001.74" $0.00 $0.00 $842.85 $0.00 "$1,993.88" "$1,993.88" $0.00 "$2,022.19" "$3,203.15" "$3,235.50" $0.00 $0.00 $632.94 $0.00 $0.00 $643.86 $0.00 $0.00 $0.00 $0.00 $0.00 71636136 SUP HCPCS C1713 71636136 - NAIL IM 8.5MM 36CM GRY TRGN ANTGRD TI FEM BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71636138 SUP HCPCS C1713 71636138 - NAIL IM 8.5MM 38CM GRY TRGN ANTGRD TI FEM BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71636140 SUP HCPCS C1713 71636140 - NAIL IM 8.5MM 40CM GRY TRGN ANTGRD TI FEM BOTH IP/OP "$3,870.00 " "$2,863.80" $0.00 "$3,096.00" "$1,741.50" "$1,741.50" $0.00 $0.00 $0.00 $806.60 "$2,872.31" "$2,872.31" $0.00 $0.00 $806.51 $0.00 "$1,907.91" "$1,907.91" $0.00 "$1,935.00" "$3,065.04" "$3,096.00" $0.00 $0.00 $605.66 $0.00 $0.00 $616.10 $0.00 $0.00 $0.00 $0.00 $0.00 71637124 SUP HCPCS C1713 71637124 - NAIL IM 135D 8.5MM 24CM LIME LT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71637130 SUP HCPCS C1713 71637130 - NAIL IM 135D 8.5MM 30CM LIME LT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71637132 SUP HCPCS C1713 71637132 - NAIL IM 135D 8.5MM 32CM LIME LT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71637134 SUP HCPCS C1713 71637134 - NAIL IM 135D 8.5MM 34CM LIME LT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71637136 SUP HCPCS C1713 71637136 - NAIL IM 135D 8.5MM 36CM LIME LT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71637138 SUP HCPCS C1713 71637138 - NAIL IM 135D 8.5MM 38CM LIME LT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71637140 SUP HCPCS C1713 71637140 - NAIL IM 135D 8.5MM 40CM LIME LT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71637230 SUP HCPCS C1713 71637230 - NAIL IM 135D 10MM 30CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637232 SUP HCPCS C1713 71637232 - NAIL IM 135D 10MM 32CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637234 SUP HCPCS C1713 71637234 - NAIL IM 135D 10MM 34MM LGHT LIME TRGN ANTGRD TI LT BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637236 SUP HCPCS C1713 71637236 - NAIL IM 135D 10MM 36MM LGHT LIME TRGN ANTGRD TI LT BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637238 SUP HCPCS C1713 71637238 - NAIL IM 135D 10MM 38MM LGHT LIME TRGN ANTGRD TI LT BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637240 SUP HCPCS C1713 71637240 - NAIL IM 135D 10MM 40CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637242 SUP HCPCS C1713 71637242 - NAIL IM 135D 10MM 42CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637244 SUP HCPCS C1713 71637244 - NAIL IM 135D 10MM 44CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637246 SUP HCPCS C1713 71637246 - NAIL IM 135D 10MM 46CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637248 SUP HCPCS C1713 71637248 - NAIL IM 135D 10MM 48CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637250 SUP HCPCS C1713 71637250 - NAIL IM 135D 10MM 50CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637330 SUP HCPCS C1713 71637330 - NAIL IM 135D 11.5MM 30CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637332 SUP HCPCS C1713 71637332 - NAIL IM 135D 11.5MM 32CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637334 SUP HCPCS C1713 71637334 - NAIL IM 135D 11.5MM 34CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637336 SUP HCPCS C1713 71637336 - NAIL IM 135D 11.5MM 36CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637338 SUP HCPCS C1713 71637338 - NAIL IM 135D 11.5MM 38CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637340 SUP HCPCS C1713 71637340 - NAIL IM 135D 11.5MM 40CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637342 SUP HCPCS C1713 71637342 - NAIL IM 135D 11.5MM 42CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637344 SUP HCPCS C1713 71637344 - NAIL IM 135D 11.5MM 44CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637346 SUP HCPCS C1713 71637346 - NAIL IM 135D 11.5MM 46CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637348 SUP HCPCS C1713 71637348 - NAIL IM 135D 11.5MM 48CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637350 SUP HCPCS C1713 71637350 - NAIL IM 135D 11.5MM 50CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637430 SUP HCPCS C1713 71637430 - NAIL IM 135D 13MM 30CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637432 SUP HCPCS C1713 71637432 - NAIL IM 135D 13MM 32CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637434 SUP HCPCS C1713 71637434 - NAIL IM 135D 13MM 34CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637436 SUP HCPCS C1713 71637436 - NAIL IM 135D 13MM 36CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637438 SUP HCPCS C1713 71637438 - NAIL IM 135D 13MM 38CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637440 SUP HCPCS C1713 71637440 - NAIL IM 135D 13MM 40CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637442 SUP HCPCS C1713 71637442 - NAIL IM 135D 13MM 42CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71637444 SUP HCPCS C1713 71637444 - NAIL IM 135D 13MM 44CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637446 SUP HCPCS C1713 71637446 - NAIL IM 135D 13MM 46CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637448 SUP HCPCS C1713 71637448 - NAIL IM 135D 13MM 48CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71637450 SUP HCPCS C1713 71637450 - NAIL IM 135D 13MM 50CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638124 SUP HCPCS C1713 71638124 - NAIL IM 135D 8.5MM 24CM ROSE RT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71638128 SUP HCPCS C1713 71638128 - NAIL IM 135D 8.5MM 28CM ROSE RT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71638130 SUP HCPCS C1713 71638130 - NAIL IM 135D 8.5MM 30CM ROSE RT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71638132 SUP HCPCS C1713 71638132 - NAIL IM 135D 8.5MM 32CM ROSE RT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71638134 SUP HCPCS C1713 71638134 - NAIL IM 135D 8.5MM 34CM ROSE RT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71638136 SUP HCPCS C1713 71638136 - NAIL IM 135D 8.5MM 36CM ROSE RT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71638138 SUP HCPCS C1713 71638138 - NAIL IM 135D 8.5MM 38CM ROSE RT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71638140 SUP HCPCS C1713 71638140 - NAIL IM 135D 8.5MM 40CM ROSE RT TROCH BOTH IP/OP "$2,840.63 " "$2,102.07" $0.00 "$2,272.50" "$1,278.28" "$1,278.28" $0.00 $0.00 $0.00 $592.06 "$2,108.31" "$2,108.31" $0.00 $0.00 $591.99 $0.00 "$1,400.43" "$1,400.43" $0.00 "$1,420.31" "$2,249.78" "$2,272.50" $0.00 $0.00 $444.56 $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 $0.00 71638230 SUP HCPCS C1713 71638230 - NAIL IM 135D 10MM 30CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638232 SUP HCPCS C1713 71638232 - NAIL IM 135D 10MM 32CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638234 SUP HCPCS C1713 71638234 - NAIL IM 135D 10MM 34CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638236 SUP HCPCS C1713 71638236 - NAIL IM 135D 10MM 36CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638238 SUP HCPCS C1713 71638238 - NAIL IM 135D 10MM 38CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638240 SUP HCPCS C1713 71638240 - NAIL IM 135D 10MM 40CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638242 SUP HCPCS C1713 71638242 - NAIL IM 135D 10MM 42CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638244 SUP HCPCS C1713 71638244 - NAIL IM 135D 10MM 44CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638246 SUP HCPCS C1713 71638246 - NAIL IM 135D 10MM 46CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638248 SUP HCPCS C1713 71638248 - NAIL IM 135D 10MM 48CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638250 SUP HCPCS C1713 71638250 - NAIL IM 135D 10MM 50CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638330 SUP HCPCS C1713 71638330 - NAIL IM 135D 11.5MM 30CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638332 SUP HCPCS C1713 71638332 - NAIL IM 135D 11.5MM 32CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638334 SUP HCPCS C1713 71638334 - NAIL IM 135D 11.5MM 34CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638336 SUP HCPCS C1713 71638336 - NAIL IM 135D 11.5MM 36CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638338 SUP HCPCS C1713 71638338 - NAIL IM 135D 11.5MM 38CM ROSE TN TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638340 SUP HCPCS C1713 71638340 - NAIL IM 135D 11.5MM 40CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638342 SUP HCPCS C1713 71638342 - NAIL IM 135D 11.5MM 42CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638344 SUP HCPCS C1713 71638344 - NAIL IM 135D 11.5MM 44CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638346 SUP HCPCS C1713 71638346 - NAIL IM 135D 11.5MM 46CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638348 SUP HCPCS C1713 71638348 - NAIL IM 135D 11.5MM 48CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638350 SUP HCPCS C1713 71638350 - NAIL IM 135D 11.5MM 50CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638430 SUP HCPCS C1713 71638430 - NAIL IM 135D 13MM 30CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638432 SUP HCPCS C1713 71638432 - NAIL IM 135D 13MM 32CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638434 SUP HCPCS C1713 71638434 - NAIL IM 135D 13MM 34CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638436 SUP HCPCS C1713 71638436 - NAIL IM 135D 13MM 36CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638438 SUP HCPCS C1713 71638438 - NAIL IM 135D 13MM 38CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638440 SUP HCPCS C1713 71638440 - NAIL IM 135D 13MM 40CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638442 SUP HCPCS C1713 71638442 - NAIL IM 135D 13MM 42CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,696.88 " "$3,475.69" $0.00 "$3,757.50" "$2,113.59" "$2,113.59" $0.00 $0.00 $0.00 $978.95 "$3,486.02" "$3,486.02" $0.00 $0.00 $978.83 $0.00 "$2,315.56" "$2,315.56" $0.00 "$2,348.44" "$3,719.93" "$3,757.50" $0.00 $0.00 $735.06 $0.00 $0.00 $747.74 $0.00 $0.00 $0.00 $0.00 $0.00 71638444 SUP HCPCS C1713 71638444 - NAIL IM 135D 13MM 44CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638446 SUP HCPCS C1713 71638446 - NAIL IM 135D 13MM 46CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638448 SUP HCPCS C1713 71638448 - NAIL IM 135D 13MM 48CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71638450 SUP HCPCS C1713 71638450 - NAIL IM 135D 13MM 50CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 71639215 SUP HCPCS C1713 71639215 - NAIL IM SHRT BND 10MM 15CM BLU TRGN ANTGRD TI FEM TROCH BOTH IP/OP "$2,857.50 " "$2,114.55" $0.00 "$2,286.00" "$1,285.88" "$1,285.88" $0.00 $0.00 $0.00 $595.57 "$2,120.84" "$2,120.84" $0.00 $0.00 $595.50 $0.00 "$1,408.75" "$1,408.75" $0.00 "$1,428.75" "$2,263.14" "$2,286.00" $0.00 $0.00 $447.20 $0.00 $0.00 $454.91 $0.00 $0.00 $0.00 $0.00 $0.00 71639315 SUP HCPCS C1713 71639315 - NAIL IM SHRT 11.5MM 15CM BLU TRGN ANTGRD BND TI FEM TROCH BOTH IP/OP "$4,033.13 " "$2,984.52" $0.00 "$3,226.50" "$1,814.91" "$1,814.91" $0.00 $0.00 $0.00 $840.60 "$2,993.39" "$2,993.39" $0.00 $0.00 $840.50 $0.00 "$1,988.33" "$1,988.33" $0.00 "$2,016.56" "$3,194.24" "$3,226.50" $0.00 $0.00 $631.18 $0.00 $0.00 $642.07 $0.00 $0.00 $0.00 $0.00 $0.00 71640530 SUP HCPCS C1713 71640530 - NAIL IM 9MM 30CM ROSE TRGN MT-TN ANTGRD FEM TROCH RT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640532 SUP HCPCS C1713 71640532 - NAIL IM 9MM 32CM ROSE TRGN MT-TN ANTGRD FEM TROCH RT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640534 SUP HCPCS C1713 71640534 - NAIL IM 9MM 34CM ROSE TRGN MT-TN ANTGRD FEM TROCH RT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640536 SUP HCPCS C1713 71640536 - NAIL IM 9MM 36CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640538 SUP HCPCS C1713 71640538 - NAIL IM 9MM 38CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640540 SUP HCPCS C1713 71640540 - NAIL IM 9MM 40CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640542 SUP HCPCS C1713 71640542 - NAIL IM 9MM 42CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640544 SUP HCPCS C1713 71640544 - NAIL IM 9MM 44CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640546 SUP HCPCS C1713 71640546 - NAIL IM 9MM 46CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640548 SUP HCPCS C1713 71640548 - NAIL IM 9MM 48CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640550 SUP HCPCS C1713 71640550 - NAIL IM 9MM 50CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640630 SUP HCPCS C1713 71640630 - NAIL IM 10MM 30CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640632 SUP HCPCS C1713 71640632 - NAIL IM 10MM 32CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640634 SUP HCPCS C1713 71640634 - NAIL IM 10MM 34CM ROSE TRGN MT-TN RT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640636 SUP HCPCS C1713 71640636 - NAIL IM 10MM 36CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640638 SUP HCPCS C1713 71640638 - NAIL IM 10MM 38CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640640 SUP HCPCS C1713 71640640 - NAIL IM 10MM 40CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640642 SUP HCPCS C1713 71640642 - NAIL IM 10MM 42CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640644 SUP HCPCS C1713 71640644 - NAIL IM 10MM 44CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640646 SUP HCPCS C1713 71640646 - NAIL IM 10MM 46CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640648 SUP HCPCS C1713 71640648 - NAIL IM 10MM 48CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640650 SUP HCPCS C1713 71640650 - NAIL IM 10MM 50CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640730 SUP HCPCS C1713 71640730 - NAIL IM 11.5MM 30CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640732 SUP HCPCS C1713 71640732 - NAIL IM 11.5MM 32CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640734 SUP HCPCS C1713 71640734 - NAIL IM 11.5MM 34CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640736 SUP HCPCS C1713 71640736 - NAIL IM 11.5MM 36CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640738 SUP HCPCS C1713 71640738 - NAIL IM 11.5MM 38CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640740 SUP HCPCS C1713 71640740 - NAIL IM 11.5MM 40CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640742 SUP HCPCS C1713 71640742 - NAIL IM 11.5MM 42CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640744 SUP HCPCS C1713 71640744 - NAIL IM 11.5MM 44CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640746 SUP HCPCS C1713 71640746 - NAIL IM 11.5MM 46CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640748 SUP HCPCS C1713 71640748 - NAIL IM 11.5MM 48CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640750 SUP HCPCS C1713 71640750 - NAIL IM 11.5MM 50CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640830 SUP HCPCS C1713 71640830 - NAIL IM 13MM 30CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640832 SUP HCPCS C1713 71640832 - NAIL IM 13MM 32CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640834 SUP HCPCS C1713 71640834 - NAIL IM 13MM 34CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640836 SUP HCPCS C1713 71640836 - NAIL IM 13MM 36CM MT-NL TN RT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640838 SUP HCPCS C1713 71640838 - NAIL IM 13MM 38CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640840 SUP HCPCS C1713 71640840 - NAIL IM 13MM 40CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640842 SUP HCPCS C1713 71640842 - NAIL IM 13MM 42CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640844 SUP HCPCS C1713 71640844 - NAIL IM 13MM 44CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640846 SUP HCPCS C1713 71640846 - NAIL IM 13MM 46CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640848 SUP HCPCS C1713 71640848 - NAIL IM 13MM 48CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71640850 SUP HCPCS C1713 71640850 - NAIL IM 13MM 50CM ROSE TRGN MT-TN ANTGRD FEM RT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71641123 SUP Custom 27203010 71641123 - BIT DRL SHRT 4MM STRL TRGN AO STP SET DPHSL DISP BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642120 SUP HCPCS C1713 71642120 - SCREW BN 4.5MM 20MM TRGN CPTR TI ORTH BOTH IP/OP $283.50 $209.79 $0.00 $226.80 $127.58 $127.58 $0.00 $0.00 $0.00 $59.09 $210.41 $210.41 $0.00 $0.00 $59.08 $0.00 $167.69 $167.69 $0.00 $141.75 $224.53 $226.80 $0.00 $0.00 $44.37 $0.00 $0.00 $45.13 $0.00 $0.00 $0.00 $0.00 $0.00 71642125 SUP HCPCS C1713 71642125 - SCREW BN 4.5MM 25MM GRY TRGN INTNL CPTR HEX TI FEM IM NL BOTH IP/OP $438.75 $324.68 $0.00 $351.00 $197.44 $197.44 $0.00 $0.00 $0.00 $91.45 $325.64 $325.64 $0.00 $0.00 $91.44 $0.00 $259.52 $259.52 $0.00 $219.38 $347.49 $351.00 $0.00 $0.00 $68.66 $0.00 $0.00 $69.85 $0.00 $0.00 $0.00 $0.00 $0.00 71642130 SUP HCPCS C1713 71642130 - SCREW BN 4.5MM 30MM GRY TRGN INTNL CPTR TI FEM IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642135 SUP HCPCS C1713 71642135 - SCREW BN HEX 4.5MM 35MM GRY TRGN INTNL CPTR TI FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642140 SUP HCPCS C1713 71642140 - SCREW BN HEX 4.5MM 40MM GRY TRGN INTNL CPTR TI KN TIB IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642145 SUP HCPCS C1713 71642145 - SCREW BN 4.5MM 45MM GRY TRGN INTNL CPTR TI ORTH IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642150 SUP HCPCS C1713 71642150 - SCREW BN HEX 4.5MM 50MM GRY TRGN INTNL CPTR TI FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642155 SUP HCPCS C1713 71642155 - SCREW BN FT 4.5MM 55MM GRY TRGN INTNL CPTR HEX HD TI FEM BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642160 SUP HCPCS C1713 71642160 - SCREW BN 4.5MM 60MM GRY TRGN INTNL CPTR HEX HD TI FEM IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642165 SUP HCPCS C1713 71642165 - SCREW BN 4.5MM 65MM GRY TRGN INTNL CPTR TI ORTH IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642200 SUP HCPCS C1713 71642200 - SCREW BN HEX 5MM 100MM AU TRGN INTNL CPTR TI FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642205 SUP HCPCS C1713 71642205 - SCREW BN FT 5MM 105MM AU TRGN NTERNAL CPTR HEX HD TI FEM BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642210 SUP HCPCS C1713 71642210 - SCREW BN FT 5MM 110MM AU TRGN INTNL CPTR HEX HD TI FEM BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642220 SUP HCPCS C1713 71642220 - SCREW BN 5MM 20MM TRGN INTNL CPTR HEX HD TI FEM IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642225 SUP HCPCS C1713 71642225 - SCREW BN 5MM 25MM AU INTNL CPTR HEX TI FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642230 SUP HCPCS C1713 71642230 - SCREW BN 5MM 30MM AU INTNL CPTR HEX TI FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642235 SUP HCPCS C1713 71642235 - SCREW BN HEX 5MM 35MM AU TRGN INTNL CPTR TI FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642240 SUP HCPCS C1713 71642240 - SCREW BONE HEXAGON 5MM 40MM INTERNAL CAPTURE TRIGEN GOLD BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642245 SUP HCPCS C1713 71642245 - SCREW BONE HEXAGON 5MM 45MM INTERNAL CAPTURE TRIGEN GOLD BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642250 SUP HCPCS C1713 71642250 - SCREW BONE HEXAGON 5MM 50MM INTERNAL CAPTURE TRIGEN GOLD BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642255 SUP HCPCS C1713 71642255 - SCREW BN HEX 5MM 55MM AU TRGN INTNL CPTR TI FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642260 SUP HCPCS C1713 71642260 - SCREW BONE HEXAGON 5MM 60MM INTERNAL CAPTURE TRIGEN GOLD BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642265 SUP HCPCS C1713 71642265 - SCREW BN HEX 5MM 65MM AU TRGN INTNL CPTR TI FEM IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642270 SUP HCPCS C1713 71642270 - SCREW BONE HEXAGON 5MM 70MM INTERNAL CAPTURE TRIGEN GOLD BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642275 SUP HCPCS C1713 71642275 - SCREW BN HEX 5MM 75MM AU TRGN INTNL CPTR TI FEM IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642280 SUP HCPCS C1713 71642280 - SCREW BN HEX 5MM 80MM AU TRGN INTNL CPTR TI FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642285 SUP HCPCS C1713 71642285 - SCREW BN HEX 5MM 85MM AU TRGN INTNL CPTR TI FEM IM NL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642290 SUP HCPCS C1713 71642290 - SCREW BN HEX 5MM 90MM AU TRGN INTNL CPTR TI FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642295 SUP HCPCS C1713 71642295 - SCREW BN HEX 5MM 95MM AU TRGN INTNL CPTR TI FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71642300 SUP HCPCS C1713 71642300 - SCREW BONE HEXAGON 6.4MM 100MM INTERNAL CAPTURE BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642305 SUP HCPCS C1713 71642305 - SCREW BONE HEXAGON 6.4MM 105MM INTERNAL CAPTURE BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642320 SUP HCPCS C1713 71642320 - SCREW BN HEX 6.4MM 120MM BLU TRGN INTNL CPTR RECON TI FEM IM BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642325 SUP HCPCS C1713 71642325 - SCREW BN HEX 6.4MM 125MM BLU TRGN INTNL CPTR RECON TI FEM IM BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642365 SUP HCPCS C1713 71642365 - SCREW BN HEX 6.4MM 65MM BLU TRGN INTNL CPTR RECON TI FEM IM BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642370 SUP HCPCS C1713 71642370 - SCREW BONE HEXAGON 6.4MM 70MM INTERNAL CAPTURE BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642375 SUP HCPCS C1713 71642375 - SCREW BONE HEXAGON 6.4MM 75MM INTERNAL CAPTURE BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642380 SUP HCPCS C1713 71642380 - SCREW BONE HEXAGON 6.4MM 80MM INTERNAL CAPTURE BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642385 SUP HCPCS C1713 71642385 - SCREW BONE HEXAGON 6.4MM 85MM INTERNAL CAPTURE BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642390 SUP HCPCS C1713 71642390 - SCREW BN 6.4MM 90MM BLU INTNL CPTR RECON HEX TI TROCH TRGN BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642395 SUP HCPCS C1713 71642395 - SCREW BN 6.4MM 95MM BLU INTNL CPTR RECON HEX TI TROCH TRGN BOTH IP/OP $727.88 $538.63 $0.00 $582.30 $327.54 $327.54 $0.00 $0.00 $0.00 $151.71 $540.23 $540.23 $0.00 $0.00 $151.69 $0.00 $430.54 $430.54 $0.00 $363.94 $576.48 $582.30 $0.00 $0.00 $113.91 $0.00 $0.00 $115.88 $0.00 $0.00 $0.00 $0.00 $0.00 71642520 SUP HCPCS C1713 71642520 - SCREW BN 5MM 20MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642527 SUP HCPCS C1713 71642527 - SCREW BN 5MM 27.5MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642530 SUP HCPCS C1713 71642530 - SCREW BN 5MM 30MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642532 SUP HCPCS C1713 71642532 - SCREW BN 5MM 32.5MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642535 SUP HCPCS C1713 71642535 - SCREW BN 5MM 35MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642537 SUP HCPCS C1713 71642537 - SCREW BN 5MM 37.5MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642540 SUP HCPCS C1713 71642540 - SCREW BN 5MM 40MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642542 SUP HCPCS C1713 71642542 - SCREW BN 5MM 42.5MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642545 SUP HCPCS C1713 71642545 - SCREW BN 5MM 45MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642550 SUP HCPCS C1713 71642550 - SCREW BN 5MM 50MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642552 SUP HCPCS C1713 71642552 - SCREW BN 5MM 52.5MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642555 SUP HCPCS C1713 71642555 - SCREW BN 5MM 55MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642557 SUP HCPCS C1713 71642557 - SCREW BN 5MM 57.5MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642565 SUP HCPCS C1713 71642565 - SCREW BN 5MM 65MM SURESHOT BOTH IP/OP $356.63 $263.91 $0.00 $285.30 $160.48 $160.48 $0.00 $0.00 $0.00 $74.33 $264.69 $264.69 $0.00 $0.00 $74.32 $0.00 $210.94 $210.94 $0.00 $178.31 $282.45 $285.30 $0.00 $0.00 $55.81 $0.00 $0.00 $56.77 $0.00 $0.00 $0.00 $0.00 $0.00 71642575 SUP HCPCS C1713 71642575 - SCREW BN 5MM 75MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642630 SUP HCPCS C1713 71642630 - SCREW BN 2.5MM 30MM TN SURESHOT LG CMPR TROCH BOTH IP/OP $706.00 $522.44 $0.00 $564.80 $317.70 $317.70 $0.00 $0.00 $0.00 $147.15 $523.99 $523.99 $0.00 $0.00 $147.13 $0.00 $417.60 $417.60 $0.00 $353.00 $559.15 $564.80 $0.00 $0.00 $110.49 $0.00 $0.00 $112.40 $0.00 $0.00 $0.00 $0.00 $0.00 71642735 SUP HCPCS C1713 71642735 - SCREW SET 0MM TN SURESHOT BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71642736 SUP HCPCS C1713 71642736 - SCREW SET 5MM TN SURESHOT BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71642737 SUP HCPCS C1713 71642737 - SCREW SET 10MM TN SURESHOT BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71642840 SUP HCPCS C1713 71642840 - SCREW BN 4.5MM 40MM SURESHOT LNG BN BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642845 SUP HCPCS C1713 71642845 - SCREW BN 4.5MM 45MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642850 SUP HCPCS C1713 71642850 - SCREW BN 4.5MM 50MM SURESHOT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 71642935 SUP HCPCS C1713 71642935 - SCREW BN 35MM MT-TN CMPR FEM BOTH IP/OP $559.13 $413.76 $0.00 $447.30 $251.61 $251.61 $0.00 $0.00 $0.00 $116.54 $414.98 $414.98 $0.00 $0.00 $116.52 $0.00 $330.72 $330.72 $0.00 $279.56 $442.83 $447.30 $0.00 $0.00 $87.50 $0.00 $0.00 $89.01 $0.00 $0.00 $0.00 $0.00 $0.00 71642936 SUP HCPCS C1713 71642936 - SET SCR MT-TN INTGR CNN BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $192.38 $192.38 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 71642937 SUP HCPCS C1713 71642937 - SET SCR 5MM TRGN MT-TN BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $192.38 $192.38 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 71642938 SUP HCPCS C1713 71642938 - SCREW SET 10MM MT-TN MT-TN BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $192.38 $192.38 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 71644536 SUP HCPCS C1713 71644536 - NAIL IM 14.5MM 36CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644538 SUP HCPCS C1713 71644538 - NAIL IM 14.5MM 38CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644540 SUP HCPCS C1713 71644540 - NAIL IM 14.5MM 40CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644542 SUP HCPCS C1713 71644542 - NAIL IM 14.5MM 42CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644544 SUP HCPCS C1713 71644544 - NAIL IM 14.5MM 44CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644636 SUP HCPCS C1713 71644636 - NAIL IM 16MM 36CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644638 SUP HCPCS C1713 71644638 - NAIL IM 16MM 38CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644640 SUP HCPCS C1713 71644640 - NAIL IM 16MM 40CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644642 SUP HCPCS C1713 71644642 - NAIL IM 16MM 42CM LIME ANTGRD FEM BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71644644 SUP HCPCS C1713 71644644 - NAIL IM 16MM 44CM LIME TRGN ANTGRD TI FEM LT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645020 SUP HCPCS C1713 71645020 - SCREW BN 5MM 20MM TRGN LOPRFL FEM BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645022 SUP HCPCS C1713 71645022 - SCREW BONE 5MM 22.5MM TRGN FEM LP HEXDRIVER BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645025 SUP HCPCS C1713 71645025 - SCREW BN 5MM 25MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645027 SUP HCPCS C1713 71645027 - SCREW BN 5MM 27MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645030 SUP HCPCS C1713 71645030 - SCREW BN 5MM 30MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645032 SUP HCPCS C1713 71645032 - SCREW BN 5MM 32.5MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645035 SUP HCPCS C1713 71645035 - SCREW BN 5MM 35MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645037 SUP HCPCS C1713 71645037 - SCREW BN 5MM 37.5MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645040 SUP HCPCS C1713 71645040 - SCREW BN 5MM 40MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645042 SUP HCPCS C1713 71645042 - SCREW BN 5MM 42.5MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645045 SUP HCPCS C1713 71645045 - SCREW BN 5MM 45MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645047 SUP HCPCS C1713 71645047 - SCREW BN 5MM 47.5MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645050 SUP HCPCS C1713 71645050 - SCREW BN 5MM 50MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645052 SUP HCPCS C1713 71645052 - SCREW BN 5MM 52.5MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645055 SUP HCPCS C1713 71645055 - SCREW BN 5MM 55MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645057 SUP HCPCS C1713 71645057 - SCREW BN 5MM 57MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645060 SUP HCPCS C1713 71645060 - SCREW BN 5MM 60MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645062 SUP HCPCS C1713 71645062 - SCREW BONE 5MM 62.5MM LP TRIGEN FEMUR BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645065 SUP HCPCS C1713 71645065 - SCREW BN LOPRFL 5MM 65MM TRGN FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645067 SUP HCPCS C1713 71645067 - SCREW BN 5MM 67MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645070 SUP HCPCS C1713 71645070 - SCREW BN 5MM 70MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645072 SUP HCPCS C1713 71645072 - SCREW BN 5MM 72MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645075 SUP HCPCS C1713 71645075 - SCREW BN 5MM 75MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645077 SUP HCPCS C1713 71645077 - SCREW BONE 5MM 77.5MM LP TRIGEN FEMUR BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645080 SUP HCPCS C1713 71645080 - SCREW BN 5MM 80MM LOPRFL INTNL HEX FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645085 SUP HCPCS C1713 71645085 - SCREW BN LOPRFL 5MM 85MM TRGN FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645090 SUP HCPCS C1713 71645090 - SCREW BN LOPRFL 5MM 90MM TRGN FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645095 SUP HCPCS C1713 71645095 - SCREW BN 5MM 95MM TRGN LOPRFL HEXDRIVER FEM BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645100 SUP HCPCS C1713 71645100 - SCREW BONE 5MM 100MM TRGN FEM LP BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645105 SUP HCPCS C1713 71645105 - SCREW BN 5MM 105MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645110 SUP HCPCS C1713 71645110 - SCREW BN 5MM 110MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645124 SUP HCPCS C1713 71645124 - NAIL IM 130D 8.5MM 24CM LIME TRGN ANTGRD TI ADLT FEM LT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645126 SUP HCPCS C1713 71645126 - NAIL IM 130D 8.5MM 26CM LIME TRGN ANTGRD TI PED LT TROCH BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645128 SUP HCPCS C1713 71645128 - NAIL IM 130D 8.5MM 28CM TRGN ANTGRD TI PED LT TROCH BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645130 SUP HCPCS C1713 71645130 - NAIL IM 130D 8.5MM 30CM LIME TRGN ANTGRD TI PED LT TROCH BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645132 SUP HCPCS C1713 71645132 - NAIL IM 130D 8.5MM 32CM LIME TRGN ANTGRD PED LT TROCH BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645134 SUP HCPCS C1713 71645134 - NAIL IM 130D 8.5MM 34CM LIME TRGN ANTGRD TI ADLT FEM LT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645136 SUP HCPCS C1713 71645136 - NAIL IM 130D 8.5MM 36CM LIME TRGN ANTGRD SET TI PED LT TROCH BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645138 SUP HCPCS C1713 71645138 - NAIL IM 130D 8.5MM 38CM LIME TRGN ANTGRD TI ADLT FEM LT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645140 SUP HCPCS C1713 71645140 - NAIL IM 130D 8.5MM 40CM LIME TRGN ANTGRD SET TI PED LT TROCH BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71645420 SUP HCPCS C1713 71645420 - SCREW BN 4.5MM 20MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645422 SUP HCPCS C1713 71645422 - SCREW BN 4.5MM 22.5MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645425 SUP HCPCS C1713 71645425 - SCREW BN LOPRFL 4.5MM 25MM TRGN FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645427 SUP HCPCS C1713 71645427 - SCREW BONE 4.5MM 27.5MM TRGN LP IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645430 SUP HCPCS C1713 71645430 - SCREW BN LOPRFL 4.5MM 30MM TRGN FEM IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645432 SUP HCPCS C1713 71645432 - SCREW BN 4.5MM 32.5MM LOPRFL INTNL CPTR FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645435 SUP HCPCS C1713 71645435 - SCREW BONE LP 4.5MM 35MM TRIGEN FEMUR INTRAMEDULLARY NAIL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645437 SUP HCPCS C1713 71645437 - SCREW BN 4.5MM 37.5MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645440 SUP HCPCS C1713 71645440 - SCREW BN 4.5MM 40MM LOPRFL INTNL CPTR FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645442 SUP HCPCS C1713 71645442 - SCREW BN 4.5MM 42.5MM TRGN LOPRFL FEM BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645445 SUP HCPCS C1713 71645445 - SCREW BN 4.5MM 45MM LOPRFL INTNL CPTR FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645447 SUP HCPCS C1713 71645447 - SCREW BN 4.5MM 47.5MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645450 SUP HCPCS C1713 71645450 - SCREW BN 4.5MM 50MM LOPRFL INTNL CPTR FEM TRGN IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645452 SUP HCPCS C1713 71645452 - SCREW BN 4.5MM 52.5MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645455 SUP HCPCS C1713 71645455 - SCREW BN 4.5MM 55MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645457 SUP HCPCS C1713 71645457 - SCREW BN 4.5MM 57.5MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645460 SUP HCPCS C1713 71645460 - SCREW BN 4.5MM 60MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645462 SUP HCPCS C1713 71645462 - SCREW BN 4.5MM 62.5MM TRGN LOPRFL IM NL SYS BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645465 SUP HCPCS C1713 71645465 - SCREW BN 4.5MM 6.5MM TRGN LOPRFL FEM BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 71645536 SUP HCPCS C1713 71645536 - NAIL IM 14.5MM 36CM ROSE ANTGRD FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645538 SUP HCPCS C1713 71645538 - NAIL IM 14.5MM 38CM ROSE ANTGRD FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645540 SUP HCPCS C1713 71645540 - NAIL IM 14.5MM 40CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645542 SUP HCPCS C1713 71645542 - NAIL IM 14.5MM 42CM ROSE ANTGRD FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645544 SUP HCPCS C1713 71645544 - NAIL IM 14.5MM 44CM ROSE ANTGRD FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645636 SUP HCPCS C1713 71645636 - NAIL IM 16MM 36CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645638 SUP HCPCS C1713 71645638 - NAIL IM 16MM 38CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645640 SUP HCPCS C1713 71645640 - NAIL IM 16MM 40CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645642 SUP HCPCS C1713 71645642 - NAIL IM 16MM 42CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71645644 SUP HCPCS C1713 71645644 - NAIL IM 16MM 44CM ROSE TRGN ANTGRD TI FEM RT BOTH IP/OP "$7,008.75 " "$5,186.48" $0.00 "$5,607.00" "$3,153.94" "$3,153.94" $0.00 $0.00 $0.00 "$1,460.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,460.62" $0.00 "$3,455.31" "$3,455.31" $0.00 "$3,504.38" "$5,550.93" "$5,607.00" $0.00 $0.00 "$1,096.87" $0.00 $0.00 "$1,115.79" $0.00 $0.00 $0.00 $0.00 $0.00 71646124 SUP HCPCS C1713 71646124 - NAIL IM 130D 8.5MM 24CM ROSE TRGN ANTGRD TI ADLT FEM RT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71646126 SUP HCPCS C1713 71646126 - NAIL IM 130D 8.5MM 26CM ROSE TRGN ANTGRD TI ADLT FEM RT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71646128 SUP HCPCS C1713 71646128 - NAIL IM 130D 8.5MM 28CM ROSE TRGN ANTGRD TI ADLT FEM RT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71646130 SUP HCPCS C1713 71646130 - NAIL IM 8.5MM 30CM TN RT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71646132 SUP HCPCS C1713 71646132 - NAIL IM 130D 8.5MM 32CM ROSE TRGN ANTGRD TI ADLT FEM RT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71646134 SUP HCPCS C1713 71646134 - NAIL IM 130D 8.5MM 34CM ROSE TRGN ANTGRD TI ADLT FEM RT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71646136 SUP HCPCS C1713 71646136 - NAIL IM 130D 8.5MM 36CM ROSE TRGN ANTGRD TI ADLT FEM RT BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71646138 SUP HCPCS C1713 71646138 - NAIL INTRAMEDULLARY 130D 8.5MM 38CM ANTEGRADE TRIGEN ROSE BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71646140 SUP HCPCS C1713 71646140 - NAIL IM 130D 8.5MM 40CM ROSE TRGN ANTGRD TI PED RT TROCH BOTH IP/OP "$3,751.88 " "$2,776.39" $0.00 "$3,001.50" "$1,688.34" "$1,688.34" $0.00 $0.00 $0.00 $781.98 "$2,784.64" "$2,784.64" $0.00 $0.00 $781.89 $0.00 "$1,849.67" "$1,849.67" $0.00 "$1,875.94" "$2,971.49" "$3,001.50" $0.00 $0.00 $587.17 $0.00 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 71647230 SUP HCPCS C1713 71647230 - NAIL IM 130D 10MM 30CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647232 SUP HCPCS C1713 71647232 - NAIL IM 130D 10MM 32CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647234 SUP HCPCS C1713 71647234 - NAIL IM 130D 10MM 34CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647236 SUP HCPCS C1713 71647236 - NAIL INTRAMEDULLARY 130D 10MM 36CM ANTEGRADE TRIGEN LIME BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647238 SUP HCPCS C1713 71647238 - NAIL IM 130D 10MM 38CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647240 SUP HCPCS C1713 71647240 - NAIL INTRAMEDULLARY 130D 10MM 40CM ANTEGRADE TRIGEN LIME BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647242 SUP HCPCS C1713 71647242 - NAIL IM 130D 10MM 42CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647244 SUP HCPCS C1713 71647244 - NAIL IM 130D 10MM 44CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647246 SUP HCPCS C1713 71647246 - NAIL INTRAMEDULLARY 130D 10MM 46CM ANTEGRADE TRIGEN LIME BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647248 SUP HCPCS C1713 71647248 - NAIL IM 130D 10MM 48CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647250 SUP HCPCS C1713 71647250 - NAIL IM 130D 10MM 50CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647330 SUP HCPCS C1713 71647330 - NAIL IM 130D 11.5MM 30CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647332 SUP HCPCS C1713 71647332 - NAIL IM 130D 11.5MM 32CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647334 SUP HCPCS C1713 71647334 - NAIL IM 130D 11.5MM 34CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647336 SUP HCPCS C1713 71647336 - NAIL IM 130D 11.5MM 36CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647338 SUP HCPCS C1713 71647338 - NAIL INTRAMEDULLARY 130D 11.5MM 38CM 5 HOLE STATIC DYNAMIC BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647340 SUP HCPCS C1713 71647340 - NAIL INTRAMEDULLARY 130D 11.5MM 40CM 5 HOLE STATIC DYNAMIC BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647342 SUP HCPCS C1713 71647342 - NAIL INTRAMEDULLARY 130D 11.5MM 42CM ANTEGRADE TRIGEN LIME BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647346 SUP HCPCS C1713 71647346 - NAIL IM 130D 11.5MM 46CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647348 SUP HCPCS C1713 71647348 - NAIL IM 130D 11.5MM 48CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647350 SUP HCPCS C1713 71647350 - NAIL IM 130D 11.5MM 50CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647430 SUP HCPCS C1713 71647430 - NAIL IM 130D 13MM 30CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647432 SUP HCPCS C1713 71647432 - NAIL IM 130D 13MM 32CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647434 SUP HCPCS C1713 71647434 - NAIL IM 130D 13MM 34CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647436 SUP HCPCS C1713 71647436 - NAIL IM 130D 13MM 36CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647438 SUP HCPCS C1713 71647438 - NAIL IM 130D 13MM 38CM LIME TRGN ANTGRD TI LT TROCH IM NL BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647440 SUP HCPCS C1713 71647440 - NAIL IM 130D 13MM 40CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647442 SUP HCPCS C1713 71647442 - NAIL IM 130D 13MM 42CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647444 SUP HCPCS C1713 71647444 - NAIL IM 130D 13MM 44CM LIME TRGN TN 5 HL STC DYNMC PROX DIST BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647446 SUP HCPCS C1713 71647446 - NAIL IM 130D 13MM 46CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647448 SUP HCPCS C1713 71647448 - NAIL IM 130D 13MM 48CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71647450 SUP HCPCS C1713 71647450 - NAIL IM 130D 13MM 50CM LIME TRGN ANTGRD TI LT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648230 SUP HCPCS C1713 71648230 - NAIL IM 130D 10MM 30CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648232 SUP HCPCS C1713 71648232 - NAIL IM 130D 10MM 32CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648234 SUP HCPCS C1713 71648234 - NAIL IM 130D 10MM 34CM ROSE TRGN TN 5 HL STC DYNMC RND XSECT BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648236 SUP HCPCS C1713 71648236 - NAIL INTRAMEDULLARY 130D 10MM 36CM ANTEGRADE TRIGEN ROSE BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648238 SUP HCPCS C1713 71648238 - NAIL INTRAMEDULLARY 130D 10MM 38CM SET ANTEGRADE TRIGEN ROSE BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648240 SUP HCPCS C1713 71648240 - NAIL INTRAMEDULLARY 130D 10MM 40CM ANTEGRADE TRIGEN ROSE BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648242 SUP HCPCS C1713 71648242 - NAIL INTRAMEDULLARY 130D 10MM 42CM ANTEGRADE TRIGEN ROSE BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648244 SUP HCPCS C1713 71648244 - NAIL IM 130D 10MM 44CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648246 SUP HCPCS C1713 71648246 - NAIL IM 130D 10MM 46CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648248 SUP HCPCS C1713 71648248 - NAIL IM 130D 10MM 48CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648250 SUP HCPCS C1713 71648250 - NAIL IM 130D 10MM 50CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648330 SUP HCPCS C1713 71648330 - NAIL IM 130D 11.5MM 30CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648332 SUP HCPCS C1713 71648332 - NAIL IM 130D 11.5MM 32CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648334 SUP HCPCS C1713 71648334 - NAIL INTRAMEDULLARY 130D 11.5MM 34CM ANTEGRADE TRIGEN ROSE BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648336 SUP HCPCS C1713 71648336 - NAIL IM 130D 11.5MM 36CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648338 SUP HCPCS C1713 71648338 - NAIL INTRAMEDULLARY 130D 11.5MM 38CM SET ANTEGRADE TRIGEN BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648340 SUP HCPCS C1713 71648340 - NAIL INTRAMEDULLARY 130D 11.5MM 40CM ANTEGRADE SET TRIGEN BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648342 SUP HCPCS C1713 71648342 - NAIL IM 130D 11.5MM 42CM ROSE STRL TRGN TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648344 SUP HCPCS C1713 71648344 - NAIL INTRAMEDULLARY TRIGEN TITANIUM L44 CM OD11.5 MM TAN BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648348 SUP HCPCS C1713 71648348 - NAIL IM 130D 11.5MM 48CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648350 SUP HCPCS C1713 71648350 - NAIL IM 130D 11.5MM 50CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648430 SUP HCPCS C1713 71648430 - NAIL IM 130D 13MM 30CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648432 SUP HCPCS C1713 71648432 - NAIL IM 130D 13MM 32CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648434 SUP HCPCS C1713 71648434 - NAIL IM 130D 13MM 34CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648436 SUP HCPCS C1713 71648436 - NAIL IM 130D 13MM 36CM ROSE TRGN ANTGRD TN SET TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648438 SUP HCPCS C1713 71648438 - NAIL IM 130D 13MM 38CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648440 SUP HCPCS C1713 71648440 - NAIL IM 130D 13MM 40CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648442 SUP HCPCS C1713 71648442 - NAIL IM 130D 13MM 42CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648446 SUP HCPCS C1713 71648446 - NAIL IM 130D 13MM 46CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648448 SUP HCPCS C1713 71648448 - NAIL IM 130D 13MM 48CM ROSE TRGN ANTGRD TI RT TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71648450 SUP HCPCS C1713 71648450 - NAIL IM 130D RT ANG 13MM 50CM ROSE TN SET TROCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 71649530 SUP HCPCS C1713 71649530 - NAIL IM 9MM 30CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649532 SUP HCPCS C1713 71649532 - NAIL IM 9MM 32CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649534 SUP HCPCS C1713 71649534 - NAIL IM 9MM 34CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649536 SUP HCPCS C1713 71649536 - NAIL IM 9MM 36CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649538 SUP HCPCS C1713 71649538 - NAIL IM 9MM 38CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649540 SUP HCPCS C1713 71649540 - NAIL IM 9MM 40CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649542 SUP HCPCS C1713 71649542 - NAIL IM 9MM 42MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649544 SUP HCPCS C1713 71649544 - NAIL IM 9MM 44MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649546 SUP HCPCS C1713 71649546 - NAIL IM 9MM 46MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649548 SUP HCPCS C1713 71649548 - NAIL IM 9MM 48MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649550 SUP HCPCS C1713 71649550 - NAIL IM 9MM 50MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649630 SUP HCPCS C1713 71649630 - NAIL IM 10MM 30MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649632 SUP HCPCS C1713 71649632 - NAIL IM 10MM 32MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649634 SUP HCPCS C1713 71649634 - NAIL IM 10MM 34CM LIME TRGN MT-TN LT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649636 SUP HCPCS C1713 71649636 - NAIL IM 10MM 36MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649638 SUP HCPCS C1713 71649638 - NAIL IM 10MM 38MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649640 SUP HCPCS C1713 71649640 - NAIL IM 10MM 40MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649642 SUP HCPCS C1713 71649642 - NAIL IM 10MM 42MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649644 SUP HCPCS C1713 71649644 - NAIL IM 10MM 44MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649646 SUP HCPCS C1713 71649646 - NAIL IM 10MM 46MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649648 SUP HCPCS C1713 71649648 - NAIL IM 10MM 48MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649650 SUP HCPCS C1713 71649650 - NAIL IM 10MM 50MM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649730 SUP HCPCS C1713 71649730 - NAIL IM 11.5MM 30CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649732 SUP HCPCS C1713 71649732 - NAIL IM 11.5MM 32CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649734 SUP HCPCS C1713 71649734 - NAIL IM 11.5MM 34CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649736 SUP HCPCS C1713 71649736 - NAIL IM 11.5MM 36CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649738 SUP HCPCS C1713 71649738 - NAIL IM 11.5MM 38CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649740 SUP HCPCS C1713 71649740 - NAIL IM 11.5MM 40CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649742 SUP HCPCS C1713 71649742 - NAIL IM 11.5MM 42CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649744 SUP HCPCS C1713 71649744 - NAIL IM 11.5MM 44CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649746 SUP HCPCS C1713 71649746 - NAIL IM 11.5MM 46CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649748 SUP HCPCS C1713 71649748 - NAIL IM 11.5MM 48CM MT-TN LT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649750 SUP HCPCS C1713 71649750 - NAIL IM 11.5MM 50CM MT-TN LT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649830 SUP HCPCS C1713 71649830 - NAIL IM 13MM 30CM LIME TRGN MT-TN LT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649832 SUP HCPCS C1713 71649832 - NAIL IM 13MM 32CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649834 SUP HCPCS C1713 71649834 - NAIL IM 13MM 34CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649836 SUP HCPCS C1713 71649836 - NAIL IM 13MM 36CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649838 SUP HCPCS C1713 71649838 - NAIL IM 13MM 38CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649840 SUP HCPCS C1713 71649840 - NAIL IM 13MM 40CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649842 SUP HCPCS C1713 71649842 - NAIL IM 13MM 42CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649844 SUP HCPCS C1713 71649844 - NAIL IM 13MM 44CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649846 SUP HCPCS C1713 71649846 - NAIL IM 13MM 46CM LIME TRGN MT-TN ANTGRD FEM LT TROCH BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649848 SUP HCPCS C1713 71649848 - NAIL IM 13MM 48CM MT-TN LT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71649850 SUP HCPCS C1713 71649850 - NAIL IM 13MM 50CM MT-TN LT BOTH IP/OP "$3,526.88 " "$2,609.89" $0.00 "$2,821.50" "$1,587.09" "$1,587.09" $0.00 $0.00 $0.00 $735.09 "$2,617.65" "$2,617.65" $0.00 $0.00 $735.00 $0.00 "$1,738.75" "$1,738.75" $0.00 "$1,763.44" "$2,793.29" "$2,821.50" $0.00 $0.00 $551.96 $0.00 $0.00 $561.48 $0.00 $0.00 $0.00 $0.00 $0.00 71653018 SUP HCPCS C1713 71653018 - NAIL IM 10MM 18CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653020 SUP HCPCS C1713 71653020 - NAIL IM 10MM 20CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653022 SUP HCPCS C1713 71653022 - NAIL IM 10MM 22CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653024 SUP HCPCS C1713 71653024 - NAIL IM 10MM 24CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653026 SUP HCPCS C1713 71653026 - NAIL IM 10MM 26CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653028 SUP HCPCS C1713 71653028 - NAIL IM 10MM 28CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653030 SUP HCPCS C1713 71653030 - NAIL IM 10MM 30CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653032 SUP HCPCS C1713 71653032 - NAIL IM 10MM 32CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653034 SUP HCPCS C1713 71653034 - NAIL IM 10MM 34CM AU TRGN MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653036 SUP HCPCS C1713 71653036 - NAIL IM 10MM 36CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653038 SUP HCPCS C1713 71653038 - NAIL IM 10MM 38CM AU TRGN MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653040 SUP HCPCS C1713 71653040 - NAIL IM STD 10MM 40CM AU STRL TRGN MT-NL RTRGD HMR SLT TI BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653042 SUP HCPCS C1713 71653042 - NAIL IM STD 10MM 42CM AU STRL TRGN MT-NL RTRGD HMR SLT TI BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653044 SUP HCPCS C1713 71653044 - NAIL IM 10MM 44CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653046 SUP HCPCS C1713 71653046 - NAIL IM 10MM 46CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653048 SUP HCPCS C1713 71653048 - NAIL IM 10MM 48CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653050 SUP HCPCS C1713 71653050 - NAIL IM 10MM 50CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653120 SUP HCPCS C1713 71653120 - NAIL IM 11.5MM 20CM TRGN TI SP CNDL BOTH IP/OP "$3,510.00 " "$2,597.40" $0.00 "$2,808.00" "$1,579.50" "$1,579.50" $0.00 $0.00 $0.00 $731.57 "$2,605.12" "$2,605.12" $0.00 $0.00 $731.48 $0.00 "$1,730.43" "$1,730.43" $0.00 "$1,755.00" "$2,779.92" "$2,808.00" $0.00 $0.00 $549.32 $0.00 $0.00 $558.79 $0.00 $0.00 $0.00 $0.00 $0.00 71653125 SUP HCPCS C1713 71653125 - NAIL IM 11.5MM 25CM TRGN TI SP CNDL BOTH IP/OP "$3,510.00 " "$2,597.40" $0.00 "$2,808.00" "$1,579.50" "$1,579.50" $0.00 $0.00 $0.00 $731.57 "$2,605.12" "$2,605.12" $0.00 $0.00 $731.48 $0.00 "$1,730.43" "$1,730.43" $0.00 "$1,755.00" "$2,779.92" "$2,808.00" $0.00 $0.00 $549.32 $0.00 $0.00 $558.79 $0.00 $0.00 $0.00 $0.00 $0.00 71653218 SUP HCPCS C1713 71653218 - NAIL IM 11.5MM 18CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653220 SUP HCPCS C1713 71653220 - NAIL IM 11.5MM 20CM MT-NL RTRGD TI6AL4V FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653222 SUP HCPCS C1713 71653222 - NAIL IM 11.5MM 22CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653224 SUP HCPCS C1713 71653224 - NAIL IM 11.5MM 24CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653226 SUP HCPCS C1713 71653226 - NAIL IM 11.5MM 26CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653228 SUP HCPCS C1713 71653228 - NAIL IM 11.5MM 28CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653230 SUP HCPCS C1713 71653230 - NAIL IM 11.5MM 30CM TRGN MT-NL IMPL SET RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653232 SUP HCPCS C1713 71653232 - NAIL IM 11.5MM 32CM AU TRGN MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653234 SUP HCPCS C1713 71653234 - NAIL IM 11.5MM 34CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653236 SUP HCPCS C1713 71653236 - NAIL IM 11.5MM 36CM TRGN MT-NL IMPL SET RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653238 SUP HCPCS C1713 71653238 - NAIL IM 10MM 38CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653240 SUP HCPCS C1713 "71653240 - RETROGRADE FEMUR NAIL, 11.5MMX40CM" BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653242 SUP HCPCS C1713 71653242 - NAIL IM 11.5MM 42CM TRGN MT-NL RTRGD FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653244 SUP HCPCS C1713 71653244 - NAIL IM 11.5MM 44CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653246 SUP HCPCS C1713 71653246 - NAIL IM 11.5MM 46CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653248 SUP HCPCS C1713 71653248 - NAIL IM 11.5MM 48CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653250 SUP HCPCS C1713 71653250 - NAIL IM 11.5MM 50CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653320 SUP HCPCS C1713 71653320 - NAIL IM 13MM 20CM TRGN TI TIB BOTH IP/OP "$3,510.00 " "$2,597.40" $0.00 "$2,808.00" "$1,579.50" "$1,579.50" $0.00 $0.00 $0.00 $731.57 "$2,605.12" "$2,605.12" $0.00 $0.00 $731.48 $0.00 "$1,730.43" "$1,730.43" $0.00 "$1,755.00" "$2,779.92" "$2,808.00" $0.00 $0.00 $549.32 $0.00 $0.00 $558.79 $0.00 $0.00 $0.00 $0.00 $0.00 71653325 SUP HCPCS C1713 71653325 - NAIL IM 13MM 25CM TRGN TI TIB BOTH IP/OP "$3,510.00 " "$2,597.40" $0.00 "$2,808.00" "$1,579.50" "$1,579.50" $0.00 $0.00 $0.00 $731.57 "$2,605.12" "$2,605.12" $0.00 $0.00 $731.48 $0.00 "$1,730.43" "$1,730.43" $0.00 "$1,755.00" "$2,779.92" "$2,808.00" $0.00 $0.00 $549.32 $0.00 $0.00 $558.79 $0.00 $0.00 $0.00 $0.00 $0.00 71653418 SUP HCPCS C1713 71653418 - NAIL IM 13MM 18CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653420 SUP HCPCS C1713 71653420 - NAIL IM 13MM 20CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653422 SUP HCPCS C1713 71653422 - NAIL IM 13MM 22CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653424 SUP HCPCS C1713 71653424 - NAIL IM 13MM 24CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653426 SUP HCPCS C1713 71653426 - NAIL IM 13MM 26CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653428 SUP HCPCS C1713 71653428 - NAIL IM 13MM 28CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653430 SUP HCPCS C1713 71653430 - NAIL IM 13MM 30CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653432 SUP HCPCS C1713 71653432 - NAIL IM 13MM 32CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653434 SUP HCPCS C1713 71653434 - NAIL IM 13MM 34CM TRGN MT-NL IMPL SET RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653436 SUP HCPCS C1713 71653436 - NAIL IM 13MM 36CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653438 SUP HCPCS C1713 71653438 - NAIL IM 13MM 38CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653440 SUP HCPCS C1713 71653440 - NAIL IM STD 13MM 40CM AU STRL TRGN MT-NL RTRGD HMR SLT TI BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653442 SUP HCPCS C1713 71653442 - NAIL IM 13MM 42CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653444 SUP HCPCS C1713 71653444 - NAIL IM 13MM 44CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653446 SUP HCPCS C1713 71653446 - NAIL IM 13MM 46CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653448 SUP HCPCS C1713 71653448 - NAIL IM 13MM 48CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71653450 SUP HCPCS C1713 71653450 - NAIL IM 13MM 50CM MT-NL RTRGD TI FEM BOTH IP/OP "$3,622.50 " "$2,680.65" $0.00 "$2,898.00" "$1,630.13" "$1,630.13" $0.00 $0.00 $0.00 $755.02 "$2,688.62" "$2,688.62" $0.00 $0.00 $754.93 $0.00 "$1,785.89" "$1,785.89" $0.00 "$1,811.25" "$2,869.02" "$2,898.00" $0.00 $0.00 $566.92 $0.00 $0.00 $576.70 $0.00 $0.00 $0.00 $0.00 $0.00 71655016 SUP HCPCS C1713 71655016 - NAIL IM 8.5MM 16CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655018 SUP HCPCS C1713 71655018 - NAIL IM 8.5MM 18CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655020 SUP HCPCS C1713 71655020 - NAIL IM 8.5MM 20CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655022 SUP HCPCS C1713 71655022 - NAIL IM 8.5MM 22CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655024 SUP HCPCS C1713 71655024 - NAIL IM 8.5MM 24CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655026 SUP HCPCS C1713 71655026 - NAIL IM 8.5MM 26CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655028 SUP HCPCS C1713 71655028 - NAIL IM 8.5MM 28CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655029 SUP HCPCS C1713 71655029 - NAIL IM 8.5MM 29CM TRGN MT-NL TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655030 SUP HCPCS C1713 71655030 - NAIL 8.5MM 30CM TIB MT-NAIL IM TI BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655031 SUP HCPCS C1713 71655031 - NAIL IM 8.5MM 31CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655032 SUP HCPCS C1713 71655032 - NAIL IM 8.5MM 32CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655034 SUP HCPCS C1713 71655034 - NAIL IM 8.5MM 34CM TRGN MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655035 SUP HCPCS C1713 71655035 - NAIL IM 8.5MM 35CM MT-NL TI TIB METAPHYSIS BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655036 SUP HCPCS C1713 71655036 - NAIL IM 8.5MM 36CM TRGN MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655037 SUP HCPCS C1713 71655037 - NAIL IM 8.5MM 37CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655038 SUP HCPCS C1713 71655038 - NAIL IM 8.5MM 38CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655039 SUP HCPCS C1713 71655039 - NAIL IM 8.5MM 39CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655040 SUP HCPCS C1713 71655040 - NAIL IM 8.5MM 40CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655041 SUP HCPCS C1713 71655041 - NAIL IM 8.5MM 41CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655042 SUP HCPCS C1713 71655042 - NAIL IM 8.5MM 42CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655043 SUP HCPCS C1713 71655043 - NAIL IM 8.5MM 43CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655044 SUP HCPCS C1713 71655044 - NAIL IM 8.5MM 44CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655046 SUP HCPCS C1713 71655046 - NAIL IM 8.5MM 46CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655048 SUP HCPCS C1713 71655048 - NAIL IM 8.5MM 48CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655050 SUP HCPCS C1713 71655050 - NAIL IM 8.5MM 50CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655116 SUP HCPCS C1713 71655116 - NAIL IM 10MM 16CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655118 SUP HCPCS C1713 71655118 - NAIL IM 10MM 18CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655120 SUP HCPCS C1713 71655120 - NAIL IM 10MM 20CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655122 SUP HCPCS C1713 71655122 - NAIL IM 10MM 22CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655124 SUP HCPCS C1713 71655124 - NAIL IM 10MM 24CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655126 SUP HCPCS C1713 71655126 - NAIL IM 10MM 26CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655128 SUP HCPCS C1713 71655128 - NAIL IM 10MM 28CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655129 SUP HCPCS C1713 71655129 - NAIL IM 10MM 29CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655130 SUP HCPCS C1713 71655130 - NAIL IM 10MM 30CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655131 SUP HCPCS C1713 71655131 - NAIL IM 10MM 31CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655132 SUP HCPCS C1713 71655132 - NAIL INTRAMEDULLARY 10MM 32CM META-NAIL TITANIUM TIBIA BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655133 SUP HCPCS C1713 71655133 - NAIL IM 10MM 33CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655134 SUP HCPCS C1713 71655134 - NAIL INTRAMEDULLARY 10MM 34CM META-NAIL TITANIUM TIBIA BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655135 SUP HCPCS C1713 71655135 - NAIL INTRAMEDULLARY 10MM 35CM META-NAIL TITANIUM TIBIA BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655136 SUP HCPCS C1713 71655136 - NAIL INTRAMEDULLARY 10MM 36CM META-NAIL TITANIUM TIBIA BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655137 SUP HCPCS C1713 71655137 - NAIL INTRAMEDULLARY 10MM 37CM META-NAIL TITANIUM TIBIA BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655138 SUP HCPCS C1713 71655138 - NAIL INTRAMEDULLARY 10MM 38CM META-NAIL TITANIUM TIBIA BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655139 SUP HCPCS C1713 71655139 - NAIL INTRAMEDULLARY 10MM 39CM META-NAIL TITANIUM TIBIA BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655142 SUP HCPCS C1713 71655142 - NAIL IM 10MM 42CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655143 SUP HCPCS C1713 71655143 - NAIL IM 10MM 43CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655144 SUP HCPCS C1713 71655144 - NAIL IM 10MM 44CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655146 SUP HCPCS C1713 71655146 - NAIL IM 10MM 46CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655148 SUP HCPCS C1713 71655148 - NAIL IM 10MM 48CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655150 SUP HCPCS C1713 71655150 - NAIL IM 10MM 50CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655216 SUP HCPCS C1713 71655216 - NAIL IM 11.5MM 16CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655218 SUP HCPCS C1713 71655218 - NAIL IM 11.5MM 18CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655220 SUP HCPCS C1713 71655220 - NAIL IM 11.5MM 20CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655222 SUP HCPCS C1713 71655222 - NAIL IM 11.5MM 22CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655224 SUP HCPCS C1713 71655224 - NAIL IM 11.5MM 24CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655226 SUP HCPCS C1713 71655226 - NAIL IM 11.5MM 26CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655228 SUP HCPCS C1713 71655228 - NAIL IM 11.5MM 28CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655229 SUP HCPCS C1713 71655229 - NAIL IM 11.5MM 29CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655230 SUP HCPCS C1713 71655230 - NAIL IM 11.5MM 30CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655231 SUP HCPCS C1713 71655231 - NAIL IM 11.5MM 31CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655232 SUP HCPCS C1713 71655232 - NAIL IM 11.5MM 32CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655233 SUP HCPCS C1713 71655233 - NAIL IM 11.5MM 33CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655234 SUP HCPCS C1713 71655234 - NAIL IM 11.5MM 34CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655235 SUP HCPCS C1713 71655235 - NAIL IM 11.5MM 35CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655236 SUP HCPCS C1713 71655236 - NAIL 11.5MM 36CM TIB TRGN MT-NAIL IM HMR SLT TI BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655237 SUP HCPCS C1713 71655237 - NAIL IM 11.5MM 37CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655238 SUP HCPCS C1713 71655238 - NAIL IM 11.5MM 38CM AU STRL TRGN MT-NL HMR SLT TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655239 SUP HCPCS C1713 71655239 - NAIL IM 11.5MM 39CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655240 SUP HCPCS C1713 71655240 - NAIL INTRAMEDULLARY 11.5MM 40CM META-NAIL TITANIUM TIBIA BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655241 SUP HCPCS C1713 71655241 - NAIL IM 11.5MM 41CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655242 SUP HCPCS C1713 71655242 - NAIL IM 11.5MM 42CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655243 SUP HCPCS C1713 71655243 - NAIL IM 11.5MM 43CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655244 SUP HCPCS C1713 71655244 - NAIL IM 11.5MM 44CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655246 SUP HCPCS C1713 71655246 - NAIL IM 11.5MM 46CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655248 SUP HCPCS C1713 71655248 - NAIL IM 11.5MM 48CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655250 SUP HCPCS C1713 71655250 - NAIL IM 11.5MM 50CM MT-NL TI TIB BOTH IP/OP "$3,538.13 " "$2,618.22" $0.00 "$2,830.50" "$1,592.16" "$1,592.16" $0.00 $0.00 $0.00 $737.43 "$2,626.00" "$2,626.00" $0.00 $0.00 $737.35 $0.00 "$1,744.30" "$1,744.30" $0.00 "$1,769.06" "$2,802.20" "$2,830.50" $0.00 $0.00 $553.72 $0.00 $0.00 $563.27 $0.00 $0.00 $0.00 $0.00 $0.00 71655316 SUP HCPCS C1713 71655316 - NAIL IM 13MM 16CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655318 SUP HCPCS C1713 71655318 - NAIL IM 13MM 18CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655320 SUP HCPCS C1713 71655320 - NAIL IM 13MM 20CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655322 SUP HCPCS C1713 71655322 - NAIL IM 13MM 22CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655324 SUP HCPCS C1713 71655324 - NAIL IM 13MM 24CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655326 SUP HCPCS C1713 71655326 - NAIL IM 13MM 26CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655328 SUP HCPCS C1713 71655328 - NAIL IM 13MM 28CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655329 SUP HCPCS C1713 71655329 - NAIL IM 13MM 29CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655330 SUP HCPCS C1713 71655330 - NAIL IM 13MM 30CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655331 SUP HCPCS C1713 71655331 - NAIL IM 13MM 31CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655332 SUP HCPCS C1713 71655332 - NAIL IM 13MM 32CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655333 SUP HCPCS C1713 71655333 - NAIL IM 13MM 33CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655334 SUP HCPCS C1713 71655334 - NAIL IM RND 13MM 34CM AU MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655335 SUP HCPCS C1713 71655335 - NAIL IM 13MM 35CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655336 SUP HCPCS C1713 71655336 - NAIL IM 13MM 36CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655337 SUP HCPCS C1713 71655337 - NAIL IM 13MM 37CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655338 SUP HCPCS C1713 71655338 - NAIL IM 13MM 38CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655339 SUP HCPCS C1713 71655339 - NAIL IM 13MM 39CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655340 SUP HCPCS C1713 71655340 - NAIL IM RND 13MM 40CM AU MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655341 SUP HCPCS C1713 71655341 - NAIL IM 13MM 41CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655342 SUP HCPCS C1713 71655342 - NAIL IM 13MM 42CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655343 SUP HCPCS C1713 71655343 - NAIL IM 13MM 43CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655344 SUP HCPCS C1713 71655344 - NAIL IM 13MM 44CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655346 SUP HCPCS C1713 71655346 - NAIL IM 13MM 46CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655348 SUP HCPCS C1713 71655348 - NAIL IM 13MM 48CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71655350 SUP HCPCS C1713 71655350 - NAIL IM 13MM 50CM MT-NL TI TIB BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 71656000 SUP HCPCS C1713 71656000 - CAP END 0MM MT-NL NL SCR SET TI TIB BOTH IP/OP $354.38 $262.24 $0.00 $283.50 $159.47 $159.47 $0.00 $0.00 $0.00 $73.86 $263.02 $263.02 $0.00 $0.00 $73.85 $0.00 $209.61 $209.61 $0.00 $177.19 $280.67 $283.50 $0.00 $0.00 $55.46 $0.00 $0.00 $56.42 $0.00 $0.00 $0.00 $0.00 $0.00 71661222 SUP HCPCS C1713 71661222 - SCREW BN 4.5MM 22MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661224 SUP HCPCS C1713 71661224 - SCREW BN 4.5MM 24MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661226 SUP HCPCS C1713 71661226 - SCREW BN 4.5MM 26MM IMHS CP CPTR LCK HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661228 SUP HCPCS C1713 71661228 - SCREW BN 4.5MM 28MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661230 SUP HCPCS C1713 71661230 - SCREW BN 4.5MM 30MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661232 SUP HCPCS C1713 71661232 - SCREW BN 4.5MM 32MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661234 SUP HCPCS C1713 71661234 - SCREW BN 4.5MM 34MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661236 SUP HCPCS C1713 71661236 - SCREW BN 4.5MM 36MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661238 SUP HCPCS C1713 71661238 - SCREW BN 4.5MM 38MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661240 SUP HCPCS C1713 71661240 - SCREW BN 4.5MM 40MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661242 SUP HCPCS C1713 71661242 - SCREW BN 4.5MM 42MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661244 SUP HCPCS C1713 71661244 - SCREW BN 4.5MM 44MM IMHS CP LCK CPTR HIP IM NL BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661246 SUP HCPCS C1713 71661246 - SCREW BN 4.5MM 46MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661248 SUP HCPCS C1713 71661248 - SCREW BN 4.5MM 48MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661250 SUP HCPCS C1713 71661250 - SCREW BN 4.5MM 50MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661252 SUP HCPCS C1713 71661252 - SCREW BN 4.5MM 52MM IMHS CP LCK CPTR HIP IM NL BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661254 SUP HCPCS C1713 71661254 - SCREW BN 4.5MM 54MM IMHS CP LCK CPTR HIP IM NL BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661256 SUP HCPCS C1713 71661256 - SCREW BN 4.5MM 56MM IMHS CP LCK CPTR HIP IM NL BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661258 SUP HCPCS C1713 71661258 - SCREW BN 4.5MM 58MM IMHS CP LCK CPTR HIP IM NL SYS BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661260 SUP HCPCS C1713 71661260 - SCREW BN 4.5MM 60MM IMHS CP LCK CPTR HIP IM NL BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661262 SUP HCPCS C1713 71661262 - SCREW BN 4.5MM 62MM IMHS CP LCK CPTR HIP IM NL BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71661264 SUP HCPCS C1713 71661264 - SCREW BN 4.5MM 64MM IMHS CP LCK CPTR HIP IM NL BOTH IP/OP $593.25 $439.01 $0.00 $474.60 $266.96 $266.96 $0.00 $0.00 $0.00 $123.65 $440.31 $440.31 $0.00 $0.00 $123.63 $0.00 $350.91 $350.91 $0.00 $296.63 $469.85 $474.60 $0.00 $0.00 $92.84 $0.00 $0.00 $94.45 $0.00 $0.00 $0.00 $0.00 $0.00 71665026 SUP HCPCS C1769 71665026 - GUIDE ROD ORTHOPEDIC 3MM 600MM BALL TIP TRIGEN DISPOSABLE BOTH IP/OP $490.88 $363.25 $0.00 $392.70 $266.55 $266.55 $0.00 $0.00 $0.00 $102.31 $364.33 $364.33 $0.00 $0.00 $102.30 $0.00 $290.35 $290.35 $0.00 $245.44 $388.78 $392.70 $0.00 $0.00 $76.82 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $0.00 71672030 SUP HCPCS C1713 71672030 - SCREW BONE 11MM 30MM COMPRESSION INTERTAN TROCHANTER BOTH IP/OP $659.25 $487.85 $0.00 $527.40 $296.66 $296.66 $0.00 $0.00 $0.00 $137.40 $489.30 $489.30 $0.00 $0.00 $137.39 $0.00 $389.95 $389.95 $0.00 $329.63 $522.13 $527.40 $0.00 $0.00 $103.17 $0.00 $0.00 $104.95 $0.00 $0.00 $0.00 $0.00 $0.00 71672035 SUP HCPCS C1713 71672035 - SCREW BN 35MM CMPR ORTH BOTH IP/OP $676.00 $500.24 $0.00 $540.80 $304.20 $304.20 $0.00 $0.00 $0.00 $140.90 $501.73 $501.73 $0.00 $0.00 $140.88 $0.00 $399.85 $399.85 $0.00 $338.00 $535.39 $540.80 $0.00 $0.00 $105.79 $0.00 $0.00 $107.62 $0.00 $0.00 $0.00 $0.00 $0.00 71672040 SUP HCPCS C1713 71672040 - SCREW BN 40MM CMPR ORTH BOTH IP/OP $460.13 $340.50 $0.00 $368.10 $207.06 $207.06 $0.00 $0.00 $0.00 $95.90 $341.50 $341.50 $0.00 $0.00 $95.89 $0.00 $272.16 $272.16 $0.00 $230.06 $364.42 $368.10 $0.00 $0.00 $72.01 $0.00 $0.00 $73.25 $0.00 $0.00 $0.00 $0.00 $0.00 71673040 SUP HCPCS C1713 71673040 - NAIL IM 130D 10MM 40CM INTERTAN LT TROCH BOTH IP/OP "$3,155.63 " "$2,335.17" $0.00 "$2,524.50" "$1,420.03" "$1,420.03" $0.00 $0.00 $0.00 $657.71 "$2,342.10" "$2,342.10" $0.00 $0.00 $657.63 $0.00 "$1,555.72" "$1,555.72" $0.00 "$1,577.81" "$2,499.26" "$2,524.50" $0.00 $0.00 $493.86 $0.00 $0.00 $502.38 $0.00 $0.00 $0.00 $0.00 $0.00 71673125 SUP HCPCS C1713 71673125 - SCREW BN 11MM 125MM LG BOTH IP/OP $892.00 $660.08 $0.00 $713.60 $401.40 $401.40 $0.00 $0.00 $0.00 $185.92 $662.04 $662.04 $0.00 $0.00 $185.89 $0.00 $527.62 $527.62 $0.00 $446.00 $706.46 $713.60 $0.00 $0.00 $139.60 $0.00 $0.00 $142.01 $0.00 $0.00 $0.00 $0.00 $0.00 71674029 SUP HCPCS C1713 71674029 - GUIDEPIN ORTH 343MM 3.2MM THRD BOTH IP/OP $335.65 $248.38 $0.00 $268.52 $151.04 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.83 $265.83 $268.52 $0.00 $0.00 $52.53 $0.00 $0.00 $53.44 $0.00 $0.00 $0.00 $0.00 $0.00 71674034 SUP HCPCS C1713 71674034 - GUIDE SURG 7MM 7MM COMPRESSION SCREW TRIGEN INTERTAN BOTH IP/OP $381.38 $282.22 $0.00 $305.10 $171.62 $171.62 $0.00 $0.00 $0.00 $0.00 $283.06 $283.06 $0.00 $0.00 $79.48 $0.00 $0.00 $0.00 $0.00 $190.69 $302.05 $305.10 $0.00 $0.00 $59.69 $0.00 $0.00 $60.71 $0.00 $0.00 $0.00 $0.00 $0.00 71674130 SUP Custom 27203010 71674130 - GUIDE PIN ORTHOPEDIC 3.2MM 343MM BRAD POINT TIP THREADED BOTH IP/OP $308.25 $228.11 $0.00 $246.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.78 $228.78 $0.00 $0.00 $64.24 $0.00 $0.00 $0.00 $0.00 $154.13 $244.13 $246.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71674540 SUP HCPCS C1713 71674540 - INTERTAN LAG SCREW DRILL BOTH IP/OP "$1,032.75 " $764.24 $0.00 $826.20 $464.74 $464.74 $0.00 $0.00 $0.00 $215.25 $766.51 $766.51 $0.00 $0.00 $215.23 $0.00 $610.87 $610.87 $0.00 $516.38 $817.94 $826.20 $0.00 $0.00 $161.63 $0.00 $0.00 $164.41 $0.00 $0.00 $0.00 $0.00 $0.00 71675030 SUP HCPCS C1713 71675030 - SCREW BN INTERTAN SET BOTH IP/OP $493.88 $365.47 $0.00 $395.10 $222.24 $222.24 $0.00 $0.00 $0.00 $102.94 $366.55 $366.55 $0.00 $0.00 $102.92 $0.00 $292.13 $292.13 $0.00 $246.94 $391.15 $395.10 $0.00 $0.00 $77.29 $0.00 $0.00 $78.62 $0.00 $0.00 $0.00 $0.00 $0.00 71675040 SUP HCPCS C1713 71675040 - CAP END INTERTAN TROCH IM NL BOTH IP/OP $279.00 $206.46 $0.00 $223.20 $125.55 $125.55 $0.00 $0.00 $0.00 $58.15 $207.07 $207.07 $0.00 $0.00 $58.14 $0.00 $165.03 $165.03 $0.00 $139.50 $220.97 $223.20 $0.00 $0.00 $43.66 $0.00 $0.00 $44.42 $0.00 $0.00 $0.00 $0.00 $0.00 71675201 SUP HCPCS C1713 71675201 - NAIL IM 125D SHRT 10MM 180MM INTERTAN TI TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675202 SUP HCPCS C1713 71675202 - NAIL IM 125D 11.5MM 18CM INTERTAN TI TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675203 SUP HCPCS C1713 71675203 - NAIL IM 125D SHRT 13MM 18CM INTERTAN TI TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675204 SUP HCPCS C1713 71675204 - NAIL IM 125D 10MM 20CM INTERTAN TI TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675205 SUP HCPCS C1713 71675205 - NAIL IM 125D 11.5MM 20CM INTERTAN TI TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675206 SUP HCPCS C1713 71675206 - NAIL IM 125D 13MM 20CM INTERTAN BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675207 SUP HCPCS C1713 71675207 - NAIL IM 130D SHRT 10MM 18CM INTERTAN ANTGRD TI INTST BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675208 SUP HCPCS C1713 71675208 - NAIL IM 130D SHRT 11.5MM 18CM INTERTAN ANTGRD TI INTST BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675209 SUP HCPCS C1713 71675209 - NAIL IM 130D SHRT 13MM 18CM INTERTAN TI TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675210 SUP HCPCS C1713 71675210 - NAIL IM 130D 10MM 20CM INTERTAN TI ORTH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675211 SUP HCPCS C1713 71675211 - NAIL IM 130D 11.5MM 20CM INTERTAN TI TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675212 SUP HCPCS C1713 71675212 - NAIL IM 130D 13MM 20CM INTERTAN TI TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675213 SUP HCPCS C1713 71675213 - NAIL IM 125D 10MM 26CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675214 SUP HCPCS C1713 71675214 - NAIL IM 125D 10MM 26CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675215 SUP HCPCS C1713 71675215 - NAIL IM 125D 10MM 28CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675216 SUP HCPCS C1713 71675216 - NAIL IM 125D 10MM 28CM INTERTAN TI RT ORTH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675217 SUP HCPCS C1713 71675217 - NAIL IM 125D 10MM 30CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675218 SUP HCPCS C1713 71675218 - NAIL IM 125D 10MM 30CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675219 SUP HCPCS C1713 71675219 - NAIL IM 125D 10MM 32CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675220 SUP HCPCS C1713 71675220 - NAIL IM 125D 10MM 32CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675221 SUP HCPCS C1713 71675221 - NAIL IM 125D LG 10MM 34CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675222 SUP HCPCS C1713 71675222 - NAIL IM 125D 10MM 34CM ROSE INTERTAN TI RT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675223 SUP HCPCS C1713 71675223 - NAIL IM 125D 10MM 36CM LIME INTERTAN TI LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675224 SUP HCPCS C1713 71675224 - NAIL IM 125D 10MM 36CM ROSE INTERTAN TI RT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675225 SUP HCPCS C1713 71675225 - NAIL IM 125D LG 10MM 38CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675226 SUP HCPCS C1713 71675226 - NAIL IM 125D LG 10MM 38CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675227 SUP HCPCS C1713 71675227 - NAIL IM 125D LG 10MM 40CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675228 SUP HCPCS C1713 71675228 - NAIL IM 125D LG 10MM 400MM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675229 SUP HCPCS C1713 71675229 - NAIL IM 125D 10MM 42CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675230 SUP HCPCS C1713 71675230 - NAIL IM 125D 10MM 42CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675231 SUP HCPCS C1713 71675231 - NAIL IM 125D 10MM 44CM INTERTAN LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675232 SUP HCPCS C1713 71675232 - NAIL IM 125D 10MM 44CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675233 SUP HCPCS C1713 71675233 - NAIL IM 125D 10MM 46CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675234 SUP HCPCS C1713 71675234 - NAIL IM 125D 10MM 46CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675235 SUP HCPCS C1713 71675235 - NAIL IM 125D 11.5MM 26CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675236 SUP HCPCS C1713 71675236 - NAIL IM 125D 11.5MM 26CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675237 SUP HCPCS C1713 71675237 - NAIL IM 125D 11.5MM 28CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675238 SUP HCPCS C1713 71675238 - NAIL IM 125D 11.5MM 28CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675239 SUP HCPCS C1713 71675239 - NAIL IM 125D LG 11.5MM 30CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675240 SUP HCPCS C1713 71675240 - NAIL IM 125D 11.5MM 30CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675241 SUP HCPCS C1713 71675241 - NAIL IM 125D 11.5MM 32CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675242 SUP HCPCS C1713 71675242 - NAIL IM 125D 11.5MM 32CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675243 SUP HCPCS C1713 71675243 - NAIL IM 125D LG 11.5MM 34CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675244 SUP HCPCS C1713 71675244 - NAIL IM 125D 11.5MM 34CM ROSE INTERTAN TI RT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675245 SUP HCPCS C1713 71675245 - NAIL IM 125D LG 11.5MM 360MM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675246 SUP HCPCS C1713 71675246 - NAIL IM 125D LG 11.5MM 36CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675247 SUP HCPCS C1713 71675247 - NAIL IM 125D 11.5MM 38CM LIME INTERTAN TI LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675248 SUP HCPCS C1713 71675248 - NAIL IM 125D LG 11.5MM 380MM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675249 SUP HCPCS C1713 71675249 - NAIL IM 125D LG 11.5MM 40CM LIME TRGN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675250 SUP HCPCS C1713 71675250 - NAIL IM 125D LG 11.5MM 400MM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675251 SUP HCPCS C1713 71675251 - NAIL IM 125D 11.5MM 42CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675252 SUP HCPCS C1713 71675252 - NAIL IM 125D 11.5MM 42CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675253 SUP HCPCS C1713 71675253 - NAIL IM 125D 11.5MM 44CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675254 SUP HCPCS C1713 71675254 - NAIL IM 125D 11.5MM 44CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675255 SUP HCPCS C1713 71675255 - NAIL IM 125D 11.5MM 46CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675256 SUP HCPCS C1713 71675256 - NAIL IM 125D 11.5MM 46CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675257 SUP HCPCS C1713 71675257 - NAIL IM 130D 10MM 26CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675258 SUP HCPCS C1713 71675258 - NAIL IM 130D 10MM 26CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675259 SUP HCPCS C1713 71675259 - NAIL IM 130D 10MM 28CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675260 SUP HCPCS C1713 71675260 - NAIL IM 130D 10MM 28CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675261 SUP HCPCS C1713 71675261 - NAIL IM 130D 10MM 30CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675262 SUP HCPCS C1713 71675262 - NAIL IM 130D 10MM 30CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675263 SUP HCPCS C1713 71675263 - NAIL IM 130D 10MM 32CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675264 SUP HCPCS C1713 71675264 - NAIL IM 130D 10MM 32CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675265 SUP HCPCS C1713 71675265 - NAIL IM 130D LNG 10MM 34CM LIME ROSE INTERTAN TRGN NK ANG LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675266 SUP HCPCS C1713 71675266 - NAIL IM 130D LNG 10MM 34CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675267 SUP HCPCS C1713 71675267 - NAIL IM 130D LNG 10MM 36CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675268 SUP HCPCS C1713 71675268 - NAIL IM 130D LNG 10MM 36CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675269 SUP HCPCS C1713 71675269 - NAIL IM 130D 10MM 38CM LIME INTERTAN TI LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675270 SUP HCPCS C1713 71675270 - NAIL IM 130D LNG 10MM 380MM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675271 SUP HCPCS C1713 71675271 - NAIL IM 130D LNG 10MM 40CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675272 SUP HCPCS C1713 71675272 - NAIL IM 130D LNG 10MM 40CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675273 SUP HCPCS C1713 71675273 - NAIL IM 130D 10MM 42CM INTERTAN LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675274 SUP HCPCS C1713 71675274 - NAIL IM 130D LNG 10MM 42CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675275 SUP HCPCS C1713 71675275 - NAIL IM 130D 10MM 44CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675276 SUP HCPCS C1713 71675276 - NAIL IM 130D 10MM 44CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675277 SUP HCPCS C1713 71675277 - NAIL IM 130D 10MM 46CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675278 SUP HCPCS C1713 71675278 - NAIL IM 130D 10MM 46CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675279 SUP HCPCS C1713 71675279 - NAIL IM 130D 11.5MM 26CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675280 SUP HCPCS C1713 71675280 - NAIL IM 130D 11.5MM 26CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675281 SUP HCPCS C1713 71675281 - NAIL IM 130D 11.5MM 28CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675282 SUP HCPCS C1713 71675282 - NAIL IM 130D 11.5MM 28CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675283 SUP HCPCS C1713 71675283 - NAIL IM 130D 11.5MM 30CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675284 SUP HCPCS C1713 71675284 - NAIL IM 130D 11.5MM 30CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675285 SUP HCPCS C1713 71675285 - NAIL IM 130D 11.5MM 32CM INTERTAN LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675286 SUP HCPCS C1713 71675286 - NAIL IM 130D 11.5MM 32CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675287 SUP HCPCS C1713 71675287 - NAIL IM 130D 11.5MM 34CM INTERTAN ANTGRD TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675288 SUP HCPCS C1713 71675288 - NAIL IM 130D LNG 11.5MM 34CM ROSE INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675289 SUP HCPCS C1713 71675289 - NAIL IM 130D LNG 11.5MM 360MM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675290 SUP HCPCS C1713 71675290 - NAIL IM 130D LNG 11.5MM 36CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675291 SUP HCPCS C1713 71675291 - NAIL IM 130D LNG 11.5MM 380MM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675292 SUP HCPCS C1713 71675292 - NAIL IM 130D LNG 11.5MM 380MM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675293 SUP HCPCS C1713 71675293 - NAIL IM 130D LNG 11.5MM 40CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675294 SUP HCPCS C1713 71675294 - NAIL IM 130D LNG 11.5MM 40CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675295 SUP HCPCS C1713 71675295 - NAIL IM 130D LNG 11.5MM 42CM LIME INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675361 SUP HCPCS C1713 71675361 - NAIL IM 135D 13MM 26CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675362 SUP HCPCS C1713 71675362 - NAIL IM 135D 13MM 26CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675363 SUP HCPCS C1713 71675363 - NAIL IM 135D 13MM 28CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675364 SUP HCPCS C1713 71675364 - NAIL IM 135D 13MM 28CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675365 SUP HCPCS C1713 71675365 - NAIL IM 135D 13MM 30CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675366 SUP HCPCS C1713 71675366 - NAIL IM 135D 13MM 30CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675367 SUP HCPCS C1713 71675367 - NAIL IM 135D 13MM 32CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675368 SUP HCPCS C1713 71675368 - NAIL IM 135D 13MM 32CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675369 SUP HCPCS C1713 71675369 - NAIL IM 135D 13MM 34CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675370 SUP HCPCS C1713 71675370 - NAIL IM 135D 13MM 34CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675371 SUP HCPCS C1713 71675371 - NAIL IM 135D 13MM 36CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675372 SUP HCPCS C1713 71675372 - NAIL IM 135D 13MM 36CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675373 SUP HCPCS C1713 71675373 - NAIL IM 135D 13MM 38CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675374 SUP HCPCS C1713 71675374 - NAIL IM 135D 13MM 38CM INTERTAN TI RT TROCH BOTH IP/OP "$6,220.00 " "$4,602.80" $0.00 "$4,976.00" "$2,799.00" "$2,799.00" $0.00 $0.00 $0.00 "$1,296.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,296.25" $0.00 "$3,066.46" "$3,066.46" $0.00 "$3,110.00" "$4,926.24" "$4,976.00" $0.00 $0.00 $973.43 $0.00 $0.00 $990.22 $0.00 $0.00 $0.00 $0.00 $0.00 71675375 SUP HCPCS C1713 71675375 - NAIL IM 135D 13MM 40CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675376 SUP HCPCS C1713 71675376 - NAIL IM 135D 13MM 40CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675377 SUP HCPCS C1713 71675377 - NAIL IM 135D 13MM 42CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675378 SUP HCPCS C1713 71675378 - NAIL IM 135D 13MM 42CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675379 SUP HCPCS C1713 71675379 - NAIL IM 135D 13MM 44CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675380 SUP HCPCS C1713 71675380 - NAIL IM 135D 13MM 44CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675381 SUP HCPCS C1713 71675381 - NAIL IM 135D 13MM 46CM INTERTAN TI LT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675382 SUP HCPCS C1713 71675382 - NAIL IM 135D 13MM 46CM INTERTAN TI RT TROCH BOTH IP/OP "$5,550.00 " "$4,107.00" $0.00 "$4,440.00" "$2,497.50" "$2,497.50" $0.00 $0.00 $0.00 "$1,156.76" "$4,119.21" "$4,119.21" $0.00 $0.00 "$1,156.62" $0.00 "$2,736.15" "$2,736.15" $0.00 "$2,775.00" "$4,395.60" "$4,440.00" $0.00 $0.00 $868.58 $0.00 $0.00 $883.56 $0.00 $0.00 $0.00 $0.00 $0.00 71675383 SUP HCPCS C1713 71675383 - NAIL IM 125D 10MM 18CM INTERTAN BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675384 SUP HCPCS C1713 71675384 - NAIL IM 130D 10MM 18CM INTERTAN BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675385 SUP HCPCS C1713 71675385 - NAIL IM 125D SHRT 10MM 20CM INTERTAN TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675386 SUP HCPCS C1713 71675386 - NAIL IM 130D SHRT 10MM 20CM INTERTAN TROCH BOTH IP/OP "$3,330.00 " "$2,464.20" $0.00 "$2,664.00" "$1,498.50" "$1,498.50" $0.00 $0.00 $0.00 $694.06 "$2,471.53" "$2,471.53" $0.00 $0.00 $693.97 $0.00 "$1,641.69" "$1,641.69" $0.00 "$1,665.00" "$2,637.36" "$2,664.00" $0.00 $0.00 $521.15 $0.00 $0.00 $530.14 $0.00 $0.00 $0.00 $0.00 $0.00 71675401 SUP HCPCS C1713 71675401 - NAIL IM 125D 13MM 26CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675402 SUP HCPCS C1713 71675402 - NAIL IM 125D 13MM 26CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675403 SUP HCPCS C1713 71675403 - NAIL IM 125D 13MM 28CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675404 SUP HCPCS C1713 71675404 - NAIL IM 125D 13MM 28CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675405 SUP HCPCS C1713 71675405 - NAIL IM 125D 13MM 30CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675406 SUP HCPCS C1713 71675406 - NAIL IM 125D 13MM 30CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675407 SUP HCPCS C1713 71675407 - NAIL IM 125D LNG 13MM 32CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675408 SUP HCPCS C1713 71675408 - NAIL IM 125D 13MM 32CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675409 SUP HCPCS C1713 71675409 - NAIL IM 125D 13MM 34CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675410 SUP HCPCS C1713 71675410 - NAIL IM 125D 13MM 34CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675411 SUP HCPCS C1713 71675411 - NAIL IM 125D 13MM 36CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675412 SUP HCPCS C1713 71675412 - NAIL IM 125D 13MM 36CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675413 SUP HCPCS C1713 71675413 - NAIL IM 125D 13MM 38CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675414 SUP HCPCS C1713 71675414 - NAIL IM 125D 13MM 38CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675415 SUP HCPCS C1713 71675415 - NAIL IM 125D 13MM 40CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675416 SUP HCPCS C1713 71675416 - NAIL IM 125D 13MM 40CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675417 SUP HCPCS C1713 71675417 - NAIL IM 125D 13MM 42CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675418 SUP HCPCS C1713 71675418 - NAIL IM 125D 13MM 42CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675419 SUP HCPCS C1713 71675419 - NAIL IM 125D 13MM 44CM INTERTAN LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675420 SUP HCPCS C1713 71675420 - NAIL IM 125D 13MM 44CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675421 SUP HCPCS C1713 71675421 - NAIL IM 125D 13MM 46CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675422 SUP HCPCS C1713 71675422 - NAIL IM 125D 13MM 46CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675423 SUP HCPCS C1713 71675423 - NAIL IM 130D 13MM 26CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675424 SUP HCPCS C1713 71675424 - NAIL IM 130D 13MM 26CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675425 SUP HCPCS C1713 71675425 - NAIL IM 130D 13MM 28CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675426 SUP HCPCS C1713 71675426 - NAIL IM 130D 13MM 28CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675427 SUP HCPCS C1713 71675427 - NAIL IM 130D 13MM 30CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675428 SUP HCPCS C1713 71675428 - NAIL IM 130D 13MM 30CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675429 SUP HCPCS C1713 71675429 - NAIL IM 130D 13MM 32CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675430 SUP HCPCS C1713 71675430 - NAIL IM 130D 13MM 32CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675431 SUP HCPCS C1713 71675431 - NAIL IM 130D 13MM 34CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675432 SUP HCPCS C1713 71675432 - NAIL IM 130D 13MM 34CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675433 SUP HCPCS C1713 71675433 - NAIL IM 130D 13MM 36CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675434 SUP HCPCS C1713 71675434 - NAIL IM 130D 13MM 36CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675435 SUP HCPCS C1713 71675435 - NAIL IM 130D 13MM 38CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675436 SUP HCPCS C1713 71675436 - NAIL IM 130D 13MM 38CM INTERTAN ANTGRD TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675437 SUP HCPCS C1713 71675437 - NAIL IM 130D 13MM 40CM INTERTAN TI LT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675438 SUP HCPCS C1713 71675438 - NAIL IM 130D 13MM 40CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675439 SUP HCPCS C1713 71675439 - NAIL IM 130D 13MM 42CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675440 SUP HCPCS C1713 71675440 - NAIL IM 130D 13MM 42CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675441 SUP HCPCS C1713 71675441 - NAIL IM 130D 13MM 44CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675442 SUP HCPCS C1713 71675442 - NAIL IM 130D 13MM 44CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675443 SUP HCPCS C1713 71675443 - NAIL IM 130D 13MM 46CM INTERTAN TI LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675444 SUP HCPCS C1713 71675444 - NAIL IM 130D 13MM 46CM INTERTAN TI RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675501 SUP HCPCS C1713 71675501 - NAIL IM 125D 10MM 26CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675502 SUP HCPCS C1713 71675502 - NAIL IM 130D 10MM 26CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675503 SUP HCPCS C1713 71675503 - NAIL IM 125D 10MM 28CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675504 SUP HCPCS C1713 71675504 - NAIL IM 130D 10MM 28CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675505 SUP HCPCS C1713 71675505 - NAIL IM 125D 10MM 30CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675506 SUP HCPCS C1713 71675506 - NAIL IM 130D 10MM 30CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675507 SUP HCPCS C1713 71675507 - NAIL IM 125D 10MM 32CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675508 SUP HCPCS C1713 71675508 - NAIL IM 130D 10MM 30CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675509 SUP HCPCS C1713 71675509 - NAIL IM 125D 10MM 34CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675510 SUP HCPCS C1713 71675510 - NAIL IM 130D 10MM 34CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675511 SUP HCPCS C1713 71675511 - NAIL IM 125D 10MM 36CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675512 SUP HCPCS C1713 71675512 - NAIL IM 130D 10MM 36CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675513 SUP HCPCS C1713 71675513 - NAIL IM 125D 10MM 38CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675514 SUP HCPCS C1713 71675514 - NAIL IM 130D 10MM 38CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675515 SUP HCPCS C1713 71675515 - NAIL IM 125D 10MM 40CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675516 SUP HCPCS C1713 71675516 - NAIL IM 130D 10MM 40CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675517 SUP HCPCS C1713 71675517 - NAIL IM 125D 10MM 42CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675518 SUP HCPCS C1713 71675518 - NAIL IM 130D 10MM 42CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675519 SUP HCPCS C1713 71675519 - NAIL IM 125D 10MM 44CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675520 SUP HCPCS C1713 71675520 - NAIL IM 130D 10MM 44CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675521 SUP HCPCS C1713 71675521 - NAIL IM 125D 10MM 46CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675522 SUP HCPCS C1713 71675522 - NAIL IM 130D 10MM 46CM INTERTAN LT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675523 SUP HCPCS C1713 71675523 - NAIL IM 125D 10MM 26CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675524 SUP HCPCS C1713 71675524 - NAIL IM 130D 10MM 26CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675525 SUP HCPCS C1713 71675525 - NAIL IM 125D 10MM 28CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675526 SUP HCPCS C1713 71675526 - NAIL IM 130D 10MM 28CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675527 SUP HCPCS C1713 71675527 - NAIL IM 125D 10MM 30CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675528 SUP HCPCS C1713 71675528 - NAIL IM 130D 10MM 30CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675529 SUP HCPCS C1713 71675529 - NAIL IM 125D 10MM 36CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675530 SUP HCPCS C1713 71675530 - NAIL IM 130D 10MM 32CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675531 SUP HCPCS C1713 71675531 - NAIL IM 125D 10MM 34CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675532 SUP HCPCS C1713 71675532 - NAIL IM 130D 10MM 34CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675533 SUP HCPCS C1713 71675533 - NAIL IM 125D 10MM 36CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675534 SUP HCPCS C1713 71675534 - NAIL IM 130D 10MM 36CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675535 SUP HCPCS C1713 71675535 - NAIL IM 125D 10MM 38CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675536 SUP HCPCS C1713 71675536 - NAIL IM 130D 10MM 38CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675537 SUP HCPCS C1713 71675537 - NAIL IM 125D 10MM 40CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675538 SUP HCPCS C1713 71675538 - NAIL IM 130D 10MM 40CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675539 SUP HCPCS C1713 71675539 - NAIL IM 125D 10MM 42CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675540 SUP HCPCS C1713 71675540 - NAIL IM 130D 10MM 42CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675541 SUP HCPCS C1713 71675541 - NAIL IM 125D 10MM 44CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675542 SUP HCPCS C1713 71675542 - NAIL IM 130D 10MM 44CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675543 SUP HCPCS C1713 71675543 - NAIL IM 125D 10MM 46CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71675544 SUP HCPCS C1713 71675544 - NAIL IM 130D 10MM 46CM INTERTAN RT TROCH BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676501 SUP HCPCS C1713 71676501 - NAIL IM 125D 1.5MM 26CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676502 SUP HCPCS C1713 71676502 - NAIL IM 125D 1.5MM 26CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676503 SUP HCPCS C1713 71676503 - NAIL IM 125D 1.5MM 28CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676504 SUP HCPCS C1713 71676504 - NAIL IM 125D 1.5MM 10MM 28CM INTERTAN INTERTROCHANTER RT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676505 SUP HCPCS C1713 71676505 - NAIL IM 125D 1.5MM 30CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676506 SUP HCPCS C1713 71676506 - NAIL IM 125D 1.5MM 30CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676507 SUP HCPCS C1713 71676507 - NAIL IM 125D 1.5MM 32CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676508 SUP HCPCS C1713 71676508 - NAIL IM 125D 1.5MM 32CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676509 SUP HCPCS C1713 71676509 - NAIL IM 125D 1.5MM 34CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676510 SUP HCPCS C1713 71676510 - NAIL IM 125D 1.5MM 34CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676511 SUP HCPCS C1713 71676511 - NAIL IM 125D 1.5MM 36CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676512 SUP HCPCS C1713 71676512 - NAIL IM 125D 1.5MM 36CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676513 SUP HCPCS C1713 71676513 - NAIL IM 125D 1.5MM 38CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676514 SUP HCPCS C1713 71676514 - NAIL IM 125D 1.5MM 38CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676515 SUP HCPCS C1713 71676515 - NAIL IM 125D 1.5MM 40CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676516 SUP HCPCS C1713 71676516 - NAIL IM 125D 1.5MM 40CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676517 SUP HCPCS C1713 71676517 - NAIL IM 125D 1.5MM 42CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676518 SUP HCPCS C1713 71676518 - NAIL IM 125D 1.5MM 42CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676519 SUP HCPCS C1713 71676519 - NAIL IM 125D 1.5MM 44CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676520 SUP HCPCS C1713 71676520 - NAIL IM 125D 1.5MM 44CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676521 SUP HCPCS C1713 71676521 - NAIL IM 125D 1.5MM 46CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676522 SUP HCPCS C1713 71676522 - NAIL IM 125D 1.5MM 46CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676523 SUP HCPCS C1713 71676523 - NAIL IM 130D 1.5MM 26CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676524 SUP HCPCS C1713 71676524 - NAIL IM 130D 1.5MM 26CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676525 SUP HCPCS C1713 71676525 - NAIL IM 130D 1.5MM 28CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676526 SUP HCPCS C1713 71676526 - NAIL IM 130D 1.5MM 28CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676527 SUP HCPCS C1713 71676527 - NAIL IM 130D 1.5MM 30CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676528 SUP HCPCS C1713 71676528 - NAIL IM 130D 1.5MM 30CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676529 SUP HCPCS C1713 71676529 - NAIL IM 130D 1.5MM 32CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676530 SUP HCPCS C1713 71676530 - NAIL IM 130D 1.5MM 32CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676531 SUP HCPCS C1713 71676531 - NAIL IM 130D 1.5MM 34CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676532 SUP HCPCS C1713 71676532 - NAIL IM 130D 1.5MM 34CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676533 SUP HCPCS C1713 71676533 - NAIL IM 130D 1.5MM 36CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676534 SUP HCPCS C1713 71676534 - NAIL IM 130D 1.5MM 36CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676535 SUP HCPCS C1713 71676535 - NAIL IM 130D 1.5MM 38CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676536 SUP HCPCS C1713 71676536 - NAIL IM 130D 1.5MM 38CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676537 SUP HCPCS C1713 71676537 - NAIL IM 130D 1.5MM 40CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676538 SUP HCPCS C1713 71676538 - NAIL IM 130D 1.5MM 40CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676539 SUP HCPCS C1713 71676539 - NAIL IM 130D 1.5MM 42CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676540 SUP HCPCS C1713 71676540 - NAIL IM 130D 1.5MM 42CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676541 SUP HCPCS C1713 71676541 - NAIL IM 130D 1.5MM 44CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676542 SUP HCPCS C1713 71676542 - NAIL IM 130D 1.5MM 44CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676543 SUP HCPCS C1713 71676543 - NAIL IM 130D 1.5MM 46CM 10MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676544 SUP HCPCS C1713 71676544 - NAIL IM 130D 1.5MM 46CM 10MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676545 SUP HCPCS C1713 71676545 - NAIL IM 125D 1.5MM 26CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676546 SUP HCPCS C1713 71676546 - NAIL IM 125D 1.5MM 26CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676547 SUP HCPCS C1713 71676547 - NAIL IM 125D 1.5MM 28CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676548 SUP HCPCS C1713 71676548 - NAIL IM 125D 1.5MM 28CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676549 SUP HCPCS C1713 71676549 - NAIL IM 125D 1.5MM 30CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676550 SUP HCPCS C1713 71676550 - NAIL IM 125D 1.5MM 30CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676551 SUP HCPCS C1713 71676551 - NAIL IM 125D 1.5MM 32CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676552 SUP HCPCS C1713 71676552 - NAIL IM 125D 1.5MM 32CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676553 SUP HCPCS C1713 71676553 - NAIL INTRAMEDULLARY 125D 1.5MM 34CM 11.5MM INTERTAN LEFT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676554 SUP HCPCS C1713 71676554 - NAIL IM 125D 1.5MM 34CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676555 SUP HCPCS C1713 71676555 - NAIL IM 125D 1.5MM 36CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676556 SUP HCPCS C1713 71676556 - NAIL IM 125D 1.5MM 36CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676557 SUP HCPCS C1713 71676557 - NAIL IM 125D 1.5MM 38CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676558 SUP HCPCS C1713 71676558 - NAIL INTRAMEDULLARY 125D 1.5MM 38CM 11.5MM INTERTAN RIGHT BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676559 SUP HCPCS C1713 71676559 - NAIL IM 125D 1.5MM 40CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676560 SUP HCPCS C1713 71676560 - NAIL IM 125D 1.5MM 40CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676561 SUP HCPCS C1713 71676561 - NAIL IM 125D 1.5MM 42CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676562 SUP HCPCS C1713 71676562 - NAIL IM 125D 1.5MM 42CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676563 SUP HCPCS C1713 71676563 - NAIL IM 125D 1.5MM 44CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676564 SUP HCPCS C1713 71676564 - NAIL IM 125D 1.5MM 44CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676565 SUP HCPCS C1713 71676565 - NAIL IM 125D 1.5MM 46CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676566 SUP HCPCS C1713 71676566 - NAIL IM 125D 1.5MM 46CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676567 SUP HCPCS C1713 71676567 - NAIL IM 130D 1.5MM 26CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676568 SUP HCPCS C1713 71676568 - NAIL IM 130D 1.5MM 26CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676569 SUP HCPCS C1713 71676569 - NAIL IM 130D 1.5MM 28CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676570 SUP HCPCS C1713 71676570 - NAIL IM 130D 1.5MM 28CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676571 SUP HCPCS C1713 71676571 - NAIL IM 130D 1.5MM 30CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676572 SUP HCPCS C1713 71676572 - NAIL IM 130D 1.5MM 30CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676573 SUP HCPCS C1713 71676573 - NAIL IM 130D 1.5MM 32CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676574 SUP HCPCS C1713 71676574 - NAIL IM 130D 1.5MM 32CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676575 SUP HCPCS C1713 71676575 - NAIL IM 130D 1.5MM 34CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676576 SUP HCPCS C1713 71676576 - NAIL IM 130D 1.5MM 34CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676577 SUP HCPCS C1713 71676577 - NAIL IM 130D 1.5MM 36CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676578 SUP HCPCS C1713 71676578 - NAIL IM 130D 1.5MM 36CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676579 SUP HCPCS C1713 71676579 - NAIL IM 130D 1.5MM 38CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676580 SUP HCPCS C1713 71676580 - NAIL IM 130D 1.5MM 38CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676581 SUP HCPCS C1713 71676581 - NAIL IM 130D 1.5MM 40CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676582 SUP HCPCS C1713 71676582 - NAIL IM 130D 1.5MM 40CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676583 SUP HCPCS C1713 71676583 - NAIL IM 130D 1.5MM 42CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676584 SUP HCPCS C1713 71676584 - NAIL IM 130D 1.5MM 42CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676585 SUP HCPCS C1713 71676585 - NAIL IM 130D 1.5MM 44CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676586 SUP HCPCS C1713 71676586 - NAIL IM 130D 1.5MM 44CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676587 SUP HCPCS C1713 71676587 - NAIL IM 130D 1.5MM 46CM 11.5MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676588 SUP HCPCS C1713 71676588 - NAIL IM 130D 1.5MM 46CM 11.5MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676589 SUP HCPCS C1713 71676589 - NAIL IM 125D 1.5MM 26CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676590 SUP HCPCS C1713 71676590 - NAIL IM 125D 1.5MM 26CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676591 SUP HCPCS C1713 71676591 - NAIL IM 125D 1.5MM 28CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676592 SUP HCPCS C1713 71676592 - NAIL IM 125D 1.5MM 28CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676593 SUP HCPCS C1713 71676593 - NAIL IM 125D 1.5MM 30CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676594 SUP HCPCS C1713 71676594 - NAIL IM 125D 1.5MM 30CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676595 SUP HCPCS C1713 71676595 - NAIL IM 125D 1.5MM 32CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676596 SUP HCPCS C1713 71676596 - NAIL IM 125D 1.5MM 32CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676597 SUP HCPCS C1713 71676597 - NAIL IM 125D 1.5MM 34CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676598 SUP HCPCS C1713 71676598 - NAIL IM 125D 1.5MM 34CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676599 SUP HCPCS C1713 71676599 - NAIL IM 125D 1.5MM 36CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676600 SUP HCPCS C1713 71676600 - NAIL IM 125D 1.5MM 36CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676601 SUP HCPCS C1713 71676601 - NAIL IM 125D 1.5MM 38CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676602 SUP HCPCS C1713 71676602 - NAIL IM 125D 1.5MM 38CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676603 SUP HCPCS C1713 71676603 - NAIL IM 125D 1.5MM 40CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676604 SUP HCPCS C1713 71676604 - NAIL IM 125D 1.5MM 40CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676605 SUP HCPCS C1713 71676605 - NAIL IM 125D 1.5MM 42CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676606 SUP HCPCS C1713 71676606 - NAIL IM 125D 1.5MM 42CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676607 SUP HCPCS C1713 71676607 - NAIL IM 125D 1.5MM 44CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676608 SUP HCPCS C1713 71676608 - NAIL IM 125D 1.5MM 44CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676609 SUP HCPCS C1713 71676609 - NAIL IM 125D 1.5MM 46CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676610 SUP HCPCS C1713 71676610 - NAIL IM 125D 1.5MM 46CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676611 SUP HCPCS C1713 71676611 - NAIL IM 130D 1.5MM 26CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676612 SUP HCPCS C1713 71676612 - NAIL IM 130D 1.5MM 26CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676613 SUP HCPCS C1713 71676613 - NAIL IM 130D 1.5MM 28CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676614 SUP HCPCS C1713 71676614 - NAIL IM 130D 1.5MM 28CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676615 SUP HCPCS C1713 71676615 - NAIL IM 130D 1.5MM 30CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676616 SUP HCPCS C1713 71676616 - NAIL IM 130D 1.5MM 30CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676617 SUP HCPCS C1713 71676617 - NAIL IM 130D 1.5MM 32CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676618 SUP HCPCS C1713 71676618 - NAIL IM 130D 1.5MM 32CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676619 SUP HCPCS C1713 71676619 - NAIL IM 130D 1.5MM 34CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676620 SUP HCPCS C1713 71676620 - NAIL IM 130D 1.5MM 34CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676621 SUP HCPCS C1713 71676621 - NAIL IM 130D 1.5MM 36CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676622 SUP HCPCS C1713 71676622 - NAIL IM 130D 1.5MM 36CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676623 SUP HCPCS C1713 71676623 - NAIL IM 130D 1.5MM 38CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676624 SUP HCPCS C1713 71676624 - NAIL IM 130D 1.5MM 38CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676625 SUP HCPCS C1713 71676625 - NAIL IM 130D 1.5MM 40CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676626 SUP HCPCS C1713 71676626 - NAIL IM 130D 1.5MM 40CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676627 SUP HCPCS C1713 71676627 - NAIL IM 130D 1.5MM 42CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676628 SUP HCPCS C1713 71676628 - NAIL IM 130D 1.5MM 42CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676629 SUP HCPCS C1713 71676629 - NAIL IM 130D 1.5MM 44CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676630 SUP HCPCS C1713 71676630 - NAIL IM 130D 1.5MM 44CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676631 SUP HCPCS C1713 71676631 - NAIL IM 130D 1.5MM 46CM 13MM INTERTAN LT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71676632 SUP HCPCS C1713 71676632 - NAIL IM 130D 1.5MM 46CM 13MM INTERTAN RT INTERTROCHANTER BOTH IP/OP "$4,443.75 " "$3,288.38" $0.00 "$3,555.00" "$1,999.69" "$1,999.69" $0.00 $0.00 $0.00 $926.19 "$3,298.15" "$3,298.15" $0.00 $0.00 $926.08 $0.00 "$2,190.77" "$2,190.77" $0.00 "$2,221.88" "$3,519.45" "$3,555.00" $0.00 $0.00 $695.45 $0.00 $0.00 $707.45 $0.00 $0.00 $0.00 $0.00 $0.00 71677070 SUP HCPCS C1713 71677070 - SCREW BN 70/65MM INTERTAN LG CMPR TROCH CMBN PK BOTH IP/OP "$1,417.50 " "$1,048.95" $0.00 "$1,134.00" $637.88 $637.88 $0.00 $0.00 $0.00 $295.44 "$1,052.07" "$1,052.07" $0.00 $0.00 $295.41 $0.00 $838.45 $838.45 $0.00 $708.75 "$1,122.66" "$1,134.00" $0.00 $0.00 $221.84 $0.00 $0.00 $225.67 $0.00 $0.00 $0.00 $0.00 $0.00 71677075 SUP HCPCS C1713 71677075 - SCREW BN 75/70MM INTERTAN LG CMPR TROCH CMBN PK BOTH IP/OP "$1,417.50 " "$1,048.95" $0.00 "$1,134.00" $637.88 $637.88 $0.00 $0.00 $0.00 $295.44 "$1,052.07" "$1,052.07" $0.00 $0.00 $295.41 $0.00 $838.45 $838.45 $0.00 $708.75 "$1,122.66" "$1,134.00" $0.00 $0.00 $221.84 $0.00 $0.00 $225.67 $0.00 $0.00 $0.00 $0.00 $0.00 71677080 SUP HCPCS C1713 71677080 - KIT SCR 80MMX70MM INTERTAN LG CMPR TROCH TI CMBN PK BOTH IP/OP "$1,417.50 " "$1,048.95" $0.00 "$1,134.00" $637.88 $637.88 $0.00 $0.00 $0.00 $295.44 "$1,052.07" "$1,052.07" $0.00 $0.00 $295.41 $0.00 $838.45 $838.45 $0.00 $708.75 "$1,122.66" "$1,134.00" $0.00 $0.00 $221.84 $0.00 $0.00 $225.67 $0.00 $0.00 $0.00 $0.00 $0.00 71677085 SUP HCPCS C1713 71677085 - SCREW BN 11MM 7MM 85MM 80MM INTERTAN KT CMPR LG INTGR INTLK BOTH IP/OP "$1,417.50 " "$1,048.95" $0.00 "$1,134.00" $637.88 $637.88 $0.00 $0.00 $0.00 $295.44 "$1,052.07" "$1,052.07" $0.00 $0.00 $295.41 $0.00 $838.45 $838.45 $0.00 $708.75 "$1,122.66" "$1,134.00" $0.00 $0.00 $221.84 $0.00 $0.00 $225.67 $0.00 $0.00 $0.00 $0.00 $0.00 71677090 SUP HCPCS C1713 71677090 - KIT SCREW 4.5MM 90MM 85MM LAG COMPRESSION INTEGRATE BOTH IP/OP "$1,417.50 " "$1,048.95" $0.00 "$1,134.00" $637.88 $637.88 $0.00 $0.00 $0.00 $295.44 "$1,052.07" "$1,052.07" $0.00 $0.00 $295.41 $0.00 $838.45 $838.45 $0.00 $708.75 "$1,122.66" "$1,134.00" $0.00 $0.00 $221.84 $0.00 $0.00 $225.67 $0.00 $0.00 $0.00 $0.00 $0.00 71677095 SUP HCPCS C1713 71677095 - KIT SCREW 4.5MM 95MM 90MM LAG COMPRESSION INTEGRATED INTLCK BOTH IP/OP "$1,417.50 " "$1,048.95" $0.00 "$1,134.00" $637.88 $637.88 $0.00 $0.00 $0.00 $295.44 "$1,052.07" "$1,052.07" $0.00 $0.00 $295.41 $0.00 $838.45 $838.45 $0.00 $708.75 "$1,122.66" "$1,134.00" $0.00 $0.00 $221.84 $0.00 $0.00 $225.67 $0.00 $0.00 $0.00 $0.00 $0.00 71677120 SUP HCPCS C1713 71677120 - SCREW BN 11MM 7MM 120MM 115MM INTERTAN KT CMPR LG INTGR BOTH IP/OP "$1,417.50 " "$1,048.95" $0.00 "$1,134.00" $637.88 $637.88 $0.00 $0.00 $0.00 $295.44 "$1,052.07" "$1,052.07" $0.00 $0.00 $295.41 $0.00 $838.45 $838.45 $0.00 $708.75 "$1,122.66" "$1,134.00" $0.00 $0.00 $221.84 $0.00 $0.00 $225.67 $0.00 $0.00 $0.00 $0.00 $0.00 71677125 SUP HCPCS C1713 71677125 - SCREW BN 125/120MM INTERTAN LG CMPR TROCH CMBN PK BOTH IP/OP "$1,417.50 " "$1,048.95" $0.00 "$1,134.00" $637.88 $637.88 $0.00 $0.00 $0.00 $295.44 "$1,052.07" "$1,052.07" $0.00 $0.00 $295.41 $0.00 $838.45 $838.45 $0.00 $708.75 "$1,122.66" "$1,134.00" $0.00 $0.00 $221.84 $0.00 $0.00 $225.67 $0.00 $0.00 $0.00 $0.00 $0.00 71678005 SUP HCPCS C1713 71678005 - SCREW BN 11MM 105MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678010 SUP HCPCS C1713 71678010 - SCREW BN 11MM 100MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678011 SUP HCPCS C1713 71678011 - SCREW BN 11MM 110MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678012 SUP HCPCS C1713 71678012 - SCREW BN 11MM 120MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678015 SUP HCPCS C1713 71678015 - SCREW BN 11MM 115MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678025 SUP HCPCS C1713 71678025 - SCREW BN 11MM 125MM INTERTAN LG SBTCH BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678070 SUP HCPCS C1713 71678070 - SCREW BN 11MM 70MM INTERTAN LG SBTCH BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678075 SUP HCPCS C1713 71678075 - SCREW BN 11MM 75MM INTERTAN LG SBTCH BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678080 SUP HCPCS C1713 71678080 - SCREW BN 11MM 80MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678085 SUP HCPCS C1713 71678085 - SCREW BN 11MM 85MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678090 SUP HCPCS C1713 71678090 - SCREW BN 11MM 90MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71678095 SUP HCPCS C1713 71678095 - SCREW BN 11MM 95MM INTERTAN LG TI SUBTROCHANTER BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 71679002 SUP HCPCS C1713 71679002 - PLATE BN 127D 80MM INTERTAN CHS 2 HL SS BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679003 SUP HCPCS C1713 71679003 - PLATE BN 127D 92MM INTERTAN CHS 3 HL SS BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679004 SUP HCPCS C1713 71679004 - PLATE BN 127D 104MM INTERTAN CHS 4 HL SS BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679005 SUP HCPCS C1713 71679005 - PLATE BN 127D 116MM INTERTAN CHS 5 HL SS HIP BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679006 SUP HCPCS C1713 71679006 - PLATE BN 127D 128MM INTERTAN CHS 6 HL SS HIP BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679102 SUP HCPCS C1713 71679102 - PLATE BN 135D 84MM INTERTAN CHS 2 HL SS BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679103 SUP HCPCS C1713 71679103 - PLATE BN 135D 96MM INTERTAN CHS 3 HL SS HIP BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679104 SUP HCPCS C1713 71679104 - PLATE BN 135D 4 HL CMPR ORTH BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679105 SUP HCPCS C1713 71679105 - PLATE BN 135D 120MM INTERTAN CHS 5 HL SS HIP BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679106 SUP HCPCS C1713 71679106 - SCREW BN 135D 132MM INTERTAN CHS 6 HL SS BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 71679230 SUP HCPCS C1713 71679230 - SCREW BN 30MM INTERTAN CHS CMPR SS BOTH IP/OP $904.00 $668.96 $0.00 $723.20 $406.80 $406.80 $0.00 $0.00 $0.00 $188.42 $670.95 $670.95 $0.00 $0.00 $188.39 $0.00 $534.72 $534.72 $0.00 $452.00 $715.97 $723.20 $0.00 $0.00 $141.48 $0.00 $0.00 $143.92 $0.00 $0.00 $0.00 $0.00 $0.00 71679265 SUP HCPCS C1713 71679265 - SCREW BN 65/60 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679270 SUP HCPCS C1713 71679270 - SCREW BN 70/65 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679275 SUP HCPCS C1713 71679275 - SCREW BN 75/70 INTERTAN CHS CMPR LG SS HIP BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679280 SUP HCPCS C1713 71679280 - SCREW BN 80/75 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679285 SUP HCPCS C1713 71679285 - SCREW BN 85/80 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679290 SUP HCPCS C1713 71679290 - SCREW BN 90/85 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679295 SUP HCPCS C1713 71679295 - SCREW BN 95/90 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679300 SUP HCPCS C1713 71679300 - SCREW BN 100/95 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679305 SUP HCPCS C1713 71679305 - SCREW BN 105/100 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679310 SUP HCPCS C1713 71679310 - SCREW BN 110/105 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679315 SUP HCPCS C1713 71679315 - SCREW BN 115/110 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,642.00 " "$1,215.08" $0.00 "$1,313.60" $738.90 $738.90 $0.00 $0.00 $0.00 $342.23 "$1,218.69" "$1,218.69" $0.00 $0.00 $342.19 $0.00 $971.24 $971.24 $0.00 $821.00 "$1,300.46" "$1,313.60" $0.00 $0.00 $256.97 $0.00 $0.00 $261.41 $0.00 $0.00 $0.00 $0.00 $0.00 71679320 SUP HCPCS C1713 71679320 - SCREW BN 120/115 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,530.00 " "$1,132.20" $0.00 "$1,224.00" $688.50 $688.50 $0.00 $0.00 $0.00 $318.89 "$1,135.57" "$1,135.57" $0.00 $0.00 $318.85 $0.00 $905.00 $905.00 $0.00 $765.00 "$1,211.76" "$1,224.00" $0.00 $0.00 $239.45 $0.00 $0.00 $243.58 $0.00 $0.00 $0.00 $0.00 $0.00 71679325 SUP HCPCS C1713 71679325 - SCREW BN 125/120 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,530.00 " "$1,132.20" $0.00 "$1,224.00" $688.50 $688.50 $0.00 $0.00 $0.00 $318.89 "$1,135.57" "$1,135.57" $0.00 $0.00 $318.85 $0.00 $905.00 $905.00 $0.00 $765.00 "$1,211.76" "$1,224.00" $0.00 $0.00 $239.45 $0.00 $0.00 $243.58 $0.00 $0.00 $0.00 $0.00 $0.00 71679330 SUP HCPCS C1713 71679330 - SCREW BN 130/125 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,530.00 " "$1,132.20" $0.00 "$1,224.00" $688.50 $688.50 $0.00 $0.00 $0.00 $318.89 "$1,135.57" "$1,135.57" $0.00 $0.00 $318.85 $0.00 $905.00 $905.00 $0.00 $765.00 "$1,211.76" "$1,224.00" $0.00 $0.00 $239.45 $0.00 $0.00 $243.58 $0.00 $0.00 $0.00 $0.00 $0.00 71679335 SUP HCPCS C1713 71679335 - SCREW BN 135/130MM INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,530.00 " "$1,132.20" $0.00 "$1,224.00" $688.50 $688.50 $0.00 $0.00 $0.00 $318.89 "$1,135.57" "$1,135.57" $0.00 $0.00 $318.85 $0.00 $905.00 $905.00 $0.00 $765.00 "$1,211.76" "$1,224.00" $0.00 $0.00 $239.45 $0.00 $0.00 $243.58 $0.00 $0.00 $0.00 $0.00 $0.00 71679340 SUP HCPCS C1713 71679340 - SCREW BN 140/135 INTERTAN CHS LG CMPR SS BOTH IP/OP "$1,530.00 " "$1,132.20" $0.00 "$1,224.00" $688.50 $688.50 $0.00 $0.00 $0.00 $318.89 "$1,135.57" "$1,135.57" $0.00 $0.00 $318.85 $0.00 $905.00 $905.00 $0.00 $765.00 "$1,211.76" "$1,224.00" $0.00 $0.00 $239.45 $0.00 $0.00 $243.58 $0.00 $0.00 $0.00 $0.00 $0.00 71683935 SUP HCPCS C1713 71683935 - CAP END IMHS CP HIP IM NL BOTH IP/OP $700.88 $518.65 $0.00 $560.70 $315.39 $315.39 $0.00 $0.00 $0.00 $146.08 $520.19 $520.19 $0.00 $0.00 $146.06 $0.00 $414.57 $414.57 $0.00 $350.44 $555.10 $560.70 $0.00 $0.00 $109.69 $0.00 $0.00 $111.58 $0.00 $0.00 $0.00 $0.00 $0.00 71683940 SUP HCPCS C1713 71683940 - SET SCR IMHS CP CNN INTRAMEDULLARLY HIP SCR BOTH IP/OP $476.88 $352.89 $0.00 $381.50 $214.59 $214.59 $0.00 $0.00 $0.00 $99.39 $353.94 $353.94 $0.00 $0.00 $99.38 $0.00 $282.07 $282.07 $0.00 $238.44 $377.69 $381.50 $0.00 $0.00 $74.63 $0.00 $0.00 $75.92 $0.00 $0.00 $0.00 $0.00 $0.00 71683945 SUP HCPCS C1713 71683945 - SCREW BN 19MM IMHS CP CPTR CMPR HIP IM NL SYS BOTH IP/OP $600.25 $444.19 $0.00 $480.20 $270.11 $270.11 $0.00 $0.00 $0.00 $125.11 $445.51 $445.51 $0.00 $0.00 $125.09 $0.00 $355.05 $355.05 $0.00 $300.13 $475.40 $480.20 $0.00 $0.00 $93.94 $0.00 $0.00 $95.56 $0.00 $0.00 $0.00 $0.00 $0.00 71684070 SUP HCPCS C1713 71684070 - SCREW BN 12.7MM 70MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684075 SUP HCPCS C1713 71684075 - SCREW BN 12.7MM 75MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684080 SUP HCPCS C1713 71684080 - SCREW BN 12.7MM 80MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684085 SUP HCPCS C1713 71684085 - SCREW BN 12.7MM 85MM IMHS CP LG SUBTROCHANTER IM NL SYS BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684090 SUP HCPCS C1713 71684090 - SCREW BN 12.7MM 90MM IMHS CP LG SUBTROCHANTER IM NL SYS BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684095 SUP HCPCS C1713 71684095 - SCREW BN 12.7MM 95MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684100 SUP HCPCS C1713 71684100 - SCREW BN 12.7MM 100MM IMHS CP LG SUBTROCHANTER IM NL SYS BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684105 SUP HCPCS C1713 71684105 - SCREW BN 12.7MM 105MM IMHS CP LG SUBTROCHANTER IM NL SYS BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684110 SUP HCPCS C1713 71684110 - SCREW BN 12.7MM 110MM IMHS CP LG SUBTROCHANTER IM NL SYS BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684115 SUP HCPCS C1713 71684115 - SCREW BN 12.7MM 115MM IMHS CP LG SUBTROCHANTER IM NL SYS BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684120 SUP HCPCS C1713 71684120 - SCREW BN 12.7MM 120MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684125 SUP HCPCS C1713 71684125 - SCREW BN 12.7MM 125MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684130 SUP HCPCS C1713 71684130 - SCREW BN 12.7MM 130MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684135 SUP HCPCS C1713 71684135 - SCREW BN 12.7MM 135MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71684140 SUP HCPCS C1713 71684140 - SCREW BN 12.7MM 140MM IMHS CP LG SBTCH IM NL BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 71687000 SUP Custom 27203010 71687000 - GUIDE PIN ORTHOPEDIC 3.2MM THREAD TIP IMHS CP INTRAMEDULLARY BOTH IP/OP $189.00 $139.86 $0.00 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $140.28 $140.28 $0.00 $0.00 $39.39 $0.00 $0.00 $0.00 $0.00 $94.50 $149.69 $151.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71751136 SUP HCPCS C1713 71751136 - TROCAR SRG 3.2MM 3.2MM TRGN PIN HUM DISP BOTH IP/OP $353.25 $261.41 $0.00 $282.60 $158.96 $158.96 $0.00 $0.00 $0.00 $73.63 $262.18 $262.18 $0.00 $0.00 $73.62 $0.00 $208.95 $208.95 $0.00 $176.63 $279.77 $282.60 $0.00 $0.00 $55.28 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $0.00 71751148 SUP Custom 27203010 71751148 - BIT DRL SHRT 3.2MM STRL TRGN GRAD BRAD PNT DISP IM NL BOTH IP/OP $505.13 $373.80 $0.00 $404.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.90 $374.90 $0.00 $0.00 $105.27 $0.00 $0.00 $0.00 $0.00 $252.56 $400.06 $404.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71751149 SUP Custom 27203010 71751149 - BIT DRL LNG 3.2MM STRL TRGN GRAD BRAD PNT DISP IM NL BOTH IP/OP $505.13 $373.80 $0.00 $404.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.90 $374.90 $0.00 $0.00 $105.27 $0.00 $0.00 $0.00 $0.00 $252.56 $400.06 $404.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71754020 SUP HCPCS C1713 71754020 - SCREW BN 4MM 20MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754022 SUP HCPCS C1713 71754022 - SCREW BN 4MM 22MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754024 SUP HCPCS C1713 71754024 - SCREW BN 4MM 24MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754026 SUP HCPCS C1713 71754026 - SCREW BN 4MM 26MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754028 SUP HCPCS C1713 71754028 - SCREW BN 4MM 28MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754030 SUP HCPCS C1713 71754030 - SCREW BN 4MM 30MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754032 SUP HCPCS C1713 71754032 - SCREW BN 4MM 32MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754034 SUP HCPCS C1713 71754034 - SCREW BN 4MM 34MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754036 SUP HCPCS C1713 71754036 - SCREW BN 4MM 36MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754038 SUP HCPCS C1713 71754038 - SCREW BN 4MM 38MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754040 SUP HCPCS C1713 71754040 - SCREW BN 4MM 40MM TRGN ST TI HUM CORT IM NL SYS BOTH IP/OP $360.00 $266.40 $0.00 $288.00 $162.00 $162.00 $0.00 $0.00 $0.00 $75.03 $267.19 $267.19 $0.00 $0.00 $75.02 $0.00 $212.94 $212.94 $0.00 $180.00 $285.12 $288.00 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 71754042 SUP HCPCS C1713 71754042 - SCREW BN 4MM 42MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $153.90 $153.90 $0.00 $0.00 $0.00 $71.28 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $202.29 $202.29 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $53.52 $0.00 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 71754044 SUP HCPCS C1713 71754044 - SCREW BN 4MM 44MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $153.90 $153.90 $0.00 $0.00 $0.00 $71.28 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $202.29 $202.29 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $53.52 $0.00 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 71754046 SUP HCPCS C1713 71754046 - SCREW BN 4MM 44MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $153.90 $153.90 $0.00 $0.00 $0.00 $71.28 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $202.29 $202.29 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $53.52 $0.00 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 71754048 SUP HCPCS C1713 71754048 - SCREW BN 4MM 48MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $153.90 $153.90 $0.00 $0.00 $0.00 $71.28 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $202.29 $202.29 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $53.52 $0.00 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 71754050 SUP HCPCS C1713 71754050 - SCREW BN 4MM 50MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $153.90 $153.90 $0.00 $0.00 $0.00 $71.28 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $202.29 $202.29 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $53.52 $0.00 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 71754052 SUP HCPCS C1713 71754052 - SCREW BN 4MM 52MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $139.73 $139.73 $0.00 $0.00 $0.00 $64.72 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $183.66 $183.66 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $48.59 $0.00 $0.00 $49.43 $0.00 $0.00 $0.00 $0.00 $0.00 71754054 SUP HCPCS C1713 71754054 - SCREW BN 4MM 54MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $342.00 $253.08 $0.00 $273.60 $153.90 $153.90 $0.00 $0.00 $0.00 $71.28 $253.83 $253.83 $0.00 $0.00 $71.27 $0.00 $202.29 $202.29 $0.00 $171.00 $270.86 $273.60 $0.00 $0.00 $53.52 $0.00 $0.00 $54.45 $0.00 $0.00 $0.00 $0.00 $0.00 71754056 SUP HCPCS C1713 71754056 - SCREW BN 4MM 56MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $139.73 $139.73 $0.00 $0.00 $0.00 $64.72 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $183.66 $183.66 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $48.59 $0.00 $0.00 $49.43 $0.00 $0.00 $0.00 $0.00 $0.00 71754058 SUP HCPCS C1713 71754058 - SCREW BN 4MM 58MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $139.73 $139.73 $0.00 $0.00 $0.00 $64.72 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $183.66 $183.66 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $48.59 $0.00 $0.00 $49.43 $0.00 $0.00 $0.00 $0.00 $0.00 71754060 SUP HCPCS C1713 71754060 - SCREW BN 4MM 60MM TRGN ST TI HUM CORT IM NL BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $139.73 $139.73 $0.00 $0.00 $0.00 $64.72 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $183.66 $183.66 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $48.59 $0.00 $0.00 $49.43 $0.00 $0.00 $0.00 $0.00 $0.00 71755024 SUP HCPCS C1713 71755024 - SCREW BN 5MM 24MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755026 SUP HCPCS C1713 71755026 - SCREW BN 5MM 26MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755028 SUP HCPCS C1713 71755028 - SCREW BN 5MM 28MM TRGN CNN ST TI HUM CANC IM NL BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755030 SUP HCPCS C1713 71755030 - SCREW BN 5MM 30MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755032 SUP HCPCS C1713 71755032 - SCREW BN 5MM 32MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755034 SUP HCPCS C1713 71755034 - SCREW BN 5MM 34MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755036 SUP HCPCS C1713 71755036 - SCREW BN 5MM 36MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755038 SUP HCPCS C1713 71755038 - SCREW BN 5MM 38MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755040 SUP HCPCS C1713 71755040 - SCREW BN 5MM 40MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755042 SUP HCPCS C1713 71755042 - SCREW BN 5MM 42MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755044 SUP HCPCS C1713 71755044 - SCREW BN 5MM 44MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755046 SUP HCPCS C1713 71755046 - SCREW BN 5MM 46MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755048 SUP HCPCS C1713 71755048 - SCREW BN 5MM 48MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755050 SUP HCPCS C1713 71755050 - SCREW BN 5MM 50MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755052 SUP HCPCS C1713 71755052 - SCREW BN 5MM 52MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755054 SUP HCPCS C1713 71755054 - SCREW BN 5MM 54MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755056 SUP HCPCS C1713 71755056 - SCREW BN 5MM 56MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755058 SUP HCPCS C1713 71755058 - SCREW BN 5MM 58MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755060 SUP HCPCS C1713 71755060 - SCREW BN 5MM 60MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755062 SUP HCPCS C1713 71755062 - SCREW BN 5MM 62MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71755064 SUP HCPCS C1713 71755064 - SCREW BN 5MM 64MM TRGN ST TI HUM CANC IM NL SYS BOTH IP/OP $437.63 $323.85 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $91.21 $324.81 $324.81 $0.00 $0.00 $91.20 $0.00 $258.86 $258.86 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $68.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 71760000 SUP HCPCS C1713 71760000 - CAP END 0MM TRGN HUM IM NL BOTH IP/OP $221.63 $164.01 $0.00 $177.30 $99.73 $99.73 $0.00 $0.00 $0.00 $46.19 $164.49 $164.49 $0.00 $0.00 $46.19 $0.00 $131.09 $131.09 $0.00 $110.81 $175.53 $177.30 $0.00 $0.00 $34.68 $0.00 $0.00 $35.28 $0.00 $0.00 $0.00 $0.00 $0.00 71760816 SUP HCPCS C1713 71760816 - NAIL IM 8/7MM 16CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760818 SUP HCPCS C1713 71760818 - NAIL IM 8/7MM 18CM TRGN STRG TI HUM BOTH IP/OP "$3,048.75 " "$2,256.08" $0.00 "$2,439.00" "$1,371.94" "$1,371.94" $0.00 $0.00 $0.00 $635.44 "$2,262.78" "$2,262.78" $0.00 $0.00 $635.36 $0.00 "$1,503.03" "$1,503.03" $0.00 "$1,524.38" "$2,414.61" "$2,439.00" $0.00 $0.00 $477.13 $0.00 $0.00 $485.36 $0.00 $0.00 $0.00 $0.00 $0.00 71760820 SUP HCPCS C1713 71760820 - NAIL IM 8/7MM 20CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760822 SUP HCPCS C1713 71760822 - NAIL IM 8/7MM 22CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760826 SUP HCPCS C1713 71760826 - NAIL IM 8/7MM 26CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760828 SUP HCPCS C1713 71760828 - NAIL IM 8/7MM 28CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760830 SUP HCPCS C1713 71760830 - NAIL IM 8/7MM 30CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71760918 SUP HCPCS C1713 71760918 - NAIL IM 8/7MM 18CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760920 SUP HCPCS C1713 71760920 - NAIL IM 9/7.5MM 20CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760922 SUP HCPCS C1713 71760922 - NAIL IM 9/7.5MM 22CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760924 SUP HCPCS C1713 71760924 - NAIL IM 9/7.5MM 24CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760926 SUP HCPCS C1713 71760926 - NAIL IM 9/7.5MM 26CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760928 SUP HCPCS C1713 71760928 - NAIL IM 9/7.5MM 28CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71760930 SUP HCPCS C1713 71760930 - NAIL IM 9/7MM 30CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71761018 SUP HCPCS C1713 71761018 - NAIL IM 10/8.5MM 18CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71761020 SUP HCPCS C1713 71761020 - NAIL IM 10/8.5MM 20CM TRGN STRG TI HUM BOTH IP/OP "$3,048.75 " "$2,256.08" $0.00 "$2,439.00" "$1,371.94" "$1,371.94" $0.00 $0.00 $0.00 $635.44 "$2,262.78" "$2,262.78" $0.00 $0.00 $635.36 $0.00 "$1,503.03" "$1,503.03" $0.00 "$1,524.38" "$2,414.61" "$2,439.00" $0.00 $0.00 $477.13 $0.00 $0.00 $485.36 $0.00 $0.00 $0.00 $0.00 $0.00 71761022 SUP HCPCS C1713 71761022 - NAIL IM 10/8.5MM 22CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71761024 SUP HCPCS C1713 71761024 - NAIL IM 10/8.5MM 24CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71761026 SUP HCPCS C1713 71761026 - NAIL IM 10/8.5MM 26CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71761028 SUP HCPCS C1713 71761028 - NAIL IM 10/8.5MM 28CM TRGN STRG TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71761030 SUP HCPCS C1713 71761030 - NAIL IM 10/8.5MM 30CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71761118 SUP HCPCS C1713 71761118 - NAIL IM 11/9.5MM 18CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71761120 SUP HCPCS C1713 71761120 - NAIL IM 11/9.5MM 20CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71761122 SUP HCPCS C1713 71761122 - NAIL IM 11/9.5MM 22CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71761124 SUP HCPCS C1713 71761124 - NAIL IM 11/9.5MM 24CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71761126 SUP HCPCS C1713 71761126 - NAIL IM 11/9.5MM 26CM HUM BOTH IP/OP "$3,048.75 " "$2,256.08" $0.00 "$2,439.00" "$1,371.94" "$1,371.94" $0.00 $0.00 $0.00 $635.44 "$2,262.78" "$2,262.78" $0.00 $0.00 $635.36 $0.00 "$1,503.03" "$1,503.03" $0.00 "$1,524.38" "$2,414.61" "$2,439.00" $0.00 $0.00 $477.13 $0.00 $0.00 $485.36 $0.00 $0.00 $0.00 $0.00 $0.00 71761128 SUP HCPCS C1713 71761128 - NAIL IM 11/9.5MM 28CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71761130 SUP HCPCS C1713 71761130 - NAIL IM 11/9.5MM 30CM HUM BOTH IP/OP "$4,370.00 " "$3,233.80" $0.00 "$3,496.00" "$1,966.50" "$1,966.50" $0.00 $0.00 $0.00 $910.82 "$3,243.41" "$3,243.41" $0.00 $0.00 $910.71 $0.00 "$2,154.41" "$2,154.41" $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $683.91 $0.00 $0.00 $695.70 $0.00 $0.00 $0.00 $0.00 $0.00 71770816 SUP HCPCS C1713 71770816 - NAIL IM LNG 8/7MM 16CM TRGN IMPL SET BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770818 SUP HCPCS C1713 71770818 - NAIL IM 8/7MM 18CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770820 SUP HCPCS C1713 71770820 - NAIL IM 8/7MM 20CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770822 SUP HCPCS C1713 71770822 - NAIL IM 8/7MM 22CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770824 SUP HCPCS C1713 71770824 - NAIL IM 8/7MM 24CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770826 SUP HCPCS C1713 71770826 - NAIL IM LNG 8/7MM 26CM TRGN IMPL SET BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770828 SUP HCPCS C1713 71770828 - NAIL IM 8/7MM 28CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770830 SUP HCPCS C1713 71770830 - NAIL IM 8/7MM 30CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770918 SUP HCPCS C1713 71770918 - NAIL IM 9/7.5MM 18CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770920 SUP HCPCS C1713 71770920 - NAIL IM LNG 9/7.5MM 20CM TRGN IMPL SET BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770922 SUP HCPCS C1713 71770922 - NAIL IM LNG 9/7.5MM 22CM TRGN IMPL SET BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770924 SUP HCPCS C1713 71770924 - NAIL IM LNG 9/7.5MM 24CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770926 SUP HCPCS C1713 71770926 - NAIL IM 9 7.5MM 26CM TRGN SET TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770928 SUP HCPCS C1713 71770928 - NAIL IM 9/7.5MM 28CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71770930 SUP HCPCS C1713 71770930 - NAIL IM 9/7.5MM 30CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71771018 SUP HCPCS C1713 71771018 - NAIL IM 10/8.5MM 18CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71771020 SUP HCPCS C1713 71771020 - NAIL IM 10/8.5MM 20CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71771022 SUP HCPCS C1713 71771022 - NAIL IM LNG 10MM 8.5MM 22CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71771024 SUP HCPCS C1713 71771024 - NAIL IM 10MM 8.5MM 24CM FRSGHT BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71771026 SUP HCPCS C1713 71771026 - NAIL IM 10MM 8.5MM 26CM TRGN IMPL SET TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71771028 SUP HCPCS C1713 71771028 - NAIL IM 10 8.5MM 28CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71771030 SUP HCPCS C1713 71771030 - NAIL IM 10/8.5MM 30CM TRGN BNT TI HUM BOTH IP/OP "$3,656.25 " "$2,705.63" $0.00 "$2,925.00" "$1,645.31" "$1,645.31" $0.00 $0.00 $0.00 $762.05 "$2,713.67" "$2,713.67" $0.00 $0.00 $761.96 $0.00 "$1,802.53" "$1,802.53" $0.00 "$1,828.13" "$2,895.75" "$2,925.00" $0.00 $0.00 $572.20 $0.00 $0.00 $582.08 $0.00 $0.00 $0.00 $0.00 $0.00 71771118 SUP HCPCS C1713 71771118 - NAIL IM 11/9.5MM 18CM HUM BOTH IP/OP "$2,576.25 " "$1,906.43" $0.00 "$2,061.00" "$1,159.31" "$1,159.31" $0.00 $0.00 $0.00 $536.95 "$1,912.09" "$1,912.09" $0.00 $0.00 $536.89 $0.00 "$1,270.09" "$1,270.09" $0.00 "$1,288.13" "$2,040.39" "$2,061.00" $0.00 $0.00 $403.18 $0.00 $0.00 $410.14 $0.00 $0.00 $0.00 $0.00 $0.00 71771120 SUP HCPCS C1713 71771120 - NAIL IM 11/9.5MM 20CM HUM BOTH IP/OP "$2,576.25 " "$1,906.43" $0.00 "$2,061.00" "$1,159.31" "$1,159.31" $0.00 $0.00 $0.00 $536.95 "$1,912.09" "$1,912.09" $0.00 $0.00 $536.89 $0.00 "$1,270.09" "$1,270.09" $0.00 "$1,288.13" "$2,040.39" "$2,061.00" $0.00 $0.00 $403.18 $0.00 $0.00 $410.14 $0.00 $0.00 $0.00 $0.00 $0.00 71771122 SUP HCPCS C1713 71771122 - NAIL IM 11/9.5MM 22CM HUM BOTH IP/OP "$2,576.25 " "$1,906.43" $0.00 "$2,061.00" "$1,159.31" "$1,159.31" $0.00 $0.00 $0.00 $536.95 "$1,912.09" "$1,912.09" $0.00 $0.00 $536.89 $0.00 "$1,270.09" "$1,270.09" $0.00 "$1,288.13" "$2,040.39" "$2,061.00" $0.00 $0.00 $403.18 $0.00 $0.00 $410.14 $0.00 $0.00 $0.00 $0.00 $0.00 71771124 SUP HCPCS C1713 71771124 - NAIL IM 11/9.5MM 24CM HUM BOTH IP/OP "$2,576.25 " "$1,906.43" $0.00 "$2,061.00" "$1,159.31" "$1,159.31" $0.00 $0.00 $0.00 $536.95 "$1,912.09" "$1,912.09" $0.00 $0.00 $536.89 $0.00 "$1,270.09" "$1,270.09" $0.00 "$1,288.13" "$2,040.39" "$2,061.00" $0.00 $0.00 $403.18 $0.00 $0.00 $410.14 $0.00 $0.00 $0.00 $0.00 $0.00 71771126 SUP HCPCS C1713 71771126 - NAIL IM 11/9.5MM 26CM HUM BOTH IP/OP "$2,576.25 " "$1,906.43" $0.00 "$2,061.00" "$1,159.31" "$1,159.31" $0.00 $0.00 $0.00 $536.95 "$1,912.09" "$1,912.09" $0.00 $0.00 $536.89 $0.00 "$1,270.09" "$1,270.09" $0.00 "$1,288.13" "$2,040.39" "$2,061.00" $0.00 $0.00 $403.18 $0.00 $0.00 $410.14 $0.00 $0.00 $0.00 $0.00 $0.00 71771128 SUP HCPCS C1713 71771128 - NAIL IM 11/9.5MM 28CM HUM BOTH IP/OP "$2,576.25 " "$1,906.43" $0.00 "$2,061.00" "$1,159.31" "$1,159.31" $0.00 $0.00 $0.00 $536.95 "$1,912.09" "$1,912.09" $0.00 $0.00 $536.89 $0.00 "$1,270.09" "$1,270.09" $0.00 "$1,288.13" "$2,040.39" "$2,061.00" $0.00 $0.00 $403.18 $0.00 $0.00 $410.14 $0.00 $0.00 $0.00 $0.00 $0.00 71771130 SUP HCPCS C1713 71771130 - NAIL IM 11/9.5MM 30CM HUM BOTH IP/OP "$3,048.75 " "$2,256.08" $0.00 "$2,439.00" "$1,371.94" "$1,371.94" $0.00 $0.00 $0.00 $635.44 "$2,262.78" "$2,262.78" $0.00 $0.00 $635.36 $0.00 "$1,503.03" "$1,503.03" $0.00 "$1,524.38" "$2,414.61" "$2,439.00" $0.00 $0.00 $477.13 $0.00 $0.00 $485.36 $0.00 $0.00 $0.00 $0.00 $0.00 71800308 SUP HCPCS C1713 71800308 - PLATE BN 165MM PRLC 8 HL LCK SS TIB RT PROX LAT 4.5MM SCR BOTH IP/OP "$3,402.00 " "$2,517.48" $0.00 "$2,721.60" "$1,530.90" "$1,530.90" $0.00 $0.00 $0.00 $709.06 "$2,524.96" "$2,524.96" $0.00 $0.00 $708.98 $0.00 "$1,677.19" "$1,677.19" $0.00 "$1,701.00" "$2,694.38" "$2,721.60" $0.00 $0.00 $532.41 $0.00 $0.00 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 71800313 SUP HCPCS C1713 71800313 - PLATE BN 255MM PRLC 13 HL LCK SS TIB RT PROX LAT 4.5MM SCR BOTH IP/OP "$3,491.25 " "$2,583.53" $0.00 "$2,793.00" "$1,571.06" "$1,571.06" $0.00 $0.00 $0.00 $727.66 "$2,591.21" "$2,591.21" $0.00 $0.00 $727.58 $0.00 "$1,721.19" "$1,721.19" $0.00 "$1,745.63" "$2,765.07" "$2,793.00" $0.00 $0.00 $546.38 $0.00 $0.00 $555.81 $0.00 $0.00 $0.00 $0.00 $0.00 71800413 SUP HCPCS C1713 71800413 - PLATE BN 187MM PRLC 13 HL LCK SS TIB LT PROX LAT 3.5MM SCR BOTH IP/OP "$3,491.25 " "$2,583.53" $0.00 "$2,793.00" "$1,571.06" "$1,571.06" $0.00 $0.00 $0.00 $727.66 "$2,591.21" "$2,591.21" $0.00 $0.00 $727.58 $0.00 "$1,721.19" "$1,721.19" $0.00 "$1,745.63" "$2,765.07" "$2,793.00" $0.00 $0.00 $546.38 $0.00 $0.00 $555.81 $0.00 $0.00 $0.00 $0.00 $0.00 71800513 SUP HCPCS C1713 71800513 - PLATE BN 187MM PRLC 13 HL LCK SS TIB RT PROX LAT 3.5MM SCR BOTH IP/OP "$3,491.25 " "$2,583.53" $0.00 "$2,793.00" "$1,571.06" "$1,571.06" $0.00 $0.00 $0.00 $727.66 "$2,591.21" "$2,591.21" $0.00 $0.00 $727.58 $0.00 "$1,721.19" "$1,721.19" $0.00 "$1,745.63" "$2,765.07" "$2,793.00" $0.00 $0.00 $546.38 $0.00 $0.00 $555.81 $0.00 $0.00 $0.00 $0.00 $0.00 71801222 SUP HCPCS C1713 71801222 - SCREW BN 3.5MM 22MM STRL PRLC VLP ST LCK FT FIB CORT BOTH IP/OP $244.65 $181.04 $0.00 $195.72 $110.09 $110.09 $0.00 $0.00 $0.00 $50.99 $181.58 $181.58 $0.00 $0.00 $50.99 $0.00 $144.71 $144.71 $0.00 $122.33 $193.76 $195.72 $0.00 $0.00 $38.29 $0.00 $0.00 $38.95 $0.00 $0.00 $0.00 $0.00 $0.00 71801320 SUP HCPCS C1713 71801320 - SCREW BN HEX LOPRFL 3.5MM 20MM STRL PRLC VLP ST FT CORT BOTH IP/OP $43.58 $32.25 $0.00 $34.86 $19.61 $19.61 $0.00 $0.00 $0.00 $9.08 $32.34 $32.34 $0.00 $0.00 $9.08 $0.00 $25.77 $25.77 $0.00 $21.79 $34.52 $34.86 $0.00 $0.00 $6.82 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 71801328 SUP HCPCS C1713 71801328 - SCREW BN LOPRFL 3.5MM 28MM STRL VLP ST HEX DRV RCS CORT FT BOTH IP/OP $43.58 $32.25 $0.00 $34.86 $19.61 $19.61 $0.00 $0.00 $0.00 $9.08 $32.34 $32.34 $0.00 $0.00 $9.08 $0.00 $25.77 $25.77 $0.00 $21.79 $34.52 $34.86 $0.00 $0.00 $6.82 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 71801332 SUP HCPCS C1713 71801332 - SCREW BN HEX LOPRFL 3.5MM 32MM STRL PRLC VLP ST FT CORT BOTH IP/OP $43.58 $32.25 $0.00 $34.86 $19.61 $19.61 $0.00 $0.00 $0.00 $9.08 $32.34 $32.34 $0.00 $0.00 $9.08 $0.00 $25.77 $25.77 $0.00 $21.79 $34.52 $34.86 $0.00 $0.00 $6.82 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 71801336 SUP HCPCS C1713 71801336 - SCREW BN LOPRFL 3.5MM 36MM STRL VLP ST HEX DRV RCS CORT FT BOTH IP/OP $43.58 $32.25 $0.00 $34.86 $19.61 $19.61 $0.00 $0.00 $0.00 $9.08 $32.34 $32.34 $0.00 $0.00 $9.08 $0.00 $25.77 $25.77 $0.00 $21.79 $34.52 $34.86 $0.00 $0.00 $6.82 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 71801340 SUP HCPCS C1713 71801340 - SCREW BN LOPRFL 3.5MM 40MM STRL VLP ST HEX DRV RCS CORT FT BOTH IP/OP $43.58 $32.25 $0.00 $34.86 $19.61 $19.61 $0.00 $0.00 $0.00 $9.08 $32.34 $32.34 $0.00 $0.00 $9.08 $0.00 $25.77 $25.77 $0.00 $21.79 $34.52 $34.86 $0.00 $0.00 $6.82 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 71801365 SUP HCPCS C1713 71801365 - SCREW BN HEX LOPRFL 3.5MM 65MM STRL PRLC VLP ST FT CORT BOTH IP/OP $43.58 $32.25 $0.00 $34.86 $19.61 $19.61 $0.00 $0.00 $0.00 $9.08 $32.34 $32.34 $0.00 $0.00 $9.08 $0.00 $25.77 $25.77 $0.00 $21.79 $34.52 $34.86 $0.00 $0.00 $6.82 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 71801375 SUP HCPCS C1713 71801375 - SCREW BN HEX LOPRFL 3.5MM 75MM STRL PRLC VLP ST FT CORT BOTH IP/OP $43.58 $32.25 $0.00 $34.86 $19.61 $19.61 $0.00 $0.00 $0.00 $9.08 $32.34 $32.34 $0.00 $0.00 $9.08 $0.00 $25.77 $25.77 $0.00 $21.79 $34.52 $34.86 $0.00 $0.00 $6.82 $0.00 $0.00 $6.94 $0.00 $0.00 $0.00 $0.00 $0.00 71802506 SUP HCPCS C1713 71802506 - SCREW BN 2.5MM 6MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802508 SUP HCPCS C1713 71802508 - SCREW BN 2.5MM 8MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802532 SUP HCPCS C1713 71802532 - SCREW BN 2.5MM 32MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802534 SUP HCPCS C1713 71802534 - SCREW BN 2.5MM 34MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802536 SUP HCPCS C1713 71802536 - SCREW BN 2.5MM 36MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802538 SUP HCPCS C1713 71802538 - SCREW BN 2.5MM 38MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802540 SUP HCPCS C1713 71802540 - SCREW BN 2.5MM 40MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802545 SUP HCPCS C1713 71802545 - SCREW BN 2.5MM 45MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802550 SUP HCPCS C1713 71802550 - SCREW BN 2.5MM 50MM ST CORT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71802606 SUP HCPCS C1713 71802606 - PLATE BN 70MM PRLC 6 HL LCK RECON SS 3.5MM SCR BOTH IP/OP "$1,060.50 " $784.77 $0.00 $848.40 $477.23 $477.23 $0.00 $0.00 $0.00 $221.03 $787.10 $787.10 $0.00 $0.00 $221.01 $0.00 $627.29 $627.29 $0.00 $530.25 $839.92 $848.40 $0.00 $0.00 $165.97 $0.00 $0.00 $168.83 $0.00 $0.00 $0.00 $0.00 $0.00 71803006 SUP HCPCS C1713 71803006 - SCREW BN 2.7MM 6MM STRL ST CORT FOREFOOT MIDFOOT BOTH IP/OP $75.58 $55.93 $0.00 $60.46 $34.01 $34.01 $0.00 $0.00 $0.00 $15.75 $56.09 $56.09 $0.00 $0.00 $15.75 $0.00 $44.70 $44.70 $0.00 $37.79 $59.86 $60.46 $0.00 $0.00 $11.83 $0.00 $0.00 $12.03 $0.00 $0.00 $0.00 $0.00 $0.00 71809006 SUP HCPCS C1713 71809006 - PLATE BN TBLR RCHRD 6 HL LCK HIP 3.5MM SCR BOTH IP/OP $347.55 $257.19 $0.00 $278.04 $156.40 $156.40 $0.00 $0.00 $0.00 $72.44 $257.95 $257.95 $0.00 $0.00 $72.43 $0.00 $205.58 $205.58 $0.00 $173.78 $275.26 $278.04 $0.00 $0.00 $54.39 $0.00 $0.00 $55.33 $0.00 $0.00 $0.00 $0.00 $0.00 71823032 SUP HCPCS C1713 71823032 - SCREW BN 2.7MM 32MM ST SS CORT PRLC VLP SM FRAG SYS BOTH IP/OP $44.90 $33.23 $0.00 $35.92 $20.21 $20.21 $0.00 $0.00 $0.00 $9.36 $33.32 $33.32 $0.00 $0.00 $9.36 $0.00 $26.56 $26.56 $0.00 $22.45 $35.56 $35.92 $0.00 $0.00 $7.03 $0.00 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $0.00 71840112 SUP HCPCS C1713 71840112 - TEMPLATE BNDRG TC100 12 HL CMPR LG FRAG PLT BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 71840202 SUP HCPCS C1713 71840202 - PLATE BN 26MM 2 HL CMPR 3.5MM SCR SM FRAG SET BOTH IP/OP $332.85 $246.31 $0.00 $266.28 $149.78 $149.78 $0.00 $0.00 $0.00 $69.37 $247.04 $247.04 $0.00 $0.00 $69.37 $0.00 $196.88 $196.88 $0.00 $166.43 $263.62 $266.28 $0.00 $0.00 $52.09 $0.00 $0.00 $52.99 $0.00 $0.00 $0.00 $0.00 $0.00 71840203 SUP HCPCS C1713 71840203 - PLATE BN 39MM 3 HL CMPR ORTH 3.5MM SCR SM FRAG SET BOTH IP/OP $341.25 $252.53 $0.00 $273.00 $153.56 $153.56 $0.00 $0.00 $0.00 $71.13 $253.28 $253.28 $0.00 $0.00 $71.12 $0.00 $201.85 $201.85 $0.00 $170.63 $270.27 $273.00 $0.00 $0.00 $53.41 $0.00 $0.00 $54.33 $0.00 $0.00 $0.00 $0.00 $0.00 71840204 SUP HCPCS C1713 71840204 - PLATE BN 52MM TC100 4 HL CMPR PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $354.90 $262.63 $0.00 $283.92 $159.71 $159.71 $0.00 $0.00 $0.00 $73.97 $263.41 $263.41 $0.00 $0.00 $73.96 $0.00 $209.92 $209.92 $0.00 $177.45 $281.08 $283.92 $0.00 $0.00 $55.54 $0.00 $0.00 $56.50 $0.00 $0.00 $0.00 $0.00 $0.00 71840205 SUP HCPCS C1713 71840205 - PLATE BN 65MM TC100 5 HL CMPR PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $382.20 $282.83 $0.00 $305.76 $171.99 $171.99 $0.00 $0.00 $0.00 $79.66 $283.67 $283.67 $0.00 $0.00 $79.65 $0.00 $226.07 $226.07 $0.00 $191.10 $302.70 $305.76 $0.00 $0.00 $59.81 $0.00 $0.00 $60.85 $0.00 $0.00 $0.00 $0.00 $0.00 71840206 SUP HCPCS C1713 71840206 - PLATE BN 78MM TC100 6 HL CMPR PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 71840207 SUP HCPCS C1713 71840207 - PLATE BN 91MM TC100 7 HL CMPR PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $414.75 $306.92 $0.00 $331.80 $186.64 $186.64 $0.00 $0.00 $0.00 $86.44 $307.83 $307.83 $0.00 $0.00 $86.43 $0.00 $245.32 $245.32 $0.00 $207.38 $328.48 $331.80 $0.00 $0.00 $64.91 $0.00 $0.00 $66.03 $0.00 $0.00 $0.00 $0.00 $0.00 71840208 SUP HCPCS C1713 71840208 - PLATE BN 104MM TC100 8 HL CMPR PLVC 3.5MM SCR SM FRAG SET BOTH IP/OP $446.25 $330.23 $0.00 $357.00 $200.81 $200.81 $0.00 $0.00 $0.00 $93.01 $331.21 $331.21 $0.00 $0.00 $93.00 $0.00 $263.96 $263.96 $0.00 $223.13 $353.43 $357.00 $0.00 $0.00 $69.84 $0.00 $0.00 $71.04 $0.00 $0.00 $0.00 $0.00 $0.00 71840209 SUP HCPCS C1713 71840209 - PLATE BN 117MM 9 HL CMPR ORTH 3.5MM SCR SM FRAG SET BOTH IP/OP $454.65 $336.44 $0.00 $363.72 $204.59 $204.59 $0.00 $0.00 $0.00 $94.76 $337.44 $337.44 $0.00 $0.00 $94.75 $0.00 $268.93 $268.93 $0.00 $227.33 $360.08 $363.72 $0.00 $0.00 $71.15 $0.00 $0.00 $72.38 $0.00 $0.00 $0.00 $0.00 $0.00 71840210 SUP HCPCS C1713 71840210 - PLATE BN 130MM 10 HL CMPR ORTH 3.5MM SCR SM FRAG SET BOTH IP/OP $470.40 $348.10 $0.00 $376.32 $211.68 $211.68 $0.00 $0.00 $0.00 $98.04 $349.13 $349.13 $0.00 $0.00 $98.03 $0.00 $278.24 $278.24 $0.00 $235.20 $372.56 $376.32 $0.00 $0.00 $73.62 $0.00 $0.00 $74.89 $0.00 $0.00 $0.00 $0.00 $0.00 71840211 SUP HCPCS C1713 71840211 - PLATE BN 143MM 11 HL CMPR 3.5MM SCR SM FRAG SET BOTH IP/OP $470.40 $348.10 $0.00 $376.32 $211.68 $211.68 $0.00 $0.00 $0.00 $98.04 $349.13 $349.13 $0.00 $0.00 $98.03 $0.00 $278.24 $278.24 $0.00 $235.20 $372.56 $376.32 $0.00 $0.00 $73.62 $0.00 $0.00 $74.89 $0.00 $0.00 $0.00 $0.00 $0.00 71840212 SUP HCPCS C1713 71840212 - PLATE BN 156MM 12 HL CMPR 3.5MM SCR SM FRAG SET BOTH IP/OP $520.80 $385.39 $0.00 $416.64 $234.36 $234.36 $0.00 $0.00 $0.00 $108.55 $386.54 $386.54 $0.00 $0.00 $108.53 $0.00 $308.05 $308.05 $0.00 $260.40 $412.47 $416.64 $0.00 $0.00 $81.51 $0.00 $0.00 $82.91 $0.00 $0.00 $0.00 $0.00 $0.00 71840214 SUP HCPCS C1713 71840214 - PLATE BN 182MM 14 HL CMPR 3.5MM SCR SM FRAG SET BOTH IP/OP "$1,181.25 " $874.13 $0.00 $945.00 $531.56 $531.56 $0.00 $0.00 $0.00 $246.20 $876.72 $876.72 $0.00 $0.00 $246.17 $0.00 $698.71 $698.71 $0.00 $590.63 $935.55 $945.00 $0.00 $0.00 $184.87 $0.00 $0.00 $188.06 $0.00 $0.00 $0.00 $0.00 $0.00 71840215 SUP HCPCS C1713 71840215 - PLATE BN 195MM 15 HL CMPR 3.5MM SCR SM FRAG SET BOTH IP/OP "$1,233.75 " $912.98 $0.00 $987.00 $555.19 $555.19 $0.00 $0.00 $0.00 $257.14 $915.69 $915.69 $0.00 $0.00 $257.11 $0.00 $729.76 $729.76 $0.00 $616.88 $977.13 $987.00 $0.00 $0.00 $193.08 $0.00 $0.00 $196.41 $0.00 $0.00 $0.00 $0.00 $0.00 71840216 SUP HCPCS C1713 71840216 - PLATE BN 208MM 16 HL CMPR 3.5MM SCR SM FRAG SET BOTH IP/OP "$1,359.75 " "$1,006.22" $0.00 "$1,087.80" $611.89 $611.89 $0.00 $0.00 $0.00 $283.41 "$1,009.21" "$1,009.21" $0.00 $0.00 $283.37 $0.00 $804.29 $804.29 $0.00 $679.88 "$1,076.92" "$1,087.80" $0.00 $0.00 $212.80 $0.00 $0.00 $216.47 $0.00 $0.00 $0.00 $0.00 $0.00 71840218 SUP HCPCS C1713 71840218 - PLATE BN 234MM 18 HL CMPR 3.5MM SCR SM FRAG SET BOTH IP/OP "$1,517.25 " "$1,122.77" $0.00 "$1,213.80" $682.76 $682.76 $0.00 $0.00 $0.00 $316.23 "$1,126.10" "$1,126.10" $0.00 $0.00 $316.19 $0.00 $897.45 $897.45 $0.00 $758.63 "$1,201.66" "$1,213.80" $0.00 $0.00 $237.45 $0.00 $0.00 $241.55 $0.00 $0.00 $0.00 $0.00 $0.00 71840220 SUP HCPCS C1713 71840220 - PLATE BN 260MM 20 HL CMPR 3.5MM SCR SM FRAG SET BOTH IP/OP "$1,711.50 " "$1,266.51" $0.00 "$1,369.20" $770.18 $770.18 $0.00 $0.00 $0.00 $356.72 "$1,270.28" "$1,270.28" $0.00 $0.00 $356.68 $0.00 "$1,012.35" "$1,012.35" $0.00 $855.75 "$1,355.51" "$1,369.20" $0.00 $0.00 $267.85 $0.00 $0.00 $272.47 $0.00 $0.00 $0.00 $0.00 $0.00 71841012 SUP HCPCS C1713 71841012 - TEMPLATE BNDRG TC100 12 HL SM FRAG PLT BOTH IP/OP $88.68 $65.62 $0.00 $70.94 $39.90 $39.90 $0.00 $0.00 $0.00 $18.48 $65.81 $65.81 $0.00 $0.00 $18.48 $0.00 $52.45 $52.45 $0.00 $44.34 $70.23 $70.94 $0.00 $0.00 $13.88 $0.00 $0.00 $14.12 $0.00 $0.00 $0.00 $0.00 $0.00 71841206 SUP HCPCS C1713 71841206 - PLATE BN BRD 108MM 6 HL CMPR 4.5MM SCR BOTH IP/OP $577.50 $427.35 $0.00 $462.00 $259.88 $259.88 $0.00 $0.00 $0.00 $120.37 $428.62 $428.62 $0.00 $0.00 $120.35 $0.00 $341.59 $341.59 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 71841207 SUP HCPCS C1713 71841207 - PLATE BN BRD 126MM 7 HL CMPR 4.5MM SCR BOTH IP/OP $577.50 $427.35 $0.00 $462.00 $259.88 $259.88 $0.00 $0.00 $0.00 $120.37 $428.62 $428.62 $0.00 $0.00 $120.35 $0.00 $341.59 $341.59 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 71841208 SUP HCPCS C1713 71841208 - PLATE BN BRD 144MM 8 HL CMPR 4.5MM SCR BOTH IP/OP $718.20 $531.47 $0.00 $574.56 $323.19 $323.19 $0.00 $0.00 $0.00 $149.69 $533.05 $533.05 $0.00 $0.00 $149.67 $0.00 $424.82 $424.82 $0.00 $359.10 $568.81 $574.56 $0.00 $0.00 $112.40 $0.00 $0.00 $114.34 $0.00 $0.00 $0.00 $0.00 $0.00 71841209 SUP HCPCS C1713 71841209 - PLATE BN BRD 162MM 9 HL CMPR 4.5MM SCR BOTH IP/OP $718.20 $531.47 $0.00 $574.56 $323.19 $323.19 $0.00 $0.00 $0.00 $149.69 $533.05 $533.05 $0.00 $0.00 $149.67 $0.00 $424.82 $424.82 $0.00 $359.10 $568.81 $574.56 $0.00 $0.00 $112.40 $0.00 $0.00 $114.34 $0.00 $0.00 $0.00 $0.00 $0.00 71841210 SUP HCPCS C1713 71841210 - PLATE BN BRD 180MM 10 HL CMPR 4.5MM SCR BOTH IP/OP $718.20 $531.47 $0.00 $574.56 $323.19 $323.19 $0.00 $0.00 $0.00 $149.69 $533.05 $533.05 $0.00 $0.00 $149.67 $0.00 $424.82 $424.82 $0.00 $359.10 $568.81 $574.56 $0.00 $0.00 $112.40 $0.00 $0.00 $114.34 $0.00 $0.00 $0.00 $0.00 $0.00 71841211 SUP HCPCS C1713 71841211 - PLATE BN BRD 198MM 11 HL CMPR 4.5MM SCR BOTH IP/OP $904.05 $669.00 $0.00 $723.24 $406.82 $406.82 $0.00 $0.00 $0.00 $188.43 $670.99 $670.99 $0.00 $0.00 $188.40 $0.00 $534.75 $534.75 $0.00 $452.03 $716.01 $723.24 $0.00 $0.00 $141.48 $0.00 $0.00 $143.92 $0.00 $0.00 $0.00 $0.00 $0.00 71841212 SUP HCPCS C1713 71841212 - PLATE BN BRD 216MM 12 HL CMPR ORTH 4.5MM SCR BOTH IP/OP $770.70 $570.32 $0.00 $616.56 $346.82 $346.82 $0.00 $0.00 $0.00 $160.63 $572.01 $572.01 $0.00 $0.00 $160.61 $0.00 $455.87 $455.87 $0.00 $385.35 $610.39 $616.56 $0.00 $0.00 $120.61 $0.00 $0.00 $122.70 $0.00 $0.00 $0.00 $0.00 $0.00 71841214 SUP HCPCS C1713 71841214 - PLATE BN BRD 252MM 14 HL CMPR 4.5MM SCR BOTH IP/OP $770.70 $570.32 $0.00 $616.56 $346.82 $346.82 $0.00 $0.00 $0.00 $160.63 $572.01 $572.01 $0.00 $0.00 $160.61 $0.00 $455.87 $455.87 $0.00 $385.35 $610.39 $616.56 $0.00 $0.00 $120.61 $0.00 $0.00 $122.70 $0.00 $0.00 $0.00 $0.00 $0.00 71841218 SUP HCPCS C1713 71841218 - PLATE BN BRD 324MM 18 HL CMPR 4.5MM SCR BOTH IP/OP "$1,139.25 " $843.05 $0.00 $911.40 $512.66 $512.66 $0.00 $0.00 $0.00 $237.45 $845.55 $845.55 $0.00 $0.00 $237.42 $0.00 $673.87 $673.87 $0.00 $569.63 $902.29 $911.40 $0.00 $0.00 $178.29 $0.00 $0.00 $181.37 $0.00 $0.00 $0.00 $0.00 $0.00 71841222 SUP HCPCS C1713 71841222 - PLATE BN BRD 396MM 22 HL CMPR 4.5MM SCR BOTH IP/OP "$1,722.00 " "$1,274.28" $0.00 "$1,377.60" $774.90 $774.90 $0.00 $0.00 $0.00 $358.91 "$1,278.07" "$1,278.07" $0.00 $0.00 $358.86 $0.00 "$1,018.56" "$1,018.56" $0.00 $861.00 "$1,363.82" "$1,377.60" $0.00 $0.00 $269.49 $0.00 $0.00 $274.14 $0.00 $0.00 $0.00 $0.00 $0.00 71841402 SUP HCPCS C1713 71841402 - PLATE BN NAR 36MM 2 HL CMPR 4.5MM SCR BOTH IP/OP $473.55 $350.43 $0.00 $378.84 $213.10 $213.10 $0.00 $0.00 $0.00 $98.70 $351.47 $351.47 $0.00 $0.00 $98.69 $0.00 $280.10 $280.10 $0.00 $236.78 $375.05 $378.84 $0.00 $0.00 $74.11 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 71841403 SUP HCPCS C1713 71841403 - PLATE BN NAR 54MM 3 HL CMPR 4.5MM SCR BOTH IP/OP $387.45 $286.71 $0.00 $309.96 $174.35 $174.35 $0.00 $0.00 $0.00 $80.75 $287.57 $287.57 $0.00 $0.00 $80.74 $0.00 $229.18 $229.18 $0.00 $193.73 $306.86 $309.96 $0.00 $0.00 $60.64 $0.00 $0.00 $61.68 $0.00 $0.00 $0.00 $0.00 $0.00 71841404 SUP HCPCS C1713 71841404 - PLATE BN NAR 72MM 4 HL CMPR 4.5MM SCR BOTH IP/OP $387.45 $286.71 $0.00 $309.96 $174.35 $174.35 $0.00 $0.00 $0.00 $80.75 $287.57 $287.57 $0.00 $0.00 $80.74 $0.00 $229.18 $229.18 $0.00 $193.73 $306.86 $309.96 $0.00 $0.00 $60.64 $0.00 $0.00 $61.68 $0.00 $0.00 $0.00 $0.00 $0.00 71841405 SUP HCPCS C1713 71841405 - PLATE BN NAR 90MM 5 HL CMPR 4.5MM SCR BOTH IP/OP $387.45 $286.71 $0.00 $309.96 $174.35 $174.35 $0.00 $0.00 $0.00 $80.75 $287.57 $287.57 $0.00 $0.00 $80.74 $0.00 $229.18 $229.18 $0.00 $193.73 $306.86 $309.96 $0.00 $0.00 $60.64 $0.00 $0.00 $61.68 $0.00 $0.00 $0.00 $0.00 $0.00 71841406 SUP HCPCS C1713 71841406 - PLATE BN NAR 108MM 6 HL CMPR 4.5MM SCR BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $198.45 $198.45 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $220.50 $349.27 $352.80 $0.00 $0.00 $69.02 $0.00 $0.00 $70.21 $0.00 $0.00 $0.00 $0.00 $0.00 71841407 SUP HCPCS C1713 71841407 - PLATE BN NAR 126MM 7 HL CMPR 4.5MM SCR BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $198.45 $198.45 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $220.50 $349.27 $352.80 $0.00 $0.00 $69.02 $0.00 $0.00 $70.21 $0.00 $0.00 $0.00 $0.00 $0.00 71841408 SUP HCPCS C1713 71841408 - PLATE BN NAR 144MM 8 HL CMPR 4.5MM SCR BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $198.45 $198.45 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $220.50 $349.27 $352.80 $0.00 $0.00 $69.02 $0.00 $0.00 $70.21 $0.00 $0.00 $0.00 $0.00 $0.00 71841409 SUP HCPCS C1713 71841409 - PLATE BN NAR 162MM 9 HL CMPR 4.5MM SCR BOTH IP/OP $441.00 $326.34 $0.00 $352.80 $198.45 $198.45 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $220.50 $349.27 $352.80 $0.00 $0.00 $69.02 $0.00 $0.00 $70.21 $0.00 $0.00 $0.00 $0.00 $0.00 71841410 SUP HCPCS C1713 71841410 - PLATE BN NAR 180MM 10 HL CMPR 4.5MM SCR BOTH IP/OP $568.05 $420.36 $0.00 $454.44 $255.62 $255.62 $0.00 $0.00 $0.00 $118.40 $421.61 $421.61 $0.00 $0.00 $118.38 $0.00 $336.00 $336.00 $0.00 $284.03 $449.90 $454.44 $0.00 $0.00 $88.90 $0.00 $0.00 $90.43 $0.00 $0.00 $0.00 $0.00 $0.00 71841411 SUP HCPCS C1713 71841411 - PLATE BN NAR 198MM 11 HL CMPR 4.5MM SCR BOTH IP/OP $568.05 $420.36 $0.00 $454.44 $255.62 $255.62 $0.00 $0.00 $0.00 $118.40 $421.61 $421.61 $0.00 $0.00 $118.38 $0.00 $336.00 $336.00 $0.00 $284.03 $449.90 $454.44 $0.00 $0.00 $88.90 $0.00 $0.00 $90.43 $0.00 $0.00 $0.00 $0.00 $0.00 71841412 SUP HCPCS C1713 71841412 - PLATE BN NAR 216MM 12 HL CMPR 4.5MM SCR BOTH IP/OP $568.05 $420.36 $0.00 $454.44 $255.62 $255.62 $0.00 $0.00 $0.00 $118.40 $421.61 $421.61 $0.00 $0.00 $118.38 $0.00 $336.00 $336.00 $0.00 $284.03 $449.90 $454.44 $0.00 $0.00 $88.90 $0.00 $0.00 $90.43 $0.00 $0.00 $0.00 $0.00 $0.00 71841413 SUP HCPCS C1713 71841413 - PLATE BN NAR 234MM 13 HL CMPR 4.5MM SCR BOTH IP/OP $820.05 $606.84 $0.00 $656.04 $369.02 $369.02 $0.00 $0.00 $0.00 $170.92 $608.64 $608.64 $0.00 $0.00 $170.90 $0.00 $485.06 $485.06 $0.00 $410.03 $649.48 $656.04 $0.00 $0.00 $128.34 $0.00 $0.00 $130.55 $0.00 $0.00 $0.00 $0.00 $0.00 71841414 SUP HCPCS C1713 71841414 - PLATE BN NAR 252MM 14 HL CMPR 4.5MM SCR BOTH IP/OP $820.05 $606.84 $0.00 $656.04 $369.02 $369.02 $0.00 $0.00 $0.00 $170.92 $608.64 $608.64 $0.00 $0.00 $170.90 $0.00 $485.06 $485.06 $0.00 $410.03 $649.48 $656.04 $0.00 $0.00 $128.34 $0.00 $0.00 $130.55 $0.00 $0.00 $0.00 $0.00 $0.00 71841416 SUP HCPCS C1713 71841416 - PLATE BN NAR 288MM 16 HL CMPR 4.5MM SCR BOTH IP/OP $866.25 $641.03 $0.00 $693.00 $389.81 $389.81 $0.00 $0.00 $0.00 $180.55 $642.93 $642.93 $0.00 $0.00 $180.53 $0.00 $512.39 $512.39 $0.00 $433.13 $686.07 $693.00 $0.00 $0.00 $135.57 $0.00 $0.00 $137.91 $0.00 $0.00 $0.00 $0.00 $0.00 71841418 SUP HCPCS C1713 71841418 - PLATE BN NAR 324MM 18 HL CMPR 4.5MM SCR BOTH IP/OP "$1,270.50 " $940.17 $0.00 "$1,016.40" $571.73 $571.73 $0.00 $0.00 $0.00 $264.80 $942.97 $942.97 $0.00 $0.00 $264.77 $0.00 $751.50 $751.50 $0.00 $635.25 "$1,006.24" "$1,016.40" $0.00 $0.00 $198.83 $0.00 $0.00 $202.26 $0.00 $0.00 $0.00 $0.00 $0.00 71841420 SUP HCPCS C1713 71841420 - PLATE BN NAR 360MM 20 HL CMPR 4.5MM SCR BOTH IP/OP "$1,396.50 " "$1,033.41" $0.00 "$1,117.20" $628.43 $628.43 $0.00 $0.00 $0.00 $291.07 "$1,036.48" "$1,036.48" $0.00 $0.00 $291.03 $0.00 $826.03 $826.03 $0.00 $698.25 "$1,106.03" "$1,117.20" $0.00 $0.00 $218.55 $0.00 $0.00 $222.32 $0.00 $0.00 $0.00 $0.00 $0.00 71925062 SUP Custom 27203010 71925062 - GUIDE PIN ORTHOPEDIC 2.4MM 450MM THREAD BOTH IP/OP "$1,605.00 " "$1,187.70" $0.00 "$1,191.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,191.23" "$1,191.23" $0.00 $0.00 $334.48 $0.00 $0.00 $0.00 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71931590 SUP HCPCS C1713 71931590 - NAIL IM 11.5MM 60CM FEM BOTH IP/OP "$6,918.75 " "$5,119.88" $0.00 "$5,535.00" "$3,113.44" "$3,113.44" $0.00 $0.00 $0.00 "$1,442.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,441.87" $0.00 "$3,410.94" "$3,410.94" $0.00 "$3,459.38" "$5,479.65" "$5,535.00" $0.00 $0.00 "$1,082.78" $0.00 $0.00 "$1,101.47" $0.00 $0.00 $0.00 $0.00 $0.00 71931594 SUP HCPCS C1713 71931594 - NAIL IM 11.5MM 80CM KN RT FEM BOTH IP/OP "$6,918.75 " "$5,119.88" $0.00 "$5,535.00" "$3,113.44" "$3,113.44" $0.00 $0.00 $0.00 "$1,442.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,441.87" $0.00 "$3,410.94" "$3,410.94" $0.00 "$3,459.38" "$5,479.65" "$5,535.00" $0.00 $0.00 "$1,082.78" $0.00 $0.00 "$1,101.47" $0.00 $0.00 $0.00 $0.00 $0.00 71931602 SUP HCPCS C1713 71931602 - NAIL IM 11.5MM FAN FSN KN BOTH IP/OP "$6,918.75 " "$5,119.88" $0.00 "$5,535.00" "$3,113.44" "$3,113.44" $0.00 $0.00 $0.00 "$1,442.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,441.87" $0.00 "$3,410.94" "$3,410.94" $0.00 "$3,459.38" "$5,479.65" "$5,535.00" $0.00 $0.00 "$1,082.78" $0.00 $0.00 "$1,101.47" $0.00 $0.00 $0.00 $0.00 $0.00 71931604 SUP HCPCS C1713 71931604 - NAIL IM 11.5MM 85MM LCK FSN FEM BOTH IP/OP "$6,918.75 " "$5,119.88" $0.00 "$5,535.00" "$3,113.44" "$3,113.44" $0.00 $0.00 $0.00 "$1,442.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,441.87" $0.00 "$3,410.94" "$3,410.94" $0.00 "$3,459.38" "$5,479.65" "$5,535.00" $0.00 $0.00 "$1,082.78" $0.00 $0.00 "$1,101.47" $0.00 $0.00 $0.00 $0.00 $0.00 71931663 SUP HCPCS C1713 71931663 - NAIL IM 13MM 75CM FSN LT KN BOTH IP/OP "$6,918.75 " "$5,119.88" $0.00 "$5,535.00" "$3,113.44" "$3,113.44" $0.00 $0.00 $0.00 "$1,442.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,441.87" $0.00 "$3,410.94" "$3,410.94" $0.00 "$3,459.38" "$5,479.65" "$5,535.00" $0.00 $0.00 "$1,082.78" $0.00 $0.00 "$1,101.47" $0.00 $0.00 $0.00 $0.00 $0.00 71931664 SUP HCPCS C1713 71931664 - NAIL IM 13MM 80CM KN FEM BOTH IP/OP "$6,918.75 " "$5,119.88" $0.00 "$5,535.00" "$3,113.44" "$3,113.44" $0.00 $0.00 $0.00 "$1,442.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,441.87" $0.00 "$3,410.94" "$3,410.94" $0.00 "$3,459.38" "$5,479.65" "$5,535.00" $0.00 $0.00 "$1,082.78" $0.00 $0.00 "$1,101.47" $0.00 $0.00 $0.00 $0.00 $0.00 71931665 SUP HCPCS C1713 71931665 - NAIL IM 85CMX13MM ANTGRD FSN LT BOTH IP/OP "$6,918.75 " "$5,119.88" $0.00 "$5,535.00" "$3,113.44" "$3,113.44" $0.00 $0.00 $0.00 "$1,442.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,441.87" $0.00 "$3,410.94" "$3,410.94" $0.00 "$3,459.38" "$5,479.65" "$5,535.00" $0.00 $0.00 "$1,082.78" $0.00 $0.00 "$1,101.47" $0.00 $0.00 $0.00 $0.00 $0.00 71931672 SUP HCPCS C1713 71931672 - NAIL IM 13MM 75CM KN FEM BOTH IP/OP "$6,918.75 " "$5,119.88" $0.00 "$5,535.00" "$3,113.44" "$3,113.44" $0.00 $0.00 $0.00 "$1,442.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,441.87" $0.00 "$3,410.94" "$3,410.94" $0.00 "$3,459.38" "$5,479.65" "$5,535.00" $0.00 $0.00 "$1,082.78" $0.00 $0.00 "$1,101.47" $0.00 $0.00 $0.00 $0.00 $0.00 71933134 SUP HCPCS C1713 71933134 - SCREW BN 3MM 4MM 30MM 3MM SM HDLS SCR CNN SCR SYS TI ACPT BOTH IP/OP "$6,283.13 " "$4,649.52" $0.00 "$5,026.50" "$2,827.41" "$2,827.41" $0.00 $0.00 $0.00 "$1,309.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,309.40" $0.00 "$3,097.58" "$3,097.58" $0.00 "$3,141.56" "$4,976.24" "$5,026.50" $0.00 $0.00 $983.31 $0.00 $0.00 "$1,000.27" $0.00 $0.00 $0.00 $0.00 $0.00 71933306 SUP Custom 27203010 71933306 - RING EXFIX 255MM 2/3 RING BOTH IP/OP "$9,400.00 " "$6,956.00" $0.00 "$7,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,958.96" $0.00 $0.00 $0.00 $0.00 "$4,700.00" "$7,444.80" "$7,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71933335 SUP Custom 27203010 71933335 - RAIL XTRNFX STD SEG DIST MDLR SYS BOTH IP/OP "$1,534.25 " "$1,135.35" $0.00 "$1,227.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,138.72" "$1,138.72" $0.00 $0.00 $319.74 $0.00 $0.00 $0.00 $0.00 $767.13 "$1,215.13" "$1,227.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71933336 SUP Custom 27203010 71933336 - ARCH XTRNFX RAIL ROT CNCT BOTH IP/OP "$2,443.75 " "$1,808.38" $0.00 "$1,955.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,813.75" "$1,813.75" $0.00 $0.00 $509.28 $0.00 $0.00 $0.00 $0.00 "$1,221.88" "$1,935.45" "$1,955.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71933338 SUP Custom 27203010 71933338 - ARCH XTRNFX RAIL ROT CNCT BOTH IP/OP "$1,525.75 " "$1,129.06" $0.00 "$1,220.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,132.41" "$1,132.41" $0.00 $0.00 $317.97 $0.00 $0.00 $0.00 $0.00 $762.88 "$1,208.39" "$1,220.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71933339 SUP Custom 27203010 71933339 - ARCH XTRNFX RAIL ROT CNCT BOTH IP/OP "$1,323.88 " $979.67 $0.00 "$1,059.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $982.58 $982.58 $0.00 $0.00 $275.90 $0.00 $0.00 $0.00 $0.00 $661.94 "$1,048.51" "$1,059.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71933501 SUP HCPCS C1713 71933501 - SCREW BN 4.5MM 48MM ST CORT BOTH IP/OP $38.50 $28.49 $0.00 $30.80 $17.33 $17.33 $0.00 $0.00 $0.00 $8.02 $28.57 $28.57 $0.00 $0.00 $8.02 $0.00 $22.77 $22.77 $0.00 $19.25 $30.49 $30.80 $0.00 $0.00 $6.03 $0.00 $0.00 $6.13 $0.00 $0.00 $0.00 $0.00 $0.00 71933626 SUP Custom 27203010 71933626 - CONNECTOR XTRNFX RAIL CLP BOTH IP/OP "$1,039.13 " $768.96 $0.00 $831.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $771.24 $771.24 $0.00 $0.00 $216.55 $0.00 $0.00 $0.00 $0.00 $519.56 $822.99 $831.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71933940 SUP Custom 27203010 71933940 - RAIL XTRNFX SM MDLR RL ARC CNCT BOTH IP/OP "$1,564.00 " "$1,157.36" $0.00 "$1,251.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,160.80" "$1,160.80" $0.00 $0.00 $325.94 $0.00 $0.00 $0.00 $0.00 $782.00 "$1,238.69" "$1,251.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71933941 SUP Custom 27203010 71933941 - RAIL XTRNFX SM BOTH IP/OP "$2,613.75 " "$1,934.18" $0.00 "$2,091.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,939.93" "$1,939.93" $0.00 $0.00 $544.71 $0.00 $0.00 $0.00 $0.00 "$1,306.88" "$2,070.09" "$2,091.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71933943 SUP Custom 27203010 71933943 - RAIL XTRNFX SM ARC ROT CNCT BOTH IP/OP "$1,323.88 " $979.67 $0.00 "$1,059.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $982.58 $982.58 $0.00 $0.00 $275.90 $0.00 $0.00 $0.00 $0.00 $661.94 "$1,048.51" "$1,059.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934046 SUP Custom 27203010 71934046 - ARCH XTRNFX SHRT MDLR RL SM RAIL BOTH IP/OP "$2,613.75 " "$1,934.18" $0.00 "$2,091.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,939.93" "$1,939.93" $0.00 $0.00 $544.71 $0.00 $0.00 $0.00 $0.00 "$1,306.88" "$2,070.09" "$2,091.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934155 SUP Custom 27203010 71934155 - RAIL XTRNFX SM ARC PREASSEMBLE BOTH IP/OP "$9,360.63 " "$6,926.87" $0.00 "$7,488.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,950.75" $0.00 $0.00 $0.00 $0.00 "$4,680.31" "$7,413.62" "$7,488.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934479 SUP HCPCS C1713 71934479 - NAIL IM 125D 10MM 24CM TRGN FEM BOTH IP/OP "$3,780.00 " "$2,797.20" $0.00 "$3,024.00" "$1,701.00" "$1,701.00" $0.00 $0.00 $0.00 $787.85 "$2,805.52" "$2,805.52" $0.00 $0.00 $787.75 $0.00 "$1,863.54" "$1,863.54" $0.00 "$1,890.00" "$2,993.76" "$3,024.00" $0.00 $0.00 $591.57 $0.00 $0.00 $601.78 $0.00 $0.00 $0.00 $0.00 $0.00 71934482 SUP HCPCS C1713 71934482 - NAIL IM 130D 11.5MM 24CM TRGN FEM BOTH IP/OP "$3,780.00 " "$2,797.20" $0.00 "$3,024.00" "$1,701.00" "$1,701.00" $0.00 $0.00 $0.00 $787.85 "$2,805.52" "$2,805.52" $0.00 $0.00 $787.75 $0.00 "$1,863.54" "$1,863.54" $0.00 "$1,890.00" "$2,993.76" "$3,024.00" $0.00 $0.00 $591.57 $0.00 $0.00 $601.78 $0.00 $0.00 $0.00 $0.00 $0.00 71934624 SUP Custom 27203010 71934624 - RAIL XTRNFX ARC CNCT THRD BOTH IP/OP "$1,525.75 " "$1,129.06" $0.00 "$1,220.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,132.41" "$1,132.41" $0.00 $0.00 $317.97 $0.00 $0.00 $0.00 $0.00 $762.88 "$1,208.39" "$1,220.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934625 SUP Custom 27203010 71934625 - RAIL XTRNFX ARC BOTH IP/OP "$2,496.88 " "$1,847.69" $0.00 "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,853.18" "$1,853.18" $0.00 $0.00 $520.35 $0.00 $0.00 $0.00 $0.00 "$1,248.44" "$1,977.53" "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934626 SUP Custom 27203010 71934626 - RAIL XTRNFX SM ARC CNCT THRD BOTH IP/OP "$1,525.75 " "$1,129.06" $0.00 "$1,220.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,132.41" "$1,132.41" $0.00 $0.00 $317.97 $0.00 $0.00 $0.00 $0.00 $762.88 "$1,208.39" "$1,220.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934627 SUP Custom 27203010 71934627 - RAIL XTRNFX SM ARC BOTH IP/OP "$2,496.88 " "$1,847.69" $0.00 "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,853.18" "$1,853.18" $0.00 $0.00 $520.35 $0.00 $0.00 $0.00 $0.00 "$1,248.44" "$1,977.53" "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934628 SUP Custom 27203010 71934628 - RAIL XTRNFX SM ARCH BOTH IP/OP "$2,496.88 " "$1,847.69" $0.00 "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,853.18" "$1,853.18" $0.00 $0.00 $520.35 $0.00 $0.00 $0.00 $0.00 "$1,248.44" "$1,977.53" "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934629 SUP Custom 27203010 71934629 - RAIL XTRNFX 180MM ARC BOTH IP/OP "$2,496.88 " "$1,847.69" $0.00 "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,853.18" "$1,853.18" $0.00 $0.00 $520.35 $0.00 $0.00 $0.00 $0.00 "$1,248.44" "$1,977.53" "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934630 SUP Custom 27203010 71934630 - RAIL XTRNFX SM 180MM ARC BOTH IP/OP "$2,496.88 " "$1,847.69" $0.00 "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,853.18" "$1,853.18" $0.00 $0.00 $520.35 $0.00 $0.00 $0.00 $0.00 "$1,248.44" "$1,977.53" "$1,997.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934647 SUP Custom 27203010 71934647 - RAIL XTRNFX 50MM LCK BOTH IP/OP "$1,071.00 " $792.54 $0.00 $856.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $794.90 $794.90 $0.00 $0.00 $223.20 $0.00 $0.00 $0.00 $0.00 $535.50 $848.23 $856.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934648 SUP Custom 27203010 71934648 - RAIL XTRNFX 60MM LCK BOTH IP/OP "$1,060.38 " $784.68 $0.00 $848.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $787.01 $787.01 $0.00 $0.00 $220.98 $0.00 $0.00 $0.00 $0.00 $530.19 $839.82 $848.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934649 SUP Custom 27203010 71934649 - RAIL XTRNFX 70MM LCK BOTH IP/OP "$1,071.00 " $792.54 $0.00 $856.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $794.90 $794.90 $0.00 $0.00 $223.20 $0.00 $0.00 $0.00 $0.00 $535.50 $848.23 $856.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934650 SUP Custom 27203010 71934650 - RAIL XTRNFX 80MM LCK BOTH IP/OP "$1,060.38 " $784.68 $0.00 $848.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $787.01 $787.01 $0.00 $0.00 $220.98 $0.00 $0.00 $0.00 $0.00 $530.19 $839.82 $848.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934651 SUP Custom 27203010 71934651 - RAIL XTRNFX 90MM LCK BOTH IP/OP "$1,060.38 " $784.68 $0.00 $848.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $787.01 $787.01 $0.00 $0.00 $220.98 $0.00 $0.00 $0.00 $0.00 $530.19 $839.82 $848.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934652 SUP Custom 27203010 71934652 - RAIL XTRNFX 100MM LCK BOTH IP/OP "$1,060.38 " $784.68 $0.00 $848.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $787.01 $787.01 $0.00 $0.00 $220.98 $0.00 $0.00 $0.00 $0.00 $530.19 $839.82 $848.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934776 SUP HCPCS C1713 71934776 - NAIL 10MM 34CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934777 SUP HCPCS C1713 71934777 - NAIL 10MM 36CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934778 SUP HCPCS C1713 71934778 - NAIL 10MM 38CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934779 SUP HCPCS C1713 71934779 - NAIL 10MM 40CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934780 SUP HCPCS C1713 71934780 - NAIL 10MM 42CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934781 SUP HCPCS C1713 71934781 - NAIL 10MM 44CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934782 SUP HCPCS C1713 71934782 - NAIL 10MM 34CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934783 SUP HCPCS C1713 71934783 - NAIL 10MM 36CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934784 SUP HCPCS C1713 71934784 - NAIL 10MM 38CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934785 SUP HCPCS C1713 71934785 - NAIL 10MM 40CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934787 SUP HCPCS C1713 71934787 - NAIL 10MM 44CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934788 SUP HCPCS C1713 71934788 - NAIL 11.5MM 36CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934789 SUP HCPCS C1713 71934789 - NAIL 11.5MM 38CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934790 SUP HCPCS C1713 71934790 - NAIL 11.5MM 40CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934791 SUP HCPCS C1713 71934791 - NAIL 11.5MM 42CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934792 SUP HCPCS C1713 71934792 - NAIL 11.5MM 44CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934793 SUP HCPCS C1713 71934793 - NAIL 11.5MM 46CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934794 SUP HCPCS C1713 71934794 - NAIL 11.5MM 36CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934795 SUP HCPCS C1713 71934795 - NAIL 11.5MM 38CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934796 SUP HCPCS C1713 71934796 - NAIL 11.5MM 40CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934797 SUP HCPCS C1713 71934797 - NAIL 11.5MM 42CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934798 SUP HCPCS C1713 71934798 - NAIL 11.5MM 44CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934799 SUP HCPCS C1713 71934799 - NAIL 11.5MM 46CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934800 SUP HCPCS C1713 71934800 - NAIL 13MM 36CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934801 SUP HCPCS C1713 71934801 - NAIL 13MM 38CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934802 SUP HCPCS C1713 71934802 - NAIL 13MM 40CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934803 SUP HCPCS C1713 71934803 - NAIL 13MM 42CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934804 SUP HCPCS C1713 71934804 - NAIL 13MM 44CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934805 SUP HCPCS C1713 71934805 - NAIL 13MM 46CM FEM LEFT IM 25D ANTGRD LIME BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934806 SUP HCPCS C1713 71934806 - NAIL 13MM 36CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934807 SUP HCPCS C1713 71934807 - NAIL 13MM 38CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934808 SUP HCPCS C1713 71934808 - NAIL 13MM 40CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934809 SUP HCPCS C1713 71934809 - NAIL 13MM 42CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934810 SUP HCPCS C1713 71934810 - NAIL 13MM 44CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934811 SUP HCPCS C1713 71934811 - NAIL 13MM 46CM FEM RIGHT IM 25D ANTGRD ROSE BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934845 SUP Custom 27203010 71934845 - RAIL XTRNFX 339MM BOTH IP/OP "$2,666.88 " "$1,973.49" $0.00 "$2,133.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,979.35" "$1,979.35" $0.00 $0.00 $555.78 $0.00 $0.00 $0.00 $0.00 "$1,333.44" "$2,112.17" "$2,133.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934846 SUP Custom 27203010 71934846 - RAIL XTRNFX SM 226MM BOTH IP/OP "$2,666.88 " "$1,973.49" $0.00 "$2,133.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,979.35" "$1,979.35" $0.00 $0.00 $555.78 $0.00 $0.00 $0.00 $0.00 "$1,333.44" "$2,112.17" "$2,133.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71934996 SUP HCPCS C1713 71934996 - NAIL 10MM 46CM LEFT FAN IM 25D LIME DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934997 SUP HCPCS C1713 71934997 - NAIL 10MM 46CM RIGHT FAN IM 25D ROSE DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934998 SUP HCPCS C1713 71934998 - NAIL 11.5MM 32CM LEFT FAN IM 25D LIME DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71934999 SUP HCPCS C1713 71934999 - NAIL 11.5MM 34CM LEFT FAN IM 25D LIME DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71935001 SUP HCPCS C1713 71935001 - NAIL 11.5MM 34CM RIGHT FAN IM 25D ROSE DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71935002 SUP HCPCS C1713 71935002 - NAIL 13MM 32CM LEFT FAN IM 25D LIME DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71935003 SUP HCPCS C1713 71935003 - NAIL 13MM 34CM LEFT FAN IM 25D LIME DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71935004 SUP HCPCS C1713 71935004 - NAIL 13MM 32CM RIGHT FAN IM 25D ROSE DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 71935005 SUP HCPCS C1713 71935005 - NAIL 13MM 34CM RIGHT FAN IM 25D ROSE DH BOTH IP/OP "$4,522.50 " "$3,346.65" $0.00 "$3,618.00" "$2,035.13" "$2,035.13" $0.00 $0.00 $0.00 $942.60 "$3,356.60" "$3,356.60" $0.00 $0.00 $942.49 $0.00 "$2,229.59" "$2,229.59" $0.00 "$2,261.25" "$3,581.82" "$3,618.00" $0.00 $0.00 $707.77 $0.00 $0.00 $719.98 $0.00 $0.00 $0.00 $0.00 $0.00 72200634 SUP Custom 27203010 72200634 - PAD PSTN 9IN 1.5IN 11IN SUPN POST HIP PERINEUM DISP BOTH IP/OP $208.70 $154.44 $0.00 $166.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.90 $154.90 $0.00 $0.00 $43.49 $0.00 $0.00 $0.00 $0.00 $104.35 $165.29 $166.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72202468 SUP HCPCS C1713 72202468 - DEVICE FX 360D CRV FSTFX 2 ANCH PRETIE 2-0 5MM SUT MNSCL BOTH IP/OP "$1,163.90 " $861.29 $0.00 $931.12 $523.76 $523.76 $0.00 $0.00 $0.00 $242.59 $863.85 $863.85 $0.00 $0.00 $242.56 $0.00 $688.45 $688.45 $0.00 $581.95 $921.81 $931.12 $0.00 $0.00 $182.15 $0.00 $0.00 $185.29 $0.00 $0.00 $0.00 $0.00 $0.00 72400024 SUP HCPCS C1815 72400024 - IMPL URO A800 CONTINENCE URN CNTRL SYS INHBZN 61-70 CMW URN BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 72400025 SUP HCPCS C1815 72400025 - IMPLANT UROLOGICAL 71-80CU CM PRESSURE BALLOON AMS 800 BOTH IP/OP "$5,867.50 " "$4,341.95" $0.00 "$4,694.00" "$2,640.38" "$2,640.38" $0.00 $0.00 $0.00 "$1,222.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,222.79" $0.00 "$2,892.68" "$2,892.68" $0.00 "$2,933.75" "$4,647.06" "$4,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $934.11 $0.00 $0.00 $0.00 $0.00 $0.00 72402006 SUP HCPCS C1713 72402006 - SCREW BN T6 2MM 3MM 6MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402007 SUP HCPCS C1713 72402007 - SCREW BN T6 2MM 3MM 7MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402008 SUP HCPCS C1713 72402008 - SCREW BN T6 2MM 8MM STRL EVOS ST SLFRET DRV SS SM BN LNG BN BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402009 SUP HCPCS C1713 72402009 - SCREW BN T6 2MM 3MM 9MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402010 SUP HCPCS C1713 72402010 - SCREW BN T6 2MM 3MM 10MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402011 SUP HCPCS C1713 72402011 - SCREW BN T6 2MM 3MM 11MM EVOS ST CORT MN PLT SYS BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402012 SUP HCPCS C1713 72402012 - SCREW BN T6 2MM 3MM 12MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402013 SUP HCPCS C1713 72402013 - SCREW BN T6 2MM 3MM 13MM EVOS ST CORT MN PLT SYS BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402014 SUP HCPCS C1713 72402014 - SCREW BN T6 2MM 3MM 14MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402015 SUP HCPCS C1713 72402015 - SCREW BN T6 2MM 3MM 15MM STRL EVOS MN ST CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402016 SUP HCPCS C1713 72402016 - SCREW BN T6 2MM 3MM 16MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402017 SUP HCPCS C1713 72402017 - SCREW BN T6 2MM 3MM 17MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402018 SUP HCPCS C1713 72402018 - SCREW BN T6 2MM 3MM 18MM EVOS ST CORT MN PLT SYS BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402019 SUP HCPCS C1713 72402019 - SCREW BN T6 2MM 3MM 19MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402020 SUP HCPCS C1713 72402020 - SCREW BN T6 2MM 3MM 20MM EVOS ST CORT MN PLT SYS BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402021 SUP HCPCS C1713 72402021 - SCREW BN T6 2MM 3MM 21MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402022 SUP HCPCS C1713 72402022 - SCREW BN T6 2MM 3MM 22MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402023 SUP HCPCS C1713 72402023 - SCREW BN T6 2MM 3MM 23MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402024 SUP HCPCS C1713 72402024 - SCREW BN T6 2MM 3MM 24MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402026 SUP HCPCS C1713 72402026 - SCREW BN T6 2MM 3MM 26MM STRL EVOS MN ST DRVR LNG BN SM BN BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402028 SUP HCPCS C1713 72402028 - SCREW BN T6 2MM 3MM 28MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402030 SUP HCPCS C1713 72402030 - SCREW BN T6 2MM 3MM 30MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402032 SUP HCPCS C1713 72402032 - SCREW BN T6 2MM 3MM 32MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402034 SUP HCPCS C1713 72402034 - SCREW BN T6 2MM 3MM 34MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402036 SUP HCPCS C1713 72402036 - SCREW BN T6 2MM 3MM 36MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402038 SUP HCPCS C1713 72402038 - SCREW BN T6 2MM 3MM 38MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402040 SUP HCPCS C1713 72402040 - SCREW BN T6 2MM 3MM 40MM STRL SLFRET SCRDRVR ST FLT HD CORT BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72402406 SUP HCPCS C1713 72402406 - SCREW BN 3.5MM T7 2.4MM 3.8MM 6MM STRL SLFRET SCRDRVR ST FLT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402407 SUP HCPCS C1713 72402407 - SCREW BN T7 2.4MM 7MM STRL EVOS MN SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402408 SUP HCPCS C1713 72402408 - SCREW BN 3.5MM T7 2.4MM 3.8MM 8MM STRL SLFRET SCRDRVR ST FLT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402409 SUP HCPCS C1713 72402409 - SCREW BN 3.5MM T7 2.4MM 3.8MM 9MM STRL SLFRET SCRDRVR ST FLT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402410 SUP HCPCS C1713 72402410 - SCREW BN 3.5MM T7 2.4MM 3.8MM 10MM STRL SLFRET SCRDRVR ST BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402411 SUP HCPCS C1713 72402411 - SCREW BN T7 2.4MM 3.8MM 11MM STRL EVOS MN ST DRVR LNG BN SM BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402412 SUP HCPCS C1713 72402412 - SCREW BN T7 2.4MM 3.8MM 12MM STRL EVOS MN ST DRVR LNG BN SM BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402413 SUP HCPCS C1713 72402413 - SCREW BN T7 2.4MM 3.8MM 13MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402414 SUP HCPCS C1713 72402414 - SCREW BN T7 2.4MM 14MM EVOS ST SLFRET DRV SS SM BN LNG BN BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402415 SUP HCPCS C1713 72402415 - SCREW BN 3.5MM T7 2.4MM 3.8MM 15MM STRL SLFRET SCRDRVR ST BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402416 SUP HCPCS C1713 72402416 - SCREW BN T7 2.4MM 16MM EVOS ST SLFRET DRV SS SM BN LNG BN BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402417 SUP HCPCS C1713 72402417 - SCREW BN 3.5MM T7 2.4MM 3.8MM 17MM STRL SLFRET SCRDRVR ST BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402418 SUP HCPCS C1713 72402418 - SCREW BN T7 2.4MM 3.8MM 18MM STRL EVOS MN ST DRVR LNG BN SM BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402419 SUP HCPCS C1713 72402419 - SCREW BN 3.5MM T7 2.4MM 3.8MM 19MM STRL SLFRET SCRDRVR ST BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402420 SUP HCPCS C1713 72402420 - SCREW BN 3.5MM T7 2.4MM 3.8MM 20MM STRL SLFRET SCRDRVR ST BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402421 SUP HCPCS C1713 72402421 - SCREW BN T7 2.4MM 21MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402422 SUP HCPCS C1713 72402422 - SCREW BN T7 2.4MM 22MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402423 SUP HCPCS C1713 72402423 - SCREW BN T7 2.4MM 23MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402424 SUP HCPCS C1713 72402424 - SCREW BN T7 2.4MM 24MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402426 SUP HCPCS C1713 72402426 - SCREW BN T7 2.4MM 26MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402430 SUP HCPCS C1713 72402430 - SCREW BN T7 2.4MM 30MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402432 SUP HCPCS C1713 72402432 - SCREW BN T7 2.4MM 32MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402434 SUP HCPCS C1713 72402434 - SCREW BN T7 2.4MM 34MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402436 SUP HCPCS C1713 72402436 - SCREW BN T7 2.4MM 36MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402438 SUP HCPCS C1713 72402438 - SCREW BN T7 2.4MM 38MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402442 SUP HCPCS C1713 72402442 - SCREW BN T7 2.4MM 42MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402444 SUP HCPCS C1713 72402444 - SCREW BN T7 2.4MM 44MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402446 SUP HCPCS C1713 72402446 - SCREW BN T7 2.4MM 46MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402448 SUP HCPCS C1713 72402448 - SCREW BN T7 2.4MM 48MM STRL EVOS MN ST CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402455 SUP HCPCS C1713 72402455 - SCREW BN 3.5MM T7 2.4MM 3.8MM 55MM STRL SLFRET SCRDRVR ST BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402460 SUP HCPCS C1713 72402460 - SCREW BN 3.5MM T7 2.4MM 3.8MM 60MM STRL SLFRET SCRDRVR ST BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 72402465 SUP HCPCS C1713 72402465 - SCREW BN 3.5MM T7 2.4MM 3.8MM 65MM STRL SLFRET SCRDRVR ST BOTH IP/OP $106.15 $78.55 $0.00 $84.92 $47.77 $47.77 $0.00 $0.00 $0.00 $22.12 $78.78 $78.78 $0.00 $0.00 $22.12 $0.00 $62.79 $62.79 $0.00 $53.08 $84.07 $84.92 $0.00 $0.00 $16.61 $0.00 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 72402470 SUP HCPCS C1713 72402470 - SCREW BN 3.5MM T7 2.4MM 3.8MM 70MM STRL SLFRET SCRDRVR ST BOTH IP/OP $106.15 $78.55 $0.00 $84.92 $47.77 $47.77 $0.00 $0.00 $0.00 $22.12 $78.78 $78.78 $0.00 $0.00 $22.12 $0.00 $62.79 $62.79 $0.00 $53.08 $84.07 $84.92 $0.00 $0.00 $16.61 $0.00 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 72402475 SUP HCPCS C1713 72402475 - SCREW BN 3.5MM T7 2.4MM 3.8MM 75MM STRL SLFRET SCRDRVR ST BOTH IP/OP $106.15 $78.55 $0.00 $84.92 $47.77 $47.77 $0.00 $0.00 $0.00 $22.12 $78.78 $78.78 $0.00 $0.00 $22.12 $0.00 $62.79 $62.79 $0.00 $53.08 $84.07 $84.92 $0.00 $0.00 $16.61 $0.00 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 72402480 SUP HCPCS C1713 72402480 - SCREW BN 3.5MM T7 2.4MM 3.8MM 80MM STRL SLFRET SCRDRVR ST BOTH IP/OP $106.15 $78.55 $0.00 $84.92 $47.77 $47.77 $0.00 $0.00 $0.00 $22.12 $78.78 $78.78 $0.00 $0.00 $22.12 $0.00 $62.79 $62.79 $0.00 $53.08 $84.07 $84.92 $0.00 $0.00 $16.61 $0.00 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 72402706 SUP HCPCS C1713 72402706 - SCREW BN T8 2MM 2.7MM 4.5MM 6MM ST CORT EVOS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402707 SUP HCPCS C1713 72402707 - SCREW BN T7 2.7MM 4.5MM 7MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402708 SUP HCPCS C1713 72402708 - SCREW BN T8 2.7MM 4.5MM 8MM EVOS ST CORT MN PLT SYS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402709 SUP HCPCS C1713 72402709 - SCREW BN T8 2.7MM 9MM EVOS ST SLFRET DRV SS SM BN LNG BN BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402710 SUP HCPCS C1713 72402710 - SCREW BN T8 2.7MM 4.5MM 10MM EVOS ST CORT MN PLT SYS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402711 SUP HCPCS C1713 72402711 - SCREW BN 2.7MM 4.5MM 11MM EVOS T8 DRVR 2 END DRL GD ST CORT BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402712 SUP HCPCS C1713 72402712 - SCREW BN T8 2.7MM 12MM STRL EVOS MN SS CORT BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402713 SUP HCPCS C1713 72402713 - SCREW BN 2.7MM 4.5MM 13MM EVOS T8 DRVR 2 END DRL GD ST CORT BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402714 SUP HCPCS C1713 72402714 - SCREW BN T7 2.7MM 4.5MM 14MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402715 SUP HCPCS C1713 72402715 - SCREW BN T7 2.7MM 4.5MM 15MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402716 SUP HCPCS C1713 72402716 - SCREW BN T8 2.7MM 4.5MM 16MM EVOS ST CORT MN PLT SYS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402717 SUP HCPCS C1713 72402717 - SCREW BN T8 2.7MM 4.5MM 17MM NS EVOS ST CORT MN PLT SYS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402718 SUP HCPCS C1713 72402718 - SCREW BN T8 2.7MM 4.5MM 18MM NS EVOS ST CORT MN PLT SYS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402719 SUP HCPCS C1713 72402719 - SCREW BN T8 2MM 2.7MM 4.5MM 19MM ST CORT EVOS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402720 SUP HCPCS C1713 72402720 - SCREW BN T7 2.7MM 4.5MM 20MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402721 SUP HCPCS C1713 72402721 - SCREW BN T7 2.7MM 4.5MM 21MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402722 SUP HCPCS C1713 72402722 - SCREW BN T7 2.7MM 4.5MM 22MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402723 SUP HCPCS C1713 72402723 - SCREW BN T7 2.7MM 4.5MM 23MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402724 SUP HCPCS C1713 72402724 - SCREW BN T7 2.7MM 4.5MM 24MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402726 SUP HCPCS C1713 72402726 - SCREW BN T7 2.7MM 4.5MM 26MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402728 SUP HCPCS C1713 72402728 - SCREW BN T8 2MM 2.7MM 4.5MM 28MM ST CORT EVOS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402730 SUP HCPCS C1713 72402730 - SCREW BN T7 2.7MM 4.5MM 30MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402732 SUP HCPCS C1713 72402732 - SCREW BN T8 2MM 2.7MM 4.5MM 32MM ST CORT EVOS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402734 SUP HCPCS C1713 72402734 - SCREW BN T7 2.7MM 4.5MM 34MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402736 SUP HCPCS C1713 72402736 - SCREW BN T8 2MM 2.7MM 4.5MM 36MM ST CORT EVOS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402738 SUP HCPCS C1713 72402738 - SCREW BN T8 2.7MM 4.5MM 38MM STRL EVOS MN ST CORT BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402740 SUP HCPCS C1713 72402740 - SCREW BN T8 2.7MM 4.5MM 40MM STRL EVOS MN ST DRVR LNG BN SM BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402742 SUP HCPCS C1713 72402742 - SCREW BN T7 2.7MM 4.5MM 42MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402744 SUP HCPCS C1713 72402744 - SCREW BN T8 2MM 2.7MM 4.5MM 44MM ST CORT EVOS BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402746 SUP HCPCS C1713 72402746 - SCREW BN T7 2.7MM 4.5MM 46MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402748 SUP HCPCS C1713 72402748 - SCREW BN T7 2.7MM 4.5MM 48MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402750 SUP HCPCS C1713 72402750 - SCREW BN T7 2.7MM 4.5MM 50MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402755 SUP HCPCS C1713 72402755 - SCREW BN T7 2.7MM 4.5MM 55MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402760 SUP HCPCS C1713 72402760 - SCREW BN T7 2.7MM 4.5MM 60MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $81.68 $60.44 $0.00 $65.34 $36.75 $36.75 $0.00 $0.00 $0.00 $17.02 $60.62 $60.62 $0.00 $0.00 $17.02 $0.00 $48.31 $48.31 $0.00 $40.84 $64.69 $65.34 $0.00 $0.00 $12.78 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402765 SUP HCPCS C1713 72402765 - SCREW BN T7 2.7MM 4.5MM 65MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $110.28 $81.61 $0.00 $88.22 $49.62 $49.62 $0.00 $0.00 $0.00 $22.98 $81.85 $81.85 $0.00 $0.00 $22.98 $0.00 $65.23 $65.23 $0.00 $55.14 $87.34 $88.22 $0.00 $0.00 $17.26 $0.00 $0.00 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 72402770 SUP HCPCS C1713 72402770 - SCREW BN T7 2.7MM 4.5MM 70MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $110.28 $81.61 $0.00 $88.22 $49.62 $49.62 $0.00 $0.00 $0.00 $22.98 $81.85 $81.85 $0.00 $0.00 $22.98 $0.00 $65.23 $65.23 $0.00 $55.14 $87.34 $88.22 $0.00 $0.00 $17.26 $0.00 $0.00 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 72402775 SUP HCPCS C1713 72402775 - SCREW BN T8 2.7MM 4.5MM 75MM STRL EVOS MN ST DRVR LNG BN SM BOTH IP/OP $110.28 $81.61 $0.00 $88.22 $49.62 $49.62 $0.00 $0.00 $0.00 $22.98 $81.85 $81.85 $0.00 $0.00 $22.98 $0.00 $65.23 $65.23 $0.00 $55.14 $87.34 $88.22 $0.00 $0.00 $17.26 $0.00 $0.00 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 72402780 SUP HCPCS C1713 72402780 - SCREW BN T7 2.7MM 4.5MM 80MM STRL SLFRET SCRDRVR ST FLT HD BOTH IP/OP $110.28 $81.61 $0.00 $88.22 $49.62 $49.62 $0.00 $0.00 $0.00 $22.98 $81.85 $81.85 $0.00 $0.00 $22.98 $0.00 $65.23 $65.23 $0.00 $55.14 $87.34 $88.22 $0.00 $0.00 $17.26 $0.00 $0.00 $17.56 $0.00 $0.00 $0.00 $0.00 $0.00 72403513 SUP HCPCS C1713 72403513 - SCREW BN 1.7MM 5MM ST AX STAB LWR PRFL BOTH IP/OP $58.73 $43.46 $0.00 $46.98 $26.43 $26.43 $0.00 $0.00 $0.00 $12.24 $43.59 $43.59 $0.00 $0.00 $12.24 $0.00 $34.74 $34.74 $0.00 $29.36 $46.51 $46.98 $0.00 $0.00 $9.19 $0.00 $0.00 $9.35 $0.00 $0.00 $0.00 $0.00 $0.00 72403514 SUP HCPCS C1713 72403514 - SCREW BN 1.7MM 4MM SLF DRL AX STAB LWR PRFL BOTH IP/OP $58.73 $43.46 $0.00 $46.98 $26.43 $26.43 $0.00 $0.00 $0.00 $12.24 $43.59 $43.59 $0.00 $0.00 $12.24 $0.00 $34.74 $34.74 $0.00 $29.36 $46.51 $46.98 $0.00 $0.00 $9.19 $0.00 $0.00 $9.35 $0.00 $0.00 $0.00 $0.00 $0.00 72403528 SUP HCPCS C1713 72403528 - SCREW BN 3.5MM 28MM STRL EVOS ST CORT BOTH IP/OP $58.73 $43.46 $0.00 $46.98 $26.43 $26.43 $0.00 $0.00 $0.00 $12.24 $43.59 $43.59 $0.00 $0.00 $12.24 $0.00 $34.74 $34.74 $0.00 $29.36 $46.51 $46.98 $0.00 $0.00 $9.19 $0.00 $0.00 $9.35 $0.00 $0.00 $0.00 $0.00 $0.00 72403540 SUP HCPCS C1713 72403540 - SCREW BN 3.5MM 40MM STRL EVOS ST CORT BOTH IP/OP $58.73 $43.46 $0.00 $46.98 $26.43 $26.43 $0.00 $0.00 $0.00 $12.24 $43.59 $43.59 $0.00 $0.00 $12.24 $0.00 $34.74 $34.74 $0.00 $29.36 $46.51 $46.98 $0.00 $0.00 $9.19 $0.00 $0.00 $9.35 $0.00 $0.00 $0.00 $0.00 $0.00 72403550 SUP HCPCS C1713 72403550 - SCREW BN 3.5MM 50MM STRL EVOS ST CORT BOTH IP/OP $58.73 $43.46 $0.00 $46.98 $26.43 $26.43 $0.00 $0.00 $0.00 $12.24 $43.59 $43.59 $0.00 $0.00 $12.24 $0.00 $34.74 $34.74 $0.00 $29.36 $46.51 $46.98 $0.00 $0.00 $9.19 $0.00 $0.00 $9.35 $0.00 $0.00 $0.00 $0.00 $0.00 72403830 SUP HCPCS C1771 72403830 - SLING PUBOVAGINAL MONARC FMALE BOTH IP/OP "$3,177.50 " "$2,351.35" $0.00 "$2,542.00" "$1,429.88" "$1,429.88" $0.00 $0.00 $0.00 $662.27 "$2,358.34" "$2,358.34" $0.00 $0.00 $662.19 $0.00 "$1,566.51" "$1,566.51" $0.00 "$1,588.75" "$2,516.58" "$2,542.00" $0.00 $0.00 $497.28 $0.00 $0.00 $505.86 $0.00 $0.00 $0.00 $0.00 $0.00 72403867 SUP HCPCS C1813 72403867 - PROS PENL AMS 700 DP PENOSCROTAL BOTH IP/OP $725.00 $536.50 $0.00 $580.00 $326.25 $326.25 $0.00 $0.00 $0.00 $0.00 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $0.00 $0.00 $0.00 $362.50 $574.20 $580.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.42 $0.00 $0.00 $0.00 $0.00 $0.00 72404127 SUP HCPCS C1813 72404127 - PROS PENL A800 PMP INHBZN BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 $0.00 $0.00 $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 72404131 SUP HCPCS C1815 72404131 - IMPLANT UROLOGICAL 4.5CM CUFF AMS 800 INHIBIZONE SPHINCTER BOTH IP/OP "$9,010.63 " "$6,667.87" $0.00 "$7,208.50" "$4,054.78" "$4,054.78" $0.00 $0.00 $0.00 "$1,878.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,877.81" $0.00 "$4,442.24" "$4,442.24" $0.00 "$4,505.31" "$7,136.42" "$7,208.50" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,434.49" $0.00 $0.00 $0.00 $0.00 $0.00 72404132 SUP HCPCS C1815 72404132 - IMPLANT UROLOGICAL 5CM CONTINENCE PUMP AMS 800 INHIBIZONE BOTH IP/OP "$12,487.50 " "$9,240.75" $0.00 "$9,990.00" "$5,619.38" "$5,619.38" $0.00 $0.00 $0.00 "$2,602.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,602.40" $0.00 "$6,156.34" "$6,156.34" $0.00 "$6,243.75" "$9,890.10" "$9,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,988.01" $0.00 $0.00 $0.00 $0.00 $0.00 72404133 SUP HCPCS C1815 72404133 - IMPLANT UROLOGICAL 5.5CM CONTINENCE PUMP AMS 800 INHIBIZONE BOTH IP/OP "$12,487.50 " "$9,240.75" $0.00 "$9,990.00" "$5,619.38" "$5,619.38" $0.00 $0.00 $0.00 "$2,602.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,602.40" $0.00 "$6,156.34" "$6,156.34" $0.00 "$6,243.75" "$9,890.10" "$9,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,988.01" $0.00 $0.00 $0.00 $0.00 $0.00 72404250 SUP HCPCS C1813 72404250 - PROSTHESIS PENILE 12/12MM PRECONNECT PUMP PRECON MS BOTH IP/OP "$19,557.50 " "$14,472.55" $0.00 "$15,646.00" "$8,800.88" "$8,800.88" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,075.78" $0.00 $0.00 $0.00 $0.00 "$9,778.75" "$15,489.54" "$15,646.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,113.55" $0.00 $0.00 $0.00 $0.00 $0.00 72404256 SUP HCPCS C1813 72404256 - PROSTHESIS PENL AMS 700 LGX MS PMP 15CM 3 PC INFL BOTH IP/OP "$23,330.00 " "$17,264.20" $0.00 "$18,664.00" "$10,498.50" "$10,498.50" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,861.97" $0.00 $0.00 $0.00 $0.00 "$11,665.00" "$18,477.36" "$18,664.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,714.14" $0.00 $0.00 $0.00 $0.00 $0.00 72404257 SUP HCPCS C1813 72404257 - PROSTHESIS PENILE 18CM INFLATABLE AMS 700 MS PUMP INHIBIZONE BOTH IP/OP "$21,352.50 " "$15,800.85" $0.00 "$17,082.00" "$9,608.63" "$9,608.63" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,449.86" $0.00 $0.00 $0.00 $0.00 "$10,676.25" "$16,911.18" "$17,082.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$3,399.32" $0.00 $0.00 $0.00 $0.00 $0.00 72412006 SUP HCPCS C1713 72412006 - SCREW BN T6 2.7MM 4.5MM 6MM STRL LCK SLFRET SCRDRVR ST FLT BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412007 SUP HCPCS C1713 72412007 - SCREW BN T6 2MM 3.3MM 7MM STRL LCK SLFRET SCRDRVR ST FLT HD BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412008 SUP HCPCS C1713 72412008 - SCREW BN T6 2MM 8MM STRL EVOS ST SLFRET DRV SS SM BN LNG BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412009 SUP HCPCS C1713 72412009 - SCREW BN T6 2MM 3.3MM 9MM STRL LCK SLFRET SCRDRVR ST FLT HD BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412010 SUP HCPCS C1713 72412010 - SCREW BN T6 2MM 3.3MM 10MM STRL EVOS MN LCK DRVR LNG BN SM BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412011 SUP HCPCS C1713 72412011 - SCREW BN T6 2MM 3.3MM 11MM STRL LCK SLFRET SCRDRVR ST FLT HD BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412012 SUP HCPCS C1713 72412012 - SCREW BN T6 2MM 3.3MM 12MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412013 SUP HCPCS C1713 72412013 - SCREW BN T6 2MM 3.3MM 13MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412014 SUP HCPCS C1713 72412014 - SCREW BN T6 2MM 3.3MM 14MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412015 SUP HCPCS C1713 72412015 - SCREW BN T6 2MM 3.3MM 15MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412016 SUP HCPCS C1713 72412016 - SCREW BN T6 2MM 3.3MM 16MM STRL EVOS MN LCK DRVR LNG BN SM BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412017 SUP HCPCS C1713 72412017 - SCREW BN T6 2MM 3.3MM 17MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412018 SUP HCPCS C1713 72412018 - SCREW BN T6 2MM 3.3MM 18MM STRL EVOS MN LCK DRVR LNG BN SM BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412019 SUP HCPCS C1713 72412019 - SCREW BN T6 2MM 3.3MM 19MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412020 SUP HCPCS C1713 72412020 - SCREW BN T6 2MM 3.3MM 20MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412021 SUP HCPCS C1713 72412021 - SCREW BN T6 2MM 3.3MM 21MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412022 SUP HCPCS C1713 72412022 - SCREW BN T6 2MM 3.3MM 22MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412023 SUP HCPCS C1713 72412023 - SCREW BN T6 2MM 3.3MM 23MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412024 SUP HCPCS C1713 72412024 - SCREW BN T6 2MM 3.3MM 24MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412026 SUP HCPCS C1713 72412026 - SCREW BN T6 2MM 3.3MM 26MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412028 SUP HCPCS C1713 72412028 - SCREW BN T6 2MM 3.3MM 28MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412030 SUP HCPCS C1713 72412030 - SCREW BN T6 2MM 3.3MM 30MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412032 SUP HCPCS C1713 72412032 - SCREW BN T6 2MM 3.3MM 32MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412034 SUP HCPCS C1713 72412034 - SCREW BN T6 2MM 3.3MM 34MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412036 SUP HCPCS C1713 72412036 - SCREW BN T6 2MM 3.3MM 36MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412038 SUP HCPCS C1713 72412038 - SCREW BN T6 2MM 3.3MM 38MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412040 SUP HCPCS C1713 72412040 - SCREW BN T6 2MM 3.3MM 40MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $246.13 $182.14 $0.00 $196.90 $110.76 $110.76 $0.00 $0.00 $0.00 $51.30 $182.67 $182.67 $0.00 $0.00 $51.29 $0.00 $145.58 $145.58 $0.00 $123.06 $194.93 $196.90 $0.00 $0.00 $38.52 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $0.00 72412406 SUP HCPCS C1713 72412406 - SCREW BN T7 2.4MM 3.8MM 6MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412407 SUP HCPCS C1713 72412407 - SCREW BN T7 2.4MM 3.8MM 7MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412408 SUP HCPCS C1713 72412408 - SCREW BN T7 2.4MM 3.8MM 8MM STRL EVOS LCK SM BN LNG BN MN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412409 SUP HCPCS C1713 72412409 - SCREW BN T7 2.4MM 3.8MM 9MM STRL EVOS MN LCK SS LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412410 SUP HCPCS C1713 72412410 - SCREW BN T7 2.4MM 3.8MM 10MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412411 SUP HCPCS C1713 72412411 - SCREW BN T7 2.4MM 3.8MM 11MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412412 SUP HCPCS C1713 72412412 - SCREW BN T7 2.4MM 3.8MM 12MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412413 SUP HCPCS C1713 72412413 - SCREW BN T7 2.4MM 3.8MM 13MM STRL EVOS MN LCK DRVR LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412414 SUP HCPCS C1713 72412414 - SCREW BN T7 2.4MM 3.8MM 14MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412415 SUP HCPCS C1713 72412415 - SCREW BN T7 2.4MM 3.8MM 15MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412416 SUP HCPCS C1713 72412416 - SCREW BN T7 2.4MM 3.8MM 16MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412417 SUP HCPCS C1713 72412417 - SCREW BN T7 2.4MM 3.8MM 17MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412418 SUP HCPCS C1713 72412418 - SCREW BN T7 2.4MM 3.8MM 18MM STRL EVOS MN LCK DRVR LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412419 SUP HCPCS C1713 72412419 - SCREW BN T7 2.4MM 3.8MM 19MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412420 SUP HCPCS C1713 72412420 - SCREW BN T7 2.4MM 3.8MM 20MM STRL EVOS LCK SM BN LNG BN MN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412421 SUP HCPCS C1713 72412421 - SCREW BN T7 2.4MM 3.8MM 21MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412422 SUP HCPCS C1713 72412422 - SCREW BN T7 2.4MM 3.8MM 22MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412423 SUP HCPCS C1713 72412423 - SCREW BN T7 2.4MM 3.8MM 23MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412424 SUP HCPCS C1713 72412424 - SCREW BN T7 2.4MM 3.8MM 24MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412426 SUP HCPCS C1713 72412426 - SCREW BN T7 2.4MM 3.8MM 26MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412428 SUP HCPCS C1713 72412428 - SCREW BN T7 2.4MM 3.8MM 28MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412430 SUP HCPCS C1713 72412430 - SCREW BN T7 2.4MM 3.8MM 30MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412432 SUP HCPCS C1713 72412432 - SCREW BN T7 2.4MM 3.8MM 32MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412434 SUP HCPCS C1713 72412434 - SCREW BN T7 2.4MM 3.8MM 34MM STRL EVOS MN LCK SS LNG BN SM BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412436 SUP HCPCS C1713 72412436 - SCREW BN T7 2.4MM 3.8MM 36MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412438 SUP HCPCS C1713 72412438 - SCREW BN T7 2.4MM 3.8MM 38MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412440 SUP HCPCS C1713 72412440 - SCREW BN T7 2.4MM 3.8MM 40MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412442 SUP HCPCS C1713 72412442 - SCREW BN T7 2.4MM 3.8MM 42MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412444 SUP HCPCS C1713 72412444 - SCREW BN T7 2.4MM 3.8MM 44MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412446 SUP HCPCS C1713 72412446 - SCREW BN T7 2.4MM 3.8MM 46MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412448 SUP HCPCS C1713 72412448 - SCREW BN T7 2.4MM 3.8MM 48MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412450 SUP HCPCS C1713 72412450 - SCREW BN T7 2.4MM 3.8MM 50MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412455 SUP HCPCS C1713 72412455 - SCREW BN T7 2.4MM 3.8MM 55MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412460 SUP HCPCS C1713 72412460 - SCREW BN T7 2.4MM 3.8MM 60MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $251.63 $186.21 $0.00 $201.30 $113.23 $113.23 $0.00 $0.00 $0.00 $52.44 $186.76 $186.76 $0.00 $0.00 $52.44 $0.00 $148.84 $148.84 $0.00 $125.81 $199.29 $201.30 $0.00 $0.00 $39.38 $0.00 $0.00 $40.06 $0.00 $0.00 $0.00 $0.00 $0.00 72412465 SUP HCPCS C1713 72412465 - SCREW BN T7 2.4MM 3.8MM 65MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $279.13 $206.56 $0.00 $223.30 $125.61 $125.61 $0.00 $0.00 $0.00 $58.18 $207.17 $207.17 $0.00 $0.00 $58.17 $0.00 $165.10 $165.10 $0.00 $139.56 $221.07 $223.30 $0.00 $0.00 $43.68 $0.00 $0.00 $44.44 $0.00 $0.00 $0.00 $0.00 $0.00 72412470 SUP HCPCS C1713 72412470 - SCREW BN T7 2.4MM 3.8MM 70MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $279.13 $206.56 $0.00 $223.30 $125.61 $125.61 $0.00 $0.00 $0.00 $58.18 $207.17 $207.17 $0.00 $0.00 $58.17 $0.00 $165.10 $165.10 $0.00 $139.56 $221.07 $223.30 $0.00 $0.00 $43.68 $0.00 $0.00 $44.44 $0.00 $0.00 $0.00 $0.00 $0.00 72412475 SUP HCPCS C1713 72412475 - SCREW BN T7 2.4MM 3.8MM 75MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $279.13 $206.56 $0.00 $223.30 $125.61 $125.61 $0.00 $0.00 $0.00 $58.18 $207.17 $207.17 $0.00 $0.00 $58.17 $0.00 $165.10 $165.10 $0.00 $139.56 $221.07 $223.30 $0.00 $0.00 $43.68 $0.00 $0.00 $44.44 $0.00 $0.00 $0.00 $0.00 $0.00 72412480 SUP HCPCS C1713 72412480 - SCREW BN T7 2.4MM 3.8MM 80MM STRL EVOS MN LCK LNG BN SM BN BOTH IP/OP $279.13 $206.56 $0.00 $223.30 $125.61 $125.61 $0.00 $0.00 $0.00 $58.18 $207.17 $207.17 $0.00 $0.00 $58.17 $0.00 $165.10 $165.10 $0.00 $139.56 $221.07 $223.30 $0.00 $0.00 $43.68 $0.00 $0.00 $44.44 $0.00 $0.00 $0.00 $0.00 $0.00 72412706 SUP HCPCS C1713 72412706 - SCREW BN T8 2.7MM 4.5MM 6MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412707 SUP HCPCS C1713 72412707 - SCREW BN T8 2.7MM 4.5MM 7MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412708 SUP HCPCS C1713 72412708 - SCREW BN T8 2.7MM 4.3MM 8MM STRL EVOS LCK SM BN LNG BN MN BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412709 SUP HCPCS C1713 72412709 - SCREW BN T8 2.7MM 4.5MM 9MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412710 SUP HCPCS C1713 72412710 - SCREW BN T8 2.7MM 4.5MM 10MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412711 SUP HCPCS C1713 72412711 - SCREW BN T8 2.7MM 4.5MM 11MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412712 SUP HCPCS C1713 72412712 - SCREW BN T8 2.7MM 4.5MM 12MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412713 SUP HCPCS C1713 72412713 - SCREW BN T8 2.7MM 4.5MM 13MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412714 SUP HCPCS C1713 72412714 - SCREW BN T8 2MM 2.7MM 4.3MM 14MM ST LCK SM BN LNG BN EVOS BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412715 SUP HCPCS C1713 72412715 - SCREW BN T8 2.7MM 4.5MM 15MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412716 SUP HCPCS C1713 72412716 - SCREW BN T8 2MM 2.7MM 4.3MM 16MM ST LCK EVOS BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412717 SUP HCPCS C1713 72412717 - SCREW BN T8 2.7MM 4.5MM 17MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412718 SUP HCPCS C1713 72412718 - SCREW BN T8 2MM 2.7MM 4.3MM 18MM ST LCK SM BN LNG BN EVOS BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412719 SUP HCPCS C1713 72412719 - SCREW BN T8 2.7MM 4.5MM 19MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412720 SUP HCPCS C1713 72412720 - SCREW BN T8 2.7MM 4.5MM 20MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412721 SUP HCPCS C1713 72412721 - SCREW BN T8 2.7MM 4.5MM 21MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412722 SUP HCPCS C1713 72412722 - SCREW BN T8 2.7MM 4.5MM 22MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412723 SUP HCPCS C1713 72412723 - SCREW BN T8 2.7MM 4.5MM 23MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412724 SUP HCPCS C1713 72412724 - SCREW BN T8 2MM 2.7MM 4.3MM 24MM ST LCK EVOS BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412726 SUP HCPCS C1713 72412726 - SCREW BN T8 2.7MM 4.3MM 26MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412728 SUP HCPCS C1713 72412728 - SCREW BN T8 2.7MM 4.3MM 28MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412730 SUP HCPCS C1713 72412730 - SCREW BN T8 2.7MM 4.3MM 30MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412732 SUP HCPCS C1713 72412732 - SCREW BN T8 2.7MM 4.3MM 32MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412734 SUP HCPCS C1713 72412734 - SCREW BN T8 2.7MM 4.3MM 34MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412736 SUP HCPCS C1713 72412736 - SCREW BN T8 2.7MM 4.3MM 36MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412738 SUP HCPCS C1713 72412738 - SCREW BN T8 2.7MM 4.3MM 38MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412740 SUP HCPCS C1713 72412740 - SCREW BN T8 2.7MM 4.3MM 40MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412742 SUP HCPCS C1713 72412742 - SCREW BN T8 2.7MM 4.3MM 42MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412744 SUP HCPCS C1713 72412744 - SCREW BN T8 2.7MM 4.3MM 44MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412746 SUP HCPCS C1713 72412746 - SCREW BN T8 2.7MM 4.3MM 46MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412748 SUP HCPCS C1713 72412748 - SCREW BN T8 2.7MM 4.3MM 48MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412750 SUP HCPCS C1713 72412750 - SCREW BN T8 2.7MM 4.3MM 50MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412755 SUP HCPCS C1713 72412755 - SCREW BN T8 2.7MM 4.3MM 55MM LCK SLF RTN FLT HD SS LNG BN SM BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412760 SUP HCPCS C1713 72412760 - SCREW BN T8 2.7MM 4.5MM 60MM STRL EVOS MN ST SS CORT BOTH IP/OP $254.38 $188.24 $0.00 $203.50 $114.47 $114.47 $0.00 $0.00 $0.00 $53.02 $188.80 $188.80 $0.00 $0.00 $53.01 $0.00 $150.46 $150.46 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 72412765 SUP HCPCS C1713 72412765 - SCREW BN T8 2.7MM 4.5MM 65MM STRL EVOS MN ST SS CORT BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $129.32 $129.32 $0.00 $0.00 $0.00 $59.90 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $169.98 $169.98 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $44.97 $0.00 $0.00 $45.75 $0.00 $0.00 $0.00 $0.00 $0.00 72412770 SUP HCPCS C1713 72412770 - SCREW BN T8 2.7MM 4.5MM 70MM STRL EVOS MN ST SS CORT BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $129.32 $129.32 $0.00 $0.00 $0.00 $59.90 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $169.98 $169.98 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $44.97 $0.00 $0.00 $45.75 $0.00 $0.00 $0.00 $0.00 $0.00 72412775 SUP HCPCS C1713 72412775 - SCREW BN T8 2.7MM 4.5MM 75MM STRL EVOS MN ST SS CORT BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $129.32 $129.32 $0.00 $0.00 $0.00 $59.90 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $169.98 $169.98 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $44.97 $0.00 $0.00 $45.75 $0.00 $0.00 $0.00 $0.00 $0.00 72412780 SUP HCPCS C1713 72412780 - SCREW BN T8 2.7MM 4.5MM 80MM STRL EVOS MN ST SS CORT BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $129.32 $129.32 $0.00 $0.00 $0.00 $59.90 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $169.98 $169.98 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $44.97 $0.00 $0.00 $45.75 $0.00 $0.00 $0.00 $0.00 $0.00 72413565 SUP HCPCS C1713 72413565 - SCREW BN 3.5MM 65MM STRL EVOS ST LCK BOTH IP/OP $305.25 $225.89 $0.00 $244.20 $137.36 $137.36 $0.00 $0.00 $0.00 $63.62 $226.56 $226.56 $0.00 $0.00 $63.61 $0.00 $180.56 $180.56 $0.00 $152.63 $241.76 $244.20 $0.00 $0.00 $47.77 $0.00 $0.00 $48.60 $0.00 $0.00 $0.00 $0.00 $0.00 72413570 SUP HCPCS C1713 72413570 - SCREW BN 3.5MM 70MM STRL EVOS ST LCK BOTH IP/OP $305.25 $225.89 $0.00 $244.20 $137.36 $137.36 $0.00 $0.00 $0.00 $63.62 $226.56 $226.56 $0.00 $0.00 $63.61 $0.00 $180.56 $180.56 $0.00 $152.63 $241.76 $244.20 $0.00 $0.00 $47.77 $0.00 $0.00 $48.60 $0.00 $0.00 $0.00 $0.00 $0.00 72423010 SUP HCPCS C1713 72423010 - SCREW BN T7 3MM 3.8MM 10MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423012 SUP HCPCS C1713 72423012 - SCREW BN T7 3MM 3.8MM 12MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423014 SUP HCPCS C1713 72423014 - SCREW BN T7 3MM 3.8MM 14MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423016 SUP HCPCS C1713 72423016 - SCREW BN T7 3MM 3.8MM 16MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423018 SUP HCPCS C1713 72423018 - SCREW BN T7 3MM 3.8MM 18MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423020 SUP HCPCS C1713 72423020 - SCREW BN T7 3MM 3.8MM 20MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423022 SUP HCPCS C1713 72423022 - SCREW BN T7 3MM 3.8MM 22MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423024 SUP HCPCS C1713 72423024 - SCREW BN T7 3MM 3.8MM 24MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423026 SUP HCPCS C1713 72423026 - SCREW BN T7 3MM 3.8MM 26MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423028 SUP HCPCS C1713 72423028 - SCREW BN T7 3MM 3.8MM 28MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423030 SUP HCPCS C1713 72423030 - SCREW BN T7 3MM 3.8MM 30MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423032 SUP HCPCS C1713 72423032 - SCREW BN T7 3MM 3.8MM 32MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423034 SUP HCPCS C1713 72423034 - SCREW BN T7 3MM 3.8MM 34MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423036 SUP HCPCS C1713 72423036 - SCREW BN T7 3MM 3.8MM 36MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423038 SUP HCPCS C1713 72423038 - SCREW BN T7 3MM 3.8MM 38MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423040 SUP HCPCS C1713 72423040 - SCREW BN T7 3MM 3.8MM 40MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423042 SUP HCPCS C1713 72423042 - SCREW BN T7 3MM 3.8MM 42MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423044 SUP HCPCS C1713 72423044 - SCREW BN T7 3MM 3.8MM 44MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423046 SUP HCPCS C1713 72423046 - SCREW BN T7 3MM 3.8MM 46MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423048 SUP HCPCS C1713 72423048 - SCREW BN T7 3MM 3.8MM 48MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423050 SUP HCPCS C1713 72423050 - SCREW BN T7 3MM 3.8MM 50MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423055 SUP HCPCS C1713 72423055 - SCREW BN T7 3MM 3.8MM 55MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423060 SUP HCPCS C1713 72423060 - SCREW BN T7 3MM 3.8MM 60MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 72423065 SUP HCPCS C1713 72423065 - SCREW BN T7 3MM 3.8MM 65MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72423070 SUP HCPCS C1713 72423070 - SCREW BN T7 3MM 3.8MM 70MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72423075 SUP HCPCS C1713 72423075 - SCREW BN T7 3MM 3.8MM 75MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72423080 SUP HCPCS C1713 72423080 - SCREW BN T7 3MM 3.8MM 80MM STRL EVOS MN SS LNG BN SM BN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424010 SUP HCPCS C1713 72424010 - SCREW BN T8 FT 4MM 4.5MM 10MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424012 SUP HCPCS C1713 72424012 - SCREW BN T8 FT 4MM 4.5MM 12MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424014 SUP HCPCS C1713 72424014 - SCREW BN T8 FT 4MM 4.5MM 14MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424016 SUP HCPCS C1713 72424016 - SCREW BN T8 FT 4MM 4.5MM 16MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424018 SUP HCPCS C1713 72424018 - SCREW BN T8 FT 4MM 4.5MM 18MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424020 SUP HCPCS C1713 72424020 - SCREW BN T8 FT 4MM 4.5MM 20MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424022 SUP HCPCS C1713 72424022 - SCREW BN T8 FT 4MM 4.5MM 22MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424024 SUP HCPCS C1713 72424024 - SCREW BN T8 FT 4MM 4.5MM 24MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424026 SUP HCPCS C1713 72424026 - SCREW BN T8 FT 4MM 4.5MM 10MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424028 SUP HCPCS C1713 72424028 - SCREW BN T8 FT 4MM 4.5MM 10MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424030 SUP HCPCS C1713 72424030 - SCREW BN T8 FT 4MM 4.5MM 30MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424032 SUP HCPCS C1713 72424032 - SCREW BN FT T8 4MM 4.5MM 32MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424034 SUP HCPCS C1713 72424034 - SCREW BN FT T8 4MM 4.5MM 34MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424036 SUP HCPCS C1713 72424036 - SCREW BN FT T8 4MM 4.5MM 36MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424038 SUP HCPCS C1713 72424038 - SCREW BN FT T8 4MM 4.5MM 38MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424040 SUP HCPCS C1713 72424040 - SCREW BN FT T8 4MM 4.5MM 40MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424042 SUP HCPCS C1713 72424042 - SCREW BN FT T8 4MM 4.5MM 42MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424044 SUP HCPCS C1713 72424044 - SCREW BN FT T8 4MM 4.5MM 44MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424046 SUP HCPCS C1713 72424046 - SCREW BN FT T8 4MM 4.5MM 46MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424048 SUP HCPCS C1713 72424048 - SCREW BN FT T8 4MM 4.5MM 48MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424050 SUP HCPCS C1713 72424050 - SCREW BN FT T8 4MM 4.5MM 50MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424055 SUP HCPCS C1713 72424055 - SCREW BN FT T8 4MM 4.5MM 55MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424060 SUP HCPCS C1713 72424060 - SCREW BN FT T8 4MM 4.5MM 60MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424065 SUP HCPCS C1713 72424065 - SCREW BN FT T8 4MM 4.5MM 65MM STRL EVOS MN VA SLFRET SCRDRVR BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424070 SUP HCPCS C1713 72424070 - SCREW BN FT T8 4MM 4.5MM 70MM STRL EVOS MN LNG BN SM BN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424075 SUP HCPCS C1713 72424075 - SCREW BN FT T8 4MM 4.5MM 75MM STRL EVOS MN LNG BN SM BN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72424080 SUP HCPCS C1713 72424080 - SCREW BN FT T8 4MM 4.5MM 80MM STRL EVOS MN LNG BN SM BN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434026 SUP HCPCS C1713 72434026 - SCREW BN T8 P/T 4MM 4.5MM 26MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434028 SUP HCPCS C1713 72434028 - SCREW BN T8 P/T 4MM 4.5MM 28MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434030 SUP HCPCS C1713 72434030 - SCREW BN T8 P/T 4MM 4.5MM 30MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434032 SUP HCPCS C1713 72434032 - SCREW BN T8 P/T 4MM 4.5MM 32MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434034 SUP HCPCS C1713 72434034 - SCREW BN T8 P/T 4MM 4.5MM 34MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434036 SUP HCPCS C1713 72434036 - SCREW BN T8 P/T 4MM 4.5MM 36MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434038 SUP HCPCS C1713 72434038 - SCREW BN T8 P/T 4MM 4.5MM 38MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434040 SUP HCPCS C1713 72434040 - SCREW BN T8 P/T 4MM 4.5MM 40MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434042 SUP HCPCS C1713 72434042 - SCREW BN T8 P/T 4MM 4.5MM 42MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434044 SUP HCPCS C1713 72434044 - SCREW BN T8 P/T 4MM 4.5MM 44MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434046 SUP HCPCS C1713 72434046 - SCREW BN T8 P/T 4MM 4.5MM 46MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434048 SUP HCPCS C1713 72434048 - SCREW BN T8 P/T 4MM 4.5MM 48MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434050 SUP HCPCS C1713 72434050 - SCREW BN T8 P/T 4MM 4.5MM 50MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434055 SUP HCPCS C1713 72434055 - SCREW BN T8 P/T 4MM 4.5MM 55MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434060 SUP HCPCS C1713 72434060 - SCREW BN T8 P/T 4MM 4.5MM 60MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $84.77 $84.77 $0.00 $0.00 $0.00 $39.26 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $111.42 $111.42 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $29.48 $0.00 $0.00 $29.99 $0.00 $0.00 $0.00 $0.00 $0.00 72434065 SUP HCPCS C1713 72434065 - SCREW BN T8 P/T 4MM 4.5MM 65MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $95.91 $95.91 $0.00 $0.00 $0.00 $44.42 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $126.06 $126.06 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 72434070 SUP HCPCS C1713 72434070 - SCREW BN T8 P/T 4MM 4.5MM 70MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $95.91 $95.91 $0.00 $0.00 $0.00 $44.42 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $126.06 $126.06 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 72434075 SUP HCPCS C1713 72434075 - SCREW BN T8 P/T 4MM 4.5MM 75MM SLFRET SCRDRVR TAP EVOS MN BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $95.91 $95.91 $0.00 $0.00 $0.00 $44.42 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $126.06 $126.06 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 72434080 SUP HCPCS C1713 72434080 - SCREW BN T8 P/T 4MM 4.5MM 80MM SLFRET SCRDRVR EVOS MN BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $95.91 $95.91 $0.00 $0.00 $0.00 $44.42 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $126.06 $126.06 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 72441010 SUP HCPCS C1713 72441010 - PLATE BN 127MM STRL EVOS 10 HL CMPR 3.5MM SCR BOTH IP/OP $456.50 $337.81 $0.00 $365.20 $205.43 $205.43 $0.00 $0.00 $0.00 $95.15 $338.81 $338.81 $0.00 $0.00 $95.13 $0.00 $270.02 $270.02 $0.00 $228.25 $361.55 $365.20 $0.00 $0.00 $71.44 $0.00 $0.00 $72.67 $0.00 $0.00 $0.00 $0.00 $0.00 72442050 SUP HCPCS C1713 72442050 - PLATE BN T 36MM EVOS MN 2 HLE/HD 6 HL SHFT LOPRFL VA SS SM BOTH IP/OP "$1,225.13 " $906.60 $0.00 $980.10 $551.31 $551.31 $0.00 $0.00 $0.00 $255.35 $909.29 $909.29 $0.00 $0.00 $255.32 $0.00 $724.66 $724.66 $0.00 $612.56 $970.30 $980.10 $0.00 $0.00 $191.73 $0.00 $0.00 $195.04 $0.00 $0.00 $0.00 $0.00 $0.00 72442052 SUP HCPCS C1713 72442052 - PLATE BN T 46MM EVOS MN 2 HLE/HD 8 HL SHFT LOPRFL VA SS SM BOTH IP/OP "$1,225.13 " $906.60 $0.00 $980.10 $551.31 $551.31 $0.00 $0.00 $0.00 $255.35 $909.29 $909.29 $0.00 $0.00 $255.32 $0.00 $724.66 $724.66 $0.00 $612.56 $970.30 $980.10 $0.00 $0.00 $191.73 $0.00 $0.00 $195.04 $0.00 $0.00 $0.00 $0.00 $0.00 72442054 SUP HCPCS C1713 72442054 - PLATE BN 5MM SPC T 31X5-15.3X1.2MM STRL 71MM EVOS MN 3 BOTH IP/OP "$1,225.13 " $906.60 $0.00 $980.10 $551.31 $551.31 $0.00 $0.00 $0.00 $255.35 $909.29 $909.29 $0.00 $0.00 $255.32 $0.00 $724.66 $724.66 $0.00 $612.56 $970.30 $980.10 $0.00 $0.00 $191.73 $0.00 $0.00 $195.04 $0.00 $0.00 $0.00 $0.00 $0.00 72442056 SUP HCPCS C1713 72442056 - PLATE BN T 51MM EVOS MN 2 HLE/HD 9 HL SHFT LOPRFL VA SS SM BOTH IP/OP "$1,225.13 " $906.60 $0.00 $980.10 $551.31 $551.31 $0.00 $0.00 $0.00 $255.35 $909.29 $909.29 $0.00 $0.00 $255.32 $0.00 $724.66 $724.66 $0.00 $612.56 $970.30 $980.10 $0.00 $0.00 $191.73 $0.00 $0.00 $195.04 $0.00 $0.00 $0.00 $0.00 $0.00 72442058 SUP HCPCS C1713 72442058 - PLATE BN 21MM EVOS MN 4 HL FLX LOPRFL VA SS SM BN LNG BN 2MM BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442060 SUP HCPCS C1713 72442060 - PLATE BN 5MM SPC 31X5X1.2MM STRL EVOS LOPRFL 6 HL VA FLX SS BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442062 SUP HCPCS C1713 72442062 - PLATE BN 41MM EVOS MN 8 HL FLX LOPRFL VA SS SM BN LNG BN 2MM BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442064 SUP HCPCS C1713 72442064 - PLATE BN 51MM EVOS MN 10 HL FLX LOPRFL VA SS SM BN LNG BN 2 BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442066 SUP HCPCS C1713 72442066 - PLATE BN 101MM EVOS MN 20 HL FLX LOPRFL VA SS SM BN LNG BN 2 BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442068 SUP HCPCS C1713 72442068 - PLATE BN 21MM EVOS MN 4 HL STRTH LOPRFL VA SS SM BN LNG BN 2 BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442070 SUP HCPCS C1713 72442070 - PLATE BN 31MM EVOS MN 6 HL STRTH LOPRFL VA SS SM BN LNG BN 2 BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442072 SUP HCPCS C1713 72442072 - PLATE BN 41MM EVOS MN 8 HL STRTH LOPRFL VA SS SM BN LNG BN 2 BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442074 SUP HCPCS C1713 72442074 - PLATE BN 51MM EVOS MN 10 HL STRTH LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442076 SUP HCPCS C1713 72442076 - PLATE BN 101MM EVOS MN 20 HL STRTH LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,266.38 " $937.12 $0.00 "$1,013.10" $569.87 $569.87 $0.00 $0.00 $0.00 $263.94 $939.90 $939.90 $0.00 $0.00 $263.91 $0.00 $749.06 $749.06 $0.00 $633.19 "$1,002.97" "$1,013.10" $0.00 $0.00 $198.19 $0.00 $0.00 $201.61 $0.00 $0.00 $0.00 $0.00 $0.00 72442078 SUP HCPCS C1713 72442078 - PLATE BN STRG 28MM EVOS MN 5 HL TINE LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,512.50 " "$1,119.25" $0.00 "$1,210.00" $680.63 $680.63 $0.00 $0.00 $0.00 $315.24 "$1,122.58" "$1,122.58" $0.00 $0.00 $315.21 $0.00 $894.64 $894.64 $0.00 $756.25 "$1,197.90" "$1,210.00" $0.00 $0.00 $236.71 $0.00 $0.00 $240.79 $0.00 $0.00 $0.00 $0.00 $0.00 72442080 SUP HCPCS C1713 72442080 - PLATE BN STRG 38MM EVOS MN 7 HL TINE LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,512.50 " "$1,119.25" $0.00 "$1,210.00" $680.63 $680.63 $0.00 $0.00 $0.00 $315.24 "$1,122.58" "$1,122.58" $0.00 $0.00 $315.21 $0.00 $894.64 $894.64 $0.00 $756.25 "$1,197.90" "$1,210.00" $0.00 $0.00 $236.71 $0.00 $0.00 $240.79 $0.00 $0.00 $0.00 $0.00 $0.00 72442120 SUP HCPCS C1713 72442120 - WASHER ORTH 5MM EVOS 2MM SCR MN PLT SYS BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72442124 SUP HCPCS C1713 72442124 - WASHER ORTH 6MM EVOS 2.4MM SCR MN PLT SYS BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72442127 SUP HCPCS C1713 72442127 - WASHER ORTH 7MM EVOS 2.7MM SCR MN PLT SYS BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $33.08 $33.08 $0.00 $0.00 $0.00 $15.32 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $43.48 $43.48 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $11.50 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $0.00 72442135 SUP HCPCS C1713 72442135 - WASHER ORTH STRL EVOS 3.5 MM SCR BOTH IP/OP $83.60 $61.86 $0.00 $66.88 $37.62 $37.62 $0.00 $0.00 $0.00 $17.42 $62.05 $62.05 $0.00 $0.00 $17.42 $0.00 $49.45 $49.45 $0.00 $41.80 $66.21 $66.88 $0.00 $0.00 $13.08 $0.00 $0.00 $13.31 $0.00 $0.00 $0.00 $0.00 $0.00 72442220 SUP HCPCS C1713 72442220 - WASHER ORTH 10MM EVOS 2 2.4MM SCR MN PLT SYS BOTH IP/OP $147.13 $108.88 $0.00 $117.70 $66.21 $66.21 $0.00 $0.00 $0.00 $30.66 $109.20 $109.20 $0.00 $0.00 $30.66 $0.00 $87.02 $87.02 $0.00 $73.56 $116.53 $117.70 $0.00 $0.00 $23.03 $0.00 $0.00 $23.42 $0.00 $0.00 $0.00 $0.00 $0.00 72442224 SUP HCPCS C1713 72442224 - WASHER ORTH 11MM EVOS 2 2.4MM SCR MN PLT SYS BOTH IP/OP $147.13 $108.88 $0.00 $117.70 $66.21 $66.21 $0.00 $0.00 $0.00 $30.66 $109.20 $109.20 $0.00 $0.00 $30.66 $0.00 $87.02 $87.02 $0.00 $73.56 $116.53 $117.70 $0.00 $0.00 $23.03 $0.00 $0.00 $23.42 $0.00 $0.00 $0.00 $0.00 $0.00 72442227 SUP HCPCS C1713 72442227 - WASHER ORTH 13MM EVOS 2 2.7MM SCR MN PLT SYS BOTH IP/OP $147.13 $108.88 $0.00 $117.70 $66.21 $66.21 $0.00 $0.00 $0.00 $30.66 $109.20 $109.20 $0.00 $0.00 $30.66 $0.00 $87.02 $87.02 $0.00 $73.56 $116.53 $117.70 $0.00 $0.00 $23.03 $0.00 $0.00 $23.42 $0.00 $0.00 $0.00 $0.00 $0.00 72442450 SUP HCPCS C1713 72442450 - PLATE BN T 43MM EVOS MN 2 HLE/HD 6 HL SHFT LOPRFL VA SS SM BOTH IP/OP "$1,553.75 " "$1,149.78" $0.00 "$1,243.00" $699.19 $699.19 $0.00 $0.00 $0.00 $323.84 "$1,153.19" "$1,153.19" $0.00 $0.00 $323.80 $0.00 $919.04 $919.04 $0.00 $776.88 "$1,230.57" "$1,243.00" $0.00 $0.00 $243.16 $0.00 $0.00 $247.36 $0.00 $0.00 $0.00 $0.00 $0.00 72442452 SUP HCPCS C1713 72442452 - PLATE BN T 55MM EVOS MN 2 HLE/HD 8 HL SHFT LOPRFL VA SS SM BOTH IP/OP "$1,553.75 " "$1,149.78" $0.00 "$1,243.00" $699.19 $699.19 $0.00 $0.00 $0.00 $323.84 "$1,153.19" "$1,153.19" $0.00 $0.00 $323.80 $0.00 $919.04 $919.04 $0.00 $776.88 "$1,230.57" "$1,243.00" $0.00 $0.00 $243.16 $0.00 $0.00 $247.36 $0.00 $0.00 $0.00 $0.00 $0.00 72442454 SUP HCPCS C1713 72442454 - PLATE BN T 37MM EVOS MN 3 HLE/HD 5 HL SHFT LOPRFL VA SS SM BOTH IP/OP "$1,553.75 " "$1,149.78" $0.00 "$1,243.00" $699.19 $699.19 $0.00 $0.00 $0.00 $323.84 "$1,153.19" "$1,153.19" $0.00 $0.00 $323.80 $0.00 $919.04 $919.04 $0.00 $776.88 "$1,230.57" "$1,243.00" $0.00 $0.00 $243.16 $0.00 $0.00 $247.36 $0.00 $0.00 $0.00 $0.00 $0.00 72442456 SUP HCPCS C1713 72442456 - PLATE BN T 61MM EVOS MN 3 HLE/HD 9 HL SHFT LOPRFL VA SS SM BOTH IP/OP "$1,553.75 " "$1,149.78" $0.00 "$1,243.00" $699.19 $699.19 $0.00 $0.00 $0.00 $323.84 "$1,153.19" "$1,153.19" $0.00 $0.00 $323.80 $0.00 $919.04 $919.04 $0.00 $776.88 "$1,230.57" "$1,243.00" $0.00 $0.00 $243.16 $0.00 $0.00 $247.36 $0.00 $0.00 $0.00 $0.00 $0.00 72442458 SUP HCPCS C1713 72442458 - PLATE BN 25MM EVOS MN 4 HL FLX LOPRFL VA SS SM BN LNG BN 2.4 BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442460 SUP HCPCS C1713 72442460 - PLATE BN 37X6X1.4MM EVOS MN 6 HL FLX LOPRFL VA SS LG BN SM BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442462 SUP HCPCS C1713 72442462 - PLATE BN 49MM EVOS MN 8 HL FLX LOPRFL VA SS SM BN LNG BN 2.4 BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442464 SUP HCPCS C1713 72442464 - PLATE BN 61MM EVOS MN 10 HL FLX LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442466 SUP HCPCS C1713 72442466 - PLATE BN 121MM EVOS MN 20 HL FLX LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442468 SUP HCPCS C1713 72442468 - PLATE BN 25MM STRL EVOS MN 4 HL LOPRFL VA LCK SS 2.4MM SCR BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442470 SUP HCPCS C1713 72442470 - PLATE BN 37MM EVOS MN 6 HL STRTH LOPRFL SS BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442472 SUP HCPCS C1713 72442472 - PLATE BN 49MM EVOS MN 20 HL STRENGHT LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442474 SUP HCPCS C1713 72442474 - PLATE BN 61MM EVOS MN 10 HL STRENGHT LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442476 SUP HCPCS C1713 72442476 - PLATE BN 121MM EVOS MN 20 HL STRENGHT LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,595.00 " "$1,180.30" $0.00 "$1,276.00" $717.75 $717.75 $0.00 $0.00 $0.00 $332.44 "$1,183.81" "$1,183.81" $0.00 $0.00 $332.40 $0.00 $943.44 $943.44 $0.00 $797.50 "$1,263.24" "$1,276.00" $0.00 $0.00 $249.62 $0.00 $0.00 $253.92 $0.00 $0.00 $0.00 $0.00 $0.00 72442478 SUP HCPCS C1713 72442478 - PLATE BN STRG 34MM EVOS MN 5 HL TINE LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,677.50 " "$1,241.35" $0.00 "$1,342.00" $754.88 $754.88 $0.00 $0.00 $0.00 $349.63 "$1,245.04" "$1,245.04" $0.00 $0.00 $349.59 $0.00 $992.24 $992.24 $0.00 $838.75 "$1,328.58" "$1,342.00" $0.00 $0.00 $262.53 $0.00 $0.00 $267.06 $0.00 $0.00 $0.00 $0.00 $0.00 72442482 SUP HCPCS C1713 72442482 - PLATE BN 47MM EVOS MN 5 HL LOPRFL VA SS SM BN LNG BN 2.4MM BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442484 SUP HCPCS C1713 72442484 - PLATE BN 59MM EVOS MN 7 HL LOPRFL VA SS SM BN LNG BN 2.4MM BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442486 SUP HCPCS C1713 72442486 - PLATE BN Y 45MM EVOS MN 5 HL TINE LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,966.25 " "$1,455.03" $0.00 "$1,573.00" $884.81 $884.81 $0.00 $0.00 $0.00 $409.82 "$1,459.35" "$1,459.35" $0.00 $0.00 $409.77 $0.00 "$1,163.04" "$1,163.04" $0.00 $983.13 "$1,557.27" "$1,573.00" $0.00 $0.00 $307.72 $0.00 $0.00 $313.03 $0.00 $0.00 $0.00 $0.00 $0.00 72442488 SUP HCPCS C1713 72442488 - PLATE BN Y 57MM EVOS MN 7 HL TINE LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,966.25 " "$1,455.03" $0.00 "$1,573.00" $884.81 $884.81 $0.00 $0.00 $0.00 $409.82 "$1,459.35" "$1,459.35" $0.00 $0.00 $409.77 $0.00 "$1,163.04" "$1,163.04" $0.00 $983.13 "$1,557.27" "$1,573.00" $0.00 $0.00 $307.72 $0.00 $0.00 $313.03 $0.00 $0.00 $0.00 $0.00 $0.00 72442490 SUP HCPCS C1713 72442490 - PLATE BN 3ANG 55MM EVOS MN 6 HL LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442492 SUP HCPCS C1713 72442492 - PLATE BN 3ANG 67MM EVOS MN 8 HL LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442494 SUP HCPCS C1713 72442494 - PLATE BN TRPZD 24X18X1.4MM EVOS LOPRFL VA 5 HL SS 2.4MM SCR BOTH IP/OP "$2,000.63 " "$1,480.47" $0.00 "$1,600.50" $900.28 $900.28 $0.00 $0.00 $0.00 $416.98 "$1,484.86" "$1,484.86" $0.00 $0.00 $416.93 $0.00 "$1,183.37" "$1,183.37" $0.00 "$1,000.31" "$1,584.50" "$1,600.50" $0.00 $0.00 $313.10 $0.00 $0.00 $318.50 $0.00 $0.00 $0.00 $0.00 $0.00 72442720 SUP HCPCS C1713 72442720 - PLATE BN T 42X7.5-21.5X1.4MM STRL EVOS MN 3 HLE/HD 5 HL SHFT BOTH IP/OP "$1,718.75 " "$1,271.88" $0.00 "$1,375.00" $773.44 $773.44 $0.00 $0.00 $0.00 $358.23 "$1,275.66" "$1,275.66" $0.00 $0.00 $358.19 $0.00 "$1,016.64" "$1,016.64" $0.00 $859.38 "$1,361.25" "$1,375.00" $0.00 $0.00 $268.98 $0.00 $0.00 $273.63 $0.00 $0.00 $0.00 $0.00 $0.00 72442722 SUP HCPCS C1713 72442722 - PLATE BN T 71MM EVOS MN 3 HLE/HD 9 HL SHFT LOPRFL VA SS SM BOTH IP/OP "$1,718.75 " "$1,271.88" $0.00 "$1,375.00" $773.44 $773.44 $0.00 $0.00 $0.00 $358.23 "$1,275.66" "$1,275.66" $0.00 $0.00 $358.19 $0.00 "$1,016.64" "$1,016.64" $0.00 $859.38 "$1,361.25" "$1,375.00" $0.00 $0.00 $268.98 $0.00 $0.00 $273.63 $0.00 $0.00 $0.00 $0.00 $0.00 72442724 SUP HCPCS C1713 72442724 - PLATE BN 28MM EVOS MN 4 HL FLX LOPRFL VA SS SM BN LNG BN 2.7 BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442726 SUP HCPCS C1713 72442726 - PLATE BN 42MM EVOS MN 4 HL FLX LOPRFL VA SS SM BN LNG BN 2.7 BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442728 SUP HCPCS C1713 72442728 - PLATE BN 56MM EVOS MN 8 HL FLX LOPRFL VA SS SM BN LNG BN 2.7 BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442760 SUP HCPCS C1713 72442760 - PLATE BN 70MM EVOS MN 10 HL FLX LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442762 SUP HCPCS C1713 72442762 - PLATE BN 140MM EVOS MN 20 HL FLX LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442764 SUP HCPCS C1713 72442764 - PLATE BN 28MM EVOS MN 4 HL STRENGHT LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442766 SUP HCPCS C1713 72442766 - PLATE BN 7MM SPC 42X7.5X2.2MM 140MM EVOS MN 6 HL SHFT VA LCK BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442768 SUP HCPCS C1713 72442768 - PLATE BN 7MM SPC 56X7.5X2.2MM 140MM EVOS MN 6 HL SHFT VA LCK BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442770 SUP HCPCS C1713 72442770 - PLATE BN 7MM SPC 70X7.5X2.2MM 140MM EVOS MN 6 HL SHFT VA LCK BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442772 SUP HCPCS C1713 72442772 - PLATE BN 140MM EVOS MN 20 HL STRENGHT LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,753.13 " "$1,297.32" $0.00 "$1,402.50" $788.91 $788.91 $0.00 $0.00 $0.00 $365.40 "$1,301.17" "$1,301.17" $0.00 $0.00 $365.35 $0.00 "$1,036.97" "$1,036.97" $0.00 $876.56 "$1,388.48" "$1,402.50" $0.00 $0.00 $274.36 $0.00 $0.00 $279.10 $0.00 $0.00 $0.00 $0.00 $0.00 72442774 SUP HCPCS C1713 72442774 - PLATE BN STRG 38MM EVOS MN 5 HL TINE LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,842.50 " "$1,363.45" $0.00 "$1,474.00" $829.13 $829.13 $0.00 $0.00 $0.00 $384.02 "$1,367.50" "$1,367.50" $0.00 $0.00 $383.98 $0.00 "$1,089.84" "$1,089.84" $0.00 $921.25 "$1,459.26" "$1,474.00" $0.00 $0.00 $288.35 $0.00 $0.00 $293.33 $0.00 $0.00 $0.00 $0.00 $0.00 72442776 SUP HCPCS C1713 72442776 - PLATE BN STRG 52MM EVOS MN 7 HL TINE LOPRFL VA SS SM BN LNG BOTH IP/OP "$1,842.50 " "$1,363.45" $0.00 "$1,474.00" $829.13 $829.13 $0.00 $0.00 $0.00 $384.02 "$1,367.50" "$1,367.50" $0.00 $0.00 $383.98 $0.00 "$1,089.84" "$1,089.84" $0.00 $921.25 "$1,459.26" "$1,474.00" $0.00 $0.00 $288.35 $0.00 $0.00 $293.33 $0.00 $0.00 $0.00 $0.00 $0.00 72442778 SUP HCPCS C1713 72442778 - PLATE BN Y 55MM EVOS MN 5 HL LOPRFL VA SS SM BN LNG BN 2.7MM BOTH IP/OP "$1,931.88 " "$1,429.59" $0.00 "$1,545.50" $869.34 $869.34 $0.00 $0.00 $0.00 $402.65 "$1,433.84" "$1,433.84" $0.00 $0.00 $402.60 $0.00 "$1,142.70" "$1,142.70" $0.00 $965.94 "$1,530.05" "$1,545.50" $0.00 $0.00 $302.34 $0.00 $0.00 $307.55 $0.00 $0.00 $0.00 $0.00 $0.00 72442780 SUP HCPCS C1713 72442780 - PLATE BN Y 69MM EVOS MN 7 HL LOPRFL VA SS SM BN LNG BN 2.7MM BOTH IP/OP "$1,931.88 " "$1,429.59" $0.00 "$1,545.50" $869.34 $869.34 $0.00 $0.00 $0.00 $402.65 "$1,433.84" "$1,433.84" $0.00 $0.00 $402.60 $0.00 "$1,142.70" "$1,142.70" $0.00 $965.94 "$1,530.05" "$1,545.50" $0.00 $0.00 $302.34 $0.00 $0.00 $307.55 $0.00 $0.00 $0.00 $0.00 $0.00 72442782 SUP HCPCS C1713 72442782 - PLATE BN Y 52MM EVOS MN 5 HL TINE LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$2,206.88 " "$1,633.09" $0.00 "$1,765.50" $993.09 $993.09 $0.00 $0.00 $0.00 $459.97 "$1,637.94" "$1,637.94" $0.00 $0.00 $459.91 $0.00 "$1,305.37" "$1,305.37" $0.00 "$1,103.44" "$1,747.85" "$1,765.50" $0.00 $0.00 $345.38 $0.00 $0.00 $351.33 $0.00 $0.00 $0.00 $0.00 $0.00 72442784 SUP HCPCS C1713 72442784 - PLATE BN Y 66MM EVOS MN 7HOLE TINE LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$2,206.88 " "$1,633.09" $0.00 "$1,765.50" $993.09 $993.09 $0.00 $0.00 $0.00 $459.97 "$1,637.94" "$1,637.94" $0.00 $0.00 $459.91 $0.00 "$1,305.37" "$1,305.37" $0.00 "$1,103.44" "$1,747.85" "$1,765.50" $0.00 $0.00 $345.38 $0.00 $0.00 $351.33 $0.00 $0.00 $0.00 $0.00 $0.00 72442786 SUP HCPCS C1713 72442786 - PLATE BN 3ANG 54MM EVOS MN 6 HL LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,931.88 " "$1,429.59" $0.00 "$1,545.50" $869.34 $869.34 $0.00 $0.00 $0.00 $402.65 "$1,433.84" "$1,433.84" $0.00 $0.00 $402.60 $0.00 "$1,142.70" "$1,142.70" $0.00 $965.94 "$1,530.05" "$1,545.50" $0.00 $0.00 $302.34 $0.00 $0.00 $307.55 $0.00 $0.00 $0.00 $0.00 $0.00 72442788 SUP HCPCS C1713 72442788 - PLATE BN 3ANG 68MM EVOS MN 8 HL LOPRFL VA SS SM BN LNG BN BOTH IP/OP "$1,931.88 " "$1,429.59" $0.00 "$1,545.50" $869.34 $869.34 $0.00 $0.00 $0.00 $402.65 "$1,433.84" "$1,433.84" $0.00 $0.00 $402.60 $0.00 "$1,142.70" "$1,142.70" $0.00 $965.94 "$1,530.05" "$1,545.50" $0.00 $0.00 $302.34 $0.00 $0.00 $307.55 $0.00 $0.00 $0.00 $0.00 $0.00 72800107 SUP HCPCS C1713 72800107 - PLATE BN 98MM PRLC VLP 7 HL LCK TIB LT POSTEROMEDIAL PROX BOTH IP/OP "$2,157.75 " "$1,596.74" $0.00 "$1,726.20" $970.99 $970.99 $0.00 $0.00 $0.00 $449.73 "$1,601.48" "$1,601.48" $0.00 $0.00 $449.68 $0.00 "$1,276.31" "$1,276.31" $0.00 "$1,078.88" "$1,708.94" "$1,726.20" $0.00 $0.00 $337.69 $0.00 $0.00 $343.51 $0.00 $0.00 $0.00 $0.00 $0.00 72823110 SUP HCPCS C1713 72823110 - SCREW BN 2.7MM 10MM PRLC VLP LCK ST SS CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823112 SUP HCPCS C1713 72823112 - SCREW BN 2.7MM 12MM PRLC VLP ST LCK SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823114 SUP HCPCS C1713 72823114 - SCREW BN 2.7MM 14MM PRLC VLP ST LCK SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823116 SUP HCPCS C1713 72823116 - SCREW BN 2.7MM 16MM PRLC VLP ST LCK SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823118 SUP HCPCS C1713 72823118 - SCREW BN 2.7MM 18MM PRLC VLP ST LCK SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823120 SUP HCPCS C1713 72823120 - SCREW BN 2.7MM 20MM PRLC VLP ST LCK SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823122 SUP HCPCS C1713 72823122 - SCREW BN 2.7MM 22MM VLP LCK ST VA FT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823124 SUP HCPCS C1713 72823124 - SCREW BN 2.7MM 24MM PRLC VLP LCK ST SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823126 SUP HCPCS C1713 72823126 - SCREW BN 2.7MM 26MM PRLC VLP LCK ST CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823128 SUP HCPCS C1713 72823128 - SCREW BN 2.7MM 28MM PRLC VLP LCK ST SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823130 SUP HCPCS C1713 72823130 - SCREW BN 2.7MM 30MM PRLC VLP LCK ST SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823132 SUP HCPCS C1713 72823132 - SCREW BN 2.7MM 32MM PRLC VLP LCK ST SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823134 SUP HCPCS C1713 72823134 - SCREW BN 2.7MM 34MM PRLC VLP LCK ST SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823136 SUP HCPCS C1713 72823136 - SCREW BN 2.7MM 36MM PRLC VLP LCK ST SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823138 SUP HCPCS C1713 72823138 - SCREW BN 2.7MM 38MM PRLC VLP LCK ST SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823140 SUP HCPCS C1713 72823140 - SCREW BN 2.7MM 40MM PRLC VLP LCK ST SS FOREFOOT MIDFOOT CORT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823210 SUP HCPCS C1713 72823210 - SCREW BN FT 4MM 10MM PRLC VLP OSTEOPENIA CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823212 SUP HCPCS C1713 72823212 - SCREW BN FT 4MM 12MM PRLC VLP SS FOREFOOT MIDFOOT CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823214 SUP HCPCS C1713 72823214 - SCREW BN FT 4MM 14MM PRLC VLP OSTEOPENIA CORT FT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823216 SUP HCPCS C1713 72823216 - SCREW BN FT 4MM 16MM PRLC VLP OSTEOPENIA CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823218 SUP HCPCS C1713 72823218 - SCREW BN FT 4MM 18MM PRLC VLP SS FOREFOOT MIDFOOT CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823220 SUP HCPCS C1713 72823220 - SCREW BN FT 4MM 20MM PRLC VLP OSTEOPENIA CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823222 SUP HCPCS C1713 72823222 - SCREW BN 4MM 22MM PRLC VLP FT OSTEOPENIA BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823224 SUP HCPCS C1713 72823224 - SCREW BN FT 4MM 24MM PRLC VLP OSTEOPENIA CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823226 SUP HCPCS C1713 72823226 - SCREW BN FT 4MM 26MM PRLC VLP OSTEOPENIA CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823228 SUP HCPCS C1713 72823228 - SCREW BN FT 4MM 28MM PRLC VLP OSTEOPENIA CORT FT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823230 SUP HCPCS C1713 72823230 - SCREW BN FT 4MM 4.9MM 30MM NS LOPRFL HEX FT PRLC VLP BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823232 SUP HCPCS C1713 72823232 - SCREW BONE FULTHD 4MM 32MM OSTEOPENIA VAR ANG PERI-LOC VLP BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823234 SUP HCPCS C1713 72823234 - SCREW BONE 4MM 34MM FULTHRD OSTEOPENIA PERI-LOC VLP BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823236 SUP HCPCS C1713 72823236 - SCREW BN FT 4MM 36MM PRLC VLP SS FOREFOOT MIDFOOT CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823238 SUP HCPCS C1713 72823238 - SCREW BN 4MM 38MM PRLC VLP FT OSTEOPENIA BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823240 SUP HCPCS C1713 72823240 - SCREW BN FT 4MM 40MM PRLC VLP SS FOREFOOT MIDFOOT CORT BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 72823410 SUP HCPCS C1713 72823410 - SCREW BN 4MM 10MM PRLC VLP LCK OSTEOPENIA CORT BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823412 SUP HCPCS C1713 72823412 - SCREW BN 4MM 12MM PRLC VLP LCK OSTEOPENIA CORT BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823414 SUP HCPCS C1713 72823414 - SCREW BN 4MM 14MM PRLC VLP LCK OSTEOPENIA CORT BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823416 SUP HCPCS C1713 72823416 - SCREW BN 4MM 16MM PRLC VLP LCK OSTEOPENIA CORT BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823418 SUP HCPCS C1713 72823418 - SCREW BN 4MM 18MM PRLC VLP LCK OSTEOPENIA CORT BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823420 SUP HCPCS C1713 72823420 - SCREW BN 4MM 20MM PRLC VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823422 SUP HCPCS C1713 72823422 - SCREW BN 4MM 22MM PRLC VLP LCK OSTEOPENIA CORT BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823424 SUP HCPCS C1713 72823424 - SCREW BN 4MM 24MM PRLC VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823426 SUP HCPCS C1713 72823426 - SCREW BONE 4MM 26MM LOCKING OSTEOPENIA PERI-LOC VLP CORTICAL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823428 SUP HCPCS C1713 72823428 - SCREW BN 4MM 4.9MM 28MM LCK LOPRFL HD FT PRLC VLP OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823430 SUP HCPCS C1713 72823430 - SCREW BONE 4MM 30MM LOCKING OSTEOPENIA PERI-LOC VLP CORTICAL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823432 SUP HCPCS C1713 72823432 - SCREW BONE 4MM 32MM LOCKING OSTEOPENIA PERI-LOC VLP CORTICAL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823434 SUP HCPCS C1713 72823434 - SCREW BN 4MM 34MM PRLC VLP LCK OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823436 SUP HCPCS C1713 72823436 - SCREW BN 4MM 36MM PRLC VLP LCK OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823438 SUP HCPCS C1713 72823438 - SCREW BN 4MM 38MM PRLC VLP LCK OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823440 SUP HCPCS C1713 72823440 - SCREW BN 4MM 40MM PRLC VLP LCK OSTEOPENIA CORT BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823510 SUP HCPCS C1713 72823510 - SCREW BN 15D 2.5MM 5MM 5.4MM 10MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823512 SUP HCPCS C1713 72823512 - SCREW BN 15D 2.5MM 5MM 5.4MM 12MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823514 SUP HCPCS C1713 72823514 - SCREW BN 15D 2.5MM 5MM 5.4MM 14MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823516 SUP HCPCS C1713 72823516 - SCREW BN 15D 2.5MM 5MM 5.4MM 16MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823518 SUP HCPCS C1713 72823518 - SCREW BN 15D 2.5MM 5MM 5.4MM 18MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823520 SUP HCPCS C1713 72823520 - SCREW BN 15D 2.5MM 5MM 5.4MM 20MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823522 SUP HCPCS C1713 72823522 - SCREW BN 15D 2.5MM 5MM 5.4MM 22MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823524 SUP HCPCS C1713 72823524 - SCREW BN 15D 2.5MM 5MM 5.4MM 24MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823526 SUP HCPCS C1713 72823526 - SCREW BN 15D 2.5MM 5MM 5.4MM 26MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823528 SUP HCPCS C1713 72823528 - SCREW BN 15D 2.5MM 5MM 5.4MM 28MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823530 SUP HCPCS C1713 72823530 - SCREW BN 15D 2.5MM 5MM 5.4MM 30MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823532 SUP HCPCS C1713 72823532 - SCREW BN 15D 2.5MM 5MM 5.4MM 32MM VLP LCK LOPRFL HD HEX RCS BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823534 SUP HCPCS C1713 72823534 - SCREW BN 15D 2.5MM 5MM 5.4MM 34MM VLP LCK LOPRFL HD HEX RCS BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823536 SUP HCPCS C1713 72823536 - SCREW BN 15D 2.5MM 5MM 5.4MM 36MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823538 SUP HCPCS C1713 72823538 - SCREW BN 15D 2.5MM 5MM 5.4MM 38MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823540 SUP HCPCS C1713 72823540 - SCREW BN 15D 2.5MM 5MM 5.4MM 40MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823542 SUP HCPCS C1713 72823542 - SCREW BN 15D 2.5MM 5MM 5.4MM 42MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823544 SUP HCPCS C1713 72823544 - SCREW BN 15D 2.5MM 5MM 5.4MM 44MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823546 SUP HCPCS C1713 72823546 - SCREW BN 15D 2.5MM 5MM 5.4MM 46MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823548 SUP HCPCS C1713 72823548 - SCREW BN 15D 2.5MM 5MM 5.4MM 48MM VLP LCK LOPRFL HD HEX RCS BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823550 SUP HCPCS C1713 72823550 - SCREW BN 15D 2.5MM 5MM 5.4MM 50MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823555 SUP HCPCS C1713 72823555 - SCREW BN 15D 2.5MM 5MM 5.4MM 55MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823560 SUP HCPCS C1713 72823560 - SCREW BN 15D 2.5MM 5MM 5.4MM 60MMX3.3MM VLP LCK LOPRFL HD BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 73804026 SUP HCPCS C1713 73804026 - SCREW BN T20 3.5MM 26MM PRLC ST STRDR CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73804028 SUP HCPCS C1713 73804028 - SCREW BN 3.5MM 28MM PRLC ST T20 STRDR RCS CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73804030 SUP HCPCS C1713 73804030 - SCREW BN 3.5MM 30MM PRLC ST T20 STRDR RCS CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73804032 SUP HCPCS C1713 73804032 - SCREW BN 3.5MM 32MM PRLC ST T20 STRDR RCS CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73804034 SUP HCPCS C1713 73804034 - SCREW BN T20 3.5MM 34MM PRLC ST STRDR CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73804038 SUP HCPCS C1713 73804038 - SCREW BN 3.5MM 38MM PRLC ST T20 STRDR RCS CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73804040 SUP HCPCS C1713 73804040 - SCREW BN 3.5MM 40MM PRLC ST T20 STRDR RCS CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73804044 SUP HCPCS C1713 73804044 - SCREW BN 3.5MM 44MM PRLC ST T20 STRDR RCS CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73804050 SUP HCPCS C1713 73804050 - SCREW BN 3.5MM 50MM PRLC ST T20 STRDR RCS CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73805026 SUP HCPCS C1713 73805026 - SCREW BN T20 3.5MM 26MM PRLC ST LCK BOTH IP/OP $254.10 $188.03 $0.00 $203.28 $114.35 $114.35 $0.00 $0.00 $0.00 $52.96 $188.59 $188.59 $0.00 $0.00 $52.95 $0.00 $150.30 $150.30 $0.00 $127.05 $201.25 $203.28 $0.00 $0.00 $39.77 $0.00 $0.00 $40.45 $0.00 $0.00 $0.00 $0.00 $0.00 73805030 SUP HCPCS C1713 73805030 - SCREW BN 3.5MM 30MM PRLC ST LCK T20 STRDR RCS SM BN LNG BN BOTH IP/OP $254.10 $188.03 $0.00 $203.28 $114.35 $114.35 $0.00 $0.00 $0.00 $52.96 $188.59 $188.59 $0.00 $0.00 $52.95 $0.00 $150.30 $150.30 $0.00 $127.05 $201.25 $203.28 $0.00 $0.00 $39.77 $0.00 $0.00 $40.45 $0.00 $0.00 $0.00 $0.00 $0.00 73805065 SUP HCPCS C1713 73805065 - SCREW BN 3.5MM 65MM PRLC ST LCK T20 STRDR RCS SM BN LNG BN BOTH IP/OP $292.95 $216.78 $0.00 $234.36 $131.83 $131.83 $0.00 $0.00 $0.00 $61.06 $217.43 $217.43 $0.00 $0.00 $61.05 $0.00 $173.28 $173.28 $0.00 $146.48 $232.02 $234.36 $0.00 $0.00 $45.85 $0.00 $0.00 $46.64 $0.00 $0.00 $0.00 $0.00 $0.00 73805070 SUP HCPCS C1713 73805070 - SCREW BN 3.5MM 70MM PRLC ST LCK T20 STRDR RCS SM BN LNG BN BOTH IP/OP $292.95 $216.78 $0.00 $234.36 $131.83 $131.83 $0.00 $0.00 $0.00 $61.06 $217.43 $217.43 $0.00 $0.00 $61.05 $0.00 $173.28 $173.28 $0.00 $146.48 $232.02 $234.36 $0.00 $0.00 $45.85 $0.00 $0.00 $46.64 $0.00 $0.00 $0.00 $0.00 $0.00 73805075 SUP HCPCS C1713 73805075 - SCREW BN 3.5MM 75MM PRLC ST LCK T20 STRDR RCS SM BN LNG BN BOTH IP/OP $292.95 $216.78 $0.00 $234.36 $131.83 $131.83 $0.00 $0.00 $0.00 $61.06 $217.43 $217.43 $0.00 $0.00 $61.05 $0.00 $173.28 $173.28 $0.00 $146.48 $232.02 $234.36 $0.00 $0.00 $45.85 $0.00 $0.00 $46.64 $0.00 $0.00 $0.00 $0.00 $0.00 73805080 SUP HCPCS C1713 73805080 - SCREW BN 3.5MM 80MM PRLC ST LCK T20 STRDR RCS SM BN LNG BN BOTH IP/OP $292.95 $216.78 $0.00 $234.36 $131.83 $131.83 $0.00 $0.00 $0.00 $61.06 $217.43 $217.43 $0.00 $0.00 $61.05 $0.00 $173.28 $173.28 $0.00 $146.48 $232.02 $234.36 $0.00 $0.00 $45.85 $0.00 $0.00 $46.64 $0.00 $0.00 $0.00 $0.00 $0.00 73805230 SUP HCPCS C1713 73805230 - SCREW BN FT 4MM 30MM PRLC T20 STRDR RCS CANC BOTH IP/OP $64.43 $47.68 $0.00 $51.54 $28.99 $28.99 $0.00 $0.00 $0.00 $13.43 $47.82 $47.82 $0.00 $0.00 $13.43 $0.00 $38.11 $38.11 $0.00 $32.21 $51.03 $51.54 $0.00 $0.00 $10.08 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 73806024 SUP HCPCS C1713 73806024 - SCREW BN 4.5MM 24MM PRLC ST T25 STRDR RCS FT/ANKL CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73806026 SUP HCPCS C1713 73806026 - SCREW BN 4.5MM 26MM PRLC ST T25 STRDR RCS FT/ANKL CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73806028 SUP HCPCS C1713 73806028 - SCREW BN 4.5MM 28MM PRLC ST T25 STRDR RCS FT/ANKL CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73806030 SUP HCPCS C1713 73806030 - SCREW BN 4.5MM 30MM PRLC ST T25 STRDR RCS FT/ANKL CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73806034 SUP HCPCS C1713 73806034 - SCREW BN 4.5MM 34MM PRLC ST T25 STRDR RCS FT/ANKL CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73806040 SUP HCPCS C1713 73806040 - SCREW BN 4.5MM 40MM PRLC ST T25 STRDR RCS FT/ANKL CORT BOTH IP/OP $48.83 $36.13 $0.00 $39.06 $21.97 $21.97 $0.00 $0.00 $0.00 $10.18 $36.24 $36.24 $0.00 $0.00 $10.18 $0.00 $28.88 $28.88 $0.00 $24.41 $38.67 $39.06 $0.00 $0.00 $7.64 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $0.00 73807060 SUP HCPCS C1713 73807060 - SCREW BN 4.5MM 60MM PRLC ST LCK T25 STRDR RCS ANKL/FT BOTH IP/OP $298.20 $220.67 $0.00 $238.56 $134.19 $134.19 $0.00 $0.00 $0.00 $62.15 $221.32 $221.32 $0.00 $0.00 $62.14 $0.00 $176.39 $176.39 $0.00 $149.10 $236.17 $238.56 $0.00 $0.00 $46.67 $0.00 $0.00 $47.47 $0.00 $0.00 $0.00 $0.00 $0.00 73807066 SUP HCPCS C1713 73807066 - SCREW BN 4.5MM 66MM PRLC ST LCK T25 STRDR RCS ANKL/FT BOTH IP/OP $298.20 $220.67 $0.00 $238.56 $134.19 $134.19 $0.00 $0.00 $0.00 $62.15 $221.32 $221.32 $0.00 $0.00 $62.14 $0.00 $176.39 $176.39 $0.00 $149.10 $236.17 $238.56 $0.00 $0.00 $46.67 $0.00 $0.00 $47.47 $0.00 $0.00 $0.00 $0.00 $0.00 73807070 SUP HCPCS C1713 73807070 - SCREW BN 4.5MM 70MM PRLC ST LCK T25 STRDR RCS ANKL/FT BOTH IP/OP $298.20 $220.67 $0.00 $238.56 $134.19 $134.19 $0.00 $0.00 $0.00 $62.15 $221.32 $221.32 $0.00 $0.00 $62.14 $0.00 $176.39 $176.39 $0.00 $149.10 $236.17 $238.56 $0.00 $0.00 $46.67 $0.00 $0.00 $47.47 $0.00 $0.00 $0.00 $0.00 $0.00 73807074 SUP HCPCS C1713 73807074 - SCREW BN 4.5MM 74MM PRLC ST LCK T25 STRDR RCS ANKL/FT BOTH IP/OP $298.20 $220.67 $0.00 $238.56 $134.19 $134.19 $0.00 $0.00 $0.00 $62.15 $221.32 $221.32 $0.00 $0.00 $62.14 $0.00 $176.39 $176.39 $0.00 $149.10 $236.17 $238.56 $0.00 $0.00 $46.67 $0.00 $0.00 $47.47 $0.00 $0.00 $0.00 $0.00 $0.00 73807076 SUP HCPCS C1713 73807076 - SCREW BN 4.5MM 76MM PRLC ST LCK T25 STRDR RCS ANKL/FT BOTH IP/OP $298.20 $220.67 $0.00 $238.56 $134.19 $134.19 $0.00 $0.00 $0.00 $62.15 $221.32 $221.32 $0.00 $0.00 $62.14 $0.00 $176.39 $176.39 $0.00 $149.10 $236.17 $238.56 $0.00 $0.00 $46.67 $0.00 $0.00 $47.47 $0.00 $0.00 $0.00 $0.00 $0.00 73807085 SUP HCPCS C1713 73807085 - SCREW BN 4.5MM 85MM PRLC ST LCK T25 STRDR RCS ANKL/FT BOTH IP/OP $298.20 $220.67 $0.00 $238.56 $134.19 $134.19 $0.00 $0.00 $0.00 $62.15 $221.32 $221.32 $0.00 $0.00 $62.14 $0.00 $176.39 $176.39 $0.00 $149.10 $236.17 $238.56 $0.00 $0.00 $46.67 $0.00 $0.00 $47.47 $0.00 $0.00 $0.00 $0.00 $0.00 73807090 SUP HCPCS C1713 73807090 - SCREW BN 4.5MM 90MM PRLC ST LCK T25 STRDR RCS ANKL/FT BOTH IP/OP $309.75 $229.22 $0.00 $247.80 $139.39 $139.39 $0.00 $0.00 $0.00 $64.56 $229.90 $229.90 $0.00 $0.00 $64.55 $0.00 $183.22 $183.22 $0.00 $154.88 $245.32 $247.80 $0.00 $0.00 $48.48 $0.00 $0.00 $49.31 $0.00 $0.00 $0.00 $0.00 $0.00 74132105 SUP HCPCS C1713 74132105 - SCREW BN 6.5MM 105MM 22MM CNN CNCL P/T SS BOTH IP/OP $481.50 $356.31 $0.00 $385.20 $216.68 $216.68 $0.00 $0.00 $0.00 $100.36 $357.37 $357.37 $0.00 $0.00 $100.34 $0.00 $284.81 $284.81 $0.00 $240.75 $381.35 $385.20 $0.00 $0.00 $75.35 $0.00 $0.00 $76.65 $0.00 $0.00 $0.00 $0.00 $0.00 74133070 SUP HCPCS C1713 74133070 - SCREW BN FT 6.5MM 70MM CNN LCK SS BOTH IP/OP $554.63 $410.43 $0.00 $443.70 $249.58 $249.58 $0.00 $0.00 $0.00 $115.60 $411.64 $411.64 $0.00 $0.00 $115.58 $0.00 $328.06 $328.06 $0.00 $277.31 $439.27 $443.70 $0.00 $0.00 $86.80 $0.00 $0.00 $88.30 $0.00 $0.00 $0.00 $0.00 $0.00 74133075 SUP HCPCS C1713 74133075 - SCREW BN FT 6.5MM 75MM CNN LCK SS BOTH IP/OP $684.00 $506.16 $0.00 $547.20 $307.80 $307.80 $0.00 $0.00 $0.00 $142.56 $507.66 $507.66 $0.00 $0.00 $142.55 $0.00 $404.59 $404.59 $0.00 $342.00 $541.73 $547.20 $0.00 $0.00 $107.05 $0.00 $0.00 $108.89 $0.00 $0.00 $0.00 $0.00 $0.00 74133080 SUP HCPCS C1713 74133080 - SCREW BN FT 6.5MM 80MM CNN LCK SS BOTH IP/OP $684.00 $506.16 $0.00 $547.20 $307.80 $307.80 $0.00 $0.00 $0.00 $142.56 $507.66 $507.66 $0.00 $0.00 $142.55 $0.00 $404.59 $404.59 $0.00 $342.00 $541.73 $547.20 $0.00 $0.00 $107.05 $0.00 $0.00 $108.89 $0.00 $0.00 $0.00 $0.00 $0.00 74133085 SUP HCPCS C1713 74133085 - SCREW BN FT 6.5MM 85MM CNN LCK SS BOTH IP/OP $684.00 $506.16 $0.00 $547.20 $307.80 $307.80 $0.00 $0.00 $0.00 $142.56 $507.66 $507.66 $0.00 $0.00 $142.55 $0.00 $404.59 $404.59 $0.00 $342.00 $541.73 $547.20 $0.00 $0.00 $107.05 $0.00 $0.00 $108.89 $0.00 $0.00 $0.00 $0.00 $0.00 74133411 SUP HCPCS C1713 74133411 - PIN FX SHRT 4.5MM 80MM PRLC TRL BOTH IP/OP $480.00 $355.20 $0.00 $384.00 $216.00 $216.00 $0.00 $0.00 $0.00 $100.04 $356.26 $356.26 $0.00 $0.00 $100.03 $0.00 $283.92 $283.92 $0.00 $240.00 $380.16 $384.00 $0.00 $0.00 $75.12 $0.00 $0.00 $76.42 $0.00 $0.00 $0.00 $0.00 $0.00 74133412 SUP HCPCS C1713 74133412 - PIN FX 3.5MM 18MM PRLC BOTH IP/OP $520.00 $384.80 $0.00 $416.00 $234.00 $234.00 $0.00 $0.00 $0.00 $108.38 $385.94 $385.94 $0.00 $0.00 $108.37 $0.00 $307.58 $307.58 $0.00 $260.00 $411.84 $416.00 $0.00 $0.00 $81.38 $0.00 $0.00 $82.78 $0.00 $0.00 $0.00 $0.00 $0.00 74133413 SUP HCPCS C1713 74133413 - PIN FX SHRT 3.5MM 18MM PRLC PRV FX BOTH IP/OP $520.00 $384.80 $0.00 $416.00 $234.00 $234.00 $0.00 $0.00 $0.00 $108.38 $385.94 $385.94 $0.00 $0.00 $108.37 $0.00 $307.58 $307.58 $0.00 $260.00 $411.84 $416.00 $0.00 $0.00 $81.38 $0.00 $0.00 $82.78 $0.00 $0.00 $0.00 $0.00 $0.00 74133420 SUP Custom 27203010 74133420 - BIT DRL 2.7MM 358MM TARGETER BOTH IP/OP "$1,102.00 " $815.48 $0.00 $881.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $817.90 $817.90 $0.00 $0.00 $229.66 $0.00 $0.00 $0.00 $0.00 $551.00 $872.78 $881.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74133421 SUP HCPCS C1713 74133421 - PIN FX SHRT 4.5MM 80MM PRLC TARGETER DRL TIP PRV FX BOTH IP/OP $520.00 $384.80 $0.00 $416.00 $234.00 $234.00 $0.00 $0.00 $0.00 $108.38 $385.94 $385.94 $0.00 $0.00 $108.37 $0.00 $307.58 $307.58 $0.00 $260.00 $411.84 $416.00 $0.00 $0.00 $81.38 $0.00 $0.00 $82.78 $0.00 $0.00 $0.00 $0.00 $0.00 74133424 SUP HCPCS C1713 74133424 - PLATE BN TLL PRLC CBL SDL BOTH IP/OP $363.38 $268.90 $0.00 $290.70 $163.52 $163.52 $0.00 $0.00 $0.00 $75.74 $269.70 $269.70 $0.00 $0.00 $75.73 $0.00 $214.94 $214.94 $0.00 $181.69 $287.80 $290.70 $0.00 $0.00 $56.87 $0.00 $0.00 $57.85 $0.00 $0.00 $0.00 $0.00 $0.00 74133425 SUP HCPCS C1713 74133425 - SCREW BN PRLC HL FIL BOTH IP/OP $492.00 $364.08 $0.00 $393.60 $221.40 $221.40 $0.00 $0.00 $0.00 $102.55 $365.16 $365.16 $0.00 $0.00 $102.53 $0.00 $291.02 $291.02 $0.00 $246.00 $389.66 $393.60 $0.00 $0.00 $77.00 $0.00 $0.00 $78.33 $0.00 $0.00 $0.00 $0.00 $0.00 74402001 SUP HCPCS C1713 74402001 - WASHER ORTH VLP 2 MM SCR BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $65.70 $65.70 $0.00 $0.00 $0.00 $30.43 $108.36 $108.36 $0.00 $0.00 $30.43 $0.00 $86.36 $86.36 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $22.85 $0.00 $0.00 $23.24 $0.00 $0.00 $0.00 $0.00 $0.00 74402006 SUP HCPCS C1713 74402006 - SCREW BN T6 2MM 6MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402007 SUP HCPCS C1713 74402007 - SCREW BN T6 2MM 7MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402008 SUP HCPCS C1713 74402008 - SCREW BN T6 2MM 8MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402009 SUP HCPCS C1713 74402009 - SCREW BN T6 2MM 9MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402011 SUP HCPCS C1713 74402011 - SCREW BN T6 2MM 11MM VLP ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402012 SUP HCPCS C1713 74402012 - SCREW BN T6 2MM 12MM VLP ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402013 SUP HCPCS C1713 74402013 - SCREW BN T6 2MM 13MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402014 SUP HCPCS C1713 74402014 - SCREW BN T6 2MM 14MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402015 SUP HCPCS C1713 74402015 - SCREW BN T6 2MM 15MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402016 SUP HCPCS C1713 74402016 - SCREW BN T6 2MM 16MM VLP ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402017 SUP HCPCS C1713 74402017 - SCREW BN T6 2MM 17MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402018 SUP HCPCS C1713 74402018 - SCREW BN T6 2MM 18MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402019 SUP HCPCS C1713 74402019 - SCREW BN T6 2MM 19MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402020 SUP HCPCS C1713 74402020 - SCREW BN T6 2MM 20MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402021 SUP HCPCS C1713 74402021 - SCREW BN T6 2MM 21MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402022 SUP HCPCS C1713 74402022 - SCREW BN T6 2MM 22MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402023 SUP HCPCS C1713 74402023 - SCREW BN T6 2MM 23MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402024 SUP HCPCS C1713 74402024 - SCREW BN T6 2MM 24MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402026 SUP HCPCS C1713 74402026 - SCREW BN T6 2MM 26MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402028 SUP HCPCS C1713 74402028 - SCREW BN T6 2MM 28MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402030 SUP HCPCS C1713 74402030 - SCREW BN T6 2MM 30MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402032 SUP HCPCS C1713 74402032 - SCREW BN T6 2MM 32MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402034 SUP HCPCS C1713 74402034 - SCREW BN T6 2MM 34MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402036 SUP HCPCS C1713 74402036 - SCREW BN T6 2MM 36MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402038 SUP HCPCS C1713 74402038 - SCREW BN T6 2MM 38MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402040 SUP HCPCS C1713 74402040 - SCREW BN T6 2MM 40MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402401 SUP HCPCS C1713 74402401 - WASHER ORTH VLP 2.4 MM T7 SCR BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $65.70 $65.70 $0.00 $0.00 $0.00 $30.43 $108.36 $108.36 $0.00 $0.00 $30.43 $0.00 $86.36 $86.36 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $22.85 $0.00 $0.00 $23.24 $0.00 $0.00 $0.00 $0.00 $0.00 74402406 SUP HCPCS C1713 74402406 - SCREW BN T7 2.4MM 6MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402407 SUP HCPCS C1713 74402407 - SCREW BN T7 2.4MM 7MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402408 SUP HCPCS C1713 74402408 - SCREW BN T7 2.4MM 8MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402409 SUP HCPCS C1713 74402409 - SCREW BN T7 2.4MM 9MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402410 SUP HCPCS C1713 74402410 - SCREW BN T7 2.4MM 10MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402411 SUP HCPCS C1713 74402411 - SCREW BN T7 2.4MM 11MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402412 SUP HCPCS C1713 74402412 - SCREW BN T7 2.4MM 12MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402413 SUP HCPCS C1713 74402413 - SCREW BN T7 2.4MM 13MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402414 SUP HCPCS C1713 74402414 - SCREW BN T7 2.4MM 14MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402415 SUP HCPCS C1713 74402415 - SCREW BN T7 2.4MM 15MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402416 SUP HCPCS C1713 74402416 - SCREW BN T7 2.4MM 16MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402417 SUP HCPCS C1713 74402417 - SCREW BN T7 2.4MM 17MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402418 SUP HCPCS C1713 74402418 - SCREW BN T7 2.4MM 18MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402419 SUP HCPCS C1713 74402419 - SCREW BN T7 2.4MM 19MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402420 SUP HCPCS C1713 74402420 - SCREW BN T7 2.4MM 20MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402421 SUP HCPCS C1713 74402421 - SCREW BN T7 2.4MM 21MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402422 SUP HCPCS C1713 74402422 - SCREW BN T7 2.4MM 22MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402423 SUP HCPCS C1713 74402423 - SCREW BN T7 2.4MM 23MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402424 SUP HCPCS C1713 74402424 - SCREW BN T7 2.4MM 24MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402426 SUP HCPCS C1713 74402426 - SCREW BN T7 2.4MM 26MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402428 SUP HCPCS C1713 74402428 - SCREW BN T7 2.4MM 28MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402430 SUP HCPCS C1713 74402430 - SCREW BN T7 2.4MM 30MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402434 SUP HCPCS C1713 74402434 - SCREW BN T7 2.4MM 34MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402438 SUP HCPCS C1713 74402438 - SCREW BN T7 2.4MM 38MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402440 SUP HCPCS C1713 74402440 - SCREW BN T7 2.4MM 40MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402442 SUP HCPCS C1713 74402442 - SCREW BN T7 2.4MM 42MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402444 SUP HCPCS C1713 74402444 - SCREW BN T7 2.4MM 44MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402446 SUP HCPCS C1713 74402446 - SCREW BN T7 2.4MM 46MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402448 SUP HCPCS C1713 74402448 - SCREW BN T7 2.4MM 48MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402450 SUP HCPCS C1713 74402450 - SCREW BN T7 2.4MM 50MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402455 SUP HCPCS C1713 74402455 - SCREW BN T7 2.4MM 55MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402460 SUP HCPCS C1713 74402460 - SCREW BN T7 2.4MM 60MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402465 SUP HCPCS C1713 74402465 - SCREW BN T7 2.4MM 65MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402470 SUP HCPCS C1713 74402470 - SCREW BN T7 2.4MM 70MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402475 SUP HCPCS C1713 74402475 - SCREW BN T7 2.4MM 75MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402480 SUP HCPCS C1713 74402480 - SCREW BN T7 2.4MM 80MM VLP ST TI FT CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74412007 SUP HCPCS C1713 74412007 - SCREW BN T6 2MM 7MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412008 SUP HCPCS C1713 74412008 - SCREW BN T6 2MM 8MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412011 SUP HCPCS C1713 74412011 - SCREW BN T6 2MM 11MM VLP LCK ST TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412012 SUP HCPCS C1713 74412012 - SCREW BN T6 2MM 12MM NS VLP LCK ST TI SM BN LNG BN BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412014 SUP HCPCS C1713 74412014 - SCREW BN T6 2MM 14MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412015 SUP HCPCS C1713 74412015 - SCREW BN T6 2MM 15MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412016 SUP HCPCS C1713 74412016 - SCREW BN T6 2MM 16MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412017 SUP HCPCS C1713 74412017 - SCREW BN T6 2MM 17MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412018 SUP HCPCS C1713 74412018 - SCREW BN T6 2MM 18MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412019 SUP HCPCS C1713 74412019 - SCREW BN T6 2MM 19MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412020 SUP HCPCS C1713 74412020 - SCREW BN T6 2MM 20MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412021 SUP HCPCS C1713 74412021 - SCREW BN T6 2MM 21MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412022 SUP HCPCS C1713 74412022 - SCREW BN T6 2MM 22MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412023 SUP HCPCS C1713 74412023 - SCREW BN T6 2MM 23MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412024 SUP HCPCS C1713 74412024 - SCREW BN T6 2MM 24MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412026 SUP HCPCS C1713 74412026 - SCREW BN T6 2MM 26MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412028 SUP HCPCS C1713 74412028 - SCREW BN T6 2MM 28MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412030 SUP HCPCS C1713 74412030 - SCREW BN T6 2MM 30MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412032 SUP HCPCS C1713 74412032 - SCREW BN T6 2MM 32MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412034 SUP HCPCS C1713 74412034 - SCREW BN T6 2MM 34MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412036 SUP HCPCS C1713 74412036 - SCREW BN T6 2MM 36MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412038 SUP HCPCS C1713 74412038 - SCREW BN T6 2MM 38MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412040 SUP HCPCS C1713 74412040 - SCREW BN T6 2MM 40MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412406 SUP HCPCS C1713 74412406 - SCREW BN T7 2.4MM 6MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412407 SUP HCPCS C1713 74412407 - SCREW BN T7 2.4MM 7MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412408 SUP HCPCS C1713 74412408 - SCREW BN T7 2.4MM 8MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412409 SUP HCPCS C1713 74412409 - SCREW BN T7 2.4MM 9MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412410 SUP HCPCS C1713 74412410 - SCREW BN T7 2.4MM 10MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412411 SUP HCPCS C1713 74412411 - SCREW BN T7 2.4MM 11MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412412 SUP HCPCS C1713 74412412 - SCREW BN T7 2.4MM 12MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412413 SUP HCPCS C1713 74412413 - SCREW BN 2.4MM 13MM VLP LCK ST T7 DRVR TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412414 SUP HCPCS C1713 74412414 - SCREW BN 2.4MM 14MM VLP LCK ST T7 DRVR TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412415 SUP HCPCS C1713 74412415 - SCREW BN T7 2.4MM 15MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412416 SUP HCPCS C1713 74412416 - SCREW BN T7 2.4MM 16MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412417 SUP HCPCS C1713 74412417 - SCREW BN T7 2.4MM 17MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412418 SUP HCPCS C1713 74412418 - SCREW BN 2.4MM 18MM VLP LCK ST T7 DRVR TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412419 SUP HCPCS C1713 74412419 - SCREW BN T7 2.4MM 19MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412420 SUP HCPCS C1713 74412420 - SCREW BN T7 2.4MM 20MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412421 SUP HCPCS C1713 74412421 - SCREW BN T7 2.4MM 21MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412422 SUP HCPCS C1713 74412422 - SCREW BN 2.4MM 22MM VLP LCK ST T7 DRVR TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412423 SUP HCPCS C1713 74412423 - SCREW BN T7 2.4MM 23MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412424 SUP HCPCS C1713 74412424 - SCREW BN T7 2.4MM 24MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412426 SUP HCPCS C1713 74412426 - SCREW BN T7 2.4MM 26MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412428 SUP HCPCS C1713 74412428 - SCREW BN T7 2.4MM 28MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412430 SUP HCPCS C1713 74412430 - SCREW BN T7 2.4MM 30MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412432 SUP HCPCS C1713 74412432 - SCREW BN T7 2.4MM 32MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412434 SUP HCPCS C1713 74412434 - SCREW BN T7 2.4MM 34MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412436 SUP HCPCS C1713 74412436 - SCREW BN T7 2.4MM 36MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412438 SUP HCPCS C1713 74412438 - SCREW BN T7 2.4MM 38MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412440 SUP HCPCS C1713 74412440 - SCREW BN T7 2.4MM 40MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412442 SUP HCPCS C1713 74412442 - SCREW BN T7 2.4MM 42MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412444 SUP HCPCS C1713 74412444 - SCREW BN T7 2.4MM 44MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412446 SUP HCPCS C1713 74412446 - SCREW BN T7 2.4MM 46MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412448 SUP HCPCS C1713 74412448 - SCREW BN T7 2.4MM 48MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412450 SUP HCPCS C1713 74412450 - SCREW BN T7 2.4MM 50MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412455 SUP HCPCS C1713 74412455 - SCREW BN T7 2.4MM 55MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412460 SUP HCPCS C1713 74412460 - SCREW BN T7 2.4MM 60MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412465 SUP HCPCS C1713 74412465 - SCREW BN T7 2.4MM 65MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412470 SUP HCPCS C1713 74412470 - SCREW BN T7 2.4MM 70MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412475 SUP HCPCS C1713 74412475 - SCREW BN T7 2.4MM 75MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412480 SUP HCPCS C1713 74412480 - SCREW BN T7 2.4MM 80MM VLP LCK ST TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74423010 SUP HCPCS C1713 74423010 - SCREW BN T7 3MM 10MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423012 SUP HCPCS C1713 74423012 - SCREW BN T7 3MM 12MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423014 SUP HCPCS C1713 74423014 - SCREW BN T7 3MM 14MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423016 SUP HCPCS C1713 74423016 - SCREW BN T7 3MM 16MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423018 SUP HCPCS C1713 74423018 - SCREW BN T7 3MM 18MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423020 SUP HCPCS C1713 74423020 - SCREW BN T7 3MM 20MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423022 SUP HCPCS C1713 74423022 - SCREW BN T7 3MM 22MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423024 SUP HCPCS C1713 74423024 - SCREW BN T7 3MM 24MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423026 SUP HCPCS C1713 74423026 - SCREW BN T7 3MM 26MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423028 SUP HCPCS C1713 74423028 - SCREW BN T7 3MM 28MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423030 SUP HCPCS C1713 74423030 - SCREW BN T7 3MM 30MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423032 SUP HCPCS C1713 74423032 - SCREW BN T7 3MM 32MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423034 SUP HCPCS C1713 74423034 - SCREW BN T7 3MM 34MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423036 SUP HCPCS C1713 74423036 - SCREW BN T7 3MM 36MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423038 SUP HCPCS C1713 74423038 - SCREW BN T7 3MM 38MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423040 SUP HCPCS C1713 74423040 - SCREW BN T7 3MM 40MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423042 SUP HCPCS C1713 74423042 - SCREW BN T7 3MM 42MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423044 SUP HCPCS C1713 74423044 - SCREW BN T7 3MM 44MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423046 SUP HCPCS C1713 74423046 - SCREW BN T7 3MM 46MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423048 SUP HCPCS C1713 74423048 - SCREW BN T7 3MM 48MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423050 SUP HCPCS C1713 74423050 - SCREW BN T7 3MM 50MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423055 SUP HCPCS C1713 74423055 - SCREW BN T7 3MM 55MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423060 SUP HCPCS C1713 74423060 - SCREW BN T7 3MM 60MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423065 SUP HCPCS C1713 74423065 - SCREW BN T7 3MM 65MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423070 SUP HCPCS C1713 74423070 - SCREW BN T7 3MM 70MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423075 SUP HCPCS C1713 74423075 - SCREW BN T7 3MM 75MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74423080 SUP HCPCS C1713 74423080 - SCREW BN T7 3MM 80MM VLP TI FT OSTEOPENIA BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $79.20 $79.20 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 74442010 SUP HCPCS C1713 74442010 - PLATE BN Y VLP MN-MOD 6 HL 2MM SCR BOTH IP/OP "$1,608.75 " "$1,190.48" $0.00 "$1,287.00" $723.94 $723.94 $0.00 $0.00 $0.00 $335.30 "$1,194.01" "$1,194.01" $0.00 $0.00 $335.26 $0.00 $951.58 $951.58 $0.00 $804.38 "$1,274.13" "$1,287.00" $0.00 $0.00 $251.77 $0.00 $0.00 $256.11 $0.00 $0.00 $0.00 $0.00 $0.00 74442012 SUP HCPCS C1713 74442012 - PLATE BN Y VLP MN-MOD 8 HL 2MM SCR BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 74442014 SUP HCPCS C1713 74442014 - PLATE BN T VLP MN-MOD 2X6 HL 2MM SCR BOTH IP/OP "$1,124.75 " $832.32 $0.00 $899.80 $506.14 $506.14 $0.00 $0.00 $0.00 $234.43 $834.79 $834.79 $0.00 $0.00 $234.40 $0.00 $665.29 $665.29 $0.00 $562.38 $890.80 $899.80 $0.00 $0.00 $176.02 $0.00 $0.00 $179.06 $0.00 $0.00 $0.00 $0.00 $0.00 74442016 SUP HCPCS C1713 74442016 - PLATE BN T 1.2MM VLP MN-MOD 2 HLE/HD 8 HL SHFT TI SM BN 2MM BOTH IP/OP "$1,443.75 " "$1,068.38" $0.00 "$1,155.00" $649.69 $649.69 $0.00 $0.00 $0.00 $300.91 "$1,071.55" "$1,071.55" $0.00 $0.00 $300.88 $0.00 $853.98 $853.98 $0.00 $721.88 "$1,143.45" "$1,155.00" $0.00 $0.00 $225.95 $0.00 $0.00 $229.85 $0.00 $0.00 $0.00 $0.00 $0.00 74442018 SUP HCPCS C1713 74442018 - PLATE BN T VLP MN-MOD 3X6 HL 2MM SCR BOTH IP/OP "$1,608.75 " "$1,190.48" $0.00 "$1,287.00" $723.94 $723.94 $0.00 $0.00 $0.00 $335.30 "$1,194.01" "$1,194.01" $0.00 $0.00 $335.26 $0.00 $951.58 $951.58 $0.00 $804.38 "$1,274.13" "$1,287.00" $0.00 $0.00 $251.77 $0.00 $0.00 $256.11 $0.00 $0.00 $0.00 $0.00 $0.00 74442020 SUP HCPCS C1713 74442020 - PLATE BN T VLP MN-MOD 3X8 HL 2MM SCR BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 74442022 SUP HCPCS C1713 74442022 - PLATE BN STRG VLP MN-MOD 6 HL 2MM SCR BOTH IP/OP $965.25 $714.29 $0.00 $772.20 $434.36 $434.36 $0.00 $0.00 $0.00 $201.18 $716.41 $716.41 $0.00 $0.00 $201.16 $0.00 $570.95 $570.95 $0.00 $482.63 $764.48 $772.20 $0.00 $0.00 $151.06 $0.00 $0.00 $153.67 $0.00 $0.00 $0.00 $0.00 $0.00 74442024 SUP HCPCS C1713 74442024 - PLATE BN STRG VLP MN-MOD 8 HL 2MM SCR BOTH IP/OP "$1,285.63 " $951.37 $0.00 "$1,028.50" $578.53 $578.53 $0.00 $0.00 $0.00 $267.96 $954.19 $954.19 $0.00 $0.00 $267.92 $0.00 $760.45 $760.45 $0.00 $642.81 "$1,018.22" "$1,028.50" $0.00 $0.00 $201.20 $0.00 $0.00 $204.67 $0.00 $0.00 $0.00 $0.00 $0.00 74442028 SUP HCPCS C1713 74442028 - PLATE BN STOUT VLP MN-MOD 6 HL 2MM SCR BOTH IP/OP "$1,124.75 " $832.32 $0.00 $899.80 $506.14 $506.14 $0.00 $0.00 $0.00 $234.43 $834.79 $834.79 $0.00 $0.00 $234.40 $0.00 $665.29 $665.29 $0.00 $562.38 $890.80 $899.80 $0.00 $0.00 $176.02 $0.00 $0.00 $179.06 $0.00 $0.00 $0.00 $0.00 $0.00 74442030 SUP HCPCS C1713 74442030 - PLATE BN STOUT VLP MN-MOD 8 HL 2MM SCR BOTH IP/OP "$1,443.75 " "$1,068.38" $0.00 "$1,155.00" $649.69 $649.69 $0.00 $0.00 $0.00 $300.91 "$1,071.55" "$1,071.55" $0.00 $0.00 $300.88 $0.00 $853.98 $853.98 $0.00 $721.88 "$1,143.45" "$1,155.00" $0.00 $0.00 $225.95 $0.00 $0.00 $229.85 $0.00 $0.00 $0.00 $0.00 $0.00 74442410 SUP HCPCS C1713 74442410 - PLATE BN Y VLP MN-MOD 6 HL 2.4MM SCR BOTH IP/OP "$1,608.75 " "$1,190.48" $0.00 "$1,287.00" $723.94 $723.94 $0.00 $0.00 $0.00 $335.30 "$1,194.01" "$1,194.01" $0.00 $0.00 $335.26 $0.00 $951.58 $951.58 $0.00 $804.38 "$1,274.13" "$1,287.00" $0.00 $0.00 $251.77 $0.00 $0.00 $256.11 $0.00 $0.00 $0.00 $0.00 $0.00 74442412 SUP HCPCS C1713 74442412 - PLATE BN Y VLP MN-MOD 8 HL 2.4MM SCR BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 74442414 SUP HCPCS C1713 74442414 - PLATE BN T VLP MN-MOD 2X6 HL SM BN 2.4MM BOTH IP/OP "$1,124.75 " $832.32 $0.00 $899.80 $506.14 $506.14 $0.00 $0.00 $0.00 $234.43 $834.79 $834.79 $0.00 $0.00 $234.40 $0.00 $665.29 $665.29 $0.00 $562.38 $890.80 $899.80 $0.00 $0.00 $176.02 $0.00 $0.00 $179.06 $0.00 $0.00 $0.00 $0.00 $0.00 74442416 SUP HCPCS C1713 74442416 - PLATE BN T VLP MN-MOD 2X8 HL 2.4MM SCR BOTH IP/OP "$1,443.75 " "$1,068.38" $0.00 "$1,155.00" $649.69 $649.69 $0.00 $0.00 $0.00 $300.91 "$1,071.55" "$1,071.55" $0.00 $0.00 $300.88 $0.00 $853.98 $853.98 $0.00 $721.88 "$1,143.45" "$1,155.00" $0.00 $0.00 $225.95 $0.00 $0.00 $229.85 $0.00 $0.00 $0.00 $0.00 $0.00 74442418 SUP HCPCS C1713 74442418 - PLATE BN T VLP MN-MOD 3X6 HL 2.4MM SCR BOTH IP/OP "$1,608.75 " "$1,190.48" $0.00 "$1,287.00" $723.94 $723.94 $0.00 $0.00 $0.00 $335.30 "$1,194.01" "$1,194.01" $0.00 $0.00 $335.26 $0.00 $951.58 $951.58 $0.00 $804.38 "$1,274.13" "$1,287.00" $0.00 $0.00 $251.77 $0.00 $0.00 $256.11 $0.00 $0.00 $0.00 $0.00 $0.00 74442420 SUP HCPCS C1713 74442420 - PLATE BN T VLP MN-MOD 3X8 HL 2.4MM SCR BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 74442422 SUP HCPCS C1713 74442422 - PLATE BN STRG VLP MN-MOD 6 HL 2.4MM SCR BOTH IP/OP $965.25 $714.29 $0.00 $772.20 $434.36 $434.36 $0.00 $0.00 $0.00 $201.18 $716.41 $716.41 $0.00 $0.00 $201.16 $0.00 $570.95 $570.95 $0.00 $482.63 $764.48 $772.20 $0.00 $0.00 $151.06 $0.00 $0.00 $153.67 $0.00 $0.00 $0.00 $0.00 $0.00 74442424 SUP HCPCS C1713 74442424 - PLATE BN STRG VLP MN-MOD 8 HL 2.4MM SCR BOTH IP/OP "$1,285.63 " $951.37 $0.00 "$1,028.50" $578.53 $578.53 $0.00 $0.00 $0.00 $267.96 $954.19 $954.19 $0.00 $0.00 $267.92 $0.00 $760.45 $760.45 $0.00 $642.81 "$1,018.22" "$1,028.50" $0.00 $0.00 $201.20 $0.00 $0.00 $204.67 $0.00 $0.00 $0.00 $0.00 $0.00 74442426 SUP HCPCS C1713 74442426 - PLATE BN STRG VLP MN-MOD 12 HL 2.4MM SCR BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 74442428 SUP HCPCS C1713 74442428 - PLATE BN VLP MN-MOD 12X3 HL MESH 2.4 MM SCR BOTH IP/OP "$2,413.13 " "$1,785.72" $0.00 "$1,930.50" "$1,085.91" "$1,085.91" $0.00 $0.00 $0.00 $502.96 "$1,791.02" "$1,791.02" $0.00 $0.00 $502.90 $0.00 "$1,427.36" "$1,427.36" $0.00 "$1,206.56" "$1,911.20" "$1,930.50" $0.00 $0.00 $377.65 $0.00 $0.00 $384.17 $0.00 $0.00 $0.00 $0.00 $0.00 74442430 SUP HCPCS C1713 74442430 - PLATE BN STOUT VLP MN-MOD 6 HL 2.4MM SCR BOTH IP/OP "$1,124.75 " $832.32 $0.00 $899.80 $506.14 $506.14 $0.00 $0.00 $0.00 $234.43 $834.79 $834.79 $0.00 $0.00 $234.40 $0.00 $665.29 $665.29 $0.00 $562.38 $890.80 $899.80 $0.00 $0.00 $176.02 $0.00 $0.00 $179.06 $0.00 $0.00 $0.00 $0.00 $0.00 74442432 SUP HCPCS C1713 74442432 - PLATE BN STOUT VLP MN-MOD 8 HL 2.4MM SCR BOTH IP/OP "$1,443.75 " "$1,068.38" $0.00 "$1,155.00" $649.69 $649.69 $0.00 $0.00 $0.00 $300.91 "$1,071.55" "$1,071.55" $0.00 $0.00 $300.88 $0.00 $853.98 $853.98 $0.00 $721.88 "$1,143.45" "$1,155.00" $0.00 $0.00 $225.95 $0.00 $0.00 $229.85 $0.00 $0.00 $0.00 $0.00 $0.00 74442434 SUP HCPCS C1713 74442434 - PLATE BN STOUT VLP MN-MOD 12 HL 2.4MM SCR BOTH IP/OP "$1,766.88 " "$1,307.49" $0.00 "$1,413.50" $795.09 $795.09 $0.00 $0.00 $0.00 $368.26 "$1,311.37" "$1,311.37" $0.00 $0.00 $368.22 $0.00 "$1,045.11" "$1,045.11" $0.00 $883.44 "$1,399.37" "$1,413.50" $0.00 $0.00 $276.52 $0.00 $0.00 $281.29 $0.00 $0.00 $0.00 $0.00 $0.00 74444020 SUP HCPCS C1713 74444020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444025 SUP HCPCS C1713 74444025 - SCREW BN 4MM 25MM LGC CD HZN MA TI SPNE 4.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444030 SUP HCPCS C1713 74444030 - SCREW BN 4MM 30MM LGC CD HZN MA TI SPNE 4.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444035 SUP HCPCS C1713 74444035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444040 SUP HCPCS C1713 74444040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444520 SUP HCPCS C1713 74444520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444525 SUP HCPCS C1713 74444525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444530 SUP HCPCS C1713 74444530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444535 SUP HCPCS C1713 74444535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74444540 SUP HCPCS C1713 74444540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445025 SUP HCPCS C1713 74445025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445030 SUP HCPCS C1713 74445030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445035 SUP HCPCS C1713 74445035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445040 SUP HCPCS C1713 74445040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445045 SUP HCPCS C1713 74445045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445050 SUP HCPCS C1713 74445050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445525 SUP HCPCS C1713 74445525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445530 SUP HCPCS C1713 74445530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445535 SUP HCPCS C1713 74445535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445540 SUP HCPCS C1713 74445540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445545 SUP HCPCS C1713 74445545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74445550 SUP HCPCS C1713 74445550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446025 SUP HCPCS C1713 74446025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446030 SUP HCPCS C1713 74446030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446035 SUP HCPCS C1713 74446035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446040 SUP HCPCS C1713 74446040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446045 SUP HCPCS C1713 74446045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446050 SUP HCPCS C1713 74446050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446525 SUP HCPCS C1713 74446525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446530 SUP HCPCS C1713 74446530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446535 SUP HCPCS C1713 74446535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446540 SUP HCPCS C1713 74446540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446545 SUP HCPCS C1713 74446545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446550 SUP HCPCS C1713 74446550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74446555 SUP HCPCS C1713 74446555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74447525 SUP HCPCS C1713 74447525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74447530 SUP HCPCS C1713 74447530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74447535 SUP HCPCS C1713 74447535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74447540 SUP HCPCS C1713 74447540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74447545 SUP HCPCS C1713 74447545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74447550 SUP HCPCS C1713 74447550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74447555 SUP HCPCS C1713 74447555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74462002 SUP Custom 27203010 74462002 - BIT DRL SHRT 1.5MM VLP MN-MOD QC BOTH IP/OP $242.00 $179.08 $0.00 $193.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.61 $179.61 $0.00 $0.00 $50.43 $0.00 $0.00 $0.00 $0.00 $121.00 $191.66 $193.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74462004 SUP Custom 27203010 74462004 - BIT DRL LNG 1.5MM VLP MN-MOD QC BOTH IP/OP $281.88 $208.59 $0.00 $225.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $209.21 $209.21 $0.00 $0.00 $58.74 $0.00 $0.00 $0.00 $0.00 $140.94 $223.25 $225.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74462006 SUP Custom 27203010 74462006 - BIT DRL 2MM VLP MN-MOD QC OVR BOTH IP/OP $242.00 $179.08 $0.00 $193.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.61 $179.61 $0.00 $0.00 $50.43 $0.00 $0.00 $0.00 $0.00 $121.00 $191.66 $193.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74462410 SUP Custom 27203010 74462410 - BIT DRL 2.4MM VLP MN-MOD AO QC OVR BOTH IP/OP $242.00 $179.08 $0.00 $193.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.61 $179.61 $0.00 $0.00 $50.43 $0.00 $0.00 $0.00 $0.00 $121.00 $191.66 $193.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74640132 SUP HCPCS C1713 74640132 - SCREW BN 9MM 32MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640134 SUP HCPCS C1713 74640134 - SCREW BN 9MM 34MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640136 SUP HCPCS C1713 74640136 - SCREW BN 9MM 36MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640138 SUP HCPCS C1713 74640138 - SCREW BN 9MM 38MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640234 SUP HCPCS C1713 74640234 - SCREW BN 10MM 34MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640236 SUP HCPCS C1713 74640236 - SCREW BN 10MM 36MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640238 SUP HCPCS C1713 74640238 - SCREW BN 10MM 38MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640240 SUP HCPCS C1713 74640240 - SCREW BN 10MM 40MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640336 SUP HCPCS C1713 74640336 - SCREW BN 11.5MM 36MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640338 SUP HCPCS C1713 74640338 - SCREW BN 11.5MM 38MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640340 SUP HCPCS C1713 74640340 - SCREW BN 11.5MM 40MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640342 SUP HCPCS C1713 74640342 - SCREW BN 11.5MM 42MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640440 SUP HCPCS C1713 74640440 - SCREW BN 13MM 40MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74640442 SUP HCPCS C1713 74640442 - SCREW BN 13MM 42MM TN SURESHOT RT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74644020 SUP HCPCS C1713 74644020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644025 SUP HCPCS C1713 74644025 - SCREW BN 4MM 25MM STRL LGC CD HZN MA SS SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644030 SUP HCPCS C1713 74644030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644035 SUP HCPCS C1713 74644035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644040 SUP HCPCS C1713 74644040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644520 SUP HCPCS C1713 74644520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644525 SUP HCPCS C1713 74644525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644530 SUP HCPCS C1713 74644530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644535 SUP HCPCS C1713 74644535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74644540 SUP HCPCS C1713 74644540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645025 SUP HCPCS C1713 74645025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645030 SUP HCPCS C1713 74645030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645035 SUP HCPCS C1713 74645035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645040 SUP HCPCS C1713 74645040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645045 SUP HCPCS C1713 74645045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645050 SUP HCPCS C1713 74645050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645525 SUP HCPCS C1713 74645525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645530 SUP HCPCS C1713 74645530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645535 SUP HCPCS C1713 74645535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645540 SUP HCPCS C1713 74645540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645545 SUP HCPCS C1713 74645545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74645550 SUP HCPCS C1713 74645550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646025 SUP HCPCS C1713 74646025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646030 SUP HCPCS C1713 74646030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646035 SUP HCPCS C1713 74646035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646040 SUP HCPCS C1713 74646040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646045 SUP HCPCS C1713 74646045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646050 SUP HCPCS C1713 74646050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646525 SUP HCPCS C1713 74646525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646530 SUP HCPCS C1713 74646530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646535 SUP HCPCS C1713 74646535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646540 SUP HCPCS C1713 74646540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646545 SUP HCPCS C1713 74646545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646550 SUP HCPCS C1713 74646550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74646555 SUP HCPCS C1713 74646555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74647525 SUP HCPCS C1713 74647525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74647530 SUP HCPCS C1713 74647530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74647535 SUP HCPCS C1713 74647535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74647540 SUP HCPCS C1713 74647540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74647545 SUP HCPCS C1713 74647545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74647550 SUP HCPCS C1713 74647550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74647555 SUP HCPCS C1713 74647555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 74649132 SUP HCPCS C1713 74649132 - SCREW BN 9MM 32MM SURESHOT TN LT EVAL BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649134 SUP HCPCS C1713 74649134 - SCREW BN 9MM 34MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649136 SUP HCPCS C1713 74649136 - SCREW BN 9MM 36MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649138 SUP HCPCS C1713 74649138 - SCREW BN 9MM 38MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649234 SUP HCPCS C1713 74649234 - SCREW BN 10MM 34MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649236 SUP HCPCS C1713 74649236 - SCREW BN 10MM 36MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649238 SUP HCPCS C1713 74649238 - SCREW BN 10MM 38MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649240 SUP HCPCS C1713 74649240 - SCREW BN 10MM 40MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649336 SUP HCPCS C1713 74649336 - SCREW BN 11.5MM 36MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649338 SUP HCPCS C1713 74649338 - SCREW BN 11.5MM 38MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649340 SUP HCPCS C1713 74649340 - SCREW BN 11.5MM 40MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649342 SUP HCPCS C1713 74649342 - SCREW BN 11.5MM 42MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649440 SUP HCPCS C1713 74649440 - SCREW BN 13MM 40MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74649442 SUP HCPCS C1713 74649442 - SCREW BN 13MM 42MM TN SURESHOT LT TROCH BOTH IP/OP "$5,270.00 " "$3,899.80" $0.00 "$4,216.00" "$2,371.50" "$2,371.50" $0.00 $0.00 $0.00 "$1,098.40" "$3,911.39" "$3,911.39" $0.00 $0.00 "$1,098.27" $0.00 "$2,598.11" "$2,598.11" $0.00 "$2,635.00" "$4,173.84" "$4,216.00" $0.00 $0.00 $824.76 $0.00 $0.00 $838.98 $0.00 $0.00 $0.00 $0.00 $0.00 74692424 SUP HCPCS C1713 74692424 - SCREW BN 2.4MM 24MM D-RAD SMRT PK LCK ST T7 DRVR TI DIST BOTH IP/OP $182.70 $135.20 $0.00 $146.16 $82.22 $82.22 $0.00 $0.00 $0.00 $38.08 $135.60 $135.60 $0.00 $0.00 $38.07 $0.00 $108.07 $108.07 $0.00 $91.35 $144.70 $146.16 $0.00 $0.00 $28.59 $0.00 $0.00 $29.09 $0.00 $0.00 $0.00 $0.00 $0.00 74800060 SUP HCPCS C1713 74800060 - SCREW BN CONE 6.5MM 60MM CNN SS PROX FEM BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74800065 SUP HCPCS C1713 74800065 - SCREW BN CONE 6.5MM 65MM CNN SS PROX FEM BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74800070 SUP HCPCS C1713 74800070 - SCREW BN CONE 6.5MM 70MM CNN SS PROX FEM BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74800075 SUP HCPCS C1713 74800075 - SCREW BN CONE 6.5MM 75MM CNN SS PROX FEM BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74800080 SUP HCPCS C1713 74800080 - SCREW BN CONE 6.5MM 80MM CNN SS PROX FEM BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74800085 SUP HCPCS C1713 74800085 - SCREW BN CONE 6.5MM 85MM CNN SS PROX FEM BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74800095 SUP HCPCS C1713 74800095 - SCREW BN CONE 6.5MM 95MM CNN SS PROX FEM BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74800100 SUP HCPCS C1713 74800100 - SCREW BN CONE 6.5MM 100MM CNN SS PROX FEM BOTH IP/OP $559.13 $413.76 $0.00 $447.30 $251.61 $251.61 $0.00 $0.00 $0.00 $116.54 $414.98 $414.98 $0.00 $0.00 $116.52 $0.00 $330.72 $330.72 $0.00 $279.56 $442.83 $447.30 $0.00 $0.00 $87.50 $0.00 $0.00 $89.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800105 SUP HCPCS C1713 74800105 - SCREW BN CONE 6.5MM 105MM CNN SS PROX FEM BOTH IP/OP $559.13 $413.76 $0.00 $447.30 $251.61 $251.61 $0.00 $0.00 $0.00 $116.54 $414.98 $414.98 $0.00 $0.00 $116.52 $0.00 $330.72 $330.72 $0.00 $279.56 $442.83 $447.30 $0.00 $0.00 $87.50 $0.00 $0.00 $89.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800110 SUP HCPCS C1713 74800110 - SCREW BN CONE 6.5MM 110MM CNN SS PROX FEM BOTH IP/OP $559.13 $413.76 $0.00 $447.30 $251.61 $251.61 $0.00 $0.00 $0.00 $116.54 $414.98 $414.98 $0.00 $0.00 $116.52 $0.00 $330.72 $330.72 $0.00 $279.56 $442.83 $447.30 $0.00 $0.00 $87.50 $0.00 $0.00 $89.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800115 SUP HCPCS C1713 74800115 - SCREW BN CONE 6.5MM 115MM CNN SS PROX FEM BOTH IP/OP $559.13 $413.76 $0.00 $447.30 $251.61 $251.61 $0.00 $0.00 $0.00 $116.54 $414.98 $414.98 $0.00 $0.00 $116.52 $0.00 $330.72 $330.72 $0.00 $279.56 $442.83 $447.30 $0.00 $0.00 $87.50 $0.00 $0.00 $89.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800120 SUP HCPCS C1713 74800120 - SCREW BN CONE 6.5MM 120MM CNN SS PROX FEM BOTH IP/OP $559.13 $413.76 $0.00 $447.30 $251.61 $251.61 $0.00 $0.00 $0.00 $116.54 $414.98 $414.98 $0.00 $0.00 $116.52 $0.00 $330.72 $330.72 $0.00 $279.56 $442.83 $447.30 $0.00 $0.00 $87.50 $0.00 $0.00 $89.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800125 SUP HCPCS C1713 74800125 - SCREW BN CONE 6.5MM 125MM CNN SS PROX FEM BOTH IP/OP $559.13 $413.76 $0.00 $447.30 $251.61 $251.61 $0.00 $0.00 $0.00 $116.54 $414.98 $414.98 $0.00 $0.00 $116.52 $0.00 $330.72 $330.72 $0.00 $279.56 $442.83 $447.30 $0.00 $0.00 $87.50 $0.00 $0.00 $89.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800130 SUP HCPCS C1713 74800130 - SCREW BN CONE 6.5MM 130MM CNN SS PROX FEM BOTH IP/OP $559.13 $413.76 $0.00 $447.30 $251.61 $251.61 $0.00 $0.00 $0.00 $116.54 $414.98 $414.98 $0.00 $0.00 $116.52 $0.00 $330.72 $330.72 $0.00 $279.56 $442.83 $447.30 $0.00 $0.00 $87.50 $0.00 $0.00 $89.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800260 SUP HCPCS C1713 74800260 - SCREW BN 6.5MM 60MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800265 SUP HCPCS C1713 74800265 - SCREW BN 6.5MM 65MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800270 SUP HCPCS C1713 74800270 - SCREW BN 6.5MM 70MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800275 SUP HCPCS C1713 74800275 - SCREW BN 6.5MM 75MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800280 SUP HCPCS C1713 74800280 - SCREW BN 6.5MM 80MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800285 SUP HCPCS C1713 74800285 - SCREW BN 6.5MM 85MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800290 SUP HCPCS C1713 74800290 - SCREW BN 6.5MM 90MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800295 SUP HCPCS C1713 74800295 - SCREW BN 6.5MM 95MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800300 SUP HCPCS C1713 74800300 - SCREW BN 6.5MM 100MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800305 SUP HCPCS C1713 74800305 - SCREW BN 6.5MM 105MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800310 SUP HCPCS C1713 74800310 - SCREW BN 6.5MM 110MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800315 SUP HCPCS C1713 74800315 - SCREW BN 6.5MM 115MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800320 SUP HCPCS C1713 74800320 - SCREW BN 6.5MM 120MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800325 SUP HCPCS C1713 74800325 - SCREW BN 6.5MM 125MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800330 SUP HCPCS C1713 74800330 - SCREW BN 6.5MM 130MM CNN LCK SS PROX FEM BOTH IP/OP $645.75 $477.86 $0.00 $516.60 $290.59 $290.59 $0.00 $0.00 $0.00 $134.59 $479.28 $479.28 $0.00 $0.00 $134.57 $0.00 $381.96 $381.96 $0.00 $322.88 $511.43 $516.60 $0.00 $0.00 $101.06 $0.00 $0.00 $102.80 $0.00 $0.00 $0.00 $0.00 $0.00 74800402 SUP HCPCS C1713 74800402 - PLATE BN 44MM 2 HL LCK SS LT PROX FEM 4.5MM SCR BOTH IP/OP "$3,380.63 " "$2,501.67" $0.00 "$2,704.50" "$1,521.28" "$1,521.28" $0.00 $0.00 $0.00 $704.61 "$2,509.10" "$2,509.10" $0.00 $0.00 $704.52 $0.00 "$1,666.65" "$1,666.65" $0.00 "$1,690.31" "$2,677.46" "$2,704.50" $0.00 $0.00 $529.07 $0.00 $0.00 $538.20 $0.00 $0.00 $0.00 $0.00 $0.00 74800404 SUP HCPCS C1713 74800404 - PLATE BN 144MM 4 HL LCK SS LT PROX FEM 4.5MM SCR BOTH IP/OP "$3,431.25 " "$2,539.13" $0.00 "$2,745.00" "$1,544.06" "$1,544.06" $0.00 $0.00 $0.00 $715.16 "$2,546.67" "$2,546.67" $0.00 $0.00 $715.07 $0.00 "$1,691.61" "$1,691.61" $0.00 "$1,715.63" "$2,717.55" "$2,745.00" $0.00 $0.00 $536.99 $0.00 $0.00 $546.26 $0.00 $0.00 $0.00 $0.00 $0.00 74800406 SUP HCPCS C1713 74800406 - PLATE BN 180MM 6 HL LCK SS LT PROX FEM 4.5MM SCR BOTH IP/OP "$3,498.75 " "$2,589.08" $0.00 "$2,799.00" "$1,574.44" "$1,574.44" $0.00 $0.00 $0.00 $729.23 "$2,596.77" "$2,596.77" $0.00 $0.00 $729.14 $0.00 "$1,724.88" "$1,724.88" $0.00 "$1,749.38" "$2,771.01" "$2,799.00" $0.00 $0.00 $547.55 $0.00 $0.00 $557.00 $0.00 $0.00 $0.00 $0.00 $0.00 74800409 SUP HCPCS C1713 74800409 - PLATE BN 234MM 9 HL LCK SS LT PROX FEM 4.5MM SCR BOTH IP/OP "$3,633.75 " "$2,688.98" $0.00 "$2,907.00" "$1,635.19" "$1,635.19" $0.00 $0.00 $0.00 $757.36 "$2,696.97" "$2,696.97" $0.00 $0.00 $757.27 $0.00 "$1,791.44" "$1,791.44" $0.00 "$1,816.88" "$2,877.93" "$2,907.00" $0.00 $0.00 $568.68 $0.00 $0.00 $578.49 $0.00 $0.00 $0.00 $0.00 $0.00 74800412 SUP HCPCS C1713 74800412 - PLATE BN 288MM 12 HL LCK SS LT PROX FEM 4.5MM SCR BOTH IP/OP "$4,246.88 " "$3,142.69" $0.00 "$3,397.50" "$1,911.09" "$1,911.09" $0.00 $0.00 $0.00 $885.15 "$3,152.03" "$3,152.03" $0.00 $0.00 $885.05 $0.00 "$2,093.71" "$2,093.71" $0.00 "$2,123.44" "$3,363.53" "$3,397.50" $0.00 $0.00 $664.64 $0.00 $0.00 $676.10 $0.00 $0.00 $0.00 $0.00 $0.00 74800415 SUP HCPCS C1713 74800415 - PLATE BN 15MM LCK SS LT PROX FEM BOTH IP/OP "$4,584.38 " "$3,392.44" $0.00 "$3,667.50" "$2,062.97" "$2,062.97" $0.00 $0.00 $0.00 $955.50 "$3,402.52" "$3,402.52" $0.00 $0.00 $955.38 $0.00 "$2,260.10" "$2,260.10" $0.00 "$2,292.19" "$3,630.83" "$3,667.50" $0.00 $0.00 $717.45 $0.00 $0.00 $729.83 $0.00 $0.00 $0.00 $0.00 $0.00 74800418 SUP HCPCS C1713 74800418 - PLATE BN 396MM 18 HL LCK SS LT PROX FEM 4.5MM SCR BOTH IP/OP "$4,921.88 " "$3,642.19" $0.00 "$3,937.50" "$2,214.84" "$2,214.84" $0.00 $0.00 $0.00 "$1,025.84" "$3,653.02" "$3,653.02" $0.00 $0.00 "$1,025.72" $0.00 "$2,426.48" "$2,426.48" $0.00 "$2,460.94" "$3,898.13" "$3,937.50" $0.00 $0.00 $770.27 $0.00 $0.00 $783.56 $0.00 $0.00 $0.00 $0.00 $0.00 74800502 SUP HCPCS C1713 74800502 - PLATE BN 99MM 2 HL LCK SS RT PROX FEM 4.5MM SCR BOTH IP/OP "$3,380.63 " "$2,501.67" $0.00 "$2,704.50" "$1,521.28" "$1,521.28" $0.00 $0.00 $0.00 $704.61 "$2,509.10" "$2,509.10" $0.00 $0.00 $704.52 $0.00 "$1,666.65" "$1,666.65" $0.00 "$1,690.31" "$2,677.46" "$2,704.50" $0.00 $0.00 $529.07 $0.00 $0.00 $538.20 $0.00 $0.00 $0.00 $0.00 $0.00 74800504 SUP HCPCS C1713 74800504 - PLATE BN 144MM 4 HL LCK SS RT PROX FEM 4.5MM SCR BOTH IP/OP "$3,431.25 " "$2,539.13" $0.00 "$2,745.00" "$1,544.06" "$1,544.06" $0.00 $0.00 $0.00 $715.16 "$2,546.67" "$2,546.67" $0.00 $0.00 $715.07 $0.00 "$1,691.61" "$1,691.61" $0.00 "$1,715.63" "$2,717.55" "$2,745.00" $0.00 $0.00 $536.99 $0.00 $0.00 $546.26 $0.00 $0.00 $0.00 $0.00 $0.00 74800506 SUP HCPCS C1713 74800506 - PLATE BN 180MM 6 HL LCK SS RT PROX FEM 4.5MM SCR BOTH IP/OP "$3,498.75 " "$2,589.08" $0.00 "$2,799.00" "$1,574.44" "$1,574.44" $0.00 $0.00 $0.00 $729.23 "$2,596.77" "$2,596.77" $0.00 $0.00 $729.14 $0.00 "$1,724.88" "$1,724.88" $0.00 "$1,749.38" "$2,771.01" "$2,799.00" $0.00 $0.00 $547.55 $0.00 $0.00 $557.00 $0.00 $0.00 $0.00 $0.00 $0.00 74800509 SUP HCPCS C1713 74800509 - PLATE BN 234MM 9 HL LCK SS RT PROX FEM 4.5MM SCR BOTH IP/OP "$3,633.75 " "$2,688.98" $0.00 "$2,907.00" "$1,635.19" "$1,635.19" $0.00 $0.00 $0.00 $757.36 "$2,696.97" "$2,696.97" $0.00 $0.00 $757.27 $0.00 "$1,791.44" "$1,791.44" $0.00 "$1,816.88" "$2,877.93" "$2,907.00" $0.00 $0.00 $568.68 $0.00 $0.00 $578.49 $0.00 $0.00 $0.00 $0.00 $0.00 74800512 SUP HCPCS C1713 74800512 - PLATE BN 288MM 12 HL LCK SS RT PROX FEM 4.5MM SCR BOTH IP/OP "$4,246.88 " "$3,142.69" $0.00 "$3,397.50" "$1,911.09" "$1,911.09" $0.00 $0.00 $0.00 $885.15 "$3,152.03" "$3,152.03" $0.00 $0.00 $885.05 $0.00 "$2,093.71" "$2,093.71" $0.00 "$2,123.44" "$3,363.53" "$3,397.50" $0.00 $0.00 $664.64 $0.00 $0.00 $676.10 $0.00 $0.00 $0.00 $0.00 $0.00 74800515 SUP HCPCS C1713 74800515 - PLATE BN 342MM 15 HL LCK SS RT PROX FEM 4.5MM SCR BOTH IP/OP "$4,550.63 " "$3,367.47" $0.00 "$3,640.50" "$2,047.78" "$2,047.78" $0.00 $0.00 $0.00 $948.46 "$3,377.47" "$3,377.47" $0.00 $0.00 $948.35 $0.00 "$2,243.46" "$2,243.46" $0.00 "$2,275.31" "$3,604.10" "$3,640.50" $0.00 $0.00 $712.17 $0.00 $0.00 $724.46 $0.00 $0.00 $0.00 $0.00 $0.00 74800518 SUP HCPCS C1713 74800518 - PLATE BN 396MM PRLC 18 HL LCK SS FEM RT PROX 4.5MM SCR BOTH IP/OP "$4,882.50 " "$3,613.05" $0.00 "$3,906.00" "$2,197.13" "$2,197.13" $0.00 $0.00 $0.00 "$1,017.64" "$3,623.79" "$3,623.79" $0.00 $0.00 "$1,017.51" $0.00 "$2,407.07" "$2,407.07" $0.00 "$2,441.25" "$3,866.94" "$3,906.00" $0.00 $0.00 $764.11 $0.00 $0.00 $777.29 $0.00 $0.00 $0.00 $0.00 $0.00 74800601 SUP HCPCS C1713 74800601 - PLATE BN SHRT PRLC CBL SDL SS BOTH IP/OP $408.38 $302.20 $0.00 $326.70 $183.77 $183.77 $0.00 $0.00 $0.00 $85.12 $303.10 $303.10 $0.00 $0.00 $85.11 $0.00 $241.55 $241.55 $0.00 $204.19 $323.44 $326.70 $0.00 $0.00 $63.91 $0.00 $0.00 $65.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800602 SUP HCPCS C1713 74800602 - PLATE BN TLL PRLC CBL SDL SS BOTH IP/OP $408.38 $302.20 $0.00 $326.70 $183.77 $183.77 $0.00 $0.00 $0.00 $85.12 $303.10 $303.10 $0.00 $0.00 $85.11 $0.00 $241.55 $241.55 $0.00 $204.19 $323.44 $326.70 $0.00 $0.00 $63.91 $0.00 $0.00 $65.01 $0.00 $0.00 $0.00 $0.00 $0.00 74800603 SUP HCPCS C1713 74800603 - SCREW BN 4.5MM PRLC HL FIL SS FEM PROX BOTH IP/OP $319.50 $236.43 $0.00 $255.60 $143.78 $143.78 $0.00 $0.00 $0.00 $66.59 $237.13 $237.13 $0.00 $0.00 $66.58 $0.00 $188.98 $188.98 $0.00 $159.75 $253.04 $255.60 $0.00 $0.00 $50.00 $0.00 $0.00 $50.86 $0.00 $0.00 $0.00 $0.00 $0.00 74800607 SUP HCPCS C1713 74800607 - PLATE BN PRLC LCK INS HEX SS HUM 4.5 MM SCR BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 74820060 SUP HCPCS C1713 74820060 - SCREW BN CONE 6.5MM 60MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820065 SUP HCPCS C1713 74820065 - SCREW BN CONE 6.5MM 65MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820070 SUP HCPCS C1713 74820070 - SCREW BN CONE 6.5MM 70MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820075 SUP HCPCS C1713 74820075 - SCREW BN CONE 6.5MM 75MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820080 SUP HCPCS C1713 74820080 - SCREW BN CONE 6.5MM 80MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820085 SUP HCPCS C1713 74820085 - SCREW BN CONE 6.5MM 85MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820090 SUP HCPCS C1713 74820090 - SCREW BN CONE 6.5MM 90MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820095 SUP HCPCS C1713 74820095 - SCREW BN CONE 6.5MM 95MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820100 SUP HCPCS C1713 74820100 - SCREW BN CONE 6.5MM 100MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820105 SUP HCPCS C1713 74820105 - SCREW BN CONE 6.5MM 105MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820110 SUP HCPCS C1713 74820110 - SCREW BN CONE 6.5MM 110MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820115 SUP HCPCS C1713 74820115 - SCREW BN CONE 6.5MM 115MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820120 SUP HCPCS C1713 74820120 - SCREW BN CONE 6.5MM 120MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820125 SUP HCPCS C1713 74820125 - SCREW BN CONE 6.5MM 125MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820130 SUP HCPCS C1713 74820130 - SCREW BN CONE 6.5MM 130MM PRLC CNN SS FEM PROX BOTH IP/OP $555.75 $411.26 $0.00 $444.60 $250.09 $250.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $277.88 $440.15 $444.60 $0.00 $0.00 $86.97 $0.00 $0.00 $88.48 $0.00 $0.00 $0.00 $0.00 $0.00 74820260 SUP HCPCS C1713 74820260 - SCREW BN FT 6.5MM 60MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820265 SUP HCPCS C1713 74820265 - SCREW BN FT 6.5MM 65MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820270 SUP HCPCS C1713 74820270 - SCREW BN FT 6.5MM 70MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820275 SUP HCPCS C1713 74820275 - SCREW BN FT 6.5MM 75MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820280 SUP HCPCS C1713 74820280 - SCREW BN FT 6.5MM 80MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820285 SUP HCPCS C1713 74820285 - SCREW BN FT 6.5MM 85MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820290 SUP HCPCS C1713 74820290 - SCREW BN FT 6.5MM 90MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820295 SUP HCPCS C1713 74820295 - SCREW BN FT 6.5MM 95MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820300 SUP HCPCS C1713 74820300 - SCREW BN FT 6.5MM 100MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820305 SUP HCPCS C1713 74820305 - SCREW BN FT 6.5MM 105MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820310 SUP HCPCS C1713 74820310 - SCREW BN FT 6.5MM 110MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820315 SUP HCPCS C1713 74820315 - SCREW BN FT 6.5MM 115MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820320 SUP HCPCS C1713 74820320 - SCREW BN FT 6.5MM 120MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820325 SUP HCPCS C1713 74820325 - SCREW BN FT 6.5MM 125MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820330 SUP HCPCS C1713 74820330 - SCREW BN FT 6.5MM 130MM PRLC LCK CNN SS FEM PROX BOTH IP/OP $637.88 $472.03 $0.00 $510.30 $287.04 $287.04 $0.00 $0.00 $0.00 $132.95 $473.43 $473.43 $0.00 $0.00 $132.93 $0.00 $377.30 $377.30 $0.00 $318.94 $505.20 $510.30 $0.00 $0.00 $99.83 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 74820402 SUP HCPCS C1713 74820402 - PLATE BN 99MMX2MM LCK FEM PROX 4.5MM SCR BOTH IP/OP "$3,493.13 " "$2,584.92" $0.00 "$2,794.50" "$1,571.91" "$1,571.91" $0.00 $0.00 $0.00 $728.05 "$2,592.60" "$2,592.60" $0.00 $0.00 $727.97 $0.00 "$1,722.11" "$1,722.11" $0.00 "$1,746.56" "$2,766.56" "$2,794.50" $0.00 $0.00 $546.67 $0.00 $0.00 $556.11 $0.00 $0.00 $0.00 $0.00 $0.00 74820404 SUP HCPCS C1713 74820404 - PLATE BN 144MM 4 HL LCK LT PROX FEM 4.5MM SCR BOTH IP/OP "$3,549.38 " "$2,626.54" $0.00 "$2,839.50" "$1,597.22" "$1,597.22" $0.00 $0.00 $0.00 $739.78 "$2,634.35" "$2,634.35" $0.00 $0.00 $739.69 $0.00 "$1,749.84" "$1,749.84" $0.00 "$1,774.69" "$2,811.11" "$2,839.50" $0.00 $0.00 $555.48 $0.00 $0.00 $565.06 $0.00 $0.00 $0.00 $0.00 $0.00 74820406 SUP HCPCS C1713 74820406 - PLATE BN 180MMX6MM LCK FEM PROX 4.5MM SCR BOTH IP/OP "$3,611.25 " "$2,672.33" $0.00 "$2,889.00" "$1,625.06" "$1,625.06" $0.00 $0.00 $0.00 $752.67 "$2,680.27" "$2,680.27" $0.00 $0.00 $752.58 $0.00 "$1,780.35" "$1,780.35" $0.00 "$1,805.63" "$2,860.11" "$2,889.00" $0.00 $0.00 $565.16 $0.00 $0.00 $574.91 $0.00 $0.00 $0.00 $0.00 $0.00 74820409 SUP HCPCS C1713 74820409 - PLATE BN 234MM 9 HL LCK FEM PROX 4.5MM SCR BOTH IP/OP "$3,746.25 " "$2,772.23" $0.00 "$2,997.00" "$1,685.81" "$1,685.81" $0.00 $0.00 $0.00 $780.81 "$2,780.47" "$2,780.47" $0.00 $0.00 $780.72 $0.00 "$1,846.90" "$1,846.90" $0.00 "$1,873.13" "$2,967.03" "$2,997.00" $0.00 $0.00 $586.29 $0.00 $0.00 $596.40 $0.00 $0.00 $0.00 $0.00 $0.00 74820412 SUP HCPCS C1713 74820412 - PLATE BN 288MM 12 HL LCK LT PROX FEM 4.5MM SCR BOTH IP/OP "$4,218.75 " "$3,121.88" $0.00 "$3,375.00" "$1,898.44" "$1,898.44" $0.00 $0.00 $0.00 $879.29 "$3,131.16" "$3,131.16" $0.00 $0.00 $879.19 $0.00 "$2,079.84" "$2,079.84" $0.00 "$2,109.38" "$3,341.25" "$3,375.00" $0.00 $0.00 $660.23 $0.00 $0.00 $671.63 $0.00 $0.00 $0.00 $0.00 $0.00 74820502 SUP HCPCS C1713 74820502 - PLATE BN 4.5MM 99MM 2 HL LCK FEM RT BOTH IP/OP "$3,493.13 " "$2,584.92" $0.00 "$2,794.50" "$1,571.91" "$1,571.91" $0.00 $0.00 $0.00 $728.05 "$2,592.60" "$2,592.60" $0.00 $0.00 $727.97 $0.00 "$1,722.11" "$1,722.11" $0.00 "$1,746.56" "$2,766.56" "$2,794.50" $0.00 $0.00 $546.67 $0.00 $0.00 $556.11 $0.00 $0.00 $0.00 $0.00 $0.00 74820504 SUP HCPCS C1713 74820504 - PLATE BN 144MM 4 HL LCK FEM RT PROX 4.5MM SCR BOTH IP/OP "$3,549.38 " "$2,626.54" $0.00 "$2,839.50" "$1,597.22" "$1,597.22" $0.00 $0.00 $0.00 $739.78 "$2,634.35" "$2,634.35" $0.00 $0.00 $739.69 $0.00 "$1,749.84" "$1,749.84" $0.00 "$1,774.69" "$2,811.11" "$2,839.50" $0.00 $0.00 $555.48 $0.00 $0.00 $565.06 $0.00 $0.00 $0.00 $0.00 $0.00 74820506 SUP HCPCS C1713 74820506 - PLATE BN 180MM 6 HL LCK PROX FEM RT 4.5MM SCR BOTH IP/OP "$3,611.25 " "$2,672.33" $0.00 "$2,889.00" "$1,625.06" "$1,625.06" $0.00 $0.00 $0.00 $752.67 "$2,680.27" "$2,680.27" $0.00 $0.00 $752.58 $0.00 "$1,780.35" "$1,780.35" $0.00 "$1,805.63" "$2,860.11" "$2,889.00" $0.00 $0.00 $565.16 $0.00 $0.00 $574.91 $0.00 $0.00 $0.00 $0.00 $0.00 74820509 SUP HCPCS C1713 74820509 - PLATE BN 234MM 9 HL LCK RT PROX FEM 4.5MM SCR BOTH IP/OP "$3,746.25 " "$2,772.23" $0.00 "$2,997.00" "$1,685.81" "$1,685.81" $0.00 $0.00 $0.00 $780.81 "$2,780.47" "$2,780.47" $0.00 $0.00 $780.72 $0.00 "$1,846.90" "$1,846.90" $0.00 "$1,873.13" "$2,967.03" "$2,997.00" $0.00 $0.00 $586.29 $0.00 $0.00 $596.40 $0.00 $0.00 $0.00 $0.00 $0.00 74820512 SUP HCPCS C1713 74820512 - PLATE BN 288MM 12 HL LCK FEM RT PROX 4.5MM SCR BOTH IP/OP "$4,218.75 " "$3,121.88" $0.00 "$3,375.00" "$1,898.44" "$1,898.44" $0.00 $0.00 $0.00 $879.29 "$3,131.16" "$3,131.16" $0.00 $0.00 $879.19 $0.00 "$2,079.84" "$2,079.84" $0.00 "$2,109.38" "$3,341.25" "$3,375.00" $0.00 $0.00 $660.23 $0.00 $0.00 $671.63 $0.00 $0.00 $0.00 $0.00 $0.00 75001233 SUP HCPCS C1713 75001233 - PIN FX 34MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001234 SUP HCPCS C1713 75001234 - PIN FX 36MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001235 SUP HCPCS C1713 75001235 - PIN FX 38MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001236 SUP HCPCS C1713 75001236 - PIN FX 40MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001237 SUP HCPCS C1713 75001237 - PIN FX 42MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001238 SUP HCPCS C1713 75001238 - PIN FX 44MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001239 SUP HCPCS C1713 75001239 - PIN FX 46MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001240 SUP HCPCS C1713 75001240 - PIN FX 50MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001241 SUP HCPCS C1713 75001241 - PIN FX 60MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75001242 SUP HCPCS C1713 75001242 - PIN FX 70MM LCK DIST BOTH IP/OP $602.50 $445.85 $0.00 $482.00 $271.13 $271.13 $0.00 $0.00 $0.00 $125.58 $447.18 $447.18 $0.00 $0.00 $125.56 $0.00 $356.38 $356.38 $0.00 $301.25 $477.18 $482.00 $0.00 $0.00 $94.29 $0.00 $0.00 $95.92 $0.00 $0.00 $0.00 $0.00 $0.00 75405535 SUP HCPCS C1713 75405535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75405540 SUP HCPCS C1713 75405540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75405545 SUP HCPCS C1713 75405545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75406535 SUP HCPCS C1713 75406535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75406540 SUP HCPCS C1713 75406540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75406545 SUP HCPCS C1713 75406545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75407535 SUP HCPCS C1713 75407535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75407540 SUP HCPCS C1713 75407540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75407545 SUP HCPCS C1713 75407545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75407550 SUP HCPCS C1713 75407550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444020 SUP HCPCS C1713 75444020 - SCREW BN FLUT 4MM 20MM STRL LGC CD HZN G4 TCH MA ST LCK MECH BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444025 SUP HCPCS C1713 75444025 - SCREW BN 4MM 25MM STRL CD HZN LGC MA TI PDCL SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444030 SUP HCPCS C1713 75444030 - SCREW BN FLUT 4MM 30MM STRL LGC CD HZN G4 TCH MA ST LCK MECH BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444040 SUP HCPCS C1713 75444040 - SCREW BN FLUT 4MM 40MM STRL LGC CD HZN G4 TCH MA ST LCK MECH BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444045 SUP HCPCS C1713 75444045 - SCREW BN 4MM 45MM STRL CD HZN LGC MA TI SPNE PDCL 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444050 SUP HCPCS C1713 75444050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444520 SUP HCPCS C1713 75444520 - SCREW BN FLUT 4.5MM 20MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444525 SUP HCPCS C1713 75444525 - SCREW BN FLUT 4.5MM 25MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444530 SUP HCPCS C1713 75444530 - SCREW BN FLUT 4.5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444535 SUP HCPCS C1713 75444535 - SCREW BN FLUT 4.5MM 35MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444540 SUP HCPCS C1713 75444540 - SCREW BN FLUT 4.5MM 40MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444545 SUP HCPCS C1713 75444545 - SCREW BN FLUT 4.5MM 45MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75444550 SUP HCPCS C1713 75444550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445020 SUP HCPCS C1713 75445020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445025 SUP HCPCS C1713 75445025 - SCREW BN FLUT 5MM 25MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445030 SUP HCPCS C1713 75445030 - SCREW BN FLUT 5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445035 SUP HCPCS C1713 75445035 - SCREW BN FLUT 5MM 35MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445040 SUP HCPCS C1713 75445040 - SCREW BN FLUT 5MM 40MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445045 SUP HCPCS C1713 75445045 - SCREW BN FLUT 5MM 45MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445050 SUP HCPCS C1713 75445050 - SCREW BN FLUT 5MM 50MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445520 SUP HCPCS C1713 75445520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445525 SUP HCPCS C1713 75445525 - SCREW BN FLUT 5.5MM 25MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445530 SUP HCPCS C1713 75445530 - SCREW BN FLUT 5.5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445535 SUP HCPCS C1713 75445535 - SCREW BN FLUT 5.5MM 35MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445540 SUP HCPCS C1713 75445540 - SCREW BN FLUT 5.5MM 40MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445545 SUP HCPCS C1713 75445545 - SCREW BN FLUT 5.5MM 45MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445550 SUP HCPCS C1713 75445550 - SCREW BN FLUT 5.5MM 50MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445555 SUP HCPCS C1713 75445555 - SCREW BN FLUT 5.5MM 55MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75445560 SUP HCPCS C1713 75445560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446025 SUP HCPCS C1713 75446025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446030 SUP HCPCS C1713 75446030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446035 SUP HCPCS C1713 75446035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446040 SUP HCPCS C1713 75446040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446045 SUP HCPCS C1713 75446045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446050 SUP HCPCS C1713 75446050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446055 SUP HCPCS C1713 75446055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446060 SUP HCPCS C1713 75446060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446070 SUP HCPCS C1713 75446070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446520 SUP HCPCS C1713 75446520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446525 SUP HCPCS C1713 75446525 - SCREW BN FLUT 6.5MM 25MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446530 SUP HCPCS C1713 75446530 - SCREW BN FLUT 6.5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446535 SUP HCPCS C1713 75446535 - SCREW BN FLUT 6.5MM 35MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446540 SUP HCPCS C1713 75446540 - SCREW BN FLUT 6.5MM 40MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446545 SUP HCPCS C1713 75446545 - SCREW BN FLUT 6.5MM 45MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446550 SUP HCPCS C1713 75446550 - SCREW BN FLUT 6.5MM 50MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446555 SUP HCPCS C1713 75446555 - SCREW BN FLUT 6.5MM 55MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446560 SUP HCPCS C1713 75446560 - SCREW BN FLUT 6.5MM 60MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75446565 SUP HCPCS C1713 75446565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447525 SUP HCPCS C1713 75447525 - SCREW BN FLUT 7.5MM 25MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447530 SUP HCPCS C1713 75447530 - SCREW BN FLUT 7.5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447535 SUP HCPCS C1713 75447535 - SCREW BN FLUT 7.5MM 35MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447540 SUP HCPCS C1713 75447540 - SCREW BN FLUT 7.5MM 40MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447545 SUP HCPCS C1713 75447545 - SCREW BN FLUT 7.5MM 45MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447550 SUP HCPCS C1713 75447550 - SCREW BN FLUT 7.5MM 50MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447555 SUP HCPCS C1713 75447555 - SCREW BN FLUT 7.5MM 55MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447560 SUP HCPCS C1713 75447560 - SCREW BN FLUT 7.5MM 60MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447565 SUP HCPCS C1713 75447565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75447570 SUP HCPCS C1713 75447570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448525 SUP HCPCS C1713 75448525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448530 SUP HCPCS C1713 75448530 - SCREW BN FLUT 8.5MM 30MM STRL LGC CD HZN G4 TCH MA ST LCK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448535 SUP HCPCS C1713 75448535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448540 SUP HCPCS C1713 75448540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448545 SUP HCPCS C1713 75448545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448550 SUP HCPCS C1713 75448550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448555 SUP HCPCS C1713 75448555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448560 SUP HCPCS C1713 75448560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75448565 SUP HCPCS C1713 75448565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75454020 SUP HCPCS C1713 75454020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454025 SUP HCPCS C1713 75454025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454030 SUP HCPCS C1713 75454030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454035 SUP HCPCS C1713 75454035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454040 SUP HCPCS C1713 75454040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454045 SUP HCPCS C1713 75454045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454050 SUP HCPCS C1713 75454050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454520 SUP HCPCS C1713 75454520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454525 SUP HCPCS C1713 75454525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454530 SUP HCPCS C1713 75454530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454535 SUP HCPCS C1713 75454535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454540 SUP HCPCS C1713 75454540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454545 SUP HCPCS C1713 75454545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75454550 SUP HCPCS C1713 75454550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455020 SUP HCPCS C1713 75455020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455025 SUP HCPCS C1713 75455025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455030 SUP HCPCS C1713 75455030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455035 SUP HCPCS C1713 75455035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455040 SUP HCPCS C1713 75455040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455045 SUP HCPCS C1713 75455045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455050 SUP HCPCS C1713 75455050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455520 SUP HCPCS C1713 75455520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455525 SUP HCPCS C1713 75455525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455530 SUP HCPCS C1713 75455530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455535 SUP HCPCS C1713 75455535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455540 SUP HCPCS C1713 75455540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455545 SUP HCPCS C1713 75455545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455550 SUP HCPCS C1713 75455550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455555 SUP HCPCS C1713 75455555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75455560 SUP HCPCS C1713 75455560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456020 SUP HCPCS C1713 75456020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456025 SUP HCPCS C1713 75456025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456030 SUP HCPCS C1713 75456030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456035 SUP HCPCS C1713 75456035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456040 SUP HCPCS C1713 75456040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456045 SUP HCPCS C1713 75456045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456050 SUP HCPCS C1713 75456050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456055 SUP HCPCS C1713 75456055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456060 SUP HCPCS C1713 75456060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456065 SUP HCPCS C1713 75456065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456070 SUP HCPCS C1713 75456070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456520 SUP HCPCS C1713 75456520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456525 SUP HCPCS C1713 75456525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456530 SUP HCPCS C1713 75456530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456535 SUP HCPCS C1713 75456535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456540 SUP HCPCS C1713 75456540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456545 SUP HCPCS C1713 75456545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456550 SUP HCPCS C1713 75456550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456555 SUP HCPCS C1713 75456555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456560 SUP HCPCS C1713 75456560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75456565 SUP HCPCS C1713 75456565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457525 SUP HCPCS C1713 75457525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457530 SUP HCPCS C1713 75457530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457535 SUP HCPCS C1713 75457535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457540 SUP HCPCS C1713 75457540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457545 SUP HCPCS C1713 75457545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457550 SUP HCPCS C1713 75457550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457555 SUP HCPCS C1713 75457555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457560 SUP HCPCS C1713 75457560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457565 SUP HCPCS C1713 75457565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75457570 SUP HCPCS C1713 75457570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458525 SUP HCPCS C1713 75458525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458530 SUP HCPCS C1713 75458530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458535 SUP HCPCS C1713 75458535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458540 SUP HCPCS C1713 75458540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458545 SUP HCPCS C1713 75458545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458550 SUP HCPCS C1713 75458550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458555 SUP HCPCS C1713 75458555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458560 SUP HCPCS C1713 75458560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75458565 SUP HCPCS C1713 75458565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,643.00 " "$1,955.82" $0.00 "$2,114.40" "$1,189.35" "$1,189.35" $0.00 $0.00 $0.00 $550.87 "$1,961.63" "$1,961.63" $0.00 $0.00 $550.80 $0.00 "$1,303.00" "$1,303.00" $0.00 "$1,321.50" "$2,093.26" "$2,114.40" $0.00 $0.00 $413.63 $0.00 $0.00 $420.77 $0.00 $0.00 $0.00 $0.00 $0.00 75464015 SUP HCPCS C1713 75464015 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464020 SUP HCPCS C1713 75464020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464025 SUP HCPCS C1713 75464025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464030 SUP HCPCS C1713 75464030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464035 SUP HCPCS C1713 75464035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464040 SUP HCPCS C1713 75464040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464045 SUP HCPCS C1713 75464045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464050 SUP HCPCS C1713 75464050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464055 SUP HCPCS C1713 75464055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464060 SUP HCPCS C1713 75464060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464515 SUP HCPCS C1713 75464515 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464520 SUP HCPCS C1713 75464520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464525 SUP HCPCS C1713 75464525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464530 SUP HCPCS C1713 75464530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464535 SUP HCPCS C1713 75464535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464540 SUP HCPCS C1713 75464540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464545 SUP HCPCS C1713 75464545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464550 SUP HCPCS C1713 75464550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464555 SUP HCPCS C1713 75464555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75464560 SUP HCPCS C1713 75464560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465015 SUP HCPCS C1713 75465015 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465020 SUP HCPCS C1713 75465020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465025 SUP HCPCS C1713 75465025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465030 SUP HCPCS C1713 75465030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465035 SUP HCPCS C1713 75465035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465040 SUP HCPCS C1713 75465040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465045 SUP HCPCS C1713 75465045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465050 SUP HCPCS C1713 75465050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465055 SUP HCPCS C1713 75465055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465060 SUP HCPCS C1713 75465060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465515 SUP HCPCS C1713 75465515 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465520 SUP HCPCS C1713 75465520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465525 SUP HCPCS C1713 75465525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75465530 SUP HCPCS C1713 75465530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75470735 SUP Custom 27803010 75470735 - PLATE 18MM TI BONE SPNL BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75470740 SUP Custom 27803010 75470740 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75470745 SUP Custom 27803010 75470745 - PLATE 18MM TI BONE SPNL BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75470750 SUP Custom 27803010 75470750 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75470755 SUP Custom 27803010 75470755 - PLATE 18MM TI BONE SPNL BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75470760 SUP Custom 27803010 75470760 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75470865 SUP Custom 27803010 75470865 - PLATE 18MM TI BONE SPNL BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75470870 SUP Custom 27803010 75470870 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75470875 SUP Custom 27803010 75470875 - PLATE 18MM TI BONE SPNL BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $0.00 $0.00 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75494520 SUP HCPCS C1713 75494520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75494525 SUP HCPCS C1713 75494525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75494530 SUP HCPCS C1713 75494530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75494535 SUP HCPCS C1713 75494535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75494540 SUP HCPCS C1713 75494540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75494545 SUP HCPCS C1713 75494545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75494550 SUP HCPCS C1713 75494550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495020 SUP HCPCS C1713 75495020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495025 SUP HCPCS C1713 75495025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495030 SUP HCPCS C1713 75495030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495035 SUP HCPCS C1713 75495035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495040 SUP HCPCS C1713 75495040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495045 SUP HCPCS C1713 75495045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495050 SUP HCPCS C1713 75495050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495520 SUP HCPCS C1713 75495520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495525 SUP HCPCS C1713 75495525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495530 SUP HCPCS C1713 75495530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495535 SUP HCPCS C1713 75495535 - SCREW BN 5.5MM 35MM CD HZN LGC MA RDC TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495540 SUP HCPCS C1713 75495540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495545 SUP HCPCS C1713 75495545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495550 SUP HCPCS C1713 75495550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495555 SUP HCPCS C1713 75495555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75495560 SUP HCPCS C1713 75495560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496520 SUP HCPCS C1713 75496520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496525 SUP HCPCS C1713 75496525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496530 SUP HCPCS C1713 75496530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496535 SUP HCPCS C1713 75496535 - SCREW BN 6.5MM 35MM CD HZN LGC MA RDC TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496540 SUP HCPCS C1713 75496540 - SCREW BN 6.5MM 40MM CD HZN LGC MA RDC TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496545 SUP HCPCS C1713 75496545 - SCREW BN 6.5MM 45MM CD HZN LGC MA RDC TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496550 SUP HCPCS C1713 75496550 - SCREW BN 6.5MM 50MM CD HZN LGC MA RDC TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496555 SUP HCPCS C1713 75496555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496560 SUP HCPCS C1713 75496560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75496565 SUP HCPCS C1713 75496565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497525 SUP HCPCS C1713 75497525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497530 SUP HCPCS C1713 75497530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497535 SUP HCPCS C1713 75497535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497540 SUP HCPCS C1713 75497540 - SCREW BN 7.5MM 40MM CD HZN LGC MA RDC TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497545 SUP HCPCS C1713 75497545 - SCREW BN 7.5MM 45MM CD HZN LGC MA RDC TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497550 SUP HCPCS C1713 75497550 - SCREW BN 7.5MM 50MM CD HZN LGC MA RDC TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497555 SUP HCPCS C1713 75497555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497560 SUP HCPCS C1713 75497560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497565 SUP HCPCS C1713 75497565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75497570 SUP HCPCS C1713 75497570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498525 SUP HCPCS C1713 75498525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498530 SUP HCPCS C1713 75498530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498535 SUP HCPCS C1713 75498535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498540 SUP HCPCS C1713 75498540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498545 SUP HCPCS C1713 75498545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498550 SUP HCPCS C1713 75498550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498555 SUP HCPCS C1713 75498555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498560 SUP HCPCS C1713 75498560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75498565 SUP HCPCS C1713 75498565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644020 SUP HCPCS C1713 75644020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644025 SUP HCPCS C1713 75644025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644030 SUP HCPCS C1713 75644030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644035 SUP HCPCS C1713 75644035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644040 SUP HCPCS C1713 75644040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644045 SUP HCPCS C1713 75644045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644050 SUP HCPCS C1713 75644050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644520 SUP HCPCS C1713 75644520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644525 SUP HCPCS C1713 75644525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644530 SUP HCPCS C1713 75644530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644535 SUP HCPCS C1713 75644535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644540 SUP HCPCS C1713 75644540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644545 SUP HCPCS C1713 75644545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75644550 SUP HCPCS C1713 75644550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645020 SUP HCPCS C1713 75645020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645025 SUP HCPCS C1713 75645025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645030 SUP HCPCS C1713 75645030 - SCREW BN FLUT 5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645035 SUP HCPCS C1713 75645035 - SCREW BN FLUT 5MM 35MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645040 SUP HCPCS C1713 75645040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645045 SUP HCPCS C1713 75645045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645050 SUP HCPCS C1713 75645050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645520 SUP HCPCS C1713 75645520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645525 SUP HCPCS C1713 75645525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645530 SUP HCPCS C1713 75645530 - SCREW BN FLUT 5.5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645535 SUP HCPCS C1713 75645535 - SCREW BN FLUT 5.5MM 35MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645540 SUP HCPCS C1713 75645540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645545 SUP HCPCS C1713 75645545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645550 SUP HCPCS C1713 75645550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645555 SUP HCPCS C1713 75645555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75645560 SUP HCPCS C1713 75645560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646025 SUP HCPCS C1713 75646025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646030 SUP HCPCS C1713 75646030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646035 SUP HCPCS C1713 75646035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646040 SUP HCPCS C1713 75646040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646045 SUP HCPCS C1713 75646045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646050 SUP HCPCS C1713 75646050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646055 SUP HCPCS C1713 75646055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646060 SUP HCPCS C1713 75646060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646065 SUP HCPCS C1713 75646065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646070 SUP HCPCS C1713 75646070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646520 SUP HCPCS C1713 75646520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646525 SUP HCPCS C1713 75646525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646530 SUP HCPCS C1713 75646530 - SCREW BN FLUT 6.5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646535 SUP HCPCS C1713 75646535 - SCREW BN FLUT 6.5MM 35MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646540 SUP HCPCS C1713 75646540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646545 SUP HCPCS C1713 75646545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646550 SUP HCPCS C1713 75646550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646555 SUP HCPCS C1713 75646555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646560 SUP HCPCS C1713 75646560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75646565 SUP HCPCS C1713 75646565 - SCREW BN FLUT 6.5MM 65MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647525 SUP HCPCS C1713 75647525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647530 SUP HCPCS C1713 75647530 - SCREW BN FLUT 7.5MM 30MM NS CD HZN LGC MA ST RVRS ANG THRDLK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647535 SUP HCPCS C1713 75647535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647540 SUP HCPCS C1713 75647540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647545 SUP HCPCS C1713 75647545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647550 SUP HCPCS C1713 75647550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647555 SUP HCPCS C1713 75647555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647560 SUP HCPCS C1713 75647560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647565 SUP HCPCS C1713 75647565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75647570 SUP HCPCS C1713 75647570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648525 SUP HCPCS C1713 75648525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648530 SUP HCPCS C1713 75648530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648535 SUP HCPCS C1713 75648535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648540 SUP HCPCS C1713 75648540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648545 SUP HCPCS C1713 75648545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648550 SUP HCPCS C1713 75648550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648555 SUP HCPCS C1713 75648555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648560 SUP HCPCS C1713 75648560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75648565 SUP HCPCS C1713 75648565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75654020 SUP HCPCS C1713 75654020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654025 SUP HCPCS C1713 75654025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654030 SUP HCPCS C1713 75654030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654035 SUP HCPCS C1713 75654035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654040 SUP HCPCS C1713 75654040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654045 SUP HCPCS C1713 75654045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654050 SUP HCPCS C1713 75654050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654520 SUP HCPCS C1713 75654520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654525 SUP HCPCS C1713 75654525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654530 SUP HCPCS C1713 75654530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654535 SUP HCPCS C1713 75654535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654540 SUP HCPCS C1713 75654540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654545 SUP HCPCS C1713 75654545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75654550 SUP HCPCS C1713 75654550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655020 SUP HCPCS C1713 75655020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655025 SUP HCPCS C1713 75655025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655030 SUP HCPCS C1713 75655030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655035 SUP HCPCS C1713 75655035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655040 SUP HCPCS C1713 75655040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655045 SUP HCPCS C1713 75655045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655050 SUP HCPCS C1713 75655050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655520 SUP HCPCS C1713 75655520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655525 SUP HCPCS C1713 75655525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655530 SUP HCPCS C1713 75655530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655535 SUP HCPCS C1713 75655535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655540 SUP HCPCS C1713 75655540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655545 SUP HCPCS C1713 75655545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655550 SUP HCPCS C1713 75655550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655555 SUP HCPCS C1713 75655555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75655560 SUP HCPCS C1713 75655560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656020 SUP HCPCS C1713 75656020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656025 SUP HCPCS C1713 75656025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656030 SUP HCPCS C1713 75656030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656035 SUP HCPCS C1713 75656035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656040 SUP HCPCS C1713 75656040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656045 SUP HCPCS C1713 75656045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656050 SUP HCPCS C1713 75656050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656055 SUP HCPCS C1713 75656055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656060 SUP HCPCS C1713 75656060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656065 SUP HCPCS C1713 75656065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656070 SUP HCPCS C1713 75656070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656520 SUP HCPCS C1713 75656520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656525 SUP HCPCS C1713 75656525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656530 SUP HCPCS C1713 75656530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656535 SUP HCPCS C1713 75656535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656540 SUP HCPCS C1713 75656540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656545 SUP HCPCS C1713 75656545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656550 SUP HCPCS C1713 75656550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656555 SUP HCPCS C1713 75656555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656560 SUP HCPCS C1713 75656560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75656565 SUP HCPCS C1713 75656565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657525 SUP HCPCS C1713 75657525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657530 SUP HCPCS C1713 75657530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657535 SUP HCPCS C1713 75657535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657540 SUP HCPCS C1713 75657540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657545 SUP HCPCS C1713 75657545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657550 SUP HCPCS C1713 75657550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657555 SUP HCPCS C1713 75657555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657560 SUP HCPCS C1713 75657560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657565 SUP HCPCS C1713 75657565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75657570 SUP HCPCS C1713 75657570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658525 SUP HCPCS C1713 75658525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658530 SUP HCPCS C1713 75658530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658535 SUP HCPCS C1713 75658535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658540 SUP HCPCS C1713 75658540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658545 SUP HCPCS C1713 75658545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658550 SUP HCPCS C1713 75658550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658555 SUP HCPCS C1713 75658555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658560 SUP HCPCS C1713 75658560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75658565 SUP HCPCS C1713 75658565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,452.50 " "$1,814.85" $0.00 "$1,962.00" "$1,103.63" "$1,103.63" $0.00 $0.00 $0.00 $511.16 "$1,820.25" "$1,820.25" $0.00 $0.00 $511.10 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,226.25" "$1,942.38" "$1,962.00" $0.00 $0.00 $383.82 $0.00 $0.00 $390.44 $0.00 $0.00 $0.00 $0.00 $0.00 75694520 SUP HCPCS C1713 75694520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75694525 SUP HCPCS C1713 75694525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75694530 SUP HCPCS C1713 75694530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75694535 SUP HCPCS C1713 75694535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75694540 SUP HCPCS C1713 75694540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75694545 SUP HCPCS C1713 75694545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75694550 SUP HCPCS C1713 75694550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695020 SUP HCPCS C1713 75695020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695025 SUP HCPCS C1713 75695025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695030 SUP HCPCS C1713 75695030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695035 SUP HCPCS C1713 75695035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695040 SUP HCPCS C1713 75695040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695045 SUP HCPCS C1713 75695045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695050 SUP HCPCS C1713 75695050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695520 SUP HCPCS C1713 75695520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695525 SUP HCPCS C1713 75695525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695530 SUP HCPCS C1713 75695530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695535 SUP HCPCS C1713 75695535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695540 SUP HCPCS C1713 75695540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695545 SUP HCPCS C1713 75695545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695550 SUP HCPCS C1713 75695550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695555 SUP HCPCS C1713 75695555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75695560 SUP HCPCS C1713 75695560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696520 SUP HCPCS C1713 75696520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696525 SUP HCPCS C1713 75696525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696530 SUP HCPCS C1713 75696530 - SCREW BN FLUT 6.5MM 30MM CD HZN LGC MA RDC SS SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696535 SUP HCPCS C1713 75696535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696540 SUP HCPCS C1713 75696540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696545 SUP HCPCS C1713 75696545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696550 SUP HCPCS C1713 75696550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696555 SUP HCPCS C1713 75696555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696560 SUP HCPCS C1713 75696560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75696565 SUP HCPCS C1713 75696565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697525 SUP HCPCS C1713 75697525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697530 SUP HCPCS C1713 75697530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697535 SUP HCPCS C1713 75697535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697540 SUP HCPCS C1713 75697540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697545 SUP HCPCS C1713 75697545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697550 SUP HCPCS C1713 75697550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697555 SUP HCPCS C1713 75697555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697560 SUP HCPCS C1713 75697560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697565 SUP HCPCS C1713 75697565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75697570 SUP HCPCS C1713 75697570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698525 SUP HCPCS C1713 75698525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698530 SUP HCPCS C1713 75698530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698535 SUP HCPCS C1713 75698535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698540 SUP HCPCS C1713 75698540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698545 SUP HCPCS C1713 75698545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698550 SUP HCPCS C1713 75698550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698555 SUP HCPCS C1713 75698555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698560 SUP HCPCS C1713 75698560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 75698565 SUP HCPCS C1713 75698565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76440020 SUP HCPCS C1713 76440020 - SCREW BONE 20MM CD HZN LGC PDCL TI MULTIAX 5.5MM ROD STRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 76444020 SUP HCPCS C1713 76444020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444025 SUP HCPCS C1713 76444025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444030 SUP HCPCS C1713 76444030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444035 SUP HCPCS C1713 76444035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444040 SUP HCPCS C1713 76444040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444045 SUP HCPCS C1713 76444045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444050 SUP HCPCS C1713 76444050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444520 SUP HCPCS C1713 76444520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444525 SUP HCPCS C1713 76444525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444530 SUP HCPCS C1713 76444530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444535 SUP HCPCS C1713 76444535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444540 SUP HCPCS C1713 76444540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444545 SUP HCPCS C1713 76444545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76444550 SUP HCPCS C1713 76444550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445020 SUP HCPCS C1713 76445020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445025 SUP HCPCS C1713 76445025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445030 SUP HCPCS C1713 76445030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445035 SUP HCPCS C1713 76445035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445040 SUP HCPCS C1713 76445040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445045 SUP HCPCS C1713 76445045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445050 SUP HCPCS C1713 76445050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445520 SUP HCPCS C1713 76445520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445525 SUP HCPCS C1713 76445525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445530 SUP HCPCS C1713 76445530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445535 SUP HCPCS C1713 76445535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445540 SUP HCPCS C1713 76445540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445545 SUP HCPCS C1713 76445545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445550 SUP HCPCS C1713 76445550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445555 SUP HCPCS C1713 76445555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76445560 SUP HCPCS C1713 76445560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446025 SUP HCPCS C1713 76446025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446030 SUP HCPCS C1713 76446030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446035 SUP HCPCS C1713 76446035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446040 SUP HCPCS C1713 76446040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446045 SUP HCPCS C1713 76446045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446050 SUP HCPCS C1713 76446050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446055 SUP HCPCS C1713 76446055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446060 SUP HCPCS C1713 76446060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446065 SUP HCPCS C1713 76446065 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446070 SUP HCPCS C1713 76446070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446075 SUP HCPCS C1713 76446075 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446520 SUP HCPCS C1713 76446520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446525 SUP HCPCS C1713 76446525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446530 SUP HCPCS C1713 76446530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446535 SUP HCPCS C1713 76446535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446540 SUP HCPCS C1713 76446540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446545 SUP HCPCS C1713 76446545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446550 SUP HCPCS C1713 76446550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446555 SUP HCPCS C1713 76446555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446560 SUP HCPCS C1713 76446560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446565 SUP HCPCS C1713 76446565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446570 SUP HCPCS C1713 76446570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76446575 SUP HCPCS C1713 76446575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447525 SUP HCPCS C1713 76447525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447530 SUP HCPCS C1713 76447530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447535 SUP HCPCS C1713 76447535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447540 SUP HCPCS C1713 76447540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447545 SUP HCPCS C1713 76447545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447550 SUP HCPCS C1713 76447550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447555 SUP HCPCS C1713 76447555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447560 SUP HCPCS C1713 76447560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447565 SUP HCPCS C1713 76447565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447570 SUP HCPCS C1713 76447570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76447575 SUP HCPCS C1713 76447575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448525 SUP HCPCS C1713 76448525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448530 SUP HCPCS C1713 76448530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448535 SUP HCPCS C1713 76448535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448540 SUP HCPCS C1713 76448540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448545 SUP HCPCS C1713 76448545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448550 SUP HCPCS C1713 76448550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448555 SUP HCPCS C1713 76448555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448560 SUP HCPCS C1713 76448560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448565 SUP HCPCS C1713 76448565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448570 SUP HCPCS C1713 76448570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76448575 SUP HCPCS C1713 76448575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76494520 SUP HCPCS C1713 76494520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76494525 SUP HCPCS C1713 76494525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76494530 SUP HCPCS C1713 76494530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76494535 SUP HCPCS C1713 76494535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76494540 SUP HCPCS C1713 76494540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76494545 SUP HCPCS C1713 76494545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76494550 SUP HCPCS C1713 76494550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495020 SUP HCPCS C1713 76495020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495025 SUP HCPCS C1713 76495025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495030 SUP HCPCS C1713 76495030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495035 SUP HCPCS C1713 76495035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495040 SUP HCPCS C1713 76495040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495045 SUP HCPCS C1713 76495045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495050 SUP HCPCS C1713 76495050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495520 SUP HCPCS C1713 76495520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495525 SUP HCPCS C1713 76495525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495530 SUP HCPCS C1713 76495530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495535 SUP HCPCS C1713 76495535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495540 SUP HCPCS C1713 76495540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495545 SUP HCPCS C1713 76495545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495550 SUP HCPCS C1713 76495550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495555 SUP HCPCS C1713 76495555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76495560 SUP HCPCS C1713 76495560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496525 SUP HCPCS C1713 76496525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496530 SUP HCPCS C1713 76496530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496535 SUP HCPCS C1713 76496535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496540 SUP HCPCS C1713 76496540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496545 SUP HCPCS C1713 76496545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496550 SUP HCPCS C1713 76496550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496555 SUP HCPCS C1713 76496555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496560 SUP HCPCS C1713 76496560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496565 SUP HCPCS C1713 76496565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496570 SUP HCPCS C1713 76496570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76496575 SUP HCPCS C1713 76496575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497525 SUP HCPCS C1713 76497525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497530 SUP HCPCS C1713 76497530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497535 SUP HCPCS C1713 76497535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497540 SUP HCPCS C1713 76497540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497545 SUP HCPCS C1713 76497545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497550 SUP HCPCS C1713 76497550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497555 SUP HCPCS C1713 76497555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497560 SUP HCPCS C1713 76497560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497565 SUP HCPCS C1713 76497565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497570 SUP HCPCS C1713 76497570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76497575 SUP HCPCS C1713 76497575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498525 SUP HCPCS C1713 76498525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498530 SUP HCPCS C1713 76498530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498535 SUP HCPCS C1713 76498535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498540 SUP HCPCS C1713 76498540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498545 SUP HCPCS C1713 76498545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498550 SUP HCPCS C1713 76498550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498555 SUP HCPCS C1713 76498555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498560 SUP HCPCS C1713 76498560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498565 SUP HCPCS C1713 76498565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498570 SUP HCPCS C1713 76498570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76498575 SUP HCPCS C1713 76498575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644020 SUP HCPCS C1713 76644020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644025 SUP HCPCS C1713 76644025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644030 SUP HCPCS C1713 76644030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644035 SUP HCPCS C1713 76644035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644040 SUP HCPCS C1713 76644040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644045 SUP HCPCS C1713 76644045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644050 SUP HCPCS C1713 76644050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644520 SUP HCPCS C1713 76644520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644525 SUP HCPCS C1713 76644525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644530 SUP HCPCS C1713 76644530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644535 SUP HCPCS C1713 76644535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644540 SUP HCPCS C1713 76644540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644545 SUP HCPCS C1713 76644545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76644550 SUP HCPCS C1713 76644550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645020 SUP HCPCS C1713 76645020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645025 SUP HCPCS C1713 76645025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645030 SUP HCPCS C1713 76645030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645035 SUP HCPCS C1713 76645035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645040 SUP HCPCS C1713 76645040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645045 SUP HCPCS C1713 76645045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645050 SUP HCPCS C1713 76645050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645520 SUP HCPCS C1713 76645520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645525 SUP HCPCS C1713 76645525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645530 SUP HCPCS C1713 76645530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645535 SUP HCPCS C1713 76645535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645540 SUP HCPCS C1713 76645540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645545 SUP HCPCS C1713 76645545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645550 SUP HCPCS C1713 76645550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645555 SUP HCPCS C1713 76645555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76645560 SUP HCPCS C1713 76645560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646025 SUP HCPCS C1713 76646025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646030 SUP HCPCS C1713 76646030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646035 SUP HCPCS C1713 76646035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646040 SUP HCPCS C1713 76646040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646045 SUP HCPCS C1713 76646045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646050 SUP HCPCS C1713 76646050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646055 SUP HCPCS C1713 76646055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646060 SUP HCPCS C1713 76646060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646065 SUP HCPCS C1713 76646065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646070 SUP HCPCS C1713 76646070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646075 SUP HCPCS C1713 76646075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646525 SUP HCPCS C1713 76646525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646530 SUP HCPCS C1713 76646530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646535 SUP HCPCS C1713 76646535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646540 SUP HCPCS C1713 76646540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646545 SUP HCPCS C1713 76646545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646550 SUP HCPCS C1713 76646550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646555 SUP HCPCS C1713 76646555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646560 SUP HCPCS C1713 76646560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646565 SUP HCPCS C1713 76646565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646570 SUP HCPCS C1713 76646570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76646575 SUP HCPCS C1713 76646575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647525 SUP HCPCS C1713 76647525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647530 SUP HCPCS C1713 76647530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647535 SUP HCPCS C1713 76647535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647540 SUP HCPCS C1713 76647540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647545 SUP HCPCS C1713 76647545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647550 SUP HCPCS C1713 76647550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647555 SUP HCPCS C1713 76647555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647560 SUP HCPCS C1713 76647560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647565 SUP HCPCS C1713 76647565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647570 SUP HCPCS C1713 76647570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76647575 SUP HCPCS C1713 76647575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648525 SUP HCPCS C1713 76648525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648530 SUP HCPCS C1713 76648530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648535 SUP HCPCS C1713 76648535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648540 SUP HCPCS C1713 76648540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648545 SUP HCPCS C1713 76648545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648550 SUP HCPCS C1713 76648550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648555 SUP HCPCS C1713 76648555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648560 SUP HCPCS C1713 76648560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648565 SUP HCPCS C1713 76648565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648570 SUP HCPCS C1713 76648570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76648575 SUP HCPCS C1713 76648575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76694520 SUP HCPCS C1713 76694520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76694525 SUP HCPCS C1713 76694525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76694530 SUP HCPCS C1713 76694530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76694535 SUP HCPCS C1713 76694535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76694540 SUP HCPCS C1713 76694540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76694545 SUP HCPCS C1713 76694545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76694550 SUP HCPCS C1713 76694550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695020 SUP HCPCS C1713 76695020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695025 SUP HCPCS C1713 76695025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695030 SUP HCPCS C1713 76695030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695035 SUP HCPCS C1713 76695035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695040 SUP HCPCS C1713 76695040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695045 SUP HCPCS C1713 76695045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695050 SUP HCPCS C1713 76695050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695520 SUP HCPCS C1713 76695520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695525 SUP HCPCS C1713 76695525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695530 SUP HCPCS C1713 76695530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695535 SUP HCPCS C1713 76695535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695540 SUP HCPCS C1713 76695540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695545 SUP HCPCS C1713 76695545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695550 SUP HCPCS C1713 76695550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695555 SUP HCPCS C1713 76695555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76695560 SUP HCPCS C1713 76695560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696525 SUP HCPCS C1713 76696525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696530 SUP HCPCS C1713 76696530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696535 SUP HCPCS C1713 76696535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696540 SUP HCPCS C1713 76696540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696545 SUP HCPCS C1713 76696545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696550 SUP HCPCS C1713 76696550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696555 SUP HCPCS C1713 76696555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696560 SUP HCPCS C1713 76696560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696565 SUP HCPCS C1713 76696565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696570 SUP HCPCS C1713 76696570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76696575 SUP HCPCS C1713 76696575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697525 SUP HCPCS C1713 76697525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697530 SUP HCPCS C1713 76697530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697535 SUP HCPCS C1713 76697535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697540 SUP HCPCS C1713 76697540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697545 SUP HCPCS C1713 76697545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697550 SUP HCPCS C1713 76697550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697555 SUP HCPCS C1713 76697555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697560 SUP HCPCS C1713 76697560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697565 SUP HCPCS C1713 76697565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697570 SUP HCPCS C1713 76697570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76697575 SUP HCPCS C1713 76697575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698525 SUP HCPCS C1713 76698525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698530 SUP HCPCS C1713 76698530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698535 SUP HCPCS C1713 76698535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698540 SUP HCPCS C1713 76698540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698545 SUP HCPCS C1713 76698545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698550 SUP HCPCS C1713 76698550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698555 SUP HCPCS C1713 76698555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698560 SUP HCPCS C1713 76698560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698565 SUP HCPCS C1713 76698565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698570 SUP HCPCS C1713 76698570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 76698575 SUP HCPCS C1713 76698575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 77101050 SUP HCPCS C1762 77101050 - GRAFT SFT TIS ALGRF BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77101054 SUP Custom 27803010 77101054 - SPACER CMNT 4D 14X12X5MM CERV SPNL BONE PLUG BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77101060 SUP HCPCS C1713 77101060 - SPACER ALGRF 0D 14X12X6MM BIO AVS OPN PLG CRV BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77101064 SUP Custom 27803010 77101064 - SPACER CMNT 4D 14X12X6MM CERV SPNL BONE PLUG BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77101070 SUP HCPCS C1713 77101070 - PLATE 0D 8MM HOLE BONE CERV BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77101074 SUP HCPCS C1713 77101074 - PLATE 4D 7IN HOLE BONE CERV SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77101080 SUP HCPCS C1713 77101080 - PLATE 0D 7MM HOLE BONE CERV BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77101084 SUP HCPCS C1713 77101084 - SCREW BONE 8MM 14MM 12MM SPNL WDG BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77101090 SUP HCPCS C1713 77101090 - PLATE 0D 9MM HOLE BONE CERV BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77101094 SUP HCPCS C1713 77101094 - SPACER ALGRF 4D 14X12X9MM BIO AVS OPN PLG CRV BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77101100 SUP Custom 27803010 77101100 - SPACER SPNL 14X12X10MM AVS 0D CAGE BIO BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77102050 SUP HCPCS C1713 77102050 - PLATE 0D 14X12IN N LORD CCANC 5 HOLE BONE BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77102054 SUP Custom 27803010 77102054 - SPACER SPNL 5MM AVS 4D BONE PLUG BABSR BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77102060 SUP HCPCS C1713 77102060 - PLATE 0D 14X12IN N LORD CCANC 6 HOLE BONE BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77102064 SUP Custom 27803010 77102064 - SPACER SPNL 6MM AVS 4D BONE PLUG BABSR BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77102070 SUP HCPCS C1713 77102070 - PLATE 0D 14X12IN N LORD CCANC 7 HOLE BONE BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77102074 SUP Custom 27803010 77102074 - SPACER SPNL 7MM AVS 4D BONE PLUG BABSR BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77102084 SUP Custom 27803010 77102084 - SPACER SPNL 8MM AVS 4D BONE PLUG BABSR BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77102090 SUP HCPCS C1713 77102090 - PLATE 0D 14X12IN N LORD CCANC 9 HOLE BONE BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77102094 SUP Custom 27803010 77102094 - SPACER ALGRF 4D LORDOSIS 12MM 14X9MM BIO AVS PRESERVON FRZDR BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77102100 SUP Custom 27803010 77102100 - SPACER ALGRF 4D 14X12X10MM BIO AVS OPN PLG CRV BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77102104 SUP HCPCS C1713 77102104 - SPACER ALGRF 4D LORDOSIS 12MM 14X10MM BIO AVS FRZDR C PLG 1 BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" "$3,003.75" "$3,003.75" $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 "$1,062.66" $0.00 $0.00 $0.00 $0.00 $0.00 77562815 SUP Custom 27203010 77562815 - BIT DRILL FLEXIBLE 3.2MM BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $0.00 $0.00 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77805200 SUP HCPCS C1887 CATHETER GUID XB3 CURVE 7FR .078IN 100CM PTFE VSBR BLUE YLW BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 77805500 SUP HCPCS C1887 CATHETER GUID XB3.5 CURVE 7FR .078IN 100CM SH PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 77805600 SUP HCPCS C1887 CATHETER GUID XB4 CURVE 7FR .078IN 100CM PTFE VSBR BLUE YLW BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 77827100 SUP HCPCS C1887 CATHETER GUID MPA1 CURVE 7FR .078IN 100CM SH PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 80008455 SUP HCPCS C1892 612603 - INTRODUCER SHTH 7FR 19CM 16CM TRAW ADPR DILAT SET INDN SPNLK BOTH IP/OP $69.35 $51.32 $0.00 $55.48 $37.66 $37.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.68 $54.93 $55.48 $0.00 $0.00 $10.85 $0.00 $0.00 $11.04 $0.00 $0.00 $0.00 $0.00 $0.00 80100100 SUP HCPCS C1769 80100100 - GUIDEWIRE ORTH .045IN BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $20.36 $20.36 $0.00 $0.00 $0.00 $7.82 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $22.18 $22.18 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $5.87 $0.00 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 80100101 SUP HCPCS C1769 80100101 - GUIDEWIRE SRG .035IN BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $20.36 $20.36 $0.00 $0.00 $0.00 $7.82 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $22.18 $22.18 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $5.87 $0.00 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 80100102 SUP Custom 27203010 80100102 - WIRE FX .035IN 7IN KRSH STRG BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $0.00 $0.00 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80100103 SUP Custom 27203010 80100103 - WIRE FX .035IN KRSH BIOTRACK BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $0.00 $0.00 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80100125 SUP Custom 27203010 80100125 - HANDLE QRLSE SCRDRVR NONSTRL BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80200102 SUP HCPCS C1713 80200102 - PIN FIX 203MM 4.8MM RUSH A IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200103 SUP HCPCS C1713 80200103 - PIN FIX 222MM 4.8MM RUSH B IM SS NONSTRL BOTH IP/OP "$1,183.00 " $875.42 $0.00 $946.40 $642.37 $642.37 $0.00 $0.00 $0.00 $246.57 $878.02 $878.02 $844.31 $0.00 $246.54 $0.00 $117.12 $117.12 $0.00 $591.50 $156.82 $946.40 $0.00 $0.00 $185.14 $0.00 $0.00 $188.33 $0.00 $0.00 $0.00 $0.00 $0.00 80200104 SUP HCPCS C1713 80200104 - PIN FIX 241MM 4.8MM RUSH C IM SS NONSTRL BOTH IP/OP $163.00 $120.62 $0.00 $156.82 $88.51 $88.51 $0.00 $0.00 $0.00 $33.97 $120.98 $120.98 $116.33 $0.00 $33.97 $0.00 $117.12 $117.12 $0.00 $81.50 $156.82 $130.40 $0.00 $0.00 $25.51 $0.00 $0.00 $25.95 $0.00 $0.00 $0.00 $0.00 $0.00 80200105 SUP HCPCS C1713 80200105 - PIN FIX 260MM 4.8MM RUSH D IM SS NONSTRL BOTH IP/OP $88.00 $65.12 $0.00 $156.82 $47.78 $47.78 $0.00 $0.00 $0.00 $18.34 $65.31 $65.31 $62.81 $0.00 $18.34 $0.00 $117.12 $117.12 $0.00 $44.00 $156.82 $70.40 $0.00 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 80200106 SUP HCPCS C1713 80200106 - PIN FIX 279MM 4.8MM RUSH E IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200107 SUP HCPCS C1713 80200107 - PIN FIX 298MM 4.8MM RUSH F IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200108 SUP HCPCS C1713 80200108 - PIN FIX 318MM 4.8MM RUSH G IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200109 SUP HCPCS C1713 80200109 - PIN FIX 337MM 4.8MM RUSH H IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200110 SUP HCPCS C1713 80200110 - PIN FIX 35.6CM 4.8MM RUSH I IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200111 SUP HCPCS C1713 80200111 - PIN FIX 18.4CM 4.8MM RUSH A1 IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200112 SUP HCPCS C1713 80200112 - PIN FIX 37.5CM 4.8MM RUSH J IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200113 SUP HCPCS C1713 80200113 - PIN FIX 39.4CM 4.8MM RUSH K IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200114 SUP HCPCS C1713 80200114 - PIN FIX 41.3CM 4.8MM RUSH L IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200115 SUP HCPCS C1713 80200115 - PIN FIX 43.2CM 4.8MM RUSH M IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200116 SUP HCPCS C1713 80200116 - PIN FIX 45.1CM 4.8MM RUSH N IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80200117 SUP HCPCS C1713 80200117 - PIN FIX 47CM 4.8MM RUSH O IM SS NONSTRL BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $89.10 $89.10 $0.00 $0.00 $0.00 $41.27 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $117.12 $117.12 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 80202700 SUP HCPCS C1713 80202700 - SET TRAUMA FIX 4.8MM RACK RUSH NONSTRL BOTH IP/OP "$7,028.00 " "$5,200.72" $0.00 "$5,622.40" "$3,162.60" "$3,162.60" $0.00 $0.00 $0.00 "$1,464.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,464.64" $0.00 "$3,464.80" "$3,464.80" $0.00 "$3,514.00" "$5,566.18" "$5,622.40" $0.00 $0.00 "$1,099.88" $0.00 $0.00 "$1,118.86" $0.00 $0.00 $0.00 $0.00 $0.00 80300102 SUP HCPCS C1713 80300102 - PIN FIX 102MM 3.2MM RUSH IM BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300103 SUP HCPCS C1713 80300103 - PIN FX 1/8IN 4.5IN RUSH MDLRY BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300104 SUP HCPCS C1713 80300104 - PIN FIX 127MM 3.2MM RUSH C IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300105 SUP HCPCS C1713 80300105 - PIN FIX 140MM 3.2MM RUSH D IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300106 SUP HCPCS C1713 80300106 - PIN FIX 152MM 3.2MM RUSH E IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300107 SUP HCPCS C1713 80300107 - PIN FIX 165MM 3.2MM RUSH F IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300108 SUP HCPCS C1713 80300108 - PIN FIX 178MM 3.2MM RUSH G IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300109 SUP HCPCS C1713 80300109 - PIN FIX 191MM 3.2MM RUSH H IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300110 SUP HCPCS C1713 80300110 - PIN FIX 203MM 3.2MM RUSH I IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300111 SUP HCPCS C1713 80300111 - PIN FIX 216MM 3.2MM RUSH J IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300112 SUP HCPCS C1713 80300112 - PIN FIX 229MM 3.2MM RUSH K IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300113 SUP HCPCS C1713 80300113 - PIN FIX 241MM 3.2MM RUSH L IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300114 SUP HCPCS C1713 80300114 - PIN FIX 254MM 3.2MM RUSH M IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80300120 SUP HCPCS C1713 80300120 - PIN FIX 267MM 3.2MM RUSH N IM SS NONSTRL BOTH IP/OP $168.30 $124.54 $0.00 $134.64 $75.74 $75.74 $0.00 $0.00 $0.00 $35.08 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $99.55 $99.55 $0.00 $84.15 $133.29 $134.64 $0.00 $0.00 $26.34 $0.00 $0.00 $26.79 $0.00 $0.00 $0.00 $0.00 $0.00 80302700 SUP HCPCS C1713 80302700 - SET TRAUMA FIX 3.2MM RACK RUSH NONSTRL BOTH IP/OP "$5,604.00 " "$4,146.96" $0.00 "$4,483.20" "$2,521.80" "$2,521.80" $0.00 $0.00 $0.00 "$1,168.01" "$4,159.29" "$4,159.29" $0.00 $0.00 "$1,167.87" $0.00 "$2,762.77" "$2,762.77" $0.00 "$2,802.00" "$4,438.37" "$4,483.20" $0.00 $0.00 $877.03 $0.00 $0.00 $892.16 $0.00 $0.00 $0.00 $0.00 $0.00 80322944 SUP HCPCS C1713 186801020 - PLATE BN 20MM NS SKYLINE 1 LVL SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 80400102 SUP HCPCS C1713 80400102 - PIN FIX 2.5CM 2.4MM RUSH A IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400103 SUP HCPCS C1713 80400103 - PIN FIX 3.2CM 2.4MM RUSH B IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400104 SUP HCPCS C1713 80400104 - PIN FIX 3.8CM 2.4MM RUSH C IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400105 SUP HCPCS C1713 80400105 - PIN FIX 4.5CM 2.4MM RUSH D IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400106 SUP HCPCS C1713 80400106 - PIN FIX 5.1CM 2.4MM RUSH E IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400107 SUP HCPCS C1713 80400107 - PIN FIX 5.7CM 2.4MM RUSH F IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400108 SUP HCPCS C1713 80400108 - PIN FIX 6.4CM 2.4MM RUSH G IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400109 SUP HCPCS C1713 80400109 - PIN FIX 7CM 2.4MM RUSH H IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400110 SUP HCPCS C1713 80400110 - PIN FIX 7.6CM 2.4MM RUSH I IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400111 SUP HCPCS C1713 80400111 - PIN FIX 8.3CM 2.4MM RUSH J IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400112 SUP HCPCS C1713 80400112 - PIN FIX 8.9CM 2.4MM RUSH K IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400113 SUP HCPCS C1713 80400113 - PIN FIX 9.5CM 2.4MM RUSH L IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80400114 SUP HCPCS C1713 80400114 - PIN FIX 10.2CM 2.4MM RUSH M IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80402700 SUP HCPCS C1713 80402700 - SET TRAUMA FIX 2.4MM RACK RUSH NONSTRL BOTH IP/OP "$8,110.00 " "$6,001.40" $0.00 "$6,488.00" "$3,649.50" "$3,649.50" $0.00 $0.00 $0.00 "$1,690.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,690.12" $0.00 "$3,998.23" "$3,998.23" $0.00 "$4,055.00" "$6,423.12" "$6,488.00" $0.00 $0.00 "$1,269.22" $0.00 $0.00 "$1,291.11" $0.00 $0.00 $0.00 $0.00 $0.00 80600103 SUP HCPCS C1713 80600103 - PIN FIX 11.4CM 2.4MM RUSH N LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600104 SUP HCPCS C1713 80600104 - PIN FIX 12.7CM 2.4MM RUSH O LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600105 SUP HCPCS C1713 80600105 - PIN FIX 14CM 2.4MM RUSH P LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600106 SUP HCPCS C1713 80600106 - PIN FIX 15.2CM 2.4MM RUSH Q LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600107 SUP HCPCS C1713 80600107 - PIN FIX 16.5CM 2.4MM RUSH R LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600108 SUP HCPCS C1713 80600108 - PIN FIX 17.8CM 2.4MM RUSH S LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600109 SUP HCPCS C1713 80600109 - PIN 19.1CM 2.4MM RUSH T LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600110 SUP HCPCS C1713 80600110 - PIN FIX 20.3CM 2.4MM RUSH U LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600111 SUP HCPCS C1713 80600111 - PIN FIX 21.6CM 2.4MM RUSH V LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600112 SUP HCPCS C1713 80600112 - PIN FIX 22.9CM 2.4MM RUSH W LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600113 SUP HCPCS C1713 80600113 - PIN FIX 24.1CM 2.4MM RUSH X LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 80600114 SUP HCPCS C1713 80600114 - PIN FIX 25.4CM 2.4MM RUSH Y LNG IM SS NONSTRL BOTH IP/OP $150.70 $111.52 $0.00 $120.56 $67.82 $67.82 $0.00 $0.00 $0.00 $31.41 $111.85 $111.85 $0.00 $0.00 $31.41 $0.00 $89.14 $89.14 $0.00 $75.35 $119.35 $120.56 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 83545201 SUP HCPCS C1713 83545201 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545251 SUP HCPCS C1713 83545251 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545301 SUP HCPCS C1713 83545301 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545306 SUP HCPCS C1713 83545306 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83545309 SUP HCPCS C1713 83545309 - SCREW BN 4.5MM 30MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545351 SUP HCPCS C1713 83545351 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545356 SUP HCPCS C1713 83545356 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83545359 SUP HCPCS C1713 83545359 - SCREW BN 4.5MM 35MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545401 SUP HCPCS C1713 83545401 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545406 SUP HCPCS C1713 83545406 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83545409 SUP HCPCS C1713 83545409 - SCREW BN 4.5MM 40MM 3DX TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545451 SUP HCPCS C1713 83545451 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545456 SUP HCPCS C1713 83545456 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83545459 SUP HCPCS C1713 83545459 - SCREW BN 4.5MM 45MM TSRH OSTEOGRIP THNLN SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545501 SUP HCPCS C1713 83545501 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545506 SUP HCPCS C1713 83545506 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83545509 SUP HCPCS C1713 83545509 - SCREW BN 4.5MM 50MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545551 SUP HCPCS C1713 83545551 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545556 SUP HCPCS C1713 83545556 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83545559 SUP HCPCS C1713 83545559 - SCREW BN 4.5MM 55MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545601 SUP HCPCS C1713 83545601 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83545606 SUP HCPCS C1713 83545606 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83545609 SUP HCPCS C1713 83545609 - SCREW BN 4.5MM 60MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555201 SUP HCPCS C1713 83555201 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555251 SUP HCPCS C1713 83555251 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555301 SUP HCPCS C1713 83555301 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555306 SUP HCPCS C1713 83555306 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83555307 SUP HCPCS C1713 83555307 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83555308 SUP HCPCS C1713 83555308 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83555309 SUP HCPCS C1713 83555309 - SCREW BN 5.5MM 30MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555351 SUP HCPCS C1713 83555351 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555356 SUP HCPCS C1713 83555356 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83555357 SUP HCPCS C1713 83555357 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83555358 SUP HCPCS C1713 83555358 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83555359 SUP HCPCS C1713 83555359 - SCREW BN 5.5MM 35MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555401 SUP HCPCS C1713 83555401 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555406 SUP HCPCS C1713 83555406 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83555407 SUP HCPCS C1713 83555407 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83555408 SUP HCPCS C1713 83555408 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83555409 SUP HCPCS C1713 83555409 - SCREW BN 5.5MM 40MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555451 SUP HCPCS C1713 83555451 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555456 SUP HCPCS C1713 83555456 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83555457 SUP HCPCS C1713 83555457 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83555458 SUP HCPCS C1713 83555458 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83555459 SUP HCPCS C1713 83555459 - SCREW BN 5.5MM 45MM TSRH THNLN OSTEOGRIP SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555501 SUP HCPCS C1713 83555501 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555506 SUP HCPCS C1713 83555506 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83555507 SUP HCPCS C1713 83555507 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83555508 SUP HCPCS C1713 83555508 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83555509 SUP HCPCS C1713 83555509 - SCREW BN 5.5MM 50MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555551 SUP HCPCS C1713 83555551 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555556 SUP HCPCS C1713 83555556 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83555557 SUP HCPCS C1713 83555557 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83555559 SUP HCPCS C1713 83555559 - SCREW BN 5.5MM 55MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555601 SUP HCPCS C1713 83555601 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83555606 SUP HCPCS C1713 83555606 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83555607 SUP HCPCS C1713 83555607 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83555608 SUP HCPCS C1713 83555608 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83555609 SUP HCPCS C1713 83555609 - SCREW BN 5.5MM 60MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565201 SUP HCPCS C1713 83565201 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565251 SUP HCPCS C1713 83565251 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565259 SUP HCPCS C1713 83565259 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565301 SUP HCPCS C1713 83565301 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565306 SUP HCPCS C1713 83565306 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83565307 SUP HCPCS C1713 83565307 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83565308 SUP HCPCS C1713 83565308 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565309 SUP HCPCS C1713 83565309 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565351 SUP HCPCS C1713 83565351 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565356 SUP HCPCS C1713 83565356 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83565357 SUP HCPCS C1713 83565357 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83565358 SUP HCPCS C1713 83565358 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565359 SUP HCPCS C1713 83565359 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565401 SUP HCPCS C1713 83565401 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565406 SUP HCPCS C1713 83565406 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83565407 SUP HCPCS C1713 83565407 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83565408 SUP HCPCS C1713 83565408 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565409 SUP HCPCS C1713 83565409 - SCREW BN 6.5MM 40MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565451 SUP HCPCS C1713 83565451 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565454 SUP HCPCS C1713 83565454 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565456 SUP HCPCS C1713 83565456 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83565457 SUP HCPCS C1713 83565457 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83565458 SUP HCPCS C1713 83565458 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565459 SUP HCPCS C1713 83565459 - SCREW BN 6.5MM 45MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565501 SUP HCPCS C1713 83565501 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565504 SUP HCPCS C1713 83565504 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565506 SUP HCPCS C1713 83565506 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83565507 SUP HCPCS C1713 83565507 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83565508 SUP HCPCS C1713 83565508 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565509 SUP HCPCS C1713 83565509 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565551 SUP HCPCS C1713 83565551 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565554 SUP HCPCS C1713 83565554 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565556 SUP HCPCS C1713 83565556 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83565557 SUP HCPCS C1713 83565557 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83565558 SUP HCPCS C1713 83565558 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565559 SUP HCPCS C1713 83565559 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565601 SUP HCPCS C1713 83565601 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83565606 SUP HCPCS C1713 83565606 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83565607 SUP HCPCS C1713 83565607 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83565608 SUP HCPCS C1713 83565608 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83565609 SUP HCPCS C1713 83565609 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575201 SUP HCPCS C1713 83575201 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575251 SUP HCPCS C1713 83575251 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575301 SUP HCPCS C1713 83575301 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575306 SUP HCPCS C1713 83575306 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83575307 SUP HCPCS C1713 83575307 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83575308 SUP HCPCS C1713 83575308 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83575309 SUP HCPCS C1713 83575309 - SCREW BN 7.5MM 30MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575351 SUP HCPCS C1713 83575351 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575356 SUP HCPCS C1713 83575356 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83575357 SUP HCPCS C1713 83575357 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83575358 SUP HCPCS C1713 83575358 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83575359 SUP HCPCS C1713 83575359 - SCREW BN 7.5MM 35MM TSRH OSTEOGRIP RECON TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575401 SUP HCPCS C1713 83575401 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575406 SUP HCPCS C1713 83575406 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83575407 SUP HCPCS C1713 83575407 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83575408 SUP HCPCS C1713 83575408 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83575409 SUP HCPCS C1713 83575409 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575451 SUP HCPCS C1713 83575451 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575456 SUP HCPCS C1713 83575456 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83575457 SUP HCPCS C1713 83575457 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83575458 SUP HCPCS C1713 83575458 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83575459 SUP HCPCS C1713 83575459 - SCREW BN 7.5MM 45MM TSRH OSTEOGRIP THNLN TI SPNE PDCL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575501 SUP HCPCS C1713 83575501 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575506 SUP HCPCS C1713 83575506 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83575507 SUP HCPCS C1713 83575507 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83575508 SUP HCPCS C1713 83575508 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83575509 SUP HCPCS C1713 83575509 - SCREW BN 7.5MM 50MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575551 SUP HCPCS C1713 83575551 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575556 SUP HCPCS C1713 83575556 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83575557 SUP HCPCS C1713 83575557 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83575558 SUP HCPCS C1713 83575558 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83575559 SUP HCPCS C1713 83575559 - SCREW BN 7.5MM 55MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575601 SUP HCPCS C1713 83575601 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83575606 SUP HCPCS C1713 83575606 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83575607 SUP HCPCS C1713 83575607 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83575608 SUP HCPCS C1713 83575608 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 83575609 SUP HCPCS C1713 83575609 - SCREW BN 7.5MM 60MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585201 SUP HCPCS C1713 83585201 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585251 SUP HCPCS C1713 83585251 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585301 SUP HCPCS C1713 83585301 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585306 SUP HCPCS C1713 83585306 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83585307 SUP HCPCS C1713 83585307 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83585309 SUP HCPCS C1713 83585309 - SCREW BN 8.5MM 30MM TSRH OSTEOGRIP THNLN TI SPNE PDCL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585351 SUP HCPCS C1713 83585351 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585356 SUP HCPCS C1713 83585356 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83585357 SUP HCPCS C1713 83585357 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83585359 SUP HCPCS C1713 83585359 - SCREW BN 8.5MM 35MM TSRH OSTEOGRIP THNLN SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585401 SUP HCPCS C1713 83585401 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585406 SUP HCPCS C1713 83585406 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83585407 SUP HCPCS C1713 83585407 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83585409 SUP HCPCS C1713 83585409 - SCREW BN 8.5MM 40MM TSRH OSTEOGRIP THNLN SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585451 SUP HCPCS C1713 83585451 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585456 SUP HCPCS C1713 83585456 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83585457 SUP HCPCS C1713 83585457 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83585459 SUP HCPCS C1713 83585459 - SCREW BN 8.5MM 45MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585501 SUP HCPCS C1713 83585501 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585506 SUP HCPCS C1713 83585506 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83585507 SUP HCPCS C1713 83585507 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83585509 SUP HCPCS C1713 83585509 - SCREW BN 8.5MM 50MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585551 SUP HCPCS C1713 83585551 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585556 SUP HCPCS C1713 83585556 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83585557 SUP HCPCS C1713 83585557 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83585559 SUP HCPCS C1713 83585559 - SCREW BN 8.5MM 55MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585601 SUP HCPCS C1713 83585601 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 83585606 SUP HCPCS C1713 83585606 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $742.50 $742.50 $0.00 $0.00 $0.00 $343.90 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $975.98 $975.98 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $258.23 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 83585607 SUP HCPCS C1713 83585607 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $810.00 $810.00 $0.00 $0.00 $0.00 $375.17 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 "$1,064.70" "$1,064.70" $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $281.70 $0.00 $0.00 $286.56 $0.00 $0.00 $0.00 $0.00 $0.00 83585609 SUP HCPCS C1713 83585609 - SCREW BN 8.5MM 60MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$1,072.50 " $793.65 $0.00 $858.00 $482.63 $482.63 $0.00 $0.00 $0.00 $223.54 $796.01 $796.01 $0.00 $0.00 $223.51 $0.00 $634.38 $634.38 $0.00 $536.25 $849.42 $858.00 $0.00 $0.00 $167.85 $0.00 $0.00 $170.74 $0.00 $0.00 $0.00 $0.00 $0.00 86944520 SUP HCPCS C1713 86944520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86944525 SUP HCPCS C1713 86944525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86944530 SUP HCPCS C1713 86944530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86944535 SUP HCPCS C1713 86944535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86944540 SUP HCPCS C1713 86944540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86944545 SUP HCPCS C1713 86944545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86944550 SUP HCPCS C1713 86944550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945020 SUP HCPCS C1713 86945020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945025 SUP HCPCS C1713 86945025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945030 SUP HCPCS C1713 86945030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945035 SUP HCPCS C1713 86945035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945040 SUP HCPCS C1713 86945040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945045 SUP HCPCS C1713 86945045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945050 SUP HCPCS C1713 86945050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945520 SUP HCPCS C1713 86945520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945525 SUP HCPCS C1713 86945525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945530 SUP HCPCS C1713 86945530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945535 SUP HCPCS C1713 86945535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945540 SUP HCPCS C1713 86945540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945545 SUP HCPCS C1713 86945545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945550 SUP HCPCS C1713 86945550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945555 SUP HCPCS C1713 86945555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945560 SUP HCPCS C1713 86945560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86945565 SUP HCPCS C1713 86945565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946520 SUP HCPCS C1713 86946520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946530 SUP HCPCS C1713 86946530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946535 SUP HCPCS C1713 86946535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946540 SUP HCPCS C1713 86946540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946545 SUP HCPCS C1713 86946545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946550 SUP HCPCS C1713 86946550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946555 SUP HCPCS C1713 86946555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946560 SUP HCPCS C1713 86946560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946565 SUP HCPCS C1713 86946565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946570 SUP HCPCS C1713 86946570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86946575 SUP HCPCS C1713 86946575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947520 SUP HCPCS C1713 86947520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947525 SUP HCPCS C1713 86947525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947530 SUP HCPCS C1713 86947530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947535 SUP HCPCS C1713 86947535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947540 SUP HCPCS C1713 86947540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947545 SUP HCPCS C1713 86947545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947550 SUP HCPCS C1713 86947550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947555 SUP HCPCS C1713 86947555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947560 SUP HCPCS C1713 86947560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947565 SUP HCPCS C1713 86947565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947570 SUP HCPCS C1713 86947570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86947575 SUP HCPCS C1713 86947575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948520 SUP HCPCS C1713 86948520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948525 SUP HCPCS C1713 86948525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948530 SUP HCPCS C1713 86948530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948535 SUP HCPCS C1713 86948535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948540 SUP HCPCS C1713 86948540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948545 SUP HCPCS C1713 86948545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948550 SUP HCPCS C1713 86948550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948555 SUP HCPCS C1713 86948555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948560 SUP HCPCS C1713 86948560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948565 SUP HCPCS C1713 86948565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948570 SUP HCPCS C1713 86948570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86948575 SUP HCPCS C1713 86948575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992320 SUP HCPCS C1713 86992320 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992325 SUP HCPCS C1713 86992325 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992330 SUP HCPCS C1713 86992330 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992335 SUP HCPCS C1713 86992335 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992340 SUP HCPCS C1713 86992340 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992345 SUP HCPCS C1713 86992345 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992350 SUP HCPCS C1713 86992350 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992420 SUP HCPCS C1713 86992420 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992425 SUP HCPCS C1713 86992425 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992430 SUP HCPCS C1713 86992430 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992435 SUP HCPCS C1713 86992435 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992440 SUP HCPCS C1713 86992440 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992445 SUP HCPCS C1713 86992445 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992450 SUP HCPCS C1713 86992450 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992525 SUP HCPCS C1713 86992525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992530 SUP HCPCS C1713 86992530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992535 SUP HCPCS C1713 86992535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992540 SUP HCPCS C1713 86992540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992545 SUP HCPCS C1713 86992545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992550 SUP HCPCS C1713 86992550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992555 SUP HCPCS C1713 86992555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992625 SUP HCPCS C1713 86992625 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992630 SUP HCPCS C1713 86992630 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992635 SUP HCPCS C1713 86992635 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992640 SUP HCPCS C1713 86992640 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992645 SUP HCPCS C1713 86992645 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992650 SUP HCPCS C1713 86992650 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992655 SUP HCPCS C1713 86992655 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992725 SUP HCPCS C1713 86992725 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992730 SUP HCPCS C1713 86992730 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992735 SUP HCPCS C1713 86992735 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992740 SUP HCPCS C1713 86992740 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992745 SUP HCPCS C1713 86992745 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 86992750 SUP HCPCS C1713 86992750 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88900101 SUP HCPCS C1713 88900101 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900102 SUP HCPCS C1713 88900102 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900105 SUP HCPCS C1713 88900105 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900107 SUP HCPCS C1713 88900107 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900108 SUP HCPCS C1713 88900108 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900109 SUP HCPCS C1713 88900109 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900110 SUP HCPCS C1713 88900110 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900111 SUP HCPCS C1713 88900111 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900113 SUP HCPCS C1713 88900113 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900114 SUP HCPCS C1713 88900114 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900201 SUP HCPCS C1713 88900201 - HOOK SPNL TSRH SILO LT OFST TI LMR THOR 5.5 MM ROD BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900202 SUP HCPCS C1713 88900202 - HOOK SPNL TSRH SILO LT OFST TI LMR THOR 5.5 MM ROD BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900205 SUP HCPCS C1713 88900205 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900207 SUP HCPCS C1713 88900207 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900208 SUP HCPCS C1713 88900208 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900209 SUP HCPCS C1713 88900209 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900210 SUP HCPCS C1713 88900210 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900211 SUP HCPCS C1713 88900211 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900213 SUP HCPCS C1713 88900213 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88900214 SUP HCPCS C1713 88900214 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 88901000 SUP HCPCS C1713 88901000 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 88905512 SUP Custom 27803010 88905512 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88905522 SUP Custom 27803010 88905522 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88905532 SUP Custom 27803010 88905532 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88924520 SUP HCPCS C1713 88924520 - SCREW BN 4.5MM 20MM TSRH SILO FA TI SPNE 5.5MM ROD BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88924525 SUP HCPCS C1713 88924525 - SCREW BN 4.5MM 25MM TSRH SILO FA TI SPNE 5.5MM ROD BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88924530 SUP HCPCS C1713 88924530 - SCREW BN 4.5MM 30MM TSRH SILO FA TI SPNE 5.5MM ROD BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88924535 SUP HCPCS C1713 88924535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88924540 SUP HCPCS C1713 88924540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88924545 SUP HCPCS C1713 88924545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88924550 SUP HCPCS C1713 88924550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925025 SUP HCPCS C1713 88925025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925030 SUP HCPCS C1713 88925030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925035 SUP HCPCS C1713 88925035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925040 SUP HCPCS C1713 88925040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925045 SUP HCPCS C1713 88925045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925050 SUP HCPCS C1713 88925050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925055 SUP HCPCS C1713 88925055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925525 SUP HCPCS C1713 88925525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925530 SUP HCPCS C1713 88925530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925535 SUP HCPCS C1713 88925535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925540 SUP HCPCS C1713 88925540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925545 SUP HCPCS C1713 88925545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925550 SUP HCPCS C1713 88925550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88925555 SUP HCPCS C1713 88925555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88926525 SUP HCPCS C1713 88926525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88926530 SUP HCPCS C1713 88926530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88926535 SUP HCPCS C1713 88926535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88926540 SUP HCPCS C1713 88926540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88926545 SUP HCPCS C1713 88926545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88926550 SUP HCPCS C1713 88926550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88926555 SUP HCPCS C1713 88926555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88926560 SUP HCPCS C1713 88926560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88927530 SUP HCPCS C1713 88927530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88927535 SUP HCPCS C1713 88927535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88927540 SUP HCPCS C1713 88927540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88927545 SUP HCPCS C1713 88927545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88927550 SUP HCPCS C1713 88927550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88927555 SUP HCPCS C1713 88927555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88927560 SUP HCPCS C1713 88927560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,906.50 " "$1,410.81" $0.00 "$1,525.20" $857.93 $857.93 $0.00 $0.00 $0.00 $397.36 "$1,415.00" "$1,415.00" $0.00 $0.00 $397.31 $0.00 "$1,127.69" "$1,127.69" $0.00 $953.25 "$1,509.95" "$1,525.20" $0.00 $0.00 $298.37 $0.00 $0.00 $303.51 $0.00 $0.00 $0.00 $0.00 $0.00 88934520 SUP Custom 27803010 88934520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88934525 SUP Custom 27803010 88934525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88934530 SUP HCPCS C1713 88934530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88934535 SUP Custom 27803010 88934535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88935525 SUP HCPCS C1713 88935525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88935530 SUP HCPCS C1713 88935530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88935535 SUP HCPCS C1713 88935535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88935540 SUP HCPCS C1713 88935540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88935545 SUP HCPCS C1713 88935545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88935550 SUP HCPCS C1713 88935550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88935555 SUP HCPCS C1713 88935555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88936525 SUP HCPCS C1713 88936525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88936530 SUP HCPCS C1713 88936530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88936535 SUP HCPCS C1713 88936535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88936540 SUP HCPCS C1713 88936540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88936545 SUP HCPCS C1713 88936545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88936550 SUP HCPCS C1713 88936550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88936555 SUP HCPCS C1713 88936555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88936560 SUP HCPCS C1713 88936560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88937525 SUP HCPCS C1713 88937525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88937530 SUP HCPCS C1713 88937530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88937535 SUP HCPCS C1713 88937535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88937540 SUP HCPCS C1713 88937540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88937545 SUP HCPCS C1713 88937545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88937550 SUP HCPCS C1713 88937550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88937555 SUP HCPCS C1713 88937555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88937560 SUP HCPCS C1713 88937560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 88944520 SUP HCPCS C1713 88944520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88944525 SUP HCPCS C1713 88944525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88944530 SUP HCPCS C1713 88944530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88944535 SUP HCPCS C1713 88944535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88944540 SUP HCPCS C1713 88944540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88944545 SUP HCPCS C1713 88944545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88944550 SUP HCPCS C1713 88944550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945025 SUP HCPCS C1713 88945025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945030 SUP HCPCS C1713 88945030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945035 SUP HCPCS C1713 88945035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945040 SUP HCPCS C1713 88945040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945045 SUP HCPCS C1713 88945045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945050 SUP HCPCS C1713 88945050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945055 SUP HCPCS C1713 88945055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945525 SUP HCPCS C1713 88945525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945530 SUP HCPCS C1713 88945530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945535 SUP HCPCS C1713 88945535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945540 SUP HCPCS C1713 88945540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945545 SUP HCPCS C1713 88945545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945550 SUP HCPCS C1713 88945550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88945555 SUP HCPCS C1713 88945555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88946525 SUP HCPCS C1713 88946525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88946530 SUP HCPCS C1713 88946530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88946535 SUP HCPCS C1713 88946535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88946540 SUP HCPCS C1713 88946540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88946545 SUP HCPCS C1713 88946545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88946550 SUP HCPCS C1713 88946550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88946555 SUP HCPCS C1713 88946555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88946560 SUP HCPCS C1713 88946560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947525 SUP HCPCS C1713 88947525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947530 SUP HCPCS C1713 88947530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947535 SUP HCPCS C1713 88947535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947540 SUP HCPCS C1713 88947540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947545 SUP HCPCS C1713 88947545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947550 SUP HCPCS C1713 88947550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947555 SUP HCPCS C1713 88947555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947560 SUP HCPCS C1713 88947560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947565 SUP HCPCS C1713 88947565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 88947570 SUP HCPCS C1713 88947570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,658.00 " "$1,966.92" $0.00 "$2,126.40" "$1,196.10" "$1,196.10" $0.00 $0.00 $0.00 $553.99 "$1,972.77" "$1,972.77" $0.00 $0.00 $553.93 $0.00 "$1,310.39" "$1,310.39" $0.00 "$1,329.00" "$2,105.14" "$2,126.40" $0.00 $0.00 $415.98 $0.00 $0.00 $423.15 $0.00 $0.00 $0.00 $0.00 $0.00 98716200 SUP HCPCS C1713 98716200 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $880.50 $651.57 $0.00 $704.40 $396.23 $396.23 $0.00 $0.00 $0.00 $183.52 $653.51 $653.51 $0.00 $0.00 $183.50 $0.00 $520.82 $520.82 $0.00 $440.25 $697.36 $704.40 $0.00 $0.00 $137.80 $0.00 $0.00 $140.18 $0.00 $0.00 $0.00 $0.00 $0.00 98716250 SUP HCPCS C1713 98716250 - SCREW BN 6.5MM 25MM PRMD VA TI SPNE ANT BOTH IP/OP $880.50 $651.57 $0.00 $704.40 $396.23 $396.23 $0.00 $0.00 $0.00 $183.52 $653.51 $653.51 $0.00 $0.00 $183.50 $0.00 $520.82 $520.82 $0.00 $440.25 $697.36 $704.40 $0.00 $0.00 $137.80 $0.00 $0.00 $140.18 $0.00 $0.00 $0.00 $0.00 $0.00 98716300 SUP HCPCS C1713 98716300 - SCREW BN 6.5MM 30MM PRMD VA TI SPNE ANT BOTH IP/OP $880.50 $651.57 $0.00 $704.40 $396.23 $396.23 $0.00 $0.00 $0.00 $183.52 $653.51 $653.51 $0.00 $0.00 $183.50 $0.00 $520.82 $520.82 $0.00 $440.25 $697.36 $704.40 $0.00 $0.00 $137.80 $0.00 $0.00 $140.18 $0.00 $0.00 $0.00 $0.00 $0.00 98716350 SUP HCPCS C1713 98716350 - SCREW BN 6.5MM 35MM PRMD VA TI SPNE ANT BOTH IP/OP $880.50 $651.57 $0.00 $704.40 $396.23 $396.23 $0.00 $0.00 $0.00 $183.52 $653.51 $653.51 $0.00 $0.00 $183.50 $0.00 $520.82 $520.82 $0.00 $440.25 $697.36 $704.40 $0.00 $0.00 $137.80 $0.00 $0.00 $140.18 $0.00 $0.00 $0.00 $0.00 $0.00 99415530 SUP HCPCS C1713 99415530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99415535 SUP HCPCS C1713 99415535 - PLATE 18MM TI BONE SPNL BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99415540 SUP HCPCS C1713 99415540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99415545 SUP HCPCS C1713 99415545 - PLATE 18MM TI BONE SPNL BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99415550 SUP HCPCS C1713 99415550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99415555 SUP HCPCS C1713 99415555 - PLATE 18MM TI BONE SPNL BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99416530 SUP HCPCS C1713 99416530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99416535 SUP HCPCS C1713 99416535 - PLATE 18MM TI BONE SPNL BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99416540 SUP HCPCS C1713 99416540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99416545 SUP HCPCS C1713 99416545 - PLATE 18MM TI BONE SPNL BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99416550 SUP HCPCS C1713 99416550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99417535 SUP HCPCS C1713 99417535 - PLATE 18MM TI BONE SPNL BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99417540 SUP HCPCS C1713 99417540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99417545 SUP HCPCS C1713 99417545 - PLATE 18MM TI BONE SPNL BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99417550 SUP HCPCS C1713 99417550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 99435530 SUP Custom 27803010 99435530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99435535 SUP Custom 27803010 99435535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99435540 SUP Custom 27803010 99435540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99435545 SUP Custom 27803010 99435545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99435550 SUP Custom 27803010 99435550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99435555 SUP Custom 27803010 99435555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99436530 SUP Custom 27803010 99436530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99436535 SUP Custom 27803010 99436535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99436540 SUP Custom 27803010 99436540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99436545 SUP Custom 27803010 99436545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99436550 SUP Custom 27803010 99436550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99436555 SUP Custom 27803010 99436555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99436560 SUP Custom 27803010 99436560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99437535 SUP Custom 27803010 99437535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99437540 SUP HCPCS C1713 99437540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $741.15 $741.15 $0.00 $0.00 $0.00 $343.28 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $974.20 $974.20 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $257.76 $0.00 $0.00 $262.20 $0.00 $0.00 $0.00 $0.00 $0.00 99437545 SUP HCPCS C1713 99437545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $741.15 $741.15 $0.00 $0.00 $0.00 $343.28 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $974.20 $974.20 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $257.76 $0.00 $0.00 $262.20 $0.00 $0.00 $0.00 $0.00 $0.00 99437550 SUP Custom 27803010 99437550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99437555 SUP Custom 27803010 99437555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99437560 SUP Custom 27803010 99437560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,647.00 " "$1,218.78" $0.00 "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.40" "$1,222.40" $0.00 $0.00 $343.23 $0.00 $0.00 $0.00 $0.00 $823.50 "$1,304.42" "$1,317.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453105 SUP HCPCS C1713 99453105 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 99453110 SUP HCPCS C1713 99453110 - PLATE 18MM TI BONE SPNL BOTH IP/OP $201.00 $148.74 $0.00 $160.80 $90.45 $90.45 $0.00 $0.00 $0.00 $41.89 $149.18 $149.18 $0.00 $0.00 $41.89 $0.00 $118.89 $118.89 $0.00 $100.50 $159.19 $160.80 $0.00 $0.00 $31.46 $0.00 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453115 SUP HCPCS C1713 99453115 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 99453200 SUP Custom 27803010 99453200 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,596.43 " "$1,181.36" $0.00 "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,184.87" "$1,184.87" $0.00 $0.00 $332.69 $0.00 $0.00 $0.00 $0.00 $798.21 "$1,264.37" "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453201 SUP Custom 27803010 99453201 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,596.43 " "$1,181.36" $0.00 "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,184.87" "$1,184.87" $0.00 $0.00 $332.69 $0.00 $0.00 $0.00 $0.00 $798.21 "$1,264.37" "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453202 SUP Custom 27803010 99453202 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,596.43 " "$1,181.36" $0.00 "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,184.87" "$1,184.87" $0.00 $0.00 $332.69 $0.00 $0.00 $0.00 $0.00 $798.21 "$1,264.37" "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453301 SUP HCPCS C1713 99453301 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,596.43 " "$1,181.36" $0.00 "$1,277.14" $718.39 $718.39 $0.00 $0.00 $0.00 $332.73 "$1,184.87" "$1,184.87" $0.00 $0.00 $332.69 $0.00 $944.29 $944.29 $0.00 $798.21 "$1,264.37" "$1,277.14" $0.00 $0.00 $249.84 $0.00 $0.00 $254.15 $0.00 $0.00 $0.00 $0.00 $0.00 99453302 SUP Custom 27803010 99453302 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,596.43 " "$1,181.36" $0.00 "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,184.87" "$1,184.87" $0.00 $0.00 $332.69 $0.00 $0.00 $0.00 $0.00 $798.21 "$1,264.37" "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453305 SUP Custom 27803010 99453305 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,596.43 " "$1,181.36" $0.00 "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,184.87" "$1,184.87" $0.00 $0.00 $332.69 $0.00 $0.00 $0.00 $0.00 $798.21 "$1,264.37" "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453306 SUP Custom 27803010 99453306 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,596.43 " "$1,181.36" $0.00 "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,184.87" "$1,184.87" $0.00 $0.00 $332.69 $0.00 $0.00 $0.00 $0.00 $798.21 "$1,264.37" "$1,277.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453501 SUP Custom 27803010 99453501 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,183.50 " $875.79 $0.00 $946.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $878.39 $878.39 $0.00 $0.00 $246.64 $0.00 $0.00 $0.00 $0.00 $591.75 $937.33 $946.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99453502 SUP Custom 27803010 99453502 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,183.50 " $875.79 $0.00 $946.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $878.39 $878.39 $0.00 $0.00 $246.64 $0.00 $0.00 $0.00 $0.00 $591.75 $937.33 $946.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99460035 SUP HCPCS C1713 99460035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460040 SUP HCPCS C1713 99460040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460045 SUP HCPCS C1713 99460045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460050 SUP HCPCS C1713 99460050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460055 SUP HCPCS C1713 99460055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460060 SUP HCPCS C1713 99460060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460065 SUP HCPCS C1713 99460065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460070 SUP HCPCS C1713 99460070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460075 SUP HCPCS C1713 99460075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99460080 SUP HCPCS C1713 99460080 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461035 SUP HCPCS C1713 99461035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461040 SUP HCPCS C1713 99461040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461045 SUP HCPCS C1713 99461045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461050 SUP HCPCS C1713 99461050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461055 SUP HCPCS C1713 99461055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461060 SUP HCPCS C1713 99461060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461065 SUP HCPCS C1713 99461065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461070 SUP HCPCS C1713 99461070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461075 SUP HCPCS C1713 99461075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99461080 SUP HCPCS C1713 99461080 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99462040 SUP HCPCS C1713 99462040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99462060 SUP HCPCS C1713 99462060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99462080 SUP HCPCS C1713 99462080 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99464035 SUP HCPCS C1713 99464035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99464040 SUP HCPCS C1713 99464040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99464050 SUP HCPCS C1713 99464050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99464060 SUP HCPCS C1713 99464060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99464070 SUP HCPCS C1713 99464070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99465106 SUP HCPCS C1713 99465106 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 99465115 SUP Custom 27803010 99465115 - PLATE 18MM TI BONE SPNL BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $142.50 $0.00 $0.00 $40.01 $0.00 $0.00 $0.00 $0.00 $96.00 $152.06 $153.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99465126 SUP HCPCS C1713 99465126 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 99465135 SUP HCPCS C1713 99465135 - PLATE 18MM TI BONE SPNL BOTH IP/OP $109.50 $81.03 $0.00 $87.60 $49.28 $49.28 $0.00 $0.00 $0.00 $22.82 $81.27 $81.27 $0.00 $0.00 $22.82 $0.00 $64.77 $64.77 $0.00 $54.75 $86.72 $87.60 $0.00 $0.00 $17.14 $0.00 $0.00 $17.43 $0.00 $0.00 $0.00 $0.00 $0.00 99465140 SUP HCPCS C1713 99465140 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $192.00 $142.08 $0.00 $153.60 $86.40 $86.40 $0.00 $0.00 $0.00 $40.02 $142.50 $142.50 $0.00 $0.00 $40.01 $0.00 $113.57 $113.57 $0.00 $96.00 $152.06 $153.60 $0.00 $0.00 $30.05 $0.00 $0.00 $30.57 $0.00 $0.00 $0.00 $0.00 $0.00 99466035 SUP HCPCS C1713 99466035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99466040 SUP HCPCS C1713 99466040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99466050 SUP HCPCS C1713 99466050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99466060 SUP HCPCS C1713 99466060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99466070 SUP HCPCS C1713 99466070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 99467085 SUP HCPCS C1713 99467085 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99467090 SUP HCPCS C1713 99467090 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99467095 SUP HCPCS C1713 99467095 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99467100 SUP HCPCS C1713 99467100 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467105 SUP HCPCS C1713 99467105 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467110 SUP HCPCS C1713 99467110 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467115 SUP HCPCS C1713 99467115 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467120 SUP HCPCS C1713 99467120 - PLATE BN STRG 120MM TI SPNE BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467125 SUP HCPCS C1713 99467125 - PLATE BN STRG 125MM TI SPNE BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467130 SUP HCPCS C1713 99467130 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467135 SUP HCPCS C1713 99467135 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467140 SUP HCPCS C1713 99467140 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467145 SUP HCPCS C1713 99467145 - PLATE BN STRG 145MM TI SPNE BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467150 SUP HCPCS C1713 99467150 - PLATE BN STRG 150MM TI SPNE BOTH IP/OP "$2,425.50 " "$1,794.87" $0.00 "$1,940.40" "$1,091.48" "$1,091.48" $0.00 $0.00 $0.00 $505.53 "$1,800.21" "$1,800.21" $0.00 $0.00 $505.47 $0.00 "$1,434.68" "$1,434.68" $0.00 "$1,212.75" "$1,921.00" "$1,940.40" $0.00 $0.00 $379.59 $0.00 $0.00 $386.14 $0.00 $0.00 $0.00 $0.00 $0.00 99467170 SUP HCPCS C1713 99467170 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,887.50 " "$2,136.75" $0.00 "$2,310.00" "$1,299.38" "$1,299.38" $0.00 $0.00 $0.00 $601.83 "$2,143.10" "$2,143.10" $0.00 $0.00 $601.76 $0.00 "$1,423.54" "$1,423.54" $0.00 "$1,443.75" "$2,286.90" "$2,310.00" $0.00 $0.00 $451.89 $0.00 $0.00 $459.69 $0.00 $0.00 $0.00 $0.00 $0.00 99467180 SUP HCPCS C1713 99467180 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,887.50 " "$2,136.75" $0.00 "$2,310.00" "$1,299.38" "$1,299.38" $0.00 $0.00 $0.00 $601.83 "$2,143.10" "$2,143.10" $0.00 $0.00 $601.76 $0.00 "$1,423.54" "$1,423.54" $0.00 "$1,443.75" "$2,286.90" "$2,310.00" $0.00 $0.00 $451.89 $0.00 $0.00 $459.69 $0.00 $0.00 $0.00 $0.00 $0.00 99467190 SUP HCPCS C1713 99467190 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,887.50 " "$2,136.75" $0.00 "$2,310.00" "$1,299.38" "$1,299.38" $0.00 $0.00 $0.00 $601.83 "$2,143.10" "$2,143.10" $0.00 $0.00 $601.76 $0.00 "$1,423.54" "$1,423.54" $0.00 "$1,443.75" "$2,286.90" "$2,310.00" $0.00 $0.00 $451.89 $0.00 $0.00 $459.69 $0.00 $0.00 $0.00 $0.00 $0.00 99467200 SUP HCPCS C1713 99467200 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,887.50 " "$2,136.75" $0.00 "$2,310.00" "$1,299.38" "$1,299.38" $0.00 $0.00 $0.00 $601.83 "$2,143.10" "$2,143.10" $0.00 $0.00 $601.76 $0.00 "$1,423.54" "$1,423.54" $0.00 "$1,443.75" "$2,286.90" "$2,310.00" $0.00 $0.00 $451.89 $0.00 $0.00 $459.69 $0.00 $0.00 $0.00 $0.00 $0.00 99468085 SUP HCPCS C1713 99468085 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99468090 SUP HCPCS C1713 99468090 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99468095 SUP HCPCS C1713 99468095 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 99468100 SUP HCPCS C1713 99468100 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,253.00 " "$1,667.22" $0.00 "$1,802.40" "$1,013.85" "$1,013.85" $0.00 $0.00 $0.00 $469.58 "$1,672.18" "$1,672.18" $0.00 $0.00 $469.53 $0.00 "$1,332.65" "$1,332.65" $0.00 "$1,126.50" "$1,784.38" "$1,802.40" $0.00 $0.00 $352.59 $0.00 $0.00 $358.68 $0.00 $0.00 $0.00 $0.00 $0.00 100003331 SUP Custom 27203010 100003331 - KIT ELTRD NS LF ENSITE NAVX SRFC DISP BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $0.00 $0.00 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 136521000 SUP HCPCS C1776 136521000 - HEAD FEM +1MM 12/14 STD TPR 32MM STRL LF ART/EZE MTL HIP BOTH IP/OP "$2,985.00 " "$2,208.90" $0.00 "$2,388.00" "$1,343.25" "$1,343.25" $0.00 $0.00 $0.00 $622.15 "$2,215.47" "$2,215.47" $0.00 $0.00 $622.07 $0.00 "$1,471.61" "$1,471.61" $0.00 "$1,492.50" "$2,364.12" "$2,388.00" $0.00 $0.00 $467.15 $0.00 $0.00 $475.21 $0.00 $0.00 $0.00 $0.00 $0.00 136522000 SUP HCPCS C1776 136522000 - HEAD FEM +5MM 12/14 STD TPR 32MM STRL LF ART/EZE MTL HIP BOTH IP/OP "$2,985.00 " "$2,208.90" $0.00 "$2,388.00" "$1,343.25" "$1,343.25" $0.00 $0.00 $0.00 $622.15 "$2,215.47" "$2,215.47" $0.00 $0.00 $622.07 $0.00 "$1,471.61" "$1,471.61" $0.00 "$1,492.50" "$2,364.12" "$2,388.00" $0.00 $0.00 $467.15 $0.00 $0.00 $475.21 $0.00 $0.00 $0.00 $0.00 $0.00 136523000 SUP HCPCS C1776 136523000 - HEAD FEM +9MM 12/14 STD TPR 32MM STRL LF ART/EZE MTL HIP BOTH IP/OP "$3,045.00 " "$2,253.30" $0.00 "$2,436.00" "$1,370.25" "$1,370.25" $0.00 $0.00 $0.00 $634.65 "$2,260.00" "$2,260.00" $0.00 $0.00 $634.58 $0.00 "$1,501.19" "$1,501.19" $0.00 "$1,522.50" "$2,411.64" "$2,436.00" $0.00 $0.00 $476.54 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 154106000 SUP HCPCS C1776 154106000 - STEM FEMORAL 1 HIGH OFFST 105MM CEMENTED HIP BOTH IP/OP "$14,182.50 " "$10,495.05" $0.00 "$11,346.00" "$6,382.13" "$6,382.13" $0.00 $0.00 $0.00 "$2,955.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,955.63" $0.00 "$6,991.97" "$6,991.97" $0.00 "$7,091.25" "$11,232.54" "$11,346.00" $0.00 $0.00 "$2,219.56" $0.00 $0.00 "$2,257.85" $0.00 $0.00 $0.00 $0.00 $0.00 154118000 SUP HCPCS C1776 154118000 - STEM FEMORAL 3 150MM CEMENTED EXTN PROSTALAC HIP RIGHT BOTH IP/OP "$14,820.00 " "$10,966.80" $0.00 "$11,856.00" "$6,669.00" "$6,669.00" $0.00 $0.00 $0.00 "$3,088.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,088.49" $0.00 "$7,306.26" "$7,306.26" $0.00 "$7,410.00" "$11,737.44" "$11,856.00" $0.00 $0.00 "$2,319.33" $0.00 $0.00 "$2,359.34" $0.00 $0.00 $0.00 $0.00 $0.00 177300130 SUP Custom 27803010 177300130 - CAGE SPNL 12MM STD PRLL 14X30MM NS LF BENGAL STKBL RDLCNT BOTH IP/OP "$8,790.00 " "$6,504.60" $0.00 "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,831.84" $0.00 $0.00 $0.00 $0.00 "$4,395.00" "$6,961.68" "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 177306122 SUP Custom 27803010 177306122 - CAGE SPNL 12MM STD LRDTC 14X22MM NS LF BENGAL STKBL RDLCNT BOTH IP/OP "$8,790.00 " "$6,504.60" $0.00 "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,831.84" $0.00 $0.00 $0.00 $0.00 "$4,395.00" "$6,961.68" "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 177306124 SUP Custom 27803010 177306124 - CAGE SPNL STD LRDTC 24X14X12MM NS LF BENGAL STKBL RDLCNT BOTH IP/OP "$8,790.00 " "$6,504.60" $0.00 "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,831.84" $0.00 $0.00 $0.00 $0.00 "$4,395.00" "$6,961.68" "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 177306126 SUP Custom 27803010 177306126 - CAGE SPNL 12MM STD LRDTC 14X26MM NS LF BENGAL STKBL RDLCNT BOTH IP/OP "$8,790.00 " "$6,504.60" $0.00 "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,831.84" $0.00 $0.00 $0.00 $0.00 "$4,395.00" "$6,961.68" "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 177306128 SUP Custom 27803010 177306128 - CAGE SPNL 12MM STD LRDTC 14X28MM NS LF BENGAL STKBL RDLCNT BOTH IP/OP "$8,790.00 " "$6,504.60" $0.00 "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,831.84" $0.00 $0.00 $0.00 $0.00 "$4,395.00" "$6,961.68" "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 177306130 SUP Custom 27803010 177306130 - CAGE SPNL 12MM STD LRDTC 14X30MM NS LF BENGAL STKBL RDLCNT BOTH IP/OP "$8,790.00 " "$6,504.60" $0.00 "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,831.84" $0.00 $0.00 $0.00 $0.00 "$4,395.00" "$6,961.68" "$7,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179702000 SUP HCPCS C1713 179702000 - SCREW SET 1 INNER MNOAX EXPEDIUM TITANIUM SPN BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 179706070 SUP HCPCS C1713 179706070 - SCREW BONE 10MM 70MM T27 VIPER TITANIUM ILIUM BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 179706870 SUP HCPCS C1713 179706870 - SCREW BONE 8MM 70MM VIPER TITANIUM SPN ILIUM PEDICLE T27 BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 179706880 SUP HCPCS C1713 179706880 - SCREW BONE 8MM 80MM VIPER TITANIUM SPN ILIUM PEDICLE T27 BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 179706970 SUP HCPCS C1713 179706970 - SCREW BONE 9MM 70MM VIPER TITANIUM ILIUM T27 BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712035 SUP HCPCS C1713 179712035 - SCREW BN 7.5MM 35MM NS XPDM 1 INNIE PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712040 SUP HCPCS C1713 179712040 - SCREW BN 7.5MM 40MM NS XPDM 1 INNIE PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712045 SUP HCPCS C1713 179712045 - SCREW BN 7.5MM 45MM NS XPDM 1 INNIE PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712050 SUP HCPCS C1713 179712050 - SCREW BN 7.5MM 50MM NS XPDM 1 INNIE PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712055 SUP HCPCS C1713 179712055 - SCREW BN 7.5MM 55MM NS XPDM 1 INNIE PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712080 SUP HCPCS C1713 179712080 - SCREW BONE 7.5MM 80MM XPDM TI SPNL POLYAX 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712420 SUP HCPCS C1713 179712420 - SCREW BONE 4.35MM 20MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712425 SUP HCPCS C1713 179712425 - SCREW BONE 4.35MM 25MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712430 SUP HCPCS C1713 179712430 - SCREW BONE 4.35MM 30MM 1 INNIE POLYAX EXPEDIUM TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712435 SUP HCPCS C1713 179712435 - SCREW BONE 4.35MM 35MM 1 INNIE POLYAX EXPEDIUM TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712440 SUP HCPCS C1713 179712440 - SCREW BONE 4.35MM 40MM 1 INNIE POLYAX EXPEDIUM TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712445 SUP HCPCS C1713 179712445 - SCREW BN 4.5MM 45MM NS XPDM 1 INNIE PA TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712530 SUP HCPCS C1713 179712530 - SCREW BONE 5MM 30MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712535 SUP HCPCS C1713 179712535 - SCREW BONE 5MM 35MM 1 INNIE POLYAX EXPEDIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712540 SUP HCPCS C1713 179712540 - SCREW BONE 5MM 40MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712545 SUP HCPCS C1713 179712545 - SCREW BONE 5MM 45MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712550 SUP HCPCS C1713 179712550 - SCREW BONE 5MM 50MM 1 INNIE POLYAX EXPEDIUM TITANIUM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712630 SUP HCPCS C1713 179712630 - SCREW BONE 6MM 30MM POLYAX 1 INNIE EXPEDIUM TITANIUM SPN 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712635 SUP HCPCS C1713 179712635 - SCREW BONE 6MM 35MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712640 SUP HCPCS C1713 179712640 - SCREW BONE 6MM 40MM XPDM TI ANT CERV SPN POLYAX 1 INNIE 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712645 SUP HCPCS C1713 179712645 - SCREW BONE 6MM 45MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712650 SUP HCPCS C1713 179712650 - SCREW BONE 6MM 50MM 1 INNIE POLYAX EXPEDIUM TITANIUM SPN 5.5 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712735 SUP HCPCS C1713 179712735 - SCREW BONE 7MM 35MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712740 SUP HCPCS C1713 179712740 - SCREW BONE 7MM 40MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712745 SUP HCPCS C1713 179712745 - SCREW BONE 7MM 45MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712750 SUP HCPCS C1713 179712750 - SCREW BONE 7MM 50MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179712755 SUP HCPCS C1713 179712755 - SCREW BONE 7MM 55MM XPDM TI SPNL POLYAX 1 INNIE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179715540 SUP HCPCS C1713 179715540 - SCREW BONE 5.5MM 40MM POLYAX EXPEDIUM TITANIUM SPN 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179715545 SUP HCPCS C1713 179715545 - SCREW BONE 5.5MM 45MM POLYAX EXPEDIUM TITANIUM SPN 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179715635 SUP HCPCS C1713 179715635 - SCREW BONE 6.5MM 35MM POLYAX EXPEDIUM TITANIUM SPN 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179715645 SUP HCPCS C1713 179715645 - SCREW BONE 6.5MM 45MM 1 INNIE POLYAX EXPEDIUM TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 179722050 SUP HCPCS C1713 179722050 - SET SCR DISTAL TI UNT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 179722890 SUP HCPCS C1713 179722890 - SCREW DI POLYAXL 8 X 90MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 179762120 SUP HCPCS C1713 179762120 - ROD SPINAL 5.5MM 120MM PRECUT HEXAGONAL END EXPEDIUM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 179762300 SUP HCPCS C1713 179762300 - ROD SPINAL 300MM NONSTRL BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $627.75 $627.75 $0.00 $0.00 $0.00 $290.75 "$1,035.37" "$1,035.37" $0.00 $0.00 $290.72 $0.00 $825.14 $825.14 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $218.32 $0.00 $0.00 $222.08 $0.00 $0.00 $0.00 $0.00 $0.00 179762480 SUP HCPCS C1713 179762480 - ROD SPINAL 5.5MM 480MM PRECUT HEXAGONAL END EXPEDIUM BOTH IP/OP "$1,395.00 " "$1,032.30" $0.00 "$1,116.00" $627.75 $627.75 $0.00 $0.00 $0.00 $290.75 "$1,035.37" "$1,035.37" $0.00 $0.00 $290.72 $0.00 $825.14 $825.14 $0.00 $697.50 "$1,104.84" "$1,116.00" $0.00 $0.00 $218.32 $0.00 $0.00 $222.08 $0.00 $0.00 $0.00 $0.00 $0.00 179771055 SUP HCPCS C1713 179771055 - ROD SPNL 5.5MM 55MM NS XPDM PREBNT LN TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 179771065 SUP HCPCS C1713 179771065 - ROD SPINAL 5.5MM 65MM PRELORDOSED LINE EXPEDIUM TITANIUM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 179771075 SUP HCPCS C1713 179771075 - ROD SPINAL 5.5MM 75MM PRELORDOSED LINE EXPEDIUM TITANIUM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 179771085 SUP HCPCS C1713 179771085 - ROD SPINAL 5.5MM 85MM PRELORDOSED LINE EXPEDIUM TITANIUM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 179771090 SUP HCPCS C1713 179771090 - ROD SPINAL 5.5MM 90MM PRELORDOSED LINE EXPEDIUM TITANIUM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 179771095 SUP HCPCS C1713 179771095 - ROD SPINAL 5.5MM 95MM PRELORDOSED LINE EXPEDIUM TITANIUM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 179772045 SUP Custom 27803010 179772045 - ROD SPNL 45MM 5.5MM MS M SI TI PREBNT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179772055 SUP Custom 27803010 179772055 - ROD SPNL 55MM 5.5MM MS M SI TI PREBNT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179793020 SUP HCPCS C1713 179793020 - CONNECTOR ROD 5.5MM 20MM OPEN FIX TITANIUM LATERAL BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $968.63 $968.63 $0.00 $0.00 $0.00 $448.63 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 "$1,273.20" "$1,273.20" $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $336.87 $0.00 $0.00 $342.68 $0.00 $0.00 $0.00 $0.00 $0.00 179797020 SUP HCPCS C1713 179797020 - CONNECTOR ROD 5.5MM 20MM OPEN EXPEDIUM TITANIUM ILIAC SPN BOTH IP/OP "$2,550.00 " "$1,887.00" $0.00 "$2,040.00" "$1,147.50" "$1,147.50" $0.00 $0.00 $0.00 $531.48 "$1,892.61" "$1,892.61" $0.00 $0.00 $531.42 $0.00 "$1,257.15" "$1,257.15" $0.00 "$1,275.00" "$2,019.60" "$2,040.00" $0.00 $0.00 $399.08 $0.00 $0.00 $405.96 $0.00 $0.00 $0.00 $0.00 $0.00 179797025 SUP HCPCS C1713 179797025 - CONNECTOR ROD 5.5MM 20MM OPEN EXTENDED TAB EXPEDIUM TITANIUM BOTH IP/OP "$2,550.00 " "$1,887.00" $0.00 "$2,040.00" "$1,147.50" "$1,147.50" $0.00 $0.00 $0.00 $531.48 "$1,892.61" "$1,892.61" $0.00 $0.00 $531.42 $0.00 "$1,257.15" "$1,257.15" $0.00 "$1,275.00" "$2,019.60" "$2,040.00" $0.00 $0.00 $399.08 $0.00 $0.00 $405.96 $0.00 $0.00 $0.00 $0.00 $0.00 179797040 SUP HCPCS C1713 179797040 - CONNECTOR ROD 5.5MM 40MM OPEN EXPEDIUM TITANIUM ILIAC SPN BOTH IP/OP "$2,550.00 " "$1,887.00" $0.00 "$2,040.00" "$1,147.50" "$1,147.50" $0.00 $0.00 $0.00 $531.48 "$1,892.61" "$1,892.61" $0.00 $0.00 $531.42 $0.00 "$1,257.15" "$1,257.15" $0.00 "$1,275.00" "$2,019.60" "$2,040.00" $0.00 $0.00 $399.08 $0.00 $0.00 $405.96 $0.00 $0.00 $0.00 $0.00 $0.00 179798020 SUP HCPCS C1713 179798020 - CONNECTOR ROD 5.5MM 20MM XPDM CLS TI SPNE ILC BOTH IP/OP "$2,550.00 " "$1,887.00" $0.00 "$2,040.00" "$1,147.50" "$1,147.50" $0.00 $0.00 $0.00 $531.48 "$1,892.61" "$1,892.61" $0.00 $0.00 $531.42 $0.00 "$1,257.15" "$1,257.15" $0.00 "$1,275.00" "$2,019.60" "$2,040.00" $0.00 $0.00 $399.08 $0.00 $0.00 $405.96 $0.00 $0.00 $0.00 $0.00 $0.00 183612032 SUP HCPCS C1713 183612032 - PLATE 32MM LVL 2 EGL PLUS BONE ANT CERV SPN BOTH IP/OP "$2,328.75 " "$1,723.28" $0.00 "$1,863.00" "$1,047.94" "$1,047.94" $0.00 $0.00 $0.00 $485.37 "$1,728.40" "$1,728.40" $0.00 $0.00 $485.31 $0.00 "$1,377.46" "$1,377.46" $0.00 "$1,164.38" "$1,844.37" "$1,863.00" $0.00 $0.00 $364.45 $0.00 $0.00 $370.74 $0.00 $0.00 $0.00 $0.00 $0.00 183651016 SUP HCPCS C1713 183651016 - SCREW BONE 4.4MM 16MM EGL PLUS SWIFT PLUS ANT CERV SPN OVSZ BOTH IP/OP $388.13 $287.22 $0.00 $310.50 $174.66 $174.66 $0.00 $0.00 $0.00 $80.89 $288.07 $288.07 $0.00 $0.00 $80.89 $0.00 $229.58 $229.58 $0.00 $194.06 $307.40 $310.50 $0.00 $0.00 $60.74 $0.00 $0.00 $61.79 $0.00 $0.00 $0.00 $0.00 $0.00 183656016 SUP HCPCS C1713 183656016 - SCREW BONE 4.25MM 16MM EGL PLUS SWIFT PLUS ANT CERV SPN PRIM BOTH IP/OP $388.13 $287.22 $0.00 $310.50 $174.66 $174.66 $0.00 $0.00 $0.00 $80.89 $288.07 $288.07 $0.00 $0.00 $80.89 $0.00 $229.58 $229.58 $0.00 $194.06 $307.40 $310.50 $0.00 $0.00 $60.74 $0.00 $0.00 $61.79 $0.00 $0.00 $0.00 $0.00 $0.00 185200320 SUP HCPCS C1757 185200320 - TUBE NASOPHARYNGEAL 32FR 170MM ADJUSTABLE FLANGE ROUND TIP BOTH IP/OP $11.68 $8.64 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 $2.43 $8.67 $8.67 $0.00 $0.00 $2.43 $0.00 $6.91 $6.91 $0.00 $5.84 $9.25 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186715000 SUP HCPCS C1713 186715000 - SCREW SET TI SPNL 1 INNIE INR XPDM BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 186715080 SUP HCPCS C1713 186715080 - SCREW BONE 7.5MM 80MM POLYAX CANN VIPER 2 TITANIUM SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186715530 SUP HCPCS C1713 186715530 - SCREW BONE 5MM 30MM VPR TI SPNL POLYAX CANN MN INV SRG BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186715535 SUP HCPCS C1713 186715535 - SCREW BONE 5MM 35MM VPR TI SPNL POLYAX CANN MN INV SRG BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186715540 SUP HCPCS C1713 186715540 - SCREW BONE 5MM 40MM VPR TI SPNL POLYAX CANN MN INV SRG BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186715635 SUP HCPCS C1713 186715635 - SCREW BONE 6MM 35MM VPR TI SPNL POLYAX CANN MN INV SRG BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186715640 SUP HCPCS C1713 186715640 - SCREW BONE 6MM 40MM POLYAX CANN VIPER TITANIUM SPN MIS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186715645 SUP HCPCS C1713 186715645 - SCREW BONE 6MM 45MM VPR TI SPNL POLYAX CANN MN INV SRG BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186715730 SUP HCPCS C1713 186715730 - SCREW BONE 7MM 30MM POLYAX CANN VIPER 2 TITANIUM SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186715855 SUP HCPCS C1713 186715855 - SCREW BONE 8MM 55MM POLYAX VIPER TITANIUM SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186731530 SUP HCPCS C1713 186731530 - SCREW BONE 5MM 30MM POLYAX FIX TITANIUM SPN CORTICAL 5.5MM BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 186731535 SUP HCPCS C1713 186731535 - SCREW BONE 5MM 35MM POLYAX FIX TITANIUM SPN CORTICAL 5.5MM BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 186731540 SUP HCPCS C1713 186731540 - SCREW BONE 5MM 40MM FIX EXPEDIUM TITANIUM SPN CORTICAL 5.5MM BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 186731635 SUP HCPCS C1713 186731635 - SCREW BONE 6MM 35MM XPDM VPR TI SPN CORT FIX 5.5MM BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 186731640 SUP HCPCS C1713 186731640 - SCREW BONE 6MM 40MM FIX EXPEDIUM TITANIUM SPN CORTICAL 5.5MM BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 186731650 SUP HCPCS C1713 186731650 - SCREW BN 6MM 50MM VPR FX TI SPNE CORT 5.5MM ROD BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 186750030 SUP HCPCS C1713 186750030 - SCREW BONE 5MM 30MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750035 SUP HCPCS C1713 186750035 - SCREW BONE 5MM 35MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750040 SUP HCPCS C1713 186750040 - SCREW BONE 5MM 40MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750045 SUP HCPCS C1713 186750045 - SCREW BONE 5MM 45MM CANN EXTENDED TAB VIPER 2 TITANIUM SPN BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750050 SUP HCPCS C1713 186750050 - SCREW BONE 5MM 50MM CANN EXTENDED TAB VIPER 2 TITANIUM SPN BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750230 SUP HCPCS C1713 186750230 - SCREW BONE 5X30MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750235 SUP HCPCS C1713 186750235 - SCREW BONE 5X35MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750250 SUP HCPCS C1713 186750250 - SCREW BONE 5X50MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750255 SUP HCPCS C1713 186750255 - SCREW BONE 5X55MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186750430 SUP HCPCS C1713 186750430 - SCREW BONE 5X30MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186750435 SUP HCPCS C1713 186750435 - SCREW BONE 5X35MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186750450 SUP HCPCS C1713 186750450 - SCREW BONE 5X50MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186750455 SUP HCPCS C1713 186750455 - SCREW BONE 5X55MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186760035 SUP HCPCS C1713 186760035 - SCREW BONE 6MM 35MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186760040 SUP HCPCS C1713 186760040 - SCREW BONE 6MM 40MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186760045 SUP HCPCS C1713 186760045 - SCREW BONE 6MM 45MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186760050 SUP HCPCS C1713 186760050 - SCREW BONE 6MM 50MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186760230 SUP HCPCS C1713 186760230 - SCREW BONE 6X30MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186760255 SUP HCPCS C1713 186760255 - SCREW BONE 6X55MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186760430 SUP HCPCS C1713 186760430 - SCREW BONE 6X30MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186760455 SUP HCPCS C1713 186760455 - SCREW BONE 6X55MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186770035 SUP HCPCS C1713 186770035 - SCREW BONE 7MM 35MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186770040 SUP HCPCS C1713 186770040 - SCREW BONE 7MM 40MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186770045 SUP HCPCS C1713 186770045 - SCREW BONE 7MM 45MM VPR 2 TI SPNL CANN XTD TAB MN INV SRG BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186770050 SUP HCPCS C1713 186770050 - SCREW BONE 7MM 50MM CANN EXTENDED TAB VIPER 2 TITANIUM SPN BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186770230 SUP HCPCS C1713 186770230 - SCREW BONE 7X30MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186770235 SUP HCPCS C1713 186770235 - SCREW BONE 7X35MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186770430 SUP HCPCS C1713 186770430 - SCREW BONE 7X30MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186770435 SUP HCPCS C1713 186770435 - SCREW BONE 7X35MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186770460 SUP HCPCS C1713 186770460 - SCREW BONE 7X60MM VIPER PRIME CFXFEN XTAB BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 186775235 SUP HCPCS C1713 186775235 - SCREW BONE 7.5X35MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186775240 SUP HCPCS C1713 186775240 - SCREW BONE 7.5X40MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186775245 SUP HCPCS C1713 186775245 - SCREW BONE 7.5X45MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186775250 SUP HCPCS C1713 186775250 - SCREW BONE 7.5X50MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186775255 SUP HCPCS C1713 186775255 - SCREW BONE 7.5X55MM TI VIPER PRIME X-TAB BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 186787040 SUP Custom 27803010 186787040 - ROD SPNL 40MM VPR 2 TI KYPHOSED MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186787080 SUP Custom 27803010 186787080 - ROD SPNL 80MM VPR 2 TI KYPHOSED MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186787090 SUP Custom 27803010 186787090 - ROD SPNL 90MM VPR 2 TI KYPHOSED MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186787100 SUP Custom 27803010 186787100 - ROD SPNL 100MM VPR 2 TI KYPHOSED MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186787110 SUP Custom 27803010 186787110 - ROD SPNL 110MM VPR 2 TI KYPHOSED MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186787200 SUP Custom 27803010 186787200 - ROD SPNL 200MM VPR 2 TI KYPHOSED MN INV SRG BOTH IP/OP "$1,710.00 " "$1,265.40" $0.00 "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,269.16" "$1,269.16" $0.00 $0.00 $356.36 $0.00 $0.00 $0.00 $0.00 $855.00 "$1,354.32" "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186788035 SUP HCPCS C1713 186788035 - ROD SPINAL 35MM LORDOTIC VIPER 2 TITANIUM MINIMALLY INVASIVE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 186788045 SUP Custom 27803010 186788045 - ROD SPNL 45MM VPR 2 TI LRDTC MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186788065 SUP Custom 27803010 186788065 - ROD SPNL 65MM VPR 2 PRELORDOTIC MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186788075 SUP Custom 27803010 186788075 - ROD SPNL 75MM 5.5MM VPR 2 TI LRDTC MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186788080 SUP Custom 27803010 186788080 - ROD SPNL 80MM VPR 2 TI LRDTC MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186788090 SUP Custom 27803010 186788090 - ROD SPNL 90MM 5.5MM VPR 2 TI LRDTC MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186788100 SUP Custom 27803010 186788100 - ROD SPNL 100MM VPR 2 TI LRDTC MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186788120 SUP HCPCS C1713 186788120 - ROD SPINAL 120MM LORDOTIC VIPER 2 TITANIUM MINIMALLY BOTH IP/OP "$1,537.50 " "$1,137.75" $0.00 "$1,230.00" $691.88 $691.88 $0.00 $0.00 $0.00 $320.45 "$1,141.13" "$1,141.13" $0.00 $0.00 $320.42 $0.00 $909.43 $909.43 $0.00 $768.75 "$1,217.70" "$1,230.00" $0.00 $0.00 $240.62 $0.00 $0.00 $244.77 $0.00 $0.00 $0.00 $0.00 $0.00 186788150 SUP Custom 27803010 186788150 - ROD SPNL 150MM VPR 2 TI LRDTC MN INV SRG BOTH IP/OP "$1,537.50 " "$1,137.75" $0.00 "$1,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,141.13" "$1,141.13" $0.00 $0.00 $320.42 $0.00 $0.00 $0.00 $0.00 $768.75 "$1,217.70" "$1,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186789040 SUP Custom 27803010 186789040 - ROD SPNL 40MM VPR 2 TI STR MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186789050 SUP Custom 27803010 186789050 - ROD SPNL 50MM VPR 2 TI STR MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186789070 SUP Custom 27803010 186789070 - ROD SPNL 70MM VPR 2 TI STR MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186789080 SUP Custom 27803010 186789080 - ROD SPNL 80MM VPR 2 TI STR MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186789100 SUP Custom 27803010 186789100 - ROD SPNL 100MM VPR 2 TI STR MN INV SRG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186789150 SUP HCPCS C1713 186789150 - ROD SPINAL 150MM STR VIPER 2 TITANIUM MINIMALLY INVASIVE BOTH IP/OP "$1,537.50 " "$1,137.75" $0.00 "$1,230.00" $691.88 $691.88 $0.00 $0.00 $0.00 $320.45 "$1,141.13" "$1,141.13" $0.00 $0.00 $320.42 $0.00 $909.43 $909.43 $0.00 $768.75 "$1,217.70" "$1,230.00" $0.00 $0.00 $240.62 $0.00 $0.00 $244.77 $0.00 $0.00 $0.00 $0.00 $0.00 186789200 SUP Custom 27803010 186789200 - ROD SPNL 200MM VPR 2 TI STR MN INV SRG BOTH IP/OP "$1,710.00 " "$1,265.40" $0.00 "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,269.16" "$1,269.16" $0.00 $0.00 $356.36 $0.00 $0.00 $0.00 $0.00 $855.00 "$1,354.32" "$1,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186789300 SUP Custom 27803010 186789300 - ROD SPNL 300MM VPR 2 TI STR MN INV SRG BOTH IP/OP "$1,882.50 " "$1,393.05" $0.00 "$1,506.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,397.19" "$1,397.19" $0.00 $0.00 $392.31 $0.00 $0.00 $0.00 $0.00 $941.25 "$1,490.94" "$1,506.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186789400 SUP HCPCS C1713 186789400 - ROD SPINAL 400MM STR VIPER 2 TITANIUM MINIMALLY INVASIVE BOTH IP/OP "$2,055.00 " "$1,520.70" $0.00 "$1,644.00" $924.75 $924.75 $0.00 $0.00 $0.00 $428.31 "$1,525.22" "$1,525.22" $0.00 $0.00 $428.26 $0.00 "$1,215.53" "$1,215.53" $0.00 "$1,027.50" "$1,627.56" "$1,644.00" $0.00 $0.00 $321.61 $0.00 $0.00 $327.16 $0.00 $0.00 $0.00 $0.00 $0.00 186789480 SUP HCPCS C1713 186789480 - ROD SPINAL STR 480MM VIPER 2 TITANIUM MINIMALLY INVASIVE BOTH IP/OP "$2,055.00 " "$1,520.70" $0.00 "$1,644.00" $924.75 $924.75 $0.00 $0.00 $0.00 $428.31 "$1,525.22" "$1,525.22" $0.00 $0.00 $428.26 $0.00 "$1,215.53" "$1,215.53" $0.00 "$1,027.50" "$1,627.56" "$1,644.00" $0.00 $0.00 $321.61 $0.00 $0.00 $327.16 $0.00 $0.00 $0.00 $0.00 $0.00 186801012 SUP HCPCS C1713 186801012 - PLATE BONE PRELORDOTIC 19.8X16X2.5MM 12MM LEVEL 1 MEDIAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 186801014 SUP HCPCS C1713 186801014 - PLATE BONE PRELORDOTIC 21.8X16X2.5MM 14MM LEVEL 1 MEDIAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 186801016 SUP HCPCS C1713 186801016 - PLATE BONE PRELORDOTIC 23.8X16X2.5MM 16MM LEVEL 1 MEDIAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 186801024 SUP HCPCS C1713 186801024 - PLATE BN 14MM PREBNT 24X16X2.5MM NS SKYLINE 1 LVL TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 186801026 SUP HCPCS C1713 186801026 - PLATE 26MM TI 1 LVL SKYLINE BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 186801028 SUP HCPCS C1713 186801028 - PLATE 28MM TI 1 LVL SKYLINE BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 186801030 SUP HCPCS C1713 186801030 - PLATE 30MM TI 1 LVL SKYLINE BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 186802028 SUP HCPCS C1713 186802028 - PLATE BONE PRELORDOTIC 35.8X16X2.5MM 28MM LEVEL 2 MEDIAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186802030 SUP HCPCS C1713 186802030 - PLATE 30MM TI 2 LVL SKYLINE BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186802032 SUP HCPCS C1713 186802032 - PLATE 32MM TI 2 LVL SKYLINE BONE SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186802036 SUP HCPCS C1713 186802036 - PLATE 36MM TI 2 LVL SKYLINE BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 186803039 SUP HCPCS C1713 186803039 - PLATE BN 39MM NS SKYLINE 3 LVL SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 186803042 SUP HCPCS C1713 186803042 - PLATE BONE PRELORDOTIC 49.8X16X2.5MM 42MM LEVEL 3 MEDIAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 186803045 SUP HCPCS C1713 186803045 - PLATE BONE PRELORDOTIC 52.8X16X2.5MM 45MM LEVEL 3 MEDIAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 186803051 SUP HCPCS C1713 186803051 - PLATE BONE PRELORDOTIC 58.8X16X2.5MM 51MM LEVEL 3 MEDIAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 186820012 SUP Custom 27203010 186820012 - 14MM DRILL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 186850012 SUP HCPCS C1713 186850012 - SCREW BONE 12MM VAR ANG SELF DRILL SKYLINE TITANIUM SPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186850014 SUP HCPCS C1713 186850014 - SCREW BONE 0-20D 4MM 14MM VARIABLE SLFDRILL SKYLINE GOLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186850016 SUP HCPCS C1713 186850016 - SCREW BONE 16MM SKYLINE TI SPNL SLFDRILL VAR ANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186850017 SUP HCPCS C1713 186850017 - SCREW BN 0-20D 4MM 17MM LGHT GRN SKYLINE VAR SLFDRL TI ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186850018 SUP HCPCS C1713 186850018 - SCREW BONE 18MM VAR ANG SELF DRILL SKYLINE TITANIUM SPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186852014 SUP HCPCS C1713 186852014 - SCREW BONE 14MM SKYLINE TI SPNL SLFTAP VAR ANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186852015 SUP HCPCS C1713 186852015 - SCREW BONE 15MM SLFTAP VAR ANG SKYLINE TITANIUM SPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186852016 SUP HCPCS C1713 186852016 - SCREW BONE 16MM SKYLINE TI SPNL SLFTAP VAR ANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186852017 SUP HCPCS C1713 186852017 - SCREW BONE 17MM SLFTAP VAR ANG SKYLINE TITANIUM SPN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186852018 SUP HCPCS C1713 186852018 - SCREW BONE 18MM SKYLINE TI SPNL SLFTAP VAR ANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186854014 SUP HCPCS C1713 186854014 - SCREW BONE LARGE DIAMETER 14MM VAR ANG SELF TAP SKYLINE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186854016 SUP HCPCS C1713 186854016 - SCREW BN OVSZ 4.5MM 16MM NS SKYLINE VAR SLF DRL TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186854018 SUP HCPCS C1713 186854018 - SCREW BONE LARGE DIAMETER 18MM VAR ANG SELF TAP SKYLINE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186862014 SUP HCPCS C1713 186862014 - SCREW BONE 4MM 14MM SKYLINE TI ANT CERV SPN SLFTAP CNSTRN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186862016 SUP HCPCS C1713 186862016 - SCREW BONE 16MM SKYLINE TI SPNL SLFTAP CNSTRN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 186864014 SUP HCPCS C1713 186864014 - SCREW BONE 14MM SKYLINE TI SPNL SLFTAP CNSTRN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 187301105 SUP Custom 27803010 187301105 - CAGE SPNL 7D STD 5MM NS LF BENGAL CFRP CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187301106 SUP Custom 27803010 187301106 - CAGE SPNL 7D STD 6MM NS LF BENGAL CFRP CRV INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187301107 SUP Custom 27803010 187301107 - CAGE SPNL 7D STD 7MM NS LF BENGAL CFRP CRV INTRBD FS BOTH IP/OP "$2,458.13 " "$1,819.02" $0.00 "$1,966.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,824.42" "$1,824.42" $0.00 $0.00 $512.27 $0.00 $0.00 $0.00 $0.00 "$1,229.06" "$1,946.84" "$1,966.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187301108 SUP Custom 27803010 187301108 - CAGE SPNL 7D STD 8MM NS LF BENGAL CFRP CRV INTRBD FS BOTH IP/OP "$2,458.13 " "$1,819.02" $0.00 "$1,966.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,824.42" "$1,824.42" $0.00 $0.00 $512.27 $0.00 $0.00 $0.00 $0.00 "$1,229.06" "$1,946.84" "$1,966.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187301207 SUP HCPCS C1713 187301207 - CAGE SPNL 7D LG LRDTC 7MM NS LF BENGAL CFBR LMBR INTRBD FS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 187823107 SUP HCPCS C1713 187823107 - CAGE SPNL PRLL BLT 23X9X7MM NS LF CNCRD BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 187823108 SUP Custom 27803010 187823108 - CAGE SPNL PRLL BLT NOSE 23X9X8MM NS LF CNCRD RADOPQ CFRP BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187823409 SUP Custom 27803010 187823409 - CAGE SPNL 5D LRDTC BLT NOSE 23X9X9MM NS LF CNCRD RADOPQ CFRP BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187823410 SUP Custom 27803010 187823410 - CAGE SPNL 5D LRDTC BLT NOSE 23X9X10MM NS LF CNCRD RADOPQ BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187827108 SUP Custom 27803010 187827108 - CAGE SPNL PRLL BLT NOSE 27X9X8MM NS LF CNCRD RADOPQ CFRP BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187827212 SUP Custom 27803010 187827212 - CAGE SPNL PRLL BLT NOSE 27X11X12MM NS LF CNCRD RADOPQ CFRP BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 187827409 SUP Custom 27803010 187827409 - CAGE SPNL 5D LRDTC BLT NOSE 27X9X9MM NS LF CNCRD RADOPQ CFRP BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188311002 SUP HCPCS C1713 188311002 - ROD SPINAL 3.5-5.5MM 420MM 2 OPENING MOUNTAINEER TITANIUM BOTH IP/OP "$2,145.00 " "$1,587.30" $0.00 "$1,716.00" $965.25 $965.25 $0.00 $0.00 $0.00 $447.07 "$1,592.02" "$1,592.02" $0.00 $0.00 $447.02 $0.00 "$1,268.77" "$1,268.77" $0.00 "$1,072.50" "$1,698.84" "$1,716.00" $0.00 $0.00 $335.69 $0.00 $0.00 $341.48 $0.00 $0.00 $0.00 $0.00 $0.00 188311200 SUP Custom 27803010 188311200 - CONCTR SPNL 3.5MM 3.5MM MTNR OCT WDBND BOTH IP/OP "$1,740.00 " "$1,287.60" $0.00 "$1,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,291.43" "$1,291.43" $0.00 $0.00 $362.62 $0.00 $0.00 $0.00 $0.00 $870.00 "$1,378.08" "$1,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188312001 SUP Custom 27803010 188312001 - CONCTR ROD MTNR OFFST ASMBLY OCT SPN LAT BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $0.00 $0.00 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188312003 SUP Custom 27803010 188312003 - CONCTR ROD MTNR J HOOK ASMBLY OCT SPN BOTH IP/OP "$1,170.00 " $865.80 $0.00 $936.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $868.37 $868.37 $0.00 $0.00 $243.83 $0.00 $0.00 $0.00 $0.00 $585.00 $926.64 $936.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316030 SUP Custom 27803010 188316030 - ROD SPNL 30MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316035 SUP Custom 27803010 188316035 - ROD SPNL 35MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316040 SUP Custom 27803010 188316040 - ROD SPNL 40MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316045 SUP Custom 27803010 188316045 - ROD SPNL 45MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316050 SUP Custom 27803010 188316050 - ROD SPNL 50MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316055 SUP Custom 27803010 188316055 - ROD SPNL 55MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316060 SUP Custom 27803010 188316060 - ROD SPNL 60MM 3.5MM MTNR TI RGD STRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316065 SUP Custom 27803010 188316065 - ROD SPNL 65MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316070 SUP Custom 27803010 188316070 - ROD SPNL 70MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316075 SUP Custom 27803010 188316075 - ROD SPNL 75MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316085 SUP HCPCS C1713 188316085 - ROD SPINAL 3.5MM 85MM MOUNTAINEER BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 188316100 SUP Custom 27803010 188316100 - ROD SPNL 100MM 3.5MM MTNR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188316120 SUP Custom 27803010 188316120 - ROD SPNL 120MM 3.5MM MTNR TI RGD STRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188318310 SUP HCPCS C1713 188318310 - SCREW BONE 3.5MM 10MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318312 SUP HCPCS C1713 188318312 - SCREW BONE 3.5MM 12MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318314 SUP HCPCS C1713 188318314 - SCREW BONE 3.5MM 14MM MTNR TI SPNL FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318316 SUP HCPCS C1713 188318316 - SCREW BONE 3.5MM 16MM MTNR TI OCT SPN FIXANG MDLN FIX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318318 SUP HCPCS C1713 188318318 - SCREW BONE 3.5MM 18MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318320 SUP HCPCS C1713 188318320 - SCREW BONE 3.5MM 20MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318324 SUP HCPCS C1713 188318324 - SCREW BONE 3.5MM 24MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318412 SUP HCPCS C1713 188318412 - SCREW BONE 4MM 12MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318414 SUP HCPCS C1713 188318414 - SCREW BONE 4MM 14MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318418 SUP HCPCS C1713 188318418 - SCREW BONE 4MM 18MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318420 SUP HCPCS C1713 188318420 - SCREW BONE 4MM 20MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188318426 SUP HCPCS C1713 188318426 - SCREW BONE 4MM 26MM MTNR TI OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319310 SUP HCPCS C1713 188319310 - SCREW BONE 3.5MM 10MM MTNR TI OCT SPN MDLN FIX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319312 SUP HCPCS C1713 188319312 - SCREW BONE 3.5MM 12MM FAVOR ANGLE MINIPOLYAXIAL SELF FORM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319314 SUP HCPCS C1713 188319314 - SCREW BONE 3.5MM 14MM FAVOR ANGLE MINIPOLYAXIAL SELF FORM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319316 SUP HCPCS C1713 188319316 - SCREW BONE 3.5MM 16MM MTNR MDL LAT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319420 SUP HCPCS C1713 188319420 - SCREW BONE 4MM 20MM MTNR TI OCT SPN MDLN FIX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319424 SUP HCPCS C1713 188319424 - SCREW BONE 4MM 24MM MTNR TI OCT SPN MDLN FIX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319426 SUP HCPCS C1713 188319426 - SCREW BONE 4MM 26MM MTNR TI OCT SPN MDLN FIX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319525 SUP HCPCS C1713 188319525 - SCREW BONE 4.35MM 25MM MTNR TI ML OCT SPN FIXANG BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319530 SUP HCPCS C1713 188319530 - SCREW BONE 4.35MM 30MM MTNR TI OCT SPN STRL MDLN FIX SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188319535 SUP HCPCS C1713 188319535 - SCREW BONE 4.35MM 35MM FIX ANGLE MOUNTAINEER TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188341021 SUP HCPCS C1713 188341021 - PLATE BN 21MM NS MTNR HD TO HD CX CNCT SPNE OCT 3.5MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188341028 SUP HCPCS C1713 188341028 - PLATE BN 28MM NS MTNR HD TO HD CX CNCT SPNE OCT 3.5MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188341035 SUP HCPCS C1713 188341035 - PLATE BN 35MM NS MTNR HD TO HD CX CNCT SPNE OCT 3.5MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188341042 SUP HCPCS C1713 188341042 - PLATE BN 42MM NS MTNR HD TO HD CX CNCT SPNE OCT 3.5MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 188341100 SUP Custom 27803010 188341100 - NUT OUTR MTNR OCT SPN TI HEAD TO HEAD CX CONECTION BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188341200 SUP HCPCS C1713 188341200 - SCREW BONE 3.5MM 200MM MTNR TI OCT SPN INR HEAD TO HEAD CX BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 188341300 SUP Custom 27803010 188341300 - CONCTR ROD CX HEAD TO HEAD HOOK BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188342200 SUP HCPCS C1713 188342200 - SCREW BONE 3.5MM 20MM MTNR TI OCT SPN INR HEAD TO HEAD CX BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 188362006 SUP HCPCS C1713 188362006 - SCREW BONE 4.5MM 6MM MTNR TI OCT SPN BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 188362007 SUP HCPCS C1713 188362007 - SCREW BONE 4.5MM 7MM MTNR TI OCT SPN BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 188362008 SUP HCPCS C1713 188362008 - SCREW BONE 4.5MM 8MM MTNR TI OCT SPN BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 188362010 SUP HCPCS C1713 188362010 - SCREW BONE 4.5MM 10MM MTNR TI OCT SPN BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 188362012 SUP HCPCS C1713 188362012 - SCREW BONE 4.5MM 12MM MTNR TI OCT SPN BOTH IP/OP $765.00 $566.10 $0.00 $612.00 $344.25 $344.25 $0.00 $0.00 $0.00 $159.45 $567.78 $567.78 $0.00 $0.00 $159.43 $0.00 $452.50 $452.50 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $119.72 $0.00 $0.00 $121.79 $0.00 $0.00 $0.00 $0.00 $0.00 188362025 SUP HCPCS C1713 188362025 - SCREW BONE 4.5MM 25MM MTNR TI OCT SPN BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 188362031 SUP HCPCS C1713 188362031 - PLATE BN 31MM NS MTNR SPNE OC 3.5MM SCR BOTH IP/OP "$8,130.00 " "$6,016.20" $0.00 "$6,504.00" "$3,658.50" "$3,658.50" $0.00 $0.00 $0.00 "$1,694.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,694.29" $0.00 "$4,008.09" "$4,008.09" $0.00 "$4,065.00" "$6,438.96" "$6,504.00" $0.00 $0.00 "$1,272.35" $0.00 $0.00 "$1,294.30" $0.00 $0.00 $0.00 $0.00 $0.00 188362106 SUP HCPCS C1713 188362106 - SCREW BONE 5.25MM 6MM MTNR TI OCT SPN BOTH IP/OP $817.50 $604.95 $0.00 $654.00 $367.88 $367.88 $0.00 $0.00 $0.00 $170.39 $606.75 $606.75 $0.00 $0.00 $170.37 $0.00 $483.55 $483.55 $0.00 $408.75 $647.46 $654.00 $0.00 $0.00 $127.94 $0.00 $0.00 $130.15 $0.00 $0.00 $0.00 $0.00 $0.00 188363200 SUP Custom 27803010 188363200 - ROD SPNL 120MM 3.5MM MTNR TI PREBNT STRL BOTH IP/OP $877.50 $649.35 $0.00 $702.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $651.28 $651.28 $0.00 $0.00 $182.87 $0.00 $0.00 $0.00 $0.00 $438.75 $694.98 $702.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188901040 SUP Custom 27803010 188901040 - CAGE SPNL 0D MED 20MM 40-56MM NS LF X-MESH XPD FTPRNT TI BOTH IP/OP "$13,737.50 " "$10,165.75" $0.00 "$10,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,862.90" $0.00 $0.00 $0.00 $0.00 "$6,868.75" "$10,880.10" "$10,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 188920022 SUP Custom 27803010 188920022 - CAGE SPNL 0D SM 16MM 22-30MM NS LF X-MESH XPD FTPRNT TI POST BOTH IP/OP "$11,743.75 " "$8,690.38" $0.00 "$9,395.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,447.40" $0.00 $0.00 $0.00 $0.00 "$5,871.88" "$9,301.05" "$9,395.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 189401207 SUP Custom 27803010 189401207 - CONCTR ROD F7 5.5MM SFX TI MDL SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 189401208 SUP Custom 27803010 189401208 - CONCTR ROD F8 5.5MM XPDM SFX CX MDL OFFST TI SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 189401209 SUP Custom 27803010 189401209 - CONCTR ROD F9 5.5MM SFX TI MDL SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 189401302 SUP HCPCS C1713 189401302 - CONNECTOR ROD A2 5.5MM EXPEDIUM SFX TITANIUM LATERAL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 189401404 SUP Custom 27803010 189401404 - CONCTR ROD A4 5.5MM SFX TI MDL SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 189401405 SUP Custom 27803010 189401405 - CONCTR ROD A5 MED 5.5MM SFX XLNK TI SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 189401406 SUP Custom 27803010 189401406 - CONCTR ROD MED A6 5.5MM SFX XLNK TI SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 189403303 SUP Custom 27803010 189403303 - CONCTR ROD A3 6.35MM SFX TI LAT SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 189706012 SUP HCPCS C1713 189706012 - SCREW BONE 4.6MM 12MM UNIPLATE 2 TI ANT CERV SPN SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 189707012 SUP HCPCS C1713 189707012 - SCREW BONE 4.6MM 12MM UNIPLATE 2 TI ANT CERV SPN SLFDRILL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 189707014 SUP HCPCS C1713 189707014 - SCREW BONE 4.6MM 14MM UNIPLATE 2 TI ANT CERV SPN SLFDRILL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 189707015 SUP HCPCS C1713 189707015 - SCREW BONE 4.6MM 15MM UNIPLATE 2 TI ANT CERV SPN SLFDRILL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 196789120 SUP HCPCS C1713 196789120 - ROD SPINAL STR 120MM VIPER 2 COCR MIS BOTH IP/OP "$1,612.50 " "$1,193.25" $0.00 "$1,290.00" $725.63 $725.63 $0.00 $0.00 $0.00 $336.09 "$1,196.80" "$1,196.80" $0.00 $0.00 $336.05 $0.00 $953.79 $953.79 $0.00 $806.25 "$1,277.10" "$1,290.00" $0.00 $0.00 $252.36 $0.00 $0.00 $256.71 $0.00 $0.00 $0.00 $0.00 $0.00 206710000 SUP HCPCS C1713 0206710000 - KIT BN CMNT STRL BIOPREP PREP PLG INSRTR BRSH CURT SCT FEM BOTH IP/OP $256.29 $189.65 $0.00 $205.03 $115.33 $115.33 $0.00 $0.00 $0.00 $53.42 $190.22 $190.22 $0.00 $0.00 $53.41 $0.00 $151.60 $151.60 $0.00 $128.15 $202.98 $205.03 $0.00 $0.00 $40.11 $0.00 $0.00 $40.80 $0.00 $0.00 $0.00 $0.00 $0.00 219501200 SUP Custom 27203010 00219501200 - CARRIER GRAFT 1.5 1 PLATEAU GROOVE 8X3IN RATCHET HANDLE BOTH IP/OP $81.20 $60.09 $0.00 $64.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.27 $60.27 $0.00 $0.00 $16.92 $0.00 $0.00 $0.00 $0.00 $40.60 $64.31 $64.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 234020053 SUP HCPCS C1713 234020053 - PIN FIX 2.4MM 12IN TROCAR TIPPED EYE LOOP LATEX FREE FEMUR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 234800835 SUP HCPCS C1713 00234800835 - SCREW BONE 3.5MM 2.7MM 8MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234802435 SUP HCPCS C1713 00234802435 - SCREW BONE 3.5MM 2.7MM 24MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234802835 SUP HCPCS C1713 00234802835 - SCREW BONE 3.5MM 2.7MM 28MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234803035 SUP HCPCS C1713 00234803035 - SCREW BONE 3.5MM 2.7MM 30MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234803235 SUP HCPCS C1713 00234803235 - SCREW BONE 3.5MM 2.7MM 32MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234803435 SUP HCPCS C1713 00234803435 - SCREW BONE 3.5MM 2.7MM 34MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234803635 SUP HCPCS C1713 00234803635 - SCREW BONE 3.5MM 2.7MM 36MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234803835 SUP HCPCS C1713 00234803835 - SCREW BONE 3.5MM 2.7MM 38MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234804035 SUP HCPCS C1713 00234804035 - SCREW BONE 3.5MM 2.7MM 40MM SLFTAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234804235 SUP HCPCS C1713 00234804235 - SCREW BONE 3.5MM 2.7MM 42MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234804435 SUP HCPCS C1713 00234804435 - SCREW BONE 3.5MM 2.7MM 44MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234804635 SUP HCPCS C1713 00234804635 - SCREW BONE 3.5MM 2.7MM 46MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234804835 SUP HCPCS C1713 00234804835 - SCREW BONE 3.5MM 2.7MM 48MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234805035 SUP HCPCS C1713 00234805035 - SCREW BONE 3.5MM 2.7MM 50MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234805235 SUP HCPCS C1713 00234805235 - SCREW BONE 3.5MM 2.7MM 52MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234805435 SUP HCPCS C1713 00234805435 - SCREW BONE 3.5MM 2.7MM 54MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234805635 SUP HCPCS C1713 00234805635 - SCREW BONE 2.5MM 3.5MM 2.7MM 56MM SELF TAP LOCK STAINLESS BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234805835 SUP HCPCS C1713 00234805835 - SCREW BONE 3.5MM 2.7MM 58MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234806035 SUP HCPCS C1713 00234806035 - SCREW BONE 3.5MM 2.7MM 60MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234806535 SUP HCPCS C1713 00234806535 - SCREW BONE 3.5MM 2.7MM 65MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234807035 SUP HCPCS C1713 00234807035 - SCREW BONE 3.5MM 2.7MM 70MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234807535 SUP HCPCS C1713 00234807535 - SCREW BONE 3.5MM 2.7MM 75MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234808035 SUP HCPCS C1713 00234808035 - SCREW BONE 3.5MM 2.7MM 80MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234808535 SUP HCPCS C1713 00234808535 - SCREW BONE 3.5MM 2.7MM 85MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234809035 SUP HCPCS C1713 00234809035 - SCREW BONE 3.5MM 2.7MM 90MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234809535 SUP HCPCS C1713 00234809535 - SCREW BONE 3.5MM 2.7MM 95MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234810035 SUP HCPCS C1713 00234810035 - SCREW BONE 3.5MM 2.7MM 100MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234810535 SUP HCPCS C1713 00234810535 - SCREW BONE 3.5MM 2.7MM 105MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 234811035 SUP HCPCS C1713 00234811035 - SCREW BONE 3.5MM 2.7MM 110MM SELF TAP STAINLESS STEEL BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 235701710 SUP HCPCS C1713 00235701710 - PLATE BONE 158MM 10 HOLE LOCK STAINLESS STEEL FIBULA RIGHT BOTH IP/OP "$1,404.15 " "$1,039.07" $0.00 "$1,123.32" $631.87 $631.87 $0.00 $0.00 $0.00 $292.66 "$1,042.16" "$1,042.16" $0.00 $0.00 $292.62 $0.00 $830.55 $830.55 $0.00 $702.08 "$1,112.09" "$1,123.32" $0.00 $0.00 $219.75 $0.00 $0.00 $223.54 $0.00 $0.00 $0.00 $0.00 $0.00 235701808 SUP HCPCS C1713 00235701808 - PLATE BONE 132MM 8 HOLE LOCK STAINLESS STEEL FIBULA LEFT BOTH IP/OP "$1,319.05 " $976.10 $0.00 "$1,055.24" $593.57 $593.57 $0.00 $0.00 $0.00 $274.92 $979.00 $979.00 $0.00 $0.00 $274.89 $0.00 $780.22 $780.22 $0.00 $659.53 "$1,044.69" "$1,055.24" $0.00 $0.00 $206.43 $0.00 $0.00 $209.99 $0.00 $0.00 $0.00 $0.00 $0.00 235701810 SUP HCPCS C1713 00235701810 - PLATE BONE 158MM 10 HOLE LOCK STAINLESS STEEL FIBULA LEFT BOTH IP/OP "$1,404.15 " "$1,039.07" $0.00 "$1,123.32" $631.87 $631.87 $0.00 $0.00 $0.00 $292.66 "$1,042.16" "$1,042.16" $0.00 $0.00 $292.62 $0.00 $830.55 $830.55 $0.00 $702.08 "$1,112.09" "$1,123.32" $0.00 $0.00 $219.75 $0.00 $0.00 $223.54 $0.00 $0.00 $0.00 $0.00 $0.00 248001040 SUP HCPCS C1713 00248001040 - SCREW BONE 4MM 10MM 5MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001041 SUP HCPCS C1713 00248001041 - SCREW BONE FULTHD 4MM 10MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001240 SUP HCPCS C1713 00248001240 - SCREW BONE 4MM 12MM 5MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001241 SUP HCPCS C1713 00248001241 - SCREW BONE FULTHD 4MM 12MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001440 SUP HCPCS C1713 00248001440 - SCREW BONE 4MM 14MM 5MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001441 SUP HCPCS C1713 00248001441 - SCREW BONE FULTHD 4MM 14MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001640 SUP HCPCS C1713 00248001640 - SCREW BONE 4MM 16MM 6MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001641 SUP HCPCS C1713 00248001641 - SCREW BONE FULTHD 4MM 16MM FORTE STAINLESS STEEL BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001840 SUP HCPCS C1713 00248001840 - SCREW BONE 4MM 18MM 7MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248001841 SUP HCPCS C1713 00248001841 - SCREW BONE FULTHD 4MM 18MM FORTE STAINLESS STEEL BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002040 SUP HCPCS C1713 00248002040 - SCREW BONE 4MM 20MM 8MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002041 SUP HCPCS C1713 00248002041 - SCREW BONE FULTHD 4MM 20MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002240 SUP HCPCS C1713 00248002240 - SCREW BONE 4MM 22MM 9MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002241 SUP HCPCS C1713 00248002241 - SCREW BONE FULTHD 4MM 22MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002440 SUP HCPCS C1713 00248002440 - SCREW BONE 4MM 24MM 10MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002441 SUP HCPCS C1713 00248002441 - SCREW BONE FULTHD 4MM 24MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002640 SUP HCPCS C1713 00248002640 - SCREW BONE 4MM 26MM 12MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002641 SUP HCPCS C1713 00248002641 - SCREW BONE FULTHD 4MM 26MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002840 SUP HCPCS C1713 00248002840 - SCREW BONE 4MM 28MM 14MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248002841 SUP HCPCS C1713 00248002841 - SCREW BONE FULTHD 4MM 28MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003040 SUP HCPCS C1713 00248003040 - SCREW BONE 4MM 30MM 14MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003041 SUP HCPCS C1713 00248003041 - SCREW BONE FULTHD 4MM 30MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003240 SUP HCPCS C1713 00248003240 - SCREW BONE 4MM 32MM 14MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003241 SUP HCPCS C1713 00248003241 - SCREW BONE FULTHD 4MM 32MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003440 SUP HCPCS C1713 00248003440 - SCREW BONE 4MM 34MM 14MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003441 SUP HCPCS C1713 00248003441 - SCREW BONE FULTHD 4MM 34MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003640 SUP HCPCS C1713 00248003640 - SCREW BONE 4MM 36MM 14MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003641 SUP HCPCS C1713 00248003641 - SCREW BONE FULTHD 4MM 36MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003840 SUP HCPCS C1713 00248003840 - SCREW BONE 4MM 38MM 14MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248003841 SUP HCPCS C1713 00248003841 - SCREW BONE FULTHD 4MM 38MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248004040 SUP HCPCS C1713 00248004040 - SCREW BONE 4MM 40MM 14MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248004041 SUP HCPCS C1713 00248004041 - SCREW BONE FULTHD 4MM 40MM FORTE STAINLESS STEEL CANCELLOUS BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 248781032 SUP Custom 27203010 248781032 - STATION EYEWASH 17.5X15IN 4 SCREW HOLE SAFETY BOTTLE WALL BOTH IP/OP $141.66 $104.83 $0.00 $113.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.14 $105.14 $0.00 $0.00 $29.52 $0.00 $0.00 $0.00 $0.00 $70.83 $112.19 $113.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 272350250 SUP HCPCS C1769 272350250 - GUIDEWIRE ORTHOPEDIC 1.57MM SHARP BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $101.81 $101.81 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 279351100 SUP Custom 27203010 0279351100 - ELTRD ESURG 90MM 3.5MM SERFAS ENRG 90D PRB SCT ARTHRO LATEX BOTH IP/OP $507.88 $375.83 $0.00 $406.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $376.94 $376.94 $0.00 $0.00 $105.84 $0.00 $0.00 $0.00 $0.00 $253.94 $402.24 $406.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 279351300 SUP Custom 27203010 0279351300 - PROBE SCT 90MM SERFAS ENRG 3.5MM LATEX FREE BOTH IP/OP $522.75 $386.84 $0.00 $418.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $387.99 $387.99 $0.00 $0.00 $108.94 $0.00 $0.00 $0.00 $0.00 $261.38 $414.02 $418.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 283903611 SUP HCPCS C1894 283903611 - NEEDLE SPNL 11GA 6IN INTRO CNFD DMD TIP BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $89.60 $89.60 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 286565001 SUP Custom 27803010 286565001 - HOLDER IMPL SWIFT PIN TEMP FIX THRD BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 286705200 SUP Custom 27203010 286705200 - GWIRE ORTH 1.37MM VPR THRD BLNT DISP BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 286705220 SUP Custom 27203010 286705220 - GWIRE ORTH 1.45MM VPR 2 BLNT BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $0.00 $0.00 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 286820012 SUP Custom 27203010 286820012 - BIT DRL 2.2MM 12MM NS SKYLINE REUSE ANT CRV PLT SYS BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 286820014 SUP Custom 27203010 286820014 - DRILL SURG 14MM BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 286820016 SUP Custom 27203010 286820016 - BIT DRILL FLAT 16MM CHUCK SKYLINE DISPOSABLE BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 286850100 SUP HCPCS C1713 286850100 - PIN FIX STR TEMPORARY SKYLINE SPN BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 286850200 SUP HCPCS C1713 286850200 - PIN FIX 200MM 50MM THREADED TEMPORARY SKYLINE SPN BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 288301114 SUP Custom 27203010 288301114 - GUIDE DRILL 14MM FIX BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288302030 SUP Custom 27203010 288302030 - TAP SURG 3MM BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288302035 SUP Custom 27203010 288302035 - TAP SPINAL 3.5MM STAINLESS STEEL DISPOSABLE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288302040 SUP Custom 27203010 288302040 - TAP SURG 4MM MOUNTAINEER DISPOSABLE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 288310035 SUP Custom 27100030 288310035 - BIT DRILL 3.5MM QC BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 292301001 SUP Custom 27011340 292301001 - HALTER TRC 19-26IN 3DHLCR HEAD BOTH IP/OP "$1,560.00 " "$1,154.40" $0.00 "$1,248.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,157.83" "$1,157.83" $0.00 $0.00 $325.10 $0.00 $0.00 $0.00 $0.00 $780.00 "$1,235.52" "$1,248.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 306573000 SUP HCPCS C1713 306573000 - KIT BN CMNT ACM BWL CMNT CRTDG FEM NOZ MED PRS 180GM BOTH IP/OP "$1,440.03 " "$1,065.62" $0.00 "$1,152.02" $648.01 $648.01 $0.00 $0.00 $0.00 $300.14 "$1,068.79" "$1,068.79" $0.00 $0.00 $300.10 $0.00 $990.35 $990.35 $0.00 $720.01 $185.55 "$1,152.02" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 306573000 SUP HCPCS C1713 0306573000 - KIT BN CMNT ACM BWL CMNT CRTDG FEM NOZ MED PRS 180GM BOTH IP/OP "$1,440.03 " "$1,065.62" $0.00 "$1,152.02" $648.01 $648.01 $0.00 $0.00 $0.00 $300.14 "$1,068.79" "$1,068.79" $0.00 $0.00 $300.10 $0.00 $990.35 $990.35 $0.00 $720.01 "$1,140.50" "$1,152.02" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 321500000 SUP Custom 27203010 AIRWAY ESPH 5 ADLT ARNC LRYNG MASK CUF CURVE UNQ LF PVC 40ML BOTH IP/OP $15.63 $11.57 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.81 $12.38 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336612008 SUP Custom 27803010 336612008 - CAGE SPNL 12MM 8MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336612009 SUP Custom 27803010 336612009 - CAGE SPNL 12MM 9MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336612010 SUP Custom 27803010 336612010 - CAGE SPNL 12MM 10MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336612011 SUP Custom 27803010 336612011 - CAGE SPNL 12MM 11MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336612012 SUP Custom 27803010 336612012 - CAGE SPNL 12MM 12MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336612040 SUP Custom 27803010 336612040 - CAGE SPNL 12MM 40MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336612080 SUP Custom 27803010 336612080 - CAGE SPNL 12MM 80MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336614008 SUP Custom 27803010 336614008 - CAGE SPNL 14MM 8MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336614009 SUP Custom 27803010 336614009 - CAGE SPNL 14MM 9MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336614010 SUP Custom 27803010 336614010 - CAGE SPNL 14MM 10MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336614011 SUP Custom 27803010 336614011 - CAGE SPNL 14MM 11MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336614012 SUP Custom 27803010 336614012 - CAGE SPNL 14MM 12MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336614040 SUP Custom 27803010 336614040 - CAGE SPNL 14MM 40MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336614080 SUP Custom 27803010 336614080 - CAGE SPNL 14MM 80MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336616040 SUP Custom 27803010 336616040 - CAGE SPNL 16MM 40MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336616080 SUP Custom 27803010 336616080 - CAGE SPNL 16MM 80MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336620040 SUP Custom 27803010 336620040 - CAGE SPNL 20MM 40MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336620080 SUP Custom 27803010 336620080 - CAGE SPNL 20MM 80MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336620120 SUP Custom 27803010 336620120 - CAGE SPNL 20MM 120MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336625040 SUP Custom 27803010 336625040 - CAGE SPNL 25MM 40MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336625080 SUP Custom 27803010 336625080 - CAGE SPNL 25MM 80MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 336625120 SUP Custom 27803010 336625120 - CAGE SPNL 25MM 120MM VBOSS TI THORLMBR INTRBD FS BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 $0.00 $0.00 $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 380544150 SUP Custom 27203010 380544150 - CUTTER ENDSCP ANG AGRS+ FRML 4.5MM BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $176.64 $0.00 $0.00 $49.60 $0.00 $0.00 $0.00 $0.00 $119.00 $188.50 $190.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 381003004 SUP HCPCS C1773 381003004 - KIT SNR 3.2FR 2-4MM 175CM 150CM ATRIEVE VASC SNR 3 LOOP SHRT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $678.75 $678.75 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 381003008 SUP HCPCS C1773 381003008 - KIT SNR 15D 3.2FR 4-8MM 175CM 150CM ATRIEVE VASC SNR 3 SHRT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $678.75 $678.75 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 382006010 SUP HCPCS C1773 382006010 - KIT SNR 6-10MM 6FR .062IN 120CM 100CM ATRIEVE VASC SNR 3 BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 382006015 SUP HCPCS C1773 382006015 - KIT SNR 9-15MM 6FR .062IN 120CM 100CM ATRIEVE VASC SNR 3 BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 382006020 SUP HCPCS C1757 382006020 - SNARE VASC STD 12-20MM 6FR 120CM 100CM ENSNR CATH BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 382007030 SUP HCPCS C1773 382007030 - KIT SNR MN 18-30MM 7FR 120CM 100CM ATRIEVE VASC SNR DLV CATH BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 382007045 SUP HCPCS C1773 382007045 - KIT SNR 27-45MM 7FR 120MM 100MM ATRIEVE VASC SNR DLV CATH BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 382412000 SUP Custom 27203010 382412000 - KNEE IMMOBILIZER MEDIUM BOTH IP/OP $48.24 $35.70 $0.00 $38.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.80 $35.80 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $24.12 $38.21 $38.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 392006015 SUP Custom 27203010 SYSTEM SNARE 9 15MM TRIPLE LOOP STANDARD BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 408831100 SUP Custom 27203010 0408831100 - TOGA SRG XL FLYTE SURGICOOL PLWY ZP BOTH IP/OP $27.27 $20.18 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.24 $20.24 $0.00 $0.00 $5.68 $0.00 $0.00 $0.00 $0.00 $13.64 $21.60 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 436020300 SUP HCPCS C1713 436020300 - ENDCAP 436020300 EXTNDED 20 X 30MM 0 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436020305 SUP HCPCS C1713 436020305 - ENDCAP 436020305 EXTND 20 X 30MM 15 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436020350 SUP HCPCS C1713 436020350 - ENDCAP 436020350 EXTNDED 20 X 35MM 0 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436020355 SUP HCPCS C1713 436020355 - ENDCAP 436020355 EXTND 20 X 35MM 15 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436020400 SUP HCPCS C1713 436020400 - ENDCAP 436020400 EXTNDED 20 X 40MM 0 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436020405 SUP HCPCS C1713 436020405 - ENDCAP 436020405 EXTND 20 X 40MM 15 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436020450 SUP HCPCS C1713 436020450 - ENDCAP 436020450 EXTNDED 20 X 45MM 0 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436020455 SUP HCPCS C1713 436020455 - ENDCAP 436020455 EXTND 20 X 45MM 15 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436025300 SUP HCPCS C1713 436025300 - ENDCAP 436025300 EXTNDED 25 X 30MM 0 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436025305 SUP HCPCS C1713 436025305 - ENDCAP 436025305 EXTND 25 X 30MM 15 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436025350 SUP HCPCS C1713 436025350 - ENDCAP 436025350 EXTNDED 25 X 35MM 0 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436025355 SUP HCPCS C1713 436025355 - ENDCAP 436025355 EXTND 25 X 35MM 15 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436025400 SUP HCPCS C1713 436025400 - ENDCAP 436025400 EXTNDED 25 X 40MM 0 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436025405 SUP HCPCS C1713 436025405 - ENDCAP 436025405 EXTND 25 X 40MM 15 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436025450 SUP HCPCS C1713 436025450 - ENDCAP 436025450 EXTNDED 25 X 45MM 0 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436025455 SUP HCPCS C1713 436025455 - ENDCAP 436025455 EXTND 25 X 45MM 15 DEG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436120300 SUP HCPCS C1713 436120300 - ENDCAP 436120300 EXTENDED 20 X 30MM STER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436120305 SUP HCPCS C1713 436120305 - ENDCAP 436120305 EXTND 20X30MM 15 DEG ST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436120350 SUP HCPCS C1713 436120350 - ENDCAP 436120350 EXTENDED 20 X 35MM STER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436120355 SUP HCPCS C1713 436120355 - ENDCAP 436120355 EXTND 20X35MM 15 DEG ST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436120400 SUP HCPCS C1713 436120400 - ENDCAP 436120400 EXTENDED 20 X 40MM STER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436120405 SUP HCPCS C1713 436120405 - ENDCAP 436120405 EXTND 20X40MM 15 DEG ST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436120450 SUP HCPCS C1713 436120450 - ENDCAP 436120450 EXTENDED 20 X 45MM STER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436120455 SUP HCPCS C1713 436120455 - ENDCAP 436120455 EXTND 20X45MM 15 DEG ST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436125300 SUP HCPCS C1713 436125300 - ENDCAP 436125300 EXTENDED 25 X 30MM STER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436125305 SUP HCPCS C1713 436125305 - ENDCAP 436125305 EXTND 25X30MM 15 DEG ST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436125350 SUP HCPCS C1713 436125350 - ENDCAP 436125350 EXTENDED 25 X 35MM STER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436125355 SUP HCPCS C1713 436125355 - ENDCAP 436125355 EXTND 25X35MM 15 DEG ST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436125400 SUP HCPCS C1713 436125400 - ENDCAP 436125400 EXTENDED 25 X 40MM STER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436125405 SUP HCPCS C1713 436125405 - ENDCAP 436125405 EXTND 25X40MM 15 DEG ST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436125450 SUP HCPCS C1713 436125450 - ENDCAP 436125450 EXTENDED 25 X 45MM STER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 436125455 SUP HCPCS C1713 436125455 - ENDCAP 436125455 EXTND 25X45MM 15 DEG ST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 480316022 SUP HCPCS C1713 480316022 - SCREW BONE LONG STANDARD 6MM 22MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316025 SUP HCPCS C1713 480316025 - SCREW BONE LONG STANDARD 6MM 25MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316028 SUP HCPCS C1713 480316028 - SCREW BONE LONG STANDARD 6MM 28MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316031 SUP HCPCS C1713 480316031 - SCREW BONE LONG STANDARD 6MM 31MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316034 SUP HCPCS C1713 480316034 - SCREW BONE LONG STANDARD 6MM 34MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316037 SUP HCPCS C1713 480316037 - SCREW BONE LONG STANDARD 6MM 37MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316040 SUP HCPCS C1713 480316040 - SCREW BONE LONG STANDARD 6MM 40MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316043 SUP HCPCS C1713 480316043 - SCREW BONE LONG STANDARD 6MM 43MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316046 SUP HCPCS C1713 480316046 - SCREW BONE LONG STANDARD 6MM 46MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316049 SUP HCPCS C1713 480316049 - SCREW BONE LONG STANDARD 6MM 49MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316052 SUP HCPCS C1713 480316052 - SCREW BONE LONG STANDARD 6MM 52MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316055 SUP HCPCS C1713 480316055 - SCREW BONE LONG STANDARD 6MM 55MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316058 SUP HCPCS C1713 480316058 - SCREW BONE LONG STANDARD 6MM 58MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316061 SUP HCPCS C1713 480316061 - SCREW BONE LONG STANDARD 6MM 61MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316064 SUP HCPCS C1713 480316064 - SCREW BONE LONG STANDARD 6MM 64MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316067 SUP HCPCS C1713 480316067 - SCREW BONE LONG STANDARD 6MM 67MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316522 SUP HCPCS C1713 480316522 - SCREW BONE STANDARD 6.5MM 22MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316525 SUP HCPCS C1713 480316525 - SCREW BONE STANDARD 6.5MM 25MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316528 SUP HCPCS C1713 480316528 - SCREW BONE STANDARD 6.5MM 28MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316531 SUP HCPCS C1713 480316531 - SCREW BONE STANDARD 6.5MM 31MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316534 SUP HCPCS C1713 480316534 - SCREW BONE STANDARD 6.5MM 34MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316537 SUP HCPCS C1713 480316537 - SCREW BONE STANDARD 6.5MM 37MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316540 SUP HCPCS C1713 480316540 - SCREW BONE LONG STANDARD 6.5MM 40MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316543 SUP HCPCS C1713 480316543 - SCREW BONE LONG STANDARD 6.5MM 43MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316546 SUP HCPCS C1713 480316546 - SCREW BONE LONG STANDARD 6.5MM 46MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316549 SUP HCPCS C1713 480316549 - SCREW BONE LONG STANDARD 6.5MM 49MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316552 SUP HCPCS C1713 480316552 - SCREW BONE LONG STANDARD 6.5MM 52MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316555 SUP HCPCS C1713 480316555 - SCREW BONE LONG STANDARD 6.5MM 55MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316558 SUP HCPCS C1713 480316558 - SCREW BONE LONG STANDARD 6.5MM 58MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316561 SUP HCPCS C1713 480316561 - SCREW BONE LONG STANDARD 6.5MM 61MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316564 SUP HCPCS C1713 480316564 - SCREW BONE LONG STANDARD 6.5MM 64MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 480316567 SUP HCPCS C1713 480316567 - SCREW BONE LONG STANDARD 6.5MM 67MM SPN THORACIC BOTH IP/OP $914.88 $677.01 $0.00 $731.90 $411.69 $411.69 $0.00 $0.00 $0.00 $190.68 $679.02 $679.02 $0.00 $0.00 $190.66 $0.00 $541.15 $541.15 $0.00 $457.44 $724.58 $731.90 $0.00 $0.00 $143.18 $0.00 $0.00 $145.65 $0.00 $0.00 $0.00 $0.00 $0.00 481322040 SUP HCPCS C1713 481322040 - ROD SPNL 4.5MM 40MM NS LF XIA PREBNT PCUT VIT SPNE BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 481322050 SUP HCPCS C1713 481322050 - ROD SPNL 50MM 4.5MM XIA PREBNT VIT PCUT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 481322070 SUP HCPCS C1713 481322070 - ROD SPNL PREBNT HEX 4.5MM 70MM PCUT VITALIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 482204020 SUP HCPCS C1713 482204020 - SCREW BONE 4MM 20MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482204025 SUP HCPCS C1713 482204025 - SCREW BONE 4MM 25MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482204030 SUP HCPCS C1713 482204030 - SCREW BONE 4MM 30MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482204035 SUP HCPCS C1713 482204035 - SCREW BONE 4MM 35MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482204040 SUP HCPCS C1713 482204040 - SCREW BONE 4MM 40MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482205025 SUP HCPCS C1713 482205025 - SCREW BONE 5MM 25MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482205030 SUP HCPCS C1713 482205030 - SCREW BONE 5MM 30MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482205035 SUP HCPCS C1713 482205035 - SCREW BONE 5MM 35MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482205040 SUP HCPCS C1713 482205040 - SCREW BONE 5MM 40MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482205045 SUP HCPCS C1713 482205045 - SCREW BONE 5MM 45MM MNOAX XIA STAINLESS STEEL SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 482214020 SUP HCPCS C1713 482214020 - SCREW BONE 4MM 20MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 482214025 SUP HCPCS C1713 482214025 - SCREW BONE 4MM 25MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 482214030 SUP HCPCS C1713 482214030 - SCREW BONE 4MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 "$1,195.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 "$2,828.59" "$2,828.59" $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 482214035 SUP HCPCS C1713 482214035 - SCREW BONE 4MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 482214040 SUP HCPCS C1713 482214040 - SCREW BONE 4MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 482215025 SUP HCPCS C1713 482215025 - SCREW BONE 5MM 25MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 482215030 SUP HCPCS C1713 482215030 - SCREW BONE 5MM 30MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 482215035 SUP HCPCS C1713 482215035 - SCREW BONE 5MM 35MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" "$2,379.38" "$2,379.38" $0.00 $0.00 $0.00 "$1,102.05" "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 "$2,606.74" "$2,606.74" $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $827.49 $0.00 $0.00 $841.77 $0.00 $0.00 $0.00 $0.00 $0.00 482215040 SUP HCPCS C1713 482215040 - SCREW BONE 5MM 40MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 482215045 SUP HCPCS C1713 482215045 - SCREW BONE 5MM 45MM POLYAX XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301500 SUP HCPCS C1713 482301500 - SCREW BONE 1.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301540 SUP HCPCS C1713 482301540 - SCREW BONE 1.5MM 40MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301545 SUP HCPCS C1713 482301545 - SCREW BONE 1.5MM 45MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301550 SUP HCPCS C1713 482301550 - SCREW BONE 1.5MM 50MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301555 SUP HCPCS C1713 482301555 - SCREW BONE 1.5MM 55MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301560 SUP HCPCS C1713 482301560 - SCREW BONE 1.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301565 SUP HCPCS C1713 482301565 - SCREW BONE 1.5MM 65MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301570 SUP HCPCS C1713 482301570 - SCREW BONE 1.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301580 SUP HCPCS C1713 482301580 - SCREW BONE 1.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482301590 SUP HCPCS C1713 482301590 - SCREW BONE 1.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 482304020 SUP HCPCS C1713 482304020 - SCREW BONE 4MM 20MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304025 SUP HCPCS C1713 482304025 - SCREW BONE 4MM 25MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304030 SUP HCPCS C1713 482304030 - SCREW BONE 4MM 30MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304035 SUP HCPCS C1713 482304035 - SCREW BONE 4MM 35MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304040 SUP HCPCS C1713 482304040 - SCREW BONE 4MM 40MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304045 SUP HCPCS C1713 482304045 - SCREW BONE 4MM 45MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304520 SUP HCPCS C1713 482304520 - SCREW BONE 4.5MM 20MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304525 SUP HCPCS C1713 482304525 - SCREW BONE 4.5MM 25MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304530 SUP HCPCS C1713 482304530 - SCREW BONE 4.5MM 30MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304535 SUP HCPCS C1713 482304535 - SCREW BONE 4.5MM 35MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304540 SUP HCPCS C1713 482304540 - SCREW BONE 4.5MM 40MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482304545 SUP HCPCS C1713 482304545 - SCREW BONE 4.5MM 45MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305020 SUP HCPCS C1713 482305020 - SCREW BONE 5MM 20MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305025 SUP HCPCS C1713 482305025 - SCREW BONE 5MM 25MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305030 SUP HCPCS C1713 482305030 - SCREW BONE 5MM 30MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305035 SUP HCPCS C1713 482305035 - SCREW BONE 5MM 35MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305040 SUP HCPCS C1713 482305040 - SCREW BONE 5MM 40MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305045 SUP HCPCS C1713 482305045 - SCREW BONE 5MM 45MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305050 SUP HCPCS C1713 482305050 - SCREW BONE 5MM 50MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305525 SUP HCPCS C1713 482305525 - SCREW BONE 5.5MM 25MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305530 SUP HCPCS C1713 482305530 - SCREW BONE 5.5MM 30MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305535 SUP HCPCS C1713 482305535 - SCREW BONE 5.5MM 35MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305540 SUP HCPCS C1713 482305540 - SCREW BONE 5.5MM 40MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305545 SUP HCPCS C1713 482305545 - SCREW BONE 5.5MM 45MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305550 SUP HCPCS C1713 482305550 - SCREW BONE 5.5MM 50MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482305555 SUP HCPCS C1713 482305555 - SCREW BONE 5.5MM 55MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306025 SUP HCPCS C1713 482306025 - SCREW BONE 6MM 25MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306030 SUP HCPCS C1713 482306030 - SCREW BONE 6MM 30MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306035 SUP HCPCS C1713 482306035 - SCREW BONE 6MM 35MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306040 SUP HCPCS C1713 482306040 - SCREW BONE 6MM 40MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306045 SUP HCPCS C1713 482306045 - SCREW BONE 6MM 45MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306050 SUP HCPCS C1713 482306050 - SCREW BONE 6MM 50MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306055 SUP HCPCS C1713 482306055 - SCREW BONE 6MM 55MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306060 SUP HCPCS C1713 482306060 - SCREW BONE 6MM 60MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306065 SUP HCPCS C1713 482306065 - SCREW BONE 6MM 65MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306070 SUP HCPCS C1713 482306070 - SCREW BONE 6MM 70MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306080 SUP HCPCS C1713 482306080 - SCREW BONE 6MM 80MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306090 SUP HCPCS C1713 482306090 - SCREW BONE 6MM 90MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306525 SUP HCPCS C1713 482306525 - SCREW BONE 6.5MM 25MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306530 SUP HCPCS C1713 482306530 - SCREW BONE 6.5MM 30MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306535 SUP HCPCS C1713 482306535 - SCREW BONE 6.5MM 35MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306540 SUP HCPCS C1713 482306540 - SCREW BONE 6.5MM 40MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306545 SUP HCPCS C1713 482306545 - SCREW BONE 6.5MM 45MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306550 SUP HCPCS C1713 482306550 - SCREW BONE 6.5MM 50MM MULTIAX XIA 3 TITANIUM SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306555 SUP HCPCS C1713 482306555 - SCREW BONE 6.5MM 55MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306560 SUP HCPCS C1713 482306560 - SCREW BONE 6.5MM 60MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306565 SUP HCPCS C1713 482306565 - SCREW BONE 6.5MM 65MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306570 SUP HCPCS C1713 482306570 - SCREW BONE 6.5MM 70MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306580 SUP HCPCS C1713 482306580 - SCREW BONE 6.5MM 80MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482306590 SUP HCPCS C1713 482306590 - SCREW BONE 6.5MM 90MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307025 SUP HCPCS C1713 482307025 - SCREW BONE 7MM 25MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307030 SUP HCPCS C1713 482307030 - SCREW BONE 7MM 30MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307035 SUP HCPCS C1713 482307035 - SCREW BONE 7MM 35MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307040 SUP HCPCS C1713 482307040 - SCREW BONE 7MM 40MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307045 SUP HCPCS C1713 482307045 - SCREW BONE 7MM 45MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307050 SUP HCPCS C1713 482307050 - SCREW BONE 7MM 50MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307055 SUP HCPCS C1713 482307055 - SCREW BONE 7MM 55MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307060 SUP HCPCS C1713 482307060 - SCREW BONE 7MM 60MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307065 SUP HCPCS C1713 482307065 - SCREW BONE 7MM 65MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307070 SUP HCPCS C1713 482307070 - SCREW BONE 7MM 70MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307080 SUP HCPCS C1713 482307080 - SCREW BONE 7MM 80MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307090 SUP HCPCS C1713 482307090 - SCREW BONE 7MM 90MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307525 SUP HCPCS C1713 482307525 - SCREW BONE 7.5MM 25MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307530 SUP HCPCS C1713 482307530 - SCREW BONE 7.5MM 30MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307535 SUP HCPCS C1713 482307535 - SCREW BONE 7.5MM 35MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307540 SUP HCPCS C1713 482307540 - SCREW BONE 7.5MM 40MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307545 SUP HCPCS C1713 482307545 - SCREW BONE 7.5MM 45MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307550 SUP HCPCS C1713 482307550 - SCREW BONE 7.5MM 50MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307555 SUP HCPCS C1713 482307555 - SCREW BONE 7.5MM 55MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307560 SUP HCPCS C1713 482307560 - SCREW BONE 7.5MM 60MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307565 SUP HCPCS C1713 482307565 - SCREW BONE 7.5MM 65MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307570 SUP HCPCS C1713 482307570 - SCREW BONE 7.5MM 70MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307580 SUP HCPCS C1713 482307580 - SCREW BONE 7.5MM 80MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482307590 SUP HCPCS C1713 482307590 - SCREW BONE 7.5MM 90MM MNOAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308500 SUP HCPCS C1713 482308500 - SCREW BONE 8.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308525 SUP HCPCS C1713 482308525 - SCREW BONE 8.5MM 25MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308530 SUP HCPCS C1713 482308530 - SCREW BONE 8.5MM 30MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308535 SUP HCPCS C1713 482308535 - SCREW BONE 8.5MM 35MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308540 SUP HCPCS C1713 482308540 - SCREW BONE 8.5MM 40MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308545 SUP HCPCS C1713 482308545 - SCREW BONE 8.5MM 45MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308550 SUP HCPCS C1713 482308550 - SCREW BONE 8.5MM 50MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308555 SUP HCPCS C1713 482308555 - SCREW BONE 8.5MM 55MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308560 SUP HCPCS C1713 482308560 - SCREW BONE 8.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308565 SUP HCPCS C1713 482308565 - SCREW BONE 8.5MM 65MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308570 SUP HCPCS C1713 482308570 - SCREW BONE 8.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308580 SUP HCPCS C1713 482308580 - SCREW BONE 8.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482308590 SUP HCPCS C1713 482308590 - SCREW BONE 8.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309500 SUP HCPCS C1713 482309500 - SCREW BONE 9.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309540 SUP HCPCS C1713 482309540 - SCREW BONE 9.5MM 40MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309545 SUP HCPCS C1713 482309545 - SCREW BONE 9.5MM 45MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309550 SUP HCPCS C1713 482309550 - SCREW BONE 9.5MM 50MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309555 SUP HCPCS C1713 482309555 - SCREW BONE 9.5MM 55MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309560 SUP HCPCS C1713 482309560 - SCREW BONE 9.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309565 SUP HCPCS C1713 482309565 - SCREW BONE 9.5MM 65MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309570 SUP HCPCS C1713 482309570 - SCREW BONE 9.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309580 SUP HCPCS C1713 482309580 - SCREW BONE 9.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482309590 SUP HCPCS C1713 482309590 - SCREW BONE 9.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 482311500 SUP HCPCS C1713 482311500 - SCREW BONE 1.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311540 SUP HCPCS C1713 482311540 - SCREW BONE 1.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311545 SUP HCPCS C1713 482311545 - SCREW BONE 1.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311550 SUP HCPCS C1713 482311550 - SCREW BONE 1.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311555 SUP HCPCS C1713 482311555 - SCREW BONE 1.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311560 SUP HCPCS C1713 482311560 - SCREW BONE 1.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311565 SUP HCPCS C1713 482311565 - SCREW BONE 1.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311570 SUP HCPCS C1713 482311570 - SCREW BONE 1.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311580 SUP HCPCS C1713 482311580 - SCREW BONE 1.5MM 80MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482311590 SUP HCPCS C1713 482311590 - SCREW BONE 1.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314020 SUP HCPCS C1713 482314020 - SCREW BONE 4MM 20MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314025 SUP HCPCS C1713 482314025 - SCREW BONE 4MM 25MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314030 SUP HCPCS C1713 482314030 - SCREW BONE 4MM 30MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314035 SUP HCPCS C1713 482314035 - SCREW BONE 4MM 35MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314040 SUP HCPCS C1713 482314040 - SCREW BONE 4MM 40MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314045 SUP HCPCS C1713 482314045 - SCREW BONE 4MM 45MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314520 SUP HCPCS C1713 482314520 - SCREW BONE 4.5MM 20MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314525 SUP HCPCS C1713 482314525 - SCREW BONE 4.5MM 25MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314530 SUP HCPCS C1713 482314530 - SCREW BONE 4.5MM 30MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314535 SUP HCPCS C1713 482314535 - SCREW BONE 4.5MM 35MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314540 SUP HCPCS C1713 482314540 - SCREW BONE 4.5MM 40MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482314545 SUP HCPCS C1713 482314545 - SCREW BONE 4.5MM 45MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315020 SUP HCPCS C1713 482315020 - SCREW BONE 5MM 20MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315025 SUP HCPCS C1713 482315025 - SCREW BONE 5MM 25MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315030 SUP HCPCS C1713 482315030 - SCREW BONE 5MM 30MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315035 SUP HCPCS C1713 482315035 - SCREW BONE 5MM 35MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315040 SUP HCPCS C1713 482315040 - SCREW BONE 5MM 40MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315045 SUP HCPCS C1713 482315045 - SCREW BONE 5MM 45MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315050 SUP HCPCS C1713 482315050 - SCREW BONE 5MM 50MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315525 SUP HCPCS C1713 482315525 - SCREW BONE 5.5MM 25MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315530 SUP HCPCS C1713 482315530 - SCREW BONE 5.5MM 30MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315535 SUP HCPCS C1713 482315535 - SCREW BONE 5.5MM 35MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315540 SUP HCPCS C1713 482315540 - SCREW BONE 5.5MM 40MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315545 SUP HCPCS C1713 482315545 - SCREW BONE 5.5MM 45MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315550 SUP HCPCS C1713 482315550 - SCREW BONE 5.5MM 50MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482315555 SUP HCPCS C1713 482315555 - SCREW BONE 5.5MM 55MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316025 SUP HCPCS C1713 482316025 - SCREW BONE 6MM 25MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316030 SUP HCPCS C1713 482316030 - SCREW BONE 6MM 30MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316035 SUP HCPCS C1713 482316035 - SCREW BONE 6MM 35MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316040 SUP HCPCS C1713 482316040 - SCREW BONE 6MM 40MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316045 SUP HCPCS C1713 482316045 - SCREW BN 6MM 50MM XIA 3 PA TI SPNE THORLMBR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316050 SUP HCPCS C1713 482316050 - SCREW BONE 6MM 50MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316055 SUP HCPCS C1713 482316055 - SCREW BONE 6MM 55MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316060 SUP HCPCS C1713 482316060 - SCREW BONE 6MM 60MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316065 SUP HCPCS C1713 482316065 - SCREW BN 6MM 70MM XIA 3 PA TI SPNE THORLMBR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316070 SUP HCPCS C1713 482316070 - SCREW BONE 6MM 70MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316080 SUP HCPCS C1713 482316080 - SCREW BONE 6MM 80MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316090 SUP HCPCS C1713 482316090 - SCREW BONE 6MM 90MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316525 SUP HCPCS C1713 482316525 - SCREW BONE 6.5MM 25MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316530 SUP HCPCS C1713 482316530 - SCREW BONE 6.5MM 30MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316535 SUP HCPCS C1713 482316535 - SCREW BONE 6.5MM 35MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316540 SUP HCPCS C1713 482316540 - SCREW BONE 6.5MM 40MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316545 SUP HCPCS C1713 482316545 - SCREW BONE 6.5MM 45MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316550 SUP HCPCS C1713 482316550 - SCREW BONE 6.5MM 50MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316555 SUP HCPCS C1713 482316555 - SCREW BONE 6.5MM 55MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316560 SUP HCPCS C1713 482316560 - SCREW BONE 6.5MM 60MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316565 SUP HCPCS C1713 482316565 - SCREW BONE 6.5MM 65MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316570 SUP HCPCS C1713 482316570 - SCREW BONE 6.5MM 70MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316580 SUP HCPCS C1713 482316580 - SCREW BONE 6.5MM 80MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482316590 SUP HCPCS C1713 482316590 - SCREW BONE 6.5MM 90MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317025 SUP HCPCS C1713 482317025 - SCREW BONE 7MM 25MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317030 SUP HCPCS C1713 482317030 - SCREW BONE 7MM 30MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317035 SUP HCPCS C1713 482317035 - SCREW BONE 7MM 35MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317040 SUP HCPCS C1713 482317040 - SCREW BONE 7MM 40MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317045 SUP HCPCS C1713 482317045 - SCREW BONE 7MM 45MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317050 SUP HCPCS C1713 482317050 - SCREW BONE 7MM 50MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317055 SUP HCPCS C1713 482317055 - SCREW BONE 7MM 55MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317060 SUP HCPCS C1713 482317060 - SCREW BONE 7MM 60MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317065 SUP HCPCS C1713 482317065 - SCREW BONE 7MM 65MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317070 SUP HCPCS C1713 482317070 - SCREW BONE 7MM 70MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317080 SUP HCPCS C1713 482317080 - SCREW BONE 7MM 80MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317090 SUP HCPCS C1713 482317090 - SCREW BONE 7MM 90MM POLYAX XIA 3 TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317525 SUP HCPCS C1713 482317525 - SCREW BONE 7.5MM 25MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317530 SUP HCPCS C1713 482317530 - SCREW BONE 7.5MM 30MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317535 SUP HCPCS C1713 482317535 - SCREW BONE 7.5MM 35MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317540 SUP HCPCS C1713 482317540 - SCREW BONE 7.5MM 40MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317545 SUP HCPCS C1713 482317545 - SCREW BONE 7.5MM 45MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317550 SUP HCPCS C1713 482317550 - SCREW BONE 7.5MM 55MM CANN XIA TITANIUM SPN THORACOLUMBAR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317555 SUP HCPCS C1713 482317555 - SCREW BONE 7.5MM 55MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317560 SUP HCPCS C1713 482317560 - SCREW BONE 7.5MM 60MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317565 SUP HCPCS C1713 482317565 - SCREW BONE 7.5MM 65MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317570 SUP HCPCS C1713 482317570 - SCREW BONE 7.5MM 70MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317580 SUP HCPCS C1713 482317580 - SCREW BONE 7.5MM 80MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482317590 SUP HCPCS C1713 482317590 - SCREW BONE 7.5MM 90MM POLYAX XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318500 SUP HCPCS C1713 482318500 - SCREW BONE 8.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318525 SUP HCPCS C1713 482318525 - SCREW BONE 8.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318530 SUP HCPCS C1713 482318530 - SCREW BONE 8.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318535 SUP HCPCS C1713 482318535 - SCREW BONE 8.5MM 35MM XIA 3 TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318540 SUP HCPCS C1713 482318540 - SCREW BONE 8.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318545 SUP HCPCS C1713 482318545 - SCREW BONE 8.5MM 45MM POLYAX REVISION SPN ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318550 SUP HCPCS C1713 482318550 - SCREW BONE 8.5MM 50MM POLYAX REVISION SPN ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318555 SUP HCPCS C1713 482318555 - SCREW BONE 8.5MM 55MM POLYAX REVISION SPN ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318560 SUP HCPCS C1713 482318560 - SCREW BONE 8.5MM 60MM REVISION POLYAX SPN PEDICLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318565 SUP HCPCS C1713 482318565 - SCREW BONE 8.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318570 SUP HCPCS C1713 482318570 - BOLT SPINAL 8.5MM 70MM POLYAX XIA ILIUM BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318580 SUP HCPCS C1713 482318580 - SCREW BONE 80MM XIA TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482318590 SUP HCPCS C1713 482318590 - SCREW BN 9.5MM 100MM REV PA ILSCRL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319500 SUP HCPCS C1713 482319500 - SCREW BONE 9.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319540 SUP HCPCS C1713 482319540 - SCREW BONE 9.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319545 SUP HCPCS C1713 482319545 - SCREW BONE 9.5MM 45MM POLYAX REVISION SPN ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319550 SUP HCPCS C1713 482319550 - SCREW BONE 9.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319555 SUP HCPCS C1713 482319555 - SCREW BONE 9.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319560 SUP HCPCS C1713 482319560 - SCREW BONE 9.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319565 SUP HCPCS C1713 482319565 - SCREW BONE 9.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319570 SUP HCPCS C1713 482319570 - SCREW BONE 9.5MM 70MM POLYAX RED PROFILE REVISION XIA SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319580 SUP HCPCS C1713 482319580 - SCREW BONE 9.5MM 80MM POLYAX RED PROFILE REVISION XIA SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482319590 SUP HCPCS C1713 482319590 - SCREW BONE 9.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482326500 SUP HCPCS C1713 482326500 - SCREW BONE 6.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326530 SUP HCPCS C1713 482326530 - SCREW BONE 6.5MM 30MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326535 SUP HCPCS C1713 482326535 - SCREW BONE 6.5MM 35MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326540 SUP HCPCS C1713 482326540 - SCREW BONE 6.5MM 40MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326545 SUP HCPCS C1713 482326545 - SCREW BONE 6.5MM 45MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326550 SUP HCPCS C1713 482326550 - SCREW BONE 6.5MM 50MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326555 SUP HCPCS C1713 482326555 - SCREW BONE 6.5MM 55MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326560 SUP HCPCS C1713 482326560 - SCREW BONE 6.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326565 SUP HCPCS C1713 482326565 - SCREW BONE 6.5MM 65MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326570 SUP HCPCS C1713 482326570 - SCREW BONE 6.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326580 SUP HCPCS C1713 482326580 - SCREW BONE 6.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482326590 SUP HCPCS C1713 482326590 - SCREW BONE 6.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327500 SUP HCPCS C1713 482327500 - SCREW BONE 7.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327530 SUP HCPCS C1713 482327530 - SCREW BONE 7.5MM 30MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327535 SUP HCPCS C1713 482327535 - SCREW BONE 7.5MM 35MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327540 SUP HCPCS C1713 482327540 - SCREW BONE 7.5MM 40MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327545 SUP HCPCS C1713 482327545 - SCREW BONE 7.5MM 45MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327550 SUP HCPCS C1713 482327550 - SCREW BONE 7.5MM 50MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327555 SUP HCPCS C1713 482327555 - SCREW BONE 7.5MM 55MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327560 SUP HCPCS C1713 482327560 - SCREW BONE 7.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327565 SUP HCPCS C1713 482327565 - SCREW BONE 7.5MM 65MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327570 SUP HCPCS C1713 482327570 - SCREW BONE 7.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327580 SUP HCPCS C1713 482327580 - SCREW BONE 7.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482327590 SUP HCPCS C1713 482327590 - SCREW BONE 7.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328500 SUP HCPCS C1713 482328500 - SCREW BONE 8.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328530 SUP HCPCS C1713 482328530 - SCREW BONE 8.5MM 30MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328535 SUP HCPCS C1713 482328535 - SCREW BONE 8.5MM 35MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328540 SUP HCPCS C1713 482328540 - SCREW BONE 8.5MM 40MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328545 SUP HCPCS C1713 482328545 - SCREW BONE 8.5MM 45MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328550 SUP HCPCS C1713 482328550 - SCREW BONE 8.5MM 50MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328555 SUP HCPCS C1713 482328555 - SCREW BONE 8.5MM 55MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328560 SUP HCPCS C1713 482328560 - SCREW BONE 8.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328565 SUP HCPCS C1713 482328565 - SCREW BONE 8.5MM 65MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328570 SUP HCPCS C1713 482328570 - SCREW BONE 8.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328580 SUP HCPCS C1713 482328580 - SCREW BONE 8.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482328590 SUP HCPCS C1713 482328590 - SCREW BONE 8.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329500 SUP HCPCS C1713 482329500 - SCREW BONE 9.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329530 SUP HCPCS C1713 482329530 - SCREW BONE 9.5MM 30MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329535 SUP HCPCS C1713 482329535 - SCREW BONE 9.5MM 35MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329540 SUP HCPCS C1713 482329540 - SCREW BONE 9.5MM 40MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329545 SUP HCPCS C1713 482329545 - SCREW BONE 9.5MM 45MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329550 SUP HCPCS C1713 482329550 - SCREW BONE 9.5MM 50MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329555 SUP HCPCS C1713 482329555 - SCREW BONE 9.5MM 55MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329560 SUP HCPCS C1713 482329560 - SCREW BONE 9.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329565 SUP HCPCS C1713 482329565 - SCREW BONE 9.5MM 65MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329570 SUP HCPCS C1713 482329570 - SCREW BONE 9.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329580 SUP HCPCS C1713 482329580 - SCREW BONE 9.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482329590 SUP HCPCS C1713 482329590 - SCREW BONE 9.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482335020 SUP HCPCS C1713 482335020 - SCREW BONE 5MM 20MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482335025 SUP HCPCS C1713 482335025 - SCREW BONE 5MM 25MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482335030 SUP HCPCS C1713 482335030 - SCREW BONE 5MM 30MM UNIPLNR XIA SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482335035 SUP HCPCS C1713 482335035 - SCREW BONE 5MM 35MM UNIPLNR XIA SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482335040 SUP HCPCS C1713 482335040 - SCREW BONE 5MM 40MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482335045 SUP HCPCS C1713 482335045 - SCREW BONE 5MM 45MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482336025 SUP HCPCS C1713 482336025 - SCREW BONE 6MM 25MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482336030 SUP HCPCS C1713 482336030 - SCREW BONE 6MM 30MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482336035 SUP HCPCS C1713 482336035 - SCREW BONE 6MM 35MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482336040 SUP HCPCS C1713 482336040 - SCREW BONE 6MM 40MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482336045 SUP HCPCS C1713 482336045 - SCREW BONE 6MM 45MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482336050 SUP HCPCS C1713 482336050 - SCREW BONE 6MM 50MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482336055 SUP HCPCS C1713 482336055 - SCREW BONE 6MM 55MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482336060 SUP HCPCS C1713 482336060 - SCREW BONE 6MM 60MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482337030 SUP HCPCS C1713 482337030 - SCREW BONE 7MM 30MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482337035 SUP HCPCS C1713 482337035 - SCREW BONE 7MM 35MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482337040 SUP HCPCS C1713 482337040 - SCREW BONE 7MM 40MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482337045 SUP HCPCS C1713 482337045 - SCREW BONE 7MM 45MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482337050 SUP HCPCS C1713 482337050 - SCREW BONE 7MM 50MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482337055 SUP HCPCS C1713 482337055 - SCREW BONE 7MM 55MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482337060 SUP HCPCS C1713 482337060 - SCREW BONE 7MM 60MM UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482364520 SUP HCPCS C1713 482364520 - SCREW BONE 4.5MM 20MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482364525 SUP HCPCS C1713 482364525 - SCREW BONE 4.5MM 25MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482364530 SUP HCPCS C1713 482364530 - SCREW BONE 4.5MM 30MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482364535 SUP HCPCS C1713 482364535 - SCREW BONE 4.5MM 35MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482364540 SUP HCPCS C1713 482364540 - SCREW BONE 4.5MM 40MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482364545 SUP HCPCS C1713 482364545 - SCREW BONE 4.5MM 45MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365020 SUP HCPCS C1713 482365020 - SCREW BONE 5MM 20MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365025 SUP HCPCS C1713 482365025 - SCREW BONE 5MM 25MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365030 SUP HCPCS C1713 482365030 - SCREW BONE 5MM 30MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365035 SUP HCPCS C1713 482365035 - SCREW BONE 5MM 35MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365040 SUP HCPCS C1713 482365040 - SCREW BONE 5MM 40MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365045 SUP HCPCS C1713 482365045 - SCREW BONE 5MM 45MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365520 SUP HCPCS C1713 482365520 - SCREW BONE 5.5MM 20MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365525 SUP HCPCS C1713 482365525 - SCREW BONE 5.5MM 25MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365530 SUP HCPCS C1713 482365530 - SCREW BONE 5.5MM 30MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365535 SUP HCPCS C1713 482365535 - SCREW BONE 5.5MM 35MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365540 SUP HCPCS C1713 482365540 - SCREW BONE 5.5MM 40MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365545 SUP HCPCS C1713 482365545 - SCREW BONE 5.5MM 45MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365550 SUP HCPCS C1713 482365550 - SCREW BONE 5.5MM 50MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482365555 SUP HCPCS C1713 482365555 - SCREW BONE 5.5MM 55MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366025 SUP HCPCS C1713 482366025 - SCREW BONE 6MM 25MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366030 SUP HCPCS C1713 482366030 - SCREW BONE 6MM 30MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366035 SUP HCPCS C1713 482366035 - SCREW BONE 6MM 35MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366040 SUP HCPCS C1713 482366040 - SCREW BONE 6MM 40MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366045 SUP HCPCS C1713 482366045 - SCREW BONE 6MM 45MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366050 SUP HCPCS C1713 482366050 - SCREW BONE 6MM 50MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366055 SUP HCPCS C1713 482366055 - SCREW BONE 6MM 55MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366060 SUP HCPCS C1713 482366060 - SCREW BONE 6MM 60MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366525 SUP HCPCS C1713 482366525 - SCREW BONE 6.5MM 25MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366530 SUP HCPCS C1713 482366530 - SCREW BONE 6.5MM 30MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366535 SUP HCPCS C1713 482366535 - SCREW BONE 6.5MM 35MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366540 SUP HCPCS C1713 482366540 - SCREW BONE 6.5MM 40MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366545 SUP HCPCS C1713 482366545 - SCREW BONE 6.5MM 45MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366550 SUP HCPCS C1713 482366550 - SCREW BONE 6.5MM 50MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366555 SUP HCPCS C1713 482366555 - SCREW BONE 6.5MM 55MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482366560 SUP HCPCS C1713 482366560 - SCREW BONE 6.5MM 60MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367030 SUP HCPCS C1713 482367030 - SCREW BONE 7MM 30MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367035 SUP HCPCS C1713 482367035 - SCREW BONE 7MM 35MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367040 SUP HCPCS C1713 482367040 - SCREW BONE 7MM 40MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367045 SUP HCPCS C1713 482367045 - SCREW BONE 7MM 45MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367050 SUP HCPCS C1713 482367050 - SCREW BONE 7MM 50MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367055 SUP HCPCS C1713 482367055 - SCREW BONE 7MM 55MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367060 SUP HCPCS C1713 482367060 - SCREW BONE 7MM 60MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367530 SUP HCPCS C1713 482367530 - SCREW BONE 7.5MM 30MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367535 SUP HCPCS C1713 482367535 - SCREW BONE 7.5MM 35MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367540 SUP HCPCS C1713 482367540 - SCREW BONE 7.5MM 40MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367545 SUP HCPCS C1713 482367545 - SCREW BONE 7.5MM 45MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367550 SUP HCPCS C1713 482367550 - SCREW BONE 7.5MM 50MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367555 SUP HCPCS C1713 482367555 - SCREW BONE 7.5MM 55MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482367560 SUP HCPCS C1713 482367560 - SCREW BONE 7.5MM 60MM REDX UNIPLNR XIA 3 SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376500 SUP HCPCS C1713 482376500 - SCREW BONE 6.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376530 SUP HCPCS C1713 482376530 - SCREW BONE 6.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376535 SUP HCPCS C1713 482376535 - SCREW BONE 6.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376540 SUP HCPCS C1713 482376540 - SCREW BONE 6.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376545 SUP HCPCS C1713 482376545 - SCREW BONE 6.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376550 SUP HCPCS C1713 482376550 - SCREW BONE 6.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376555 SUP HCPCS C1713 482376555 - SCREW BONE 6.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376560 SUP HCPCS C1713 482376560 - SCREW BONE 6.5MM 60MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376565 SUP HCPCS C1713 482376565 - SCREW BONE 6.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376570 SUP HCPCS C1713 482376570 - SCREW BONE 6.5MM 70MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376580 SUP HCPCS C1713 482376580 - SCREW BONE 6.5MM 80MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482376590 SUP HCPCS C1713 482376590 - SCREW BONE 6.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377500 SUP HCPCS C1713 482377500 - SCREW BONE 7.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377530 SUP HCPCS C1713 482377530 - SCREW BONE 7.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377535 SUP HCPCS C1713 482377535 - SCREW BONE 7.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377540 SUP HCPCS C1713 482377540 - SCREW BONE 7.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377545 SUP HCPCS C1713 482377545 - SCREW BONE 7.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377550 SUP HCPCS C1713 482377550 - SCREW BONE 7.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377555 SUP HCPCS C1713 482377555 - SCREW BONE 7.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377560 SUP HCPCS C1713 482377560 - SCREW BONE 7.5MM 60MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377565 SUP HCPCS C1713 482377565 - SCREW BONE 7.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377570 SUP HCPCS C1713 482377570 - SCREW BONE 7.5MM 70MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377580 SUP HCPCS C1713 482377580 - SCREW BONE 7.5MM 80MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482377590 SUP HCPCS C1713 482377590 - SCREW BONE 7.5MM 90MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378500 SUP HCPCS C1713 482378500 - SCREW BONE 8.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378530 SUP HCPCS C1713 482378530 - SCREW BONE 8.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378535 SUP HCPCS C1713 482378535 - SCREW BONE 8.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378540 SUP HCPCS C1713 482378540 - SCREW BONE 8.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378545 SUP HCPCS C1713 482378545 - SCREW BONE 8.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378550 SUP HCPCS C1713 482378550 - SCREW BONE 8.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378555 SUP HCPCS C1713 482378555 - SCREW BONE 8.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378560 SUP HCPCS C1713 482378560 - SCREW BONE 8.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378565 SUP HCPCS C1713 482378565 - SCREW BONE 8.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378570 SUP HCPCS C1713 482378570 - SCREW BONE 8.5MM 70MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378580 SUP HCPCS C1713 482378580 - SCREW BONE 8.5MM 80MM REVISION POLYAX CLOSE HEAD ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482378590 SUP HCPCS C1713 482378590 - SCREW BONE 8.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379500 SUP HCPCS C1713 482379500 - SCREW BONE 9.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379530 SUP HCPCS C1713 482379530 - SCREW BONE 9.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379535 SUP HCPCS C1713 482379535 - SCREW BONE 9.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379540 SUP HCPCS C1713 482379540 - SCREW BONE 9.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379545 SUP HCPCS C1713 482379545 - SCREW BONE 9.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379550 SUP HCPCS C1713 482379550 - SCREW BONE 9.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379555 SUP HCPCS C1713 482379555 - SCREW BONE 9.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379560 SUP HCPCS C1713 482379560 - SCREW BONE 9.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379565 SUP HCPCS C1713 482379565 - SCREW BONE 9.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379570 SUP HCPCS C1713 482379570 - SCREW BONE 9.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379580 SUP HCPCS C1713 482379580 - SCREW BONE 9.5MM 80MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482379590 SUP HCPCS C1713 482379590 - SCREW BONE 9.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384020 SUP HCPCS C1713 482384020 - SCREW BONE 4MM 20MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384025 SUP HCPCS C1713 482384025 - SCREW BONE 4MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384030 SUP HCPCS C1713 482384030 - SCREW BONE 4MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384035 SUP HCPCS C1713 482384035 - SCREW BONE 4MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384040 SUP HCPCS C1713 482384040 - SCREW BONE 4MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384045 SUP HCPCS C1713 482384045 - SCREW BONE 4MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384520 SUP HCPCS C1713 482384520 - SCREW BONE 4.5MM 20MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384525 SUP HCPCS C1713 482384525 - SCREW BONE 4.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384530 SUP HCPCS C1713 482384530 - SCREW BONE 4.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384535 SUP HCPCS C1713 482384535 - SCREW BONE 4.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384540 SUP HCPCS C1713 482384540 - SCREW BONE 4.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482384545 SUP HCPCS C1713 482384545 - SCREW BONE 4.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385020 SUP Custom 27803010 482385020 - CONNECTOR ROD 5MM 20MM ROD TO ROD RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 482385025 SUP HCPCS C1713 482385025 - SCREW BONE 5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385030 SUP HCPCS C1713 482385030 - SCREW BONE 5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385035 SUP HCPCS C1713 482385035 - SCREW BONE 5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385040 SUP HCPCS C1713 482385040 - SCREW BONE 5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385045 SUP HCPCS C1713 482385045 - SCREW BONE 5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385050 SUP HCPCS C1713 482385050 - SCREW BONE 5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385525 SUP HCPCS C1713 482385525 - SCREW BONE 5.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385530 SUP HCPCS C1713 482385530 - SCREW BONE 5.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385535 SUP HCPCS C1713 482385535 - SCREW BONE 5.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385540 SUP HCPCS C1713 482385540 - SCREW BONE 5.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385545 SUP HCPCS C1713 482385545 - SCREW BONE 5.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385550 SUP HCPCS C1713 482385550 - SCREW BONE 5.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482385555 SUP HCPCS C1713 482385555 - SCREW BONE 5.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386525 SUP HCPCS C1713 482386525 - SCREW BONE 6.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386530 SUP HCPCS C1713 482386530 - SCREW BONE 6.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386535 SUP HCPCS C1713 482386535 - SCREW BONE 6.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386540 SUP HCPCS C1713 482386540 - SCREW BONE 6.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386545 SUP HCPCS C1713 482386545 - SCREW BONE 6.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386550 SUP HCPCS C1713 482386550 - SCREW BONE 6.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386555 SUP HCPCS C1713 482386555 - SCREW BONE 6.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386560 SUP HCPCS C1713 482386560 - SCREW BONE 6.5MM 60MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386565 SUP HCPCS C1713 482386565 - SCREW BONE 6.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386570 SUP HCPCS C1713 482386570 - SCREW BONE 6.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386580 SUP HCPCS C1713 482386580 - SCREW BONE 6.5MM 80MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482386590 SUP HCPCS C1713 482386590 - SCREW BONE 6.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387525 SUP HCPCS C1713 482387525 - SCREW BONE 7.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387530 SUP HCPCS C1713 482387530 - SCREW BONE 7.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387535 SUP HCPCS C1713 482387535 - SCREW BONE 7.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387540 SUP HCPCS C1713 482387540 - SCREW BONE 7.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387545 SUP HCPCS C1713 482387545 - SCREW BONE 7.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387550 SUP HCPCS C1713 482387550 - SCREW BONE 7.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387555 SUP HCPCS C1713 482387555 - SCREW BONE 7.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387560 SUP HCPCS C1713 482387560 - SCREW BONE 7.5MM 60MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387565 SUP HCPCS C1713 482387565 - SCREW BONE 7.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387570 SUP HCPCS C1713 482387570 - SCREW BONE 7.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387580 SUP HCPCS C1713 482387580 - SCREW BONE 7.5MM 80MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482387590 SUP HCPCS C1713 482387590 - SCREW BONE 7.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482388500 SUP HCPCS C1713 482388500 - SCREW BONE 8.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482388560 SUP HCPCS C1713 482388560 - SCREW BONE 8.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482388570 SUP HCPCS C1713 482388570 - SCREW BONE 8.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482388580 SUP HCPCS C1713 482388580 - SCREW BONE 8.5MM 80MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482388590 SUP HCPCS C1713 482388590 - SCREW BONE 8.5MM 90MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482389500 SUP HCPCS C1713 482389500 - SCREW BONE 9.5MM 100MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482389560 SUP HCPCS C1713 482389560 - SCREW BONE 9.5MM 60MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482389570 SUP HCPCS C1713 482389570 - SCREW BONE 9.5MM 70MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482389580 SUP HCPCS C1713 482389580 - SCREW BONE 9.5MM 80MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482389590 SUP HCPCS C1713 482389590 - SCREW BONE 9.5MM 90MM REVISION POLYAX BIASED ANGLE BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 482396500 SUP HCPCS C1713 482396500 - SCREW BONE 6.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482396560 SUP HCPCS C1713 482396560 - SCREW BONE 6.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482396570 SUP HCPCS C1713 482396570 - SCREW BONE 6.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482396580 SUP HCPCS C1713 482396580 - SCREW BONE 6.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482396590 SUP HCPCS C1713 482396590 - SCREW BONE 6.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482397500 SUP HCPCS C1713 482397500 - SCREW BONE 7.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482397560 SUP HCPCS C1713 482397560 - SCREW BONE 7.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482397570 SUP HCPCS C1713 482397570 - SCREW BONE 15D 7.5MM 70MM REVISION MNOAX BIASED ANGLE BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482397580 SUP HCPCS C1713 482397580 - SCREW BONE 15D 7.5MM 80MM REVISION MNOAX BIASED ANGLE BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482397590 SUP HCPCS C1713 482397590 - SCREW BONE 7.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482398500 SUP HCPCS C1713 482398500 - SCREW BONE 8.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482398560 SUP HCPCS C1713 482398560 - SCREW BONE 8.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482398570 SUP HCPCS C1713 482398570 - SCREW BONE 8.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482398580 SUP HCPCS C1713 482398580 - SCREW BONE 8.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482398590 SUP HCPCS C1713 482398590 - SCREW BONE 8.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482399500 SUP HCPCS C1713 482399500 - SCREW BONE 9.5MM 100MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482399560 SUP HCPCS C1713 482399560 - SCREW BONE 9.5MM 60MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482399570 SUP HCPCS C1713 482399570 - SCREW BONE 9.5MM 70MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482399580 SUP HCPCS C1713 482399580 - SCREW BONE 9.5MM 80MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482399590 SUP HCPCS C1713 482399590 - SCREW BONE 9.5MM 90MM REVISION MNOAX ILIOSACRAL BOTH IP/OP "$3,654.83 " "$2,704.57" $0.00 "$2,923.86" "$1,644.67" "$1,644.67" $0.00 $0.00 $0.00 $761.76 "$2,712.61" "$2,712.61" $0.00 $0.00 $761.67 $0.00 "$1,801.83" "$1,801.83" $0.00 "$1,827.41" "$2,894.63" "$2,923.86" $0.00 $0.00 $571.98 $0.00 $0.00 $581.85 $0.00 $0.00 $0.00 $0.00 $0.00 482700601 SUP HCPCS C1713 00482700601 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 6MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482700701 SUP HCPCS C1713 00482700701 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 7MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482700800 SUP HCPCS C1713 00482700800 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 8MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482700801 SUP HCPCS C1713 00482700801 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 8MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482700901 SUP HCPCS C1713 00482700901 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 9MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482701000 SUP HCPCS C1713 00482701000 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 10MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482701001 SUP HCPCS C1713 00482701001 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 10MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482701200 SUP HCPCS C1713 00482701200 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 12MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482701201 SUP HCPCS C1713 00482701201 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 12MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482701400 SUP HCPCS C1713 00482701400 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 14MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482701401 SUP HCPCS C1713 00482701401 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 14MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482701600 SUP HCPCS C1713 00482701600 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 16MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482701601 SUP HCPCS C1713 00482701601 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 16MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482701800 SUP HCPCS C1713 00482701800 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 18MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482701801 SUP HCPCS C1713 00482701801 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 18MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482702000 SUP HCPCS C1713 00482702000 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 20MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482702200 SUP HCPCS C1713 00482702200 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 22MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482702201 SUP HCPCS C1713 00482702201 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 22MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482702400 SUP HCPCS C1713 00482702400 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 24MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482702401 SUP HCPCS C1713 00482702401 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 24MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482702600 SUP HCPCS C1713 00482702600 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 26MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482702601 SUP HCPCS C1713 00482702601 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 26MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482702800 SUP HCPCS C1713 00482702800 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 28MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482702801 SUP HCPCS C1713 00482702801 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 28MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482703000 SUP HCPCS C1713 00482703000 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 30MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482703001 SUP HCPCS C1713 00482703001 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 30MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482703200 SUP HCPCS C1713 00482703200 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 32MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482703201 SUP HCPCS C1713 00482703201 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 32MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482703400 SUP HCPCS C1713 00482703400 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 34MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482703401 SUP HCPCS C1713 00482703401 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 34MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482703600 SUP HCPCS C1713 00482703600 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 36MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482703601 SUP HCPCS C1713 00482703601 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 36MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482703800 SUP HCPCS C1713 00482703800 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 38MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482703801 SUP HCPCS C1713 00482703801 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 38MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482704000 SUP HCPCS C1713 00482704000 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 40MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482704001 SUP HCPCS C1713 00482704001 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 40MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482704201 SUP HCPCS C1713 00482704201 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 42MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482704401 SUP HCPCS C1713 00482704401 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 44MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482704500 SUP HCPCS C1713 00482704500 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 45MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482704501 SUP HCPCS C1713 00482704501 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 45MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482704601 SUP HCPCS C1713 00482704601 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 46MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482704801 SUP HCPCS C1713 00482704801 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 48MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482705000 SUP HCPCS C1713 00482705000 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 50MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482705001 SUP HCPCS C1713 00482705001 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 50MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482705201 SUP HCPCS C1713 00482705201 - SCREW BONE SMALL HEXAGON 2.7MM 52MM SELF TAP CORTICAL BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482705401 SUP HCPCS C1713 00482705401 - SCREW BONE SMALL HEXAGON 2.7MM 54MM SELF TAP CORTICAL BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482705500 SUP HCPCS C1713 00482705500 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 55MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482705501 SUP HCPCS C1713 00482705501 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 55MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482705601 SUP HCPCS C1713 00482705601 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 56MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482705801 SUP HCPCS C1713 00482705801 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 58MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482706000 SUP HCPCS C1713 00482706000 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 60MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482706001 SUP HCPCS C1713 00482706001 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 60MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482706500 SUP HCPCS C1713 00482706500 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 65MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482706501 SUP HCPCS C1713 00482706501 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 65MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482707000 SUP HCPCS C1713 00482707000 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 70MM STAINLESS STEEL BOTH IP/OP $32.20 $23.83 $0.00 $25.76 $14.49 $14.49 $0.00 $0.00 $0.00 $6.71 $23.90 $23.90 $0.00 $0.00 $6.71 $0.00 $19.05 $19.05 $0.00 $16.10 $25.50 $25.76 $0.00 $0.00 $5.04 $0.00 $0.00 $5.13 $0.00 $0.00 $0.00 $0.00 $0.00 482707001 SUP HCPCS C1713 00482707001 - SCREW BONE SMALL HEXAGON 2.7MM 2.5MM 70MM SELF TAP STAINLESS BOTH IP/OP $36.80 $27.23 $0.00 $29.44 $16.56 $16.56 $0.00 $0.00 $0.00 $7.67 $27.31 $27.31 $0.00 $0.00 $7.67 $0.00 $21.77 $21.77 $0.00 $18.40 $29.15 $29.44 $0.00 $0.00 $5.76 $0.00 $0.00 $5.86 $0.00 $0.00 $0.00 $0.00 $0.00 482802540 SUP HCPCS C1713 482802540 - SCREW BONE 5.5MM 40MM 15MM ES2 LT XIA 3 SHRT BLADE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482802640 SUP HCPCS C1713 482802640 - SCREW BONE 6.5MM 40MM 15MM ES2 LT XIA 3 SHRT BLADE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482802645 SUP HCPCS C1713 482802645 - SCREW BONE 6.5MM 45MM 15MM ES2 LT XIA 3 SHRT BLADE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482802650 SUP HCPCS C1713 482802650 - SCREW BN SHRT BLDE LOPRFL 6.5MM 50MM 15MM ES2 LT XIA 3 6 PNT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482802745 SUP HCPCS C1713 482802745 - SCREW BN SHRT BLDE LOPRFL 7.5MM 45MM 15MM ES2 LT XIA 3 6 PNT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482804545 SUP HCPCS C1713 482804545 - SCREW BN LNG BLDE LOPRFL 5.5MM 45MM 15MM ES2 LT XIA 3 6 PNT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482804645 SUP HCPCS C1713 482804645 - SCREW BN LNG BLDE LOPRFL 6.5MM 45MM 15MM ES2 LT XIA 3 6 PNT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482804650 SUP HCPCS C1713 482804650 - SCREW BN LNG BLDE LOPRFL 6.5MM 50MM 15MM ES2 LT XIA 3 6 PNT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482804750 SUP HCPCS C1713 482804750 - SCREW BN LNG BLDE LOPRFL 7.5MM 50MM 15MM ES2 LT XIA 3 6 PNT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 482806050 SUP HCPCS C1713 482806050 - ROD SPNL HEX 5.5MM 50MM ES2 RDS TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 482806055 SUP HCPCS C1713 482806055 - ROD SPNL HEX 5.5MM 55MM ES2 RDS TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 482807060 SUP HCPCS C1713 "482807060 - TITANIUM STRAIGHT ROD, 5.5X60MM" BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 482807090 SUP HCPCS C1713 482807090 - ROD SPNL 90MM 5.5MM ES2 STR HEX TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 482911180 SUP HCPCS C1713 482911180 - ENDCAP SPNL 18MM 0D BOTH IP/OP $746.78 $552.62 $0.00 $597.42 $336.05 $336.05 $0.00 $0.00 $0.00 $155.65 $554.26 $554.26 $0.00 $0.00 $155.63 $0.00 $441.72 $441.72 $0.00 $373.39 $591.45 $597.42 $0.00 $0.00 $116.87 $0.00 $0.00 $118.89 $0.00 $0.00 $0.00 $0.00 $0.00 483510098 SUP Custom 27803010 483510098 - SPACER SPNL 8D LRDTC WDG NOSE 20X11X9MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510108 SUP Custom 27803010 483510108 - SPACER SPNL 8D LRDTC WDG NOSE 20X11X10MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510118 SUP Custom 27803010 483510118 - SPACER SPNL 8D LRDTC WDG NOSE 20X11X11MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510128 SUP Custom 27803010 483510128 - SPACER SPNL 8D LRDTC WDG NOSE 20X11X12MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510138 SUP Custom 27803010 483510138 - SPACER SPNL 8D LRDTC WDG NOSE 20X11X13MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510140 SUP Custom 27803010 483510140 - SPACER SPNL 0D WDG NOSE 20X11X14MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510144 SUP Custom 27803010 483510144 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X14MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510148 SUP Custom 27803010 483510148 - SPACER SPNL 8D LRDTC WDG NOSE 20X11X14MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510150 SUP Custom 27803010 483510150 - SPACER SPNL 0D WDG NOSE 20X11X15MM AVS UNILIF HLW PEEK-OPTM BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510154 SUP Custom 27803010 483510154 - SPACER SPNL 4D LRDTC WDG NOSE 20X11X15MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510158 SUP Custom 27803010 483510158 - SPACER SPNL 8D LRDTC WDG NOSE 20X11X15MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483510168 SUP Custom 27803010 483510168 - SPACER SPNL 8D LRDTC WDG NOSE 20X11X16MM AVS UNILIF HLW BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515098 SUP Custom 27803010 483515098 - SPACER SPNL 8D WDG 25X11X9MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515108 SUP Custom 27803010 483515108 - SPACER SPNL 8D WDG 25X11X10MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515118 SUP Custom 27803010 483515118 - SPACER SPNL 8D WDG 25X11X11MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515128 SUP Custom 27803010 483515128 - SPACER SPNL 8D WDG 25X11X12MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515138 SUP Custom 27803010 483515138 - SPACER SPNL 8D WDG 25X11X13MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515140 SUP Custom 27803010 483515140 - SPACER SPNL 0D RECT 25X11X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515144 SUP Custom 27803010 483515144 - SPACER SPNL 4D WDG 25X11X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515148 SUP Custom 27803010 483515148 - SPACER SPNL 8D WDG 25X11X14MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515150 SUP Custom 27803010 483515150 - SPACER SPNL 0D RECT 25X11X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515154 SUP Custom 27803010 483515154 - SPACER SPNL 4D WDG 25X11X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515158 SUP Custom 27803010 483515158 - SPACER SPNL 8D WDG 25X11X15MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 483515168 SUP Custom 27803010 483515168 - SPACER SPNL 8D WDG 25X11X16MM AVS PL HLW PEEK PLIF BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486610000 SUP HCPCS C1713 486610000 - CAP LOCKING SPN BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 486610425 SUP HCPCS C1713 486610425 - SCREW BONE STANDARD 4.75MM 25MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610430 SUP HCPCS C1713 486610430 - SCREW BONE STANDARD 4.75MM 30MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610435 SUP HCPCS C1713 486610435 - SCREW BONE STANDARD 4.75MM 35MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610440 SUP HCPCS C1713 486610440 - SCREW BONE STANDARD 4.75MM 40MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610445 SUP HCPCS C1713 486610445 - SCREW BONE STANDARD 4.75MM 45MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610450 SUP HCPCS C1713 486610450 - SCREW BONE 4.75MM 50MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610455 SUP HCPCS C1713 486610455 - SCREW BONE 4.75MM 55MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610525 SUP HCPCS C1713 486610525 - SCREW BONE 5.75MM 25MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610530 SUP HCPCS C1713 486610530 - SCREW BONE STANDARD 5.75MM 30MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610535 SUP HCPCS C1713 486610535 - SCREW BONE STANDARD 5.75MM 35MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610540 SUP HCPCS C1713 486610540 - SCREW BONE STANDARD 5.75MM 40MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610545 SUP HCPCS C1713 486610545 - SCREW BONE STANDARD 5.75MM 45MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610550 SUP HCPCS C1713 486610550 - SCREW BONE 5.75MM 50MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610555 SUP HCPCS C1713 486610555 - SCREW BONE 5.75MM 55MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610560 SUP HCPCS C1713 486610560 - SCREW BONE 5.75MM 60MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610565 SUP HCPCS C1713 486610565 - SCREW BONE 5.75MM 65MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610600 SUP HCPCS C1713 486610600 - SCREW BONE 6.75MM 100MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610625 SUP HCPCS C1713 486610625 - SCREW BONE 6.75MM 25MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610630 SUP HCPCS C1713 486610630 - SCREW BONE STANDARD 6.75MM 30MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610635 SUP HCPCS C1713 486610635 - SCREW BONE STANDARD 6.75MM 35MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610640 SUP HCPCS C1713 486610640 - SCREW BONE STANDARD 6.75MM 40MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610645 SUP HCPCS C1713 486610645 - SCREW BONE STANDARD 6.75MM 45MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610650 SUP HCPCS C1713 486610650 - SCREW BONE STANDARD 6.75MM 50MM RAD SPN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610655 SUP HCPCS C1713 486610655 - SCREW BONE 6.75MM 55MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610660 SUP HCPCS C1713 486610660 - SCREW BONE 6.75MM 60MM SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610665 SUP HCPCS C1713 486610665 - SCREW BONE 6.75MM 65MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610670 SUP HCPCS C1713 486610670 - SCREW BONE 6.75MM 70MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610680 SUP HCPCS C1713 486610680 - SCREW BONE 6.75MM 80MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610690 SUP HCPCS C1713 486610690 - SCREW BONE 6.75MM 90MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610700 SUP HCPCS C1713 486610700 - SCREW BONE 7.75MM 100MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610725 SUP HCPCS C1713 486610725 - SCREW BONE 7.75MM 25MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610730 SUP HCPCS C1713 486610730 - SCREW BONE 7.75MM 30MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610735 SUP HCPCS C1713 486610735 - SCREW BONE 7.75MM 35MM RADSTD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610740 SUP HCPCS C1713 486610740 - SCREW BONE 7.75MM 40MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610745 SUP HCPCS C1713 486610745 - SCREW BONE 7.75MM 45MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610750 SUP HCPCS C1713 486610750 - SCREW BONE 7.75MM 50MM SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610755 SUP HCPCS C1713 486610755 - SCREW BONE 7.75MM 55MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610760 SUP HCPCS C1713 486610760 - SCREW BONE 7.75MM 60MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610765 SUP HCPCS C1713 486610765 - SCREW BONE 7.75MM 65MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610770 SUP HCPCS C1713 486610770 - SCREW BONE 7.75MM 70MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610780 SUP HCPCS C1713 486610780 - SCREW BONE 7.75MM 80MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610790 SUP HCPCS C1713 486610790 - SCREW BONE 7.75MM 90MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610800 SUP HCPCS C1713 486610800 - SCREW BONE 8.75MM 100MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610830 SUP HCPCS C1713 486610830 - SCREW BONE 8.75MM 30MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610835 SUP HCPCS C1713 486610835 - SCREW BONE 8.75MM 35MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610840 SUP HCPCS C1713 486610840 - SCREW BONE 8.75MM 40MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610845 SUP HCPCS C1713 486610845 - SCREW BONE 8.75MM 45MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610850 SUP HCPCS C1713 486610850 - SCREW BONE 8.75MM 50MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610855 SUP HCPCS C1713 486610855 - SCREW BONE 8.75MM 55MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610860 SUP HCPCS C1713 486610860 - SCREW BONE 8.75MM 60MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610865 SUP HCPCS C1713 486610865 - SCREW BONE 8.75MM 65MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610870 SUP HCPCS C1713 486610870 - SCREW BONE 8.75MM 70MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610880 SUP HCPCS C1713 486610880 - SCREW BONE 8.75MM 80MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610890 SUP HCPCS C1713 486610890 - SCREW BONE 8.75MM 90MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610900 SUP HCPCS C1713 486610900 - SCREW BONE 9.75MM 100MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610960 SUP HCPCS C1713 486610960 - SCREW BONE 9.75MM 60MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610970 SUP HCPCS C1713 486610970 - SCREW BONE 9.75MM 70MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610980 SUP HCPCS C1713 486610980 - SCREW BONE 9.75MM 80MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486610990 SUP HCPCS C1713 486610990 - SCREW BONE 9.75MM 90MM RADSTD SPNL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486611425 SUP HCPCS C1713 486611425 - SCREW BONE 4.75MM 25MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611430 SUP HCPCS C1713 486611430 - SCREW BONE 4.75MM 30MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611435 SUP HCPCS C1713 486611435 - SCREW BONE 4.75MM 35MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611440 SUP HCPCS C1713 486611440 - SCREW BONE 4.75MM 40MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611445 SUP HCPCS C1713 486611445 - SCREW BONE 4.75MM 45MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611450 SUP HCPCS C1713 486611450 - SCREW BONE 4.75MM 50MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611455 SUP HCPCS C1713 486611455 - SCREW BONE 4.75MM 55MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611525 SUP HCPCS C1713 486611525 - SCREW BONE 5.75MM 25MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611530 SUP HCPCS C1713 486611530 - SCREW BONE 5.75MM 30MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611535 SUP HCPCS C1713 486611535 - SCREW BONE 5.75MM 35MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611540 SUP HCPCS C1713 486611540 - SCREW BONE 5MM 40MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611545 SUP HCPCS C1713 486611545 - SCREW BONE 5.75MM 45MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611550 SUP HCPCS C1713 486611550 - SCREW BONE 5.75MM 50MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611555 SUP HCPCS C1713 486611555 - SCREW BONE 5MM 55MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611560 SUP HCPCS C1713 486611560 - SCREW BONE 5.75MM 60MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611565 SUP HCPCS C1713 486611565 - SCREW BONE 5.75MM 65MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611600 SUP HCPCS C1713 486611600 - SCREW BONE 6.75MM 100MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611625 SUP HCPCS C1713 486611625 - SCREW BONE 6.75MM 25MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611630 SUP HCPCS C1713 486611630 - SCREW BONE 6.75MM 30MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611635 SUP HCPCS C1713 486611635 - SCREW BONE 6.75MM 35MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611640 SUP HCPCS C1713 486611640 - SCREW BONE 6.75MM 40MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611645 SUP HCPCS C1713 486611645 - SCREW BONE 6.75MM 45MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611650 SUP HCPCS C1713 486611650 - SCREW BONE 6.75MM 50MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611655 SUP HCPCS C1713 486611655 - SCREW BONE 6.75MM 55MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611660 SUP HCPCS C1713 486611660 - SCREW BONE 6.75MM 60MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611665 SUP HCPCS C1713 486611665 - SCREW BONE 6.75MM 65MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611670 SUP HCPCS C1713 486611670 - SCREW BONE 6.75MM 70MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611680 SUP HCPCS C1713 486611680 - SCREW BONE 6.75MM 80MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611690 SUP HCPCS C1713 486611690 - SCREW BONE 6.75MM 90MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611700 SUP HCPCS C1713 486611700 - SCREW BONE 7.75MM 100MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611725 SUP HCPCS C1713 486611725 - SCREW BONE 7.75MM 25MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611730 SUP HCPCS C1713 486611730 - SCREW BONE 7.75MM 30MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611735 SUP HCPCS C1713 486611735 - SCREW BONE 7.75MM 35MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611740 SUP HCPCS C1713 486611740 - SCREW BONE 7.75MM 40MM MULTIANG TITANIUM SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611745 SUP HCPCS C1713 486611745 - SCREW BONE 7.75MM 45MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611750 SUP HCPCS C1713 486611750 - SCREW BONE 7.75MM 50MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611755 SUP HCPCS C1713 486611755 - SCREW BONE 7.75MM 55MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611760 SUP HCPCS C1713 486611760 - SCREW BONE 7.75MM 60MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611765 SUP HCPCS C1713 486611765 - SCREW BONE 7.75MM 65MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611770 SUP HCPCS C1713 486611770 - SCREW BONE 7.75MM 70MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611780 SUP HCPCS C1713 486611780 - SCREW BONE 7.75MM 80MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611790 SUP HCPCS C1713 486611790 - SCREW BONE 7.75MM 90MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611800 SUP HCPCS C1713 486611800 - SCREW BONE 8.75MM 100MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611830 SUP HCPCS C1713 486611830 - SCREW BONE 8.75MM 30MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611835 SUP HCPCS C1713 486611835 - SCREW BONE 8.75MM 35MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611840 SUP HCPCS C1713 486611840 - SCREW BONE 8.75MM 40MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611845 SUP HCPCS C1713 486611845 - SCREW BONE 8.75MM 45MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611850 SUP HCPCS C1713 486611850 - SCREW BONE 8.75MM 50MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611855 SUP HCPCS C1713 486611855 - SCREW BONE 8.75MM 55MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611860 SUP HCPCS C1713 486611860 - SCREW BONE 8.75MM 60MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611865 SUP HCPCS C1713 486611865 - SCREW BONE 8.75MM 65MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611870 SUP HCPCS C1713 486611870 - SCREW BONE 8.75MM 70MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611880 SUP HCPCS C1713 486611880 - SCREW BONE 8.75MM 80MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611890 SUP HCPCS C1713 486611890 - SCREW BONE 8.75MM 90MM MULTIANG RAD SPN BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 486611900 SUP HCPCS C1713 486611900 - SCREW BONE 9.75MM 100MM RAD SPNL MULTIANG BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486611960 SUP HCPCS C1713 486611960 - SCREW BONE 9.75MM 60MM RADL SPNL MULTIANG BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486611970 SUP HCPCS C1713 486611970 - SCREW BONE 9.75MM 70MM RAD SPNL CANN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486611980 SUP HCPCS C1713 486611980 - SCREW BONE 9.75MM 80MM RAD SPNL MULTIANG BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486611990 SUP HCPCS C1713 486611990 - SCREW BONE 9.75MM 90MM RAD SPNL MULTIANG BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 486612535 SUP HCPCS C1713 486612535 - SCREW BONE 5.75MM 35MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612540 SUP HCPCS C1713 486612540 - SCREW BONE 5.75MM 40MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612545 SUP HCPCS C1713 486612545 - SCREW BONE 5.75MM 45MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612550 SUP HCPCS C1713 486612550 - SCREW BONE 5.75MM 50MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612630 SUP HCPCS C1713 486612630 - SCREW BONE 6.75MM 30MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612635 SUP Custom 27203010 486612635 - SCREW BONE 6.75MM 35MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 $0.00 $0.00 $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486612640 SUP HCPCS C1713 486612640 - SCREW BONE 6.75MM 40MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612645 SUP HCPCS C1713 486612645 - SCREW BONE 6.75MM 45MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612650 SUP HCPCS C1713 486612650 - SCREW BONE 6.75MM 50MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612655 SUP HCPCS C1713 486612655 - SCREW BONE 6.75MM 55MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612730 SUP HCPCS C1713 486612730 - SCREW BONE 7.75MM 30MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612735 SUP HCPCS C1713 486612735 - SCREW BONE 7.75MM 35MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612740 SUP HCPCS C1713 486612740 - SCREW BONE 7.75MM 40MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612745 SUP HCPCS C1713 486612745 - SCREW BONE 7.75MM 45MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612750 SUP HCPCS C1713 486612750 - SCREW BONE 7.75MM 50MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486612755 SUP HCPCS C1713 486612755 - SCREW BONE 7.75MM 55MM MULTIANG CANN RAD SPN BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 486613000 SUP Custom 27803010 486613000 - ROD SPINAL 5.5MM 100MM NONHEXAGONAL TITANIUM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613003 SUP Custom 27803010 486613003 - ROD SPINAL 5.5MM 30MM W/O HEXAGONAL RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613004 SUP Custom 27803010 486613004 - ROD SPINAL 40MM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613005 SUP Custom 27803010 486613005 - ROD SPINAL 5.5MM 50MM NONHEXAGONAL RAD TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613006 SUP Custom 27803010 486613006 - ROD SPINAL 5.5MM 60MM W/O HEXAGONAL RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613007 SUP Custom 27803010 486613007 - ROD SPNL 5.5MM 70MM RDS NONHEXAGONAL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613008 SUP Custom 27803010 486613008 - ROD SPINAL 5.5MM 80MM W/O HEXAGONAL RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613009 SUP Custom 27803010 486613009 - ROD SPINAL 5.5MM 90MM NONHEXAGONAL RAD TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613010 SUP Custom 27803010 486613010 - ROD SPINAL 5.5MM 110MM W/O HEXAGONAL RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613020 SUP Custom 27803010 486613020 - ROD SPINAL 5.5MM 120MM RAD W/O HEXAGONAL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613050 SUP Custom 27803010 486613050 - ROD SPINAL 5.5MM 50MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613053 SUP Custom 27803010 486613053 - ROD SPINAL 5.5MM 35MM RAD NONHEXAGONAL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613054 SUP Custom 27803010 486613054 - ROD SPINAL 5.5MM 45MM NONHEXAGONAL RAD TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613060 SUP Custom 27803010 486613060 - ROD SPINAL 5.5MM 60MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613070 SUP Custom 27803010 486613070 - ROD SPINAL 5.5MM 70MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613080 SUP Custom 27803010 486613080 - ROD SPINAL 5.5MM 80MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613090 SUP Custom 27803010 486613090 - ROD SPINAL 5.5MM 90MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613100 SUP Custom 27803010 486613100 - ROD SPINAL 5.5MM 100MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613110 SUP Custom 27803010 486613110 - ROD SPINAL 5.5MM 110MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613120 SUP Custom 27803010 486613120 - ROD SPINAL 5.5MM 120MM HEXAGONAL RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613140 SUP Custom 27803010 486613140 - ROD SPINAL 5.5MM 140MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613160 SUP Custom 27803010 486613160 - ROD SPINAL 5.5MM 160MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613180 SUP Custom 27803010 486613180 - ROD SPINAL 5.5MM 180MM HEXAGONAL RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613200 SUP Custom 27803010 486613200 - ROD SPINAL 5.5MM 200MM HEXAGON RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613220 SUP Custom 27803010 486613220 - ROD SPINAL 5.5MM 220MM RAD HEXAGONAL BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613240 SUP Custom 27803010 486613240 - ROD SPINAL 5.5MM 240MM HEXAGON RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613260 SUP Custom 27803010 486613260 - ROD SPINAL 5.5MM 260MM HEXAGON RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613280 SUP Custom 27803010 486613280 - ROD SPINAL 5.5MM 280MM HEXAGON RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613300 SUP Custom 27803010 486613300 - ROD SPINAL 5.5MM 300MM HEXAGONAL RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613320 SUP Custom 27803010 486613320 - ROD SPINAL 5.5MM 320MM HEXAGON RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613340 SUP Custom 27803010 486613340 - ROD SPINAL 5.5MM 340MM HEXAGON RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613360 SUP Custom 27803010 486613360 - ROD SPINAL 5.5MM 360MM HEXAGON RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613380 SUP Custom 27803010 486613380 - ROD SPINAL 5.5MM 380MM HEXAGON RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613400 SUP Custom 27803010 486613400 - ROD SPINAL 5.5MM 400MM RAD HEXAGONAL BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613600 SUP Custom 27803010 486613600 - ROD SPINAL 5.5MM 600MM HEXAGONAL RAD BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613601 SUP Custom 27803010 486613601 - ROD SPINAL 6.5MM 600MM RAD VITALLIUM PEDICLE BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486613602 SUP Custom 27803010 486613602 - ROD SPINAL 5.5MM HEXAGON VITALLIUM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614022 SUP Custom 27803010 486614022 - CONNECTOR ROD 22MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614024 SUP Custom 27803010 486614024 - CONNECTOR ROD 24MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614026 SUP Custom 27803010 486614026 - CONNECTOR ROD 26MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614028 SUP Custom 27803010 486614028 - CONNECTOR ROD 28MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614030 SUP Custom 27803010 486614030 - CONNECTOR ROD 30MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614032 SUP Custom 27803010 486614032 - CONNECTOR ROD 32MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614034 SUP Custom 27803010 486614034 - CONNECTOR ROD 34MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614036 SUP Custom 27803010 486614036 - CONNECTOR ROD 36MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614100 SUP Custom 27803010 486614100 - CONNECTOR ROD SHORT CROSS VARIABLE RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614110 SUP Custom 27803010 486614110 - CONNECTOR ROD MEDIUM CROSS RAD VARIABLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614120 SUP Custom 27803010 486614120 - CONNECTOR ROD LONG CROSS VARIABLE RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614130 SUP Custom 27803010 486614130 - CONNECTOR ROD MEDIUM CROSS CVD RAD VARIABLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614140 SUP Custom 27803010 486614140 - CONNECTOR ROD LONG VARIABLE CROSS CVD RAD MA BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614170 SUP Custom 27803010 486614170 - CONNECTOR ROD MEDIUM CROSS MULTIANGLED RAD VARIABLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614180 SUP Custom 27803010 486614180 - CONNECTOR ROD LONG POLYAX CROSS VAR ANG RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614215 SUP Custom 27803010 486614215 - CONNECTOR ROD 15MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614216 SUP Custom 27803010 486614216 - CONNECTOR ROD 16MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614217 SUP Custom 27803010 486614217 - CONNECTOR ROD 18MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614218 SUP Custom 27803010 486614218 - CONNECTOR ROD 18MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614219 SUP Custom 27803010 486614219 - CONNECTOR ROD 19MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614220 SUP Custom 27803010 486614220 - CONNECTOR ROD 20MM CROSS RAD SPN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614300 SUP Custom 27803010 486614300 - CONNECTOR ROD 0D SMALL ROD TO ROD RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614305 SUP Custom 27803010 486614305 - CONNECTOR ROD 105D OFFST RAD BEN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614310 SUP Custom 27803010 486614310 - CONNECTOR ROD NEUTRAL OFFST RAD BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614320 SUP Custom 27803010 486614320 - CONNECTOR ROD NEUTRAL LONG OFFST RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614330 SUP Custom 27803010 486614330 - CONNECTOR ROD 30D SMALL ROD TO ROD RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614375 SUP Custom 27803010 486614375 - CONNECTOR ROD 75D SMALL ROD TO ROD RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614400 SUP Custom 27803010 486614400 - CONNECTOR ROD 10D LARGE ROD TO ROD RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614430 SUP Custom 27803010 486614430 - CONNECTOR ROD 10D LARGE ROD TO ROD RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614530 SUP Custom 27803010 486614530 - CONCTR ROD 5MM RAD ROD TO ROD SPNL BOTH IP/OP "$2,076.80 " "$1,536.83" $0.00 "$1,661.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,541.40" "$1,541.40" $0.00 $0.00 $432.81 $0.00 $0.00 $0.00 $0.00 "$1,038.40" "$1,644.83" "$1,661.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614550 SUP Custom 27803010 486614550 - CONNECTOR ROD 5MM ROD TO ROD RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614555 SUP Custom 27803010 486614555 - CONNECTOR ROD ROD TO ROD POLYAX RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614560 SUP Custom 27803010 486614560 - CONNECTOR ROD 5MM ROD TO ROD RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486614565 SUP Custom 27803010 486614565 - CONNECTOR ROD OFFST RAD SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615000 SUP Custom 27803010 486615000 - ROD SPINAL 5.5MM 100MM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615010 SUP Custom 27803010 486615010 - ROD SPINAL 5.5MM 110MM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615020 SUP Custom 27803010 486615020 - ROD SPINAL 5.5MM 120MM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615030 SUP Custom 27803010 486615030 - ROD SPINAL 5.5MM 30MM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615035 SUP Custom 27803010 486615035 - ROD SPNL 35MM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615040 SUP Custom 27803010 486615040 - ROD SPINAL 5.5MM 40MM TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615045 SUP Custom 27803010 486615045 - ROD SPINAL 5.5MM 45MM TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615050 SUP Custom 27803010 486615050 - ROD SPINAL 50X5.5MM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615060 SUP Custom 27803010 486615060 - ROD SPINAL 60X5.5MM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615070 SUP Custom 27803010 486615070 - ROD SPINAL 70X5.5MM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615080 SUP Custom 27803010 486615080 - ROD SPNL 5.5MM 80MM SPRL RDS BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615090 SUP Custom 27803010 486615090 - ROD SPINAL 5.5MM 90MM TITANIUM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615500 SUP Custom 27803010 486615500 - ROD SPINAL 5.5MM 100MM RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615510 SUP Custom 27803010 486615510 - ROD SPINAL 5.5MM 110MM MAX RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615520 SUP Custom 27803010 486615520 - ROD SPINAL 5.5MM 120MM RAD MAX BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615550 SUP Custom 27803010 486615550 - ROD SPINAL 5.5MM 50MM RAD MAX BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615560 SUP Custom 27803010 486615560 - ROD SPNL 60MM ISOBAR BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615570 SUP Custom 27803010 486615570 - ROD SPNL 5.5MM 70MM MAX BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615580 SUP Custom 27803010 486615580 - ROD SPINAL 5.5MM 80MM MAX RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486615590 SUP Custom 27803010 486615590 - ROD SPINAL 5.5MM 90MM MAX RAD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616000 SUP Custom 27803010 486616000 - HOOK SPNL RADSM LMNR STR BLADE BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616001 SUP Custom 27803010 486616001 - HOOK SPNL RADSM LMNR NAR BLADE BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616002 SUP Custom 27803010 486616002 - HOOK SPNL RADLG LMNR STR BLADE BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616003 SUP Custom 27803010 486616003 - HOOK SPNL RADLG LMNR NAR BLADE BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616004 SUP Custom 27803010 486616004 - HOOK SPNL RAD LMNR XTD BLADE BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616005 SUP Custom 27803010 486616005 - HOOK SPNL RADLG LMNR RIGHT OFFST BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616006 SUP Custom 27803010 486616006 - HOOK SPNL RADLG LMNR LEFT OFFST BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616007 SUP Custom 27803010 486616007 - HOOK SPNL RAD LMNR ANG BLADE BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616008 SUP Custom 27803010 486616008 - HOOK SPNL RAD LMNR THOR BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616009 SUP Custom 27803010 486616009 - HOOK SPNL RAD LMNR THOR BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616010 SUP Custom 27803010 486616010 - HOOK SPNL RAD LMNR THOR BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616011 SUP Custom 27803010 486616011 - HOOK SPNL RAD LMNR THOR BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616012 SUP Custom 27803010 486616012 - HOOK SPNL RAD LMNR THOR BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616013 SUP Custom 27803010 486616013 - HOOK SPNL RAD LMNR THOR BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616014 SUP Custom 27803010 486616014 - HOOK SPNL RADSM PDCL BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616015 SUP Custom 27803010 486616015 - HOOK SPNL RADLG PDCL BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616016 SUP Custom 27803010 486616016 - HOOK SPNL RAD RIGHT TRNSVRS PRC BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616017 SUP Custom 27803010 486616017 - HOOK SPNL RAD LEFT TRNSVRS PRC BOTH IP/OP "$2,392.80 " "$1,770.67" $0.00 "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,775.94" "$1,775.94" $0.00 $0.00 $498.66 $0.00 $0.00 $0.00 $0.00 "$1,196.40" "$1,895.10" "$1,914.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616018 SUP Custom 27803010 486616018 - HOOK SPNL RAD LMNR NAR BLADE BOTH IP/OP "$2,686.30 " "$1,987.86" $0.00 "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,993.77" "$1,993.77" $0.00 $0.00 $559.82 $0.00 $0.00 $0.00 $0.00 "$1,343.15" "$2,127.55" "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616019 SUP Custom 27803010 486616019 - HOOK SPNL RAD LMNR STD BLADE BOTH IP/OP "$2,686.30 " "$1,987.86" $0.00 "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,993.77" "$1,993.77" $0.00 $0.00 $559.82 $0.00 $0.00 $0.00 $0.00 "$1,343.15" "$2,127.55" "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616020 SUP Custom 27803010 486616020 - HOOK SPNL RAD LMNR ANG BLADE BOTH IP/OP "$2,686.30 " "$1,987.86" $0.00 "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,993.77" "$1,993.77" $0.00 $0.00 $559.82 $0.00 $0.00 $0.00 $0.00 "$1,343.15" "$2,127.55" "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616021 SUP Custom 27803010 486616021 - HOOK SPNL RAD LMNR THOR BOTH IP/OP "$2,686.30 " "$1,987.86" $0.00 "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,993.77" "$1,993.77" $0.00 $0.00 $559.82 $0.00 $0.00 $0.00 $0.00 "$1,343.15" "$2,127.55" "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486616022 SUP Custom 27803010 486616022 - HOOK SPNL RAD PDCL BOTH IP/OP "$2,686.30 " "$1,987.86" $0.00 "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,993.77" "$1,993.77" $0.00 $0.00 $559.82 $0.00 $0.00 $0.00 $0.00 "$1,343.15" "$2,127.55" "$2,149.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 486617005 SUP HCPCS C1713 486617005 - STAPLE BONE DUAL RSTRL RADXS BOTH IP/OP "$2,493.88 " "$1,845.47" $0.00 "$1,995.10" "$1,122.24" "$1,122.24" $0.00 $0.00 $0.00 $519.79 "$1,850.95" "$1,850.95" $0.00 $0.00 $519.72 $0.00 "$1,475.13" "$1,475.13" $0.00 "$1,246.94" "$1,975.15" "$1,995.10" $0.00 $0.00 $390.29 $0.00 $0.00 $397.02 $0.00 $0.00 $0.00 $0.00 $0.00 486617006 SUP HCPCS C1713 486617006 - STAPLE BONE DUAL CDL RADXS BOTH IP/OP "$2,493.88 " "$1,845.47" $0.00 "$1,995.10" "$1,122.24" "$1,122.24" $0.00 $0.00 $0.00 $519.79 "$1,850.95" "$1,850.95" $0.00 $0.00 $519.72 $0.00 "$1,475.13" "$1,475.13" $0.00 "$1,246.94" "$1,975.15" "$1,995.10" $0.00 $0.00 $390.29 $0.00 $0.00 $397.02 $0.00 $0.00 $0.00 $0.00 $0.00 486617010 SUP HCPCS C1713 486617010 - STAPLE BONE DUAL CDL RADSM BOTH IP/OP "$2,493.88 " "$1,845.47" $0.00 "$1,995.10" "$1,122.24" "$1,122.24" $0.00 $0.00 $0.00 $519.79 "$1,850.95" "$1,850.95" $0.00 $0.00 $519.72 $0.00 "$1,475.13" "$1,475.13" $0.00 "$1,246.94" "$1,975.15" "$1,995.10" $0.00 $0.00 $390.29 $0.00 $0.00 $397.02 $0.00 $0.00 $0.00 $0.00 $0.00 486617015 SUP HCPCS C1713 486617015 - STAPLE BONE DUAL RSTRL RADSM BOTH IP/OP "$2,493.88 " "$1,845.47" $0.00 "$1,995.10" "$1,122.24" "$1,122.24" $0.00 $0.00 $0.00 $519.79 "$1,850.95" "$1,850.95" $0.00 $0.00 $519.72 $0.00 "$1,475.13" "$1,475.13" $0.00 "$1,246.94" "$1,975.15" "$1,995.10" $0.00 $0.00 $390.29 $0.00 $0.00 $397.02 $0.00 $0.00 $0.00 $0.00 $0.00 486617020 SUP HCPCS C1713 486617020 - STAPLE BONE DUAL CDL RADMED BOTH IP/OP "$2,493.88 " "$1,845.47" $0.00 "$1,995.10" "$1,122.24" "$1,122.24" $0.00 $0.00 $0.00 $519.79 "$1,850.95" "$1,850.95" $0.00 $0.00 $519.72 $0.00 "$1,475.13" "$1,475.13" $0.00 "$1,246.94" "$1,975.15" "$1,995.10" $0.00 $0.00 $390.29 $0.00 $0.00 $397.02 $0.00 $0.00 $0.00 $0.00 $0.00 486617025 SUP HCPCS C1713 486617025 - STAPLE BONE DUAL RSTRL RADMED BOTH IP/OP "$2,493.88 " "$1,845.47" $0.00 "$1,995.10" "$1,122.24" "$1,122.24" $0.00 $0.00 $0.00 $519.79 "$1,850.95" "$1,850.95" $0.00 $0.00 $519.72 $0.00 "$1,475.13" "$1,475.13" $0.00 "$1,246.94" "$1,975.15" "$1,995.10" $0.00 $0.00 $390.29 $0.00 $0.00 $397.02 $0.00 $0.00 $0.00 $0.00 $0.00 486617030 SUP HCPCS C1713 486617030 - STAPLE BONE DUAL CDL RADLG BOTH IP/OP "$2,493.88 " "$1,845.47" $0.00 "$1,995.10" "$1,122.24" "$1,122.24" $0.00 $0.00 $0.00 $519.79 "$1,850.95" "$1,850.95" $0.00 $0.00 $519.72 $0.00 "$1,475.13" "$1,475.13" $0.00 "$1,246.94" "$1,975.15" "$1,995.10" $0.00 $0.00 $390.29 $0.00 $0.00 $397.02 $0.00 $0.00 $0.00 $0.00 $0.00 486617035 SUP HCPCS C1713 486617035 - STAPLE BONE DUAL RSTRL RADLG BOTH IP/OP "$2,493.88 " "$1,845.47" $0.00 "$1,995.10" "$1,122.24" "$1,122.24" $0.00 $0.00 $0.00 $519.79 "$1,850.95" "$1,850.95" $0.00 $0.00 $519.72 $0.00 "$1,475.13" "$1,475.13" $0.00 "$1,246.94" "$1,975.15" "$1,995.10" $0.00 $0.00 $390.29 $0.00 $0.00 $397.02 $0.00 $0.00 $0.00 $0.00 $0.00 486617040 SUP HCPCS C1713 486617040 - STAPLE BONE SGL TI RAD BOTH IP/OP "$1,031.95 " $763.64 $0.00 $825.56 $464.38 $464.38 $0.00 $0.00 $0.00 $215.08 $765.91 $765.91 $0.00 $0.00 $215.06 $0.00 $610.40 $610.40 $0.00 $515.98 $817.30 $825.56 $0.00 $0.00 $161.50 $0.00 $0.00 $164.29 $0.00 $0.00 $0.00 $0.00 $0.00 486617045 SUP HCPCS C1713 486617045 - WASHER RAD ORTH BOTH IP/OP $780.43 $577.52 $0.00 $624.34 $351.19 $351.19 $0.00 $0.00 $0.00 $162.66 $579.23 $579.23 $0.00 $0.00 $162.64 $0.00 $461.62 $461.62 $0.00 $390.21 $618.10 $624.34 $0.00 $0.00 $122.14 $0.00 $0.00 $124.24 $0.00 $0.00 $0.00 $0.00 $0.00 486617050 SUP HCPCS C1713 486617050 - WASHER 4.75MM RADTALL ORTH BOTH IP/OP $795.48 $588.66 $0.00 $636.38 $357.96 $357.96 $0.00 $0.00 $0.00 $165.80 $590.40 $590.40 $0.00 $0.00 $165.78 $0.00 $470.52 $470.52 $0.00 $397.74 $630.02 $636.38 $0.00 $0.00 $124.49 $0.00 $0.00 $126.64 $0.00 $0.00 $0.00 $0.00 $0.00 486617051 SUP HCPCS C1713 486617051 - WASHER 5.75MM RADTALL ORTH BOTH IP/OP $795.48 $588.66 $0.00 $636.38 $357.96 $357.96 $0.00 $0.00 $0.00 $165.80 $590.40 $590.40 $0.00 $0.00 $165.78 $0.00 $470.52 $470.52 $0.00 $397.74 $630.02 $636.38 $0.00 $0.00 $124.49 $0.00 $0.00 $126.64 $0.00 $0.00 $0.00 $0.00 $0.00 486617052 SUP HCPCS C1713 486617052 - WASHER 6.75MM RADTALL ORTH BOTH IP/OP $795.48 $588.66 $0.00 $636.38 $357.96 $357.96 $0.00 $0.00 $0.00 $165.80 $590.40 $590.40 $0.00 $0.00 $165.78 $0.00 $470.52 $470.52 $0.00 $397.74 $630.02 $636.38 $0.00 $0.00 $124.49 $0.00 $0.00 $126.64 $0.00 $0.00 $0.00 $0.00 $0.00 486617053 SUP HCPCS C1713 486617053 - WASHER 7.75MM RADTALL ORTH BOTH IP/OP $795.48 $588.66 $0.00 $636.38 $357.96 $357.96 $0.00 $0.00 $0.00 $165.80 $590.40 $590.40 $0.00 $0.00 $165.78 $0.00 $470.52 $470.52 $0.00 $397.74 $630.02 $636.38 $0.00 $0.00 $124.49 $0.00 $0.00 $126.64 $0.00 $0.00 $0.00 $0.00 $0.00 486617054 SUP HCPCS C1713 486617054 - WASHER 8.75MM RADTALL ORTH BOTH IP/OP $795.48 $588.66 $0.00 $636.38 $357.96 $357.96 $0.00 $0.00 $0.00 $165.80 $590.40 $590.40 $0.00 $0.00 $165.78 $0.00 $470.52 $470.52 $0.00 $397.74 $630.02 $636.38 $0.00 $0.00 $124.49 $0.00 $0.00 $126.64 $0.00 $0.00 $0.00 $0.00 $0.00 488514535 SUP HCPCS C1713 488514535 - SCREW BN 4.5MM 35MM STRL XIA PA SPNE LMBR CORT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 488515035 SUP HCPCS C1713 488515035 - SCREW BN 5MM 35MM XIA CT PA SPNE CORT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 488515540 SUP HCPCS C1713 488515540 - SCREW BN 5.5MM 40MM STRL XIA PA SPNE LMBR CORT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 540133500 SUP Custom 27803010 540133500 - SYSTEM BONE CEMENT CARTRIDGE SELF CLEAN MIXING PADDLES SNAP BOTH IP/OP $920.42 $681.11 $0.00 $736.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $683.14 $683.14 $0.00 $0.00 $191.82 $0.00 $0.00 $0.00 $0.00 $460.21 $728.97 $736.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 582010140 SUP Custom 27203010 582010140 - BURR SURG ROUND 4MM ROUND SOFT TOUCH LATEX FREE ELITE BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 606004102 SUP HCPCS Q4130 606004102 - MATRIX TISS THK1MM RECT 20X10CM STRL SURGIMEND PRS BOTH IP/OP "$9,000.00 " "$6,660.00" $0.00 "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,875.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,875.60" $0.00 "$4,437.00" "$4,437.00" $0.00 "$5,875.00" "$9,306.00" "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 606200006 SUP HCPCS C1713 606200006 - SCREW BONE 2.7MM 16MM SPN SNPOF BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$6,900.00" "$3,881.25" "$3,881.25" $0.00 $0.00 $0.00 "$1,172.39" "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 "$2,773.13" "$2,773.13" $0.00 "$4,312.50" "$6,831.00" "$6,900.00" $0.00 $0.00 "$1,349.81" $0.00 $0.00 "$1,373.10" $0.00 $0.00 $0.00 $0.00 $0.00 630505036 SUP HCPCS C1776 630505036 - LINER ACETAB STANDARD NEUTRAL 50/52/54MM 36MM 6.8MM PRIM BOTH IP/OP "$2,978.75 " "$2,204.28" $0.00 "$2,383.00" "$1,340.44" "$1,340.44" $0.00 $0.00 $0.00 $620.85 "$2,210.83" "$2,210.83" $0.00 $0.00 $620.77 $0.00 "$1,468.52" "$1,468.52" $0.00 "$1,489.38" "$2,359.17" "$2,383.00" $0.00 $0.00 $466.17 $0.00 $0.00 $474.22 $0.00 $0.00 $0.00 $0.00 $0.00 630505636 SUP HCPCS C1776 630505636 - LINER ACETAB STANDARD NEUTRAL 56MM 36MM 7.9MM PRIM MODULAR BOTH IP/OP "$4,007.50 " "$2,965.55" $0.00 "$3,206.00" "$1,803.38" "$1,803.38" $0.00 $0.00 $0.00 $835.26 "$2,974.37" "$2,974.37" $0.00 $0.00 $835.16 $0.00 "$1,975.70" "$1,975.70" $0.00 "$2,003.75" "$3,173.94" "$3,206.00" $0.00 $0.00 $627.17 $0.00 $0.00 $637.99 $0.00 $0.00 $0.00 $0.00 $0.00 641003030 SUP HCPCS C1713 641003030 - ROD SPNL 30MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003035 SUP HCPCS C1713 641003035 - ROD SPNL 35MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003040 SUP HCPCS C1713 641003040 - ROD SPNL 40MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003045 SUP HCPCS C1713 641003045 - ROD SPNL 45MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003050 SUP HCPCS C1713 641003050 - ROD SPNL 50MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003055 SUP HCPCS C1713 641003055 - ROD SPNL 55MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003060 SUP HCPCS C1713 641003060 - ROD SPNL 60MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003065 SUP HCPCS C1713 641003065 - ROD SPNL 65MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003070 SUP HCPCS C1713 641003070 - ROD SPNL 70MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003075 SUP HCPCS C1713 641003075 - ROD SPNL 75MM 4.75MM CD HZN CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003080 SUP HCPCS C1713 641003080 - ROD SPNL 80MM 4.75MM CD HZN COCRMO CAP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003085 SUP HCPCS C1713 641003085 - ROD SPNL 85MM 4.75MM CD HZN COCRMO CAP STRL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003090 SUP HCPCS C1713 641003090 - ROD SPNL 90MM 4.75MM CD HZN COCRMO CAP STRL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 641003095 SUP HCPCS C1713 641003095 - ROD SPNL 95MM 4.75MM CD HZN COCRMO CAP STRL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 651506000 SUP HCPCS C1894 651506000 - SYSTEM INTRO .018IN 80CM SKTR GW SS BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $109.96 $109.96 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 654000100 SUP HCPCS C1713 654000100 - ROD SPNL 5.5MM 100MM NS CD HZN SOLERA TI PERC BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" $0.00 $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 673395000 SUP Custom 27203010 ADAPTER QCK 800 SER ANALY BOTH IP/OP $39.38 $29.14 $0.00 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.69 $31.19 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 703046000 SUP Custom 27203010 "0703046000 - CTRY,PENCIL,PUSH BUTTON,SMOKE EVAC,70MM" BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 755308040 SUP HCPCS C1729 755308040 - CATHETER DRN 8FR 40CM STRL LF SKTR LCK PGTL RADOPQ BAND PU BOTH IP/OP $227.50 $168.35 $0.00 $182.00 $123.53 $123.53 $0.00 $0.00 $0.00 $47.42 $168.85 $168.85 $0.00 $0.00 $47.41 $0.00 $134.57 $134.57 $0.00 $113.75 $180.18 $182.00 $0.00 $0.00 $35.60 $0.00 $0.00 $36.22 $0.00 $0.00 $0.00 $0.00 $0.00 755608035 SUP HCPCS C1729 755608035 - CATHETER NPHSTM PGTL CRV LOPRFL 8FR 35CM SKTR LCK KINK RST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $128.96 $128.96 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 755610035 SUP HCPCS C1729 755610035 - CATHETER NPHSTM .038IN PGTL CRV 10FR 35CM SKTR LCK GW PU BIL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 756506020 SUP HCPCS C1729 756506020 - CATHETER DRN 6FR 20CM SKTR CHC LCK AP LOPRFL TROC STY BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $130.32 $130.32 $0.00 $0.00 $0.00 $50.02 $178.13 $178.13 $0.00 $0.00 $50.02 $0.00 $141.96 $141.96 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 756510025 SUP HCPCS C1729 756510025 - CATHETER DRN PGTL CRV 10FR 25CM SKTR CHC LCK LCK TROC STY LG BOTH IP/OP $234.95 $173.86 $0.00 $187.96 $127.58 $127.58 $0.00 $0.00 $0.00 $48.97 $174.38 $174.38 $0.00 $0.00 $48.96 $0.00 $138.97 $138.97 $0.00 $117.47 $186.08 $187.96 $0.00 $0.00 $36.77 $0.00 $0.00 $37.40 $0.00 $0.00 $0.00 $0.00 $0.00 756512025 SUP HCPCS C1729 756512025 - CATHETER DRN PGTL CRV 12FR 25CM SKTR CHC LCK LCK TROC STY LG BOTH IP/OP "$1,174.73 " $869.30 $0.00 $939.78 $637.88 $637.88 $0.00 $0.00 $0.00 $244.84 $871.88 $871.88 $0.00 $0.00 $244.81 $0.00 $694.85 $694.85 $0.00 $587.36 $930.39 $939.78 $0.00 $0.00 $183.84 $0.00 $0.00 $187.02 $0.00 $0.00 $0.00 $0.00 $0.00 756514025 SUP HCPCS C1729 756514025 - CATHETER DRN PGTL CRV 14FR 25CM SKTR CHC LCK LCK TROC STY LG BOTH IP/OP "$1,135.00 " $839.90 $0.00 $908.00 $616.31 $616.31 $0.00 $0.00 $0.00 $236.56 $842.40 $842.40 $0.00 $0.00 $236.53 $0.00 $671.35 $671.35 $0.00 $567.50 $898.92 $908.00 $0.00 $0.00 $177.63 $0.00 $0.00 $180.69 $0.00 $0.00 $0.00 $0.00 $0.00 771600010 SUP Custom 27203010 00771600010 - CARRIER GRAFT 16X4IN BOARD LATEX FREE MESHGRAFT BOTH IP/OP $126.88 $93.89 $0.00 $101.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.17 $94.17 $0.00 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $63.44 $100.49 $101.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778114545 SUP Custom 27803010 778114545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778114555 SUP Custom 27803010 778114555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778114565 SUP Custom 27803010 778114565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778115545 SUP Custom 27803010 778115545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778115555 SUP Custom 27803010 778115555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778115565 SUP Custom 27803010 778115565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778116545 SUP Custom 27803010 778116545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778116555 SUP Custom 27803010 778116555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778116565 SUP Custom 27803010 778116565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778124545 SUP Custom 27803010 778124545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778124555 SUP Custom 27803010 778124555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778124565 SUP Custom 27803010 778124565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,052.75 " "$1,519.04" $0.00 "$1,642.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,523.55" "$1,523.55" $0.00 $0.00 $427.79 $0.00 $0.00 $0.00 $0.00 "$1,026.38" "$1,625.78" "$1,642.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778125555 SUP Custom 27803010 778125555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778125565 SUP Custom 27803010 778125565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778126565 SUP Custom 27803010 778126565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778144545 SUP Custom 27803010 778144545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778144565 SUP Custom 27803010 778144565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778145545 SUP Custom 27803010 778145545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778145555 SUP Custom 27803010 778145555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778145565 SUP Custom 27803010 778145565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778146545 SUP Custom 27803010 778146545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778146555 SUP Custom 27803010 778146555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778146565 SUP Custom 27803010 778146565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778161045 SUP HCPCS C1713 778161045 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778161065 SUP HCPCS C1713 778161065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778162045 SUP HCPCS C1713 778162045 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778162055 SUP HCPCS C1713 778162055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778162065 SUP HCPCS C1713 778162065 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778164045 SUP HCPCS C1713 778164045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778164065 SUP HCPCS C1713 778164065 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778167045 SUP HCPCS C1713 778167045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778167055 SUP HCPCS C1713 778167055 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778167065 SUP HCPCS C1713 778167065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778170001 SUP HCPCS C1713 778170001 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 778214545 SUP Custom 27803010 778214545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778214555 SUP Custom 27803010 778214555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778214565 SUP Custom 27803010 778214565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778215545 SUP Custom 27803010 778215545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778215555 SUP Custom 27803010 778215555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778215565 SUP Custom 27803010 778215565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778216545 SUP Custom 27803010 778216545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778216555 SUP Custom 27803010 778216555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778216565 SUP Custom 27803010 778216565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778224545 SUP Custom 27803010 778224545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,969.50 " "$1,457.43" $0.00 "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.76" "$1,461.76" $0.00 $0.00 $410.44 $0.00 $0.00 $0.00 $0.00 $984.75 "$1,559.84" "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778224555 SUP Custom 27803010 778224555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,969.50 " "$1,457.43" $0.00 "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.76" "$1,461.76" $0.00 $0.00 $410.44 $0.00 $0.00 $0.00 $0.00 $984.75 "$1,559.84" "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778224565 SUP Custom 27803010 778224565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,251.70 " "$1,666.26" $0.00 "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,671.21" "$1,671.21" $0.00 $0.00 $469.25 $0.00 $0.00 $0.00 $0.00 "$1,125.85" "$1,783.35" "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778225555 SUP Custom 27803010 778225555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,969.50 " "$1,457.43" $0.00 "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.76" "$1,461.76" $0.00 $0.00 $410.44 $0.00 $0.00 $0.00 $0.00 $984.75 "$1,559.84" "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778225565 SUP Custom 27803010 778225565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,969.50 " "$1,457.43" $0.00 "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.76" "$1,461.76" $0.00 $0.00 $410.44 $0.00 $0.00 $0.00 $0.00 $984.75 "$1,559.84" "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778226565 SUP Custom 27803010 778226565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,969.50 " "$1,457.43" $0.00 "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.76" "$1,461.76" $0.00 $0.00 $410.44 $0.00 $0.00 $0.00 $0.00 $984.75 "$1,559.84" "$1,575.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778244545 SUP Custom 27803010 778244545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778244555 SUP Custom 27803010 778244555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778244565 SUP Custom 27803010 778244565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778245545 SUP Custom 27803010 778245545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778245555 SUP Custom 27803010 778245555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778245565 SUP Custom 27803010 778245565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,175.95 " "$1,610.20" $0.00 "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,614.99" "$1,614.99" $0.00 $0.00 $453.47 $0.00 $0.00 $0.00 $0.00 "$1,087.98" "$1,723.35" "$1,740.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778246545 SUP Custom 27803010 778246545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,052.75 " "$1,519.04" $0.00 "$1,642.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,523.55" "$1,523.55" $0.00 $0.00 $427.79 $0.00 $0.00 $0.00 $0.00 "$1,026.38" "$1,625.78" "$1,642.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778246555 SUP Custom 27803010 778246555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,052.75 " "$1,519.04" $0.00 "$1,642.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,523.55" "$1,523.55" $0.00 $0.00 $427.79 $0.00 $0.00 $0.00 $0.00 "$1,026.38" "$1,625.78" "$1,642.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778246565 SUP Custom 27803010 778246565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,981.85 " "$1,466.57" $0.00 "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,470.93" "$1,470.93" $0.00 $0.00 $413.02 $0.00 $0.00 $0.00 $0.00 $990.93 "$1,569.63" "$1,585.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 778261045 SUP HCPCS C1713 778261045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778261055 SUP HCPCS C1713 778261055 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778261065 SUP HCPCS C1713 778261065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778262045 SUP HCPCS C1713 778262045 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778262055 SUP HCPCS C1713 778262055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778262065 SUP HCPCS C1713 778262065 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778264045 SUP HCPCS C1713 778264045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778264055 SUP HCPCS C1713 778264055 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778264065 SUP HCPCS C1713 778264065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778267045 SUP HCPCS C1713 778267045 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778267055 SUP HCPCS C1713 778267055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778267065 SUP HCPCS C1713 778267065 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 778270001 SUP HCPCS C1713 778270001 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 779115545 SUP Custom 27803010 779115545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779115555 SUP Custom 27803010 779115555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779115565 SUP Custom 27803010 779115565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 $0.00 $0.00 $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779124555 SUP Custom 27803010 779124555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,251.70 " "$1,666.26" $0.00 "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,671.21" "$1,671.21" $0.00 $0.00 $469.25 $0.00 $0.00 $0.00 $0.00 "$1,125.85" "$1,783.35" "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779125555 SUP Custom 27803010 779125555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,251.70 " "$1,666.26" $0.00 "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,671.21" "$1,671.21" $0.00 $0.00 $469.25 $0.00 $0.00 $0.00 $0.00 "$1,125.85" "$1,783.35" "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779125565 SUP Custom 27803010 779125565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,251.70 " "$1,666.26" $0.00 "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,671.21" "$1,671.21" $0.00 $0.00 $469.25 $0.00 $0.00 $0.00 $0.00 "$1,125.85" "$1,783.35" "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779144555 SUP Custom 27803010 779144555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,251.70 " "$1,666.26" $0.00 "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,671.21" "$1,671.21" $0.00 $0.00 $469.25 $0.00 $0.00 $0.00 $0.00 "$1,125.85" "$1,783.35" "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779145555 SUP Custom 27803010 779145555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,251.70 " "$1,666.26" $0.00 "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,671.21" "$1,671.21" $0.00 $0.00 $469.25 $0.00 $0.00 $0.00 $0.00 "$1,125.85" "$1,783.35" "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779146555 SUP Custom 27803010 779146555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,251.70 " "$1,666.26" $0.00 "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,671.21" "$1,671.21" $0.00 $0.00 $469.25 $0.00 $0.00 $0.00 $0.00 "$1,125.85" "$1,783.35" "$1,801.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 779170005 SUP HCPCS C1713 779170005 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 880000010 SUP Custom 27203010 00880000010 - BLADE DERMATOME 1.25-4.25IN STERILE BOTH IP/OP $140.38 $103.88 $0.00 $99.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.23 $99.23 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $60.63 $96.03 $97.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 998604014 SUP HCPCS C1776 998604014 - SET TOT JOINT 11MM 8IN TREPHINE MRI NONSTRL BOTH IP/OP "$2,037.50 " "$1,507.75" $0.00 "$1,630.00" $916.88 $916.88 $0.00 $0.00 $0.00 $424.67 "$1,512.23" "$1,512.23" $0.00 $0.00 $424.62 $0.00 "$1,205.18" "$1,205.18" $0.00 "$1,018.75" "$1,613.70" "$1,630.00" $0.00 $0.00 $318.87 $0.00 $0.00 $324.37 $0.00 $0.00 $0.00 $0.00 $0.00 1474000500 SUP HCPCS C1713 1474000500 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475000500 SUP HCPCS C1713 1475000500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001030 SUP HCPCS C1713 1475001030 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001035 SUP HCPCS C1713 1475001035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001040 SUP HCPCS C1713 1475001040 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001045 SUP HCPCS C1713 1475001045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001050 SUP HCPCS C1713 1475001050 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001055 SUP HCPCS C1713 1475001055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001060 SUP HCPCS C1713 1475001060 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001065 SUP HCPCS C1713 1475001065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001070 SUP HCPCS C1713 1475001070 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001075 SUP HCPCS C1713 1475001075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001080 SUP HCPCS C1713 1475001080 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001085 SUP HCPCS C1713 1475001085 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001090 SUP HCPCS C1713 1475001090 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001100 SUP HCPCS C1713 1475001100 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001110 SUP HCPCS C1713 1475001110 - ROD SPNL CRV PREBNT 4.75MM 110MM NS SOLERA CD HZN CCM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475001120 SUP HCPCS C1713 1475001120 - ROD SPNL CRV 4.75MM 120MM NS SOLERA CD HZN COCR MLBDN BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475005040 SUP HCPCS C1713 1475005040 - ROD SPNL CRV 4.75MM 40MM NS SXTNT COCR MLBDN BOTH IP/OP "$2,820.00 " "$2,086.80" $0.00 "$2,256.00" "$1,269.00" "$1,269.00" $0.00 $0.00 $0.00 $587.76 "$2,093.00" "$2,093.00" $0.00 $0.00 $587.69 $0.00 "$1,390.26" "$1,390.26" $0.00 "$1,410.00" "$2,233.44" "$2,256.00" $0.00 $0.00 $441.33 $0.00 $0.00 $448.94 $0.00 $0.00 $0.00 $0.00 $0.00 1475005050 SUP HCPCS C1713 1475005050 - ROD SPINAL CURVE 4.75MM 50MM SEXTANT COCR BOTH IP/OP "$2,820.00 " "$2,086.80" $0.00 "$2,256.00" "$1,269.00" "$1,269.00" $0.00 $0.00 $0.00 $587.76 "$2,093.00" "$2,093.00" $0.00 $0.00 $587.69 $0.00 "$1,390.26" "$1,390.26" $0.00 "$1,410.00" "$2,233.44" "$2,256.00" $0.00 $0.00 $441.33 $0.00 $0.00 $448.94 $0.00 $0.00 $0.00 $0.00 $0.00 1475200500 SUP HCPCS C1713 1475200500 - ROD SPINAL 500MM LINE STR COCR MOLYBDENUM 4.75MM BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $956.48 $956.48 $0.00 $0.00 $0.00 $443.01 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 "$1,257.23" "$1,257.23" $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $332.64 $0.00 $0.00 $338.38 $0.00 $0.00 $0.00 $0.00 $0.00 1475501030 SUP HCPCS C1713 1475501030 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501035 SUP HCPCS C1713 1475501035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501040 SUP HCPCS C1713 1475501040 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501045 SUP HCPCS C1713 1475501045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501050 SUP HCPCS C1713 1475501050 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501055 SUP HCPCS C1713 1475501055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501060 SUP HCPCS C1713 1475501060 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501065 SUP HCPCS C1713 1475501065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501070 SUP HCPCS C1713 1475501070 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501075 SUP HCPCS C1713 1475501075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501080 SUP HCPCS C1713 1475501080 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501085 SUP HCPCS C1713 1475501085 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501090 SUP HCPCS C1713 1475501090 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501095 SUP HCPCS C1713 1475501095 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501100 SUP HCPCS C1713 1475501100 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501105 SUP HCPCS C1713 1475501105 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501110 SUP HCPCS C1713 1475501110 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501115 SUP HCPCS C1713 1475501115 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1475501120 SUP HCPCS C1713 1475501120 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476000500 SUP HCPCS C1713 1476000500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006040 SUP HCPCS C1713 1476006040 - ROD SPNL 40MM 4.75MM LNGT II STR CCM PLUS PERC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006070 SUP HCPCS C1713 1476006070 - ROD SPINAL 70MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006080 SUP HCPCS C1713 1476006080 - ROD SPINAL 80MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006090 SUP HCPCS C1713 1476006090 - ROD SPINAL STR 4.75MM 90MM CCM PLUS PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006100 SUP HCPCS C1713 1476006100 - ROD SPINAL 100MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006110 SUP HCPCS C1713 1476006110 - ROD SPINAL 110MM STR COCR 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006120 SUP HCPCS C1713 1476006120 - ROD SPINAL 120MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006130 SUP HCPCS C1713 1476006130 - ROD SPINAL STR 4.75MM 130MM CCM PLUS PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006140 SUP HCPCS C1713 1476006140 - ROD SPINAL 140MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006150 SUP HCPCS C1713 1476006150 - ROD SPINAL 150MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006160 SUP HCPCS C1713 1476006160 - ROD SPINAL 160MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006170 SUP HCPCS C1713 1476006170 - ROD SPINAL 170MM SOLERA STR COCR MOLYBDENUM 4.75MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006180 SUP HCPCS C1713 1476006180 - ROD SPINAL 180MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006200 SUP HCPCS C1713 1476006200 - ROD SPINAL 200MM STR CCM PLUS 4.75MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476006220 SUP HCPCS C1713 1476006220 - ROD SPNL STRG 4.75MM 220MM CCM + PERC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1476200500 SUP HCPCS C1713 1476200500 - ROD SPINAL 500MM LINE CD HORIZON CURVE COBALT 5.5MM STERILE BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $956.48 $956.48 $0.00 $0.00 $0.00 $443.01 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 "$1,257.23" "$1,257.23" $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $332.64 $0.00 $0.00 $338.38 $0.00 $0.00 $0.00 $0.00 $0.00 1553200500 SUP HCPCS C1713 1553200500 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201030 SUP HCPCS C1713 1553201030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201035 SUP HCPCS C1713 1553201035 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201040 SUP HCPCS C1713 1553201040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201045 SUP HCPCS C1713 1553201045 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201050 SUP HCPCS C1713 1553201050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201055 SUP HCPCS C1713 1553201055 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201060 SUP HCPCS C1713 1553201060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201070 SUP HCPCS C1713 1553201070 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201080 SUP HCPCS C1713 1553201080 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201090 SUP HCPCS C1713 1553201090 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201100 SUP HCPCS C1713 1553201100 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201110 SUP HCPCS C1713 1553201110 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1553201120 SUP HCPCS C1713 1553201120 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1554200500 SUP HCPCS C1713 1554200500 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555000500 SUP HCPCS C1713 1555000500 - ROD SPNL STRG 5.5MM 500MM NS CD HZN COCRMO BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555006100 SUP HCPCS C1713 1555006100 - ROD SPINAL 100MM PRECUT CD HORIZON STR COCR 5.5MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555006110 SUP HCPCS C1713 1555006110 - ROD SPNL STRG 5.5MM 110MM CCM PERC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555006120 SUP HCPCS C1713 1555006120 - ROD SPINAL 120MM STR CCM 5.5MM PERCUTANEOUS BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555006170 SUP HCPCS C1713 1555006170 - ROD SPINAL 170MM PRECUT CD HORIZON STR COCR 5.5MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501030 SUP HCPCS C1713 1555501030 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501035 SUP HCPCS C1713 1555501035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501040 SUP HCPCS C1713 1555501040 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501045 SUP HCPCS C1713 1555501045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501050 SUP HCPCS C1713 1555501050 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501055 SUP HCPCS C1713 1555501055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501060 SUP HCPCS C1713 1555501060 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501070 SUP HCPCS C1713 1555501070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501080 SUP HCPCS C1713 1555501080 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501090 SUP HCPCS C1713 1555501090 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501100 SUP HCPCS C1713 1555501100 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501110 SUP HCPCS C1713 1555501110 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1555501120 SUP HCPCS C1713 1555501120 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556000500 SUP HCPCS C1713 1556000500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556000600 SUP HCPCS C1713 1556000600 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001030 SUP HCPCS C1713 1556001030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001035 SUP HCPCS C1713 1556001035 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001040 SUP HCPCS C1713 1556001040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001045 SUP HCPCS C1713 1556001045 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001050 SUP HCPCS C1713 1556001050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001055 SUP HCPCS C1713 1556001055 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001060 SUP HCPCS C1713 1556001060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001065 SUP HCPCS C1713 1556001065 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001070 SUP HCPCS C1713 1556001070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001075 SUP HCPCS C1713 1556001075 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001080 SUP HCPCS C1713 1556001080 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001085 SUP HCPCS C1713 1556001085 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001090 SUP HCPCS C1713 1556001090 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001095 SUP HCPCS C1713 1556001095 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001100 SUP HCPCS C1713 1556001100 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001105 SUP HCPCS C1713 1556001105 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001110 SUP HCPCS C1713 1556001110 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1556001115 SUP HCPCS C1713 1556001115 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1603200500 SUP HCPCS C1713 1603200500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1604200500 SUP HCPCS C1713 1604200500 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1605000500 SUP HCPCS C1713 1605000500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1606000500 SUP HCPCS C1713 1606000500 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1606000600 SUP HCPCS C1713 1606000600 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1606000700 SUP HCPCS C1713 1606000700 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1606200500 SUP HCPCS C1713 1606200500 - ROD SPINAL 500MM LINE STR RED CCM PLUS 6MM BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 1607002003 SUP Custom 27203010 1607002003 - BURR SURG BARREL EGG 6MM STERILE BOTH IP/OP $145.75 $107.86 $0.00 $116.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.18 $108.18 $0.00 $0.00 $30.37 $0.00 $0.00 $0.00 $0.00 $72.88 $115.43 $116.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1608002005 SUP Custom 27203010 1608002005 - BURR SURG 6.1MM 54MM 9.5MM PEAR HEAD STAINLESS STEEL STERILE BOTH IP/OP $145.75 $107.86 $0.00 $116.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.18 $108.18 $0.00 $0.00 $30.37 $0.00 $0.00 $0.00 $0.00 $72.88 $115.43 $116.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1705015006 SUP Custom 27203010 1705015006 - PATCH CV THK.6MM 15X5CM STRL GRTX BOTH IP/OP "$1,555.00 " "$1,150.70" $0.00 "$1,244.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,154.12" "$1,154.12" $0.00 $0.00 $324.06 $0.00 $0.00 $0.00 $0.00 $777.50 "$1,231.56" "$1,244.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3571129240 SUP HCPCS C1713 3571129240 - SCREW BN 4.5MM 40MM ST HEX HD HIP BOTH IP/OP $50.88 $37.65 $0.00 $40.70 $22.89 $22.89 $0.00 $0.00 $0.00 $10.60 $37.76 $37.76 $0.00 $0.00 $10.60 $0.00 $30.09 $30.09 $0.00 $25.44 $40.30 $40.70 $0.00 $0.00 $7.96 $0.00 $0.00 $8.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571140003 SUP HCPCS C1713 3571140003 - PLATE BN 45MM 3 HL RECON PLVC 4.5MM SCR BOTH IP/OP $798.00 $590.52 $0.00 $638.40 $359.10 $359.10 $0.00 $0.00 $0.00 $166.32 $592.28 $592.28 $0.00 $0.00 $166.30 $0.00 $472.02 $472.02 $0.00 $399.00 $632.02 $638.40 $0.00 $0.00 $124.89 $0.00 $0.00 $127.04 $0.00 $0.00 $0.00 $0.00 $0.00 3571140004 SUP HCPCS C1713 3571140004 - PLATE BN 61MM 4 HL RECON PLVC 4.5MM SCR BOTH IP/OP $846.30 $626.26 $0.00 $677.04 $380.84 $380.84 $0.00 $0.00 $0.00 $176.39 $628.12 $628.12 $0.00 $0.00 $176.37 $0.00 $500.59 $500.59 $0.00 $423.15 $670.27 $677.04 $0.00 $0.00 $132.45 $0.00 $0.00 $134.73 $0.00 $0.00 $0.00 $0.00 $0.00 3571140005 SUP HCPCS C1713 3571140005 - PLATE BN 77MM STRL 5 HL RECON PLVC 4.5MM SCR BOTH IP/OP $910.35 $673.66 $0.00 $728.28 $409.66 $409.66 $0.00 $0.00 $0.00 $189.74 $675.66 $675.66 $0.00 $0.00 $189.72 $0.00 $538.47 $538.47 $0.00 $455.18 $721.00 $728.28 $0.00 $0.00 $142.47 $0.00 $0.00 $144.93 $0.00 $0.00 $0.00 $0.00 $0.00 3571140006 SUP HCPCS C1713 3571140006 - PLATE BN 93MM STRL 6 HL RECON PLVC 4.5MM SCR BOTH IP/OP $972.30 $719.50 $0.00 $777.84 $437.54 $437.54 $0.00 $0.00 $0.00 $202.65 $721.64 $721.64 $0.00 $0.00 $202.63 $0.00 $575.12 $575.12 $0.00 $486.15 $770.06 $777.84 $0.00 $0.00 $152.16 $0.00 $0.00 $154.79 $0.00 $0.00 $0.00 $0.00 $0.00 3571140007 SUP HCPCS C1713 3571140007 - PLATE BN 109MM STRL 7 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,025.85 " $759.13 $0.00 $820.68 $461.63 $461.63 $0.00 $0.00 $0.00 $213.81 $761.39 $761.39 $0.00 $0.00 $213.79 $0.00 $606.79 $606.79 $0.00 $512.93 $812.47 $820.68 $0.00 $0.00 $160.55 $0.00 $0.00 $163.32 $0.00 $0.00 $0.00 $0.00 $0.00 3571140008 SUP HCPCS C1713 3571140008 - PLATE BN 125MM STRL 8 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 3571140009 SUP HCPCS C1713 3571140009 - PLATE BN 141MM STRL 9 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,391.25 " "$1,029.53" $0.00 "$1,113.00" $626.06 $626.06 $0.00 $0.00 $0.00 $289.97 "$1,032.59" "$1,032.59" $0.00 $0.00 $289.94 $0.00 $822.92 $822.92 $0.00 $695.63 "$1,101.87" "$1,113.00" $0.00 $0.00 $217.73 $0.00 $0.00 $221.49 $0.00 $0.00 $0.00 $0.00 $0.00 3571140010 SUP HCPCS C1713 3571140010 - PLATE BN 157MM STRL 10 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,464.75 " "$1,083.92" $0.00 "$1,171.80" $659.14 $659.14 $0.00 $0.00 $0.00 $305.29 "$1,087.14" "$1,087.14" $0.00 $0.00 $305.25 $0.00 $866.40 $866.40 $0.00 $732.38 "$1,160.08" "$1,171.80" $0.00 $0.00 $229.23 $0.00 $0.00 $233.19 $0.00 $0.00 $0.00 $0.00 $0.00 3571140011 SUP HCPCS C1713 3571140011 - PLATE BN 173MM STRL 11 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,506.75 " "$1,115.00" $0.00 "$1,205.40" $678.04 $678.04 $0.00 $0.00 $0.00 $314.04 "$1,118.31" "$1,118.31" $0.00 $0.00 $314.01 $0.00 $891.24 $891.24 $0.00 $753.38 "$1,193.35" "$1,205.40" $0.00 $0.00 $235.81 $0.00 $0.00 $239.87 $0.00 $0.00 $0.00 $0.00 $0.00 3571140012 SUP HCPCS C1713 3571140012 - PLATE BN 189MM STRL 12 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,302.00 " $963.48 $0.00 "$1,041.60" $585.90 $585.90 $0.00 $0.00 $0.00 $271.37 $966.34 $966.34 $0.00 $0.00 $271.34 $0.00 $770.13 $770.13 $0.00 $651.00 "$1,031.18" "$1,041.60" $0.00 $0.00 $203.76 $0.00 $0.00 $207.28 $0.00 $0.00 $0.00 $0.00 $0.00 3571140013 SUP HCPCS C1713 3571140013 - PLATE BN 205MM STRL 13 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,701.00 " "$1,258.74" $0.00 "$1,360.80" $765.45 $765.45 $0.00 $0.00 $0.00 $354.53 "$1,262.48" "$1,262.48" $0.00 $0.00 $354.49 $0.00 "$1,006.14" "$1,006.14" $0.00 $850.50 "$1,347.19" "$1,360.80" $0.00 $0.00 $266.21 $0.00 $0.00 $270.80 $0.00 $0.00 $0.00 $0.00 $0.00 3571140014 SUP HCPCS C1713 3571140014 - PLATE BN 221MM 14 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 3571140015 SUP HCPCS C1713 3571140015 - PLATE BN 237MM STRL 15 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,806.00 " "$1,336.44" $0.00 "$1,444.80" $812.70 $812.70 $0.00 $0.00 $0.00 $376.42 "$1,340.41" "$1,340.41" $0.00 $0.00 $376.37 $0.00 "$1,068.25" "$1,068.25" $0.00 $903.00 "$1,430.35" "$1,444.80" $0.00 $0.00 $282.64 $0.00 $0.00 $287.52 $0.00 $0.00 $0.00 $0.00 $0.00 3571140016 SUP HCPCS C1713 3571140016 - PLATE BN 253MM STRL 16 HL RECON PLVC 4.5MM SCR BOTH IP/OP "$1,869.00 " "$1,383.06" $0.00 "$1,495.20" $841.05 $841.05 $0.00 $0.00 $0.00 $389.55 "$1,387.17" "$1,387.17" $0.00 $0.00 $389.50 $0.00 "$1,105.51" "$1,105.51" $0.00 $934.50 "$1,480.25" "$1,495.20" $0.00 $0.00 $292.50 $0.00 $0.00 $297.54 $0.00 $0.00 $0.00 $0.00 $0.00 3571140104 SUP HCPCS C1713 3571140104 - PLATE BN 46MM STRL 4 HL RECON PLVC 3.5MM SCR BOTH IP/OP $875.70 $648.02 $0.00 $700.56 $394.07 $394.07 $0.00 $0.00 $0.00 $182.52 $649.94 $649.94 $0.00 $0.00 $182.50 $0.00 $517.98 $517.98 $0.00 $437.85 $693.55 $700.56 $0.00 $0.00 $137.05 $0.00 $0.00 $139.41 $0.00 $0.00 $0.00 $0.00 $0.00 3571140105 SUP HCPCS C1713 3571140105 - PLATE BN 58MM 5 HL RECON PLVC 3.5MM SCR BOTH IP/OP $812.70 $601.40 $0.00 $650.16 $365.72 $365.72 $0.00 $0.00 $0.00 $169.39 $603.19 $603.19 $0.00 $0.00 $169.37 $0.00 $480.71 $480.71 $0.00 $406.35 $643.66 $650.16 $0.00 $0.00 $127.19 $0.00 $0.00 $129.38 $0.00 $0.00 $0.00 $0.00 $0.00 3571140106 SUP HCPCS C1713 3571140106 - PLATE BN 70MM 6 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,022.70 " $756.80 $0.00 $818.16 $460.22 $460.22 $0.00 $0.00 $0.00 $213.16 $759.05 $759.05 $0.00 $0.00 $213.13 $0.00 $604.93 $604.93 $0.00 $511.35 $809.98 $818.16 $0.00 $0.00 $160.05 $0.00 $0.00 $162.81 $0.00 $0.00 $0.00 $0.00 $0.00 3571140107 SUP HCPCS C1713 3571140107 - PLATE BN 82MM 7 HL RECON PLVC 3.5MM SCR BOTH IP/OP $974.40 $721.06 $0.00 $779.52 $438.48 $438.48 $0.00 $0.00 $0.00 $203.09 $723.20 $723.20 $0.00 $0.00 $203.06 $0.00 $576.36 $576.36 $0.00 $487.20 $771.72 $779.52 $0.00 $0.00 $152.49 $0.00 $0.00 $155.12 $0.00 $0.00 $0.00 $0.00 $0.00 3571140108 SUP HCPCS C1713 3571140108 - PLATE BN 94MM 8 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,118.25 " $827.51 $0.00 $894.60 $503.21 $503.21 $0.00 $0.00 $0.00 $233.07 $829.97 $829.97 $0.00 $0.00 $233.04 $0.00 $661.44 $661.44 $0.00 $559.13 $885.65 $894.60 $0.00 $0.00 $175.01 $0.00 $0.00 $178.03 $0.00 $0.00 $0.00 $0.00 $0.00 3571140109 SUP HCPCS C1713 3571140109 - PLATE BN 106MM 9 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,050.00 " $777.00 $0.00 $840.00 $472.50 $472.50 $0.00 $0.00 $0.00 $218.85 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $621.08 $621.08 $0.00 $525.00 $831.60 $840.00 $0.00 $0.00 $164.33 $0.00 $0.00 $167.16 $0.00 $0.00 $0.00 $0.00 $0.00 3571140110 SUP HCPCS C1713 3571140110 - PLATE BN 118MM 10 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 3571140111 SUP HCPCS C1713 3571140111 - PLATE BN 130MM STRL 11 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,118.25 " $827.51 $0.00 $894.60 $503.21 $503.21 $0.00 $0.00 $0.00 $233.07 $829.97 $829.97 $0.00 $0.00 $233.04 $0.00 $661.44 $661.44 $0.00 $559.13 $885.65 $894.60 $0.00 $0.00 $175.01 $0.00 $0.00 $178.03 $0.00 $0.00 $0.00 $0.00 $0.00 3571140112 SUP HCPCS C1713 3571140112 - PLATE BN 142MM 12 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 3571140113 SUP HCPCS C1713 3571140113 - PLATE BN 154MM STRL 13 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 3571140114 SUP HCPCS C1713 3571140114 - PLATE BN 166MM 14 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,380.75 " "$1,021.76" $0.00 "$1,104.60" $621.34 $621.34 $0.00 $0.00 $0.00 $287.78 "$1,024.79" "$1,024.79" $0.00 $0.00 $287.75 $0.00 $816.71 $816.71 $0.00 $690.38 "$1,093.55" "$1,104.60" $0.00 $0.00 $216.09 $0.00 $0.00 $219.82 $0.00 $0.00 $0.00 $0.00 $0.00 3571140115 SUP HCPCS C1713 3571140115 - PLATE BN 178MM STRL 15 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,648.50 " "$1,219.89" $0.00 "$1,318.80" $741.83 $741.83 $0.00 $0.00 $0.00 $343.59 "$1,223.52" "$1,223.52" $0.00 $0.00 $343.55 $0.00 $975.09 $975.09 $0.00 $824.25 "$1,305.61" "$1,318.80" $0.00 $0.00 $257.99 $0.00 $0.00 $262.44 $0.00 $0.00 $0.00 $0.00 $0.00 3571140116 SUP HCPCS C1713 3571140116 - PLATE BN 190MM 16 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,407.00 " "$1,041.18" $0.00 "$1,125.60" $633.15 $633.15 $0.00 $0.00 $0.00 $293.25 "$1,044.28" "$1,044.28" $0.00 $0.00 $293.22 $0.00 $832.24 $832.24 $0.00 $703.50 "$1,114.34" "$1,125.60" $0.00 $0.00 $220.20 $0.00 $0.00 $223.99 $0.00 $0.00 $0.00 $0.00 $0.00 3571140118 SUP HCPCS C1713 3571140118 - PLATE BN 214MM 18 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,480.50 " "$1,095.57" $0.00 "$1,184.40" $666.23 $666.23 $0.00 $0.00 $0.00 $308.57 "$1,098.83" "$1,098.83" $0.00 $0.00 $308.54 $0.00 $875.72 $875.72 $0.00 $740.25 "$1,172.56" "$1,184.40" $0.00 $0.00 $231.70 $0.00 $0.00 $235.70 $0.00 $0.00 $0.00 $0.00 $0.00 3571140120 SUP HCPCS C1713 3571140120 - PLATE BN 238MM STRL 20 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$1,800.75 " "$1,332.56" $0.00 "$1,440.60" $810.34 $810.34 $0.00 $0.00 $0.00 $375.32 "$1,336.52" "$1,336.52" $0.00 $0.00 $375.28 $0.00 "$1,065.14" "$1,065.14" $0.00 $900.38 "$1,426.19" "$1,440.60" $0.00 $0.00 $281.82 $0.00 $0.00 $286.68 $0.00 $0.00 $0.00 $0.00 $0.00 3571140122 SUP HCPCS C1713 3571140122 - PLATE BN 263MM STRL 22 HL RECON PLVC 3.5MM SCR BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,827.00" "$1,027.69" "$1,027.69" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,141.88" "$1,808.73" "$1,827.00" $0.00 $0.00 $357.41 $0.00 $0.00 $363.57 $0.00 $0.00 $0.00 $0.00 $0.00 3571140202 SUP HCPCS C1713 3571140202 - PLATE BN 25MM STRL 2 HL 3.5MM SCR SM FRAG BOTH IP/OP $296.10 $219.11 $0.00 $236.88 $133.25 $133.25 $0.00 $0.00 $0.00 $61.71 $219.77 $219.77 $0.00 $0.00 $61.71 $0.00 $175.14 $175.14 $0.00 $148.05 $234.51 $236.88 $0.00 $0.00 $46.34 $0.00 $0.00 $47.14 $0.00 $0.00 $0.00 $0.00 $0.00 3571140203 SUP HCPCS C1713 3571140203 - PLATE BN 37MM STRL 3 HL 3.5MM SCR SM FRAG BOTH IP/OP $309.75 $229.22 $0.00 $247.80 $139.39 $139.39 $0.00 $0.00 $0.00 $64.56 $229.90 $229.90 $0.00 $0.00 $64.55 $0.00 $183.22 $183.22 $0.00 $154.88 $245.32 $247.80 $0.00 $0.00 $48.48 $0.00 $0.00 $49.31 $0.00 $0.00 $0.00 $0.00 $0.00 3571140204 SUP HCPCS C1713 3571140204 - PLATE BN 49MM STRL 4 HL 3.5MM SCR SM FRAG BOTH IP/OP $316.05 $233.88 $0.00 $252.84 $142.22 $142.22 $0.00 $0.00 $0.00 $65.87 $234.57 $234.57 $0.00 $0.00 $65.86 $0.00 $186.94 $186.94 $0.00 $158.03 $250.31 $252.84 $0.00 $0.00 $49.46 $0.00 $0.00 $50.32 $0.00 $0.00 $0.00 $0.00 $0.00 3571140205 SUP HCPCS C1713 3571140205 - PLATE BN 61MM STRL 5 HL 3.5MM SCR SM FRAG BOTH IP/OP $345.45 $255.63 $0.00 $276.36 $155.45 $155.45 $0.00 $0.00 $0.00 $72.00 $256.39 $256.39 $0.00 $0.00 $71.99 $0.00 $204.33 $204.33 $0.00 $172.73 $273.60 $276.36 $0.00 $0.00 $54.06 $0.00 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 3571140206 SUP HCPCS C1713 3571140206 - PLATE BN 73MM STRL 6 HL 3.5MM SCR SM FRAG BOTH IP/OP $361.20 $267.29 $0.00 $288.96 $162.54 $162.54 $0.00 $0.00 $0.00 $75.28 $268.08 $268.08 $0.00 $0.00 $75.27 $0.00 $213.65 $213.65 $0.00 $180.60 $286.07 $288.96 $0.00 $0.00 $56.53 $0.00 $0.00 $57.50 $0.00 $0.00 $0.00 $0.00 $0.00 3571140207 SUP HCPCS C1713 3571140207 - PLATE BN 85MM STRL 7 HL 3.5MM SCR SM FRAG BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $170.10 $170.10 $0.00 $0.00 $0.00 $78.78 $280.55 $280.55 $0.00 $0.00 $78.78 $0.00 $223.59 $223.59 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $59.16 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 3571140208 SUP HCPCS C1713 3571140208 - PLATE BN 97MM STRL 8 HL 3.5MM SCR SM FRAG BOTH IP/OP $405.30 $299.92 $0.00 $324.24 $182.39 $182.39 $0.00 $0.00 $0.00 $84.47 $300.81 $300.81 $0.00 $0.00 $84.46 $0.00 $239.73 $239.73 $0.00 $202.65 $321.00 $324.24 $0.00 $0.00 $63.43 $0.00 $0.00 $64.52 $0.00 $0.00 $0.00 $0.00 $0.00 3571140209 SUP HCPCS C1713 3571140209 - PLATE BN 109MM STRL 9 HL 3.5MM SCR SM FRAG BOTH IP/OP $414.75 $306.92 $0.00 $331.80 $186.64 $186.64 $0.00 $0.00 $0.00 $86.44 $307.83 $307.83 $0.00 $0.00 $86.43 $0.00 $245.32 $245.32 $0.00 $207.38 $328.48 $331.80 $0.00 $0.00 $64.91 $0.00 $0.00 $66.03 $0.00 $0.00 $0.00 $0.00 $0.00 3571140210 SUP HCPCS C1713 3571140210 - PLATE BN 121MM STRL 10 HL 3.5MM SCR SM FRAG BOTH IP/OP $426.30 $315.46 $0.00 $341.04 $191.84 $191.84 $0.00 $0.00 $0.00 $88.85 $316.40 $316.40 $0.00 $0.00 $88.84 $0.00 $252.16 $252.16 $0.00 $213.15 $337.63 $341.04 $0.00 $0.00 $66.72 $0.00 $0.00 $67.87 $0.00 $0.00 $0.00 $0.00 $0.00 3571140212 SUP HCPCS C1713 3571140212 - PLATE BN 145MM STRL 12 HL 3.5MM SCR SM FRAG BOTH IP/OP $473.55 $350.43 $0.00 $378.84 $213.10 $213.10 $0.00 $0.00 $0.00 $98.70 $351.47 $351.47 $0.00 $0.00 $98.69 $0.00 $280.10 $280.10 $0.00 $236.78 $375.05 $378.84 $0.00 $0.00 $74.11 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 3571140214 SUP HCPCS C1713 3571140214 - PLATE BN 169MM STRL 14 HL 3.5MM SCR SM FRAG BOTH IP/OP $889.35 $658.12 $0.00 $711.48 $400.21 $400.21 $0.00 $0.00 $0.00 $185.36 $660.08 $660.08 $0.00 $0.00 $185.34 $0.00 $526.05 $526.05 $0.00 $444.68 $704.37 $711.48 $0.00 $0.00 $139.18 $0.00 $0.00 $141.58 $0.00 $0.00 $0.00 $0.00 $0.00 3571140216 SUP HCPCS C1713 3571140216 - PLATE BN 194MM STRL 16 HL 3.5MM SCR SM FRAG BOTH IP/OP "$1,025.85 " $759.13 $0.00 $820.68 $461.63 $461.63 $0.00 $0.00 $0.00 $213.81 $761.39 $761.39 $0.00 $0.00 $213.79 $0.00 $606.79 $606.79 $0.00 $512.93 $812.47 $820.68 $0.00 $0.00 $160.55 $0.00 $0.00 $163.32 $0.00 $0.00 $0.00 $0.00 $0.00 3571140218 SUP HCPCS C1713 3571140218 - PLATE BN 217MM STRL 18 HL 3.5MM SCR SM FRAG BOTH IP/OP "$1,380.75 " "$1,021.76" $0.00 "$1,104.60" $621.34 $621.34 $0.00 $0.00 $0.00 $287.78 "$1,024.79" "$1,024.79" $0.00 $0.00 $287.75 $0.00 $816.71 $816.71 $0.00 $690.38 "$1,093.55" "$1,104.60" $0.00 $0.00 $216.09 $0.00 $0.00 $219.82 $0.00 $0.00 $0.00 $0.00 $0.00 3571140220 SUP HCPCS C1713 3571140220 - PLATE BN 242MM STRL 20 HL 3.5MM SCR SM FRAG BOTH IP/OP "$1,270.50 " $940.17 $0.00 "$1,016.40" $571.73 $571.73 $0.00 $0.00 $0.00 $264.80 $942.97 $942.97 $0.00 $0.00 $264.77 $0.00 $751.50 $751.50 $0.00 $635.25 "$1,006.24" "$1,016.40" $0.00 $0.00 $198.83 $0.00 $0.00 $202.26 $0.00 $0.00 $0.00 $0.00 $0.00 3571140222 SUP HCPCS C1713 3571140222 - PLATE BN 265MM STRL 22 HL 3.5MM SCR SM FRAG BOTH IP/OP "$1,701.00 " "$1,258.74" $0.00 "$1,360.80" $765.45 $765.45 $0.00 $0.00 $0.00 $354.53 "$1,262.48" "$1,262.48" $0.00 $0.00 $354.49 $0.00 "$1,006.14" "$1,006.14" $0.00 $850.50 "$1,347.19" "$1,360.80" $0.00 $0.00 $266.21 $0.00 $0.00 $270.80 $0.00 $0.00 $0.00 $0.00 $0.00 3571140302 SUP HCPCS C1713 3571140302 - PLATE BN 25MM STRL 1/3 TBLR 2 HL COLR BOTH IP/OP $169.05 $125.10 $0.00 $135.24 $76.07 $76.07 $0.00 $0.00 $0.00 $35.23 $125.47 $125.47 $0.00 $0.00 $35.23 $0.00 $99.99 $99.99 $0.00 $84.53 $133.89 $135.24 $0.00 $0.00 $26.46 $0.00 $0.00 $26.91 $0.00 $0.00 $0.00 $0.00 $0.00 3571140303 SUP HCPCS C1713 3571140303 - PLATE BN 37MM STRL 1/3 TBLR 3 HL COLR BOTH IP/OP $143.85 $106.45 $0.00 $115.08 $64.73 $64.73 $0.00 $0.00 $0.00 $29.98 $106.77 $106.77 $0.00 $0.00 $29.98 $0.00 $85.09 $85.09 $0.00 $71.93 $113.93 $115.08 $0.00 $0.00 $22.51 $0.00 $0.00 $22.90 $0.00 $0.00 $0.00 $0.00 $0.00 3571140304 SUP HCPCS C1713 3571140304 - PLATE BN 49MM STRL 1/3 TBLR 4 HL COLR BOTH IP/OP $169.05 $125.10 $0.00 $135.24 $76.07 $76.07 $0.00 $0.00 $0.00 $35.23 $125.47 $125.47 $0.00 $0.00 $35.23 $0.00 $99.99 $99.99 $0.00 $84.53 $133.89 $135.24 $0.00 $0.00 $26.46 $0.00 $0.00 $26.91 $0.00 $0.00 $0.00 $0.00 $0.00 3571140305 SUP HCPCS C1713 3571140305 - PLATE BN 61MM STRL 1/3 TBLR 5 HL COLR BOTH IP/OP $211.05 $156.18 $0.00 $168.84 $94.97 $94.97 $0.00 $0.00 $0.00 $43.99 $156.64 $156.64 $0.00 $0.00 $43.98 $0.00 $124.84 $124.84 $0.00 $105.53 $167.15 $168.84 $0.00 $0.00 $33.03 $0.00 $0.00 $33.60 $0.00 $0.00 $0.00 $0.00 $0.00 3571140306 SUP HCPCS C1713 3571140306 - PLATE BN 73MM STRL 1/3 TBLR 6 HL COLR DIST FIB BOTH IP/OP $175.35 $129.76 $0.00 $140.28 $78.91 $78.91 $0.00 $0.00 $0.00 $36.55 $130.14 $130.14 $0.00 $0.00 $36.54 $0.00 $103.72 $103.72 $0.00 $87.68 $138.88 $140.28 $0.00 $0.00 $27.44 $0.00 $0.00 $27.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571140307 SUP HCPCS C1713 3571140307 - PLATE BN 85MM STRL 1/3 TBLR 7 HL COLR DIST FIB BOTH IP/OP $175.35 $129.76 $0.00 $140.28 $78.91 $78.91 $0.00 $0.00 $0.00 $36.55 $130.14 $130.14 $0.00 $0.00 $36.54 $0.00 $103.72 $103.72 $0.00 $87.68 $138.88 $140.28 $0.00 $0.00 $27.44 $0.00 $0.00 $27.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571140308 SUP HCPCS C1713 3571140308 - PLATE BN 97MM STRL 1/3 TBLR 8 HL COLR DIST FIB BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 3571140309 SUP HCPCS C1713 3571140309 - PLATE BN 109MM STRL 1/3 TBLR 9 HL COLR DIST FIB BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 3571140310 SUP HCPCS C1713 3571140310 - PLATE BN 121MM STRL 1/3 TBLR 10 HL COLR DIST FIB BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 3571140312 SUP HCPCS C1713 3571140312 - PLATE BN 145MM STRL 1/3 TBLR 12 HL COLR DIST FIB BOTH IP/OP $181.65 $134.42 $0.00 $145.32 $81.74 $81.74 $0.00 $0.00 $0.00 $37.86 $134.82 $134.82 $0.00 $0.00 $37.86 $0.00 $107.45 $107.45 $0.00 $90.83 $143.87 $145.32 $0.00 $0.00 $28.43 $0.00 $0.00 $28.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571140403 SUP HCPCS C1713 3571140403 - PLATE BN T RT ANG 50MM STRL 3X3 HL BOTH IP/OP $313.95 $232.32 $0.00 $251.16 $141.28 $141.28 $0.00 $0.00 $0.00 $65.44 $233.01 $233.01 $0.00 $0.00 $65.43 $0.00 $185.70 $185.70 $0.00 $156.98 $248.65 $251.16 $0.00 $0.00 $49.13 $0.00 $0.00 $49.98 $0.00 $0.00 $0.00 $0.00 $0.00 3571140404 SUP HCPCS C1713 3571140404 - PLATE BN T RT ANG 56MM STRL 4X4 HL BOTH IP/OP $320.25 $236.99 $0.00 $256.20 $144.11 $144.11 $0.00 $0.00 $0.00 $66.75 $237.69 $237.69 $0.00 $0.00 $66.74 $0.00 $189.43 $189.43 $0.00 $160.13 $253.64 $256.20 $0.00 $0.00 $50.12 $0.00 $0.00 $50.98 $0.00 $0.00 $0.00 $0.00 $0.00 3571140405 SUP HCPCS C1713 3571140405 - PLATE BN T RT ANG 67MM STRL 3X5 HL BOTH IP/OP $360.15 $266.51 $0.00 $288.12 $162.07 $162.07 $0.00 $0.00 $0.00 $75.06 $267.30 $267.30 $0.00 $0.00 $75.06 $0.00 $213.03 $213.03 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $56.36 $0.00 $0.00 $57.34 $0.00 $0.00 $0.00 $0.00 $0.00 3571140406 SUP HCPCS C1713 3571140406 - PLATE BN T RT ANG 78MM STRL 4X6 HL BOTH IP/OP $414.75 $306.92 $0.00 $331.80 $186.64 $186.64 $0.00 $0.00 $0.00 $86.44 $307.83 $307.83 $0.00 $0.00 $86.43 $0.00 $245.32 $245.32 $0.00 $207.38 $328.48 $331.80 $0.00 $0.00 $64.91 $0.00 $0.00 $66.03 $0.00 $0.00 $0.00 $0.00 $0.00 3571140503 SUP HCPCS C1713 3571140503 - PLATE BN T 53MM STRL 3X3 HL OBLQ BOTH IP/OP $563.85 $417.25 $0.00 $451.08 $253.73 $253.73 $0.00 $0.00 $0.00 $117.52 $418.49 $418.49 $0.00 $0.00 $117.51 $0.00 $333.52 $333.52 $0.00 $281.93 $446.57 $451.08 $0.00 $0.00 $88.24 $0.00 $0.00 $89.76 $0.00 $0.00 $0.00 $0.00 $0.00 3571140504 SUP HCPCS C1713 3571140504 - PLATE BN T 63MM STRL 3X4 HL OBLQ BOTH IP/OP $588.00 $435.12 $0.00 $470.40 $264.60 $264.60 $0.00 $0.00 $0.00 $122.55 $436.41 $436.41 $0.00 $0.00 $122.54 $0.00 $347.80 $347.80 $0.00 $294.00 $465.70 $470.40 $0.00 $0.00 $92.02 $0.00 $0.00 $93.61 $0.00 $0.00 $0.00 $0.00 $0.00 3571140505 SUP HCPCS C1713 3571140505 - PLATE BN T 73MM STRL 5X4 HL OBLQ BOTH IP/OP $609.00 $450.66 $0.00 $487.20 $274.05 $274.05 $0.00 $0.00 $0.00 $126.93 $452.00 $452.00 $0.00 $0.00 $126.92 $0.00 $360.22 $360.22 $0.00 $304.50 $482.33 $487.20 $0.00 $0.00 $95.31 $0.00 $0.00 $96.95 $0.00 $0.00 $0.00 $0.00 $0.00 3571140603 SUP HCPCS C1713 3571140603 - PLATE BN CLVRLF 88MM STRL 3 HL BOTH IP/OP $744.45 $550.89 $0.00 $595.56 $335.00 $335.00 $0.00 $0.00 $0.00 $155.16 $552.53 $552.53 $0.00 $0.00 $155.14 $0.00 $440.34 $440.34 $0.00 $372.23 $589.60 $595.56 $0.00 $0.00 $116.51 $0.00 $0.00 $118.52 $0.00 $0.00 $0.00 $0.00 $0.00 3571140604 SUP HCPCS C1713 3571140604 - PLATE BN CLVRLF 104MM STRL 4 HL BOTH IP/OP $798.00 $590.52 $0.00 $638.40 $359.10 $359.10 $0.00 $0.00 $0.00 $166.32 $592.28 $592.28 $0.00 $0.00 $166.30 $0.00 $472.02 $472.02 $0.00 $399.00 $632.02 $638.40 $0.00 $0.00 $124.89 $0.00 $0.00 $127.04 $0.00 $0.00 $0.00 $0.00 $0.00 3571140606 SUP HCPCS C1713 3571140606 - PLATE BN CRV 70MM 6 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,039.50 " $769.23 $0.00 $831.60 $467.78 $467.78 $0.00 $0.00 $0.00 $216.66 $771.52 $771.52 $0.00 $0.00 $216.63 $0.00 $614.86 $614.86 $0.00 $519.75 $823.28 $831.60 $0.00 $0.00 $162.68 $0.00 $0.00 $165.49 $0.00 $0.00 $0.00 $0.00 $0.00 3571140608 SUP HCPCS C1713 3571140608 - PLATE BN CRV 94MM 8 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,134.00 " $839.16 $0.00 $907.20 $510.30 $510.30 $0.00 $0.00 $0.00 $236.35 $841.65 $841.65 $0.00 $0.00 $236.33 $0.00 $670.76 $670.76 $0.00 $567.00 $898.13 $907.20 $0.00 $0.00 $177.47 $0.00 $0.00 $180.53 $0.00 $0.00 $0.00 $0.00 $0.00 3571140610 SUP HCPCS C1713 3571140610 - PLATE BN CRV 118MM 10 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,186.50 " $878.01 $0.00 $949.20 $533.93 $533.93 $0.00 $0.00 $0.00 $247.30 $880.62 $880.62 $0.00 $0.00 $247.27 $0.00 $701.81 $701.81 $0.00 $593.25 $939.71 $949.20 $0.00 $0.00 $185.69 $0.00 $0.00 $188.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571140612 SUP HCPCS C1713 3571140612 - PLATE BN CRV 142MM 12 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,244.25 " $920.75 $0.00 $995.40 $559.91 $559.91 $0.00 $0.00 $0.00 $259.33 $923.48 $923.48 $0.00 $0.00 $259.30 $0.00 $735.97 $735.97 $0.00 $622.13 $985.45 $995.40 $0.00 $0.00 $194.73 $0.00 $0.00 $198.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571140614 SUP HCPCS C1713 3571140614 - PLATE BN CRV 166MM 14 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,401.75 " "$1,037.30" $0.00 "$1,121.40" $630.79 $630.79 $0.00 $0.00 $0.00 $292.16 "$1,040.38" "$1,040.38" $0.00 $0.00 $292.12 $0.00 $829.14 $829.14 $0.00 $700.88 "$1,110.19" "$1,121.40" $0.00 $0.00 $219.37 $0.00 $0.00 $223.16 $0.00 $0.00 $0.00 $0.00 $0.00 3571140616 SUP HCPCS C1713 3571140616 - PLATE BN CRV 190MM 16 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,485.75 " "$1,099.46" $0.00 "$1,188.60" $668.59 $668.59 $0.00 $0.00 $0.00 $309.67 "$1,102.72" "$1,102.72" $0.00 $0.00 $309.63 $0.00 $878.82 $878.82 $0.00 $742.88 "$1,176.71" "$1,188.60" $0.00 $0.00 $232.52 $0.00 $0.00 $236.53 $0.00 $0.00 $0.00 $0.00 $0.00 3571140618 SUP HCPCS C1713 3571140618 - PLATE BN CRV 214MM STRL 18 HL RECON SS 3.5MM SCR BOTH IP/OP "$1,601.25 " "$1,184.93" $0.00 "$1,281.00" $720.56 $720.56 $0.00 $0.00 $0.00 $333.74 "$1,188.45" "$1,188.45" $0.00 $0.00 $333.70 $0.00 $947.14 $947.14 $0.00 $800.63 "$1,268.19" "$1,281.00" $0.00 $0.00 $250.60 $0.00 $0.00 $254.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571140704 SUP HCPCS C1713 3571140704 - PLATE BN 80MM STRL 4 HL TBTRS BOTH IP/OP $926.10 $685.31 $0.00 $740.88 $416.75 $416.75 $0.00 $0.00 $0.00 $193.02 $687.35 $687.35 $0.00 $0.00 $193.00 $0.00 $547.79 $547.79 $0.00 $463.05 $733.47 $740.88 $0.00 $0.00 $144.93 $0.00 $0.00 $147.44 $0.00 $0.00 $0.00 $0.00 $0.00 3571140705 SUP HCPCS C1713 3571140705 - PLATE BN 96MM STRL 5 HL TBTRS BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 3571140706 SUP HCPCS C1713 3571140706 - PLATE BN 112MM STRL 6 HL TBTRS BOTH IP/OP "$1,249.50 " $924.63 $0.00 $999.60 $562.28 $562.28 $0.00 $0.00 $0.00 $260.43 $927.38 $927.38 $0.00 $0.00 $260.40 $0.00 $739.08 $739.08 $0.00 $624.75 $989.60 $999.60 $0.00 $0.00 $195.55 $0.00 $0.00 $198.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571140804 SUP HCPCS C1713 3571140804 - PLATE BN 86MM STRL 4 HL L BTRS TIB LT BOTH IP/OP $828.45 $613.05 $0.00 $662.76 $372.80 $372.80 $0.00 $0.00 $0.00 $172.67 $614.88 $614.88 $0.00 $0.00 $172.65 $0.00 $490.03 $490.03 $0.00 $414.23 $656.13 $662.76 $0.00 $0.00 $129.65 $0.00 $0.00 $131.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571140904 SUP HCPCS C1713 3571140904 - PLATE BN 86MM STRL 4 HL L BTRS TIB RT BOTH IP/OP $828.45 $613.05 $0.00 $662.76 $372.80 $372.80 $0.00 $0.00 $0.00 $172.67 $614.88 $614.88 $0.00 $0.00 $172.65 $0.00 $490.03 $490.03 $0.00 $414.23 $656.13 $662.76 $0.00 $0.00 $129.65 $0.00 $0.00 $131.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571141003 SUP HCPCS C1713 3571141003 - PLATE BN STRL 3 HL BTRS TIBHD RL BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 3571141005 SUP HCPCS C1713 3571141005 - PLATE BN 118MM STRL 5 HL BTRS TIBHD RL BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 3571141007 SUP HCPCS C1713 3571141007 - PLATE BN 149MM STRL 7 HL BTRS TIBHD RL BOTH IP/OP "$1,785.00 " "$1,320.90" $0.00 "$1,428.00" $803.25 $803.25 $0.00 $0.00 $0.00 $372.04 "$1,324.83" "$1,324.83" $0.00 $0.00 $371.99 $0.00 "$1,055.83" "$1,055.83" $0.00 $892.50 "$1,413.72" "$1,428.00" $0.00 $0.00 $279.35 $0.00 $0.00 $284.17 $0.00 $0.00 $0.00 $0.00 $0.00 3571141009 SUP HCPCS C1713 3571141009 - PLATE BN 181MM STRL 9 HL BTRS TIBHD RL BOTH IP/OP "$1,905.75 " "$1,410.26" $0.00 "$1,524.60" $857.59 $857.59 $0.00 $0.00 $0.00 $397.21 "$1,414.45" "$1,414.45" $0.00 $0.00 $397.16 $0.00 "$1,127.25" "$1,127.25" $0.00 $952.88 "$1,509.35" "$1,524.60" $0.00 $0.00 $298.25 $0.00 $0.00 $303.40 $0.00 $0.00 $0.00 $0.00 $0.00 3571141011 SUP HCPCS C1713 3571141011 - PLATE BN 214MM STRL 11 HL BTRS TIBHD RL BOTH IP/OP "$2,499.00 " "$1,849.26" $0.00 "$1,999.20" "$1,124.55" "$1,124.55" $0.00 $0.00 $0.00 $520.85 "$1,854.76" "$1,854.76" $0.00 $0.00 $520.79 $0.00 "$1,478.16" "$1,478.16" $0.00 "$1,249.50" "$1,979.21" "$1,999.20" $0.00 $0.00 $391.09 $0.00 $0.00 $397.84 $0.00 $0.00 $0.00 $0.00 $0.00 3571141013 SUP HCPCS C1713 3571141013 - PLATE BN 246MM STRL 13 HL BTRS TIBHD RL BOTH IP/OP "$2,593.50 " "$1,919.19" $0.00 "$2,074.80" "$1,167.08" "$1,167.08" $0.00 $0.00 $0.00 $540.55 "$1,924.90" "$1,924.90" $0.00 $0.00 $540.49 $0.00 "$1,278.60" "$1,278.60" $0.00 "$1,296.75" "$2,054.05" "$2,074.80" $0.00 $0.00 $405.88 $0.00 $0.00 $412.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571141103 SUP HCPCS C1713 3571141103 - PLATE BN STRL 3 HL BTRS TIBHD L/L BOTH IP/OP "$1,422.75 " "$1,052.84" $0.00 "$1,138.20" $640.24 $640.24 $0.00 $0.00 $0.00 $296.54 "$1,055.97" "$1,055.97" $0.00 $0.00 $296.50 $0.00 $841.56 $841.56 $0.00 $711.38 "$1,126.82" "$1,138.20" $0.00 $0.00 $222.66 $0.00 $0.00 $226.50 $0.00 $0.00 $0.00 $0.00 $0.00 3571141105 SUP HCPCS C1713 3571141105 - PLATE BN 118MM STRL 5 HL BTRS TIBHD L/L BOTH IP/OP "$1,669.50 " "$1,235.43" $0.00 "$1,335.60" $751.28 $751.28 $0.00 $0.00 $0.00 $347.97 "$1,239.10" "$1,239.10" $0.00 $0.00 $347.92 $0.00 $987.51 $987.51 $0.00 $834.75 "$1,322.24" "$1,335.60" $0.00 $0.00 $261.28 $0.00 $0.00 $265.78 $0.00 $0.00 $0.00 $0.00 $0.00 3571141107 SUP HCPCS C1713 3571141107 - PLATE BN 149MM STRL 7 HL BTRS TIBHD L/L BOTH IP/OP "$1,785.00 " "$1,320.90" $0.00 "$1,428.00" $803.25 $803.25 $0.00 $0.00 $0.00 $372.04 "$1,324.83" "$1,324.83" $0.00 $0.00 $371.99 $0.00 "$1,055.83" "$1,055.83" $0.00 $892.50 "$1,413.72" "$1,428.00" $0.00 $0.00 $279.35 $0.00 $0.00 $284.17 $0.00 $0.00 $0.00 $0.00 $0.00 3571141109 SUP HCPCS C1713 3571141109 - PLATE BN 181MM STRL 9 HL BTRS TIBHD L/L BOTH IP/OP "$1,905.75 " "$1,410.26" $0.00 "$1,524.60" $857.59 $857.59 $0.00 $0.00 $0.00 $397.21 "$1,414.45" "$1,414.45" $0.00 $0.00 $397.16 $0.00 "$1,127.25" "$1,127.25" $0.00 $952.88 "$1,509.35" "$1,524.60" $0.00 $0.00 $298.25 $0.00 $0.00 $303.40 $0.00 $0.00 $0.00 $0.00 $0.00 3571141111 SUP HCPCS C1713 3571141111 - PLATE BN 214MM STRL 11 HL BTRS TIBHD L/L BOTH IP/OP "$2,499.00 " "$1,849.26" $0.00 "$1,999.20" "$1,124.55" "$1,124.55" $0.00 $0.00 $0.00 $520.85 "$1,854.76" "$1,854.76" $0.00 $0.00 $520.79 $0.00 "$1,478.16" "$1,478.16" $0.00 "$1,249.50" "$1,979.21" "$1,999.20" $0.00 $0.00 $391.09 $0.00 $0.00 $397.84 $0.00 $0.00 $0.00 $0.00 $0.00 3571141113 SUP HCPCS C1713 3571141113 - PLATE BN 246MM STRL 13 HL BTRS TIBHD L/L BOTH IP/OP "$2,593.50 " "$1,919.19" $0.00 "$2,074.80" "$1,167.08" "$1,167.08" $0.00 $0.00 $0.00 $540.55 "$1,924.90" "$1,924.90" $0.00 $0.00 $540.49 $0.00 "$1,278.60" "$1,278.60" $0.00 "$1,296.75" "$2,054.05" "$2,074.80" $0.00 $0.00 $405.88 $0.00 $0.00 $412.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571141206 SUP HCPCS C1713 3571141206 - PLATE BN BRD 103MM STRL 6 HL 4.5MM SCR BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $245.70 $245.70 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571141207 SUP HCPCS C1713 3571141207 - PLATE BN BRD 119MM STRL 7 HL 4.5MM SCR BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $245.70 $245.70 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571141208 SUP HCPCS C1713 3571141208 - PLATE BN BRD 135MM STRL 8 HL 4.5MM SCR BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 3571141209 SUP HCPCS C1713 3571141209 - PLATE BN BRD 151MM STRL 9 HL 4.5MM SCR BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 3571141210 SUP HCPCS C1713 3571141210 - PLATE BN BRD 167MM STRL 10 HL 4.5MM SCR BOTH IP/OP $680.40 $503.50 $0.00 $544.32 $306.18 $306.18 $0.00 $0.00 $0.00 $141.81 $504.99 $504.99 $0.00 $0.00 $141.80 $0.00 $402.46 $402.46 $0.00 $340.20 $538.88 $544.32 $0.00 $0.00 $106.48 $0.00 $0.00 $108.32 $0.00 $0.00 $0.00 $0.00 $0.00 3571141212 SUP HCPCS C1713 3571141212 - PLATE BN BRD 199MM STRL 12 HL 4.5MM SCR BOTH IP/OP $731.85 $541.57 $0.00 $585.48 $329.33 $329.33 $0.00 $0.00 $0.00 $152.54 $543.18 $543.18 $0.00 $0.00 $152.52 $0.00 $432.89 $432.89 $0.00 $365.93 $579.63 $585.48 $0.00 $0.00 $114.53 $0.00 $0.00 $116.51 $0.00 $0.00 $0.00 $0.00 $0.00 3571141214 SUP HCPCS C1713 3571141214 - PLATE BN BRD 231MM STRL 14 HL 4.5MM SCR BOTH IP/OP $731.85 $541.57 $0.00 $585.48 $329.33 $329.33 $0.00 $0.00 $0.00 $152.54 $543.18 $543.18 $0.00 $0.00 $152.52 $0.00 $432.89 $432.89 $0.00 $365.93 $579.63 $585.48 $0.00 $0.00 $114.53 $0.00 $0.00 $116.51 $0.00 $0.00 $0.00 $0.00 $0.00 3571141216 SUP HCPCS C1713 3571141216 - PLATE BN BRD 263MM STRL 16 HL 4.5MM SCR BOTH IP/OP $926.10 $685.31 $0.00 $740.88 $416.75 $416.75 $0.00 $0.00 $0.00 $193.02 $687.35 $687.35 $0.00 $0.00 $193.00 $0.00 $547.79 $547.79 $0.00 $463.05 $733.47 $740.88 $0.00 $0.00 $144.93 $0.00 $0.00 $147.44 $0.00 $0.00 $0.00 $0.00 $0.00 3571141218 SUP HCPCS C1713 3571141218 - PLATE BN BRD 295MM STRL 18 HL 4.5MM SCR BOTH IP/OP "$1,022.70 " $756.80 $0.00 $818.16 $460.22 $460.22 $0.00 $0.00 $0.00 $213.16 $759.05 $759.05 $0.00 $0.00 $213.13 $0.00 $604.93 $604.93 $0.00 $511.35 $809.98 $818.16 $0.00 $0.00 $160.05 $0.00 $0.00 $162.81 $0.00 $0.00 $0.00 $0.00 $0.00 3571141220 SUP HCPCS C1713 3571141220 - PLATE BN BRD 326MM STRL 20 HL 4.5MM SCR BOTH IP/OP "$1,459.50 " "$1,080.03" $0.00 "$1,167.60" $656.78 $656.78 $0.00 $0.00 $0.00 $304.20 "$1,083.24" "$1,083.24" $0.00 $0.00 $304.16 $0.00 $863.29 $863.29 $0.00 $729.75 "$1,155.92" "$1,167.60" $0.00 $0.00 $228.41 $0.00 $0.00 $232.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571141222 SUP HCPCS C1713 3571141222 - PLATE BN BRD 358MM STRL 22 HL 4.5MM SCR BOTH IP/OP "$1,543.50 " "$1,142.19" $0.00 "$1,234.80" $694.58 $694.58 $0.00 $0.00 $0.00 $321.70 "$1,145.59" "$1,145.59" $0.00 $0.00 $321.67 $0.00 $912.98 $912.98 $0.00 $771.75 "$1,222.45" "$1,234.80" $0.00 $0.00 $241.56 $0.00 $0.00 $245.73 $0.00 $0.00 $0.00 $0.00 $0.00 3571141224 SUP HCPCS C1713 3571141224 - PLATE BN BRD 390MM STRL 24 HL 4.5MM SCR BOTH IP/OP "$1,711.50 " "$1,266.51" $0.00 "$1,369.20" $770.18 $770.18 $0.00 $0.00 $0.00 $356.72 "$1,270.28" "$1,270.28" $0.00 $0.00 $356.68 $0.00 "$1,012.35" "$1,012.35" $0.00 $855.75 "$1,355.51" "$1,369.20" $0.00 $0.00 $267.85 $0.00 $0.00 $272.47 $0.00 $0.00 $0.00 $0.00 $0.00 3571141302 SUP HCPCS C1713 3571141302 - PLATE BN 39MM STRL 2 HL SMTB BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 3571141303 SUP HCPCS C1713 3571141303 - PLATE BN 55MM STRL 3 HL SMTB BOTH IP/OP $147.00 $108.78 $0.00 $117.60 $66.15 $66.15 $0.00 $0.00 $0.00 $30.64 $109.10 $109.10 $0.00 $0.00 $30.63 $0.00 $86.95 $86.95 $0.00 $73.50 $116.42 $117.60 $0.00 $0.00 $23.01 $0.00 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 3571141304 SUP HCPCS C1713 3571141304 - PLATE BN 71MM STRL 4 HL SMTB BOTH IP/OP $159.60 $118.10 $0.00 $127.68 $71.82 $71.82 $0.00 $0.00 $0.00 $33.26 $118.46 $118.46 $0.00 $0.00 $33.26 $0.00 $94.40 $94.40 $0.00 $79.80 $126.40 $127.68 $0.00 $0.00 $24.98 $0.00 $0.00 $25.41 $0.00 $0.00 $0.00 $0.00 $0.00 3571141305 SUP HCPCS C1713 3571141305 - PLATE BN 87MM STRL 5 HL SMTB BOTH IP/OP $166.95 $123.54 $0.00 $133.56 $75.13 $75.13 $0.00 $0.00 $0.00 $34.80 $123.91 $123.91 $0.00 $0.00 $34.79 $0.00 $98.75 $98.75 $0.00 $83.48 $132.22 $133.56 $0.00 $0.00 $26.13 $0.00 $0.00 $26.58 $0.00 $0.00 $0.00 $0.00 $0.00 3571141306 SUP HCPCS C1713 3571141306 - PLATE BN 103MM STRL 6 HL SMTB BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 3571141307 SUP HCPCS C1713 3571141307 - PLATE BN 119MM STRL 7 HL SMTB BOTH IP/OP $192.15 $142.19 $0.00 $153.72 $86.47 $86.47 $0.00 $0.00 $0.00 $40.05 $142.61 $142.61 $0.00 $0.00 $40.04 $0.00 $113.66 $113.66 $0.00 $96.08 $152.18 $153.72 $0.00 $0.00 $30.07 $0.00 $0.00 $30.59 $0.00 $0.00 $0.00 $0.00 $0.00 3571141308 SUP HCPCS C1713 3571141308 - PLATE BN 135MM STRL 8 HL SMTB BOTH IP/OP $246.75 $182.60 $0.00 $197.40 $111.04 $111.04 $0.00 $0.00 $0.00 $51.43 $183.14 $183.14 $0.00 $0.00 $51.42 $0.00 $145.95 $145.95 $0.00 $123.38 $195.43 $197.40 $0.00 $0.00 $38.62 $0.00 $0.00 $39.28 $0.00 $0.00 $0.00 $0.00 $0.00 3571141309 SUP HCPCS C1713 3571141309 - PLATE BN 151MM STRL 9 HL SMTB BOTH IP/OP $218.40 $161.62 $0.00 $174.72 $98.28 $98.28 $0.00 $0.00 $0.00 $45.52 $162.10 $162.10 $0.00 $0.00 $45.51 $0.00 $129.18 $129.18 $0.00 $109.20 $172.97 $174.72 $0.00 $0.00 $34.18 $0.00 $0.00 $34.77 $0.00 $0.00 $0.00 $0.00 $0.00 3571141310 SUP HCPCS C1713 3571141310 - PLATE BN 167MM STRL 10 HL SMTB BOTH IP/OP $270.90 $200.47 $0.00 $216.72 $121.91 $121.91 $0.00 $0.00 $0.00 $56.46 $201.06 $201.06 $0.00 $0.00 $56.46 $0.00 $160.24 $160.24 $0.00 $135.45 $214.55 $216.72 $0.00 $0.00 $42.40 $0.00 $0.00 $43.13 $0.00 $0.00 $0.00 $0.00 $0.00 3571141311 SUP HCPCS C1713 3571141311 - PLATE BN 183MM STRL 11 HL SMTB BOTH IP/OP $282.45 $209.01 $0.00 $225.96 $127.10 $127.10 $0.00 $0.00 $0.00 $58.87 $209.63 $209.63 $0.00 $0.00 $58.86 $0.00 $167.07 $167.07 $0.00 $141.23 $223.70 $225.96 $0.00 $0.00 $44.20 $0.00 $0.00 $44.97 $0.00 $0.00 $0.00 $0.00 $0.00 3571141312 SUP HCPCS C1713 3571141312 - PLATE BN 199MM STRL 12 HL SMTB BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 3571141402 SUP HCPCS C1713 3571141402 - PLATE BN NAR 39MM 2 HL SS 4.5MM SCR BOTH IP/OP $336.00 $248.64 $0.00 $268.80 $151.20 $151.20 $0.00 $0.00 $0.00 $70.03 $249.38 $249.38 $0.00 $0.00 $70.02 $0.00 $198.74 $198.74 $0.00 $168.00 $266.11 $268.80 $0.00 $0.00 $52.58 $0.00 $0.00 $53.49 $0.00 $0.00 $0.00 $0.00 $0.00 3571141403 SUP HCPCS C1713 3571141403 - PLATE BN NAR 55MM 3 HL SS 4.5MM SCR BOTH IP/OP $352.80 $261.07 $0.00 $282.24 $158.76 $158.76 $0.00 $0.00 $0.00 $73.53 $261.85 $261.85 $0.00 $0.00 $73.52 $0.00 $208.68 $208.68 $0.00 $176.40 $279.42 $282.24 $0.00 $0.00 $55.21 $0.00 $0.00 $56.17 $0.00 $0.00 $0.00 $0.00 $0.00 3571141404 SUP HCPCS C1713 3571141404 - PLATE BN NAR 71MM STRL 4 HL 4.5MM SCR BOTH IP/OP $368.55 $272.73 $0.00 $294.84 $165.85 $165.85 $0.00 $0.00 $0.00 $76.82 $273.54 $273.54 $0.00 $0.00 $76.81 $0.00 $218.00 $218.00 $0.00 $184.28 $291.89 $294.84 $0.00 $0.00 $57.68 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 3571141405 SUP HCPCS C1713 3571141405 - PLATE BN NAR 87MM STRL 5 HL 4.5MM SCR BOTH IP/OP $368.55 $272.73 $0.00 $294.84 $165.85 $165.85 $0.00 $0.00 $0.00 $76.82 $273.54 $273.54 $0.00 $0.00 $76.81 $0.00 $218.00 $218.00 $0.00 $184.28 $291.89 $294.84 $0.00 $0.00 $57.68 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 3571141406 SUP HCPCS C1713 3571141406 - PLATE BN NAR 103MM STRL 6 HL 4.5MM SCR BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 3571141407 SUP HCPCS C1713 3571141407 - PLATE BN NAR 119MM STRL 7 HL 4.5MM SCR BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 3571141408 SUP HCPCS C1713 3571141408 - PLATE BN NAR 135MM STRL 8 HL 4.5MM SCR BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 3571141409 SUP HCPCS C1713 3571141409 - PLATE BN NAR 151MM STRL 9 HL 4.5MM SCR BOTH IP/OP $410.55 $303.81 $0.00 $328.44 $184.75 $184.75 $0.00 $0.00 $0.00 $85.57 $304.71 $304.71 $0.00 $0.00 $85.56 $0.00 $242.84 $242.84 $0.00 $205.28 $325.16 $328.44 $0.00 $0.00 $64.25 $0.00 $0.00 $65.36 $0.00 $0.00 $0.00 $0.00 $0.00 3571141410 SUP HCPCS C1713 3571141410 - PLATE BN NAR 167MM STRL 10 HL 4.5MM SCR BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 3571141411 SUP HCPCS C1713 3571141411 - PLATE BN NAR 183MM STRL 11 HL 4.5MM SCR BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 3571141412 SUP HCPCS C1713 3571141412 - PLATE BN NAR 199MM STRL 12 HL 4.5MM SCR BOTH IP/OP $535.50 $396.27 $0.00 $428.40 $240.98 $240.98 $0.00 $0.00 $0.00 $111.61 $397.45 $397.45 $0.00 $0.00 $111.60 $0.00 $316.75 $316.75 $0.00 $267.75 $424.12 $428.40 $0.00 $0.00 $83.81 $0.00 $0.00 $85.25 $0.00 $0.00 $0.00 $0.00 $0.00 3571141413 SUP HCPCS C1713 3571141413 - PLATE BN NAR 215MM STRL 13 HL 4.5MM SCR BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 3571141414 SUP HCPCS C1713 3571141414 - PLATE BN NAR 231MM STRL 14 HL 4.5MM SCR BOTH IP/OP $763.35 $564.88 $0.00 $610.68 $343.51 $343.51 $0.00 $0.00 $0.00 $159.10 $566.56 $566.56 $0.00 $0.00 $159.08 $0.00 $451.52 $451.52 $0.00 $381.68 $604.57 $610.68 $0.00 $0.00 $119.46 $0.00 $0.00 $121.53 $0.00 $0.00 $0.00 $0.00 $0.00 3571141415 SUP HCPCS C1713 3571141415 - PLATE BN NAR 247MM STRL 15 HL 4.5MM SCR BOTH IP/OP $805.35 $595.96 $0.00 $644.28 $362.41 $362.41 $0.00 $0.00 $0.00 $167.86 $597.73 $597.73 $0.00 $0.00 $167.83 $0.00 $476.36 $476.36 $0.00 $402.68 $637.84 $644.28 $0.00 $0.00 $126.04 $0.00 $0.00 $128.21 $0.00 $0.00 $0.00 $0.00 $0.00 3571141416 SUP HCPCS C1713 3571141416 - PLATE BN NAR 263MM STRL 16 HL 4.5MM SCR BOTH IP/OP $805.35 $595.96 $0.00 $644.28 $362.41 $362.41 $0.00 $0.00 $0.00 $167.86 $597.73 $597.73 $0.00 $0.00 $167.83 $0.00 $476.36 $476.36 $0.00 $402.68 $637.84 $644.28 $0.00 $0.00 $126.04 $0.00 $0.00 $128.21 $0.00 $0.00 $0.00 $0.00 $0.00 3571141418 SUP HCPCS C1713 3571141418 - PLATE BN NAR 295MM STRL 18 HL 4.5MM SCR BOTH IP/OP "$1,149.75 " $850.82 $0.00 $919.80 $517.39 $517.39 $0.00 $0.00 $0.00 $239.64 $853.34 $853.34 $0.00 $0.00 $239.61 $0.00 $680.08 $680.08 $0.00 $574.88 $910.60 $919.80 $0.00 $0.00 $179.94 $0.00 $0.00 $183.04 $0.00 $0.00 $0.00 $0.00 $0.00 3571141420 SUP HCPCS C1713 3571141420 - PLATE BN NAR 326MM STRL 20 HL 4.5MM SCR BOTH IP/OP "$1,038.45 " $768.45 $0.00 $830.76 $467.30 $467.30 $0.00 $0.00 $0.00 $216.44 $770.74 $770.74 $0.00 $0.00 $216.41 $0.00 $614.24 $614.24 $0.00 $519.23 $822.45 $830.76 $0.00 $0.00 $162.52 $0.00 $0.00 $165.32 $0.00 $0.00 $0.00 $0.00 $0.00 3571141422 SUP HCPCS C1713 3571141422 - PLATE BN NAR 358MM STRL 22 HL 4.5MM SCR BOTH IP/OP "$1,401.75 " "$1,037.30" $0.00 "$1,121.40" $630.79 $630.79 $0.00 $0.00 $0.00 $292.16 "$1,040.38" "$1,040.38" $0.00 $0.00 $292.12 $0.00 $829.14 $829.14 $0.00 $700.88 "$1,110.19" "$1,121.40" $0.00 $0.00 $219.37 $0.00 $0.00 $223.16 $0.00 $0.00 $0.00 $0.00 $0.00 3571141424 SUP HCPCS C1713 3571141424 - PLATE BN NAR 390MM STRL 24 HL 4.5MM SCR BOTH IP/OP "$1,517.25 " "$1,122.77" $0.00 "$1,213.80" $682.76 $682.76 $0.00 $0.00 $0.00 $316.23 "$1,126.10" "$1,126.10" $0.00 $0.00 $316.19 $0.00 $897.45 $897.45 $0.00 $758.63 "$1,201.66" "$1,213.80" $0.00 $0.00 $237.45 $0.00 $0.00 $241.55 $0.00 $0.00 $0.00 $0.00 $0.00 3571141603 SUP HCPCS C1713 3571141603 - PLATE BN T 68MM STRL 3 HL BOTH IP/OP $568.05 $420.36 $0.00 $454.44 $255.62 $255.62 $0.00 $0.00 $0.00 $118.40 $421.61 $421.61 $0.00 $0.00 $118.38 $0.00 $336.00 $336.00 $0.00 $284.03 $449.90 $454.44 $0.00 $0.00 $88.90 $0.00 $0.00 $90.43 $0.00 $0.00 $0.00 $0.00 $0.00 3571141604 SUP HCPCS C1713 3571141604 - PLATE BN T 84MM STRL 4 HL BOTH IP/OP $631.05 $466.98 $0.00 $504.84 $283.97 $283.97 $0.00 $0.00 $0.00 $131.53 $468.37 $468.37 $0.00 $0.00 $131.51 $0.00 $373.27 $373.27 $0.00 $315.53 $499.79 $504.84 $0.00 $0.00 $98.76 $0.00 $0.00 $100.46 $0.00 $0.00 $0.00 $0.00 $0.00 3571141605 SUP HCPCS C1713 3571141605 - PLATE BN T 100MM STRL 5 HL BOTH IP/OP $670.95 $496.50 $0.00 $536.76 $301.93 $301.93 $0.00 $0.00 $0.00 $139.84 $497.98 $497.98 $0.00 $0.00 $139.83 $0.00 $396.87 $396.87 $0.00 $335.48 $531.39 $536.76 $0.00 $0.00 $105.00 $0.00 $0.00 $106.82 $0.00 $0.00 $0.00 $0.00 $0.00 3571141606 SUP HCPCS C1713 3571141606 - PLATE BN T 116MM STRL 6 HL BOTH IP/OP $742.35 $549.34 $0.00 $593.88 $334.06 $334.06 $0.00 $0.00 $0.00 $154.72 $550.97 $550.97 $0.00 $0.00 $154.71 $0.00 $439.10 $439.10 $0.00 $371.18 $587.94 $593.88 $0.00 $0.00 $116.18 $0.00 $0.00 $118.18 $0.00 $0.00 $0.00 $0.00 $0.00 3571141608 SUP HCPCS C1713 3571141608 - PLATE BN T 148MM STRL 8 HL BOTH IP/OP "$1,025.85 " $759.13 $0.00 $820.68 $461.63 $461.63 $0.00 $0.00 $0.00 $213.81 $761.39 $761.39 $0.00 $0.00 $213.79 $0.00 $606.79 $606.79 $0.00 $512.93 $812.47 $820.68 $0.00 $0.00 $160.55 $0.00 $0.00 $163.32 $0.00 $0.00 $0.00 $0.00 $0.00 3571142007 SUP HCPCS C1713 3571142007 - PLATE BN 158MM STRL 7 HL BTRS CNDYL BOTH IP/OP "$1,953.00 " "$1,445.22" $0.00 "$1,562.40" $878.85 $878.85 $0.00 $0.00 $0.00 $407.05 "$1,449.52" "$1,449.52" $0.00 $0.00 $407.01 $0.00 "$1,155.20" "$1,155.20" $0.00 $976.50 "$1,546.78" "$1,562.40" $0.00 $0.00 $305.64 $0.00 $0.00 $310.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571142009 SUP HCPCS C1713 3571142009 - PLATE BN 190MM STRL 9 HL BTRS CNDYL BOTH IP/OP "$2,026.50 " "$1,499.61" $0.00 "$1,621.20" $911.93 $911.93 $0.00 $0.00 $0.00 $422.37 "$1,504.07" "$1,504.07" $0.00 $0.00 $422.32 $0.00 "$1,198.67" "$1,198.67" $0.00 "$1,013.25" "$1,604.99" "$1,621.20" $0.00 $0.00 $317.15 $0.00 $0.00 $322.62 $0.00 $0.00 $0.00 $0.00 $0.00 3571142011 SUP HCPCS C1713 3571142011 - PLATE BN 221MM STRL 11 HL BTRS CNDYL BOTH IP/OP "$2,541.00 " "$1,880.34" $0.00 "$2,032.80" "$1,143.45" "$1,143.45" $0.00 $0.00 $0.00 $529.61 "$1,885.93" "$1,885.93" $0.00 $0.00 $529.54 $0.00 "$1,252.71" "$1,252.71" $0.00 "$1,270.50" "$2,012.47" "$2,032.80" $0.00 $0.00 $397.67 $0.00 $0.00 $404.53 $0.00 $0.00 $0.00 $0.00 $0.00 3571142013 SUP HCPCS C1713 3571142013 - PLATE BN 253MM STRL 13 HL BTRS CNDYL BOTH IP/OP "$2,136.75 " "$1,581.20" $0.00 "$1,709.40" $961.54 $961.54 $0.00 $0.00 $0.00 $445.35 "$1,585.90" "$1,585.90" $0.00 $0.00 $445.30 $0.00 "$1,263.89" "$1,263.89" $0.00 "$1,068.38" "$1,692.31" "$1,709.40" $0.00 $0.00 $334.40 $0.00 $0.00 $340.17 $0.00 $0.00 $0.00 $0.00 $0.00 3571142015 SUP HCPCS C1713 3571142015 - PLATE BN 285MM STRL 15 HL BTRS CNDYL BOTH IP/OP "$2,682.75 " "$1,985.24" $0.00 "$2,146.20" "$1,207.24" "$1,207.24" $0.00 $0.00 $0.00 $559.15 "$1,991.14" "$1,991.14" $0.00 $0.00 $559.09 $0.00 "$1,322.60" "$1,322.60" $0.00 "$1,341.38" "$2,124.74" "$2,146.20" $0.00 $0.00 $419.85 $0.00 $0.00 $427.09 $0.00 $0.00 $0.00 $0.00 $0.00 3571142107 SUP HCPCS C1713 3571142107 - PLATE BN 158MM STRL 7 HL BTRS CNDYL BOTH IP/OP "$2,367.75 " "$1,752.14" $0.00 "$1,894.20" "$1,065.49" "$1,065.49" $0.00 $0.00 $0.00 $493.50 "$1,757.34" "$1,757.34" $0.00 $0.00 $493.44 $0.00 "$1,400.52" "$1,400.52" $0.00 "$1,183.88" "$1,875.26" "$1,894.20" $0.00 $0.00 $370.55 $0.00 $0.00 $376.95 $0.00 $0.00 $0.00 $0.00 $0.00 3571142109 SUP HCPCS C1713 3571142109 - PLATE BN 190MM STRL 9 HL BTRS CNDYL BOTH IP/OP "$2,026.50 " "$1,499.61" $0.00 "$1,621.20" $911.93 $911.93 $0.00 $0.00 $0.00 $422.37 "$1,504.07" "$1,504.07" $0.00 $0.00 $422.32 $0.00 "$1,198.67" "$1,198.67" $0.00 "$1,013.25" "$1,604.99" "$1,621.20" $0.00 $0.00 $317.15 $0.00 $0.00 $322.62 $0.00 $0.00 $0.00 $0.00 $0.00 3571142111 SUP HCPCS C1713 3571142111 - PLATE BN 221MM STRL 11 HL BTRS CNDYL BOTH IP/OP "$2,541.00 " "$1,880.34" $0.00 "$2,032.80" "$1,143.45" "$1,143.45" $0.00 $0.00 $0.00 $529.61 "$1,885.93" "$1,885.93" $0.00 $0.00 $529.54 $0.00 "$1,252.71" "$1,252.71" $0.00 "$1,270.50" "$2,012.47" "$2,032.80" $0.00 $0.00 $397.67 $0.00 $0.00 $404.53 $0.00 $0.00 $0.00 $0.00 $0.00 3571142113 SUP HCPCS C1713 3571142113 - PLATE BN 253MM STRL 13 HL BTRS CNDYL BOTH IP/OP "$2,604.00 " "$1,926.96" $0.00 "$2,083.20" "$1,171.80" "$1,171.80" $0.00 $0.00 $0.00 $542.74 "$1,932.69" "$1,932.69" $0.00 $0.00 $542.67 $0.00 "$1,283.77" "$1,283.77" $0.00 "$1,302.00" "$2,062.37" "$2,083.20" $0.00 $0.00 $407.53 $0.00 $0.00 $414.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571142115 SUP HCPCS C1713 3571142115 - PLATE BN 285MM STRL 15 HL BTRS CNDYL BOTH IP/OP "$2,682.75 " "$1,985.24" $0.00 "$2,146.20" "$1,207.24" "$1,207.24" $0.00 $0.00 $0.00 $559.15 "$1,991.14" "$1,991.14" $0.00 $0.00 $559.09 $0.00 "$1,322.60" "$1,322.60" $0.00 "$1,341.38" "$2,124.74" "$2,146.20" $0.00 $0.00 $419.85 $0.00 $0.00 $427.09 $0.00 $0.00 $0.00 $0.00 $0.00 3571143113 SUP HCPCS C1713 3571143113 - WASHER BN 13MM SS BOTH IP/OP $85.20 $63.05 $0.00 $68.16 $38.34 $38.34 $0.00 $0.00 $0.00 $17.76 $63.24 $63.24 $0.00 $0.00 $17.76 $0.00 $50.40 $50.40 $0.00 $42.60 $67.48 $68.16 $0.00 $0.00 $13.33 $0.00 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571145020 SUP HCPCS C1713 3571145020 - PLATE BN STRG STRL 20 HL SS CNDYL 1.5MM SCR BOTH IP/OP $570.15 $421.91 $0.00 $456.12 $256.57 $256.57 $0.00 $0.00 $0.00 $118.83 $423.17 $423.17 $0.00 $0.00 $118.82 $0.00 $337.24 $337.24 $0.00 $285.08 $451.56 $456.12 $0.00 $0.00 $89.23 $0.00 $0.00 $90.77 $0.00 $0.00 $0.00 $0.00 $0.00 3571145022 SUP HCPCS C1713 3571145022 - PLATE BN T 3X9 HL SS CNDYL 1.5MM SCR BOTH IP/OP $504.00 $372.96 $0.00 $403.20 $226.80 $226.80 $0.00 $0.00 $0.00 $105.05 $374.07 $374.07 $0.00 $0.00 $105.03 $0.00 $298.12 $298.12 $0.00 $252.00 $399.17 $403.20 $0.00 $0.00 $78.88 $0.00 $0.00 $80.24 $0.00 $0.00 $0.00 $0.00 $0.00 3571145024 SUP HCPCS C1713 3571145024 - PLATE BN T 4X9 HL SS CNDYL 1.5MM SCR BOTH IP/OP $534.45 $395.49 $0.00 $427.56 $240.50 $240.50 $0.00 $0.00 $0.00 $111.39 $396.67 $396.67 $0.00 $0.00 $111.38 $0.00 $316.13 $316.13 $0.00 $267.23 $423.28 $427.56 $0.00 $0.00 $83.64 $0.00 $0.00 $85.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571145026 SUP HCPCS C1713 3571145026 - PLATE BN 6 HL SS CNDYL LT 1.5 MM SCR BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 3571145028 SUP HCPCS C1713 3571145028 - PLATE BN 6 HL SS CNDYL RT 1.5 MM SCR BOTH IP/OP $708.75 $524.48 $0.00 $567.00 $318.94 $318.94 $0.00 $0.00 $0.00 $147.72 $526.03 $526.03 $0.00 $0.00 $147.70 $0.00 $419.23 $419.23 $0.00 $354.38 $561.33 $567.00 $0.00 $0.00 $110.92 $0.00 $0.00 $112.83 $0.00 $0.00 $0.00 $0.00 $0.00 3571145030 SUP HCPCS C1713 3571145030 - PLATE BN H STRL 4 HL CNDYL 1.5MM SCR BOTH IP/OP $406.35 $300.70 $0.00 $325.08 $182.86 $182.86 $0.00 $0.00 $0.00 $84.69 $301.59 $301.59 $0.00 $0.00 $84.68 $0.00 $240.36 $240.36 $0.00 $203.18 $321.83 $325.08 $0.00 $0.00 $63.59 $0.00 $0.00 $64.69 $0.00 $0.00 $0.00 $0.00 $0.00 3571146020 SUP HCPCS C1713 3571146020 - PLATE BN STRG 3 HL SS CNDYL 2MM SCR BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 3571146022 SUP HCPCS C1713 3571146022 - PLATE BN STRG 4 HL SS CNDYL 2MM SCR BOTH IP/OP $148.05 $109.56 $0.00 $118.44 $66.62 $66.62 $0.00 $0.00 $0.00 $30.86 $109.88 $109.88 $0.00 $0.00 $30.85 $0.00 $87.57 $87.57 $0.00 $74.03 $117.26 $118.44 $0.00 $0.00 $23.17 $0.00 $0.00 $23.57 $0.00 $0.00 $0.00 $0.00 $0.00 3571146024 SUP HCPCS C1713 3571146024 - PLATE BN STRG 5 HL SS CNDYL 2MM SCR BOTH IP/OP $159.60 $118.10 $0.00 $127.68 $71.82 $71.82 $0.00 $0.00 $0.00 $33.26 $118.46 $118.46 $0.00 $0.00 $33.26 $0.00 $94.40 $94.40 $0.00 $79.80 $126.40 $127.68 $0.00 $0.00 $24.98 $0.00 $0.00 $25.41 $0.00 $0.00 $0.00 $0.00 $0.00 3571146026 SUP HCPCS C1713 3571146026 - PLATE BN STRG STRL 6 HL CNDYL 2MM SCR BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 3571146028 SUP HCPCS C1713 3571146028 - PLATE BN STRG 20 HL SS CNDYL 2MM SCR BOTH IP/OP $568.05 $420.36 $0.00 $454.44 $255.62 $255.62 $0.00 $0.00 $0.00 $118.40 $421.61 $421.61 $0.00 $0.00 $118.38 $0.00 $336.00 $336.00 $0.00 $284.03 $449.90 $454.44 $0.00 $0.00 $88.90 $0.00 $0.00 $90.43 $0.00 $0.00 $0.00 $0.00 $0.00 3571146030 SUP HCPCS C1713 3571146030 - PLATE BN T 3X9 HL SS CNDYL 2MM SCR BOTH IP/OP $504.00 $372.96 $0.00 $403.20 $226.80 $226.80 $0.00 $0.00 $0.00 $105.05 $374.07 $374.07 $0.00 $0.00 $105.03 $0.00 $298.12 $298.12 $0.00 $252.00 $399.17 $403.20 $0.00 $0.00 $78.88 $0.00 $0.00 $80.24 $0.00 $0.00 $0.00 $0.00 $0.00 3571146032 SUP HCPCS C1713 3571146032 - PLATE BN T 4X9 HL SS CNDYL 2MM SCR BOTH IP/OP $534.45 $395.49 $0.00 $427.56 $240.50 $240.50 $0.00 $0.00 $0.00 $111.39 $396.67 $396.67 $0.00 $0.00 $111.38 $0.00 $316.13 $316.13 $0.00 $267.23 $423.28 $427.56 $0.00 $0.00 $83.64 $0.00 $0.00 $85.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571146034 SUP HCPCS C1713 3571146034 - PLATE BN T 2X2 HL SS CNDYL 2MM SCR BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 3571146036 SUP HCPCS C1713 3571146036 - PLATE BN L 3 HL OBLQ SS CNDYL RT 2MM SCR BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 3571146038 SUP HCPCS C1713 3571146038 - PLATE BN L 3 HL OBLQ SS CNDYL LT 2MM SCR BOTH IP/OP $134.40 $99.46 $0.00 $107.52 $60.48 $60.48 $0.00 $0.00 $0.00 $28.01 $99.75 $99.75 $0.00 $0.00 $28.01 $0.00 $79.50 $79.50 $0.00 $67.20 $106.44 $107.52 $0.00 $0.00 $21.03 $0.00 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 3571146040 SUP HCPCS C1713 3571146040 - PLATE BN 6 HL OBLQ SS CNDYL LT 2 MM SCR BOTH IP/OP $678.30 $501.94 $0.00 $542.64 $305.24 $305.24 $0.00 $0.00 $0.00 $141.37 $503.43 $503.43 $0.00 $0.00 $141.36 $0.00 $401.21 $401.21 $0.00 $339.15 $537.21 $542.64 $0.00 $0.00 $106.15 $0.00 $0.00 $107.99 $0.00 $0.00 $0.00 $0.00 $0.00 3571146042 SUP HCPCS C1713 3571146042 - PLATE BN 6 HL OBLQ SS CNDYL RT 2 MM SCR BOTH IP/OP $678.30 $501.94 $0.00 $542.64 $305.24 $305.24 $0.00 $0.00 $0.00 $141.37 $503.43 $503.43 $0.00 $0.00 $141.36 $0.00 $401.21 $401.21 $0.00 $339.15 $537.21 $542.64 $0.00 $0.00 $106.15 $0.00 $0.00 $107.99 $0.00 $0.00 $0.00 $0.00 $0.00 3571146048 SUP HCPCS C1713 3571146048 - PLATE BN H STRL 4 HL CNDYL 2MM SCR BOTH IP/OP $406.35 $300.70 $0.00 $325.08 $182.86 $182.86 $0.00 $0.00 $0.00 $84.69 $301.59 $301.59 $0.00 $0.00 $84.68 $0.00 $240.36 $240.36 $0.00 $203.18 $321.83 $325.08 $0.00 $0.00 $63.59 $0.00 $0.00 $64.69 $0.00 $0.00 $0.00 $0.00 $0.00 3571147001 SUP HCPCS C1713 3571147001 - PLATE BN L STRL CNDYL RT 2.7MM SCR BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 3571147002 SUP HCPCS C1713 3571147002 - PLATE BN L 3 HL OBLQ SS CNDYL LT 2.7MM SCR BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 3571147003 SUP HCPCS C1713 3571147003 - PLATE BN L STRL CNDYL LT 2.7MM SCR BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 3571147004 SUP HCPCS C1713 3571147004 - PLATE BN L 3 HL OBLQ SS CNDYL RT 2.7MM SCR BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 3571147006 SUP HCPCS C1713 3571147006 - PLATE BN T 3 HL SS CNDYL 2.7MM SCR BOTH IP/OP $142.80 $105.67 $0.00 $114.24 $64.26 $64.26 $0.00 $0.00 $0.00 $29.76 $105.99 $105.99 $0.00 $0.00 $29.76 $0.00 $84.47 $84.47 $0.00 $71.40 $113.10 $114.24 $0.00 $0.00 $22.35 $0.00 $0.00 $22.73 $0.00 $0.00 $0.00 $0.00 $0.00 3571147008 SUP HCPCS C1713 3571147008 - PLATE BN 6 HL SS CNDYL LT 2.7 MM SCR BOTH IP/OP $720.30 $533.02 $0.00 $576.24 $324.14 $324.14 $0.00 $0.00 $0.00 $150.13 $534.61 $534.61 $0.00 $0.00 $150.11 $0.00 $426.06 $426.06 $0.00 $360.15 $570.48 $576.24 $0.00 $0.00 $112.73 $0.00 $0.00 $114.67 $0.00 $0.00 $0.00 $0.00 $0.00 3571147010 SUP HCPCS C1713 3571147010 - PLATE BN 6 HL SS CNDYL RT 2.7 MM SCR BOTH IP/OP $720.30 $533.02 $0.00 $576.24 $324.14 $324.14 $0.00 $0.00 $0.00 $150.13 $534.61 $534.61 $0.00 $0.00 $150.11 $0.00 $426.06 $426.06 $0.00 $360.15 $570.48 $576.24 $0.00 $0.00 $112.73 $0.00 $0.00 $114.67 $0.00 $0.00 $0.00 $0.00 $0.00 3571147012 SUP HCPCS C1713 3571147012 - PLATE BN STRL 7 HL MLT FRAG CNDYL 2.7 MM SCR BOTH IP/OP $169.05 $125.10 $0.00 $135.24 $76.07 $76.07 $0.00 $0.00 $0.00 $35.23 $125.47 $125.47 $0.00 $0.00 $35.23 $0.00 $99.99 $99.99 $0.00 $84.53 $133.89 $135.24 $0.00 $0.00 $26.46 $0.00 $0.00 $26.91 $0.00 $0.00 $0.00 $0.00 $0.00 3571148003 SUP HCPCS C1713 3571148003 - PLATE BN STRL 3 HL QT TBLR SS CNDYL BOTH IP/OP $159.60 $118.10 $0.00 $127.68 $71.82 $71.82 $0.00 $0.00 $0.00 $33.26 $118.46 $118.46 $0.00 $0.00 $33.26 $0.00 $94.40 $94.40 $0.00 $79.80 $126.40 $127.68 $0.00 $0.00 $24.98 $0.00 $0.00 $25.41 $0.00 $0.00 $0.00 $0.00 $0.00 3571148004 SUP HCPCS C1713 3571148004 - PLATE BN 4 HL QT TBLR SS CNDYL BOTH IP/OP $175.35 $129.76 $0.00 $140.28 $78.91 $78.91 $0.00 $0.00 $0.00 $36.55 $130.14 $130.14 $0.00 $0.00 $36.54 $0.00 $103.72 $103.72 $0.00 $87.68 $138.88 $140.28 $0.00 $0.00 $27.44 $0.00 $0.00 $27.92 $0.00 $0.00 $0.00 $0.00 $0.00 3571148005 SUP HCPCS C1713 3571148005 - PLATE BN 5 HL QT TBLR SS CNDYL BOTH IP/OP $185.85 $137.53 $0.00 $148.68 $83.63 $83.63 $0.00 $0.00 $0.00 $38.74 $137.94 $137.94 $0.00 $0.00 $38.73 $0.00 $109.93 $109.93 $0.00 $92.93 $147.19 $148.68 $0.00 $0.00 $29.09 $0.00 $0.00 $29.59 $0.00 $0.00 $0.00 $0.00 $0.00 3571148006 SUP HCPCS C1713 3571148006 - PLATE BN 6 HL QT TBLR SS CNDYL BOTH IP/OP $205.80 $152.29 $0.00 $164.64 $92.61 $92.61 $0.00 $0.00 $0.00 $42.89 $152.74 $152.74 $0.00 $0.00 $42.89 $0.00 $121.73 $121.73 $0.00 $102.90 $162.99 $164.64 $0.00 $0.00 $32.21 $0.00 $0.00 $32.76 $0.00 $0.00 $0.00 $0.00 $0.00 3571148007 SUP HCPCS C1713 3571148007 - PLATE BN STRL 7 HL QT TBLR CNDYL BOTH IP/OP $214.20 $158.51 $0.00 $171.36 $96.39 $96.39 $0.00 $0.00 $0.00 $44.64 $158.98 $158.98 $0.00 $0.00 $44.64 $0.00 $126.70 $126.70 $0.00 $107.10 $169.65 $171.36 $0.00 $0.00 $33.52 $0.00 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571148008 SUP HCPCS C1713 3571148008 - PLATE BN STRL 8 HL QT TBLR CNDYL BOTH IP/OP $227.85 $168.61 $0.00 $182.28 $102.53 $102.53 $0.00 $0.00 $0.00 $47.49 $169.11 $169.11 $0.00 $0.00 $47.48 $0.00 $134.77 $134.77 $0.00 $113.93 $180.46 $182.28 $0.00 $0.00 $35.66 $0.00 $0.00 $36.27 $0.00 $0.00 $0.00 $0.00 $0.00 3571149106 SUP HCPCS C1713 3571149106 - SCREW BN 1.5MM 6MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149107 SUP HCPCS C1713 3571149107 - SCREW BN 1.5MM 7MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149108 SUP HCPCS C1713 3571149108 - SCREW BN 1.5MM 8MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149109 SUP HCPCS C1713 3571149109 - SCREW BN 1.5MM 9MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149110 SUP HCPCS C1713 3571149110 - SCREW BN 1.5MM 10MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149111 SUP HCPCS C1713 3571149111 - SCREW BN 1.5MM 11MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149112 SUP HCPCS C1713 3571149112 - SCREW BN 1.5MM 12MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149114 SUP HCPCS C1713 3571149114 - SCREW BN 1.5MM 14MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149116 SUP HCPCS C1713 3571149116 - SCREW BN 1.5MM 16MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149118 SUP HCPCS C1713 3571149118 - SCREW BN 1.5MM 18MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149120 SUP HCPCS C1713 3571149120 - SCREW BN 1.5MM 20MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149122 SUP HCPCS C1713 3571149122 - SCREW BN 1.5MM 22MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149124 SUP HCPCS C1713 3571149124 - SCREW BN 1.5MM 24MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $77.55 $57.39 $0.00 $62.04 $34.90 $34.90 $0.00 $0.00 $0.00 $16.16 $57.56 $57.56 $0.00 $0.00 $16.16 $0.00 $45.87 $45.87 $0.00 $38.78 $61.42 $62.04 $0.00 $0.00 $12.14 $0.00 $0.00 $12.35 $0.00 $0.00 $0.00 $0.00 $0.00 3571149306 SUP HCPCS C1713 3571149306 - SCREW BN 2MM 6MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149308 SUP HCPCS C1713 3571149308 - SCREW BN 2MM 8MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149310 SUP HCPCS C1713 3571149310 - SCREW BN 2MM 10MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149312 SUP HCPCS C1713 3571149312 - SCREW BN 2MM 12MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149314 SUP HCPCS C1713 3571149314 - SCREW BN 2MM 14MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149316 SUP HCPCS C1713 3571149316 - SCREW BN 2MM 16MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149318 SUP HCPCS C1713 3571149318 - SCREW BN 2MM 18MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149320 SUP HCPCS C1713 3571149320 - SCREW BN 2MM 20MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149322 SUP HCPCS C1713 3571149322 - SCREW BN 2MM 22MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149324 SUP HCPCS C1713 3571149324 - SCREW BN 2MM 24MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149326 SUP HCPCS C1713 3571149326 - SCREW BN 2MM 26MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149328 SUP HCPCS C1713 3571149328 - SCREW BN 2MM 28MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149330 SUP HCPCS C1713 3571149330 - SCREW BN 2MM 30MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $79.43 $58.78 $0.00 $63.54 $35.74 $35.74 $0.00 $0.00 $0.00 $16.55 $58.95 $58.95 $0.00 $0.00 $16.55 $0.00 $46.98 $46.98 $0.00 $39.71 $62.91 $63.54 $0.00 $0.00 $12.43 $0.00 $0.00 $12.64 $0.00 $0.00 $0.00 $0.00 $0.00 3571149406 SUP HCPCS C1713 3571149406 - SCREW BN 2.7MM 6MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149408 SUP HCPCS C1713 3571149408 - SCREW BN 2.7MM 8MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149410 SUP HCPCS C1713 3571149410 - SCREW BN 2.7MM 10MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149412 SUP HCPCS C1713 3571149412 - SCREW BN 2.7MM 12MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149414 SUP HCPCS C1713 3571149414 - SCREW BN 2.7MM 14MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149416 SUP HCPCS C1713 3571149416 - SCREW BN 2.7MM 16MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149418 SUP HCPCS C1713 3571149418 - SCREW BN 2.7MM 18MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149420 SUP HCPCS C1713 3571149420 - SCREW BN 2.7MM 20MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149422 SUP HCPCS C1713 3571149422 - SCREW BN 2.7MM 22MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149424 SUP HCPCS C1713 3571149424 - SCREW BN 2.7MM 24MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149426 SUP HCPCS C1713 3571149426 - SCREW BN 2.7MM 26MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149428 SUP HCPCS C1713 3571149428 - SCREW BN 2.7MM 28MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149430 SUP HCPCS C1713 3571149430 - SCREW BN 2.7MM 30MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149432 SUP HCPCS C1713 3571149432 - SCREW BN 2.7MM 32MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149434 SUP HCPCS C1713 3571149434 - SCREW BN 2.7MM 34MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149436 SUP HCPCS C1713 3571149436 - SCREW BN 2.7MM 36MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149440 SUP HCPCS C1713 3571149440 - SCREW BN 2.7MM 40MM STRL TC100 HEX HD ST SS CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149445 SUP HCPCS C1713 3571149445 - SCREW BN 2.7MM 45MM STRL HEX HD ST CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149450 SUP HCPCS C1713 3571149450 - SCREW BN 2.7MM 50MM STRL HEX HD ST CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149455 SUP HCPCS C1713 3571149455 - SCREW BN 2.7MM 55MM STRL HEX HD ST CORT BOTH IP/OP $69.73 $51.60 $0.00 $55.78 $31.38 $31.38 $0.00 $0.00 $0.00 $14.53 $51.75 $51.75 $0.00 $0.00 $14.53 $0.00 $41.24 $41.24 $0.00 $34.86 $55.23 $55.78 $0.00 $0.00 $10.91 $0.00 $0.00 $11.10 $0.00 $0.00 $0.00 $0.00 $0.00 3571149510 SUP HCPCS C1713 3571149510 - SCREW BN 3.5MM 10MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149512 SUP HCPCS C1713 3571149512 - SCREW BN 3.5MM 12MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149514 SUP HCPCS C1713 3571149514 - SCREW BN 3.5MM 14MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149516 SUP HCPCS C1713 3571149516 - SCREW BN 3.5MM 16MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149518 SUP HCPCS C1713 3571149518 - SCREW BN 3.5MM 18MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149520 SUP HCPCS C1713 3571149520 - SCREW BN 3.5MM 20MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149522 SUP HCPCS C1713 3571149522 - SCREW BN 3.5MM 22MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149524 SUP HCPCS C1713 3571149524 - SCREW BN 3.5MM 24MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149526 SUP HCPCS C1713 3571149526 - SCREW BN 3.5MM 26MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149528 SUP HCPCS C1713 3571149528 - SCREW BN 3.5MM 28MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149530 SUP HCPCS C1713 3571149530 - SCREW BN 3.5MM 30MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149532 SUP HCPCS C1713 3571149532 - SCREW BN 3.5MM 32MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149534 SUP HCPCS C1713 3571149534 - SCREW BN 3.5MM 34MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149536 SUP HCPCS C1713 3571149536 - SCREW BN 3.5MM 36MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149538 SUP HCPCS C1713 3571149538 - SCREW BN 3.5MM 38MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149540 SUP HCPCS C1713 3571149540 - SCREW BN 3.5MM 40MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149545 SUP HCPCS C1713 3571149545 - SCREW BN 3.5MM 45MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149550 SUP HCPCS C1713 3571149550 - SCREW BN 3.5MM 50MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149555 SUP HCPCS C1713 3571149555 - SCREW BN 3.5MM 55MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149560 SUP HCPCS C1713 3571149560 - SCREW BN 3.5MM 60MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149565 SUP HCPCS C1713 3571149565 - SCREW BN 3.5MM 65MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149570 SUP HCPCS C1713 3571149570 - SCREW BN 3.5MM 70MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149575 SUP HCPCS C1713 3571149575 - SCREW BN 3.5MM 75MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149580 SUP HCPCS C1713 3571149580 - SCREW BN 3.5MM 80MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149585 SUP HCPCS C1713 3571149585 - SCREW BN 3.5MM 85MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149590 SUP HCPCS C1713 3571149590 - SCREW BN 3.5MM 90MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149595 SUP HCPCS C1713 3571149595 - SCREW BN 3.5MM 95MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149600 SUP HCPCS C1713 3571149600 - SCREW BN 3.5MM 100MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149605 SUP HCPCS C1713 3571149605 - SCREW BN 3.5MM 105MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149610 SUP HCPCS C1713 3571149610 - SCREW BN 3.5MM 110MM STRL HEX HD ST CORT BOTH IP/OP $91.45 $67.67 $0.00 $73.16 $41.15 $41.15 $0.00 $0.00 $0.00 $19.06 $67.87 $67.87 $0.00 $0.00 $19.06 $0.00 $54.09 $54.09 $0.00 $45.73 $72.43 $73.16 $0.00 $0.00 $14.31 $0.00 $0.00 $14.56 $0.00 $0.00 $0.00 $0.00 $0.00 3571149615 SUP HCPCS C1713 3571149615 - SCREW BN 3.5MM 115MM STRL HEX HD ST CORT BOTH IP/OP $93.35 $69.08 $0.00 $74.68 $42.01 $42.01 $0.00 $0.00 $0.00 $19.46 $69.28 $69.28 $0.00 $0.00 $19.45 $0.00 $55.22 $55.22 $0.00 $46.68 $73.93 $74.68 $0.00 $0.00 $14.61 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 3571149620 SUP HCPCS C1713 3571149620 - SCREW BN 3.5MM 120MM STRL HEX HD ST CORT BOTH IP/OP $93.35 $69.08 $0.00 $74.68 $42.01 $42.01 $0.00 $0.00 $0.00 $19.46 $69.28 $69.28 $0.00 $0.00 $19.45 $0.00 $55.22 $55.22 $0.00 $46.68 $73.93 $74.68 $0.00 $0.00 $14.61 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 3571149625 SUP HCPCS C1713 3571149625 - SCREW BN 3.5MM 125MM STRL HEX HD ST CORT BOTH IP/OP $93.35 $69.08 $0.00 $74.68 $42.01 $42.01 $0.00 $0.00 $0.00 $19.46 $69.28 $69.28 $0.00 $0.00 $19.45 $0.00 $55.22 $55.22 $0.00 $46.68 $73.93 $74.68 $0.00 $0.00 $14.61 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 3571149630 SUP HCPCS C1713 3571149630 - SCREW BN 3.5MM 130MM STRL HEX HD ST CORT BOTH IP/OP $93.35 $69.08 $0.00 $74.68 $42.01 $42.01 $0.00 $0.00 $0.00 $19.46 $69.28 $69.28 $0.00 $0.00 $19.45 $0.00 $55.22 $55.22 $0.00 $46.68 $73.93 $74.68 $0.00 $0.00 $14.61 $0.00 $0.00 $14.86 $0.00 $0.00 $0.00 $0.00 $0.00 3571149714 SUP HCPCS C1713 3571149714 - SCREW BN 4.5MM 14MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149716 SUP HCPCS C1713 3571149716 - SCREW BN 4.5MM 16MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149718 SUP HCPCS C1713 3571149718 - SCREW BN 4.5MM 18MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149720 SUP HCPCS C1713 3571149720 - SCREW BN 4.5MM 20MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149722 SUP HCPCS C1713 3571149722 - SCREW BN 4.5MM 22MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149724 SUP HCPCS C1713 3571149724 - SCREW BN 4.5MM 24MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149726 SUP HCPCS C1713 3571149726 - SCREW BN 4.5MM 26MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149728 SUP HCPCS C1713 3571149728 - SCREW BN 4.5MM 28MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149730 SUP HCPCS C1713 3571149730 - SCREW BN 4.5MM 30MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149732 SUP HCPCS C1713 3571149732 - SCREW BN 4.5MM 32MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149734 SUP HCPCS C1713 3571149734 - SCREW BN 4.5MM 34MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149736 SUP HCPCS C1713 3571149736 - SCREW BN 4.5MM 36MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149738 SUP HCPCS C1713 3571149738 - SCREW BN 4.5MM 38MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149740 SUP HCPCS C1713 3571149740 - SCREW BN 4.5MM 40MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149742 SUP HCPCS C1713 3571149742 - SCREW BN 4.5MM 42MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149744 SUP HCPCS C1713 3571149744 - SCREW BN 4.5MM 44MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149746 SUP HCPCS C1713 3571149746 - SCREW BN 4.5MM 46MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149748 SUP HCPCS C1713 3571149748 - SCREW BN 4.5MM 48MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149750 SUP HCPCS C1713 3571149750 - SCREW BN 4.5MM 50MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149752 SUP HCPCS C1713 3571149752 - SCREW BN 4.5MM 52MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149754 SUP HCPCS C1713 3571149754 - SCREW BN 4.5MM 54MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149756 SUP HCPCS C1713 3571149756 - SCREW BN 4.5MM 56MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149758 SUP HCPCS C1713 3571149758 - SCREW BN 4.5MM 58MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149760 SUP HCPCS C1713 3571149760 - SCREW BN 4.5MM 60MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149762 SUP HCPCS C1713 3571149762 - SCREW BN 4.5MM 62MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149764 SUP HCPCS C1713 3571149764 - SCREW BN 4.5MM 64MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149766 SUP HCPCS C1713 3571149766 - SCREW BN 4.5MM 66MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149768 SUP HCPCS C1713 3571149768 - SCREW BN 4.5MM 68MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149770 SUP HCPCS C1713 3571149770 - SCREW BN 4.5MM 70MM STRL HEX HD ST CORT BOTH IP/OP $75.70 $56.02 $0.00 $60.56 $34.07 $34.07 $0.00 $0.00 $0.00 $15.78 $56.18 $56.18 $0.00 $0.00 $15.78 $0.00 $44.78 $44.78 $0.00 $37.85 $59.95 $60.56 $0.00 $0.00 $11.85 $0.00 $0.00 $12.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571149772 SUP HCPCS C1713 3571149772 - SCREW BN 4.5MM 72MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149776 SUP HCPCS C1713 3571149776 - SCREW BN 4.5MM 76MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149780 SUP HCPCS C1713 3571149780 - SCREW BN 4.5MM 80MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149785 SUP HCPCS C1713 3571149785 - SCREW BN 4.5MM 85MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149790 SUP HCPCS C1713 3571149790 - SCREW BN 4.5MM 90MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149795 SUP HCPCS C1713 3571149795 - SCREW BN 4.5MM 95MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149800 SUP HCPCS C1713 3571149800 - SCREW BN 4.5MM 100MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149805 SUP HCPCS C1713 3571149805 - SCREW BN 4.5MM 105MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149810 SUP HCPCS C1713 3571149810 - SCREW BN 4.5MM 110MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149815 SUP HCPCS C1713 3571149815 - SCREW BN 4.5MM 115MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149820 SUP HCPCS C1713 3571149820 - SCREW BN 4.5MM 120MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149825 SUP HCPCS C1713 3571149825 - SCREW BN 4.5MM 125MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149830 SUP HCPCS C1713 3571149830 - SCREW BN 4.5MM 130MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149835 SUP HCPCS C1713 3571149835 - SCREW BN 4.5MM 135MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149840 SUP HCPCS C1713 3571149840 - SCREW BN 4.5MM 140MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571149845 SUP HCPCS C1713 3571149845 - SCREW BN 4.5MM 145MM STRL HEX HD ST CORT BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $56.70 $56.70 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $19.72 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 3571223010 SUP HCPCS C1713 3571223010 - SCREW BN FT 4MM 10MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223012 SUP HCPCS C1713 3571223012 - SCREW BN FT 4MM 12MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223014 SUP HCPCS C1713 3571223014 - SCREW BN FT 4MM 14MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223016 SUP HCPCS C1713 3571223016 - SCREW BN FT 4MM 16MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223018 SUP HCPCS C1713 3571223018 - SCREW BN FT 4MM 18MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223020 SUP HCPCS C1713 3571223020 - SCREW BN FT 4MM 20MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223022 SUP HCPCS C1713 3571223022 - SCREW BN FT 4MM 22MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223024 SUP HCPCS C1713 3571223024 - SCREW BN FT 4MM 24MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223026 SUP HCPCS C1713 3571223026 - SCREW BN FT 4MM 26MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223028 SUP HCPCS C1713 3571223028 - SCREW BN FT 4MM 28MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223030 SUP HCPCS C1713 3571223030 - SCREW BN FT 4MM 30MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223035 SUP HCPCS C1713 3571223035 - SCREW BN FT 4MM 35MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223040 SUP HCPCS C1713 3571223040 - SCREW BN FT 4MM 40MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223045 SUP HCPCS C1713 3571223045 - SCREW BN FT 4MM 45MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223050 SUP HCPCS C1713 3571223050 - SCREW BN FT 4MM 50MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223055 SUP HCPCS C1713 3571223055 - SCREW BN FT 4MM 55MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223060 SUP HCPCS C1713 3571223060 - SCREW BN FT 4MM 60MM STRL CANC BOTH IP/OP $57.03 $42.20 $0.00 $45.62 $25.66 $25.66 $0.00 $0.00 $0.00 $11.89 $42.32 $42.32 $0.00 $0.00 $11.88 $0.00 $33.73 $33.73 $0.00 $28.51 $45.17 $45.62 $0.00 $0.00 $8.92 $0.00 $0.00 $9.08 $0.00 $0.00 $0.00 $0.00 $0.00 3571223210 SUP HCPCS C1713 3571223210 - SCREW BN P/T 4MM 10MM STRL CANC BOTH IP/OP $55.08 $40.76 $0.00 $44.06 $24.78 $24.78 $0.00 $0.00 $0.00 $11.48 $40.88 $40.88 $0.00 $0.00 $11.48 $0.00 $32.58 $32.58 $0.00 $27.54 $43.62 $44.06 $0.00 $0.00 $8.62 $0.00 $0.00 $8.77 $0.00 $0.00 $0.00 $0.00 $0.00 3571223212 SUP HCPCS C1713 3571223212 - SCREW BN P/T 4MM 12MM STRL CANC BOTH IP/OP $55.08 $40.76 $0.00 $44.06 $24.78 $24.78 $0.00 $0.00 $0.00 $11.48 $40.88 $40.88 $0.00 $0.00 $11.48 $0.00 $32.58 $32.58 $0.00 $27.54 $43.62 $44.06 $0.00 $0.00 $8.62 $0.00 $0.00 $8.77 $0.00 $0.00 $0.00 $0.00 $0.00 3571223214 SUP HCPCS C1713 3571223214 - SCREW BN P/T 4MM 14MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223216 SUP HCPCS C1713 3571223216 - SCREW BN P/T 4MM 16MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223218 SUP HCPCS C1713 3571223218 - SCREW BN P/T 4MM 18MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223220 SUP HCPCS C1713 3571223220 - SCREW BN P/T 4MM 20MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223222 SUP HCPCS C1713 3571223222 - SCREW BN P/T 4MM 22MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223226 SUP HCPCS C1713 3571223226 - SCREW BN P/T 4MM 26MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223228 SUP HCPCS C1713 3571223228 - SCREW BN P/T 4MM 28MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223230 SUP HCPCS C1713 3571223230 - SCREW BN P/T 4MM 30MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223235 SUP HCPCS C1713 3571223235 - SCREW BN P/T 4MM 35MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223240 SUP HCPCS C1713 3571223240 - SCREW BN P/T 4MM 40MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223245 SUP HCPCS C1713 3571223245 - SCREW BN P/T 4MM 45MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571223250 SUP HCPCS C1713 3571223250 - SCREW BN P/T 4MM 50MM STRL CANC BOTH IP/OP $36.75 $27.20 $0.00 $29.40 $16.54 $16.54 $0.00 $0.00 $0.00 $7.66 $27.28 $27.28 $0.00 $0.00 $7.66 $0.00 $21.74 $21.74 $0.00 $18.38 $29.11 $29.40 $0.00 $0.00 $5.75 $0.00 $0.00 $5.85 $0.00 $0.00 $0.00 $0.00 $0.00 3571226030 SUP HCPCS C1713 3571226030 - SCREW BN 6.5MM 30MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226035 SUP HCPCS C1713 3571226035 - SCREW BN 6.5MM 35MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226040 SUP HCPCS C1713 3571226040 - SCREW BN 6.5MM 40MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226045 SUP HCPCS C1713 3571226045 - SCREW BN 6.5MM 45MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226050 SUP HCPCS C1713 3571226050 - SCREW BN 6.5MM 50MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226055 SUP HCPCS C1713 3571226055 - SCREW BN 6.5MM 55MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226060 SUP HCPCS C1713 3571226060 - SCREW BN 6.5MM 60MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226065 SUP HCPCS C1713 3571226065 - SCREW BN 6.5MM 65MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226070 SUP HCPCS C1713 3571226070 - SCREW BN 6.5MM 70MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226075 SUP HCPCS C1713 3571226075 - SCREW BN 6.5MM 75MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226080 SUP HCPCS C1713 3571226080 - SCREW BN 6.5MM 80MM STRL 16MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571226085 SUP HCPCS C1713 3571226085 - SCREW BN 6.5MM 85MM STRL 16MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571226090 SUP HCPCS C1713 3571226090 - SCREW BN 6.5MM 90MM STRL 16MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571226095 SUP HCPCS C1713 3571226095 - SCREW BN 6.5MM 95MM STRL 16MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571226100 SUP HCPCS C1713 3571226100 - SCREW BN 6.5MM 100MM STRL 16MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571226105 SUP HCPCS C1713 3571226105 - SCREW BN 6.5MM 105MM STRL 16MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571226110 SUP HCPCS C1713 3571226110 - SCREW BN 6.5MM 110MM STRL 16MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571228045 SUP HCPCS C1713 3571228045 - SCREW BN 6.5MM 45MM STRL 32MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571228050 SUP HCPCS C1713 3571228050 - SCREW BN 6.5MM 50MM STRL 32MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571228055 SUP HCPCS C1713 3571228055 - SCREW BN 6.5MM 55MM STRL 32MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571228060 SUP HCPCS C1713 3571228060 - SCREW BN 6.5MM 60MM STRL 32MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571228065 SUP HCPCS C1713 3571228065 - SCREW BN 6.5MM 65MM STRL 32MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571228070 SUP HCPCS C1713 3571228070 - SCREW BN 6.5MM 70MM STRL 32MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571228075 SUP HCPCS C1713 3571228075 - SCREW BN 6.5MM 75MM STRL 32MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571228080 SUP HCPCS C1713 3571228080 - SCREW BN 6.5MM 80MM STRL 32MM THRD CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571228085 SUP HCPCS C1713 3571228085 - SCREW BN 6.5MM 85MM STRL 32MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571228090 SUP HCPCS C1713 3571228090 - SCREW BN 6.5MM 90MM STRL 32MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571228095 SUP HCPCS C1713 3571228095 - SCREW BN 6.5MM 95MM STRL 32MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571228100 SUP HCPCS C1713 3571228100 - SCREW BN 6.5MM 100MM STRL 32MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571228105 SUP HCPCS C1713 3571228105 - SCREW BN 6.5MM 105MM STRL 32MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571228110 SUP HCPCS C1713 3571228110 - SCREW BN 6.5MM 110MM STRL 32MM THRD CANC BOTH IP/OP $124.95 $92.46 $0.00 $99.96 $56.23 $56.23 $0.00 $0.00 $0.00 $26.04 $92.74 $92.74 $0.00 $0.00 $26.04 $0.00 $73.91 $73.91 $0.00 $62.48 $98.96 $99.96 $0.00 $0.00 $19.55 $0.00 $0.00 $19.89 $0.00 $0.00 $0.00 $0.00 $0.00 3571229025 SUP HCPCS C1713 3571229025 - SCREW BN FT 6.5MM 25MM STRL CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571229030 SUP HCPCS C1713 3571229030 - SCREW BN FT 6.5MM 30MM STRL CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571229035 SUP HCPCS C1713 3571229035 - SCREW BN FT 6.5MM 35MM STRL CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571229040 SUP HCPCS C1713 3571229040 - SCREW BN FT 6.5MM 40MM STRL CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571229045 SUP HCPCS C1713 3571229045 - SCREW BN FT 6.5MM 45MM STRL CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571229050 SUP HCPCS C1713 3571229050 - SCREW BN FT 6.5MM 50MM STRL CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571229055 SUP HCPCS C1713 3571229055 - SCREW BN FT 6.5MM 55MM STRL CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 3571229060 SUP HCPCS C1713 3571229060 - SCREW BN FT 6.5MM 60MM STRL CANC BOTH IP/OP $113.40 $83.92 $0.00 $90.72 $51.03 $51.03 $0.00 $0.00 $0.00 $23.64 $84.17 $84.17 $0.00 $0.00 $23.63 $0.00 $67.08 $67.08 $0.00 $56.70 $89.81 $90.72 $0.00 $0.00 $17.75 $0.00 $0.00 $18.05 $0.00 $0.00 $0.00 $0.00 $0.00 4823714020 SUP HCPCS C1713 4823714020 - SCREW BONE 4MM 20MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714025 SUP HCPCS C1713 4823714025 - SCREW BONE 4MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714030 SUP HCPCS C1713 4823714030 - SCREW BONE 4MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714035 SUP HCPCS C1713 4823714035 - SCREW BONE 4MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714040 SUP HCPCS C1713 4823714040 - SCREW BONE 4MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714045 SUP HCPCS C1713 4823714045 - SCREW BONE 4MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714520 SUP HCPCS C1713 4823714520 - SCREW BONE 4.5MM 20MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714525 SUP HCPCS C1713 4823714525 - SCREW BONE 4.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714530 SUP HCPCS C1713 4823714530 - SCREW BONE 4.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714535 SUP HCPCS C1713 4823714535 - SCREW BONE 4.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714540 SUP HCPCS C1713 4823714540 - SCREW BONE 4.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823714545 SUP HCPCS C1713 4823714545 - SCREW BONE 4.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715020 SUP HCPCS C1713 4823715020 - SCREW BONE 5MM 20MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715025 SUP HCPCS C1713 4823715025 - SCREW BONE 5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715030 SUP HCPCS C1713 4823715030 - SCREW BONE 5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715035 SUP HCPCS C1713 4823715035 - SCREW BONE 5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715040 SUP HCPCS C1713 4823715040 - SCREW BONE 5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715045 SUP HCPCS C1713 4823715045 - SCREW BONE 5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715050 SUP HCPCS C1713 4823715050 - SCREW BONE 5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715525 SUP HCPCS C1713 4823715525 - SCREW BONE 5.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715530 SUP HCPCS C1713 4823715530 - SCREW BONE 5.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715535 SUP HCPCS C1713 4823715535 - SCREW BONE 5.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715540 SUP HCPCS C1713 4823715540 - SCREW BONE 5.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715545 SUP HCPCS C1713 4823715545 - SCREW BONE 5.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715550 SUP HCPCS C1713 4823715550 - SCREW BONE 5.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823715555 SUP HCPCS C1713 4823715555 - SCREW BONE 5.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716525 SUP HCPCS C1713 4823716525 - SCREW BONE 6.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716530 SUP HCPCS C1713 4823716530 - SCREW BONE 6.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716535 SUP HCPCS C1713 4823716535 - SCREW BONE 6.5MM 35MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716540 SUP HCPCS C1713 4823716540 - SCREW BONE 6.5MM 40MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716545 SUP HCPCS C1713 4823716545 - SCREW BONE 6.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716550 SUP HCPCS C1713 4823716550 - SCREW BONE 6.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716555 SUP HCPCS C1713 4823716555 - SCREW BONE 6.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716560 SUP HCPCS C1713 4823716560 - SCREW BONE 6.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716565 SUP HCPCS C1713 4823716565 - SCREW BONE 6.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716570 SUP HCPCS C1713 4823716570 - SCREW BONE 6.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716580 SUP HCPCS C1713 4823716580 - SCREW BONE 6.5MM 80MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823716590 SUP HCPCS C1713 4823716590 - SCREW BONE 6.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717525 SUP HCPCS C1713 4823717525 - SCREW BONE 7.5MM 25MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717530 SUP HCPCS C1713 4823717530 - SCREW BONE 7.5MM 30MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717535 SUP HCPCS C1713 4823717535 - SCREW BONE 7.5MM 35MM REVISION POLYAX MEDIAL BIASED BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717540 SUP HCPCS C1713 4823717540 - SCREW BONE 7.5MM 40MM REVISION POLYAX MEDIAL BIASED BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717545 SUP HCPCS C1713 4823717545 - SCREW BONE 7.5MM 45MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717550 SUP HCPCS C1713 4823717550 - SCREW BONE 7.5MM 50MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717555 SUP HCPCS C1713 4823717555 - SCREW BONE 7.5MM 55MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717560 SUP HCPCS C1713 4823717560 - SCREW BONE 7.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717565 SUP HCPCS C1713 4823717565 - SCREW BONE 7.5MM 65MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717570 SUP HCPCS C1713 4823717570 - SCREW BONE 7.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717580 SUP HCPCS C1713 4823717580 - SCREW BONE 7.5MM 80MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823717590 SUP HCPCS C1713 4823717590 - SCREW BONE 7.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823718500 SUP HCPCS C1713 4823718500 - SCREW BONE 8.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823718560 SUP HCPCS C1713 4823718560 - SCREW BONE 8.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823718570 SUP HCPCS C1713 4823718570 - SCREW BONE 8.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823718580 SUP HCPCS C1713 4823718580 - SCREW BONE 8.5MM 80MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823718590 SUP HCPCS C1713 4823718590 - SCREW BONE 8.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823719500 SUP HCPCS C1713 4823719500 - SCREW BONE 9.5MM 100MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823719560 SUP HCPCS C1713 4823719560 - SCREW BONE 9.5MM 60MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823719570 SUP HCPCS C1713 4823719570 - SCREW BONE 9.5MM 70MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823719580 SUP HCPCS C1713 4823719580 - SCREW BONE 9.5MM 80MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 4823719590 SUP HCPCS C1713 4823719590 - SCREW BONE 9.5MM 90MM REVISION POLYAX ILIOSACRAL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 5100060001 SUP Custom 27203010 5100060001 - BIT DRILL LARGE 14MM PERFORATOR HUDSON END SHARP CRANIAL BOTH IP/OP $474.38 $351.04 $0.00 $379.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.08 $352.08 $0.00 $0.00 $98.86 $0.00 $0.00 $0.00 $0.00 $237.19 $375.71 $379.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5130020060 SUP Custom 27203010 5130020060 - BURR SURG LONG 6MM 7.9MM DRUM FLUTED BOTH IP/OP $244.38 $180.84 $0.00 $195.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.38 $181.38 $0.00 $0.00 $50.93 $0.00 $0.00 $0.00 $0.00 $122.19 $193.55 $195.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5130130250 SUP Custom 27203010 5130130250 - BURR SURG LONG .8MM 25.4MM DISK DIAMOND STERILE BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5220030575 SUP Custom 27203010 5220030575 - BURR SURG MEDIUM 7.5MM PRECISION ACORN BOTH IP/OP $488.75 $361.68 $0.00 $391.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $362.75 $362.75 $0.00 $0.00 $101.86 $0.00 $0.00 $0.00 $0.00 $244.38 $387.09 $391.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5450800303 SUP Custom 27203010 5450800303 - TIP ASPIRAT 25KHZ SUPERLONG SPETZLER MICRO CLAW BONE BOTH IP/OP "$10,675.00 " "$7,899.50" $0.00 "$8,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,224.67" $0.00 $0.00 $0.00 $0.00 "$5,337.50" "$8,454.60" "$8,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5450800306 SUP Custom 27203010 5450800306 - TIP ASPIRAT 25KHZ UNIVERSAL ULTRASONIC LARGE DIAMETER SOFT BOTH IP/OP "$8,455.28 " "$6,256.91" $0.00 "$6,764.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,762.08" $0.00 $0.00 $0.00 $0.00 "$4,227.64" "$6,696.58" "$6,764.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5450800307 SUP Custom 27203010 5450800307 - TIP ASPIRAT 25KHZ UNIVERSAL STR SONOPET DISPOSABLE BOTH IP/OP "$7,750.00 " "$5,735.00" $0.00 "$6,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,615.10" $0.00 $0.00 $0.00 $0.00 "$3,875.00" "$6,138.00" "$6,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5450800308 SUP Custom 27203010 5450800308 - TIP ASP LG DIA STRG 4.6IN STRL LF SONOPET SFT TIS DISP BOTH IP/OP "$1,649.99 " "$1,220.99" $0.00 "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $0.00 $0.00 $0.00 $825.00 "$1,306.79" "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820009060 SUP Custom 27203010 5820009060 - BURR SURG ROUND 6MM PRECISION BOTH IP/OP $505.88 $374.35 $0.00 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.46 $375.46 $0.00 $0.00 $105.42 $0.00 $0.00 $0.00 $0.00 $252.94 $400.66 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820009075 SUP Custom 27203010 5820009075 - BURR SURG ROUND 7.5MM RIM GLIDE PRECISION BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820010010 SUP Custom 27203010 5820010010 - BURR SURG ROUND FLUTE 1MM TPS ELITE BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820010125 SUP Custom 27203010 5820010125 - BURR SURG 2.5MM ROUND SOFT TOUCH FLUTED ELITE STERILE BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820010130 SUP Custom 27203010 5820010130 - BURR SURG 3MM TPS ELT OSTN RND FLUT SFTCH 5 NTCH BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820010150 SUP Custom 27203010 5820010150 - BURR SURG ROUND FLUTE 5MM 5 NOTCH SOFT TOUCH SMOOTH CUT GOOD BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820010160 SUP Custom 27203010 5820010160 - BURR SURG ROUND FLUTE 6MM SOFT TOUCH ROUND FLUTED AGGRESSIVE BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820010170 SUP Custom 27203010 5820010170 - BURR SURG 7MM ROUND SOFT TOUCH ELITE STERILE BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820012010 SUP Custom 27203010 5820012010 - BURR SURG ROUND 1MM ROUND HEAD CUTTING TPS ELITE DIAMOND BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820012020 SUP Custom 27203010 5820012020 - BURR SRG RND 2MM TPS ELT DMD BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820012025 SUP Custom 27203010 5820012025 - BURR SURG ROUND 2.5MM TPS ELITE DIAMOND BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820012050 SUP Custom 27203010 5820012050 - BURR SURG DIAMOND 5MM 5 STEP NOTCH NUMBER SAFETY MARK CUT BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820012060 SUP Custom 27203010 5820012060 - BURR SURG ROUND 6MM LATEX FREE ELITE DIAMOND STERILE BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820013060 SUP Custom 27203010 5820013060 - BURR SRG RND CRS DMD 6MM STRL LF TPS ELT DISP BOTH IP/OP $777.50 $575.35 $0.00 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.06 $577.06 $0.00 $0.00 $162.03 $0.00 $0.00 $0.00 $0.00 $388.75 $615.78 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820070011 SUP Custom 27203010 5820070011 - BURR SURG STR 1.1MM 6MM ROUTER STR BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820107020 SUP Custom 27203010 5820107020 - BURR SRG 2MM 3.1MM STRL LF MTCH HD SFTCH DISP NEURO BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820107120 SUP Custom 27203010 5820107120 - BURR SURG 2MM 3.1MM DIAMOND NEURO ELITE STERILE BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820107125 SUP Custom 27203010 5820107125 - BIT DRILL 2.5MM 3.4MM NEURO ELITE STERILE BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820107130 SUP Custom 27203010 5820107130 - BURR SURG 3MM 3.8MM DIAMOND NEURO ELITE STERILE BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6279409577 SUP Custom 27203010 6279409577 - DRESSING BURN ADH SIL NYL 15X10IN BBRN BOTH IP/OP $248.05 $183.56 $0.00 $198.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.10 $184.10 $0.00 $0.00 $51.69 $0.00 $0.00 $0.00 $0.00 $124.03 $196.46 $198.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6770200005 SUP Custom 27203010 6770200005 - FORCEPS BP .5MM 8IN SPTZLR MLS 2 IRR DISP BOTH IP/OP "$1,209.99 " $895.39 $0.00 $967.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.05 $898.05 $0.00 $0.00 $252.16 $0.00 $0.00 $0.00 $0.00 $605.00 $958.31 $967.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6770200010 SUP Custom 27203010 6770200010 - FORCEPS BP 1MM 8IN SPTZLR MLS 2 IRR DISP BOTH IP/OP "$1,135.50 " $840.27 $0.00 $908.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $842.77 $842.77 $0.00 $0.00 $236.64 $0.00 $0.00 $0.00 $0.00 $567.75 $899.32 $908.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065149527 SUP Custom 27203010 8065149527 - CANNULA OPHTHALMIC SHORT 23GA SOFT TIP STERILE DISPOSABLE BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $0.00 $0.00 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065149530 SUP Custom 27203010 8065149530 - CANNULA OPTH SHRT 25GA .8MM STRL GRSHBR SFTP DISP BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065740632 SUP Custom 27203010 8065740632 - PACK PHACO 30D RND .9MM STRL LF ABS LGC MXV DISP BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065741080 SUP Custom 27203010 8065741080 - PACK PHACO US BSC BOTH IP/OP $113.55 $84.03 $0.00 $90.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.28 $84.28 $0.00 $0.00 $23.66 $0.00 $0.00 $0.00 $0.00 $56.78 $89.93 $90.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065741089 SUP Custom 27203010 8065741089 - PACK PHACO 30D 1.1MM STRL INFNT RND US ABS TIP FLD MGMT SYS BOTH IP/OP $342.50 $253.45 $0.00 $274.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.20 $254.20 $0.00 $0.00 $71.38 $0.00 $0.00 $0.00 $0.00 $171.25 $271.26 $274.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065750157 SUP Custom 27203010 8065750157 - PACK VITRECTOMY INFINITI ANTERIOR STERILE DISPOSABLE BOTH IP/OP $434.00 $321.16 $0.00 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.11 $322.11 $0.00 $0.00 $90.45 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065750159 SUP Custom 27203010 8065750159 - KIT PHACOEMULSIFICATION .9MM SMALL PART MICROSMOOTH STERILE BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065751176 SUP Custom 27203010 8065751176 - TIP 30 DEG OZIL 12 PHACO BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $0.00 $0.00 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065751177 SUP Custom 27203010 8065751177 - TIP PHACOEMULSIFICATION 45D .9MM 12MM MINIFLARE OZIL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $0.00 $0.00 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065751576 SUP Custom 27203010 8065751576 - PROBE LASER 23GA ILLUMINATED PIK RFID BOTH IP/OP "$3,570.90 " "$2,642.47" $0.00 "$2,856.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,650.32" "$2,650.32" $0.00 $0.00 $744.18 $0.00 $0.00 $0.00 $0.00 "$1,785.45" "$2,828.15" "$2,856.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065751577 SUP Custom 27203010 8065751577 - ILLUMINATOR OPHTHALMIC 25GA RADIO FREQUENCY IDENTIFICATION BOTH IP/OP "$3,731.10 " "$2,761.01" $0.00 "$2,984.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,769.22" "$2,769.22" $0.00 $0.00 $777.56 $0.00 $0.00 $0.00 $0.00 "$1,865.55" "$2,955.03" "$2,984.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065751592 SUP Custom 27203010 8065751592 - PROBE LASER 78D 23GA 2IN ILLUMINATION CURVE TIP LARGE BOTH IP/OP "$2,760.00 " "$2,042.40" $0.00 "$2,208.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,048.47" "$2,048.47" $0.00 $0.00 $575.18 $0.00 $0.00 $0.00 $0.00 "$1,380.00" "$2,185.92" "$2,208.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065751593 SUP Custom 27203010 8065751593 - PROBE LASER 78D 25GA 2IN ILLUMINATION CURVE TIP LARGE BOTH IP/OP $540.75 $400.16 $0.00 "$2,595.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $0.00 $0.00 $0.00 "$1,622.25" "$2,569.64" "$2,595.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065751922 SUP Custom 27203010 8065751922 - SET OPHTHALMIC INTREPID IRRIGATION ASPIRATION BIMANUAL HANDP BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065752201 SUP Custom 27203010 8065752201 - PACK PHACO 45D .9MM STRL ABS TIP FLD MGMT SYS ULT SLV DISP BOTH IP/OP "$1,663.65 " "$1,231.10" $0.00 "$1,330.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,234.76" "$1,234.76" $0.00 $0.00 $346.70 $0.00 $0.00 $0.00 $0.00 $831.83 "$1,317.61" "$1,330.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065754003 SUP HCPCS L8610 8065754003 - SHUNT GLCM STRL LF CYPASS BOTH IP/OP "$3,962.50 " "$2,932.25" $0.00 "$3,170.00" "$1,783.13" "$1,783.13" $0.00 $0.00 $0.00 $825.88 "$2,940.97" "$2,940.97" $0.00 $0.00 $825.79 $0.00 "$1,953.51" "$1,953.51" $0.00 "$1,981.25" "$3,138.30" "$3,170.00" $0.00 $0.00 $620.13 $0.00 $0.00 $630.83 $0.00 $0.00 $0.00 $0.00 $0.00 8065817001 SUP Custom 27203010 8065817001 - TIP IRR/ASPIRAT .3MM ULFL 1 PC STR BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,224.63" "$1,224.63" $0.00 $0.00 $343.86 $0.00 $0.00 $0.00 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065900163 SUP Custom 27203010 8065900163 - KIT ACCESSORY PROCEDURAL LIQUID PERFLUORON BOTH IP/OP "$3,049.88 " "$2,256.91" $0.00 "$2,439.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,263.62" "$2,263.62" $0.00 $0.00 $635.59 $0.00 $0.00 $0.00 $0.00 "$1,524.94" "$2,415.50" "$2,439.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065992747 SUP Custom 27203010 8065992747 - KNIFE OPHTHALMIC ANGLE 2 BEVEL 2.75MM SLIT SATIN FINISH FULL BOTH IP/OP $46.13 $34.14 $0.00 $36.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.23 $34.23 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $23.06 $36.53 $36.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8065997001 SUP HCPCS C1713 8065997001 - SCREW BN 2.3MM STRL IKNF II STNCRSNT TIP STRG DISP BOTH IP/OP $41.58 $30.77 $0.00 $33.26 $18.71 $18.71 $0.00 $0.00 $0.00 $8.67 $30.86 $30.86 $0.00 $0.00 $8.66 $0.00 $24.59 $24.59 $0.00 $20.79 $32.93 $33.26 $0.00 $0.00 $6.51 $0.00 $0.00 $6.62 $0.00 $0.00 $0.00 $0.00 $0.00 8450107030 SUP Custom 27203010 8450107030 - BURR SURG 3MM MATCH HEAD LATEX FREE BOTH IP/OP $466.35 $345.10 $0.00 $373.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.12 $346.12 $0.00 $0.00 $97.19 $0.00 $0.00 $0.00 $0.00 $233.18 $369.35 $373.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8815668007 SUP Custom 27203010 TRAY CATH 19.5CM 11.5FR MHRKR DUAL STRG NDLHLDR GZE SPNG SH BOTH IP/OP $314.88 $233.01 $0.00 $251.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.44 $249.38 $251.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8831663001 SUP Custom 27203010 TRAY CATH MHRKR INS 2LUM STRG EXTN BOTH IP/OP $314.88 $233.01 $0.00 $251.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.44 $249.38 $251.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8884200026 SUP Custom 27203010 PROBE THRMTR ORAL CORD ADLT FLC 2000 REUSE BOTH IP/OP $114.85 $84.99 $0.00 $91.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.43 $90.96 $91.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8886808300 SUP Custom 27803010 8886808300 - RING ANSTM 2MM 25MM STRL VALTRAC RADOPQ BFRG MECH LCK CNCT BOTH IP/OP $829.45 $613.79 $0.00 $663.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $615.62 $615.62 $0.00 $0.00 $172.86 $0.00 $0.00 $0.00 $0.00 $414.72 $656.92 $663.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8886808800 SUP Custom 27803010 8886808800 - RING ANSTM 2MM 28MM STRL VALTRAC RADOPQ BFRG MECH LCK CNCT BOTH IP/OP $777.13 $575.08 $0.00 $621.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $388.56 $615.49 $621.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8887654088 SUP HCPCS C1729 CATHETER URTH DOV 8FR 2W FOLEY BLN SIL-EL 3ML LTX PED BOTH IP/OP $10.33 $7.64 $0.00 $8.26 $5.61 $5.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.16 $8.18 $8.26 $0.00 $0.00 $1.62 $0.00 $0.00 $1.64 $0.00 $0.00 $0.00 $0.00 $0.00 8887654104 SUP HCPCS C1729 CATHETER URTH DOV 10FR FOLEY 2W SIL-EL 3ML LTX PED BOTH IP/OP $10.33 $7.64 $0.00 $8.26 $5.61 $5.61 $0.00 $0.00 $0.00 $2.15 $7.66 $7.66 $0.00 $0.00 $2.15 $0.00 $6.11 $6.11 $0.00 $5.16 $8.18 $8.26 $0.00 $0.00 $1.62 $0.00 $0.00 $1.64 $0.00 $0.00 $0.00 $0.00 $0.00 8888119362 SUP HCPCS C1750 8888119362 - CATHETER HMDIAL 14.5FR 19CM MH MXD SPORTPACK 2 LUM KINK RST BOTH IP/OP $210.68 $155.90 $0.00 $168.54 $94.81 $94.81 $0.00 $0.00 $0.00 $43.91 $156.37 $156.37 $0.00 $0.00 $43.91 $0.00 $124.62 $124.62 $0.00 $105.34 $166.86 $168.54 $0.00 $0.00 $32.97 $0.00 $0.00 $33.54 $0.00 $0.00 $0.00 $0.00 $0.00 8888160333 SUP Custom 27203010 8888160333 - CATHETER UMB 3.5FR 15IN .15ML CLR STRL LF ARG 1 LUM LL HUB BOTH IP/OP $86.01 $63.65 $0.00 $63.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.83 $63.83 $0.00 $0.00 $17.92 $0.00 $0.00 $0.00 $0.00 $16.92 $27.99 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8888160341 SUP Custom 27203010 8888160341 - CAP TUBE 13MM BLU EZTPR DBL FLNG SL THB TAB PE BOTH IP/OP $34.28 $25.37 $0.00 $27.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.44 $25.44 $0.00 $0.00 $7.14 $0.00 $0.00 $0.00 $0.00 $16.92 $27.99 $27.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8888160358 SUP HCPCS C1729 CATHETER UMB 3.5FR 15IN FLXB SMTH LUER LOCK LOCK HUB WNG ARG BOTH IP/OP $33.33 $24.66 $0.00 $26.66 $18.10 $18.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.66 $26.40 $26.66 $0.00 $0.00 $5.22 $0.00 $0.00 $5.31 $0.00 $0.00 $0.00 $0.00 $0.00 8888160408 SUP Custom 27203010 8888160408 - TRAY CATH LF A NEOS 2 TIER DSGN FN TIP FCP INS DEPH FR MGLN BOTH IP/OP $126.90 $93.91 $0.00 $104.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.19 $94.19 $0.00 $0.00 $26.45 $0.00 $0.00 $0.00 $0.00 $63.33 $104.77 $101.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8888265108 SUP Custom 27203010 TUBE NG 36IN 10FR SNTNL LN A SLM SM SIL BOTH IP/OP $28.47 $21.07 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.13 $21.13 $0.00 $0.00 $5.93 $0.00 $0.00 $0.00 $0.00 $14.36 $22.75 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8888492120 SUP HCPCS C1758 8888492120 - CATH URTH DV RBNL 20FR 16IN PVC STRL LATEX FREE BOTH IP/OP $1.38 $1.02 $0.00 $1.11 $0.75 $0.75 $0.00 $0.00 $0.00 $0.29 $1.03 $1.03 $0.00 $0.00 $0.29 $0.00 $0.82 $0.82 $0.00 $0.69 $1.09 $1.11 $0.00 $0.00 $0.22 $0.00 $0.00 $0.22 $0.00 $0.00 $0.00 $0.00 $0.00 8888560805 SUP HCPCS C1729 8888560805 - CATHETER DRAIN 8FR 9IN SHARP TROCAR TIP RADIOPQ DEPTH MARK BOTH IP/OP $34.18 $25.29 $0.00 $28.98 $19.67 $19.67 $0.00 $0.00 $0.00 $7.12 $25.36 $25.36 $0.00 $0.00 $7.12 $0.00 $20.21 $20.21 $0.00 $18.11 $28.69 $28.98 $0.00 $0.00 $5.67 $0.00 $0.00 $5.77 $0.00 $0.00 $0.00 $0.00 $0.00 8888561019 SUP HCPCS C1729 8888561019 - CATHETER DRN 10FR 3.3MM 9IN TROC STRG SFT PVC THOR BOTH IP/OP $34.18 $25.29 $0.00 $28.69 $18.84 $18.84 $0.00 $0.00 $0.00 $7.12 $25.36 $25.36 $0.00 $0.00 $7.12 $0.00 $20.21 $20.21 $0.00 $17.34 $28.69 $27.75 $0.00 $0.00 $5.67 $0.00 $0.00 $5.52 $0.00 $0.00 $0.00 $0.00 $0.00 8888561027 SUP HCPCS C1729 8888561027 - CATHETER DRAIN 12FR 9IN SHARP TROCAR TIP RADIOPQ DEPTH MARK BOTH IP/OP $34.18 $25.29 $0.00 $28.69 $18.84 $18.84 $0.00 $0.00 $0.00 $7.12 $25.36 $25.36 $0.00 $0.00 $7.12 $0.00 $20.21 $20.21 $0.00 $17.34 $28.69 $27.75 $0.00 $0.00 $5.67 $0.00 $0.00 $5.52 $0.00 $0.00 $0.00 $0.00 $0.00 8888570515 SUP HCPCS C1725 CATHETER DRAIN 16FR 5.3MM 20IN 4 SD EYE STRG THOR THRMSNS BOTH IP/OP $12.63 $9.35 $0.00 $10.10 $6.86 $6.86 $0.00 $0.00 $0.00 $2.63 $9.37 $9.37 $0.00 $0.00 $2.63 $0.00 $7.47 $7.47 $0.00 $6.31 $10.00 $10.10 $0.00 $0.00 $1.98 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 8888570523 SUP HCPCS C1725 CATHETER DRAIN 20FR 6.7MM 20IN EYLT RT ANG THRMSNS DEPTH BOTH IP/OP $12.63 $9.35 $0.00 $10.10 $6.86 $6.86 $0.00 $0.00 $0.00 $2.63 $9.37 $9.37 $0.00 $0.00 $2.63 $0.00 $7.47 $7.47 $0.00 $6.31 $10.00 $10.10 $0.00 $0.00 $1.98 $0.00 $0.00 $2.01 $0.00 $0.00 $0.00 $0.00 $0.00 8888570572 SUP HCPCS C1729 8888570572 - CATH DRAIN 40FR 20IN ARG 6 EYLT STR THRMSNS DEPTH MARK BOTH IP/OP $12.83 $9.49 $0.00 $98.50 $66.86 $66.86 $0.00 $0.00 $0.00 $2.67 $9.52 $9.52 $0.00 $0.00 $2.67 $0.00 $7.59 $7.59 $0.00 $61.56 $97.52 $98.50 $0.00 $0.00 $19.27 $0.00 $0.00 $19.60 $0.00 $0.00 $0.00 $0.00 $0.00 8888571042 SUP HCPCS C1729 8888571042 - CATHETER DRAIN RIGHT ANG 28FR 20IN 6 SIDE EYE RADIOPQ TUBE BOTH IP/OP $185.03 $136.92 $0.00 $155.33 $101.98 $101.98 $0.00 $0.00 $0.00 $38.56 $137.33 $137.33 $0.00 $0.00 $38.56 $0.00 $109.44 $109.44 $0.00 $93.90 $155.33 $150.24 $0.00 $0.00 $30.69 $0.00 $0.00 $29.90 $0.00 $0.00 $0.00 $0.00 $0.00 8888577700 SUP Custom 27803010 8888577700 - SHUNT CARDIO 11IN 8FR ARG CRTD 4 TUBE KIT PLSH TPR END BOTH IP/OP $86.51 $64.02 $0.00 $69.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.20 $64.20 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $43.25 $68.52 $69.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8888577775 SUP HCPCS C1877 8888577775 - SHUNT CARDIO 6IN 8-14FR ARG CRTD 4 TUBE KT PLSH TPR END BOTH IP/OP $137.21 $101.54 $0.00 $101.84 $39.56 $39.56 $0.00 $0.00 $0.00 $0.00 $101.84 $101.84 $0.00 $0.00 $28.59 $0.00 $0.00 $0.00 $0.00 $43.95 $69.62 $70.33 $0.00 $0.00 $13.76 $0.00 $0.00 $13.99 $0.00 $0.00 $0.00 $0.00 $0.00 8888590018 SUP HCPCS C1725 CATHETER DRAIN 20IN 18FR FERG VNTRC PVC 4 EYLT VNT STRL LF BOTH IP/OP $123.61 $91.47 $0.00 $91.74 $40.55 $40.55 $0.00 $0.00 $0.00 $25.76 $91.74 $91.74 $0.00 $0.00 $25.76 $0.00 $73.11 $73.11 $0.00 $37.34 $59.15 $59.74 $0.00 $0.00 $11.69 $0.00 $0.00 $11.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004020 SUP HCPCS C1713 54410004020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004025 SUP HCPCS C1713 54410004025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004030 SUP HCPCS C1713 54410004030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004035 SUP HCPCS C1713 54410004035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004040 SUP HCPCS C1713 54410004040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004045 SUP HCPCS C1713 54410004045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004520 SUP HCPCS C1713 54410004520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004525 SUP HCPCS C1713 54410004525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004530 SUP HCPCS C1713 54410004530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004535 SUP HCPCS C1713 54410004535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004540 SUP HCPCS C1713 54410004540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410004545 SUP HCPCS C1713 54410004545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005020 SUP HCPCS C1713 54410005020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005025 SUP HCPCS C1713 54410005025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005030 SUP HCPCS C1713 54410005030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005035 SUP HCPCS C1713 54410005035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005040 SUP HCPCS C1713 54410005040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005045 SUP HCPCS C1713 54410005045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005050 SUP HCPCS C1713 54410005050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005520 SUP HCPCS C1713 54410005520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005525 SUP HCPCS C1713 54410005525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005530 SUP HCPCS C1713 54410005530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005535 SUP HCPCS C1713 54410005535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005540 SUP HCPCS C1713 54410005540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005545 SUP HCPCS C1713 54410005545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005550 SUP HCPCS C1713 54410005550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410005555 SUP HCPCS C1713 54410005555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006025 SUP HCPCS C1713 54410006025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006030 SUP HCPCS C1713 54410006030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006035 SUP HCPCS C1713 54410006035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006040 SUP HCPCS C1713 54410006040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006045 SUP HCPCS C1713 54410006045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006050 SUP HCPCS C1713 54410006050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006055 SUP HCPCS C1713 54410006055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006520 SUP HCPCS C1713 54410006520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006525 SUP HCPCS C1713 54410006525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006530 SUP HCPCS C1713 54410006530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006535 SUP HCPCS C1713 54410006535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006540 SUP HCPCS C1713 54410006540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006545 SUP HCPCS C1713 54410006545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006550 SUP HCPCS C1713 54410006550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006555 SUP HCPCS C1713 54410006555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410006560 SUP HCPCS C1713 54410006560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410007530 SUP HCPCS C1713 54410007530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410007535 SUP HCPCS C1713 54410007535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410007540 SUP HCPCS C1713 54410007540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410007545 SUP HCPCS C1713 54410007545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410007550 SUP HCPCS C1713 54410007550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410007555 SUP HCPCS C1713 54410007555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54410007560 SUP HCPCS C1713 54410007560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 54740044520 SUP HCPCS C1713 54740044520 - SCREW BONE 4.5MM 20MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740044525 SUP HCPCS C1713 54740044525 - SCREW BONE 4.5MM 25MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740044530 SUP HCPCS C1713 54740044530 - SCREW BONE 4.5MM 30MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740044535 SUP HCPCS C1713 54740044535 - SCREW BONE 4.5MM 35MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740044540 SUP HCPCS C1713 54740044540 - SCREW BONE 4.5MM 40MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740044545 SUP HCPCS C1713 54740044545 - SCREW BONE 4.5MM 45MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740044550 SUP HCPCS C1713 54740044550 - SCREW BONE 4.5MM 50MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740044555 SUP HCPCS C1713 54740044555 - SCREW BONE 4.5MM 55MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740044560 SUP HCPCS C1713 54740044560 - SCREW BONE 4.5MM 60MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045520 SUP HCPCS C1713 54740045520 - SCREW BONE 5.5MM 20MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045525 SUP HCPCS C1713 54740045525 - SCREW BONE 5.5MM 25MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045530 SUP HCPCS C1713 54740045530 - SCREW BONE 5.5MM 30MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045535 SUP HCPCS C1713 54740045535 - SCREW BONE 5.5MM 35MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045540 SUP HCPCS C1713 54740045540 - SCREW BONE 5.5MM 40MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045545 SUP HCPCS C1713 54740045545 - SCREW BONE 5.5MM 45MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045550 SUP HCPCS C1713 54740045550 - SCREW BONE 5.5MM 50MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045555 SUP HCPCS C1713 54740045555 - SCREW BONE 5.5MM 55MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740045560 SUP HCPCS C1713 54740045560 - SCREW BONE 5.5MM 60MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046520 SUP HCPCS C1713 54740046520 - SCREW BONE 6.5MM 20MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046525 SUP HCPCS C1713 54740046525 - SCREW BONE 6.5MM 25MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046530 SUP HCPCS C1713 54740046530 - SCREW BONE 6.5MM 30MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046535 SUP HCPCS C1713 54740046535 - SCREW BONE 6.5MM 35MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046540 SUP HCPCS C1713 54740046540 - SCREW BONE 6.5MM 40MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046545 SUP HCPCS C1713 54740046545 - SCREW BONE 6.5MM 45MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046550 SUP HCPCS C1713 54740046550 - SCREW BONE 6.5MM 50MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046555 SUP HCPCS C1713 54740046555 - SCREW BONE 6.5MM 55MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740046560 SUP HCPCS C1713 54740046560 - SCREW BONE 6.5MM 60MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047520 SUP HCPCS C1713 54740047520 - SCREW BONE 7.5MM 20MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047525 SUP HCPCS C1713 54740047525 - SCREW BONE 7.5MM 25MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047530 SUP HCPCS C1713 54740047530 - SCREW BONE 7.5MM 30MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047535 SUP HCPCS C1713 54740047535 - SCREW BONE 7.5MM 35MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047540 SUP HCPCS C1713 54740047540 - SCREW BONE 7.5MM 40MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047545 SUP HCPCS C1713 54740047545 - SCREW BONE 7.5MM 45MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047550 SUP HCPCS C1713 54740047550 - SCREW BONE 7.5MM 50MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047555 SUP HCPCS C1713 54740047555 - SCREW BONE 7.5MM 55MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740047560 SUP HCPCS C1713 54740047560 - SCREW BONE 7.5MM 60MM ATS SPN MULTIAX 4.75MM ROD ST BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54740105515 SUP HCPCS C1713 54740105515 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105520 SUP HCPCS C1713 54740105520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105525 SUP HCPCS C1713 54740105525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105530 SUP HCPCS C1713 54740105530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105535 SUP HCPCS C1713 54740105535 - SCREW BN 5.5MM 35MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105540 SUP HCPCS C1713 54740105540 - SCREW BN 5.5MM 40MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105545 SUP HCPCS C1713 54740105545 - SCREW BN 5.5MM 45MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105550 SUP HCPCS C1713 54740105550 - SCREW BN 5.5MM 50MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105555 SUP HCPCS C1713 54740105555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105560 SUP HCPCS C1713 54740105560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105565 SUP HCPCS C1713 54740105565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105570 SUP HCPCS C1713 54740105570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105575 SUP HCPCS C1713 54740105575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740105580 SUP HCPCS C1713 54740105580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106015 SUP HCPCS C1713 54740106015 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106020 SUP HCPCS C1713 54740106020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106025 SUP HCPCS C1713 54740106025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106030 SUP HCPCS C1713 54740106030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106035 SUP HCPCS C1713 54740106035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106040 SUP HCPCS C1713 54740106040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106045 SUP HCPCS C1713 54740106045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106050 SUP HCPCS C1713 54740106050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106055 SUP HCPCS C1713 54740106055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106060 SUP HCPCS C1713 54740106060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106065 SUP HCPCS C1713 54740106065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106070 SUP HCPCS C1713 54740106070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106075 SUP HCPCS C1713 54740106075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106080 SUP HCPCS C1713 54740106080 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106515 SUP HCPCS C1713 54740106515 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106520 SUP HCPCS C1713 54740106520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106525 SUP HCPCS C1713 54740106525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106530 SUP HCPCS C1713 54740106530 - SCREW BN 6.5MM 30MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106535 SUP HCPCS C1713 54740106535 - SCREW BN 6.5MM 35MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106540 SUP HCPCS C1713 54740106540 - SCREW BN 6.5MM 40MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106545 SUP HCPCS C1713 54740106545 - SCREW BN 6.5MM 45MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106550 SUP HCPCS C1713 54740106550 - SCREW BN 6.5MM 50MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106555 SUP HCPCS C1713 54740106555 - SCREW BN 6.5MM 55MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106560 SUP HCPCS C1713 54740106560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106565 SUP HCPCS C1713 54740106565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106570 SUP HCPCS C1713 54740106570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106575 SUP HCPCS C1713 54740106575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740106580 SUP HCPCS C1713 54740106580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107020 SUP HCPCS C1713 54740107020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107025 SUP HCPCS C1713 54740107025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107030 SUP HCPCS C1713 54740107030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107035 SUP HCPCS C1713 54740107035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107040 SUP HCPCS C1713 54740107040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107045 SUP HCPCS C1713 54740107045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107050 SUP HCPCS C1713 54740107050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107055 SUP HCPCS C1713 54740107055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107060 SUP HCPCS C1713 54740107060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107065 SUP HCPCS C1713 54740107065 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107070 SUP HCPCS C1713 54740107070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107075 SUP HCPCS C1713 54740107075 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107080 SUP HCPCS C1713 54740107080 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107500 SUP HCPCS C1713 54740107500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107511 SUP HCPCS C1713 54740107511 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107520 SUP HCPCS C1713 54740107520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107525 SUP HCPCS C1713 54740107525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107530 SUP HCPCS C1713 54740107530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107535 SUP HCPCS C1713 54740107535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107540 SUP HCPCS C1713 54740107540 - SCREW BN 7.5MM 40MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107545 SUP HCPCS C1713 54740107545 - SCREW BN 7.5MM 45MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107550 SUP HCPCS C1713 54740107550 - SCREW BN 7.5MM 50MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107555 SUP HCPCS C1713 54740107555 - SCREW BN 7.5MM 55MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107560 SUP HCPCS C1713 54740107560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107565 SUP HCPCS C1713 54740107565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107570 SUP HCPCS C1713 54740107570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107575 SUP HCPCS C1713 54740107575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107580 SUP HCPCS C1713 54740107580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107585 SUP HCPCS C1713 54740107585 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107590 SUP HCPCS C1713 54740107590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740107595 SUP HCPCS C1713 54740107595 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108000 SUP HCPCS C1713 54740108000 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108011 SUP HCPCS C1713 54740108011 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108020 SUP HCPCS C1713 54740108020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108025 SUP HCPCS C1713 54740108025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108030 SUP HCPCS C1713 54740108030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108035 SUP HCPCS C1713 54740108035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108040 SUP HCPCS C1713 54740108040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108045 SUP HCPCS C1713 54740108045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108050 SUP HCPCS C1713 54740108050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108055 SUP HCPCS C1713 54740108055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108060 SUP HCPCS C1713 54740108060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108065 SUP HCPCS C1713 54740108065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108070 SUP HCPCS C1713 54740108070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108075 SUP HCPCS C1713 54740108075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108080 SUP HCPCS C1713 54740108080 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108085 SUP HCPCS C1713 54740108085 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108090 SUP HCPCS C1713 54740108090 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108095 SUP HCPCS C1713 54740108095 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108500 SUP HCPCS C1713 54740108500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108511 SUP HCPCS C1713 54740108511 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108520 SUP HCPCS C1713 54740108520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108525 SUP HCPCS C1713 54740108525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108530 SUP HCPCS C1713 54740108530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108535 SUP HCPCS C1713 54740108535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108540 SUP HCPCS C1713 54740108540 - SCREW BN 8.5MM 40MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108545 SUP HCPCS C1713 54740108545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108550 SUP HCPCS C1713 54740108550 - SCREW BN 8.5MM 50MM CD HZN SOLERA MA CNN COCR HA SPNE PDCL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108555 SUP HCPCS C1713 54740108555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108560 SUP HCPCS C1713 54740108560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108565 SUP HCPCS C1713 54740108565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108570 SUP HCPCS C1713 54740108570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108575 SUP HCPCS C1713 54740108575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108580 SUP HCPCS C1713 54740108580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108585 SUP HCPCS C1713 54740108585 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108590 SUP HCPCS C1713 54740108590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740108595 SUP HCPCS C1713 54740108595 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109500 SUP HCPCS C1713 54740109500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109511 SUP HCPCS C1713 54740109511 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109520 SUP HCPCS C1713 54740109520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109525 SUP HCPCS C1713 54740109525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109530 SUP HCPCS C1713 54740109530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109535 SUP HCPCS C1713 54740109535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109540 SUP HCPCS C1713 54740109540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109545 SUP HCPCS C1713 54740109545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109550 SUP HCPCS C1713 54740109550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109555 SUP HCPCS C1713 54740109555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109560 SUP HCPCS C1713 54740109560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109565 SUP HCPCS C1713 54740109565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109570 SUP HCPCS C1713 54740109570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109575 SUP HCPCS C1713 54740109575 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109580 SUP HCPCS C1713 54740109580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109585 SUP HCPCS C1713 54740109585 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109590 SUP HCPCS C1713 54740109590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54740109595 SUP HCPCS C1713 54740109595 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54750014525 SUP HCPCS C1713 54750014525 - SCREW BONE 4.5MM 25MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750014530 SUP HCPCS C1713 54750014530 - SCREW BONE 4.5MM 30MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750014535 SUP HCPCS C1713 54750014535 - SCREW BONE 4.5MM 35MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750014540 SUP HCPCS C1713 54750014540 - SCREW BONE 4.5MM 40MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750014545 SUP HCPCS C1713 54750014545 - SCREW BONE 4.5MM 45MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750014550 SUP HCPCS C1713 54750014550 - SCREW BONE 4.5MM 50MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750014555 SUP HCPCS C1713 54750014555 - SCREW BONE 4.5MM 55MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015525 SUP HCPCS C1713 54750015525 - SCREW BONE 5.5MM 25MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015530 SUP HCPCS C1713 54750015530 - SCREW BONE 5.5MM 30MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015535 SUP HCPCS C1713 54750015535 - SCREW BONE 5.5MM 35MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015540 SUP HCPCS C1713 54750015540 - SCREW BONE 5.5MM 40MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015545 SUP HCPCS C1713 54750015545 - SCREW BONE 5.5MM 45MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015550 SUP HCPCS C1713 54750015550 - SCREW BONE 5.5MM 50MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015555 SUP HCPCS C1713 54750015555 - SCREW BONE 5.5MM 55MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015560 SUP HCPCS C1713 54750015560 - SCREW BONE 5.5MM 60MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750015565 SUP HCPCS C1713 54750015565 - SCREW BONE 5.5MM 65MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750016530 SUP HCPCS C1713 54750016530 - SCREW BONE 6.5MM 30MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750016535 SUP HCPCS C1713 54750016535 - SCREW BONE 6.5MM 35MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750016540 SUP HCPCS C1713 54750016540 - SCREW BONE 6.5MM 40MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750016545 SUP HCPCS C1713 54750016545 - SCREW BONE 6.5MM 45MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750016550 SUP HCPCS C1713 54750016550 - SCREW BONE 6.5MM 50MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750016555 SUP HCPCS C1713 54750016555 - SCREW BONE 6.5MM 55MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750016560 SUP HCPCS C1713 54750016560 - SCREW BONE 6.5MM 60MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750016565 SUP HCPCS C1713 54750016565 - SCREW BONE 6.5MM 65MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017530 SUP HCPCS C1713 54750017530 - SCREW BONE 7.5MM 30MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017535 SUP HCPCS C1713 54750017535 - SCREW BONE 7.5MM 35MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017540 SUP HCPCS C1713 54750017540 - SCREW BONE 7.5MM 40MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017545 SUP HCPCS C1713 54750017545 - SCREW BONE 7.5MM 45MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017550 SUP HCPCS C1713 54750017550 - SCREW BONE 7.5MM 50MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017555 SUP HCPCS C1713 54750017555 - SCREW BONE 7.5MM 55MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017560 SUP HCPCS C1713 54750017560 - SCREW BONE 7.5MM 60MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017565 SUP HCPCS C1713 54750017565 - SCREW BONE 7.5MM 65MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750017570 SUP HCPCS C1713 54750017570 - SCREW BONE 7.5MM 70MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018530 SUP HCPCS C1713 54750018530 - SCREW BONE 8.5MM 30MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018535 SUP HCPCS C1713 54750018535 - SCREW BONE 8.5MM 35MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018540 SUP HCPCS C1713 54750018540 - SCREW BONE 8.5MM 40MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018545 SUP HCPCS C1713 54750018545 - SCREW BONE 8.5MM 45MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018550 SUP HCPCS C1713 54750018550 - SCREW BONE 8.5MM 50MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018555 SUP HCPCS C1713 54750018555 - SCREW BONE 8.5MM 55MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018560 SUP HCPCS C1713 54750018560 - SCREW BONE 8.5MM 60MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018565 SUP HCPCS C1713 54750018565 - SCREW BONE 8.5MM 65MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54750018570 SUP HCPCS C1713 54750018570 - SCREW BONE 8.5MM 70MM CD HZN SPN MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840004020 SUP HCPCS C1713 54840004020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004025 SUP HCPCS C1713 54840004025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004030 SUP HCPCS C1713 54840004030 - SCREW BN 4MM 30MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004035 SUP HCPCS C1713 54840004035 - SCREW BN 4MM 35MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004040 SUP HCPCS C1713 54840004040 - SCREW BN 4MM 40MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004045 SUP HCPCS C1713 54840004045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004050 SUP HCPCS C1713 54840004050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004055 SUP HCPCS C1713 54840004055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004520 SUP HCPCS C1713 54840004520 - SCREW BN 4.5MM 20MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004525 SUP HCPCS C1713 54840004525 - SCREW BN 4.5MM 25MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004530 SUP HCPCS C1713 54840004530 - SCREW BN 4.5MM 30MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004535 SUP HCPCS C1713 54840004535 - SCREW BN 4.5MM 35MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004540 SUP HCPCS C1713 54840004540 - SCREW BN 4.5MM 40MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004545 SUP HCPCS C1713 54840004545 - SCREW BN 4.5MM 45MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004550 SUP HCPCS C1713 54840004550 - SCREW BN 4.5MM 50MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840004555 SUP HCPCS C1713 54840004555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005020 SUP HCPCS C1713 54840005020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005025 SUP HCPCS C1713 54840005025 - SCREW BN 5MM 25MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005030 SUP HCPCS C1713 54840005030 - SCREW BN 5MM 30MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005035 SUP HCPCS C1713 54840005035 - SCREW BN 5MM 35MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005040 SUP HCPCS C1713 54840005040 - SCREW BN 5MM 40MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005045 SUP HCPCS C1713 54840005045 - SCREW BN 5MM 45MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005050 SUP HCPCS C1713 54840005050 - SCREW BN 5MM 50MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005055 SUP HCPCS C1713 54840005055 - SCREW BN 5MM 55MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005520 SUP HCPCS C1713 54840005520 - SCREW BN 5.5MM 20MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005525 SUP HCPCS C1713 54840005525 - SCREW BN 5.5MM 25MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005530 SUP HCPCS C1713 54840005530 - SCREW BN 5.5MM 30MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005535 SUP HCPCS C1713 54840005535 - SCREW BN 5.5MM 35MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005540 SUP HCPCS C1713 54840005540 - SCREW BN 5.5MM 40MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005545 SUP HCPCS C1713 54840005545 - SCREW BN 5.5MM 45MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005550 SUP HCPCS C1713 54840005550 - SCREW BN 5.5MM 50MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005555 SUP HCPCS C1713 54840005555 - SCREW BN 5.5MM 55MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840005560 SUP HCPCS C1713 54840005560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006020 SUP HCPCS C1713 54840006020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006025 SUP HCPCS C1713 54840006025 - SCREW BN 6MM 25MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006030 SUP HCPCS C1713 54840006030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006035 SUP HCPCS C1713 54840006035 - SCREW BN 6MM 35MM NS CD HZN MA COCR SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006040 SUP HCPCS C1713 54840006040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006045 SUP HCPCS C1713 54840006045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006050 SUP HCPCS C1713 54840006050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006055 SUP HCPCS C1713 54840006055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006060 SUP HCPCS C1713 54840006060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006520 SUP HCPCS C1713 54840006520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006525 SUP HCPCS C1713 54840006525 - SCREW BN 6.5MM 25MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006530 SUP HCPCS C1713 54840006530 - SCREW BN 6.5MM 30MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006535 SUP HCPCS C1713 54840006535 - SCREW BN 6.5MM 35MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006540 SUP HCPCS C1713 54840006540 - SCREW BN 6.5MM 40MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006545 SUP HCPCS C1713 54840006545 - SCREW BN 6.5MM 45MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006550 SUP HCPCS C1713 54840006550 - SCREW BN 6.5MM 50MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006555 SUP HCPCS C1713 54840006555 - SCREW BN 6.5MM 55MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006560 SUP HCPCS C1713 54840006560 - SCREW BN 6.5MM 60MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006565 SUP HCPCS C1713 54840006565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006570 SUP HCPCS C1713 54840006570 - SCREW BN 6.5MM 70MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840006580 SUP HCPCS C1713 54840006580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007500 SUP HCPCS C1713 54840007500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007520 SUP HCPCS C1713 54840007520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007525 SUP HCPCS C1713 54840007525 - SCREW BN 7.5MM 25MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007530 SUP HCPCS C1713 54840007530 - SCREW BN 7.5MM 30MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007535 SUP HCPCS C1713 54840007535 - SCREW BN 7.5MM 35MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007540 SUP HCPCS C1713 54840007540 - SCREW BN 7.5MM 40MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007545 SUP HCPCS C1713 54840007545 - SCREW BN 7.5MM 45MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007550 SUP HCPCS C1713 54840007550 - SCREW BN 7.5MM 50MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007555 SUP HCPCS C1713 54840007555 - SCREW BN 7.5MM 55MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007560 SUP HCPCS C1713 54840007560 - SCREW BN 7.5MM 60MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007565 SUP HCPCS C1713 54840007565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007570 SUP HCPCS C1713 54840007570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007580 SUP HCPCS C1713 54840007580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840007590 SUP HCPCS C1713 54840007590 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008500 SUP HCPCS C1713 54840008500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008525 SUP HCPCS C1713 54840008525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008530 SUP HCPCS C1713 54840008530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008535 SUP HCPCS C1713 54840008535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008540 SUP HCPCS C1713 54840008540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008545 SUP HCPCS C1713 54840008545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008550 SUP HCPCS C1713 54840008550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008555 SUP HCPCS C1713 54840008555 - SCREW BN 8.5MM 55MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008560 SUP HCPCS C1713 54840008560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008565 SUP HCPCS C1713 54840008565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008570 SUP HCPCS C1713 54840008570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008580 SUP HCPCS C1713 54840008580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840008590 SUP HCPCS C1713 54840008590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009500 SUP HCPCS C1713 54840009500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009525 SUP HCPCS C1713 54840009525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009530 SUP HCPCS C1713 54840009530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009535 SUP HCPCS C1713 54840009535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009540 SUP HCPCS C1713 54840009540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009545 SUP HCPCS C1713 54840009545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009550 SUP HCPCS C1713 54840009550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009555 SUP HCPCS C1713 54840009555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009560 SUP HCPCS C1713 54840009560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009565 SUP HCPCS C1713 54840009565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009570 SUP HCPCS C1713 54840009570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009580 SUP HCPCS C1713 54840009580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840009590 SUP HCPCS C1713 54840009590 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54840014530 SUP HCPCS C1713 54840014530 - SCREW BONE 30MM MULTIAX CANN SOLERA CD HORIZON COCR 4.5MM BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840014535 SUP HCPCS C1713 54840014535 - SCREW BONE 35MM MULTIAX CANN SOLERA CD HORIZON COCR 4.5MM BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840014540 SUP HCPCS C1713 54840014540 - SCREW BONE 40MM MULTIAX CANN SOLERA CD HORIZON COCR 4.5MM BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840014545 SUP HCPCS C1713 54840014545 - SCREW BONE 4.5MM 45MM MULTIAX CANN SOLERA CD HORIZON COCR BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840015535 SUP HCPCS C1713 54840015535 - SCREW BONE 5.5MM 35MM MULTIAX CANN COCR SPN BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840015540 SUP HCPCS C1713 54840015540 - SCREW BONE 5.5MM 40MM MULTIAX CANN SOLERA CD HORIZON COCR BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840015545 SUP HCPCS C1713 54840015545 - SCREW BONE 5.5MM 45MM MULTIAX CANN SOLERA CD HORIZON BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840015550 SUP HCPCS C1713 54840015550 - SCREW BONE 5.5MM 50MM MULTIAX CANN SOLERA CD HORIZON BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840016535 SUP HCPCS C1713 54840016535 - SCREW BONE LP 6.5MM 35MM 2 LEAD MULTIAX CANN COLOR CODED BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840016540 SUP HCPCS C1713 54840016540 - SCREW BN 6.5MM 40MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840016545 SUP HCPCS C1713 54840016545 - SCREW BN 6.5MM 45MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840016550 SUP HCPCS C1713 54840016550 - SCREW BN 6.5MM 50MM NS SOLERA CD HZN OSTEOGRIP 2 LD THRD FRM BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840016555 SUP HCPCS C1713 54840016555 - SCREW BONE 6.5MM 55MM SOLERA CD HZN OSTEOGRIP TI BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840017540 SUP HCPCS C1713 54840017540 - SCREW BONE 7.5MM 40MM MULTIAX CANN COCR SPN BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840017545 SUP HCPCS C1713 54840017545 - SCREW BONE 7.5MM 45MM MULTIAX CANN SOLERA CD HORIZON COCR BOTH IP/OP "$6,492.50 " "$4,804.45" $0.00 "$5,194.00" "$2,921.63" "$2,921.63" $0.00 $0.00 $0.00 "$1,353.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,353.04" $0.00 "$3,200.80" "$3,200.80" $0.00 "$3,246.25" "$5,142.06" "$5,194.00" $0.00 $0.00 "$1,016.08" $0.00 $0.00 "$1,033.61" $0.00 $0.00 $0.00 $0.00 $0.00 54840044520 SUP HCPCS C1713 54840044520 - SCREW BONE 4.5MM 20MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840044525 SUP HCPCS C1713 54840044525 - SCREW BONE 4.5MM 25MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840044530 SUP HCPCS C1713 54840044530 - SCREW BONE 4.5MM 30MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840044535 SUP HCPCS C1713 54840044535 - SCREW BONE 4.5MM 35MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840044540 SUP HCPCS C1713 54840044540 - SCREW BONE 4.5MM 40MM MULTIAX ATS SPN 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840044545 SUP HCPCS C1713 54840044545 - SCREW BONE 4.5MM 45MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840044550 SUP HCPCS C1713 54840044550 - SCREW BONE 4.5MM 50MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840044555 SUP HCPCS C1713 54840044555 - SCREW BONE 4.5MM 55MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840044560 SUP HCPCS C1713 54840044560 - SCREW BONE 4.5MM 60MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045520 SUP HCPCS C1713 54840045520 - SCREW BONE 5.5MM 20MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045525 SUP HCPCS C1713 54840045525 - SCREW BONE 5.5MM 25MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045530 SUP HCPCS C1713 54840045530 - SCREW BONE 5.5MM 30MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045535 SUP HCPCS C1713 54840045535 - SCREW BONE 5.5MM 35MM MULTIAX ATS SPN 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045540 SUP HCPCS C1713 54840045540 - SCREW BONE 5.5MM 40MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045545 SUP HCPCS C1713 54840045545 - SCREW BONE 5.5MM 45MM MULTIAX ATS SPN 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045550 SUP HCPCS C1713 54840045550 - SCREW BONE 5.5MM 50MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045555 SUP HCPCS C1713 54840045555 - SCREW BONE 5.5MM 55MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840045560 SUP HCPCS C1713 54840045560 - SCREW BONE 5.5MM 60MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046520 SUP HCPCS C1713 54840046520 - SCREW BONE 6.5MM 20MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046525 SUP HCPCS C1713 54840046525 - SCREW BONE 6.5MM 25MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046530 SUP HCPCS C1713 54840046530 - SCREW BONE 6.5MM 30MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046535 SUP HCPCS C1713 54840046535 - SCREW BONE 6.5MM 35MM MULTIAX ATS SPN 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046540 SUP HCPCS C1713 54840046540 - SCREW BONE 6.5MM 40MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046545 SUP HCPCS C1713 54840046545 - SCREW BONE 6.5MM 45MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046550 SUP HCPCS C1713 54840046550 - SCREW BONE 6.5MM 50MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046555 SUP HCPCS C1713 54840046555 - SCREW BONE 6.5MM 55MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840046560 SUP HCPCS C1713 54840046560 - SCREW BONE 6.5MM 60MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047520 SUP HCPCS C1713 54840047520 - SCREW BONE 7.5MM 20MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047525 SUP HCPCS C1713 54840047525 - SCREW BONE 7.5MM 25MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047530 SUP HCPCS C1713 54840047530 - SCREW BONE 7.5MM 30MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047535 SUP HCPCS C1713 54840047535 - SCREW BONE 7.5MM 35MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047540 SUP HCPCS C1713 54840047540 - SCREW BONE 7.5MM 40MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047545 SUP HCPCS C1713 54840047545 - SCREW BONE 7.5MM 45MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047550 SUP HCPCS C1713 54840047550 - SCREW BONE 7.5MM 50MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047555 SUP HCPCS C1713 54840047555 - SCREW BONE 7.5MM 55MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54840047560 SUP HCPCS C1713 54840047560 - SCREW BONE 7.5MM 60MM ATS SPN MULTIAX 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014530 SUP HCPCS C1713 54850014530 - SCREW BONE 4.5MM 30MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014535 SUP HCPCS C1713 54850014535 - SCREW BN 4.5MM 35MM MAS CNN XTN TAB SPNE 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014540 SUP HCPCS C1713 54850014540 - SCREW BN 4.5MM 40MM MAS CNN XTN TAB SPNE 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014545 SUP HCPCS C1713 54850014545 - SCREW BN 4.5MM 45MM MAS CNN XTN TAB SPNE 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014550 SUP HCPCS C1713 54850014550 - SCREW BONE 4.5MM 50MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014555 SUP HCPCS C1713 54850014555 - SCREW BONE 4.5MM 55MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014560 SUP HCPCS C1713 54850014560 - SCREW BONE 4.5MM 60MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014565 SUP HCPCS C1713 54850014565 - SCREW BONE 4.5MM 65MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014570 SUP HCPCS C1713 54850014570 - SCREW BONE 4.5MM 70MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850014575 SUP HCPCS C1713 54850014575 - SCREW BONE 4.5MM 75MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015530 SUP HCPCS C1713 54850015530 - SCREW BONE 5.5MM 30MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015535 SUP HCPCS C1713 54850015535 - SCREW BN 5.5MM 35MM MAS CNN XTN TAB SPNE 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015540 SUP HCPCS C1713 54850015540 - SCREW BN 5.5MM 40MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015545 SUP HCPCS C1713 54850015545 - SCREW BN 5.5MM 45MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015550 SUP HCPCS C1713 54850015550 - SCREW BN 5.5MM 50MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015555 SUP HCPCS C1713 54850015555 - SCREW BONE 5.5MM 55MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015560 SUP HCPCS C1713 54850015560 - SCREW BONE 5.5MM 60MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015565 SUP HCPCS C1713 54850015565 - SCREW BONE 5.5MM 65MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015570 SUP HCPCS C1713 54850015570 - SCREW BONE 5.5MM 70MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850015575 SUP HCPCS C1713 54850015575 - SCREW BONE 5.5MM 75MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850016530 SUP HCPCS C1713 54850016530 - SCREW BONE 6.5MM 30MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850016535 SUP HCPCS C1713 54850016535 - SCREW BN 6.5MM 35MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850016540 SUP HCPCS C1713 54850016540 - SCREW BN 6.5MM 40MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850016545 SUP HCPCS C1713 54850016545 - SCREW BN 6.5MM 45MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850016550 SUP HCPCS C1713 54850016550 - SCREW BN 6.5MM 50MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850016555 SUP HCPCS C1713 54850016555 - SCREW BN 6.5MM 55MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850016560 SUP HCPCS C1713 54850016560 - SCREW BONE 6.5MM 60MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850016565 SUP HCPCS C1713 54850016565 - SCREW BONE 6.5MM 65MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850017530 SUP HCPCS C1713 54850017530 - SCREW BONE 7.5MM 30MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850017535 SUP HCPCS C1713 54850017535 - SCREW BONE 7.5MM 35MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850017540 SUP HCPCS C1713 54850017540 - SCREW BN 7.5MM 40MM MAS CNN XTN TAB SPNE 4.75MM ROD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850017545 SUP HCPCS C1713 54850017545 - SCREW BN 7.5MM 45MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850017550 SUP HCPCS C1713 54850017550 - SCREW BN 7.5MM 50MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850017555 SUP HCPCS C1713 54850017555 - SCREW BN 7.5MM 55MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850017560 SUP HCPCS C1713 54850017560 - SCREW BN 7.5MM 60MM NS SOLERA CD HZN MA CNN XTD TAB SPNE BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850017565 SUP HCPCS C1713 54850017565 - SCREW BONE 7.5MM 65MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018530 SUP HCPCS C1713 54850018530 - SCREW BONE 8.5MM 30MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018535 SUP HCPCS C1713 54850018535 - SCREW BONE 8.5MM 35MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018540 SUP HCPCS C1713 54850018540 - SCREW BONE 8.5MM 40MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018545 SUP HCPCS C1713 54850018545 - SCREW BONE 8.5MM 45MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018550 SUP HCPCS C1713 54850018550 - SCREW BONE 8.5MM 50MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018555 SUP HCPCS C1713 54850018555 - SCREW BONE 8.5MM 55MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018560 SUP HCPCS C1713 54850018560 - SCREW BONE 8.5MM 60MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018565 SUP HCPCS C1713 54850018565 - SCREW BONE 8.5MM 65MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018570 SUP HCPCS C1713 54850018570 - SCREW BONE 8.5MM 70MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018575 SUP HCPCS C1713 54850018575 - SCREW BONE 8.5MM 75MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54850018580 SUP HCPCS C1713 54850018580 - SCREW BONE 8.5MM 80MM CD HZN SPNL MULTIAX CANN XTD BOTH IP/OP "$3,895.50 " "$2,882.67" $0.00 "$3,116.40" "$1,752.98" "$1,752.98" $0.00 $0.00 $0.00 $811.92 "$2,891.24" "$2,891.24" $0.00 $0.00 $811.82 $0.00 "$1,920.48" "$1,920.48" $0.00 "$1,947.75" "$3,085.24" "$3,116.40" $0.00 $0.00 $609.65 $0.00 $0.00 $620.16 $0.00 $0.00 $0.00 $0.00 $0.00 54890004525 SUP HCPCS C1713 54890004525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890004530 SUP HCPCS C1713 54890004530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890004535 SUP HCPCS C1713 54890004535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890004540 SUP HCPCS C1713 54890004540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890005525 SUP HCPCS C1713 54890005525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890005530 SUP HCPCS C1713 54890005530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890005535 SUP HCPCS C1713 54890005535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890005540 SUP HCPCS C1713 54890005540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890005545 SUP HCPCS C1713 54890005545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890005550 SUP HCPCS C1713 54890005550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890006530 SUP HCPCS C1713 54890006530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890006535 SUP HCPCS C1713 54890006535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890006540 SUP HCPCS C1713 54890006540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890006545 SUP HCPCS C1713 54890006545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890006550 SUP HCPCS C1713 54890006550 - SCREW BN 6.5MM 50MM NS SOLERA CD HZN MA RDC COCR SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890006555 SUP HCPCS C1713 54890006555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890007535 SUP HCPCS C1713 54890007535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890007540 SUP HCPCS C1713 54890007540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890007545 SUP HCPCS C1713 54890007545 - SCREW BN 7.5MM 45MM NS SOLERA CD HZN MA RDC COCR SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890007550 SUP HCPCS C1713 54890007550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 54890007555 SUP HCPCS C1713 54890007555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55410004020 SUP HCPCS C1713 55410004020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004025 SUP HCPCS C1713 55410004025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004030 SUP HCPCS C1713 55410004030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004035 SUP HCPCS C1713 55410004035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004040 SUP HCPCS C1713 55410004040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004045 SUP HCPCS C1713 55410004045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004520 SUP HCPCS C1713 55410004520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004525 SUP HCPCS C1713 55410004525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004530 SUP HCPCS C1713 55410004530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004535 SUP HCPCS C1713 55410004535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004540 SUP HCPCS C1713 55410004540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410004545 SUP HCPCS C1713 55410004545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005020 SUP HCPCS C1713 55410005020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005025 SUP HCPCS C1713 55410005025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005030 SUP HCPCS C1713 55410005030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005035 SUP HCPCS C1713 55410005035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005040 SUP HCPCS C1713 55410005040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005045 SUP HCPCS C1713 55410005045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005520 SUP HCPCS C1713 55410005520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005525 SUP HCPCS C1713 55410005525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005530 SUP HCPCS C1713 55410005530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005535 SUP HCPCS C1713 55410005535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005540 SUP HCPCS C1713 55410005540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005545 SUP HCPCS C1713 55410005545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410005550 SUP HCPCS C1713 55410005550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006025 SUP HCPCS C1713 55410006025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006030 SUP HCPCS C1713 55410006030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006035 SUP HCPCS C1713 55410006035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006040 SUP HCPCS C1713 55410006040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006045 SUP HCPCS C1713 55410006045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006050 SUP HCPCS C1713 55410006050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006055 SUP HCPCS C1713 55410006055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006520 SUP HCPCS C1713 55410006520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006525 SUP HCPCS C1713 55410006525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006530 SUP HCPCS C1713 55410006530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006535 SUP HCPCS C1713 55410006535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006540 SUP HCPCS C1713 55410006540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006545 SUP HCPCS C1713 55410006545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006550 SUP HCPCS C1713 55410006550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410006555 SUP HCPCS C1713 55410006555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410007535 SUP HCPCS C1713 55410007535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410007540 SUP HCPCS C1713 55410007540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410007545 SUP HCPCS C1713 55410007545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410007550 SUP HCPCS C1713 55410007550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55410007555 SUP HCPCS C1713 55410007555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,990.50 " "$1,472.97" $0.00 "$1,592.40" $895.73 $895.73 $0.00 $0.00 $0.00 $414.87 "$1,477.35" "$1,477.35" $0.00 $0.00 $414.82 $0.00 "$1,177.38" "$1,177.38" $0.00 $995.25 "$1,576.48" "$1,592.40" $0.00 $0.00 $311.51 $0.00 $0.00 $316.89 $0.00 $0.00 $0.00 $0.00 $0.00 55740105535 SUP HCPCS C1713 55740105535 - SCREW BN 5.5MM 35MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740105540 SUP HCPCS C1713 55740105540 - SCREW BN 5.5MM 40MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740105545 SUP HCPCS C1713 55740105545 - SCREW BN 5.5MM 45MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740105550 SUP HCPCS C1713 55740105550 - SCREW BN 5.5MM 50MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740106540 SUP HCPCS C1713 55740106540 - SCREW BN 6.5MM 40MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740106545 SUP HCPCS C1713 55740106545 - SCREW BN 6.5MM 45MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740106550 SUP HCPCS C1713 55740106550 - SCREW BN 6.5MM 50MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740106555 SUP HCPCS C1713 55740106555 - SCREW BN 6.5MM 55MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740107540 SUP HCPCS C1713 55740107540 - SCREW BN 7.5MM 40MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740107545 SUP HCPCS C1713 55740107545 - SCREW BN 7.5MM 45MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740107550 SUP HCPCS C1713 55740107550 - SCREW BN 7.5MM 50MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740107555 SUP HCPCS C1713 55740107555 - SCREW BN 7.5MM 55MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740108535 SUP HCPCS C1713 55740108535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740108540 SUP HCPCS C1713 55740108540 - SCREW BN 8.5MM 40MM SOLERA CD HZN MA HA SPNE 5/6MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740108545 SUP HCPCS C1713 55740108545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55740108550 SUP HCPCS C1713 55740108550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004025 SUP HCPCS C1713 55811004025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004030 SUP HCPCS C1713 55811004030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004035 SUP HCPCS C1713 55811004035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004040 SUP HCPCS C1713 55811004040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004045 SUP HCPCS C1713 55811004045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004520 SUP HCPCS C1713 55811004520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004525 SUP HCPCS C1713 55811004525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004530 SUP HCPCS C1713 55811004530 - SCREW BN 4.5MM 30MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004535 SUP HCPCS C1713 55811004535 - SCREW BN 4.5MM 35MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004540 SUP HCPCS C1713 55811004540 - SCREW BN 4.5MM 40MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811004545 SUP HCPCS C1713 55811004545 - SCREW BN 4.5MM 45MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005020 SUP HCPCS C1713 55811005020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005025 SUP HCPCS C1713 55811005025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005030 SUP HCPCS C1713 55811005030 - SCREW BN 5MM 30MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005035 SUP HCPCS C1713 55811005035 - SCREW BN 5MM 35MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005040 SUP HCPCS C1713 55811005040 - SCREW BN 5MM 40MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005045 SUP HCPCS C1713 55811005045 - SCREW BN 5MM 45MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005050 SUP HCPCS C1713 55811005050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005520 SUP HCPCS C1713 55811005520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005525 SUP HCPCS C1713 55811005525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005530 SUP HCPCS C1713 55811005530 - SCREW BN 5.5MM 30MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005535 SUP HCPCS C1713 55811005535 - SCREW BN 5.5MM 35MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005540 SUP HCPCS C1713 55811005540 - SCREW BN 5.5MM 40MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005545 SUP HCPCS C1713 55811005545 - SCREW BN 5.5MM 45MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005550 SUP HCPCS C1713 55811005550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811005555 SUP HCPCS C1713 55811005555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006030 SUP HCPCS C1713 55811006030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006035 SUP HCPCS C1713 55811006035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006040 SUP HCPCS C1713 55811006040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006045 SUP HCPCS C1713 55811006045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006050 SUP HCPCS C1713 55811006050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006525 SUP HCPCS C1713 55811006525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006530 SUP HCPCS C1713 55811006530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006535 SUP HCPCS C1713 55811006535 - SCREW BN 6.5MM 35MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006540 SUP HCPCS C1713 55811006540 - SCREW BN 6.5MM 40MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006545 SUP HCPCS C1713 55811006545 - SCREW BN 6.5MM 45MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006550 SUP HCPCS C1713 55811006550 - SCREW BN 6.5MM 50MM SOLERA CD HZN SGTL ADJ COCR SPNE 5.5MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006555 SUP HCPCS C1713 55811006555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811006560 SUP HCPCS C1713 55811006560 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811007535 SUP HCPCS C1713 55811007535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811007540 SUP HCPCS C1713 55811007540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811007545 SUP HCPCS C1713 55811007545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811007550 SUP HCPCS C1713 55811007550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811007555 SUP HCPCS C1713 55811007555 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811008540 SUP HCPCS C1713 55811008540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811008545 SUP HCPCS C1713 55811008545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55811008550 SUP HCPCS C1713 55811008550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840001540 SUP HCPCS C1713 55840001540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840001545 SUP HCPCS C1713 55840001545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840001550 SUP HCPCS C1713 55840001550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840001555 SUP HCPCS C1713 55840001555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004020 SUP HCPCS C1713 55840004020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004025 SUP HCPCS C1713 55840004025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004030 SUP HCPCS C1713 55840004030 - SCREW BN 4MM 30MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004035 SUP HCPCS C1713 55840004035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004040 SUP HCPCS C1713 55840004040 - SCREW BN 4MM 40MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004045 SUP HCPCS C1713 55840004045 - SCREW BN 4MM 45MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004050 SUP HCPCS C1713 55840004050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004055 SUP HCPCS C1713 55840004055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004520 SUP HCPCS C1713 55840004520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004525 SUP HCPCS C1713 55840004525 - SCREW BN 4.5MM 25MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004530 SUP HCPCS C1713 55840004530 - SCREW BN 4.5MM 30MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004535 SUP HCPCS C1713 55840004535 - SCREW BN 4.5MM 35MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004540 SUP HCPCS C1713 55840004540 - SCREW BN 4.5MM 40MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004545 SUP HCPCS C1713 55840004545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004550 SUP HCPCS C1713 55840004550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840004555 SUP HCPCS C1713 55840004555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005020 SUP HCPCS C1713 55840005020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005025 SUP HCPCS C1713 55840005025 - SCREW BN 5MM 25MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005030 SUP HCPCS C1713 55840005030 - SCREW BN 5MM 30MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005035 SUP HCPCS C1713 55840005035 - SCREW BN 5MM 35MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005040 SUP HCPCS C1713 55840005040 - SCREW BN 5MM 40MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005045 SUP HCPCS C1713 55840005045 - SCREW BN 5MM 45MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005050 SUP HCPCS C1713 55840005050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005055 SUP HCPCS C1713 55840005055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005520 SUP HCPCS C1713 55840005520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005525 SUP HCPCS C1713 55840005525 - SCREW BN 5.5MM 25MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005530 SUP HCPCS C1713 55840005530 - SCREW BN 5.5MM 30MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005535 SUP HCPCS C1713 55840005535 - SCREW BN 5.5MM 35MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005540 SUP HCPCS C1713 55840005540 - SCREW BN 5.5MM 40MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005545 SUP HCPCS C1713 55840005545 - SCREW BN 5.5MM 45MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005550 SUP HCPCS C1713 55840005550 - SCREW BN 5.5MM 50MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005555 SUP HCPCS C1713 55840005555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840005560 SUP HCPCS C1713 55840005560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006020 SUP HCPCS C1713 55840006020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006025 SUP HCPCS C1713 55840006025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006030 SUP HCPCS C1713 55840006030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006035 SUP HCPCS C1713 55840006035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006040 SUP HCPCS C1713 55840006040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006045 SUP HCPCS C1713 55840006045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006050 SUP HCPCS C1713 55840006050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006055 SUP HCPCS C1713 55840006055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006060 SUP HCPCS C1713 55840006060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006500 SUP HCPCS C1713 55840006500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006520 SUP HCPCS C1713 55840006520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006525 SUP HCPCS C1713 55840006525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006530 SUP HCPCS C1713 55840006530 - SCREW BN 6.5MM 30MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006535 SUP HCPCS C1713 55840006535 - SCREW BN 6.5MM 35MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006540 SUP HCPCS C1713 55840006540 - SCREW BN 6.5MM 40MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006545 SUP HCPCS C1713 55840006545 - SCREW BN 6.5MM 45MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006550 SUP HCPCS C1713 55840006550 - SCREW BN 6.5MM 50MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006555 SUP HCPCS C1713 55840006555 - SCREW BN 6.5MM 55MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006560 SUP HCPCS C1713 55840006560 - SCREW BN 6.5MM 60MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006565 SUP HCPCS C1713 55840006565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006570 SUP HCPCS C1713 55840006570 - SCREW BN 6.5MM 70MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006580 SUP HCPCS C1713 55840006580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840006590 SUP HCPCS C1713 55840006590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007500 SUP HCPCS C1713 55840007500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007525 SUP HCPCS C1713 55840007525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007530 SUP HCPCS C1713 55840007530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007535 SUP HCPCS C1713 55840007535 - SCREW BN 7.5MM 35MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007540 SUP HCPCS C1713 55840007540 - SCREW BN 7.5MM 40MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 55840007545 SUP HCPCS C1713 55840007545 - SCREW BN 7.5MM 45MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007550 SUP HCPCS C1713 55840007550 - SCREW BN 7.5MM 50MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007555 SUP HCPCS C1713 55840007555 - SCREW BN 7.5MM 55MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007560 SUP HCPCS C1713 55840007560 - SCREW BN 7.5MM 60MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007565 SUP HCPCS C1713 55840007565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007570 SUP HCPCS C1713 55840007570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007580 SUP HCPCS C1713 55840007580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840007590 SUP HCPCS C1713 55840007590 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008500 SUP HCPCS C1713 55840008500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008525 SUP HCPCS C1713 55840008525 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008530 SUP HCPCS C1713 55840008530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008535 SUP HCPCS C1713 55840008535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008540 SUP HCPCS C1713 55840008540 - SCREW BN 8.5MM 40MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008545 SUP HCPCS C1713 55840008545 - SCREW BN 8.5MM 45MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008550 SUP HCPCS C1713 55840008550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008555 SUP HCPCS C1713 55840008555 - SCREW BN 8.5MM 55MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008560 SUP HCPCS C1713 55840008560 - SCREW BN 8.5MM 60MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008565 SUP HCPCS C1713 55840008565 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008570 SUP HCPCS C1713 55840008570 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008580 SUP HCPCS C1713 55840008580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840008590 SUP HCPCS C1713 55840008590 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009500 SUP HCPCS C1713 55840009500 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009525 SUP HCPCS C1713 55840009525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009530 SUP HCPCS C1713 55840009530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009535 SUP HCPCS C1713 55840009535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009540 SUP HCPCS C1713 55840009540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009545 SUP HCPCS C1713 55840009545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009550 SUP HCPCS C1713 55840009550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009555 SUP HCPCS C1713 55840009555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009560 SUP HCPCS C1713 55840009560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009565 SUP HCPCS C1713 55840009565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009570 SUP HCPCS C1713 55840009570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009580 SUP HCPCS C1713 55840009580 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840009590 SUP HCPCS C1713 55840009590 - SCREW BN 9.5MM 90MM NS SOLERA CD HZN MA COCR SPNE 5.5MM ROD BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55840015545 SUP HCPCS C1713 55840015545 - SCREW BONE 5.5MM 45MM MULTIAX CANN SOLERA COCR SPN 5.5/6MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 55840015550 SUP HCPCS C1713 55840015550 - SCREW BONE 5.5MM 50MM CANN MULTIAX COCR SPN 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 55840016550 SUP HCPCS C1713 55840016550 - SCREW BONE 6.5MM 50MM MULTIAX CANN SOLERA COCR SPN 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 55840016555 SUP HCPCS C1713 55840016555 - SCREW BONE 6.5MM 55MM MULTIAX CANN COCR SPN 5.5 ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 55890004015 SUP HCPCS C1713 55890004015 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004020 SUP HCPCS C1713 55890004020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004025 SUP HCPCS C1713 55890004025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004030 SUP HCPCS C1713 55890004030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004035 SUP HCPCS C1713 55890004035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004040 SUP HCPCS C1713 55890004040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004045 SUP HCPCS C1713 55890004045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004050 SUP HCPCS C1713 55890004050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004055 SUP HCPCS C1713 55890004055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004060 SUP HCPCS C1713 55890004060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004065 SUP HCPCS C1713 55890004065 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004070 SUP HCPCS C1713 55890004070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004075 SUP HCPCS C1713 55890004075 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004080 SUP HCPCS C1713 55890004080 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004515 SUP HCPCS C1713 55890004515 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004520 SUP HCPCS C1713 55890004520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004525 SUP HCPCS C1713 55890004525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004530 SUP HCPCS C1713 55890004530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004535 SUP HCPCS C1713 55890004535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004540 SUP HCPCS C1713 55890004540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004545 SUP HCPCS C1713 55890004545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004550 SUP HCPCS C1713 55890004550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004555 SUP HCPCS C1713 55890004555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004560 SUP HCPCS C1713 55890004560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004565 SUP HCPCS C1713 55890004565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004570 SUP HCPCS C1713 55890004570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004575 SUP HCPCS C1713 55890004575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890004580 SUP HCPCS C1713 55890004580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005015 SUP HCPCS C1713 55890005015 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005020 SUP HCPCS C1713 55890005020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005025 SUP HCPCS C1713 55890005025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005030 SUP HCPCS C1713 55890005030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005035 SUP HCPCS C1713 55890005035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005040 SUP HCPCS C1713 55890005040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005045 SUP HCPCS C1713 55890005045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005050 SUP HCPCS C1713 55890005050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005055 SUP HCPCS C1713 55890005055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005060 SUP HCPCS C1713 55890005060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005065 SUP HCPCS C1713 55890005065 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005070 SUP HCPCS C1713 55890005070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005075 SUP HCPCS C1713 55890005075 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005080 SUP HCPCS C1713 55890005080 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005085 SUP HCPCS C1713 55890005085 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005090 SUP HCPCS C1713 55890005090 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005515 SUP HCPCS C1713 55890005515 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005520 SUP HCPCS C1713 55890005520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005525 SUP HCPCS C1713 55890005525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005530 SUP HCPCS C1713 55890005530 - SCREW BN 5.5MM 30MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005535 SUP HCPCS C1713 55890005535 - SCREW BN 5.5MM 35MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005540 SUP HCPCS C1713 55890005540 - SCREW BN 5.5MM 40MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005545 SUP HCPCS C1713 55890005545 - SCREW BN 5.5MM 45MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005550 SUP HCPCS C1713 55890005550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005555 SUP HCPCS C1713 55890005555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005560 SUP HCPCS C1713 55890005560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005565 SUP HCPCS C1713 55890005565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005570 SUP HCPCS C1713 55890005570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005575 SUP HCPCS C1713 55890005575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890005580 SUP HCPCS C1713 55890005580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006015 SUP HCPCS C1713 55890006015 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006020 SUP HCPCS C1713 55890006020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006025 SUP HCPCS C1713 55890006025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006030 SUP HCPCS C1713 55890006030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006035 SUP HCPCS C1713 55890006035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006040 SUP HCPCS C1713 55890006040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006045 SUP HCPCS C1713 55890006045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006050 SUP HCPCS C1713 55890006050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006055 SUP HCPCS C1713 55890006055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006060 SUP HCPCS C1713 55890006060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006065 SUP HCPCS C1713 55890006065 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006070 SUP HCPCS C1713 55890006070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006075 SUP HCPCS C1713 55890006075 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006080 SUP HCPCS C1713 55890006080 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006515 SUP HCPCS C1713 55890006515 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006520 SUP HCPCS C1713 55890006520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006525 SUP HCPCS C1713 55890006525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006530 SUP HCPCS C1713 55890006530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006535 SUP HCPCS C1713 55890006535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006540 SUP HCPCS C1713 55890006540 - SCREW BN 6.5MM 40MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006545 SUP HCPCS C1713 55890006545 - SCREW BN 6.5MM 45MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006550 SUP HCPCS C1713 55890006550 - SCREW BN 6.5MM 50MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006555 SUP HCPCS C1713 55890006555 - SCREW BN 6.5MM 55MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006560 SUP HCPCS C1713 55890006560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006565 SUP HCPCS C1713 55890006565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006570 SUP HCPCS C1713 55890006570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006575 SUP HCPCS C1713 55890006575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890006580 SUP HCPCS C1713 55890006580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007015 SUP HCPCS C1713 55890007015 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007020 SUP HCPCS C1713 55890007020 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007025 SUP HCPCS C1713 55890007025 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007030 SUP HCPCS C1713 55890007030 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007035 SUP HCPCS C1713 55890007035 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007040 SUP HCPCS C1713 55890007040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007045 SUP HCPCS C1713 55890007045 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007050 SUP HCPCS C1713 55890007050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007055 SUP HCPCS C1713 55890007055 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007060 SUP HCPCS C1713 55890007060 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007065 SUP HCPCS C1713 55890007065 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007070 SUP HCPCS C1713 55890007070 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007075 SUP HCPCS C1713 55890007075 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007080 SUP HCPCS C1713 55890007080 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007500 SUP HCPCS C1713 55890007500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007511 SUP HCPCS C1713 55890007511 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007515 SUP HCPCS C1713 55890007515 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007520 SUP HCPCS C1713 55890007520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007525 SUP HCPCS C1713 55890007525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007530 SUP HCPCS C1713 55890007530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007535 SUP HCPCS C1713 55890007535 - SCREW BN 7.5MM 35MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007540 SUP HCPCS C1713 55890007540 - SCREW BN 7.5MM 40MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007545 SUP HCPCS C1713 55890007545 - SCREW BN 7.5MM 45MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007550 SUP HCPCS C1713 55890007550 - SCREW BN 7.5MM 50MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007555 SUP HCPCS C1713 55890007555 - SCREW BN 7.5MM 55MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007560 SUP HCPCS C1713 55890007560 - SCREW BN 7.5MM 60MM SOLERA CD HZN RDC MA COCR SPNE 5.5/6MM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007565 SUP HCPCS C1713 55890007565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007570 SUP HCPCS C1713 55890007570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007575 SUP HCPCS C1713 55890007575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007580 SUP HCPCS C1713 55890007580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007585 SUP HCPCS C1713 55890007585 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007590 SUP HCPCS C1713 55890007590 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890007595 SUP HCPCS C1713 55890007595 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008000 SUP HCPCS C1713 55890008000 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008011 SUP HCPCS C1713 55890008011 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008015 SUP HCPCS C1713 55890008015 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008020 SUP HCPCS C1713 55890008020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008025 SUP HCPCS C1713 55890008025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008030 SUP HCPCS C1713 55890008030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008035 SUP HCPCS C1713 55890008035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008040 SUP HCPCS C1713 55890008040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008045 SUP HCPCS C1713 55890008045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008050 SUP HCPCS C1713 55890008050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008055 SUP HCPCS C1713 55890008055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008060 SUP HCPCS C1713 55890008060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008065 SUP HCPCS C1713 55890008065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008070 SUP HCPCS C1713 55890008070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008075 SUP HCPCS C1713 55890008075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008080 SUP HCPCS C1713 55890008080 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008085 SUP HCPCS C1713 55890008085 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008090 SUP HCPCS C1713 55890008090 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008095 SUP HCPCS C1713 55890008095 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008500 SUP HCPCS C1713 55890008500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008511 SUP HCPCS C1713 55890008511 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008515 SUP HCPCS C1713 55890008515 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008520 SUP HCPCS C1713 55890008520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008525 SUP HCPCS C1713 55890008525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008530 SUP HCPCS C1713 55890008530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008535 SUP HCPCS C1713 55890008535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008540 SUP HCPCS C1713 55890008540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008545 SUP HCPCS C1713 55890008545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008550 SUP HCPCS C1713 55890008550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008555 SUP HCPCS C1713 55890008555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008560 SUP HCPCS C1713 55890008560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008565 SUP HCPCS C1713 55890008565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008570 SUP HCPCS C1713 55890008570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008575 SUP HCPCS C1713 55890008575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008580 SUP HCPCS C1713 55890008580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008585 SUP HCPCS C1713 55890008585 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008590 SUP HCPCS C1713 55890008590 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890008595 SUP HCPCS C1713 55890008595 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009000 SUP HCPCS C1713 55890009000 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009011 SUP HCPCS C1713 55890009011 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009015 SUP HCPCS C1713 55890009015 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009020 SUP HCPCS C1713 55890009020 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009025 SUP HCPCS C1713 55890009025 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009030 SUP HCPCS C1713 55890009030 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009035 SUP HCPCS C1713 55890009035 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009040 SUP HCPCS C1713 55890009040 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009045 SUP HCPCS C1713 55890009045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009050 SUP HCPCS C1713 55890009050 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009055 SUP HCPCS C1713 55890009055 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009060 SUP HCPCS C1713 55890009060 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009065 SUP HCPCS C1713 55890009065 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009070 SUP HCPCS C1713 55890009070 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009075 SUP HCPCS C1713 55890009075 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009080 SUP HCPCS C1713 55890009080 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009085 SUP HCPCS C1713 55890009085 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009090 SUP HCPCS C1713 55890009090 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009095 SUP HCPCS C1713 55890009095 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009500 SUP HCPCS C1713 55890009500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009511 SUP HCPCS C1713 55890009511 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009515 SUP HCPCS C1713 55890009515 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009520 SUP HCPCS C1713 55890009520 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009525 SUP HCPCS C1713 55890009525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009530 SUP HCPCS C1713 55890009530 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009535 SUP HCPCS C1713 55890009535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009540 SUP HCPCS C1713 55890009540 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009545 SUP HCPCS C1713 55890009545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009550 SUP HCPCS C1713 55890009550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009555 SUP HCPCS C1713 55890009555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009560 SUP HCPCS C1713 55890009560 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009565 SUP HCPCS C1713 55890009565 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009570 SUP HCPCS C1713 55890009570 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009575 SUP HCPCS C1713 55890009575 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009580 SUP HCPCS C1713 55890009580 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009585 SUP HCPCS C1713 55890009585 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009590 SUP HCPCS C1713 55890009590 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55890009595 SUP HCPCS C1713 55890009595 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 60181210100 SUP Custom 27203010 ADAPTER TRNQT 36IN DUAL EXTN CPC CONNCTR STRL LF BOTH IP/OP $50.83 $37.61 $0.00 $40.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.41 $40.26 $40.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60707010400 SUP Custom 27203010 60707010400 - CUFF TRNQT 24X4IN 2 PORT 1 BLDR W/O SLV ATS STRL LATEX FREE BOTH IP/OP $73.39 $54.31 $0.00 $58.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.47 $54.47 $0.00 $0.00 $15.29 $0.00 $0.00 $0.00 $0.00 $36.69 $58.12 $58.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60707010500 SUP Custom 27203010 60707010500 - CUFF TRNQT 30X4IN 2 PORT 1 BLDR W/O SLV ATS STRL LATEX FREE BOTH IP/OP $78.02 $57.73 $0.00 $62.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.91 $57.91 $0.00 $0.00 $16.26 $0.00 $0.00 $0.00 $0.00 $39.01 $61.79 $62.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60707010600 SUP Custom 27203010 60707010600 - CUFF TRNQT 34X4IN 2 PORT 1 BLDR W/O SLV ATS STRL LATEX FREE BOTH IP/OP $84.46 $62.50 $0.00 $67.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.69 $62.69 $0.00 $0.00 $17.60 $0.00 $0.00 $0.00 $0.00 $42.23 $66.89 $67.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60707010700 SUP Custom 27203010 60707010700 - CUFF TRNQT CYL 42X4IN RUBY STRL LF ATS 3K 2 PORT BLDR POS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $0.00 $0.00 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9.89803E+11 SUP Custom 27203010 989803104341 - TUBING MONITR SMALL STATURE 10FT NIBP LATEX FREE REUSABLE BOTH IP/OP $252.17 $186.61 $0.00 $187.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.16 $187.16 $0.00 $0.00 $52.55 $0.00 $0.00 $0.00 $0.00 $62.16 $98.45 $99.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0.8P8 SUP Custom 27803010 0.8P8 - PATCH VASCULAR 8X.8CM BIOLOGIC XENOSURE THK.45MM TAPER BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00-0114-006-00 SUP Custom 27203010 00-0114-006-00 - HOLDER PIN 3/16IN 21X11CM LF BHLR-STNM THB SCR SS SKL TRX BOTH IP/OP $442.00 $327.08 $0.00 $353.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.05 $328.05 $0.00 $0.00 $92.11 $0.00 $0.00 $0.00 $0.00 $221.00 $350.06 $353.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 000-2090 SUP HCPCS C1781 000-2090 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,277.13 " $945.08 $0.00 "$1,021.70" $574.71 $574.71 $0.00 $0.00 $0.00 $266.18 $947.88 $947.88 $0.00 $0.00 $266.15 $0.00 $755.42 $755.42 $0.00 $638.56 "$1,011.49" "$1,021.70" $0.00 $0.00 $199.87 $0.00 $0.00 $203.32 $0.00 $0.00 $0.00 $0.00 $0.00 00085-4602-02 SUP HCPCS C2626 00085-4602-02 - SCREW SYSTEM INSPIREASE DRUG DELIVERY EA BOTH IP/OP $111.93 $82.83 $0.00 $89.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.07 $83.07 $0.00 $0.00 $23.33 $0.00 $0.00 $0.00 $0.00 $55.97 $88.65 $89.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0010DTR SUP Custom 27203010 BAG LNDR RD 38X38IN DRAWTAPE 40GL BOTH IP/OP $1.40 $1.04 $0.00 $1.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.70 $1.11 $1.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00208-00 SUP Custom 27203010 ASSEMBLY ANTICOAGULATION/ASPIRATION TUBING FOR CELL SAVER PA BOTH IP/OP $63.38 $46.90 $0.00 $50.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.04 $47.04 $0.00 $0.00 $13.21 $0.00 $0.00 $0.00 $0.00 $31.69 $50.20 $50.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00-2348-010-35 SUP HCPCS C1713 00-2348-010-35 - SCREW BONE 3.5MM 10MM SS 2.7MM HEAD CORT PERIART SLFTAP BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $15.58 $55.48 $55.48 $0.00 $0.00 $15.58 $0.00 $44.21 $44.21 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 00-2348-012-35 SUP HCPCS C1713 00-2348-012-35 - SCREW BONE 3.5MM 2.7MM 12MM SS 2.7MM HEAD PERIART SLFTAP BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $15.58 $55.48 $55.48 $0.00 $0.00 $15.58 $0.00 $44.21 $44.21 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 00-2348-014-35 SUP HCPCS C1713 00-2348-014-35 - SCREW BONE 3.5MM 2.7MM 14MM SS 2.7MM HEAD CORT PERIART BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $15.58 $55.48 $55.48 $0.00 $0.00 $15.58 $0.00 $44.21 $44.21 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 00-2348-016-35 SUP HCPCS C1713 00-2348-016-35 - SCREW BONE 3.5MM 2.7MM 16MM SS 2.7MM HEAD CORT PERIART BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $15.58 $55.48 $55.48 $0.00 $0.00 $15.58 $0.00 $44.21 $44.21 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 00-2348-018-35 SUP HCPCS C1713 00-2348-018-35 - SCREW BONE 3.5MM 2.7MM 18MM SS 2.7MM HEAD CORT PERIART BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $15.58 $55.48 $55.48 $0.00 $0.00 $15.58 $0.00 $44.21 $44.21 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 00-2348-020-35 SUP HCPCS C1713 00-2348-020-35 - SCREW BONE 3.5MM 2.7MM 20MM SS 2.7MM HEAD CORT PERIART BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $15.58 $55.48 $55.48 $0.00 $0.00 $15.58 $0.00 $44.21 $44.21 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 00-2348-022-35 SUP HCPCS C1713 00-2348-022-35 - SCREW BONE 3.5MM 2.7MM 22MM SS 2.7MM HEAD CORT PERIART BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $15.58 $55.48 $55.48 $0.00 $0.00 $15.58 $0.00 $44.21 $44.21 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 00-2348-026-35 SUP HCPCS C1713 00-2348-026-35 - SCREW BONE 3.5MM 2.7MM 26MM SS 2.7MM HEAD CORT PERIART BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $15.58 $55.48 $55.48 $0.00 $0.00 $15.58 $0.00 $44.21 $44.21 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 00-2357-017-04 SUP HCPCS C1713 00-2357-017-04 - PLATE 80MM 4 HOLE LCK BONE RIGHT DISTAL LAT FIB BOTH IP/OP "$1,378.00 " "$1,019.72" $0.00 "$1,102.40" $620.10 $620.10 $0.00 $0.00 $0.00 $287.21 "$1,022.75" "$1,022.75" $0.00 $0.00 $287.18 $0.00 $815.09 $815.09 $0.00 $689.00 "$1,091.38" "$1,102.40" $0.00 $0.00 $215.66 $0.00 $0.00 $219.38 $0.00 $0.00 $0.00 $0.00 $0.00 00-2357-017-06 SUP HCPCS C1713 00-2357-017-06 - PLATE 106MM 6 HOLE LCK BONE RIGHT DISTAL LAT FIB BOTH IP/OP "$1,478.75 " "$1,094.28" $0.00 "$1,183.00" $665.44 $665.44 $0.00 $0.00 $0.00 $308.21 "$1,097.53" "$1,097.53" $0.00 $0.00 $308.17 $0.00 $874.68 $874.68 $0.00 $739.38 "$1,171.17" "$1,183.00" $0.00 $0.00 $231.42 $0.00 $0.00 $235.42 $0.00 $0.00 $0.00 $0.00 $0.00 00-2357-017-08 SUP HCPCS C1713 00-2357-017-08 - PLATE 132MM 8 HOLE LCK BONE RL DISTAL FIB BOTH IP/OP "$1,579.50 " "$1,168.83" $0.00 "$1,263.60" $710.78 $710.78 $0.00 $0.00 $0.00 $329.21 "$1,172.30" "$1,172.30" $0.00 $0.00 $329.17 $0.00 $934.27 $934.27 $0.00 $789.75 "$1,250.96" "$1,263.60" $0.00 $0.00 $247.19 $0.00 $0.00 $251.46 $0.00 $0.00 $0.00 $0.00 $0.00 00-2357-018-04 SUP HCPCS C1713 00-2357-018-04 - PLATE 40 HOLE BONE RIGHT FIB BOTH IP/OP "$1,378.00 " "$1,019.72" $0.00 "$1,102.40" $620.10 $620.10 $0.00 $0.00 $0.00 $287.21 "$1,022.75" "$1,022.75" $0.00 $0.00 $287.18 $0.00 $815.09 $815.09 $0.00 $689.00 "$1,091.38" "$1,102.40" $0.00 $0.00 $215.66 $0.00 $0.00 $219.38 $0.00 $0.00 $0.00 $0.00 $0.00 00-2357-018-06 SUP HCPCS C1713 00-2357-018-06 - PLATE 106MM 6 HOLE LCK BONE LEFT DISTAL LAT FIB BOTH IP/OP "$1,478.75 " "$1,094.28" $0.00 "$1,183.00" $665.44 $665.44 $0.00 $0.00 $0.00 $308.21 "$1,097.53" "$1,097.53" $0.00 $0.00 $308.17 $0.00 $874.68 $874.68 $0.00 $739.38 "$1,171.17" "$1,183.00" $0.00 $0.00 $231.42 $0.00 $0.00 $235.42 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-012-38 SUP HCPCS C1713 00-2359-012-38 - SCREW BONE 3.5MM 2.7MM 12MM SS PERIART LCK HEAD NONSTRL BOTH IP/OP $201.50 $149.11 $0.00 $161.20 $90.68 $90.68 $0.00 $0.00 $0.00 $42.00 $149.55 $149.55 $0.00 $0.00 $41.99 $0.00 $119.19 $119.19 $0.00 $100.75 $159.59 $161.20 $0.00 $0.00 $31.53 $0.00 $0.00 $32.08 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-014-38 SUP HCPCS C1713 00-2359-014-38 - SCREW BONE 3.5MM 2.7MM 14MM SS PERIART LCK NONSTRL BOTH IP/OP $201.50 $149.11 $0.00 $161.20 $90.68 $90.68 $0.00 $0.00 $0.00 $42.00 $149.55 $149.55 $0.00 $0.00 $41.99 $0.00 $119.19 $119.19 $0.00 $100.75 $159.59 $161.20 $0.00 $0.00 $31.53 $0.00 $0.00 $32.08 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-016-26 SUP HCPCS C1713 00-2359-016-26 - SCREW BONE 2.7MM 16MM SS CONICAL NONSTRL BOTH IP/OP $113.75 $84.18 $0.00 $91.00 $51.19 $51.19 $0.00 $0.00 $0.00 $23.71 $84.43 $84.43 $0.00 $0.00 $23.71 $0.00 $67.28 $67.28 $0.00 $56.88 $90.09 $91.00 $0.00 $0.00 $17.80 $0.00 $0.00 $18.11 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-016-38 SUP HCPCS C1713 00-2359-016-38 - SCREW BONE 3.5MM 2.7MM 16MM SS PERIART LCK NONSTRL BOTH IP/OP $201.50 $149.11 $0.00 $161.20 $90.68 $90.68 $0.00 $0.00 $0.00 $42.00 $149.55 $149.55 $0.00 $0.00 $41.99 $0.00 $119.19 $119.19 $0.00 $100.75 $159.59 $161.20 $0.00 $0.00 $31.53 $0.00 $0.00 $32.08 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-018-35 SUP HCPCS C1713 00-2359-018-35 - SCREW BONE 3.5MM 18MM SS PERIART LCK NONSTRL BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-018-38 SUP HCPCS C1713 00-2359-018-38 - SCREW BONE 3.5MM 2.7MM 18MM SS 2.7MM HEAD PERIART LCK BOTH IP/OP $201.50 $149.11 $0.00 $161.20 $90.68 $90.68 $0.00 $0.00 $0.00 $42.00 $149.55 $149.55 $0.00 $0.00 $41.99 $0.00 $119.19 $119.19 $0.00 $100.75 $159.59 $161.20 $0.00 $0.00 $31.53 $0.00 $0.00 $32.08 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-040-35 SUP HCPCS C1713 00-2359-040-35 - SCREW BONE 3.5MM 40MM PRLC SS PERIART LCK NCLNLT NONSTRL PLT BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-044-35 SUP HCPCS C1713 00-2359-044-35 - SCREW BONE 3.5MM 44MM SS PERIART LCK NCLNLT NONSTRL PLT SYS BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-046-35 SUP HCPCS C1713 00-2359-046-35 - SCREW BONE 3.5MM 46MM SS PERIART NON CANN LCK NONSTRL PLT BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-048-35 SUP HCPCS C1713 00-2359-048-35 - SCREW BONE 3.5MM 48MM SS PERIART NCLNLT LCK NONSTRL PLT SYS BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-2359-050-37 SUP HCPCS C1713 00-2359-050-37 - SCREW BONE 3.5MM 50MM PRLC SS PERIART CANN CONICAL LCK BOTH IP/OP $191.75 $141.90 $0.00 $153.40 $86.29 $86.29 $0.00 $0.00 $0.00 $39.97 $142.32 $142.32 $0.00 $0.00 $39.96 $0.00 $113.42 $113.42 $0.00 $95.88 $151.87 $153.40 $0.00 $0.00 $30.01 $0.00 $0.00 $30.53 $0.00 $0.00 $0.00 $0.00 $0.00 00-2410-029-00 SUP Custom 27203010 00-2410-029-00 - BIT DRL 2.5MM 220MM QCK CNCT BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00-2490-012-30 SUP HCPCS C1713 00-2490-012-30 - PIN EXFIX 305MM 3MM NTR NAIL THRD BOTH IP/OP $211.25 $156.33 $0.00 $169.00 $95.06 $95.06 $0.00 $0.00 $0.00 $44.03 $156.79 $156.79 $0.00 $0.00 $44.02 $0.00 $124.95 $124.95 $0.00 $105.63 $167.31 $169.00 $0.00 $0.00 $33.06 $0.00 $0.00 $33.63 $0.00 $0.00 $0.00 $0.00 $0.00 00-2490-034-49 SUP Custom 27203010 00-2490-034-49 - DRILL SRG 4.9MM RTRGD CLBRT FEM BOTH IP/OP $955.50 $707.07 $0.00 $764.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $709.17 $709.17 $0.00 $0.00 $199.13 $0.00 $0.00 $0.00 $0.00 $477.75 $756.76 $764.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00-2490-046-30 SUP HCPCS C1713 00-2490-046-30 - PIN 3MM NTR NAIL THRD STD IM NAIL BOTH IP/OP $227.50 $168.35 $0.00 $182.00 $102.38 $102.38 $0.00 $0.00 $0.00 $47.42 $168.85 $168.85 $0.00 $0.00 $47.41 $0.00 $134.57 $134.57 $0.00 $113.75 $180.18 $182.00 $0.00 $0.00 $35.60 $0.00 $0.00 $36.22 $0.00 $0.00 $0.00 $0.00 $0.00 00-2490-047-30 SUP HCPCS C1713 00-2490-047-30 - PIN FIX 355MM 3MM NTR NAIL NTHRD BOTH IP/OP $253.50 $187.59 $0.00 $202.80 $114.08 $114.08 $0.00 $0.00 $0.00 $52.84 $188.15 $188.15 $0.00 $0.00 $52.83 $0.00 $149.95 $149.95 $0.00 $126.75 $200.77 $202.80 $0.00 $0.00 $39.67 $0.00 $0.00 $40.36 $0.00 $0.00 $0.00 $0.00 $0.00 00-4806-100-20 SUP Custom 27203010 00-4806-100-20 - BIT DRL 2MM 100MM QCK CNCT BOTH IP/OP $139.75 $103.42 $0.00 $111.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.72 $103.72 $0.00 $0.00 $29.12 $0.00 $0.00 $0.00 $0.00 $69.88 $110.68 $111.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00-4806-110-25 SUP Custom 27203010 00-4806-110-25 - BIT DRL 2.5MM 110MM QCK CNCT BOTH IP/OP $139.75 $103.42 $0.00 $111.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.72 $103.72 $0.00 $0.00 $29.12 $0.00 $0.00 $0.00 $0.00 $69.88 $110.68 $111.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00-4806-110-35 SUP Custom 27203010 00-4806-110-35 - BIT DRL 3.5MM BOTH IP/OP $139.75 $103.42 $0.00 $111.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.72 $103.72 $0.00 $0.00 $29.12 $0.00 $0.00 $0.00 $0.00 $69.88 $110.68 $111.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00-4827-020-01 SUP HCPCS C1713 00-4827-020-01 - SCREW BONE 2.7MM 20MM ZPS SS SM CORT SLFTAP SM HEX RECESS BOTH IP/OP $45.50 $33.67 $0.00 $36.40 $20.48 $20.48 $0.00 $0.00 $0.00 $9.48 $33.77 $33.77 $0.00 $0.00 $9.48 $0.00 $26.91 $26.91 $0.00 $22.75 $36.04 $36.40 $0.00 $0.00 $7.12 $0.00 $0.00 $7.24 $0.00 $0.00 $0.00 $0.00 $0.00 00-4828-012-02 SUP HCPCS C1713 00-4828-012-02 - SCREW BONE 2.7MM 12MM SS UNV LCK NONSTRL BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-4828-014-02 SUP HCPCS C1713 00-4828-014-02 - SCREW BONE 2.7MM 14MM SS UNV LCK NONSTRL BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-4828-016-02 SUP HCPCS C1713 00-4828-016-02 - SCREW BONE 2.7MM 16MM ORTH BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-4828-018-02 SUP HCPCS C1713 00-4828-018-02 - SCREW BONE 2.7MM 18MM SS UNV LCK NONSTRL BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-4828-020-02 SUP HCPCS C1713 00-4828-020-02 - SCREW BONE 2.7MM 20MM SS UNV PERIART ELB LCK NONSTRL BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $97.99 $97.99 $0.00 $0.00 $0.00 $45.38 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $128.80 $128.80 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $34.08 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $0.00 00-4835-016-01 SUP HCPCS C1713 00-4835-016-01 - SCREW BONE 3.5MM 16MM ZPS SS SM CORT SLFTAP SM HEX RECESS BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $10.84 $38.59 $38.59 $0.00 $0.00 $10.84 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $8.14 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 00-4835-018-01 SUP HCPCS C1713 00-4835-018-01 - SCREW BONE 3.5MM 18MM ZPS SS LNG CORT SLFTAP SM HEX RECESS BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $10.84 $38.59 $38.59 $0.00 $0.00 $10.84 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $8.14 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 00-4835-026-01 SUP HCPCS C1713 00-4835-026-01 - SCREW BONE 3.5MM 26MM ZPS SS CORT SLFTAP SM HEX RECESS BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $10.84 $38.59 $38.59 $0.00 $0.00 $10.84 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $8.14 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 00-4835-040-01 SUP HCPCS C1713 00-4835-040-01 - SCREW BONE 3.5MM 40MM ZPS SS CORT SLFTAP SM HEX RECESS SM BOTH IP/OP $52.00 $38.48 $0.00 $41.60 $23.40 $23.40 $0.00 $0.00 $0.00 $10.84 $38.59 $38.59 $0.00 $0.00 $10.84 $0.00 $30.76 $30.76 $0.00 $26.00 $41.18 $41.60 $0.00 $0.00 $8.14 $0.00 $0.00 $8.28 $0.00 $0.00 $0.00 $0.00 $0.00 00-4840-040-00 SUP HCPCS C1713 00-4840-040-00 - SCREW BONE 4MM 40MM 14MM ZPS SS PTHRD CANC SM HEX RECESS BOTH IP/OP $42.25 $31.27 $0.00 $33.80 $19.01 $19.01 $0.00 $0.00 $0.00 $8.81 $31.36 $31.36 $0.00 $0.00 $8.80 $0.00 $24.99 $24.99 $0.00 $21.13 $33.46 $33.80 $0.00 $0.00 $6.61 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 00-4840-050-00 SUP HCPCS C1713 00-4840-050-00 - SCREW BONE 4MM 50MM ZPS SS FULTHD CANC SM HEX RECESS NONSTRL BOTH IP/OP $42.25 $31.27 $0.00 $33.80 $19.01 $19.01 $0.00 $0.00 $0.00 $8.81 $31.36 $31.36 $0.00 $0.00 $8.80 $0.00 $24.99 $24.99 $0.00 $21.13 $33.46 $33.80 $0.00 $0.00 $6.61 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 00-4840-050-01 SUP HCPCS C1713 00-4840-050-01 - SCREW BONE 4MM 15MM ZPS SS CANC PTTHRD SM HEX RECESS FRAG BOTH IP/OP $42.25 $31.27 $0.00 $33.80 $19.01 $19.01 $0.00 $0.00 $0.00 $8.81 $31.36 $31.36 $0.00 $0.00 $8.80 $0.00 $24.99 $24.99 $0.00 $21.13 $33.46 $33.80 $0.00 $0.00 $6.61 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $0.00 00-4901-016-15 SUP Custom 27203010 00-4901-016-15 - WIRE 1.6MM .063IN 15.2CM KWIRE ZPS SS 1 END TROCAR PNT BOTH IP/OP $16.58 $12.27 $0.00 $13.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.30 $12.30 $0.00 $0.00 $3.45 $0.00 $0.00 $0.00 $0.00 $8.29 $13.13 $13.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 005280-901 SUP Custom 27203010 005280-901 - LGTR 8MM FRNG FLLPN TUBE BAND STRL DISP ENDSCP LATEX FREE BOTH IP/OP $36.09 $26.71 $0.00 $28.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.79 $26.79 $0.00 $0.00 $7.52 $0.00 $0.00 $0.00 $0.00 $18.05 $28.58 $28.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 00-6202-066-20 SUP HCPCS C1776 00-6202-066-20 - SHELL ACETAB 66MM HIP MLHL PRIM MDLR REV TRB MTL STRL BOTH IP/OP "$7,315.00 " "$5,413.10" $0.00 "$5,852.00" "$3,291.75" "$3,291.75" $0.00 $0.00 $0.00 "$1,524.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,524.45" $0.00 "$3,606.30" "$3,606.30" $0.00 "$3,657.50" "$5,793.48" "$5,852.00" $0.00 $0.00 "$1,144.80" $0.00 $0.00 "$1,164.55" $0.00 $0.00 $0.00 $0.00 $0.00 00-6250-65-20 SUP HCPCS C1713 00-6250-65-20 - SCREW BN 6.5MM 20MM TRLG ST BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 00-6250-65-35 SUP HCPCS C1713 00-6250-65-35 - SCREW BN 6.5MM 35MM TRLG ST BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 00-6334-050-28 SUP HCPCS C1776 00-6334-050-28 - LINER ACETAB TRLG 8.3MM 50/52/54MM 28MM LNGVT HIP BOTH IP/OP "$14,925.00 " "$11,044.50" $0.00 "$11,940.00" "$6,716.25" "$6,716.25" $0.00 $0.00 $0.00 "$3,110.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,110.37" $0.00 "$7,358.03" "$7,358.03" $0.00 "$7,462.50" "$11,820.60" "$11,940.00" $0.00 $0.00 "$2,335.76" $0.00 $0.00 "$2,376.06" $0.00 $0.00 $0.00 $0.00 $0.00 00-7708-000-10 SUP Custom 27203010 00-7708-000-10 - CRR GFT 8IN SKIN PVC BRD CRR STRL LATEX FREE BOTH IP/OP $67.79 $50.16 $0.00 $54.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.31 $50.31 $0.00 $0.00 $14.13 $0.00 $0.00 $0.00 $0.00 $33.89 $53.69 $54.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 008556P SUP HCPCS C1733 008556P - CATHETER EP 5FR 110CM BP TEMP PCNG BLN FLW AST BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 01-0001-S SUP Custom 27803010 01-0001-S - CBL SLV ORTH 850MM 2MM HIP COCR SET STRL BOTH IP/OP "$1,047.50 " $775.15 $0.00 $838.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.45 $777.45 $0.00 $0.00 $218.30 $0.00 $0.00 $0.00 $0.00 $523.75 $829.62 $838.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0002-S SUP Custom 27203010 01-0002-S - SLEEVE CABLE 850MM 1.6MM ORTH COCR STRL BOTH IP/OP "$1,047.50 " $775.15 $0.00 $838.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.45 $777.45 $0.00 $0.00 $218.30 $0.00 $0.00 $0.00 $0.00 $523.75 $829.62 $838.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0011-S SUP Custom 27803010 01-0011-S - CABLE ORTH COCR 2MM 850MM BOTH IP/OP $715.00 $529.10 $0.00 $572.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $530.67 $530.67 $0.00 $0.00 $149.01 $0.00 $0.00 $0.00 $0.00 $357.50 $566.28 $572.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0012-S SUP Custom 27803010 01-0012-S - CABLE ORTH COCR 1.6MM 850MM STRL BOTH IP/OP $715.00 $529.10 $0.00 $572.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $530.67 $530.67 $0.00 $0.00 $149.01 $0.00 $0.00 $0.00 $0.00 $357.50 $566.28 $572.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0013-S SUP Custom 27203010 01-0013-S - SLEEVE CABLE 2MM COCR STRL BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0014-S SUP Custom 27203010 01-0014-S - SLEEVE CABLE 1.6MM COCR STRL BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0020-S SUP Custom 27203010 01-0020-S - SLEEVE CABLE 850MM 2MM SS STRL BOTH IP/OP "$1,047.50 " $775.15 $0.00 $838.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.45 $777.45 $0.00 $0.00 $218.30 $0.00 $0.00 $0.00 $0.00 $523.75 $829.62 $838.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0022-S SUP Custom 27203010 01-0022-S - SLEEVE CMPR SS 2MM BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $0.00 $0.00 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 010-0604 SUP Custom 27203010 010-0604 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $225.25 $166.69 $0.00 $180.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.18 $167.18 $0.00 $0.00 $46.94 $0.00 $0.00 $0.00 $0.00 $112.63 $178.40 $180.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 010-0806 SUP Custom 27203010 010-0806 - PLATE 18MM TI BONE SPNL BOTH IP/OP $272.00 $201.28 $0.00 $217.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.88 $201.88 $0.00 $0.00 $56.68 $0.00 $0.00 $0.00 $0.00 $136.00 $215.42 $217.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 010-103L SUP HCPCS C1713 010-103L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 010-103R SUP HCPCS C1713 010-103R - PLATE 18MM TI BONE SPNL BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 010-2001-5 SUP HCPCS C1781 010-2001-5 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,606.50 " "$1,188.81" $0.00 "$1,285.20" $722.93 $722.93 $0.00 $0.00 $0.00 $334.83 "$1,192.34" "$1,192.34" $0.00 $0.00 $334.79 $0.00 $950.24 $950.24 $0.00 $803.25 "$1,272.35" "$1,285.20" $0.00 $0.00 $251.42 $0.00 $0.00 $255.75 $0.00 $0.00 $0.00 $0.00 $0.00 010-2010 SUP HCPCS C1781 010-2010 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,115.63 " $825.57 $0.00 $892.50 $502.03 $502.03 $0.00 $0.00 $0.00 $232.52 $828.02 $828.02 $0.00 $0.00 $232.50 $0.00 $659.89 $659.89 $0.00 $557.81 $883.58 $892.50 $0.00 $0.00 $174.60 $0.00 $0.00 $177.61 $0.00 $0.00 $0.00 $0.00 $0.00 010-234 SUP HCPCS C1713 010-234 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 01-02950 SUP Custom 27803010 01-02950 - BAR ARCH 5IN ERICH SS FACE FX BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.12 $24.12 $0.00 $0.00 $6.77 $0.00 $0.00 $0.00 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0298 SUP HCPCS C1713 01-0298 - BAR ARCH PREFORM OMNIMAX MMF SYSTEM BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 01-0299 SUP Custom 27203010 01-0299 - BAR ARCH 1MR ROLL WIRE INSTR ERICH BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0102L12 SUP HCPCS C1729 0102L12 - CATHETER URETHRAL 12FR 2 WAY 1 DRAIN EYE FOLEY MEDIUM OLIVE BOTH IP/OP $25.13 $18.60 $0.00 $20.40 $13.85 $13.85 $0.00 $0.00 $0.00 $5.24 $18.65 $18.65 $0.00 $0.00 $5.24 $0.00 $14.86 $14.86 $0.00 $12.75 $20.20 $20.40 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 0102L14 SUP HCPCS C1729 0102L14 - CATH URTH BDX LBR 14FR FOLEY 2W CDE RADIOPQ DDRGL 5ML STRL BOTH IP/OP $25.75 $19.06 $0.00 $20.92 $14.20 $14.20 $0.00 $0.00 $0.00 $5.24 $18.65 $18.65 $0.00 $0.00 $5.24 $0.00 $14.86 $14.86 $0.00 $13.07 $20.71 $20.92 $0.00 $0.00 $4.09 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 0102L16 SUP HCPCS C1729 0102L16 - CATH URTH BDX LBR 16FR FOLEY 2W CDE 1 EYE DDRGL 5ML STRL BOTH IP/OP $26.15 $19.35 $0.00 $20.92 $14.20 $14.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.07 $20.71 $20.92 $0.00 $0.00 $4.09 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 0102L18 SUP HCPCS C1729 0102L18 - CATH URTH BDX LBR 18FR FOLEY 2W CDE RADIOPQ DDRGL 5ML STRL BOTH IP/OP $25.13 $18.60 $0.00 $20.92 $14.20 $14.20 $0.00 $0.00 $0.00 $5.24 $18.65 $18.65 $0.00 $0.00 $5.24 $0.00 $14.86 $14.86 $0.00 $13.07 $20.70 $20.92 $0.00 $0.00 $4.09 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 0102L20 SUP HCPCS C1729 0102L20 - CATH URTH BDX LBR 20FR FOLEY 2W CDE 1 EYE DDRGL 5ML STRL BOTH IP/OP $25.75 $19.06 $0.00 $20.92 $14.20 $14.20 $0.00 $0.00 $0.00 $5.24 $18.65 $18.65 $0.00 $0.00 $5.24 $0.00 $14.86 $14.86 $0.00 $13.07 $20.70 $20.92 $0.00 $0.00 $4.09 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 0102L22 SUP Custom 27203010 0102L22 - CATHETER URETHRAL 22FR 2 WAY 1 DRAIN EYE FOLEY MEDIUM OLIVE BOTH IP/OP $25.13 $18.60 $0.00 $20.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.65 $18.65 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $12.56 $19.90 $20.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0102L24 SUP Custom 27203010 0102L24 - CATHETER URETHRAL 24FR 2 WAY 1 DRAIN EYE FOLEY MEDIUM OLIVE BOTH IP/OP $25.13 $18.60 $0.00 $20.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.65 $18.65 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $12.56 $19.90 $20.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0102SI16 SUP Custom 27203010 0102SI16 - CATHETER URTH 16FR 5CC RD STRL LTX BDX IC 2W FL MED OLV CDE BOTH IP/OP $35.13 $26.00 $0.00 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.07 $26.07 $0.00 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $17.56 $27.82 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0102SI18 SUP Custom 27203010 0102SI18 - CATHETER URTH 18FR 5CC RD STRL LTX BDX IC 2W FL MED OLV CDE BOTH IP/OP $35.13 $26.00 $0.00 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.07 $26.07 $0.00 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $17.56 $27.82 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0102SI20 SUP Custom 27203010 0102SI20 - CATHETER URTH 20FR 5CC RD STRL LTX BDX IC 2W FL INFCT CNTRL BOTH IP/OP $35.13 $26.00 $0.00 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.07 $26.07 $0.00 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $17.56 $27.82 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0102SI22 SUP Custom 27203010 0102SI22 - CATHETER URTH 22FR 5CC RD STRL LTX BDX IC 2W FL MED OLV CDE BOTH IP/OP $35.13 $26.00 $0.00 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.07 $26.07 $0.00 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $17.56 $27.82 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0102SI24 SUP Custom 27203010 0102SI24 - CATHETER URTH 24FR 5CC RD STRL LTX BDX IC 2W FL INFCT CNTRL BOTH IP/OP $35.13 $26.00 $0.00 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.07 $26.07 $0.00 $0.00 $7.32 $0.00 $0.00 $0.00 $0.00 $17.56 $27.82 $28.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-0301 SUP Custom 27203010 01-0301 - BAND RUBBER SMALL 4MM ARCH BAR BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-03490 SUP Custom 27203010 01-03490 - WIRE FX .5MM 160MM LGT BLNT BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 01-03492 SUP Custom 27203010 01-03492 - WIRE FX .64MM 160MM LGT BLNT BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0104-07 SUP Custom 27203010 MEDIA CULT TETRATHIONATE BROTH BASE 2KG BOTH IP/OP $547.50 $405.15 $0.00 $438.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.75 $433.62 $438.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0112-18 SUP Custom 27203010 0112-18 - TUBE GSTRM Y 18FR ORNG LF MGNPRT BLN RND SKN DISK DEHP-FR BOTH IP/OP "$1,000.88 " $740.65 $0.00 $75.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.48 $75.48 $0.00 $0.00 $21.19 $0.00 $0.00 $0.00 $0.00 $33.31 $52.76 $53.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0112-20 SUP HCPCS B4087 0112-20 - TUBE GSTRM UNV 20FR 7-10ML STRL ASMB VAL G SIL ENTRL BOTH IP/OP $45.31 $33.53 $0.00 $36.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.63 $33.63 $0.00 $0.00 $9.44 $0.00 $0.00 $0.00 $0.00 $22.65 $35.89 $36.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0112-22 SUP HCPCS B4087 0112-22 - TUBE GSTRM 22FR 14IN BLU LF MGNPRT YPRT BLN CNCT SIL DISP BOTH IP/OP $45.31 $33.53 $0.00 $36.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.63 $33.63 $0.00 $0.00 $9.44 $0.00 $0.00 $0.00 $0.00 $22.65 $35.89 $36.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0112-24 SUP HCPCS B4087 0112-24 - TUBE GSTRM 24FR 14IN PEACH LF MGNPRT SDPRT BLN REPL SIL BOTH IP/OP $45.31 $33.53 $0.00 $36.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.63 $33.63 $0.00 $0.00 $9.44 $0.00 $0.00 $0.00 $0.00 $22.65 $35.89 $36.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0119L22 SUP Custom 27203010 0119L22 - CATHETER URETHRAL STANDARD 22FR 3 WAY 2 OPPOSING DRAIN EYE BOTH IP/OP $21.05 $15.58 $0.00 $16.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.62 $15.62 $0.00 $0.00 $4.39 $0.00 $0.00 $0.00 $0.00 $10.53 $16.67 $16.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0119SI18 SUP Custom 27203010 0119SI18 - CATHETER URTH 18FR 5CC AMBR STRL LTX BDX IC 3W FL BLN INFCT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0120-14-1.7 SUP Custom 27203010 0120-14-1.7 - KIT GASTROSTOMY LP TAPER 14FR 1.7CM 12IN ENTERAL FEED TUBE BOTH IP/OP $259.94 $192.36 $0.00 $209.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.93 $192.93 $0.00 $0.00 $54.17 $0.00 $0.00 $0.00 $0.00 $129.97 $209.07 $207.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0120-18-2.3 SUP HCPCS C1713 0120-18-2.3 - KIT GASTROSTOMY 18FR 2.3CM INTERNAL RETENTION BALLOON BOTH IP/OP $260.08 $192.46 $0.00 $208.06 $117.03 $117.03 $0.00 $0.00 $0.00 $54.21 $193.03 $193.03 $0.00 $0.00 $54.20 $0.00 $153.83 $153.83 $0.00 $130.04 $205.98 $208.06 $0.00 $0.00 $40.70 $0.00 $0.00 $41.40 $0.00 $0.00 $0.00 $0.00 $0.00 0120-18-2.5 SUP Custom 27203010 0120-18-2.5 - KIT GASTROSTOMY LP TAPER 18FR 2.5CM ENTERAL FEED TUBE DEHP BOTH IP/OP $494.62 $366.02 $0.00 $367.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $367.11 $367.11 $0.00 $0.00 $103.08 $0.00 $0.00 $0.00 $0.00 $129.97 $209.07 $207.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0120-18-4.5 SUP HCPCS C1713 0120-18-4.5 - KIT GASTROSTOMY LP TAPER 18FR 4.5CM ENTERAL FEED TUBE DEHP BOTH IP/OP $260.08 $192.46 $0.00 $208.06 $117.03 $117.03 $0.00 $0.00 $0.00 $54.21 $193.03 $193.03 $0.00 $0.00 $54.20 $0.00 $153.83 $153.83 $0.00 $130.04 $205.98 $208.06 $0.00 $0.00 $40.70 $0.00 $0.00 $41.40 $0.00 $0.00 $0.00 $0.00 $0.00 012DTC SUP Custom 27203010 012DTC - BAG DRAWTAPE 38 X38 CLEAR BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-016 SUP HCPCS C1713 015-016 - PLATE 18MM TI BONE SPNL BOTH IP/OP $452.63 $334.95 $0.00 $362.10 $203.68 $203.68 $0.00 $0.00 $0.00 $94.34 $335.94 $335.94 $0.00 $0.00 $94.33 $0.00 $267.73 $267.73 $0.00 $226.31 $358.48 $362.10 $0.00 $0.00 $70.84 $0.00 $0.00 $72.06 $0.00 $0.00 $0.00 $0.00 $0.00 015-016-C SUP HCPCS C1713 015-016-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $488.75 $361.68 $0.00 $391.00 $219.94 $219.94 $0.00 $0.00 $0.00 $101.87 $362.75 $362.75 $0.00 $0.00 $101.86 $0.00 $289.10 $289.10 $0.00 $244.38 $387.09 $391.00 $0.00 $0.00 $76.49 $0.00 $0.00 $77.81 $0.00 $0.00 $0.00 $0.00 $0.00 015-017 SUP HCPCS C1713 015-017 - PLATE 18MM TI BONE SPNL BOTH IP/OP $435.63 $322.37 $0.00 $348.50 $196.03 $196.03 $0.00 $0.00 $0.00 $90.80 $323.32 $323.32 $0.00 $0.00 $90.78 $0.00 $257.67 $257.67 $0.00 $217.81 $345.02 $348.50 $0.00 $0.00 $68.18 $0.00 $0.00 $69.35 $0.00 $0.00 $0.00 $0.00 $0.00 015-017-C SUP HCPCS C1713 015-017-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $463.25 $342.81 $0.00 $370.60 $208.46 $208.46 $0.00 $0.00 $0.00 $96.55 $343.82 $343.82 $0.00 $0.00 $96.54 $0.00 $274.01 $274.01 $0.00 $231.63 $366.89 $370.60 $0.00 $0.00 $72.50 $0.00 $0.00 $73.75 $0.00 $0.00 $0.00 $0.00 $0.00 015-018 SUP HCPCS C1713 015-018 - PLATE 18MM TI BONE SPNL BOTH IP/OP $461.13 $341.24 $0.00 $368.90 $207.51 $207.51 $0.00 $0.00 $0.00 $96.11 $342.25 $342.25 $0.00 $0.00 $96.10 $0.00 $272.76 $272.76 $0.00 $230.56 $365.21 $368.90 $0.00 $0.00 $72.17 $0.00 $0.00 $73.41 $0.00 $0.00 $0.00 $0.00 $0.00 015-018-C SUP HCPCS C1713 015-018-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $463.25 $342.81 $0.00 $370.60 $208.46 $208.46 $0.00 $0.00 $0.00 $96.55 $343.82 $343.82 $0.00 $0.00 $96.54 $0.00 $274.01 $274.01 $0.00 $231.63 $366.89 $370.60 $0.00 $0.00 $72.50 $0.00 $0.00 $73.75 $0.00 $0.00 $0.00 $0.00 $0.00 015-032 SUP HCPCS C1713 015-032 - PLATE 18MM TI BONE SPNL BOTH IP/OP $654.50 $484.33 $0.00 $523.60 $294.53 $294.53 $0.00 $0.00 $0.00 $136.41 $485.77 $485.77 $0.00 $0.00 $136.40 $0.00 $387.14 $387.14 $0.00 $327.25 $518.36 $523.60 $0.00 $0.00 $102.43 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $0.00 015-040 SUP HCPCS C1713 015-040 - PLATE BN STD STRG 4MM TIMESH 2 HL TI CRNL 1.5MM SCR BOTH IP/OP $93.50 $69.19 $0.00 $74.80 $42.08 $42.08 $0.00 $0.00 $0.00 $19.49 $69.40 $69.40 $0.00 $0.00 $19.49 $0.00 $55.31 $55.31 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $14.63 $0.00 $0.00 $14.89 $0.00 $0.00 $0.00 $0.00 $0.00 015-040-C SUP HCPCS C1713 015-040-C - PLATE 18MM TI BONE SPNL BOTH IP/OP $95.63 $70.77 $0.00 $76.50 $43.03 $43.03 $0.00 $0.00 $0.00 $19.93 $70.97 $70.97 $0.00 $0.00 $19.93 $0.00 $56.56 $56.56 $0.00 $47.81 $75.74 $76.50 $0.00 $0.00 $14.97 $0.00 $0.00 $15.22 $0.00 $0.00 $0.00 $0.00 $0.00 015-042 SUP HCPCS C1713 015-042 - PLATE BN STD STRG 8MM TIMESH 2 HL TI CRNL 1.5MM SCR BOTH IP/OP $95.63 $70.77 $0.00 $76.50 $43.03 $43.03 $0.00 $0.00 $0.00 $19.93 $70.97 $70.97 $0.00 $0.00 $19.93 $0.00 $56.56 $56.56 $0.00 $47.81 $75.74 $76.50 $0.00 $0.00 $14.97 $0.00 $0.00 $15.22 $0.00 $0.00 $0.00 $0.00 $0.00 015-042-C SUP HCPCS C1713 015-042-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $95.63 $70.77 $0.00 $76.50 $43.03 $43.03 $0.00 $0.00 $0.00 $19.93 $70.97 $70.97 $0.00 $0.00 $19.93 $0.00 $56.56 $56.56 $0.00 $47.81 $75.74 $76.50 $0.00 $0.00 $14.97 $0.00 $0.00 $15.22 $0.00 $0.00 $0.00 $0.00 $0.00 015-044 SUP HCPCS C1713 015-044 - PLATE 18MM TI BONE SPNL BOTH IP/OP $93.50 $69.19 $0.00 $74.80 $42.08 $42.08 $0.00 $0.00 $0.00 $19.49 $69.40 $69.40 $0.00 $0.00 $19.49 $0.00 $55.31 $55.31 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $14.63 $0.00 $0.00 $14.89 $0.00 $0.00 $0.00 $0.00 $0.00 015-044-C SUP HCPCS C1713 015-044-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $102.00 $75.48 $0.00 $81.60 $45.90 $45.90 $0.00 $0.00 $0.00 $21.26 $75.70 $75.70 $0.00 $0.00 $21.26 $0.00 $60.33 $60.33 $0.00 $51.00 $80.78 $81.60 $0.00 $0.00 $15.96 $0.00 $0.00 $16.24 $0.00 $0.00 $0.00 $0.00 $0.00 015-090 SUP HCPCS C1713 015-090 - PLATE BN STD CRV TIMESH 12 HL TI CRNL BOTH IP/OP $486.63 $360.11 $0.00 $389.30 $218.98 $218.98 $0.00 $0.00 $0.00 $101.42 $361.17 $361.17 $0.00 $0.00 $101.41 $0.00 $287.84 $287.84 $0.00 $243.31 $385.41 $389.30 $0.00 $0.00 $76.16 $0.00 $0.00 $77.47 $0.00 $0.00 $0.00 $0.00 $0.00 015-090-C SUP HCPCS C1713 015-090-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $486.63 $360.11 $0.00 $389.30 $218.98 $218.98 $0.00 $0.00 $0.00 $101.42 $361.17 $361.17 $0.00 $0.00 $101.41 $0.00 $287.84 $287.84 $0.00 $243.31 $385.41 $389.30 $0.00 $0.00 $76.16 $0.00 $0.00 $77.47 $0.00 $0.00 $0.00 $0.00 $0.00 015-1006 SUP Custom 27203010 015-1006 - PLATE 18MM TI BONE SPNL BOTH IP/OP $265.63 $196.57 $0.00 $212.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.15 $197.15 $0.00 $0.00 $55.36 $0.00 $0.00 $0.00 $0.00 $132.81 $210.38 $212.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-102L SUP HCPCS C1713 015-102L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 015-102R SUP HCPCS C1713 015-102R - PLATE 18MM TI BONE SPNL BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 015-104L SUP HCPCS C1713 015-104L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 015-104R SUP HCPCS C1713 015-104R - PLATE 18MM TI BONE SPNL BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 015-105L SUP HCPCS C1713 015-105L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $181.69 $181.69 $0.00 $0.00 $0.00 $84.15 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $238.82 $238.82 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $63.19 $0.00 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 015-105R SUP HCPCS C1713 015-105R - PLATE 18MM TI BONE SPNL BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $181.69 $181.69 $0.00 $0.00 $0.00 $84.15 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $238.82 $238.82 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $63.19 $0.00 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 015-106L SUP HCPCS C1713 015-106L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 015-106R SUP HCPCS C1713 015-106R - PLATE 18MM TI BONE SPNL BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 015-107R SUP HCPCS C1713 015-107R - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 015-1206 SUP Custom 27203010 015-1206 - PLATE 18MM TI BONE SPNL BOTH IP/OP $267.75 $198.14 $0.00 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.72 $198.72 $0.00 $0.00 $55.80 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-1208 SUP Custom 27203010 015-1208 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $267.75 $198.14 $0.00 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.72 $198.72 $0.00 $0.00 $55.80 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-130 SUP HCPCS C1713 015-130 - PLATE 18MM TI BONE SPNL BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $181.69 $181.69 $0.00 $0.00 $0.00 $84.15 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $238.82 $238.82 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $63.19 $0.00 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 015-1304 SUP Custom 27203010 015-1304 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $252.88 $187.13 $0.00 $202.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.68 $187.68 $0.00 $0.00 $52.70 $0.00 $0.00 $0.00 $0.00 $126.44 $200.28 $202.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-1306 SUP Custom 27203010 015-1306 - PLATE 18MM TI BONE SPNL BOTH IP/OP $252.88 $187.13 $0.00 $202.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.68 $187.68 $0.00 $0.00 $52.70 $0.00 $0.00 $0.00 $0.00 $126.44 $200.28 $202.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-1308 SUP Custom 27203010 015-1308 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $267.75 $198.14 $0.00 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.72 $198.72 $0.00 $0.00 $55.80 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-1312 SUP Custom 27203010 015-1312 - PLATE 18MM TI BONE SPNL BOTH IP/OP $225.25 $166.69 $0.00 $180.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.18 $167.18 $0.00 $0.00 $46.94 $0.00 $0.00 $0.00 $0.00 $112.63 $178.40 $180.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-132 SUP HCPCS C1713 015-132 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $181.69 $181.69 $0.00 $0.00 $0.00 $84.15 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $238.82 $238.82 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $63.19 $0.00 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 015-160 SUP HCPCS C1713 015-160 - PLATE 18MM TI BONE SPNL BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $181.69 $181.69 $0.00 $0.00 $0.00 $84.15 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $238.82 $238.82 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $63.19 $0.00 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 015-161 SUP HCPCS C1713 015-161 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $181.69 $181.69 $0.00 $0.00 $0.00 $84.15 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $238.82 $238.82 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $63.19 $0.00 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 015-2001-4 SUP HCPCS C1781 015-2001-4 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,519.38 " "$1,124.34" $0.00 "$1,215.50" $683.72 $683.72 $0.00 $0.00 $0.00 $316.68 "$1,127.68" "$1,127.68" $0.00 $0.00 $316.64 $0.00 $898.71 $898.71 $0.00 $759.69 "$1,203.35" "$1,215.50" $0.00 $0.00 $237.78 $0.00 $0.00 $241.88 $0.00 $0.00 $0.00 $0.00 $0.00 015-2001-4-C SUP HCPCS C1713 015-2001-4-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,468.38 " "$1,086.60" $0.00 "$1,174.70" $660.77 $660.77 $0.00 $0.00 $0.00 $306.05 "$1,089.83" "$1,089.83" $0.00 $0.00 $306.01 $0.00 $868.54 $868.54 $0.00 $734.19 "$1,162.96" "$1,174.70" $0.00 $0.00 $229.80 $0.00 $0.00 $233.77 $0.00 $0.00 $0.00 $0.00 $0.00 015-2001-5 SUP HCPCS C1713 015-2001-5 - PLATE BN 11CMX7.5CMX5MM GRIDMESH TI CRNM HERNIATED CRV DISK BOTH IP/OP "$1,489.63 " "$1,102.33" $0.00 "$1,191.70" $670.33 $670.33 $0.00 $0.00 $0.00 $310.48 "$1,105.60" "$1,105.60" $0.00 $0.00 $310.44 $0.00 $881.11 $881.11 $0.00 $744.81 "$1,179.79" "$1,191.70" $0.00 $0.00 $233.13 $0.00 $0.00 $237.15 $0.00 $0.00 $0.00 $0.00 $0.00 015-2001-5-C SUP HCPCS C1713 015-2001-5-C - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,538.50 " "$1,138.49" $0.00 "$1,230.80" $692.33 $692.33 $0.00 $0.00 $0.00 $320.66 "$1,141.87" "$1,141.87" $0.00 $0.00 $320.62 $0.00 $910.02 $910.02 $0.00 $769.25 "$1,218.49" "$1,230.80" $0.00 $0.00 $240.78 $0.00 $0.00 $244.93 $0.00 $0.00 $0.00 $0.00 $0.00 015-2010 SUP HCPCS C1713 015-2010 - PLATE BN SQ RECT 8MM TIMESH MESH TI CRNM 1.5MM SCR BOTH IP/OP "$1,230.38 " $910.48 $0.00 $984.30 $553.67 $553.67 $0.00 $0.00 $0.00 $256.44 $913.18 $913.18 $0.00 $0.00 $256.41 $0.00 $727.77 $727.77 $0.00 $615.19 $974.46 $984.30 $0.00 $0.00 $192.55 $0.00 $0.00 $195.88 $0.00 $0.00 $0.00 $0.00 $0.00 0152-0218S SUP Custom 27803010 0152-0218S - WIRE FX 1.8MM 310MM STRL KRSH CNDYL SCR BOTH IP/OP $192.10 $142.15 $0.00 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.58 $142.58 $0.00 $0.00 $40.03 $0.00 $0.00 $0.00 $0.00 $103.81 $164.44 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-2050 SUP Custom 27203010 015-2050 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,241.00 " $918.34 $0.00 $992.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $921.07 $921.07 $0.00 $0.00 $258.62 $0.00 $0.00 $0.00 $0.00 $620.50 $982.87 $992.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-230 SUP HCPCS C1713 015-230 - PLATE 18MM TI BONE SPNL BOTH IP/OP $384.63 $284.63 $0.00 $307.70 $173.08 $173.08 $0.00 $0.00 $0.00 $80.17 $285.47 $285.47 $0.00 $0.00 $80.16 $0.00 $227.51 $227.51 $0.00 $192.31 $304.63 $307.70 $0.00 $0.00 $60.19 $0.00 $0.00 $61.23 $0.00 $0.00 $0.00 $0.00 $0.00 015-233 SUP HCPCS C1713 015-233 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $384.63 $284.63 $0.00 $307.70 $173.08 $173.08 $0.00 $0.00 $0.00 $80.17 $285.47 $285.47 $0.00 $0.00 $80.16 $0.00 $227.51 $227.51 $0.00 $192.31 $304.63 $307.70 $0.00 $0.00 $60.19 $0.00 $0.00 $61.23 $0.00 $0.00 $0.00 $0.00 $0.00 015-234 SUP HCPCS C1713 015-234 - PLATE 18MM TI BONE SPNL BOTH IP/OP $384.63 $284.63 $0.00 $307.70 $173.08 $173.08 $0.00 $0.00 $0.00 $80.17 $285.47 $285.47 $0.00 $0.00 $80.16 $0.00 $227.51 $227.51 $0.00 $192.31 $304.63 $307.70 $0.00 $0.00 $60.19 $0.00 $0.00 $61.23 $0.00 $0.00 $0.00 $0.00 $0.00 015-236 SUP HCPCS C1713 015-236 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $363.38 $268.90 $0.00 $290.70 $163.52 $163.52 $0.00 $0.00 $0.00 $75.74 $269.70 $269.70 $0.00 $0.00 $75.73 $0.00 $214.94 $214.94 $0.00 $181.69 $287.80 $290.70 $0.00 $0.00 $56.87 $0.00 $0.00 $57.85 $0.00 $0.00 $0.00 $0.00 $0.00 015-237 SUP HCPCS C1713 015-237 - PLATE BN 2Y 5MM TIMESH 3X3 HL TI CRNL 1.5MM SCR BOTH IP/OP $376.13 $278.34 $0.00 $300.90 $169.26 $169.26 $0.00 $0.00 $0.00 $78.39 $279.16 $279.16 $0.00 $0.00 $78.38 $0.00 $222.48 $222.48 $0.00 $188.06 $297.89 $300.90 $0.00 $0.00 $58.86 $0.00 $0.00 $59.88 $0.00 $0.00 $0.00 $0.00 $0.00 015-246 SUP HCPCS C1713 015-246 - PLATE 18MM TI BONE SPNL BOTH IP/OP $233.75 $172.98 $0.00 $187.00 $105.19 $105.19 $0.00 $0.00 $0.00 $48.72 $173.49 $173.49 $0.00 $0.00 $48.71 $0.00 $138.26 $138.26 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $36.58 $0.00 $0.00 $37.21 $0.00 $0.00 $0.00 $0.00 $0.00 015-247 SUP HCPCS C1713 015-247 - PLATE BN STRG 5MM TIMESH 2X2 HL TI CRNMXF 1.5MM SCR BOTH IP/OP $233.75 $172.98 $0.00 $187.00 $105.19 $105.19 $0.00 $0.00 $0.00 $48.72 $173.49 $173.49 $0.00 $0.00 $48.71 $0.00 $138.26 $138.26 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $36.58 $0.00 $0.00 $37.21 $0.00 $0.00 $0.00 $0.00 $0.00 015-255 SUP HCPCS C1713 015-255 - PLATE BN X TIMESH TI CRNM 1.5MM SCR BOTH IP/OP $384.63 $284.63 $0.00 $307.70 $173.08 $173.08 $0.00 $0.00 $0.00 $80.17 $285.47 $285.47 $0.00 $0.00 $80.16 $0.00 $227.51 $227.51 $0.00 $192.31 $304.63 $307.70 $0.00 $0.00 $60.19 $0.00 $0.00 $61.23 $0.00 $0.00 $0.00 $0.00 $0.00 015-257 SUP HCPCS C1713 015-257 - PLATE BN STD SM SQ TIMESH 4 HL TI CRNL 1.5MM SCR BOTH IP/OP $393.13 $290.92 $0.00 $314.50 $176.91 $176.91 $0.00 $0.00 $0.00 $81.94 $291.78 $291.78 $0.00 $0.00 $81.93 $0.00 $232.53 $232.53 $0.00 $196.56 $311.36 $314.50 $0.00 $0.00 $61.52 $0.00 $0.00 $62.59 $0.00 $0.00 $0.00 $0.00 $0.00 015-257-C SUP HCPCS C1713 015-257-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $414.38 $306.64 $0.00 $331.50 $186.47 $186.47 $0.00 $0.00 $0.00 $86.37 $307.55 $307.55 $0.00 $0.00 $86.36 $0.00 $245.10 $245.10 $0.00 $207.19 $328.19 $331.50 $0.00 $0.00 $64.85 $0.00 $0.00 $65.97 $0.00 $0.00 $0.00 $0.00 $0.00 015-258 SUP HCPCS C1713 015-258 - PLATE 18MM TI BONE SPNL BOTH IP/OP $401.63 $297.21 $0.00 $321.30 $180.73 $180.73 $0.00 $0.00 $0.00 $83.71 $298.09 $298.09 $0.00 $0.00 $83.70 $0.00 $237.56 $237.56 $0.00 $200.81 $318.09 $321.30 $0.00 $0.00 $62.85 $0.00 $0.00 $63.94 $0.00 $0.00 $0.00 $0.00 $0.00 015-260-11 SUP HCPCS C1781 015-260-11 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $431.38 $319.22 $0.00 $345.10 $194.12 $194.12 $0.00 $0.00 $0.00 $89.91 $320.17 $320.17 $0.00 $0.00 $89.90 $0.00 $255.16 $255.16 $0.00 $215.69 $341.65 $345.10 $0.00 $0.00 $67.51 $0.00 $0.00 $68.67 $0.00 $0.00 $0.00 $0.00 $0.00 015-260-14 SUP HCPCS C1781 015-260-14 - PLATE 18MM TI BONE SPNL BOTH IP/OP $431.38 $319.22 $0.00 $345.10 $194.12 $194.12 $0.00 $0.00 $0.00 $89.91 $320.17 $320.17 $0.00 $0.00 $89.90 $0.00 $255.16 $255.16 $0.00 $215.69 $341.65 $345.10 $0.00 $0.00 $67.51 $0.00 $0.00 $68.67 $0.00 $0.00 $0.00 $0.00 $0.00 015-260-18 SUP HCPCS C1781 015-260-18 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $465.38 $344.38 $0.00 $372.30 $209.42 $209.42 $0.00 $0.00 $0.00 $97.00 $345.40 $345.40 $0.00 $0.00 $96.98 $0.00 $275.27 $275.27 $0.00 $232.69 $368.58 $372.30 $0.00 $0.00 $72.83 $0.00 $0.00 $74.09 $0.00 $0.00 $0.00 $0.00 $0.00 015-260-25 SUP Custom 27803010 015-260-25 - PLATE 18MM TI BONE SPNL BOTH IP/OP $558.88 $413.57 $0.00 $447.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $414.80 $414.80 $0.00 $0.00 $116.47 $0.00 $0.00 $0.00 $0.00 $279.44 $442.63 $447.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-262-14 SUP Custom 27803010 015-262-14 - COVER BUR HL 14MM TIMESH FAN BLDE TI CRNL BOTH IP/OP $431.38 $319.22 $0.00 $345.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.17 $320.17 $0.00 $0.00 $89.90 $0.00 $0.00 $0.00 $0.00 $215.69 $341.65 $345.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-262-16 SUP Custom 27803010 015-262-16 - LG BURR HOLE CVR. BOTH IP/OP $320.63 $237.27 $0.00 $256.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.97 $237.97 $0.00 $0.00 $66.82 $0.00 $0.00 $0.00 $0.00 $160.31 $253.94 $256.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-262-18 SUP Custom 27803010 015-262-18 - COVER BUR HL 18MM TIMESH FAN BLDE TI CRNMXF 1.5MM SCR BOTH IP/OP $439.88 $325.51 $0.00 $351.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.48 $326.48 $0.00 $0.00 $91.67 $0.00 $0.00 $0.00 $0.00 $219.94 $348.38 $351.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 015-273 SUP HCPCS C1713 015-273 - PLATE 18MM TI BONE SPNL BOTH IP/OP $618.38 $457.60 $0.00 $494.70 $278.27 $278.27 $0.00 $0.00 $0.00 $128.88 $458.96 $458.96 $0.00 $0.00 $128.87 $0.00 $365.77 $365.77 $0.00 $309.19 $489.76 $494.70 $0.00 $0.00 $96.78 $0.00 $0.00 $98.45 $0.00 $0.00 $0.00 $0.00 $0.00 015-275 SUP HCPCS C1713 015-275 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $433.50 $320.79 $0.00 $346.80 $195.08 $195.08 $0.00 $0.00 $0.00 $90.35 $321.74 $321.74 $0.00 $0.00 $90.34 $0.00 $256.42 $256.42 $0.00 $216.75 $343.33 $346.80 $0.00 $0.00 $67.84 $0.00 $0.00 $69.01 $0.00 $0.00 $0.00 $0.00 $0.00 015-276 SUP HCPCS C1713 015-276 - PLATE 18MM TI BONE SPNL BOTH IP/OP $454.75 $336.52 $0.00 $363.80 $204.64 $204.64 $0.00 $0.00 $0.00 $94.78 $337.52 $337.52 $0.00 $0.00 $94.77 $0.00 $268.98 $268.98 $0.00 $227.38 $360.16 $363.80 $0.00 $0.00 $71.17 $0.00 $0.00 $72.40 $0.00 $0.00 $0.00 $0.00 $0.00 016-100 SUP Custom 27803010 016-100 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,436.50 " "$1,063.01" $0.00 "$1,149.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,066.17" "$1,066.17" $0.00 $0.00 $299.37 $0.00 $0.00 $0.00 $0.00 $718.25 "$1,137.71" "$1,149.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 016-120 SUP Custom 27803010 016-120 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,967.75 " "$1,456.14" $0.00 "$1,574.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,460.46" "$1,460.46" $0.00 $0.00 $410.08 $0.00 $0.00 $0.00 $0.00 $983.88 "$1,558.46" "$1,574.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 016-128 SUP Custom 27803010 016-128 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,646.88 " "$1,218.69" $0.00 "$1,317.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.31" "$1,222.31" $0.00 $0.00 $343.21 $0.00 $0.00 $0.00 $0.00 $823.44 "$1,304.33" "$1,317.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 016-152 SUP Custom 27803010 016-152 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,171.75 " "$1,607.10" $0.00 "$1,737.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,611.87" "$1,611.87" $0.00 $0.00 $452.59 $0.00 $0.00 $0.00 $0.00 "$1,085.88" "$1,720.03" "$1,737.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 016-200 SUP Custom 27803010 016-200 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,069.38 " "$3,011.34" $0.00 "$3,255.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,020.29" "$3,020.29" $0.00 $0.00 $848.06 $0.00 $0.00 $0.00 $0.00 "$2,034.69" "$3,222.95" "$3,255.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0166L30 SUP HCPCS C1729 CATHETER URINARY BARDEX LUBRICATH FOLEY 30FR 30ML 2 WAY 2 ST BOTH IP/OP $9.58 $7.09 $0.00 $7.66 $5.20 $5.20 $0.00 $0.00 $0.00 $2.00 $7.11 $7.11 $0.00 $0.00 $2.00 $0.00 $5.66 $5.66 $0.00 $4.79 $7.59 $7.66 $0.00 $0.00 $1.50 $0.00 $0.00 $1.52 $0.00 $0.00 $0.00 $0.00 $0.00 0166SI20 SUP Custom 27203010 0166SI20 - CATHETER URTH 20FR 30CC STRL LTX BDX IC 2W FL BLN ATRM INS BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0166SI28 SUP Custom 27203010 0166SI28 - CATHETER URTH 28FR 30CC STRL LTX BDX IC 2W FL BLN ATRM INS BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0167L18 SUP Custom 27203010 0167L18 - CATHETER URETHRAL 18FR FOLEY 3 WAY ROUND TIP 2 STAGGERED EYE BOTH IP/OP $21.20 $15.69 $0.00 $16.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.73 $15.73 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $10.60 $16.79 $16.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0167L20 SUP Custom 27203010 0167L20 - CATHETER URETHRAL STANDARD 20FR 3 WAY 2 STAGGER DRAIN EYE BOTH IP/OP $21.20 $15.69 $0.00 $16.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.73 $15.73 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $10.60 $16.79 $16.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0167L22 SUP Custom 27203010 0167L22 - CATHETER URETHRAL STANDARD 22FR 3 WAY 2 STAGGER DRAIN EYE BOTH IP/OP $21.20 $15.69 $0.00 $16.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.73 $15.73 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $10.60 $16.79 $16.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0196L16 SUP Custom 27203010 0196L16 - CATHETER URTH 16FR 5CC RD STRL LTX BDX LBR 2W FL 2 OPPS DRN BOTH IP/OP $29.40 $21.76 $0.00 $24.82 $0.00 $0.00 $0.00 $0.00 $0.00 $6.13 $21.82 $21.82 $0.00 $0.00 $6.13 $0.00 $17.39 $17.39 $0.00 $15.51 $24.58 $24.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0196L18 SUP Custom 27203010 0196L18 - CATHETER URTH 18FR 5CC RD STRL LTX BDX LBR 2W FL 2 OPPS DRN BOTH IP/OP $29.40 $21.76 $0.00 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.82 $21.82 $0.00 $0.00 $6.13 $0.00 $0.00 $0.00 $0.00 $14.70 $23.28 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0196L20 SUP Custom 27203010 0196L20 - CATHETER URTH 20FR 5CC RD STRL LTX BDX LBR 2W FL 2 OPPS DRN BOTH IP/OP $352.80 $261.07 $0.00 $261.85 $0.00 $0.00 $0.00 $0.00 $0.00 $73.53 $261.85 $261.85 $0.00 $0.00 $73.52 $0.00 $208.68 $208.68 $0.00 $14.78 $23.40 $23.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0196L22 SUP Custom 27203010 0196L22 - CATHETER URTH 22FR 5CC RD STRL LTX BDX LBR 2W FL 2 OPPS DRN BOTH IP/OP $29.40 $21.76 $0.00 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.82 $21.82 $0.00 $0.00 $6.13 $0.00 $0.00 $0.00 $0.00 $14.70 $23.28 $23.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.00024.001 SUP Custom 27203010 02.00024.001 - BIT DRILL 145MM 4.3MM NCB SHRT STD FEM SS QC NONSTRL BOTH IP/OP $230.75 $170.76 $0.00 $184.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.26 $171.26 $0.00 $0.00 $48.09 $0.00 $0.00 $0.00 $0.00 $115.38 $182.75 $184.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.300 SUP HCPCS C1713 02.001.300 - PLATE BONE CURVE 242X17.5X5.2MM 10 HOLE LP PRECONTOUR BOTH IP/OP "$3,079.88 " "$2,279.11" $0.00 "$2,392.14" "$1,345.58" "$1,345.58" $0.00 $0.00 $0.00 $641.92 "$2,285.88" "$2,285.88" $0.00 $0.00 $641.85 $0.00 "$1,518.38" "$1,518.38" $0.00 "$1,495.09" "$2,368.22" "$2,392.14" $0.00 $0.00 $454.33 $0.00 $0.00 $476.04 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.300S SUP HCPCS C1713 02.001.300S - PLATE 242MM SS 4.5MM SCR 10 HOLE CVD LCP BONE LEFT CNDYLR BOTH IP/OP "$3,171.25 " "$2,346.73" $0.00 "$2,887.94" "$1,624.47" "$1,624.47" $0.00 $0.00 $0.00 $660.97 "$2,353.70" "$2,353.70" $0.00 $0.00 $660.89 $0.00 "$1,563.43" "$1,563.43" $0.00 "$1,804.96" "$2,859.06" "$2,887.94" $0.00 $0.00 $564.95 $0.00 $0.00 $574.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.302 SUP HCPCS C1713 02.001.302 - PLATE BN CRV 278X17.5X5.2MM NS LCP CMBN 12 HL LOPRFL BOTH IP/OP "$3,144.53 " "$2,326.95" $0.00 "$2,442.36" "$1,373.83" "$1,373.83" $0.00 $0.00 $0.00 $655.40 "$2,333.87" "$2,333.87" $0.00 $0.00 $655.32 $0.00 "$1,550.25" "$1,550.25" $0.00 "$1,526.48" "$2,417.94" "$2,442.36" $0.00 $0.00 $463.87 $0.00 $0.00 $486.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.304 SUP HCPCS C1713 02.001.304 - PLATE BN CRV 314X17.5X5.2MM NS LCP CMBN 14 HL LOPRFL BOTH IP/OP "$3,210.60 " "$2,375.84" $0.00 "$2,493.68" "$1,402.70" "$1,402.70" $0.00 $0.00 $0.00 $669.17 "$2,382.91" "$2,382.91" $0.00 $0.00 $669.09 $0.00 "$1,582.83" "$1,582.83" $0.00 "$1,558.55" "$2,468.74" "$2,493.68" $0.00 $0.00 $473.62 $0.00 $0.00 $496.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.304S SUP HCPCS C1713 02.001.304S - PLATE 314MM SS 4.5MM SCR 14 HOLE CVD LCK LCP BONE LEFT BOTH IP/OP "$3,301.98 " "$2,443.47" $0.00 "$3,007.34" "$1,691.63" "$1,691.63" $0.00 $0.00 $0.00 $688.21 "$2,450.73" "$2,450.73" $0.00 $0.00 $688.13 $0.00 "$1,627.87" "$1,627.87" $0.00 "$1,879.59" "$2,977.27" "$3,007.34" $0.00 $0.00 $588.31 $0.00 $0.00 $598.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.306 SUP HCPCS C1713 02.001.306 - PLATE BN CRV 350X17.5X5.2MM NS LCP CMBN 16 HL LOPRFL BOTH IP/OP "$3,272.45 " "$2,421.61" $0.00 "$2,541.72" "$1,429.72" "$1,429.72" $0.00 $0.00 $0.00 $682.06 "$2,428.81" "$2,428.81" $0.00 $0.00 $681.98 $0.00 "$1,613.32" "$1,613.32" $0.00 "$1,588.58" "$2,516.30" "$2,541.72" $0.00 $0.00 $482.74 $0.00 $0.00 $505.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.308 SUP HCPCS C1713 02.001.308 - PLATE BN CRV 386X17.5X5.2MM NS LCP CMBN 18 HL LOPRFL BOTH IP/OP "$3,453.78 " "$2,555.80" $0.00 "$2,682.56" "$1,508.94" "$1,508.94" $0.00 $0.00 $0.00 $719.85 "$2,563.39" "$2,563.39" $0.00 $0.00 $719.77 $0.00 "$1,702.71" "$1,702.71" $0.00 "$1,676.60" "$2,655.73" "$2,682.56" $0.00 $0.00 $509.49 $0.00 $0.00 $533.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.308S SUP HCPCS C1713 02.001.308S - PLATE 386MM SS 4.5MM SCR 18 HOLE CVD LCK LCP BONE LEFT BOTH IP/OP "$3,545.15 " "$2,623.41" $0.00 "$3,126.76" "$1,758.80" "$1,758.80" $0.00 $0.00 $0.00 $738.90 "$2,631.21" "$2,631.21" $0.00 $0.00 $738.81 $0.00 "$1,747.76" "$1,747.76" $0.00 "$1,954.23" "$3,095.49" "$3,126.76" $0.00 $0.00 $611.67 $0.00 $0.00 $622.23 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.320 SUP HCPCS C1713 02.001.320 - PLATE BN CRV 242X17.5X5.2MM NS LCP CMBN 10 HL LOPRFL BOTH IP/OP "$3,079.88 " "$2,279.11" $0.00 "$2,392.14" "$1,345.58" "$1,345.58" $0.00 $0.00 $0.00 $641.92 "$2,285.88" "$2,285.88" $0.00 $0.00 $641.85 $0.00 "$1,518.38" "$1,518.38" $0.00 "$1,495.09" "$2,368.22" "$2,392.14" $0.00 $0.00 $454.33 $0.00 $0.00 $476.04 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.322 SUP HCPCS C1713 02.001.322 - PLATE BN CRV 278X17.5X5.2MM NS LCP CMBN 12 HL LOPRFL BOTH IP/OP "$3,144.53 " "$2,326.95" $0.00 "$2,442.36" "$1,373.83" "$1,373.83" $0.00 $0.00 $0.00 $655.40 "$2,333.87" "$2,333.87" $0.00 $0.00 $655.32 $0.00 "$1,550.25" "$1,550.25" $0.00 "$1,526.48" "$2,417.94" "$2,442.36" $0.00 $0.00 $463.87 $0.00 $0.00 $486.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.324 SUP HCPCS C1713 02.001.324 - PLATE BN CRV 314X17.5X5.2MM NS LCP CMBN 14 HL LOPRFL BOTH IP/OP "$3,210.60 " "$2,375.84" $0.00 "$2,493.68" "$1,402.70" "$1,402.70" $0.00 $0.00 $0.00 $669.17 "$2,382.91" "$2,382.91" $0.00 $0.00 $669.09 $0.00 "$1,582.83" "$1,582.83" $0.00 "$1,558.55" "$2,468.74" "$2,493.68" $0.00 $0.00 $473.62 $0.00 $0.00 $496.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.326 SUP HCPCS C1713 02.001.326 - PLATE BN CRV 350X17.5X5.2MM NS LCP CMBN 16 HL LOPRFL BOTH IP/OP "$3,272.45 " "$2,421.61" $0.00 "$2,541.72" "$1,429.72" "$1,429.72" $0.00 $0.00 $0.00 $682.06 "$2,428.81" "$2,428.81" $0.00 $0.00 $681.98 $0.00 "$1,613.32" "$1,613.32" $0.00 "$1,588.58" "$2,516.30" "$2,541.72" $0.00 $0.00 $482.74 $0.00 $0.00 $505.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.328 SUP HCPCS C1713 02.001.328 - PLATE BN CRV 386X17.5X5.2MM NS LCP CMBN 18 HL LOPRFL BOTH IP/OP "$3,453.78 " "$2,555.80" $0.00 "$2,682.56" "$1,508.94" "$1,508.94" $0.00 $0.00 $0.00 $719.85 "$2,563.39" "$2,563.39" $0.00 $0.00 $719.77 $0.00 "$1,702.71" "$1,702.71" $0.00 "$1,676.60" "$2,655.73" "$2,682.56" $0.00 $0.00 $509.49 $0.00 $0.00 $533.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.330S SUP HCPCS C1713 02.001.330S - PLATE BN CRV 422X17.5X5.2MM STRL LCP CMBN 20 HL LOPRFL BOTH IP/OP "$3,597.18 " "$2,661.91" $0.00 "$2,793.92" "$1,571.58" "$1,571.58" $0.00 $0.00 $0.00 $749.74 "$2,669.82" "$2,669.82" $0.00 $0.00 $749.65 $0.00 "$1,773.41" "$1,773.41" $0.00 "$1,746.20" "$2,765.98" "$2,793.92" $0.00 $0.00 $530.64 $0.00 $0.00 $555.99 $0.00 $0.00 $0.00 $0.00 $0.00 02.001.332S SUP HCPCS C1713 02.001.332S - PLATE BN CRV 458X17.5X5.2MM STRL LCP CMBN 22 HL LOPRFL BOTH IP/OP "$3,654.80 " "$2,704.55" $0.00 "$2,838.68" "$1,596.76" "$1,596.76" $0.00 $0.00 $0.00 $761.75 "$2,712.59" "$2,712.59" $0.00 $0.00 $761.66 $0.00 "$1,801.82" "$1,801.82" $0.00 "$1,774.18" "$2,810.29" "$2,838.68" $0.00 $0.00 $539.14 $0.00 $0.00 $564.90 $0.00 $0.00 $0.00 $0.00 $0.00 02.007.000S SUP Custom 27203010 02.007.000S - NAIL INTRAMEDULLARY END CAP STAINLESS STEEL OLECRANON BOTH IP/OP "$1,210.30 " $895.62 $0.00 $940.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.28 $898.28 $0.00 $0.00 $252.23 $0.00 $0.00 $0.00 $0.00 $587.53 $930.64 $940.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.007.001 SUP HCPCS C1713 02.007.001 - NAIL INTRAMEDULLARY OSTMY IMPLANT STAINLESS STEEL OLECRANON BOTH IP/OP $684.75 $506.72 $0.00 $547.80 $308.14 $308.14 $0.00 $0.00 $0.00 $142.72 $508.22 $508.22 $0.00 $0.00 $142.70 $0.00 $405.03 $405.03 $0.00 $342.38 $542.32 $547.80 $0.00 $0.00 $107.16 $0.00 $0.00 $109.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.03150.044 SUP HCPCS C1713 02.03150.044 - SCREW BONE 44MM CORT BOTH IP/OP $344.50 $254.93 $0.00 $275.60 $155.03 $155.03 $0.00 $0.00 $0.00 $71.80 $255.69 $255.69 $0.00 $0.00 $71.79 $0.00 $203.77 $203.77 $0.00 $172.25 $272.84 $275.60 $0.00 $0.00 $53.91 $0.00 $0.00 $54.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.03150.048 SUP HCPCS C1713 02.03150.048 - SCREW BONE 48MM TI CORT BOTH IP/OP $344.50 $254.93 $0.00 $275.60 $155.03 $155.03 $0.00 $0.00 $0.00 $71.80 $255.69 $255.69 $0.00 $0.00 $71.79 $0.00 $203.77 $203.77 $0.00 $172.25 $272.84 $275.60 $0.00 $0.00 $53.91 $0.00 $0.00 $54.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.03150.055 SUP HCPCS C1713 02.03150.055 - SCREW BONE 55MM CORT BOTH IP/OP $344.50 $254.93 $0.00 $275.60 $155.03 $155.03 $0.00 $0.00 $0.00 $71.80 $255.69 $255.69 $0.00 $0.00 $71.79 $0.00 $203.77 $203.77 $0.00 $172.25 $272.84 $275.60 $0.00 $0.00 $53.91 $0.00 $0.00 $54.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.03150.300 SUP HCPCS C1713 02.03150.300 - SCREW BONE 3.5MM 8MM NCB M8 PROX HUM PROTASUL-64 LCK IM NAIL BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $143.33 $143.33 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.03152.055 SUP HCPCS C1713 02.03152.055 - SCREW BONE 5MM 55MM 32MM NCB PROTASUL 64 CANC FEM SLFTAP BOTH IP/OP $295.75 $218.86 $0.00 $236.60 $133.09 $133.09 $0.00 $0.00 $0.00 $61.64 $219.51 $219.51 $0.00 $0.00 $61.63 $0.00 $174.94 $174.94 $0.00 $147.88 $234.23 $236.60 $0.00 $0.00 $46.28 $0.00 $0.00 $47.08 $0.00 $0.00 $0.00 $0.00 $0.00 02.03152.065 SUP HCPCS C1713 02.03152.065 - SCREW BONE 5MM 65MM 32MM NCB PROTASUL-64 CANC SLFTAP NONSTRL BOTH IP/OP $295.75 $218.86 $0.00 $236.60 $133.09 $133.09 $0.00 $0.00 $0.00 $61.64 $219.51 $219.51 $0.00 $0.00 $61.63 $0.00 $174.94 $174.94 $0.00 $147.88 $234.23 $236.60 $0.00 $0.00 $46.28 $0.00 $0.00 $47.08 $0.00 $0.00 $0.00 $0.00 $0.00 02.03152.080 SUP HCPCS C1713 02.03152.080 - SCREW BONE 5MM 80MM 32MM NCB PROTASUL-64 CANC SLFTAP NONSTRL BOTH IP/OP $295.75 $218.86 $0.00 $236.60 $133.09 $133.09 $0.00 $0.00 $0.00 $61.64 $219.51 $219.51 $0.00 $0.00 $61.63 $0.00 $174.94 $174.94 $0.00 $147.88 $234.23 $236.60 $0.00 $0.00 $46.28 $0.00 $0.00 $47.08 $0.00 $0.00 $0.00 $0.00 $0.00 02.03152.085 SUP HCPCS C1713 02.03152.085 - SCREW BONE 5MM 85MM 32MM NCB PROTASUL-64 CANC SLFTAP NONSTRL BOTH IP/OP $295.75 $218.86 $0.00 $236.60 $133.09 $133.09 $0.00 $0.00 $0.00 $61.64 $219.51 $219.51 $0.00 $0.00 $61.63 $0.00 $174.94 $174.94 $0.00 $147.88 $234.23 $236.60 $0.00 $0.00 $46.28 $0.00 $0.00 $47.08 $0.00 $0.00 $0.00 $0.00 $0.00 02.03260.109 SUP HCPCS C1713 02.03260.109 - PLATE 246MM PROTASUL-64 9 HOLE NCB-DF BONE LEFT FEM NONSTRL BOTH IP/OP "$2,957.50 " "$2,188.55" $0.00 "$2,366.00" "$1,330.88" "$1,330.88" $0.00 $0.00 $0.00 $616.42 "$2,195.06" "$2,195.06" $0.00 $0.00 $616.34 $0.00 "$1,458.05" "$1,458.05" $0.00 "$1,478.75" "$2,342.34" "$2,366.00" $0.00 $0.00 $462.85 $0.00 $0.00 $470.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.004 SUP HCPCS C1713 02.100.004 - PLATE BN 57X10X3.4MM NS CMBN 4 HL LCK LOPRFL COAX SS PUBIC BOTH IP/OP "$1,478.80 " "$1,094.31" $0.00 "$1,148.58" $646.08 $646.08 $0.00 $0.00 $0.00 $308.22 "$1,097.57" "$1,097.57" $0.00 $0.00 $308.18 $0.00 $874.71 $874.71 $0.00 $717.86 "$1,137.10" "$1,148.58" $0.00 $0.00 $218.15 $0.00 $0.00 $228.57 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.006 SUP HCPCS C1713 02.100.006 - PLATE BN 78X10X3.4MM NS CMBN 6 HL LCK LOPRFL COAX SS PUBIC BOTH IP/OP "$1,620.78 " "$1,199.38" $0.00 "$1,258.84" $708.10 $708.10 $0.00 $0.00 $0.00 $337.81 "$1,202.94" "$1,202.94" $0.00 $0.00 $337.77 $0.00 $958.69 $958.69 $0.00 $786.78 "$1,246.25" "$1,258.84" $0.00 $0.00 $239.09 $0.00 $0.00 $250.51 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.014 SUP HCPCS C1713 02.100.014 - PLATE BONE 57MM 4 HOLE LP STAINLESS STEEL PUBIC SYMPHYSIS BOTH IP/OP "$1,623.58 " "$1,201.45" $0.00 "$1,261.02" $709.32 $709.32 $0.00 $0.00 $0.00 $338.39 "$1,205.02" "$1,205.02" $0.00 $0.00 $338.35 $0.00 $960.34 $960.34 $0.00 $788.14 "$1,248.41" "$1,261.02" $0.00 $0.00 $239.50 $0.00 $0.00 $250.94 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.016 SUP HCPCS C1713 02.100.016 - PLATE BONE 78MM 6 HOLE LP STAINLESS STEEL PUBIC SYMPHYSIS BOTH IP/OP "$1,781.00 " "$1,317.94" $0.00 "$1,383.32" $778.12 $778.12 $0.00 $0.00 $0.00 $371.20 "$1,321.86" "$1,321.86" $0.00 $0.00 $371.16 $0.00 "$1,053.46" "$1,053.46" $0.00 $864.58 "$1,369.49" "$1,383.32" $0.00 $0.00 $262.73 $0.00 $0.00 $275.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.020 SUP HCPCS C1713 02.100.020 - PLATE BONE LOCK LCP STAINLESS STEEL NAVICULAR NONSTRL BOTH IP/OP "$1,464.73 " "$1,083.90" $0.00 "$1,137.66" $639.93 $639.93 $0.00 $0.00 $0.00 $305.29 "$1,087.12" "$1,087.12" $0.00 $0.00 $305.25 $0.00 $866.38 $866.38 $0.00 $711.04 "$1,126.29" "$1,137.66" $0.00 $0.00 $216.07 $0.00 $0.00 $226.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.021 SUP HCPCS C1713 02.100.021 - PLATE BONE LOCK STAINLESS STEEL LEFT CUBOID NONSTRL 2.4/2.7 BOTH IP/OP "$1,425.38 " "$1,054.78" $0.00 "$1,107.08" $622.73 $622.73 $0.00 $0.00 $0.00 $297.08 "$1,057.91" "$1,057.91" $0.00 $0.00 $297.05 $0.00 $843.11 $843.11 $0.00 $691.93 "$1,096.01" "$1,107.08" $0.00 $0.00 $210.27 $0.00 $0.00 $220.31 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.022 SUP HCPCS C1713 02.100.022 - PLATE BONE LOCK STAINLESS STEEL RIGHT CUBOID NONSTRL 2.4/2.7 BOTH IP/OP "$1,425.38 " "$1,054.78" $0.00 "$1,107.08" $622.73 $622.73 $0.00 $0.00 $0.00 $297.08 "$1,057.91" "$1,057.91" $0.00 $0.00 $297.05 $0.00 $843.11 $843.11 $0.00 $691.93 "$1,096.01" "$1,107.08" $0.00 $0.00 $210.27 $0.00 $0.00 $220.31 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.023 SUP HCPCS C1713 02.100.023 - PLATE BONE LOCK STAINLESS STEEL TALAR NONSTRL 2.4/2.7 MM BOTH IP/OP "$1,408.50 " "$1,042.29" $0.00 "$1,093.98" $615.36 $615.36 $0.00 $0.00 $0.00 $293.57 "$1,045.39" "$1,045.39" $0.00 $0.00 $293.53 $0.00 $833.13 $833.13 $0.00 $683.74 "$1,083.04" "$1,093.98" $0.00 $0.00 $207.78 $0.00 $0.00 $217.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.032S SUP HCPCS C1713 02.100.032S - PLATE BN 100MM STRL LCP CMBN 6 HL SS ANKL ANT 4.5MM CORT BOTH IP/OP "$2,015.98 " "$1,491.83" $0.00 "$1,565.80" $880.76 $880.76 $0.00 $0.00 $0.00 $420.18 "$1,496.26" "$1,496.26" $0.00 $0.00 $420.13 $0.00 "$1,192.45" "$1,192.45" $0.00 $978.63 "$1,550.14" "$1,565.80" $0.00 $0.00 $297.39 $0.00 $0.00 $311.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.033S SUP HCPCS C1713 02.100.033S - PLATE BONE 116MM 7 HOLE LCP STAINLESS STEEL ANTERIOR ANKLE BOTH IP/OP "$2,069.95 " "$1,531.76" $0.00 "$1,607.72" $904.34 $904.34 $0.00 $0.00 $0.00 $431.43 "$1,536.32" "$1,536.32" $0.00 $0.00 $431.38 $0.00 "$1,224.38" "$1,224.38" $0.00 "$1,004.83" "$1,591.64" "$1,607.72" $0.00 $0.00 $305.35 $0.00 $0.00 $319.94 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.103 SUP HCPCS C1713 02.100.103 - PLATE BN STRG 39X10.1X3.7MM NS CMBN 3 HL LCK LOPRFL RECON SS BOTH IP/OP $983.98 $728.15 $0.00 $764.26 $429.90 $429.90 $0.00 $0.00 $0.00 $205.08 $730.31 $730.31 $0.00 $0.00 $205.06 $0.00 $582.02 $582.02 $0.00 $477.66 $756.62 $764.26 $0.00 $0.00 $145.15 $0.00 $0.00 $152.09 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.104 SUP HCPCS C1713 02.100.104 - PLATE BN STRG 52X10.1X3.7MM NS CMBN 4 HL LCK LOPRFL RECON SS BOTH IP/OP "$1,033.18 " $764.55 $0.00 $802.48 $451.40 $451.40 $0.00 $0.00 $0.00 $215.34 $766.82 $766.82 $0.00 $0.00 $215.31 $0.00 $611.12 $611.12 $0.00 $501.55 $794.46 $802.48 $0.00 $0.00 $152.41 $0.00 $0.00 $159.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.105 SUP HCPCS C1713 02.100.105 - PLATE BN STRG 65X10.1X3.7MM NS CMBN 5 HL LCK LOPRFL RECON SS BOTH IP/OP "$1,079.58 " $798.89 $0.00 $838.50 $471.66 $471.66 $0.00 $0.00 $0.00 $225.01 $801.26 $801.26 $0.00 $0.00 $224.98 $0.00 $638.57 $638.57 $0.00 $524.06 $830.12 $838.50 $0.00 $0.00 $159.25 $0.00 $0.00 $166.86 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.106 SUP HCPCS C1713 02.100.106 - PLATE BN STRG 78X10.1X3.7MM NS CMBN 6 HL LCK LOPRFL RECON SS BOTH IP/OP "$1,124.55 " $832.17 $0.00 $873.44 $491.31 $491.31 $0.00 $0.00 $0.00 $234.38 $834.64 $834.64 $0.00 $0.00 $234.36 $0.00 $665.17 $665.17 $0.00 $545.90 $864.71 $873.44 $0.00 $0.00 $165.89 $0.00 $0.00 $173.81 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.107 SUP HCPCS C1713 02.100.107 - PLATE BN STRG 91X10.1X3.7MM NS CMBN 7 HL LCK LOPRFL RECON SS BOTH IP/OP "$1,168.13 " $864.42 $0.00 $907.28 $510.35 $510.35 $0.00 $0.00 $0.00 $243.47 $866.98 $866.98 $0.00 $0.00 $243.44 $0.00 $690.95 $690.95 $0.00 $567.05 $898.21 $907.28 $0.00 $0.00 $172.32 $0.00 $0.00 $180.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.108 SUP HCPCS C1713 02.100.108 - PLATE BN STRG 104X10.1X3.7MM NS CMBN 8 HL LCK LOPRFL RECON BOTH IP/OP "$1,213.13 " $897.72 $0.00 $942.22 $530.00 $530.00 $0.00 $0.00 $0.00 $252.85 $900.38 $900.38 $0.00 $0.00 $252.82 $0.00 $717.56 $717.56 $0.00 $588.89 $932.80 $942.22 $0.00 $0.00 $178.95 $0.00 $0.00 $187.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.109 SUP HCPCS C1713 02.100.109 - PLATE BN STRG 117X10.1X3.7MM NS CMBN 9 HL LCK LOPRFL RECON BOTH IP/OP "$1,258.10 " $930.99 $0.00 $977.16 $549.65 $549.65 $0.00 $0.00 $0.00 $262.22 $933.76 $933.76 $0.00 $0.00 $262.19 $0.00 $744.17 $744.17 $0.00 $610.73 $967.39 $977.16 $0.00 $0.00 $185.59 $0.00 $0.00 $194.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.110 SUP HCPCS C1713 02.100.110 - PLATE BN STRG 130X10.1X3.7MM NS CMBN 10 HL LCK LOPRFL RECON BOTH IP/OP "$1,304.48 " $965.32 $0.00 "$1,013.20" $569.93 $569.93 $0.00 $0.00 $0.00 $271.89 $968.18 $968.18 $0.00 $0.00 $271.85 $0.00 $771.60 $771.60 $0.00 $633.25 "$1,003.07" "$1,013.20" $0.00 $0.00 $192.43 $0.00 $0.00 $201.63 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.111 SUP HCPCS C1713 02.100.111 - PLATE BN STRG 143X10.1X3.7MM NS CMBN 11 HL LCK LOPRFL RECON BOTH IP/OP "$1,349.48 " $998.62 $0.00 "$1,048.12" $589.57 $589.57 $0.00 $0.00 $0.00 $281.26 "$1,001.58" "$1,001.58" $0.00 $0.00 $281.23 $0.00 $798.21 $798.21 $0.00 $655.08 "$1,037.64" "$1,048.12" $0.00 $0.00 $199.07 $0.00 $0.00 $208.58 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.112 SUP HCPCS C1713 02.100.112 - PLATE BN STRG 156X10.1X3.7MM NS CMBN 12 HL LCK LOPRFL RECON BOTH IP/OP "$1,393.05 " "$1,030.86" $0.00 "$1,081.98" $608.61 $608.61 $0.00 $0.00 $0.00 $290.35 "$1,033.92" "$1,033.92" $0.00 $0.00 $290.31 $0.00 $823.99 $823.99 $0.00 $676.24 "$1,071.16" "$1,081.98" $0.00 $0.00 $205.50 $0.00 $0.00 $215.31 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.113 SUP HCPCS C1713 02.100.113 - PLATE BN STRG 169X10.1X3.7MM NS CMBN 13 HL LCK LOPRFL RECON BOTH IP/OP "$1,439.43 " "$1,065.18" $0.00 "$1,118.00" $628.88 $628.88 $0.00 $0.00 $0.00 $300.01 "$1,068.34" "$1,068.34" $0.00 $0.00 $299.98 $0.00 $851.42 $851.42 $0.00 $698.75 "$1,106.82" "$1,118.00" $0.00 $0.00 $212.34 $0.00 $0.00 $222.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.114 SUP HCPCS C1713 02.100.114 - PLATE BN STRG 182X10.1X3.7MM NS CMBN 14 HL LCK LOPRFL RECON BOTH IP/OP "$1,487.23 " "$1,100.55" $0.00 "$1,155.12" $649.76 $649.76 $0.00 $0.00 $0.00 $309.97 "$1,103.82" "$1,103.82" $0.00 $0.00 $309.94 $0.00 $879.69 $879.69 $0.00 $721.95 "$1,143.57" "$1,155.12" $0.00 $0.00 $219.39 $0.00 $0.00 $229.87 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.115 SUP HCPCS C1713 02.100.115 - PLATE BN STRG 195X10.1X3.7MM NS CMBN 15 HL LCK LOPRFL RECON BOTH IP/OP "$1,532.20 " "$1,133.83" $0.00 "$1,190.06" $669.41 $669.41 $0.00 $0.00 $0.00 $319.35 "$1,137.20" "$1,137.20" $0.00 $0.00 $319.31 $0.00 $906.30 $906.30 $0.00 $743.79 "$1,178.16" "$1,190.06" $0.00 $0.00 $226.03 $0.00 $0.00 $236.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.116 SUP HCPCS C1713 02.100.116 - PLATE BN STRG 208X10.1X3.7MM NS CMBN 16 HL LCK LOPRFL RECON BOTH IP/OP "$1,577.18 " "$1,167.11" $0.00 "$1,225.00" $689.06 $689.06 $0.00 $0.00 $0.00 $328.72 "$1,170.58" "$1,170.58" $0.00 $0.00 $328.68 $0.00 $932.90 $932.90 $0.00 $765.63 "$1,212.75" "$1,225.00" $0.00 $0.00 $232.66 $0.00 $0.00 $243.78 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.118 SUP HCPCS C1713 02.100.118 - PLATE BN STRG 234X10.1X3.7MM NS CMBN 18 HL LCK LOPRFL RECON BOTH IP/OP "$1,622.18 " "$1,200.41" $0.00 "$1,259.94" $708.72 $708.72 $0.00 $0.00 $0.00 $338.10 "$1,203.98" "$1,203.98" $0.00 $0.00 $338.06 $0.00 $959.52 $959.52 $0.00 $787.46 "$1,247.34" "$1,259.94" $0.00 $0.00 $239.30 $0.00 $0.00 $250.73 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.120 SUP HCPCS C1713 02.100.120 - PLATE BN STRG 260X10.1X3.7MM NS CMBN 20 HL LCK LOPRFL RECON BOTH IP/OP "$1,669.98 " "$1,235.79" $0.00 "$1,297.06" $729.60 $729.60 $0.00 $0.00 $0.00 $348.06 "$1,239.46" "$1,239.46" $0.00 $0.00 $348.02 $0.00 $987.79 $987.79 $0.00 $810.66 "$1,284.09" "$1,297.06" $0.00 $0.00 $246.35 $0.00 $0.00 $258.11 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.203 SUP HCPCS C1713 02.100.203 - PLATE BONE WIDE ANGLE LP 39MM 3 HOLE RECONSTRUCTION BOTH IP/OP $607.25 $449.37 $0.00 $471.66 $265.31 $265.31 $0.00 $0.00 $0.00 $126.57 $450.70 $450.70 $0.00 $0.00 $126.55 $0.00 $359.19 $359.19 $0.00 $294.79 $466.95 $471.66 $0.00 $0.00 $89.58 $0.00 $0.00 $93.86 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.204 SUP HCPCS C1713 02.100.204 - PLATE BONE WIDE ANGLE LP 52MM 4 HOLE RECONSTRUCTION BOTH IP/OP $635.38 $470.18 $0.00 $493.50 $277.59 $277.59 $0.00 $0.00 $0.00 $132.43 $471.58 $471.58 $0.00 $0.00 $132.41 $0.00 $375.82 $375.82 $0.00 $308.44 $488.57 $493.50 $0.00 $0.00 $93.73 $0.00 $0.00 $98.21 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.205 SUP HCPCS C1713 02.100.205 - PLATE BONE WIDE ANGLE LP 65MM 5 HOLE RECONSTRUCTION BOTH IP/OP $662.08 $489.94 $0.00 $514.24 $289.26 $289.26 $0.00 $0.00 $0.00 $137.99 $491.39 $491.39 $0.00 $0.00 $137.98 $0.00 $391.62 $391.62 $0.00 $321.40 $509.10 $514.24 $0.00 $0.00 $97.67 $0.00 $0.00 $102.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.206 SUP HCPCS C1713 02.100.206 - PLATE BONE WIDE ANGLE LP 78MM 6 HOLE RECONSTRUCTION BOTH IP/OP $693.00 $512.82 $0.00 $538.26 $302.77 $302.77 $0.00 $0.00 $0.00 $144.44 $514.34 $514.34 $0.00 $0.00 $144.42 $0.00 $409.91 $409.91 $0.00 $336.41 $532.88 $538.26 $0.00 $0.00 $102.23 $0.00 $0.00 $107.11 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.207 SUP HCPCS C1713 02.100.207 - PLATE BONE WIDE ANGLE LP 91MM 7 HOLE RECONSTRUCTION BOTH IP/OP $721.13 $533.64 $0.00 $560.10 $315.06 $315.06 $0.00 $0.00 $0.00 $150.30 $535.22 $535.22 $0.00 $0.00 $150.28 $0.00 $426.55 $426.55 $0.00 $350.06 $554.50 $560.10 $0.00 $0.00 $106.38 $0.00 $0.00 $111.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.208 SUP HCPCS C1713 02.100.208 - PLATE BONE WIDE ANGLE 104MM 8 HOLE LP STAINLESS STEEL PELVIS BOTH IP/OP $747.83 $553.39 $0.00 $580.84 $326.72 $326.72 $0.00 $0.00 $0.00 $155.87 $555.04 $555.04 $0.00 $0.00 $155.85 $0.00 $442.34 $442.34 $0.00 $363.03 $575.03 $580.84 $0.00 $0.00 $110.32 $0.00 $0.00 $115.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.209 SUP HCPCS C1713 02.100.209 - PLATE BONE WIDE ANGLE LP 117MM 9 HOLE RECONSTRUCTION BOTH IP/OP $778.75 $576.28 $0.00 $604.86 $340.23 $340.23 $0.00 $0.00 $0.00 $162.31 $577.99 $577.99 $0.00 $0.00 $162.29 $0.00 $460.63 $460.63 $0.00 $378.04 $598.82 $604.86 $0.00 $0.00 $114.88 $0.00 $0.00 $120.37 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.210 SUP HCPCS C1713 02.100.210 - PLATE BONE WIDE ANGLE LP 130MM 10 HOLE RECONSTRUCTION BOTH IP/OP $808.28 $598.13 $0.00 $627.78 $353.13 $353.13 $0.00 $0.00 $0.00 $168.46 $599.90 $599.90 $0.00 $0.00 $168.44 $0.00 $478.09 $478.09 $0.00 $392.36 $621.51 $627.78 $0.00 $0.00 $119.23 $0.00 $0.00 $124.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.211 SUP HCPCS C1713 02.100.211 - PLATE BONE WIDE ANGLE LP 143MM 11 HOLE RECONSTRUCTION BOTH IP/OP $850.45 $629.33 $0.00 $660.54 $371.55 $371.55 $0.00 $0.00 $0.00 $177.26 $631.20 $631.20 $0.00 $0.00 $177.23 $0.00 $503.04 $503.04 $0.00 $412.84 $653.94 $660.54 $0.00 $0.00 $125.45 $0.00 $0.00 $131.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.212 SUP HCPCS C1713 02.100.212 - PLATE BN WA 156X10.1X3.85MM NS CMBN 12 HL RECON LOPRFL SS BOTH IP/OP $898.25 $664.71 $0.00 $697.66 $392.43 $392.43 $0.00 $0.00 $0.00 $187.22 $666.68 $666.68 $0.00 $0.00 $187.20 $0.00 $531.31 $531.31 $0.00 $436.04 $690.69 $697.66 $0.00 $0.00 $132.50 $0.00 $0.00 $138.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.213 SUP HCPCS C1713 02.100.213 - PLATE BONE WIDE ANGLE LP 169MM 13 HOLE RECONSTRUCTION BOTH IP/OP $944.63 $699.03 $0.00 $733.68 $412.70 $412.70 $0.00 $0.00 $0.00 $196.88 $701.10 $701.10 $0.00 $0.00 $196.86 $0.00 $558.75 $558.75 $0.00 $458.55 $726.34 $733.68 $0.00 $0.00 $139.35 $0.00 $0.00 $146.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.214 SUP HCPCS C1713 02.100.214 - PLATE BONE WIDE ANGLE LP 182MM 14 HOLE RECONSTRUCTION BOTH IP/OP $985.40 $729.20 $0.00 $765.36 $430.52 $430.52 $0.00 $0.00 $0.00 $205.38 $731.36 $731.36 $0.00 $0.00 $205.36 $0.00 $582.86 $582.86 $0.00 $478.35 $757.71 $765.36 $0.00 $0.00 $145.36 $0.00 $0.00 $152.31 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.215 SUP HCPCS C1713 02.100.215 - PLATE BONE WIDE ANGLE LP 195MM 15 HOLE RECONSTRUCTION BOTH IP/OP "$1,034.60 " $765.60 $0.00 $803.56 $452.00 $452.00 $0.00 $0.00 $0.00 $215.64 $767.88 $767.88 $0.00 $0.00 $215.61 $0.00 $611.97 $611.97 $0.00 $502.23 $795.52 $803.56 $0.00 $0.00 $152.62 $0.00 $0.00 $159.91 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.216 SUP HCPCS C1713 02.100.216 - PLATE BONE WIDE ANGLE LP 208MM 16 HOLE RECONSTRUCTION BOTH IP/OP "$1,080.98 " $799.93 $0.00 $839.60 $472.28 $472.28 $0.00 $0.00 $0.00 $225.30 $802.30 $802.30 $0.00 $0.00 $225.28 $0.00 $639.40 $639.40 $0.00 $524.75 $831.20 $839.60 $0.00 $0.00 $159.46 $0.00 $0.00 $167.08 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.218 SUP HCPCS C1713 02.100.218 - PLATE BONE WIDE ANGLE LP 234MM 18 HOLE RECONSTRUCTION BOTH IP/OP "$1,127.38 " $834.26 $0.00 $875.62 $492.54 $492.54 $0.00 $0.00 $0.00 $234.97 $836.74 $836.74 $0.00 $0.00 $234.94 $0.00 $666.84 $666.84 $0.00 $547.26 $866.87 $875.62 $0.00 $0.00 $166.30 $0.00 $0.00 $174.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.220 SUP HCPCS C1713 02.100.220 - PLATE BONE WIDE ANGLE LP 260MM 20 HOLE RECONSTRUCTION BOTH IP/OP "$1,169.53 " $865.45 $0.00 $908.38 $510.96 $510.96 $0.00 $0.00 $0.00 $243.76 $868.02 $868.02 $0.00 $0.00 $243.73 $0.00 $691.77 $691.77 $0.00 $567.74 $899.30 $908.38 $0.00 $0.00 $172.53 $0.00 $0.00 $180.77 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.301 SUP HCPCS C1713 02.100.301 - PLATE BONE 1 HOLE SPRING LCP STAINLESS STEEL PELVIC NONSTRL BOTH IP/OP $424.53 $314.15 $0.00 $329.72 $185.47 $185.47 $0.00 $0.00 $0.00 $88.48 $315.08 $315.08 $0.00 $0.00 $88.47 $0.00 $251.11 $251.11 $0.00 $206.08 $326.42 $329.72 $0.00 $0.00 $62.62 $0.00 $0.00 $65.61 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.302 SUP HCPCS C1713 02.100.302 - PLATE BONE 2 HOLE SPRING LCP STAINLESS STEEL PELVIC NONSTRL BOTH IP/OP $461.08 $341.20 $0.00 $358.12 $201.44 $201.44 $0.00 $0.00 $0.00 $96.10 $342.21 $342.21 $0.00 $0.00 $96.09 $0.00 $272.73 $272.73 $0.00 $223.83 $354.54 $358.12 $0.00 $0.00 $68.01 $0.00 $0.00 $71.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.303 SUP HCPCS C1713 02.100.303 - PLATE BONE 3 HOLE SPRING LCP STAINLESS STEEL PELVIC NONSTRL BOTH IP/OP $506.05 $374.48 $0.00 $393.04 $221.09 $221.09 $0.00 $0.00 $0.00 $105.47 $375.59 $375.59 $0.00 $0.00 $105.46 $0.00 $299.33 $299.33 $0.00 $245.65 $389.11 $393.04 $0.00 $0.00 $74.65 $0.00 $0.00 $78.21 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.325S SUP HCPCS C1713 02.100.325S - PLATE BONE STANDARD QUADRILATERAL SURFACE STAINLESS STEEL BOTH IP/OP $736.58 $545.07 $0.00 $572.10 $321.81 $321.81 $0.00 $0.00 $0.00 $153.52 $546.69 $546.69 $0.00 $0.00 $153.50 $0.00 $435.68 $435.68 $0.00 $357.56 $566.38 $572.10 $0.00 $0.00 $108.66 $0.00 $0.00 $113.85 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.326S SUP HCPCS C1713 02.100.326S - PLATE BONE LONG QUADRILATERAL SURFACE STAINLESS STEEL PELVIS BOTH IP/OP $811.08 $600.20 $0.00 $629.96 $354.35 $354.35 $0.00 $0.00 $0.00 $169.05 $601.98 $601.98 $0.00 $0.00 $169.03 $0.00 $479.75 $479.75 $0.00 $393.73 $623.66 $629.96 $0.00 $0.00 $119.65 $0.00 $0.00 $125.36 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.327S SUP HCPCS C1713 02.100.327S - PLATE BONE SHORT LP QUADRILATERAL SURFACE STAINLESS STEEL BOTH IP/OP $669.10 $495.13 $0.00 $519.70 $292.33 $292.33 $0.00 $0.00 $0.00 $139.46 $496.61 $496.61 $0.00 $0.00 $139.44 $0.00 $395.77 $395.77 $0.00 $324.81 $514.51 $519.70 $0.00 $0.00 $98.70 $0.00 $0.00 $103.42 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.360 SUP HCPCS C1713 02.100.360 - PLATE BONE J CVD 130X10.1X3.7MM 10 HOLE LOCKING COAXIAL BOTH IP/OP "$1,356.50 " "$1,003.81" $0.00 "$1,053.58" $592.64 $592.64 $0.00 $0.00 $0.00 $282.73 "$1,006.79" "$1,006.79" $0.00 $0.00 $282.69 $0.00 $802.37 $802.37 $0.00 $658.49 "$1,043.05" "$1,053.58" $0.00 $0.00 $200.10 $0.00 $0.00 $209.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.361 SUP HCPCS C1713 02.100.361 - PLATE BN 88MM RDS J 130X10.1X3.7MM NS CMBN 10 HL LCK LOPRFL BOTH IP/OP "$1,356.50 " "$1,003.81" $0.00 "$1,053.58" $592.64 $592.64 $0.00 $0.00 $0.00 $282.73 "$1,006.79" "$1,006.79" $0.00 $0.00 $282.69 $0.00 $802.37 $802.37 $0.00 $658.49 "$1,043.05" "$1,053.58" $0.00 $0.00 $200.10 $0.00 $0.00 $209.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.362 SUP HCPCS C1713 02.100.362 - PLATE BONE 156MM 12 HOLE J LOCKING LP RECONSTRUCTION LCP BOTH IP/OP "$1,432.40 " "$1,059.98" $0.00 "$1,112.54" $625.80 $625.80 $0.00 $0.00 $0.00 $298.55 "$1,063.13" "$1,063.13" $0.00 $0.00 $298.51 $0.00 $847.26 $847.26 $0.00 $695.34 "$1,101.42" "$1,112.54" $0.00 $0.00 $211.30 $0.00 $0.00 $221.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.363 SUP HCPCS C1713 02.100.363 - PLATE BONE J CVD 156X10.1X3.7MM 12 HOLE LOCKING COAXIAL BOTH IP/OP "$1,432.40 " "$1,059.98" $0.00 "$1,112.54" $625.80 $625.80 $0.00 $0.00 $0.00 $298.55 "$1,063.13" "$1,063.13" $0.00 $0.00 $298.51 $0.00 $847.26 $847.26 $0.00 $695.34 "$1,101.42" "$1,112.54" $0.00 $0.00 $211.30 $0.00 $0.00 $221.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.364 SUP HCPCS C1713 02.100.364 - PLATE BONE J CVD 182X10.1X3.7MM 14 HOLE LOCKING COAXIAL BOTH IP/OP "$1,509.73 " "$1,117.20" $0.00 "$1,172.60" $659.59 $659.59 $0.00 $0.00 $0.00 $314.66 "$1,120.52" "$1,120.52" $0.00 $0.00 $314.63 $0.00 $893.00 $893.00 $0.00 $732.88 "$1,160.87" "$1,172.60" $0.00 $0.00 $222.71 $0.00 $0.00 $233.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.365 SUP HCPCS C1713 02.100.365 - PLATE BONE 182MM 14 HOLE J LOCKING LP RECONSTRUCTION LCP BOTH IP/OP "$1,509.73 " "$1,117.20" $0.00 "$1,172.60" $659.59 $659.59 $0.00 $0.00 $0.00 $314.66 "$1,120.52" "$1,120.52" $0.00 $0.00 $314.63 $0.00 $893.00 $893.00 $0.00 $732.88 "$1,160.87" "$1,172.60" $0.00 $0.00 $222.71 $0.00 $0.00 $233.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.366 SUP HCPCS C1713 02.100.366 - PLATE BN 88MM RDS J 208X10.1X3.7MM NS CMBN 16 HL LCK LOPRFL BOTH IP/OP "$1,596.88 " "$1,181.69" $0.00 "$1,240.28" $697.66 $697.66 $0.00 $0.00 $0.00 $332.83 "$1,185.20" "$1,185.20" $0.00 $0.00 $332.79 $0.00 $944.55 $944.55 $0.00 $775.18 "$1,227.88" "$1,240.28" $0.00 $0.00 $235.56 $0.00 $0.00 $246.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.100.367 SUP HCPCS C1713 02.100.367 - PLATE BN 88MM RDS J 208X10.1X3.7MM NS CMBN 16 HL LCK LOPRFL BOTH IP/OP "$1,596.88 " "$1,181.69" $0.00 "$1,240.28" $697.66 $697.66 $0.00 $0.00 $0.00 $332.83 "$1,185.20" "$1,185.20" $0.00 $0.00 $332.79 $0.00 $944.55 $944.55 $0.00 $775.18 "$1,227.88" "$1,240.28" $0.00 $0.00 $235.56 $0.00 $0.00 $246.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.102.001 SUP HCPCS C1713 02.102.001 - PLATE BONE UNIVERSAL 131MM LOCKING STABILIZATION LCP BOTH IP/OP "$1,234.20 " $913.31 $0.00 $958.60 $539.21 $539.21 $0.00 $0.00 $0.00 $257.24 $916.02 $916.02 $0.00 $0.00 $257.21 $0.00 $730.03 $730.03 $0.00 $599.13 $949.01 $958.60 $0.00 $0.00 $182.06 $0.00 $0.00 $190.76 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.004 SUP HCPCS C1713 02.104.004 - PLATE BN 122MM NS LCP CMBN 4 HL PRECONTOUR LMT CNTCT TPR HD BOTH IP/OP "$2,292.68 " "$1,696.58" $0.00 "$1,780.72" "$1,001.66" "$1,001.66" $0.00 $0.00 $0.00 $477.85 "$1,701.62" "$1,701.62" $0.00 $0.00 $477.79 $0.00 "$1,356.12" "$1,356.12" $0.00 "$1,112.95" "$1,762.91" "$1,780.72" $0.00 $0.00 $338.21 $0.00 $0.00 $354.36 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.006 SUP HCPCS C1713 02.104.006 - PLATE BONE 158MM 6 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$2,623.03 " "$1,941.04" $0.00 "$2,037.30" "$1,145.98" "$1,145.98" $0.00 $0.00 $0.00 $546.70 "$1,946.81" "$1,946.81" $0.00 $0.00 $546.64 $0.00 "$1,293.15" "$1,293.15" $0.00 "$1,273.31" "$2,016.93" "$2,037.30" $0.00 $0.00 $386.94 $0.00 $0.00 $405.42 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.008 SUP HCPCS C1713 02.104.008 - PLATE BONE 194MM 8 HOLE LOCKING TAPER HEAD LIMIT CONTACT BOTH IP/OP "$2,783.28 " "$2,059.63" $0.00 "$2,161.76" "$1,215.99" "$1,215.99" $0.00 $0.00 $0.00 $580.10 "$2,065.75" "$2,065.75" $0.00 $0.00 $580.03 $0.00 "$1,372.15" "$1,372.15" $0.00 "$1,351.10" "$2,140.14" "$2,161.76" $0.00 $0.00 $410.58 $0.00 $0.00 $430.19 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.010 SUP HCPCS C1713 02.104.010 - PLATE BONE 230MM 10 HOLE LCP STAINLESS STEEL EXTART RIGHT BOTH IP/OP "$2,946.33 " "$2,180.28" $0.00 "$2,288.42" "$1,287.24" "$1,287.24" $0.00 $0.00 $0.00 $614.09 "$2,186.76" "$2,186.76" $0.00 $0.00 $614.01 $0.00 "$1,452.54" "$1,452.54" $0.00 "$1,430.26" "$2,265.54" "$2,288.42" $0.00 $0.00 $434.63 $0.00 $0.00 $455.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.012 SUP HCPCS C1713 02.104.012 - PLATE BN 266MM NS LCP CMBN 12 HL PRECONTOUR LMT CNTCT TPR HD BOTH IP/OP "$3,366.63 " "$2,491.31" $0.00 "$2,614.86" "$1,470.86" "$1,470.86" $0.00 $0.00 $0.00 $701.69 "$2,498.71" "$2,498.71" $0.00 $0.00 $701.60 $0.00 "$1,659.75" "$1,659.75" $0.00 "$1,634.29" "$2,588.72" "$2,614.86" $0.00 $0.00 $496.63 $0.00 $0.00 $520.36 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.014 SUP HCPCS C1713 02.104.014 - PLATE BN 302MM NS LCP CMBN 14 HL PRECONTOUR LMT CNTCT TPR HD BOTH IP/OP "$3,705.40 " "$2,742.00" $0.00 "$2,877.98" "$1,618.86" "$1,618.86" $0.00 $0.00 $0.00 $772.30 "$2,750.15" "$2,750.15" $0.00 $0.00 $772.21 $0.00 "$1,826.76" "$1,826.76" $0.00 "$1,798.74" "$2,849.20" "$2,877.98" $0.00 $0.00 $546.61 $0.00 $0.00 $572.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.024 SUP HCPCS C1713 02.104.024 - PLATE BN 122MM NS LCP CMBN 4 HL PRECONTOUR LMT CNTCT TPR HD BOTH IP/OP "$2,292.68 " "$1,696.58" $0.00 "$1,780.72" "$1,001.66" "$1,001.66" $0.00 $0.00 $0.00 $477.85 "$1,701.62" "$1,701.62" $0.00 $0.00 $477.79 $0.00 "$1,356.12" "$1,356.12" $0.00 "$1,112.95" "$1,762.91" "$1,780.72" $0.00 $0.00 $338.21 $0.00 $0.00 $354.36 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.026 SUP HCPCS C1713 02.104.026 - PLATE BONE 158MM 6 HOLE LCP STAINLESS STEEL LEFT DISTAL BOTH IP/OP "$2,623.03 " "$1,941.04" $0.00 "$2,037.30" "$1,145.98" "$1,145.98" $0.00 $0.00 $0.00 $546.70 "$1,946.81" "$1,946.81" $0.00 $0.00 $546.64 $0.00 "$1,293.15" "$1,293.15" $0.00 "$1,273.31" "$2,016.93" "$2,037.30" $0.00 $0.00 $386.94 $0.00 $0.00 $405.42 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.028 SUP HCPCS C1713 02.104.028 - PLATE BONE 194MM 8 HOLE LCP STAINLESS STEEL LEFT DISTAL BOTH IP/OP "$2,783.28 " "$2,059.63" $0.00 "$2,161.76" "$1,215.99" "$1,215.99" $0.00 $0.00 $0.00 $580.10 "$2,065.75" "$2,065.75" $0.00 $0.00 $580.03 $0.00 "$1,372.15" "$1,372.15" $0.00 "$1,351.10" "$2,140.14" "$2,161.76" $0.00 $0.00 $410.58 $0.00 $0.00 $430.19 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.030 SUP HCPCS C1713 02.104.030 - PLATE BONE 230MM 10 HOLE LCP STAINLESS STEEL LEFT DISTAL BOTH IP/OP "$2,946.33 " "$2,180.28" $0.00 "$2,288.42" "$1,287.24" "$1,287.24" $0.00 $0.00 $0.00 $614.09 "$2,186.76" "$2,186.76" $0.00 $0.00 $614.01 $0.00 "$1,452.54" "$1,452.54" $0.00 "$1,430.26" "$2,265.54" "$2,288.42" $0.00 $0.00 $434.63 $0.00 $0.00 $455.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.032 SUP HCPCS C1713 02.104.032 - PLATE BN 266MM NS LCP CMBN 12 HL PRECONTOUR LMT CNTCT TPR HD BOTH IP/OP "$3,366.63 " "$2,491.31" $0.00 "$2,614.86" "$1,470.86" "$1,470.86" $0.00 $0.00 $0.00 $701.69 "$2,498.71" "$2,498.71" $0.00 $0.00 $701.60 $0.00 "$1,659.75" "$1,659.75" $0.00 "$1,634.29" "$2,588.72" "$2,614.86" $0.00 $0.00 $496.63 $0.00 $0.00 $520.36 $0.00 $0.00 $0.00 $0.00 $0.00 02.104.034 SUP HCPCS C1713 02.104.034 - PLATE BN 302MM NS LCP CMBN 14 HL PRECONTOUR LMT CNTCT TPR HD BOTH IP/OP "$3,705.40 " "$2,742.00" $0.00 "$2,877.98" "$1,618.86" "$1,618.86" $0.00 $0.00 $0.00 $772.30 "$2,750.15" "$2,750.15" $0.00 $0.00 $772.21 $0.00 "$1,826.76" "$1,826.76" $0.00 "$1,798.74" "$2,849.20" "$2,877.98" $0.00 $0.00 $546.61 $0.00 $0.00 $572.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.002 SUP HCPCS C1713 02.107.002 - PLATE BN 73MM NS LCP CMBN 2 HL VA TPR TIP RND PRFL SS OLCRN BOTH IP/OP "$1,730.40 " "$1,280.50" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $360.66 "$1,284.30" "$1,284.30" $0.00 $0.00 $360.62 $0.00 "$1,023.53" "$1,023.53" $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $255.26 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.002S SUP HCPCS C1713 02.107.002S - PLATE BONE 73MM 2 HOLE VAR ANG LCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,821.78 " "$1,348.12" $0.00 "$1,414.98" $795.93 $795.93 $0.00 $0.00 $0.00 $379.70 "$1,352.12" "$1,352.12" $0.00 $0.00 $379.66 $0.00 "$1,077.58" "$1,077.58" $0.00 $884.36 "$1,400.83" "$1,414.98" $0.00 $0.00 $268.74 $0.00 $0.00 $281.58 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.102 SUP HCPCS C1713 02.107.102 - PLATE BONE 73MM 2 HOLE VAR ANG LCP STAINLESS STEEL ELBOW BOTH IP/OP "$1,730.40 " "$1,280.50" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $360.66 "$1,284.30" "$1,284.30" $0.00 $0.00 $360.62 $0.00 "$1,023.53" "$1,023.53" $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $255.26 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.102S SUP HCPCS C1713 02.107.102S - PLATE BN 73MM STRL LCP CMBN 2 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$1,821.78 " "$1,348.12" $0.00 "$1,414.98" $795.93 $795.93 $0.00 $0.00 $0.00 $379.70 "$1,352.12" "$1,352.12" $0.00 $0.00 $379.66 $0.00 "$1,077.58" "$1,077.58" $0.00 $884.36 "$1,400.83" "$1,414.98" $0.00 $0.00 $268.74 $0.00 $0.00 $281.58 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.202S SUP HCPCS C1713 02.107.202S - PLATE BONE 90MM 2 HOLE VAR ANG LCP STAINLESS STEEL RIGHT BOTH IP/OP "$2,036.85 " "$1,507.27" $0.00 "$1,582.02" $889.89 $889.89 $0.00 $0.00 $0.00 $424.53 "$1,511.75" "$1,511.75" $0.00 $0.00 $424.48 $0.00 "$1,204.80" "$1,204.80" $0.00 $988.76 "$1,566.20" "$1,582.02" $0.00 $0.00 $300.47 $0.00 $0.00 $314.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.204 SUP HCPCS C1713 02.107.204 - PLATE BN 116MM NS LCP CMBN 4 HL VA TPR TIP RND PRFL SS OLCRN BOTH IP/OP "$1,945.48 " "$1,439.66" $0.00 "$1,511.06" $849.97 $849.97 $0.00 $0.00 $0.00 $405.49 "$1,443.93" "$1,443.93" $0.00 $0.00 $405.44 $0.00 "$1,150.75" "$1,150.75" $0.00 $944.41 "$1,495.95" "$1,511.06" $0.00 $0.00 $286.99 $0.00 $0.00 $300.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.204S SUP HCPCS C1713 02.107.204S - PLATE BONE 116MM 4 HOLE VAR ANG LCP STAINLESS STEEL RIGHT BOTH IP/OP "$2,036.85 " "$1,507.27" $0.00 "$1,582.02" $889.89 $889.89 $0.00 $0.00 $0.00 $424.53 "$1,511.75" "$1,511.75" $0.00 $0.00 $424.48 $0.00 "$1,204.80" "$1,204.80" $0.00 $988.76 "$1,566.20" "$1,582.02" $0.00 $0.00 $300.47 $0.00 $0.00 $314.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.206S SUP HCPCS C1713 02.107.206S - PLATE BONE 142MM 2 HOLE VAR ANG RECONSTRUCTION SEGMENT BOTH IP/OP "$2,036.85 " "$1,507.27" $0.00 "$1,582.02" $889.89 $889.89 $0.00 $0.00 $0.00 $424.53 "$1,511.75" "$1,511.75" $0.00 $0.00 $424.48 $0.00 "$1,204.80" "$1,204.80" $0.00 $988.76 "$1,566.20" "$1,582.02" $0.00 $0.00 $300.47 $0.00 $0.00 $314.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.208S SUP HCPCS C1713 02.107.208S - PLATE BN 169MM STRL LCP CMBN 8 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,036.85 " "$1,507.27" $0.00 "$1,582.02" $889.89 $889.89 $0.00 $0.00 $0.00 $424.53 "$1,511.75" "$1,511.75" $0.00 $0.00 $424.48 $0.00 "$1,204.80" "$1,204.80" $0.00 $988.76 "$1,566.20" "$1,582.02" $0.00 $0.00 $300.47 $0.00 $0.00 $314.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.302S SUP HCPCS C1713 02.107.302S - PLATE BONE 90MM 2 HOLE VAR ANG LCP STAINLESS STEEL LEFT BOTH IP/OP "$2,036.85 " "$1,507.27" $0.00 "$1,582.02" $889.89 $889.89 $0.00 $0.00 $0.00 $424.53 "$1,511.75" "$1,511.75" $0.00 $0.00 $424.48 $0.00 "$1,204.80" "$1,204.80" $0.00 $988.76 "$1,566.20" "$1,582.02" $0.00 $0.00 $300.47 $0.00 $0.00 $314.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.304 SUP HCPCS C1713 02.107.304 - PLATE BN 116MM NS LCP CMBN 4 HL VA TPR TIP RND PRFL SS OLCRN BOTH IP/OP "$1,945.48 " "$1,439.66" $0.00 "$1,511.06" $849.97 $849.97 $0.00 $0.00 $0.00 $405.49 "$1,443.93" "$1,443.93" $0.00 $0.00 $405.44 $0.00 "$1,150.75" "$1,150.75" $0.00 $944.41 "$1,495.95" "$1,511.06" $0.00 $0.00 $286.99 $0.00 $0.00 $300.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.304S SUP HCPCS C1713 02.107.304S - PLATE BONE 116MM 4 HOLE VAR ANG RECONSTRUCTION SEGMENT BOTH IP/OP "$2,036.85 " "$1,507.27" $0.00 "$1,582.02" $889.89 $889.89 $0.00 $0.00 $0.00 $424.53 "$1,511.75" "$1,511.75" $0.00 $0.00 $424.48 $0.00 "$1,204.80" "$1,204.80" $0.00 $988.76 "$1,566.20" "$1,582.02" $0.00 $0.00 $300.47 $0.00 $0.00 $314.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.306S SUP HCPCS C1713 02.107.306S - PLATE BONE 142MM 6 HOLE VAR ANG STAINLESS STEEL LEFT BOTH IP/OP "$2,036.85 " "$1,507.27" $0.00 "$1,582.02" $889.89 $889.89 $0.00 $0.00 $0.00 $424.53 "$1,511.75" "$1,511.75" $0.00 $0.00 $424.48 $0.00 "$1,204.80" "$1,204.80" $0.00 $988.76 "$1,566.20" "$1,582.02" $0.00 $0.00 $300.47 $0.00 $0.00 $314.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.308S SUP HCPCS C1713 02.107.308S - PLATE BN 169MM STRL LCP CMBN 8 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,036.85 " "$1,507.27" $0.00 "$1,582.02" $889.89 $889.89 $0.00 $0.00 $0.00 $424.53 "$1,511.75" "$1,511.75" $0.00 $0.00 $424.48 $0.00 "$1,204.80" "$1,204.80" $0.00 $988.76 "$1,566.20" "$1,582.02" $0.00 $0.00 $300.47 $0.00 $0.00 $314.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.408S SUP HCPCS C1713 02.107.408S - PLATE BONE 157MM 8 HOLE VAR ANG RECONSTRUCTION SEGMENT BOTH IP/OP "$2,329.23 " "$1,723.63" $0.00 "$1,809.12" "$1,017.63" "$1,017.63" $0.00 $0.00 $0.00 $485.47 "$1,728.75" "$1,728.75" $0.00 $0.00 $485.41 $0.00 "$1,377.74" "$1,377.74" $0.00 "$1,130.70" "$1,791.03" "$1,809.12" $0.00 $0.00 $343.60 $0.00 $0.00 $360.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.506S SUP HCPCS C1713 02.107.506S - PLATE BN 131MM STRL LCP CMBN 6 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,261.40 " "$1,673.44" $0.00 "$1,809.12" "$1,017.63" "$1,017.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,130.70" "$1,791.03" "$1,809.12" $0.00 $0.00 $343.60 $0.00 $0.00 $360.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.508 SUP HCPCS C1713 02.107.508 - PLATE BN 157MM NS LCP CMBN 8 HL VA TPR TIP RND PRFL SS ULNA BOTH IP/OP "$2,237.85 " "$1,656.01" $0.00 "$1,738.14" $977.70 $977.70 $0.00 $0.00 $0.00 $466.42 "$1,660.93" "$1,660.93" $0.00 $0.00 $466.37 $0.00 "$1,323.69" "$1,323.69" $0.00 "$1,086.34" "$1,720.76" "$1,738.14" $0.00 $0.00 $330.12 $0.00 $0.00 $345.89 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.508S SUP HCPCS C1713 02.107.508S - PLATE BONE 157MM 8 HOLE VAR ANG RECONSTRUCTION SEGMENT BOTH IP/OP "$2,329.23 " "$1,723.63" $0.00 "$1,809.12" "$1,017.63" "$1,017.63" $0.00 $0.00 $0.00 $485.47 "$1,728.75" "$1,728.75" $0.00 $0.00 $485.41 $0.00 "$1,377.74" "$1,377.74" $0.00 "$1,130.70" "$1,791.03" "$1,809.12" $0.00 $0.00 $343.60 $0.00 $0.00 $360.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.107.512S SUP HCPCS C1713 02.107.512S - PLATE BONE 211MM 12 HOLE VAR ANG RECONSTRUCTION SEGMENT BOTH IP/OP "$2,329.23 " "$1,723.63" $0.00 "$1,809.12" "$1,017.63" "$1,017.63" $0.00 $0.00 $0.00 $485.47 "$1,728.75" "$1,728.75" $0.00 $0.00 $485.41 $0.00 "$1,377.74" "$1,377.74" $0.00 "$1,130.70" "$1,791.03" "$1,809.12" $0.00 $0.00 $343.60 $0.00 $0.00 $360.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.200 SUP Custom 27203010 02.108.200 - GUIDEWIRE ORTHOPEDIC THREAD 3MM 230MM DRILL TIP NONSTRL BOTH IP/OP $36.13 $26.74 $0.00 $28.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.81 $26.81 $0.00 $0.00 $7.53 $0.00 $0.00 $0.00 $0.00 $17.54 $27.78 $28.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.310 SUP HCPCS C1713 02.108.310 - PLATE BONE 100D 3 HOLE LCP STAINLESS STEEL PEDIATRIC HIP BOTH IP/OP "$1,005.08 " $743.76 $0.00 $780.64 $439.11 $439.11 $0.00 $0.00 $0.00 $209.48 $745.97 $745.97 $0.00 $0.00 $209.46 $0.00 $594.50 $594.50 $0.00 $487.90 $772.83 $780.64 $0.00 $0.00 $148.26 $0.00 $0.00 $155.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.311 SUP HCPCS C1713 02.108.311 - PLATE BONE 110D 3 HOLE LCP STAINLESS STEEL PEDIATRIC HIP BOTH IP/OP "$1,005.08 " $743.76 $0.00 $780.64 $439.11 $439.11 $0.00 $0.00 $0.00 $209.48 $745.97 $745.97 $0.00 $0.00 $209.46 $0.00 $594.50 $594.50 $0.00 $487.90 $772.83 $780.64 $0.00 $0.00 $148.26 $0.00 $0.00 $155.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.313 SUP HCPCS C1713 02.108.313 - PLATE BN 120D 75X19-12MM NS LCP 4 HL SHFT SS PED HIP 3.5MM BOTH IP/OP "$1,005.08 " $743.76 $0.00 $780.64 $439.11 $439.11 $0.00 $0.00 $0.00 $209.48 $745.97 $745.97 $0.00 $0.00 $209.46 $0.00 $594.50 $594.50 $0.00 $487.90 $772.83 $780.64 $0.00 $0.00 $148.26 $0.00 $0.00 $155.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.315 SUP HCPCS C1713 02.108.315 - PLATE BONE 150D 60X18.5MM 3 HOLE LCP STAINLESS STEEL BOTH IP/OP "$1,005.08 " $743.76 $0.00 $780.64 $439.11 $439.11 $0.00 $0.00 $0.00 $209.48 $745.97 $745.97 $0.00 $0.00 $209.46 $0.00 $594.50 $594.50 $0.00 $487.90 $772.83 $780.64 $0.00 $0.00 $148.26 $0.00 $0.00 $155.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.320 SUP HCPCS C1713 02.108.320 - PLATE BONE 100D 3 HOLE LCP STAINLESS STEEL PEDIATRIC HIP BOTH IP/OP "$1,044.43 " $772.88 $0.00 $811.20 $456.30 $456.30 $0.00 $0.00 $0.00 $217.68 $775.17 $775.17 $0.00 $0.00 $217.66 $0.00 $617.78 $617.78 $0.00 $507.00 $803.09 $811.20 $0.00 $0.00 $154.07 $0.00 $0.00 $161.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.321 SUP HCPCS C1713 02.108.321 - PLATE BONE 110D 5 HOLE LCP STAINLESS STEEL PEDIATRIC HIP BOTH IP/OP "$1,044.43 " $772.88 $0.00 $811.20 $456.30 $456.30 $0.00 $0.00 $0.00 $217.68 $775.17 $775.17 $0.00 $0.00 $217.66 $0.00 $617.78 $617.78 $0.00 $507.00 $803.09 $811.20 $0.00 $0.00 $154.07 $0.00 $0.00 $161.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.323 SUP HCPCS C1713 02.108.323 - PLATE BN 120D 95X23-15MM NS LCP 4 HL SHFT SS PED HIP 5MM SCR BOTH IP/OP "$1,044.43 " $772.88 $0.00 $811.20 $456.30 $456.30 $0.00 $0.00 $0.00 $217.68 $775.17 $775.17 $0.00 $0.00 $217.66 $0.00 $617.78 $617.78 $0.00 $507.00 $803.09 $811.20 $0.00 $0.00 $154.07 $0.00 $0.00 $161.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.108.325 SUP HCPCS C1713 02.108.325 - PLATE BONE 150D 3 HOLE LCP STAINLESS STEEL PEDIATRIC HIP BOTH IP/OP "$1,044.43 " $772.88 $0.00 $811.20 $456.30 $456.30 $0.00 $0.00 $0.00 $217.68 $775.17 $775.17 $0.00 $0.00 $217.66 $0.00 $617.78 $617.78 $0.00 $507.00 $803.09 $811.20 $0.00 $0.00 $154.07 $0.00 $0.00 $161.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.005 SUP HCPCS C1713 02.110.005 - PLATE BN NS LCP 5 HL SHFT SS RDS RT VOLR DIST BOTH IP/OP "$2,921.03 " "$2,161.56" $0.00 "$2,268.76" "$1,276.18" "$1,276.18" $0.00 $0.00 $0.00 $608.81 "$2,167.98" "$2,167.98" $0.00 $0.00 $608.74 $0.00 "$1,440.07" "$1,440.07" $0.00 "$1,417.98" "$2,246.07" "$2,268.76" $0.00 $0.00 $430.90 $0.00 $0.00 $451.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.007 SUP HCPCS C1713 02.110.007 - PLATE BN NS LCP 7 HL SHFT SS RDS RT VOLR DIST BOTH IP/OP "$2,992.73 " "$2,214.62" $0.00 "$2,324.44" "$1,307.50" "$1,307.50" $0.00 $0.00 $0.00 $623.76 "$2,221.20" "$2,221.20" $0.00 $0.00 $623.68 $0.00 "$1,475.41" "$1,475.41" $0.00 "$1,452.78" "$2,301.20" "$2,324.44" $0.00 $0.00 $441.47 $0.00 $0.00 $462.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.009 SUP HCPCS C1713 02.110.009 - PLATE BN NS LCP 9 HL SHFT SS RDS RT VOLR DIST BOTH IP/OP "$3,063.00 " "$2,266.62" $0.00 "$2,379.04" "$1,338.21" "$1,338.21" $0.00 $0.00 $0.00 $638.41 "$2,273.36" "$2,273.36" $0.00 $0.00 $638.33 $0.00 "$1,510.06" "$1,510.06" $0.00 "$1,486.90" "$2,355.25" "$2,379.04" $0.00 $0.00 $451.84 $0.00 $0.00 $473.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.011 SUP HCPCS C1713 02.110.011 - PLATE BN NS LCP 11 HL SHFT SS RDS RT VOLR DIST BOTH IP/OP "$3,251.38 " "$2,406.02" $0.00 "$2,525.34" "$1,420.50" "$1,420.50" $0.00 $0.00 $0.00 $677.67 "$2,413.17" "$2,413.17" $0.00 $0.00 $677.59 $0.00 "$1,602.93" "$1,602.93" $0.00 "$1,578.34" "$2,500.09" "$2,525.34" $0.00 $0.00 $479.63 $0.00 $0.00 $502.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.013S SUP HCPCS C1713 02.110.013S - PLATE BONE 13 HOLE LCP STAINLESS STEEL RIGHT DIAPHYSIS BOTH IP/OP "$3,432.70 " "$2,540.20" $0.00 "$2,666.18" "$1,499.73" "$1,499.73" $0.00 $0.00 $0.00 $715.46 "$2,547.75" "$2,547.75" $0.00 $0.00 $715.37 $0.00 "$1,692.32" "$1,692.32" $0.00 "$1,666.36" "$2,639.52" "$2,666.18" $0.00 $0.00 $506.38 $0.00 $0.00 $530.57 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.015S SUP HCPCS C1713 02.110.015S - PLATE BONE 15 HOLE LCP STAINLESS STEEL RIGHT DIAPHYSIS BOTH IP/OP "$3,611.23 " "$2,672.31" $0.00 "$2,804.84" "$1,577.72" "$1,577.72" $0.00 $0.00 $0.00 $752.67 "$2,680.25" "$2,680.25" $0.00 $0.00 $752.58 $0.00 "$1,780.33" "$1,780.33" $0.00 "$1,753.03" "$2,776.79" "$2,804.84" $0.00 $0.00 $532.71 $0.00 $0.00 $558.16 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.105 SUP HCPCS C1713 02.110.105 - PLATE BN NS LCP 5 HL SHFT SS RDS LT VOLR DIST BOTH IP/OP "$2,921.03 " "$2,161.56" $0.00 "$2,268.76" "$1,276.18" "$1,276.18" $0.00 $0.00 $0.00 $608.81 "$2,167.98" "$2,167.98" $0.00 $0.00 $608.74 $0.00 "$1,440.07" "$1,440.07" $0.00 "$1,417.98" "$2,246.07" "$2,268.76" $0.00 $0.00 $430.90 $0.00 $0.00 $451.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.107 SUP HCPCS C1713 02.110.107 - PLATE BN NS LCP 7 HL SHFT SS RDS LT VOLR DIST BOTH IP/OP "$2,992.73 " "$2,214.62" $0.00 "$2,324.44" "$1,307.50" "$1,307.50" $0.00 $0.00 $0.00 $623.76 "$2,221.20" "$2,221.20" $0.00 $0.00 $623.68 $0.00 "$1,475.41" "$1,475.41" $0.00 "$1,452.78" "$2,301.20" "$2,324.44" $0.00 $0.00 $441.47 $0.00 $0.00 $462.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.109 SUP HCPCS C1713 02.110.109 - PLATE BN NS LCP 9 HL SHFT SS RDS LT VOLR DIST BOTH IP/OP "$3,063.00 " "$2,266.62" $0.00 "$2,379.04" "$1,338.21" "$1,338.21" $0.00 $0.00 $0.00 $638.41 "$2,273.36" "$2,273.36" $0.00 $0.00 $638.33 $0.00 "$1,510.06" "$1,510.06" $0.00 "$1,486.90" "$2,355.25" "$2,379.04" $0.00 $0.00 $451.84 $0.00 $0.00 $473.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.111 SUP HCPCS C1713 02.110.111 - PLATE BN NS LCP 11 HL SHFT SS RDS LT VOLR DIST BOTH IP/OP "$3,133.30 " "$2,318.64" $0.00 "$2,433.62" "$1,368.91" "$1,368.91" $0.00 $0.00 $0.00 $653.06 "$2,325.54" "$2,325.54" $0.00 $0.00 $652.98 $0.00 "$1,544.72" "$1,544.72" $0.00 "$1,521.01" "$2,409.29" "$2,433.62" $0.00 $0.00 $462.21 $0.00 $0.00 $484.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.113S SUP HCPCS C1713 02.110.113S - PLATE BONE 13 HOLE LCP STAINLESS STEEL LEFT DISTAL VOLAR BOTH IP/OP "$3,497.38 " "$2,588.06" $0.00 "$2,716.40" "$1,527.98" "$1,527.98" $0.00 $0.00 $0.00 $728.94 "$2,595.75" "$2,595.75" $0.00 $0.00 $728.85 $0.00 "$1,724.21" "$1,724.21" $0.00 "$1,697.75" "$2,689.24" "$2,716.40" $0.00 $0.00 $515.92 $0.00 $0.00 $540.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.115S SUP HCPCS C1713 02.110.115S - PLATE BONE 15 HOLE LCP STAINLESS STEEL LEFT DISTAL VOLAR BOTH IP/OP "$3,611.23 " "$2,672.31" $0.00 "$2,804.84" "$1,577.72" "$1,577.72" $0.00 $0.00 $0.00 $752.67 "$2,680.25" "$2,680.25" $0.00 $0.00 $752.58 $0.00 "$1,780.33" "$1,780.33" $0.00 "$1,753.03" "$2,776.79" "$2,804.84" $0.00 $0.00 $532.71 $0.00 $0.00 $558.16 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.150 SUP HCPCS C1713 02.110.150 - PLATE BN STD BND 118MM NS LCP FSN SS WRST BOTH IP/OP "$3,145.95 " "$2,328.00" $0.00 "$2,443.44" "$1,374.44" "$1,374.44" $0.00 $0.00 $0.00 $655.69 "$2,334.92" "$2,334.92" $0.00 $0.00 $655.62 $0.00 "$1,550.95" "$1,550.95" $0.00 "$1,527.15" "$2,419.01" "$2,443.44" $0.00 $0.00 $464.08 $0.00 $0.00 $486.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.151 SUP HCPCS C1713 02.110.151 - PLATE BN SHRT BND 118MM NS LCP FSN SS WRST BOTH IP/OP "$3,145.95 " "$2,328.00" $0.00 "$2,443.44" "$1,374.44" "$1,374.44" $0.00 $0.00 $0.00 $655.69 "$2,334.92" "$2,334.92" $0.00 $0.00 $655.62 $0.00 "$1,550.95" "$1,550.95" $0.00 "$1,527.15" "$2,419.01" "$2,443.44" $0.00 $0.00 $464.08 $0.00 $0.00 $486.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.152 SUP HCPCS C1713 02.110.152 - PLATE BONE STR 112MM FUSION LCP STAINLESS STEEL WRIST BOTH IP/OP "$3,145.95 " "$2,328.00" $0.00 "$2,443.44" "$1,374.44" "$1,374.44" $0.00 $0.00 $0.00 $655.69 "$2,334.92" "$2,334.92" $0.00 $0.00 $655.62 $0.00 "$1,550.95" "$1,550.95" $0.00 "$1,527.15" "$2,419.01" "$2,443.44" $0.00 $0.00 $464.08 $0.00 $0.00 $486.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.201 SUP HCPCS C1713 02.110.201 - PLATE BN 48MM NS LCP CMBN 5 HLE/HD 3 HL SHFT VA SS RDS RT BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.202 SUP HCPCS C1713 02.110.202 - PLATE BN 66MM NS LCP CMBN 5 HLE/HD 5 HL SHFT VA SS RDS RT BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.203 SUP HCPCS C1713 02.110.203 - PLATE BN 48MM NS LCP CMBN 5 HLE/HD 3 HL SHFT VA SS RDS LT BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.204 SUP HCPCS C1713 02.110.204 - PLATE BN 66MM NS LCP CMBN 5 HLE/HD 5 HL SHFT VA SS RDS LT BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.205 SUP HCPCS C1713 02.110.205 - PLATE BN 45MM NS LCP CMBN 4 HLE/HD 3 HL SHFT VA SS RDS RT BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.206 SUP HCPCS C1713 02.110.206 - PLATE BN 65MM NS LCP CMBN 4 HLE/HD 5 HL SHFT VA SS RDS RT BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.207 SUP HCPCS C1713 02.110.207 - PLATE BN 45MM NS LCP CMBN 4 HLE/HD 3 HL SHFT VA SS RDS LT BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.208 SUP HCPCS C1713 02.110.208 - PLATE BN 65MM NS LCP CMBN 4 HLE/HD 5 HL SHFT VA SS RDS LT BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.300 SUP Custom 27203010 02.110.300 - WIRE FIX 1.8MM 150MM TROCAR POINT KWIRE STAINLESS STEEL BOTH IP/OP $15.18 $11.23 $0.00 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.27 $11.27 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $7.37 $11.67 $11.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.330 SUP HCPCS C1713 02.110.330 - PLATE BN CNTR 50.5MM NS LCP CMBN 9 HLE/HD 3 HL SHFT CLMN RND BOTH IP/OP "$1,570.15 " "$1,161.91" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $327.26 "$1,165.37" "$1,165.37" $0.00 $0.00 $327.22 $0.00 $928.74 $928.74 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.331 SUP HCPCS C1713 02.110.331 - PLATE BN CNTR 50.5MM NS LCP CMBN 9 HLE/HD 3 HL SHFT CLMN RND BOTH IP/OP "$1,570.15 " "$1,161.91" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $327.26 "$1,165.37" "$1,165.37" $0.00 $0.00 $327.22 $0.00 $928.74 $928.74 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.340 SUP HCPCS C1713 02.110.340 - PLATE BN CNTR 59.5MM NS LCP CMBN 9 HLE/HD 4 HL SHFT CLMN RND BOTH IP/OP "$1,619.35 " "$1,198.32" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $337.51 "$1,201.88" "$1,201.88" $0.00 $0.00 $337.47 $0.00 $957.85 $957.85 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.341 SUP HCPCS C1713 02.110.341 - PLATE BN CNTR 59.5MM NS LCP CMBN 9 HLE/HD 4 HL SHFT CLMN RND BOTH IP/OP "$1,619.35 " "$1,198.32" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $337.51 "$1,201.88" "$1,201.88" $0.00 $0.00 $337.47 $0.00 $957.85 $957.85 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.350 SUP HCPCS C1713 02.110.350 - PLATE BN CNTR 68.5MM NS LCP CMBN 9 HLE/HD 5 HL SHFT CLMN RND BOTH IP/OP "$1,667.15 " "$1,233.69" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $347.48 "$1,237.36" "$1,237.36" $0.00 $0.00 $347.43 $0.00 $986.12 $986.12 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.351 SUP HCPCS C1713 02.110.351 - PLATE BN CNTR 68.5MM NS LCP CMBN 9 HLE/HD 5 HL SHFT CLMN RND BOTH IP/OP "$1,667.15 " "$1,233.69" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $347.48 "$1,237.36" "$1,237.36" $0.00 $0.00 $347.43 $0.00 $986.12 $986.12 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.430 SUP HCPCS C1713 02.110.430 - PLATE BN CNTR 50.5MM NS LCP CMBN 8 HLE/HD 3 HL SHFT CLMN RND BOTH IP/OP "$1,570.15 " "$1,161.91" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $327.26 "$1,165.37" "$1,165.37" $0.00 $0.00 $327.22 $0.00 $928.74 $928.74 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.431 SUP HCPCS C1713 02.110.431 - PLATE BN CNTR 50.5MM NS LCP CMBN 8 HLE/HD 3 HL SHFT CLMN RND BOTH IP/OP "$1,570.15 " "$1,161.91" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $327.26 "$1,165.37" "$1,165.37" $0.00 $0.00 $327.22 $0.00 $928.74 $928.74 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.440 SUP HCPCS C1713 02.110.440 - PLATE BN CNTR 59.5MM NS LCP CMBN 8 HLE/HD 4 HL SHFT CLMN RND BOTH IP/OP "$1,619.35 " "$1,198.32" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $337.51 "$1,201.88" "$1,201.88" $0.00 $0.00 $337.47 $0.00 $957.85 $957.85 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.441 SUP HCPCS C1713 02.110.441 - PLATE BN CNTR 59.5MM NS LCP CMBN 8 HLE/HD 4 HL SHFT CLMN RND BOTH IP/OP "$1,619.35 " "$1,198.32" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $337.51 "$1,201.88" "$1,201.88" $0.00 $0.00 $337.47 $0.00 $957.85 $957.85 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.450 SUP HCPCS C1713 02.110.450 - PLATE BN CNTR 68.5MM NS LCP CMBN 8 HLE/HD 5 HL SHFT CLMN RND BOTH IP/OP "$1,667.15 " "$1,233.69" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $347.48 "$1,237.36" "$1,237.36" $0.00 $0.00 $347.43 $0.00 $986.12 $986.12 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.451 SUP HCPCS C1713 02.110.451 - PLATE BN CNTR 68.5MM NS LCP CMBN 8 HLE/HD 5 HL SHFT CLMN RND BOTH IP/OP "$1,667.15 " "$1,233.69" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $347.48 "$1,237.36" "$1,237.36" $0.00 $0.00 $347.43 $0.00 $986.12 $986.12 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.730 SUP HCPCS C1713 02.110.730 - PLATE BN CNTR 45MM NS LCP CMBN 6 HLE/HD 3 HL SHFT CLMN RND BOTH IP/OP "$1,570.15 " "$1,161.91" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $327.26 "$1,165.37" "$1,165.37" $0.00 $0.00 $327.22 $0.00 $928.74 $928.74 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.731 SUP HCPCS C1713 02.110.731 - PLATE BN CNTR 45MM NS LCP CMBN 6 HLE/HD 3 HL SHFT CLMN RND BOTH IP/OP "$1,570.15 " "$1,161.91" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $327.26 "$1,165.37" "$1,165.37" $0.00 $0.00 $327.22 $0.00 $928.74 $928.74 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.740 SUP HCPCS C1713 02.110.740 - PLATE BN CNTR 54MM NS LCP CMBN 6 HLE/HD 4 HL SHFT CLMN RND BOTH IP/OP "$1,619.35 " "$1,198.32" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $337.51 "$1,201.88" "$1,201.88" $0.00 $0.00 $337.47 $0.00 $957.85 $957.85 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.741 SUP HCPCS C1713 02.110.741 - PLATE BN CNTR 54MM NS LCP CMBN 6 HLE/HD 4 HL SHFT CLMN RND BOTH IP/OP "$1,619.35 " "$1,198.32" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $337.51 "$1,201.88" "$1,201.88" $0.00 $0.00 $337.47 $0.00 $957.85 $957.85 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.750 SUP HCPCS C1713 02.110.750 - PLATE BN CNTR 63MM NS LCP CMBN 6 HLE/HD 5 HL SHFT CLMN RND BOTH IP/OP "$1,667.15 " "$1,233.69" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $347.48 "$1,237.36" "$1,237.36" $0.00 $0.00 $347.43 $0.00 $986.12 $986.12 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.751 SUP HCPCS C1713 02.110.751 - PLATE BN CNTR 63MM NS LCP CMBN 6 HLE/HD 5 HL SHFT CLMN RND BOTH IP/OP "$1,667.15 " "$1,233.69" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $347.48 "$1,237.36" "$1,237.36" $0.00 $0.00 $347.43 $0.00 $986.12 $986.12 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.830 SUP HCPCS C1713 02.110.830 - PLATE BN CNTR 45MM NS LCP CMBN 7 HLE/HD 3 HL SHFT CLMN RND BOTH IP/OP "$1,570.15 " "$1,161.91" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $327.26 "$1,165.37" "$1,165.37" $0.00 $0.00 $327.22 $0.00 $928.74 $928.74 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.831 SUP HCPCS C1713 02.110.831 - PLATE BN CNTR 45MM NS LCP CMBN 7 HLE/HD 3 HL SHFT CLMN RND BOTH IP/OP "$1,570.15 " "$1,161.91" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $327.26 "$1,165.37" "$1,165.37" $0.00 $0.00 $327.22 $0.00 $928.74 $928.74 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.840 SUP HCPCS C1713 02.110.840 - PLATE BN CNTR 54MM NS LCP CMBN 7 HLE/HD 4 HL SHFT CLMN RND BOTH IP/OP "$1,619.35 " "$1,198.32" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $337.51 "$1,201.88" "$1,201.88" $0.00 $0.00 $337.47 $0.00 $957.85 $957.85 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.841 SUP HCPCS C1713 02.110.841 - PLATE BN CNTR 54MM NS LCP CMBN 7 HLE/HD 4 HL SHFT CLMN RND BOTH IP/OP "$1,619.35 " "$1,198.32" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $337.51 "$1,201.88" "$1,201.88" $0.00 $0.00 $337.47 $0.00 $957.85 $957.85 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.850 SUP HCPCS C1713 02.110.850 - PLATE BN CNTR 63MM NS LCP CMBN 7 HLE/HD 5 HL SHFT CLMN RND BOTH IP/OP "$1,667.15 " "$1,233.69" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $347.48 "$1,237.36" "$1,237.36" $0.00 $0.00 $347.43 $0.00 $986.12 $986.12 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.110.851 SUP HCPCS C1713 02.110.851 - PLATE BN CNTR 63MM NS LCP CMBN 7 HLE/HD 5 HL SHFT CLMN RND BOTH IP/OP "$1,667.15 " "$1,233.69" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $347.48 "$1,237.36" "$1,237.36" $0.00 $0.00 $347.43 $0.00 $986.12 $986.12 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.500.01S SUP HCPCS C1713 02.111.500.01S - PLATE BONE 1.25MM 150MM REDX SMALL STOP WIRE THREADED BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.500.10 SUP HCPCS C1713 02.111.500.10 - WIRE REDX SMALL 1.25MM 150MM THREAD STOP STAINLESS STEEL BOTH IP/OP $32.19 $23.82 $0.00 $25.00 $14.06 $14.06 $0.00 $0.00 $0.00 $6.71 $23.89 $23.89 $0.00 $0.00 $6.71 $0.00 $19.04 $19.04 $0.00 $15.63 $24.75 $25.00 $0.00 $0.00 $4.75 $0.00 $0.00 $4.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.501.01S SUP HCPCS C1713 02.111.501.01S - PLATE BONE 1.25MM REDX WIRE LARGE STOP THREADED TIP LCP BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.501.10 SUP HCPCS C1713 02.111.501.10 - WIRE REDX 1.25MM 150MM THREAD TIP LARGE STOP STAINLESS STEEL BOTH IP/OP $31.25 $23.13 $0.00 $25.00 $14.06 $14.06 $0.00 $0.00 $0.00 $6.51 $23.20 $23.20 $0.00 $0.00 $6.51 $0.00 $18.49 $18.49 $0.00 $15.63 $24.75 $25.00 $0.00 $0.00 $4.75 $0.00 $0.00 $4.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.520 SUP HCPCS C1713 02.111.520 - PLATE BONE 42MM 6X2 HOLE 2 COLUMN VAR ANG LCP STAINLESS BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.521 SUP HCPCS C1713 02.111.521 - PLATE BN NAR 42MM NS LCP CMBN 6 HLE/HD 2 HL SHFT 2 CLMN VA BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.530 SUP HCPCS C1713 02.111.530 - PLATE BN NAR 51MM NS LCP CMBN 6 HLE/HD 3 HL SHFT 2 CLMN VA BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.531 SUP HCPCS C1713 02.111.531 - PLATE BONE NARROW 51MM 6X3 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.540 SUP HCPCS C1713 02.111.540 - PLATE BONE NARROW 63MM 6X4 HOLE 2 COLUMN VAR ANG SET LCP BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.541 SUP HCPCS C1713 02.111.541 - PLATE BONE NARROW 63MM 6X4 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.550 SUP HCPCS C1713 02.111.550 - PLATE BONE NARROW 72MM 6X5 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.551 SUP HCPCS C1713 02.111.551 - PLATE BONE NARROW 72MM 6X5 HOLE 2 COLUMN VAR ANG SET LCP BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.620 SUP HCPCS C1713 02.111.620 - PLATE BN STD 45MM NS LCP CMBN 6 HLE/HD 2 HL SHFT 2 CLMN VA BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.621 SUP HCPCS C1713 02.111.621 - PLATE BN STD 45MM NS LCP CMBN 6 HLE/HD 2 HL SHFT 2 CLMN VA BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.630 SUP HCPCS C1713 02.111.630 - PLATE BN STD 54MM NS LCP CMBN 6 HLE/HD 3 HL SHFT 2 CLMN VA BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.630S SUP HCPCS C1713 02.111.630S - PLATE BONE 58MM 6X3 HOLE 2 COLUMN VAR ANG LCP STAINLESS BOTH IP/OP "$1,965.15 " "$1,454.21" $0.00 "$1,526.34" $858.57 $858.57 $0.00 $0.00 $0.00 $409.59 "$1,458.53" "$1,458.53" $0.00 $0.00 $409.54 $0.00 "$1,162.39" "$1,162.39" $0.00 $953.96 "$1,511.08" "$1,526.34" $0.00 $0.00 $289.89 $0.00 $0.00 $303.74 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.631 SUP HCPCS C1713 02.111.631 - PLATE BN STD 54MM NS LCP CMBN 6 HLE/HD 3 HL SHFT 2 CLMN VA BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.631S SUP HCPCS C1713 02.111.631S - PLATE BONE 54MM 6X3 HOLE 2 COLUMN VAR ANG LCP STAINLESS BOTH IP/OP "$1,965.15 " "$1,454.21" $0.00 "$1,526.34" $858.57 $858.57 $0.00 $0.00 $0.00 $409.59 "$1,458.53" "$1,458.53" $0.00 $0.00 $409.54 $0.00 "$1,162.39" "$1,162.39" $0.00 $953.96 "$1,511.08" "$1,526.34" $0.00 $0.00 $289.89 $0.00 $0.00 $303.74 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.640 SUP HCPCS C1713 02.111.640 - PLATE BN STD 66MM NS LCP CMBN 6 HLE/HD 4 HL SHFT 2 CLMN VA BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.641 SUP HCPCS C1713 02.111.641 - PLATE BN STD 66MM NS LCP CMBN 6 HLE/HD 4 HL SHFT 2 CLMN VA BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.650 SUP HCPCS C1713 02.111.650 - PLATE BN STD 75MM NS LCP CMBN 6 HLE/HD 5 HL SHFT 2 CLMN VA BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.651 SUP HCPCS C1713 02.111.651 - PLATE BN STD 75MM NS LCP CMBN 6 HLE/HD 5 HL SHFT 2 CLMN VA BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.720 SUP HCPCS C1713 02.111.720 - PLATE BN STD 47MM NS LCP CMBN 7 HLE/HD 2 HL SHFT 2 CLMN VA BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.721 SUP HCPCS C1713 02.111.721 - PLATE BN STD 47MM NS LCP CMBN 7 HLE/HD 2 HL SHFT 2 CLMN VA BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.730 SUP HCPCS C1713 02.111.730 - PLATE BN STD 55MM NS LCP CMBN 7 HLE/HD 3 HL SHFT 2 CLMN VA BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.731 SUP HCPCS C1713 02.111.731 - PLATE BN STD 55MM NS LCP CMBN 7 HLE/HD 3 HL SHFT 2 CLMN VA BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.740 SUP HCPCS C1713 02.111.740 - PLATE BN STD 68MM NS LCP CMBN 7 HLE/HD 4 HL SHFT 2 CLMN VA BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.741 SUP HCPCS C1713 02.111.741 - PLATE BN STD 68MM NS LCP CMBN 7 HLE/HD 4 HL SHFT 2 CLMN VA BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.750 SUP HCPCS C1713 02.111.750 - PLATE BN STD 77MM NS LCP CMBN 7 HLE/HD 5 HL SHFT 2 CLMN VA BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.111.751 SUP HCPCS C1713 02.111.751 - PLATE BN STD 77MM NS LCP CMBN 7 HLE/HD 5 HL SHFT 2 CLMN VA BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.006 SUP HCPCS C1713 02.112.006 - PLATE BN 69MM NS LCP CMBN 3 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,623.58 " "$1,201.45" $0.00 "$1,261.02" $709.32 $709.32 $0.00 $0.00 $0.00 $338.39 "$1,205.02" "$1,205.02" $0.00 $0.00 $338.35 $0.00 $960.34 $960.34 $0.00 $788.14 "$1,248.41" "$1,261.02" $0.00 $0.00 $239.50 $0.00 $0.00 $250.94 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.007 SUP HCPCS C1713 02.112.007 - PLATE BN 69MM NS LCP CMBN 3 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,623.58 " "$1,201.45" $0.00 "$1,261.02" $709.32 $709.32 $0.00 $0.00 $0.00 $338.39 "$1,205.02" "$1,205.02" $0.00 $0.00 $338.35 $0.00 $960.34 $960.34 $0.00 $788.14 "$1,248.41" "$1,261.02" $0.00 $0.00 $239.50 $0.00 $0.00 $250.94 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.008 SUP HCPCS C1713 02.112.008 - PLATE BN 108MM NS LCP CMBN 6 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.009 SUP HCPCS C1713 02.112.009 - PLATE BN 108MM NS LCP CMBN 6 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.010 SUP HCPCS C1713 02.112.010 - PLATE BN 81MM NS LCP CMBN 4 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,648.88 " "$1,220.17" $0.00 "$1,280.68" $720.38 $720.38 $0.00 $0.00 $0.00 $343.67 "$1,223.80" "$1,223.80" $0.00 $0.00 $343.63 $0.00 $975.31 $975.31 $0.00 $800.43 "$1,267.87" "$1,280.68" $0.00 $0.00 $243.24 $0.00 $0.00 $254.86 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.011 SUP HCPCS C1713 02.112.011 - PLATE BN 81MM NS LCP CMBN 4 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,648.88 " "$1,220.17" $0.00 "$1,280.68" $720.38 $720.38 $0.00 $0.00 $0.00 $343.67 "$1,223.80" "$1,223.80" $0.00 $0.00 $343.63 $0.00 $975.31 $975.31 $0.00 $800.43 "$1,267.87" "$1,280.68" $0.00 $0.00 $243.24 $0.00 $0.00 $254.86 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.012 SUP HCPCS C1713 02.112.012 - PLATE BN 94MM NS LCP CMBN 5 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,677.00 " "$1,240.98" $0.00 "$1,302.52" $732.67 $732.67 $0.00 $0.00 $0.00 $349.53 "$1,244.67" "$1,244.67" $0.00 $0.00 $349.49 $0.00 $991.95 $991.95 $0.00 $814.08 "$1,289.49" "$1,302.52" $0.00 $0.00 $247.38 $0.00 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.013 SUP HCPCS C1713 02.112.013 - PLATE BN 94MM NS LCP CMBN 5 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,677.00 " "$1,240.98" $0.00 "$1,302.52" $732.67 $732.67 $0.00 $0.00 $0.00 $349.53 "$1,244.67" "$1,244.67" $0.00 $0.00 $349.49 $0.00 $991.95 $991.95 $0.00 $814.08 "$1,289.49" "$1,302.52" $0.00 $0.00 $247.38 $0.00 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.018 SUP HCPCS C1713 02.112.018 - PLATE BN 123MM NS LCP CMBN 7 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.019 SUP HCPCS C1713 02.112.019 - PLATE BN 123MM NS LCP CMBN 7 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.020 SUP HCPCS C1713 02.112.020 - PLATE BN 135MM NS LCP CMBN 8 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.021 SUP HCPCS C1713 02.112.021 - PLATE BN 135MM NS LCP CMBN 8 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.026 SUP HCPCS C1713 02.112.026 - PLATE BN 94MM NS LCP CMBN 6 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.027 SUP HCPCS C1713 02.112.027 - PLATE BN 94MM NS LCP CMBN 6 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.028 SUP HCPCS C1713 02.112.028 - PLATE BN 110MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.029 SUP HCPCS C1713 02.112.029 - PLATE BN 110MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.030 SUP HCPCS C1713 02.112.030 - PLATE BN 120MM NS LCP CMBN 8 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.031 SUP HCPCS C1713 02.112.031 - PLATE BN 120MM NS LCP CMBN 8 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.040 SUP HCPCS C1713 02.112.040 - PLATE BONE 79MM 6 HOLE LCP STAINLESS STEEL ANTERIOR MEDIAL BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.041 SUP HCPCS C1713 02.112.041 - PLATE BONE 91MM 7 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.042 SUP HCPCS C1713 02.112.042 - PLATE BONE 8 HOLE LCP STAINLESS STEEL MEDIAL ANTERIOR BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.045 SUP HCPCS C1713 02.112.045 - PLATE BONE 77MM 7 HOLE VAR ANG LCP STAINLESS STEEL LATERAL BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.046 SUP HCPCS C1713 02.112.046 - PLATE BONE 89MM 9 HOLE VAR ANG LCP STAINLESS STEEL LATERAL BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.047 SUP HCPCS C1713 02.112.047 - PLATE BONE 101MM 10 HOLE VAR ANG LCP STAINLESS STEEL LATERAL BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.048 SUP HCPCS C1713 02.112.048 - PLATE BONE 113MM 11 HOLE VAR ANG LCP STAINLESS STEEL LATERAL BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.049 SUP HCPCS C1713 02.112.049 - PLATE BONE 12 HOLE LCP STAINLESS STEEL LATERAL VOLAR BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.080 SUP HCPCS C1713 02.112.080 - PLATE BN 85MM NS LCP CMBN 6 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.081 SUP HCPCS C1713 02.112.081 - PLATE BN 85MM NS LCP CMBN 6 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.082 SUP HCPCS C1713 02.112.082 - PLATE BN 100MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.083 SUP HCPCS C1713 02.112.083 - PLATE BN 100MM NS LCP CMBN 7 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.084 SUP HCPCS C1713 02.112.084 - PLATE BN 115MM NS LCP CMBN 8 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.085 SUP HCPCS C1713 02.112.085 - PLATE BN 115MM NS LCP CMBN 8 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.090 SUP HCPCS C1713 02.112.090 - PLATE BN 105MM NS LCP CMBN 6 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.091 SUP HCPCS C1713 02.112.091 - PLATE BN 105MM NS LCP CMBN 6 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.092 SUP HCPCS C1713 02.112.092 - PLATE BN 120MM NS LCP CMBN 7 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.093 SUP HCPCS C1713 02.112.093 - PLATE BN 120MM NS LCP CMBN 7 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.094 SUP HCPCS C1713 02.112.094 - PLATE BN 130MM NS LCP CMBN 8 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.095 SUP HCPCS C1713 02.112.095 - PLATE BN 130MM NS LCP CMBN 8 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.106 SUP HCPCS C1713 02.112.106 - PLATE BONE 77MM 3 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$1,186.40 " $877.94 $0.00 $921.48 $518.33 $518.33 $0.00 $0.00 $0.00 $247.28 $880.55 $880.55 $0.00 $0.00 $247.25 $0.00 $701.76 $701.76 $0.00 $575.93 $912.27 $921.48 $0.00 $0.00 $175.01 $0.00 $0.00 $183.37 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.107 SUP HCPCS C1713 02.112.107 - PLATE BONE 77MM 3 HOLE LCP STAINLESS STEEL LEFT DISTAL BOTH IP/OP "$1,186.40 " $877.94 $0.00 $921.48 $518.33 $518.33 $0.00 $0.00 $0.00 $247.28 $880.55 $880.55 $0.00 $0.00 $247.25 $0.00 $701.76 $701.76 $0.00 $575.93 $912.27 $921.48 $0.00 $0.00 $175.01 $0.00 $0.00 $183.37 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.108 SUP HCPCS C1713 02.112.108 - PLATE BONE 9CM 4 HOLE LCP STAINLESS STEEL RIGHT POSTLAT BOTH IP/OP "$1,206.08 " $892.50 $0.00 $936.76 $526.93 $526.93 $0.00 $0.00 $0.00 $251.38 $895.15 $895.15 $0.00 $0.00 $251.35 $0.00 $713.39 $713.39 $0.00 $585.48 $927.39 $936.76 $0.00 $0.00 $177.92 $0.00 $0.00 $186.42 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.109 SUP HCPCS C1713 02.112.109 - PLATE BONE 9CM 4 HOLE LCP STAINLESS STEEL LEFT POSTLAT BOTH IP/OP "$1,206.08 " $892.50 $0.00 $936.76 $526.93 $526.93 $0.00 $0.00 $0.00 $251.38 $895.15 $895.15 $0.00 $0.00 $251.35 $0.00 $713.39 $713.39 $0.00 $585.48 $927.39 $936.76 $0.00 $0.00 $177.92 $0.00 $0.00 $186.42 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.110 SUP HCPCS C1713 02.112.110 - PLATE BONE 103MM 5 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$1,221.55 " $903.95 $0.00 $948.78 $533.69 $533.69 $0.00 $0.00 $0.00 $254.60 $906.63 $906.63 $0.00 $0.00 $254.57 $0.00 $722.55 $722.55 $0.00 $592.99 $939.30 $948.78 $0.00 $0.00 $180.20 $0.00 $0.00 $188.81 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.111 SUP HCPCS C1713 02.112.111 - PLATE BONE 103MM 5 HOLE LCP STAINLESS STEEL LEFT POSTLAT BOTH IP/OP "$1,221.55 " $903.95 $0.00 $948.78 $533.69 $533.69 $0.00 $0.00 $0.00 $254.60 $906.63 $906.63 $0.00 $0.00 $254.57 $0.00 $722.55 $722.55 $0.00 $592.99 $939.30 $948.78 $0.00 $0.00 $180.20 $0.00 $0.00 $188.81 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.112 SUP HCPCS C1713 02.112.112 - PLATE BONE 112MM 6 HOLE LCP STAINLESS STEEL RIGHT POSTLAT BOTH IP/OP "$1,241.23 " $918.51 $0.00 $964.06 $542.28 $542.28 $0.00 $0.00 $0.00 $258.70 $921.24 $921.24 $0.00 $0.00 $258.67 $0.00 $734.18 $734.18 $0.00 $602.54 $954.42 $964.06 $0.00 $0.00 $183.10 $0.00 $0.00 $191.85 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.113 SUP HCPCS C1713 02.112.113 - PLATE BONE 112MM 6 HOLE LCP STAINLESS STEEL LEFT POSTLAT BOTH IP/OP "$1,241.23 " $918.51 $0.00 $964.06 $542.28 $542.28 $0.00 $0.00 $0.00 $258.70 $921.24 $921.24 $0.00 $0.00 $258.67 $0.00 $734.18 $734.18 $0.00 $602.54 $954.42 $964.06 $0.00 $0.00 $183.10 $0.00 $0.00 $191.85 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.114 SUP HCPCS C1713 02.112.114 - PLATE BONE 12.9CM 7 HOLE LCP STAINLESS STEEL RIGHT POSTLAT BOTH IP/OP "$1,258.10 " $930.99 $0.00 $977.16 $549.65 $549.65 $0.00 $0.00 $0.00 $262.22 $933.76 $933.76 $0.00 $0.00 $262.19 $0.00 $744.17 $744.17 $0.00 $610.73 $967.39 $977.16 $0.00 $0.00 $185.59 $0.00 $0.00 $194.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.115 SUP HCPCS C1713 02.112.115 - PLATE BONE 12.9CM 7 HOLE LCP STAINLESS STEEL LEFT POSTLAT BOTH IP/OP "$1,258.10 " $930.99 $0.00 $977.16 $549.65 $549.65 $0.00 $0.00 $0.00 $262.22 $933.76 $933.76 $0.00 $0.00 $262.19 $0.00 $744.17 $744.17 $0.00 $610.73 $967.39 $977.16 $0.00 $0.00 $185.59 $0.00 $0.00 $194.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.118 SUP HCPCS C1713 02.112.118 - PLATE BONE 151MM 9 HOLE LCP STAINLESS STEEL RIGHT POSTLAT BOTH IP/OP "$1,276.38 " $944.52 $0.00 $991.36 $557.64 $557.64 $0.00 $0.00 $0.00 $266.03 $947.33 $947.33 $0.00 $0.00 $266.00 $0.00 $754.98 $754.98 $0.00 $619.60 $981.45 $991.36 $0.00 $0.00 $188.29 $0.00 $0.00 $197.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.119 SUP HCPCS C1713 02.112.119 - PLATE BONE 151MM 9 HOLE LCP STAINLESS STEEL LEFT POSTLAT BOTH IP/OP "$1,276.38 " $944.52 $0.00 $991.36 $557.64 $557.64 $0.00 $0.00 $0.00 $266.03 $947.33 $947.33 $0.00 $0.00 $266.00 $0.00 $754.98 $754.98 $0.00 $619.60 $981.45 $991.36 $0.00 $0.00 $188.29 $0.00 $0.00 $197.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.122 SUP HCPCS C1713 02.112.122 - PLATE BONE 177MM 11 HOLE LCP STAINLESS STEEL RIGHT POSTLAT BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.123 SUP HCPCS C1713 02.112.123 - PLATE BONE 177MM 11 HOLE LCP STAINLESS STEEL LEFT POSTLAT BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.126 SUP HCPCS C1713 02.112.126 - PLATE BONE 126MM 13 HOLE LCP STAINLESS STEEL RIGHT POSTLAT BOTH IP/OP "$1,312.93 " $971.57 $0.00 "$1,019.74" $573.60 $573.60 $0.00 $0.00 $0.00 $273.65 $974.45 $974.45 $0.00 $0.00 $273.61 $0.00 $776.60 $776.60 $0.00 $637.34 "$1,009.55" "$1,019.74" $0.00 $0.00 $193.68 $0.00 $0.00 $202.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.127 SUP HCPCS C1713 02.112.127 - PLATE BONE 127MM 13 HOLE LCP STAINLESS STEEL LEFT POSTLAT BOTH IP/OP "$1,312.93 " $971.57 $0.00 "$1,019.74" $573.60 $573.60 $0.00 $0.00 $0.00 $273.65 $974.45 $974.45 $0.00 $0.00 $273.61 $0.00 $776.60 $776.60 $0.00 $637.34 "$1,009.55" "$1,019.74" $0.00 $0.00 $193.68 $0.00 $0.00 $202.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.130 SUP HCPCS C1713 02.112.130 - PLATE BONE 233MM 15 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$1,329.78 " $984.04 $0.00 "$1,032.84" $580.97 $580.97 $0.00 $0.00 $0.00 $277.16 $986.96 $986.96 $0.00 $0.00 $277.13 $0.00 $786.56 $786.56 $0.00 $645.53 "$1,022.51" "$1,032.84" $0.00 $0.00 $196.16 $0.00 $0.00 $205.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.131 SUP HCPCS C1713 02.112.131 - PLATE BONE 233MM 15 HOLE LCP STAINLESS STEEL LEFT POSTLAT BOTH IP/OP "$1,329.78 " $984.04 $0.00 "$1,032.84" $580.97 $580.97 $0.00 $0.00 $0.00 $277.16 $986.96 $986.96 $0.00 $0.00 $277.13 $0.00 $786.56 $786.56 $0.00 $645.53 "$1,022.51" "$1,032.84" $0.00 $0.00 $196.16 $0.00 $0.00 $205.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.136 SUP HCPCS C1713 02.112.136 - PLATE BN CNTR 73MM NS LCP CMBN 3 HL SS FIB RT DIST LAT BOTH IP/OP "$1,147.05 " $848.82 $0.00 $890.90 $501.13 $501.13 $0.00 $0.00 $0.00 $239.07 $851.34 $851.34 $0.00 $0.00 $239.05 $0.00 $678.48 $678.48 $0.00 $556.81 $881.99 $890.90 $0.00 $0.00 $169.21 $0.00 $0.00 $177.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.137 SUP HCPCS C1713 02.112.137 - PLATE BN CNTR 73MM NS LCP CMBN 3 HL SS FIB LT DIST LAT BOTH IP/OP "$1,147.05 " $848.82 $0.00 $890.90 $501.13 $501.13 $0.00 $0.00 $0.00 $239.07 $851.34 $851.34 $0.00 $0.00 $239.05 $0.00 $678.48 $678.48 $0.00 $556.81 $881.99 $890.90 $0.00 $0.00 $169.21 $0.00 $0.00 $177.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.138 SUP HCPCS C1713 02.112.138 - PLATE BN CNTR 86MM NS LCP CMBN 4 HL SS FIB RT DIST LAT BOTH IP/OP "$1,166.73 " $863.38 $0.00 $906.20 $509.74 $509.74 $0.00 $0.00 $0.00 $243.17 $865.94 $865.94 $0.00 $0.00 $243.15 $0.00 $690.12 $690.12 $0.00 $566.38 $897.14 $906.20 $0.00 $0.00 $172.11 $0.00 $0.00 $180.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.138S SUP HCPCS C1713 02.112.138S - PLATE BONE 86MM 4 HOLE LOCKING COMPRESSION LCP STAINLESS BOTH IP/OP "$1,258.10 " $930.99 $0.00 $977.16 $549.65 $549.65 $0.00 $0.00 $0.00 $262.22 $933.76 $933.76 $0.00 $0.00 $262.19 $0.00 $744.17 $744.17 $0.00 $610.73 $967.39 $977.16 $0.00 $0.00 $185.59 $0.00 $0.00 $194.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.139 SUP HCPCS C1713 02.112.139 - PLATE BN CNTR 86MM NS LCP CMBN 4 HL SS FIB LT DIST LAT BOTH IP/OP "$1,166.73 " $863.38 $0.00 $906.20 $509.74 $509.74 $0.00 $0.00 $0.00 $243.17 $865.94 $865.94 $0.00 $0.00 $243.15 $0.00 $690.12 $690.12 $0.00 $566.38 $897.14 $906.20 $0.00 $0.00 $172.11 $0.00 $0.00 $180.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.140 SUP HCPCS C1713 02.112.140 - PLATE BN CNTR 99MM NS LCP CMBN 5 HL SS FIB RT DIST LAT BOTH IP/OP "$1,182.18 " $874.81 $0.00 $918.20 $516.49 $516.49 $0.00 $0.00 $0.00 $246.39 $877.41 $877.41 $0.00 $0.00 $246.37 $0.00 $699.26 $699.26 $0.00 $573.88 $909.02 $918.20 $0.00 $0.00 $174.39 $0.00 $0.00 $182.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.141 SUP HCPCS C1713 02.112.141 - PLATE BN CNTR 99MM NS LCP CMBN 5 HL SS FIB LT DIST LAT BOTH IP/OP "$1,182.18 " $874.81 $0.00 $918.20 $516.49 $516.49 $0.00 $0.00 $0.00 $246.39 $877.41 $877.41 $0.00 $0.00 $246.37 $0.00 $699.26 $699.26 $0.00 $573.88 $909.02 $918.20 $0.00 $0.00 $174.39 $0.00 $0.00 $182.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.142 SUP HCPCS C1713 02.112.142 - PLATE BN CNTR 112MM NS LCP CMBN 6 HL SS FIB RT DIST LAT BOTH IP/OP "$1,200.45 " $888.33 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $250.20 $890.97 $890.97 $0.00 $0.00 $250.17 $0.00 $710.07 $710.07 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $177.09 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.143 SUP HCPCS C1713 02.112.143 - PLATE BN CNTR 112MM NS LCP CMBN 6 HL SS FIB LT DIST LAT BOTH IP/OP "$1,200.45 " $888.33 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $250.20 $890.97 $890.97 $0.00 $0.00 $250.17 $0.00 $710.07 $710.07 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $177.09 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.144 SUP HCPCS C1713 02.112.144 - PLATE BONE 125MM 7 HOLE LCP STAINLESS STEEL RIGHT DISTAL BOTH IP/OP "$1,217.33 " $900.82 $0.00 $945.50 $531.84 $531.84 $0.00 $0.00 $0.00 $253.72 $903.50 $903.50 $0.00 $0.00 $253.69 $0.00 $720.05 $720.05 $0.00 $590.94 $936.05 $945.50 $0.00 $0.00 $179.58 $0.00 $0.00 $188.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.145 SUP HCPCS C1713 02.112.145 - PLATE BN CNTR 125MM NS LCP CMBN 7 HL SS FIB LT DIST LAT BOTH IP/OP "$1,217.33 " $900.82 $0.00 $945.50 $531.84 $531.84 $0.00 $0.00 $0.00 $253.72 $903.50 $903.50 $0.00 $0.00 $253.69 $0.00 $720.05 $720.05 $0.00 $590.94 $936.05 $945.50 $0.00 $0.00 $179.58 $0.00 $0.00 $188.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.148 SUP HCPCS C1713 02.112.148 - PLATE BONE 151MM 9 HOLE ANATOMICALLY CNTOUR LCP STAINLESS BOTH IP/OP "$1,276.38 " $944.52 $0.00 $991.36 $557.64 $557.64 $0.00 $0.00 $0.00 $266.03 $947.33 $947.33 $0.00 $0.00 $266.00 $0.00 $754.98 $754.98 $0.00 $619.60 $981.45 $991.36 $0.00 $0.00 $188.29 $0.00 $0.00 $197.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.149 SUP HCPCS C1713 02.112.149 - PLATE BONE 151MM 9 HOLE LCP STAINLESS STEEL LEFT DISTAL BOTH IP/OP "$1,276.38 " $944.52 $0.00 $991.36 $557.64 $557.64 $0.00 $0.00 $0.00 $266.03 $947.33 $947.33 $0.00 $0.00 $266.00 $0.00 $754.98 $754.98 $0.00 $619.60 $981.45 $991.36 $0.00 $0.00 $188.29 $0.00 $0.00 $197.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.152 SUP HCPCS C1713 02.112.152 - PLATE BONE 177MM 11 HOLE LCP STAINLESS STEEL RIGHT LATERAL BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.153 SUP HCPCS C1713 02.112.153 - PLATE BONE 177MM 11 HOLE LCP STAINLESS STEEL LEFT LATERAL BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.156 SUP HCPCS C1713 02.112.156 - PLATE BONE 203MM 13 HOLE LCP STAINLESS STEEL RIGHT LATERAL BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.157 SUP HCPCS C1713 02.112.157 - PLATE BONE 203MM 13 HOLE LCP STAINLESS STEEL LEFT LATERAL BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.160 SUP HCPCS C1713 02.112.160 - PLATE BONE 299MM 15 HOLE LCP STAINLESS STEEL RIGHT LATERAL BOTH IP/OP "$1,370.55 " "$1,014.21" $0.00 "$1,064.50" $598.78 $598.78 $0.00 $0.00 $0.00 $285.66 "$1,017.22" "$1,017.22" $0.00 $0.00 $285.62 $0.00 $810.68 $810.68 $0.00 $665.31 "$1,053.86" "$1,064.50" $0.00 $0.00 $202.18 $0.00 $0.00 $211.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.161 SUP HCPCS C1713 02.112.161 - PLATE BONE 229MM 15 HOLE LCP STAINLESS STEEL LEFT LATERAL BOTH IP/OP "$1,370.55 " "$1,014.21" $0.00 "$1,064.50" $598.78 $598.78 $0.00 $0.00 $0.00 $285.66 "$1,017.22" "$1,017.22" $0.00 $0.00 $285.62 $0.00 $810.68 $810.68 $0.00 $665.31 "$1,053.86" "$1,064.50" $0.00 $0.00 $202.18 $0.00 $0.00 $211.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.203 SUP HCPCS C1713 02.112.203 - PLATE BONE T 64MM 3 HOLE LCP STAINLESS STEEL DISTAL TIBIA BOTH IP/OP "$1,384.60 " "$1,024.60" $0.00 "$1,075.42" $604.92 $604.92 $0.00 $0.00 $0.00 $288.59 "$1,027.65" "$1,027.65" $0.00 $0.00 $288.55 $0.00 $818.99 $818.99 $0.00 $672.14 "$1,064.67" "$1,075.42" $0.00 $0.00 $204.25 $0.00 $0.00 $214.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.205S SUP HCPCS C1713 02.112.205S - PLATE BONE T 90X4.5X1.5MM 5 HOLE 4 LOCKING ANGULAR STABILITY BOTH IP/OP "$1,530.80 " "$1,132.79" $0.00 "$1,188.98" $668.80 $668.80 $0.00 $0.00 $0.00 $319.06 "$1,136.16" "$1,136.16" $0.00 $0.00 $319.02 $0.00 $905.47 $905.47 $0.00 $743.11 "$1,177.09" "$1,188.98" $0.00 $0.00 $225.82 $0.00 $0.00 $236.61 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.208 SUP HCPCS C1713 02.112.208 - PLATE BONE T 13.2CM 8 HOLE LCP STAINLESS STEEL POSTERIOR BOTH IP/OP "$2,396.70 " "$1,773.56" $0.00 "$1,861.52" "$1,047.11" "$1,047.11" $0.00 $0.00 $0.00 $499.53 "$1,778.83" "$1,778.83" $0.00 $0.00 $499.47 $0.00 "$1,417.65" "$1,417.65" $0.00 "$1,163.45" "$1,842.90" "$1,861.52" $0.00 $0.00 $353.55 $0.00 $0.00 $370.44 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.212 SUP HCPCS C1713 02.112.212 - PLATE BONE T 184MM 4 LOCKING 12 HOLE SHAFT PROFILE ANGULAR BOTH IP/OP "$2,558.35 " "$1,893.18" $0.00 "$1,987.08" "$1,117.73" "$1,117.73" $0.00 $0.00 $0.00 $533.22 "$1,898.81" "$1,898.81" $0.00 $0.00 $533.16 $0.00 "$1,261.27" "$1,261.27" $0.00 "$1,241.93" "$1,967.21" "$1,987.08" $0.00 $0.00 $377.40 $0.00 $0.00 $395.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.216 SUP HCPCS C1713 02.112.216 - PLATE BONE T 236MM 4 LOCKING 16 HOLE SHAFT PROFILE ANGULAR BOTH IP/OP "$2,652.55 " "$1,962.89" $0.00 "$2,060.22" "$1,158.87" "$1,158.87" $0.00 $0.00 $0.00 $552.86 "$1,968.72" "$1,968.72" $0.00 $0.00 $552.79 $0.00 "$1,307.71" "$1,307.71" $0.00 "$1,287.64" "$2,039.62" "$2,060.22" $0.00 $0.00 $391.29 $0.00 $0.00 $409.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.510 SUP HCPCS C1713 02.112.510 - PLATE BN LO BND 109MM NS LCP CMBN 4 HL LOPRFL RND EDG SS TIB BOTH IP/OP "$2,597.73 " "$1,922.32" $0.00 "$2,017.64" "$1,134.92" "$1,134.92" $0.00 $0.00 $0.00 $541.43 "$1,928.03" "$1,928.03" $0.00 $0.00 $541.37 $0.00 "$1,280.68" "$1,280.68" $0.00 "$1,261.03" "$1,997.46" "$2,017.64" $0.00 $0.00 $383.21 $0.00 $0.00 $401.51 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.511 SUP HCPCS C1713 02.112.511 - PLATE BN LO BND 109MM NS LCP CMBN 4 HL LOPRFL RND EDG SS TIB BOTH IP/OP "$2,597.73 " "$1,922.32" $0.00 "$2,017.64" "$1,134.92" "$1,134.92" $0.00 $0.00 $0.00 $541.43 "$1,928.03" "$1,928.03" $0.00 $0.00 $541.37 $0.00 "$1,280.68" "$1,280.68" $0.00 "$1,261.03" "$1,997.46" "$2,017.64" $0.00 $0.00 $383.21 $0.00 $0.00 $401.51 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.514 SUP HCPCS C1713 02.112.514 - PLATE BN LO BND 135MM NS LCP CMBN 6 HL LOPRFL RND EDG SS TIB BOTH IP/OP "$2,627.25 " "$1,944.17" $0.00 "$2,040.58" "$1,147.83" "$1,147.83" $0.00 $0.00 $0.00 $547.58 "$1,949.94" "$1,949.94" $0.00 $0.00 $547.52 $0.00 "$1,295.23" "$1,295.23" $0.00 "$1,275.36" "$2,020.18" "$2,040.58" $0.00 $0.00 $387.56 $0.00 $0.00 $406.08 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.514S SUP HCPCS C1713 02.112.514S - PLATE BN 135MM STRL LCP CMBN 6 HL LO BND LOPRFL RND EDG SS BOTH IP/OP "$2,718.60 " "$2,011.76" $0.00 "$2,111.54" "$1,187.74" "$1,187.74" $0.00 $0.00 $0.00 $566.62 "$2,017.74" "$2,017.74" $0.00 $0.00 $566.56 $0.00 "$1,340.27" "$1,340.27" $0.00 "$1,319.71" "$2,090.43" "$2,111.54" $0.00 $0.00 $401.04 $0.00 $0.00 $420.20 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.515 SUP HCPCS C1713 02.112.515 - PLATE BONE 135MM 6 HOLE LOW BEND LP HEAD ROUNDED EDGE LCP BOTH IP/OP "$2,627.25 " "$1,944.17" $0.00 "$2,040.58" "$1,147.83" "$1,147.83" $0.00 $0.00 $0.00 $547.58 "$1,949.94" "$1,949.94" $0.00 $0.00 $547.52 $0.00 "$1,295.23" "$1,295.23" $0.00 "$1,275.36" "$2,020.18" "$2,040.58" $0.00 $0.00 $387.56 $0.00 $0.00 $406.08 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.518 SUP HCPCS C1713 02.112.518 - PLATE BN 161MM NS LCP CMBN 8 HL LO BND LOPRFL RND EDG SS TIB BOTH IP/OP "$2,652.55 " "$1,962.89" $0.00 "$2,060.22" "$1,158.87" "$1,158.87" $0.00 $0.00 $0.00 $552.86 "$1,968.72" "$1,968.72" $0.00 $0.00 $552.79 $0.00 "$1,307.71" "$1,307.71" $0.00 "$1,287.64" "$2,039.62" "$2,060.22" $0.00 $0.00 $391.29 $0.00 $0.00 $409.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.519 SUP HCPCS C1713 02.112.519 - PLATE BONE 161MM 8 HOLE LOW BEND ROUNDED EDGE LP LCP BOTH IP/OP "$2,652.55 " "$1,962.89" $0.00 "$2,060.22" "$1,158.87" "$1,158.87" $0.00 $0.00 $0.00 $552.86 "$1,968.72" "$1,968.72" $0.00 $0.00 $552.79 $0.00 "$1,307.71" "$1,307.71" $0.00 "$1,287.64" "$2,039.62" "$2,060.22" $0.00 $0.00 $391.29 $0.00 $0.00 $409.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.522 SUP HCPCS C1713 02.112.522 - PLATE BONE 187MM 10 HOLE LOW BEND ROUNDED EDGE LP LCP BOTH IP/OP "$2,680.65 " "$1,983.68" $0.00 "$2,082.06" "$1,171.16" "$1,171.16" $0.00 $0.00 $0.00 $558.71 "$1,989.58" "$1,989.58" $0.00 $0.00 $558.65 $0.00 "$1,321.56" "$1,321.56" $0.00 "$1,301.29" "$2,061.24" "$2,082.06" $0.00 $0.00 $395.44 $0.00 $0.00 $414.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.523 SUP HCPCS C1713 02.112.523 - PLATE BONE 187MM 10 HOLE LOW BEND ROUNDED EDGE LP LCP BOTH IP/OP "$2,680.65 " "$1,983.68" $0.00 "$2,082.06" "$1,171.16" "$1,171.16" $0.00 $0.00 $0.00 $558.71 "$1,989.58" "$1,989.58" $0.00 $0.00 $558.65 $0.00 "$1,321.56" "$1,321.56" $0.00 "$1,301.29" "$2,061.24" "$2,082.06" $0.00 $0.00 $395.44 $0.00 $0.00 $414.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.526 SUP HCPCS C1713 02.112.526 - PLATE BONE 213MM 12 HOLE LOW BEND LCP STAINLESS STEEL TIBIA BOTH IP/OP "$2,710.18 " "$2,005.53" $0.00 "$2,105.00" "$1,184.06" "$1,184.06" $0.00 $0.00 $0.00 $564.87 "$2,011.49" "$2,011.49" $0.00 $0.00 $564.80 $0.00 "$1,336.12" "$1,336.12" $0.00 "$1,315.63" "$2,083.95" "$2,105.00" $0.00 $0.00 $399.79 $0.00 $0.00 $418.90 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.527 SUP HCPCS C1713 02.112.527 - PLATE BONE 213MM 12 HOLE LOW BEND LCP STAINLESS STEEL TIBIA BOTH IP/OP "$2,710.18 " "$2,005.53" $0.00 "$2,105.00" "$1,184.06" "$1,184.06" $0.00 $0.00 $0.00 $564.87 "$2,011.49" "$2,011.49" $0.00 $0.00 $564.80 $0.00 "$1,336.12" "$1,336.12" $0.00 "$1,315.63" "$2,083.95" "$2,105.00" $0.00 $0.00 $399.79 $0.00 $0.00 $418.90 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.530 SUP HCPCS C1713 02.112.530 - PLATE BONE 239MM 14 HOLE LOW BEND LCP STAINLESS STEEL RIGHT BOTH IP/OP "$2,745.33 " "$2,031.54" $0.00 "$2,132.28" "$1,199.41" "$1,199.41" $0.00 $0.00 $0.00 $572.19 "$2,037.58" "$2,037.58" $0.00 $0.00 $572.13 $0.00 "$1,353.45" "$1,353.45" $0.00 "$1,332.68" "$2,110.96" "$2,132.28" $0.00 $0.00 $404.98 $0.00 $0.00 $424.32 $0.00 $0.00 $0.00 $0.00 $0.00 02.112.531 SUP HCPCS C1713 02.112.531 - PLATE BONE 239MM 14 HOLE LOW BEND LCP STAINLESS STEEL TIBIA BOTH IP/OP "$2,745.33 " "$2,031.54" $0.00 "$2,132.28" "$1,199.41" "$1,199.41" $0.00 $0.00 $0.00 $572.19 "$2,037.58" "$2,037.58" $0.00 $0.00 $572.13 $0.00 "$1,353.45" "$1,353.45" $0.00 "$1,332.68" "$2,110.96" "$2,132.28" $0.00 $0.00 $404.98 $0.00 $0.00 $424.32 $0.00 $0.00 $0.00 $0.00 $0.00 02.113.001 SUP Custom 27203010 02.113.001 - GUIDEWIRE ORTHOPEDIC 1.6MM 200MM DRILL TIP LCP STAINLESS BOTH IP/OP $69.58 $51.49 $0.00 $54.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.64 $51.64 $0.00 $0.00 $14.50 $0.00 $0.00 $0.00 $0.00 $33.78 $53.50 $54.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.113.103 SUP HCPCS C1713 02.113.103 - PLATE BONE 62MM 3 HOLE SHARP HOOK LP PRECONTOUR SCALLOPED BOTH IP/OP "$1,019.13 " $754.16 $0.00 $791.56 $445.25 $445.25 $0.00 $0.00 $0.00 $212.41 $756.39 $756.39 $0.00 $0.00 $212.39 $0.00 $602.81 $602.81 $0.00 $494.73 $783.64 $791.56 $0.00 $0.00 $150.34 $0.00 $0.00 $157.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.002 SUP HCPCS C1713 02.114.002 - PLATE BONE 23MM 4 HOLE LCP STAINLESS STEEL NONSTRL 1.5MM BOTH IP/OP $410.45 $303.73 $0.00 $318.80 $179.33 $179.33 $0.00 $0.00 $0.00 $85.55 $304.64 $304.64 $0.00 $0.00 $85.54 $0.00 $242.78 $242.78 $0.00 $199.25 $315.61 $318.80 $0.00 $0.00 $60.55 $0.00 $0.00 $63.44 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.003 SUP HCPCS C1713 02.114.003 - PLATE BONE 29MM 6 HOLE ADAPTION LCP STAINLESS STEEL HAND BOTH IP/OP $752.05 $556.52 $0.00 $584.12 $328.57 $328.57 $0.00 $0.00 $0.00 $156.75 $558.17 $558.17 $0.00 $0.00 $156.73 $0.00 $444.84 $444.84 $0.00 $365.08 $578.28 $584.12 $0.00 $0.00 $110.94 $0.00 $0.00 $116.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.004 SUP HCPCS C1713 02.114.004 - PLATE BONE 36MM 6 HOLE LCP STAINLESS STEEL NONSTRL 1.5MM BOTH IP/OP $410.45 $303.73 $0.00 $318.80 $179.33 $179.33 $0.00 $0.00 $0.00 $85.55 $304.64 $304.64 $0.00 $0.00 $85.54 $0.00 $242.78 $242.78 $0.00 $199.25 $315.61 $318.80 $0.00 $0.00 $60.55 $0.00 $0.00 $63.44 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.005 SUP HCPCS C1713 02.114.005 - PLATE BONE 59MM 12 HOLE ADAPTION LCP STAINLESS STEEL NONSTRL BOTH IP/OP $752.05 $556.52 $0.00 $584.12 $328.57 $328.57 $0.00 $0.00 $0.00 $156.75 $558.17 $558.17 $0.00 $0.00 $156.73 $0.00 $444.84 $444.84 $0.00 $365.08 $578.28 $584.12 $0.00 $0.00 $110.94 $0.00 $0.00 $116.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.006 SUP HCPCS C1713 02.114.006 - PLATE BONE 3X8 HOLE T LCP STAINLESS STEEL NONSTRL 1.5 MM BOTH IP/OP $790.00 $584.60 $0.00 $613.60 $345.15 $345.15 $0.00 $0.00 $0.00 $164.66 $586.34 $586.34 $0.00 $0.00 $164.64 $0.00 $467.29 $467.29 $0.00 $383.50 $607.46 $613.60 $0.00 $0.00 $116.54 $0.00 $0.00 $122.11 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.007 SUP HCPCS C1713 02.114.007 - PLATE BONE 4X8 HOLE T LCP STAINLESS STEEL NONSTRL 1.5 MM BOTH IP/OP $790.00 $584.60 $0.00 $613.60 $345.15 $345.15 $0.00 $0.00 $0.00 $164.66 $586.34 $586.34 $0.00 $0.00 $164.64 $0.00 $467.29 $467.29 $0.00 $383.50 $607.46 $613.60 $0.00 $0.00 $116.54 $0.00 $0.00 $122.11 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.009 SUP HCPCS C1713 02.114.009 - PLATE BONE H EXTENDED LCP STAINLESS STEEL LEFT NONSTRL 1.5 BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.010 SUP HCPCS C1713 02.114.010 - PLATE BONE H EXTENDED LCP STAINLESS STEEL RIGHT NONSTRL 1.5 BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.013 SUP HCPCS C1713 02.114.013 - PLATE BONE 3X8 HOLE Y LCP STAINLESS STEEL NONSTRL 1.5 MM BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.014 SUP HCPCS C1713 02.114.014 - PLATE BONE 6 HOLE LCP STAINLESS STEEL CONDYLE NONSTRL 1.5 MM BOTH IP/OP $944.63 $699.03 $0.00 $733.68 $412.70 $412.70 $0.00 $0.00 $0.00 $196.88 $701.10 $701.10 $0.00 $0.00 $196.86 $0.00 $558.75 $558.75 $0.00 $458.55 $726.34 $733.68 $0.00 $0.00 $139.35 $0.00 $0.00 $146.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.502 SUP HCPCS C1713 02.114.502 - PLATE BONE 2.3CM 4 HOLE SHORT THREADED DRILL GUIDE LP CUT TO BOTH IP/OP $490.58 $363.03 $0.00 $381.04 $214.34 $214.34 $0.00 $0.00 $0.00 $102.25 $364.10 $364.10 $0.00 $0.00 $102.24 $0.00 $290.18 $290.18 $0.00 $238.15 $377.23 $381.04 $0.00 $0.00 $72.37 $0.00 $0.00 $75.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.503 SUP HCPCS C1713 02.114.503 - PLATE BONE 2.9CM 6 HOLE SHORT THREADED DRILL GUIDE ADAPTION BOTH IP/OP $836.38 $618.92 $0.00 $649.62 $365.41 $365.41 $0.00 $0.00 $0.00 $174.32 $620.76 $620.76 $0.00 $0.00 $174.30 $0.00 $494.72 $494.72 $0.00 $406.01 $643.13 $649.62 $0.00 $0.00 $123.38 $0.00 $0.00 $129.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.504 SUP HCPCS C1713 02.114.504 - PLATE BONE 3.6CM 6 HOLE SHORT THREADED DRILL GUIDE LP CUT TO BOTH IP/OP $490.58 $363.03 $0.00 $381.04 $214.34 $214.34 $0.00 $0.00 $0.00 $102.25 $364.10 $364.10 $0.00 $0.00 $102.24 $0.00 $290.18 $290.18 $0.00 $238.15 $377.23 $381.04 $0.00 $0.00 $72.37 $0.00 $0.00 $75.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.505 SUP HCPCS C1713 02.114.505 - PLATE BONE 5.9CM 12 HOLE SHORT THREADED DRILL GUIDE ADAPTION BOTH IP/OP $836.38 $618.92 $0.00 $649.62 $365.41 $365.41 $0.00 $0.00 $0.00 $174.32 $620.76 $620.76 $0.00 $0.00 $174.30 $0.00 $494.72 $494.72 $0.00 $406.01 $643.13 $649.62 $0.00 $0.00 $123.38 $0.00 $0.00 $129.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.506 SUP HCPCS C1713 02.114.506 - PLATE BONE T 3X8 HOLE SHORT THREADED DRILL GUIDE LP CUT TO BOTH IP/OP $885.58 $655.33 $0.00 $687.84 $386.91 $386.91 $0.00 $0.00 $0.00 $184.58 $657.27 $657.27 $0.00 $0.00 $184.55 $0.00 $523.82 $523.82 $0.00 $429.90 $680.96 $687.84 $0.00 $0.00 $130.64 $0.00 $0.00 $136.88 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.507 SUP HCPCS C1713 02.114.507 - PLATE BONE T 4 HOLE HEAD 8 HOLE SHAFT LP CUT TO LENGTH LCP BOTH IP/OP $885.58 $655.33 $0.00 $687.84 $386.91 $386.91 $0.00 $0.00 $0.00 $184.58 $657.27 $657.27 $0.00 $0.00 $184.55 $0.00 $523.82 $523.82 $0.00 $429.90 $680.96 $687.84 $0.00 $0.00 $130.64 $0.00 $0.00 $136.88 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.509 SUP HCPCS C1713 02.114.509 - PLATE BONE H EXTENDED PRELOADED DRILL GUIDE LP CUT TO LENGTH BOTH IP/OP $846.23 $626.21 $0.00 $657.26 $369.71 $369.71 $0.00 $0.00 $0.00 $176.37 $628.07 $628.07 $0.00 $0.00 $176.35 $0.00 $500.54 $500.54 $0.00 $410.79 $650.69 $657.26 $0.00 $0.00 $124.83 $0.00 $0.00 $130.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.510 SUP HCPCS C1713 02.114.510 - PLATE BONE H EXTENDED PRELOADED DRILL GUIDE LP CUT TO LENGTH BOTH IP/OP $846.23 $626.21 $0.00 $657.26 $369.71 $369.71 $0.00 $0.00 $0.00 $176.37 $628.07 $628.07 $0.00 $0.00 $176.35 $0.00 $500.54 $500.54 $0.00 $410.79 $650.69 $657.26 $0.00 $0.00 $124.83 $0.00 $0.00 $130.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.513 SUP HCPCS C1713 02.114.513 - PLATE BONE Y 3X8 HOLE LP SHORT THREADED DRILL GUIDE CUT TO BOTH IP/OP $846.23 $626.21 $0.00 $657.26 $369.71 $369.71 $0.00 $0.00 $0.00 $176.37 $628.07 $628.07 $0.00 $0.00 $176.35 $0.00 $500.54 $500.54 $0.00 $410.79 $650.69 $657.26 $0.00 $0.00 $124.83 $0.00 $0.00 $130.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.114.514 SUP HCPCS C1713 02.114.514 - PLATE BONE 6 HOLE LP SHORT THREADED DRILL GUIDE CUT TO BOTH IP/OP "$1,030.38 " $762.48 $0.00 $800.28 $450.16 $450.16 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $500.18 $792.28 $800.28 $0.00 $0.00 $152.00 $0.00 $0.00 $159.26 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.130 SUP HCPCS C1713 02.115.130 - PLATE BONE 90D L 37MM 2X3 HOLE VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.131 SUP HCPCS C1713 02.115.131 - PLATE BONE -90D L 37MM 2X3 HOLE VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.150 SUP HCPCS C1713 02.115.150 - PLATE BONE 90+ D L 51MM 2 HOLE HEAD 5 HOLE SHAFT VAR ANG LCP BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.150S SUP HCPCS C1713 02.115.150S - PLATE BN +90D L 51MM STRL LCP CMBN 2 HLE/HD 5 HL SHFT VA SS BOTH IP/OP "$1,135.48 " $840.26 $0.00 $908.38 $510.96 $510.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $567.74 $899.30 $908.38 $0.00 $0.00 $172.53 $0.00 $0.00 $180.77 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.151 SUP HCPCS C1713 02.115.151 - PLATE BONE -90D 51MM 2X5 HOLE L VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.230 SUP HCPCS C1713 02.115.230 - PLATE BONE +90D L 37MM 3X3 HOLE VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.231 SUP HCPCS C1713 02.115.231 - PLATE BONE -90D 37MM 3X3 HOLE L VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.250 SUP HCPCS C1713 02.115.250 - PLATE BONE +90D 51MM 3X5 HOLE L VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.251 SUP HCPCS C1713 02.115.251 - PLATE BONE -90D 51MM 3X5 HOLE L VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.330 SUP HCPCS C1713 02.115.330 - PLATE BONE 37MM 3X3 HOLE T VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,059.90 " $784.33 $0.00 $823.22 $463.06 $463.06 $0.00 $0.00 $0.00 $220.91 $786.66 $786.66 $0.00 $0.00 $220.88 $0.00 $626.93 $626.93 $0.00 $514.51 $814.99 $823.22 $0.00 $0.00 $156.35 $0.00 $0.00 $163.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.350 SUP HCPCS C1713 02.115.350 - PLATE BONE 51MM 3X5 HOLE T VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,106.28 " $818.65 $0.00 $859.24 $483.32 $483.32 $0.00 $0.00 $0.00 $230.58 $821.08 $821.08 $0.00 $0.00 $230.55 $0.00 $654.36 $654.36 $0.00 $537.03 $850.65 $859.24 $0.00 $0.00 $163.19 $0.00 $0.00 $170.99 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.430 SUP HCPCS C1713 02.115.430 - PLATE BONE 20D 41MM 3X3 HOLE L VAR ANG OBLIQUE LCP STAINLESS BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.430S SUP HCPCS C1713 02.115.430S - PLATE BN +20D OBLQ L 41MM STRL LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP "$1,084.98 " $802.89 $0.00 $867.98 $488.24 $488.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $542.49 $859.30 $867.98 $0.00 $0.00 $164.85 $0.00 $0.00 $172.73 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.431 SUP HCPCS C1713 02.115.431 - PLATE BONE -20D L 41MM 3X3 HOLE VAR ANG OBLIQUE LCP BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.431S SUP HCPCS C1713 02.115.431S - PLATE BN -20D OBLQ L 41MM STRL LCP CMBN 3 HLE/HD 3 HL SHFT BOTH IP/OP "$1,117.53 " $826.97 $0.00 $867.98 $488.24 $488.24 $0.00 $0.00 $0.00 $232.92 $829.43 $829.43 $0.00 $0.00 $232.89 $0.00 $661.02 $661.02 $0.00 $542.49 $859.30 $867.98 $0.00 $0.00 $164.85 $0.00 $0.00 $172.73 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.450 SUP HCPCS C1713 02.115.450 - PLATE BONE +20D 55MM 3X5 HOLE L VAR ANG OBLIQUE LCP BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.451 SUP HCPCS C1713 02.115.451 - PLATE BONE -20D 55MM 3X5 HOLE L VAR ANG OBLIQUE LCP BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.530 SUP HCPCS C1713 02.115.530 - PLATE BONE 46MM 5 HOLE VAR ANG COLUMN LCP STAINLESS STEEL BOTH IP/OP "$1,006.48 " $744.80 $0.00 $781.72 $439.72 $439.72 $0.00 $0.00 $0.00 $209.77 $747.01 $747.01 $0.00 $0.00 $209.75 $0.00 $595.33 $595.33 $0.00 $488.58 $773.90 $781.72 $0.00 $0.00 $148.47 $0.00 $0.00 $155.56 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.540 SUP HCPCS C1713 02.115.540 - PLATE BONE 57MM 6 HOLE VAR ANG COLUMN LCP STAINLESS STEEL BOTH IP/OP "$1,059.90 " $784.33 $0.00 $823.22 $463.06 $463.06 $0.00 $0.00 $0.00 $220.91 $786.66 $786.66 $0.00 $0.00 $220.88 $0.00 $626.93 $626.93 $0.00 $514.51 $814.99 $823.22 $0.00 $0.00 $156.35 $0.00 $0.00 $163.82 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.630 SUP HCPCS C1713 02.115.630 - PLATE BONE 90D 41MM 3 HOLE VAR ANG INTERMEDIATE COLUMN LCP BOTH IP/OP "$1,106.28 " $818.65 $0.00 $859.24 $483.32 $483.32 $0.00 $0.00 $0.00 $230.58 $821.08 $821.08 $0.00 $0.00 $230.55 $0.00 $654.36 $654.36 $0.00 $537.03 $850.65 $859.24 $0.00 $0.00 $163.19 $0.00 $0.00 $170.99 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.631 SUP HCPCS C1713 02.115.631 - PLATE BONE -90D 41MM 3 HOLE VAR ANG INTERMEDIATE COLUMN LCP BOTH IP/OP "$1,106.28 " $818.65 $0.00 $859.24 $483.32 $483.32 $0.00 $0.00 $0.00 $230.58 $821.08 $821.08 $0.00 $0.00 $230.55 $0.00 $654.36 $654.36 $0.00 $537.03 $850.65 $859.24 $0.00 $0.00 $163.19 $0.00 $0.00 $170.99 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.640 SUP HCPCS C1713 02.115.640 - PLATE BONE +90D 49MM 4 HOLE VAR ANG INTERMEDIATE COLUMN LCP BOTH IP/OP "$1,147.05 " $848.82 $0.00 $890.90 $501.13 $501.13 $0.00 $0.00 $0.00 $239.07 $851.34 $851.34 $0.00 $0.00 $239.05 $0.00 $678.48 $678.48 $0.00 $556.81 $881.99 $890.90 $0.00 $0.00 $169.21 $0.00 $0.00 $177.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.641 SUP HCPCS C1713 02.115.641 - PLATE BONE -90D 49MM 4 HOLE VAR ANG INTERMEDIATE COLUMN LCP BOTH IP/OP "$1,147.05 " $848.82 $0.00 $890.90 $501.13 $501.13 $0.00 $0.00 $0.00 $239.07 $851.34 $851.34 $0.00 $0.00 $239.05 $0.00 $678.48 $678.48 $0.00 $556.81 $881.99 $890.90 $0.00 $0.00 $169.21 $0.00 $0.00 $177.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.115.751S SUP HCPCS C1713 02.115.751S - PLATE BN 57MM STRL LCP CMBN 6 HLE/HD 5 HL SHFT VA SS RDS LT BOTH IP/OP "$1,834.23 " "$1,357.33" $0.00 "$1,467.38" $825.40 $825.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $917.11 "$1,452.71" "$1,467.38" $0.00 $0.00 $278.70 $0.00 $0.00 $292.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.003S SUP HCPCS C1713 02.117.003S - PLATE BN SHRT 75MM STRL LCP CMBN 3 HL VA TPR TIP LAT SPRT SS BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.004S SUP HCPCS C1713 02.117.004S - PLATE BONE MEDIUM 88MM 4 HOLE VAR ANG LATERAL SUPPORT BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.007S SUP HCPCS C1713 02.117.007S - PLATE BONE LONG 127MM 7 HOLE VAR ANG TAPER TIP LATERAL BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.009S SUP HCPCS C1713 02.117.009S - PLATE BONE XLONG 153MM 9 HOLE VAR ANG LATERAL SUPPORT BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.103S SUP HCPCS C1713 02.117.103S - PLATE BONE SHORT 75MM 3 HOLE VAR ANG LATERAL SUPPORT LCP BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.104 SUP HCPCS C1713 02.117.104 - PLATE BN MED 88MM NS LCP CMBN 4 HL VA TPR TIP LAT SPRT SS BOTH IP/OP "$2,204.13 " "$1,631.06" $0.00 "$1,711.94" $962.97 $962.97 $0.00 $0.00 $0.00 $459.39 "$1,635.90" "$1,635.90" $0.00 $0.00 $459.34 $0.00 "$1,303.74" "$1,303.74" $0.00 "$1,069.96" "$1,694.82" "$1,711.94" $0.00 $0.00 $325.14 $0.00 $0.00 $340.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.104S SUP HCPCS C1713 02.117.104S - PLATE BONE MEDIUM 88MM 4 HOLE VAR ANG LATERAL SUPPORT BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.107S SUP HCPCS C1713 02.117.107S - PLATE BONE LONG 127MM 7 HOLE VAR ANG LATERAL SUPPORT TAPERED BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.203S SUP HCPCS C1713 02.117.203S - PLATE SHRT 75MM SS 2.7/3.5MM SCR 3 HOLE VAR ANG BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.204S SUP HCPCS C1713 02.117.204S - PLATE BN MED 88MM STRL LCP CMBN 4 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.207S SUP HCPCS C1713 02.117.207S - PLATE BN LNG 127MM STRL LCP CMBN 7 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.303S SUP HCPCS C1713 02.117.303S - PLATE BONE SHORT 75MM 3 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.304S SUP HCPCS C1713 02.117.304S - PLATE BONE MEDIUM 88MM 4 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.307S SUP HCPCS C1713 02.117.307S - PLATE BN LNG 127MM STRL LCP CMBN 7 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.309S SUP HCPCS C1713 02.117.309S - PLATE BONE XLONG 153MM 9 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.401S SUP HCPCS C1713 02.117.401S - PLATE BONE SHORT 69MM 1 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.402S SUP HCPCS C1713 02.117.402S - PLATE BN MED 82MM STRL LCP CMBN 2 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,164.50 " "$1,601.73" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.404S SUP HCPCS C1713 02.117.404S - PLATE BONE LONG 108MM 4 HOLE VAR ANG TAPER TIP ROUND PROFILE BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.406S SUP HCPCS C1713 02.117.406S - PLATE BONE XLONG 134MM 6 HOLE VAR ANG TAPER TIP ROUND BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.501S SUP HCPCS C1713 02.117.501S - PLATE BONE SHORT 69MM 1 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.502 SUP HCPCS C1713 02.117.502 - PLATE BONE MEDIUM 82MM 2 HOLE VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$2,138.05 " "$1,582.16" $0.00 "$1,660.62" $934.10 $934.10 $0.00 $0.00 $0.00 $445.62 "$1,586.86" "$1,586.86" $0.00 $0.00 $445.57 $0.00 "$1,264.66" "$1,264.66" $0.00 "$1,037.89" "$1,644.02" "$1,660.62" $0.00 $0.00 $315.40 $0.00 $0.00 $330.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.502S SUP HCPCS C1713 02.117.502S - PLATE BONE MEDIUM 82MM 2 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.504 SUP HCPCS C1713 02.117.504 - PLATE BN LNG 108MM NS LCP CMBN 4 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,138.05 " "$1,582.16" $0.00 "$1,660.62" $934.10 $934.10 $0.00 $0.00 $0.00 $445.62 "$1,586.86" "$1,586.86" $0.00 $0.00 $445.57 $0.00 "$1,264.66" "$1,264.66" $0.00 "$1,037.89" "$1,644.02" "$1,660.62" $0.00 $0.00 $315.40 $0.00 $0.00 $330.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.504S SUP HCPCS C1713 02.117.504S - PLATE BONE LONG 108MM 4 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.506 SUP HCPCS C1713 02.117.506 - PLATE BN XLNG 134MM NS LCP CMBN 6 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,138.05 " "$1,582.16" $0.00 "$1,660.62" $934.10 $934.10 $0.00 $0.00 $0.00 $445.62 "$1,586.86" "$1,586.86" $0.00 $0.00 $445.57 $0.00 "$1,264.66" "$1,264.66" $0.00 "$1,037.89" "$1,644.02" "$1,660.62" $0.00 $0.00 $315.40 $0.00 $0.00 $330.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.506S SUP HCPCS C1713 02.117.506S - PLATE BN XLNG 134MM STRL LCP CMBN 6 HL VA TPR TIP RND PRFL BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.601S SUP HCPCS C1713 02.117.601S - PLATE BONE LCP COMBI STAINLESS STEEL SHORT L72 MM HUMERUS RI BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.602 SUP HCPCS C1713 02.117.602 - PLATE BONE MEDIUM 85MM 2 HOLE EXTENDED VAR ANG LCP STAINLESS BOTH IP/OP "$2,204.13 " "$1,631.06" $0.00 "$1,711.94" $962.97 $962.97 $0.00 $0.00 $0.00 $459.39 "$1,635.90" "$1,635.90" $0.00 $0.00 $459.34 $0.00 "$1,303.74" "$1,303.74" $0.00 "$1,069.96" "$1,694.82" "$1,711.94" $0.00 $0.00 $325.14 $0.00 $0.00 $340.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.602S SUP HCPCS C1713 02.117.602S - PLATE BONE LCP COMBI STAINLESS STEEL MEDIUM L85 MM HUMERUS R BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.604 SUP HCPCS C1713 02.117.604 - PLATE BN LNG 111MM NS LCP CMBN 4 HL VA TPR TIP XTD SS HUM RT BOTH IP/OP "$2,204.13 " "$1,631.06" $0.00 "$1,711.94" $962.97 $962.97 $0.00 $0.00 $0.00 $459.39 "$1,635.90" "$1,635.90" $0.00 $0.00 $459.34 $0.00 "$1,303.74" "$1,303.74" $0.00 "$1,069.96" "$1,694.82" "$1,711.94" $0.00 $0.00 $325.14 $0.00 $0.00 $340.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.604S SUP HCPCS C1713 02.117.604S - PLATE BONE LONG 111MM 4 HOLE EXTENDED VAR ANG ROUND PROFILE BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.606S SUP HCPCS C1713 02.117.606S - PLATE BN XLNG 137MM STRL LCP CMBN 6 HL VA TPR TIP XTD SS HUM BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.701S SUP HCPCS C1713 02.117.701S - PLATE BONE SHORT 72MM 1 HOLE VAR ANG EXTENDED LCP STAINLESS BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.702S SUP HCPCS C1713 02.117.702S - PLATE BONE MEDIUM 85MM 2 HOLE EXTENDED VAR ANG ROUND PROFILE BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.704 SUP HCPCS C1713 02.117.704 - PLATE BN LNG 111MM NS LCP CMBN 4 HL VA TPR TIP XTD SS HUM LT BOTH IP/OP "$2,204.13 " "$1,631.06" $0.00 "$1,711.94" $962.97 $962.97 $0.00 $0.00 $0.00 $459.39 "$1,635.90" "$1,635.90" $0.00 $0.00 $459.34 $0.00 "$1,303.74" "$1,303.74" $0.00 "$1,069.96" "$1,694.82" "$1,711.94" $0.00 $0.00 $325.14 $0.00 $0.00 $340.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.704S SUP HCPCS C1713 02.117.704S - PLATE BN LNG 111MM STRL LCP CMBN 4 HL VA TPR TIP XTD SS HUM BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.706 SUP HCPCS C1713 02.117.706 - PLATE BN XLNG 137MM NS LCP CMBN 6 HL VA TPR TIP XTD SS HUM BOTH IP/OP "$2,204.13 " "$1,631.06" $0.00 "$1,711.94" $962.97 $962.97 $0.00 $0.00 $0.00 $459.39 "$1,635.90" "$1,635.90" $0.00 $0.00 $459.34 $0.00 "$1,303.74" "$1,303.74" $0.00 "$1,069.96" "$1,694.82" "$1,711.94" $0.00 $0.00 $325.14 $0.00 $0.00 $340.68 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.706S SUP HCPCS C1713 02.117.706S - PLATE BONE XLONG 137MM 6 HOLE VAR ANG TAPER TIP EXTEND LCP BOTH IP/OP "$2,295.50 " "$1,698.67" $0.00 "$1,782.90" "$1,002.88" "$1,002.88" $0.00 $0.00 $0.00 $478.44 "$1,703.72" "$1,703.72" $0.00 $0.00 $478.38 $0.00 "$1,357.79" "$1,357.79" $0.00 "$1,114.31" "$1,765.07" "$1,782.90" $0.00 $0.00 $338.62 $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.802 SUP HCPCS C1713 02.117.802 - PLATE BONE MEDIUM 82MM 2 HOLE VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$2,138.05 " "$1,582.16" $0.00 "$1,660.62" $934.10 $934.10 $0.00 $0.00 $0.00 $445.62 "$1,586.86" "$1,586.86" $0.00 $0.00 $445.57 $0.00 "$1,264.66" "$1,264.66" $0.00 "$1,037.89" "$1,644.02" "$1,660.62" $0.00 $0.00 $315.40 $0.00 $0.00 $330.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.802S SUP HCPCS C1713 02.117.802S - PLATE BONE MEDIUM 82MM 2 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.805S SUP HCPCS C1713 02.117.805S - PLATE BONE LONG 121MM 5 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.807S SUP HCPCS C1713 02.117.807S - PLATE BONE LCP COMBI STAINLESS STEEL XLONG L147 MM HUMERUS R BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.902 SUP HCPCS C1713 02.117.902 - PLATE BN MED 82MM NS LCP CMBN 2 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,138.05 " "$1,582.16" $0.00 "$1,660.62" $934.10 $934.10 $0.00 $0.00 $0.00 $445.62 "$1,586.86" "$1,586.86" $0.00 $0.00 $445.57 $0.00 "$1,264.66" "$1,264.66" $0.00 "$1,037.89" "$1,644.02" "$1,660.62" $0.00 $0.00 $315.40 $0.00 $0.00 $330.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.902S SUP HCPCS C1713 02.117.902S - PLATE BONE MEDIUM 82MM 2 HOLE VAR ANG EXTENDED LCP STAINLESS BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.905 SUP HCPCS C1713 02.117.905 - PLATE BN LNG 121MM NS LCP CMBN 5 HL VA TPR TIP RND PRFL SS BOTH IP/OP "$2,138.05 " "$1,582.16" $0.00 "$1,660.62" $934.10 $934.10 $0.00 $0.00 $0.00 $445.62 "$1,586.86" "$1,586.86" $0.00 $0.00 $445.57 $0.00 "$1,264.66" "$1,264.66" $0.00 "$1,037.89" "$1,644.02" "$1,660.62" $0.00 $0.00 $315.40 $0.00 $0.00 $330.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.905S SUP HCPCS C1713 02.117.905S - PLATE BONE LONG 121MM 5 HOLE VAR ANG ROUND PROFILE TAPERED BOTH IP/OP "$2,229.43 " "$1,649.78" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $464.67 "$1,654.68" "$1,654.68" $0.00 $0.00 $464.61 $0.00 "$1,318.70" "$1,318.70" $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.117.909S SUP HCPCS C1713 02.117.909S - PLATE BN 173MM STRL LCP CMBN 9 HL VA TPR TIP RND PRFL SS HUM BOTH IP/OP "$2,164.50 " "$1,601.73" $0.00 "$1,731.60" $974.03 $974.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,082.25" "$1,714.28" "$1,731.60" $0.00 $0.00 $328.88 $0.00 $0.00 $344.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.003S SUP HCPCS C1713 02.118.003S - PLATE BN 112MM STRL LCP CMBN 4 HL VA LOPRFL SS TIB LT DIST BOTH IP/OP "$2,857.78 " "$2,114.76" $0.00 "$2,219.62" "$1,248.54" "$1,248.54" $0.00 $0.00 $0.00 $595.63 "$2,121.04" "$2,121.04" $0.00 $0.00 $595.56 $0.00 "$1,408.88" "$1,408.88" $0.00 "$1,387.26" "$2,197.43" "$2,219.62" $0.00 $0.00 $421.57 $0.00 $0.00 $441.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.005S SUP HCPCS C1713 02.118.005S - PLATE BN 142MM STRL LCP CMBN 6 HL VA LOPRFL SS TIB LT DIST BOTH IP/OP "$2,888.70 " "$2,137.64" $0.00 "$2,243.64" "$1,262.05" "$1,262.05" $0.00 $0.00 $0.00 $602.08 "$2,143.99" "$2,143.99" $0.00 $0.00 $602.01 $0.00 "$1,424.13" "$1,424.13" $0.00 "$1,402.28" "$2,221.20" "$2,243.64" $0.00 $0.00 $426.13 $0.00 $0.00 $446.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.006S SUP HCPCS C1713 02.118.006S - PLATE BN 172MM STRL LCP CMBN 8 HL VA LOPRFL SS TIB RT DIST BOTH IP/OP "$2,916.80 " "$2,158.43" $0.00 "$2,265.48" "$1,274.33" "$1,274.33" $0.00 $0.00 $0.00 $607.93 "$2,164.85" "$2,164.85" $0.00 $0.00 $607.86 $0.00 "$1,437.98" "$1,437.98" $0.00 "$1,415.93" "$2,242.83" "$2,265.48" $0.00 $0.00 $430.28 $0.00 $0.00 $450.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.007S SUP HCPCS C1713 02.118.007S - PLATE BN 172MM STRL LCP CMBN 8 HL VA LOPRFL SS TIB LT DIST BOTH IP/OP "$2,916.80 " "$2,158.43" $0.00 "$2,265.48" "$1,274.33" "$1,274.33" $0.00 $0.00 $0.00 $607.93 "$2,164.85" "$2,164.85" $0.00 $0.00 $607.86 $0.00 "$1,437.98" "$1,437.98" $0.00 "$1,415.93" "$2,242.83" "$2,265.48" $0.00 $0.00 $430.28 $0.00 $0.00 $450.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.011S SUP HCPCS C1713 02.118.011S - PLATE BN 232MM STRL LCP CMBN 12 HL VA LOPRFL SS TIB LT DIST BOTH IP/OP "$3,422.85 " "$2,532.91" $0.00 "$2,658.54" "$1,495.43" "$1,495.43" $0.00 $0.00 $0.00 $713.41 "$2,540.44" "$2,540.44" $0.00 $0.00 $713.32 $0.00 "$1,687.47" "$1,687.47" $0.00 "$1,661.59" "$2,631.96" "$2,658.54" $0.00 $0.00 $504.93 $0.00 $0.00 $529.05 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.510 SUP HCPCS C1713 02.118.510 - SCREW BN T8 2.7MM 10MM NS LCP ST STRDR LOPRFL SS ELB MTPHSL BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.512 SUP HCPCS C1713 02.118.512 - SCREW BONE T8 LP 2.7MM 12MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.514 SUP HCPCS C1713 02.118.514 - SCREW BONE T8 LP 2.7MM 14MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.516 SUP HCPCS C1713 02.118.516 - SCREW BONE T8 LP 2.7MM 16MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.518 SUP HCPCS C1713 02.118.518 - SCREW BONE T8 LP 2.7MM 18MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.520 SUP HCPCS C1713 02.118.520 - SCREW BONE T8 LP 2.7MM 20MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.522 SUP HCPCS C1713 02.118.522 - SCREW BONE T8 LP 2.7MM 22MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.524 SUP HCPCS C1713 02.118.524 - SCREW BONE T8 2.7MM 24MM SELF TAP STARDRIVE LP LCP STAINLESS BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.526 SUP HCPCS C1713 02.118.526 - SCREW BONE 2.7MM 26MM VAR ANG SELF TAP T8 STARDRIVE LP HEAD BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.528 SUP HCPCS C1713 02.118.528 - SCREW BONE T8 LP 2.7MM 28MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.530 SUP HCPCS C1713 02.118.530 - SCREW BONE T8 LP 2.7MM 30MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.532 SUP HCPCS C1713 02.118.532 - SCREW BONE T8 LP 2.7MM 32MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.534 SUP HCPCS C1713 02.118.534 - SCREW BONE T8 LP 2.7MM 34MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.536 SUP HCPCS C1713 02.118.536 - SCREW BN T8 2.7MM 36MM NS ST STRDR LOPRFL HD SS MTPHSL BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.538 SUP HCPCS C1713 02.118.538 - SCREW BONE T8 LP 2.7MM 38MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.540 SUP HCPCS C1713 02.118.540 - SCREW BN T8 2.7MM 40MM NS LCP ST STRDR LOPRFL SS ELB MTPHSL BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.542 SUP HCPCS C1713 02.118.542 - SCREW BONE T8 2.7MM 42MM SELF TAP STARDRIVE LP LCP STAINLESS BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.544 SUP HCPCS C1713 02.118.544 - SCREW BONE 2.7MM 44MM VAR ANG SELF TAP T8 STARDRIVE LP HEAD BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.546 SUP HCPCS C1713 02.118.546 - SCREW BONE T8 LP 2.7MM 46MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.548 SUP HCPCS C1713 02.118.548 - SCREW BONE T8 LP 2.7MM 48MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.550 SUP HCPCS C1713 02.118.550 - SCREW BONE T8 LP 2.7MM 50MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.552 SUP HCPCS C1713 02.118.552 - SCREW BONE 2.7MM 52MM VAR ANG SELF TAP T8 STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.554 SUP HCPCS C1713 02.118.554 - SCREW BONE T8 LP 2.7MM 54MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.556 SUP HCPCS C1713 02.118.556 - SCREW BONE T8 LP 2.7MM 56MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.558 SUP HCPCS C1713 02.118.558 - SCREW BONE T8 LP 2.7MM 58MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.560 SUP HCPCS C1713 02.118.560 - SCREW BONE T8 LP 2.7MM 60MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.562 SUP HCPCS C1713 02.118.562 - SCREW BONE T8 LP 2.7MM 62MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.564 SUP HCPCS C1713 02.118.564 - SCREW BONE T8 LP 2.7MM 64MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.566 SUP HCPCS C1713 02.118.566 - SCREW BONE T8 LP 2.7MM 66MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.568 SUP HCPCS C1713 02.118.568 - SCREW BONE T8 LP 2.7MM 68MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.570 SUP HCPCS C1713 02.118.570 - SCREW BONE T8 LP 2.7MM 70MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $37.46 $37.46 $0.00 $0.00 $0.00 $17.87 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $50.72 $50.72 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $12.65 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $0.00 02.118.575S SUP HCPCS C1713 02.118.575S - SCREW BN 2.7MM 75MM STRL LCP T8 STRDR RCS ST LOPRFL SS BOTH IP/OP $177.13 $131.08 $0.00 $137.56 $77.38 $77.38 $0.00 $0.00 $0.00 $36.92 $131.46 $131.46 $0.00 $0.00 $36.91 $0.00 $104.77 $104.77 $0.00 $85.98 $136.18 $137.56 $0.00 $0.00 $26.13 $0.00 $0.00 $27.37 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.601 SUP HCPCS C1713 02.120.601 - PLATE BONE 4 HOLE LOCKING LCP STAINLESS STEEL FEMUR PROXIMAL BOTH IP/OP $940.40 $695.90 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $196.00 $697.96 $697.96 $0.00 $0.00 $195.98 $0.00 $556.25 $556.25 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.602 SUP HCPCS C1713 02.120.602 - PLATE BONE 8 HOLE ATTCH LOCKING LCP STAINLESS STEEL FEMUR BOTH IP/OP "$1,030.38 " $762.48 $0.00 $800.28 $450.16 $450.16 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $500.18 $792.28 $800.28 $0.00 $0.00 $152.00 $0.00 $0.00 $159.26 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.603 SUP HCPCS C1713 02.120.603 - PLATE BONE 4.5MM 4 HOLE ATTCH LOCKING LCP STAINLESS STEEL BOTH IP/OP $940.40 $695.90 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $196.00 $697.96 $697.96 $0.00 $0.00 $195.98 $0.00 $556.25 $556.25 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.604 SUP HCPCS C1713 02.120.604 - PLATE BONE 4.5MM 8 HOLE ATTCH LOCKING LCP STAINLESS STEEL BOTH IP/OP "$1,030.38 " $762.48 $0.00 $800.28 $450.16 $450.16 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $500.18 $792.28 $800.28 $0.00 $0.00 $152.00 $0.00 $0.00 $159.26 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.606 SUP HCPCS C1713 02.120.606 - SCREW BONE 2 PART CONNECT STARDRIVE LCP STAINLESS STEEL BOTH IP/OP $303.63 $224.69 $0.00 $235.82 $132.65 $132.65 $0.00 $0.00 $0.00 $63.28 $225.35 $225.35 $0.00 $0.00 $63.28 $0.00 $179.59 $179.59 $0.00 $147.39 $233.47 $235.82 $0.00 $0.00 $44.79 $0.00 $0.00 $46.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.701 SUP HCPCS C1713 02.120.701 - PLATE BONE 69MM 1 HOLE SET W/O CASE LCP STAINLESS STEEL BOTH IP/OP "$1,750.08 " "$1,295.06" $0.00 "$1,359.30" $764.61 $764.61 $0.00 $0.00 $0.00 $364.76 "$1,298.91" "$1,298.91" $0.00 $0.00 $364.72 $0.00 "$1,035.17" "$1,035.17" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $258.17 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.702 SUP HCPCS C1713 02.120.702 - PLATE BONE 79MM 2 HOLE SET W/O CASE LCP STAINLESS STEEL BOTH IP/OP "$1,769.78 " "$1,309.64" $0.00 "$1,374.58" $773.20 $773.20 $0.00 $0.00 $0.00 $368.87 "$1,313.53" "$1,313.53" $0.00 $0.00 $368.82 $0.00 "$1,046.82" "$1,046.82" $0.00 $859.11 "$1,360.84" "$1,374.58" $0.00 $0.00 $261.07 $0.00 $0.00 $273.54 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.704 SUP HCPCS C1713 02.120.704 - PLATE BONE 105MM 4 HOLE LCP STAINLESS STEEL TIBIA BOTH IP/OP "$1,788.05 " "$1,323.16" $0.00 "$1,388.76" $781.18 $781.18 $0.00 $0.00 $0.00 $372.67 "$1,327.09" "$1,327.09" $0.00 $0.00 $372.63 $0.00 "$1,057.63" "$1,057.63" $0.00 $867.98 "$1,374.87" "$1,388.76" $0.00 $0.00 $263.77 $0.00 $0.00 $276.36 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.706 SUP HCPCS C1713 02.120.706 - PLATE BONE 131MM 6 HOLE LCP STAINLESS STEEL TIBIA BOTH IP/OP "$1,804.90 " "$1,335.63" $0.00 "$1,401.88" $788.56 $788.56 $0.00 $0.00 $0.00 $376.19 "$1,339.60" "$1,339.60" $0.00 $0.00 $376.14 $0.00 "$1,067.60" "$1,067.60" $0.00 $876.18 "$1,387.86" "$1,401.88" $0.00 $0.00 $266.25 $0.00 $0.00 $278.97 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.708 SUP HCPCS C1713 02.120.708 - PLATE BONE 157MM 8 HOLE SET W/O CASE LCP STAINLESS STEEL BOTH IP/OP "$1,876.60 " "$1,388.68" $0.00 "$1,457.56" $819.88 $819.88 $0.00 $0.00 $0.00 $391.13 "$1,392.81" "$1,392.81" $0.00 $0.00 $391.08 $0.00 "$1,110.01" "$1,110.01" $0.00 $910.98 "$1,442.98" "$1,457.56" $0.00 $0.00 $276.83 $0.00 $0.00 $290.05 $0.00 $0.00 $0.00 $0.00 $0.00 02.120.710 SUP HCPCS C1713 02.120.710 - PLATE BONE 183MM 10 HOLE SET W/O CASE LCP STAINLESS STEEL BOTH IP/OP "$1,896.28 " "$1,403.25" $0.00 "$1,472.84" $828.47 $828.47 $0.00 $0.00 $0.00 $395.23 "$1,407.42" "$1,407.42" $0.00 $0.00 $395.18 $0.00 "$1,121.65" "$1,121.65" $0.00 $920.53 "$1,458.11" "$1,472.84" $0.00 $0.00 $279.73 $0.00 $0.00 $293.10 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.020 SUP HCPCS C1713 02.123.020 - PLATE BN CNTR 91MM NS LCP CMBN 2 HL LMT CNTCT TPR TIP SS HUM BOTH IP/OP "$2,857.78 " "$2,114.76" $0.00 "$2,219.62" "$1,248.54" "$1,248.54" $0.00 $0.00 $0.00 $595.63 "$2,121.04" "$2,121.04" $0.00 $0.00 $595.56 $0.00 "$1,408.88" "$1,408.88" $0.00 "$1,387.26" "$2,197.43" "$2,219.62" $0.00 $0.00 $421.57 $0.00 $0.00 $441.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.021 SUP HCPCS C1713 02.123.021 - PLATE BN CNTR 91MM NS LCP CMBN 2 HL LMT CNTCT TPR TIP SS HUM BOTH IP/OP "$2,857.78 " "$2,114.76" $0.00 "$2,219.62" "$1,248.54" "$1,248.54" $0.00 $0.00 $0.00 $595.63 "$2,121.04" "$2,121.04" $0.00 $0.00 $595.56 $0.00 "$1,408.88" "$1,408.88" $0.00 "$1,387.26" "$2,197.43" "$2,219.62" $0.00 $0.00 $421.57 $0.00 $0.00 $441.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.022 SUP HCPCS C1713 02.123.022 - PLATE BONE 91MM 4 HOLE LCP STAINLESS STEEL PERIARTICULAR BOTH IP/OP "$2,943.53 " "$2,178.21" $0.00 "$2,286.22" "$1,286.00" "$1,286.00" $0.00 $0.00 $0.00 $613.50 "$2,184.68" "$2,184.68" $0.00 $0.00 $613.43 $0.00 "$1,451.16" "$1,451.16" $0.00 "$1,428.89" "$2,263.36" "$2,286.22" $0.00 $0.00 $434.22 $0.00 $0.00 $454.96 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.023 SUP HCPCS C1713 02.123.023 - PLATE BN CNTR 127MM NS LCP CMBN 4 HL LMT CNTCT TPR TIP SS BOTH IP/OP "$2,943.53 " "$2,178.21" $0.00 "$2,286.22" "$1,286.00" "$1,286.00" $0.00 $0.00 $0.00 $613.50 "$2,184.68" "$2,184.68" $0.00 $0.00 $613.43 $0.00 "$1,451.16" "$1,451.16" $0.00 "$1,428.89" "$2,263.36" "$2,286.22" $0.00 $0.00 $434.22 $0.00 $0.00 $454.96 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.024 SUP HCPCS C1713 02.123.024 - PLATE BONE 163MM 6 HOLE LCP STAINLESS STEEL PERIARTICULAR BOTH IP/OP "$3,100.95 " "$2,294.70" $0.00 "$2,408.52" "$1,354.79" "$1,354.79" $0.00 $0.00 $0.00 $646.32 "$2,301.53" "$2,301.53" $0.00 $0.00 $646.24 $0.00 "$1,528.77" "$1,528.77" $0.00 "$1,505.33" "$2,384.43" "$2,408.52" $0.00 $0.00 $457.44 $0.00 $0.00 $479.30 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.025 SUP HCPCS C1713 02.123.025 - PLATE BONE 163MM 6 HOLE LCP STAINLESS STEEL LEFT PROXIMAL BOTH IP/OP "$3,100.95 " "$2,294.70" $0.00 "$2,408.52" "$1,354.79" "$1,354.79" $0.00 $0.00 $0.00 $646.32 "$2,301.53" "$2,301.53" $0.00 $0.00 $646.24 $0.00 "$1,528.77" "$1,528.77" $0.00 "$1,505.33" "$2,384.43" "$2,408.52" $0.00 $0.00 $457.44 $0.00 $0.00 $479.30 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.026 SUP HCPCS C1713 02.123.026 - PLATE BN CNTR 199MM NS LCP CMBN 8 HL LMT CNTCT TPR TIP SS BOTH IP/OP "$3,220.45 " "$2,383.13" $0.00 "$2,501.32" "$1,406.99" "$1,406.99" $0.00 $0.00 $0.00 $671.22 "$2,390.22" "$2,390.22" $0.00 $0.00 $671.14 $0.00 "$1,587.68" "$1,587.68" $0.00 "$1,563.33" "$2,476.31" "$2,501.32" $0.00 $0.00 $475.07 $0.00 $0.00 $497.76 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.027 SUP HCPCS C1713 02.123.027 - PLATE BN CNTR 199MM NS LCP CMBN 8 HL LMT CNTCT TPR TIP SS BOTH IP/OP "$3,220.45 " "$2,383.13" $0.00 "$2,501.32" "$1,406.99" "$1,406.99" $0.00 $0.00 $0.00 $671.22 "$2,390.22" "$2,390.22" $0.00 $0.00 $671.14 $0.00 "$1,587.68" "$1,587.68" $0.00 "$1,563.33" "$2,476.31" "$2,501.32" $0.00 $0.00 $475.07 $0.00 $0.00 $497.76 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.028 SUP HCPCS C1713 02.123.028 - PLATE BN CNTR 235MM NS LCP CMBN 10 HL LMT CNTCT TPR TIP SS BOTH IP/OP "$3,341.33 " "$2,472.58" $0.00 "$2,595.20" "$1,459.80" "$1,459.80" $0.00 $0.00 $0.00 $696.42 "$2,479.93" "$2,479.93" $0.00 $0.00 $696.33 $0.00 "$1,647.27" "$1,647.27" $0.00 "$1,622.00" "$2,569.25" "$2,595.20" $0.00 $0.00 $492.90 $0.00 $0.00 $516.44 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.029 SUP HCPCS C1713 02.123.029 - PLATE BONE 235MM 10 HOLE LCP STAINLESS STEEL LEFT PROXIMAL BOTH IP/OP "$3,341.33 " "$2,472.58" $0.00 "$2,595.20" "$1,459.80" "$1,459.80" $0.00 $0.00 $0.00 $696.42 "$2,479.93" "$2,479.93" $0.00 $0.00 $696.33 $0.00 "$1,647.27" "$1,647.27" $0.00 "$1,622.00" "$2,569.25" "$2,595.20" $0.00 $0.00 $492.90 $0.00 $0.00 $516.44 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.030 SUP HCPCS C1713 02.123.030 - PLATE BN CNTR 271MM NS LCP CMBN 12 HL LMT CNTCT TPR TIP SS BOTH IP/OP "$3,448.18 " "$2,551.65" $0.00 "$2,678.18" "$1,506.48" "$1,506.48" $0.00 $0.00 $0.00 $718.69 "$2,559.24" "$2,559.24" $0.00 $0.00 $718.60 $0.00 "$1,699.95" "$1,699.95" $0.00 "$1,673.86" "$2,651.40" "$2,678.18" $0.00 $0.00 $508.66 $0.00 $0.00 $532.96 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.031 SUP HCPCS C1713 02.123.031 - PLATE BONE 271MM 12 HOLE LCP STAINLESS STEEL PERIARTICULAR BOTH IP/OP "$3,448.18 " "$2,551.65" $0.00 "$2,678.18" "$1,506.48" "$1,506.48" $0.00 $0.00 $0.00 $718.69 "$2,559.24" "$2,559.24" $0.00 $0.00 $718.60 $0.00 "$1,699.95" "$1,699.95" $0.00 "$1,673.86" "$2,651.40" "$2,678.18" $0.00 $0.00 $508.66 $0.00 $0.00 $532.96 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.032S SUP HCPCS C1713 02.123.032S - PLATE BONE 307MM 14 HOLE LCP STAINLESS STEEL PERIARTICULAR BOTH IP/OP "$3,767.25 " "$2,787.77" $0.00 "$2,926.02" "$1,645.89" "$1,645.89" $0.00 $0.00 $0.00 $785.19 "$2,796.05" "$2,796.05" $0.00 $0.00 $785.09 $0.00 "$1,857.25" "$1,857.25" $0.00 "$1,828.76" "$2,896.76" "$2,926.02" $0.00 $0.00 $555.73 $0.00 $0.00 $582.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.033S SUP HCPCS C1713 02.123.033S - PLATE BONE 307MM 14 HOLE LCP STAINLESS STEEL PERIARTICULAR BOTH IP/OP "$3,767.25 " "$2,787.77" $0.00 "$2,926.02" "$1,645.89" "$1,645.89" $0.00 $0.00 $0.00 $785.19 "$2,796.05" "$2,796.05" $0.00 $0.00 $785.09 $0.00 "$1,857.25" "$1,857.25" $0.00 "$1,828.76" "$2,896.76" "$2,926.02" $0.00 $0.00 $555.73 $0.00 $0.00 $582.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.040 SUP HCPCS C1713 02.123.040 - PLATE BONE 109MM 3 HOLE LCP STAINLESS STEEL RIGHT PROXIMAL BOTH IP/OP "$2,898.55 " "$2,144.93" $0.00 "$2,251.30" "$1,266.36" "$1,266.36" $0.00 $0.00 $0.00 $604.13 "$2,151.30" "$2,151.30" $0.00 $0.00 $604.06 $0.00 "$1,428.99" "$1,428.99" $0.00 "$1,407.06" "$2,228.79" "$2,251.30" $0.00 $0.00 $427.58 $0.00 $0.00 $448.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.041 SUP HCPCS C1713 02.123.041 - PLATE BN CNTR 109MM NS LCP CMBN 3 HL LMT CNTCT TPR TIP SS BOTH IP/OP "$2,898.55 " "$2,144.93" $0.00 "$2,251.30" "$1,266.36" "$1,266.36" $0.00 $0.00 $0.00 $604.13 "$2,151.30" "$2,151.30" $0.00 $0.00 $604.06 $0.00 "$1,428.99" "$1,428.99" $0.00 "$1,407.06" "$2,228.79" "$2,251.30" $0.00 $0.00 $427.58 $0.00 $0.00 $448.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.042 SUP HCPCS C1713 02.123.042 - PLATE BN CNTR 145MM NS LCP CMBN 5 HL LMT CNTCT TPR TIP SS BOTH IP/OP "$3,016.63 " "$2,232.31" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $628.74 "$2,238.94" "$2,238.94" $0.00 $0.00 $628.66 $0.00 "$1,487.20" "$1,487.20" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $445.00 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 02.123.043 SUP HCPCS C1713 02.123.043 - PLATE BONE 14.5CM 5 HOLE SET LCP STAINLESS STEEL LEFT BOTH IP/OP "$3,016.63 " "$2,232.31" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $628.74 "$2,238.94" "$2,238.94" $0.00 $0.00 $628.66 $0.00 "$1,487.20" "$1,487.20" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $445.00 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.030S SUP HCPCS C1713 02.124.030S - PLATE BONE 356MM 15 HOLE ANATOMIC LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,318.85 " "$2,455.95" $0.00 "$2,577.74" "$1,449.98" "$1,449.98" $0.00 $0.00 $0.00 $691.73 "$2,463.25" "$2,463.25" $0.00 $0.00 $691.65 $0.00 "$1,636.19" "$1,636.19" $0.00 "$1,611.09" "$2,551.97" "$2,577.74" $0.00 $0.00 $489.58 $0.00 $0.00 $512.97 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.031S SUP HCPCS C1713 02.124.031S - PLATE BONE 356MM 15 HOLE ANATOMIC LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,318.85 " "$2,455.95" $0.00 "$2,577.74" "$1,449.98" "$1,449.98" $0.00 $0.00 $0.00 $691.73 "$2,463.25" "$2,463.25" $0.00 $0.00 $691.65 $0.00 "$1,636.19" "$1,636.19" $0.00 "$1,611.09" "$2,551.97" "$2,577.74" $0.00 $0.00 $489.58 $0.00 $0.00 $512.97 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.034S SUP HCPCS C1713 02.124.034S - PLATE BN 396MM STRL LCP CMBN 17 HL PSHP RND TIP LOPRFL SS BOTH IP/OP "$3,379.28 " "$2,500.67" $0.00 "$2,624.68" "$1,476.38" "$1,476.38" $0.00 $0.00 $0.00 $704.33 "$2,508.10" "$2,508.10" $0.00 $0.00 $704.24 $0.00 "$1,665.98" "$1,665.98" $0.00 "$1,640.43" "$2,598.43" "$2,624.68" $0.00 $0.00 $498.50 $0.00 $0.00 $522.31 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.035S SUP HCPCS C1713 02.124.035S - PLATE BONE 396MM 17 HOLE ANATOMIC LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,379.28 " "$2,500.67" $0.00 "$2,624.68" "$1,476.38" "$1,476.38" $0.00 $0.00 $0.00 $704.33 "$2,508.10" "$2,508.10" $0.00 $0.00 $704.24 $0.00 "$1,665.98" "$1,665.98" $0.00 "$1,640.43" "$2,598.43" "$2,624.68" $0.00 $0.00 $498.50 $0.00 $0.00 $522.31 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.038S SUP HCPCS C1713 02.124.038S - PLATE BONE 436MM 19 HOLE ANATOMIC LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,441.13 " "$2,546.44" $0.00 "$2,672.72" "$1,503.41" "$1,503.41" $0.00 $0.00 $0.00 $717.22 "$2,554.00" "$2,554.00" $0.00 $0.00 $717.13 $0.00 "$1,696.47" "$1,696.47" $0.00 "$1,670.45" "$2,645.99" "$2,672.72" $0.00 $0.00 $507.62 $0.00 $0.00 $531.87 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.039S SUP HCPCS C1713 02.124.039S - PLATE BONE 436MM 19 HOLE ANATOMIC LCP STAINLESS STEEL FEMUR BOTH IP/OP "$3,441.13 " "$2,546.44" $0.00 "$2,672.72" "$1,503.41" "$1,503.41" $0.00 $0.00 $0.00 $717.22 "$2,554.00" "$2,554.00" $0.00 $0.00 $717.13 $0.00 "$1,696.47" "$1,696.47" $0.00 "$1,670.45" "$2,645.99" "$2,672.72" $0.00 $0.00 $507.62 $0.00 $0.00 $531.87 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.200 SUP HCPCS C1713 02.124.200 - PLATE BN CNTR LO BND 76MM NS LCP CMBN 4 HL LMT CNTCT SS TIB BOTH IP/OP "$2,663.78 " "$1,971.20" $0.00 "$2,068.96" "$1,163.79" "$1,163.79" $0.00 $0.00 $0.00 $555.20 "$1,977.05" "$1,977.05" $0.00 $0.00 $555.13 $0.00 "$1,313.24" "$1,313.24" $0.00 "$1,293.10" "$2,048.27" "$2,068.96" $0.00 $0.00 $392.95 $0.00 $0.00 $411.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.200S SUP HCPCS C1713 02.124.200S - PLATE BN 76MM STRL LCP CMBN 4 HL LO BND LMT CNTCT SS TIB RT BOTH IP/OP "$2,755.15 " "$2,038.81" $0.00 "$2,139.92" "$1,203.71" "$1,203.71" $0.00 $0.00 $0.00 $574.24 "$2,044.87" "$2,044.87" $0.00 $0.00 $574.17 $0.00 "$1,358.29" "$1,358.29" $0.00 "$1,337.45" "$2,118.52" "$2,139.92" $0.00 $0.00 $406.43 $0.00 $0.00 $425.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.201 SUP HCPCS C1713 02.124.201 - PLATE BN CNTR LO BND 76MM NS LCP CMBN 4 HL LMT CNTCT SS TIB BOTH IP/OP "$2,663.78 " "$1,971.20" $0.00 "$2,068.96" "$1,163.79" "$1,163.79" $0.00 $0.00 $0.00 $555.20 "$1,977.05" "$1,977.05" $0.00 $0.00 $555.13 $0.00 "$1,313.24" "$1,313.24" $0.00 "$1,293.10" "$2,048.27" "$2,068.96" $0.00 $0.00 $392.95 $0.00 $0.00 $411.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.201S SUP HCPCS C1713 02.124.201S - PLATE BN 76MM STRL LCP CMBN 4 HL LO BND LMT CNTCT SS TIB LT BOTH IP/OP "$2,755.15 " "$2,038.81" $0.00 "$2,139.92" "$1,203.71" "$1,203.71" $0.00 $0.00 $0.00 $574.24 "$2,044.87" "$2,044.87" $0.00 $0.00 $574.17 $0.00 "$1,358.29" "$1,358.29" $0.00 "$1,337.45" "$2,118.52" "$2,139.92" $0.00 $0.00 $406.43 $0.00 $0.00 $425.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.204 SUP HCPCS C1713 02.124.204 - PLATE BN CNTR LO BND 102MM NS LCP CMBN 6 HL LMT CNTCT SS TIB BOTH IP/OP "$2,696.13 " "$1,995.14" $0.00 "$2,094.08" "$1,177.92" "$1,177.92" $0.00 $0.00 $0.00 $561.94 "$2,001.06" "$2,001.06" $0.00 $0.00 $561.87 $0.00 "$1,329.19" "$1,329.19" $0.00 "$1,308.80" "$2,073.14" "$2,094.08" $0.00 $0.00 $397.72 $0.00 $0.00 $416.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.205 SUP HCPCS C1713 02.124.205 - PLATE BN CNTR LO BND 102MM NS LCP CMBN 6 HL LMT CNTCT SS TIB BOTH IP/OP "$2,696.13 " "$1,995.14" $0.00 "$2,094.08" "$1,177.92" "$1,177.92" $0.00 $0.00 $0.00 $561.94 "$2,001.06" "$2,001.06" $0.00 $0.00 $561.87 $0.00 "$1,329.19" "$1,329.19" $0.00 "$1,308.80" "$2,073.14" "$2,094.08" $0.00 $0.00 $397.72 $0.00 $0.00 $416.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.205S SUP HCPCS C1713 02.124.205S - PLATE BN 102MM STRL LCP CMBN 6 HL LO BND LMT CNTCT SS TIB LT BOTH IP/OP "$2,787.50 " "$2,062.75" $0.00 "$2,165.04" "$1,217.84" "$1,217.84" $0.00 $0.00 $0.00 $580.98 "$2,068.88" "$2,068.88" $0.00 $0.00 $580.92 $0.00 "$1,374.24" "$1,374.24" $0.00 "$1,353.15" "$2,143.39" "$2,165.04" $0.00 $0.00 $411.20 $0.00 $0.00 $430.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.208 SUP HCPCS C1713 02.124.208 - PLATE BN CNTR LO BND 128MM NS LCP CMBN 8 HL LMT CNTCT SS TIB BOTH IP/OP "$2,727.05 " "$2,018.02" $0.00 "$2,118.10" "$1,191.43" "$1,191.43" $0.00 $0.00 $0.00 $568.39 "$2,024.02" "$2,024.02" $0.00 $0.00 $568.32 $0.00 "$1,344.44" "$1,344.44" $0.00 "$1,323.81" "$2,096.92" "$2,118.10" $0.00 $0.00 $402.28 $0.00 $0.00 $421.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.209 SUP HCPCS C1713 02.124.209 - PLATE BN CNTR LO BND 128MM NS LCP CMBN 8 HL LMT CNTCT SS TIB BOTH IP/OP "$2,727.05 " "$2,018.02" $0.00 "$2,118.10" "$1,191.43" "$1,191.43" $0.00 $0.00 $0.00 $568.39 "$2,024.02" "$2,024.02" $0.00 $0.00 $568.32 $0.00 "$1,344.44" "$1,344.44" $0.00 "$1,323.81" "$2,096.92" "$2,118.10" $0.00 $0.00 $402.28 $0.00 $0.00 $421.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.212 SUP HCPCS C1713 02.124.212 - PLATE BN CNTR LO BND 154MM NS LCP CMBN 10 HL LMT CNTCT SS BOTH IP/OP "$2,756.58 " "$2,039.87" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $574.54 "$2,045.93" "$2,045.93" $0.00 $0.00 $574.47 $0.00 "$1,358.99" "$1,358.99" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.213 SUP HCPCS C1713 02.124.213 - PLATE BN CNTR LO BND 154MM NS LCP CMBN 10 HL LMT CNTCT SS BOTH IP/OP "$2,756.58 " "$2,039.87" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $574.54 "$2,045.93" "$2,045.93" $0.00 $0.00 $574.47 $0.00 "$1,358.99" "$1,358.99" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.216 SUP HCPCS C1713 02.124.216 - PLATE BN CNTR LO BND 180MM NS LCP CMBN 12 HL LMT CNTCT SS BOTH IP/OP "$2,887.30 " "$2,136.60" $0.00 "$2,242.56" "$1,261.44" "$1,261.44" $0.00 $0.00 $0.00 $601.79 "$2,142.95" "$2,142.95" $0.00 $0.00 $601.71 $0.00 "$1,423.44" "$1,423.44" $0.00 "$1,401.60" "$2,220.13" "$2,242.56" $0.00 $0.00 $425.92 $0.00 $0.00 $446.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.217 SUP HCPCS C1713 02.124.217 - PLATE BN CNTR LO BND 180MM NS LCP CMBN 12 HL LMT CNTCT SS BOTH IP/OP "$2,887.30 " "$2,136.60" $0.00 "$2,242.56" "$1,261.44" "$1,261.44" $0.00 $0.00 $0.00 $601.79 "$2,142.95" "$2,142.95" $0.00 $0.00 $601.71 $0.00 "$1,423.44" "$1,423.44" $0.00 "$1,401.60" "$2,220.13" "$2,242.56" $0.00 $0.00 $425.92 $0.00 $0.00 $446.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.220 SUP HCPCS C1713 02.124.220 - PLATE BN CNTR LO BND 206MM NS LCP CMBN 14 HL LMT CNTCT SS BOTH IP/OP "$2,918.23 " "$2,159.49" $0.00 "$2,266.58" "$1,274.95" "$1,274.95" $0.00 $0.00 $0.00 $608.23 "$2,165.91" "$2,165.91" $0.00 $0.00 $608.16 $0.00 "$1,438.68" "$1,438.68" $0.00 "$1,416.61" "$2,243.92" "$2,266.58" $0.00 $0.00 $430.48 $0.00 $0.00 $451.05 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.220S SUP HCPCS C1713 02.124.220S - PLATE BN 206MM STRL LCP CMBN 14 HL LO BND LMT CNTCT SS TIB BOTH IP/OP "$3,009.60 " "$2,227.10" $0.00 "$2,337.54" "$1,314.87" "$1,314.87" $0.00 $0.00 $0.00 $627.28 "$2,233.73" "$2,233.73" $0.00 $0.00 $627.20 $0.00 "$1,483.73" "$1,483.73" $0.00 "$1,460.96" "$2,314.17" "$2,337.54" $0.00 $0.00 $443.96 $0.00 $0.00 $465.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.221 SUP HCPCS C1713 02.124.221 - PLATE BN CNTR LO BND 206MM NS LCP CMBN 14 HL LMT CNTCT SS BOTH IP/OP "$2,918.23 " "$2,159.49" $0.00 "$2,266.58" "$1,274.95" "$1,274.95" $0.00 $0.00 $0.00 $608.23 "$2,165.91" "$2,165.91" $0.00 $0.00 $608.16 $0.00 "$1,438.68" "$1,438.68" $0.00 "$1,416.61" "$2,243.92" "$2,266.58" $0.00 $0.00 $430.48 $0.00 $0.00 $451.05 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.224 SUP HCPCS C1713 02.124.224 - PLATE BN CNTR LO BND 232MM NS LCP CMBN 16 HL LMT CNTCT SS BOTH IP/OP "$3,020.83 " "$2,235.41" $0.00 "$2,346.28" "$1,319.78" "$1,319.78" $0.00 $0.00 $0.00 $629.62 "$2,242.06" "$2,242.06" $0.00 $0.00 $629.54 $0.00 "$1,489.27" "$1,489.27" $0.00 "$1,466.43" "$2,322.82" "$2,346.28" $0.00 $0.00 $445.62 $0.00 $0.00 $466.91 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.225 SUP HCPCS C1713 02.124.225 - PLATE BN CNTR LO BND 232MM NS LCP CMBN 16 HL LMT CNTCT SS BOTH IP/OP "$3,020.83 " "$2,235.41" $0.00 "$2,346.28" "$1,319.78" "$1,319.78" $0.00 $0.00 $0.00 $629.62 "$2,242.06" "$2,242.06" $0.00 $0.00 $629.54 $0.00 "$1,489.27" "$1,489.27" $0.00 "$1,466.43" "$2,322.82" "$2,346.28" $0.00 $0.00 $445.62 $0.00 $0.00 $466.91 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.408S SUP HCPCS C1713 02.124.408S - PLATE CURVE 195MM SS 4.5MM SCR 8 HOLE 4 CLMN THRD BOTH IP/OP "$3,282.30 " "$2,428.90" $0.00 "$2,549.36" "$1,434.02" "$1,434.02" $0.00 $0.00 $0.00 $684.11 "$2,436.12" "$2,436.12" $0.00 $0.00 $684.03 $0.00 "$1,618.17" "$1,618.17" $0.00 "$1,593.35" "$2,523.87" "$2,549.36" $0.00 $0.00 $484.19 $0.00 $0.00 $507.32 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.410S SUP HCPCS C1713 02.124.410S - PLATE BONE CURVE 230MM 10 HOLE VAR ANG LCP COMBI STAINLESS BOTH IP/OP "$3,431.30 " "$2,539.16" $0.00 "$2,665.08" "$1,499.11" "$1,499.11" $0.00 $0.00 $0.00 $715.17 "$2,546.71" "$2,546.71" $0.00 $0.00 $715.08 $0.00 "$1,691.63" "$1,691.63" $0.00 "$1,665.68" "$2,638.43" "$2,665.08" $0.00 $0.00 $506.17 $0.00 $0.00 $530.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.411 SUP HCPCS C1713 02.124.411 - PLATE BONE CURVE 23CM 10 HOLE VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$3,339.93 " "$2,471.55" $0.00 "$2,594.12" "$1,459.19" "$1,459.19" $0.00 $0.00 $0.00 $696.12 "$2,478.89" "$2,478.89" $0.00 $0.00 $696.04 $0.00 "$1,646.58" "$1,646.58" $0.00 "$1,621.33" "$2,568.18" "$2,594.12" $0.00 $0.00 $492.69 $0.00 $0.00 $516.23 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.412 SUP HCPCS C1713 02.124.412 - PLATE BONE 267MM 12 HOLE VAR ANG CVD LCP STAINLESS STEEL BOTH IP/OP "$3,410.20 " "$2,523.55" $0.00 "$2,648.70" "$1,489.89" "$1,489.89" $0.00 $0.00 $0.00 $710.77 "$2,531.05" "$2,531.05" $0.00 $0.00 $710.69 $0.00 "$1,681.23" "$1,681.23" $0.00 "$1,655.44" "$2,622.22" "$2,648.70" $0.00 $0.00 $503.06 $0.00 $0.00 $527.09 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.412S SUP HCPCS C1713 02.124.412S - PLATE BN CRV 266MM STRL LCP CMBN 12 HL 4 CLMN THRD VA SS BOTH IP/OP "$3,300.58 " "$2,442.43" $0.00 "$2,640.46" "$1,485.26" "$1,485.26" $0.00 $0.00 $0.00 $687.92 "$2,449.69" "$2,449.69" $0.00 $0.00 $687.84 $0.00 "$1,627.18" "$1,627.18" $0.00 "$1,650.29" "$2,614.06" "$2,640.46" $0.00 $0.00 $516.54 $0.00 $0.00 $525.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.413 SUP HCPCS C1713 02.124.413 - PLATE BN CRV 266MM NS LCP CMBN 12 HL 4 CLMN THRD VA SS CNDRL BOTH IP/OP "$3,410.20 " "$2,523.55" $0.00 "$2,648.70" "$1,489.89" "$1,489.89" $0.00 $0.00 $0.00 $710.77 "$2,531.05" "$2,531.05" $0.00 $0.00 $710.69 $0.00 "$1,681.23" "$1,681.23" $0.00 "$1,655.44" "$2,622.22" "$2,648.70" $0.00 $0.00 $503.06 $0.00 $0.00 $527.09 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.413S SUP HCPCS C1713 02.124.413S - PLATE BN CRV 266MM STRL LCP CMBN 12 HL 4 CLMN THRD VA SS BOTH IP/OP "$3,501.58 " "$2,591.17" $0.00 "$2,719.68" "$1,529.82" "$1,529.82" $0.00 $0.00 $0.00 $729.82 "$2,598.87" "$2,598.87" $0.00 $0.00 $729.73 $0.00 "$1,726.28" "$1,726.28" $0.00 "$1,699.80" "$2,692.48" "$2,719.68" $0.00 $0.00 $516.54 $0.00 $0.00 $541.22 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.414S SUP HCPCS C1713 02.124.414S - PLATE BN CRV 301MM STRL LCP CMBN 14 HL 4 CLMN THRD VA SS BOTH IP/OP "$3,730.70 " "$2,760.72" $0.00 "$2,897.64" "$1,629.92" "$1,629.92" $0.00 $0.00 $0.00 $777.57 "$2,768.93" "$2,768.93" $0.00 $0.00 $777.48 $0.00 "$1,839.24" "$1,839.24" $0.00 "$1,811.03" "$2,868.66" "$2,897.64" $0.00 $0.00 $550.34 $0.00 $0.00 $576.63 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.415 SUP HCPCS C1713 02.124.415 - PLATE BN CRV 301MM NS LCP CMBN 14 HL 4 CLMN THRD VA SS CNDRL BOTH IP/OP "$3,639.35 " "$2,693.12" $0.00 "$2,826.68" "$1,590.01" "$1,590.01" $0.00 $0.00 $0.00 $758.53 "$2,701.13" "$2,701.13" $0.00 $0.00 $758.44 $0.00 "$1,794.20" "$1,794.20" $0.00 "$1,766.68" "$2,798.41" "$2,826.68" $0.00 $0.00 $536.86 $0.00 $0.00 $562.51 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.416 SUP HCPCS C1713 02.124.416 - PLATE BONE CURVE 336MM 16 HOLE LCP STAINLESS STEEL RIGHT BOTH IP/OP "$3,709.63 " "$2,745.13" $0.00 "$2,881.26" "$1,620.71" "$1,620.71" $0.00 $0.00 $0.00 $773.18 "$2,753.28" "$2,753.28" $0.00 $0.00 $773.09 $0.00 "$1,828.85" "$1,828.85" $0.00 "$1,800.79" "$2,852.45" "$2,881.26" $0.00 $0.00 $547.23 $0.00 $0.00 $573.37 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.416S SUP HCPCS C1713 02.124.416S - PLATE CURVE 336MM SS 4.5MM SCR 16 HOLE 4 CLMN THRD BOTH IP/OP "$3,801.00 " "$2,812.74" $0.00 "$2,952.22" "$1,660.62" "$1,660.62" $0.00 $0.00 $0.00 $792.22 "$2,821.10" "$2,821.10" $0.00 $0.00 $792.13 $0.00 "$1,873.89" "$1,873.89" $0.00 "$1,845.14" "$2,922.70" "$2,952.22" $0.00 $0.00 $560.71 $0.00 $0.00 $587.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.417S SUP HCPCS C1713 02.124.417S - PLATE BONE CURVE 336MM 16 HOLE VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$3,801.00 " "$2,812.74" $0.00 "$2,952.22" "$1,660.62" "$1,660.62" $0.00 $0.00 $0.00 $792.22 "$2,821.10" "$2,821.10" $0.00 $0.00 $792.13 $0.00 "$1,873.89" "$1,873.89" $0.00 "$1,845.14" "$2,922.70" "$2,952.22" $0.00 $0.00 $560.71 $0.00 $0.00 $587.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.124.419 SUP HCPCS C1713 02.124.419 - PLATE BONE 375MM 18 HOLE VAR ANG CVD LCP STAINLESS STEEL BOTH IP/OP "$3,951.40 " "$2,924.04" $0.00 "$3,069.04" "$1,726.34" "$1,726.34" $0.00 $0.00 $0.00 $823.57 "$2,932.73" "$2,932.73" $0.00 $0.00 $823.47 $0.00 "$1,948.04" "$1,948.04" $0.00 "$1,918.15" "$3,038.35" "$3,069.04" $0.00 $0.00 $582.90 $0.00 $0.00 $610.74 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.004 SUP HCPCS C1713 02.130.004 - SCREW BN T4 1.3MM 4MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.005 SUP HCPCS C1713 02.130.005 - SCREW BN T4 1.3MM 5MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.006 SUP HCPCS C1713 02.130.006 - SCREW BN T4 1.3MM 6MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.007 SUP HCPCS C1713 02.130.007 - SCREW BN T4 1.3MM 7MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.008 SUP HCPCS C1713 02.130.008 - SCREW BN T4 1.3MM 8MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.009 SUP HCPCS C1713 02.130.009 - SCREW BN T4 1.3MM 9MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.010 SUP HCPCS C1713 02.130.010 - SCREW BN T4 1.3MM 10MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.011 SUP HCPCS C1713 02.130.011 - SCREW BN T4 1.3MM 11MM NS SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.012 SUP HCPCS C1713 02.130.012 - SCREW BN T4 1.3MM 12MM NS SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.013 SUP HCPCS C1713 02.130.013 - SCREW BN T4 1.3MM 13MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.014 SUP HCPCS C1713 02.130.014 - SCREW BN T4 1.3MM 14MM SLFRET ST TIP STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.015 SUP HCPCS C1713 02.130.015 - SCREW BN T4 1.3MM 15MM SLFRET ST STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.016 SUP HCPCS C1713 02.130.016 - SCREW BN T4 1.3MM 16MM ST TIP SLFRET STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.018 SUP HCPCS C1713 02.130.018 - SCREW BN T4 1.3MM 18MM ST TIP SLFRET LCK STRDR SS CORT BOTH IP/OP $81.53 $60.33 $0.00 $63.32 $35.62 $35.62 $0.00 $0.00 $0.00 $16.99 $60.51 $60.51 $0.00 $0.00 $16.99 $0.00 $48.22 $48.22 $0.00 $39.58 $62.69 $63.32 $0.00 $0.00 $12.03 $0.00 $0.00 $12.60 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.104 SUP HCPCS C1713 02.130.104 - SCREW BN T4 1.3MM 4MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.105 SUP HCPCS C1713 02.130.105 - SCREW BN T4 1.3MM 5MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.106 SUP HCPCS C1713 02.130.106 - SCREW BN T4 1.3MM 6MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.107 SUP HCPCS C1713 02.130.107 - SCREW BN T4 1.3MM 7MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.108 SUP HCPCS C1713 02.130.108 - SCREW BN T4 1.3MM 8MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.109 SUP HCPCS C1713 02.130.109 - SCREW BN T4 1.3MM 9MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.110 SUP HCPCS C1713 02.130.110 - SCREW BN T4 1.3MM 10MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.111 SUP HCPCS C1713 02.130.111 - SCREW BN T4 1.3MM 11MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.112 SUP HCPCS C1713 02.130.112 - SCREW BN T4 1.3MM 12MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.113 SUP HCPCS C1713 02.130.113 - SCREW BN T4 1.3MM 13MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.114 SUP HCPCS C1713 02.130.114 - SCREW BN T4 1.3MM 14MM SLFRET ST TIP LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.115 SUP HCPCS C1713 02.130.115 - SCREW BN T4 1.3MM 15MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.116 SUP HCPCS C1713 02.130.116 - SCREW BN T4 1.3MM 16MM ST TIP SLFRET LCK STRDR SS HND BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.118 SUP HCPCS C1713 02.130.118 - SCREW BN T4 1.3MM 18MM ST SLF RTN LCK STRDR SS BOTH IP/OP $215.08 $159.16 $0.00 $167.04 $93.96 $93.96 $0.00 $0.00 $0.00 $44.83 $159.63 $159.63 $0.00 $0.00 $44.82 $0.00 $127.22 $127.22 $0.00 $104.40 $165.37 $167.04 $0.00 $0.00 $31.73 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.150 SUP HCPCS C1713 02.130.150 - PLATE BN STRG .75MM LCK 6 HL LOPRFL PRECONTOUR SS HND 1.3MM BOTH IP/OP $723.93 $535.71 $0.00 $562.28 $316.28 $316.28 $0.00 $0.00 $0.00 $150.88 $537.30 $537.30 $0.00 $0.00 $150.87 $0.00 $428.20 $428.20 $0.00 $351.43 $556.66 $562.28 $0.00 $0.00 $106.79 $0.00 $0.00 $111.89 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.151 SUP HCPCS C1713 02.130.151 - PLATE BN STRG .75MM LCK 12 HL LOPRFL PRECONTOUR SS HND 1.3MM BOTH IP/OP $794.23 $587.73 $0.00 $616.86 $346.98 $346.98 $0.00 $0.00 $0.00 $165.54 $589.47 $589.47 $0.00 $0.00 $165.52 $0.00 $469.78 $469.78 $0.00 $385.54 $610.70 $616.86 $0.00 $0.00 $117.16 $0.00 $0.00 $122.76 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.152 SUP HCPCS C1713 02.130.152 - PLATE BN T .75MM LCK 3 HLE/HD 5 HL SHFT LOPRFL SS HND 1.3MM BOTH IP/OP $794.23 $587.73 $0.00 $616.86 $346.98 $346.98 $0.00 $0.00 $0.00 $165.54 $589.47 $589.47 $0.00 $0.00 $165.52 $0.00 $469.78 $469.78 $0.00 $385.54 $610.70 $616.86 $0.00 $0.00 $117.16 $0.00 $0.00 $122.76 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.153 SUP HCPCS C1713 02.130.153 - PLATE BN Y .75MM LCK 3 HLE/HD 5 HL SHFT LOPRFL SS HND 1.3MM BOTH IP/OP $794.23 $587.73 $0.00 $616.86 $346.98 $346.98 $0.00 $0.00 $0.00 $165.54 $589.47 $589.47 $0.00 $0.00 $165.52 $0.00 $469.78 $469.78 $0.00 $385.54 $610.70 $616.86 $0.00 $0.00 $117.16 $0.00 $0.00 $122.76 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.154 SUP HCPCS C1713 02.130.154 - PLATE BN .75MM LCK 2 HLE/HD 5 HL SHFT LOPRFL SS PHLNG BS 1.3 BOTH IP/OP $905.28 $669.91 $0.00 $703.12 $395.51 $395.51 $0.00 $0.00 $0.00 $188.68 $671.90 $671.90 $0.00 $0.00 $188.66 $0.00 $535.47 $535.47 $0.00 $439.45 $696.09 $703.12 $0.00 $0.00 $133.54 $0.00 $0.00 $139.92 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.156 SUP HCPCS C1713 02.130.156 - PLATE BN CRV .75MM LCK LOPRFL PRECONTOUR SS PHLNG HD RT 1.3 BOTH IP/OP $905.28 $669.91 $0.00 $703.12 $395.51 $395.51 $0.00 $0.00 $0.00 $188.68 $671.90 $671.90 $0.00 $0.00 $188.66 $0.00 $535.47 $535.47 $0.00 $439.45 $696.09 $703.12 $0.00 $0.00 $133.54 $0.00 $0.00 $139.92 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.157 SUP HCPCS C1713 02.130.157 - PLATE BN CRV .75MM LCK LOPRFL PRECONTOUR SS PHLNG HD LT 1.3 BOTH IP/OP $905.28 $669.91 $0.00 $703.12 $395.51 $395.51 $0.00 $0.00 $0.00 $188.68 $671.90 $671.90 $0.00 $0.00 $188.66 $0.00 $535.47 $535.47 $0.00 $439.45 $696.09 $703.12 $0.00 $0.00 $133.54 $0.00 $0.00 $139.92 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.158 SUP HCPCS C1713 02.130.158 - PLATE BN STRUT OBLQ .75MM 8 HL LCK LOPRFL PRECONTOUR SS HND BOTH IP/OP $794.23 $587.73 $0.00 $616.86 $346.98 $346.98 $0.00 $0.00 $0.00 $165.54 $589.47 $589.47 $0.00 $0.00 $165.52 $0.00 $469.78 $469.78 $0.00 $385.54 $610.70 $616.86 $0.00 $0.00 $117.16 $0.00 $0.00 $122.76 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.159 SUP HCPCS C1713 02.130.159 - PLATE BN STRUT OBLQ .75MM 8 HL LCK LOPRFL PRECONTOUR SS HND BOTH IP/OP $794.23 $587.73 $0.00 $616.86 $346.98 $346.98 $0.00 $0.00 $0.00 $165.54 $589.47 $589.47 $0.00 $0.00 $165.52 $0.00 $469.78 $469.78 $0.00 $385.54 $610.70 $616.86 $0.00 $0.00 $117.16 $0.00 $0.00 $122.76 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.161 SUP HCPCS C1713 02.130.161 - PLATE BN WEB .75MM 14 HL LCK LOPRFL PRECONTOUR SS HND 1.3MM BOTH IP/OP $836.38 $618.92 $0.00 $649.62 $365.41 $365.41 $0.00 $0.00 $0.00 $174.32 $620.76 $620.76 $0.00 $0.00 $174.30 $0.00 $494.72 $494.72 $0.00 $406.01 $643.13 $649.62 $0.00 $0.00 $123.38 $0.00 $0.00 $129.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.204 SUP HCPCS C1713 02.130.204 - SCREW BN T4 1.5MM 4MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.205 SUP HCPCS C1713 02.130.205 - SCREW BN T4 1.5MM 5MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.206 SUP HCPCS C1713 02.130.206 - SCREW BN T4 1.5MM 6MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.207 SUP HCPCS C1713 02.130.207 - SCREW BN T4 1.5MM 7MM PUR ST VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.208 SUP HCPCS C1713 02.130.208 - SCREW BN T4 1.5MM 8MM ST LCK VA STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.209 SUP HCPCS C1713 02.130.209 - SCREW BN T4 1.5MM 9MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.210 SUP HCPCS C1713 02.130.210 - SCREW BN T4 1.5MM 10MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.211 SUP HCPCS C1713 02.130.211 - SCREW BN T4 1.5MM 11MM ST LCK VA STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.212 SUP HCPCS C1713 02.130.212 - SCREW BN T4 1.5MM 12MM ST LCK VA STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.213 SUP HCPCS C1713 02.130.213 - SCREW BN T4 1.5MM 13MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.214 SUP HCPCS C1713 02.130.214 - SCREW BN T4 1.5MM 14MM PUR ST TIP LCK VA STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.215 SUP HCPCS C1713 02.130.215 - SCREW BN T4 1.5MM 15MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.216 SUP HCPCS C1713 02.130.216 - SCREW BN T4 1.5MM 16MM PUR ST TIP LCK VA STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.218 SUP HCPCS C1713 02.130.218 - SCREW BN T4 1.5MM 18MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.220 SUP HCPCS C1713 02.130.220 - SCREW BN T4 1.5MM 20MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.222 SUP HCPCS C1713 02.130.222 - SCREW BN T4 1.5MM 22MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.224 SUP HCPCS C1713 02.130.224 - SCREW BN T4 1.5MM 24MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $238.98 $176.85 $0.00 $185.60 $104.40 $104.40 $0.00 $0.00 $0.00 $49.81 $177.37 $177.37 $0.00 $0.00 $49.80 $0.00 $141.35 $141.35 $0.00 $116.00 $183.74 $185.60 $0.00 $0.00 $35.25 $0.00 $0.00 $36.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.250 SUP HCPCS C1713 02.130.250 - PLATE BN STRG 1MM 6 HL VA LCK LOPRFL SS 1.5MM SCR BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.251 SUP HCPCS C1713 02.130.251 - PLATE BN STRG 1MM NS 12 HL VA LCK LOPRFL SS 1.5MM SCR BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.252 SUP HCPCS C1713 02.130.252 - PLATE BN T 1MM 3 HLE/HD 7 HL SHFT VA LCK SS 1.5MM SCR BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.253 SUP HCPCS C1713 02.130.253 - PLATE BN Y 1MM 3 HLE/HD 7 HL SHFT VA LCK SS 1.5MM SCR BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.254 SUP HCPCS C1713 02.130.254 - PLATE BN 1MM 2 HLE/HD 6 HL SHFT VA LCK PHLNG BS 1.5MM SCR BOTH IP/OP $969.93 $717.75 $0.00 $753.34 $423.75 $423.75 $0.00 $0.00 $0.00 $202.16 $719.88 $719.88 $0.00 $0.00 $202.13 $0.00 $573.71 $573.71 $0.00 $470.84 $745.81 $753.34 $0.00 $0.00 $143.08 $0.00 $0.00 $149.91 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.255 SUP HCPCS C1713 02.130.255 - PLATE BN STRG 1MM 2 HLE/HD 6 HL SHFT VA LCK SS CNDRL 1.5MM BOTH IP/OP $927.75 $686.54 $0.00 $720.58 $405.33 $405.33 $0.00 $0.00 $0.00 $193.37 $688.58 $688.58 $0.00 $0.00 $193.34 $0.00 $548.76 $548.76 $0.00 $450.36 $713.38 $720.58 $0.00 $0.00 $136.86 $0.00 $0.00 $143.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.256 SUP HCPCS C1713 02.130.256 - PLATE BN CRV 1MM VA LCK LOPRFL PRECONTOUR SS PHLNG HD RT 1.5 BOTH IP/OP $969.93 $717.75 $0.00 $753.34 $423.75 $423.75 $0.00 $0.00 $0.00 $202.16 $719.88 $719.88 $0.00 $0.00 $202.13 $0.00 $573.71 $573.71 $0.00 $470.84 $745.81 $753.34 $0.00 $0.00 $143.08 $0.00 $0.00 $149.91 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.257 SUP HCPCS C1713 02.130.257 - PLATE BN CRV 1MM VA LCK LOPRFL PRECONTOUR SS PHLNG HD LT 1.5 BOTH IP/OP $969.93 $717.75 $0.00 $753.34 $423.75 $423.75 $0.00 $0.00 $0.00 $202.16 $719.88 $719.88 $0.00 $0.00 $202.13 $0.00 $573.71 $573.71 $0.00 $470.84 $745.81 $753.34 $0.00 $0.00 $143.08 $0.00 $0.00 $149.91 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.258 SUP HCPCS C1713 02.130.258 - PLATE BN STRUT OBLQ 1MM VA LCK 8 HL LOPRFL SS HND RT 1.5MM BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.259 SUP HCPCS C1713 02.130.259 - PLATE BN STRUT OBLQ 1MM VA LCK 8 HL LOPRFL SS HND LT 1.5MM BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.260 SUP HCPCS C1713 02.130.260 - PLATE BN STRUT 1MM VA LCK 12 HL LOPRFL SS HND 1.5MM SCR BOTH IP/OP $969.93 $717.75 $0.00 $753.34 $423.75 $423.75 $0.00 $0.00 $0.00 $202.16 $719.88 $719.88 $0.00 $0.00 $202.13 $0.00 $573.71 $573.71 $0.00 $470.84 $745.81 $753.34 $0.00 $0.00 $143.08 $0.00 $0.00 $149.91 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.261 SUP HCPCS C1713 02.130.261 - PLATE BN WEB 1MM VA LCK 14 HL LOPRFL SS HND 1.5MM SCR BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.263 SUP HCPCS C1713 02.130.263 - PLATE BN CNTR 1MM VA LCK LOPRFL SS 1ST MTCRPL DRSL 1.5MM SCR BOTH IP/OP $941.83 $696.95 $0.00 $731.50 $411.47 $411.47 $0.00 $0.00 $0.00 $196.30 $699.02 $699.02 $0.00 $0.00 $196.28 $0.00 $557.09 $557.09 $0.00 $457.19 $724.19 $731.50 $0.00 $0.00 $138.93 $0.00 $0.00 $145.57 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.264 SUP HCPCS C1713 02.130.264 - PLATE BN Y 1MM VA LCK ELONGATE HL SS 1ST MTCRPL RL 1.5MM SCR BOTH IP/OP "$1,237.00 " $915.38 $0.00 $960.78 $540.44 $540.44 $0.00 $0.00 $0.00 $257.82 $918.10 $918.10 $0.00 $0.00 $257.79 $0.00 $731.69 $731.69 $0.00 $600.49 $951.18 $960.78 $0.00 $0.00 $182.48 $0.00 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.265 SUP HCPCS C1713 02.130.265 - PLATE BN Y 1MM VA LCK ELONGATE HL SS 1ST MATECARPAL L/L 1.5 BOTH IP/OP "$1,237.00 " $915.38 $0.00 $960.78 $540.44 $540.44 $0.00 $0.00 $0.00 $257.82 $918.10 $918.10 $0.00 $0.00 $257.79 $0.00 $731.69 $731.69 $0.00 $600.49 $951.18 $960.78 $0.00 $0.00 $182.48 $0.00 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.266 SUP HCPCS C1713 02.130.266 - PLATE BN 1MM VA LCK 6 HL ROT CRRT SS MTCRPL PHALANGE 1.5MM BOTH IP/OP "$1,237.00 " $915.38 $0.00 $960.78 $540.44 $540.44 $0.00 $0.00 $0.00 $257.82 $918.10 $918.10 $0.00 $0.00 $257.79 $0.00 $731.69 $731.69 $0.00 $600.49 $951.18 $960.78 $0.00 $0.00 $182.48 $0.00 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.268 SUP HCPCS C1713 02.130.268 - PLATE BN 1MM VA LCK KWR HL SS MTCRPL NK 1.5MM SCR BOTH IP/OP "$1,237.00 " $915.38 $0.00 $960.78 $540.44 $540.44 $0.00 $0.00 $0.00 $257.82 $918.10 $918.10 $0.00 $0.00 $257.79 $0.00 $731.69 $731.69 $0.00 $600.49 $951.18 $960.78 $0.00 $0.00 $182.48 $0.00 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.306 SUP HCPCS C1713 02.130.306 - SCREW BN T6 2MM 6MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.307 SUP HCPCS C1713 02.130.307 - SCREW BN T6 2MM 7MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.308 SUP HCPCS C1713 02.130.308 - SCREW BN T6 2MM 8MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.309 SUP HCPCS C1713 02.130.309 - SCREW BN T6 2MM 9MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.310 SUP HCPCS C1713 02.130.310 - SCREW BN T6 2MM 10MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.311 SUP HCPCS C1713 02.130.311 - SCREW BN T6 2MM 11MM PUR VA LCK ST TIP STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.312 SUP HCPCS C1713 02.130.312 - SCREW BN T6 2MM 12MM PUR STRDR VA ST LCK SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.313 SUP HCPCS C1713 02.130.313 - SCREW BN T6 2MM 13MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.314 SUP HCPCS C1713 02.130.314 - SCREW BN T6 2MM 14MM PUR NS STRDR ST LCK VA SS BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.315 SUP HCPCS C1713 02.130.315 - SCREW BN T6 2MM 15MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.316 SUP HCPCS C1713 02.130.316 - SCREW BN T6 2MM 16MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.318 SUP HCPCS C1713 02.130.318 - SCREW BN T6 2MM 18MM PUR STRDR VA ST LCK SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.320 SUP HCPCS C1713 02.130.320 - SCREW BN T6 2MM 20MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.322 SUP HCPCS C1713 02.130.322 - SCREW BN T6 2MM 22MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.324 SUP HCPCS C1713 02.130.324 - SCREW BN T6 2MM 24MM PUR ST TIP VA LCK STRDR SS HND BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $108.09 $108.09 $0.00 $0.00 $0.00 $51.56 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $146.34 $146.34 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $36.50 $0.00 $0.00 $38.24 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.350 SUP HCPCS C1713 02.130.350 - PLATE BN STRG 1.3MM 6 HL LCK VA LOPRFL HND 2MM SCR BOTH IP/OP $948.85 $702.15 $0.00 $736.96 $414.54 $414.54 $0.00 $0.00 $0.00 $197.76 $704.24 $704.24 $0.00 $0.00 $197.74 $0.00 $561.24 $561.24 $0.00 $460.60 $729.59 $736.96 $0.00 $0.00 $139.97 $0.00 $0.00 $146.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.351 SUP HCPCS C1713 02.130.351 - PLATE BN FT STRG 1.3MM 12 HL VA LCK COAX SS HND 2MM SCR BOTH IP/OP "$1,019.13 " $754.16 $0.00 $791.56 $445.25 $445.25 $0.00 $0.00 $0.00 $212.41 $756.39 $756.39 $0.00 $0.00 $212.39 $0.00 $602.81 $602.81 $0.00 $494.73 $783.64 $791.56 $0.00 $0.00 $150.34 $0.00 $0.00 $157.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.352 SUP HCPCS C1713 02.130.352 - PLATE BN FT T 1.3MM 3 HLE/HD 7 HL SHFT VA LCK SS HND 2MM SCR BOTH IP/OP "$1,019.13 " $754.16 $0.00 $791.56 $445.25 $445.25 $0.00 $0.00 $0.00 $212.41 $756.39 $756.39 $0.00 $0.00 $212.39 $0.00 $602.81 $602.81 $0.00 $494.73 $783.64 $791.56 $0.00 $0.00 $150.34 $0.00 $0.00 $157.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.353 SUP HCPCS C1713 02.130.353 - PLATE BN Y 1.3MM 3 HLE/HD 7 HL SHFT LCK VA SS HND 2MM SCR BOTH IP/OP "$1,019.13 " $754.16 $0.00 $791.56 $445.25 $445.25 $0.00 $0.00 $0.00 $212.41 $756.39 $756.39 $0.00 $0.00 $212.39 $0.00 $602.81 $602.81 $0.00 $494.73 $783.64 $791.56 $0.00 $0.00 $150.34 $0.00 $0.00 $157.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.354 SUP HCPCS C1713 02.130.354 - PLATE BN CNTR 1.3MM 2 HLE/HD 6 HL SHFT LCK ELONGATE HL SS BOTH IP/OP "$1,117.53 " $826.97 $0.00 $867.98 $488.24 $488.24 $0.00 $0.00 $0.00 $232.92 $829.43 $829.43 $0.00 $0.00 $232.89 $0.00 $661.02 $661.02 $0.00 $542.49 $859.30 $867.98 $0.00 $0.00 $164.85 $0.00 $0.00 $172.73 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.355 SUP HCPCS C1713 02.130.355 - PLATE BN 1.3MM 2 HLE/HD 6 HL SHFT LCK VA SS CNDRL 2MM SCR BOTH IP/OP "$1,089.40 " $806.16 $0.00 $846.14 $475.95 $475.95 $0.00 $0.00 $0.00 $227.06 $808.55 $808.55 $0.00 $0.00 $227.03 $0.00 $644.38 $644.38 $0.00 $528.84 $837.68 $846.14 $0.00 $0.00 $160.71 $0.00 $0.00 $168.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.360 SUP HCPCS C1713 02.130.360 - PLATE BN STRUT 1.3MM 12 HL LCK VA LOPRFL SS HND 2MM SCR BOTH IP/OP "$1,117.53 " $826.97 $0.00 $867.98 $488.24 $488.24 $0.00 $0.00 $0.00 $232.92 $829.43 $829.43 $0.00 $0.00 $232.89 $0.00 $661.02 $661.02 $0.00 $542.49 $859.30 $867.98 $0.00 $0.00 $164.85 $0.00 $0.00 $172.73 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.363 SUP HCPCS C1713 02.130.363 - PLATE BN 1.3MM LCK VA LOPRFL ANTM CNTR SS 1ST MTCRPL DRSL 2 BOTH IP/OP "$1,398.68 " "$1,035.02" $0.00 "$1,086.34" $611.07 $611.07 $0.00 $0.00 $0.00 $291.52 "$1,038.10" "$1,038.10" $0.00 $0.00 $291.48 $0.00 $827.32 $827.32 $0.00 $678.96 "$1,075.48" "$1,086.34" $0.00 $0.00 $206.33 $0.00 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.130.366 SUP HCPCS C1713 02.130.366 - PLATE BN 1.3MM 6 HL LCK VA ROT CRRT SS HND 2MM SCR BOTH IP/OP "$1,398.68 " "$1,035.02" $0.00 "$1,086.34" $611.07 $611.07 $0.00 $0.00 $0.00 $291.52 "$1,038.10" "$1,038.10" $0.00 $0.00 $291.48 $0.00 $827.32 $827.32 $0.00 $678.96 "$1,075.48" "$1,086.34" $0.00 $0.00 $206.33 $0.00 $0.00 $216.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.210 SUP HCPCS C1713 02.161.210 - PLATE BONE NARROW 10 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP $704.25 $521.15 $0.00 $547.00 $307.69 $307.69 $0.00 $0.00 $0.00 $146.78 $522.69 $522.69 $0.00 $0.00 $146.77 $0.00 $416.56 $416.56 $0.00 $341.88 $541.53 $547.00 $0.00 $0.00 $103.89 $0.00 $0.00 $108.85 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.212 SUP HCPCS C1713 02.161.212 - PLATE BONE NARROW CVD 12 HOLE LCP STAINLESS STEEL HUMERUS BOTH IP/OP "$1,072.55 " $793.69 $0.00 $833.04 $468.59 $468.59 $0.00 $0.00 $0.00 $223.55 $796.05 $796.05 $0.00 $0.00 $223.52 $0.00 $634.41 $634.41 $0.00 $520.65 $824.71 $833.04 $0.00 $0.00 $158.22 $0.00 $0.00 $165.77 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.214 SUP HCPCS C1713 02.161.214 - PLATE BONE NARROW 14 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,241.23 " $918.51 $0.00 $964.06 $542.28 $542.28 $0.00 $0.00 $0.00 $258.70 $921.24 $921.24 $0.00 $0.00 $258.67 $0.00 $734.18 $734.18 $0.00 $602.54 $954.42 $964.06 $0.00 $0.00 $183.10 $0.00 $0.00 $191.85 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.216 SUP HCPCS C1713 02.161.216 - PLATE BONE NARROW 16 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,341.03 " $992.36 $0.00 "$1,041.58" $585.89 $585.89 $0.00 $0.00 $0.00 $279.50 $995.31 $995.31 $0.00 $0.00 $279.47 $0.00 $793.22 $793.22 $0.00 $650.99 "$1,031.17" "$1,041.58" $0.00 $0.00 $197.82 $0.00 $0.00 $207.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.218 SUP HCPCS C1713 02.161.218 - PLATE BONE NARROW 18 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,509.73 " "$1,117.20" $0.00 "$1,172.60" $659.59 $659.59 $0.00 $0.00 $0.00 $314.66 "$1,120.52" "$1,120.52" $0.00 $0.00 $314.63 $0.00 $893.00 $893.00 $0.00 $732.88 "$1,160.87" "$1,172.60" $0.00 $0.00 $222.71 $0.00 $0.00 $233.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.220 SUP HCPCS C1713 02.161.220 - PLATE BONE NARROW 20 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,675.58 " "$1,239.93" $0.00 "$1,301.42" $732.05 $732.05 $0.00 $0.00 $0.00 $349.23 "$1,243.61" "$1,243.61" $0.00 $0.00 $349.19 $0.00 $991.10 $991.10 $0.00 $813.39 "$1,288.41" "$1,301.42" $0.00 $0.00 $247.18 $0.00 $0.00 $258.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.222 SUP HCPCS C1713 02.161.222 - PLATE BONE NARROW 22 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,675.58 " "$1,239.93" $0.00 "$1,301.42" $732.05 $732.05 $0.00 $0.00 $0.00 $349.23 "$1,243.61" "$1,243.61" $0.00 $0.00 $349.19 $0.00 $991.10 $991.10 $0.00 $813.39 "$1,288.41" "$1,301.42" $0.00 $0.00 $247.18 $0.00 $0.00 $258.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.240 SUP HCPCS C1713 02.161.240 - PLATE BONE NARROW 10 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,165.33 " $862.34 $0.00 $905.10 $509.12 $509.12 $0.00 $0.00 $0.00 $242.88 $864.90 $864.90 $0.00 $0.00 $242.85 $0.00 $689.29 $689.29 $0.00 $565.69 $896.05 $905.10 $0.00 $0.00 $171.90 $0.00 $0.00 $180.11 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.242 SUP HCPCS C1713 02.161.242 - PLATE BONE NARROW 12 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,345.25 " $995.49 $0.00 "$1,044.86" $587.73 $587.73 $0.00 $0.00 $0.00 $280.38 $998.44 $998.44 $0.00 $0.00 $280.35 $0.00 $795.72 $795.72 $0.00 $653.04 "$1,034.42" "$1,044.86" $0.00 $0.00 $198.45 $0.00 $0.00 $207.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.244 SUP HCPCS C1713 02.161.244 - PLATE BONE NARROW 14 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,435.20 " "$1,062.05" $0.00 "$1,114.72" $627.03 $627.03 $0.00 $0.00 $0.00 $299.13 "$1,065.21" "$1,065.21" $0.00 $0.00 $299.10 $0.00 $848.92 $848.92 $0.00 $696.70 "$1,103.57" "$1,114.72" $0.00 $0.00 $211.72 $0.00 $0.00 $221.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.246 SUP HCPCS C1713 02.161.246 - PLATE BONE NARROW 16 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,613.73 " "$1,194.16" $0.00 "$1,253.38" $705.03 $705.03 $0.00 $0.00 $0.00 $336.34 "$1,197.71" "$1,197.71" $0.00 $0.00 $336.30 $0.00 $954.52 $954.52 $0.00 $783.36 "$1,240.85" "$1,253.38" $0.00 $0.00 $238.05 $0.00 $0.00 $249.42 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.248 SUP HCPCS C1713 02.161.248 - PLATE BONE NARROW 18 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$1,969.38 " "$1,457.34" $0.00 "$1,529.62" $860.41 $860.41 $0.00 $0.00 $0.00 $410.47 "$1,461.67" "$1,461.67" $0.00 $0.00 $410.42 $0.00 "$1,164.89" "$1,164.89" $0.00 $956.01 "$1,514.33" "$1,529.62" $0.00 $0.00 $290.51 $0.00 $0.00 $304.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.250 SUP HCPCS C1713 02.161.250 - PLATE BONE NARROW 20 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$2,329.23 " "$1,723.63" $0.00 "$1,809.12" "$1,017.63" "$1,017.63" $0.00 $0.00 $0.00 $485.47 "$1,728.75" "$1,728.75" $0.00 $0.00 $485.41 $0.00 "$1,377.74" "$1,377.74" $0.00 "$1,130.70" "$1,791.03" "$1,809.12" $0.00 $0.00 $343.60 $0.00 $0.00 $360.01 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.252 SUP HCPCS C1713 02.161.252 - PLATE BONE NARROW 22 HOLE CVD LCP STAINLESS STEEL NONSTRL BOTH IP/OP "$2,597.73 " "$1,922.32" $0.00 "$2,017.64" "$1,134.92" "$1,134.92" $0.00 $0.00 $0.00 $541.43 "$1,928.03" "$1,928.03" $0.00 $0.00 $541.37 $0.00 "$1,280.68" "$1,280.68" $0.00 "$1,261.03" "$1,997.46" "$2,017.64" $0.00 $0.00 $383.21 $0.00 $0.00 $401.51 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.270 SUP HCPCS C1713 02.161.270 - PLATE BONE BROAD 10 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP $889.80 $658.45 $0.00 $691.10 $388.74 $388.74 $0.00 $0.00 $0.00 $185.46 $660.41 $660.41 $0.00 $0.00 $185.43 $0.00 $526.32 $526.32 $0.00 $431.94 $684.19 $691.10 $0.00 $0.00 $131.26 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.272 SUP HCPCS C1713 02.161.272 - PLATE BONE BROAD CVD 12 HOLE LCP STAINLESS STEEL TIBIA BOTH IP/OP "$1,156.88 " $856.09 $0.00 $898.56 $505.44 $505.44 $0.00 $0.00 $0.00 $241.12 $858.63 $858.63 $0.00 $0.00 $241.09 $0.00 $684.29 $684.29 $0.00 $561.60 $889.57 $898.56 $0.00 $0.00 $170.66 $0.00 $0.00 $178.81 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.274 SUP HCPCS C1713 02.161.274 - PLATE BONE BROAD 14 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP "$1,241.23 " $918.51 $0.00 $964.06 $542.28 $542.28 $0.00 $0.00 $0.00 $258.70 $921.24 $921.24 $0.00 $0.00 $258.67 $0.00 $734.18 $734.18 $0.00 $602.54 $954.42 $964.06 $0.00 $0.00 $183.10 $0.00 $0.00 $191.85 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.276 SUP HCPCS C1713 02.161.276 - PLATE BN BRD CRV NS LCP CMBN 16 HL LMT CNTCT TPR END SS BOTH IP/OP "$1,341.03 " $992.36 $0.00 "$1,041.58" $585.89 $585.89 $0.00 $0.00 $0.00 $279.50 $995.31 $995.31 $0.00 $0.00 $279.47 $0.00 $793.22 $793.22 $0.00 $650.99 "$1,031.17" "$1,041.58" $0.00 $0.00 $197.82 $0.00 $0.00 $207.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.278 SUP HCPCS C1713 02.161.278 - PLATE BONE BROAD 18 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP "$1,509.73 " "$1,117.20" $0.00 "$1,172.60" $659.59 $659.59 $0.00 $0.00 $0.00 $314.66 "$1,120.52" "$1,120.52" $0.00 $0.00 $314.63 $0.00 $893.00 $893.00 $0.00 $732.88 "$1,160.87" "$1,172.60" $0.00 $0.00 $222.71 $0.00 $0.00 $233.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.280 SUP HCPCS C1713 02.161.280 - PLATE BONE BROAD 20 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP "$1,608.10 " "$1,189.99" $0.00 "$1,249.02" $702.57 $702.57 $0.00 $0.00 $0.00 $335.17 "$1,193.53" "$1,193.53" $0.00 $0.00 $335.13 $0.00 $951.19 $951.19 $0.00 $780.64 "$1,236.53" "$1,249.02" $0.00 $0.00 $237.22 $0.00 $0.00 $248.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.282 SUP HCPCS C1713 02.161.282 - PLATE BONE BROAD 22 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.284 SUP HCPCS C1713 02.161.284 - PLATE BONE BROAD 24 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.286 SUP HCPCS C1713 02.161.286 - PLATE BONE BROAD 26 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP "$1,795.08 " "$1,328.36" $0.00 "$1,394.22" $784.25 $784.25 $0.00 $0.00 $0.00 $374.14 "$1,332.30" "$1,332.30" $0.00 $0.00 $374.09 $0.00 "$1,061.79" "$1,061.79" $0.00 $871.39 "$1,380.28" "$1,394.22" $0.00 $0.00 $264.80 $0.00 $0.00 $277.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.288 SUP HCPCS C1713 02.161.288 - PLATE BONE BROAD 28 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP "$1,973.60 " "$1,460.46" $0.00 "$1,532.88" $862.25 $862.25 $0.00 $0.00 $0.00 $411.35 "$1,464.81" "$1,464.81" $0.00 $0.00 $411.30 $0.00 "$1,167.38" "$1,167.38" $0.00 $958.05 "$1,517.55" "$1,532.88" $0.00 $0.00 $291.14 $0.00 $0.00 $305.04 $0.00 $0.00 $0.00 $0.00 $0.00 02.161.290 SUP HCPCS C1713 02.161.290 - PLATE BONE BROAD 30 HOLE CVD LCP STAINLESS STEEL NONSTRL 3.5 BOTH IP/OP "$2,153.53 " "$1,593.61" $0.00 "$1,672.64" $940.86 $940.86 $0.00 $0.00 $0.00 $448.85 "$1,598.35" "$1,598.35" $0.00 $0.00 $448.79 $0.00 "$1,273.81" "$1,273.81" $0.00 "$1,045.40" "$1,655.91" "$1,672.64" $0.00 $0.00 $317.68 $0.00 $0.00 $332.86 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.003 SUP HCPCS C1713 02.200.003 - PLUG PLT 3.5MM NS LCP THRD STRDR RCS SS LOPRFL PLVC SYS BOTH IP/OP $203.83 $150.83 $0.00 $158.32 $89.06 $89.06 $0.00 $0.00 $0.00 $42.48 $151.28 $151.28 $0.00 $0.00 $42.48 $0.00 $120.56 $120.56 $0.00 $98.95 $156.74 $158.32 $0.00 $0.00 $30.07 $0.00 $0.00 $31.51 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.010 SUP HCPCS C1713 02.200.010 - SCREW BONE T15 LP 3.5MM 6MM 10MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.012 SUP HCPCS C1713 02.200.012 - SCREW BONE FULTHD 3.5MM 6MM 12MM T15 STARDRIVE SELF TAP LP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.014 SUP HCPCS C1713 02.200.014 - SCREW BONE T15 LP 3.5MM 6MM 14MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.016 SUP HCPCS C1713 02.200.016 - SCREW BONE T15 LP 3.5MM 6MM 16MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.018 SUP HCPCS C1713 02.200.018 - SCREW BONE T15 LP 3.5MM 6MM 18MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.020 SUP HCPCS C1713 02.200.020 - SCREW BONE FULTHD 3.5MM 20MM T15 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.022 SUP HCPCS C1713 02.200.022 - SCREW BONE T15 LP 3.5MM 6MM 22MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.024 SUP HCPCS C1713 02.200.024 - SCREW BONE T15 LP 3.5MM 6MM 24MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.026 SUP HCPCS C1713 02.200.026 - SCREW BONE T15 LP 3.5MM 6MM 26MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.028 SUP HCPCS C1713 02.200.028 - SCREW BONE T15 LP 3.5MM 6MM 28MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.030 SUP HCPCS C1713 02.200.030 - SCREW BONE FULTHD 3.5MM 6MM 30MM T15 STARDRIVE RECESS SLFTAP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.032 SUP HCPCS C1713 02.200.032 - SCREW BONE T15 LP 3.5MM 6MM 32MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.034 SUP HCPCS C1713 02.200.034 - SCREW BONE T15 LP 3.5MM 6MM 34MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.036 SUP HCPCS C1713 02.200.036 - SCREW BONE T15 LP 3.5MM 6MM 36MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.038 SUP HCPCS C1713 02.200.038 - SCREW BONE FULTHD LP 3.5MM 6MM 38MM SELF TAP T15 STARDRIVE BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.040 SUP HCPCS C1713 02.200.040 - SCREW BONE T15 LP 3.5MM 6MM 40MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.042 SUP HCPCS C1713 02.200.042 - SCREW BONE T15 LP 3.5MM 6MM 42MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.044 SUP HCPCS C1713 02.200.044 - SCREW BONE T15 LP 3.5MM 6MM 44MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.045 SUP HCPCS C1713 02.200.045 - SCREW BONE 3.5MM 45MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.046 SUP HCPCS C1713 02.200.046 - SCREW BONE T15 LP 3.5MM 6MM 46MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.048 SUP HCPCS C1713 02.200.048 - SCREW BONE 3.5MM 48MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.050 SUP HCPCS C1713 02.200.050 - SCREW BONE T15 LP 3.5MM 6MM 50MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.055 SUP HCPCS C1713 02.200.055 - SCREW BONE T15 LP 3.5MM 6MM 55MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.060 SUP HCPCS C1713 02.200.060 - SCREW BONE 3.5MM 60MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.065 SUP HCPCS C1713 02.200.065 - SCREW BONE 3.5MM 65MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.070 SUP HCPCS C1713 02.200.070 - SCREW BONE 3.5MM 70MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.075 SUP HCPCS C1713 02.200.075 - SCREW BONE 3.5MM 75MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.080 SUP HCPCS C1713 02.200.080 - SCREW BONE 3.5MM 80MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.085 SUP HCPCS C1713 02.200.085 - SCREW BONE T15 LP 3.5MM 6MM 85MM SELF TAP STARDRIVE LCP BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.090 SUP HCPCS C1713 02.200.090 - SCREW BONE 3.5MM 90MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.095 SUP HCPCS C1713 02.200.095 - SCREW BONE 3.5MM 95MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.100 SUP HCPCS C1713 02.200.100 - SCREW BONE 3.5MM 100MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $59.05 $43.70 $0.00 $45.86 $25.80 $25.80 $0.00 $0.00 $0.00 $12.31 $43.83 $43.83 $0.00 $0.00 $12.31 $0.00 $34.93 $34.93 $0.00 $28.66 $45.41 $45.86 $0.00 $0.00 $8.71 $0.00 $0.00 $9.13 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.105 SUP HCPCS C1713 02.200.105 - SCREW BONE 3.5MM 105MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $59.05 $43.70 $0.00 $45.86 $25.80 $25.80 $0.00 $0.00 $0.00 $12.31 $43.83 $43.83 $0.00 $0.00 $12.31 $0.00 $34.93 $34.93 $0.00 $28.66 $45.41 $45.86 $0.00 $0.00 $8.71 $0.00 $0.00 $9.13 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.110 SUP HCPCS C1713 02.200.110 - SCREW BONE 3.5MM 110MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $59.05 $43.70 $0.00 $45.86 $25.80 $25.80 $0.00 $0.00 $0.00 $12.31 $43.83 $43.83 $0.00 $0.00 $12.31 $0.00 $34.93 $34.93 $0.00 $28.66 $45.41 $45.86 $0.00 $0.00 $8.71 $0.00 $0.00 $9.13 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.115 SUP HCPCS C1713 02.200.115 - SCREW BONE 3.5MM 115MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $59.05 $43.70 $0.00 $45.86 $25.80 $25.80 $0.00 $0.00 $0.00 $12.31 $43.83 $43.83 $0.00 $0.00 $12.31 $0.00 $34.93 $34.93 $0.00 $28.66 $45.41 $45.86 $0.00 $0.00 $8.71 $0.00 $0.00 $9.13 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.120 SUP HCPCS C1713 02.200.120 - SCREW BONE 3.5MM 120MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $59.05 $43.70 $0.00 $45.86 $25.80 $25.80 $0.00 $0.00 $0.00 $12.31 $43.83 $43.83 $0.00 $0.00 $12.31 $0.00 $34.93 $34.93 $0.00 $28.66 $45.41 $45.86 $0.00 $0.00 $8.71 $0.00 $0.00 $9.13 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.125 SUP HCPCS C1713 02.200.125 - SCREW BONE 3.5MM 125MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $59.05 $43.70 $0.00 $45.86 $25.80 $25.80 $0.00 $0.00 $0.00 $12.31 $43.83 $43.83 $0.00 $0.00 $12.31 $0.00 $34.93 $34.93 $0.00 $28.66 $45.41 $45.86 $0.00 $0.00 $8.71 $0.00 $0.00 $9.13 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.130 SUP HCPCS C1713 02.200.130 - SCREW BONE 3.5MM 130MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $191.18 $141.47 $0.00 $148.48 $83.52 $83.52 $0.00 $0.00 $0.00 $39.85 $141.89 $141.89 $0.00 $0.00 $39.84 $0.00 $113.08 $113.08 $0.00 $92.80 $147.00 $148.48 $0.00 $0.00 $28.20 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.135 SUP HCPCS C1713 02.200.135 - SCREW BONE 3.5MM 135MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $191.18 $141.47 $0.00 $148.48 $83.52 $83.52 $0.00 $0.00 $0.00 $39.85 $141.89 $141.89 $0.00 $0.00 $39.84 $0.00 $113.08 $113.08 $0.00 $92.80 $147.00 $148.48 $0.00 $0.00 $28.20 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.140 SUP HCPCS C1713 02.200.140 - SCREW BONE 3.5MM 140MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $191.18 $141.47 $0.00 $148.48 $83.52 $83.52 $0.00 $0.00 $0.00 $39.85 $141.89 $141.89 $0.00 $0.00 $39.84 $0.00 $113.08 $113.08 $0.00 $92.80 $147.00 $148.48 $0.00 $0.00 $28.20 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.145 SUP HCPCS C1713 02.200.145 - SCREW BONE 3.5MM 145MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $191.18 $141.47 $0.00 $148.48 $83.52 $83.52 $0.00 $0.00 $0.00 $39.85 $141.89 $141.89 $0.00 $0.00 $39.84 $0.00 $113.08 $113.08 $0.00 $92.80 $147.00 $148.48 $0.00 $0.00 $28.20 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.200.150 SUP HCPCS C1713 02.200.150 - SCREW BONE 3.5MM 150MM SLFTAP LP STARDRIVE RECESS STAINLESS BOTH IP/OP $191.18 $141.47 $0.00 $148.48 $83.52 $83.52 $0.00 $0.00 $0.00 $39.85 $141.89 $141.89 $0.00 $0.00 $39.84 $0.00 $113.08 $113.08 $0.00 $92.80 $147.00 $148.48 $0.00 $0.00 $28.20 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.014 SUP HCPCS C1713 02.204.014 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 14MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.016 SUP HCPCS C1713 02.204.016 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 16MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.018 SUP HCPCS C1713 02.204.018 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 18MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.020 SUP HCPCS C1713 02.204.020 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 20MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.022 SUP HCPCS C1713 02.204.022 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 22MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.024 SUP HCPCS C1713 02.204.024 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 24MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.026 SUP HCPCS C1713 02.204.026 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 26MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.028 SUP HCPCS C1713 02.204.028 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 28MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.030 SUP HCPCS C1713 02.204.030 - SCREW BONE FULTHD 4MM 30MM T25 STARDRIVE RECESS SLFTAP TIP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.032 SUP HCPCS C1713 02.204.032 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 32MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.034 SUP HCPCS C1713 02.204.034 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 34MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.036 SUP HCPCS C1713 02.204.036 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 36MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.038 SUP HCPCS C1713 02.204.038 - SCREW BONE FULTHD 4MM 38MM T25 STARDRIVE SELF TAP TIP LOCK BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.040 SUP HCPCS C1713 02.204.040 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 40MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.042 SUP HCPCS C1713 02.204.042 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 42MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.044 SUP HCPCS C1713 02.204.044 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 44MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.046 SUP HCPCS C1713 02.204.046 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 46MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.048 SUP HCPCS C1713 02.204.048 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 48MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.050 SUP HCPCS C1713 02.204.050 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 50MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.052 SUP HCPCS C1713 02.204.052 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 52MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.054 SUP HCPCS C1713 02.204.054 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 54MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.056 SUP HCPCS C1713 02.204.056 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 56MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.058 SUP HCPCS C1713 02.204.058 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 58MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.060 SUP HCPCS C1713 02.204.060 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 60MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.062 SUP HCPCS C1713 02.204.062 - SCREW BONE T25 FULTHD CONE 4MM 3.4MM 62MM FIX ANGLE SELF TAP BOTH IP/OP $269.90 $199.73 $0.00 $209.62 $117.91 $117.91 $0.00 $0.00 $0.00 $56.25 $200.32 $200.32 $0.00 $0.00 $56.25 $0.00 $159.65 $159.65 $0.00 $131.01 $207.53 $209.62 $0.00 $0.00 $39.81 $0.00 $0.00 $41.71 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.420 SUP HCPCS C1713 02.204.420 - SCREW BONE 4MM 20MM LOCK STAINLESS STEEL PERIARTICULAR BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.424 SUP HCPCS C1713 02.204.424 - SCREW BONE 4MM 24MM LOCK STAINLESS STEEL PERIARTICULAR BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.428 SUP HCPCS C1713 02.204.428 - SCREW BONE 4MM 3.4MM 28MM LOCKING SLFTAP TIP THREADED BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.432 SUP HCPCS C1713 02.204.432 - SCREW BONE 4MM 32MM LOCKING SLFTAP TIP THREADED CONICAL HEAD BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.436 SUP HCPCS C1713 02.204.436 - SCREW BONE 4MM 36MM LOCKING SLFTAP TIP THREADED CONICAL HEAD BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.440 SUP HCPCS C1713 02.204.440 - SCREW BONE 4MM 40MM LOCKING SLFTAP TIP THREADED CONICAL HEAD BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.444 SUP HCPCS C1713 02.204.444 - SCREW BONE 4MM 44MM LOCKING SLFTAP TIP THREADED CONICAL HEAD BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.448 SUP HCPCS C1713 02.204.448 - SCREW BONE 4MM 48MM LOCKING HEX RECESS STAINLESS STEEL BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.452 SUP HCPCS C1713 02.204.452 - SCREW BONE 4MM 52MM LOCKING HEX RECESS STAINLESS STEEL BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.456 SUP HCPCS C1713 02.204.456 - SCREW BONE 4MM 56MM LOCKING HEX RECESS STAINLESS STEEL BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.204.460 SUP HCPCS C1713 02.204.460 - SCREW BONE 4MM 60MM LOCKING HEX RECESS STAINLESS STEEL BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.025 SUP HCPCS C1713 02.205.025 - SCREW BONE 4MM FULTHD 5MM 4.4MM 25MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.030 SUP HCPCS C1713 02.205.030 - SCREW BONE 4MM FULTHD 5MM 4.4MM 30MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.035 SUP HCPCS C1713 02.205.035 - SCREW BONE 4MM FULTHD 5MM 4.4MM 35MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.040 SUP HCPCS C1713 02.205.040 - SCREW BONE 4MM FULTHD 5MM 4.4MM 40MM CANN LOCKING SLFDRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.045 SUP HCPCS C1713 02.205.045 - SCREW BONE 4MM FULTHD 5MM 4.4MM 45MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.050 SUP HCPCS C1713 02.205.050 - SCREW BONE 4MM FULTHD 5MM 4.4MM 50MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.055 SUP HCPCS C1713 02.205.055 - SCREW BONE 4MM FULTHD 5MM 4.4MM 55MM CANN LOCK DRILL SELF BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.060 SUP HCPCS C1713 02.205.060 - SCREW BONE 4MM FULTHD 5MM 4.4MM 60MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.065 SUP HCPCS C1713 02.205.065 - SCREW BONE 4MM FULTHD 5MM 4.4MM 65MM CANN LOCK DRILL SELF BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.070 SUP HCPCS C1713 02.205.070 - SCREW BONE 4MM FULTHD 5MM 4.4MM 70MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.075 SUP HCPCS C1713 02.205.075 - SCREW BONE 4MM FULTHD 5MM 4.4MM 75MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.080 SUP HCPCS C1713 02.205.080 - SCREW BONE 4MM FULTHD 5MM 4.4MM 80MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.085 SUP HCPCS C1713 02.205.085 - SCREW BONE 4MM FULTHD 5MM 4.4MM 85MM CANN LOCKING SLFDRILL BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.090 SUP HCPCS C1713 02.205.090 - SCREW BONE 4MM FULTHD 5MM 4.4MM 90MM SELF DRILL SELF TAP BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.095 SUP HCPCS C1713 02.205.095 - SCREW BONE 4MM FULTHD 5MM 4.4MM 95MM CANN LOCK DRILL SELF BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.100 SUP HCPCS C1713 02.205.100 - SCREW BONE FULTHD 5MM 100MM SELF TAP SELF DRILL CANN LOCK BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.105 SUP HCPCS C1713 02.205.105 - SCREW BONE FULTHD 5MM 105MM SELF TAP SELF DRILL CANN LOCK BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.110 SUP HCPCS C1713 02.205.110 - SCREW BONE 4MM FULTHD 5MM 4.4MM 110MM SELF DRILL SELF TAP BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.115 SUP HCPCS C1713 02.205.115 - SCREW BONE FULTHD 5MM 115MM SELF TAP TIP SELF DRILL CANN BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.120 SUP HCPCS C1713 02.205.120 - SCREW BONE FULTHD 5MM 120MM SELF TAP SELF DRILL CANN LOCK BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.125 SUP HCPCS C1713 02.205.125 - SCREW BONE FULTHD 5MM 125MM SELF TAP SELF DRILL CANN LOCK BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.130 SUP HCPCS C1713 02.205.130 - SCREW BONE FULTHD 5MM 130MM SELF TAP SELF DRILL CANN LOCK BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.135 SUP HCPCS C1713 02.205.135 - SCREW BONE FULTHD 5MM 135MM SELF TAP SELF DRILL CANN LOCK BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.140 SUP HCPCS C1713 02.205.140 - SCREW BONE FULTHD 5MM 140MM SELF TAP SELF DRILL CANN LOCK BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.145 SUP HCPCS C1713 02.205.145 - SCREW BONE 4MM FULTHD 5MM 4.4MM 145MM SELF DRILL SELF TAP BOTH IP/OP $379.53 $280.85 $0.00 $294.78 $165.81 $165.81 $0.00 $0.00 $0.00 $79.10 $281.68 $281.68 $0.00 $0.00 $79.09 $0.00 $224.49 $224.49 $0.00 $184.24 $291.84 $294.78 $0.00 $0.00 $55.99 $0.00 $0.00 $58.66 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.240 SUP HCPCS C1713 02.205.240 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 40MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.245 SUP HCPCS C1713 02.205.245 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 45MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.250 SUP HCPCS C1713 02.205.250 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 50MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.255 SUP HCPCS C1713 02.205.255 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 55MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.260 SUP HCPCS C1713 02.205.260 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 60MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.265 SUP HCPCS C1713 02.205.265 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 65MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.270 SUP HCPCS C1713 02.205.270 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 70MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.275 SUP HCPCS C1713 02.205.275 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 75MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.280 SUP HCPCS C1713 02.205.280 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 80MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.285 SUP HCPCS C1713 02.205.285 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 85MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.290 SUP HCPCS C1713 02.205.290 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 90MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.205.295 SUP HCPCS C1713 02.205.295 - SCREW BONE 4MM PTHRD CONE HEXAGON 5MM 4.4MM 95MM SELF DRILL BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 02.206.214 SUP HCPCS C1713 02.206.214 - SCREW BONE T15 3.5MM 14MM LP HEAD STARDRIVE SELF TAP TIP BOTH IP/OP $67.48 $49.94 $0.00 $52.40 $29.48 $29.48 $0.00 $0.00 $0.00 $14.06 $50.08 $50.08 $0.00 $0.00 $14.06 $0.00 $39.91 $39.91 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $9.95 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.206.216 SUP HCPCS C1713 02.206.216 - SCREW BONE T15 3.5MM 16MM SELF TAP LP STARDRIVE STAINLESS BOTH IP/OP $67.48 $49.94 $0.00 $52.40 $29.48 $29.48 $0.00 $0.00 $0.00 $14.06 $50.08 $50.08 $0.00 $0.00 $14.06 $0.00 $39.91 $39.91 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $9.95 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.206.218 SUP HCPCS C1713 02.206.218 - SCREW BONE T15 LP 3.5MM 18MM SELF TAP STAINLESS STEEL BOTH IP/OP $67.48 $49.94 $0.00 $52.40 $29.48 $29.48 $0.00 $0.00 $0.00 $14.06 $50.08 $50.08 $0.00 $0.00 $14.06 $0.00 $39.91 $39.91 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $9.95 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.206.228 SUP HCPCS C1713 02.206.228 - SCREW BONE T15 3.5MM 28MM LP HEAD STARDRIVE SELF TAP TIP BOTH IP/OP $67.48 $49.94 $0.00 $52.40 $29.48 $29.48 $0.00 $0.00 $0.00 $14.06 $50.08 $50.08 $0.00 $0.00 $14.06 $0.00 $39.91 $39.91 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $9.95 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.206.230 SUP Custom 27203010 02.206.230 - SCREW BONE 3.5MM 30MM LCP SS MIDFT HINDFOOT TIB BOTH IP/OP $67.48 $49.94 $0.00 $52.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.08 $50.08 $0.00 $0.00 $14.06 $0.00 $0.00 $0.00 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.206.232 SUP HCPCS C1713 02.206.232 - SCREW BONE 3.5MM 32MM SS T15 LP CLVCL FEM HUM TIB BOTH IP/OP $67.48 $49.94 $0.00 $52.40 $29.48 $29.48 $0.00 $0.00 $0.00 $14.06 $50.08 $50.08 $0.00 $0.00 $14.06 $0.00 $39.91 $39.91 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $9.95 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.206.238 SUP HCPCS C1713 02.206.238 - SCREW BONE T15 3.5MM 38MM LP HEAD STARDRIVE SELF TAP TIP BOTH IP/OP $67.48 $49.94 $0.00 $52.40 $29.48 $29.48 $0.00 $0.00 $0.00 $14.06 $50.08 $50.08 $0.00 $0.00 $14.06 $0.00 $39.91 $39.91 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $9.95 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.206.240 SUP HCPCS C1713 02.206.240 - SCREW BONE 3.5MM 40MM SELF TAP LP HEAD TI5 STARDRIVE LCP BOTH IP/OP $67.48 $49.94 $0.00 $52.40 $29.48 $29.48 $0.00 $0.00 $0.00 $14.06 $50.08 $50.08 $0.00 $0.00 $14.06 $0.00 $39.91 $39.91 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $9.95 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.001 SUP HCPCS C1769 02.207.001 - GUIDEWIRE ORTHOPEDIC FLUTE 2.8MM 450MM NONSTRL BOTH IP/OP $167.28 $123.79 $0.00 $129.92 $88.18 $88.18 $0.00 $0.00 $0.00 $34.86 $124.15 $124.15 $0.00 $0.00 $34.86 $0.00 $98.94 $98.94 $0.00 $81.20 $128.62 $129.92 $0.00 $0.00 $24.68 $0.00 $0.00 $25.85 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.020 SUP HCPCS C1713 02.207.020 - SCREW BONE 4MM FULTHD 7.3MM 5MM 20MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.025 SUP HCPCS C1713 02.207.025 - SCREW BONE 4MM FULTHD 7.3MM 5MM 25MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.030 SUP HCPCS C1713 02.207.030 - SCREW BONE 4MM FULTHD 7.3MM 5MM 30MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.035 SUP HCPCS C1713 02.207.035 - SCREW BONE 4MM FULTHD 7.3MM 5MM 35MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.040 SUP HCPCS C1713 02.207.040 - SCREW BONE 4MM FULTHD 7.3MM 5MM 40MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.045 SUP HCPCS C1713 02.207.045 - SCREW BONE 4MM FULTHD 7.3MM 5MM 45MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.050 SUP HCPCS C1713 02.207.050 - SCREW BONE 4MM FULTHD 7.3MM 5MM 50MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.055 SUP HCPCS C1713 02.207.055 - SCREW BONE 4MM FULTHD 7.3MM 5MM 55MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.060 SUP HCPCS C1713 02.207.060 - SCREW BONE 4MM FULTHD 7.3MM 5MM 60MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.065 SUP HCPCS C1713 02.207.065 - SCREW BONE 4MM FULTHD 7.3MM 5MM 65MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.070 SUP HCPCS C1713 02.207.070 - SCREW BONE 4MM FULTHD 7.3MM 5MM 70MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.075 SUP HCPCS C1713 02.207.075 - SCREW BONE 4MM FULTHD 7.3MM 5MM 75MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.080 SUP HCPCS C1713 02.207.080 - SCREW BONE 4MM FULTHD 7.3MM 5MM 80MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.085 SUP HCPCS C1713 02.207.085 - SCREW BONE 4MM FULTHD 7.3MM 5MM 85MM SLFTAP TIP SLFDRILL BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.090 SUP HCPCS C1713 02.207.090 - SCREW BONE 4MM FULTHD 7.3MM 5MM 90MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.095 SUP HCPCS C1713 02.207.095 - SCREW BONE 4MM FULTHD 7.3MM 5MM 95MM SELF DRILL SELF TAP BOTH IP/OP $546.83 $404.65 $0.00 $424.72 $238.91 $238.91 $0.00 $0.00 $0.00 $113.97 $405.85 $405.85 $0.00 $0.00 $113.96 $0.00 $323.45 $323.45 $0.00 $265.45 $420.47 $424.72 $0.00 $0.00 $80.66 $0.00 $0.00 $84.52 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.100 SUP HCPCS C1713 02.207.100 - SCREW BONE 4MM FULTHD 7.3MM 5MM 100MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.105 SUP HCPCS C1713 02.207.105 - SCREW BONE 4MM FULTHD 7.3MM 5MM 105MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.110 SUP HCPCS C1713 02.207.110 - SCREW BONE 4MM FULTHD 7.3MM 5MM 110MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.115 SUP HCPCS C1713 02.207.115 - SCREW BONE 4MM FULTHD 7.3MM 5MM 115MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.120 SUP HCPCS C1713 02.207.120 - SCREW BONE 4MM FULTHD 7.3MM 5MM 120MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.125 SUP HCPCS C1713 02.207.125 - SCREW BONE 4MM FULTHD 7.3MM 5MM 125MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.130 SUP HCPCS C1713 02.207.130 - SCREW BONE 4MM FULTHD 7.3MM 5MM 130MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.135 SUP HCPCS C1713 02.207.135 - SCREW BONE 4MM FULTHD 7.3MM 5MM 135MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.140 SUP HCPCS C1713 02.207.140 - SCREW BONE 4MM FULTHD 7.3MM 5MM 140MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.145 SUP HCPCS C1713 02.207.145 - SCREW BONE 4MM FULTHD 7.3MM 5MM 145MM SELF DRILL SELF TAP BOTH IP/OP $559.48 $414.02 $0.00 $434.54 $244.43 $244.43 $0.00 $0.00 $0.00 $116.61 $415.24 $415.24 $0.00 $0.00 $116.59 $0.00 $330.93 $330.93 $0.00 $271.59 $430.20 $434.54 $0.00 $0.00 $82.53 $0.00 $0.00 $86.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.250 SUP HCPCS C1713 02.207.250 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 50MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.255 SUP HCPCS C1713 02.207.255 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 55MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.260 SUP HCPCS C1713 02.207.260 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 60MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.265 SUP HCPCS C1713 02.207.265 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 65MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.270 SUP HCPCS C1713 02.207.270 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 70MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.275 SUP HCPCS C1713 02.207.275 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 75MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.280 SUP HCPCS C1713 02.207.280 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 80MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.285 SUP HCPCS C1713 02.207.285 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 85MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.290 SUP HCPCS C1713 02.207.290 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 90MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.295 SUP HCPCS C1713 02.207.295 - SCREW BONE 4MM FULTHD CONE HEXAGON 7.3MM 5MM 95MM SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.450 SUP HCPCS C1713 02.207.450 - SCREW BONE CONICAL PTHRD 7.3MM 5MM 50MM SELF TAP SELF DRILL BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.455 SUP HCPCS C1713 02.207.455 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 55MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.460 SUP HCPCS C1713 02.207.460 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 60MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.465 SUP HCPCS C1713 02.207.465 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 65MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.470 SUP HCPCS C1713 02.207.470 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 70MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.475 SUP HCPCS C1713 02.207.475 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 75MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.480 SUP HCPCS C1713 02.207.480 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 80MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.485 SUP HCPCS C1713 02.207.485 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 85MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.490 SUP HCPCS C1713 02.207.490 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 90MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.495 SUP HCPCS C1713 02.207.495 - SCREW BONE 95D PTHRD CONE 7.3MM 5MM 95MM SELF DRILL SELF TAP BOTH IP/OP $487.78 $360.96 $0.00 $378.86 $213.11 $213.11 $0.00 $0.00 $0.00 $101.66 $362.03 $362.03 $0.00 $0.00 $101.65 $0.00 $288.52 $288.52 $0.00 $236.79 $375.08 $378.86 $0.00 $0.00 $71.95 $0.00 $0.00 $75.39 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.500 SUP HCPCS C1713 02.207.500 - SCREW BONE PTHRD 7.3MM 100MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.505 SUP HCPCS C1713 02.207.505 - SCREW BONE PTHRD 7.3MM 105MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.510 SUP HCPCS C1713 02.207.510 - SCREW BONE PTHRD 7.3MM 110MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.515 SUP HCPCS C1713 02.207.515 - SCREW BONE PTHRD 7.3MM 115MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.520 SUP HCPCS C1713 02.207.520 - SCREW BONE PTHRD 7.3MM 120MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.525 SUP HCPCS C1713 02.207.525 - SCREW BONE PTHRD 7.3MM 125MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.530 SUP HCPCS C1713 02.207.530 - SCREW BONE PTHRD 7.3MM 130MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.535 SUP HCPCS C1713 02.207.535 - SCREW BONE PTHRD 7.3MM 135MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.540 SUP HCPCS C1713 02.207.540 - SCREW BONE PTHRD 7.3MM 140MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.545 SUP HCPCS C1713 02.207.545 - SCREW BONE PTHRD 7.3MM 145MM CANN SMOOTH CONICAL HEAD BOTH IP/OP $518.70 $383.84 $0.00 $402.88 $226.62 $226.62 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.80 $398.85 $402.88 $0.00 $0.00 $76.52 $0.00 $0.00 $80.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.600 SUP HCPCS C1713 02.207.600 - SCREW BONE 7.3MM 45MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.601 SUP HCPCS C1713 02.207.601 - SCREW BONE 7.3MM 50MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.602 SUP HCPCS C1713 02.207.602 - SCREW BONE 7.3MM 55MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.603 SUP HCPCS C1713 02.207.603 - SCREW BONE 7.3MM 60MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.604 SUP HCPCS C1713 02.207.604 - SCREW BONE 7.3MM 65MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.605 SUP HCPCS C1713 02.207.605 - SCREW BONE 7.3MM 70MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.606 SUP HCPCS C1713 02.207.606 - SCREW BONE 7.3MM 75MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.607 SUP HCPCS C1713 02.207.607 - SCREW BONE 7.3MM 80MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.608 SUP HCPCS C1713 02.207.608 - SCREW BONE 7.3MM 85MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.609 SUP HCPCS C1713 02.207.609 - SCREW BONE 7.3MM 90MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.610 SUP HCPCS C1713 02.207.610 - SCREW BONE 7.3MM 95MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.611 SUP HCPCS C1713 02.207.611 - SCREW BONE 7.3MM 100MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.612 SUP HCPCS C1713 02.207.612 - SCREW BONE 7.3MM 105MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.613 SUP HCPCS C1713 02.207.613 - SCREW BONE 7.3MM 110MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.614 SUP HCPCS C1713 02.207.614 - SCREW BONE 7.3MM 115MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.615 SUP HCPCS C1713 02.207.615 - SCREW BONE 7.3MM 120MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.616 SUP HCPCS C1713 02.207.616 - SCREW BONE 7.3MM 125MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.617 SUP HCPCS C1713 02.207.617 - SCREW BONE 7.3MM 103MM 10MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.618 SUP HCPCS C1713 02.207.618 - SCREW BONE 7.3MM 45MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.619 SUP HCPCS C1713 02.207.619 - SCREW BONE 7.3MM 50MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.620 SUP HCPCS C1713 02.207.620 - SCREW BONE 7.3MM 55MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.621 SUP HCPCS C1713 02.207.621 - SCREW BONE 7.3MM 60MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.622 SUP HCPCS C1713 02.207.622 - SCREW BONE 7.3MM 65MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.623 SUP HCPCS C1713 02.207.623 - SCREW BONE 7.3MM 70MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.624 SUP HCPCS C1713 02.207.624 - SCREW BONE 7.3MM 75MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.625 SUP HCPCS C1713 02.207.625 - SCREW BONE 7.3MM 80MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.626 SUP HCPCS C1713 02.207.626 - SCREW BONE 7.3MM 85MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.627 SUP HCPCS C1713 02.207.627 - SCREW BONE 7.3MM 90MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.628 SUP HCPCS C1713 02.207.628 - SCREW BONE 7.3MM 95MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.629 SUP HCPCS C1713 02.207.629 - SCREW BONE 7.3MM 100MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.630 SUP HCPCS C1713 02.207.630 - SCREW BONE 7.3MM 105MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.631 SUP HCPCS C1713 02.207.631 - SCREW BONE 7.3MM 110MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.632 SUP HCPCS C1713 02.207.632 - SCREW BONE 7.3MM 115MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.633 SUP HCPCS C1713 02.207.633 - SCREW BONE 7.3MM 120MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.634 SUP HCPCS C1713 02.207.634 - SCREW BONE 7.3MM 125MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.635 SUP HCPCS C1713 02.207.635 - SCREW BONE 7.3MM 130MM 20MM CANN THREADED SCFE STAINLESS BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.636 SUP Custom 27803010 02.207.636 - WASHER ORTHOPEDIC OVAL 1MM STAINLESS STEEL FEMUR NONSTRL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.207.637 SUP Custom 27803010 02.207.637 - WASHER ORTHOPEDIC OVAL 2MM STAINLESS STEEL FEMUR NONSTRL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.078 SUP HCPCS C1713 02.210.078 - PIN FIX 1.8MM 8MM T8 STARDRIVE RECESS VAR ANG LOCKING BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.080 SUP HCPCS C1713 02.210.080 - PIN FIX 1.8MM 10MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.082 SUP HCPCS C1713 02.210.082 - PIN FIX 1.8MM 12MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.084 SUP HCPCS C1713 02.210.084 - PIN FIX 1.8MM 14MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.086 SUP Custom 27203010 02.210.086 - PIN FIX 1.8MM 16MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $0.00 $0.00 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.088 SUP Custom 27203010 02.210.088 - PIN FIX 1.8MM 18MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $0.00 $0.00 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.090 SUP HCPCS C1713 02.210.090 - PIN FIX 1.8MM 20MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.092 SUP Custom 27203010 02.210.092 - PIN FIX 1.8MM 22MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $0.00 $0.00 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.094 SUP HCPCS C1713 02.210.094 - PIN FIX 1.8MM 24MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.096 SUP HCPCS C1713 02.210.096 - PIN FIX 1.8MM 26MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.098 SUP HCPCS C1713 02.210.098 - PIN FIX 1.8MM 28MM T8 STARDRIVE RECESS BUTTRESS VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.100 SUP HCPCS C1713 02.210.100 - PIN FIX 1.8MM 30MM T8 STARDRIVE RECESS VAR ANG LOCKING BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.107 SUP HCPCS C1713 02.210.107 - SCREW BONE 2.4MM 7MM STARDRIVE VAR ANG SLFTAP LOCKING LCP BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.108 SUP HCPCS C1713 02.210.108 - SCREW BONE T8 2.4MM 8MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.109 SUP HCPCS C1713 02.210.109 - SCREW BONE 2.4MM 9MM STARDRIVE VAR ANG SLFTAP LOCKING LCP BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.110 SUP HCPCS C1713 02.210.110 - SCREW BONE T8 2.4MM 10MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.111 SUP HCPCS C1713 02.210.111 - SCREW BONE 2.4MM 11MM STARDRIVE VAR ANG SLFTAP LOCKING LCP BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.112 SUP HCPCS C1713 02.210.112 - SCREW BONE T8 2.4MM 12MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.113 SUP HCPCS C1713 02.210.113 - SCREW BONE 2.4MM 13MM STARDRIVE VAR ANG SLFTAP LOCKING LCP BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.114 SUP HCPCS C1713 02.210.114 - SCREW BONE T8 2.4MM 14MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.116 SUP HCPCS C1713 02.210.116 - SCREW BONE T8 2.4MM 16MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.118 SUP HCPCS C1713 02.210.118 - SCREW BONE T8 2.4MM 18MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.120 SUP HCPCS C1713 02.210.120 - SCREW BONE 2.4MM 20MM T8 STARDRIVE RECESS LOCKING VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.122 SUP HCPCS C1713 02.210.122 - SCREW BONE 2.4MM 22MM VAR ANG SELF TAP THREAD T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.124 SUP HCPCS C1713 02.210.124 - SCREW BONE T8 2.4MM 24MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.126 SUP HCPCS C1713 02.210.126 - SCREW BONE T8 2.4MM 26MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.128 SUP HCPCS C1713 02.210.128 - SCREW BONE T8 2.4MM 28MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.130 SUP HCPCS C1713 02.210.130 - SCREW BONE T8 2.4MM 30MM VAR ANG SELF TAP THREAD STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.132 SUP HCPCS C1713 02.210.132 - SCREW BONE 2.4MM 32MM T8 STARDRIVE RECESS SLFTAP LOCKING VAR BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.134 SUP HCPCS C1713 02.210.134 - SCREW BONE 2.4MM 34MM SLFTAP LOCKING VAR ANG T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.136 SUP HCPCS C1713 02.210.136 - SCREW BONE 2.4MM 36MM T8 STARDRIVE RECESS SLFTAP LOCKING VAR BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.138 SUP HCPCS C1713 02.210.138 - SCREW BONE 2.4MM 38MM T8 STARDRIVE RECESS SLFTAP LOCKING VAR BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.140 SUP HCPCS C1713 02.210.140 - SCREW BONE 2.4MM 40MM T8 STARDRIVE RECESS SLFTAP LOCKING VAR BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.142 SUP HCPCS C1713 02.210.142 - SCREW BONE 2.4MM 42MM T8 STARDRIVE RECESS SLFTAP LOCKING VAR BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.144 SUP HCPCS C1713 02.210.144 - SCREW BONE 2.4MM 44MM SLFTAP LOCKING VAR ANG T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.146 SUP HCPCS C1713 02.210.146 - SCREW BONE 2.4MM 46MM SLFTAP LOCKING VAR ANG T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.148 SUP HCPCS C1713 02.210.148 - SCREW BONE 2.4MM 48MM T8 STARDRIVE RECESS SLFTAP LOCKING VAR BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.150 SUP HCPCS C1713 02.210.150 - SCREW BONE 2.4MM 50MM T8 STARDRIVE RECESS SLFTAP LOCKING VAR BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.152 SUP HCPCS C1713 02.210.152 - SCREW BONE 2.4MM 52MM SLFTAP LOCKING VAR ANG T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.154 SUP HCPCS C1713 02.210.154 - SCREW BONE 2.4MM 54MM SLFTAP LOCKING VAR ANG T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.156 SUP HCPCS C1713 02.210.156 - SCREW BONE 2.4MM 56MM SLFTAP LOCKING VAR ANG T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.158 SUP HCPCS C1713 02.210.158 - SCREW BONE 2.4MM 58MM STARDRIVE SLFTAP LOCKING VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.160 SUP HCPCS C1713 02.210.160 - SCREW BONE 2.4MM 60MM STARDRIVE SLFTAP LOCKING VAR ANG BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.942 SUP HCPCS C1713 02.210.942 - SCREW BONE T8 2.4MM 42MM SLFTAP STARDRIVE RECESS STAINLESS BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.944 SUP HCPCS C1713 02.210.944 - SCREW BONE 2.4MM 44MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.946 SUP HCPCS C1713 02.210.946 - SCREW BONE 2.4MM 46MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.948 SUP HCPCS C1713 02.210.948 - SCREW BONE 2.4MM 48MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.950 SUP HCPCS C1713 02.210.950 - SCREW BONE 2.4MM 50MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.952 SUP HCPCS C1713 02.210.952 - SCREW BONE T8 2.4MM 52MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.954 SUP HCPCS C1713 02.210.954 - SCREW BONE 2.4MM 54MM T8 STARDRIVE RECESS SLFTAP LCP BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.956 SUP HCPCS C1713 02.210.956 - SCREW BONE T8 2.4MM 56MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.958 SUP HCPCS C1713 02.210.958 - SCREW BONE 2.4MM 58MM T8 STARDRIVE SLFTAP STAINLESS STEEL BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.210.960 SUP HCPCS C1713 02.210.960 - SCREW BONE 2.4MM 60MM T8 STARDRIVE SLFTAP STAINLESS STEEL BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.008 SUP HCPCS C1713 02.211.008 - SCREW BONE 2.7MM 8MM T8 STARDRIVE RECESS VAR ANG SLFTAP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.009 SUP HCPCS C1713 02.211.009 - SCREW BONE 2.7MM 9MM T8 STARDRIVE RECESS VAR ANG SLFTAP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.010 SUP HCPCS C1713 02.211.010 - SCREW BONE T8 2.7MM 10MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.011 SUP HCPCS C1713 02.211.011 - SCREW BONE 2.7MM 11MM T8 STARDRIVE RECESS VAR ANG SLFTAP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.012 SUP HCPCS C1713 02.211.012 - SCREW BONE T8 2.7MM 12MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.013 SUP HCPCS C1713 02.211.013 - SCREW BONE 2.7MM 13MM T8 STARDRIVE RECESS VAR ANG SLFTAP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.014 SUP HCPCS C1713 02.211.014 - SCREW BONE T8 2.7MM 14MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.016 SUP HCPCS C1713 02.211.016 - SCREW BONE T8 2.7MM 16MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.018 SUP HCPCS C1713 02.211.018 - SCREW BONE T8 2.7MM 18MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.020 SUP HCPCS C1713 02.211.020 - SCREW BONE T8 2.7MM 20MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.022 SUP HCPCS C1713 02.211.022 - SCREW BONE T8 2.7MM 22MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.024 SUP HCPCS C1713 02.211.024 - SCREW BONE T8 2.7MM 24MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.026 SUP HCPCS C1713 02.211.026 - SCREW BONE T8 2.7MM 26MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.028 SUP HCPCS C1713 02.211.028 - SCREW BONE T8 2.7MM 28MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.030 SUP HCPCS C1713 02.211.030 - SCREW BONE 2.7MM 30MM LOCK VAR ANG SELF TAP T8 STARDRIVE BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.032 SUP HCPCS C1713 02.211.032 - SCREW BONE T8 2.7MM 32MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.034 SUP HCPCS C1713 02.211.034 - SCREW BONE T8 2.7MM 34MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.036 SUP HCPCS C1713 02.211.036 - SCREW BONE 2.7MM 36MM LOCK VAR ANG SELF TAP T8 STARDRIVE BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.038 SUP HCPCS C1713 02.211.038 - SCREW BONE T8 2.7MM 38MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.040 SUP HCPCS C1713 02.211.040 - SCREW BONE T8 2.7MM 40MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.042 SUP HCPCS C1713 02.211.042 - SCREW BONE 2.7MM 42MM VAR ANG SELF TAP T8 STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.044 SUP HCPCS C1713 02.211.044 - SCREW BONE T8 2.7MM 44MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.046 SUP HCPCS C1713 02.211.046 - SCREW BONE T8 2.7MM 46MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.048 SUP HCPCS C1713 02.211.048 - SCREW BONE T8 2.7MM 48MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.050 SUP HCPCS C1713 02.211.050 - SCREW BONE T8 2.7MM 50MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.052 SUP HCPCS C1713 02.211.052 - SCREW BONE T8 2.7MM 52MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.054 SUP HCPCS C1713 02.211.054 - SCREW BONE T8 2.7MM 54MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.056 SUP HCPCS C1713 02.211.056 - SCREW BONE T8 2.7MM 56MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.058 SUP HCPCS C1713 02.211.058 - SCREW BONE T8 2.7MM 58MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.060 SUP HCPCS C1713 02.211.060 - SCREW BONE T8 2.7MM 60MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $267.08 $197.64 $0.00 $207.44 $116.69 $116.69 $0.00 $0.00 $0.00 $55.67 $198.22 $198.22 $0.00 $0.00 $55.66 $0.00 $157.97 $157.97 $0.00 $129.65 $205.37 $207.44 $0.00 $0.00 $39.40 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.201 SUP HCPCS C1713 02.211.201 - PLATE BN XS X 24MM NS LCP VA LCK LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.202 SUP HCPCS C1713 02.211.202 - PLATE BN SM X 27MM NS LCP VA LCK LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.203 SUP HCPCS C1713 02.211.203 - PLATE BN MED X 32MM NS LCP VA LCK LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,772.58 " "$1,311.71" $0.00 "$1,376.76" $774.43 $774.43 $0.00 $0.00 $0.00 $369.45 "$1,315.61" "$1,315.61" $0.00 $0.00 $369.40 $0.00 "$1,048.48" "$1,048.48" $0.00 $860.48 "$1,362.99" "$1,376.76" $0.00 $0.00 $261.48 $0.00 $0.00 $273.98 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.204 SUP HCPCS C1713 02.211.204 - PLATE BN LG X 36MM NS LCP VA LCK LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,821.78 " "$1,348.12" $0.00 "$1,414.98" $795.93 $795.93 $0.00 $0.00 $0.00 $379.70 "$1,352.12" "$1,352.12" $0.00 $0.00 $379.66 $0.00 "$1,077.58" "$1,077.58" $0.00 $884.36 "$1,400.83" "$1,414.98" $0.00 $0.00 $268.74 $0.00 $0.00 $281.58 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.210 SUP HCPCS C1713 02.211.210 - PLATE BONE LP OPENING WEDGE LOCKING VAR ANG ANATOMIC LCP BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.211 SUP HCPCS C1713 02.211.211 - PLATE BONE 3MM SPACER OPENING WEDGE LOCKING VAR ANG LCP BOTH IP/OP "$1,730.40 " "$1,280.50" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $360.66 "$1,284.30" "$1,284.30" $0.00 $0.00 $360.62 $0.00 "$1,023.53" "$1,023.53" $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $255.26 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.212 SUP HCPCS C1713 02.211.212 - PLATE BONE 4MM SPACER OPENING WEDGE LOCKING VAR ANG LCP BOTH IP/OP "$1,730.40 " "$1,280.50" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $360.66 "$1,284.30" "$1,284.30" $0.00 $0.00 $360.62 $0.00 "$1,023.53" "$1,023.53" $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $255.26 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.213 SUP HCPCS C1713 02.211.213 - PLATE BONE 5MM SPACER OPENING WEDGE LOCKING VAR ANG LCP BOTH IP/OP "$1,730.40 " "$1,280.50" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $360.66 "$1,284.30" "$1,284.30" $0.00 $0.00 $360.62 $0.00 "$1,023.53" "$1,023.53" $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $255.26 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.214 SUP HCPCS C1713 02.211.214 - PLATE BONE 6MM SPACER OPENING WEDGE VAR ANG LOCKING LCP BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.215 SUP HCPCS C1713 02.211.215 - PLATE BONE 7MM SPACER OPENING WEDGE VAR ANG LOCKING LCP BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.220 SUP HCPCS C1713 02.211.220 - PLATE BN CNTR NS LCP VA LCK LOPRFL SS NAVICULAR 2.4/2.7MM BOTH IP/OP "$2,109.95 " "$1,561.36" $0.00 "$1,638.80" $921.83 $921.83 $0.00 $0.00 $0.00 $439.77 "$1,566.00" "$1,566.00" $0.00 $0.00 $439.71 $0.00 "$1,248.04" "$1,248.04" $0.00 "$1,024.25" "$1,622.41" "$1,638.80" $0.00 $0.00 $311.25 $0.00 $0.00 $326.12 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.221 SUP HCPCS C1713 02.211.221 - PLATE BN CNTR NS LCP VA LCK LOPRFL SS CUBOID LT 2.4/2.7MM BOTH IP/OP "$2,109.95 " "$1,561.36" $0.00 "$1,638.80" $921.83 $921.83 $0.00 $0.00 $0.00 $439.77 "$1,566.00" "$1,566.00" $0.00 $0.00 $439.71 $0.00 "$1,248.04" "$1,248.04" $0.00 "$1,024.25" "$1,622.41" "$1,638.80" $0.00 $0.00 $311.25 $0.00 $0.00 $326.12 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.222 SUP HCPCS C1713 02.211.222 - PLATE BN CNTR NS LCP VA LCK LOPRFL SS CUBOID RT 2.4/2.7MM BOTH IP/OP "$2,109.95 " "$1,561.36" $0.00 "$1,638.80" $921.83 $921.83 $0.00 $0.00 $0.00 $439.77 "$1,566.00" "$1,566.00" $0.00 $0.00 $439.71 $0.00 "$1,248.04" "$1,248.04" $0.00 "$1,024.25" "$1,622.41" "$1,638.80" $0.00 $0.00 $311.25 $0.00 $0.00 $326.12 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.224 SUP HCPCS C1713 02.211.224 - PLATE BONE 5X12 HOLE VAR ANG LOCK MESH LCP STAINLESS STEEL BOTH IP/OP "$2,971.63 " "$2,199.01" $0.00 "$2,308.06" "$1,298.28" "$1,298.28" $0.00 $0.00 $0.00 $619.36 "$2,205.54" "$2,205.54" $0.00 $0.00 $619.29 $0.00 "$1,465.01" "$1,465.01" $0.00 "$1,442.54" "$2,284.98" "$2,308.06" $0.00 $0.00 $438.36 $0.00 $0.00 $459.30 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.230 SUP HCPCS C1713 02.211.230 - PLATE BN 0D SM 42MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.231 SUP HCPCS C1713 02.211.231 - PLATE BN 0D SM 42MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.232 SUP HCPCS C1713 02.211.232 - PLATE BN 5D SM 42MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.233 SUP HCPCS C1713 02.211.233 - PLATE BN 5D SM 42MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.234 SUP HCPCS C1713 02.211.234 - PLATE BN 10D SM 42MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.235 SUP HCPCS C1713 02.211.235 - PLATE BN 10D SM 42MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.236 SUP HCPCS C1713 02.211.236 - PLATE BN 0D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.237 SUP HCPCS C1713 02.211.237 - PLATE BN 0D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.238 SUP HCPCS C1713 02.211.238 - PLATE BN 5D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.239 SUP HCPCS C1713 02.211.239 - PLATE BN 5D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.240 SUP HCPCS C1713 02.211.240 - PLATE BN 10D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1 BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.241 SUP HCPCS C1713 02.211.241 - PLATE BN 10D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1 BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.242 SUP HCPCS C1713 02.211.242 - PLATE BN 5D LG 57MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$2,109.95 " "$1,561.36" $0.00 "$1,638.80" $921.83 $921.83 $0.00 $0.00 $0.00 $439.77 "$1,566.00" "$1,566.00" $0.00 $0.00 $439.71 $0.00 "$1,248.04" "$1,248.04" $0.00 "$1,024.25" "$1,622.41" "$1,638.80" $0.00 $0.00 $311.25 $0.00 $0.00 $326.12 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.243 SUP HCPCS C1713 02.211.243 - PLATE BN 5D LG 57MM NS LCP VA FSN LOPRFL CMPR WRE HL SS 1ST BOTH IP/OP "$2,109.95 " "$1,561.36" $0.00 "$1,638.80" $921.83 $921.83 $0.00 $0.00 $0.00 $439.77 "$1,566.00" "$1,566.00" $0.00 $0.00 $439.71 $0.00 "$1,248.04" "$1,248.04" $0.00 "$1,024.25" "$1,622.41" "$1,638.80" $0.00 $0.00 $311.25 $0.00 $0.00 $326.12 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.244 SUP HCPCS C1713 02.211.244 - PLATE BONE 0D 53MM VAR ANG FUSION REVISION DORSIFLEXION LCP BOTH IP/OP "$2,341.88 " "$1,732.99" $0.00 "$1,818.94" "$1,023.15" "$1,023.15" $0.00 $0.00 $0.00 $488.11 "$1,738.14" "$1,738.14" $0.00 $0.00 $488.05 $0.00 "$1,385.22" "$1,385.22" $0.00 "$1,136.84" "$1,800.75" "$1,818.94" $0.00 $0.00 $345.47 $0.00 $0.00 $361.97 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.245 SUP HCPCS C1713 02.211.245 - PLATE BONE 0D 53MM VAR ANG FUSION REVISION DORSIFLEXION LCP BOTH IP/OP "$2,341.88 " "$1,732.99" $0.00 "$1,818.94" "$1,023.15" "$1,023.15" $0.00 $0.00 $0.00 $488.11 "$1,738.14" "$1,738.14" $0.00 $0.00 $488.05 $0.00 "$1,385.22" "$1,385.22" $0.00 "$1,136.84" "$1,800.75" "$1,818.94" $0.00 $0.00 $345.47 $0.00 $0.00 $361.97 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.246 SUP HCPCS C1713 02.211.246 - PLATE BN STD 39MM NS LCP VA FSN LOPRFL PRECONTOUR SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.247 SUP HCPCS C1713 02.211.247 - PLATE BN LNG 48MM NS LCP VA FSN LOPRFL PRECONTOUR SS 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.250 SUP HCPCS C1713 02.211.250 - PLATE BN SHRT CLVRLF 38MM NS LCP VA FSN LOPRFL CMPR WRE HL BOTH IP/OP "$1,603.90 " "$1,186.89" $0.00 "$1,245.74" $700.73 $700.73 $0.00 $0.00 $0.00 $334.29 "$1,190.41" "$1,190.41" $0.00 $0.00 $334.25 $0.00 $948.71 $948.71 $0.00 $778.59 "$1,233.29" "$1,245.74" $0.00 $0.00 $236.60 $0.00 $0.00 $247.90 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.251 SUP HCPCS C1713 02.211.251 - PLATE BN STD CLVRLF 45MM NS LCP VA FSN LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,646.08 " "$1,218.10" $0.00 "$1,278.50" $719.16 $719.16 $0.00 $0.00 $0.00 $343.08 "$1,221.72" "$1,221.72" $0.00 $0.00 $343.04 $0.00 $973.65 $973.65 $0.00 $799.06 "$1,265.72" "$1,278.50" $0.00 $0.00 $242.82 $0.00 $0.00 $254.42 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.252 SUP HCPCS C1713 02.211.252 - PLATE BN LNG CLVRLF 64MM NS LCP VA FSN LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,686.83 " "$1,248.25" $0.00 "$1,310.16" $736.97 $736.97 $0.00 $0.00 $0.00 $351.58 "$1,251.96" "$1,251.96" $0.00 $0.00 $351.53 $0.00 $997.76 $997.76 $0.00 $818.85 "$1,297.06" "$1,310.16" $0.00 $0.00 $248.84 $0.00 $0.00 $260.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.253 SUP HCPCS C1713 02.211.253 - PLATE BONE T SHORT 35MM 2 HOLE FUSION VAR ANG LCP STAINLESS BOTH IP/OP "$1,603.90 " "$1,186.89" $0.00 "$1,245.74" $700.73 $700.73 $0.00 $0.00 $0.00 $334.29 "$1,190.41" "$1,190.41" $0.00 $0.00 $334.25 $0.00 $948.71 $948.71 $0.00 $778.59 "$1,233.29" "$1,245.74" $0.00 $0.00 $236.60 $0.00 $0.00 $247.90 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.254 SUP HCPCS C1713 02.211.254 - PLATE BONE STANDARD 42MM 2 HOLE T FUSION VAR ANG LCP BOTH IP/OP "$1,646.08 " "$1,218.10" $0.00 "$1,278.50" $719.16 $719.16 $0.00 $0.00 $0.00 $343.08 "$1,221.72" "$1,221.72" $0.00 $0.00 $343.04 $0.00 $973.65 $973.65 $0.00 $799.06 "$1,265.72" "$1,278.50" $0.00 $0.00 $242.82 $0.00 $0.00 $254.42 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.255 SUP HCPCS C1713 02.211.255 - PLATE BONE T LONG 6.1CM 2 HOLE VAR ANG LCP STAINLESS STEEL BOTH IP/OP "$1,686.83 " "$1,248.25" $0.00 "$1,310.16" $736.97 $736.97 $0.00 $0.00 $0.00 $351.58 "$1,251.96" "$1,251.96" $0.00 $0.00 $351.53 $0.00 $997.76 $997.76 $0.00 $818.85 "$1,297.06" "$1,310.16" $0.00 $0.00 $248.84 $0.00 $0.00 $260.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.256 SUP HCPCS C1713 02.211.256 - PLATE BN SHRT L 37MM NS LCP VA FSN LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,648.88 " "$1,220.17" $0.00 "$1,280.68" $720.38 $720.38 $0.00 $0.00 $0.00 $343.67 "$1,223.80" "$1,223.80" $0.00 $0.00 $343.63 $0.00 $975.31 $975.31 $0.00 $800.43 "$1,267.87" "$1,280.68" $0.00 $0.00 $243.24 $0.00 $0.00 $254.86 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.257 SUP HCPCS C1713 02.211.257 - PLATE BN SHRT L 37MM NS LCP VA FSN LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,603.90 " "$1,186.89" $0.00 "$1,245.74" $700.73 $700.73 $0.00 $0.00 $0.00 $334.29 "$1,190.41" "$1,190.41" $0.00 $0.00 $334.25 $0.00 $948.71 $948.71 $0.00 $778.59 "$1,233.29" "$1,245.74" $0.00 $0.00 $236.60 $0.00 $0.00 $247.90 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.258 SUP HCPCS C1713 02.211.258 - PLATE BN STD L 44MM NS LCP VA FSN LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.259 SUP HCPCS C1713 02.211.259 - PLATE BN STD L 44MM NS LCP VA FSN LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.260 SUP HCPCS C1713 02.211.260 - PLATE BN LNG L 62MM NS LCP VA FSN LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,734.63 " "$1,283.63" $0.00 "$1,347.28" $757.85 $757.85 $0.00 $0.00 $0.00 $361.54 "$1,287.44" "$1,287.44" $0.00 $0.00 $361.50 $0.00 "$1,026.03" "$1,026.03" $0.00 $842.05 "$1,333.81" "$1,347.28" $0.00 $0.00 $255.89 $0.00 $0.00 $268.11 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.261 SUP HCPCS C1713 02.211.261 - PLATE BN LNG L 62MM NS LCP VA FSN LOPRFL CMPR WRE HL SS BOTH IP/OP "$1,734.63 " "$1,283.63" $0.00 "$1,347.28" $757.85 $757.85 $0.00 $0.00 $0.00 $361.54 "$1,287.44" "$1,287.44" $0.00 $0.00 $361.50 $0.00 "$1,026.03" "$1,026.03" $0.00 $842.05 "$1,333.81" "$1,347.28" $0.00 $0.00 $255.89 $0.00 $0.00 $268.11 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.262 SUP HCPCS C1713 02.211.262 - PLATE BONE 27MM 2 HOLE STR FUSION VAR ANG LOCKING LCP BOTH IP/OP "$1,435.20 " "$1,062.05" $0.00 "$1,114.72" $627.03 $627.03 $0.00 $0.00 $0.00 $299.13 "$1,065.21" "$1,065.21" $0.00 $0.00 $299.10 $0.00 $848.92 $848.92 $0.00 $696.70 "$1,103.57" "$1,114.72" $0.00 $0.00 $211.72 $0.00 $0.00 $221.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.263 SUP HCPCS C1713 02.211.263 - PLATE BONE 43MM 4 HOLE STR FUSION VAR ANG LOCKING LCP BOTH IP/OP "$1,518.15 " "$1,123.43" $0.00 "$1,179.14" $663.27 $663.27 $0.00 $0.00 $0.00 $316.42 "$1,126.77" "$1,126.77" $0.00 $0.00 $316.38 $0.00 $897.99 $897.99 $0.00 $736.96 "$1,167.35" "$1,179.14" $0.00 $0.00 $223.95 $0.00 $0.00 $234.65 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.265 SUP HCPCS C1713 02.211.265 - PLATE BONE XLONG 92MM 3 HOLE T FUSION VAR ANG LCP STAINLESS BOTH IP/OP "$2,109.95 " "$1,561.36" $0.00 "$1,638.80" $921.83 $921.83 $0.00 $0.00 $0.00 $439.77 "$1,566.00" "$1,566.00" $0.00 $0.00 $439.71 $0.00 "$1,248.04" "$1,248.04" $0.00 "$1,024.25" "$1,622.41" "$1,638.80" $0.00 $0.00 $311.25 $0.00 $0.00 $326.12 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.266 SUP HCPCS C1713 02.211.266 - PLATE BN 43MM NS LCP VA FSN LOPRFL PRECONTOUR SS BOTH IP/OP "$1,686.83 " "$1,248.25" $0.00 "$1,310.16" $736.97 $736.97 $0.00 $0.00 $0.00 $351.58 "$1,251.96" "$1,251.96" $0.00 $0.00 $351.53 $0.00 $997.76 $997.76 $0.00 $818.85 "$1,297.06" "$1,310.16" $0.00 $0.00 $248.84 $0.00 $0.00 $260.72 $0.00 $0.00 $0.00 $0.00 $0.00 02.211.412S SUP HCPCS C1713 02.211.412S - PLATE BN LNG 56MM STRL LCP VA LCK LOPRFL PRECONTOUR SS CALC BOTH IP/OP "$2,042.48 " "$1,511.44" $0.00 "$1,586.38" $892.34 $892.34 $0.00 $0.00 $0.00 $425.70 "$1,515.92" "$1,515.92" $0.00 $0.00 $425.65 $0.00 "$1,208.12" "$1,208.12" $0.00 $991.49 "$1,570.52" "$1,586.38" $0.00 $0.00 $301.30 $0.00 $0.00 $315.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.212.054 SUP HCPCS C1713 02.212.054 - SCREW BONE T15 3.5MM 54MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.212.056 SUP HCPCS C1713 02.212.056 - SCREW BONE T15 3.5MM 56MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.212.058 SUP HCPCS C1713 02.212.058 - SCREW BONE T15 3.5MM 58MM SELF TAP STARDRIVE LCP STAINLESS BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.006 SUP HCPCS C1713 02.214.006 - SCREW BONE 1.5MM 6MM T4 STARDRIVE RECESS LOCKING SLFTAP BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.007 SUP HCPCS C1713 02.214.007 - SCREW BONE T4 LP 1.5MM 7MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.008 SUP HCPCS C1713 02.214.008 - SCREW BONE T4 LP 1.5MM 8MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.009 SUP HCPCS C1713 02.214.009 - SCREW BONE T4 LP 1.5MM 9MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.010 SUP HCPCS C1713 02.214.010 - SCREW BONE T4 1.5MM 10MM SELF TAP SELF RETAINING LP BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.011 SUP HCPCS C1713 02.214.011 - SCREW BONE T4 LP 1.5MM 11MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.012 SUP HCPCS C1713 02.214.012 - SCREW BONE T4 LP 1.5MM 12MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.013 SUP HCPCS C1713 02.214.013 - SCREW BONE T4 LP 1.5MM 13MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.014 SUP HCPCS C1713 02.214.014 - SCREW BONE 1.5MM 14MM LOCK SELF TAP MODULAR T4 STARDRIVE LCP BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.015 SUP HCPCS C1713 02.214.015 - SCREW BONE T4 LP 1.5MM 15MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.016 SUP HCPCS C1713 02.214.016 - SCREW BONE T4 LP 1.5MM 16MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.018 SUP HCPCS C1713 02.214.018 - SCREW BONE T4 LP 1.5MM 18MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.020 SUP HCPCS C1713 02.214.020 - SCREW BONE T4 LP 1.5MM 20MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.022 SUP HCPCS C1713 02.214.022 - SCREW BONE T4 LP 1.5MM 22MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.024 SUP HCPCS C1713 02.214.024 - SCREW BONE T4 LP 1.5MM 24MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.104 SUP HCPCS C1713 02.214.104 - SCREW BN T4 1.5MM 4MM ST TIP VA LCK STRDR SS CORT BOTH IP/OP $87.15 $64.49 $0.00 $67.70 $38.08 $38.08 $0.00 $0.00 $0.00 $18.16 $64.68 $64.68 $0.00 $0.00 $18.16 $0.00 $51.55 $51.55 $0.00 $42.31 $67.03 $67.70 $0.00 $0.00 $12.86 $0.00 $0.00 $13.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.105 SUP HCPCS C1713 02.214.105 - SCREW BN T4 1.5MM 5MM SLFRET ST STRDR SS HND CORT VA LCK SYS BOTH IP/OP $87.15 $64.49 $0.00 $67.70 $38.08 $38.08 $0.00 $0.00 $0.00 $18.16 $64.68 $64.68 $0.00 $0.00 $18.16 $0.00 $51.55 $51.55 $0.00 $42.31 $67.03 $67.70 $0.00 $0.00 $12.86 $0.00 $0.00 $13.47 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.106 SUP HCPCS C1713 02.214.106 - SCREW BONE T4 LP 1.5MM 6MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.107 SUP HCPCS C1713 02.214.107 - SCREW BONE T4 LP 1.5MM 7MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.108 SUP HCPCS C1713 02.214.108 - SCREW BONE T4 LP 1.5MM 8MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.109 SUP HCPCS C1713 02.214.109 - SCREW BONE T4 LP 1.5MM 9MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.110 SUP HCPCS C1713 02.214.110 - SCREW BONE T4 LP 1.5MM 10MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.111 SUP HCPCS C1713 02.214.111 - SCREW BONE T4 LP 1.5MM 11MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.112 SUP HCPCS C1713 02.214.112 - SCREW BONE T4 LP 1.5MM 12MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.113 SUP HCPCS C1713 02.214.113 - SCREW BONE T4 LP 1.5MM 13MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.114 SUP HCPCS C1713 02.214.114 - SCREW BONE T4 LP 1.5MM 14MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.115 SUP HCPCS C1713 02.214.115 - SCREW BONE T4 LP 1.5MM 15MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.116 SUP HCPCS C1713 02.214.116 - SCREW BONE T4 LP 1.5MM 16MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.118 SUP HCPCS C1713 02.214.118 - SCREW BONE T4 LP 1.5MM 18MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.120 SUP HCPCS C1713 02.214.120 - SCREW BONE T4 LP 1.5MM 20MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.122 SUP HCPCS C1713 02.214.122 - SCREW BONE T4 LP 1.5MM 22MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.214.124 SUP HCPCS C1713 02.214.124 - SCREW BONE T4 LP 1.5MM 24MM SELF TAP SELF RETAINING THREAD BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.002S SUP Custom 27803010 02.221.002S - BUTTON CERCLAGE 2.5MM T15 STARDRIVE STAINLESS STEEL STERILE BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.003S SUP Custom 27803010 02.221.003S - BUTTON FIX 3.5MM 3.5MM T25 STARDRIVE/HEXAGONAL RECESS BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.004S SUP Custom 27803010 02.221.004S - BUTTON FIX 4MM CERCLAGE HEXAGONAL CANN STAINLESS STEEL BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.005S SUP Custom 27803010 02.221.005S - PIN POSITIONING 5MM CRIMP STAINLESS STEEL STERILE BOTH IP/OP $515.90 $381.77 $0.00 $400.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.90 $382.90 $0.00 $0.00 $107.51 $0.00 $0.00 $0.00 $0.00 $250.44 $396.70 $400.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.006S SUP HCPCS C1713 02.221.006S - PIN POSITIONING 7.3MM CRIMP STAINLESS STEEL STERILE BOTH IP/OP $515.90 $381.77 $0.00 $400.70 $225.39 $225.39 $0.00 $0.00 $0.00 $107.53 $382.90 $382.90 $0.00 $0.00 $107.51 $0.00 $305.15 $305.15 $0.00 $250.44 $396.70 $400.70 $0.00 $0.00 $76.10 $0.00 $0.00 $79.74 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.458 SUP HCPCS C1713 02.221.458 - SCREW BONE 5MM 8MM SLFTAP LOCKING LCP STAINLESS STEEL DISTAL BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.460 SUP HCPCS C1713 02.221.460 - SCREW BONE 5MM 10MM SLFTAP LOCKING LCP STAINLESS STEEL BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.462 SUP HCPCS C1713 02.221.462 - SCREW BONE 5MM 12MM SLFTAP LOCKING LCP STAINLESS STEEL BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.508 SUP HCPCS C1713 02.221.508 - SCREW BONE T25 BLUNT CONE 5MM 4.4MM 8MM SELF TAP THREAD HEAD BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.510 SUP HCPCS C1713 02.221.510 - SCREW BONE FULTHD 5MM 4.4MM 10MM T25 STARDRIVE RECESS BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.510S SUP HCPCS C1713 02.221.510S - SCREW BONE 5MM 10MM LCP SS PROX MDL PERIART FEM/TIB BOTH IP/OP $489.18 $361.99 $0.00 $425.24 $239.20 $239.20 $0.00 $0.00 $0.00 $101.96 $363.07 $363.07 $0.00 $0.00 $101.94 $0.00 $289.35 $289.35 $0.00 $265.78 $420.99 $425.24 $0.00 $0.00 $83.19 $0.00 $0.00 $84.62 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.512 SUP HCPCS C1713 02.221.512 - SCREW BONE T25 BLUNT CONE 5MM 4.4MM 12MM SELF TAP THREAD BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.514 SUP HCPCS C1713 02.221.514 - SCREW BONE 5MM 14MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.221.518 SUP HCPCS C1713 02.221.518 - SCREW BONE 5MM 18MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 02.224.030S SUP HCPCS C1713 02.224.030S - SCREW BONE HELIX 30MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $173.60 $128.46 $0.00 $134.82 $75.84 $75.84 $0.00 $0.00 $0.00 $36.18 $128.85 $128.85 $0.00 $0.00 $36.18 $0.00 $102.68 $102.68 $0.00 $84.26 $133.48 $134.82 $0.00 $0.00 $25.61 $0.00 $0.00 $26.83 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.000 SUP HCPCS C1713 02.226.000 - GUIDEWIRE ORTHOPEDIC 1.6MM 220MM TROCAR POINT THREADED BOTH IP/OP $70.98 $52.53 $0.00 $55.12 $31.01 $31.01 $0.00 $0.00 $0.00 $14.79 $52.68 $52.68 $0.00 $0.00 $14.79 $0.00 $41.98 $41.98 $0.00 $34.45 $54.57 $55.12 $0.00 $0.00 $10.47 $0.00 $0.00 $10.97 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.001 SUP HCPCS C1713 02.226.001 - GUIDEWIRE ORTHOPEDIC 1.6MM 220MM TROCAR POINT NONTHREADED BOTH IP/OP $70.28 $52.01 $0.00 $54.60 $30.71 $30.71 $0.00 $0.00 $0.00 $14.65 $52.16 $52.16 $0.00 $0.00 $14.65 $0.00 $41.57 $41.57 $0.00 $34.13 $54.05 $54.60 $0.00 $0.00 $10.37 $0.00 $0.00 $10.87 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.010 SUP HCPCS C1713 02.226.010 - SCREW BONE T8 3MM 2MM 1.1MM 10MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.011 SUP HCPCS C1713 02.226.011 - SCREW BONE T8 3MM 2MM 1.1MM 11MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.012 SUP HCPCS C1713 02.226.012 - SCREW BONE T8 3MM 2MM 1.1MM 12MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.013 SUP HCPCS C1713 02.226.013 - SCREW BONE T8 3MM 2MM 1.1MM 13MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.014 SUP HCPCS C1713 02.226.014 - SCREW BONE T8 3MM 2MM 1.1MM 14MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.015 SUP HCPCS C1713 02.226.015 - SCREW BONE T8 3MM 2MM 1.1MM 15MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.016 SUP HCPCS C1713 02.226.016 - SCREW BONE T8 3MM 2MM 1.1MM 16MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.017 SUP HCPCS C1713 02.226.017 - SCREW BONE T8 3MM 2MM 1.1MM 17MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.018 SUP HCPCS C1713 02.226.018 - SCREW BONE 1.1MM SHORT THREAD 3MM 2MM 18MM 4MM T8 STARDRIVE BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.019 SUP HCPCS C1713 02.226.019 - SCREW BONE T8 3MM 2MM 1.1MM 19MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.020 SUP HCPCS C1713 02.226.020 - SCREW BONE T8 3MM 2MM 1.1MM 20MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.021 SUP HCPCS C1713 02.226.021 - SCREW BONE T8 3MM 2MM 1.1MM 21MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.022 SUP HCPCS C1713 02.226.022 - SCREW BONE T8 3MM 2MM 1.1MM 22MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.023 SUP HCPCS C1713 02.226.023 - SCREW BONE T8 3MM 2MM 1.1MM 23MM 4MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.024 SUP HCPCS C1713 02.226.024 - SCREW BONE T8 3MM 2MM 1.1MM 24MM 5MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.025 SUP HCPCS C1713 02.226.025 - SCREW BONE T8 3MM 2MM 1.1MM 25MM 5MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.026 SUP HCPCS C1713 02.226.026 - SCREW BONE T8 3MM 2MM 1.1MM 26MM 5MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.027 SUP HCPCS C1713 02.226.027 - SCREW BONE T8 3MM 2MM 1.1MM 27MM 6MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.028 SUP HCPCS C1713 02.226.028 - SCREW BONE T8 3MM 2MM 1.1MM 28MM 6MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.029 SUP HCPCS C1713 02.226.029 - SCREW BONE T8 3MM 2MM 1.1MM 29MM 6MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.030 SUP HCPCS C1713 02.226.030 - SCREW BONE T8 3MM 2MM 1.1MM 30MM 7MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.032 SUP HCPCS C1713 02.226.032 - SCREW BONE T8 3MM 2MM 1.1MM 32MM 7MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.034 SUP HCPCS C1713 02.226.034 - SCREW BONE T8 3MM 2MM 1.1MM 34MM 8MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.036 SUP HCPCS C1713 02.226.036 - SCREW BONE 1.1MM SHORT THREAD 3MM 2MM 36MM 9MM T8 STARDRIVE BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.038 SUP HCPCS C1713 02.226.038 - SCREW BONE T8 3MM 2MM 1.1MM 38MM 9MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.040 SUP HCPCS C1713 02.226.040 - SCREW BONE T8 3MM 2MM 1.1MM 40MM 10MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.116 SUP HCPCS C1713 02.226.116 - SCREW BONE LNGTHRD 3MM 2MM 16MM 5MM SELF TAP DRILL BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.117 SUP HCPCS C1713 02.226.117 - SCREW BONE LNGTHRD 3MM 2MM 17MM 6MM T8 STARDRIVE CANN SELF BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.118 SUP HCPCS C1713 02.226.118 - SCREW BONE LNGTHRD 3MM 2MM 1.1MM 18MM 6MM T8 STARDRIVE CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.119 SUP HCPCS C1713 02.226.119 - SCREW BONE LNGTHRD 3MM 2MM 1.1MM 19MM 7MM T8 STARDRIVE CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.120 SUP HCPCS C1713 02.226.120 - SCREW BONE LNGTHRD 3MM 2MM 20MM 7MM T8 STARDRIVE CANN SELF BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.121 SUP HCPCS C1713 02.226.121 - SCREW BONE LNGTHRD 3MM 2MM 1.1MM 21MM 8MM T8 STARDRIVE CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.122 SUP HCPCS C1713 02.226.122 - SCREW BONE T8 3MM 2MM 1.1MM 22MM 8MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.123 SUP HCPCS C1713 02.226.123 - SCREW BONE LNGTHRD 3MM 2MM 1.1MM 23MM 8MM T8 STARDRIVE CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.124 SUP HCPCS C1713 02.226.124 - SCREW BONE LNGTHRD 3MM 2MM 1.1MM 24MM 8MM T8 STARDRIVE CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.125 SUP HCPCS C1713 02.226.125 - SCREW BONE T8 3MM 2MM 1.1MM 25MM 8MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.126 SUP HCPCS C1713 02.226.126 - SCREW BONE 1.1MM LNGTHRD 3MM 2MM 26MM 10MM T8 STARDRIVE BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.127 SUP HCPCS C1713 02.226.127 - SCREW BONE T8 3MM 2MM 1.1MM 27MM 10MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.128 SUP HCPCS C1713 02.226.128 - SCREW BONE T8 3MM 2MM 1.1MM 28MM 10MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.129 SUP HCPCS C1713 02.226.129 - SCREW BONE LNGTHRD 3MM 2MM 1.1MM 29MM 10MM T8 STARDRIVE CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.130 SUP HCPCS C1713 02.226.130 - SCREW BONE T8 3MM 2MM 1.1MM 30MM 12MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.132 SUP HCPCS C1713 02.226.132 - SCREW BONE 1.1MM LNGTHRD 3MM 2MM 32MM 12MM COMPRESSION CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.134 SUP HCPCS C1713 02.226.134 - SCREW BONE T8 3MM 2MM 1.1MM 34MM 14MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.136 SUP HCPCS C1713 02.226.136 - SCREW BONE LNGTHRD 3MM 2MM 36MM 14MM COMPRESSION CANN T8 BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.138 SUP HCPCS C1713 02.226.138 - SCREW BN T8 L/T FLUT 3MM 2MM 38MM NS 16MM CMPR CNN ST HDLS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.140 SUP HCPCS C1713 02.226.140 - SCREW BONE T8 3MM 2MM 1.1MM 40MM 16MM SELF DRILL SELF TAP BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.209 SUP HCPCS C1713 02.226.209 - SCREW BONE SHORT THREAD 2.4MM 9MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.210 SUP HCPCS C1713 02.226.210 - SCREW BONE T8 2.4MM 10MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.211 SUP HCPCS C1713 02.226.211 - SCREW BONE T8 2.4MM 11MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.212 SUP HCPCS C1713 02.226.212 - SCREW BONE T8 2.4MM 12MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.213 SUP HCPCS C1713 02.226.213 - SCREW BONE T8 2.4MM 13MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.214 SUP HCPCS C1713 02.226.214 - SCREW BONE T8 2.4MM 14MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.215 SUP HCPCS C1713 02.226.215 - SCREW BONE T8 2.4MM 15MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.216 SUP HCPCS C1713 02.226.216 - SCREW BONE T8 2.4MM 16MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.217 SUP HCPCS C1713 02.226.217 - SCREW BONE T8 2.4MM 17MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.218 SUP HCPCS C1713 02.226.218 - SCREW BONE T8 2.4MM 18MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.219 SUP HCPCS C1713 02.226.219 - SCREW BONE T8 2.4MM 19MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.220 SUP HCPCS C1713 02.226.220 - SCREW BONE T8 2.4MM 20MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.221 SUP HCPCS C1713 02.226.221 - SCREW BONE T8 2.4MM 21MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.222 SUP HCPCS C1713 02.226.222 - SCREW BONE T8 2.4MM 22MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.223 SUP HCPCS C1713 02.226.223 - SCREW BONE T8 2.4MM 23MM 4MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.224 SUP HCPCS C1713 02.226.224 - SCREW BONE T8 2.4MM 24MM 5MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.225 SUP HCPCS C1713 02.226.225 - SCREW BONE T8 2.4MM 25MM 5MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.226 SUP HCPCS C1713 02.226.226 - SCREW BONE T8 2.4MM 26MM 5MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.227 SUP HCPCS C1713 02.226.227 - SCREW BONE T8 2.4MM 27MM 6MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.228 SUP HCPCS C1713 02.226.228 - SCREW BONE T8 2.4MM 28MM 6MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.229 SUP HCPCS C1713 02.226.229 - SCREW BONE T8 2.4MM 29MM 6MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.230 SUP HCPCS C1713 02.226.230 - SCREW BONE T8 2.4MM 30MM 7MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.232 SUP HCPCS C1713 02.226.232 - SCREW BONE T8 2.4MM 32MM 7MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.234 SUP HCPCS C1713 02.226.234 - SCREW BONE T8 2.4MM 34MM 8MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.236 SUP HCPCS C1713 02.226.236 - SCREW BONE T8 2.4MM 36MM 9MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.238 SUP HCPCS C1713 02.226.238 - SCREW BONE T8 2.4MM 38MM 9MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.240 SUP HCPCS C1713 02.226.240 - SCREW BONE T8 2.4MM 40MM 10MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.317 SUP HCPCS C1713 02.226.317 - SCREW BONE T8 2.4MM 17MM 6MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.318 SUP HCPCS C1713 02.226.318 - SCREW BONE T8 2.4MM 18MM 6MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.319 SUP HCPCS C1713 02.226.319 - SCREW BONE T8 2.4MM 19MM 7MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.320 SUP HCPCS C1713 02.226.320 - SCREW BONE T8 2.4MM 20MM 7MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.321 SUP HCPCS C1713 02.226.321 - SCREW BONE T8 2.4MM 21MM 8MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.322 SUP HCPCS C1713 02.226.322 - SCREW BONE T8 2.4MM 22MM 8MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.323 SUP HCPCS C1713 02.226.323 - SCREW BONE T8 2.4MM 23MM 8MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.324 SUP HCPCS C1713 02.226.324 - SCREW BONE T8 2.4MM 24MM 8MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.325 SUP HCPCS C1713 02.226.325 - SCREW BONE T8 2.4MM 25MM 8MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.326 SUP HCPCS C1713 02.226.326 - SCREW BONE T8 2.4MM 26MM 10MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.327 SUP HCPCS C1713 02.226.327 - SCREW BONE T8 2.4MM 27MM 10MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.328 SUP HCPCS C1713 02.226.328 - SCREW BONE T8 2.4MM 28MM 10MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.329 SUP HCPCS C1713 02.226.329 - SCREW BONE T8 2.4MM 29MM 10MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.330 SUP HCPCS C1713 02.226.330 - SCREW BONE T8 2.4MM 30MM 12MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.332 SUP HCPCS C1713 02.226.332 - SCREW BONE T8 2.4MM 32MM 12MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.334 SUP HCPCS C1713 02.226.334 - SCREW BONE T8 2.4MM 34MM 14MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.336 SUP HCPCS C1713 02.226.336 - SCREW BONE T8 2.4MM 36MM 14MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.338 SUP HCPCS C1713 02.226.338 - SCREW BONE T8 2.4MM 38MM 16MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.340 SUP HCPCS C1713 02.226.340 - SCREW BONE T8 2.4MM 40MM 16MM SELF DRILL SELF TAP CANN BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.620 SUP HCPCS C1713 02.226.620 - SCREW BONE T15 4.5MM 20MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.622 SUP HCPCS C1713 02.226.622 - SCREW BONE T15 4.5MM 22MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.624 SUP HCPCS C1713 02.226.624 - SCREW BONE T15 4.5MM 24MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.626 SUP HCPCS C1713 02.226.626 - SCREW BONE T15 4.5MM 26MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.628 SUP HCPCS C1713 02.226.628 - SCREW BONE T15 4.5MM 28MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.630 SUP HCPCS C1713 02.226.630 - SCREW BONE SHORT THREAD 4.5MM 30MM 7MM COMPRESSION HEADLESS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.632 SUP HCPCS C1713 02.226.632 - SCREW BONE T15 4.5MM 32MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.634 SUP HCPCS C1713 02.226.634 - SCREW BONE T15 4.5MM 34MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.636 SUP HCPCS C1713 02.226.636 - SCREW BONE T15 4.5MM 36MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.638 SUP HCPCS C1713 02.226.638 - SCREW BONE T15 4.5MM 38MM 7MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.640 SUP HCPCS C1713 02.226.640 - SCREW BONE T15 4.5MM 40MM 8MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.642 SUP HCPCS C1713 02.226.642 - SCREW BONE T15 4.5MM 42MM 8MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.644 SUP HCPCS C1713 02.226.644 - SCREW BONE T15 4.5MM 44MM 9MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.646 SUP HCPCS C1713 02.226.646 - SCREW BONE T15 4.5MM 46MM 9MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.648 SUP HCPCS C1713 02.226.648 - SCREW BONE T15 4.5MM 48MM 9MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.650 SUP HCPCS C1713 02.226.650 - SCREW BONE T15 4.5MM 50MM 10MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.652 SUP HCPCS C1713 02.226.652 - SCREW BONE T15 4.5MM 52MM 10MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.654 SUP HCPCS C1713 02.226.654 - SCREW BONE T15 4.5MM 54MM 11MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.656 SUP HCPCS C1713 02.226.656 - SCREW BONE T15 4.5MM 56MM 11MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.658 SUP HCPCS C1713 02.226.658 - SCREW BONE T15 4.5MM 58MM 11MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.660 SUP HCPCS C1713 02.226.660 - SCREW BONE T15 4.5MM 60MM 12MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.665 SUP HCPCS C1713 02.226.665 - SCREW BONE T15 4.5MM 65MM 13MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.670 SUP HCPCS C1713 02.226.670 - SCREW BONE T15 4.5MM 70MM 14MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.675 SUP HCPCS C1713 02.226.675 - SCREW BONE T15 4.5MM 75MM 15MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.680 SUP HCPCS C1713 02.226.680 - SCREW BONE T15 4.5MM 80MM 16MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.685 SUP HCPCS C1713 02.226.685 - SCREW BONE T15 4.5MM 85MM 17MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.690 SUP HCPCS C1713 02.226.690 - SCREW BONE T15 4.5MM 90MM 18MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.695 SUP HCPCS C1713 02.226.695 - SCREW BONE T15 4.5MM 95MM 19MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.700 SUP HCPCS C1713 02.226.700 - SCREW BONE T15 4.5MM 100MM 20MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.730 SUP HCPCS C1713 02.226.730 - SCREW BONE T15 4.5MM 30MM 12MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.732 SUP HCPCS C1713 02.226.732 - SCREW BONE T15 4.5MM 32MM 12MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.734 SUP HCPCS C1713 02.226.734 - SCREW BONE T15 4.5MM 34MM 12MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.736 SUP HCPCS C1713 02.226.736 - SCREW BONE T15 4.5MM 36MM 14MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.738 SUP HCPCS C1713 02.226.738 - SCREW BONE T15 4.5MM 38MM 14MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.740 SUP HCPCS C1713 02.226.740 - SCREW BONE T15 4.5MM 40MM 16MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.742 SUP HCPCS C1713 02.226.742 - SCREW BONE T15 4.5MM 42MM 16MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.744 SUP HCPCS C1713 02.226.744 - SCREW BONE T15 4.5MM 44MM 18MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.746 SUP HCPCS C1713 02.226.746 - SCREW BONE T15 4.5MM 46MM 18MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.748 SUP HCPCS C1713 02.226.748 - SCREW BONE T15 4.5MM 48MM 18MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.750 SUP HCPCS C1713 02.226.750 - SCREW BONE T15 4.5MM 50MM 20MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.752 SUP HCPCS C1713 02.226.752 - SCREW BONE T15 4.5MM 52MM 20MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.754 SUP HCPCS C1713 02.226.754 - SCREW BONE T15 4.5MM 54MM 22MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.756 SUP HCPCS C1713 02.226.756 - SCREW BONE LNGTHRD 4.5MM 56MM 22MM SLFDRILL SLFTAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.758 SUP HCPCS C1713 02.226.758 - SCREW BONE T15 4.5MM 58MM 22MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.760 SUP HCPCS C1713 02.226.760 - SCREW BONE T15 4.5MM 60MM 24MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.765 SUP HCPCS C1713 02.226.765 - SCREW BONE T15 4.5MM 65MM 26MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.770 SUP HCPCS C1713 02.226.770 - SCREW BONE T15 4.5MM 70MM 28MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.775 SUP HCPCS C1713 02.226.775 - SCREW BONE T15 4.5MM 75MM 30MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.780 SUP HCPCS C1713 02.226.780 - SCREW BONE T15 4.5MM 80MM 32MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.785 SUP HCPCS C1713 02.226.785 - SCREW BONE T15 4.5MM 85MM 34MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.790 SUP HCPCS C1713 02.226.790 - SCREW BONE T15 4.5MM 90MM 36MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.795 SUP HCPCS C1713 02.226.795 - SCREW BONE T15 4.5MM 95MM 38MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.226.800 SUP HCPCS C1713 02.226.800 - SCREW BONE T15 4.5MM 100MM 40MM SELF DRILL SELF TAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.001 SUP HCPCS C1713 02.227.001 - GUIDEWIRE ORTHOPEDIC 2.8MM 300MM NONTHREADED TROCAR POINT BOTH IP/OP $79.40 $58.76 $0.00 $61.68 $34.70 $34.70 $0.00 $0.00 $0.00 $16.55 $58.93 $58.93 $0.00 $0.00 $16.55 $0.00 $46.97 $46.97 $0.00 $38.55 $61.06 $61.68 $0.00 $0.00 $11.71 $0.00 $0.00 $12.27 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.030 SUP HCPCS C1713 02.227.030 - SCREW BONE 6.5MM 30MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.035 SUP HCPCS C1713 02.227.035 - SCREW BONE 6.5MM 35MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.040 SUP HCPCS C1713 02.227.040 - SCREW BONE 6.5MM 40MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.045 SUP HCPCS C1713 02.227.045 - SCREW BONE 6.5MM 45MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.050 SUP HCPCS C1713 02.227.050 - SCREW BONE 6.5MM 50MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.055 SUP HCPCS C1713 02.227.055 - SCREW BONE 6.5MM 55MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.060 SUP HCPCS C1713 02.227.060 - SCREW BONE 6.5MM 60MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.065 SUP HCPCS C1713 02.227.065 - SCREW BONE 6.5MM 65MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.070 SUP HCPCS C1713 02.227.070 - SCREW BONE 6.5MM 70MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.075 SUP HCPCS C1713 02.227.075 - SCREW BONE 6.5MM 75MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.080 SUP HCPCS C1713 02.227.080 - SCREW BONE 6.5MM 80MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.085 SUP HCPCS C1713 02.227.085 - SCREW BONE 6.5MM 85MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.090 SUP HCPCS C1713 02.227.090 - SCREW BONE 6.5MM 90MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.095 SUP HCPCS C1713 02.227.095 - SCREW BONE 6.5MM 95MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.100 SUP HCPCS C1713 02.227.100 - SCREW BONE 6.5MM 100MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.105 SUP HCPCS C1713 02.227.105 - SCREW BONE 6.5MM 105MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.110 SUP HCPCS C1713 02.227.110 - SCREW BONE 6.5MM 110MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.115 SUP HCPCS C1713 02.227.115 - SCREW BONE 6.5MM 115MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.120 SUP HCPCS C1713 02.227.120 - SCREW BONE 6.5MM 120MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.125 SUP HCPCS C1713 02.227.125 - SCREW BONE 6.5MM 125MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.130 SUP HCPCS C1713 02.227.130 - SCREW BONE 6.5MM 130MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.135 SUP HCPCS C1713 02.227.135 - SCREW BONE 6.5MM 135MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.140 SUP HCPCS C1713 02.227.140 - SCREW BONE 6.5MM 140MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.145 SUP HCPCS C1713 02.227.145 - SCREW BONE 6.5MM 145MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.150 SUP HCPCS C1713 02.227.150 - SCREW BONE 6.5MM 150MM 16MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.245 SUP HCPCS C1713 02.227.245 - SCREW BONE 6.5MM 45MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.250 SUP HCPCS C1713 02.227.250 - SCREW BONE 6.5MM 50MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.255 SUP HCPCS C1713 02.227.255 - SCREW BONE 6.5MM 55MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.260 SUP HCPCS C1713 02.227.260 - SCREW BONE 6.5MM 60MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.265 SUP HCPCS C1713 02.227.265 - SCREW BONE 6.5MM 65MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.270 SUP HCPCS C1713 02.227.270 - SCREW BONE 6.5MM 70MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.275 SUP HCPCS C1713 02.227.275 - SCREW BONE 6.5MM 75MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.280 SUP HCPCS C1713 02.227.280 - SCREW BONE 6.5MM 80MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.285 SUP HCPCS C1713 02.227.285 - SCREW BONE 6.5MM 7.5MM 85MM 32MM 2 LEAD COMPRESSION SLFTAP BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.290 SUP HCPCS C1713 02.227.290 - SCREW BN 6.5MM 7.5MM 90MM NS 32MM CMPR ST SLF DRL HDLS SS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.295 SUP HCPCS C1713 02.227.295 - SCREW BONE 6.5MM 95MM 32MM COMPRESSION HEADLESS STAINLESS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.300 SUP HCPCS C1713 02.227.300 - SCREW BONE 6.5MM 100MM 32MM COMPRESSION HEADLESS STAINLESS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.305 SUP HCPCS C1713 02.227.305 - SCREW BONE FLUTE 6.5MM 7.5MM 105MM 32MM 2 LEAD SELF TAP SELF BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.310 SUP HCPCS C1713 02.227.310 - SCREW BONE FLUTE 6.5MM 7.5MM 110MM 32MM 2 LEAD SELF TAP SELF BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.315 SUP HCPCS C1713 02.227.315 - SCREW BONE FLUTE 6.5MM 7.5MM 115MM 32MM 2 LEAD SELF TAP SELF BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.320 SUP HCPCS C1713 02.227.320 - SCREW BN 4MM FLUT 6.5MM 7.5MM 120MM NS 32MM 2 LD ST SLF DRL BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.325 SUP HCPCS C1713 02.227.325 - SCREW BN 4MM FLUT 6.5MM 7.5MM 125MM NS 32MM 2 LD ST SLF DRL BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.330 SUP HCPCS C1713 02.227.330 - SCREW BONE FLUTE 6.5MM 7.5MM 130MM 32MM 2 LEAD SELF TAP SELF BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.335 SUP HCPCS C1713 02.227.335 - SCREW BONE 6.5MM 135MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.340 SUP HCPCS C1713 02.227.340 - SCREW BONE 6.5MM 140MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.345 SUP HCPCS C1713 02.227.345 - SCREW BONE 6.5MM 145MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.227.350 SUP HCPCS C1713 02.227.350 - SCREW BONE 6.5MM 150MM 32MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.109 SUP HCPCS C1713 02.230.109 - SCREW BONE T4 1.5MM 9MM 4MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.110 SUP HCPCS C1713 02.230.110 - SCREW BONE T4 1.5MM 10MM 4MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.111 SUP HCPCS C1713 02.230.111 - SCREW BONE T4 1.5MM 11MM 4MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.112 SUP HCPCS C1713 02.230.112 - SCREW BONE T4 1.5MM 12MM 4MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.113 SUP HCPCS C1713 02.230.113 - SCREW BONE T4 1.5MM 13MM 4MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.114 SUP HCPCS C1713 02.230.114 - SCREW BONE 1.5MM 1MM 14MM 4MM COMPRESSION THREAD HEADLESS T4 BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.115 SUP HCPCS C1713 02.230.115 - SCREW BONE T4 1.5MM 15MM 4MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.116 SUP HCPCS C1713 02.230.116 - SCREW BONE T4 1.5MM 16MM 5MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.117 SUP HCPCS C1713 02.230.117 - SCREW BONE T4 1.5MM 17MM 5MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.118 SUP HCPCS C1713 02.230.118 - SCREW BONE T4 1.5MM 18MM 5MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.119 SUP HCPCS C1713 02.230.119 - SCREW BONE T4 1.5MM 19MM 5MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.230.120 SUP HCPCS C1713 02.230.120 - SCREW BONE T4 1.5MM 20MM 6MM SELF DRILL SELF TAP COMPRESSION BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.012 SUP HCPCS C1713 02.231.012 - SCREW BONE T25 5MM 12MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $479.35 $354.72 $0.00 $372.30 $209.42 $209.42 $0.00 $0.00 $0.00 $99.91 $355.77 $355.77 $0.00 $0.00 $99.90 $0.00 $283.54 $283.54 $0.00 $232.69 $368.58 $372.30 $0.00 $0.00 $70.71 $0.00 $0.00 $74.09 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.016 SUP HCPCS C1713 02.231.016 - SCREW BONE T25 5MM 16MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $479.35 $354.72 $0.00 $372.30 $209.42 $209.42 $0.00 $0.00 $0.00 $99.91 $355.77 $355.77 $0.00 $0.00 $99.90 $0.00 $283.54 $283.54 $0.00 $232.69 $368.58 $372.30 $0.00 $0.00 $70.71 $0.00 $0.00 $74.09 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.018S SUP HCPCS C1713 02.231.018S - SCREW BN T25 5MM 18MM STRL ST LCK VA THRD RND HD SS CNDRL BOTH IP/OP $570.70 $422.32 $0.00 $443.28 $249.35 $249.35 $0.00 $0.00 $0.00 $118.95 $423.57 $423.57 $0.00 $0.00 $118.93 $0.00 $337.57 $337.57 $0.00 $277.05 $438.85 $443.28 $0.00 $0.00 $84.19 $0.00 $0.00 $88.21 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.220 SUP HCPCS C1713 02.231.220 - SCREW BONE T25 5MM 20MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.222 SUP HCPCS C1713 02.231.222 - SCREW BONE T25 5MM 22MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.224 SUP HCPCS C1713 02.231.224 - SCREW BONE T25 5MM 24MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.226 SUP HCPCS C1713 02.231.226 - SCREW BONE T25 5MM 26MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.228 SUP HCPCS C1713 02.231.228 - SCREW BONE T25 5MM 28MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.230 SUP HCPCS C1713 02.231.230 - SCREW BONE T25 5MM 30MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.234 SUP HCPCS C1713 02.231.234 - SCREW BONE T25 5MM 34MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.236 SUP HCPCS C1713 02.231.236 - SCREW BONE T25 5MM 36MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.238 SUP HCPCS C1713 02.231.238 - SCREW BONE T25 5MM 38MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.240 SUP HCPCS C1713 02.231.240 - SCREW BONE T25 5MM 40MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.280 SUP HCPCS C1713 02.231.280 - SCREW BONE T25 5MM 80MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.285 SUP HCPCS C1713 02.231.285 - SCREW BONE T25 5MM 85MM VAR ANG SELF TAP STARDRIVE LCP BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.295S SUP HCPCS C1713 02.231.295S - SCREW BN 5MM 95MM STRL LCP T25 STRDR RCS LCK VA ST SS CNDYL BOTH IP/OP $435.78 $322.48 $0.00 $338.46 $190.38 $190.38 $0.00 $0.00 $0.00 $90.83 $323.43 $323.43 $0.00 $0.00 $90.82 $0.00 $257.76 $257.76 $0.00 $211.54 $335.08 $338.46 $0.00 $0.00 $64.28 $0.00 $0.00 $67.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.300S SUP HCPCS C1713 02.231.300S - SCREW BN 5MM 100MM STRL LCP T25 STRDR RCS LCK VA ST SS CNDYL BOTH IP/OP $435.78 $322.48 $0.00 $338.46 $190.38 $190.38 $0.00 $0.00 $0.00 $90.83 $323.43 $323.43 $0.00 $0.00 $90.82 $0.00 $257.76 $257.76 $0.00 $211.54 $335.08 $338.46 $0.00 $0.00 $64.28 $0.00 $0.00 $67.35 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.640 SUP HCPCS C1713 02.231.640 - SCREW BONE 3.5MM HEXAGON FLUTE 5MM 40MM VAR ANG SELF DRILL BOTH IP/OP $463.88 $343.27 $0.00 $360.30 $202.67 $202.67 $0.00 $0.00 $0.00 $96.68 $344.29 $344.29 $0.00 $0.00 $96.67 $0.00 $274.38 $274.38 $0.00 $225.19 $356.70 $360.30 $0.00 $0.00 $68.43 $0.00 $0.00 $71.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.675 SUP HCPCS C1713 02.231.675 - SCREW BONE 3.5MM HEXAGON FLUTE 5MM 75MM VAR ANG SELF DRILL BOTH IP/OP $463.88 $343.27 $0.00 $360.30 $202.67 $202.67 $0.00 $0.00 $0.00 $96.68 $344.29 $344.29 $0.00 $0.00 $96.67 $0.00 $274.38 $274.38 $0.00 $225.19 $356.70 $360.30 $0.00 $0.00 $68.43 $0.00 $0.00 $71.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.680 SUP HCPCS C1713 02.231.680 - SCREW BONE 3.5MM HEXAGON FLUTE 5MM 80MM VAR ANG SELF DRILL BOTH IP/OP $463.88 $343.27 $0.00 $360.30 $202.67 $202.67 $0.00 $0.00 $0.00 $96.68 $344.29 $344.29 $0.00 $0.00 $96.67 $0.00 $274.38 $274.38 $0.00 $225.19 $356.70 $360.30 $0.00 $0.00 $50.39 $0.00 $0.00 $71.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.685 SUP HCPCS C1713 02.231.685 - SCREW BONE 3.5MM HEXAGON FLUTE 5MM 85MM VAR ANG SELF DRILL BOTH IP/OP $463.88 $343.27 $0.00 $360.30 $202.67 $202.67 $0.00 $0.00 $0.00 $96.68 $344.29 $344.29 $0.00 $0.00 $96.67 $0.00 $274.38 $274.38 $0.00 $225.19 $356.70 $360.30 $0.00 $0.00 $68.43 $0.00 $0.00 $71.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.690 SUP HCPCS C1713 02.231.690 - SCREW BONE 3.5MM HEXAGON FLUTE 5MM 90MM VAR ANG SELF DRILL BOTH IP/OP $463.88 $343.27 $0.00 $360.30 $202.67 $202.67 $0.00 $0.00 $0.00 $96.68 $344.29 $344.29 $0.00 $0.00 $96.67 $0.00 $274.38 $274.38 $0.00 $225.19 $356.70 $360.30 $0.00 $0.00 $68.43 $0.00 $0.00 $71.70 $0.00 $0.00 $0.00 $0.00 $0.00 02.231.695S SUP HCPCS C1713 02.231.695S - SCREW BN 5MM 3.5MM 95MM STRL VA ST TIP LCK CNN SS CNDRL BOTH IP/OP $560.88 $415.05 $0.00 $435.62 $245.04 $245.04 $0.00 $0.00 $0.00 $116.90 $416.28 $416.28 $0.00 $0.00 $116.89 $0.00 $331.76 $331.76 $0.00 $272.26 $431.27 $435.62 $0.00 $0.00 $82.74 $0.00 $0.00 $86.69 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.010 SUP HCPCS C1713 02.240.010 - SCREW BONE T15 FULTHD 3.7MM 10MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.012 SUP HCPCS C1713 02.240.012 - SCREW BONE T15 FULTHD 3.7MM 12MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.014 SUP HCPCS C1713 02.240.014 - SCREW BONE T15 FULTHD 3.7MM 14MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.016 SUP HCPCS C1713 02.240.016 - SCREW BONE T15 FULTHD 3.7MM 16MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.018 SUP HCPCS C1713 02.240.018 - SCREW BONE T15 FULTHD 3.7MM 18MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.020 SUP HCPCS C1713 02.240.020 - SCREW BONE T15 FULTHD 3.7MM 20MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.022 SUP HCPCS C1713 02.240.022 - SCREW BONE T15 FULTHD 3.7MM 22MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.024 SUP HCPCS C1713 02.240.024 - SCREW BONE T15 FULTHD 3.7MM 24MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.026 SUP HCPCS C1713 02.240.026 - SCREW BONE T15 FULTHD 3.7MM 26MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.028 SUP HCPCS C1713 02.240.028 - SCREW BONE T15 FULTHD 3.7MM 28MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.030 SUP HCPCS C1713 02.240.030 - SCREW BONE T15 FULTHD 3.7MM 30MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.032 SUP HCPCS C1713 02.240.032 - SCREW BONE T15 FULTHD 3.7MM 32MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.034 SUP HCPCS C1713 02.240.034 - SCREW BONE T15 FULTHD 3.7MM 34MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.036 SUP HCPCS C1713 02.240.036 - SCREW BONE T15 FULTHD 3.7MM 36MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.038 SUP HCPCS C1713 02.240.038 - SCREW BONE T15 FULTHD 3.7MM 38MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.040 SUP HCPCS C1713 02.240.040 - SCREW BONE T15 FULTHD 3.7MM 40MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.042 SUP HCPCS C1713 02.240.042 - SCREW BONE T15 FULTHD 3.7MM 42MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.044 SUP HCPCS C1713 02.240.044 - SCREW BONE T15 FULTHD 3.7MM 44MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.046 SUP HCPCS C1713 02.240.046 - SCREW BONE T15 FULTHD 3.7MM 46MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.048 SUP HCPCS C1713 02.240.048 - SCREW BONE T15 FULTHD 3.7MM 48MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.050 SUP HCPCS C1713 02.240.050 - SCREW BONE T15 FULTHD 3.7MM 50MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.052 SUP HCPCS C1713 02.240.052 - SCREW BONE T15 FULTHD 3.7MM 52MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.054 SUP HCPCS C1713 02.240.054 - SCREW BONE T15 FULTHD 3.7MM 54MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.056 SUP HCPCS C1713 02.240.056 - SCREW BONE T15 FULTHD 3.7MM 56MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.058 SUP HCPCS C1713 02.240.058 - SCREW BONE T15 FULTHD 3.7MM 58MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.060 SUP HCPCS C1713 02.240.060 - SCREW BONE T15 FULTHD 3.7MM 60MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.065 SUP HCPCS C1713 02.240.065 - SCREW BONE T15 FULTHD 3.7MM 65MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.070 SUP HCPCS C1713 02.240.070 - SCREW BONE T15 FULTHD 3.7MM 70MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.075 SUP HCPCS C1713 02.240.075 - SCREW BONE T15 FULTHD 3.7MM 75MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.080 SUP HCPCS C1713 02.240.080 - SCREW BONE T15 FULTHD 3.7MM 80MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.085 SUP HCPCS C1713 02.240.085 - SCREW BONE T15 FULTHD 3.7MM 85MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.090 SUP HCPCS C1713 02.240.090 - SCREW BONE T15 FULTHD 3.7MM 90MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.095 SUP HCPCS C1713 02.240.095 - SCREW BONE T15 FULTHD 3.7MM 95MM SELF DRILL SELF TAP LOCK BOTH IP/OP $358.45 $265.25 $0.00 $278.40 $156.60 $156.60 $0.00 $0.00 $0.00 $74.71 $266.04 $266.04 $0.00 $0.00 $74.70 $0.00 $212.02 $212.02 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $52.88 $0.00 $0.00 $55.40 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.210 SUP HCPCS C1713 02.240.210 - SCREW BONE CONE 3.7MM 10MM 6MM SELF DRILL SELF TAP LOCK CANN BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.212 SUP HCPCS C1713 02.240.212 - SCREW BONE CONE 3.7MM 12MM 8MM SELF DRILL SELF TAP LOCK CANN BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.214 SUP HCPCS C1713 02.240.214 - SCREW BONE CONE 3.7MM 14MM 8MM SELF DRILL SELF TAP LOCK CANN BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.216 SUP HCPCS C1713 02.240.216 - SCREW BONE CONE 3.7MM 16MM 8MM SELF DRILL SELF TAP LOCK CANN BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.218 SUP HCPCS C1713 02.240.218 - SCREW BONE CONE 3.7MM 18MM 8MM SELF DRILL SELF TAP LOCK CANN BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.220 SUP HCPCS C1713 02.240.220 - SCREW BONE CONE 3.7MM 20MM 15MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.222 SUP HCPCS C1713 02.240.222 - SCREW BONE CONE 3.7MM 22MM 15MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.224 SUP HCPCS C1713 02.240.224 - SCREW BONE CONE 3.7MM 24MM 15MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.226 SUP HCPCS C1713 02.240.226 - SCREW BONE CONE 3.7MM 26MM 15MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.228 SUP HCPCS C1713 02.240.228 - SCREW BONE CONE 3.7MM 28MM 15MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.230 SUP HCPCS C1713 02.240.230 - SCREW BONE CONE 3.7MM 30MM 15MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.232 SUP HCPCS C1713 02.240.232 - SCREW BONE CONE 3.7MM 32MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.234 SUP HCPCS C1713 02.240.234 - SCREW BONE CONE 3.7MM 34MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.236 SUP HCPCS C1713 02.240.236 - SCREW BONE CONE 3.7MM 36MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.238 SUP HCPCS C1713 02.240.238 - SCREW BONE CONE 3.7MM 38MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.240 SUP HCPCS C1713 02.240.240 - SCREW BONE CONE 3.7MM 40MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.242 SUP HCPCS C1713 02.240.242 - SCREW BONE CONE 3.7MM 42MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.244 SUP HCPCS C1713 02.240.244 - SCREW BONE CONE 3.7MM 44MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.246 SUP HCPCS C1713 02.240.246 - SCREW BONE CONE 3.7MM 46MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.248 SUP HCPCS C1713 02.240.248 - SCREW BONE CONE 3.7MM 48MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.250 SUP HCPCS C1713 02.240.250 - SCREW BONE CONE 3.7MM 50MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.252 SUP HCPCS C1713 02.240.252 - SCREW BONE CONE 3.7MM 52MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.254 SUP HCPCS C1713 02.240.254 - SCREW BONE CONE 3.7MM 54MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.256 SUP HCPCS C1713 02.240.256 - SCREW BONE CONE 3.7MM 56MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.258 SUP HCPCS C1713 02.240.258 - SCREW BONE CONE 3.7MM 58MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.260 SUP HCPCS C1713 02.240.260 - SCREW BONE CONE 3.7MM 60MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.265 SUP HCPCS C1713 02.240.265 - SCREW BONE CONE 3.7MM 65MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.270 SUP HCPCS C1713 02.240.270 - SCREW BONE CONE 3.7MM 70MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.275 SUP HCPCS C1713 02.240.275 - SCREW BONE CONE 3.7MM 75MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.280 SUP HCPCS C1713 02.240.280 - SCREW BONE CONE 3.7MM 80MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.285 SUP HCPCS C1713 02.240.285 - SCREW BONE CONE 3.7MM 85MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.290 SUP HCPCS C1713 02.240.290 - SCREW BONE CONE 3.7MM 90MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.240.295 SUP HCPCS C1713 02.240.295 - SCREW BONE CONE 3.7MM 95MM 25MM SELF DRILL SELF TAP LOCK BOTH IP/OP $313.48 $231.98 $0.00 $243.48 $136.96 $136.96 $0.00 $0.00 $0.00 $65.34 $232.66 $232.66 $0.00 $0.00 $65.33 $0.00 $185.42 $185.42 $0.00 $152.18 $241.05 $243.48 $0.00 $0.00 $46.24 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $0.00 02.306.006 SUP HCPCS C1713 02.306.006 - NAIL INTRAMEDULLARY SHORT CANN ORTHOPEDIC NONSTRL PELVIC BOTH IP/OP $967.13 $715.68 $0.00 $751.16 $422.53 $422.53 $0.00 $0.00 $0.00 $201.57 $717.80 $717.80 $0.00 $0.00 $201.55 $0.00 $572.05 $572.05 $0.00 $469.48 $743.65 $751.16 $0.00 $0.00 $142.67 $0.00 $0.00 $149.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.306.007 SUP HCPCS C1713 02.306.007 - NAIL INTRAMEDULLARY LONG CANN ORTHOPEDIC NONSTRL PELVIC BOTH IP/OP $967.13 $715.68 $0.00 $751.16 $422.53 $422.53 $0.00 $0.00 $0.00 $201.57 $717.80 $717.80 $0.00 $0.00 $201.55 $0.00 $572.05 $572.05 $0.00 $469.48 $743.65 $751.16 $0.00 $0.00 $142.67 $0.00 $0.00 $149.48 $0.00 $0.00 $0.00 $0.00 $0.00 02.600.020 SUP Custom 27203010 02.600.020 - WIRE FX 1.6MM 400MM NS KRSH TROC PNT SS BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $0.00 $0.00 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02.600.022.02S SUP HCPCS C1713 02.600.022.02S - PIN 12MM DSTRCT STRL BOTH IP/OP $204.75 $151.52 $0.00 $163.80 $92.14 $92.14 $0.00 $0.00 $0.00 $42.68 $151.97 $151.97 $0.00 $0.00 $42.67 $0.00 $121.11 $121.11 $0.00 $102.38 $162.16 $163.80 $0.00 $0.00 $32.04 $0.00 $0.00 $32.60 $0.00 $0.00 $0.00 $0.00 $0.00 0200-12LV SUP Custom 27203010 0200-12LV - TUBE JJNSTM 12FR 2-3ML STRL LF MC SLK MED PORT RADOPQ STRP BOTH IP/OP $337.35 $249.64 $0.00 $269.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.38 $250.38 $0.00 $0.00 $70.30 $0.00 $0.00 $0.00 $0.00 $168.68 $267.18 $269.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0200-18 SUP Custom 27203010 0200-18 - TUBE JEJUNOSTOMY STANDARD J 18FR TRIMMABLE DISTAL TIP BOTH IP/OP $337.35 $249.64 $0.00 $273.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.38 $250.38 $0.00 $0.00 $70.30 $0.00 $0.00 $0.00 $0.00 $171.21 $271.19 $273.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 022-001 SUP Custom 27203010 022-001 - WIRE PACING 2-0 TAPER LOOP 1/8IN 61CM 89MM 1 ARM SNAP OFF BOTH IP/OP $49.32 $36.50 $0.00 $39.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.61 $36.61 $0.00 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $24.66 $39.06 $39.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02-2005-S SUP HCPCS C1713 02-2005-S - PLATE SS 5 HOLE CMPR BONE 6MM STRL BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 02-2007-S SUP HCPCS C1713 02-2007-S - PLATE 203.2MM SS 7 HOLE 8 GRV CMPR BONE ORTH STRL BOTH IP/OP "$1,342.50 " $993.45 $0.00 "$1,074.00" $604.13 $604.13 $0.00 $0.00 $0.00 $279.81 $996.40 $996.40 $0.00 $0.00 $279.78 $0.00 $794.09 $794.09 $0.00 $671.25 "$1,063.26" "$1,074.00" $0.00 $0.00 $210.10 $0.00 $0.00 $213.73 $0.00 $0.00 $0.00 $0.00 $0.00 02-2009-S SUP HCPCS C1713 02-2009-S - PLATE 6 SS 9 HOLE CMPR BONE 10MM STRL BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 02-2011-S SUP HCPCS C1713 02-2011-S - PLATE 6 12IN SS 11 HOLE 12 GRV CMPR BONE 12MM STRL BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 02-205-085 SUP HCPCS C1713 02-205-085 - SCREW BONE 5MM 85MM LCP SS PROX FEM CANN LCK NONSTRL BOTH IP/OP $415.40 $307.40 $0.00 $332.32 $186.93 $186.93 $0.00 $0.00 $0.00 $86.58 $308.31 $308.31 $0.00 $0.00 $86.57 $0.00 $245.71 $245.71 $0.00 $207.70 $329.00 $332.32 $0.00 $0.00 $65.01 $0.00 $0.00 $66.13 $0.00 $0.00 $0.00 $0.00 $0.00 02-205-280 SUP HCPCS C1713 02-205-280 - SCREW BONE 5MM 80MM LCP SS PERIART FEM/TIB CANN CONICAL BOTH IP/OP $354.75 $262.52 $0.00 $283.80 $159.64 $159.64 $0.00 $0.00 $0.00 $73.94 $263.30 $263.30 $0.00 $0.00 $73.93 $0.00 $209.83 $209.83 $0.00 $177.38 $280.96 $283.80 $0.00 $0.00 $55.52 $0.00 $0.00 $56.48 $0.00 $0.00 $0.00 $0.00 $0.00 02-210-122 SUP HCPCS C1713 02-210-122 - SCREW BONE 2.4MM 22MM LCP SS DISTAL RADL LCK VAR ANG BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 023-001 SUP Custom 27203010 KIT IMMUN TST ELISA ANCRDLPN IGG IGM 96 TST BOTH IP/OP $962.50 $712.25 $0.00 $770.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0250-18 SUP HCPCS B4088 0250-18 - TUBE JJNSTM 18FR 45CM 7-10ML STRL LF MC SLK RADOPQ STRP RTNT BOTH IP/OP $564.68 $417.86 $0.00 $451.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $419.10 $419.10 $0.00 $0.00 $117.68 $0.00 $0.00 $0.00 $0.00 $282.34 $447.23 $451.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0250-22 SUP HCPCS B4088 0250-22 - TUBE JJNSTM 22FR 45CM 7-10ML STRL LF MC SLK RADOPQ STRP RTNT BOTH IP/OP $564.68 $417.86 $0.00 $451.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $419.10 $419.10 $0.00 $0.00 $117.68 $0.00 $0.00 $0.00 $0.00 $282.34 $447.23 $451.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 025-200 SUP Custom 27203010 025-200 - WIRE PACING 2-0 26MM .5 CIR CURVE TAPER 61CM 89MM M25 STYLE BOTH IP/OP $32.29 $23.89 $0.00 $25.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.97 $23.97 $0.00 $0.00 $6.73 $0.00 $0.00 $0.00 $0.00 $16.15 $25.57 $25.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0270-0626 SUP Custom 27203010 LARYNGOSCOPE VID 3 STAT GVL GLIDESCOPE DISP BOTH IP/OP $35.73 $26.44 $0.00 $28.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.86 $28.30 $28.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0270-0628 SUP Custom 27203010 LARYNGOSCOPE VID 4 LG GLIDESCOPE BOTH IP/OP $35.73 $26.44 $0.00 $28.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.86 $28.30 $28.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0277082085S5 SUP Custom 27203010 0277082085S5 - BIT DRILL 7/64IN 128MM BOTH IP/OP $722.50 $534.65 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $536.24 $536.24 $0.00 $0.00 $150.57 $0.00 $0.00 $0.00 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 028506-CE SUP HCPCS C1729 028506-CE - CATH URTH 6FR 25CM 2W FOLEY CLOSE END RND SIL 1.5ML BOTH IP/OP $49.75 $36.82 $0.00 $39.80 $27.01 $27.01 $0.00 $0.00 $0.00 $10.37 $36.92 $36.92 $0.00 $0.00 $10.37 $0.00 $29.43 $29.43 $0.00 $24.88 $39.40 $39.80 $0.00 $0.00 $7.79 $0.00 $0.00 $7.92 $0.00 $0.00 $0.00 $0.00 $0.00 0298-097-100 SUP Custom 27203010 0298-097-100 - BLADE SAW THK.031IN 32MM CUT EDGE HEAVY DUTY STERNUM BOTH IP/OP $57.13 $42.28 $0.00 $45.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.40 $42.40 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $28.56 $45.25 $45.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 02B002 SUP HCPCS C1776 02B002 - GRAFT SFT TIS STRUT AT BOTH IP/OP "$4,592.50 " "$3,398.45" $0.00 "$3,674.00" "$2,066.63" "$2,066.63" $0.00 $0.00 $0.00 $957.19 "$3,408.55" "$3,408.55" $0.00 $0.00 $957.08 $0.00 "$2,264.10" "$2,264.10" $0.00 "$2,296.25" "$3,637.26" "$3,674.00" $0.00 $0.00 $718.73 $0.00 $0.00 $731.13 $0.00 $0.00 $0.00 $0.00 $0.00 02B003 SUP Custom 27804086 02B003 - FILLER BN VOID BLCK .5-1MM 4.5X5X10MM .3ML STRL PO 200R RSRB BOTH IP/OP "$6,170.00 " "$4,565.80" $0.00 "$4,936.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,285.83" $0.00 $0.00 $0.00 $0.00 "$3,085.00" "$4,886.64" "$4,936.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.000.409.98S SUP Custom 27203010 03.000.409.98S - CUTTER SRG THK.6MM 24.6X12.85X2.6MM STRL DMD PIEZOELECTRIC BOTH IP/OP $623.25 $461.21 $0.00 $498.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.58 $462.58 $0.00 $0.00 $129.89 $0.00 $0.00 $0.00 $0.00 $311.63 $493.61 $498.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.000.410.98S SUP Custom 27203010 03.000.410.98S - CUTTER SRG THK.6MM RND 21.9X12.4X1.8MM STRL DMD BOTH IP/OP $623.25 $461.21 $0.00 $498.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.58 $462.58 $0.00 $0.00 $129.89 $0.00 $0.00 $0.00 $0.00 $311.63 $493.61 $498.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.000.411.98S SUP Custom 27803010 03.000.411.98S - SINUS LIFT 22.9X10.1X5X0.4MM FOR PIEZOELECTRIC SYSTEM-STER BOTH IP/OP $623.25 $461.21 $0.00 $498.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.58 $462.58 $0.00 $0.00 $129.89 $0.00 $0.00 $0.00 $0.00 $311.63 $493.61 $498.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.007.020 SUP HCPCS C1769 03.007.020 - GUIDEWIRE ORTHOPEDIC 2.8MM 180MM 10MM TROCAR NONSTRL BOTH IP/OP $117.35 $86.84 $0.00 $91.16 $61.87 $61.87 $0.00 $0.00 $0.00 $24.46 $87.10 $87.10 $0.00 $0.00 $24.46 $0.00 $69.41 $69.41 $0.00 $56.98 $90.25 $91.16 $0.00 $0.00 $17.31 $0.00 $0.00 $18.14 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.015 SUP Custom 27203010 03.010.015 - SET TRAUMA FIX CANN COMPRESSION DEVICE TITANIUM TIBIA BOTH IP/OP $875.25 $647.69 $0.00 $679.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.61 $649.61 $0.00 $0.00 $182.40 $0.00 $0.00 $0.00 $0.00 $424.88 $673.00 $679.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.025 SUP HCPCS C1713 03.010.025 - WIRE FIX 2MM 240MM TROCAR POINT KWIRE NONSTRL EXPERT CANN BOTH IP/OP $66.00 $48.84 $0.00 $51.26 $28.83 $28.83 $0.00 $0.00 $0.00 $13.76 $48.99 $48.99 $0.00 $0.00 $13.75 $0.00 $39.04 $39.04 $0.00 $32.04 $50.75 $51.26 $0.00 $0.00 $9.73 $0.00 $0.00 $10.20 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.028 SUP Custom 27203010 03.010.028 - BIT DRL 15MM 280MM NS CNN LG QC BOTH IP/OP $971.53 $718.93 $0.00 $754.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $721.07 $721.07 $0.00 $0.00 $202.47 $0.00 $0.00 $0.00 $0.00 $471.61 $747.04 $754.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.029 SUP Custom 27203010 03.010.029 - BIT DRILL LARGE 17MM 280MM QUICK COUPLING CANN NONSTRL BOTH IP/OP "$1,215.13 " $899.20 $0.00 $943.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.87 $901.87 $0.00 $0.00 $253.23 $0.00 $0.00 $0.00 $0.00 $589.86 $934.35 $943.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.034 SUP Custom 27203010 03.010.034 - BIT DRL 13MM 465MM NS CNN LG QC FLXB BOTH IP/OP "$1,365.38 " "$1,010.38" $0.00 "$1,060.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,013.38" "$1,013.38" $0.00 $0.00 $284.54 $0.00 $0.00 $0.00 $0.00 $662.80 "$1,049.88" "$1,060.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.036 SUP Custom 27203010 03.010.036 - BIT DRILL LARGE 12MM 190MM CANN LARGE QUICK COUPLING EXPERT BOTH IP/OP "$1,025.50 " $758.87 $0.00 $796.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $761.13 $761.13 $0.00 $0.00 $213.71 $0.00 $0.00 $0.00 $0.00 $497.81 $788.54 $796.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.044 SUP HCPCS C1713 03.010.044 - SCREW INSERTION HANDLE CANN CONNCTNG EXPERT NONSTRL TIBIAL BOTH IP/OP $598.08 $442.58 $0.00 $464.54 $261.30 $261.30 $0.00 $0.00 $0.00 $124.65 $443.89 $443.89 $0.00 $0.00 $124.64 $0.00 $353.76 $353.76 $0.00 $290.34 $459.90 $464.54 $0.00 $0.00 $88.23 $0.00 $0.00 $92.44 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.060 SUP Custom 27203010 03.010.060 - BIT DRL 100MM 3 FLUT 3.2MM 330MM NS CLBRT QC BOTH IP/OP $462.43 $342.20 $0.00 $359.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.21 $343.21 $0.00 $0.00 $96.37 $0.00 $0.00 $0.00 $0.00 $224.48 $355.57 $359.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.061 SUP Custom 27203010 03.010.061 - BIT DRL 100MM 3 FLUT 4.2MM 330MM NS CLBRT QC BOTH IP/OP $462.43 $342.20 $0.00 $359.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.21 $343.21 $0.00 $0.00 $96.37 $0.00 $0.00 $0.00 $0.00 $224.48 $355.57 $359.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.062 SUP Custom 27203010 03.010.062 - BIT DRL 100MM 3 FLUT 5MM 330MM NS CLBRT QC BOTH IP/OP $462.43 $342.20 $0.00 $359.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.21 $343.21 $0.00 $0.00 $96.37 $0.00 $0.00 $0.00 $0.00 $224.48 $355.57 $359.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.078 SUP Custom 27203010 03.010.078 - BIT DRL 4.5-6.5MM 485MM NS LG QC STP BOTH IP/OP $980.28 $725.41 $0.00 $761.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $727.56 $727.56 $0.00 $0.00 $204.29 $0.00 $0.00 $0.00 $0.00 $475.86 $753.77 $761.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.089 SUP Custom 27203010 03.010.089 - BIT DRL 135MM 4.5MM 165MM NS CNN JCHK STP BOTH IP/OP $692.90 $512.75 $0.00 $538.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $514.27 $514.27 $0.00 $0.00 $144.40 $0.00 $0.00 $0.00 $0.00 $336.36 $532.80 $538.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.089S SUP Custom 27203010 03.010.089S - BIT DRILL 165MM 4.5MM CANN JCHK STOP 135MM STRL BOTH IP/OP $849.48 $628.62 $0.00 $679.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $630.48 $630.48 $0.00 $0.00 $177.03 $0.00 $0.00 $0.00 $0.00 $424.74 $672.79 $679.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.100 SUP Custom 27203010 03.010.100 - BIT DRILL 3.2MM 145MM 3 FLUTED QUICK COUPLING NEEDLE POINT BOTH IP/OP $459.50 $340.03 $0.00 $356.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.04 $341.04 $0.00 $0.00 $95.76 $0.00 $0.00 $0.00 $0.00 $223.06 $353.33 $356.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.101 SUP Custom 27203010 03.010.101 - BIT DRILL 4.2MM 145MM 3 FLUTED QUICK COUPLING NEEDLE POINT BOTH IP/OP $459.50 $340.03 $0.00 $356.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.04 $341.04 $0.00 $0.00 $95.76 $0.00 $0.00 $0.00 $0.00 $223.06 $353.33 $356.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.102 SUP Custom 27203010 03.010.102 - BIT DRILL 5MM 145MM QUICK COUPLING 3 FLUTED NONSTRL BOTH IP/OP $459.50 $340.03 $0.00 $356.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.04 $341.04 $0.00 $0.00 $95.76 $0.00 $0.00 $0.00 $0.00 $223.06 $353.33 $356.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.103 SUP Custom 27203010 03.010.103 - BIT DRL 3 FLUT 3.2MM 145MM NS QC BOTH IP/OP $329.68 $243.96 $0.00 $256.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.68 $244.68 $0.00 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $160.04 $253.50 $256.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.104 SUP Custom 27203010 03.010.104 - BIT DRL 3 FLUT 4.2MM 145MM NS QC NDL PNT BOTH IP/OP $329.68 $243.96 $0.00 $256.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.68 $244.68 $0.00 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $160.04 $253.50 $256.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.105 SUP Custom 27203010 03.010.105 - BIT DRILL SHORT 5MM 145MM 3 FLUTED QUICK COUPLING NEEDLE BOTH IP/OP $329.68 $243.96 $0.00 $256.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.68 $244.68 $0.00 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $160.04 $253.50 $256.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.115 SUP HCPCS C1769 03.010.115 - GUIDEWIRE ORTHOPEDIC 3.2MM 290MM THREAD NONSTRL TITANIUM BOTH IP/OP $183.80 $136.01 $0.00 $142.76 $96.90 $96.90 $0.00 $0.00 $0.00 $38.31 $136.42 $136.42 $0.00 $0.00 $38.30 $0.00 $108.72 $108.72 $0.00 $89.23 $141.33 $142.76 $0.00 $0.00 $27.11 $0.00 $0.00 $28.41 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.165 SUP Custom 27203010 03.010.165 - BIT DRILL LARGE 15MM 310MM LARGE QUICK COUPLING CANN BOTH IP/OP "$1,336.20 " $988.79 $0.00 "$1,037.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $991.73 $991.73 $0.00 $0.00 $278.46 $0.00 $0.00 $0.00 $0.00 $648.64 "$1,027.45" "$1,037.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.167 SUP Custom 27203010 03.010.167 - BIT DRILL LARGE 17MM 310MM LARGE QUICK COUPLING CANN BOTH IP/OP "$1,429.58 " "$1,057.89" $0.00 "$1,110.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,061.03" "$1,061.03" $0.00 $0.00 $297.92 $0.00 $0.00 $0.00 $0.00 $693.96 "$1,099.24" "$1,110.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.228 SUP Custom 27203010 03.010.228 - BIT DRILL LARGE 3.2MM 474MM 3 FLUTE CALIBRATED NONSTRL 5MM BOTH IP/OP $827.95 $612.68 $0.00 $643.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $614.50 $614.50 $0.00 $0.00 $172.54 $0.00 $0.00 $0.00 $0.00 $401.93 $636.65 $643.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.437S SUP Custom 27203010 03.010.437S - SLEEVE PROTECTION 12MM STERILE SUPRAPATELLAR BOTH IP/OP $195.48 $144.66 $0.00 $151.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.08 $145.08 $0.00 $0.00 $40.74 $0.00 $0.00 $0.00 $0.00 $94.89 $150.31 $151.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.010.439 SUP Custom 27203010 03.010.439 - BIT DRILL LARGE 12MM 270MM QUICK COUPLING CANN NAIL-EX BOTH IP/OP $935.05 $691.94 $0.00 $726.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $693.99 $693.99 $0.00 $0.00 $194.86 $0.00 $0.00 $0.00 $0.00 $453.91 $719.00 $726.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.019.003 SUP Custom 27203010 03.019.003 - BIT DRILL 10MM HOLLOW NONSTRL OPEN MEDULLARY CANAL MULTILOC BOTH IP/OP $551.40 $408.04 $0.00 $428.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $409.25 $409.25 $0.00 $0.00 $114.91 $0.00 $0.00 $0.00 $0.00 $267.68 $424.00 $428.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.019.016 SUP Custom 27203010 03.019.016 - BIT DRL 3 FLUT 3.8MM 270MM NS QC CLBRT BOTH IP/OP $408.45 $302.25 $0.00 $317.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $303.15 $303.15 $0.00 $0.00 $85.12 $0.00 $0.00 $0.00 $0.00 $198.28 $314.07 $317.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.019.026 SUP HCPCS C1713 03.019.026 - GUIDE ROD ORTH 2.5MM 230MM NS MULTILOC STP TROC TIP SS HLW BOTH IP/OP $39.38 $29.14 $0.00 $30.60 $17.21 $17.21 $0.00 $0.00 $0.00 $8.21 $29.22 $29.22 $0.00 $0.00 $8.21 $0.00 $23.29 $23.29 $0.00 $19.13 $30.29 $30.60 $0.00 $0.00 $5.81 $0.00 $0.00 $6.09 $0.00 $0.00 $0.00 $0.00 $0.00 03.019.026S SUP HCPCS C1713 03.019.026S - GUIDE ROD ORTH 2.5MM 230MM STRL STP TROC TIP SS HLW DRL BOTH IP/OP $134.20 $99.31 $0.00 $104.24 $58.64 $58.64 $0.00 $0.00 $0.00 $27.97 $99.60 $99.60 $0.00 $0.00 $27.97 $0.00 $79.38 $79.38 $0.00 $65.15 $103.20 $104.24 $0.00 $0.00 $19.80 $0.00 $0.00 $20.74 $0.00 $0.00 $0.00 $0.00 $0.00 03.100.034 SUP HCPCS C1713 03.100.034 - TEMPLATE SIZING 20 HOLE PELVIS 3.5 MM LP RECONSTRUCTION BOTH IP/OP $185.55 $137.31 $0.00 $144.12 $81.07 $81.07 $0.00 $0.00 $0.00 $38.67 $137.72 $137.72 $0.00 $0.00 $38.67 $0.00 $109.75 $109.75 $0.00 $90.08 $142.68 $144.12 $0.00 $0.00 $27.37 $0.00 $0.00 $28.68 $0.00 $0.00 $0.00 $0.00 $0.00 03.100.036 SUP HCPCS C1713 03.100.036 - TEMPLATE BENDING 88MM 16 HOLE PELVIS 3.5MM LP CVD BOTH IP/OP $210.85 $156.03 $0.00 $163.78 $92.13 $92.13 $0.00 $0.00 $0.00 $43.95 $156.49 $156.49 $0.00 $0.00 $43.94 $0.00 $124.72 $124.72 $0.00 $102.36 $162.15 $163.78 $0.00 $0.00 $31.10 $0.00 $0.00 $32.59 $0.00 $0.00 $0.00 $0.00 $0.00 03.100.037 SUP HCPCS C1713 03.100.037 - TEMPLATE BENDING 108MM RAD 16 HOLE PELVIS NONSTRL 3.5MM LP BOTH IP/OP $210.85 $156.03 $0.00 $163.78 $92.13 $92.13 $0.00 $0.00 $0.00 $43.95 $156.49 $156.49 $0.00 $0.00 $43.94 $0.00 $124.72 $124.72 $0.00 $102.36 $162.15 $163.78 $0.00 $0.00 $31.10 $0.00 $0.00 $32.59 $0.00 $0.00 $0.00 $0.00 $0.00 03.111.002 SUP Custom 27203010 03.111.002 - BIT DRILL 5MM 300MM 200MM 3 FLUTED CANN CALIBRATION NONSTRL BOTH IP/OP $735.18 $544.03 $0.00 $571.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.65 $545.65 $0.00 $0.00 $153.21 $0.00 $0.00 $0.00 $0.00 $356.89 $565.31 $571.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.112.003 SUP Custom 27203010 03.112.003 - BIT DRILL SHORT 2.8MM CALIBRATED STOP NONSTRL BOTH IP/OP $233.35 $172.68 $0.00 $181.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.19 $173.19 $0.00 $0.00 $48.63 $0.00 $0.00 $0.00 $0.00 $113.28 $179.43 $181.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.114.007 SUP Custom 27203010 03.114.007 - BIT DRL 2 FLUT 1.1MM 75MM NS 61MM MNQK CPLNG 1.5MM CORT SCR BOTH IP/OP $168.68 $124.82 $0.00 $131.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.19 $125.19 $0.00 $0.00 $35.15 $0.00 $0.00 $0.00 $0.00 $81.89 $129.71 $131.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.120.023 SUP Custom 27203010 03.120.023 - DEVICE XTRNFX PUL RDC 4.3 MM PERC DRL GD BOTH IP/OP $979.78 $725.04 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $727.19 $727.19 $0.00 $0.00 $204.19 $0.00 $0.00 $0.00 $0.00 $475.61 $753.37 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.120.026 SUP Custom 27203010 03.120.026 - GUIDEWIRE ORTHOPEDIC 2.5MM 300MM DRILL TIP NONSTRL BOTH IP/OP $127.93 $94.67 $0.00 $99.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.95 $94.95 $0.00 $0.00 $26.66 $0.00 $0.00 $0.00 $0.00 $62.10 $98.37 $99.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.122.002 SUP Custom 27203010 03.122.002 - BIT DRL 95MM 2.8MM 248MM NS QC CLBRT BOTH IP/OP $296.60 $219.48 $0.00 $230.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.14 $220.14 $0.00 $0.00 $61.81 $0.00 $0.00 $0.00 $0.00 $143.98 $228.06 $230.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.122.056 SUP Custom 27203010 03.122.056 - DEVICE MEASURING AIMING NOSE PHILOS NONSTRL BOTH IP/OP "$2,745.33 " "$2,031.54" $0.00 "$2,132.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,037.58" "$2,037.58" $0.00 $0.00 $572.13 $0.00 $0.00 $0.00 $0.00 "$1,332.68" "$2,110.96" "$2,132.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.100 SUP Custom 27203010 03.130.100 - BIT DRL 1MM 75MM KRSH THRD HL WRE HND 1.3MM SCR BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.102 SUP Custom 27203010 03.130.102 - BIT DRL 1MM 61MM MNQK CPLNG THRD HL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.110 SUP Custom 27203010 03.130.110 - BIT DRL 1.3MM 60MM KRSH THRD HL WRE GLD HND BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.112 SUP Custom 27203010 03.130.112 - BIT DRL 1.3MM 46MM MNQK CPLNG GLD HL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.120 SUP Custom 27203010 03.130.120 - GUIDE DRL 1MM THRD 1.3MM LCK PLT BOTH IP/OP $499.03 $369.28 $0.00 $387.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.38 $370.38 $0.00 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $242.24 $383.71 $387.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.125 SUP Custom 27203010 03.130.125 - SLEEVE DRL 1.3MM 1MM YLW 2 1.3MM CORT SCR BOTH IP/OP $618.50 $457.69 $0.00 $480.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $459.05 $459.05 $0.00 $0.00 $128.90 $0.00 $0.00 $0.00 $0.00 $300.25 $475.60 $480.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.130 SUP HCPCS C1713 03.130.130 - HOLDER PLT 1.3-2 MM BOTH IP/OP $529.95 $392.16 $0.00 $411.60 $231.53 $231.53 $0.00 $0.00 $0.00 $110.45 $393.33 $393.33 $0.00 $0.00 $110.44 $0.00 $313.47 $313.47 $0.00 $257.25 $407.48 $411.60 $0.00 $0.00 $78.18 $0.00 $0.00 $81.91 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.140 SUP HCPCS C1713 03.130.140 - PIN BNDRG 1.3MM LCK PLT BOTH IP/OP $499.03 $369.28 $0.00 $387.58 $218.01 $218.01 $0.00 $0.00 $0.00 $104.01 $370.38 $370.38 $0.00 $0.00 $104.00 $0.00 $295.17 $295.17 $0.00 $242.24 $383.71 $387.58 $0.00 $0.00 $73.61 $0.00 $0.00 $77.13 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.200 SUP Custom 27203010 03.130.200 - BIT DRL 1.1MM 70MM KWR 1.5MM SCR THRD HL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.202 SUP Custom 27203010 03.130.202 - BIT DRL 1.1MM 56MM MNQK CPLNG THRD HL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.210 SUP Custom 27203010 03.130.210 - BIT DRL 1.5MM 62MM BLU KWR ATCH 2MM SCR GLD HL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.212 SUP Custom 27203010 03.130.212 - BIT DRL 1.5MM 48MM MNQK CPLNG GLD HL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.215 SUP Custom 27203010 03.130.215 - COUNTERSINK DRL 1.3 MM 1.5 MM 2 MM SCR BOTH IP/OP $414.68 $306.86 $0.00 $322.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.77 $307.77 $0.00 $0.00 $86.42 $0.00 $0.00 $0.00 $0.00 $201.30 $318.86 $322.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.221 SUP Custom 27203010 03.130.221 - GUIDE DRL 1.1MM 2 VA FRHD 1.5MM LCK PLT BOTH IP/OP "$1,234.20 " $913.31 $0.00 $958.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $916.02 $916.02 $0.00 $0.00 $257.21 $0.00 $0.00 $0.00 $0.00 $599.13 $949.01 $958.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.225 SUP Custom 27203010 03.130.225 - SLEEVE DRL 1.5MM 1.1MM RD 2 1.5MM CORT SCR BOTH IP/OP $618.50 $457.69 $0.00 $480.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $459.05 $459.05 $0.00 $0.00 $128.90 $0.00 $0.00 $0.00 $0.00 $300.25 $475.60 $480.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.250 SUP Custom 27203010 03.130.250 - GAUGE D 1.3/1.5/2 MM SCR BOTH IP/OP "$2,242.08 " "$1,659.14" $0.00 "$1,741.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,664.07" "$1,664.07" $0.00 $0.00 $467.25 $0.00 $0.00 $0.00 $0.00 "$1,088.39" "$1,724.01" "$1,741.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.260 SUP HCPCS C1713 03.130.260 - PLIERS PLT BNDRG RT 1.3 MM LCK 1.5/2 MM VA PLT BOTH IP/OP $833.58 $616.85 $0.00 $647.44 $364.19 $364.19 $0.00 $0.00 $0.00 $173.74 $618.68 $618.68 $0.00 $0.00 $173.72 $0.00 $493.06 $493.06 $0.00 $404.65 $640.97 $647.44 $0.00 $0.00 $122.97 $0.00 $0.00 $128.84 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.261 SUP HCPCS C1713 03.130.261 - PLIERS PLT BNDRG LT 1.3 MM LCK 1.5/2 MM VA PLT BOTH IP/OP $833.58 $616.85 $0.00 $647.44 $364.19 $364.19 $0.00 $0.00 $0.00 $173.74 $618.68 $618.68 $0.00 $0.00 $173.72 $0.00 $493.06 $493.06 $0.00 $404.65 $640.97 $647.44 $0.00 $0.00 $122.97 $0.00 $0.00 $128.84 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.292 SUP Custom 27203010 03.130.292 - GUIDE DRL YLW INS 1MM BIT BOTH IP/OP $217.88 $161.23 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.71 $161.71 $0.00 $0.00 $45.41 $0.00 $0.00 $0.00 $0.00 $105.76 $167.53 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.293 SUP Custom 27203010 03.130.293 - GUIDE DRL RD INS 1.1MM BIT BOTH IP/OP $217.88 $161.23 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.71 $161.71 $0.00 $0.00 $45.41 $0.00 $0.00 $0.00 $0.00 $105.76 $167.53 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.294 SUP Custom 27203010 03.130.294 - GUIDE DRL YLW INS 1.3MM BIT BOTH IP/OP $217.88 $161.23 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.71 $161.71 $0.00 $0.00 $45.41 $0.00 $0.00 $0.00 $0.00 $105.76 $167.53 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.295 SUP Custom 27203010 03.130.295 - GUIDE DRL RD INS 1.5MM BIT BOTH IP/OP $217.88 $161.23 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.71 $161.71 $0.00 $0.00 $45.41 $0.00 $0.00 $0.00 $0.00 $105.76 $167.53 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.296 SUP Custom 27203010 03.130.296 - GUIDE DRL BLU INS 1.5MM BIT BOTH IP/OP $217.88 $161.23 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.71 $161.71 $0.00 $0.00 $45.41 $0.00 $0.00 $0.00 $0.00 $105.76 $167.53 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.297 SUP Custom 27203010 03.130.297 - GUIDE DRL BLU INS 2MM BIT BOTH IP/OP $217.88 $161.23 $0.00 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.71 $161.71 $0.00 $0.00 $45.41 $0.00 $0.00 $0.00 $0.00 $105.76 $167.53 $169.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.300 SUP Custom 27203010 03.130.300 - BIT DRL 1.5MM 88MM BLU KRSH WRE ATCH 2MM SCR BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.302 SUP Custom 27203010 03.130.302 - BIT DRL 1.5MM 74MM 57MM CLR CD PILT HL MNQK CPLNG BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.310 SUP Custom 27203010 03.130.310 - BIT DRL 2MM 71MM 41MM CLR CD GLD HL JCHK BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.312 SUP Custom 27203010 03.130.312 - BIT DRL 2MM 57MM MNQK CPLNG GLD HL BOTH IP/OP $161.65 $119.62 $0.00 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.98 $119.98 $0.00 $0.00 $33.69 $0.00 $0.00 $0.00 $0.00 $78.48 $124.30 $125.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.321 SUP Custom 27203010 03.130.321 - GUIDE DRL 1.5MM 2 VA LCK FR HND 2MM PLT BOTH IP/OP "$1,234.20 " $913.31 $0.00 $958.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $916.02 $916.02 $0.00 $0.00 $257.21 $0.00 $0.00 $0.00 $0.00 $599.13 $949.01 $958.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.130.325 SUP Custom 27203010 03.130.325 - SLEEVE DRL 1.5MM BLU 2 2MM CORT SCR BOTH IP/OP $618.50 $457.69 $0.00 $480.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $459.05 $459.05 $0.00 $0.00 $128.90 $0.00 $0.00 $0.00 $0.00 $300.25 $475.60 $480.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.161.024 SUP Custom 27203010 03.161.024 - BIT DRL 3.2MM NS OCPTL CRV FSN SYS BOTH IP/OP "$1,060.00 " $784.40 $0.00 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $786.73 $786.73 $0.00 $0.00 $220.90 $0.00 $0.00 $0.00 $0.00 $530.00 $839.52 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.161.026 SUP HCPCS C1713 03.161.026 - TAP SURG NONSTRL 4.5 MM OCCPTL SCREW BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 03.161.027 SUP Custom 27203010 03.161.027 - SCREWDRIVER SURG UNIVERSAL JOINT 4 MM OCCPTL SCREW BOTH IP/OP "$3,267.50 " "$2,417.95" $0.00 "$2,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,425.14" "$2,425.14" $0.00 $0.00 $680.95 $0.00 $0.00 $0.00 $0.00 "$1,633.75" "$2,587.86" "$2,614.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.211.410 SUP Custom 27203010 03.211.410 - WIRE FX 1.6MM 150MM NS 10MM LCP CMPR THRD BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $0.00 $0.00 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.211.415 SUP Custom 27203010 03.211.415 - WIRE FX 1.6MM 150MM NS 15MM LCP CMPR THRD BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $0.00 $0.00 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.211.420 SUP Custom 27203010 03.211.420 - WIRE FX 1.6MM 150MM NS 20MM LCP CMPR THRD BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $0.00 $0.00 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.211.425 SUP Custom 27203010 03.211.425 - WIRE FX 1.6MM 150MM NS 25MM LCP CMPR THRD BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $0.00 $0.00 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.211.430 SUP Custom 27203010 03.211.430 - WIRE FX 1.6MM 150MM NS 30MM LCP CMPR THRD BOTH IP/OP $85.75 $63.46 $0.00 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.64 $63.64 $0.00 $0.00 $17.87 $0.00 $0.00 $0.00 $0.00 $41.63 $65.93 $66.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.211.435 SUP Custom 27203010 03.211.435 - WIRE FX 1.6MM 150MM NS 35MM LCP CMPR THRD BOTH IP/OP $88.55 $65.53 $0.00 $68.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.72 $65.72 $0.00 $0.00 $18.45 $0.00 $0.00 $0.00 $0.00 $42.99 $68.10 $68.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.211.440 SUP Custom 27203010 03.211.440 - WIRE FX 1.6MM 150MM NS 40MM LCP CMPR THRD BOTH IP/OP $88.55 $65.53 $0.00 $68.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.72 $65.72 $0.00 $0.00 $18.45 $0.00 $0.00 $0.00 $0.00 $42.99 $68.10 $68.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.226.039 SUP Custom 27203010 03.226.039 - BIT DRILL 3.2MM CANN NONSTRL 4.5MM SCREW BOTH IP/OP $753.45 $557.55 $0.00 $585.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $559.21 $559.21 $0.00 $0.00 $157.02 $0.00 $0.00 $0.00 $0.00 $365.75 $579.35 $585.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.226.042 SUP Custom 27203010 03.226.042 - BIT DRILL 4MM DEVICE CANN BOTH IP/OP $811.08 $600.20 $0.00 $629.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $601.98 $601.98 $0.00 $0.00 $169.03 $0.00 $0.00 $0.00 $0.00 $393.73 $623.66 $629.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.227.042 SUP Custom 27203010 03.227.042 - BIT DRILL 6MM CANN NONSTRL 6.5MM HEADLESS COMPRESSION SCREW BOTH IP/OP $773.13 $572.12 $0.00 $600.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $573.81 $573.81 $0.00 $0.00 $161.12 $0.00 $0.00 $0.00 $0.00 $375.31 $594.50 $600.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.301.010S SUP Custom 27203010 03.301.010S - SET EXFIX LARGE FRAME ANKLE STERILE BOTH IP/OP "$5,761.33 " "$4,263.38" $0.00 "$4,474.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.66" $0.00 $0.00 $0.00 $0.00 "$2,796.76" "$4,430.08" "$4,474.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.301.011S SUP Custom 27203010 03.301.011S - KIT TRAUMA LARGE EXFIX STERILE BOTH IP/OP "$6,037.58 " "$4,467.81" $0.00 "$4,689.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,258.23" $0.00 $0.00 $0.00 $0.00 "$2,930.86" "$4,642.49" "$4,689.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.301.012S SUP Custom 27203010 03.301.012S - KIT FRAME LARGE EXFIX PELVIC STERILE BOTH IP/OP "$8,095.05 " "$5,990.34" $0.00 "$6,287.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,687.01" $0.00 $0.00 $0.00 $0.00 "$3,929.63" "$6,224.53" "$6,287.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.304.220S SUP HCPCS C1713 03.304.220S - FIXATOR XTRNFX 2.5MM 4MM 200MM STRL LF SCHNZ LOPRFL ROD CFBR BOTH IP/OP "$1,659.78 " "$1,228.24" $0.00 "$1,289.14" $725.14 $725.14 $0.00 $0.00 $0.00 $345.94 "$1,231.89" "$1,231.89" $0.00 $0.00 $345.90 $0.00 $981.76 $981.76 $0.00 $805.71 "$1,276.25" "$1,289.14" $0.00 $0.00 $244.84 $0.00 $0.00 $256.54 $0.00 $0.00 $0.00 $0.00 $0.00 03.304.222S SUP HCPCS C1713 03.304.222S - FIXATOR XTRNFX 2.5-4MM 220MM STRL LOPRFL ROD CFBR WRST BOTH IP/OP "$1,659.78 " "$1,228.24" $0.00 "$1,289.14" $725.14 $725.14 $0.00 $0.00 $0.00 $345.94 "$1,231.89" "$1,231.89" $0.00 $0.00 $345.90 $0.00 $981.76 $981.76 $0.00 $805.71 "$1,276.25" "$1,289.14" $0.00 $0.00 $244.84 $0.00 $0.00 $256.54 $0.00 $0.00 $0.00 $0.00 $0.00 03.304.320S SUP Custom 27203010 03.304.320S - FIXATOR XTRNFX 3MM 4MM 200MM STRL LF SCHNZ ROD LOPRFL SLF BOTH IP/OP "$2,106.48 " "$1,558.80" $0.00 "$1,636.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,563.43" "$1,563.43" $0.00 $0.00 $438.99 $0.00 $0.00 $0.00 $0.00 "$1,022.56" "$1,619.74" "$1,636.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.304.322S SUP Custom 27203010 03.304.322S - ROD EXFIX 220MM MRI SAFE LOW-PROFILE WRIST FIXATOR BOTH IP/OP "$2,106.48 " "$1,558.80" $0.00 "$1,636.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,563.43" "$1,563.43" $0.00 $0.00 $438.99 $0.00 $0.00 $0.00 $0.00 "$1,022.56" "$1,619.74" "$1,636.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.305.004 SUP Custom 27203010 03.305.004 - BIT DRL 24MM 1.8/4MM NS MATRIXRIB JLTCH CPLNG STP STRYK BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $0.00 $0.00 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.305.006 SUP Custom 27203010 03.305.006 - CLAMP XTRNFX NS ADJ MNDB XTRNFXTR II BOTH IP/OP "$1,392.50 " "$1,030.45" $0.00 "$1,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.51" "$1,033.51" $0.00 $0.00 $290.20 $0.00 $0.00 $0.00 $0.00 $696.25 "$1,102.86" "$1,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.305.009 SUP Custom 27203010 03.305.009 - TEMPLATE SIZING 4MM ROD BOTH IP/OP $917.50 $678.95 $0.00 $734.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $680.97 $680.97 $0.00 $0.00 $191.21 $0.00 $0.00 $0.00 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.305.500 SUP Custom 27203010 03.305.500 - ROD EXFIX 500MM NONSTRL MANDIB FIXATOR BOTH IP/OP "$4,300.00 " "$3,182.00" $0.00 "$3,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,191.46" "$3,191.46" $0.00 $0.00 $896.12 $0.00 $0.00 $0.00 $0.00 "$2,150.00" "$3,405.60" "$3,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.306.010 SUP Custom 27203010 03.306.010 - SET ORTHOPEDIC C CLMP II PELVIC BOTH IP/OP "$13,379.38 " "$9,900.74" $0.00 "$10,391.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,788.26" $0.00 $0.00 $0.00 $0.00 "$6,494.85" "$10,287.84" "$10,391.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.307.001 SUP Custom 27203010 03.307.001 - CLAMP EXFIX WIRE FIX EXTERNAL MIDFAC DISTRCT BOTH IP/OP $632.50 $468.05 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.44 $469.44 $0.00 $0.00 $131.81 $0.00 $0.00 $0.00 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.307.010 SUP Custom 27203010 03.307.010 - ROD EXFIX 100MM CARFBR NONSTRL MIDFAC DISTRCT BOTH IP/OP $515.00 $381.10 $0.00 $412.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.23 $382.23 $0.00 $0.00 $107.33 $0.00 $0.00 $0.00 $0.00 $257.50 $407.88 $412.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.307.105 SUP Custom 27203010 03.307.105 - BAR EXFIX 50MM CONNCTNG EXTERNAL MIDFAC DISTRCT BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $0.00 $0.00 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.307.112 SUP Custom 27203010 03.307.112 - BAR EXFIX 120MM CONNCTNG EXTERNAL MIDFAC DISTRCT BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $0.00 $0.00 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.011 SUP Custom 27203010 03.311.011 - CLAMP EXFIX SCREW MR SAFE PIVOT SCHANZ NONSTRL BOTH IP/OP $680.63 $503.67 $0.00 $528.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.16 $505.16 $0.00 $0.00 $141.84 $0.00 $0.00 $0.00 $0.00 $330.40 $523.35 $528.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.012 SUP Custom 27803010 03.311.012 - HINGE XTRNFX NS LCK MRI SAFE BOTH IP/OP $340.88 $252.25 $0.00 $264.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.00 $253.00 $0.00 $0.00 $71.04 $0.00 $0.00 $0.00 $0.00 $165.48 $262.11 $264.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.022 SUP HCPCS C1713 03.311.022 - PLATE EXFIX 90D 2 HOLE OFFST CONNCTNG NONSTRL BOTH IP/OP $157.08 $116.24 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $32.74 $116.58 $116.58 $0.00 $0.00 $32.73 $0.00 $92.91 $92.91 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.17 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.023 SUP HCPCS C1713 03.311.023 - PLATE EXFIX 90D 3 HOLE OFFST CONNCTNG NONSTRL BOTH IP/OP $168.20 $124.47 $0.00 $130.64 $73.49 $73.49 $0.00 $0.00 $0.00 $35.06 $124.84 $124.84 $0.00 $0.00 $35.05 $0.00 $99.49 $99.49 $0.00 $81.65 $129.33 $130.64 $0.00 $0.00 $24.81 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.024 SUP HCPCS C1713 03.311.024 - PLATE EXFIX 90D 4 HOLE OFFST CONNCTNG NONSTRL BOTH IP/OP $180.45 $133.53 $0.00 $140.16 $78.84 $78.84 $0.00 $0.00 $0.00 $37.61 $133.93 $133.93 $0.00 $0.00 $37.61 $0.00 $106.74 $106.74 $0.00 $87.60 $138.76 $140.16 $0.00 $0.00 $26.62 $0.00 $0.00 $27.89 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.025 SUP HCPCS C1713 03.311.025 - PLATE EXFIX 90D 5 HOLE OFFST CONNCTNG NONSTRL BOTH IP/OP $192.70 $142.60 $0.00 $149.68 $84.20 $84.20 $0.00 $0.00 $0.00 $40.16 $143.02 $143.02 $0.00 $0.00 $40.16 $0.00 $113.98 $113.98 $0.00 $93.55 $148.18 $149.68 $0.00 $0.00 $28.43 $0.00 $0.00 $29.79 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.031 SUP Custom 27203010 03.311.031 - EXTRACTOR SRG 1.5MM 400MM NS SMTH MR SF DSTRCT OSTEOGENESIS BOTH IP/OP $119.20 $88.21 $0.00 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.47 $88.47 $0.00 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $57.86 $91.66 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.032 SUP Custom 27203010 03.311.032 - WIRE FIX 1.8MM 400MM SMOOTH MRI SAFE NONSTRL BOTH IP/OP $119.20 $88.21 $0.00 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.47 $88.47 $0.00 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $57.86 $91.66 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.033 SUP Custom 27203010 03.311.033 - WIRE FX 2MM 400MM NS SMTH MRI SAFE BOTH IP/OP $119.20 $88.21 $0.00 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.47 $88.47 $0.00 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $57.86 $91.66 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.036 SUP Custom 27203010 03.311.036 - WIRE XTRNFX 1.5MM SMTH HLF PNT TIP MRI SAFE BOTH IP/OP $119.20 $88.21 $0.00 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.47 $88.47 $0.00 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $57.86 $91.66 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.037 SUP Custom 27203010 03.311.037 - WIRE XTRNFX 1.8MM SMTH HLF PNT TIP MRI SAFE BOTH IP/OP $119.20 $88.21 $0.00 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.47 $88.47 $0.00 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $57.86 $91.66 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.038 SUP Custom 27203010 03.311.038 - WIRE XTRNFX 2MM SMTH HLF PNT TIP MRI SAFE BOTH IP/OP $119.20 $88.21 $0.00 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.47 $88.47 $0.00 $0.00 $24.84 $0.00 $0.00 $0.00 $0.00 $57.86 $91.66 $92.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.041 SUP Custom 27203010 03.311.041 - WIRE XTRNFX 1.5MM 400MM RDC MRI SAFE BOTH IP/OP $370.95 $274.50 $0.00 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.32 $275.32 $0.00 $0.00 $77.31 $0.00 $0.00 $0.00 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.042 SUP Custom 27203010 03.311.042 - WIRE XTRNFX 1.8MM 400MM RDC MRI SAFE BOTH IP/OP $370.95 $274.50 $0.00 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.32 $275.32 $0.00 $0.00 $77.31 $0.00 $0.00 $0.00 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.043 SUP Custom 27203010 03.311.043 - WIRE FX 2MM 400MM NS SMTH MRI SAFE BOTH IP/OP $370.95 $274.50 $0.00 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.32 $275.32 $0.00 $0.00 $77.31 $0.00 $0.00 $0.00 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.046 SUP Custom 27203010 03.311.046 - WIRE XTRNFX 1.5MM RDC HLF PNT TIP MRI SAFE BOTH IP/OP $370.95 $274.50 $0.00 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.32 $275.32 $0.00 $0.00 $77.31 $0.00 $0.00 $0.00 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.047 SUP Custom 27203010 03.311.047 - WIRE XTRNFX 1.8MM RDC HLF PNT TIP MRI SAFE BOTH IP/OP $370.95 $274.50 $0.00 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.32 $275.32 $0.00 $0.00 $77.31 $0.00 $0.00 $0.00 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.048 SUP Custom 27203010 03.311.048 - WIRE XTRNFX 2MM RDC HLF PNT TIP MRI SAFE BOTH IP/OP $370.95 $274.50 $0.00 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.32 $275.32 $0.00 $0.00 $77.31 $0.00 $0.00 $0.00 $0.00 $180.08 $285.24 $288.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.060 SUP Custom 27203010 03.311.060 - NUT XTRNFX SQ MRI SAFE BOTH IP/OP $127.00 $93.98 $0.00 $98.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.26 $94.26 $0.00 $0.00 $26.47 $0.00 $0.00 $0.00 $0.00 $61.65 $97.65 $98.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.061.10 SUP Custom 27203010 03.311.061.10 - NUT XTRNFX NS LF DISP BOTH IP/OP $6.09 $4.51 $0.00 $4.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.52 $4.52 $0.00 $0.00 $1.27 $0.00 $0.00 $0.00 $0.00 $3.05 $4.82 $4.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.062 SUP Custom 27803010 03.311.062 - NUT ORTHOPEDIC MRI SAFE NONSTRL BOTH IP/OP $246.18 $182.17 $0.00 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.71 $182.71 $0.00 $0.00 $51.30 $0.00 $0.00 $0.00 $0.00 $119.50 $189.29 $191.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.070 SUP Custom 27203010 03.311.070 - POST EXFIX SHORT WIRE MRI SAFE NONSTRL BOTH IP/OP $305.23 $225.87 $0.00 $237.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $226.54 $226.54 $0.00 $0.00 $63.61 $0.00 $0.00 $0.00 $0.00 $148.16 $234.69 $237.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.071 SUP Custom 27203010 03.311.071 - POST XTRNFX TLL NS WRE MRI SAFE BOTH IP/OP $346.43 $256.36 $0.00 $269.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.12 $257.12 $0.00 $0.00 $72.19 $0.00 $0.00 $0.00 $0.00 $168.18 $266.39 $269.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.090 SUP Custom 27803010 03.311.090 - WASHER XTRNFX SPHRCL CPLNG MRI SAFE BOTH IP/OP $54.03 $39.98 $0.00 $41.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.10 $40.10 $0.00 $0.00 $11.26 $0.00 $0.00 $0.00 $0.00 $26.23 $41.54 $41.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.091 SUP Custom 27203010 03.311.091 - SUPPORT XTRNFX OBLQ NS BOTH IP/OP $859.98 $636.39 $0.00 $667.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.27 $638.27 $0.00 $0.00 $179.22 $0.00 $0.00 $0.00 $0.00 $417.46 $661.26 $667.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.106 SUP HCPCS C1713 03.311.106 - ROD EXFIX 60MM THREAD SLOT MR SAFE NONSTRL DISTRACTION BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.108 SUP HCPCS C1713 03.311.108 - ROD EXFIX 80MM THREAD SLOT MR SAFE NONSTRL DISTRACTION BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.110 SUP Custom 27203010 03.311.110 - ROD EXFIX 100MM THREAD SLOT MR SAFE NONSTRL DISTRACTION BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.112 SUP HCPCS C1713 03.311.112 - ROD EXFIX 120MM THREAD MR SAFE NONSTRL DISTRACTION BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $21.82 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $61.93 $61.93 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.115 SUP HCPCS C1713 03.311.115 - ROD EXFIX 150MM THREAD MR SAFE NONSTRL DISTRACTION BOTH IP/OP $104.70 $77.48 $0.00 $81.32 $45.74 $45.74 $0.00 $0.00 $0.00 $0.00 $77.71 $77.71 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $50.83 $80.51 $81.32 $0.00 $0.00 $15.45 $0.00 $0.00 $16.18 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.120 SUP Custom 27203010 03.311.120 - ROD EXFIX 200MM THREAD MR SAFE NONSTRL DISTRACTION BOTH IP/OP $113.63 $84.09 $0.00 $88.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.33 $84.33 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $55.16 $87.38 $88.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.125 SUP Custom 27203010 03.311.125 - ROD EXFIX 250MM THREAD MR SAFE NONSTRL DISTRACTION BOTH IP/OP $113.63 $84.09 $0.00 $88.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.33 $84.33 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $55.16 $87.38 $88.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.130 SUP Custom 27203010 03.311.130 - ROD EXFIX 300MM THREAD MR SAFE NONSTRL DISTRACTION BOTH IP/OP $131.45 $97.27 $0.00 $102.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.56 $97.56 $0.00 $0.00 $27.39 $0.00 $0.00 $0.00 $0.00 $63.81 $101.08 $102.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.135 SUP Custom 27203010 03.311.135 - ROD EXFIX 350MM THREAD MR SAFE NONSTRL DISTRACTION BOTH IP/OP $131.45 $97.27 $0.00 $102.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.56 $97.56 $0.00 $0.00 $27.39 $0.00 $0.00 $0.00 $0.00 $63.81 $101.08 $102.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.140 SUP Custom 27203010 03.311.140 - ROD EXFIX 400MM THREAD MR SAFE NONSTRL DISTRACTION BOTH IP/OP $172.65 $127.76 $0.00 $134.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.14 $128.14 $0.00 $0.00 $35.98 $0.00 $0.00 $0.00 $0.00 $83.81 $132.76 $134.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.171 SUP Custom 27203010 03.311.171 - POST XTRNFX NS 1 HL WRE FEM BOTH IP/OP $333.08 $246.48 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.21 $247.21 $0.00 $0.00 $69.41 $0.00 $0.00 $0.00 $0.00 $161.69 $256.12 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.172 SUP Custom 27203010 03.311.172 - POST XTRNFX NS 2 HL WRE FEM BOTH IP/OP $346.43 $256.36 $0.00 $269.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.12 $257.12 $0.00 $0.00 $72.19 $0.00 $0.00 $0.00 $0.00 $168.18 $266.39 $269.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.173 SUP Custom 27203010 03.311.173 - POST XTRNFX NS 3 HL WRE FEM BOTH IP/OP $358.70 $265.44 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $266.23 $266.23 $0.00 $0.00 $74.75 $0.00 $0.00 $0.00 $0.00 $174.13 $275.81 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.174 SUP Custom 27203010 03.311.174 - POST XTRNFX NS 4 HL WRE FEM BOTH IP/OP $373.18 $276.15 $0.00 $289.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.97 $276.97 $0.00 $0.00 $77.77 $0.00 $0.00 $0.00 $0.00 $181.15 $286.94 $289.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.175 SUP Custom 27203010 03.311.175 - POST XTRNFX NS 5 HL WRE FEM BOTH IP/OP $385.43 $285.22 $0.00 $299.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.06 $286.06 $0.00 $0.00 $80.32 $0.00 $0.00 $0.00 $0.00 $187.10 $296.37 $299.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.200 SUP HCPCS C1713 03.311.200 - PLATE XTRNFX FLT NS 1 HL CNCT MRI SAFE FEM CFBR RING BOTH IP/OP $118.08 $87.38 $0.00 $91.72 $51.59 $51.59 $0.00 $0.00 $0.00 $24.61 $87.64 $87.64 $0.00 $0.00 $24.61 $0.00 $69.84 $69.84 $0.00 $57.33 $90.80 $91.72 $0.00 $0.00 $17.42 $0.00 $0.00 $18.25 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.201 SUP HCPCS C1713 03.311.201 - PLATE XTRNFX NS 1 HL CNCT MRI SAFE FEM CFBR RING BOTH IP/OP $118.08 $87.38 $0.00 $91.72 $51.59 $51.59 $0.00 $0.00 $0.00 $24.61 $87.64 $87.64 $0.00 $0.00 $24.61 $0.00 $69.84 $69.84 $0.00 $57.33 $90.80 $91.72 $0.00 $0.00 $17.42 $0.00 $0.00 $18.25 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.202 SUP HCPCS C1713 03.311.202 - PLATE XTRNFX NS 2 HL CNCT MRI SAFE FEM CFBR RING BOTH IP/OP $127.00 $93.98 $0.00 $98.64 $55.49 $55.49 $0.00 $0.00 $0.00 $26.47 $94.26 $94.26 $0.00 $0.00 $26.47 $0.00 $75.12 $75.12 $0.00 $61.65 $97.65 $98.64 $0.00 $0.00 $18.73 $0.00 $0.00 $19.63 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.203 SUP HCPCS C1713 03.311.203 - PLATE XTRNFX NS 3 HL CNCT MRI SAFE FEM CFBR RING BOTH IP/OP $131.45 $97.27 $0.00 $102.10 $57.43 $57.43 $0.00 $0.00 $0.00 $27.40 $97.56 $97.56 $0.00 $0.00 $27.39 $0.00 $77.75 $77.75 $0.00 $63.81 $101.08 $102.10 $0.00 $0.00 $19.39 $0.00 $0.00 $20.32 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.204 SUP HCPCS C1713 03.311.204 - PLATE XTRNFX NS 4 HL CNCT MRI SAFE FEM CFBR RING BOTH IP/OP $149.28 $110.47 $0.00 $115.94 $65.22 $65.22 $0.00 $0.00 $0.00 $31.11 $110.79 $110.79 $0.00 $0.00 $31.11 $0.00 $88.30 $88.30 $0.00 $72.46 $114.78 $115.94 $0.00 $0.00 $22.02 $0.00 $0.00 $23.07 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.205 SUP HCPCS C1713 03.311.205 - PLATE XTRNFX NS 5 HL CNCT MRI SAFE FEM CFBR RING BOTH IP/OP $172.65 $127.76 $0.00 $134.10 $75.43 $75.43 $0.00 $0.00 $0.00 $35.98 $128.14 $128.14 $0.00 $0.00 $35.98 $0.00 $102.12 $102.12 $0.00 $83.81 $132.76 $134.10 $0.00 $0.00 $25.47 $0.00 $0.00 $26.69 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.212 SUP HCPCS C1713 03.311.212 - PLATE XTRNFX NS 2 HL CNCT BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $54.99 $54.99 $0.00 $0.00 $0.00 $26.24 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $74.46 $74.46 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $18.57 $0.00 $0.00 $19.45 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.213 SUP HCPCS C1713 03.311.213 - PLATE XTRNFX NS 3 HL CNCT BOTH IP/OP $139.25 $103.05 $0.00 $108.16 $60.84 $60.84 $0.00 $0.00 $0.00 $29.02 $103.35 $103.35 $0.00 $0.00 $29.02 $0.00 $82.37 $82.37 $0.00 $67.60 $107.08 $108.16 $0.00 $0.00 $20.54 $0.00 $0.00 $21.52 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.214 SUP HCPCS C1713 03.311.214 - PLATE XTRNFX NS 4 HL CNCT BOTH IP/OP $150.38 $111.28 $0.00 $116.80 $65.70 $65.70 $0.00 $0.00 $0.00 $31.34 $111.61 $111.61 $0.00 $0.00 $31.34 $0.00 $88.95 $88.95 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $22.18 $0.00 $0.00 $23.24 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.215 SUP HCPCS C1713 03.311.215 - PLATE XTRNFX NS 5 HL CNCT BOTH IP/OP $162.63 $120.35 $0.00 $126.32 $71.06 $71.06 $0.00 $0.00 $0.00 $33.90 $120.70 $120.70 $0.00 $0.00 $33.89 $0.00 $96.19 $96.19 $0.00 $78.95 $125.06 $126.32 $0.00 $0.00 $23.99 $0.00 $0.00 $25.14 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.220 SUP Custom 27203010 03.311.220 - SPACER XTRNFX 20MM NS STNDOF MRI SAFE DSTRCT OSTEOGENESIS BOTH IP/OP $72.98 $54.01 $0.00 $56.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.16 $54.16 $0.00 $0.00 $15.21 $0.00 $0.00 $0.00 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.230 SUP Custom 27803010 03.311.230 - SPACER XTRNFX 30MM NS STNDOF MRI SAFE DSTRCT OSTEOGENESIS BOTH IP/OP $79.10 $58.53 $0.00 $61.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.71 $58.71 $0.00 $0.00 $16.48 $0.00 $0.00 $0.00 $0.00 $38.39 $60.81 $61.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.240 SUP Custom 27203010 03.311.240 - SPACER XTRNFX 40MM NS STNDOF MRI SAFE DSTRCT OSTEOGENESIS BOTH IP/OP $87.45 $64.71 $0.00 $67.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.91 $64.91 $0.00 $0.00 $18.22 $0.00 $0.00 $0.00 $0.00 $42.45 $67.24 $67.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.250 SUP Custom 27203010 03.311.250 - SPACER XTRNFX 50MM NS STNDOF MRI SAFE DSTRCT OSTEOGENESIS BOTH IP/OP $118.08 $87.38 $0.00 $91.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.64 $87.64 $0.00 $0.00 $24.61 $0.00 $0.00 $0.00 $0.00 $57.33 $90.80 $91.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.308 SUP Custom 27203010 03.311.308 - RING EXFIX HALF 80MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $578.13 $427.82 $0.00 $449.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $429.08 $429.08 $0.00 $0.00 $120.48 $0.00 $0.00 $0.00 $0.00 $280.65 $444.55 $449.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.310 SUP Custom 27203010 03.311.310 - RING EXFIX HALF 100MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $623.80 $461.61 $0.00 $484.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.98 $462.98 $0.00 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $302.83 $479.67 $484.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.311 SUP Custom 27203010 03.311.311 - RING EXFIX HALF 110MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $639.40 $473.16 $0.00 $496.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $474.56 $474.56 $0.00 $0.00 $133.25 $0.00 $0.00 $0.00 $0.00 $310.39 $491.66 $496.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.312 SUP Custom 27203010 03.311.312 - RING EXFIX HALF 120MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $666.15 $492.95 $0.00 $517.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $494.42 $494.42 $0.00 $0.00 $138.83 $0.00 $0.00 $0.00 $0.00 $323.36 $512.21 $517.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.313 SUP Custom 27203010 03.311.313 - RING EXFIX HALF 130MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $682.85 $505.31 $0.00 $530.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.81 $506.81 $0.00 $0.00 $142.31 $0.00 $0.00 $0.00 $0.00 $331.48 $525.06 $530.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.314 SUP Custom 27203010 03.311.314 - RING EXFIX HALF 140MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $709.58 $525.09 $0.00 $551.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.65 $526.65 $0.00 $0.00 $147.88 $0.00 $0.00 $0.00 $0.00 $344.46 $545.63 $551.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.315 SUP Custom 27203010 03.311.315 - RING EXFIX HALF 150MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $755.25 $558.89 $0.00 $586.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $560.55 $560.55 $0.00 $0.00 $157.39 $0.00 $0.00 $0.00 $0.00 $366.63 $580.73 $586.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.316 SUP Custom 27203010 03.311.316 - RING EXFIX HALF 160MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $823.20 $609.17 $0.00 $639.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.98 $610.98 $0.00 $0.00 $171.55 $0.00 $0.00 $0.00 $0.00 $399.61 $632.99 $639.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.318 SUP Custom 27203010 03.311.318 - RING EXFIX HALF 180MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $884.48 $654.52 $0.00 $686.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $656.46 $656.46 $0.00 $0.00 $184.32 $0.00 $0.00 $0.00 $0.00 $429.35 $680.09 $686.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.320 SUP Custom 27203010 03.311.320 - RING EXFIX HALF 200MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $958.00 $708.92 $0.00 $744.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $711.03 $711.03 $0.00 $0.00 $199.65 $0.00 $0.00 $0.00 $0.00 $465.05 $736.64 $744.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.322 SUP Custom 27203010 03.311.322 - RING EXFIX HALF 220MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,019.25 " $754.25 $0.00 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $756.49 $756.49 $0.00 $0.00 $212.41 $0.00 $0.00 $0.00 $0.00 $494.79 $783.75 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.324 SUP Custom 27203010 03.311.324 - RING EXFIX HALF 240MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,063.83 " $787.23 $0.00 $826.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $789.57 $789.57 $0.00 $0.00 $221.70 $0.00 $0.00 $0.00 $0.00 $516.41 $818.00 $826.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.344 SUP Custom 27203010 03.311.344 - RING EXFIX FULL 140MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,414.70 " "$1,046.88" $0.00 "$1,098.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,049.99" "$1,049.99" $0.00 $0.00 $294.82 $0.00 $0.00 $0.00 $0.00 $686.75 "$1,087.81" "$1,098.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.346 SUP Custom 27203010 03.311.346 - RING EXFIX FULL 160MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,645.30 " "$1,217.52" $0.00 "$1,277.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,221.14" "$1,221.14" $0.00 $0.00 $342.88 $0.00 $0.00 $0.00 $0.00 $798.69 "$1,265.12" "$1,277.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.348 SUP Custom 27203010 03.311.348 - RING EXFIX FULL 180MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,768.95 " "$1,309.02" $0.00 "$1,373.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,312.91" "$1,312.91" $0.00 $0.00 $368.65 $0.00 $0.00 $0.00 $0.00 $858.71 "$1,360.20" "$1,373.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.350 SUP Custom 27203010 03.311.350 - RING EXFIX FULL 200MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,920.45 " "$1,421.13" $0.00 "$1,491.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,425.36" "$1,425.36" $0.00 $0.00 $400.22 $0.00 $0.00 $0.00 $0.00 $932.25 "$1,476.68" "$1,491.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.373 SUP Custom 27203010 03.311.373 - RING EXFIX 5/8 130MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP $930.15 $688.31 $0.00 $722.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.36 $690.36 $0.00 $0.00 $193.84 $0.00 $0.00 $0.00 $0.00 $451.53 $715.22 $722.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.375 SUP Custom 27203010 03.311.375 - RING EXFIX 5/8 150MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,019.25 " $754.25 $0.00 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $756.49 $756.49 $0.00 $0.00 $212.41 $0.00 $0.00 $0.00 $0.00 $494.79 $783.75 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.376 SUP Custom 27203010 03.311.376 - RING EXFIX 5/8 160MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,106.15 " $818.55 $0.00 $859.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $820.98 $820.98 $0.00 $0.00 $230.52 $0.00 $0.00 $0.00 $0.00 $536.96 $850.55 $859.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.378 SUP Custom 27203010 03.311.378 - RING EXFIX 5/8 180MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,284.38 " $950.44 $0.00 $997.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $953.26 $953.26 $0.00 $0.00 $267.66 $0.00 $0.00 $0.00 $0.00 $623.49 $987.61 $997.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.380 SUP Custom 27203010 03.311.380 - RING EXFIX 5/8 200MM TITANIUM NONSTRL DISTRACTION BOTH IP/OP "$1,327.83 " $982.59 $0.00 "$1,031.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $985.51 $985.51 $0.00 $0.00 $276.72 $0.00 $0.00 $0.00 $0.00 $644.58 "$1,021.01" "$1,031.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.391 SUP HCPCS C1713 03.311.391 - PLATE XTRNFX 90D ARCH 180MM NS TI FEM DSTRCT OSTEOGENESIS BOTH IP/OP "$1,592.95 " "$1,178.78" $0.00 "$1,237.24" $695.95 $695.95 $0.00 $0.00 $0.00 $332.01 "$1,182.29" "$1,182.29" $0.00 $0.00 $331.97 $0.00 $942.23 $942.23 $0.00 $773.28 "$1,224.87" "$1,237.24" $0.00 $0.00 $234.98 $0.00 $0.00 $246.21 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.392 SUP HCPCS C1713 03.311.392 - PLATE XTRNFX 120D ARCH 180MM NS TI FEM DSTRCT OSTEOGENESIS BOTH IP/OP "$1,636.38 " "$1,210.92" $0.00 "$1,270.98" $714.93 $714.93 $0.00 $0.00 $0.00 $341.06 "$1,214.52" "$1,214.52" $0.00 $0.00 $341.02 $0.00 $967.92 $967.92 $0.00 $794.36 "$1,258.27" "$1,270.98" $0.00 $0.00 $241.39 $0.00 $0.00 $252.93 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.396 SUP HCPCS C1713 03.311.396 - PLATE XTRNFX 90D ARCH 240MM NS TI FEM DSTRCT OSTEOGENESIS BOTH IP/OP "$1,727.73 " "$1,278.52" $0.00 "$1,341.92" $754.83 $754.83 $0.00 $0.00 $0.00 $360.10 "$1,282.32" "$1,282.32" $0.00 $0.00 $360.06 $0.00 "$1,021.95" "$1,021.95" $0.00 $838.70 "$1,328.50" "$1,341.92" $0.00 $0.00 $254.87 $0.00 $0.00 $267.04 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.397 SUP HCPCS C1713 03.311.397 - PLATE XTRNFX 120D ARCH 240MM NS TI FEM DSTRCT OSTEOGENESIS BOTH IP/OP "$1,768.95 " "$1,309.02" $0.00 "$1,373.94" $772.84 $772.84 $0.00 $0.00 $0.00 $368.69 "$1,312.91" "$1,312.91" $0.00 $0.00 $368.65 $0.00 "$1,046.33" "$1,046.33" $0.00 $858.71 "$1,360.20" "$1,373.94" $0.00 $0.00 $260.95 $0.00 $0.00 $273.41 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.406 SUP Custom 27803010 03.311.406 - DISTRACTOR SURG 60MM 25MM LINEAR NONSTRL BOTH IP/OP "$1,019.25 " $754.25 $0.00 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $756.49 $756.49 $0.00 $0.00 $212.41 $0.00 $0.00 $0.00 $0.00 $494.79 $783.75 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.412 SUP Custom 27803010 03.311.412 - DISTRACTOR SURG 85MM TRAVEL 120MM LINEAR MRI SAFE NONSTRL BOTH IP/OP "$1,106.15 " $818.55 $0.00 $859.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $820.98 $820.98 $0.00 $0.00 $230.52 $0.00 $0.00 $0.00 $0.00 $536.96 $850.55 $859.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.418 SUP Custom 27803010 03.311.418 - DISTRACTOR SURG 180MM LINEAR MRI SAFE NONSTRL BOTH IP/OP "$1,239.83 " $917.47 $0.00 $962.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $920.20 $920.20 $0.00 $0.00 $258.38 $0.00 $0.00 $0.00 $0.00 $601.85 $953.33 $962.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.425 SUP Custom 27803010 03.311.425 - DISTRACTOR SURG 215MM TRAVEL 250MM LINEAR MRI SAFE NONSTRL BOTH IP/OP "$1,504.95 " "$1,113.66" $0.00 "$1,168.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,116.97" "$1,116.97" $0.00 $0.00 $313.63 $0.00 $0.00 $0.00 $0.00 $730.55 "$1,157.19" "$1,168.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.450 SUP Custom 27803010 03.311.450 - DISTRACTOR SURG ANGLE NONSTRL BOTH IP/OP $990.30 $732.82 $0.00 $769.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $735.00 $735.00 $0.00 $0.00 $206.38 $0.00 $0.00 $0.00 $0.00 $480.73 $761.47 $769.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.451 SUP Custom 27803010 03.311.451 - DISTRACTOR SURG ANGLE PIVOT NONSTRL BOTH IP/OP $432.20 $319.83 $0.00 $335.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.78 $320.78 $0.00 $0.00 $90.07 $0.00 $0.00 $0.00 $0.00 $209.81 $332.35 $335.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.810 SUP Custom 27203010 03.311.810 - RING EXFIX .5 100MM MRI SAFE CARFBR NONSTRL BOTH IP/OP $709.58 $525.09 $0.00 $551.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.65 $526.65 $0.00 $0.00 $147.88 $0.00 $0.00 $0.00 $0.00 $344.46 $545.63 $551.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.812 SUP Custom 27203010 03.311.812 - RING EXFIX .5 120MM MRI SAFE CARFBR NONSTRL BOTH IP/OP $755.25 $558.89 $0.00 $586.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $560.55 $560.55 $0.00 $0.00 $157.39 $0.00 $0.00 $0.00 $0.00 $366.63 $580.73 $586.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.814 SUP Custom 27203010 03.311.814 - RING EXFIX .5 140MM MRI SAFE CARFBR NONSTRL BOTH IP/OP $798.70 $591.04 $0.00 $620.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $592.80 $592.80 $0.00 $0.00 $166.45 $0.00 $0.00 $0.00 $0.00 $387.71 $614.14 $620.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.816 SUP Custom 27203010 03.311.816 - RING EXFIX .5 160MM MRI SAFE CARFBR NONSTRL BOTH IP/OP $884.48 $654.52 $0.00 $686.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $656.46 $656.46 $0.00 $0.00 $184.32 $0.00 $0.00 $0.00 $0.00 $429.35 $680.09 $686.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.818 SUP Custom 27203010 03.311.818 - RING EXFIX .5 180MM MRI SAFE CARFBR NONSTRL BOTH IP/OP $930.15 $688.31 $0.00 $722.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.36 $690.36 $0.00 $0.00 $193.84 $0.00 $0.00 $0.00 $0.00 $451.53 $715.22 $722.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.820 SUP Custom 27203010 03.311.820 - RING EXFIX .5 200MM MRI SAFE CARFBR NONSTRL BOTH IP/OP $974.70 $721.28 $0.00 $757.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.42 $723.42 $0.00 $0.00 $203.13 $0.00 $0.00 $0.00 $0.00 $473.16 $749.49 $757.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.844 SUP Custom 27203010 03.311.844 - RING EXFIX 140MM FULL RING MRI SAFE CARFBR BOTH IP/OP "$1,592.95 " "$1,178.78" $0.00 "$1,237.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,182.29" "$1,182.29" $0.00 $0.00 $331.97 $0.00 $0.00 $0.00 $0.00 $773.28 "$1,224.87" "$1,237.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.846 SUP Custom 27203010 03.311.846 - RING EXFIX FULL 160MM FULL RING MRI SAFE CARFBR NONSTRL BOTH IP/OP "$1,768.95 " "$1,309.02" $0.00 "$1,373.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,312.91" "$1,312.91" $0.00 $0.00 $368.65 $0.00 $0.00 $0.00 $0.00 $858.71 "$1,360.20" "$1,373.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.848 SUP Custom 27203010 03.311.848 - RING EXFIX 180MM FULL RING MRI SAFE CARFBR BOTH IP/OP "$1,947.18 " "$1,440.91" $0.00 "$1,512.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,445.19" "$1,445.19" $0.00 $0.00 $405.79 $0.00 $0.00 $0.00 $0.00 $945.23 "$1,497.24" "$1,512.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.850 SUP Custom 27203010 03.311.850 - RING EXFIX 200MM FULL RING MRI SAFE CARFBR BOTH IP/OP "$2,122.08 " "$1,570.34" $0.00 "$1,648.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,575.00" "$1,575.00" $0.00 $0.00 $442.24 $0.00 $0.00 $0.00 $0.00 "$1,030.13" "$1,631.72" "$1,648.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.874 SUP Custom 27203010 03.311.874 - RING EXFIX 5/8 140MM MRI SAFE CARFBR NONSTRL BOTH IP/OP $930.15 $688.31 $0.00 $722.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.36 $690.36 $0.00 $0.00 $193.84 $0.00 $0.00 $0.00 $0.00 $451.53 $715.22 $722.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.876 SUP Custom 27203010 03.311.876 - RING EXFIX 5/8 160MM MRI SAFE CARFBR NONSTRL BOTH IP/OP $974.70 $721.28 $0.00 $757.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.42 $723.42 $0.00 $0.00 $203.13 $0.00 $0.00 $0.00 $0.00 $473.16 $749.49 $757.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.878 SUP Custom 27203010 03.311.878 - RING EXFIX 5/8 180MM MRI SAFE CARFBR NONSTRL BOTH IP/OP "$1,019.25 " $754.25 $0.00 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $756.49 $756.49 $0.00 $0.00 $212.41 $0.00 $0.00 $0.00 $0.00 $494.79 $783.75 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.880 SUP Custom 27203010 03.311.880 - RING EXFIX 5/8 200MM MRI SAFE CARFBR NONSTRL BOTH IP/OP "$1,063.83 " $787.23 $0.00 $826.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $789.57 $789.57 $0.00 $0.00 $221.70 $0.00 $0.00 $0.00 $0.00 $516.41 $818.00 $826.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.891 SUP HCPCS C1713 03.311.891 - PLATE XTRNFX 90D ARCH 180MM NS MRI SAFE CFBR FEM BOTH IP/OP "$1,462.60 " "$1,082.32" $0.00 "$1,136.00" $639.00 $639.00 $0.00 $0.00 $0.00 $304.84 "$1,085.54" "$1,085.54" $0.00 $0.00 $304.81 $0.00 $865.13 $865.13 $0.00 $710.00 "$1,124.64" "$1,136.00" $0.00 $0.00 $215.76 $0.00 $0.00 $226.06 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.892 SUP HCPCS C1713 03.311.892 - PLATE XTRNFX 120D ARCH 180MM NS MRI SAFE CFBR FEM BOTH IP/OP "$1,511.63 " "$1,118.61" $0.00 "$1,174.08" $660.42 $660.42 $0.00 $0.00 $0.00 $315.06 "$1,121.93" "$1,121.93" $0.00 $0.00 $315.02 $0.00 $894.13 $894.13 $0.00 $733.80 "$1,162.34" "$1,174.08" $0.00 $0.00 $222.99 $0.00 $0.00 $233.64 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.896 SUP HCPCS C1713 03.311.896 - PLATE XTRNFX 90D ARCH 240MM NS MRI SAFE CFBR FEM BOTH IP/OP "$1,556.18 " "$1,151.57" $0.00 "$1,208.68" $679.88 $679.88 $0.00 $0.00 $0.00 $324.35 "$1,154.99" "$1,154.99" $0.00 $0.00 $324.31 $0.00 $920.48 $920.48 $0.00 $755.43 "$1,196.59" "$1,208.68" $0.00 $0.00 $229.56 $0.00 $0.00 $240.53 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.897 SUP HCPCS C1713 03.311.897 - PLATE XTRNFX 120D ARCH 240MM NS MRI SAFE CFBR FEM BOTH IP/OP "$1,646.40 " "$1,218.34" $0.00 "$1,278.76" $719.30 $719.30 $0.00 $0.00 $0.00 $343.15 "$1,221.96" "$1,221.96" $0.00 $0.00 $343.11 $0.00 $973.85 $973.85 $0.00 $799.23 "$1,265.97" "$1,278.76" $0.00 $0.00 $242.87 $0.00 $0.00 $254.47 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.910 SUP Custom 27203010 03.311.910 - RING EXFIX SHORT 100MM MRI SAFE CARFBR FT BOTH IP/OP "$1,144.03 " $846.58 $0.00 $888.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $849.10 $849.10 $0.00 $0.00 $238.41 $0.00 $0.00 $0.00 $0.00 $555.35 $879.67 $888.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.914 SUP Custom 27203010 03.311.914 - RING EXFIX SHORT 140MM MRI SAFE CARFBR FT BOTH IP/OP "$1,189.70 " $880.38 $0.00 $924.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.00 $883.00 $0.00 $0.00 $247.93 $0.00 $0.00 $0.00 $0.00 $577.53 $914.80 $924.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.916 SUP Custom 27203010 03.311.916 - RING EXFIX SHORT 160MM FT RING MRI SAFE CARFBR BOTH IP/OP "$1,236.48 " $915.00 $0.00 $960.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $917.71 $917.71 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $600.24 $950.78 $960.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.918 SUP Custom 27203010 03.311.918 - RING EXFIX SHORT 180MM MRI SAFE CARFBR FT BOTH IP/OP "$1,282.15 " $948.79 $0.00 $995.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.61 $951.61 $0.00 $0.00 $267.20 $0.00 $0.00 $0.00 $0.00 $622.40 $985.88 $995.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.940 SUP Custom 27203010 03.311.940 - RING EXFIX LONG 100MM MRI SAFE CARFBR FT BOTH IP/OP "$1,144.03 " $846.58 $0.00 $888.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $849.10 $849.10 $0.00 $0.00 $238.41 $0.00 $0.00 $0.00 $0.00 $555.35 $879.67 $888.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.944 SUP Custom 27203010 03.311.944 - RING EXFIX LONG 140MM MRI SAFE CARFBR FT BOTH IP/OP "$1,189.70 " $880.38 $0.00 $924.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.00 $883.00 $0.00 $0.00 $247.93 $0.00 $0.00 $0.00 $0.00 $577.53 $914.80 $924.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.946 SUP Custom 27203010 03.311.946 - RING EXFIX 160MM MRI SAFE CARFBR FT BOTH IP/OP "$1,236.48 " $915.00 $0.00 $960.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $917.71 $917.71 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $600.24 $950.78 $960.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.948 SUP Custom 27203010 03.311.948 - RING EXFIX LONG 180MM MRI SAFE CARFBR FT BOTH IP/OP "$1,282.15 " $948.79 $0.00 $995.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.61 $951.61 $0.00 $0.00 $267.20 $0.00 $0.00 $0.00 $0.00 $622.40 $985.88 $995.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.960 SUP Custom 27203010 03.311.960 - RING EXFIX SHORT 100MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,504.95 " "$1,113.66" $0.00 "$1,168.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,116.97" "$1,116.97" $0.00 $0.00 $313.63 $0.00 $0.00 $0.00 $0.00 $730.55 "$1,157.19" "$1,168.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.964 SUP Custom 27203010 03.311.964 - RING EXFIX SHORT 140MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,566.20 " "$1,158.99" $0.00 "$1,216.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,162.43" "$1,162.43" $0.00 $0.00 $326.40 $0.00 $0.00 $0.00 $0.00 $760.30 "$1,204.32" "$1,216.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.966 SUP Custom 27203010 03.311.966 - RING EXFIX SHORT 160MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,628.60 " "$1,205.16" $0.00 "$1,264.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,208.75" "$1,208.75" $0.00 $0.00 $339.40 $0.00 $0.00 $0.00 $0.00 $790.58 "$1,252.27" "$1,264.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.968 SUP Custom 27203010 03.311.968 - RING EXFIX SHORT 180MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,689.85 " "$1,250.49" $0.00 "$1,312.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,254.21" "$1,254.21" $0.00 $0.00 $352.16 $0.00 $0.00 $0.00 $0.00 $820.31 "$1,299.38" "$1,312.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.970 SUP Custom 27203010 03.311.970 - RING EXFIX SHORT 200MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,359.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $849.51 "$1,345.63" "$1,359.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.980 SUP Custom 27203010 03.311.980 - RING EXFIX LONG 100MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,504.95 " "$1,113.66" $0.00 "$1,168.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,116.97" "$1,116.97" $0.00 $0.00 $313.63 $0.00 $0.00 $0.00 $0.00 $730.55 "$1,157.19" "$1,168.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.984 SUP Custom 27203010 03.311.984 - RING EXFIX LONG 140MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,566.20 " "$1,158.99" $0.00 "$1,216.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,162.43" "$1,162.43" $0.00 $0.00 $326.40 $0.00 $0.00 $0.00 $0.00 $760.30 "$1,204.32" "$1,216.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.986 SUP Custom 27203010 03.311.986 - RING EXFIX LONG 160MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,628.60 " "$1,205.16" $0.00 "$1,264.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,208.75" "$1,208.75" $0.00 $0.00 $339.40 $0.00 $0.00 $0.00 $0.00 $790.58 "$1,252.27" "$1,264.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.988 SUP Custom 27203010 03.311.988 - RING EXFIX LONG 180+ MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,689.85 " "$1,250.49" $0.00 "$1,312.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,254.21" "$1,254.21" $0.00 $0.00 $352.16 $0.00 $0.00 $0.00 $0.00 $820.31 "$1,299.38" "$1,312.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.311.990 SUP Custom 27203010 03.311.990 - RING EXFIX LONG 200+ MM MRI SAFE TITANIUM FT NONSTRL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,359.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $849.51 "$1,345.63" "$1,359.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.390.052S SUP HCPCS C1713 03.390.052S - FIXATOR XTRNFX 200MM STRL SCHNZ PREASSEMBLE FRM SLF DRL CFBR BOTH IP/OP "$4,161.70 " "$3,079.66" $0.00 "$3,232.38" "$1,818.21" "$1,818.21" $0.00 $0.00 $0.00 $867.40 "$3,088.81" "$3,088.81" $0.00 $0.00 $867.30 $0.00 "$2,051.72" "$2,051.72" $0.00 "$2,020.24" "$3,200.06" "$3,232.38" $0.00 $0.00 $613.92 $0.00 $0.00 $643.24 $0.00 $0.00 $0.00 $0.00 $0.00 03.390.053S SUP Custom 27203010 03.390.053S - SET EXFIX 220MM SCREW ROD MRI SAFE DISTAL RAD NONSTRL BOTH IP/OP "$4,161.70 " "$3,079.66" $0.00 "$3,232.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,088.81" "$3,088.81" $0.00 $0.00 $867.30 $0.00 $0.00 $0.00 $0.00 "$2,020.24" "$3,200.06" "$3,232.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.390.054S SUP HCPCS C1713 03.390.054S - FIXATOR XTRNFX 240MM STRL SCHNZ PREASSEMBLE FRM SLF DRL CFBR BOTH IP/OP "$4,161.70 " "$3,079.66" $0.00 "$3,232.38" "$1,818.21" "$1,818.21" $0.00 $0.00 $0.00 $867.40 "$3,088.81" "$3,088.81" $0.00 $0.00 $867.30 $0.00 "$2,051.72" "$2,051.72" $0.00 "$2,020.24" "$3,200.06" "$3,232.38" $0.00 $0.00 $613.92 $0.00 $0.00 $643.24 $0.00 $0.00 $0.00 $0.00 $0.00 03.390.055S SUP HCPCS C1713 03.390.055S - FIXATOR EXFIX 200MM SLFDRILL SCHANZ SCREW ROD MRI SAFE BOTH IP/OP "$4,446.88 " "$3,290.69" $0.00 "$3,453.88" "$1,942.81" "$1,942.81" $0.00 $0.00 $0.00 $926.84 "$3,300.47" "$3,300.47" $0.00 $0.00 $926.73 $0.00 "$2,192.31" "$2,192.31" $0.00 "$2,158.68" "$3,419.34" "$3,453.88" $0.00 $0.00 $655.99 $0.00 $0.00 $687.32 $0.00 $0.00 $0.00 $0.00 $0.00 03.390.056S SUP HCPCS C1713 03.390.056S - FIXATOR EXFIX 220MM SLFDRILL SCHANZ SCREW ROD MRI SAFE BOTH IP/OP "$4,446.88 " "$3,290.69" $0.00 "$3,453.88" "$1,942.81" "$1,942.81" $0.00 $0.00 $0.00 $926.84 "$3,300.47" "$3,300.47" $0.00 $0.00 $926.73 $0.00 "$2,192.31" "$2,192.31" $0.00 "$2,158.68" "$3,419.34" "$3,453.88" $0.00 $0.00 $655.99 $0.00 $0.00 $687.32 $0.00 $0.00 $0.00 $0.00 $0.00 03.390.057S SUP Custom 27203010 03.390.057S - SET EXFIX SLFDRILL SCHANZ SCREW CARFBR ROD MR SAFE TITANIUM BOTH IP/OP "$4,446.88 " "$3,290.69" $0.00 "$3,453.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,300.47" "$3,300.47" $0.00 $0.00 $926.73 $0.00 $0.00 $0.00 $0.00 "$2,158.68" "$3,419.34" "$3,453.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.004 SUP Custom 27203010 03.500.004 - BIT DRILL 44.5MM 1.25MM TI JLTCH STOP 4MM OTHDNTC BONE ANCH BOTH IP/OP $355.50 $263.07 $0.00 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.85 $263.85 $0.00 $0.00 $74.09 $0.00 $0.00 $0.00 $0.00 $177.75 $281.56 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.006 SUP Custom 27203010 03.500.006 - BIT DRILL 44.5MM 1.25MM TI JLTCH STOP 6MM OTHDNTC BONE ANCH BOTH IP/OP $355.50 $263.07 $0.00 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.85 $263.85 $0.00 $0.00 $74.09 $0.00 $0.00 $0.00 $0.00 $177.75 $281.56 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.008 SUP Custom 27203010 03.500.008 - 1.25MM DRILL BIT J-LATCH/8MM STOP/44.5MM BOTH IP/OP $355.50 $263.07 $0.00 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.85 $263.85 $0.00 $0.00 $74.09 $0.00 $0.00 $0.00 $0.00 $177.75 $281.56 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.010 SUP Custom 27203010 03.500.010 - 1.25MM DRILL BIT J-LATCH/10MM STOP/44.5MM BOTH IP/OP $355.50 $263.07 $0.00 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.85 $263.85 $0.00 $0.00 $74.09 $0.00 $0.00 $0.00 $0.00 $177.75 $281.56 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.018 SUP Custom 27203010 03.500.018 - TEMPLATE BENDING STR NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.030 SUP Custom 27203010 03.500.030 - TEMPLATE BENDING 30MM RAD RIGHT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.031 SUP Custom 27203010 03.500.031 - TEMPLATE BENDING 30MM RAD LEFT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.040 SUP Custom 27203010 03.500.040 - TEMPLATE BENDING 40MM RAD RIGHT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.041 SUP Custom 27203010 03.500.041 - TEMPLATE BENDING 40MM RAD LEFT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.050 SUP Custom 27203010 03.500.050 - TEMPLATE BENDING 50MM RAD RIGHT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.051 SUP Custom 27203010 03.500.051 - TEMPLATE BENDING 50MM RAD LEFT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.070 SUP Custom 27203010 03.500.070 - TEMPLATE BENDING 70MM RAD RIGHT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.071 SUP Custom 27203010 03.500.071 - TEMPLATE BENDING 70MM RAD LEFT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.100 SUP Custom 27203010 03.500.100 - TEMPLATE BENDING 100MM RAD RIGHT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.500.101 SUP Custom 27203010 03.500.101 - TEMPLATE BENDING 100MM RAD LEFT NONSTRL CURVILINEAR DISTRCT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.008 SUP Custom 27203010 03.501.008 - BIT DRILL 8MM STOP 1.5MM 82MM J LATCH COUPLING 2 FLUTED BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $0.00 $0.00 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.010 SUP Custom 27203010 03.501.010 - BIT DRILL 10MM STOP 82MM J LATCH TITANIUM NONSTRL BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $0.00 $0.00 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.012 SUP Custom 27203010 03.501.012 - BIT DRILL 12MM STOP 1.5MM 82MM J LATCH COUPLING 2 FLUTED BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $0.00 $0.00 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.014 SUP Custom 27203010 03.501.014 - BIT DRILL 1.5MM 82MM 14MM J LATCH COUPLING SELF STOP BOTH IP/OP $572.50 $423.65 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.91 $424.91 $0.00 $0.00 $119.31 $0.00 $0.00 $0.00 $0.00 $286.25 $453.42 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.016 SUP Custom 27203010 03.501.016 - BIT DRILL 16MM STOP 1.5MM 82MM J LATCH STERNUM NONSTRL BOTH IP/OP $572.50 $423.65 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.91 $424.91 $0.00 $0.00 $119.31 $0.00 $0.00 $0.00 $0.00 $286.25 $453.42 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.018 SUP Custom 27203010 03.501.018 - BIT DRILL 18MM STOP 1.5MM 82MM J LATCH STERNUM NONSTRL BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $0.00 $0.00 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.020 SUP Custom 27203010 03.501.020 - BIT DRILL 20MM STOP 1.5MM 88MM J LATCH BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $0.00 $0.00 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.022 SUP Custom 27203010 03.501.022 - BIT DRILL 1.5MM 88MM 22MM J LATCH COUPLING SELF STOP BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $0.00 $0.00 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.024 SUP Custom 27203010 03.501.024 - BIT DRILL 88MM 1.5MM STRNL TI STOP JLTCH 24MM NONSTRL BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.55 $280.55 $0.00 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.036 SUP Custom 27203010 03.501.036 - BIT DRILL 135MM 2.2MM JLTCH STOP 6MM STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.038 SUP Custom 27203010 03.501.038 - BIT DRL 8MM 2.2MM 135MM NS MATRIXRIB JLTCH CPLNG STP STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.040 SUP Custom 27203010 03.501.040 - BIT DRILL 135MM 2.2MM JLTCH STOP 10MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.042 SUP Custom 27203010 03.501.042 - BIT DRL 12MM 2.2MM 135MM NS MATRIXRIB JLTCH CPLNG STP STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.044 SUP Custom 27203010 03.501.044 - BIT DRILL 135MM 2.2MM JLTCH STOP 14MM STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.046 SUP Custom 27203010 03.501.046 - BIT DRL 16MM 2.2MM 135MM NS MATRIXRIB JLTCH CPLNG STP STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.048 SUP Custom 27203010 03.501.048 - BIT DRL 18MM 2.2MM 135MM NS MATRIXRIB JLTCH CPLNG STP STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.072 SUP HCPCS C1713 03.501.072 - TEMPLATE BENDING CNTOUR NONSTRL MATRIXRIB LOCK PLATE BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.210 SUP Custom 27203010 03.501.210 - 1.8MM DRILL BIT STRYKER J-LATCH/10MM STOP/82MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.212 SUP Custom 27203010 03.501.212 - BIT DRILL 82MM 1.8MM 12MM STOP JLTCH NONSTRL BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.214 SUP Custom 27203010 03.501.214 - BIT DRILL 82MM 1.8MM 14MM STOP STRNL JLTCH STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.216 SUP Custom 27203010 03.501.216 - BIT DRILL 82MM 1.8MM 16MM STOP STRNL JLTCH STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.218 SUP Custom 27203010 03.501.218 - BIT DRILL 82MM 1.8MM JLTCH STOP 18MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.220 SUP Custom 27203010 03.501.220 - BIT DRILL 88MM 1.8MM JLTCH FIX STOP 20MM STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.222 SUP Custom 27203010 03.501.222 - BIT DRILL 88MM 1.8MM JLTCH FIX STOP 22MM STRYK BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.224 SUP Custom 27203010 03.501.224 - 1.8MM DRILL BIT STRYKER J-LATCH/24MM STOP/88MM BOTH IP/OP $398.25 $294.71 $0.00 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.58 $295.58 $0.00 $0.00 $83.00 $0.00 $0.00 $0.00 $0.00 $199.13 $315.41 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.410 SUP Custom 27203010 03.501.410 - BIT DRILL 82MM 1.5MM 10MM STOP HEX CPLNG NONSTRL BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.412 SUP Custom 27203010 03.501.412 - BIT DRILL 82MM 1.5MM 12MM STOP HEX CPLNG NONSTRL BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.414 SUP Custom 27203010 03.501.414 - 1.5MM DRILL BIT HEX COUPLING WITH 14MM STOP/82MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.416 SUP Custom 27203010 03.501.416 - BIT DRILL 82MM 1.5MM STRNL TI STOP HEX COULPLING FIX 16MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.418 SUP Custom 27203010 03.501.418 - BIT DRILL 82MM 1.5MM 18MM STOP HEX CPLNG NONSTRL BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.420 SUP Custom 27203010 03.501.420 - BIT DRILL 88MM 1.5MM 20MM STOP HEX CPLNG NONSTRL BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.422 SUP Custom 27203010 03.501.422 - 1.5MM DRILL BIT HEX COUPLING WITH 22MM STOP/88MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.424 SUP Custom 27203010 03.501.424 - 1.5MM DRILL BIT HEX COUPLING WITH 24MM STOP/88MM BOTH IP/OP $398.25 $294.71 $0.00 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.58 $295.58 $0.00 $0.00 $83.00 $0.00 $0.00 $0.00 $0.00 $199.13 $315.41 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.510 SUP Custom 27203010 03.501.510 - BIT DRILL 82MM 1.8MM STRNL TI STOP HEX COULPLING FIX 10MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.512 SUP Custom 27203010 03.501.512 - BIT DRILL 82MM 1.8MM 12MM STOP HEX CPLNG NONSTRL BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.514 SUP Custom 27203010 03.501.514 - BIT DRILL 82MM 1.8MM STRNL TI STOP HEX COULPLING FIX 14MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.516 SUP Custom 27203010 03.501.516 - 1.8MM DRILL BIT HEX COUPLING WITH 16MM STOP/82MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.518 SUP Custom 27203010 03.501.518 - 1.8MM DRILL BIT HEX COUPLING WITH 18MM STOP/82MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.520 SUP Custom 27203010 03.501.520 - 1.8MM DRILL BIT HEX COUPLING WITH 20MM STOP/88MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.522 SUP Custom 27203010 03.501.522 - BIT DRILL 88MM 1.8MM STRNL TI STOP HEX COULPLING FIX 22MM BOTH IP/OP $416.25 $308.03 $0.00 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.94 $308.94 $0.00 $0.00 $86.75 $0.00 $0.00 $0.00 $0.00 $208.13 $329.67 $333.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.524 SUP Custom 27203010 03.501.524 - 1.8MM DRILL BIT HEX COUPLING WITH 24MM STOP/88MM BOTH IP/OP $398.25 $294.71 $0.00 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.58 $295.58 $0.00 $0.00 $83.00 $0.00 $0.00 $0.00 $0.00 $199.13 $315.41 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.612 SUP Custom 27203010 03.501.612 - BIT DRL 2.2MM 135MM NS 12MM MATRIXRIB AO QC STP STRNM BOTH IP/OP $486.63 $360.11 $0.00 $389.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.17 $361.17 $0.00 $0.00 $101.41 $0.00 $0.00 $0.00 $0.00 $243.31 $385.41 $389.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.614 SUP Custom 27203010 03.501.614 - BIT DRL 2.2MM 135MM NS 14MM MATRIXRIB AO QC STP STRNM BOTH IP/OP $398.25 $294.71 $0.00 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.13 $315.41 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.501.764 SUP Custom 27203010 03.501.764 - BIT DRL 2 FLUT 2.2MM 14MM NS MATRIXRIB STP 90D SCRDRVR BOTH IP/OP $398.25 $294.71 $0.00 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.13 $315.41 $318.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.103 SUP Custom 27203010 03.503.103 - MATRIXMIDFACE 1.25MM DRILL BIT J-LATCH/3MM STOP/44.5MM BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.104 SUP HCPCS C1713 03.503.104 - PLATE 44.5X4MM MIDFAC STOP BONE NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $191.36 $191.36 $0.00 $0.00 $0.00 $88.63 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $251.54 $251.54 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $66.55 $0.00 $0.00 $67.70 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.106 SUP Custom 27203010 03.503.106 - BIT DRILL 44.5MM 1.25MM STOP JLTCH 6MM NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.108 SUP Custom 27203010 03.503.108 - BIT DRILL 44.5MM 1.25MM JLTCH STOP 8MM NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.110 SUP Custom 27203010 03.503.110 - BIT DRILL 44.5MM 1.25MM MTRXMDFACE 10MM STOP JLTCH BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.112 SUP Custom 27203010 03.503.112 - BIT DRILL 12MM 44.5MM 1.25MM MTRXMDFACE CRNMXF JLTCH CPLNG BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.118 SUP Custom 27203010 03.503.118 - BIT DRILL 18MM 44.5MM 1.25MM MTRXMDFACE CRNMXF JLTCH CPLNG BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.120 SUP Custom 27203010 03.503.120 - BIT DRL 1.25MM 80MM NS MATRIXMIDFACE JLTCH CPLNG WO STP BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.121 SUP Custom 27203010 03.503.121 - BIT DRILL 125MM 1.25MM MTRXMDFACE W/O STOP NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.122 SUP Custom 27203010 03.503.122 - BIT DRILL 125MM 1.25MM MTRXMDFACE JLTCH STOP 8MM PLT SYS BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.123 SUP Custom 27203010 03.503.123 - BIT DRILL 125MM 1.25MM MTRXMDFACE STOP JLTCH 18MM NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.133 SUP Custom 27203010 03.503.133 - MATRIXMIDFACE 1.25MM DRILL BIT MQC/3MM STOP/44.5MM BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.136 SUP Custom 27203010 03.503.136 - MATRIXMIDFACE 1.25MM DRILL BIT MQC/6MM STOP/44.5MM BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.140 SUP Custom 27203010 03.503.140 - BIT DRILL 44.5MM 1.25MM MTRXMDFACE MINI STOP QC 10MM NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.142 SUP Custom 27203010 03.503.142 - BIT DRILL 44.5MM 1.25MM MTRXMDFACE MINI STOP QC 12MM NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.148 SUP Custom 27203010 03.503.148 - BIT DRILL 44.5MM 1.25MM MTRXMDFACE MINI STOP QC 18MM NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.150 SUP Custom 27203010 03.503.150 - BIT DRILL 80MM 1.25MM MTRXMDFACE 2 FLUT MNQK CPLNG NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.151 SUP Custom 27203010 03.503.151 - BIT DRILL 125MM 1.25MM MTRXMDFACE 2 FLUT MNQK CPLNG NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.152 SUP Custom 27203010 03.503.152 - BIT DRILL 125MM 1.25MM MTRXMDFACE MINI STOP QC 8MM NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.153 SUP Custom 27203010 03.503.153 - BIT DRILL 125MM 1.25MM MTRXMDFACE MINI STOP QC 18MM NONSTRL BOTH IP/OP $425.25 $314.69 $0.00 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.62 $315.62 $0.00 $0.00 $88.62 $0.00 $0.00 $0.00 $0.00 $212.63 $336.80 $340.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.160 SUP Custom 27203010 03.503.160 - TMPLT BNDRG MTRXMAND NAR TNSNBND PLT NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.161 SUP Custom 27203010 03.503.161 - TMPLT BNDRG MTRX MANDIB 1 MM BRD TNSNBND PLT NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.162 SUP Custom 27203010 03.503.162 - TMPLT BNDRG MTRXMAND 1 MM THK ADP PLT NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.163 SUP Custom 27203010 03.503.163 - TMPLT BNDRG MTRXMAND 1.25 MM THK STR PLT NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.164 SUP Custom 27203010 03.503.164 - TMPLT BNDRG MTRXMAND 1.25 MM 2X2 HOLE THK CRSNT PLT NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.165 SUP Custom 27203010 03.503.165 - TMPLT BNDRG MTRXMAND 1.25 MM THK CRSNT PLT 3X3 HOLE NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.166 SUP Custom 27203010 03.503.166 - TMPLT BNDRG MTRXMAND 1.25MM NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.167 SUP Custom 27203010 03.503.167 - TMPLT BNDRG MTRXMAND 1.25 MM THK ADP PLT NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.168 SUP Custom 27203010 03.503.168 - TMPLT BNDRG MTRXMAND BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.169 SUP Custom 27203010 03.503.169 - TMPLT BNDRG MTRXMAND 1.5 MM PLT NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.170 SUP Custom 27203010 03.503.170 - TMPLT BNDRG MTRXMAND THK1.5MM 3X3 HOLE ANG PLT BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.171 SUP Custom 27203010 03.503.171 - TMPLT BNDRG MTRXMAND THK1.5MM CRSNT PLT 6 HOLE BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.172 SUP Custom 27203010 03.503.172 - TMPLT BNDRG MTRXMAND THK1.5MM 2X2 HOLE 3X3 HOLE BRD NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.173 SUP Custom 27203010 03.503.173 - TMPLT BNDRG 2MM MTRXMAND BRD CRSNT PLT BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.174 SUP Custom 27203010 03.503.174 - TMPLT BNDRG MTRXMAND 1.25MM NONSTRL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.175 SUP Custom 27203010 03.503.175 - TMPLT BNDRG MTRXMAND 2MM 3X3 HOLE BRD ANG PLT BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $0.00 $0.00 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.176 SUP HCPCS C1713 03.503.176 - TEMPLATE BNDRG NS MATRIXMANDIBLE 2 MM ANG RECON PLT BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.177 SUP Custom 27203010 03.503.177 - TMPLT BNDRG MTRXMAND 2 MM 2 ANG RECON SM PLT NONSTRL BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.178 SUP Custom 27203010 03.503.178 - TMPLT BNDRG MTRXMAND 2 MM 2 ANG RECON MED PLT NONSTRL BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.179 SUP Custom 27203010 03.503.179 - TMPLT BNDRG MTRXMAND 2 MM 2 ANG RECON LG PLT NONSTRL BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.180 SUP Custom 27203010 03.503.180 - TMPLT BNDRG MATRIXMANDIBULAR RECON PLT BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.181 SUP Custom 27203010 03.503.181 - TMPLT BNDRG 2.5-2.8MM RECON BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.182 SUP Custom 27203010 03.503.182 - TMPLT BNDRG MTRXMAND PLT BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.183 SUP Custom 27203010 03.503.183 - TMPLT BNDRG MTRXMAND 2 ANG 2.5 MM RECON PLT NONSTRL BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.184 SUP Custom 27203010 03.503.184 - TMPLT BNDRG MTRXMAND 2.5 MM 2 ANG RECON LG PLT NONSTRL BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.201 SUP Custom 27203010 03.503.201 - BLADE SHRT HEX CPLNG SLFRET 52MM MTRXMDFACE SCRDRVR NONSTRL BOTH IP/OP "$1,586.25 " "$1,173.83" $0.00 "$1,269.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,177.31" "$1,177.31" $0.00 $0.00 $330.57 $0.00 $0.00 $0.00 $0.00 $793.13 "$1,256.31" "$1,269.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.202 SUP Custom 27203010 03.503.202 - BLADE MED HEX CPLNG SLFRET 76MM MTRXMDFACE SCRDRVR CRNMXF BOTH IP/OP "$1,586.25 " "$1,173.83" $0.00 "$1,269.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,177.31" "$1,177.31" $0.00 $0.00 $330.57 $0.00 $0.00 $0.00 $0.00 $793.13 "$1,256.31" "$1,269.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.203 SUP Custom 27203010 03.503.203 - BLADE LNG HEX CPLNG SLFRET 96MM MTRXMDFACE SCRDRVR CRNMXF BOTH IP/OP "$1,586.25 " "$1,173.83" $0.00 "$1,269.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,177.31" "$1,177.31" $0.00 $0.00 $330.57 $0.00 $0.00 $0.00 $0.00 $793.13 "$1,256.31" "$1,269.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.244 SUP Custom 27203010 03.503.244 - BIT DRILL 44.5MM 1.1MM MTRXMDFACE CRNMXF JLTCH CPLNG STOP 4 BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.55 $280.55 $0.00 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.246 SUP Custom 27203010 03.503.246 - BIT DRL 6MM 1.1MM 44.5MM NS MTRX JLTCH CPLNG STP STRYK BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.55 $280.55 $0.00 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.248 SUP Custom 27203010 03.503.248 - BIT DRL 8MM 1.1MM 44.5MM NS MTRX JLTCH CPLNG STP STRYK BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.55 $280.55 $0.00 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.264 SUP Custom 27203010 03.503.264 - MATRIX 1.1MM DRILL BIT/HXC 4MM STOP/52MM BOTH IP/OP $378.00 $279.72 $0.00 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.55 $280.55 $0.00 $0.00 $78.78 $0.00 $0.00 $0.00 $0.00 $189.00 $299.38 $302.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.360 SUP Custom 27203010 03.503.360 - BENDING TEMPLATE F/ORBITAL FLR PL/ANATOMIC/SM/MATRIXMIDFACE BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $0.00 $0.00 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.361 SUP Custom 27203010 03.503.361 - BENDING TEMPLATE F/ORBITAL FLR PL/ANATOMIC/MED/MATRIXMIDFACE BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $0.00 $0.00 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.362 SUP Custom 27203010 03.503.362 - BENDING TEMPLATE F/ORBITAL FLR PL/ANATOMIC/LRG/MATRIXMIDFACE BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $0.00 $0.00 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.363 SUP Custom 27203010 03.503.363 - BENDING TEMPLATE F/UNIVERSAL ORBITAL FLR PL/MATRIXMIDFACE BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $0.00 $0.00 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.364 SUP Custom 27203010 03.503.364 - BENDING TEMPLATE F/UNIVERSAL MEDIAL WALL PL/MATRIXMIDFACE BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $0.00 $0.00 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.365 SUP Custom 27203010 03.503.365 - TMPLT BNDRG ORBTL MESH PLT MTRXMDFACE PLT SYS NONSTRL BOTH IP/OP $515.25 $381.29 $0.00 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.42 $382.42 $0.00 $0.00 $107.38 $0.00 $0.00 $0.00 $0.00 $257.63 $408.08 $412.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.366 SUP Custom 27203010 03.503.366 - BENDING TEMPLATE F/ADAPTION PLATES/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.367 SUP Custom 27203010 03.503.367 - BENDING TEMPLATE F/ORBITAL RIM PLATES/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.368 SUP Custom 27203010 03.503.368 - BENDING TEMPLATE F/OBLIQUE L PLATES/2X3/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.369 SUP Custom 27203010 03.503.369 - BENDING TEMPLATE F/OBLIQUE L PLATES/3X4/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.370 SUP Custom 27203010 03.503.370 - TMPLT THK.5MM BNDRG 4X6 OBLQ L PLT MTRXMDFACE NONSTRL BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.371 SUP Custom 27203010 03.503.371 - BENDING TEMPLATE F/Y-PLATES 1X3/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.372 SUP Custom 27203010 03.503.372 - BENDING TEMPLATE F/X-PLATES MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.373 SUP Custom 27203010 03.503.373 - BENDING TEMPLATE F/H-PLATES MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.374 SUP Custom 27203010 03.503.374 - BENDING TEMPLATE F/T-PLATES MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.375 SUP Custom 27203010 03.503.375 - BENDING TEMPLATE F/BOX PLATES 5MMX10MM/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.376 SUP Custom 27203010 03.503.376 - TMPLT 10X10MM BNDRG BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.377 SUP Custom 27203010 03.503.377 - BENDING TEMPLATE F/STRUT PLATES/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.378 SUP Custom 27203010 03.503.378 - BENDING TEMPLATE F/SILVER DOUBLE Y-PLATE/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.379 SUP Custom 27203010 03.503.379 - BENDING TEMPLATE F/BLUE DOUBLE Y-PLATE/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.380 SUP Custom 27203010 03.503.380 - BENDING TEMPLATE F/PINK DOUBLE Y-PLATE/MATRIXMIDFACE BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $0.00 $0.00 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.404 SUP Custom 27203010 03.503.404 - BIT DRL 4MM 1.5MM 50MM NS MATRIXMANDIBLE JLTCH CPLNG STP BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.406 SUP Custom 27203010 03.503.406 - MATRIXMANDIBLE 1.5MM DRILL BIT J-LATCH W/6MM STOP/50MM BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.408 SUP Custom 27203010 03.503.408 - BIT DRL 8MM 1.5MM 50MM NS MATRIXMANDIBLE JLTCH CPLNG STP BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.412 SUP Custom 27203010 03.503.412 - BIT DRILL 50MM MTRXMAND STOP JLTCH 12MM STRL BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.451 SUP Custom 27203010 03.503.451 - BIT DRL 1.5MM 90MM NS MATRIXMANDIBLE JLTCH CPLNG STRYK BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.452 SUP Custom 27203010 03.503.452 - BIT DRILL 1.5MM MTRXMAND BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.461 SUP Custom 27203010 03.503.461 - BIT DRILL 90MM 1.8MM JLTCH NSTRL BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.462 SUP Custom 27203010 03.503.462 - BIT DRILL 145MM 1.8MM JLTCH BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.471 SUP Custom 27203010 03.503.471 - BIT DRL 2.4MM 90MM NS MATRIXMANDIBLE JLTCH CPLNG STRYK BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.472 SUP Custom 27203010 03.503.472 - BIT DRILL 90MM 2.4MM CLBRT BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.476 SUP Custom 27203010 03.503.476 - BIT DRL 1.5MM 125MM NS MATRIXMANDIBLE JLTCH CPLNG CLBRT BOTH IP/OP $468.00 $346.32 $0.00 $374.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.35 $347.35 $0.00 $0.00 $97.53 $0.00 $0.00 $0.00 $0.00 $234.00 $370.66 $374.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.477 SUP Custom 27203010 03.503.477 - BIT DRL 1.8MM 125MM NS MATRIXMANDIBLE JLTCH CPLNG CLBRT BOTH IP/OP $468.00 $346.32 $0.00 $374.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.35 $347.35 $0.00 $0.00 $97.53 $0.00 $0.00 $0.00 $0.00 $234.00 $370.66 $374.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.478 SUP Custom 27203010 03.503.478 - BIT DRL 2.4MM 125MM NS MATRIXMANDIBLE JLTCH CPLNG CLBRT BOTH IP/OP $468.00 $346.32 $0.00 $374.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.35 $347.35 $0.00 $0.00 $97.53 $0.00 $0.00 $0.00 $0.00 $234.00 $370.66 $374.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.479 SUP Custom 27203010 03.503.479 - BIT DRILL 125MM 1.5MM MTRXMAND MINI CPLNG QC CLBRT NONSTRL BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.480 SUP Custom 27203010 03.503.480 - BIT DRILL 125MM 1.8MM MTRXMAND CLBRT BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.481 SUP Custom 27203010 03.503.481 - BIT DRILL 125MM 2.4MM MTRXMAND MINI CLBRT QC NONSTRL BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.504 SUP Custom 27203010 03.503.504 - MATRIXMANDIBLE 1.5MM DRILL BIT MQC W/4MM STOP/50MM BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.506 SUP Custom 27203010 03.503.506 - MATRIXMANDIBLE 1.5MM DRILL BIT MQC W/6MM STOP/50MM BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.508 SUP Custom 27203010 03.503.508 - MATRIXMANDIBLE 1.5MM DRILL BIT MQC W/8MM STOP/50MM BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.512 SUP Custom 27203010 03.503.512 - MATRIXMANDIBLE 1.5MM DRILL BIT MQC W/12MM STOP/50MM BOTH IP/OP $380.25 $281.39 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.22 $282.22 $0.00 $0.00 $79.24 $0.00 $0.00 $0.00 $0.00 $190.13 $301.16 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.551 SUP Custom 27203010 03.503.551 - BIT DRILL MTRXMAND MINI QC BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.552 SUP Custom 27203010 03.503.552 - MATRIXMANDIBLE 1.5MM DRILL BIT MQC/145MM F/03.503.042 BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.561 SUP Custom 27203010 03.503.561 - MATRIXMANDIBLE 1.8MM DRILL BIT MQC/90MM FOR 03.503.044 BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.562 SUP Custom 27203010 03.503.562 - MATRIXMANDIBLE 1.8MM DRILL BIT MQC/145MM F/03.503.042 BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.571 SUP Custom 27203010 03.503.571 - MATRIXMANDIBLE 2.4MM DRILL BIT MQC/90MM FOR 03.503.046 BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.503.572 SUP Custom 27203010 03.503.572 - MATRIXMANDIBLE 2.4MM DRILL BIT MQC/145MM F/03.503.042 BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $0.00 $0.00 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.507.002S SUP Custom 27203010 03.507.002S - TOOL REDX HEXGAON 2.4MM 78MM THREADED SLFDRILL COUPLING BOTH IP/OP $384.75 $284.72 $0.00 $307.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.56 $285.56 $0.00 $0.00 $80.18 $0.00 $0.00 $0.00 $0.00 $192.38 $304.72 $307.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.507.003 SUP Custom 27203010 03.507.003 - BIT DRILL 78MM 3.5MM SLFTAP REDX TL 3.5MM SCR NONSTRL BOTH IP/OP $614.25 $454.55 $0.00 $491.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $455.90 $455.90 $0.00 $0.00 $128.01 $0.00 $0.00 $0.00 $0.00 $307.13 $486.49 $491.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03.614.015 SUP HCPCS C1713 03.614.015 - TAP SURG 4.5MM 205MM 50MM CALIBRATED CANCELLOUS BOTH IP/OP $545.00 $403.30 $0.00 $436.00 $245.25 $245.25 $0.00 $0.00 $0.00 $113.59 $404.50 $404.50 $0.00 $0.00 $113.58 $0.00 $322.37 $322.37 $0.00 $272.50 $431.64 $436.00 $0.00 $0.00 $85.29 $0.00 $0.00 $86.76 $0.00 $0.00 $0.00 $0.00 $0.00 03.620.104 SUP HCPCS C1713 03.620.104 - TAP 6MM HEX CPLNG SURG 4MM DUAL CORE SCR NONSTRL BOTH IP/OP $628.25 $464.91 $0.00 $502.60 $282.71 $282.71 $0.00 $0.00 $0.00 $130.94 $466.29 $466.29 $0.00 $0.00 $130.93 $0.00 $371.61 $371.61 $0.00 $314.13 $497.57 $502.60 $0.00 $0.00 $98.32 $0.00 $0.00 $100.02 $0.00 $0.00 $0.00 $0.00 $0.00 03.620.105 SUP HCPCS C1713 03.620.105 - TAP 5MM 6MM HEX CPLNG SPNL DUAL CORE SCR NONSTRL BOTH IP/OP $628.25 $464.91 $0.00 $502.60 $282.71 $282.71 $0.00 $0.00 $0.00 $130.94 $466.29 $466.29 $0.00 $0.00 $130.93 $0.00 $371.61 $371.61 $0.00 $314.13 $497.57 $502.60 $0.00 $0.00 $98.32 $0.00 $0.00 $100.02 $0.00 $0.00 $0.00 $0.00 $0.00 03.620.106 SUP HCPCS C1713 03.620.106 - TAP 6MM HEX CPLNG SURG NONSTRL BOTH IP/OP $628.25 $464.91 $0.00 $502.60 $282.71 $282.71 $0.00 $0.00 $0.00 $130.94 $466.29 $466.29 $0.00 $0.00 $130.93 $0.00 $371.61 $371.61 $0.00 $314.13 $497.57 $502.60 $0.00 $0.00 $98.32 $0.00 $0.00 $100.02 $0.00 $0.00 $0.00 $0.00 $0.00 0301-14 SUP Custom 27203010 0301-14 - TUBE JJNSTM 14FR 9FR STRL LF MIC LL RADOPQ STRP TRM DIST TIP BOTH IP/OP $479.38 $354.74 $0.00 $563.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $355.80 $355.80 $0.00 $0.00 $99.90 $0.00 $0.00 $0.00 $0.00 $239.69 $563.02 $383.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0110 SUP HCPCS C1713 03-10-0110 - PLATE BONE 10MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0112 SUP HCPCS C1713 03-10-0112 - PLATE BONE 12MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0114 SUP HCPCS C1713 03-10-0114 - PLATE BONE 14MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0116 SUP HCPCS C1713 03-10-0116 - PLATE BONE 16MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0118 SUP HCPCS C1713 03-10-0118 - PLATE BONE 18MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0120 SUP HCPCS C1713 03-10-0120 - PLATE BONE 20MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0122 SUP HCPCS C1713 03-10-0122 - PLATE BONE 22MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0124 SUP HCPCS C1713 03-10-0124 - PLATE BONE 24MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0126 SUP HCPCS C1713 03-10-0126 - PLATE BONE 26MM LEVEL 1 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0229 SUP HCPCS C1713 03-10-0229 - PLATE 29MM TI 2 LVL BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0232 SUP HCPCS C1713 03-10-0232 - PLATE 32MM TI 2 LVL BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0235 SUP HCPCS C1713 03-10-0235 - PLATE 35MM TI 2 LVL BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0238 SUP HCPCS C1713 03-10-0238 - PLATE 38MM TI 2 LVL BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0241 SUP HCPCS C1713 03-10-0241 - PLATE 41MM TI 2 LVL BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0244 SUP HCPCS C1713 03-10-0244 - PLATE 44MM TI 2 LVL BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0343 SUP HCPCS C1713 03-10-0343 - PLATE BONE 43MM LEVEL 3 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0346 SUP HCPCS C1713 03-10-0346 - PLATE BONE 46MM LEVEL 3 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0349 SUP HCPCS C1713 03-10-0349 - PLATE BONE 49MM LEVEL 3 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0352 SUP HCPCS C1713 03-10-0352 - PLATE BONE 52MM LEVEL 3 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0355 SUP HCPCS C1713 03-10-0355 - PLATE BONE 55MM LEVEL 3 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0358 SUP HCPCS C1713 03-10-0358 - PLATE BONE 58MM LEVEL 3 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0362 SUP HCPCS C1713 03-10-0362 - PLATE BONE 62MM LEVEL 3 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0366 SUP HCPCS C1713 03-10-0366 - PLATE BONE 66MM LEVEL 3 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0460 SUP HCPCS C1713 03-10-0460 - PLATE BONE 60MM LEVEL 4 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0464 SUP HCPCS C1713 03-10-0464 - PLATE BONE 64MM LEVEL 4 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0468 SUP HCPCS C1713 03-10-0468 - PLATE BONE 68MM LEVEL 4 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0472 SUP HCPCS C1713 03-10-0472 - PLATE BONE 72MM LEVEL 4 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0476 SUP HCPCS C1713 03-10-0476 - PLATE BONE 76MM LEVEL 4 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0480 SUP HCPCS C1713 03-10-0480 - PLATE BONE 80MM LEVEL 4 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 03-10-0484 SUP HCPCS C1713 03-10-0484 - PLATE BONE 84MM LEVEL 4 TETHER TITANIUM SPN CERV ANTERIOR BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 03-503-246 SUP Custom 27203010 03-503-246 - BIT DRILL 44.5MM 1.1MM MTRX 6MM STOP JLTCH CPLNG NONSTRL BOTH IP/OP $285.75 $211.46 $0.00 $228.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.08 $212.08 $0.00 $0.00 $59.55 $0.00 $0.00 $0.00 $0.00 $142.88 $226.31 $228.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 038-001 SUP Custom 27203010 KIT IMMUN TST ELISA B2-GLYPRTN 1 IGG 96 TST 038-001 BOTH IP/OP $962.50 $712.25 $0.00 $770.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0382-1425 SUP HCPCS C1713 0382-1425 - SCREW BONE 4.5MM 25MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 0382-1430 SUP HCPCS C1713 0382-1430 - SCREW BONE 4.5MM 30MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 0382-1445 SUP HCPCS C1713 0382-1445 - SCREW BN 4.5MM 45MM X2 PA TI SPNE THORLMBR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 0382-1525 SUP HCPCS C1713 0382-1525 - SCREW BONE 5.5MM 25MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 0382-1535 SUP HCPCS C1713 0382-1535 - SCREW BONE 5.5MM 35MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 0382-1650 SUP HCPCS C1713 0382-1650 - SCREW BONE 6.5MM 50MM POLYAX XIA II TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.000 SUP HCPCS C1713 04.001.000 - CAP END 0MM HUM XTD STARDRIVE RECESS CANN IM NAIL TI NONSTRL BOTH IP/OP $330.25 $244.39 $0.00 $264.20 $148.61 $148.61 $0.00 $0.00 $0.00 $68.83 $245.11 $245.11 $0.00 $0.00 $68.82 $0.00 $195.34 $195.34 $0.00 $165.13 $261.56 $264.20 $0.00 $0.00 $51.68 $0.00 $0.00 $52.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.000S SUP Custom 27803010 04.001.000S - CAP END 0MM EXTENDED SPIRAL BLADE SELF HOLDING T25 STARDRIVE BOTH IP/OP $389.48 $288.22 $0.00 $302.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.07 $289.07 $0.00 $0.00 $81.17 $0.00 $0.00 $0.00 $0.00 $189.08 $299.49 $302.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.001S SUP Custom 27803010 04.001.001S - CAP END 5MM EXTENDED SPIRAL BLADE SELF HOLDING T25 STARDRIVE BOTH IP/OP $389.48 $288.22 $0.00 $302.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.07 $289.07 $0.00 $0.00 $81.17 $0.00 $0.00 $0.00 $0.00 $189.08 $299.49 $302.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.002S SUP Custom 27803010 04.001.002S - CAP END 10MM EXTENDED STARDRIVE RECESS NAIL-EX TITANIUM BOTH IP/OP $389.48 $288.22 $0.00 $302.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.07 $289.07 $0.00 $0.00 $81.17 $0.00 $0.00 $0.00 $0.00 $189.08 $299.49 $302.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.003S SUP Custom 27803010 04.001.003S - CAP END 15MM 15MM EXTENDED SPIRAL BLADE SELF HOLDING T25 BOTH IP/OP $389.48 $288.22 $0.00 $302.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.07 $289.07 $0.00 $0.00 $81.17 $0.00 $0.00 $0.00 $0.00 $189.08 $299.49 $302.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.210S SUP HCPCS C1713 04.001.210S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 7MM 15CM CANN BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.218S SUP HCPCS C1713 04.001.218S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 7MM 19CM CANN BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.220S SUP HCPCS C1713 04.001.220S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 7MM 20CM CANN BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.222S SUP HCPCS C1713 04.001.222S - NAIL INTRAMEDULLARY UNIVERSAL 7MM 210MM SOLID CANN EXPERT BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.224S SUP HCPCS C1713 04.001.224S - NAIL INTRAMEDULLARY UNIVERSAL 7MM 220MM CANN ROUND BARREL BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.226S SUP HCPCS C1713 04.001.226S - NAIL INTRAMEDULLARY 7MM 230MM CANN NAIL-EX BLUE TITANIUM BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.228S SUP HCPCS C1713 04.001.228S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 7MM 24CM CANN BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.230S SUP HCPCS C1713 04.001.230S - NAIL INTRAMEDULLARY UNIVERSAL 7MM 250MM SOLID CANN EXPERT BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.232S SUP HCPCS C1713 04.001.232S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 7MM 26CM CANN BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.234S SUP HCPCS C1713 04.001.234S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 7MM 27CM CANN BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.236S SUP HCPCS C1713 04.001.236S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 7MM 28CM CANN BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.238S SUP HCPCS C1713 04.001.238S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 7MM 29CM CANN BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.240S SUP HCPCS C1713 04.001.240S - NAIL INTRAMEDULLARY 7MM 300MM SOLID CANN EXPERT BLUE BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.242S SUP HCPCS C1713 04.001.242S - NAIL INTRAMEDULLARY 7MM 310MM CANN NAIL-EX BLUE TITANIUM BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.244S SUP HCPCS C1713 04.001.244S - NAIL INTRAMEDULLARY 7MM 320MM SOLID CANN EXPERT BLUE BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.410S SUP HCPCS C1713 04.001.410S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 150MM CANN ROUND BARREL BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.418S SUP HCPCS C1713 04.001.418S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 9MM 19CM CANN BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.420S SUP HCPCS C1713 04.001.420S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 9MM 20CM CANN BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.422S SUP HCPCS C1713 04.001.422S - NAIL INTRAMEDULLARY 9MM 210MM SOLID CANN EXPERT BLUE BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.424S SUP HCPCS C1713 04.001.424S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 9MM 220MM CANN BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.426S SUP HCPCS C1713 04.001.426S - NAIL INTRAMEDULLARY 9MM 230MM CANN IMPLANT NAIL-EX TITANIUM BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.428S SUP HCPCS C1713 04.001.428S - NAIL INTRAMEDULLARY ROUND BARREL UNIVERSAL 9MM 24CM CANN BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.430S SUP HCPCS C1713 04.001.430S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 250MM SOLID CANN EXPERT BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.432S SUP HCPCS C1713 04.001.432S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 260MM SOLID CANN EXPERT BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.434S SUP HCPCS C1713 04.001.434S - NAIL INTRAMEDULLARY 9MM 270MM SOLID CANN EXPERT BLUE BOTH IP/OP "$3,589.95 " "$2,656.56" $0.00 "$2,788.32" "$1,568.43" "$1,568.43" $0.00 $0.00 $0.00 $748.24 "$2,664.46" "$2,664.46" $0.00 $0.00 $748.15 $0.00 "$1,769.85" "$1,769.85" $0.00 "$1,742.70" "$2,760.44" "$2,788.32" $0.00 $0.00 $529.58 $0.00 $0.00 $554.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.436S SUP HCPCS C1713 04.001.436S - NAIL INTRAMEDULLARY 9MM 280MM SOLID CANN EXPERT BLUE BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.438S SUP HCPCS C1713 04.001.438S - NAIL INTRAMEDULLARY 9MM 290MM CANN NAIL-EX BLUE TITANIUM BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.440S SUP HCPCS C1713 04.001.440S - NAIL INTRAMEDULLARY 9MM 300MM SOLID CANN EXPERT BLUE BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.442S SUP HCPCS C1713 04.001.442S - NAIL INTRAMEDULLARY 9MM 310MM CANN NAIL-EX BLUE TITANIUM BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.444S SUP HCPCS C1713 04.001.444S - NAIL INTRAMEDULLARY 9MM 320MM SOLID CANN EXPERT BLUE BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.610S SUP HCPCS C1713 04.001.610S - NAIL INTRAMEDULLARY 11MM 150MM CANN EXPERT BLUE TITANIUM BOTH IP/OP "$3,697.90 " "$2,736.45" $0.00 "$2,872.16" "$1,615.59" "$1,615.59" $0.00 $0.00 $0.00 $770.73 "$2,744.58" "$2,744.58" $0.00 $0.00 $770.64 $0.00 "$1,823.06" "$1,823.06" $0.00 "$1,795.10" "$2,843.44" "$2,872.16" $0.00 $0.00 $545.50 $0.00 $0.00 $571.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.618S SUP HCPCS C1713 04.001.618S - NAIL INTRAMEDULLARY 11MM 19CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.620S SUP HCPCS C1713 04.001.620S - NAIL INTRAMEDULLARY 11MM 20CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.622S SUP HCPCS C1713 04.001.622S - NAIL INTRAMEDULLARY 11MM 21CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.624S SUP HCPCS C1713 04.001.624S - NAIL INTRAMEDULLARY 11MM 22CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.626S SUP HCPCS C1713 04.001.626S - NAIL INTRAMEDULLARY 11MM 23CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.628S SUP HCPCS C1713 04.001.628S - NAIL INTRAMEDULLARY 11MM 24CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.630S SUP HCPCS C1713 04.001.630S - NAIL INTRAMEDULLARY 11MM 25CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.632S SUP HCPCS C1713 04.001.632S - NAIL INTRAMEDULLARY 11MM 26CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.634S SUP HCPCS C1713 04.001.634S - NAIL INTRAMEDULLARY 11MM 270MM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.636S SUP HCPCS C1713 04.001.636S - NAIL INTRAMEDULLARY 11MM 28CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.638S SUP HCPCS C1713 04.001.638S - NAIL INTRAMEDULLARY 11MM 29CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.640S SUP HCPCS C1713 04.001.640S - NAIL INTRAMEDULLARY 11MM 30CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.642S SUP HCPCS C1713 04.001.642S - NAIL INTRAMEDULLARY 11MM 31CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.001.644S SUP HCPCS C1713 04.001.644S - NAIL INTRAMEDULLARY 11MM 32CM CANN NAIL-EX TITANIUM HUMERUS BOTH IP/OP "$3,823.35 " "$2,829.28" $0.00 "$2,969.60" "$1,670.40" "$1,670.40" $0.00 $0.00 $0.00 $796.88 "$2,837.69" "$2,837.69" $0.00 $0.00 $796.79 $0.00 "$1,884.91" "$1,884.91" $0.00 "$1,856.00" "$2,939.90" "$2,969.60" $0.00 $0.00 $564.01 $0.00 $0.00 $590.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.000S SUP Custom 27803010 04.003.000S - CAP END 0MM T40 STARDRIVE RECESS CANN FLUSH SELF RETAINING BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.001S SUP Custom 27803010 04.003.001S - CAP END 5MM T40 STARDRIVE RECESS CANN SELF RETAINING LATERAL BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.002S SUP Custom 27803010 04.003.002S - CAP END 10MM T40 STARDRIVE RECESS CANN SELF RETAINING BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.003S SUP Custom 27803010 04.003.003S - CAP END 15MM 12MM T40 STARDRIVE RECESS CANN SELF RETAINING BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.004S SUP Custom 27803010 04.003.004S - CAP END 20MM T40 STARDRIVE RECESS CANN SELF RETAINING BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.006S SUP Custom 27803010 04.003.006S - CAP END 5MM 16MM T40 STARDRIVE RECESS CANN SELF RETAINING BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.007S SUP Custom 27803010 04.003.007S - CAP END 10MM 16MM T40 STARDRIVE RECESS CANN SELF RETAINING BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.008S SUP Custom 27803010 04.003.008S - CAP END 15MM 16MM T40 STARDRIVE RECESS CANN SELF RETAINING BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.009S SUP Custom 27803010 04.003.009S - CAP END 20MM 16MM T40 STARDRIVE RECESS CANN SELF RETAINING BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.022 SUP HCPCS C1713 04.003.022 - SCREW BONE 6.5MM 60MM TI FEM SLFTAP TIP RECON T25 STARDRIVE BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.022S SUP HCPCS C1713 04.003.022S - SCREW BN T25 6.5MM 60MM AU STRL ST BLNT TIP STRDR TI FEM LAT BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.023 SUP HCPCS C1713 04.003.023 - SCREW BONE 6.5MM 65MM TI FEM SLFTAP TIP RECON T25 STARDRIVE BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.023S SUP HCPCS C1713 04.003.023S - SCREW BN T25 6.5MM 65MM AU STRL ST BLNT TIP STRDR TI FEM LAT BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.024 SUP HCPCS C1713 04.003.024 - SCREW BONE 6.5MM 70MM TI FEM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.024S SUP HCPCS C1713 04.003.024S - SCREW BN T25 6.5MM 70MM AU STRL ST BLNT TIP STRDR TI FEM LAT BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.025 SUP HCPCS C1713 04.003.025 - SCREW BONE 6.5MM 75MM TI FEM SLFTAP TIP RECON T25 STARDRIVE BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.025S SUP HCPCS C1713 04.003.025S - SCREW BN T25 6.5MM 75MM AU STRL ST BLNT TIP STRDR TI FEM LAT BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.026 SUP HCPCS C1713 04.003.026 - SCREW BONE 6.5MM 80MM TI FEM SLFTAP RECON STARDRIVE RECESS BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.026S SUP HCPCS C1713 04.003.026S - SCREW BN T25 6.5MM 80MM AU STRL ST BLNT TIP STRDR TI FEM LAT BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.027 SUP HCPCS C1713 04.003.027 - SCREW BONE 6.5MM 85MM TI FEM SLFTAP TIP RECON T25 STARDRIVE BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.027S SUP HCPCS C1713 04.003.027S - SCREW BN T25 6.5MM 85MM AU STRL ST BLNT TIP STRDR TI FEM LAT BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.028 SUP HCPCS C1713 04.003.028 - SCREW BONE 6.5MM 90MM TI FEM SLFTAP TIP RECON T25 STARDRIVE BOTH IP/OP $424.75 $314.32 $0.00 $339.80 $191.14 $191.14 $0.00 $0.00 $0.00 $88.53 $315.25 $315.25 $0.00 $0.00 $88.52 $0.00 $251.24 $251.24 $0.00 $212.38 $336.40 $339.80 $0.00 $0.00 $66.47 $0.00 $0.00 $67.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.028S SUP HCPCS C1713 04.003.028S - SCREW BN T25 6.5MM 90MM AU STRL ST BLNT TIP STRDR TI FEM LAT BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.029 SUP HCPCS C1713 04.003.029 - SCREW BONE 6.5MM 95MM TI FEM SLFTAP TIP RECON T25 STARDRIVE BOTH IP/OP $424.75 $314.32 $0.00 $339.80 $191.14 $191.14 $0.00 $0.00 $0.00 $88.53 $315.25 $315.25 $0.00 $0.00 $88.52 $0.00 $251.24 $251.24 $0.00 $212.38 $336.40 $339.80 $0.00 $0.00 $66.47 $0.00 $0.00 $67.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.029S SUP HCPCS C1713 04.003.029S - SCREW BN T25 6.5MM 95MM AU STRL ST BLNT TIP STRDR TI FEM LAT BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.030 SUP HCPCS C1713 04.003.030 - SCREW BONE NONSTRL 6.5MM 100MM TI FEM T25 STARDRIVE RECESS BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.030S SUP HCPCS C1713 04.003.030S - SCREW BN T25 6.5MM 100MM AU STRL ST BLNT TIP STRDR TI FEM BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.031 SUP HCPCS C1713 04.003.031 - SCREW BONE 6.5MM 105MM TI FEM T25 STARDRIVE RECESS RECON BOTH IP/OP $424.75 $314.32 $0.00 $339.80 $191.14 $191.14 $0.00 $0.00 $0.00 $88.53 $315.25 $315.25 $0.00 $0.00 $88.52 $0.00 $251.24 $251.24 $0.00 $212.38 $336.40 $339.80 $0.00 $0.00 $66.47 $0.00 $0.00 $67.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.031S SUP HCPCS C1713 04.003.031S - SCREW BN T25 6.5MM 105MM AU STRL ST BLNT TIP STRDR TI FEM BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.032 SUP HCPCS C1713 04.003.032 - SCREW BONE 6.5MM 110MM TI FEM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.032S SUP HCPCS C1713 04.003.032S - SCREW BN T25 6.5MM 110MM AU STRL ST BLNT TIP STRDR TI FEM BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.033 SUP HCPCS C1713 04.003.033 - SCREW BONE 6.5MM 115MM TI FEM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.033S SUP HCPCS C1713 04.003.033S - SCREW BN T25 6.5MM 115MM AU STRL ST BLNT TIP STRDR TI FEM BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.034 SUP HCPCS C1713 04.003.034 - SCREW BONE 6.5MM 120MM TI FEM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.034S SUP HCPCS C1713 04.003.034S - SCREW BN T25 6.5MM 120MM AU STRL ST BLNT TIP STRDR TI FEM BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.035 SUP HCPCS C1713 04.003.035 - SCREW BONE 6.5MM 125MM TI FEM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.035S SUP HCPCS C1713 04.003.035S - SCREW BN T25 6.5MM 125MM AU STRL ST BLNT TIP STRDR TI FEM BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.036 SUP HCPCS C1713 04.003.036 - SCREW BONE 6.5MM 130MM TI FEM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $400.38 $296.28 $0.00 $320.30 $180.17 $180.17 $0.00 $0.00 $0.00 $83.45 $297.16 $297.16 $0.00 $0.00 $83.44 $0.00 $236.82 $236.82 $0.00 $200.19 $317.10 $320.30 $0.00 $0.00 $62.66 $0.00 $0.00 $63.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.036S SUP HCPCS C1713 04.003.036S - SCREW BN T25 6.5MM 130MM AU STRL ST BLNT TIP STRDR TI FEM BOTH IP/OP $450.75 $333.56 $0.00 $350.10 $196.93 $196.93 $0.00 $0.00 $0.00 $93.95 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $266.62 $266.62 $0.00 $218.81 $346.60 $350.10 $0.00 $0.00 $66.49 $0.00 $0.00 $69.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.240S SUP HCPCS C1713 04.003.240S - NAIL INTRAMEDULLARY 9MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.241S SUP HCPCS C1713 04.003.241S - NAIL INTRAMEDULLARY 9MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.244S SUP HCPCS C1713 04.003.244S - NAIL INTRAMEDULLARY 9MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.245S SUP HCPCS C1713 04.003.245S - NAIL INTRAMEDULLARY 9MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.248S SUP HCPCS C1713 04.003.248S - NAIL INTRAMEDULLARY 9MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.249S SUP HCPCS C1713 04.003.249S - NAIL INTRAMEDULLARY 9MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.252S SUP HCPCS C1713 04.003.252S - NAIL INTRAMEDULLARY 9MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.253S SUP HCPCS C1713 04.003.253S - NAIL INTRAMEDULLARY 9MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.256S SUP HCPCS C1713 04.003.256S - NAIL INTRAMEDULLARY 9MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.257S SUP HCPCS C1713 04.003.257S - NAIL INTRAMEDULLARY 9MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.260S SUP HCPCS C1713 04.003.260S - NAIL INTRAMEDULLARY 9MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.261S SUP HCPCS C1713 04.003.261S - NAIL INTRAMEDULLARY 9MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.264S SUP HCPCS C1713 04.003.264S - NAIL INTRAMEDULLARY 9MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.265S SUP HCPCS C1713 04.003.265S - NAIL INTRAMEDULLARY 9MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.268S SUP HCPCS C1713 04.003.268S - NAIL INTRAMEDULLARY 9MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.269S SUP HCPCS C1713 04.003.269S - NAIL INTRAMEDULLARY 9MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.272S SUP HCPCS C1713 04.003.272S - NAIL INTRAMEDULLARY 9MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.273S SUP HCPCS C1713 04.003.273S - NAIL INTRAMEDULLARY 9MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.276S SUP HCPCS C1713 04.003.276S - NAIL INTRAMEDULLARY 9MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.277S SUP HCPCS C1713 04.003.277S - NAIL INTRAMEDULLARY 9MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.340S SUP HCPCS C1713 04.003.340S - NAIL INTRAMEDULLARY 10MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.341S SUP HCPCS C1713 04.003.341S - NAIL INTRAMEDULLARY 10MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.344S SUP HCPCS C1713 04.003.344S - NAIL INTRAMEDULLARY 10MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.345S SUP HCPCS C1713 04.003.345S - NAIL INTRAMEDULLARY 10MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.348S SUP HCPCS C1713 04.003.348S - NAIL INTRAMEDULLARY 10MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.349S SUP HCPCS C1713 04.003.349S - NAIL INTRAMEDULLARY 10MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.352S SUP HCPCS C1713 04.003.352S - NAIL INTRAMEDULLARY 10MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.353S SUP HCPCS C1713 04.003.353S - NAIL INTRAMEDULLARY 10MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.356S SUP HCPCS C1713 04.003.356S - NAIL INTRAMEDULLARY 10MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.357S SUP HCPCS C1713 04.003.357S - NAIL INTRAMEDULLARY 10MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.360S SUP HCPCS C1713 04.003.360S - NAIL INTRAMEDULLARY 10MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.361S SUP HCPCS C1713 04.003.361S - NAIL INTRAMEDULLARY 10MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $594.10 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.364S SUP HCPCS C1713 04.003.364S - NAIL INTRAMEDULLARY 10MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.365S SUP HCPCS C1713 04.003.365S - NAIL INTRAMEDULLARY 10MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.368S SUP HCPCS C1713 04.003.368S - NAIL INTRAMEDULLARY 10MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.369S SUP HCPCS C1713 04.003.369S - NAIL INTRAMEDULLARY 10MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.372S SUP HCPCS C1713 04.003.372S - NAIL INTRAMEDULLARY 10MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.373S SUP HCPCS C1713 04.003.373S - NAIL INTRAMEDULLARY 10MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.376S SUP HCPCS C1713 04.003.376S - NAIL INTRAMEDULLARY 10MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.377S SUP HCPCS C1713 04.003.377S - NAIL INTRAMEDULLARY 10MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.440S SUP HCPCS C1713 04.003.440S - NAIL INTRAMEDULLARY 11MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.441S SUP HCPCS C1713 04.003.441S - NAIL INTRAMEDULLARY 11MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.444S SUP HCPCS C1713 04.003.444S - NAIL INTRAMEDULLARY 11MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.445S SUP HCPCS C1713 04.003.445S - NAIL INTRAMEDULLARY 11MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.448S SUP HCPCS C1713 04.003.448S - NAIL INTRAMEDULLARY 11MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.449S SUP HCPCS C1713 04.003.449S - NAIL INTRAMEDULLARY 11MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.452S SUP HCPCS C1713 04.003.452S - NAIL INTRAMEDULLARY 11MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.453S SUP HCPCS C1713 04.003.453S - NAIL INTRAMEDULLARY 11MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.456S SUP HCPCS C1713 04.003.456S - NAIL INTRAMEDULLARY 11MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.457S SUP HCPCS C1713 04.003.457S - NAIL INTRAMEDULLARY 11MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.460S SUP HCPCS C1713 04.003.460S - NAIL INTRAMEDULLARY 11MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.461S SUP HCPCS C1713 04.003.461S - NAIL INTRAMEDULLARY 11MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.464S SUP HCPCS C1713 04.003.464S - NAIL INTRAMEDULLARY 11MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.465S SUP HCPCS C1713 04.003.465S - NAIL INTRAMEDULLARY 11MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.468S SUP HCPCS C1713 04.003.468S - NAIL INTRAMEDULLARY 11MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.469S SUP HCPCS C1713 04.003.469S - NAIL INTRAMEDULLARY 11MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.472S SUP HCPCS C1713 04.003.472S - NAIL INTRAMEDULLARY 11MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.473S SUP HCPCS C1713 04.003.473S - NAIL INTRAMEDULLARY 11MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.476S SUP HCPCS C1713 04.003.476S - NAIL INTRAMEDULLARY 11MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.477S SUP HCPCS C1713 04.003.477S - NAIL INTRAMEDULLARY 11MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.540S SUP HCPCS C1713 04.003.540S - NAIL INTRAMEDULLARY 12MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.541S SUP HCPCS C1713 04.003.541S - NAIL INTRAMEDULLARY 12MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.544S SUP HCPCS C1713 04.003.544S - NAIL INTRAMEDULLARY 12MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.545S SUP HCPCS C1713 04.003.545S - NAIL INTRAMEDULLARY 12MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.548S SUP HCPCS C1713 04.003.548S - NAIL INTRAMEDULLARY 12MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.549S SUP HCPCS C1713 04.003.549S - NAIL INTRAMEDULLARY 12MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.552S SUP HCPCS C1713 04.003.552S - NAIL INTRAMEDULLARY 12MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.553S SUP HCPCS C1713 04.003.553S - NAIL INTRAMEDULLARY 12MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.556S SUP HCPCS C1713 04.003.556S - NAIL INTRAMEDULLARY 12MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.557S SUP HCPCS C1713 04.003.557S - NAIL INTRAMEDULLARY 12MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.560S SUP HCPCS C1713 04.003.560S - NAIL INTRAMEDULLARY 12MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.561S SUP HCPCS C1713 04.003.561S - NAIL INTRAMEDULLARY 12MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.564S SUP HCPCS C1713 04.003.564S - NAIL INTRAMEDULLARY 12MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.565S SUP HCPCS C1713 04.003.565S - NAIL INTRAMEDULLARY 12MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.568S SUP HCPCS C1713 04.003.568S - NAIL INTRAMEDULLARY 12MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.569S SUP HCPCS C1713 04.003.569S - NAIL INTRAMEDULLARY 12MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.572S SUP HCPCS C1713 04.003.572S - NAIL INTRAMEDULLARY 12MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.573S SUP HCPCS C1713 04.003.573S - NAIL INTRAMEDULLARY 12MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.576S SUP HCPCS C1713 04.003.576S - NAIL INTRAMEDULLARY 12MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.577S SUP HCPCS C1713 04.003.577S - NAIL INTRAMEDULLARY 12MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.640S SUP HCPCS C1713 04.003.640S - NAIL INTRAMEDULLARY 13MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.641S SUP HCPCS C1713 04.003.641S - NAIL INTRAMEDULLARY 13MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.644S SUP HCPCS C1713 04.003.644S - NAIL INTRAMEDULLARY 13MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.645S SUP HCPCS C1713 04.003.645S - NAIL INTRAMEDULLARY 13MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.648S SUP HCPCS C1713 04.003.648S - NAIL INTRAMEDULLARY 13MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.649S SUP HCPCS C1713 04.003.649S - NAIL INTRAMEDULLARY 13MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.652S SUP HCPCS C1713 04.003.652S - NAIL INTRAMEDULLARY 13MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.653S SUP HCPCS C1713 04.003.653S - NAIL INTRAMEDULLARY 13MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.656S SUP HCPCS C1713 04.003.656S - NAIL INTRAMEDULLARY 13MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.657S SUP HCPCS C1713 04.003.657S - NAIL INTRAMEDULLARY 13MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.660S SUP HCPCS C1713 04.003.660S - NAIL INTRAMEDULLARY 13MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.661S SUP HCPCS C1713 04.003.661S - NAIL INTRAMEDULLARY 13MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.664S SUP HCPCS C1713 04.003.664S - NAIL INTRAMEDULLARY 13MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.665S SUP HCPCS C1713 04.003.665S - NAIL INTRAMEDULLARY 13MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.668S SUP HCPCS C1713 04.003.668S - NAIL INTRAMEDULLARY 13MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.669S SUP HCPCS C1713 04.003.669S - NAIL INTRAMEDULLARY 13MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.672S SUP HCPCS C1713 04.003.672S - NAIL INTRAMEDULLARY 13MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.673S SUP HCPCS C1713 04.003.673S - NAIL INTRAMEDULLARY 13MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.676S SUP HCPCS C1713 04.003.676S - NAIL INTRAMEDULLARY 13MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,136.28 " "$2,320.85" $0.00 "$2,435.96" "$1,370.23" "$1,370.23" $0.00 $0.00 $0.00 $653.68 "$2,327.74" "$2,327.74" $0.00 $0.00 $653.60 $0.00 "$1,546.18" "$1,546.18" $0.00 "$1,522.48" "$2,411.60" "$2,435.96" $0.00 $0.00 $462.65 $0.00 $0.00 $484.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.677S SUP HCPCS C1713 04.003.677S - NAIL INTRAMEDULLARY 13MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,242.78 " "$2,399.66" $0.00 "$2,518.66" "$1,416.75" "$1,416.75" $0.00 $0.00 $0.00 $675.88 "$2,406.79" "$2,406.79" $0.00 $0.00 $675.79 $0.00 "$1,598.69" "$1,598.69" $0.00 "$1,574.16" "$2,493.48" "$2,518.66" $0.00 $0.00 $478.36 $0.00 $0.00 $501.21 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.740S SUP HCPCS C1713 04.003.740S - NAIL INTRAMEDULLARY 14MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.741S SUP HCPCS C1713 04.003.741S - NAIL INTRAMEDULLARY 14MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.744S SUP HCPCS C1713 04.003.744S - NAIL INTRAMEDULLARY 14MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.745S SUP HCPCS C1713 04.003.745S - NAIL INTRAMEDULLARY 14MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.748S SUP HCPCS C1713 04.003.748S - NAIL INTRAMEDULLARY 14MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.749S SUP HCPCS C1713 04.003.749S - NAIL INTRAMEDULLARY 14MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.752S SUP HCPCS C1713 04.003.752S - NAIL INTRAMEDULLARY 14MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.753S SUP HCPCS C1713 04.003.753S - NAIL INTRAMEDULLARY 14MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.756S SUP HCPCS C1713 04.003.756S - NAIL INTRAMEDULLARY 14MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.757S SUP HCPCS C1713 04.003.757S - NAIL INTRAMEDULLARY 14MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.760S SUP HCPCS C1713 04.003.760S - NAIL INTRAMEDULLARY 14MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.761S SUP HCPCS C1713 04.003.761S - NAIL INTRAMEDULLARY 14MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.764S SUP HCPCS C1713 04.003.764S - NAIL INTRAMEDULLARY 14MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.765S SUP HCPCS C1713 04.003.765S - NAIL INTRAMEDULLARY 14MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.768S SUP HCPCS C1713 04.003.768S - NAIL INTRAMEDULLARY 14MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.769S SUP HCPCS C1713 04.003.769S - NAIL INTRAMEDULLARY 14MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.772S SUP HCPCS C1713 04.003.772S - NAIL INTRAMEDULLARY 14MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.773S SUP HCPCS C1713 04.003.773S - NAIL INTRAMEDULLARY 14MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.776S SUP HCPCS C1713 04.003.776S - NAIL INTRAMEDULLARY 14MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.777S SUP HCPCS C1713 04.003.777S - NAIL INTRAMEDULLARY 14MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.840S SUP HCPCS C1713 04.003.840S - NAIL INTRAMEDULLARY 15MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.841S SUP HCPCS C1713 04.003.841S - NAIL INTRAMEDULLARY 15MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.844S SUP HCPCS C1713 04.003.844S - NAIL INTRAMEDULLARY 15MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.845S SUP HCPCS C1713 04.003.845S - NAIL INTRAMEDULLARY 15MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.848S SUP HCPCS C1713 04.003.848S - NAIL INTRAMEDULLARY 15MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.849S SUP HCPCS C1713 04.003.849S - NAIL INTRAMEDULLARY 15MM 340MM RECONSTRUCTION ANATOMIC CANN BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.852S SUP HCPCS C1713 04.003.852S - NAIL INTRAMEDULLARY 15MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.853S SUP HCPCS C1713 04.003.853S - NAIL INTRAMEDULLARY 15MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.856S SUP HCPCS C1713 04.003.856S - NAIL INTRAMEDULLARY 15MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.857S SUP HCPCS C1713 04.003.857S - NAIL INTRAMEDULLARY 15MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.860S SUP HCPCS C1713 04.003.860S - NAIL INTRAMEDULLARY 15MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.861S SUP HCPCS C1713 04.003.861S - NAIL INTRAMEDULLARY 15MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.864S SUP HCPCS C1713 04.003.864S - NAIL INTRAMEDULLARY 15MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.865S SUP HCPCS C1713 04.003.865S - NAIL INTRAMEDULLARY 15MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.868S SUP HCPCS C1713 04.003.868S - NAIL INTRAMEDULLARY 15MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.869S SUP HCPCS C1713 04.003.869S - NAIL INTRAMEDULLARY 15MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.872S SUP HCPCS C1713 04.003.872S - NAIL INTRAMEDULLARY 15MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.873S SUP HCPCS C1713 04.003.873S - NAIL INTRAMEDULLARY 15MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.876S SUP HCPCS C1713 04.003.876S - NAIL INTRAMEDULLARY 15MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.877S SUP HCPCS C1713 04.003.877S - NAIL INTRAMEDULLARY 15MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.940S SUP HCPCS C1713 04.003.940S - NAIL INTRAMEDULLARY 16MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.941S SUP HCPCS C1713 04.003.941S - NAIL INTRAMEDULLARY 16MM 300MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.944S SUP HCPCS C1713 04.003.944S - NAIL INTRAMEDULLARY 16MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.945S SUP HCPCS C1713 04.003.945S - NAIL INTRAMEDULLARY 16MM 320MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.948S SUP HCPCS C1713 04.003.948S - NAIL INTRAMEDULLARY 16MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.949S SUP HCPCS C1713 04.003.949S - NAIL INTRAMEDULLARY 16MM 340MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.952S SUP HCPCS C1713 04.003.952S - NAIL INTRAMEDULLARY 16MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.953S SUP HCPCS C1713 04.003.953S - NAIL INTRAMEDULLARY 16MM 360MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.956S SUP HCPCS C1713 04.003.956S - NAIL INTRAMEDULLARY 16MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.957S SUP HCPCS C1713 04.003.957S - NAIL INTRAMEDULLARY 16MM 380MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.960S SUP HCPCS C1713 04.003.960S - NAIL INTRAMEDULLARY 16MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.961S SUP HCPCS C1713 04.003.961S - NAIL INTRAMEDULLARY 16MM 400MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.964S SUP HCPCS C1713 04.003.964S - NAIL INTRAMEDULLARY 16MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.965S SUP HCPCS C1713 04.003.965S - NAIL INTRAMEDULLARY 16MM 420MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.968S SUP HCPCS C1713 04.003.968S - NAIL INTRAMEDULLARY 16MM 440MM CANN LATERAL ENTRY BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.969S SUP HCPCS C1713 04.003.969S - NAIL INTRAMEDULLARY 16MM 440MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.972S SUP HCPCS C1713 04.003.972S - NAIL INTRAMEDULLARY 16MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.973S SUP HCPCS C1713 04.003.973S - NAIL INTRAMEDULLARY 16MM 460MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.976S SUP HCPCS C1713 04.003.976S - NAIL INTRAMEDULLARY 16MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.003.977S SUP HCPCS C1713 04.003.977S - NAIL INTRAMEDULLARY 16MM 480MM ANATOMIC CANN HELICAL FLUTED BOTH IP/OP "$3,340.50 " "$2,471.97" $0.00 "$2,594.58" "$1,459.45" "$1,459.45" $0.00 $0.00 $0.00 $696.24 "$2,479.32" "$2,479.32" $0.00 $0.00 $696.16 $0.00 "$1,646.87" "$1,646.87" $0.00 "$1,621.61" "$2,568.64" "$2,594.58" $0.00 $0.00 $492.78 $0.00 $0.00 $516.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.000S SUP Custom 27803010 04.004.000S - CAP END 5MM T40 STARDRIVE RECESS EXTENDED NAIL-EX GOLD BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.001S SUP Custom 27803010 04.004.001S - CAP END 5MM STARDRIVE T40 RECESS EXTENDED EXPERT GOLD BOTH IP/OP $504.73 $373.50 $0.00 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.61 $374.61 $0.00 $0.00 $105.18 $0.00 $0.00 $0.00 $0.00 $245.01 $388.10 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.002S SUP Custom 27803010 04.004.002S - CAP END 10MM EXTN T40 STARDRIVE RECESS EXPERT GOLD TITANIUM BOTH IP/OP $504.73 $373.50 $0.00 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.61 $374.61 $0.00 $0.00 $105.18 $0.00 $0.00 $0.00 $0.00 $245.01 $388.10 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.003S SUP Custom 27803010 04.004.003S - CAP END 15MM EXTN T40 STARDRIVE RECESS EXPERT GOLD TITANIUM BOTH IP/OP $504.73 $373.50 $0.00 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.61 $374.61 $0.00 $0.00 $105.18 $0.00 $0.00 $0.00 $0.00 $245.01 $388.10 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.008S SUP Custom 27803010 04.004.008S - CAP END 0MM T40 STARDRIVE RECESS EXTENDED NAIL-EX GRAY BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.009S SUP Custom 27803010 04.004.009S - CAP END 5MM EXTENDED T40 STARDRIVE RECESS LOCKING HOLE BOTH IP/OP $504.73 $373.50 $0.00 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.61 $374.61 $0.00 $0.00 $105.18 $0.00 $0.00 $0.00 $0.00 $245.01 $388.10 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.010S SUP Custom 27803010 04.004.010S - CAP END 10MM EXTENDED T40 STARDRIVE RECESS LOCKING HOLE BOTH IP/OP $504.73 $373.50 $0.00 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.61 $374.61 $0.00 $0.00 $105.18 $0.00 $0.00 $0.00 $0.00 $245.01 $388.10 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.011S SUP Custom 27803010 04.004.011S - CAP END 15MM EXTN T40 STARDRIVE RECESS EXPERT GRAY TITANIUM BOTH IP/OP $504.73 $373.50 $0.00 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.61 $374.61 $0.00 $0.00 $105.18 $0.00 $0.00 $0.00 $0.00 $245.01 $388.10 $392.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.231S SUP HCPCS C1713 04.004.231S - NAIL INTRAMEDULLARY 8MM 25.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.234S SUP HCPCS C1713 04.004.234S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 270MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.237S SUP HCPCS C1713 04.004.237S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 285MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.240S SUP HCPCS C1713 04.004.240S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 300MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.243S SUP HCPCS C1713 04.004.243S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 315MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.246S SUP HCPCS C1713 04.004.246S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 330MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.249S SUP HCPCS C1713 04.004.249S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 345MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.252S SUP HCPCS C1713 04.004.252S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 360MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.255S SUP HCPCS C1713 04.004.255S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 375MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.258S SUP HCPCS C1713 04.004.258S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 390MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.261S SUP HCPCS C1713 04.004.261S - NAIL INTRAMEDULLARY 8MM 40.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,917.48 " "$2,158.94" $0.00 "$2,266.00" "$1,274.63" "$1,274.63" $0.00 $0.00 $0.00 $608.07 "$2,165.35" "$2,165.35" $0.00 $0.00 $608.00 $0.00 "$1,438.32" "$1,438.32" $0.00 "$1,416.25" "$2,243.34" "$2,266.00" $0.00 $0.00 $430.38 $0.00 $0.00 $450.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.264S SUP HCPCS C1713 04.004.264S - NAIL INTRAMEDULLARY 8MM 42CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,917.48 " "$2,158.94" $0.00 "$2,266.00" "$1,274.63" "$1,274.63" $0.00 $0.00 $0.00 $608.07 "$2,165.35" "$2,165.35" $0.00 $0.00 $608.00 $0.00 "$1,438.32" "$1,438.32" $0.00 "$1,416.25" "$2,243.34" "$2,266.00" $0.00 $0.00 $430.38 $0.00 $0.00 $450.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.267S SUP HCPCS C1713 04.004.267S - NAIL INTRAMEDULLARY 8MM 43.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.331S SUP HCPCS C1713 04.004.331S - NAIL INTRAMEDULLARY 9MM 25.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.334S SUP HCPCS C1713 04.004.334S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 270MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.337S SUP HCPCS C1713 04.004.337S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 285MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.340S SUP HCPCS C1713 04.004.340S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 300MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.343S SUP HCPCS C1713 04.004.343S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 315MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.346S SUP HCPCS C1713 04.004.346S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 330MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.349S SUP HCPCS C1713 04.004.349S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 345MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.352S SUP HCPCS C1713 04.004.352S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 360MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.355S SUP HCPCS C1713 04.004.355S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 375MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.358S SUP HCPCS C1713 04.004.358S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 390MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.361S SUP HCPCS C1713 04.004.361S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 405MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.364S SUP HCPCS C1713 04.004.364S - NAIL INTRAMEDULLARY 9MM 42CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.367S SUP HCPCS C1713 04.004.367S - NAIL INTRAMEDULLARY 9MM 43.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.431S SUP HCPCS C1713 04.004.431S - NAIL INTRAMEDULLARY 10MM 25.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,917.48 " "$2,158.94" $0.00 "$2,266.00" "$1,274.63" "$1,274.63" $0.00 $0.00 $0.00 $608.07 "$2,165.35" "$2,165.35" $0.00 $0.00 $608.00 $0.00 "$1,438.32" "$1,438.32" $0.00 "$1,416.25" "$2,243.34" "$2,266.00" $0.00 $0.00 $430.38 $0.00 $0.00 $450.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.434S SUP HCPCS C1713 04.004.434S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 270MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.437S SUP HCPCS C1713 04.004.437S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 285MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.440S SUP HCPCS C1713 04.004.440S - NAIL INTRAMEDULLARY UNIVERSAL ROUND BARREL 10MM 300MM CANN BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.443S SUP HCPCS C1713 04.004.443S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 315MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.446S SUP HCPCS C1713 04.004.446S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 33CM CANN EXPERT LIGHT BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.449S SUP HCPCS C1713 04.004.449S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 34.5CM CANN EXPERT LIGHT BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.452S SUP HCPCS C1713 04.004.452S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 360MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.455S SUP HCPCS C1713 04.004.455S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 375MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.458S SUP HCPCS C1713 04.004.458S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 390MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.461S SUP HCPCS C1713 04.004.461S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 405MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.464S SUP HCPCS C1713 04.004.464S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 420MM CANN ROUND BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.467S SUP HCPCS C1713 04.004.467S - NAIL INTRAMEDULLARY 10MM 43.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.531S SUP HCPCS C1713 04.004.531S - NAIL INTRAMEDULLARY 11MM 25.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.534S SUP HCPCS C1713 04.004.534S - NAIL INTRAMEDULLARY 11MM 27CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.537S SUP HCPCS C1713 04.004.537S - NAIL INTRAMEDULLARY 11MM 28.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.540S SUP HCPCS C1713 04.004.540S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 300MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.543S SUP HCPCS C1713 04.004.543S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 315MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.546S SUP HCPCS C1713 04.004.546S - NAIL INTRAMEDULLARY 11MM 330MM CANN NAIL-EX LIGHT GREEN BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.549S SUP HCPCS C1713 04.004.549S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 345MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.552S SUP HCPCS C1713 04.004.552S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 360MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.555S SUP HCPCS C1713 04.004.555S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 375MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.558S SUP HCPCS C1713 04.004.558S - NAIL INTRAMEDULLARY UNIVERSAL FLUTE BARREL 11MM 390MM CANN BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.561S SUP HCPCS C1713 04.004.561S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 405MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.564S SUP HCPCS C1713 04.004.564S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 420MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.567S SUP HCPCS C1713 04.004.567S - NAIL INTRAMEDULLARY 11MM 43.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.631S SUP HCPCS C1713 04.004.631S - NAIL INTRAMEDULLARY 12MM 25.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.634S SUP HCPCS C1713 04.004.634S - NAIL INTRAMEDULLARY 12MM 27CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.637S SUP HCPCS C1713 04.004.637S - NAIL INTRAMEDULLARY 12MM 28.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.640S SUP HCPCS C1713 04.004.640S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 300MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.643S SUP HCPCS C1713 04.004.643S - NAIL INTRAMEDULLARY UNIVERSAL FLUTE 12MM 315MM CANN EXPERT BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.646S SUP HCPCS C1713 04.004.646S - NAIL INTRAMEDULLARY UNIVERSAL FLUTE BARREL 12MM 330MM CANN BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.649S SUP HCPCS C1713 04.004.649S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 345MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.652S SUP HCPCS C1713 04.004.652S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 360MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.655S SUP HCPCS C1713 04.004.655S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 375MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.658S SUP HCPCS C1713 04.004.658S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 390MM CANN EXPERT LIGHT BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.661S SUP HCPCS C1713 04.004.661S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 405MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.664S SUP HCPCS C1713 04.004.664S - NAIL INTRAMEDULLARY 12MM 42CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.667S SUP HCPCS C1713 04.004.667S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 435MM CANN FLUTED BARREL BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.731S SUP HCPCS C1713 04.004.731S - NAIL INTRAMEDULLARY 13MM 25.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.734S SUP HCPCS C1713 04.004.734S - NAIL INTRAMEDULLARY 13MM 27CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.737S SUP HCPCS C1713 04.004.737S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 285MM CANN FLUTED BARREL BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.740S SUP HCPCS C1713 04.004.740S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 300MM CANN FLUTED BARREL BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.743S SUP HCPCS C1713 04.004.743S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 315MM CANN FLUTED BARREL BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.746S SUP HCPCS C1713 04.004.746S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 330MM CANN FLUTED BARREL BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.749S SUP HCPCS C1713 04.004.749S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 345MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.752S SUP HCPCS C1713 04.004.752S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 360MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.755S SUP HCPCS C1713 04.004.755S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 375MM CANN FLUTED BARREL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.758S SUP HCPCS C1713 04.004.758S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 390MM CANN FLUTED BARREL BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.761S SUP HCPCS C1713 04.004.761S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 405MM CANN FLUTED BARREL BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.764S SUP HCPCS C1713 04.004.764S - NAIL INTRAMEDULLARY 13MM 42CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.004.767S SUP HCPCS C1713 04.004.767S - NAIL INTRAMEDULLARY 13MM 43.5CM CANN NAIL-EX TITANIUM TIBIA BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.408 SUP HCPCS C1713 04.005.408 - SCREW BONE NONSTRL 4MM 18MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.408S SUP HCPCS C1713 04.005.408S - SCREW BN T25 FT 4MM 3.3MM 18MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.410 SUP HCPCS C1713 04.005.410 - SCREW BONE NONSTRL 4MM 20MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.410S SUP HCPCS C1713 04.005.410S - SCREW BN T25 FT 4MM 3.3MM 20MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.412 SUP HCPCS C1713 04.005.412 - SCREW BONE NONSTRL 4MM 22MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.412S SUP HCPCS C1713 04.005.412S - SCREW BN T25 FT 4MM 3.3MM 22MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.414 SUP HCPCS C1713 04.005.414 - SCREW BONE NONSTRL 4MM 24MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.414S SUP HCPCS C1713 04.005.414S - SCREW BN T25 FT 4MM 3.3MM 24MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.416 SUP HCPCS C1713 04.005.416 - SCREW BONE NONSTRL 4MM 26MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.416S SUP HCPCS C1713 04.005.416S - SCREW BN T25 FT 4MM 3.3MM 26MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.418 SUP HCPCS C1713 04.005.418 - SCREW BONE 4MM 28MM NLEX TI HUM TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.418S SUP HCPCS C1713 04.005.418S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 28MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.420 SUP HCPCS C1713 04.005.420 - SCREW BONE 4MM 30MM NLEX TI HUM TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.420S SUP HCPCS C1713 04.005.420S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 30MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.422 SUP HCPCS C1713 04.005.422 - SCREW BONE 4MM 32MM NLEX TI HUM TIB LCK STARDRIVE RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.422S SUP HCPCS C1713 04.005.422S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 32MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.424 SUP HCPCS C1713 04.005.424 - SCREW BONE NONSTRL 4MM 34MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.424S SUP HCPCS C1713 04.005.424S - SCREW BN T25 FT 4MM 3.3MM 34MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.426 SUP HCPCS C1713 04.005.426 - SCREW BONE NONSTRL 4MM 36MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.426S SUP HCPCS C1713 04.005.426S - SCREW BN T25 FT 4MM 3.3MM 36MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.428 SUP HCPCS C1713 04.005.428 - SCREW BONE NONSTRL 4MM 38MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.428S SUP HCPCS C1713 04.005.428S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 38MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.430 SUP HCPCS C1713 04.005.430 - SCREW BONE NONSTRL 4MM 40MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.430S SUP HCPCS C1713 04.005.430S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 40MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.432 SUP HCPCS C1713 04.005.432 - SCREW BONE NONSTRL 4MM 42MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.432S SUP HCPCS C1713 04.005.432S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 42MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.434 SUP HCPCS C1713 04.005.434 - SCREW BONE 4MM 44MM NLEX TI FULTHD HUM TIB SLFTAP LCK BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.434S SUP HCPCS C1713 04.005.434S - SCREW BN T25 FT 4MM 3.3MM 44MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.436 SUP HCPCS C1713 04.005.436 - SCREW BONE NONSTRL 4MM 46MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.436S SUP HCPCS C1713 04.005.436S - SCREW BN T25 FT 4MM 3.3MM 46MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.438 SUP HCPCS C1713 04.005.438 - SCREW BONE NONSTRL 4MM 48MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.438S SUP HCPCS C1713 04.005.438S - SCREW BN T25 FT 4MM 3.3MM 48MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.440 SUP HCPCS C1713 04.005.440 - SCREW BONE NONSTRL 4MM 50MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.440S SUP HCPCS C1713 04.005.440S - SCREW BN T25 FT 4MM 3.3MM 50MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.442 SUP HCPCS C1713 04.005.442 - SCREW BONE NONSTRL 4MM 52MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.442S SUP HCPCS C1713 04.005.442S - SCREW BN T25 FT 4MM 3.3MM 52MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.444 SUP HCPCS C1713 04.005.444 - SCREW BONE NONSTRL 4MM 54MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.444S SUP HCPCS C1713 04.005.444S - SCREW BN T25 FT 4MM 3.3MM 54MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.446 SUP HCPCS C1713 04.005.446 - SCREW BONE NONSTRL 4MM 56MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.446S SUP HCPCS C1713 04.005.446S - SCREW BN T25 FT 4MM 3.3MM 56MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.448 SUP HCPCS C1713 04.005.448 - SCREW BONE NONSTRL 4MM 58MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.448S SUP HCPCS C1713 04.005.448S - SCREW BN T25 FT 4MM 3.3MM 58MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.450 SUP HCPCS C1713 04.005.450 - SCREW BONE NONSTRL 4MM 60MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.450S SUP HCPCS C1713 04.005.450S - SCREW BN T25 FT 4MM 3.3MM 60MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.452 SUP HCPCS C1713 04.005.452 - SCREW BONE NONSTRL 4MM 62MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.452S SUP HCPCS C1713 04.005.452S - SCREW BN T25 FT 4MM 3.3MM 62MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.454 SUP HCPCS C1713 04.005.454 - SCREW BONE NONSTRL 4MM 64MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.454S SUP HCPCS C1713 04.005.454S - SCREW BN T25 FT 4MM 3.3MM 64MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.456 SUP HCPCS C1713 04.005.456 - SCREW BONE NONSTRL 4MM 66MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.456S SUP HCPCS C1713 04.005.456S - SCREW BN T25 FT 4MM 3.3MM 66MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.458 SUP HCPCS C1713 04.005.458 - SCREW BONE NONSTRL 4MM 68MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.458S SUP HCPCS C1713 04.005.458S - SCREW BN T25 FT 4MM 3.3MM 68MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.460 SUP HCPCS C1713 04.005.460 - SCREW BONE NONSTRL 4MM 70MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.460S SUP HCPCS C1713 04.005.460S - SCREW BN T25 FT 4MM 3.3MM 70MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.462 SUP HCPCS C1713 04.005.462 - SCREW BONE NONSTRL 4MM 72MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.462S SUP HCPCS C1713 04.005.462S - SCREW BN T25 FT 4MM 3.3MM 72MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.464 SUP HCPCS C1713 04.005.464 - SCREW BONE NONSTRL 4MM 74MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.464S SUP HCPCS C1713 04.005.464S - SCREW BN T25 FT 4MM 3.3MM 74MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.466 SUP HCPCS C1713 04.005.466 - SCREW BONE NONSTRL 4MM 76MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.466S SUP HCPCS C1713 04.005.466S - SCREW BN T25 FT 4MM 3.3MM 76MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.468 SUP HCPCS C1713 04.005.468 - SCREW BONE NONSTRL 4MM 78MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.468S SUP HCPCS C1713 04.005.468S - SCREW BN T25 FT 4MM 3.3MM 78MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.470 SUP HCPCS C1713 04.005.470 - SCREW BONE NONSTRL 4MM 80MM NLEX TI FULTHD HUM TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.470S SUP HCPCS C1713 04.005.470S - SCREW BN T25 FT 4MM 3.3MM 80MM BLU STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.516 SUP HCPCS C1713 04.005.516 - SCREW BONE 5MM 26MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.516S SUP HCPCS C1713 04.005.516S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 26MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.518 SUP HCPCS C1713 04.005.518 - SCREW BONE 5MM 4.3MM 28MM NLEX TI FULTHD FEM/TIB T25 BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.518S SUP HCPCS C1713 04.005.518S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 28MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.520 SUP HCPCS C1713 04.005.520 - SCREW BONE 5MM 30MM NLEX TI FULTHD FEM/TIB SLFTAP LCK BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.520S SUP HCPCS C1713 04.005.520S - SCREW BONE FULTHD 5MM 4.3MM 30MM T25 STARDRIVE RECESS BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.522 SUP HCPCS C1713 04.005.522 - SCREW BONE NONSTRL 5MM 32MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.522S SUP HCPCS C1713 04.005.522S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 32MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.524 SUP HCPCS C1713 04.005.524 - SCREW BONE NONSTRL 5MM 34MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.524S SUP HCPCS C1713 04.005.524S - SCREW BONE FULTHD 5MM 4.3MM 34MM T25 STARDRIVE RECESS BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.526 SUP HCPCS C1713 04.005.526 - SCREW BONE NONSTRL 5MM 36MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.526S SUP HCPCS C1713 04.005.526S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 36MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.528 SUP HCPCS C1713 04.005.528 - SCREW BONE NONSTRL 5MM 38MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.528S SUP HCPCS C1713 04.005.528S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 38MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.530 SUP HCPCS C1713 04.005.530 - SCREW BONE NONSTRL 5MM 40MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.530S SUP HCPCS C1713 04.005.530S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 40MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.532 SUP HCPCS C1713 04.005.532 - SCREW BONE NONSTRL 5MM 42MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.532S SUP HCPCS C1713 04.005.532S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 42MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.534 SUP HCPCS C1713 04.005.534 - SCREW BONE NONSTRL 5MM 44MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.534S SUP HCPCS C1713 04.005.534S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 44MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.536 SUP HCPCS C1713 04.005.536 - SCREW BONE NONSTRL 5MM 46MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.536S SUP HCPCS C1713 04.005.536S - SCREW BN T25 FT 5MM 4.3MM 46MM LGHT GRN STRL LCK ST BLNT TIP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.538 SUP HCPCS C1713 04.005.538 - SCREW BONE NONSTRL 5MM 48MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.538S SUP HCPCS C1713 04.005.538S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 48MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.540 SUP HCPCS C1713 04.005.540 - SCREW BONE NONSTRL 5MM 50MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.540S SUP HCPCS C1713 04.005.540S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 50MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.542 SUP HCPCS C1713 04.005.542 - SCREW BONE NONSTRL 5MM 52MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.542S SUP HCPCS C1713 04.005.542S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 52MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.544 SUP HCPCS C1713 04.005.544 - SCREW BONE NONSTRL 5MM 54MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.544S SUP HCPCS C1713 04.005.544S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 54MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.546 SUP HCPCS C1713 04.005.546 - SCREW BONE NONSTRL 5MM 56MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.546S SUP HCPCS C1713 04.005.546S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 56MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.548 SUP HCPCS C1713 04.005.548 - SCREW BONE NONSTRL 5MM 58MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.548S SUP HCPCS C1713 04.005.548S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 58MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.550 SUP HCPCS C1713 04.005.550 - SCREW BONE NONSTRL 5MM 60MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.550S SUP HCPCS C1713 04.005.550S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 60MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.552 SUP HCPCS C1713 04.005.552 - SCREW BONE 5MM 62MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.552S SUP HCPCS C1713 04.005.552S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 62MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.554 SUP HCPCS C1713 04.005.554 - SCREW BONE 5MM 64MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.554S SUP HCPCS C1713 04.005.554S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 64MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.556 SUP HCPCS C1713 04.005.556 - SCREW BONE 5MM 66MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.556S SUP HCPCS C1713 04.005.556S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 66MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.558 SUP HCPCS C1713 04.005.558 - SCREW BONE 5MM 68MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $138.44 $138.44 $0.00 $0.00 $0.00 $64.12 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $181.97 $181.97 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $48.15 $0.00 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.558S SUP HCPCS C1713 04.005.558S - SCREW BONE FULTHD 5MM 8MM 68MM T25 STARDRIVE RECESS LOCKING BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.560 SUP HCPCS C1713 04.005.560 - SCREW BONE 5MM 70MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.560S SUP HCPCS C1713 04.005.560S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 70MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.562 SUP HCPCS C1713 04.005.562 - SCREW BONE 5MM 72MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.562S SUP HCPCS C1713 04.005.562S - SCREW BN T25 FT 5MM 4.3MM 72MM LGHT GRN STRL LCK ST BLNT TIP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.564 SUP HCPCS C1713 04.005.564 - SCREW BONE 5MM 74MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.564S SUP HCPCS C1713 04.005.564S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 74MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.566 SUP HCPCS C1713 04.005.566 - SCREW BONE 5MM 76MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.566S SUP HCPCS C1713 04.005.566S - SCREW BONE FULTHD 5MM 8MM 76MM T25 STARDRIVE RECESS LOCKING BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.568 SUP HCPCS C1713 04.005.568 - SCREW BONE 5MM 78MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.568S SUP HCPCS C1713 04.005.568S - SCREW BONE FULTHD 5MM 8MM 78MM LOCK CANN SELF TAP BLUNT TIP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.570 SUP HCPCS C1713 04.005.570 - SCREW BONE 5MM 80MM NLEX TI FEM/TIB LCK STARDRIVE RECESS BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.570S SUP HCPCS C1713 04.005.570S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 80MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.575 SUP HCPCS C1713 04.005.575 - SCREW BONE NONSTRL 5MM 85MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.575S SUP HCPCS C1713 04.005.575S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 85MM 2 LEAD SELF TAP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.580 SUP HCPCS C1713 04.005.580 - SCREW BONE NONSTRL 5MM 90MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.580S SUP HCPCS C1713 04.005.580S - SCREW BONE FULTHD 5MM 8MM 90MM T25 STARDRIVE RECESS LOCKING BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.585 SUP HCPCS C1713 04.005.585 - SCREW BONE NONSTRL 5MM 95MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.585S SUP HCPCS C1713 04.005.585S - SCREW BN T25 FT 5MM 4.3MM 95MM LGHT GRN STRL LCK ST BLNT TIP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.590 SUP HCPCS C1713 04.005.590 - SCREW BONE NONSTRL 5MM 100MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.590S SUP HCPCS C1713 04.005.590S - SCREW BONE FULTHD 5MM 8MM 100MM T25 STARDRIVE RECESS LOCKING BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.616 SUP HCPCS C1713 04.005.616 - SCREW BONE NONSTRL 6MM 26MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.616S SUP HCPCS C1713 04.005.616S - SCREW BN FT 6MM 8MM 26MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.618 SUP HCPCS C1713 04.005.618 - SCREW BONE NONSTRL 6MM 28MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.618S SUP HCPCS C1713 04.005.618S - SCREW BN FT 6MM 8MM 28MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.620 SUP HCPCS C1713 04.005.620 - SCREW BONE NONSTRL 6MM 30MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.620S SUP HCPCS C1713 04.005.620S - SCREW BN FT 6MM 8MM 30MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.622 SUP HCPCS C1713 04.005.622 - SCREW BONE NONSTRL 6MM 32MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.622S SUP HCPCS C1713 04.005.622S - SCREW BN T25 FT BLNT 6MM 8MM 32MM AQ STRL XPRT 2 LD ST LCK BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.624 SUP HCPCS C1713 04.005.624 - SCREW BONE NONSTRL 6MM 34MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.624S SUP HCPCS C1713 04.005.624S - SCREW BN FT 6MM 8MM 34MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.626 SUP HCPCS C1713 04.005.626 - SCREW BONE NONSTRL 6MM 36MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.626S SUP HCPCS C1713 04.005.626S - SCREW BN T25 FT BLNT 6MM 8MM 36MM AQ STRL XPRT 2 LD ST LCK BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.628 SUP HCPCS C1713 04.005.628 - SCREW BONE NONSTRL 6MM 38MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.628S SUP HCPCS C1713 04.005.628S - SCREW BN T25 FT 6MM 4.8MM 38MM AQ STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.630 SUP HCPCS C1713 04.005.630 - SCREW BONE NONSTRL 6MM 40MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.630S SUP HCPCS C1713 04.005.630S - SCREW BN FT 6MM 8MM 40MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.632 SUP HCPCS C1713 04.005.632 - SCREW BONE NONSTRL 6MM 42MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.632S SUP HCPCS C1713 04.005.632S - SCREW BN FT 6MM 8MM 42MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.634 SUP HCPCS C1713 04.005.634 - SCREW BONE NONSTRL 6MM 44MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.634S SUP HCPCS C1713 04.005.634S - SCREW BN T25 FT 6MM 4.8MM 44MM AQ STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.636 SUP HCPCS C1713 04.005.636 - SCREW BONE NONSTRL 6MM 46MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.636S SUP HCPCS C1713 04.005.636S - SCREW BN FT 6MM 8MM 46MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.638 SUP HCPCS C1713 04.005.638 - SCREW BONE NONSTRL 6MM 48MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.638S SUP HCPCS C1713 04.005.638S - SCREW BN FT 6MM 8MM 48MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.640 SUP HCPCS C1713 04.005.640 - SCREW BONE NONSTRL 6MM 50MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.640S SUP HCPCS C1713 04.005.640S - SCREW BN FT 6MM 8MM 50MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.642 SUP HCPCS C1713 04.005.642 - SCREW BONE NONSTRL 6MM 52MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.642S SUP HCPCS C1713 04.005.642S - SCREW BN T25 FT BLNT 6MM 8MM 52MM AQ STRL XPRT 2 LD ST LCK BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.644 SUP HCPCS C1713 04.005.644 - SCREW BONE NONSTRL 6MM 54MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.644S SUP HCPCS C1713 04.005.644S - SCREW BN T25 FT 6MM 8MM 54MM AQ STRL ST LCK BLNT TIP STRDR BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.646 SUP HCPCS C1713 04.005.646 - SCREW BONE NONSTRL 6MM 56MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.646S SUP HCPCS C1713 04.005.646S - SCREW BN T25 FT 6MM 8MM 56MM AQ STRL ST LCK 2 LD STRDR TI BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.648 SUP HCPCS C1713 04.005.648 - SCREW BONE NONSTRL 6MM 58MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.648S SUP HCPCS C1713 04.005.648S - SCREW BN T25 FT 6MM 4.8MM 58MM AQ STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.650 SUP HCPCS C1713 04.005.650 - SCREW BONE NONSTRL 6MM 60MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.650S SUP HCPCS C1713 04.005.650S - SCREW BN T25 FT 6MM 4.8MM 60MM AQ STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.654 SUP HCPCS C1713 04.005.654 - SCREW BONE NONSTRL 6MM 64MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.654S SUP HCPCS C1713 04.005.654S - SCREW BN T25 FT 6MM 4.8MM 64MM AQ STRL LCK CNN ST BLNT TIP BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.658 SUP HCPCS C1713 04.005.658 - SCREW BONE 6MM 68MM NLEX TI FEM LCK STARDRIVE RECESS NONSTRL BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.658S SUP HCPCS C1713 04.005.658S - SCREW BN T25 FT 6MM 4.8MM 68MM AQ STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.662 SUP HCPCS C1713 04.005.662 - SCREW BONE NONSTRL 6MM 72MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.662S SUP HCPCS C1713 04.005.662S - SCREW BN T25 FT 6MM 4.8MM 72MM AQ STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.666 SUP HCPCS C1713 04.005.666 - SCREW BONE NONSTRL 6MM 76MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.666S SUP HCPCS C1713 04.005.666S - SCREW BN T25 FT BLNT 6MM 8MM 76MM AQ STRL XPRT 2 LD ST LCK BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.670 SUP HCPCS C1713 04.005.670 - SCREW BONE 6MM 80MM NLEX TI FEM LCK STARDRIVE RECESS NONSTRL BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.670S SUP HCPCS C1713 04.005.670S - SCREW BN FT 6MM 8MM 80MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.675 SUP HCPCS C1713 04.005.675 - SCREW BONE NONSTRL 6MM 85MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.675S SUP HCPCS C1713 04.005.675S - SCREW BN T25 FT 6MM 4.8MM 85MM AQ STRL LCK ST BLNT TIP 2 LD BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.680 SUP HCPCS C1713 04.005.680 - SCREW BONE NONSTRL 6MM 90MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.680S SUP HCPCS C1713 04.005.680S - SCREW BN FT 6MM 8MM 90MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.685 SUP HCPCS C1713 04.005.685 - SCREW BONE NONSTRL 6MM 95MM NLEX TI FULTHD FEM/TIB SLFTAP BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.685S SUP HCPCS C1713 04.005.685S - SCREW BN FT 6MM 8MM 95MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.690 SUP HCPCS C1713 04.005.690 - SCREW BONE 6MM 100MM NLEX TI FULTHD FEM/TIB SLFTAP CANN LCK BOTH IP/OP $413.95 $306.32 $0.00 $331.16 $186.28 $186.28 $0.00 $0.00 $0.00 $86.28 $307.23 $307.23 $0.00 $0.00 $86.27 $0.00 $244.85 $244.85 $0.00 $206.98 $327.85 $331.16 $0.00 $0.00 $64.78 $0.00 $0.00 $65.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.690S SUP HCPCS C1713 04.005.690S - SCREW BN FT 6MM 8MM 100MM AQ STRL NLEX T25 STRDR RCS LCK CNN BOTH IP/OP $436.18 $322.77 $0.00 $338.76 $190.55 $190.55 $0.00 $0.00 $0.00 $90.91 $323.73 $323.73 $0.00 $0.00 $90.90 $0.00 $258.00 $258.00 $0.00 $211.73 $335.37 $338.76 $0.00 $0.00 $64.34 $0.00 $0.00 $67.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.691 SUP HCPCS C1713 04.005.691 - SCREW BONE FULTHD 6MM 105MM SLFTAP CANN LOCKING STARDRIVE BOTH IP/OP $341.35 $252.60 $0.00 $265.12 $149.13 $149.13 $0.00 $0.00 $0.00 $71.15 $253.35 $253.35 $0.00 $0.00 $71.14 $0.00 $201.91 $201.91 $0.00 $165.70 $262.47 $265.12 $0.00 $0.00 $50.35 $0.00 $0.00 $52.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.692 SUP HCPCS C1713 04.005.692 - SCREW BONE FULTHD 6MM 110MM SLFTAP CANN LOCKING STARDRIVE BOTH IP/OP $341.35 $252.60 $0.00 $265.12 $149.13 $149.13 $0.00 $0.00 $0.00 $71.15 $253.35 $253.35 $0.00 $0.00 $71.14 $0.00 $201.91 $201.91 $0.00 $165.70 $262.47 $265.12 $0.00 $0.00 $50.35 $0.00 $0.00 $52.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.693 SUP HCPCS C1713 04.005.693 - SCREW BONE FULTHD 6MM 115MM SLFTAP CANN LOCKING STARDRIVE BOTH IP/OP $341.35 $252.60 $0.00 $265.12 $149.13 $149.13 $0.00 $0.00 $0.00 $71.15 $253.35 $253.35 $0.00 $0.00 $71.14 $0.00 $201.91 $201.91 $0.00 $165.70 $262.47 $265.12 $0.00 $0.00 $50.35 $0.00 $0.00 $52.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.694 SUP HCPCS C1713 04.005.694 - SCREW BONE FULTHD 6MM 120MM SLFTAP CANN LOCKING STARDRIVE BOTH IP/OP $341.35 $252.60 $0.00 $265.12 $149.13 $149.13 $0.00 $0.00 $0.00 $71.15 $253.35 $253.35 $0.00 $0.00 $71.14 $0.00 $201.91 $201.91 $0.00 $165.70 $262.47 $265.12 $0.00 $0.00 $50.35 $0.00 $0.00 $52.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.005.695 SUP HCPCS C1713 04.005.695 - SCREW BONE FULTHD 6MM 125MM SLFTAP CANN LOCKING STARDRIVE BOTH IP/OP $341.35 $252.60 $0.00 $265.12 $149.13 $149.13 $0.00 $0.00 $0.00 $71.15 $253.35 $253.35 $0.00 $0.00 $71.14 $0.00 $201.91 $201.91 $0.00 $165.70 $262.47 $265.12 $0.00 $0.00 $50.35 $0.00 $0.00 $52.76 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.000S SUP Custom 27803010 04.008.000S - CAP END T25 STARDRIVE RECESS NAIL-EX GOLD TITANIUM HINDFOOT BOTH IP/OP $428.88 $317.37 $0.00 $333.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $318.31 $318.31 $0.00 $0.00 $89.38 $0.00 $0.00 $0.00 $0.00 $208.19 $329.77 $333.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.001S SUP Custom 27803010 04.008.001S - CAP END 0MM EXTENDED STARDRIVE RECESS NAIL-EX AQUA TITANIUM BOTH IP/OP $428.88 $317.37 $0.00 $333.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $318.31 $318.31 $0.00 $0.00 $89.38 $0.00 $0.00 $0.00 $0.00 $208.19 $329.77 $333.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.010S SUP HCPCS C1713 04.008.010S - NAIL INTRAMEDULLARY 10MM 150CM CANN EXPERT GREEN TITANIUM BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.016S SUP HCPCS C1713 04.008.016S - NAIL INTRAMEDULLARY 12D 10MM 180MM CANN BALL TIPPED REAMING BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.028S SUP HCPCS C1713 04.008.028S - NAIL INTRAMEDULLARY 12D 10MM 240MM CANN BALL TIPPED REAMING BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.060S SUP HCPCS C1713 04.008.060S - NAIL INTRAMEDULLARY 10MM 15CM CANN NAIL-EX GREEN TITANIUM BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.066S SUP HCPCS C1713 04.008.066S - NAIL INTRAMEDULLARY 10MM 180MM CANN NAIL-EX GREEN TITANIUM BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.078S SUP HCPCS C1713 04.008.078S - NAIL INTRAMEDULLARY 10MM 24CM CANN NAIL-EX TITANIUM LEFT BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.210S SUP HCPCS C1713 04.008.210S - NAIL INTRAMEDULLARY 12MM 15CM CANN NAIL-EX TITANIUM RIGHT BOTH IP/OP "$3,096.90 " "$2,291.71" $0.00 "$2,405.36" "$1,353.02" "$1,353.02" $0.00 $0.00 $0.00 $645.47 "$2,298.52" "$2,298.52" $0.00 $0.00 $645.39 $0.00 "$1,526.77" "$1,526.77" $0.00 "$1,503.35" "$2,381.31" "$2,405.36" $0.00 $0.00 $456.84 $0.00 $0.00 $478.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.216S SUP HCPCS C1713 04.008.216S - NAIL INTRAMEDULLARY 12MM 180MM CANN NAIL-EX TITANIUM RIGHT BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.228S SUP HCPCS C1713 04.008.228S - NAIL INTRAMEDULLARY 12MM 24CM CANN NAIL-EX TITANIUM RIGHT BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.260S SUP HCPCS C1713 04.008.260S - NAIL INTRAMEDULLARY 12MM 15CM CANN NAIL-EX TITANIUM LEFT BOTH IP/OP "$3,096.90 " "$2,291.71" $0.00 "$2,405.36" "$1,353.02" "$1,353.02" $0.00 $0.00 $0.00 $645.47 "$2,298.52" "$2,298.52" $0.00 $0.00 $645.39 $0.00 "$1,526.77" "$1,526.77" $0.00 "$1,503.35" "$2,381.31" "$2,405.36" $0.00 $0.00 $456.84 $0.00 $0.00 $478.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.266S SUP HCPCS C1713 04.008.266S - NAIL INTRAMEDULLARY 12MM 18CM CANN NAIL-EX TITANIUM LEFT BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.278S SUP HCPCS C1713 04.008.278S - NAIL INTRAMEDULLARY 12MM 24CM CANN NAIL-EX TITANIUM LEFT BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.310S SUP HCPCS C1713 04.008.310S - NAIL INTRAMEDULLARY 13MM 15CM CANN NAIL-EX TITANIUM RIGHT BOTH IP/OP "$3,096.90 " "$2,291.71" $0.00 "$2,405.36" "$1,353.02" "$1,353.02" $0.00 $0.00 $0.00 $645.47 "$2,298.52" "$2,298.52" $0.00 $0.00 $645.39 $0.00 "$1,526.77" "$1,526.77" $0.00 "$1,503.35" "$2,381.31" "$2,405.36" $0.00 $0.00 $456.84 $0.00 $0.00 $478.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.316S SUP HCPCS C1713 04.008.316S - NAIL INTRAMEDULLARY 13MM 18CM CANN NAIL-EX TITANIUM RIGHT BOTH IP/OP "$3,096.90 " "$2,291.71" $0.00 "$2,405.36" "$1,353.02" "$1,353.02" $0.00 $0.00 $0.00 $645.47 "$2,298.52" "$2,298.52" $0.00 $0.00 $645.39 $0.00 "$1,526.77" "$1,526.77" $0.00 "$1,503.35" "$2,381.31" "$2,405.36" $0.00 $0.00 $456.84 $0.00 $0.00 $478.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.328S SUP HCPCS C1713 04.008.328S - NAIL INTRAMEDULLARY 13MM 240MM FLUTED EXPERT LIGHT GREEN BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.360S SUP HCPCS C1713 04.008.360S - NAIL INTRAMEDULLARY 13MM 15CM CANN NAIL-EX TITANIUM LEFT BOTH IP/OP "$3,096.90 " "$2,291.71" $0.00 "$2,405.36" "$1,353.02" "$1,353.02" $0.00 $0.00 $0.00 $645.47 "$2,298.52" "$2,298.52" $0.00 $0.00 $645.39 $0.00 "$1,526.77" "$1,526.77" $0.00 "$1,503.35" "$2,381.31" "$2,405.36" $0.00 $0.00 $456.84 $0.00 $0.00 $478.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.366S SUP HCPCS C1713 04.008.366S - NAIL INTRAMEDULLARY 13MM 18CM CANN NAIL-EX TITANIUM LEFT BOTH IP/OP "$3,096.90 " "$2,291.71" $0.00 "$2,405.36" "$1,353.02" "$1,353.02" $0.00 $0.00 $0.00 $645.47 "$2,298.52" "$2,298.52" $0.00 $0.00 $645.39 $0.00 "$1,526.77" "$1,526.77" $0.00 "$1,503.35" "$2,381.31" "$2,405.36" $0.00 $0.00 $456.84 $0.00 $0.00 $478.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.008.378S SUP HCPCS C1713 04.008.378S - NAIL INTRAMEDULLARY 13MM 24CM CANN NAIL-EX TITANIUM LEFT BOTH IP/OP "$3,006.45 " "$2,224.77" $0.00 "$2,335.12" "$1,313.51" "$1,313.51" $0.00 $0.00 $0.00 $626.62 "$2,231.39" "$2,231.39" $0.00 $0.00 $626.54 $0.00 "$1,482.18" "$1,482.18" $0.00 "$1,459.45" "$2,311.77" "$2,335.12" $0.00 $0.00 $443.50 $0.00 $0.00 $464.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.000 SUP HCPCS C1713 04.013.000 - CAP END 0MM FEM XTD STARDRIVE RECESS CANN IM NAIL TI NONSTRL BOTH IP/OP $357.38 $264.46 $0.00 $285.90 $160.82 $160.82 $0.00 $0.00 $0.00 $74.49 $265.24 $265.24 $0.00 $0.00 $74.48 $0.00 $211.39 $211.39 $0.00 $178.69 $283.04 $285.90 $0.00 $0.00 $55.93 $0.00 $0.00 $56.89 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.000S SUP Custom 27803010 04.013.000S - CAP END 0MM T40 STARDRIVE NAIL-EX GOLD TITANIUM FEMUR BOTH IP/OP $414.28 $306.57 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.47 $307.47 $0.00 $0.00 $86.33 $0.00 $0.00 $0.00 $0.00 $201.11 $318.57 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.041S SUP Custom 27803010 04.013.041S - BLADE INTRAMEDULLARY NAIL 45MM CANN SPIRAL RTRGRD NAIL-EX BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.042S SUP Custom 27803010 04.013.042S - BLADE INTRAMEDULLARY NAIL 50MM CANN SPIRAL RTRGRD NAIL-EX BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.043S SUP Custom 27803010 04.013.043S - BLADE INTRAMEDULLARY NAIL 55MM CANN SPIRAL RTRGRD NAIL-EX BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.044S SUP Custom 27803010 04.013.044S - BLADE INTRAMEDULLARY NAIL 60MM CANN SPIRAL RTRGRD NAIL-EX BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.045S SUP Custom 27803010 04.013.045S - BLADE INTRAMEDULLARY FIX SPIRAL 65MM RTRGRD EXPERT GOLD BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.046 SUP HCPCS C1713 04.013.046 - BLADE IM NAIL 70MM NLEX FEM TI CANN SPRL RTRGRD NONSTRL BOTH IP/OP "$1,214.65 " $898.84 $0.00 $971.72 $546.59 $546.59 $0.00 $0.00 $0.00 $253.16 $901.51 $901.51 $0.00 $0.00 $253.13 $0.00 $718.47 $718.47 $0.00 $607.33 $962.00 $971.72 $0.00 $0.00 $190.09 $0.00 $0.00 $193.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.046S SUP Custom 27803010 04.013.046S - BLADE INTRAMEDULLARY NAIL 70MM SPIRAL RTRGRD NAIL-EX GOLD BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.047S SUP Custom 27803010 04.013.047S - BLADE INTRAMEDULLARY FIX 12.5MM 75MM SPIRAL CANN NAIL-EX BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.048S SUP Custom 27803010 04.013.048S - BLADE INTRAMEDULLARY FIX 80MM SPIRAL NAIL-EX TITANIUM FEMUR BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.049S SUP Custom 27803010 04.013.049S - BLADE INTRAMEDULLARY NAIL SPIRAL 12.5MM 85MM RTRGRD CANN BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.050S SUP Custom 27803010 04.013.050S - BLADE INTRAMEDULLARY FIX SPIRAL 90MM CANN RTRGRD EXPERT GOLD BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.051S SUP Custom 27803010 04.013.051S - BLADE INTRAMEDULLARY NAIL 95MM CANN SPIRAL RTRGRD NAIL-EX BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.052S SUP Custom 27803010 04.013.052S - BLADE INTRAMEDULLARY NAIL 100MM CANN SPIRAL RTRGRD NAIL-EX BOTH IP/OP "$1,161.15 " $859.25 $0.00 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.81 $861.81 $0.00 $0.00 $241.98 $0.00 $0.00 $0.00 $0.00 $563.66 $892.85 $901.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.312S SUP HCPCS C1713 04.013.312S - NAIL INTRAMEDULLARY 9MM 16CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.316S SUP HCPCS C1713 04.013.316S - NAIL INTRAMEDULLARY 9MM 18CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.320S SUP HCPCS C1713 04.013.320S - NAIL INTRAMEDULLARY 9MM 20CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.324S SUP HCPCS C1713 04.013.324S - NAIL INTRAMEDULLARY 9MM 22CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.328S SUP HCPCS C1713 04.013.328S - NAIL INTRAMEDULLARY 9MM 24CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.332S SUP HCPCS C1713 04.013.332S - NAIL INTRAMEDULLARY 9MM 26CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.336S SUP HCPCS C1713 04.013.336S - NAIL INTRAMEDULLARY 9MM 28CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.340S SUP HCPCS C1713 04.013.340S - NAIL INTRAMEDULLARY 9MM 30CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.344S SUP HCPCS C1713 04.013.344S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 320MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.348S SUP HCPCS C1713 04.013.348S - NAIL INTRAMEDULLARY 9MM 34CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.352S SUP HCPCS C1713 04.013.352S - NAIL INTRAMEDULLARY 9MM 36CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.356S SUP HCPCS C1713 04.013.356S - NAIL INTRAMEDULLARY 9MM 38CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.360S SUP HCPCS C1713 04.013.360S - NAIL INTRAMEDULLARY 9MM 40CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.364S SUP HCPCS C1713 04.013.364S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 420MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.368S SUP HCPCS C1713 04.013.368S - NAIL INTRAMEDULLARY 9MM 44CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.372S SUP HCPCS C1713 04.013.372S - NAIL INTRAMEDULLARY 9MM 46CM CANN ANTEGRADE/RTRGRD NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.376S SUP HCPCS C1713 04.013.376S - NAIL INTRAMEDULLARY 9MM 48CM CANN ANTEGRADE/RTRGRD NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.412S SUP HCPCS C1713 04.013.412S - NAIL INTRAMEDULLARY 10MM 16CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.416S SUP HCPCS C1713 04.013.416S - NAIL INTRAMEDULLARY 10MM 18CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.420S SUP HCPCS C1713 04.013.420S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 200MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.424S SUP HCPCS C1713 04.013.424S - NAIL INTRAMEDULLARY 10MM 22CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.428S SUP HCPCS C1713 04.013.428S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 240MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.432S SUP HCPCS C1713 04.013.432S - NAIL INTRAMEDULLARY 10MM 26CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.436S SUP HCPCS C1713 04.013.436S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 280MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.440S SUP HCPCS C1713 04.013.440S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 300MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.444S SUP HCPCS C1713 04.013.444S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 320MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.448S SUP HCPCS C1713 04.013.448S - NAIL INTRAMEDULLARY 10MM 34CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.452S SUP HCPCS C1713 04.013.452S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 360MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.456S SUP HCPCS C1713 04.013.456S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 380MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.460S SUP HCPCS C1713 04.013.460S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 400MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.464S SUP HCPCS C1713 04.013.464S - NAIL INTRAMEDULLARY UNIVERSAL ROUND 10MM 420MM CANN RTRGRD BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.468S SUP HCPCS C1713 04.013.468S - NAIL INTRAMEDULLARY 10MM 440MM CANN NAIL-EX GREEN TITANIUM BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.472S SUP HCPCS C1713 04.013.472S - NAIL INTRAMEDULLARY 10MM 46CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.476S SUP HCPCS C1713 04.013.476S - NAIL INTRAMEDULLARY 10MM 48CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.512S SUP HCPCS C1713 04.013.512S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 160MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.516S SUP HCPCS C1713 04.013.516S - NAIL INTRAMEDULLARY 11MM 18CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.520S SUP HCPCS C1713 04.013.520S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 200MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.524S SUP HCPCS C1713 04.013.524S - NAIL INTRAMEDULLARY 11MM 22CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.528S SUP HCPCS C1713 04.013.528S - NAIL INTRAMEDULLARY 11MM 24CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.532S SUP HCPCS C1713 04.013.532S - NAIL INTRAMEDULLARY 11MM 26CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.536S SUP HCPCS C1713 04.013.536S - NAIL INTRAMEDULLARY 11MM 28CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.540S SUP HCPCS C1713 04.013.540S - NAIL INTRAMEDULLARY 11MM 30CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.544S SUP HCPCS C1713 04.013.544S - NAIL INTRAMEDULLARY UNIVERSAL FLUTED BARREL 11MM 320MM CANN BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.548S SUP HCPCS C1713 04.013.548S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 340MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.552S SUP HCPCS C1713 04.013.552S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 360MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.556S SUP HCPCS C1713 04.013.556S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 380MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.560S SUP HCPCS C1713 04.013.560S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 400MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.564S SUP HCPCS C1713 04.013.564S - NAIL INTRAMEDULLARY 11MM 42CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.568S SUP HCPCS C1713 04.013.568S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 440MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.572S SUP HCPCS C1713 04.013.572S - NAIL INTRAMEDULLARY 11MM 46CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.576S SUP HCPCS C1713 04.013.576S - NAIL INTRAMEDULLARY 11MM 48CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.612S SUP HCPCS C1713 04.013.612S - NAIL INTRAMEDULLARY 12MM 16CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.616S SUP HCPCS C1713 04.013.616S - NAIL INTRAMEDULLARY 12MM 18CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.620S SUP HCPCS C1713 04.013.620S - NAIL INTRAMEDULLARY 12MM 20CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.624S SUP HCPCS C1713 04.013.624S - NAIL INTRAMEDULLARY 12MM 22CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.628S SUP HCPCS C1713 04.013.628S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 240MM CANN FLUTED BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.632S SUP HCPCS C1713 04.013.632S - NAIL INTRAMEDULLARY 12MM 26CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.636S SUP HCPCS C1713 04.013.636S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 280MM CANN FLUTED BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.640S SUP HCPCS C1713 04.013.640S - NAIL INTRAMEDULLARY UNIVERSAL FLUTED 12MM 300MM CANN RTRGRD BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.644S SUP HCPCS C1713 04.013.644S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 320MM CANN FLUTED BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.648S SUP HCPCS C1713 04.013.648S - NAIL INTRAMEDULLARY 12MM 340MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.652S SUP HCPCS C1713 04.013.652S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 36CM CANN RTRGRD BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.656S SUP HCPCS C1713 04.013.656S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 380MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.660S SUP HCPCS C1713 04.013.660S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 400MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.664S SUP HCPCS C1713 04.013.664S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 420MM CANN ROUND BARREL BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.668S SUP HCPCS C1713 04.013.668S - NAIL INTRAMEDULLARY 12MM 44CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.672S SUP HCPCS C1713 04.013.672S - NAIL INTRAMEDULLARY 12MM 46CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,331.75 " "$2,465.50" $0.00 "$2,587.78" "$1,455.63" "$1,455.63" $0.00 $0.00 $0.00 $694.42 "$2,472.82" "$2,472.82" $0.00 $0.00 $694.34 $0.00 "$1,642.55" "$1,642.55" $0.00 "$1,617.36" "$2,561.91" "$2,587.78" $0.00 $0.00 $491.49 $0.00 $0.00 $514.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.676S SUP HCPCS C1713 04.013.676S - NAIL INTRAMEDULLARY 12MM 48CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.712S SUP HCPCS C1713 04.013.712S - NAIL INTRAMEDULLARY 13MM 16CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,331.75 " "$2,465.50" $0.00 "$2,587.78" "$1,455.63" "$1,455.63" $0.00 $0.00 $0.00 $694.42 "$2,472.82" "$2,472.82" $0.00 $0.00 $694.34 $0.00 "$1,642.55" "$1,642.55" $0.00 "$1,617.36" "$2,561.91" "$2,587.78" $0.00 $0.00 $491.49 $0.00 $0.00 $514.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.716S SUP HCPCS C1713 04.013.716S - NAIL INTRAMEDULLARY 13MM 18CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,331.75 " "$2,465.50" $0.00 "$2,587.78" "$1,455.63" "$1,455.63" $0.00 $0.00 $0.00 $694.42 "$2,472.82" "$2,472.82" $0.00 $0.00 $694.34 $0.00 "$1,642.55" "$1,642.55" $0.00 "$1,617.36" "$2,561.91" "$2,587.78" $0.00 $0.00 $491.49 $0.00 $0.00 $514.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.720S SUP HCPCS C1713 04.013.720S - NAIL INTRAMEDULLARY 13MM 200CM CANN RTRGRD ANTEGRADE EXPERT BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.724S SUP HCPCS C1713 04.013.724S - NAIL INTRAMEDULLARY 13MM 22CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.728S SUP HCPCS C1713 04.013.728S - NAIL INTRAMEDULLARY 13MM 24CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.732S SUP HCPCS C1713 04.013.732S - NAIL INTRAMEDULLARY 13MM 26CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.736S SUP HCPCS C1713 04.013.736S - NAIL INTRAMEDULLARY 13MM 28CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.740S SUP HCPCS C1713 04.013.740S - NAIL INTRAMEDULLARY 13MM 30CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.744S SUP HCPCS C1713 04.013.744S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 320MM CANN RTRGRD NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.748S SUP HCPCS C1713 04.013.748S - NAIL INTRAMEDULLARY 13MM 340MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.752S SUP HCPCS C1713 04.013.752S - NAIL INTRAMEDULLARY 13MM 360CM CANN RTRGRD ANTEGRADE EXPERT BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.756S SUP HCPCS C1713 04.013.756S - NAIL INTRAMEDULLARY 13MM 380MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.760S SUP HCPCS C1713 04.013.760S - NAIL INTRAMEDULLARY 13MM 400CM CANN RTRGRD ANTEGRADE EXPERT BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.764S SUP HCPCS C1713 04.013.764S - NAIL INTRAMEDULLARY 13MM 420MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.768S SUP HCPCS C1713 04.013.768S - NAIL INTRAMEDULLARY 13MM 44CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.772S SUP HCPCS C1713 04.013.772S - NAIL INTRAMEDULLARY 13MM 46CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,331.75 " "$2,465.50" $0.00 "$2,587.78" "$1,455.63" "$1,455.63" $0.00 $0.00 $0.00 $694.42 "$2,472.82" "$2,472.82" $0.00 $0.00 $694.34 $0.00 "$1,642.55" "$1,642.55" $0.00 "$1,617.36" "$2,561.91" "$2,587.78" $0.00 $0.00 $491.49 $0.00 $0.00 $514.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.776S SUP HCPCS C1713 04.013.776S - NAIL INTRAMEDULLARY 13MM 48CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.812S SUP HCPCS C1713 04.013.812S - NAIL INTRAMEDULLARY 14MM 16CM CANN RTRGRD ANTEGRADE TITANIUM BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.816S SUP HCPCS C1713 04.013.816S - NAIL INTRAMEDULLARY 14MM 18CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.820S SUP HCPCS C1713 04.013.820S - NAIL INTRAMEDULLARY 14MM 20CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.824S SUP HCPCS C1713 04.013.824S - NAIL INTRAMEDULLARY 14MM 22CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.828S SUP HCPCS C1713 04.013.828S - NAIL INTRAMEDULLARY 14MM 240MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.832S SUP HCPCS C1713 04.013.832S - NAIL INTRAMEDULLARY 14MM 26CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.836S SUP HCPCS C1713 04.013.836S - NAIL INTRAMEDULLARY 14MM 280MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.840S SUP HCPCS C1713 04.013.840S - NAIL INTRAMEDULLARY 14MM 300MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.844S SUP HCPCS C1713 04.013.844S - NAIL INTRAMEDULLARY 14MM 320MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.848S SUP HCPCS C1713 04.013.848S - NAIL INTRAMEDULLARY 14MM 340MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.852S SUP HCPCS C1713 04.013.852S - NAIL INTRAMEDULLARY 14MM 360MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.856S SUP HCPCS C1713 04.013.856S - NAIL INTRAMEDULLARY 14MM 38CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.860S SUP HCPCS C1713 04.013.860S - NAIL INTRAMEDULLARY 14MM 40CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.864S SUP HCPCS C1713 04.013.864S - NAIL INTRAMEDULLARY 14MM 42CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.868S SUP HCPCS C1713 04.013.868S - NAIL INTRAMEDULLARY 14MM 44CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.872S SUP HCPCS C1713 04.013.872S - NAIL INTRAMEDULLARY 14MM 46CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.876S SUP HCPCS C1713 04.013.876S - NAIL INTRAMEDULLARY 14MM 480MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.912S SUP HCPCS C1713 04.013.912S - NAIL INTRAMEDULLARY 15MM 160MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.916S SUP HCPCS C1713 04.013.916S - NAIL INTRAMEDULLARY 15MM 18CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.920S SUP HCPCS C1713 04.013.920S - NAIL INTRAMEDULLARY 15MM 200MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.924S SUP HCPCS C1713 04.013.924S - NAIL INTRAMEDULLARY 15MM 22CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.928S SUP HCPCS C1713 04.013.928S - NAIL INTRAMEDULLARY 15MM 24CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.932S SUP HCPCS C1713 04.013.932S - NAIL INTRAMEDULLARY 15MM 26CM CANN RTRGRD NAIL-EX TITANIUM BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.936S SUP HCPCS C1713 04.013.936S - NAIL INTRAMEDULLARY 15MM 280MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.940S SUP HCPCS C1713 04.013.940S - NAIL INTRAMEDULLARY 15MM 300MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.944S SUP HCPCS C1713 04.013.944S - NAIL INTRAMEDULLARY 15MM 320MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.948S SUP HCPCS C1713 04.013.948S - NAIL INTRAMEDULLARY 15MM 340MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.952S SUP HCPCS C1713 04.013.952S - NAIL INTRAMEDULLARY 15MM 360MM CANN RTRGRD ANTEGRADE FLUTED BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.956S SUP HCPCS C1713 04.013.956S - NAIL INTRAMEDULLARY 15MM 380MM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.960S SUP HCPCS C1713 04.013.960S - NAIL INTRAMEDULLARY 15MM 40CM CANN RTRGRD/ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.964S SUP HCPCS C1713 04.013.964S - NAIL INTRAMEDULLARY 15MM 42CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.968S SUP HCPCS C1713 04.013.968S - NAIL INTRAMEDULLARY 15MM 44CM CANN RTRGRD/ANTEGRADE NAIL-EX BOTH IP/OP "$3,232.55 " "$2,392.09" $0.00 "$2,510.72" "$1,412.28" "$1,412.28" $0.00 $0.00 $0.00 $673.74 "$2,399.20" "$2,399.20" $0.00 $0.00 $673.66 $0.00 "$1,593.65" "$1,593.65" $0.00 "$1,569.20" "$2,485.61" "$2,510.72" $0.00 $0.00 $476.86 $0.00 $0.00 $499.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.972S SUP HCPCS C1713 04.013.972S - NAIL INTRAMEDULLARY 15MM 46CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,341.98 " "$2,473.07" $0.00 "$2,595.70" "$1,460.08" "$1,460.08" $0.00 $0.00 $0.00 $696.55 "$2,480.41" "$2,480.41" $0.00 $0.00 $696.47 $0.00 "$1,647.59" "$1,647.59" $0.00 "$1,622.31" "$2,569.75" "$2,595.70" $0.00 $0.00 $492.99 $0.00 $0.00 $516.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.013.976S SUP HCPCS C1713 04.013.976S - NAIL INTRAMEDULLARY 15MM 48CM CANN RTRGRD ANTEGRADE NAIL-EX BOTH IP/OP "$3,444.08 " "$2,548.62" $0.00 "$2,675.02" "$1,504.70" "$1,504.70" $0.00 $0.00 $0.00 $717.83 "$2,556.19" "$2,556.19" $0.00 $0.00 $717.75 $0.00 "$1,697.93" "$1,697.93" $0.00 "$1,671.89" "$2,648.27" "$2,675.02" $0.00 $0.00 $508.06 $0.00 $0.00 $532.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.518S SUP HCPCS C1713 04.015.518S - SCREW BONE FULTHD 5MM 28MM 2 CORE LOCK GOLD TITANIUM KNEE BOTH IP/OP $477.00 $352.98 $0.00 $370.50 $208.41 $208.41 $0.00 $0.00 $0.00 $99.42 $354.03 $354.03 $0.00 $0.00 $99.41 $0.00 $282.15 $282.15 $0.00 $231.56 $366.80 $370.50 $0.00 $0.00 $70.37 $0.00 $0.00 $73.73 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.520 SUP HCPCS C1713 04.015.520 - SCREW BONE T25 BLUNT 5MM 8MM 30MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.522S SUP HCPCS C1713 04.015.522S - SCREW BONE FULTHD 5MM 32MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.525 SUP HCPCS C1713 04.015.525 - SCREW BONE T25 BLUNT 5MM 8MM 35MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.527S SUP HCPCS C1713 04.015.527S - SCREW BONE FULTHD 5MM 37MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.530 SUP HCPCS C1713 04.015.530 - SCREW BONE T25 BLUNT 5MM 8MM 40MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.532S SUP HCPCS C1713 04.015.532S - SCREW BONE FULTHD 5MM 42MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.535 SUP HCPCS C1713 04.015.535 - SCREW BONE T25 BLUNT 5MM 8MM 45MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.537S SUP HCPCS C1713 04.015.537S - SCREW BONE FULTHD 5MM 47MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.540 SUP HCPCS C1713 04.015.540 - SCREW BONE T25 BLUNT 5MM 8MM 50MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.542S SUP HCPCS C1713 04.015.542S - SCREW BONE FULTHD 5MM 52MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.545 SUP HCPCS C1713 04.015.545 - SCREW BONE T25 FULTHD 5MM 55MM 2 CORE LOCK STARDRIVE RECESS BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.547S SUP HCPCS C1713 04.015.547S - SCREW BONE FULTHD 5MM 57MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.550 SUP HCPCS C1713 04.015.550 - SCREW BONE T25 BLUNT 5MM 8MM 60MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.552S SUP HCPCS C1713 04.015.552S - SCREW BONE FULTHD 5MM 62MM 2 CORE LOCK SELF TAP T25 BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.555 SUP HCPCS C1713 04.015.555 - SCREW BONE T25 BLUNT 5MM 8MM 65MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.555S SUP HCPCS C1713 04.015.555S - SCREW BONE 5MM 65MM NLEX TI FULTHD TIB SLFTAP LCK 2 CORE BOTH IP/OP $482.85 $357.31 $0.00 $405.36 $228.02 $228.02 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $253.35 $401.31 $405.36 $0.00 $0.00 $79.30 $0.00 $0.00 $80.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.557S SUP HCPCS C1713 04.015.557S - SCREW BONE FULTHD 5MM 67MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.560 SUP HCPCS C1713 04.015.560 - SCREW BONE T25 BLUNT 5MM 8MM 70MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.562S SUP HCPCS C1713 04.015.562S - SCREW BONE FULTHD 5MM 72MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.565 SUP HCPCS C1713 04.015.565 - SCREW BONE T25 BLUNT 5MM 8MM 75MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.567S SUP HCPCS C1713 04.015.567S - SCREW BONE FULTHD 5MM 77MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.570 SUP HCPCS C1713 04.015.570 - SCREW BONE T25 BLUNT 5MM 8MM 80MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.572S SUP HCPCS C1713 04.015.572S - SCREW BONE FULTHD 5MM 82MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.575 SUP HCPCS C1713 04.015.575 - SCREW BONE T25 BLUNT 5MM 8MM 85MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.577S SUP HCPCS C1713 04.015.577S - SCREW BONE FULTHD 5MM 87MM 2 CORE LOCK T25 STARDRIVE RECESS BOTH IP/OP $482.85 $357.31 $0.00 $375.02 $210.95 $210.95 $0.00 $0.00 $0.00 $100.64 $358.37 $358.37 $0.00 $0.00 $100.63 $0.00 $285.61 $285.61 $0.00 $234.39 $371.27 $375.02 $0.00 $0.00 $71.23 $0.00 $0.00 $74.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.015.580 SUP HCPCS C1713 04.015.580 - SCREW BONE T25 BLUNT 5MM 8MM 90MM 2 CORE SELF TAP LOCK BOTH IP/OP $388.03 $287.14 $0.00 $301.38 $169.53 $169.53 $0.00 $0.00 $0.00 $80.87 $287.99 $287.99 $0.00 $0.00 $80.86 $0.00 $229.52 $229.52 $0.00 $188.36 $298.37 $301.38 $0.00 $0.00 $57.24 $0.00 $0.00 $59.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.016.034S SUP HCPCS C1713 04.016.034S - NAIL INTRAMEDULLARY SHORT STR 8MM 9.5MM 160MM CANN MULTILOC BOTH IP/OP "$3,667.28 " "$2,713.79" $0.00 "$2,848.36" "$1,602.20" "$1,602.20" $0.00 $0.00 $0.00 $764.35 "$2,721.85" "$2,721.85" $0.00 $0.00 $764.26 $0.00 "$1,807.97" "$1,807.97" $0.00 "$1,780.23" "$2,819.88" "$2,848.36" $0.00 $0.00 $540.98 $0.00 $0.00 $566.82 $0.00 $0.00 $0.00 $0.00 $0.00 04.016.255S SUP HCPCS C1713 04.016.255S - NAIL INTRAMEDULLARY LONG STR 7MM 255MM CANN ROUND BARREL BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.017.240S SUP HCPCS C1713 04.017.240S - NAIL INTRAMEDULLARY LONG STR 7MM 240MM CANN ROUND BARREL BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.018.225S SUP HCPCS C1713 04.018.225S - NAIL IM LNG STRG 8.5MM 9.5MM 225MM BLU STRL MULTILOC CNN TI BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.018.255S SUP HCPCS C1713 04.018.255S - NAIL IM LNG STRG 8.5MM 9.5MM 255MM BLU STRL MULTILOC CNN TI BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.018.270S SUP HCPCS C1713 04.018.270S - NAIL INTRAMEDULLARY LONG STR 8.5MM 270MM CANN ROUND BARREL BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.030S SUP HCPCS C1713 04.019.030S - SCREW BONE FULTHD 4.5MM 30MM BLUNT TIP SELF CUTTING BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.034S SUP HCPCS C1713 04.019.034S - SCREW BONE 3.8MM FULTHD BLUNT 4.5MM 3.9MM 34MM SELF CUT BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.036S SUP HCPCS C1713 04.019.036S - SCREW BONE 3.8MM FULTHD BLUNT 4.5MM 3.9MM 36MM SELF CUT BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.038S SUP HCPCS C1713 04.019.038S - SCREW BONE FULTHD 4.5MM 38MM BLUNT TIP SELF CUTTING BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.040S SUP HCPCS C1713 04.019.040S - SCREW BONE FULTHD 4.5MM 3.9MM 40MM BLUNT TIP SELF CUTTING BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.042S SUP HCPCS C1713 04.019.042S - SCREW BONE 3.8MM FULTHD BLUNT 4.5MM 3.9MM 42MM SELF CUT BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.044S SUP HCPCS C1713 04.019.044S - SCREW BONE 3.8MM FULTHD BLUNT 4.5MM 3.9MM 44MM SELF CUT BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.046S SUP HCPCS C1713 04.019.046S - SCREW BONE FULTHD 4.5MM 46MM BLUNT TIP SELF CUTTING BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.050S SUP HCPCS C1713 04.019.050S - SCREW BN FT 4.5MM 3.9MM 50MM AU STRL MULTILOC BLNT TIP SLF BOTH IP/OP $579.13 $428.56 $0.00 $449.80 $253.01 $253.01 $0.00 $0.00 $0.00 $120.70 $429.83 $429.83 $0.00 $0.00 $120.69 $0.00 $342.55 $342.55 $0.00 $281.13 $445.30 $449.80 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.225S SUP HCPCS C1713 04.019.225S - NAIL IM LNG STRG 8.5MM 9.5MM 225MM BLU STRL MULTILOC CNN TI BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.240S SUP HCPCS C1713 04.019.240S - NAIL INTRAMEDULLARY LONG STR 8.5MM 240MM CANN ROUND BARREL BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.255S SUP HCPCS C1713 04.019.255S - NAIL INTRAMEDULLARY MULTILOC TITANIUM ALUMINUM NIOBIUM LONG BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.270S SUP HCPCS C1713 04.019.270S - NAIL INTRAMEDULLARY LONG STR 8.5MM 270MM CANN ROUND BARREL BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.019.285S SUP HCPCS C1713 04.019.285S - NAIL INTRAMEDULLARY LONG STR 8.5MM 285MM CANN ROUND BARREL BOTH IP/OP "$3,821.90 " "$2,828.21" $0.00 "$2,968.46" "$1,669.76" "$1,669.76" $0.00 $0.00 $0.00 $796.58 "$2,836.61" "$2,836.61" $0.00 $0.00 $796.48 $0.00 "$1,884.20" "$1,884.20" $0.00 "$1,855.29" "$2,938.78" "$2,968.46" $0.00 $0.00 $563.79 $0.00 $0.00 $590.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.416S SUP HCPCS C1713 04.025.416S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 26MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.418S SUP HCPCS C1713 04.025.418S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 28MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.420S SUP HCPCS C1713 04.025.420S - SCREW BONE FULTHD 4MM 30MM T25 STARDRIVE RECESS LOCKING BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.422S SUP HCPCS C1713 04.025.422S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 32MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.424S SUP HCPCS C1713 04.025.424S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 34MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.426S SUP HCPCS C1713 04.025.426S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 36MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.428S SUP HCPCS C1713 04.025.428S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 38MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.430S SUP HCPCS C1713 04.025.430S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 40MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.432S SUP HCPCS C1713 04.025.432S - SCREW BONE 4MM 42MM T25 STARDRIVE RECESS ANGULAR STABLE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.434S SUP HCPCS C1713 04.025.434S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 44MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.436S SUP HCPCS C1713 04.025.436S - SCREW BONE T25 FULTHD BLUNT 4MM 8MM 46MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.438S SUP HCPCS C1713 04.025.438S - SCREW BONE FULTHD 4MM 48MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.440S SUP HCPCS C1713 04.025.440S - SCREW BONE FULTHD 4MM 50MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.442S SUP HCPCS C1713 04.025.442S - SCREW BONE FULTHD 4MM 52MM T25 STARDRIVE RECESS LOCKING BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.444S SUP HCPCS C1713 04.025.444S - SCREW BONE FULTHD 4MM 54MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.446S SUP HCPCS C1713 04.025.446S - SCREW BONE FULTHD 4MM 56MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.448S SUP HCPCS C1713 04.025.448S - SCREW BONE FULTHD 4MM 58MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.450S SUP HCPCS C1713 04.025.450S - SCREW BONE FULTHD 4MM 60MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.452S SUP HCPCS C1713 04.025.452S - SCREW BONE FULTHD 4MM 62MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.454S SUP HCPCS C1713 04.025.454S - SCREW BONE FULTHD 4MM 64MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.456S SUP HCPCS C1713 04.025.456S - SCREW BONE FULTHD 4MM 66MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.458S SUP HCPCS C1713 04.025.458S - SCREW BONE FULTHD 4MM 68MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.460S SUP HCPCS C1713 04.025.460S - SCREW BONE FULTHD 4MM 70MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.462S SUP HCPCS C1713 04.025.462S - SCREW BONE FULTHD 4MM 72MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.464S SUP HCPCS C1713 04.025.464S - SCREW BONE FULTHD 4MM 74MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.466S SUP HCPCS C1713 04.025.466S - SCREW BONE FULTHD 4MM 76MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.468S SUP HCPCS C1713 04.025.468S - SCREW BONE FULTHD 4MM 78MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.470S SUP HCPCS C1713 04.025.470S - SCREW BONE FULTHD 4MM 80MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.520S SUP HCPCS C1713 04.025.520S - SCREW BONE FULTHD 5MM 8MM 30MM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.522S SUP HCPCS C1713 04.025.522S - SCREW BONE FULTHD 5MM 32MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.524S SUP HCPCS C1713 04.025.524S - SCREW BONE FULTHD 5MM 34MM T25 STARDRIVE RECESS LOCKING ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.526S SUP HCPCS C1713 04.025.526S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 36MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.528S SUP HCPCS C1713 04.025.528S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 38MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.530S SUP HCPCS C1713 04.025.530S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 40MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.532S SUP HCPCS C1713 04.025.532S - SCREW BONE FULTHD 5MM 8MM 42MM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.534S SUP HCPCS C1713 04.025.534S - SCREW BONE FULTHD 5MM 30MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.536S SUP HCPCS C1713 04.025.536S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 46MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.538S SUP HCPCS C1713 04.025.538S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 48MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.540S SUP HCPCS C1713 04.025.540S - SCREW BONE FULTHD 5MM 50MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.542S SUP HCPCS C1713 04.025.542S - SCREW BONE FULTHD 5MM 52MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.544S SUP HCPCS C1713 04.025.544S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 54MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.546S SUP HCPCS C1713 04.025.546S - SCREW BONE FULTHD 5MM 56MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.548S SUP HCPCS C1713 04.025.548S - SCREW BONE FULTHD 5MM 58MM T25 STARDRIVE RECESS LOCKING ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.550S SUP HCPCS C1713 04.025.550S - SCREW BONE FULTHD 5MM 8MM 60MM T25 STARDRIVE RECESS SLFTAP BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.552S SUP HCPCS C1713 04.025.552S - SCREW BONE FULTHD 5MM 8MM 62MM SLFTAP BLUNT TIP T25 BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.554S SUP HCPCS C1713 04.025.554S - SCREW BONE FULTHD 5MM 64MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.556S SUP HCPCS C1713 04.025.556S - SCREW BONE FULTHD 5MM 66MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.558S SUP HCPCS C1713 04.025.558S - SCREW BONE FULTHD 5MM 68MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.560S SUP HCPCS C1713 04.025.560S - SCREW BONE FULTHD 5MM 70MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.562S SUP HCPCS C1713 04.025.562S - SCREW BONE FULTHD 5MM 72MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.564S SUP HCPCS C1713 04.025.564S - SCREW BONE FULTHD 5MM 8MM 74MM SLFTAP BLUNT TIP T25 BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.566S SUP HCPCS C1713 04.025.566S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 76MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.568S SUP HCPCS C1713 04.025.568S - SCREW BONE FULTHD 5MM 78MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.570S SUP HCPCS C1713 04.025.570S - SCREW BONE FULTHD 5MM 80MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.575S SUP HCPCS C1713 04.025.575S - SCREW BONE T25 FULTHD BLUNT 5MM 8MM 85MM SELF TAP STARDRIVE BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.580S SUP HCPCS C1713 04.025.580S - SCREW BONE FULTHD 5MM 90MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.585S SUP HCPCS C1713 04.025.585S - SCREW BONE FULTHD 5MM 95MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.590S SUP HCPCS C1713 04.025.590S - SCREW BONE FULTHD 5MM 100MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $418.65 $309.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $87.26 $310.72 $310.72 $0.00 $0.00 $87.25 $0.00 $247.63 $247.63 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.622S SUP HCPCS C1713 04.025.622S - SCREW BONE FULTHD 6MM 32MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.624S SUP HCPCS C1713 04.025.624S - SCREW BONE FULTHD 6MM 34MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.626S SUP HCPCS C1713 04.025.626S - SCREW BONE FULTHD 6MM 36MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.628S SUP HCPCS C1713 04.025.628S - SCREW BONE FULTHD 6MM 38MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.630S SUP HCPCS C1713 04.025.630S - SCREW BONE FULTHD 6MM 40MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.632S SUP HCPCS C1713 04.025.632S - SCREW BONE FULTHD 6MM 42MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.634S SUP HCPCS C1713 04.025.634S - SCREW BONE FULTHD 6MM 44MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.636S SUP HCPCS C1713 04.025.636S - SCREW BONE FULTHD 6MM 46MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.638S SUP HCPCS C1713 04.025.638S - SCREW BONE FULTHD 6MM 48MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.640S SUP HCPCS C1713 04.025.640S - SCREW BONE FULTHD 6MM 50MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.642S SUP HCPCS C1713 04.025.642S - SCREW BONE FULTHD 6MM 52MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.644S SUP HCPCS C1713 04.025.644S - SCREW BONE FULTHD 6MM 54MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.646S SUP HCPCS C1713 04.025.646S - SCREW BONE FULTHD 6MM 56MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.648S SUP HCPCS C1713 04.025.648S - SCREW BONE FULTHD 6MM 58MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.650S SUP HCPCS C1713 04.025.650S - SCREW BONE FULTHD 6MM 60MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.652S SUP HCPCS C1713 04.025.652S - SCREW BONE FULTHD 6MM 62MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.654S SUP HCPCS C1713 04.025.654S - SCREW BONE FULTHD 6MM 64MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.656S SUP HCPCS C1713 04.025.656S - SCREW BONE FULTHD 6MM 66MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.658S SUP HCPCS C1713 04.025.658S - SCREW BONE FULTHD 6MM 68MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.660S SUP HCPCS C1713 04.025.660S - SCREW BONE FULTHD 6MM 70MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.662S SUP HCPCS C1713 04.025.662S - SCREW BONE FULTHD 6MM 72MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.664S SUP HCPCS C1713 04.025.664S - SCREW BONE FULTHD 6MM 74MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.666S SUP HCPCS C1713 04.025.666S - SCREW BONE FULTHD 6MM 78MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.668S SUP HCPCS C1713 04.025.668S - SCREW BONE FULTHD 6MM 78MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.670S SUP HCPCS C1713 04.025.670S - SCREW BONE FULTHD 6MM 80MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.675S SUP HCPCS C1713 04.025.675S - SCREW BONE FULTHD 6MM 85MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.680S SUP HCPCS C1713 04.025.680S - SCREW BONE FULTHD 6MM 90MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.685S SUP HCPCS C1713 04.025.685S - SCREW BONE FULTHD 6MM 95MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.690S SUP HCPCS C1713 04.025.690S - SCREW BONE FULTHD 6MM 100MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.695S SUP HCPCS C1713 04.025.695S - SCREW BONE FULTHD 6MM 105MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.700S SUP HCPCS C1713 04.025.700S - SCREW BONE FULTHD 6MM 110MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.705S SUP HCPCS C1713 04.025.705S - SCREW BONE FULTHD 6MM 115MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.710S SUP HCPCS C1713 04.025.710S - SCREW BONE FULTHD 6MM 120MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.025.715S SUP HCPCS C1713 04.025.715S - SCREW BONE FULTHD 6MM 125MM LOCKING STARDRIVE RECESS ASLS BOTH IP/OP $406.48 $300.80 $0.00 $325.18 $182.91 $182.91 $0.00 $0.00 $0.00 $84.72 $301.69 $301.69 $0.00 $0.00 $84.71 $0.00 $240.43 $240.43 $0.00 $203.24 $321.93 $325.18 $0.00 $0.00 $61.76 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.030S SUP HCPCS C1713 04.030.030S - NAIL 10MM 30CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.031S SUP HCPCS C1713 04.030.031S - NAIL 10MM 30CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.032S SUP HCPCS C1713 04.030.032S - NAIL 10MM 32CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.033S SUP HCPCS C1713 04.030.033S - NAIL 10MM 32CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.034S SUP HCPCS C1713 04.030.034S - NAIL 10MM 34CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.035S SUP HCPCS C1713 04.030.035S - NAIL 10MM 34CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.036S SUP HCPCS C1713 04.030.036S - NAIL 10MM 36CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.037S SUP HCPCS C1713 04.030.037S - NAIL 10MM 36CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.038S SUP HCPCS C1713 04.030.038S - NAIL 10MM 38CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.039S SUP HCPCS C1713 04.030.039S - NAIL 10MM 38CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.040S SUP HCPCS C1713 04.030.040S - NAIL 10MM 40CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.041S SUP HCPCS C1713 04.030.041S - NAIL 10MM 40CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.042S SUP HCPCS C1713 04.030.042S - NAIL 10MM 42CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.043S SUP HCPCS C1713 04.030.043S - NAIL 10MM 42CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL GRN BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.044S SUP HCPCS C1713 04.030.044S - NAIL 10MM 44CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.045S SUP HCPCS C1713 04.030.045S - NAIL 10MM 44CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.046S SUP HCPCS C1713 04.030.046S - NAIL 10MM 46CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.047S SUP HCPCS C1713 04.030.047S - NAIL 10MM 46CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.048S SUP HCPCS C1713 04.030.048S - NAIL 10MM 48CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.049S SUP HCPCS C1713 04.030.049S - NAIL 10MM 48CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.130S SUP HCPCS C1713 04.030.130S - NAIL 11MM 30CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.131S SUP HCPCS C1713 04.030.131S - NAIL 11MM 30CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.132S SUP HCPCS C1713 04.030.132S - NAIL 11MM 32CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.133S SUP HCPCS C1713 04.030.133S - NAIL 11MM 32CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.134S SUP HCPCS C1713 04.030.134S - NAIL IM 11MM 340MM LGHT GRN STRL NLEX CNN LAT ENTRY TI AL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.135S SUP HCPCS C1713 04.030.135S - NAIL 11MM 34CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.136S SUP HCPCS C1713 04.030.136S - NAIL 11MM 36CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.137S SUP HCPCS C1713 04.030.137S - NAIL 11MM 36CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.138S SUP HCPCS C1713 04.030.138S - NAIL 11MM 38CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.139S SUP HCPCS C1713 04.030.139S - NAIL 11MM 38CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.140S SUP HCPCS C1713 04.030.140S - NAIL 11MM 40CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.141S SUP HCPCS C1713 04.030.141S - NAIL 11MM 40CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.142S SUP HCPCS C1713 04.030.142S - NAIL 11MM 42CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.143S SUP HCPCS C1713 04.030.143S - NAIL 11MM 42CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.144S SUP HCPCS C1713 04.030.144S - NAIL 11MM 44CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.145S SUP HCPCS C1713 04.030.145S - NAIL 11MM 44CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.146S SUP HCPCS C1713 04.030.146S - NAIL 11MM 46CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.147S SUP HCPCS C1713 04.030.147S - NAIL 11MM 46CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.148S SUP HCPCS C1713 04.030.148S - NAIL 11MM 48CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.149S SUP HCPCS C1713 04.030.149S - NAIL 11MM 48CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.230S SUP HCPCS C1713 04.030.230S - NAIL 12MM 30CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.231S SUP HCPCS C1713 04.030.231S - NAIL 12MM 30CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.232S SUP HCPCS C1713 04.030.232S - NAIL 12MM 32CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.233S SUP HCPCS C1713 04.030.233S - NAIL 12MM 32CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.234S SUP HCPCS C1713 04.030.234S - NAIL 12MM 34CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.235S SUP HCPCS C1713 04.030.235S - NAIL 12MM 34CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.236S SUP HCPCS C1713 04.030.236S - NAIL 12MM 36CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.237S SUP HCPCS C1713 04.030.237S - NAIL 12MM 36CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.238S SUP HCPCS C1713 04.030.238S - NAIL 12MM 38CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.239S SUP HCPCS C1713 04.030.239S - NAIL 12MM 38CM LEFT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.240S SUP HCPCS C1713 04.030.240S - NAIL 12MM 40CM RIGHT FEM NLEX IM CANN TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.241S SUP HCPCS C1713 04.030.241S - NAIL 12MM 40CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.242S SUP HCPCS C1713 04.030.242S - NAIL 12MM 42CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.243S SUP HCPCS C1713 04.030.243S - NAIL 12MM 42CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.244S SUP HCPCS C1713 04.030.244S - NAIL 12MM 44CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.245S SUP HCPCS C1713 04.030.245S - NAIL 12MM 44CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.246S SUP HCPCS C1713 04.030.246S - NAIL 12MM 46CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.247S SUP HCPCS C1713 04.030.247S - NAIL 12MM 46CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.248S SUP HCPCS C1713 04.030.248S - NAIL 12MM 48CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.249S SUP HCPCS C1713 04.030.249S - NAIL 12MM 48CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.330S SUP HCPCS C1713 04.030.330S - NAIL 13MM 30CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.331S SUP HCPCS C1713 04.030.331S - NAIL 13MM 30CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.332S SUP HCPCS C1713 04.030.332S - NAIL 13MM 32CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.333S SUP HCPCS C1713 04.030.333S - NAIL 13MM 32CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.334S SUP HCPCS C1713 04.030.334S - NAIL 13MM 34CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.335S SUP HCPCS C1713 04.030.335S - NAIL 13MM 34CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.336S SUP HCPCS C1713 04.030.336S - NAIL 13MM 36CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.337S SUP HCPCS C1713 04.030.337S - NAIL 13MM 36CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.338S SUP HCPCS C1713 04.030.338S - NAIL 13MM 38CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.339S SUP HCPCS C1713 04.030.339S - NAIL 13MM 38CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.340S SUP HCPCS C1713 04.030.340S - NAIL 13MM 40CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.341S SUP HCPCS C1713 04.030.341S - NAIL 13MM 40CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.342S SUP HCPCS C1713 04.030.342S - NAIL 13MM 42CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.343S SUP HCPCS C1713 04.030.343S - NAIL 13MM 42CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.344S SUP HCPCS C1713 04.030.344S - NAIL 13MM 44CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.345S SUP HCPCS C1713 04.030.345S - NAIL 13MM 44CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.346S SUP HCPCS C1713 04.030.346S - NAIL 13MM 46CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.347S SUP HCPCS C1713 04.030.347S - NAIL 13MM 46CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.348S SUP HCPCS C1713 04.030.348S - NAIL 13MM 48CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.349S SUP HCPCS C1713 04.030.349S - NAIL 13MM 48CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.430S SUP HCPCS C1713 04.030.430S - NAIL 14MM 30CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.431S SUP HCPCS C1713 04.030.431S - NAIL 14MM 30CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.432S SUP HCPCS C1713 04.030.432S - NAIL 14MM 32CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.433S SUP HCPCS C1713 04.030.433S - NAIL 14MM 32CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.434S SUP HCPCS C1713 04.030.434S - NAIL 14MM 34CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.435S SUP HCPCS C1713 04.030.435S - NAIL 14MM 34CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.436S SUP HCPCS C1713 04.030.436S - NAIL 14MM 36CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.437S SUP HCPCS C1713 04.030.437S - NAIL 14MM 36CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.438S SUP HCPCS C1713 04.030.438S - NAIL 14MM 38CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.439S SUP HCPCS C1713 04.030.439S - NAIL 14MM 38CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.440S SUP HCPCS C1713 04.030.440S - NAIL 14MM 40CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.441S SUP HCPCS C1713 04.030.441S - NAIL 14MM 40CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.442S SUP HCPCS C1713 04.030.442S - NAIL 14MM 42CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.443S SUP HCPCS C1713 04.030.443S - NAIL 14MM 42CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.444S SUP HCPCS C1713 04.030.444S - NAIL 14MM 44CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.445S SUP HCPCS C1713 04.030.445S - NAIL 14MM 44CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.446S SUP HCPCS C1713 04.030.446S - NAIL 14MM 46CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.447S SUP HCPCS C1713 04.030.447S - NAIL 14MM 46CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.448S SUP HCPCS C1713 04.030.448S - NAIL 14MM 48CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.449S SUP HCPCS C1713 04.030.449S - NAIL 14MM 48CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.530S SUP HCPCS C1713 04.030.530S - NAIL 15MM 30CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.531S SUP HCPCS C1713 04.030.531S - NAIL 15MM 30CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.532S SUP HCPCS C1713 04.030.532S - NAIL 15MM 32CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.533S SUP HCPCS C1713 04.030.533S - NAIL 15MM 32CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.534S SUP HCPCS C1713 04.030.534S - NAIL 15MM 34CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.535S SUP HCPCS C1713 04.030.535S - NAIL 15MM 34CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.536S SUP HCPCS C1713 04.030.536S - NAIL 15MM 36CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.537S SUP HCPCS C1713 04.030.537S - NAIL 15MM 36CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.538S SUP HCPCS C1713 04.030.538S - NAIL 15MM 38CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.539S SUP HCPCS C1713 04.030.539S - NAIL 15MM 38CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.540S SUP HCPCS C1713 04.030.540S - NAIL 15MM 40CM FEM NLEX IM CANN PROX BND TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.541S SUP HCPCS C1713 04.030.541S - NAIL 15MM 40CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.542S SUP HCPCS C1713 04.030.542S - NAIL 15MM 42CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.543S SUP HCPCS C1713 04.030.543S - NAIL 15MM 42CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.544S SUP HCPCS C1713 04.030.544S - NAIL 15MM 44CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.545S SUP HCPCS C1713 04.030.545S - NAIL 15MM 44CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.546S SUP HCPCS C1713 04.030.546S - NAIL 15MM 46CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.547S SUP HCPCS C1713 04.030.547S - NAIL 15MM 46CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.548S SUP HCPCS C1713 04.030.548S - NAIL 15MM 48CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.549S SUP HCPCS C1713 04.030.549S - NAIL 15MM 48CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.630S SUP HCPCS C1713 04.030.630S - NAIL 16MM 30CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.631S SUP HCPCS C1713 04.030.631S - NAIL 16MM 30CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.632S SUP HCPCS C1713 04.030.632S - NAIL 16MM 32CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.633S SUP HCPCS C1713 04.030.633S - NAIL 16MM 32CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.634S SUP HCPCS C1713 04.030.634S - NAIL 16MM 34CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.635S SUP HCPCS C1713 04.030.635S - NAIL 16MM 34CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.636S SUP HCPCS C1713 04.030.636S - NAIL 16MM 36CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.637S SUP HCPCS C1713 04.030.637S - NAIL 16MM 36CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.638S SUP HCPCS C1713 04.030.638S - NAIL 16MM 38CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.639S SUP HCPCS C1713 04.030.639S - NAIL 16MM 38CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.640S SUP HCPCS C1713 04.030.640S - NAIL 16MM 40CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.641S SUP HCPCS C1713 04.030.641S - NAIL 16MM 40CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.642S SUP HCPCS C1713 04.030.642S - NAIL 16MM 42CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.643S SUP HCPCS C1713 04.030.643S - NAIL 16MM 42CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.644S SUP HCPCS C1713 04.030.644S - NAIL 16MM 44CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.645S SUP HCPCS C1713 04.030.645S - NAIL 16MM 44CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.646S SUP HCPCS C1713 04.030.646S - NAIL 16MM 46CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.647S SUP HCPCS C1713 04.030.647S - NAIL 16MM 46CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.648S SUP HCPCS C1713 04.030.648S - NAIL 16MM 48CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.649S SUP HCPCS C1713 04.030.649S - NAIL 16MM 48CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.930S SUP HCPCS C1713 04.030.930S - NAIL 9MM 30CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.931S SUP HCPCS C1713 04.030.931S - NAIL 9MM 30CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.932S SUP HCPCS C1713 04.030.932S - NAIL 9MM 320MM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.933S SUP HCPCS C1713 04.030.933S - NAIL 9MM 320MM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.934S SUP HCPCS C1713 04.030.934S - NAIL 9MM 340MM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.935S SUP HCPCS C1713 04.030.935S - NAIL 9MM 340MM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.936S SUP HCPCS C1713 04.030.936S - NAIL 9MM 360MM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.937S SUP HCPCS C1713 04.030.937S - NAIL 9MM 36CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.938S SUP HCPCS C1713 04.030.938S - NAIL 9MM 380MM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.939S SUP HCPCS C1713 04.030.939S - NAIL 9MM 380MM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.940S SUP HCPCS C1713 04.030.940S - NAIL 9MM 400MM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.941S SUP HCPCS C1713 04.030.941S - NAIL 9MM 400MM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.942S SUP HCPCS C1713 04.030.942S - NAIL 9MM 420MM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.943S SUP HCPCS C1713 04.030.943S - NAIL 9MM 420MM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.944S SUP HCPCS C1713 04.030.944S - NAIL 9MM 44CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.945S SUP HCPCS C1713 04.030.945S - NAIL 9MM 44CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.946S SUP HCPCS C1713 04.030.946S - NAIL 9MM 46CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.947S SUP HCPCS C1713 04.030.947S - NAIL 9MM 46CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.948S SUP HCPCS C1713 04.030.948S - NAIL 9MM 48CM RIGHT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.030.949S SUP HCPCS C1713 04.030.949S - NAIL 9MM 48CM LEFT FEM NLEX IM CANN LAT ENTRY TI STRL BOTH IP/OP "$3,685.58 " "$2,727.33" $0.00 "$2,948.46" "$1,658.51" "$1,658.51" $0.00 $0.00 $0.00 $768.17 "$2,735.43" "$2,735.43" $0.00 $0.00 $768.07 $0.00 "$1,816.99" "$1,816.99" $0.00 "$1,842.79" "$2,918.98" "$2,948.46" $0.00 $0.00 $576.79 $0.00 $0.00 $586.74 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.000S SUP HCPCS C1713 04.031.000S - CAP END 0MM T40 STARDRIVE RECESS CANN LATERAL ENTRY NAIL-EX BOTH IP/OP $389.38 $288.14 $0.00 $302.42 $170.11 $170.11 $0.00 $0.00 $0.00 $81.16 $288.99 $288.99 $0.00 $0.00 $81.15 $0.00 $230.32 $230.32 $0.00 $189.01 $299.40 $302.42 $0.00 $0.00 $57.44 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.001S SUP HCPCS C1713 04.031.001S - CAP END 5MM T40 LATERAL ENTRY EXTN STARDRIVE RECESS NAIL-EX BOTH IP/OP $389.38 $288.14 $0.00 $302.42 $170.11 $170.11 $0.00 $0.00 $0.00 $81.16 $288.99 $288.99 $0.00 $0.00 $81.15 $0.00 $230.32 $230.32 $0.00 $189.01 $299.40 $302.42 $0.00 $0.00 $57.44 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.002S SUP HCPCS C1713 04.031.002S - CAP END 10MM T40 EXTENDED STARDRIVE RECESS NAIL-EX TITANIUM BOTH IP/OP $389.38 $288.14 $0.00 $302.42 $170.11 $170.11 $0.00 $0.00 $0.00 $81.16 $288.99 $288.99 $0.00 $0.00 $81.15 $0.00 $230.32 $230.32 $0.00 $189.01 $299.40 $302.42 $0.00 $0.00 $57.44 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.003S SUP HCPCS C1713 04.031.003S - CAP END 15MM T40 LATERAL ENTRY EXTN STARDRIVE RECESS NAIL-EX BOTH IP/OP $389.38 $288.14 $0.00 $302.42 $170.11 $170.11 $0.00 $0.00 $0.00 $81.16 $288.99 $288.99 $0.00 $0.00 $81.15 $0.00 $230.32 $230.32 $0.00 $189.01 $299.40 $302.42 $0.00 $0.00 $57.44 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.021 SUP HCPCS C1713 04.031.021 - SCREW BONE PTHRD 5MM 55MM T25 STARDRIVE RECESS SLFTAP BLUNT BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.022 SUP HCPCS C1713 04.031.022 - SCREW BONE PTHRD 5MM 60MM T25 STARDRIVE RECESS SLFTAP BLUNT BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.023 SUP HCPCS C1713 04.031.023 - SCREW BONE STANDARD PTHRD BLUNT 5MM 8.2MM 65MM SELF TAP SELF BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.024 SUP HCPCS C1713 04.031.024 - SCREW BONE STANDARD PTHRD BLUNT 5MM 8.2MM 70MM SELF TAP SELF BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.025 SUP HCPCS C1713 04.031.025 - SCREW BONE PTHRD 5MM 75MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.026 SUP HCPCS C1713 04.031.026 - SCREW BONE PTHRD 5MM 80MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.027 SUP HCPCS C1713 04.031.027 - SCREW BONE PTHRD 5MM 85MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.028 SUP HCPCS C1713 04.031.028 - SCREW BONE PTHRD 5MM 90MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.029 SUP HCPCS C1713 04.031.029 - SCREW BONE PTHRD 5MM 3.2MM 95MM T25 STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.030 SUP HCPCS C1713 04.031.030 - SCREW BONE PTHRD 5MM 100MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.031 SUP HCPCS C1713 04.031.031 - SCREW BONE PTHRD 5MM 105MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.032 SUP HCPCS C1713 04.031.032 - SCREW BONE PTHRD 5MM 110MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.033 SUP HCPCS C1713 04.031.033 - SCREW BONE PTHRD 5MM 115MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.034 SUP HCPCS C1713 04.031.034 - SCREW BONE PTHRD 5MM 120MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.035 SUP HCPCS C1713 04.031.035 - SCREW BONE PTHRD 5MM 125MM RECONSTRUCTION STARDRIVE RECESS BOTH IP/OP $321.90 $238.21 $0.00 $250.02 $140.64 $140.64 $0.00 $0.00 $0.00 $67.09 $238.91 $238.91 $0.00 $0.00 $67.08 $0.00 $190.40 $190.40 $0.00 $156.26 $247.52 $250.02 $0.00 $0.00 $47.49 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.924S SUP HCPCS C1713 04.031.924S - NAIL INTRAMEDULLARY 8.2MM 240MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.925S SUP HCPCS C1713 04.031.925S - NAIL INTRAMEDULLARY 8.2MM 240MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.926S SUP HCPCS C1713 04.031.926S - NAIL INTRAMEDULLARY 8.2MM 260MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.927S SUP HCPCS C1713 04.031.927S - NAIL INTRAMEDULLARY 8.2MM 260MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.928S SUP HCPCS C1713 04.031.928S - NAIL INTRAMEDULLARY 8.2MM 280MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.929S SUP HCPCS C1713 04.031.929S - NAIL INTRAMEDULLARY 8.2MM 280MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.930S SUP HCPCS C1713 04.031.930S - NAIL INTRAMEDULLARY 8.2MM 300MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.931S SUP HCPCS C1713 04.031.931S - NAIL INTRAMEDULLARY 8.2MM 300MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.932S SUP HCPCS C1713 04.031.932S - NAIL INTRAMEDULLARY 8.2MM 320MM LATERAL ENTRY TITANIUM BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.933S SUP HCPCS C1713 04.031.933S - NAIL INTRAMEDULLARY 8.2MM LATERAL ENTRY TITANIUM PEDIATRIC BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.934S SUP HCPCS C1713 04.031.934S - NAIL INTRAMEDULLARY 8.2MM LATERAL ENTRY TITANIUM PEDIATRIC BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.935S SUP HCPCS C1713 04.031.935S - NAIL INTRAMEDULLARY 8.2MM 340MM LATERAL ENTRY NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.936S SUP HCPCS C1713 04.031.936S - NAIL INTRAMEDULLARY 8.2MM LATERAL ENTRY TITANIUM PEDIATRIC BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.937S SUP HCPCS C1713 04.031.937S - NAIL INTRAMEDULLARY 8.2MM LATERAL ENTRY TITANIUM PEDIATRIC BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.938S SUP HCPCS C1713 04.031.938S - NAIL INTRAMEDULLARY 380MM CANN LATERAL ENTRY NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.939S SUP HCPCS C1713 04.031.939S - NAIL INTRAMEDULLARY 380MM CANN LATERAL ENTRY NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.940S SUP HCPCS C1713 04.031.940S - NAIL INTRAMEDULLARY 8.2MM 400MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.941S SUP HCPCS C1713 04.031.941S - NAIL INTRAMEDULLARY 8.2MM 400MM LATERAL ENTRY EXPERT BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.944S SUP HCPCS C1713 04.031.944S - NAIL INTRAMEDULLARY 9MM 240MM LATERAL ENTRY CANN EXPERT DARK BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.945S SUP HCPCS C1713 04.031.945S - NAIL INTRAMEDULLARY 9MM 240MM LATERAL ENTRY CANN EXPERT DARK BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.946S SUP HCPCS C1713 04.031.946S - NAIL INTRAMEDULLARY 9MM 260MM LATERAL ENTRY CANN EXPERT DARK BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.947S SUP HCPCS C1713 04.031.947S - NAIL INTRAMEDULLARY 9MM 260MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.948S SUP HCPCS C1713 04.031.948S - NAIL INTRAMEDULLARY 9MM 280MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.949S SUP HCPCS C1713 04.031.949S - NAIL INTRAMEDULLARY 9MM 280MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.950S SUP HCPCS C1713 04.031.950S - NAIL INTRAMEDULLARY 9MM 300MM LATERAL ENTRY CANN HELICAL BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.951S SUP HCPCS C1713 04.031.951S - NAIL INTRAMEDULLARY 9MM 300MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.952S SUP HCPCS C1713 04.031.952S - NAIL INTRAMEDULLARY 9MM 320MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.953S SUP HCPCS C1713 04.031.953S - NAIL INTRAMEDULLARY 9MM 320MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.954S SUP HCPCS C1713 04.031.954S - NAIL INTRAMEDULLARY 9MM 340MM LATERAL ENTRY TITANIUM BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.955S SUP HCPCS C1713 04.031.955S - NAIL INTRAMEDULLARY 9MM 340MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.956S SUP HCPCS C1713 04.031.956S - NAIL INTRAMEDULLARY 9MM 360MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.957S SUP HCPCS C1713 04.031.957S - NAIL INTRAMEDULLARY 9MM 360MM LATERAL ENTRY NAIL-EX TITANIUM BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.958S SUP HCPCS C1713 04.031.958S - NAIL INTRAMEDULLARY 9MM 380MM LATERAL ENTRY NAIL-EX TITANIUM BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.959S SUP HCPCS C1713 04.031.959S - NAIL INTRAMEDULLARY 9MM 380MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.960S SUP HCPCS C1713 04.031.960S - NAIL INTRAMEDULLARY 9MM 400MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.961S SUP HCPCS C1713 04.031.961S - NAIL INTRAMEDULLARY 9MM 400MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,807.18 " "$2,077.31" $0.00 "$2,180.32" "$1,226.43" "$1,226.43" $0.00 $0.00 $0.00 $585.09 "$2,083.49" "$2,083.49" $0.00 $0.00 $585.02 $0.00 "$1,383.94" "$1,383.94" $0.00 "$1,362.70" "$2,158.52" "$2,180.32" $0.00 $0.00 $414.10 $0.00 $0.00 $433.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.964S SUP HCPCS C1713 04.031.964S - NAIL INTRAMEDULLARY 10MM 240MM LATERAL ENTRY CANN EXPERT BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.965S SUP HCPCS C1713 04.031.965S - NAIL INTRAMEDULLARY 10MM 240MM LATERAL ENTRY CANN EXPERT BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.966S SUP HCPCS C1713 04.031.966S - NAIL INTRAMEDULLARY 10MM 260MM LATERAL ENTRY CANN EXPERT BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.967S SUP HCPCS C1713 04.031.967S - NAIL INTRAMEDULLARY 10MM 260MM LATERAL ENTRY CANN EXPERT BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.968S SUP HCPCS C1713 04.031.968S - NAIL INTRAMEDULLARY 10MM 280MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.969S SUP HCPCS C1713 04.031.969S - NAIL INTRAMEDULLARY 10MM 280MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.970S SUP HCPCS C1713 04.031.970S - NAIL INTRAMEDULLARY 10MM 300MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.971S SUP HCPCS C1713 04.031.971S - NAIL INTRAMEDULLARY 10MM 300MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.972S SUP HCPCS C1713 04.031.972S - NAIL INTRAMEDULLARY 10MM 320MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.973S SUP HCPCS C1713 04.031.973S - NAIL INTRAMEDULLARY 10MM 320MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.974S SUP HCPCS C1713 04.031.974S - NAIL INTRAMEDULLARY 10MM 340MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.975S SUP HCPCS C1713 04.031.975S - NAIL INTRAMEDULLARY 10MM 340MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.976S SUP HCPCS C1713 04.031.976S - NAIL INTRAMEDULLARY 10MM 360MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.977S SUP HCPCS C1713 04.031.977S - NAIL INTRAMEDULLARY 10MM 360MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.978S SUP HCPCS C1713 04.031.978S - NAIL INTRAMEDULLARY 10MM 380MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.979S SUP HCPCS C1713 04.031.979S - NAIL INTRAMEDULLARY 10MM 380MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.980S SUP HCPCS C1713 04.031.980S - NAIL INTRAMEDULLARY 10MM 400MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.031.981S SUP HCPCS C1713 04.031.981S - NAIL INTRAMEDULLARY 10MM 400MM LATERAL ENTRY IMPLANT NAIL-EX BOTH IP/OP "$2,892.93 " "$2,140.77" $0.00 "$2,246.92" "$1,263.89" "$1,263.89" $0.00 $0.00 $0.00 $602.96 "$2,147.13" "$2,147.13" $0.00 $0.00 $602.89 $0.00 "$1,426.21" "$1,426.21" $0.00 "$1,404.33" "$2,224.45" "$2,246.92" $0.00 $0.00 $426.75 $0.00 $0.00 $447.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.001S SUP HCPCS C1713 04.032.001S - SCREW SET 130D TITANIUM INTRAMEDULLARY STERILE TROC NAIL BOTH IP/OP $322.38 $238.56 $0.00 $250.40 $140.85 $140.85 $0.00 $0.00 $0.00 $67.19 $239.27 $239.27 $0.00 $0.00 $67.18 $0.00 $190.68 $190.68 $0.00 $156.50 $247.90 $250.40 $0.00 $0.00 $47.56 $0.00 $0.00 $49.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.070S SUP HCPCS C1713 04.032.070S - SCREW BONE THREAD 11MM 70X130MM FIX SELFTAPPING INVERSE BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.075S SUP HCPCS C1713 04.032.075S - SCREW BONE 11MM 75MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.080S SUP HCPCS C1713 04.032.080S - SCREW BONE 11MM 80MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.085S SUP HCPCS C1713 04.032.085S - SCREW BONE 11MM 85MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.090S SUP HCPCS C1713 04.032.090S - SCREW BONE 11MM 90MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.095S SUP HCPCS C1713 04.032.095S - SCREW BONE 11MM 95MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.100S SUP HCPCS C1713 04.032.100S - SCREW BONE 11MM 100MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.105S SUP HCPCS C1713 04.032.105S - SCREW BONE 11MM 105MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.110S SUP HCPCS C1713 04.032.110S - SCREW BONE 11MM 110MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.115S SUP HCPCS C1713 04.032.115S - SCREW BONE 11MM 115MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.120S SUP HCPCS C1713 04.032.120S - SCREW BONE 11MM 120MM FIX TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.125S SUP HCPCS C1713 04.032.125S - SCREW BONE 11MM 125MM TITANIUM FEMUR TROCHANTER PROXIMAL BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.032.130S SUP HCPCS C1713 04.032.130S - SCREW BN 11MM 130MM AU STRL CNN SELP TAP INVERSE ANG THRD TI BOTH IP/OP "$1,102.80 " $816.07 $0.00 $856.54 $481.80 $481.80 $0.00 $0.00 $0.00 $229.85 $818.50 $818.50 $0.00 $0.00 $229.82 $0.00 $652.31 $652.31 $0.00 $535.34 $847.98 $856.54 $0.00 $0.00 $162.68 $0.00 $0.00 $170.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.231S SUP HCPCS C1713 04.034.231S - NAIL INTRAMEDULLARY 8MM 255MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.234S SUP HCPCS C1713 04.034.234S - NAIL INTRAMEDULLARY 8MM 27CM CANN PROXIMAL BEND NAIL-EX DARK BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.237S SUP HCPCS C1713 04.034.237S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 285MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.240S SUP HCPCS C1713 04.034.240S - NAIL INTRAMEDULLARY 8MM 30CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.243S SUP HCPCS C1713 04.034.243S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 315MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.246S SUP HCPCS C1713 04.034.246S - NAIL INTRAMEDULLARY 8MM 33CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.249S SUP HCPCS C1713 04.034.249S - NAIL INTRAMEDULLARY 8MM 34.5CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.252S SUP HCPCS C1713 04.034.252S - NAIL INTRAMEDULLARY UNIVERSAL ROUND BARREL 8MM 36CM CANN BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.255S SUP HCPCS C1713 04.034.255S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 375MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.258S SUP HCPCS C1713 04.034.258S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 390MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.261S SUP HCPCS C1713 04.034.261S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 405MM CANN PROXIMAL BEND BOTH IP/OP "$2,917.48 " "$2,158.94" $0.00 "$2,266.00" "$1,274.63" "$1,274.63" $0.00 $0.00 $0.00 $608.07 "$2,165.35" "$2,165.35" $0.00 $0.00 $608.00 $0.00 "$1,438.32" "$1,438.32" $0.00 "$1,416.25" "$2,243.34" "$2,266.00" $0.00 $0.00 $430.38 $0.00 $0.00 $450.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.264S SUP HCPCS C1713 04.034.264S - NAIL INTRAMEDULLARY UNIVERSAL 8MM 420MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.267S SUP HCPCS C1713 04.034.267S - NAIL INTRAMEDULLARY 8MM 43.5CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.331S SUP HCPCS C1713 04.034.331S - NAIL INTRAMEDULLARY 9MM 25.5CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.334S SUP HCPCS C1713 04.034.334S - NAIL INTRAMEDULLARY 9MM 27CM CANN PROXIMAL BEND NAIL-EX DARK BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.337S SUP HCPCS C1713 04.034.337S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 285MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.340S SUP HCPCS C1713 04.034.340S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 300MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.343S SUP HCPCS C1713 04.034.343S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 315MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.346S SUP HCPCS C1713 04.034.346S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 330MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.349S SUP HCPCS C1713 04.034.349S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 345MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.352S SUP HCPCS C1713 04.034.352S - NAIL INTRAMEDULLARY UNIVERSAL ROUND 9MM 36CM CANN PROXIMAL BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.355S SUP HCPCS C1713 04.034.355S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 375MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.358S SUP HCPCS C1713 04.034.358S - NAIL INTRAMEDULLARY 9MM 39CM PROXIMAL BEND CANN EXPERT BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.361S SUP HCPCS C1713 04.034.361S - NAIL INTRAMEDULLARY 9MM 40.5CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.364S SUP HCPCS C1713 04.034.364S - NAIL INTRAMEDULLARY 9MM 420MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.367S SUP HCPCS C1713 04.034.367S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 435MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.431S SUP HCPCS C1713 04.034.431S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 255MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.434S SUP HCPCS C1713 04.034.434S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 270MM CANN PROXIMAL BEND BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.437S SUP HCPCS C1713 04.034.437S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 285MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.440S SUP HCPCS C1713 04.034.440S - NAIL INTRAMEDULLARY 10MM 30CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.443S SUP HCPCS C1713 04.034.443S - NAIL INTRAMEDULLARY 10MM 315MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.446S SUP HCPCS C1713 04.034.446S - NAIL INTRAMEDULLARY 10MM 33CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.449S SUP HCPCS C1713 04.034.449S - NAIL INTRAMEDULLARY 10MM 34.5CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.452S SUP HCPCS C1713 04.034.452S - NAIL INTRAMEDULLARY 10MM 360MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.455S SUP HCPCS C1713 04.034.455S - NAIL INTRAMEDULLARY 10MM 375MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.458S SUP HCPCS C1713 04.034.458S - NAIL INTRAMEDULLARY 10MM 390MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.461S SUP HCPCS C1713 04.034.461S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 405MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.464S SUP HCPCS C1713 04.034.464S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 420MM CANN PROXIMAL BEND BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.467S SUP HCPCS C1713 04.034.467S - NAIL INTRAMEDULLARY 10MM 435MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.531S SUP HCPCS C1713 04.034.531S - NAIL INTRAMEDULLARY 11MM 255MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.534S SUP HCPCS C1713 04.034.534S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 270MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.537S SUP HCPCS C1713 04.034.537S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 285MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.540S SUP HCPCS C1713 04.034.540S - NAIL INTRAMEDULLARY UNIVERSAL FLUTE BARREL 11MM 300MM CANN BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.543S SUP HCPCS C1713 04.034.543S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 315MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.546S SUP HCPCS C1713 04.034.546S - NAIL INTRAMEDULLARY 11MM 330MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.549S SUP HCPCS C1713 04.034.549S - NAIL INTRAMEDULLARY 11MM 345MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.552S SUP HCPCS C1713 04.034.552S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 360MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.555S SUP HCPCS C1713 04.034.555S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 375MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.558S SUP HCPCS C1713 04.034.558S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 390MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.561S SUP HCPCS C1713 04.034.561S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 405MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.564S SUP HCPCS C1713 04.034.564S - NAIL INTRAMEDULLARY 11MM 420MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.567S SUP HCPCS C1713 04.034.567S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 235MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.631S SUP HCPCS C1713 04.034.631S - NAIL INTRAMEDULLARY 12MM 255MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.634S SUP HCPCS C1713 04.034.634S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 270MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.637S SUP HCPCS C1713 04.034.637S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 285MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.640S SUP HCPCS C1713 04.034.640S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 300MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.643S SUP HCPCS C1713 04.034.643S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 315MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.646S SUP HCPCS C1713 04.034.646S - NAIL INTRAMEDULLARY 12MM 33CM CANN PROXIMAL BEND EXPERT BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.649S SUP HCPCS C1713 04.034.649S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 345MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.652S SUP HCPCS C1713 04.034.652S - NAIL INTRAMEDULLARY 12MM 360MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.655S SUP HCPCS C1713 04.034.655S - NAIL INTRAMEDULLARY 12MM 375MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.658S SUP HCPCS C1713 04.034.658S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 390MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.661S SUP HCPCS C1713 04.034.661S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 405MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.664S SUP HCPCS C1713 04.034.664S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 420MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.667S SUP HCPCS C1713 04.034.667S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 435MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.731S SUP HCPCS C1713 04.034.731S - NAIL INTRAMEDULLARY 13MM 255MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.734S SUP HCPCS C1713 04.034.734S - NAIL INTRAMEDULLARY 13MM 270MM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.737S SUP HCPCS C1713 04.034.737S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 285MM CANN PROXIMAL BEND BOTH IP/OP "$2,917.48 " "$2,158.94" $0.00 "$2,266.00" "$1,274.63" "$1,274.63" $0.00 $0.00 $0.00 $608.07 "$2,165.35" "$2,165.35" $0.00 $0.00 $608.00 $0.00 "$1,438.32" "$1,438.32" $0.00 "$1,416.25" "$2,243.34" "$2,266.00" $0.00 $0.00 $430.38 $0.00 $0.00 $450.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.740S SUP HCPCS C1713 04.034.740S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 300MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.743S SUP HCPCS C1713 04.034.743S - NAIL INTRAMEDULLARY 13MM 31.5CM CANN PROXIMAL BEND TITANIUM BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.746S SUP HCPCS C1713 04.034.746S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 330MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.749S SUP HCPCS C1713 04.034.749S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 345MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.752S SUP HCPCS C1713 04.034.752S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 360MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.755S SUP HCPCS C1713 04.034.755S - NAIL INTRAMEDULLARY UNIVERSAL ROUND BARREL 13MM 37.5CM CANN BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.758S SUP HCPCS C1713 04.034.758S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 390MM CANN PROXIMAL BEND BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.761S SUP HCPCS C1713 04.034.761S - NAIL INTRAMEDULLARY 13MM 40.5CM CANN PROXIMAL BEND NAIL-EX BOTH IP/OP "$2,831.40 " "$2,095.24" $0.00 "$2,199.16" "$1,237.03" "$1,237.03" $0.00 $0.00 $0.00 $590.13 "$2,101.47" "$2,101.47" $0.00 $0.00 $590.06 $0.00 "$1,395.88" "$1,395.88" $0.00 "$1,374.48" "$2,177.17" "$2,199.16" $0.00 $0.00 $417.68 $0.00 $0.00 $437.63 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.764S SUP HCPCS C1713 04.034.764S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 420MM CANN PROXIMAL BEND BOTH IP/OP "$2,927.68 " "$2,166.48" $0.00 "$2,273.94" "$1,279.09" "$1,279.09" $0.00 $0.00 $0.00 $610.20 "$2,172.92" "$2,172.92" $0.00 $0.00 $610.13 $0.00 "$1,443.34" "$1,443.34" $0.00 "$1,421.21" "$2,251.20" "$2,273.94" $0.00 $0.00 $431.88 $0.00 $0.00 $452.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.034.767S SUP HCPCS C1713 04.034.767S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 435MM CANN PROXIMAL BEND BOTH IP/OP "$3,016.68 " "$2,232.34" $0.00 "$2,343.04" "$1,317.96" "$1,317.96" $0.00 $0.00 $0.00 $628.75 "$2,238.98" "$2,238.98" $0.00 $0.00 $628.68 $0.00 "$1,487.22" "$1,487.22" $0.00 "$1,464.40" "$2,319.61" "$2,343.04" $0.00 $0.00 $445.01 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.037.142S SUP HCPCS C1713 04.037.142S - NAIL IM 130D SHRT 11MM 170MM GRN STRL TFN-ADV CNN BOTH IP/OP "$3,133.30 " "$2,318.64" $0.00 "$2,433.62" "$1,368.91" "$1,368.91" $0.00 $0.00 $0.00 $653.06 "$2,325.54" "$2,325.54" $0.00 $0.00 $652.98 $0.00 "$1,544.72" "$1,544.72" $0.00 "$1,521.01" "$2,409.29" "$2,433.62" $0.00 $0.00 $462.21 $0.00 $0.00 $484.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.037.165S SUP HCPCS C1713 04.037.165S - NAIL IM 130D LNG 11MM 440MM GRN STRL TFN-ADV CNN PREASSEMBLE BOTH IP/OP "$4,391.38 " "$3,249.62" $0.00 "$3,410.78" "$1,918.56" "$1,918.56" $0.00 $0.00 $0.00 $915.27 "$3,259.28" "$3,259.28" $0.00 $0.00 $915.16 $0.00 "$2,164.95" "$2,164.95" $0.00 "$2,131.74" "$3,376.68" "$3,410.78" $0.00 $0.00 $647.80 $0.00 $0.00 $678.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.037.167S SUP HCPCS C1713 04.037.167S - NAIL IM 130D LNG 11MM 460MM GRN STRL TFN-ADV LAT RLF CUT CNN BOTH IP/OP "$4,391.38 " "$3,249.62" $0.00 "$3,410.78" "$1,918.56" "$1,918.56" $0.00 $0.00 $0.00 $915.27 "$3,259.28" "$3,259.28" $0.00 $0.00 $915.16 $0.00 "$2,164.95" "$2,164.95" $0.00 "$2,131.74" "$3,376.68" "$3,410.78" $0.00 $0.00 $647.80 $0.00 $0.00 $678.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.037.242S SUP HCPCS C1713 04.037.242S - NAIL IM 130D SHRT 12MM 170MM GRN STRL TFN-ADV CNN BOTH IP/OP "$3,133.30 " "$2,318.64" $0.00 "$2,433.62" "$1,368.91" "$1,368.91" $0.00 $0.00 $0.00 $653.06 "$2,325.54" "$2,325.54" $0.00 $0.00 $652.98 $0.00 "$1,544.72" "$1,544.72" $0.00 "$1,521.01" "$2,409.29" "$2,433.62" $0.00 $0.00 $462.21 $0.00 $0.00 $484.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.037.257S SUP HCPCS C1713 04.037.257S - NAIL IM 130D LNG 12MM 360MM GRN STRL TFN-ADV LAT RLF CUT CNN BOTH IP/OP "$4,391.38 " "$3,249.62" $0.00 "$3,410.78" "$1,918.56" "$1,918.56" $0.00 $0.00 $0.00 $915.27 "$3,259.28" "$3,259.28" $0.00 $0.00 $915.16 $0.00 "$2,164.95" "$2,164.95" $0.00 "$2,131.74" "$3,376.68" "$3,410.78" $0.00 $0.00 $647.80 $0.00 $0.00 $678.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.037.259S SUP HCPCS C1713 04.037.259S - NAIL IM 130D LNG 12MM 380MM GRN STRL TFN-ADV LAT RLF CUT CNN BOTH IP/OP "$4,391.38 " "$3,249.62" $0.00 "$3,410.78" "$1,918.56" "$1,918.56" $0.00 $0.00 $0.00 $915.27 "$3,259.28" "$3,259.28" $0.00 $0.00 $915.16 $0.00 "$2,164.95" "$2,164.95" $0.00 "$2,131.74" "$3,376.68" "$3,410.78" $0.00 $0.00 $647.80 $0.00 $0.00 $678.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.037.261S SUP HCPCS C1713 04.037.261S - NAIL IM 130D LNG 12MM 400MM GRN STRL TFN-ADV LAT RLF CUT CNN BOTH IP/OP "$4,391.38 " "$3,249.62" $0.00 "$3,410.78" "$1,918.56" "$1,918.56" $0.00 $0.00 $0.00 $915.27 "$3,259.28" "$3,259.28" $0.00 $0.00 $915.16 $0.00 "$2,164.95" "$2,164.95" $0.00 "$2,131.74" "$3,376.68" "$3,410.78" $0.00 $0.00 $647.80 $0.00 $0.00 $678.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.037.262S SUP HCPCS C1713 04.037.262S - NAIL IM 130D LNG 12MM 420MM GRN STRL TFN-ADV LAT RLF CUT CNN BOTH IP/OP "$4,391.38 " "$3,249.62" $0.00 "$3,410.78" "$1,918.56" "$1,918.56" $0.00 $0.00 $0.00 $915.27 "$3,259.28" "$3,259.28" $0.00 $0.00 $915.16 $0.00 "$2,164.95" "$2,164.95" $0.00 "$2,131.74" "$3,376.68" "$3,410.78" $0.00 $0.00 $647.80 $0.00 $0.00 $678.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.038.105S SUP HCPCS C1713 04.038.105S - SCREW BN 10.35MM 105MM AU STRL LF TFN-ADV CNN TI BOTH IP/OP "$1,426.78 " "$1,055.82" $0.00 "$1,108.18" $623.35 $623.35 $0.00 $0.00 $0.00 $297.38 "$1,058.95" "$1,058.95" $0.00 $0.00 $297.34 $0.00 $843.94 $843.94 $0.00 $692.61 "$1,097.10" "$1,108.18" $0.00 $0.00 $210.47 $0.00 $0.00 $220.53 $0.00 $0.00 $0.00 $0.00 $0.00 04.038.285S SUP Custom 27203010 04.038.285S - BLADE IM NL HLCL 10.35MM 85MM AU STRL TFN-ADV CNN TI-6AL-7NB BOTH IP/OP "$1,497.08 " "$1,107.84" $0.00 "$1,162.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,111.13" "$1,111.13" $0.00 $0.00 $311.99 $0.00 $0.00 $0.00 $0.00 $726.73 "$1,151.13" "$1,162.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.038.290S SUP Custom 27203010 04.038.290S - BLADE IM NL HLCL 90MM STRL TFN-ADV CNN TI FEM PROX BOTH IP/OP "$1,497.08 " "$1,107.84" $0.00 "$1,162.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,111.13" "$1,111.13" $0.00 $0.00 $311.99 $0.00 $0.00 $0.00 $0.00 $726.73 "$1,151.13" "$1,162.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.038.295S SUP Custom 27203010 04.038.295S - BLADE IM NL HLCL 10.35MM 95MM AU STRL TFN-ADV CNN TI-6AL-7NB BOTH IP/OP "$1,497.08 " "$1,107.84" $0.00 "$1,162.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,111.13" "$1,111.13" $0.00 $0.00 $311.99 $0.00 $0.00 $0.00 $0.00 $726.73 "$1,151.13" "$1,162.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.038.305S SUP Custom 27203010 04.038.305S - BLADE IM NL HLCL 10.35MM 105MM AU STRL TFN-ADV CNN TI-6AL-7 BOTH IP/OP "$1,497.08 " "$1,107.84" $0.00 "$1,162.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,111.13" "$1,111.13" $0.00 $0.00 $311.99 $0.00 $0.00 $0.00 $0.00 $726.73 "$1,151.13" "$1,162.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.100.020 SUP HCPCS C1713 04.100.020 - PLATE BONE LOCK TITANIUM FT NONSTRL 2.4-2.7 MM SCREWS BOTH IP/OP "$1,464.73 " "$1,083.90" $0.00 "$1,137.66" $639.93 $639.93 $0.00 $0.00 $0.00 $305.29 "$1,087.12" "$1,087.12" $0.00 $0.00 $305.25 $0.00 $866.38 $866.38 $0.00 $711.04 "$1,126.29" "$1,137.66" $0.00 $0.00 $216.07 $0.00 $0.00 $226.39 $0.00 $0.00 $0.00 $0.00 $0.00 04.100.021 SUP HCPCS C1713 04.100.021 - PLATE BONE LOCK TITANIUM LEFT CUBOID FT NONSTRL 2.4-2.7 MM BOTH IP/OP "$1,425.38 " "$1,054.78" $0.00 "$1,107.08" $622.73 $622.73 $0.00 $0.00 $0.00 $297.08 "$1,057.91" "$1,057.91" $0.00 $0.00 $297.05 $0.00 $843.11 $843.11 $0.00 $691.93 "$1,096.01" "$1,107.08" $0.00 $0.00 $210.27 $0.00 $0.00 $220.31 $0.00 $0.00 $0.00 $0.00 $0.00 04.100.022 SUP HCPCS C1713 04.100.022 - PLATE BONE LOCK TITANIUM RIGHT CUBOID FT NONSTRL 2.4-2.7 MM BOTH IP/OP "$1,425.38 " "$1,054.78" $0.00 "$1,107.08" $622.73 $622.73 $0.00 $0.00 $0.00 $297.08 "$1,057.91" "$1,057.91" $0.00 $0.00 $297.05 $0.00 $843.11 $843.11 $0.00 $691.93 "$1,096.01" "$1,107.08" $0.00 $0.00 $210.27 $0.00 $0.00 $220.31 $0.00 $0.00 $0.00 $0.00 $0.00 04.100.023 SUP HCPCS C1713 04.100.023 - PLATE BONE LOCK TITANIUM TALUS FT NONSTRL 2.4-2.7 MM SCREW BOTH IP/OP "$1,408.50 " "$1,042.29" $0.00 "$1,093.98" $615.36 $615.36 $0.00 $0.00 $0.00 $293.57 "$1,045.39" "$1,045.39" $0.00 $0.00 $293.53 $0.00 $833.13 $833.13 $0.00 $683.74 "$1,083.04" "$1,093.98" $0.00 $0.00 $207.78 $0.00 $0.00 $217.70 $0.00 $0.00 $0.00 $0.00 $0.00 04.100.032S SUP HCPCS C1713 04.100.032S - PLATE 100MM TI 6 HOLE LCP BONE ANT ANKL FT STRL BOTH IP/OP "$2,315.60 " "$1,713.54" $0.00 "$1,852.48" "$1,042.02" "$1,042.02" $0.00 $0.00 $0.00 $482.63 "$1,718.64" "$1,718.64" $0.00 $0.00 $482.57 $0.00 "$1,369.68" "$1,369.68" $0.00 "$1,157.80" "$1,833.96" "$1,852.48" $0.00 $0.00 $362.39 $0.00 $0.00 $368.64 $0.00 $0.00 $0.00 $0.00 $0.00 04.100.033S SUP HCPCS C1713 04.100.033S - PLATE 116MM TI 7 HOLE LCP BONE ANT ANKL FT STRL BOTH IP/OP "$2,380.43 " "$1,761.52" $0.00 "$1,904.34" "$1,071.19" "$1,071.19" $0.00 $0.00 $0.00 $496.14 "$1,766.75" "$1,766.75" $0.00 $0.00 $496.08 $0.00 "$1,408.02" "$1,408.02" $0.00 "$1,190.21" "$1,885.30" "$1,904.34" $0.00 $0.00 $372.54 $0.00 $0.00 $378.96 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.004S SUP HCPCS C1713 04.104.004S - PLATE BONE 122MM 4 HOLE LCP TITANIUM EXTART RIGHT HUMERUS BOTH IP/OP "$2,384.05 " "$1,764.20" $0.00 "$1,851.70" "$1,041.58" "$1,041.58" $0.00 $0.00 $0.00 $496.90 "$1,769.44" "$1,769.44" $0.00 $0.00 $496.84 $0.00 "$1,410.17" "$1,410.17" $0.00 "$1,157.31" "$1,833.19" "$1,851.70" $0.00 $0.00 $351.69 $0.00 $0.00 $368.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.006S SUP HCPCS C1713 04.104.006S - PLATE BONE 158MM 6 HOLE LCP TITANIUM EXTART RIGHT HUMERUS BOTH IP/OP "$2,714.40 " "$2,008.66" $0.00 "$2,108.26" "$1,185.90" "$1,185.90" $0.00 $0.00 $0.00 $565.75 "$2,014.63" "$2,014.63" $0.00 $0.00 $565.68 $0.00 "$1,338.20" "$1,338.20" $0.00 "$1,317.66" "$2,087.18" "$2,108.26" $0.00 $0.00 $400.42 $0.00 $0.00 $419.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.008S SUP HCPCS C1713 04.104.008S - PLATE BN 194MM STRL LCP CMBN 8 HL PRECONTOUR LMT CNTCT TI BOTH IP/OP "$2,874.65 " "$2,127.24" $0.00 "$2,232.74" "$1,255.92" "$1,255.92" $0.00 $0.00 $0.00 $599.15 "$2,133.57" "$2,133.57" $0.00 $0.00 $599.08 $0.00 "$1,417.20" "$1,417.20" $0.00 "$1,395.46" "$2,210.42" "$2,232.74" $0.00 $0.00 $424.06 $0.00 $0.00 $444.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.010S SUP HCPCS C1713 04.104.010S - PLATE BONE 230MM 10 HOLE LCP TITANIUM EXTART RIGHT HUMERUS BOTH IP/OP "$3,037.70 " "$2,247.90" $0.00 "$2,359.38" "$1,327.15" "$1,327.15" $0.00 $0.00 $0.00 $633.13 "$2,254.58" "$2,254.58" $0.00 $0.00 $633.06 $0.00 "$1,497.59" "$1,497.59" $0.00 "$1,474.61" "$2,335.79" "$2,359.38" $0.00 $0.00 $448.11 $0.00 $0.00 $469.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.012S SUP HCPCS C1713 04.104.012S - PLATE BONE 266MM 12 HOLE LCP TITANIUM EXTART RIGHT HUMERUS BOTH IP/OP "$3,458.00 " "$2,558.92" $0.00 "$2,685.82" "$1,510.77" "$1,510.77" $0.00 $0.00 $0.00 $720.73 "$2,566.53" "$2,566.53" $0.00 $0.00 $720.65 $0.00 "$1,704.79" "$1,704.79" $0.00 "$1,678.64" "$2,658.97" "$2,685.82" $0.00 $0.00 $510.11 $0.00 $0.00 $534.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.014S SUP HCPCS C1713 04.104.014S - PLATE BONE 302MM 14 HOLE LCP TITANIUM EXTART RIGHT HUMERUS BOTH IP/OP "$3,796.78 " "$2,809.62" $0.00 "$2,948.96" "$1,658.79" "$1,658.79" $0.00 $0.00 $0.00 $791.34 "$2,817.97" "$2,817.97" $0.00 $0.00 $791.25 $0.00 "$1,871.81" "$1,871.81" $0.00 "$1,843.10" "$2,919.47" "$2,948.96" $0.00 $0.00 $560.09 $0.00 $0.00 $586.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.024S SUP HCPCS C1713 04.104.024S - PLATE BONE 122MM 4 HOLE LCP TITANIUM LEFT DISTAL EXTART BOTH IP/OP "$2,384.05 " "$1,764.20" $0.00 "$1,851.70" "$1,041.58" "$1,041.58" $0.00 $0.00 $0.00 $496.90 "$1,769.44" "$1,769.44" $0.00 $0.00 $496.84 $0.00 "$1,410.17" "$1,410.17" $0.00 "$1,157.31" "$1,833.19" "$1,851.70" $0.00 $0.00 $351.69 $0.00 $0.00 $368.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.026S SUP HCPCS C1713 04.104.026S - PLATE BONE 158MM 6 HOLE LCP TITANIUM LEFT DISTAL EXTART BOTH IP/OP "$2,714.40 " "$2,008.66" $0.00 "$2,108.26" "$1,185.90" "$1,185.90" $0.00 $0.00 $0.00 $565.75 "$2,014.63" "$2,014.63" $0.00 $0.00 $565.68 $0.00 "$1,338.20" "$1,338.20" $0.00 "$1,317.66" "$2,087.18" "$2,108.26" $0.00 $0.00 $400.42 $0.00 $0.00 $419.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.028S SUP HCPCS C1713 04.104.028S - PLATE BONE 194MM 8 HOLE LCP TITANIUM LEFT DISTAL EXTART BOTH IP/OP "$2,874.65 " "$2,127.24" $0.00 "$2,232.74" "$1,255.92" "$1,255.92" $0.00 $0.00 $0.00 $599.15 "$2,133.57" "$2,133.57" $0.00 $0.00 $599.08 $0.00 "$1,417.20" "$1,417.20" $0.00 "$1,395.46" "$2,210.42" "$2,232.74" $0.00 $0.00 $424.06 $0.00 $0.00 $444.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.030S SUP HCPCS C1713 04.104.030S - PLATE BONE 230MM 10 HOLE LCP TITANIUM LEFT DISTAL EXTART BOTH IP/OP "$3,037.70 " "$2,247.90" $0.00 "$2,359.38" "$1,327.15" "$1,327.15" $0.00 $0.00 $0.00 $633.13 "$2,254.58" "$2,254.58" $0.00 $0.00 $633.06 $0.00 "$1,497.59" "$1,497.59" $0.00 "$1,474.61" "$2,335.79" "$2,359.38" $0.00 $0.00 $448.11 $0.00 $0.00 $469.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.032S SUP HCPCS C1713 04.104.032S - PLATE BONE 266MM 12 HOLE LCP TITANIUM LEFT DISTAL EXTART BOTH IP/OP "$3,458.00 " "$2,558.92" $0.00 "$2,685.82" "$1,510.77" "$1,510.77" $0.00 $0.00 $0.00 $720.73 "$2,566.53" "$2,566.53" $0.00 $0.00 $720.65 $0.00 "$1,704.79" "$1,704.79" $0.00 "$1,678.64" "$2,658.97" "$2,685.82" $0.00 $0.00 $510.11 $0.00 $0.00 $534.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.104.034S SUP HCPCS C1713 04.104.034S - PLATE BONE 302MM 14 HOLE LCP TITANIUM LEFT DISTAL EXTART BOTH IP/OP "$3,796.78 " "$2,809.62" $0.00 "$2,948.96" "$1,658.79" "$1,658.79" $0.00 $0.00 $0.00 $791.34 "$2,817.97" "$2,817.97" $0.00 $0.00 $791.25 $0.00 "$1,871.81" "$1,871.81" $0.00 "$1,843.10" "$2,919.47" "$2,948.96" $0.00 $0.00 $560.09 $0.00 $0.00 $586.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.005 SUP HCPCS C1713 04.110.005 - PLATE BONE 5 HOLE LCP TITANIUM RIGHT DISTAL DIAPHYSEAL BOTH IP/OP "$2,921.03 " "$2,161.56" $0.00 "$2,268.76" "$1,276.18" "$1,276.18" $0.00 $0.00 $0.00 $608.81 "$2,167.98" "$2,167.98" $0.00 $0.00 $608.74 $0.00 "$1,440.07" "$1,440.07" $0.00 "$1,417.98" "$2,246.07" "$2,268.76" $0.00 $0.00 $430.90 $0.00 $0.00 $451.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.007 SUP HCPCS C1713 04.110.007 - PLATE BONE 7 HOLE LCP TITANIUM RIGHT DISTAL DIAPHYSEAL BOTH IP/OP "$2,992.73 " "$2,214.62" $0.00 "$2,324.44" "$1,307.50" "$1,307.50" $0.00 $0.00 $0.00 $623.76 "$2,221.20" "$2,221.20" $0.00 $0.00 $623.68 $0.00 "$1,475.41" "$1,475.41" $0.00 "$1,452.78" "$2,301.20" "$2,324.44" $0.00 $0.00 $441.47 $0.00 $0.00 $462.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.009 SUP HCPCS C1713 04.110.009 - PLATE BONE 9 HOLE LCP TITANIUM RIGHT DISTAL DIAPHYSEAL BOTH IP/OP "$3,063.00 " "$2,266.62" $0.00 "$2,379.04" "$1,338.21" "$1,338.21" $0.00 $0.00 $0.00 $638.41 "$2,273.36" "$2,273.36" $0.00 $0.00 $638.33 $0.00 "$1,510.06" "$1,510.06" $0.00 "$1,486.90" "$2,355.25" "$2,379.04" $0.00 $0.00 $451.84 $0.00 $0.00 $473.43 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.011 SUP HCPCS C1713 04.110.011 - PLATE BONE 11 HOLE LCP TITANIUM RIGHT DISTAL DIAPHYSEAL BOTH IP/OP "$3,251.38 " "$2,406.02" $0.00 "$2,525.34" "$1,420.50" "$1,420.50" $0.00 $0.00 $0.00 $677.67 "$2,413.17" "$2,413.17" $0.00 $0.00 $677.59 $0.00 "$1,602.93" "$1,602.93" $0.00 "$1,578.34" "$2,500.09" "$2,525.34" $0.00 $0.00 $479.63 $0.00 $0.00 $502.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.013S SUP HCPCS C1713 04.110.013S - PLATE BONE 13 HOLE LCP TITANIUM RIGHT DISTAL DIAPHYSEAL BOTH IP/OP "$3,497.38 " "$2,588.06" $0.00 "$2,716.40" "$1,527.98" "$1,527.98" $0.00 $0.00 $0.00 $728.94 "$2,595.75" "$2,595.75" $0.00 $0.00 $728.85 $0.00 "$1,724.21" "$1,724.21" $0.00 "$1,697.75" "$2,689.24" "$2,716.40" $0.00 $0.00 $515.92 $0.00 $0.00 $540.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.015S SUP HCPCS C1713 04.110.015S - PLATE BONE 15 HOLE LCP TITANIUM RIGHT DISTAL DIAPHYSEAL BOTH IP/OP "$3,611.23 " "$2,672.31" $0.00 "$2,804.84" "$1,577.72" "$1,577.72" $0.00 $0.00 $0.00 $752.67 "$2,680.25" "$2,680.25" $0.00 $0.00 $752.58 $0.00 "$1,780.33" "$1,780.33" $0.00 "$1,753.03" "$2,776.79" "$2,804.84" $0.00 $0.00 $532.71 $0.00 $0.00 $558.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.105 SUP HCPCS C1713 04.110.105 - PLATE BONE 5 HOLE LCP TITANIUM LEFT DISTAL RADIAL NONSTRL BOTH IP/OP "$2,921.03 " "$2,161.56" $0.00 "$2,268.76" "$1,276.18" "$1,276.18" $0.00 $0.00 $0.00 $608.81 "$2,167.98" "$2,167.98" $0.00 $0.00 $608.74 $0.00 "$1,440.07" "$1,440.07" $0.00 "$1,417.98" "$2,246.07" "$2,268.76" $0.00 $0.00 $430.90 $0.00 $0.00 $451.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.107 SUP HCPCS C1713 04.110.107 - PLATE BONE 7 HOLE LCP TITANIUM LEFT DISTAL DIAPHYSEAL BOTH IP/OP "$2,992.73 " "$2,214.62" $0.00 "$2,324.44" "$1,307.50" "$1,307.50" $0.00 $0.00 $0.00 $623.76 "$2,221.20" "$2,221.20" $0.00 $0.00 $623.68 $0.00 "$1,475.41" "$1,475.41" $0.00 "$1,452.78" "$2,301.20" "$2,324.44" $0.00 $0.00 $441.47 $0.00 $0.00 $462.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.109 SUP HCPCS C1713 04.110.109 - PLATE BONE 9 HOLE LCP TITANIUM LEFT DISTAL DIAPHYSEAL BOTH IP/OP "$3,063.00 " "$2,266.62" $0.00 "$2,379.04" "$1,338.21" "$1,338.21" $0.00 $0.00 $0.00 $638.41 "$2,273.36" "$2,273.36" $0.00 $0.00 $638.33 $0.00 "$1,510.06" "$1,510.06" $0.00 "$1,486.90" "$2,355.25" "$2,379.04" $0.00 $0.00 $451.84 $0.00 $0.00 $473.43 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.111 SUP HCPCS C1713 04.110.111 - PLATE BONE 11 HOLE LCP TITANIUM LEFT DISTAL DIAPHYSEAL BOTH IP/OP "$3,251.38 " "$2,406.02" $0.00 "$2,525.34" "$1,420.50" "$1,420.50" $0.00 $0.00 $0.00 $677.67 "$2,413.17" "$2,413.17" $0.00 $0.00 $677.59 $0.00 "$1,602.93" "$1,602.93" $0.00 "$1,578.34" "$2,500.09" "$2,525.34" $0.00 $0.00 $479.63 $0.00 $0.00 $502.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.113S SUP HCPCS C1713 04.110.113S - PLATE BONE 13 HOLE LCP TITANIUM LEFT DISTAL DIAPHYSEAL BOTH IP/OP "$3,497.38 " "$2,588.06" $0.00 "$2,716.40" "$1,527.98" "$1,527.98" $0.00 $0.00 $0.00 $728.94 "$2,595.75" "$2,595.75" $0.00 $0.00 $728.85 $0.00 "$1,724.21" "$1,724.21" $0.00 "$1,697.75" "$2,689.24" "$2,716.40" $0.00 $0.00 $515.92 $0.00 $0.00 $540.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.115S SUP HCPCS C1713 04.110.115S - PLATE BONE 15 HOLE LCP TITANIUM LEFT DISTAL DIAPHYSEAL BOTH IP/OP "$3,611.23 " "$2,672.31" $0.00 "$2,804.84" "$1,577.72" "$1,577.72" $0.00 $0.00 $0.00 $752.67 "$2,680.25" "$2,680.25" $0.00 $0.00 $752.58 $0.00 "$1,780.33" "$1,780.33" $0.00 "$1,753.03" "$2,776.79" "$2,804.84" $0.00 $0.00 $532.71 $0.00 $0.00 $558.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.150 SUP HCPCS C1713 04.110.150 - PLATE BONE STANDARD BEND 118MM FUSION LCP TITANIUM WRIST BOTH IP/OP "$3,145.95 " "$2,328.00" $0.00 "$2,443.44" "$1,374.44" "$1,374.44" $0.00 $0.00 $0.00 $655.69 "$2,334.92" "$2,334.92" $0.00 $0.00 $655.62 $0.00 "$1,550.95" "$1,550.95" $0.00 "$1,527.15" "$2,419.01" "$2,443.44" $0.00 $0.00 $464.08 $0.00 $0.00 $486.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.151 SUP HCPCS C1713 04.110.151 - PLATE BN SHRT BND 118MM NS LCP FSN TI WRST BOTH IP/OP "$3,145.95 " "$2,328.00" $0.00 "$2,443.44" "$1,374.44" "$1,374.44" $0.00 $0.00 $0.00 $655.69 "$2,334.92" "$2,334.92" $0.00 $0.00 $655.62 $0.00 "$1,550.95" "$1,550.95" $0.00 "$1,527.15" "$2,419.01" "$2,443.44" $0.00 $0.00 $464.08 $0.00 $0.00 $486.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.152 SUP HCPCS C1713 04.110.152 - PLATE BONE 112MM STR FUSION LCP TITANIUM WRIST NONSTRL BOTH IP/OP "$3,145.95 " "$2,328.00" $0.00 "$2,443.44" "$1,374.44" "$1,374.44" $0.00 $0.00 $0.00 $655.69 "$2,334.92" "$2,334.92" $0.00 $0.00 $655.62 $0.00 "$1,550.95" "$1,550.95" $0.00 "$1,527.15" "$2,419.01" "$2,443.44" $0.00 $0.00 $464.08 $0.00 $0.00 $486.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.201 SUP HCPCS C1713 04.110.201 - PLATE BONE 5X3 HOLE VAR ANG LCP TITANIUM RIGHT VOLAR DISTAL BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.202 SUP HCPCS C1713 04.110.202 - PLATE BONE 5X5 HOLE VAR ANG LCP TITANIUM RIGHT VOLAR DISTAL BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.203 SUP HCPCS C1713 04.110.203 - PLATE BONE 4X3 HOLE VAR ANG LCP TITANIUM LEFT VOLAR DISTAL BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.204 SUP HCPCS C1713 04.110.204 - PLATE BONE 5X5 HOLE VAR ANG LCP TITANIUM LEFT VOLAR DISTAL BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.205 SUP HCPCS C1713 04.110.205 - PLATE BONE 4X3 HOLE VAR ANG LCP TITANIUM RIGHT VOLAR DISTAL BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.206 SUP HCPCS C1713 04.110.206 - PLATE BONE 4X5 HOLE VAR ANG LCP TITANIUM RIGHT VOLAR DISTAL BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.207 SUP HCPCS C1713 04.110.207 - PLATE BONE 4X3 HOLE VAR ANG LCP TITANIUM LEFT VOLAR DISTAL BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.208 SUP HCPCS C1713 04.110.208 - PLATE BONE 4X5 HOLE VAR ANG LCP TITANIUM LEFT VOLAR DISTAL BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.300 SUP Custom 27203010 04.110.300 - WIRE FIX 1.8MM 150MM TROCAR POINT DEPTH MARKING KWIRE BOTH IP/OP $20.10 $14.87 $0.00 $15.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.92 $14.92 $0.00 $0.00 $4.19 $0.00 $0.00 $0.00 $0.00 $9.76 $15.46 $15.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.330 SUP HCPCS C1713 04.110.330 - PLATE BONE 50.5MM 9X3 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,524.43 " "$1,128.08" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $317.73 "$1,131.43" "$1,131.43" $0.00 $0.00 $317.69 $0.00 $901.70 $901.70 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.331 SUP HCPCS C1713 04.110.331 - PLATE BONE 50.5MM 9X3 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,524.43 " "$1,128.08" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $317.73 "$1,131.43" "$1,131.43" $0.00 $0.00 $317.69 $0.00 $901.70 $901.70 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.340 SUP HCPCS C1713 04.110.340 - PLATE BONE 59.5MM 9X4 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,572.20 " "$1,163.43" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $327.69 "$1,166.89" "$1,166.89" $0.00 $0.00 $327.65 $0.00 $929.96 $929.96 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.341 SUP HCPCS C1713 04.110.341 - PLATE BONE 59.5MM 9X4 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,572.20 " "$1,163.43" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $327.69 "$1,166.89" "$1,166.89" $0.00 $0.00 $327.65 $0.00 $929.96 $929.96 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.350 SUP HCPCS C1713 04.110.350 - PLATE BONE 68.5MM 9X5 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,618.60 " "$1,197.76" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $337.36 "$1,201.32" "$1,201.32" $0.00 $0.00 $337.32 $0.00 $957.40 $957.40 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.351 SUP HCPCS C1713 04.110.351 - PLATE BONE 68.5MM 9X5 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,618.60 " "$1,197.76" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $337.36 "$1,201.32" "$1,201.32" $0.00 $0.00 $337.32 $0.00 $957.40 $957.40 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.430 SUP HCPCS C1713 04.110.430 - PLATE BONE 50.5MM 8X3 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,524.43 " "$1,128.08" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $317.73 "$1,131.43" "$1,131.43" $0.00 $0.00 $317.69 $0.00 $901.70 $901.70 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.431 SUP HCPCS C1713 04.110.431 - PLATE BN 50.5MM NS LCP CMBN 8 HLE/HD 3 HL SHFT CLMN RND EDG BOTH IP/OP "$1,524.43 " "$1,128.08" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $317.73 "$1,131.43" "$1,131.43" $0.00 $0.00 $317.69 $0.00 $901.70 $901.70 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.440 SUP HCPCS C1713 04.110.440 - PLATE BONE 59.5MM 8X4 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,572.20 " "$1,163.43" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $327.69 "$1,166.89" "$1,166.89" $0.00 $0.00 $327.65 $0.00 $929.96 $929.96 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.441 SUP HCPCS C1713 04.110.441 - PLATE BONE 59.5MM 8X4 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,572.20 " "$1,163.43" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $327.69 "$1,166.89" "$1,166.89" $0.00 $0.00 $327.65 $0.00 $929.96 $929.96 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.450 SUP HCPCS C1713 04.110.450 - PLATE BONE 68.5MM 8X5 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,618.60 " "$1,197.76" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $337.36 "$1,201.32" "$1,201.32" $0.00 $0.00 $337.32 $0.00 $957.40 $957.40 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.451 SUP HCPCS C1713 04.110.451 - PLATE BONE 68.5MM 8X5 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,618.60 " "$1,197.76" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $337.36 "$1,201.32" "$1,201.32" $0.00 $0.00 $337.32 $0.00 $957.40 $957.40 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.730 SUP HCPCS C1713 04.110.730 - PLATE BONE 45MM 6X3 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,524.43 " "$1,128.08" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $317.73 "$1,131.43" "$1,131.43" $0.00 $0.00 $317.69 $0.00 $901.70 $901.70 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.731 SUP HCPCS C1713 04.110.731 - PLATE BONE 45MM 6X3 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,524.43 " "$1,128.08" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $317.73 "$1,131.43" "$1,131.43" $0.00 $0.00 $317.69 $0.00 $901.70 $901.70 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.740 SUP HCPCS C1713 04.110.740 - PLATE BONE 54MM 6X4 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,572.20 " "$1,163.43" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $327.69 "$1,166.89" "$1,166.89" $0.00 $0.00 $327.65 $0.00 $929.96 $929.96 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.741 SUP HCPCS C1713 04.110.741 - PLATE BONE 54MM 6X4 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,572.20 " "$1,163.43" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $327.69 "$1,166.89" "$1,166.89" $0.00 $0.00 $327.65 $0.00 $929.96 $929.96 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.750 SUP HCPCS C1713 04.110.750 - PLATE BONE 63MM 6X5 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,618.60 " "$1,197.76" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $337.36 "$1,201.32" "$1,201.32" $0.00 $0.00 $337.32 $0.00 $957.40 $957.40 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.751 SUP HCPCS C1713 04.110.751 - PLATE BONE 63MM 6X5 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,618.60 " "$1,197.76" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $337.36 "$1,201.32" "$1,201.32" $0.00 $0.00 $337.32 $0.00 $957.40 $957.40 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.830 SUP HCPCS C1713 04.110.830 - PLATE BONE 45MM 7X3 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,524.43 " "$1,128.08" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $317.73 "$1,131.43" "$1,131.43" $0.00 $0.00 $317.69 $0.00 $901.70 $901.70 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.831 SUP HCPCS C1713 04.110.831 - PLATE BONE 45MM 7X3 HOLE COLUMN LCP TITANIUM LEFT VOLAR BOTH IP/OP "$1,524.43 " "$1,128.08" $0.00 "$1,219.54" $685.99 $685.99 $0.00 $0.00 $0.00 $317.73 "$1,131.43" "$1,131.43" $0.00 $0.00 $317.69 $0.00 $901.70 $901.70 $0.00 $762.21 "$1,207.35" "$1,219.54" $0.00 $0.00 $231.62 $0.00 $0.00 $242.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.840 SUP HCPCS C1713 04.110.840 - PLATE BONE 54MM 7X4 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,572.20 " "$1,163.43" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $327.69 "$1,166.89" "$1,166.89" $0.00 $0.00 $327.65 $0.00 $929.96 $929.96 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.841 SUP HCPCS C1713 04.110.841 - PLATE BONE 54MM 7X4 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,572.20 " "$1,163.43" $0.00 "$1,257.76" $707.49 $707.49 $0.00 $0.00 $0.00 $327.69 "$1,166.89" "$1,166.89" $0.00 $0.00 $327.65 $0.00 $929.96 $929.96 $0.00 $786.10 "$1,245.18" "$1,257.76" $0.00 $0.00 $238.88 $0.00 $0.00 $250.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.850 SUP HCPCS C1713 04.110.850 - PLATE BONE 63MM 7X5 HOLE COLUMN LCP TITANIUM RIGHT DISTAL BOTH IP/OP "$1,618.60 " "$1,197.76" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $337.36 "$1,201.32" "$1,201.32" $0.00 $0.00 $337.32 $0.00 $957.40 $957.40 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.110.851 SUP HCPCS C1713 04.110.851 - PLATE BONE 63MM 7X5 HOLE COLUMN LCP TITANIUM LEFT DISTAL BOTH IP/OP "$1,618.60 " "$1,197.76" $0.00 "$1,294.88" $728.37 $728.37 $0.00 $0.00 $0.00 $337.36 "$1,201.32" "$1,201.32" $0.00 $0.00 $337.32 $0.00 $957.40 $957.40 $0.00 $809.30 "$1,281.93" "$1,294.88" $0.00 $0.00 $245.93 $0.00 $0.00 $257.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.520 SUP HCPCS C1713 04.111.520 - PLATE BONE NARROW 42MM 6X2 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.521 SUP HCPCS C1713 04.111.521 - PLATE BONE NARROW 42MM 6X2 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.530 SUP HCPCS C1713 04.111.530 - PLATE BONE NARROW 51MM 6X3 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.531 SUP HCPCS C1713 04.111.531 - PLATE BONE NARROW 51MM 6X3 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.540 SUP HCPCS C1713 04.111.540 - PLATE BONE NARROW 63MM 6X4 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.541 SUP HCPCS C1713 04.111.541 - PLATE BONE NARROW 63MM 6X4 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.550 SUP HCPCS C1713 04.111.550 - PLATE BONE NARROW 72MM 6X5 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.551 SUP HCPCS C1713 04.111.551 - PLATE BONE NARROW 72MM 6X5 HOLE 2 COLUMN VAR ANG LCP BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.620 SUP HCPCS C1713 04.111.620 - PLATE BN STD 45MM NS LCP CMBN 6 HLE/HD 2 HL SHFT 2 CLMN VA BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.621 SUP HCPCS C1713 04.111.621 - PLATE BN STD 45MM NS LCP CMBN 6 HLE/HD 2 HL SHFT 2 CLMN VA BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.630 SUP HCPCS C1713 04.111.630 - PLATE BN STD 54MM NS LCP CMBN 6 HLE/HD 3 HL SHFT 2 CLMN VA BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.631 SUP HCPCS C1713 04.111.631 - PLATE BONE 54MM 6X3 HOLE 2 COLUMN VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.640 SUP HCPCS C1713 04.111.640 - PLATE BONE 70MM 6X4 HOLE VAR ANG 2 COLUMN LCP TITANIUM LEFT BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.641 SUP HCPCS C1713 04.111.641 - PLATE BONE 70MM 6X4 HOLE VAR ANG 2 COLUMN LCP TITANIUM RIGHT BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.650 SUP HCPCS C1713 04.111.650 - PLATE BONE 75MM 6X5 HOLE 2 COLUMN VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.651 SUP HCPCS C1713 04.111.651 - PLATE BONE 75MM 6X5 HOLE 2 COLUMN VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.720 SUP HCPCS C1713 04.111.720 - PLATE BN STD 47MM NS LCP CMBN 7 HLE/HD 2 HL SHFT 2 CLMN VA BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.721 SUP HCPCS C1713 04.111.721 - PLATE BONE 49MM 7X2 HOLE 2 COLUMN VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,802.10 " "$1,333.55" $0.00 "$1,399.68" $787.32 $787.32 $0.00 $0.00 $0.00 $375.60 "$1,337.52" "$1,337.52" $0.00 $0.00 $375.56 $0.00 "$1,065.94" "$1,065.94" $0.00 $874.80 "$1,385.68" "$1,399.68" $0.00 $0.00 $265.84 $0.00 $0.00 $278.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.730 SUP HCPCS C1713 04.111.730 - PLATE BONE 55MM 7X3 HOLE 2 COLUMN VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.731 SUP HCPCS C1713 04.111.731 - PLATE BONE 55MM 7X3 HOLE 2 COLUMN VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,873.80 " "$1,386.61" $0.00 "$1,455.36" $818.64 $818.64 $0.00 $0.00 $0.00 $390.55 "$1,390.73" "$1,390.73" $0.00 $0.00 $390.50 $0.00 "$1,108.35" "$1,108.35" $0.00 $909.60 "$1,440.81" "$1,455.36" $0.00 $0.00 $276.41 $0.00 $0.00 $289.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.740 SUP HCPCS C1713 04.111.740 - PLATE BONE 70MM 7X4 HOLE VAR ANG 2 COLUMN LCP TITANIUM RIGHT BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.741 SUP HCPCS C1713 04.111.741 - PLATE BONE 70MM 7X4 HOLE VAR ANG 2 COLUMN LCP TITANIUM LEFT BOTH IP/OP "$1,944.08 " "$1,438.62" $0.00 "$1,509.96" $849.35 $849.35 $0.00 $0.00 $0.00 $405.19 "$1,442.89" "$1,442.89" $0.00 $0.00 $405.15 $0.00 "$1,149.92" "$1,149.92" $0.00 $943.73 "$1,494.86" "$1,509.96" $0.00 $0.00 $286.78 $0.00 $0.00 $300.48 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.750 SUP HCPCS C1713 04.111.750 - PLATE BONE 77MM 7X5 HOLE 2 COLUMN VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.111.751 SUP HCPCS C1713 04.111.751 - PLATE BONE 77MM 7X5 HOLE 2 COLUMN VARIABLE LCP TITANIUM LEFT BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.006 SUP HCPCS C1713 04.112.006 - PLATE BONE 69MM 3 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,623.58 " "$1,201.45" $0.00 "$1,261.02" $709.32 $709.32 $0.00 $0.00 $0.00 $338.39 "$1,205.02" "$1,205.02" $0.00 $0.00 $338.35 $0.00 $960.34 $960.34 $0.00 $788.14 "$1,248.41" "$1,261.02" $0.00 $0.00 $239.50 $0.00 $0.00 $250.94 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.007 SUP HCPCS C1713 04.112.007 - PLATE BONE 69MM 3 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,623.58 " "$1,201.45" $0.00 "$1,261.02" $709.32 $709.32 $0.00 $0.00 $0.00 $338.39 "$1,205.02" "$1,205.02" $0.00 $0.00 $338.35 $0.00 $960.34 $960.34 $0.00 $788.14 "$1,248.41" "$1,261.02" $0.00 $0.00 $239.50 $0.00 $0.00 $250.94 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.008 SUP HCPCS C1713 04.112.008 - PLATE BONE 108MM 6 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.009 SUP HCPCS C1713 04.112.009 - PLATE BONE 108MM 6 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.010 SUP HCPCS C1713 04.112.010 - PLATE BONE 81MM 4 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,648.88 " "$1,220.17" $0.00 "$1,280.68" $720.38 $720.38 $0.00 $0.00 $0.00 $343.67 "$1,223.80" "$1,223.80" $0.00 $0.00 $343.63 $0.00 $975.31 $975.31 $0.00 $800.43 "$1,267.87" "$1,280.68" $0.00 $0.00 $243.24 $0.00 $0.00 $254.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.011 SUP HCPCS C1713 04.112.011 - PLATE BONE 81MM 4 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,648.88 " "$1,220.17" $0.00 "$1,280.68" $720.38 $720.38 $0.00 $0.00 $0.00 $343.67 "$1,223.80" "$1,223.80" $0.00 $0.00 $343.63 $0.00 $975.31 $975.31 $0.00 $800.43 "$1,267.87" "$1,280.68" $0.00 $0.00 $243.24 $0.00 $0.00 $254.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.012 SUP HCPCS C1713 04.112.012 - PLATE BONE 94MM 5 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,677.00 " "$1,240.98" $0.00 "$1,302.52" $732.67 $732.67 $0.00 $0.00 $0.00 $349.53 "$1,244.67" "$1,244.67" $0.00 $0.00 $349.49 $0.00 $991.95 $991.95 $0.00 $814.08 "$1,289.49" "$1,302.52" $0.00 $0.00 $247.38 $0.00 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.013 SUP HCPCS C1713 04.112.013 - PLATE BONE 94MM 5 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,677.00 " "$1,240.98" $0.00 "$1,302.52" $732.67 $732.67 $0.00 $0.00 $0.00 $349.53 "$1,244.67" "$1,244.67" $0.00 $0.00 $349.49 $0.00 $991.95 $991.95 $0.00 $814.08 "$1,289.49" "$1,302.52" $0.00 $0.00 $247.38 $0.00 $0.00 $259.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.018 SUP HCPCS C1713 04.112.018 - PLATE BONE 123MM 7 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.019 SUP HCPCS C1713 04.112.019 - PLATE BONE 123MM 7 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.020 SUP HCPCS C1713 04.112.020 - PLATE BONE 135MM 8 HOLE LATERAL EXTN LCP TITANIUM RIGHT BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.021 SUP HCPCS C1713 04.112.021 - PLATE BONE 135MM 8 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.026 SUP HCPCS C1713 04.112.026 - PLATE BN 94MM NS LCP CMBN 6 HL PRECONTOUR LMT CNTCT TPR TIP BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.027 SUP HCPCS C1713 04.112.027 - PLATE BONE 94MM 6 HOLE LCP TITANIUM LEFT SUPERIOR ANTERIOR BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.028 SUP HCPCS C1713 04.112.028 - PLATE BONE 110MM 7 HOLE LCP TITANIUM RIGHT SUPERIOR ANTERIOR BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.029 SUP HCPCS C1713 04.112.029 - PLATE BONE 110MM 7 HOLE LCP TITANIUM LEFT SUPERIOR ANTERIOR BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.030 SUP HCPCS C1713 04.112.030 - PLATE BONE 120MM 8 HOLE LCP TITANIUM RIGHT SUPERIOR ANTERIOR BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.031 SUP HCPCS C1713 04.112.031 - PLATE BONE 120MM 8 HOLE LCP TITANIUM RIGHT SUPERIOR ANTERIOR BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.040S SUP HCPCS C1713 04.112.040S - PLATE BONE 79MM 6 HOLE LCP TITANIUM MEDIAL ANTERIOR CLAVICLE BOTH IP/OP "$1,876.60 " "$1,388.68" $0.00 "$1,457.56" $819.88 $819.88 $0.00 $0.00 $0.00 $391.13 "$1,392.81" "$1,392.81" $0.00 $0.00 $391.08 $0.00 "$1,110.01" "$1,110.01" $0.00 $910.98 "$1,442.98" "$1,457.56" $0.00 $0.00 $276.83 $0.00 $0.00 $290.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.041 SUP HCPCS C1713 04.112.041 - PLATE BONE 91MM 7 HOLE LCP TITANIUM MEDIAL ANTERIOR CLAVICLE BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.042 SUP HCPCS C1713 04.112.042 - PLATE BONE 102MM 8 HOLE LCP TITANIUM MEDIAL ANTERIOR BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.045 SUP HCPCS C1713 04.112.045 - PLATE BONE 77MM 7 HOLE VAR ANG LCP TITANIUM LATERAL ANTERIOR BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.046 SUP HCPCS C1713 04.112.046 - PLATE BONE 89MM 9 HOLE VAR ANG LCP TITANIUM LATERAL ANTERIOR BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.047 SUP HCPCS C1713 04.112.047 - PLATE BONE 101MM 10 HOLE VAR ANG LCP TITANIUM LATERAL BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.048S SUP HCPCS C1713 04.112.048S - PLATE BONE 113MM 11 HOLE VAR ANG LCP TITANIUM LATERAL BOTH IP/OP "$1,876.60 " "$1,388.68" $0.00 "$1,457.56" $819.88 $819.88 $0.00 $0.00 $0.00 $391.13 "$1,392.81" "$1,392.81" $0.00 $0.00 $391.08 $0.00 "$1,110.01" "$1,110.01" $0.00 $910.98 "$1,442.98" "$1,457.56" $0.00 $0.00 $276.83 $0.00 $0.00 $290.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.049S SUP HCPCS C1713 04.112.049S - PLATE BONE 124MM 12 HOLE VAR ANG LCP TITANIUM LATERAL BOTH IP/OP "$1,876.60 " "$1,388.68" $0.00 "$1,457.56" $819.88 $819.88 $0.00 $0.00 $0.00 $391.13 "$1,392.81" "$1,392.81" $0.00 $0.00 $391.08 $0.00 "$1,110.01" "$1,110.01" $0.00 $910.98 "$1,442.98" "$1,457.56" $0.00 $0.00 $276.83 $0.00 $0.00 $290.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.080 SUP HCPCS C1713 04.112.080 - PLATE BONE 85MM 6 HOLE LCP TITANIUM RIGHT SUPERIOR ANTERIOR BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.081 SUP HCPCS C1713 04.112.081 - PLATE BONE 85MM 6 HOLE LCP TITANIUM LEFT SUPERIOR ANTERIOR BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.082 SUP HCPCS C1713 04.112.082 - PLATE BONE 100MM 7 HOLE LCP TITANIUM RIGHT SUPERIOR ANTERIOR BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.083 SUP HCPCS C1713 04.112.083 - PLATE BONE 100MM 7 HOLE LCP TITANIUM LEFT SUPERIOR CLAVICLE BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.084 SUP HCPCS C1713 04.112.084 - PLATE BONE 115MM 8 HOLE LCP TITANIUM RIGHT SUPERIOR CLAVICLE BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.085 SUP HCPCS C1713 04.112.085 - PLATE BONE 115MM 8 HOLE LCP TITANIUM LEFT SUPERIOR CLAVICLE BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.090 SUP HCPCS C1713 04.112.090 - PLATE BONE 105MM 6 HOLE LATERAL EXTN LCP TITANIUM RIGHT BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.091 SUP HCPCS C1713 04.112.091 - PLATE BN 105MM NS LCP CMBN 6 HL LAT XTN PRECONTOUR LMT CNTCT BOTH IP/OP "$1,695.28 " "$1,254.51" $0.00 "$1,316.72" $740.66 $740.66 $0.00 $0.00 $0.00 $353.34 "$1,258.23" "$1,258.23" $0.00 $0.00 $353.30 $0.00 "$1,002.76" "$1,002.76" $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $250.08 $0.00 $0.00 $262.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.092 SUP HCPCS C1713 04.112.092 - PLATE BONE 120MM 7 HOLE LATERAL EXTN LCP TITANIUM RIGHT BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.093 SUP HCPCS C1713 04.112.093 - PLATE BONE 120MM 7 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,740.25 " "$1,287.79" $0.00 "$1,351.64" $760.30 $760.30 $0.00 $0.00 $0.00 $362.71 "$1,291.61" "$1,291.61" $0.00 $0.00 $362.67 $0.00 "$1,029.36" "$1,029.36" $0.00 $844.78 "$1,338.12" "$1,351.64" $0.00 $0.00 $256.71 $0.00 $0.00 $268.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.094 SUP HCPCS C1713 04.112.094 - PLATE BONE 130MM 8 HOLE LATERAL EXTN LCP TITANIUM RIGHT BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.095 SUP HCPCS C1713 04.112.095 - PLATE BONE 130MM 8 HOLE LATERAL EXTN LCP TITANIUM LEFT BOTH IP/OP "$1,785.23 " "$1,321.07" $0.00 "$1,386.58" $779.95 $779.95 $0.00 $0.00 $0.00 $372.09 "$1,324.99" "$1,324.99" $0.00 $0.00 $372.04 $0.00 "$1,055.96" "$1,055.96" $0.00 $866.61 "$1,372.72" "$1,386.58" $0.00 $0.00 $263.35 $0.00 $0.00 $275.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.106 SUP HCPCS C1713 04.112.106 - PLATE BONE 73MM 3 HOLE LCP TITANIUM RIGHT DISTAL POSTLAT BOTH IP/OP "$1,186.40 " $877.94 $0.00 $921.48 $518.33 $518.33 $0.00 $0.00 $0.00 $247.28 $880.55 $880.55 $0.00 $0.00 $247.25 $0.00 $701.76 $701.76 $0.00 $575.93 $912.27 $921.48 $0.00 $0.00 $175.01 $0.00 $0.00 $183.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.107 SUP HCPCS C1713 04.112.107 - PLATE BONE 73MM 3 HOLE LCP TITANIUM LEFT DISTAL POSTLAT BOTH IP/OP "$1,186.40 " $877.94 $0.00 $921.48 $518.33 $518.33 $0.00 $0.00 $0.00 $247.28 $880.55 $880.55 $0.00 $0.00 $247.25 $0.00 $701.76 $701.76 $0.00 $575.93 $912.27 $921.48 $0.00 $0.00 $175.01 $0.00 $0.00 $183.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.108 SUP HCPCS C1713 04.112.108 - PLATE BONE 86MM 4 HOLE LCP TITANIUM RIGHT DISTAL POSTLAT BOTH IP/OP "$1,206.08 " $892.50 $0.00 $936.76 $526.93 $526.93 $0.00 $0.00 $0.00 $251.38 $895.15 $895.15 $0.00 $0.00 $251.35 $0.00 $713.39 $713.39 $0.00 $585.48 $927.39 $936.76 $0.00 $0.00 $177.92 $0.00 $0.00 $186.42 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.109 SUP HCPCS C1713 04.112.109 - PLATE BONE 86MM 4 HOLE LCP TITANIUM LEFT DISTAL POSTLAT BOTH IP/OP "$1,206.08 " $892.50 $0.00 $936.76 $526.93 $526.93 $0.00 $0.00 $0.00 $251.38 $895.15 $895.15 $0.00 $0.00 $251.35 $0.00 $713.39 $713.39 $0.00 $585.48 $927.39 $936.76 $0.00 $0.00 $177.92 $0.00 $0.00 $186.42 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.110 SUP HCPCS C1713 04.112.110 - PLATE BONE 99MM 5 HOLE LCP TITANIUM RIGHT DISTAL POSTLAT BOTH IP/OP "$1,221.55 " $903.95 $0.00 $948.78 $533.69 $533.69 $0.00 $0.00 $0.00 $254.60 $906.63 $906.63 $0.00 $0.00 $254.57 $0.00 $722.55 $722.55 $0.00 $592.99 $939.30 $948.78 $0.00 $0.00 $180.20 $0.00 $0.00 $188.81 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.111 SUP HCPCS C1713 04.112.111 - PLATE BONE 99MM 5 HOLE LCP TITANIUM LEFT DISTAL POSTLAT BOTH IP/OP "$1,221.55 " $903.95 $0.00 $948.78 $533.69 $533.69 $0.00 $0.00 $0.00 $254.60 $906.63 $906.63 $0.00 $0.00 $254.57 $0.00 $722.55 $722.55 $0.00 $592.99 $939.30 $948.78 $0.00 $0.00 $180.20 $0.00 $0.00 $188.81 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.112 SUP HCPCS C1713 04.112.112 - PLATE BONE 112MM 6 HOLE LCP TITANIUM RIGHT DISTAL POSTLAT BOTH IP/OP "$1,241.23 " $918.51 $0.00 $964.06 $542.28 $542.28 $0.00 $0.00 $0.00 $258.70 $921.24 $921.24 $0.00 $0.00 $258.67 $0.00 $734.18 $734.18 $0.00 $602.54 $954.42 $964.06 $0.00 $0.00 $183.10 $0.00 $0.00 $191.85 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.113 SUP HCPCS C1713 04.112.113 - PLATE BONE 112MM 6 HOLE LCP TITANIUM LEFT DISTAL POSTLAT BOTH IP/OP "$1,241.23 " $918.51 $0.00 $964.06 $542.28 $542.28 $0.00 $0.00 $0.00 $258.70 $921.24 $921.24 $0.00 $0.00 $258.67 $0.00 $734.18 $734.18 $0.00 $602.54 $954.42 $964.06 $0.00 $0.00 $183.10 $0.00 $0.00 $191.85 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.114 SUP HCPCS C1713 04.112.114 - PLATE BONE 125MM 7 HOLE LCP TITANIUM RIGHT DISTAL POSTLAT BOTH IP/OP "$1,258.10 " $930.99 $0.00 $977.16 $549.65 $549.65 $0.00 $0.00 $0.00 $262.22 $933.76 $933.76 $0.00 $0.00 $262.19 $0.00 $744.17 $744.17 $0.00 $610.73 $967.39 $977.16 $0.00 $0.00 $185.59 $0.00 $0.00 $194.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.115 SUP HCPCS C1713 04.112.115 - PLATE BONE 125MM 7 HOLE LCP TITANIUM LEFT DISTAL POSTLAT BOTH IP/OP "$1,258.10 " $930.99 $0.00 $977.16 $549.65 $549.65 $0.00 $0.00 $0.00 $262.22 $933.76 $933.76 $0.00 $0.00 $262.19 $0.00 $744.17 $744.17 $0.00 $610.73 $967.39 $977.16 $0.00 $0.00 $185.59 $0.00 $0.00 $194.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.118 SUP HCPCS C1713 04.112.118 - PLATE BONE 151MM 9 HOLE LCP TITANIUM RIGHT DISTAL POSTLAT BOTH IP/OP "$1,276.38 " $944.52 $0.00 $991.36 $557.64 $557.64 $0.00 $0.00 $0.00 $266.03 $947.33 $947.33 $0.00 $0.00 $266.00 $0.00 $754.98 $754.98 $0.00 $619.60 $981.45 $991.36 $0.00 $0.00 $188.29 $0.00 $0.00 $197.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.119 SUP HCPCS C1713 04.112.119 - PLATE BONE 151MM 9 HOLE LCP TITANIUM LEFT DISTAL POSTLAT BOTH IP/OP "$1,276.38 " $944.52 $0.00 $991.36 $557.64 $557.64 $0.00 $0.00 $0.00 $266.03 $947.33 $947.33 $0.00 $0.00 $266.00 $0.00 $754.98 $754.98 $0.00 $619.60 $981.45 $991.36 $0.00 $0.00 $188.29 $0.00 $0.00 $197.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.122 SUP HCPCS C1713 04.112.122 - PLATE BONE 177MM 11 HOLE LCP TITANIUM RIGHT DISTAL POSTLAT BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.123 SUP HCPCS C1713 04.112.123 - PLATE BONE 177MM 11 HOLE LCP TITANIUM LEFT DISTAL POSTLAT BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.126 SUP HCPCS C1713 04.112.126 - PLATE BONE 207MM 13 HOLE LCP TITANIUM RIGHT POSTLAT DISTAL BOTH IP/OP "$1,312.93 " $971.57 $0.00 "$1,019.74" $573.60 $573.60 $0.00 $0.00 $0.00 $273.65 $974.45 $974.45 $0.00 $0.00 $273.61 $0.00 $776.60 $776.60 $0.00 $637.34 "$1,009.55" "$1,019.74" $0.00 $0.00 $193.68 $0.00 $0.00 $202.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.127 SUP HCPCS C1713 04.112.127 - PLATE BONE 207MM 13 HOLE LCP TITANIUM LEFT POSTLAT DISTAL BOTH IP/OP "$1,312.93 " $971.57 $0.00 "$1,019.74" $573.60 $573.60 $0.00 $0.00 $0.00 $273.65 $974.45 $974.45 $0.00 $0.00 $273.61 $0.00 $776.60 $776.60 $0.00 $637.34 "$1,009.55" "$1,019.74" $0.00 $0.00 $193.68 $0.00 $0.00 $202.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.130 SUP HCPCS C1713 04.112.130 - PLATE BONE 233MM 15 HOLE LCP RIGHT POSTLAT DISTAL FIBULAR BOTH IP/OP "$1,329.78 " $984.04 $0.00 "$1,032.84" $580.97 $580.97 $0.00 $0.00 $0.00 $277.16 $986.96 $986.96 $0.00 $0.00 $277.13 $0.00 $786.56 $786.56 $0.00 $645.53 "$1,022.51" "$1,032.84" $0.00 $0.00 $196.16 $0.00 $0.00 $205.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.131 SUP HCPCS C1713 04.112.131 - PLATE BONE 233MM 15 HOLE LCP LEFT POSTLAT DISTAL FIBULAR BOTH IP/OP "$1,329.78 " $984.04 $0.00 "$1,032.84" $580.97 $580.97 $0.00 $0.00 $0.00 $277.16 $986.96 $986.96 $0.00 $0.00 $277.13 $0.00 $786.56 $786.56 $0.00 $645.53 "$1,022.51" "$1,032.84" $0.00 $0.00 $196.16 $0.00 $0.00 $205.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.136 SUP HCPCS C1713 04.112.136 - PLATE BONE 73MM 3 HOLE LCP TITANIUM RIGHT DISTAL FIBULAR BOTH IP/OP "$1,147.05 " $848.82 $0.00 $890.90 $501.13 $501.13 $0.00 $0.00 $0.00 $239.07 $851.34 $851.34 $0.00 $0.00 $239.05 $0.00 $678.48 $678.48 $0.00 $556.81 $881.99 $890.90 $0.00 $0.00 $169.21 $0.00 $0.00 $177.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.137 SUP HCPCS C1713 04.112.137 - PLATE BONE 73MM 3 HOLE LCP TITANIUM LEFT DISTAL FIBULA BOTH IP/OP "$1,147.05 " $848.82 $0.00 $890.90 $501.13 $501.13 $0.00 $0.00 $0.00 $239.07 $851.34 $851.34 $0.00 $0.00 $239.05 $0.00 $678.48 $678.48 $0.00 $556.81 $881.99 $890.90 $0.00 $0.00 $169.21 $0.00 $0.00 $177.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.138 SUP HCPCS C1713 04.112.138 - PLATE BONE 86MM LCP TITANIUM RIGHT LEFT DISTAL LATERAL BOTH IP/OP "$1,166.73 " $863.38 $0.00 $906.20 $509.74 $509.74 $0.00 $0.00 $0.00 $243.17 $865.94 $865.94 $0.00 $0.00 $243.15 $0.00 $690.12 $690.12 $0.00 $566.38 $897.14 $906.20 $0.00 $0.00 $172.11 $0.00 $0.00 $180.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.139 SUP HCPCS C1713 04.112.139 - PLATE BONE 86MM 4 HOLE LCP TITANIUM RIGHT DISTAL FIBULAR BOTH IP/OP "$1,166.73 " $863.38 $0.00 $906.20 $509.74 $509.74 $0.00 $0.00 $0.00 $243.17 $865.94 $865.94 $0.00 $0.00 $243.15 $0.00 $690.12 $690.12 $0.00 $566.38 $897.14 $906.20 $0.00 $0.00 $172.11 $0.00 $0.00 $180.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.140 SUP HCPCS C1713 04.112.140 - PLATE BONE 99MM 5 HOLE LCP TITANIUM RIGHT DISTAL FIBULAR BOTH IP/OP "$1,182.18 " $874.81 $0.00 $918.20 $516.49 $516.49 $0.00 $0.00 $0.00 $246.39 $877.41 $877.41 $0.00 $0.00 $246.37 $0.00 $699.26 $699.26 $0.00 $573.88 $909.02 $918.20 $0.00 $0.00 $174.39 $0.00 $0.00 $182.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.141 SUP HCPCS C1713 04.112.141 - PLATE BONE 99MM 5 HOLE LCP TITANIUM LEFT DISTAL FIBULAR BOTH IP/OP "$1,182.18 " $874.81 $0.00 $918.20 $516.49 $516.49 $0.00 $0.00 $0.00 $246.39 $877.41 $877.41 $0.00 $0.00 $246.37 $0.00 $699.26 $699.26 $0.00 $573.88 $909.02 $918.20 $0.00 $0.00 $174.39 $0.00 $0.00 $182.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.142 SUP HCPCS C1713 04.112.142 - PLATE BONE 112MM 6 HOLE LCP TITANIUM RIGHT DISTAL FIBULAR BOTH IP/OP "$1,200.45 " $888.33 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $250.20 $890.97 $890.97 $0.00 $0.00 $250.17 $0.00 $710.07 $710.07 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $177.09 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.143 SUP HCPCS C1713 04.112.143 - PLATE BONE 112MM 6 HOLE LCP TITANIUM LEFT LATERAL DISTAL BOTH IP/OP "$1,200.45 " $888.33 $0.00 $932.40 $524.48 $524.48 $0.00 $0.00 $0.00 $250.20 $890.97 $890.97 $0.00 $0.00 $250.17 $0.00 $710.07 $710.07 $0.00 $582.75 $923.08 $932.40 $0.00 $0.00 $177.09 $0.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.144 SUP HCPCS C1713 04.112.144 - PLATE BONE 125MM 7 HOLE LCP TITANIUM RIGHT LATERAL DISTAL BOTH IP/OP "$1,217.33 " $900.82 $0.00 $945.50 $531.84 $531.84 $0.00 $0.00 $0.00 $253.72 $903.50 $903.50 $0.00 $0.00 $253.69 $0.00 $720.05 $720.05 $0.00 $590.94 $936.05 $945.50 $0.00 $0.00 $179.58 $0.00 $0.00 $188.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.145 SUP HCPCS C1713 04.112.145 - PLATE BONE 125MM 7 HOLE LCP TITANIUM LEFT LATERAL DISTAL BOTH IP/OP "$1,217.33 " $900.82 $0.00 $945.50 $531.84 $531.84 $0.00 $0.00 $0.00 $253.72 $903.50 $903.50 $0.00 $0.00 $253.69 $0.00 $720.05 $720.05 $0.00 $590.94 $936.05 $945.50 $0.00 $0.00 $179.58 $0.00 $0.00 $188.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.148 SUP HCPCS C1713 04.112.148 - PLATE BONE 177MM 11 HOLE LCP TITANIUM RIGHT LATERAL DISTAL BOTH IP/OP "$1,276.38 " $944.52 $0.00 $991.36 $557.64 $557.64 $0.00 $0.00 $0.00 $266.03 $947.33 $947.33 $0.00 $0.00 $266.00 $0.00 $754.98 $754.98 $0.00 $619.60 $981.45 $991.36 $0.00 $0.00 $188.29 $0.00 $0.00 $197.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.149 SUP HCPCS C1713 04.112.149 - PLATE BONE 151MM 9 HOLE LCP TITANIUM LEFT LATERAL DISTAL BOTH IP/OP "$1,276.38 " $944.52 $0.00 $991.36 $557.64 $557.64 $0.00 $0.00 $0.00 $266.03 $947.33 $947.33 $0.00 $0.00 $266.00 $0.00 $754.98 $754.98 $0.00 $619.60 $981.45 $991.36 $0.00 $0.00 $188.29 $0.00 $0.00 $197.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.152 SUP HCPCS C1713 04.112.152 - PLATE BONE 177MM 11 HOLE LCP TITANIUM RIGHT LATERAL DISTAL BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.153 SUP HCPCS C1713 04.112.153 - PLATE BONE 177MM 11 HOLE LCP TITANIUM LEFT LATERAL DISTAL BOTH IP/OP "$1,296.05 " $959.08 $0.00 "$1,006.64" $566.24 $566.24 $0.00 $0.00 $0.00 $270.13 $961.93 $961.93 $0.00 $0.00 $270.10 $0.00 $766.61 $766.61 $0.00 $629.15 $996.57 "$1,006.64" $0.00 $0.00 $191.19 $0.00 $0.00 $200.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.156 SUP HCPCS C1713 04.112.156 - PLATE BONE 203MM 13 HOLE LCP RIGHT LATERAL DISTAL FIBULAR BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.157 SUP HCPCS C1713 04.112.157 - PLATE BONE 203MM 13 HOLE LCP LEFT LATERAL DISTAL FIBULAR BOTH IP/OP "$1,350.88 " $999.65 $0.00 "$1,049.22" $590.19 $590.19 $0.00 $0.00 $0.00 $281.56 "$1,002.62" "$1,002.62" $0.00 $0.00 $281.52 $0.00 $799.04 $799.04 $0.00 $655.76 "$1,038.73" "$1,049.22" $0.00 $0.00 $199.28 $0.00 $0.00 $208.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.160 SUP HCPCS C1713 04.112.160 - PLATE BONE 229MM LCP LATERAL DISTAL FIBULAR NONSTRL 2.7/3.5 BOTH IP/OP "$1,370.55 " "$1,014.21" $0.00 "$1,064.50" $598.78 $598.78 $0.00 $0.00 $0.00 $285.66 "$1,017.22" "$1,017.22" $0.00 $0.00 $285.62 $0.00 $810.68 $810.68 $0.00 $665.31 "$1,053.86" "$1,064.50" $0.00 $0.00 $202.18 $0.00 $0.00 $211.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.161 SUP HCPCS C1713 04.112.161 - PLATE BONE 229MM 15 HOLE LCP LATERAL DISTAL FIBULAR NONSTRL BOTH IP/OP "$1,370.55 " "$1,014.21" $0.00 "$1,064.50" $598.78 $598.78 $0.00 $0.00 $0.00 $285.66 "$1,017.22" "$1,017.22" $0.00 $0.00 $285.62 $0.00 $810.68 $810.68 $0.00 $665.31 "$1,053.86" "$1,064.50" $0.00 $0.00 $202.18 $0.00 $0.00 $211.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.510 SUP HCPCS C1713 04.112.510 - PLATE BONE 109MM 4 HOLE LOW BEND LCP TITANIUM RIGHT MEDIAL BOTH IP/OP "$2,684.88 " "$1,986.81" $0.00 "$2,085.34" "$1,173.00" "$1,173.00" $0.00 $0.00 $0.00 $559.60 "$1,992.71" "$1,992.71" $0.00 $0.00 $559.53 $0.00 "$1,323.64" "$1,323.64" $0.00 "$1,303.34" "$2,064.49" "$2,085.34" $0.00 $0.00 $396.06 $0.00 $0.00 $414.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.511 SUP HCPCS C1713 04.112.511 - PLATE BONE 109MM 4 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,684.88 " "$1,986.81" $0.00 "$2,085.34" "$1,173.00" "$1,173.00" $0.00 $0.00 $0.00 $559.60 "$1,992.71" "$1,992.71" $0.00 $0.00 $559.53 $0.00 "$1,323.64" "$1,323.64" $0.00 "$1,303.34" "$2,064.49" "$2,085.34" $0.00 $0.00 $396.06 $0.00 $0.00 $414.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.514 SUP HCPCS C1713 04.112.514 - PLATE BONE 135MM 6 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,627.25 " "$1,944.17" $0.00 "$2,040.58" "$1,147.83" "$1,147.83" $0.00 $0.00 $0.00 $547.58 "$1,949.94" "$1,949.94" $0.00 $0.00 $547.52 $0.00 "$1,295.23" "$1,295.23" $0.00 "$1,275.36" "$2,020.18" "$2,040.58" $0.00 $0.00 $387.56 $0.00 $0.00 $406.08 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.515 SUP HCPCS C1713 04.112.515 - PLATE BONE 135MM 6 HOLE LOW BEND LCP TITANIUM LEFT MEDIAL BOTH IP/OP "$2,627.25 " "$1,944.17" $0.00 "$2,040.58" "$1,147.83" "$1,147.83" $0.00 $0.00 $0.00 $547.58 "$1,949.94" "$1,949.94" $0.00 $0.00 $547.52 $0.00 "$1,295.23" "$1,295.23" $0.00 "$1,275.36" "$2,020.18" "$2,040.58" $0.00 $0.00 $387.56 $0.00 $0.00 $406.08 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.518 SUP HCPCS C1713 04.112.518 - PLATE BONE 161MM 8 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,652.55 " "$1,962.89" $0.00 "$2,060.22" "$1,158.87" "$1,158.87" $0.00 $0.00 $0.00 $552.86 "$1,968.72" "$1,968.72" $0.00 $0.00 $552.79 $0.00 "$1,307.71" "$1,307.71" $0.00 "$1,287.64" "$2,039.62" "$2,060.22" $0.00 $0.00 $391.29 $0.00 $0.00 $409.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.519 SUP HCPCS C1713 04.112.519 - PLATE BONE 161MM 8 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,652.55 " "$1,962.89" $0.00 "$2,060.22" "$1,158.87" "$1,158.87" $0.00 $0.00 $0.00 $552.86 "$1,968.72" "$1,968.72" $0.00 $0.00 $552.79 $0.00 "$1,307.71" "$1,307.71" $0.00 "$1,287.64" "$2,039.62" "$2,060.22" $0.00 $0.00 $391.29 $0.00 $0.00 $409.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.522 SUP HCPCS C1713 04.112.522 - PLATE BONE 187MM 10 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,680.65 " "$1,983.68" $0.00 "$2,082.06" "$1,171.16" "$1,171.16" $0.00 $0.00 $0.00 $558.71 "$1,989.58" "$1,989.58" $0.00 $0.00 $558.65 $0.00 "$1,321.56" "$1,321.56" $0.00 "$1,301.29" "$2,061.24" "$2,082.06" $0.00 $0.00 $395.44 $0.00 $0.00 $414.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.523 SUP HCPCS C1713 04.112.523 - PLATE BONE 187MM 10 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,680.65 " "$1,983.68" $0.00 "$2,082.06" "$1,171.16" "$1,171.16" $0.00 $0.00 $0.00 $558.71 "$1,989.58" "$1,989.58" $0.00 $0.00 $558.65 $0.00 "$1,321.56" "$1,321.56" $0.00 "$1,301.29" "$2,061.24" "$2,082.06" $0.00 $0.00 $395.44 $0.00 $0.00 $414.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.526 SUP HCPCS C1713 04.112.526 - PLATE BONE 213MM 12 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,710.18 " "$2,005.53" $0.00 "$2,105.00" "$1,184.06" "$1,184.06" $0.00 $0.00 $0.00 $564.87 "$2,011.49" "$2,011.49" $0.00 $0.00 $564.80 $0.00 "$1,336.12" "$1,336.12" $0.00 "$1,315.63" "$2,083.95" "$2,105.00" $0.00 $0.00 $399.79 $0.00 $0.00 $418.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.527 SUP HCPCS C1713 04.112.527 - PLATE BONE 213MM 12 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,710.18 " "$2,005.53" $0.00 "$2,105.00" "$1,184.06" "$1,184.06" $0.00 $0.00 $0.00 $564.87 "$2,011.49" "$2,011.49" $0.00 $0.00 $564.80 $0.00 "$1,336.12" "$1,336.12" $0.00 "$1,315.63" "$2,083.95" "$2,105.00" $0.00 $0.00 $399.79 $0.00 $0.00 $418.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.530 SUP HCPCS C1713 04.112.530 - PLATE BONE 239MM 14 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,838.10 " "$2,100.19" $0.00 "$2,204.34" "$1,239.94" "$1,239.94" $0.00 $0.00 $0.00 $591.53 "$2,106.44" "$2,106.44" $0.00 $0.00 $591.46 $0.00 "$1,399.18" "$1,399.18" $0.00 "$1,377.71" "$2,182.30" "$2,204.34" $0.00 $0.00 $418.66 $0.00 $0.00 $438.66 $0.00 $0.00 $0.00 $0.00 $0.00 04.112.531 SUP HCPCS C1713 04.112.531 - PLATE BONE 239MM 14 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,838.10 " "$2,100.19" $0.00 "$2,204.34" "$1,239.94" "$1,239.94" $0.00 $0.00 $0.00 $591.53 "$2,106.44" "$2,106.44" $0.00 $0.00 $591.46 $0.00 "$1,399.18" "$1,399.18" $0.00 "$1,377.71" "$2,182.30" "$2,204.34" $0.00 $0.00 $418.66 $0.00 $0.00 $438.66 $0.00 $0.00 $0.00 $0.00 $0.00 04.113.103 SUP HCPCS C1713 04.113.103 - PLATE BONE 62MM 3 HOLE HOOK LCP TITANIUM NONSTRL 3.5MM BOTH IP/OP "$1,019.13 " $754.16 $0.00 $791.56 $445.25 $445.25 $0.00 $0.00 $0.00 $212.41 $756.39 $756.39 $0.00 $0.00 $212.39 $0.00 $602.81 $602.81 $0.00 $494.73 $783.64 $791.56 $0.00 $0.00 $150.34 $0.00 $0.00 $157.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.002 SUP HCPCS C1713 04.114.002 - PLATE BONE 23MM 4 HOLE PURE STR LCP TITANIUM HAND WRIST BOTH IP/OP $410.45 $303.73 $0.00 $318.80 $179.33 $179.33 $0.00 $0.00 $0.00 $85.55 $304.64 $304.64 $0.00 $0.00 $85.54 $0.00 $242.78 $242.78 $0.00 $199.25 $315.61 $318.80 $0.00 $0.00 $60.55 $0.00 $0.00 $63.44 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.003 SUP HCPCS C1713 04.114.003 - PLATE BONE 29MM 6 HOLE PURE STR LOCKING LCP TITANIUM HAND BOTH IP/OP $752.05 $556.52 $0.00 $584.12 $328.57 $328.57 $0.00 $0.00 $0.00 $156.75 $558.17 $558.17 $0.00 $0.00 $156.73 $0.00 $444.84 $444.84 $0.00 $365.08 $578.28 $584.12 $0.00 $0.00 $110.94 $0.00 $0.00 $116.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.004 SUP HCPCS C1713 04.114.004 - PLATE BONE 36MM 6 HOLE PURE STR LCP TITANIUM HAND WRIST BOTH IP/OP $410.45 $303.73 $0.00 $318.80 $179.33 $179.33 $0.00 $0.00 $0.00 $85.55 $304.64 $304.64 $0.00 $0.00 $85.54 $0.00 $242.78 $242.78 $0.00 $199.25 $315.61 $318.80 $0.00 $0.00 $60.55 $0.00 $0.00 $63.44 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.005 SUP HCPCS C1713 04.114.005 - PLATE BONE 59MM 12 HOLE PURE STR LOCKING ADAPTION LCP BOTH IP/OP $752.05 $556.52 $0.00 $584.12 $328.57 $328.57 $0.00 $0.00 $0.00 $156.75 $558.17 $558.17 $0.00 $0.00 $156.73 $0.00 $444.84 $444.84 $0.00 $365.08 $578.28 $584.12 $0.00 $0.00 $110.94 $0.00 $0.00 $116.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.006 SUP HCPCS C1713 04.114.006 - PLATE BONE T 3X8 HOLE LCP TITANIUM SPN NONSTRL 1.5MM SCREW BOTH IP/OP $790.00 $584.60 $0.00 $613.60 $345.15 $345.15 $0.00 $0.00 $0.00 $164.66 $586.34 $586.34 $0.00 $0.00 $164.64 $0.00 $467.29 $467.29 $0.00 $383.50 $607.46 $613.60 $0.00 $0.00 $116.54 $0.00 $0.00 $122.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.007 SUP HCPCS C1713 04.114.007 - PLATE BONE T 4X8 HOLE LCP TITANIUM SPN NONSTRL 1.5MM SCREW BOTH IP/OP $790.00 $584.60 $0.00 $613.60 $345.15 $345.15 $0.00 $0.00 $0.00 $164.66 $586.34 $586.34 $0.00 $0.00 $164.64 $0.00 $467.29 $467.29 $0.00 $383.50 $607.46 $613.60 $0.00 $0.00 $116.54 $0.00 $0.00 $122.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.009 SUP HCPCS C1713 04.114.009 - PLATE BONE H LEFT EXTEND LCP TITANIUM SPN NONSTRL 1.5MM BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.010 SUP HCPCS C1713 04.114.010 - PLATE BONE H RIGHT EXTEND LCP TITANIUM SPN NONSTRL 1.5MM BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.013 SUP HCPCS C1713 04.114.013 - PLATE BONE Y 3X8 HOLE LCP TITANIUM SPN NONSTRL 1.5MM SCREW BOTH IP/OP $760.48 $562.76 $0.00 $590.66 $332.25 $332.25 $0.00 $0.00 $0.00 $158.50 $564.42 $564.42 $0.00 $0.00 $158.48 $0.00 $449.82 $449.82 $0.00 $369.16 $584.76 $590.66 $0.00 $0.00 $112.18 $0.00 $0.00 $117.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.014 SUP HCPCS C1713 04.114.014 - PLATE BONE Y 3X8 HOLE LCP TITANIUM SPN NONSTRL 1.5MM SCREW BOTH IP/OP $884.18 $654.29 $0.00 $686.74 $386.29 $386.29 $0.00 $0.00 $0.00 $184.28 $656.23 $656.23 $0.00 $0.00 $184.26 $0.00 $522.99 $522.99 $0.00 $429.21 $679.88 $686.74 $0.00 $0.00 $130.43 $0.00 $0.00 $136.66 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.502 SUP HCPCS C1713 04.114.502 - PLATE BONE SHORT THREAD 23MM 4 HOLE ASSEMBLE DRILL GUIDE LCP BOTH IP/OP $490.58 $363.03 $0.00 $381.04 $214.34 $214.34 $0.00 $0.00 $0.00 $102.25 $364.10 $364.10 $0.00 $0.00 $102.24 $0.00 $290.18 $290.18 $0.00 $238.15 $377.23 $381.04 $0.00 $0.00 $72.37 $0.00 $0.00 $75.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.503 SUP HCPCS C1713 04.114.503 - PLATE BONE SHORT THREAD 29MM 6 HOLE ADAPTION LCP TITANIUM BOTH IP/OP $836.38 $618.92 $0.00 $649.62 $365.41 $365.41 $0.00 $0.00 $0.00 $174.32 $620.76 $620.76 $0.00 $0.00 $174.30 $0.00 $494.72 $494.72 $0.00 $406.01 $643.13 $649.62 $0.00 $0.00 $123.38 $0.00 $0.00 $129.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.504 SUP HCPCS C1713 04.114.504 - PLATE BONE 36MM 6 HOLE PURE STR PREASSEMBLED DRILL SLEEVE BOTH IP/OP $490.58 $363.03 $0.00 $381.04 $214.34 $214.34 $0.00 $0.00 $0.00 $102.25 $364.10 $364.10 $0.00 $0.00 $102.24 $0.00 $290.18 $290.18 $0.00 $238.15 $377.23 $381.04 $0.00 $0.00 $72.37 $0.00 $0.00 $75.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.505 SUP HCPCS C1713 04.114.505 - PLATE BONE 59MM 12 HOLE PURE STR PREASSEMBLED DRILL SLEEVE BOTH IP/OP $836.38 $618.92 $0.00 $649.62 $365.41 $365.41 $0.00 $0.00 $0.00 $174.32 $620.76 $620.76 $0.00 $0.00 $174.30 $0.00 $494.72 $494.72 $0.00 $406.01 $643.13 $649.62 $0.00 $0.00 $123.38 $0.00 $0.00 $129.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.506 SUP HCPCS C1713 04.114.506 - PLATE BONE 3X8 HOLE T PREASSEMBLED DRILL SLEEVE LOCKING LCP BOTH IP/OP $885.58 $655.33 $0.00 $687.84 $386.91 $386.91 $0.00 $0.00 $0.00 $184.58 $657.27 $657.27 $0.00 $0.00 $184.55 $0.00 $523.82 $523.82 $0.00 $429.90 $680.96 $687.84 $0.00 $0.00 $130.64 $0.00 $0.00 $136.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.507 SUP HCPCS C1713 04.114.507 - PLATE BONE 4X8 HOLE T PREASSEMBLED DRILL SLEEVE LOCKING LCP BOTH IP/OP $885.58 $655.33 $0.00 $687.84 $386.91 $386.91 $0.00 $0.00 $0.00 $184.58 $657.27 $657.27 $0.00 $0.00 $184.55 $0.00 $523.82 $523.82 $0.00 $429.90 $680.96 $687.84 $0.00 $0.00 $130.64 $0.00 $0.00 $136.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.509 SUP HCPCS C1713 04.114.509 - PLATE BONE 8 HOLE STRUT PREASSEMBLED DRILL SLEEVE LOCKING BOTH IP/OP $846.23 $626.21 $0.00 $657.26 $369.71 $369.71 $0.00 $0.00 $0.00 $176.37 $628.07 $628.07 $0.00 $0.00 $176.35 $0.00 $500.54 $500.54 $0.00 $410.79 $650.69 $657.26 $0.00 $0.00 $124.83 $0.00 $0.00 $130.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.510 SUP HCPCS C1713 04.114.510 - PLATE BONE H RIGHT EXTEND LCP TITANIUM SPN NONSTRL 1.5MM BOTH IP/OP $846.23 $626.21 $0.00 $657.26 $369.71 $369.71 $0.00 $0.00 $0.00 $176.37 $628.07 $628.07 $0.00 $0.00 $176.35 $0.00 $500.54 $500.54 $0.00 $410.79 $650.69 $657.26 $0.00 $0.00 $124.83 $0.00 $0.00 $130.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.513 SUP HCPCS C1713 04.114.513 - PLATE BONE Y 3X8 HOLE LCP TITANIUM SPN NONSTRL 1.5MM SCREW BOTH IP/OP $846.23 $626.21 $0.00 $657.26 $369.71 $369.71 $0.00 $0.00 $0.00 $176.37 $628.07 $628.07 $0.00 $0.00 $176.35 $0.00 $500.54 $500.54 $0.00 $410.79 $650.69 $657.26 $0.00 $0.00 $124.83 $0.00 $0.00 $130.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.114.514 SUP HCPCS C1713 04.114.514 - PLATE BONE 6 HOLE LCP TITANIUM CONDYLE NONSTRL 1.5 MM SCREWS BOTH IP/OP $968.53 $716.71 $0.00 $752.26 $423.15 $423.15 $0.00 $0.00 $0.00 $201.86 $718.84 $718.84 $0.00 $0.00 $201.84 $0.00 $572.88 $572.88 $0.00 $470.16 $744.74 $752.26 $0.00 $0.00 $142.87 $0.00 $0.00 $149.70 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.130 SUP HCPCS C1713 04.115.130 - PLATE BONE +90D 37MM 2X3 HOLE L VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.131 SUP HCPCS C1713 04.115.131 - PLATE BONE -90D 37MM 2X3 HOLE L VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.150 SUP HCPCS C1713 04.115.150 - PLATE BONE +90D 51MM 2X5 HOLE L VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.151 SUP HCPCS C1713 04.115.151 - PLATE BONE -90D 51MM 2X5 HOLE L VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.230 SUP HCPCS C1713 04.115.230 - PLATE BONE +90D 37MM 3X3 HOLE L VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.231 SUP HCPCS C1713 04.115.231 - PLATE BONE -90D 37MM 3X3 HOLE L VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.250 SUP HCPCS C1713 04.115.250 - PLATE BONE +90D 51MM 3X5 HOLE L VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.251 SUP HCPCS C1713 04.115.251 - PLATE BONE -90D 51MM 3X5 HOLE L VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.330 SUP HCPCS C1713 04.115.330 - PLATE BONE 37MM 3X3 HOLE T VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,059.90 " $784.33 $0.00 $823.22 $463.06 $463.06 $0.00 $0.00 $0.00 $220.91 $786.66 $786.66 $0.00 $0.00 $220.88 $0.00 $626.93 $626.93 $0.00 $514.51 $814.99 $823.22 $0.00 $0.00 $156.35 $0.00 $0.00 $163.82 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.350 SUP HCPCS C1713 04.115.350 - PLATE BONE 51MM 3X5 HOLE T VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$1,106.28 " $818.65 $0.00 $859.24 $483.32 $483.32 $0.00 $0.00 $0.00 $230.58 $821.08 $821.08 $0.00 $0.00 $230.55 $0.00 $654.36 $654.36 $0.00 $537.03 $850.65 $859.24 $0.00 $0.00 $163.19 $0.00 $0.00 $170.99 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.430 SUP HCPCS C1713 04.115.430 - PLATE BONE +20D 41MM 3X3 HOLE L VAR ANG OPLIQUE LOCKING LCP BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.431 SUP HCPCS C1713 04.115.431 - PLATE BONE -20D 41MM 3X3 HOLE L VAR ANG OBLIQUE LOCKING LCP BOTH IP/OP "$1,026.15 " $759.35 $0.00 $797.02 $448.32 $448.32 $0.00 $0.00 $0.00 $213.88 $761.61 $761.61 $0.00 $0.00 $213.85 $0.00 $606.97 $606.97 $0.00 $498.14 $789.05 $797.02 $0.00 $0.00 $151.37 $0.00 $0.00 $158.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.450 SUP HCPCS C1713 04.115.450 - PLATE BONE +20D 55MM 3X5 HOLE L VAR ANG OBLIQUE LOCKING LCP BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.451 SUP HCPCS C1713 04.115.451 - PLATE BONE -20D 55MM 3X5 HOLE L VAR ANG OBLIQUE LOCKING LCP BOTH IP/OP "$1,078.18 " $797.85 $0.00 $837.42 $471.05 $471.05 $0.00 $0.00 $0.00 $224.72 $800.22 $800.22 $0.00 $0.00 $224.69 $0.00 $637.74 $637.74 $0.00 $523.39 $829.05 $837.42 $0.00 $0.00 $159.05 $0.00 $0.00 $166.65 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.530 SUP HCPCS C1713 04.115.530 - PLATE BONE 46MM 3X5 HOLE VAR ANG COLUMN LOCKING LCP TITANIUM BOTH IP/OP "$1,059.90 " $784.33 $0.00 $823.22 $463.06 $463.06 $0.00 $0.00 $0.00 $220.91 $786.66 $786.66 $0.00 $0.00 $220.88 $0.00 $626.93 $626.93 $0.00 $514.51 $814.99 $823.22 $0.00 $0.00 $156.35 $0.00 $0.00 $163.82 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.540 SUP HCPCS C1713 04.115.540 - PLATE BONE 57MM 6 HOLE L VAR ANG COLUMN LCP TITANIUM DISTAL BOTH IP/OP "$1,106.28 " $818.65 $0.00 $859.24 $483.32 $483.32 $0.00 $0.00 $0.00 $230.58 $821.08 $821.08 $0.00 $0.00 $230.55 $0.00 $654.36 $654.36 $0.00 $537.03 $850.65 $859.24 $0.00 $0.00 $163.19 $0.00 $0.00 $170.99 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.630 SUP HCPCS C1713 04.115.630 - PLATE BONE +90D 41MM 2X3 HOLE VARIABLE INTERMEDIATE COLUMN BOTH IP/OP "$1,106.28 " $818.65 $0.00 $859.24 $483.32 $483.32 $0.00 $0.00 $0.00 $230.58 $821.08 $821.08 $0.00 $0.00 $230.55 $0.00 $654.36 $654.36 $0.00 $537.03 $850.65 $859.24 $0.00 $0.00 $163.19 $0.00 $0.00 $170.99 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.631 SUP HCPCS C1713 04.115.631 - PLATE BONE -90D 41MM 2X3 HOLE VARIABLE INTERMEDIATE COLUMN BOTH IP/OP "$1,106.28 " $818.65 $0.00 $859.24 $483.32 $483.32 $0.00 $0.00 $0.00 $230.58 $821.08 $821.08 $0.00 $0.00 $230.55 $0.00 $654.36 $654.36 $0.00 $537.03 $850.65 $859.24 $0.00 $0.00 $163.19 $0.00 $0.00 $170.99 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.640 SUP HCPCS C1713 04.115.640 - PLATE BONE +90D 49MM 2X4 HOLE VARIABLE INTERMEDIATE COLUMN BOTH IP/OP "$1,147.05 " $848.82 $0.00 $890.90 $501.13 $501.13 $0.00 $0.00 $0.00 $239.07 $851.34 $851.34 $0.00 $0.00 $239.05 $0.00 $678.48 $678.48 $0.00 $556.81 $881.99 $890.90 $0.00 $0.00 $169.21 $0.00 $0.00 $177.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.115.641 SUP HCPCS C1713 04.115.641 - PLATE BONE -90D 49MM 2X4 HOLE VARIABLE INTERMEDIATE COLUMN BOTH IP/OP "$1,147.05 " $848.82 $0.00 $890.90 $501.13 $501.13 $0.00 $0.00 $0.00 $239.07 $851.34 $851.34 $0.00 $0.00 $239.05 $0.00 $678.48 $678.48 $0.00 $556.81 $881.99 $890.90 $0.00 $0.00 $169.21 $0.00 $0.00 $177.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.601 SUP HCPCS C1713 04.120.601 - PLATE BONE 4.5MM 4 HOLE LOCKING ATTCH LCP TITANIUM FEMUR BOTH IP/OP $940.40 $695.90 $0.00 $730.42 $410.86 $410.86 $0.00 $0.00 $0.00 $196.00 $697.96 $697.96 $0.00 $0.00 $195.98 $0.00 $556.25 $556.25 $0.00 $456.51 $723.12 $730.42 $0.00 $0.00 $138.73 $0.00 $0.00 $145.35 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.602 SUP HCPCS C1713 04.120.602 - PLATE BONE 4.5MM 8 HOLE LOCKING ATTCH LCP TITANIUM FEMUR BOTH IP/OP "$1,030.38 " $762.48 $0.00 $800.28 $450.16 $450.16 $0.00 $0.00 $0.00 $214.76 $764.74 $764.74 $0.00 $0.00 $214.73 $0.00 $609.47 $609.47 $0.00 $500.18 $792.28 $800.28 $0.00 $0.00 $152.00 $0.00 $0.00 $159.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.606 SUP HCPCS C1713 04.120.606 - SCREW BONE 6MM CONNCTNG STARDRIVE RECESS TITANIUM NONSTRL BOTH IP/OP $303.63 $224.69 $0.00 $235.82 $132.65 $132.65 $0.00 $0.00 $0.00 $63.28 $225.35 $225.35 $0.00 $0.00 $63.28 $0.00 $179.59 $179.59 $0.00 $147.39 $233.47 $235.82 $0.00 $0.00 $44.79 $0.00 $0.00 $46.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.701 SUP HCPCS C1713 04.120.701 - PLATE BONE 69MM 1 HOLE LCP TITANIUM TIBIA POSTEROMEDIAL BOTH IP/OP "$1,750.08 " "$1,295.06" $0.00 "$1,359.30" $764.61 $764.61 $0.00 $0.00 $0.00 $364.76 "$1,298.91" "$1,298.91" $0.00 $0.00 $364.72 $0.00 "$1,035.17" "$1,035.17" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $258.17 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.702 SUP HCPCS C1713 04.120.702 - PLATE BONE 79MM 2 HOLE LCP TITANIUM TIBIA POSTEROMEDIAL BOTH IP/OP "$1,769.78 " "$1,309.64" $0.00 "$1,374.58" $773.20 $773.20 $0.00 $0.00 $0.00 $368.87 "$1,313.53" "$1,313.53" $0.00 $0.00 $368.82 $0.00 "$1,046.82" "$1,046.82" $0.00 $859.11 "$1,360.84" "$1,374.58" $0.00 $0.00 $261.07 $0.00 $0.00 $273.54 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.704 SUP HCPCS C1713 04.120.704 - PLATE BONE 105MM 4 HOLE LCP TITANIUM TIBIA POSTEROMEDIAL BOTH IP/OP "$1,788.05 " "$1,323.16" $0.00 "$1,388.76" $781.18 $781.18 $0.00 $0.00 $0.00 $372.67 "$1,327.09" "$1,327.09" $0.00 $0.00 $372.63 $0.00 "$1,057.63" "$1,057.63" $0.00 $867.98 "$1,374.87" "$1,388.76" $0.00 $0.00 $263.77 $0.00 $0.00 $276.36 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.706 SUP HCPCS C1713 04.120.706 - PLATE BONE 131MM 6 HOLE LCP TITANIUM TIBIA POSTEROMEDIAL BOTH IP/OP "$1,804.90 " "$1,335.63" $0.00 "$1,401.88" $788.56 $788.56 $0.00 $0.00 $0.00 $376.19 "$1,339.60" "$1,339.60" $0.00 $0.00 $376.14 $0.00 "$1,067.60" "$1,067.60" $0.00 $876.18 "$1,387.86" "$1,401.88" $0.00 $0.00 $266.25 $0.00 $0.00 $278.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.708 SUP HCPCS C1713 04.120.708 - PLATE BONE 157MM 8 HOLE LCP TITANIUM TIBIA POSTEROMEDIAL BOTH IP/OP "$1,824.60 " "$1,350.20" $0.00 "$1,417.16" $797.15 $797.15 $0.00 $0.00 $0.00 $380.29 "$1,354.22" "$1,354.22" $0.00 $0.00 $380.25 $0.00 "$1,079.25" "$1,079.25" $0.00 $885.73 "$1,402.99" "$1,417.16" $0.00 $0.00 $269.16 $0.00 $0.00 $282.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.120.710 SUP HCPCS C1713 04.120.710 - PLATE BONE 183MM 10 HOLE LCP TITANIUM TIBIA POSTEROMEDIAL BOTH IP/OP "$1,844.28 " "$1,364.77" $0.00 "$1,432.44" $805.75 $805.75 $0.00 $0.00 $0.00 $384.39 "$1,368.82" "$1,368.82" $0.00 $0.00 $384.35 $0.00 "$1,090.89" "$1,090.89" $0.00 $895.28 "$1,418.12" "$1,432.44" $0.00 $0.00 $272.06 $0.00 $0.00 $285.06 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.030S SUP HCPCS C1713 04.124.030S - PLATE BONE 356MM 15 HOLE LCP TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$3,318.85 " "$2,455.95" $0.00 "$2,577.74" "$1,449.98" "$1,449.98" $0.00 $0.00 $0.00 $691.73 "$2,463.25" "$2,463.25" $0.00 $0.00 $691.65 $0.00 "$1,636.19" "$1,636.19" $0.00 "$1,611.09" "$2,551.97" "$2,577.74" $0.00 $0.00 $489.58 $0.00 $0.00 $512.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.031S SUP HCPCS C1713 04.124.031S - PLATE BONE 356MM 15 HOLE LCP TITANIUM FEMUR LEFT DISTAL BOTH IP/OP "$3,318.85 " "$2,455.95" $0.00 "$2,577.74" "$1,449.98" "$1,449.98" $0.00 $0.00 $0.00 $691.73 "$2,463.25" "$2,463.25" $0.00 $0.00 $691.65 $0.00 "$1,636.19" "$1,636.19" $0.00 "$1,611.09" "$2,551.97" "$2,577.74" $0.00 $0.00 $489.58 $0.00 $0.00 $512.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.034S SUP HCPCS C1713 04.124.034S - PLATE BONE 396MM 17 HOLE LCP TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$3,379.28 " "$2,500.67" $0.00 "$2,624.68" "$1,476.38" "$1,476.38" $0.00 $0.00 $0.00 $704.33 "$2,508.10" "$2,508.10" $0.00 $0.00 $704.24 $0.00 "$1,665.98" "$1,665.98" $0.00 "$1,640.43" "$2,598.43" "$2,624.68" $0.00 $0.00 $498.50 $0.00 $0.00 $522.31 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.035S SUP HCPCS C1713 04.124.035S - PLATE BONE 396MM 17 HOLE LCP TITANIUM FEMUR LEFT DISTAL BOTH IP/OP "$3,379.28 " "$2,500.67" $0.00 "$2,624.68" "$1,476.38" "$1,476.38" $0.00 $0.00 $0.00 $704.33 "$2,508.10" "$2,508.10" $0.00 $0.00 $704.24 $0.00 "$1,665.98" "$1,665.98" $0.00 "$1,640.43" "$2,598.43" "$2,624.68" $0.00 $0.00 $498.50 $0.00 $0.00 $522.31 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.038S SUP HCPCS C1713 04.124.038S - PLATE BONE 436MM 19 HOLE LCP TITANIUM FEMUR RIGHT DISTAL BOTH IP/OP "$3,441.13 " "$2,546.44" $0.00 "$2,672.72" "$1,503.41" "$1,503.41" $0.00 $0.00 $0.00 $717.22 "$2,554.00" "$2,554.00" $0.00 $0.00 $717.13 $0.00 "$1,696.47" "$1,696.47" $0.00 "$1,670.45" "$2,645.99" "$2,672.72" $0.00 $0.00 $507.62 $0.00 $0.00 $531.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.039S SUP HCPCS C1713 04.124.039S - PLATE BONE 436MM 19 HOLE LCP TITANIUM FEMUR LEFT DISTAL BOTH IP/OP "$3,441.13 " "$2,546.44" $0.00 "$2,672.72" "$1,503.41" "$1,503.41" $0.00 $0.00 $0.00 $717.22 "$2,554.00" "$2,554.00" $0.00 $0.00 $717.13 $0.00 "$1,696.47" "$1,696.47" $0.00 "$1,670.45" "$2,645.99" "$2,672.72" $0.00 $0.00 $507.62 $0.00 $0.00 $531.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.200 SUP HCPCS C1713 04.124.200 - PLATE BONE 76MM 4 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,663.78 " "$1,971.20" $0.00 "$2,068.96" "$1,163.79" "$1,163.79" $0.00 $0.00 $0.00 $555.20 "$1,977.05" "$1,977.05" $0.00 $0.00 $555.13 $0.00 "$1,313.24" "$1,313.24" $0.00 "$1,293.10" "$2,048.27" "$2,068.96" $0.00 $0.00 $392.95 $0.00 $0.00 $411.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.201 SUP HCPCS C1713 04.124.201 - PLATE BONE 76MM 6 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,663.78 " "$1,971.20" $0.00 "$2,068.96" "$1,163.79" "$1,163.79" $0.00 $0.00 $0.00 $555.20 "$1,977.05" "$1,977.05" $0.00 $0.00 $555.13 $0.00 "$1,313.24" "$1,313.24" $0.00 "$1,293.10" "$2,048.27" "$2,068.96" $0.00 $0.00 $392.95 $0.00 $0.00 $411.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.204 SUP HCPCS C1713 04.124.204 - PLATE BONE 102MM 6 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,696.13 " "$1,995.14" $0.00 "$2,094.08" "$1,177.92" "$1,177.92" $0.00 $0.00 $0.00 $561.94 "$2,001.06" "$2,001.06" $0.00 $0.00 $561.87 $0.00 "$1,329.19" "$1,329.19" $0.00 "$1,308.80" "$2,073.14" "$2,094.08" $0.00 $0.00 $397.72 $0.00 $0.00 $416.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.205 SUP HCPCS C1713 04.124.205 - PLATE BONE 102MM 6 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,696.13 " "$1,995.14" $0.00 "$2,094.08" "$1,177.92" "$1,177.92" $0.00 $0.00 $0.00 $561.94 "$2,001.06" "$2,001.06" $0.00 $0.00 $561.87 $0.00 "$1,329.19" "$1,329.19" $0.00 "$1,308.80" "$2,073.14" "$2,094.08" $0.00 $0.00 $397.72 $0.00 $0.00 $416.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.208 SUP HCPCS C1713 04.124.208 - PLATE BONE 128MM 8 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,727.05 " "$2,018.02" $0.00 "$2,118.10" "$1,191.43" "$1,191.43" $0.00 $0.00 $0.00 $568.39 "$2,024.02" "$2,024.02" $0.00 $0.00 $568.32 $0.00 "$1,344.44" "$1,344.44" $0.00 "$1,323.81" "$2,096.92" "$2,118.10" $0.00 $0.00 $402.28 $0.00 $0.00 $421.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.209 SUP HCPCS C1713 04.124.209 - PLATE BONE 128MM 8 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,727.05 " "$2,018.02" $0.00 "$2,118.10" "$1,191.43" "$1,191.43" $0.00 $0.00 $0.00 $568.39 "$2,024.02" "$2,024.02" $0.00 $0.00 $568.32 $0.00 "$1,344.44" "$1,344.44" $0.00 "$1,323.81" "$2,096.92" "$2,118.10" $0.00 $0.00 $402.28 $0.00 $0.00 $421.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.212 SUP HCPCS C1713 04.124.212 - PLATE BONE 154MM 10 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,756.58 " "$2,039.87" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $574.54 "$2,045.93" "$2,045.93" $0.00 $0.00 $574.47 $0.00 "$1,358.99" "$1,358.99" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.213 SUP HCPCS C1713 04.124.213 - PLATE BONE 154MM 10 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,756.58 " "$2,039.87" $0.00 "$2,141.02" "$1,204.32" "$1,204.32" $0.00 $0.00 $0.00 $574.54 "$2,045.93" "$2,045.93" $0.00 $0.00 $574.47 $0.00 "$1,358.99" "$1,358.99" $0.00 "$1,338.14" "$2,119.61" "$2,141.02" $0.00 $0.00 $406.64 $0.00 $0.00 $426.06 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.216 SUP HCPCS C1713 04.124.216 - PLATE BONE 180MM 12 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,887.30 " "$2,136.60" $0.00 "$2,242.56" "$1,261.44" "$1,261.44" $0.00 $0.00 $0.00 $601.79 "$2,142.95" "$2,142.95" $0.00 $0.00 $601.71 $0.00 "$1,423.44" "$1,423.44" $0.00 "$1,401.60" "$2,220.13" "$2,242.56" $0.00 $0.00 $425.92 $0.00 $0.00 $446.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.217 SUP HCPCS C1713 04.124.217 - PLATE BONE 180MM 12 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,887.30 " "$2,136.60" $0.00 "$2,242.56" "$1,261.44" "$1,261.44" $0.00 $0.00 $0.00 $601.79 "$2,142.95" "$2,142.95" $0.00 $0.00 $601.71 $0.00 "$1,423.44" "$1,423.44" $0.00 "$1,401.60" "$2,220.13" "$2,242.56" $0.00 $0.00 $425.92 $0.00 $0.00 $446.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.220 SUP HCPCS C1713 04.124.220 - PLATE BONE 206MM 14 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$2,918.23 " "$2,159.49" $0.00 "$2,266.58" "$1,274.95" "$1,274.95" $0.00 $0.00 $0.00 $608.23 "$2,165.91" "$2,165.91" $0.00 $0.00 $608.16 $0.00 "$1,438.68" "$1,438.68" $0.00 "$1,416.61" "$2,243.92" "$2,266.58" $0.00 $0.00 $430.48 $0.00 $0.00 $451.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.221 SUP HCPCS C1713 04.124.221 - PLATE BONE 206MM 14 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$2,918.23 " "$2,159.49" $0.00 "$2,266.58" "$1,274.95" "$1,274.95" $0.00 $0.00 $0.00 $608.23 "$2,165.91" "$2,165.91" $0.00 $0.00 $608.16 $0.00 "$1,438.68" "$1,438.68" $0.00 "$1,416.61" "$2,243.92" "$2,266.58" $0.00 $0.00 $430.48 $0.00 $0.00 $451.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.224 SUP HCPCS C1713 04.124.224 - PLATE BONE 232MM 16 HOLE LOW BEND LCP TITANIUM TIBIA RIGHT BOTH IP/OP "$3,020.83 " "$2,235.41" $0.00 "$2,346.28" "$1,319.78" "$1,319.78" $0.00 $0.00 $0.00 $629.62 "$2,242.06" "$2,242.06" $0.00 $0.00 $629.54 $0.00 "$1,489.27" "$1,489.27" $0.00 "$1,466.43" "$2,322.82" "$2,346.28" $0.00 $0.00 $445.62 $0.00 $0.00 $466.91 $0.00 $0.00 $0.00 $0.00 $0.00 04.124.225 SUP HCPCS C1713 04.124.225 - PLATE BONE 232MM 16 HOLE LOW BEND LCP TITANIUM TIBIA LEFT BOTH IP/OP "$3,020.83 " "$2,235.41" $0.00 "$2,346.28" "$1,319.78" "$1,319.78" $0.00 $0.00 $0.00 $629.62 "$2,242.06" "$2,242.06" $0.00 $0.00 $629.54 $0.00 "$1,489.27" "$1,489.27" $0.00 "$1,466.43" "$2,322.82" "$2,346.28" $0.00 $0.00 $445.62 $0.00 $0.00 $466.91 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.001 SUP HCPCS C1713 04.161.001 - PLATE 50MM TI BONE OCCPTL NONSTRL BOTH IP/OP "$8,232.00 " "$6,091.68" $0.00 "$6,585.60" "$3,704.40" "$3,704.40" $0.00 $0.00 $0.00 "$1,715.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,715.55" $0.00 "$4,058.38" "$4,058.38" $0.00 "$4,116.00" "$6,519.74" "$6,585.60" $0.00 $0.00 "$1,288.31" $0.00 $0.00 "$1,310.53" $0.00 $0.00 $0.00 $0.00 $0.00 04.161.032 SUP HCPCS C1713 04.161.032 - ROD SPNL 240MM 3.5MM OCCPTL TI PREBNT BOTH IP/OP $892.50 $660.45 $0.00 $714.00 $401.63 $401.63 $0.00 $0.00 $0.00 $186.02 $662.41 $662.41 $0.00 $0.00 $186.00 $0.00 $527.91 $527.91 $0.00 $446.25 $706.86 $714.00 $0.00 $0.00 $139.68 $0.00 $0.00 $142.09 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.210S SUP HCPCS C1713 04.161.210S - PLATE BONE NARROW 10 HOLE CVD LCP TITANIUM STERILE 3.5MM BOTH IP/OP $795.63 $588.77 $0.00 $617.96 $347.60 $347.60 $0.00 $0.00 $0.00 $165.83 $590.51 $590.51 $0.00 $0.00 $165.81 $0.00 $470.61 $470.61 $0.00 $386.23 $611.78 $617.96 $0.00 $0.00 $117.37 $0.00 $0.00 $122.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.212S SUP HCPCS C1713 04.161.212S - PLATE BONE NARROW 12 HOLE CVD LCP TITANIUM PEDIATRIC STERILE BOTH IP/OP "$1,163.93 " $861.31 $0.00 $904.02 $508.51 $508.51 $0.00 $0.00 $0.00 $242.59 $863.87 $863.87 $0.00 $0.00 $242.56 $0.00 $688.46 $688.46 $0.00 $565.01 $894.98 $904.02 $0.00 $0.00 $171.70 $0.00 $0.00 $179.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.214S SUP HCPCS C1713 04.161.214S - PLATE BONE CURVE NARROW 14 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,332.60 " $986.12 $0.00 "$1,035.02" $582.20 $582.20 $0.00 $0.00 $0.00 $277.75 $989.06 $989.06 $0.00 $0.00 $277.71 $0.00 $788.23 $788.23 $0.00 $646.89 "$1,024.67" "$1,035.02" $0.00 $0.00 $196.58 $0.00 $0.00 $205.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.216S SUP HCPCS C1713 04.161.216S - PLATE BONE CURVE NARROW 16 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,432.40 " "$1,059.98" $0.00 "$1,112.54" $625.80 $625.80 $0.00 $0.00 $0.00 $298.55 "$1,063.13" "$1,063.13" $0.00 $0.00 $298.51 $0.00 $847.26 $847.26 $0.00 $695.34 "$1,101.42" "$1,112.54" $0.00 $0.00 $211.30 $0.00 $0.00 $221.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.218S SUP HCPCS C1713 04.161.218S - PLATE BONE CURVE NARROW 18 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,601.08 " "$1,184.80" $0.00 "$1,243.56" $699.50 $699.50 $0.00 $0.00 $0.00 $333.70 "$1,188.32" "$1,188.32" $0.00 $0.00 $333.66 $0.00 $947.04 $947.04 $0.00 $777.23 "$1,231.12" "$1,243.56" $0.00 $0.00 $236.19 $0.00 $0.00 $247.47 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.220S SUP HCPCS C1713 04.161.220S - PLATE BONE CURVE NARROW 20 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,766.95 " "$1,307.54" $0.00 "$1,372.40" $771.98 $771.98 $0.00 $0.00 $0.00 $368.28 "$1,311.43" "$1,311.43" $0.00 $0.00 $368.23 $0.00 "$1,045.15" "$1,045.15" $0.00 $857.75 "$1,358.68" "$1,372.40" $0.00 $0.00 $260.65 $0.00 $0.00 $273.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.222S SUP HCPCS C1713 04.161.222S - PLATE BONE CURVE NARROW 22 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,766.95 " "$1,307.54" $0.00 "$1,372.40" $771.98 $771.98 $0.00 $0.00 $0.00 $368.28 "$1,311.43" "$1,311.43" $0.00 $0.00 $368.23 $0.00 "$1,045.15" "$1,045.15" $0.00 $857.75 "$1,358.68" "$1,372.40" $0.00 $0.00 $260.65 $0.00 $0.00 $273.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.240S SUP HCPCS C1713 04.161.240S - PLATE BONE CURVE NARROW 10 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,256.70 " $929.96 $0.00 $976.06 $549.03 $549.03 $0.00 $0.00 $0.00 $261.93 $932.72 $932.72 $0.00 $0.00 $261.90 $0.00 $743.34 $743.34 $0.00 $610.04 $966.30 $976.06 $0.00 $0.00 $185.38 $0.00 $0.00 $194.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.242S SUP HCPCS C1713 04.161.242S - PLATE BONE CURVE NARROW 12 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,436.63 " "$1,063.11" $0.00 "$1,115.82" $627.65 $627.65 $0.00 $0.00 $0.00 $299.43 "$1,066.26" "$1,066.26" $0.00 $0.00 $299.39 $0.00 $849.76 $849.76 $0.00 $697.39 "$1,104.67" "$1,115.82" $0.00 $0.00 $211.92 $0.00 $0.00 $222.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.244S SUP HCPCS C1713 04.161.244S - PLATE BONE CURVE NARROW 14 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,526.58 " "$1,129.67" $0.00 "$1,185.70" $666.96 $666.96 $0.00 $0.00 $0.00 $318.18 "$1,133.02" "$1,133.02" $0.00 $0.00 $318.14 $0.00 $902.97 $902.97 $0.00 $741.06 "$1,173.85" "$1,185.70" $0.00 $0.00 $225.20 $0.00 $0.00 $235.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.246S SUP HCPCS C1713 04.161.246S - PLATE BONE CURVE NARROW 16 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,705.10 " "$1,261.77" $0.00 "$1,324.36" $744.95 $744.95 $0.00 $0.00 $0.00 $355.39 "$1,265.53" "$1,265.53" $0.00 $0.00 $355.34 $0.00 "$1,008.57" "$1,008.57" $0.00 $827.73 "$1,311.12" "$1,324.36" $0.00 $0.00 $251.53 $0.00 $0.00 $263.55 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.248S SUP HCPCS C1713 04.161.248S - PLATE BONE CURVE NARROW 18 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$2,060.75 " "$1,524.96" $0.00 "$1,600.58" $900.33 $900.33 $0.00 $0.00 $0.00 $429.51 "$1,529.49" "$1,529.49" $0.00 $0.00 $429.46 $0.00 "$1,218.93" "$1,218.93" $0.00 "$1,000.36" "$1,584.58" "$1,600.58" $0.00 $0.00 $303.99 $0.00 $0.00 $318.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.250S SUP HCPCS C1713 04.161.250S - PLATE BONE CURVE NARROW 20 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$2,420.60 " "$1,791.24" $0.00 "$1,880.08" "$1,057.55" "$1,057.55" $0.00 $0.00 $0.00 $504.51 "$1,796.57" "$1,796.57" $0.00 $0.00 $504.45 $0.00 "$1,431.78" "$1,431.78" $0.00 "$1,175.05" "$1,861.28" "$1,880.08" $0.00 $0.00 $357.08 $0.00 $0.00 $374.14 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.252S SUP HCPCS C1713 04.161.252S - PLATE BONE CURVE NARROW 22 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$2,689.10 " "$1,989.93" $0.00 "$2,088.62" "$1,174.85" "$1,174.85" $0.00 $0.00 $0.00 $560.48 "$1,995.85" "$1,995.85" $0.00 $0.00 $560.41 $0.00 "$1,325.73" "$1,325.73" $0.00 "$1,305.39" "$2,067.74" "$2,088.62" $0.00 $0.00 $396.68 $0.00 $0.00 $415.64 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.270S SUP HCPCS C1713 04.161.270S - PLATE BONE CURVE BROAD 10 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP $981.18 $726.07 $0.00 $762.08 $428.67 $428.67 $0.00 $0.00 $0.00 $204.50 $728.23 $728.23 $0.00 $0.00 $204.48 $0.00 $580.37 $580.37 $0.00 $476.30 $754.46 $762.08 $0.00 $0.00 $144.74 $0.00 $0.00 $151.65 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.272S SUP HCPCS C1713 04.161.272S - PLATE BONE CURVE BROAD 12 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,248.25 " $923.71 $0.00 $969.52 $545.36 $545.36 $0.00 $0.00 $0.00 $260.17 $926.45 $926.45 $0.00 $0.00 $260.14 $0.00 $738.34 $738.34 $0.00 $605.95 $959.82 $969.52 $0.00 $0.00 $184.14 $0.00 $0.00 $192.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.274S SUP HCPCS C1713 04.161.274S - PLATE BONE CURVE BROAD 14 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,332.60 " $986.12 $0.00 "$1,035.02" $582.20 $582.20 $0.00 $0.00 $0.00 $277.75 $989.06 $989.06 $0.00 $0.00 $277.71 $0.00 $788.23 $788.23 $0.00 $646.89 "$1,024.67" "$1,035.02" $0.00 $0.00 $196.58 $0.00 $0.00 $205.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.276S SUP HCPCS C1713 04.161.276S - PLATE BONE CURVE BROAD 16 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,432.40 " "$1,059.98" $0.00 "$1,112.54" $625.80 $625.80 $0.00 $0.00 $0.00 $298.55 "$1,063.13" "$1,063.13" $0.00 $0.00 $298.51 $0.00 $847.26 $847.26 $0.00 $695.34 "$1,101.42" "$1,112.54" $0.00 $0.00 $211.30 $0.00 $0.00 $221.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.278S SUP HCPCS C1713 04.161.278S - PLATE BONE CURVE BROAD 18 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,601.08 " "$1,184.80" $0.00 "$1,243.56" $699.50 $699.50 $0.00 $0.00 $0.00 $333.70 "$1,188.32" "$1,188.32" $0.00 $0.00 $333.66 $0.00 $947.04 $947.04 $0.00 $777.23 "$1,231.12" "$1,243.56" $0.00 $0.00 $236.19 $0.00 $0.00 $247.47 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.280S SUP HCPCS C1713 04.161.280S - PLATE BONE CURVE BROAD 20 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,699.48 " "$1,257.62" $0.00 "$1,319.98" $742.49 $742.49 $0.00 $0.00 $0.00 $354.21 "$1,261.35" "$1,261.35" $0.00 $0.00 $354.17 $0.00 "$1,005.24" "$1,005.24" $0.00 $824.99 "$1,306.78" "$1,319.98" $0.00 $0.00 $250.70 $0.00 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.282S SUP HCPCS C1713 04.161.282S - PLATE BONE CURVE BROAD 22 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,783.83 " "$1,320.03" $0.00 "$1,385.50" $779.34 $779.34 $0.00 $0.00 $0.00 $371.79 "$1,323.95" "$1,323.95" $0.00 $0.00 $371.75 $0.00 "$1,055.13" "$1,055.13" $0.00 $865.94 "$1,371.65" "$1,385.50" $0.00 $0.00 $263.14 $0.00 $0.00 $275.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.284S SUP HCPCS C1713 04.161.284S - PLATE BONE CURVE BROAD 24 HOLE LCP TITANIUM PEDIATRIC SPN BOTH IP/OP "$1,783.83 " "$1,320.03" $0.00 "$1,385.50" $779.34 $779.34 $0.00 $0.00 $0.00 $371.79 "$1,323.95" "$1,323.95" $0.00 $0.00 $371.75 $0.00 "$1,055.13" "$1,055.13" $0.00 $865.94 "$1,371.65" "$1,385.50" $0.00 $0.00 $263.14 $0.00 $0.00 $275.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.286S SUP HCPCS C1713 04.161.286S - PLATE BONE 26 HOLE CVD LCP TITANIUM PEDIATRIC STERILE 3.5 MM BOTH IP/OP "$1,886.45 " "$1,395.97" $0.00 "$1,465.20" $824.18 $824.18 $0.00 $0.00 $0.00 $393.18 "$1,400.12" "$1,400.12" $0.00 $0.00 $393.14 $0.00 "$1,115.84" "$1,115.84" $0.00 $915.75 "$1,450.55" "$1,465.20" $0.00 $0.00 $278.28 $0.00 $0.00 $291.57 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.288S SUP HCPCS C1713 04.161.288S - PLATE BONE 28 HOLE CVD LCP TITANIUM PEDIATRIC STERILE 3.5 MM BOTH IP/OP "$2,064.95 " "$1,528.06" $0.00 "$1,603.86" $902.17 $902.17 $0.00 $0.00 $0.00 $430.39 "$1,532.61" "$1,532.61" $0.00 $0.00 $430.34 $0.00 "$1,221.42" "$1,221.42" $0.00 "$1,002.41" "$1,587.83" "$1,603.86" $0.00 $0.00 $304.62 $0.00 $0.00 $319.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.161.290S SUP HCPCS C1713 04.161.290S - PLATE BONE 30 HOLE CVD LCP TITANIUM PEDIATRIC STERILE 3.5 MM BOTH IP/OP "$2,244.90 " "$1,661.23" $0.00 "$1,743.60" $980.78 $980.78 $0.00 $0.00 $0.00 $467.89 "$1,666.16" "$1,666.16" $0.00 $0.00 $467.84 $0.00 "$1,327.86" "$1,327.86" $0.00 "$1,089.75" "$1,726.16" "$1,743.60" $0.00 $0.00 $331.16 $0.00 $0.00 $346.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.010 SUP HCPCS C1713 04.200.010 - SCREW BONE FULTHD 3.5MM 10MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.012 SUP HCPCS C1713 04.200.012 - SCREW BONE FULTHD 3.5MM 12MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.014 SUP HCPCS C1713 04.200.014 - SCREW BONE FULTHD 3.5MM 14MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.016 SUP HCPCS C1713 04.200.016 - SCREW BONE FULTHD 3.5MM 16MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.018 SUP HCPCS C1713 04.200.018 - SCREW BONE FULTHD 3.5MM 18MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.020 SUP HCPCS C1713 04.200.020 - SCREW BONE FULTHD 3.5MM 20MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.022 SUP HCPCS C1713 04.200.022 - SCREW BONE FULTHD 3.5MM 22MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.024 SUP HCPCS C1713 04.200.024 - SCREW BONE FULTHD 3.5MM 25MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.026 SUP HCPCS C1713 04.200.026 - SCREW BONE FULTHD 3.5MM 26MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.028 SUP HCPCS C1713 04.200.028 - SCREW BONE FULTHD 3.5MM 28MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.030 SUP HCPCS C1713 04.200.030 - SCREW BONE FULTHD 3.5MM 30MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.032 SUP HCPCS C1713 04.200.032 - SCREW BONE FULTHD 3.5MM 32MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.034 SUP HCPCS C1713 04.200.034 - SCREW BONE FULTHD 3.5MM 34MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.036 SUP HCPCS C1713 04.200.036 - SCREW BONE FULTHD 3.5MM 36MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.038 SUP HCPCS C1713 04.200.038 - SCREW BONE FULTHD 3.5MM 38MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.040 SUP HCPCS C1713 04.200.040 - SCREW BONE FULTHD 3.5MM 40MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.042 SUP HCPCS C1713 04.200.042 - SCREW BONE FULTHD 3.5MM 42MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.044 SUP HCPCS C1713 04.200.044 - SCREW BONE FULTHD 3.5MM 44MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.045 SUP HCPCS C1713 04.200.045 - SCREW BONE FULTHD 3.5MM 45MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.046 SUP HCPCS C1713 04.200.046 - SCREW BONE FULTHD 3.5MM 46MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.048 SUP HCPCS C1713 04.200.048 - SCREW BONE FULTHD 3.5MM 48MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.050 SUP HCPCS C1713 04.200.050 - SCREW BONE FULTHD 3.5MM 50MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.055 SUP HCPCS C1713 04.200.055 - SCREW BONE FULTHD 3.5MM 55MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.200.060 SUP HCPCS C1713 04.200.060 - SCREW BONE FULTHD 3.5MM 60MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $47.43 $35.10 $0.00 $36.84 $20.72 $20.72 $0.00 $0.00 $0.00 $9.88 $35.20 $35.20 $0.00 $0.00 $9.88 $0.00 $28.05 $28.05 $0.00 $23.03 $36.47 $36.84 $0.00 $0.00 $7.00 $0.00 $0.00 $7.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.014 SUP HCPCS C1713 04.204.014 - SCREW BONE 4MM 14MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.016 SUP HCPCS C1713 04.204.016 - SCREW BONE 4MM 16MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.018 SUP HCPCS C1713 04.204.018 - SCREW BONE 4MM 18MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.020 SUP HCPCS C1713 04.204.020 - SCREW BONE 4MM 20MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.022 SUP HCPCS C1713 04.204.022 - SCREW BONE 4MM 22MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.024 SUP HCPCS C1713 04.204.024 - SCREW BONE 4MM 24MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.026 SUP HCPCS C1713 04.204.026 - SCREW BONE 4MM 26MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.028 SUP HCPCS C1713 04.204.028 - SCREW BONE 4MM 28MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.030 SUP HCPCS C1713 04.204.030 - SCREW BONE 4MM 30MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.032 SUP HCPCS C1713 04.204.032 - SCREW BONE 4MM 32MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.034 SUP HCPCS C1713 04.204.034 - SCREW BONE 4MM 34MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.036 SUP HCPCS C1713 04.204.036 - SCREW BONE 4MM 36MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.038 SUP HCPCS C1713 04.204.038 - SCREW BONE 4MM 38MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.040 SUP HCPCS C1713 04.204.040 - SCREW BONE 4MM 40MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.042 SUP HCPCS C1713 04.204.042 - SCREW BONE 4MM 42MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.044 SUP HCPCS C1713 04.204.044 - SCREW BONE 4MM 44MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.046 SUP HCPCS C1713 04.204.046 - SCREW BONE 4MM 46MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.048 SUP HCPCS C1713 04.204.048 - SCREW BONE 4MM 48MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.050 SUP HCPCS C1713 04.204.050 - SCREW BONE 4MM 50MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.052 SUP HCPCS C1713 04.204.052 - SCREW BONE 4MM 52MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.054 SUP HCPCS C1713 04.204.054 - SCREW BONE 4MM 54MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.056 SUP HCPCS C1713 04.204.056 - SCREW BONE 4MM 56MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.058 SUP HCPCS C1713 04.204.058 - SCREW BONE 4MM 58MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.060 SUP HCPCS C1713 04.204.060 - SCREW BONE 4MM 60MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.204.062 SUP HCPCS C1713 04.204.062 - SCREW BONE 4MM 62MM SLFTAP LOCKING STARDRIVE RECESS LCP BOTH IP/OP $254.40 $188.26 $0.00 $203.52 $114.48 $114.48 $0.00 $0.00 $0.00 $53.02 $188.82 $188.82 $0.00 $0.00 $53.02 $0.00 $150.48 $150.48 $0.00 $127.20 $201.48 $203.52 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.025 SUP HCPCS C1713 04.205.025 - SCREW BONE 5MM 25MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.030 SUP HCPCS C1713 04.205.030 - SCREW BONE 5MM 30MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.035 SUP HCPCS C1713 04.205.035 - SCREW BONE 5MM 35MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.040 SUP HCPCS C1713 04.205.040 - SCREW BONE 5MM 40MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.045 SUP HCPCS C1713 04.205.045 - SCREW BONE 5MM 45MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.050 SUP HCPCS C1713 04.205.050 - SCREW BONE 5MM 50MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.055 SUP HCPCS C1713 04.205.055 - SCREW BONE 5MM 55MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.060 SUP HCPCS C1713 04.205.060 - SCREW BONE 5MM 60MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.065 SUP HCPCS C1713 04.205.065 - SCREW BONE 5MM 65MM CANN SELF DRILL LOCK THREAD CONICAL HEAD BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.070 SUP HCPCS C1713 04.205.070 - SCREW BONE 5MM 70MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.075 SUP HCPCS C1713 04.205.075 - SCREW BONE 5MM 75MM CANN SELF DRILL LOCK THREAD CONICAL HEAD BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.080 SUP HCPCS C1713 04.205.080 - SCREW BONE 5MM 80MM CANN SELF DRILL LOCK THREAD CONICAL HEAD BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.085 SUP HCPCS C1713 04.205.085 - SCREW BONE 5MM 85MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.090 SUP HCPCS C1713 04.205.090 - SCREW BONE 5MM 90MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.095 SUP HCPCS C1713 04.205.095 - SCREW BONE 5MM 95MM LOCK CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $368.30 $272.54 $0.00 $286.06 $160.91 $160.91 $0.00 $0.00 $0.00 $76.76 $273.35 $273.35 $0.00 $0.00 $76.75 $0.00 $217.85 $217.85 $0.00 $178.79 $283.20 $286.06 $0.00 $0.00 $54.33 $0.00 $0.00 $56.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.240 SUP HCPCS C1713 04.205.240 - SCREW BONE CONE 5MM 40MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.245 SUP HCPCS C1713 04.205.245 - SCREW BONE CONE 5MM 45MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.250 SUP HCPCS C1713 04.205.250 - SCREW BONE CONE 5MM 50MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.255 SUP HCPCS C1713 04.205.255 - SCREW BONE CONE 5MM 55MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.260 SUP HCPCS C1713 04.205.260 - SCREW BONE CONE 5MM 60MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.265 SUP HCPCS C1713 04.205.265 - SCREW BONE CONE 5MM 65MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.270 SUP HCPCS C1713 04.205.270 - SCREW BONE CONE 5MM 70MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.275 SUP HCPCS C1713 04.205.275 - SCREW BONE CONE 5MM 75MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.280 SUP HCPCS C1713 04.205.280 - SCREW BONE CONE 5MM 80MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.285 SUP HCPCS C1713 04.205.285 - SCREW BONE CONE 5MM 85MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.290 SUP HCPCS C1713 04.205.290 - SCREW BONE CONE 5MM 90MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.205.295 SUP HCPCS C1713 04.205.295 - SCREW BONE CONE 5MM 95MM CANN LCP TITANIUM PERIARTICULAR BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.078 SUP HCPCS C1713 04.210.078 - PIN FIX 1.8MM 8MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $254.43 $188.28 $0.00 $197.62 $111.16 $111.16 $0.00 $0.00 $0.00 $53.03 $188.83 $188.83 $0.00 $0.00 $53.02 $0.00 $150.49 $150.49 $0.00 $123.51 $195.65 $197.62 $0.00 $0.00 $37.53 $0.00 $0.00 $39.33 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.080 SUP HCPCS C1713 04.210.080 - PIN FIX 1.8MM 10MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.082 SUP HCPCS C1713 04.210.082 - PIN FIX 1.8MM 12MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.084 SUP HCPCS C1713 04.210.084 - PIN FIX 1.8MM 14MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.086 SUP HCPCS C1713 04.210.086 - PIN FIX 1.8MM 16MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.088 SUP HCPCS C1713 04.210.088 - PIN FIX 1.8MM 18MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.090 SUP HCPCS C1713 04.210.090 - PIN FIX 1.8MM 20MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.092 SUP HCPCS C1713 04.210.092 - PIN FIX 1.8MM 22MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.094 SUP HCPCS C1713 04.210.094 - PIN FIX 1.8MM 24MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.096 SUP HCPCS C1713 04.210.096 - PIN FIX 1.8MM 26MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.098 SUP HCPCS C1713 04.210.098 - PIN FIX 1.8MM 28MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.100 SUP HCPCS C1713 04.210.100 - PIN FIX 1.8MM 30MM BUTTRESS VAR ANG LOCKING T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.107 SUP HCPCS C1713 04.210.107 - SCREW BONE 2.4MM 7MM STARDRIVE LOCKING VAR ANG SLFTAP LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.108 SUP HCPCS C1713 04.210.108 - SCREW BONE 2.4MM 8MM T8 STARDRIVE RECESS LOCKING VAR ANG LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.109 SUP HCPCS C1713 04.210.109 - SCREW BONE 2.4MM 9MM STARDRIVE LOCKING VAR ANG SLFTAP LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.110 SUP HCPCS C1713 04.210.110 - SCREW BONE 2.4MM 10MM LOCKING VAR ANG STARDRIVE RECESS LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.111 SUP HCPCS C1713 04.210.111 - SCREW BONE 2.4MM 11MM STARDRIVE LOCKING VAR ANG SLFTAP LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.112 SUP HCPCS C1713 04.210.112 - SCREW BONE 2.4MM 12MM LOCKING VAR ANG STARDRIVE RECESS LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.113 SUP HCPCS C1713 04.210.113 - SCREW BONE 2.4MM 13MM STARDRIVE LOCKING VAR ANG SLFTAP LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.114 SUP HCPCS C1713 04.210.114 - SCREW BONE T8 2.4MM 14MM VAR ANG LOCK STARDRIVE LCP TITANIUM BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.116 SUP HCPCS C1713 04.210.116 - SCREW BONE T8 2.4MM 16MM VAR ANG LOCK STARDRIVE LCP TITANIUM BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.118 SUP HCPCS C1713 04.210.118 - SCREW BONE T8 2.4MM 18MM VAR ANG LOCK STARDRIVE LCP TITANIUM BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.120 SUP HCPCS C1713 04.210.120 - SCREW BONE T8 2.4MM 20MM VAR ANG LOCK STARDRIVE LCP TITANIUM BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.122 SUP HCPCS C1713 04.210.122 - SCREW BONE T8 2.4MM 22MM VAR ANG LOCK STARDRIVE LCP TITANIUM BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.124 SUP HCPCS C1713 04.210.124 - SCREW BONE T8 2.4MM 24MM VAR ANG LOCK STARDRIVE LCP TITANIUM BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.126 SUP HCPCS C1713 04.210.126 - SCREW BONE 2.4MM 26MM LOCKING VAR ANG STARDRIVE RECESS LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.128 SUP HCPCS C1713 04.210.128 - SCREW BONE 2.4MM 28MM LOCKING STARDRIVE RECESS VAR ANG LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.130 SUP HCPCS C1713 04.210.130 - SCREW BONE 2.4MM 30MM LOCKING STARDRIVE RECESS VAR ANG LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.132 SUP HCPCS C1713 04.210.132 - SCREW BONE 2.4MM 32MM LOCKING VAR ANG STARDRIVE RECESS LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.134 SUP HCPCS C1713 04.210.134 - SCREW BONE 2.4MM 34MM STARDRIVE LOCKING VAR ANG SLFTAP LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.136 SUP HCPCS C1713 04.210.136 - SCREW BONE 2.4MM 36MM STARDRIVE LOCKING VAR ANG SLFTAP LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.138 SUP HCPCS C1713 04.210.138 - SCREW BONE 2.4MM 38MM STARDRIVE LOCKING VAR ANG SLFTAP LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.140 SUP HCPCS C1713 04.210.140 - SCREW BONE 2.4MM 40MM STARDRIVE LOCKING VAR ANG SLFTAP LCP BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.142 SUP HCPCS C1713 04.210.142 - SCREW BONE 2.4MM 42MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.144 SUP HCPCS C1713 04.210.144 - SCREW BONE 2.4MM 44MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.146 SUP HCPCS C1713 04.210.146 - SCREW BONE 2.4MM 46MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.148 SUP HCPCS C1713 04.210.148 - SCREW BONE 2.4MM 48MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.150 SUP HCPCS C1713 04.210.150 - SCREW BONE 2.4MM 50MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.152 SUP HCPCS C1713 04.210.152 - SCREW BONE 2.4MM 52MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.154 SUP HCPCS C1713 04.210.154 - SCREW BONE 2.4MM 54MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.156 SUP HCPCS C1713 04.210.156 - SCREW BONE 2.4MM 56MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.158 SUP HCPCS C1713 04.210.158 - SCREW BONE 2.4MM 58MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.160 SUP HCPCS C1713 04.210.160 - SCREW BONE 2.4MM 60MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $250.23 $185.17 $0.00 $194.34 $109.32 $109.32 $0.00 $0.00 $0.00 $52.15 $185.72 $185.72 $0.00 $0.00 $52.15 $0.00 $148.01 $148.01 $0.00 $121.46 $192.40 $194.34 $0.00 $0.00 $36.91 $0.00 $0.00 $38.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.942 SUP HCPCS C1713 04.210.942 - SCREW BONE 2.4MM 42MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.944 SUP HCPCS C1713 04.210.944 - SCREW BONE 2.4MM 44MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.946 SUP HCPCS C1713 04.210.946 - SCREW BONE 2.4MM 46MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.948 SUP HCPCS C1713 04.210.948 - SCREW BONE 2.4MM 48MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.950 SUP HCPCS C1713 04.210.950 - SCREW BONE 2.4MM 50MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.952 SUP HCPCS C1713 04.210.952 - SCREW BONE 2.4MM 52MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.954 SUP HCPCS C1713 04.210.954 - SCREW BONE 2.4MM 54MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.956 SUP HCPCS C1713 04.210.956 - SCREW BONE 2.4MM 56MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.958 SUP HCPCS C1713 04.210.958 - SCREW BONE 2.4MM 58MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.210.960 SUP HCPCS C1713 04.210.960 - SCREW BONE 2.4MM 60MM T8 STARDRIVE RECESS VAR ANG SLFTAP LCP BOTH IP/OP $93.48 $69.18 $0.00 $72.60 $40.84 $40.84 $0.00 $0.00 $0.00 $19.48 $69.38 $69.38 $0.00 $0.00 $19.48 $0.00 $55.29 $55.29 $0.00 $45.38 $71.87 $72.60 $0.00 $0.00 $13.79 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.008 SUP HCPCS C1713 04.211.008 - SCREW BONE 2.7MM 8MM T8 STARDRIVE RECESS VAR ANG SLFTAP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.009 SUP HCPCS C1713 04.211.009 - SCREW BONE 2.7MM 9MM T8 STARDRIVE RECESS VAR ANG SLFTAP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.010 SUP HCPCS C1713 04.211.010 - SCREW BONE 2.7MM 10MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.011 SUP HCPCS C1713 04.211.011 - SCREW BONE 2.7MM 11MM T8 STARDRIVE RECESS VAR ANG SLFTAP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.012 SUP HCPCS C1713 04.211.012 - SCREW BONE 2.7MM 12MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.013 SUP HCPCS C1713 04.211.013 - SCREW BONE 2.7MM 13MM T8 STARDRIVE RECESS VAR ANG SLFTAP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.014 SUP HCPCS C1713 04.211.014 - SCREW BONE 2.7MM 14MM T8 STARDRIVE RECESS SLFTAP LOCKING VAR BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.016 SUP HCPCS C1713 04.211.016 - SCREW BONE 2.7MM 16MM LOCKING VAR ANG SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.018 SUP HCPCS C1713 04.211.018 - SCREW BONE T8 2.7MM 18MM VAR ANG SELF TAP LOCK STARDRIVE LCP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.020 SUP HCPCS C1713 04.211.020 - SCREW BONE T8 2.7MM 20MM VAR ANG SELF TAP LOCK STARDRIVE LCP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.022 SUP HCPCS C1713 04.211.022 - SCREW BONE T8 2.7MM 22MM VAR ANG SELF TAP LOCK STARDRIVE LCP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.024 SUP HCPCS C1713 04.211.024 - SCREW BONE T8 2.7MM 24MM VAR ANG SELF TAP LOCK STARDRIVE LCP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.026 SUP HCPCS C1713 04.211.026 - SCREW BONE T8 2.7MM 26MM VAR ANG SELF TAP LOCK STARDRIVE LCP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.028 SUP HCPCS C1713 04.211.028 - SCREW BONE T8 2.7MM 28MM VAR ANG SELF TAP LOCK STARDRIVE LCP BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.030 SUP HCPCS C1713 04.211.030 - SCREW BONE 2.7MM 30MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.032 SUP HCPCS C1713 04.211.032 - SCREW BONE 2.7MM 32MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.034 SUP HCPCS C1713 04.211.034 - SCREW BONE 2.7MM 34MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.036 SUP HCPCS C1713 04.211.036 - SCREW BONE 2.7MM 36MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.038 SUP HCPCS C1713 04.211.038 - SCREW BONE 2.7MM 38MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.040 SUP HCPCS C1713 04.211.040 - SCREW BONE 2.7MM 40MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.042 SUP HCPCS C1713 04.211.042 - SCREW BONE 2.7MM 42MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.044 SUP HCPCS C1713 04.211.044 - SCREW BONE 2.7MM 44MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.046 SUP HCPCS C1713 04.211.046 - SCREW BONE 2.7MM 46MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.048 SUP HCPCS C1713 04.211.048 - SCREW BONE 2.7MM 48MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.050 SUP HCPCS C1713 04.211.050 - SCREW BONE 2.7MM 50MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.052 SUP HCPCS C1713 04.211.052 - SCREW BONE 2.7MM 52MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.054 SUP HCPCS C1713 04.211.054 - SCREW BONE 2.7MM 54MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.056 SUP HCPCS C1713 04.211.056 - SCREW BONE 2.7MM 56MM VAR ANG LOCKING SLFTAP T8 STARDRIVE BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.058 SUP HCPCS C1713 04.211.058 - SCREW BONE 2.4MM 58MM LOCKING T8 STARDRIVE RECESS VAR ANG BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.060 SUP HCPCS C1713 04.211.060 - SCREW BONE 2.4MM 60MM LOCKING T8 STARDRIVE RECESS VAR ANG BOTH IP/OP $253.03 $187.24 $0.00 $196.52 $110.54 $110.54 $0.00 $0.00 $0.00 $52.74 $187.80 $187.80 $0.00 $0.00 $52.73 $0.00 $149.66 $149.66 $0.00 $122.83 $194.55 $196.52 $0.00 $0.00 $37.33 $0.00 $0.00 $39.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.201 SUP HCPCS C1713 04.211.201 - PLATE BONE XS 24MM VAR ANG LOCKING X LCP TITANIUM FRFT MIDFT BOTH IP/OP "$1,821.78 " "$1,348.12" $0.00 "$1,414.98" $795.93 $795.93 $0.00 $0.00 $0.00 $379.70 "$1,352.12" "$1,352.12" $0.00 $0.00 $379.66 $0.00 "$1,077.58" "$1,077.58" $0.00 $884.36 "$1,400.83" "$1,414.98" $0.00 $0.00 $268.74 $0.00 $0.00 $281.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.202 SUP HCPCS C1713 04.211.202 - PLATE BONE SMALL 27MM VAR ANG LOCKING X LCP TITANIUM FRFT BOTH IP/OP "$1,821.78 " "$1,348.12" $0.00 "$1,414.98" $795.93 $795.93 $0.00 $0.00 $0.00 $379.70 "$1,352.12" "$1,352.12" $0.00 $0.00 $379.66 $0.00 "$1,077.58" "$1,077.58" $0.00 $884.36 "$1,400.83" "$1,414.98" $0.00 $0.00 $268.74 $0.00 $0.00 $281.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.203 SUP HCPCS C1713 04.211.203 - PLATE BONE MEDIUM 32MM VAR ANG LOCKING X LCP TITANIUM FRFT BOTH IP/OP "$1,821.78 " "$1,348.12" $0.00 "$1,414.98" $795.93 $795.93 $0.00 $0.00 $0.00 $379.70 "$1,352.12" "$1,352.12" $0.00 $0.00 $379.66 $0.00 "$1,077.58" "$1,077.58" $0.00 $884.36 "$1,400.83" "$1,414.98" $0.00 $0.00 $268.74 $0.00 $0.00 $281.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.204 SUP HCPCS C1713 04.211.204 - PLATE BN LG X 36MM NS LCP VA LCK LOPRFL CMPR WRE HL TI BOTH IP/OP "$1,821.78 " "$1,348.12" $0.00 "$1,414.98" $795.93 $795.93 $0.00 $0.00 $0.00 $379.70 "$1,352.12" "$1,352.12" $0.00 $0.00 $379.66 $0.00 "$1,077.58" "$1,077.58" $0.00 $884.36 "$1,400.83" "$1,414.98" $0.00 $0.00 $268.74 $0.00 $0.00 $281.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.210 SUP HCPCS C1713 04.211.210 - PLATE BONE 0MM SPACER VAR ANG LOCKING LCP TITANIUM FRFT BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.211 SUP HCPCS C1713 04.211.211 - PLATE BONE 3MM SPACER VAR ANG LOCKING LCP TITANIUM FRFT BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.212 SUP HCPCS C1713 04.211.212 - PLATE BONE 4MM SPACER VAR ANG LOCKING LCP TITANIUM FRFT BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.213 SUP HCPCS C1713 04.211.213 - PLATE BONE 5MM SPACER VAR ANG LOCKING LCP TITANIUM FRFT BOTH IP/OP "$1,730.40 " "$1,280.50" $0.00 "$1,344.00" $756.00 $756.00 $0.00 $0.00 $0.00 $360.66 "$1,284.30" "$1,284.30" $0.00 $0.00 $360.62 $0.00 "$1,023.53" "$1,023.53" $0.00 $840.00 "$1,330.56" "$1,344.00" $0.00 $0.00 $255.26 $0.00 $0.00 $267.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.214 SUP HCPCS C1713 04.211.214 - PLATE BONE 6MM SPACER VAR ANG LOCKING LCP TITANIUM FRFT BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.215 SUP HCPCS C1713 04.211.215 - PLATE BONE 7MM SPACER VAR ANG LOCKING LCP TITANIUM FRFT BOTH IP/OP "$1,778.20 " "$1,315.87" $0.00 "$1,381.12" $776.88 $776.88 $0.00 $0.00 $0.00 $370.62 "$1,319.78" "$1,319.78" $0.00 $0.00 $370.58 $0.00 "$1,051.81" "$1,051.81" $0.00 $863.20 "$1,367.31" "$1,381.12" $0.00 $0.00 $262.31 $0.00 $0.00 $274.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.220 SUP HCPCS C1713 04.211.220 - PLATE BONE VAR ANG LOCKING LCP TITANIUM NAVICULAR TARSAL BOTH IP/OP "$2,168.98 " "$1,605.05" $0.00 "$1,684.64" $947.61 $947.61 $0.00 $0.00 $0.00 $452.07 "$1,609.81" "$1,609.81" $0.00 $0.00 $452.01 $0.00 "$1,282.95" "$1,282.95" $0.00 "$1,052.90" "$1,667.79" "$1,684.64" $0.00 $0.00 $319.96 $0.00 $0.00 $335.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.221 SUP HCPCS C1713 04.211.221 - PLATE BONE VAR ANG LOCKING LCP TITANIUM LEFT CUBOID TARSAL BOTH IP/OP "$2,168.98 " "$1,605.05" $0.00 "$1,684.64" $947.61 $947.61 $0.00 $0.00 $0.00 $452.07 "$1,609.81" "$1,609.81" $0.00 $0.00 $452.01 $0.00 "$1,282.95" "$1,282.95" $0.00 "$1,052.90" "$1,667.79" "$1,684.64" $0.00 $0.00 $319.96 $0.00 $0.00 $335.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.222 SUP HCPCS C1713 04.211.222 - PLATE BONE VAR ANG LOCKING LCP TITANIUM RIGHT CUBOID TARSAL BOTH IP/OP "$2,168.98 " "$1,605.05" $0.00 "$1,684.64" $947.61 $947.61 $0.00 $0.00 $0.00 $452.07 "$1,609.81" "$1,609.81" $0.00 $0.00 $452.01 $0.00 "$1,282.95" "$1,282.95" $0.00 "$1,052.90" "$1,667.79" "$1,684.64" $0.00 $0.00 $319.96 $0.00 $0.00 $335.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.224 SUP HCPCS C1713 04.211.224 - PLATE BONE 5X12 HOLE MESH VAR ANG LOCKING LCP TITANIUM BOTH IP/OP "$3,054.58 " "$2,260.39" $0.00 "$2,372.48" "$1,334.52" "$1,334.52" $0.00 $0.00 $0.00 $636.65 "$2,267.11" "$2,267.11" $0.00 $0.00 $636.57 $0.00 "$1,505.91" "$1,505.91" $0.00 "$1,482.80" "$2,348.76" "$2,372.48" $0.00 $0.00 $450.60 $0.00 $0.00 $472.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.230 SUP HCPCS C1713 04.211.230 - PLATE BN 0D SM 42MM NS LCP VA FSN LOPRFL CMPR WRE HL TI 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.231 SUP HCPCS C1713 04.211.231 - PLATE BONE 0D SMALL 42MM FUSION VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.232 SUP HCPCS C1713 04.211.232 - PLATE BONE 5D SMALL 42MM FUSION VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.233 SUP HCPCS C1713 04.211.233 - PLATE BONE 5D SMALL 42MM FUSION VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.234 SUP HCPCS C1713 04.211.234 - PLATE BONE 10D SMALL 42MM FUSION VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$1,907.53 " "$1,411.57" $0.00 "$1,481.58" $833.39 $833.39 $0.00 $0.00 $0.00 $397.58 "$1,415.77" "$1,415.77" $0.00 $0.00 $397.53 $0.00 "$1,128.30" "$1,128.30" $0.00 $925.99 "$1,466.77" "$1,481.58" $0.00 $0.00 $281.39 $0.00 $0.00 $294.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.235 SUP HCPCS C1713 04.211.235 - PLATE BONE 10D SMALL 42MM FUSION VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,907.53 " "$1,411.57" $0.00 "$1,481.58" $833.39 $833.39 $0.00 $0.00 $0.00 $397.58 "$1,415.77" "$1,415.77" $0.00 $0.00 $397.53 $0.00 "$1,128.30" "$1,128.30" $0.00 $925.99 "$1,466.77" "$1,481.58" $0.00 $0.00 $281.39 $0.00 $0.00 $294.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.236 SUP HCPCS C1713 04.211.236 - PLATE BN 0D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL TI 1ST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.237 SUP HCPCS C1713 04.211.237 - PLATE BN 0D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL TI 1ST BOTH IP/OP "$1,907.53 " "$1,411.57" $0.00 "$1,481.58" $833.39 $833.39 $0.00 $0.00 $0.00 $397.58 "$1,415.77" "$1,415.77" $0.00 $0.00 $397.53 $0.00 "$1,128.30" "$1,128.30" $0.00 $925.99 "$1,466.77" "$1,481.58" $0.00 $0.00 $281.39 $0.00 $0.00 $294.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.238 SUP HCPCS C1713 04.211.238 - PLATE BONE 5D MEDIUM 52MM FUSION VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.239 SUP HCPCS C1713 04.211.239 - PLATE BN 5D MED 52MM NS LCP VA FSN LOPRFL CMPR WRE HL TI 1ST BOTH IP/OP "$1,907.53 " "$1,411.57" $0.00 "$1,481.58" $833.39 $833.39 $0.00 $0.00 $0.00 $397.58 "$1,415.77" "$1,415.77" $0.00 $0.00 $397.53 $0.00 "$1,128.30" "$1,128.30" $0.00 $925.99 "$1,466.77" "$1,481.58" $0.00 $0.00 $281.39 $0.00 $0.00 $294.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.240 SUP HCPCS C1713 04.211.240 - PLATE BONE 10D MEDIUM 52MM FUSION VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$1,907.53 " "$1,411.57" $0.00 "$1,481.58" $833.39 $833.39 $0.00 $0.00 $0.00 $397.58 "$1,415.77" "$1,415.77" $0.00 $0.00 $397.53 $0.00 "$1,128.30" "$1,128.30" $0.00 $925.99 "$1,466.77" "$1,481.58" $0.00 $0.00 $281.39 $0.00 $0.00 $294.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.241 SUP HCPCS C1713 04.211.241 - PLATE BONE 10D MEDIUM 52MM FUSION VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,907.53 " "$1,411.57" $0.00 "$1,481.58" $833.39 $833.39 $0.00 $0.00 $0.00 $397.58 "$1,415.77" "$1,415.77" $0.00 $0.00 $397.53 $0.00 "$1,128.30" "$1,128.30" $0.00 $925.99 "$1,466.77" "$1,481.58" $0.00 $0.00 $281.39 $0.00 $0.00 $294.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.242 SUP HCPCS C1713 04.211.242 - PLATE BONE 5D LARGE 57MM FUSION VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$2,168.98 " "$1,605.05" $0.00 "$1,684.64" $947.61 $947.61 $0.00 $0.00 $0.00 $452.07 "$1,609.81" "$1,609.81" $0.00 $0.00 $452.01 $0.00 "$1,282.95" "$1,282.95" $0.00 "$1,052.90" "$1,667.79" "$1,684.64" $0.00 $0.00 $319.96 $0.00 $0.00 $335.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.243 SUP HCPCS C1713 04.211.243 - PLATE BONE 5D LARGE 57MM FUSION VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$2,168.98 " "$1,605.05" $0.00 "$1,684.64" $947.61 $947.61 $0.00 $0.00 $0.00 $452.07 "$1,609.81" "$1,609.81" $0.00 $0.00 $452.01 $0.00 "$1,282.95" "$1,282.95" $0.00 "$1,052.90" "$1,667.79" "$1,684.64" $0.00 $0.00 $319.96 $0.00 $0.00 $335.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.244 SUP HCPCS C1713 04.211.244 - PLATE BONE 0D 53MM REVISION FUSION VAR ANG LCP TITANIUM BOTH IP/OP "$2,341.88 " "$1,732.99" $0.00 "$1,818.94" "$1,023.15" "$1,023.15" $0.00 $0.00 $0.00 $488.11 "$1,738.14" "$1,738.14" $0.00 $0.00 $488.05 $0.00 "$1,385.22" "$1,385.22" $0.00 "$1,136.84" "$1,800.75" "$1,818.94" $0.00 $0.00 $345.47 $0.00 $0.00 $361.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.245 SUP HCPCS C1713 04.211.245 - PLATE BONE 0D 53MM REVISION FUSION VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$2,341.88 " "$1,732.99" $0.00 "$1,818.94" "$1,023.15" "$1,023.15" $0.00 $0.00 $0.00 $488.11 "$1,738.14" "$1,738.14" $0.00 $0.00 $488.05 $0.00 "$1,385.22" "$1,385.22" $0.00 "$1,136.84" "$1,800.75" "$1,818.94" $0.00 $0.00 $345.47 $0.00 $0.00 $361.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.246 SUP HCPCS C1713 04.211.246 - PLATE BONE LONG 39MM FUSION VAR ANG LCP TITANIUM FIRST BOTH IP/OP "$1,855.53 " "$1,373.09" $0.00 "$1,441.18" $810.66 $810.66 $0.00 $0.00 $0.00 $386.74 "$1,377.17" "$1,377.17" $0.00 $0.00 $386.69 $0.00 "$1,097.54" "$1,097.54" $0.00 $900.74 "$1,426.77" "$1,441.18" $0.00 $0.00 $273.72 $0.00 $0.00 $286.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.247 SUP HCPCS C1713 04.211.247 - PLATE BONE LONG 48MM FUSION VAR ANG LCP TITANIUM FIRST BOTH IP/OP "$1,907.53 " "$1,411.57" $0.00 "$1,481.58" $833.39 $833.39 $0.00 $0.00 $0.00 $397.58 "$1,415.77" "$1,415.77" $0.00 $0.00 $397.53 $0.00 "$1,128.30" "$1,128.30" $0.00 $925.99 "$1,466.77" "$1,481.58" $0.00 $0.00 $281.39 $0.00 $0.00 $294.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.250 SUP HCPCS C1713 04.211.250 - PLATE BONE SHORT 38MM CLOVERLEAF FUSION VAR ANG LCP TITANIUM BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.251 SUP HCPCS C1713 04.211.251 - PLATE BONE STANDARD 45MM CLOVERLEAF FUSION VAR ANG LCP BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.252 SUP HCPCS C1713 04.211.252 - PLATE BONE LONG 64MM CLOVERLEAF FUSION VAR ANG LCP TITANIUM BOTH IP/OP "$1,734.63 " "$1,283.63" $0.00 "$1,347.28" $757.85 $757.85 $0.00 $0.00 $0.00 $361.54 "$1,287.44" "$1,287.44" $0.00 $0.00 $361.50 $0.00 "$1,026.03" "$1,026.03" $0.00 $842.05 "$1,333.81" "$1,347.28" $0.00 $0.00 $255.89 $0.00 $0.00 $268.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.253 SUP HCPCS C1713 04.211.253 - PLATE BONE SHORT 35MM T FUSION VAR ANG LCP TITANIUM FRFT BOTH IP/OP "$1,603.90 " "$1,186.89" $0.00 "$1,245.74" $700.73 $700.73 $0.00 $0.00 $0.00 $334.29 "$1,190.41" "$1,190.41" $0.00 $0.00 $334.25 $0.00 $948.71 $948.71 $0.00 $778.59 "$1,233.29" "$1,245.74" $0.00 $0.00 $236.60 $0.00 $0.00 $247.90 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.254 SUP HCPCS C1713 04.211.254 - PLATE BONE STANDARD 42MM T FUSION VAR ANG LCP TITANIUM FRFT BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.255 SUP HCPCS C1713 04.211.255 - PLATE BONE LONG 61MM T FUSION VAR ANG LCP TITANIUM FRFT BOTH IP/OP "$1,734.63 " "$1,283.63" $0.00 "$1,347.28" $757.85 $757.85 $0.00 $0.00 $0.00 $361.54 "$1,287.44" "$1,287.44" $0.00 $0.00 $361.50 $0.00 "$1,026.03" "$1,026.03" $0.00 $842.05 "$1,333.81" "$1,347.28" $0.00 $0.00 $255.89 $0.00 $0.00 $268.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.256 SUP HCPCS C1713 04.211.256 - PLATE BONE SHORT 37MM L FUSION VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$1,648.88 " "$1,220.17" $0.00 "$1,280.68" $720.38 $720.38 $0.00 $0.00 $0.00 $343.67 "$1,223.80" "$1,223.80" $0.00 $0.00 $343.63 $0.00 $975.31 $975.31 $0.00 $800.43 "$1,267.87" "$1,280.68" $0.00 $0.00 $243.24 $0.00 $0.00 $254.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.257 SUP HCPCS C1713 04.211.257 - PLATE BONE SHORT 37MM L FUSION VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,648.88 " "$1,220.17" $0.00 "$1,280.68" $720.38 $720.38 $0.00 $0.00 $0.00 $343.67 "$1,223.80" "$1,223.80" $0.00 $0.00 $343.63 $0.00 $975.31 $975.31 $0.00 $800.43 "$1,267.87" "$1,280.68" $0.00 $0.00 $243.24 $0.00 $0.00 $254.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.258 SUP HCPCS C1713 04.211.258 - PLATE BONE STANDARD 37MM L FUSION VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.259 SUP HCPCS C1713 04.211.259 - PLATE BONE STANDARD 44MM L FUSION VAR ANG LCP TITANIUM LEFT BOTH IP/OP "$1,692.45 " "$1,252.41" $0.00 "$1,314.52" $739.42 $739.42 $0.00 $0.00 $0.00 $352.75 "$1,256.14" "$1,256.14" $0.00 $0.00 $352.71 $0.00 "$1,001.08" "$1,001.08" $0.00 $821.58 "$1,301.37" "$1,314.52" $0.00 $0.00 $249.66 $0.00 $0.00 $261.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.260 SUP HCPCS C1713 04.211.260 - PLATE BONE LONG 62MM L FUSION VAR ANG LCP TITANIUM RIGHT BOTH IP/OP "$1,734.63 " "$1,283.63" $0.00 "$1,347.28" $757.85 $757.85 $0.00 $0.00 $0.00 $361.54 "$1,287.44" "$1,287.44" $0.00 $0.00 $361.50 $0.00 "$1,026.03" "$1,026.03" $0.00 $842.05 "$1,333.81" "$1,347.28" $0.00 $0.00 $255.89 $0.00 $0.00 $268.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.261 SUP HCPCS C1713 04.211.261 - PLATE BN LNG L 62MM NS LCP VA FSN LOPRFL CMPR WRE HL TI BOTH IP/OP "$1,734.63 " "$1,283.63" $0.00 "$1,347.28" $757.85 $757.85 $0.00 $0.00 $0.00 $361.54 "$1,287.44" "$1,287.44" $0.00 $0.00 $361.50 $0.00 "$1,026.03" "$1,026.03" $0.00 $842.05 "$1,333.81" "$1,347.28" $0.00 $0.00 $255.89 $0.00 $0.00 $268.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.262 SUP HCPCS C1713 04.211.262 - PLATE BONE 27MM 2 HOLE STR FUSION LOCKING VAR ANG LCP BOTH IP/OP "$1,475.98 " "$1,092.23" $0.00 "$1,146.40" $644.85 $644.85 $0.00 $0.00 $0.00 $307.63 "$1,095.47" "$1,095.47" $0.00 $0.00 $307.59 $0.00 $873.04 $873.04 $0.00 $716.50 "$1,134.94" "$1,146.40" $0.00 $0.00 $217.73 $0.00 $0.00 $228.13 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.263 SUP HCPCS C1713 04.211.263 - PLATE BONE 40MM 4 HOLE STR FUSION LOCKING VAR ANG LCP BOTH IP/OP "$1,560.33 " "$1,154.64" $0.00 "$1,211.90" $681.69 $681.69 $0.00 $0.00 $0.00 $325.21 "$1,158.07" "$1,158.07" $0.00 $0.00 $325.17 $0.00 $922.93 $922.93 $0.00 $757.44 "$1,199.78" "$1,211.90" $0.00 $0.00 $230.17 $0.00 $0.00 $241.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.265 SUP HCPCS C1713 04.211.265 - PLATE BONE XLONG 92MM 3 HOLE T FUSION VAR ANG LCP TITANIUM BOTH IP/OP "$2,168.98 " "$1,605.05" $0.00 "$1,684.64" $947.61 $947.61 $0.00 $0.00 $0.00 $452.07 "$1,609.81" "$1,609.81" $0.00 $0.00 $452.01 $0.00 "$1,282.95" "$1,282.95" $0.00 "$1,052.90" "$1,667.79" "$1,684.64" $0.00 $0.00 $319.96 $0.00 $0.00 $335.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.211.266 SUP HCPCS C1713 04.211.266 - PLATE BONE 43MM TMT FUSION VAR ANG LCP TITANIUM FRFT MIDFT BOTH IP/OP "$1,686.83 " "$1,248.25" $0.00 "$1,310.16" $736.97 $736.97 $0.00 $0.00 $0.00 $351.58 "$1,251.96" "$1,251.96" $0.00 $0.00 $351.53 $0.00 $997.76 $997.76 $0.00 $818.85 "$1,297.06" "$1,310.16" $0.00 $0.00 $248.84 $0.00 $0.00 $260.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.212.054 SUP HCPCS C1713 04.212.054 - SCREW BONE 3.5MM 54MM SELF TAP LOCK LCP TITANIUM FIBULA BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.212.056 SUP HCPCS C1713 04.212.056 - SCREW BONE 3.5MM 56MM SELF TAP LOCK LCP TITANIUM FIBULA BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.212.058 SUP HCPCS C1713 04.212.058 - SCREW BONE 3.5MM 58MM SELF TAP LOCK LCP TITANIUM FIBULA BOTH IP/OP $234.75 $173.72 $0.00 $182.34 $102.57 $102.57 $0.00 $0.00 $0.00 $48.93 $174.23 $174.23 $0.00 $0.00 $48.92 $0.00 $138.85 $138.85 $0.00 $113.96 $180.52 $182.34 $0.00 $0.00 $34.63 $0.00 $0.00 $36.29 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.006 SUP HCPCS C1713 04.214.006 - SCREW BONE 1.5MM 6MM LOCKING SLFTAP T4 STARDRIVE RECESS BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.007 SUP HCPCS C1713 04.214.007 - SCREW BONE 1.5MM 7MM LOCKING SLFTAP T4 STARDRIVE RECESS BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.008 SUP HCPCS C1713 04.214.008 - SCREW BONE 1.5MM 8MM LOCKING SLFTAP T4 STARDRIVE RECESS BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.009 SUP HCPCS C1713 04.214.009 - SCREW BONE 1.5MM 9MM LOCKING SLFTAP T4 STARDRIVE RECESS BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.010 SUP HCPCS C1713 04.214.010 - SCREW BONE 1.5MM 10MM LOCKING SLFTAP T4 STARDRIVE RECESS BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.011 SUP HCPCS C1713 04.214.011 - SCREW BONE 1.5MM 11MM LOCKING SLFTAP T4 STARDRIVE RECESS BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.012 SUP HCPCS C1713 04.214.012 - SCREW BONE 1.5MM 12MM LOCKING SLFTAP T4 STARDRIVE RECESS BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.013 SUP HCPCS C1713 04.214.013 - SCREW BONE 1.5MM 13MM SLFTAP STARDRIVE TITANIUM ALLOY BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.014 SUP HCPCS C1713 04.214.014 - SCREW BONE 1.5MM 14MM SLFTAP STARDRIVE TITANIUM ALLOY BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.015 SUP HCPCS C1713 04.214.015 - SCREW BONE 1.5MM 15MM SLFTAP STARDRIVE TITANIUM ALLOY BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.016 SUP HCPCS C1713 04.214.016 - SCREW BONE 1.5MM 16MM SLFTAP STARDRIVE TITANIUM ALLOY BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.018 SUP HCPCS C1713 04.214.018 - SCREW BONE 1.5MM 18MM SLFTAP STARDRIVE TITANIUM ALLOY BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.020 SUP HCPCS C1713 04.214.020 - SCREW BONE 1.5MM 20MM SLFTAP STARDRIVE TITANIUM ALLOY BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.022 SUP HCPCS C1713 04.214.022 - SCREW BONE 1.5MM 22MM LOCKING SLFTAP COMPACT STARDRIVE LCP BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.024 SUP HCPCS C1713 04.214.024 - SCREW BONE 1.5MM 24MM LOCKING SLFTAP COMPACT STARDRIVE LCP BOTH IP/OP $208.05 $153.96 $0.00 $161.58 $90.89 $90.89 $0.00 $0.00 $0.00 $43.36 $154.41 $154.41 $0.00 $0.00 $43.36 $0.00 $123.06 $123.06 $0.00 $100.99 $159.97 $161.58 $0.00 $0.00 $30.69 $0.00 $0.00 $32.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.106 SUP HCPCS C1713 04.214.106 - SCREW BONE 1.5MM 6MM SLFTAP COMPACT STARDRIVE LCP TITANIUM BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.107 SUP HCPCS C1713 04.214.107 - SCREW BONE 1.5MM 7MM SLFTAP COMPACT STARDRIVE LCP TITANIUM BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.108 SUP HCPCS C1713 04.214.108 - SCREW BONE 1.5MM 8MM SLFTAP COMPACT STARDRIVE LCP TITANIUM BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.109 SUP HCPCS C1713 04.214.109 - SCREW BONE 1.5MM 9MM SLFTAP COMPACT STARDRIVE LCP TITANIUM BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.110 SUP HCPCS C1713 04.214.110 - SCREW BONE 1.5MM 8MM SLFTAP COMPACT STARDRIVE LCP TITANIUM BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.111 SUP HCPCS C1713 04.214.111 - SCREW BONE 1.5MM 11MM SLFTAP COMPACT STARDRIVE LCP TITANIUM BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.112 SUP HCPCS C1713 04.214.112 - SCREW BONE 1.5MM 12MM SLFTAP COMPACT STARDRIVE LCP TITANIUM BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.113 SUP HCPCS C1713 04.214.113 - SCREW BONE 1.5MM 13MM SLFTAP COMPACT STARDRIVE LCP TITANIUM BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.114 SUP HCPCS C1713 04.214.114 - SCREW BONE 1.5MM 14MM SLFTAP LCP STARDRIVE TITANIUM ALLOY BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.115 SUP HCPCS C1713 04.214.115 - SCREW BONE 1.5MM 15MM SLFTAP T4 STARDRIVE RECESS MODULAR LCP BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.116 SUP HCPCS C1713 04.214.116 - SCREW BONE 1.5MM 16MM SLFTAP T4 STARDRIVE RECESS MODULAR LCP BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.118 SUP HCPCS C1713 04.214.118 - SCREW BONE 1.5MM 18MM SLFTAP T4 STARDRIVE RECESS MODULAR LCP BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.120 SUP HCPCS C1713 04.214.120 - SCREW BONE 1.5MM 20MM SLFTAP T4 STARDRIVE RECESS MODULAR LCP BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.122 SUP HCPCS C1713 04.214.122 - SCREW BONE 1.5MM 22MM SLFTAP T4 STARDRIVE RECESS MODULAR LCP BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.214.124 SUP HCPCS C1713 04.214.124 - SCREW BONE 1.5MM 24MM SLFTAP T4 STARDRIVE RECESS MODULAR LCP BOTH IP/OP $84.35 $62.42 $0.00 $65.50 $36.84 $36.84 $0.00 $0.00 $0.00 $17.58 $62.60 $62.60 $0.00 $0.00 $17.58 $0.00 $49.89 $49.89 $0.00 $40.94 $64.85 $65.50 $0.00 $0.00 $12.44 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.002S SUP HCPCS C1713 04.221.002S - BUTTON FIX 2.5MM CERCLAGE HEXAGONAL STARDRIVE RECESS BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.003S SUP HCPCS C1713 04.221.003S - BUTTON FIX HEXAGON 3.5MM CERCLAGE T25 STARDRIVE TITANIUM BOTH IP/OP $341.58 $252.77 $0.00 $265.30 $149.23 $149.23 $0.00 $0.00 $0.00 $71.19 $253.52 $253.52 $0.00 $0.00 $71.18 $0.00 $202.04 $202.04 $0.00 $165.81 $262.65 $265.30 $0.00 $0.00 $50.39 $0.00 $0.00 $52.79 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.004S SUP HCPCS C1713 04.221.004S - NAIL INTRAMEDULLARY 4MM CANN HEXAGONAL TITANIUM ORTHOPEDIC BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $149.85 $149.85 $0.00 $0.00 $0.00 $71.49 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $202.88 $202.88 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $50.60 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.005S SUP Custom 27803010 04.221.005S - CABLE ORTHOPEDIC 5MM POSITIONING PIN CRIMP STAINLESS STEEL BOTH IP/OP $515.90 $381.77 $0.00 $400.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.90 $382.90 $0.00 $0.00 $107.51 $0.00 $0.00 $0.00 $0.00 $250.44 $396.70 $400.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.508 SUP HCPCS C1713 04.221.508 - SCREW BONE 5MM 8MM SLFTAP LOCKING STARDRIVE PERIPROSTHETIC BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.510 SUP HCPCS C1713 04.221.510 - SCREW BONE 5MM 10MM SLFTAP LOCKING STARDRIVE RECESS BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.512 SUP HCPCS C1713 04.221.512 - SCREW BONE 5MM 12MM SLFTAP LOCKING STARDRIVE RECESS TITANIUM BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.514 SUP HCPCS C1713 04.221.514 - SCREW BONE 5MM 14MM SLFTAP LOCKING STARDRIVE RECESS TITANIUM BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.221.518 SUP HCPCS C1713 04.221.518 - SCREW BONE 5MM 18MM SLFTAP LOCKING STARDRIVE RECESS TITANIUM BOTH IP/OP $397.80 $294.37 $0.00 $308.98 $173.80 $173.80 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $193.11 $305.89 $308.98 $0.00 $0.00 $58.68 $0.00 $0.00 $61.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.010 SUP HCPCS C1713 04.226.010 - SCREW BONE SHORT THREAD 3MM 10MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.011 SUP HCPCS C1713 04.226.011 - SCREW BONE SHORT THREAD 3MM 11MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.012 SUP HCPCS C1713 04.226.012 - SCREW BONE SHORT THREAD 3MM 12MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.013 SUP HCPCS C1713 04.226.013 - SCREW BONE SHORT THREAD 3MM 13MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.014 SUP HCPCS C1713 04.226.014 - SCREW BONE SHORT THREAD 3MM 14MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.015 SUP HCPCS C1713 04.226.015 - SCREW BONE SHORT THREAD 3MM 15MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.016 SUP HCPCS C1713 04.226.016 - SCREW BONE SHORT THREAD 3MM 16MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.017 SUP HCPCS C1713 04.226.017 - SCREW BONE SHORT THREAD 3MM 17MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.018 SUP HCPCS C1713 04.226.018 - SCREW BONE SHORT THREAD 3MM 18MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.019 SUP HCPCS C1713 04.226.019 - SCREW BONE SHORT THREAD 3MM 19MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.020 SUP HCPCS C1713 04.226.020 - SCREW BONE SHORT THREAD 3MM 20MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.021 SUP HCPCS C1713 04.226.021 - SCREW BONE SHORT THREAD 3MM 21MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.022 SUP HCPCS C1713 04.226.022 - SCREW BONE SHORT THREAD 3MM 22MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.023 SUP HCPCS C1713 04.226.023 - SCREW BONE SHORT THREAD 3MM 23MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.024 SUP HCPCS C1713 04.226.024 - SCREW BONE SHORT THREAD 3MM 24MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.025 SUP HCPCS C1713 04.226.025 - SCREW BONE SHORT THREAD 3MM 25MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.026 SUP HCPCS C1713 04.226.026 - SCREW BONE SHORT THREAD 3MM 26MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.027 SUP HCPCS C1713 04.226.027 - SCREW BONE SHORT THREAD 3MM 27MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.028 SUP HCPCS C1713 04.226.028 - SCREW BONE SHORT THREAD 3MM 28MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.029 SUP HCPCS C1713 04.226.029 - SCREW BONE SHORT THREAD 3MM 29MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.030 SUP HCPCS C1713 04.226.030 - SCREW BONE SHORT THREAD 3MM 30MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.032 SUP HCPCS C1713 04.226.032 - SCREW BONE SHORT THREAD 3MM 32MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.034 SUP HCPCS C1713 04.226.034 - SCREW BONE SHORT THREAD 3MM 34MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.036 SUP HCPCS C1713 04.226.036 - SCREW BONE SHORT THREAD 3MM 36MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.038 SUP HCPCS C1713 04.226.038 - SCREW BONE SHORT THREAD 3MM 38MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.040 SUP HCPCS C1713 04.226.040 - SCREW BONE SHORT THREAD 3MM 40MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.116 SUP HCPCS C1713 04.226.116 - SCREW BONE LNGTHRD 3MM 16MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.117 SUP HCPCS C1713 04.226.117 - SCREW BONE 3MM 17MM 6MM COMPRESSION TITANIUM SMALL BONE BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.118 SUP HCPCS C1713 04.226.118 - SCREW BONE LNGTHRD 3MM 18MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.119 SUP HCPCS C1713 04.226.119 - SCREW BONE LNGTHRD 3MM 19MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.120 SUP HCPCS C1713 04.226.120 - SCREW BONE 3MM 20MM 7MM COMPRESSION TITANIUM SMALL BONE BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.121 SUP HCPCS C1713 04.226.121 - SCREW BONE LNGTHRD 3MM 21MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.122 SUP HCPCS C1713 04.226.122 - SCREW BONE LNGTHRD 3MM 22MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.123 SUP HCPCS C1713 04.226.123 - SCREW BONE LNGTHRD 3MM 23MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.124 SUP HCPCS C1713 04.226.124 - SCREW BONE LNGTHRD 3MM 24MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.125 SUP HCPCS C1713 04.226.125 - SCREW BONE LNGTHRD 3MM 25MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.126 SUP HCPCS C1713 04.226.126 - SCREW BONE LNGTHRD 3MM 26MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.127 SUP HCPCS C1713 04.226.127 - SCREW BONE LNGTHRD 3MM 27MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.128 SUP HCPCS C1713 04.226.128 - SCREW BONE LNGTHRD 3MM 28MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.129 SUP HCPCS C1713 04.226.129 - SCREW BONE LNGTHRD 3MM 29MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.130 SUP HCPCS C1713 04.226.130 - SCREW BONE LNGTHRD 3MM 30MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.132 SUP HCPCS C1713 04.226.132 - SCREW BONE LNGTHRD 3MM 32MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.134 SUP HCPCS C1713 04.226.134 - SCREW BONE LNGTHRD 3MM 34MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.136 SUP HCPCS C1713 04.226.136 - SCREW BONE LNGTHRD 3MM 36MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.138 SUP HCPCS C1713 04.226.138 - SCREW BONE LNGTHRD 3MM 38MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.140 SUP HCPCS C1713 04.226.140 - SCREW BONE LNGTHRD 3MM 40MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.209 SUP HCPCS C1713 04.226.209 - SCREW BONE SHORT THREAD 2.4MM 9MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.210 SUP HCPCS C1713 04.226.210 - SCREW BONE SHORT THREAD 2.4MM 10MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.211 SUP HCPCS C1713 04.226.211 - SCREW BONE SHORT THREAD 2.4MM 11MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.212 SUP HCPCS C1713 04.226.212 - SCREW BONE SHORT THREAD 2.4MM 12MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.213 SUP HCPCS C1713 04.226.213 - SCREW BONE SHORT THREAD 2.4MM 13MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.214 SUP HCPCS C1713 04.226.214 - SCREW BONE SHORT THREAD 2.4MM 14MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.215 SUP HCPCS C1713 04.226.215 - SCREW BONE SHORT THREAD 2.4MM 15MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.216 SUP HCPCS C1713 04.226.216 - SCREW BONE SHORT THREAD 2.4MM 16MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.217 SUP HCPCS C1713 04.226.217 - SCREW BONE SHORT THREAD 2.4MM 17MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.218 SUP HCPCS C1713 04.226.218 - SCREW BONE 2.4MM 18MM 4MM COMPRESSION TITANIUM SMALL BONE BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.219 SUP HCPCS C1713 04.226.219 - SCREW BONE SHORT THREAD 2.4MM 19MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.220 SUP HCPCS C1713 04.226.220 - SCREW BONE 2.4MM 20MM 4MM COMPRESSION TITANIUM SMALL BONE BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.221 SUP HCPCS C1713 04.226.221 - SCREW BONE SHORT THREAD 2.4MM 21MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.222 SUP HCPCS C1713 04.226.222 - SCREW BONE SHORT THREAD 2.4MM 22MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.223 SUP HCPCS C1713 04.226.223 - SCREW BONE SHORT THREAD 2.4MM 23MM 4MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.224 SUP HCPCS C1713 04.226.224 - SCREW BONE SHORT THREAD 2.4MM 24MM 5MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.225 SUP HCPCS C1713 04.226.225 - SCREW BONE SHORT THREAD 2.4MM 25MM 5MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.226 SUP HCPCS C1713 04.226.226 - SCREW BONE SHORT THREAD 2.4MM 26MM 5MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.227 SUP HCPCS C1713 04.226.227 - SCREW BONE SHORT THREAD 2.4MM 27MM 6MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.228 SUP HCPCS C1713 04.226.228 - SCREW BONE SHORT THREAD 2.4MM 28MM 6MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.229 SUP HCPCS C1713 04.226.229 - SCREW BONE SHORT THREAD 2.4MM 29MM 6MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.230 SUP HCPCS C1713 04.226.230 - SCREW BONE 2.4MM 30MM 7MM COMPRESSION TITANIUM SMALL BONE BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.232 SUP HCPCS C1713 04.226.232 - SCREW BONE SHORT THREAD 2.4MM 32MM 7MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.234 SUP HCPCS C1713 04.226.234 - SCREW BONE SHORT THREAD 2.4MM 34MM 8MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.236 SUP HCPCS C1713 04.226.236 - SCREW BONE SHORT THREAD 2.4MM 36MM 9MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.238 SUP HCPCS C1713 04.226.238 - SCREW BONE SHORT THREAD 2.4MM 38MM 9MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.240 SUP HCPCS C1713 04.226.240 - SCREW BONE 2.4MM 40MM 10MM COMPRESSION SHORT THREAD HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.317 SUP HCPCS C1713 04.226.317 - SCREW BONE LNGTHRD 2.4MM 17MM 6MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.318 SUP HCPCS C1713 04.226.318 - SCREW BONE LNGTHRD 2.4MM 18MM 6MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.319 SUP HCPCS C1713 04.226.319 - SCREW BONE LNGTHRD 2.4MM 19MM 7MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.320 SUP HCPCS C1713 04.226.320 - SCREW BONE LNGTHRD 2.4MM 20MM 7MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.321 SUP HCPCS C1713 04.226.321 - SCREW BONE LNGTHRD 2.4MM 21MM 8MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.322 SUP HCPCS C1713 04.226.322 - SCREW BONE LNGTHRD 2.4MM 22MM 8MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.323 SUP HCPCS C1713 04.226.323 - SCREW BONE LNGTHRD 2.4MM 23MM 8MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.324 SUP HCPCS C1713 04.226.324 - SCREW BONE LNGTHRD 2.4MM 24MM 8MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.325 SUP HCPCS C1713 04.226.325 - SCREW BONE LNGTHRD 2.4MM 25MM 8MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.326 SUP HCPCS C1713 04.226.326 - SCREW BONE LNGTHRD 2.4MM 26MM 10MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.327 SUP HCPCS C1713 04.226.327 - SCREW BONE LNGTHRD 2.4MM 27MM 10MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.328 SUP HCPCS C1713 04.226.328 - SCREW BONE LNGTHRD 2.4MM 28MM 10MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.329 SUP HCPCS C1713 04.226.329 - SCREW BONE LNGTHRD 2.4MM 29MM 10MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.330 SUP HCPCS C1713 04.226.330 - SCREW BONE LNGTHRD 2.4MM 30MM 12MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.332 SUP HCPCS C1713 04.226.332 - SCREW BONE LNGTHRD 2.4MM 32MM 12MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.334 SUP HCPCS C1713 04.226.334 - SCREW BONE LNGTHRD 2.4MM 34MM 14MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.336 SUP HCPCS C1713 04.226.336 - SCREW BONE LNGTHRD 2.4MM 36MM 14MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.338 SUP HCPCS C1713 04.226.338 - SCREW BONE LNGTHRD 2.4MM 38MM 16MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.340 SUP HCPCS C1713 04.226.340 - SCREW BONE LNGTHRD 2.4MM 40MM 16MM COMPRESSION HEADLESS BOTH IP/OP $641.00 $474.34 $0.00 $497.86 $280.05 $280.05 $0.00 $0.00 $0.00 $133.60 $475.75 $475.75 $0.00 $0.00 $133.58 $0.00 $379.15 $379.15 $0.00 $311.16 $492.89 $497.86 $0.00 $0.00 $94.56 $0.00 $0.00 $99.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.620 SUP HCPCS C1713 04.226.620 - SCREW BONE SHORT THREAD 4.5MM 20MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.622 SUP HCPCS C1713 04.226.622 - SCREW BONE SHORT THREAD 4.5MM 22MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.624 SUP HCPCS C1713 04.226.624 - SCREW BONE SHORT THREAD 4.5MM 24MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.626 SUP HCPCS C1713 04.226.626 - SCREW BONE SHORT THREAD 4.5MM 26MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.628 SUP HCPCS C1713 04.226.628 - SCREW BONE SHORT THREAD 4.5MM 28MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.630 SUP HCPCS C1713 04.226.630 - SCREW BONE SHORT THREAD 4.5MM 30MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.632 SUP HCPCS C1713 04.226.632 - SCREW BONE SHORT THREAD 4.5MM 32MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.634 SUP HCPCS C1713 04.226.634 - SCREW BONE SHORT THREAD 4.5MM 34MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.636 SUP HCPCS C1713 04.226.636 - SCREW BONE SHORT THREAD 4.5MM 36MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.638 SUP HCPCS C1713 04.226.638 - SCREW BONE SHORT THREAD 4.5MM 38MM 7MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.640 SUP HCPCS C1713 04.226.640 - SCREW BONE SHORT THREAD 4.5MM 40MM 8MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.642 SUP HCPCS C1713 04.226.642 - SCREW BONE SHORT THREAD 4.5MM 42MM 8MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.644 SUP HCPCS C1713 04.226.644 - SCREW BONE SHORT THREAD 4.5MM 44MM 9MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.646 SUP HCPCS C1713 04.226.646 - SCREW BONE SHORT THREAD 4.5MM 46MM 9MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.648 SUP HCPCS C1713 04.226.648 - SCREW BONE SHORT THREAD 4.5MM 48MM 9MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.650 SUP HCPCS C1713 04.226.650 - SCREW BONE SHORT THREAD 4.5MM 50MM 10MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.652 SUP HCPCS C1713 04.226.652 - SCREW BONE SHORT THREAD 4.5MM 52MM 10MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.654 SUP HCPCS C1713 04.226.654 - SCREW BONE SHORT THREAD 6.5MM 54MM 16MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.656 SUP HCPCS C1713 04.226.656 - SCREW BONE SHORT THREAD 4.5MM 56MM 11MM COMPRESSION HEADLESS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.658 SUP HCPCS C1713 04.226.658 - SCREW BONE SHORT THREAD 4.5MM 58MM 11MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.660 SUP HCPCS C1713 04.226.660 - SCREW BONE SHORT THREAD 4.5MM 60MM 12MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.665 SUP HCPCS C1713 04.226.665 - SCREW BONE SHORT THREAD 4.5MM 65MM 13MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.670 SUP HCPCS C1713 04.226.670 - SCREW BONE SHORT THREAD 4.5MM 70MM 14MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.675 SUP HCPCS C1713 04.226.675 - SCREW BONE SHORT THREAD 4.5MM 75MM 15MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.680 SUP HCPCS C1713 04.226.680 - SCREW BONE SHORT THREAD 4.5MM 80MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.685 SUP HCPCS C1713 04.226.685 - SCREW BONE SHORT THREAD 4.5MM 85MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.690 SUP HCPCS C1713 04.226.690 - SCREW BONE SHORT THREAD 4.5MM 90MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.695 SUP HCPCS C1713 04.226.695 - SCREW BONE SHORT THREAD 4.5MM 95MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.700 SUP HCPCS C1713 04.226.700 - SCREW BONE SHORT THREAD 4.5MM 100MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.730 SUP HCPCS C1713 04.226.730 - SCREW BONE LNGTHRD 4.5MM 32MM 12MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.732 SUP HCPCS C1713 04.226.732 - SCREW BONE LNGTHRD 4.5MM 32MM 12MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.734 SUP HCPCS C1713 04.226.734 - SCREW BONE LNGTHRD 4.5MM 34MM 12MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.736 SUP HCPCS C1713 04.226.736 - SCREW BONE LNGTHRD 4.5MM 36MM 14MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.738 SUP HCPCS C1713 04.226.738 - SCREW BONE LNGTHRD 4.5MM 38MM 14MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.740 SUP HCPCS C1713 04.226.740 - SCREW BONE LNGTHRD 4.5MM 40MM 16MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.742 SUP HCPCS C1713 04.226.742 - SCREW BONE LNGTHRD 4.5MM 42MM 16MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.744 SUP HCPCS C1713 04.226.744 - SCREW BONE LNGTHRD 4.5MM 44MM 18MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.746 SUP HCPCS C1713 04.226.746 - SCREW BONE LNGTHRD 4.5MM 46MM 18MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.748 SUP HCPCS C1713 04.226.748 - SCREW BONE LNGTHRD 4.5MM 48MM 18MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.750 SUP HCPCS C1713 04.226.750 - SCREW BONE LNGTHRD 4.5MM 50MM 20MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.752 SUP HCPCS C1713 04.226.752 - SCREW BONE LNGTHRD 4.5MM 52MM 20MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.754 SUP HCPCS C1713 04.226.754 - SCREW BONE LNGTHRD 4.5MM 54MM 22MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.756 SUP HCPCS C1713 04.226.756 - SCREW BONE LNGTHRD 4.5MM 56MM 22MM COMPRESSION HEADLESS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.758 SUP HCPCS C1713 04.226.758 - SCREW BONE LNGTHRD 4.5MM 58MM 22MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.760 SUP HCPCS C1713 04.226.760 - SCREW BONE LNGTHRD 4.5MM 60MM 24MM COMPRESSION HEADLESS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.765 SUP HCPCS C1713 04.226.765 - SCREW BONE LNGTHRD 4.5MM 65MM 26MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.770 SUP HCPCS C1713 04.226.770 - SCREW BONE LNGTHRD 4.5MM 70MM 28MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.775 SUP HCPCS C1713 04.226.775 - SCREW BONE LNGTHRD 4.5MM 75MM 30MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.780 SUP HCPCS C1713 04.226.780 - SCREW BONE LNGTHRD 4.5MM 80MM 32MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.785 SUP HCPCS C1713 04.226.785 - SCREW BONE LNGTHRD 4.5MM 85MM 34MM COMPRESSION HEADLESS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.790 SUP HCPCS C1713 04.226.790 - SCREW BONE LNGTHRD 4.5MM 90MM 36MM COMPRESSION HEADLESS BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.795 SUP HCPCS C1713 04.226.795 - SCREW BONE LNGTHRD 4.5MM 95MM 38MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.226.800 SUP HCPCS C1713 04.226.800 - SCREW BONE LNGTHRD 4.5MM 100MM 40MM HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.030 SUP HCPCS C1713 04.227.030 - SCREW BONE 6.5MM 30MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.035 SUP HCPCS C1713 04.227.035 - SCREW BONE 6.5MM 35MM 16MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.040 SUP HCPCS C1713 04.227.040 - SCREW BONE 6.5MM 40MM 16MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.045 SUP HCPCS C1713 04.227.045 - SCREW BONE 6.5MM 45MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.050 SUP HCPCS C1713 04.227.050 - SCREW BONE 6.5MM 50MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.055 SUP HCPCS C1713 04.227.055 - SCREW BONE 6.5MM 55MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.060 SUP HCPCS C1713 04.227.060 - SCREW BONE 6.5MM 60MM 16MM HEADLESS COMPRESSION THREADED SET BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.065 SUP HCPCS C1713 04.227.065 - SCREW BONE 6.5MM 65MM 16MM HEADLESS COMPRESSION THREADED SET BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.070 SUP HCPCS C1713 04.227.070 - SCREW BONE 6.5MM 70MM 16MM COMPRESSION THREAD TITANIUM FEMUR BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.075 SUP HCPCS C1713 04.227.075 - SCREW BONE 6.5MM 75MM 16MM HEADLESS COMPRESSION THREADED SET BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.080 SUP HCPCS C1713 04.227.080 - SCREW BONE 6.5MM 80MM 16MM HEADLESS COMPRESSION THREADED SET BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.085 SUP HCPCS C1713 04.227.085 - SCREW BONE 6.5MM 85MM 16MM COMPRESSION HEADLESS THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.090 SUP HCPCS C1713 04.227.090 - SCREW BONE 6.5MM 90MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.095 SUP HCPCS C1713 04.227.095 - SCREW BONE 6.5MM 95MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.100 SUP HCPCS C1713 04.227.100 - SCREW BONE 6.5MM 100MM 16MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.105 SUP HCPCS C1713 04.227.105 - SCREW BONE 6.5MM 105MM 16MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.110 SUP HCPCS C1713 04.227.110 - SCREW BONE 6.5MM 105MM 16MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.115 SUP HCPCS C1713 04.227.115 - SCREW BONE 6.5MM 115MM 16MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.120 SUP HCPCS C1713 04.227.120 - SCREW BONE 6.5MM 120MM 16MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.125 SUP HCPCS C1713 04.227.125 - SCREW BONE 6.5MM 125MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.130 SUP HCPCS C1713 04.227.130 - SCREW BONE 6.5MM 130MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.135 SUP HCPCS C1713 04.227.135 - SCREW BONE 6.5MM 135MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.140 SUP HCPCS C1713 04.227.140 - SCREW BONE 6.5MM 140MM 16MM HEADLESS COMPRESSION THREADED BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.145 SUP HCPCS C1713 04.227.145 - SCREW BONE 6.5MM 145MM 16MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.150 SUP HCPCS C1713 04.227.150 - SCREW BONE 6.5MM 150MM 16MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.245 SUP HCPCS C1713 04.227.245 - SCREW BONE 6.5MM 45MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.250 SUP HCPCS C1713 04.227.250 - SCREW BONE 6.5MM 50MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.255 SUP HCPCS C1713 04.227.255 - SCREW BONE 6.5MM 55MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.260 SUP HCPCS C1713 04.227.260 - SCREW BONE 6.5MM 60MM 32MM COMPRESSION HEADLESS TITANIUM BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.265 SUP HCPCS C1713 04.227.265 - SCREW BONE 6.5MM 65MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.270 SUP HCPCS C1713 04.227.270 - SCREW BONE 6.5MM 70MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.275 SUP HCPCS C1713 04.227.275 - SCREW BONE 6.5MM 75MM 32MM COMPRESSION THREAD TITANIUM FEMUR BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.280 SUP HCPCS C1713 04.227.280 - SCREW BONE 6.5MM 80MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.285 SUP HCPCS C1713 04.227.285 - SCREW BONE 6.5MM 85MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.290 SUP HCPCS C1713 04.227.290 - SCREW BONE 6.5MM 90MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.295 SUP HCPCS C1713 04.227.295 - SCREW BONE 6.5MM 95MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.300 SUP HCPCS C1713 04.227.300 - SCREW BONE 6.5MM 100MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.305 SUP HCPCS C1713 04.227.305 - SCREW BONE 6.5MM 105MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.310 SUP HCPCS C1713 04.227.310 - SCREW BONE 6.5MM 110MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.315 SUP HCPCS C1713 04.227.315 - SCREW BONE 6.5MM 115MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.320 SUP HCPCS C1713 04.227.320 - SCREW BONE 6.5MM 120MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.325 SUP HCPCS C1713 04.227.325 - SCREW BONE 6.5MM 125MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.330 SUP HCPCS C1713 04.227.330 - SCREW BONE 6.5MM 130MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.335 SUP HCPCS C1713 04.227.335 - SCREW BONE 6.5MM 135MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.340 SUP HCPCS C1713 04.227.340 - SCREW BONE 6.5MM 140MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.345 SUP HCPCS C1713 04.227.345 - SCREW BONE 6.5MM 145MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.227.350 SUP HCPCS C1713 04.227.350 - SCREW BONE 6.5MM 150MM 32MM THREADED HEADLESS COMPRESSION BOTH IP/OP $649.43 $480.58 $0.00 $504.42 $283.74 $283.74 $0.00 $0.00 $0.00 $135.36 $482.00 $482.00 $0.00 $0.00 $135.34 $0.00 $384.13 $384.13 $0.00 $315.26 $499.38 $504.42 $0.00 $0.00 $95.80 $0.00 $0.00 $100.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.109 SUP HCPCS C1713 04.230.109 - SCREW BONE 1.5MM 9MM 4MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.110 SUP HCPCS C1713 04.230.110 - SCREW BONE 1.5MM 10MM 4MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.111 SUP HCPCS C1713 04.230.111 - SCREW BONE 1.5MM 11MM 4MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.112 SUP HCPCS C1713 04.230.112 - SCREW BONE 1.5MM 12MM 4MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.113 SUP HCPCS C1713 04.230.113 - SCREW BONE 1.5MM 13MM 4MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.114 SUP HCPCS C1713 04.230.114 - SCREW BONE 1.5MM 14MM 4MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.115 SUP HCPCS C1713 04.230.115 - SCREW BONE 1.5MM 15MM 4MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.116 SUP HCPCS C1713 04.230.116 - SCREW BONE 1.5MM 16MM 5MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.117 SUP HCPCS C1713 04.230.117 - SCREW BONE 1.5MM 17MM 5MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.118 SUP HCPCS C1713 04.230.118 - SCREW BONE 1.5MM 18MM 5MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.119 SUP HCPCS C1713 04.230.119 - SCREW BONE 1.5MM 19MM 5MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.230.120 SUP HCPCS C1713 04.230.120 - SCREW BONE 1.5MM 20MM 6MM HEADLESS COMPRESSION THREAD BOTH IP/OP $486.38 $359.92 $0.00 $377.76 $212.49 $212.49 $0.00 $0.00 $0.00 $101.37 $360.99 $360.99 $0.00 $0.00 $101.36 $0.00 $287.69 $287.69 $0.00 $236.10 $373.98 $377.76 $0.00 $0.00 $71.75 $0.00 $0.00 $75.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.003 SUP HCPCS C1713 04.305.003 - SCREW BONE 2.5/4MM 50MM BLUNT TIP SCHANZ TITANIUM MANDIB BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.004 SUP HCPCS C1713 04.305.004 - SCREW BONE 2.5/4MM 60MM BLUNT TIP SCHANZ TITANIUM MANDIB BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.005 SUP HCPCS C1713 04.305.005 - SCREW BONE 2.5/4MM 70MM BLUNT TIP SCHANZ TITANIUM MANDIB BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.010 SUP HCPCS C1713 04.305.010 - SCREW BONE 2.5/4MM 50MM SLFDRILL SCHANZ TITANIUM MANDIB BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $474.75 $474.75 $0.00 $0.00 $0.00 $219.89 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $624.03 $624.03 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.011 SUP HCPCS C1713 04.305.011 - SCREW BONE 2.5/4MM 60MM SLFDRILL SCHANZ TITANIUM MANDIB BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $474.75 $474.75 $0.00 $0.00 $0.00 $219.89 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $624.03 $624.03 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.012 SUP HCPCS C1713 04.305.012 - SCREW BONE 2.5/4MM 70MM SLFDRILL SCHANZ TITANIUM MANDIB BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $474.75 $474.75 $0.00 $0.00 $0.00 $219.89 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $624.03 $624.03 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.100 SUP Custom 27203010 04.305.100 - ROD EXFIX 4MM FULL PREBENT RAMUS TITANIUM MANDIB NONSTRL BOTH IP/OP "$2,167.50 " "$1,603.95" $0.00 "$1,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,608.72" "$1,608.72" $0.00 $0.00 $451.71 $0.00 $0.00 $0.00 $0.00 "$1,083.75" "$1,716.66" "$1,734.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.101 SUP Custom 27203010 04.305.101 - ROD EXFIX 4MM FULL PREBENT TITANIUM MANDIB NONSTRL MANDIB BOTH IP/OP "$1,852.50 " "$1,370.85" $0.00 "$1,482.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,374.93" "$1,374.93" $0.00 $0.00 $386.06 $0.00 $0.00 $0.00 $0.00 $926.25 "$1,467.18" "$1,482.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.102 SUP Custom 27203010 04.305.102 - ROD EXFIX 4MM .75 PREBENT TITANIUM MANDIB NONSTRL MANDIB BOTH IP/OP "$1,702.50 " "$1,259.85" $0.00 "$1,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,263.60" "$1,263.60" $0.00 $0.00 $354.80 $0.00 $0.00 $0.00 $0.00 $851.25 "$1,348.38" "$1,362.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.103 SUP HCPCS C1713 04.305.103 - ROD FIX 4MM .5 PREBENT TITANIUM MANDIB NONSTRL EXFIX SYSTEM BOTH IP/OP "$1,552.50 " "$1,148.85" $0.00 "$1,242.00" $698.63 $698.63 $0.00 $0.00 $0.00 $323.58 "$1,152.27" "$1,152.27" $0.00 $0.00 $323.54 $0.00 $918.30 $918.30 $0.00 $776.25 "$1,229.58" "$1,242.00" $0.00 $0.00 $242.97 $0.00 $0.00 $247.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.128 SUP HCPCS C1713 04.305.128 - SCREW BONE 2.5MM 4MM 8MM SELF DRILL SCHANZ TITANIUM MANDIB BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.130 SUP HCPCS C1713 04.305.130 - SCREW XTRNFX 2.5MM 4MM 10MM SCHNZ SLF DRL TI MNDB RAMUS BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.134 SUP HCPCS C1713 04.305.134 - SCREW XTRNFX 2.5MM 4MM 14MM SCHNZ SLF DRL TI MNDB XTRNFXTR BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.138 SUP HCPCS C1713 04.305.138 - SCREW XTRNFX 2.5MM 4MM 18MM SCHNZ SLF DRL TI MNDB XTRNFXTR BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.140 SUP HCPCS C1713 04.305.140 - SCREW BONE 2.5/4MM 20MM SLFDRILL SCHANZ TITANIUM RAMUS BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.305.142 SUP HCPCS C1713 04.305.142 - SCREW BONE 2.5/4MM 22MM SLFDRILL SCHANZ TITANIUM MANDIB BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.307.001 SUP Custom 27803010 04.307.001 - FOOTPLATE BONE 40MM TITANIUM MAXL NONSTRL BOTH IP/OP "$1,277.50 " $945.35 $0.00 "$1,022.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $948.16 $948.16 $0.00 $0.00 $266.23 $0.00 $0.00 $0.00 $0.00 $638.75 "$1,011.78" "$1,022.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.307.008 SUP HCPCS C1713 04.307.008 - ROD FIX 80MM TITANIUM MAXL NONSTRL BOTH IP/OP $767.50 $567.95 $0.00 $614.00 $345.38 $345.38 $0.00 $0.00 $0.00 $159.97 $569.64 $569.64 $0.00 $0.00 $159.95 $0.00 $453.98 $453.98 $0.00 $383.75 $607.86 $614.00 $0.00 $0.00 $120.11 $0.00 $0.00 $122.19 $0.00 $0.00 $0.00 $0.00 $0.00 04.307.108 SUP HCPCS C1713 04.307.108 - ROD FIX 80MM TALL OFFST TITANIUM MAXL NONSTRL BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.307.111 SUP HCPCS C1713 04.307.111 - ROD FIX 110MM TALL OFFST TITANIUM MAXL NONSTRL BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.000 SUP HCPCS C1713 04.315.000 - SCREW MACHINE 2.7MM TITANIUM CMF DISTRCT BOTH IP/OP $647.50 $479.15 $0.00 $518.00 $291.38 $291.38 $0.00 $0.00 $0.00 $134.96 $480.57 $480.57 $0.00 $0.00 $134.94 $0.00 $383.00 $383.00 $0.00 $323.75 $512.82 $518.00 $0.00 $0.00 $101.33 $0.00 $0.00 $103.08 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.001 SUP Custom 27803010 04.315.001 - CAP END REMOVABLE CMF DISTRCT BOTH IP/OP "$1,070.00 " $791.80 $0.00 $856.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $794.15 $794.15 $0.00 $0.00 $222.99 $0.00 $0.00 $0.00 $0.00 $535.00 $847.44 $856.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.003 SUP Custom 27803010 04.315.003 - AB DISTRACTOR BODY END ACT 15MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.004 SUP Custom 27803010 04.315.004 - AB DISTRACTOR BODY END ACT. 20MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.005 SUP Custom 27803010 04.315.005 - AB DISTRACTOR BODY END ACT. 25MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.006 SUP Custom 27803010 04.315.006 - AB DISTRACTOR BODY END ACT. 30MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.023 SUP Custom 27803010 04.315.023 - BC DISTRACTOR BODY END ACT. 15MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.024 SUP Custom 27803010 04.315.024 - BC DISTRACTOR BODY END ACT. 20MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.025 SUP Custom 27803010 04.315.025 - DISTRCT 25MM BODY SURG BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.026 SUP Custom 27803010 04.315.026 - BC DISTRACTOR BODY END ACT. 30MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.027 SUP Custom 27803010 04.315.027 - BC DISTRACTOR BODY END ACT 35MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.028 SUP Custom 27803010 04.315.028 - BC DISTRACTOR BODY END ACT 40MM FOR CMF DISTRACTOR BOTH IP/OP "$11,330.00 " "$8,384.20" $0.00 "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,361.17" $0.00 $0.00 $0.00 $0.00 "$5,665.00" "$8,973.36" "$9,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.053 SUP Custom 27803010 04.315.053 - AB DISTRACTOR BODY END ACT. W/U-JOINT 15MM FOR CMF DSTR BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.054 SUP Custom 27803010 04.315.054 - DISTRCT 20MM CRNMXF U JNT BD END ACT SURG TI NONSTRL BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.055 SUP Custom 27803010 04.315.055 - AB DISTRACTOR BODY END ACT. W/U-JOINT 25MM FOR CMF DSTR BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.056 SUP Custom 27803010 04.315.056 - AB DISTRACTOR BODY END ACT. W/U-JOINT 30MM FOR CMF DSTR BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.063 SUP Custom 27803010 04.315.063 - DISTRCT 15MM CRNMXF BD END ACT U JNT SURG TI BC NONSTRL BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.064 SUP Custom 27803010 04.315.064 - DISTRCT 20MM BD END ACT U JNT SURG TI BC CMF NONSTRL BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.065 SUP Custom 27803010 04.315.065 - DISTRCT U JNT BODY 25MM SURG BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.066 SUP Custom 27803010 04.315.066 - DISTRCT 30MM SURG NONSTRL BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.067 SUP Custom 27803010 04.315.067 - BC DISTRACTOR BODY END ACT W/U-JOINT 35MM FOR CMF DSTR BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.068 SUP Custom 27803010 04.315.068 - BC DISTRACTOR BODY END ACT W/U-JOINT 40MM FOR CMF DSTR BOTH IP/OP "$11,952.50 " "$8,844.85" $0.00 "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,490.90" $0.00 $0.00 $0.00 $0.00 "$5,976.25" "$9,466.38" "$9,562.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.104 SUP Custom 27203010 04.315.104 - ARM DISTRCT 20MM EXTN RIGID BOTH IP/OP "$2,282.50 " "$1,689.05" $0.00 "$1,826.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.07" "$1,694.07" $0.00 $0.00 $475.67 $0.00 $0.00 $0.00 $0.00 "$1,141.25" "$1,807.74" "$1,826.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.108 SUP Custom 27203010 04.315.108 - SET EXTN 40MM REMOVABLE RIGID ARM NONSTRL BOTH IP/OP "$2,282.50 " "$1,689.05" $0.00 "$1,826.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.07" "$1,694.07" $0.00 $0.00 $475.67 $0.00 $0.00 $0.00 $0.00 "$1,141.25" "$1,807.74" "$1,826.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.112 SUP Custom 27803010 04.315.112 - ARM EXTN 60MM RIGID REMOVAL TITANIUM COCR SILICONE NONSTRL BOTH IP/OP "$2,282.50 " "$1,689.05" $0.00 "$1,826.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.07" "$1,694.07" $0.00 $0.00 $475.67 $0.00 $0.00 $0.00 $0.00 "$1,141.25" "$1,807.74" "$1,826.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.125 SUP Custom 27203010 04.315.125 - SET EXTN 30MM FLEXIBLE REMOVABLE ARM BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$2,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,003.94" "$2,003.94" $0.00 $0.00 $562.68 $0.00 $0.00 $0.00 $0.00 "$1,350.00" "$2,138.40" "$2,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.127 SUP Custom 27203010 04.315.127 - SET EXTN 40MM FLEXIBLE REMOVABLE ARM BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$2,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,003.94" "$2,003.94" $0.00 $0.00 $562.68 $0.00 $0.00 $0.00 $0.00 "$1,350.00" "$2,138.40" "$2,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.132 SUP Custom 27203010 04.315.132 - ARM DISTRCT 60MM EXTN FLEXIBLE REMOVABLE TITANIUM NONSTRL BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$2,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,003.94" "$2,003.94" $0.00 $0.00 $562.68 $0.00 $0.00 $0.00 $0.00 "$1,350.00" "$2,138.40" "$2,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.201 SUP Custom 27803010 04.315.201 - COMPONENT DISTRCT 1MM A TYPE MESH FEET TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.202 SUP Custom 27803010 04.315.202 - COMPONENT DISTRCT 1MM MESH FT B TYPE INTERNAL MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.203 SUP Custom 27803010 04.315.203 - COMPONENT DISTRCT 1MM MESH FT C TYPE INTERNAL MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.211 SUP Custom 27803010 04.315.211 - FOOTPLATE BONE TYPE B CLOVERLEAF GREEN TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.212 SUP Custom 27803010 04.315.212 - FOOTPLATE BONE CLOVERLEAF B TYPE INTERNAL MANDIB 1 MM SCREW BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.213 SUP Custom 27803010 04.315.213 - FOOTPLATE BONE MESH C TYPE INTERNAL MANDIB 1 MM SCREW BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.301 SUP Custom 27803010 04.315.301 - FOOTPLATE BONE TYPE A MESH PINK TITANIUM MANDIB NONSTRL 1.5 BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.302 SUP HCPCS C1713 04.315.302 - FOOTPLATE BONE B TYPE MESH TITANIUM MANDIB NONSTRL CMF BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.303 SUP HCPCS C1713 04.315.303 - FOOTPLATE BONE C TYPE MESH TITANIUM MANDIB NONSTRL CMF BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.311 SUP Custom 27803010 04.315.311 - FOOTPLATE BONE TYPE A CLOVERLEAF PINK TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.312 SUP Custom 27803010 04.315.312 - FOOTPLATE BONE TYPE B CLOVERLEAF PINK TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.313 SUP Custom 27803010 04.315.313 - FOOTPLATE BONE TYPE C CLOVERLEAF PINK TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.321 SUP Custom 27803010 04.315.321 - FOOTPLATE BONE 5.5MM TYPE B ELEVATED MESH OFFST PINK BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.322 SUP Custom 27803010 04.315.322 - FOOTPLATE BONE 7.5MM TYPE B ELEVATED MESH OFFST PINK BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.323 SUP Custom 27803010 04.315.323 - FOOTPLATE BONE TYPE C ELEVATED MESH OFFST PINK TITANIUM BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.401 SUP Custom 27803010 04.315.401 - FOOTPLATE BONE TYPE A MESH BLUE TITANIUM MANDIB NONSTRL 2MM BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.402 SUP Custom 27803010 04.315.402 - FOOTPLATE BONE TYPE B MESH BLUE TITANIUM MANDIB NONSTRL 2MM BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.403 SUP Custom 27803010 04.315.403 - FOOTPLATE BONE TYPE C MESH BLUE TITANIUM MANDIB NONSTRL 2MM BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.411 SUP Custom 27803010 04.315.411 - FOOTPLATE BONE TYPE A CLOVERLEAF BLUE TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.412 SUP Custom 27803010 04.315.412 - FOOTPLATE BONE TYPE B CLOVERLEAF BLUE TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.413 SUP Custom 27803010 04.315.413 - FOOTPLATE BONE TYPE C CLOVERLEAF BLUE TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.421 SUP Custom 27803010 04.315.421 - FOOTPLATE BONE 5.5MM TYPE B MESH OFFST BLUE TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.422 SUP Custom 27803010 04.315.422 - FOOTPLATE BONE 7.5MM TYPE C MESH OFFST BLUE TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.423 SUP Custom 27803010 04.315.423 - FOOTPLATE BONE TYPE C MESH OFFST BLUE TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.501 SUP Custom 27803010 04.315.501 - FOOTPLATE BONE TYPE A MESH YELLOW TITANIUM MANDIB NONSTRL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.502 SUP Custom 27803010 04.315.502 - COMPONENT DISTRCT 1.3MM MESH FEET INTERNAL B TYPE MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.503 SUP Custom 27803010 04.315.503 - COMPONENT DISTRCT 1.3MM MESH FEET C TYPE INTERNAL MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.511 SUP Custom 27803010 04.315.511 - FOOTPLATE BONE TYPE A CLOVERLEAF YELLOW TITANIUM MANDIB BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.512 SUP HCPCS C1713 04.315.512 - PLATE BONE B MANDIB NONSTRL 1.3 MM SCREWS BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.315.513 SUP HCPCS C1713 04.315.513 - PLATE BONE C MANDIB NONSTRL 1.3 MM SCREWS BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.402.007S SUP HCPCS C1713 04.402.007S - STEM RADIAL STR 7MM 26MM TITANIUM STERILE BOTH IP/OP "$3,286.33 " "$2,431.88" $0.00 "$2,629.06" "$1,478.85" "$1,478.85" $0.00 $0.00 $0.00 $684.95 "$2,439.11" "$2,439.11" $0.00 $0.00 $684.87 $0.00 "$1,620.16" "$1,620.16" $0.00 "$1,643.16" "$2,602.77" "$2,629.06" $0.00 $0.00 $499.33 $0.00 $0.00 $523.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.449.000 SUP HCPCS C1713 04.449.000 - HEAD SCR CNDYLR TI NONSTRL BOTH IP/OP "$6,745.50 " "$4,991.67" $0.00 "$5,396.40" "$3,035.48" "$3,035.48" $0.00 $0.00 $0.00 "$1,405.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,405.76" $0.00 "$3,325.53" "$3,325.53" $0.00 "$3,372.75" "$5,342.44" "$5,396.40" $0.00 $0.00 "$1,055.67" $0.00 $0.00 "$1,073.88" $0.00 $0.00 $0.00 $0.00 $0.00 04.449.010 SUP HCPCS C1713 04.449.010 - PLATE BONE 0MM CRNMXF TI LCK CNDYLR HEAD RECON NONSTRL BOTH IP/OP $771.75 $571.10 $0.00 $617.40 $347.29 $347.29 $0.00 $0.00 $0.00 $160.85 $572.79 $572.79 $0.00 $0.00 $160.83 $0.00 $456.49 $456.49 $0.00 $385.88 $611.23 $617.40 $0.00 $0.00 $120.78 $0.00 $0.00 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.449.020 SUP HCPCS C1713 04.449.020 - PLATE 2MM CRNMXF LCK CNDYLR HEAD RECON BONE TI NONSTRL BOTH IP/OP $771.75 $571.10 $0.00 $617.40 $347.29 $347.29 $0.00 $0.00 $0.00 $160.85 $572.79 $572.79 $0.00 $0.00 $160.83 $0.00 $456.49 $456.49 $0.00 $385.88 $611.23 $617.40 $0.00 $0.00 $120.78 $0.00 $0.00 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.449.030 SUP HCPCS C1713 04.449.030 - PLATE 4MM CRNMXF LCK CNDYLR HEAD RECON BONE TI NONSTRL BOTH IP/OP $771.75 $571.10 $0.00 $617.40 $347.29 $347.29 $0.00 $0.00 $0.00 $160.85 $572.79 $572.79 $0.00 $0.00 $160.83 $0.00 $456.49 $456.49 $0.00 $385.88 $611.23 $617.40 $0.00 $0.00 $120.78 $0.00 $0.00 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.449.040 SUP HCPCS C1713 04.449.040 - PLATE 6MM CRNMXF LCK CNDYLR HEAD RECON BONE TI NONSTRL BOTH IP/OP $771.75 $571.10 $0.00 $617.40 $347.29 $347.29 $0.00 $0.00 $0.00 $160.85 $572.79 $572.79 $0.00 $0.00 $160.83 $0.00 $456.49 $456.49 $0.00 $385.88 $611.23 $617.40 $0.00 $0.00 $120.78 $0.00 $0.00 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.497.000 SUP HCPCS C1713 04.497.000 - SCREW TI CNDYLR HEAD BONE NONSTRL BOTH IP/OP $328.50 $243.09 $0.00 $262.80 $147.83 $147.83 $0.00 $0.00 $0.00 $68.47 $243.81 $243.81 $0.00 $0.00 $68.46 $0.00 $194.31 $194.31 $0.00 $164.25 $260.17 $262.80 $0.00 $0.00 $51.41 $0.00 $0.00 $52.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.497.001 SUP HCPCS C1713 04.497.001 - SCREW TI CNDYLR SLT HEAD BONE MTRXMAND BOTH IP/OP $384.75 $284.72 $0.00 $307.80 $173.14 $173.14 $0.00 $0.00 $0.00 $80.19 $285.56 $285.56 $0.00 $0.00 $80.18 $0.00 $227.58 $227.58 $0.00 $192.38 $304.72 $307.80 $0.00 $0.00 $60.21 $0.00 $0.00 $61.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.000 SUP HCPCS C1713 04.500.000 - ROD FIX 110MM TITANIUM MAXL NONSTRL BOTH IP/OP $767.50 $567.95 $0.00 $614.00 $345.38 $345.38 $0.00 $0.00 $0.00 $159.97 $569.64 $569.64 $0.00 $0.00 $159.95 $0.00 $453.98 $453.98 $0.00 $383.75 $607.86 $614.00 $0.00 $0.00 $120.11 $0.00 $0.00 $122.19 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.001 SUP HCPCS C1713 04.500.001 - SCREW SURG DISTRCT EXTERNAL TITANIUM MAXILLOMANDIBULAR BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $130.50 $130.50 $0.00 $0.00 $0.00 $60.44 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $171.54 $171.54 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $45.39 $0.00 $0.00 $46.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.002 SUP HCPCS C1713 04.500.002 - SCREW BONE 27MM SLFDRILL WIRE FIX TITANIUM MANDIB NONSTRL BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $156.38 $156.38 $0.00 $0.00 $0.00 $72.43 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $205.55 $205.55 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $54.38 $0.00 $0.00 $55.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.006 SUP HCPCS C1713 04.500.006 - ANCHOR SCR 6MM OTHDNTC BONE TI ANCHORAGE SLFDRILL BOTH IP/OP $274.50 $203.13 $0.00 $219.60 $123.53 $123.53 $0.00 $0.00 $0.00 $57.21 $203.73 $203.73 $0.00 $0.00 $57.21 $0.00 $162.37 $162.37 $0.00 $137.25 $217.40 $219.60 $0.00 $0.00 $42.96 $0.00 $0.00 $43.70 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.008 SUP HCPCS C1713 04.500.008 - ANCHOR SCR 8MM OTHDNTC BONE TI SLFDRILL NONSTRL BOTH IP/OP $274.50 $203.13 $0.00 $219.60 $123.53 $123.53 $0.00 $0.00 $0.00 $57.21 $203.73 $203.73 $0.00 $0.00 $57.21 $0.00 $162.37 $162.37 $0.00 $137.25 $217.40 $219.60 $0.00 $0.00 $42.96 $0.00 $0.00 $43.70 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.010 SUP HCPCS C1713 04.500.010 - SCREW ANCH 10MM TI ANCH SLFTAP OBA BOTH IP/OP $274.50 $203.13 $0.00 $219.60 $123.53 $123.53 $0.00 $0.00 $0.00 $57.21 $203.73 $203.73 $0.00 $0.00 $57.21 $0.00 $162.37 $162.37 $0.00 $137.25 $217.40 $219.60 $0.00 $0.00 $42.96 $0.00 $0.00 $43.70 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.012 SUP HCPCS C1713 04.500.012 - TI OBA PLATE ANCHOR BRACKET DESIGN 4 HOLES BOTH IP/OP $483.75 $357.98 $0.00 $387.00 $217.69 $217.69 $0.00 $0.00 $0.00 $100.83 $359.04 $359.04 $0.00 $0.00 $100.81 $0.00 $286.14 $286.14 $0.00 $241.88 $383.13 $387.00 $0.00 $0.00 $75.71 $0.00 $0.00 $77.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.013 SUP HCPCS C1713 04.500.013 - PLATE ANCH TI 4 HOLE DOMED DSGN BOTH IP/OP $483.75 $357.98 $0.00 $387.00 $217.69 $217.69 $0.00 $0.00 $0.00 $100.83 $359.04 $359.04 $0.00 $0.00 $100.81 $0.00 $286.14 $286.14 $0.00 $241.88 $383.13 $387.00 $0.00 $0.00 $75.71 $0.00 $0.00 $77.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.014 SUP HCPCS C1713 04.500.014 - PLATE OTHDNTC 4 HOLE ANCH MESH PAD DSGN BONE TI NONSTRL BOTH IP/OP $483.75 $357.98 $0.00 $387.00 $217.69 $217.69 $0.00 $0.00 $0.00 $100.83 $359.04 $359.04 $0.00 $0.00 $100.81 $0.00 $286.14 $286.14 $0.00 $241.88 $383.13 $387.00 $0.00 $0.00 $75.71 $0.00 $0.00 $77.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.015 SUP HCPCS C1713 04.500.015 - TI OBA PLATE ANCHOR BRACKET DESIGN 5 HOLES BOTH IP/OP $483.75 $357.98 $0.00 $387.00 $217.69 $217.69 $0.00 $0.00 $0.00 $100.83 $359.04 $359.04 $0.00 $0.00 $100.81 $0.00 $286.14 $286.14 $0.00 $241.88 $383.13 $387.00 $0.00 $0.00 $75.71 $0.00 $0.00 $77.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.016 SUP HCPCS C1713 04.500.016 - PLATE ANCH TI 5 HOLE DOMED DSGN BOTH IP/OP $483.75 $357.98 $0.00 $387.00 $217.69 $217.69 $0.00 $0.00 $0.00 $100.83 $359.04 $359.04 $0.00 $0.00 $100.81 $0.00 $286.14 $286.14 $0.00 $241.88 $383.13 $387.00 $0.00 $0.00 $75.71 $0.00 $0.00 $77.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.017 SUP HCPCS C1713 04.500.017 - PLATE OTHDNTC 5 HOLE ANCH MESH PAD DSGN BONE TI NONSTRL BOTH IP/OP $483.75 $357.98 $0.00 $387.00 $217.69 $217.69 $0.00 $0.00 $0.00 $100.83 $359.04 $359.04 $0.00 $0.00 $100.81 $0.00 $286.14 $286.14 $0.00 $241.88 $383.13 $387.00 $0.00 $0.00 $75.71 $0.00 $0.00 $77.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.018 SUP Custom 27803010 04.500.018 - BODY DISTRCT 100MM RAD STR CURVILINEAR TITANIUM MANDIB BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.024.01 SUP HCPCS C1713 04.500.024.01 - TI OBA PLATE ANCHOR SCREW SELF-DRILLING 4MM BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.026.01 SUP HCPCS C1713 04.500.026.01 - TI OBA PLATE ANCHOR SCREW SELF-DRILLING 6MM BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.028.01 SUP HCPCS C1713 04.500.028.01 - TI OBA PLATE ANCHOR SCREW SELF-DRILLING 8MM BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.034.01 SUP HCPCS C1713 04.500.034.01 - SCREW TI 4MM MAXFACL OTHDNTC ER BONE NONSTRL BOTH IP/OP $214.88 $159.01 $0.00 $171.90 $96.69 $96.69 $0.00 $0.00 $0.00 $44.79 $159.48 $159.48 $0.00 $0.00 $44.78 $0.00 $127.10 $127.10 $0.00 $107.44 $170.18 $171.90 $0.00 $0.00 $33.63 $0.00 $0.00 $34.21 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.036.01 SUP HCPCS C1713 04.500.036.01 - TI OBA EMERGENCY SCREW 6MM BOTH IP/OP $214.88 $159.01 $0.00 $171.90 $96.69 $96.69 $0.00 $0.00 $0.00 $44.79 $159.48 $159.48 $0.00 $0.00 $44.78 $0.00 $127.10 $127.10 $0.00 $107.44 $170.18 $171.90 $0.00 $0.00 $33.63 $0.00 $0.00 $34.21 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.038.01 SUP HCPCS C1713 04.500.038.01 - SCREW TI 8MM MAXFACL ER BONE BOTH IP/OP $214.88 $159.01 $0.00 $171.90 $96.69 $96.69 $0.00 $0.00 $0.00 $44.79 $159.48 $159.48 $0.00 $0.00 $44.78 $0.00 $127.10 $127.10 $0.00 $107.44 $170.18 $171.90 $0.00 $0.00 $33.63 $0.00 $0.00 $34.21 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.100 SUP Custom 27803010 04.500.100 - BODY DSTRCT 100MM RDS STRG NS CURVILINEAR TI MNDB RT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.101 SUP Custom 27803010 04.500.101 - BODY DSTRCT 100MM RDS STRG NS CURVILINEAR TI MNDB LT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.130 SUP Custom 27803010 04.500.130 - BODY DSTRCT 30MM RDS STRG NS CURVILINEAR TI MNDB RT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.131 SUP Custom 27803010 04.500.131 - BODY DSTRCT 30MM RDS STRG NS CURVILINEAR TI MNDB LT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.140 SUP Custom 27803010 04.500.140 - BODY DSTRCT 40MM RDS STRG NS CURVILINEAR TI MNDB RT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.141 SUP Custom 27803010 04.500.141 - BODY DSTRCT 40MM RDS STRG NS CURVILINEAR TI MNDB LT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.150 SUP Custom 27803010 04.500.150 - BODY DSTRCT 50MM RDS STRG NS CURVILINEAR TI MNDB RT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.151 SUP Custom 27803010 04.500.151 - BODY DSTRCT 50MM RDS STRG NS CURVILINEAR TI MNDB LT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.170 SUP Custom 27803010 04.500.170 - BODY DSTRCT 70MM RDS STRG NS CURVILINEAR TI MNDB RT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.500.171 SUP Custom 27803010 04.500.171 - BODY DSTRCT 70MM RDS STRG NS CURVILINEAR TI MNDB LT 2MM LCK BOTH IP/OP "$16,962.50 " "$12,552.25" $0.00 "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,534.99" $0.00 $0.00 $0.00 $0.00 "$8,481.25" "$13,434.30" "$13,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.001 SUP HCPCS C1713 04.501.001 - PLATE BN 1.5MM NS MATRIXRIB 15 HL PRECONTOUR LCK LOPRFL TI 3 BOTH IP/OP "$4,307.50 " "$3,187.55" $0.00 "$3,446.00" "$1,938.38" "$1,938.38" $0.00 $0.00 $0.00 $897.79 "$3,197.03" "$3,197.03" $0.00 $0.00 $897.68 $0.00 "$2,123.60" "$2,123.60" $0.00 "$2,153.75" "$3,411.54" "$3,446.00" $0.00 $0.00 $674.12 $0.00 $0.00 $685.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.002 SUP HCPCS C1713 04.501.002 - PLATE BN 1.5MM NS MATRIXRIB 15 HL PRECONTOUR LCK LOPRFL TI 3 BOTH IP/OP "$4,307.50 " "$3,187.55" $0.00 "$3,446.00" "$1,938.38" "$1,938.38" $0.00 $0.00 $0.00 $897.79 "$3,197.03" "$3,197.03" $0.00 $0.00 $897.68 $0.00 "$2,123.60" "$2,123.60" $0.00 "$2,153.75" "$3,411.54" "$3,446.00" $0.00 $0.00 $674.12 $0.00 $0.00 $685.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.003 SUP HCPCS C1713 04.501.003 - PLATE BN 1.5MM NS MATRIXRIB 16 HL PRECONTOUR LCK LOPRFL TI 4 BOTH IP/OP "$4,154.38 " "$3,074.24" $0.00 "$3,323.50" "$1,869.47" "$1,869.47" $0.00 $0.00 $0.00 $865.88 "$3,083.38" "$3,083.38" $0.00 $0.00 $865.77 $0.00 "$2,048.11" "$2,048.11" $0.00 "$2,077.19" "$3,290.27" "$3,323.50" $0.00 $0.00 $650.16 $0.00 $0.00 $661.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.004 SUP HCPCS C1713 04.501.004 - PLATE BN 1.5MM NS MATRIXRIB 16 HL PRECONTOUR LCK LOPRFL TI 4 BOTH IP/OP "$4,154.38 " "$3,074.24" $0.00 "$3,323.50" "$1,869.47" "$1,869.47" $0.00 $0.00 $0.00 $865.88 "$3,083.38" "$3,083.38" $0.00 $0.00 $865.77 $0.00 "$2,048.11" "$2,048.11" $0.00 "$2,077.19" "$3,290.27" "$3,323.50" $0.00 $0.00 $650.16 $0.00 $0.00 $661.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.005 SUP HCPCS C1713 04.501.005 - PLATE BN 1.5MM NS MATRIXRIB 17 HL PRECONTOUR LCK LOPRFL TI 6 BOTH IP/OP "$4,154.38 " "$3,074.24" $0.00 "$3,323.50" "$1,869.47" "$1,869.47" $0.00 $0.00 $0.00 $865.88 "$3,083.38" "$3,083.38" $0.00 $0.00 $865.77 $0.00 "$2,048.11" "$2,048.11" $0.00 "$2,077.19" "$3,290.27" "$3,323.50" $0.00 $0.00 $650.16 $0.00 $0.00 $661.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.006 SUP HCPCS C1713 04.501.006 - PLATE BN 1.5MM NS MATRIXRIB 17 HL PRECONTOUR LCK LOPRFL TI 6 BOTH IP/OP "$4,154.38 " "$3,074.24" $0.00 "$3,323.50" "$1,869.47" "$1,869.47" $0.00 $0.00 $0.00 $865.88 "$3,083.38" "$3,083.38" $0.00 $0.00 $865.77 $0.00 "$2,048.11" "$2,048.11" $0.00 "$2,077.19" "$3,290.27" "$3,323.50" $0.00 $0.00 $650.16 $0.00 $0.00 $661.38 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.007 SUP HCPCS C1713 04.501.007 - PLATE BN 1.5MM NS MATRIXRIB 18 HL PRECONTOUR LCK LOPRFL TI BOTH IP/OP "$4,307.50 " "$3,187.55" $0.00 "$3,446.00" "$1,938.38" "$1,938.38" $0.00 $0.00 $0.00 $897.79 "$3,197.03" "$3,197.03" $0.00 $0.00 $897.68 $0.00 "$2,123.60" "$2,123.60" $0.00 "$2,153.75" "$3,411.54" "$3,446.00" $0.00 $0.00 $674.12 $0.00 $0.00 $685.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.008 SUP HCPCS C1713 04.501.008 - PLATE BN 1.5MM NS MATRIXRIB 18 HL PRECONTOUR LCK LOPRFL TI BOTH IP/OP "$4,307.50 " "$3,187.55" $0.00 "$3,446.00" "$1,938.38" "$1,938.38" $0.00 $0.00 $0.00 $897.79 "$3,197.03" "$3,197.03" $0.00 $0.00 $897.68 $0.00 "$2,123.60" "$2,123.60" $0.00 "$2,153.75" "$3,411.54" "$3,446.00" $0.00 $0.00 $674.12 $0.00 $0.00 $685.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.009 SUP HCPCS C1713 04.501.009 - PLATE BONE UNIVERSAL 8 HOLE MATRIXRIB TITANIUM RIB NONSTRL BOTH IP/OP "$2,935.00 " "$2,171.90" $0.00 "$2,348.00" "$1,320.75" "$1,320.75" $0.00 $0.00 $0.00 $611.73 "$2,178.36" "$2,178.36" $0.00 $0.00 $611.65 $0.00 "$1,446.96" "$1,446.96" $0.00 "$1,467.50" "$2,324.52" "$2,348.00" $0.00 $0.00 $459.33 $0.00 $0.00 $467.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.010 SUP HCPCS C1713 04.501.010 - IMPLANT FIX SMALL 3MM SPLINT MATRIXRIB TITANIUM BOTH IP/OP "$1,557.50 " "$1,152.55" $0.00 "$1,246.00" $700.88 $700.88 $0.00 $0.00 $0.00 $324.62 "$1,155.98" "$1,155.98" $0.00 $0.00 $324.58 $0.00 $921.26 $921.26 $0.00 $778.75 "$1,233.54" "$1,246.00" $0.00 $0.00 $243.75 $0.00 $0.00 $247.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.011 SUP HCPCS C1713 04.501.011 - IMPLANT FIX MEDIUM 4MM SPLINT MATRIXRIB TITANIUM BOTH IP/OP "$1,557.50 " "$1,152.55" $0.00 "$1,246.00" $700.88 $700.88 $0.00 $0.00 $0.00 $324.62 "$1,155.98" "$1,155.98" $0.00 $0.00 $324.58 $0.00 $921.26 $921.26 $0.00 $778.75 "$1,233.54" "$1,246.00" $0.00 $0.00 $243.75 $0.00 $0.00 $247.95 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.012 SUP Custom 27803010 04.501.012 - IMPLANT FIX LARGE 5MM SPLINT MATRIXRIB TITANIUM BOTH IP/OP "$1,557.50 " "$1,152.55" $0.00 "$1,246.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,155.98" "$1,155.98" $0.00 $0.00 $324.58 $0.00 $0.00 $0.00 $0.00 $778.75 "$1,233.54" "$1,246.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.016.01 SUP HCPCS C1713 04.501.016.01 - SCREW BONE 2.9MM 6MM SELF TAP LOCK MATRIXRIB TITANIUM RIB BOTH IP/OP $542.50 $401.45 $0.00 $434.00 $244.13 $244.13 $0.00 $0.00 $0.00 $113.07 $402.64 $402.64 $0.00 $0.00 $113.06 $0.00 $320.89 $320.89 $0.00 $271.25 $429.66 $434.00 $0.00 $0.00 $84.90 $0.00 $0.00 $86.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.018.01 SUP HCPCS C1713 04.501.018.01 - SCREW BONE 2.9MM 8MM SELF TAP LOCK MATRIXRIB TITANIUM RIB BOTH IP/OP $542.50 $401.45 $0.00 $434.00 $244.13 $244.13 $0.00 $0.00 $0.00 $113.07 $402.64 $402.64 $0.00 $0.00 $113.06 $0.00 $320.89 $320.89 $0.00 $271.25 $429.66 $434.00 $0.00 $0.00 $84.90 $0.00 $0.00 $86.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.020.01 SUP HCPCS C1713 04.501.020.01 - SCREW BONE 2.9MM 10MM SELF TAP LOCK MATRIXRIB TITANIUM RIB BOTH IP/OP $542.50 $401.45 $0.00 $434.00 $244.13 $244.13 $0.00 $0.00 $0.00 $113.07 $402.64 $402.64 $0.00 $0.00 $113.06 $0.00 $320.89 $320.89 $0.00 $271.25 $429.66 $434.00 $0.00 $0.00 $84.90 $0.00 $0.00 $86.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.022.01 SUP HCPCS C1713 04.501.022.01 - SCREW BONE 2.9MM 12MM SELF TAP LOCK MATRIXRIB TITANIUM RIB BOTH IP/OP $524.88 $388.41 $0.00 $419.90 $236.19 $236.19 $0.00 $0.00 $0.00 $109.40 $389.56 $389.56 $0.00 $0.00 $109.38 $0.00 $310.46 $310.46 $0.00 $262.44 $415.70 $419.90 $0.00 $0.00 $82.14 $0.00 $0.00 $83.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.024.01 SUP HCPCS C1713 04.501.024.01 - IMPLANT FIX 14MM SYSTEM SET MATRIXRIB BOTH IP/OP $542.50 $401.45 $0.00 $434.00 $244.13 $244.13 $0.00 $0.00 $0.00 $113.07 $402.64 $402.64 $0.00 $0.00 $113.06 $0.00 $320.89 $320.89 $0.00 $271.25 $429.66 $434.00 $0.00 $0.00 $84.90 $0.00 $0.00 $86.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.026.01 SUP HCPCS C1713 04.501.026.01 - SCREW BONE 2.9MM 16MM ANGULAR STABLE SLFTAP LOCKING BOTH IP/OP $542.50 $401.45 $0.00 $434.00 $244.13 $244.13 $0.00 $0.00 $0.00 $113.07 $402.64 $402.64 $0.00 $0.00 $113.06 $0.00 $320.89 $320.89 $0.00 $271.25 $429.66 $434.00 $0.00 $0.00 $84.90 $0.00 $0.00 $86.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.028.01 SUP HCPCS C1713 04.501.028.01 - SCREW BONE 2.9MM 18MM ANGULAR STABLE SLFTAP LOCKING BOTH IP/OP $542.50 $401.45 $0.00 $434.00 $244.13 $244.13 $0.00 $0.00 $0.00 $113.07 $402.64 $402.64 $0.00 $0.00 $113.06 $0.00 $320.89 $320.89 $0.00 $271.25 $429.66 $434.00 $0.00 $0.00 $84.90 $0.00 $0.00 $86.37 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.036.05 SUP HCPCS C1713 04.501.036.05 - SCREW BONE 2.9MM 6MM MATRIXRIB TI RB SLFTAP NLCKG NONSTRL BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.094 SUP HCPCS C1713 04.501.094 - PLATE BN I 2.8MM NS MATRIXRIB 9 HL TI RB BOTH IP/OP "$3,170.00 " "$2,345.80" $0.00 "$2,536.00" "$1,426.50" "$1,426.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,585.00" "$2,510.64" "$2,536.00" $0.00 $0.00 $496.11 $0.00 $0.00 $504.66 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.110.01 SUP HCPCS C1713 04.501.110.01 - SCREW BONE 3MM 10MM LOCK SELF DRILL TITANIUM STERNAL NONSTRL BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.112.01 SUP HCPCS C1713 04.501.112.01 - SCREW BONE 3MM 12MM SELF DRILL UNILOCK TITANIUM STERNUM BOTH IP/OP $490.88 $363.25 $0.00 $392.70 $220.89 $220.89 $0.00 $0.00 $0.00 $102.31 $364.33 $364.33 $0.00 $0.00 $102.30 $0.00 $290.35 $290.35 $0.00 $245.44 $388.78 $392.70 $0.00 $0.00 $76.82 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.114.01 SUP HCPCS C1713 04.501.114.01 - SCREW BONE 3MM 14MM SELF DRILL UNILOCK TITANIUM STERNUM BOTH IP/OP $577.50 $427.35 $0.00 $462.00 $259.88 $259.88 $0.00 $0.00 $0.00 $120.37 $428.62 $428.62 $0.00 $0.00 $120.35 $0.00 $341.59 $341.59 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.116.01 SUP HCPCS C1713 04.501.116.01 - SCREW BONE 3MM 16MM SELF DRILL UNILOCK TITANIUM STERNUM BOTH IP/OP $577.50 $427.35 $0.00 $462.00 $259.88 $259.88 $0.00 $0.00 $0.00 $120.37 $428.62 $428.62 $0.00 $0.00 $120.35 $0.00 $341.59 $341.59 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.118.01 SUP HCPCS C1713 04.501.118.01 - SCREW BONE 3MM 18MM SELF DRILL UNILOCK TITANIUM STERNUM BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 04.501.120.01 SUP HCPCS C1713 04.501.120.01 - SCREW BONE 3MM 20MM SLFDRILL TITANIUM STERNUM NONSTRL BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.021 SUP Custom 27803010 04.503.021 - COVER BUR HOLE BLUE 12MM MATRIXNEURO TI NONSTRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.022 SUP Custom 27803010 04.503.022 - COVER BUR HOLE 15MM MATRIXNEURO TI NONSTRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.023 SUP Custom 27803010 04.503.023 - COVER BUR HOLE 17MM MATRIXNEURO MIDFAC CRANFCL TI NONSTRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.024 SUP Custom 27803010 04.503.024 - COVER BUR HOLE 24MM MATRIXNEURO CRANIAL TI NONSTRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.026 SUP Custom 27803010 04.503.026 - COVER BUR HOLE 12MM MATRIXNEURO CRNMXF TI SHNT NONSTRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.027 SUP Custom 27803010 04.503.027 - COVER BUR HOLE 15MM MATRIXNEURO CRNMXF TI SHNT NONSTRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.028 SUP Custom 27803010 04.503.028 - COVER BUR HOLE 17MM MATRIXNEURO TI SHNT NONSTRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.029 SUP Custom 27803010 04.503.029 - COVER BUR HOLE 24MM MATRIXNEURO CRNMXF TI NONSTRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.056 SUP HCPCS C1713 04.503.056 - PLATE BONE MATRIXNEURO CRANIAL TI MESH STRUT MALBLE NONSTRL BOTH IP/OP "$1,665.00 " "$1,232.10" $0.00 "$1,332.00" $749.25 $749.25 $0.00 $0.00 $0.00 $347.03 "$1,235.76" "$1,235.76" $0.00 $0.00 $346.99 $0.00 $984.85 $984.85 $0.00 $832.50 "$1,318.68" "$1,332.00" $0.00 $0.00 $260.57 $0.00 $0.00 $265.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.057 SUP HCPCS C1713 04.503.057 - PLATE BONE MATRIXNEURO TMPR TI MESH MALBLE NONSTRL BOTH IP/OP "$2,202.75 " "$1,630.04" $0.00 "$1,762.20" $991.24 $991.24 $0.00 $0.00 $0.00 $459.11 "$1,634.88" "$1,634.88" $0.00 $0.00 $459.05 $0.00 "$1,302.93" "$1,302.93" $0.00 "$1,101.38" "$1,744.58" "$1,762.20" $0.00 $0.00 $344.73 $0.00 $0.00 $350.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.061 SUP HCPCS C1713 04.503.061 - PLATE BONE 9MM MATRIXNEURO CRNMXF TI 2 HOLE STR NONSTRL BOTH IP/OP $176.63 $130.71 $0.00 $141.30 $79.48 $79.48 $0.00 $0.00 $0.00 $36.81 $131.09 $131.09 $0.00 $0.00 $36.81 $0.00 $104.47 $104.47 $0.00 $88.31 $139.89 $141.30 $0.00 $0.00 $27.64 $0.00 $0.00 $28.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.062 SUP HCPCS C1713 04.503.062 - PLATE BN STRG 12MMX.4MM NS MATRIXNEURO 2 HL TI CRNL BOTH IP/OP $183.38 $135.70 $0.00 $146.70 $82.52 $82.52 $0.00 $0.00 $0.00 $38.22 $136.10 $136.10 $0.00 $0.00 $38.22 $0.00 $108.47 $108.47 $0.00 $91.69 $145.24 $146.70 $0.00 $0.00 $28.70 $0.00 $0.00 $29.19 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.063 SUP HCPCS C1713 04.503.063 - PLATE BN STRG 24MMX.4MM NS MATRIXNEURO 4 HL TI CRNL BOTH IP/OP $209.25 $154.85 $0.00 $167.40 $94.16 $94.16 $0.00 $0.00 $0.00 $43.61 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $123.77 $123.77 $0.00 $104.63 $165.73 $167.40 $0.00 $0.00 $32.75 $0.00 $0.00 $33.31 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.064 SUP HCPCS C1713 04.503.064 - PLATE BN X .4MM NS MATRIXNEURO 4 HL TI CRNL BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.065 SUP HCPCS C1713 04.503.065 - PLATE BN BX 14X14X.4MM NS MATRIXNEURO 4 HL TI CRNL BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.066 SUP HCPCS C1713 04.503.066 - PLATE BONE 16X16MM MATRIXNEURO CRNMXF TI BOX NONSTRL BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.067 SUP HCPCS C1713 04.503.067 - PLATE BN Y .4MM NS MATRIXNEURO 5 HL TI CRNL BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.068 SUP HCPCS C1713 04.503.068 - PLATE BN 2Y 18MMX.4MM NS MATRIXNEURO 6 HL TI CRNL BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.069 SUP HCPCS C1713 04.503.069 - PLATE BN 2Y 21MMX.4MM NS MATRIXNEURO 6 HL TI CRNL BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.070 SUP HCPCS C1713 04.503.070 - PLATE BN .4MM NS MATRIXNEURO 5 HL ADP TI CRNL BOTH IP/OP $605.25 $447.89 $0.00 $484.20 $272.36 $272.36 $0.00 $0.00 $0.00 $126.15 $449.22 $449.22 $0.00 $0.00 $126.13 $0.00 $358.01 $358.01 $0.00 $302.63 $479.36 $484.20 $0.00 $0.00 $94.72 $0.00 $0.00 $96.36 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.071 SUP HCPCS C1713 04.503.071 - PLATE BONE MATRIXNEURO CRNMXF TI 7 HOLE ADP NONSTRL BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.072 SUP HCPCS C1713 04.503.072 - PLATE BONE MATRIXNEURO CRNMXF TI 20 HOLE ADP NONSTRL BOTH IP/OP "$1,498.50 " "$1,108.89" $0.00 "$1,198.80" $674.33 $674.33 $0.00 $0.00 $0.00 $312.32 "$1,112.19" "$1,112.19" $0.00 $0.00 $312.29 $0.00 $886.36 $886.36 $0.00 $749.25 "$1,186.81" "$1,198.80" $0.00 $0.00 $234.52 $0.00 $0.00 $238.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.073 SUP HCPCS C1713 04.503.073 - PLATE BN BX 16X10X.4MM NS MATRIXNEURO 4 HL TI CRNL BOTH IP/OP $643.50 $476.19 $0.00 $514.80 $289.58 $289.58 $0.00 $0.00 $0.00 $134.12 $477.61 $477.61 $0.00 $0.00 $134.11 $0.00 $380.63 $380.63 $0.00 $321.75 $509.65 $514.80 $0.00 $0.00 $100.71 $0.00 $0.00 $102.45 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.074 SUP HCPCS C1713 04.503.074 - PLATE BONE 9MM MATRIXNEURO CRNMXF TI 2X3 HOLE STRUT NONSTRL BOTH IP/OP "$1,170.00 " $865.80 $0.00 $936.00 $526.50 $526.50 $0.00 $0.00 $0.00 $243.86 $868.37 $868.37 $0.00 $0.00 $243.83 $0.00 $692.06 $692.06 $0.00 $585.00 $926.64 $936.00 $0.00 $0.00 $183.11 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.075 SUP HCPCS C1713 04.503.075 - PLATE BONE 34X14MM MATRIXNEURO CRNMXF TI 2X4 HOLE STRUT BOTH IP/OP "$1,665.00 " "$1,232.10" $0.00 "$1,332.00" $749.25 $749.25 $0.00 $0.00 $0.00 $347.03 "$1,235.76" "$1,235.76" $0.00 $0.00 $346.99 $0.00 $984.85 $984.85 $0.00 $832.50 "$1,318.68" "$1,332.00" $0.00 $0.00 $260.57 $0.00 $0.00 $265.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.076 SUP HCPCS C1713 04.503.076 - PLATE BONE MATRIXNEURO CRNMXF TI 2X3 HOLE STRUT CVD NONSTRL BOTH IP/OP "$1,091.25 " $807.53 $0.00 $873.00 $491.06 $491.06 $0.00 $0.00 $0.00 $227.44 $809.93 $809.93 $0.00 $0.00 $227.42 $0.00 $645.47 $645.47 $0.00 $545.63 $864.27 $873.00 $0.00 $0.00 $170.78 $0.00 $0.00 $173.73 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.077 SUP HCPCS C1713 04.503.077 - TI MATRIXNEURO CURVED STRUT PLATE/2 X 4 HOLE BOTH IP/OP "$1,554.75 " "$1,150.52" $0.00 "$1,243.80" $699.64 $699.64 $0.00 $0.00 $0.00 $324.05 "$1,153.94" "$1,153.94" $0.00 $0.00 $324.01 $0.00 $919.63 $919.63 $0.00 $777.38 "$1,231.36" "$1,243.80" $0.00 $0.00 $243.32 $0.00 $0.00 $247.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.081 SUP HCPCS C1713 04.503.081 - PLATE BONE 45X38X.4MM MATRIXNEURO TI CONTUR MESH MALBLE BOTH IP/OP "$3,831.75 " "$2,835.50" $0.00 "$3,065.40" "$1,724.29" "$1,724.29" $0.00 $0.00 $0.00 $798.63 "$2,843.92" "$2,843.92" $0.00 $0.00 $798.54 $0.00 "$1,889.05" "$1,889.05" $0.00 "$1,915.88" "$3,034.75" "$3,065.40" $0.00 $0.00 $599.67 $0.00 $0.00 $610.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.082 SUP HCPCS C1713 04.503.082 - PLATE BONE 45X38X.4MM MATRIXNEURO TI CONTUR MESH RGD NONSTRL BOTH IP/OP "$3,831.75 " "$2,835.50" $0.00 "$3,065.40" "$1,724.29" "$1,724.29" $0.00 $0.00 $0.00 $798.63 "$2,843.92" "$2,843.92" $0.00 $0.00 $798.54 $0.00 "$1,889.05" "$1,889.05" $0.00 "$1,915.88" "$3,034.75" "$3,065.40" $0.00 $0.00 $599.67 $0.00 $0.00 $610.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.083 SUP HCPCS C1713 04.503.083 - MESH CRNL CNTR 100X100X.4MM SLVR NS MATRIXNEURO RGD TI BOTH IP/OP "$5,964.75 " "$4,413.92" $0.00 "$4,771.80" "$2,684.14" "$2,684.14" $0.00 $0.00 $0.00 "$1,243.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,243.05" $0.00 "$2,940.62" "$2,940.62" $0.00 "$2,982.38" "$4,724.08" "$4,771.80" $0.00 $0.00 $933.48 $0.00 $0.00 $949.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.084 SUP HCPCS C1713 04.503.084 - MESH CRNL CNTR 100X100X.4MM BLU NS MATRIXNEURO RGD TI BOTH IP/OP "$5,964.75 " "$4,413.92" $0.00 "$4,771.80" "$2,684.14" "$2,684.14" $0.00 $0.00 $0.00 "$1,243.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,243.05" $0.00 "$2,940.62" "$2,940.62" $0.00 "$2,982.38" "$4,724.08" "$4,771.80" $0.00 $0.00 $933.48 $0.00 $0.00 $949.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.085 SUP HCPCS C1713 04.503.085 - PLATE BONE MATRIXNEURO CRNMXF TI CONTUR MESH RGD NONSTRL BOTH IP/OP "$22,842.00 " "$16,903.08" $0.00 "$18,273.60" "$10,278.90" "$10,278.90" $0.00 $0.00 $0.00 "$4,760.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,760.27" $0.00 "$11,261.11" "$11,261.11" $0.00 "$11,421.00" "$18,090.86" "$18,273.60" $0.00 $0.00 "$3,574.77" $0.00 $0.00 "$3,636.45" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.086 SUP HCPCS C1713 04.503.086 - PLATE BONE MATRIXNEURO SM CRNMXF TI CONTUR MESH MALBLE ARC BOTH IP/OP "$2,202.75 " "$1,630.04" $0.00 "$1,762.20" $991.24 $991.24 $0.00 $0.00 $0.00 $459.11 "$1,634.88" "$1,634.88" $0.00 $0.00 $459.05 $0.00 "$1,302.93" "$1,302.93" $0.00 "$1,101.38" "$1,744.58" "$1,762.20" $0.00 $0.00 $344.73 $0.00 $0.00 $350.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.087 SUP HCPCS C1713 04.503.087 - PLATE BONE MATRIXNEURO LG CRNMXF TI CONTUR MESH MALBLE ARC BOTH IP/OP "$3,433.50 " "$2,540.79" $0.00 "$2,746.80" "$1,545.08" "$1,545.08" $0.00 $0.00 $0.00 $715.63 "$2,548.34" "$2,548.34" $0.00 $0.00 $715.54 $0.00 "$1,692.72" "$1,692.72" $0.00 "$1,716.75" "$2,719.33" "$2,746.80" $0.00 $0.00 $537.34 $0.00 $0.00 $546.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.088 SUP HCPCS C1713 04.503.088 - PLATE BONE MATRIXNEURO SM CRNMXF TI CONTUR MESH RGD ARC BOTH IP/OP "$2,202.75 " "$1,630.04" $0.00 "$1,762.20" $991.24 $991.24 $0.00 $0.00 $0.00 $459.11 "$1,634.88" "$1,634.88" $0.00 $0.00 $459.05 $0.00 "$1,302.93" "$1,302.93" $0.00 "$1,101.38" "$1,744.58" "$1,762.20" $0.00 $0.00 $344.73 $0.00 $0.00 $350.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.089 SUP HCPCS C1713 04.503.089 - PLATE LG MIDFAC RGD ARC BONE MATRIXNEURO TI NONSTRL BLUE BOTH IP/OP "$3,433.50 " "$2,540.79" $0.00 "$2,746.80" "$1,545.08" "$1,545.08" $0.00 $0.00 $0.00 $715.63 "$2,548.34" "$2,548.34" $0.00 $0.00 $715.54 $0.00 "$1,692.72" "$1,692.72" $0.00 "$1,716.75" "$2,719.33" "$2,746.80" $0.00 $0.00 $537.34 $0.00 $0.00 $546.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.090 SUP HCPCS C1713 04.503.090 - PLATE BONE 30MM MATRIXNEURO CRNMXF TI CONTUR MESH MALBLE BOTH IP/OP "$2,202.75 " "$1,630.04" $0.00 "$1,762.20" $991.24 $991.24 $0.00 $0.00 $0.00 $459.11 "$1,634.88" "$1,634.88" $0.00 $0.00 $459.05 $0.00 "$1,302.93" "$1,302.93" $0.00 "$1,101.38" "$1,744.58" "$1,762.20" $0.00 $0.00 $344.73 $0.00 $0.00 $350.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.091 SUP HCPCS C1713 04.503.091 - PLATE BONE 70MM MATRIXNEURO CRNMXF TI CONTUR MESH MALBLE BOTH IP/OP "$4,560.75 " "$3,374.96" $0.00 "$3,648.60" "$2,052.34" "$2,052.34" $0.00 $0.00 $0.00 $950.57 "$3,384.99" "$3,384.99" $0.00 $0.00 $950.46 $0.00 "$2,248.45" "$2,248.45" $0.00 "$2,280.38" "$3,612.11" "$3,648.60" $0.00 $0.00 $713.76 $0.00 $0.00 $726.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.092 SUP HCPCS C1713 04.503.092 - PLATE BONE 100MM MATRIXNEURO CRNMXF TI MESH CONTUR MALBLE BOTH IP/OP "$5,688.00 " "$4,209.12" $0.00 "$4,550.40" "$2,559.60" "$2,559.60" $0.00 $0.00 $0.00 "$1,185.52" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,185.38" $0.00 "$2,804.18" "$2,804.18" $0.00 "$2,844.00" "$4,504.90" "$4,550.40" $0.00 $0.00 $890.17 $0.00 $0.00 $905.53 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.093 SUP HCPCS C1713 04.503.093 - PLATE BONE 30MM MATRIXNEURO CRNMXF TI CONTUR MESH RGD BOTH IP/OP "$2,202.75 " "$1,630.04" $0.00 "$1,762.20" $991.24 $991.24 $0.00 $0.00 $0.00 $459.11 "$1,634.88" "$1,634.88" $0.00 $0.00 $459.05 $0.00 "$1,302.93" "$1,302.93" $0.00 "$1,101.38" "$1,744.58" "$1,762.20" $0.00 $0.00 $344.73 $0.00 $0.00 $350.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.094 SUP HCPCS C1713 04.503.094 - PLATE BONE 70MM MATRIXNEURO CRNMXF TI CONTUR MESH RGD BOTH IP/OP "$4,560.75 " "$3,374.96" $0.00 "$3,648.60" "$2,052.34" "$2,052.34" $0.00 $0.00 $0.00 $950.57 "$3,384.99" "$3,384.99" $0.00 $0.00 $950.46 $0.00 "$2,248.45" "$2,248.45" $0.00 "$2,280.38" "$3,612.11" "$3,648.60" $0.00 $0.00 $713.76 $0.00 $0.00 $726.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.095 SUP HCPCS C1713 04.503.095 - PLATE BONE 100MM MATRIXNEURO .4MM CRNMXF TI CONTUR MESH RGD BOTH IP/OP "$5,688.00 " "$4,209.12" $0.00 "$4,550.40" "$2,559.60" "$2,559.60" $0.00 $0.00 $0.00 "$1,185.52" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,185.38" $0.00 "$2,804.18" "$2,804.18" $0.00 "$2,844.00" "$4,504.90" "$4,550.40" $0.00 $0.00 $890.17 $0.00 $0.00 $905.53 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.096 SUP HCPCS C1713 04.503.096 - PLATE SM .4MM MSTD CONTUR MESH MALBLE BONE MATRIXNEURO TI BOTH IP/OP "$2,135.25 " "$1,580.09" $0.00 "$1,708.20" $960.86 $960.86 $0.00 $0.00 $0.00 $445.04 "$1,584.78" "$1,584.78" $0.00 $0.00 $444.99 $0.00 "$1,263.00" "$1,263.00" $0.00 "$1,067.63" "$1,691.12" "$1,708.20" $0.00 $0.00 $334.17 $0.00 $0.00 $339.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.097 SUP HCPCS C1713 04.503.097 - PLATE MED .4MM MSTD CONTUR MESH MALBLE BONE MATRIXNEURO TI BOTH IP/OP "$2,416.50 " "$1,788.21" $0.00 "$1,933.20" "$1,087.43" "$1,087.43" $0.00 $0.00 $0.00 $503.66 "$1,793.53" "$1,793.53" $0.00 $0.00 $503.60 $0.00 "$1,429.36" "$1,429.36" $0.00 "$1,208.25" "$1,913.87" "$1,933.20" $0.00 $0.00 $378.18 $0.00 $0.00 $384.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.098 SUP HCPCS C1713 04.503.098 - PLATE LG .4MM MSTD CONTUR MESH MALBLE BONE MATRIXNEURO TI BOTH IP/OP "$2,664.00 " "$1,971.36" $0.00 "$2,131.20" "$1,198.80" "$1,198.80" $0.00 $0.00 $0.00 $555.24 "$1,977.22" "$1,977.22" $0.00 $0.00 $555.18 $0.00 "$1,313.35" "$1,313.35" $0.00 "$1,332.00" "$2,109.89" "$2,131.20" $0.00 $0.00 $416.92 $0.00 $0.00 $424.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.103.01 SUP HCPCS C1713 04.503.103.01 - SCREW BONE 3MM MATRIXNEURO CRNMXF TI SLFDRILL NONSTRL BOTH IP/OP $217.13 $160.68 $0.00 $173.70 $97.71 $97.71 $0.00 $0.00 $0.00 $45.25 $161.15 $161.15 $0.00 $0.00 $45.25 $0.00 $128.43 $128.43 $0.00 $108.56 $171.97 $173.70 $0.00 $0.00 $33.98 $0.00 $0.00 $34.57 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.104.01 SUP HCPCS C1713 04.503.104.01 - SCREW BN 4MM NS MATRIXNEURO SLF DRL TI CRNMXF BOTH IP/OP $217.13 $160.68 $0.00 $173.70 $97.71 $97.71 $0.00 $0.00 $0.00 $45.25 $161.15 $161.15 $0.00 $0.00 $45.25 $0.00 $128.43 $128.43 $0.00 $108.56 $171.97 $173.70 $0.00 $0.00 $33.98 $0.00 $0.00 $34.57 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.105.01 SUP HCPCS C1713 04.503.105.01 - SCREW BN 5MM NS MATRIXNEURO SLF DRL TI CRNMXF BOTH IP/OP $217.13 $160.68 $0.00 $173.70 $97.71 $97.71 $0.00 $0.00 $0.00 $45.25 $161.15 $161.15 $0.00 $0.00 $45.25 $0.00 $128.43 $128.43 $0.00 $108.56 $171.97 $173.70 $0.00 $0.00 $33.98 $0.00 $0.00 $34.57 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.113.01 SUP HCPCS C1713 04.503.113.01 - SCREW BONE 3MM MATRIXNEURO CRNMXF TI ER NONSTRL BOTH IP/OP $217.13 $160.68 $0.00 $173.70 $97.71 $97.71 $0.00 $0.00 $0.00 $45.25 $161.15 $161.15 $0.00 $0.00 $45.25 $0.00 $128.43 $128.43 $0.00 $108.56 $171.97 $173.70 $0.00 $0.00 $33.98 $0.00 $0.00 $34.57 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.114.01 SUP HCPCS C1713 04.503.114.01 - SCREW BN 4MM NS MATRIXNEURO ER TI CRNMXF BOTH IP/OP $217.13 $160.68 $0.00 $173.70 $97.71 $97.71 $0.00 $0.00 $0.00 $45.25 $161.15 $161.15 $0.00 $0.00 $45.25 $0.00 $128.43 $128.43 $0.00 $108.56 $171.97 $173.70 $0.00 $0.00 $33.98 $0.00 $0.00 $34.57 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.115.01 SUP HCPCS C1713 04.503.115.01 - SCREW BONE 5MM MATRIXNEURO CRNMXF TI ER NONSTRL BOTH IP/OP $217.13 $160.68 $0.00 $173.70 $97.71 $97.71 $0.00 $0.00 $0.00 $45.25 $161.15 $161.15 $0.00 $0.00 $45.25 $0.00 $128.43 $128.43 $0.00 $108.56 $171.97 $173.70 $0.00 $0.00 $33.98 $0.00 $0.00 $34.57 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.120 SUP HCPCS C1713 04.503.120 - PLATE BONE 45X38MM MATRIXNEURO .6MM CRNMXF TI CONTUR MESH BOTH IP/OP "$3,831.75 " "$2,835.50" $0.00 "$3,065.40" "$1,724.29" "$1,724.29" $0.00 $0.00 $0.00 $798.63 "$2,843.92" "$2,843.92" $0.00 $0.00 $798.54 $0.00 "$1,889.05" "$1,889.05" $0.00 "$1,915.88" "$3,034.75" "$3,065.40" $0.00 $0.00 $599.67 $0.00 $0.00 $610.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.121 SUP HCPCS C1713 04.503.121 - PLATE 100X100X.6MM TI CONTUR MESH RGD MATRIXNEURO BONE BOTH IP/OP "$5,964.75 " "$4,413.92" $0.00 "$4,771.80" "$2,684.14" "$2,684.14" $0.00 $0.00 $0.00 "$1,243.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,243.05" $0.00 "$2,940.62" "$2,940.62" $0.00 "$2,982.38" "$4,724.08" "$4,771.80" $0.00 $0.00 $933.48 $0.00 $0.00 $949.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.122 SUP Custom 27803010 04.503.122 - TI MATRIXNEURO CONTOUR MESH 200MM X 200MM/0.6MM RIGID BOTH IP/OP "$22,842.00 " "$16,903.08" $0.00 "$18,273.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,760.27" $0.00 $0.00 $0.00 $0.00 "$11,421.00" "$18,090.86" "$18,273.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.123 SUP Custom 27803010 04.503.123 - TI MATRIXNEURO CONTOUR MESH SMALL ARC/0.6MM RIGID BOTH IP/OP "$2,202.75 " "$1,630.04" $0.00 "$1,762.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,634.88" "$1,634.88" $0.00 $0.00 $459.05 $0.00 $0.00 $0.00 $0.00 "$1,101.38" "$1,744.58" "$1,762.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.124 SUP Custom 27803010 04.503.124 - TI MATRIXNEURO CONTOUR MESH LARGE ARC/0.6MM RIGID BOTH IP/OP "$3,433.50 " "$2,540.79" $0.00 "$2,746.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,548.34" "$2,548.34" $0.00 $0.00 $715.54 $0.00 $0.00 $0.00 $0.00 "$1,716.75" "$2,719.33" "$2,746.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.125 SUP HCPCS C1713 04.503.125 - PLATE BONE PNK .6MM 30MM MATRIXNEURO TI CONTUR MESH RGD BOTH IP/OP "$2,202.75 " "$1,630.04" $0.00 "$1,762.20" $991.24 $991.24 $0.00 $0.00 $0.00 $459.11 "$1,634.88" "$1,634.88" $0.00 $0.00 $459.05 $0.00 "$1,302.93" "$1,302.93" $0.00 "$1,101.38" "$1,744.58" "$1,762.20" $0.00 $0.00 $344.73 $0.00 $0.00 $350.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.126 SUP HCPCS C1713 04.503.126 - PLATE BONE PNK .6MM 70MM MATRIXNEURO TI CONTUR MESH RGD BOTH IP/OP "$4,560.75 " "$3,374.96" $0.00 "$3,648.60" "$2,052.34" "$2,052.34" $0.00 $0.00 $0.00 $950.57 "$3,384.99" "$3,384.99" $0.00 $0.00 $950.46 $0.00 "$2,248.45" "$2,248.45" $0.00 "$2,280.38" "$3,612.11" "$3,648.60" $0.00 $0.00 $713.76 $0.00 $0.00 $726.07 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.127 SUP Custom 27803010 04.503.127 - TI MATRIXNEURO CONTOUR MESH 100MM DIA/0.6MM RIGID BOTH IP/OP "$5,688.00 " "$4,209.12" $0.00 "$4,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,185.38" $0.00 $0.00 $0.00 $0.00 "$2,844.00" "$4,504.90" "$4,550.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.131S SUP Custom 27803010 04.503.131S - KIT SCR MATRIXNEURO 4MM STD RTU LP RPD INS CRANIAL BONE FLP BOTH IP/OP "$1,842.75 " "$1,363.64" $0.00 "$1,474.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,367.69" "$1,367.69" $0.00 $0.00 $384.03 $0.00 $0.00 $0.00 $0.00 $921.38 "$1,459.46" "$1,474.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.134S SUP Custom 27803010 04.503.134S - MATRIXNEURO STERILE KIT 17MM BURR HOLE COVER/4MM BOTH IP/OP "$2,781.00 " "$2,057.94" $0.00 "$2,224.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,064.06" "$2,064.06" $0.00 $0.00 $579.56 $0.00 $0.00 $0.00 $0.00 "$1,390.50" "$2,202.55" "$2,224.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.203.01 SUP HCPCS C1713 04.503.203.01 - SCREW TI 3MM SLFTAP BONE MTRXMDFACE NONSTRL BRNZ BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.204.01 SUP HCPCS C1713 04.503.204.01 - SCREW TI 4MM SLFTAP ER BONE MTRXMDFACE BRNZ BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.205.01 SUP HCPCS C1713 04.503.205.01 - SCREW TI 5MM SLFTAP BONE MTRXMDFACE NONSTRL BRNZ BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.206.01 SUP HCPCS C1713 04.503.206.01 - SCREW TI 6MM SLFTAP BONE MTRXMDFACE NONSTRL BRNZ BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.208.01 SUP HCPCS C1713 04.503.208.01 - SCREW TI BRNZ 8MM MIDFAC SLFTAP BONE MTRXMDFACE NONSTRL BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.210.01 SUP HCPCS C1713 04.503.210.01 - SCREW TI 10MM CRNMXF SLFTAP BONE MTRXMDFACE NONSTRL BRNZ BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.212.01 SUP HCPCS C1713 04.503.212.01 - SCREW TI 12MM CRNMXF SLFTAP BONE MTRXMDFACE NONSTRL BRNZ BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.214.01 SUP HCPCS C1713 04.503.214.01 - SCREW TI 14MM CRNMXF SLFTAP BONE MTRXMDFACE NONSTRL BRNZ BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.216.01 SUP HCPCS C1713 04.503.216.01 - SCREW TI 16MM MIDFAC SLFTAP BONE NONSTRL BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.218.01 SUP HCPCS C1713 04.503.218.01 - TI MATRIXMIDFACE SCREW SELF-TAPPING 18MM BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.223.01 SUP HCPCS C1713 04.503.223.01 - SCREW BONE SLVR 3MM MTRXMDFACE CRNMXF TI SLFDRILL NONSTRL BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.224 SUP HCPCS C1713 04.503.224 - SCREW TI 4MM CRNMXF ORBTL FLR SLFDRILL BONE MTRX MIDFAC BOTH IP/OP $164.25 $121.55 $0.00 $131.40 $73.91 $73.91 $0.00 $0.00 $0.00 $34.23 $121.91 $121.91 $0.00 $0.00 $34.23 $0.00 $97.15 $97.15 $0.00 $82.13 $130.09 $131.40 $0.00 $0.00 $25.71 $0.00 $0.00 $26.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.224.01 SUP HCPCS C1713 04.503.224.01 - SCREW TI 4MM 1.5MM MIDFAC SLFDRILL BONE MTRXMDFACE NONSTRL BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.225 SUP HCPCS C1713 04.503.225 - SCREW TI 5MM MIDFAC BONE MTRXMDFACE NONSTRL BOTH IP/OP $164.25 $121.55 $0.00 $131.40 $73.91 $73.91 $0.00 $0.00 $0.00 $34.23 $121.91 $121.91 $0.00 $0.00 $34.23 $0.00 $97.15 $97.15 $0.00 $82.13 $130.09 $131.40 $0.00 $0.00 $25.71 $0.00 $0.00 $26.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.225.01 SUP HCPCS C1713 04.503.225.01 - SCREW TI 5MM 1.5MM ORBTL FLR SLFDRILL BONE MTRXMDFACE BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.226 SUP HCPCS C1713 04.503.226 - SCREW TI 6MM CRNMXF ORBTL FLR SLFDRILL BONE MTRXMDFACE BOTH IP/OP $164.25 $121.55 $0.00 $131.40 $73.91 $73.91 $0.00 $0.00 $0.00 $34.23 $121.91 $121.91 $0.00 $0.00 $34.23 $0.00 $97.15 $97.15 $0.00 $82.13 $130.09 $131.40 $0.00 $0.00 $25.71 $0.00 $0.00 $26.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.226.01 SUP HCPCS C1713 04.503.226.01 - SCREW TI 6MM 1.5MM ORBTL FLR SLFDRILL BONE MTRXMDFACE BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.228.01 SUP HCPCS C1713 04.503.228.01 - SCREW TI 8MM 1.5MM ORBTL FLR SLFDRILL BONE MTRXMDFACE BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.233.01 SUP HCPCS C1713 04.503.233.01 - SCREW TI 3MM ER BONE MTRXMDFACE LBLU BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.234.01 SUP HCPCS C1713 04.503.234.01 - SCREW_ TI MATRIXMIDFACE EMERGENCY 4MM BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.235.01 SUP HCPCS C1713 04.503.235.01 - SCREW TI 5MM 1.5MM ORBTL FLR ER BONE MTRXMDFACE NONSTRL LBLU BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.236.01 SUP HCPCS C1713 04.503.236.01 - SCREW TI 6MM 1.5MM ORBTL FLR ER BONE MTRXMDFACE NONSTRL BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.238.01 SUP HCPCS C1713 04.503.238.01 - SCREW TI 8MM ER BONE MTRXMDFACE NONSTRL BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.240.01 SUP HCPCS C1713 04.503.240.01 - SCREW TI 10MM ER BONE MTRXMDFACE BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.242.01 SUP HCPCS C1713 04.503.242.01 - SCREW TI 12MM ER BONE MTRXMDFACE BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.244.01 SUP HCPCS C1713 04.503.244.01 - SCREW TI 14MM ER BONE MTRXMDFACE BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.246.01 SUP HCPCS C1713 04.503.246.01 - SCREW TI 16MM ER BONE MTRXMDFACE BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.248.01 SUP HCPCS C1713 04.503.248.01 - SCREW TI 18MM ER BONE MTRXMDFACE BOTH IP/OP $218.25 $161.51 $0.00 $174.60 $98.21 $98.21 $0.00 $0.00 $0.00 $45.49 $161.99 $161.99 $0.00 $0.00 $45.48 $0.00 $129.09 $129.09 $0.00 $109.13 $172.85 $174.60 $0.00 $0.00 $34.16 $0.00 $0.00 $34.75 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.301 SUP HCPCS C1713 04.503.301 - PLATE BN SM .3MM NS MATRIXMIDFACE TI ORBT FLR BOTH IP/OP "$3,201.75 " "$2,369.30" $0.00 "$2,561.40" "$1,440.79" "$1,440.79" $0.00 $0.00 $0.00 $667.32 "$2,376.34" "$2,376.34" $0.00 $0.00 $667.24 $0.00 "$1,578.46" "$1,578.46" $0.00 "$1,600.88" "$2,535.79" "$2,561.40" $0.00 $0.00 $501.07 $0.00 $0.00 $509.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.302 SUP HCPCS C1713 04.503.302 - PLATE BN MED .3MM NS MATRIXMIDFACE TI ORBT FLR BOTH IP/OP "$3,201.75 " "$2,369.30" $0.00 "$2,561.40" "$1,440.79" "$1,440.79" $0.00 $0.00 $0.00 $667.32 "$2,376.34" "$2,376.34" $0.00 $0.00 $667.24 $0.00 "$1,578.46" "$1,578.46" $0.00 "$1,600.88" "$2,535.79" "$2,561.40" $0.00 $0.00 $501.07 $0.00 $0.00 $509.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.303 SUP HCPCS C1713 04.503.303 - PLATE BN LG .3MM NS MATRIXMIDFACE TI ORBT FLR BOTH IP/OP "$3,201.75 " "$2,369.30" $0.00 "$2,561.40" "$1,440.79" "$1,440.79" $0.00 $0.00 $0.00 $667.32 "$2,376.34" "$2,376.34" $0.00 $0.00 $667.24 $0.00 "$1,578.46" "$1,578.46" $0.00 "$1,600.88" "$2,535.79" "$2,561.40" $0.00 $0.00 $501.07 $0.00 $0.00 $509.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.304 SUP HCPCS C1713 04.503.304 - PLATE BN UNV .4MM NS MATRIXMIDFACE TI ORBT FLR BOTH IP/OP "$3,201.75 " "$2,369.30" $0.00 "$2,561.40" "$1,440.79" "$1,440.79" $0.00 $0.00 $0.00 $667.32 "$2,376.34" "$2,376.34" $0.00 $0.00 $667.24 $0.00 "$1,578.46" "$1,578.46" $0.00 "$1,600.88" "$2,535.79" "$2,561.40" $0.00 $0.00 $501.07 $0.00 $0.00 $509.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.305 SUP HCPCS C1713 04.503.305 - PLATE BN UNV .5MM NS MATRIXMIDFACE TI ORBT FLR MDL WL BOTH IP/OP "$3,201.75 " "$2,369.30" $0.00 "$2,561.40" "$1,440.79" "$1,440.79" $0.00 $0.00 $0.00 $667.32 "$2,376.34" "$2,376.34" $0.00 $0.00 $667.24 $0.00 "$1,578.46" "$1,578.46" $0.00 "$1,600.88" "$2,535.79" "$2,561.40" $0.00 $0.00 $501.07 $0.00 $0.00 $509.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.306 SUP HCPCS C1713 04.503.306 - PLATE BN .2MM NS MATRIXMIDFACE MESH TI ORBT FLR BOTH IP/OP "$3,323.25 " "$2,459.21" $0.00 "$2,658.60" "$1,495.46" "$1,495.46" $0.00 $0.00 $0.00 $692.65 "$2,466.52" "$2,466.52" $0.00 $0.00 $692.57 $0.00 "$1,638.36" "$1,638.36" $0.00 "$1,661.63" "$2,632.01" "$2,658.60" $0.00 $0.00 $520.09 $0.00 $0.00 $529.06 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.307 SUP HCPCS C1713 04.503.307 - PLATE BN .3MM NS MATRIXMIDFACE MESH TI ORBT FLR BOTH IP/OP "$3,323.25 " "$2,459.21" $0.00 "$2,658.60" "$1,495.46" "$1,495.46" $0.00 $0.00 $0.00 $692.65 "$2,466.52" "$2,466.52" $0.00 $0.00 $692.57 $0.00 "$1,638.36" "$1,638.36" $0.00 "$1,661.63" "$2,632.01" "$2,658.60" $0.00 $0.00 $520.09 $0.00 $0.00 $529.06 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.308 SUP HCPCS C1713 04.503.308 - PLATE BN .4MM NS MATRIXMIDFACE MESH TI ORBT FLR BOTH IP/OP "$3,323.25 " "$2,459.21" $0.00 "$2,658.60" "$1,495.46" "$1,495.46" $0.00 $0.00 $0.00 $692.65 "$2,466.52" "$2,466.52" $0.00 $0.00 $692.57 $0.00 "$1,638.36" "$1,638.36" $0.00 "$1,661.63" "$2,632.01" "$2,658.60" $0.00 $0.00 $520.09 $0.00 $0.00 $529.06 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.313 SUP HCPCS C1713 04.503.313 - PLATE BN STD MIC .4MM NS MATRIXMIDFACE 12 HL TI ORBT RIM BOTH IP/OP $927.00 $685.98 $0.00 $741.60 $417.15 $417.15 $0.00 $0.00 $0.00 $193.21 $688.02 $688.02 $0.00 $0.00 $193.19 $0.00 $548.32 $548.32 $0.00 $463.50 $734.18 $741.60 $0.00 $0.00 $145.08 $0.00 $0.00 $147.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.314 SUP HCPCS C1713 04.503.314 - PLATE BONE .4MM MTRXMDFACE CRNMXF TI 6 HOLE ADP NONSTRL BOTH IP/OP $679.50 $502.83 $0.00 $543.60 $305.78 $305.78 $0.00 $0.00 $0.00 $141.62 $504.32 $504.32 $0.00 $0.00 $141.61 $0.00 $401.92 $401.92 $0.00 $339.75 $538.16 $543.60 $0.00 $0.00 $106.34 $0.00 $0.00 $108.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.315 SUP HCPCS C1713 04.503.315 - PLATE BN STD MIC .4MM SLVR NS MATRIXMIDFACE 8 HL ADP TI MDFC BOTH IP/OP $841.50 $622.71 $0.00 $673.20 $378.68 $378.68 $0.00 $0.00 $0.00 $175.39 $624.56 $624.56 $0.00 $0.00 $175.37 $0.00 $497.75 $497.75 $0.00 $420.75 $666.47 $673.20 $0.00 $0.00 $131.69 $0.00 $0.00 $133.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.316 SUP HCPCS C1713 04.503.316 - PLATE BN STD MIC .4MM NS MATRIXMIDFACE 20 HL ADP TI MDFC BOTH IP/OP "$1,680.75 " "$1,243.76" $0.00 "$1,344.60" $756.34 $756.34 $0.00 $0.00 $0.00 $350.31 "$1,247.45" "$1,247.45" $0.00 $0.00 $350.27 $0.00 $994.16 $994.16 $0.00 $840.38 "$1,331.15" "$1,344.60" $0.00 $0.00 $263.04 $0.00 $0.00 $267.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.317 SUP HCPCS C1713 04.503.317 - PLATE BN STD MIC Y .4MM NS MATRIXMIDFACE 1X3 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.318 SUP HCPCS C1713 04.503.318 - PLATE BN STD MIC 2Y .4MM NS MATRIXMIDFACE 6 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.322 SUP HCPCS C1713 04.503.322 - PLATE BN STD MN H .5MM NS MATRIXMIDFACE 11 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.323 SUP HCPCS C1713 04.503.323 - PLATE BN STD MN OB L L .5MM NS MATRIXMIDFACE 2X3 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.324 SUP HCPCS C1713 04.503.324 - PLATE BN STD MN OB R L .5MM NS MATRIXMIDFACE 2X3 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.325 SUP HCPCS C1713 04.503.325 - PLATE BN STD MN OB L L .5MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $776.25 $574.43 $0.00 $621.00 $349.31 $349.31 $0.00 $0.00 $0.00 $161.79 $576.13 $576.13 $0.00 $0.00 $161.77 $0.00 $459.15 $459.15 $0.00 $388.13 $614.79 $621.00 $0.00 $0.00 $121.48 $0.00 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.326 SUP HCPCS C1713 04.503.326 - PLATE BN STD MN OB R L .5MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $776.25 $574.43 $0.00 $621.00 $349.31 $349.31 $0.00 $0.00 $0.00 $161.79 $576.13 $576.13 $0.00 $0.00 $161.77 $0.00 $459.15 $459.15 $0.00 $388.13 $614.79 $621.00 $0.00 $0.00 $121.48 $0.00 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.327 SUP HCPCS C1713 04.503.327 - PLATE BN STD MN T .5MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.330 SUP HCPCS C1713 04.503.330 - PLATE BN STD MIC BX 10X5X.4MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.331 SUP HCPCS C1713 04.503.331 - PLATE BN STD MN BX 10X10X.4MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.332 SUP HCPCS C1713 04.503.332 - PLATE BN STD MIC X .4MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.333 SUP HCPCS C1713 04.503.333 - PLATE BN STD MIC .4MM NS MATRIXMIDFACE 18 HL STRUT TI MDFC BOTH IP/OP "$1,599.75 " "$1,183.82" $0.00 "$1,279.80" $719.89 $719.89 $0.00 $0.00 $0.00 $333.43 "$1,187.33" "$1,187.33" $0.00 $0.00 $333.39 $0.00 $946.25 $946.25 $0.00 $799.88 "$1,267.00" "$1,279.80" $0.00 $0.00 $250.36 $0.00 $0.00 $254.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.334 SUP HCPCS C1713 04.503.334 - PLATE BN STD MN OB L L .5MM NS MATRIXMIDFACE 4X6 HL TI MDFC BOTH IP/OP $803.25 $594.41 $0.00 $642.60 $361.46 $361.46 $0.00 $0.00 $0.00 $167.42 $596.17 $596.17 $0.00 $0.00 $167.40 $0.00 $475.12 $475.12 $0.00 $401.63 $636.17 $642.60 $0.00 $0.00 $125.71 $0.00 $0.00 $127.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.335 SUP HCPCS C1713 04.503.335 - PLATE BN STD MN OB R L .5MM NS MATRIXMIDFACE 4X6 HL TI MDFC BOTH IP/OP $803.25 $594.41 $0.00 $642.60 $361.46 $361.46 $0.00 $0.00 $0.00 $167.42 $596.17 $596.17 $0.00 $0.00 $167.40 $0.00 $475.12 $475.12 $0.00 $401.63 $636.17 $642.60 $0.00 $0.00 $125.71 $0.00 $0.00 $127.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.343 SUP HCPCS C1713 04.503.343 - PLATE BN STD MN .5MM NS MATRIXMIDFACE 12 HL TI ORBT RIM BOTH IP/OP $927.00 $685.98 $0.00 $741.60 $417.15 $417.15 $0.00 $0.00 $0.00 $193.21 $688.02 $688.02 $0.00 $0.00 $193.19 $0.00 $548.32 $548.32 $0.00 $463.50 $734.18 $741.60 $0.00 $0.00 $145.08 $0.00 $0.00 $147.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.344 SUP HCPCS C1713 04.503.344 - PLATE .5MM ORBTL RIM 6 HOLE ADP BONE MTRXMDFACE TI NONSTRL BOTH IP/OP $679.50 $502.83 $0.00 $543.60 $305.78 $305.78 $0.00 $0.00 $0.00 $141.62 $504.32 $504.32 $0.00 $0.00 $141.61 $0.00 $401.92 $401.92 $0.00 $339.75 $538.16 $543.60 $0.00 $0.00 $106.34 $0.00 $0.00 $108.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.345 SUP HCPCS C1713 04.503.345 - PLATE BN STD MN .5MM NS MATRIXMIDFACE 8 HL ADP TI MDFC BOTH IP/OP $841.50 $622.71 $0.00 $673.20 $378.68 $378.68 $0.00 $0.00 $0.00 $175.39 $624.56 $624.56 $0.00 $0.00 $175.37 $0.00 $497.75 $497.75 $0.00 $420.75 $666.47 $673.20 $0.00 $0.00 $131.69 $0.00 $0.00 $133.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.346 SUP HCPCS C1713 04.503.346 - PLATE BONE BLUE .5MM MTRXMDFACE CRNMXF TI 20 HOLE ADP BOTH IP/OP "$1,680.75 " "$1,243.76" $0.00 "$1,247.45" $672.30 $672.30 $0.00 $0.00 $0.00 $350.31 "$1,247.45" "$1,247.45" $0.00 $0.00 $350.27 $0.00 $994.16 $994.16 $0.00 $747.00 "$1,183.25" "$1,195.20" $0.00 $0.00 $233.81 $0.00 $0.00 $237.84 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.347 SUP HCPCS C1713 04.503.347 - PLATE BN STD MN Y .5MM NS MATRIXMIDFACE 1X3 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.348 SUP HCPCS C1713 04.503.348 - PLATE BN STD MN 2Y .5MM NS MATRIXMIDFACE 6 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.352 SUP HCPCS C1713 04.503.352 - PLATE BN STD MED H .7MM NS MATRIXMIDFACE 11 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.353 SUP HCPCS C1713 04.503.353 - PLATE BN STD MED OB L L .7MM NS MATRIXMIDFACE 2X3 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.354 SUP HCPCS C1713 04.503.354 - PLATE BN STD MED OB R L .7MM NS MATRIXMIDFACE 2X3 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.355 SUP HCPCS C1713 04.503.355 - PLATE BN STD MN OB L L .7MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $776.25 $574.43 $0.00 $621.00 $349.31 $349.31 $0.00 $0.00 $0.00 $161.79 $576.13 $576.13 $0.00 $0.00 $161.77 $0.00 $459.15 $459.15 $0.00 $388.13 $614.79 $621.00 $0.00 $0.00 $121.48 $0.00 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.356 SUP HCPCS C1713 04.503.356 - PLATE BN STD MN OB R L .7MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $776.25 $574.43 $0.00 $621.00 $349.31 $349.31 $0.00 $0.00 $0.00 $161.79 $576.13 $576.13 $0.00 $0.00 $161.77 $0.00 $459.15 $459.15 $0.00 $388.13 $614.79 $621.00 $0.00 $0.00 $121.48 $0.00 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.357 SUP HCPCS C1713 04.503.357 - PLATE BN STD MED T .7MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.360 SUP HCPCS C1713 04.503.360 - PLATE BN STD MN BX 10X5X.5MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.361 SUP HCPCS C1713 04.503.361 - PLATE BN STD MN BX 10X10X.5MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.362 SUP HCPCS C1713 04.503.362 - PLATE BN STD MN X .5MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.363 SUP HCPCS C1713 04.503.363 - PLATE BN STD MN .5MM NS MATRIXMIDFACE 18 HL STRUT TI MDFC BOTH IP/OP "$1,599.75 " "$1,183.82" $0.00 "$1,279.80" $719.89 $719.89 $0.00 $0.00 $0.00 $333.43 "$1,187.33" "$1,187.33" $0.00 $0.00 $333.39 $0.00 $946.25 $946.25 $0.00 $799.88 "$1,267.00" "$1,279.80" $0.00 $0.00 $250.36 $0.00 $0.00 $254.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.364 SUP HCPCS C1713 04.503.364 - PLATE BN STD MED OB L L .7MM NS MATRIXMIDFACE 4X6 HL TI MDFC BOTH IP/OP $803.25 $594.41 $0.00 $642.60 $361.46 $361.46 $0.00 $0.00 $0.00 $167.42 $596.17 $596.17 $0.00 $0.00 $167.40 $0.00 $475.12 $475.12 $0.00 $401.63 $636.17 $642.60 $0.00 $0.00 $125.71 $0.00 $0.00 $127.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.365 SUP HCPCS C1713 04.503.365 - PLATE BN STD MED OB R L .7MM NS MATRIXMIDFACE 4X6 HL TI MDFC BOTH IP/OP $803.25 $594.41 $0.00 $642.60 $361.46 $361.46 $0.00 $0.00 $0.00 $167.42 $596.17 $596.17 $0.00 $0.00 $167.40 $0.00 $475.12 $475.12 $0.00 $401.63 $636.17 $642.60 $0.00 $0.00 $125.71 $0.00 $0.00 $127.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.373 SUP HCPCS C1713 04.503.373 - PLATE BN STD MED .7MM NS MATRIXMIDFACE 12 HL TI ORBT RIM BOTH IP/OP $927.00 $685.98 $0.00 $741.60 $417.15 $417.15 $0.00 $0.00 $0.00 $193.21 $688.02 $688.02 $0.00 $0.00 $193.19 $0.00 $548.32 $548.32 $0.00 $463.50 $734.18 $741.60 $0.00 $0.00 $145.08 $0.00 $0.00 $147.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.374 SUP HCPCS C1713 04.503.374 - PLATE .7MM CRANFCL 6 HOLE ADP BONE MTRXMDFACE TI NONSTRL BOTH IP/OP $679.50 $502.83 $0.00 $543.60 $305.78 $305.78 $0.00 $0.00 $0.00 $141.62 $504.32 $504.32 $0.00 $0.00 $141.61 $0.00 $401.92 $401.92 $0.00 $339.75 $538.16 $543.60 $0.00 $0.00 $106.34 $0.00 $0.00 $108.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.375 SUP HCPCS C1713 04.503.375 - PLATE BN STD MED .7MM NS MATRIXMIDFACE 8 HL ADP TI MDFC BOTH IP/OP $841.50 $622.71 $0.00 $673.20 $378.68 $378.68 $0.00 $0.00 $0.00 $175.39 $624.56 $624.56 $0.00 $0.00 $175.37 $0.00 $497.75 $497.75 $0.00 $420.75 $666.47 $673.20 $0.00 $0.00 $131.69 $0.00 $0.00 $133.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.376 SUP HCPCS C1713 04.503.376 - PLATE BN STD MED .7MM NS MATRIXMIDFACE 20 HL ADP TI MDFC BOTH IP/OP "$1,680.75 " "$1,243.76" $0.00 "$1,344.60" $756.34 $756.34 $0.00 $0.00 $0.00 $350.31 "$1,247.45" "$1,247.45" $0.00 $0.00 $350.27 $0.00 $994.16 $994.16 $0.00 $840.38 "$1,331.15" "$1,344.60" $0.00 $0.00 $263.04 $0.00 $0.00 $267.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.377 SUP HCPCS C1713 04.503.377 - PLATE BN STD MED Y .7MM NS MATRIXMIDFACE 1X3 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.378 SUP HCPCS C1713 04.503.378 - PLATE BN STD MED 2Y .7MM NS MATRIXMIDFACE 6 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.382 SUP HCPCS C1713 04.503.382 - PLATE BN STD LG H .8MM NS MATRIXMIDFACE 11 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.383 SUP HCPCS C1713 04.503.383 - PLATE BN STD LG OB L L .8MM NS MATRIXMIDFACE 2X3 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.384 SUP HCPCS C1713 04.503.384 - PLATE BN STD LG OB R L .8MM NS MATRIXMIDFACE 2X3 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.385 SUP HCPCS C1713 04.503.385 - PLATE BN STD LG OB L L .8MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $776.25 $574.43 $0.00 $621.00 $349.31 $349.31 $0.00 $0.00 $0.00 $161.79 $576.13 $576.13 $0.00 $0.00 $161.77 $0.00 $459.15 $459.15 $0.00 $388.13 $614.79 $621.00 $0.00 $0.00 $121.48 $0.00 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.386 SUP HCPCS C1713 04.503.386 - PLATE BN STD LG OB R L .8MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $776.25 $574.43 $0.00 $621.00 $349.31 $349.31 $0.00 $0.00 $0.00 $161.79 $576.13 $576.13 $0.00 $0.00 $161.77 $0.00 $459.15 $459.15 $0.00 $388.13 $614.79 $621.00 $0.00 $0.00 $121.48 $0.00 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.387 SUP HCPCS C1713 04.503.387 - PLATE BN STD LG T .8MM NS MATRIXMIDFACE 3X4 HL TI MDFC BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.390 SUP HCPCS C1713 04.503.390 - PLATE BN STD MED BX 10X5X.7MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.391 SUP HCPCS C1713 04.503.391 - PLATE BN STD MED BX 10X10X.7MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $758.25 $561.11 $0.00 $606.60 $341.21 $341.21 $0.00 $0.00 $0.00 $158.04 $562.77 $562.77 $0.00 $0.00 $158.02 $0.00 $448.50 $448.50 $0.00 $379.13 $600.53 $606.60 $0.00 $0.00 $118.67 $0.00 $0.00 $120.71 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.392 SUP HCPCS C1713 04.503.392 - PLATE BN STD MED X .7MM NS MATRIXMIDFACE 4 HL TI MDFC BOTH IP/OP $747.00 $552.78 $0.00 $597.60 $336.15 $336.15 $0.00 $0.00 $0.00 $155.69 $554.42 $554.42 $0.00 $0.00 $155.67 $0.00 $441.85 $441.85 $0.00 $373.50 $591.62 $597.60 $0.00 $0.00 $116.91 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.393 SUP HCPCS C1713 04.503.393 - PLATE BN STD MED .7MM NS MATRIXMIDFACE 18 HL STRUT TI MDFC BOTH IP/OP "$1,599.75 " "$1,183.82" $0.00 "$1,279.80" $719.89 $719.89 $0.00 $0.00 $0.00 $333.43 "$1,187.33" "$1,187.33" $0.00 $0.00 $333.39 $0.00 $946.25 $946.25 $0.00 $799.88 "$1,267.00" "$1,279.80" $0.00 $0.00 $250.36 $0.00 $0.00 $254.68 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.394 SUP HCPCS C1713 04.503.394 - PLATE BN L OB L .8MM NS MATRIXMIDFACE 4X6 HL TI MDFC BOTH IP/OP $803.25 $594.41 $0.00 $642.60 $361.46 $361.46 $0.00 $0.00 $0.00 $167.42 $596.17 $596.17 $0.00 $0.00 $167.40 $0.00 $475.12 $475.12 $0.00 $401.63 $636.17 $642.60 $0.00 $0.00 $125.71 $0.00 $0.00 $127.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.395 SUP HCPCS C1713 04.503.395 - PLATE BN STD LG OB R L .8MM NS MATRIXMIDFACE 4X6 HL TI MDFC BOTH IP/OP $803.25 $594.41 $0.00 $642.60 $361.46 $361.46 $0.00 $0.00 $0.00 $167.42 $596.17 $596.17 $0.00 $0.00 $167.40 $0.00 $475.12 $475.12 $0.00 $401.63 $636.17 $642.60 $0.00 $0.00 $125.71 $0.00 $0.00 $127.88 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.396 SUP HCPCS C1713 04.503.396 - PLATE BN LG .8MM NS MATRIXMIDFACE 20 HL ADP TI MDFC BOTH IP/OP "$1,680.75 " "$1,243.76" $0.00 "$1,344.60" $756.34 $756.34 $0.00 $0.00 $0.00 $350.31 "$1,247.45" "$1,247.45" $0.00 $0.00 $350.27 $0.00 $994.16 $994.16 $0.00 $840.38 "$1,331.15" "$1,344.60" $0.00 $0.00 $263.04 $0.00 $0.00 $267.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.397 SUP HCPCS C1713 04.503.397 - PLATE BONE .8MM MTRXMDFACE ORBTL RIM TI 12 HOLE NONSTRL BOTH IP/OP $927.00 $685.98 $0.00 $741.60 $417.15 $417.15 $0.00 $0.00 $0.00 $193.21 $688.02 $688.02 $0.00 $0.00 $193.19 $0.00 $548.32 $548.32 $0.00 $463.50 $734.18 $741.60 $0.00 $0.00 $145.08 $0.00 $0.00 $147.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.398 SUP HCPCS C1713 04.503.398 - PLATE .8MM ORBTL RIM 6 HOLE ADP BONE MTRXMDFACE TI NONSTRL BOTH IP/OP $679.50 $502.83 $0.00 $543.60 $305.78 $305.78 $0.00 $0.00 $0.00 $141.62 $504.32 $504.32 $0.00 $0.00 $141.61 $0.00 $401.92 $401.92 $0.00 $339.75 $538.16 $543.60 $0.00 $0.00 $106.34 $0.00 $0.00 $108.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.399 SUP HCPCS C1713 04.503.399 - PLATE .8MM ORBTL RIM 8 HOLE ADP BONE MTRXMDFACE TI NONSTRL BOTH IP/OP $841.50 $622.71 $0.00 $673.20 $378.68 $378.68 $0.00 $0.00 $0.00 $175.39 $624.56 $624.56 $0.00 $0.00 $175.37 $0.00 $497.75 $497.75 $0.00 $420.75 $666.47 $673.20 $0.00 $0.00 $131.69 $0.00 $0.00 $133.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.405.01 SUP HCPCS C1713 04.503.405.01 - SCREW BONE 5MM 2MM MTRXMAND CRNMXF TI SLFTAP NONSTRL BOTH IP/OP $168.75 $124.88 $0.00 $135.00 $75.94 $75.94 $0.00 $0.00 $0.00 $35.17 $125.25 $125.25 $0.00 $0.00 $35.17 $0.00 $99.82 $99.82 $0.00 $84.38 $133.65 $135.00 $0.00 $0.00 $26.41 $0.00 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.406 SUP HCPCS C1713 04.503.406 - SCREW TI 6MM 2MM MIDFAC SLFTAP BONE MTRXMDFACE NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $60.75 $60.75 $0.00 $0.00 $0.00 $28.14 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $79.85 $79.85 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $21.13 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.406.01 SUP HCPCS C1713 04.503.406.01 - SCREW TI 6MM 2MM CRNMXF SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $168.75 $124.88 $0.00 $135.00 $75.94 $75.94 $0.00 $0.00 $0.00 $35.17 $125.25 $125.25 $0.00 $0.00 $35.17 $0.00 $99.82 $99.82 $0.00 $84.38 $133.65 $135.00 $0.00 $0.00 $26.41 $0.00 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.408 SUP HCPCS C1713 04.503.408 - SCREW TI 8MM 2MM CRNMXF SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $60.75 $60.75 $0.00 $0.00 $0.00 $28.14 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $79.85 $79.85 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $21.13 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.408.01 SUP HCPCS C1713 04.503.408.01 - SCREW TI 8MM 2MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $168.75 $124.88 $0.00 $135.00 $75.94 $75.94 $0.00 $0.00 $0.00 $35.17 $125.25 $125.25 $0.00 $0.00 $35.17 $0.00 $99.82 $99.82 $0.00 $84.38 $133.65 $135.00 $0.00 $0.00 $26.41 $0.00 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.408.01E SUP HCPCS C1713 04.503.408.01E - SCREW TI 8MM 2MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $60.75 $60.75 $0.00 $0.00 $0.00 $28.14 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $79.85 $79.85 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $21.13 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.410.01 SUP HCPCS C1713 04.503.410.01 - SCREW TI 10MM 2MM CRNMXF SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $168.75 $124.88 $0.00 $135.00 $75.94 $75.94 $0.00 $0.00 $0.00 $35.17 $125.25 $125.25 $0.00 $0.00 $35.17 $0.00 $99.82 $99.82 $0.00 $84.38 $133.65 $135.00 $0.00 $0.00 $26.41 $0.00 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.412 SUP HCPCS C1713 04.503.412 - SCREW TI 12MM 2MM CRNMXF SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $60.75 $60.75 $0.00 $0.00 $0.00 $28.14 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $79.85 $79.85 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $21.13 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.412.01 SUP HCPCS C1713 04.503.412.01 - SCREW TI 12MM 2MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $168.75 $124.88 $0.00 $135.00 $75.94 $75.94 $0.00 $0.00 $0.00 $35.17 $125.25 $125.25 $0.00 $0.00 $35.17 $0.00 $99.82 $99.82 $0.00 $84.38 $133.65 $135.00 $0.00 $0.00 $26.41 $0.00 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.414.01 SUP HCPCS C1713 04.503.414.01 - SCREW TI 14MM 2MM MANDIB SLFTAP BONE MTRX BOTH IP/OP $168.75 $124.88 $0.00 $135.00 $75.94 $75.94 $0.00 $0.00 $0.00 $35.17 $125.25 $125.25 $0.00 $0.00 $35.17 $0.00 $99.82 $99.82 $0.00 $84.38 $133.65 $135.00 $0.00 $0.00 $26.41 $0.00 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.416.01 SUP HCPCS C1713 04.503.416.01 - SCREW TI 16MM 2MM CRNMXF SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $168.75 $124.88 $0.00 $135.00 $75.94 $75.94 $0.00 $0.00 $0.00 $35.17 $125.25 $125.25 $0.00 $0.00 $35.17 $0.00 $99.82 $99.82 $0.00 $84.38 $133.65 $135.00 $0.00 $0.00 $26.41 $0.00 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.418.01 SUP HCPCS C1713 04.503.418.01 - SCREW TI 18MM 2.4MM SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $168.75 $124.88 $0.00 $135.00 $75.94 $75.94 $0.00 $0.00 $0.00 $35.17 $125.25 $125.25 $0.00 $0.00 $35.17 $0.00 $99.82 $99.82 $0.00 $84.38 $133.65 $135.00 $0.00 $0.00 $26.41 $0.00 $0.00 $26.87 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.435.01 SUP HCPCS C1713 04.503.435.01 - SCREW TI 5MM 2.4MM SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.436.01 SUP HCPCS C1713 04.503.436.01 - SCREW TI 6MM 2.4MM SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.438.01 SUP HCPCS C1713 04.503.438.01 - SCREW TI 8MM 2.4MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.440.01 SUP HCPCS C1713 04.503.440.01 - SCREW TI 10MM 2.4MM MANDIB SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.442.01 SUP HCPCS C1713 04.503.442.01 - SCREW TI 12MM 2.4MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.444 SUP HCPCS C1713 04.503.444 - SCREW TI 14MM 2.4MM SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $193.50 $143.19 $0.00 $154.80 $87.08 $87.08 $0.00 $0.00 $0.00 $40.33 $143.62 $143.62 $0.00 $0.00 $40.33 $0.00 $114.46 $114.46 $0.00 $96.75 $153.25 $154.80 $0.00 $0.00 $30.28 $0.00 $0.00 $30.81 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.444.01 SUP HCPCS C1713 04.503.444.01 - SCREW BONE 14MM 2.4MM MTRXMAND CRNMXF TI SLFTAP NONSTRL BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.446 SUP HCPCS C1713 04.503.446 - SCREW TI 16MM 2.4MM SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $193.50 $143.19 $0.00 $154.80 $87.08 $87.08 $0.00 $0.00 $0.00 $40.33 $143.62 $143.62 $0.00 $0.00 $40.33 $0.00 $114.46 $114.46 $0.00 $96.75 $153.25 $154.80 $0.00 $0.00 $30.28 $0.00 $0.00 $30.81 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.446.01 SUP HCPCS C1713 04.503.446.01 - SCREW TI 16MM 2.4MM SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.448.01 SUP HCPCS C1713 04.503.448.01 - SCREW TI 18MM 2.4MM SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $243.00 $179.82 $0.00 $194.40 $109.35 $109.35 $0.00 $0.00 $0.00 $50.65 $180.35 $180.35 $0.00 $0.00 $50.64 $0.00 $143.73 $143.73 $0.00 $121.50 $192.46 $194.40 $0.00 $0.00 $38.03 $0.00 $0.00 $38.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.465.01 SUP HCPCS C1713 04.503.465.01 - SCREW TI 5MM 2.7MM SLFTAP BONE MTRXMAND NONSTRL ER BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $119.48 $119.48 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $41.55 $0.00 $0.00 $42.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.466.01 SUP HCPCS C1713 04.503.466.01 - SCREW TI 6MM 2.7MM ER SLFTAP BONE MTRXMAND BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $119.48 $119.48 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $41.55 $0.00 $0.00 $42.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.468 SUP HCPCS C1713 04.503.468 - SCREW TI 8MM 2.7MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.468.01 SUP HCPCS C1713 04.503.468.01 - SCREW TI 8MM 2.7MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $119.48 $119.48 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $41.55 $0.00 $0.00 $42.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.470 SUP HCPCS C1713 04.503.470 - SCREW TI 10MM 2.7MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.470.01 SUP HCPCS C1713 04.503.470.01 - SCREW TI 10MM 2.7MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $119.48 $119.48 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $41.55 $0.00 $0.00 $42.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.472.01 SUP HCPCS C1713 04.503.472.01 - SCREW TI 12MM 2.7MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $119.48 $119.48 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $41.55 $0.00 $0.00 $42.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.474.01 SUP HCPCS C1713 04.503.474.01 - SCREW TI 14MM 2.7MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $119.48 $119.48 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $41.55 $0.00 $0.00 $42.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.476.01 SUP HCPCS C1713 04.503.476.01 - SCREW TI 16MM 2.7MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $119.48 $119.48 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $41.55 $0.00 $0.00 $42.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.478.01 SUP HCPCS C1713 04.503.478.01 - SCREW TI 18MM 2.7MM SLFTAP ER BONE MTRXMAND NONSTRL BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $119.48 $119.48 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $41.55 $0.00 $0.00 $42.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.506.01 SUP HCPCS C1713 04.503.506.01 - SCREW TI 6MM 2MM MANDIB SLFDRILL MTRX BONE MTRXMAND NONSTRL BOTH IP/OP $187.88 $139.03 $0.00 $150.30 $84.54 $84.54 $0.00 $0.00 $0.00 $39.16 $139.44 $139.44 $0.00 $0.00 $39.15 $0.00 $111.13 $111.13 $0.00 $93.94 $148.80 $150.30 $0.00 $0.00 $29.40 $0.00 $0.00 $29.91 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.508.01 SUP HCPCS C1713 04.503.508.01 - SCREW TI 8MM 2MM MANDIB SLFDRILL MTRX BONE MTRXMAND NONSTRL BOTH IP/OP $187.88 $139.03 $0.00 $150.30 $84.54 $84.54 $0.00 $0.00 $0.00 $39.16 $139.44 $139.44 $0.00 $0.00 $39.15 $0.00 $111.13 $111.13 $0.00 $93.94 $148.80 $150.30 $0.00 $0.00 $29.40 $0.00 $0.00 $29.91 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.546.01 SUP HCPCS C1713 04.503.546.01 - SCREW BONE 6MM 2MM MTRXMAND CRNMXF TI LCK SLFDRILL NONSTRL BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $145.80 $145.80 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $0.00 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.548.01 SUP HCPCS C1713 04.503.548.01 - SCREW BONE 8MM 2MM MTRXMAND CRNMXF TI LCK SLFDRILL NONSTRL BOTH IP/OP $324.00 $239.76 $0.00 $259.20 $145.80 $145.80 $0.00 $0.00 $0.00 $67.53 $240.47 $240.47 $0.00 $0.00 $67.52 $0.00 $191.65 $191.65 $0.00 $162.00 $256.61 $259.20 $0.00 $0.00 $50.71 $0.00 $0.00 $51.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.605 SUP HCPCS C1713 04.503.605 - SCREW TI 5MM 2MM LCK SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $113.40 $113.40 $0.00 $0.00 $0.00 $52.52 $187.03 $187.03 $0.00 $0.00 $52.52 $0.00 $149.06 $149.06 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $39.44 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.605.01 SUP HCPCS C1713 04.503.605.01 - SCREW TI 5MM 2MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $317.25 $234.77 $0.00 $253.80 $142.76 $142.76 $0.00 $0.00 $0.00 $66.12 $235.46 $235.46 $0.00 $0.00 $66.11 $0.00 $187.65 $187.65 $0.00 $158.63 $251.26 $253.80 $0.00 $0.00 $49.65 $0.00 $0.00 $50.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.606.01 SUP HCPCS C1713 04.503.606.01 - SCREW TI 6MM 2MM MANDIB SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $317.25 $234.77 $0.00 $253.80 $142.76 $142.76 $0.00 $0.00 $0.00 $66.12 $235.46 $235.46 $0.00 $0.00 $66.11 $0.00 $187.65 $187.65 $0.00 $158.63 $251.26 $253.80 $0.00 $0.00 $49.65 $0.00 $0.00 $50.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.608 SUP HCPCS C1713 04.503.608 - SCREW TI 8MM 2MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $113.40 $113.40 $0.00 $0.00 $0.00 $52.52 $187.03 $187.03 $0.00 $0.00 $52.52 $0.00 $149.06 $149.06 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $39.44 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.608.01 SUP HCPCS C1713 04.503.608.01 - SCREW TI 8MM 2.4MM SLFTAP ER BONE MTRXMAND STRL BOTH IP/OP $317.25 $234.77 $0.00 $253.80 $142.76 $142.76 $0.00 $0.00 $0.00 $66.12 $235.46 $235.46 $0.00 $0.00 $66.11 $0.00 $187.65 $187.65 $0.00 $158.63 $251.26 $253.80 $0.00 $0.00 $49.65 $0.00 $0.00 $50.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.608.01E SUP HCPCS C1713 04.503.608.01E - SCREW TI 8MM 2.4MM SLFTAP ER BONE MTRXMAND STRL BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $113.40 $113.40 $0.00 $0.00 $0.00 $52.52 $187.03 $187.03 $0.00 $0.00 $52.52 $0.00 $149.06 $149.06 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $39.44 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.610 SUP HCPCS C1713 04.503.610 - SCREW TI 10MM 2MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $113.40 $113.40 $0.00 $0.00 $0.00 $52.52 $187.03 $187.03 $0.00 $0.00 $52.52 $0.00 $149.06 $149.06 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $39.44 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.610.01 SUP HCPCS C1713 04.503.610.01 - SCREW TI 10MM 2MM MANDIB SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $317.25 $234.77 $0.00 $253.80 $142.76 $142.76 $0.00 $0.00 $0.00 $66.12 $235.46 $235.46 $0.00 $0.00 $66.11 $0.00 $187.65 $187.65 $0.00 $158.63 $251.26 $253.80 $0.00 $0.00 $49.65 $0.00 $0.00 $50.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.612 SUP HCPCS C1713 04.503.612 - SCREW TI 12MM 2MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $113.40 $113.40 $0.00 $0.00 $0.00 $52.52 $187.03 $187.03 $0.00 $0.00 $52.52 $0.00 $149.06 $149.06 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $39.44 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.612.01 SUP HCPCS C1713 04.503.612.01 - SCREW BONE 2MM 12MM TI MAXFACL SLFTAP LCK NONSTRL BOTH IP/OP $317.25 $234.77 $0.00 $253.80 $142.76 $142.76 $0.00 $0.00 $0.00 $66.12 $235.46 $235.46 $0.00 $0.00 $66.11 $0.00 $187.65 $187.65 $0.00 $158.63 $251.26 $253.80 $0.00 $0.00 $49.65 $0.00 $0.00 $50.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.614 SUP HCPCS C1713 04.503.614 - SCREW TI 14MM 2MM LCK SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $113.40 $113.40 $0.00 $0.00 $0.00 $52.52 $187.03 $187.03 $0.00 $0.00 $52.52 $0.00 $149.06 $149.06 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $39.44 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.614.01 SUP HCPCS C1713 04.503.614.01 - SCREW BONE 2MM 14MM TI MAXFACL SLFTAP LCK NONSTRL BOTH IP/OP $317.25 $234.77 $0.00 $253.80 $142.76 $142.76 $0.00 $0.00 $0.00 $66.12 $235.46 $235.46 $0.00 $0.00 $66.11 $0.00 $187.65 $187.65 $0.00 $158.63 $251.26 $253.80 $0.00 $0.00 $49.65 $0.00 $0.00 $50.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.616 SUP HCPCS C1713 04.503.616 - SCREW TI 16MM 2MM LCK SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $252.00 $186.48 $0.00 $201.60 $113.40 $113.40 $0.00 $0.00 $0.00 $52.52 $187.03 $187.03 $0.00 $0.00 $52.52 $0.00 $149.06 $149.06 $0.00 $126.00 $199.58 $201.60 $0.00 $0.00 $39.44 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.616.01 SUP HCPCS C1713 04.503.616.01 - SCREW TI 16MM 2MM MANDIB SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $317.25 $234.77 $0.00 $253.80 $142.76 $142.76 $0.00 $0.00 $0.00 $66.12 $235.46 $235.46 $0.00 $0.00 $66.11 $0.00 $187.65 $187.65 $0.00 $158.63 $251.26 $253.80 $0.00 $0.00 $49.65 $0.00 $0.00 $50.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.618.01 SUP HCPCS C1713 04.503.618.01 - SCREW TI 18MM 2MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $317.25 $234.77 $0.00 $253.80 $142.76 $142.76 $0.00 $0.00 $0.00 $66.12 $235.46 $235.46 $0.00 $0.00 $66.11 $0.00 $187.65 $187.65 $0.00 $158.63 $251.26 $253.80 $0.00 $0.00 $49.65 $0.00 $0.00 $50.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.638.01 SUP HCPCS C1713 04.503.638.01 - SCREW TI 8MM 2.4MM MIDFAC SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.640 SUP HCPCS C1713 04.503.640 - SCREW TI 10MM 2.4MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $139.73 $139.73 $0.00 $0.00 $0.00 $64.72 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $183.66 $183.66 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $48.59 $0.00 $0.00 $49.43 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.640.01 SUP HCPCS C1713 04.503.640.01 - SCREW TI 10MM 2.4MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.642.01 SUP HCPCS C1713 04.503.642.01 - SCREW TI 12MM 2.4MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.644 SUP HCPCS C1713 04.503.644 - SCREW TI 14MM 2.4MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $139.73 $139.73 $0.00 $0.00 $0.00 $64.72 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $183.66 $183.66 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $48.59 $0.00 $0.00 $49.43 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.644.01 SUP HCPCS C1713 04.503.644.01 - SCREW TI 14MM 2.4MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.646 SUP HCPCS C1713 04.503.646 - SCREW TI 16MM 2.4MM LCK SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $139.73 $139.73 $0.00 $0.00 $0.00 $64.72 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $183.66 $183.66 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $48.59 $0.00 $0.00 $49.43 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.646.01 SUP HCPCS C1713 04.503.646.01 - SCREW TI 16MM 2.4MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.648.01 SUP HCPCS C1713 04.503.648.01 - SCREW TI 18MM 2.4MM SLFTAP LCK BONE MTRXMAND NONSTRL BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.668.01 SUP HCPCS C1713 04.503.668.01 - SCREW BONE 2.8MM 8MM TI LCK BOTH IP/OP $447.75 $331.34 $0.00 $358.20 $201.49 $201.49 $0.00 $0.00 $0.00 $93.32 $332.32 $332.32 $0.00 $0.00 $93.31 $0.00 $264.84 $264.84 $0.00 $223.88 $354.62 $358.20 $0.00 $0.00 $70.07 $0.00 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.670 SUP HCPCS C1713 04.503.670 - SCREW TI 10MM 2.9MM LCK SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.670.01 SUP HCPCS C1713 04.503.670.01 - SCREW BONE 2.8MM 10MM TI LCK BOTH IP/OP $447.75 $331.34 $0.00 $358.20 $201.49 $201.49 $0.00 $0.00 $0.00 $93.32 $332.32 $332.32 $0.00 $0.00 $93.31 $0.00 $264.84 $264.84 $0.00 $223.88 $354.62 $358.20 $0.00 $0.00 $70.07 $0.00 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.672 SUP HCPCS C1713 04.503.672 - SCREW TI 12MM 2.9MM LCK SLFTAP BONE MTRXMAND NONSTRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.672.01 SUP HCPCS C1713 04.503.672.01 - SCREW BONE 2.9MM 12MM TI LCK BOTH IP/OP $447.75 $331.34 $0.00 $358.20 $201.49 $201.49 $0.00 $0.00 $0.00 $93.32 $332.32 $332.32 $0.00 $0.00 $93.31 $0.00 $264.84 $264.84 $0.00 $223.88 $354.62 $358.20 $0.00 $0.00 $70.07 $0.00 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.674.01 SUP HCPCS C1713 04.503.674.01 - SCREW BONE 2.9MM 14MM TI LCK BOTH IP/OP $447.75 $331.34 $0.00 $358.20 $201.49 $201.49 $0.00 $0.00 $0.00 $93.32 $332.32 $332.32 $0.00 $0.00 $93.31 $0.00 $264.84 $264.84 $0.00 $223.88 $354.62 $358.20 $0.00 $0.00 $70.07 $0.00 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.676.01 SUP HCPCS C1713 04.503.676.01 - SCREW BONE 2.8MM 16MM TI LCK BOTH IP/OP $447.75 $331.34 $0.00 $358.20 $201.49 $201.49 $0.00 $0.00 $0.00 $93.32 $332.32 $332.32 $0.00 $0.00 $93.31 $0.00 $264.84 $264.84 $0.00 $223.88 $354.62 $358.20 $0.00 $0.00 $70.07 $0.00 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.678.01 SUP HCPCS C1713 04.503.678.01 - SCREW TI 18MM 2.9MM SLFTAP LCK BONE MTRXMAND BOTH IP/OP $447.75 $331.34 $0.00 $358.20 $201.49 $201.49 $0.00 $0.00 $0.00 $93.32 $332.32 $332.32 $0.00 $0.00 $93.31 $0.00 $264.84 $264.84 $0.00 $223.88 $354.62 $358.20 $0.00 $0.00 $70.07 $0.00 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.701 SUP HCPCS C1713 04.503.701 - PLATE BN MN NAR 1MM NS MATRIXMANDIBLE 2X2 HL TNSNBND MLBL TI BOTH IP/OP $922.50 $682.65 $0.00 $738.00 $415.13 $415.13 $0.00 $0.00 $0.00 $192.27 $684.68 $684.68 $0.00 $0.00 $192.25 $0.00 $545.66 $545.66 $0.00 $461.25 $730.62 $738.00 $0.00 $0.00 $144.37 $0.00 $0.00 $146.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.702 SUP HCPCS C1713 04.503.702 - PLATE MINI NAR 1MM MANDIB 2X2 HOLE TNSNBND BONE MTRXMAND TI BOTH IP/OP $922.50 $682.65 $0.00 $738.00 $415.13 $415.13 $0.00 $0.00 $0.00 $192.27 $684.68 $684.68 $0.00 $0.00 $192.25 $0.00 $545.66 $545.66 $0.00 $461.25 $730.62 $738.00 $0.00 $0.00 $144.37 $0.00 $0.00 $146.86 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.703 SUP HCPCS C1713 04.503.703 - PLATE BN MN NAR 1MM NS MATRIXMANDIBLE 3X3 HL TNSNBND MLBL TI BOTH IP/OP "$1,005.75 " $744.26 $0.00 $804.60 $452.59 $452.59 $0.00 $0.00 $0.00 $209.62 $746.47 $746.47 $0.00 $0.00 $209.60 $0.00 $594.90 $594.90 $0.00 $502.88 $796.55 $804.60 $0.00 $0.00 $157.40 $0.00 $0.00 $160.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.704 SUP HCPCS C1713 04.503.704 - PLATE MINI NAR NONSTRL 1MM 2X2 HOLE TNSNBND MALBLE BONE BOTH IP/OP "$1,005.75 " $744.26 $0.00 $804.60 $452.59 $452.59 $0.00 $0.00 $0.00 $209.62 $746.47 $746.47 $0.00 $0.00 $209.60 $0.00 $594.90 $594.90 $0.00 $502.88 $796.55 $804.60 $0.00 $0.00 $157.40 $0.00 $0.00 $160.12 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.705 SUP HCPCS C1713 04.503.705 - PLATE BN 1MM NS MATRIXMANDIBLE 12 HL ADP TI MNDB BOTH IP/OP "$1,651.50 " "$1,222.11" $0.00 "$1,321.20" $743.18 $743.18 $0.00 $0.00 $0.00 $344.21 "$1,225.74" "$1,225.74" $0.00 $0.00 $344.17 $0.00 $976.86 $976.86 $0.00 $825.75 "$1,307.99" "$1,321.20" $0.00 $0.00 $258.46 $0.00 $0.00 $262.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.706 SUP HCPCS C1713 04.503.706 - PLATE BN 1MM NS MATRIXMANDIBLE 20 HL ADP TI MNDB BOTH IP/OP "$1,809.00 " "$1,338.66" $0.00 "$1,447.20" $814.05 $814.05 $0.00 $0.00 $0.00 $377.04 "$1,342.64" "$1,342.64" $0.00 $0.00 $377.00 $0.00 "$1,070.02" "$1,070.02" $0.00 $904.50 "$1,432.73" "$1,447.20" $0.00 $0.00 $283.11 $0.00 $0.00 $287.99 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.707 SUP HCPCS C1713 04.503.707 - PLATE BN BX 1MM NS MATRIXMANDIBLE 4 HL MLBL TI MNDB BOTH IP/OP $722.25 $534.47 $0.00 $577.80 $325.01 $325.01 $0.00 $0.00 $0.00 $150.53 $536.05 $536.05 $0.00 $0.00 $150.52 $0.00 $427.21 $427.21 $0.00 $361.13 $572.02 $577.80 $0.00 $0.00 $113.03 $0.00 $0.00 $114.98 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.708 SUP HCPCS C1713 04.503.708 - PLATE BN 1MM NS MATRIXMANDIBLE 8 HL MLBL STRUT TI MNDB BOTH IP/OP "$1,419.75 " "$1,050.62" $0.00 "$1,135.80" $638.89 $638.89 $0.00 $0.00 $0.00 $295.91 "$1,053.74" "$1,053.74" $0.00 $0.00 $295.88 $0.00 $839.78 $839.78 $0.00 $709.88 "$1,124.44" "$1,135.80" $0.00 $0.00 $222.19 $0.00 $0.00 $226.02 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.709 SUP HCPCS C1713 04.503.709 - PLATE BN MN CRV 1MM NS MATRIXMANDIBLE 8 HL MLBL STRUT TI BOTH IP/OP "$1,419.75 " "$1,050.62" $0.00 "$1,135.80" $638.89 $638.89 $0.00 $0.00 $0.00 $295.91 "$1,053.74" "$1,053.74" $0.00 $0.00 $295.88 $0.00 $839.78 $839.78 $0.00 $709.88 "$1,124.44" "$1,135.80" $0.00 $0.00 $222.19 $0.00 $0.00 $226.02 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.710 SUP HCPCS C1713 04.503.710 - PLATE BN STRG 1.25MM NS MATRIXMANDIBLE DCP 2X2 HL TI MNDB BOTH IP/OP $893.25 $661.01 $0.00 $714.60 $401.96 $401.96 $0.00 $0.00 $0.00 $186.18 $662.97 $662.97 $0.00 $0.00 $186.15 $0.00 $528.36 $528.36 $0.00 $446.63 $707.45 $714.60 $0.00 $0.00 $139.79 $0.00 $0.00 $142.21 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.711 SUP HCPCS C1713 04.503.711 - PLATE BN CRSNT 1.25MM NS MATRIXMANDIBLE 2X2 HL TI MNDB BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $0.00 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.712 SUP HCPCS C1713 04.503.712 - PLATE BN STRG 1.25MM NS MATRIXMANDIBLE DCP 3X3 HL TI MNDB BOTH IP/OP "$1,050.75 " $777.56 $0.00 $840.60 $472.84 $472.84 $0.00 $0.00 $0.00 $219.00 $779.87 $779.87 $0.00 $0.00 $218.98 $0.00 $621.52 $621.52 $0.00 $525.38 $832.19 $840.60 $0.00 $0.00 $164.44 $0.00 $0.00 $167.28 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.713 SUP HCPCS C1713 04.503.713 - PLATE BN CRSNT 1.25MM NS MATRIXMANDIBLE DCP 3X3 HL TI MNDB BOTH IP/OP "$1,264.50 " $935.73 $0.00 "$1,011.60" $569.03 $569.03 $0.00 $0.00 $0.00 $263.55 $938.51 $938.51 $0.00 $0.00 $263.52 $0.00 $747.95 $747.95 $0.00 $632.25 "$1,001.48" "$1,011.60" $0.00 $0.00 $197.89 $0.00 $0.00 $201.31 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.714 SUP HCPCS C1713 04.503.714 - PLATE BN ANG 1.25MM NS MATRIXMANDIBLE DCP 3X3 HL TI MNDB BOTH IP/OP "$1,323.00 " $979.02 $0.00 "$1,058.40" $595.35 $595.35 $0.00 $0.00 $0.00 $275.75 $981.93 $981.93 $0.00 $0.00 $275.71 $0.00 $782.55 $782.55 $0.00 $661.50 "$1,047.82" "$1,058.40" $0.00 $0.00 $207.05 $0.00 $0.00 $210.62 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.715 SUP HCPCS C1713 04.503.715 - PLATE BN STRG 1.5MM NS MATRIXMANDIBLE 6 HL TI MNDB BOTH IP/OP "$1,784.25 " "$1,320.35" $0.00 "$1,427.40" $802.91 $802.91 $0.00 $0.00 $0.00 $371.88 "$1,324.27" "$1,324.27" $0.00 $0.00 $371.84 $0.00 "$1,055.38" "$1,055.38" $0.00 $892.13 "$1,413.13" "$1,427.40" $0.00 $0.00 $279.24 $0.00 $0.00 $284.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.716 SUP HCPCS C1713 04.503.716 - PLATE BN STRG 1.5MM NS MATRIXMANDIBLE 3X3 HL TI MNDB BOTH IP/OP "$1,784.25 " "$1,320.35" $0.00 "$1,427.40" $802.91 $802.91 $0.00 $0.00 $0.00 $371.88 "$1,324.27" "$1,324.27" $0.00 $0.00 $371.84 $0.00 "$1,055.38" "$1,055.38" $0.00 $892.13 "$1,413.13" "$1,427.40" $0.00 $0.00 $279.24 $0.00 $0.00 $284.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.717 SUP HCPCS C1713 04.503.717 - PLATE BN STRG 1.5MM NS MATRIXMANDIBLE 12 HL TI MNDB BOTH IP/OP "$2,043.00 " "$1,511.82" $0.00 "$1,634.40" $919.35 $919.35 $0.00 $0.00 $0.00 $425.81 "$1,516.31" "$1,516.31" $0.00 $0.00 $425.76 $0.00 "$1,208.43" "$1,208.43" $0.00 "$1,021.50" "$1,618.06" "$1,634.40" $0.00 $0.00 $319.73 $0.00 $0.00 $325.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.718 SUP HCPCS C1713 04.503.718 - PLATE BN STRG 1.5MM NS MATRIXMANDIBLE 20 HL TI MNDB BOTH IP/OP "$2,819.25 " "$2,086.25" $0.00 "$2,255.40" "$1,268.66" "$1,268.66" $0.00 $0.00 $0.00 $587.60 "$2,092.45" "$2,092.45" $0.00 $0.00 $587.53 $0.00 "$1,389.89" "$1,389.89" $0.00 "$1,409.63" "$2,232.85" "$2,255.40" $0.00 $0.00 $441.21 $0.00 $0.00 $448.82 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.721 SUP HCPCS C1713 04.503.721 - PLATE BN ANG 1.5MM NS MATRIXMANDIBLE 3X3 HL TI MNDB BOTH IP/OP "$2,457.00 " "$1,818.18" $0.00 "$1,965.60" "$1,105.65" "$1,105.65" $0.00 $0.00 $0.00 $512.10 "$1,823.59" "$1,823.59" $0.00 $0.00 $512.04 $0.00 "$1,453.32" "$1,453.32" $0.00 "$1,228.50" "$1,945.94" "$1,965.60" $0.00 $0.00 $384.52 $0.00 $0.00 $391.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.722 SUP HCPCS C1713 04.503.722 - PLATE BN CRSNT 1.5MM NS MATRIXMANDIBLE 3X3 HL TI MNDB BOTH IP/OP "$2,457.00 " "$1,818.18" $0.00 "$1,965.60" "$1,105.65" "$1,105.65" $0.00 $0.00 $0.00 $512.10 "$1,823.59" "$1,823.59" $0.00 $0.00 $512.04 $0.00 "$1,453.32" "$1,453.32" $0.00 "$1,228.50" "$1,945.94" "$1,965.60" $0.00 $0.00 $384.52 $0.00 $0.00 $391.15 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.723 SUP HCPCS C1713 04.503.723 - PLATE BN STRG 1.5MM NS MATRIXMANDIBLE DCP 2X2 HL TI MNDB BOTH IP/OP "$1,590.75 " "$1,177.16" $0.00 "$1,272.60" $715.84 $715.84 $0.00 $0.00 $0.00 $331.55 "$1,180.65" "$1,180.65" $0.00 $0.00 $331.51 $0.00 $940.93 $940.93 $0.00 $795.38 "$1,259.87" "$1,272.60" $0.00 $0.00 $248.95 $0.00 $0.00 $253.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.724 SUP HCPCS C1713 04.503.724 - PLATE BN STRG 1.5MM NS MATRIXMANDIBLE DCP 3X3 HL TI MNDB BOTH IP/OP "$1,683.00 " "$1,245.42" $0.00 "$1,346.40" $757.35 $757.35 $0.00 $0.00 $0.00 $350.78 "$1,249.12" "$1,249.12" $0.00 $0.00 $350.74 $0.00 $995.49 $995.49 $0.00 $841.50 "$1,332.94" "$1,346.40" $0.00 $0.00 $263.39 $0.00 $0.00 $267.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.726 SUP HCPCS C1713 04.503.726 - PLATE BN BRD CRSNT 2MM NS MATRIXMANDIBLE 2X2 HL TI MNDB BOTH IP/OP "$1,732.50 " "$1,282.05" $0.00 "$1,386.00" $779.63 $779.63 $0.00 $0.00 $0.00 $361.10 "$1,285.86" "$1,285.86" $0.00 $0.00 $361.05 $0.00 "$1,024.77" "$1,024.77" $0.00 $866.25 "$1,372.14" "$1,386.00" $0.00 $0.00 $271.14 $0.00 $0.00 $275.81 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.727 SUP HCPCS C1713 04.503.727 - PLATE BN BRD CRSNT 2MM NS MATRIXMANDIBLE 3X3 HL TI MNDB BOTH IP/OP "$1,863.00 " "$1,378.62" $0.00 "$1,490.40" $838.35 $838.35 $0.00 $0.00 $0.00 $388.30 "$1,382.72" "$1,382.72" $0.00 $0.00 $388.25 $0.00 "$1,101.96" "$1,101.96" $0.00 $931.50 "$1,475.50" "$1,490.40" $0.00 $0.00 $291.56 $0.00 $0.00 $296.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.728 SUP HCPCS C1713 04.503.728 - PLATE BN STRG 2MM NS MATRIXMANDIBLE 6 HL TI MNDB BOTH IP/OP "$1,732.50 " "$1,282.05" $0.00 "$1,386.00" $779.63 $779.63 $0.00 $0.00 $0.00 $361.10 "$1,285.86" "$1,285.86" $0.00 $0.00 $361.05 $0.00 "$1,024.77" "$1,024.77" $0.00 $866.25 "$1,372.14" "$1,386.00" $0.00 $0.00 $271.14 $0.00 $0.00 $275.81 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.729 SUP HCPCS C1713 04.503.729 - PLATE BN STRG 2MM NS MATRIXMANDIBLE 12 HL TI MNDB BOTH IP/OP "$2,342.25 " "$1,733.27" $0.00 "$1,873.80" "$1,054.01" "$1,054.01" $0.00 $0.00 $0.00 $488.18 "$1,738.42" "$1,738.42" $0.00 $0.00 $488.12 $0.00 "$1,385.44" "$1,385.44" $0.00 "$1,171.13" "$1,855.06" "$1,873.80" $0.00 $0.00 $366.56 $0.00 $0.00 $372.89 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.730 SUP HCPCS C1713 04.503.730 - PLATE BN STRG 2MM NS MATRIXMANDIBLE 20 HL TI MNDB BOTH IP/OP "$2,954.25 " "$2,186.15" $0.00 "$2,363.40" "$1,329.41" "$1,329.41" $0.00 $0.00 $0.00 $615.74 "$2,192.64" "$2,192.64" $0.00 $0.00 $615.67 $0.00 "$1,456.45" "$1,456.45" $0.00 "$1,477.13" "$2,339.77" "$2,363.40" $0.00 $0.00 $462.34 $0.00 $0.00 $470.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.731 SUP HCPCS C1713 04.503.731 - PLATE BN BRD ANG 2MM NS MATRIXMANDIBLE 3X3 HL TI MNDB BOTH IP/OP "$2,556.00 " "$1,891.44" $0.00 "$2,044.80" "$1,150.20" "$1,150.20" $0.00 $0.00 $0.00 $532.73 "$1,897.06" "$1,897.06" $0.00 $0.00 $532.67 $0.00 "$1,260.11" "$1,260.11" $0.00 "$1,278.00" "$2,024.35" "$2,044.80" $0.00 $0.00 $400.01 $0.00 $0.00 $406.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.732 SUP HCPCS C1713 04.503.732 - PLATE BN LT ANG 2MM NS MATRIXMANDIBLE 7X23 HL RECON TI MNDB BOTH IP/OP "$4,887.00 " "$3,616.38" $0.00 "$3,909.60" "$2,199.15" "$2,199.15" $0.00 $0.00 $0.00 "$1,018.57" "$3,627.13" "$3,627.13" $0.00 $0.00 "$1,018.45" $0.00 "$2,409.29" "$2,409.29" $0.00 "$2,443.50" "$3,870.50" "$3,909.60" $0.00 $0.00 $764.82 $0.00 $0.00 $778.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.733 SUP HCPCS C1713 04.503.733 - PLATE BN RT ANG 2MM NS MATRIXMANDIBLE 7X23 HL RECON TI MNDB BOTH IP/OP "$4,887.00 " "$3,616.38" $0.00 "$3,909.60" "$2,199.15" "$2,199.15" $0.00 $0.00 $0.00 "$1,018.57" "$3,627.13" "$3,627.13" $0.00 $0.00 "$1,018.45" $0.00 "$2,409.29" "$2,409.29" $0.00 "$2,443.50" "$3,870.50" "$3,909.60" $0.00 $0.00 $764.82 $0.00 $0.00 $778.01 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.734 SUP HCPCS C1713 04.503.734 - PLATE BN 2 ANG SM 2MM NS MATRIXMANDIBLE 4X20X4 HL RECON TI BOTH IP/OP "$5,656.50 " "$4,185.81" $0.00 "$4,525.20" "$2,545.43" "$2,545.43" $0.00 $0.00 $0.00 "$1,178.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,178.81" $0.00 "$2,788.65" "$2,788.65" $0.00 "$2,828.25" "$4,479.95" "$4,525.20" $0.00 $0.00 $885.24 $0.00 $0.00 $900.51 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.735 SUP HCPCS C1713 04.503.735 - PLATE BN 2 ANG MED 2MM NS MATRIXMANDIBLE 5X22X5 HL RECON TI BOTH IP/OP "$5,973.75 " "$4,420.58" $0.00 "$4,779.00" "$2,688.19" "$2,688.19" $0.00 $0.00 $0.00 "$1,245.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,244.93" $0.00 "$2,945.06" "$2,945.06" $0.00 "$2,986.88" "$4,731.21" "$4,779.00" $0.00 $0.00 $934.89 $0.00 $0.00 $951.02 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.736 SUP HCPCS C1713 04.503.736 - PLATE BN 2 ANG LG 2MM NS MATRIXMANDIBLE 6X24X6 HL RECON TI BOTH IP/OP "$6,293.25 " "$4,657.01" $0.00 "$5,034.60" "$2,831.96" "$2,831.96" $0.00 $0.00 $0.00 "$1,311.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,311.51" $0.00 "$3,102.57" "$3,102.57" $0.00 "$3,146.63" "$4,984.25" "$5,034.60" $0.00 $0.00 $984.89 $0.00 $0.00 "$1,001.89" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.737 SUP HCPCS C1713 04.503.737 - PLATE BN STRG 2.5MM NS MATRIXMANDIBLE 12 HL RECON TI MNDB BOTH IP/OP "$2,520.00 " "$1,864.80" $0.00 "$2,016.00" "$1,134.00" "$1,134.00" $0.00 $0.00 $0.00 $525.23 "$1,870.34" "$1,870.34" $0.00 $0.00 $525.17 $0.00 "$1,242.36" "$1,242.36" $0.00 "$1,260.00" "$1,995.84" "$2,016.00" $0.00 $0.00 $394.38 $0.00 $0.00 $401.18 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.738 SUP HCPCS C1713 04.503.738 - PLATE BN STRG 2.5MM NS MATRIXMANDIBLE 20 HL RECON TI MNDB BOTH IP/OP "$3,492.00 " "$2,584.08" $0.00 "$2,793.60" "$1,571.40" "$1,571.40" $0.00 $0.00 $0.00 $727.82 "$2,591.76" "$2,591.76" $0.00 $0.00 $727.73 $0.00 "$1,721.56" "$1,721.56" $0.00 "$1,746.00" "$2,765.66" "$2,793.60" $0.00 $0.00 $546.50 $0.00 $0.00 $555.93 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.739 SUP HCPCS C1713 04.503.739 - PLATE BN LT ANG 2.5MM NS MATRIXMANDIBLE 7X23 HL RECON TI BOTH IP/OP "$5,260.50 " "$3,892.77" $0.00 "$4,208.40" "$2,367.23" "$2,367.23" $0.00 $0.00 $0.00 "$1,096.42" "$3,904.34" "$3,904.34" $0.00 $0.00 "$1,096.29" $0.00 "$2,593.43" "$2,593.43" $0.00 "$2,630.25" "$4,166.32" "$4,208.40" $0.00 $0.00 $823.27 $0.00 $0.00 $837.47 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.740 SUP HCPCS C1713 04.503.740 - PLATE BN RT ANG 2.5MM NS MATRIXMANDIBLE 7X23 HL RECON TI BOTH IP/OP "$5,260.50 " "$3,892.77" $0.00 "$4,208.40" "$2,367.23" "$2,367.23" $0.00 $0.00 $0.00 "$1,096.42" "$3,904.34" "$3,904.34" $0.00 $0.00 "$1,096.29" $0.00 "$2,593.43" "$2,593.43" $0.00 "$2,630.25" "$4,166.32" "$4,208.40" $0.00 $0.00 $823.27 $0.00 $0.00 $837.47 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.741 SUP HCPCS C1713 04.503.741 - PLATE BN 2 ANG SM 2.5MM NS MATRIXMANDIBLE 4X20X4 HL RECON TI BOTH IP/OP "$6,090.75 " "$4,507.16" $0.00 "$4,872.60" "$2,740.84" "$2,740.84" $0.00 $0.00 $0.00 "$1,269.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,269.31" $0.00 "$3,002.74" "$3,002.74" $0.00 "$3,045.38" "$4,823.87" "$4,872.60" $0.00 $0.00 $953.20 $0.00 $0.00 $969.65 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.742 SUP HCPCS C1713 04.503.742 - PLATE BN 2 ANG MED 2.5MM NS MATRIXMANDIBLE 5X22X5 HL RECON BOTH IP/OP "$6,428.25 " "$4,756.91" $0.00 "$5,142.60" "$2,892.71" "$2,892.71" $0.00 $0.00 $0.00 "$1,339.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,339.65" $0.00 "$3,169.13" "$3,169.13" $0.00 "$3,214.13" "$5,091.17" "$5,142.60" $0.00 $0.00 "$1,006.02" $0.00 $0.00 "$1,023.38" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.743 SUP HCPCS C1713 04.503.743 - PLATE BN 2 ANG LG 2.5MM NS MATRIXMANDIBLE 6X24X6 HL RECON TI BOTH IP/OP "$6,783.75 " "$5,019.98" $0.00 "$5,427.00" "$3,052.69" "$3,052.69" $0.00 $0.00 $0.00 "$1,413.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.73" $0.00 "$3,344.39" "$3,344.39" $0.00 "$3,391.88" "$5,372.73" "$5,427.00" $0.00 $0.00 "$1,061.66" $0.00 $0.00 "$1,079.97" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.750 SUP HCPCS C1713 04.503.750 - PLATE BN BRD MN 1MM NS MATRIXMANDIBLE 2X2 HL MLBL TNSNBND TI BOTH IP/OP "$1,152.00 " $852.48 $0.00 $921.60 $518.40 $518.40 $0.00 $0.00 $0.00 $240.11 $855.01 $855.01 $0.00 $0.00 $240.08 $0.00 $681.41 $681.41 $0.00 $576.00 $912.38 $921.60 $0.00 $0.00 $180.29 $0.00 $0.00 $183.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.751 SUP HCPCS C1713 04.503.751 - PLATE BN BRD MN 1MM NS MATRIXMANDIBLE 2X3 HL MLBL TNSNBND TI BOTH IP/OP "$1,197.00 " $885.78 $0.00 $957.60 $538.65 $538.65 $0.00 $0.00 $0.00 $249.48 $888.41 $888.41 $0.00 $0.00 $249.45 $0.00 $708.03 $708.03 $0.00 $598.50 $948.02 $957.60 $0.00 $0.00 $187.33 $0.00 $0.00 $190.56 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.752 SUP HCPCS C1713 04.503.752 - PLATE BN BRD MN 1MM NS MATRIXMANDIBLE 3X3 HL MLBL TNSNBND TI BOTH IP/OP "$1,244.25 " $920.75 $0.00 $995.40 $559.91 $559.91 $0.00 $0.00 $0.00 $259.33 $923.48 $923.48 $0.00 $0.00 $259.30 $0.00 $735.97 $735.97 $0.00 $622.13 $985.45 $995.40 $0.00 $0.00 $194.73 $0.00 $0.00 $198.08 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.756 SUP HCPCS C1713 04.503.756 - PLATE BN 1.25MM NS MATRIXMANDIBLE 12 HL ADP TI MNDB BOTH IP/OP "$1,773.00 " "$1,312.02" $0.00 "$1,418.40" $797.85 $797.85 $0.00 $0.00 $0.00 $369.54 "$1,315.92" "$1,315.92" $0.00 $0.00 $369.49 $0.00 "$1,048.73" "$1,048.73" $0.00 $886.50 "$1,404.22" "$1,418.40" $0.00 $0.00 $277.47 $0.00 $0.00 $282.26 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.761 SUP HCPCS C1713 04.503.761 - PLATE BONE STR 1.25MM 2X2 HOLE MTRXMAND DCP SILVER TITANIUM BOTH IP/OP "$1,188.00 " $879.12 $0.00 $950.40 $534.60 $534.60 $0.00 $0.00 $0.00 $247.61 $881.73 $881.73 $0.00 $0.00 $247.58 $0.00 $702.70 $702.70 $0.00 $594.00 $940.90 $950.40 $0.00 $0.00 $185.92 $0.00 $0.00 $189.13 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.770 SUP HCPCS C1713 04.503.770 - PLATE BN STRG 2.8MM NS MATRIXMANDIBLE 12 HL RECON TI MNDB BOTH IP/OP "$2,965.50 " "$2,194.47" $0.00 "$2,372.40" "$1,334.48" "$1,334.48" $0.00 $0.00 $0.00 $618.08 "$2,200.99" "$2,200.99" $0.00 $0.00 $618.01 $0.00 "$1,461.99" "$1,461.99" $0.00 "$1,482.75" "$2,348.68" "$2,372.40" $0.00 $0.00 $464.10 $0.00 $0.00 $472.11 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.771 SUP HCPCS C1713 04.503.771 - PLATE BN STRG 2.8MM NS MATRIXMANDIBLE 20 HL RECON TI MNDB BOTH IP/OP "$4,338.00 " "$3,210.12" $0.00 "$3,470.40" "$1,952.10" "$1,952.10" $0.00 $0.00 $0.00 $904.15 "$3,219.66" "$3,219.66" $0.00 $0.00 $904.04 $0.00 "$2,138.63" "$2,138.63" $0.00 "$2,169.00" "$3,435.70" "$3,470.40" $0.00 $0.00 $678.90 $0.00 $0.00 $690.61 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.772 SUP HCPCS C1713 04.503.772 - PLATE BN LT ANG 2.8MM NS MATRIXMANDIBLE 7X23 HL RECON TI BOTH IP/OP "$6,444.00 " "$4,768.56" $0.00 "$5,155.20" "$2,899.80" "$2,899.80" $0.00 $0.00 $0.00 "$1,343.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,342.93" $0.00 "$3,176.89" "$3,176.89" $0.00 "$3,222.00" "$5,103.65" "$5,155.20" $0.00 $0.00 "$1,008.49" $0.00 $0.00 "$1,025.88" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.773 SUP HCPCS C1713 04.503.773 - PLATE BN RT ANG 2.8MM NS MATRIXMANDIBLE 7X23 HL RECON TI BOTH IP/OP "$6,444.00 " "$4,768.56" $0.00 "$5,155.20" "$2,899.80" "$2,899.80" $0.00 $0.00 $0.00 "$1,343.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,342.93" $0.00 "$3,176.89" "$3,176.89" $0.00 "$3,222.00" "$5,103.65" "$5,155.20" $0.00 $0.00 "$1,008.49" $0.00 $0.00 "$1,025.88" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.780 SUP HCPCS C1713 04.503.780 - PLATE 1MM RIGHT MANDIB 2 HOLE LCK TNSNBND PREBNT BONE BOTH IP/OP $987.75 $730.94 $0.00 $790.20 $444.49 $444.49 $0.00 $0.00 $0.00 $205.87 $733.11 $733.11 $0.00 $0.00 $205.85 $0.00 $584.25 $584.25 $0.00 $493.88 $782.30 $790.20 $0.00 $0.00 $154.58 $0.00 $0.00 $157.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.781 SUP HCPCS C1713 04.503.781 - PLATE 1MM LEFT MANDIB 2 HOLE LCK TNSNBND PREBNT BONE BOTH IP/OP $987.75 $730.94 $0.00 $790.20 $444.49 $444.49 $0.00 $0.00 $0.00 $205.87 $733.11 $733.11 $0.00 $0.00 $205.85 $0.00 $584.25 $584.25 $0.00 $493.88 $782.30 $790.20 $0.00 $0.00 $154.58 $0.00 $0.00 $157.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.783 SUP HCPCS C1713 04.503.783 - PLATE BONE 1MM 4 HOLE ADAPTION MTRXMAND SILVER TITANIUM BOTH IP/OP $927.00 $685.98 $0.00 $741.60 $417.15 $417.15 $0.00 $0.00 $0.00 $193.21 $688.02 $688.02 $0.00 $0.00 $193.19 $0.00 $548.32 $548.32 $0.00 $463.50 $734.18 $741.60 $0.00 $0.00 $145.08 $0.00 $0.00 $147.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.801 SUP HCPCS C1713 04.503.801 - PLATE BN 3D SM .4MM NS MATRIXMIDFACE MATRIXORBITAL PREFORM BOTH IP/OP "$4,167.00 " "$3,083.58" $0.00 "$3,333.60" "$1,875.15" "$1,875.15" $0.00 $0.00 $0.00 $868.51 "$3,092.75" "$3,092.75" $0.00 $0.00 $868.40 $0.00 "$2,054.33" "$2,054.33" $0.00 "$2,083.50" "$3,300.26" "$3,333.60" $0.00 $0.00 $652.14 $0.00 $0.00 $663.39 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.802 SUP HCPCS C1713 04.503.802 - PLATE BN 3D LG .4MM NS MATRIXMIDFACE MATRIXORBITAL PREFORM BOTH IP/OP "$4,311.00 " "$3,190.14" $0.00 "$3,448.80" "$1,939.95" "$1,939.95" $0.00 $0.00 $0.00 $898.52 "$3,199.62" "$3,199.62" $0.00 $0.00 $898.41 $0.00 "$2,125.32" "$2,125.32" $0.00 "$2,155.50" "$3,414.31" "$3,448.80" $0.00 $0.00 $674.67 $0.00 $0.00 $686.31 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.811 SUP HCPCS C1713 04.503.811 - PLATE BN 3D SM .4MM NS MATRIXMIDFACE MATRIXORBITAL PREFORM BOTH IP/OP "$4,167.00 " "$3,083.58" $0.00 "$3,333.60" "$1,875.15" "$1,875.15" $0.00 $0.00 $0.00 $868.51 "$3,092.75" "$3,092.75" $0.00 $0.00 $868.40 $0.00 "$2,054.33" "$2,054.33" $0.00 "$2,083.50" "$3,300.26" "$3,333.60" $0.00 $0.00 $652.14 $0.00 $0.00 $663.39 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.812 SUP HCPCS C1713 04.503.812 - PLATE BN 3D LG .4MM NS MATRIXMIDFACE MATRIXORBITAL PREFORM BOTH IP/OP "$4,311.00 " "$3,190.14" $0.00 "$3,448.80" "$1,939.95" "$1,939.95" $0.00 $0.00 $0.00 $898.52 "$3,199.62" "$3,199.62" $0.00 $0.00 $898.41 $0.00 "$2,125.32" "$2,125.32" $0.00 "$2,155.50" "$3,414.31" "$3,448.80" $0.00 $0.00 $674.67 $0.00 $0.00 $686.31 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.820 SUP HCPCS C1713 04.503.820 - PLATE BN SHRT NS MATRIXWAVE 10 HL TI MXLMNDB BOTH IP/OP $776.25 $574.43 $0.00 $621.00 $349.31 $349.31 $0.00 $0.00 $0.00 $161.79 $576.13 $576.13 $0.00 $0.00 $161.77 $0.00 $459.15 $459.15 $0.00 $388.13 $614.79 $621.00 $0.00 $0.00 $121.48 $0.00 $0.00 $123.58 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.824.01 SUP HCPCS C1713 04.503.824.01 - MATRIXWAVE MMF TI 1.85MM SCREW SELF-DRILLING/6MM LENGTH BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.825.01 SUP HCPCS C1713 04.503.825.01 - SCREW BONE 8MM SELF DRILL MATRIXWAVE TITANIUM 1.85MM BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.830 SUP HCPCS C1713 04.503.830 - PLATE RIGHT SUBCONDYLAR 7 HOLE MALBLE LMBD BONE MTRXMAND BOTH IP/OP "$2,099.25 " "$1,553.45" $0.00 "$1,679.40" $944.66 $944.66 $0.00 $0.00 $0.00 $437.54 "$1,558.06" "$1,558.06" $0.00 $0.00 $437.48 $0.00 "$1,241.71" "$1,241.71" $0.00 "$1,049.63" "$1,662.61" "$1,679.40" $0.00 $0.00 $328.53 $0.00 $0.00 $334.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.831 SUP HCPCS C1713 04.503.831 - PLATE LEFT SUBCONDYLAR 7 HOLE MALBLE LMBD BONE MTRXMAND BOTH IP/OP "$2,099.25 " "$1,553.45" $0.00 "$1,679.40" $944.66 $944.66 $0.00 $0.00 $0.00 $437.54 "$1,558.06" "$1,558.06" $0.00 $0.00 $437.48 $0.00 "$1,241.71" "$1,241.71" $0.00 "$1,049.63" "$1,662.61" "$1,679.40" $0.00 $0.00 $328.53 $0.00 $0.00 $334.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.834 SUP HCPCS C1713 04.503.834 - PLATE THK1MM SM SUBCONDYLAR 4 HOLE TRPZD MALBLE BONE BOTH IP/OP "$2,099.25 " "$1,553.45" $0.00 "$1,679.40" $944.66 $944.66 $0.00 $0.00 $0.00 $437.54 "$1,558.06" "$1,558.06" $0.00 $0.00 $437.48 $0.00 "$1,241.71" "$1,241.71" $0.00 "$1,049.63" "$1,662.61" "$1,679.40" $0.00 $0.00 $328.53 $0.00 $0.00 $334.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.503.900 SUP HCPCS C1713 04.503.900 - PLATE BN SM 2.5MM NS MATRIXMANDIBLE PRFRM RECON TI MNDB RT BOTH IP/OP "$7,143.75 " "$5,286.38" $0.00 "$5,715.00" "$3,214.69" "$3,214.69" $0.00 $0.00 $0.00 "$1,488.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,488.76" $0.00 "$3,521.87" "$3,521.87" $0.00 "$3,571.88" "$5,657.85" "$5,715.00" $0.00 $0.00 "$1,118.00" $0.00 $0.00 "$1,137.29" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.901 SUP HCPCS C1713 04.503.901 - PLATE BN SM 2.5MM NS MATRIXMANDIBLE PRFRM RECON TI MNDB LT BOTH IP/OP "$7,143.75 " "$5,286.38" $0.00 "$5,715.00" "$3,214.69" "$3,214.69" $0.00 $0.00 $0.00 "$1,488.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,488.76" $0.00 "$3,521.87" "$3,521.87" $0.00 "$3,571.88" "$5,657.85" "$5,715.00" $0.00 $0.00 "$1,118.00" $0.00 $0.00 "$1,137.29" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.902 SUP HCPCS C1713 04.503.902 - PLATE BN MED 2.5MM NS MATRIXMANDIBLE PRFRM RECON TI MNDB RT BOTH IP/OP "$7,411.50 " "$5,484.51" $0.00 "$5,929.20" "$3,335.18" "$3,335.18" $0.00 $0.00 $0.00 "$1,544.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,544.56" $0.00 "$3,653.87" "$3,653.87" $0.00 "$3,705.75" "$5,869.91" "$5,929.20" $0.00 $0.00 "$1,159.90" $0.00 $0.00 "$1,179.91" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.903 SUP HCPCS C1713 04.503.903 - PLATE BN MED 2.5MM NS MATRIXMANDIBLE PRFRM RECON TI MNDB LT BOTH IP/OP "$7,411.50 " "$5,484.51" $0.00 "$5,929.20" "$3,335.18" "$3,335.18" $0.00 $0.00 $0.00 "$1,544.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,544.56" $0.00 "$3,653.87" "$3,653.87" $0.00 "$3,705.75" "$5,869.91" "$5,929.20" $0.00 $0.00 "$1,159.90" $0.00 $0.00 "$1,179.91" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.904 SUP HCPCS C1713 04.503.904 - PLATE BN LG 2.5MM NS MATRIXMANDIBLE PRFRM RECON TI MNDB RT BOTH IP/OP "$7,679.25 " "$5,682.65" $0.00 "$6,143.40" "$3,455.66" "$3,455.66" $0.00 $0.00 $0.00 "$1,600.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,600.36" $0.00 "$3,785.87" "$3,785.87" $0.00 "$3,839.63" "$6,081.97" "$6,143.40" $0.00 $0.00 "$1,201.80" $0.00 $0.00 "$1,222.54" $0.00 $0.00 $0.00 $0.00 $0.00 04.503.905 SUP HCPCS C1713 04.503.905 - PLATE BN LG 2.5MM NS MATRIXMANDIBLE PRFRM RECON TI MNDB LT BOTH IP/OP "$7,679.25 " "$5,682.65" $0.00 "$6,143.40" "$3,455.66" "$3,455.66" $0.00 $0.00 $0.00 "$1,600.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,600.36" $0.00 "$3,785.87" "$3,785.87" $0.00 "$3,839.63" "$6,081.97" "$6,143.40" $0.00 $0.00 "$1,201.80" $0.00 $0.00 "$1,222.54" $0.00 $0.00 $0.00 $0.00 $0.00 04.511.204.01 SUP HCPCS C1713 04.511.204.01 - SCREW TI 4MM 1.85MM MANDIB SLFTAP ORTHGNAT BONE MTRX NONSTRL BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.205.01 SUP HCPCS C1713 04.511.205.01 - SCREW BONE 1.85MM 15MM MTRX TI LEFT SLFDRILL NONSTRL BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.206.01 SUP HCPCS C1713 04.511.206.01 - SCREW TI 6MM 1.85MM MANDIB SLFTAP ORTHGNAT BONE MTRX NONSTRL BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.208.01 SUP HCPCS C1713 04.511.208.01 - SCREW TI 8MM 1.85MM MANDIB SLFTAP ORTHGNAT BONE MTRX NONSTRL BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.210.01 SUP HCPCS C1713 04.511.210.01 - SCREW TI 10MM 1.85MM MANDIB SLFTAP ORTHGNAT BONE MTRX BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.212.01 SUP HCPCS C1713 04.511.212.01 - SCREW TI 12MM 1.85MM MANDIB SLFTAP ORTHGNAT BONE MTRX BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.214.01 SUP HCPCS C1713 04.511.214.01 - SCREW TI 14MM 1.85MM MANDIB SLFTAP ORTHGNAT BONE MTRX BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.216.01 SUP HCPCS C1713 04.511.216.01 - SCREW TI 16MM 1.85MM MANDIB SLFTAP ORTHGNAT BONE MTRX BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.218.01 SUP HCPCS C1713 04.511.218.01 - SCREW TI 18MM 1.85MM MANDIB SLFTAP ORTHGNAT BONE MTRX BOTH IP/OP $211.50 $156.51 $0.00 $169.20 $95.18 $95.18 $0.00 $0.00 $0.00 $44.08 $156.98 $156.98 $0.00 $0.00 $44.08 $0.00 $125.10 $125.10 $0.00 $105.75 $167.51 $169.20 $0.00 $0.00 $33.10 $0.00 $0.00 $33.67 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.224.01 SUP HCPCS C1713 04.511.224.01 - SCREW TI 4MM 1.85MM MANDIB SLFDRILL ORTHGNAT BONE MTRX BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.225.01 SUP HCPCS C1713 04.511.225.01 - SCREW TI 5MM 1.85MM SLFDRILL BONE MATRIXORTHOGNATHIC NONSTRL BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.226.01 SUP HCPCS C1713 04.511.226.01 - SCREW BONE 1.85MM 6MM MTRX TI CRNMXF SLFDRILL ORTHGNAT BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.228.01 SUP HCPCS C1713 04.511.228.01 - SCREW TI 8MM 1.85MM MANDIB SLFDRILL ORTHGNAT BONE MTRX BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.234.01 SUP HCPCS C1713 04.511.234.01 - SCREW TI 4MM 2.1MM MANDIB SLFTAP ORTHGNAT BONE MTRX NONSTRL BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.235.01 SUP HCPCS C1713 04.511.235.01 - SCREW BONE 2.1MM 5MM MTRX TI LEFT STR NONSTRL BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.236.01 SUP HCPCS C1713 04.511.236.01 - SCREW TI 6MM 2.1MM MANDIB SLFTAP ORTHGNAT BONE MTRX NONSTRL BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.238.01 SUP HCPCS C1713 04.511.238.01 - SCREW TI 8MM 2.1MM MANDIB SLFDRILL ORTHGNAT BONE MTRX BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.240.01 SUP HCPCS C1713 04.511.240.01 - SCREW TI 10MM 2.1MM COARSE PTCH SLFTAP ORTHGNAT BONE MTRX BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.242.01 SUP HCPCS C1713 04.511.242.01 - SCREW TI 12MM 2.1MM SLFTAP COARSE PTCH BONE MTRX NONSTRL PNK BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.244.01 SUP HCPCS C1713 04.511.244.01 - SCREW TI 14MM 2.1MM MANDIB SLFTAP ORTHGNAT BONE MTRX NONSTRL BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.246.01 SUP HCPCS C1713 04.511.246.01 - SCREW BONE PNK 16MM 2.1MM MTRX CRNMXF TI SLFTAP COARSE PTCH BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.248.01 SUP HCPCS C1713 04.511.248.01 - SCREW TI 18MM 2.1MM MANDIB SLFTAP ORTHGNAT BONE MTRX NONSTRL BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.301 SUP HCPCS C1713 04.511.301 - PLATE BN 90D L 2MMX.5MM NS MATRIXORTHOGNATHIC 2X2 HL RVRS BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.302 SUP HCPCS C1713 04.511.302 - PLATE BN 90D L 6MMX.5MM NS MATRIXORTHOGNATHIC 2X2 HL RVRS BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.303 SUP HCPCS C1713 04.511.303 - PLATE BN 90D L 11MMX.5MM NS MATRIXORTHOGNATHIC 2X2 HL RVRS BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.304 SUP HCPCS C1713 04.511.304 - PLATE BN 90D L 2MMX.7MM NS MATRIXORTHOGNATHIC 2X2 HL RVRS BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.305 SUP HCPCS C1713 04.511.305 - PLATE BN 90D L 6MMX.7MM NS MATRIXORTHOGNATHIC 2X2 HL RVRS BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.306 SUP HCPCS C1713 04.511.306 - PLATE BN 90D L 11MMX.7MM NS MATRIXORTHOGNATHIC 2X2 HL RVRS BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.307 SUP HCPCS C1713 04.511.307 - PLATE 90D .8MM 2X2 HOLE L RVRS SHRT BAR BONE BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.308 SUP HCPCS C1713 04.511.308 - PLATE 90D MED .8MM MAXL 2X2 HOLE L RVRS ORTHGNAT BONE MTRX BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.309 SUP HCPCS C1713 04.511.309 - PLATE BN 90D L 11MMX.8MM NS MATRIXORTHOGNATHIC 2X2 HL RVRS BOTH IP/OP $657.00 $486.18 $0.00 $525.60 $295.65 $295.65 $0.00 $0.00 $0.00 $136.94 $487.63 $487.63 $0.00 $0.00 $136.92 $0.00 $388.62 $388.62 $0.00 $328.50 $520.34 $525.60 $0.00 $0.00 $102.82 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.321 SUP HCPCS C1713 04.511.321 - PLATE BN L OBLQ 4MMX.5MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.322 SUP HCPCS C1713 04.511.322 - PLATE BN L OBLQ 8MMX.5MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.323 SUP HCPCS C1713 04.511.323 - PLATE BN L OBLQ 13MMX.5MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.324 SUP HCPCS C1713 04.511.324 - PLATE BN L OBLQ 4MMX.7MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.325 SUP HCPCS C1713 04.511.325 - PLATE BN L OBLQ 8MMX.7MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.326 SUP HCPCS C1713 04.511.326 - PLATE BN L OBLQ 13MMX.7MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.327 SUP HCPCS C1713 04.511.327 - PLATE BN L OBLQ 4MMX.8MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.328 SUP HCPCS C1713 04.511.328 - PLATE BN L OBLQ 8MMX.8MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.329 SUP HCPCS C1713 04.511.329 - PLATE BN L OBLQ 13MMX.8MM NS MATRIXORTHOGNATHIC 3X3 HL RVRS BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $308.81 $308.81 $0.00 $0.00 $0.00 $143.03 $509.33 $509.33 $0.00 $0.00 $143.01 $0.00 $405.92 $405.92 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $107.40 $0.00 $0.00 $109.25 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.341 SUP HCPCS C1713 04.511.341 - PLATE BN L 4MMX.5MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.342 SUP HCPCS C1713 04.511.342 - PLATE BN L 8MMX.5MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.343 SUP HCPCS C1713 04.511.343 - PLATE BN L 12MMX.5MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.344 SUP HCPCS C1713 04.511.344 - PLATE BN L 4MMX.7MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.345 SUP HCPCS C1713 04.511.345 - PLATE BN L 8MMX.7MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.346 SUP HCPCS C1713 04.511.346 - PLATE BN L 12MMX.7MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.347 SUP HCPCS C1713 04.511.347 - PLATE BN L 4MMX.8MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.348 SUP HCPCS C1713 04.511.348 - PLATE BN L 8MMX.8MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.349 SUP HCPCS C1713 04.511.349 - PLATE BN L 12MMX.8MM NS MATRIXORTHOGNATHIC 3X3 HL ANTM RVRS BOTH IP/OP $717.75 $531.14 $0.00 $574.20 $322.99 $322.99 $0.00 $0.00 $0.00 $149.60 $532.71 $532.71 $0.00 $0.00 $149.58 $0.00 $424.55 $424.55 $0.00 $358.88 $568.46 $574.20 $0.00 $0.00 $112.33 $0.00 $0.00 $114.27 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.381 SUP HCPCS C1713 04.511.381 - PLATE BN 2MM LT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.382 SUP HCPCS C1713 04.511.382 - PLATE BN 2MM RT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.383 SUP HCPCS C1713 04.511.383 - PLATE BN 4MM LT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.384 SUP HCPCS C1713 04.511.384 - PLATE BN 4MM RT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.385 SUP HCPCS C1713 04.511.385 - PLATE BN 6MM LT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.386 SUP HCPCS C1713 04.511.386 - PLATE BN 6MM RT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.387 SUP HCPCS C1713 04.511.387 - PLATE BN 8MM LT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.388 SUP HCPCS C1713 04.511.388 - PLATE BN 8MM RT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.389 SUP HCPCS C1713 04.511.389 - PLATE BN 10MM LT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.390 SUP HCPCS C1713 04.511.390 - PLATE BN 10MM RT OFST PREBNT .8MM NS MATRIXORTHOGNATHIC BOTH IP/OP "$1,100.25 " $814.19 $0.00 $880.20 $495.11 $495.11 $0.00 $0.00 $0.00 $229.32 $816.61 $816.61 $0.00 $0.00 $229.29 $0.00 $650.80 $650.80 $0.00 $550.13 $871.40 $880.20 $0.00 $0.00 $172.19 $0.00 $0.00 $175.16 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.401 SUP HCPCS C1713 04.511.401 - PLATE BN CRV 6MMX1MM NS MATRIXORTHOGNATHIC 6 HL LOPRFL SGTL BOTH IP/OP $956.25 $707.63 $0.00 $765.00 $430.31 $430.31 $0.00 $0.00 $0.00 $199.31 $709.73 $709.73 $0.00 $0.00 $199.28 $0.00 $565.62 $565.62 $0.00 $478.13 $757.35 $765.00 $0.00 $0.00 $149.65 $0.00 $0.00 $152.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.402 SUP HCPCS C1713 04.511.402 - PLATE BN CRV 8MMX1MM NS MATRIXORTHOGNATHIC 6 HL LOPRFL SGTL BOTH IP/OP $956.25 $707.63 $0.00 $765.00 $430.31 $430.31 $0.00 $0.00 $0.00 $199.31 $709.73 $709.73 $0.00 $0.00 $199.28 $0.00 $565.62 $565.62 $0.00 $478.13 $757.35 $765.00 $0.00 $0.00 $149.65 $0.00 $0.00 $152.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.403 SUP HCPCS C1713 04.511.403 - PLATE BN CRV 10MMX1MM NS MATRIXORTHOGNATHIC 6 HL LOPRFL SGTL BOTH IP/OP $956.25 $707.63 $0.00 $765.00 $430.31 $430.31 $0.00 $0.00 $0.00 $199.31 $709.73 $709.73 $0.00 $0.00 $199.28 $0.00 $565.62 $565.62 $0.00 $478.13 $757.35 $765.00 $0.00 $0.00 $149.65 $0.00 $0.00 $152.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.404 SUP HCPCS C1713 04.511.404 - PLATE BN CRV 12MMX1MM NS MATRIXORTHOGNATHIC 6 HL LOPRFL SGTL BOTH IP/OP $956.25 $707.63 $0.00 $765.00 $430.31 $430.31 $0.00 $0.00 $0.00 $199.31 $709.73 $709.73 $0.00 $0.00 $199.28 $0.00 $565.62 $565.62 $0.00 $478.13 $757.35 $765.00 $0.00 $0.00 $149.65 $0.00 $0.00 $152.24 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.421 SUP HCPCS C1713 04.511.421 - PLATE BN STRG 6MMX1MM NS MATRIXORTHOGNATHIC 4 HL LOPRFL SGTL BOTH IP/OP $940.50 $695.97 $0.00 $752.40 $423.23 $423.23 $0.00 $0.00 $0.00 $196.02 $698.04 $698.04 $0.00 $0.00 $196.00 $0.00 $556.31 $556.31 $0.00 $470.25 $744.88 $752.40 $0.00 $0.00 $147.19 $0.00 $0.00 $149.73 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.422 SUP HCPCS C1713 04.511.422 - PLATE BN STRG 8MMX1MM NS MATRIXORTHOGNATHIC 4 HL LOPRFL SGTL BOTH IP/OP $940.50 $695.97 $0.00 $752.40 $423.23 $423.23 $0.00 $0.00 $0.00 $196.02 $698.04 $698.04 $0.00 $0.00 $196.00 $0.00 $556.31 $556.31 $0.00 $470.25 $744.88 $752.40 $0.00 $0.00 $147.19 $0.00 $0.00 $149.73 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.423 SUP HCPCS C1713 04.511.423 - PLATE BN STRG 10MMX1MM NS MATRIXORTHOGNATHIC 4 HL LOPRFL BOTH IP/OP $940.50 $695.97 $0.00 $752.40 $423.23 $423.23 $0.00 $0.00 $0.00 $196.02 $698.04 $698.04 $0.00 $0.00 $196.00 $0.00 $556.31 $556.31 $0.00 $470.25 $744.88 $752.40 $0.00 $0.00 $147.19 $0.00 $0.00 $149.73 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.424 SUP HCPCS C1713 04.511.424 - PLATE BN STRG 12MMX1MM NS MATRIXORTHOGNATHIC 4 HL LOPRFL BOTH IP/OP $940.50 $695.97 $0.00 $752.40 $423.23 $423.23 $0.00 $0.00 $0.00 $196.02 $698.04 $698.04 $0.00 $0.00 $196.00 $0.00 $556.31 $556.31 $0.00 $470.25 $744.88 $752.40 $0.00 $0.00 $147.19 $0.00 $0.00 $149.73 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.444 SUP HCPCS C1713 04.511.444 - PLATE BN 33MMX.7MM NS MATRIXORTHOGNATHIC 4 HL SGTL SPLT ADJ BOTH IP/OP "$1,282.50 " $949.05 $0.00 "$1,026.00" $577.13 $577.13 $0.00 $0.00 $0.00 $267.31 $951.87 $951.87 $0.00 $0.00 $267.27 $0.00 $758.60 $758.60 $0.00 $641.25 "$1,015.74" "$1,026.00" $0.00 $0.00 $200.71 $0.00 $0.00 $204.17 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.445 SUP Custom 27203010 04.511.445 - INSRTR SURG LINR CNSTRN TI MTRX 40MMX.7MM NONSTRL BOTH IP/OP "$1,282.50 " $949.05 $0.00 "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.87 $951.87 $0.00 $0.00 $267.27 $0.00 $0.00 $0.00 $0.00 $641.25 "$1,015.74" "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.461 SUP HCPCS C1713 04.511.461 - PLATE BN 4MM OFST 2 CRV .7MM NS MATRIXORTHOGNATHIC 5 HL BOTH IP/OP $897.75 $664.34 $0.00 $718.20 $403.99 $403.99 $0.00 $0.00 $0.00 $187.11 $666.31 $666.31 $0.00 $0.00 $187.09 $0.00 $531.02 $531.02 $0.00 $448.88 $711.02 $718.20 $0.00 $0.00 $140.50 $0.00 $0.00 $142.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.462 SUP HCPCS C1713 04.511.462 - PLATE BN 6MM OFST 2 CRV .7MM NS MATRIXORTHOGNATHIC 5 HL BOTH IP/OP $897.75 $664.34 $0.00 $718.20 $403.99 $403.99 $0.00 $0.00 $0.00 $187.11 $666.31 $666.31 $0.00 $0.00 $187.09 $0.00 $531.02 $531.02 $0.00 $448.88 $711.02 $718.20 $0.00 $0.00 $140.50 $0.00 $0.00 $142.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.463 SUP HCPCS C1713 04.511.463 - PLATE BN 8MM OFST 2 CRV .7MM NS MATRIXORTHOGNATHIC 5 HL BOTH IP/OP $897.75 $664.34 $0.00 $718.20 $403.99 $403.99 $0.00 $0.00 $0.00 $187.11 $666.31 $666.31 $0.00 $0.00 $187.09 $0.00 $531.02 $531.02 $0.00 $448.88 $711.02 $718.20 $0.00 $0.00 $140.50 $0.00 $0.00 $142.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.511.464 SUP HCPCS C1713 04.511.464 - PLATE BN 10MM OFST 2 CRV .7MM NS MATRIXORTHOGNATHIC 5 HL BOTH IP/OP $897.75 $664.34 $0.00 $718.20 $403.99 $403.99 $0.00 $0.00 $0.00 $187.11 $666.31 $666.31 $0.00 $0.00 $187.09 $0.00 $531.02 $531.02 $0.00 $448.88 $711.02 $718.20 $0.00 $0.00 $140.50 $0.00 $0.00 $142.92 $0.00 $0.00 $0.00 $0.00 $0.00 04.600.022.02S SUP HCPCS C1713 04.600.022.02S - PIN 12MM DSTRCT TI STRL BOTH IP/OP $896.00 $663.04 $0.00 $716.80 $403.20 $403.20 $0.00 $0.00 $0.00 $186.75 $665.01 $665.01 $0.00 $0.00 $186.73 $0.00 $529.98 $529.98 $0.00 $448.00 $709.63 $716.80 $0.00 $0.00 $140.22 $0.00 $0.00 $142.64 $0.00 $0.00 $0.00 $0.00 $0.00 04.600.023.02S SUP HCPCS C1713 04.600.023.02S - PIN 14MM DSTRCT TI STRL BOTH IP/OP $448.00 $331.52 $0.00 $358.40 $201.60 $201.60 $0.00 $0.00 $0.00 $93.37 $332.51 $332.51 $0.00 $0.00 $93.36 $0.00 $264.99 $264.99 $0.00 $224.00 $354.82 $358.40 $0.00 $0.00 $70.11 $0.00 $0.00 $71.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.600.029.02S SUP HCPCS C1713 04.600.029.02S - PIN 16MM DSTRCT TI STRL BOTH IP/OP $448.00 $331.52 $0.00 $358.40 $201.60 $201.60 $0.00 $0.00 $0.00 $93.37 $332.51 $332.51 $0.00 $0.00 $93.36 $0.00 $264.99 $264.99 $0.00 $224.00 $354.82 $358.40 $0.00 $0.00 $70.11 $0.00 $0.00 $71.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.601.108 SUP HCPCS C1713 04.601.108 - SCREW BN T15 4.5MM 3.2MM 8MM NS SLF RTN STRDR BLNT TIP TI BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.601.110 SUP HCPCS C1713 04.601.110 - SCREW BONE 4.5MM 10MM TI OCCPTL NONSTRL BOTH IP/OP $392.00 $290.08 $0.00 $313.60 $176.40 $176.40 $0.00 $0.00 $0.00 $81.70 $290.94 $290.94 $0.00 $0.00 $81.69 $0.00 $231.87 $231.87 $0.00 $196.00 $310.46 $313.60 $0.00 $0.00 $61.35 $0.00 $0.00 $62.41 $0.00 $0.00 $0.00 $0.00 $0.00 04.601.112 SUP HCPCS C1713 04.601.112 - SCREW BONE 4.5MM 12MM TITANIUM OCCIPITOCERVICAL SPN NONSTRL BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.601.208 SUP HCPCS C1713 04.601.208 - SCREW BN T15 5MM 3.2MM 8MM NS SLFRET STRDR BLNT TIP 7% BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.601.210 SUP HCPCS C1713 04.601.210 - SCREW BN T15 5MM 3.2MM 10MM NS SLFRET STRDR BLNT TIP 7% BOTH IP/OP $399.00 $295.26 $0.00 $319.20 $179.55 $179.55 $0.00 $0.00 $0.00 $83.16 $296.14 $296.14 $0.00 $0.00 $83.15 $0.00 $236.01 $236.01 $0.00 $199.50 $316.01 $319.20 $0.00 $0.00 $62.44 $0.00 $0.00 $63.52 $0.00 $0.00 $0.00 $0.00 $0.00 04.613.014 SUP HCPCS C1713 04.613.014 - PLATE 23MM TI 1 LVL VCTR BONE 14MM ANT CERV SPN NONSTRL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.613.016 SUP HCPCS C1713 04.613.016 - PLATE 25MM TI 1 LVL VCTR BONE 16MM ANT CERV SPN NONSTRL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.613.130 SUP HCPCS C1713 04.613.130 - PLATE BN BNT GRV PREBNT 39X16.5X2.5MM NS 30MM VCTR 2 LVL 1 BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.613.132 SUP HCPCS C1713 04.613.132 - PLATE BN BNT GRV PREBNT 41X16.5X2.5MM NS 32MM VCTR 2 LVL 1 BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 04.613.516 SUP HCPCS C1713 04.613.516 - SCREW BONE 4MM 16MM VCT-T TI ANT CERV SPN SLFRET SLFDRILL BOTH IP/OP $498.10 $368.59 $0.00 $398.48 $224.15 $224.15 $0.00 $0.00 $0.00 $103.82 $369.69 $369.69 $0.00 $0.00 $103.80 $0.00 $294.63 $294.63 $0.00 $249.05 $394.50 $398.48 $0.00 $0.00 $77.95 $0.00 $0.00 $79.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.613.616 SUP HCPCS C1713 04.613.616 - SCREW BONE 4MM 16MM VCT-T TI ANT CERV SPN SLFTAP SLFRET VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 04.613.618 SUP HCPCS C1713 04.613.618 - SCREW BONE 4MM 18MM VCT-T TI ANT CERV SPN SLFTAP SLFRET VAR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 04.613.666 SUP HCPCS C1713 04.613.666 - SCREW BONE 4.5MM 16MM VCT-T TI ANT CERV SPN SLFTAP SLFRET BOTH IP/OP $477.70 $353.50 $0.00 $382.16 $214.97 $214.97 $0.00 $0.00 $0.00 $99.56 $354.55 $354.55 $0.00 $0.00 $99.55 $0.00 $282.56 $282.56 $0.00 $238.85 $378.34 $382.16 $0.00 $0.00 $74.76 $0.00 $0.00 $76.05 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.010 SUP HCPCS C1713 04.614.010 - SCREW BONE 3.5MM 10MM SYNAPSE TI CANC SPNL POLYAX NONSTRL BOTH IP/OP "$2,576.00 " "$1,906.24" $0.00 "$2,060.80" "$1,159.20" "$1,159.20" $0.00 $0.00 $0.00 $536.90 "$1,911.91" "$1,911.91" $0.00 $0.00 $536.84 $0.00 "$1,269.97" "$1,269.97" $0.00 "$1,288.00" "$2,040.19" "$2,060.80" $0.00 $0.00 $403.14 $0.00 $0.00 $410.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.012 SUP HCPCS C1713 04.614.012 - SCREW BONE 3.5MM 12MM SYNAPSE TI CANC SPNL POLYAX NONSTRL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.014 SUP HCPCS C1713 04.614.014 - SCREW BONE 3.5MM 14MM SYNAPSE TI CANC SPNL POLYAX NONSTRL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.016 SUP HCPCS C1713 04.614.016 - SCREW BONE 3.5MM 16MM SYNAPSE TI CANC SPNL POLYAX NONSTRL BOTH IP/OP "$2,576.00 " "$1,906.24" $0.00 "$2,060.80" "$1,159.20" "$1,159.20" $0.00 $0.00 $0.00 $536.90 "$1,911.91" "$1,911.91" $0.00 $0.00 $536.84 $0.00 "$1,269.97" "$1,269.97" $0.00 "$1,288.00" "$2,040.19" "$2,060.80" $0.00 $0.00 $403.14 $0.00 $0.00 $410.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.020 SUP HCPCS C1713 04.614.020 - SCREW BONE 3.5MM 20MM SYNAPSE TI CANC SPNL POLYAX NONSTRL BOTH IP/OP "$2,576.00 " "$1,906.24" $0.00 "$2,060.80" "$1,159.20" "$1,159.20" $0.00 $0.00 $0.00 $536.90 "$1,911.91" "$1,911.91" $0.00 $0.00 $536.84 $0.00 "$1,269.97" "$1,269.97" $0.00 "$1,288.00" "$2,040.19" "$2,060.80" $0.00 $0.00 $403.14 $0.00 $0.00 $410.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.110 SUP HCPCS C1713 04.614.110 - SCREW BONE 4MM 10MM SYNAPSE TI CANC SPNL POLYAX BOTH IP/OP "$2,576.00 " "$1,906.24" $0.00 "$2,060.80" "$1,159.20" "$1,159.20" $0.00 $0.00 $0.00 $536.90 "$1,911.91" "$1,911.91" $0.00 $0.00 $536.84 $0.00 "$1,269.97" "$1,269.97" $0.00 "$1,288.00" "$2,040.19" "$2,060.80" $0.00 $0.00 $403.14 $0.00 $0.00 $410.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.112 SUP HCPCS C1713 04.614.112 - SCREW BONE 0-50D 4MM 2.4MM 12MM T15 STARDRIVE POLYAX SLFTAP BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.114 SUP HCPCS C1713 04.614.114 - SCREW BONE 4MM 2.4MM 14MM SYNAPSE TI 50- D T15 SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.118 SUP HCPCS C1713 04.614.118 - SCREW BN 50- D T15 4MM 2.4MM 18MM GRN GRY NS SYNAPSE PA ST BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.124 SUP HCPCS C1713 04.614.124 - SCREW BONE 4MM 24MM SYNAPSE TI CANC SPNL POLYAX BOTH IP/OP "$2,576.00 " "$1,906.24" $0.00 "$2,060.80" "$1,159.20" "$1,159.20" $0.00 $0.00 $0.00 $536.90 "$1,911.91" "$1,911.91" $0.00 $0.00 $536.84 $0.00 "$1,269.97" "$1,269.97" $0.00 "$1,288.00" "$2,040.19" "$2,060.80" $0.00 $0.00 $403.14 $0.00 $0.00 $410.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.126 SUP HCPCS C1713 04.614.126 - SCREW BONE 4MM 26MM SYNAPSE TI CANC SPNL POLYAX NONSTRL BOTH IP/OP "$2,576.00 " "$1,906.24" $0.00 "$2,060.80" "$1,159.20" "$1,159.20" $0.00 $0.00 $0.00 $536.90 "$1,911.91" "$1,911.91" $0.00 $0.00 $536.84 $0.00 "$1,269.97" "$1,269.97" $0.00 "$1,288.00" "$2,040.19" "$2,060.80" $0.00 $0.00 $403.14 $0.00 $0.00 $410.10 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.226 SUP HCPCS C1713 04.614.226 - SCREW BONE 40D LARGE DIAMETER T15 SQUARE 4.5MM 3.2MM 26MM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.508 SUP HCPCS C1713 04.614.508 - SCREW BONE 5MM 8MM TI SPNL LCK NONSTRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.510 SUP HCPCS C1713 04.614.510 - ROD SPNL 120-175MM 3.5-6MM TI HRD NONSTRL BOTH IP/OP "$1,748.25 " "$1,293.71" $0.00 "$1,398.60" $786.71 $786.71 $0.00 $0.00 $0.00 $364.38 "$1,297.55" "$1,297.55" $0.00 $0.00 $364.34 $0.00 "$1,034.09" "$1,034.09" $0.00 $874.13 "$1,384.61" "$1,398.60" $0.00 $0.00 $273.60 $0.00 $0.00 $278.32 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.513 SUP Custom 27803010 04.614.513 - TRNCON ROD 60MM SPNL TI NONSTRL BOTH IP/OP "$2,709.00 " "$2,004.66" $0.00 "$2,167.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,010.62" "$2,010.62" $0.00 $0.00 $564.56 $0.00 $0.00 $0.00 $0.00 "$1,354.50" "$2,145.53" "$2,167.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.516 SUP Custom 27803010 04.614.516 - TRNCON ROD MED TI TOP LD NONSTRL BOTH IP/OP "$3,150.00 " "$2,331.00" $0.00 "$2,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,337.93" "$2,337.93" $0.00 $0.00 $656.46 $0.00 $0.00 $0.00 $0.00 "$1,575.00" "$2,494.80" "$2,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.521 SUP HCPCS C1713 04.614.521 - SCREW BONE 7.5MM SYNAPSE TI SPNL LCK TRNCON NONSTRL BOTH IP/OP $218.75 $161.88 $0.00 $175.00 $98.44 $98.44 $0.00 $0.00 $0.00 $45.59 $162.36 $162.36 $0.00 $0.00 $45.59 $0.00 $129.39 $129.39 $0.00 $109.38 $173.25 $175.00 $0.00 $0.00 $34.23 $0.00 $0.00 $34.83 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.522 SUP HCPCS C1713 04.614.522 - SCREW BONE SYNAPSE TI SPNL LCK TRNCON NONSTRL BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 04.614.745 SUP HCPCS C1713 04.614.745 - ROD SPNL 45MM 3.5MM CURVE TI NONSTRL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 04.617.129S SUP Custom 27803010 04.617.129S - SPACER SPNL STD LRDTC 9MM STRL ZERO-PPEEK-OPTM TI BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 $0.00 $0.00 $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.617.814 SUP HCPCS C1713 04.617.814 - SCREW BONE 3MM 14MM TI CERV SPN LCK NONSTRL BOTH IP/OP $722.50 $534.65 $0.00 $578.00 $325.13 $325.13 $0.00 $0.00 $0.00 $150.59 $536.24 $536.24 $0.00 $0.00 $150.57 $0.00 $427.36 $427.36 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $113.07 $0.00 $0.00 $115.02 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.000 SUP Custom 27803010 04.620.000 - CAP LCK PANGEA SPNL TI NONSTRL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.170 SUP HCPCS C1713 04.620.170 - ROD SPNL 70MM 6MM PANGEA USS PDCL TI CVD SFT PRECONTOURED BOTH IP/OP $483.00 $357.42 $0.00 $386.40 $217.35 $217.35 $0.00 $0.00 $0.00 $100.67 $358.48 $358.48 $0.00 $0.00 $100.66 $0.00 $285.69 $285.69 $0.00 $241.50 $382.54 $386.40 $0.00 $0.00 $75.59 $0.00 $0.00 $76.89 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.203 SUP Custom 27803010 04.620.203 - TRNCON ROD 33-36.5MM PANGEA PDCL TI LP 6MM ROD NONSTRL BOTH IP/OP "$2,432.50 " "$1,800.05" $0.00 "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,805.40" "$1,805.40" $0.00 $0.00 $506.93 $0.00 $0.00 $0.00 $0.00 "$1,216.25" "$1,926.54" "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.204 SUP Custom 27803010 04.620.204 - TRNCON ROD 38.5-48MM 6MM PANGEA USS SPNL PDCL TI LP NONSTRL BOTH IP/OP "$2,432.50 " "$1,800.05" $0.00 "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,805.40" "$1,805.40" $0.00 $0.00 $506.93 $0.00 $0.00 $0.00 $0.00 "$1,216.25" "$1,926.54" "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.205 SUP Custom 27803010 04.620.205 - TRNCON ROD 49-69MM 6MM PANGEA USS SPNL PDCL TI LP NONSTRL BOTH IP/OP "$2,432.50 " "$1,800.05" $0.00 "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,805.40" "$1,805.40" $0.00 $0.00 $506.93 $0.00 $0.00 $0.00 $0.00 "$1,216.25" "$1,926.54" "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.425 SUP HCPCS C1713 04.620.425 - SCREW BONE 4MM 25MM PANGEA TI PDCL POLYAX STARDRIVE RECESS 2 BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.430 SUP HCPCS C1713 04.620.430 - SCREW BONE 4MM 30MM PANGEA TI PDCL POLYAX STARDRIVE RECESS 2 BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.530 SUP HCPCS C1713 04.620.530 - SCREW BONE 5MM 30MM PANGEA TI PDCL POLYAX DUAL CORE THRD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.535 SUP HCPCS C1713 04.620.535 - SCREW BONE 5MM 35MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.540 SUP HCPCS C1713 04.620.540 - SCREW BONE 5MM 40MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.630 SUP HCPCS C1713 04.620.630 - SCREW BONE 6MM 30MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.635 SUP HCPCS C1713 04.620.635 - SCREW BONE 6MM 35MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.640 SUP HCPCS C1713 04.620.640 - SCREW BONE 6MM 40MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.645 SUP HCPCS C1713 04.620.645 - SCREW BONE 6MM 45MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.650 SUP HCPCS C1713 04.620.650 - SCREW BONE 6MM 50MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.740 SUP HCPCS C1713 04.620.740 - SCREW BONE 7MM 40MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.745 SUP HCPCS C1713 04.620.745 - SCREW BONE 7MM 45MM PANGEA TI PDCL POLYAX 2 CORE NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.620.750 SUP HCPCS C1713 04.620.750 - SCREW BONE 7MM 50MM PANGEA TI PDCL 2 CORE POLYAX NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 04.808.003 SUP HCPCS C1713 04.808.003 - CAGE SPNL 29X21MM SYNEX 2 TI ALIF NONSTRL BOTH IP/OP "$10,017.00 " "$7,412.58" $0.00 "$8,013.60" "$4,507.65" "$4,507.65" $0.00 $0.00 $0.00 "$2,087.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,087.54" $0.00 "$4,938.38" "$4,938.38" $0.00 "$5,008.50" "$7,933.46" "$8,013.60" $0.00 $0.00 "$1,567.66" $0.00 $0.00 "$1,594.71" $0.00 $0.00 $0.00 $0.00 $0.00 04.808.004 SUP HCPCS C1713 04.808.004 - CAGE SPNL 25-33MM SYNEX 2 TI LMBR INTRBD FS CENTRL BODY BOTH IP/OP "$11,408.25 " "$8,442.11" $0.00 "$9,126.60" "$5,133.71" "$5,133.71" $0.00 $0.00 $0.00 "$2,377.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,377.48" $0.00 "$5,624.27" "$5,624.27" $0.00 "$5,704.13" "$9,035.33" "$9,126.60" $0.00 $0.00 "$1,785.39" $0.00 $0.00 "$1,816.19" $0.00 $0.00 $0.00 $0.00 $0.00 04.808.018 SUP HCPCS C1713 04.808.018 - EPLT SPNL GOLD 20X19MM SYNEX 2 SM 0 BOTH IP/OP "$2,040.50 " "$1,509.97" $0.00 "$1,632.40" $918.23 $918.23 $0.00 $0.00 $0.00 $425.29 "$1,514.46" "$1,514.46" $0.00 $0.00 $425.24 $0.00 "$1,206.96" "$1,206.96" $0.00 "$1,020.25" "$1,616.08" "$1,632.40" $0.00 $0.00 $319.34 $0.00 $0.00 $324.85 $0.00 $0.00 $0.00 $0.00 $0.00 04.808.027 SUP HCPCS C1713 04.808.027 - EPLT SPNL 25MM 22MM 0D TI NONSTRL BOTH IP/OP "$2,040.50 " "$1,509.97" $0.00 "$1,632.40" $918.23 $918.23 $0.00 $0.00 $0.00 $425.29 "$1,514.46" "$1,514.46" $0.00 $0.00 $425.24 $0.00 "$1,206.96" "$1,206.96" $0.00 "$1,020.25" "$1,616.08" "$1,632.40" $0.00 $0.00 $319.34 $0.00 $0.00 $324.85 $0.00 $0.00 $0.00 $0.00 $0.00 04-503-228 SUP HCPCS C1713 04-503-228 - SCREW TI 8MM SLFDRILL BONE MTRXMDFACE PLT SYS BOTH IP/OP $164.25 $121.55 $0.00 $131.40 $73.91 $73.91 $0.00 $0.00 $0.00 $34.23 $121.91 $121.91 $0.00 $0.00 $34.23 $0.00 $97.15 $97.15 $0.00 $82.13 $130.09 $131.40 $0.00 $0.00 $25.71 $0.00 $0.00 $26.15 $0.00 $0.00 $0.00 $0.00 $0.00 04-503-346 SUP HCPCS C1713 04-503-346 - PLATE .5MM 20 HOLE ADP BONE MATRIXMIDFACE TI NSTRL BLUE BOTH IP/OP "$1,206.00 " $892.44 $0.00 $964.80 $542.70 $542.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.00 $955.15 $964.80 $0.00 $0.00 $188.74 $0.00 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 04-503-396 SUP HCPCS C1713 04-503-396 - PLATE STD MINI .8MM 20 HOLE ADP BONE MATRIXMIDFACE TI NSTRL BOTH IP/OP "$1,206.00 " $892.44 $0.00 $964.80 $542.70 $542.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.00 $955.15 $964.80 $0.00 $0.00 $188.74 $0.00 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 046-237 SUP Custom 27803010 046-237 - WIRE SUTURE 6 CCS-1 14IN 2 MONOFILAMENT MYO/WIRE II BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 $0.00 $0.00 $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 050-508-000 SUP Custom 27203010 CONNECTOR PRFSN STRG EQL .5IN X.5IN STRL BOTH IP/OP $19.90 $14.73 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.77 $14.77 $0.00 $0.00 $4.15 $0.00 $0.00 $0.00 $0.00 $9.95 $15.76 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 050-526-000 SUP Custom 27011340 050-526-000 - CONNECTOR PERFUSION 3/8INX3/8INX3/8IN 3/8INX3/8INX3/8IN Y BOTH IP/OP $0.53 $0.39 $0.00 $0.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.39 $0.39 $0.00 $0.00 $0.11 $0.00 $0.00 $0.00 $0.00 $0.26 $0.42 $0.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 050-604-000 SUP Custom 27203010 CONNECTOR PRFSN STRG LUER LOCK LOCK .25IN X.25IN BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0523-48 SUP Custom 27203010 ADHESIVE LQ VL AMPULE MSTSL STRL 2/3ML SKN BOTH IP/OP $3.25 $2.41 $0.00 $2.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.41 $2.41 $0.00 $0.00 $0.68 $0.00 $0.00 $0.00 $0.00 $1.63 $2.57 $2.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 05-538-51 SUP Custom 27203010 TUBE CNTRF 119MM 17MM 15ML POLYPRO GRAD SKRT BTM SCR CAP BOTH IP/OP $1.18 $0.87 $0.00 $0.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.59 $0.93 $0.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-200 SUP HCPCS C1776 0580-0-200 - STEM FEM 200MM OFFST EXTR 3 LNG BOTH IP/OP "$6,271.00 " "$4,640.54" $0.00 "$5,016.80" "$2,821.95" "$2,821.95" $0.00 $0.00 $0.00 "$1,307.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,306.88" $0.00 "$3,091.60" "$3,091.60" $0.00 "$3,135.50" "$4,966.63" "$5,016.80" $0.00 $0.00 $981.41 $0.00 $0.00 $998.34 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-220 SUP HCPCS C1776 0580-0-220 - STEM FEM 220MM OFFST EXTR 3 LNG BOTH IP/OP "$6,271.00 " "$4,640.54" $0.00 "$5,016.80" "$2,821.95" "$2,821.95" $0.00 $0.00 $0.00 "$1,307.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,306.88" $0.00 "$3,091.60" "$3,091.60" $0.00 "$3,135.50" "$4,966.63" "$5,016.80" $0.00 $0.00 $981.41 $0.00 $0.00 $998.34 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-240 SUP HCPCS C1776 0580-0-240 - STEM FEM 240MM OFFST EXTR 3 LNG BOTH IP/OP "$6,271.00 " "$4,640.54" $0.00 "$5,016.80" "$2,821.95" "$2,821.95" $0.00 $0.00 $0.00 "$1,307.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,306.88" $0.00 "$3,091.60" "$3,091.60" $0.00 "$3,135.50" "$4,966.63" "$5,016.80" $0.00 $0.00 $981.41 $0.00 $0.00 $998.34 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-260 SUP HCPCS C1776 0580-0-260 - STEM FEM 260MM OFFST EXTR 3 LNG BOTH IP/OP "$6,271.00 " "$4,640.54" $0.00 "$5,016.80" "$2,821.95" "$2,821.95" $0.00 $0.00 $0.00 "$1,307.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,306.88" $0.00 "$3,091.60" "$3,091.60" $0.00 "$3,135.50" "$4,966.63" "$5,016.80" $0.00 $0.00 $981.41 $0.00 $0.00 $998.34 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-330 SUP HCPCS C1776 0580-0-330 - STEM FEM 120MM EXTR 2 ANT POST BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-351 SUP HCPCS C1776 0580-0-351 - STEM FEM OFFST EXTR 1 35.5MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-352 SUP HCPCS C1776 0580-0-352 - STEM FEM OFFST SYS EXTR ORTHNX 37.5MM LG TOT HIP BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-371 SUP HCPCS C1776 0580-0-371 - STEM FEM OFFST EXTR ORTHNX 1 37.5MM HIP BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-372 SUP HCPCS C1776 0580-0-372 - STEM FEM OFFST EXTR 2 37.5MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-373 SUP HCPCS C1776 0580-0-373 - STEM FEM OFFST EXTR 3 37.5MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-374 SUP HCPCS C1776 0580-0-374 - STEM FEM OFFST EXTR 4 37.5MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-441 SUP HCPCS C1776 0580-0-441 - STEM FEM 44MM OFFST EXTR 1 BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-442 SUP HCPCS C1776 0580-0-442 - STEM FEM OFFST EXTR 2 44MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-443 SUP HCPCS C1776 0580-0-443 - STEM FEM OFFST EXTR 3 44MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-444 SUP HCPCS C1776 0580-0-444 - STEM FEM OFFST EXTR 4 44MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-445 SUP HCPCS C1776 0580-0-445 - STEM FEM OFFST EXTR 5 44MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-446 SUP HCPCS C1776 0580-0-446 - STEM FEM OFFST EXTR 6 44MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-503 SUP HCPCS C1776 0580-0-503 - STEM FEM OFFST EXTR 3 50MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-504 SUP HCPCS C1776 0580-0-504 - STEM FEM 50MM OFFST EXTR 4 BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-505 SUP HCPCS C1776 0580-0-505 - STEM FEM OFFST EXTR 5 50MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-0-506 SUP HCPCS C1776 0580-0-506 - STEM FEM OFFST EXTR 6 50MM BOTH IP/OP "$4,264.00 " "$3,155.36" $0.00 "$3,411.20" "$1,918.80" "$1,918.80" $0.00 $0.00 $0.00 $888.72 "$3,164.74" "$3,164.74" $0.00 $0.00 $888.62 $0.00 "$2,102.15" "$2,102.15" $0.00 "$2,132.00" "$3,377.09" "$3,411.20" $0.00 $0.00 $667.32 $0.00 $0.00 $678.83 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-044 SUP HCPCS C1776 0580-1-044 - STEM FEMORAL 0 44MM OFFST LONG CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-200 SUP HCPCS C1776 0580-1-200 - STEM FEMORAL 3 44MM OFFST LONG 200MM CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-220 SUP HCPCS C1776 0580-1-220 - STEM FEMORAL 3 44MM OFFST LONG 220MM CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-240 SUP HCPCS C1776 0580-1-240 - STEM FEMORAL 3 44MM OFFST LONG 240MM CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-260 SUP HCPCS C1776 0580-1-260 - STEM FEMORAL 3 44MM OFFST LONG 260MM CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-300 SUP HCPCS C1776 0580-1-300 - STEM FEMORAL 30MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-330 SUP HCPCS C1776 0580-1-330 - STEM FEMORAL 33MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-351 SUP HCPCS C1776 0580-1-351 - STEM FEMORAL 35.5MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-352 SUP HCPCS C1776 0580-1-352 - STEM FEMORAL 0 35.5MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-371 SUP HCPCS C1776 0580-1-371 - STEM FEMORAL 1 37.5MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-372 SUP HCPCS C1776 0580-1-372 - STEM FEMORAL 2 37.5MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-373 SUP HCPCS C1776 0580-1-373 - STEM FEMORAL 3 37.5MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-374 SUP HCPCS C1776 0580-1-374 - STEM FEMORAL 4 37.5MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-440 SUP HCPCS C1776 0580-1-440 - STEM FEMORAL 0 44MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-441 SUP HCPCS C1776 0580-1-441 - STEM FEMORAL 1 44MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-442 SUP HCPCS C1776 0580-1-442 - STEM FEMORAL 2 44MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-443 SUP HCPCS C1776 0580-1-443 - STEM FEMORAL 3 44MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-444 SUP HCPCS C1776 0580-1-444 - STEM FEMORAL 4 44MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-445 SUP HCPCS C1776 0580-1-445 - STEM FEMORAL 5 45MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-446 SUP HCPCS C1776 0580-1-446 - STEM FEMORAL 6 45MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-501 SUP HCPCS C1776 0580-1-501 - STEM FEMORAL 1 50MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-502 SUP HCPCS C1776 0580-1-502 - STEM FEMORAL 2 50MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-503 SUP HCPCS C1776 0580-1-503 - STEM FEMORAL 3 50MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-504 SUP HCPCS C1776 0580-1-504 - STEM FEMORAL 4 50MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-1-505 SUP HCPCS C1776 0580-1-505 - STEM FEMORAL 5 50MM OFFST CEMENTED EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-2-442 SUP HCPCS C1776 0580-2-442 - STEM FEM 205MM TPR EXTR V40 2 LNG 44MM BOTH IP/OP "$6,271.00 " "$4,640.54" $0.00 "$5,016.80" "$2,821.95" "$2,821.95" $0.00 $0.00 $0.00 "$1,307.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,306.88" $0.00 "$3,091.60" "$3,091.60" $0.00 "$3,135.50" "$4,966.63" "$5,016.80" $0.00 $0.00 $981.41 $0.00 $0.00 $998.34 $0.00 $0.00 $0.00 $0.00 $0.00 0580-3-371 SUP HCPCS C1776 0580-3-371 - STEM FEM 1 37.5MM OFST 125MM STRL EXTR V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-3-422 SUP HCPCS C1776 0580-3-422 - STEM FEMORAL 2 44MM TAPER 44MM 205MM EXETER V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-3-441 SUP HCPCS C1776 0580-3-441 - STEM FEM 1 44MM OFST 125MM STRL EXTR V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-3-501 SUP HCPCS C1776 0580-3-501 - STEM FEM 1 50MM OFST 125MM STRL EXTR V40 HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 0580-9-300 SUP Custom 27803010 0580-9-300 - STEM SURG 30MM EXTR ANTEROPOSTERIOR ORTHNX AP1 TCHQ OFFST BOTH IP/OP $721.00 $533.54 $0.00 $576.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $535.13 $535.13 $0.00 $0.00 $150.26 $0.00 $0.00 $0.00 $0.00 $360.50 $571.03 $576.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-0-022 SUP Custom 27803010 0586-0-022 - HEAD FEMORAL +0MM 22MM CEMENTED EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-0-026 SUP Custom 27803010 0586-0-026 - HEAD FEMORAL +0MM 26MM CEMENTED EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-0-028 SUP Custom 27803010 0586-0-028 - HEAD FEMORAL +0MM 28MM CEMENTED EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-0-032 SUP Custom 27803010 0586-0-032 - HEAD FEMORAL +0MM 32MM CEMENTED EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-0-326 SUP Custom 27803010 0586-0-326 - HEAD FEMORAL -3MM 26MM CEMENTED EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-0-328 SUP Custom 27803010 0586-0-328 - HEAD FEMORAL -3MM 28MM NECK EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-0-332 SUP Custom 27803010 0586-0-332 - HEAD FEMORAL -3MM 32MM NECK EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-5-026 SUP Custom 27803010 0586-5-026 - HEAD FEMORAL +5MM 26MM NECK EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-5-028 SUP Custom 27803010 0586-5-028 - HEAD FEMORAL +5MM 28MM NECK EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0586-5-032 SUP Custom 27803010 0586-5-032 - HEAD FEMORAL 5MM 35MM NECK EXETER ORTHINOX HIP BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $0.00 $0.00 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 05CR000029 SUP Custom 27203010 REAGENT ANALY RNS SOL ALC BLND 3.6L BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 05CR000037 SUP Custom 27203010 REAGENT CYTO CYSTOLITH FLUID PRSV GYN 4L BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0650HYB0605A SUP HCPCS C1768 0650HYB0605A - GRAFT CARDIO 50CM 6MM 6MM 5CM HBRD REINF GORE NTNL BOTH IP/OP "$6,125.00 " "$4,532.50" $0.00 "$4,900.00" "$2,756.25" "$2,756.25" $0.00 $0.00 $0.00 "$1,276.60" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,276.45" $0.00 "$3,019.63" "$3,019.63" $0.00 "$3,062.50" "$4,851.00" "$4,900.00" $0.00 $0.00 $958.56 $0.00 $0.00 $975.10 $0.00 $0.00 $0.00 $0.00 $0.00 0650HYB0610A SUP HCPCS C1768 0650HYB0610A - GRAFT VASCULAR 50CM HYBRID REINFORCED COATED NITINOL PTFE 10 BOTH IP/OP "$7,125.00 " "$5,272.50" $0.00 "$5,700.00" "$3,206.25" "$3,206.25" $0.00 $0.00 $0.00 "$1,485.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,484.85" $0.00 "$3,512.63" "$3,512.63" $0.00 "$3,562.50" "$5,643.00" "$5,700.00" $0.00 $0.00 "$1,115.06" $0.00 $0.00 "$1,134.30" $0.00 $0.00 $0.00 $0.00 $0.00 0650HYB0705A SUP HCPCS C1768 0650HYB0705A - GRAFT VASC 50CM 7MM 6MM GORE NTNL HBRD REINF CNFIG 5CM BOTH IP/OP "$6,125.00 " "$4,532.50" $0.00 "$4,900.00" "$2,756.25" "$2,756.25" $0.00 $0.00 $0.00 "$1,276.60" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,276.45" $0.00 "$3,019.63" "$3,019.63" $0.00 "$3,062.50" "$4,851.00" "$4,900.00" $0.00 $0.00 $958.56 $0.00 $0.00 $975.10 $0.00 $0.00 $0.00 $0.00 $0.00 0650HYB0805A SUP HCPCS C1768 0650HYB0805A - GRAFT VASC 50CM 8MM 6MM GORE NTNL HBRD REINF CNFIG 5CM BOTH IP/OP "$6,125.00 " "$4,532.50" $0.00 "$4,900.00" "$2,756.25" "$2,756.25" $0.00 $0.00 $0.00 "$1,276.60" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,276.45" $0.00 "$3,019.63" "$3,019.63" $0.00 "$3,062.50" "$4,851.00" "$4,900.00" $0.00 $0.00 $958.56 $0.00 $0.00 $975.10 $0.00 $0.00 $0.00 $0.00 $0.00 0684-00-0568-01 SUP Custom 27803010 0684-00-0568-01 - CATHETER IAB 7.5FR 6IN 40ML SNS + 2 STLK DEV FO INS KT INTRO BOTH IP/OP "$2,725.00 " "$2,016.50" $0.00 "$2,180.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,022.50" "$2,022.50" $0.00 $0.00 $567.89 $0.00 $0.00 $0.00 $0.00 "$1,362.50" "$2,158.20" "$2,180.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0684-00-0576-01 SUP Custom 27803010 0684-00-0576-01 - CATHETER IAB .025IN 8FR 17.4MM .027IN 6IN 50CC 258MM SNS + BOTH IP/OP "$2,613.63 " "$1,934.09" $0.00 "$2,090.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,939.83" "$1,939.83" $0.00 $0.00 $544.68 $0.00 $0.00 $0.00 $0.00 "$1,306.81" "$2,069.99" "$2,090.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 07.704.105S SUP HCPCS C1713 07.704.105S - FILLER BONE VOID DRILLABLE FAST SET PUTTY NORIAN 5ML STERILE BOTH IP/OP "$3,678.00 " "$2,721.72" $0.00 "$2,856.70" "$1,606.89" "$1,606.89" $0.00 $0.00 $0.00 $766.59 "$2,729.81" "$2,729.81" $0.00 $0.00 $766.50 $0.00 "$1,813.25" "$1,813.25" $0.00 "$1,785.44" "$2,828.14" "$2,856.70" $0.00 $0.00 $542.57 $0.00 $0.00 $568.48 $0.00 $0.00 $0.00 $0.00 $0.00 07.704.110S SUP HCPCS C1713 07.704.110S - FILLER BONE VOID DRILLABLE FAST SET PUTTY NORIAN 10ML BOTH IP/OP "$7,228.70 " "$5,349.24" $0.00 "$5,614.54" "$3,158.18" "$3,158.18" $0.00 $0.00 $0.00 "$1,506.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,506.46" $0.00 "$3,563.75" "$3,563.75" $0.00 "$3,509.09" "$5,558.40" "$5,614.54" $0.00 $0.00 "$1,066.35" $0.00 $0.00 "$1,117.29" $0.00 $0.00 $0.00 $0.00 $0.00 07.704-003S SUP HCPCS C1713 07.704-003S - CEMENT BONE NRN SRS 3ML VOID FILR ROT MX STRL BOTH IP/OP "$2,018.60 " "$1,493.76" $0.00 "$1,614.88" $908.37 $908.37 $0.00 $0.00 $0.00 $420.73 "$1,498.20" "$1,498.20" $0.00 $0.00 $420.68 $0.00 "$1,194.00" "$1,194.00" $0.00 "$1,009.30" "$1,598.73" "$1,614.88" $0.00 $0.00 $315.91 $0.00 $0.00 $321.36 $0.00 $0.00 $0.00 $0.00 $0.00 07.704-005S SUP HCPCS C1713 07.704-005S - FILLER BONE VOID DRILLABLE INJECT REINFORCED BIORESORBABLE BOTH IP/OP "$3,678.00 " "$2,721.72" $0.00 "$2,856.70" "$1,606.89" "$1,606.89" $0.00 $0.00 $0.00 $766.59 "$2,729.81" "$2,729.81" $0.00 $0.00 $766.50 $0.00 "$1,813.25" "$1,813.25" $0.00 "$1,785.44" "$2,828.14" "$2,856.70" $0.00 $0.00 $518.81 $0.00 $0.00 $568.48 $0.00 $0.00 $0.00 $0.00 $0.00 07.704-010S SUP HCPCS C1713 07.704-010S - FILLER BONE VOID DRILLABLE INJECT REINFORCED BIORESORBABLE BOTH IP/OP "$7,228.70 " "$5,349.24" $0.00 "$5,614.54" "$3,158.18" "$3,158.18" $0.00 $0.00 $0.00 "$1,506.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,506.46" $0.00 "$3,563.75" "$3,563.75" $0.00 "$3,509.09" "$5,558.40" "$5,614.54" $0.00 $0.00 "$1,066.35" $0.00 $0.00 "$1,117.29" $0.00 $0.00 $0.00 $0.00 $0.00 07-036P SUP HCPCS C1713 07-036P - 7 MM WASHER BOTH IP/OP $28.50 $21.09 $0.00 $22.80 $12.83 $12.83 $0.00 $0.00 $0.00 $5.94 $21.15 $21.15 $0.00 $0.00 $5.94 $0.00 $16.86 $16.86 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $4.46 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 07-150-10 SUP Custom 27203010 07-150-10 - PROBE DOPPLER 20MHZ 280MM BAYONETED STERILE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 $0.00 $0.00 $0.00 "$1,273.75" "$2,017.62" "$2,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 07-150-12 SUP Custom 27203010 07-150-12 - PROBE DOPPLER MINI NEURO DISPOSABLE BOTH IP/OP "$4,015.00 " "$2,971.10" $0.00 "$3,118.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,979.93" "$2,979.93" $0.00 $0.00 $836.73 $0.00 $0.00 $0.00 $0.00 "$1,948.75" "$3,086.82" "$3,118.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 073701-CD SUP Custom 27203010 073701-CD - SET DILAT S-CURVE HYDPHI PLMR SDPRT LFRIC SLIP SRFC 37CM BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $0.00 $0.00 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 07-40230 SUP Custom 27803010 07-40230 - DRILL DRL 2.4MM CNN D STP BOTH IP/OP $463.25 $342.81 $0.00 $391.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.82 $343.82 $0.00 $0.00 $96.54 $0.00 $0.00 $0.00 $0.00 $244.75 $387.68 $391.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 07-40232 SUP Custom 27803010 07-40232 - TAP CANN DEPTH STOP SURG BOTH IP/OP $417.00 $308.58 $0.00 $309.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $309.50 $309.50 $0.00 $0.00 $86.90 $0.00 $0.00 $0.00 $0.00 $187.69 $297.30 $300.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 07-40280 SUP HCPCS C1713 07-40280 - WIRE FIX 1MM 160MM KWIRE SS ORTH LEIBINGER BOTH IP/OP $44.25 $32.75 $0.00 $32.84 $1.86 $1.86 $0.00 $0.00 $0.00 $9.22 $32.84 $32.84 $0.00 $0.00 $9.22 $0.00 $26.17 $26.17 $0.00 $2.06 $3.27 $3.30 $0.00 $0.00 $0.65 $0.00 $0.00 $0.66 $0.00 $0.00 $0.00 $0.00 $0.00 07-40281 SUP HCPCS C1713 07-40281 - WIRE FX 1.1MM 160MM NS KRSH LGTH MRK SS BOTH IP/OP $37.40 $27.68 $0.00 $30.80 $17.33 $17.33 $0.00 $0.00 $0.00 $7.80 $27.76 $27.76 $0.00 $0.00 $7.79 $0.00 $22.12 $22.12 $0.00 $19.25 $30.49 $30.80 $0.00 $0.00 $6.03 $0.00 $0.00 $6.13 $0.00 $0.00 $0.00 $0.00 $0.00 07782G SUP Custom 27203010 CORK GRAD LAB 4 BOTH IP/OP $0.25 $0.19 $0.00 $0.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.13 $0.20 $0.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 08.510.543S SUP HCPCS C1713 08.510.543S - PLATE BONE 24MMX1.5MM SYNPOR POLYETHYLENE POROUS ORBTL FLOOR BOTH IP/OP "$1,447.50 " "$1,071.15" $0.00 "$1,158.00" $651.38 $651.38 $0.00 $0.00 $0.00 $301.70 "$1,074.33" "$1,074.33" $0.00 $0.00 $301.66 $0.00 $856.20 $856.20 $0.00 $723.75 "$1,146.42" "$1,158.00" $0.00 $0.00 $226.53 $0.00 $0.00 $230.44 $0.00 $0.00 $0.00 $0.00 $0.00 08.520.221S SUP HCPCS C1713 08.520.221S - PLATE BN FAN .8MM STRL SYNPOR SMTH EXPOSE FX HL RADGR VSB TI BOTH IP/OP "$4,292.50 " "$3,176.45" $0.00 "$3,434.00" "$1,931.63" "$1,931.63" $0.00 $0.00 $0.00 $894.66 "$3,185.89" "$3,185.89" $0.00 $0.00 $894.56 $0.00 "$2,116.20" "$2,116.20" $0.00 "$2,146.25" "$3,399.66" "$3,434.00" $0.00 $0.00 $671.78 $0.00 $0.00 $683.37 $0.00 $0.00 $0.00 $0.00 $0.00 08.803.209 SUP HCPCS C1713 08.803.209 - SPACER SPNL BLT NOSE 32X10X9MM NS OPAL REVOLVE RADOPQ SLF BOTH IP/OP "$13,782.50 " "$10,199.05" $0.00 "$11,026.00" "$6,202.13" "$6,202.13" $0.00 $0.00 $0.00 "$2,872.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,872.27" $0.00 "$6,794.77" "$6,794.77" $0.00 "$6,891.25" "$10,915.74" "$11,026.00" $0.00 $0.00 "$2,156.96" $0.00 $0.00 "$2,194.17" $0.00 $0.00 $0.00 $0.00 $0.00 08A020 SUP Custom 27804086 08A020 - GRAFT BONE CANC 30ML 4-10MM FRZDR BOTH IP/OP "$1,165.00 " $862.10 $0.00 $952.56 $0.00 $0.00 $0.00 $0.00 $0.00 $242.82 $864.66 $864.66 $0.00 $0.00 $242.79 $0.00 $689.10 $689.10 $0.00 $595.35 $943.03 $952.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 08A022 SUP Custom 27803010 08A022 - GRAFT BN 15ML CHP CANC BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.23 $549.23 $0.00 $0.00 $154.22 $0.00 $0.00 $0.00 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 08A024 SUP Custom 27804086 08A024 - GRAFT BN 4-10MM 5ML CHP CANC TBA 013470059 09 BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $0.00 $0.00 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 09.402.022S SUP HCPCS C1713 09.402.022S - HEAD RADIAL STANDARD 22MM 12MM COCR ELBOW STERILE BOTH IP/OP "$3,286.33 " "$2,431.88" $0.00 "$2,629.06" "$1,478.85" "$1,478.85" $0.00 $0.00 $0.00 $684.95 "$2,439.11" "$2,439.11" $0.00 $0.00 $684.87 $0.00 "$1,620.16" "$1,620.16" $0.00 "$1,643.16" "$2,602.77" "$2,629.06" $0.00 $0.00 $499.33 $0.00 $0.00 $523.18 $0.00 $0.00 $0.00 $0.00 $0.00 0900-05 SUP Custom 27203010 NUNC NULL STRIPS BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0920-2-920 SUP Custom 27803010 0920-2-920 - CENTRALIZER STEM EXETER PMMA BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0939-0-106 SUP HCPCS C1713 0939-0-106 - PLUG BONE CEMENT 6MM EXETER PMMA INTRAMEDULLARY BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 0939-0-108 SUP HCPCS C1713 0939-0-108 - PLUG BONE CEMENT 8MM EXETER PMMA INTRAMEDULLARY BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 0939-0-110 SUP HCPCS C1713 0939-0-110 - PLUG BONE CEMENT 10MM EXETER PMMA INTRAMEDULLARY BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 0939-0-112 SUP HCPCS C1713 0939-0-112 - PLUG BONE CEMENT 12MM EXETER PMMA INTRAMEDULLARY BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 0939-0-114 SUP HCPCS C1713 0939-0-114 - PLUG BONE CEMENT 14MM EXETER PMMA INTRAMEDULLARY BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 0939-0-116 SUP HCPCS C1713 0939-0-116 - PLUG BONE CEMENT 16MM EXETER PMMA INTRAMEDULLARY BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 0939-0-118 SUP HCPCS C1713 0939-0-118 - PLUG BONE CEMENT 18MM EXETER PMMA INTRAMEDULLARY BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 0939-0-120 SUP HCPCS C1713 0939-0-120 - PLUG BONE CEMENT 20MM EXETER PMMA INTRAMEDULLARY BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 0942-2-110 SUP HCPCS C1713 0942-2-110 - PLUG BONE CEMENT 10MM EXETER X-CHANGE BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-2-112 SUP HCPCS C1713 0942-2-112 - PLUG BONE CEMENT 12MM EXETER X-CHANGE BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-2-114 SUP HCPCS C1713 0942-2-114 - SPACER CEMENT 14MM 14MM BONE PLUGS ACCESSORIES EXETER BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-2-116 SUP HCPCS C1713 0942-2-116 - PLUG BONE CEMENT 16MM EXETER X-CHANGE BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-2-118 SUP HCPCS C1713 0942-2-118 - SPACER CEMENT 18MM BONE PLUGS ACCESSORIES EXETER X-CHANGE BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-2-120 SUP HCPCS C1713 0942-2-120 - PLUG BONE CEMENT 20MM 20MM EXETER X-CHANGE HIP BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-000 SUP HCPCS C1713 0942-8-000 - SCREW BONE 3.5MM 10MM SELF TAP SELF DRILL X-CHANGE HIP BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-001 SUP HCPCS C1713 0942-8-001 - SCREW BONE 3.5MM 15MM SELF TAP SELF DRILL X-CHANGE HIP BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-002 SUP HCPCS C1713 0942-8-002 - SCREW BONE 3.5MM 20MM SELF TAP SELF DRILL X-CHANGE HIP BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-003 SUP HCPCS C1713 0942-8-003 - SCREW BONE 3.5MM 25MM SELF TAP SELF DRILL X-CHANGE HIP BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-004 SUP HCPCS C1713 0942-8-004 - SCREW BONE 3.5MM 30MM SELF TAP SELF DRILL X-CHANGE HIP BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-005 SUP HCPCS C1713 0942-8-005 - SCREW BONE 3.5MM 35MM SELF TAP SELF DRILL X-CHANGE HIP BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-010 SUP HCPCS C1781 0942-8-010 - MESH ACETAB CURVE X-CHANGE RSTOR HIP BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-020 SUP HCPCS C1781 0942-8-020 - MESH ACETAB LARGE X-CHANGE RSTOR HIP MEDIAL WALL BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-025 SUP HCPCS C1781 0942-8-025 - MESH ACETAB SMALL X-CHANGE RSTOR HIP MEDIAL WALL BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-030 SUP HCPCS C1781 0942-8-030 - MESH ACETAB FLAT X-CHANGE RSTOR HIP BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-040 SUP HCPCS C1781 0942-8-040 - MESH ACETAB SMALL X-CHANGE RSTOR HIP RIM BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-050 SUP HCPCS C1781 0942-8-050 - MESH ACETAB MEDIUM X-CHANGE RSTOR HIP RIM BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-060 SUP HCPCS C1781 0942-8-060 - MESH ACETAB LARGE X-CHANGE RSTOR HIP RIM BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 0942-8-070 SUP HCPCS C1781 0942-8-070 - MESH ACETAB ANATOMIC X-CHANGE RSTOR HIP FEMURAL BOTH IP/OP "$1,285.00 " $950.90 $0.00 "$1,028.00" $578.25 $578.25 $0.00 $0.00 $0.00 $267.83 $953.73 $953.73 $0.00 $0.00 $267.79 $0.00 $760.08 $760.08 $0.00 $642.50 "$1,017.72" "$1,028.00" $0.00 $0.00 $201.10 $0.00 $0.00 $204.57 $0.00 $0.00 $0.00 $0.00 $0.00 0994-001 SUP HCPCS C1887 0994-001 - CATHETER GD 6FR 140CM VNTR OTW RADOPQ STRBL ML LR COIL TRQ BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $882.38 $882.38 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-0614 SUP HCPCS C1713 1000-00-0614 - CAGE SPNL 7D LRDTC 14X12X6MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-0616 SUP HCPCS C1713 1000-00-0616 - CAGE SPNL 7D LRDTC 16X14X6MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-0714 SUP HCPCS C1713 1000-00-0714 - CAGE SPNL 7D LRDTC 14X12X7MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-0716 SUP HCPCS C1713 1000-00-0716 - CAGE SPNL 7D LRDTC 16X14X7MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-0814 SUP HCPCS C1713 1000-00-0814 - CAGE SPNL 7D LRDTC 14X12X8MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-0816 SUP HCPCS C1713 1000-00-0816 - CAGE SPNL 7D LRDTC 16X14X8MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-0914 SUP HCPCS C1713 1000-00-0914 - CAGE SPNL 7D LRDTC 14X12X9MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-0916 SUP HCPCS C1713 1000-00-0916 - CAGE SPNL 7D LRDTC 16X14X9MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-1014 SUP HCPCS C1713 1000-00-1014 - CAGE SPNL 7D LRDTC 14X12X10MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 1000-00-1016 SUP HCPCS C1713 1000-00-1016 - CAGE SPNL 7D LRDTC 16X14X10MM COHERE LOPRFL MATTE FNSH PEEK BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 100-06 SUP HCPCS C1713 100-06 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $248.63 $183.99 $0.00 $198.90 $111.88 $111.88 $0.00 $0.00 $0.00 $51.82 $184.53 $184.53 $0.00 $0.00 $51.81 $0.00 $147.06 $147.06 $0.00 $124.31 $196.91 $198.90 $0.00 $0.00 $38.91 $0.00 $0.00 $39.58 $0.00 $0.00 $0.00 $0.00 $0.00 1001-2200 SUP Custom 27803010 1001-2200 - HEAD FEMORAL +00MM MORSE TAPER 32MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-2205 SUP Custom 27803010 1001-2205 - HEAD FEMORAL +05MM MORSE TAPER 22MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-2600 SUP Custom 27803010 1001-2600 - HEAD FEMORAL +00MM MORSE TAPER 26MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-2605 SUP Custom 27803010 1001-2605 - HEAD FEMORAL +05MM MORSE TAPER 26MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-2610 SUP Custom 27803010 1001-2610 - HEAD FEMORAL +10MM MORSE TAPER 26MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-2800 SUP Custom 27803010 1001-2800 - HEAD FEMORAL +00MM MORSE TAPER 28MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-2805 SUP Custom 27803010 1001-2805 - HEAD FEMORAL +5MM 28MM MORSE TAPERED LFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-2810 SUP Custom 27803010 1001-2810 - HEAD FEM +10 28MM HIP MRS TPR COCR LFIT BOTH IP/OP $814.00 $602.36 $0.00 $651.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $604.15 $604.15 $0.00 $0.00 $169.64 $0.00 $0.00 $0.00 $0.00 $407.00 $644.69 $651.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-3200 SUP Custom 27803010 1001-3200 - HEAD FEMORAL +00MM MORSE TAPER 32MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-3205 SUP Custom 27803010 1001-3205 - HEAD FEMORAL +05MM MORSE TAPER 32MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-3210 SUP Custom 27803010 1001-3210 - HEAD FEMORAL +10MM MORSE TAPER 32MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-3299 SUP Custom 27803010 1001-3299 - HEAD FEMORAL +99MM MORSE TAPER 32MM OMNIFIT COCR HIP BOTH IP/OP "$1,297.50 " $960.15 $0.00 "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.00 $963.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $648.75 "$1,027.62" "$1,038.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1001-532 SUP Custom 27203010 1001-532 - CLAMP SURG 75-80GM CLAMPING PRESSURE MIDI STR BULLDOG BOTH IP/OP $209.50 $155.03 $0.00 $167.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.49 $155.49 $0.00 $0.00 $43.66 $0.00 $0.00 $0.00 $0.00 $104.75 $165.92 $167.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1003381-13 SUP HCPCS C1874 1003381-13 - STENT CORON .014IN LP 4.5MM 13MM RAPEX SMOOTH SURFACE MARKER BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1003381-18 SUP HCPCS C1874 1003381-18 - SYSTEM COR STNT 4.5MM 18MM MTLNK UL RX LOPRFL RADOPQ SMTH BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1003381-28 SUP HCPCS C1874 1003381-28 - STENT CORON .014IN LP 4.5MM 28MM RAPEX SMOOTH SURFACE MARKER BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 100-36-01 SUP Custom 27203010 100-36-01 - CHEST TUBE INSERTION DEVICE MINIMALLY INVASIVE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1005359H SUP HCPCS C1760 1005359H - GUIDEWIRE VASCULAR STR .014IN 300CM 3CM HI-TORQUE WHISPER MS BOTH IP/OP $177.50 $131.35 $0.00 $142.00 $79.88 $79.88 $0.00 $0.00 $0.00 $37.00 $131.74 $131.74 $0.00 $0.00 $36.99 $0.00 $104.99 $104.99 $0.00 $88.75 $140.58 $142.00 $0.00 $0.00 $27.78 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $0.00 1005359H NEW ITEM # 80322174 SUP HCPCS C1760 1005359H NEW ITEM # 80322174 - GUIDEWIRE VASCULAR STR .014IN 300CM 3CM HI-TORQUE WHISPER MS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 1007-00 SUP Custom 27203010 1007-00 - VALVULOTOME ANGIOSCOPIC 98CM EXPANDABLE OTW 1.5MM BOTH IP/OP "$4,197.50 " "$3,106.15" $0.00 "$3,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,115.38" "$3,115.38" $0.00 $0.00 $874.76 $0.00 $0.00 $0.00 $0.00 "$2,098.75" "$3,324.42" "$3,358.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007822-08 SUP HCPCS C1874 1007822-08 - STENT CORON 2.25MM 8MM 2 RADIOPQ MARKER BALLOON EXPANDABLE BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007823-08 SUP HCPCS C1874 1007823-08 - STENT CORON 2.5MM 8MM .014IN RAPEX FLXB LP MTLNK MVSN COCR BOTH IP/OP $875.00 $647.50 $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 1007823-15 SUP HCPCS C1874 1007823-15 - STENT CORON LP 2.5MM 15MM 2 RADIOPQ MARKER BALLOON BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007823-28 SUP HCPCS C1874 1007823-28 - STENT CORON LP 2.5MM 28MM 2 RADIOPQ MARKER BALLOON BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007848-08 SUP HCPCS C1874 1007848-08 - SYSTEM CORON STENT 3MM 8MM RAPEX MULTI-LINK VISION BARE BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007848-12 SUP HCPCS C1874 1007848-12 - SYSTEM CORON STENT 3MM 12MM RAPEX MULTI-LINK VISION BARE BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007848-23 SUP HCPCS C1874 1007848-23 - STENT CORON LP 3MM 23MM 2 RADIOPQ MARKER BALLOON EXPANDABLE BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007848-28 SUP HCPCS C1874 1007848-28 - SYSTEM CORON STENT 3MM 28MM RAPEX MULTI-LINK VISION BARE BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007849-12 SUP HCPCS C1874 1007849-12 - SYSTEM COR STNT 3.5MM 12MM MTLNK VSN RX LOPRFL RADOPQ BLN BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007849-18 SUP HCPCS C1874 1007849-18 - STENT CORON LP 3.5MM 18MM 2 RADIOPQ MARKER BALLOON BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007849-23 SUP HCPCS C1874 1007849-23 - STENT CORON LP 3.5MM 23MM 2 RADIOPQ MARKER BALLOON BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007849-28 SUP HCPCS C1874 1007849-28 - SYSTEM COR STNT 3.5MM 28MM MTLNK VSN RX LOPRFL RADOPQ BLN BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007850-08 SUP HCPCS C1874 1007850-08 - STENT CORON 4MM 8MM .014IN RAPEX FLXB LP MTLNK VSN COCR BOTH IP/OP $875.00 $647.50 $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 1007850-12 SUP HCPCS C1874 1007850-12 - STENT CORON LP 4MM 12MM 2 RADIOPQ MARKER BALLOON EXPANDABLE BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1007850-15 SUP HCPCS C1874 1007850-15 - STENT CORON LP 4MM 15MM 2 RADIOPQ MARKER BALLOON EXPANDABLE BOTH IP/OP $875.00 $647.50 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1008193-20 SUP HCPCS C1725 1008193-20 - CATHETER BLNDIL 5MM 135CM 20MM VTRC14 + RX LOPRFL FLXB KINK BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $244.35 $244.35 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 1009539-08 SUP HCPCS C1874 1009539-08 - STENT COR 2.5MM 8MM 143CM XIENCE V DLV SYS RX RADOPQ TPR BLN BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009539-12 SUP HCPCS C1874 1009539-12 - SYSTEM COR STNT 2.5MM 12MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009539-15 SUP HCPCS C1874 1009539-15 - SYSTEM COR STNT 2.5MM 15MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009539-18 SUP HCPCS C1874 1009539-18 - SYSTEM COR STNT 2.5MM 18MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009539-23 SUP HCPCS C1874 1009539-23 - SYSTEM COR STNT 2.5MM 23MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009539-28 SUP HCPCS C1874 1009539-28 - SYSTEM COR STNT 2.5MM 28MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009540-12 SUP HCPCS C1874 1009540-12 - SYSTEM COR STNT 2.75MM 12MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009540-15 SUP HCPCS C1874 1009540-15 - SYSTEM COR STNT 2.75MM 15MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009540-18 SUP HCPCS C1874 1009540-18 - SYSTEM COR STNT 2.75MM 18MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009540-23 SUP HCPCS C1874 1009540-23 - SYSTEM COR STNT 2.75MM 23MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009540-28 SUP HCPCS C1874 1009540-28 - SYSTEM COR STNT 2.75MM 28MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009541-12 SUP HCPCS C1874 1009541-12 - SYSTEM COR STNT 3MM 12MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009541-15 SUP HCPCS C1874 1009541-15 - SYSTEM COR STNT 3MM 15MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009541-18 SUP HCPCS C1874 1009541-18 - SYSTEM COR STNT 3MM 18MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009541-23 SUP HCPCS C1874 1009541-23 - SYSTEM COR STNT 3MM 23MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009541-28 SUP HCPCS C1874 1009541-28 - SYSTEM COR STNT 3MM 28MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009542-08 SUP HCPCS C1874 1009542-08 - SYSTEM COR STNT 3.5MM 8MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009542-12 SUP HCPCS C1874 1009542-12 - SYSTEM COR STNT 3.5MM 12MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009542-15 SUP HCPCS C1874 1009542-15 - SYSTEM COR STNT 3.5MM 15MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009542-18 SUP HCPCS C1874 1009542-18 - SYSTEM COR STNT 3.5MM 18MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009542-23 SUP HCPCS C1874 1009542-23 - SYSTEM COR STNT 3.5MM 23MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009542-28 SUP HCPCS C1874 1009542-28 - SYSTEM COR STNT 3.5MM 28MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009543-08 SUP HCPCS C1874 1009543-08 - SYSTEM COR STNT 4MM 8MM 143CM XIENCE V RX DLV SYS RADOPQ TPR BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009543-12 SUP HCPCS C1874 1009543-12 - SYSTEM COR STNT 4MM 12MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009543-15 SUP HCPCS C1874 1009543-15 - SYSTEM COR STNT 4MM 15MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009543-18 SUP HCPCS C1874 1009543-18 - SYSTEM COR STNT 4MM 18MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009543-23 SUP HCPCS C1874 1009543-23 - SYSTEM COR STNT 4MM 23MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009543-28 SUP HCPCS C1874 1009543-28 - SYSTEM COR STNT 4MM 28MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009544-08 SUP HCPCS C1874 1009544-08 - SYSTEM COR STNT 2.25MM 8MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009544-15 SUP HCPCS C1874 1009544-15 - SYSTEM COR STNT 2.25MM 15MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009544-18 SUP HCPCS C1874 1009544-18 - SYSTEM COR STNT 2.25MM 18MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1009544-28 SUP HCPCS C1874 1009544-28 - SYSTEM COR STNT 2.25MM 28MM 143CM XIENCE V RX DLV SYS RADOPQ BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 1010-10-PAD SUP HCPCS A4565 1010-10-PAD - SLING ORTH XL BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $5.25 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1010-10-PAD-30 SUP HCPCS A4565 1010-10-PAD-30 - SLING ORTH MED BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $5.25 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1010-10-PAD-40 SUP HCPCS A4565 1010-10-PAD-40 - SLING ORTH LG BOTH IP/OP $7.07 $5.23 $0.00 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.25 $5.25 $0.00 $0.00 $1.47 $0.00 $0.00 $0.00 $0.00 $3.54 $5.60 $5.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1010480H SUP HCPCS C1769 GUIDEWIRE VASC .014IN 190CM 3CM STRG HTORQ PILT 50 HDRCT BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $101.81 $101.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 10-1073 SUP Custom 27203010 10-1073 - SET BONE BIOP 16CM BONOPTY CORT CANNU STY EJTR PIN DEPTH GA BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1011337-40 SUP HCPCS C1876 1011337-40 - STENT VASCULAR STR LP 5MM 8FR 40MM 132CM SELF EXPANDABLE BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011338-40 SUP HCPCS C1876 1011338-40 - STENT VASCULAR STR LP 6MM 8FR 40MM 132CM SELF EXPANDABLE BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011339-40 SUP HCPCS C1876 1011339-40 - STENT VASCULAR STR LP 7MM 8FR 40MM 132CM SELF EXPANDABLE BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011340-40 SUP HCPCS C1876 1011340-40 - STENT VASCULAR STR LP 8MM 8FR 40MM 132CM SELF EXPANDABLE BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011341-40 SUP HCPCS C1876 1011341-40 - STENT VASCULAR STR LP 9MM 8FR 40MM 132CM SELF EXPANDABLE BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011342-40 SUP HCPCS C1876 1011342-40 - STENT VASCULAR STR LP 10MM 8FR 40MM 132CM SELF EXPANDABLE BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011343-30 SUP HCPCS C1876 1011343-30 - STENT VASCULAR LP TAPER 6-8MM 8FR 30MM 132CM SELF EXPANDABLE BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011343-40 SUP HCPCS C1876 1011343-40 - STENT VASCULAR LP TAPER 6-8MM 8FR 40MM 132CM SELF EXPANDABLE BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011344-40 SUP HCPCS C1876 1011344-40 - STENT VASCULAR LP TAPER 7-10MM 8FR 40MM 132CM SELF BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 1011650-55 SUP HCPCS C1760 1011650-55 - SYSTEM EMBOLIC PROTECTION LP 4.5MM 6-8FR 300CM GWIRE BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 1012402-15A SUP HCPCS C1725 1012402-15A - CATHETER BLNDIL 1.5MM 145CM 15MM MN TREK II OTW 2 LUM ULT BOTH IP/OP $175.00 $129.50 $0.00 $170.00 $115.39 $115.39 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 1012534-100 SUP HCPCS C1876 1012534-100 - STENT BILIARY 6MM 100MM 135CM SELF EXPANDABLE RADIOPQ MARKER BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 1012535-100 SUP HCPCS C1876 1012535-100 - STENT BILIARY 7MM 100MM 135CM SELF EXPANDABLE RADIOPQ MARKER BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 1016-17 SUP HCPCS Q4116 1016-17 - GRAFT SKIN MEDIUM FROZEN CADAVER NONMESHED 232 SQ CM/ Ľ SQ F BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $504.00 $504.00 $0.00 $0.00 $0.00 $233.44 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $662.48 $662.48 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $175.28 $0.00 $0.00 $178.30 $0.00 $0.00 $0.00 $0.00 $0.00 1017-17 SUP HCPCS Q4116 1017-17 - GRAFT SKN 154SQ CM NONMESHED CRPRS BOTH IP/OP $645.00 $477.30 $0.00 $516.00 $290.25 $290.25 $0.00 $0.00 $0.00 $134.43 $478.72 $478.72 $0.00 $0.00 $134.42 $0.00 $381.52 $381.52 $0.00 $322.50 $510.84 $516.00 $0.00 $0.00 $100.94 $0.00 $0.00 $102.68 $0.00 $0.00 $0.00 $0.00 $0.00 101-L05-C SUP HCPCS C1713 101-L05-C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 101-L25 SUP HCPCS C1713 101-L25 - PLATE 18MM TI BONE SPNL BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $181.69 $181.69 $0.00 $0.00 $0.00 $84.15 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $238.82 $238.82 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $63.19 $0.00 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 101-R25 SUP HCPCS C1713 101-R25 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0004 SUP Custom 27803010 1022-0004 - STEM FEM COLLAR SMTH OMFLX 4 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0005 SUP Custom 27803010 1022-0005 - STEM FEM COLLAR SMTH OMFLX 5 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0006 SUP Custom 27803010 1022-0006 - STEM FEM COLLAR SMTH OMFLX 6 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0007 SUP Custom 27803010 1022-0007 - STEM FEM COLLAR SMTH OMFLX 7 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0008 SUP Custom 27803010 1022-0008 - STEM FEM COLLAR SMTH OMFLX 8 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0009 SUP Custom 27803010 1022-0009 - STEM FEM COLLAR SMTH OMFLX 9 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0010 SUP Custom 27803010 1022-0010 - STEM FEM COLLAR SMTH OMFLX 10 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0011 SUP Custom 27803010 1022-0011 - STEM FEM COLLAR SMTH OMFLX 11 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0012 SUP Custom 27803010 1022-0012 - STEM FEM COLLAR SMTH OMFLX 12 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0013 SUP Custom 27803010 1022-0013 - STEM FEM COLLAR SMTH OMFLX 13 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1022-0014 SUP Custom 27803010 1022-0014 - STEM FEM COLLAR SMTH OMFLX 14 BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103.25.180 SUP Custom 27203010 103.25.180 - BIT DRL 2 FLUT 2.5MM 180MM 154MM QC BOTH IP/OP $208.00 $153.92 $0.00 $166.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.38 $154.38 $0.00 $0.00 $43.35 $0.00 $0.00 $0.00 $0.00 $104.00 $164.74 $166.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103-0304 SUP Custom 27203010 103-0304 - DEVICE CADENCE PRCS 1ML SYR INJECTOR INFLAT BOTH IP/OP $237.50 $175.75 $0.00 $199.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $124.75 $197.60 $199.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 103-0601-200 SUP HCPCS C1769 103-0601-200 - GWIRE VASC .01IN 200CM 10CM SILVERSPEED HYDPHI BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $312.23 $312.23 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 103-0602-300 SUP HCPCS C1769 103-0602-300 - GWIRE VASC .014IN 300CM 20CM FLXB EXCH XCLRT HYDPHI BOTH IP/OP $867.50 $641.95 $0.00 $694.00 $471.05 $471.05 $0.00 $0.00 $0.00 $180.81 $643.86 $643.86 $0.00 $0.00 $180.79 $0.00 $513.13 $513.13 $0.00 $433.75 $687.06 $694.00 $0.00 $0.00 $135.76 $0.00 $0.00 $138.11 $0.00 $0.00 $0.00 $0.00 $0.00 103-0603-200 SUP HCPCS C1769 103-0603-200 - GWIRE VASC .016IN 200CM FLXB SILVERSPEED HYDPHI BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $291.86 $291.86 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $0.00 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 103-0605-200 SUP HCPCS C1769 103-0605-200 - GWIRE VASC 175CM 20CM .014IN SFT COIL TIP HYDPHI XPDN BOTH IP/OP $657.50 $486.55 $0.00 $526.00 $357.02 $357.02 $0.00 $0.00 $0.00 $137.04 $488.00 $488.00 $0.00 $0.00 $137.02 $0.00 $388.91 $388.91 $0.00 $328.75 $520.74 $526.00 $0.00 $0.00 $102.90 $0.00 $0.00 $104.67 $0.00 $0.00 $0.00 $0.00 $0.00 103-0608 SUP HCPCS C1769 103-0608 - GWIRE VASC .008IN 200CM 10CM SFT COIL TIP TPR X SPRT MRG BOTH IP/OP "$1,090.00 " $806.60 $0.00 $872.00 $591.87 $591.87 $0.00 $0.00 $0.00 $227.18 $809.00 $809.00 $0.00 $0.00 $227.16 $0.00 $644.74 $644.74 $0.00 $545.00 $863.28 $872.00 $0.00 $0.00 $170.59 $0.00 $0.00 $173.53 $0.00 $0.00 $0.00 $0.00 $0.00 103-L05 SUP HCPCS C1713 103-L05 - PLATE 18MM TI BONE SPNL BOTH IP/OP $403.75 $298.78 $0.00 $323.00 $181.69 $181.69 $0.00 $0.00 $0.00 $84.15 $299.66 $299.66 $0.00 $0.00 $84.14 $0.00 $238.82 $238.82 $0.00 $201.88 $319.77 $323.00 $0.00 $0.00 $63.19 $0.00 $0.00 $64.28 $0.00 $0.00 $0.00 $0.00 $0.00 103-R05 SUP HCPCS C1713 103-R05 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $408.00 $301.92 $0.00 $326.40 $183.60 $183.60 $0.00 $0.00 $0.00 $85.04 $302.82 $302.82 $0.00 $0.00 $85.03 $0.00 $241.33 $241.33 $0.00 $204.00 $323.14 $326.40 $0.00 $0.00 $63.85 $0.00 $0.00 $64.95 $0.00 $0.00 $0.00 $0.00 $0.00 10-403FC SUP Custom 27203010 10-403FC - DEVICE SPECIMEN RETRIEVAL TISSUE REMOVAL MYOSURE BOTH IP/OP "$3,890.00 " "$2,878.60" $0.00 "$3,112.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,887.16" "$2,887.16" $0.00 $0.00 $810.68 $0.00 $0.00 $0.00 $0.00 "$1,945.00" "$3,080.88" "$3,112.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104-4112 SUP HCPCS C2628 104-4112 - CATH BLNOCC 2.8-2.2FR 4MM 150CM 15MM REINF SHFT HYDPHI BOTH IP/OP "$2,675.00 " "$1,979.50" $0.00 "$2,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $557.54 "$1,985.39" "$1,985.39" $0.00 $0.00 $557.47 $0.00 "$1,582.26" "$1,582.26" $0.00 "$1,337.50" "$2,118.60" "$2,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104-4127 SUP HCPCS C2628 104-4127 - CATH BLNOCC 2.8-2.2FR 20MM 150CM 4MM REINF SHFT HYDPHI BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$2,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $534.09 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 "$1,515.72" "$1,515.72" $0.00 "$1,281.25" "$2,029.50" "$2,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104-4132 SUP HCPCS C2628 104-4132 - CATH BLNOCC 2.3FR 4MM 150CM 30MM REINF SHFT HYDPHI BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$2,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $534.09 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 "$1,515.72" "$1,515.72" $0.00 "$1,281.25" "$2,029.50" "$2,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104-4310 SUP HCPCS C1726 104-4310 - HYPERGLIDE 3.0 X 10MM BOTH IP/OP "$2,675.00 " "$1,979.50" $0.00 "$2,140.00" "$1,452.53" "$1,452.53" $0.00 $0.00 $0.00 $557.54 "$1,985.39" "$1,985.39" $0.00 $0.00 $557.47 $0.00 "$1,582.26" "$1,582.26" $0.00 "$1,337.50" "$2,118.60" "$2,140.00" $0.00 $0.00 $418.64 $0.00 $0.00 $425.86 $0.00 $0.00 $0.00 $0.00 $0.00 104-4315 SUP HCPCS C2628 104-4315 - CATHETER BALLOON HYPERGLIDE .010 IN L150 CM L15 MM BOTH IP/OP "$2,675.00 " "$1,979.50" $0.00 "$2,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $557.54 "$1,985.39" "$1,985.39" $0.00 $0.00 $557.47 $0.00 "$1,582.26" "$1,582.26" $0.00 "$1,337.50" "$2,118.60" "$2,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104-4470 SUP HCPCS C1751 104-4470 - CATHETER BLNOCC .01IN 2MM 2.5-2.8FR 4MM 150CM 7MM HYPERFORM BOTH IP/OP "$3,312.50 " "$2,451.25" $0.00 "$2,650.00" "$1,798.69" "$1,798.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,656.25" "$2,623.50" "$2,650.00" $0.00 $0.00 $518.41 $0.00 $0.00 $527.35 $0.00 $0.00 $0.00 $0.00 $0.00 104-44770 SUP HCPCS C2628 "104-44770 - BALLOON, HYPERFORM 4MM X 7MM" BOTH IP/OP "$3,312.50 " "$2,451.25" $0.00 "$2,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $690.41 "$2,458.54" "$2,458.54" $0.00 $0.00 $690.33 $0.00 "$1,959.34" "$1,959.34" $0.00 "$1,656.25" "$2,623.50" "$2,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104-4515 SUP HCPCS C1757 104-4515 - CATHETER BLNOCC .01IN 4MM 2.8-2.2FR 5MM 150CM 15MM BOTH IP/OP "$2,675.00 " "$1,979.50" $0.00 "$2,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $557.54 "$1,985.39" "$1,985.39" $0.00 $0.00 $557.47 $0.00 "$1,582.26" "$1,582.26" $0.00 "$1,337.50" "$2,118.60" "$2,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104-4520 SUP HCPCS C1757 104-4520 - CATHETER BLNOCC 4MM 2.8-2.2FR 5MM 150CM 20MM HYPERGLIDE 1 BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$2,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $534.09 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 "$1,515.72" "$1,515.72" $0.00 "$1,281.25" "$2,029.50" "$2,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104-4770 SUP HCPCS C2628 104-4770 - CATH BLNOCC .01IN 7MM 150CM 7MM GWIRE SL ASYM VASCULATURE BOTH IP/OP "$3,312.50 " "$2,451.25" $0.00 "$2,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $690.41 "$2,458.54" "$2,458.54" $0.00 $0.00 $690.33 $0.00 "$1,959.34" "$1,959.34" $0.00 "$1,656.25" "$2,623.50" "$2,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104834-001 SUP Custom 27203010 104834-001 - CATHETER THROMBECTOMY Y SPIKE 6FR LATEX FREE ANGIOJET POWER BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 104834-002 SUP HCPCS C1757 104834-002 - KIT THRMB 1.5MM 3-4FR 145CM LF 15MM ANGJT ULT ULT SYS OTW BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.72 $63.09 $63.09 $0.00 $0.00 $17.71 $0.00 $50.28 $50.28 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1050-02 SUP Custom 27203010 1050-02 - VLVLTM ANGIOSCOPIC ANTGRD 12.5CM LEMILLS BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 $0.00 $0.00 $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1050-0523 SUP HCPCS C1776 1050-0523 - STEM FEM HDNK OMFT BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-0531 SUP HCPCS C1776 1050-0531 - STEM FEM HDNK OMFT BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-0727 SUP HCPCS C1776 1050-0727 - STEM FEM HDNK OMFT BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-0737 SUP HCPCS C1776 1050-0737 - STEM FEM 37MM OMFT 7 HIP BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-0747 SUP HCPCS C1776 1050-0747 - STEM FEM HDNK OMFT BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-0932 SUP HCPCS C1776 1050-0932 - STEM FEM 32MM OMFT 9 HIP BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-0943 SUP HCPCS C1776 1050-0943 - STEM FEM 43MM OMFT 9 HIP BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-0955 SUP HCPCS C1776 1050-0955 - STEM FEM HDNK OMFT BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-1136 SUP HCPCS C1776 1050-1136 - STEM FEM HDNK OMFT BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-1149 SUP HCPCS C1776 1050-1149 - STEM FEM 49MM OMFT 11 HIP BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 1050-1163 SUP HCPCS C1776 1050-1163 - STEM FEM HDNK OMFT BOTH IP/OP "$5,486.00 " "$4,059.64" $0.00 "$4,388.80" "$2,468.70" "$2,468.70" $0.00 $0.00 $0.00 "$1,143.42" "$4,071.71" "$4,071.71" $0.00 $0.00 "$1,143.28" $0.00 "$2,704.60" "$2,704.60" $0.00 "$2,743.00" "$4,344.91" "$4,388.80" $0.00 $0.00 $858.56 $0.00 $0.00 $873.37 $0.00 $0.00 $0.00 $0.00 $0.00 105039-001 SUP HCPCS C1757 105039-001 - KIT CATH 50CM 6FR AVX ANGJT ULT .035IN CMPT SYS SHFT VSL OTW BOTH IP/OP "$1,850.00 " "$1,369.00" $0.00 "$1,480.00" $0.00 $0.00 $0.00 $0.00 $0.00 $385.59 "$1,373.07" "$1,373.07" $0.00 $0.00 $385.54 $0.00 "$1,094.28" "$1,094.28" $0.00 $925.00 "$1,465.20" "$1,480.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105040-001 SUP HCPCS C1757 105040-001 - SET THRMB 6FR 3MM 120CM LF ANGJT ULT XPEEDIOR 1 LUM OTW CATH BOTH IP/OP "$3,287.50 " "$2,432.75" $0.00 "$2,630.00" $0.00 $0.00 $0.00 $0.00 $0.00 $685.20 "$2,439.98" "$2,439.98" $0.00 $0.00 $685.12 $0.00 "$1,944.56" "$1,944.56" $0.00 "$1,643.75" "$2,603.70" "$2,630.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105042-001 SUP HCPCS C1757 105042-001 - SET THROMBECTOMY XVC BOTH IP/OP "$4,362.50 " "$3,228.25" $0.00 "$3,490.00" $0.00 $0.00 $0.00 $0.00 $0.00 $909.25 "$3,237.85" "$3,237.85" $0.00 $0.00 $909.15 $0.00 "$2,580.42" "$2,580.42" $0.00 "$2,181.25" "$3,455.10" "$3,490.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105-5055 SUP HCPCS C1757 105-5055 - CATHETER INFUS .010IN MICRO 2.7-1.5FR .013IN 170CM 25CM COIL BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105-5056 SUP HCPCS C1757 105-5056 - CATHETER INFS .010IN MIC 2.7-1.5FR .013IN 170CM 25CM MRTHN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105-5091-150 SUP HCPCS C1751 105-5091-150 - CATH INFUS 250 PSI 5FR .014IN 155CM 150CM STR GWIRE NTNL BOTH IP/OP "$1,587.50 " "$1,174.75" $0.00 "$1,334.00" $905.45 $905.45 $0.00 $0.00 $0.00 $330.87 "$1,178.24" "$1,178.24" $0.00 $0.00 $330.84 $0.00 $939.01 $939.01 $0.00 $833.75 "$1,320.66" "$1,334.00" $0.00 $0.00 $260.96 $0.00 $0.00 $265.47 $0.00 $0.00 $0.00 $0.00 $0.00 105-5092-150 SUP HCPCS C1751 105-5092-150 - CATH INFUS 45D MIC 2.4-1.9FR .014IN 150CM STR GWIRE BRAID BOTH IP/OP "$1,587.50 " "$1,174.75" $0.00 "$1,334.00" $905.45 $905.45 $0.00 $0.00 $0.00 $330.87 "$1,178.24" "$1,178.24" $0.00 $0.00 $330.84 $0.00 $939.01 $939.01 $0.00 $833.75 "$1,320.66" "$1,334.00" $0.00 $0.00 $260.96 $0.00 $0.00 $265.47 $0.00 $0.00 $0.00 $0.00 $0.00 105-5094-153 SUP HCPCS C1757 105-5094-153 - MICROCATHETER GD 2.8-2.2FR 155CM NAUTICA 14XL OTW REINF ACPT BOTH IP/OP "$1,310.00 " $969.40 $0.00 "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $273.04 $972.28 $972.28 $0.00 $0.00 $273.00 $0.00 $774.87 $774.87 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1057-0018 SUP HCPCS C1713 1057-0018 - SPACER CMNT 18MM KNEE CMNT BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.75 $33.75 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 1057-0019 SUP HCPCS C1713 1057-0019 - SPACER CMNT 19MM KNEE CMNT BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.75 $33.75 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 1057-0020 SUP HCPCS C1713 1057-0020 - SPACER CMNT 20MM KNEE CMNT BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.75 $33.75 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 1057-0021 SUP HCPCS C1713 1057-0021 - SPACER CMNT 21MM KNEE CMNT BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.75 $33.75 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 1057-0022 SUP HCPCS C1713 1057-0022 - SPACER CMNT 22MM KNEE CMNT BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.75 $33.75 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 105-7100-060 SUP Custom 27803010 105-7100-060 - SYSTEM EMBL 1.5ML 1ML ONX18 SYR DMTH SLFXD BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 105-7100-080 SUP HCPCS C1760 105-7100-080 - PRTCL EMBL NADH LQ ONX34 8% EVOH BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,726.00" "$2,658.38" "$2,658.38" $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,953.75" "$4,678.74" "$4,726.00" $0.00 $0.00 $924.52 $0.00 $0.00 $940.47 $0.00 $0.00 $0.00 $0.00 $0.00 1058-0005 SUP Custom 27803010 1058-0005 - SPACER FEMORAL 5MM OMNIFIT BARIUM HIP PROXIMAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1058-0006 SUP Custom 27803010 1058-0006 - SPACER FEMORAL 6MM OMNIFIT BARIUM HIP PROXIMAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1058-0007 SUP Custom 27803010 1058-0007 - SPACER FEMORAL 7MM OMNIFIT BARIUM HIP PROXIMAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1058-0008 SUP Custom 27803010 1058-0008 - SPACER FEMORAL 8MM OMNIFIT BARIUM HIP PROXIMAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1058-0009 SUP Custom 27803010 1058-0009 - SPACER FEMORAL 9MM OMNIFIT BARIUM HIP PROXIMAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1058-0010 SUP Custom 27803010 1058-0010 - SPACER FEMORAL 10MM OMNIFIT BARIUM HIP PROXIMAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1058-0011 SUP Custom 27803010 1058-0011 - SPACER FEMORAL 11MM OMNIFIT BARIUM HIP PROXIMAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-2310 SUP Custom 27803010 1059-2310 - SPACER FEMORAL SMALL 10MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-2311 SUP Custom 27803010 1059-2311 - SPACER FEMORAL SMALL 11MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-2312 SUP Custom 27803010 1059-2312 - SPACER FEMORAL SMALL 12MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-2313 SUP Custom 27803010 1059-2313 - SPACER FEMORAL SMALL 13MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-2314 SUP Custom 27803010 1059-2314 - SPACER FEMORAL SMALL 14MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-2315 SUP Custom 27803010 1059-2315 - SPACER FEMORAL SMALL 15MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-4512 SUP Custom 27803010 1059-4512 - SPACER FEMORAL MEDIUM 12MM RING STYLE CEMENTED ACCOLADE C BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-4513 SUP Custom 27803010 1059-4513 - SPACER FEMORAL MEDIUM 13MM RING STYLE CEMENTED ACCOLADE C BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-4514 SUP Custom 27803010 1059-4514 - SPACER FEMORAL MEDIUM 14MM RING STYLE CEMENTED ACCOLADE C BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-4515 SUP Custom 27803010 1059-4515 - SPACER FEMORAL MEDIUM 15MM RING STYLE CEMENTED ACCOLADE C BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-4516 SUP Custom 27803010 1059-4516 - SPACER FEMORAL MEDIUM 16MM RING STYLE CEMENTED ACCOLADE C BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-4517 SUP Custom 27803010 1059-4517 - SPACER FEMORAL MEDIUM 17MM RING STYLE CEMENTED ACCOLADE C BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-6713 SUP Custom 27803010 1059-6713 - SPACER FEMORAL LARGE 13MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-6714 SUP Custom 27803010 1059-6714 - SPACER FEMORAL LARGE 14MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-6715 SUP Custom 27803010 1059-6715 - SPACER FEMORAL LARGE 15MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-6716 SUP Custom 27803010 1059-6716 - SPACER FEMORAL LARGE 16MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-6717 SUP Custom 27803010 1059-6717 - SPACER FEMORAL LARGE 17MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1059-6718 SUP Custom 27803010 1059-6718 - SPACER FEMORAL LARGE 18MM RING STYLE CEMENTED ACCOLADE C HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1064-0425 SUP HCPCS C1776 1064-0425 - STEM FEM CMNT OMFT EON HIP BOTH IP/OP "$5,062.00 " "$3,745.88" $0.00 "$4,049.60" "$2,277.90" "$2,277.90" $0.00 $0.00 $0.00 "$1,055.05" "$3,757.02" "$3,757.02" $0.00 $0.00 "$1,054.92" $0.00 "$2,495.57" "$2,495.57" $0.00 "$2,531.00" "$4,009.10" "$4,049.60" $0.00 $0.00 $792.20 $0.00 $0.00 $805.87 $0.00 $0.00 $0.00 $0.00 $0.00 1064-0525 SUP HCPCS C1776 1064-0525 - OMNIFIT CEMENTED STEM (MT) BOTH IP/OP "$5,062.00 " "$3,745.88" $0.00 "$4,049.60" "$2,277.90" "$2,277.90" $0.00 $0.00 $0.00 "$1,055.05" "$3,757.02" "$3,757.02" $0.00 $0.00 "$1,054.92" $0.00 "$2,495.57" "$2,495.57" $0.00 "$2,531.00" "$4,009.10" "$4,049.60" $0.00 $0.00 $792.20 $0.00 $0.00 $805.87 $0.00 $0.00 $0.00 $0.00 $0.00 1064-0625 SUP HCPCS C1776 1064-0625 - STEM FEM CMNT OMFT EON HIP BOTH IP/OP "$3,657.00 " "$2,706.18" $0.00 "$2,925.60" "$1,645.65" "$1,645.65" $0.00 $0.00 $0.00 $762.21 "$2,714.23" "$2,714.23" $0.00 $0.00 $762.12 $0.00 "$1,802.90" "$1,802.90" $0.00 "$1,828.50" "$2,896.34" "$2,925.60" $0.00 $0.00 $572.32 $0.00 $0.00 $582.19 $0.00 $0.00 $0.00 $0.00 $0.00 1064-0730 SUP HCPCS C1776 1064-0730 - STEM FEM CMNT OMFT EON HIP BOTH IP/OP "$5,062.00 " "$3,745.88" $0.00 "$4,049.60" "$2,277.90" "$2,277.90" $0.00 $0.00 $0.00 "$1,055.05" "$3,757.02" "$3,757.02" $0.00 $0.00 "$1,054.92" $0.00 "$2,495.57" "$2,495.57" $0.00 "$2,531.00" "$4,009.10" "$4,049.60" $0.00 $0.00 $792.20 $0.00 $0.00 $805.87 $0.00 $0.00 $0.00 $0.00 $0.00 1064-0830 SUP HCPCS C1776 1064-0830 - STEM FEM CMNT OMFT EON HIP BOTH IP/OP "$5,062.00 " "$3,745.88" $0.00 "$4,049.60" "$2,277.90" "$2,277.90" $0.00 $0.00 $0.00 "$1,055.05" "$3,757.02" "$3,757.02" $0.00 $0.00 "$1,054.92" $0.00 "$2,495.57" "$2,495.57" $0.00 "$2,531.00" "$4,009.10" "$4,049.60" $0.00 $0.00 $792.20 $0.00 $0.00 $805.87 $0.00 $0.00 $0.00 $0.00 $0.00 106552-001 SUP HCPCS C1757 106552-001 - CATH THRMB 90CM 6FR ANGJT DVX ULT .035IN OTW LP TIP RADIOPQ BOTH IP/OP "$3,787.50 " "$2,802.75" $0.00 "$3,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $789.41 "$2,811.08" "$2,811.08" $0.00 $0.00 $789.32 $0.00 "$2,240.31" "$2,240.31" $0.00 "$1,893.75" "$2,999.70" "$3,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106553-001 SUP HCPCS C1757 106553-001 - SET THROMBECTOMY LONG TAPER 4FR 2MM 135CM OTW RAPEX CATHETER BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,654.36" "$2,654.36" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 106608-001 SUP HCPCS C1757 106608-001 - SET CATH 135CM 5FR 3MM SPIROFLEX VG ANGJT .014IN THRMB GWIRE BOTH IP/OP "$5,375.00 " "$3,977.50" $0.00 "$4,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.28" "$3,989.33" "$3,989.33" $0.00 $0.00 "$1,120.15" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0002 SUP HCPCS C1713 1067-0002 - SPACER FEMORAL UNIVERSAL HOLE PLUG CEMENTED OMNIFIT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0008 SUP HCPCS C1713 1067-0008 - SPACER FEMORAL UNIVERSAL 8MM CEMENTED ACCOLADE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0009 SUP HCPCS C1713 1067-0009 - SPACER FEMORAL UNIVERSAL 9MM CEMENTED ACCOLADE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0010 SUP Custom 27803010 1067-0010 - SPACER CMNT UNV 10MM HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0011 SUP HCPCS C1713 1067-0011 - SPACER FEMORAL UNIVERSAL 11MM CEMENTED ACCOLADE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0012 SUP Custom 27803010 1067-0012 - SPACER FEMORAL UNIVERSAL 12MM CEMENTED ACCOLADE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0013 SUP HCPCS C1713 1067-0013 - SPACER FEMORAL UNIVERSAL 13MM CEMENTED ACCOLADE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0014 SUP HCPCS C1713 1067-0014 - SPACER CMNT UNV 14MM ACLD HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0015 SUP HCPCS C1713 1067-0015 - SPACER FEMORAL UNIVERSAL 15MM CEMENTED ACCOLADE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0016 SUP HCPCS C1713 1067-0016 - SPACER CMNT UNV 16MM ACLD HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0017 SUP HCPCS C1713 1067-0017 - SPACER CMNT UNV 17MM ACLD HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0018 SUP HCPCS C1713 1067-0018 - SPACER FEMORAL UNIVERSAL 18MM CEMENTED ACCOLADE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0019 SUP HCPCS C1713 1067-0019 - SPACER CMNT UNV 19MM ACLD HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0020 SUP HCPCS C1713 1067-0020 - SPACER FEMORAL UNIVERSAL 20MM PRIM C-STEM HIP DISTAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0021 SUP HCPCS C1713 1067-0021 - SPACER CMNT UNV 21MM ACLD HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0022 SUP HCPCS C1713 1067-0022 - SPACER CMNT UNV 22MM ACLD HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0023 SUP HCPCS C1713 1067-0023 - SPACER CMNT UNV 23MM ACLD HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0024 SUP HCPCS C1713 1067-0024 - SPACER CMNT UNV 24MM ACLD HIP DIST BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1067-0025 SUP HCPCS C1713 1067-0025 - SPACER FEM UNV 25MM ACLD POLYMETHYLMETHACRYLATE DIST HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 1074225-08 SUP HCPCS C1874 1074225-08 - STENT CORON .014IN TAPER 2.25MM 8MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074225-12 SUP HCPCS C1874 1074225-12 - STENT CORON .014IN TAPER 2.25MM 12MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074225-15 SUP HCPCS C1874 1074225-15 - STENT CORON .014IN TAPER 2.25MM 15MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074225-18 SUP HCPCS C1874 1074225-18 - STENT CORON .014IN TAPER 2.25MM 18MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074225-23 SUP HCPCS C1874 1074225-23 - STENT CORON .014IN TAPER 2.25MM 23MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074225-28 SUP HCPCS C1874 1074225-28 - STENT CORON .014IN TAPER 2.25MM 28MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074250-08 SUP HCPCS C1874 1074250-08 - STENT CORON .014IN TAPER 2.5MM 8MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074250-12 SUP HCPCS C1874 1074250-12 - STENT CORON .014IN TAPER 2.5MM 12MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074250-15 SUP HCPCS C1874 1074250-15 - STENT CORON .014IN TAPER 2.5MM 15MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074250-18 SUP HCPCS C1874 1074250-18 - STENT CORON .014IN TAPER 2.5MM 18MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074250-23 SUP HCPCS C1874 1074250-23 - STENT CORON .014IN TAPER 2.5MM 23MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074250-28 SUP HCPCS C1874 1074250-28 - STENT CORON .014IN TAPER 2.5MM 28MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074250-33 SUP HCPCS C1874 1074250-33 - STENT CORON .014IN TAPER 2.5MM 33MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074250-38 SUP HCPCS C1874 1074250-38 - STENT CORON .014IN TAPER 2.5MM 38MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074275-08 SUP HCPCS C1874 1074275-08 - STENT CORON .014IN TAPER 2.75MM 8MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074275-12 SUP HCPCS C1874 1074275-12 - STENT CORON .014IN TAPER 2.75MM 12MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074275-15 SUP HCPCS C1874 1074275-15 - STENT CORON .014IN TAPER 2.75MM 15MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074275-18 SUP HCPCS C1874 1074275-18 - STENT CORON .014IN TAPER 2.75MM 18MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074275-23 SUP HCPCS C1874 1074275-23 - STENT CORON .014IN TAPER 2.75MM 23MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074275-28 SUP HCPCS C1874 1074275-28 - STENT CORON .014IN TAPER 2.75MM 28MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074275-33 SUP HCPCS C1874 1074275-33 - STENT CORON .014IN TAPER 2.75MM 33MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074275-38 SUP HCPCS C1874 1074275-38 - STENT CORON .014IN TAPER 2.75MM 38MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074300-08 SUP HCPCS C1874 1074300-08 - STENT CORON .014IN TAPER 3MM 8MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074300-12 SUP HCPCS C1874 1074300-12 - STENT CORON .014IN TAPER 3MM 12MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074300-15 SUP HCPCS C1874 1074300-15 - STENT CORON .014IN TAPER 3MM 15MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074300-18 SUP HCPCS C1874 1074300-18 - STENT CORON .014IN TAPER 3MM 18MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074300-23 SUP HCPCS C1874 1074300-23 - STENT CORON .014IN TAPER 3MM 23MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074300-28 SUP HCPCS C1874 1074300-28 - STENT CORON .014IN TAPER 3MM 28MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074300-33 SUP HCPCS C1874 1074300-33 - STENT CORON .014IN TAPER 3MM 33MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074300-38 SUP HCPCS C1874 1074300-38 - STENT CORON .014IN TAPER 3MM 38MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074325-08 SUP HCPCS C1874 1074325-08 - STENT CORON .014IN TAPER 3.25MM .028IN 5FR 8MM 145CM 2 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074325-12 SUP HCPCS C1874 1074325-12 - STENT CORON .014IN TAPER 3.25MM .028IN 5FR 12MM 145CM 2 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074325-18 SUP HCPCS C1874 1074325-18 - STENT CORON .014IN TAPER 3.25MM 18MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074325-23 SUP HCPCS C1874 1074325-23 - STENT CORON .014IN TAPER 3.25MM 23MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074325-28 SUP HCPCS C1874 1074325-28 - STENT CORON .014IN TAPER 3.25MM 28MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074325-33 SUP HCPCS C1874 1074325-33 - STENT CORON .014IN TAPER 3.25MM 33MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074325-38 SUP HCPCS C1874 1074325-38 - STENT CORON .014IN TAPER 3.25MM 38MM 145CM 2 RADIOPQ MARKER BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074350-08 SUP HCPCS C1874 1074350-08 - STENT CORON .014IN TAPER 3.5MM 8MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074350-12 SUP HCPCS C1874 1074350-12 - STENT CORON .014IN TAPER 3.5MM 12MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074350-15 SUP HCPCS C1874 1074350-15 - STENT CORON .014IN TAPER 3.5MM 15MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074350-18 SUP HCPCS C1874 1074350-18 - STENT CORON .014IN TAPER 3.5MM 18MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074350-23 SUP HCPCS C1874 1074350-23 - STENT CORON .014IN TAPER 3.5MM 23MM 145CM 2 RADIOPQ 1 ACCES BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074350-28 SUP HCPCS C1874 1074350-28 - STENT CORON .014IN TAPER 3.5MM 28MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074350-33 SUP HCPCS C1874 1074350-33 - STENT CORON .014IN TAPER 3.5MM 33MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074350-38 SUP HCPCS C1874 1074350-38 - STENT CORON .014IN TAPER 3.5MM 38MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074400-08 SUP HCPCS C1874 1074400-08 - STENT CORON .014IN TAPER 4MM 8MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074400-12 SUP HCPCS C1874 1074400-12 - STENT CORON .014IN TAPER 4MM 12MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074400-15 SUP HCPCS C1874 1074400-15 - STENT CORON .014IN TAPER 4MM 15MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074400-18 SUP HCPCS C1874 1074400-18 - STENT CORON .014IN TAPER 4MM 18MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074400-23 SUP HCPCS C1874 1074400-23 - STENT CORON .014IN TAPER 4MM 23MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074400-28 SUP HCPCS C1874 1074400-28 - STENT CORON .014IN TAPER 4MM 28MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074400-33 SUP HCPCS C1874 1074400-33 - STENT CORON .014IN TAPER 4MM 33MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1074400-38 SUP HCPCS C1874 1074400-38 - STENT CORON .014IN TAPER 4MM 38MM 145CM 2 RADIOPQ MARKER 1 BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 1082-MED SUP HCPCS L3702 1082-MED - SPRT ORTH MED 10IN LS CRST ELAST VLCR CLSR WHT BOTH IP/OP $44.75 $33.12 $0.00 $208.54 $20.14 $20.14 $0.00 $0.00 $198.92 $208.54 $33.21 $33.21 $0.00 $0.00 $9.33 $0.00 $26.47 $26.47 $0.00 $22.38 $35.44 $35.80 $26.85 $26.85 $198.56 $0.00 $0.00 $202.65 $0.00 $0.00 $0.00 $0.00 $0.00 109681-001 SUP HCPCS C1757 109681-001 - SET THROMBECTOMY 6FR 3MM 120CM 15MM OTW CONTRAST INJEC PORT BOTH IP/OP "$4,225.00 " "$3,126.50" $0.00 "$3,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $880.60 "$3,135.80" "$3,135.80" $0.00 $0.00 $880.49 $0.00 "$2,499.09" "$2,499.09" $0.00 "$2,112.50" "$3,346.20" "$3,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10A001 SUP Custom 27804086 10A001 - GRAFT BONE 1-4MM CANCELLOUS CORTICAL 30ML BOTH IP/OP "$1,042.50 " $771.45 $0.00 $834.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $773.74 $773.74 $0.00 $0.00 $217.26 $0.00 $0.00 $0.00 $0.00 $521.25 $825.66 $834.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10A002 SUP Custom 27804086 10A002 - GRAFT BONE 1-4MM CANCELLOUS CORTICAL 15ML BOTH IP/OP $595.00 $440.30 $0.00 $476.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $441.61 $441.61 $0.00 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $297.50 $471.24 $476.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10AC50 SUP Custom 27203010 10AC50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $314.50 $232.73 $0.00 $251.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.42 $233.42 $0.00 $0.00 $65.54 $0.00 $0.00 $0.00 $0.00 $157.25 $249.08 $251.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10AC60 SUP Custom 27203010 10AC60 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $314.50 $232.73 $0.00 $251.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.42 $233.42 $0.00 $0.00 $65.54 $0.00 $0.00 $0.00 $0.00 $157.25 $249.08 $251.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA10 SUP Custom 27203010 10BA10 - PLATE 18MM TI BONE SPNL BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA10D SUP Custom 27203010 10BA10D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA10D-MN SUP Custom 27203010 10BA10D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA10-MN SUP Custom 27203010 10BA10-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA20 SUP Custom 27203010 10BA20 - PLATE 18MM TI BONE SPNL BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA20D SUP Custom 27203010 10BA20D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA20D-MN SUP Custom 27203010 10BA20D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA20-MN SUP Custom 27203010 10BA20-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA30 SUP Custom 27203010 10BA30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA30D SUP Custom 27203010 10BA30D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA30DC SUP Custom 27203010 10BA30DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $329.38 $243.74 $0.00 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.46 $244.46 $0.00 $0.00 $68.64 $0.00 $0.00 $0.00 $0.00 $164.69 $260.87 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA30D-MN SUP Custom 27203010 10BA30D-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA30-MN SUP Custom 27203010 10BA30-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA40 SUP Custom 27203010 10BA40 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA40D SUP Custom 27203010 10BA40D - PLATE 18MM TI BONE SPNL BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA40DC SUP Custom 27203010 10BA40DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $335.75 $248.46 $0.00 $268.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.19 $249.19 $0.00 $0.00 $69.97 $0.00 $0.00 $0.00 $0.00 $167.88 $265.91 $268.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA40D-MN SUP Custom 27203010 10BA40D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA40DX SUP Custom 27203010 10BA40DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $346.38 $256.32 $0.00 $277.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.08 $257.08 $0.00 $0.00 $72.18 $0.00 $0.00 $0.00 $0.00 $173.19 $274.33 $277.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA40-MN SUP Custom 27203010 10BA40-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $314.50 $232.73 $0.00 $251.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.42 $233.42 $0.00 $0.00 $65.54 $0.00 $0.00 $0.00 $0.00 $157.25 $249.08 $251.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA50 SUP Custom 27203010 10BA50 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA50D SUP Custom 27203010 10BA50D - PLATE 18MM TI BONE SPNL BOTH IP/OP $329.38 $243.74 $0.00 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.46 $244.46 $0.00 $0.00 $68.64 $0.00 $0.00 $0.00 $0.00 $164.69 $260.87 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA50DC SUP Custom 27203010 10BA50DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $329.38 $243.74 $0.00 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.46 $244.46 $0.00 $0.00 $68.64 $0.00 $0.00 $0.00 $0.00 $164.69 $260.87 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA50D-MN SUP Custom 27203010 10BA50D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA50DX SUP Custom 27203010 10BA50DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $335.75 $248.46 $0.00 $268.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.19 $249.19 $0.00 $0.00 $69.97 $0.00 $0.00 $0.00 $0.00 $167.88 $265.91 $268.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA50-MN SUP Custom 27203010 10BA50-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA60 SUP Custom 27203010 10BA60 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA60D SUP Custom 27203010 10BA60D - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA60D-MN SUP Custom 27203010 10BA60D-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA60DX SUP Custom 27203010 10BA60DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10BA60-MN SUP Custom 27203010 10BA60-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10CY40 SUP Custom 27203010 10CY40 - PLATE 18MM TI BONE SPNL BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10CY40BR SUP Custom 27203010 10CY40BR - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10CY50 SUP Custom 27203010 10CY50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10CY50BR SUP Custom 27203010 10CY50BR - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10CY50L SUP Custom 27203010 10CY50L - PLATE 18MM TI BONE SPNL BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $0.00 $0.00 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10CY60 SUP Custom 27203010 10CY60 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10CY60BR SUP Custom 27203010 10CY60BR - PLATE 18MM TI BONE SPNL BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10CY65DX SUP Custom 27203010 10CY65DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.35 $252.35 $0.00 $0.00 $70.86 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10DCT SUP Custom 27203010 10DCT - TUBE TRCH 10 13.8MM 8.9MM 79MM STRL LF SHLY CUF DISP INR CNN BOTH IP/OP $93.68 $69.32 $0.00 $76.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.53 $69.53 $0.00 $0.00 $19.52 $0.00 $0.00 $0.00 $0.00 $47.54 $75.30 $76.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10DFEN SUP Custom 27203010 10DFEN - TUBE TRACHEOSTOMY 10 13MM 8.9MM 79MM CUFF DISPOSABLE INNER BOTH IP/OP $91.35 $67.60 $0.00 $73.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.80 $67.80 $0.00 $0.00 $19.04 $0.00 $0.00 $0.00 $0.00 $45.68 $72.35 $73.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10LGT SUP Custom 27203010 10LGT - TUBE TRACHEOSTOMY 10 13.7MM 8.9MM 50MM SMOOTH INNER CANNU BOTH IP/OP $114.73 $84.90 $0.00 $93.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.15 $85.15 $0.00 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $58.22 $92.23 $93.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10LGT SUP Custom 27203010 TUBE 8.9MM UNCUF LRNTMY INR CANNU SHLY TRCH 10 DISP BOTH IP/OP $114.73 $84.90 $0.00 $95.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.15 $85.15 $0.00 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $58.22 $95.02 $93.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH17 SUP Custom 27203010 10MH17 - PLATE 18MM TI BONE SPNL BOTH IP/OP $284.75 $210.72 $0.00 $227.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.34 $211.34 $0.00 $0.00 $59.34 $0.00 $0.00 $0.00 $0.00 $142.38 $225.52 $227.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH17D SUP Custom 27203010 10MH17D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH22 SUP Custom 27203010 10MH22 - PLATE 18MM TI BONE SPNL BOTH IP/OP $278.38 $206.00 $0.00 $222.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.61 $206.61 $0.00 $0.00 $58.01 $0.00 $0.00 $0.00 $0.00 $139.19 $220.48 $222.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH22D SUP Custom 27203010 10MH22D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH30 SUP Custom 27203010 10MH30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $286.88 $212.29 $0.00 $229.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.92 $212.92 $0.00 $0.00 $59.78 $0.00 $0.00 $0.00 $0.00 $143.44 $227.21 $229.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH30DC SUP Custom 27203010 10MH30DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $310.25 $229.59 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.27 $230.27 $0.00 $0.00 $64.66 $0.00 $0.00 $0.00 $0.00 $155.13 $245.72 $248.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH30D-MN SUP Custom 27203010 10MH30D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH30L SUP Custom 27203010 10MH30L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10MH30-MN SUP Custom 27203010 10MH30-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10OV40 SUP Custom 27203010 10OV40 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10OV40L SUP Custom 27203010 10OV40L - PLATE 18MM TI BONE SPNL BOTH IP/OP $342.13 $253.18 $0.00 $273.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.93 $253.93 $0.00 $0.00 $71.30 $0.00 $0.00 $0.00 $0.00 $171.06 $270.97 $273.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10SCT SUP Custom 27203010 10SCT - TUBE TRACHEOSTOMY 10 13.3MM 10MM 105MM CANNU CUFF LOW BOTH IP/OP $71.38 $52.82 $0.00 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.97 $52.97 $0.00 $0.00 $14.87 $0.00 $0.00 $0.00 $0.00 $36.22 $57.38 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10TA23 SUP Custom 27203010 10TA23 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $295.38 $218.58 $0.00 $236.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.23 $219.23 $0.00 $0.00 $61.56 $0.00 $0.00 $0.00 $0.00 $147.69 $233.94 $236.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10X52 SUP Custom 27203010 10X52 - SUTURE NONABSORBABLE 2-0 V-5 30IN 2 ARM BRAID 10 STRAND BOTH IP/OP $137.82 $101.99 $0.00 $111.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.29 $102.29 $0.00 $0.00 $28.72 $0.00 $0.00 $0.00 $0.00 $69.94 $110.78 $111.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 10X72 SUP Custom 27203010 10X72 - SUTURE NONABSORBABLE 2-0 V-7 30IN 2 ARM BRAID 10 STRAND BOTH IP/OP $137.91 $102.05 $0.00 $111.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.36 $102.36 $0.00 $0.00 $28.74 $0.00 $0.00 $0.00 $0.00 $69.99 $110.86 $111.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110-08 SUP HCPCS C1713 110-08 - PLATE 18MM TI BONE SPNL BOTH IP/OP $248.63 $183.99 $0.00 $198.90 $111.88 $111.88 $0.00 $0.00 $0.00 $51.82 $184.53 $184.53 $0.00 $0.00 $51.81 $0.00 $147.06 $147.06 $0.00 $124.31 $196.91 $198.90 $0.00 $0.00 $38.91 $0.00 $0.00 $39.58 $0.00 $0.00 $0.00 $0.00 $0.00 11-0401-CA SUP Custom 27203010 11-0401-CA - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,600.00 " "$2,664.00" $0.00 "$2,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,671.92" "$2,671.92" $0.00 $0.00 $750.24 $0.00 $0.00 $0.00 $0.00 "$1,800.00" "$2,851.20" "$2,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11-0401-CAL SUP Custom 27203010 11-0401-CAL - KIT CRANIOTOMY SEPS SLIDOCAINE EPINEPHRINE STERILE BOTH IP/OP "$4,221.00 " "$3,123.54" $0.00 "$3,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,132.83" "$3,132.83" $0.00 $0.00 $879.66 $0.00 $0.00 $0.00 $0.00 "$2,110.50" "$3,343.03" "$3,376.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 11-0401-CE SUP Custom 27203010 11-0401-CE - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,712.50 " "$2,747.25" $0.00 "$2,970.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,755.42" "$2,755.42" $0.00 $0.00 $773.69 $0.00 $0.00 $0.00 $0.00 "$1,856.25" "$2,940.30" "$2,970.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1104B SUP Custom 27803010 1104B - KIT PRESSURE MONITR TRANSDUCER TIPPED CATHETER DRILL BIT BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 $0.00 $0.00 $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110-4HMC SUP Custom 27203010 110-4HMC - KIT PRSS MNTR MIC 4FR 12FR STRL CMN TRNDCR TIP CATH DRN STY BOTH IP/OP "$5,034.00 " "$3,725.16" $0.00 "$4,027.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,736.23" "$3,736.23" $0.00 $0.00 "$1,049.09" $0.00 $0.00 $0.00 $0.00 "$2,517.00" "$3,986.93" "$4,027.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 110-4L SUP Custom 27803010 110-4L - KIT PRESSURE MONITR 4FR TRANSDUCER TIPPED CATHETER BOLT BOTH IP/OP "$2,007.50 " "$1,485.55" $0.00 "$1,606.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,489.97" "$1,489.97" $0.00 $0.00 $418.36 $0.00 $0.00 $0.00 $0.00 "$1,003.75" "$1,589.94" "$1,606.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1111-1-501 SUP HCPCS C1713 1111-1-501 - TRAY STRL ML NUT GRS-K LCK NAIL SYS BOTH IP/OP $368.50 $272.69 $0.00 $294.80 $165.83 $165.83 $0.00 $0.00 $0.00 $76.80 $273.50 $273.50 $0.00 $0.00 $76.80 $0.00 $217.97 $217.97 $0.00 $184.25 $291.85 $294.80 $0.00 $0.00 $57.67 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 111303-001 SUP Custom 27203010 111303-001 - SET THROMBECTOMY .014IN 3FR 1.5MM 145CM OTW DISTAL SHAFT BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1120-1810 SUP Custom 27203010 TIP PIP 1-20UL TIPONE BVL RK STRL NTR BOTH IP/OP $132.50 $98.05 $0.00 $106.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.25 $104.94 $106.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1156T/75 SUP HCPCS C1900 1156T/75 - LEAD PCNG S LOPRFL 5-5.6FR 7FR 75CM 8MM QUICKFLEX IS-1 BP BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1156T/86 SUP HCPCS C1900 1156T/86 - QUICKFLEX+++PMM#:89271 BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1158T/75 SUP HCPCS C1900 1158T/75 - QUICKFLEX+++PMM#:89272 BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1158T/86 SUP HCPCS C1900 1158T/86 - LEAD PCNG 16MM S 7FR 86CM QUICKFLEX IS 1 BP CNCT STRBL TIP BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1174108D SUP HCPCS C1751 1174108D - CATHETER CV 4FR P PICC SHRLK 3CG LUM MAXIMAL BRR TPS STY PP BOTH IP/OP $516.28 $382.05 $0.00 $417.20 $283.17 $283.17 $0.00 $0.00 $0.00 $107.60 $383.18 $383.18 $0.00 $0.00 $107.59 $0.00 $305.38 $305.38 $0.00 $260.75 $413.03 $417.20 $0.00 $0.00 $81.61 $0.00 $0.00 $83.02 $0.00 $0.00 $0.00 $0.00 $0.00 11-996-16 SUP Custom 27203010 SCISSORS 6.25IN SMTH SRR NTCH SURG TC BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1200-01-1022 SUP HCPCS C1713 "1200-01-1022 - DYNANAIL, 10 MM X 22 CM" BOTH IP/OP "$11,000.00 " "$8,140.00" $0.00 "$8,800.00" "$4,950.00" "$4,950.00" $0.00 $0.00 $0.00 "$2,292.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,292.40" $0.00 "$5,423.00" "$5,423.00" $0.00 "$5,500.00" "$8,712.00" "$8,800.00" $0.00 $0.00 "$1,721.50" $0.00 $0.00 "$1,751.20" $0.00 $0.00 $0.00 $0.00 $0.00 1200-01-1222 SUP HCPCS C1713 "1200-01-1222 - DYNANAIL, 12 MM X 22 CM" BOTH IP/OP "$11,000.00 " "$8,140.00" $0.00 "$8,800.00" "$4,950.00" "$4,950.00" $0.00 $0.00 $0.00 "$2,292.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,292.40" $0.00 "$5,423.00" "$5,423.00" $0.00 "$5,500.00" "$8,712.00" "$8,800.00" $0.00 $0.00 "$1,721.50" $0.00 $0.00 "$1,751.20" $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5020 SUP HCPCS C1713 1200-02-5020 - SCREW BONE 5MM 20MM CORT BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5025 SUP HCPCS C1713 "1200-02-5025 - HEADED CORTICAL SCREW, 5.0 MM X 25 MM" BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5030 SUP HCPCS C1713 1200-02-5030 - SCREW BONE 5MM 30MM HEADED SECURE FIX DYNANAIL HINDFOOT BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5035 SUP HCPCS C1713 "1200-02-5035 - HEADED CORTICAL SCREW, 5.0 MM X 35 MM" BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5040 SUP HCPCS C1713 "1200-02-5040 - HEADED CORTICAL SCREW, 5.0 MM X 40 MM" BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5045 SUP HCPCS C1713 "1200-02-5045 - HEADED CORTICAL SCREW, 5.0 MM X 45 MM" BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5050 SUP HCPCS C1713 "1200-02-5050 - HEADED CORTICAL SCREW, 5.0 MM X 50 MM" BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5055 SUP HCPCS C1713 "1200-02-5055 - HEADED CORTICAL SCREW, 5.0 MM X 55 MM" BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-02-5060 SUP HCPCS C1713 "1200-02-5060 - HEADED CORTICAL SCREW, 5.0 MM X 60 MM" BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5065 SUP HCPCS C1713 1200-03-5065 - SCREW BONE 5MM 65MM CORT BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5070 SUP HCPCS C1713 "1200-03-5070 - HEADLESS PA SCREW, 5.0 MM X 70 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5075 SUP HCPCS C1713 "1200-03-5075 - HEADLESS PA SCREW, 5.0 MM X 75 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5080 SUP HCPCS C1713 "1200-03-5080 - HEADLESS PA SCREW, 5.0 MM X 80 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5085 SUP HCPCS C1713 "1200-03-5085 - HEADLESS PA SCREW, 5.0 MM X 85 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5090 SUP HCPCS C1713 "1200-03-5090 - HEADLESS PA SCREW, 5.0 MM X 90 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5095 SUP HCPCS C1713 "1200-03-5095 - HEADLESS PA SCREW, 5.0 MM X 95 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5100 SUP HCPCS C1713 "1200-03-5100 - HEADLESS PA SCREW, 5.0 MM X 100 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5105 SUP HCPCS C1713 "1200-03-5105 - HEADLESS PA SCREW, 5.0 MM X 105 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 1200-03-5110 SUP HCPCS C1713 "1200-03-5110 - HEADLESS PA SCREW, 5.0 MM X 110 MM" BOTH IP/OP $428.13 $316.82 $0.00 $342.50 $192.66 $192.66 $0.00 $0.00 $0.00 $89.23 $317.75 $317.75 $0.00 $0.00 $89.22 $0.00 $253.24 $253.24 $0.00 $214.06 $339.08 $342.50 $0.00 $0.00 $67.00 $0.00 $0.00 $68.16 $0.00 $0.00 $0.00 $0.00 $0.00 120602F SUP HCPCS C1884 120602F - CATHETER EMBL RND 2FR 4MM 60CM STRL LTX FGRTY BLN REINF SMTH BOTH IP/OP $220.00 $162.80 $0.00 $174.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.24 $0.00 $0.00 $0.00 $34.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120803F SUP HCPCS C1757 120803F - CATHETER EMBL RND 3FR 5MM 80CM .1ML STRL LTX FGRTY BLN REINF BOTH IP/OP $125.00 $92.50 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120804F SUP Custom 27203010 120804F - CATHETER EMBL RND 4FR 9MM 80CM .5ML STRL LTX FGRTY BLN REINF BOTH IP/OP $125.00 $92.50 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120805F SUP HCPCS C1757 120805F - CATHETER EMBL RND 5FR 11MM 80CM STRL LTX FGRTY BLN REINF BOTH IP/OP $125.00 $92.50 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120806F SUP HCPCS C1757 120806F - CATHETER EMBL RND 6FR 13MM 80CM STRL LTX FGRTY BLN REINF BOTH IP/OP $125.00 $92.50 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 120807F SUP HCPCS C1757 120807F - CATHETER EMBL RND 7FR 14MM 80CM 2ML STRL LTX FGRTY BLN REINF BOTH IP/OP $129.95 $96.16 $0.00 $102.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1210-3 SUP HCPCS C1713 "1210-3 - ""MRI PRESSURE PIN SET FOR TRACTION TONGS, 3""""""" BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $613.13 $613.13 $0.00 $0.00 $0.00 $283.98 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $805.92 $805.92 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $213.23 $0.00 $0.00 $216.91 $0.00 $0.00 $0.00 $0.00 $0.00 1210-5-250 SUP HCPCS C1769 1210-5-250 - GWIRE ORTH KWIRE GAMA BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $268.79 $268.79 $0.00 $0.00 $0.00 $103.17 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $292.79 $292.79 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $77.47 $0.00 $0.00 $78.80 $0.00 $0.00 $0.00 $0.00 $0.00 1210-6450 SUP HCPCS C1713 1210-6450 - WIRE FIX 3.2MM 450MM KWIRE SS ORTH GAMA BOTH IP/OP $127.88 $94.63 $0.00 $102.30 $57.54 $57.54 $0.00 $0.00 $0.00 $26.65 $94.91 $94.91 $0.00 $0.00 $26.65 $0.00 $75.64 $75.64 $0.00 $63.94 $101.28 $102.30 $0.00 $0.00 $20.01 $0.00 $0.00 $20.36 $0.00 $0.00 $0.00 $0.00 $0.00 1210-6450S SUP Custom 27203010 1210-6450S - WIRE FX 3.2MM 450MM STRL KRSH BOTH IP/OP $192.50 $142.45 $0.00 $154.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.87 $142.87 $0.00 $0.00 $40.12 $0.00 $0.00 $0.00 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12-1113 SUP HCPCS C1713 12-1113 - SCREW BN STD .5IN 9MM 120MM 21MM AMBI CLS IMHS LG BOTH IP/OP "$1,134.00 " $839.16 $0.00 $907.20 $510.30 $510.30 $0.00 $0.00 $0.00 $236.35 $841.65 $841.65 $0.00 $0.00 $236.33 $0.00 $670.76 $670.76 $0.00 $567.00 $898.13 $907.20 $0.00 $0.00 $177.47 $0.00 $0.00 $180.53 $0.00 $0.00 $0.00 $0.00 $0.00 12-1114 SUP HCPCS C1713 12-1114 - SCREW BN STD .5IN 9MM 125MM 21MM AMBI CLS IMHS LG BOTH IP/OP "$1,134.00 " $839.16 $0.00 $907.20 $510.30 $510.30 $0.00 $0.00 $0.00 $236.35 $841.65 $841.65 $0.00 $0.00 $236.33 $0.00 $670.76 $670.76 $0.00 $567.00 $898.13 $907.20 $0.00 $0.00 $177.47 $0.00 $0.00 $180.53 $0.00 $0.00 $0.00 $0.00 $0.00 1211-3055 SUP Custom 27203010 1211-3055 - DRILL SRG 5.5MM GMA NL DIST BOTH IP/OP $203.50 $150.59 $0.00 $162.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.04 $151.04 $0.00 $0.00 $42.41 $0.00 $0.00 $0.00 $0.00 $101.75 $161.17 $162.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12-1180 SUP HCPCS C1713 12-1180 - SCREW BN 9/16IN 9MM 55MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1182 SUP HCPCS C1713 12-1182 - SCREW BN 9/16IN 9MM 65MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1183 SUP HCPCS C1713 12-1183 - SCREW BN 9/16IN 9MM 70MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1184 SUP HCPCS C1713 12-1184 - SCREW BN 9/16IN 9MM 75MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1185 SUP HCPCS C1713 12-1185 - SCREW BN 9/16IN 9MM 80MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1186 SUP HCPCS C1713 12-1186 - SCREW BN 9/16IN 9MM 85MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1187 SUP HCPCS C1713 12-1187 - SCREW BN 9/16IN 9MM 90MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1188 SUP HCPCS C1713 12-1188 - SCREW BN 9/16IN 9MM 95MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1189 SUP HCPCS C1713 12-1189 - SCREW BN 9/16IN 9MM 100MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 12-1190 SUP HCPCS C1713 12-1190 - SCREW BN 9/16IN 9MM 105MM 21MM AMBI CLS SPLG BOTH IP/OP "$1,210.00 " $895.40 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 1212-5160S SUP Custom 27203010 1212-5160S - DRILL SURG 160MM AO HIP GAMA 5.5MM STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $0.00 $0.00 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1212-5300S SUP Custom 27203010 1212-5300S - DRILL SURG 300MM AO CLBRT GAMA 5.5MM STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $0.00 $0.00 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1213-9091S SUP HCPCS C1713 1213-9091S - GDPN ORTH 400MM 4MM GAMMA3 HIP CANN CANN CTR STRL BOTH IP/OP $192.50 $142.45 $0.00 $154.00 $86.63 $86.63 $0.00 $0.00 $0.00 $40.12 $142.87 $142.87 $0.00 $0.00 $40.12 $0.00 $113.86 $113.86 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $30.13 $0.00 $0.00 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 1214-5055 SUP Custom 27203010 1214-5055 - BIT DRILL 300MM 5.2MM GAMA SS STRL BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $0.00 $0.00 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1214-5160S SUP Custom 27203010 1214-5160S - BIT DRILL 165MM 5.5MM GAMA SS STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $0.00 $0.00 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1214-5-180 SUP Custom 27203010 1214-5-180 - BIT DRILL 220MM 5.5MM GAMA SS STRL BOTH IP/OP $203.50 $150.59 $0.00 $162.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.04 $151.04 $0.00 $0.00 $42.41 $0.00 $0.00 $0.00 $0.00 $101.75 $161.17 $162.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1214-5300S SUP Custom 27203010 1214-5300S - BIT DRILL 300MM 5.5MM GAMA SS STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $0.00 $0.00 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-461 SUP Custom 27803010 1235-2-461 - CUP ACETAB 46MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-462 SUP Custom 27803010 1235-2-462 - CUP ACETAB 46MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-481 SUP Custom 27803010 1235-2-481 - CUP ACETAB 48MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-482 SUP Custom 27803010 1235-2-482 - CUP ACTB 48MM RSTR ADM MBL BR HIP PERI SLF LCK X3 HA HIP LT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-501 SUP Custom 27803010 1235-2-501 - CUP ACETAB 50MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-502 SUP Custom 27803010 1235-2-502 - CUP ACTB 50MM RSTR ADM MBL BR HIP PERI SLF LCK X3 HA HIP LT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-521 SUP Custom 27803010 1235-2-521 - CUP ACETAB 52MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-522 SUP Custom 27803010 1235-2-522 - SHELL ACETAB 52MM ANATOMIC DUAL MOBILITY MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-541 SUP Custom 27803010 1235-2-541 - CUP ACETAB 54MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-542 SUP Custom 27803010 1235-2-542 - CUP ACETAB 54MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-561 SUP Custom 27803010 1235-2-561 - CUP ACETAB 56MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-562 SUP Custom 27803010 1235-2-562 - CUP ACETAB 56MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-581 SUP Custom 27803010 1235-2-581 - CUP ACETAB 58MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-582 SUP Custom 27803010 1235-2-582 - CUP ACETAB 58MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-601 SUP Custom 27803010 1235-2-601 - CUP ACETAB 60MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-602 SUP Custom 27803010 1235-2-602 - CUP ACETAB 60MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-621 SUP Custom 27803010 1235-2-621 - CUP ACETAB 62MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-622 SUP Custom 27803010 1235-2-622 - CUP ACETAB 62MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-641 SUP Custom 27803010 1235-2-641 - CUP ACETAB 64MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-642 SUP Custom 27803010 1235-2-642 - CUP ACETAB 64MM PERIPHERAL SELF LOCK ADM MOBILE BEARING HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-848 SUP Custom 27803010 1235-2-848 - INSERT ACETAB 0D 48MM 28MM 6.9MM ADM MOBILE BEARING HIP BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-850 SUP Custom 27803010 1235-2-850 - INSERT ACTB 0D 50MM 28MM 7.9MM ADM MBL BR HIP RSTR DRTN BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-852 SUP Custom 27803010 1235-2-852 - INSERT ACETAB 0D 52MM 28MM 8.9MM ADM MOBILE BEARING HIP BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-854 SUP Custom 27803010 1235-2-854 - INSERT ACETAB 0D 54MM 28MM 9.9MM ADM MOBILE BEARING HIP BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-856 SUP Custom 27803010 1235-2-856 - INSERT ACETAB 0D 56MM 28MM 10.9MM ADM MOBILE BEARING HIP BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-858 SUP Custom 27803010 1235-2-858 - INSERT ACETAB 0D 58MM 28MM 11.9MM ADM MOBILE BEARING HIP BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-860 SUP Custom 27803010 1235-2-860 - INSERT ACETAB 0D 60MM 28MM 12.9MM ADM MOBILE BEARING HIP BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-862 SUP Custom 27803010 1235-2-862 - INSERT ACETAB 0D 62MM 28MM 13.9MM ADM MOBILE BEARING HIP BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1235-2-864 SUP Custom 27803010 1235-2-864 - INSERT ACETAB 0D 64MM 28MM 14.9MM ADM MOBILE BEARING HIP BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-242 SUP HCPCS C1776 1236-2-242 - INSERT ACTB MBL BR HIP ANTM DL MBL MDLR X3 HIP 22.2 MM FEM BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-244 SUP HCPCS C1776 1236-2-244 - INSERT ACTB 38MM ADM MDM MBL BR HIP RSTR X3 HIP 22.2MM FEM BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-846 SUP HCPCS C1776 1236-2-846 - INSERT ACTB 0D 46MM 28MM 5.9MM ADM MBL BR HIP RSTR X3 BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-848 SUP Custom 27803010 "1236-2-848 - INSERT, X3 FOR ADM/ MDM, RESTORATION" BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 $0.00 $0.00 $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-850 SUP HCPCS C1776 1236-2-850 - INSERT ACTB 0D 50MM 28MM 7.9MM ADM MBL BR HIP RSTR X3 BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-856 SUP HCPCS C1776 1236-2-856 - INSERT ACTB 0D 56MM 28MM 10.9MM ADM MBL BR HIP RSTR X3 BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-858 SUP HCPCS C1776 1236-2-858 - INSERT ACTB 58MM 14.9MM ADM MDM MBL BR HIP RSTR X3 HIP 28MM BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-860 SUP HCPCS C1776 1236-2-860 - INSERT ACTB 0D 60MM 28MM 12.9MM DRTN ADM X3 BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-862 SUP HCPCS C1776 1236-2-862 - INSERT ACTB 62MM 13.9MM ADM MDM MBL BR HIP RSTR X3 HIP 28MM BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 1236-2-864 SUP HCPCS C1776 1236-2-864 - INSERT ACTB 0D 64MM 28MM 14.9MM ADM MBL BR HIP RSTR X3 BOTH IP/OP "$2,015.00 " "$1,491.10" $0.00 "$1,612.00" $906.75 $906.75 $0.00 $0.00 $0.00 $419.98 "$1,495.53" "$1,495.53" $0.00 $0.00 $419.93 $0.00 "$1,191.87" "$1,191.87" $0.00 "$1,007.50" "$1,595.88" "$1,612.00" $0.00 $0.00 $315.35 $0.00 $0.00 $320.79 $0.00 $0.00 $0.00 $0.00 $0.00 125-150P SUP Custom 27203010 125-150P - GUIDEPIN1.25 MM BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $0.00 $0.00 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1258T/75 SUP HCPCS C1900 1258T/75 - LEAD PACING MICRO S CURVE 4.3FR 75CM BIPOL STEERABLE TIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$3,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$2,137.50" "$3,385.80" "$3,420.00" $0.00 $0.00 $669.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1258T/86 SUP HCPCS C1900 1258T/86 - LEAD PCNG MIC S 4.3FR 86CM QUICKFLEX BP STRBL TIP OPTIM INSL BOTH IP/OP "$4,275.00 " "$3,163.50" $0.00 "$3,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $891.02 "$3,172.91" "$3,172.91" $0.00 $0.00 $890.91 $0.00 "$2,107.58" "$2,107.58" $0.00 "$2,137.50" "$3,385.80" "$3,420.00" $0.00 $0.00 $669.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1258T/92 SUP HCPCS C1900 1258T/92 - LEAD PACING MICRO S CURVE 4.3FR 92CM BIPOL STEERABLE TIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$3,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$2,137.50" "$3,385.80" "$3,420.00" $0.00 $0.00 $669.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1259BOP16 SUP Custom 27203010 1259BOP16 - IMMOBILIZER ORTH THK3/8IN 16IN KNEE EZ WRP FOAM BOTH IP/OP $56.13 $41.54 $0.00 $68.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.66 $41.66 $0.00 $0.00 $11.70 $0.00 $0.00 $0.00 $0.00 $42.95 $68.03 $68.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1259BOP18 SUP Custom 27203010 1259BOP18 - IMMOBILIZER ORTH THK3/8IN 18IN KNEE EZ WRP FOAM BOTH IP/OP $63.58 $47.05 $0.00 $71.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.19 $47.19 $0.00 $0.00 $13.25 $0.00 $0.00 $0.00 $0.00 $44.82 $70.99 $71.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12673-03 SUP HCPCS C1760 12673-03 - DEVICE CLOSURE 6FR SUTURE MEDIATE KNOT PUSHER LATEX FREE BOTH IP/OP $65.00 $48.10 $0.00 $520.00 $292.50 $292.50 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $101.73 $0.00 $0.00 $103.48 $0.00 $0.00 $0.00 $0.00 $0.00 12744-16 SUP HCPCS C1875 12744-16 - STENT COR 3MM 16MM JSTNT GFTMSTR OTW BLN EXPANDABLE SS PTFE BOTH IP/OP "$5,987.50 " "$4,430.75" $0.00 "$4,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.80" $0.00 $0.00 $0.00 $0.00 "$2,993.75" "$4,742.10" "$4,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12745-16 SUP HCPCS C1875 12745-16 - STENT COR 3.5MM 16MM JSTNT GFTMSTR OTW BLN EXPANDABLE SS BOTH IP/OP "$5,987.50 " "$4,430.75" $0.00 "$4,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.80" $0.00 $0.00 $0.00 $0.00 "$2,993.75" "$4,742.10" "$4,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12746-19 SUP HCPCS C1874 12746-19 - STENT COR 4MM 19MM JSTNT GFTMSTR OTW BLN EXPANDABLE SS PTFE BOTH IP/OP "$5,987.50 " "$4,430.75" $0.00 "$4,790.00" "$2,694.38" "$2,694.38" $0.00 $0.00 $0.00 "$1,247.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.80" $0.00 "$2,951.84" "$2,951.84" $0.00 "$2,993.75" "$4,742.10" "$4,790.00" $0.00 $0.00 $937.04 $0.00 $0.00 $953.21 $0.00 $0.00 $0.00 $0.00 $0.00 1275108D SUP HCPCS C1751 1275108D - CATHETER CV 5FR LF P PICC SHRLK 3CG 2 LUM MAXIMAL BRR TRY BOTH IP/OP $533.13 $394.52 $0.00 $430.80 $292.41 $292.41 $0.00 $0.00 $0.00 $111.12 $395.69 $395.69 $0.00 $0.00 $111.10 $0.00 $315.34 $315.34 $0.00 $269.25 $426.49 $430.80 $0.00 $0.00 $84.28 $0.00 $0.00 $85.73 $0.00 $0.00 $0.00 $0.00 $0.00 12A0806F SUP HCPCS C1757 12A0806F - CATH EMBL 80CM 6FR FGRTY ART BLN INFLAT PORT TUBE PK STRL BOTH IP/OP $134.50 $99.53 $0.00 $106.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA30 SUP Custom 27203010 12BA30 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $329.38 $243.74 $0.00 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.46 $244.46 $0.00 $0.00 $68.64 $0.00 $0.00 $0.00 $0.00 $164.69 $260.87 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA30D SUP Custom 27203010 12BA30D - PLATE 18MM TI BONE SPNL BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA40 SUP Custom 27203010 12BA40 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $329.38 $243.74 $0.00 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.46 $244.46 $0.00 $0.00 $68.64 $0.00 $0.00 $0.00 $0.00 $164.69 $260.87 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA40D SUP Custom 27203010 12BA40D - PLATE 18MM TI BONE SPNL BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA40DX SUP Custom 27203010 12BA40DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $395.25 $292.49 $0.00 $316.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $293.35 $293.35 $0.00 $0.00 $82.37 $0.00 $0.00 $0.00 $0.00 $197.63 $313.04 $316.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA50 SUP Custom 27203010 12BA50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $329.38 $243.74 $0.00 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.46 $244.46 $0.00 $0.00 $68.64 $0.00 $0.00 $0.00 $0.00 $164.69 $260.87 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA50D SUP Custom 27203010 12BA50D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA60 SUP Custom 27203010 12BA60 - PLATE 18MM TI BONE SPNL BOTH IP/OP $329.38 $243.74 $0.00 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.46 $244.46 $0.00 $0.00 $68.64 $0.00 $0.00 $0.00 $0.00 $164.69 $260.87 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA60D SUP Custom 27203010 12BA60D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $329.38 $243.74 $0.00 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.46 $244.46 $0.00 $0.00 $68.64 $0.00 $0.00 $0.00 $0.00 $164.69 $260.87 $263.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12BA60DX SUP Custom 27203010 12BA60DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $401.63 $297.21 $0.00 $321.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.09 $298.09 $0.00 $0.00 $83.70 $0.00 $0.00 $0.00 $0.00 $200.81 $318.09 $321.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12MH22 SUP Custom 27203010 12MH22 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $295.38 $218.58 $0.00 $236.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.23 $219.23 $0.00 $0.00 $61.56 $0.00 $0.00 $0.00 $0.00 $147.69 $233.94 $236.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12MH30 SUP Custom 27203010 12MH30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $299.63 $221.73 $0.00 $239.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.38 $222.38 $0.00 $0.00 $62.44 $0.00 $0.00 $0.00 $0.00 $149.81 $237.31 $239.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12MH30D SUP Custom 27203010 12MH30D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.35 $252.35 $0.00 $0.00 $70.86 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 12TLW805F35 SUP HCPCS C1757 12TLW805F35 - CATHETER EMBOLECTOMY 5.5FR 11MM 80CM OTW RADIOPACITY LATEX BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13016540P3 SUP HCPCS C1713 13016540P3 - SCREW BN 6.5MM 40MM NS RELINE PA SPNL 2S BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13016545P3 SUP HCPCS C1713 13016545P3 - SCREW BN 6.5MM 45MM NS RELINE PA SPNL 2S BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13016550P3 SUP HCPCS C1713 13016550P3 - SCREW BN 6.5MM 50MM NS RELINE PA SPNL 2S BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 13-066P SUP HCPCS C1713 13-066P - WASHERS 13MM BOTH IP/OP $28.50 $21.09 $0.00 $22.80 $12.83 $12.83 $0.00 $0.00 $0.00 $5.94 $21.15 $21.15 $0.00 $0.00 $5.94 $0.00 $16.86 $16.86 $0.00 $14.25 $22.57 $22.80 $0.00 $0.00 $4.46 $0.00 $0.00 $4.54 $0.00 $0.00 $0.00 $0.00 $0.00 1314-3042 SUP Custom 27203010 1314-3042 - BIT DRL 4.2MM 300MM TRFLT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 131712-01 SUP HCPCS Q4130 131712-01 - DRESSING BIO 12X3IN EZ DERM MSH BOTH IP/OP $459.00 $339.66 $0.00 $340.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $0.00 $0.00 $0.00 $107.87 $170.87 $172.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1320-0125S SUP Custom 27203010 1320-0125S - CLIP SURG CLOSE TUBE STRL GAMMA3 BOTH IP/OP $226.88 $167.89 $0.00 $181.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.39 $168.39 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1320-0190 SUP Custom 27203010 1320-0190 - BIT DRILL 3 LAG STP STRL BOTH IP/OP "$2,695.00 " "$1,994.30" $0.00 "$2,156.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,000.23" "$2,000.23" $0.00 $0.00 $561.64 $0.00 $0.00 $0.00 $0.00 "$1,347.50" "$2,134.44" "$2,156.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1320-3030S SUP Custom 27203010 1320-3030S - BIT DRILL 300MM 3MM GAMA SS STRL BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1320-3042S SUP Custom 27203010 1320-3042S - BIT DRL 4.2MM 300MM STRL QC DISP BOTH IP/OP $281.88 $208.59 $0.00 $225.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $209.21 $209.21 $0.00 $0.00 $58.74 $0.00 $0.00 $0.00 $0.00 $140.94 $223.25 $225.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 132-40-53 SUP HCPCS C1776 132-40-53 - LINER ACETAB LIPPED NOVATION CROWN CUP CONNEXION GXL GRAY 40 BOTH IP/OP "$4,118.13 " "$3,047.42" $0.00 "$3,294.50" "$1,853.16" "$1,853.16" $0.00 $0.00 $0.00 $858.32 "$3,056.47" "$3,056.47" $0.00 $0.00 $858.22 $0.00 "$2,030.24" "$2,030.24" $0.00 "$2,059.06" "$3,261.56" "$3,294.50" $0.00 $0.00 $644.49 $0.00 $0.00 $655.61 $0.00 $0.00 $0.00 $0.00 $0.00 134046J SUP Custom 27203010 134046J - APPLIER IN CLP SM 9IN LF PRM SGCLP SUP INTLK 20 ATO CLIP LGT BOTH IP/OP $20.79 $15.38 $0.00 $16.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.43 $15.43 $0.00 $0.00 $4.33 $0.00 $0.00 $0.00 $0.00 $10.40 $16.47 $16.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1365-24-000 SUP HCPCS C1776 1365-24-000 - HEAD FEM +13MM 12/14 STD 32MM STRL LF ART/EZE SKRT COCR HIP BOTH IP/OP "$2,897.50 " "$2,144.15" $0.00 "$2,318.00" "$1,303.88" "$1,303.88" $0.00 $0.00 $0.00 $603.91 "$2,150.52" "$2,150.52" $0.00 $0.00 $603.84 $0.00 "$1,428.47" "$1,428.47" $0.00 "$1,448.75" "$2,294.82" "$2,318.00" $0.00 $0.00 $453.46 $0.00 $0.00 $461.28 $0.00 $0.00 $0.00 $0.00 $0.00 13-678-31F SUP Custom 27203010 PIPETTE SERO BOROSIL GLS 1ML GRAD NONPLUGGED REG TIP NSTRL BOTH IP/OP $0.35 $0.26 $0.00 $0.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.18 $0.28 $0.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 13-678-31J SUP Custom 27203010 PIPETTE SERO BOROSIL GLS 10ML GRAD NONPLUGGED REG TIP NSTRL BOTH IP/OP $0.55 $0.41 $0.00 $0.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.28 $0.44 $0.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 138-36-53 SUP HCPCS C1776 138-36-53 - LINER ACETAB FACE NOVATION CONNEXION GXL 10D 53MM 36MM HIP BOTH IP/OP "$4,118.13 " "$3,047.42" $0.00 "$3,294.50" "$1,853.16" "$1,853.16" $0.00 $0.00 $0.00 $858.32 "$3,056.47" "$3,056.47" $0.00 $0.00 $858.22 $0.00 "$2,030.24" "$2,030.24" $0.00 "$2,059.06" "$3,261.56" "$3,294.50" $0.00 $0.00 $644.49 $0.00 $0.00 $655.61 $0.00 $0.00 $0.00 $0.00 $0.00 1385108QD SUP HCPCS C1751 1385108QD - CATHETER CV 5FR LF P PICC SHRLK 3CG 3 LUM MAXIMAL BRR TRY BOTH IP/OP $618.00 $457.32 $0.00 $499.40 $338.97 $338.97 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $312.13 $494.41 $499.40 $0.00 $0.00 $97.70 $0.00 $0.00 $99.38 $0.00 $0.00 $0.00 $0.00 $0.00 14 377 259 SUP Custom 27203010 SLIDE DECISLIDE URISYS ACRL INTGR CVRSLP UA 10 TST BOTH IP/OP $247.90 $183.45 $0.00 $198.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.95 $196.34 $198.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14-375-560 SUP Custom 27203010 PIPETTE KOVA DECANTING BLB SED SYS UA BOTH IP/OP $133.18 $98.55 $0.00 $106.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.59 $105.48 $106.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14-521014 SUP Custom 27203010 14-521014 - BIT DRL 4MM 14MM MAXAN SPNE ANT CRV PLT SYS BOTH IP/OP $752.00 $556.48 $0.00 $601.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $558.13 $558.13 $0.00 $0.00 $156.72 $0.00 $0.00 $0.00 $0.00 $376.00 $595.58 $601.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14-521614 SUP HCPCS C1713 14-521614 - SCREW BN 4MM 14MM MAXAN VA SLF DRL SPNE BOTH IP/OP "$1,064.00 " $787.36 $0.00 $851.20 $478.80 $478.80 $0.00 $0.00 $0.00 $221.76 $789.70 $789.70 $0.00 $0.00 $221.74 $0.00 $629.36 $629.36 $0.00 $532.00 $842.69 $851.20 $0.00 $0.00 $166.52 $0.00 $0.00 $169.39 $0.00 $0.00 $0.00 $0.00 $0.00 14-521616 SUP HCPCS C1713 14-521616 - SCREW BONE 4MM 16MM MAXAN SPN VAR ANG BOTH IP/OP "$1,064.00 " $787.36 $0.00 $851.20 $478.80 $478.80 $0.00 $0.00 $0.00 $221.76 $789.70 $789.70 $0.00 $0.00 $221.74 $0.00 $629.36 $629.36 $0.00 $532.00 $842.69 $851.20 $0.00 $0.00 $166.52 $0.00 $0.00 $169.39 $0.00 $0.00 $0.00 $0.00 $0.00 14-524004 SUP HCPCS C1713 14-524004 - ROD SPINAL 40MM PRECUT LINEUM UNIVERSAL BLUE TITANIUM 3.5MM BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 14-524008 SUP HCPCS C1713 14-524008 - ROD SPNL UNV 3.5MM 80MM BLU NS LINEUM PCUT TI OCT BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 14-524018 SUP HCPCS C1713 14-524018 - ROD SPINAL UNIVERSAL 3.5MM 180MM PRECUT LINEUM BLUE TITANIUM BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 14-524024 SUP HCPCS C1713 14-524024 - ROD SPNL UNV 3.5MM 240MM BLU NS LINEUM PCUT TI OCT BOTH IP/OP "$1,050.00 " $777.00 $0.00 $840.00 $472.50 $472.50 $0.00 $0.00 $0.00 $218.85 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $621.08 $621.08 $0.00 $525.00 $831.60 $840.00 $0.00 $0.00 $164.33 $0.00 $0.00 $167.16 $0.00 $0.00 $0.00 $0.00 $0.00 14-524038 SUP HCPCS C1713 14-524038 - SCREW SET PLUG LINEUM HELICAL FLANGE TITANIUM SPN CERV UPPER BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $193.50 $193.50 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 14-524212 SUP HCPCS C1713 14-524212 - SCREW BN 3.5MM 12MM AU NS LINEUM TRNSL HLCL FLNG ST TOP LD BOTH IP/OP "$4,694.00 " "$3,473.56" $0.00 "$3,755.20" "$2,112.30" "$2,112.30" $0.00 $0.00 $0.00 $978.35 "$3,483.89" "$3,483.89" $0.00 $0.00 $978.23 $0.00 "$2,314.14" "$2,314.14" $0.00 "$2,347.00" "$3,717.65" "$3,755.20" $0.00 $0.00 $734.61 $0.00 $0.00 $747.28 $0.00 $0.00 $0.00 $0.00 $0.00 14-524214 SUP HCPCS C1713 14-524214 - SCREW BONE 14MM SELF TAP TOP LOAD FRICTION FIT SMOOTH SHANK BOTH IP/OP "$4,694.00 " "$3,473.56" $0.00 "$3,755.20" "$2,112.30" "$2,112.30" $0.00 $0.00 $0.00 $978.35 "$3,483.89" "$3,483.89" $0.00 $0.00 $978.23 $0.00 "$2,314.14" "$2,314.14" $0.00 "$2,347.00" "$3,717.65" "$3,755.20" $0.00 $0.00 $734.61 $0.00 $0.00 $747.28 $0.00 $0.00 $0.00 $0.00 $0.00 14-524218 SUP HCPCS C1713 14-524218 - SCREW BONE STANDARD 3.5MM 18MM SLFTAP TOP LOADING FRICTION BOTH IP/OP "$4,694.00 " "$3,473.56" $0.00 "$3,755.20" "$2,112.30" "$2,112.30" $0.00 $0.00 $0.00 $978.35 "$3,483.89" "$3,483.89" $0.00 $0.00 $978.23 $0.00 "$2,314.14" "$2,314.14" $0.00 "$2,347.00" "$3,717.65" "$3,755.20" $0.00 $0.00 $734.61 $0.00 $0.00 $747.28 $0.00 $0.00 $0.00 $0.00 $0.00 14-524378 SUP HCPCS C1713 14-524378 - SCREW BONE LINEUM TITANIUM L28 MM OD3.5 MM OCCIPITOCERVICOTH BOTH IP/OP "$4,694.00 " "$3,473.56" $0.00 "$3,755.20" "$2,112.30" "$2,112.30" $0.00 $0.00 $0.00 $978.35 "$3,483.89" "$3,483.89" $0.00 $0.00 $978.23 $0.00 "$2,314.14" "$2,314.14" $0.00 "$2,347.00" "$3,717.65" "$3,755.20" $0.00 $0.00 $734.61 $0.00 $0.00 $747.28 $0.00 $0.00 $0.00 $0.00 $0.00 14-524380 SUP HCPCS C1713 14-524380 - SCREW BONE 3.5MM 30MM SMOOTH SHANK TRANSLATION TECHNOLOGY BOTH IP/OP "$4,694.00 " "$3,473.56" $0.00 "$3,755.20" "$2,112.30" "$2,112.30" $0.00 $0.00 $0.00 $978.35 "$3,483.89" "$3,483.89" $0.00 $0.00 $978.23 $0.00 "$2,314.14" "$2,314.14" $0.00 "$2,347.00" "$3,717.65" "$3,755.20" $0.00 $0.00 $734.61 $0.00 $0.00 $747.28 $0.00 $0.00 $0.00 $0.00 $0.00 14-524512 SUP HCPCS C1713 14-524512 - SCREW BONE 12MM TRANSLATION TECHNOLOGY GREEN HEAD LINEUM BOTH IP/OP "$5,867.50 " "$4,341.95" $0.00 "$4,694.00" "$2,640.38" "$2,640.38" $0.00 $0.00 $0.00 "$1,222.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,222.79" $0.00 "$2,892.68" "$2,892.68" $0.00 "$2,933.75" "$4,647.06" "$4,694.00" $0.00 $0.00 $918.26 $0.00 $0.00 $934.11 $0.00 $0.00 $0.00 $0.00 $0.00 14-524514 SUP HCPCS C1713 14-524514 - SCREW BN 4MM 14MM LINEUM TRNSL TCH GRN HD TI OCT SPNE BOTH IP/OP "$5,867.50 " "$4,341.95" $0.00 "$4,694.00" "$2,640.38" "$2,640.38" $0.00 $0.00 $0.00 "$1,222.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,222.79" $0.00 "$2,892.68" "$2,892.68" $0.00 "$2,933.75" "$4,647.06" "$4,694.00" $0.00 $0.00 $918.26 $0.00 $0.00 $934.11 $0.00 $0.00 $0.00 $0.00 $0.00 14-524530 SUP HCPCS C1713 14-524530 - SCREW BONE 30MM TRANSLATION TECHNOLOGY GREEN HEAD LINEUM BOTH IP/OP "$4,694.00 " "$3,473.56" $0.00 "$3,755.20" "$2,112.30" "$2,112.30" $0.00 $0.00 $0.00 $978.35 "$3,483.89" "$3,483.89" $0.00 $0.00 $978.23 $0.00 "$2,314.14" "$2,314.14" $0.00 "$2,347.00" "$3,717.65" "$3,755.20" $0.00 $0.00 $734.61 $0.00 $0.00 $747.28 $0.00 $0.00 $0.00 $0.00 $0.00 14-524728 SUP HCPCS C1713 14-524728 - SCREW BONE 4.35MM 28MM TRANSLATION TECHNOLOGY BLUE HEAD BOTH IP/OP "$4,694.00 " "$3,473.56" $0.00 "$3,755.20" "$2,112.30" "$2,112.30" $0.00 $0.00 $0.00 $978.35 "$3,483.89" "$3,483.89" $0.00 $0.00 $978.23 $0.00 "$2,314.14" "$2,314.14" $0.00 "$2,347.00" "$3,717.65" "$3,755.20" $0.00 $0.00 $734.61 $0.00 $0.00 $747.28 $0.00 $0.00 $0.00 $0.00 $0.00 14-525000 SUP HCPCS C1713 14-525000 - DRILL SURG SLEEVE LINEUM STANDARD GOLD TITANIUM 3.5MM BOTH IP/OP $892.50 $660.45 $0.00 $714.00 $401.63 $401.63 $0.00 $0.00 $0.00 $186.02 $662.41 $662.41 $0.00 $0.00 $186.00 $0.00 $527.91 $527.91 $0.00 $446.25 $706.86 $714.00 $0.00 $0.00 $139.68 $0.00 $0.00 $142.09 $0.00 $0.00 $0.00 $0.00 $0.00 14-525055 SUP HCPCS C1713 14-525055 - TAP SURGICAL LINEUM STANDARD OD3 MM OCCIPITOCERVICOTHORACIC BOTH IP/OP "$1,050.00 " $777.00 $0.00 $840.00 $472.50 $472.50 $0.00 $0.00 $0.00 $218.85 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $621.08 $621.08 $0.00 $525.00 $831.60 $840.00 $0.00 $0.00 $164.33 $0.00 $0.00 $167.16 $0.00 $0.00 $0.00 $0.00 $0.00 145-351 SUP HCPCS C1768 145-351 - STENT URET 4.8FR 24CM W/O GWIRE PRCFLX HDR+ BOTH IP/OP $315.53 $233.49 $0.00 $252.42 $141.99 $141.99 $0.00 $0.00 $0.00 $65.76 $234.18 $234.18 $0.00 $0.00 $65.76 $0.00 $186.63 $186.63 $0.00 $157.76 $249.90 $252.42 $0.00 $0.00 $49.38 $0.00 $0.00 $50.23 $0.00 $0.00 $0.00 $0.00 $0.00 145-5091-150 SUP HCPCS C1751 145-5091-150 - CATH INFUS 45D .014IN 2.1FR 1.7FR 150CM 3MM GWIRE TIP MCTH BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,418.00" $962.47 $962.47 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $277.40 $0.00 $0.00 $282.18 $0.00 $0.00 $0.00 $0.00 $0.00 145-5092-150 SUP HCPCS C1751 145-5092-150 - CATH INFUS .014IN 45D 250 PSI 2.4-1.9FR .017IN 150CM 3MM BOTH IP/OP "$1,772.50 " "$1,311.65" $0.00 "$1,418.00" $962.47 $962.47 $0.00 $0.00 $0.00 $369.43 "$1,315.55" "$1,315.55" $0.00 $0.00 $369.39 $0.00 "$1,048.43" "$1,048.43" $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $277.40 $0.00 $0.00 $282.18 $0.00 $0.00 $0.00 $0.00 $0.00 14574-01 SUP HCPCS C2617 14574-01 - STENT BIL 5MM 30MM 120CM .018IN SLF XPD FLXB TRNSHEP XPERT BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $898.83 "$3,200.74" "$3,200.74" $0.00 $0.00 $898.73 $0.00 "$2,126.06" "$2,126.06" $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 14575-01 SUP HCPCS C2617 14575-01 - STENT BIL 5MM 40MM 120CM .018IN SLF XPD FLXB TRNSHEP XPERT BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $898.83 "$3,200.74" "$3,200.74" $0.00 $0.00 $898.73 $0.00 "$2,126.06" "$2,126.06" $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 14577-01 SUP HCPCS C2617 14577-01 - STENT BIL 6MM 30MM 120CM .018IN SLF XPD FLXB TRNSHEP XPERT BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $898.83 "$3,200.74" "$3,200.74" $0.00 $0.00 $898.73 $0.00 "$2,126.06" "$2,126.06" $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 14578-01 SUP HCPCS C2617 14578-01 - STENT BIL 6MM 40MM 120CM .018IN SLF XPD FLXB TRNSHEP XPERT BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $898.83 "$3,200.74" "$3,200.74" $0.00 $0.00 $898.73 $0.00 "$2,126.06" "$2,126.06" $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 145FS38 SUP HCPCS C1769 145FS38 - GWIRE ENDSCP .038IN 145CM STR TIP HDRGLD HYDPHI STRL DISP BOTH IP/OP $157.50 $116.55 $0.00 $126.00 $85.52 $85.52 $0.00 $0.00 $0.00 $32.83 $116.90 $116.90 $0.00 $0.00 $32.82 $0.00 $93.16 $93.16 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $24.65 $0.00 $0.00 $25.07 $0.00 $0.00 $0.00 $0.00 $0.00 14679-01 SUP HCPCS C1760 14679-01 - DEVICE CLOSURE 6FR CLIP LATEX FREE STARCLOSE SE NITINOL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 14937-01 SUP HCPCS C1769 14937-01 - GUIDEWIRE VASC .014IN 300CM STRL 11CM ASAHI MRCLBRS 3 RADOPQ BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $32.58 $32.58 $0.00 $0.00 $0.00 $12.51 $44.53 $44.53 $0.00 $0.00 $12.50 $0.00 $35.49 $35.49 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $9.39 $0.00 $0.00 $9.55 $0.00 $0.00 $0.00 $0.00 $0.00 149R SUP Custom 27203010 149R - BRUSH CYTOLOGY RING HANDLE 3MM LATEX FREE PULMONARY STERILE BOTH IP/OP $24.33 $18.00 $0.00 $19.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.05 $18.05 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $12.16 $19.27 $19.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14AC50 SUP Custom 27203010 14AC50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14AC60 SUP Custom 27203010 14AC60 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14AC90 SUP Custom 27203010 14AC90 - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA20 SUP Custom 27203010 14BA20 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA25 SUP Custom 27203010 14BA25 - PLATE 18MM TI BONE SPNL BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA25D SUP Custom 27203010 14BA25D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $371.88 $275.19 $0.00 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.01 $276.01 $0.00 $0.00 $77.50 $0.00 $0.00 $0.00 $0.00 $185.94 $294.53 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA30 SUP Custom 27203010 14BA30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA30D SUP Custom 27203010 14BA30D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $371.88 $275.19 $0.00 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.01 $276.01 $0.00 $0.00 $77.50 $0.00 $0.00 $0.00 $0.00 $185.94 $294.53 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA30DC SUP Custom 27203010 14BA30DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $376.13 $278.34 $0.00 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.16 $279.16 $0.00 $0.00 $78.38 $0.00 $0.00 $0.00 $0.00 $188.06 $297.89 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA40D SUP Custom 27203010 14BA40D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $378.25 $279.91 $0.00 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.74 $280.74 $0.00 $0.00 $78.83 $0.00 $0.00 $0.00 $0.00 $189.13 $299.57 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA40DC SUP Custom 27203010 14BA40DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $376.13 $278.34 $0.00 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.16 $279.16 $0.00 $0.00 $78.38 $0.00 $0.00 $0.00 $0.00 $188.06 $297.89 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA40DX SUP Custom 27203010 14BA40DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA50 SUP Custom 27203010 14BA50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $363.38 $268.90 $0.00 $290.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.70 $269.70 $0.00 $0.00 $75.73 $0.00 $0.00 $0.00 $0.00 $181.69 $287.80 $290.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA50D SUP Custom 27203010 14BA50D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $378.25 $279.91 $0.00 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.74 $280.74 $0.00 $0.00 $78.83 $0.00 $0.00 $0.00 $0.00 $189.13 $299.57 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA50DC SUP Custom 27203010 14BA50DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $378.25 $279.91 $0.00 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.74 $280.74 $0.00 $0.00 $78.83 $0.00 $0.00 $0.00 $0.00 $189.13 $299.57 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA50DX SUP Custom 27203010 14BA50DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA60 SUP Custom 27203010 14BA60 - PLATE 18MM TI BONE SPNL BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA60D SUP Custom 27203010 14BA60D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $371.88 $275.19 $0.00 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.01 $276.01 $0.00 $0.00 $77.50 $0.00 $0.00 $0.00 $0.00 $185.94 $294.53 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA60DC SUP Custom 27203010 14BA60DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $376.13 $278.34 $0.00 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.16 $279.16 $0.00 $0.00 $78.38 $0.00 $0.00 $0.00 $0.00 $188.06 $297.89 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA60DX SUP Custom 27203010 14BA60DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA70DX SUP Custom 27203010 14BA70DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA75 SUP Custom 27203010 14BA75 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA75D SUP Custom 27203010 14BA75D - PLATE 18MM TI BONE SPNL BOTH IP/OP $371.88 $275.19 $0.00 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.01 $276.01 $0.00 $0.00 $77.50 $0.00 $0.00 $0.00 $0.00 $185.94 $294.53 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA80DX SUP Custom 27203010 14BA80DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14BA90 SUP Custom 27203010 14BA90 - PLATE 18MM TI BONE SPNL BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY50 SUP Custom 27203010 14CY50 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY50B SUP Custom 27203010 14CY50B - PLATE 18MM TI BONE SPNL BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY50DCSH SUP Custom 27203010 14CY50DCSH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY60DCSH SUP Custom 27203010 14CY60DCSH - PLATE 18MM TI BONE SPNL BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY65DX SUP Custom 27203010 14CY65DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $378.25 $279.91 $0.00 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.74 $280.74 $0.00 $0.00 $78.83 $0.00 $0.00 $0.00 $0.00 $189.13 $299.57 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY70DCSH SUP Custom 27203010 14CY70DCSH - PLATE 18MM TI BONE SPNL BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY75 SUP Custom 27203010 14CY75 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY76L SUP Custom 27203010 14CY76L - PLATE 18MM TI BONE SPNL BOTH IP/OP $388.88 $287.77 $0.00 $311.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $288.62 $288.62 $0.00 $0.00 $81.04 $0.00 $0.00 $0.00 $0.00 $194.44 $307.99 $311.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14CY90 SUP Custom 27203010 14CY90 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14HM126 SUP Custom 27203010 14HM126 - PLATE 18MM TI BONE SPNL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14HM95 SUP Custom 27203010 14HM95 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14MH30DC SUP Custom 27203010 14MH30DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $376.13 $278.34 $0.00 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.16 $279.16 $0.00 $0.00 $78.38 $0.00 $0.00 $0.00 $0.00 $188.06 $297.89 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14OV55 SUP Custom 27203010 14OV55 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14TA30 SUP Custom 27203010 14TA30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 14TA31 SUP Custom 27203010 14TA31 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1501652SP SUP HCPCS C9250 1501652SP - KIT TISS CLSR FRZN SLNT ARTISS 4ML BOTH IP/OP $741.80 $548.93 $0.00 $593.44 $333.81 $333.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.09 $370.90 $587.51 $593.44 $239.03 $239.03 $116.09 $0.00 $0.00 $118.09 $164.85 $0.00 $0.00 $0.00 $0.00 1501653SP SUP Custom 27203010 1501653SP - KIT TISS CLSR 10ML ARTISS DUO PREFL SYR HMN FBRN SLNT SPRY BOTH IP/OP "$1,494.23 " "$1,105.73" $0.00 "$1,494.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,109.01" "$1,109.01" $0.00 $0.00 $311.40 $0.00 $0.00 $0.00 $0.00 $934.31 "$1,479.95" "$1,494.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 151F7 SUP Custom 27203010 151F7 - CATHETER ART LN STD 7FR 110CM SG 4 LUM S TIP TD FEM VN BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15-28126 SUP Custom 27203010 15-28126 - SPLINT NSL MED FOAM RBR LTWT AL LNNG WTR RS ADH XTRN SKNPRP BOTH IP/OP $20.50 $15.17 $0.00 $16.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.22 $15.22 $0.00 $0.00 $4.27 $0.00 $0.00 $0.00 $0.00 $10.25 $16.24 $16.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1541-01-000 SUP HCPCS C1776 1541-01-000 - STEM FEM 1 STD OFST 105MM LF PROSTALAC CMNT XTN HIP BOTH IP/OP "$13,132.50 " "$9,718.05" $0.00 "$10,506.00" "$5,909.63" "$5,909.63" $0.00 $0.00 $0.00 "$2,737.14" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,736.81" $0.00 "$6,474.32" "$6,474.32" $0.00 "$6,566.25" "$10,400.94" "$10,506.00" $0.00 $0.00 "$2,055.24" $0.00 $0.00 "$2,090.69" $0.00 $0.00 $0.00 $0.00 $0.00 1541-28-000 SUP HCPCS C1776 1541-28-000 - STEM FEM 3 RT HIP BOTH IP/OP "$10,425.00 " "$7,714.50" $0.00 "$8,340.00" "$4,691.25" "$4,691.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,212.50" "$8,256.60" "$8,340.00" $0.00 $0.00 "$1,631.51" $0.00 $0.00 "$1,659.66" $0.00 $0.00 $0.00 $0.00 $0.00 1541-42-320 SUP HCPCS C1776 1541-42-320 - CUP ACETAB 42MM 32MM CEMENTED PROSTALAC ALL POLY HIP BOTH IP/OP "$2,615.00 " "$1,935.10" $0.00 "$2,092.00" "$1,176.75" "$1,176.75" $0.00 $0.00 $0.00 $545.03 "$1,940.85" "$1,940.85" $0.00 $0.00 $544.97 $0.00 "$1,289.20" "$1,289.20" $0.00 "$1,307.50" "$2,071.08" "$2,092.00" $0.00 $0.00 $409.25 $0.00 $0.00 $416.31 $0.00 $0.00 $0.00 $0.00 $0.00 15-711 SUP HCPCS C1894 INTRODUCER SHTH 5FR 2.5CM 10CM MINI GUIDEWIRE DILAT PNCL BOTH IP/OP $24.38 $18.04 $0.00 $19.50 $13.24 $13.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.19 $19.31 $19.50 $0.00 $0.00 $3.81 $0.00 $0.00 $3.88 $0.00 $0.00 $0.00 $0.00 $0.00 1584S SUP Custom 27203010 1584S - WRAP COMPRESSION 5YDX4IN ELAST SELF ADHERENT FULL STRETCH BOTH IP/OP $69.35 $51.32 $0.00 $56.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.47 $51.47 $0.00 $0.00 $14.45 $0.00 $0.00 $0.00 $0.00 $35.20 $55.75 $56.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15AC50 SUP Custom 27203010 15AC50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15AC60 SUP Custom 27203010 15AC60 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15BA40D SUP Custom 27203010 15BA40D - PLATE 18MM TI BONE SPNL BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15BA40DX SUP Custom 27203010 15BA40DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $386.75 $286.20 $0.00 $309.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.05 $287.05 $0.00 $0.00 $80.60 $0.00 $0.00 $0.00 $0.00 $193.38 $306.31 $309.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15BA50 SUP Custom 27203010 15BA50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15BA50D SUP Custom 27203010 15BA50D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15BA60 SUP Custom 27203010 15BA60 - PLATE 18MM TI BONE SPNL BOTH IP/OP $354.88 $262.61 $0.00 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.39 $263.39 $0.00 $0.00 $73.96 $0.00 $0.00 $0.00 $0.00 $177.44 $281.06 $283.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15BA60D SUP Custom 27203010 15BA60D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15CY50 SUP Custom 27203010 15CY50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15CY50L SUP Custom 27203010 15CY50L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15CY60 SUP Custom 27203010 15CY60 - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15CY65DX SUP Custom 27203010 15CY65DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $376.13 $278.34 $0.00 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.16 $279.16 $0.00 $0.00 $78.38 $0.00 $0.00 $0.00 $0.00 $188.06 $297.89 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15MH17 SUP Custom 27203010 15MH17 - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15MH17D SUP Custom 27203010 15MH17D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $327.25 $242.17 $0.00 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.88 $242.88 $0.00 $0.00 $68.20 $0.00 $0.00 $0.00 $0.00 $163.63 $259.18 $261.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15MH22 SUP Custom 27203010 15MH22 - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15MH30D SUP Custom 27203010 15MH30D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $363.38 $268.90 $0.00 $290.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.70 $269.70 $0.00 $0.00 $75.73 $0.00 $0.00 $0.00 $0.00 $181.69 $287.80 $290.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15TA23 SUP Custom 27203010 15TA23 - PLATE 18MM TI BONE SPNL BOTH IP/OP $342.13 $253.18 $0.00 $273.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.93 $253.93 $0.00 $0.00 $71.30 $0.00 $0.00 $0.00 $0.00 $171.06 $270.97 $273.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 15TA23L SUP Custom 27203010 15TA23L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $342.13 $253.18 $0.00 $273.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.93 $253.93 $0.00 $0.00 $71.30 $0.00 $0.00 $0.00 $0.00 $171.06 $270.97 $273.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1601-04132 SUP HCPCS C1776 1601-04132 - STEM FEM 132D 4 31.5MM OFST 5.1MM 110MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-05132 SUP HCPCS C1776 1601-05132 - STEM FEM 132D 5 32.5MM OFST 6MM 115MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-06127 SUP HCPCS C1776 1601-06127 - STEM FEM 127D 6 37.2MM OFST 6.9MM 120MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-06132 SUP HCPCS C1776 1601-06132 - STEM FEM 132D 6 33.6MM OFST 6.9MM 120MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-07127 SUP HCPCS C1776 1601-07127 - STEM FEM 127D 7 41.5MM OFST 7.4MM 130MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-07132 SUP HCPCS C1776 1601-07132 - STEM FEM 132D 7 37.5MM OFST 7.4MM 130MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-08127 SUP HCPCS C1776 1601-08127 - STEM FEM 127D 8 42.4MM OFST 8.1MM 136MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-08132 SUP HCPCS C1776 1601-08132 - STEM FEM 132D 8 38.4MM OFST 8.1MM 136MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-09127 SUP HCPCS C1776 1601-09127 - STEM FEM 127D 9 46.9MM OFST 8.9MM 142MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-09132 SUP HCPCS C1776 1601-09132 - STEM FEM 132D 9 42.6MM OFST 8.9MM 142MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-10127 SUP HCPCS C1776 1601-10127 - STEM FEM 127D 10 48.1MM OFST 9.7MM 148MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-10132 SUP HCPCS C1776 1601-10132 - STEM FEM 132D 10 43.8MM OFST 9.7MM 148MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-11127 SUP HCPCS C1776 1601-11127 - STEM FEM 127D 11 52.6MM OFST 9.7MM 155MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-11132 SUP HCPCS C1776 1601-11132 - STEM FEM 132D 11 47.9MM OFST 9.7MM 155MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-12127 SUP HCPCS C1776 1601-12127 - STEM FEM 127D 12 53.7MM OFST 10.7MM 160MM STRL SCRFT ADV BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 1601-12132 SUP HCPCS C1776 1601-12132 - STEM FEM 132D 12 49MM OFST 10.7MM 160MM STRL SCRFT ADV PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 16-3663 SUP HCPCS C1776 16-3663 - HEAD FEMORAL +3MM 28MM MODULAR TYPE 1 COCR HIP BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 1663H SUP Custom 27203010 1663H - SUTURE NABSB 3-0 PS1 18IN BLK ETH MTPS MFL BOTH IP/OP $29.35 $21.72 $0.00 $23.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.79 $21.79 $0.00 $0.00 $6.12 $0.00 $0.00 $0.00 $0.00 $14.68 $23.25 $23.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1698G SUP Custom 27203010 1698G - SUTURE NABSB 6-0 P-3 18IN BLK ETH MTPS MFL BOTH IP/OP $9.77 $7.23 $0.00 $7.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.25 $7.25 $0.00 $0.00 $2.04 $0.00 $0.00 $0.00 $0.00 $4.96 $7.86 $7.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1699T/40 SUP HCPCS C1898 1699T/40 - OPTISENSE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1699T/58 SUP HCPCS C1898 1699T/58 - OPTISENSE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1699TC/40 SUP HCPCS C1898 1699TC/40 - LEAD PCNG 6.2FR 40CM LF TNDRL FSR STRD ELUT ATR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 1699TC/46 SUP HCPCS C1898 1699TC/46 - OPTISENSE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1699TC/52 SUP HCPCS C1898 1699TC/52 - LEAD PCNG 1.1MM SPC 6.2FR 52CM LF OPTISENSE 1 PASS VDD BP BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 16MH18 SUP Custom 27203010 16MH18 - PLATE 18MM TI BONE SPNL BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16MH18L SUP Custom 27203010 16MH18L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16MH22 SUP Custom 27203010 16MH22 - PLATE 18MM TI BONE SPNL BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16TA11 SUP Custom 27203010 16TA11 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16TA13 SUP Custom 27203010 16TA13 - PLATE 18MM TI BONE SPNL BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16TA15 SUP Custom 27203010 16TA15 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16TA17 SUP Custom 27203010 16TA17 - PLATE 18MM TI BONE SPNL BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16TA23 SUP Custom 27203010 16TA23 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 16TA24 SUP Custom 27203010 16TA24 - PLATE 18MM TI BONE SPNL BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-0000E SUP Custom 27803010 17-0000E - SLEEVE ADAPTER V40 TITANIUM ALUM CERAMIC NONSTRL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-01 SUP HCPCS C1713 17-001-01 - CLIP ANEURYSM 1 8.5MM OPENING STANDARD 7MM STR SUGITA BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-02 SUP HCPCS C1713 17-001-02 - CLIP ANEURYSM 10.5MM STANDARD 10MM STR SUGITA TITANIUM 2 BOTH IP/OP "$1,222.50 " $904.65 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-03 SUP HCPCS C1713 17-001-03 - CLIP ANEURYSM 11MM STANDARD 7MM BAYONET SUGITA TITANIUM 2 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-04 SUP HCPCS C1713 17-001-04 - CLIP ANEURYSM 9.5MM STANDARD 8MM BENT SUGITA TITANIUM 2 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-05 SUP HCPCS C1713 17-001-05 - CLIP ANRSM 8MM SGTA 11MM STD TI 2 SDWRD BNT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-06 SUP HCPCS C1713 17-001-06 - CLIP ANEURYSM 6 10MM OPENING STANDARD 9MM SIDEWARD CVD BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-07 SUP HCPCS C1713 17-001-07 - CLIP ANEURYSM 12MM STANDARD 8.5MM SLIGHTLY CVD BAYONET BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-08 SUP HCPCS C1713 17-001-08 - CLIP ANRSM 9MM SGTA 9.5MM STD TI 2 CVD NONSTRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-09 SUP HCPCS C1713 17-001-09 - CLIP ANEURYSM 10MM STANDARD 9MM SLIGHTLY CVD SUGITA TITANIUM BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-10 SUP HCPCS C1713 17-001-10 - CLIP ANEURYSM 11.5MM STANDARD 12MM STR SUGITA TITANIUM 2 BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $742.50 $974.00 $0.00 $0.00 $146.72 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-11 SUP HCPCS C1713 17-001-11 - CLIP ANRSM 12MM SGTA 13.5MM STD TI 2 SDWRD BNT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-13 SUP HCPCS C1713 17-001-13 - CLIP ANEURYSM 13MM STANDARD 10MM BAYONET SUGITA TITANIUM 2 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-15 SUP HCPCS C1713 17-001-15 - CLIP ANRSM 15MM SGTA 13.5MM STD TI 2 STR NONSTRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-18 SUP HCPCS C1713 17-001-18 - CLIP ANRSM 18MM SGTA 15.5MM STD TI 2 STR BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-20 SUP HCPCS C1713 17-001-20 - CLIP ANEURYSM 8MM STANDARD 5MM L SUGITA TITANIUM 2 NONSTRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-23 SUP HCPCS C1713 17-001-23 - CLIP ANRSM 6MM SGTA 9MM STD TI 2 J BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-26 SUP HCPCS C1713 17-001-26 - CLIP ANEURYSM 26 11MM OPENING STANDARD STR FENST SUGITA BOTH IP/OP "$1,217.50 " $900.95 $0.00 $903.63 $365.63 $365.63 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-27 SUP HCPCS C1713 17-001-27 - CLIP ANRSM 9MM 3.5MM SGTA 13MM STD TI 2 STR FENST BOTH IP/OP "$1,222.50 " $904.65 $0.00 $907.34 $365.63 $365.63 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-29 SUP HCPCS C1713 17-001-29 - CLIP ANEURYSM 29 12MM OPENING STANDARD 5MM 6MM STR FENST BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-30 SUP HCPCS C1713 17-001-30 - CLIP ANEURYSM 14MM STANDARD 5MM 9MM STR FENST SUGITA BOTH IP/OP "$1,182.50 " $875.05 $0.00 $946.00 $532.13 $532.13 $0.00 $0.00 $0.00 $246.46 $877.65 $877.65 $0.00 $0.00 $246.43 $0.00 $699.45 $699.45 $0.00 $591.25 $936.54 $946.00 $0.00 $0.00 $185.06 $0.00 $0.00 $188.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-31 SUP HCPCS C1713 17-001-31 - CLIP ANEURYSM 15.5MM STANDARD 5MM 12MM STR FENST SUGITA BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-35 SUP HCPCS C1713 17-001-35 - CLIP ANRSM 5MM 5MM SGTA 9.5MM STD TI 2 BNT FENST BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-36 SUP HCPCS C1713 17-001-36 - CLIP ANRSM 7.5MM 5MM SGTA 10MM STD TI 2 BNT FENST BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-37 SUP HCPCS C1713 17-001-37 - CLIP ANRSM 10MM 5MM SGTA 11MM STD TI 2 BNT FENST BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-38 SUP HCPCS C1713 17-001-38 - CLIP ANRSM 5MM 3.5MM SGTA 7.5MM STD TI 2 L FENST BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-41 SUP HCPCS C1713 17-001-41 - CLIP ANRSM 5MM 5MM SGTA 8.5MM STD TI 2 L FENST BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-48 SUP HCPCS C1713 17-001-48 - CLIP ANRSM 7.5MM SGTA 45D 11.5MM STD TI 2 ANG BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-50 SUP HCPCS C1713 17-001-50 - CLIP ANEURYSM 13MM STANDARD 14MM CVD SUGITA TITANIUM 2 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-51 SUP HCPCS C1713 17-001-51 - CLIP ANEURYSM 9MM STANDARD 7MM STR TEMPORARY SUGITA TITANIUM BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-52 SUP HCPCS C1713 17-001-52 - CLIP ANEURYSM 10.5MM STANDARD 10MM STR TEMPORARY SUGITA BOTH IP/OP "$1,217.50 " $900.95 $0.00 $903.63 $365.63 $365.63 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-53 SUP HCPCS C1713 17-001-53 - CLIP ANEURYSM 11.5MM STANDARD 7MM BAYONET TEMPORARY SUGITA BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-54 SUP HCPCS C1713 17-001-54 - CLIP ANRSM 8MM SGTA 9.5MM STD TI 2 BNT TEMP BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-55 SUP HCPCS C1713 17-001-55 - CLIP ANRSM 11MM SGTA 11MM STD TI 2 SLT CVD TEMP BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-56 SUP HCPCS C1713 17-001-56 - CLIP ANEURYSM 56 7MM MINI STR 6MM TEMPORARY WIDE OPENING BOTH IP/OP "$1,222.50 " $904.65 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-57 SUP HCPCS C1713 17-001-57 - CLIP ANEURYSM 7MM MINI 5MM BENT TEMPORARY SUGITA TITANIUM 2 BOTH IP/OP "$1,217.50 " $900.95 $0.00 $903.63 $365.63 $365.63 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-58 SUP HCPCS C1713 17-001-58 - CLIP ANEURYSM 7MM MINI 6MM STR TEMPORARY SLIM TIP SUGITA BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-64 SUP HCPCS C1713 17-001-64 - CLIP ANRSM 8MM SGTA 10.5MM STD TI 2 SLT BNT BOTH IP/OP "$1,182.50 " $875.05 $0.00 $946.00 $532.13 $532.13 $0.00 $0.00 $0.00 $246.46 $877.65 $877.65 $0.00 $0.00 $246.43 $0.00 $699.45 $699.45 $0.00 $591.25 $936.54 $946.00 $0.00 $0.00 $185.06 $0.00 $0.00 $188.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-65 SUP HCPCS C1713 17-001-65 - CLIP ANEURYSM 11MM STANDARD 11MM SLIGHTLY CVD SUGITA BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-66 SUP HCPCS C1713 17-001-66 - CLIP ANRSM 11MM SGTA 11MM STD TI 2 CVD NONSTRL BOTH IP/OP "$1,217.50 " $900.95 $0.00 $903.63 $421.88 $421.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-68 SUP HCPCS C1713 17-001-68 - CLIP ANEURYSM 10MM STANDARD 9MM SLIGHTLY CVD SUGITA TITANIUM BOTH IP/OP "$1,217.50 " $900.95 $0.00 $903.63 $421.88 $421.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-69 SUP HCPCS C1713 17-001-69 - CLIP ANRSM 9MM SGTA 69 9.5MM OPN STD TI 2 CVD BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-72 SUP HCPCS C1713 17-001-72 - TII 18.0 STRAIGHT 25MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-76 SUP HCPCS C1713 17-001-76 - CLIP ANRSM 10MM 5MM 8.5MM STD LEFT TI 2 L FENST BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-79 SUP HCPCS C1713 17-001-79 - CLIP ANRSM 10MM 5MM 8.5MM STD RIGHT TI 2 L FENST BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-80 SUP HCPCS C1713 17-001-80 - CLIP ANEURYSM 5.5MM MINI 4MM STR SUGITA TITANIUM 2 NONSTRL BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-81 SUP HCPCS C1713 17-001-81 - CLIP ANEURYSM 7MM MINI 6MM STR SUGITA TITANIUM 2 NONSTRL BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-83 SUP HCPCS C1713 17-001-83 - CLIP ANRSM 5MM SGTA 6.5MM MINI TI 2 CVD NONSTRL BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-84 SUP HCPCS C1713 17-001-84 - CLIP ANEURYSM 7MM MINI 5MM BENT SUGITA TITANIUM 2 NONSTRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-85 SUP HCPCS C1713 17-001-85 - CLIP ANRSM 4MM SGTA 5.5MM MINI TI 2 CVD NONSTRL BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-86 SUP HCPCS C1713 17-001-86 - CLIP ANRSM 7MM SGTA 7.5MM MINI TI 2 SDWRD CVD BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-88 SUP HCPCS C1713 17-001-88 - CLIP ANEURYSM 7.5MM MINI 7MM CVD SUGITA TITANIUM 2 NONSTRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-89 SUP HCPCS C1713 17-001-89 - CLIP ANRSM 5MM SGTA 89 8.5MM OPN MINI TI 2 BYNT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-90 SUP HCPCS C1713 17-001-90 - T2 20.5 STRAIGHT 30MM BOTH IP/OP "$1,740.05 " "$1,287.64" $0.00 "$1,392.04" $783.02 $783.02 $0.00 $0.00 $0.00 $362.67 "$1,291.47" "$1,291.47" $0.00 $0.00 $362.63 $0.00 "$1,029.24" "$1,029.24" $0.00 $870.03 "$1,378.12" "$1,392.04" $0.00 $0.00 $272.32 $0.00 $0.00 $277.02 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-91 SUP HCPCS C1713 17-001-91 - T2 23.5 STRAIGHT 35MM BOTH IP/OP "$1,740.05 " "$1,287.64" $0.00 "$1,392.04" $783.02 $783.02 $0.00 $0.00 $0.00 $362.67 "$1,291.47" "$1,291.47" $0.00 $0.00 $362.63 $0.00 "$1,029.24" "$1,029.24" $0.00 $870.03 "$1,378.12" "$1,392.04" $0.00 $0.00 $272.32 $0.00 $0.00 $277.02 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-92 SUP HCPCS C1713 17-001-92 - CLIP ANRSM 92 26MM OPN LNG STRG 40MM TI 2 BOTH IP/OP "$1,740.05 " "$1,287.64" $0.00 "$1,392.04" $783.02 $783.02 $0.00 $0.00 $0.00 $362.67 "$1,291.47" "$1,291.47" $0.00 $0.00 $362.63 $0.00 "$1,029.24" "$1,029.24" $0.00 $870.03 "$1,378.12" "$1,392.04" $0.00 $0.00 $272.32 $0.00 $0.00 $277.02 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-95 SUP HCPCS C1713 17-001-95 - CLIP ANEURYSM 5.5MM MINI 4MM STR SLIM TIP SUGITA TITANIUM 2 BOTH IP/OP "$1,182.50 " $875.05 $0.00 $946.00 $532.13 $532.13 $0.00 $0.00 $0.00 $246.46 $877.65 $877.65 $0.00 $0.00 $246.43 $0.00 $699.45 $699.45 $0.00 $591.25 $936.54 $946.00 $0.00 $0.00 $185.06 $0.00 $0.00 $188.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-96 SUP HCPCS C1713 17-001-96 - CLIP ANEURYSM 7MM MINI 6MM STR SLIM TIP SUGITA TITANIUM 2 BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-97 SUP HCPCS C1713 17-001-97 - CLIP ANRSM 6.7MM SGTA 7MM MINI TI 2 CVD SLIM TIP BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-001-99 SUP HCPCS C1713 17-001-99 - CLIP ANRSM 5.2MM SGTA 6.5MM MINI TI 2 CVD SLIM TIP BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-002-03 SUP HCPCS C1713 17-002-03 - CLIP ANRSM 10 T2 STD TLL 4MM SGTA CRANK SHFT TI BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-002-05 SUP HCPCS C1713 17-002-05 - CLIP ANRSM 12MM 5MM HEAD STRNG 7.5MM STD TI 2 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-002-15 SUP HCPCS C1713 17-002-15 - CLIP ANEURYSM 8MM MINI 8MM STR SUGITA TITANIUM 2 BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $742.50 $974.00 $0.00 $0.00 $146.72 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-002-16 SUP HCPCS C1713 17-002-16 - CLIP ANRSM 6.5MM SGTA 7MM MINI TI 2 CVD BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 17-002-17 SUP HCPCS C1713 17-002-17 - CLIP ANRSM 5.5MM SGTA 6.5MM MINI TI 2 SLT CVD BOTH IP/OP "$1,222.50 " $904.65 $0.00 $907.34 $365.63 $365.63 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-002-19 SUP Custom 27011340 17-002-19 - CLIP ANRSM 6MM SGTA 8.5MM MINI TI 2 SDWRD BNT BOTH IP/OP "$1,182.50 " $875.05 $0.00 $946.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $877.65 $877.65 $0.00 $0.00 $246.43 $0.00 $0.00 $0.00 $0.00 $591.25 $936.54 $946.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-002-20 SUP HCPCS C1713 17-002-20 - CLIP ANRSM 7MM SGTA 10MM MINI TI 2 BYNT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-002-21 SUP HCPCS C1713 17-002-21 - CLIP ANRSM 5.5MM SGTA 6.5MM MINI TI 2 CVD SLIM TIP BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-25008 SUP HCPCS C1874 170-03-25008 - SYSTEM COR STNT 2.5MM 8MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-25012 SUP HCPCS C1874 170-03-25012 - SYSTEM COR STNT 2.5MM 12MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-25015 SUP HCPCS C1874 170-03-25015 - SYSTEM COR STNT 2.5MM 15MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-25018 SUP HCPCS C1874 170-03-25018 - SYSTEM COR STNT 2.5MM 18MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-25024 SUP HCPCS C1874 170-03-25024 - SYSTEM COR STNT 2.5MM 24MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-25030 SUP HCPCS C1874 170-03-25030 - SYSTEM COR STNT 2.5MM 30MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-27508 SUP HCPCS C1874 170-03-27508 - SYSTEM COR STNT 2.75MM 8MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-27512 SUP HCPCS C1874 170-03-27512 - SYSTEM COR STNT 2.75MM 12MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-27515 SUP HCPCS C1874 170-03-27515 - SYSTEM COR STNT 2.75MM 15MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-27518 SUP HCPCS C1874 170-03-27518 - SYSTEM COR STNT 2.75MM 18MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-27524 SUP HCPCS C1874 170-03-27524 - SYSTEM COR STNT 2.75MM 24MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-27530 SUP HCPCS C1874 170-03-27530 - SYSTEM COR STNT 2.75MM 30MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-30008 SUP HCPCS C1874 170-03-30008 - SYSTEM COR STNT 3MM 8MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-30012 SUP HCPCS C1874 170-03-30012 - SYSTEM COR STNT 3MM 12MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-30015 SUP HCPCS C1874 170-03-30015 - SYSTEM COR STNT 3MM 15MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-30018 SUP HCPCS C1874 170-03-30018 - SYSTEM COR STNT 3MM 18MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-30024 SUP HCPCS C1874 170-03-30024 - SYSTEM COR STNT 3MM 24MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-30030 SUP HCPCS C1874 170-03-30030 - SYSTEM COR STNT 3MM 30MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-35008 SUP HCPCS C1874 170-03-35008 - SYSTEM COR STNT 3.5MM 8MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-35012 SUP HCPCS C1874 170-03-35012 - SYSTEM COR STNT 3.5MM 12MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-35015 SUP HCPCS C1876 170-03-35015 - SYSTEM COR STNT 3.5MM 15MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-35018 SUP HCPCS C1876 170-03-35018 - SYSTEM COR STNT 3.5MM 18MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-35024 SUP HCPCS C1874 170-03-35024 - SYSTEM COR STNT 3.5MM 24MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-35030 SUP HCPCS C1874 170-03-35030 - SYSTEM COR STNT 3.5MM 30MM CBR PZF RX DLV SYS POLYZENE-F BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-40008 SUP HCPCS C1874 170-03-40008 - SYSTEM COR STNT 4MM 8MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-40012 SUP HCPCS C1874 170-03-40012 - SYSTEM COR STNT 4MM 12MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-40015 SUP HCPCS C1874 170-03-40015 - SYSTEM COR STNT 4MM 15MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-40018 SUP HCPCS C1874 170-03-40018 - SYSTEM COR STNT 4MM 18MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-40024 SUP HCPCS C1874 170-03-40024 - SYSTEM COR STNT 4MM 24MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 170-03-40030 SUP HCPCS C1874 170-03-40030 - SYSTEM COR STNT 4MM 30MM CBR PZF RX DLV SYS POLYZENE-F COCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 17-006-03 SUP HCPCS C1713 17-006-03 - CLIP ANRSM 11 T2 STD L 5MM SGTA WDW TI BOTH IP/OP "$1,302.30 " $963.70 $0.00 "$1,041.84" $586.04 $586.04 $0.00 $0.00 $0.00 $271.43 $966.57 $966.57 $0.00 $0.00 $271.40 $0.00 $770.31 $770.31 $0.00 $651.15 "$1,031.42" "$1,041.84" $0.00 $0.00 $203.81 $0.00 $0.00 $207.33 $0.00 $0.00 $0.00 $0.00 $0.00 17-006-36 SUP HCPCS C1713 17-006-36 - CLIP ANRSM 142 006-36 STD BNT 5MM 3MM FENESTRATE TI BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 17-006-39 SUP HCPCS C1713 17-006-39 - CLIP ANRSM STRG 3.5MM 4MM SGTA T2 FENESTRATE TI BOTH IP/OP "$1,217.50 " $900.95 $0.00 $974.00 $547.88 $547.88 $0.00 $0.00 $0.00 $253.76 $903.63 $903.63 $0.00 $0.00 $253.73 $0.00 $720.15 $720.15 $0.00 $608.75 $964.26 $974.00 $0.00 $0.00 $190.54 $0.00 $0.00 $193.83 $0.00 $0.00 $0.00 $0.00 $0.00 17-006-40 SUP HCPCS C1713 17-006-40 - CLIP ANRSM STRG 5MM 4MM SGTA T2 FENESTRATE TI BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 1714G SUP Custom 27203010 1714G - SUTURE NONABSORBABLE 8-0 TG100-8 12IN 2 ARM MONOFILAMENT BOTH IP/OP $33.48 $24.78 $0.00 $27.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.85 $24.85 $0.00 $0.00 $6.98 $0.00 $0.00 $0.00 $0.00 $16.99 $26.91 $27.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1716G SUP Custom 27203010 1716G - SUTURE NONABSORBABLE 8-0 TG175-8 12IN 2 ARM MONOFILAMENT BOTH IP/OP $33.61 $24.87 $0.00 $27.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.95 $24.95 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $17.06 $27.02 $27.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D600 SUP Custom 27203010 17200D600 - PUNCH SURG 6MM CORNEUM 2 PC VAC UL SHRP BLADE SPRG BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D650 SUP Custom 27203010 17200D650 - PUNCH SURG 6.5MM CORNEUM 2 PC VAC UL SHRP BLADE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D700 SUP Custom 27203010 17200D700 - PUNCH SURG 7MM CORNEUM 2 PC VAC UL SHRP BLADE SPRG BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D725 SUP Custom 27203010 17200D725 - PUNCH SURG 7.25MM CORNEUM 2 PC VAC UL SHRP BLADE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D750 SUP Custom 27203010 17200D750 - PUNCH SURG 7.5MM CORNEUM 2 PC VAC UL SHRP BLADE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D775 SUP Custom 27203010 17200D775 - PUNCH SURG 7.75MM CORNEUM 2 PC VAC UL SHRP BLADE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D800 SUP Custom 27203010 17200D800 - PUNCH SURG 8MM CORNEUM 2 PC VAC UL SHRP BLADE SPRG BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D825 SUP Custom 27203010 17200D825 - PUNCH SURG 8.25MM CORNEUM 2 PC VAC UL SHRP BLADE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D850 SUP Custom 27203010 17200D850 - PUNCH SURG 8.5MM CORNEUM 2 PC VAC UL SHRP BLADE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D875 SUP Custom 27203010 17200D875 - PUNCH SURG 8.75MM CORNEUM 2 PC VAC UL SHRP BLADE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D900 SUP Custom 27203010 17200D900 - PUNCH SURG 9MM CORNEUM 2 PC VAC UL SHRP BLADE SPRG BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17200D950 SUP Custom 27203010 17200D950 - PUNCH SURG 9.5MM CORNEUM 2 PC VAC UL SHRP BLADE BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1722G SUP Custom 27203010 1722G - SUTURE MERS 6-0 S-14 18IN WVN TPE BRAID DBL ARM WHT NABSB BOTH IP/OP $33.57 $24.84 $0.00 $26.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.91 $24.91 $0.00 $0.00 $7.00 $0.00 $0.00 $0.00 $0.00 $16.78 $26.59 $26.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-2800E SUP Custom 27803010 17-2800E - HEAD FEMORAL C TAPER ALUM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-2805E SUP Custom 27803010 17-2805E - HEAD FEMORAL +5MM 28MM C TAPER ALUM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-28-3E SUP Custom 27803010 17-28-3E - HEAD FEMORAL +3MM 28MM C TAPER ALUM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 173050G SUP Custom 27203010 173050G - POUCH SPECIMEN RETRIEVAL 10MM 34.5CM MINIMIZE SPILLAGE BOTH IP/OP $147.95 $109.48 $0.00 $120.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.81 $109.81 $0.00 $0.00 $30.83 $0.00 $0.00 $0.00 $0.00 $75.08 $118.93 $120.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-3200E SUP Custom 27803010 17-3200E - HEAD FEM +0MM OFST CTPR 32MM STRL AL CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-3205E SUP Custom 27803010 17-3205E - HEAD FEMORAL +5MM 32MM C TAPER ALUM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-32-3E SUP Custom 27803010 17-32-3E - HEAD FEM -2.5MM CTPR 32MM STRL AL CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1735G SUP Custom 27203010 1735G - SUTURE ABSORBABLE 6-0 TG140-8 18IN 2 ARM MONOFILAMENT BOTH IP/OP $55.72 $41.23 $0.00 $45.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.36 $41.36 $0.00 $0.00 $11.61 $0.00 $0.00 $0.00 $0.00 $28.28 $44.80 $45.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-3600E SUP Custom 27803010 17-3600E - HEAD FEM +0MM OFST CTPR 36MM STRL AL CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-3605E SUP Custom 27803010 17-3605E - HEAD FEMORAL +5MM 36MM C TAPER ALUM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 17-36-5E SUP HCPCS C1713 17-36-5E - HEAD FEMORAL -5MM C-TAPER 36MM OFFST ALUM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 174105-2 SUP Custom 27203010 174105-2 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 175031EN SUP Custom 27203010 175031EN - PLATE 18MM TI BONE SPNL BOTH IP/OP $24.00 $17.76 $0.00 $19.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $17.81 $0.00 $0.00 $5.00 $0.00 $0.00 $0.00 $0.00 $12.00 $19.01 $19.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1754G SUP Custom 27203010 1754G - SUTURE NONABSORBABLE 9-0 TG140-8 6IN 2 ARM MONOFILAMENT BOTH IP/OP $42.02 $31.09 $0.00 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.19 $31.19 $0.00 $0.00 $8.76 $0.00 $0.00 $0.00 $0.00 $21.01 $33.28 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1758SI16 SUP Custom 27203010 1758SI16 - CATHETER URTH 16FR 5CC STRL LF BARD LBRSL IC 2W FL BLN BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1762G SUP Custom 27203010 1762G - SUTURE NONABSORBABLE 4-0 S-24 18IN MONOFILAMENT PLIABILIZE BOTH IP/OP $37.27 $27.58 $0.00 $30.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.66 $27.66 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $18.91 $29.96 $30.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1764G SUP Custom 27203010 1764G - SUTURE NABSB 5-0 S-24 18IN WHT MERS SABRELOC 2 ARM BRD BOTH IP/OP $36.90 $27.31 $0.00 $29.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.39 $27.39 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $18.73 $29.66 $29.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1773.00.126 SUP HCPCS C1713 1773.00.126 - CAGE SPNL 12MM STD PRLL 14X26MM NS LF BENGAL STKBL RDLCNT BOTH IP/OP "$8,790.00 " "$6,504.60" $0.00 "$7,032.00" "$3,955.50" "$3,955.50" $0.00 $0.00 $0.00 "$1,832.06" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,831.84" $0.00 "$4,333.47" "$4,333.47" $0.00 "$4,395.00" "$6,961.68" "$7,032.00" $0.00 $0.00 "$1,375.64" $0.00 $0.00 "$1,399.37" $0.00 $0.00 $0.00 $0.00 $0.00 1779G SUP Custom 27203010 1779G - SUTURE NONABSORBABLE 4-0 S-2 18IN MONOFILAMENT PLIABILIZE BOTH IP/OP $33.94 $25.12 $0.00 $27.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.19 $25.19 $0.00 $0.00 $7.07 $0.00 $0.00 $0.00 $0.00 $16.97 $26.88 $27.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179071P SUP Custom 27203010 179071P - TROCAR LAPSCOP 100MM 5-12MM VPRT+ RPF BLADED CNVTRLS RDLCNT BOTH IP/OP $128.52 $95.10 $0.00 $102.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.26 $101.79 $102.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179075P SUP Custom 27203010 179075P - TROCAR LAPSCOP 5-12MM BLNTPRT PLUS VRSPRT SLV CNVTRLS STAB BOTH IP/OP $35.84 $26.52 $0.00 $28.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.92 $28.39 $28.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179078P SUP Custom 27203010 179078P - TROCAR LAPSCOP PYRAMID 10-15MM 100MM 5MM SAFETY SHIELD SELF BOTH IP/OP $120.15 $88.91 $0.00 $96.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.18 $89.18 $0.00 $0.00 $25.04 $0.00 $0.00 $0.00 $0.00 $60.08 $95.16 $96.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179094F SUP Custom 27203010 179094F - TROCAR LAPSCP 5MM LVN VPRT+ V2 VERSASEAL + FX CNN CNVTRLS BOTH IP/OP $73.95 $54.72 $0.00 $59.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.98 $58.57 $59.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179096PF SUP Custom 27203010 179096PF - TROCAR LAPSCOP 12MM VPRT+ V2 BLADED FIX CANNU STRL DISP BOTH IP/OP $86.28 $63.85 $0.00 $98.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.03 $64.03 $0.00 $0.00 $17.98 $0.00 $0.00 $0.00 $0.00 $61.51 $97.42 $98.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 179097P SUP Custom 27203010 179097P - TROCAR LAPSCOP LONG 5-12MM 150MM SHARP LINEAR BLADE SPRING BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1797.12.765 SUP HCPCS C1713 1797.12.765 - SCREW BONE 7MM 65MM 1 INNIE POLYAX EXPEDIUM TITANIUM SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 1797.71.150 SUP HCPCS C1713 1797.71.150 - ROD SPNL PREBNT 5.5MM 150MM NS XPDM LN TI BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 1797.71.555 SUP HCPCS C1713 1797.71.555 - CONNECTOR ROD 5.5MM TOP NOTCH OUTER TO OUTER SIDE SPN BOTH IP/OP "$2,752.50 " "$2,036.85" $0.00 "$2,202.00" "$1,238.63" "$1,238.63" $0.00 $0.00 $0.00 $573.69 "$2,042.91" "$2,042.91" $0.00 $0.00 $573.62 $0.00 "$1,356.98" "$1,356.98" $0.00 "$1,376.25" "$2,179.98" "$2,202.00" $0.00 $0.00 $430.77 $0.00 $0.00 $438.20 $0.00 $0.00 $0.00 $0.00 $0.00 1797G SUP Custom 27203010 1797G - SUTURE ABSORBABLE 7-0 TG140-8 18IN 2 ARM MONOFILAMENT BOTH IP/OP $67.02 $49.59 $0.00 $54.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.74 $49.74 $0.00 $0.00 $13.97 $0.00 $0.00 $0.00 $0.00 $34.01 $53.88 $54.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 180204HC-S-V SUP HCPCS C1884 COIL MICROPLEX 18SOFT 2MM X 4CM BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 180208HC-S-V SUP HCPCS C1884 COIL MICROPLEX 18SOFT 2MM X 8CM BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 180308HC-S-V SUP HCPCS C1884 COIL MICROPLEX 18SOFT 3MM X 8CM BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 180320-1 SUP HCPCS C1776 180320-1 - COMPONENT PTLR RND 26MM RSRFC KN MCK SYS BOTH IP/OP "$2,192.50 " "$1,622.45" $0.00 "$1,754.00" $986.63 $986.63 $0.00 $0.00 $0.00 $456.97 "$1,627.27" "$1,627.27" $0.00 $0.00 $456.92 $0.00 "$1,296.86" "$1,296.86" $0.00 "$1,096.25" "$1,736.46" "$1,754.00" $0.00 $0.00 $343.13 $0.00 $0.00 $349.05 $0.00 $0.00 $0.00 $0.00 $0.00 180320-2 SUP HCPCS C1776 180320-2 - COMPONENT PTLR RND 29MM RSRFC KN MCK SYS BOTH IP/OP "$2,192.50 " "$1,622.45" $0.00 "$1,754.00" $986.63 $986.63 $0.00 $0.00 $0.00 $456.97 "$1,627.27" "$1,627.27" $0.00 $0.00 $456.92 $0.00 "$1,296.86" "$1,296.86" $0.00 "$1,096.25" "$1,736.46" "$1,754.00" $0.00 $0.00 $343.13 $0.00 $0.00 $349.05 $0.00 $0.00 $0.00 $0.00 $0.00 180320-3 SUP HCPCS C1776 180320-3 - COMPONENT PTLR RND 32MM RSRFC KN MCK SYS BOTH IP/OP "$2,192.50 " "$1,622.45" $0.00 "$1,754.00" $986.63 $986.63 $0.00 $0.00 $0.00 $456.97 "$1,627.27" "$1,627.27" $0.00 $0.00 $456.92 $0.00 "$1,296.86" "$1,296.86" $0.00 "$1,096.25" "$1,736.46" "$1,754.00" $0.00 $0.00 $343.13 $0.00 $0.00 $349.05 $0.00 $0.00 $0.00 $0.00 $0.00 180320-4 SUP HCPCS C1776 180320-4 - DOME PTLR RND 35MM RSRFC KN MCK SYS BOTH IP/OP "$2,192.50 " "$1,622.45" $0.00 "$1,754.00" $986.63 $986.63 $0.00 $0.00 $0.00 $456.97 "$1,627.27" "$1,627.27" $0.00 $0.00 $456.92 $0.00 "$1,296.86" "$1,296.86" $0.00 "$1,096.25" "$1,736.46" "$1,754.00" $0.00 $0.00 $343.13 $0.00 $0.00 $349.05 $0.00 $0.00 $0.00 $0.00 $0.00 180320-6 SUP HCPCS C1776 180320-6 - DOME PTLR RND 41MM RSRFC KN MCK SYS BOTH IP/OP "$2,192.50 " "$1,622.45" $0.00 "$1,754.00" $986.63 $986.63 $0.00 $0.00 $0.00 $456.97 "$1,627.27" "$1,627.27" $0.00 $0.00 $456.92 $0.00 "$1,296.86" "$1,296.86" $0.00 "$1,096.25" "$1,736.46" "$1,754.00" $0.00 $0.00 $343.13 $0.00 $0.00 $349.05 $0.00 $0.00 $0.00 $0.00 $0.00 180406HC-S-V SUP HCPCS C1884 COIL MICROPLEX 18SOFT 4MM X 6CM BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 180512HC-S-V SUP HCPCS C1884 COIL MICROPLEX 18SOFT 5MM X 12CM BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 180520HC-R-V SUP HCPCS C1884 COIL MICROPLEX 18REG 5MM X 20CM BOTH IP/OP "$1,536.65 " "$1,137.12" $0.00 "$1,229.32" $691.49 $691.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.33 "$1,217.03" "$1,229.32" $0.00 $0.00 $240.49 $0.00 $0.00 $244.63 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0004 SUP HCPCS C1713 1806-0004 - SCREW BONE T2 LCK INS BOTH IP/OP $460.63 $340.87 $0.00 $368.50 $207.28 $207.28 $0.00 $0.00 $0.00 $96.01 $341.88 $341.88 $0.00 $0.00 $95.99 $0.00 $272.46 $272.46 $0.00 $230.31 $364.82 $368.50 $0.00 $0.00 $72.09 $0.00 $0.00 $73.33 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0007 SUP HCPCS C1713 1806-0007 - SCREW BONE T2 CNDYLR INS BOTH IP/OP $426.25 $315.43 $0.00 $341.00 $191.81 $191.81 $0.00 $0.00 $0.00 $88.84 $316.36 $316.36 $0.00 $0.00 $88.83 $0.00 $252.13 $252.13 $0.00 $213.13 $337.59 $341.00 $0.00 $0.00 $66.71 $0.00 $0.00 $67.86 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0009 SUP HCPCS C1713 1806-0009 - SCREW BONE T2 FEM/TIB INS CMPR BOTH IP/OP $526.63 $389.71 $0.00 $421.30 $236.98 $236.98 $0.00 $0.00 $0.00 $109.76 $390.86 $390.86 $0.00 $0.00 $109.75 $0.00 $311.50 $311.50 $0.00 $263.31 $417.09 $421.30 $0.00 $0.00 $82.42 $0.00 $0.00 $83.84 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0050S SUP HCPCS C1713 1806-0050S - WIRE FX 3MM 285MM STRL KRSH T2 SS BOTH IP/OP $195.50 $144.67 $0.00 $160.60 $90.34 $90.34 $0.00 $0.00 $0.00 $40.75 $145.10 $145.10 $0.00 $0.00 $40.74 $0.00 $115.64 $115.64 $0.00 $100.38 $158.99 $160.60 $0.00 $0.00 $31.42 $0.00 $0.00 $31.96 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0073S SUP Custom 27203010 1806-0073S - TUBE ORTH TFLN T2 HUM NL SYS BOTH IP/OP $387.75 $286.94 $0.00 $310.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.79 $287.79 $0.00 $0.00 $80.81 $0.00 $0.00 $0.00 $0.00 $193.88 $307.10 $310.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0080S SUP HCPCS C1769 1806-0080S - GWIRE ORTH 800MM 3MM T2 TI BALL TIP FEM NAIL SYS STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $160.52 $160.52 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0083S SUP HCPCS C1769 1806-0083S - GWIRE ORTH 800MM 2.5MM T2 TI BALL TIP FEM NAIL SYS STRL BOTH IP/OP $290.70 $215.12 $0.00 $235.40 $159.78 $159.78 $0.00 $0.00 $0.00 $60.59 $215.76 $215.76 $0.00 $0.00 $60.58 $0.00 $171.95 $171.95 $0.00 $147.13 $233.05 $235.40 $0.00 $0.00 $46.05 $0.00 $0.00 $46.84 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0085S SUP HCPCS C1769 1806-0085S - GWIRE ORTH 1000MM 3MM T2 TI BALL TIP FEM NAIL SYS STRL BOTH IP/OP $312.80 $231.47 $0.00 $269.50 $182.92 $182.92 $0.00 $0.00 $0.00 $65.20 $232.16 $232.16 $0.00 $0.00 $65.19 $0.00 $185.02 $185.02 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $52.72 $0.00 $0.00 $53.63 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0090S SUP HCPCS C1769 1806-0090S - GWIRE ORTH 800MM 3MM T2 TI SMTH TIP FEM NAIL SYS STRL BOTH IP/OP $294.10 $217.63 $0.00 $242.00 $164.26 $164.26 $0.00 $0.00 $0.00 $61.30 $218.28 $218.28 $0.00 $0.00 $61.29 $0.00 $173.96 $173.96 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0093S SUP HCPCS C1769 1806-0093S - GWIRE ORTH 800MM 2.2MM T2 TI SMTH TIP FEM NAIL SYS STRL BOTH IP/OP $283.05 $209.46 $0.00 $235.40 $159.78 $159.78 $0.00 $0.00 $0.00 $58.99 $210.08 $210.08 $0.00 $0.00 $58.99 $0.00 $167.42 $167.42 $0.00 $147.13 $233.05 $235.40 $0.00 $0.00 $46.05 $0.00 $0.00 $46.84 $0.00 $0.00 $0.00 $0.00 $0.00 1806-0225 SUP Custom 27203010 1806-0225 - BIT DRILL 3.5MM T2 LNG DRVR AO BOTH IP/OP $716.38 $530.12 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $531.69 $531.69 $0.00 $0.00 $149.29 $0.00 $0.00 $0.00 $0.00 $358.19 $567.37 $573.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-1005 SUP Custom 27203010 1806-1005 - SET ORTH FEM TRGT DEV BOTH IP/OP "$6,639.88 " "$4,913.51" $0.00 "$5,311.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,383.75" $0.00 $0.00 $0.00 $0.00 "$3,319.94" "$5,258.78" "$5,311.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-1250S SUP HCPCS C1769 1806-1250S - GWIRE ORTH 1250MM 3MM T2 BALL TIP STRL BOTH IP/OP $294.95 $218.26 $0.00 $242.00 $164.26 $164.26 $0.00 $0.00 $0.00 $61.47 $218.91 $218.91 $0.00 $0.00 $61.47 $0.00 $174.46 $174.46 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 180615HC-S-V SUP HCPCS C1884 COIL MICROPLEX 18SOFT 6MM X 15CM BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 1806-2020 SUP Custom 27203010 1806-2020 - DRILL SURG CRWN T2 NONSTRL BOTH IP/OP $598.13 $442.62 $0.00 $478.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.93 $443.93 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $299.06 $473.72 $478.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 180620HC-R-V SUP HCPCS C1884 COIL MICROPLEX 18REG 6MM X 20CM BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3025 SUP Custom 27203010 1806-3025 - BIT DRILL T2 CANN STP BOTH IP/OP "$2,151.88 " "$1,592.39" $0.00 "$1,721.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.12" "$1,597.12" $0.00 $0.00 $448.45 $0.00 $0.00 $0.00 $0.00 "$1,075.94" "$1,704.29" "$1,721.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3030 SUP HCPCS C1713 1806-3030 - WIRE FX 3.2MM 400MM NS KRSH T2 RECON SS NL SYS BOTH IP/OP $282.20 $208.83 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3030S SUP HCPCS C1713 1806-3030S - WIRE 400MM 3.2MM KWIRE T2 SS RECON NL SYS STRL BOTH IP/OP $373.15 $276.13 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $77.77 $276.95 $276.95 $0.00 $0.00 $77.76 $0.00 $220.72 $220.72 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3031S SUP HCPCS C1713 1806-3031S - WIRE FX 3.2MM 400MM STRL KRSH T2 RECON COCR NL SYS BOTH IP/OP $237.15 $175.49 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3500S SUP Custom 27203010 1806-3500S - BIT DRILL 130MM 3.5MM T2 AO STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $0.00 $0.00 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3505 SUP Custom 27203010 1806-3505 - BIT DRILL 130MM 3.5MM T2 TRFLT BOTH IP/OP $226.88 $167.89 $0.00 $181.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.39 $168.39 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3510S SUP Custom 27203010 1806-3510S - BIT DRILL 230MM 3.5MM T2 AO STRL BOTH IP/OP $207.63 $153.65 $0.00 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.10 $154.10 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $103.81 $164.44 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3515 SUP Custom 27203010 1806-3515 - BIT DRILL 230MM 3.5MM T2 TRFLT BOTH IP/OP $259.50 $192.03 $0.00 $192.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.60 $192.60 $0.00 $0.00 $54.08 $0.00 $0.00 $0.00 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3520S SUP Custom 27203010 1806-3520S - BIT DRILL 130MM 3.5MM T2 AO STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $0.00 $0.00 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3525S SUP Custom 27203010 1806-3525S - BIT DRILL 130MM 3.5MM T2 TRFLT STRL BOTH IP/OP $294.25 $217.75 $0.00 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.39 $218.39 $0.00 $0.00 $61.32 $0.00 $0.00 $0.00 $0.00 $147.13 $233.05 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3540S SUP Custom 27203010 1806-3540S - BIT DRILL 230MM 3.5MM T2 AO STRL BOTH IP/OP $294.10 $217.63 $0.00 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.28 $218.28 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $147.13 $233.05 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3545S SUP Custom 27203010 1806-3545S - BIT DRILL 230MM 3.5MM T2 TRFLT STRL BOTH IP/OP $259.50 $192.03 $0.00 $192.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.60 $192.60 $0.00 $0.00 $54.08 $0.00 $0.00 $0.00 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3550S SUP Custom 27203010 1806-3550S - BIT DRL 3.5MM 130MM STRL AO CPLNG BOTH IP/OP $294.10 $217.63 $0.00 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.28 $218.28 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $147.13 $233.05 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-3555S SUP Custom 27203010 1806-3555S - BIT DRILL 130MM 3.5MM T2 AO STRL BOTH IP/OP $259.50 $192.03 $0.00 $192.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.60 $192.60 $0.00 $0.00 $54.08 $0.00 $0.00 $0.00 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4000S SUP Custom 27203010 1806-4000S - BIT DRL 4MM 180MM STRL AO CPLNG BOTH IP/OP $294.10 $217.63 $0.00 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.28 $218.28 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $147.13 $233.05 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4005S SUP Custom 27203010 1806-4005S - BIT DRILL 180MM 4MM T2 TRFLT HUM NL SYS STRL BOTH IP/OP $294.10 $217.63 $0.00 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.28 $218.28 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $147.13 $233.05 $235.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4200S SUP Custom 27203010 1806-4200S - BIT DRILL 260MM 4.2MM T2 AO STRL BOTH IP/OP $200.75 $148.56 $0.00 $160.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.00 $149.00 $0.00 $0.00 $41.84 $0.00 $0.00 $0.00 $0.00 $100.38 $158.99 $160.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4205 SUP Custom 27203010 1806-4205 - BIT DRILL 260MM 4.2MM T2 TRFLT BOTH IP/OP $191.13 $141.44 $0.00 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.85 $141.85 $0.00 $0.00 $39.83 $0.00 $0.00 $0.00 $0.00 $95.56 $151.37 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4210 SUP Custom 27203010 1806-4210 - BIT DRILL 340MM 4.2MM T2 AO BOTH IP/OP $210.38 $155.68 $0.00 $168.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.14 $156.14 $0.00 $0.00 $43.84 $0.00 $0.00 $0.00 $0.00 $105.19 $166.62 $168.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4220 SUP Custom 27203010 1806-4220 - BIT DRILL 180MM 4.2MM T2 AO BOTH IP/OP $210.38 $155.68 $0.00 $168.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.14 $156.14 $0.00 $0.00 $43.84 $0.00 $0.00 $0.00 $0.00 $105.19 $166.62 $168.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4230S SUP Custom 27203010 1806-4230S - BIT DRILL 130MM 4.2MM T2 AO STRL BOTH IP/OP $200.75 $148.56 $0.00 $160.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.00 $149.00 $0.00 $0.00 $41.84 $0.00 $0.00 $0.00 $0.00 $100.38 $158.99 $160.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4235 SUP Custom 27203010 1806-4235 - BIT DRILL 130MM 4.2MM T2 TRFLT BOTH IP/OP $191.13 $141.44 $0.00 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.85 $141.85 $0.00 $0.00 $39.83 $0.00 $0.00 $0.00 $0.00 $95.56 $151.37 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4240 SUP Custom 27203010 1806-4240 - BIT DRILL 30MM 4.2MM T2 AO BOTH IP/OP $210.38 $155.68 $0.00 $168.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.14 $156.14 $0.00 $0.00 $43.84 $0.00 $0.00 $0.00 $0.00 $105.19 $166.62 $168.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4245 SUP Custom 27203010 1806-4245 - BIT DRILL 230MM 4.2MM T2 TRFLT BOTH IP/OP $191.13 $141.44 $0.00 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.85 $141.85 $0.00 $0.00 $39.83 $0.00 $0.00 $0.00 $0.00 $95.56 $151.37 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4250S SUP Custom 27203010 1806-4250S - BIT DRL 4.2MM 260MM STRL AO BOTH IP/OP $283.90 $210.09 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.71 $210.71 $0.00 $0.00 $59.16 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4255S SUP Custom 27203010 1806-4255S - BIT DRILL 260MM 4.2MM T2 TRFLT STRL BOTH IP/OP $294.95 $218.26 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.91 $218.91 $0.00 $0.00 $61.47 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4260S SUP Custom 27203010 1806-4260S - BIT DRL 4.2MM 340MM STRL AO CPLNG BOTH IP/OP $283.90 $210.09 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.71 $210.71 $0.00 $0.00 $59.16 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4265S SUP Custom 27203010 1806-4265S - BIT DRILL 340MM 4.2MM T2 TRFLT STRL BOTH IP/OP $187.00 $138.38 $0.00 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.79 $138.79 $0.00 $0.00 $38.97 $0.00 $0.00 $0.00 $0.00 $95.56 $151.37 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4270S SUP Custom 27203010 1806-4270S - DRILL SRG 4.2MM 180MM STRL AO CPLNG BOTH IP/OP $304.30 $225.18 $0.00 $258.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.85 $225.85 $0.00 $0.00 $63.42 $0.00 $0.00 $0.00 $0.00 $161.56 $255.92 $258.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4275S SUP Custom 27203010 1806-4275S - BIT DRILL 180MM 4.2MM T2 TRFLT STRL BOTH IP/OP $204.85 $151.59 $0.00 $168.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.04 $152.04 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $105.19 $166.62 $168.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4280S SUP Custom 27203010 1806-4280S - BIT DRL 4.2MM 130MM STRL AO CPLNG BOTH IP/OP $283.90 $210.09 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.71 $210.71 $0.00 $0.00 $59.16 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4285S SUP Custom 27203010 1806-4285S - BIT DRILL 130MM 4.2MM T2 TRFLT STRL BOTH IP/OP $288.15 $213.23 $0.00 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.86 $213.86 $0.00 $0.00 $60.05 $0.00 $0.00 $0.00 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4290S SUP Custom 27203010 1806-4290S - BIT DRILL 230MM 4.2MM T2 AO STRL BOTH IP/OP $305.15 $225.81 $0.00 $260.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $226.48 $226.48 $0.00 $0.00 $63.59 $0.00 $0.00 $0.00 $0.00 $162.94 $258.10 $260.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-4295S SUP Custom 27203010 1806-4295S - BIT DRILL GRN 230MM 4.2MM T2 AO CPLNG TRFLT STRL BOTH IP/OP $288.15 $213.23 $0.00 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.86 $213.86 $0.00 $0.00 $60.05 $0.00 $0.00 $0.00 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-5000S SUP Custom 27203010 1806-5000S - BIT DRL 5MM 230MM STRL AO CPLNG BOTH IP/OP $283.90 $210.09 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.71 $210.71 $0.00 $0.00 $59.16 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-5005S SUP Custom 27203010 1806-5005S - BIT DRILL 230MM 5MM T2 TRFLT STRL DISP BOTH IP/OP $294.95 $218.26 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.91 $218.91 $0.00 $0.00 $61.47 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-5010S SUP Custom 27203010 1806-5010S - BIT DRILL 180MM 5MM T2 STD AO FIT STRL BOTH IP/OP $294.95 $218.26 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.91 $218.91 $0.00 $0.00 $61.47 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-5015S SUP Custom 27203010 1806-5015S - BIT DRILL 180MM 5MM T2 TRFLT OPTN STRL BOTH IP/OP $288.15 $213.23 $0.00 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.86 $213.86 $0.00 $0.00 $60.05 $0.00 $0.00 $0.00 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-5020S SUP Custom 27203010 1806-5020S - BIT DRILL 340MM 5MM T2 AO STRL BOTH IP/OP $305.15 $225.81 $0.00 $260.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $226.48 $226.48 $0.00 $0.00 $63.59 $0.00 $0.00 $0.00 $0.00 $162.94 $258.10 $260.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-5025S SUP Custom 27203010 1806-5025S - BIT DRILL 340MM 5MM T2 TRFLT STRL BOTH IP/OP $288.15 $213.23 $0.00 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.86 $213.86 $0.00 $0.00 $60.05 $0.00 $0.00 $0.00 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1806-5032S SUP HCPCS C1713 1806-5032S - SCREW BONE 5MM 32.5MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1806-5045S SUP HCPCS C1713 1806-5045S - SCREW BONE 45MM ORTH LCK BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1806-8018S SUP Custom 27203010 1806-8018S - BIT DRILL 250MM 4.2MM S2 AO OBLQ STRL BOTH IP/OP $288.15 $213.23 $0.00 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.86 $213.86 $0.00 $0.00 $60.05 $0.00 $0.00 $0.00 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 180701-2 SUP HCPCS C1776 180701-2 - INSERT TIB 1 9MM STRL RESTORIS ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180702-1 SUP HCPCS C1776 180702-1 - INSERT TIB 2 8MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180702-2 SUP HCPCS C1776 180702-2 - INSERT TIB 2 9MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180702-3 SUP HCPCS C1776 180702-3 - INSERT TIB 2 10MM STRL RESTORIS ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180702-5 SUP HCPCS C1776 180702-5 - INSERT TIB 2 12MM STRL RESTORIS ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180703-1 SUP HCPCS C1776 180703-1 - INSERT TIB 3 8MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180703-2 SUP HCPCS C1776 180703-2 - INSERT TIB 3 9MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180703-3 SUP HCPCS C1776 180703-3 - INSERT TIB 3 10MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180704-1 SUP HCPCS C1776 180704-1 - INSERT TIB 4 8MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180704-2 SUP HCPCS C1776 180704-2 - INSERT TIB 4 9MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180704-3 SUP HCPCS C1776 180704-3 - INSERT TIB 4 10MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180704-5 SUP HCPCS C1776 180704-5 - INSERT TIB 4 12MM STRL RESTORIS ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180705-1 SUP HCPCS C1776 180705-1 - INSERT TIB 5 8MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180705-3 SUP HCPCS C1776 180705-3 - INSERT TIB 5 10MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180705-4 SUP HCPCS C1776 180705-4 - INSERT TIB 5 10MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180705-6 SUP HCPCS C1776 180705-6 - INSERT TIB 5 13MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180705-7 SUP HCPCS C1776 180705-7 - INSERT TIB 5 14MM ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180705-8 SUP HCPCS C1776 180705-8 - INSERT TIB 5 15MM ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180705-9 SUP HCPCS C1776 180705-9 - INSERT TIB 5 16MM ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180706-1 SUP HCPCS C1776 180706-1 - INSERT TIB 6 8MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180706-2 SUP HCPCS C1776 180706-2 - INSERT TIB 6 9MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180706-3 SUP HCPCS C1776 180706-3 - INSERT TIB 6 10MM ONLAY BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180706-4 SUP HCPCS C1776 180706-4 - INSERT TIB 6 11MM ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180706-6 SUP HCPCS C1776 180706-6 - INSERT TIB 6 13MM ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180706-7 SUP HCPCS C1776 180706-7 - INSERT TIB 6 14MM ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180706-8 SUP HCPCS C1776 180706-8 - INSERT TIB 6 15MM ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180706-9 SUP HCPCS C1776 180706-9 - INSERT TIB 6 16MM ONLAY MULTICOMPARTMENTAL KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180707-1 SUP HCPCS C1776 180707-1 - INSERT TIB 7 8MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180707-2 SUP HCPCS C1776 180707-2 - INSERT TIB 7 9MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180707-3 SUP HCPCS C1776 180707-3 - INSERT TIB 7 10MM ONLAY KN MCK SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180707-4 SUP HCPCS C1776 180707-4 - INSERT TIB 7 11MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180707-6 SUP HCPCS C1776 180707-6 - INSERT TIB 7 13MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180707-7 SUP HCPCS C1776 180707-7 - INSERT TIB 7 14MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180707-8 SUP HCPCS C1776 180707-8 - INSERT TIB 7 15MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180707-9 SUP HCPCS C1776 180707-9 - INSERT TIB 7 16MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180708-4 SUP HCPCS C1776 180708-4 - INSERT TIB 8 11MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180708-6 SUP HCPCS C1776 180708-6 - INSERT TIB 8 13MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180708-7 SUP HCPCS C1776 180708-7 - INSERT TIB 8 14MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180708-8 SUP HCPCS C1776 180708-8 - INSERT TIB 8 15MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180708-9 SUP HCPCS C1776 180708-9 - INSERT TIB 8 16MM ONLAY KN MULTICOMPARTMENTAL SYS BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 180731-1 SUP HCPCS C1776 180731-1 - INSERT TIB 1 8MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180731-1-E SUP HCPCS C1776 180731-1-E - INSERT TIB 1 8MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180731-2 SUP HCPCS C1776 180731-2 - INSERT TIB 1 9MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180731-2-E SUP HCPCS C1776 180731-2-E - INSERT TIB 1 9MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180731-3 SUP HCPCS C1776 180731-3 - INSERT TIB 1 10MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180731-3-E SUP HCPCS C1776 180731-3-E - INSERT TIB 1 10MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180731-5 SUP HCPCS C1776 180731-5 - INSERT TIB 1 12MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180731-5-E SUP HCPCS C1776 180731-5-E - INSERT TIB 1 12MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180732-1 SUP HCPCS C1776 180732-1 - INSERT TIB 2 8MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180732-1-E SUP HCPCS C1776 180732-1-E - INSERT TIB 2 8MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180732-2 SUP HCPCS C1776 180732-2 - INSERT TIB 2 9MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180732-2-E SUP HCPCS C1776 180732-2-E - INSERT TIB 2 9MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180732-3 SUP HCPCS C1776 180732-3 - INSERT TIB 2 10MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180732-3-E SUP HCPCS C1776 180732-3-E - INSERT TIB 2 10MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180732-5 SUP HCPCS C1776 180732-5 - INSERT TIB BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180732-5-E SUP HCPCS C1776 180732-5-E - INSERT TIB 2 12MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180733-1 SUP HCPCS C1776 180733-1 - INSERT TIB 3 8MM MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180733-1-E SUP HCPCS C1776 180733-1-E - INSERT TIB 3 8MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180733-2 SUP HCPCS C1776 180733-2 - INSERT TIB 3 9MM MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180733-2-E SUP HCPCS C1776 180733-2-E - INSERT TIB 3 9MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180733-3 SUP HCPCS C1776 180733-3 - INSERT TIB 10MM STRL MAKO BRNG ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180733-3-E SUP HCPCS C1776 180733-3-E - INSERT TIB 3 10MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180733-5 SUP HCPCS C1776 180733-5 - INSERT TIB 3 12MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180733-5-E SUP HCPCS C1776 180733-5-E - INSERT TIB 3 12MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180734-1 SUP HCPCS C1776 180734-1 - INSERT TIB 4 8MM MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180734-1-E SUP HCPCS C1776 180734-1-E - INSERT TIB 4 8MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180734-2 SUP HCPCS C1776 180734-2 - INSERT TIB 4 9MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180734-2-E SUP HCPCS C1776 180734-2-E - INSERT TIB 4 9MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180734-3 SUP HCPCS C1776 180734-3 - INSERT TIB 10MM STRL MAKO BRNG ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180734-3-E SUP HCPCS C1776 180734-3-E - INSERT TIB 4 10MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180734-5 SUP HCPCS C1776 180734-5 - INSERT TIB BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180735-1 SUP HCPCS C1776 180735-1 - INSERT TIB 5 8MM MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180735-1-E SUP HCPCS C1776 180735-1-E - INSERT TIB 5 8MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180735-2 SUP HCPCS C1776 180735-2 - INSERT TIB 5 9MM MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180735-2-E SUP HCPCS C1776 180735-2-E - INSERT TIB 5 9MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180735-3 SUP HCPCS C1776 180735-3 - INSERT TIB BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180735-5 SUP HCPCS C1776 180735-5 - INSERT TIB 5 12MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180735-5-E SUP HCPCS C1776 180735-5-E - INSERT TIB 5 12MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180736-1 SUP HCPCS C1776 180736-1 - INSERT TIB 6 8MM MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180736-1-E SUP HCPCS C1776 180736-1-E - INSERT TIB 6 8MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180736-2 SUP HCPCS C1776 180736-2 - INSERT TIB 6 9MM MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180736-2-E SUP HCPCS C1776 180736-2-E - INSERT TIB 6 9MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180736-3 SUP HCPCS C1776 180736-3 - INSERT TIB 6 10MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180736-3-E SUP HCPCS C1776 180736-3-E - INSERT TIB 6 10MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180736-5 SUP HCPCS C1776 180736-5 - INSERT TIB BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180736-5-E SUP HCPCS C1776 180736-5-E - INSERT TIB 6 12MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180737-1 SUP HCPCS C1776 180737-1 - INSERT TIB 8MM STRL MAKO BRNG ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180737-1-E SUP HCPCS C1776 180737-1-E - INSERT TIB 7 8MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180737-2 SUP HCPCS C1776 180737-2 - INSERT TIB 7 9MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180737-2-E SUP HCPCS C1776 180737-2-E - INSERT TIB 7 9MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180737-3 SUP HCPCS C1776 180737-3 - INSERT TIB 7 10MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180737-3-E SUP HCPCS C1776 180737-3-E - INSERT TIB 7 10MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180737-5 SUP HCPCS C1776 180737-5 - INSERT TIB BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180737-5-E SUP HCPCS C1776 180737-5-E - INSERT TIB 7 12MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180738-1 SUP HCPCS C1776 180738-1 - INSERT TIB 8 8MM MAKO X3 UNCMP ONLAY KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180738-1-E SUP HCPCS C1776 180738-1-E - INSERT TIB 8 8MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180738-2 SUP HCPCS C1776 180738-2 - INSERT TIB BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180738-2-E SUP HCPCS C1776 180738-2-E - INSERT TIB 8 9MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180738-3 SUP HCPCS C1776 180738-3 - INSERT TIB BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180738-3-E SUP HCPCS C1776 180738-3-E - INSERT TIB 8 10MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180738-5 SUP HCPCS C1776 180738-5 - INSERT TIB BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 180738-5-E SUP HCPCS C1776 180738-5-E - INSERT TIB 8 12MM STRL MAKO UNCMP ONLAY X3 KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 18-131 SUP HCPCS C1887 18-131 - CATH GUID 130CM 20CM MCTH STR HYDPHI RNGD STC-18 BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $665.18 $665.18 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 1818-0001S SUP HCPCS C1713 1818-0001S - SCREW BONE 8MM 14.5MM T2 TI ANKL CMPR CANN PRELD ARTHDES BOTH IP/OP $300.90 $222.67 $0.00 $223.33 $124.37 $124.37 $0.00 $0.00 $0.00 $62.72 $223.33 $223.33 $0.00 $0.00 $62.71 $0.00 $177.98 $177.98 $0.00 $138.19 $218.89 $221.10 $0.00 $0.00 $43.25 $0.00 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1015S SUP HCPCS C1713 1818-1015S - NAIL 10MM 15CM LEFT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1020S SUP HCPCS C1713 1818-1020S - NAIL 10MM 20CM LEFT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1030S SUP HCPCS C1713 1818-1030S - NAIL 10MM 30CM LEFT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1115S SUP HCPCS C1713 1818-1115S - NAIL 11MM 15CM LEFT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1120S SUP HCPCS C1713 1818-1120S - NAIL 11MM 20CM LEFT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1130S SUP HCPCS C1713 1818-1130S - NAIL 11MM 30CM LEFT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1215S SUP HCPCS C1713 1818-1215S - NAIL 12MM 15CM LEFT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1220S SUP HCPCS C1713 1818-1220S - NAIL 12MM 20CM LEFT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1818-1230S SUP HCPCS C1713 1818-1230S - T2 ANKLE ARTHRODESIS NAIL LEFT 12MM X 300MM BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1015S SUP HCPCS C1713 1819-1015S - NAIL 10MM 15CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1020S SUP HCPCS C1713 1819-1020S - NAIL 10MM 20CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1030S SUP HCPCS C1713 1819-1030S - NAIL 10MM 30CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1115S SUP HCPCS C1713 1819-1115S - NAIL 11MM 15CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1120S SUP HCPCS C1713 1819-1120S - NAIL 11MM 20CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1130S SUP HCPCS C1713 1819-1130S - NAIL 11MM 30CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1215S SUP HCPCS C1713 1819-1215S - NAIL 12MM 15CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1220S SUP HCPCS C1713 1819-1220S - NAIL 12MM 20CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1819-1230S SUP HCPCS C1713 1819-1230S - NAIL 12MM 30CM RIGHT ANKL T2 IM ARTHDES LCK TI STRL BOTH IP/OP "$3,744.25 " "$2,770.75" $0.00 "$2,788.50" "$1,568.53" "$1,568.53" $0.00 $0.00 $0.00 $780.40 "$2,778.98" "$2,778.98" $0.00 $0.00 $780.30 $0.00 "$1,845.92" "$1,845.92" $0.00 "$1,742.81" "$2,760.62" "$2,788.50" $0.00 $0.00 $545.50 $0.00 $0.00 $554.91 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0001S SUP HCPCS C1713 1822-0001S - SCREW BONE 8MM T2 TI TIB CMPR STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0003S SUP HCPCS C1713 1822-0003S - CAP END STD STRL T2 8MM BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0004S SUP HCPCS C1713 1822-0004S - CAP END FULTHRD T2 BOTH IP/OP $239.25 $177.05 $0.00 $191.40 $107.66 $107.66 $0.00 $0.00 $0.00 $49.87 $177.57 $177.57 $0.00 $0.00 $49.86 $0.00 $141.52 $141.52 $0.00 $119.63 $189.49 $191.40 $0.00 $0.00 $37.44 $0.00 $0.00 $38.09 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0005S SUP HCPCS C1713 1822-0005S - CAP END +5MM STRL T2 11.5MM BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0010S SUP HCPCS C1713 1822-0010S - CAP END 10MM 10+ MM HUM IM NAIL STRL T2 11.5MM BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0015S SUP HCPCS C1713 1822-0015S - CAP END 15MM FEM IM NAIL TI STRL T2 BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0824S SUP HCPCS C1713 1822-0824S - NAIL 8MM 24CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0825S SUP HCPCS C1713 1822-0825S - NAIL 8MM 25.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0827S SUP HCPCS C1713 1822-0827S - NAIL 8MM 27CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0828S SUP HCPCS C1713 1822-0828S - NAIL 8MM 28.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0830S SUP HCPCS C1713 1822-0830S - NAIL 8MM 30CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0831S SUP HCPCS C1713 1822-0831S - NAIL 8MM 31.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0833S SUP HCPCS C1713 1822-0833S - NAIL 8MM 330MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0834S SUP HCPCS C1713 1822-0834S - NAIL 8MM 345MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0836S SUP HCPCS C1713 1822-0836S - NAIL 8MM 36CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0837S SUP HCPCS C1713 1822-0837S - NAIL 8MM 37.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0839S SUP HCPCS C1713 1822-0839S - NAIL 8MM 39CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0840S SUP HCPCS C1713 1822-0840S - NAIL 8MM 40.5CM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0842S SUP HCPCS C1713 1822-0842S - NAIL 8MM 42CM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0924S SUP HCPCS C1713 1822-0924S - NAIL 9MM 24CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0925S SUP HCPCS C1713 1822-0925S - NAIL 9MM 25.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0927S SUP HCPCS C1713 1822-0927S - NAIL 9MM 27CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0928S SUP HCPCS C1713 1822-0928S - NAIL 0D9MM 28.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0930S SUP HCPCS C1713 1822-0930S - NAIL 9MM 30CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0931S SUP HCPCS C1713 1822-0931S - NAIL 9MM 31.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0933S SUP HCPCS C1713 1822-0933S - NAIL 9MM 33CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0934S SUP HCPCS C1713 1822-0934S - NAIL 9MM 345MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0936S SUP HCPCS C1713 1822-0936S - NAIL 9MM 360MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0937S SUP HCPCS C1713 1822-0937S - NAIL 9MM 37.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0939S SUP HCPCS C1713 1822-0939S - NAIL 9MM 39CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0940S SUP HCPCS C1713 1822-0940S - NAIL 9MM 40.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0942S SUP HCPCS C1713 1822-0942S - NAIL 9MM 42CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-0945S SUP HCPCS C1713 1822-0945S - NAIL 9MM 450MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1024S SUP HCPCS C1713 1822-1024S - NAIL 10MM 24CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1025S SUP HCPCS C1713 1822-1025S - NAIL 10MM 25.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1027S SUP HCPCS C1713 1822-1027S - NAIL 10MM 27CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1028S SUP HCPCS C1713 1822-1028S - NAIL 10MM 28.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1030S SUP HCPCS C1713 1822-1030S - NAIL 10MM 300MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1031S SUP HCPCS C1713 1822-1031S - NAIL 10MM 31.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1033S SUP HCPCS C1713 1822-1033S - NAIL 10MM 33CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1034S SUP HCPCS C1713 1822-1034S - NAIL 10MM 34.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1036S SUP HCPCS C1713 1822-1036S - NAIL 10MM 36CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1037S SUP HCPCS C1713 1822-1037S - NAIL 10MM 37.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1039S SUP HCPCS C1713 1822-1039S - NAIL 11MM 390MM TIB T2 IM STD STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1040S SUP HCPCS C1713 1822-1040S - NAIL 10MM 40.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1042S SUP HCPCS C1713 1822-1042S - NAIL 10MM 420MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1043S SUP HCPCS C1713 1822-1043S - NAIL 10MM 435MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1045S SUP HCPCS C1713 1822-1045S - NAIL 10MM 450MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1046S SUP HCPCS C1713 1822-1046S - NAIL 10MM 465MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1048S SUP HCPCS C1713 1822-1048S - NAIL 10MM 480MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1124S SUP HCPCS C1713 1822-1124S - NAIL 11MM 240MM TIB T2 IM STD IMPL TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1125S SUP HCPCS C1713 1822-1125S - NAIL 11MM 25.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1127S SUP HCPCS C1713 1822-1127S - NAIL 11MM 27CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1128S SUP HCPCS C1713 1822-1128S - NAIL 11MM 28CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1130S SUP HCPCS C1713 1822-1130S - NAIL 11MM 300MM TIB T2 IM STD BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1131S SUP HCPCS C1713 1822-1131S - NAIL 11MM 315MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1133S SUP HCPCS C1713 1822-1133S - NAIL 11MM 330MM TIB T2 IM STD BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1134S SUP HCPCS C1713 1822-1134S - NAIL 11MM 345MM TIB T2 IM STD TI ALLOY STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1136S SUP HCPCS C1713 1822-1136S - NAIL 11MM 36CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1137S SUP HCPCS C1713 1822-1137S - NAIL 11MM 375MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1139S SUP HCPCS C1713 1822-1139S - NAIL 11MM 390MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1140S SUP HCPCS C1713 1822-1140S - NAIL 11MM 40.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1142S SUP HCPCS C1713 1822-1142S - NAIL 11MM 42CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1143S SUP HCPCS C1713 1822-1143S - NAIL 11MM 435MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1145S SUP HCPCS C1713 1822-1145S - NAIL 11MM 450MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1146S SUP HCPCS C1713 1822-1146S - NAIL 11MM 465MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1148S SUP HCPCS C1713 1822-1148S - NAIL 11MM 480MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1224S SUP HCPCS C1713 1822-1224S - NAIL 12MM 24CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1225S SUP HCPCS C1713 1822-1225S - NAIL 12MM 25.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1227S SUP HCPCS C1713 1822-1227S - NAIL 12MM 27CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1228S SUP HCPCS C1713 1822-1228S - NAIL 12MM 28.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1230S SUP HCPCS C1713 1822-1230S - NAIL 12MM 300MM TIB T2 IM STD TI BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1231S SUP HCPCS C1713 1822-1231S - NAIL 12MM 31.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1233S SUP HCPCS C1713 1822-1233S - NAIL 12MM 33CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1234S SUP HCPCS C1713 1822-1234S - NAIL 12MM 345MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1236S SUP HCPCS C1713 1822-1236S - NAIL 12MM 360MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1237S SUP HCPCS C1713 1822-1237S - NAIL 12MM 370MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1239S SUP HCPCS C1713 1822-1239S - NAIL 12MM 390MM TIB T2 IM STD TI BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1240S SUP HCPCS C1713 1822-1240S - NAIL 12MM 405MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1242S SUP HCPCS C1713 1822-1242S - NAIL 12MM 420MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1245S SUP HCPCS C1713 1822-1245S - NAIL 12MM 450MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1324S SUP HCPCS C1713 1822-1324S - NAIL 13MM 240MM TIB T2 IM STD BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1325S SUP HCPCS C1713 1822-1325S - NAIL 13MM 255MM TIB T2 IM STD BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1327S SUP HCPCS C1713 1822-1327S - NAIL 13MM 270MM TIB T2 IM STD BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1328S SUP HCPCS C1713 1822-1328S - NAIL 13MM 285MM TIB T2 IM STD BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1330S SUP HCPCS C1713 1822-1330S - NAIL 13MM 30CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1331S SUP HCPCS C1713 1822-1331S - NAIL 13MM 31.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1333S SUP HCPCS C1713 1822-1333S - NAIL 13MM 33CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1334S SUP HCPCS C1713 1822-1334S - NAIL 13MM 34.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1336S SUP HCPCS C1713 1822-1336S - NAIL 13MM 36CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1337S SUP HCPCS C1713 1822-1337S - NAIL 13MM 37.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1339S SUP HCPCS C1713 1822-1339S - NAIL 13MM 39CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1340S SUP HCPCS C1713 1822-1340S - NAIL 13MM 40.5CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1342S SUP HCPCS C1713 1822-1342S - NAIL 13MM 42CM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1424S SUP HCPCS C1713 1822-1424S - NAIL 14MM 240MM TIB T2 IM STD BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1425S SUP HCPCS C1713 1822-1425S - NAIL 14MM 255MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1427S SUP Custom 27803010 1822-1427S - CMPNT PATLR 15MM CONC SGL T2 MDL LAT STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 $0.00 $0.00 $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1428S SUP HCPCS C1713 1822-1428S - NAIL 14MM 285MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1430S SUP HCPCS C1713 1822-1430S - NAIL 14MM 300MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1431S SUP HCPCS C1713 1822-1431S - NAIL 14MM 315MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1433S SUP HCPCS C1713 1822-1433S - NAIL 14MM 330MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1434S SUP HCPCS C1713 1822-1434S - NAIL 14MM 34.5CM TIB T2 IM STD STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1436S SUP HCPCS C1713 1822-1436S - NAIL 14MM 360MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1437S SUP HCPCS C1713 1822-1437S - NAIL 14MM 375MM TIB T2 IM STD LCK TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1439S SUP HCPCS C1713 1822-1439S - NAIL 14MM 390MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1440S SUP HCPCS C1713 1822-1440S - NAIL 14MM 405MM TIB T2 IM STD TI STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1442S SUP HCPCS C1713 1822-1442S - NAIL 14MM 420MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1524S SUP HCPCS C1713 1822-1524S - NAIL 15MM 240MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1525S SUP HCPCS C1713 1822-1525S - NAIL 15MM 255MM TIB T2 IM STD IMPL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1527S SUP HCPCS C1713 1822-1527S - NAIL 15MM 270MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1528S SUP HCPCS C1713 1822-1528S - NAIL 15MM 285MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1530S SUP HCPCS C1713 1822-1530S - NAIL 15MM 300MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1531S SUP HCPCS C1713 1822-1531S - NAIL 15MM 315MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1533S SUP HCPCS C1713 1822-1533S - NAIL 15MM 330MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1534S SUP HCPCS C1713 1822-1534S - NAIL 15MM 345MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1536S SUP HCPCS C1713 1822-1536S - NAIL 15MM 360MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1537S SUP HCPCS C1713 1822-1537S - NAIL 15MM 375MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1539S SUP HCPCS C1713 1822-1539S - NAIL 15MM 390MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1540S SUP HCPCS C1713 1822-1540S - NAIL 15MM 330MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1822-1542S SUP HCPCS C1713 1822-1542S - NAIL 15MM 420MM TIB T2 IM STD IMPL STRL BOTH IP/OP "$2,322.38 " "$1,718.56" $0.00 "$1,857.90" "$1,045.07" "$1,045.07" $0.00 $0.00 $0.00 $484.04 "$1,723.67" "$1,723.67" $0.00 $0.00 $483.98 $0.00 "$1,373.68" "$1,373.68" $0.00 "$1,161.19" "$1,839.32" "$1,857.90" $0.00 $0.00 $363.45 $0.00 $0.00 $369.72 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0000S SUP HCPCS C1713 1825-0000S - SCREW BONE 8MM T2 TI STD FEM CMPR STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0001S SUP HCPCS C1713 1825-0001S - SCREW BONE 8MM T2 TI +0MM FEM CMPR STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0005S SUP HCPCS C1713 1825-0005S - SCREW BONE 8MM T2 TI +5MM FEM CMPR STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0010S SUP HCPCS C1713 1825-0010S - SCREW BONE 8MM T2 TI +10MM FEM CMPR STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0015S SUP HCPCS C1713 1825-0015S - SCREW BONE 8MM T2 TI +15MM FEM CMPR STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0814S SUP HCPCS C1713 1825-0814S - NAIL 8MM 14CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0816S SUP HCPCS C1713 1825-0816S - NAIL 8MM 16CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0818S SUP HCPCS C1713 1825-0818S - NAIL 8MM 18CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0820S SUP HCPCS C1713 1825-0820S - NAIL 8MM 20CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0822S SUP HCPCS C1713 1825-0822S - NAIL 8MM 22CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0824S SUP HCPCS C1713 1825-0824S - NAIL 8MM 24CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0826S SUP HCPCS C1713 1825-0826S - NAIL 8MM 26CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0828S SUP HCPCS C1713 1825-0828S - NAIL 8MM 28CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0830S SUP HCPCS C1713 1825-0830S - NAIL 8MM 30CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0832S SUP HCPCS C1713 1825-0832S - NAIL 8MM 32CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0834S SUP HCPCS C1713 1825-0834S - NAIL 8MM 34CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0836S SUP HCPCS C1713 1825-0836S - NAIL 8MM 36CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0838S SUP HCPCS C1713 1825-0838S - NAIL 8MM 38CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0840S SUP HCPCS C1713 1825-0840S - NAIL 8MM 40CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0842S SUP HCPCS C1713 1825-0842S - NAIL 8MM 42CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0844S SUP HCPCS C1713 1825-0844S - NAIL 8MM 44CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0846S SUP HCPCS C1713 1825-0846S - NAIL 8MM 46CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0848S SUP HCPCS C1713 1825-0848S - NAIL 8MM 48CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0914S SUP HCPCS C1713 1825-0914S - NAIL 9MM 140MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0916S SUP HCPCS C1713 1825-0916S - NAIL 9MM 160MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0918S SUP HCPCS C1713 1825-0918S - NAIL 9MM 18CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0920S SUP HCPCS C1713 1825-0920S - NAIL 9MM 20CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0922S SUP HCPCS C1713 1825-0922S - NAIL 9MM 22CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0924S SUP HCPCS C1713 1825-0924S - NAIL 9MM 24CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0926S SUP HCPCS C1713 1825-0926S - NAIL 9MM 26CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0928S SUP HCPCS C1713 1825-0928S - NAIL 9MM 28CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0930S SUP HCPCS C1713 1825-0930S - NAIL 9MM 30CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0932S SUP HCPCS C1713 1825-0932S - NAIL 9MM 32CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0934S SUP HCPCS C1713 1825-0934S - NAIL 9MM 34CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0936S SUP HCPCS C1713 1825-0936S - NAIL 9MM 360MM FEM T2 IM TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0938S SUP HCPCS C1713 1825-0938S - NAIL 9MM 380MM FEM T2 IM TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0940S SUP HCPCS C1713 1825-0940S - NAIL 9MM 40CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0942S SUP HCPCS C1713 1825-0942S - NAIL 9MM 42CM FEM T2 IM ANTGRD RTRGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0944S SUP HCPCS C1713 1825-0944S - NAIL 9MM 44CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0946S SUP HCPCS C1713 1825-0946S - NAIL 9MM 46CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-0948S SUP HCPCS C1713 1825-0948S - NAIL 9MM 48CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1014S SUP HCPCS C1713 1825-1014S - NAIL 10MM 140MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1016S SUP HCPCS C1713 1825-1016S - NAIL 10MM 160MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1018S SUP HCPCS C1713 1825-1018S - NAIL 10MM 18CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1020S SUP HCPCS C1713 1825-1020S - NAIL 10MM 20CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1022S SUP HCPCS C1713 1825-1022S - NAIL 10MM 22CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1024S SUP HCPCS C1713 1825-1024S - NAIL 10MM 24CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1026S SUP HCPCS C1713 1825-1026S - NAIL 10MM 26CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1028S SUP HCPCS C1713 1825-1028S - NAIL 10MM 60MM FEM T2 IM TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1030S SUP HCPCS C1713 1825-1030S - NAIL 10MM 30CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1032S SUP HCPCS C1713 1825-1032S - NAIL 10MM 320MM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1034S SUP HCPCS C1713 1825-1034S - NAIL 10MM 340MM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1036S SUP HCPCS C1713 1825-1036S - NAIL 10MM 36CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1038S SUP HCPCS C1713 1825-1038S - NAIL 10MM 38CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1040S SUP HCPCS C1713 1825-1040S - NAIL 10MM 400MM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1042S SUP HCPCS C1713 1825-1042S - NAIL 10MM 42CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1044S SUP HCPCS C1713 1825-1044S - NAIL 10MM 44CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1046S SUP HCPCS C1713 1825-1046S - NAIL 10MM 46CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1048S SUP HCPCS C1713 1825-1048S - NAIL 10MM 48CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1114S SUP HCPCS C1713 1825-1114S - NAIL 11MM 140MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1116S SUP HCPCS C1713 1825-1116S - NAIL 11MM 160MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1118S SUP HCPCS C1713 1825-1118S - NAIL 11MM 18CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1120S SUP HCPCS C1713 1825-1120S - NAIL 11MM 20CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1122S SUP HCPCS C1713 1825-1122S - NAIL 11MM 22CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1124S SUP HCPCS C1713 1825-1124S - NAIL 11MM 24CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1126S SUP HCPCS C1713 1825-1126S - NAIL 11MM 26CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1128S SUP HCPCS C1713 1825-1128S - NAIL 11MM 280MM FEM T2 IM TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1130S SUP HCPCS C1713 1825-1130S - NAIL 11MM 30CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1132S SUP HCPCS C1713 1825-1132S - NAIL 11MM 320MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1134S SUP HCPCS C1713 1825-1134S - NAIL 11MM 340MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1136S SUP HCPCS C1713 1825-1136S - NAIL 11MM 36CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1138S SUP HCPCS C1713 1825-1138S - NAIL 11MM 38CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1140S SUP HCPCS C1713 1825-1140S - NAIL 11MM 40CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1142S SUP HCPCS C1713 1825-1142S - NAIL 11MM 42CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1144S SUP HCPCS C1713 1825-1144S - NAIL 11MM 44CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1146S SUP HCPCS C1713 1825-1146S - NAIL 11MM 46CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1148S SUP HCPCS C1713 1825-1148S - NAIL 11MM 48CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1214S SUP HCPCS C1713 1825-1214S - NAIL 12MM 14CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1216S SUP HCPCS C1713 1825-1216S - NAIL 12MM 160MM FEM T2 IM ANTGRD RTRGRD STR LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1218S SUP HCPCS C1713 1825-1218S - NAIL 12MM 18CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1220S SUP HCPCS C1713 1825-1220S - NAIL 12MM 20CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1222S SUP HCPCS C1713 1825-1222S - NAIL 12MM 22CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1224S SUP HCPCS C1713 1825-1224S - NAIL 12MM 24CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1226S SUP HCPCS C1713 1825-1226S - NAIL 12MM 26CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1228S SUP HCPCS C1713 1825-1228S - NAIL 12MM 28CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1230S SUP HCPCS C1713 1825-1230S - NAIL 12MM 30CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1232S SUP HCPCS C1713 1825-1232S - NAIL 12MM 320MM FEM T2 IM TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1234S SUP HCPCS C1713 1825-1234S - NAIL 12MM 340MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1236S SUP HCPCS C1713 1825-1236S - NAIL 12MM 36CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1238S SUP HCPCS C1713 1825-1238S - NAIL 12MM 38CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1240S SUP HCPCS C1713 1825-1240S - NAIL 12MM 400MM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1242S SUP HCPCS C1713 1825-1242S - NAIL 12MM 42CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1244S SUP HCPCS C1713 1825-1244S - NAIL 12MM 440MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1246S SUP HCPCS C1713 1825-1246S - NAIL 12MM 46CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1248S SUP HCPCS C1713 1825-1248S - NAIL 12MM 48CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1314S SUP HCPCS C1713 1825-1314S - NAIL 13MM 140MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1316S SUP HCPCS C1713 1825-1316S - NAIL 13MM 160MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1318S SUP HCPCS C1713 1825-1318S - NAIL 13MM 18CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1320S SUP HCPCS C1713 1825-1320S - NAIL 13MM 20CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1322S SUP HCPCS C1713 1825-1322S - NAIL 13MM 22CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1324S SUP HCPCS C1713 1825-1324S - NAIL 13MM 24CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1326S SUP HCPCS C1713 1825-1326S - NAIL 13MM 26CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1328S SUP HCPCS C1713 1825-1328S - NAIL 13MM 28CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1330S SUP HCPCS C1713 1825-1330S - NAIL 13MM 30CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1332S SUP HCPCS C1713 1825-1332S - NAIL 13MM 32CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1334S SUP HCPCS C1713 1825-1334S - NAIL 13MM 34CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1336S SUP HCPCS C1713 1825-1336S - NAIL 13MM 36CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1338S SUP HCPCS C1713 1825-1338S - NAIL 13MM 380MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1340S SUP HCPCS C1713 1825-1340S - NAIL 13MM 40CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1342S SUP HCPCS C1713 1825-1342S - NAIL 13MM 42CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1344S SUP HCPCS C1713 1825-1344S - NAIL 13MM 440MM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1346S SUP HCPCS C1713 1825-1346S - NAIL 13MM 46CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1348S SUP HCPCS C1713 1825-1348S - NAIL 13MM 48CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1414S SUP HCPCS C1713 1825-1414S - NAIL 14MM 160MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1416S SUP HCPCS C1713 1825-1416S - NAIL 14MM 160MM FEM T2 IM BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1418S SUP HCPCS C1713 1825-1418S - NAIL 14MM 18CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1420S SUP HCPCS C1713 1825-1420S - NAIL 14MM 20CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1422S SUP HCPCS C1713 1825-1422S - NAIL 14MM 22CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1424S SUP HCPCS C1713 1825-1424S - NAIL 14MM 24CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1426S SUP HCPCS C1713 1825-1426S - NAIL 14MM 26CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1428S SUP HCPCS C1713 1825-1428S - NAIL 14MM 28CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1430S SUP HCPCS C1713 1825-1430S - NAIL 14MM 30CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1432S SUP HCPCS C1713 1825-1432S - NAIL 14MM 32CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1434S SUP HCPCS C1713 1825-1434S - NAIL 14MM 34CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1436S SUP HCPCS C1713 1825-1436S - NAIL 14MM 36CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1438S SUP HCPCS C1713 1825-1438S - NAIL 14MM 38CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1440S SUP HCPCS C1713 1825-1440S - NAIL 14MM 40CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1442S SUP HCPCS C1713 1825-1442S - NAIL 14MM 42CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1444S SUP HCPCS C1713 1825-1444S - NAIL 14MM 44CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1446S SUP HCPCS C1713 1825-1446S - NAIL 14MM 46CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1448S SUP HCPCS C1713 1825-1448S - NAIL 14MM 48CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1514S SUP HCPCS C1713 1825-1514S - NAIL 15MM 140MM FEM T2 IM LCK STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1516S SUP HCPCS C1713 1825-1516S - NAIL 15MM 160MM FEM T2 IM LCK STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1518S SUP HCPCS C1713 1825-1518S - NAIL 15MM 18CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1520S SUP HCPCS C1713 1825-1520S - NAIL 15MM 20CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1522S SUP HCPCS C1713 1825-1522S - NAIL 15MM 22CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1524S SUP HCPCS C1713 1825-1524S - NAIL 15MM 24CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1526S SUP HCPCS C1713 1825-1526S - NAIL 15MM 26CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1528S SUP HCPCS C1713 1825-1528S - NAIL 15MM 28CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1530S SUP HCPCS C1713 1825-1530S - NAIL 15MM 30CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1532S SUP HCPCS C1713 1825-1532S - NAIL 15MM 32CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1534S SUP HCPCS C1713 1825-1534S - NAIL 15MM 34CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1536S SUP HCPCS C1713 1825-1536S - NAIL 15MM 36CM FEM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1538S SUP HCPCS C1713 1825-1538S - NAIL 15MM 38CM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1540S SUP HCPCS C1713 1825-1540S - NAIL 15MM 400MM FEM T2 IM LCK TI STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1542S SUP HCPCS C1713 1825-1542S - NAIL 15MM 420MM FEM T2 IM LCK TI ALLOY STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1544S SUP HCPCS C1713 1825-1544S - NAIL 15MM 44CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1546S SUP HCPCS C1713 1825-1546S - NAIL 15MM 46CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1825-1548S SUP HCPCS C1713 1825-1548S - NAIL 15MM 48CM FEM T2 IM STRL BOTH IP/OP "$2,442.00 " "$1,807.08" $0.00 "$1,953.60" "$1,098.90" "$1,098.90" $0.00 $0.00 $0.00 $508.97 "$1,812.45" "$1,812.45" $0.00 $0.00 $508.91 $0.00 "$1,444.44" "$1,444.44" $0.00 "$1,221.00" "$1,934.06" "$1,953.60" $0.00 $0.00 $382.17 $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0003S SUP HCPCS C1713 1826-0003S - CAP END 4MM ANKL INS ARTHDES NAIL STRL T2 8MM BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0917S SUP HCPCS C1713 1826-0917S - NAIL 9MM 17CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0920S SUP HCPCS C1713 1826-0920S - NAIL 9MM 20CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0924S SUP HCPCS C1713 1826-0924S - NAIL 9MM 24CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0926S SUP HCPCS C1713 1826-0926S - NAIL 9MM 26CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0928S SUP HCPCS C1713 1826-0928S - NAIL 9MM 28CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0930S SUP HCPCS C1713 1826-0930S - NAIL 9MM 30CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0932S SUP HCPCS C1713 1826-0932S - NAIL 9MM 32CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0934S SUP HCPCS C1713 1826-0934S - NAIL 9MM 34CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0936S SUP HCPCS C1713 1826-0936S - NAIL 9MM 36CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0938S SUP HCPCS C1713 1826-0938S - NAIL 9MM 38CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0940S SUP HCPCS C1713 1826-0940S - NAIL 9MM 40CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0942S SUP HCPCS C1713 1826-0942S - NAIL 9MM 42CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-0944S SUP HCPCS C1713 1826-0944S - NAIL 9MM 440MM SPCNDYL T2 IM BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1017S SUP HCPCS C1713 1826-1017S - NAIL 10MM 17CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1020S SUP HCPCS C1713 1826-1020S - NAIL 10MM 20CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1024S SUP HCPCS C1713 1826-1024S - NAIL 10MM 24CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1026S SUP HCPCS C1713 1826-1026S - NAIL 10MM 26CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1028S SUP HCPCS C1713 1826-1028S - NAIL 10MM 28CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1030S SUP HCPCS C1713 1826-1030S - NAIL 10MM 30CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1032S SUP HCPCS C1713 1826-1032S - NAIL 10MM 32CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1034S SUP HCPCS C1713 1826-1034S - NAIL 10MM 34CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1036S SUP HCPCS C1713 1826-1036S - NAIL 10MM 36CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1038S SUP HCPCS C1713 1826-1038S - NAIL 10MM 38CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1040S SUP HCPCS C1713 1826-1040S - NAIL 10MM 40CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1042S SUP HCPCS C1713 1826-1042S - NAIL 10MM 42CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1044S SUP HCPCS C1713 1826-1044S - NAIL 10MM 44CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1117S SUP HCPCS C1713 1826-1117S - NAIL 11MM 17CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1120S SUP HCPCS C1713 1826-1120S - NAIL 11MM 20CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1124S SUP HCPCS C1713 1826-1124S - NAIL 11MM 24CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1126S SUP HCPCS C1713 1826-1126S - NAIL 11MM 26CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1128S SUP HCPCS C1713 1826-1128S - NAIL 11MM 28CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1130S SUP HCPCS C1713 1826-1130S - NAIL 11MM 30CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1132S SUP HCPCS C1713 1826-1132S - NAIL 11MM 32CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1134S SUP HCPCS C1713 1826-1134S - NAIL 11MM 34CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1136S SUP HCPCS C1713 1826-1136S - NAIL 11MM 36CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1138S SUP HCPCS C1713 1826-1138S - NAIL 11MM 38CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1140S SUP HCPCS C1713 1826-1140S - NAIL 11MM 40CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1142S SUP HCPCS C1713 1826-1142S - NAIL 11MM 42CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1144S SUP HCPCS C1713 1826-1144S - NAIL 11MM 44CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1217S SUP HCPCS C1713 1826-1217S - NAIL 12MM 17CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1220S SUP HCPCS C1713 1826-1220S - NAIL 12MM 20CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1224S SUP HCPCS C1713 1826-1224S - NAIL 12MM 24CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1226S SUP HCPCS C1713 1826-1226S - NAIL 12MM 26CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1228S SUP HCPCS C1713 1826-1228S - NAIL 12MM 28CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1230S SUP HCPCS C1713 1826-1230S - NAIL 12MM 30CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1232S SUP HCPCS C1713 1826-1232S - NAIL 12MM 32CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1234S SUP HCPCS C1713 1826-1234S - NAIL 12MM 34CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1236S SUP HCPCS C1713 1826-1236S - NAIL 12MM 360MM SPCNDYL T2 IM BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1238S SUP HCPCS C1713 1826-1238S - NAIL 12MM 38CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1240S SUP HCPCS C1713 1826-1240S - NAIL 12MM 40CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1242S SUP HCPCS C1713 1826-1242S - NAIL 12MM 42CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1244S SUP HCPCS C1713 1826-1244S - NAIL 12MM 44CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1317S SUP HCPCS C1713 1826-1317S - NAIL 13MM 17CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1320S SUP HCPCS C1713 1826-1320S - NAIL 13MM 200MM SPCNDYL T2 IM SHRT TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1324S SUP HCPCS C1713 1826-1324S - NAIL 13MM 24CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1326S SUP HCPCS C1713 1826-1326S - NAIL 13MM 26CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1328S SUP HCPCS C1713 1826-1328S - NAIL 13MM 28CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1330S SUP HCPCS C1713 1826-1330S - NAIL 13MM 30CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1332S SUP HCPCS C1713 1826-1332S - NAIL 13MM 32CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1334S SUP HCPCS C1713 1826-1334S - NAIL 13MM 34CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1336S SUP HCPCS C1713 1826-1336S - NAIL 13MM 360MM SPCNDYL T2 IM LNG TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1338S SUP HCPCS C1713 1826-1338S - NAIL 13MM 38CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1340S SUP HCPCS C1713 1826-1340S - NAIL 13MM 40CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1342S SUP HCPCS C1713 1826-1342S - NAIL 13MM 42CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1344S SUP HCPCS C1713 1826-1344S - NAIL 13MM 44CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1417S SUP HCPCS C1713 1826-1417S - NAIL 14MM 17CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1420S SUP HCPCS C1713 1826-1420S - NAIL 14MM 20CM SPCNDYL T2 IM SHRT LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1424S SUP HCPCS C1713 1826-1424S - NAIL 14MM 24CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1426S SUP HCPCS C1713 1826-1426S - NAIL 14MM 26CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1428S SUP HCPCS C1713 1826-1428S - NAIL 14MM 28CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1430S SUP HCPCS C1713 1826-1430S - NAIL 14MM 30CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1432S SUP HCPCS C1713 1826-1432S - NAIL 14MM 32CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1434S SUP HCPCS C1713 1826-1434S - NAIL 14MM 34CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1436S SUP HCPCS C1713 1826-1436S - NAIL 14MM 36CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1438S SUP HCPCS C1713 1826-1438S - NAIL 14MM 38CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1440S SUP HCPCS C1713 1826-1440S - NAIL 14MM 40CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1442S SUP HCPCS C1713 1826-1442S - NAIL 14MM 42CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 1826-1444S SUP HCPCS C1713 1826-1444S - NAIL 14MM 44CM SPCNDYL T2 IM LNG LCK RTRGRD TI STRL BOTH IP/OP "$3,022.25 " "$2,236.47" $0.00 "$2,417.80" "$1,360.01" "$1,360.01" $0.00 $0.00 $0.00 $629.91 "$2,243.11" "$2,243.11" $0.00 $0.00 $629.84 $0.00 "$1,489.97" "$1,489.97" $0.00 "$1,511.13" "$2,393.62" "$2,417.80" $0.00 $0.00 $472.98 $0.00 $0.00 $481.14 $0.00 $0.00 $0.00 $0.00 $0.00 18-2800 SUP Custom 27803010 18-2800 - HEAD FEMORAL +0MM OFFST C TAPER 28MM HIGH PERFORMANCE BIOLOX BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18-2805 SUP Custom 27803010 18-2805 - HEAD FEMORAL +5MM OFFST C TAPER 28MM HIGH PERFORMANCE BIOLOX BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0824S SUP HCPCS C1713 1828-0824S - NAIL 8MM 24CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0826S SUP HCPCS C1713 1828-0826S - NAIL 8MM 26CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0828S SUP HCPCS C1713 1828-0828S - NAIL 8MM 28CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0830S SUP HCPCS C1713 1828-0830S - NAIL 8MM 30CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0832S SUP HCPCS C1713 1828-0832S - NAIL 8MM 32CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0834S SUP HCPCS C1713 1828-0834S - NAIL 8MM 34CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0836S SUP HCPCS C1713 1828-0836S - NAIL 8MM 36CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0838S SUP HCPCS C1713 1828-0838S - NAIL 8MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0840S SUP HCPCS C1713 1828-0840S - NAIL 8MM 40CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0842S SUP HCPCS C1713 1828-0842S - NAIL 8MM 42CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0844S SUP HCPCS C1713 1828-0844S - NAIL 8MM 44CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0846S SUP HCPCS C1713 1828-0846S - NAIL 8MM 46CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0848S SUP HCPCS C1713 1828-0848S - NAIL 8MM 48CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0924S SUP HCPCS C1713 1828-0924S - NAIL 9MM 24CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0926S SUP HCPCS C1713 1828-0926S - NAIL 9MM 26CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0928S SUP HCPCS C1713 1828-0928S - NAIL 9MM 28CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0930S SUP HCPCS C1713 1828-0930S - NAIL 9MM 30CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0932S SUP HCPCS C1713 1828-0932S - NAIL 9MM 32CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0934S SUP HCPCS C1713 1828-0934S - NAIL 9MM 34CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0936S SUP HCPCS C1713 1828-0936S - NAIL 9MM 36CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0938S SUP HCPCS C1713 1828-0938S - NAIL 9MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0940S SUP HCPCS C1713 1828-0940S - NAIL 9MM 40CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0942S SUP HCPCS C1713 1828-0942S - NAIL 9MM 42CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0944S SUP HCPCS C1713 1828-0944S - NAIL 9MM 44CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0946S SUP HCPCS C1713 1828-0946S - NAIL 9MM 46CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-0948S SUP HCPCS C1713 1828-0948S - NAIL 9MM 48CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1024S SUP HCPCS C1713 1828-1024S - NAIL 10MM 24CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1026S SUP HCPCS C1713 1828-1026S - NAIL 10MM 26CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1028S SUP HCPCS C1713 1828-1028S - NAIL 10MM 28CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1030S SUP HCPCS C1713 1828-1030S - NAIL 10MM 30CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1032S SUP HCPCS C1713 1828-1032S - NAIL 10MM 32CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1034S SUP HCPCS C1713 1828-1034S - NAIL 10MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1036S SUP HCPCS C1713 1828-1036S - NAIL 10MM 36CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1038S SUP HCPCS C1713 1828-1038S - NAIL 10MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1040S SUP HCPCS C1713 1828-1040S - NAIL 10MM 40CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1042S SUP HCPCS C1713 1828-1042S - NAIL 10MM 42CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1044S SUP HCPCS C1713 1828-1044S - NAIL 10MM 44CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1046S SUP HCPCS C1713 1828-1046S - NAIL 10MM 46CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1048S SUP HCPCS C1713 1828-1048S - NAIL 10MM 48CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1124S SUP HCPCS C1713 1828-1124S - NAIL 11MM 24CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1126S SUP HCPCS C1713 1828-1126S - NAIL 11MM 26CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1128S SUP HCPCS C1713 1828-1128S - NAIL 11MM 28CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1130S SUP HCPCS C1713 1828-1130S - NAIL 11MM 30CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1132S SUP HCPCS C1713 1828-1132S - T2 FEMORAL NAIL R1500 11MMX320MM BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1134S SUP HCPCS C1713 1828-1134S - NAIL 11MM 34CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1136S SUP HCPCS C1713 1828-1136S - NAIL 11MM 36CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1138S SUP HCPCS C1713 1828-1138S - NAIL 11MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1140S SUP HCPCS C1713 1828-1140S - NAIL 11MM 40CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1142S SUP HCPCS C1713 1828-1142S - NAIL 11MM 42CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1144S SUP HCPCS C1713 1828-1144S - NAIL 11MM 44CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1146S SUP HCPCS C1713 1828-1146S - NAIL 11MM 46CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1148S SUP HCPCS C1713 1828-1148S - NAIL 11MM 48CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1224S SUP HCPCS C1713 1828-1224S - NAIL 12MM 24CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1226S SUP HCPCS C1713 1828-1226S - NAIL 12MM 26CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1228S SUP HCPCS C1713 1828-1228S - NAIL 12MM 28CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1230S SUP HCPCS C1713 1828-1230S - NAIL 12MM 20CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1232S SUP HCPCS C1713 1828-1232S - NAIL 12MM 32CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1234S SUP HCPCS C1713 1828-1234S - NAIL 12MM 34CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1236S SUP HCPCS C1713 1828-1236S - NAIL 12MM 36CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1238S SUP HCPCS C1713 1828-1238S - NAIL 12MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1240S SUP HCPCS C1713 1828-1240S - NAIL 12MM 40CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1242S SUP HCPCS C1713 1828-1242S - NAIL 12MM 42CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1244S SUP HCPCS C1713 1828-1244S - NAIL 12MM 44CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1246S SUP HCPCS C1713 1828-1246S - NAIL 12MM 46CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1248S SUP HCPCS C1713 1828-1248S - NAIL 12MM 48CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1324S SUP HCPCS C1713 1828-1324S - NAIL 13MM 24CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1326S SUP HCPCS C1713 1828-1326S - NAIL 13MM 26CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1328S SUP HCPCS C1713 1828-1328S - NAIL 13MM 28CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1330S SUP HCPCS C1713 1828-1330S - NAIL 13MM 30CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1332S SUP HCPCS C1713 1828-1332S - NAIL 13MM 32CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1334S SUP HCPCS C1713 1828-1334S - NAIL 13MM 34CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1336S SUP HCPCS C1713 1828-1336S - NAIL 13MM 36CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1338S SUP HCPCS C1713 1828-1338S - NAIL 13MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1340S SUP HCPCS C1713 1828-1340S - NAIL 13MM 40CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1342S SUP HCPCS C1713 1828-1342S - NAIL 13MM 42CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1344S SUP HCPCS C1713 1828-1344S - NAIL 13MM 44CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1346S SUP HCPCS C1713 1828-1346S - NAIL 13MM 46CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1348S SUP HCPCS C1713 1828-1348S - NAIL 13MM 48CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1424S SUP HCPCS C1713 1828-1424S - NAIL 14MM 24CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1426S SUP HCPCS C1713 1828-1426S - NAIL 14MM 26CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1428S SUP HCPCS C1713 1828-1428S - NAIL 14MM 28CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1430S SUP HCPCS C1713 1828-1430S - NAIL 14MM 30CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1432S SUP HCPCS C1713 1828-1432S - NAIL 14MM 32CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1434S SUP HCPCS C1713 1828-1434S - NAIL 14MM 34CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1436S SUP HCPCS C1713 1828-1436S - NAIL 14MM 36CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1438S SUP HCPCS C1713 1828-1438S - NAIL 14MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1440S SUP HCPCS C1713 1828-1440S - NAIL 14MM 40CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1442S SUP HCPCS C1713 1828-1442S - NAIL 14MM 42CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1444S SUP HCPCS C1713 1828-1444S - NAIL 14MM 44CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1446S SUP HCPCS C1713 1828-1446S - NAIL 14MM 46CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1448S SUP HCPCS C1713 1828-1448S - NAIL 14MM 48CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1524S SUP HCPCS C1713 1828-1524S - NAIL 15MM 24CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1526S SUP HCPCS C1713 1828-1526S - NAIL 15MM 26CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1528S SUP HCPCS C1713 1828-1528S - NAIL 15MM 28CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1530S SUP HCPCS C1713 1828-1530S - NAIL 15MM 30CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1532S SUP HCPCS C1713 1828-1532S - NAIL 15MM 32CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1534S SUP HCPCS C1713 1828-1534S - NAIL 15MM 34CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1536S SUP HCPCS C1713 1828-1536S - NAIL 15MM 36CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1538S SUP HCPCS C1713 1828-1538S - NAIL 15MM 38CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1540S SUP HCPCS C1713 1828-1540S - NAIL 15MM 40CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1542S SUP HCPCS C1713 1828-1542S - NAIL 15MM 42CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1544S SUP HCPCS C1713 1828-1544S - NAIL 15MM 44CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1546S SUP HCPCS C1713 1828-1546S - NAIL 15MM 46CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 1828-1548S SUP HCPCS C1713 1828-1548S - NAIL 15MM 48CM FEM T2 IM LCK TI STRL R1.5 BOTH IP/OP "$2,601.50 " "$1,925.11" $0.00 "$2,081.20" "$1,170.68" "$1,170.68" $0.00 $0.00 $0.00 $542.22 "$1,930.83" "$1,930.83" $0.00 $0.00 $542.15 $0.00 "$1,282.54" "$1,282.54" $0.00 "$1,300.75" "$2,060.39" "$2,081.20" $0.00 $0.00 $407.13 $0.00 $0.00 $414.16 $0.00 $0.00 $0.00 $0.00 $0.00 18-2825 SUP Custom 27803010 18-2825 - HEAD FEMORAL +2.5MM OFFST C TAPER 28MM HIGH PERFORMANCE BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18-28-3 SUP Custom 27803010 18-28-3 - HEAD FEM -2.5MM OFST CTPR 28MM HPRFR BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1829-1104S SUP HCPCS C1713 1829-1104S - NAIL 11.5MM 54CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1108S SUP HCPCS C1713 1829-1108S - NAIL 11.5MM 58CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1112S SUP HCPCS C1713 1829-1112S - NAIL 11.5MM 62CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1116S SUP HCPCS C1713 1829-1116S - NAIL 11.5MM 66CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1120S SUP HCPCS C1713 1829-1120S - NAIL 11.5MM 70CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1124S SUP HCPCS C1713 1829-1124S - NAIL 11.5MM 74CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1128S SUP HCPCS C1713 1829-1128S - NAIL 11.5MM 78CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1154S SUP HCPCS C1713 1829-1154S - NAIL 11.5MM 54CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1158S SUP HCPCS C1713 1829-1158S - NAIL 11.5MM 58CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1162S SUP HCPCS C1713 1829-1162S - NAIL 11.5MM 62CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1166S SUP HCPCS C1713 1829-1166S - NAIL 11.5MM 66CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1170S SUP HCPCS C1713 1829-1170S - NAIL 11.5MM 70CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1174S SUP HCPCS C1713 1829-1174S - NAIL 11.5MM 75CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1178S SUP HCPCS C1713 1829-1178S - NAIL 11.5MM 78CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1304S SUP HCPCS C1713 1829-1304S - NAIL 13MM 54CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1308S SUP HCPCS C1713 1829-1308S - NAIL 13MM 58CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1312S SUP HCPCS C1713 1829-1312S - NAIL 13MM 62CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1316S SUP HCPCS C1713 1829-1316S - NAIL 13MM 66CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1320S SUP HCPCS C1713 1829-1320S - NAIL 13MM 70CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1324S SUP HCPCS C1713 1829-1324S - NAIL 13MM 74CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1328S SUP HCPCS C1713 1829-1328S - NAIL 13MM 78CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1354S SUP HCPCS C1713 1829-1354S - NAIL 13MM 54CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1358S SUP HCPCS C1713 1829-1358S - NAIL 13MM 58CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1362S SUP HCPCS C1713 1829-1362S - NAIL 13MM 62CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1366S SUP HCPCS C1713 1829-1366S - NAIL 13MM 66CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1370S SUP HCPCS C1713 1829-1370S - NAIL 13MM 70CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1374S SUP HCPCS C1713 1829-1374S - NAIL 13MM 74CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-1378S SUP HCPCS C1713 1829-1378S - NAIL 13MM 78CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2004S SUP HCPCS C1713 1829-2004S - NAIL 10MM 54CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2008S SUP HCPCS C1713 1829-2008S - NAIL 10MM 58CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2012S SUP HCPCS C1713 1829-2012S - NAIL 10MM 62CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2016S SUP HCPCS C1713 1829-2016S - NAIL 10MM 66CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2020S SUP HCPCS C1713 1829-2020S - NAIL 10MM 70CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2024S SUP HCPCS C1713 1829-2024S - NAIL 10MM 74CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2028S SUP HCPCS C1713 1829-2028S - NAIL 10MM 78CM LEFT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2054S SUP HCPCS C1713 1829-2054S - NAIL 10MM 54CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2058S SUP HCPCS C1713 1829-2058S - NAIL 10MM 58CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2062S SUP HCPCS C1713 1829-2062S - NAIL 10MM 62CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2066S SUP HCPCS C1713 1829-2066S - NAIL 10MM 66CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2070S SUP HCPCS C1713 1829-2070S - NAIL 10MM 70CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2074S SUP HCPCS C1713 1829-2074S - NAIL 10MM 74CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1829-2078S SUP HCPCS C1713 1829-2078S - NAIL 10MM 78CM RIGHT T2 IM ARTHDES TI STRL BOTH IP/OP "$10,267.15 " "$7,597.69" $0.00 "$6,926.70" "$3,896.27" "$3,896.27" $0.00 $0.00 $0.00 "$2,139.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,139.67" $0.00 "$5,061.70" "$5,061.70" $0.00 "$4,329.19" "$6,857.44" "$6,926.70" $0.00 $0.00 "$1,355.04" $0.00 $0.00 "$1,378.41" $0.00 $0.00 $0.00 $0.00 $0.00 1830-0001S SUP HCPCS C1713 1830-0001S - SCREW BONE T2 TI CMPR ADV STRL IM NAIL BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0003S SUP HCPCS C1713 1830-0003S - CAP END 6MM HUM IM NAIL TI STRL T2 9MM BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0005S SUP HCPCS C1713 1830-0005S - CAP END +5MM HUM IM NAIL TI STRL T2 9MM BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0008S SUP HCPCS C1713 1830-0008S - WASHER HUM RND T2 ORTH TI IM NAIL STRL BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0009S SUP HCPCS C1713 1830-0009S - WASHER HUM SQ T2 ORTH TI IM NAIL STRL BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0010S SUP HCPCS C1713 1830-0010S - CAP END +10MM HUM IM NAIL TI STRL T2 BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0015S SUP HCPCS C1713 1830-0015S - CAP END +15MM HUM IM NAIL TI STRL T2 BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0020S SUP HCPCS C1713 1830-0020S - CAP END +20MM HUM IM NAIL TI STRL T2 BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0025S SUP HCPCS C1713 1830-0025S - CAP END +25MM HUM IM NAIL TI STRL T2 BOTH IP/OP $282.20 $208.83 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $58.82 $209.45 $209.45 $0.00 $0.00 $58.81 $0.00 $166.92 $166.92 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0714S SUP HCPCS C1713 1830-0714S - NAIL 7MM 14CM HUM T2 IM LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0716S SUP HCPCS C1713 1830-0716S - NAIL 7MM 16CM HUM T2 IM LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0718S SUP HCPCS C1713 1830-0718S - NAIL 7MM 18CM HUM T2 IM LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0719S SUP HCPCS C1713 1830-0719S - NAIL 7MM 19CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0720S SUP HCPCS C1713 1830-0720S - NAIL 7MM 20CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0721S SUP HCPCS C1713 1830-0721S - NAIL 7MM 21CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0722S SUP HCPCS C1713 1830-0722S - NAIL 7MM 22CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0723S SUP HCPCS C1713 1830-0723S - NAIL 7MM 23CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0724S SUP HCPCS C1713 1830-0724S - NAIL 7MM 24CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0725S SUP HCPCS C1713 1830-0725S - NAIL 7MM 25CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0726S SUP HCPCS C1713 1830-0726S - NAIL 7MM 26CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0727S SUP HCPCS C1713 1830-0727S - NAIL 7MM 27CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0728S SUP HCPCS C1713 1830-0728S - NAIL 7MM 28CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0729S SUP HCPCS C1713 1830-0729S - NAIL 7MM 29CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0730S SUP HCPCS C1713 1830-0730S - NAIL 7MM 30CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0731S SUP HCPCS C1713 1830-0731S - NAIL 7MM 31CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0732S SUP HCPCS C1713 1830-0732S - NAIL 7MM 32CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0814S SUP HCPCS C1713 1830-0814S - NAIL 8MM 14CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0816S SUP HCPCS C1713 1830-0816S - NAIL 8MM 16CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0818S SUP HCPCS C1713 1830-0818S - NAIL 8MM 18CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0819S SUP HCPCS C1713 1830-0819S - NAIL 8MM 19CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0820S SUP HCPCS C1713 1830-0820S - NAIL 8MM 20CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0821S SUP HCPCS C1713 1830-0821S - NAIL 8MM 21CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0822S SUP HCPCS C1713 1830-0822S - NAIL 8MM 22CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0823S SUP HCPCS C1713 1830-0823S - NAIL 8MM 23CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0824S SUP HCPCS C1713 1830-0824S - NAIL 8MM 24CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0825S SUP HCPCS C1713 1830-0825S - NAIL 8MM 25CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0826S SUP HCPCS C1713 1830-0826S - NAIL 8MM 26CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0827S SUP HCPCS C1713 1830-0827S - NAIL 8MM 27CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0828S SUP HCPCS C1713 1830-0828S - NAIL 8MM 28CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0829S SUP HCPCS C1713 1830-0829S - NAIL 8MM 29CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0830S SUP HCPCS C1713 1830-0830S - NAIL 8MM 30CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0831S SUP HCPCS C1713 1830-0831S - NAIL 8MM 31CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0832S SUP HCPCS C1713 1830-0832S - NAIL 8MM 32CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0914S SUP HCPCS C1713 1830-0914S - NAIL 9MM 14CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0916S SUP HCPCS C1713 1830-0916S - NAIL 9MM 16CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0918S SUP HCPCS C1713 1830-0918S - NAIL 9MM 18CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0919S SUP HCPCS C1713 1830-0919S - NAIL 9MM 19CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0920S SUP HCPCS C1713 1830-0920S - NAIL 9MM 20CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0921S SUP HCPCS C1713 1830-0921S - NAIL 9MM 21CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0922S SUP HCPCS C1713 1830-0922S - NAIL 9MM 22CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0923S SUP HCPCS C1713 1830-0923S - NAIL 9MM 23CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0924S SUP HCPCS C1713 1830-0924S - NAIL 9MM 24CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0925S SUP HCPCS C1713 1830-0925S - NAIL 9MM 25CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0926S SUP HCPCS C1713 1830-0926S - NAIL 9MM 26CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0927S SUP HCPCS C1713 1830-0927S - NAIL 9MM 27CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0928S SUP HCPCS C1713 1830-0928S - NAIL 9MM 28CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0929S SUP HCPCS C1713 1830-0929S - NAIL 9MM 29CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0930S SUP HCPCS C1713 1830-0930S - NAIL 9MM 30CM HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0931S SUP HCPCS C1713 1830-0931S - NAIL 9MM 31CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 1830-0932S SUP HCPCS C1713 1830-0932S - NAIL 9MM 32CM HUM T2 IM ANTGRD/RTRGRD LCK TI STRL BOTH IP/OP "$2,353.65 " "$1,741.70" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $490.56 "$1,746.88" "$1,746.88" $0.00 $0.00 $490.50 $0.00 "$1,392.18" "$1,392.18" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 18-3200 SUP Custom 27803010 18-3200 - HEAD FEMORAL +0MM OFFST C TAPER 32MM HIGH PERFORMANCE BIOLOX BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1832-0002S SUP HCPCS C1713 1832-0002S - CAP END +2MM PROX HUM IM NAIL TI STRL T2 BOTH IP/OP $284.75 $210.72 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $59.35 $211.34 $211.34 $0.00 $0.00 $59.34 $0.00 $168.43 $168.43 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1832-0003S SUP HCPCS C1713 1832-0003S - CAP END +3MM PROX HUM IM NAIL TI STRL T2 BOTH IP/OP $284.75 $210.72 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $59.35 $211.34 $211.34 $0.00 $0.00 $59.34 $0.00 $168.43 $168.43 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1832-0004S SUP HCPCS C1713 1832-0004S - CAP END +4MM PROX HUM IM NAIL TI STRL T2 BOTH IP/OP $284.75 $210.72 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $59.35 $211.34 $211.34 $0.00 $0.00 $59.34 $0.00 $168.43 $168.43 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 18-3205 SUP Custom 27803010 18-3205 - HEAD FEMORAL +5MM OFFST C TAPER 32MM HIGH PERFORMANCE BIOLOX BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18-3225 SUP Custom 27803010 18-3225 - HEAD FEMORAL +2.5MM OFFST C TAPER 32MM HIGH PERFORMANCE BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1832-2822S SUP HCPCS C1713 1832-2822S - NAIL 8MM 22CM LEFT PROX HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 1832-2824S SUP HCPCS C1713 1832-2824S - NAIL 8MM 240MM LEFT PROX HUM T2 IM LG BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 1832-2826S SUP HCPCS C1713 1832-2826S - NAIL 8MM 26CM LEFT PROX HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 1832-2828S SUP HCPCS C1713 1832-2828S - NAIL 8MM 28CM LEFT PROX HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 1832-2830S SUP HCPCS C1713 1832-2830S - NAIL 8MM 30CM LEFT PROX HUM T2 IM RTRGRD ANTGRD LCK TI STRL BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 18-32-3 SUP Custom 27803010 18-32-3 - HEAD FEMORAL -2.5MM OFFST C TAPER 32MM HIGH PERFORMANCE BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1832-3822S SUP HCPCS C1713 1832-3822S - NAIL 8MM 22CM RIGHT PROX HUM T2 IM LNG RTRGRD ANTGRD LCK TI BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 1832-3824S SUP HCPCS C1713 1832-3824S - NAIL 8MM 24CM RIGHT PROX HUM T2 IM LNG RTRGRD ANTGRD LCK TI BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 1832-3826S SUP HCPCS C1713 1832-3826S - NAIL 8MM 26CM RIGHT PROX HUM T2 IM LNG RTRGRD ANTGRD LCK TI BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 1832-3828S SUP HCPCS C1713 1832-3828S - NAIL 8MM 28CM RIGHT PROX HUM T2 IM LNG RTRGRD ANTGRD LCK TI BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 1832-3830S SUP HCPCS C1713 1832-3830S - NAIL 8MM 30CM RIGHT PROX HUM T2 IM LNG RTRGRD ANTGRD LCK TI BOTH IP/OP "$2,918.05 " "$2,159.36" $0.00 "$2,343.00" "$1,317.94" "$1,317.94" $0.00 $0.00 $0.00 $608.19 "$2,165.78" "$2,165.78" $0.00 $0.00 $608.12 $0.00 "$1,438.60" "$1,438.60" $0.00 "$1,464.38" "$2,319.57" "$2,343.00" $0.00 $0.00 $458.35 $0.00 $0.00 $466.26 $0.00 $0.00 $0.00 $0.00 $0.00 18-3600 SUP Custom 27803010 18-3600 - HEAD FEMORAL 0MM OFFST C TAPER 36MM HIGH PERFORMANCE BIOLOX BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18-3605 SUP Custom 27803010 18-3605 - HEAD FEMORAL +5MM OFFST C TAPER 36MM HIGH PERFORMANCE BIOLOX BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18-3625 SUP Custom 27803010 18-3625 - HEAD FEMORAL +2.5MM OFFST C TAPER 36MM HIGH PERFORMANCE BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18-36-3 SUP Custom 27803010 18-36-3 - HEAD FEMORAL -2.5MM OFFST C TAPER 36MM HIGH PERFORMANCE BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18-36-5 SUP Custom 27803010 18-36-5 - HEAD FEMORAL -5MM OFFST C TAPER 36MM HIGH PERFORMANCE BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 18-3675 SUP Custom 27803010 18-3675 - HEAD FEMORAL +7.5MM 36MM C TAPER BIOLOX DELTA HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0928S SUP HCPCS C1713 1846-0928S - NAIL 9MM 28CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0930S SUP HCPCS C1713 1846-0930S - NAIL 9MM 30CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0932S SUP HCPCS C1713 1846-0932S - NAIL 9MM 32CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0934S SUP HCPCS C1713 1846-0934S - NAIL 9MM 34CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0936S SUP HCPCS C1713 1846-0936S - NAIL 9MM 36CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0938S SUP HCPCS C1713 1846-0938S - NAIL 9MM 38CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0940S SUP HCPCS C1713 1846-0940S - NAIL 9MM 40CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0942S SUP HCPCS C1713 1846-0942S - NAIL 9MM 42CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0944S SUP HCPCS C1713 1846-0944S - NAIL 9MM 44CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0946S SUP HCPCS C1713 1846-0946S - NAIL 9MM 460MM LEFT T2 IM RECON STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-0948S SUP HCPCS C1713 1846-0948S - NAIL 9MM 480MM LEFT T2 IM RECON STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1128S SUP HCPCS C1713 1846-1128S - NAIL 11MM 28CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1130S SUP HCPCS C1713 1846-1130S - NAIL 11MM 30CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1132S SUP HCPCS C1713 1846-1132S - NAIL 11MM 32CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1134S SUP HCPCS C1713 1846-1134S - NAIL 11MM 34CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1136S SUP HCPCS C1713 1846-1136S - NAIL 11MM 36CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1138S SUP HCPCS C1713 1846-1138S - NAIL 11MM 38CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1140S SUP HCPCS C1713 1846-1140S - NAIL 11MM 40CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1142S SUP HCPCS C1713 1846-1142S - NAIL 11MM 42CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1144S SUP HCPCS C1713 1846-1144S - NAIL 11MM 44CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1146S SUP HCPCS C1713 1846-1146S - NAIL 11MM 460MM LEFT T2 IM RECON STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1148S SUP HCPCS C1713 1846-1148S - NAIL 11MM 480MM LEFT T2 IM RECON STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1334S SUP HCPCS C1713 1846-1334S - NAIL 13MM 34CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1336S SUP HCPCS C1713 1846-1336S - NAIL 13MM 36CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1338S SUP HCPCS C1713 1846-1338S - NAIL 13MM 38CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1340S SUP HCPCS C1713 1846-1340S - NAIL 13MM 40CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1342S SUP HCPCS C1713 1846-1342S - NAIL 13MM 42CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1344S SUP HCPCS C1713 1846-1344S - NAIL 13MM 44CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1346S SUP HCPCS C1713 1846-1346S - NAIL 13MM 46CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1348S SUP HCPCS C1713 1846-1348S - NAIL 13MM 48CM LEFT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1534S SUP HCPCS C1713 1846-1534S - NAIL 15MM 340MM LEFT T2 IM RECON BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1536S SUP HCPCS C1713 1846-1536S - NAIL 360MM LEFT IM LCK ANTEGADE BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1538S SUP HCPCS C1713 1846-1538S - NAIL 15MM 380MM LEFT ORTH T2 IM ANTGRD RECON TI 5MM STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1540S SUP HCPCS C1713 1846-1540S - NAIL 400MM LEFT IM LCK ANTEGADE BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1542S SUP HCPCS C1713 1846-1542S - NAIL 420MM LEFT IM LCK ANTEGADE BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1544S SUP HCPCS C1713 1846-1544S - NAIL 440MM LEFT IM LCK ANTEGADE BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1546S SUP HCPCS C1713 1846-1546S - NAIL 460MM LEFT IM LCK RECON TI BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1846-1548S SUP HCPCS C1713 1846-1548S - NAIL 15MM 480MM LEFT T2 IM RECON BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0001S SUP HCPCS C1713 1847-0001S - SCREW SET T2 8MM STRL LCK RECON ANGL STAB TI PROX IM NL BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0002S SUP HCPCS C1713 1847-0002S - SCREW SET TI 8MM PROX RECON MODE T2 STRL IM NAIL BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0003S SUP HCPCS C1713 1847-0003S - SCREW SET TI 8MM PROX ANTGRD T2 STRL IM NAIL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0005S SUP HCPCS C1713 1847-0005S - CAP END +5MM RECON IM NAIL TI STRL T2 BOTH IP/OP $284.75 $210.72 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $59.35 $211.34 $211.34 $0.00 $0.00 $59.34 $0.00 $168.43 $168.43 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0010S SUP HCPCS C1713 1847-0010S - CAP END +10MM RECON IM NAIL TI STRL T2 BOTH IP/OP $284.75 $210.72 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $59.35 $211.34 $211.34 $0.00 $0.00 $59.34 $0.00 $168.43 $168.43 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0015S SUP HCPCS C1713 1847-0015S - CAP END +15MM RECON IM NAIL TI STRL T2 BOTH IP/OP $284.75 $210.72 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $59.35 $211.34 $211.34 $0.00 $0.00 $59.34 $0.00 $168.43 $168.43 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0928S SUP HCPCS C1713 1847-0928S - NAIL 9MM 28CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0930S SUP HCPCS C1713 1847-0930S - NAIL 9MM 30CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0932S SUP HCPCS C1713 1847-0932S - NAIL 9MM 32CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0934S SUP HCPCS C1713 1847-0934S - NAIL 9MM 34CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0936S SUP HCPCS C1713 1847-0936S - NAIL 9MM 36CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0938S SUP HCPCS C1713 1847-0938S - NAIL 9MM 38CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0940S SUP HCPCS C1713 1847-0940S - NAIL 9MM 40CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0942S SUP HCPCS C1713 1847-0942S - NAIL 9MM 42CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0944S SUP HCPCS C1713 1847-0944S - NAIL 9MM 44CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0946S SUP HCPCS C1713 1847-0946S - NAIL 9MM 460MM RIGHT T2 IM RECON STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-0948S SUP HCPCS C1713 1847-0948S - NAIL 9MM 480MM RIGHT T2 IM RECON STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1128S SUP HCPCS C1713 1847-1128S - NAIL 11MM 28CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1130S SUP HCPCS C1713 1847-1130S - NAIL 11MM 30CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1132S SUP HCPCS C1713 1847-1132S - NAIL 11MM 32CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1134S SUP HCPCS C1713 1847-1134S - NAIL 11MM 34CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1136S SUP HCPCS C1713 1847-1136S - NAIL 11MM 36CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1138S SUP HCPCS C1713 1847-1138S - NAIL 11MM 38CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1140S SUP HCPCS C1713 1847-1140S - NAIL 11MM 40CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1142S SUP HCPCS C1713 1847-1142S - NAIL 11MM 42CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1144S SUP HCPCS C1713 1847-1144S - NAIL 11MM 44CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1146S SUP HCPCS C1713 1847-1146S - NAIL 11MM 460MM RIGHT T2 IM RECON STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1148S SUP HCPCS C1713 1847-1148S - NAIL 11MM 480MM RIGHT T2 IM RECON STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1334S SUP HCPCS C1713 1847-1334S - NAIL 13MM 34CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1336S SUP HCPCS C1713 1847-1336S - NAIL 13MM 36CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1338S SUP HCPCS C1713 1847-1338S - NAIL 13MM 38CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1340S SUP HCPCS C1713 1847-1340S - NAIL 13MM 40CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1342S SUP HCPCS C1713 1847-1342S - NAIL 13MM 42CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1344S SUP HCPCS C1713 1847-1344S - NAIL 13MM 44CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1346S SUP HCPCS C1713 1847-1346S - NAIL 13MM 46CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1348S SUP HCPCS C1713 1847-1348S - NAIL 13MM 48CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1534S SUP HCPCS C1713 1847-1534S - NAIL 15MM 340MM RIGHT T2 IM RECON ANTEGADE TI BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1536S SUP HCPCS C1713 1847-1536S - NAIL 15MM 36CM RIGHT ORTH T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1538S SUP HCPCS C1713 1847-1538S - NAIL 15MM 38CM RIGHT T2 IM RECON TI STRL BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1540S SUP HCPCS C1713 1847-1540S - NAIL 15MM 400MM RIGHT T2 IM ANTGRD RECON TI BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1542S SUP HCPCS C1713 1847-1542S - NAIL 15MM 420MM RIGHT T2 IM LCK ANTEGADE RECON TI 5MM BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1544S SUP HCPCS C1713 1847-1544S - NAIL 15MM 440MM RIGHT T2 IM ANTGRD RECON TI BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1546S SUP HCPCS C1713 1847-1546S - NAIL 15MM 460MM RIGHT T2 IM RECON IMPL TI BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1847-1548S SUP HCPCS C1713 1847-1548S - NAIL 480MM IM LCK BOTH IP/OP "$3,196.88 " "$2,365.69" $0.00 "$2,557.50" "$1,438.59" "$1,438.59" $0.00 $0.00 $0.00 $666.31 "$2,372.72" "$2,372.72" $0.00 $0.00 $666.23 $0.00 "$1,576.06" "$1,576.06" $0.00 "$1,598.44" "$2,531.93" "$2,557.50" $0.00 $0.00 $500.31 $0.00 $0.00 $508.94 $0.00 $0.00 $0.00 $0.00 $0.00 1850-0002S SUP HCPCS C1713 1850-0002S - END CAP PLUS 0 MM BOTH IP/OP $278.80 $206.31 $0.00 $247.50 $139.22 $139.22 $0.00 $0.00 $0.00 $58.11 $206.93 $206.93 $0.00 $0.00 $58.10 $0.00 $164.91 $164.91 $0.00 $154.69 $245.03 $247.50 $0.00 $0.00 $48.42 $0.00 $0.00 $49.25 $0.00 $0.00 $0.00 $0.00 $0.00 1850-0003S SUP HCPCS C1713 1850-0003S - T2 CANNULATED COMP. SCREW BOTH IP/OP $304.30 $225.18 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $63.42 $225.85 $225.85 $0.00 $0.00 $63.42 $0.00 $179.99 $179.99 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 1850-0005S SUP HCPCS C1713 1850-0005S - END CAP PLUS 5 MM BOTH IP/OP $278.80 $206.31 $0.00 $247.50 $139.22 $139.22 $0.00 $0.00 $0.00 $58.11 $206.93 $206.93 $0.00 $0.00 $58.10 $0.00 $164.91 $164.91 $0.00 $154.69 $245.03 $247.50 $0.00 $0.00 $48.42 $0.00 $0.00 $49.25 $0.00 $0.00 $0.00 $0.00 $0.00 1850-0010S SUP HCPCS C1713 1850-0010S - END CAP PLUS 10 MM BOTH IP/OP $278.80 $206.31 $0.00 $247.50 $139.22 $139.22 $0.00 $0.00 $0.00 $58.11 $206.93 $206.93 $0.00 $0.00 $58.10 $0.00 $164.91 $164.91 $0.00 $154.69 $245.03 $247.50 $0.00 $0.00 $48.42 $0.00 $0.00 $49.25 $0.00 $0.00 $0.00 $0.00 $0.00 1850-0015S SUP HCPCS C1713 1850-0015S - END CAP PLUS 15 MM BOTH IP/OP $278.80 $206.31 $0.00 $247.50 $139.22 $139.22 $0.00 $0.00 $0.00 $58.11 $206.93 $206.93 $0.00 $0.00 $58.10 $0.00 $164.91 $164.91 $0.00 $154.69 $245.03 $247.50 $0.00 $0.00 $48.42 $0.00 $0.00 $49.25 $0.00 $0.00 $0.00 $0.00 $0.00 186002-44 SUP HCPCS C1776 186002-44 - SHELL ACTB 44MM CH POR HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-46 SUP HCPCS C1776 186002-46 - SHELL ACTB HMSPHR 46MM 3.1MM PST RESTORIS CH CUP TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-48 SUP HCPCS C1776 186002-48 - SHELL ACTB HMSPHR 48MM 3.2MM PST RESTORIS CH CUP TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-50 SUP HCPCS C1776 186002-50 - SHELL ACTB HMSPHR 50MM 3.1MM STRL PST RESTORIS CH TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-52 SUP HCPCS C1776 186002-52 - SHELL ACTB HMSPHR 52MM 3.1MM STRL PST RESTORIS CH TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-54 SUP HCPCS C1776 186002-54 - SHELL ACTB HMSPHR 54MM 3.5MM STRL PST RESTORIS TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-56 SUP HCPCS C1776 186002-56 - SHELL ACTB HMSPHR 56MM 3.7MM STRL PST RESTORIS TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-58 SUP HCPCS C1776 186002-58 - SHELL ACTB 58MM CH POR HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-60 SUP HCPCS C1776 186002-60 - SHELL ACTB HMSPHR 60MM 4.8MM PST RESTORIS CH CUP TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-62 SUP HCPCS C1776 186002-62 - SHELL ACTB HMSPHR 62MM 4MM STRL PST RESTORIS CH CUP TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-64 SUP HCPCS C1776 186002-64 - SHELL ACTB HMSPHR 64MM 5MM PST RESTORIS CH CUP TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-66 SUP HCPCS C1776 186002-66 - SHELL ACTB HMSPHR 66MM 4.6MM PST RESTORIS CH CUP TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186002-68 SUP HCPCS C1776 186002-68 - SHELL ACTB HMSPHR 68MM 5.6MM PST RESTORIS CH CUP TI HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 186003-02 SUP HCPCS C1776 186003-02 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-03 SUP HCPCS C1776 186003-03 - STEM FEM 3 12/14 TPR STRL RESTORIS STD NK HIP BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-04 SUP HCPCS C1776 186003-04 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-05 SUP HCPCS C1776 186003-05 - STEM FEM 5 12/14 TPR STRL RESTORIS STD NK HIP BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-06 SUP HCPCS C1776 186003-06 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-07 SUP HCPCS C1776 186003-07 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-08 SUP HCPCS C1776 186003-08 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-09 SUP HCPCS C1776 186003-09 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-10 SUP HCPCS C1776 186003-10 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-11 SUP HCPCS C1776 186003-11 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186003-12 SUP HCPCS C1776 186003-12 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-02 SUP HCPCS C1776 186004-02 - STEM FEM 2 12/14 TPR STRL RESTORIS HI OFST NK HIP BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-03 SUP HCPCS C1776 186004-03 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-04 SUP HCPCS C1776 186004-04 - STEM FEM 4 12/14 TPR STRL RESTORIS HI OFST NK HIP BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-05 SUP HCPCS C1776 186004-05 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-06 SUP HCPCS C1776 186004-06 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-07 SUP HCPCS C1776 186004-07 - STEM FEM 7 12/14 TPR STRL RESTORIS XTD OFST NK HIP BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-08 SUP HCPCS C1776 186004-08 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-09 SUP HCPCS C1776 186004-09 - STEM FEM 9 12/14 TPR STRL RESTORIS HI OFST NK HIP BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-10 SUP HCPCS C1776 186004-10 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-11 SUP HCPCS C1776 186004-11 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186004-12 SUP HCPCS C1776 186004-12 - STEM FEM BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 186005-15 SUP HCPCS C1713 186005-15 - SCREW ACTB 6.5MM 15MM ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 186005-20 SUP HCPCS C1713 186005-20 - SCREW ACTB 6.5MM 20MM ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 186005-25 SUP HCPCS C1713 186005-25 - SCREW ACTB 6.5MM 25MM ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 186005-30 SUP HCPCS C1713 186005-30 - SCREW ACTB 6.5MM 30MM ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 186005-35 SUP HCPCS C1713 186005-35 - SCREW ACTB 6.5MM 35MM ACTB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 186005-40 SUP HCPCS C1713 186005-40 - SCREW ACTB 6.5MM 40MM STRL RESTORIS BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 186128-44 SUP HCPCS C1776 186128-44 - LINER ACTB 44MM 28MM 7.1MM RESTORIS WR RST OXDT STAB XLVE BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186128-46 SUP HCPCS C1776 186128-46 - LINER ACTB 46MM 28MM 7.1MM RESTORIS WR RST OXDT STAB XLVE BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186128-48 SUP HCPCS C1776 186128-48 - LINER ACTB 48MM 28MM 7.6MM RESTORIS WR RST OXDT STAB XLVE BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186128-50 SUP HCPCS C1776 186128-50 - LINER ACTB 50MM 28MM 8.6MM RESTORIS WR RST OXDT STAB XLVE BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186132-48 SUP HCPCS C1776 186132-48 - LINER ACTB NTRL 48MM 32MM E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186132-50 SUP HCPCS C1776 186132-50 - LINER ACTB HMSPHR 50MM 32MM 6.9MM STRL 4.5MM RESTORIS XLVE BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186132-52 SUP HCPCS C1776 186132-52 - LINER ACTB NTRL 52MM 32MM E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186132-54 SUP HCPCS C1776 186132-54 - LINER ACTB 54MM 32MM 7.8MM RESTORIS WR RST OXDT STAB XLVE BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186136-52 SUP HCPCS C1776 186136-52 - LINER ACTB HMSPHR 52MM 36MM 6.6MM STRL 3.7MM RESTORIS XLVE BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186136-54 SUP HCPCS C1776 186136-54 - LINER ACTB HMSPHR 36MM 54MM 6.7MM STRL RESTORIS XLVE HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186136-56 SUP HCPCS C1776 186136-56 - LINER ACTB HMSPHR 36MM 56MM 7.1MM STRL RESTORIS XLVE HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186136-58 SUP HCPCS C1776 186136-58 - LINER ACTB NTRL DOME TPR 58-60MM 36MM 7.7MM LD BRNG XLVE HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186136-62 SUP HCPCS C1776 186136-62 - LINER ACTB 62-64MM 36MM 9.3MM RESTORIS WR RST OXDT STAB XLVE BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186136-66 SUP HCPCS C1776 186136-66 - LINER ACTB 66-68MM 36MM 10.9MM RESTORIS WR RST OXDT STAB BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186140-56 SUP HCPCS C1776 186140-56 - LINER ACTB 7.5MM BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186140-58 SUP HCPCS C1776 186140-58 - LINER ACTB 8.4MM BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186140-62 SUP HCPCS C1776 186140-62 - LINER ACTB 10.3MM BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186140-66 SUP HCPCS C1776 186140-66 - LINER ACTB 11.9MM BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186228-44 SUP HCPCS C1776 186228-44 - LINER ACTB 44MM 28MM HW E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186228-46 SUP HCPCS C1776 186228-46 - LINER ACTB 46MM 28MM HW E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186228-48 SUP HCPCS C1776 186228-48 - LINER ACTB BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186228-50 SUP HCPCS C1776 186228-50 - LINER ACTB BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186232-48 SUP HCPCS C1776 186232-48 - LINER ACTB 48MM 32MM HW E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186232-50 SUP HCPCS C1776 186232-50 - LINER ACTB 50MM PST RESTORIS HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186232-52 SUP HCPCS C1776 186232-52 - LINER ACTB 52MM 32MM HW E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186232-54 SUP HCPCS C1776 186232-54 - LINER ACTB BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186236-52 SUP HCPCS C1776 186236-52 - LINER ACTB 52MM 36MM HW E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186236-54 SUP HCPCS C1776 186236-54 - LINER ACTB 54MM 36MM HW E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186236-56 SUP HCPCS C1776 186236-56 - LINER ACTB 56MM 36MM HW E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186236-58 SUP HCPCS C1776 186236-58 - LINER ACTB 58-60MM 36MM HW E-POLY HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186236-62 SUP HCPCS C1776 186236-62 - LINER ACTB 62/63/64MM 36MM STRL RESTORIS HW XLVE HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186236-66 SUP HCPCS C1776 186236-66 - LINER ACTB BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $648.00 $648.00 $0.00 $0.00 $0.00 $300.13 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $851.76 $851.76 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $225.36 $0.00 $0.00 $229.25 $0.00 $0.00 $0.00 $0.00 $0.00 186628-00 SUP HCPCS C1776 186628-00 - HEAD FEM BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186628-01 SUP HCPCS C1776 186628-01 - HEAD FEM BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186628-02 SUP HCPCS C1776 186628-02 - HEAD FEM BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186632-00 SUP HCPCS C1776 186632-00 - HEAD FEM SM 32MM RESTORIS CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186632-01 SUP HCPCS C1776 186632-01 - SHELL ACTB HMSPHR 50MM 3.1MM STRL PST RESTORIS CH TI HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186632-02 SUP HCPCS C1776 186632-02 - HEAD FEM BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186632-03 SUP HCPCS C1776 186632-03 - HEAD FEM BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186636-00 SUP HCPCS C1776 186636-00 - HEAD FEM BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186636-01 SUP HCPCS C1776 186636-01 - HEAD FEM +0MM 12/14 TPR MED 36MM STRL RESTORIS CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186636-02 SUP HCPCS C1776 186636-02 - HEAD FEM LG 36MM RESTORIS CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186636-03 SUP HCPCS C1776 186636-03 - HEAD FEM XL 36MM RESTORIS CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186640-00 SUP HCPCS C1776 186640-00 - HEAD FEM SM 40MM RESTORIS CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186640-01 SUP HCPCS C1776 186640-01 - HEAD FEM MED 40MM RESTORIS CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186640-02 SUP HCPCS C1776 186640-02 - HEAD FEM LG 40MM RESTORIS CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 186640-03 SUP HCPCS C1776 186640-03 - HEAD FEM XL 40MM RESTORIS CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $776.25 $776.25 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 1867.31.430 SUP HCPCS C1713 1867.31.430 - SCREW BN 4.35MM 30MM NS VPR FX PA TI SPNE CORT 5.5MM ROD BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 1867.31.435 SUP HCPCS C1713 1867.31.435 - SCREW BN 4.35MM 35MM NS VPR FX PA TI SPNE CORT 5.5MM ROD BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 1867.31.525 SUP HCPCS C1713 1867.31.525 - SCREW BN 5MM 25MM NS VPR XPDM FX PA TI SPNE CORT 5.5MM ROD BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 1867.31.645 SUP HCPCS C1713 1867.31.645 - SCREW BONE 6MM 45MM FIX EXPEDIUM TITANIUM SPN CORTICAL 5.5MM BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 1867.31.675 SUP HCPCS C1713 1867.31.675 - SCREW BONE 7MM 50MM XPDM TI SPN CORT FIX 5.5MM ROD BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 1867.31.845 SUP HCPCS C1713 1867.31.845 - SCREW BONE 8MM 45MM FIX EXPEDIUM TITANIUM SPN CORTICAL 5.5MM BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 1867.31.850 SUP HCPCS C1713 1867.31.850 - SCREW BONE 8MM 50MM FIX EXPEDIUM TITANIUM SPN CORTICAL 5.5MM BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 1867-15-780 SUP HCPCS C1713 1867-15-780 - SCREW BN 7MM 80MM VPR 2 PA CNN TI SPNE MIS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 1882TC/46 SUP HCPCS C1898 1882TC/46 - TENDRIL ST OPTIM BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1882TC/52 SUP HCPCS C1898 1882TC/52 - TENDRIL ST OPTIM BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 18-83525 SUP Custom 27203010 18-83525 - BLADE SHVR 18CM 3.5MM SKMR 15D LRYNG 2 CVD ANG TIP LP IRR BOTH IP/OP "$2,137.50 " "$1,581.75" $0.00 "$1,710.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,586.45" "$1,586.45" $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 "$1,068.75" "$1,692.90" "$1,710.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1888TC/46 SUP HCPCS C1898 1888TC/46 - LEAD PCNG 46CM VNTRC LUBRICITY FLXB DRBLTY BIOSTABILITY BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1888TC/52 SUP HCPCS C1898 1888TC/52 - LEAD PCNG 52CM VNTRC LUBRICITY FLXB DRBLTY BIOSTABILITY BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1888TC/58 SUP HCPCS C1898 1888TC/58 - LEAD PCNG STRG THN 6FR 58CM TNDRL ST IS-1 BP CNCT XTD-RETRAC BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1888TC/65 SUP HCPCS C1898 1888TC/65 - LEAD PCNG THN STRG 6FR 65CM TNDRL ST IS-1 BP CNCT XTD-RETRAC BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4020S SUP HCPCS C1713 1891-4020S - SCREW BONE 4MM 20MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4022S SUP HCPCS C1713 1891-4022S - SCREW BONE 4MM 22MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4024S SUP HCPCS C1713 1891-4024S - SCREW BONE 4MM 24MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4025S SUP HCPCS C1713 1891-4025S - SCREW BONE 4MM 25MM T2 TI ORTH SHFT PTHRD STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4026S SUP HCPCS C1713 1891-4026S - SCREW BONE 4MM 26MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4028S SUP HCPCS C1713 1891-4028S - SCREW BONE 4MM 28MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4030S SUP HCPCS C1713 1891-4030S - SCREW BONE 4MM 30MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4032S SUP HCPCS C1713 1891-4032S - SCREW BONE 4MM 32MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4034S SUP HCPCS C1713 1891-4034S - SCREW BONE 4MM 34MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4035S SUP HCPCS C1713 1891-4035S - SCREW BONE 4MM 35MM T2 TI ORTH SHFT PTHRD STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4036S SUP HCPCS C1713 1891-4036S - SCREW BONE 4MM 36MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4038S SUP HCPCS C1713 1891-4038S - SCREW BONE 4MM 38MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4040S SUP HCPCS C1713 1891-4040S - SCREW BONE 4MM 40MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4045S SUP HCPCS C1713 1891-4045S - SCREW BONE 4MM 45MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4050S SUP HCPCS C1713 1891-4050S - SCREW BONE 4MM 50MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4055S SUP HCPCS C1713 1891-4055S - SCREW BONE 4MM 55MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-4060S SUP HCPCS C1713 1891-4060S - SCREW BONE 4MM 60MM T2 TI PTHRD HUM SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5025S SUP HCPCS C1713 1891-5025S - SCREW BONE 5MM 25MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5030S SUP HCPCS C1713 1891-5030S - SCREW BONE 5MM 30MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5035S SUP HCPCS C1713 1891-5035S - SCREW BONE 5MM 35MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5040S SUP HCPCS C1713 1891-5040S - SCREW BONE 5MM 40MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5045S SUP HCPCS C1713 1891-5045S - SCREW BONE 5MM 45MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5050S SUP HCPCS C1713 1891-5050S - SCREW BONE 5MM 50MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5055S SUP HCPCS C1713 1891-5055S - SCREW BONE 5MM 55MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5060S SUP HCPCS C1713 1891-5060S - SCREW BONE 5MM 60MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5065S SUP HCPCS C1713 1891-5065S - SCREW BONE 5MM 65MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5070S SUP HCPCS C1713 1891-5070S - SCREW BONE 5MM 70MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5075S SUP HCPCS C1713 1891-5075S - SCREW BONE 5MM 75MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5080S SUP HCPCS C1713 1891-5080S - SCREW BONE 5MM 80MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5085S SUP HCPCS C1713 1891-5085S - SCREW BONE 5MM 85MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5090S SUP HCPCS C1713 1891-5090S - SCREW BONE 5MM 90MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5095S SUP HCPCS C1713 1891-5095S - SCREW BONE 5MM 95MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5100S SUP HCPCS C1713 1891-5100S - SCREW BONE 5MM 100MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5105S SUP HCPCS C1713 1891-5105S - SCREW BONE 5MM 105MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5110S SUP HCPCS C1713 1891-5110S - SCREW BONE 5MM 110MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5115S SUP HCPCS C1713 1891-5115S - SCREW BONE 5MM 115MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1891-5120S SUP HCPCS C1713 1891-5120S - SCREW BONE 5MM 120MM T2 TI PTHRD FEM/TIB SHFT STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5001S SUP HCPCS C1713 1895-5001S - NUT ORTH 5MM T2 CNDYLR TI CNDYLR SCR STRL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5040S SUP HCPCS C1713 1895-5040S - SCREW BONE 5MM 40MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5045S SUP HCPCS C1713 1895-5045S - SCREW BONE 5MM 45MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5050S SUP HCPCS C1713 1895-5050S - SCREW BONE 5MM 50MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5055S SUP HCPCS C1713 1895-5055S - SCREW BONE 5MM 55MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5060S SUP HCPCS C1713 1895-5060S - SCREW BONE 5MM 60MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5065S SUP HCPCS C1713 1895-5065S - SCREW BONE 5MM 65MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5070S SUP HCPCS C1713 1895-5070S - SCREW BONE 5MM 70MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5075S SUP HCPCS C1713 1895-5075S - SCREW BONE 5MM 75MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5080S SUP HCPCS C1713 1895-5080S - SCREW BONE 5MM 80MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5085S SUP HCPCS C1713 1895-5085S - SCREW BONE 5MM 85MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5090S SUP HCPCS C1713 1895-5090S - SCREW BONE 5MM 90MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5095S SUP HCPCS C1713 1895-5095S - SCREW BONE 5MM 95MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5100S SUP HCPCS C1713 1895-5100S - SCREW BONE 5MM 100MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5105S SUP HCPCS C1713 1895-5105S - SCREW BONE 5MM 105MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5110S SUP HCPCS C1713 1895-5110S - SCREW BONE 5MM 110MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5115S SUP HCPCS C1713 1895-5115S - SCREW BONE 5MM 115MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1895-5120S SUP HCPCS C1713 1895-5120S - SCREW BONE 5MM 120MM T2 TI PTHRD CNDYLR LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4020S SUP HCPCS C1713 1896-4020S - SCREW BONE 4MM 20MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4022S SUP HCPCS C1713 1896-4022S - SCREW BONE 4MM 22MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4024S SUP HCPCS C1713 1896-4024S - SCREW BONE 4MM 24MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4025S SUP HCPCS C1713 1896-4025S - SCREW BN FT 4MM 25MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4026S SUP HCPCS C1713 1896-4026S - SCREW BONE 4MM 26MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4028S SUP HCPCS C1713 1896-4028S - SCREW BONE 4MM 28MM T2 TI DISTAL LCK FULTHRD STRL IM NL SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4030S SUP HCPCS C1713 1896-4030S - SCREW BONE 4MM 30MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4032S SUP HCPCS C1713 1896-4032S - SCREW BONE 4MM 32MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4034S SUP HCPCS C1713 1896-4034S - SCREW BONE 4MM 34MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4035S SUP HCPCS C1713 1896-4035S - SCREW BONE 4MM 35MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4036S SUP HCPCS C1713 1896-4036S - SCREW BONE 4MM 36MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4038S SUP HCPCS C1713 1896-4038S - SCREW BONE 4MM 38MM T2 TI FULTHD LCK BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4040S SUP HCPCS C1713 1896-4040S - SCREW BONE 4MM 40MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4045S SUP HCPCS C1713 1896-4045S - SCREW BONE 4MM 45MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4050S SUP HCPCS C1713 1896-4050S - SCREW BONE 4MM 50MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4055S SUP HCPCS C1713 1896-4055S - SCREW BONE 4MM 55MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-4060S SUP HCPCS C1713 1896-4060S - SCREW BONE 4MM 60MM T2 TI FULTHD HUM TIB LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5025S SUP HCPCS C1713 1896-5025S - SCREW BONE 5MM 25MM T2 TI6AL4V PROX LCK FULTHRD STRL IM NL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5027S SUP HCPCS C1713 1896-5027S - SCREW BN FT 5MM 27.5MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5030S SUP HCPCS C1713 1896-5030S - SCREW BONE 5MM 30MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5032S SUP HCPCS C1713 1896-5032S - SCREW BN FT 5MM 32.5MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5035S SUP HCPCS C1713 1896-5035S - SCREW BONE 5MM 35MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5037S SUP HCPCS C1713 1896-5037S - SCREW BN FT 5MM 37.5MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5040S SUP HCPCS C1713 1896-5040S - SCREW BONE 5MM 40MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5042S SUP HCPCS C1713 1896-5042S - SCREW BN FT 5MM 42.5MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5045S SUP HCPCS C1713 1896-5045S - SCREW BONE 5MM 45MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5047S SUP HCPCS C1713 1896-5047S - SCREW BN FT 5MM 47.5MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5050S SUP HCPCS C1713 1896-5050S - SCREW BONE 5MM 50MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5052S SUP HCPCS C1713 1896-5052S - SCREW BN FT 5MM 52.5MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5055S SUP HCPCS C1713 1896-5055S - SCREW BONE 5MM 55MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5057S SUP HCPCS C1713 1896-5057S - SCREW BN FT 5MM 57.5MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5060S SUP HCPCS C1713 1896-5060S - SCREW BONE 5MM 60MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5065S SUP HCPCS C1713 1896-5065S - SCREW BN FT 5MM 65MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5070S SUP HCPCS C1713 1896-5070S - SCREW BONE 5MM 70MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5075S SUP HCPCS C1713 1896-5075S - SCREW BONE 5MM 75MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5080S SUP HCPCS C1713 1896-5080S - SCREW BONE 5MM 80MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5085S SUP HCPCS C1713 1896-5085S - SCREW BONE 5MM 85MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5090S SUP HCPCS C1713 1896-5090S - SCREW BONE 5MM 90MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5095S SUP HCPCS C1713 1896-5095S - SCREW BONE 5MM 95MM T2 TI FULTHD LCK STRL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5100S SUP HCPCS C1713 1896-5100S - SCREW BONE 5MM 100MM T2 FULTHD FEM HIP LCK STRL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5105S SUP HCPCS C1713 1896-5105S - SCREW BONE 5MM 105MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5110S SUP HCPCS C1713 1896-5110S - SCREW BONE 5MM 110MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5115S SUP HCPCS C1713 1896-5115S - SCREW BONE 5MM 115MM T2 TI FULTHD PROX FEM LCK STRL IM NAIL BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1896-5120S SUP HCPCS C1713 1896-5120S - SCREW BN FT 5MM 120MM STRL LCK TI T2 NL SYS UNV SYS BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $131.18 $131.18 $0.00 $0.00 $0.00 $60.76 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $172.42 $172.42 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $45.62 $0.00 $0.00 $46.41 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6065S SUP HCPCS C1713 1897-6065S - SCREW BONE 6.5MM 65MM T2 TI FEM LAG RECON STRL IM NAIL BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6070S SUP HCPCS C1713 1897-6070S - SCREW BONE 6.5MM 70MM T2 TI FEM LAG RECON STRL IM NAIL BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6075S SUP HCPCS C1713 1897-6075S - SCREW BN 6.5MM 75MM BRNZ STRL LG CNN TI FEM T2 RECON NL SYS BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6080S SUP HCPCS C1713 1897-6080S - SCREW BN 6.5MM 80MM BRNZ STRL LG CNN TI FEM T2 RECON NL SYS BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6085S SUP HCPCS C1713 1897-6085S - SCREW BN 6.5MM 85MM BRNZ STRL LG CNN TI FEM T2 RECON NL SYS BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6090S SUP HCPCS C1713 1897-6090S - SCREW BN 6.5MM 90MM BRNZ STRL LG CNN TI FEM T2 RECON NL SYS BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6095S SUP HCPCS C1713 1897-6095S - SCREW BN 6.5MM 95MM BRNZ STRL LG CNN TI FEM T2 RECON NL SYS BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6100S SUP HCPCS C1713 1897-6100S - SCREW BN 6.5MM 100MM BRNZ STRL LG CNN TI FEM T2 RECON NL SYS BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6105S SUP HCPCS C1713 1897-6105S - SCREW BN 6.5MM 105MM BRNZ STRL LG CNN TI FEM T2 RECON NL SYS BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6110S SUP HCPCS C1713 1897-6110S - SCREW BONE 6.5MM 110MM T2 TI FEM LAG RECON STRL IM NAIL BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6115S SUP HCPCS C1713 1897-6115S - SCREW BONE 6.5MM 115MM T2 TI FEM LAG RECON STRL IM NAIL BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6120S SUP HCPCS C1713 1897-6120S - SCREW BONE 6.5MM 120MM T2 TI FEM LAG RECON STRL IM NAIL BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6125S SUP HCPCS C1713 1897-6125S - SCREW BONE 6.5MM 125MM T2 TI FEM LAG RECON STRL IM NAIL BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 1897-6130S SUP HCPCS C1713 1897-6130S - SCREW BONE 6.5MM 130MM T2 TI FEM LAG RECON STRL IM NAIL BOTH IP/OP $380.80 $281.79 $0.00 $319.00 $179.44 $179.44 $0.00 $0.00 $0.00 $79.37 $282.63 $282.63 $0.00 $0.00 $79.36 $0.00 $225.24 $225.24 $0.00 $199.38 $315.81 $319.00 $0.00 $0.00 $62.40 $0.00 $0.00 $63.48 $0.00 $0.00 $0.00 $0.00 $0.00 19-0000T SUP Custom 27203010 19-0000T - SLEEVE ADPR +0MM OFST UNV CTPR TI BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19-0005T SUP Custom 27203010 19-0005T - SLEEVE ADPR 5MM OFST UNV CTPR STRL LF HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19-0025T SUP Custom 27203010 19-0025T - SLEEVE ADAPTER +2.5MM OFFST UNIVERSAL C TAPER TITANIUM BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 190-151 SUP HCPCS C2617 190-151 - STENT URET 8FR 22CM W/O GWIRE DUAL DRMTR PLRS HDR+ BOTH IP/OP $306.25 $226.63 $0.00 $245.00 $137.81 $137.81 $0.00 $0.00 $0.00 $63.83 $227.30 $227.30 $0.00 $0.00 $63.82 $0.00 $181.15 $181.15 $0.00 $153.13 $242.55 $245.00 $0.00 $0.00 $47.93 $0.00 $0.00 $48.76 $0.00 $0.00 $0.00 $0.00 $0.00 19-0325T SUP Custom 27203010 19-0325T - UNIVERSAL C-TAPER -2.5mm ADAPTER SLEEVE (Ti) BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 190-5091-150 SUP HCPCS C1751 190-5091-150 - CATH INFUS 90D .014IN ANG 2.1-1.7FR .017IN 150CM 5MM MCTH BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,418.00" $962.47 $962.47 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $277.40 $0.00 $0.00 $282.18 $0.00 $0.00 $0.00 $0.00 $0.00 190-5092-150 SUP HCPCS C1751 190-5092-150 - CATH INFUS 90D 2.4-1.9FR .017IN 150CM 5MM MCTH ANG PSHP NTNL BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,418.00" $962.47 $962.47 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $886.25 "$1,403.82" "$1,418.00" $0.00 $0.00 $277.40 $0.00 $0.00 $282.18 $0.00 $0.00 $0.00 $0.00 $0.00 19-1005 SUP HCPCS C1713 19-1005 - PLATE BN STRG 15MM THINFLAP 2 HL TI CRNMXF BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $88.88 $88.88 $0.00 $0.00 $0.00 $41.16 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $116.82 $116.82 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $30.91 $0.00 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $0.00 19-1010 SUP HCPCS C1713 19-1010 - PLATE BONE WIDE 2 HOLE THINFLAP TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 19-1015 SUP HCPCS C1713 19-1015 - PLATE BN SQ 13MM THINFLAP 4 HL TI CRNMXF BOTH IP/OP $780.00 $577.20 $0.00 $624.00 $351.00 $351.00 $0.00 $0.00 $0.00 $162.57 $578.92 $578.92 $0.00 $0.00 $162.55 $0.00 $461.37 $461.37 $0.00 $390.00 $617.76 $624.00 $0.00 $0.00 $122.07 $0.00 $0.00 $124.18 $0.00 $0.00 $0.00 $0.00 $0.00 19-1019 SUP HCPCS C1713 19-1019 - COVER BURR HOLE 13.5MM BENT SPN BOTH IP/OP $847.50 $627.15 $0.00 $678.00 $381.38 $381.38 $0.00 $0.00 $0.00 $176.64 $629.01 $629.01 $0.00 $0.00 $176.62 $0.00 $501.30 $501.30 $0.00 $423.75 $671.22 $678.00 $0.00 $0.00 $132.63 $0.00 $0.00 $134.92 $0.00 $0.00 $0.00 $0.00 $0.00 19-1020 SUP HCPCS C1713 19-1020 - PLATE BONE 18.5MM BURR HOLE THINFLAP TITANIUM BOTH IP/OP $847.50 $627.15 $0.00 $678.00 $381.38 $381.38 $0.00 $0.00 $0.00 $176.64 $629.01 $629.01 $0.00 $0.00 $176.62 $0.00 $501.30 $501.30 $0.00 $423.75 $671.22 $678.00 $0.00 $0.00 $132.63 $0.00 $0.00 $134.92 $0.00 $0.00 $0.00 $0.00 $0.00 19-1021 SUP HCPCS C1713 19-1021 - COVER BURR HOLE BENT LP 24MM THINFLAP CRANIOMAXILLOFACIAL BOTH IP/OP $847.50 $627.15 $0.00 $678.00 $381.38 $381.38 $0.00 $0.00 $0.00 $176.64 $629.01 $629.01 $0.00 $0.00 $176.62 $0.00 $501.30 $501.30 $0.00 $423.75 $671.22 $678.00 $0.00 $0.00 $132.63 $0.00 $0.00 $134.92 $0.00 $0.00 $0.00 $0.00 $0.00 19-1030 SUP HCPCS C1713 19-1030 - PLATE BONE 85X53X.5MM GRID PANEL THINFLAP TITANIUM BOTH IP/OP "$4,047.50 " "$2,995.15" $0.00 "$3,238.00" "$1,821.38" "$1,821.38" $0.00 $0.00 $0.00 $843.60 "$3,004.05" "$3,004.05" $0.00 $0.00 $843.50 $0.00 "$1,995.42" "$1,995.42" $0.00 "$2,023.75" "$3,205.62" "$3,238.00" $0.00 $0.00 $633.43 $0.00 $0.00 $644.36 $0.00 $0.00 $0.00 $0.00 $0.00 19-1040 SUP HCPCS C1713 19-1040 - PLATE BONE LONG 6 HOLE STR THINFLAP TITANIUM BOTH IP/OP $820.00 $606.80 $0.00 $656.00 $369.00 $369.00 $0.00 $0.00 $0.00 $170.91 $608.60 $608.60 $0.00 $0.00 $170.89 $0.00 $485.03 $485.03 $0.00 $410.00 $649.44 $656.00 $0.00 $0.00 $128.33 $0.00 $0.00 $130.54 $0.00 $0.00 $0.00 $0.00 $0.00 19-1045 SUP HCPCS C1713 19-1045 - PLATE BONE LONG 4 HOLE STR THINFLAP TITANIUM BOTH IP/OP $405.00 $299.70 $0.00 $324.00 $182.25 $182.25 $0.00 $0.00 $0.00 $84.41 $300.59 $300.59 $0.00 $0.00 $84.40 $0.00 $239.56 $239.56 $0.00 $202.50 $320.76 $324.00 $0.00 $0.00 $63.38 $0.00 $0.00 $64.48 $0.00 $0.00 $0.00 $0.00 $0.00 19-1050 SUP HCPCS C1713 19-1050 - PLATE BONE STANDARD 6 HOLE CVD THINFLAP TITANIUM CRANFCL BOTH IP/OP $820.00 $606.80 $0.00 $656.00 $369.00 $369.00 $0.00 $0.00 $0.00 $170.91 $608.60 $608.60 $0.00 $0.00 $170.89 $0.00 $485.03 $485.03 $0.00 $410.00 $649.44 $656.00 $0.00 $0.00 $128.33 $0.00 $0.00 $130.54 $0.00 $0.00 $0.00 $0.00 $0.00 19-1060 SUP HCPCS C1713 19-1060 - PLATE BN 2Y 16MM THINFLAP 6 HL TI CRNMXF BOTH IP/OP $820.00 $606.80 $0.00 $656.00 $369.00 $369.00 $0.00 $0.00 $0.00 $170.91 $608.60 $608.60 $0.00 $0.00 $170.89 $0.00 $485.03 $485.03 $0.00 $410.00 $649.44 $656.00 $0.00 $0.00 $128.33 $0.00 $0.00 $130.54 $0.00 $0.00 $0.00 $0.00 $0.00 19-1065 SUP HCPCS C1713 19-1065 - PLATE BONE STANDARD 6 HOLE Y THINFLAP TITANIUM BOTH IP/OP $880.00 $651.20 $0.00 $704.00 $396.00 $396.00 $0.00 $0.00 $0.00 $183.41 $653.14 $653.14 $0.00 $0.00 $183.39 $0.00 $520.52 $520.52 $0.00 $440.00 $696.96 $704.00 $0.00 $0.00 $137.72 $0.00 $0.00 $140.10 $0.00 $0.00 $0.00 $0.00 $0.00 19-1200AU SUP Custom 27203010 19-1200AU - FORCEP BIPOL 8-.7MM HARDY BAYONETTE DISP BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $0.00 $0.00 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1924-508 SUP Custom 27203010 1924-508 - CIRCUIT BRTHG CSTM RESP HMD LN UNHT 1.5FT INF 10MM BOTH IP/OP $6.22 $4.60 $0.00 $4.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.62 $4.62 $0.00 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $3.11 $4.93 $4.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1944/46 SUP HCPCS C1898 1944/46 - LEAD PCNG 10MM SPC S J 7FR 46CM ISFLX ATCPT IS-1 BP CNCT PSV BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1944/52 SUP HCPCS C1898 1944/52 - LEAD PCNG J 7FR 52CM ISFLX IS-1 BP CNCT TINE FX OPTIM STRD BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1948/46 SUP HCPCS C1898 1948/46 - LEAD PCNG STRG 46CM STRL LF ISFLX ATCPT TINE FX IS-1 BP CNCT BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1948/52 SUP HCPCS C1898 1948/52 - LEAD PCNG 7FR 52CM ISFLX BP PSV FX TINE IS 1 OPTIM STRD BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 1948/58 SUP HCPCS C1898 1948/58 - LEAD PCNG STRG 7FR 58CM ISFLX ABRSN RST IS-1 BP CNCT TINE FX BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 195-7112-6 SUP Custom 27203010 REAGENT DPS EXCH BUFF RMD HS ANALY BOTH IP/OP "$2,335.00 " "$1,727.90" $0.00 "$1,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,167.50" "$1,849.32" "$1,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 195-7115 SUP Custom 27203010 REAGENT WSH SOL CHM BOTH IP/OP $840.00 $621.60 $0.00 $672.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.00 $665.28 $672.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 195-7119HS SUP Custom 27203010 REAGENT CHK MX ANALY BOTH IP/OP $36.88 $27.29 $0.00 $29.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.44 $29.21 $29.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 195-7137 SUP Custom 27203010 REAGENT DILU ANALY BOTH IP/OP $133.00 $98.42 $0.00 $106.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.50 $105.34 $106.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 195-7150 SUP Custom 27203010 CARTRIDGE ANALY PURF BOTH IP/OP $777.50 $575.35 $0.00 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $388.75 $615.78 $622.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1967.89.300 SUP HCPCS C1713 1967.89.300 - ROD SPINAL STR 300MM HEXAGON VIPER 2 COCR BOTH IP/OP "$1,957.50 " "$1,448.55" $0.00 "$1,566.00" $880.88 $880.88 $0.00 $0.00 $0.00 $407.99 "$1,452.86" "$1,452.86" $0.00 $0.00 $407.94 $0.00 "$1,157.86" "$1,157.86" $0.00 $978.75 "$1,550.34" "$1,566.00" $0.00 $0.00 $306.35 $0.00 $0.00 $311.63 $0.00 $0.00 $0.00 $0.00 $0.00 1967.89.480 SUP HCPCS C1713 1967.89.480 - ROD SPINAL STR 480MM VIPER 2 COCR BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 197230FLA SUP HCPCS C1894 197230FLA - SHEATH IRRIGATION ENDO-SCRUB 2 45D 4MM LEFT STERILE BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 199.933S SUP Custom 27203010 199.933S - KIT SCRL BAR THRD 6MM 200MM STRL BOTH IP/OP "$2,308.15 " "$1,708.03" $0.00 "$1,792.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,713.11" "$1,713.11" $0.00 $0.00 $481.02 $0.00 $0.00 $0.00 $0.00 "$1,120.46" "$1,774.82" "$1,792.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 199.936S SUP HCPCS C1713 199.936S - BAR SACRAL 6MM 260MM THREAD SPN STERILE BOTH IP/OP "$2,308.15 " "$1,708.03" $0.00 "$1,792.74" "$1,008.42" "$1,008.42" $0.00 $0.00 $0.00 $481.08 "$1,713.11" "$1,713.11" $0.00 $0.00 $481.02 $0.00 "$1,365.27" "$1,365.27" $0.00 "$1,120.46" "$1,774.82" "$1,792.74" $0.00 $0.00 $340.49 $0.00 $0.00 $356.76 $0.00 $0.00 $0.00 $0.00 $0.00 19A001 SUP Custom 27804086 19A001 - GRAFT BONE 4-10MM FREEZE DRIED CANCELLOUS CORTICAL 30ML BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $0.00 $0.00 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19A002 SUP Custom 27804086 19A002 - GRAFT BONE 4-10MM FREEZE DRIED CANCELLOUS CORTICAL 15ML BOTH IP/OP $582.50 $431.05 $0.00 $466.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $432.33 $432.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $291.25 $461.34 $466.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 19AGFN-756 SUP Custom 27803010 19AGFN-756 - VALVE AORTIC 85D 19MM 17.8MM 1 DIGIT GRADIENT MECHANICAL BOTH IP/OP "$11,750.00 " "$8,695.00" $0.00 "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,448.70" $0.00 $0.00 $0.00 $0.00 "$5,875.00" "$9,306.00" "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1DLMC03 SUP HCPCS C1781 1DLMC03 - MESH SURG THK1MM 15X10CM BIOMATERIAL DUALMESH GORE-TEX SOFT BOTH IP/OP $982.50 $727.05 $0.00 $786.00 $442.13 $442.13 $0.00 $0.00 $0.00 $204.78 $729.21 $729.21 $0.00 $0.00 $204.75 $0.00 $581.15 $581.15 $0.00 $491.25 $778.14 $786.00 $0.00 $0.00 $153.76 $0.00 $0.00 $156.41 $0.00 $0.00 $0.00 $0.00 $0.00 1MTD202 SUP Custom 27203010 1MTD202 - DEVICE THYRPL 20CMX.4CMX.6MM VOCAL CORD SFT INERT NALRG BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2000-49 SUP HCPCS C1877 2000-49 - SHUNT CARDIO 9FR P-I CRTD OUTLYING T PORT 31CM STRL BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 200-120 SUP Custom 27203010 200-120 - KIT DIL .035IN 18GA 180CM GW INS NDL SCPL PCTV SHTH FLSH BOTH IP/OP $421.68 $312.04 $0.00 $337.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.97 $312.97 $0.00 $0.00 $87.88 $0.00 $0.00 $0.00 $0.00 $210.84 $333.97 $337.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2240 SUP Custom 27803010 2001-2240 - INSERT ACETAB 10D 40MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2242 SUP Custom 27803010 2001-2242 - INSERT ACETAB 10D 42MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2244 SUP Custom 27803010 2001-2244 - INSERT ACETAB 10D 44MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2246 SUP Custom 27803010 2001-2246 - INSERT ACETAB 10D 46MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2248 SUP Custom 27803010 2001-2248 - INSERT ACETAB 10D 48MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2250 SUP Custom 27803010 2001-2250 - INSERT ACETAB 10D 50MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2252 SUP Custom 27803010 2001-2252 - INSERT ACETAB 10D 52MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2254 SUP Custom 27803010 2001-2254 - INSERT ACETAB 10D 54MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2256 SUP Custom 27803010 2001-2256 - INSERT ACETAB 10D 56MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2258 SUP Custom 27803010 2001-2258 - INSERT ACETAB 10D 58MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2261 SUP Custom 27803010 2001-2261 - INSERT ACETAB 10D 61MM 22MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2644 SUP Custom 27803010 2001-2644 - INSERT ACETAB 10D 44MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2646 SUP Custom 27803010 2001-2646 - INSERT ACETAB 10D 46MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2648 SUP Custom 27803010 2001-2648 - INSERT ACETAB 10D 48MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2650 SUP Custom 27803010 2001-2650 - INSERT ACETAB 10D 50MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2652 SUP Custom 27803010 2001-2652 - INSERT ACETAB 10D 52MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2654 SUP Custom 27803010 2001-2654 - INSERT ACETAB 10D 54MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2656 SUP Custom 27803010 2001-2656 - INSERT ACETAB 10D 56MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2658 SUP Custom 27803010 2001-2658 - INSERT ACETAB 10D 58MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2661 SUP Custom 27803010 2001-2661 - INSERT ACETAB 10D 61MM 26MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2844 SUP Custom 27803010 2001-2844 - INSERT ACETAB 10D 44MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2846 SUP Custom 27803010 2001-2846 - INSERT ACETAB 10D 46MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2848 SUP Custom 27803010 2001-2848 - INSERT ACETAB 10D 48MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2850 SUP Custom 27803010 2001-2850 - INSERT ACETAB 10D 50MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2852 SUP Custom 27803010 2001-2852 - INSERT ACETAB 10D 52MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2854 SUP Custom 27803010 2001-2854 - INSERT ACETAB 10D 54MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2856 SUP Custom 27803010 2001-2856 - INSERT ACETAB 10D 56MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2858 SUP Custom 27803010 2001-2858 - INSERT ACETAB 10D 58MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-2861 SUP Custom 27803010 2001-2861 - INSERT ACETAB 10D 61MM 28MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-3250 SUP Custom 27803010 2001-3250 - INSERT ACETAB 10D 50MM 32MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-3252 SUP Custom 27803010 2001-3252 - INSERT ACETAB 10D 52MM 32MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-3254 SUP Custom 27803010 2001-3254 - INSERT ACETAB 10D 54MM 32MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-3256 SUP Custom 27803010 2001-3256 - INSERT ACETAB 10D 56MM 32MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-3258 SUP Custom 27803010 2001-3258 - INSERT ACETAB 10D 58MM 32MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2001-3261 SUP Custom 27803010 2001-3261 - INSERT ACETAB 10D 61MM 32MM OMNIFIT HIP SERIES I BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2002-000 SUP HCPCS C1729 2002-000 - DRAIN INCISION SMALL STATURE 1 CHAMBER SUCTION CONTROL BOTH IP/OP $53.29 $39.43 $0.00 $42.63 $28.94 $28.94 $0.00 $0.00 $0.00 $11.11 $39.55 $39.55 $0.00 $0.00 $11.11 $0.00 $31.52 $31.52 $0.00 $26.64 $42.21 $42.63 $0.00 $0.00 $8.34 $0.00 $0.00 $8.48 $0.00 $0.00 $0.00 $0.00 $0.00 20022 B-M SUP Custom 27803010 20022 B-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$7,326.88 " "$5,421.89" $0.00 "$5,861.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,526.92" $0.00 $0.00 $0.00 $0.00 "$3,663.44" "$5,802.89" "$5,861.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20026 A-H SUP Custom 27803010 20026 A-H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,543.75 " "$1,142.38" $0.00 "$1,235.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.77" "$1,145.77" $0.00 $0.00 $321.72 $0.00 $0.00 $0.00 $0.00 $771.88 "$1,222.65" "$1,235.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20026 A-M SUP Custom 27803010 20026 A-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,700.50 " "$1,258.37" $0.00 "$1,360.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,262.11" "$1,262.11" $0.00 $0.00 $354.38 $0.00 $0.00 $0.00 $0.00 $850.25 "$1,346.80" "$1,360.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2003-01 SUP Custom 27203010 2003-01 - STABILIT FIRST FRACTURE KIT WITH POWERCURVE BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 $0.00 $0.00 $0.00 "$3,500.00" "$5,544.00" "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20038 B SUP Custom 27803010 20038 B - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20038 C SUP Custom 27803010 20038 C - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20038 D SUP Custom 27803010 20038 D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,282.50 " $949.05 $0.00 "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.87 $951.87 $0.00 $0.00 $267.27 $0.00 $0.00 $0.00 $0.00 $641.25 "$1,015.74" "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20040 L SUP Custom 27203010 20040 L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,374.88 " "$2,497.41" $0.00 "$2,699.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,504.83" "$2,504.83" $0.00 $0.00 $703.32 $0.00 $0.00 $0.00 $0.00 "$1,687.44" "$2,672.90" "$2,699.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20040 M SUP Custom 27203010 20040 M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,374.88 " "$2,497.41" $0.00 "$2,699.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,504.83" "$2,504.83" $0.00 $0.00 $703.32 $0.00 $0.00 $0.00 $0.00 "$1,687.44" "$2,672.90" "$2,699.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20049 A-H SUP Custom 27803010 20049 A-H - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,615.00 " "$1,195.10" $0.00 "$1,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,198.65" "$1,198.65" $0.00 $0.00 $336.57 $0.00 $0.00 $0.00 $0.00 $807.50 "$1,279.08" "$1,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20049 C-H SUP Custom 27803010 20049 C-H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,615.00 " "$1,195.10" $0.00 "$1,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,198.65" "$1,198.65" $0.00 $0.00 $336.57 $0.00 $0.00 $0.00 $0.00 $807.50 "$1,279.08" "$1,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2240 SUP Custom 27803010 2006-2240 - INSERT ACETAB 40MM 22MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2242 SUP Custom 27803010 2006-2242 - INSERT ACETAB 42MM 22MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2244 SUP Custom 27803010 2006-2244 - INSERT ACETAB 20D 44MM 22MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2246 SUP Custom 27803010 2006-2246 - INSERT ACETAB 46MM 22MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2248 SUP Custom 27803010 2006-2248 - INSERT ACETAB 20D 48MM 22MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2250 SUP Custom 27803010 2006-2250 - INSERT ACETAB 50MM 22MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2252 SUP Custom 27803010 2006-2252 - INSERT ACETAB 20D 52MM 22MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2254 SUP Custom 27803010 2006-2254 - INSERT ACETAB 54MM 22MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2256 SUP Custom 27803010 2006-2256 - INSERT ACETAB 20D 56MM 22MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2258 SUP Custom 27803010 2006-2258 - INSERT ACETAB 58MM 22MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2261 SUP Custom 27803010 2006-2261 - INSERT ACETAB 20D 61MM 22MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2644 SUP Custom 27803010 2006-2644 - INSERT ACETAB 20D 44MM 26MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2646 SUP Custom 27803010 2006-2646 - INSERT ACETAB 46MM 26MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2648 SUP Custom 27803010 2006-2648 - INSERT ACETAB 20D 48MM 26MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2650 SUP Custom 27803010 2006-2650 - INSERT ACETAB 50MM 26MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2652 SUP Custom 27803010 2006-2652 - INSERT ACETAB 20D 52MM 26MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2654 SUP Custom 27803010 2006-2654 - INSERT ACETAB 54MM 26MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2656 SUP Custom 27803010 2006-2656 - INSERT ACETAB 20D 56MM 26MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2658 SUP Custom 27803010 2006-2658 - INSERT ACETAB 58MM 26MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2661 SUP Custom 27803010 2006-2661 - INSERT ACETAB 20D 61MM 26MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2846 SUP Custom 27803010 2006-2846 - INSERT ACETAB 46MM 28MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2848 SUP Custom 27803010 2006-2848 - INSERT ACETAB 20D 48MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2850 SUP Custom 27803010 2006-2850 - INSERT ACETAB 50MM 28MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2852 SUP Custom 27803010 2006-2852 - INSERT ACETAB 20D 52MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2854 SUP Custom 27803010 2006-2854 - INSERT ACETAB 54MM 28MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2856 SUP Custom 27803010 2006-2856 - INSERT ACETAB 20D 54MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2858 SUP Custom 27803010 2006-2858 - INSERT ACETAB 58MM 28MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-2861 SUP Custom 27803010 2006-2861 - INSERT ACETAB 20D 61MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-3250 SUP Custom 27803010 2006-3250 - INSERT ACETAB 50MM 32MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-3252 SUP Custom 27803010 2006-3252 - INSERT ACETAB 20D 61MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-3254 SUP Custom 27803010 2006-3254 - INSERT ACETAB 54MM 32MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-3256 SUP Custom 27803010 2006-3256 - INSERT ACETAB 20D 61MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-3258 SUP Custom 27803010 2006-3258 - INSERT ACETAB 58MM 32MM 20D HIP OMFT BOTH IP/OP "$1,925.63 " "$1,424.97" $0.00 "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,429.20" "$1,429.20" $0.00 $0.00 $401.30 $0.00 $0.00 $0.00 $0.00 $962.81 "$1,525.10" "$1,540.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2006-3261 SUP Custom 27803010 2006-3261 - INSERT ACETAB 20D 61MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$2,002.50 " "$1,481.85" $0.00 "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,486.26" "$1,486.26" $0.00 $0.00 $417.32 $0.00 $0.00 $0.00 $0.00 "$1,001.25" "$1,585.98" "$1,602.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2007-4-211 SUP Custom 27203010 2007-4-211 - VITALLIUM ALLERGY DISC BOTH IP/OP $60.13 $44.50 $0.00 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.62 $44.62 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $30.06 $47.62 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2007-4-212 SUP Custom 27203010 2007-4-212 - TITANIUM ALLERGY DISC BOTH IP/OP $60.13 $44.50 $0.00 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.62 $44.62 $0.00 $0.00 $12.53 $0.00 $0.00 $0.00 $0.00 $30.06 $47.62 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2008774-001 SUP Custom 27203010 PROBE ORAL TEMP CLR CD TRB TMP THRMTR LF REUSE BOTH IP/OP $298.08 $220.58 $0.00 $238.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.04 $236.08 $238.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.356.97 SUP HCPCS C1713 201.356.97 - SCREW BONE T6 LP 2MM 6MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.357.97 SUP HCPCS C1713 201.357.97 - SCREW BONE T6 LP 2MM 7MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.358.97 SUP HCPCS C1713 201.358.97 - SCREW BONE T6 LP 2MM 8MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.359.97 SUP HCPCS C1713 201.359.97 - SCREW BONE T6 LP 2MM 9MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.360.97 SUP HCPCS C1713 201.360.97 - SCREW BONE T6 LP 2MM 10MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.361.97 SUP HCPCS C1713 201.361.97 - SCREW BONE T6 LP 2MM 11MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.362.97 SUP HCPCS C1713 201.362.97 - SCREW BONE T6 LP 2MM 12MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.363.97 SUP HCPCS C1713 201.363.97 - SCREW BONE T6 LP 2MM 13MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.364.97 SUP HCPCS C1713 201.364.97 - SCREW BONE T6 LP 2MM 14MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.365.97 SUP HCPCS C1713 201.365.97 - SCREW BN T6 2MM 15MM ST SLF RTN STRDR SS CORT BOTH IP/OP $68.50 $50.69 $0.00 $53.20 $29.93 $29.93 $0.00 $0.00 $0.00 $14.28 $50.84 $50.84 $0.00 $0.00 $14.28 $0.00 $40.52 $40.52 $0.00 $33.25 $52.67 $53.20 $0.00 $0.00 $10.11 $0.00 $0.00 $10.59 $0.00 $0.00 $0.00 $0.00 $0.00 201.366.97 SUP HCPCS C1713 201.366.97 - SCREW BONE T6 LP 2MM 16MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.368.97 SUP HCPCS C1713 201.368.97 - SCREW BONE T6 LP 2MM 18MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.370.97 SUP HCPCS C1713 201.370.97 - SCREW BONE T6 LP 2MM 20MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.372.97 SUP HCPCS C1713 201.372.97 - SCREW BONE T6 LP 2MM 22MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.374.97 SUP HCPCS C1713 201.374.97 - SCREW BONE T6 LP 2MM 24MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.375.97 SUP HCPCS C1713 201.375.97 - SCREW BONE T6 LP 2MM 26MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.376.97 SUP HCPCS C1713 201.376.97 - SCREW BONE T6 LP 2MM 28MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.377.97 SUP HCPCS C1713 201.377.97 - SCREW BONE T6 LP 2MM 30MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.378.97 SUP HCPCS C1713 201.378.97 - SCREW BONE T6 LP 2MM 32MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.379.97 SUP HCPCS C1713 201.379.97 - SCREW BONE T6 LP 2MM 34MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.380.97 SUP HCPCS C1713 201.380.97 - SCREW BONE T6 LP 2MM 36MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.381.97 SUP HCPCS C1713 201.381.97 - SCREW BONE T6 LP 2MM 38MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.382.97 SUP HCPCS C1713 201.382.97 - SCREW BONE T6 LP 2MM 40MM SELF TAP MODULAR STARDRIVE LCP BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 201.804.98 SUP HCPCS C1713 201.804.98 - SCREW BONE 2MM 3.5MM 4MM SLFTAP CRCIFRM RECESS STAINLESS BOTH IP/OP $119.38 $88.34 $0.00 $95.50 $53.72 $53.72 $0.00 $0.00 $0.00 $24.88 $88.60 $88.60 $0.00 $0.00 $24.88 $0.00 $70.61 $70.61 $0.00 $59.69 $94.55 $95.50 $0.00 $0.00 $18.68 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.806.98 SUP HCPCS C1713 201.806.98 - SCREW BONE 2MM 3.5MM 6MM SLFTAP CRCIFRM RECESS STAINLESS BOTH IP/OP $119.38 $88.34 $0.00 $95.50 $53.72 $53.72 $0.00 $0.00 $0.00 $24.88 $88.60 $88.60 $0.00 $0.00 $24.88 $0.00 $70.61 $70.61 $0.00 $59.69 $94.55 $95.50 $0.00 $0.00 $18.68 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.808.98 SUP HCPCS C1713 201.808.98 - SCREW BONE 2MM 3.5MM 8MM SLFTAP CRCIFRM RECESS STAINLESS BOTH IP/OP $119.38 $88.34 $0.00 $95.50 $53.72 $53.72 $0.00 $0.00 $0.00 $24.88 $88.60 $88.60 $0.00 $0.00 $24.88 $0.00 $70.61 $70.61 $0.00 $59.69 $94.55 $95.50 $0.00 $0.00 $18.68 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.810.98 SUP HCPCS C1713 201.810.98 - SCREW BONE 2MM 3.5MM 10MM SLFTAP CRCIFRM RECESS STAINLESS BOTH IP/OP $119.38 $88.34 $0.00 $95.50 $53.72 $53.72 $0.00 $0.00 $0.00 $24.88 $88.60 $88.60 $0.00 $0.00 $24.88 $0.00 $70.61 $70.61 $0.00 $59.69 $94.55 $95.50 $0.00 $0.00 $18.68 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.812.98 SUP HCPCS C1713 201.812.98 - SCREW BONE 2MM 3.5MM 12MM SLFTAP CRCIFRM RECESS STAINLESS BOTH IP/OP $119.38 $88.34 $0.00 $95.50 $53.72 $53.72 $0.00 $0.00 $0.00 $24.88 $88.60 $88.60 $0.00 $0.00 $24.88 $0.00 $70.61 $70.61 $0.00 $59.69 $94.55 $95.50 $0.00 $0.00 $18.68 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.814.98 SUP HCPCS C1713 201.814.98 - SCREW BONE 2MM 3.5MM 14MM SLFTAP CRCIFRM RECESS STAINLESS BOTH IP/OP $119.38 $88.34 $0.00 $95.50 $53.72 $53.72 $0.00 $0.00 $0.00 $24.88 $88.60 $88.60 $0.00 $0.00 $24.88 $0.00 $70.61 $70.61 $0.00 $59.69 $94.55 $95.50 $0.00 $0.00 $18.68 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 201.932E SUP HCPCS C1713 201.932E - SCREW BONE 12MM 2MM MAXFACL SS SLF DRILING IMF NONSTRL BOTH IP/OP $288.00 $213.12 $0.00 $230.40 $129.60 $129.60 $0.00 $0.00 $0.00 $60.03 $213.75 $213.75 $0.00 $0.00 $60.02 $0.00 $170.35 $170.35 $0.00 $144.00 $228.10 $230.40 $0.00 $0.00 $45.07 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $0.00 2010-01 SUP Custom 27203010 2010-01 - LARYNGECTOMY PULMONARY KIT 9/36 BOTH IP/OP $970.00 $717.80 $0.00 $776.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $719.93 $719.93 $0.00 $0.00 $202.15 $0.00 $0.00 $0.00 $0.00 $485.00 $768.24 $776.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20100-190 SUP HCPCS C1884 20100-190 - SYSTEM EMBL PRTC .014IN 110UM 3.2FR 6FR 3.5-5.5MM 190CM F EZ BOTH IP/OP "$4,187.50 " "$3,098.75" $0.00 "$3,350.00" "$1,884.38" "$1,884.38" $0.00 $0.00 $0.00 $872.78 "$3,107.96" "$3,107.96" $0.00 $0.00 $872.68 $0.00 "$2,064.44" "$2,064.44" $0.00 "$2,093.75" "$3,316.50" "$3,350.00" $0.00 $0.00 $655.34 $0.00 $0.00 $666.65 $0.00 $0.00 $0.00 $0.00 $0.00 20-1226 SUP Custom 27203010 20-1226 - TUBE NASOGASTRIC 6FR 22IN 2 LUMEN Y PORT RADIOPQ STRIPE BOTH IP/OP $23.55 $17.43 $0.00 $17.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.48 $17.48 $0.00 $0.00 $4.91 $0.00 $0.00 $0.00 $0.00 $10.31 $16.32 $16.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2012-320 SUP HCPCS C1729 2012-320 - DRAIN INCISION C220ML .25IN 1 COLLECT SUCTION CONTROL BOTH IP/OP $77.27 $57.18 $0.00 $61.81 $41.96 $41.96 $0.00 $0.00 $0.00 $16.10 $57.35 $57.35 $0.00 $0.00 $16.10 $0.00 $45.70 $45.70 $0.00 $38.63 $61.20 $61.81 $0.00 $0.00 $12.09 $0.00 $0.00 $12.30 $0.00 $0.00 $0.00 $0.00 $0.00 20132-214 SUP Custom 27203010 20132-214 - PROBE ELECTROSURGICAL 2.3MM 220CM FLEXIBLE STR FIRE FIAPC BOTH IP/OP $547.38 $405.06 $0.00 $437.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $406.26 $406.26 $0.00 $0.00 $114.07 $0.00 $0.00 $0.00 $0.00 $273.69 $433.52 $437.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20-1384KI SUP Custom 27203010 20-1384KI - KIT ESURG .75MM BYNT STRG 7.75IN STRL 3IN OLSN BP FCP SMTH BOTH IP/OP $118.41 $87.62 $0.00 $94.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.88 $87.88 $0.00 $0.00 $24.68 $0.00 $0.00 $0.00 $0.00 $59.20 $93.78 $94.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 20-2050 SUP Custom 27203010 20-2050 - SEALANT DURA 5ML DURASEAL PG TRILYSINE AMINE BOTH IP/OP "$8,626.25 " "$6,383.43" $0.00 "$6,901.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,797.71" $0.00 $0.00 $0.00 $0.00 "$4,313.13" "$6,831.99" "$6,901.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6520-1 SUP HCPCS C1713 2020-6520-1 - SCREW BONE 6.5MM 20MM CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6525-1 SUP HCPCS C1713 2020-6525-1 - SCREW ACETAB 6.5MM 25MM PRIM HIP CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6530-1 SUP HCPCS C1713 2020-6530-1 - SCREW BONE 6.5MM 30MM CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6535-1 SUP HCPCS C1713 2020-6535-1 - SCREW ACETAB 6.5MM 35MM PRIM HIP CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6540-1 SUP HCPCS C1713 2020-6540-1 - SCREW ACETAB 6.5MM 40MM PRIM HIP CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6545-1 SUP HCPCS C1713 2020-6545-1 - SCREW ACETAB 6.5MM 45MM PRIM HIP CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6550-1 SUP HCPCS C1713 2020-6550-1 - SCREW ACETAB 6.5MM 50MM PRIM HIP CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6555-1 SUP HCPCS C1713 2020-6555-1 - SCREW ACETAB 6.5MM 55MM PRIM HIP CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2020-6560-1 SUP HCPCS C1713 2020-6560-1 - SCREW ACETAB 6.5MM 60MM PRIM HIP CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4520-1 SUP HCPCS C1713 2028-4520-1 - SCREW BONE 4.5MM 20MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4525-1 SUP HCPCS C1713 2028-4525-1 - SCREW BONE 4.5MM 25MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4530-1 SUP HCPCS C1713 2028-4530-1 - SCREW BONE 4.5MM 30MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4535 SUP HCPCS C1713 2028-4535 - S-FIT X-TRA BN SCRW 4.5 MM BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $57.15 $57.15 $0.00 $0.00 $0.00 $26.47 $94.26 $94.26 $0.00 $0.00 $26.47 $0.00 $75.12 $75.12 $0.00 $63.50 $100.58 $101.60 $0.00 $0.00 $19.88 $0.00 $0.00 $20.22 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4535-1 SUP HCPCS C1713 2028-4535-1 - SCREW BONE 4.5MM 35MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4540-1 SUP HCPCS C1713 2028-4540-1 - SCREW BONE 4.5MM 40MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4545-1 SUP HCPCS C1713 2028-4545-1 - SCREW BONE 4.5MM 45MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4550-1 SUP HCPCS C1713 2028-4550-1 - SCREW BONE 4.5MM 50MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4555-1 SUP HCPCS C1713 2028-4555-1 - SCREW BONE 4.5MM 55MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2028-4560-1 SUP HCPCS C1713 2028-4560-1 - SCREW BONE 4.5MM 60MM SECFIT X CANC BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5515-1 SUP HCPCS C1713 2029-5515-1 - SCREW BONE 5.5MM 15MM CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5520-1 SUP HCPCS C1713 2029-5520-1 - SCREW ACETAB 5.5MM 20MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5525-1 SUP HCPCS C1713 2029-5525-1 - SCREW ACETAB 5.5MM 25MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5530-1 SUP HCPCS C1713 2029-5530-1 - SCREW ACETAB 5.5MM 30MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5535-1 SUP HCPCS C1713 2029-5535-1 - SCREW ACETAB 5.5MM 35MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5540-1 SUP HCPCS C1713 2029-5540-1 - SCREW ACETAB 5.5MM 40MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5545-1 SUP HCPCS C1713 2029-5545-1 - SCREW ACETAB 5.5MM 45MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5550-1 SUP HCPCS C1713 2029-5550-1 - SCREW ACETAB 5.5MM 50MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5555-1 SUP HCPCS C1713 2029-5555-1 - SCREW ACETAB 5.5MM 55MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2029-5560-1 SUP HCPCS C1713 2029-5560-1 - SCREW ACETAB 5.5MM 60MM SECFIT TRIDENT TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-1125S SUP HCPCS C1713 2030-1125S - NAIL 300MM HIP GAMMA3 IM R2 LNG STRL STSCR BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2030-1130S SUP HCPCS C1713 2030-1130S - NAIL 11MM 30CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2030-1135S SUP HCPCS C1713 2030-1135S - NAIL 11MM 300MM RIGHT GAMA IM 135D R2 LNG LCK STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2030-1330S SUP HCPCS C1713 2030-1330S - NAIL 300MM HIP RIGHT GAMMA3 IM R2 LNG ORTHNX BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 203-060-200 SUP HCPCS C1769 203-060-200 - GUILDWIRE X PEION -142 BOTH IP/OP $657.50 $486.55 $0.00 $526.00 $357.02 $357.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.75 $520.74 $526.00 $0.00 $0.00 $102.90 $0.00 $0.00 $104.67 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6516-1 SUP HCPCS C1713 2030-6516-1 - SCREW BN 6.5MM 16MM NS TX TI ACTB CANC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6520-1 SUP HCPCS C1713 2030-6520-1 - SCREW BN 6.5MM 20MM NS TX TI ACTB CANC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6525-1 SUP HCPCS C1713 2030-6525-1 - SCREW ACETAB 6.5MM 25MM SECFIT TRIDENT TITANIUM CANCELLOUS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6530-1 SUP HCPCS C1713 2030-6530-1 - SCREW BONE 6.5MM 30MM TRIDENT SECFIT TORX TITANIUM ACETAB BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6535-1 SUP HCPCS C1713 2030-6535-1 - SCREW BN 6.5MM 35MM NS TX TI ACTB CANC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6540-1 SUP HCPCS C1713 2030-6540-1 - SCREW BN 6.5MM 40MM NS TX TI ACTB CANC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6545-1 SUP HCPCS C1713 2030-6545-1 - SCREW BN 6.5MM 45MM NS TX TI ACTB CANC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6550-1 SUP HCPCS C1713 2030-6550-1 - SCREW BONE HEMISPHERE 6.5MM 50MM TRIDENT TITANIUM ACETAB BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6555-1 SUP HCPCS C1713 2030-6555-1 - SCREW BONE HEMISPHERE 6.5MM 55MM TRIDENT TITANIUM ACETAB BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2030-6560-1 SUP HCPCS C1713 2030-6560-1 - SCREW BONE HEMISPHERE 6.5MM 60MM TRIDENT TITANIUM ACETAB BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 2032-1125S SUP HCPCS C1713 2032-1125S - NAIL 320MM HIP RIGHT GAMMA3 IM R2 LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2032-1130S SUP HCPCS C1713 2032-1130S - NAIL 11MM 32CM RIGHT FEM GAMA IM 130D LNG KIT STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2032-1135S SUP HCPCS C1713 2032-1135S - NAIL 11MM 320MM HIP RIGHT GAMMA3 IM 135D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2032-1330S SUP HCPCS C1713 2032-1330S - NAIL 13MM 32CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2034-1125S SUP HCPCS C1713 2034-1125S - NAIL 11MM 340MM HIP RIGHT GAMMA3 IM 125D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2034-1130S SUP HCPCS C1713 2034-1130S - NAIL 11MM 34CM RIGHT FEM GAMA IM 130D LNG KIT TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2034-1135S SUP HCPCS C1713 2034-1135S - NAIL 11MM 340MM RIGHT GAMA IM 135D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2034-1330S SUP HCPCS C1713 2034-1330S - NAIL 13MM 34CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2036-1125S SUP HCPCS C1713 2036-1125S - NAIL 11MM 36CM RIGHT FEM GAMA IM 125D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2036-1130S SUP HCPCS C1713 2036-1130S - NAIL 11MM 36CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2036-1135S SUP HCPCS C1713 2036-1135S - NAIL 11MM 36CM RIGHT FEM GAMA IM 135D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2036-1330S SUP HCPCS C1713 2036-1330S - NAIL 13MM 36CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2038-1125S SUP HCPCS C1713 2038-1125S - NAIL 11MM 38CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2038-1130S SUP HCPCS C1713 2038-1130S - NAIL 11MM 38CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2038-1135S SUP HCPCS C1713 2038-1135S - NAIL 11MM 38CM RIGHT FEM GAMA IM 135D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2038-1330S SUP HCPCS C1713 2038-1330S - NAIL 13MM 38CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2040-1125S SUP HCPCS C1713 2040-1125S - NAIL 400MM HIP LEFT GAMMA3 IM R2 LNG STRL STSCR BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2040-1130S SUP HCPCS C1713 2040-1130S - NAIL 11MM 40CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2040-1135S SUP HCPCS C1713 2040-1135S - NAIL 11MM 40CM RIGHT FEM GAMA IM 135D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2040-1330S SUP HCPCS C1713 2040-1330S - NAIL 400MM HIP RIGHT GAMMA3 IM R2 LNG ORTHNX BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2240 SUP Custom 27803010 2041-2240 - INSERT ACETAB 40MM 22MM 10D HIP S2 OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2242 SUP Custom 27803010 2041-2242 - INSERT ACETAB 42MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2246 SUP Custom 27803010 2041-2246 - INSERT ACETAB 46MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2250 SUP Custom 27803010 2041-2250 - INSERT ACETAB 50MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2254 SUP Custom 27803010 2041-2254 - INSERT ACETAB 54MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2258 SUP Custom 27803010 2041-2258 - INSERT ACETAB 58MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2262 SUP Custom 27803010 2041-2262 - INSERT ACETAB 62MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2266 SUP Custom 27803010 2041-2266 - INSERT ACETAB 66MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2270 SUP Custom 27803010 2041-2270 - INSERT ACETAB 70MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2274 SUP Custom 27803010 2041-2274 - INSERT ACETAB 74MM 22MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2642 SUP Custom 27803010 2041-2642 - INSERT ACETAB 42MM 26MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2646 SUP Custom 27803010 2041-2646 - INSERT ACETAB 46MM 26MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2650 SUP Custom 27803010 2041-2650 - INSERT ACETAB 50-52MM 26MM 10D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2654 SUP Custom 27803010 2041-2654 - INSERT ACETAB 54-56MM 26MM 10D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2658 SUP Custom 27803010 2041-2658 - INSERT ACETAB 58MM 26MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2662 SUP Custom 27803010 2041-2662 - INSERT ACETAB 62MM 26MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2666 SUP Custom 27803010 2041-2666 - INSERT ACETAB 66MM 26MM -10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2670 SUP Custom 27803010 2041-2670 - INSERT ACETAB 70MM 26MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2674 SUP Custom 27803010 2041-2674 - INSERT ACETAB 74MM 26MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2846 SUP Custom 27803010 2041-2846 - INSERT ACETAB 46MM 28MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2850 SUP Custom 27803010 2041-2850 - INSERT ACETAB 50MM 28MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2854 SUP Custom 27803010 2041-2854 - INSERT ACETAB 55-56MM 28MM 10D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2858 SUP Custom 27803010 2041-2858 - INSERT ACETAB 58MM 28MM 10D HIP S2 OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2862 SUP Custom 27803010 2041-2862 - INSERT ACETAB 62MM 28MM 10D HIP S2 OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2866 SUP Custom 27803010 2041-2866 - INSERT ACETAB 66MM 28MM -10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2870 SUP Custom 27803010 2041-2870 - INSERT ACETAB 70MM 28MM -10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-2874 SUP Custom 27803010 2041-2874 - INSERT ACETAB 74MM 28MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-3250 SUP Custom 27803010 2041-3250 - INSERT ACETAB 10D 50-52MM 32MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-3254 SUP Custom 27803010 2041-3254 - INSERT ACETAB 10D 54MM 32MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-3258 SUP Custom 27803010 2041-3258 - INSERT ACETAB 58MM 32MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-3262 SUP Custom 27803010 2041-3262 - INSERT ACETAB 62MM 32MM 10D HIP S2 OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-3266 SUP Custom 27803010 2041-3266 - INSERT ACETAB 66MM 32MM -10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-3270 SUP Custom 27803010 2041-3270 - INSERT ACETAB 70MM 32MM -10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-3274 SUP Custom 27803010 2041-3274 - INSERT ACETAB 74MM 32MM 10D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2244 SUP Custom 27803010 2041C-2244 - INSERT ACETAB 10D 44MM 22MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2248 SUP Custom 27803010 2041C-2248 - INSERT ACETAB 10D 48MM 22MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2252 SUP Custom 27803010 2041C-2252 - INSERT ACETAB 10D 52MM 22MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2256 SUP Custom 27803010 2041C-2256 - INSERT ACETAB 10D 56MM 22MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2642 SUP Custom 27803010 2041C-2642 - INSERT ACETAB 26MM 10D HIP S2 XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2646 SUP Custom 27803010 2041C-2646 - INSERT ACETAB 10D 46MM 26MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2648 SUP Custom 27803010 2041C-2648 - INSERT ACETAB 10D 48MM 26MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2650 SUP Custom 27803010 2041C-2650 - INSERT ACETAB 10D 50MM 26MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2652 SUP Custom 27803010 2041C-2652 - INSERT ACETAB 10D 52MM 26MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2654 SUP Custom 27803010 2041C-2654 - INSERT ACETAB 10D 54MM 26MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2656 SUP Custom 27803010 2041C-2656 - INSERT ACETAB 10D 56MM 26MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2658 SUP Custom 27803010 2041C-2658 - INSERT ACETAB 10D 58MM 26MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2662 SUP Custom 27803010 2041C-2662 - INSERT ACETAB 10D 62MM 26MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2846 SUP Custom 27803010 2041C-2846 - INSERT ACETAB 10D 46MM 28MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2848 SUP Custom 27803010 2041C-2848 - INSERT ACETAB 10D 48MM 28MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2850 SUP Custom 27803010 2041C-2850 - INSERT ACETAB 10D 50MM 28MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2852 SUP Custom 27803010 2041C-2852 - INSERT ACETAB 10D 52MM 28MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2854 SUP Custom 27803010 2041C-2854 - INSERT ACETAB 10D 54-56MM 28MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2856 SUP Custom 27803010 2041C-2856 - INSERT ACETAB 10D 56MM 28MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2858 SUP Custom 27803010 2041C-2858 - INSERT ACETAB 10D 58MM 28MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-2862 SUP Custom 27803010 2041C-2862 - INSERT ACETAB 10D 62-72MM 28MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-3250 SUP Custom 27803010 2041C-3250 - INSERT ACETAB 10D 50-52MM 32MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-3254 SUP Custom 27803010 2041C-3254 - INSERT ACETAB 10D 54MM 32MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-3256 SUP Custom 27803010 2041C-3256 - INSERT ACETAB 10D 56MM 32MM XFIRE HIP SERIES II BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-3258 SUP Custom 27803010 2041C-3258 - INSERT ACETAB 10D 58-60MM 32MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-3262 SUP Custom 27803010 2041C-3262 - INSERT ACETAB 10D 62MM 32MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-3266 SUP Custom 27803010 2041C-3266 - INSERT ACETAB 10D 66MM 32MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-3270 SUP Custom 27803010 2041C-3270 - INSERT ACETAB 10D 70MM 32MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041C-3274 SUP Custom 27803010 2041C-3274 - INSERT ACETAB 10D 74MM 32MM XFIRE HIP SERIES II BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-H-228 SUP Custom 27803010 2041-H-228 - LINER ACETAB 46-48MM 28MM HIP S2 CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041J-2246 SUP Custom 27803010 2041J-2246 - INSERT ACETAB 10D S2 OMFT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-N-228 SUP Custom 27803010 2041-N-228 - LINER ACETAB 46-48MM 28MM HIP S2 CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2041-N-532 SUP Custom 27803010 2041-N-532 - LINER ACETAB 58-60MM 32MM HIP S2 CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-1125S SUP HCPCS C1713 2042-1125S - NAIL 11MM 42CM HIP RIGHT FEM GAMMA3 IM 125D LNG TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2042-1130S SUP HCPCS C1713 2042-1130S - NAIL 11MM 420MM RIGHT FEM GAMA IM 130D R2 LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2042-1135S SUP HCPCS C1713 2042-1135S - NAIL 11MM 420MM HIP RIGHT GAMMA3 IM 135D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2042-1330S SUP HCPCS C1713 2042-1330S - NAIL 13MM 42CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2240 SUP Custom 27803010 2042-2240 - INSERT ACETAB 20D 40MM 22MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2242 SUP Custom 27803010 2042-2242 - INSERT ACETAB 42MM 22MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2246 SUP Custom 27803010 2042-2246 - INSERT ACETAB 46MM 22MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2250 SUP Custom 27803010 2042-2250 - INSERT ACETAB 20D 50MM 22MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2254 SUP Custom 27803010 2042-2254 - INSERT ACETAB 54MM 22MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2258 SUP Custom 27803010 2042-2258 - INSERT ACETAB 58MM 22MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2262 SUP Custom 27803010 2042-2262 - INSERT ACETAB 62MM 22MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2266 SUP Custom 27803010 2042-2266 - INSERT ACETAB 66MM 22MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2270 SUP Custom 27803010 2042-2270 - INSERT ACETAB 70MM 22MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2274 SUP Custom 27803010 2042-2274 - INSERT ACETAB 20D 74MM 22MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2642 SUP Custom 27803010 2042-2642 - INSERT ACETAB 20D 42MM 26MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2646 SUP Custom 27803010 2042-2646 - INSERT ACETAB 46MM 26MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2650 SUP Custom 27803010 2042-2650 - INSERT ACETAB 20D 50MM 26MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2654 SUP Custom 27803010 2042-2654 - INSERT ACETAB 20D 54MM 26MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2658 SUP Custom 27803010 2042-2658 - INSERT ACETAB 58MM 26MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2662 SUP Custom 27803010 2042-2662 - INSERT ACETAB 62MM 26MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2666 SUP Custom 27803010 2042-2666 - INSERT ACETAB 66MM 26MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2670 SUP Custom 27803010 2042-2670 - INSERT ACETAB 70MM 26MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2674 SUP Custom 27803010 2042-2674 - INSERT ACETAB 74MM 26MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2846 SUP Custom 27803010 2042-2846 - INSERT ACETAB 20D 46MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2850 SUP Custom 27803010 2042-2850 - INSERT ACETAB 20D 50MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2854 SUP Custom 27803010 2042-2854 - INSERT ACETAB 20D 54MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2858 SUP Custom 27803010 2042-2858 - INSERT ACETAB 20D 58MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2862 SUP Custom 27803010 2042-2862 - INSERT ACETAB 20D 62-72MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2866 SUP Custom 27803010 2042-2866 - INSERT ACETAB 20D 66MM 28MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2870 SUP Custom 27803010 2042-2870 - INSERT ACETAB 70MM 28MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-2874 SUP Custom 27803010 2042-2874 - INSERT ACETAB 74MM 28MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-3250 SUP Custom 27803010 2042-3250 - INSERT ACETAB 20D 50MM 32MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-3254 SUP Custom 27803010 2042-3254 - INSERT ACETAB 20D 54MM 32MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-3258 SUP Custom 27803010 2042-3258 - INSERT ACETAB 20D 58-60MM 32MM OMNIFIT HIP BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-3262 SUP Custom 27803010 2042-3262 - INSERT ACETAB 20D 62MM 32MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-3266 SUP Custom 27803010 2042-3266 - INSERT ACETAB 20D 66MM 32MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-3270 SUP Custom 27803010 2042-3270 - INSERT ACETAB 20D 70MM 32MM OMNIFIT HIP SERIES II BOTH IP/OP "$1,767.50 " "$1,307.95" $0.00 "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.84" "$1,311.84" $0.00 $0.00 $368.35 $0.00 $0.00 $0.00 $0.00 $883.75 "$1,399.86" "$1,414.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042-3274 SUP Custom 27803010 2042-3274 - INSERT ACETAB 74MM 32MM 20D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2244 SUP Custom 27803010 2042C-2244 - INSERT ACETAB 22MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2248 SUP Custom 27803010 2042C-2248 - INSERT ACETAB 22MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2252 SUP Custom 27803010 2042C-2252 - INSERT ACETAB 22MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2256 SUP Custom 27803010 2042C-2256 - INSERT ACETAB 22MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2648 SUP Custom 27803010 2042C-2648 - INSERT ACETAB 26MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2652 SUP Custom 27803010 2042C-2652 - INSERT ACETAB 26MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2656 SUP Custom 27803010 2042C-2656 - INSERT ACETAB 26MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2848 SUP Custom 27803010 2042C-2848 - INSERT ACETAB 28MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2852 SUP Custom 27803010 2042C-2852 - INSERT ACETAB 28MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-2856 SUP Custom 27803010 2042C-2856 - INSERT ACETAB 56MM 28MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2042C-3256 SUP Custom 27803010 2042C-3256 - INSERT ACETAB 56MM 32MM 20D HIP XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2240 SUP Custom 27803010 2043-2240 - INSERT ACETAB 40MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2242 SUP Custom 27803010 2043-2242 - INSERT ACETAB 42MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2246 SUP Custom 27803010 2043-2246 - INSERT ACETAB 46-48MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2250 SUP Custom 27803010 2043-2250 - INSERT ACETAB 50-52MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2254 SUP Custom 27803010 2043-2254 - INSERT ACETAB 54-56MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2258 SUP Custom 27803010 2043-2258 - INSERT ACETAB 58-60MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2262 SUP Custom 27803010 2043-2262 - INSERT ACETAB 62-72MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2266 SUP Custom 27803010 2043-2266 - INSERT ACETAB 66MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2270 SUP Custom 27803010 2043-2270 - INSERT ACETAB 70MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2274 SUP Custom 27803010 2043-2274 - INSERT ACETAB 74MM 22MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2642 SUP Custom 27803010 2043-2642 - INSERT ACETAB 42MM 26MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2646 SUP Custom 27803010 2043-2646 - INSERT ACETAB 46-48MM 26MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2650 SUP Custom 27803010 2043-2650 - INSERT ACETAB 50-52MM 26MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2654 SUP Custom 27803010 2043-2654 - INSERT ACETAB 54-56MM 26MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2658 SUP Custom 27803010 2043-2658 - INSERT ACETAB 58MM ID 26MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2662 SUP Custom 27803010 2043-2662 - INSERT ACETAB 62-72MM 26MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2666 SUP Custom 27803010 2043-2666 - INSERT ACETAB 66MM 26MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2670 SUP Custom 27803010 2043-2670 - INSERT ACETAB 70MM 26MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2674 SUP Custom 27803010 2043-2674 - INSERT ACETAB 74MM 26MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2846 SUP Custom 27803010 2043-2846 - INSERT ACETAB 46-48MM 28MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2850 SUP Custom 27803010 2043-2850 - INSERT ACETAB 50-52MM 28MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2854 SUP Custom 27803010 2043-2854 - INSERT ACETAB 54-56MM 28MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2858 SUP Custom 27803010 2043-2858 - INSERT ACETAB 58-60MM 28MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2862 SUP Custom 27803010 2043-2862 - INSERT ACETAB 62-72MM 28MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2866 SUP Custom 27803010 2043-2866 - INSERT ACETAB 66MM 28MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2870 SUP Custom 27803010 2043-2870 - INSERT ACETAB 70MM 28MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-2874 SUP Custom 27803010 2043-2874 - INSERT ACETAB 74MM 28MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-3246 SUP Custom 27803010 2043-3246 - INSERT ACETAB 46-48MM 32MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-3250 SUP Custom 27803010 2043-3250 - INSERT ACETAB 50-52MM 32MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-3254 SUP Custom 27803010 2043-3254 - INSERT ACETAB 54-56MM 32MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-3258 SUP Custom 27803010 2043-3258 - INSERT ACETAB 58-60MM 32MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-3262 SUP Custom 27803010 2043-3262 - INSERT ACETAB 62-70MM 32MM 0D HIP S2 UHMWPE OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-3266 SUP Custom 27803010 2043-3266 - INSERT ACETAB 66MM 32MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-3270 SUP Custom 27803010 2043-3270 - INSERT ACETAB 70MM 32MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043-3274 SUP Custom 27803010 2043-3274 - INSERT ACETAB 74MM 32MM 0D HIP OMFT BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2642 SUP Custom 27803010 2043C-2642 - INSERT ACETAB 42MM 26MM 0D HIP S2 XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2646 SUP Custom 27803010 2043C-2646 - INSERT ACETAB 46MM 26MM 0D HIP S2 XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2650 SUP Custom 27803010 2043C-2650 - INSERT ACETAB 26MM 0D HIP S2 XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2654 SUP Custom 27803010 2043C-2654 - INSERT ACETAB 26MM 0D HIP S2 XFIRE BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $0.00 $0.00 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2846 SUP Custom 27803010 2043C-2846 - INSERT ACETAB 0D 46MM 28MM XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2850 SUP Custom 27803010 2043C-2850 - INSERT ACETAB 0D 50-52MM 28MM SERIES II XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2854 SUP Custom 27803010 2043C-2854 - INSERT ACETAB 0D 54-56MM 28MM 11.4MM SERIES II OMNIFIT XFIRE BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2858 SUP Custom 27803010 2043C-2858 - INSERT ACETAB 0D 58-60MM 28MM SERIES II XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2862 SUP Custom 27803010 2043C-2862 - INSERT ACETAB 0D 62-72MM 28MM SERIES II XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-2866 SUP Custom 27803010 2043C-2866 - INSERT ACETAB 0D 66MM 28MM XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-3250 SUP Custom 27803010 2043C-3250 - INSERT ACETAB 0D 50MM 32MM XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-3254 SUP Custom 27803010 2043C-3254 - INSERT ACETAB 0D 32MM LINER XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-3258 SUP Custom 27803010 2043C-3258 - INSERT ACETAB 0D 58-60MM 32MM SERIES II XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-3262 SUP Custom 27803010 2043C-3262 - INSERT ACETAB 10D 62MM 32MM XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-3266 SUP Custom 27803010 2043C-3266 - INSERT ACETAB 0D 66MM 32MM XFIRE HIP BOTH IP/OP "$2,397.50 " "$1,774.15" $0.00 "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.42" "$1,779.42" $0.00 $0.00 $499.64 $0.00 $0.00 $0.00 $0.00 "$1,198.75" "$1,898.82" "$1,918.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-3270 SUP Custom 27803010 2043C-3270 - INSERT ACETAB 0D 70MM 32MM XFIRE HIP BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2043C-3274 SUP Custom 27803010 2043C-3274 - INSERT ACETAB 0D 74MM 32MM XFIRE HIP BOTH IP/OP "$2,720.00 " "$2,012.80" $0.00 "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.78" "$2,018.78" $0.00 $0.00 $566.85 $0.00 $0.00 $0.00 $0.00 "$1,360.00" "$2,154.24" "$2,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2044-1125S SUP HCPCS C1713 2044-1125S - NAIL 440MM HIP RIGHT GAMMA3 IM R2 LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2044-1130S SUP HCPCS C1713 2044-1130S - NAIL 11MM 44CM RIGHT FEM GAMA IM 130D LNG TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2044-1135S SUP HCPCS C1713 2044-1135S - NAIL 11MM 44CM RIGHT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2044-1330S SUP HCPCS C1713 2044-1330S - NAIL 440MM HIP RIGHT GAMMA3 IM R2 LNG ORTHNX BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2040 SUP Custom 27803010 2050-2040 - SHELL ACETAB 40MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2040CS SUP Custom 27803010 2050-2040CS - SHELL ACETAB 40MM HIP SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2042 SUP Custom 27803010 2050-2042 - SHELL ACETAB 42MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2042CS SUP Custom 27803010 2050-2042CS - SHELL ACETAB 42MM HIP SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2044 SUP Custom 27803010 2050-2044 - SHELL ACETAB 44MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2044CS SUP Custom 27803010 2050-2044CS - SHELL ACETAB 44MM HIP SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2046 SUP Custom 27803010 2050-2046 - SHELL ACETAB 46MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2048 SUP Custom 27803010 2050-2048 - SHELL ACETAB 48MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2050 SUP Custom 27803010 2050-2050 - SHELL ACETAB 50MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2052 SUP Custom 27803010 2050-2052 - SHELL ACETAB 52MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2054 SUP Custom 27803010 2050-2054 - SHELL ACETAB 54MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2056 SUP Custom 27803010 2050-2056 - SHELL ACETAB 56MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2058 SUP Custom 27803010 2050-2058 - SHELL ACETAB 58MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2060 SUP Custom 27803010 2050-2060 - SHELL ACETAB 60MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2062 SUP Custom 27803010 2050-2062 - SHELL ACETAB 62MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2064 SUP Custom 27803010 2050-2064 - SHELL ACETAB HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,377.00 " "$1,758.98" $0.00 "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,764.21" "$1,764.21" $0.00 $0.00 $495.37 $0.00 $0.00 $0.00 $0.00 "$1,188.50" "$1,882.58" "$1,901.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2066 SUP Custom 27803010 2050-2066 - SHELL ACETAB 66MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2068 SUP Custom 27803010 2050-2068 - SHELL ACETAB 68MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2070 SUP Custom 27803010 2050-2070 - SHELL ACETAB 70MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-2072 SUP Custom 27803010 2050-2072 - SHELL ACETAB 72MM HIP CLSHOLE SECFIT PSL BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3040 SUP Custom 27803010 2050-3040 - SHELL ACETAB 40MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3042 SUP Custom 27803010 2050-3042 - SHELL ACETAB 42MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3044 SUP Custom 27803010 2050-3044 - SHELL ACETAB 44MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3046 SUP Custom 27803010 2050-3046 - SHELL ACETAB 46MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3048 SUP Custom 27803010 2050-3048 - SHELL ACETAB 48MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3050 SUP Custom 27803010 2050-3050 - SHELL ACETAB 50MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3052 SUP Custom 27803010 2050-3052 - SHELL ACETAB 52MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3054 SUP Custom 27803010 2050-3054 - SHELL ACETAB 54MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3056 SUP Custom 27803010 2050-3056 - SHELL ACETAB 56MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3058 SUP Custom 27803010 2050-3058 - SHELL ACETAB 58MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3060 SUP Custom 27803010 2050-3060 - SHELL ACETAB 60MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3062 SUP Custom 27803010 2050-3062 - SHELL ACETAB 62MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3064 SUP Custom 27803010 2050-3064 - SHELL ACETAB 64MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3066 SUP Custom 27803010 2050-3066 - SHELL ACETAB 66MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3068 SUP Custom 27803010 2050-3068 - SHELL ACETAB 68MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3070 SUP Custom 27803010 2050-3070 - SHELL ACETAB 70MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-3072 SUP Custom 27803010 2050-3072 - SHELL ACETAB 72MM HIP SCRLES SECFIT PSL BOTH IP/OP "$2,505.00 " "$1,853.70" $0.00 "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.21" "$1,859.21" $0.00 $0.00 $522.04 $0.00 $0.00 $0.00 $0.00 "$1,252.50" "$1,983.96" "$2,004.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2050-5060P SUP Custom 27803010 2050-5060P - SHELL ACETAB ARC DEPOSITED OPTN SECFIT BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2040 SUP Custom 27803010 2051-2040 - SHELL ACETAB 40MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,135.00 " "$1,579.90" $0.00 "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,584.60" "$1,584.60" $0.00 $0.00 $444.93 $0.00 $0.00 $0.00 $0.00 "$1,067.50" "$1,690.92" "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2040P SUP Custom 27803010 2051-2040P - CUP ACETAB 40MM CLSHOLE SECFIT PSL HA HIP BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2042 SUP Custom 27803010 2051-2042 - SHELL ACETAB 42MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,135.00 " "$1,579.90" $0.00 "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,584.60" "$1,584.60" $0.00 $0.00 $444.93 $0.00 $0.00 $0.00 $0.00 "$1,067.50" "$1,690.92" "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2042P SUP Custom 27803010 2051-2042P - SHELL ACETAB 42MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2044 SUP Custom 27803010 2051-2044 - SHELL ACETAB 44MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,135.00 " "$1,579.90" $0.00 "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,584.60" "$1,584.60" $0.00 $0.00 $444.93 $0.00 $0.00 $0.00 $0.00 "$1,067.50" "$1,690.92" "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2044P SUP Custom 27803010 2051-2044P - SHELL ACETAB 44MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2046 SUP Custom 27803010 2051-2046 - SHELL ACETAB 46MM HIP CLSHOLE HYDRXAPT SECFIT BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2046P SUP Custom 27803010 2051-2046P - CUP ACETAB 46MM CLSHOLE SECFIT PSL HA HIP BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2048 SUP Custom 27803010 2051-2048 - SHELL ACETAB 48MM CLSTR SH HYDRXAPT SECFIT PSL BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2048P SUP Custom 27803010 2051-2048P - SHELL ACETAB 48MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2050 SUP Custom 27803010 2051-2050 - SHELL ACETAB 50MM CLSTR SH HYDRXAPT SECFIT PSL BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2050P SUP Custom 27803010 2051-2050P - SHELL ACETAB 50MM HIP CLSHOLE HYDRXAPT PSL SECFIT BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2052 SUP Custom 27803010 2051-2052 - SHELL ACETAB 52MM CLSTR SH HYDRXAPT SECFIT PSL BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2052P SUP Custom 27803010 2051-2052P - SHELL ACETAB 52MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2054 SUP Custom 27803010 2051-2054 - SHELL ACETAB 54MM CLSTR SH HYDRXAPT SECFIT PSL BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2054P SUP Custom 27803010 2051-2054P - CUP ACETAB 54MM SECFIT PSL CLSTR HIP HYDRXAPT BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2056 SUP Custom 27803010 2051-2056 - SHELL ACETAB 56MM CLSTR CUP SH HYDRXAPT SECFIT PSL BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2056P SUP Custom 27803010 2051-2056P - CUP ACETAB 56MM SECFIT PSL CLSTR HIP HYDRXAPT BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2058 SUP Custom 27803010 2051-2058 - CUP ACETAB 58MM SECFIT CLSTR SCR HOLE HIP HYDRXAPT BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2058P SUP Custom 27803010 2051-2058P - CUP ACETAB 58MM SECFIT PSL CLSTR HIP HYDRXAPT BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2060 SUP Custom 27803010 2051-2060 - SHELL ACETAB 60MM CLSTR CUP SH HYDRXAPT SECFIT PSL BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2060P SUP Custom 27803010 2051-2060P - CUP ACETAB 60MM SECFIT PSL CLSTR HIP HYDRXAPT BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2062 SUP Custom 27803010 2051-2062 - SHELL ACETAB CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2062P SUP Custom 27803010 2051-2062P - CUP ACETAB 62MM SECFIT PSL CLSTR HIP HYDRXAPT BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2064 SUP Custom 27803010 2051-2064 - SHELL ACETAB 64MM HIP CLSHOLE PUREFIX HYDRXAPT SECFIT BOTH IP/OP "$2,102.00 " "$1,555.48" $0.00 "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,560.10" "$1,560.10" $0.00 $0.00 $438.06 $0.00 $0.00 $0.00 $0.00 "$1,051.00" "$1,664.78" "$1,681.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2064P SUP Custom 27803010 2051-2064P - CUP ACETAB 64MM SECFIT PSL CLSTR HIP HYDRXAPT BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2066 SUP Custom 27803010 2051-2066 - SHELL ACETAB 66MM HIP CLSHOLE HYDRXAPT SECFIT BOTH IP/OP "$2,135.00 " "$1,579.90" $0.00 "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,584.60" "$1,584.60" $0.00 $0.00 $444.93 $0.00 $0.00 $0.00 $0.00 "$1,067.50" "$1,690.92" "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2066P SUP Custom 27803010 2051-2066P - SHELL ACETAB 66MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2068 SUP Custom 27803010 2051-2068 - SHELL ACETAB 68MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,135.00 " "$1,579.90" $0.00 "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,584.60" "$1,584.60" $0.00 $0.00 $444.93 $0.00 $0.00 $0.00 $0.00 "$1,067.50" "$1,690.92" "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2068P SUP Custom 27803010 2051-2068P - SHELL ACETAB 68MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2070 SUP Custom 27803010 2051-2070 - SHELL ACETAB 70MM HIP CLSHOLE HYDRXAPT SECFIT BOTH IP/OP "$2,135.00 " "$1,579.90" $0.00 "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,584.60" "$1,584.60" $0.00 $0.00 $444.93 $0.00 $0.00 $0.00 $0.00 "$1,067.50" "$1,690.92" "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2070P SUP Custom 27803010 2051-2070P - SHELL ACETAB 70MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2072 SUP Custom 27803010 2051-2072 - SHELL ACETAB 72MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,135.00 " "$1,579.90" $0.00 "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,584.60" "$1,584.60" $0.00 $0.00 $444.93 $0.00 $0.00 $0.00 $0.00 "$1,067.50" "$1,690.92" "$1,708.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-2072P SUP Custom 27803010 2051-2072P - SHELL ACETAB 72MM HIP CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$2,228.00 " "$1,648.72" $0.00 "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.62" "$1,653.62" $0.00 $0.00 $464.32 $0.00 $0.00 $0.00 $0.00 "$1,114.00" "$1,764.58" "$1,782.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3040 SUP Custom 27803010 2051-3040 - SHELL ACETAB 40MM HIP SCRLES HYDRXAPT SECFIT BOTH IP/OP "$2,260.00 " "$1,672.40" $0.00 "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.37" "$1,677.37" $0.00 $0.00 $470.98 $0.00 $0.00 $0.00 $0.00 "$1,130.00" "$1,789.92" "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3042 SUP Custom 27803010 2051-3042 - SHELL ACETAB 42MM HIP SCRLES HYDRXAPT SECFIT BOTH IP/OP "$2,260.00 " "$1,672.40" $0.00 "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.37" "$1,677.37" $0.00 $0.00 $470.98 $0.00 $0.00 $0.00 $0.00 "$1,130.00" "$1,789.92" "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3044 SUP Custom 27803010 2051-3044 - CUP ACETAB 44MM SECFIT PSL SCRLES HIP HYDRXAPT BOTH IP/OP "$2,260.00 " "$1,672.40" $0.00 "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.37" "$1,677.37" $0.00 $0.00 $470.98 $0.00 $0.00 $0.00 $0.00 "$1,130.00" "$1,789.92" "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3046 SUP Custom 27803010 2051-3046 - CUP ACETAB 46MM SECFIT PSL SCRLES HIP HYDRXAPT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3048 SUP Custom 27803010 2051-3048 - CUP ACETAB 48MM SECFIT PSL SCRLES HIP HYDRXAPT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3050 SUP Custom 27803010 2051-3050 - CUP ACETAB 50MM SECFIT PSL SCRLES HIP HYDRXAPT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3052 SUP Custom 27803010 2051-3052 - CUP ACETAB 52MM SECFIT PSL SCRLES HIP HYDRXAPT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3054 SUP Custom 27803010 2051-3054 - SHELL ACETAB 54MM HIP NO HOLE SLD PUREFIX HYDRXAPT SECFIT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3056 SUP Custom 27803010 2051-3056 - CUP ACETAB 56MM SECFIT NO HOLE SLD HIP HYDRXAPT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3058 SUP Custom 27803010 2051-3058 - CUP ACETAB 58MM SECFIT NO HOLE SLD HIP HYDRXAPT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3060 SUP Custom 27803010 2051-3060 - CUP ACETAB 60MM SECFIT NO HOLE SLD HIP HYDRXAPT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3062 SUP Custom 27803010 2051-3062 - SHELL ACETAB 62MM HIP SCRLES HYDRXAPT SECFIT PSL BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3064 SUP Custom 27803010 2051-3064 - CUP ACETAB 64MM SECFIT PSL SCRLES HIP HYDRXAPT BOTH IP/OP "$2,227.00 " "$1,647.98" $0.00 "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.88" "$1,652.88" $0.00 $0.00 $464.11 $0.00 $0.00 $0.00 $0.00 "$1,113.50" "$1,763.78" "$1,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3066 SUP Custom 27803010 2051-3066 - SHELL ACETAB 66MM HIP SCRLES HYDRXAPT SECFIT PSL BOTH IP/OP "$2,260.00 " "$1,672.40" $0.00 "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.37" "$1,677.37" $0.00 $0.00 $470.98 $0.00 $0.00 $0.00 $0.00 "$1,130.00" "$1,789.92" "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3068 SUP Custom 27803010 2051-3068 - SHELL ACETAB 68MM HIP SCRLES HYDRXAPT SECFIT PSL BOTH IP/OP "$2,260.00 " "$1,672.40" $0.00 "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.37" "$1,677.37" $0.00 $0.00 $470.98 $0.00 $0.00 $0.00 $0.00 "$1,130.00" "$1,789.92" "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3070 SUP Custom 27803010 2051-3070 - SHELL ACETAB 70MM HIP SCRLES HYDRXAPT SECFIT BOTH IP/OP "$2,260.00 " "$1,672.40" $0.00 "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.37" "$1,677.37" $0.00 $0.00 $470.98 $0.00 $0.00 $0.00 $0.00 "$1,130.00" "$1,789.92" "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2051-3072 SUP Custom 27803010 2051-3072 - SHELL ACETAB 72MM HIP SCRLES HYDRXAPT SECFIT BOTH IP/OP "$2,260.00 " "$1,672.40" $0.00 "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.37" "$1,677.37" $0.00 $0.00 $470.98 $0.00 $0.00 $0.00 $0.00 "$1,130.00" "$1,789.92" "$1,808.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2048 SUP Custom 27803010 2053-2048 - SHELL ACETAB 48MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2050 SUP Custom 27803010 2053-2050 - SHELL ACETAB 50MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2052 SUP Custom 27803010 2053-2052 - SHELL ACETAB 52MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2054 SUP Custom 27803010 2053-2054 - SHELL ACETAB 54MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2056 SUP Custom 27803010 2053-2056 - SHELL ACETAB 56MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2058 SUP Custom 27803010 2053-2058 - SHELL ACETAB 58MM CLSHOLE HYDRXAPT SECFIT PSL BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2060 SUP Custom 27803010 2053-2060 - SHELL ACETAB 60MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2062 SUP Custom 27803010 2053-2062 - SHELL ACETAB 62MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2064 SUP Custom 27803010 2053-2064 - SHELL ACETAB 64MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2066 SUP Custom 27803010 2053-2066 - SHELL ACETAB 66MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2068 SUP Custom 27803010 2053-2068 - SHELL ACETAB 68MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2070 SUP Custom 27803010 2053-2070 - SHELL ACETAB 70MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2072 SUP Custom 27803010 2053-2072 - SHELL ACETAB 72MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2074 SUP Custom 27803010 2053-2074 - SHELL ACETAB 74MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2076 SUP Custom 27803010 2053-2076 - SHELL ACETAB 76MM HIP CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2078 SUP Custom 27803010 2053-2078 - SHELL ACETAB CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-2080 SUP Custom 27803010 2053-2080 - SHELL ACETAB CLSHOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,190.88 " "$3,101.25" $0.00 "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.47" "$3,110.47" $0.00 $0.00 $873.38 $0.00 $0.00 $0.00 $0.00 "$2,095.44" "$3,319.18" "$3,352.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3048 SUP Custom 27803010 2053-3048 - SHELL ACETAB 48MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3050 SUP Custom 27803010 2053-3050 - SHELL ACETAB 50MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3052 SUP Custom 27803010 2053-3052 - SHELL ACETAB 52MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3054 SUP Custom 27803010 2053-3054 - SHELL ACETAB 54MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3056 SUP Custom 27803010 2053-3056 - SHELL ACETAB 56MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3058 SUP Custom 27803010 2053-3058 - SHELL ACETAB 58MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3060 SUP Custom 27803010 2053-3060 - SHELL ACETAB 60MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3062 SUP Custom 27803010 2053-3062 - SHELL ACETAB 62MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3064 SUP Custom 27803010 2053-3064 - SHELL ACETAB 64MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3066 SUP Custom 27803010 2053-3066 - SHELL ACETAB 66MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3068 SUP Custom 27803010 2053-3068 - SHELL ACETAB 68MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3070 SUP Custom 27803010 2053-3070 - SHELL ACETAB 70MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3072 SUP Custom 27803010 2053-3072 - SHELL ACETAB 72MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3074 SUP Custom 27803010 2053-3074 - SHELL ACETAB 74MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3076 SUP Custom 27803010 2053-3076 - SHELL ACETAB 76MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3078 SUP Custom 27803010 2053-3078 - SHELL ACETAB 78MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2053-3080 SUP Custom 27803010 2053-3080 - SHELL ACETAB 80MM HIP NO DOME HOLE HYDRXAPT SECFIT X BOTH IP/OP "$4,423.25 " "$3,273.21" $0.00 "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,282.94" "$3,282.94" $0.00 $0.00 $921.81 $0.00 $0.00 $0.00 $0.00 "$2,211.63" "$3,503.21" "$3,538.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2060-0000 SUP Custom 27803010 2060-0000 - PLUG DOME HOLE ACETAB DOME BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.26 $94.26 $0.00 $0.00 $26.47 $0.00 $0.00 $0.00 $0.00 $63.50 $100.58 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2060-0000-1 SUP Custom 27803010 2060-0000-1 - PLUG DOME HL ACTB BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2078-1330S SUP HCPCS C1713 2078-1330S - NAIL 280MM HIP RIGHT GAMMA3 IM R2 LNG ORTHNX BOTH IP/OP "$2,090.00 " "$1,546.60" $0.00 "$1,672.00" $940.50 $940.50 $0.00 $0.00 $0.00 $435.61 "$1,551.20" "$1,551.20" $0.00 $0.00 $435.56 $0.00 "$1,236.24" "$1,236.24" $0.00 "$1,045.00" "$1,655.28" "$1,672.00" $0.00 $0.00 $327.09 $0.00 $0.00 $332.73 $0.00 $0.00 $0.00 $0.00 $0.00 2078-1530S SUP HCPCS C1713 2078-1530S - NAIL 280MM HIP LEFT GAMMA3 IM R2 LNG STRL STSCR BOTH IP/OP "$2,090.00 " "$1,546.60" $0.00 "$1,672.00" $940.50 $940.50 $0.00 $0.00 $0.00 $435.61 "$1,551.20" "$1,551.20" $0.00 $0.00 $435.56 $0.00 "$1,236.24" "$1,236.24" $0.00 "$1,045.00" "$1,655.28" "$1,672.00" $0.00 $0.00 $327.09 $0.00 $0.00 $332.73 $0.00 $0.00 $0.00 $0.00 $0.00 207-G SUP Custom 27203010 REMOVER STAIN ERANDO-SOL 1 GAL BOTH IP/OP $194.18 $143.69 $0.00 $155.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.09 $153.79 $155.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0015 SUP HCPCS C1713 2080-0015 - SCREW BN 6.5MM 15MM TX ACTB CANC TRITANIUM MLHL SHL BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0020 SUP HCPCS C1713 2080-0020 - SCREW BN 6.5MM 20MM TX ACTB CANC TRITANIUM MLHL SHL BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0025 SUP HCPCS C1713 2080-0025 - SCREW BN 6.5MM 25MM TX ACTB CANC TRITANIUM MLHL SHL BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0030 SUP HCPCS C1713 2080-0030 - SCREW BN 6.5MM 30MM TX ACTB CANC TRITANIUM MLHL SHL BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0035 SUP HCPCS C1713 2080-0035 - SCREW BN 6.5MM 35MM TX ACTB CANC TRITANIUM MLHL SHL BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0040 SUP HCPCS C1713 2080-0040 - SCREW BN 6.5MM 40MM TX ACTB CANC TRITANIUM MLHL SHL BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0045 SUP HCPCS C1713 2080-0045 - SCREW BN 6.5MM 45MM TX ACTB CANC TRITANIUM MLHL SHL BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0050 SUP HCPCS C1713 2080-0050 - SCREW ACETAB 6.5MM 50MM GAP HIP CANCELLOUS BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0055 SUP HCPCS C1713 2080-0055 - SCREW ACETAB 6.5MM 55MM PLATE TORX GAP II CANCELLOUS BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-0060 SUP HCPCS C1713 2080-0060 - SCREW ACETAB 6.5MM 60MM GAP II HIP STERILE BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $128.25 $128.25 $0.00 $0.00 $0.00 $59.40 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $168.58 $168.58 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $44.60 $0.00 $0.00 $45.37 $0.00 $0.00 $0.00 $0.00 $0.00 2080-1125S SUP HCPCS C1713 2080-1125S - NAIL 300MM HIP RIGHT GAMMA3 IM R2 LNG ORTHNX BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2080-1130S SUP HCPCS C1713 2080-1130S - NAIL 11MM 30CM LEFT FEM GAMA IM 130D LNG TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2080-1135S SUP HCPCS C1713 2080-1135S - NAIL 11MM 300MM HIP LEFT GAMMA3 IM 135D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2080-1330S SUP HCPCS C1713 2080-1330S - NAIL 300MM HIP GAMMA3 IM R2 LNG ORTHNX BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0048L SUP Custom 27803010 2082-0048L - SHELL ACETAB 48MM 45MM RSTOR GAP II TITANIUM HIP LEFT BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0048R SUP Custom 27803010 2082-0048R - SHELL ACETAB 48MM RSTOR GAP II TITANIUM RIGHT HIP BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0052L SUP Custom 27803010 2082-0052L - SHELL ACETAB 52MM RSTOR GAP II TITANIUM LEFT HIP BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0052R SUP Custom 27803010 2082-0052R - SHELL ACETAB 52MM RSTOR GAP II TITANIUM RIGHT HIP BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0056L SUP Custom 27803010 2082-0056L - SHELL ACETAB 56MM 53MM RSTOR GAP II TITANIUM HIP LEFT BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0056R SUP Custom 27803010 2082-0056R - SHELL ACETAB 56MM RSTOR GAP II TITANIUM RIGHT HIP BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0060L SUP Custom 27803010 2082-0060L - SHELL ACETAB 60MM 56MM RSTOR GAP II TITANIUM HIP LEFT BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0060R SUP Custom 27803010 2082-0060R - SHELL ACETAB 60MM RSTOR GAP II TITANIUM RIGHT HIP BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0064L SUP Custom 27803010 2082-0064L - SHELL ACETAB 64MM 61MM RSTOR GAP II TITANIUM HIP LEFT BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0064R SUP Custom 27803010 2082-0064R - SHELL ACETAB 64MM RSTOR GAP II TITANIUM RIGHT HIP BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0068L SUP Custom 27803010 2082-0068L - SHELL ACETAB 68MM 64MM RSTOR GAP II TITANIUM HIP LEFT BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0068R SUP Custom 27803010 2082-0068R - SHELL ACETAB 68MM RSTOR GAP II TITANIUM RIGHT HIP BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0072L SUP Custom 27803010 2082-0072L - SHELL ACETAB 72MM 69MM RSTOR GAP II TITANIUM HIP LEFT BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-0072R SUP Custom 27803010 2082-0072R - SHELL ACETAB 72MM RSTOR GAP II TITANIUM RIGHT HIP BOTH IP/OP "$6,930.00 " "$5,128.20" $0.00 "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,444.21" $0.00 $0.00 $0.00 $0.00 "$3,465.00" "$5,488.56" "$5,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2082-1125S SUP HCPCS C1713 2082-1125S - NAIL 11MM 320MM LEFT GAMA IM LNG 125D LCK SCR STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2082-1130S SUP HCPCS C1713 2082-1130S - NAIL 11MM 32CM LEFT FEM GAMA IM 130D LNG TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2082-1135S SUP HCPCS C1713 2082-1135S - NAIL 11MM 32CM LEFT HIP GAMA IM 135D LNG LCK ORTHNX STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2082-1330S SUP HCPCS C1713 2082-1330S - NAIL 13MM 320MM LEFT GAMA IM LNG 130D LCK SCR STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2083-0048 SUP Custom 27803010 2083-0048 - SHELL ACETAB 48MM RING GAP OMNIFIT OSTEOLOCK RSTOR SECFIT BOTH IP/OP "$5,675.00 " "$4,199.50" $0.00 "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,182.67" $0.00 $0.00 $0.00 $0.00 "$2,837.50" "$4,494.60" "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2083-0052 SUP Custom 27803010 2083-0052 - RING ACETAB 52MM RSTOR GAP TITANIUM HIP BOTH IP/OP "$5,675.00 " "$4,199.50" $0.00 "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,182.67" $0.00 $0.00 $0.00 $0.00 "$2,837.50" "$4,494.60" "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2083-0056 SUP Custom 27803010 2083-0056 - RING ACETAB 56MM RSTOR GAP II TITANIUM HIP BOTH IP/OP "$5,675.00 " "$4,199.50" $0.00 "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,182.67" $0.00 $0.00 $0.00 $0.00 "$2,837.50" "$4,494.60" "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2083-0060 SUP Custom 27803010 2083-0060 - RING ACETAB 60MM RSTOR GAP II TITANIUM HIP BOTH IP/OP "$5,675.00 " "$4,199.50" $0.00 "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,182.67" $0.00 $0.00 $0.00 $0.00 "$2,837.50" "$4,494.60" "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2083-0064 SUP Custom 27803010 2083-0064 - RING ACETAB 64MM RSTOR GAP II TITANIUM HIP BOTH IP/OP "$5,675.00 " "$4,199.50" $0.00 "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,182.67" $0.00 $0.00 $0.00 $0.00 "$2,837.50" "$4,494.60" "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2083-0068 SUP Custom 27803010 2083-0068 - SHELL ACETAB 68MM RING GAP OMNIFIT OSTEOLOCK RSTOR SECFIT BOTH IP/OP "$5,675.00 " "$4,199.50" $0.00 "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,182.67" $0.00 $0.00 $0.00 $0.00 "$2,837.50" "$4,494.60" "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2083-0072 SUP Custom 27803010 2083-0072 - RING ACETAB 72MM RSTOR GAP II TITANIUM HIP BOTH IP/OP "$5,675.00 " "$4,199.50" $0.00 "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,182.67" $0.00 $0.00 $0.00 $0.00 "$2,837.50" "$4,494.60" "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2084-1125S SUP HCPCS C1713 2084-1125S - NAIL 11MM 34CM LEFT HIP GAMA IM 125D LNG LCK ORTHNX STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2084-1130S SUP HCPCS C1713 2084-1130S - NAIL 11MM 34CM LEFT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2084-1135S SUP HCPCS C1713 2084-1135S - NAIL 11MM 34CM LEFT ORTH GAMA IM 135D LNG STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2084-1330S SUP HCPCS C1713 2084-1330S - NAIL 13MM 340MM HIP LEFT GAMMA3 IM 130D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2086-1125S SUP HCPCS C1713 2086-1125S - NAIL 11MM 36CM HIP LEFT FEM GAMMA3 IM 125D LNG TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2086-1130S SUP HCPCS C1713 2086-1130S - NAIL 11MM 36CM LEFT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2086-1135S SUP HCPCS C1713 2086-1135S - NAIL 11MM 36CM LEFT ORTH GAMA IM 135D LNG STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2086-1330S SUP HCPCS C1713 2086-1330S - NAIL 13MM 360MM LEFT GAMA IM LNG 130D LCK SCR STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2088-1125S SUP HCPCS C1713 2088-1125S - NAIL 11MM 380MM HIP LEFT GAMMA3 IM 125D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2088-1130S SUP HCPCS C1713 2088-1130S - NAIL 11MM 38CM LEFT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2088-1135S SUP HCPCS C1713 2088-1135S - NAIL 11MM 38CM LEFT HIP GAMA IM 135D LNG LCK ORTHNX STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2088-1330S SUP HCPCS C1713 2088-1330S - NAIL 13MM 380MM HIP LEFT GAMMA3 IM 130D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2088TC/100 SUP HCPCS C1898 2088TC/100 - LEAD PCNG HLX 6FR 100CM TNDRL STS IS 1 BP CNCT RING ELTRD BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 2088TC/46 SUP HCPCS C1898 2088TC/46 - LEAD PCNG HLX 6FR 46CM TNDRL STS IS-1 CNCT BP ACTFX XTD STRD BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 2088TC/52 SUP HCPCS C1898 2088TC/52 - LEAD PCNG 6FR 52CM TNDRL STS IS-1 BP CNCT ACT RTRCT XTD HLX BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 2088TC/58 SUP HCPCS C1898 2088TC/58 - LEAD PCNG HLX 6FR 58CM TNDRL STS IS 1 CNCT ACTFX BP SFT STRD BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 2088TC/65 SUP HCPCS C1898 2088TC/65 - TENDRIL STS 2088TC/65 BOTH IP/OP $680.00 $503.20 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $141.73 $504.70 $504.70 $0.00 $0.00 $141.71 $0.00 $402.22 $402.22 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 209.740S SUP HCPCS C1713 209.740S - SCREW BN FT 7.3MM 140MM STRL CNN SS BOTH IP/OP $579.15 $428.57 $0.00 $449.82 $253.02 $253.02 $0.00 $0.00 $0.00 $120.71 $429.85 $429.85 $0.00 $0.00 $120.69 $0.00 $342.57 $342.57 $0.00 $281.14 $445.33 $449.82 $0.00 $0.00 $85.43 $0.00 $0.00 $89.51 $0.00 $0.00 $0.00 $0.00 $0.00 2090-1125S SUP HCPCS C1713 2090-1125S - NAIL 400MM HIP RIGHT GAMMA3 IM R2 LNG ORTHNX BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2090-1130S SUP HCPCS C1713 2090-1130S - NAIL 11MM 40CM LEFT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2090-1135S SUP HCPCS C1713 2090-1135S - NAIL 11MM 40CM LEFT HIP GAMA IM 135D LNG LCK ORTHNX STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2090-1330S SUP HCPCS C1713 2090-1330S - NAIL 13MM 400MM HIP LEFT GAMMA3 IM 130D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2092-1125S SUP HCPCS C1713 2092-1125S - NAIL 11MM 420MM HIP LEFT GAMMA3 IM LNG 125D BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2092-1130S SUP HCPCS C1713 2092-1130S - NAIL 11MM 42CM LEFT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2092-1135S SUP HCPCS C1713 2092-1135S - NAIL 11MM 42CM LEFT HIP GAMA IM 135D LNG LCK ORTHNX STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2092-1330S SUP HCPCS C1713 2092-1330S - NAIL 13MM 42CM LEFT HIP GAMA IM 130D LNG LCK ORTHNX STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2092-1530S SUP HCPCS C1713 2092-1530S - NAIL 15MM 420MM HIP LEFT GAMMA3 IM 130D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2092-3-963 SUP HCPCS C1713 2092-3-963 - PIN HALF 240MM 5MM APEX SLFDRILL 50MM BOTH IP/OP $119.85 $88.69 $0.00 $97.90 $55.07 $55.07 $0.00 $0.00 $0.00 $24.98 $88.95 $88.95 $0.00 $0.00 $24.98 $0.00 $70.89 $70.89 $0.00 $61.19 $96.92 $97.90 $0.00 $0.00 $19.15 $0.00 $0.00 $19.48 $0.00 $0.00 $0.00 $0.00 $0.00 2094-1125S SUP HCPCS C1713 2094-1125S - NAIL 11MM 44CM LEFT HIP GAMA IM 125D LNG LCK ORTHNX STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2094-1130S SUP HCPCS C1713 2094-1130S - NAIL 11MM 44CM LEFT FEM GAMA IM 130D LNG LCK TI STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2094-1135S SUP HCPCS C1713 2094-1135S - NAIL 11MM 44CM LEFT HIP GAMA IM 135D LNG LCK ORTHNX STRL BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2094-1330S SUP HCPCS C1713 2094-1330S - NAIL 13MM 440MM HIP LEFT GAMMA3 IM 130D LNG BOTH IP/OP "$2,908.13 " "$2,152.02" $0.00 "$2,326.50" "$1,308.66" "$1,308.66" $0.00 $0.00 $0.00 $606.13 "$2,158.41" "$2,158.41" $0.00 $0.00 $606.05 $0.00 "$1,433.71" "$1,433.71" $0.00 "$1,454.06" "$2,303.24" "$2,326.50" $0.00 $0.00 $455.12 $0.00 $0.00 $462.97 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2250 SUP Custom 27803010 2099-2250 - INSERT ACETAB 50MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2252 SUP Custom 27803010 2099-2252 - INSERT ACETAB 52MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2254 SUP Custom 27803010 2099-2254 - INSERT ACETAB 54MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2256 SUP Custom 27803010 2099-2256 - INSERT ACETAB 56MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2258 SUP Custom 27803010 2099-2258 - INSERT ACETAB 58MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2261 SUP Custom 27803010 2099-2261 - INSERT ACETAB 61MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2266 SUP Custom 27803010 2099-2266 - INSERT ACETAB 66MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2270 SUP Custom 27803010 2099-2270 - INSERT ACETAB 70MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2274 SUP Custom 27803010 2099-2274 - INSERT ACETAB 74MM 22MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2656 SUP Custom 27803010 2099-2656 - INSERT ACETAB 56MM 26MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2658 SUP Custom 27803010 2099-2658 - INSERT ACETAB 58MM 26MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2661 SUP Custom 27803010 2099-2661 - INSERT ACETAB 61MM 26MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2666 SUP Custom 27803010 2099-2666 - INSERT ACETAB 66MM 26MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2670 SUP Custom 27803010 2099-2670 - INSERT ACETAB 70MM 26MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2674 SUP Custom 27803010 2099-2674 - INSERT ACETAB 74MM 26MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2858 SUP Custom 27803010 2099-2858 - INSERT ACETAB 58MM 28MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2861 SUP Custom 27803010 2099-2861 - INSERT ACETAB 61MM 28MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2866 SUP Custom 27803010 2099-2866 - INSERT ACETAB 66MM 28MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2870 SUP Custom 27803010 2099-2870 - INSERT ACETAB 70MM 28MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2099-2874 SUP Custom 27803010 2099-2874 - INSERT ACETAB 74MM 28MM CONSTRAIN HIP BOTH IP/OP "$6,550.00 " "$4,847.00" $0.00 "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,365.02" $0.00 $0.00 $0.00 $0.00 "$3,275.00" "$5,187.60" "$5,240.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21000 A SUP Custom 27803010 21000 A - PLATE 18MM TI BONE SPNL BOTH IP/OP $888.25 $657.31 $0.00 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.26 $659.26 $0.00 $0.00 $185.11 $0.00 $0.00 $0.00 $0.00 $444.13 $703.49 $710.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21000 B SUP Custom 27803010 21000 B - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $997.50 $738.15 $0.00 $798.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $740.34 $740.34 $0.00 $0.00 $207.88 $0.00 $0.00 $0.00 $0.00 $498.75 $790.02 $798.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21020 A-M SUP Custom 27803010 21020 A-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,037.88 " $768.03 $0.00 $830.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $770.31 $770.31 $0.00 $0.00 $216.29 $0.00 $0.00 $0.00 $0.00 $518.94 $822.00 $830.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21020 B-M SUP Custom 27803010 21020 B-M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,037.88 " $768.03 $0.00 $830.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $770.31 $770.31 $0.00 $0.00 $216.29 $0.00 $0.00 $0.00 $0.00 $518.94 $822.00 $830.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1500 SUP HCPCS C9359 2102-1500 - SUBSTITUTE BNGFT 100X25X4MM VOID FILR FOAM STRIP BIOACTIVE BOTH IP/OP "$3,857.50 " "$2,854.55" $0.00 "$3,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $804.00 "$2,863.04" "$2,863.04" $0.00 $0.00 $803.90 $0.00 "$1,901.75" "$1,901.75" $0.00 "$1,928.75" "$3,055.14" "$3,086.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1505 SUP HCPCS C9359 2102-1505 - SUBSTITUTE BNGFT 240X25X4MM VOID FILR FOAM STRIP BIOACTIVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1510 SUP HCPCS C9359 2102-1510 - SUBSTITUTE BNGFT 50X25X8MM VOID FILR FOAM STRIP COMPRESSION BOTH IP/OP "$3,997.00 " "$2,957.78" $0.00 "$3,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $833.07 "$2,966.57" "$2,966.57" $0.00 $0.00 $832.97 $0.00 "$1,970.52" "$1,970.52" $0.00 "$1,998.50" "$3,165.62" "$3,197.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1520 SUP HCPCS C9359 2102-1520 - SUBSTITUTE BNGFT 25MMX100MMX8MM 100X25X8MM VOID FILR FOAM BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1601 SUP HCPCS C9359 2102-1601 - SUBSTITUTE BNGFT FOAM PACK BIOACTIVE VITOSS BTCP COLLAGEN BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1602 SUP HCPCS C9359 2102-1602 - SUBSTITUTE BNGFT VOID FILR FOAM PACK BIOACTIVE VITOSS BTCP BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1605 SUP HCPCS C9359 2102-1605 - SUBSTITUTE BNGFT VOID FILR FOAM PACK BIOACTIVE VITOSS BTCP BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1610 SUP HCPCS C9359 2102-1610 - SUBSTITUTE BNGFT VOID FILR FOAM PACK BIOACTIVE VITOSS BTCP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1901 SUP HCPCS C1713 2102-1901 - SUBSTITUTE BNGFT BIOMODAL FOAM PACK VITOSS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1902 SUP HCPCS C1713 2102-1902 - SUBSTITUTE BNGFT BIOMODAL FOAM PACK VITOSS BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1905 SUP HCPCS C1713 2102-1905 - SUBSTITUTE BNGFT BIMODAL FOAM PACK VITOSS BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-1910 SUP HCPCS C1713 2102-1910 - SUBSTITUTE BNGFT BIOMODAL FOAM PACK VITOSS BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 2102-2110 SUP HCPCS C1713 2102-2110 - SUBSTITUTE BNGFT VOID FILR PACK BIOACTIVE COMPRESSION BOTH IP/OP "$4,589.50 " "$3,396.23" $0.00 "$5,040.00" "$2,835.00" "$2,835.00" $0.00 $0.00 $0.00 $956.57 "$3,406.33" "$3,406.33" $0.00 $0.00 $956.45 $0.00 "$2,262.62" "$2,262.62" $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $985.95 $0.00 $0.00 "$1,002.96" $0.00 $0.00 $0.00 $0.00 $0.00 2108-110 SUP Custom 27203010 BLADE SW W THK SGTL BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-110-000 SUP Custom 27203010 2108-110-000 - BLADE SAW THK1.3MM 73MM WIDE 25MM 2 CUT SAGITTAL STAINLESS BOTH IP/OP $77.25 $57.17 $0.00 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.33 $57.33 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $38.63 $61.18 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-120 SUP Custom 27203010 BLADE SW SHRT SGTL THN BOTH IP/OP $191.40 $141.64 $0.00 $153.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.70 $151.59 $153.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-120-000 SUP Custom 27203010 2108-120-000 - BLADE SAW SHORT NARROW THIN 60.5X18.5X.64MM SAGITTAL BOTH IP/OP $77.25 $57.17 $0.00 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.33 $57.33 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $38.63 $61.18 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-120-006 SUP Custom 27203010 2108-120-006 - BLADE SAW THK.64MM 63X18.5MM SAGITTAL HEAVY DUTY STAINLESS BOTH IP/OP $77.25 $57.17 $0.00 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.33 $57.33 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $38.63 $61.18 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-131-000 SUP Custom 27203010 2108-131-000 - BLADE SAW THK.6MM 46X17MM SAGITTAL CUT EDGE SAFEDGE BOTH IP/OP $77.25 $57.17 $0.00 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.33 $57.33 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $38.63 $61.18 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-148 SUP Custom 27203010 BLADE SW 34.5X9X.64MM SHRT NAR THN SGTL STRL BOTH IP/OP $191.40 $141.64 $0.00 $153.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.70 $151.59 $153.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-148-000 SUP Custom 27203010 2108-148-000 - BLADE SAW THK.64MM SHORT NARROW THIN 34.5X9MM SAGITTAL BOTH IP/OP $77.25 $57.17 $0.00 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.33 $57.33 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $38.63 $61.18 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-151 SUP Custom 27203010 BLADE SW 85X25.4X1.19MM W THK STANILESS STL SGTL WO OFST BOTH IP/OP $191.40 $141.64 $0.00 $153.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.70 $151.59 $153.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-151-000 SUP Custom 27203010 2108-151-000 - BLADE SAW THK1.19MM WIDE THICK 85X25MM SAGITTAL STAINLESS BOTH IP/OP $77.25 $57.17 $0.00 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.33 $57.33 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $38.63 $61.18 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-175-000 SUP Custom 27203010 2108-175-000 - BLADE SAW THK1.5MM SHORT NARROW THIN 79.5X25MM SAGITTAL BOTH IP/OP $77.25 $57.17 $0.00 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.33 $57.33 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $38.63 $61.18 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-182-000 SUP Custom 27203010 2108-182-000 - BLADE SAW LONG THICK 18MM SAGITTAL NO OFFST STAINLESS STEEL BOTH IP/OP $72.89 $53.94 $0.00 $58.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.10 $54.10 $0.00 $0.00 $15.19 $0.00 $0.00 $0.00 $0.00 $36.44 $57.73 $58.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2108-193-000 SUP Custom 27203010 2108-193-000 - BLADE SAW THK.96MM MEDIUM WIDE 81.5X25MM SAGITTAL STAINLESS BOTH IP/OP $77.25 $57.17 $0.00 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.33 $57.33 $0.00 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $38.63 $61.18 $61.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21-2000-24 SUP HCPCS C1752 21-2000-24 - CATHETER DLYS STRG BLNT 14.7FR 4.9MM 2.6MM 48CM DELTEC BOTH IP/OP $657.50 $486.55 $0.00 $526.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $488.00 $488.00 $0.00 $0.00 $137.02 $0.00 $0.00 $0.00 $0.00 $328.75 $520.74 $526.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2120F SUP HCPCS C1880 2120F - FILTER CARDIO 7FR 48CM SIM VC SNF/SL FEM DLV KIT NTNL BOTH IP/OP "$1,937.50 " "$1,433.75" $0.00 "$1,550.00" $871.88 $871.88 $0.00 $0.00 $0.00 $403.82 "$1,438.01" "$1,438.01" $0.00 $0.00 $403.78 $0.00 "$1,146.03" "$1,146.03" $0.00 $968.75 "$1,534.50" "$1,550.00" $0.00 $0.00 $303.22 $0.00 $0.00 $308.45 $0.00 $0.00 $0.00 $0.00 $0.00 21-2369 SUP HCPCS C1751 21-2369 - TRAY CATH 9FR 72.5CM 72.5L VENTRA 2 LUM SIL PERC BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $174.38 $174.38 $0.00 $0.00 $0.00 $80.76 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $229.21 $229.21 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $60.64 $0.00 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $0.00 21-343 SUP Custom 27203010 TIP PIP 1ML MLA 3 TRY AUTOCLAV BOTH IP/OP $146.65 $108.52 $0.00 $117.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.33 $116.15 $117.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21-4055 SUP HCPCS C1788 21-4055 - TRAY INFS PORT 7.8FR 11.4MM 1MM 76CM 30.5MMX14.7MM PRTACTH BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $247.50 $247.50 $0.00 $0.00 $0.00 $114.63 $408.21 $408.21 $0.00 $0.00 $114.62 $0.00 $325.33 $325.33 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $86.08 $0.00 $0.00 $87.56 $0.00 $0.00 $0.00 $0.00 $0.00 21-4065-24 SUP HCPCS C1788 21-4065-24 - TRAY INFS PORT 8.5FR STRL PRTACTH II 1 LUM CATHETHER PRTL BOTH IP/OP $769.35 $569.32 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $160.35 $571.01 $571.01 $0.00 $0.00 $160.33 $0.00 $455.07 $455.07 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 21-4082 SUP HCPCS C1788 21-4082 - PORT-A-CATHETER II BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $2.61 $9.28 $9.28 $0.00 $0.00 $2.61 $0.00 $7.39 $7.39 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 21-4165-24 SUP HCPCS C1788 21-4165-24 - PROPORT PLASTIC BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $2.61 $9.28 $9.28 $0.00 $0.00 $2.61 $0.00 $7.39 $7.39 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 21-4483-24 SUP Custom 27203010 21-4483-24 - TRAY INFUS PORT LP 6FR 1.9MM 1MM 76CM 1 LUMEN INTROD NEEDLE BOTH IP/OP "$1,693.28 " "$1,253.03" $0.00 "$1,290.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,256.75" "$1,256.75" $0.00 $0.00 $352.88 $0.00 $0.00 $0.00 $0.00 $806.33 "$1,277.22" "$1,290.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21-4572 SUP HCPCS C1788 DEVICE PAST-PORT BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 21-4572-24 SUP HCPCS C1788 21-4572-24 - KIT INFS PORT 5.8FR PSPRT T2 1 LUM PLFLW CATH INTRO UNAS BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 21-4590 SUP HCPCS C1788 PASPORT ELITE KIT BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $5.63 $5.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 21-8067 SUP HCPCS C1751 21-8067 - KIT INFS PORT LOPRFL 10FR 3.2MM 1.4MM 760MM PCTH2 PLFL 2 LUM BOTH IP/OP "$1,070.00 " $791.80 $0.00 $856.00 $481.50 $481.50 $0.00 $0.00 $0.00 $223.01 $794.15 $794.15 $0.00 $0.00 $222.99 $0.00 $632.91 $632.91 $0.00 $535.00 $847.44 $856.00 $0.00 $0.00 $167.46 $0.00 $0.00 $170.34 $0.00 $0.00 $0.00 $0.00 $0.00 219.952S SUP Custom 27803010 219.952S - WASHER ORTHOPEDIC SMALL OVAL STAINLESS STEEL STERILE 6.5/7.3 BOTH IP/OP $373.93 $276.71 $0.00 $290.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.53 $277.53 $0.00 $0.00 $77.93 $0.00 $0.00 $0.00 $0.00 $181.51 $287.52 $290.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 219.953S SUP Custom 27803010 219.953S - WASHER ORTHOPEDIC LARGE ROUND STAINLESS STEEL STERILE BOTH IP/OP $373.93 $276.71 $0.00 $290.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.53 $277.53 $0.00 $0.00 $77.93 $0.00 $0.00 $0.00 $0.00 $181.51 $287.52 $290.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21AC60 SUP Custom 27203010 21AC60 - PLATE 18MM TI BONE SPNL BOTH IP/OP $337.88 $250.03 $0.00 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.77 $250.77 $0.00 $0.00 $70.41 $0.00 $0.00 $0.00 $0.00 $168.94 $267.60 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21AC75 SUP Custom 27203010 21AC75 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $337.88 $250.03 $0.00 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.77 $250.77 $0.00 $0.00 $70.41 $0.00 $0.00 $0.00 $0.00 $168.94 $267.60 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21AC90 SUP Custom 27203010 21AC90 - PLATE 18MM TI BONE SPNL BOTH IP/OP $337.88 $250.03 $0.00 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.77 $250.77 $0.00 $0.00 $70.41 $0.00 $0.00 $0.00 $0.00 $168.94 $267.60 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21AGFN-756 SUP Custom 27803010 21AGFN-756 - VALVE AORTIC 85D 21MM 19.6MM 1 DIGIT GRADIENT MECHANICAL BOTH IP/OP "$11,750.00 " "$8,695.00" $0.00 "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,448.70" $0.00 $0.00 $0.00 $0.00 "$5,875.00" "$9,306.00" "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21AJ-501 SUP Custom 27803010 21AJ-501 - VALVE AOR 85D 2.06SQ CM 1.51SQ CM 21MM 16.7MM MSTR SER MECH BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21BA50 SUP Custom 27203010 21BA50 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $484.50 $358.53 $0.00 $387.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.60 $359.60 $0.00 $0.00 $100.97 $0.00 $0.00 $0.00 $0.00 $242.25 $383.72 $387.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21BA50DX SUP Custom 27203010 21BA50DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $401.63 $297.21 $0.00 $321.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.09 $298.09 $0.00 $0.00 $83.70 $0.00 $0.00 $0.00 $0.00 $200.81 $318.09 $321.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21BA60 SUP Custom 27203010 21BA60 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $401.63 $297.21 $0.00 $321.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.09 $298.09 $0.00 $0.00 $83.70 $0.00 $0.00 $0.00 $0.00 $200.81 $318.09 $321.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21BA70DX SUP Custom 27203010 21BA70DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $401.63 $297.21 $0.00 $321.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.09 $298.09 $0.00 $0.00 $83.70 $0.00 $0.00 $0.00 $0.00 $200.81 $318.09 $321.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21BA75 SUP Custom 27203010 21BA75 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $391.00 $289.34 $0.00 $312.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.20 $290.20 $0.00 $0.00 $81.48 $0.00 $0.00 $0.00 $0.00 $195.50 $309.67 $312.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21BA90 SUP Custom 27203010 21BA90 - PLATE 18MM TI BONE SPNL BOTH IP/OP $384.63 $284.63 $0.00 $307.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.47 $285.47 $0.00 $0.00 $80.16 $0.00 $0.00 $0.00 $0.00 $192.31 $304.63 $307.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21CY64BC SUP Custom 27203010 21CY64BC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $374.00 $276.76 $0.00 $299.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.58 $277.58 $0.00 $0.00 $77.94 $0.00 $0.00 $0.00 $0.00 $187.00 $296.21 $299.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21CY65DX SUP Custom 27203010 21CY65DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $386.75 $286.20 $0.00 $309.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.05 $287.05 $0.00 $0.00 $80.60 $0.00 $0.00 $0.00 $0.00 $193.38 $306.31 $309.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21CY90 SUP Custom 27203010 21CY90 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $335.75 $248.46 $0.00 $268.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.19 $249.19 $0.00 $0.00 $69.97 $0.00 $0.00 $0.00 $0.00 $167.88 $265.91 $268.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21MH30 SUP Custom 27203010 21MH30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $337.88 $250.03 $0.00 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.77 $250.77 $0.00 $0.00 $70.41 $0.00 $0.00 $0.00 $0.00 $168.94 $267.60 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21MJ-501 SUP Custom 27803010 21MJ-501 - VALVE MTRL 85D STD RING 21MM 16.7MM MSTR MECH LFLT ORFC BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21TA30 SUP Custom 27203010 21TA30 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $371.88 $275.19 $0.00 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.01 $276.01 $0.00 $0.00 $77.50 $0.00 $0.00 $0.00 $0.00 $185.94 $294.53 $297.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2200-09-0040 SUP Custom 27203010 2200-09-0040 - DRILL SURG DYNANAIL 4MM DISP TIBIOTALOCALCANEAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2200-09-0050 SUP Custom 27203010 2200-09-0050 - DRILL SURG STP DYNANAIL 5MM DISP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2200-18-4031 SUP Custom 27203010 2200-18-4031 - GUIDEWIRE ORTH 400MM 3.1MM DYNANAIL TROCAR TIP BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2200-18-5031 SUP Custom 27203010 2200-18-5031 - GUIDEWIRE ORTH 500MM 3.1MM DYNANAIL BEAD TIP BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2200-19-0031 SUP Custom 27203010 2200-19-0031 - PIN FIX 3.1MM DYNANAIL STNM DISP BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22002 H SUP Custom 27803010 22002 H - PLATE 18MM TI BONE SPNL BOTH IP/OP $748.13 $553.62 $0.00 $598.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $555.26 $555.26 $0.00 $0.00 $155.91 $0.00 $0.00 $0.00 $0.00 $374.06 $592.52 $598.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22002 L SUP Custom 27803010 22002 L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $748.13 $553.62 $0.00 $598.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $555.26 $555.26 $0.00 $0.00 $155.91 $0.00 $0.00 $0.00 $0.00 $374.06 $592.52 $598.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22002 M SUP Custom 27803010 22002 M - PLATE 18MM TI BONE SPNL BOTH IP/OP $748.13 $553.62 $0.00 $598.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $555.26 $555.26 $0.00 $0.00 $155.91 $0.00 $0.00 $0.00 $0.00 $374.06 $592.52 $598.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22-004-186 SUP Custom 27203010 KIT SYR LUER LOCK SLIP NDL PRDVC SPRT FLTRPRO 23.5IU/ML 5/8 BOTH IP/OP $313.60 $232.06 $0.00 $250.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.80 $248.37 $250.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22017 A-L SUP Custom 27803010 22017 A-L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,750.25 " "$2,035.19" $0.00 "$2,200.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.24" "$2,041.24" $0.00 $0.00 $573.15 $0.00 $0.00 $0.00 $0.00 "$1,375.13" "$2,178.20" "$2,200.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22017 A-M SUP Custom 27803010 22017 A-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,750.25 " "$2,035.19" $0.00 "$2,200.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.24" "$2,041.24" $0.00 $0.00 $573.15 $0.00 $0.00 $0.00 $0.00 "$1,375.13" "$2,178.20" "$2,200.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22017 B-L SUP Custom 27803010 22017 B-L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22017 B-M SUP Custom 27803010 22017 B-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22017A-LL SUP HCPCS C1713 22017A-LL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 22017B-LL SUP Custom 27803010 22017B-LL - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22-046-221 SUP Custom 27203010 RENOL OSMOLALITY CONTROL BOTH IP/OP $385.63 $285.37 $0.00 $308.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.81 $305.42 $308.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22-046346 SUP Custom 27203010 REAGENT METHNL ISOPRPNL FLX 95 1GL DEHYDRANT BTL HISTOLGY BOTH IP/OP $95.25 $70.49 $0.00 $76.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.63 $75.44 $76.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22-046-781 SUP Custom 27203010 CONTROL PROTINOL 280 OSMOLALITY 3X3ML BOTH IP/OP $412.65 $305.36 $0.00 $330.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.33 $326.82 $330.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22050 B SUP Custom 27803010 22050 B - KIT VNCLSTM STD DOME 6MM STRL CSF SNP BOTH IP/OP $629.38 $465.74 $0.00 $503.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $467.12 $467.12 $0.00 $0.00 $131.16 $0.00 $0.00 $0.00 $0.00 $314.69 $498.47 $503.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22082 F SUP Custom 27803010 22082 F - PLATE 18MM TI BONE SPNL BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22082 G SUP Custom 27803010 22082 G - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22082 H SUP Custom 27803010 22082 H - PLATE 18MM TI BONE SPNL BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22082 I SUP Custom 27803010 22082 I - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22082 K SUP Custom 27803010 22082 K - PLATE 18MM TI BONE SPNL BOTH IP/OP $513.00 $379.62 $0.00 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.75 $380.75 $0.00 $0.00 $106.91 $0.00 $0.00 $0.00 $0.00 $256.50 $406.30 $410.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22097 A-L SUP Custom 27803010 22097 A-L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22097 A-M SUP Custom 27803010 22097 A-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22097 B-L SUP Custom 27803010 22097 B-L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22097 B-M SUP Custom 27803010 22097 B-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22098 B-L SUP Custom 27803010 22098 B-L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22098 B-M SUP Custom 27803010 22098 B-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22098 C-L SUP Custom 27803010 22098 C-L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,415.25 " "$2,527.29" $0.00 "$2,732.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,534.80" "$2,534.80" $0.00 $0.00 $711.74 $0.00 $0.00 $0.00 $0.00 "$1,707.63" "$2,704.88" "$2,732.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22098 C-M SUP Custom 27803010 22098 C-M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,028.13 " "$2,240.82" $0.00 "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,247.47" "$2,247.47" $0.00 $0.00 $631.06 $0.00 $0.00 $0.00 $0.00 "$1,514.06" "$2,398.28" "$2,422.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22101 A SUP Custom 27803010 22101 A - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22101 B SUP Custom 27803010 22101 B - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22101 C SUP Custom 27803010 22101 C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22101 D SUP Custom 27803010 22101 D - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22-1266 SUP Custom 27203010 22-1266 - PROBE ESURG STR BIPOL TPR BLNT PNT WTFLD STRL 20-23GA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22-143-975 SUP Custom 27203010 REAGENT XYLN CTRSLV 1GL CLR AGNT HISTOLGY BOTH IP/OP $481.98 $356.67 $0.00 $385.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.99 $381.73 $385.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2220J SUP HCPCS C1880 2220J - FILTER CV 7FR 83CM SIM SBCLV DLV KT NTNL JUG VN VC BOTH IP/OP "$2,544.16 " "$1,882.68" $0.00 "$2,035.33" "$1,144.87" "$1,144.87" $0.00 $0.00 $0.00 $530.27 "$1,888.28" "$1,888.28" $0.00 $0.00 $530.20 $0.00 "$1,254.27" "$1,254.27" $0.00 "$1,272.08" "$2,014.97" "$2,035.33" $0.00 $0.00 $398.16 $0.00 $0.00 $405.03 $0.00 $0.00 $0.00 $0.00 $0.00 22-267-013 SUP Custom 27203010 SLIDE 3X2IN MSCP X THK FRST END PRECLN PLN THK1.2MM BOTH IP/OP $245.15 $181.41 $0.00 $196.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.58 $194.16 $196.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 224.510. SUP Custom 27803010 224.510. - ROD SPNL 100MM 5.5MM REVERE SS STR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 22438-19 SUP HCPCS C1884 22438-19 - SYSTEM EMBOLIC PROTECTION .014IN LARGE 4-7MM 5-6FR 190CM BOTH IP/OP "$3,425.00 " "$2,534.50" $0.00 "$2,740.00" "$1,541.25" "$1,541.25" $0.00 $0.00 $0.00 $713.86 "$2,542.04" "$2,542.04" $0.00 $0.00 $713.77 $0.00 "$1,688.53" "$1,688.53" $0.00 "$1,712.50" "$2,712.60" "$2,740.00" $0.00 $0.00 $536.01 $0.00 $0.00 $545.26 $0.00 $0.00 $0.00 $0.00 $0.00 22-553 SUP HCPCS C2617 22-553 - STENT URET 8FR 28CM REG DRMTR LG DRAIN HOLE LCK PGTL 22-553 BOTH IP/OP $270.75 $200.36 $0.00 $216.60 $121.84 $121.84 $0.00 $0.00 $0.00 $56.43 $200.95 $200.95 $0.00 $0.00 $56.42 $0.00 $160.15 $160.15 $0.00 $135.38 $214.43 $216.60 $0.00 $0.00 $42.37 $0.00 $0.00 $43.10 $0.00 $0.00 $0.00 $0.00 $0.00 226.662S SUP HCPCS C1713 226.662S - PLATE BRD 300MM SS 4.5MM SCR 16 HOLE CVD LCP BONE ORTH STRL BOTH IP/OP "$1,903.30 " "$1,408.44" $0.00 "$1,720.82" $967.96 $967.96 $0.00 $0.00 $0.00 $396.70 "$1,412.63" "$1,412.63" $0.00 $0.00 $396.65 $0.00 "$1,125.80" "$1,125.80" $0.00 "$1,075.51" "$1,703.62" "$1,720.82" $0.00 $0.00 $336.64 $0.00 $0.00 $342.44 $0.00 $0.00 $0.00 $0.00 $0.00 226.702S SUP HCPCS C1713 226.702S - PLATE BONE BROAD 372MM 20 HOLE CVD LCP STAINLESS STEEL BOTH IP/OP "$2,443.10 " "$1,807.89" $0.00 "$1,897.54" "$1,067.37" "$1,067.37" $0.00 $0.00 $0.00 $509.20 "$1,813.27" "$1,813.27" $0.00 $0.00 $509.14 $0.00 "$1,445.09" "$1,445.09" $0.00 "$1,185.96" "$1,878.57" "$1,897.54" $0.00 $0.00 $360.40 $0.00 $0.00 $377.61 $0.00 $0.00 $0.00 $0.00 $0.00 226.722S SUP HCPCS C1713 226.722S - PLATE BONE BROAD 408MM 22 HOLE CVD LCP STAINLESS STEEL BOTH IP/OP "$2,759.38 " "$2,041.94" $0.00 "$2,143.20" "$1,205.55" "$1,205.55" $0.00 $0.00 $0.00 $575.12 "$2,048.01" "$2,048.01" $0.00 $0.00 $575.05 $0.00 "$1,360.37" "$1,360.37" $0.00 "$1,339.50" "$2,121.77" "$2,143.20" $0.00 $0.00 $407.05 $0.00 $0.00 $426.50 $0.00 $0.00 $0.00 $0.00 $0.00 226.742S SUP HCPCS C1713 226.742S - PLATE BONE BROAD 443MM 24 HOLE CVD LCP STAINLESS STEEL BOTH IP/OP "$2,995.53 " "$2,216.69" $0.00 "$2,326.62" "$1,308.72" "$1,308.72" $0.00 $0.00 $0.00 $624.34 "$2,223.28" "$2,223.28" $0.00 $0.00 $624.27 $0.00 "$1,476.79" "$1,476.79" $0.00 "$1,454.14" "$2,303.36" "$2,326.62" $0.00 $0.00 $441.89 $0.00 $0.00 $463.00 $0.00 $0.00 $0.00 $0.00 $0.00 226.762S SUP HCPCS C1713 226.762S - PLATE BONE BROAD 479MM 26 HOLE CVD LCP STAINLESS STEEL BOTH IP/OP "$3,234.50 " "$2,393.53" $0.00 "$2,512.24" "$1,413.14" "$1,413.14" $0.00 $0.00 $0.00 $674.15 "$2,400.65" "$2,400.65" $0.00 $0.00 $674.07 $0.00 "$1,594.61" "$1,594.61" $0.00 "$1,570.15" "$2,487.12" "$2,512.24" $0.00 $0.00 $477.14 $0.00 $0.00 $499.94 $0.00 $0.00 $0.00 $0.00 $0.00 2284-0-426 SUP Custom 27803010 2284-0-426 - HEAD FEMORAL 15MM OFFST 26MM PCA HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2284-0-428 SUP Custom 27803010 2284-0-428 - HEAD FEM +15MM OFST 28MM STRL PCA HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2284-0-432 SUP Custom 27803010 2284-0-432 - HEAD FEMORAL +15MM OFFST 32MM PCA HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296003109S2 SUP Custom 27203010 2296003109S2 - BLADE SW LF CMND II MODIFICATION HVDTY SGTL MNT RT BOTH IP/OP $206.00 $152.44 $0.00 $164.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.89 $152.89 $0.00 $0.00 $42.93 $0.00 $0.00 $0.00 $0.00 $103.00 $163.15 $164.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-003-115 SUP Custom 27203010 2296-003-115 - BLADE SW 29.5X7X.38MM PRCS LNG MIC NAR THN SS OSC/SAG STRL BOTH IP/OP $90.10 $66.67 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.87 $66.87 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-003-414 SUP Custom 27203010 2296-003-414 - BLADE SW MIC THN 25X5.5X.38MM STRL PRCS OSC/SAG SS BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-102 SUP Custom 27203010 2296-033-102 - BLADE SW MED W AGRS BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-103 SUP Custom 27203010 2296-033-103 - BLADE SW 25X7X.51MM CORE SS OSC/SAG AGRS STRL BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-104 SUP Custom 27203010 2296-033-104 - BLADE SW 16.5MM CORE TPS 34.5MM THK.51MM MIC OSC/SAG BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-105 SUP Custom 27203010 2296-033-105 - BLADE SAW THK.4MM MEDIUM 18.5X9MM OSCILLATING SAGITTAL BOTH IP/OP $90.10 $66.67 $0.00 $72.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.87 $66.87 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $45.05 $71.36 $72.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-111 SUP Custom 27203010 2296-033-111 - BLADE SAW MEDIUM LONG 25X9MM SAGITTAL LATEX FREE STAINLESS BOTH IP/OP $90.10 $66.67 $0.00 $72.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.87 $66.87 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $45.05 $71.36 $72.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-114 SUP Custom 27203010 2296-033-114 - BLADE SAW MEDIUM 18.5X7X.51MM SAGITTAL OSCILLATE AGGRESSIVE BOTH IP/OP $90.10 $66.67 $0.00 $72.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.87 $66.87 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $45.05 $71.36 $72.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-125 SUP Custom 27203010 2296-033-125 - BLADE SW 31X9X.51MM LNG MED SS OSC/SAG AGRS BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.09 $63.09 $0.00 $0.00 $17.71 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-212 SUP Custom 27203010 2296-033-212 - BLADE SAW MEDIUM NARROW 18.5X5.5X.51MM AGGRESSIVE CORE TPS BOTH IP/OP $90.10 $66.67 $0.00 $72.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.87 $66.87 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $45.05 $71.36 $72.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-033-411 SUP Custom 27203010 2296-033-411 - BLADE SW 9MM CORE TPS 11.5MM THK.51MM MIC OSC/SAG BOTH IP/OP $90.10 $66.67 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.87 $66.87 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-191 SUP Custom 27203010 2296-100-191 - BURR SURG 39MM 3MM RND DMD STRL BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $0.00 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-193 SUP Custom 27203010 2296-100-193 - BURR SURG 3MM 3.5MM RND DMD STRL BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $0.00 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-195 SUP Custom 27203010 2296-100-195 - BURR SURG 39MM 4MM RND DMD STRL BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $0.00 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-210 SUP Custom 27203010 2296-100-210 - BURR SURG 44.5MM 1MM CRB XCUT FSSR STRL BOTH IP/OP $18.02 $13.33 $0.00 $14.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.37 $13.37 $0.00 $0.00 $3.76 $0.00 $0.00 $0.00 $0.00 $9.01 $14.27 $14.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-212 SUP Custom 27203010 2296-100-212 - BURR SURG 1.2MM 44.5MM CROSS CUT FISSURE CARBIDE STERILE BOTH IP/OP $15.90 $11.77 $0.00 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $11.80 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.95 $12.59 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-216 SUP Custom 27203010 2296-100-216 - BURR SURG 1.6MM 44.5MM CROSS CUT FISSURE CARBIDE STERILE BOTH IP/OP $15.90 $11.77 $0.00 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $11.80 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.95 $12.59 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-221 SUP Custom 27203010 2296-100-221 - BURR SURG 2.1MM 44.5MM CROSS CUT FISSURE CARBIDE STERILE BOTH IP/OP $15.90 $11.77 $0.00 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $11.80 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.95 $12.59 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-240 SUP Custom 27203010 2296-100-240 - BURR SURG 39MM 4MM CRB RND 6 FLUT STRL BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $0.00 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-245 SUP Custom 27203010 2296-100-245 - BURR SURG 39MM 4.5MM CRB RND STRL BOTH IP/OP $138.00 $102.12 $0.00 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.42 $102.42 $0.00 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $69.00 $109.30 $110.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-418 SUP Custom 27203010 2296-100-418 - BURR SURG 1.8MM ROUND HEAD CARBIDE STERILE BOTH IP/OP $15.90 $11.77 $0.00 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $11.80 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.95 $12.59 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-100-423 SUP Custom 27203010 2296-100-423 - BURR SURG 2.3MM 45MM 8 FLUTED ROUND HEAD CARBIDE STERILE BOTH IP/OP $15.90 $11.77 $0.00 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.80 $11.80 $0.00 $0.00 $3.31 $0.00 $0.00 $0.00 $0.00 $7.95 $12.59 $12.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-101-230 SUP Custom 27203010 2296-101-230 - BURR SURG 3MM 55MM 6 FLUTED ROUND HEAD CARBIDE STERILE BOTH IP/OP $84.80 $62.75 $0.00 $67.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.94 $62.94 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $42.40 $67.16 $67.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-101-418 SUP Custom 27203010 2296-101-418 - BURR SURG 1.8MM ROUND CARBIDE STERILE BOTH IP/OP $16.38 $12.12 $0.00 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.15 $12.15 $0.00 $0.00 $3.41 $0.00 $0.00 $0.00 $0.00 $8.19 $12.97 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2296-101-421 SUP Custom 27203010 2296-101-421 - BURR SURG 2.1MM 58.5MM ROUND HEAD CROSS CUT FISSURE CARBIDE BOTH IP/OP $16.38 $12.12 $0.00 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.15 $12.15 $0.00 $0.00 $3.41 $0.00 $0.00 $0.00 $0.00 $8.19 $12.97 $13.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23011 L SUP Custom 27803010 23011 L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,562.50 " "$2,636.25" $0.00 "$2,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,644.09" "$2,644.09" $0.00 $0.00 $742.43 $0.00 $0.00 $0.00 $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23011 M SUP Custom 27803010 23011 M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,738.25 " "$2,766.31" $0.00 "$2,990.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,774.53" "$2,774.53" $0.00 $0.00 $779.05 $0.00 $0.00 $0.00 $0.00 "$1,869.13" "$2,960.69" "$2,990.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23038 A SUP Custom 27803010 23038 A - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23038 B SUP Custom 27803010 23038 B - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23038 C SUP Custom 27803010 23038 C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23038 D SUP Custom 27803010 23038 D - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23038 E SUP Custom 27803010 23038 E - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-038-386 SUP Custom 27203010 MAS CSF TRK LIQCNTL 2X3.3.5ML BOTH IP/OP $196.88 $145.69 $0.00 $157.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.44 $155.93 $157.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23059 L SUP Custom 27803010 23059 L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23059 M SUP Custom 27803010 23059 M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23064 B SUP Custom 27803010 23064 B - PLATE 18MM TI BONE SPNL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23066 B SUP Custom 27803010 23066 B - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,401.25 " "$1,036.93" $0.00 "$1,121.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,040.01" "$1,040.01" $0.00 $0.00 $292.02 $0.00 $0.00 $0.00 $0.00 $700.63 "$1,109.79" "$1,121.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23066 C SUP Custom 27803010 23066 C - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,258.75 " $931.48 $0.00 "$1,007.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $934.24 $934.24 $0.00 $0.00 $262.32 $0.00 $0.00 $0.00 $0.00 $629.38 $996.93 "$1,007.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 231120M5 SUP HCPCS C1713 231120M5 - SCREW INTERFERENCE 20MM PROVEN BONE INGROWTH UNIFORMLY BOTH IP/OP $653.63 $483.69 $0.00 $522.90 $294.13 $294.13 $0.00 $0.00 $0.00 $136.23 $485.12 $485.12 $0.00 $0.00 $136.22 $0.00 $386.62 $386.62 $0.00 $326.81 $517.67 $522.90 $0.00 $0.00 $102.29 $0.00 $0.00 $104.06 $0.00 $0.00 $0.00 $0.00 $0.00 23-112-1 SUP Custom 27011340 23-112-1 - SEALER BIPOL 5.1IN .226IN 2 ELTRD HMST DISP BOTH IP/OP "$1,450.78 " "$1,073.58" $0.00 "$1,160.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,076.77" "$1,076.77" $0.00 $0.00 $302.34 $0.00 $0.00 $0.00 $0.00 $725.39 "$1,149.02" "$1,160.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-139109 SUP Custom 27203010 CONTROL MLANLT MAS URCHMTK LVL 1 15ML UA BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-139110 SUP Custom 27203010 CONTROL MLANLT MAS URCHMTK LVL 2 15ML UA BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2320A SUP HCPCS C1884 2320A - SYSTEM EMBL PRTC 103CM VC FEM AC APRCH INTROD GWIRE 7FR NTNL BOTH IP/OP "$2,544.16 " "$1,882.68" $0.00 "$2,035.33" "$1,144.87" "$1,144.87" $0.00 $0.00 $0.00 $530.27 "$1,888.28" "$1,888.28" $0.00 $0.00 $530.20 $0.00 "$1,254.27" "$1,254.27" $0.00 "$1,272.08" "$2,014.97" "$2,035.33" $0.00 $0.00 $398.16 $0.00 $0.00 $405.03 $0.00 $0.00 $0.00 $0.00 $0.00 23-247056 SUP Custom 27203010 STAIN WRTS PRC HMTK 1GL REG HMTL BOTH IP/OP $360.70 $266.92 $0.00 $288.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.35 $285.67 $288.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-309178 SUP Custom 27203010 REAGENT .85% NA CHLOR 20L PH 7.2 BUFF BLOOD BANK BOTH IP/OP $71.13 $52.64 $0.00 $56.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.56 $56.33 $56.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-453-18 SUP Custom 27203010 ELEVATOR SURG 9 KNURL HNDL PROST BOTH IP/OP $131.25 $97.13 $0.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.63 $103.95 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-02 SUP HCPCS C1713 2347-15-02 - PLATE 51MM SS 2 HOLE BONE PERIART RIGHT FIB DISTAL BOTH IP/OP $846.40 $626.34 $0.00 $677.12 $380.88 $380.88 $0.00 $0.00 $0.00 $176.41 $628.20 $628.20 $0.00 $0.00 $176.39 $0.00 $500.65 $500.65 $0.00 $423.20 $670.35 $677.12 $0.00 $0.00 $132.46 $0.00 $0.00 $134.75 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-04 SUP HCPCS C1713 2347-15-04 - PLATE 74MM SS 4 HOLE BONE PERIART RIGHT FIB DISTAL BOTH IP/OP $852.15 $630.59 $0.00 $681.72 $383.47 $383.47 $0.00 $0.00 $0.00 $177.61 $632.47 $632.47 $0.00 $0.00 $177.59 $0.00 $504.05 $504.05 $0.00 $426.08 $674.90 $681.72 $0.00 $0.00 $133.36 $0.00 $0.00 $135.66 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-06 SUP HCPCS C1713 2347-15-06 - PLATE 95MM SS 6 HOLE BONE PERIART RIGHT FIB DISTAL BOTH IP/OP $863.65 $639.10 $0.00 $690.92 $388.64 $388.64 $0.00 $0.00 $0.00 $180.01 $641.00 $641.00 $0.00 $0.00 $179.98 $0.00 $510.85 $510.85 $0.00 $431.83 $684.01 $690.92 $0.00 $0.00 $135.16 $0.00 $0.00 $137.49 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-08 SUP HCPCS C1713 2347-15-08 - PLATE 116MM SS 8 HOLE BONE PERIART RIGHT FIB DISTAL BOTH IP/OP $876.20 $648.39 $0.00 $700.96 $394.29 $394.29 $0.00 $0.00 $0.00 $182.62 $650.32 $650.32 $0.00 $0.00 $182.60 $0.00 $518.27 $518.27 $0.00 $438.10 $693.95 $700.96 $0.00 $0.00 $137.13 $0.00 $0.00 $139.49 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-10 SUP HCPCS C1713 2347-15-10 - PLATE 136MM SS 10 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP $891.00 $659.34 $0.00 $712.80 $400.95 $400.95 $0.00 $0.00 $0.00 $185.71 $661.30 $661.30 $0.00 $0.00 $185.68 $0.00 $527.03 $527.03 $0.00 $445.50 $705.67 $712.80 $0.00 $0.00 $139.44 $0.00 $0.00 $141.85 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-12 SUP HCPCS C1713 2347-15-12 - PLATE 157MM SS 12 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP "$1,054.55 " $780.37 $0.00 $843.64 $474.55 $474.55 $0.00 $0.00 $0.00 $219.79 $782.69 $782.69 $0.00 $0.00 $219.77 $0.00 $623.77 $623.77 $0.00 $527.28 $835.20 $843.64 $0.00 $0.00 $165.04 $0.00 $0.00 $167.88 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-14 SUP HCPCS C1713 2347-15-14 - PLATE 178MM SS 14 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP "$1,125.85 " $833.13 $0.00 $900.68 $506.63 $506.63 $0.00 $0.00 $0.00 $234.66 $835.61 $835.61 $0.00 $0.00 $234.63 $0.00 $665.94 $665.94 $0.00 $562.93 $891.67 $900.68 $0.00 $0.00 $176.20 $0.00 $0.00 $179.24 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-16 SUP HCPCS C1713 2347-15-16 - PLATE 199MM SS 16 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP "$1,220.15 " $902.91 $0.00 $976.12 $549.07 $549.07 $0.00 $0.00 $0.00 $254.31 $905.60 $905.60 $0.00 $0.00 $254.28 $0.00 $721.72 $721.72 $0.00 $610.08 $966.36 $976.12 $0.00 $0.00 $190.95 $0.00 $0.00 $194.25 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-18 SUP HCPCS C1713 2347-15-18 - PLATE 220MM SS 18 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP "$1,315.60 " $973.54 $0.00 "$1,052.48" $592.02 $592.02 $0.00 $0.00 $0.00 $274.20 $976.44 $976.44 $0.00 $0.00 $274.17 $0.00 $778.18 $778.18 $0.00 $657.80 "$1,041.96" "$1,052.48" $0.00 $0.00 $205.89 $0.00 $0.00 $209.44 $0.00 $0.00 $0.00 $0.00 $0.00 2347-15-20 SUP HCPCS C1713 2347-15-20 - PLATE 241MM SS 20 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP "$1,434.05 " "$1,061.20" $0.00 "$1,147.24" $645.32 $645.32 $0.00 $0.00 $0.00 $298.89 "$1,064.35" "$1,064.35" $0.00 $0.00 $298.86 $0.00 $848.24 $848.24 $0.00 $717.03 "$1,135.77" "$1,147.24" $0.00 $0.00 $224.43 $0.00 $0.00 $228.30 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-02 SUP HCPCS C1713 2347-16-02 - PLATE 51MM SS 2 HOLE BONE FIB LEFT DISTAL LAT BOTH IP/OP $846.40 $626.34 $0.00 $677.12 $380.88 $380.88 $0.00 $0.00 $0.00 $176.41 $628.20 $628.20 $0.00 $0.00 $176.39 $0.00 $500.65 $500.65 $0.00 $423.20 $670.35 $677.12 $0.00 $0.00 $132.46 $0.00 $0.00 $134.75 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-04 SUP HCPCS C1713 2347-16-04 - PLATE 74MM SS 2.7MM 3.5MM CORT PERIART 2.7MM CANC BOTH IP/OP $852.15 $630.59 $0.00 $681.72 $383.47 $383.47 $0.00 $0.00 $0.00 $177.61 $632.47 $632.47 $0.00 $0.00 $177.59 $0.00 $504.05 $504.05 $0.00 $426.08 $674.90 $681.72 $0.00 $0.00 $133.36 $0.00 $0.00 $135.66 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-06 SUP HCPCS C1713 2347-16-06 - PLATE 95MM 6 HOLE BONE FIB L/L BOTH IP/OP $863.90 $639.29 $0.00 $691.12 $388.76 $388.76 $0.00 $0.00 $0.00 $180.06 $641.19 $641.19 $0.00 $0.00 $180.04 $0.00 $511.00 $511.00 $0.00 $431.95 $684.21 $691.12 $0.00 $0.00 $135.20 $0.00 $0.00 $137.53 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-08 SUP HCPCS C1713 2347-16-08 - PLATE 116MM 8 HOLE BONE FIB L/L BOTH IP/OP $876.20 $648.39 $0.00 $700.96 $394.29 $394.29 $0.00 $0.00 $0.00 $182.62 $650.32 $650.32 $0.00 $0.00 $182.60 $0.00 $518.27 $518.27 $0.00 $438.10 $693.95 $700.96 $0.00 $0.00 $137.13 $0.00 $0.00 $139.49 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-10 SUP HCPCS C1713 2347-16-10 - PLATE 135MM 10 HOLE BONE FIB L/L BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-12 SUP HCPCS C1713 2347-16-12 - PLATE 157MM 12 HOLE BONE FIB L/L BOTH IP/OP "$1,054.55 " $780.37 $0.00 $843.64 $474.55 $474.55 $0.00 $0.00 $0.00 $219.79 $782.69 $782.69 $0.00 $0.00 $219.77 $0.00 $623.77 $623.77 $0.00 $527.28 $835.20 $843.64 $0.00 $0.00 $165.04 $0.00 $0.00 $167.88 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-14 SUP HCPCS C1713 2347-16-14 - PLATE 178MM 14 HOLE BONE FIB L/L BOTH IP/OP "$1,125.85 " $833.13 $0.00 $900.68 $506.63 $506.63 $0.00 $0.00 $0.00 $234.66 $835.61 $835.61 $0.00 $0.00 $234.63 $0.00 $665.94 $665.94 $0.00 $562.93 $891.67 $900.68 $0.00 $0.00 $176.20 $0.00 $0.00 $179.24 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-16 SUP HCPCS C1713 2347-16-16 - PLATE 199MM 16 HOLE BONE FIB L/L BOTH IP/OP "$1,220.15 " $902.91 $0.00 $976.12 $549.07 $549.07 $0.00 $0.00 $0.00 $254.31 $905.60 $905.60 $0.00 $0.00 $254.28 $0.00 $721.72 $721.72 $0.00 $610.08 $966.36 $976.12 $0.00 $0.00 $190.95 $0.00 $0.00 $194.25 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-18 SUP HCPCS C1713 2347-16-18 - PLATE 220MM 18 HOLE BONE FIB L/L BOTH IP/OP "$1,315.60 " $973.54 $0.00 "$1,052.48" $592.02 $592.02 $0.00 $0.00 $0.00 $274.20 $976.44 $976.44 $0.00 $0.00 $274.17 $0.00 $778.18 $778.18 $0.00 $657.80 "$1,041.96" "$1,052.48" $0.00 $0.00 $205.89 $0.00 $0.00 $209.44 $0.00 $0.00 $0.00 $0.00 $0.00 2347-16-20 SUP HCPCS C1713 2347-16-20 - PLATE 241MM 20 HOLE BONE FIB L/L BOTH IP/OP "$1,434.05 " "$1,061.20" $0.00 "$1,147.24" $645.32 $645.32 $0.00 $0.00 $0.00 $298.89 "$1,064.35" "$1,064.35" $0.00 $0.00 $298.86 $0.00 $848.24 $848.24 $0.00 $717.03 "$1,135.77" "$1,147.24" $0.00 $0.00 $224.43 $0.00 $0.00 $228.30 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-02 SUP HCPCS C1713 2347-17-02 - PLATE 51MM 2 HOLE BONE FIB RIGHT BOTH IP/OP $846.40 $626.34 $0.00 $677.12 $380.88 $380.88 $0.00 $0.00 $0.00 $176.41 $628.20 $628.20 $0.00 $0.00 $176.39 $0.00 $500.65 $500.65 $0.00 $423.20 $670.35 $677.12 $0.00 $0.00 $132.46 $0.00 $0.00 $134.75 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-04 SUP HCPCS C1713 2347-17-04 - PLATE 73MM SS 4 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP $852.15 $630.59 $0.00 $681.72 $383.47 $383.47 $0.00 $0.00 $0.00 $177.61 $632.47 $632.47 $0.00 $0.00 $177.59 $0.00 $504.05 $504.05 $0.00 $426.08 $674.90 $681.72 $0.00 $0.00 $133.36 $0.00 $0.00 $135.66 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-06 SUP HCPCS C1713 2347-17-06 - PLATE 94MM SS 6 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP $863.65 $639.10 $0.00 $690.92 $388.64 $388.64 $0.00 $0.00 $0.00 $180.01 $641.00 $641.00 $0.00 $0.00 $179.98 $0.00 $510.85 $510.85 $0.00 $431.83 $684.01 $690.92 $0.00 $0.00 $135.16 $0.00 $0.00 $137.49 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-08 SUP HCPCS C1713 2347-17-08 - PLATE 115MM SS 8 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP $876.20 $648.39 $0.00 $700.96 $394.29 $394.29 $0.00 $0.00 $0.00 $182.62 $650.32 $650.32 $0.00 $0.00 $182.60 $0.00 $518.27 $518.27 $0.00 $438.10 $693.95 $700.96 $0.00 $0.00 $137.13 $0.00 $0.00 $139.49 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-10 SUP HCPCS C1713 2347-17-10 - PLATE 135MM SS 10 HOLE BONE FIB RIGHT DISTAL LAT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-12 SUP HCPCS C1713 2347-17-12 - PLATE 156MM SS 12 HOLE BONE PERIART RIGHT FIB BOTH IP/OP "$1,054.55 " $780.37 $0.00 $843.64 $474.55 $474.55 $0.00 $0.00 $0.00 $219.79 $782.69 $782.69 $0.00 $0.00 $219.77 $0.00 $623.77 $623.77 $0.00 $527.28 $835.20 $843.64 $0.00 $0.00 $165.04 $0.00 $0.00 $167.88 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-14 SUP HCPCS C1713 2347-17-14 - PLATE 177MM SS 14 HOLE BONE PERIART RIGHT FIB BOTH IP/OP "$1,125.85 " $833.13 $0.00 $900.68 $506.63 $506.63 $0.00 $0.00 $0.00 $234.66 $835.61 $835.61 $0.00 $0.00 $234.63 $0.00 $665.94 $665.94 $0.00 $562.93 $891.67 $900.68 $0.00 $0.00 $176.20 $0.00 $0.00 $179.24 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-16 SUP HCPCS C1713 2347-17-16 - PLATE 198MM SS 16 HOLE BONE PERIART RIGHT FIB BOTH IP/OP "$1,220.15 " $902.91 $0.00 $976.12 $549.07 $549.07 $0.00 $0.00 $0.00 $254.31 $905.60 $905.60 $0.00 $0.00 $254.28 $0.00 $721.72 $721.72 $0.00 $610.08 $966.36 $976.12 $0.00 $0.00 $190.95 $0.00 $0.00 $194.25 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-18 SUP HCPCS C1713 2347-17-18 - PLATE 219MM SS 18 HOLE BONE PERIART RIGHT FIB BOTH IP/OP "$1,315.60 " $973.54 $0.00 "$1,052.48" $592.02 $592.02 $0.00 $0.00 $0.00 $274.20 $976.44 $976.44 $0.00 $0.00 $274.17 $0.00 $778.18 $778.18 $0.00 $657.80 "$1,041.96" "$1,052.48" $0.00 $0.00 $205.89 $0.00 $0.00 $209.44 $0.00 $0.00 $0.00 $0.00 $0.00 2347-17-20 SUP HCPCS C1713 2347-17-20 - PLATE 239MM SS 20 HOLE BONE PERIART RIGHT FIB BOTH IP/OP "$1,284.05 " $950.20 $0.00 "$1,027.24" $577.82 $577.82 $0.00 $0.00 $0.00 $267.63 $953.02 $953.02 $0.00 $0.00 $267.60 $0.00 $759.52 $759.52 $0.00 $642.03 "$1,016.97" "$1,027.24" $0.00 $0.00 $200.95 $0.00 $0.00 $204.42 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-02 SUP HCPCS C1713 2347-18-02 - PLATE 51MM SS 2 HOLE BONE PERIART LEFT FIB BOTH IP/OP $846.40 $626.34 $0.00 $677.12 $380.88 $380.88 $0.00 $0.00 $0.00 $176.41 $628.20 $628.20 $0.00 $0.00 $176.39 $0.00 $500.65 $500.65 $0.00 $423.20 $670.35 $677.12 $0.00 $0.00 $132.46 $0.00 $0.00 $134.75 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-04 SUP HCPCS C1713 2347-18-04 - PLATE BN 73MM STRL 4 HL SS FIB LT DIST LAT PERIART BOTH IP/OP $852.15 $630.59 $0.00 $681.72 $383.47 $383.47 $0.00 $0.00 $0.00 $177.61 $632.47 $632.47 $0.00 $0.00 $177.59 $0.00 $504.05 $504.05 $0.00 $426.08 $674.90 $681.72 $0.00 $0.00 $133.36 $0.00 $0.00 $135.66 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-06 SUP HCPCS C1713 2347-18-06 - PLATE 94MM 6 HOLE BONE LEFT DISTAL LAT FIB BOTH IP/OP $863.65 $639.10 $0.00 $690.92 $388.64 $388.64 $0.00 $0.00 $0.00 $180.01 $641.00 $641.00 $0.00 $0.00 $179.98 $0.00 $510.85 $510.85 $0.00 $431.83 $684.01 $690.92 $0.00 $0.00 $135.16 $0.00 $0.00 $137.49 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-08 SUP HCPCS C1713 2347-18-08 - PLATE 115MM SS 8 HOLE BONE FIB LEFT DISTAL LAT BOTH IP/OP $876.20 $648.39 $0.00 $700.96 $394.29 $394.29 $0.00 $0.00 $0.00 $182.62 $650.32 $650.32 $0.00 $0.00 $182.60 $0.00 $518.27 $518.27 $0.00 $438.10 $693.95 $700.96 $0.00 $0.00 $137.13 $0.00 $0.00 $139.49 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-10 SUP HCPCS C1713 2347-18-10 - PLATE 135MM SS 10 HOLE BONE FIB LEFT DISTAL LAT BOTH IP/OP $966.00 $714.84 $0.00 $772.80 $434.70 $434.70 $0.00 $0.00 $0.00 $201.34 $716.97 $716.97 $0.00 $0.00 $201.31 $0.00 $571.39 $571.39 $0.00 $483.00 $765.07 $772.80 $0.00 $0.00 $151.18 $0.00 $0.00 $153.79 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-12 SUP HCPCS C1713 2347-18-12 - PLATE 156MM SS 12 HOLE BONE FIB LEFT DISTAL LAT BOTH IP/OP "$1,054.55 " $780.37 $0.00 $843.64 $474.55 $474.55 $0.00 $0.00 $0.00 $219.79 $782.69 $782.69 $0.00 $0.00 $219.77 $0.00 $623.77 $623.77 $0.00 $527.28 $835.20 $843.64 $0.00 $0.00 $165.04 $0.00 $0.00 $167.88 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-14 SUP HCPCS C1713 2347-18-14 - PLATE 177MM SS 14 HOLE BONE FIB LEFT DISTAL LAT BOTH IP/OP "$1,125.85 " $833.13 $0.00 $900.68 $506.63 $506.63 $0.00 $0.00 $0.00 $234.66 $835.61 $835.61 $0.00 $0.00 $234.63 $0.00 $665.94 $665.94 $0.00 $562.93 $891.67 $900.68 $0.00 $0.00 $176.20 $0.00 $0.00 $179.24 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-16 SUP HCPCS C1713 2347-18-16 - PLATE 198MM SS 16 HOLE BONE FIB LEFT DISTAL LAT BOTH IP/OP "$1,220.15 " $902.91 $0.00 $976.12 $549.07 $549.07 $0.00 $0.00 $0.00 $254.31 $905.60 $905.60 $0.00 $0.00 $254.28 $0.00 $721.72 $721.72 $0.00 $610.08 $966.36 $976.12 $0.00 $0.00 $190.95 $0.00 $0.00 $194.25 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-18 SUP HCPCS C1713 2347-18-18 - PLATE 219MM SS 18 HOLE BONE FIB LEFT DISTAL LAT BOTH IP/OP "$1,300.60 " $962.44 $0.00 "$1,040.48" $585.27 $585.27 $0.00 $0.00 $0.00 $271.08 $965.31 $965.31 $0.00 $0.00 $271.05 $0.00 $769.30 $769.30 $0.00 $650.30 "$1,030.08" "$1,040.48" $0.00 $0.00 $203.54 $0.00 $0.00 $207.06 $0.00 $0.00 $0.00 $0.00 $0.00 2347-18-20 SUP HCPCS C1713 2347-18-20 - PLATE 239MM SS 20 HOLE BONE FIB LEFT DISTAL LAT BOTH IP/OP "$1,434.05 " "$1,061.20" $0.00 "$1,147.24" $645.32 $645.32 $0.00 $0.00 $0.00 $298.89 "$1,064.35" "$1,064.35" $0.00 $0.00 $298.86 $0.00 $848.24 $848.24 $0.00 $717.03 "$1,135.77" "$1,147.24" $0.00 $0.00 $224.43 $0.00 $0.00 $228.30 $0.00 $0.00 $0.00 $0.00 $0.00 2348-12-35 SUP HCPCS C1713 2348-12-35 - SCREW BN 3.5MM 2.7MM 12MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-14-35 SUP HCPCS C1713 2348-14-35 - SCREW BN 3.5MM 2.7MM 14MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-16-35 SUP HCPCS C1713 2348-16-35 - SCREW BN 3.5MM 2.7MM 16MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-18-35 SUP HCPCS C1713 2348-18-35 - SCREW BONE 3.5MM 2.7MM 18MM SELF TAP STAINLESS STEEL BOTH IP/OP $74.75 $55.32 $0.00 $59.80 $33.64 $33.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.38 $59.20 $59.80 $0.00 $0.00 $11.70 $0.00 $0.00 $11.90 $0.00 $0.00 $0.00 $0.00 $0.00 2348-20-35 SUP HCPCS C1713 2348-20-35 - SCREW BN 2.7MM 3.5MM 20MM ST CORT BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-22-35 SUP HCPCS C1713 2348-22-35 - SCREW BN 3.5MM 2.7MM 22MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-24-35 SUP HCPCS C1713 2348-24-35 - SCREW BN 3.5MM 2.7MM 24MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-26-35 SUP HCPCS C1713 2348-26-35 - SCREW BN 3.5MM 2.7MM 26MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-28-35 SUP HCPCS C1713 2348-28-35 - SCREW BN 3.5MM 2.7MM 28MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-30-35 SUP HCPCS C1713 2348-30-35 - SCREW BN 3.5MM 2.7MM 30MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-32-35 SUP HCPCS C1713 2348-32-35 - SCREW BN 3.5MM 2.7MM 32MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-34-35 SUP HCPCS C1713 2348-34-35 - SCREW BN 3.5MM 2.7MM 34MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-36-35 SUP HCPCS C1713 2348-36-35 - SCREW BN 3.5MM 2.7MM 36MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-38-35 SUP HCPCS C1713 2348-38-35 - SCREW BN 3.5MM 2.7MM 38MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-40-35 SUP HCPCS C1713 2348-40-35 - SCREW BN 3.5MM 2.7MM 40MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-42-35 SUP HCPCS C1713 2348-42-35 - SCREW BN 3.5MM 2.7MM 42MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-44-35 SUP HCPCS C1713 2348-44-35 - SCREW BN 3.5MM 2.7MM 44MM NS ST SS ELB CORT PERIART BOTH IP/OP $62.10 $45.95 $0.00 $49.68 $27.95 $27.95 $0.00 $0.00 $0.00 $12.94 $46.09 $46.09 $0.00 $0.00 $12.94 $0.00 $36.73 $36.73 $0.00 $31.05 $49.18 $49.68 $0.00 $0.00 $9.72 $0.00 $0.00 $9.89 $0.00 $0.00 $0.00 $0.00 $0.00 2348-46-35 SUP HCPCS C1713 2348-46-35 - SCREW BN 3.5MM 2.7MM 46MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-48-35 SUP HCPCS C1713 2348-48-35 - SCREW BN 3.5MM 2.7MM 48MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-50-35 SUP HCPCS C1713 2348-50-35 - SCREW BN 3.5MM 2.7MM 50MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-52-35 SUP HCPCS C1713 2348-52-35 - SCREW BN 3.5MM 2.7MM 52MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-54-35 SUP HCPCS C1713 2348-54-35 - SCREW BN 3.5MM 2.7MM 54MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-56-35 SUP HCPCS C1713 2348-56-35 - SCREW BN 3.5MM 2.7MM 56MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-58-35 SUP HCPCS C1713 2348-58-35 - SCREW BN 3.5MM 58MM PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-60-35 SUP HCPCS C1713 2348-60-35 - SCREW BN 3.5MM 2.7MM 60MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-65-35 SUP HCPCS C1713 2348-65-35 - SCREW BN 3.5MM 2.7MM 65MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-70-35 SUP HCPCS C1713 2348-70-35 - SCREW BN 3.5MM 2.7MM 70MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-75-35 SUP HCPCS C1713 2348-75-35 - SCREW BN 3.5MM 2.7MM 75MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-80-35 SUP HCPCS C1713 2348-80-35 - SCREW BN 3.5MM 2.7MM 80MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-85-35 SUP HCPCS C1713 2348-85-35 - SCREW BN 3.5MM 2.7MM 85MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-90-35 SUP HCPCS C1713 2348-90-35 - SCREW BN 3.5MM 2.7MM 90MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 2348-95-35 SUP HCPCS C1713 2348-95-35 - SCREW BN 3.5MM 2.7MM 95MM NS ST SS ELB CORT PERIART BOTH IP/OP $60.85 $45.03 $0.00 $48.68 $27.38 $27.38 $0.00 $0.00 $0.00 $12.68 $45.16 $45.16 $0.00 $0.00 $12.68 $0.00 $35.99 $35.99 $0.00 $30.43 $48.19 $48.68 $0.00 $0.00 $9.52 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $0.00 235-F SUP Custom 27803010 235-F - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,623.50 " "$1,201.39" $0.00 "$1,298.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,204.96" "$1,204.96" $0.00 $0.00 $338.34 $0.00 $0.00 $0.00 $0.00 $811.75 "$1,285.81" "$1,298.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 236.504S SUP HCPCS C1713 236.504S - PLATE BN CNTR 112MM STRL LCP CMBN 4 HL ELONGATE HL PROX TAB BOTH IP/OP "$1,807.73 " "$1,337.72" $0.00 "$1,404.06" $789.78 $789.78 $0.00 $0.00 $0.00 $376.78 "$1,341.69" "$1,341.69" $0.00 $0.00 $376.73 $0.00 "$1,069.27" "$1,069.27" $0.00 $877.54 "$1,390.02" "$1,404.06" $0.00 $0.00 $266.67 $0.00 $0.00 $279.41 $0.00 $0.00 $0.00 $0.00 $0.00 236-01 SUP HCPCS C1713 236-01 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $490.88 $363.25 $0.00 $392.70 $220.89 $220.89 $0.00 $0.00 $0.00 $102.31 $364.33 $364.33 $0.00 $0.00 $102.30 $0.00 $290.35 $290.35 $0.00 $245.44 $388.78 $392.70 $0.00 $0.00 $76.82 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $0.00 236-02 SUP HCPCS C1713 236-02 - PLATE 18MM TI BONE SPNL BOTH IP/OP $575.88 $426.15 $0.00 $460.70 $259.14 $259.14 $0.00 $0.00 $0.00 $120.03 $427.41 $427.41 $0.00 $0.00 $120.01 $0.00 $340.63 $340.63 $0.00 $287.94 $456.10 $460.70 $0.00 $0.00 $90.12 $0.00 $0.00 $91.68 $0.00 $0.00 $0.00 $0.00 $0.00 236-04 SUP HCPCS C1713 236-04 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $735.25 $544.09 $0.00 $588.20 $330.86 $330.86 $0.00 $0.00 $0.00 $153.24 $545.70 $545.70 $0.00 $0.00 $153.23 $0.00 $434.90 $434.90 $0.00 $367.63 $582.32 $588.20 $0.00 $0.00 $115.07 $0.00 $0.00 $117.05 $0.00 $0.00 $0.00 $0.00 $0.00 23-640-000 SUP Custom 27203010 MAS CARDIOIMMUNE XL LVL 1 3ML 6/PK BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-640-001 SUP Custom 27203010 MAS CARDIOIMMUNE XL LVL 2 3ML 6/PK BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-640-002 SUP Custom 27203010 MAS CARDIOIMMUNE XL LVL 3 3ML 6/PK BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-640-003 SUP Custom 27203010 MAS CARDIOIMMUNE XL LVL L 3ML 6/PK BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-666471 SUP Custom 27203010 REAGENT B-OHB R1 R2 50ML ANALY BOTH IP/OP $854.13 $632.06 $0.00 $683.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.06 $676.47 $683.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23-666472 SUP Custom 27203010 CONTROL CHM 5ML SET B-OHB BOTH IP/OP $723.00 $535.02 $0.00 $578.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.50 $572.62 $578.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 237.043S SUP HCPCS C1713 237.043S - PLATE BONE 90D 30MM 4 HOLE LIMITED CONTACT ANGLED BLADE CANN BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.044S SUP HCPCS C1713 237.044S - PLATE BONE 90D 40MM 4 HOLE LIMITED CONTACT ANGLED BLADE CANN BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.053S SUP HCPCS C1713 237.053S - PLATE BN 90D 30X11.7MM STRL 5 HL LMT CNTCT CNN SS 4.5MM SCR BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.054S SUP HCPCS C1713 237.054S - PLATE BONE 90D 40MM 5 HOLE LIMITED CONTACT ANGLED BLADE CANN BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.063S SUP HCPCS C1713 237.063S - PLATE BONE 90D 30MM 6 HOLE LIMITED CONTACT ANGLED BLADE CANN BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.064S SUP HCPCS C1713 237.064S - PLATE BONE 90D 40MM 6 HOLE LIMITED CONTACT ANGLED BLADE CANN BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.083S SUP HCPCS C1713 237.083S - PLATE BONE 90D 30MM 8 HOLE LIMITED CONTACT ANGLED BLADE CANN BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.084S SUP HCPCS C1713 237.084S - PLATE BONE 90D 40MM 8 HOLE LIMITED CONTACT ANGLED BLADE CANN BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.085S SUP HCPCS C1713 237.085S - PLATE BONE 90D 50MM 8 HOLE LIMITED CONTACT ANGLED BLADE CANN BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.086S SUP HCPCS C1713 237.086S - PLATE BN 90D 60X11.7MM STRL 8 HL LMT CNTCT CNN SS 4.5MM SCR BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 237.103S SUP HCPCS C1713 237.103S - PLATE BONE 90D 30MM 10 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,134.58 " "$1,579.59" $0.00 "$1,707.66" $960.56 $960.56 $0.00 $0.00 $0.00 $444.90 "$1,584.28" "$1,584.28" $0.00 $0.00 $444.85 $0.00 "$1,262.60" "$1,262.60" $0.00 "$1,067.29" "$1,690.59" "$1,707.66" $0.00 $0.00 $334.06 $0.00 $0.00 $339.82 $0.00 $0.00 $0.00 $0.00 $0.00 237.104S SUP HCPCS C1713 237.104S - PLATE BONE 90D 40MM 10 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,134.58 " "$1,579.59" $0.00 "$1,707.66" $960.56 $960.56 $0.00 $0.00 $0.00 $444.90 "$1,584.28" "$1,584.28" $0.00 $0.00 $444.85 $0.00 "$1,262.60" "$1,262.60" $0.00 "$1,067.29" "$1,690.59" "$1,707.66" $0.00 $0.00 $334.06 $0.00 $0.00 $339.82 $0.00 $0.00 $0.00 $0.00 $0.00 237.105S SUP HCPCS C1713 237.105S - PLATE BONE 90D 50MM 10 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,134.58 " "$1,579.59" $0.00 "$1,707.66" $960.56 $960.56 $0.00 $0.00 $0.00 $444.90 "$1,584.28" "$1,584.28" $0.00 $0.00 $444.85 $0.00 "$1,262.60" "$1,262.60" $0.00 "$1,067.29" "$1,690.59" "$1,707.66" $0.00 $0.00 $334.06 $0.00 $0.00 $339.82 $0.00 $0.00 $0.00 $0.00 $0.00 237.106S SUP HCPCS C1713 237.106S - PLATE BONE 90D 60MM 10 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,134.58 " "$1,579.59" $0.00 "$1,707.66" $960.56 $960.56 $0.00 $0.00 $0.00 $444.90 "$1,584.28" "$1,584.28" $0.00 $0.00 $444.85 $0.00 "$1,262.60" "$1,262.60" $0.00 "$1,067.29" "$1,690.59" "$1,707.66" $0.00 $0.00 $334.06 $0.00 $0.00 $339.82 $0.00 $0.00 $0.00 $0.00 $0.00 237.123S SUP HCPCS C1713 237.123S - PLATE BONE 90D 30MM 12 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,134.58 " "$1,579.59" $0.00 "$1,707.66" $960.56 $960.56 $0.00 $0.00 $0.00 $444.90 "$1,584.28" "$1,584.28" $0.00 $0.00 $444.85 $0.00 "$1,262.60" "$1,262.60" $0.00 "$1,067.29" "$1,690.59" "$1,707.66" $0.00 $0.00 $334.06 $0.00 $0.00 $339.82 $0.00 $0.00 $0.00 $0.00 $0.00 237.124S SUP HCPCS C1713 237.124S - PLATE BONE 90D 40MM 220MM 12 HOLE SHAFT LCP STAINLESS STEEL BOTH IP/OP "$2,134.58 " "$1,579.59" $0.00 "$1,707.66" $960.56 $960.56 $0.00 $0.00 $0.00 $444.90 "$1,584.28" "$1,584.28" $0.00 $0.00 $444.85 $0.00 "$1,262.60" "$1,262.60" $0.00 "$1,067.29" "$1,690.59" "$1,707.66" $0.00 $0.00 $334.06 $0.00 $0.00 $339.82 $0.00 $0.00 $0.00 $0.00 $0.00 237.125S SUP HCPCS C1713 237.125S - PLATE BONE 90D 50MM 12 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,134.58 " "$1,579.59" $0.00 "$1,707.66" $960.56 $960.56 $0.00 $0.00 $0.00 $444.90 "$1,584.28" "$1,584.28" $0.00 $0.00 $444.85 $0.00 "$1,262.60" "$1,262.60" $0.00 "$1,067.29" "$1,690.59" "$1,707.66" $0.00 $0.00 $334.06 $0.00 $0.00 $339.82 $0.00 $0.00 $0.00 $0.00 $0.00 237.126S SUP HCPCS C1713 237.126S - PLATE BONE 90D 60MM 12 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,134.58 " "$1,579.59" $0.00 "$1,707.66" $960.56 $960.56 $0.00 $0.00 $0.00 $444.90 "$1,584.28" "$1,584.28" $0.00 $0.00 $444.85 $0.00 "$1,262.60" "$1,262.60" $0.00 "$1,067.29" "$1,690.59" "$1,707.66" $0.00 $0.00 $334.06 $0.00 $0.00 $339.82 $0.00 $0.00 $0.00 $0.00 $0.00 237.143S SUP HCPCS C1713 237.143S - PLATE BONE 90D 30MM 14 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,709.63 " "$2,005.13" $0.00 "$2,167.70" "$1,219.33" "$1,219.33" $0.00 $0.00 $0.00 $564.75 "$2,011.08" "$2,011.08" $0.00 $0.00 $564.69 $0.00 "$1,335.85" "$1,335.85" $0.00 "$1,354.81" "$2,146.03" "$2,167.70" $0.00 $0.00 $424.06 $0.00 $0.00 $431.37 $0.00 $0.00 $0.00 $0.00 $0.00 237.144S SUP HCPCS C1713 237.144S - PLATE BONE 90D 40MM 14 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,709.63 " "$2,005.13" $0.00 "$2,167.70" "$1,219.33" "$1,219.33" $0.00 $0.00 $0.00 $564.75 "$2,011.08" "$2,011.08" $0.00 $0.00 $564.69 $0.00 "$1,335.85" "$1,335.85" $0.00 "$1,354.81" "$2,146.03" "$2,167.70" $0.00 $0.00 $424.06 $0.00 $0.00 $431.37 $0.00 $0.00 $0.00 $0.00 $0.00 237.145S SUP HCPCS C1713 237.145S - PLATE BONE 90D 50MM 14 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,709.63 " "$2,005.13" $0.00 "$2,167.70" "$1,219.33" "$1,219.33" $0.00 $0.00 $0.00 $564.75 "$2,011.08" "$2,011.08" $0.00 $0.00 $564.69 $0.00 "$1,335.85" "$1,335.85" $0.00 "$1,354.81" "$2,146.03" "$2,167.70" $0.00 $0.00 $424.06 $0.00 $0.00 $431.37 $0.00 $0.00 $0.00 $0.00 $0.00 237.146S SUP HCPCS C1713 237.146S - PLATE BONE 90D 60MM 14 HOLE LIMITED CONTACT ANGLED BLADE BOTH IP/OP "$2,709.63 " "$2,005.13" $0.00 "$2,167.70" "$1,219.33" "$1,219.33" $0.00 $0.00 $0.00 $564.75 "$2,011.08" "$2,011.08" $0.00 $0.00 $564.69 $0.00 "$1,335.85" "$1,335.85" $0.00 "$1,354.81" "$2,146.03" "$2,167.70" $0.00 $0.00 $424.06 $0.00 $0.00 $431.37 $0.00 $0.00 $0.00 $0.00 $0.00 237020T5 SUP HCPCS C1713 237020T5 - SCREW INTFR PLA 20MM 7.3MM ACL BABSR SLF REINF MATRYX STRL BOTH IP/OP $725.00 $536.50 $0.00 $580.00 $326.25 $326.25 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $362.50 $574.20 $580.00 $0.00 $0.00 $113.46 $0.00 $0.00 $115.42 $0.00 $0.00 $0.00 $0.00 $0.00 238020T5 SUP HCPCS C1713 238020T5 - SCREW BABSR 20MM 8MM MATRYX BOTH IP/OP $725.00 $536.50 $0.00 $580.00 $326.25 $326.25 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $362.50 $574.20 $580.00 $0.00 $0.00 $113.46 $0.00 $0.00 $115.42 $0.00 $0.00 $0.00 $0.00 $0.00 23-875-595 SUP Custom 27203010 KIT BIOSTAR ACV HCG CNTRL POS NEG MCBLTST BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 239.955S SUP HCPCS C1713 239.955S - PLATE 93MM SS 3.5MM SCR 4 HOLE SM FRAG LCP BONE OD LEFT MDL BOTH IP/OP "$2,746.73 " "$2,032.58" $0.00 "$2,515.18" "$1,414.79" "$1,414.79" $0.00 $0.00 $0.00 $572.49 "$2,038.62" "$2,038.62" $0.00 $0.00 $572.42 $0.00 "$1,354.14" "$1,354.14" $0.00 "$1,571.99" "$2,490.03" "$2,515.18" $0.00 $0.00 $492.03 $0.00 $0.00 $500.52 $0.00 $0.00 $0.00 $0.00 $0.00 239.986S SUP HCPCS C1713 239.986S - PLATE BN CNTR 142MM STRL LCP CMBN 6 HL LMT CNTCT SS TIB RT BOTH IP/OP "$2,788.90 " "$2,063.79" $0.00 "$2,166.14" "$1,218.45" "$1,218.45" $0.00 $0.00 $0.00 $581.28 "$2,069.92" "$2,069.92" $0.00 $0.00 $581.21 $0.00 "$1,374.93" "$1,374.93" $0.00 "$1,353.84" "$2,144.48" "$2,166.14" $0.00 $0.00 $411.41 $0.00 $0.00 $431.06 $0.00 $0.00 $0.00 $0.00 $0.00 23AGFN-756 SUP Custom 27803010 23AGFN-756 - VALVE AOR 85D 23MM 21.4MM REGENT FLEXCUFF 1 DGT GRDNT LFLT BOTH IP/OP "$11,750.00 " "$8,695.00" $0.00 "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,448.70" $0.00 $0.00 $0.00 $0.00 "$5,875.00" "$9,306.00" "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 23AJ-501 SUP Custom 27803010 23AJ-501 - VALVE AOR 85D STD 23MM 18.6MM MSTR-SER CUF LFLT OPN CNTRL BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 240.048S SUP HCPCS C1713 240.048S - PLATE BN CNTR 298MM STRL LCP CMBN 4 HL LMT CNTCT TPR END SS BOTH IP/OP "$3,023.65 " "$2,237.50" $0.00 "$2,348.46" "$1,321.01" "$1,321.01" $0.00 $0.00 $0.00 $630.20 "$2,244.15" "$2,244.15" $0.00 $0.00 $630.13 $0.00 "$1,490.66" "$1,490.66" $0.00 "$1,467.79" "$2,324.98" "$2,348.46" $0.00 $0.00 $446.04 $0.00 $0.00 $467.34 $0.00 $0.00 $0.00 $0.00 $0.00 240.049S SUP HCPCS C1713 240.049S - PLATE BONE 298MM 16 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$3,023.65 " "$2,237.50" $0.00 "$2,348.46" "$1,321.01" "$1,321.01" $0.00 $0.00 $0.00 $630.20 "$2,244.15" "$2,244.15" $0.00 $0.00 $630.13 $0.00 "$1,490.66" "$1,490.66" $0.00 "$1,467.79" "$2,324.98" "$2,348.46" $0.00 $0.00 $446.04 $0.00 $0.00 $467.34 $0.00 $0.00 $0.00 $0.00 $0.00 240.052S SUP HCPCS C1713 240.052S - PLATE BONE 334MM 18 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$3,081.28 " "$2,280.15" $0.00 "$2,393.22" "$1,346.19" "$1,346.19" $0.00 $0.00 $0.00 $642.21 "$2,286.92" "$2,286.92" $0.00 $0.00 $642.14 $0.00 "$1,519.07" "$1,519.07" $0.00 "$1,495.76" "$2,369.29" "$2,393.22" $0.00 $0.00 $454.54 $0.00 $0.00 $476.25 $0.00 $0.00 $0.00 $0.00 $0.00 240.053S SUP HCPCS C1713 240.053S - PLATE BONE 334MM 18 HOLE LCP STAINLESS STEEL TIBIA LEFT BOTH IP/OP "$3,081.28 " "$2,280.15" $0.00 "$2,393.22" "$1,346.19" "$1,346.19" $0.00 $0.00 $0.00 $642.21 "$2,286.92" "$2,286.92" $0.00 $0.00 $642.14 $0.00 "$1,519.07" "$1,519.07" $0.00 "$1,495.76" "$2,369.29" "$2,393.22" $0.00 $0.00 $454.54 $0.00 $0.00 $476.25 $0.00 $0.00 $0.00 $0.00 $0.00 240.054S SUP HCPCS C1713 240.054S - PLATE BONE 370MM 20 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$3,140.33 " "$2,323.84" $0.00 "$2,439.08" "$1,371.98" "$1,371.98" $0.00 $0.00 $0.00 $654.52 "$2,330.75" "$2,330.75" $0.00 $0.00 $654.44 $0.00 "$1,548.18" "$1,548.18" $0.00 "$1,524.43" "$2,414.69" "$2,439.08" $0.00 $0.00 $463.25 $0.00 $0.00 $485.38 $0.00 $0.00 $0.00 $0.00 $0.00 240.055S SUP HCPCS C1713 240.055S - PLATE BONE 370MM 20 HOLE LOCKING LCP STAINLESS STEEL BOTH IP/OP "$3,140.33 " "$2,323.84" $0.00 "$2,439.08" "$1,371.98" "$1,371.98" $0.00 $0.00 $0.00 $654.52 "$2,330.75" "$2,330.75" $0.00 $0.00 $654.44 $0.00 "$1,548.18" "$1,548.18" $0.00 "$1,524.43" "$2,414.69" "$2,439.08" $0.00 $0.00 $463.25 $0.00 $0.00 $485.38 $0.00 $0.00 $0.00 $0.00 $0.00 24003 L SUP Custom 27803010 24003 L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24003 LL SUP Custom 27803010 24003 LL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24003 M SUP Custom 27803010 24003 M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,147.00 " "$1,588.78" $0.00 "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,593.50" "$1,593.50" $0.00 $0.00 $447.43 $0.00 $0.00 $0.00 $0.00 "$1,073.50" "$1,700.42" "$1,717.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24004 B SUP Custom 27803010 24004 B - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2400-58 SUP Custom 27203010 2400-58 - CATHETER CHOLANGIOGRAM 50CM REDDICK CYSTIC DUCT STERILE BOTH IP/OP "$1,499.38 " "$1,109.54" $0.00 "$1,199.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,112.84" "$1,112.84" $0.00 $0.00 $312.47 $0.00 $0.00 $0.00 $0.00 $749.69 "$1,187.51" "$1,199.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24013-1 SUP Custom 27803010 24013-1 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24013-2 SUP Custom 27803010 24013-2 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24013-5 SUP Custom 27803010 24013-5 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24-025-01-09 SUP HCPCS C1713 24-025-01-09 - STERNAL LCK PLATE 6 HOLE XIPHOID PLATE 2.0MM THICK BOTH IP/OP $718.25 $531.51 $0.00 $574.60 $323.21 $323.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.13 $568.85 $574.60 $0.00 $0.00 $112.41 $0.00 $0.00 $114.35 $0.00 $0.00 $0.00 $0.00 $0.00 24-025-03-09 SUP HCPCS C1713 24-025-03-09 - STERNAL LOCK PLATE 10 HOLE BODY PLATE 2.0MM THICK BOTH IP/OP $967.20 $715.73 $0.00 $773.76 $435.24 $435.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.60 $766.02 $773.76 $0.00 $0.00 $151.37 $0.00 $0.00 $153.98 $0.00 $0.00 $0.00 $0.00 $0.00 24-025-04-09 SUP HCPCS C1713 24-025-04-09 - STERNAL LOCK PLATE 14 HOLE MANUBRIUM PLATE 2.0MM THICK BOTH IP/OP "$1,212.53 " $897.27 $0.00 $970.02 $545.64 $545.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $606.26 $960.32 $970.02 $0.00 $0.00 $189.76 $0.00 $0.00 $193.03 $0.00 $0.00 $0.00 $0.00 $0.00 24027-1 SUP Custom 27803010 24027-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24027-2 SUP Custom 27803010 24027-2 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24027-4 SUP Custom 27803010 24027-4 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,657.38 " "$3,446.46" $0.00 "$3,725.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,456.70" "$3,456.70" $0.00 $0.00 $970.60 $0.00 $0.00 $0.00 $0.00 "$2,328.69" "$3,688.64" "$3,725.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24027-5 SUP Custom 27803010 24027-5 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24028-1 SUP Custom 27803010 24028-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24028-2 SUP Custom 27803010 24028-2 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24028-5 SUP Custom 27803010 24028-5 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24039-1 SUP Custom 27803010 24039-1 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,094.50 " "$3,029.93" $0.00 "$3,275.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,038.94" "$3,038.94" $0.00 $0.00 $853.29 $0.00 $0.00 $0.00 $0.00 "$2,047.25" "$3,242.84" "$3,275.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24039-2 SUP Custom 27803010 24039-2 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,094.50 " "$3,029.93" $0.00 "$3,275.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,038.94" "$3,038.94" $0.00 $0.00 $853.29 $0.00 $0.00 $0.00 $0.00 "$2,047.25" "$3,242.84" "$3,275.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24039-5 SUP Custom 27203010 24039-5 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,094.50 " "$3,029.93" $0.00 "$3,275.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,038.94" "$3,038.94" $0.00 $0.00 $853.29 $0.00 $0.00 $0.00 $0.00 "$2,047.25" "$3,242.84" "$3,275.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24079-1 SUP Custom 27803010 24079-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24079-2 SUP Custom 27803010 24079-2 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$5,526.63 " "$4,089.71" $0.00 "$4,421.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,101.86" "$4,101.86" $0.00 $0.00 "$1,151.75" $0.00 $0.00 $0.00 $0.00 "$2,763.31" "$4,377.09" "$4,421.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24079-5 SUP Custom 27803010 24079-5 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24088 C SUP Custom 27803010 24088 C - PLATE 18MM TI BONE SPNL BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24088 D SUP Custom 27803010 24088 D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $501.13 $370.84 $0.00 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.93 $371.93 $0.00 $0.00 $104.43 $0.00 $0.00 $0.00 $0.00 $250.56 $396.89 $400.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 241.072S SUP HCPCS C1713 241.072S - PLATE BN 12MM 70MM STRL LCP CMBN 4 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,473.18 " "$1,090.15" $0.00 "$1,144.20" $643.61 $643.61 $0.00 $0.00 $0.00 $307.05 "$1,093.39" "$1,093.39" $0.00 $0.00 $307.01 $0.00 $871.38 $871.38 $0.00 $715.13 "$1,132.76" "$1,144.20" $0.00 $0.00 $217.32 $0.00 $0.00 $227.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.073S SUP HCPCS C1713 241.073S - PLATE BONE 12MM 4 HOLE HOOK LCP STAINLESS STEEL LEFT BOTH IP/OP "$1,473.18 " "$1,090.15" $0.00 "$1,144.20" $643.61 $643.61 $0.00 $0.00 $0.00 $307.05 "$1,093.39" "$1,093.39" $0.00 $0.00 $307.01 $0.00 $871.38 $871.38 $0.00 $715.13 "$1,132.76" "$1,144.20" $0.00 $0.00 $217.32 $0.00 $0.00 $227.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.074S SUP HCPCS C1713 241.074S - PLATE BN 15MM 70MM STRL LCP CMBN 4 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,473.18 " "$1,090.15" $0.00 "$1,144.20" $643.61 $643.61 $0.00 $0.00 $0.00 $307.05 "$1,093.39" "$1,093.39" $0.00 $0.00 $307.01 $0.00 $871.38 $871.38 $0.00 $715.13 "$1,132.76" "$1,144.20" $0.00 $0.00 $217.32 $0.00 $0.00 $227.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.075S SUP HCPCS C1713 241.075S - PLATE BN 15MM 70MM STRL LCP CMBN 4 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,473.18 " "$1,090.15" $0.00 "$1,144.20" $643.61 $643.61 $0.00 $0.00 $0.00 $307.05 "$1,093.39" "$1,093.39" $0.00 $0.00 $307.01 $0.00 $871.38 $871.38 $0.00 $715.13 "$1,132.76" "$1,144.20" $0.00 $0.00 $217.32 $0.00 $0.00 $227.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.076S SUP HCPCS C1713 241.076S - PLATE BN 18MM 70MM STRL LCP CMBN 4 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,473.18 " "$1,090.15" $0.00 "$1,144.20" $643.61 $643.61 $0.00 $0.00 $0.00 $307.05 "$1,093.39" "$1,093.39" $0.00 $0.00 $307.01 $0.00 $871.38 $871.38 $0.00 $715.13 "$1,132.76" "$1,144.20" $0.00 $0.00 $217.32 $0.00 $0.00 $227.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.077S SUP HCPCS C1713 241.077S - PLATE BONE 18MM 4 HOLE HOOK PRECONTOUR LCP STAINLESS STEEL BOTH IP/OP "$1,473.18 " "$1,090.15" $0.00 "$1,144.20" $643.61 $643.61 $0.00 $0.00 $0.00 $307.05 "$1,093.39" "$1,093.39" $0.00 $0.00 $307.01 $0.00 $871.38 $871.38 $0.00 $715.13 "$1,132.76" "$1,144.20" $0.00 $0.00 $217.32 $0.00 $0.00 $227.70 $0.00 $0.00 $0.00 $0.00 $0.00 241.082S SUP HCPCS C1713 241.082S - PLATE BONE 12MM 5 HOLE HOOK LCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,540.65 " "$1,140.08" $0.00 "$1,196.62" $673.10 $673.10 $0.00 $0.00 $0.00 $321.11 "$1,143.47" "$1,143.47" $0.00 $0.00 $321.07 $0.00 $911.29 $911.29 $0.00 $747.89 "$1,184.66" "$1,196.62" $0.00 $0.00 $227.27 $0.00 $0.00 $238.13 $0.00 $0.00 $0.00 $0.00 $0.00 241.083S SUP HCPCS C1713 241.083S - PLATE BONE 12MM 5 HOLE HOOK LCP STAINLESS STEEL LEFT BOTH IP/OP "$1,540.65 " "$1,140.08" $0.00 "$1,196.62" $673.10 $673.10 $0.00 $0.00 $0.00 $321.11 "$1,143.47" "$1,143.47" $0.00 $0.00 $321.07 $0.00 $911.29 $911.29 $0.00 $747.89 "$1,184.66" "$1,196.62" $0.00 $0.00 $227.27 $0.00 $0.00 $238.13 $0.00 $0.00 $0.00 $0.00 $0.00 241.084S SUP HCPCS C1713 241.084S - PLATE BN 15MM 85MM STRL LCP CMBN 5 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,540.65 " "$1,140.08" $0.00 "$1,196.62" $673.10 $673.10 $0.00 $0.00 $0.00 $321.11 "$1,143.47" "$1,143.47" $0.00 $0.00 $321.07 $0.00 $911.29 $911.29 $0.00 $747.89 "$1,184.66" "$1,196.62" $0.00 $0.00 $227.27 $0.00 $0.00 $238.13 $0.00 $0.00 $0.00 $0.00 $0.00 241.085S SUP HCPCS C1713 241.085S - PLATE BONE 15MM 5 HOLE HOOK LCP STAINLESS STEEL LEFT BOTH IP/OP "$1,540.65 " "$1,140.08" $0.00 "$1,196.62" $673.10 $673.10 $0.00 $0.00 $0.00 $321.11 "$1,143.47" "$1,143.47" $0.00 $0.00 $321.07 $0.00 $911.29 $911.29 $0.00 $747.89 "$1,184.66" "$1,196.62" $0.00 $0.00 $227.27 $0.00 $0.00 $238.13 $0.00 $0.00 $0.00 $0.00 $0.00 241.086S SUP HCPCS C1713 241.086S - PLATE BN 18MM 85MM STRL LCP CMBN 5 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,540.65 " "$1,140.08" $0.00 "$1,196.62" $673.10 $673.10 $0.00 $0.00 $0.00 $321.11 "$1,143.47" "$1,143.47" $0.00 $0.00 $321.07 $0.00 $911.29 $911.29 $0.00 $747.89 "$1,184.66" "$1,196.62" $0.00 $0.00 $227.27 $0.00 $0.00 $238.13 $0.00 $0.00 $0.00 $0.00 $0.00 241.087S SUP HCPCS C1713 241.087S - PLATE BN 18MM 85MM STRL LCP CMBN 5 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,540.65 " "$1,140.08" $0.00 "$1,196.62" $673.10 $673.10 $0.00 $0.00 $0.00 $321.11 "$1,143.47" "$1,143.47" $0.00 $0.00 $321.07 $0.00 $911.29 $911.29 $0.00 $747.89 "$1,184.66" "$1,196.62" $0.00 $0.00 $227.27 $0.00 $0.00 $238.13 $0.00 $0.00 $0.00 $0.00 $0.00 241.094S SUP HCPCS C1713 241.094S - PLATE BN 15MM 99MM STRL LCP CMBN 6 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 241.095S SUP HCPCS C1713 241.095S - PLATE BN 15MM 99MM STRL LCP CMBN 6 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 241.096S SUP HCPCS C1713 241.096S - PLATE BN 18MM 99MM STRL LCP CMBN 6 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 241.097S SUP HCPCS C1713 241.097S - PLATE BONE 18MM 6 HOLE HOOK LCP STAINLESS STEEL LEFT BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 241.104S SUP HCPCS C1713 241.104S - PLATE BONE 15MM 7 HOLE HOOK LCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,651.70 " "$1,222.26" $0.00 "$1,282.86" $721.61 $721.61 $0.00 $0.00 $0.00 $344.26 "$1,225.89" "$1,225.89" $0.00 $0.00 $344.21 $0.00 $976.98 $976.98 $0.00 $801.79 "$1,270.04" "$1,282.86" $0.00 $0.00 $243.65 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $0.00 241.105S SUP HCPCS C1713 241.105S - PLATE BONE 15MM 7 HOLE HOOK LCP STAINLESS STEEL LEFT BOTH IP/OP "$1,651.70 " "$1,222.26" $0.00 "$1,282.86" $721.61 $721.61 $0.00 $0.00 $0.00 $344.26 "$1,225.89" "$1,225.89" $0.00 $0.00 $344.21 $0.00 $976.98 $976.98 $0.00 $801.79 "$1,270.04" "$1,282.86" $0.00 $0.00 $243.65 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $0.00 241.106S SUP HCPCS C1713 241.106S - PLATE BONE 18MM 7 HOLE HOOK LCP STAINLESS STEEL RIGHT BOTH IP/OP "$1,651.70 " "$1,222.26" $0.00 "$1,282.86" $721.61 $721.61 $0.00 $0.00 $0.00 $344.26 "$1,225.89" "$1,225.89" $0.00 $0.00 $344.21 $0.00 $976.98 $976.98 $0.00 $801.79 "$1,270.04" "$1,282.86" $0.00 $0.00 $243.65 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $0.00 241.107S SUP HCPCS C1713 241.107S - PLATE BONE 18MM 7 HOLE HOOK LCP STAINLESS STEEL LEFT BOTH IP/OP "$1,651.70 " "$1,222.26" $0.00 "$1,282.86" $721.61 $721.61 $0.00 $0.00 $0.00 $344.26 "$1,225.89" "$1,225.89" $0.00 $0.00 $344.21 $0.00 $976.98 $976.98 $0.00 $801.79 "$1,270.04" "$1,282.86" $0.00 $0.00 $243.65 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $0.00 241.266S SUP HCPCS C1713 241.266S - PLATE BN 116X11X2.5MM STRL LCP CMBN 7 HL PRECONTOUR LMT BOTH IP/OP "$2,204.13 " "$1,631.06" $0.00 "$1,711.94" $962.97 $962.97 $0.00 $0.00 $0.00 $459.39 "$1,635.90" "$1,635.90" $0.00 $0.00 $459.34 $0.00 "$1,303.74" "$1,303.74" $0.00 "$1,069.96" "$1,694.82" "$1,711.94" $0.00 $0.00 $325.14 $0.00 $0.00 $340.68 $0.00 $0.00 $0.00 $0.00 $0.00 241.919S SUP HCPCS C1713 241.919S - PLATE BONE LONG 160X12X3.7MM 6 HOLE PRECONTOUR LCP STAINLESS BOTH IP/OP "$3,185.30 " "$2,357.12" $0.00 "$2,474.02" "$1,391.64" "$1,391.64" $0.00 $0.00 $0.00 $663.90 "$2,364.13" "$2,364.13" $0.00 $0.00 $663.82 $0.00 "$1,570.35" "$1,570.35" $0.00 "$1,546.26" "$2,449.28" "$2,474.02" $0.00 $0.00 $469.88 $0.00 $0.00 $492.33 $0.00 $0.00 $0.00 $0.00 $0.00 241.921S SUP HCPCS C1713 241.921S - PLATE LNG 196MM SS 3.5MM SCR SM FRAG SET 8 HOLE LCP BONE BOTH IP/OP "$3,304.78 " "$2,445.54" $0.00 "$3,030.88" "$1,704.87" "$1,704.87" $0.00 $0.00 $0.00 $688.80 "$2,452.80" "$2,452.80" $0.00 $0.00 $688.72 $0.00 "$1,629.25" "$1,629.25" $0.00 "$1,894.30" "$3,000.57" "$3,030.88" $0.00 $0.00 $592.92 $0.00 $0.00 $603.15 $0.00 $0.00 $0.00 $0.00 $0.00 241-01 SUP HCPCS C1781 241-01 - PLATE 18MM TI BONE SPNL BOTH IP/OP $465.38 $344.38 $0.00 $372.30 $209.42 $209.42 $0.00 $0.00 $0.00 $97.00 $345.40 $345.40 $0.00 $0.00 $96.98 $0.00 $275.27 $275.27 $0.00 $232.69 $368.58 $372.30 $0.00 $0.00 $72.83 $0.00 $0.00 $74.09 $0.00 $0.00 $0.00 $0.00 $0.00 241-02 SUP HCPCS C1781 241-02 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $571.63 $423.01 $0.00 $457.30 $257.23 $257.23 $0.00 $0.00 $0.00 $119.14 $424.26 $424.26 $0.00 $0.00 $119.13 $0.00 $338.12 $338.12 $0.00 $285.81 $452.73 $457.30 $0.00 $0.00 $89.46 $0.00 $0.00 $91.00 $0.00 $0.00 $0.00 $0.00 $0.00 241-02-C SUP HCPCS C1781 241-02-C - PLATE BN 121MM FLEXMESH 2 HL STRP SKL BOTH IP/OP $575.88 $426.15 $0.00 $460.70 $259.14 $259.14 $0.00 $0.00 $0.00 $120.03 $427.41 $427.41 $0.00 $0.00 $120.01 $0.00 $340.63 $340.63 $0.00 $287.94 $456.10 $460.70 $0.00 $0.00 $90.12 $0.00 $0.00 $91.68 $0.00 $0.00 $0.00 $0.00 $0.00 241-03 SUP HCPCS C1781 241-03 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $652.38 $482.76 $0.00 $521.90 $293.57 $293.57 $0.00 $0.00 $0.00 $135.97 $484.19 $484.19 $0.00 $0.00 $135.95 $0.00 $385.88 $385.88 $0.00 $326.19 $516.68 $521.90 $0.00 $0.00 $102.10 $0.00 $0.00 $103.86 $0.00 $0.00 $0.00 $0.00 $0.00 241-04 SUP HCPCS C1713 241-04 - PLATE 18MM TI BONE SPNL BOTH IP/OP $735.25 $544.09 $0.00 $588.20 $330.86 $330.86 $0.00 $0.00 $0.00 $153.24 $545.70 $545.70 $0.00 $0.00 $153.23 $0.00 $434.90 $434.90 $0.00 $367.63 $582.32 $588.20 $0.00 $0.00 $115.07 $0.00 $0.00 $117.05 $0.00 $0.00 $0.00 $0.00 $0.00 24106 A SUP Custom 27803010 24106 A - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24106 B SUP Custom 27803010 24106 B - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24106 C SUP Custom 27803010 24106 C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24106 D SUP Custom 27803010 24106 D - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24106 E SUP Custom 27803010 24106 E - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 24106 H SUP HCPCS C1725 24106 H - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,220.75 " $903.36 $0.00 $976.60 $662.87 $662.87 $0.00 $0.00 $0.00 $254.43 $906.04 $906.04 $0.00 $0.00 $254.40 $0.00 $722.07 $722.07 $0.00 $610.38 $966.83 $976.60 $0.00 $0.00 $191.05 $0.00 $0.00 $194.34 $0.00 $0.00 $0.00 $0.00 $0.00 24133-1 SUP Custom 27803010 24133-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$5,241.63 " "$3,878.81" $0.00 "$4,193.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,890.33" "$3,890.33" $0.00 $0.00 "$1,092.35" $0.00 $0.00 $0.00 $0.00 "$2,620.81" "$4,151.37" "$4,193.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 242.531S SUP HCPCS C1713 242.531S - PLATE BONE 46MM 7 HOLE LCP STAINLESS STEEL DISTAL ULNA BOTH IP/OP "$1,561.73 " "$1,155.68" $0.00 "$1,212.98" $682.30 $682.30 $0.00 $0.00 $0.00 $325.50 "$1,159.11" "$1,159.11" $0.00 $0.00 $325.46 $0.00 $923.76 $923.76 $0.00 $758.11 "$1,200.85" "$1,212.98" $0.00 $0.00 $230.38 $0.00 $0.00 $241.38 $0.00 $0.00 $0.00 $0.00 $0.00 24-2050 SUP Custom 27203010 24-2050 - DRILL SURG 1.8MM 50MM 26MM STOP BLADE LORENZ MANDIB BOTH IP/OP $432.50 $320.05 $0.00 $346.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.00 $321.00 $0.00 $0.00 $90.13 $0.00 $0.00 $0.00 $0.00 $216.25 $342.54 $346.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 246.354S SUP HCPCS C1713 246.354S - PLATE BONE 27MM 2X5 HOLE ROTATION CORRECTION LCP STAINLESS BOTH IP/OP "$1,516.23 " "$1,122.01" $0.00 "$1,212.98" $682.30 $682.30 $0.00 $0.00 $0.00 $316.02 "$1,125.34" "$1,125.34" $0.00 $0.00 $315.98 $0.00 $896.85 $896.85 $0.00 $758.11 "$1,200.85" "$1,212.98" $0.00 $0.00 $230.38 $0.00 $0.00 $241.38 $0.00 $0.00 $0.00 $0.00 $0.00 246.355S SUP HCPCS C1713 246.355S - PLATE BONE 32MM 2X5 HOLE ROTATION CORRECTION LCP STAINLESS BOTH IP/OP "$1,516.23 " "$1,122.01" $0.00 "$1,212.98" $682.30 $682.30 $0.00 $0.00 $0.00 $316.02 "$1,125.34" "$1,125.34" $0.00 $0.00 $315.98 $0.00 $896.85 $896.85 $0.00 $758.11 "$1,200.85" "$1,212.98" $0.00 $0.00 $230.38 $0.00 $0.00 $241.38 $0.00 $0.00 $0.00 $0.00 $0.00 247.354S SUP HCPCS C1713 247.354S - PLATE BONE 34MM 2X5 HOLE ROTATION CORRECTION LCP STAINLESS BOTH IP/OP "$1,561.73 " "$1,155.68" $0.00 "$1,212.98" $682.30 $682.30 $0.00 $0.00 $0.00 $325.50 "$1,159.11" "$1,159.11" $0.00 $0.00 $325.46 $0.00 $923.76 $923.76 $0.00 $758.11 "$1,200.85" "$1,212.98" $0.00 $0.00 $230.38 $0.00 $0.00 $241.38 $0.00 $0.00 $0.00 $0.00 $0.00 247.355S SUP HCPCS C1713 247.355S - PLATE BONE 40MM 2X5 HOLE ROTATION CORRECTION LCP STAINLESS BOTH IP/OP "$1,561.73 " "$1,155.68" $0.00 "$1,212.98" $682.30 $682.30 $0.00 $0.00 $0.00 $325.50 "$1,159.11" "$1,159.11" $0.00 $0.00 $325.46 $0.00 $923.76 $923.76 $0.00 $758.11 "$1,200.85" "$1,212.98" $0.00 $0.00 $230.38 $0.00 $0.00 $241.38 $0.00 $0.00 $0.00 $0.00 $0.00 2480-10-41 SUP HCPCS C1713 2480-10-41 - SCREW BN FT 4MM 10MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-12-41 SUP HCPCS C1713 2480-12-41 - SCREW BN FT 4MM 12MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-14-41 SUP HCPCS C1713 2480-14-41 - SCREW BN FT 4MM 14MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-16-41 SUP HCPCS C1713 2480-16-41 - SCREW BN FT 4MM 16MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-18-41 SUP HCPCS C1713 2480-18-41 - SCREW BN FT 4MM 18MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-20-41 SUP HCPCS C1713 2480-20-41 - SCREW BN FT 4MM 20MM NS FORTE SS PERIART CANC BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-22-41 SUP HCPCS C1713 2480-22-41 - SCREW BN FT 4MM 22MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-24-41 SUP HCPCS C1713 2480-24-41 - SCREW BN FT 4MM 24MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-26-41 SUP HCPCS C1713 2480-26-41 - SCREW BN FT 4MM 26MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-28-41 SUP HCPCS C1713 2480-28-41 - SCREW BN FT 4MM 28MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-30-41 SUP HCPCS C1713 2480-30-41 - SCREW BN FT 4MM 30MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-32-41 SUP HCPCS C1713 2480-32-41 - SCREW BN FT 4MM 32MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-34-41 SUP HCPCS C1713 2480-34-41 - SCREW BN FT 4MM 34MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-36-41 SUP HCPCS C1713 2480-36-41 - SCREW BN FT 4MM 36MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-38-41 SUP HCPCS C1713 2480-38-41 - SCREW BN FT 4MM 38MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 2480-40-41 SUP HCPCS C1713 2480-40-41 - SCREW BN FT 4MM 40MM NS FORTE SS CANC PERIART BOTH IP/OP $111.55 $82.55 $0.00 $89.24 $50.20 $50.20 $0.00 $0.00 $0.00 $23.25 $82.79 $82.79 $0.00 $0.00 $23.25 $0.00 $65.98 $65.98 $0.00 $55.78 $88.35 $89.24 $0.00 $0.00 $17.46 $0.00 $0.00 $17.76 $0.00 $0.00 $0.00 $0.00 $0.00 24B002 SUP HCPCS C9359 24B002 - GRAFT BONE PROX FEM HD FRZN ALLOWASH TCH GAMA IRR BOTH IP/OP "$3,260.00 " "$2,412.40" $0.00 "$2,608.00" $0.00 $0.00 $0.00 $0.00 $0.00 $679.47 "$2,419.57" "$2,419.57" $0.00 $0.00 $679.38 $0.00 "$1,607.18" "$1,607.18" $0.00 "$1,630.00" "$2,581.92" "$2,608.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 250.25S SUP HCPCS C1713 250.25S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 255MM STAINLESS STEEL BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 250.27S SUP HCPCS C1713 250.27S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 270MM STAINLESS STEEL BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 250.28S SUP HCPCS C1713 250.28S - NAIL 10MM 285MM TIB IM UNV SS STRL BOTH IP/OP "$2,533.98 " "$1,875.15" $0.00 "$2,027.18" "$1,140.29" "$1,140.29" $0.00 $0.00 $0.00 $528.14 "$1,880.72" "$1,880.72" $0.00 $0.00 $528.08 $0.00 "$1,249.25" "$1,249.25" $0.00 "$1,266.99" "$2,006.91" "$2,027.18" $0.00 $0.00 $396.57 $0.00 $0.00 $403.41 $0.00 $0.00 $0.00 $0.00 $0.00 250.30S SUP HCPCS C1713 250.30S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 300MM TITANIUM TIBIA BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 250.31S SUP HCPCS C1713 250.31S - NAIL 10MM 315MM TIB IM UNV SS STRL BOTH IP/OP "$2,533.98 " "$1,875.15" $0.00 "$2,027.18" "$1,140.29" "$1,140.29" $0.00 $0.00 $0.00 $528.14 "$1,880.72" "$1,880.72" $0.00 $0.00 $528.08 $0.00 "$1,249.25" "$1,249.25" $0.00 "$1,266.99" "$2,006.91" "$2,027.18" $0.00 $0.00 $396.57 $0.00 $0.00 $403.41 $0.00 $0.00 $0.00 $0.00 $0.00 250.33S SUP HCPCS C1713 250.33S - NAIL 10MM 330MM TIB IM UNV SS STRL BOTH IP/OP "$2,533.98 " "$1,875.15" $0.00 "$2,027.18" "$1,140.29" "$1,140.29" $0.00 $0.00 $0.00 $528.14 "$1,880.72" "$1,880.72" $0.00 $0.00 $528.08 $0.00 "$1,249.25" "$1,249.25" $0.00 "$1,266.99" "$2,006.91" "$2,027.18" $0.00 $0.00 $396.57 $0.00 $0.00 $403.41 $0.00 $0.00 $0.00 $0.00 $0.00 250.34S SUP HCPCS C1713 250.34S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 345MM STAINLESS STEEL BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 250.36S SUP HCPCS C1713 250.36S - NAIL 10MM 360MM TIB IM UNV SS STRL BOTH IP/OP "$2,533.98 " "$1,875.15" $0.00 "$2,027.18" "$1,140.29" "$1,140.29" $0.00 $0.00 $0.00 $528.14 "$1,880.72" "$1,880.72" $0.00 $0.00 $528.08 $0.00 "$1,249.25" "$1,249.25" $0.00 "$1,266.99" "$2,006.91" "$2,027.18" $0.00 $0.00 $396.57 $0.00 $0.00 $403.41 $0.00 $0.00 $0.00 $0.00 $0.00 250.38S SUP HCPCS C1713 250.38S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 380MM STAINLESS STEEL BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 250.40S SUP HCPCS C1713 250.40S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 400MM STAINLESS STEEL BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 250.42S SUP HCPCS C1713 250.42S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 420MM STAINLESS STEEL BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+10.00 SUP HCPCS V2632 25000C+10.00 - LENS IOL +10 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+10.50 SUP HCPCS V2632 25000C+10.50 - LENS IOL +10.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+11.00 SUP HCPCS V2632 25000C+11.00 - LENS IOL +11 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+11.50 SUP HCPCS V2632 25000C+11.50 - LENS IOL +11.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+12.00 SUP HCPCS V2632 25000C+12.00 - LENS IOL +12 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+12.50 SUP HCPCS V2632 25000C+12.50 - LENS IOL +12.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+13.00 SUP HCPCS V2632 25000C+13.00 - LENS IOL +13 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+13.50 SUP HCPCS V2632 25000C+13.50 - LENS IOL +13.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+14.00 SUP HCPCS V2632 25000C+14.00 - LENS IOL +14 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+14.50 SUP HCPCS V2632 25000C+14.50 - LENS IOL +14.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+15.00 SUP HCPCS V2632 25000C+15.00 - LENS IOL +15 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+15.50 SUP HCPCS V2632 25000C+15.50 - LENS IOL +15.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+16.00 SUP HCPCS V2632 25000C+16.00 - LENS IOL +16 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+16.50 SUP HCPCS V2632 25000C+16.50 - LENS IOL +16.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+17.00 SUP HCPCS V2632 25000C+17.00 - LENS IOL +17 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+17.50 SUP HCPCS V2632 25000C+17.50 - LENS IOL +17.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+18.00 SUP HCPCS V2632 25000C+18.00 - LENS IOL +18 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+18.50 SUP HCPCS V2632 25000C+18.50 - LENS IOL +18.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+19.00 SUP HCPCS V2632 25000C+19.00 - LENS IOL +19 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+19.50 SUP HCPCS V2632 25000C+19.50 - LENS IOL +19.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+20.00 SUP HCPCS V2632 25000C+20.00 - LENS IOL +20 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+20.50 SUP HCPCS V2632 25000C+20.50 - LENS IOL +20.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+21.00 SUP HCPCS V2632 25000C+21.00 - LENS IOL +21 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+21.50 SUP HCPCS V2632 25000C+21.50 - LENS IOL +21.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+22.00 SUP HCPCS V2632 25000C+22.00 - LENS IOL +22 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+22.50 SUP HCPCS V2632 25000C+22.50 - LENS IOL +22.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+23.00 SUP HCPCS V2632 25000C+23.00 - LENS IOL +23 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+23.50 SUP HCPCS V2632 25000C+23.50 - LENS IOL +23.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+24.00 SUP HCPCS V2632 25000C+24.00 - LENS IOL +24 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+24.50 SUP HCPCS V2632 25000C+24.50 - LENS IOL +24.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+25.00 SUP HCPCS V2632 25000C+25.00 - LENS IOL +25 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+25.50 SUP HCPCS V2632 25000C+25.50 - LENS IOL +25.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+26.00 SUP HCPCS V2632 25000C+26.00 - LENS IOL +26 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+26.50 SUP HCPCS V2632 25000C+26.50 - LENS IOL +26.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+27.00 SUP HCPCS V2632 25000C+27.00 - LENS IOL +27 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+27.50 SUP HCPCS V2632 25000C+27.50 - LENS IOL +27.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+28.00 SUP HCPCS V2632 25000C+28.00 - LENS IOL +28 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+28.50 SUP HCPCS V2632 25000C+28.50 - LENS IOL +28.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+29.00 SUP HCPCS V2632 25000C+29.00 - LENS IOL +29 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+29.50 SUP HCPCS V2632 25000C+29.50 - LENS IOL +29.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+30.00 SUP HCPCS V2632 25000C+30.00 - LENS IOL +30 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+6.00 SUP HCPCS V2632 25000C+6.00 - LENS IOL +6 DIOP MOD C 6MM 12.5MM CLR HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+6.50 SUP HCPCS V2632 25000C+6.50 - LENS IOL +6.5 DIOP MOD C 6MM 12.5MM CLR HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+7.00 SUP HCPCS V2632 25000C+7.00 - LENS IOL +7 DIOP MOD C 6MM 12.5MM CLR HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+7.50 SUP HCPCS V2632 25000C+7.50 - LENS IOL +7.5 DIOP MOD C 6MM 12.5MM CLR HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+8.00 SUP HCPCS V2632 25000C+8.00 - LENS IOL +8 DIOP MOD C 6MM 12.5MM CLR HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+8.50 SUP HCPCS V2632 25000C+8.50 - LENS IOL +8.5 DIOP MOD C 6MM 12.5MM CLR HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+9.00 SUP HCPCS V2632 25000C+9.00 - LENS IOL +9 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25000C+9.50 SUP HCPCS V2632 25000C+9.50 - LENS IOL +9.5 DIOP MOD C 6MM 12.5MM CLR ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25-003-10-09 SUP HCPCS C1713 25-003-10-09 - MESH CRNL 85X50X.3MM SM GRID PNL TI 1.5MM SCR BOTH IP/OP "$1,823.00 " "$1,349.02" $0.00 "$1,458.40" $820.35 $820.35 $0.00 $0.00 $0.00 $379.96 "$1,353.03" "$1,353.03" $0.00 $0.00 $379.91 $0.00 "$1,078.30" "$1,078.30" $0.00 $911.50 "$1,443.82" "$1,458.40" $0.00 $0.00 $285.30 $0.00 $0.00 $290.22 $0.00 $0.00 $0.00 $0.00 $0.00 25-003-14-09 SUP HCPCS C1713 25-003-14-09 - NEURO PLATE ULTRA LOW PROFILE BOX STYLE 2X2-HOLE W/TAB BOTH IP/OP $701.53 $519.13 $0.00 $561.22 $315.69 $315.69 $0.00 $0.00 $0.00 $146.22 $520.67 $520.67 $0.00 $0.00 $146.20 $0.00 $414.95 $414.95 $0.00 $350.76 $555.61 $561.22 $0.00 $0.00 $109.79 $0.00 $0.00 $111.68 $0.00 $0.00 $0.00 $0.00 $0.00 25-003-21-09 SUP Custom 27803010 25-003-21-09 - COVER BURR HOLE MEDIUM 15MM .3MM HOLE ULTRA LP SMOOTH BOTH IP/OP $789.55 $584.27 $0.00 $631.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.00 $586.00 $0.00 $0.00 $164.54 $0.00 $0.00 $0.00 $0.00 $394.78 $625.32 $631.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-003-25-09 SUP Custom 27803010 25-003-25-09 - COVER BURR HOLE LARGE 25MM .3MM HOLE ULTRA LP SMOOTH ROUNDED BOTH IP/OP $789.55 $584.27 $0.00 $631.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.00 $586.00 $0.00 $0.00 $164.54 $0.00 $0.00 $0.00 $0.00 $394.78 $625.32 $631.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-004-70-09 SUP HCPCS C1781 25-004-70-09 - PLATE BONE ROUND MICRO MESH 73MM .6MM PANEL CNTOUR TITANIUM BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 25-007-80-09 SUP HCPCS C1713 25-007-80-09 - MESH CRNL 3D 80X80X.3MM TI 1.5MM SCR BOTH IP/OP "$4,042.10 " "$2,991.15" $0.00 "$3,233.68" "$1,818.95" "$1,818.95" $0.00 $0.00 $0.00 $842.47 "$3,000.05" "$3,000.05" $0.00 $0.00 $842.37 $0.00 "$1,992.76" "$1,992.76" $0.00 "$2,021.05" "$3,201.34" "$3,233.68" $0.00 $0.00 $632.59 $0.00 $0.00 $643.50 $0.00 $0.00 $0.00 $0.00 $0.00 25-008-12-09 SUP HCPCS C1781 25-008-12-09 - PLATE BONE 3D MICRO MESH 120X120X.6MM TITANIUM FRONTAL MAXL BOTH IP/OP "$5,736.28 " "$4,244.85" $0.00 "$4,589.02" "$2,581.32" "$2,581.32" $0.00 $0.00 $0.00 "$1,195.58" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.44" $0.00 "$2,827.98" "$2,827.98" $0.00 "$2,868.14" "$4,543.13" "$4,589.02" $0.00 $0.00 $897.73 $0.00 $0.00 $913.21 $0.00 $0.00 $0.00 $0.00 $0.00 25-008-80-09 SUP HCPCS C1713 25-008-80-09 - PLATE BONE 3D MESH 80X80X.6MM TITANIUM MANDIB 1.5MM SCREW BOTH IP/OP "$3,664.13 " "$2,711.46" $0.00 "$2,931.30" "$1,648.86" "$1,648.86" $0.00 $0.00 $0.00 $763.70 "$2,719.51" "$2,719.51" $0.00 $0.00 $763.60 $0.00 "$1,806.41" "$1,806.41" $0.00 "$1,832.06" "$2,901.99" "$2,931.30" $0.00 $0.00 $573.44 $0.00 $0.00 $583.33 $0.00 $0.00 $0.00 $0.00 $0.00 25014-1 SUP Custom 27803010 25014-1 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25014-2 SUP Custom 27803010 25014-2 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25014-5 SUP Custom 27803010 25014-5 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,723.88 " "$3,495.67" $0.00 "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,506.06" "$3,506.06" $0.00 $0.00 $984.46 $0.00 $0.00 $0.00 $0.00 "$2,361.94" "$3,741.31" "$3,779.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-015-04-09 SUP HCPCS C1713 25-015-04-09 - PLATE BONE MICRO SQUARE .6MM 2X2 HOLE TITANIUM FRONTAL MAXL BOTH IP/OP $377.18 $279.11 $0.00 $301.74 $169.73 $169.73 $0.00 $0.00 $0.00 $78.61 $279.94 $279.94 $0.00 $0.00 $78.60 $0.00 $223.10 $223.10 $0.00 $188.59 $298.73 $301.74 $0.00 $0.00 $59.03 $0.00 $0.00 $60.05 $0.00 $0.00 $0.00 $0.00 $0.00 25-015-06-09 SUP HCPCS C1713 25-015-06-09 - PLATE BONE MICRO SQUARE .6MM 3X2 HOLE TITANIUM MAXFACL 1.5MM BOTH IP/OP $452.60 $334.92 $0.00 $362.08 $203.67 $203.67 $0.00 $0.00 $0.00 $94.33 $335.92 $335.92 $0.00 $0.00 $94.32 $0.00 $267.71 $267.71 $0.00 $226.30 $358.46 $362.08 $0.00 $0.00 $70.83 $0.00 $0.00 $72.05 $0.00 $0.00 $0.00 $0.00 $0.00 250-202 SUP HCPCS C1892 SHEATH ACCES 35CM 12FR URETERAL FLEXOR BOTH IP/OP $296.10 $219.11 $0.00 $236.88 $160.78 $160.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.05 $234.51 $236.88 $0.00 $0.00 $46.34 $0.00 $0.00 $47.14 $0.00 $0.00 $0.00 $0.00 $0.00 250-208 SUP HCPCS C1892 SHEATH ACCES 36CM 13/15FR NVGTR URET DUAL TPR TIP HYDPHI BOTH IP/OP $286.00 $211.64 $0.00 $228.80 $155.30 $155.30 $0.00 $0.00 $0.00 $59.61 $212.27 $212.27 $0.00 $0.00 $59.60 $0.00 $169.17 $169.17 $0.00 $143.00 $226.51 $228.80 $0.00 $0.00 $44.76 $0.00 $0.00 $45.53 $0.00 $0.00 $0.00 $0.00 $0.00 25-022-28-09 SUP HCPCS C1713 25-022-28-09 - PLATE BONE 2MMX1MM 2 STRIP MESH BLUE TITANIUM MAXFACL 2MM BOTH IP/OP $608.65 $450.40 $0.00 $486.92 $273.89 $273.89 $0.00 $0.00 $0.00 $126.86 $451.74 $451.74 $0.00 $0.00 $126.84 $0.00 $360.02 $360.02 $0.00 $304.33 $482.05 $486.92 $0.00 $0.00 $95.25 $0.00 $0.00 $96.90 $0.00 $0.00 $0.00 $0.00 $0.00 25-040-25-09 SUP HCPCS C1713 25-040-25-09 - MESH CRNL 85X54X.2MM SCRN PNL TI 1MM SCR BOTH IP/OP "$1,191.80 " $881.93 $0.00 $953.44 $536.31 $536.31 $0.00 $0.00 $0.00 $248.40 $884.55 $884.55 $0.00 $0.00 $248.37 $0.00 $704.95 $704.95 $0.00 $595.90 $943.91 $953.44 $0.00 $0.00 $186.52 $0.00 $0.00 $189.73 $0.00 $0.00 $0.00 $0.00 $0.00 25-043-01-09 SUP HCPCS C1713 25-043-01-09 - MESH CRNL .3MM TI ORBT FLR 1.5MM SCR BOTH IP/OP "$1,010.08 " $747.46 $0.00 $808.06 $454.53 $454.53 $0.00 $0.00 $0.00 $210.52 $749.68 $749.68 $0.00 $0.00 $210.50 $0.00 $597.46 $597.46 $0.00 $505.04 $799.98 $808.06 $0.00 $0.00 $158.08 $0.00 $0.00 $160.80 $0.00 $0.00 $0.00 $0.00 $0.00 25-043-02-09 SUP HCPCS C1713 25-043-02-09 - MESH CRNL .5MM AU TI ORBT FLR 1.5MM SCR BOTH IP/OP "$1,010.08 " $747.46 $0.00 $808.06 $454.53 $454.53 $0.00 $0.00 $0.00 $210.52 $749.68 $749.68 $0.00 $0.00 $210.50 $0.00 $597.46 $597.46 $0.00 $505.04 $799.98 $808.06 $0.00 $0.00 $158.08 $0.00 $0.00 $160.80 $0.00 $0.00 $0.00 $0.00 $0.00 25-044-02-09 SUP HCPCS C1713 25-044-02-09 - PLATE BN 3D PSHP .4MM TI LT ORBT FLR BOTH IP/OP "$2,758.28 " "$2,041.13" $0.00 "$2,206.62" "$1,241.22" "$1,241.22" $0.00 $0.00 $0.00 $574.89 "$2,047.19" "$2,047.19" $0.00 $0.00 $574.82 $0.00 "$1,359.83" "$1,359.83" $0.00 "$1,379.14" "$2,184.56" "$2,206.62" $0.00 $0.00 $431.67 $0.00 $0.00 $439.12 $0.00 $0.00 $0.00 $0.00 $0.00 25-045-40-09 SUP HCPCS C1713 25-045-40-09 - PLATE BN NS LF LVL 1 CRNMXF ORBT FLR BOTH IP/OP "$3,512.30 " "$2,599.10" $0.00 "$2,809.84" "$1,580.54" "$1,580.54" $0.00 $0.00 $0.00 $732.05 "$2,606.83" "$2,606.83" $0.00 $0.00 $731.96 $0.00 "$1,731.56" "$1,731.56" $0.00 "$1,756.15" "$2,781.74" "$2,809.84" $0.00 $0.00 $549.67 $0.00 $0.00 $559.16 $0.00 $0.00 $0.00 $0.00 $0.00 25-092-38-91 SUP HCPCS C1713 25-092-38-91 - DRILL FREE MAXDRIVE MMF SCREW 2.0MM X 12MM 8MM THD LNGTH BOTH IP/OP $264.55 $195.77 $0.00 $211.64 $119.05 $119.05 $0.00 $0.00 $0.00 $55.14 $196.35 $196.35 $0.00 $0.00 $55.13 $0.00 $156.48 $156.48 $0.00 $132.28 $209.52 $211.64 $0.00 $0.00 $41.40 $0.00 $0.00 $42.12 $0.00 $0.00 $0.00 $0.00 $0.00 25-092-42-91 SUP HCPCS C1713 25-092-42-91 - DRILL FREE MAXDRIVE MMF SCREW 2.0MM X 16MM 12MM THD LNGTH BOTH IP/OP $264.55 $195.77 $0.00 $211.64 $119.05 $119.05 $0.00 $0.00 $0.00 $55.14 $196.35 $196.35 $0.00 $0.00 $55.13 $0.00 $156.48 $156.48 $0.00 $132.28 $209.52 $211.64 $0.00 $0.00 $41.40 $0.00 $0.00 $42.12 $0.00 $0.00 $0.00 $0.00 $0.00 251.25S SUP HCPCS C1713 251.25S - NAIL INTRAMEDULLARY 11D UNIVERSAL TAPER TUBULAR 11MM BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 251.28S SUP HCPCS C1713 251.28S - NAIL INTRAMEDULLARY 11D UNIVERSAL TAPER 11MM 285MMX1.2MM 1 BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 251.30S SUP HCPCS C1713 251.30S - NAIL INTRAMEDULLARY 11D UNIVERSAL TUBULAR BARREL 11MM BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 251.31S SUP HCPCS C1713 251.31S - NAIL 11MM 315MM TIB IM UNV SS STRL BOTH IP/OP "$2,533.98 " "$1,875.15" $0.00 "$2,027.18" "$1,140.29" "$1,140.29" $0.00 $0.00 $0.00 $528.14 "$1,880.72" "$1,880.72" $0.00 $0.00 $528.08 $0.00 "$1,249.25" "$1,249.25" $0.00 "$1,266.99" "$2,006.91" "$2,027.18" $0.00 $0.00 $396.57 $0.00 $0.00 $403.41 $0.00 $0.00 $0.00 $0.00 $0.00 251.33S SUP HCPCS C1713 251.33S - NAIL 11MM 330MM TIB IM UNV SS STRL BOTH IP/OP "$2,533.98 " "$1,875.15" $0.00 "$2,027.18" "$1,140.29" "$1,140.29" $0.00 $0.00 $0.00 $528.14 "$1,880.72" "$1,880.72" $0.00 $0.00 $528.08 $0.00 "$1,249.25" "$1,249.25" $0.00 "$1,266.99" "$2,006.91" "$2,027.18" $0.00 $0.00 $396.57 $0.00 $0.00 $403.41 $0.00 $0.00 $0.00 $0.00 $0.00 251.34S SUP HCPCS C1713 251.34S - NAIL 11MM 345MM TIB IM UNV SS STRL BOTH IP/OP "$2,533.98 " "$1,875.15" $0.00 "$2,027.18" "$1,140.29" "$1,140.29" $0.00 $0.00 $0.00 $528.14 "$1,880.72" "$1,880.72" $0.00 $0.00 $528.08 $0.00 "$1,249.25" "$1,249.25" $0.00 "$1,266.99" "$2,006.91" "$2,027.18" $0.00 $0.00 $396.57 $0.00 $0.00 $403.41 $0.00 $0.00 $0.00 $0.00 $0.00 251.36S SUP HCPCS C1713 251.36S - NAIL 11MM 360MM TIB IM UNV SS STRL BOTH IP/OP "$2,533.98 " "$1,875.15" $0.00 "$2,027.18" "$1,140.29" "$1,140.29" $0.00 $0.00 $0.00 $528.14 "$1,880.72" "$1,880.72" $0.00 $0.00 $528.08 $0.00 "$1,249.25" "$1,249.25" $0.00 "$1,266.99" "$2,006.91" "$2,027.18" $0.00 $0.00 $396.57 $0.00 $0.00 $403.41 $0.00 $0.00 $0.00 $0.00 $0.00 251.38S SUP HCPCS C1713 251.38S - NAIL INTRAMEDULLARY 11D UNIVERSAL TUBULAR BARREL 11MM BOTH IP/OP "$2,131.25 " "$1,577.13" $0.00 "$1,705.00" $959.06 $959.06 $0.00 $0.00 $0.00 $444.21 "$1,581.81" "$1,581.81" $0.00 $0.00 $444.15 $0.00 "$1,260.63" "$1,260.63" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 251.40S SUP HCPCS C1713 251.40S - NAIL INTRAMEDULLARY 11D UNIVERSAL TAPER 11MM 400MMX1.2MM 1 BOTH IP/OP "$2,135.38 " "$1,580.18" $0.00 "$1,708.30" $960.92 $960.92 $0.00 $0.00 $0.00 $445.07 "$1,584.88" "$1,584.88" $0.00 $0.00 $445.01 $0.00 "$1,263.07" "$1,263.07" $0.00 "$1,067.69" "$1,691.22" "$1,708.30" $0.00 $0.00 $334.19 $0.00 $0.00 $339.95 $0.00 $0.00 $0.00 $0.00 $0.00 251.42S SUP HCPCS C1713 251.42S - NAIL INTRAMEDULLARY 11D UNIVERSAL TAPER 11MM 420MMX1.2MM 1 BOTH IP/OP "$2,135.38 " "$1,580.18" $0.00 "$1,708.30" $960.92 $960.92 $0.00 $0.00 $0.00 $445.07 "$1,584.88" "$1,584.88" $0.00 $0.00 $445.01 $0.00 "$1,263.07" "$1,263.07" $0.00 "$1,067.69" "$1,691.22" "$1,708.30" $0.00 $0.00 $334.19 $0.00 $0.00 $339.95 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+10.00 SUP HCPCS V2632 25100C+10.00 - LENS IOL +10 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+10.50 SUP HCPCS V2632 25100C+10.50 - LENS IOL +10.5 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+11.00 SUP HCPCS V2632 25100C+11.00 - LENS IOL +11 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+11.50 SUP HCPCS V2632 25100C+11.50 - LENS IOL +11.5 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+12.00 SUP HCPCS V2632 25100C+12.00 - LENS IOL +12 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+12.50 SUP HCPCS V2632 25100C+12.50 - LENS IOL +12.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+13.00 SUP HCPCS V2632 25100C+13.00 - LENS IOL +13 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+13.50 SUP HCPCS V2632 25100C+13.50 - LENS IOL +13.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+14.00 SUP HCPCS V2632 25100C+14.00 - LENS IOL +14 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+14.50 SUP HCPCS V2632 25100C+14.50 - LENS IOL +14.5 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+15.00 SUP HCPCS V2632 25100C+15.00 - LENS IOL +15 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+15.50 SUP HCPCS V2632 25100C+15.50 - LENS IOL +15.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+16.00 SUP HCPCS V2632 25100C+16.00 - LENS IOL +16 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+16.50 SUP HCPCS V2632 25100C+16.50 - LENS IOL +16.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+17.00 SUP HCPCS V2632 25100C+17.00 - LENS IOL +17 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+17.50 SUP HCPCS V2632 25100C+17.50 - LENS IOL +17.5 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+18.00 SUP HCPCS V2632 25100C+18.00 - LENS IOL +18 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+18.50 SUP HCPCS V2632 25100C+18.50 - LENS IOL +18.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+19.00 SUP HCPCS V2632 25100C+19.00 - LENS IOL +19 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+19.50 SUP HCPCS V2632 25100C+19.50 - LENS IOL +19.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+20.00 SUP HCPCS V2632 25100C+20.00 - LENS IOL +20 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+20.50 SUP HCPCS V2632 25100C+20.50 - LENS IOL +20.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+21.00 SUP HCPCS V2632 25100C+21.00 - LENS IOL +21 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+21.50 SUP HCPCS V2632 25100C+21.50 - LENS IOL +21.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+22.00 SUP HCPCS V2632 25100C+22.00 - LENS IOL +22 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+22.50 SUP HCPCS V2632 25100C+22.50 - LENS IOL +22.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+23.00 SUP HCPCS V2632 25100C+23.00 - LENS IOL +23 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+23.50 SUP HCPCS V2632 25100C+23.50 - LENS IOL +23.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+24.00 SUP HCPCS V2632 25100C+24.00 - LENS IOL +24 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+24.50 SUP HCPCS V2632 25100C+24.50 - LENS IOL +24.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+25.00 SUP HCPCS V2632 25100C+25.00 - LENS IOL +25 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+25.50 SUP HCPCS V2632 25100C+25.50 - LENS IOL +25.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+26.00 SUP HCPCS V2632 25100C+26.00 - LENS IOL +26 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+26.50 SUP HCPCS V2632 25100C+26.50 - LENS IOL +26.5 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+27.00 SUP HCPCS V2632 25100C+27.00 - LENS IOL +27 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+27.50 SUP HCPCS V2632 25100C+27.50 - LENS IOL +27.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+28.00 SUP HCPCS V2632 25100C+28.00 - LENS IOL +28 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+28.50 SUP HCPCS V2632 25100C+28.50 - LENS IOL +28.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+29.00 SUP HCPCS V2632 25100C+29.00 - LENS IOL +29 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+29.50 SUP HCPCS V2632 25100C+29.50 - LENS IOL +29.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+30.00 SUP HCPCS V2632 25100C+30.00 - LENS IOL +30 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+6.00 SUP HCPCS V2632 25100C+6.00 - LENS IOL +6 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+6.50 SUP HCPCS V2632 25100C+6.50 - LENS IOL +6.5 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+7.00 SUP HCPCS V2632 25100C+7.00 - LENS IOL +7 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+7.50 SUP HCPCS V2632 25100C+7.50 - LENS IOL +7.5 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+8.50 SUP HCPCS V2632 25100C+8.50 - LENS IOL +8.5 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+9.00 SUP HCPCS V2632 25100C+9.00 - LENS IOL +9 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C+9.50 SUP HCPCS V2632 25100C+9.50 - LENS IOL +9.5 DIOP MOD C 6MM 12.5MM YLW ASPH BAL CRV ISERT BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25100C-8.00 SUP HCPCS V2632 25100C-8.00 - LENS IOL +8 DIOP MOD C 6MM 12.5MM YLW HOYA ISERT ASPH BAL BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 25121-1 SUP Custom 27203010 25121-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25121-2 SUP Custom 27803010 25121-2 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25121-5 SUP Custom 27203010 25121-5 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-197-07-71 SUP HCPCS C1713 25-197-07-71 - PLATE BN STRL LVL 1 HBRD CRNMXF BOTH IP/OP $828.00 $612.72 $0.00 $662.40 $372.60 $372.60 $0.00 $0.00 $0.00 $172.58 $614.54 $614.54 $0.00 $0.00 $172.56 $0.00 $489.76 $489.76 $0.00 $414.00 $655.78 $662.40 $0.00 $0.00 $129.58 $0.00 $0.00 $131.82 $0.00 $0.00 $0.00 $0.00 $0.00 25-198-06-71 SUP HCPCS C1713 25-198-06-71 - SCREW BN STRL LVL 1 MAXDRIVE CRNMXF BOTH IP/OP $358.00 $264.92 $0.00 $286.40 $161.10 $161.10 $0.00 $0.00 $0.00 $74.62 $265.71 $265.71 $0.00 $0.00 $74.61 $0.00 $211.76 $211.76 $0.00 $179.00 $283.54 $286.40 $0.00 $0.00 $56.03 $0.00 $0.00 $56.99 $0.00 $0.00 $0.00 $0.00 $0.00 25-198-06-75 SUP HCPCS C1713 25-198-06-75 - SCREW BN STRL LVL 1 MAXDRIVE CRNMXF BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 25221B SUP Custom 27203010 SARSTEDT TUBES BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25222B SUP Custom 27203010 CAP TUBE 2ML BOTH IP/OP $157.50 $116.55 $0.00 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.75 $124.74 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 252-952 SUP Custom 27203010 MASK INFANT BMV AMBU BOTH IP/OP $176.50 $130.61 $0.00 $141.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.25 $139.79 $141.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 253.27S SUP HCPCS C1713 253.27S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 270MM STAINLESS STEEL BOTH IP/OP "$2,135.38 " "$1,580.18" $0.00 "$1,708.30" $960.92 $960.92 $0.00 $0.00 $0.00 $445.07 "$1,584.88" "$1,584.88" $0.00 $0.00 $445.01 $0.00 "$1,263.07" "$1,263.07" $0.00 "$1,067.69" "$1,691.22" "$1,708.30" $0.00 $0.00 $334.19 $0.00 $0.00 $339.95 $0.00 $0.00 $0.00 $0.00 $0.00 25-302-70-91 SUP HCPCS C1713 25-302-70-91 - PLATE BONE MICRO STR MEDIUM .6MM 2 HOLE TITANIUM FRONTAL BOTH IP/OP $113.18 $83.75 $0.00 $90.54 $50.93 $50.93 $0.00 $0.00 $0.00 $23.59 $84.00 $84.00 $0.00 $0.00 $23.59 $0.00 $66.94 $66.94 $0.00 $56.59 $89.64 $90.54 $0.00 $0.00 $17.71 $0.00 $0.00 $18.02 $0.00 $0.00 $0.00 $0.00 $0.00 25-304-00-91 SUP HCPCS C1713 25-304-00-91 - PLATE BONE MICRO REGULAR STR .6MM 4 HOLE TITANIUM MAXFACL BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 25-304-55-91 SUP HCPCS C1713 25-304-55-91 - PLATE BONE MICRO MEDIUM STR .6MM 4 HOLE TITANIUM MAXFACL 1.5 BOTH IP/OP $176.13 $130.34 $0.00 $140.90 $79.26 $79.26 $0.00 $0.00 $0.00 $36.71 $130.72 $130.72 $0.00 $0.00 $36.70 $0.00 $104.18 $104.18 $0.00 $88.06 $139.49 $140.90 $0.00 $0.00 $27.56 $0.00 $0.00 $28.04 $0.00 $0.00 $0.00 $0.00 $0.00 25-306-00-91 SUP HCPCS C1713 25-306-00-91 - PLATE BN MIC STRG .6MM THREADLOCK TS 6 HL TI MXLFCL 1.5MM BOTH IP/OP $230.50 $170.57 $0.00 $184.40 $103.73 $103.73 $0.00 $0.00 $0.00 $48.04 $171.08 $171.08 $0.00 $0.00 $48.04 $0.00 $136.34 $136.34 $0.00 $115.25 $182.56 $184.40 $0.00 $0.00 $36.07 $0.00 $0.00 $36.70 $0.00 $0.00 $0.00 $0.00 $0.00 25-306-55-91 SUP HCPCS C1713 25-306-55-91 - PLATE BONE MICRO STR MEDIUM .6MM 6 HOLE TITANIUM MIDFAC 1.5 BOTH IP/OP $230.50 $170.57 $0.00 $184.40 $103.73 $103.73 $0.00 $0.00 $0.00 $48.04 $171.08 $171.08 $0.00 $0.00 $48.04 $0.00 $136.34 $136.34 $0.00 $115.25 $182.56 $184.40 $0.00 $0.00 $36.07 $0.00 $0.00 $36.70 $0.00 $0.00 $0.00 $0.00 $0.00 25-308-00-91 SUP HCPCS C1713 25-308-00-91 - PLATE BONE MICRO STR REGULAR .6MM 8 HOLE TITANIUM RIGHT BOTH IP/OP $253.80 $187.81 $0.00 $203.04 $114.21 $114.21 $0.00 $0.00 $0.00 $52.90 $188.37 $188.37 $0.00 $0.00 $52.89 $0.00 $150.12 $150.12 $0.00 $126.90 $201.01 $203.04 $0.00 $0.00 $39.72 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 25-308-16-09 SUP HCPCS C1713 25-308-16-09 - MIDFACE PLATE MEDIUM 6 HOLE DOUBLE Y 0.8MM THICK BOTH IP/OP $660.40 $488.70 $0.00 $528.32 $297.18 $297.18 $0.00 $0.00 $0.00 $137.64 $490.15 $490.15 $0.00 $0.00 $137.63 $0.00 $390.63 $390.63 $0.00 $330.20 $523.04 $528.32 $0.00 $0.00 $103.35 $0.00 $0.00 $105.14 $0.00 $0.00 $0.00 $0.00 $0.00 25-310-09-09 SUP HCPCS C1713 25-310-09-09 - PLATE LARGE L-SHAPE W/ TAB 10 HOLE 5X4 1MM BOTH IP/OP $608.65 $450.40 $0.00 $486.92 $273.89 $273.89 $0.00 $0.00 $0.00 $126.86 $451.74 $451.74 $0.00 $0.00 $126.84 $0.00 $360.02 $360.02 $0.00 $304.33 $482.05 $486.92 $0.00 $0.00 $95.25 $0.00 $0.00 $96.90 $0.00 $0.00 $0.00 $0.00 $0.00 25-310-70-91 SUP HCPCS C1713 25-310-70-91 - PLATE BONE L MICRO .6MM TITANIUM MIDFAC 1.5MM SCREW BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 25-311-70-91 SUP HCPCS C1713 25-311-70-91 - PLATE BONE L MICRO MEDIUM .6MM TITANIUM RIGHT MIDFAC STERILE BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 25-311-85-91 SUP HCPCS C1713 25-311-85-91 - PLATE BONE L MICRO LONG .6MM TITANIUM RIGHT MIDFAC STERILE BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 25-314-85-91 SUP HCPCS C1713 25-314-85-91 - PLATE BN 100D LNG MIC L .6MM THREADLOCK TS 3X2 HL TI MXLFCL BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 25-315-06-91 SUP HCPCS C1713 25-315-06-91 - PLATE BONE T MICRO REGULAR .6MM TITANIUM MIDFAC STERILE 1.5 BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 25-315-85-91 SUP HCPCS C1713 25-315-85-91 - PLATE BONE 100D L MICRO .6MM TITANIUM RIGHT MIDFAC STERILE BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 25-316-00-91 SUP HCPCS C1713 25-316-00-91 - PLATE BONE MICRO .6MM 16 HOLE TITANIUM MIDFAC STERILE 1.5MM BOTH IP/OP $414.88 $307.01 $0.00 $331.90 $186.69 $186.69 $0.00 $0.00 $0.00 $86.47 $307.92 $307.92 $0.00 $0.00 $86.46 $0.00 $245.40 $245.40 $0.00 $207.44 $328.58 $331.90 $0.00 $0.00 $64.93 $0.00 $0.00 $66.05 $0.00 $0.00 $0.00 $0.00 $0.00 25-320-70-91 SUP HCPCS C1713 25-320-70-91 - PLATE BONE Y MICRO LONG .6MM TITANIUM MIDFAC STERILE 1.5MM BOTH IP/OP $389.73 $288.40 $0.00 $311.78 $175.38 $175.38 $0.00 $0.00 $0.00 $81.23 $289.25 $289.25 $0.00 $0.00 $81.22 $0.00 $230.52 $230.52 $0.00 $194.86 $308.67 $311.78 $0.00 $0.00 $60.99 $0.00 $0.00 $62.04 $0.00 $0.00 $0.00 $0.00 $0.00 25-322-55-91 SUP HCPCS C1713 25-322-55-91 - PLATE BN MIC SHRT 2Y .6MM THREADLOCK TS 6 HL TI MXLFCL 1.5MM BOTH IP/OP $453.23 $335.39 $0.00 $362.58 $203.95 $203.95 $0.00 $0.00 $0.00 $94.46 $336.38 $336.38 $0.00 $0.00 $94.45 $0.00 $268.08 $268.08 $0.00 $226.61 $358.96 $362.58 $0.00 $0.00 $70.93 $0.00 $0.00 $72.15 $0.00 $0.00 $0.00 $0.00 $0.00 25-322-70-91 SUP HCPCS C1713 25-322-70-91 - PLATE BONE 2Y MICRO MEDIUM .6MM TITANIUM RIGHT FRONTAL MAXL BOTH IP/OP $440.03 $325.62 $0.00 $352.02 $198.01 $198.01 $0.00 $0.00 $0.00 $91.71 $326.59 $326.59 $0.00 $0.00 $91.70 $0.00 $260.27 $260.27 $0.00 $220.01 $348.50 $352.02 $0.00 $0.00 $68.86 $0.00 $0.00 $70.05 $0.00 $0.00 $0.00 $0.00 $0.00 25-325-10-91 SUP HCPCS C1713 25-325-10-91 - PLATE BN MIC CRV .6MM THREADLOCK TS 10 HL TI MXLFCL 1.5MM BOTH IP/OP $427.33 $316.22 $0.00 $341.86 $192.30 $192.30 $0.00 $0.00 $0.00 $89.07 $317.16 $317.16 $0.00 $0.00 $89.05 $0.00 $252.76 $252.76 $0.00 $213.66 $338.45 $341.86 $0.00 $0.00 $66.88 $0.00 $0.00 $68.03 $0.00 $0.00 $0.00 $0.00 $0.00 25-326-55-91 SUP HCPCS C1713 25-326-55-91 - PLATE BONE X MICRO REGULAR .6MM TITANIUM MIDFAC STERILE 1.5 BOTH IP/OP $427.33 $316.22 $0.00 $341.86 $192.30 $192.30 $0.00 $0.00 $0.00 $89.07 $317.16 $317.16 $0.00 $0.00 $89.05 $0.00 $252.76 $252.76 $0.00 $213.66 $338.45 $341.86 $0.00 $0.00 $66.88 $0.00 $0.00 $68.03 $0.00 $0.00 $0.00 $0.00 $0.00 25-329-05-09 SUP HCPCS C1713 25-329-05-09 - PLATE BONE Y MICRO .6MM 6 HOLE TITANIUM MIDFAC 1.5MM SCREW BOTH IP/OP $414.38 $306.64 $0.00 $331.50 $186.47 $186.47 $0.00 $0.00 $0.00 $86.37 $307.55 $307.55 $0.00 $0.00 $86.36 $0.00 $245.10 $245.10 $0.00 $207.19 $328.19 $331.50 $0.00 $0.00 $64.85 $0.00 $0.00 $65.97 $0.00 $0.00 $0.00 $0.00 $0.00 25-330-05-09 SUP HCPCS C1713 25-330-05-09 - PLATE BONE 100D L MICRO LEFT ANGLE .6MM 7 HOLE TITANIUM BOTH IP/OP $414.38 $306.64 $0.00 $331.50 $186.47 $186.47 $0.00 $0.00 $0.00 $86.37 $307.55 $307.55 $0.00 $0.00 $86.36 $0.00 $245.10 $245.10 $0.00 $207.19 $328.19 $331.50 $0.00 $0.00 $64.85 $0.00 $0.00 $65.97 $0.00 $0.00 $0.00 $0.00 $0.00 25-330-07-09 SUP HCPCS C1713 25-330-07-09 - PLATE BONE T MICRO .6MM 6 HOLE TITANIUM MIDFAC 1.5MM SCREW BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 25-330-24-09 SUP HCPCS C1713 25-330-24-09 - PLATE BN MIC STRG .6MM THREADLOCK TS 24 HL TI MXLFCL 1.5MM BOTH IP/OP $582.75 $431.24 $0.00 $466.20 $262.24 $262.24 $0.00 $0.00 $0.00 $121.46 $432.52 $432.52 $0.00 $0.00 $121.45 $0.00 $344.70 $344.70 $0.00 $291.38 $461.54 $466.20 $0.00 $0.00 $91.20 $0.00 $0.00 $92.77 $0.00 $0.00 $0.00 $0.00 $0.00 25-331-05-09 SUP HCPCS C1713 25-331-05-09 - PLATE BONE 100D L MICRO RIGHT ANG .6MM 7 HOLE TITANIUM BOTH IP/OP $414.38 $306.64 $0.00 $331.50 $186.47 $186.47 $0.00 $0.00 $0.00 $86.37 $307.55 $307.55 $0.00 $0.00 $86.36 $0.00 $245.10 $245.10 $0.00 $207.19 $328.19 $331.50 $0.00 $0.00 $64.85 $0.00 $0.00 $65.97 $0.00 $0.00 $0.00 $0.00 $0.00 25-331-85-91 SUP HCPCS C1713 25-331-85-91 - PLATE BONE L MICRO .6MM TITANIUM MIDFAC 1.5MM SCREW BOTH IP/OP $414.38 $306.64 $0.00 $331.50 $186.47 $186.47 $0.00 $0.00 $0.00 $86.37 $307.55 $307.55 $0.00 $0.00 $86.36 $0.00 $245.10 $245.10 $0.00 $207.19 $328.19 $331.50 $0.00 $0.00 $64.85 $0.00 $0.00 $65.97 $0.00 $0.00 $0.00 $0.00 $0.00 25-332-08-09 SUP HCPCS C1713 25-332-08-09 - PLATE BONE MICRO .6MM 8 HOLE INSERT TITANIUM ORBTL FLOOR BOTH IP/OP $401.43 $297.06 $0.00 $321.14 $180.64 $180.64 $0.00 $0.00 $0.00 $83.67 $297.94 $297.94 $0.00 $0.00 $83.66 $0.00 $237.44 $237.44 $0.00 $200.71 $317.93 $321.14 $0.00 $0.00 $62.82 $0.00 $0.00 $63.91 $0.00 $0.00 $0.00 $0.00 $0.00 25-377-04 SUP HCPCS C1713 25-377-04 - PLATE MED LEFT MAXFACL L BONE .6MM BOTH IP/OP $325.50 $240.87 $0.00 $260.40 $146.48 $146.48 $0.00 $0.00 $0.00 $67.84 $241.59 $241.59 $0.00 $0.00 $67.83 $0.00 $192.53 $192.53 $0.00 $162.75 $257.80 $260.40 $0.00 $0.00 $50.94 $0.00 $0.00 $51.82 $0.00 $0.00 $0.00 $0.00 $0.00 254.27S SUP HCPCS C1713 254.27S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 270MM STAINLESS STEEL BOTH IP/OP "$2,220.63 " "$1,643.27" $0.00 "$1,776.50" $999.28 $999.28 $0.00 $0.00 $0.00 $462.83 "$1,648.15" "$1,648.15" $0.00 $0.00 $462.78 $0.00 "$1,313.50" "$1,313.50" $0.00 "$1,110.31" "$1,758.74" "$1,776.50" $0.00 $0.00 $347.53 $0.00 $0.00 $353.52 $0.00 $0.00 $0.00 $0.00 $0.00 254.28S SUP HCPCS C1713 254.28S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 285MM STAINLESS STEEL BOTH IP/OP "$2,220.63 " "$1,643.27" $0.00 "$1,776.50" $999.28 $999.28 $0.00 $0.00 $0.00 $462.83 "$1,648.15" "$1,648.15" $0.00 $0.00 $462.78 $0.00 "$1,313.50" "$1,313.50" $0.00 "$1,110.31" "$1,758.74" "$1,776.50" $0.00 $0.00 $347.53 $0.00 $0.00 $353.52 $0.00 $0.00 $0.00 $0.00 $0.00 25-438-35-07 SUP HCPCS C1713 25-438-35-07 - SCREW BYRD MIDFACE LARGE BOTH IP/OP $640.00 $473.60 $0.00 $512.00 $288.00 $288.00 $0.00 $0.00 $0.00 $133.39 $475.01 $475.01 $0.00 $0.00 $133.38 $0.00 $378.56 $378.56 $0.00 $320.00 $506.88 $512.00 $0.00 $0.00 $100.16 $0.00 $0.00 $101.89 $0.00 $0.00 $0.00 $0.00 $0.00 25-449-07-91 SUP Custom 27203010 25-449-07-91 - DRILL TWIST 1.5MM 50MM 7MM STOP BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-449-16-91 SUP Custom 27100030 25-449-16-91 - DRILL TWIST 1.5MM 50MM 20MM NOTCH STOP STAINLESS STEEL BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-452-00-91 SUP Custom 27100030 25-452-00-91 - DRILL TWIST 1.1MM 50MM NOTCH STAINLESS STEEL BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-452-05-91 SUP Custom 27100030 25-452-05-91 - DRILL TWST 5MM 1.1MM 50MM J NTCH STP DISP BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-452-07-91 SUP Custom 27100030 25-452-07-91 - BIT DRILL 1.1MM 50MM 7MM J NOTCH STOP TWIST STAINLESS STEEL BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25452-525 SUP Custom 27203010 25452-525 - LEAD CONNCTNG WIRE SNP BOTH IP/OP $10.94 $8.10 $0.00 $8.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.12 $8.12 $0.00 $0.00 $2.28 $0.00 $0.00 $0.00 $0.00 $5.47 $8.66 $8.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-458-19-07 SUP Custom 27100030 25-458-19-07 - DRILL TWIST J 1.9MM 50MM NOTCH DISPOSABLE 2.3MM FRAC SYSTEM BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-460-19-07 SUP Custom 27100030 25-460-19-07 - DRILL TWIST 1.9MM 70MM STAINLESS STEEL BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25-469-11-07 SUP Custom 27100030 25-469-11-07 - BIT DRILL TWIST 1.5MM 115MM J NOTCH 2MM SCREW BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 255-000-001 SUP Custom 27203010 255-000-001 - GRSPR LAPSCOP ALGTR 250MM 2.3MM AL MINI STRL LATEX FREE BOTH IP/OP $534.86 $395.80 $0.00 $427.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.97 $396.97 $0.00 $0.00 $111.46 $0.00 $0.00 $0.00 $0.00 $267.43 $423.61 $427.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2552-06-L SUP HCPCS L3935 2552-06-L - TRIGGER FINGER SPLINTS LARGE BOTH IP/OP $0.42 $0.31 $0.00 $159.57 $0.19 $0.19 $0.00 $0.00 $152.21 $159.57 $0.31 $0.31 $0.00 $0.00 $0.09 $0.00 $0.25 $0.25 $0.00 $0.21 $0.33 $0.33 $0.25 $0.25 $151.93 $0.00 $0.00 $155.06 $0.00 $0.00 $0.00 $0.00 $0.00 2552-06-M SUP HCPCS L3935 2552-06-M - TRIGGER FINGER SPLINTS ME BOTH IP/OP $0.42 $0.31 $0.00 $159.57 $0.19 $0.19 $0.00 $0.00 $152.21 $159.57 $0.31 $0.31 $0.00 $0.00 $0.09 $0.00 $0.25 $0.25 $0.00 $0.21 $0.33 $0.33 $0.25 $0.25 $151.93 $0.00 $0.00 $155.06 $0.00 $0.00 $0.00 $0.00 $0.00 2552-06-S SUP HCPCS L3935 2552-06-S - TRIGGER FINGER SPLINTS SMALL BOTH IP/OP $0.42 $0.31 $0.00 $159.57 $0.19 $0.19 $0.00 $0.00 $152.21 $159.57 $0.31 $0.31 $0.00 $0.00 $0.09 $0.00 $0.25 $0.25 $0.00 $0.21 $0.33 $0.33 $0.25 $0.25 $151.93 $0.00 $0.00 $155.06 $0.00 $0.00 $0.00 $0.00 $0.00 25-550-04-91 SUP HCPCS C1713 25-550-04-91 - PLATE BONE MINI REGULAR 1MM 4 HOLE TITANIUM MANDIB 2MM SCREW BOTH IP/OP $178.73 $132.26 $0.00 $142.98 $80.43 $80.43 $0.00 $0.00 $0.00 $37.25 $132.65 $132.65 $0.00 $0.00 $37.25 $0.00 $105.72 $105.72 $0.00 $89.36 $141.55 $142.98 $0.00 $0.00 $27.97 $0.00 $0.00 $28.45 $0.00 $0.00 $0.00 $0.00 $0.00 25-550-08-91 SUP HCPCS C1713 25-550-08-91 - PLATE BONE MINI REGULAR 1MM 8 HOLE TITANIUM MANDIB 2MM SCREW BOTH IP/OP $220.13 $162.90 $0.00 $176.10 $99.06 $99.06 $0.00 $0.00 $0.00 $45.88 $163.38 $163.38 $0.00 $0.00 $45.87 $0.00 $130.20 $130.20 $0.00 $110.06 $174.34 $176.10 $0.00 $0.00 $34.45 $0.00 $0.00 $35.04 $0.00 $0.00 $0.00 $0.00 $0.00 25-551-04-91 SUP HCPCS C1713 25-551-04-91 - PLATE BONE MINI MEDIUM STANDARD 1MM 4 HOLE TITANIUM MAXFACL BOTH IP/OP $173.53 $128.41 $0.00 $138.82 $78.09 $78.09 $0.00 $0.00 $0.00 $36.17 $128.79 $128.79 $0.00 $0.00 $36.16 $0.00 $102.64 $102.64 $0.00 $86.76 $137.44 $138.82 $0.00 $0.00 $27.16 $0.00 $0.00 $27.63 $0.00 $0.00 $0.00 $0.00 $0.00 25-552-04-91 SUP HCPCS C1713 25-552-04-91 - PLATE BONE MINI LONG STANDARD 1MM 4 HOLE TITANIUM MANDIB 2MM BOTH IP/OP $176.13 $130.34 $0.00 $140.90 $79.26 $79.26 $0.00 $0.00 $0.00 $36.71 $130.72 $130.72 $0.00 $0.00 $36.70 $0.00 $104.18 $104.18 $0.00 $88.06 $139.49 $140.90 $0.00 $0.00 $27.56 $0.00 $0.00 $28.04 $0.00 $0.00 $0.00 $0.00 $0.00 25-552-06-91 SUP HCPCS C1713 25-552-06-91 - PLATE BONE MINI LONG STANDARD 1MM 6 HOLE TITANIUM MAXFACL 2 BOTH IP/OP $204.58 $151.39 $0.00 $163.66 $92.06 $92.06 $0.00 $0.00 $0.00 $42.64 $151.84 $151.84 $0.00 $0.00 $42.63 $0.00 $121.01 $121.01 $0.00 $102.29 $162.03 $163.66 $0.00 $0.00 $32.02 $0.00 $0.00 $32.57 $0.00 $0.00 $0.00 $0.00 $0.00 25-592-04-1 SUP HCPCS C1713 25-592-04-1 - LOCKING PLATE 4 HOLE BOTH IP/OP $158.10 $116.99 $0.00 $126.48 $71.15 $71.15 $0.00 $0.00 $0.00 $32.95 $117.34 $117.34 $0.00 $0.00 $32.95 $0.00 $93.52 $93.52 $0.00 $79.05 $125.22 $126.48 $0.00 $0.00 $24.74 $0.00 $0.00 $25.17 $0.00 $0.00 $0.00 $0.00 $0.00 25-672-15-1 SUP HCPCS C1713 25-672-15-1 - SCREW TI 15MM 2MM MAXFACL XDR BONE BOTH IP/OP $99.98 $73.99 $0.00 $79.98 $44.99 $44.99 $0.00 $0.00 $0.00 $20.84 $74.20 $74.20 $0.00 $0.00 $20.83 $0.00 $59.14 $59.14 $0.00 $49.99 $79.18 $79.98 $0.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 25-673-49-1 SUP HCPCS C1713 25-673-49-1 - SCREW TI 9MM 2.3MM MAXFACL XDR ER BONE BOTH IP/OP $592.88 $438.73 $0.00 $474.30 $266.79 $266.79 $0.00 $0.00 $0.00 $123.57 $440.03 $440.03 $0.00 $0.00 $123.56 $0.00 $350.69 $350.69 $0.00 $296.44 $469.56 $474.30 $0.00 $0.00 $92.78 $0.00 $0.00 $94.39 $0.00 $0.00 $0.00 $0.00 $0.00 25-677-12 SUP HCPCS C1713 25-677-12 - SCREW TI 12MM 2.7MM MAXFACL XDR ER BONE BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $107.10 $107.10 $0.00 $0.00 $0.00 $49.61 $176.64 $176.64 $0.00 $0.00 $49.60 $0.00 $140.78 $140.78 $0.00 $119.00 $188.50 $190.40 $0.00 $0.00 $37.25 $0.00 $0.00 $37.89 $0.00 $0.00 $0.00 $0.00 $0.00 25-677-12-91 SUP HCPCS C1713 25-677-12-91 - SCREW BONE 2.7MM 12MM EMERGENCY CROSS DRIVE TITANIUM MANDIB BOTH IP/OP $270.15 $199.91 $0.00 $216.12 $121.57 $121.57 $0.00 $0.00 $0.00 $56.31 $200.51 $200.51 $0.00 $0.00 $56.30 $0.00 $159.79 $159.79 $0.00 $135.08 $213.96 $216.12 $0.00 $0.00 $42.28 $0.00 $0.00 $43.01 $0.00 $0.00 $0.00 $0.00 $0.00 25-677-14 SUP HCPCS C1713 25-677-14 - SCREW TI 14MM 2.7MM MAXFACL XDR ER BONE BOTH IP/OP $238.00 $176.12 $0.00 $190.40 $107.10 $107.10 $0.00 $0.00 $0.00 $49.61 $176.64 $176.64 $0.00 $0.00 $49.60 $0.00 $140.78 $140.78 $0.00 $119.00 $188.50 $190.40 $0.00 $0.00 $37.25 $0.00 $0.00 $37.89 $0.00 $0.00 $0.00 $0.00 $0.00 25-677-14-91 SUP HCPCS C1713 25-677-14-91 - SCREW BONE 2.7MM 14MM NONLOCKING CROSS DRIVE THREADLOCK TS BOTH IP/OP $270.15 $199.91 $0.00 $216.12 $121.57 $121.57 $0.00 $0.00 $0.00 $56.31 $200.51 $200.51 $0.00 $0.00 $56.30 $0.00 $159.79 $159.79 $0.00 $135.08 $213.96 $216.12 $0.00 $0.00 $42.28 $0.00 $0.00 $43.01 $0.00 $0.00 $0.00 $0.00 $0.00 25-677-16-91 SUP HCPCS C1713 25-677-16-91 - SCREW BONE 2.7MM 16MM NONLOCKING CROSS DRIVE THREADLOCK TS BOTH IP/OP $270.15 $199.91 $0.00 $216.12 $121.57 $121.57 $0.00 $0.00 $0.00 $56.31 $200.51 $200.51 $0.00 $0.00 $56.30 $0.00 $159.79 $159.79 $0.00 $135.08 $213.96 $216.12 $0.00 $0.00 $42.28 $0.00 $0.00 $43.01 $0.00 $0.00 $0.00 $0.00 $0.00 25-677-52-91 SUP HCPCS C1713 25-677-52-91 - SCREW BONE 3.2MM 12MM EMERGENCY CROSS DRIVE TITANIUM MANDIB BOTH IP/OP $321.15 $237.65 $0.00 $256.92 $144.52 $144.52 $0.00 $0.00 $0.00 $66.94 $238.36 $238.36 $0.00 $0.00 $66.93 $0.00 $189.96 $189.96 $0.00 $160.58 $254.35 $256.92 $0.00 $0.00 $50.26 $0.00 $0.00 $51.13 $0.00 $0.00 $0.00 $0.00 $0.00 25-677-56-1 SUP HCPCS C1713 25-677-56-1 - SCREW TI 16MM 3.2MM MAXFACL XDR ER BONE BOTH IP/OP $230.50 $170.57 $0.00 $184.40 $103.73 $103.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.25 $182.56 $184.40 $0.00 $0.00 $36.07 $0.00 $0.00 $36.70 $0.00 $0.00 $0.00 $0.00 $0.00 25-750-04-09 SUP HCPCS C1713 25-750-04-09 - PLATE BONE 3D 1MM 4 HOLE THREADLOCK TITANIUM MANDIB BOTH IP/OP $668.38 $494.60 $0.00 $534.70 $300.77 $300.77 $0.00 $0.00 $0.00 $139.31 $496.07 $496.07 $0.00 $0.00 $139.29 $0.00 $395.34 $395.34 $0.00 $334.19 $529.36 $534.70 $0.00 $0.00 $104.60 $0.00 $0.00 $106.41 $0.00 $0.00 $0.00 $0.00 $0.00 25-750-14-09 SUP HCPCS C1713 25-750-14-09 - PLATE BONE 3D REGULAR 1MM 14 HOLE THREADLOCK TITANIUM MANDIB BOTH IP/OP "$1,308.90 " $968.59 $0.00 "$1,047.12" $589.01 $589.01 $0.00 $0.00 $0.00 $272.81 $971.47 $971.47 $0.00 $0.00 $272.77 $0.00 $774.21 $774.21 $0.00 $654.45 "$1,036.65" "$1,047.12" $0.00 $0.00 $204.84 $0.00 $0.00 $208.38 $0.00 $0.00 $0.00 $0.00 $0.00 25-752-04-09 SUP HCPCS C1713 25-752-04-09 - PLATE BN LNG MN 1MM THREADLOCK TS 4 HL LCK TI MNDB BOTH IP/OP $710.13 $525.50 $0.00 $568.10 $319.56 $319.56 $0.00 $0.00 $0.00 $148.01 $527.05 $527.05 $0.00 $0.00 $147.99 $0.00 $420.04 $420.04 $0.00 $355.06 $562.42 $568.10 $0.00 $0.00 $111.13 $0.00 $0.00 $113.05 $0.00 $0.00 $0.00 $0.00 $0.00 25-752-06-09 SUP HCPCS C1713 25-752-06-09 - PLATE BONE MINI LONG 1MM 6 HOLE THREADLOCK GREEN TITANIUM BOTH IP/OP $779.75 $577.02 $0.00 $623.80 $350.89 $350.89 $0.00 $0.00 $0.00 $162.52 $578.73 $578.73 $0.00 $0.00 $162.50 $0.00 $461.22 $461.22 $0.00 $389.88 $617.56 $623.80 $0.00 $0.00 $122.03 $0.00 $0.00 $124.14 $0.00 $0.00 $0.00 $0.00 $0.00 25-774-07-91 SUP HCPCS C1713 25-774-07-91 - SCREW BONE 2.7MM 7MM LOCKING CROSS DRIVE TITANIUM MANDIB BOTH IP/OP $328.63 $243.19 $0.00 $262.90 $147.88 $147.88 $0.00 $0.00 $0.00 $68.49 $243.91 $243.91 $0.00 $0.00 $68.49 $0.00 $194.38 $194.38 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 25-774-09-91 SUP HCPCS C1713 25-774-09-91 - SCREW BONE 2.7MM 9MM LOCKING CROSS DRIVE TITANIUM MANDIB BOTH IP/OP $328.63 $243.19 $0.00 $262.90 $147.88 $147.88 $0.00 $0.00 $0.00 $68.49 $243.91 $243.91 $0.00 $0.00 $68.49 $0.00 $194.38 $194.38 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 25-774-11-91 SUP HCPCS C1713 25-774-11-91 - SCREW BONE 2.7MM 11MM LOCKING CROSS DRIVE TITANIUM MANDIB BOTH IP/OP $328.63 $243.19 $0.00 $262.90 $147.88 $147.88 $0.00 $0.00 $0.00 $68.49 $243.91 $243.91 $0.00 $0.00 $68.49 $0.00 $194.38 $194.38 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 25-774-13-91 SUP HCPCS C1713 25-774-13-91 - SCREW BONE 2.7MM 13MM LOCKING CROSS DRIVE TITANIUM MANDIB BOTH IP/OP $328.63 $243.19 $0.00 $262.90 $147.88 $147.88 $0.00 $0.00 $0.00 $68.49 $243.91 $243.91 $0.00 $0.00 $68.49 $0.00 $194.38 $194.38 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 25-774-15-91 SUP HCPCS C1713 25-774-15-91 - SCREW BONE 2.7MM 15MM LOCKING CROSS DRIVE TITANIUM MANDIB BOTH IP/OP $328.63 $243.19 $0.00 $262.90 $147.88 $147.88 $0.00 $0.00 $0.00 $68.49 $243.91 $243.91 $0.00 $0.00 $68.49 $0.00 $194.38 $194.38 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 25-780-04-91 SUP HCPCS C1713 25-780-04-91 - NEURO SCREW ULTRA LOW PROFILE 1.5 X 4.0MM BOTH IP/OP $201.15 $148.85 $0.00 $160.92 $90.52 $90.52 $0.00 $0.00 $0.00 $41.92 $149.29 $149.29 $0.00 $0.00 $41.92 $0.00 $118.98 $118.98 $0.00 $100.58 $159.31 $160.92 $0.00 $0.00 $31.48 $0.00 $0.00 $32.02 $0.00 $0.00 $0.00 $0.00 $0.00 25-872-05-91 SUP HCPCS C1713 25-872-05-91 - SCREW BN 2MM 5MM NS THREADLOCK TS LVL 1 MAXDRIVE CNCV TI BOTH IP/OP $124.33 $92.00 $0.00 $99.46 $55.95 $55.95 $0.00 $0.00 $0.00 $25.91 $92.27 $92.27 $0.00 $0.00 $25.91 $0.00 $73.54 $73.54 $0.00 $62.16 $98.47 $99.46 $0.00 $0.00 $19.46 $0.00 $0.00 $19.79 $0.00 $0.00 $0.00 $0.00 $0.00 25-872-07-91 SUP HCPCS C1713 25-872-07-91 - SCREW BN 2MM 7MM NS THREADLOCK TS LVL 1 MAXDRIVE CNCV TI BOTH IP/OP $124.33 $92.00 $0.00 $99.46 $55.95 $55.95 $0.00 $0.00 $0.00 $25.91 $92.27 $92.27 $0.00 $0.00 $25.91 $0.00 $73.54 $73.54 $0.00 $62.16 $98.47 $99.46 $0.00 $0.00 $19.46 $0.00 $0.00 $19.79 $0.00 $0.00 $0.00 $0.00 $0.00 25-872-09-91 SUP HCPCS C1713 25-872-09-91 - SCREW BN 2MM 9MM NS THREADLOCK TS LVL 1 MAXDRIVE CNCV TI BOTH IP/OP $124.33 $92.00 $0.00 $99.46 $55.95 $55.95 $0.00 $0.00 $0.00 $25.91 $92.27 $92.27 $0.00 $0.00 $25.91 $0.00 $73.54 $73.54 $0.00 $62.16 $98.47 $99.46 $0.00 $0.00 $19.46 $0.00 $0.00 $19.79 $0.00 $0.00 $0.00 $0.00 $0.00 25-872-11-91 SUP HCPCS C1713 25-872-11-91 - SCREW BN 2MM 11MM NS THREADLOCK TS LVL 1 MAXDRIVE CNCV TI BOTH IP/OP $124.33 $92.00 $0.00 $99.46 $55.95 $55.95 $0.00 $0.00 $0.00 $25.91 $92.27 $92.27 $0.00 $0.00 $25.91 $0.00 $73.54 $73.54 $0.00 $62.16 $98.47 $99.46 $0.00 $0.00 $19.46 $0.00 $0.00 $19.79 $0.00 $0.00 $0.00 $0.00 $0.00 25-872-13-91 SUP HCPCS C1713 25-872-13-91 - SCREW BN 2MM 13MM NS THREADLOCK TS LVL 1 MAXDRIVE CNCV TI BOTH IP/OP $124.33 $92.00 $0.00 $99.46 $55.95 $55.95 $0.00 $0.00 $0.00 $25.91 $92.27 $92.27 $0.00 $0.00 $25.91 $0.00 $73.54 $73.54 $0.00 $62.16 $98.47 $99.46 $0.00 $0.00 $19.46 $0.00 $0.00 $19.79 $0.00 $0.00 $0.00 $0.00 $0.00 25-873-05-91 SUP HCPCS C1713 25-873-05-91 - SCREW BONE 2.3MM 5MM MAXDRIVE TITANIUM ORAL MAXFACL BOTH IP/OP $160.58 $118.83 $0.00 $128.46 $72.26 $72.26 $0.00 $0.00 $0.00 $33.47 $119.18 $119.18 $0.00 $0.00 $33.46 $0.00 $94.98 $94.98 $0.00 $80.29 $127.18 $128.46 $0.00 $0.00 $25.13 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 25-873-07-91 SUP HCPCS C1713 25-873-07-91 - SCREW BONE 2.3MM 7MM MAXDRIVE TITANIUM ORAL MAXFACL BOTH IP/OP $160.58 $118.83 $0.00 $128.46 $72.26 $72.26 $0.00 $0.00 $0.00 $33.47 $119.18 $119.18 $0.00 $0.00 $33.46 $0.00 $94.98 $94.98 $0.00 $80.29 $127.18 $128.46 $0.00 $0.00 $25.13 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 25-873-09-91 SUP HCPCS C1713 25-873-09-91 - SCREW BONE 2.3MM 9MM MAXDRIVE TITANIUM ORAL MAXFACL BOTH IP/OP $160.58 $118.83 $0.00 $128.46 $72.26 $72.26 $0.00 $0.00 $0.00 $33.47 $119.18 $119.18 $0.00 $0.00 $33.46 $0.00 $94.98 $94.98 $0.00 $80.29 $127.18 $128.46 $0.00 $0.00 $25.13 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 25-873-13-91 SUP HCPCS C1713 25-873-13-91 - SCREW BONE 2.3MM 13MM MAXDRIVE TITANIUM ORAL MAXFACL BOTH IP/OP $160.58 $118.83 $0.00 $128.46 $72.26 $72.26 $0.00 $0.00 $0.00 $33.47 $119.18 $119.18 $0.00 $0.00 $33.46 $0.00 $94.98 $94.98 $0.00 $80.29 $127.18 $128.46 $0.00 $0.00 $25.13 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 25-873-45-91 SUP HCPCS C1713 25-873-45-91 - SCREW BN 2.3MM 5MM NS THREADLOCK TS LVL 1 MAXDRIVE SLFRET ER BOTH IP/OP $160.58 $118.83 $0.00 $128.46 $72.26 $72.26 $0.00 $0.00 $0.00 $33.47 $119.18 $119.18 $0.00 $0.00 $33.46 $0.00 $94.98 $94.98 $0.00 $80.29 $127.18 $128.46 $0.00 $0.00 $25.13 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 25-873-47-91 SUP HCPCS C1713 25-873-47-91 - SCREW BN 2.3MM 7MM NS THREADLOCK TS LVL 1 MAXDRIVE SLFRET ER BOTH IP/OP $160.58 $118.83 $0.00 $128.46 $72.26 $72.26 $0.00 $0.00 $0.00 $33.47 $119.18 $119.18 $0.00 $0.00 $33.46 $0.00 $94.98 $94.98 $0.00 $80.29 $127.18 $128.46 $0.00 $0.00 $25.13 $0.00 $0.00 $25.56 $0.00 $0.00 $0.00 $0.00 $0.00 25-874-13-91 SUP HCPCS C1713 25-874-13-91 - SCREW BN 2.5MM 13MM NS THREADLOCK TS LVL 1 MAXDRIVE SLFRET BOTH IP/OP $163.18 $120.75 $0.00 $130.54 $73.43 $73.43 $0.00 $0.00 $0.00 $34.01 $121.11 $121.11 $0.00 $0.00 $34.01 $0.00 $96.52 $96.52 $0.00 $81.59 $129.24 $130.54 $0.00 $0.00 $25.54 $0.00 $0.00 $25.98 $0.00 $0.00 $0.00 $0.00 $0.00 25-875-09-91 SUP HCPCS C1713 25-875-09-91 - SCREW BONE MICRO 1.5MM 9MM MAXDRIVE TITANIUM ORAL MAXFACL BOTH IP/OP $124.33 $92.00 $0.00 $99.46 $55.95 $55.95 $0.00 $0.00 $0.00 $25.91 $92.27 $92.27 $0.00 $0.00 $25.91 $0.00 $73.54 $73.54 $0.00 $62.16 $98.47 $99.46 $0.00 $0.00 $19.46 $0.00 $0.00 $19.79 $0.00 $0.00 $0.00 $0.00 $0.00 25-876-05-91 SUP HCPCS C1713 25-876-05-91 - SCREW BN MIC 1.8MM 5MM NS LVL 1 MAXDRIVE DRLFR ER TI-6AL-4V BOTH IP/OP $142.43 $105.40 $0.00 $113.94 $64.09 $64.09 $0.00 $0.00 $0.00 $29.68 $105.71 $105.71 $0.00 $0.00 $29.68 $0.00 $84.24 $84.24 $0.00 $71.21 $112.80 $113.94 $0.00 $0.00 $22.29 $0.00 $0.00 $22.67 $0.00 $0.00 $0.00 $0.00 $0.00 25-876-07-91 SUP HCPCS C1713 25-876-07-91 - SCREW BONE MICRO 1.8MM 5MM EMERGENCY DRILL FREE MAXDRIVE BOTH IP/OP $142.43 $105.40 $0.00 $113.94 $64.09 $64.09 $0.00 $0.00 $0.00 $29.68 $105.71 $105.71 $0.00 $0.00 $29.68 $0.00 $84.24 $84.24 $0.00 $71.21 $112.80 $113.94 $0.00 $0.00 $22.29 $0.00 $0.00 $22.67 $0.00 $0.00 $0.00 $0.00 $0.00 25-878-04-91 SUP HCPCS C1713 25-878-04-91 - SCREW BN MIC 1.5MM 4MM NS LVL 1 MAXDRIVE DRLFR TI-6AL-4V BOTH IP/OP $142.43 $105.40 $0.00 $113.94 $64.09 $64.09 $0.00 $0.00 $0.00 $29.68 $105.71 $105.71 $0.00 $0.00 $29.68 $0.00 $84.24 $84.24 $0.00 $71.21 $112.80 $113.94 $0.00 $0.00 $22.29 $0.00 $0.00 $22.67 $0.00 $0.00 $0.00 $0.00 $0.00 25-878-05-91 SUP HCPCS C1713 25-878-05-91 - SCREW BN MIC 1.5MM 5MM NS LVL 1 MAXDRIVE DRLFR TI-6AL-4V BOTH IP/OP $142.43 $105.40 $0.00 $113.94 $64.09 $64.09 $0.00 $0.00 $0.00 $29.68 $105.71 $105.71 $0.00 $0.00 $29.68 $0.00 $84.24 $84.24 $0.00 $71.21 $112.80 $113.94 $0.00 $0.00 $22.29 $0.00 $0.00 $22.67 $0.00 $0.00 $0.00 $0.00 $0.00 25-878-07-91 SUP HCPCS C1713 25-878-07-91 - SCREW BONE MICRO 1.5MM 7MM DRILL FREE MAXDRIVE TITANIUM ORAL BOTH IP/OP $142.43 $105.40 $0.00 $113.94 $64.09 $64.09 $0.00 $0.00 $0.00 $29.68 $105.71 $105.71 $0.00 $0.00 $29.68 $0.00 $84.24 $84.24 $0.00 $71.21 $112.80 $113.94 $0.00 $0.00 $22.29 $0.00 $0.00 $22.67 $0.00 $0.00 $0.00 $0.00 $0.00 25-879-05-91 SUP HCPCS C1713 25-879-05-91 - SCREW BN MN 2MM 5MM NS LVL 1 MAXDRIVE DRLFR TI-6AL-4V CRNMXF BOTH IP/OP $134.68 $99.66 $0.00 $107.74 $60.60 $60.60 $0.00 $0.00 $0.00 $28.07 $99.96 $99.96 $0.00 $0.00 $28.07 $0.00 $79.66 $79.66 $0.00 $67.34 $106.67 $107.74 $0.00 $0.00 $21.08 $0.00 $0.00 $21.44 $0.00 $0.00 $0.00 $0.00 $0.00 25-879-07-91 SUP HCPCS C1713 25-879-07-91 - SCREW BN MN 2MM 7MM NS LVL 1 MAXDRIVE DRLFR TI-6AL-4V CRNMXF BOTH IP/OP $134.68 $99.66 $0.00 $107.74 $60.60 $60.60 $0.00 $0.00 $0.00 $28.07 $99.96 $99.96 $0.00 $0.00 $28.07 $0.00 $79.66 $79.66 $0.00 $67.34 $106.67 $107.74 $0.00 $0.00 $21.08 $0.00 $0.00 $21.44 $0.00 $0.00 $0.00 $0.00 $0.00 25-882-07-91 SUP HCPCS C1713 25-882-07-91 - SCREW BN 2MM 7MM GRN NS THREADLOCK TS LVL 1 MAXDRIVE SLFRET BOTH IP/OP $270.15 $199.91 $0.00 $216.12 $121.57 $121.57 $0.00 $0.00 $0.00 $56.31 $200.51 $200.51 $0.00 $0.00 $56.30 $0.00 $159.79 $159.79 $0.00 $135.08 $213.96 $216.12 $0.00 $0.00 $42.28 $0.00 $0.00 $43.01 $0.00 $0.00 $0.00 $0.00 $0.00 25-882-09-91 SUP HCPCS C1713 25-882-09-91 - SCREW BN 2MM 9MM GRN NS THREADLOCK TS LVL 1 MAXDRIVE SLFRET BOTH IP/OP $270.15 $199.91 $0.00 $216.12 $121.57 $121.57 $0.00 $0.00 $0.00 $56.31 $200.51 $200.51 $0.00 $0.00 $56.30 $0.00 $159.79 $159.79 $0.00 $135.08 $213.96 $216.12 $0.00 $0.00 $42.28 $0.00 $0.00 $43.01 $0.00 $0.00 $0.00 $0.00 $0.00 25-882-11-91 SUP HCPCS C1713 25-882-11-91 - SCREW BN 2MM 11MM NS LVL 1 MAXDRIVE LCK TI CRNMXF BOTH IP/OP $270.15 $199.91 $0.00 $216.12 $121.57 $121.57 $0.00 $0.00 $0.00 $56.31 $200.51 $200.51 $0.00 $0.00 $56.30 $0.00 $159.79 $159.79 $0.00 $135.08 $213.96 $216.12 $0.00 $0.00 $42.28 $0.00 $0.00 $43.01 $0.00 $0.00 $0.00 $0.00 $0.00 25-882-13-91 SUP HCPCS C1713 25-882-13-91 - SCREW BONE 2MM 13MM LOCKING MAXDRIVE TITANIUM ORAL MAXFACL BOTH IP/OP $270.15 $199.91 $0.00 $216.12 $121.57 $121.57 $0.00 $0.00 $0.00 $56.31 $200.51 $200.51 $0.00 $0.00 $56.30 $0.00 $159.79 $159.79 $0.00 $135.08 $213.96 $216.12 $0.00 $0.00 $42.28 $0.00 $0.00 $43.01 $0.00 $0.00 $0.00 $0.00 $0.00 25-882-15-91 SUP HCPCS C1713 25-882-15-91 - SCREW BN 2MM 15MM GRN NS THREADLOCK TS LVL 1 MAXDRIVE SLFRET BOTH IP/OP $270.15 $199.91 $0.00 $216.12 $121.57 $121.57 $0.00 $0.00 $0.00 $56.31 $200.51 $200.51 $0.00 $0.00 $56.30 $0.00 $159.79 $159.79 $0.00 $135.08 $213.96 $216.12 $0.00 $0.00 $42.28 $0.00 $0.00 $43.01 $0.00 $0.00 $0.00 $0.00 $0.00 25-883-11-91 SUP HCPCS C1713 25-883-11-91 - SCREW BN 2.3MM 11MM GRN NS THREADLOCK TS LVL 1 MAXDRIVE BOTH IP/OP $300.75 $222.56 $0.00 $240.60 $135.34 $135.34 $0.00 $0.00 $0.00 $62.68 $223.22 $223.22 $0.00 $0.00 $62.68 $0.00 $177.89 $177.89 $0.00 $150.38 $238.19 $240.60 $0.00 $0.00 $47.07 $0.00 $0.00 $47.88 $0.00 $0.00 $0.00 $0.00 $0.00 25AGFN-756 SUP Custom 27803010 25AGFN-756 - VALVE AORTIC 85D 25MM 23MM 1 DIGIT GRADIENT MECHANICAL BOTH IP/OP "$11,750.00 " "$8,695.00" $0.00 "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,448.70" $0.00 $0.00 $0.00 $0.00 "$5,875.00" "$9,306.00" "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25AJ-501 SUP Custom 27803010 25AJ-501 - VALVE AOR 25MM MSTR MECH STD CUF ROT BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 25MJ-501 SUP Custom 27803010 25MJ-501 - VALVE AORTIC 25MM MSTR HRT MECH BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 260-120 SUP Custom 27203010 260-120 - DILAT SURG AMPTZ PTFE COAX STY SF WIRE INTROD 8-10FR BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 260-250- SUP Custom 27203010 DILATOR SURG AMPTZ SET RNL STRL DISP BOTH IP/OP $566.60 $419.28 $0.00 $453.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.30 $448.75 $453.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26026-2 SUP Custom 27803010 26026-2 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,997.13 " "$2,957.88" $0.00 "$3,197.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,966.67" "$2,966.67" $0.00 $0.00 $833.00 $0.00 $0.00 $0.00 $0.00 "$1,998.56" "$3,165.73" "$3,197.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26026-5 SUP Custom 27803010 26026-5 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,134.88 " "$3,059.81" $0.00 "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,068.90" "$3,068.90" $0.00 $0.00 $861.71 $0.00 $0.00 $0.00 $0.00 "$2,067.44" "$3,274.82" "$3,307.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2627-2-905 SUP Custom 27803010 2627-2-905 - INSERT TIB STD 5MM KNEE CRUC RET HI BOTH IP/OP "$3,536.00 " "$2,616.64" $0.00 "$2,828.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.42" "$2,624.42" $0.00 $0.00 $736.90 $0.00 $0.00 $0.00 $0.00 "$1,768.00" "$2,800.51" "$2,828.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2627-2-915 SUP Custom 27803010 2627-2-915 - INSERT TIB STD 15MM KNEE CRUC RET HI BOTH IP/OP "$3,536.00 " "$2,616.64" $0.00 "$2,828.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,624.42" "$2,624.42" $0.00 $0.00 $736.90 $0.00 $0.00 $0.00 $0.00 "$1,768.00" "$2,800.51" "$2,828.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2627-6-901 SUP HCPCS C1713 2627-6-901 - PIN FIX VAK LCK ASMBLY ORTH SM BOTH IP/OP $342.88 $253.73 $0.00 $274.30 $154.29 $154.29 $0.00 $0.00 $0.00 $71.46 $254.48 $254.48 $0.00 $0.00 $71.46 $0.00 $202.81 $202.81 $0.00 $171.44 $271.56 $274.30 $0.00 $0.00 $53.66 $0.00 $0.00 $54.59 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-109 SUP Custom 27803010 2642-1-109 - INSERT TIBIAL SMALL 9MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-111 SUP Custom 27803010 2642-1-111 - INSERT TIBIAL MEDIUM 11MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-113 SUP Custom 27803010 2642-1-113 - INSERT TIBIAL SMALL 13MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-116 SUP Custom 27803010 2642-1-116 - INSERT TIBIAL SMALL 16MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-119 SUP Custom 27803010 2642-1-119 - INSERT TIBIAL SMALL 19MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-122 SUP Custom 27803010 2642-1-122 - INSERT TIBIAL SMALL 22MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-125 SUP Custom 27803010 2642-1-125 - INSERT TIBIAL PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-128 SUP Custom 27803010 2642-1-128 - INSERT TIBIAL SMALL 28MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-1-131 SUP Custom 27803010 2642-1-131 - INSERT TIBIAL SMALL 31MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-3-111 SUP Custom 27803010 2642-3-111 - INSERT TIBIAL MEDIUM 11MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-3-113 SUP Custom 27803010 2642-3-113 - INSERT TIBIAL MEDIUM 13MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-3-116 SUP Custom 27803010 2642-3-116 - INSERT TIBIAL MEDIUM 16MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-3-119 SUP Custom 27803010 2642-3-119 - INSERT TIBIAL MEDIUM 19MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-3-122 SUP Custom 27803010 2642-3-122 - INSERT TIBIAL MEDIUM 22MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-3-125 SUP Custom 27803010 2642-3-125 - INSERT TIBIAL MEDIUM 25MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-3-128 SUP Custom 27803010 2642-3-128 - INSERT TIBIAL MEDIUM 28MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-3-131 SUP Custom 27803010 2642-3-131 - INSERT TIBIAL MEDIUM 31MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-109 SUP Custom 27803010 2642-5-109 - INSERT TIBIAL LARGE 19MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-111 SUP Custom 27803010 2642-5-111 - INSERT TIBIAL LARGE 11MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-113 SUP Custom 27803010 2642-5-113 - INSERT TIBIAL LARGE 13MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-116 SUP Custom 27803010 2642-5-116 - INSERT TIBIAL LARGE 16MM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-119 SUP Custom 27803010 2642-5-119 - INSERT TIBIAL LARGE 19MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-122 SUP Custom 27803010 2642-5-122 - INSERT TIBIAL LARGE 22MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-125 SUP Custom 27803010 2642-5-125 - INSERT TIBIAL LARGE 25MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-128 SUP Custom 27803010 2642-5-128 - INSERT TIBIAL LARGE 28MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-5-131 SUP Custom 27803010 2642-5-131 - INSERT TIBIAL LARGE 31MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-109 SUP Custom 27803010 2642-6-109 - INSERT TIBIAL XL 9MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-111 SUP Custom 27803010 2642-6-111 - INSERT TIBIAL PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-113 SUP Custom 27803010 2642-6-113 - INSERT TIBIAL PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-116 SUP Custom 27803010 2642-6-116 - INSERT TIBIAL XL 16MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-119 SUP Custom 27803010 2642-6-119 - INSERT TIBIAL XL 19MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-122 SUP Custom 27803010 2642-6-122 - INSERT TIBIAL XL 22MM PRIM PCA KNEE BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-125 SUP Custom 27803010 2642-6-125 - INSERT TIBIAL XL 25MM PRIM PCA KNEE BOTH IP/OP "$2,065.00 " "$1,528.10" $0.00 "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,532.64" "$1,532.64" $0.00 $0.00 $430.35 $0.00 $0.00 $0.00 $0.00 "$1,032.50" "$1,635.48" "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-128 SUP Custom 27803010 2642-6-128 - INSERT TIBIAL XL 28MM PRIM PCA KNEE BOTH IP/OP "$2,065.00 " "$1,528.10" $0.00 "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,532.64" "$1,532.64" $0.00 $0.00 $430.35 $0.00 $0.00 $0.00 $0.00 "$1,032.50" "$1,635.48" "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2642-6-131 SUP Custom 27803010 2642-6-131 - INSERT TIBIAL XL 31MM PRIM PCA KNEE BOTH IP/OP "$2,065.00 " "$1,528.10" $0.00 "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,532.64" "$1,532.64" $0.00 $0.00 $430.35 $0.00 $0.00 $0.00 $0.00 "$1,032.50" "$1,635.48" "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26AC60 SUP Custom 27203010 26AC60 - PLATE 18MM TI BONE SPNL BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26AC75 SUP Custom 27203010 26AC75 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26AC90 SUP Custom 27203010 26AC90 - PLATE 18MM TI BONE SPNL BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26BA50DX SUP Custom 27203010 26BA50DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26BA60 SUP Custom 27203010 26BA60 - PLATE 18MM TI BONE SPNL BOTH IP/OP $384.63 $284.63 $0.00 $307.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.47 $285.47 $0.00 $0.00 $80.16 $0.00 $0.00 $0.00 $0.00 $192.31 $304.63 $307.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26BA70DX SUP Custom 27203010 26BA70DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26BA75 SUP Custom 27203010 26BA75 - PLATE 18MM TI BONE SPNL BOTH IP/OP $376.13 $278.34 $0.00 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.16 $279.16 $0.00 $0.00 $78.38 $0.00 $0.00 $0.00 $0.00 $188.06 $297.89 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26BA90 SUP Custom 27203010 26BA90 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $376.13 $278.34 $0.00 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.16 $279.16 $0.00 $0.00 $78.38 $0.00 $0.00 $0.00 $0.00 $188.06 $297.89 $300.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26CY75 SUP Custom 27203010 26CY75 - PLATE 18MM TI BONE SPNL BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26CY90 SUP Custom 27203010 26CY90 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26L2 SUP Custom 27203010 KIT MNLTX MONO LTX AGGL SERTST 50 TST BOTH IP/OP $355.10 $262.77 $0.00 $284.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.55 $281.24 $284.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26MH30 SUP Custom 27203010 26MH30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $346.38 $256.32 $0.00 $277.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.08 $257.08 $0.00 $0.00 $72.18 $0.00 $0.00 $0.00 $0.00 $173.19 $274.33 $277.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 26TA30 SUP Custom 27203010 26TA30 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $380.38 $281.48 $0.00 $304.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.31 $282.31 $0.00 $0.00 $79.27 $0.00 $0.00 $0.00 $0.00 $190.19 $301.26 $304.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27-0120 SUP HCPCS C1713 27-0120 - SCREW BN 2.7MM 12MM CNN XTRMT BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $200.25 $200.25 $0.00 $0.00 $0.00 $92.75 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $263.22 $263.22 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $69.64 $0.00 $0.00 $70.84 $0.00 $0.00 $0.00 $0.00 $0.00 27-0140 SUP HCPCS C1713 27-0140 - SCREW BN 2.7MM 14MM CNN XTRMT BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $200.25 $200.25 $0.00 $0.00 $0.00 $92.75 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $263.22 $263.22 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $69.64 $0.00 $0.00 $70.84 $0.00 $0.00 $0.00 $0.00 $0.00 27-0160 SUP HCPCS C1713 27-0160 - SCREW BN 2.7MM 16MM CNN XTRMT BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $200.25 $200.25 $0.00 $0.00 $0.00 $92.75 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $263.22 $263.22 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $69.64 $0.00 $0.00 $70.84 $0.00 $0.00 $0.00 $0.00 $0.00 27-0180 SUP HCPCS C1713 27-0180 - SCREW BN 2.7MM 18MM CNN XTRMT BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $200.25 $200.25 $0.00 $0.00 $0.00 $92.75 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $263.22 $263.22 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $69.64 $0.00 $0.00 $70.84 $0.00 $0.00 $0.00 $0.00 $0.00 27020 M SUP Custom 27803010 27020 M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,080.38 " "$2,279.48" $0.00 "$2,464.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,286.25" "$2,286.25" $0.00 $0.00 $641.95 $0.00 $0.00 $0.00 $0.00 "$1,540.19" "$2,439.66" "$2,464.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27-0200 SUP HCPCS C1713 27-0200 - SCREW BN 2.7MM 20MM CNN XTRMT BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $200.25 $200.25 $0.00 $0.00 $0.00 $92.75 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $263.22 $263.22 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $69.64 $0.00 $0.00 $70.84 $0.00 $0.00 $0.00 $0.00 $0.00 270-2149 SUP Custom 27203010 VIAL VAR 2 SMPL PRC CAP ANALY BOTH IP/OP $78.75 $58.28 $0.00 $63.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.38 $62.37 $63.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 270-2154 SUP Custom 27203010 REAGENT B THAL VAR 2 RCDR PK 500 TST ANALY BOTH IP/OP "$4,392.50 " "$3,250.45" $0.00 "$3,514.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,196.25" "$3,478.86" "$3,514.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27-0220 SUP HCPCS C1713 27-0220 - SCREW BN 2.7MM 22MM CNN XTRMT BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $200.25 $200.25 $0.00 $0.00 $0.00 $92.75 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $263.22 $263.22 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $69.64 $0.00 $0.00 $70.84 $0.00 $0.00 $0.00 $0.00 $0.00 27-0240 SUP HCPCS C1713 27-0240 - SCREW BN 2.7MM 24MM CNN XTRMT BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $200.25 $200.25 $0.00 $0.00 $0.00 $92.75 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $263.22 $263.22 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $69.64 $0.00 $0.00 $70.84 $0.00 $0.00 $0.00 $0.00 $0.00 2703-3-626 SUP Custom 27203010 2703-3-626 - WIRE FX .015IN 72IN VIT BOTH IP/OP $284.38 $210.44 $0.00 $227.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.06 $211.06 $0.00 $0.00 $59.26 $0.00 $0.00 $0.00 $0.00 $142.19 $225.23 $227.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2704-1-024 SUP Custom 27203010 2704-1-024 - WIRE FX .04IN 24MM VIT BOTH IP/OP $11.38 $8.42 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.44 $8.44 $0.00 $0.00 $2.37 $0.00 $0.00 $0.00 $0.00 $5.69 $9.01 $9.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2704-3-018 SUP Custom 27203010 2704-3-018 - WIRE FX .046IN 18IN DLMLS VIT 6 PER TUBE BOTH IP/OP $58.50 $43.29 $0.00 $46.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.42 $43.42 $0.00 $0.00 $12.19 $0.00 $0.00 $0.00 $0.00 $29.25 $46.33 $46.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27050K/6 SUP Custom 27203010 27050K/6 - ELTRD ESURG 27FR 1 PR PNT BOTH IP/OP $285.80 $211.49 $0.00 $228.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.90 $226.35 $228.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27050KG/6 SUP Custom 27203010 27050KG/6 - ELTRD ESURG YLW 24-26FR URO RLLR CUT STRL DISP BOTH IP/OP $392.93 $290.77 $0.00 $314.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.46 $311.20 $314.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 A SUP Custom 27803010 27065 A - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 B SUP Custom 27803010 27065 B - PLATE 18MM TI BONE SPNL BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 C SUP Custom 27803010 27065 C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 D SUP Custom 27803010 27065 D - PLATE 18MM TI BONE SPNL BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 E SUP Custom 27803010 27065 E - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 F SUP Custom 27803010 27065 F - PLATE 18MM TI BONE SPNL BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 G SUP Custom 27803010 27065 G - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 H SUP Custom 27803010 27065 H - PLATE 18MM TI BONE SPNL BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 J SUP Custom 27803010 27065 J - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $826.50 $611.61 $0.00 $661.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $613.43 $613.43 $0.00 $0.00 $172.24 $0.00 $0.00 $0.00 $0.00 $413.25 $654.59 $661.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 K SUP Custom 27803010 27065 K - PLATE 18MM TI BONE SPNL BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 L SUP Custom 27803010 27065 L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $665.00 $492.10 $0.00 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.56 $493.56 $0.00 $0.00 $138.59 $0.00 $0.00 $0.00 $0.00 $332.50 $526.68 $532.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 M SUP Custom 27803010 27065 M - PLATE 18MM TI BONE SPNL BOTH IP/OP $826.50 $611.61 $0.00 $661.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $613.43 $613.43 $0.00 $0.00 $172.24 $0.00 $0.00 $0.00 $0.00 $413.25 $654.59 $661.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 N SUP Custom 27803010 27065 N - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $603.25 $446.41 $0.00 $482.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $447.73 $447.73 $0.00 $0.00 $125.72 $0.00 $0.00 $0.00 $0.00 $301.63 $477.77 $482.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 R SUP Custom 27803010 27065 R - PLATE 18MM TI BONE SPNL BOTH IP/OP $826.50 $611.61 $0.00 $661.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $613.43 $613.43 $0.00 $0.00 $172.24 $0.00 $0.00 $0.00 $0.00 $413.25 $654.59 $661.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27065 T SUP Custom 27803010 27065 T - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $826.50 $611.61 $0.00 $661.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $613.43 $613.43 $0.00 $0.00 $172.24 $0.00 $0.00 $0.00 $0.00 $413.25 $654.59 $661.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27097-1 SUP Custom 27803010 27097-1 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,009.13 " "$2,226.76" $0.00 "$2,407.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,233.37" "$2,233.37" $0.00 $0.00 $627.10 $0.00 $0.00 $0.00 $0.00 "$1,504.56" "$2,383.23" "$2,407.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27167 L SUP Custom 27803010 27167 L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27167 M SUP Custom 27803010 27167 M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27183-1 SUP Custom 27803010 27183-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$5,080.13 " "$3,759.30" $0.00 "$4,064.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.47" "$3,770.47" $0.00 $0.00 "$1,058.70" $0.00 $0.00 $0.00 $0.00 "$2,540.06" "$4,023.46" "$4,064.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27183-2 SUP Custom 27803010 27183-2 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$5,080.13 " "$3,759.30" $0.00 "$4,064.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.47" "$3,770.47" $0.00 $0.00 "$1,058.70" $0.00 $0.00 $0.00 $0.00 "$2,540.06" "$4,023.46" "$4,064.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27183-4 SUP Custom 27803010 27183-4 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$5,080.13 " "$3,759.30" $0.00 "$4,064.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.47" "$3,770.47" $0.00 $0.00 "$1,058.70" $0.00 $0.00 $0.00 $0.00 "$2,540.06" "$4,023.46" "$4,064.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27183-5 SUP Custom 27803010 27183-5 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$5,080.13 " "$3,759.30" $0.00 "$4,064.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.47" "$3,770.47" $0.00 $0.00 "$1,058.70" $0.00 $0.00 $0.00 $0.00 "$2,540.06" "$4,023.46" "$4,064.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202-01 SUP HCPCS C1765 27202-01 - BRR ADH PLLC ACD BIORESBL SHT SURGIWRAP 130X100X.02MM BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $415.63 $415.63 $0.00 $0.00 $116.70 $0.00 $0.00 $0.00 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27202-05 SUP HCPCS C1765 27202-05 - BARRIER ADHESION 130X100X.02MM BIORESORBABLE SHEET SURGIWRAP BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27203-5 SUP Custom 27203010 27203-5 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$5,472.00 " "$4,049.28" $0.00 "$4,377.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,061.32" "$4,061.32" $0.00 $0.00 "$1,140.36" $0.00 $0.00 $0.00 $0.00 "$2,736.00" "$4,333.82" "$4,377.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27204-05 SUP HCPCS C1765 27204-05 - BARRIER ADHESION 130X100X.02MM BIORESORBABLE SHEET SURGIWRAP BOTH IP/OP $642.50 $475.45 $0.00 $514.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $476.86 $476.86 $0.00 $0.00 $133.90 $0.00 $0.00 $0.00 $0.00 $321.25 $508.86 $514.00 $0.00 $0.00 $100.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219-1 SUP Custom 27803010 27219-1 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219-2 SUP Custom 27803010 27219-2 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27219-5 SUP Custom 27803010 27219-5 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,684.63" "$2,684.63" $0.00 $0.00 $753.81 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27224-1 SUP Custom 27203010 27224-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27224-2 SUP Custom 27203010 27224-2 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27224-4 SUP Custom 27203010 27224-4 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27224-5 SUP Custom 27203010 27224-5 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27241 L SUP Custom 27803010 27241 L - SHUNT NS 10MM 50MM PRTNL CATH NEO BOTH IP/OP "$1,211.25 " $896.33 $0.00 $969.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.99 $898.99 $0.00 $0.00 $252.42 $0.00 $0.00 $0.00 $0.00 $605.63 $959.31 $969.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27242 L SUP Custom 27803010 27242 L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,562.63 " "$1,896.35" $0.00 "$2,050.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,901.98" "$1,901.98" $0.00 $0.00 $534.05 $0.00 $0.00 $0.00 $0.00 "$1,281.31" "$2,029.60" "$2,050.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27242 LL SUP Custom 27803010 27242 LL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,562.63 " "$1,896.35" $0.00 "$2,050.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,901.98" "$1,901.98" $0.00 $0.00 $534.05 $0.00 $0.00 $0.00 $0.00 "$1,281.31" "$2,029.60" "$2,050.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 274.00S SUP HCPCS C1713 274.00S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 340MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.01S SUP HCPCS C1713 274.01S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 36CM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.02S SUP HCPCS C1713 274.02S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 380MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.03S SUP HCPCS C1713 274.03S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 400MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.04S SUP HCPCS C1713 274.04S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 420MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.05S SUP HCPCS C1713 274.05S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 440MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.06S SUP HCPCS C1713 274.06S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 460MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.07S SUP HCPCS C1713 274.07S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 480MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.08S SUP HCPCS C1713 274.08S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 300MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.09S SUP HCPCS C1713 274.09S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 320MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.10S SUP HCPCS C1713 274.10S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 340MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.11S SUP HCPCS C1713 274.11S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 360MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.12S SUP HCPCS C1713 274.12S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 380MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.13S SUP HCPCS C1713 274.13S - NAIL INTRAMEDULLARY 400MM 11MM 40CM STAINLEES STEEL FEMUR BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.14S SUP HCPCS C1713 274.14S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 420MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.15S SUP HCPCS C1713 274.15S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 440MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.16S SUP HCPCS C1713 274.16S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 460MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.17S SUP HCPCS C1713 274.17S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 480MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.18S SUP HCPCS C1713 274.18S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 300MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.19S SUP HCPCS C1713 274.19S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 320MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.20S SUP HCPCS C1713 274.20S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 12MM 34CMX.12CM BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.21S SUP HCPCS C1713 274.21S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 360MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.22S SUP HCPCS C1713 274.22S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 380MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.23S SUP HCPCS C1713 274.23S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 4000CM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.24S SUP HCPCS C1713 274.24S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 420MM STAINLESS STEEL BOTH IP/OP "$2,101.73 " "$1,555.28" $0.00 "$1,681.38" $945.78 $945.78 $0.00 $0.00 $0.00 $438.05 "$1,559.90" "$1,559.90" $0.00 $0.00 $438.00 $0.00 "$1,243.17" "$1,243.17" $0.00 "$1,050.86" "$1,664.57" "$1,681.38" $0.00 $0.00 $331.39 $0.00 $0.00 $334.59 $0.00 $0.00 $0.00 $0.00 $0.00 274.25S SUP HCPCS C1713 274.25S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 12MM 44CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.26S SUP HCPCS C1713 274.26S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 12MM 46CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.27S SUP HCPCS C1713 274.27S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 480MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.28S SUP HCPCS C1713 274.28S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 300MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.29S SUP HCPCS C1713 274.29S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 320MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.30S SUP HCPCS C1713 274.30S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 13MM 34CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.31S SUP HCPCS C1713 274.31S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 360MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.32S SUP HCPCS C1713 274.32S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 13MM 38CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.33S SUP HCPCS C1713 274.33S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 13MM 40CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.34S SUP HCPCS C1713 274.34S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 13MM 42CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.35S SUP HCPCS C1713 274.35S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 13MM 44CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.36S SUP HCPCS C1713 274.36S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 13MM 46CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.37S SUP HCPCS C1713 274.37S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 480CM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.38S SUP HCPCS C1713 274.38S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 300MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.39S SUP HCPCS C1713 274.39S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 320MM FEMUR STERILE BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.40S SUP HCPCS C1713 274.40S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 14MM 34CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.41S SUP HCPCS C1713 274.41S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 14MM 36CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.42S SUP HCPCS C1713 274.42S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 14MM 38CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.43S SUP HCPCS C1713 274.43S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 14MM 40CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.44S SUP HCPCS C1713 274.44S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 14MM 42CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.45S SUP HCPCS C1713 274.45S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 14MM 44CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.46S SUP HCPCS C1713 274.46S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 14MM 46CMX.12CM BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.47S SUP HCPCS C1713 274.47S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 480MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.48S SUP HCPCS C1713 274.48S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 300MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.49S SUP HCPCS C1713 274.49S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 320MM STAINLESS STEEL BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $441.34 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 "$1,252.50" "$1,252.50" $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 274.50S SUP HCPCS C1713 274.50S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 15MM 34CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.51S SUP HCPCS C1713 274.51S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 15MM 36CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.52S SUP HCPCS C1713 274.52S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 380MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.53S SUP HCPCS C1713 274.53S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 15MM 40CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.54S SUP HCPCS C1713 274.54S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 15MM 42CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.55S SUP HCPCS C1713 274.55S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 15MM 44CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.56S SUP HCPCS C1713 274.56S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 15MM 46CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.57S SUP HCPCS C1713 274.57S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 480MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.58S SUP HCPCS C1713 274.58S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 300MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.59S SUP HCPCS C1713 274.59S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 320MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.60S SUP HCPCS C1713 274.60S - NAIL INTRAMEDULLARY UNIVERSAL CONE THREAD TUBE BARREL 16MM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.61S SUP HCPCS C1713 274.61S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 16MM 36CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.62S SUP HCPCS C1713 274.62S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 16MM 38CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.63S SUP HCPCS C1713 274.63S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 16MM 40CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.64S SUP HCPCS C1713 274.64S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 16MM 42CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.65S SUP HCPCS C1713 274.65S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 16MM 44CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.66S SUP HCPCS C1713 274.66S - NAIL INTRAMEDULLARY UNIVERSAL TUBULAR BARREL 16MM 46CMX.12CM BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.67S SUP HCPCS C1713 274.67S - NAIL INTRAMEDULLARY UNIVERSAL 16MM 480MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.68S SUP HCPCS C1713 274.68S - NAIL INTRAMEDULLARY UNIVERSAL 16MM 300MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.69S SUP HCPCS C1713 274.69S - NAIL INTRAMEDULLARY UNIVERSAL 16MM 320MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.70S SUP HCPCS C1713 274.70S - NAIL INTRAMEDULLARY UNIVERSAL 17MM 34CM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.71S SUP HCPCS C1713 274.71S - NAIL INTRAMEDULLARY UNIVERSAL 17MM 360MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.72S SUP HCPCS C1713 274.72S - NAIL INTRAMEDULLARY UNIVERSAL 17MM 380MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.73S SUP HCPCS C1713 274.73S - NAIL INTRAMEDULLARY UNIVERSAL 17MM 400MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.74S SUP HCPCS C1713 274.74S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 420MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.75S SUP HCPCS C1713 274.75S - NAIL INTRAMEDULLARY UNIVERSAL 17MM 440MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.76S SUP HCPCS C1713 274.76S - NAIL INTRAMEDULLARY UNIVERSAL 17MM 460MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.77S SUP HCPCS C1713 274.77S - NAIL INTRAMEDULLARY UNIVERSAL 17MM 480MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.78S SUP HCPCS C1713 274.78S - NAIL INTRAMEDULLARY 300MM 17MM 30CM STAINLEES STEEL FEMUR BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.79S SUP HCPCS C1713 274.79S - NAIL INTRAMEDULLARY UNIVERSAL 17MM 320MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.80S SUP HCPCS C1713 274.80S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 340MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.81S SUP HCPCS C1713 274.81S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 360MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.82S SUP HCPCS C1713 274.82S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 380MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.83S SUP HCPCS C1713 274.83S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 400MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.84S SUP HCPCS C1713 274.84S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 420MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.85S SUP HCPCS C1713 274.85S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 18MM 440MM STAINLESS BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.86S SUP HCPCS C1713 274.86S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 460MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.87S SUP HCPCS C1713 274.87S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 480MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.88S SUP HCPCS C1713 274.88S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 300MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.89S SUP HCPCS C1713 274.89S - NAIL INTRAMEDULLARY UNIVERSAL 18MM 320MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.92S SUP HCPCS C1713 274.92S - NAIL INTRAMEDULLARY UNIVERSAL 19MM 380MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.93S SUP HCPCS C1713 274.93S - NAIL INTRAMEDULLARY UNIVERSAL 19MM 400MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.94S SUP HCPCS C1713 274.94S - NAIL INTRAMEDULLARY UNIVERSAL 19MM 420MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.95S SUP HCPCS C1713 274.95S - NAIL INTRAMEDULLARY UNIVERSAL 19MM 440MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.96S SUP HCPCS C1713 274.96S - NAIL INTRAMEDULLARY UNIVERSAL 19MM 460MM STAINLESS STEEL BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 274.97S SUP HCPCS C1713 274.97S - NAIL INTRAMEDULLARY UNIVERSAL 19MM 480MM DCP LC-DCP BOTH IP/OP "$2,277.00 " "$1,684.98" $0.00 "$1,821.60" "$1,024.65" "$1,024.65" $0.00 $0.00 $0.00 $474.58 "$1,689.99" "$1,689.99" $0.00 $0.00 $474.53 $0.00 "$1,346.85" "$1,346.85" $0.00 "$1,138.50" "$1,803.38" "$1,821.60" $0.00 $0.00 $356.35 $0.00 $0.00 $362.50 $0.00 $0.00 $0.00 $0.00 $0.00 27448 B SUP Custom 27803010 27448 B - PLATE 18MM TI BONE SPNL BOTH IP/OP $418.00 $309.32 $0.00 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.24 $310.24 $0.00 $0.00 $87.11 $0.00 $0.00 $0.00 $0.00 $209.00 $331.06 $334.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27451-5 SUP Custom 27803010 27451-5 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,662.13 " "$3,449.98" $0.00 "$3,729.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,460.23" "$3,460.23" $0.00 $0.00 $971.59 $0.00 $0.00 $0.00 $0.00 "$2,331.06" "$3,692.41" "$3,729.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27490 L SUP Custom 27803010 27490 L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,614.88 " "$1,935.01" $0.00 "$2,091.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,940.76" "$1,940.76" $0.00 $0.00 $544.94 $0.00 $0.00 $0.00 $0.00 "$1,307.44" "$2,070.98" "$2,091.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27496 L SUP Custom 27803010 27496 L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27496 M SUP Custom 27803010 27496 M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27499-1 SUP Custom 27803010 27499-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27499-5 SUP Custom 27803010 27499-5 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,754.75 " "$3,518.52" $0.00 "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,528.98" "$3,528.98" $0.00 $0.00 $990.89 $0.00 $0.00 $0.00 $0.00 "$2,377.38" "$3,765.76" "$3,803.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27505-1 SUP Custom 27803010 27505-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,944.88 " "$2,919.21" $0.00 "$3,155.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,927.89" "$2,927.89" $0.00 $0.00 $822.11 $0.00 $0.00 $0.00 $0.00 "$1,972.44" "$3,124.34" "$3,155.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27553 H SUP Custom 27803010 27553 H - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,415.25 " "$2,527.29" $0.00 "$2,732.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,534.80" "$2,534.80" $0.00 $0.00 $711.74 $0.00 $0.00 $0.00 $0.00 "$1,707.63" "$2,704.88" "$2,732.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27553 L SUP Custom 27803010 27553 L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,415.25 " "$2,527.29" $0.00 "$2,732.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,534.80" "$2,534.80" $0.00 $0.00 $711.74 $0.00 $0.00 $0.00 $0.00 "$1,707.63" "$2,704.88" "$2,732.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27553 M SUP Custom 27803010 27553 M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,415.25 " "$2,527.29" $0.00 "$2,732.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,534.80" "$2,534.80" $0.00 $0.00 $711.74 $0.00 $0.00 $0.00 $0.00 "$1,707.63" "$2,704.88" "$2,732.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27554-1 SUP Custom 27803010 27554-1 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$5,170.38 " "$3,826.08" $0.00 "$4,136.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,837.45" "$3,837.45" $0.00 $0.00 "$1,077.51" $0.00 $0.00 $0.00 $0.00 "$2,585.19" "$4,094.94" "$4,136.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27554-2 SUP Custom 27803010 27554-2 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$5,170.38 " "$3,826.08" $0.00 "$4,136.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,837.45" "$3,837.45" $0.00 $0.00 "$1,077.51" $0.00 $0.00 $0.00 $0.00 "$2,585.19" "$4,094.94" "$4,136.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27554-5 SUP Custom 27803010 27554-5 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$5,170.38 " "$3,826.08" $0.00 "$4,136.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,837.45" "$3,837.45" $0.00 $0.00 "$1,077.51" $0.00 $0.00 $0.00 $0.00 "$2,585.19" "$4,094.94" "$4,136.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 275-637-000 SUP Custom 27203010 275-637-000 - BLADE SHVR 3.5MM FULL RAD ARTHRO STRL BOTH IP/OP $136.70 $101.16 $0.00 $109.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.46 $101.46 $0.00 $0.00 $28.49 $0.00 $0.00 $0.00 $0.00 $68.35 $108.27 $109.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 275-641-000 SUP Custom 27203010 275-641-000 - BURR SURG 2MM TMJ RND ARTHRO STRL BOTH IP/OP $144.78 $107.14 $0.00 $115.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.45 $107.45 $0.00 $0.00 $30.17 $0.00 $0.00 $0.00 $0.00 $72.39 $114.67 $115.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27573A SUP Custom 27803010 27573A - PLATE 18MM TI BONE SPNL BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $0.00 $0.00 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27589A SUP Custom 27803010 27589A - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $938.13 $694.22 $0.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.28 $696.28 $0.00 $0.00 $195.51 $0.00 $0.00 $0.00 $0.00 $469.06 $743.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27589B SUP Custom 27803010 27589B - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27589C SUP Custom 27803010 27589C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27589D SUP Custom 27803010 27589D - PLATE 18MM TI BONE SPNL BOTH IP/OP $938.13 $694.22 $0.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.28 $696.28 $0.00 $0.00 $195.51 $0.00 $0.00 $0.00 $0.00 $469.06 $743.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27589E SUP Custom 27803010 27589E - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $938.13 $694.22 $0.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.28 $696.28 $0.00 $0.00 $195.51 $0.00 $0.00 $0.00 $0.00 $469.06 $743.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27589F SUP Custom 27803010 27589F - PLATE 18MM TI BONE SPNL BOTH IP/OP $938.13 $694.22 $0.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.28 $696.28 $0.00 $0.00 $195.51 $0.00 $0.00 $0.00 $0.00 $469.06 $743.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27589H SUP Custom 27803010 27589H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $938.13 $694.22 $0.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.28 $696.28 $0.00 $0.00 $195.51 $0.00 $0.00 $0.00 $0.00 $469.06 $743.00 $750.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27607 A SUP Custom 27803010 27607 A - PLATE 18MM TI BONE SPNL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27607 B SUP Custom 27803010 27607 B - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27607 C SUP Custom 27803010 27607 C - PLATE 18MM TI BONE SPNL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27607 D SUP Custom 27803010 27607 D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27643L SUP Custom 27803010 27643L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27643M SUP Custom 27803010 27643M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27644DL SUP Custom 27803010 27644DL - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,237.13 " "$2,395.48" $0.00 "$2,589.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,402.59" "$2,402.59" $0.00 $0.00 $674.62 $0.00 $0.00 $0.00 $0.00 "$1,618.56" "$2,563.81" "$2,589.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27644DM SUP Custom 27803010 27644DM - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,237.13 " "$2,395.48" $0.00 "$2,589.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,402.59" "$2,402.59" $0.00 $0.00 $674.62 $0.00 $0.00 $0.00 $0.00 "$1,618.56" "$2,563.81" "$2,589.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27644HM SUP Custom 27803010 27644HM - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,237.13 " "$2,395.48" $0.00 "$2,589.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,402.59" "$2,402.59" $0.00 $0.00 $674.62 $0.00 $0.00 $0.00 $0.00 "$1,618.56" "$2,563.81" "$2,589.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27645L SUP Custom 27803010 27645L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27645M SUP Custom 27803010 27645M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27683H SUP Custom 27803010 27683H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27683L SUP Custom 27803010 27683L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27683M SUP Custom 27803010 27683M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,051.88 " "$2,258.39" $0.00 "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.10" "$2,265.10" $0.00 $0.00 $636.01 $0.00 $0.00 $0.00 $0.00 "$1,525.94" "$2,417.09" "$2,441.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27862M SUP Custom 27803010 27862M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27-9020 SUP HCPCS C1713 27-9020 - CNTRSNK DRILL 2.7MM XTRMT 2.7MM SCR BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 279-251-101 SUP Custom 27203010 279-251-101 - ELTRD ESURG 2.5MM SERFAS ENRG PRB AARDVARK BOTH IP/OP $413.09 $305.69 $0.00 $330.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.59 $306.59 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $206.54 $327.17 $330.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 279-351-100 SUP Custom 27203010 279-351-100 - ELTRD ESURG 90MM 3.5MM SERFAS ENRG 90D PRB SCT ARTHRO LATEX BOTH IP/OP $433.02 $320.43 $0.00 $346.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.39 $321.39 $0.00 $0.00 $90.24 $0.00 $0.00 $0.00 $0.00 $216.51 $342.95 $346.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 279-351-300 SUP Custom 27203010 279-351-300 - PROBE SCT 90MM LF 3.5MM SERFAS ENRG BOTH IP/OP $433.02 $320.43 $0.00 $346.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.39 $321.39 $0.00 $0.00 $90.24 $0.00 $0.00 $0.00 $0.00 $216.51 $342.95 $346.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2793G SUP Custom 27203010 2793G - SUTURE NABSB 9-0 BV100-4 5IN BLU PRLN MFL BOTH IP/OP $57.38 $42.46 $0.00 $46.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.59 $42.59 $0.00 $0.00 $11.96 $0.00 $0.00 $0.00 $0.00 $29.12 $46.13 $46.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 279-401-100 SUP Custom 27203010 279-401-100 - PROBE SUCTION 90D 4MM ARTHRO SERFAS ENERGY MAXL STERILE BOTH IP/OP $393.03 $290.84 $0.00 $314.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $291.70 $291.70 $0.00 $0.00 $81.91 $0.00 $0.00 $0.00 $0.00 $196.51 $311.28 $314.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 279-401-200 SUP Custom 27203010 279-401-200 - SURGICAL ARTHROSCOPIC SERFAS 90-S 4.0MM CRUISE ENERG PROBE BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2794G SUP Custom 27203010 2794G - SUTURE NONABSORBABLE 10-0 BV100-3 5CM MONOFILAMENT PROLENE BOTH IP/OP $63.69 $47.13 $0.00 $50.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.27 $47.27 $0.00 $0.00 $13.27 $0.00 $0.00 $0.00 $0.00 $31.84 $50.44 $50.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27AGFN-756 SUP Custom 27803010 27AGFN-756 - VALVE AORTIC 85D 27MM 24.9MM 1 DIGIT GRADIENT MECHANICAL BOTH IP/OP "$11,750.00 " "$8,695.00" $0.00 "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,448.70" $0.00 $0.00 $0.00 $0.00 "$5,875.00" "$9,306.00" "$9,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27AJ-501 SUP Custom 27803010 27AJ-501 - VALVE AOR 85D 3.67SQ CM 3.08SQ CM 27MM 22.5MM MSTR SER MECH BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27B006 SUP Custom 27804086 27B006 - GRAFT BONE FEMORAL SHAFT BOTH IP/OP "$2,847.50 " "$2,107.15" $0.00 "$2,278.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,113.41" "$2,113.41" $0.00 $0.00 $593.42 $0.00 $0.00 $0.00 $0.00 "$1,423.75" "$2,255.22" "$2,278.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27MJ-501 SUP Custom 27803010 27MJ-501 - VALVE MTRL 85D 3.67SQ CM STD RING 27MM 22.5MM MSTR SER LFLT BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 280.651S SUP HCPCS C1713 280.651S - SCREW BONE 14MM 50MM LAG DHS/DCS STAINLESS STEEL HIP CONDYLE BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.655S SUP HCPCS C1713 280.655S - SCREW BONE 14MM 55MM LAG CANN DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.665S SUP HCPCS C1713 280.665S - SCREW BONE 14MM 65MM LAG CANN DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.675S SUP HCPCS C1713 280.675S - SCREW BONE 14MM 75MM LAG CANN DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.685S SUP HCPCS C1713 280.685S - SCREW BONE 14MM 85MM LAG CANN DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.695S SUP HCPCS C1713 280.695S - SCREW BONE 14MM 95MM LAG CANN DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.701S SUP HCPCS C1713 280.701S - SCREW BONE 14MM 100MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.705S SUP HCPCS C1713 280.705S - SCREW BONE 14MM 105MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.715S SUP HCPCS C1713 280.715S - SCREW BONE 14MM 115MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.725S SUP HCPCS C1713 280.725S - SCREW BONE 14MM 8.2MM 125MM 22MM 1 STEP LAG CANN DHS/DCS BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.735S SUP HCPCS C1713 280.735S - SCREW BONE 14MM 135MM 22MM LAG CANN DHS/DCS STAINLESS STEEL BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 280.745S SUP HCPCS C1713 280.745S - SCREW BONE 14MM 145MM LAG DHS/DCS STAINLESS STEEL HIP BOTH IP/OP $813.90 $602.29 $0.00 $632.16 $355.59 $355.59 $0.00 $0.00 $0.00 $169.64 $604.08 $604.08 $0.00 $0.00 $169.62 $0.00 $481.42 $481.42 $0.00 $395.10 $625.84 $632.16 $0.00 $0.00 $120.06 $0.00 $0.00 $125.80 $0.00 $0.00 $0.00 $0.00 $0.00 2808G SUP Custom 27203010 2808G - SUTURE NABSB 8-0 BV130-5 5IN BLK ETH MTPS MFL BOTH IP/OP $40.53 $29.99 $0.00 $32.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.08 $30.08 $0.00 $0.00 $8.45 $0.00 $0.00 $0.00 $0.00 $20.57 $32.58 $32.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 281.502S SUP HCPCS C1713 281.502S - PLATE 130D SHRT BRL 46MM SS 2 HOLE DHS/DCP BONE 25MM CNDYLR BOTH IP/OP "$1,162.60 " $860.32 $0.00 $930.08 $523.17 $523.17 $0.00 $0.00 $0.00 $242.31 $862.88 $862.88 $0.00 $0.00 $242.29 $0.00 $687.68 $687.68 $0.00 $581.30 $920.78 $930.08 $0.00 $0.00 $181.95 $0.00 $0.00 $185.09 $0.00 $0.00 $0.00 $0.00 $0.00 2813G SUP Custom 27203010 2813G - SUTURE NABSB 9-0 BV130-4 5IN BLK ETH MFL BOTH IP/OP $40.86 $30.24 $0.00 $33.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.33 $30.33 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $20.74 $32.84 $33.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28164FGM SUP Custom 27203010 28164FGM - FORCEPS BIPOLAR 45 D L20 CM L1 MM OD3 MM INSERT ANGLED DISTA BOTH IP/OP "$2,490.00 " "$1,842.60" $0.00 "$1,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,848.08" "$1,848.08" $0.00 $0.00 $518.92 $0.00 $0.00 $0.00 $0.00 "$1,245.00" "$1,972.08" "$1,992.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.234S SUP Custom 27803010 282.234S - BLADE INTRAMEDULLARY NAIL HELIX 75MM LCP DHHS STERILE BOTH IP/OP $732.38 $541.96 $0.00 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.57 $543.57 $0.00 $0.00 $152.63 $0.00 $0.00 $0.00 $0.00 $355.51 $563.14 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.235S SUP Custom 27803010 282.235S - BLADE INTRAMEDULLARY NAIL 80MM LCP DHHS STAINLESS STEEL HIP BOTH IP/OP $732.38 $541.96 $0.00 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.57 $543.57 $0.00 $0.00 $152.63 $0.00 $0.00 $0.00 $0.00 $355.51 $563.14 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.236S SUP Custom 27803010 282.236S - BLADE SURG 85MM HELICAL STERILE BOTH IP/OP $732.38 $541.96 $0.00 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.57 $543.57 $0.00 $0.00 $152.63 $0.00 $0.00 $0.00 $0.00 $355.51 $563.14 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.237S SUP Custom 27803010 282.237S - BLADE FIX 90MM HELICAL LCP DHHS STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $732.38 $541.96 $0.00 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.57 $543.57 $0.00 $0.00 $152.63 $0.00 $0.00 $0.00 $0.00 $355.51 $563.14 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.238S SUP Custom 27803010 282.238S - BLADE FIX 95MM HELICAL LCP DHHS STAINLESS STEEL STERILE BOTH IP/OP $732.38 $541.96 $0.00 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.57 $543.57 $0.00 $0.00 $152.63 $0.00 $0.00 $0.00 $0.00 $355.51 $563.14 $568.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.239S SUP Custom 27803010 282.239S - BLADE FIX 100MM HELICAL LCP DHHS STAINLESS STEEL ORTHOPEDIC BOTH IP/OP $740.80 $548.19 $0.00 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.82 $549.82 $0.00 $0.00 $154.38 $0.00 $0.00 $0.00 $0.00 $359.61 $569.63 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.240S SUP Custom 27803010 282.240S - BLADE FIX 105MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $740.80 $548.19 $0.00 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.82 $549.82 $0.00 $0.00 $154.38 $0.00 $0.00 $0.00 $0.00 $359.61 $569.63 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.241S SUP Custom 27803010 282.241S - BLADE INTRAMEDULLARY NAIL HELIX 110MM LCP DHHS STERILE BOTH IP/OP $740.80 $548.19 $0.00 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.82 $549.82 $0.00 $0.00 $154.38 $0.00 $0.00 $0.00 $0.00 $359.61 $569.63 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.242S SUP Custom 27803010 282.242S - BLADE INTRAMEDULLARY NAIL HELIX 115MM LCP DHHS STERILE BOTH IP/OP $740.80 $548.19 $0.00 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.82 $549.82 $0.00 $0.00 $154.38 $0.00 $0.00 $0.00 $0.00 $359.61 $569.63 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.243S SUP Custom 27803010 282.243S - BLADE FIX 120MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $740.80 $548.19 $0.00 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.82 $549.82 $0.00 $0.00 $154.38 $0.00 $0.00 $0.00 $0.00 $359.61 $569.63 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.244S SUP Custom 27803010 282.244S - BLADE FIX 125MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $740.80 $548.19 $0.00 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.82 $549.82 $0.00 $0.00 $154.38 $0.00 $0.00 $0.00 $0.00 $359.61 $569.63 $575.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.245S SUP Custom 27803010 282.245S - BLADE FIX 130MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $749.23 $554.43 $0.00 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.07 $556.07 $0.00 $0.00 $156.14 $0.00 $0.00 $0.00 $0.00 $363.70 $576.10 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.246S SUP Custom 27803010 282.246S - BLADE FIX 135MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $749.23 $554.43 $0.00 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.07 $556.07 $0.00 $0.00 $156.14 $0.00 $0.00 $0.00 $0.00 $363.70 $576.10 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.247S SUP Custom 27803010 282.247S - BLADE FIX 140MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $749.23 $554.43 $0.00 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.07 $556.07 $0.00 $0.00 $156.14 $0.00 $0.00 $0.00 $0.00 $363.70 $576.10 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.248S SUP Custom 27803010 282.248S - BLADE FIX 145MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $749.23 $554.43 $0.00 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.07 $556.07 $0.00 $0.00 $156.14 $0.00 $0.00 $0.00 $0.00 $363.70 $576.10 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.249S SUP Custom 27803010 282.249S - BLADE FIX 150MM LCP DHHS STAINLESS STEEL HIP STERILE BOTH IP/OP $749.23 $554.43 $0.00 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.07 $556.07 $0.00 $0.00 $156.14 $0.00 $0.00 $0.00 $0.00 $363.70 $576.10 $581.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 282.605S SUP HCPCS C1713 282.605S - SIDEPLATE BONE 130D STANDARD BARREL 162MM 38MM 8 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.606S SUP HCPCS C1713 282.606S - SIDEPLATE BONE 130D STANDARD BARREL 198MM 38MM 10 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.607S SUP HCPCS C1713 282.607S - SIDEPLATE BONE 130D STANDARD BARREL 234MM 38MM 12 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.608S SUP HCPCS C1713 282.608S - SIDEPLATE BONE 130D STANDARD BARREL 270MM 38MM 14 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.615S SUP HCPCS C1713 282.615S - SIDEPLATE BONE 135D STANDARD BARREL 162MM 38MM 8 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.616S SUP HCPCS C1713 282.616S - SIDEPLATE BONE 135D STANDARD BARREL 198MM 38MM 10 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.617S SUP HCPCS C1713 282.617S - SIDEPLATE BONE 135D STANDARD BARREL 234MM 38MM 12 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.618S SUP HCPCS C1713 282.618S - SIDEPLATE BONE 135D STANDARD BARREL 270MM 38MM 14 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.619S SUP HCPCS C1713 282.619S - SIDEPLATE BONE 135D STANDARD BARREL 306MM 38MM 16 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.620S SUP HCPCS C1713 282.620S - SIDEPLATE BONE 135D STANDARD BARREL 342MM 38MM 18 HOLE LCP BOTH IP/OP "$1,915.95 " "$1,417.80" $0.00 "$1,488.12" $837.07 $837.07 $0.00 $0.00 $0.00 $399.33 "$1,422.02" "$1,422.02" $0.00 $0.00 $399.28 $0.00 "$1,133.28" "$1,133.28" $0.00 $930.08 "$1,473.24" "$1,488.12" $0.00 $0.00 $282.64 $0.00 $0.00 $296.14 $0.00 $0.00 $0.00 $0.00 $0.00 282.621S SUP HCPCS C1713 282.621S - SIDEPLATE BONE 135D STANDARD BARREL 378MM 38MM 20 HOLE LCP BOTH IP/OP "$1,915.95 " "$1,417.80" $0.00 "$1,488.12" $837.07 $837.07 $0.00 $0.00 $0.00 $399.33 "$1,422.02" "$1,422.02" $0.00 $0.00 $399.28 $0.00 "$1,133.28" "$1,133.28" $0.00 $930.08 "$1,473.24" "$1,488.12" $0.00 $0.00 $282.64 $0.00 $0.00 $296.14 $0.00 $0.00 $0.00 $0.00 $0.00 282.635S SUP HCPCS C1713 282.635S - SIDEPLATE BONE 140D STANDARD BARREL 162MM 38MM 8 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.636S SUP HCPCS C1713 282.636S - SIDEPLATE BONE 140D STANDARD BARREL 198MM 38MM 10 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.637S SUP HCPCS C1713 282.637S - SIDEPLATE BONE 140D STANDARD BARREL 234MM 38MM 12 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.638S SUP HCPCS C1713 282.638S - SIDEPLATE BONE 140D STANDARD BARREL 270MM 38MM 14 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.639S SUP HCPCS C1713 282.639S - SIDEPLATE BONE 140D STANDARD BARREL 306MM 38MM 16 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.645S SUP HCPCS C1713 282.645S - SIDEPLATE BONE 145D STANDARD BARREL 162MM 38MM 8 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.646S SUP HCPCS C1713 282.646S - SIDEPLATE BONE 145D STANDARD BARREL 198MM 38MM 10 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.647S SUP HCPCS C1713 282.647S - SIDEPLATE BONE 145D STANDARD BARREL 234MM 38MM 12 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.648S SUP HCPCS C1713 282.648S - SIDEPLATE BONE 145D STANDARD BARREL 270MM 38MM 14 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.649S SUP HCPCS C1713 282.649S - SIDEPLATE BONE 145D STANDARD BARREL 306MM 38MM 16 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.655S SUP HCPCS C1713 282.655S - SIDEPLATE BONE 150D STANDARD BARREL 162MM 38MM 8 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.656S SUP HCPCS C1713 282.656S - SIDEPLATE BONE 150D STANDARD BARREL 198MM 38MM 10 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.657S SUP HCPCS C1713 282.657S - SIDEPLATE BONE 150D STANDARD BARREL 234MM 38MM 12 HOLE LCP BOTH IP/OP "$1,453.48 " "$1,075.58" $0.00 "$1,128.92" $635.02 $635.02 $0.00 $0.00 $0.00 $302.94 "$1,078.77" "$1,078.77" $0.00 $0.00 $302.90 $0.00 $859.73 $859.73 $0.00 $705.58 "$1,117.63" "$1,128.92" $0.00 $0.00 $214.41 $0.00 $0.00 $224.66 $0.00 $0.00 $0.00 $0.00 $0.00 282.658S SUP HCPCS C1713 282.658S - SIDEPLATE BONE 150D STANDARD BARREL 270MM 38MM 14 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.659S SUP HCPCS C1713 282.659S - SIDEPLATE BONE 150D STANDARD BARREL 306MM 38MM 16 HOLE LCP BOTH IP/OP "$1,862.55 " "$1,378.29" $0.00 "$1,446.64" $813.74 $813.74 $0.00 $0.00 $0.00 $388.20 "$1,382.38" "$1,382.38" $0.00 $0.00 $388.16 $0.00 "$1,101.70" "$1,101.70" $0.00 $904.15 "$1,432.17" "$1,446.64" $0.00 $0.00 $274.76 $0.00 $0.00 $287.88 $0.00 $0.00 $0.00 $0.00 $0.00 282.660S SUP HCPCS C1713 282.660S - SIDEPLATE BONE 150D STANDARD BARREL 342MM 38MM 18 HOLE LCP BOTH IP/OP "$1,915.95 " "$1,417.80" $0.00 "$1,488.12" $837.07 $837.07 $0.00 $0.00 $0.00 $399.33 "$1,422.02" "$1,422.02" $0.00 $0.00 $399.28 $0.00 "$1,133.28" "$1,133.28" $0.00 $930.08 "$1,473.24" "$1,488.12" $0.00 $0.00 $282.64 $0.00 $0.00 $296.14 $0.00 $0.00 $0.00 $0.00 $0.00 282.661S SUP HCPCS C1713 282.661S - SIDEPLATE BONE 150D STANDARD BARREL 378MM 38MM 20 HOLE LCP BOTH IP/OP "$1,915.95 " "$1,417.80" $0.00 "$1,488.12" $837.07 $837.07 $0.00 $0.00 $0.00 $399.33 "$1,422.02" "$1,422.02" $0.00 $0.00 $399.28 $0.00 "$1,133.28" "$1,133.28" $0.00 $930.08 "$1,473.24" "$1,488.12" $0.00 $0.00 $282.64 $0.00 $0.00 $296.14 $0.00 $0.00 $0.00 $0.00 $0.00 282.671S SUP HCPCS C1713 282.671S - SIDEPLATE BONE 130D SHORT BARREL 72MM 25MM 3 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.673S SUP HCPCS C1713 282.673S - SIDEPLATE BONE 130D SHORT BARREL 5 HOLE LCP DHHS STAINLESS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.674S SUP HCPCS C1713 282.674S - SIDEPLATE BONE 130D SHORT BARREL 108MM 25MM 5 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.677S SUP HCPCS C1713 282.677S - SIDEPLATE BONE 135D SHORT BARREL 72MM 25MM 3 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.679S SUP HCPCS C1713 282.679S - SIDEPLATE BONE 135D SHORT BARREL 108MM 25MM 5 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.680S SUP HCPCS C1713 282.680S - SIDEPLATE BONE 135D SHORT BARREL 126MM 25MM 6 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.681S SUP HCPCS C1713 282.681S - SIDEPLATE BONE 140D SHORT BARREL 54MM 25MM 2 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.682S SUP HCPCS C1713 282.682S - SIDEPLATE BONE 140D SHORT BARREL 72MM 25MM 3 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.684S SUP HCPCS C1713 282.684S - SIDEPLATE BONE 140D SHORT BARREL 108MM 25MM 5 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.685S SUP HCPCS C1713 282.685S - SIDEPLATE BONE 140D SHORT BARREL 126MM 25MM 6 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.686S SUP HCPCS C1713 282.686S - SIDEPLATE BONE 145D SHORT BARREL 54MM 25MM 2 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.687S SUP HCPCS C1713 282.687S - SIDEPLATE BONE 145D SHORT BARREL 72MM 25MM 3 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.689S SUP HCPCS C1713 282.689S - SIDEPLATE BONE 145D SHORT BARREL 108MM 25MM 5 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.690S SUP HCPCS C1713 282.690S - SIDEPLATE BONE 145D SHORT BARREL 126MM 25MM 6 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.692S SUP HCPCS C1713 282.692S - SIDEPLATE BONE 150D SHORT BARREL 72MM 25MM 3 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.694S SUP HCPCS C1713 282.694S - SIDEPLATE BONE 150D SHORT BARREL 108MM 25MM 5 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 282.695S SUP HCPCS C1713 282.695S - SIDEPLATE BONE 150D SHORT BARREL 126MM 25MM 6 HOLE LCP DHHS BOTH IP/OP "$1,179.38 " $872.74 $0.00 $916.02 $515.26 $515.26 $0.00 $0.00 $0.00 $245.81 $875.33 $875.33 $0.00 $0.00 $245.78 $0.00 $697.60 $697.60 $0.00 $572.51 $906.86 $916.02 $0.00 $0.00 $173.98 $0.00 $0.00 $182.29 $0.00 $0.00 $0.00 $0.00 $0.00 28-300 SUP Custom 27203010 28-300 - GUIDEPIN THREAD-TIPPED 2.8MM X 300MM BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $0.00 $0.00 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2836-47 SUP Custom 27203010 REAGENT MCBL ANSR SHIG BYD2 GRP C 1-7 LYPH 3ML BOTH IP/OP $262.83 $194.49 $0.00 $210.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.41 $208.16 $210.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2837-47 SUP Custom 27203010 REAGENT MCBL ANSR SHIG BYD2 GRP D LYPH DFC 3ML BOTH IP/OP $279.20 $206.61 $0.00 $223.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.60 $221.13 $223.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2850G SUP Custom 27203010 2850G - SUTURE NONABSORBABLE 10-0 BV75-4 5IN MONOFILAMENT ETHILON BOTH IP/OP $69.48 $51.42 $0.00 $56.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.57 $51.57 $0.00 $0.00 $14.48 $0.00 $0.00 $0.00 $0.00 $35.26 $55.85 $56.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2867-05-230 SUP HCPCS C1769 2867-05-230 - GUIDEWIRE ORTH 1.37MM VPR 2 SHRP BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $312.23 $312.23 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 2887B SUP Custom 27203010 PROBE ORAL LNG CORD THRMTR BLUE TRB TMP BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2894G SUP Custom 27203010 2894G - SUTURE NONABSORBABLE 9-0 V100-3 5IN MONOFILAMENT ETHILON BOTH IP/OP $55.97 $41.42 $0.00 $45.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.54 $41.54 $0.00 $0.00 $11.66 $0.00 $0.00 $0.00 $0.00 $28.40 $44.99 $45.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 28-M322090222290U SUP HCPCS C2625 28-M322090222290U - GRAFT EVAS 22MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M322150222290U SUP HCPCS C2625 28-M322150222290U - GRAFT EVAS 22MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M322190222290U SUP HCPCS C2625 28-M322190222290U - GRAFT EVAS 22MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M322250222390U SUP HCPCS C2625 28-M322250222390U - GRAFT EVAS 22MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M324090242290U SUP HCPCS C2625 28-M324090242290U - GRAFT EVAS 24MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M324150242290U SUP HCPCS C2625 28-M324150242290U - GRAFT EVAS 24MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M324190242290U SUP HCPCS C2625 28-M324190242290U - GRAFT EVAS 24MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M324250222390U SUP HCPCS C2625 28-M324250222390U - GRAFT EVAS 24MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M326095262290U SUP HCPCS C2625 28-M326095262290U - GRAFT EVAS 26MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M326155262290U SUP HCPCS C2625 28-M326155262290U - GRAFT EVAS 26MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M326195262290U SUP HCPCS C2625 28-M326195262290U - GRAFT EVAS 26MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M326250262390U SUP HCPCS C2625 28-M326250262390U - GRAFT EVAS 26MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M328095282290U SUP HCPCS C2625 28-M328095282290U - GRAFT EVAS 28MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M328155242290U SUP HCPCS C2625 28-M328155242290U - GRAFT EVAS 28/24X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M328155282290U SUP HCPCS C2625 28-M328155282290U - GRAFT EVAS 28MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M328195242290U SUP HCPCS C2625 28-M328195242290U - GRAFT EVAS 28/24X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M328195282290U SUP HCPCS C2625 28-M328195282290U - GRAFT EVAS 28MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M328250242390U SUP HCPCS C2625 28-M328250242390U - GRAFT EVAS 28/24X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M328250282390U SUP HCPCS C2625 28-M328250282390U - GRAFT EVAS 28MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M330095302290U SUP HCPCS C2625 28-M330095302290U - GRAFT EVAS 30MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M330155262290U SUP HCPCS C2625 28-M330155262290U - GRAFT EVAS 30/26X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M330155302290U SUP HCPCS C2625 28-M330155302290U - GRAFT EVAS 30MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M330200262390U SUP HCPCS C2625 28-M330200262390U - GRAFT EVAS 30/26X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M330200302390U SUP HCPCS C2625 28-M330200302390U - GRAFT EVAS 30MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M330250262390U SUP HCPCS C2625 28-M330250262390U - GRAFT EVAS 30/26X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M330250302390U SUP HCPCS C2625 28-M330250302390U - GRAFT EVAS 30MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M332095322290U SUP HCPCS C2625 28-M332095322290U - GRAFT EVAS 32MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M332155282290U SUP HCPCS C2625 28-M332155282290U - GRAFT EVAS 32/28X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M332155322290U SUP HCPCS C2625 28-M332155322290U - GRAFT EVAS 32MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M332200282390U SUP HCPCS C2625 28-M332200282390U - GRAFT EVAS 32/28X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M332200322390U SUP HCPCS C2625 28-M332200322390U - GRAFT EVAS 32MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M332250282490U SUP HCPCS C2625 28-M332250282490U - GRAFT EVAS 32/28X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M332250322490U SUP HCPCS C2625 28-M332250322490U - GRAFT EVAS 32MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M334100342390U SUP HCPCS C2625 28-M334100342390U - GRAFT EVAS 34MMX100MM RESR MAIN BOTH IP/OP "$42,375.00 " "$31,357.50" $0.00 "$20,890.88" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$8,832.01" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,830.95" $0.00 "$20,890.88" "$20,890.88" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M334145302390U SUP HCPCS C2625 28-M334145302390U - GRAFT EVAS 34/30X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M334145342390U SUP HCPCS C2625 28-M334145342390U - GRAFT EVAS 34MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M334200302490U SUP HCPCS C2625 28-M334200302490U - GRAFT EVAS 34/30X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M334200342490U SUP HCPCS C2625 28-M334200342490U - GRAFT EVAS 34MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M334250302490U SUP HCPCS C2625 28-M334250302490U - GRAFT EVAS 34/30X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M334250342490U SUP HCPCS C2625 28-M334250342490U - GRAFT EVAS 34MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M336100362390U SUP HCPCS C2625 28-M336100362390U - GRAFT EVAS 36MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M336145322490U SUP HCPCS C2625 28-M336145322490U - GRAFT EVAS 36/32X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M336145362490U SUP HCPCS C2625 28-M336145362490U - GRAFT EVAS 36MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M336190322490U SUP HCPCS C2625 28-M336190322490U - GRAFT EVAS 36/32X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M336190362490U SUP HCPCS C2625 28-M336190362490U - GRAFT EVAS 36MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M336250322490U SUP HCPCS C2625 28-M336250322490U - GRAFT EVAS 36/32X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M336250362490U SUP HCPCS C2625 28-M336250362490U - GRAFT EVAS 36MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M338100382490U SUP HCPCS C2625 28-M338100382490U - GRAFT EVAS 38MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M338145342490U SUP HCPCS C2625 28-M338145342490U - GRAFT EVAS 38/34X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M338145382490U SUP HCPCS C2625 28-M338145382490U - GRAFT EVAS 38MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M338190342590U SUP HCPCS C2625 28-M338190342590U - GRAFT EVAS 38/34X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M338190382590U SUP HCPCS C2625 28-M338190382590U - GRAFT EVAS 38MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M338250342590U SUP HCPCS C2625 28-M338250342590U - GRAFT EVAS 38/34X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M338250382590U SUP HCPCS C2625 28-M338250382590U - GRAFT EVAS 38MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M340105402490U SUP HCPCS C2625 28-M340105402490U - GRAFT EVAS 40MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M340145362590U SUP HCPCS C2625 28-M340145362590U - GRAFT EVAS 40/36X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M340145402590U SUP HCPCS C2625 28-M340145402590U - GRAFT EVAS 40MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M340195362590U SUP HCPCS C2625 28-M340195362590U - GRAFT EVAS 40/36X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M340195402590U SUP HCPCS C2625 28-M340195402590U - GRAFT EVAS 40MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M340250362590U SUP HCPCS C2625 28-M340250362590U - GRAFT EVAS 40/36X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M340250402590U SUP HCPCS C2625 28-M340250402590U - GRAFT EVAS 40MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M342105422590U SUP HCPCS C2625 28-M342105422590U - GRAFT EVAS 42MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M342150382590U SUP HCPCS C2625 28-M342150382590U - GRAFT EVAS 42/38X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M342150422590U SUP HCPCS C2625 28-M342150422590U - GRAFT EVAS 42MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M342195382590U SUP HCPCS C2625 28-M342195382590U - GRAFT EVAS 42/38X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M342195422590U SUP HCPCS C2625 28-M342195422590U - GRAFT EVAS 42MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M342250382590U SUP HCPCS C2625 28-M342250382590U - GRAFT EVAS 42/38X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M342250422590U SUP HCPCS C2625 28-M342250422590U - GRAFT EVAS 42MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M344105442590U SUP HCPCS C2625 28-M344105442590U - GRAFT EVAS 44MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M344155402590U SUP HCPCS C2625 28-M344155402590U - GRAFT EVAS 44/40X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M344155442590U SUP HCPCS C2625 28-M344155442590U - GRAFT EVAS 44MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M344200402590U SUP HCPCS C2625 28-M344200402590U - GRAFT EVAS 44/40X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M344200442590U SUP HCPCS C2625 28-M344200442590U - GRAFT EVAS 44MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M344250402690U SUP HCPCS C2625 28-M344250402690U - GRAFT EVAS 44/40X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M344250442690U SUP HCPCS C2625 28-M344250442690U - GRAFT EVAS 44MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M346105462690U SUP HCPCS C2625 28-M346105462690U - GRAFT EVAS 46MMX100MM RESR MAIN BOTH IP/OP "$25,000.00 " "$18,500.00" $0.00 "$20,000.00" "$11,250.00" "$11,250.00" $0.00 $0.00 $0.00 "$5,210.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,210.00" $0.00 "$12,325.00" "$12,325.00" $0.00 "$12,500.00" "$19,800.00" "$20,000.00" $0.00 $0.00 "$3,912.50" $0.00 $0.00 "$3,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M346155422690U SUP HCPCS C2625 28-M346155422690U - GRAFT EVAS 46/42X150 TAPERED BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M346155462690U SUP HCPCS C2625 28-M346155462690U - GRAFT EVAS 46MMX150MM RESR MAIN BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" "$13,500.00" "$13,500.00" $0.00 $0.00 $0.00 "$6,252.75" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 "$14,790.00" "$14,790.00" $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 "$4,695.00" $0.00 $0.00 "$4,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M346200422690U SUP HCPCS C2625 28-M346200422690U - GRAFT EVAS 46/42X200 TAPERED BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M346200462690U SUP HCPCS C2625 28-M346200462690U - GRAFT EVAS 46MMX200MM RESR MAIN BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" "$15,750.00" "$15,750.00" $0.00 $0.00 $0.00 "$7,294.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 "$17,255.00" "$17,255.00" $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 "$5,477.50" $0.00 $0.00 "$5,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M346250422690U SUP HCPCS C2625 28-M346250422690U - GRAFT EVAS 46/42X250 TAPERED BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 28-M346250462690U SUP HCPCS C2625 28-M346250462690U - GRAFT EVAS 46MMX250MM RESR MAIN BOTH IP/OP "$40,000.00 " "$29,600.00" $0.00 "$32,000.00" "$18,000.00" "$18,000.00" $0.00 $0.00 $0.00 "$8,337.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,336.00" $0.00 "$19,720.00" "$19,720.00" $0.00 "$20,000.00" "$31,680.00" "$32,000.00" $0.00 $0.00 "$6,260.00" $0.00 $0.00 "$6,368.00" $0.00 $0.00 $0.00 $0.00 $0.00 290.20.280 SUP Custom 27203010 290.20.280 - WIRE FX STD 2MM 280MM NS KRSH SS BOTH IP/OP $48.75 $36.08 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $0.00 $0.00 $0.00 $24.38 $38.61 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.230.98 SUP Custom 27203010 291.230.98 - WIRE CERCLAGE .5MM 175MM PRECUT STAINLESS STEEL MANDIB BOTH IP/OP $31.50 $23.31 $0.00 $25.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.38 $23.38 $0.00 $0.00 $6.56 $0.00 $0.00 $0.00 $0.00 $15.75 $24.95 $25.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.240.98 SUP Custom 27203010 291.240.98 - WIRE FIX 175MM .6MM MANDIB SS CRLGE PCUT NONSTRL BOTH IP/OP $27.00 $19.98 $0.00 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.04 $20.04 $0.00 $0.00 $5.63 $0.00 $0.00 $0.00 $0.00 $13.50 $21.38 $21.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.911.01S SUP Custom 27803010 291.911.01S - CABLE ORTH SS 1MM 750MM STRNL W/O NDL CRIMPING FRL PRLL END BOTH IP/OP $223.75 $165.58 $0.00 $179.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.07 $166.07 $0.00 $0.00 $46.63 $0.00 $0.00 $0.00 $0.00 $111.88 $177.21 $179.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.916.01S SUP Custom 27803010 291.916.01S - CABLE ORTH SS 1MM 750MM STRNL NDL CRIMPING FRL PRLL END FIT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 291.916.03S SUP Custom 27803010 291.916.03S - CABLE ORTH SS 1MM 750MM STRNL NDL CRIMPING FRL PRLL END FIT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29-15044 SUP HCPCS C1713 29-15044 - DISK IMPL 4MM SLFTAP PRELD NONSTRL 1.5MM SCR BOTH IP/OP "$18,936.55 " "$14,013.05" $0.00 "$15,149.24" "$8,521.45" "$8,521.45" $0.00 $0.00 $0.00 "$3,946.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,946.38" $0.00 "$9,335.72" "$9,335.72" $0.00 "$9,468.28" "$14,997.75" "$15,149.24" $0.00 $0.00 "$2,963.57" $0.00 $0.00 "$3,014.70" $0.00 $0.00 $0.00 $0.00 $0.00 293.48L SUP Custom 27203010 293.48L - PIN FIX 4.5MM 275MM 3 FLAT ROUND TROCAR POINT SMOOTH SHAFT BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 293.48X SUP Custom 27203010 293.48X - PIN FIX 4.5MM 300MM 3 FLAT ROUND TROCAR POINT SMOOTH SHAFT BOTH IP/OP $125.88 $93.15 $0.00 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.42 $93.42 $0.00 $0.00 $26.23 $0.00 $0.00 $0.00 $0.00 $61.10 $96.78 $97.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 294.30SHA SUP HCPCS C1713 294.30SHA - SCREW XTRNFX 4MM 3MM 80MM STRL 20MM SCHNZ SPD PNT SS HA SEF BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.43SHA SUP HCPCS C1713 294.43SHA - SCREW XTRNFX 4MM 60MM STRL 25MM SCHNZ SPD PNT SS HA PLVC LG BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.44SHA SUP HCPCS C1713 294.44SHA - SCREW XTRNFX 4MM 80MM STRL 25MM SCHNZ SPD PNT SS HA PLVC LG BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.45SHA SUP HCPCS C1713 294.45SHA - SCREW XTRNFX 4MM 100MM STRL 25MM SCHNZ SPD PNT SS HA PLVC LG BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.46SHA SUP HCPCS C1713 294.46SHA - SCREW XTRNFX 4MM 120MM STRL 25MM SCHNZ SPD PNT SS HA PLVC LG BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.52SHA SUP HCPCS C1713 294.52SHA - SCREW XTRNFX XLNG 5MM 100MM STRL 50MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.53SHA SUP HCPCS C1713 294.53SHA - SCREW XTRNFX XLNG 5MM 125MM STRL 50MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.54SHA SUP HCPCS C1713 294.54SHA - SCREW XTRNFX XLNG 5MM 150MM STRL 50MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.55SHA SUP HCPCS C1713 294.55SHA - PIN HALF 5MM 170MM TROCAR BLUNT SCHANZ STAINLESS STEEL BOTH IP/OP $226.13 $167.34 $0.00 $175.64 $98.80 $98.80 $0.00 $0.00 $0.00 $47.13 $167.83 $167.83 $0.00 $0.00 $47.12 $0.00 $133.75 $133.75 $0.00 $109.78 $173.88 $175.64 $0.00 $0.00 $33.36 $0.00 $0.00 $34.95 $0.00 $0.00 $0.00 $0.00 $0.00 294.56SHA SUP HCPCS C1713 294.56SHA - SCREW XTRNFX XLNG 5MM 200MM STRL 50MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $226.13 $167.34 $0.00 $175.64 $98.80 $98.80 $0.00 $0.00 $0.00 $47.13 $167.83 $167.83 $0.00 $0.00 $47.12 $0.00 $133.75 $133.75 $0.00 $109.78 $173.88 $175.64 $0.00 $0.00 $33.36 $0.00 $0.00 $34.95 $0.00 $0.00 $0.00 $0.00 $0.00 294.57SHA SUP HCPCS C1713 294.57SHA - SCREW XTRNFX XLNG 5MM 250MM STRL 50MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $226.13 $167.34 $0.00 $175.64 $98.80 $98.80 $0.00 $0.00 $0.00 $47.13 $167.83 $167.83 $0.00 $0.00 $47.12 $0.00 $133.75 $133.75 $0.00 $109.78 $173.88 $175.64 $0.00 $0.00 $33.36 $0.00 $0.00 $34.95 $0.00 $0.00 $0.00 $0.00 $0.00 294.67SHA SUP HCPCS C1713 294.67SHA - SCREW XTRNFX 6MM 160MM STRL 50MM SCHNZ SPD PNT SS HA LG BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.68SHA SUP HCPCS C1713 294.68SHA - SCREW XTRNFX 6MM 190MM STRL 50MM SCHNZ SPD PNT SS HA LG BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.73SHA SUP HCPCS C1713 294.73SHA - SCREW XTRNFX ST 4.5MM 125MM STRL 18MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.74SHA SUP HCPCS C1713 294.74SHA - SCREW XTRNFX ST 4.5MM 150MM STRL 18MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $210.53 $155.79 $0.00 $163.52 $91.98 $91.98 $0.00 $0.00 $0.00 $43.88 $156.25 $156.25 $0.00 $0.00 $43.87 $0.00 $124.53 $124.53 $0.00 $102.20 $161.88 $163.52 $0.00 $0.00 $31.06 $0.00 $0.00 $32.54 $0.00 $0.00 $0.00 $0.00 $0.00 294.75SHA SUP HCPCS C1713 294.75SHA - SCREW XTRNFX ST 4.5MM 175MM STRL 18MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $218.33 $161.56 $0.00 $169.58 $95.39 $95.39 $0.00 $0.00 $0.00 $45.50 $162.04 $162.04 $0.00 $0.00 $45.50 $0.00 $129.14 $129.14 $0.00 $105.99 $167.89 $169.58 $0.00 $0.00 $32.21 $0.00 $0.00 $33.75 $0.00 $0.00 $0.00 $0.00 $0.00 294.76SHA SUP HCPCS C1713 294.76SHA - SCREW XTRNFX ST 4.5MM 200MM STRL 18MM SCHNZ BLNT TROC PNT SS BOTH IP/OP $218.33 $161.56 $0.00 $169.58 $95.39 $95.39 $0.00 $0.00 $0.00 $45.50 $162.04 $162.04 $0.00 $0.00 $45.50 $0.00 $129.14 $129.14 $0.00 $105.99 $167.89 $169.58 $0.00 $0.00 $32.21 $0.00 $0.00 $33.75 $0.00 $0.00 $0.00 $0.00 $0.00 294.771SHA SUP HCPCS C1713 294.771SHA - SCREW BONE 4/3MM 80MM SLFDRILL SCHANZ STAINLESS STEEL DISTAL BOTH IP/OP $308.58 $228.35 $0.00 $239.66 $134.81 $134.81 $0.00 $0.00 $0.00 $64.31 $229.02 $229.02 $0.00 $0.00 $64.31 $0.00 $182.52 $182.52 $0.00 $149.79 $237.27 $239.66 $0.00 $0.00 $45.52 $0.00 $0.00 $47.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.775SHA SUP HCPCS C1713 294.775SHA - SCREW XTRNFX 4MM 80MM STRL 20MM SCHNZ SLF DRL SS HA HIP BOTH IP/OP $308.58 $228.35 $0.00 $239.66 $134.81 $134.81 $0.00 $0.00 $0.00 $64.31 $229.02 $229.02 $0.00 $0.00 $64.31 $0.00 $182.52 $182.52 $0.00 $149.79 $237.27 $239.66 $0.00 $0.00 $45.52 $0.00 $0.00 $47.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.776SHA SUP HCPCS C1713 294.776SHA - SCREW XTRNFX 4MM 100MM STRL 30MM SCHNZ SLF DRL SS HA HIP BOTH IP/OP $308.58 $228.35 $0.00 $239.66 $134.81 $134.81 $0.00 $0.00 $0.00 $64.31 $229.02 $229.02 $0.00 $0.00 $64.31 $0.00 $182.52 $182.52 $0.00 $149.79 $237.27 $239.66 $0.00 $0.00 $45.52 $0.00 $0.00 $47.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.777SHA SUP HCPCS C1713 294.777SHA - SCREW XTRNFX 4MM 125MM STRL 40MM SCHNZ SLF DRL SS HA HIP BOTH IP/OP $308.58 $228.35 $0.00 $239.66 $134.81 $134.81 $0.00 $0.00 $0.00 $64.31 $229.02 $229.02 $0.00 $0.00 $64.31 $0.00 $182.52 $182.52 $0.00 $149.79 $237.27 $239.66 $0.00 $0.00 $45.52 $0.00 $0.00 $47.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.778SHA SUP HCPCS C1713 294.778SHA - SCREW XTRNFX 4MM 150MM STRL 40MM SCHNZ SLF DRL SS HA HIP BOTH IP/OP $308.58 $228.35 $0.00 $239.66 $134.81 $134.81 $0.00 $0.00 $0.00 $64.31 $229.02 $229.02 $0.00 $0.00 $64.31 $0.00 $182.52 $182.52 $0.00 $149.79 $237.27 $239.66 $0.00 $0.00 $45.52 $0.00 $0.00 $47.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.779SHA SUP HCPCS C1713 294.779SHA - SCREW BONE 4MM 175MM SLFDRILL SCHANZ STAINLESS STEEL HA BOTH IP/OP $308.58 $228.35 $0.00 $239.66 $134.81 $134.81 $0.00 $0.00 $0.00 $64.31 $229.02 $229.02 $0.00 $0.00 $64.31 $0.00 $182.52 $182.52 $0.00 $149.79 $237.27 $239.66 $0.00 $0.00 $45.52 $0.00 $0.00 $47.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.782SHA SUP HCPCS C1713 294.782SHA - SCREW XTRNFX 5MM 100MM STRL 30MM SCHNZ SLF DRL SS HA HIP BOTH IP/OP $340.88 $252.25 $0.00 $264.76 $148.93 $148.93 $0.00 $0.00 $0.00 $71.05 $253.00 $253.00 $0.00 $0.00 $71.04 $0.00 $201.63 $201.63 $0.00 $165.48 $262.11 $264.76 $0.00 $0.00 $50.28 $0.00 $0.00 $52.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.783SHA SUP HCPCS C1713 294.783SHA - SCREW XTRNFX 5MM 125MM STRL 40MM SCHNZ SLF DRL SS HA HIP BOTH IP/OP $340.88 $252.25 $0.00 $264.76 $148.93 $148.93 $0.00 $0.00 $0.00 $71.05 $253.00 $253.00 $0.00 $0.00 $71.04 $0.00 $201.63 $201.63 $0.00 $165.48 $262.11 $264.76 $0.00 $0.00 $50.28 $0.00 $0.00 $52.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.784SHA SUP HCPCS C1713 294.784SHA - SCREW BONE 5MM 150MM 60MM SLFDRILL SCHANZ STAINLESS STEEL HA BOTH IP/OP $340.88 $252.25 $0.00 $264.76 $148.93 $148.93 $0.00 $0.00 $0.00 $71.05 $253.00 $253.00 $0.00 $0.00 $71.04 $0.00 $201.63 $201.63 $0.00 $165.48 $262.11 $264.76 $0.00 $0.00 $50.28 $0.00 $0.00 $52.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.785SHA SUP HCPCS C1713 294.785SHA - SCREW BONE 5MM 175MM 60MM SLFDRILL SCHANZ STAINLESS STEEL HA BOTH IP/OP $340.88 $252.25 $0.00 $264.76 $148.93 $148.93 $0.00 $0.00 $0.00 $71.05 $253.00 $253.00 $0.00 $0.00 $71.04 $0.00 $201.63 $201.63 $0.00 $165.48 $262.11 $264.76 $0.00 $0.00 $50.28 $0.00 $0.00 $52.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.786SHA SUP HCPCS C1713 294.786SHA - SCREW BONE 5MM 200MM 80MM SLFDRILL SCHANZ STAINLESS STEEL HA BOTH IP/OP $340.88 $252.25 $0.00 $264.76 $148.93 $148.93 $0.00 $0.00 $0.00 $71.05 $253.00 $253.00 $0.00 $0.00 $71.04 $0.00 $201.63 $201.63 $0.00 $165.48 $262.11 $264.76 $0.00 $0.00 $50.28 $0.00 $0.00 $52.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.788SHA SUP HCPCS C1713 294.788SHA - SCREW XTRNFX 5MM 250MM STRL 80MM SCHNZ SLF DRL SS HA HIP BOTH IP/OP $340.88 $252.25 $0.00 $264.76 $148.93 $148.93 $0.00 $0.00 $0.00 $71.05 $253.00 $253.00 $0.00 $0.00 $71.04 $0.00 $201.63 $201.63 $0.00 $165.48 $262.11 $264.76 $0.00 $0.00 $50.28 $0.00 $0.00 $52.69 $0.00 $0.00 $0.00 $0.00 $0.00 294.796SHA SUP HCPCS C1713 294.796SHA - SCREW XTRNFX 6MM 200MM STRL 80MM SCHNZ SLF DRL SS HA HIP BOTH IP/OP $360.93 $267.09 $0.00 $280.32 $157.68 $157.68 $0.00 $0.00 $0.00 $75.23 $267.88 $267.88 $0.00 $0.00 $75.22 $0.00 $213.49 $213.49 $0.00 $175.20 $277.52 $280.32 $0.00 $0.00 $53.24 $0.00 $0.00 $55.78 $0.00 $0.00 $0.00 $0.00 $0.00 2940511S SUP HCPCS C1713 2940511S - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940512S SUP HCPCS C1713 2940512S - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940513S SUP HCPCS C1713 2940513S - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940514S SUP HCPCS C1713 2940514S - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940515S SUP HCPCS C1713 2940515S - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940516S SUP HCPCS C1713 2940516S - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940517S SUP HCPCS C1713 2940517S - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940521M SUP HCPCS C1713 2940521M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940522M SUP HCPCS C1713 2940522M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940523M SUP HCPCS C1713 2940523M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940524M SUP HCPCS C1713 2940524M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940525M SUP HCPCS C1713 2940525M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940526M SUP HCPCS C1713 2940526M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940527M SUP HCPCS C1713 2940527M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940528M SUP HCPCS C1713 2940528M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940531L SUP HCPCS C1713 2940531L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940532L SUP HCPCS C1713 2940532L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940533L SUP HCPCS C1713 2940533L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940534L SUP HCPCS C1713 2940534L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940535L SUP HCPCS C1713 2940535L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940536L SUP HCPCS C1713 2940536L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940537L SUP HCPCS C1713 2940537L - PLATE 18MM TI BONE SPNL BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 2940538L SUP HCPCS C1713 2940538L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 298.801.01S SUP Custom 27803010 298.801.01S - CABLE ORTHOPEDIC 1.7MM 750MM CRIMP CERCLAGE LCP STAINLESS BOTH IP/OP $919.33 $680.30 $0.00 $714.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $682.32 $682.32 $0.00 $0.00 $191.59 $0.00 $0.00 $0.00 $0.00 $446.28 $706.90 $714.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 298.803S SUP Custom 27203010 298.803S - PIN POSITIONING 4.5MM CERCLAGE THREADED LCP STAINLESS STEEL BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29AJ-501 SUP Custom 27803010 29AJ-501 - VALVE AOR 85D 29MM 24.2MM MSTR SER MECH STD CUF LFLT OPN BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 29MJ-501 SUP Custom 27803010 29MJ-501 - VALVE MTRL 85D 4.41SQ CM STD RING 29MM 24.2MM MSTR SER LFLT BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B0061 SUP Custom 25803010 SOLUTION IV 5% DEX 150ML VFLX LF BOTH IP/OP $2.23 $1.65 $0.00 $1.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.11 $1.77 $1.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B0062Q SUP Custom 25803010 SOLUTION IV 5% DEX 250ML VFLX LF BOTH IP/OP $2.13 $1.58 $0.00 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.06 $1.69 $1.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B0063Q SUP Custom 25803010 SOLUTION IV 5% DEX 500ML VFLX LF BOTH IP/OP $2.15 $1.59 $0.00 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.08 $1.70 $1.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B0064X SUP Custom 25803010 SOLUTION IV 5% DEX 1L VFLX LF BOTH IP/OP $2.65 $1.96 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.33 $2.10 $2.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B0089 SUP Custom 25803010 SOLUTION IV 5% DEX 100ML MPK VFLX LF BOTH IP/OP $2.60 $1.92 $0.00 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.30 $2.06 $2.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B0163Q SUP Custom 25803010 SOLUTION IV 10% DEX 500ML VFLX LF BOTH IP/OP $2.73 $2.02 $0.00 $2.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.36 $2.16 $2.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B0164X SUP Custom 25803010 SOLUTION IV 10% DEX 1L VFLX LF BOTH IP/OP $3.75 $2.78 $0.00 $3.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $2.97 $3.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1063Q SUP Custom 25803010 SOLUTION IV 5% DEX 0.9% NA CHLOR 500ML VFLX LF BOTH IP/OP $1.63 $1.21 $0.00 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.21 $1.21 $0.00 $0.00 $0.34 $0.00 $0.00 $0.00 $0.00 $0.81 $1.29 $1.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1064X SUP Custom 25803010 SOLUTION IV 5% DEX 0.9% NA CHLOR 1L VFLX LF BOTH IP/OP $2.68 $1.98 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $1.99 $0.00 $0.00 $0.56 $0.00 $0.00 $0.00 $0.00 $1.34 $2.12 $2.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1073Q SUP Custom 25803010 SOLUTION IV 5% DEX 0.45% NA CHLOR 500ML VFLX LF BOTH IP/OP $2.23 $1.65 $0.00 $1.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.11 $1.77 $1.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1074X SUP Custom 25803010 SOLUTION IV 5% DEX 0.45% NA CHLOR 1L VFLX LF BOTH IP/OP $2.70 $2.00 $0.00 $2.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.35 $2.14 $2.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1309 SUP Custom 25803010 SOLUTION IV 0.9% NA CHLOR 100ML MPK VFLX LF BOTH IP/OP $41.25 $30.53 $0.00 $33.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.63 $32.67 $33.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1313Q SUP Custom 25803010 SOLUTION IV 0.45% NA CHLOR 500ML VFLX LF BOTH IP/OP $2.23 $1.65 $0.00 $1.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.11 $1.77 $1.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1314X SUP Custom 25803010 SOLUTION IV 0.45% NA CHLOR 1L VFLX LF BOTH IP/OP $2.83 $2.09 $0.00 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.41 $2.24 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1321 SUP Custom 25803010 SOLUTION IV 0.9% NA CHLOR 150ML VFLX LF BOTH IP/OP $2.23 $1.65 $0.00 $1.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.11 $1.77 $1.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B1654X SUP Custom 25803010 SOLUTION IV 20 MEQ K CHLOR 5% DEX 0.45% NA CHLOR VFLX 1L LF BOTH IP/OP $3.45 $2.55 $0.00 $2.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.73 $2.73 $2.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B2074X SUP Custom 25803010 SOLUTION IV 5% DEX LR 1L VFLX LF BOTH IP/OP $2.68 $1.98 $0.00 $2.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.34 $2.12 $2.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B2324X SUP Custom 25803010 SOLUTION IV LR 1L VFLX LF BOTH IP/OP $2.83 $2.09 $0.00 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.41 $2.24 $2.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B2544X SUP Custom 25803010 SOLUTION IV PLSMLT A VFLX MLT ELCLY VFLX 1L LF BOTH IP/OP $5.10 $3.77 $0.00 $4.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.55 $4.04 $4.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2B7231 SUP Custom 25803010 2B7231 - SOLUTION IRRIGATION BAG USP CONTAINER 0.9% SODIUM CHLORIDE 1 BOTH IP/OP $188.28 $139.33 $0.00 $150.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.74 $139.74 $0.00 $0.00 $39.24 $0.00 $0.00 $0.00 $0.00 $94.14 $149.12 $150.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2C2164 SUP Custom 27203010 2C2164 - TUBINGIRRIGATION-LAPAROS BOTH IP/OP $36.89 $27.30 $0.00 $29.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.38 $27.38 $0.00 $0.00 $7.69 $0.00 $0.00 $0.00 $0.00 $18.44 $29.22 $29.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2N03A SUP Custom 27803010 2N03A - SUTURE NABSB CV-2 THX-22 36IN WHT MFL GRTX BOTH IP/OP $68.75 $50.88 $0.00 $53.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.03 $51.03 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $33.23 $52.64 $53.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2N05A SUP Custom 27803010 2N05A - SUTURE NABSB CV-2 THX-26 36IN WHT MFL GRTX BOTH IP/OP $68.75 $50.88 $0.00 $53.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.03 $51.03 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $33.23 $52.64 $53.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 2N1116 SUP HCPCS C1753 CATHETER INTRAVASCULAR QUIK CATH 22G X 1IN LUER PLUG BOTH IP/OP $1.83 $1.35 $0.00 $1.46 $0.99 $0.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.91 $1.45 $1.46 $0.00 $0.00 $0.29 $0.00 $0.00 $0.29 $0.00 $0.00 $0.00 $0.00 $0.00 2P9 SUP Custom 27803010 2P9 - PATCH VASCULAR 9X2CM XENOSURE THK.45MM BOVINE PERICARDIUM BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $0.00 $0.00 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3.0 NEO SUP Custom 27203010 3.0 NEO - TUBE 30MM 4.5MM 3MM UNCUF OBT TRCH PLVN CHLOR NEO BOTH IP/OP $94.29 $69.77 $0.00 $75.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.98 $69.98 $0.00 $0.00 $19.65 $0.00 $0.00 $0.00 $0.00 $47.14 $74.68 $75.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0001 SUP Custom 27203010 30-0001 - GUIDE TRGT SCPHD ASMBLY NONSTRL BOTH IP/OP $61.25 $45.33 $0.00 "$3,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.46 $45.46 $0.00 $0.00 $12.76 $0.00 $0.00 $0.00 $0.00 "$2,185.00" "$3,461.04" "$3,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0017-S SUP Custom 27203010 30-0017-S - GUIDE TRGT 1 .035IN SCPHD DISK STRL DISP BOTH IP/OP $652.50 $482.85 $0.00 $522.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $484.29 $484.29 $0.00 $0.00 $135.98 $0.00 $0.00 $0.00 $0.00 $326.25 $516.78 $522.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0018-S SUP Custom 27203010 30-0018-S - GUIDE MINI TRGT SURG SCPHD BOTH IP/OP $652.50 $482.85 $0.00 $522.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $484.29 $484.29 $0.00 $0.00 $135.98 $0.00 $0.00 $0.00 $0.00 $326.25 $516.78 $522.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0019-S SUP Custom 27203010 30-0019-S - GUIDE TRGT 3 .054IN SCPHD DISK STRL BOTH IP/OP $652.50 $482.85 $0.00 $522.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $484.29 $484.29 $0.00 $0.00 $135.98 $0.00 $0.00 $0.00 $0.00 $326.25 $516.78 $522.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0021-S SUP HCPCS C1713 30-0021-S - SCREW BN 5.5MM 25MM ACTRK2 MTP MIDFOOT BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 30-0023-S SUP HCPCS C1713 30-0023-S - SCREW BN 5.5MM 30MM ACTRK2 MTP MIDFOOT BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 30-0025-S SUP HCPCS C1713 30-0025-S - SCREW BN 5.5MM 35MM ACUTRACK II BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 30-0027-S SUP HCPCS C1713 30-0027-S - SCREW BN 5.5MM 40MM ACUTRACK II BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 30-0029-S SUP HCPCS C1713 30-0029-S - SCREW BN 5.5MM 45MM ACTRK2 MTP MIDFOOT BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 30-0031-S SUP HCPCS C1713 30-0031-S - SCREW BN 50MM ACTRK2 BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 30-0033-S SUP HCPCS C1713 30-0033-S - SCREW BONE 6MM 30MM ACTRK FSN DEV HMRTOE SYS BOTH IP/OP $895.00 $662.30 $0.00 $716.00 $402.75 $402.75 $0.00 $0.00 $0.00 $186.54 $664.27 $664.27 $0.00 $0.00 $186.52 $0.00 $529.39 $529.39 $0.00 $447.50 $708.84 $716.00 $0.00 $0.00 $140.07 $0.00 $0.00 $142.48 $0.00 $0.00 $0.00 $0.00 $0.00 300-070 SUP Custom 27203010 "300-070 - BONE GRAFT HARVESTER, COREX 7MM" BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0084-S SUP HCPCS C1713 30-0084-S - SCREW BN 5.5MM 55MM ACTRK BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 30-0085-S SUP HCPCS C1713 30-0085-S - SCREW BN 5.5MM 60MM ACTRK BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 300-090 SUP Custom 27203010 300-090 - HARVESTER BN 9MM STRL LF COREX CANC BN DISP BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0093 SUP HCPCS C1713 30-0093 - PLATE SCR ACLC 2 BONE DISTAL VOLR RADL BOTH IP/OP $590.00 $436.60 $0.00 $472.00 $265.50 $265.50 $0.00 $0.00 $0.00 $122.97 $437.90 $437.90 $0.00 $0.00 $122.96 $0.00 $348.99 $348.99 $0.00 $295.00 $467.28 $472.00 $0.00 $0.00 $92.34 $0.00 $0.00 $93.93 $0.00 $0.00 $0.00 $0.00 $0.00 30-0098 SUP HCPCS C1713 30-0098 - PIN FX 70MM NS TNSNBND BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $61.88 $61.88 $0.00 $0.00 $0.00 $28.66 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $81.33 $81.33 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $21.52 $0.00 $0.00 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 30-0099 SUP HCPCS C1713 30-0099 - PIN FX 90MM NS TNSNBND BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $61.88 $61.88 $0.00 $0.00 $0.00 $28.66 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $81.33 $81.33 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $21.52 $0.00 $0.00 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 30-0232 SUP HCPCS C1713 30-0232 - SCREW BONE 3.5MM 8MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0233 SUP HCPCS C1713 30-0233 - SCREW BONE 3.5MM 10MM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0234 SUP HCPCS C1713 30-0234 - SCREW BONE 3.5MM 12MM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0235 SUP HCPCS C1713 30-0235 - SCREW BONE 3.5MM 14MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0236 SUP HCPCS C1713 30-0236 - SCREW BONE 3.5MM 16MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0237 SUP HCPCS C1713 30-0237 - SCREW BONE 3.5MM 18MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0238 SUP HCPCS C1713 30-0238 - SCREW BONE 3.5MM 20MM LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0239 SUP HCPCS C1713 30-0239 - SCREW BONE 3.5MM 22MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0240 SUP HCPCS C1713 30-0240 - SCREW BONE 3.5MM 24MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0241 SUP HCPCS C1713 30-0241 - SCREW BONE 3.5MM 26MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0242 SUP HCPCS C1713 30-0242 - SCREW BONE 3.5MM 28MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0243 SUP HCPCS C1713 30-0243 - SCREW BONE 3.5MM 30MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0244 SUP HCPCS C1713 30-0244 - SCREW BONE 3.5MM 32MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0245 SUP HCPCS C1713 30-0245 - SCREW BONE 3.5MM 34MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0246 SUP HCPCS C1713 30-0246 - SCREW BONE 3.5MM 36MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0247 SUP HCPCS C1713 30-0247 - SCREW BONE 3.5MM 38MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0248 SUP HCPCS C1713 30-0248 - SCREW BONE 3.5MM 40MM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0249 SUP HCPCS C1713 30-0249 - SCREW BONE 3.5MM 45MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0250 SUP HCPCS C1713 30-0250 - SCREW BONE 3.5MM 50MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0251 SUP HCPCS C1713 30-0251 - SCREW BONE 3.5MM 55MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0252 SUP HCPCS C1713 30-0252 - SCREW BONE 3.5MM 60MM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0255 SUP HCPCS C1713 30-0255 - SCREW BONE 3.5MM 8MM CORT ELB NLCKG HEXALOBE HEAD BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0256 SUP HCPCS C1713 30-0256 - SCREW BN 3.5MM 10MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0257 SUP HCPCS C1713 30-0257 - SCREW BN 3.5MM 12MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0258 SUP HCPCS C1713 30-0258 - SCREW BN 3.5MM 14MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0259 SUP HCPCS C1713 30-0259 - SCREW BONE 3.5MM 16MM ELB NLCKG TRAUMA BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0260 SUP HCPCS C1713 30-0260 - SCREW BONE 3.5MM 18MM NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0261 SUP HCPCS C1713 30-0261 - SCREW BONE 3.5MM 20MM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0262 SUP HCPCS C1713 30-0262 - SCREW BONE 3.5MM 22MM NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0263 SUP HCPCS C1713 30-0263 - SCREW BONE 3.5MM 24MM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0264 SUP HCPCS C1713 30-0264 - SCREW BONE 3.5MM 26MM DISTAL HUM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0265 SUP HCPCS C1713 30-0265 - SCREW BONE 3.5MM 28MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0266 SUP HCPCS C1713 30-0266 - SCREW BN 3.5MM 30MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0267 SUP HCPCS C1713 30-0267 - SCREW BONE 3.5MM 32MM DISTAL HUM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0268 SUP HCPCS C1713 30-0268 - SCREW BONE 3.5MM 34MM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0269 SUP HCPCS C1713 30-0269 - SCREW BONE 3.5MM 36MM CORT ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0270 SUP HCPCS C1713 30-0270 - SCREW BONE 3.5MM 38MM DISTAL HUM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0271 SUP HCPCS C1713 30-0271 - SCREW BONE 3.5MM 40MM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0272 SUP HCPCS C1713 30-0272 - SCREW BONE 3.5MM 45MM DISTAL HUM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0273 SUP HCPCS C1713 30-0273 - SCREW BONE 3.5MM 50MM DISTAL HUM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0274 SUP HCPCS C1713 30-0274 - SCREW BONE 3.5MM 55MM CORT ELB NLCKG HEXALOBE HEAD BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0275 SUP HCPCS C1713 30-0275 - SCREW BONE 3.5MM 60MM DISTAL HUM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0276 SUP HCPCS C1713 30-0276 - SCREW BONE 3.5MM 65MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0278 SUP HCPCS C1713 30-0278 - SCREW BONE 3MM 8MM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0279 SUP HCPCS C1713 30-0279 - SCREW BONE 2.7MM 10MM ELB LCK BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0280 SUP HCPCS C1713 30-0280 - SCREW BONE 3MM 12MM ELB LCK BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0281 SUP HCPCS C1713 30-0281 - SCREW BONE 3MM 14MM CORT LCK BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0282 SUP HCPCS C1713 30-0282 - SCREW BONE 3MM 16MM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0283 SUP HCPCS C1713 30-0283 - SCREW BONE 3MM 18MM LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0284 SUP HCPCS C1713 30-0284 - SCREW BONE 3MM 20MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0285 SUP HCPCS C1713 30-0285 - SCREW BONE 3MM 22MM CORT ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0286 SUP HCPCS C1713 30-0286 - SCREW BONE 3MM 24MM CORT ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0287 SUP HCPCS C1713 30-0287 - SCREW BONE 3MM 26MM CORT ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0288 SUP HCPCS C1713 30-0288 - SCREW BONE 3MM 28MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0289 SUP HCPCS C1713 30-0289 - SCREW BONE 3MM 30MM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0290 SUP HCPCS C1713 30-0290 - SCREW BONE 3MM 32MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0291 SUP HCPCS C1713 30-0291 - SCREW BONE 3.5MM 34MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0292 SUP HCPCS C1713 30-0292 - SCREW BONE 3MM 36MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0293 SUP HCPCS C1713 30-0293 - SCREW BONE 3MM 38MM CORT ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0294 SUP HCPCS C1713 30-0294 - SCREW BONE 3MM 40MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0295 SUP HCPCS C1713 30-0295 - SCREW BONE 3MM 45MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0296 SUP HCPCS C1713 30-0296 - SCREW BONE 3MM 50MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0297 SUP HCPCS C1713 30-0297 - SCREW BN 3MM 55MM LCK HEXALOBE ELB BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0298 SUP HCPCS C1713 30-0298 - SCREW BONE 3MM 60MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0301 SUP HCPCS C1713 30-0301 - SCREW BONE 3MM 8MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0302 SUP HCPCS C1713 30-0302 - SCREW BONE 3MM 10MM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0303 SUP HCPCS C1713 30-0303 - SCREW BONE 3MM 12MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0304 SUP HCPCS C1713 30-0304 - SCREW BONE 3MM 14MM DISTAL HUM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0305 SUP HCPCS C1713 30-0305 - SCREW BONE 3MM 16MM CORT ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0306 SUP HCPCS C1713 30-0306 - SCREW BN 3MM 18MM NONLOCK HEXALOBE HD BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0307 SUP HCPCS C1713 30-0307 - SCREW BONE 3MM 20MM CORT ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0308 SUP HCPCS C1713 30-0308 - SCREW BN 3MM 22MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3003-0822S SUP HCPCS C1713 3003-0822S - SCREW SET TI 17.5MM 8MM TROC HIP GAMMA3 STRL LNG NAIL BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 30-0309 SUP HCPCS C1713 30-0309 - SCREW BONE 3MM 24MM CORT ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0310 SUP HCPCS C1713 30-0310 - SCREW BONE 3MM 26MM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0311 SUP HCPCS C1713 30-0311 - SCREW BONE 3.5MM 28MM ELB NLCKG BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0312 SUP HCPCS C1713 30-0312 - SCREW BONE 3.5MM 30MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0313 SUP HCPCS C1713 30-0313 - SCREW BONE 3MM 32MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0314 SUP HCPCS C1713 30-0314 - SCREW BONE 3MM 34MM DISTAL HUM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0315 SUP HCPCS C1713 30-0315 - SCREW BONE 3MM 36MM CORT ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0316 SUP HCPCS C1713 30-0316 - SCREW BONE 3MM 38MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0317 SUP HCPCS C1713 30-0317 - SCREW BONE 3MM 40MM DISTAL HUM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0318 SUP HCPCS C1713 30-0318 - SCREW BONE 3MM 45MM CORT ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0319 SUP HCPCS C1713 30-0319 - SCREW BN 3MM 50MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0320 SUP HCPCS C1713 30-0320 - SCREW BONE 3MM 55MM DISTAL HUM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0321 SUP HCPCS C1713 30-0321 - SCREW BONE 3MM 60MM DISTAL VOLR RADL NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0322 SUP HCPCS C1713 30-0322 - SCREW BONE 3MM 65MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0324 SUP HCPCS C1713 30-0324 - SCREW BONE 2.7MM 8MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0325 SUP HCPCS C1713 30-0325 - SCREW BONE 2.7MM 10MM ELB LCK BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0326 SUP HCPCS C1713 30-0326 - SCREW BONE 2.7MM 12MM TRAUMA LCK BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0327 SUP HCPCS C1713 30-0327 - SCREW BONE 2.7MM 14MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0328 SUP HCPCS C1713 30-0328 - SCREW BN 2.7MM 16MM NS LCK HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0329 SUP HCPCS C1713 30-0329 - SCREW BONE 2.7MM 18MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0330 SUP HCPCS C1713 30-0330 - SCREW BONE 2.7MM 20MM DISTAL HUM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0331 SUP HCPCS C1713 30-0331 - SCREW BN 2.7MM 22MM NS LCK HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0332 SUP HCPCS C1713 30-0332 - SCREW BONE 2.7MM 24MM ELB LCK HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0333 SUP HCPCS C1713 30-0333 - SCREW BONE 2.7MM 26MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0334 SUP HCPCS C1713 30-0334 - SCREW BONE 2.7MM 28MM DISTAL HUM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0335 SUP HCPCS C1713 30-0335 - SCREW BONE 2.7MM 30MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0336 SUP HCPCS C1713 30-0336 - SCREW BONE 2.7MM 32MM ELB LCK HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0343 SUP HCPCS C1713 30-0343 - SCREW BONE 2.7MM 8MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0344 SUP HCPCS C1713 30-0344 - SCREW BONE 2.7MM 10MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0345 SUP HCPCS C1713 30-0345 - SCREW BONE 2.7MM 12MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0346 SUP HCPCS C1713 30-0346 - SCREW BONE 2.7MM 14MM NLCKG TRAUMA BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0347 SUP HCPCS C1713 30-0347 - SCREW BONE 2.7MM 16MM TI NLCKG BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0348 SUP HCPCS C1713 30-0348 - SCREW BONE 2.7MM 18MM DISTAL HUM ELB NLCKG HEXALOBE NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0349 SUP HCPCS C1713 30-0349 - SCREW BONE 2.7MM 20MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0350 SUP HCPCS C1713 30-0350 - SCREW BN 2.7MM 22MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0351 SUP HCPCS C1713 30-0351 - SCREW BN 2.7MM 24MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0352 SUP HCPCS C1713 30-0352 - SCREW BONE 2.7MM 26MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0353 SUP HCPCS C1713 30-0353 - SCREW BONE 2.7MM 28MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0354 SUP HCPCS C1713 30-0354 - SCREW BN 2.7MM 30MM NS HEXALOBE TI SM FRAG BS SET BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0355 SUP HCPCS C1713 30-0355 - SCREW BONE 2.7MM 32MM ELB NLCKG HEXALOBE BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0370 SUP Custom 27203010 30-0370 - SLEEVE CMPR NS FRAG-LOC BN SCR BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.43 $482.43 $0.00 $0.00 $135.46 $0.00 $0.00 $0.00 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0371 SUP HCPCS C1713 30-0371 - SCREW BN STRL FRAG-LOC CMPR BOTH IP/OP $395.00 $292.30 $0.00 $316.00 $177.75 $177.75 $0.00 $0.00 $0.00 $82.33 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $233.64 $233.64 $0.00 $197.50 $312.84 $316.00 $0.00 $0.00 $61.82 $0.00 $0.00 $62.88 $0.00 $0.00 $0.00 $0.00 $0.00 3004-15010 SUP HCPCS C1713 3004-15010 - SCREW BONE 10MM HEXALOBE MULTI TITANIUM 1.5MM HAND BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3004-15011 SUP HCPCS C1713 3004-15011 - SCREW BONE 1.5MM 11MM HEXALOBE MULTI TITANIUM HAND BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3004-23009 SUP HCPCS C1713 3004-23009 - SCREW BONE 9MM MULTI HEXALOBE 2.3MM ELBOW NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3004-23010 SUP HCPCS C1713 3004-23010 - SCREW BONE 10MM MULTI HEXALOBE TITANIUM 2.3MM HAND NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3004-23011 SUP HCPCS C1713 3004-23011 - SCREW BONE 11MM HEXALOBE DRIVER 2.3MM ELBOW BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3004-23012 SUP HCPCS C1713 3004-23012 - SCREW BONE 12MM MULTI HEXALOBE 2.3MM WRIST BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3004-23013 SUP HCPCS C1713 3004-23013 - SCREW BN 2.3MM 13MM MLLK VA HEXALOBE TI HND FX SYS BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3004-23014 SUP HCPCS C1713 3004-23014 - SCREW BONE 14MM HEXALOBE DRIVER 2.3MM ELBOW BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3004-23016 SUP HCPCS C1713 3004-23016 - SCREW BONE 2.3MM 16MM ELB HEXALOBE DRVR BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 30-0426 SUP HCPCS C1713 30-0426 - SCREW BONE 5.7MM 26MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0428 SUP HCPCS C1713 30-0428 - SCREW BONE 5.7MM 28MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0430 SUP HCPCS C1713 30-0430 - SCREW BONE 5.7MM 30MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0432 SUP HCPCS C1713 30-0432 - SCREW BONE 5.7MM 32MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0434 SUP HCPCS C1713 30-0434 - SCREW BONE 5.7MM 34MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0436 SUP HCPCS C1713 30-0436 - SCREW BONE 5.7MM 36MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0438 SUP HCPCS C1713 30-0438 - SCREW BONE 5.7MM 38MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0440 SUP HCPCS C1713 30-0440 - SCREW BONE 5.7MM 40MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0442 SUP HCPCS C1713 30-0442 - SCREW BONE 5.7MM 42MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0444 SUP HCPCS C1713 30-0444 - SCREW BONE 5.7MM 44MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0446 SUP HCPCS C1713 30-0446 - SCREW BONE 5.7MM 46MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0448 SUP HCPCS C1713 30-0448 - SCREW BONE 5.7MM 48MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0450 SUP HCPCS C1713 30-0450 - SCREW BONE 5.7MM 50MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0452 SUP HCPCS C1713 30-0452 - SCREW BONE 5.7MM 52MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 30-0454 SUP HCPCS C1713 30-0454 - SCREW BONE 5.7MM 54MM PLRS TI PROX CANC HUM LCK BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 3005-1100S SUP HCPCS C1713 3005-1100S - CAP END STD 15.3MM HIP FEM IM NAIL TI STRL GAMMA3 11MM BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 3005-1105S SUP HCPCS C1713 3005-1105S - CAP END +5MM HIP FEM IM NAIL TI STRL GAMMA3 BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 3005-1110S SUP HCPCS C1713 3005-1110S - CAP END +10MM HIP FEM IM NAIL TI STRL GAMMA3 BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $129.94 $129.94 $0.00 $0.00 $0.00 $60.18 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $170.80 $170.80 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $45.19 $0.00 $0.00 $45.97 $0.00 $0.00 $0.00 $0.00 $0.00 3006-00 SUP Custom 27203010 3006-00 - PIN SKL BLU STRL DORO ADLT BOTH IP/OP $49.67 $36.76 $0.00 $39.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.86 $36.86 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $24.83 $39.34 $39.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3006-20 SUP Custom 27203010 3006-20 - PIN SKL TI ADLT CRNL DISP BOTH IP/OP $67.59 $50.02 $0.00 $54.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.17 $50.17 $0.00 $0.00 $14.09 $0.00 $0.00 $0.00 $0.00 $33.80 $53.53 $54.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-0650 SUP HCPCS C1713 30-0650 - SCREW BONE 50MM CANN COMPRESSION SELF CUTTING HELICAL RELIEF BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 3006570-06 SUP Custom 27203010 CABLE QUIK-COMBO THERAPY BOTH IP/OP $648.13 $479.62 $0.00 $518.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.06 $513.32 $518.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3008 A SUP HCPCS C1713 3008 A - PLATE 18MM TI BONE SPNL BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 3008 B SUP HCPCS C1713 3008 B - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 301130B SUP Custom 27203010 REAGENT MCBL KT AP CMB 2 250 TST BOTH IP/OP "$19,000.00 " "$14,060.00" $0.00 "$15,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,500.00" "$15,048.00" "$15,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3012-15008 SUP HCPCS C1713 3012-15008 - SCREW BONE HEXALOBE PTHRD 1.5MM 8MM LAG HAND NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-15009 SUP HCPCS C1713 3012-15009 - SCREW BONE 9MM LAG HEXALOBE PTHRD 1.5MM HAND NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-15010 SUP HCPCS C1713 3012-15010 - SCREW BONE 10MM LAG HEXALOBE PTHRD 1.5MM HAND NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-15011 SUP HCPCS C1713 3012-15011 - SCREW BONE 11MM HEXALOBE DRIVER LAG 1.5MM ELBOW BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-15013 SUP HCPCS C1713 3012-15013 - SCREW BONE 13MM HEXALOBE DRIVER LAG 1.5MM ELBOW BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-15014 SUP HCPCS C1713 3012-15014 - SCREW BONE 14MM HEXALOBE DRIVER LAG 1.5MM ELBOW BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-23008 SUP HCPCS C1713 3012-23008 - SCREW BONE 8MM LAG HEXALOBE PTHRD 2.3MM HAND NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-23009 SUP HCPCS C1713 3012-23009 - SCREW BONE 9MM LAG HEXALOBE 2.3MM HAND BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-23010 SUP HCPCS C1713 3012-23010 - SCREW BONE 10MM HEXALOBE LAG TITANIUM 2.3MM HAND METACARPAL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-23012 SUP HCPCS C1713 3012-23012 - SCREW BONE 12MM LAG HEXALOBE PTHRD 2.3MM HAND NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-23013 SUP HCPCS C1713 3012-23013 - SCREW BONE 2.3MM 13MM ACUMED TI HEXALOBE MTCRPL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-23016 SUP HCPCS C1713 3012-23016 - SCREW BN HEXALOBE 2.3MM 16MM YLW NS ACUMED LG LOPRFL TI BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3012-23018 SUP HCPCS C1713 3012-23018 - SCREW BONE 18MM LAG HEXALOBE PTHRD 2.3MM HAND NONSTRL BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 3013SP SUP Custom 27203010 3013SP - HEMOSTAT ABS SRGCL OXD REGENERATED CLU PWDR BOTH IP/OP $394.57 $291.98 $0.00 $315.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.85 $292.85 $0.00 $0.00 $82.23 $0.00 $0.00 $0.00 $0.00 $197.28 $312.50 $315.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3016-16 SUP Custom 27203010 CHEMICAL MTHY ALC ANHY 4L ACS LAB BOTH IP/OP $431.58 $319.37 $0.00 $345.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.79 $341.81 $345.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30170007-S SUP HCPCS C1713 30170007-S - SCREW BONE 3.6/4.3MM 16MM BIOTRAK .045IN STD KNEE RESORB BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170008-S SUP HCPCS C1713 30170008-S - SCREW BN 18MM BIOTRAK BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170009-S SUP HCPCS C1713 30170009-S - SCREW BONE 20MM BIOTRAK CALC BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170010-S SUP HCPCS C1713 30170010-S - SCREW BN 22MM BIOTRAK BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170011-S SUP HCPCS C1713 30170011-S - SCREW BN 24MM BIOTRAK BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170057-S SUP HCPCS C1713 30170057-S - SCREW BN MN 16MM BIOTRAK BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170058-S SUP HCPCS C1713 30170058-S - SCREW BN MN 18MM BIOTRAK BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170059-S SUP HCPCS C1713 30170059-S - SCREW BN MN FT TPR 3.2-3.6MM 20MM STRL BIOTRAK RSRB RDLCNT BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170060-S SUP HCPCS C1713 30170060-S - SCREW BN MN FT TPR 3.2-3.7MM 22MM STRL BIOTRAK RSRB RDLCNT BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170061-S SUP HCPCS C1713 30170061-S - SCREW BONE 3.2/3.5MM 24MM BIOTRAK .035IN MINI WRST ANKL HAND BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $727.88 $727.88 $0.00 $0.00 $0.00 $337.13 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $956.75 $956.75 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $253.14 $0.00 $0.00 $257.51 $0.00 $0.00 $0.00 $0.00 $0.00 30170320-S SUP Custom 27203010 30170320-S - PIN FX 20MM BIOTRAK BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.03 $449.03 $0.00 $0.00 $126.08 $0.00 $0.00 $0.00 $0.00 $302.50 $479.16 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30170330-S SUP Custom 27203010 30170330-S - PIN FX 30MM BIOTRAK BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.03 $449.03 $0.00 $0.00 $126.08 $0.00 $0.00 $0.00 $0.00 $302.50 $479.16 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30170340-S SUP Custom 27203010 30170340-S - PIN FX 40MM BIOTRAK BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.03 $449.03 $0.00 $0.00 $126.08 $0.00 $0.00 $0.00 $0.00 $302.50 $479.16 $484.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3044-0026 SUP Custom 27803010 3044-0026 - COMPONENT PATLR 26MM RECESSED UHMWPE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3044-0028 SUP Custom 27803010 3044-0028 - COMPONENT PATLR 28MM RECESSED UHMWPE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3044-0030 SUP Custom 27803010 3044-0030 - COMPONENT PATLR 30MM RECESSED UHMWPE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3044-0032 SUP Custom 27803010 3044-0032 - COMPONENT PATLR 32MM RECESSED UHMWPE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3045-0026 SUP Custom 27803010 3045-0026 - CMPNT PATLR MTLBLK RCSS BOTH IP/OP "$1,211.00 " $896.14 $0.00 $968.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.80 $898.80 $0.00 $0.00 $252.37 $0.00 $0.00 $0.00 $0.00 $605.50 $959.11 $968.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3045-0028 SUP Custom 27803010 3045-0028 - CMPNT PATLR MTLBLK RCSS BOTH IP/OP "$1,211.00 " $896.14 $0.00 $968.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.80 $898.80 $0.00 $0.00 $252.37 $0.00 $0.00 $0.00 $0.00 $605.50 $959.11 $968.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3045-0030 SUP Custom 27803010 3045-0030 - CMPNT PATLR MTLBLK RCSS BOTH IP/OP "$1,211.00 " $896.14 $0.00 $968.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.80 $898.80 $0.00 $0.00 $252.37 $0.00 $0.00 $0.00 $0.00 $605.50 $959.11 $968.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3045-0032 SUP Custom 27803010 3045-0032 - CMPNT PATLR MTLBLK RCSS BOTH IP/OP "$1,211.00 " $896.14 $0.00 $968.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.80 $898.80 $0.00 $0.00 $252.37 $0.00 $0.00 $0.00 $0.00 $605.50 $959.11 $968.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-5052122 SUP Custom 27203010 MILTEX HANK DILATOR SZ. 21-22 BOTH IP/OP $174.38 $129.04 $0.00 $139.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.19 $138.11 $139.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-5052324 SUP Custom 27203010 MILTEX HANK DILATOR SZ. 23-24 BOTH IP/OP $174.38 $129.04 $0.00 $139.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.19 $138.11 $139.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 30-505-2526 SUP Custom 27203010 MILTEX HANK DILATOR SZ. 25-26 BOTH IP/OP $181.85 $134.57 $0.00 $145.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.93 $144.03 $145.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3051-0308 SUP Custom 27803010 3051-0308 - INSERT TIB LG KNEE SER 1 BRNG BOTH IP/OP $985.00 $728.90 $0.00 $788.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $731.07 $731.07 $0.00 $0.00 $205.27 $0.00 $0.00 $0.00 $0.00 $492.50 $780.12 $788.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0308 SUP Custom 27803010 3052-0308 - INSERT TIBIAL 3 8MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0310 SUP Custom 27803010 3052-0310 - INSERT TIBIAL 3 10MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0312 SUP Custom 27803010 3052-0312 - INSERT TIBIAL 3 12MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0315 SUP Custom 27803010 3052-0315 - INSERT TIBIAL 3 15MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0318 SUP Custom 27803010 3052-0318 - INSERT TIBIAL 3 18MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0321 SUP Custom 27803010 3052-0321 - INSERT TIBIAL 3 21MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0324 SUP Custom 27803010 3052-0324 - INSERT TIBIAL 3 24MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0508 SUP Custom 27803010 3052-0508 - INSERT TIBIAL 5 8MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0510 SUP Custom 27803010 3052-0510 - INSERT TIBIAL 5 10MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0512 SUP Custom 27803010 3052-0512 - INSERT TIBIAL 5 12MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0515 SUP Custom 27803010 3052-0515 - INSERT TIBIAL 5 15MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0518 SUP Custom 27803010 3052-0518 - INSERT TIBIAL 5 18MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0521 SUP Custom 27803010 3052-0521 - INSERT TIBIAL 5 21MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0524 SUP Custom 27803010 3052-0524 - INSERT TIBIAL 5 24MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0708 SUP Custom 27803010 3052-0708 - INSERT TIBIAL 7 8MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0710 SUP Custom 27803010 3052-0710 - INSERT TIBIAL 7 10MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0712 SUP Custom 27803010 3052-0712 - INSERT TIBIAL 7 12MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0715 SUP Custom 27803010 3052-0715 - INSERT TIBIAL 7 15MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0718 SUP Custom 27803010 3052-0718 - INSERT TIBIAL 7 18MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0721 SUP Custom 27803010 3052-0721 - INSERT TIBIAL 7 21MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0724 SUP Custom 27803010 3052-0724 - INSERT TIBIAL 7 24MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0908 SUP Custom 27803010 3052-0908 - INSERT TIBIAL 9 8MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0910 SUP Custom 27803010 3052-0910 - INSERT TIBIAL 9 10MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0912 SUP Custom 27803010 3052-0912 - INSERT TIBIAL 9 12MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0915 SUP Custom 27803010 3052-0915 - INSERT TIBIAL 9 15MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0918 SUP Custom 27803010 3052-0918 - INSERT TIBIAL 9 18MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0921 SUP Custom 27803010 3052-0921 - INSERT TIBIAL 9 21MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-0924 SUP Custom 27803010 3052-0924 - INSERT TIBIAL 9 24MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-1108 SUP Custom 27803010 3052-1108 - INSERT TIBIAL 11 8MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-1110 SUP Custom 27803010 3052-1110 - INSERT TIBIAL 11 10MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-1112 SUP Custom 27803010 3052-1112 - INSERT TIBIAL 11 12MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-1115 SUP Custom 27803010 3052-1115 - INSERT TIBIAL 11 15MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-1118 SUP Custom 27803010 3052-1118 - INSERT TIBIAL 11 18MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-1121 SUP Custom 27803010 3052-1121 - INSERT TIBIAL 11 21MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3052-1124 SUP Custom 27803010 3052-1124 - INSERT TIBIAL 11 24MM BEARING KNEE SERIES II BOTH IP/OP "$2,060.00 " "$1,524.40" $0.00 "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,528.93" "$1,528.93" $0.00 $0.00 $429.30 $0.00 $0.00 $0.00 $0.00 "$1,030.00" "$1,631.52" "$1,648.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 305C2101 SUP Custom 27803010 305C2101 - VALVE AORTIC 21MM MSC BPRTH CNCH HLDR MODL 305 STRL BOTH IP/OP "$19,000.00 " "$14,060.00" $0.00 "$15,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,959.60" $0.00 $0.00 $0.00 $0.00 "$9,500.00" "$15,048.00" "$15,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 305C219 SUP Custom 27803010 305C219 - VALVE AORTIC 19MM MSC BPRTH CNCH HLDR MODL 305 STRL BOTH IP/OP "$2,022.50 " "$1,496.65" $0.00 "$1,618.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,501.10" "$1,501.10" $0.00 $0.00 $421.49 $0.00 $0.00 $0.00 $0.00 "$1,011.25" "$1,601.82" "$1,618.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 305C221 SUP Custom 27803010 305C221 - VALVE AORTIC 21MM MSC BPRTH CNCH HLDR MODL 305 STRL BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 305C223 SUP Custom 27803010 305C223 - VALVE AORTIC 23MM MSC CNCH BPRTH CNCH HLDR MODL 305 BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 305C227 SUP Custom 27803010 305C227 - VALVE AORTIC 27MM MSC BPRTH CNCH HLDR MODL 305 BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 305C229 SUP Custom 27803010 305C229 - VALVE AORTIC 29MM MSC BPRTH CNCH HLDR MODL 305 STRL BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0070S SUP HCPCS C1713 3060-0070S - SCREW BONE 10.5MM 70MM GAMMA3 TI TROC HIP LAG STRL LNG NAIL BOTH IP/OP $694.38 $513.84 $0.00 $555.50 $312.47 $312.47 $0.00 $0.00 $0.00 $144.73 $515.37 $515.37 $0.00 $0.00 $144.71 $0.00 $410.72 $410.72 $0.00 $347.19 $549.95 $555.50 $0.00 $0.00 $108.67 $0.00 $0.00 $110.54 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0075S SUP HCPCS C1713 3060-0075S - SCREW BN 10.5MM 75MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0080S SUP HCPCS C1713 3060-0080S - SCREW BONE 10.5MM 80MM GAMMA3 TI TROC HIP LAG STRL LNG NAIL BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0085S SUP HCPCS C1713 3060-0085S - SCREW BN 10.5MM 85MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0090S SUP HCPCS C1713 3060-0090S - SCREW BN 10.5MM 90MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0095S SUP HCPCS C1713 3060-0095S - SCREW BN 10.5MM 95MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0100S SUP HCPCS C1713 3060-0100S - SCREW BN 10.5MM 100MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0105S SUP HCPCS C1713 3060-0105S - SCREW BN 10.5MM 105MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0110S SUP HCPCS C1713 3060-0110S - SCREW BN 10.5MM 110MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0115S SUP HCPCS C1713 3060-0115S - SCREW BN 10.5MM 115MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0120S SUP HCPCS C1713 3060-0120S - SCREW BN 10.5MM 120MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $361.97 $361.97 $0.00 $0.00 $0.00 $167.65 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $475.79 $475.79 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $125.88 $0.00 $0.00 $128.06 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0125S SUP HCPCS C1713 3060-0125S - SCREW BN 10.5MM 125MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 3060-0130S SUP HCPCS C1713 3060-0130S - SCREW BN 10.5MM 130MM STRL GAMMA3 LG TI HIP TROCH NL 180 BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 3060L SUP Custom 27203010 RESTRAINT VST 65IN MED QRLSE TIE BACK CLSR STRAP BOTH IP/OP $42.03 $31.10 $0.00 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.01 $33.29 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3060M SUP Custom 27203010 RESTRAINT VST 65IN MED CTTN QRLSE TIE BACK CLSR STRAP BOTH IP/OP $42.03 $31.10 $0.00 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.01 $33.29 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3060S SUP Custom 27203010 RESTRAINT VST 65IN SM QRLSE TIE BACK CLSR STRAP BOTH IP/OP $42.03 $31.10 $0.00 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.01 $33.29 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3060XL SUP Custom 27203010 RESTRAINT VST 75IN XL QRLSE TIE BACK CLSR STRAP BOTH IP/OP $42.03 $31.10 $0.00 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.01 $33.29 $33.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3060XXXL SUP Custom 27203010 RESTRAINT VST 3XL ZP QRLSE STRAP MESH BOTH IP/OP $61.23 $45.31 $0.00 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.61 $48.49 $48.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 309.004S SUP Custom 27203010 309.004S - BIT DRL 4MM STRL CRB 3.5MM SCR BOTH IP/OP $524.33 $388.00 $0.00 $407.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.15 $389.15 $0.00 $0.00 $109.27 $0.00 $0.00 $0.00 $0.00 $254.53 $403.17 $407.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 309.006S SUP Custom 27203010 309.006S - BIT DRL 6MM STRL CRB BOTH IP/OP $597.43 $442.10 $0.00 $464.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.41 $443.41 $0.00 $0.00 $124.50 $0.00 $0.00 $0.00 $0.00 $290.01 $459.38 $464.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3092-040 SUP HCPCS C1713 CEMENT BONE ENDRN SST 40GM HVISC STRL BOTH IP/OP $365.00 $270.10 $0.00 $292.00 $164.25 $164.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.50 $289.08 $292.00 $0.00 $0.00 $57.12 $0.00 $0.00 $58.11 $0.00 $0.00 $0.00 $0.00 $0.00 310.11.98 SUP Custom 27203010 310.11.98 - BIT DRILL 60MM 1.1MM QC NONSTRL BOTH IP/OP $209.25 $154.85 $0.00 $167.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $104.63 $165.73 $167.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.15.98 SUP Custom 27203010 310.15.98 - BIT DRILL 85MM 1.5MM QC W/O STOP NONSTRL BOTH IP/OP $209.25 $154.85 $0.00 $167.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $104.63 $165.73 $167.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.16.98 SUP Custom 27203010 310.16.98 - BIT DRILL 110MM 1.5MM QC W/O STOP NONSTRL BOTH IP/OP $209.25 $154.85 $0.00 $167.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $104.63 $165.73 $167.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.16J SUP Custom 27203010 310.16J - BIT DRILL 1.5MM 95MM JACOBS CHUCK NONSTRL BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.21.98 SUP Custom 27203010 310.21.98 - BIT DRILL 125MM 2MM QC W/O STOP NONSTRL BOTH IP/OP $234.00 $173.16 $0.00 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.67 $173.67 $0.00 $0.00 $48.77 $0.00 $0.00 $0.00 $0.00 $117.00 $185.33 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.21J SUP Custom 27203010 310.21J - BIT DRILL LONG 2MM 110MM JACOBS CHUCK DCP STAINLESS STEEL BOTH IP/OP $135.63 $100.37 $0.00 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.66 $100.66 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $65.84 $104.29 $105.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.-288 SUP Custom 27203010 BIT DRILL 165MM 2.8MM QC NSTRL BOTH IP/OP $238.60 $176.56 $0.00 $190.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.30 $188.97 $190.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.28J SUP Custom 27203010 310.28J - BIT DRILL 2.7MM 110MM JACOBS CHUCK STERILE BOTH IP/OP $143.38 $106.10 $0.00 $111.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.41 $106.41 $0.00 $0.00 $29.88 $0.00 $0.00 $0.00 $0.00 $69.60 $110.25 $111.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.31. SUP Custom 27203010 310.31. - DRILL BIT 3.2MM X 145MM QUICK COUPLING BOTH IP/OP $91.79 $67.92 $0.00 $73.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.13 $68.13 $0.00 $0.00 $19.13 $0.00 $0.00 $0.00 $0.00 $45.90 $72.70 $73.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310.60J SUP Custom 27203010 310.60J - BIT DRILL 6MM 195MM JACOBS CHUCK NONSTRL BOTH IP/OP $282.55 $209.09 $0.00 $219.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $209.71 $209.71 $0.00 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $137.16 $217.27 $219.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3100-25 SUP Custom 27203010 KIT SYR ART LN 25 UN 1ML BAL HEP BOTH IP/OP $1.35 $1.00 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.68 $1.07 $1.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31004U SUP Custom 27203010 KIT IMMUN TST ELISA SPHL IGG 96 TST BOTH IP/OP $343.20 $253.97 $0.00 $274.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.60 $271.81 $274.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310-25M SUP Custom 27803010 310-25M - VALVE MTRL 25MM MSC CNCH PIG BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310-31M SUP Custom 27803010 310-31M - VALVE MTRL 31MM MSC CNCH PIG BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310-33M SUP Custom 27803010 310-33M - VALVE MTRL 33MM MSC CNCH PIG BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 310C29 SUP Custom 27803010 310C29 - VALVE MTRL 29MM MSC HRT PIG CNCH HLDR 310 BOTH IP/OP "$19,500.00 " "$14,430.00" $0.00 "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,063.80" $0.00 $0.00 $0.00 $0.00 "$9,750.00" "$15,444.00" "$15,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 311.031.01S SUP HCPCS C1713 311.031.01S - TAP 4MM SLFDRILL MNQK CPLNG STOP SURG 1.5MM RESORB CORTEX BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.032.01S SUP HCPCS C1713 311.032.01S - TAP 6MM SLFDRILL MNQK CPLNG STOP SURG 1.5MM RESORB CORTEX BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.033.01S SUP HCPCS C1713 311.033.01S - TAP 3MM SLFDRILL MNQK CPLNG STOP SURG 1.5MM RESORB CORTEX BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.034.01S SUP HCPCS C1713 311.034.01S - TAP 2MM RESORB CORTEX SCR 4MM SLFDRILL MNQK CPLNG STOP SURG BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.035.01S SUP HCPCS C1713 311.035.01S - TAP 5MM SLFDRILL MNQK CPLNG STOP SURG 1.5MM RESORB CORTEX BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.035.97S SUP HCPCS C1713 311.035.97S - TAP SURG 1.5MM 5MM RESORB STOP STERILE CORTICAL SCREW BOTH IP/OP $700.20 $518.15 $0.00 $543.84 $305.91 $305.91 $0.00 $0.00 $0.00 $145.94 $519.69 $519.69 $0.00 $0.00 $145.92 $0.00 $414.17 $414.17 $0.00 $339.90 $538.40 $543.84 $0.00 $0.00 $103.29 $0.00 $0.00 $108.22 $0.00 $0.00 $0.00 $0.00 $0.00 311.036.01S SUP HCPCS C1713 311.036.01S - TAP 2MM RESORB CORTEX SCR 6MM SLFDRILL MNQK CPLNG STOP SURG BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.037.01S SUP HCPCS C1713 311.037.01S - TAP 8MM SLFDRILL MNQK CPLNG STOP SURG 1.5MM RESORB CORTEX BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.038.01S SUP HCPCS C1713 311.038.01S - TAP 2MM RESORB CORTEX SCR 8MM SLFDRILL MNQK CPLNG STOP SURG BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.044.01S SUP HCPCS C1713 311.044.01S - TAP 4MM SLFDRILL MNQK CPLNG STOP SURG 2.5MM RESORB ER SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.046.01S SUP HCPCS C1713 311.046.01S - TAP 6MM SLFDRILL MNQK CPLNG STOP SURG 2.5MM RESORB ER SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.048.01S SUP HCPCS C1713 311.048.01S - TAP 8MM SLFDRILL MNQK CPLNG STOP SURG 2.5MM RESORB ER SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.054.01S SUP HCPCS C1713 311.054.01S - TAP 2MM RESORB CORTEX SCR 1.5MM PLT 4MM SLFDRILL MNQK CPLNG BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.056.01S SUP HCPCS C1713 311.056.01S - TAP 2MM RESORB CORTEX SCR 1.5MM PLT 6MM SLFDRILL MNQK CPLNG BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.056.97S SUP HCPCS C1713 311.056.97S - TAP SURG 6MM STERILE 2MM RESORB CORTICAL SCREW BOTH IP/OP $700.20 $518.15 $0.00 $543.84 $305.91 $305.91 $0.00 $0.00 $0.00 $145.94 $519.69 $519.69 $0.00 $0.00 $145.92 $0.00 $414.17 $414.17 $0.00 $339.90 $538.40 $543.84 $0.00 $0.00 $103.29 $0.00 $0.00 $108.22 $0.00 $0.00 $0.00 $0.00 $0.00 311.058.01S SUP HCPCS C1713 311.058.01S - TAP 2MM RESORB CORTEX SCR 1.5MM PLT 8MM SLFDRILL MNQK CPLNG BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.060.01S SUP HCPCS C1713 311.060.01S - TAP 4MM STOP SLFDRILL HEX CPLNG SURG 1.5MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.061.01S SUP HCPCS C1713 311.061.01S - TAP 6MM STOP SLFDRILL HEX CPLNG SURG 1.5MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.062.01S SUP HCPCS C1713 311.062.01S - TAP 3MM SLFDRILL HEX CPLNG STOP SURG 1.5MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.063.01S SUP HCPCS C1713 311.063.01S - TAP 4MM STOP SLFDRILL HEX CPLNG SURG 2MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.064.01S SUP HCPCS C1713 311.064.01S - TAP 6MM STOP SLFDRILL HEX CPLNG SURG 2MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.065.01S SUP HCPCS C1713 311.065.01S - TAP 2MM RESORB CORTEX SCR 8MM SLFDRILL HEX CPLNG STOP SURG BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.067.01S SUP HCPCS C1713 311.067.01S - TAP 4MM SLFDRILL HEX CPLNG STOP SURG 2MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.068.01S SUP HCPCS C1713 311.068.01S - TAP 6MM SLFDRILL HEX CPLNG STOP SURG 2MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.069.01S SUP HCPCS C1713 311.069.01S - TAP 2MM RESORB CORTEX SCR 1.5MM PLT 8MM SLFDRILL HEX CPLNG BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.071.01S SUP HCPCS C1713 311.071.01S - TAP 4MM SLFDRILL HEX CPLNG STOP SURG 2.5MM RESORB ER SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.072.01S SUP HCPCS C1713 311.072.01S - TAP 6MM SLFDRILL HEX CPLNG STOP SURG 2.5MM RESORB ER SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.073.01S SUP HCPCS C1713 311.073.01S - TAP 8MM SLFDRILL HEX CPLNG STOP SURG 2.5MM RESORB ER SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.093.01S SUP HCPCS C1713 311.093.01S - TAP 5MM SLFDRILL HEX CPLNG STOP SURG 1.5MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.094.01S SUP HCPCS C1713 311.094.01S - TAP 8MM SLFDRILL HEX CPLNG STOP SURG 1.5MM RESORB CORTEX SCR BOTH IP/OP $751.50 $556.11 $0.00 $601.20 $338.18 $338.18 $0.00 $0.00 $0.00 $156.63 $557.76 $557.76 $0.00 $0.00 $156.61 $0.00 $444.51 $444.51 $0.00 $375.75 $595.19 $601.20 $0.00 $0.00 $117.61 $0.00 $0.00 $119.64 $0.00 $0.00 $0.00 $0.00 $0.00 311.100.01S SUP HCPCS C1713 311.100.01S - TAP SLFDRILL ADJ LGTH SURG 1.5 MM SCR STRL BOTH IP/OP "$1,021.50 " $755.91 $0.00 $817.20 $459.68 $459.68 $0.00 $0.00 $0.00 $212.91 $758.16 $758.16 $0.00 $0.00 $212.88 $0.00 $604.22 $604.22 $0.00 $510.75 $809.03 $817.20 $0.00 $0.00 $159.86 $0.00 $0.00 $162.62 $0.00 $0.00 $0.00 $0.00 $0.00 311.101.01S SUP HCPCS C1713 311.101.01S - TAP SLFDRILL ADJ LGTH SURG 2 MM SCR STRL BOTH IP/OP "$1,021.50 " $755.91 $0.00 $817.20 $459.68 $459.68 $0.00 $0.00 $0.00 $212.91 $758.16 $758.16 $0.00 $0.00 $212.88 $0.00 $604.22 $604.22 $0.00 $510.75 $809.03 $817.20 $0.00 $0.00 $159.86 $0.00 $0.00 $162.62 $0.00 $0.00 $0.00 $0.00 $0.00 311.102.01S SUP HCPCS C1713 311.102.01S - TAP SLFDRILL ADJ LGTH SURG 2.5 MM SCR STRL BOTH IP/OP "$1,021.50 " $755.91 $0.00 $817.20 $459.68 $459.68 $0.00 $0.00 $0.00 $212.91 $758.16 $758.16 $0.00 $0.00 $212.88 $0.00 $604.22 $604.22 $0.00 $510.75 $809.03 $817.20 $0.00 $0.00 $159.86 $0.00 $0.00 $162.62 $0.00 $0.00 $0.00 $0.00 $0.00 311.110.01S SUP HCPCS C1713 311.110.01S - TAP SLFDRILL HEX CPLNG ADJ SURG 1.5 MM RESORB CORTEX SCR BOTH IP/OP "$1,021.50 " $755.91 $0.00 $817.20 $459.68 $459.68 $0.00 $0.00 $0.00 $212.91 $758.16 $758.16 $0.00 $0.00 $212.88 $0.00 $604.22 $604.22 $0.00 $510.75 $809.03 $817.20 $0.00 $0.00 $159.86 $0.00 $0.00 $162.62 $0.00 $0.00 $0.00 $0.00 $0.00 311.111.01S SUP HCPCS C1713 311.111.01S - TAP SLFDRILL HEX CPLNG ADJ SURG 2 MM RESORB CORTEX SCR STRL BOTH IP/OP "$1,021.50 " $755.91 $0.00 $817.20 $459.68 $459.68 $0.00 $0.00 $0.00 $212.91 $758.16 $758.16 $0.00 $0.00 $212.88 $0.00 $604.22 $604.22 $0.00 $510.75 $809.03 $817.20 $0.00 $0.00 $159.86 $0.00 $0.00 $162.62 $0.00 $0.00 $0.00 $0.00 $0.00 311.112.01S SUP HCPCS C1713 311.112.01S - TAP SLFDRILL ADJ LGTH HEX CPLNG SURG 2.5 MM SCR STRL BOTH IP/OP "$1,021.50 " $755.91 $0.00 $817.20 $459.68 $459.68 $0.00 $0.00 $0.00 $212.91 $758.16 $758.16 $0.00 $0.00 $212.88 $0.00 $604.22 $604.22 $0.00 $510.75 $809.03 $817.20 $0.00 $0.00 $159.86 $0.00 $0.00 $162.62 $0.00 $0.00 $0.00 $0.00 $0.00 311.21.98 SUP HCPCS C1713 311.21.98 - TAP LNG MNQK CPLNG SURG 2MM CORTEX SCR BOTH IP/OP $283.50 $209.79 $0.00 $226.80 $127.58 $127.58 $0.00 $0.00 $0.00 $59.09 $210.41 $210.41 $0.00 $0.00 $59.08 $0.00 $167.69 $167.69 $0.00 $141.75 $224.53 $226.80 $0.00 $0.00 $44.37 $0.00 $0.00 $45.13 $0.00 $0.00 $0.00 $0.00 $0.00 3120-0170S SUP HCPCS C1713 3120-0170S - NAIL 10MM 170MM TROC HIP GAMMA3 IM 120D TI STRL BOTH IP/OP "$2,710.65 " "$2,005.88" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $564.97 "$2,011.84" "$2,011.84" $0.00 $0.00 $564.90 $0.00 "$1,336.35" "$1,336.35" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3120-1180S SUP HCPCS C1713 3120-1180S - NAIL 11MM 180MM TROC HIP GAMMA3 IM 120D TI STRL BOTH IP/OP "$2,124.38 " "$1,572.04" $0.00 "$1,699.50" $955.97 $955.97 $0.00 $0.00 $0.00 $442.77 "$1,576.71" "$1,576.71" $0.00 $0.00 $442.72 $0.00 "$1,256.57" "$1,256.57" $0.00 "$1,062.19" "$1,682.51" "$1,699.50" $0.00 $0.00 $332.46 $0.00 $0.00 $338.20 $0.00 $0.00 $0.00 $0.00 $0.00 3125-0170S SUP HCPCS C1713 3125-0170S - NAIL 10MM 170MM TROC HIP GAMMA3 IM 125D TI STRL BOTH IP/OP "$2,710.65 " "$2,005.88" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $564.97 "$2,011.84" "$2,011.84" $0.00 $0.00 $564.90 $0.00 "$1,336.35" "$1,336.35" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3125-1180S SUP HCPCS C1713 3125-1180S - NAIL 11MM 180MM TROC HIP GAMMA3 IM 125D TI STRL BOTH IP/OP "$2,124.38 " "$1,572.04" $0.00 "$1,699.50" $955.97 $955.97 $0.00 $0.00 $0.00 $442.77 "$1,576.71" "$1,576.71" $0.00 $0.00 $442.72 $0.00 "$1,256.57" "$1,256.57" $0.00 "$1,062.19" "$1,682.51" "$1,699.50" $0.00 $0.00 $332.46 $0.00 $0.00 $338.20 $0.00 $0.00 $0.00 $0.00 $0.00 31287751A SUP Custom 27203010 CABLE EKG 5 LEAD 12 PNDN PT MONITR D-1585 BOTH IP/OP $327.50 $242.35 $0.00 $262.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.75 $259.38 $262.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3130-0170S SUP HCPCS C1713 3130-0170S - NAIL 10MM 170MM HIP TROC GAMMA3 IM 130D KIT TI STRL BOTH IP/OP "$2,710.65 " "$2,005.88" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $564.97 "$2,011.84" "$2,011.84" $0.00 $0.00 $564.90 $0.00 "$1,336.35" "$1,336.35" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3130-1180S SUP HCPCS C1713 3130-1180S - NAIL 11MM 180MM TROC HIP GAMMA3 IM 130D TI STRL BOTH IP/OP "$2,124.38 " "$1,572.04" $0.00 "$1,699.50" $955.97 $955.97 $0.00 $0.00 $0.00 $442.77 "$1,576.71" "$1,576.71" $0.00 $0.00 $442.72 $0.00 "$1,256.57" "$1,256.57" $0.00 "$1,062.19" "$1,682.51" "$1,699.50" $0.00 $0.00 $332.46 $0.00 $0.00 $338.20 $0.00 $0.00 $0.00 $0.00 $0.00 313-7034EA SUP Custom 27203010 313-7034EA - MASK CPAP 02 RESQ BITRAC ED WITH 7.5 CM VALVE & FLOW GENERAT BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 314.746S SUP Custom 27203010 314.746S - ASSEMBLY TUBE 520MM REAMER IRRIGATOR ASPIRAT STERILE BOTH IP/OP $824.18 $609.89 $0.00 $640.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.70 $611.70 $0.00 $0.00 $171.76 $0.00 $0.00 $0.00 $0.00 $400.09 $633.74 $640.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31-462 SUP HCPCS C1887 31-462 - CATHETER 5FR 65CM COBRA 1 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 31-466 SUP HCPCS C1887 31-466 - CATHETER 5FR 65CM COBRA 2 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 315.40S SUP Custom 27203010 315.40S - BIT DRILL 195MM 4MM QC 3 FLT STRL BOTH IP/OP $380.73 $281.74 $0.00 $295.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.57 $282.57 $0.00 $0.00 $79.34 $0.00 $0.00 $0.00 $0.00 $184.83 $292.76 $295.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31560-950 SUP Custom 27203010 BULB SCP 3.5V FBROP LGHT HEAD ANOSCP SGSCP KLNSPC DISP BOTH IP/OP "$1,092.50 " $808.45 $0.00 $874.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.25 $865.26 $874.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 315-92 SUP Custom 27203010 BIT DRILL 230MM 2.5MM 200MM CLBRT QC 3 FLT NSTRL BOTH IP/OP $456.10 $337.51 $0.00 $364.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.05 $361.23 $364.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.114.96 SUP Custom 27203010 316.114.96 - BIT DRILL 14MM STOP .76MM 44.5MM J LATCH NONSTRL BOTH IP/OP $246.00 $182.04 $0.00 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.58 $182.58 $0.00 $0.00 $51.27 $0.00 $0.00 $0.00 $0.00 $119.41 $189.15 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.235.96 SUP Custom 27203010 316.235.96 - BIT DRILL 35MM STOP 1MM 60MM J LATCH NONSTRL BOTH IP/OP $246.00 $182.04 $0.00 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.58 $182.58 $0.00 $0.00 $51.27 $0.00 $0.00 $0.00 $0.00 $119.41 $189.15 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 316.335.96 SUP Custom 27203010 316.335.96 - BIT DRILL 40MM STOP 1.3MM 65MM J LATCH NONSTRL BOTH IP/OP $246.00 $182.04 $0.00 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.58 $182.58 $0.00 $0.00 $51.27 $0.00 $0.00 $0.00 $0.00 $119.41 $189.15 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.235.96 SUP Custom 27203010 317.235.96 - BIT DRILL 40MM STOP 1.1MM 65MM J LATCH TITANIUM NONSTRL BOTH IP/OP $246.00 $182.04 $0.00 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.58 $182.58 $0.00 $0.00 $51.27 $0.00 $0.00 $0.00 $0.00 $119.41 $189.15 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 317.435.96 SUP Custom 27203010 317.435.96 - BIT DRILL 60MM STOP 1.5MM 85MM J LATCH NONSTRL BOTH IP/OP $246.00 $182.04 $0.00 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.58 $182.58 $0.00 $0.00 $51.27 $0.00 $0.00 $0.00 $0.00 $119.41 $189.15 $191.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 319416AM SUP Custom 27203010 319416AM - TRAY CATHETERIZATION 16FR 2 CONCTR TEMPERATURE SENSE BOTH IP/OP $66.48 $49.20 $0.00 $54.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.34 $49.34 $0.00 $0.00 $13.85 $0.00 $0.00 $0.00 $0.00 $34.28 $54.30 $54.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31AJ-501 SUP Custom 27803010 31AJ-501 - VALVE AORTIC 85D 5.18SQ CM 31MM 26.1MM MECHANICAL HEART BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 31MJ-501 SUP Custom 27803010 31MJ-501 - VALVE MTRL 85D 5.18SQ CM STD 31MM 26.1MM MSTR-SER CUF LFLT BOTH IP/OP "$17,425.00 " "$12,894.50" $0.00 "$13,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,631.37" $0.00 $0.00 $0.00 $0.00 "$8,712.50" "$13,800.60" "$13,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0240S SUP HCPCS C1713 3220-0240S - NAIL 11MM 240MM RIGHT FEM HIP GAMMA3 IM 120D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0260S SUP HCPCS C1713 3220-0260S - NAIL 11MM 260MM RIGHT FEM HIP GAMMA3 IM 120D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0280S SUP HCPCS C1713 3220-0280S - NAIL 11MM 28CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0300S SUP HCPCS C1713 3220-0300S - NAIL 11MM 30CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0320S SUP HCPCS C1713 3220-0320S - NAIL 11MM 32CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0340S SUP HCPCS C1713 3220-0340S - NAIL 11MM 34CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0360S SUP HCPCS C1713 3220-0360S - NAIL 11MM 36CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0380S SUP HCPCS C1713 3220-0380S - NAIL 11MM 38CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0400S SUP HCPCS C1713 3220-0400S - NAIL 11MM 40CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0420S SUP HCPCS C1713 3220-0420S - NAIL 11MM 42CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0440S SUP HCPCS C1713 3220-0440S - NAIL 11MM 44CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3220-0460S SUP HCPCS C1713 3220-0460S - NAIL 11MM 46CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3220-3340S SUP HCPCS C1713 3220-3340S - NAIL 13MM 34CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-3360S SUP HCPCS C1713 3220-3360S - NAIL 13MM 36CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-3380S SUP HCPCS C1713 3220-3380S - NAIL 13MM 38CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-3400S SUP HCPCS C1713 3220-3400S - NAIL 13MM 40CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-3420S SUP HCPCS C1713 3220-3420S - NAIL 13MM 42CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-3440S SUP HCPCS C1713 3220-3440S - NAIL 13MM 44CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-3460S SUP HCPCS C1713 3220-3460S - NAIL 13MM 46CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-5340S SUP HCPCS C1713 3220-5340S - NAIL 15MM 34CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-5360S SUP HCPCS C1713 3220-5360S - NAIL 15MM 36CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-5380S SUP HCPCS C1713 3220-5380S - NAIL 15MM 38CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-5400S SUP HCPCS C1713 3220-5400S - NAIL 15MM 40CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-5420S SUP HCPCS C1713 3220-5420S - NAIL 15MM 42CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-5440S SUP HCPCS C1713 3220-5440S - NAIL 15MM 44CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3220-5460S SUP HCPCS C1713 3220-5460S - NAIL 15MM 46CM RIGHT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 32-250 SUP HCPCS C1713 32-250 - HOLDER NDL CRV 9IN STRATTE INS SHNK TC BOTH IP/OP $373.33 $276.26 $0.00 $298.66 $168.00 $168.00 $0.00 $0.00 $0.00 $77.81 $277.08 $277.08 $0.00 $0.00 $77.80 $0.00 $220.82 $220.82 $0.00 $186.66 $295.68 $298.66 $0.00 $0.00 $58.43 $0.00 $0.00 $59.43 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0240S SUP HCPCS C1713 3225-0240S - NAIL 11MM 240MM HIP RIGHT GAMMA3 IM 125D LNG BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0260S SUP HCPCS C1713 3225-0260S - NAIL 11MM 260MM RIGHT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,688.13 " "$1,989.22" $0.00 "$2,150.50" "$1,209.66" "$1,209.66" $0.00 $0.00 $0.00 $560.27 "$1,995.13" "$1,995.13" $0.00 $0.00 $560.21 $0.00 "$1,325.25" "$1,325.25" $0.00 "$1,344.06" "$2,129.00" "$2,150.50" $0.00 $0.00 $420.69 $0.00 $0.00 $427.95 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0280S SUP HCPCS C1713 3225-0280S - NAIL 11MM 28CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0300S SUP HCPCS C1713 3225-0300S - NAIL 11MM 30CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0320S SUP HCPCS C1713 3225-0320S - NAIL 11MM 32CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0340S SUP HCPCS C1713 3225-0340S - NAIL 11MM 34CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0360S SUP HCPCS C1713 3225-0360S - NAIL 11MM 36CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0380S SUP HCPCS C1713 3225-0380S - NAIL 11MM 38CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0400S SUP HCPCS C1713 3225-0400S - NAIL 11MM 40CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0420S SUP HCPCS C1713 3225-0420S - NAIL 11MM 42CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0440S SUP HCPCS C1713 3225-0440S - NAIL 11MM 44CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3225-0460S SUP HCPCS C1713 3225-0460S - NAIL 11MM 46CM RIGHT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3300S SUP HCPCS C1713 3225-3300S - NAIL 13MM 300MM RIGHT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,688.13 " "$1,989.22" $0.00 "$2,150.50" "$1,209.66" "$1,209.66" $0.00 $0.00 $0.00 $560.27 "$1,995.13" "$1,995.13" $0.00 $0.00 $560.21 $0.00 "$1,325.25" "$1,325.25" $0.00 "$1,344.06" "$2,129.00" "$2,150.50" $0.00 $0.00 $420.69 $0.00 $0.00 $427.95 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3320S SUP HCPCS C1713 3225-3320S - NAIL 13MM 32CM HIP RIGHT FEM GAMMA3 IM 125D LNG TI STRL BOTH IP/OP "$2,688.13 " "$1,989.22" $0.00 "$2,150.50" "$1,209.66" "$1,209.66" $0.00 $0.00 $0.00 $560.27 "$1,995.13" "$1,995.13" $0.00 $0.00 $560.21 $0.00 "$1,325.25" "$1,325.25" $0.00 "$1,344.06" "$2,129.00" "$2,150.50" $0.00 $0.00 $420.69 $0.00 $0.00 $427.95 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3340S SUP HCPCS C1713 3225-3340S - NAIL 13MM 34CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3360S SUP HCPCS C1713 3225-3360S - NAIL 13MM 36CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3380S SUP HCPCS C1713 3225-3380S - NAIL 13MM 38CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3400S SUP HCPCS C1713 3225-3400S - NAIL 13MM 40CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3420S SUP HCPCS C1713 3225-3420S - NAIL 13MM 42CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3440S SUP HCPCS C1713 3225-3440S - NAIL 13MM 44CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-3460S SUP HCPCS C1713 3225-3460S - NAIL 13MM 46CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5300S SUP HCPCS C1713 3225-5300S - NAIL 15MM 300MM RIGHT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5320S SUP HCPCS C1713 3225-5320S - NAIL 15MM 320MM RIGHT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5340S SUP HCPCS C1713 3225-5340S - NAIL 15MM 34CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5360S SUP HCPCS C1713 3225-5360S - NAIL 15MM 36CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5380S SUP HCPCS C1713 3225-5380S - NAIL 15MM 38CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5400S SUP HCPCS C1713 3225-5400S - NAIL 15MM 40CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5420S SUP HCPCS C1713 3225-5420S - NAIL 15MM 42CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5440S SUP HCPCS C1713 3225-5440S - NAIL 15MM 44CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3225-5460S SUP HCPCS C1713 3225-5460S - NAIL 15MM 46CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0240S SUP HCPCS C1713 3230-0240S - NAIL 11MM 240MM RIGHT FEM HIP GAMMA3 IM LNG 130D STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0260S SUP HCPCS C1713 3230-0260S - NAIL 11MM 260MM RIGHT FEM HIP GAMMA3 IM 130D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0280S SUP HCPCS C1713 3230-0280S - NAIL 11MM 28CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0300S SUP HCPCS C1713 3230-0300S - NAIL 11MM 30CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0320S SUP HCPCS C1713 3230-0320S - NAIL 11MM 32CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0340S SUP HCPCS C1713 3230-0340S - NAIL 11MM 34CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0360S SUP HCPCS C1713 3230-0360S - NAIL 11MM 36CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0380S SUP HCPCS C1713 3230-0380S - NAIL 11MM 38CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0400S SUP HCPCS C1713 3230-0400S - NAIL 11MM 40CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0420S SUP HCPCS C1713 3230-0420S - NAIL 11MM 42CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0440S SUP HCPCS C1713 3230-0440S - NAIL 11MM 44CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-0460S SUP HCPCS C1713 3230-0460S - NAIL 11MM 46CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3300S SUP HCPCS C1713 3230-3300S - NAIL 13MM 300MM RIGHT FEM HIP GAMMA3 IM 130D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3320S SUP HCPCS C1713 3230-3320S - NAIL 13MM 32CM HIP RIGHT GAMMA3 IM LNG 130D BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3340S SUP HCPCS C1713 3230-3340S - NAIL 13MM 34CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3360S SUP HCPCS C1713 3230-3360S - NAIL 13MM 36CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3380S SUP HCPCS C1713 3230-3380S - NAIL 13MM 38CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3400S SUP HCPCS C1713 3230-3400S - NAIL 13MM 40CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3420S SUP HCPCS C1713 3230-3420S - NAIL 13MM 42CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3440S SUP HCPCS C1713 3230-3440S - NAIL 13MM 44CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-3460S SUP HCPCS C1713 3230-3460S - NAIL 13MM 46CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 323040R SUP Custom 27803010 323040R - KEEL LARYNGEAL 12MM UMBRELLA SHAPE RADIOPQ MONTGOMERY BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 323050R SUP Custom 27803010 323050R - KEEL LARYNGEAL 14MM UMBRELLA SHAPE RADIOPQ MONTGOMERY BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $0.00 $0.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3230-5340S SUP HCPCS C1713 3230-5340S - NAIL 15MM 34CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-5360S SUP HCPCS C1713 3230-5360S - NAIL 15MM 36CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-5380S SUP HCPCS C1713 3230-5380S - NAIL 15MM 38CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-5400S SUP HCPCS C1713 3230-5400S - NAIL 15MM 40CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-5420S SUP HCPCS C1713 3230-5420S - NAIL 15MM 42CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-5440S SUP HCPCS C1713 3230-5440S - NAIL 15MM 44CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3230-5460S SUP HCPCS C1713 3230-5460S - NAIL 15MM 46CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 325014S SUP HCPCS C1713 325014S - SCREW BN P/T LOPRFL RVRS CUT FLUT FLT HEX 4MM 5MM 14MM STRL BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325016S SUP HCPCS C1713 325016S - SCREW BONE 4MM 16MM 8MM ASNS 3 SS ORTH SLFTAP SLFDRILL CANN BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325018S SUP HCPCS C1713 325018S - SCREW BN 4MM 18MM STRL ASNS III P/T IMPL SS BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325020S SUP HCPCS C1713 325020S - SCREW BONE 4MM 20MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325022S SUP HCPCS C1713 325022S - SCREW BONE 4MM 22MM 8MM ASNS 3 SS ORTH SLFTAP SLFDRILL CANN BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325024S SUP HCPCS C1713 325024S - SCREW BONE 4MM 24MM 8MM ASNS 3 SS ORTH SLFTAP SLFDRILL CANN BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325026S SUP HCPCS C1713 325026S - SCREW BN P/T 4MM 26MM STRL 9MM ASNS III ST SLF DRL CNN SS BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325028S SUP HCPCS C1713 325028S - SCREW BN 4MM 28MM STRL 9.5MM ASNS III SLF DRL ST CNN SS HIP BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325030S SUP HCPCS C1713 325030S - SCREW BN P/T 4MM 30MM STRL ASNS III ST SLF DRL CNN SS HIP BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $120.04 $120.04 $0.00 $0.00 $0.00 $55.60 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 325210S SUP HCPCS C1713 325210S - SCREW BONE 4MM 10MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325212S SUP HCPCS C1713 325212S - SCREW BONE 4MM 12MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325214S SUP HCPCS C1713 325214S - SCREW BONE 4MM 14MM ASNS 3 SS FULTHRD CANN IMPL STRL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325216S SUP HCPCS C1713 325216S - SCREW BONE 4MM 16MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325218S SUP HCPCS C1713 325218S - SCREW BONE 4MM 18MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325220S SUP HCPCS C1713 325220S - SCREW BONE 4MM 20MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325222S SUP HCPCS C1713 325222S - SCREW BONE 4MM 22MM ASNS 3 SS FULTHRD CANN IMPL STRL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325224S SUP HCPCS C1713 325224S - SCREW BONE 4MM 24MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325226S SUP HCPCS C1713 325226S - SCREW BONE 4MM 26MM ASNS 3 SS FULTHD FEM HIP SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325228S SUP HCPCS C1713 325228S - SCREW BONE 4MM 28MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325230S SUP HCPCS C1713 325230S - SCREW BONE 4MM 30MM ASNS 3 SS FULTHD FEM HIP SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325232S SUP HCPCS C1713 325232S - SCREW BONE 4MM 32MM ASNS 3 SS CANN BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325234S SUP HCPCS C1713 325234S - SCREW BONE 4MM 34MM ASNS 3 SS FULTHD FEM HIP SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325236S SUP HCPCS C1713 325236S - SCREW BONE 4MM 36MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325238S SUP HCPCS C1713 325238S - SCREW BONE 4MM 38MM ASNS 3 SS FULTHD FEM HIP SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325240S SUP HCPCS C1713 325240S - SCREW BONE 4MM 40MM ASNS 3 SS FULTHD HIP CANN SLFTAP BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325242S SUP HCPCS C1713 325242S - SCREW BONE 4MM 42MM ASNS 3 SS CANN BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325244S SUP HCPCS C1713 325244S - SCREW BONE 4MM 44MM ASNS 3 SS FULTHD HIP CANN SLFTAP BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325246S SUP HCPCS C1713 325246S - SCREW BONE 4MM 46MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325248S SUP HCPCS C1713 325248S - SCREW BONE 4MM 48MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325250S SUP HCPCS C1713 325250S - SCREW BONE 4MM 50MM ASNS 3 SS PTHRD HIP CANN STRL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 325260S SUP HCPCS C1713 325260S - SCREW BONE 6.5MM 60MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $242.25 $179.27 $0.00 $179.80 $92.81 $92.81 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325265S SUP HCPCS C1713 325265S - SCREW BONE 6.5MM 65MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $206.25 $152.63 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $42.99 $153.08 $153.08 $0.00 $0.00 $42.98 $0.00 $122.00 $122.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325270S SUP HCPCS C1713 325270S - SCREW BONE 6.5MM 70MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $206.25 $152.63 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $42.99 $153.08 $153.08 $0.00 $0.00 $42.98 $0.00 $122.00 $122.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 325422S SUP HCPCS C1713 325422S - SCREW BONE 5MM 22MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325424S SUP HCPCS C1713 325424S - SCREW BONE 5MM 24MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325426S SUP HCPCS C1713 325426S - SCREW BONE 5MM 26MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325428S SUP HCPCS C1713 325428S - SCREW BONE 5MM 28MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325430S SUP HCPCS C1713 325430S - SCREW BONE 5MM 30MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325432S SUP HCPCS C1713 325432S - SCREW BONE 5MM 32MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325434S SUP HCPCS C1713 325434S - SCREW BONE 5MM 34MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325436S SUP HCPCS C1713 325436S - SCREW BONE 5MM 36MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325438S SUP HCPCS C1713 325438S - SCREW BONE 5MM 38MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325440S SUP HCPCS C1713 325440S - SCREW BONE 5MM 40MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325442S SUP HCPCS C1713 325442S - SCREW BONE 5MM 42MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325444S SUP HCPCS C1713 325444S - SCREW BONE 5MM 44MM ASNS 3 SS CANN BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325446S SUP HCPCS C1713 325446S - SCREW BONE 5MM 46MM ASNS 3 SS ORTH SLFTAP SLFDRILL CANN BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325448S SUP HCPCS C1713 325448S - SCREW BONE 5MM 48MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325450S SUP HCPCS C1713 325450S - SCREW BONE 5MM 50MM 17MM ASNS 3 SS CANN PTHRD SLFDRILL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325455S SUP HCPCS C1713 325455S - SCREW BONE 5MM 55MM ASNS 3 SS HIP SLFTAP SLFDRILL CANN PTHRD BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325460S SUP HCPCS C1713 325460S - SCREW BONE 5MM 60MM ASNS 3 SS PTHRD HIP CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325465S SUP HCPCS C1713 325465S - SCREW BONE 5MM 65MM ASNS 3 SS HIP SLFTAP SLFDRILL CANN PTHRD BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325470S SUP HCPCS C1713 325470S - SCREW BONE 5MM 70MM ASNS 3 SS ORTH CANN PTHRD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325475S SUP HCPCS C1713 325475S - SCREW BONE 5MM 75MM ASNS 3 SS ORTH SLFTAP SLFDRILL CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325480S SUP HCPCS C1713 325480S - SCREW BONE 5MM 80MM ASNS 3 SS HIP SLFTAP SLFDRILL CANN PTHRD BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325620S SUP HCPCS C1713 325620S - SCREW BONE 5MM 20MM ASNS 3 SS CANN BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325622S SUP HCPCS C1713 325622S - SCREW BONE 5MM 22MM ASNS 3 SS FULTHRD CANN SLFDRILL SLFTAP BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325624S SUP HCPCS C1713 325624S - SCREW BONE 5MM 24MM ASNS 3 SS FULTHD CANN SLFDRILL TAP BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325626S SUP HCPCS C1713 325626S - SCREW BONE 5MM 26MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325628S SUP HCPCS C1713 325628S - SCREW BONE 5MM 28MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325630S SUP HCPCS C1713 325630S - SCREW BONE 5MM 30MM ASNS 3 SS FULTHD ORTH SLFTAP SLFDRILL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325632S SUP HCPCS C1713 325632S - SCREW BONE 5MM 32MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325634S SUP HCPCS C1713 325634S - SCREW BONE 5MM 34MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325636S SUP HCPCS C1713 325636S - SCREW BONE 5MM 36MM SS FULTHRD IMPL STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325638S SUP HCPCS C1713 325638S - SCREW BONE 5MM 38MM ASNS 3 SS ORTH SLFTAP SLFDRILL CANN BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325640S SUP HCPCS C1713 325640S - SCREW BONE 5MM 40MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325642S SUP HCPCS C1713 325642S - SCREW BONE 5MM 42MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325644S SUP HCPCS C1713 325644S - SCREW BONE 5MM 44MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325646S SUP HCPCS C1713 325646S - SCREW BONE 5MM 46MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325650S SUP HCPCS C1713 325650S - SCREW BONE 5MM 50MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325655S SUP HCPCS C1713 325655S - SCREW BONE 5MM 55MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325660S SUP HCPCS C1713 325660S - SCREW BONE 5MM 60MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325665S SUP HCPCS C1713 325665S - SCREW BONE 5MM 65MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 325670S SUP HCPCS C1713 325670S - SCREW BONE 5MM 70MM ASNS 3 SS ORTH CANN FULTHD STRL BOTH IP/OP $299.75 $221.82 $0.00 $239.80 $134.89 $134.89 $0.00 $0.00 $0.00 $62.48 $222.47 $222.47 $0.00 $0.00 $62.47 $0.00 $177.30 $177.30 $0.00 $149.88 $237.40 $239.80 $0.00 $0.00 $46.91 $0.00 $0.00 $47.72 $0.00 $0.00 $0.00 $0.00 $0.00 326040S SUP HCPCS C1713 326040S - SCREW BONE 6.5MM 40MM 20MM ASNS 3 SS ORTH SLFTAP SLFDRILL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326045S SUP HCPCS C1713 326045S - SCREW BONE 6.5MM 45MM ASNS 3 SS ORTH CANN THRD STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326050S SUP HCPCS C1713 326050S - SCREW BONE 6.5MM 50MM ASNS 3 SS ORTH CANN THRD STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326055S SUP HCPCS C1713 326055S - SCREW BONE 6.5MM 55MM ASNS 3 SS ORTH CANN THRD STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326060S SUP HCPCS C1713 326060S - SCREW BONE 6.5MM 60MM 20MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326065S SUP HCPCS C1713 326065S - SCREW BONE 6.5MM 65MM ASNS 3 SS ORTH CANN THRD STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326070S SUP HCPCS C1713 326070S - SCREW BONE 6.5MM 70MM 20MM ASNS SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326075S SUP HCPCS C1713 326075S - SCREW BONE 6.5MM 75MM 20MM ASNS SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326080S SUP HCPCS C1713 326080S - SCREW BONE 6.5MM 80MM 20MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326085S SUP HCPCS C1713 326085S - SCREW BONE 6.5MM 85MM 20MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326090S SUP HCPCS C1713 326090S - SCREW BONE 6.5MM 90MM 20MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326095S SUP HCPCS C1713 326095S - SCREW BONE 6.5MM 95MM 20MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326100S SUP HCPCS C1713 326100S - SCREW BONE 6.5MM 100MM 20MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326105S SUP HCPCS C1713 326105S - SCREW BONE 6.5MM 105MM 20MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326110S SUP HCPCS C1713 326110S - SCREW BONE 6.5MM 110MM 20MM ASNS SS FEM HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326115S SUP HCPCS C1713 326115S - SCREW BONE 6.5MM 115MM 20MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326120S SUP HCPCS C1713 326120S - SCREW BONE 6.5MM 120MM 20MM ASNS 3 SS ORTH SLFTAP SLFDRILL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326255S SUP HCPCS C1713 326255S - SCREW BONE 6.5MM 55MM 40MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326260S SUP HCPCS C1713 326260S - SCREW BONE 6.5MM 60MM 40MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326265S SUP HCPCS C1713 326265S - SCREW BONE 6.5MM 65MM 40MM ASNS SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326270S SUP HCPCS C1713 326270S - SCREW BONE 6.5MM 70MM 40MM ASNS SS PTHRD ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326275S SUP HCPCS C1713 326275S - SCREW BONE 6.5MM 75MM 40MM ASNS 3 SS ORTH SLFTAP SLFDRILL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326280S SUP HCPCS C1713 326280S - SCREW BONE 6.5MM 80MM 40MM ASNS 3 SS PTHRD HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326285S SUP HCPCS C1713 326285S - SCREW BONE 6.5MM 85MM 40MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326290S SUP HCPCS C1713 326290S - SCREW BONE 6.5MM 90MM 40MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326295S SUP HCPCS C1713 326295S - SCREW BONE 6.5MM 95MM 20MM ASNS 3 SS HIP CANN THRD IMPL STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326300S SUP HCPCS C1713 326300S - SCREW BONE 6.5MM 100MM 40MM ASNS 3 SS HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326305S SUP HCPCS C1713 326305S - SCREW BONE 6.5MM 105MM 40MM ASNS SS FEM HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326310S SUP HCPCS C1713 326310S - SCREW BONE 6.5MM 110MM 40MM ASNS SS CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326315S SUP HCPCS C1713 326315S - SCREW BONE 6.5MM 115MM 40MM ASNS SS CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326320S SUP HCPCS C1713 326320S - SCREW BONE 6.5MM 120MM 40MM ASNS SS CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326325S SUP HCPCS C1713 326325S - ASNIS III SS CANN SCR6.5X125MM BOTH IP/OP $436.90 $323.31 $0.00 $352.00 $198.00 $198.00 $0.00 $0.00 $0.00 $91.06 $324.27 $324.27 $0.00 $0.00 $91.05 $0.00 $258.43 $258.43 $0.00 $220.00 $348.48 $352.00 $0.00 $0.00 $68.86 $0.00 $0.00 $70.05 $0.00 $0.00 $0.00 $0.00 $0.00 326330S SUP HCPCS C1713 326330S - ASNIS III SS CANN SCR6.5X130MM BOTH IP/OP $436.90 $323.31 $0.00 $352.00 $198.00 $198.00 $0.00 $0.00 $0.00 $91.06 $324.27 $324.27 $0.00 $0.00 $91.05 $0.00 $258.43 $258.43 $0.00 $220.00 $348.48 $352.00 $0.00 $0.00 $68.86 $0.00 $0.00 $70.05 $0.00 $0.00 $0.00 $0.00 $0.00 326430S SUP HCPCS C1713 326430S - SCREW BONE 6.5MM 30MM ASNS 3 SS FULTHRD CANN SLFDRILL SLFTAP BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326435S SUP HCPCS C1713 326435S - SCREW BONE 6.5MM 35MM ASNS 3 TI FULTHRD CANN SLFDRILL SLFTAP BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326440S SUP HCPCS C1713 326440S - SCREW BONE 6.5MM 40MM ASNS 3 SS FULTHRD CANN SLFDRILL SLFTAP BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326445S SUP HCPCS C1713 326445S - SCREW BONE 6.5MM 45MM ASNS 3 SS CANN FULTHD SLFDRILL SLFTAP BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326450S SUP HCPCS C1713 326450S - SCREW BONE 6.5MM 50MM ASNS 3 SS ORTH CANN FULTHD STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326455S SUP HCPCS C1713 326455S - SCREW BONE 6.5MM 55MM ASNS 3 SS CANN BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326460S SUP HCPCS C1713 326460S - SCREW BONE 6.5MM 60MM ASNS 3 SS CANN BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326465S SUP HCPCS C1713 326465S - SCREW BONE 6.5MM 65MM ASNS 3 SS CANN FULTHD SLFDRILL SLFTAP BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326470S SUP HCPCS C1713 326470S - SCREW BONE 6.5MM 70MM ASNS 3 SS FULTHD CANN SLFDRILL SLFTAP BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326475S SUP HCPCS C1713 326475S - SCREW BONE 6.5MM 75MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326480S SUP HCPCS C1713 326480S - SCREW BONE 6.5MM 80MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326485S SUP HCPCS C1713 326485S - SCREW BONE 6.5MM 85MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326490S SUP HCPCS C1713 326490S - SCREW BONE 6.5MM 90MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326495S SUP HCPCS C1713 326495S - SCREW BONE 6.5MM 95MM ASNS 3 SS FULTHD ORTH CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326500S SUP HCPCS C1713 326500S - SCREW BONE 6.5MM 100MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326505S SUP HCPCS C1713 326505S - SCREW BONE 6.5MM 105MM ASNS 3 SS FULTHD SLFTAP SLFDRILL CANN BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326510S SUP HCPCS C1713 326510S - SCREW BONE 6.5MM 110MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326515S SUP HCPCS C1713 326515S - SCREW BONE 6.5MM 115MM ASNS 3 SS FULTHD SLFTAP SLFDRILL CANN BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326520S SUP HCPCS C1713 326520S - SCREW BONE 6.5MM 120MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 326525S SUP HCPCS C1713 326525S - SCREW BONE 6.5MM 125MM ASNS 3 SS FULTHRD CANN STRL BOTH IP/OP $385.50 $285.27 $0.00 $297.00 $167.06 $167.06 $0.00 $0.00 $0.00 $80.35 $286.12 $286.12 $0.00 $0.00 $80.34 $0.00 $228.02 $228.02 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 326530S SUP HCPCS C1713 326530S - SCREW BONE 6.5MM 130MM ASNS 3 SS FULTHRD STRL BOTH IP/OP $385.50 $285.27 $0.00 $297.00 $167.06 $167.06 $0.00 $0.00 $0.00 $80.35 $286.12 $286.12 $0.00 $0.00 $80.34 $0.00 $228.02 $228.02 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 326640S SUP HCPCS C1713 326640S - SCREW BONE 8MM 40MM 25MM ASNS 3 SS SLFTAP SLFDRILL CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326645S SUP HCPCS C1713 326645S - SCREW BONE 8MM 45MM 25MM ASNS SS CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326650S SUP HCPCS C1713 326650S - SCREW BONE 8MM 50MM 25MM ASNS SS CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326655S SUP HCPCS C1713 326655S - SCREW BONE 8MM 55MM 25MM ASNS 3 SS ORTH CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326660S SUP HCPCS C1713 326660S - SCREW BONE 8MM 60MM 25MM ASNS SS CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326665S SUP HCPCS C1713 326665S - SCREW BONE 8MM 65MM 25MM ASNS 3 SS ORTH SLFTAP SLFDRILL CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326670S SUP HCPCS C1713 326670S - SCREW BONE 8MM 70MM 25MM ASNS 3 SS CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326675S SUP HCPCS C1713 326675S - SCREW BONE 8MM 75MM 25MM ASNS SS CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326680S SUP HCPCS C1713 326680S - SCREW BONE 8MM 80MM 25MM ASNS 3 SS CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326685S SUP HCPCS C1713 326685S - SCREW BONE 8MM 85MM 25MM ASNS 3 SS SLFTAP SLFDRILL CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326690S SUP HCPCS C1713 326690S - SCREW BONE 8MM 90MM 25MM ASNS 3 SS SLFTAP SLFDRILL CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326695S SUP HCPCS C1713 326695S - SCREW BONE 8MM 95MM 25MM ASNS 3 SS SLFTAP SLFDRILL CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326700S SUP HCPCS C1713 326700S - SCREW BONE 8MM 100MM 25MM ASNS SS THRD CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326705S SUP HCPCS C1713 326705S - SCREW BONE 8MM 105MM 25MM ASNS 3 SS SLFTAP SLFDRILL CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326710S SUP HCPCS C1713 326710S - SCREW BONE 8MM 110MM 25MM ASNS 3 SS SLFTAP SLFDRILL CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326715S SUP HCPCS C1713 326715S - SCREW BONE 8MM 115MM 25MM ASNS 3 SS SLFTAP SLFDRILL CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326720S SUP HCPCS C1713 326720S - SCREW BONE 8MM 120MM 25MM ASNS 3 SS SLFTAP SLFDRILL CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326725S SUP HCPCS C1713 326725S - SCREW BONE 8MM 125MM 25MM ASNS 3 SS HIP STRL BOTH IP/OP $436.90 $323.31 $0.00 $583.00 $327.94 $327.94 $0.00 $0.00 $0.00 $91.06 $324.27 $324.27 $0.00 $0.00 $91.05 $0.00 $258.43 $258.43 $0.00 $364.38 $577.17 $583.00 $0.00 $0.00 $114.05 $0.00 $0.00 $116.02 $0.00 $0.00 $0.00 $0.00 $0.00 326730S SUP HCPCS C1713 326730S - SCREW BONE 8MM 135MM 25MM ASNS 3 SS THRD STRL BOTH IP/OP $436.90 $323.31 $0.00 $583.00 $327.94 $327.94 $0.00 $0.00 $0.00 $91.06 $324.27 $324.27 $0.00 $0.00 $91.05 $0.00 $258.43 $258.43 $0.00 $364.38 $577.17 $583.00 $0.00 $0.00 $114.05 $0.00 $0.00 $116.02 $0.00 $0.00 $0.00 $0.00 $0.00 326840S SUP HCPCS C1713 326840S - SCREW BONE 8MM 40MM ASNS 3 SS FULTHD SLFTAP SLFDRILL CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326845S SUP HCPCS C1713 326845S - SCREW BONE 8MM 45MM ASNS 3 SS FULTHD CANN SLFDRILL SLFTAP BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326850S SUP HCPCS C1713 326850S - SCREW BONE 8MM 50MM ASNS 3 SS CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326855S SUP HCPCS C1713 326855S - SCREW BONE 8MM 55MM ASNS 3 SS FULTHD CANN SLFDRILL SLFTAP BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326860S SUP HCPCS C1713 326860S - SCREW BONE 8MM 60MM ASNS 3 SS FULTHD SLFTAP SLFDRILL CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326865S SUP HCPCS C1713 326865S - SCREW BONE 8MM 65MM ASNS 3 SS CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326870S SUP HCPCS C1713 326870S - SCREW BONE 8MM 70MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326875S SUP HCPCS C1713 326875S - SCREW BONE 8MM 75MM ASNS 3 SS FULTHD SLFTAP SLFDRILL CANN BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326880S SUP HCPCS C1713 326880S - SCREW BONE 8MM 80MM ASNS 3 SS FULTHD CANN SLFDRILL SLFTAP BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326885S SUP HCPCS C1713 326885S - SCREW BONE 8MM 85MM ASNS 3 TI ORTH CANN PTHRD STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326890S SUP HCPCS C1713 326890S - SCREW BONE 8MM 90MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326895S SUP HCPCS C1713 326895S - SCREW BONE 8MM 95MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326900S SUP HCPCS C1713 326900S - SCREW BONE 8MM 100MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326905S SUP HCPCS C1713 326905S - SCREW BONE 8MM 105MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326910S SUP HCPCS C1713 326910S - SCREW BONE 8MM 110MM ASNS 3 SS FULTHD HIP CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326915S SUP HCPCS C1713 326915S - SCREW BONE 8MM 115MM ASNS 3 SS FEM HIP CANN STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326920S SUP HCPCS C1713 326920S - SCREW BONE 8MM 120MM ASNS 3 TI ORTH CANN PTHRD STRL BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $173.25 $173.25 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 326925S SUP HCPCS C1713 326925S - SCREW BONE 8MM 125MM ASNS 3 SS FULTHRD STRL BOTH IP/OP $385.50 $285.27 $0.00 $302.50 $170.16 $170.16 $0.00 $0.00 $0.00 $80.35 $286.12 $286.12 $0.00 $0.00 $80.34 $0.00 $228.02 $228.02 $0.00 $189.06 $299.48 $302.50 $0.00 $0.00 $59.18 $0.00 $0.00 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 326930S SUP HCPCS C1713 326930S - SCREW BONE 8MM 130MM ASNS 3 SS FULTHRD CANN STRL BOTH IP/OP $385.50 $285.27 $0.00 $302.50 $170.16 $170.16 $0.00 $0.00 $0.00 $80.35 $286.12 $286.12 $0.00 $0.00 $80.34 $0.00 $228.02 $228.02 $0.00 $189.06 $299.48 $302.50 $0.00 $0.00 $59.18 $0.00 $0.00 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 327-1010 SUP HCPCS C1713 327-1010 - SCREW BN 2.7MM 10MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1012 SUP HCPCS C1713 327-1012 - SCREW BN 2.7MM 12MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1014 SUP HCPCS C1713 327-1014 - SCREW BN 2.7MM 14MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1016 SUP HCPCS C1713 327-1016 - SCREW BN 2.7MM 16MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1018 SUP HCPCS C1713 327-1018 - SCREW BN 2.7MM 18MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1020 SUP HCPCS C1713 327-1020 - SCREW BN 2.7MM 20MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1022 SUP HCPCS C1713 327-1022 - SCREW BN 2.7MM 22MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1024 SUP HCPCS C1713 327-1024 - SCREW BN 2.7MM 24MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1026 SUP HCPCS C1713 327-1026 - SCREW BN 2.7MM 26MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1028 SUP HCPCS C1713 327-1028 - SCREW BN 2.7MM 28MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1030 SUP HCPCS C1713 327-1030 - SCREW BN 2.7MM 30MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 327-1032 SUP HCPCS C1713 327-1032 - SCREW BN 2.7MM 32MM ST CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 3300TFX19MM SUP Custom 27803010 3300TFX19MM - VALVE AOR LOPRFL 19MM CRP-ED PRIMNT MG EASE BPRTH THERMAFIX BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3300TFX21MM SUP Custom 27803010 3300TFX21MM - VALVE AOR 21MM CRP-ED PRIMNT MG EASE THERMAFIX BPRTH SUP BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3300TFX23MM SUP Custom 27803010 3300TFX23MM - VALVE AOR 23MM CRP-ED PRIMNT MG EASE THERMAFIX BPRTH STNT BS BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3300TFX25MM SUP Custom 27803010 3300TFX25MM - VALVE AORTIC LP 25MM BIOPROSTHESIS THERMAFIX PROCESS STENT BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3300TFX27MM SUP Custom 27803010 3300TFX27MM - VALVE AORTIC LP 27MM BIOPROSTHESIS THERMAFIX PROCESS STENT BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3300TFX29MM SUP Custom 27803010 3300TFX29MM - VALVE AOR LOPRFL 29MM CRP-ED PRIMNT MG EASE BPRTH THERMAFIX BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3304-G SUP Custom 27203010 3304-G - RING RTRCTR LNSTR NORYL RSN PLST CATH CLIP DISP STRL LATEX BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.64 $81.64 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3307-G SUP Custom 27203010 3307-G - RING RTRCTR SM G2 NORYL RSN W/O STAY KIT RCTL BLUE DISP STRL BOTH IP/OP $121.28 $89.75 $0.00 $97.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.64 $96.05 $97.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 331 443 SUP HCPCS C1900 331 443 - PHILOS DR BOTH IP/OP "$7,250.00 " "$5,365.00" $0.00 "$5,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,625.00" "$5,742.00" "$5,800.00" $0.00 $0.00 "$1,134.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 331 446 SUP HCPCS C1900 331 446 - PHILOS SR BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,500.00" "$5,544.00" "$5,600.00" $0.00 $0.00 "$1,095.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0240S SUP HCPCS C1713 3320-0240S - NAIL 11MM 240MM LEFT FEM HIP GAMMA3 IM 120D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0260S SUP HCPCS C1713 3320-0260S - NAIL 11MM 260MM LEFT FEM HIP GAMMA3 IM 120D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0280S SUP HCPCS C1713 3320-0280S - NAIL 11MM 28CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0300S SUP HCPCS C1713 3320-0300S - NAIL 11MM 30CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0320S SUP HCPCS C1713 3320-0320S - NAIL 11MM 32CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0340S SUP HCPCS C1713 3320-0340S - NAIL 11MM 34CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0360S SUP HCPCS C1713 3320-0360S - NAIL 11MM 36CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0380S SUP HCPCS C1713 3320-0380S - NAIL 11MM 38CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0400S SUP HCPCS C1713 3320-0400S - NAIL 11MM 40CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0420S SUP HCPCS C1713 3320-0420S - NAIL 11MM 42CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0440S SUP HCPCS C1713 3320-0440S - NAIL 11MM 44CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3320-0460S SUP HCPCS C1713 3320-0460S - NAIL 11MM 46CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3320-3340S SUP HCPCS C1713 3320-3340S - NAIL 13MM 34CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-3360S SUP HCPCS C1713 3320-3360S - NAIL 13MM 36CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-3380S SUP HCPCS C1713 3320-3380S - NAIL 13MM 38CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-3400S SUP HCPCS C1713 3320-3400S - NAIL 13MM 40CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-3420S SUP HCPCS C1713 3320-3420S - NAIL 13MM 42CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-3440S SUP HCPCS C1713 3320-3440S - NAIL 13MM 46CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-3460S SUP HCPCS C1713 3320-3460S - NAIL 13MM 44CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-5340S SUP HCPCS C1713 3320-5340S - NAIL 15MM 34CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-5360S SUP HCPCS C1713 3320-5360S - NAIL 15MM 36CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-5380S SUP HCPCS C1713 3320-5380S - NAIL 15MM 38CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-5400S SUP HCPCS C1713 3320-5400S - NAIL 15MM 40CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-5420S SUP HCPCS C1713 3320-5420S - NAIL 15MM 42CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-5440S SUP HCPCS C1713 3320-5440S - NAIL 15MM 44CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3320-5460S SUP HCPCS C1713 3320-5460S - NAIL 15MM 46CM LEFT FEM HIP GAMMA3 IM 120D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0240S SUP HCPCS C1713 3325-0240S - NAIL 11MM 240MM LEFT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0260S SUP HCPCS C1713 3325-0260S - NAIL 11MM 260MM LEFT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,688.13 " "$1,989.22" $0.00 "$2,150.50" "$1,209.66" "$1,209.66" $0.00 $0.00 $0.00 $560.27 "$1,995.13" "$1,995.13" $0.00 $0.00 $560.21 $0.00 "$1,325.25" "$1,325.25" $0.00 "$1,344.06" "$2,129.00" "$2,150.50" $0.00 $0.00 $420.69 $0.00 $0.00 $427.95 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0280S SUP HCPCS C1713 3325-0280S - NAIL 11MM 28CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0300S SUP HCPCS C1713 3325-0300S - NAIL 11MM 30CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0320S SUP HCPCS C1713 3325-0320S - NAIL 11MM 32CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0340S SUP HCPCS C1713 3325-0340S - NAIL 11MM 34CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0360S SUP HCPCS C1713 3325-0360S - NAIL 11MM 36CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0380S SUP HCPCS C1713 3325-0380S - NAIL 11MM 38CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0400S SUP HCPCS C1713 3325-0400S - NAIL 11MM 40CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0420S SUP HCPCS C1713 3325-0420S - NAIL 11MM 42CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0440S SUP HCPCS C1713 3325-0440S - NAIL 11MM 44CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3325-0460S SUP HCPCS C1713 3325-0460S - NAIL 11MM 46CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3280S SUP HCPCS C1713 3325-3280S - NAIL 13MM 280MM LEFT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3300S SUP HCPCS C1713 3325-3300S - NAIL 13MM 30CM HIP LEFT GAMMA3 IM 125D LNG TI STRL BOTH IP/OP "$2,688.13 " "$1,989.22" $0.00 "$2,150.50" "$1,209.66" "$1,209.66" $0.00 $0.00 $0.00 $560.27 "$1,995.13" "$1,995.13" $0.00 $0.00 $560.21 $0.00 "$1,325.25" "$1,325.25" $0.00 "$1,344.06" "$2,129.00" "$2,150.50" $0.00 $0.00 $420.69 $0.00 $0.00 $427.95 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3320S SUP HCPCS C1713 3325-3320S - NAIL 13MM 32CM LEFT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,688.13 " "$1,989.22" $0.00 "$2,150.50" "$1,209.66" "$1,209.66" $0.00 $0.00 $0.00 $560.27 "$1,995.13" "$1,995.13" $0.00 $0.00 $560.21 $0.00 "$1,325.25" "$1,325.25" $0.00 "$1,344.06" "$2,129.00" "$2,150.50" $0.00 $0.00 $420.69 $0.00 $0.00 $427.95 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3340S SUP HCPCS C1713 3325-3340S - NAIL 13MM 34CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3360S SUP HCPCS C1713 3325-3360S - NAIL 13MM 36CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3380S SUP HCPCS C1713 3325-3380S - NAIL 13MM 38CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3400S SUP HCPCS C1713 3325-3400S - NAIL 13MM 40CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3420S SUP HCPCS C1713 3325-3420S - NAIL 13MM 42CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3440S SUP HCPCS C1713 3325-3440S - NAIL 13MM 44CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-3460S SUP HCPCS C1713 3325-3460S - NAIL 13MM 46CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5280S SUP HCPCS C1713 3325-5280S - NAIL 15MM 280MM LEFT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5300S SUP HCPCS C1713 3325-5300S - NAIL 15MM 300MM LEFT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5320S SUP HCPCS C1713 3325-5320S - NAIL 15MM 320MM LEFT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5340S SUP HCPCS C1713 3325-5340S - NAIL 15MM 34CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5360S SUP HCPCS C1713 3325-5360S - NAIL 15MM 36CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5380S SUP HCPCS C1713 3325-5380S - NAIL 15MM 38CM LEFT FEM HIP GAMMA3 IM 125D LNG KIT TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5400S SUP HCPCS C1713 3325-5400S - NAIL 15MM 40CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5420S SUP HCPCS C1713 3325-5420S - NAIL 15MM 42CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5440S SUP HCPCS C1713 3325-5440S - NAIL 15MM 44CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3325-5460S SUP HCPCS C1713 3325-5460S - NAIL 15MM 46CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0240S SUP HCPCS C1713 3330-0240S - NAIL 11MM 240MM LEFT FEM HIP GAMMA3 IM 130D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0260S SUP HCPCS C1713 3330-0260S - NAIL 11MM 260MM LEFT FEM HIP GAMMA3 IM 130D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0280S SUP HCPCS C1713 3330-0280S - NAIL 11MM 28CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0300S SUP HCPCS C1713 3330-0300S - NAIL 11MM 30CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0320S SUP HCPCS C1713 3330-0320S - NAIL 11MM 32CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0340S SUP HCPCS C1713 3330-0340S - NAIL 11MM 34CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0360S SUP HCPCS C1713 3330-0360S - NAIL 11MM 36CM LEFT FEM HIP GAMMA3 IM 130D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0380S SUP HCPCS C1713 3330-0380S - NAIL 11MM 38CM LEFT FEM HIP GAMMA3 IM 130D LNG KIT TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0400S SUP HCPCS C1713 3330-0400S - NAIL 11MM 40CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0420S SUP HCPCS C1713 3330-0420S - NAIL 11MM 42CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0440S SUP HCPCS C1713 3330-0440S - NAIL 11MM 44CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,093.75 " "$2,289.38" $0.00 "$2,475.00" "$1,392.19" "$1,392.19" $0.00 $0.00 $0.00 $644.81 "$2,296.18" "$2,296.18" $0.00 $0.00 $644.74 $0.00 "$1,525.22" "$1,525.22" $0.00 "$1,546.88" "$2,450.25" "$2,475.00" $0.00 $0.00 $484.17 $0.00 $0.00 $492.53 $0.00 $0.00 $0.00 $0.00 $0.00 3330-0460S SUP HCPCS C1713 3330-0460S - NAIL 11MM 46CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$2,798.13 " "$2,070.62" $0.00 "$2,238.50" "$1,259.16" "$1,259.16" $0.00 $0.00 $0.00 $583.20 "$2,076.77" "$2,076.77" $0.00 $0.00 $583.13 $0.00 "$1,379.48" "$1,379.48" $0.00 "$1,399.06" "$2,216.12" "$2,238.50" $0.00 $0.00 $437.91 $0.00 $0.00 $445.46 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3300S SUP HCPCS C1713 3330-3300S - NAIL 13MM 300MM LEFT FEM HIP GAMMA3 IM 130D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3320S SUP HCPCS C1713 3330-3320S - NAIL 13MM 280MM LEFT FEM HIP GAMMA3 IM 125D LNG STRL BOTH IP/OP "$2,447.50 " "$1,811.15" $0.00 "$1,958.00" "$1,101.38" "$1,101.38" $0.00 $0.00 $0.00 $510.12 "$1,816.53" "$1,816.53" $0.00 $0.00 $510.06 $0.00 "$1,447.70" "$1,447.70" $0.00 "$1,223.75" "$1,938.42" "$1,958.00" $0.00 $0.00 $383.03 $0.00 $0.00 $389.64 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3340S SUP HCPCS C1713 3330-3340S - NAIL 13MM 34CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3360S SUP HCPCS C1713 3330-3360S - NAIL 13MM 36CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3380S SUP HCPCS C1713 3330-3380S - NAIL 13MM 38CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3400S SUP HCPCS C1713 3330-3400S - NAIL 13MM 40CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3420S SUP HCPCS C1713 3330-3420S - NAIL 13MM 42CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3440S SUP HCPCS C1713 3330-3440S - NAIL 13MM 44CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-3460S SUP HCPCS C1713 3330-3460S - NAIL 13MM 46CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-5340S SUP HCPCS C1713 3330-5340S - NAIL 15MM 34CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-5360S SUP HCPCS C1713 3330-5360S - NAIL 15MM 36CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-5380S SUP HCPCS C1713 3330-5380S - NAIL 15MM 38CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-5400S SUP HCPCS C1713 3330-5400S - NAIL 15MM 40CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-5420S SUP HCPCS C1713 3330-5420S - NAIL 15MM 42CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-5440S SUP HCPCS C1713 3330-5440S - NAIL 15MM 44CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 3330-5460S SUP HCPCS C1713 3330-5460S - NAIL 15MM 46CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,293.13 " "$2,436.92" $0.00 "$2,634.50" "$1,481.91" "$1,481.91" $0.00 $0.00 $0.00 $686.37 "$2,444.16" "$2,444.16" $0.00 $0.00 $686.29 $0.00 "$1,623.51" "$1,623.51" $0.00 "$1,646.56" "$2,608.16" "$2,634.50" $0.00 $0.00 $515.37 $0.00 $0.00 $524.27 $0.00 $0.00 $0.00 $0.00 $0.00 333-070-003 SUP Custom 27203010 333-070-003 - OBT ENDSCP 70MM DRAIN CANNU BOTH IP/OP $203.06 $150.26 $0.00 $162.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.71 $150.71 $0.00 $0.00 $42.32 $0.00 $0.00 $0.00 $0.00 $101.53 $160.82 $162.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 334 051 SUP HCPCS C1900 334 051 - PHILOS SR SYSTEM BOTH IP/OP "$8,000.00 " "$5,920.00" $0.00 "$6,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,000.00" "$6,336.00" "$6,400.00" $0.00 $0.00 "$1,252.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 335-1012 SUP HCPCS C1713 335-1012 - SCREW BN 3.5MM 12MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1014 SUP HCPCS C1713 335-1014 - SCREW BN 3.5MM 14MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1016 SUP HCPCS C1713 335-1016 - SCREW BN 3.5MM 16MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1018 SUP HCPCS C1713 335-1018 - SCREW BN 3.5MM 18MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1020 SUP HCPCS C1713 335-1020 - SCREW BN 3.5MM 20MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1022 SUP HCPCS C1713 335-1022 - SCREW BN 3.5MM 22MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1024 SUP HCPCS C1713 335-1024 - SCREW BN 3.5MM 24MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1026 SUP HCPCS C1713 335-1026 - SCREW BN 3.5MM 26MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1028 SUP HCPCS C1713 335-1028 - SCREW BN 3.5MM 28MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1030 SUP HCPCS C1713 335-1030 - SCREW BN 3.5MM 30MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1032 SUP HCPCS C1713 335-1032 - SCREW BN 3.5MM 32MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1034 SUP HCPCS C1713 335-1034 - SCREW BN 3.5MM 34MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1036 SUP HCPCS C1713 335-1036 - SCREW BN 3.5MM 36MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1038 SUP HCPCS C1713 335-1038 - SCREW BN 3.5MM 38MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1040 SUP HCPCS C1713 335-1040 - SCREW BN 3.5MM 40MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1042 SUP HCPCS C1713 335-1042 - SCREW BN 3.5MM 42MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1044 SUP HCPCS C1713 335-1044 - SCREW BN 3.5MM 44MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1046 SUP HCPCS C1713 335-1046 - SCREW BN 3.5MM 46MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1048 SUP HCPCS C1713 335-1048 - SCREW BN 3.5MM 48MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1050 SUP HCPCS C1713 335-1050 - SCREW BN 3.5MM 50MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1055 SUP HCPCS C1713 335-1055 - SCREW BN 3.5MM 55MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 335-1060 SUP HCPCS C1713 335-1060 - SCREW BN 3.5MM 60MM NS ST SS CORT BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-304 SUP HCPCS C1713 3362-0-304 - SDPLT BONE OMEGA+ 130D SHRT BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-305 SUP HCPCS C1713 3362-0-305 - SDPLT BONE OMEGA+ 130D SHRT BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-354 SUP HCPCS C1713 3362-0-354 - SDPLT BONE OMEGA+ 135D SHRT BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-355 SUP HCPCS C1713 3362-0-355 - SDPLT BONE OMEGA+ 135D SHRT BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-404 SUP HCPCS C1713 3362-0-404 - SDPLT BONE OMEGA+ 140D SHRT BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-405 SUP HCPCS C1713 3362-0-405 - SDPLT BONE OMEGA+ 140D SHRT BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-454 SUP HCPCS C1713 3362-0-454 - SDPLT BONE OMEGA+ 145D SHRT BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-455 SUP HCPCS C1713 3362-0-455 - SDPLT BONE OMEGA+ 145D SHRT BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-504 SUP HCPCS C1713 3362-0-504 - SDPLT BONE OMEGA+ 150D SHRT BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-0-505 SUP HCPCS C1713 3362-0-505 - SDPLT BONE OMEGA+ 150D SHRT BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-002 SUP HCPCS C1713 3362-1-002 - SDPLT BONE OMEGA+ 130D STD BRL HIP SS 2 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-003 SUP HCPCS C1713 3362-1-003 - SDPLT BONE OMEGA+ 130D STD BRL HIP SS 3 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-004 SUP HCPCS C1713 3362-1-004 - SDPLT BONE OMEGA+ 130D STD BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-005 SUP HCPCS C1713 3362-1-005 - SDPLT BONE OMEGA+ 130D STD BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-006 SUP HCPCS C1713 3362-1-006 - SDPLT BONE OMEGA+ 130D STD BRL HIP SS 6 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-008 SUP HCPCS C1713 3362-1-008 - SDPLT BONE OMEGA+ 130D STD BRL HIP SS 8 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-010 SUP HCPCS C1713 3362-1-010 - SDPLT BONE OMEGA+ 130D STD BRL HIP SS 10 HOLE CMPR BOTH IP/OP "$1,054.63 " $780.43 $0.00 $843.70 $474.58 $474.58 $0.00 $0.00 $0.00 $219.81 $782.74 $782.74 $0.00 $0.00 $219.78 $0.00 $623.81 $623.81 $0.00 $527.31 $835.27 $843.70 $0.00 $0.00 $165.05 $0.00 $0.00 $167.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-012 SUP HCPCS C1713 3362-1-012 - SDPLT BONE OMEGA+ 130D STD BRL HIP SS 12 HOLE CMPR BOTH IP/OP "$1,054.63 " $780.43 $0.00 $843.70 $474.58 $474.58 $0.00 $0.00 $0.00 $219.81 $782.74 $782.74 $0.00 $0.00 $219.78 $0.00 $623.81 $623.81 $0.00 $527.31 $835.27 $843.70 $0.00 $0.00 $165.05 $0.00 $0.00 $167.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-102 SUP HCPCS C1713 3362-1-102 - SDPLT BONE OMEGA+ 135D HIP 2 HOLE BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-103 SUP HCPCS C1713 3362-1-103 - SDPLT BONE OMEGA+ 135D STD BRL HIP SS 3 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-104 SUP HCPCS C1713 3362-1-104 - SDPLT BONE OMEGA+ 135D STD BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-105 SUP HCPCS C1713 3362-1-105 - SDPLT BONE OMEGA+ 135D STD BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-106 SUP HCPCS C1713 3362-1-106 - SDPLT BONE OMEGA+ 135D STD BRL HIP SS 6 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-108 SUP HCPCS C1713 3362-1-108 - SDPLT BONE OMEGA+ 135D STD BRL HIP SS 8 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-110 SUP HCPCS C1713 3362-1-110 - SDPLT BONE OMEGA+ 135D STD BRL HIP SS 10 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-112 SUP HCPCS C1713 3362-1-112 - SDPLT BONE OMEGA+ 135D STD BRL HIP SS 12 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-202 SUP HCPCS C1713 3362-1-202 - SDPLT BONE OMEGA+ 140D STD BRL HIP SS 2 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-203 SUP HCPCS C1713 3362-1-203 - SDPLT BONE OMEGA+ 140D STD BRL HIP SS 3 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-204 SUP HCPCS C1713 3362-1-204 - SDPLT BONE OMEGA+ 140D STD BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-205 SUP HCPCS C1713 3362-1-205 - SDPLT BONE OMEGA+ 140D STD BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-206 SUP HCPCS C1713 3362-1-206 - SDPLT BONE OMEGA+ 140D STD BRL HIP SS 6 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-208 SUP HCPCS C1713 3362-1-208 - SDPLT BONE OMEGA+ 140D STD BRL HIP SS 8 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-210 SUP HCPCS C1713 3362-1-210 - SDPLT BONE OMEGA+ 140D STD BRL HIP SS 10 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-212 SUP HCPCS C1713 3362-1-212 - SDPLT BONE OMEGA+ 140D STD BRL HIP SS 12 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-302 SUP HCPCS C1713 3362-1-302 - SDPLT BONE OMEGA+ 145D STD BRL HIP SS 2 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-303 SUP HCPCS C1713 3362-1-303 - SDPLT BONE OMEGA+ 145D STD BRL HIP SS 3 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-304 SUP HCPCS C1713 3362-1-304 - SDPLT BONE OMEGA+ 145D STD BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-305 SUP HCPCS C1713 3362-1-305 - SDPLT BONE OMEGA+ 145D STD BRL HIP SS 5 HOLE CMPR BOTH IP/OP $856.63 $633.91 $0.00 $685.30 $385.48 $385.48 $0.00 $0.00 $0.00 $178.54 $635.79 $635.79 $0.00 $0.00 $178.52 $0.00 $506.69 $506.69 $0.00 $428.31 $678.45 $685.30 $0.00 $0.00 $134.06 $0.00 $0.00 $136.37 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-306 SUP HCPCS C1713 3362-1-306 - SDPLT BONE OMEGA+ 145D STD BRL HIP SS 6 HOLE CMPR BOTH IP/OP $856.63 $633.91 $0.00 $685.30 $385.48 $385.48 $0.00 $0.00 $0.00 $178.54 $635.79 $635.79 $0.00 $0.00 $178.52 $0.00 $506.69 $506.69 $0.00 $428.31 $678.45 $685.30 $0.00 $0.00 $134.06 $0.00 $0.00 $136.37 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-308 SUP HCPCS C1713 3362-1-308 - SDPLT BONE OMEGA+ 145D STD BRL HIP SS 8 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-310 SUP HCPCS C1713 3362-1-310 - SDPLT BONE OMEGA+ 145D STD BRL HIP SS 10 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-312 SUP HCPCS C1713 3362-1-312 - SDPLT BONE OMEGA+ 145D STD BRL HIP SS 12 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-402 SUP HCPCS C1713 3362-1-402 - SDPLT BONE OMEGA+ 150D STD BRL HIP SS 2 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-403 SUP HCPCS C1713 3362-1-403 - SDPLT BONE OMEGA+ 150D STD BRL HIP SS 3 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-404 SUP HCPCS C1713 3362-1-404 - SDPLT BONE OMEGA+ 150D STD BRL HIP SS 4 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-405 SUP HCPCS C1713 3362-1-405 - SDPLT BONE OMEGA+ 150D STD BRL HIP SS 5 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-406 SUP HCPCS C1713 3362-1-406 - SDPLT BONE OMEGA+ 150D STD BRL HIP SS 6 HOLE CMPR BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-408 SUP HCPCS C1713 3362-1-408 - SDPLT BONE OMEGA+ 150D STD BRL HIP SS 8 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-410 SUP HCPCS C1713 3362-1-410 - SDPLT BONE OMEGA+ 150D STD BRL HIP SS 10 HOLE CMPR BOTH IP/OP "$1,054.63 " $780.43 $0.00 $843.70 $474.58 $474.58 $0.00 $0.00 $0.00 $219.81 $782.74 $782.74 $0.00 $0.00 $219.78 $0.00 $623.81 $623.81 $0.00 $527.31 $835.27 $843.70 $0.00 $0.00 $165.05 $0.00 $0.00 $167.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-1-412 SUP HCPCS C1713 3362-1-412 - SDPLT BONE OMEGA+ 150D STD BRL HIP SS 12 HOLE CMPR BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-002 SUP HCPCS C1713 3362-3-002 - PLATE 130D STD BRL SS 2 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-003 SUP HCPCS C1713 3362-3-003 - PLATE 130D STD BRL SS 3 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-004 SUP HCPCS C1713 3362-3-004 - PLATE 130D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-005 SUP HCPCS C1713 3362-3-005 - PLATE 130D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-006 SUP HCPCS C1713 3362-3-006 - PLATE 130D STD BRL SS 6 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $856.63 $633.91 $0.00 $685.30 $385.48 $385.48 $0.00 $0.00 $0.00 $178.54 $635.79 $635.79 $0.00 $0.00 $178.52 $0.00 $506.69 $506.69 $0.00 $428.31 $678.45 $685.30 $0.00 $0.00 $134.06 $0.00 $0.00 $136.37 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-008 SUP HCPCS C1713 3362-3-008 - PLATE 130D STD BRL SS 8 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-010 SUP HCPCS C1713 3362-3-010 - PLATE 130D STD BRL SS 10 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-012 SUP HCPCS C1713 3362-3-012 - PLATE 130D STD BRL SS 12 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-102 SUP HCPCS C1713 3362-3-102 - PLATE 135D STD BRL SS 2 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-103 SUP HCPCS C1713 3362-3-103 - PLATE 135D STD BRL SS 3 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-104 SUP HCPCS C1713 3362-3-104 - PLATE 135D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-105 SUP HCPCS C1713 3362-3-105 - PLATE 135D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-106 SUP HCPCS C1713 3362-3-106 - PLATE 135D STD BRL SS 6 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-108 SUP HCPCS C1713 3362-3-108 - PLATE 135D STD BRL SS 8 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-110 SUP HCPCS C1713 3362-3-110 - PLATE 135D STD BRL SS 10 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-112 SUP HCPCS C1713 3362-3-112 - PLATE 135D STD BRL SS 12 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-202 SUP HCPCS C1713 3362-3-202 - PLATE 140D STD BRL SS 2 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-203 SUP HCPCS C1713 3362-3-203 - PLATE 140D STD BRL SS 3 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-204 SUP HCPCS C1713 3362-3-204 - PLATE 140D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-205 SUP HCPCS C1713 3362-3-205 - PLATE 140D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-206 SUP HCPCS C1713 3362-3-206 - PLATE 140D STD BRL SS 6 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-208 SUP HCPCS C1713 3362-3-208 - PLATE 140D STD BRL SS 8 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-210 SUP HCPCS C1713 3362-3-210 - PLATE 140D STD BRL SS 10 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,054.63 " $780.43 $0.00 $843.70 $474.58 $474.58 $0.00 $0.00 $0.00 $219.81 $782.74 $782.74 $0.00 $0.00 $219.78 $0.00 $623.81 $623.81 $0.00 $527.31 $835.27 $843.70 $0.00 $0.00 $165.05 $0.00 $0.00 $167.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-212 SUP HCPCS C1713 3362-3-212 - PLATE 140D STD BRL SS 12 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-302 SUP HCPCS C1713 3362-3-302 - PLATE 145D STD BRL SS 3 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-303 SUP HCPCS C1713 3362-3-303 - PLATE 145D STD BRL SS 3 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-304 SUP HCPCS C1713 3362-3-304 - PLATE 145D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-305 SUP HCPCS C1713 3362-3-305 - PLATE 145D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-306 SUP HCPCS C1713 3362-3-306 - PLATE 145D STD BRL SS 6 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-308 SUP HCPCS C1713 3362-3-308 - PLATE 145D STD BRL SS 8 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-310 SUP HCPCS C1713 3362-3-310 - PLATE 145D STD BRL SS 10 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-312 SUP HCPCS C1713 3362-3-312 - PLATE 145D STD BRL SS 12 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-402 SUP HCPCS C1713 3362-3-402 - PLATE 150D STD BRL SS 2 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-403 SUP HCPCS C1713 3362-3-403 - PLATE 150D STD BRL SS 3 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-404 SUP HCPCS C1713 3362-3-404 - PLATE 150D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-405 SUP HCPCS C1713 3362-3-405 - PLATE 150D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-406 SUP HCPCS C1713 3362-3-406 - PLATE 150D STD BRL SS 6 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-408 SUP HCPCS C1713 3362-3-408 - PLATE 150D STD BRL SS 8 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-410 SUP HCPCS C1713 3362-3-410 - PLATE 150D STD BRL SS 10 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-3-412 SUP HCPCS C1713 3362-3-412 - PLATE 150D STD BRL SS 12 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP "$1,058.75 " $783.48 $0.00 $847.00 $476.44 $476.44 $0.00 $0.00 $0.00 $220.67 $785.80 $785.80 $0.00 $0.00 $220.64 $0.00 $626.25 $626.25 $0.00 $529.38 $838.53 $847.00 $0.00 $0.00 $165.69 $0.00 $0.00 $168.55 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-304 SUP HCPCS C1713 3362-4-304 - PLATE 130D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-305 SUP HCPCS C1713 3362-4-305 - PLATE 130D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-354 SUP HCPCS C1713 3362-4-354 - PLATE 135D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-355 SUP HCPCS C1713 3362-4-355 - PLATE 135D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-404 SUP HCPCS C1713 3362-4-404 - PLATE 140D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-405 SUP HCPCS C1713 3362-4-405 - PLATE 140D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-454 SUP HCPCS C1713 3362-4-454 - PLATE 145D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-455 SUP HCPCS C1713 3362-4-455 - PLATE 145D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-504 SUP HCPCS C1713 3362-4-504 - PLATE 150D STD BRL SS 4 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-4-505 SUP HCPCS C1713 3362-4-505 - PLATE 150D STD BRL SS 5 HOLE KYLS OMEGA+ BONE SPCNDYL HIP BOTH IP/OP $859.38 $635.94 $0.00 $687.50 $386.72 $386.72 $0.00 $0.00 $0.00 $179.12 $637.83 $637.83 $0.00 $0.00 $179.09 $0.00 $508.32 $508.32 $0.00 $429.69 $680.63 $687.50 $0.00 $0.00 $134.49 $0.00 $0.00 $136.81 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-050 SUP HCPCS C1713 3362-5-050 - SCREW BONE 13MM 50MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-055 SUP HCPCS C1713 3362-5-055 - SCREW BONE 13MM 55MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-060 SUP HCPCS C1713 3362-5-060 - SCREW BONE 13MM 60MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-065 SUP HCPCS C1713 3362-5-065 - SCREW BONE 13MM 65MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-070 SUP HCPCS C1713 3362-5-070 - SCREW BONE 13MM 70MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-075 SUP HCPCS C1713 3362-5-075 - SCREW BONE 75MM OMEGA+ HIP LAG BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-080 SUP HCPCS C1713 3362-5-080 - SCREW BONE 13MM 80MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-085 SUP HCPCS C1713 3362-5-085 - SCREW BONE 13MM 85MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-090 SUP HCPCS C1713 3362-5-090 - SCREW BONE 13MM 90MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-095 SUP HCPCS C1713 3362-5-095 - SCREW BONE 13MM 95MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-100 SUP HCPCS C1713 3362-5-100 - SCREW BONE 13MM 100MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-105 SUP HCPCS C1713 3362-5-105 - SCREW BONE 13MM 105MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-110 SUP HCPCS C1713 3362-5-110 - SCREW BONE 13MM 110MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-115 SUP HCPCS C1713 3362-5-115 - SCREW BONE 13MM 115MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-120 SUP HCPCS C1713 3362-5-120 - SCREW BONE 13MM 120MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-125 SUP HCPCS C1713 3362-5-125 - SCREW BONE 13MM 125MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-5-130 SUP HCPCS C1713 3362-5-130 - SCREW BONE 13MM 130MM OMEGA+ SS STD FEM HIP LAG STRL BOTH IP/OP $466.40 $345.14 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-055 SUP HCPCS C1713 3362-6-055 - SCREW BONE 55MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $313.50 $231.99 $0.00 $250.80 $141.08 $141.08 $0.00 $0.00 $0.00 $65.34 $232.68 $232.68 $0.00 $0.00 $65.33 $0.00 $185.44 $185.44 $0.00 $156.75 $248.29 $250.80 $0.00 $0.00 $49.06 $0.00 $0.00 $49.91 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-060 SUP HCPCS C1713 3362-6-060 - SCREW BONE 60MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $229.63 $169.93 $0.00 $183.70 $103.33 $103.33 $0.00 $0.00 $0.00 $47.86 $170.43 $170.43 $0.00 $0.00 $47.85 $0.00 $135.82 $135.82 $0.00 $114.81 $181.87 $183.70 $0.00 $0.00 $35.94 $0.00 $0.00 $36.56 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-070 SUP HCPCS C1713 3362-6-070 - SCREW BONE 70MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $313.50 $231.99 $0.00 $250.80 $141.08 $141.08 $0.00 $0.00 $0.00 $65.34 $232.68 $232.68 $0.00 $0.00 $65.33 $0.00 $185.44 $185.44 $0.00 $156.75 $248.29 $250.80 $0.00 $0.00 $49.06 $0.00 $0.00 $49.91 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-080 SUP HCPCS C1713 3362-6-080 - SCREW BONE 80MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $280.50 $207.57 $0.00 $224.40 $126.23 $126.23 $0.00 $0.00 $0.00 $58.46 $208.19 $208.19 $0.00 $0.00 $58.46 $0.00 $165.92 $165.92 $0.00 $140.25 $222.16 $224.40 $0.00 $0.00 $43.90 $0.00 $0.00 $44.66 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-090 SUP HCPCS C1713 3362-6-090 - SCREW BONE 90MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $209.00 $154.66 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $43.56 $155.12 $155.12 $0.00 $0.00 $43.56 $0.00 $123.62 $123.62 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-100 SUP HCPCS C1713 3362-6-100 - SCREW BONE 100MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $345.13 $255.40 $0.00 $276.10 $155.31 $155.31 $0.00 $0.00 $0.00 $71.93 $256.15 $256.15 $0.00 $0.00 $71.92 $0.00 $204.14 $204.14 $0.00 $172.56 $273.34 $276.10 $0.00 $0.00 $54.01 $0.00 $0.00 $54.94 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-105 SUP HCPCS C1713 3362-6-105 - SCREW BONE 105MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-110 SUP HCPCS C1713 3362-6-110 - SCREW BONE 110MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $378.13 $279.82 $0.00 $302.50 $170.16 $170.16 $0.00 $0.00 $0.00 $78.81 $280.64 $280.64 $0.00 $0.00 $78.80 $0.00 $223.66 $223.66 $0.00 $189.06 $299.48 $302.50 $0.00 $0.00 $59.18 $0.00 $0.00 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-115 SUP HCPCS C1713 3362-6-115 - SCREW BONE 115MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $345.13 $255.40 $0.00 $276.10 $155.31 $155.31 $0.00 $0.00 $0.00 $71.93 $256.15 $256.15 $0.00 $0.00 $71.92 $0.00 $204.14 $204.14 $0.00 $172.56 $273.34 $276.10 $0.00 $0.00 $54.01 $0.00 $0.00 $54.94 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-120 SUP HCPCS C1713 3362-6-120 - SCREW BONE 120MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $313.50 $231.99 $0.00 $250.80 $141.08 $141.08 $0.00 $0.00 $0.00 $65.34 $232.68 $232.68 $0.00 $0.00 $65.33 $0.00 $185.44 $185.44 $0.00 $156.75 $248.29 $250.80 $0.00 $0.00 $49.06 $0.00 $0.00 $49.91 $0.00 $0.00 $0.00 $0.00 $0.00 3362-6-130 SUP HCPCS C1713 3362-6-130 - SCREW BONE 130MM OMEGA+ SS HIP SUPLAG BOTH IP/OP $313.50 $231.99 $0.00 $250.80 $141.08 $141.08 $0.00 $0.00 $0.00 $65.34 $232.68 $232.68 $0.00 $0.00 $65.33 $0.00 $185.44 $185.44 $0.00 $156.75 $248.29 $250.80 $0.00 $0.00 $49.06 $0.00 $0.00 $49.91 $0.00 $0.00 $0.00 $0.00 $0.00 3363-0-354 SUP HCPCS C1713 3363-0-354 - PLATE 135D 25MM SS 4 HOLE CMPR OMEGA+ BONE HIP NONSTRL BOTH IP/OP $563.75 $417.18 $0.00 $451.00 $253.69 $253.69 $0.00 $0.00 $0.00 $117.50 $418.42 $418.42 $0.00 $0.00 $117.49 $0.00 $333.46 $333.46 $0.00 $281.88 $446.49 $451.00 $0.00 $0.00 $88.23 $0.00 $0.00 $89.75 $0.00 $0.00 $0.00 $0.00 $0.00 3363-1-203 SUP HCPCS C1713 3363-1-203 - PLATE 140D SS 3 HOLE CMPR OMEGA+ BONE HIP NONSTRL BOTH IP/OP $501.88 $371.39 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $104.60 $372.49 $372.49 $0.00 $0.00 $104.59 $0.00 $296.86 $296.86 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3363-1-303 SUP HCPCS C1713 3363-1-303 - PLATE 145D SS 3 HOLE CMPR OMEGA+ BONE HIP NONSTRL BOTH IP/OP $529.38 $391.74 $0.00 $423.50 $238.22 $238.22 $0.00 $0.00 $0.00 $110.33 $392.90 $392.90 $0.00 $0.00 $110.32 $0.00 $313.13 $313.13 $0.00 $264.69 $419.27 $423.50 $0.00 $0.00 $82.85 $0.00 $0.00 $84.28 $0.00 $0.00 $0.00 $0.00 $0.00 3363-1-403 SUP HCPCS C1713 3363-1-403 - PLATE 150D SS 3 HOLE CMPR OMEGA+ BONE HIP NONSTRL BOTH IP/OP $501.88 $371.39 $0.00 $401.50 $225.84 $225.84 $0.00 $0.00 $0.00 $104.60 $372.49 $372.49 $0.00 $0.00 $104.59 $0.00 $296.86 $296.86 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $78.54 $0.00 $0.00 $79.90 $0.00 $0.00 $0.00 $0.00 $0.00 3363-5-085 SUP HCPCS C1713 3363-5-085 - SCREW BONE 85MM OMEGA+ HIP LAG NONSTRL BOTH IP/OP $488.13 $361.22 $0.00 $390.50 $219.66 $219.66 $0.00 $0.00 $0.00 $101.74 $362.29 $362.29 $0.00 $0.00 $101.73 $0.00 $288.73 $288.73 $0.00 $244.06 $386.60 $390.50 $0.00 $0.00 $76.39 $0.00 $0.00 $77.71 $0.00 $0.00 $0.00 $0.00 $0.00 3363-7-000 SUP HCPCS C1713 3363-7-000 - SCREW BONE OMEGA+ SS HIP CMPR NONSTRL BOTH IP/OP $52.25 $38.67 $0.00 $41.80 $23.51 $23.51 $0.00 $0.00 $0.00 $10.89 $38.78 $38.78 $0.00 $0.00 $10.89 $0.00 $30.91 $30.91 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $8.18 $0.00 $0.00 $8.32 $0.00 $0.00 $0.00 $0.00 $0.00 33661200MR SUP HCPCS C1713 33661200MR - CAP LOCKING LARGE ROUND 12MM SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 33661200SR SUP HCPCS C1713 33661200SR - CAP LOCKING SMALL ROUND 12MM SPN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 33661205MR SUP HCPCS C1713 33661205MR - ENDCAP SPINAL 5D LARGE ROUND 12MM MODULAR VBOSS BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 33661205SR SUP Custom 27803010 33661205SR - ENDCAP SPINAL 5D SMALL ROUND 12MM MODULAR VBOSS BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33661400MR SUP Custom 27803010 33661400MR - ENDCAP SPINAL 0D LARGE ROUND 14MM MODULAR VBOSS BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33661400SR SUP Custom 27803010 33661400SR - ENDCAP SPINAL 0D SMALL ROUND 14MM MODULAR VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33661405MR SUP Custom 27803010 33661405MR - ENDCAP SPINAL 5D LARGE ROUND 14MM MODULAR VBOSS BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33661405SR SUP Custom 27803010 33661405SR - ENDCAP SPINAL 5D SMALL ROUND 14MM MODULAR VBOSS BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33661600MR SUP Custom 27803010 33661600MR - ENDCAP SPINAL LARGE 16MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33661600SR SUP Custom 27803010 33661600SR - ENDCAP SPINAL SMALL 16MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33661605MR SUP Custom 27803010 33661605MR - ENDCAP SPINAL 5D LARGE 16MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33661605SR SUP Custom 27803010 33661605SR - ENDCAP SPINAL 5D SMALL 16MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662000MO SUP Custom 27803010 33662000MO - ENDCAP SPINAL LARGE 20MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662000MR SUP Custom 27803010 33662000MR - ENDCAP SPINAL LARGE 20MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662000SO SUP Custom 27803010 33662000SO - ENDCAP SPINAL SMALL 20MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662000SR SUP Custom 27803010 33662000SR - ENDCAP SPINAL SMALL 20MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662005MO SUP Custom 27803010 33662005MO - ENDCAP SPINAL 5D LARGE 20MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662005MR SUP Custom 27803010 33662005MR - ENDCAP SPINAL 5D LARGE 20MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662005SO SUP Custom 27803010 33662005SO - ENDCAP SPINAL 5D SMALL 20MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662005SR SUP Custom 27803010 33662005SR - ENDCAP SPINAL 5D SMALL 20MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662010MO SUP Custom 27803010 33662010MO - ENDCAP SPINAL 10D LARGE 20MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662010SO SUP Custom 27803010 33662010SO - ENDCAP SPINAL 10D SMALL 20MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662500MO SUP Custom 27803010 33662500MO - ENDCAP SPINAL LARGE 25MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662500MR SUP Custom 27803010 33662500MR - ENDCAP SPINAL LARGE 25MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662500SO SUP Custom 27803010 33662500SO - ENDCAP SPINAL SMALL 25MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662500SR SUP Custom 27803010 33662500SR - ENDCAP SPINAL SMALL 25MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662505MO SUP Custom 27803010 33662505MO - ENDCAP SPINAL 5D LARGE 25MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662505MR SUP Custom 27803010 33662505MR - ENDCAP SPINAL 5D LARGE 25MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662505SO SUP Custom 27803010 33662505SO - ENDCAP SPINAL 5D SMALL 25MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662505SR SUP Custom 27803010 33662505SR - ENDCAP SPINAL 5D SMALL 25MM ROUND VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662510MO SUP Custom 27803010 33662510MO - ENDCAP SPINAL 10D LARGE 25MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33662510SO SUP Custom 27803010 33662510SO - ENDCAP SPINAL 10D SMALL 25MM OVAL VBOSS TITANIUM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3370-0-230 SUP HCPCS C1713 3370-0-230 - NAIL 12MM 21CM HIP GAMA IM 130D STD GAMA SYS STYKER ORTH BOTH IP/OP "$1,498.75 " "$1,109.08" $0.00 "$1,199.00" $674.44 $674.44 $0.00 $0.00 $0.00 $312.38 "$1,112.37" "$1,112.37" $0.00 $0.00 $312.34 $0.00 $886.51 $886.51 $0.00 $749.38 "$1,187.01" "$1,199.00" $0.00 $0.00 $234.55 $0.00 $0.00 $238.60 $0.00 $0.00 $0.00 $0.00 $0.00 3370-0-235 SUP HCPCS C1713 3370-0-235 - NAIL 12MM 21MM HIP GAMA IM 135D STD GAMA SYS BOTH IP/OP "$1,155.00 " $854.70 $0.00 $924.00 $519.75 $519.75 $0.00 $0.00 $0.00 $240.73 $857.24 $857.24 $0.00 $0.00 $240.70 $0.00 $683.18 $683.18 $0.00 $577.50 $914.76 $924.00 $0.00 $0.00 $180.76 $0.00 $0.00 $183.88 $0.00 $0.00 $0.00 $0.00 $0.00 3370-0-430 SUP HCPCS C1713 3370-0-430 - NAIL 14MM 21CM HIP GAMA IM 130D STD GAMA SYS STRYK ORTH BOTH IP/OP "$1,051.88 " $778.39 $0.00 $841.50 $473.34 $473.34 $0.00 $0.00 $0.00 $219.24 $780.70 $780.70 $0.00 $0.00 $219.21 $0.00 $622.18 $622.18 $0.00 $525.94 $833.09 $841.50 $0.00 $0.00 $164.62 $0.00 $0.00 $167.46 $0.00 $0.00 $0.00 $0.00 $0.00 3370-0-435 SUP HCPCS C1713 3370-0-435 - NAIL 14MM 21CM HIP GAMA IM 135D STD SS GAMA SYS BOTH IP/OP "$1,361.25 " "$1,007.33" $0.00 "$1,089.00" $612.56 $612.56 $0.00 $0.00 $0.00 $283.72 "$1,010.32" "$1,010.32" $0.00 $0.00 $283.68 $0.00 $805.18 $805.18 $0.00 $680.63 "$1,078.11" "$1,089.00" $0.00 $0.00 $213.04 $0.00 $0.00 $216.71 $0.00 $0.00 $0.00 $0.00 $0.00 3370-1-000 SUP HCPCS C1713 3370-1-000 - SCREW SET 8MM 27MM GMA HIP IM NL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 3370-1-050 SUP HCPCS C1713 3370-1-050 - SCREW BONE GAMA CAP NAIL BOTH IP/OP $195.25 $144.49 $0.00 $156.20 $87.86 $87.86 $0.00 $0.00 $0.00 $40.69 $144.91 $144.91 $0.00 $0.00 $40.69 $0.00 $115.49 $115.49 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 3370-1-060 SUP HCPCS C1713 3370-1-060 - SCREW BONE 12MM 60MM GAMA SS FEM LAG IM NAIL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-080 SUP HCPCS C1713 3370-2-080 - SCREW BONE 12MM 80MM GAMA LAG IM NAIL BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-085 SUP HCPCS C1713 3370-2-085 - NAIL 12MM 85MM GAMA IM NAIL LAG BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-090 SUP HCPCS C1713 3370-2-090 - NAIL 12MM 90MM GAMA IM NAIL LAG BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-095 SUP HCPCS C1713 3370-2-095 - NAIL 12MM 95MM HIP GAMA IM NAIL LAG TI BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-100 SUP HCPCS C1713 3370-2-100 - SCREW BONE 12MM 100MM GAMA FEM LAG IM NAIL BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-105 SUP HCPCS C1713 3370-2-105 - SCREW BONE 105MM 12MM GAMA FEM LAG SCR IM NAIL BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-110 SUP HCPCS C1713 3370-2-110 - SCREW BONE 12MM 110MM GAMA FEM LAG IM NAIL BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-120 SUP HCPCS C1713 3370-2-120 - SCREW BONE 12MM 120MM GAMA SS FEM LAG IM NAIL BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-2-130 SUP HCPCS C1713 3370-2-130 - SCREW BONE 12MM 130MM GAMMA3 SS HIP FEM LAG IM NAIL BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $293.91 $293.91 $0.00 $0.00 $0.00 $136.13 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $386.32 $386.32 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $102.21 $0.00 $0.00 $103.98 $0.00 $0.00 $0.00 $0.00 $0.00 3370-3-035 SUP HCPCS C1713 3370-3-035 - SCREW BONE 6.28MM 35MM GAMMA3 HIP DISTAL NAIL BOTH IP/OP $178.75 $132.28 $0.00 $143.00 $80.44 $80.44 $0.00 $0.00 $0.00 $37.26 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $105.73 $105.73 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $27.97 $0.00 $0.00 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 3370-3-040 SUP HCPCS C1713 3370-3-040 - SCREW BONE 6.28MM 40MM GAMA DISTAL IM NAIL BOTH IP/OP $178.75 $132.28 $0.00 $143.00 $80.44 $80.44 $0.00 $0.00 $0.00 $37.26 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $105.73 $105.73 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $27.97 $0.00 $0.00 $28.46 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-025 SUP HCPCS C1713 3370-6-025 - NAIL 11MM 34CM HIP LEFT FEM GAMMA3 IM 125D LNG LCK TI BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-030 SUP HCPCS C1713 3370-6-030 - NAIL 11MM 34CM HIP LEFT FEM GAMMA3 IM 130D LNG LCK TI BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-035 SUP HCPCS C1713 3370-6-035 - NAIL 11MM 34CM LEFT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-125 SUP HCPCS C1713 3370-6-125 - NAIL 11MM 36CM LEFT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-130 SUP HCPCS C1713 3370-6-130 - NAIL 11MM 360MM LEFT GAMA IM 130D LNG BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-135 SUP HCPCS C1713 3370-6-135 - NAIL 11MM 36CM LEFT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-225 SUP HCPCS C1713 3370-6-225 - NAIL 11MM 38CM LEFT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-230 SUP HCPCS C1713 3370-6-230 - NAIL 11MM 38CM LEFT FEM GAMA IM 130D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-235 SUP HCPCS C1713 3370-6-235 - NAIL 11MM 38CM LEFT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-325 SUP HCPCS C1713 3370-6-325 - NAIL 11MM 40CM LEFT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-330 SUP HCPCS C1713 3370-6-330 - NAIL 11MM 400MM LEFT GAMA IM 130D LNG BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-335 SUP HCPCS C1713 3370-6-335 - NAIL 11MM 40CM LEFT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-425 SUP HCPCS C1713 3370-6-425 - NAIL 11MM 42CM LEFT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-430 SUP HCPCS C1713 3370-6-430 - NAIL 11MM 42CM LEFT FEM GAMA IM 130D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-435 SUP HCPCS C1713 3370-6-435 - NAIL 11MM 42CM LEFT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-525 SUP HCPCS C1713 3370-6-525 - NAIL 11MM 44CM LEFT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-530 SUP HCPCS C1713 3370-6-530 - NAIL 11MM 44CM LEFT FEM GAMA IM 130D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-6-535 SUP HCPCS C1713 3370-6-535 - NAIL 11MM 44CM LEFT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,413.13 " "$1,785.72" $0.00 "$1,930.50" "$1,085.91" "$1,085.91" $0.00 $0.00 $0.00 $502.96 "$1,791.02" "$1,791.02" $0.00 $0.00 $502.90 $0.00 "$1,427.36" "$1,427.36" $0.00 "$1,206.56" "$1,911.20" "$1,930.50" $0.00 $0.00 $377.65 $0.00 $0.00 $384.17 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-025 SUP HCPCS C1713 3370-7-025 - NAIL 11MM 34CM RIGHT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-030 SUP HCPCS C1713 3370-7-030 - NAIL 11MM 34CM RIGHT HIP GAMMA3 IM 130D LNG LCK TI BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-035 SUP HCPCS C1713 3370-7-035 - NAIL 11MM 34CM RIGHT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-125 SUP HCPCS C1713 3370-7-125 - NAIL 11MM 36CM RIGHT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-130 SUP HCPCS C1713 3370-7-130 - NAIL 11MM 360MM RIGHT TROC GAMA IM 130D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-135 SUP HCPCS C1713 3370-7-135 - NAIL 11MM 36CM RIGHT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-225 SUP HCPCS C1713 3370-7-225 - NAIL 11MM 38CM RIGHT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-230 SUP HCPCS C1713 3370-7-230 - NAIL 11MM 38CM RIGHT FEM GAMA IM 130D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-235 SUP HCPCS C1713 3370-7-235 - NAIL 11MM 38CM RIGHT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-325 SUP HCPCS C1713 3370-7-325 - NAIL 11MM 40CM RIGHT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-330 SUP HCPCS C1713 3370-7-330 - NAIL 11MM 40CM RIGHT FEM GAMA IM 130D LNG LCK STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-335 SUP HCPCS C1713 3370-7-335 - NAIL 11MM 40CM RIGHT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-425 SUP HCPCS C1713 3370-7-425 - NAIL 11MM 42CM RIGHT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-430 SUP HCPCS C1713 3370-7-430 - NAIL 11MM 42CM RIGHT FEM GAMA IM 130D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-435 SUP HCPCS C1713 3370-7-435 - NAIL 11MM 42CM RIGHT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-525 SUP HCPCS C1713 3370-7-525 - NAIL 11MM 44CM RIGHT FEM GAMA IM 125D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-530 SUP HCPCS C1713 3370-7-530 - NAIL 11MM 44CM RIGHT FEM GAMA IM 130D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-7-535 SUP HCPCS C1713 3370-7-535 - NAIL 11MM 44CM RIGHT FEM GAMA IM 135D LNG LCK SS STRL BOTH IP/OP "$2,293.50 " "$1,697.19" $0.00 "$1,834.80" "$1,032.08" "$1,032.08" $0.00 $0.00 $0.00 $478.02 "$1,702.24" "$1,702.24" $0.00 $0.00 $477.97 $0.00 "$1,356.61" "$1,356.61" $0.00 "$1,146.75" "$1,816.45" "$1,834.80" $0.00 $0.00 $358.93 $0.00 $0.00 $365.13 $0.00 $0.00 $0.00 $0.00 $0.00 3370-8-125 SUP HCPCS C1713 3370-8-125 - NAIL 11MM 18CM TROC GAMA IM 125D LCK SS STRL BOTH IP/OP "$1,863.13 " "$1,378.72" $0.00 "$1,490.50" $838.41 $838.41 $0.00 $0.00 $0.00 $388.32 "$1,382.81" "$1,382.81" $0.00 $0.00 $388.28 $0.00 "$1,102.04" "$1,102.04" $0.00 $931.56 "$1,475.60" "$1,490.50" $0.00 $0.00 $291.58 $0.00 $0.00 $296.61 $0.00 $0.00 $0.00 $0.00 $0.00 3370-8-130 SUP HCPCS C1713 3370-8-130 - NAIL TROC IM 130D BOTH IP/OP "$1,863.13 " "$1,378.72" $0.00 "$1,490.50" $838.41 $838.41 $0.00 $0.00 $0.00 $388.32 "$1,382.81" "$1,382.81" $0.00 $0.00 $388.28 $0.00 "$1,102.04" "$1,102.04" $0.00 $931.56 "$1,475.60" "$1,490.50" $0.00 $0.00 $291.58 $0.00 $0.00 $296.61 $0.00 $0.00 $0.00 $0.00 $0.00 3370-8-135 SUP HCPCS C1713 3370-8-135 - NAIL 11MM 18CM TROC GAMA IM 135D LCK SS BOTH IP/OP "$1,863.13 " "$1,378.72" $0.00 "$1,490.50" $838.41 $838.41 $0.00 $0.00 $0.00 $388.32 "$1,382.81" "$1,382.81" $0.00 $0.00 $388.28 $0.00 "$1,102.04" "$1,102.04" $0.00 $931.56 "$1,475.60" "$1,490.50" $0.00 $0.00 $291.58 $0.00 $0.00 $296.61 $0.00 $0.00 $0.00 $0.00 $0.00 3371-1-015 SUP HCPCS C1769 3371-1-015 - GUIDEWIRE ORTH 3MM STRL BLNT TIP PACKAGED BOTH IP/OP $233.75 $172.98 $0.00 $187.00 $126.93 $126.93 $0.00 $0.00 $0.00 $48.72 $173.49 $173.49 $0.00 $0.00 $48.71 $0.00 $138.26 $138.26 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $36.58 $0.00 $0.00 $37.21 $0.00 $0.00 $0.00 $0.00 $0.00 3371-1-060 SUP HCPCS C1713 3371-1-060 - WIRE FX 3.2MM 450MM KRSH SS GMA NL SYS BOTH IP/OP $192.50 $142.45 $0.00 $154.00 $86.63 $86.63 $0.00 $0.00 $0.00 $40.12 $142.87 $142.87 $0.00 $0.00 $40.12 $0.00 $113.86 $113.86 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $30.13 $0.00 $0.00 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 3371-1-078 SUP Custom 27203010 3371-1-078 - HEAD FEM +5MM OFST 36MM V40 LFIT COCR HIP BOTH IP/OP "$1,684.38 " "$1,246.44" $0.00 "$1,347.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,250.14" "$1,250.14" $0.00 $0.00 $351.02 $0.00 $0.00 $0.00 $0.00 $842.19 "$1,334.03" "$1,347.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3371-1-085 SUP Custom 27803010 3371-1-085 - TAP LAG SCR SURG BOTH IP/OP "$1,313.13 " $971.72 $0.00 "$1,050.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $974.60 $974.60 $0.00 $0.00 $273.66 $0.00 $0.00 $0.00 $0.00 $656.56 "$1,040.00" "$1,050.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3371-1-180 SUP Custom 27203010 3371-1-180 - BIT DRILL 5.5MM BOTH IP/OP $203.50 $150.59 $0.00 $162.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.04 $151.04 $0.00 $0.00 $42.41 $0.00 $0.00 $0.00 $0.00 $101.75 $161.17 $162.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3371-1-185 SUP Custom 27203010 3371-1-185 - SLEEVE DRILL 5.5MM GAMA GUIDE NAIL BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338 021 SUP HCPCS C1900 338 021 - AROX 60 BP LEAD BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338 022 SUP HCPCS C1900 338 022 - AROX 45 JBP LEAD BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 338 023 SUP HCPCS C1900 338 023 - AROX 53 BP LEAD BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 33MJ-501 SUP Custom 27803010 33MJ-501 - VALVE MTRL 85D 5.18SQ CM 33MM 26.1MM MSTR SER MECH STD CUF BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0260S SUP HCPCS C1713 3420-0260S - NAIL 10MM 26CM RIGHT FEM HIP GAMMA3 IM 120D LNG TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0280S SUP HCPCS C1713 3420-0280S - NAIL 10MM 28CM RIGHT FEM HIP GAMMA3 IM 120D LNG TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0300S SUP HCPCS C1713 3420-0300S - NAIL 10MM 30CM RIGHT FEM HIP GAMMA3 IM 120D LNG TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0320S SUP HCPCS C1713 3420-0320S - NAIL 10MM 32CM RIGHT FEM HIP GAMMA3 IM 120D LNG TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0340S SUP HCPCS C1713 3420-0340S - NAIL 10MM 34CM RIGHT FEM HIP GAMMA3 IM 120D LNG TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0360S SUP HCPCS C1713 3420-0360S - NAIL 10MM 36CM RIGHT FEM HIP GAMMA3 IM 120D LNG TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0380S SUP HCPCS C1713 3420-0380S - NAIL 10MM 38CM RIGHT FEM HIP GAMMA3 IM 120D LNG TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0400S SUP HCPCS C1713 3420-0400S - NAIL 10MM 40CM RIGHT FEM HIP GAMMA3 IM 120D LNG TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0420S SUP HCPCS C1713 3420-0420S - GAMMA 3 S NAIL RIGHT 10X420MM X 120 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0440S SUP HCPCS C1713 3420-0440S - NAIL IM 120D 10MM 440MM STRL GAMMA3 RT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3420-0460S SUP HCPCS C1713 3420-0460S - NAIL IM 120D 10MM 460MM STRL GAMMA3 RT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0260S SUP HCPCS C1713 3425-0260S - NAIL 10MM 26CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0280S SUP HCPCS C1713 3425-0280S - NAIL 10MM 28CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0300S SUP HCPCS C1713 3425-0300S - NAIL 10MM 30CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0320S SUP HCPCS C1713 3425-0320S - NAIL 10MM 32CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0340S SUP HCPCS C1713 3425-0340S - NAIL 10MM 34CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0360S SUP HCPCS C1713 3425-0360S - NAIL 10MM 36CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0380S SUP HCPCS C1713 3425-0380S - NAIL 10MM 38CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0400S SUP HCPCS C1713 3425-0400S - NAIL 10MM 40CM RIGHT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0420S SUP HCPCS C1713 3425-0420S - GAMMA 3 S NAIL RIGHT 10X420MM X 125 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0440S SUP HCPCS C1713 3425-0440S - GAMMA 3 S NAIL RIGHT 10X440MM X 125 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0460S SUP HCPCS C1713 3425-0460S - NAIL IM 125D 10MM 460MM STRL GAMMA3 RT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3425-0480S SUP HCPCS C1713 3425-0480S - NAIL IM 10MM 480MM STRL 125MM GAMMA3 RT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$3,763.10" "$2,116.74" "$2,116.74" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$2,351.94" "$3,725.47" "$3,763.10" $0.00 $0.00 $736.16 $0.00 $0.00 $748.86 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0260S SUP HCPCS C1713 3430-0260S - NAIL 10MM 26CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0280S SUP HCPCS C1713 3430-0280S - NAIL 10MM 28CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0300S SUP HCPCS C1713 3430-0300S - NAIL 10MM 30CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0320S SUP HCPCS C1713 3430-0320S - NAIL 10MM 32CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0340S SUP HCPCS C1713 3430-0340S - NAIL 10MM 34CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0360S SUP HCPCS C1713 3430-0360S - NAIL 10MM 36CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0380S SUP HCPCS C1713 3430-0380S - NAIL 10MM 38CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0400S SUP HCPCS C1713 3430-0400S - NAIL 10MM 40CM RIGHT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0420S SUP HCPCS C1713 3430-0420S - GAMMA 3 S NAIL RIGHT 10X420MM X 130 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0440S SUP HCPCS C1713 3430-0440S - GAMMA 3 S NAIL RIGHT 10X440MM X 130 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3430-0460S SUP HCPCS C1713 3430-0460S - NAIL IM 130D 10MM 460MM STRL GAMMA3 RT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 346 366 SUP HCPCS C1898 346 366 - SELOX ST 53 LEAD BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 346 367 SUP HCPCS C1898 346 367 - SELOX ST 60 LEAD BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 346 368 SUP HCPCS C1898 346 368 - SELOX JT 53 LEAD BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 346 369 SUP HCPCS C1898 346 369 - SELOX JT 45 LEAD BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 3460-7-006 SUP HCPCS C1713 3460-7-006 - SCREW BONE 8MM 19MM PED HIP OSTMY BOTH IP/OP $572.00 $423.28 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $119.22 $424.54 $424.54 $0.00 $0.00 $119.20 $0.00 $338.34 $338.34 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 3460-7-007 SUP HCPCS C1713 3460-7-007 - SCREW BONE 8MM 22MM PED ORTH OSTMY PEDI HIP SYS BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 3460-7-030 SUP HCPCS C1713 3460-7-030 - SCREW BONE 8MM 76MM PED PDCL HIP OSTMY BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 349 799 SUP HCPCS C1900 349 799 - CYLOS DR WITH CLS AUTONOMIC RESPONSE BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 "$1,330.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 349 811 SUP HCPCS C1900 349 811 - CYLOS VR WITH CLS AUTONOMIC RESPONSE BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 "$1,330.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 350 053 SUP HCPCS C1895 350 053 - LINOX SD STEROID 65/16 BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 350 056 SUP HCPCS C1895 350 056 - LINOX SD STEROID 75/18 BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 350 975 SUP HCPCS C1895 350 975 - SETROX S 60 LEAD BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 35-0002 SUP Custom 27203010 35-0002 - PIN FIX 4MM LCK CALCANEUS STNM SS BOTH IP/OP $142.50 $105.45 $0.00 $114.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.76 $105.76 $0.00 $0.00 $29.70 $0.00 $0.00 $0.00 $0.00 $71.25 $112.86 $114.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35-0003 SUP Custom 27203010 35-0003 - PIN FIX 5MM ORTH STNM SS BOTH IP/OP $142.50 $105.45 $0.00 $114.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.76 $105.76 $0.00 $0.00 $29.70 $0.00 $0.00 $0.00 $0.00 $71.25 $112.86 $114.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 35-0011 SUP HCPCS C1769 35-0011 - GUIDEWIRE ORTHOPEDIC STR .045IN 5.75IN THREAD TITANIUM BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $3.65 $12.99 $12.99 $0.00 $0.00 $3.65 $0.00 $10.35 $10.35 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 350-2001 BC SUP HCPCS C1789 350-2001 BC - IMPL BRST 200ML GEL SMTH SIL P3.2CM MODEARTE PRFL RND 10.5CM BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" $984.38 $984.38 $0.00 $0.00 $0.00 $455.93 "$1,623.56" "$1,623.56" $0.00 $0.00 $455.88 $0.00 "$1,293.91" "$1,293.91" $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 350-2500 SUP HCPCS C1789 350-2500 - IMPL BRST 500-600ML STY 2000 SMTH RND SAL P5.9CM MDRT PLUS BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 350-2501BC SUP HCPCS C1789 350-2501BC - IMPLANT BRST P3.4CM MDRT + HI PRFL RND 11.3CM 250ML STRL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 350-3001BC SUP HCPCS C1789 350-3001BC - IMPLANT BRST P3.6CM RND MDRT + PRFL 12CM 300ML STRL BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" $984.38 $984.38 $0.00 $0.00 $0.00 $455.93 "$1,623.56" "$1,623.56" $0.00 $0.00 $455.88 $0.00 "$1,293.91" "$1,293.91" $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 350-3004BC SUP HCPCS C1789 350-3004BC - IMPLANT BRST P4.5CM HI PRFL RND NAR BS 11.1CM 300CC BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 350-3501 BC SUP HCPCS C1789 350-3501 BC - IMPL BRST 350ML GEL SMTH SIL P3.9CM MDRT PLUS PRFL RND 12.5 BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" $984.38 $984.38 $0.00 $0.00 $0.00 $455.93 "$1,623.56" "$1,623.56" $0.00 $0.00 $455.88 $0.00 "$1,293.91" "$1,293.91" $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 350-3504BC SUP HCPCS C1789 350-3504BC - IMPL BRST 350ML GEL SMTH MEMORYGEL SIL P4.8CM HI PRFL RND BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 350-4001 BC SUP HCPCS C1789 350-4001 BC - IMPLANT BRST P4CM MDRT + PRFL RND 13.1CM 400CC MEMORYGEL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 350-4004 BC SUP HCPCS C1789 350-4004 BC - IMPLANT BRST P5CM HI PRFL RND NAR BS 12.2CM 400CC MEMORYGEL BOTH IP/OP "$2,325.00 " "$1,720.50" $0.00 "$1,860.00" "$1,046.25" "$1,046.25" $0.00 $0.00 $0.00 $484.59 "$1,725.62" "$1,725.62" $0.00 $0.00 $484.53 $0.00 "$1,375.24" "$1,375.24" $0.00 "$1,162.50" "$1,841.40" "$1,860.00" $0.00 $0.00 $363.86 $0.00 $0.00 $370.14 $0.00 $0.00 $0.00 $0.00 $0.00 350-4501BC SUP HCPCS C1789 350-4501BC - IMPLANT BRST P4.2CM MDRT + PRFL 13.6CM 450ML CHSV I GEL RND BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" $984.38 $984.38 $0.00 $0.00 $0.00 $455.93 "$1,623.56" "$1,623.56" $0.00 $0.00 $455.88 $0.00 "$1,293.91" "$1,293.91" $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 350-4504BC SUP HCPCS C1789 350-4504BC - IMPLANT BRST P5.1CM RND 12.8CM 450ML STRL MEMORYGEL SMTH HI BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 350-5001 BC SUP HCPCS C1789 350-5001 BC - IMPLANT BREAST P4.3CM MODERATE PLUS PROFILE ROUND MODERATE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 350-5004BC SUP HCPCS C1789 350-5004BC - IMPL BRST 500ML GEL SMTH MEMORYGEL SIL P5.3CM HI PRFL RND BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 350-5501 BC SUP HCPCS C1789 350-5501 BC - IMPL BRST 550ML GEL SMTH SIL P4.5CM MDRT PRFL RND 14.6CM BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" $984.38 $984.38 $0.00 $0.00 $0.00 $455.93 "$1,623.56" "$1,623.56" $0.00 $0.00 $455.88 $0.00 "$1,293.91" "$1,293.91" $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 350-5504 BC SUP HCPCS C1789 350-5504 BC - IMPL BRST 550ML GEL SMTH MEMORYGEL SIL P5.5CM HI PRFL RND BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 350-800 1BC SUP HCPCS C1789 350-800 1BC - IMPLANT BRST P5.1CM MDRT + PRFL RND 16.5CM 800ML STRL CHSV I BOTH IP/OP "$2,262.50 " "$1,674.25" $0.00 "$1,810.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $471.56 "$1,679.23" "$1,679.23" $0.00 $0.00 $471.51 $0.00 "$1,338.27" "$1,338.27" $0.00 "$1,131.25" "$1,791.90" "$1,810.00" $0.00 $0.00 $354.08 $0.00 $0.00 $360.19 $0.00 $0.00 $0.00 $0.00 $0.00 351 337 SUP HCPCS C1895 351 337 - LINOX TD STEROID 65/16 CM BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 351.16J SUP Custom 27203010 351.16J - CHUCK DRILL CONCTR CANN QUICK COUPLING JACOBS BOTH IP/OP $789.18 $583.99 $0.00 $612.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $585.73 $585.73 $0.00 $0.00 $164.46 $0.00 $0.00 $0.00 $0.00 $383.10 $606.83 $612.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.27S SUP Custom 27203010 351.27S - BIT DRL 13MM 300MM STRL CNN BOTH IP/OP "$1,212.20 " $897.03 $0.00 $941.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $899.69 $899.69 $0.00 $0.00 $252.62 $0.00 $0.00 $0.00 $0.00 $588.45 $932.10 $941.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.704S SUP Custom 27203010 351.704S - ROD REAMER 2.5MM 1150MM BALL TIP EXTN STERILE BOTH IP/OP $241.78 $178.92 $0.00 $187.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.45 $179.45 $0.00 $0.00 $50.39 $0.00 $0.00 $0.00 $0.00 $117.36 $185.91 $187.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.706S SUP Custom 27203010 351.706S - ROD REAMING 2.5MM 950MM BALL TIP GWIRE STERILE DISPOSABLE BOTH IP/OP $223.18 $165.15 $0.00 $173.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.64 $165.64 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $108.34 $171.61 $173.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.707S SUP Custom 27203010 351.707S - ROD REAMING 2.5MM 950MM BALL TIP EXTN STERILE DISPOSABLE BOTH IP/OP $223.18 $165.15 $0.00 $173.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.64 $165.64 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $108.34 $171.61 $173.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.708S SUP Custom 27203010 351.708S - ROD REAMING BALL 2.5MM 1150MM STERILE INTRAMEDULLARY NAIL BOTH IP/OP $269.88 $199.71 $0.00 $209.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $131.00 $207.50 $209.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.709S SUP Custom 27203010 351.709S - ROD REAMER 2.5MM 650MM BALL TIP STERILE BOTH IP/OP $237.78 $175.96 $0.00 $184.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.48 $176.48 $0.00 $0.00 $49.55 $0.00 $0.00 $0.00 $0.00 $115.43 $182.83 $184.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 351.718S SUP Custom 27203010 351.718S - SEAL DRIVE SHAFT ELASTOMERIC STERILE DISPOSABLE RIA BOTH IP/OP $20.96 $15.51 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.56 $15.56 $0.00 $0.00 $4.37 $0.00 $0.00 $0.00 $0.00 $9.88 $15.65 $15.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3515-9-100 SUP HCPCS C1713 3515-9-100 - NAIL ORTH IM BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $95.91 $95.91 $0.00 $0.00 $0.00 $44.42 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $126.06 $126.06 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 352.229S SUP Custom 27203010 352.229S - FILTER GRAFT PLUNGER GRADUATED 100ML STERILE DISPOSABLE RIA BOTH IP/OP $617.05 $456.62 $0.00 $479.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.97 $457.97 $0.00 $0.00 $128.59 $0.00 $0.00 $0.00 $0.00 $299.54 $474.47 $479.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.250S SUP Custom 27203010 352.250S - REAMER SURG 12MM HEAD STERILE DISPOSABLE RIA BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.251S SUP Custom 27203010 352.251S - REAMER SURG 12.5MM HEAD STERILE DISPOSABLE RIA BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.252S SUP Custom 27203010 352.252S - HEAD RMR DP FLUT 13MM STRL CNCL TIP SHRP EDG SS DISP IRR ASP BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.253S SUP Custom 27203010 352.253S - REAMER SURG 13.5MM HEAD STERILE DISPOSABLE RIA BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.254S SUP Custom 27203010 352.254S - REAMER SURG 14MM HEAD STERILE DISPOSABLE RIA BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.255S SUP Custom 27203010 352.255S - REAMER SURG 14.5MM CONICAL TIP DEEP FLUTE SHARP EDGE BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.256S SUP Custom 27203010 352.256S - HEAD RMR DP FLUT 15MM STRL CNCL TIP SHRP EDG SS DISP IRR ASP BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.257S SUP HCPCS C1713 352.257S - HEAD REAMER 15.5MM STERILE IRRIGATOR ASPIRAT BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $298.90 $298.90 $0.00 $0.00 $0.00 $142.59 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $404.67 $404.67 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $100.92 $0.00 $0.00 $105.74 $0.00 $0.00 $0.00 $0.00 $0.00 352.258S SUP Custom 27203010 352.258S - REAMER SURG 16MM HEAD STERILE DISPOSABLE RIA BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.259S SUP Custom 27203010 352.259S - REAMER SURG 16.5MM HEAD STERILE DISPOSABLE RIA BOTH IP/OP $684.15 $506.27 $0.00 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.78 $507.78 $0.00 $0.00 $142.58 $0.00 $0.00 $0.00 $0.00 $332.11 $526.07 $531.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 352.260S SUP Custom 27203010 352.260S - CLIP LOCKING SECURE ATTCH DRIVE SHAFT TUBE ASMBLY STERILE BOTH IP/OP $137.13 $101.48 $0.00 $106.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.77 $101.77 $0.00 $0.00 $28.58 $0.00 $0.00 $0.00 $0.00 $66.56 $105.44 $106.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0240S SUP HCPCS C1713 3520-0240S - NAIL IM 120D 10MM 240MM STRL GAMMA3 LT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0260S SUP HCPCS C1713 3520-0260S - NAIL 10MM 260MM LEFT FEM HIP GAMMA3 IM 120D TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$3,437.50" "$1,933.59" "$1,933.59" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$2,148.44" "$3,403.13" "$3,437.50" $0.00 $0.00 $672.46 $0.00 $0.00 $684.06 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0280S SUP HCPCS C1713 3520-0280S - NAIL 10MM 280MM LEFT FEM HIP GAMMA3 IM 120D TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0300S SUP HCPCS C1713 3520-0300S - NAIL 10MM 300MM LEFT FEM HIP GAMMA3 IM 120D TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0320S SUP HCPCS C1713 3520-0320S - NAIL 10MM 320MM LEFT FEM HIP GAMMA3 IM 120D TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0340S SUP HCPCS C1713 3520-0340S - NAIL 10MM 340MM LEFT FEM HIP GAMMA3 IM 120D TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0360S SUP HCPCS C1713 3520-0360S - NAIL 10MM 360MM LEFT FEM HIP GAMMA3 IM 120D TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0380S SUP HCPCS C1713 3520-0380S - NAIL 10MM 380MM LEFT FEM HIP GAMMA3 IM 120D TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0400S SUP HCPCS C1713 3520-0400S - NAIL 10MM 400MM LEFT FEM HIP GAMMA3 IM 120D TI STRL R1.5 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0420S SUP HCPCS C1713 3520-0420S - NAIL IM 120D 10MM 420MM STRL GAMMA3 LT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0440S SUP HCPCS C1713 3520-0440S - NAIL IM 120D 10MM 440MM STRL GAMMA3 LT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-0460S SUP HCPCS C1713 3520-0460S - NAIL IM 120D 10MM 460MM STRL GAMMA3 LT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-180 SUP HCPCS C1713 3520-9-180 - NAIL 9MM 180MM HUM L/R IM RECON SDL SYS BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-200 SUP HCPCS C1713 3520-9-200 - NAIL 16MM 48CM HUM IM HUM R/L RECON GRS-K SYS BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-220 SUP HCPCS C1713 3520-9-220 - NAIL 9MM 220CM IM RECON BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-240 SUP HCPCS C1713 3520-9-240 - NAIL 9MM 240MM L/R HUM IM RECON SDL SYS STR BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-250 SUP HCPCS C1713 3520-9-250 - NAIL HUM 250MM 9MM LCK BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-260 SUP HCPCS C1713 3520-9-260 - NAIL 9MM 260CM HUM IM R/L RECON BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-270 SUP HCPCS C1713 3520-9-270 - NAIL 9MM 270MM LEFT HUM IM RIGHT RECON SDL SYS BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-280 SUP HCPCS C1713 3520-9-280 - NAIL 9MM 280MM HUM LEFT IM RIGHT RECON SDL SYS BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-300 SUP HCPCS C1713 3520-9-300 - NAIL 9MM 300MM HUM IM RECON STRL BOTH IP/OP "$2,942.50 " "$2,177.45" $0.00 "$2,354.00" "$1,324.13" "$1,324.13" $0.00 $0.00 $0.00 $613.29 "$2,183.92" "$2,183.92" $0.00 $0.00 $613.22 $0.00 "$1,450.65" "$1,450.65" $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $460.50 $0.00 $0.00 $468.45 $0.00 $0.00 $0.00 $0.00 $0.00 3520-9-945 SUP HCPCS C1713 3520-9-945 - NAIL 5MM 45CM HUM IM LCK SPRD SCR BOTH IP/OP $818.13 $605.42 $0.00 $654.50 $368.16 $368.16 $0.00 $0.00 $0.00 $170.52 $607.21 $607.21 $0.00 $0.00 $170.50 $0.00 $483.92 $483.92 $0.00 $409.06 $647.96 $654.50 $0.00 $0.00 $128.04 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0260S SUP HCPCS C1713 3525-0260S - NAIL 10MM 26CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0280S SUP HCPCS C1713 3525-0280S - NAIL 10MM 28CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0300S SUP HCPCS C1713 3525-0300S - NAIL 10MM 30CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0320S SUP HCPCS C1713 3525-0320S - NAIL 10MM 32CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0340S SUP HCPCS C1713 3525-0340S - NAIL 10MM 34CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0360S SUP HCPCS C1713 3525-0360S - NAIL 10MM 36CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0380S SUP HCPCS C1713 3525-0380S - NAIL 10MM 38CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0400S SUP HCPCS C1713 3525-0400S - NAIL 10MM 40CM LEFT FEM HIP GAMMA3 IM 125D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0420S SUP HCPCS C1713 3525-0420S - GAMMA 3 S NAIL LEFT 10X420MM X 125 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0440S SUP HCPCS C1713 3525-0440S - GAMMA 3 S NAIL LEFT 10X440MM X 125 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3525-0460S SUP HCPCS C1713 3525-0460S - NAIL IM 125D 10MM 460MM STRL GAMMA3 LT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 352506070E SUP HCPCS C1880 352506070E - SYSTEM EMBOLIC PROTECTION 6.5FR 0-32MM 5FR 70CM FILTER KIT BOTH IP/OP "$1,812.50 " "$1,341.25" $0.00 "$1,450.00" $815.63 $815.63 $0.00 $0.00 $0.00 $377.77 "$1,345.24" "$1,345.24" $0.00 $0.00 $377.73 $0.00 "$1,072.09" "$1,072.09" $0.00 $906.25 "$1,435.50" "$1,450.00" $0.00 $0.00 $283.66 $0.00 $0.00 $288.55 $0.00 $0.00 $0.00 $0.00 $0.00 352506100E SUP HCPCS C1880 352506100E - FILTER EMBL 30- MM 5FR 100CM STRL LF OPTIONELITE INTRO SHTH BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0260S SUP HCPCS C1713 3530-0260S - NAIL 10MM 26CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0280S SUP HCPCS C1713 3530-0280S - NAIL 10MM 28CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0300S SUP HCPCS C1713 3530-0300S - NAIL 10MM 30CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0320S SUP HCPCS C1713 3530-0320S - NAIL 10MM 32CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0340S SUP HCPCS C1713 3530-0340S - NAIL 10MM 34CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0360S SUP HCPCS C1713 3530-0360S - NAIL 10MM 36CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0380S SUP HCPCS C1713 3530-0380S - NAIL 10MM 38CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0400S SUP HCPCS C1713 3530-0400S - NAIL 10MM 40CM LEFT FEM HIP GAMMA3 IM 130D LNG LCK TI STRL BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0420S SUP HCPCS C1713 3530-0420S - GAMMA 3 S NAIL LEFT 10X420MM X 130 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0440S SUP HCPCS C1713 3530-0440S - GAMMA 3 S NAIL LEFT 10X440MM X 130 BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 3530-0460S SUP HCPCS C1713 3530-0460S - NAIL IM 130D 10MM 460MM STRL GAMMA3 LT BOTH IP/OP "$3,668.60 " "$2,714.76" $0.00 "$2,959.00" "$1,664.44" "$1,664.44" $0.00 $0.00 $0.00 $764.63 "$2,722.83" "$2,722.83" $0.00 $0.00 $764.54 $0.00 "$1,808.62" "$1,808.62" $0.00 "$1,849.38" "$2,929.41" "$2,959.00" $0.00 $0.00 $578.85 $0.00 $0.00 $588.84 $0.00 $0.00 $0.00 $0.00 $0.00 354 805 SUP HCPCS C1900 354 805 - COROX OTW 75 BP LEAD BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 354 807 SUP HCPCS C1900 354 807 - COROX OTW 85 BP LEAD BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 354-7212 SUP HCPCS C1789 354-7212 - EXPANDER TISS P6.6CM CNTR PRFL 11.7X10CM 350ML SLTX CPX3 STY BOTH IP/OP "$3,412.50 " "$2,525.25" $0.00 "$2,730.00" "$1,535.63" "$1,535.63" $0.00 $0.00 $0.00 $711.25 "$2,532.76" "$2,532.76" $0.00 $0.00 $711.17 $0.00 "$1,682.36" "$1,682.36" $0.00 "$1,706.25" "$2,702.70" "$2,730.00" $0.00 $0.00 $534.06 $0.00 $0.00 $543.27 $0.00 $0.00 $0.00 $0.00 $0.00 354-7213 SUP HCPCS C1789 354-7213 - EXPANDER TISS P7CM MED HT 12.7X10.8CM 450CC STRL SLTX CNTR BOTH IP/OP "$3,312.50 " "$2,451.25" $0.00 "$2,650.00" "$1,490.63" "$1,490.63" $0.00 $0.00 $0.00 $690.41 "$2,458.54" "$2,458.54" $0.00 $0.00 $690.33 $0.00 "$1,633.06" "$1,633.06" $0.00 "$1,656.25" "$2,623.50" "$2,650.00" $0.00 $0.00 $518.41 $0.00 $0.00 $527.35 $0.00 $0.00 $0.00 $0.00 $0.00 354-7214 SUP HCPCS C1789 354-7214 - EXPANDER TISS P7.4CM CNTR PRFL 13.5X11.7CM 550ML SLTX CPX3 BOTH IP/OP "$3,412.50 " "$2,525.25" $0.00 "$2,730.00" "$1,535.63" "$1,535.63" $0.00 $0.00 $0.00 $711.25 "$2,532.76" "$2,532.76" $0.00 $0.00 $711.17 $0.00 "$1,682.36" "$1,682.36" $0.00 "$1,706.25" "$2,702.70" "$2,730.00" $0.00 $0.00 $534.06 $0.00 $0.00 $543.27 $0.00 $0.00 $0.00 $0.00 $0.00 354-7215 SUP HCPCS C1789 354-7215 - EXPANDER TISS P7.6CM CNTR PRFL 14.6X12.6CM 650ML SLTX CPX3 BOTH IP/OP "$3,412.50 " "$2,525.25" $0.00 "$2,730.00" "$1,535.63" "$1,535.63" $0.00 $0.00 $0.00 $711.25 "$2,532.76" "$2,532.76" $0.00 $0.00 $711.17 $0.00 "$1,682.36" "$1,682.36" $0.00 "$1,706.25" "$2,702.70" "$2,730.00" $0.00 $0.00 $534.06 $0.00 $0.00 $543.27 $0.00 $0.00 $0.00 $0.00 $0.00 354-9212 SUP HCPCS C1789 354-9212 - EXPANDER TISS P6.6CM CNTR PRFL MED HT 11.7X10CM 350ML CPX4 BOTH IP/OP "$2,937.50 " "$2,173.75" $0.00 "$2,350.00" "$1,321.88" "$1,321.88" $0.00 $0.00 $0.00 $612.25 "$2,180.21" "$2,180.21" $0.00 $0.00 $612.18 $0.00 "$1,448.19" "$1,448.19" $0.00 "$1,468.75" "$2,326.50" "$2,350.00" $0.00 $0.00 $459.72 $0.00 $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 $0.00 355 148 SUP HCPCS C1900 355 148 - COROX OTW 75 BP-S LEAD BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 355.399S SUP Custom 27203010 355.399S - HOOK EXTRACTION 650MM STERILE CANN INTRAMEDULLARY NAIL BOTH IP/OP $650.60 $481.44 $0.00 $505.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.88 $482.88 $0.00 $0.00 $135.59 $0.00 $0.00 $0.00 $0.00 $315.83 $500.27 $505.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-035 SUP HCPCS C1713 3550-0-035 - SCREW BONE 6.5MM 35MM ASNS 2 CORT GD BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $57.24 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-040 SUP HCPCS C1713 3550-0-040 - SCREW BONE 6.5MM 40MM ASNS 2 CORT GD BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $57.24 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-045 SUP HCPCS C1713 3550-0-045 - SCREW BONE 6.5MM 45MM ASNS 2 CORT GD BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $57.24 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-050 SUP HCPCS C1713 3550-0-050 - SCREW BONE 6.5MM 50MM ASNS 2 CORT GD BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $57.24 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-055 SUP HCPCS C1713 3550-0-055 - SCREW BONE 6.5MM 55MM ASNS 2 CORT GD BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $57.24 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-060 SUP HCPCS C1713 3550-0-060 - SCREW BONE 6.5MM 60MM ASNS 2 CORT GD BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $57.24 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-065 SUP HCPCS C1713 3550-0-065 - SCREW BONE 6.5MM 65MM ASNS 2 CORT GD BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $57.24 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-070 SUP HCPCS C1713 3550-0-070 - SCREW BONE 6.5MM 70MM ASNS 2 CORT GD BOTH IP/OP $365.75 $270.66 $0.00 $292.60 $164.59 $164.59 $0.00 $0.00 $0.00 $76.23 $271.46 $271.46 $0.00 $0.00 $76.22 $0.00 $216.34 $216.34 $0.00 $182.88 $289.67 $292.60 $0.00 $0.00 $57.24 $0.00 $0.00 $58.23 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-075 SUP HCPCS C1713 3550-0-075 - SCREW BONE 6.5MM 75MM ASNS 2 CORT GD BOTH IP/OP $402.88 $298.13 $0.00 $322.30 $181.29 $181.29 $0.00 $0.00 $0.00 $83.97 $299.01 $299.01 $0.00 $0.00 $83.96 $0.00 $238.30 $238.30 $0.00 $201.44 $319.08 $322.30 $0.00 $0.00 $63.05 $0.00 $0.00 $64.14 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-080 SUP HCPCS C1713 3550-0-080 - SCREW BONE 6.5MM 80MM ASNS 2 CORT GD BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-085 SUP HCPCS C1713 3550-0-085 - SCREW BONE 6.5MM 85MM ASNS 2 CORT GD BOTH IP/OP $402.88 $298.13 $0.00 $322.30 $181.29 $181.29 $0.00 $0.00 $0.00 $83.97 $299.01 $299.01 $0.00 $0.00 $83.96 $0.00 $238.30 $238.30 $0.00 $201.44 $319.08 $322.30 $0.00 $0.00 $63.05 $0.00 $0.00 $64.14 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-090 SUP HCPCS C1713 3550-0-090 - SCREW BONE 6.5MM 90MM ASNS 2 CORT GD BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-095 SUP HCPCS C1713 3550-0-095 - SCREW BONE 6.5MM 95MM ASNS 2 CORT GD BOTH IP/OP $402.88 $298.13 $0.00 $322.30 $181.29 $181.29 $0.00 $0.00 $0.00 $83.97 $299.01 $299.01 $0.00 $0.00 $83.96 $0.00 $238.30 $238.30 $0.00 $201.44 $319.08 $322.30 $0.00 $0.00 $63.05 $0.00 $0.00 $64.14 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-100 SUP HCPCS C1713 3550-0-100 - SCREW BONE 6.5MM 100MM ASNS 2 CORT GD BOTH IP/OP $402.88 $298.13 $0.00 $322.30 $181.29 $181.29 $0.00 $0.00 $0.00 $83.97 $299.01 $299.01 $0.00 $0.00 $83.96 $0.00 $238.30 $238.30 $0.00 $201.44 $319.08 $322.30 $0.00 $0.00 $63.05 $0.00 $0.00 $64.14 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-105 SUP HCPCS C1713 3550-0-105 - SCREW BONE 6.5MM 105MM ASNS 2 CORT GD BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-110 SUP HCPCS C1713 3550-0-110 - SCREW BONE 6.5MM 110MM ASNS 2 CORT GD BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-115 SUP HCPCS C1713 3550-0-115 - SCREW BONE 6.5MM 115MM ASNS 2 CORT GD BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-120 SUP HCPCS C1713 3550-0-120 - SCREW BONE 6.5MM 120MM ASNS 2 CORT GD BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-125 SUP HCPCS C1713 3550-0-125 - SCREW BONE 6.5MM 125MM ASNS 2 CORT GD BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 3550-0-130 SUP HCPCS C1713 3550-0-130 - SCREW BONE 6.5MM 130MM ASNS 2 CORT GD BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-024 SUP HCPCS C1713 3550-4-024 - ASNIS2 GUIDED SCREW 5.0CANC 24 BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-026 SUP HCPCS C1713 3550-4-026 - SCREW BONE 5MM 2MM ASNS 2 CANC GD BOTH IP/OP $257.13 $190.28 $0.00 $205.70 $115.71 $115.71 $0.00 $0.00 $0.00 $53.59 $190.84 $190.84 $0.00 $0.00 $53.58 $0.00 $152.09 $152.09 $0.00 $128.56 $203.65 $205.70 $0.00 $0.00 $40.24 $0.00 $0.00 $40.93 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-028 SUP HCPCS C1713 3550-4-028 - ASNIS2 GUIDED SCREW 5.0CANC 28 BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-030 SUP HCPCS C1713 3550-4-030 - ASNIS2 GUIDED SCREW 5.0CANC 30 BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-032 SUP HCPCS C1713 3550-4-032 - ASNIS2 GUIDED SCREW 5.0CANC 32 BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-034 SUP HCPCS C1713 3550-4-034 - SCREW BONE 5MM 34MM ASNS 2 SS PTTHRD GD CANC STRL BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-036 SUP HCPCS C1713 3550-4-036 - SCREW BONE 5MM 3MM ASNS 2 CANC GD BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-038 SUP HCPCS C1713 3550-4-038 - ASNIS2 GUIDED SCREW 5.0CANC 38 BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-040 SUP HCPCS C1713 3550-4-040 - ASNIS2 GUIDED SCREW 5.0CANC 40 BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-042 SUP HCPCS C1713 3550-4-042 - SCREW BONE 5MM 4MM ASNS 2 CANC GD BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-045 SUP HCPCS C1713 3550-4-045 - SCREW BONE 5MM 4MM ASNS 2 CANC GD BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-055 SUP HCPCS C1713 3550-4-055 - SCREW BONE 5MM 55MM ASNS 2 CANC GD BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-060 SUP HCPCS C1713 3550-4-060 - SCREW BONE 5MM 60MM ASNS 2 CANC GD BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-065 SUP HCPCS C1713 3550-4-065 - SCREW BONE 5MM 6MM ASNS 2 CANC GD BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-4-070 SUP HCPCS C1713 3550-4-070 - ASNIS2 GUIDED SCREW 5.0CANC 70 BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $123.13 $123.13 $0.00 $0.00 $0.00 $57.03 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $161.85 $161.85 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $42.82 $0.00 $0.00 $43.56 $0.00 $0.00 $0.00 $0.00 $0.00 3550-5-000 SUP Custom 27803010 3550-5-000 - SMALL WASHER BOTH IP/OP $64.63 $47.83 $0.00 $51.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.96 $47.96 $0.00 $0.00 $13.47 $0.00 $0.00 $0.00 $0.00 $32.31 $51.19 $51.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3600-100 SUP HCPCS C1729 3600-100 - DRAIN INCISION 1 COLLECT 1 CHAMBER 1 PATIENT TUBE DRY BOTH IP/OP $75.13 $55.60 $0.00 $57.55 $39.06 $39.06 $0.00 $0.00 $0.00 $14.77 $52.60 $52.60 $0.00 $0.00 $14.77 $0.00 $41.92 $41.92 $0.00 $35.97 $56.98 $57.55 $0.00 $0.00 $11.26 $0.00 $0.00 $11.45 $0.00 $0.00 $0.00 $0.00 $0.00 3611ED SUP Custom 27203010 MATTRESS COMPLETE UNIT /F BOTH IP/OP "$2,006.95 " "$1,485.14" $0.00 "$1,605.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,003.48" "$1,589.50" "$1,605.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3634LF SUP Custom 27203010 STOCKING CMPR THG HI LG SHRT ANEMB INSP TOE TED NYL BOTH IP/OP $707.48 $523.54 $0.00 $565.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $353.74 $560.32 $565.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-0-040 SUP Custom 27803010 3704-0-040 - CABLE/SLEEVE ORTHOPEDIC 1.6MM BEAD SET DALL-MILES STAINLESS BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-0-050 SUP Custom 27803010 3704-0-050 - CABLE/SLEEVE ORTHOPEDIC LP 2MM BEAD SET DALL-MILES STAINLESS BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-0-410 SUP Custom 27803010 3704-0-410 - CABLE/SLEEVE ORTHOPEDIC FLAT 1.6MM SET LP DALL-MILES BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-0-510 SUP Custom 27803010 3704-0-510 - CABLE/SLEEVE ORTHOPEDIC 2MM BEAD SET DALL-MILES STAINLESS BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-1-100 SUP Custom 27803010 3704-1-100 - SLEEVE CABLE SMALL DALL-MILES STAINLESS STEEL HIP BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-1-110 SUP Custom 27803010 3704-1-110 - SLEEVE CABLE MEDIUM DALL-MILES STAINLESS STEEL HIP BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-070 SUP Custom 27803010 3704-2-070 - GRIP CABLE SMALL 43MM DALL-MILES STAINLESS STEEL HIP TROC BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-080 SUP Custom 27803010 3704-2-080 - GRIP CABLE MEDIUM 48MM DALL-MILES STAINLESS STEEL HIP TROC BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-081 SUP HCPCS C1713 3704-2-081 - PLATE BONE MEDIUM 100MM GRIP DALL-MILES STAINLESS STEEL HIP BOTH IP/OP "$2,610.00 " "$1,931.40" $0.00 "$2,088.00" "$1,174.50" "$1,174.50" $0.00 $0.00 $0.00 $543.99 "$1,937.14" "$1,937.14" $0.00 $0.00 $543.92 $0.00 "$1,286.73" "$1,286.73" $0.00 "$1,305.00" "$2,067.12" "$2,088.00" $0.00 $0.00 $408.47 $0.00 $0.00 $415.51 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-082 SUP Custom 27803010 3704-2-082 - PLATE BONE MEDIUM 150MM GRIP DALL-MILES STAINLESS STEEL HIP BOTH IP/OP "$3,422.50 " "$2,532.65" $0.00 "$2,738.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,540.18" "$2,540.18" $0.00 $0.00 $713.25 $0.00 $0.00 $0.00 $0.00 "$1,711.25" "$2,710.62" "$2,738.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-083 SUP Custom 27803010 3704-2-083 - PLATE BONE MEDIUM 200MM GRIP DALL-MILES STAINLESS STEEL HIP BOTH IP/OP "$4,240.00 " "$3,137.60" $0.00 "$3,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,146.93" "$3,146.93" $0.00 $0.00 $883.62 $0.00 $0.00 $0.00 $0.00 "$2,120.00" "$3,358.08" "$3,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-090 SUP Custom 27803010 3704-2-090 - GRIP CABLE LARGE 200MM DALL-MILES STAINLESS STEEL HIP TROC BOTH IP/OP "$1,800.00 " "$1,332.00" $0.00 "$1,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,335.96" "$1,335.96" $0.00 $0.00 $375.12 $0.00 $0.00 $0.00 $0.00 $900.00 "$1,425.60" "$1,440.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-091 SUP Custom 27803010 3704-2-091 - PLATE BONE LARGE 110MM GRIP DALL-MILES STAINLESS STEEL HIP BOTH IP/OP "$2,217.50 " "$1,640.95" $0.00 "$1,774.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,645.83" "$1,645.83" $0.00 $0.00 $462.13 $0.00 $0.00 $0.00 $0.00 "$1,108.75" "$1,756.26" "$1,774.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-092 SUP Custom 27803010 3704-2-092 - PLATE BONE LARGE 160MM GRIP DALL-MILES STAINLESS STEEL HIP BOTH IP/OP "$3,422.50 " "$2,532.65" $0.00 "$2,738.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,540.18" "$2,540.18" $0.00 $0.00 $713.25 $0.00 $0.00 $0.00 $0.00 "$1,711.25" "$2,710.62" "$2,738.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-2-093 SUP Custom 27803010 3704-2-093 - PLATE BONE LARGE 210MM GRIP DALL-MILES STAINLESS STEEL HIP BOTH IP/OP "$4,240.00 " "$3,137.60" $0.00 "$3,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,146.93" "$3,146.93" $0.00 $0.00 $883.62 $0.00 $0.00 $0.00 $0.00 "$2,120.00" "$3,358.08" "$3,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-3-100 SUP HCPCS C1713 3704-3-100 - PLATE BONE BROAD 6.5IN 5 HOLE 6 GROOVE COMPRESSION ROUND END BOTH IP/OP "$1,190.00 " $880.60 $0.00 $952.00 $535.50 $535.50 $0.00 $0.00 $0.00 $248.03 $883.22 $883.22 $0.00 $0.00 $248.00 $0.00 $703.89 $703.89 $0.00 $595.00 $942.48 $952.00 $0.00 $0.00 $186.24 $0.00 $0.00 $189.45 $0.00 $0.00 $0.00 $0.00 $0.00 3704-3-110 SUP HCPCS C1713 3704-3-110 - PLATE BONE BROAD 8IN 7 HOLE 8 GROOVE COMPRESSION ROUND END BOTH IP/OP "$1,190.00 " $880.60 $0.00 $952.00 $535.50 $535.50 $0.00 $0.00 $0.00 $248.03 $883.22 $883.22 $0.00 $0.00 $248.00 $0.00 $703.89 $703.89 $0.00 $595.00 $942.48 $952.00 $0.00 $0.00 $186.24 $0.00 $0.00 $189.45 $0.00 $0.00 $0.00 $0.00 $0.00 3704-3-120 SUP HCPCS C1713 3704-3-120 - PLATE BONE BROAD 10IN 9 HOLE 10 GROOVE COMPRESSION ROUND END BOTH IP/OP "$1,190.00 " $880.60 $0.00 $952.00 $535.50 $535.50 $0.00 $0.00 $0.00 $248.03 $883.22 $883.22 $0.00 $0.00 $248.00 $0.00 $703.89 $703.89 $0.00 $595.00 $942.48 $952.00 $0.00 $0.00 $186.24 $0.00 $0.00 $189.45 $0.00 $0.00 $0.00 $0.00 $0.00 3704-3-130 SUP HCPCS C1713 3704-3-130 - PLATE BONE BROAD 12IN 11 HOLE 12 GROOVE COMPRESSION ROUND BOTH IP/OP "$1,190.00 " $880.60 $0.00 $952.00 $535.50 $535.50 $0.00 $0.00 $0.00 $248.03 $883.22 $883.22 $0.00 $0.00 $248.00 $0.00 $703.89 $703.89 $0.00 $595.00 $942.48 $952.00 $0.00 $0.00 $186.24 $0.00 $0.00 $189.45 $0.00 $0.00 $0.00 $0.00 $0.00 3704-8-236 SUP Custom 27803010 3704-8-236 - CABLE ORTHOPEDIC 1.6MM SLEEVE RECONSTRUCTION TRAUMA BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3704-8-240 SUP Custom 27803010 3704-8-240 - CABLE ORTHOPEDIC 2MM 650MM DALL-MILES STAINLESS STEEL HIP BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 370605.S SUP HCPCS A6209 370605.S - DRESSING WND THK10MM 6IN 665X802MM STRL LF ABTHERA VSCR PCTV BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $475.13 $475.13 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 370642.S SUP HCPCS A6209 370642.S - SET TBG ABTHERA QCK ACC STABLIZED BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 37-11068 SUP Custom 27203010 FORCEPS SURG 45D 5.2IN ANG UP PEAR SHP CUP HRZN BOTH IP/OP "$1,722.50 " "$1,274.65" $0.00 "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.25 "$1,364.22" "$1,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-535-000 SUP Custom 27203010 375-535-000 - BLADE SHVR 3.5MM FRML ARTHRO TOMCAT STRL BOTH IP/OP $186.55 $138.05 $0.00 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.46 $138.46 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $93.28 $147.75 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-542-000 SUP Custom 27203010 375-542-000 - BLADE SHVR 4MM FRML RESCT F LATEX FREE BOTH IP/OP $143.43 $106.14 $0.00 $114.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.45 $106.45 $0.00 $0.00 $29.89 $0.00 $0.00 $0.00 $0.00 $71.72 $113.60 $114.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-544-000 SUP Custom 27203010 375-544-000 - BLADE SHVR 4MM FRML STR CTR AGRS+ ARTHRO F STRL LATEX FREE BOTH IP/OP $143.43 $106.14 $0.00 $114.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.45 $106.45 $0.00 $0.00 $29.89 $0.00 $0.00 $0.00 $0.00 $71.72 $113.60 $114.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-545-000 SUP Custom 27203010 375-545-000 - BLADE SHAVER 4MM ARTHRO TOMCAT STERILE BOTH IP/OP $138.58 $102.55 $0.00 $110.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.85 $102.85 $0.00 $0.00 $28.88 $0.00 $0.00 $0.00 $0.00 $69.29 $109.76 $110.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-554-000 SUP Custom 27203010 375-554-000 - BLADE SHVR 5MM FRML AGRS+ ARTHRO STRL BOTH IP/OP $186.55 $138.05 $0.00 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.46 $138.46 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $93.28 $147.75 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-555-000 SUP Custom 27203010 375-555-000 - CUTTER ENDSCP 5MM TOMCAT FORMULA STERILE BOTH IP/OP $134.94 $99.86 $0.00 $107.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.15 $100.15 $0.00 $0.00 $28.12 $0.00 $0.00 $0.00 $0.00 $67.47 $106.87 $107.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-562-000 SUP Custom 27203010 375-562-000 - CUTTER ENDSCP 5.5MM RESECTOR LATEX FREE FORMULA STERILE BOTH IP/OP $138.58 $102.55 $0.00 $110.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.85 $102.85 $0.00 $0.00 $28.88 $0.00 $0.00 $0.00 $0.00 $69.29 $109.76 $110.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-564-000 SUP Custom 27203010 375-564-000 - BLADE SURG 5.5MM AGRS+ AGRS+ F SER STRL BOTH IP/OP $186.55 $138.05 $0.00 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.46 $138.46 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $93.28 $147.75 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-565-000 SUP Custom 27203010 375-565-000 - CUTTER ENDSCP ARTHRO FRML STRL 5.5MM BOTH IP/OP $186.55 $138.05 $0.00 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.46 $138.46 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $93.28 $147.75 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-628-000 SUP Custom 27203010 375-628-000 - BLADE SHVR 2.5MM FRML S JNT AGRS STRL BOTH IP/OP $143.43 $106.14 $0.00 $114.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.45 $106.45 $0.00 $0.00 $29.89 $0.00 $0.00 $0.00 $0.00 $71.72 $113.60 $114.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-636-000 SUP Custom 27203010 375-636-000 - BLADE SHVR 3.5MM FRML S JNT FULL RAD STRL BOTH IP/OP $186.55 $138.05 $0.00 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.46 $138.46 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $93.28 $147.75 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-638-000 SUP Custom 27203010 375-638-000 - BLADE SHVR 3.5MM FRML S JNT AGRS STRL BOTH IP/OP $186.55 $138.05 $0.00 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.46 $138.46 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $93.28 $147.75 $149.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-641-000 SUP Custom 27203010 375-641-000 - BLADE SHVR 2MM FRML ABRSN HOOD ARTHRO STRL BOTH IP/OP $197.05 $145.82 $0.00 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.25 $146.25 $0.00 $0.00 $41.07 $0.00 $0.00 $0.00 $0.00 $98.53 $156.06 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-647-000 SUP Custom 27203010 375-647-000 - BURR SHVR 3MM FRML S JNT ABRSN HOOD ARTHRO STRL BOTH IP/OP $197.05 $145.82 $0.00 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.25 $146.25 $0.00 $0.00 $41.07 $0.00 $0.00 $0.00 $0.00 $98.53 $156.06 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-930-000 SUP Custom 27203010 375-930-000 - BURR SHVR 3.5MM FRML RND 6 FLUT ABRSN RPD STRL BOTH IP/OP $151.50 $112.11 $0.00 $121.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.45 $112.45 $0.00 $0.00 $31.57 $0.00 $0.00 $0.00 $0.00 $75.75 $119.99 $121.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-940-000 SUP Custom 27203010 375-940-000 - BURR SURG 4MM ROUND 6 FLUTED ARTHRO FORMULA STERILE BOTH IP/OP $146.38 $108.32 $0.00 $117.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.64 $108.64 $0.00 $0.00 $30.51 $0.00 $0.00 $0.00 $0.00 $73.19 $115.93 $117.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-940-012 SUP Custom 27203010 375-940-012 - BURR SHVR 4MM FRML RND HLW 12 FLUT ARTHRO STRL BOTH IP/OP $151.50 $112.11 $0.00 $121.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.45 $112.45 $0.00 $0.00 $31.57 $0.00 $0.00 $0.00 $0.00 $75.75 $119.99 $121.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-941-000 SUP Custom 27203010 375-941-000 - BURR SRG 6 FLUT BRL 4MM STRL FRML F SER BOTH IP/OP $151.50 $112.11 $0.00 $121.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.45 $112.45 $0.00 $0.00 $31.57 $0.00 $0.00 $0.00 $0.00 $75.75 $119.99 $121.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-941-012 SUP Custom 27203010 375-941-012 - BURR SHVR 4MM FRML BRL 12 FLUT ARTHRO STRL BOTH IP/OP $197.05 $145.82 $0.00 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.25 $146.25 $0.00 $0.00 $41.07 $0.00 $0.00 $0.00 $0.00 $98.53 $156.06 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-950-012 SUP Custom 27203010 375-950-012 - BURR SHVR 5.5MM FRML 12 FLUT RND ARTHRO STRL BOTH IP/OP $197.05 $145.82 $0.00 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.25 $146.25 $0.00 $0.00 $41.07 $0.00 $0.00 $0.00 $0.00 $98.53 $156.06 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-950-100 SUP Custom 27203010 375-950-100 - BURR SHVR 5MM FRML 6 FLUT RND ARTHRO STRL BOTH IP/OP $151.50 $112.11 $0.00 $121.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.45 $112.45 $0.00 $0.00 $31.57 $0.00 $0.00 $0.00 $0.00 $75.75 $119.99 $121.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-950-112 SUP Custom 27203010 375-950-112 - BURR SHVR 5MM FRML 12 FLUT RND ARTHRO STRL BOTH IP/OP $197.05 $145.82 $0.00 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.25 $146.25 $0.00 $0.00 $41.07 $0.00 $0.00 $0.00 $0.00 $98.53 $156.06 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-951-000 SUP Custom 27203010 375-951-000 - BURR SHAVER 6 FLUTE ROUND BARREL 5.5MM ARTHRO FORMULA BOTH IP/OP $146.38 $108.32 $0.00 $117.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.64 $108.64 $0.00 $0.00 $30.51 $0.00 $0.00 $0.00 $0.00 $73.19 $115.93 $117.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-951-012 SUP Custom 27203010 375-951-012 - BURR SHVR 5.5MM FRML BRL 12 FLUT ARTHRO STRL BOTH IP/OP $197.05 $145.82 $0.00 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.25 $146.25 $0.00 $0.00 $41.07 $0.00 $0.00 $0.00 $0.00 $98.53 $156.06 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-951-100 SUP Custom 27203010 375-951-100 - BURR SHVR 5MM FRML 6 FLUT BRL ARTHRO STRL BOTH IP/OP $197.05 $145.82 $0.00 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.25 $146.25 $0.00 $0.00 $41.07 $0.00 $0.00 $0.00 $0.00 $98.53 $156.06 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 375-951-112 SUP Custom 27203010 375-951-112 - BURR SHVR 5MM FRML 12 FLUT BRL ARTHRO STRL BOTH IP/OP $197.05 $145.82 $0.00 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.25 $146.25 $0.00 $0.00 $41.07 $0.00 $0.00 $0.00 $0.00 $98.53 $156.06 $157.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38-051-65 SUP Custom 27203010 38-051-65 - BURR SURG 70MM 2.2MM LNDMN MED NTCH STRL BOTH IP/OP $142.50 $105.45 $0.00 $114.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.76 $105.76 $0.00 $0.00 $29.70 $0.00 $0.00 $0.00 $0.00 $71.25 $112.86 $114.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 380-544-100 SUP Custom 27203010 380-544-100 - BLADE SHVR 4MM FRML ANG AGRS+ ARTHRO STRL BOTH IP/OP $201.95 $149.44 $0.00 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.89 $149.89 $0.00 $0.00 $42.09 $0.00 $0.00 $0.00 $0.00 $100.98 $159.94 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 380-545-100 SUP Custom 27203010 380-545-100 - BLADE SHVR 4MM TOMCAT ANG TOMCAT STRL BOTH IP/OP $201.95 $149.44 $0.00 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.89 $149.89 $0.00 $0.00 $42.09 $0.00 $0.00 $0.00 $0.00 $100.98 $159.94 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 380-545-150 SUP Custom 27203010 380-545-150 - BLADE SHVR 4.5MM TOMCAT ANG TOMCAT STRL LATEX FREE BOTH IP/OP $201.95 $149.44 $0.00 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.89 $149.89 $0.00 $0.00 $42.09 $0.00 $0.00 $0.00 $0.00 $100.98 $159.94 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 380-554-100 SUP Custom 27203010 380-554-100 - CUTTER ENDSCP ANG AGRS+ FRML STRL 5MM BOTH IP/OP $201.95 $149.44 $0.00 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.89 $149.89 $0.00 $0.00 $42.09 $0.00 $0.00 $0.00 $0.00 $100.98 $159.94 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 380-555-100 SUP Custom 27203010 380-555-100 - CUTTER ENDSCP TOMCAT FRML ANG STRL 5MM BOTH IP/OP $201.95 $149.44 $0.00 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.89 $149.89 $0.00 $0.00 $42.09 $0.00 $0.00 $0.00 $0.00 $100.98 $159.94 $161.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38-130-56 SUP Custom 27203010 38-130-56 - PROP MTH PED DNTL SET BLK BOTH IP/OP $35.63 $26.37 $0.00 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.44 $26.44 $0.00 $0.00 $7.42 $0.00 $0.00 $0.00 $0.00 $17.81 $28.22 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3815-8-920 SUP HCPCS C1713 3815-8-920 - PIN FIX 4MM STNM BOTH IP/OP $68.75 $50.88 $0.00 $55.00 $30.94 $30.94 $0.00 $0.00 $0.00 $14.33 $51.03 $51.03 $0.00 $0.00 $14.33 $0.00 $40.67 $40.67 $0.00 $34.38 $54.45 $55.00 $0.00 $0.00 $10.76 $0.00 $0.00 $10.95 $0.00 $0.00 $0.00 $0.00 $0.00 3855-4-000 SUP Custom 27203010 3855-4-000 - DRILL SURG STP CORT BOTH IP/OP $474.38 $351.04 $0.00 $379.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.08 $352.08 $0.00 $0.00 $98.86 $0.00 $0.00 $0.00 $0.00 $237.19 $375.71 $379.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 38-709-03-07 SUP HCPCS C1713 38-709-03-07 - INSTRUMENT RDC LG 5IN BYRD ZYG RDC SCR SS OSTSYN BOTH IP/OP $374.38 $277.04 $0.00 $299.50 $168.47 $168.47 $0.00 $0.00 $0.00 $78.03 $277.86 $277.86 $0.00 $0.00 $78.02 $0.00 $221.44 $221.44 $0.00 $187.19 $296.51 $299.50 $0.00 $0.00 $58.59 $0.00 $0.00 $59.60 $0.00 $0.00 $0.00 $0.00 $0.00 390-110 SUP Custom 27803010 390-110 - STONE CONE COIL BOTH IP/OP $506.00 $374.44 $0.00 $404.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.55 $375.55 $0.00 $0.00 $105.45 $0.00 $0.00 $0.00 $0.00 $253.00 $400.75 $404.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3910-900-020 SUP HCPCS C1713 3910-900-020 - ANCHOR SUTURE 2 FRC FBR NDL STRN 38IN BOTH IP/OP $69.38 $51.34 $0.00 $55.50 $31.22 $31.22 $0.00 $0.00 $0.00 $14.46 $51.49 $51.49 $0.00 $0.00 $14.46 $0.00 $41.04 $41.04 $0.00 $34.69 $54.95 $55.50 $0.00 $0.00 $10.86 $0.00 $0.00 $11.04 $0.00 $0.00 $0.00 $0.00 $0.00 3910-900-050 SUP HCPCS C1713 3910-900-050 - SUTURE NABSB 5 3/8 CRC 38IN WHT BLU STRL FRC FBR NDL CO BRD BOTH IP/OP $88.30 $65.34 $0.00 $65.54 $36.00 $36.00 $0.00 $0.00 $0.00 $18.40 $65.54 $65.54 $0.00 $0.00 $18.40 $0.00 $52.23 $52.23 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $12.52 $0.00 $0.00 $12.74 $0.00 $0.00 $0.00 $0.00 $0.00 394500S SUP Custom 27203010 394500S - HOOK BONE 25MM OMEGA 3 HANSSON HIP SS CMPR SCR TWN STRL BOTH IP/OP $178.75 $132.28 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $0.00 $0.00 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3A1505 SUP Custom 27203010 LEADWIRE EKG 5 LEAD SET SNP 40IN BOTH IP/OP $26.25 $19.43 $0.00 $21.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.13 $20.79 $21.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3HSK-3038 SUP Custom 27203010 3HSK-3038 - HEARTSTRING III PROXIMAL SEAL SYSTEM 3.8 MM BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3MA005 SUP Custom 27203010 STANDARD ADV OSMTR CLBRT AMPULE 2ML 3300 SER CHM 50 MOSM/KG BOTH IP/OP $11.98 $8.87 $0.00 $9.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.99 $9.49 $9.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3MA029 SUP Custom 27203010 CONTROL OSMTR CLNTRL 290 MOSM REF SOL OSM 2ML BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3MA800 SUP Custom 27203010 SAMPLER ADV CHMBR CLNR SMPL TIP MODL 3300/3320 ANALY BOTH IP/OP $767.28 $567.79 $0.00 $613.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $383.64 $607.69 $613.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3MAXC SUP HCPCS C1757 3MAXC - CATHETER REPERFUSION 3MAX BOTH IP/OP "$3,725.00 " "$2,756.50" $0.00 "$4,110.93" $0.00 $0.00 $0.00 $0.00 $0.00 $776.38 "$2,764.70" "$2,764.70" $0.00 $0.00 $776.29 $0.00 "$4,110.93" "$4,110.93" $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3MAXCKIT SUP HCPCS C1757 3MAXCKIT - CATHETER THROMBECTOMY .014IN 4.7-3.8FR .035IN 153CM 157CM BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3N02A SUP Custom 27203010 3N02A - SUTURE NONABSORBABLE CV-3 TT-17 36IN 2 ARM MONOFILAMENT BOTH IP/OP $677.50 $501.35 $0.00 $542.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.84 $502.84 $0.00 $0.00 $141.19 $0.00 $0.00 $0.00 $0.00 $338.75 $536.58 $542.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 3X611 SUP Custom 27203010 BELT 5 56X21/32X7/16IN B53 TYPE BOTH IP/OP $48.33 $35.76 $0.00 $38.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.16 $38.28 $38.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4.0PED SUP Custom 27203010 4.0PED - TUBE 41MM 5.9MM 4MM UNCUF OBT TRCH PLVN CHLOR PED BOTH IP/OP $94.29 $69.77 $0.00 $75.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.98 $69.98 $0.00 $0.00 $19.65 $0.00 $0.00 $0.00 $0.00 $47.14 $74.68 $75.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4.5PED SUP Custom 27203010 4.5PED - TUBE 42MM 6.5MM 4.5MM UNCUF OBT TRCH PLVN CHLOR PED BOTH IP/OP $94.29 $69.77 $0.00 $75.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.98 $69.98 $0.00 $0.00 $19.65 $0.00 $0.00 $0.00 $0.00 $47.14 $74.68 $75.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 400.040E SUP HCPCS C1713 400.040E - SCREW BONE 10MM 1.5MM CORT CRANFCL TI SLFTAP +DR RECESS BOTH IP/OP $144.00 $106.56 $0.00 $115.20 $64.80 $64.80 $0.00 $0.00 $0.00 $30.01 $106.88 $106.88 $0.00 $0.00 $30.01 $0.00 $85.18 $85.18 $0.00 $72.00 $114.05 $115.20 $0.00 $0.00 $22.54 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $0.00 400.046E SUP HCPCS C1713 400.046E - 1.5MM TI CORTEX SCR SLF-TPNG WITH PLUSDRIVE(TM) RECESS 16MM BOTH IP/OP $144.00 $106.56 $0.00 $115.20 $64.80 $64.80 $0.00 $0.00 $0.00 $30.01 $106.88 $106.88 $0.00 $0.00 $30.01 $0.00 $85.18 $85.18 $0.00 $72.00 $114.05 $115.20 $0.00 $0.00 $22.54 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $0.00 400.048E SUP HCPCS C1713 400.048E - 1.5MM TI CORTEX SCR SLF-TPNG WITH PLUSDRIVE(TM) RECESS 18MM BOTH IP/OP $144.00 $106.56 $0.00 $115.20 $64.80 $64.80 $0.00 $0.00 $0.00 $30.01 $106.88 $106.88 $0.00 $0.00 $30.01 $0.00 $85.18 $85.18 $0.00 $72.00 $114.05 $115.20 $0.00 $0.00 $22.54 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $0.00 400.054E SUP HCPCS C1713 400.054E - SCREW BONE 4MM 1.5MM CORT CRANIOMAXILOFACIAL TI +DR RECESS BOTH IP/OP $173.25 $128.21 $0.00 $138.60 $77.96 $77.96 $0.00 $0.00 $0.00 $36.11 $128.59 $128.59 $0.00 $0.00 $36.11 $0.00 $102.48 $102.48 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $27.11 $0.00 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 400.055E SUP HCPCS C1713 400.055E - SCREW BONE 5MM 1.5MM CRANFCL TI SLFDRILL +DR RECESS STRL BOTH IP/OP $173.25 $128.21 $0.00 $138.60 $77.96 $77.96 $0.00 $0.00 $0.00 $36.11 $128.59 $128.59 $0.00 $0.00 $36.11 $0.00 $102.48 $102.48 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $27.11 $0.00 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 400.056E SUP HCPCS C1713 400.056E - SCREW BONE 6MM 1.5MM CRANFCL TI SLFDRILL +DR RECESS STRL BOTH IP/OP $173.25 $128.21 $0.00 $138.60 $77.96 $77.96 $0.00 $0.00 $0.00 $36.11 $128.59 $128.59 $0.00 $0.00 $36.11 $0.00 $102.48 $102.48 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $27.11 $0.00 $0.00 $27.58 $0.00 $0.00 $0.00 $0.00 $0.00 400.280E SUP HCPCS C1713 400.280E - SCREW BONE 2MM 10MM TI CRNMXF ER +DR RECESS STRL BOTH IP/OP $151.88 $112.39 $0.00 $121.50 $68.34 $68.34 $0.00 $0.00 $0.00 $31.65 $112.72 $112.72 $0.00 $0.00 $31.65 $0.00 $89.83 $89.83 $0.00 $75.94 $120.29 $121.50 $0.00 $0.00 $23.77 $0.00 $0.00 $24.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.282E SUP HCPCS C1713 400.282E - SCREW BONE 2MM 12MM TI CRNMXF ER +DR RECESS STRL BOTH IP/OP $151.88 $112.39 $0.00 $121.50 $68.34 $68.34 $0.00 $0.00 $0.00 $31.65 $112.72 $112.72 $0.00 $0.00 $31.65 $0.00 $89.83 $89.83 $0.00 $75.94 $120.29 $121.50 $0.00 $0.00 $23.77 $0.00 $0.00 $24.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.284E SUP HCPCS C1713 400.284E - 2.0MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 14MM BOTH IP/OP $151.88 $112.39 $0.00 $121.50 $68.34 $68.34 $0.00 $0.00 $0.00 $31.65 $112.72 $112.72 $0.00 $0.00 $31.65 $0.00 $89.83 $89.83 $0.00 $75.94 $120.29 $121.50 $0.00 $0.00 $23.77 $0.00 $0.00 $24.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.286E SUP HCPCS C1713 400.286E - 2.0MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 16MM BOTH IP/OP $151.88 $112.39 $0.00 $121.50 $68.34 $68.34 $0.00 $0.00 $0.00 $31.65 $112.72 $112.72 $0.00 $0.00 $31.65 $0.00 $89.83 $89.83 $0.00 $75.94 $120.29 $121.50 $0.00 $0.00 $23.77 $0.00 $0.00 $24.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.288E SUP HCPCS C1713 400.288E - 2.0MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 18MM BOTH IP/OP $151.88 $112.39 $0.00 $121.50 $68.34 $68.34 $0.00 $0.00 $0.00 $31.65 $112.72 $112.72 $0.00 $0.00 $31.65 $0.00 $89.83 $89.83 $0.00 $75.94 $120.29 $121.50 $0.00 $0.00 $23.77 $0.00 $0.00 $24.18 $0.00 $0.00 $0.00 $0.00 $0.00 400.404E SUP HCPCS C1713 400.404E - SCREW BONE STRL GOLD 4MM 1MM CORT CRANFCL TI SLFTAP +DR BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $96.19 $96.19 $0.00 $0.00 $0.00 $44.55 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $126.43 $126.43 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $33.45 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $0.00 400.405E SUP HCPCS C1713 400.405E - SCREW BONE STRL GOLD 5MM 1MM CORT CRANFCL TI SLFTAP +DR BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $96.19 $96.19 $0.00 $0.00 $0.00 $44.55 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $126.43 $126.43 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $33.45 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $0.00 400.407E SUP HCPCS C1713 400.407E - 1.0MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 7MM BOTH IP/OP $191.25 $141.53 $0.00 $153.00 $86.06 $86.06 $0.00 $0.00 $0.00 $39.86 $141.95 $141.95 $0.00 $0.00 $39.86 $0.00 $113.12 $113.12 $0.00 $95.63 $151.47 $153.00 $0.00 $0.00 $29.93 $0.00 $0.00 $30.45 $0.00 $0.00 $0.00 $0.00 $0.00 400.408E SUP HCPCS C1713 400.408E - SCREW BONE 1MM 8MM TI CORT SLFTAP NONSTRL BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $96.19 $96.19 $0.00 $0.00 $0.00 $44.55 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $126.43 $126.43 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $33.45 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $0.00 400.409E SUP HCPCS C1713 400.409E - 1.0MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 9MM BOTH IP/OP $191.25 $141.53 $0.00 $153.00 $86.06 $86.06 $0.00 $0.00 $0.00 $39.86 $141.95 $141.95 $0.00 $0.00 $39.86 $0.00 $113.12 $113.12 $0.00 $95.63 $151.47 $153.00 $0.00 $0.00 $29.93 $0.00 $0.00 $30.45 $0.00 $0.00 $0.00 $0.00 $0.00 400.410E SUP HCPCS C1713 400.410E - 1.0MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 10MM BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $96.19 $96.19 $0.00 $0.00 $0.00 $44.55 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $126.43 $126.43 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $33.45 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $0.00 400.411E SUP HCPCS C1713 400.411E - 1.0MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 11MM BOTH IP/OP $191.25 $141.53 $0.00 $153.00 $86.06 $86.06 $0.00 $0.00 $0.00 $39.86 $141.95 $141.95 $0.00 $0.00 $39.86 $0.00 $113.12 $113.12 $0.00 $95.63 $151.47 $153.00 $0.00 $0.00 $29.93 $0.00 $0.00 $30.45 $0.00 $0.00 $0.00 $0.00 $0.00 400.412E SUP HCPCS C1713 400.412E - 1.0MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 12MM BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $96.19 $96.19 $0.00 $0.00 $0.00 $44.55 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $126.43 $126.43 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $33.45 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $0.00 400.414E SUP HCPCS C1713 400.414E - 1.0MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 14MM BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $96.19 $96.19 $0.00 $0.00 $0.00 $44.55 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $126.43 $126.43 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $33.45 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $0.00 400.437E SUP HCPCS C1713 400.437E - SCREW BONE 7MM 1.3MM CORTEX TI SLFTAP DRV RECESS 3MM BOTH IP/OP $178.88 $132.37 $0.00 $143.10 $80.49 $80.49 $0.00 $0.00 $0.00 $37.28 $132.76 $132.76 $0.00 $0.00 $37.28 $0.00 $105.80 $105.80 $0.00 $89.44 $141.67 $143.10 $0.00 $0.00 $27.99 $0.00 $0.00 $28.48 $0.00 $0.00 $0.00 $0.00 $0.00 400.439E SUP HCPCS C1713 400.439E - 1.3MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 9MM BOTH IP/OP $178.88 $132.37 $0.00 $143.10 $80.49 $80.49 $0.00 $0.00 $0.00 $37.28 $132.76 $132.76 $0.00 $0.00 $37.28 $0.00 $105.80 $105.80 $0.00 $89.44 $141.67 $143.10 $0.00 $0.00 $27.99 $0.00 $0.00 $28.48 $0.00 $0.00 $0.00 $0.00 $0.00 400.440E SUP HCPCS C1713 400.440E - 1.3MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 10MM BOTH IP/OP $199.13 $147.36 $0.00 $159.30 $89.61 $89.61 $0.00 $0.00 $0.00 $41.50 $147.79 $147.79 $0.00 $0.00 $41.50 $0.00 $117.78 $117.78 $0.00 $99.56 $157.71 $159.30 $0.00 $0.00 $31.16 $0.00 $0.00 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 400.442E SUP HCPCS C1713 400.442E - 1.3MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 12MM BOTH IP/OP $199.13 $147.36 $0.00 $159.30 $89.61 $89.61 $0.00 $0.00 $0.00 $41.50 $147.79 $147.79 $0.00 $0.00 $41.50 $0.00 $117.78 $117.78 $0.00 $99.56 $157.71 $159.30 $0.00 $0.00 $31.16 $0.00 $0.00 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 400.444E SUP HCPCS C1713 400.444E - 1.3MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 14MM BOTH IP/OP $199.13 $147.36 $0.00 $159.30 $89.61 $89.61 $0.00 $0.00 $0.00 $41.50 $147.79 $147.79 $0.00 $0.00 $41.50 $0.00 $117.78 $117.78 $0.00 $99.56 $157.71 $159.30 $0.00 $0.00 $31.16 $0.00 $0.00 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 400.446E SUP HCPCS C1713 400.446E - 1.3MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 16MM BOTH IP/OP $199.13 $147.36 $0.00 $159.30 $89.61 $89.61 $0.00 $0.00 $0.00 $41.50 $147.79 $147.79 $0.00 $0.00 $41.50 $0.00 $117.78 $117.78 $0.00 $99.56 $157.71 $159.30 $0.00 $0.00 $31.16 $0.00 $0.00 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 400.448E SUP HCPCS C1713 400.448E - 1.3MM TI CRTX SCREW SLF-TPNG W/PLUSDRIVE(TM) RECESS 18MM BOTH IP/OP $199.13 $147.36 $0.00 $159.30 $89.61 $89.61 $0.00 $0.00 $0.00 $41.50 $147.79 $147.79 $0.00 $0.00 $41.50 $0.00 $117.78 $117.78 $0.00 $99.56 $157.71 $159.30 $0.00 $0.00 $31.16 $0.00 $0.00 $31.70 $0.00 $0.00 $0.00 $0.00 $0.00 400.454E SUP HCPCS C1713 400.454E - SCREW BONE STRL SLVR 4MM 1.3MM CORT CRANFCL TI SLFDRILL +DR BOTH IP/OP $204.75 $151.52 $0.00 $163.80 $92.14 $92.14 $0.00 $0.00 $0.00 $42.68 $151.97 $151.97 $0.00 $0.00 $42.67 $0.00 $121.11 $121.11 $0.00 $102.38 $162.16 $163.80 $0.00 $0.00 $32.04 $0.00 $0.00 $32.60 $0.00 $0.00 $0.00 $0.00 $0.00 400.455E SUP HCPCS C1713 400.455E - SCREW BONE SLVR 5MM 1.3MM CRANFCL TI SLFDRILL +DR RECESS BOTH IP/OP $204.75 $151.52 $0.00 $163.80 $92.14 $92.14 $0.00 $0.00 $0.00 $42.68 $151.97 $151.97 $0.00 $0.00 $42.67 $0.00 $121.11 $121.11 $0.00 $102.38 $162.16 $163.80 $0.00 $0.00 $32.04 $0.00 $0.00 $32.60 $0.00 $0.00 $0.00 $0.00 $0.00 400.456E SUP HCPCS C1713 400.456E - SCREW BONE SLVR 6MM 1.3MM CRANFCL TI SLFDRILL +DR RECESS BOTH IP/OP $204.75 $151.52 $0.00 $163.80 $92.14 $92.14 $0.00 $0.00 $0.00 $42.68 $151.97 $151.97 $0.00 $0.00 $42.67 $0.00 $121.11 $121.11 $0.00 $102.38 $162.16 $163.80 $0.00 $0.00 $32.04 $0.00 $0.00 $32.60 $0.00 $0.00 $0.00 $0.00 $0.00 400.465E SUP HCPCS C1713 400.465E - SCREW BONE TEAL 5MM 1.2MM CRANFCL TI SLFDRILL +DR RECESS BOTH IP/OP $220.50 $163.17 $0.00 $176.40 $99.23 $99.23 $0.00 $0.00 $0.00 $45.96 $163.66 $163.66 $0.00 $0.00 $45.95 $0.00 $130.43 $130.43 $0.00 $110.25 $174.64 $176.40 $0.00 $0.00 $34.51 $0.00 $0.00 $35.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.467E SUP HCPCS C1713 400.467E - SCREW BONE 7MM 1.2MM CRNMXF TI NONSTRL BOTH IP/OP $195.75 $144.86 $0.00 $156.60 $88.09 $88.09 $0.00 $0.00 $0.00 $40.80 $145.29 $145.29 $0.00 $0.00 $40.79 $0.00 $115.79 $115.79 $0.00 $97.88 $155.03 $156.60 $0.00 $0.00 $30.63 $0.00 $0.00 $31.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.469E SUP HCPCS C1713 400.469E - 1.2MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 9MM BOTH IP/OP $195.75 $144.86 $0.00 $156.60 $88.09 $88.09 $0.00 $0.00 $0.00 $40.80 $145.29 $145.29 $0.00 $0.00 $40.79 $0.00 $115.79 $115.79 $0.00 $97.88 $155.03 $156.60 $0.00 $0.00 $30.63 $0.00 $0.00 $31.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.470E SUP HCPCS C1713 400.470E - 1.2MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 10MM BOTH IP/OP $220.50 $163.17 $0.00 $176.40 $99.23 $99.23 $0.00 $0.00 $0.00 $45.96 $163.66 $163.66 $0.00 $0.00 $45.95 $0.00 $130.43 $130.43 $0.00 $110.25 $174.64 $176.40 $0.00 $0.00 $34.51 $0.00 $0.00 $35.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.471E SUP HCPCS C1713 400.471E - 1.2MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 11MM BOTH IP/OP $195.75 $144.86 $0.00 $156.60 $88.09 $88.09 $0.00 $0.00 $0.00 $40.80 $145.29 $145.29 $0.00 $0.00 $40.79 $0.00 $115.79 $115.79 $0.00 $97.88 $155.03 $156.60 $0.00 $0.00 $30.63 $0.00 $0.00 $31.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.472E SUP HCPCS C1713 400.472E - 1.2MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 12MM BOTH IP/OP $220.50 $163.17 $0.00 $176.40 $99.23 $99.23 $0.00 $0.00 $0.00 $45.96 $163.66 $163.66 $0.00 $0.00 $45.95 $0.00 $130.43 $130.43 $0.00 $110.25 $174.64 $176.40 $0.00 $0.00 $34.51 $0.00 $0.00 $35.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.474E SUP HCPCS C1713 400.474E - 1.2MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 14MM BOTH IP/OP $220.50 $163.17 $0.00 $176.40 $99.23 $99.23 $0.00 $0.00 $0.00 $45.96 $163.66 $163.66 $0.00 $0.00 $45.95 $0.00 $130.43 $130.43 $0.00 $110.25 $174.64 $176.40 $0.00 $0.00 $34.51 $0.00 $0.00 $35.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.483E SUP HCPCS C1713 400.483E - SCREW BONE 3MM 1.7MM CRANFCL TI ER +DR RECESS STRL BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $93.15 $93.15 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $0.00 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 400.487E SUP HCPCS C1713 400.487E - 1.7MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 7MM BOTH IP/OP $186.75 $138.20 $0.00 $149.40 $84.04 $84.04 $0.00 $0.00 $0.00 $38.92 $138.61 $138.61 $0.00 $0.00 $38.92 $0.00 $110.46 $110.46 $0.00 $93.38 $147.91 $149.40 $0.00 $0.00 $29.23 $0.00 $0.00 $29.73 $0.00 $0.00 $0.00 $0.00 $0.00 400.488E SUP HCPCS C1713 400.488E - SCREW BN 1.5MM 8MM NS TI CORT BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $93.15 $93.15 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $0.00 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 400.489E SUP HCPCS C1713 400.489E - 1.7MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 9MM BOTH IP/OP $186.75 $138.20 $0.00 $149.40 $84.04 $84.04 $0.00 $0.00 $0.00 $38.92 $138.61 $138.61 $0.00 $0.00 $38.92 $0.00 $110.46 $110.46 $0.00 $93.38 $147.91 $149.40 $0.00 $0.00 $29.23 $0.00 $0.00 $29.73 $0.00 $0.00 $0.00 $0.00 $0.00 400.490E SUP HCPCS C1713 400.490E - SCREW TI 10IN 1.7MM CRANFCL ER +DR RECESS BONE BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $93.15 $93.15 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $0.00 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 400.492E SUP HCPCS C1713 400.492E - 1.7MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 12MM BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $93.15 $93.15 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $0.00 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 400.494E SUP HCPCS C1713 400.494E - 1.7MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 14MM BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $93.15 $93.15 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $0.00 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 400.496E SUP HCPCS C1713 400.496E - 1.7MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 16MM BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $93.15 $93.15 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $0.00 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 400.498E SUP HCPCS C1713 400.498E - 1.7MM TI EMERGENCY SCREW WITH PLUSDRIVE(TM) RECESS 18MM BOTH IP/OP $207.00 $153.18 $0.00 $165.60 $93.15 $93.15 $0.00 $0.00 $0.00 $43.14 $153.64 $153.64 $0.00 $0.00 $43.14 $0.00 $122.44 $122.44 $0.00 $103.50 $163.94 $165.60 $0.00 $0.00 $32.40 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $0.00 400.806.96 SUP HCPCS C1713 400.806.96 - SCREW BONE LP 1.5MM 3MM 6MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $14.79 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.807.96 SUP HCPCS C1713 400.807.96 - SCREW BONE LP 1.5MM 3MM 7MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.808.96 SUP HCPCS C1713 400.808.96 - SCREW BONE 1.5MM 3MM 8MM SLFTAP TITANIUM HAND CORTICAL BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.809.96 SUP HCPCS C1713 400.809.96 - SCREW BONE 1.5MM 9MM SLFTAP TITANIUM CORTICAL HAND NONSTRL BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.810.96 SUP HCPCS C1713 400.810.96 - SCREW BONE LP 1.5MM 3MM 10MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.811.96 SUP HCPCS C1713 400.811.96 - SCREW BONE LP 1.5MM 3MM 11MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.812.96 SUP HCPCS C1713 400.812.96 - SCREW BONE 1.5MM 3MM 12MM SLFTAP TITANIUM HAND CORTICAL BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.813.96 SUP HCPCS C1713 400.813.96 - SCREW BONE 1.5MM 3MM 13MM SLFTAP LP HEAD THREADED TITANIUM BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.814.96 SUP HCPCS C1713 400.814.96 - SCREW BONE LP 1.5MM 3MM 14MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.816.96 SUP HCPCS C1713 400.816.96 - SCREW BONE 1.5MM 16MM SLFTAP TITANIUM CORTICAL HAND NONSTRL BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.818.96 SUP HCPCS C1713 400.818.96 - SCREW BONE LP 1.5MM 3MM 18MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.820.96 SUP HCPCS C1713 400.820.96 - SCREW BONE LP 1.5MM 3MM 20MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.822.96 SUP HCPCS C1713 400.822.96 - SCREW BONE LP 1.5MM 3MM 22MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.824.96 SUP HCPCS C1713 400.824.96 - SCREW BONE LP 1.5MM 3MM 24MM SELF TAP THREAD TITANIUM HAND BOTH IP/OP $65.35 $48.36 $0.00 $50.76 $28.55 $28.55 $0.00 $0.00 $0.00 $13.62 $48.50 $48.50 $0.00 $0.00 $13.62 $0.00 $38.65 $38.65 $0.00 $31.73 $50.25 $50.76 $0.00 $0.00 $9.64 $0.00 $0.00 $10.10 $0.00 $0.00 $0.00 $0.00 $0.00 400.843E SUP HCPCS C1713 400.843E - SCREW BONE 3MM 1.6MM CRNMXF TI ALLOY SLFTAP LP STRL BOTH IP/OP $196.88 $145.69 $0.00 $157.50 $88.59 $88.59 $0.00 $0.00 $0.00 $41.03 $146.12 $146.12 $0.00 $0.00 $41.03 $0.00 $116.45 $116.45 $0.00 $98.44 $155.93 $157.50 $0.00 $0.00 $30.81 $0.00 $0.00 $31.34 $0.00 $0.00 $0.00 $0.00 $0.00 400.846E SUP HCPCS C1713 400.846E - TI LOW PROFILE NEURO SCREW SELF-TAPPING 6MM BOTH IP/OP $196.88 $145.69 $0.00 $157.50 $88.59 $88.59 $0.00 $0.00 $0.00 $41.03 $146.12 $146.12 $0.00 $0.00 $41.03 $0.00 $116.45 $116.45 $0.00 $98.44 $155.93 $157.50 $0.00 $0.00 $30.81 $0.00 $0.00 $31.34 $0.00 $0.00 $0.00 $0.00 $0.00 400.855E SUP HCPCS C1713 400.855E - SCREW BONE 5MM 2MM CRANFCL TI SLFTAP LP ER STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 400.856E SUP HCPCS C1713 400.856E - SCREW BONE 6MM 2MM CRANFCL TI SLFTAP LP ER STRL BOTH IP/OP $196.88 $145.69 $0.00 $157.50 $88.59 $88.59 $0.00 $0.00 $0.00 $41.03 $146.12 $146.12 $0.00 $0.00 $41.03 $0.00 $116.45 $116.45 $0.00 $98.44 $155.93 $157.50 $0.00 $0.00 $30.81 $0.00 $0.00 $31.34 $0.00 $0.00 $0.00 $0.00 $0.00 40-0001-S SUP HCPCS C1713 40-0001-S - ROD XTRNFX CMPR OLCRN BOTH IP/OP "$2,480.00 " "$1,835.20" $0.00 "$1,984.00" "$1,116.00" "$1,116.00" $0.00 $0.00 $0.00 $516.89 "$1,840.66" "$1,840.66" $0.00 $0.00 $516.83 $0.00 "$1,466.92" "$1,466.92" $0.00 "$1,240.00" "$1,964.16" "$1,984.00" $0.00 $0.00 $388.12 $0.00 $0.00 $394.82 $0.00 $0.00 $0.00 $0.00 $0.00 40-0003 SUP Custom 27203010 40-0003 - NUT EXFIX OLCRN GUIDE ASMBLY NONSTRL BOTH IP/OP "$1,140.00 " $843.60 $0.00 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $0.00 $0.00 $0.00 $570.00 $902.88 $912.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0006 SUP HCPCS C1713 40-0006 - BOLT LCK OLCRN NONSTRL BOTH IP/OP $657.50 $486.55 $0.00 $526.00 $295.88 $295.88 $0.00 $0.00 $0.00 $137.04 $488.00 $488.00 $0.00 $0.00 $137.02 $0.00 $388.91 $388.91 $0.00 $328.75 $520.74 $526.00 $0.00 $0.00 $102.90 $0.00 $0.00 $104.67 $0.00 $0.00 $0.00 $0.00 $0.00 40-0007 SUP HCPCS C1713 40-0007 - CANNU ORTH TRGT ROD NONSTRL OLCRN BOTH IP/OP "$1,005.00 " $743.70 $0.00 $804.00 $452.25 $452.25 $0.00 $0.00 $0.00 $209.47 $745.91 $745.91 $0.00 $0.00 $209.44 $0.00 $594.46 $594.46 $0.00 $502.50 $795.96 $804.00 $0.00 $0.00 $157.28 $0.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0008 SUP Custom 27203010 40-0008 - GUIDE TRGT ASMBLY CMPR NUT SURG OLCRN NONSTRL BOTH IP/OP "$1,992.50 " "$1,474.45" $0.00 "$1,594.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,478.83" "$1,478.83" $0.00 $0.00 $415.24 $0.00 $0.00 $0.00 $0.00 $996.25 "$1,578.06" "$1,594.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0012 SUP Custom 27203010 40-0012 - DRILL SRG NUT CMPR OLCRN BOTH IP/OP $827.50 $612.35 $0.00 $662.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $614.17 $614.17 $0.00 $0.00 $172.45 $0.00 $0.00 $0.00 $0.00 $413.75 $655.38 $662.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0013-S SUP Custom 27203010 40-0013-S - NUT XTRNFX 6MM CMPR OLCRN BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $0.00 $0.00 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0014-S SUP Custom 27203010 40-0014-S - NUT XTRNFX 8MM CMPR OLCRN BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $0.00 $0.00 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0015-S SUP Custom 27203010 40-0015-S - NUT XTRNFX 10MM CMPR OLCRN BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $0.00 $0.00 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0016-S SUP Custom 27803010 40-0016-S - WASHER ORTH SMTH OLCRN BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $398.93 $398.93 $0.00 $0.00 $112.02 $0.00 $0.00 $0.00 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0021-S SUP HCPCS C1713 40-0021-S - WASHER ORTH THRD OLCRN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 40-0026-S SUP HCPCS C1713 40-0026-S - ROD ORTH 110MM 3MM FIB IM IMPL BOTH IP/OP "$2,705.00 " "$2,001.70" $0.00 "$2,164.00" "$1,217.25" "$1,217.25" $0.00 $0.00 $0.00 $563.79 "$2,007.65" "$2,007.65" $0.00 $0.00 $563.72 $0.00 "$1,333.57" "$1,333.57" $0.00 "$1,352.50" "$2,142.36" "$2,164.00" $0.00 $0.00 $423.33 $0.00 $0.00 $430.64 $0.00 $0.00 $0.00 $0.00 $0.00 40-0027-S SUP HCPCS C1713 40-0027-S - ROD ORTH 145MM 3MM FIB ANKL FIB IM IMPL STRL BOTH IP/OP "$2,705.00 " "$2,001.70" $0.00 "$2,164.00" "$1,217.25" "$1,217.25" $0.00 $0.00 $0.00 $563.79 "$2,007.65" "$2,007.65" $0.00 $0.00 $563.72 $0.00 "$1,333.57" "$1,333.57" $0.00 "$1,352.50" "$2,142.36" "$2,164.00" $0.00 $0.00 $423.33 $0.00 $0.00 $430.64 $0.00 $0.00 $0.00 $0.00 $0.00 40-0028-S SUP HCPCS C1713 40-0028-S - ROD ORTH 180MM 3MM FIB FIB IM IMPL STRL BOTH IP/OP "$2,705.00 " "$2,001.70" $0.00 "$2,164.00" "$1,217.25" "$1,217.25" $0.00 $0.00 $0.00 $563.79 "$2,007.65" "$2,007.65" $0.00 $0.00 $563.72 $0.00 "$1,333.57" "$1,333.57" $0.00 "$1,352.50" "$2,142.36" "$2,164.00" $0.00 $0.00 $423.33 $0.00 $0.00 $430.64 $0.00 $0.00 $0.00 $0.00 $0.00 40-0029-S SUP HCPCS C1713 40-0029-S - ROD ORTH 110MM 3.6MM FIB FIB IM IMPL STRL BOTH IP/OP "$2,705.00 " "$2,001.70" $0.00 "$2,164.00" "$1,217.25" "$1,217.25" $0.00 $0.00 $0.00 $563.79 "$2,007.65" "$2,007.65" $0.00 $0.00 $563.72 $0.00 "$1,333.57" "$1,333.57" $0.00 "$1,352.50" "$2,142.36" "$2,164.00" $0.00 $0.00 $423.33 $0.00 $0.00 $430.64 $0.00 $0.00 $0.00 $0.00 $0.00 40-0030-S SUP HCPCS C1713 40-0030-S - ROD XTRNFX 3.6MM 145MM FIB BOTH IP/OP "$2,705.00 " "$2,001.70" $0.00 "$2,164.00" "$1,217.25" "$1,217.25" $0.00 $0.00 $0.00 $563.79 "$2,007.65" "$2,007.65" $0.00 $0.00 $563.72 $0.00 "$1,333.57" "$1,333.57" $0.00 "$1,352.50" "$2,142.36" "$2,164.00" $0.00 $0.00 $423.33 $0.00 $0.00 $430.64 $0.00 $0.00 $0.00 $0.00 $0.00 40-0031-S SUP Custom 27203010 40-0031-S - ROD EXFIX 180MM 3.6MM FIB BOTH IP/OP "$2,705.00 " "$2,001.70" $0.00 "$2,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,007.65" "$2,007.65" $0.00 $0.00 $563.72 $0.00 $0.00 $0.00 $0.00 "$1,352.50" "$2,142.36" "$2,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0034 SUP HCPCS C1713 40-0034 - BASEPLATE ROD FIB BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 40-0136 SUP HCPCS C1713 40-0136 - SCREW BONE 3MM 80MM DL TRK TI CLVCL DIFF PTCH CUT FLUT TAIL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 40-0137 SUP HCPCS C1713 40-0137 - SCREW BONE 3MM 90MM DL TRK TI CLVCL DIFF PTCH CUT FLUT TAIL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 40-0138 SUP HCPCS C1713 40-0138 - SCREW BONE 3MM 100MM DL TRK TI CLVCL DIFF PTCH CUT FLUT TAIL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 40-0139 SUP HCPCS C1713 40-0139 - SCREW BONE 3MM 110MM DL TRK TI CLVCL DIFF PTCH CUT FLUT TAIL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 400-14 SUP Custom 27203010 400-14 - BANDAGE ADH MRDH BOTH IP/OP "$2,470.00 " "$1,827.80" $0.00 "$1,976.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,833.23" "$1,833.23" $0.00 $0.00 $514.75 $0.00 $0.00 $0.00 $0.00 "$1,235.00" "$1,956.24" "$1,976.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-0140 SUP HCPCS C1713 40-0140 - SCREW BONE 3MM 120MM DL TRK TI CLVCL DIFF PTCH CUT FLUT TAIL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 40-0143 SUP HCPCS C1713 40-0143 - SCREW BONE 3.8MM 80MM DL TRK TI CLVCL DIFF PTCH CUT FLUT BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 40-0144 SUP HCPCS C1713 40-0144 - SCREW BONE 3.8MM 90MM CLVCL DL TRK BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 40-0145 SUP HCPCS C1713 40-0145 - SCREW BONE 3.8MM 100MM DL TRK TI CLVCL DIFF PTCH CUT FLUT BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 40-0146 SUP HCPCS C1713 40-0146 - SCREW BONE 3.8MM 110MM DL TRK TI CLVCL DIFF PTCH CUT FLUT BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 40-0147 SUP HCPCS C1713 40-0147 - SCREW BONE 3.8MM 120MM DL TRK TI CLVCL DIFF PTCH CUT FLUT BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0306 SUP Custom 27803010 4002C0306 - COIL EMBL .02IN STD CMPLX 3MM 6CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,525.00 " "$4,088.50" $0.00 "$4,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,100.66" "$4,100.66" $0.00 $0.00 "$1,151.41" $0.00 $0.00 $0.00 $0.00 "$2,762.50" "$4,375.80" "$4,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0310 SUP Custom 27803010 "4002C0310 - COIL 400 COMPLEX STANDARD, 3 MM X 10 CM" BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0408 SUP Custom 27803010 4002C0408 - COIL EMBL .02IN STD CMPLX 4MM 8CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,017.50 " "$3,712.95" $0.00 "$4,014.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,723.99" "$3,723.99" $0.00 $0.00 "$1,045.65" $0.00 $0.00 $0.00 $0.00 "$2,508.75" "$3,973.86" "$4,014.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0412 SUP Custom 27803010 "4002C0412 - COIL 400 COMPLEX STANDARD, 4 MM X 12 CM" BOTH IP/OP "$5,675.00 " "$4,199.50" $0.00 "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,182.67" $0.00 $0.00 $0.00 $0.00 "$2,837.50" "$4,494.60" "$4,540.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0506 SUP Custom 27803010 4002C0506 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 5MM 6CM COMPLEX THE BOTH IP/OP "$4,972.50 " "$3,679.65" $0.00 "$3,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,690.59" "$3,690.59" $0.00 $0.00 "$1,036.27" $0.00 $0.00 $0.00 $0.00 "$2,486.25" "$3,938.22" "$3,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0510 SUP Custom 27803010 4002C0510 - COIL EMBL STD 5MM 10CM PENUMBRA COIL 400 CMPLX BOTH IP/OP "$5,062.50 " "$3,746.25" $0.00 "$4,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,757.39" "$3,757.39" $0.00 $0.00 "$1,055.03" $0.00 $0.00 $0.00 $0.00 "$2,531.25" "$4,009.50" "$4,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0610 SUP Custom 27803010 4002C0610 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 6MM 10CM COMPLEX BOTH IP/OP "$5,062.50 " "$3,746.25" $0.00 "$4,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,757.39" "$3,757.39" $0.00 $0.00 "$1,055.03" $0.00 $0.00 $0.00 $0.00 "$2,531.25" "$4,009.50" "$4,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0615 SUP Custom 27803010 4002C0615 - COIL EMBL STD 6MM 15CM PENUMBRA COIL 400 CMPLX BOTH IP/OP "$5,175.00 " "$3,829.50" $0.00 "$4,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,840.89" "$3,840.89" $0.00 $0.00 "$1,078.47" $0.00 $0.00 $0.00 $0.00 "$2,587.50" "$4,098.60" "$4,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0710 SUP Custom 27803010 4002C0710 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 7MM 10CM COMPLEX BOTH IP/OP "$5,062.50 " "$3,746.25" $0.00 "$4,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,757.39" "$3,757.39" $0.00 $0.00 "$1,055.03" $0.00 $0.00 $0.00 $0.00 "$2,531.25" "$4,009.50" "$4,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0715 SUP Custom 27803010 4002C0715 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 7MM 15CM COMPLEX BOTH IP/OP "$5,175.00 " "$3,829.50" $0.00 "$4,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,840.89" "$3,840.89" $0.00 $0.00 "$1,078.47" $0.00 $0.00 $0.00 $0.00 "$2,587.50" "$4,098.60" "$4,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0720 SUP Custom 27803010 4002C0720 - COIL EMBL STD 7MM 20CM PENUMBRA COIL 400 CMPLX BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0815 SUP Custom 27803010 "4002C0815 - COIL 400 COMPLEX STANDARD, 8 MM X 15 CM" BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 $0.00 $0.00 $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0820 SUP Custom 27803010 4002C0820 - COIL EMBL .02IN STD CMPLX 8MM 20CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0830 SUP Custom 27803010 4002C0830 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 8MM 30CM COMPLEX BOTH IP/OP "$5,512.50 " "$4,079.25" $0.00 "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,091.38" "$4,091.38" $0.00 $0.00 "$1,148.81" $0.00 $0.00 $0.00 $0.00 "$2,756.25" "$4,365.90" "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0915 SUP Custom 27803010 4002C0915 - COIL EMBL .02IN STD CMPLX 9MM 15CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 $0.00 $0.00 $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0925 SUP Custom 27803010 4002C0925 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 9MM 25CM COMPLEX BOTH IP/OP "$5,400.00 " "$3,996.00" $0.00 "$4,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,007.88" "$4,007.88" $0.00 $0.00 "$1,125.36" $0.00 $0.00 $0.00 $0.00 "$2,700.00" "$4,276.80" "$4,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C0935 SUP Custom 27803010 4002C0935 - COIL EMBL .02IN STD CMPLX 9MM 35CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,570.00 " "$4,121.80" $0.00 "$4,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,134.05" "$4,134.05" $0.00 $0.00 "$1,160.79" $0.00 $0.00 $0.00 $0.00 "$2,785.00" "$4,411.44" "$4,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1020 SUP Custom 27803010 4002C1020 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 10MM 20CM COMPLEX BOTH IP/OP "$5,287.50 " "$3,912.75" $0.00 "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,924.38" "$3,924.38" $0.00 $0.00 "$1,101.92" $0.00 $0.00 $0.00 $0.00 "$2,643.75" "$4,187.70" "$4,230.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1030 SUP Custom 27803010 4002C1030 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 10MM 30CM COMPLEX BOTH IP/OP "$5,512.50 " "$4,079.25" $0.00 "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,091.38" "$4,091.38" $0.00 $0.00 "$1,148.81" $0.00 $0.00 $0.00 $0.00 "$2,756.25" "$4,365.90" "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1040 SUP Custom 27803010 4002C1040 - COIL EMBL .02IN STD CMPLX 10MM 40CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1135 SUP Custom 27803010 4002C1135 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 11MM 35CM COMPLEX BOTH IP/OP "$5,570.00 " "$4,121.80" $0.00 "$4,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,134.05" "$4,134.05" $0.00 $0.00 "$1,160.79" $0.00 $0.00 $0.00 $0.00 "$2,785.00" "$4,411.44" "$4,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1145 SUP Custom 27803010 4002C1145 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 11MM 45CM COMPLEX BOTH IP/OP "$5,682.50 " "$4,205.05" $0.00 "$4,546.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,184.23" $0.00 $0.00 $0.00 $0.00 "$2,841.25" "$4,500.54" "$4,546.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1235 SUP Custom 27803010 4002C1235 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 12MM 35CM COMPLEX BOTH IP/OP "$5,570.00 " "$4,121.80" $0.00 "$4,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,134.05" "$4,134.05" $0.00 $0.00 "$1,160.79" $0.00 $0.00 $0.00 $0.00 "$2,785.00" "$4,411.44" "$4,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1245 SUP Custom 27803010 4002C1245 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 12MM 45CM COMPLEX BOTH IP/OP "$5,682.50 " "$4,205.05" $0.00 "$4,546.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,184.23" $0.00 $0.00 $0.00 $0.00 "$2,841.25" "$4,500.54" "$4,546.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1335 SUP Custom 27803010 "4002C1335 - COIL 400 COMPLEX STANDARD, 13MM X 35CM" BOTH IP/OP "$6,187.50 " "$4,578.75" $0.00 "$4,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,289.48" $0.00 $0.00 $0.00 $0.00 "$3,093.75" "$4,900.50" "$4,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1348 SUP Custom 27803010 4002C1348 - COIL EMBL STD .02IN 13MM 48CM DTCH CMPLX STRCH RS PLTN BOTH IP/OP "$5,715.00 " "$4,229.10" $0.00 "$4,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,191.01" $0.00 $0.00 $0.00 $0.00 "$2,857.50" "$4,526.28" "$4,572.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1450 SUP Custom 27803010 4002C1450 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 14MM 50CM COMPLEX BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1557 SUP Custom 27803010 4002C1557 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 15MM 57CM COMPLEX BOTH IP/OP "$5,817.50 " "$4,304.95" $0.00 "$4,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,212.37" $0.00 $0.00 $0.00 $0.00 "$2,908.75" "$4,607.46" "$4,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1660 SUP Custom 27803010 4002C1660 - COIL EMBL .02IN STD CMPLX 16MM 60CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,850.00 " "$4,329.00" $0.00 "$4,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,219.14" $0.00 $0.00 $0.00 $0.00 "$2,925.00" "$4,633.20" "$4,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C1857 SUP Custom 27803010 4002C1857 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 18MM 57CM COMPLEX BOTH IP/OP "$5,817.50 " "$4,304.95" $0.00 "$4,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,212.37" $0.00 $0.00 $0.00 $0.00 "$2,908.75" "$4,607.46" "$4,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C2060 SUP Custom 27803010 4002C2060 - COIL EMBL .02IN STD CMPLX 20MM 60CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,850.00 " "$4,329.00" $0.00 "$4,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,219.14" $0.00 $0.00 $0.00 $0.00 "$2,925.00" "$4,633.20" "$4,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C2260 SUP Custom 27803010 4002C2260 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 22MM 60CM COMPLEX BOTH IP/OP "$5,850.00 " "$4,329.00" $0.00 "$4,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,219.14" $0.00 $0.00 $0.00 $0.00 "$2,925.00" "$4,633.20" "$4,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C2457 SUP Custom 27803010 4002C2457 - COIL EMBL .02IN STD CMPLX 24MM 57CM THE PENUMBRA COIL 400 BOTH IP/OP "$5,817.50 " "$4,304.95" $0.00 "$4,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,212.37" $0.00 $0.00 $0.00 $0.00 "$2,908.75" "$4,607.46" "$4,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C2860 SUP Custom 27803010 4002C2860 - COIL EMBOLIZATION .02IN STANDARD COMPLEX 28MM 60CM COMPLEX BOTH IP/OP "$6,525.00 " "$4,828.50" $0.00 "$5,220.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,359.81" $0.00 $0.00 $0.00 $0.00 "$3,262.50" "$5,167.80" "$5,220.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4002C3260 SUP Custom 27803010 4002C3260 - COIL EMBL .02IN STD CMPLX 32MM 60CM THE PENUMBRA COIL 400 BOTH IP/OP "$6,525.00 " "$4,828.50" $0.00 "$5,220.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,359.81" $0.00 $0.00 $0.00 $0.00 "$3,262.50" "$5,167.80" "$5,220.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0303 SUP Custom 27803010 "4004C0303 - COIL 400 COMPLEX SOFT, 3 MM X 3 CM" BOTH IP/OP "$5,950.00 " "$4,403.00" $0.00 "$4,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,239.98" $0.00 $0.00 $0.00 $0.00 "$2,975.00" "$4,712.40" "$4,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0304 SUP Custom 27803010 "4004C0304 - COIL 400 COMPLEX SOFT, 3 MM X 4 CM" BOTH IP/OP "$5,975.00 " "$4,421.50" $0.00 "$4,780.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,245.19" $0.00 $0.00 $0.00 $0.00 "$2,987.50" "$4,732.20" "$4,780.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0306 SUP Custom 27803010 4004C0306 - COIL EMBL .02IN CMPLX 3MM 6CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,422.50 " "$4,012.65" $0.00 "$4,338.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,024.58" "$4,024.58" $0.00 $0.00 "$1,130.05" $0.00 $0.00 $0.00 $0.00 "$2,711.25" "$4,294.62" "$4,338.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0310 SUP Custom 27803010 4004C0310 - COIL EMBOLIZATION .02IN COMPLEX 3MM 10CM SOFT THE PENUMBRA BOTH IP/OP "$5,512.50 " "$4,079.25" $0.00 "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,091.38" "$4,091.38" $0.00 $0.00 "$1,148.81" $0.00 $0.00 $0.00 $0.00 "$2,756.25" "$4,365.90" "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0404 SUP Custom 27803010 4004C0404 - COIL EMBOLIZATION .02IN COMPLEX 4MM 4CM SOFT THE PENUMBRA BOTH IP/OP "$5,377.50 " "$3,979.35" $0.00 "$4,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,991.18" "$3,991.18" $0.00 $0.00 "$1,120.67" $0.00 $0.00 $0.00 $0.00 "$2,688.75" "$4,258.98" "$4,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0406 SUP Custom 27803010 4004C0406 - COIL EMBOLIZATION .02IN COMPLEX 4MM 6CM SOFT THE PENUMBRA BOTH IP/OP "$5,422.50 " "$4,012.65" $0.00 "$4,338.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,024.58" "$4,024.58" $0.00 $0.00 "$1,130.05" $0.00 $0.00 $0.00 $0.00 "$2,711.25" "$4,294.62" "$4,338.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0408 SUP Custom 27803010 4004C0408 - COIL EMBL .02IN CMPLX 4MM 8CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,467.50 " "$4,045.95" $0.00 "$4,374.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,057.98" "$4,057.98" $0.00 $0.00 "$1,139.43" $0.00 $0.00 $0.00 $0.00 "$2,733.75" "$4,330.26" "$4,374.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0412 SUP Custom 27803010 4004C0412 - COIL EMBOLIZATION .02IN COMPLEX 4MM 12CM SOFT THE PENUMBRA BOTH IP/OP "$5,557.50 " "$4,112.55" $0.00 "$4,446.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,124.78" "$4,124.78" $0.00 $0.00 "$1,158.18" $0.00 $0.00 $0.00 $0.00 "$2,778.75" "$4,401.54" "$4,446.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0509 SUP Custom 27803010 4004C0509 - COIL EMBL .02IN CMPLX 5MM 9CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,490.00 " "$4,062.60" $0.00 "$4,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,074.68" "$4,074.68" $0.00 $0.00 "$1,144.12" $0.00 $0.00 $0.00 $0.00 "$2,745.00" "$4,348.08" "$4,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0513 SUP Custom 27803010 4004C0513 - COIL EMBOLIZATION .02IN COMPLEX 5MM 13CM SOFT THE PENUMBRA BOTH IP/OP "$5,580.00 " "$4,129.20" $0.00 "$4,464.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,141.48" "$4,141.48" $0.00 $0.00 "$1,162.87" $0.00 $0.00 $0.00 $0.00 "$2,790.00" "$4,419.36" "$4,464.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0610 SUP Custom 27803010 4004C0610 - COIL EMBL .02IN CMPLX 6MM 10CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,512.50 " "$4,079.25" $0.00 "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,091.38" "$4,091.38" $0.00 $0.00 "$1,148.81" $0.00 $0.00 $0.00 $0.00 "$2,756.25" "$4,365.90" "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0615 SUP Custom 27803010 4004C0615 - COIL EMBOLIZATION .02IN COMPLEX 6MM 15CM SOFT THE PENUMBRA BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0620 SUP Custom 27803010 4004C0620 - COIL EMBL .02IN CMPLX 6MM 20CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$6,375.00 " "$4,717.50" $0.00 "$5,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,328.55" $0.00 $0.00 $0.00 $0.00 "$3,187.50" "$5,049.00" "$5,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0710 SUP Custom 27803010 4004C0710 - COIL EMBL .02IN CMPLX 7MM 10CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,512.50 " "$4,079.25" $0.00 "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,091.38" "$4,091.38" $0.00 $0.00 "$1,148.81" $0.00 $0.00 $0.00 $0.00 "$2,756.25" "$4,365.90" "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0715 SUP Custom 27803010 4004C0715 - COIL EMBL .02IN CMPLX 7MM 15CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0720 SUP Custom 27803010 4004C0720 - COIL EMBOLIZATION .02IN COMPLEX 7MM 20CM SOFT THE PENUMBRA BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0815 SUP Custom 27803010 4004C0815 - COIL EMBL .02IN CMPLX 8MM 15CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0820 SUP Custom 27803010 4004C0820 - COIL EMBL .02IN CMPLX 8MM 20CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0830 SUP Custom 27803010 "4004C0830 - COIL 400 COMPLEX SOFT, 8MM X 30CM" BOTH IP/OP "$6,625.00 " "$4,902.50" $0.00 "$5,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,380.65" $0.00 $0.00 $0.00 $0.00 "$3,312.50" "$5,247.00" "$5,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0925 SUP Custom 27803010 4004C0925 - COIL EMBL .02IN CMPLX 9MM 25CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,850.00 " "$4,329.00" $0.00 "$4,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,219.14" $0.00 $0.00 $0.00 $0.00 "$2,925.00" "$4,633.20" "$4,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C0935 SUP Custom 27803010 "4004C0935 - COIL 400 COMPLEX SOFT, 9MM X 35CM" BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 $0.00 $0.00 $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1020 SUP Custom 27803010 4004C1020 - COIL EMBL .02IN CMPLX 10MM 20CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1030 SUP Custom 27803010 4004C1030 - COIL EMBOLIZATION .02IN COMPLEX 10MM 30CM SOFT THE PENUMBRA BOTH IP/OP "$5,962.50 " "$4,412.25" $0.00 "$4,770.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,242.59" $0.00 $0.00 $0.00 $0.00 "$2,981.25" "$4,722.30" "$4,770.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1040 SUP Custom 27803010 4004C1040 - COIL EMBL .02IN CMPLX 10MM 40CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,432.75" $0.00 $0.00 $0.00 $0.00 "$3,437.50" "$5,445.00" "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1135 SUP Custom 27803010 4004C1135 - COIL EMBOLIZATION .02IN COMPLEX 11MM 35CM SOFT THE PENUMBRA BOTH IP/OP "$6,075.00 " "$4,495.50" $0.00 "$4,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,266.03" $0.00 $0.00 $0.00 $0.00 "$3,037.50" "$4,811.40" "$4,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1145 SUP Custom 27803010 4004C1145 - COIL EMBL .02IN CMPLX 11MM 45CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 $0.00 $0.00 $0.00 "$3,500.00" "$5,544.00" "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1235 SUP Custom 27803010 4004C1235 - COIL EMBL .02IN CMPLX 12MM 35CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$6,075.00 " "$4,495.50" $0.00 "$4,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,266.03" $0.00 $0.00 $0.00 $0.00 "$3,037.50" "$4,811.40" "$4,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1245 SUP Custom 27803010 "4004C1245 - COIL 400 COMPLEX SOFT, 12MM X 45CM" BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 $0.00 $0.00 $0.00 "$3,500.00" "$5,544.00" "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1335 SUP Custom 27803010 4004C1335 - COIL EMBOLIZATION .02IN COMPLEX 13MM 35CM SOFT THE PENUMBRA BOTH IP/OP "$6,075.00 " "$4,495.50" $0.00 "$4,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,266.03" $0.00 $0.00 $0.00 $0.00 "$3,037.50" "$4,811.40" "$4,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1348 SUP Custom 27803010 4004C1348 - COIL EMBL .02IN CMPLX 13MM 48CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$7,075.00 " "$5,235.50" $0.00 "$5,660.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,474.43" $0.00 $0.00 $0.00 $0.00 "$3,537.50" "$5,603.40" "$5,660.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1440 SUP Custom 27803010 4004C1440 - COIL EMBOLIZATION .02IN COMPLEX 14MM 40CM SOFT THE PENUMBRA BOTH IP/OP "$6,187.50 " "$4,578.75" $0.00 "$4,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,289.48" $0.00 $0.00 $0.00 $0.00 "$3,093.75" "$4,900.50" "$4,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1450 SUP Custom 27803010 4004C1450 - COIL EMBL .02IN CMPLX 14MM 50CM THE PENUMBRA COIL 400 SFT BOTH IP/OP "$7,125.00 " "$5,272.50" $0.00 "$5,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,484.85" $0.00 $0.00 $0.00 $0.00 "$3,562.50" "$5,643.00" "$5,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004C1645 SUP Custom 27803010 4004C1645 - COIL EMBOLIZATION 16MM 45CM COMPLEX SOFT BOTH IP/OP "$6,300.00 " "$4,662.00" $0.00 "$5,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.92" $0.00 $0.00 $0.00 $0.00 "$3,150.00" "$4,989.60" "$5,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004J10 SUP Custom 27803010 4004J10 - COIL EMBOLIZATION 10CM J SOFT FILL COIL 400 NITINOL BOTH IP/OP "$5,670.00 " "$4,195.80" $0.00 "$4,536.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,181.63" $0.00 $0.00 $0.00 $0.00 "$2,835.00" "$4,490.64" "$4,536.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004J15 SUP Custom 27803010 4004J15 - COIL EMBOLIZATION 15CM J COIL 400 BOTH IP/OP "$5,895.00 " "$4,362.30" $0.00 "$4,716.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,228.52" $0.00 $0.00 $0.00 $0.00 "$2,947.50" "$4,668.84" "$4,716.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004J25 SUP Custom 27803010 4004J25 - COIL EMBL 25CM THE PENUMBRA COIL 400 J SFT FIL NTNL BOTH IP/OP "$5,537.50 " "$4,097.75" $0.00 "$5,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,109.93" "$4,109.93" $0.00 $0.00 "$1,154.02" $0.00 $0.00 $0.00 $0.00 "$3,172.50" "$5,025.24" "$5,076.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4004J7 SUP Custom 27803010 4004J7 - COIL EMBL 7CM PENUMBRA COIL 400 J SFT FIL NTNL BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 $0.00 $0.00 $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0202 SUP Custom 27803010 4006C0202 - COIL EMBOLIZATION .02IN COMPLEX 2MM 2CM EXTRA SOFT THE BOTH IP/OP "$4,320.00 " "$3,196.80" $0.00 "$3,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,206.30" "$3,206.30" $0.00 $0.00 $900.29 $0.00 $0.00 $0.00 $0.00 "$2,160.00" "$3,421.44" "$3,456.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0203 SUP Custom 27803010 4006C0203 - COIL EMBOLIZATION .02IN COMPLEX .02IN 2MM 3CM EXTRA SOFT BOTH IP/OP "$4,557.50 " "$3,372.55" $0.00 "$3,646.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,382.58" "$3,382.58" $0.00 $0.00 $949.78 $0.00 $0.00 $0.00 $0.00 "$2,278.75" "$3,609.54" "$3,646.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0204 SUP Custom 27803010 4006C0204 - COIL EMBOLIZATION .02IN COMPLEX 2MM 4CM XSOFT THE PENUMBRA BOTH IP/OP "$4,792.50 " "$3,546.45" $0.00 "$3,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,556.99" "$3,556.99" $0.00 $0.00 $998.76 $0.00 $0.00 $0.00 $0.00 "$2,396.25" "$3,795.66" "$3,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0303 SUP Custom 27803010 4006C0303 - COIL EMBL .02IN CMPLX 3MM 3CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$4,557.50 " "$3,372.55" $0.00 "$3,646.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,382.58" "$3,382.58" $0.00 $0.00 $949.78 $0.00 $0.00 $0.00 $0.00 "$2,278.75" "$3,609.54" "$3,646.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0304 SUP Custom 27803010 4006C0304 - COIL EMBOLIZATION .02IN COMPLEX 3MM 4CM XSOFT THE PENUMBRA BOTH IP/OP "$4,792.50 " "$3,546.45" $0.00 "$3,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,556.99" "$3,556.99" $0.00 $0.00 $998.76 $0.00 $0.00 $0.00 $0.00 "$2,396.25" "$3,795.66" "$3,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0305 SUP Custom 27803010 4006C0305 - COIL EMBL .02IN CMPLX 3MM 5CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$5,030.00 " "$3,722.20" $0.00 "$4,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,733.27" "$3,733.27" $0.00 $0.00 "$1,048.25" $0.00 $0.00 $0.00 $0.00 "$2,515.00" "$3,983.76" "$4,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0306 SUP Custom 27803010 4006C0306 - COIL EMBOLIZATION .02IN COMPLEX .02IN 3MM 6CM EXTRA SOFT BOTH IP/OP "$5,265.00 " "$3,896.10" $0.00 "$4,212.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,907.68" "$3,907.68" $0.00 $0.00 "$1,097.23" $0.00 $0.00 $0.00 $0.00 "$2,632.50" "$4,169.88" "$4,212.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0308 SUP Custom 27803010 4006C0308 - COIL EMBL .02IN CMPLX 3MM 8CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0310 SUP Custom 27803010 "4006C0310 - COIL 400 COMPLEX EXTRA SOFT, 3MM X 10CM" BOTH IP/OP "$6,900.00 " "$5,106.00" $0.00 "$5,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,437.96" $0.00 $0.00 $0.00 $0.00 "$3,450.00" "$5,464.80" "$5,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0404 SUP Custom 27803010 4006C0404 - COIL EMBL .02IN CMPLX 4MM 4CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$4,792.50 " "$3,546.45" $0.00 "$3,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,556.99" "$3,556.99" $0.00 $0.00 $998.76 $0.00 $0.00 $0.00 $0.00 "$2,396.25" "$3,795.66" "$3,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0406 SUP Custom 27803010 4006C0406 - COIL EMBOLIZATION .02IN COMPLEX 4MM 6CM XSOFT THE PENUMBRA BOTH IP/OP "$5,265.00 " "$3,896.10" $0.00 "$4,212.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,907.68" "$3,907.68" $0.00 $0.00 "$1,097.23" $0.00 $0.00 $0.00 $0.00 "$2,632.50" "$4,169.88" "$4,212.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0408 SUP Custom 27803010 4006C0408 - COIL EMBL .02IN CMPLX 4MM 8CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,195.70" $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006C0410 SUP Custom 27803010 4006C0410 - COIL EMBL .02IN CMPLX 4MM 10CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$6,210.00 " "$4,595.40" $0.00 "$4,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.16" $0.00 $0.00 $0.00 $0.00 "$3,105.00" "$4,918.32" "$4,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0201 SUP Custom 27803010 4006U0201 - COIL EMBOLIZATION CURVE 2MM 1CM XSOFT THE PENUMBRA COIL 400 BOTH IP/OP "$3,860.00 " "$2,856.40" $0.00 "$3,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,864.89" "$2,864.89" $0.00 $0.00 $804.42 $0.00 $0.00 $0.00 $0.00 "$1,930.00" "$3,057.12" "$3,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0202 SUP Custom 27803010 4006U0202 - COIL EMBL CRV 2MM 2CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$4,095.00 " "$3,030.30" $0.00 "$3,276.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,039.31" "$3,039.31" $0.00 $0.00 $853.40 $0.00 $0.00 $0.00 $0.00 "$2,047.50" "$3,243.24" "$3,276.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0203 SUP Custom 27803010 4006U0203 - COIL EMBOLIZATION CURVE 2MM 3CM XSOFT THE PENUMBRA COIL 400 BOTH IP/OP "$4,332.50 " "$3,206.05" $0.00 "$3,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,215.58" "$3,215.58" $0.00 $0.00 $902.89 $0.00 $0.00 $0.00 $0.00 "$2,166.25" "$3,431.34" "$3,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0204 SUP Custom 27803010 4006U0204 - COIL EMBL CRV 2MM 4CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$4,567.50 " "$3,379.95" $0.00 "$3,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,390.00" "$3,390.00" $0.00 $0.00 $951.87 $0.00 $0.00 $0.00 $0.00 "$2,283.75" "$3,617.46" "$3,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0302 SUP Custom 27803010 4006U0302 - COIL EMBOLIZATION CURVE 3MM 2CM XSOFT THE PENUMBRA COIL 400 BOTH IP/OP "$4,095.00 " "$3,030.30" $0.00 "$3,276.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,039.31" "$3,039.31" $0.00 $0.00 $853.40 $0.00 $0.00 $0.00 $0.00 "$2,047.50" "$3,243.24" "$3,276.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0303 SUP Custom 27803010 4006U0303 - COIL EMBL CRV 3MM 3CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$4,332.50 " "$3,206.05" $0.00 "$3,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,215.58" "$3,215.58" $0.00 $0.00 $902.89 $0.00 $0.00 $0.00 $0.00 "$2,166.25" "$3,431.34" "$3,466.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0304 SUP Custom 27803010 4006U0304 - COIL EMBOLIZATION CURVE 3MM 4CM XSOFT THE PENUMBRA COIL 400 BOTH IP/OP "$4,567.50 " "$3,379.95" $0.00 "$3,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,390.00" "$3,390.00" $0.00 $0.00 $951.87 $0.00 $0.00 $0.00 $0.00 "$2,283.75" "$3,617.46" "$3,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0305 SUP Custom 27803010 4006U0305 - COIL EMBL CRV 3MM 5CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$4,805.00 " "$3,555.70" $0.00 "$3,844.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,566.27" "$3,566.27" $0.00 $0.00 "$1,001.36" $0.00 $0.00 $0.00 $0.00 "$2,402.50" "$3,805.56" "$3,844.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0306 SUP Custom 27803010 4006U0306 - COIL EMBOLIZATION CURVE 3MM 6CM XSOFT THE PENUMBRA COIL 400 BOTH IP/OP "$5,040.00 " "$3,729.60" $0.00 "$4,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,740.69" "$3,740.69" $0.00 $0.00 "$1,050.34" $0.00 $0.00 $0.00 $0.00 "$2,520.00" "$3,991.68" "$4,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0308 SUP Custom 27803010 4006U0308 - COIL EMBOLIZATION CURVE 3MM 8CM XSOFT THE PENUMBRA COIL 400 BOTH IP/OP "$5,512.50 " "$4,079.25" $0.00 "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,091.38" "$4,091.38" $0.00 $0.00 "$1,148.81" $0.00 $0.00 $0.00 $0.00 "$2,756.25" "$4,365.90" "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0310 SUP Custom 27803010 4006U0310 - COIL EMBL CRV 3MM 10CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$6,512.50 " "$4,819.25" $0.00 "$5,210.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,357.21" $0.00 $0.00 $0.00 $0.00 "$3,256.25" "$5,157.90" "$5,210.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0404 SUP Custom 27803010 4006U0404 - COIL EMBOLIZATION CURVE 4MM 4CM XSOFT THE PENUMBRA COIL 400 BOTH IP/OP "$4,567.50 " "$3,379.95" $0.00 "$3,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,390.00" "$3,390.00" $0.00 $0.00 $951.87 $0.00 $0.00 $0.00 $0.00 "$2,283.75" "$3,617.46" "$3,654.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0406 SUP Custom 27803010 4006U0406 - COIL EMBL CRV 4MM 6CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$5,040.00 " "$3,729.60" $0.00 "$4,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,740.69" "$3,740.69" $0.00 $0.00 "$1,050.34" $0.00 $0.00 $0.00 $0.00 "$2,520.00" "$3,991.68" "$4,032.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0408 SUP Custom 27803010 4006U0408 - COIL EMBOLIZATION CURVE 4MM 8CM XSOFT THE PENUMBRA COIL 400 BOTH IP/OP "$5,512.50 " "$4,079.25" $0.00 "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,091.38" "$4,091.38" $0.00 $0.00 "$1,148.81" $0.00 $0.00 $0.00 $0.00 "$2,756.25" "$4,365.90" "$4,410.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4006U0410 SUP Custom 27803010 4006U0410 - COIL EMBL CRV 4MM 10CM THE PENUMBRA COIL 400 XSFT BOTH IP/OP "$5,862.50 " "$4,338.25" $0.00 "$4,690.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,221.75" $0.00 $0.00 $0.00 $0.00 "$2,931.25" "$4,643.10" "$4,690.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 401.042E SUP HCPCS C1713 401.042E - SCREW BONE SLFTAP +DR RECESS GOLD 5MM 2MM CORT CRANFCL TI BOTH IP/OP $158.63 $117.39 $0.00 $126.90 $71.38 $71.38 $0.00 $0.00 $0.00 $33.06 $117.73 $117.73 $0.00 $0.00 $33.06 $0.00 $93.83 $93.83 $0.00 $79.31 $125.63 $126.90 $0.00 $0.00 $24.82 $0.00 $0.00 $25.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.050E SUP HCPCS C1713 401.050E - 2.0MM TI CRTX SCR COARSE PITCH SLF-TPNG W/PLUSDRIVE(TM) 20MM BOTH IP/OP $158.63 $117.39 $0.00 $126.90 $71.38 $71.38 $0.00 $0.00 $0.00 $33.06 $117.73 $117.73 $0.00 $0.00 $33.06 $0.00 $93.83 $93.83 $0.00 $79.31 $125.63 $126.90 $0.00 $0.00 $24.82 $0.00 $0.00 $25.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.051E SUP HCPCS C1713 401.051E - 2.0MM TI CRTX SCR COARSE PITCH SLF-TPNG W/PLUSDRIVE(TM) 22MM BOTH IP/OP $158.63 $117.39 $0.00 $126.90 $71.38 $71.38 $0.00 $0.00 $0.00 $33.06 $117.73 $117.73 $0.00 $0.00 $33.06 $0.00 $93.83 $93.83 $0.00 $79.31 $125.63 $126.90 $0.00 $0.00 $24.82 $0.00 $0.00 $25.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.052E SUP HCPCS C1713 401.052E - 2.0MM TI CRTX SCR COARSE PITCH SLF-TPNG W/PLUSDRIVE(TM) 24MM BOTH IP/OP $158.63 $117.39 $0.00 $126.90 $71.38 $71.38 $0.00 $0.00 $0.00 $33.06 $117.73 $117.73 $0.00 $0.00 $33.06 $0.00 $93.83 $93.83 $0.00 $79.31 $125.63 $126.90 $0.00 $0.00 $24.82 $0.00 $0.00 $25.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.061E SUP HCPCS C1713 401.061E - SCREW BONE SLVR 4MM 2MM CRANFCL TI SLFDRILL +DR RECESS STRL BOTH IP/OP $169.88 $125.71 $0.00 $135.90 $76.44 $76.44 $0.00 $0.00 $0.00 $35.41 $126.08 $126.08 $0.00 $0.00 $35.40 $0.00 $100.48 $100.48 $0.00 $84.94 $134.54 $135.90 $0.00 $0.00 $26.59 $0.00 $0.00 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 401.062E SUP HCPCS C1713 401.062E - SCREW BONE SLVR 5MM 2MM CRANFCL TI SLFDRILL +DR RECESS STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.063E SUP HCPCS C1713 401.063E - SCREW BONE SLVR 6MM 2MM CRANFCL TI SLFDRILL +DR RECESS STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.064E SUP HCPCS C1713 401.064E - SCREW BONE SLVR 7MM 2MM CRANFCL TI SLFDRILL +DR RECESS STRL BOTH IP/OP $169.88 $125.71 $0.00 $135.90 $76.44 $76.44 $0.00 $0.00 $0.00 $35.41 $126.08 $126.08 $0.00 $0.00 $35.40 $0.00 $100.48 $100.48 $0.00 $84.94 $134.54 $135.90 $0.00 $0.00 $26.59 $0.00 $0.00 $27.04 $0.00 $0.00 $0.00 $0.00 $0.00 401.065E SUP HCPCS C1713 401.065E - SCREW BONE SLVR 8MM 2MM CRANFCL TI SLFDRILL +DR RECESS STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.134.99 SUP HCPCS C1713 401.134.99 - SCREW BONE 2MM 4MM ARCH TI CORT SPNL SLFDRILL STARDRIVE BOTH IP/OP $101.50 $75.11 $0.00 $81.20 $45.68 $45.68 $0.00 $0.00 $0.00 $21.16 $75.33 $75.33 $0.00 $0.00 $21.15 $0.00 $60.04 $60.04 $0.00 $50.75 $80.39 $81.20 $0.00 $0.00 $15.88 $0.00 $0.00 $16.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.136.99 SUP HCPCS C1713 401.136.99 - SCREW BONE 2MM 6MM ARCH TI CORT SPNL SLFDRILL STARDRIVE BOTH IP/OP $101.50 $75.11 $0.00 $81.20 $45.68 $45.68 $0.00 $0.00 $0.00 $21.16 $75.33 $75.33 $0.00 $0.00 $21.15 $0.00 $60.04 $60.04 $0.00 $50.75 $80.39 $81.20 $0.00 $0.00 $15.88 $0.00 $0.00 $16.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.138.99 SUP HCPCS C1713 401.138.99 - SCREW BONE 2MM 8MM ARCH TI CORT SPNL SLFDRILL STARDRIVE BOTH IP/OP $101.50 $75.11 $0.00 $81.20 $45.68 $45.68 $0.00 $0.00 $0.00 $21.16 $75.33 $75.33 $0.00 $0.00 $21.15 $0.00 $60.04 $60.04 $0.00 $50.75 $80.39 $81.20 $0.00 $0.00 $15.88 $0.00 $0.00 $16.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.306E SUP HCPCS C1713 401.306E - SCREW TI 6MM 2.4MM CRANFCL ER CRCIFRM RECESS BONE STRL TEAL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.307E SUP HCPCS C1713 401.307E - SCREW BONE TEAL 7MM 2.4MM 2MM CORT CRANFCL TI SLFTAP ER STRP BOTH IP/OP $148.50 $109.89 $0.00 $118.80 $66.83 $66.83 $0.00 $0.00 $0.00 $30.95 $110.22 $110.22 $0.00 $0.00 $30.95 $0.00 $87.84 $87.84 $0.00 $74.25 $117.61 $118.80 $0.00 $0.00 $23.24 $0.00 $0.00 $23.64 $0.00 $0.00 $0.00 $0.00 $0.00 401.308E SUP HCPCS C1713 401.308E - SCREW TI 8MM 2.4MM CRANFCL ER CRCIFRM RECESS BONE NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.309E SUP HCPCS C1713 401.309E - SCREW BONE TEAL 9MM 2.4MM 2MM CORT CRANFCL TI SLFTAP ER STRP BOTH IP/OP $148.50 $109.89 $0.00 $118.80 $66.83 $66.83 $0.00 $0.00 $0.00 $30.95 $110.22 $110.22 $0.00 $0.00 $30.95 $0.00 $87.84 $87.84 $0.00 $74.25 $117.61 $118.80 $0.00 $0.00 $23.24 $0.00 $0.00 $23.64 $0.00 $0.00 $0.00 $0.00 $0.00 401.311E SUP HCPCS C1713 401.311E - SCREW BONE 2.4MM 11MM TI ER STRL BOTH IP/OP $148.50 $109.89 $0.00 $118.80 $66.83 $66.83 $0.00 $0.00 $0.00 $30.95 $110.22 $110.22 $0.00 $0.00 $30.95 $0.00 $87.84 $87.84 $0.00 $74.25 $117.61 $118.80 $0.00 $0.00 $23.24 $0.00 $0.00 $23.64 $0.00 $0.00 $0.00 $0.00 $0.00 401.314E SUP HCPCS C1713 401.314E - SCREW TI 14MM 2.4MM MANDIB ER CRCIFRM RECESS BONE STRL TEAL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.316E SUP HCPCS C1713 401.316E - SCREW BONE 16MM 2.4MM CRANFCL TI ER CRCIFRM RECESS NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.318E SUP HCPCS C1713 401.318E - SCREW BONE 2.4MM 18MM TI ER CRCIFRM RECESS BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.356.97 SUP HCPCS C1713 401.356.97 - SCREW BONE 2MM 6MM T6 STARDRIVE RECESS SLFTAP LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.357.97 SUP HCPCS C1713 401.357.97 - SCREW BONE 2MM 7MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.358.97 SUP HCPCS C1713 401.358.97 - SCREW BONE T6 STARDRIVE 2MM 8MM SELF TAP TITANIUM CORTICAL BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.359.97 SUP HCPCS C1713 401.359.97 - SCREW BONE 2MM 9MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.360.97 SUP HCPCS C1713 401.360.97 - SCREW BONE T6 2MM 10MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.361.97 SUP HCPCS C1713 401.361.97 - SCREW BONE 2MM 11MM SLFTAP SELF RETAINING T6 STARDRIVE BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.362.97 SUP HCPCS C1713 401.362.97 - SCREW BONE T6 2MM 12MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.363.97 SUP HCPCS C1713 401.363.97 - SCREW BONE T6 2MM 13MM SELF TAP STARDRIVE LCP TITANIUM RAD BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.364.97 SUP HCPCS C1713 401.364.97 - SCREW BONE 2MM 14MM T6 STARDRIVE RECESS SLFTAP LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.366.97 SUP HCPCS C1713 401.366.97 - SCREW BONE 2MM 16MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.368.97 SUP HCPCS C1713 401.368.97 - SCREW BONE 2MM 18MM T6 STARDRIVE RECESS SLFTAP LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.370.97 SUP HCPCS C1713 401.370.97 - SCREW BONE 2MM 20MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.372.97 SUP HCPCS C1713 401.372.97 - SCREW BONE 2MM 22MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.374.97 SUP HCPCS C1713 401.374.97 - SCREW BONE 2MM 24MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.375.97 SUP HCPCS C1713 401.375.97 - SCREW BONE 2MM 26MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.376.97 SUP HCPCS C1713 401.376.97 - SCREW BONE 2MM 28MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.377.97 SUP HCPCS C1713 401.377.97 - SCREW BONE 2MM 30MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.378.97 SUP HCPCS C1713 401.378.97 - SCREW BONE 2MM 32MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.379.97 SUP HCPCS C1713 401.379.97 - SCREW BONE 2MM 34MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.380.97 SUP HCPCS C1713 401.380.97 - SCREW BONE 2MM 36MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.381.97 SUP HCPCS C1713 401.381.97 - SCREW BONE 2MM 38MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.382.97 SUP HCPCS C1713 401.382.97 - SCREW BONE 2MM 40MM SLFTAP STARDRIVE RECESS LCP TITANIUM BOTH IP/OP $66.40 $49.14 $0.00 $51.58 $29.01 $29.01 $0.00 $0.00 $0.00 $13.84 $49.28 $49.28 $0.00 $0.00 $13.84 $0.00 $39.28 $39.28 $0.00 $32.24 $51.07 $51.58 $0.00 $0.00 $9.80 $0.00 $0.00 $10.26 $0.00 $0.00 $0.00 $0.00 $0.00 401.506.96 SUP HCPCS C1713 401.506.96 - SCREW BONE 2.4MM 4MM 6MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.507.96 SUP HCPCS C1713 401.507.96 - SCREW BONE 2.4MM 4MM 7MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.508.96 SUP HCPCS C1713 401.508.96 - SCREW BONE 2.4MM 4.5MM 8MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.509.96 SUP HCPCS C1713 401.509.96 - SCREW BONE 2.4MM 4MM 9MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.510.96 SUP HCPCS C1713 401.510.96 - SCREW BONE 2.4MM 4.5MM 10MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.511.96 SUP HCPCS C1713 401.511.96 - SCREW BONE 2.4MM 4.5MM 11MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.512.96 SUP HCPCS C1713 401.512.96 - SCREW BONE 2.4MM 4.5MM 12MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.513.96 SUP HCPCS C1713 401.513.96 - SCREW BONE 2.4MM 4.5MM 13MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.514.96 SUP HCPCS C1713 401.514.96 - SCREW BONE 2.4MM 4.5MM 14MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.516.96 SUP HCPCS C1713 401.516.96 - SCREW BONE 2.4MM 4.5MM 16MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.518.96 SUP HCPCS C1713 401.518.96 - SCREW BONE 2.4MM 4.5MM 18MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.520.96 SUP HCPCS C1713 401.520.96 - SCREW BONE 2.4MM 4.5MM 20MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.520E SUP HCPCS C1713 401.520E - SCREW BONE 20MM SLFTAP CRCIFRM RECESS TITANIUM 2.4MM 4MM BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.522.96 SUP HCPCS C1713 401.522.96 - SCREW BONE 2.4MM 4.5MM 22MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.524.96 SUP HCPCS C1713 401.524.96 - SCREW BONE 2.4MM 4.5MM 24MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.524E SUP HCPCS C1713 401.524E - SCREW BONE 2.4MM 24MM TI CORT HAND SLFTAP NONSTRL BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.526.96 SUP HCPCS C1713 401.526.96 - SCREW BONE 2.4MM 4.5MM 26MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.526E SUP HCPCS C1713 401.526E - SCREW BONE 2.4MM 26MM TI CORT HAND SLFTAP NONSTRL BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.528.96 SUP HCPCS C1713 401.528.96 - SCREW BONE 2.4MM 4.5MM 28MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.528E SUP HCPCS C1713 401.528E - SCREW BONE 2.4MM 28MM TI CORT HAND SLFTAP NONSTRL BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.530.96 SUP HCPCS C1713 401.530.96 - SCREW BONE 2.4MM 4.5MM 30MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.530E SUP HCPCS C1713 401.530E - SCREW BONE GOLD 30MM 2.4MM CRNMXF TI SLFTAP MDLR STRL BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.532.96 SUP HCPCS C1713 401.532.96 - SCREW BONE 2.4MM 4.5MM 32MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.534.96 SUP HCPCS C1713 401.534.96 - SCREW BONE 2.4MM 4.5MM 34MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.534E SUP HCPCS C1713 401.534E - SCREW BONE GOLD 34MM 2.4MM CRNMXF TI SLFTAP MDLR STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.536.96 SUP HCPCS C1713 401.536.96 - SCREW BONE 2.4MM 4.5MM 36MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.538.96 SUP HCPCS C1713 401.538.96 - SCREW BONE 2.4MM 4.5MM 38MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.540.96 SUP HCPCS C1713 401.540.96 - SCREW BONE 2.4MM 4.5MM 40MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $150.40 $111.30 $0.00 $116.82 $65.71 $65.71 $0.00 $0.00 $0.00 $31.35 $111.63 $111.63 $0.00 $0.00 $31.34 $0.00 $88.96 $88.96 $0.00 $73.01 $115.66 $116.82 $0.00 $0.00 $22.19 $0.00 $0.00 $23.25 $0.00 $0.00 $0.00 $0.00 $0.00 401.542E SUP HCPCS C1713 401.542E - SCREW BONE 2.4MM 42MM CORT MANDIB SLFTAP MDLR FIX SYS BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.544E SUP HCPCS C1713 401.544E - SCREW TI 44MM 2.4MM CORT MANDIB SLFTAP BONE NONSTRL BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.546E SUP HCPCS C1713 401.546E - SCREW TI 46MM 2.4MM CORT MANDIB SLFTAP LCK RECON BONE STRL BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.548E SUP HCPCS C1713 401.548E - SCREW TI 48MM 2.4MM CORT MANDIB SLFTAP LCK RECON BONE STRL BOTH IP/OP $231.75 $171.50 $0.00 $185.40 $104.29 $104.29 $0.00 $0.00 $0.00 $48.30 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $137.08 $137.08 $0.00 $115.88 $183.55 $185.40 $0.00 $0.00 $36.27 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $0.00 401.558E SUP HCPCS C1713 401.558E - SCREW TI 8MM 2.7MM MANDIB ER LCK BONE STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.560E SUP HCPCS C1713 401.560E - SCREW TI 10MM 2.7MM MANDIB ER LCK BONE STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.566E SUP HCPCS C1713 401.566E - SCREW TI 16MM 2.7MM MANDIB ER LCK BONE STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.568E SUP HCPCS C1713 401.568E - SCREW TI 18MM 2.7MM MANDIB ER LCK BONE STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.594E SUP HCPCS C1713 401.594E - 2.0MM TI TENSION BAND SCREW SELF-TAPPING 4MM BOTH IP/OP $191.25 $141.53 $0.00 $153.00 $86.06 $86.06 $0.00 $0.00 $0.00 $39.86 $141.95 $141.95 $0.00 $0.00 $39.86 $0.00 $113.12 $113.12 $0.00 $95.63 $151.47 $153.00 $0.00 $0.00 $29.93 $0.00 $0.00 $30.45 $0.00 $0.00 $0.00 $0.00 $0.00 401.596E SUP HCPCS C1713 401.596E - 2.0MM TI TENSION BAND SCREW SELF-TAPPING 6MM BOTH IP/OP $191.25 $141.53 $0.00 $153.00 $86.06 $86.06 $0.00 $0.00 $0.00 $39.86 $141.95 $141.95 $0.00 $0.00 $39.86 $0.00 $113.12 $113.12 $0.00 $95.63 $151.47 $153.00 $0.00 $0.00 $29.93 $0.00 $0.00 $30.45 $0.00 $0.00 $0.00 $0.00 $0.00 401.797E SUP HCPCS C1713 401.797E - SCREW BONE TEAL 14MM 2.4MM CRANFCL TI ER +DR RECESS NONSTRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 401.806.96 SUP HCPCS C1713 401.806.96 - SCREW BONE 2MM 3.5MM 6MM SLFTAP CRCIFRM RECESS TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.807.96 SUP HCPCS C1713 401.807.96 - SCREW BONE 2MM 3.5MM 7MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.808.96 SUP HCPCS C1713 401.808.96 - SCREW BONE 2MM 3.5MM 8MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.809.96 SUP HCPCS C1713 401.809.96 - SCREW BONE 2MM 3.5MM 9MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $14.70 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.810.96 SUP HCPCS C1713 401.810.96 - SCREW BONE 2MM 10MM SLFTAP TITANIUM CORTICAL NONSTRL BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $14.70 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.811.96 SUP HCPCS C1713 401.811.96 - SCREW BONE 2MM 3.5MM 11MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.812.96 SUP HCPCS C1713 401.812.96 - SCREW BONE 2MM 3.5MM 12MM SELF TAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.813.96 SUP HCPCS C1713 401.813.96 - SCREW BONE 2MM 3.5MM 13MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.814.96 SUP HCPCS C1713 401.814.96 - SCREW BONE 2MM 3.5MM 14MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $14.70 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.816.96 SUP HCPCS C1713 401.816.96 - SCREW BONE 2MM 3.5MM 16MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $14.70 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.818.96 SUP HCPCS C1713 401.818.96 - SCREW BONE 2MM 3.5MM 18MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $14.70 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.820.96 SUP HCPCS C1713 401.820.96 - SCREW BONE 2MM 3.5MM 20MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.822.96 SUP HCPCS C1713 401.822.96 - SCREW BONE 2MM 3.5MM 22MM SLFTAP CRCIFRM RECESS TITANIUM BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.824.96 SUP HCPCS C1713 401.824.96 - SCREW BONE 2MM 3.5MM 24MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.826.96 SUP HCPCS C1713 401.826.96 - SCREW BONE 2MM 3.5MM 26MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.828.96 SUP HCPCS C1713 401.828.96 - SCREW BONE 2MM 3.5MM 28MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.830.96 SUP HCPCS C1713 401.830.96 - SCREW BONE 2MM 3.5MM 30MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.832.96 SUP HCPCS C1713 401.832.96 - SCREW BONE 2MM 3.5MM 32MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.834.96 SUP HCPCS C1713 401.834.96 - SCREW BONE 2MM 3.5MM 34MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.836.96 SUP HCPCS C1713 401.836.96 - SCREW BONE 2MM 3.5MM 36MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.838.96 SUP HCPCS C1713 401.838.96 - SCREW BONE 2MM 3.5MM 38MM SELF TAP CRCIFRM TITANIUM HAND BOTH IP/OP $65.00 $48.10 $0.00 $50.50 $28.41 $28.41 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.56 $50.00 $50.50 $0.00 $0.00 $9.59 $0.00 $0.00 $10.05 $0.00 $0.00 $0.00 $0.00 $0.00 401.968.96 SUP Custom 27203010 401.968.96 - PIN FIX 1.8MM 18MM BUTTRESS TITANIUM HAND NONSTRL BOTH IP/OP $114.55 $84.77 $0.00 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.02 $85.02 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $55.61 $88.09 $88.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-10102 SUP HCPCS C1713 40-10102 - PLATE BN SM NS VARIAX MESH PA LCK LOPRFL TI FT CALCANEUS BOTH IP/OP "$1,449.00 " "$1,072.26" $0.00 "$1,075.45" $437.46 $437.46 $0.00 $0.00 $0.00 $302.01 "$1,075.45" "$1,075.45" $0.00 $0.00 $301.97 $0.00 $857.08 $857.08 $0.00 $486.06 $769.93 $777.70 $0.00 $0.00 $152.14 $0.00 $0.00 $154.76 $0.00 $0.00 $0.00 $0.00 $0.00 40-10104 SUP HCPCS C1713 40-10104 - PLATE BN MED 69MM NS VARIAX MESH PA LCK LOPRFL TI FT BOTH IP/OP "$1,449.00 " "$1,072.26" $0.00 "$1,075.45" $437.46 $437.46 $0.00 $0.00 $0.00 $302.01 "$1,075.45" "$1,075.45" $0.00 $0.00 $301.97 $0.00 $857.08 $857.08 $0.00 $486.06 $769.93 $777.70 $0.00 $0.00 $152.14 $0.00 $0.00 $154.76 $0.00 $0.00 $0.00 $0.00 $0.00 40-10106 SUP HCPCS C1713 40-10106 - PLATE BN LG NS VARIAX MESH PA LCK LOPRFL TI FT CALCANEUS BOTH IP/OP "$1,449.00 " "$1,072.26" $0.00 "$1,075.45" $437.46 $437.46 $0.00 $0.00 $0.00 $302.01 "$1,075.45" "$1,075.45" $0.00 $0.00 $301.97 $0.00 $857.08 $857.08 $0.00 $486.06 $769.93 $777.70 $0.00 $0.00 $152.14 $0.00 $0.00 $154.76 $0.00 $0.00 $0.00 $0.00 $0.00 40-10112 SUP HCPCS C1713 40-10112 - PLATE BN SM STD 1.5MM NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP "$1,449.00 " "$1,072.26" $0.00 "$1,075.45" $437.46 $437.46 $0.00 $0.00 $0.00 $302.01 "$1,075.45" "$1,075.45" $0.00 $0.00 $301.97 $0.00 $857.08 $857.08 $0.00 $486.06 $769.93 $777.70 $0.00 $0.00 $152.14 $0.00 $0.00 $154.76 $0.00 $0.00 $0.00 $0.00 $0.00 40-10114 SUP HCPCS C1713 40-10114 - PLATE BN MED STD 64MM NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP "$1,449.00 " "$1,072.26" $0.00 "$1,075.45" $437.46 $437.46 $0.00 $0.00 $0.00 $302.01 "$1,075.45" "$1,075.45" $0.00 $0.00 $301.97 $0.00 $857.08 $857.08 $0.00 $486.06 $769.93 $777.70 $0.00 $0.00 $152.14 $0.00 $0.00 $154.76 $0.00 $0.00 $0.00 $0.00 $0.00 40-10116 SUP HCPCS C1713 40-10116 - PLATE BN LG STD NS VARIAX PA LCK LOPRFL TI FT CALCANEUS BOTH IP/OP "$1,449.00 " "$1,072.26" $0.00 "$1,075.45" $437.46 $437.46 $0.00 $0.00 $0.00 $302.01 "$1,075.45" "$1,075.45" $0.00 $0.00 $301.97 $0.00 $857.08 $857.08 $0.00 $486.06 $769.93 $777.70 $0.00 $0.00 $152.14 $0.00 $0.00 $154.76 $0.00 $0.00 $0.00 $0.00 $0.00 40-12016S SUP HCPCS C1713 40-12016S - 16MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12018S SUP HCPCS C1713 40-12018S - 18 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12020S SUP HCPCS C1713 40-12020S - 20 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12022S SUP HCPCS C1713 40-12022S - 22 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12024S SUP HCPCS C1713 40-12024S - 24 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12026S SUP HCPCS C1713 40-12026S - 26 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12028S SUP HCPCS C1713 40-12028S - 28 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12030S SUP HCPCS C1713 40-12030S - 30 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12032S SUP HCPCS C1713 40-12032S - 32 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12034S SUP HCPCS C1713 40-12034S - 34 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12036S SUP HCPCS C1713 40-12036S - 36 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12038S SUP HCPCS C1713 40-12038S - 38MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12040S SUP HCPCS C1713 40-12040S - 40MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12042S SUP HCPCS C1713 40-12042S - 42 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12044S SUP HCPCS C1713 40-12044S - 44 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12046S SUP HCPCS C1713 40-12046S - 46 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12048S SUP HCPCS C1713 40-12048S - 48 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-12050S SUP HCPCS C1713 40-12050S - 50 MM LONG THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13010S SUP HCPCS C1713 40-13010S - 10 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13012S SUP HCPCS C1713 40-13012S - CANNULATED SCREW PARTIALLY THRD SHORT 4.0 MM X 12 MM BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $83.25 $83.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.50 $146.52 $148.00 $0.00 $0.00 $28.95 $0.00 $0.00 $29.45 $0.00 $0.00 $0.00 $0.00 $0.00 40-13014S SUP HCPCS C1713 40-13014S - 14MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13016S SUP HCPCS C1713 40-13016S - 16MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13018S SUP HCPCS C1713 40-13018S - 18 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13020S SUP HCPCS C1713 40-13020S - 20 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13022S SUP HCPCS C1713 40-13022S - 22 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13024S SUP HCPCS C1713 40-13024S - 24 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13026S SUP HCPCS C1713 40-13026S - 26 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13028S SUP HCPCS C1713 40-13028S - 28 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13030S SUP HCPCS C1713 40-13030S - 30 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13032S SUP HCPCS C1713 40-13032S - 32 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13034S SUP HCPCS C1713 40-13034S - 34 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13036S SUP HCPCS C1713 40-13036S - 36 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13038S SUP HCPCS C1713 40-13038S - 38MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13040S SUP HCPCS C1713 40-13040S - 40MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13042S SUP HCPCS C1713 40-13042S - 42 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13044S SUP HCPCS C1713 40-13044S - 44 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13046S SUP HCPCS C1713 40-13046S - 46 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13048S SUP HCPCS C1713 40-13048S - 48 MM SHORT THREAD BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $87.75 $87.75 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 40-13050S SUP HCPCS C1713 40-13050S - CANNULATED SCREW PARTIALLY THRD SHORT 4.0 MM X 50 MM BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $110.25 $110.25 $0.00 $0.00 $0.00 $51.06 $181.84 $181.84 $0.00 $0.00 $51.06 $0.00 $144.92 $144.92 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-15011 SUP HCPCS C1713 40-15011 - PLATE BN CRV NS VARIAX 4 HL PA LCK LOPRFL TI FT BOTH IP/OP "$1,082.00 " $800.68 $0.00 $803.06 $269.16 $269.16 $0.00 $0.00 $0.00 $225.52 $803.06 $803.06 $0.00 $0.00 $225.49 $0.00 $640.00 $640.00 $0.00 $299.06 $473.72 $478.50 $0.00 $0.00 $93.61 $0.00 $0.00 $95.22 $0.00 $0.00 $0.00 $0.00 $0.00 40-15012 SUP HCPCS C1713 40-15012 - PLATE BN CRV NS VARIAX 5 HL PA LCK LOPRFL TI FT RT BOTH IP/OP "$1,175.00 " $869.50 $0.00 $872.09 $292.67 $292.67 $0.00 $0.00 $0.00 $244.90 $872.09 $872.09 $0.00 $0.00 $244.87 $0.00 $695.01 $695.01 $0.00 $325.19 $515.10 $520.30 $0.00 $0.00 $101.78 $0.00 $0.00 $103.54 $0.00 $0.00 $0.00 $0.00 $0.00 40-15013 SUP HCPCS C1713 40-15013 - PLATE BN CRV NS VARIAX 5 HL PA LCK LOPRFL TI FT LT BOTH IP/OP "$1,175.00 " $869.50 $0.00 $872.09 $292.67 $292.67 $0.00 $0.00 $0.00 $244.90 $872.09 $872.09 $0.00 $0.00 $244.87 $0.00 $695.01 $695.01 $0.00 $325.19 $515.10 $520.30 $0.00 $0.00 $101.78 $0.00 $0.00 $103.54 $0.00 $0.00 $0.00 $0.00 $0.00 40-15014 SUP HCPCS C1713 40-15014 - PLATE BN CRV NS VARIAX 6 HL PA LCK LOPRFL TI FT BOTH IP/OP "$1,321.00 " $977.54 $0.00 $980.45 $329.18 $329.18 $0.00 $0.00 $0.00 $275.33 $980.45 $980.45 $0.00 $0.00 $275.30 $0.00 $781.37 $781.37 $0.00 $365.75 $579.35 $585.20 $0.00 $0.00 $114.48 $0.00 $0.00 $116.45 $0.00 $0.00 $0.00 $0.00 $0.00 40-15021 SUP HCPCS C1713 40-15021 - PLATE BN SM H NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP $918.00 $679.32 $0.00 $681.34 $232.03 $232.03 $0.00 $0.00 $0.00 $191.33 $681.34 $681.34 $0.00 $0.00 $191.31 $0.00 $543.00 $543.00 $0.00 $257.81 $408.38 $412.50 $0.00 $0.00 $80.70 $0.00 $0.00 $82.09 $0.00 $0.00 $0.00 $0.00 $0.00 40-15022 SUP HCPCS C1713 40-15022 - PLATE BN MED H NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP "$1,297.00 " $959.78 $0.00 $962.63 $329.18 $329.18 $0.00 $0.00 $0.00 $270.33 $962.63 $962.63 $0.00 $0.00 $270.29 $0.00 $767.18 $767.18 $0.00 $365.75 $579.35 $585.20 $0.00 $0.00 $114.48 $0.00 $0.00 $116.45 $0.00 $0.00 $0.00 $0.00 $0.00 40-15023 SUP HCPCS C1713 40-15023 - PLATE BN LG H NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP "$1,097.00 " $811.78 $0.00 $814.19 $278.44 $278.44 $0.00 $0.00 $0.00 $228.64 $814.19 $814.19 $0.00 $0.00 $228.61 $0.00 $648.88 $648.88 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 40-15031 SUP HCPCS C1713 40-15031 - PLATE TI RECT CMPR VARIAX BONE FT BOTH IP/OP "$1,082.00 " $800.68 $0.00 $803.06 $274.11 $274.11 $0.00 $0.00 $0.00 $225.52 $803.06 $803.06 $0.00 $0.00 $225.49 $0.00 $640.00 $640.00 $0.00 $304.56 $482.43 $487.30 $0.00 $0.00 $95.33 $0.00 $0.00 $96.97 $0.00 $0.00 $0.00 $0.00 $0.00 40-15032 SUP HCPCS C1713 40-15032 - PLATE BN 2 RECT NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP "$1,097.00 " $811.78 $0.00 $814.19 $278.44 $278.44 $0.00 $0.00 $0.00 $228.64 $814.19 $814.19 $0.00 $0.00 $228.61 $0.00 $648.88 $648.88 $0.00 $309.38 $490.05 $495.00 $0.00 $0.00 $96.83 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 40-15033 SUP HCPCS C1713 40-15033 - PLATE BN 2 RECT NS VARIAX PA LCK CMPR LOPRFL TI FT BOTH IP/OP "$1,190.00 " $880.60 $0.00 $883.22 $301.95 $301.95 $0.00 $0.00 $0.00 $248.03 $883.22 $883.22 $0.00 $0.00 $248.00 $0.00 $703.89 $703.89 $0.00 $335.50 $531.43 $536.80 $0.00 $0.00 $105.01 $0.00 $0.00 $106.82 $0.00 $0.00 $0.00 $0.00 $0.00 40-15041 SUP HCPCS C1713 40-15041 - PLATE BN SHRT BRD STRG NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP "$1,092.00 " $808.08 $0.00 $810.48 $259.88 $259.88 $0.00 $0.00 $0.00 $227.60 $810.48 $810.48 $0.00 $0.00 $227.57 $0.00 $645.92 $645.92 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 40-15042 SUP HCPCS C1713 40-15042 - PLATE BN MED BRD STRG NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP "$1,140.00 " $843.60 $0.00 $846.11 $271.01 $271.01 $0.00 $0.00 $0.00 $237.60 $846.11 $846.11 $0.00 $0.00 $237.58 $0.00 $674.31 $674.31 $0.00 $301.13 $476.98 $481.80 $0.00 $0.00 $94.25 $0.00 $0.00 $95.88 $0.00 $0.00 $0.00 $0.00 $0.00 40-15043 SUP HCPCS C1713 40-15043 - PLATE BN LNG BRD STRG NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP "$1,254.00 " $927.96 $0.00 $930.72 $298.24 $298.24 $0.00 $0.00 $0.00 $261.36 $930.72 $930.72 $0.00 $0.00 $261.33 $0.00 $741.74 $741.74 $0.00 $331.38 $524.90 $530.20 $0.00 $0.00 $103.72 $0.00 $0.00 $105.51 $0.00 $0.00 $0.00 $0.00 $0.00 40-15061 SUP HCPCS C1713 40-15061 - PLATE BN 3D NS VARIAX PA LCK LOPRFL TI FT LT BOTH IP/OP "$1,384.00 " "$1,024.16" $0.00 "$1,027.20" $329.18 $329.18 $0.00 $0.00 $0.00 $288.46 "$1,027.20" "$1,027.20" $0.00 $0.00 $288.43 $0.00 $818.64 $818.64 $0.00 $365.75 $579.35 $585.20 $0.00 $0.00 $114.48 $0.00 $0.00 $116.45 $0.00 $0.00 $0.00 $0.00 $0.00 40-15062 SUP HCPCS C1713 40-15062 - PLATE BN 3D NS VARIAX PA LCK LOPRFL TI FT RT BOTH IP/OP "$1,384.00 " "$1,024.16" $0.00 "$1,027.20" $329.18 $329.18 $0.00 $0.00 $0.00 $288.46 "$1,027.20" "$1,027.20" $0.00 $0.00 $288.43 $0.00 $818.64 $818.64 $0.00 $365.75 $579.35 $585.20 $0.00 $0.00 $114.48 $0.00 $0.00 $116.45 $0.00 $0.00 $0.00 $0.00 $0.00 40-15071 SUP HCPCS C1713 40-15071 - PLATE BN T OBLQ NS VARIAX PA LCK LOPRFL TI FT LT BOTH IP/OP "$1,101.00 " $814.74 $0.00 $817.16 $274.11 $274.11 $0.00 $0.00 $0.00 $229.48 $817.16 $817.16 $0.00 $0.00 $229.45 $0.00 $651.24 $651.24 $0.00 $304.56 $482.43 $487.30 $0.00 $0.00 $95.33 $0.00 $0.00 $96.97 $0.00 $0.00 $0.00 $0.00 $0.00 40-15072 SUP HCPCS C1713 40-15072 - PLATE BN T OBLQ NS VARIAX PA LCK LOPRFL TI FT RT BOTH IP/OP "$1,101.00 " $814.74 $0.00 $817.16 $274.11 $274.11 $0.00 $0.00 $0.00 $229.48 $817.16 $817.16 $0.00 $0.00 $229.45 $0.00 $651.24 $651.24 $0.00 $304.56 $482.43 $487.30 $0.00 $0.00 $95.33 $0.00 $0.00 $96.97 $0.00 $0.00 $0.00 $0.00 $0.00 40-15081 SUP HCPCS C1713 40-15081 - PLATE BN T NS VARIAX PA LCK LOPRFL TI FT BOTH IP/OP $778.00 $575.72 $0.00 $577.43 $193.67 $193.67 $0.00 $0.00 $0.00 $162.15 $577.43 $577.43 $0.00 $0.00 $162.14 $0.00 $460.19 $460.19 $0.00 $215.19 $340.86 $344.30 $0.00 $0.00 $67.35 $0.00 $0.00 $68.52 $0.00 $0.00 $0.00 $0.00 $0.00 40-15091 SUP HCPCS C1713 40-15091 - PLATE BN L NS VARIAX PA LCK LOPRFL TI FT LT BOTH IP/OP $778.00 $575.72 $0.00 $577.43 $193.67 $193.67 $0.00 $0.00 $0.00 $162.15 $577.43 $577.43 $0.00 $0.00 $162.14 $0.00 $460.19 $460.19 $0.00 $215.19 $340.86 $344.30 $0.00 $0.00 $67.35 $0.00 $0.00 $68.52 $0.00 $0.00 $0.00 $0.00 $0.00 40-15092 SUP HCPCS C1713 40-15092 - PLATE BN L NS VARIAX PA LCK LOPRFL TI FT RT BOTH IP/OP $778.00 $575.72 $0.00 $577.43 $193.67 $193.67 $0.00 $0.00 $0.00 $162.15 $577.43 $577.43 $0.00 $0.00 $162.14 $0.00 $460.19 $460.19 $0.00 $215.19 $340.86 $344.30 $0.00 $0.00 $67.35 $0.00 $0.00 $68.52 $0.00 $0.00 $0.00 $0.00 $0.00 402.110E SUP HCPCS C1713 402.110E - SCREW TI 10MM 2.7MM CORT MAXFACL HEX SCKT BONE THORP NONSTRL BOTH IP/OP $130.50 $96.57 $0.00 $104.40 $58.73 $58.73 $0.00 $0.00 $0.00 $27.20 $96.86 $96.86 $0.00 $0.00 $27.20 $0.00 $77.19 $77.19 $0.00 $65.25 $103.36 $104.40 $0.00 $0.00 $20.42 $0.00 $0.00 $20.78 $0.00 $0.00 $0.00 $0.00 $0.00 402.112E SUP HCPCS C1713 402.112E - SCREW TI 12MM 2.7MM CORT MAXFACL HEX SCKT BONE THORP NONSTRL BOTH IP/OP $130.50 $96.57 $0.00 $104.40 $58.73 $58.73 $0.00 $0.00 $0.00 $27.20 $96.86 $96.86 $0.00 $0.00 $27.20 $0.00 $77.19 $77.19 $0.00 $65.25 $103.36 $104.40 $0.00 $0.00 $20.42 $0.00 $0.00 $20.78 $0.00 $0.00 $0.00 $0.00 $0.00 402.114E SUP HCPCS C1713 402.114E - SCREW TI 14MM 2.7MM CORT MAXFACL HEX SCKT BONE THORP NONSTRL BOTH IP/OP $130.50 $96.57 $0.00 $104.40 $58.73 $58.73 $0.00 $0.00 $0.00 $27.20 $96.86 $96.86 $0.00 $0.00 $27.20 $0.00 $77.19 $77.19 $0.00 $65.25 $103.36 $104.40 $0.00 $0.00 $20.42 $0.00 $0.00 $20.78 $0.00 $0.00 $0.00 $0.00 $0.00 402.116E SUP HCPCS C1713 402.116E - SCREW TI 16MM 2.7MM CORT MAXFACL BONE THORP NONSTRL BOTH IP/OP $130.50 $96.57 $0.00 $104.40 $58.73 $58.73 $0.00 $0.00 $0.00 $27.20 $96.86 $96.86 $0.00 $0.00 $27.20 $0.00 $77.19 $77.19 $0.00 $65.25 $103.36 $104.40 $0.00 $0.00 $20.42 $0.00 $0.00 $20.78 $0.00 $0.00 $0.00 $0.00 $0.00 402.118E SUP HCPCS C1713 402.118E - SCREW TI 18MM 2.7MM CORT MAXFACL HEX SCKT BONE THORP NONSTRL BOTH IP/OP $130.50 $96.57 $0.00 $104.40 $58.73 $58.73 $0.00 $0.00 $0.00 $27.20 $96.86 $96.86 $0.00 $0.00 $27.20 $0.00 $77.19 $77.19 $0.00 $65.25 $103.36 $104.40 $0.00 $0.00 $20.42 $0.00 $0.00 $20.78 $0.00 $0.00 $0.00 $0.00 $0.00 4020-005R SUP HCPCS C1713 4020-005R - CMPNT TIBTRY 5 KNEE RIGHT BOTH IP/OP "$1,213.00 " $897.62 $0.00 $970.40 $545.85 $545.85 $0.00 $0.00 $0.00 $252.82 $900.29 $900.29 $0.00 $0.00 $252.79 $0.00 $717.49 $717.49 $0.00 $606.50 $960.70 $970.40 $0.00 $0.00 $189.83 $0.00 $0.00 $193.11 $0.00 $0.00 $0.00 $0.00 $0.00 40-20108 SUP HCPCS C1713 40-20108 - SCREW BONE 2MM 8MM 4MM ASNS TI MIC FT HAND CANN THRD NONSTRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20109 SUP HCPCS C1713 40-20109 - SCREW BONE 2MM 9MM 4MM ASNS TI MIC FT HAND CANN THRD NONSTRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20110 SUP HCPCS C1713 40-20110 - SCREW BONE 2MM 10MM 4MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20111 SUP HCPCS C1713 40-20111 - SCREW BONE 2MM 11MM 5MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20112 SUP HCPCS C1713 40-20112 - SCREW BONE 2MM 12MM 5MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20113 SUP HCPCS C1713 40-20113 - SCREW BONE 2MM 13MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20114 SUP HCPCS C1713 40-20114 - SCREW BONE 2MM 14MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20115 SUP HCPCS C1713 40-20115 - SCREW BONE 2MM 15MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20116 SUP HCPCS C1713 40-20116 - SCREW BONE 2MM 16MM 7MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20117 SUP HCPCS C1713 40-20117 - SCREW BONE 2MM 17MM 5MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20118 SUP HCPCS C1713 40-20118 - SCREW BONE 2MM 18MM 5MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20119 SUP HCPCS C1713 40-20119 - SCREW BONE 2MM 19MM 5MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20120 SUP HCPCS C1713 40-20120 - SCREW BN MIC RVRS CUT FLUT 2MM 20MM NS 5MM ASNS SLF CUT CNN BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20122 SUP HCPCS C1713 40-20122 - SCREW BONE 2MM 22MM 5MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20124 SUP HCPCS C1713 40-20124 - SCREW BONE 2MM 24MM 6MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20126 SUP HCPCS C1713 40-20126 - SCREW BONE 2MM 26MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20128 SUP HCPCS C1713 40-20128 - SCREW BONE 2MM 28MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20130 SUP HCPCS C1713 40-20130 - SCREW BONE 2MM 32MM 6MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20217 SUP HCPCS C1713 40-20217 - SCREW BONE 2MM 17MM 8MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20218 SUP HCPCS C1713 40-20218 - SCREW BONE 2MM 18MM 8MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20219 SUP HCPCS C1713 40-20219 - SCREW BONE 2MM 19MM 9MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20220 SUP HCPCS C1713 40-20220 - SCREW BONE 2MM 20MM 9MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20222 SUP HCPCS C1713 40-20222 - SCREW BONE 2MM 22MM 10MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20224 SUP HCPCS C1713 40-20224 - SCREW BONE 2MM 24MM 9MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20226 SUP HCPCS C1713 40-20226 - SCREW BONE 2MM 26MM 12MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20228 SUP HCPCS C1713 40-20228 - SCREW BONE 2MM 28MM 12MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20230 SUP HCPCS C1713 40-20230 - SCREW BONE 2MM 30MM 14MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $133.65 $133.65 $0.00 $0.00 $0.00 $61.90 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $175.68 $175.68 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $46.48 $0.00 $0.00 $47.28 $0.00 $0.00 $0.00 $0.00 $0.00 40-20805 SUP HCPCS C1713 40-20805 - PLATE BN STRG 72MMX2MM NS VARIAX 5 HL LCK LOPRFL TI FIB BOTH IP/OP $780.00 $577.20 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $162.57 $578.92 $578.92 $0.00 $0.00 $162.55 $0.00 $461.37 $461.37 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 40-20900 SUP HCPCS C1713 40-20900 - WASHER 2MM MIC ASNS ORTH NONSTRL BOTH IP/OP $98.60 $72.96 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $20.55 $73.18 $73.18 $0.00 $0.00 $20.55 $0.00 $58.32 $58.32 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 40-20903 SUP HCPCS C1713 40-20903 - PLATE BN 77X10X2MM NS 16X1.3MM VARIAX 3 HL LCK LOPRFL TI FIB BOTH IP/OP "$1,143.00 " $845.82 $0.00 $848.33 $393.53 $393.53 $0.00 $0.00 $0.00 $238.23 $848.33 $848.33 $0.00 $0.00 $238.20 $0.00 $676.08 $676.08 $0.00 $437.25 $692.60 $699.60 $0.00 $0.00 $136.86 $0.00 $0.00 $139.22 $0.00 $0.00 $0.00 $0.00 $0.00 40-20904 SUP HCPCS C1713 40-20904 - PLATE BN 89X10X2MM NS 16X1.3MM VARIAX 4 HL LCK LOPRFL TI FIB BOTH IP/OP "$1,143.00 " $845.82 $0.00 $848.33 $393.53 $393.53 $0.00 $0.00 $0.00 $238.23 $848.33 $848.33 $0.00 $0.00 $238.20 $0.00 $676.08 $676.08 $0.00 $437.25 $692.60 $699.60 $0.00 $0.00 $136.86 $0.00 $0.00 $139.22 $0.00 $0.00 $0.00 $0.00 $0.00 40-20905 SUP HCPCS C1713 40-20905 - PLATE BN 101X10X2MM NS 16X1.3MM VARIAX 5 HL LCK LOPRFL TI BOTH IP/OP "$1,143.00 " $845.82 $0.00 $848.33 $393.53 $393.53 $0.00 $0.00 $0.00 $238.23 $848.33 $848.33 $0.00 $0.00 $238.20 $0.00 $676.08 $676.08 $0.00 $437.25 $692.60 $699.60 $0.00 $0.00 $136.86 $0.00 $0.00 $139.22 $0.00 $0.00 $0.00 $0.00 $0.00 40-20906 SUP HCPCS C1713 40-20906 - PLATE BN 113X10X2MM NS 16X1.3MM VARIAX 6 HL LCK LOPRFL TI BOTH IP/OP "$1,187.00 " $878.38 $0.00 $880.99 $393.53 $393.53 $0.00 $0.00 $0.00 $247.40 $880.99 $880.99 $0.00 $0.00 $247.37 $0.00 $702.11 $702.11 $0.00 $437.25 $692.60 $699.60 $0.00 $0.00 $136.86 $0.00 $0.00 $139.22 $0.00 $0.00 $0.00 $0.00 $0.00 40-20907 SUP HCPCS C1713 40-20907 - PLATE BN 125X10X2MM NS 16X1.3MM VARIAX 7 HL LCK LOPRFL TI BOTH IP/OP "$1,288.00 " $953.12 $0.00 $955.95 $428.18 $428.18 $0.00 $0.00 $0.00 $268.45 $955.95 $955.95 $0.00 $0.00 $268.42 $0.00 $761.85 $761.85 $0.00 $475.75 $753.59 $761.20 $0.00 $0.00 $148.91 $0.00 $0.00 $151.48 $0.00 $0.00 $0.00 $0.00 $0.00 40-20908 SUP HCPCS C1713 40-20908 - PLATE BN 137X10X2MM NS 16X1.3MM VARIAX 8 HL LCK LOPRFL TI BOTH IP/OP "$1,288.00 " $953.12 $0.00 $955.95 $428.18 $428.18 $0.00 $0.00 $0.00 $268.45 $955.95 $955.95 $0.00 $0.00 $268.42 $0.00 $761.85 $761.85 $0.00 $475.75 $753.59 $761.20 $0.00 $0.00 $148.91 $0.00 $0.00 $151.48 $0.00 $0.00 $0.00 $0.00 $0.00 40-20909 SUP HCPCS C1713 40-20909 - PLATE BN 149X10X2MM NS 16X1.3MM VARIAX 9 HL LCK LOPRFL TI BOTH IP/OP "$1,288.00 " $953.12 $0.00 $955.95 $428.18 $428.18 $0.00 $0.00 $0.00 $268.45 $955.95 $955.95 $0.00 $0.00 $268.42 $0.00 $761.85 $761.85 $0.00 $475.75 $753.59 $761.20 $0.00 $0.00 $148.91 $0.00 $0.00 $151.48 $0.00 $0.00 $0.00 $0.00 $0.00 40-20910S SUP HCPCS C1713 40-20910S - PLATE 161MM 10 HOLE VARIAX BONE LAT FIB STRL BOTH IP/OP "$1,457.00 " "$1,078.18" $0.00 "$1,081.39" $483.86 $483.86 $0.00 $0.00 $0.00 $303.68 "$1,081.39" "$1,081.39" $0.00 $0.00 $303.64 $0.00 $861.82 $861.82 $0.00 $537.63 $851.60 $860.20 $0.00 $0.00 $168.28 $0.00 $0.00 $171.18 $0.00 $0.00 $0.00 $0.00 $0.00 40-20912S SUP HCPCS C1713 40-20912S - PLATE 185MM 12 HOLE VARIAX BONE LAT FIB STRL BOTH IP/OP "$1,457.00 " "$1,078.18" $0.00 "$1,081.39" $483.86 $483.86 $0.00 $0.00 $0.00 $303.68 "$1,081.39" "$1,081.39" $0.00 $0.00 $303.64 $0.00 $861.82 $861.82 $0.00 $537.63 $851.60 $860.20 $0.00 $0.00 $168.28 $0.00 $0.00 $171.18 $0.00 $0.00 $0.00 $0.00 $0.00 40-22800 SUP Custom 27203010 RULER SURG 15MM SIL MCGRD MTRC SCL BKGRND RADIOPQ STRL 30MM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 402609T SUP HCPCS C1894 INTRODUCER SHTH 9FR 23CM WO GUIDEWIRE AVNT++ .035IN BLK BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 40-27008 SUP HCPCS C1713 40-27008 - SCREW BN T7 2.7MM 8MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27010 SUP HCPCS C1713 40-27010 - SCREW BN T7 2.7MM 10MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27012 SUP HCPCS C1713 40-27012 - SCREW BN T7 2.7MM 12MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27014 SUP HCPCS C1713 40-27014 - SCREW BN T7 2.7MM 14MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27016 SUP HCPCS C1713 40-27016 - SCREW BN T7 2.7MM 16MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27018 SUP HCPCS C1713 40-27018 - SCREW BN T7 2.7MM 18MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27020 SUP HCPCS C1713 40-27020 - SCREW BN T7 2.7MM 20MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27022 SUP HCPCS C1713 40-27022 - SCREW BN T7 2.7MM 22MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27024 SUP HCPCS C1713 40-27024 - SCREW BN T7 2.7MM 24MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27026 SUP HCPCS C1713 40-27026 - SCREW BN T7 2.7MM 26MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27028 SUP HCPCS C1713 40-27028 - SCREW BN T7 2.7MM 28MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27030 SUP HCPCS C1713 40-27030 - SCREW BN T7 2.7MM 30MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27032 SUP HCPCS C1713 40-27032 - SCREW BN T7 2.7MM 32MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27034 SUP HCPCS C1713 40-27034 - SCREW BN T7 2.7MM 34MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27036 SUP HCPCS C1713 40-27036 - SCREW BN T7 2.7MM 36MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27038 SUP HCPCS C1713 40-27038 - SCREW BN T7 2.7MM 38MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27040 SUP HCPCS C1713 40-27040 - SCREW BN T7 2.7MM 40MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27045 SUP HCPCS C1713 40-27045 - SCREW BN T7 2.7MM 45MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27050 SUP HCPCS C1713 40-27050 - SCREW BN T7 2.7MM 50MM YLW NS VARIAX ST TI FT LCK PLT SYS BOTH IP/OP $100.80 $74.59 $0.00 $74.81 $40.22 $40.22 $0.00 $0.00 $0.00 $21.01 $74.81 $74.81 $0.00 $0.00 $21.01 $0.00 $59.62 $59.62 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 40-27608 SUP HCPCS C1713 40-27608 - SCREW BN T7 2.7MM 8MM BLU NS VARIAX LCK ST TI FT LCK PLT SYS BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27610 SUP HCPCS C1713 40-27610 - SCREW BONE 2.7MM 10MM VARIAX FT LCK T7 NONSTRL BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27612 SUP HCPCS C1713 40-27612 - SCREW BN T7 2.7MM 12MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27614 SUP HCPCS C1713 40-27614 - SCREW BN T7 2.7MM 14MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27616 SUP HCPCS C1713 40-27616 - SCREW BN T7 2.7MM 16MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27618 SUP HCPCS C1713 40-27618 - SCREW BN T7 2.7MM 18MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27620 SUP HCPCS C1713 40-27620 - SCREW BN T7 2.7MM 20MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27622 SUP HCPCS C1713 40-27622 - SCREW BN T7 2.7MM 22MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27624 SUP HCPCS C1713 40-27624 - SCREW BN T7 2.7MM 24MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27626 SUP HCPCS C1713 40-27626 - SCREW BN T7 2.7MM 26MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27628 SUP HCPCS C1713 40-27628 - SCREW BN T7 2.7MM 28MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27630 SUP HCPCS C1713 40-27630 - SCREW BN T7 2.7MM 30MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27632 SUP HCPCS C1713 40-27632 - SCREW BN T7 2.7MM 32MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27634 SUP HCPCS C1713 40-27634 - SCREW BN T7 2.7MM 34MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27636 SUP HCPCS C1713 40-27636 - SCREW BN T7 2.7MM 36MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27638 SUP HCPCS C1713 40-27638 - SCREW BN T7 2.7MM 38MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27640 SUP HCPCS C1713 40-27640 - SCREW BN T7 2.7MM 40MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27645 SUP HCPCS C1713 40-27645 - SCREW BN T7 2.7MM 45MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27650 SUP HCPCS C1713 40-27650 - SCREW BN T7 2.7MM 50MM BLU NS VARIAX LCK ST TI FT LCK PLT BOTH IP/OP $221.20 $163.69 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 40-27900 SUP HCPCS C1713 40-27900 - WASHER ORTH 2.7 MM SCR BOTH IP/OP $124.10 $91.83 $0.00 $100.10 $56.31 $56.31 $0.00 $0.00 $0.00 $25.87 $92.11 $92.11 $0.00 $0.00 $25.86 $0.00 $73.41 $73.41 $0.00 $62.56 $99.10 $100.10 $0.00 $0.00 $19.58 $0.00 $0.00 $19.92 $0.00 $0.00 $0.00 $0.00 $0.00 403.318E SUP HCPCS C1713 403.318E - 3.2MM TI EMERGENCY SCREW 18MM BOTH IP/OP $200.25 $148.19 $0.00 $160.20 $90.11 $90.11 $0.00 $0.00 $0.00 $41.74 $148.63 $148.63 $0.00 $0.00 $41.73 $0.00 $118.45 $118.45 $0.00 $100.13 $158.60 $160.20 $0.00 $0.00 $31.34 $0.00 $0.00 $31.88 $0.00 $0.00 $0.00 $0.00 $0.00 40-30108 SUP HCPCS C1713 40-30108 - SCREW BONE 3MM 8MM 4MM ASNS TI MIC FT HAND CANN THRD NONSTRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30109 SUP HCPCS C1713 40-30109 - SCREW BONE 3MM ASNS MIC CANN BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30110 SUP HCPCS C1713 40-30110 - SCREW BONE 3MM 10MM 4MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30111 SUP HCPCS C1713 40-30111 - SCREW BONE 3MM 11MM 4MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30112 SUP HCPCS C1713 40-30112 - SCREW BONE 3MM 12MM 4MM ASNS TI MIC HAND FT CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30113 SUP HCPCS C1713 40-30113 - SCREW BONE 3MM 13MM 4MM ASNS TI MIC HAND FT CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30114 SUP HCPCS C1713 40-30114 - SCREW BONE 3MM 14MM 4MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30115 SUP HCPCS C1713 40-30115 - SCREW BONE 3MM 15MM 4MM ASNS TI MIC HAND FT CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30116 SUP HCPCS C1713 40-30116 - SCREW BONE 3MM 16MM 4MM ASNS TI MIC HAND FT CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30117 SUP HCPCS C1713 40-30117 - SCREW BONE 3MM 17MM 4MM ASNS TI MIC HAND FT CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30118 SUP HCPCS C1713 40-30118 - SCREW BONE 3MM 18MM 5MM ASNS TI MIC HAND FT CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30119 SUP HCPCS C1713 40-30119 - SCREW BONE 3MM 19MM 5MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30120 SUP HCPCS C1713 40-30120 - SCREW BONE 3MM 20MM 5MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30121 SUP HCPCS C1713 40-30121 - SCREW BONE 3MM 21MM 5MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30122 SUP HCPCS C1713 40-30122 - SCREW BONE 3MM 22MM 5MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30123 SUP HCPCS C1713 40-30123 - SCREW BONE 3MM 23MM 5MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30124 SUP HCPCS C1713 40-30124 - SCREW BONE 3MM 24MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30125 SUP HCPCS C1713 40-30125 - SCREW BONE 3MM 25MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30126 SUP HCPCS C1713 40-30126 - SCREW BONE 3MM 26MM 6MM ASNS MIC CANN NONSTRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30127 SUP HCPCS C1713 40-30127 - SCREW BONE 3MM 27MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30128 SUP HCPCS C1713 40-30128 - SCREW BONE 3MM 28MM 6MM ASNS TI MIC FT HAND CANN NONSTRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30129 SUP HCPCS C1713 40-30129 - SCREW BONE 3MM 29MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30130 SUP HCPCS C1713 40-30130 - SCREW BONE 3MM 30MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30132 SUP HCPCS C1713 40-30132 - SCREW BONE 3MM 32MM 6MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30134 SUP HCPCS C1713 40-30134 - SCREW BONE 3MM 34MM 7MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30136 SUP HCPCS C1713 40-30136 - SCREW BONE 3MM 36MM 7MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30138 SUP HCPCS C1713 40-30138 - SCREW BONE 3MM 38MM 8MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30140 SUP HCPCS C1713 40-30140 - SCREW BN MIC RVRS CUT FLUT 3MM 40MM NS 8MM ASNS SLF CUT CNN BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30214 SUP HCPCS C1713 40-30214 - SCREW BONE 3MM 14MM 6MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30215 SUP HCPCS C1713 40-30215 - SCREW BONE 3MM 15MM 7MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30216 SUP HCPCS C1713 40-30216 - SCREW BONE 3MM 16MM 7MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30217 SUP HCPCS C1713 40-30217 - SCREW BONE 3MM 17MM 8MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30218 SUP HCPCS C1713 40-30218 - SCREW BONE 3MM 18MM 8MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30219 SUP HCPCS C1713 40-30219 - SCREW BONE 3MM 21MM 5MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30220 SUP HCPCS C1713 40-30220 - SCREW BONE 3MM 20MM 9MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30221 SUP HCPCS C1713 40-30221 - SCREW BONE 3MM 21MM 9MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30222 SUP HCPCS C1713 40-30222 - SCREW BN MIC RVRS CUT FLUT 3MM 22MM NS 10MM ASNS SLF CUT CNN BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30223 SUP HCPCS C1713 40-30223 - SCREW BONE 3MM 23MM 10MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30224 SUP HCPCS C1713 40-30224 - SCREW BONE 3MM 24MM 10MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30225 SUP HCPCS C1713 40-30225 - SCREW BONE 3MM 25MM 10MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30226 SUP HCPCS C1713 40-30226 - SCREW BONE 3MM 26MM 12MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30227 SUP HCPCS C1713 40-30227 - SCREW BONE 3MM 27MM 12MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30228 SUP HCPCS C1713 40-30228 - SCREW BONE 3MM 28MM 12MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30229 SUP HCPCS C1713 40-30229 - SCREW BONE 3MM 29MM 12MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30230 SUP HCPCS C1713 40-30230 - SCREW BONE 3MM 30MM 14MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30232 SUP HCPCS C1713 40-30232 - SCREW BONE 32MM 14MM TI MIC CANC BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30234 SUP HCPCS C1713 40-30234 - SCREW BONE 3MM 34MM 16MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30236 SUP HCPCS C1713 40-30236 - SCREW BONE 3MM 36MM 16MM ASNS TI MIC FT HAND CANN THRD STRL BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30238 SUP HCPCS C1713 40-30238 - SCREW BONE 2MM 38MM 16MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30240 SUP HCPCS C1713 40-30240 - SCREW BONE 3MM 40MM 18MM ASNS TI MIC FT HAND CANN THRD BOTH IP/OP $295.63 $218.77 $0.00 $236.50 $133.03 $133.03 $0.00 $0.00 $0.00 $61.62 $219.41 $219.41 $0.00 $0.00 $61.61 $0.00 $174.86 $174.86 $0.00 $147.81 $234.14 $236.50 $0.00 $0.00 $46.27 $0.00 $0.00 $47.06 $0.00 $0.00 $0.00 $0.00 $0.00 40-30900 SUP Custom 27803010 40-30900 - WASHER ORTH MIC 3MM ASNS BOTH IP/OP $109.65 $81.14 $0.00 $102.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.38 $81.38 $0.00 $0.00 $22.85 $0.00 $0.00 $0.00 $0.00 $63.94 $101.28 $102.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-35010 SUP HCPCS C1713 40-35010 - SCREW BN T10 FT 3.5MM 10MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35012 SUP HCPCS C1713 40-35012 - SCREW BN T10 FT 3.5MM 12MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35014 SUP HCPCS C1713 40-35014 - SCREW BN T10 FT 3.5MM 14MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35016 SUP HCPCS C1713 40-35016 - SCREW BN T10 FT 3.5MM 16MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35018 SUP HCPCS C1713 40-35018 - SCREW BN T10 FT 3.5MM 18MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35020 SUP HCPCS C1713 40-35020 - SCREW BN T10 FT 3.5MM 20MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35022 SUP HCPCS C1713 40-35022 - SCREW BN T10 FT 3.5MM 22MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35024 SUP HCPCS C1713 40-35024 - SCREW BN T10 FT 3.5MM 24MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35026 SUP HCPCS C1713 40-35026 - SCREW BN T10 FT 3.5MM 26MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35028 SUP HCPCS C1713 40-35028 - SCREW BN T10 FT 3.5MM 28MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35030 SUP HCPCS C1713 40-35030 - SCREW BN T10 FT 3.5MM 30MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35032 SUP HCPCS C1713 40-35032 - SCREW BN T10 FT 3.5MM 32MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35034 SUP HCPCS C1713 40-35034 - SCREW BN T10 FT 3.5MM 34MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35036 SUP HCPCS C1713 40-35036 - SCREW BN T10 FT 3.5MM 36MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35038 SUP HCPCS C1713 40-35038 - SCREW BN T10 FT 3.5MM 38MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35040 SUP HCPCS C1713 40-35040 - SCREW BN T10 FT 3.5MM 40MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35042 SUP HCPCS C1713 40-35042 - SCREW BN T10 FT 3.5MM 42MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35044 SUP HCPCS C1713 40-35044 - SCREW BN T10 FT 3.5MM 44MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35046 SUP HCPCS C1713 40-35046 - SCREW BN T10 FT 3.5MM 46MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35048 SUP HCPCS C1713 40-35048 - SCREW BN T10 FT 3.5MM 48MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35050 SUP HCPCS C1713 40-35050 - SCREW BN T10 FT 3.5MM 50MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35055 SUP HCPCS C1713 40-35055 - SCREW BN T10 FT 3.5MM 55MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35060 SUP HCPCS C1713 40-35060 - SCREW BN T10 FT 3.5MM 60MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35065 SUP HCPCS C1713 40-35065 - SCREW BN T10 FT 3.5MM 65MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35070 SUP HCPCS C1713 40-35070 - SCREW BN T10 FT 3.5MM 70MM YLW NS VARIAX ST TI FT/ANKL LCK BOTH IP/OP $112.00 $82.88 $0.00 $83.13 $46.41 $46.41 $0.00 $0.00 $0.00 $23.34 $83.13 $83.13 $0.00 $0.00 $23.34 $0.00 $66.25 $66.25 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $16.14 $0.00 $0.00 $16.42 $0.00 $0.00 $0.00 $0.00 $0.00 40-35610 SUP HCPCS C1713 40-35610 - SCREW BN T10 FT 3.5MM 10MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35612 SUP HCPCS C1713 40-35612 - SCREW BN T10 FT 3.5MM 12MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35614 SUP HCPCS C1713 40-35614 - SCREW BN T10 FT 3.5MM 14MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35616 SUP HCPCS C1713 40-35616 - SCREW BN T10 FT 3.5MM 16MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35618 SUP HCPCS C1713 40-35618 - SCREW BN T10 FT 3.5MM 18MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35620 SUP HCPCS C1713 40-35620 - SCREW BN T10 FT 3.5MM 20MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35622 SUP HCPCS C1713 40-35622 - SCREW BN T10 FT 3.5MM 22MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35624 SUP HCPCS C1713 40-35624 - SCREW BN T10 FT 3.5MM 24MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35626 SUP HCPCS C1713 40-35626 - SCREW BN T10 FT 3.5MM 26MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35628 SUP HCPCS C1713 40-35628 - SCREW BN T10 FT 3.5MM 28MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35630 SUP HCPCS C1713 40-35630 - SCREW BN T10 FT 3.5MM 30MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35632 SUP HCPCS C1713 40-35632 - SCREW BN T10 FT 3.5MM 32MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35634 SUP HCPCS C1713 40-35634 - SCREW BONE 3.5MM 34MM VARIAX TI FT T10 LCK NONSTRL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35636 SUP HCPCS C1713 40-35636 - SCREW BN T10 FT 3.5MM 36MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35638 SUP HCPCS C1713 40-35638 - SCREW BN T10 FT 3.5MM 38MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35640 SUP HCPCS C1713 40-35640 - SCREW BN T10 FT 3.5MM 40MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35642 SUP HCPCS C1713 40-35642 - SCREW BN T10 FT 3.5MM 42MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35644 SUP HCPCS C1713 40-35644 - SCREW BN T10 FT 3.5MM 44MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35646 SUP HCPCS C1713 40-35646 - SCREW BN T10 FT 3.5MM 46MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35648 SUP HCPCS C1713 40-35648 - SCREW BN T10 FT 3.5MM 48MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35650 SUP HCPCS C1713 40-35650 - SCREW BN T10 FT 3.5MM 50MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35655 SUP HCPCS C1713 40-35655 - SCREW BN T10 FT 3.5MM 55MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35660 SUP HCPCS C1713 40-35660 - SCREW BN T10 FT 3.5MM 60MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35665 SUP HCPCS C1713 40-35665 - SCREW BN T10 FT 3.5MM 65MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35670 SUP HCPCS C1713 40-35670 - SCREW BN T10 FT 3.5MM 70MM BLU NS VARIAX LCK ST TI FT/ANKL BOTH IP/OP $221.20 $163.69 $0.00 $167.20 $94.05 $94.05 $0.00 $0.00 $0.00 $46.10 $164.17 $164.17 $0.00 $0.00 $46.10 $0.00 $130.84 $130.84 $0.00 $104.50 $165.53 $167.20 $0.00 $0.00 $32.71 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $0.00 40-35900 SUP HCPCS C1713 40-35900 - WASHER ORTH 3.5 MM SCR BOTH IP/OP $139.40 $103.16 $0.00 $114.40 $64.35 $64.35 $0.00 $0.00 $0.00 $29.05 $103.46 $103.46 $0.00 $0.00 $29.05 $0.00 $82.46 $82.46 $0.00 $71.50 $113.26 $114.40 $0.00 $0.00 $22.38 $0.00 $0.00 $22.77 $0.00 $0.00 $0.00 $0.00 $0.00 4040-0510R SUP Custom 27803010 4040-0510R - INSERT TIB 5 10MM RIGHT KNEE BOTH IP/OP $858.00 $634.92 $0.00 $686.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $636.81 $636.81 $0.00 $0.00 $178.81 $0.00 $0.00 $0.00 $0.00 $429.00 $679.54 $686.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4040-0908R SUP Custom 27803010 4040-0908R - INSERT TIB 9 RIGHT KNEE MDLR UNICOMP 8MM BOTH IP/OP $894.00 $661.56 $0.00 $715.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $663.53 $663.53 $0.00 $0.00 $186.31 $0.00 $0.00 $0.00 $0.00 $447.00 $708.05 $715.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40-5011 SUP HCPCS C1725 40-5011 - CATH ANGIO RADIALTIGER CURVE 5FR 4MM 100CM CORON 1 SH DX BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $47.51 $47.51 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 40-5012 SUP HCPCS C1725 40-5012 - CATH ANGIO RADIALTIGER CURVE 5FR 4.5MM 100CM CORON 1 SH DX BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $47.51 $47.51 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 4076-STDJ-185 SUP HCPCS C1769 4076-STDJ-185 - 4076-STDJ-185 BOTH IP/OP $183.75 $135.98 $0.00 $147.00 $99.78 $99.78 $0.00 $0.00 $0.00 $38.30 $136.38 $136.38 $0.00 $0.00 $38.29 $0.00 $108.69 $108.69 $0.00 $91.88 $145.53 $147.00 $0.00 $0.00 $28.76 $0.00 $0.00 $29.25 $0.00 $0.00 $0.00 $0.00 $0.00 4076-STDJ-300 SUP HCPCS C1769 4076-STDJ-300 - 4076-STDJ-300 BOTH IP/OP $183.75 $135.98 $0.00 $147.00 $99.78 $99.78 $0.00 $0.00 $0.00 $38.30 $136.38 $136.38 $0.00 $0.00 $38.29 $0.00 $108.69 $108.69 $0.00 $91.88 $145.53 $147.00 $0.00 $0.00 $28.76 $0.00 $0.00 $29.25 $0.00 $0.00 $0.00 $0.00 $0.00 40A002 SUP HCPCS C1762 40A002 - GRAFT BONE SMALL 25X9X14MM WEDGE ILIAC CREST BOTH IP/OP "$2,005.00 " "$1,483.70" $0.00 "$1,604.00" $0.00 $0.00 $0.00 $0.00 $0.00 $417.89 "$1,488.11" "$1,488.11" $0.00 $0.00 $417.84 $0.00 "$1,185.96" "$1,185.96" $0.00 "$1,002.50" "$1,587.96" "$1,604.00" $0.00 $0.00 $313.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 40A74 SUP HCPCS C1768 40A74 - GRAFT VASC 40CM 7-4MM IMPR CBFL PTFE HMDIAL ACCES SHRT TPR BOTH IP/OP "$1,317.85 " $975.21 $0.00 "$1,054.28" $593.03 $593.03 $0.00 $0.00 $0.00 $274.67 $978.11 $978.11 $0.00 $0.00 $274.64 $0.00 $779.51 $779.51 $0.00 $658.93 "$1,043.74" "$1,054.28" $0.00 $0.00 $206.24 $0.00 $0.00 $209.80 $0.00 $0.00 $0.00 $0.00 $0.00 40S08 SUP HCPCS C1768 40S08 - GRAFT VASC 8MM 40CM IMPRA CARBOFLO PTFE BOTH IP/OP $955.50 $707.07 $0.00 $764.40 $429.98 $429.98 $0.00 $0.00 $0.00 $199.15 $709.17 $709.17 $0.00 $0.00 $199.13 $0.00 $565.18 $565.18 $0.00 $477.75 $756.76 $764.40 $0.00 $0.00 $149.54 $0.00 $0.00 $152.12 $0.00 $0.00 $0.00 $0.00 $0.00 4100M24 SUP Custom 27803010 4100M24 - RING ANLPLS 24MM MTRL C-M-A IMR E TI BOTH IP/OP "$9,112.50 " "$6,743.25" $0.00 "$7,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,899.05" $0.00 $0.00 $0.00 $0.00 "$4,556.25" "$7,217.10" "$7,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4100M34 SUP Custom 27803010 4100M34 - RING ANLPLS 34MM MTRL C-M-A IMR E TI SIL PLSTR BOTH IP/OP "$9,112.50 " "$6,743.25" $0.00 "$7,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,899.05" $0.00 $0.00 $0.00 $0.00 "$4,556.25" "$7,217.10" "$7,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41045-01 SUP HCPCS C1887 41045-01 - CATH INFUS 5FR 40CM 20CM VLV DRG DLV CRGG-MCNAM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $109.96 $109.96 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 41046-01 SUP HCPCS C1887 41046-01 - CATH INFUS .038IN 5FR 100CM 20CM PERI VLV CRGG-MCNAM BOTH IP/OP $202.50 $149.85 $0.00 $239.56 $109.96 $109.96 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $239.56 $239.56 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 41050-01 SUP HCPCS C1769 41050-01 - CATHETER INFS 5FR 100CM 10CM CRGG-MCNAM CRGG MICROVALVE 1 BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $142.54 $142.54 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 41053-01 SUP HCPCS C1769 41053-01 - CATHETER INFS .038IN 5FR 100CM 40CM CRGG-MCNAM CRGG BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $160.19 $160.19 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41055-01 SUP HCPCS C1887 41055-01 - CATHETER INFS 5FR 135CM 5CM CRGG-MCNAM CRGG-MICROVALVE 1 LUM BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $142.54 $142.54 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 4105535XL SUP HCPCS C1713 4105535XL - SCREW BONE 5.5MM 35MM XL SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 4105540XL SUP HCPCS C1713 4105540XL - SCREW BONE 5.5MM 40MM XL SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 4105545XL SUP HCPCS C1713 4105545XL - SCREW BONE 5.5MM 45MM XL SPNL BOTH IP/OP "$1,520.88 " "$1,125.45" $0.00 "$1,216.70" $684.39 $684.39 $0.00 $0.00 $0.00 $316.99 "$1,128.79" "$1,128.79" $0.00 $0.00 $316.95 $0.00 $899.60 $899.60 $0.00 $760.44 "$1,204.54" "$1,216.70" $0.00 $0.00 $238.02 $0.00 $0.00 $242.12 $0.00 $0.00 $0.00 $0.00 $0.00 41057-01 SUP HCPCS C1769 41057-01 - CATHETER IV .038IN 5FR 135CM 20CM CRGG-MCNAM CRGG MICROVALVE BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $109.96 $109.96 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 41059-01 SUP HCPCS C1887 41059-01 - CATH INFUS .038IN 5FR 135CM 40CM VLV CRGG-MCNAM BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $160.19 $160.19 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 4106545XL SUP HCPCS C1713 4106545XL - SCREW BONE 6.5IN 45IN XL SPNL BOTH IP/OP "$1,734.30 " "$1,283.38" $0.00 "$1,387.44" $780.44 $780.44 $0.00 $0.00 $0.00 $361.47 "$1,287.20" "$1,287.20" $0.00 $0.00 $361.43 $0.00 "$1,025.84" "$1,025.84" $0.00 $867.15 "$1,373.57" "$1,387.44" $0.00 $0.00 $271.42 $0.00 $0.00 $276.10 $0.00 $0.00 $0.00 $0.00 $0.00 4106550XL SUP HCPCS C1713 4106550XL - SCREW BONE 6.5MM 50MM XL SPNL BOTH IP/OP "$1,651.18 " "$1,221.87" $0.00 "$1,320.94" $743.03 $743.03 $0.00 $0.00 $0.00 $344.15 "$1,225.50" "$1,225.50" $0.00 $0.00 $344.10 $0.00 $976.67 $976.67 $0.00 $825.59 "$1,307.73" "$1,320.94" $0.00 $0.00 $258.41 $0.00 $0.00 $262.87 $0.00 $0.00 $0.00 $0.00 $0.00 4107540XL SUP HCPCS C1713 4107540XL - SCREW BONE 7.5MM 40MM XL SPNL BOTH IP/OP "$1,651.18 " "$1,221.87" $0.00 "$1,320.94" $743.03 $743.03 $0.00 $0.00 $0.00 $344.15 "$1,225.50" "$1,225.50" $0.00 $0.00 $344.10 $0.00 $976.67 $976.67 $0.00 $825.59 "$1,307.73" "$1,320.94" $0.00 $0.00 $258.41 $0.00 $0.00 $262.87 $0.00 $0.00 $0.00 $0.00 $0.00 4107545XL SUP HCPCS C1713 4107545XL - SCREW BONE 7.5MM 45MM XL SPNL BOTH IP/OP "$1,734.30 " "$1,283.38" $0.00 "$1,387.44" $780.44 $780.44 $0.00 $0.00 $0.00 $361.47 "$1,287.20" "$1,287.20" $0.00 $0.00 $361.43 $0.00 "$1,025.84" "$1,025.84" $0.00 $867.15 "$1,373.57" "$1,387.44" $0.00 $0.00 $271.42 $0.00 $0.00 $276.10 $0.00 $0.00 $0.00 $0.00 $0.00 4108540XL SUP HCPCS C1713 4108540XL - SCREW BONE 8.5MM 40MM XL SPNL BOTH IP/OP "$1,651.18 " "$1,221.87" $0.00 "$1,320.94" $743.03 $743.03 $0.00 $0.00 $0.00 $344.15 "$1,225.50" "$1,225.50" $0.00 $0.00 $344.10 $0.00 $976.67 $976.67 $0.00 $825.59 "$1,307.73" "$1,320.94" $0.00 $0.00 $258.41 $0.00 $0.00 $262.87 $0.00 $0.00 $0.00 $0.00 $0.00 4108545XL SUP HCPCS C1713 4108545XL - SCREW BONE 8.5MM 45MM XL SPNL BOTH IP/OP "$1,651.18 " "$1,221.87" $0.00 "$1,320.94" $743.03 $743.03 $0.00 $0.00 $0.00 $344.15 "$1,225.50" "$1,225.50" $0.00 $0.00 $344.10 $0.00 $976.67 $976.67 $0.00 $825.59 "$1,307.73" "$1,320.94" $0.00 $0.00 $258.41 $0.00 $0.00 $262.87 $0.00 $0.00 $0.00 $0.00 $0.00 412.113S SUP HCPCS C1713 412.113S - SCREW BN SD15 FT 3.5MM 2.9MM 34MM GRN STRL MULTILOC LCK BOTH IP/OP $326.13 $241.34 $0.00 $253.30 $142.48 $142.48 $0.00 $0.00 $0.00 $67.97 $242.05 $242.05 $0.00 $0.00 $67.96 $0.00 $192.90 $192.90 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $48.11 $0.00 $0.00 $50.41 $0.00 $0.00 $0.00 $0.00 $0.00 41-2005 SUP HCPCS C1713 41-2005 - SCREW 5MM 2MM MANDIB XDR NLCKG BONE LORENZ SLVR BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $72.00 $72.00 $0.00 $0.00 $0.00 $33.35 $118.75 $118.75 $0.00 $0.00 $33.34 $0.00 $94.64 $94.64 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $25.04 $0.00 $0.00 $25.47 $0.00 $0.00 $0.00 $0.00 $0.00 41-2006 SUP HCPCS C1713 41-2006 - SCREW BN 2MM 6MM BLU SLVR X-DRV NONLOCK XDR MNDB LORENZ BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 41-2008 SUP HCPCS C1713 41-2008 - SCREW BONE 2MM 8MM X DRIVE TRAUMAONE SILVER MANDIB BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 41-2010 SUP HCPCS C1713 41-2010 - SCREW BONE 2MM 10MM NONLOCKING XDRIVE LORENZ SILVER MANDIB BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 41-2012 SUP HCPCS C1713 41-2012 - SCREW BONE 2MM 12MM X DRIVE TRAUMAONE SILVER MANDIB BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 41-2014 SUP HCPCS C1713 41-2014 - SCREW BONE 2MM 14MM CROSS DRIVE NONLOCKING TRAUMAONE SILVER BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 41-2016 SUP HCPCS C1713 41-2016 - SCREW BONE 2MM 16MM NONLOCKING CROSS DRIVE TRAUMAONE SILVER BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 41-2018 SUP HCPCS C1713 41-2018 - SCREW BONE 2MM 18MM NONLOCKING CROSS DRIVE TRAUMAONE SILVER BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 41-2106 SUP HCPCS C1713 41-2106 - SCREW BN 2.3MM 6MM SLVR X-DRV LCK BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $175.50 $175.50 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 41-2108 SUP HCPCS C1713 41-2108 - SCREW BONE 2MM 8MM CROSS DRIVE LOCKING TRAUMAONE SILVER BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $175.50 $175.50 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 41-2110 SUP HCPCS C1713 41-2110 - SCREW BONE 2MM 10MM LOCKING CROSS DRIVE TRAUMAONE LORENZ BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $175.50 $175.50 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 41-2112 SUP HCPCS C1713 41-2112 - SCREW BONE 2MM 12MM CROSS DRIVE LOCKING TRAUMAONE SILVER BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $175.50 $175.50 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 41-2114 SUP HCPCS C1713 41-2114 - SCREW BONE 2MM 14MM CROSS DRIVE LOCKING TRAUMAONE SILVER BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $175.50 $175.50 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 41-2116 SUP HCPCS C1713 41-2116 - SCREW BONE 2MM 16MM X-DRIVE LOCKING TRAUMAONE SILVER MANDIB BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $175.50 $175.50 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 41-2118 SUP HCPCS C1713 41-2118 - SCREW BONE 2MM 18MM LOCKING CROSS DRIVE MANDUBULAR BOTH IP/OP $390.00 $288.60 $0.00 $312.00 $175.50 $175.50 $0.00 $0.00 $0.00 $81.29 $289.46 $289.46 $0.00 $0.00 $81.28 $0.00 $230.69 $230.69 $0.00 $195.00 $308.88 $312.00 $0.00 $0.00 $61.04 $0.00 $0.00 $62.09 $0.00 $0.00 $0.00 $0.00 $0.00 41-2205 SUP HCPCS C1713 41-2205 - SCREW 5MM 2MM MANDIB SLFDRILL XDR NLCKG BONE TRAUMAONE BLUE BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 41-2305 SUP HCPCS C1713 41-2305 - SCREW BONE 2.3MM 5MM CROSS DRIVE NONLOCKING TRAUMAONE GOLD BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41-2306 SUP HCPCS C1713 41-2306 - SCREW BN 2.3MM 6MM AU X-DRV NONLOCK BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41-2308 SUP HCPCS C1713 41-2308 - SCREW BONE 2.3MM 8MM NONLOCKING CROSS DRIVE TRAUMAONE GOLD BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41-2310 SUP HCPCS C1713 41-2310 - SCREW BONE 2.3MM 10MM NONLOCKING CROSS DRIVE TRAUMAONE GOLD BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41-2312 SUP HCPCS C1713 41-2312 - SCREW BONE 2.3MM 12MM NONLOCKING CROSS DRIVE TRAUMAONE GOLD BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41-2314 SUP HCPCS C1713 41-2314 - SCREW BONE 2.3MM 14MM NONLOCKING CROSS DRIVE TRAUMAONE GOLD BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41-2316 SUP HCPCS C1713 41-2316 - SCREW BONE 2.3MM 16MM NONLOCKING CROSS DRIVE TRAUMAONE GOLD BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41-2318 SUP HCPCS C1713 41-2318 - SCREW BONE 2.3MM 18MM NONLOCKING CROSS DRIVE TRAUMAONE GOLD BOTH IP/OP $295.00 $218.30 $0.00 $236.00 $132.75 $132.75 $0.00 $0.00 $0.00 $61.49 $218.95 $218.95 $0.00 $0.00 $61.48 $0.00 $174.49 $174.49 $0.00 $147.50 $233.64 $236.00 $0.00 $0.00 $46.17 $0.00 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 41-2406 SUP HCPCS C1713 41-2406 - SCREW BONE 2.3MM 6MM LOCK CROSS DRIVE TRAUMAONE LORENZ GOLD BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $153.00 $153.00 $0.00 $0.00 $0.00 $70.86 $252.35 $252.35 $0.00 $0.00 $70.86 $0.00 $201.11 $201.11 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $53.21 $0.00 $0.00 $54.13 $0.00 $0.00 $0.00 $0.00 $0.00 41-2408 SUP HCPCS C1713 41-2408 - SCREW BONE 2.3MM 8MM CROSS DRIVE LOCK TRAUMAONE LORENZ GOLD BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $210.38 $210.38 $0.00 $0.00 $0.00 $97.44 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $276.53 $276.53 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $73.16 $0.00 $0.00 $74.43 $0.00 $0.00 $0.00 $0.00 $0.00 41-2410 SUP HCPCS C1713 41-2410 - SCREW BONE 2.3MM 10MM CROSS DRIVE LOCK TRAUMAONE LORENZ GOLD BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $210.38 $210.38 $0.00 $0.00 $0.00 $97.44 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $276.53 $276.53 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $73.16 $0.00 $0.00 $74.43 $0.00 $0.00 $0.00 $0.00 $0.00 41-2412 SUP HCPCS C1713 41-2412 - SCREW BONE 2.3MM 12MM CROSS DRIVE LOCK TRAUMAONE LORENZ GOLD BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $210.38 $210.38 $0.00 $0.00 $0.00 $97.44 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $276.53 $276.53 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $73.16 $0.00 $0.00 $74.43 $0.00 $0.00 $0.00 $0.00 $0.00 41-2414 SUP HCPCS C1713 41-2414 - SCREW BONE 2.3MM 14MM CROSS DRIVE LOCK TRAUMAONE LORENZ GOLD BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $210.38 $210.38 $0.00 $0.00 $0.00 $97.44 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $276.53 $276.53 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $73.16 $0.00 $0.00 $74.43 $0.00 $0.00 $0.00 $0.00 $0.00 41-2416 SUP HCPCS C1713 41-2416 - SCREW BONE 2.3MM 16MM CROSS DRIVE LOCK TRAUMAONE LORENZ GOLD BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $210.38 $210.38 $0.00 $0.00 $0.00 $97.44 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $276.53 $276.53 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $73.16 $0.00 $0.00 $74.43 $0.00 $0.00 $0.00 $0.00 $0.00 41-2418 SUP HCPCS C1713 41-2418 - SCREW BN 2.3MM 18MM AU X-DRV LCK BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $210.38 $210.38 $0.00 $0.00 $0.00 $97.44 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $276.53 $276.53 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $73.16 $0.00 $0.00 $74.43 $0.00 $0.00 $0.00 $0.00 $0.00 4125-127-100 SUP Custom 27203010 4125-127-100 - BLADE SAW THK.05IN MEDIUM 3.937X.984IN 2 CUT SAGITTAL BOTH IP/OP $116.85 $86.47 $0.00 $93.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.73 $86.73 $0.00 $0.00 $24.35 $0.00 $0.00 $0.00 $0.00 $58.43 $92.55 $93.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41-2708 SUP HCPCS C1713 41-2708 - SCREW BONE 2.7MM 8MM EMERGENCY CROSS DRIVE TRAUMAONE MAGENTA BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 41-2710 SUP HCPCS C1713 41-2710 - SCREW BN 2.7MM 10MM MAG NLCKG X DRV BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 41-2712 SUP HCPCS C1713 41-2712 - SCREW BONE 2.7MM 12MM NONLOCKING X DRIVE LORENZ MAGENTA BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 41-2714 SUP HCPCS C1713 41-2714 - SCREW BONE 2.7MM 14MM NONLOCKING X DRIVE LORENZ MAGENTA BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 41-2716 SUP HCPCS C1713 41-2716 - SCREW BN 2.7MM 17MM LCK XDR ER BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 41-2718 SUP HCPCS C1713 41-2718 - SCREW BONE 2.7MM 18MM NONLOCKING X DRIVE LORENZ MAGENTA BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 413.590E SUP HCPCS C1713 413.590E - SCREW BONE 3MM 20MM LOCK TITANIUM STERNUM NONSTRL BOTH IP/OP $505.00 $373.70 $0.00 $404.00 $227.25 $227.25 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $252.50 $399.96 $404.00 $0.00 $0.00 $79.03 $0.00 $0.00 $80.40 $0.00 $0.00 $0.00 $0.00 $0.00 413.592E SUP HCPCS C1713 413.592E - SCREW BONE 3MM 22MM LOCK TITANIUM STERNUM NONSTRL BOTH IP/OP $505.00 $373.70 $0.00 $404.00 $227.25 $227.25 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $252.50 $399.96 $404.00 $0.00 $0.00 $79.03 $0.00 $0.00 $80.40 $0.00 $0.00 $0.00 $0.00 $0.00 413.594E SUP HCPCS C1713 413.594E - SCREW BONE 3MM 24MM LOCK TITANIUM STERNUM STERILE BOTH IP/OP $505.00 $373.70 $0.00 $404.00 $227.25 $227.25 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $252.50 $399.96 $404.00 $0.00 $0.00 $79.03 $0.00 $0.00 $80.40 $0.00 $0.00 $0.00 $0.00 $0.00 416-022A SUP Custom 27203010 KIT BINAXNOW FLU A B CLIA WVD NASO SWB CNTRL VIR TST 22 TST BOTH IP/OP $660.75 $488.96 $0.00 $528.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.38 $523.31 $528.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 41645B SUP Custom 27803010 41645B - RELOAD STPLR 3.5MM 45MM BLU STRL LF DVNC SI EWRST REG TISS BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $0.00 $0.00 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4170-223 SUP Custom 27203010 4170-223 - TUBING SUCT/IRR FLD MNG INFL STRL DISP BOTH IP/OP $72.94 $53.98 $0.00 $58.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.13 $54.13 $0.00 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $36.47 $57.77 $58.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 419.952S SUP Custom 27803010 419.952S - WASHER OVL SM ORTH TI 6.5/7.3MM CANN SCR STRL BOTH IP/OP $328.50 $243.09 $0.00 $262.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $243.81 $243.81 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $164.25 $260.17 $262.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 419.953S SUP Custom 27803010 419.953S - WASHER ORTHOPEDIC LARGE ROUND TITANIUM STERILE 6.5/7.3MM BOTH IP/OP $369.70 $273.58 $0.00 $287.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $274.39 $274.39 $0.00 $0.00 $77.05 $0.00 $0.00 $0.00 $0.00 $179.46 $284.27 $287.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4195-78 SUP HCPCS C1898 4195-78 - LEAD PACING 5FR 78CM IS-1 UNIPOLAR DEPLOYABLE LOBE FIX BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 4200-10 SUP Custom 27203010 4200-10 - DISSECTOR SURG MODELING CATHETER MARTIN UNBALLOON BOTH IP/OP "$3,987.50 " "$2,950.75" $0.00 "$3,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.52" "$2,959.52" $0.00 $0.00 $831.00 $0.00 $0.00 $0.00 $0.00 "$1,993.75" "$3,158.10" "$3,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4200-20 SUP HCPCS C1773 4200-20 - DEVICE RETRIEVAL REMOVAL ENDSCP HELIX BOTH IP/OP "$5,237.50 " "$3,875.75" $0.00 "$4,190.00" "$2,843.96" "$2,843.96" $0.00 $0.00 $0.00 "$1,091.63" "$3,887.27" "$3,887.27" $0.00 $0.00 "$1,091.50" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,618.75" "$4,148.10" "$4,190.00" $0.00 $0.00 $819.67 $0.00 $0.00 $833.81 $0.00 $0.00 $0.00 $0.00 $0.00 4200927F SUP Custom 27803010 4200927F - CAGE SPNL 0D 9MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4201127F SUP Custom 27803010 4201127F - CAGE SPNL 0D 11MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4201327F SUP Custom 27803010 4201327F - CAGE SPNL 0D 13MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4201527F SUP Custom 27803010 4201527F - CAGE SPNL 0D 15MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4201727F SUP Custom 27803010 4201727F - CAGE SPNL 0D 17MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 420404F SUP Custom 27203010 420404F - CATHETER CHLGM 4FR 40CM STRL 3W LL BVL BIL BOTH IP/OP $67.65 $50.06 $0.00 $54.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.21 $50.21 $0.00 $0.00 $14.10 $0.00 $0.00 $0.00 $0.00 $33.83 $53.58 $54.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 420406F SUP Custom 27203010 420406F - CATHETER CHLGM 6FR 40CM BIL BOTH IP/OP $67.65 $50.06 $0.00 $54.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.21 $50.21 $0.00 $0.00 $14.10 $0.00 $0.00 $0.00 $0.00 $33.83 $53.58 $54.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42-1002 SUP HCPCS C1713 42-1002 - PLATE LNG 1MM MANDIB 6 HOLE Y 2MM/2.3MM SCR BONE TRAUMAONE BOTH IP/OP "$1,402.50 " "$1,037.85" $0.00 "$1,122.00" $631.13 $631.13 $0.00 $0.00 $0.00 $292.32 "$1,040.94" "$1,040.94" $0.00 $0.00 $292.28 $0.00 $829.58 $829.58 $0.00 $701.25 "$1,110.78" "$1,122.00" $0.00 $0.00 $219.49 $0.00 $0.00 $223.28 $0.00 $0.00 $0.00 $0.00 $0.00 42-1003 SUP HCPCS C1713 42-1003 - PLATE 1MM MANDIB 7 HOLE CVD 2MM/2.3MM SCR BONE TRAUMAONE TI BOTH IP/OP "$1,402.50 " "$1,037.85" $0.00 "$1,122.00" $631.13 $631.13 $0.00 $0.00 $0.00 $292.32 "$1,040.94" "$1,040.94" $0.00 $0.00 $292.28 $0.00 $829.58 $829.58 $0.00 $701.25 "$1,110.78" "$1,122.00" $0.00 $0.00 $219.49 $0.00 $0.00 $223.28 $0.00 $0.00 $0.00 $0.00 $0.00 42-1004 SUP HCPCS C1713 42-1004 - PLATE BONE STR 1MM 4 HOLE GAP TRAUMAONE SILVER TITANIUM BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $868.50 $868.50 $0.00 $0.00 $0.00 $402.26 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 "$1,141.60" "$1,141.60" $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $302.05 $0.00 $0.00 $307.26 $0.00 $0.00 $0.00 $0.00 $0.00 42-1005 SUP HCPCS C1713 42-1005 - PLATE 1MM MANDIB 2X7 HOLE MTRX STR BONE TRAUMAONE SLVR BOTH IP/OP "$1,402.50 " "$1,037.85" $0.00 "$1,122.00" $631.13 $631.13 $0.00 $0.00 $0.00 $292.32 "$1,040.94" "$1,040.94" $0.00 $0.00 $292.28 $0.00 $829.58 $829.58 $0.00 $701.25 "$1,110.78" "$1,122.00" $0.00 $0.00 $219.49 $0.00 $0.00 $223.28 $0.00 $0.00 $0.00 $0.00 $0.00 42-1006 SUP HCPCS C1713 42-1006 - PLATE 2X7 CRVD MATRIX 1.0MM BOTH IP/OP "$1,402.50 " "$1,037.85" $0.00 "$1,122.00" $631.13 $631.13 $0.00 $0.00 $0.00 $292.32 "$1,040.94" "$1,040.94" $0.00 $0.00 $292.28 $0.00 $829.58 $829.58 $0.00 $701.25 "$1,110.78" "$1,122.00" $0.00 $0.00 $219.49 $0.00 $0.00 $223.28 $0.00 $0.00 $0.00 $0.00 $0.00 42-1007 SUP HCPCS C1713 42-1007 - PLATE BONE STR 1MM 7 HOLE TRAUMAONE LORENZ TITANIUM MANDIB BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $868.50 $868.50 $0.00 $0.00 $0.00 $402.26 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 "$1,141.60" "$1,141.60" $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $302.05 $0.00 $0.00 $307.26 $0.00 $0.00 $0.00 $0.00 $0.00 42-1016 SUP HCPCS C1713 42-1016 - PLATE 16 HOLE STR 1.0MM BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" "$1,032.75" "$1,032.75" $0.00 $0.00 $0.00 $478.34 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 "$1,357.49" "$1,357.49" $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $359.17 $0.00 $0.00 $365.36 $0.00 $0.00 $0.00 $0.00 $0.00 4241327F SUP Custom 27803010 4241327F - CAGE SPNL 4D 13MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4241521F SUP Custom 27803010 4241521F - CAGE SPNL 4D 15MM 21MM FRNTL STNDALN BOTH IP/OP "$2,021.88 " "$1,496.19" $0.00 "$1,617.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,500.64" "$1,500.64" $0.00 $0.00 $421.36 $0.00 $0.00 $0.00 $0.00 "$1,010.94" "$1,601.33" "$1,617.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4241527B SUP Custom 27803010 4241527B - CAGE SPNL 4D 15MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4241527F SUP Custom 27803010 4241527F - CAGE SPNL 4D 15MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4241727B SUP Custom 27803010 4241727B - CAGE SPNL 4D 17MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4241727F SUP Custom 27803010 4241727F - CAGE SPNL 4D 17MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 426.702S SUP HCPCS C1713 426.702S - PLATE BONE BROAD 372MM 20 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,443.10 " "$1,807.89" $0.00 "$1,897.54" "$1,067.37" "$1,067.37" $0.00 $0.00 $0.00 $509.20 "$1,813.27" "$1,813.27" $0.00 $0.00 $509.14 $0.00 "$1,445.09" "$1,445.09" $0.00 "$1,185.96" "$1,878.57" "$1,897.54" $0.00 $0.00 $360.40 $0.00 $0.00 $377.61 $0.00 $0.00 $0.00 $0.00 $0.00 426.722S SUP HCPCS C1713 426.722S - PLATE BONE BROAD 408MM 22 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,669.40 " "$1,975.36" $0.00 "$2,073.32" "$1,166.24" "$1,166.24" $0.00 $0.00 $0.00 $556.37 "$1,981.23" "$1,981.23" $0.00 $0.00 $556.30 $0.00 "$1,316.01" "$1,316.01" $0.00 "$1,295.83" "$2,052.59" "$2,073.32" $0.00 $0.00 $393.78 $0.00 $0.00 $412.59 $0.00 $0.00 $0.00 $0.00 $0.00 426.742S SUP HCPCS C1713 426.742S - PLATE BONE BROAD 443MM 24 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$2,897.13 " "$2,143.88" $0.00 "$2,250.20" "$1,265.74" "$1,265.74" $0.00 $0.00 $0.00 $603.83 "$2,150.25" "$2,150.25" $0.00 $0.00 $603.76 $0.00 "$1,428.28" "$1,428.28" $0.00 "$1,406.38" "$2,227.70" "$2,250.20" $0.00 $0.00 $427.37 $0.00 $0.00 $447.79 $0.00 $0.00 $0.00 $0.00 $0.00 426.762S SUP HCPCS C1713 426.762S - PLATE BONE BROAD 479MM 26 HOLE CVD LCP TITANIUM ORTHOPEDIC BOTH IP/OP "$3,129.08 " "$2,315.52" $0.00 "$2,430.34" "$1,367.07" "$1,367.07" $0.00 $0.00 $0.00 $652.18 "$2,322.40" "$2,322.40" $0.00 $0.00 $652.10 $0.00 "$1,542.63" "$1,542.63" $0.00 "$1,518.96" "$2,406.04" "$2,430.34" $0.00 $0.00 $461.59 $0.00 $0.00 $483.64 $0.00 $0.00 $0.00 $0.00 $0.00 42615-05 SUP Custom 27203010 42615-05 - KIT PRESSURE MONITR 3ML/HR 48IN 2 LINE TRANSDUCER MALE TO BOTH IP/OP $36.36 $26.91 $0.00 $29.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.99 $26.99 $0.00 $0.00 $7.58 $0.00 $0.00 $0.00 $0.00 $18.18 $28.80 $29.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42650-06 SUP Custom 27203010 42650-06 - KIT PRESSURE MONITR 84IN TRANSDUCER FLUSH DEVICE TUBE BOTH IP/OP $73.16 $54.14 $0.00 $58.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.30 $54.30 $0.00 $0.00 $15.25 $0.00 $0.00 $0.00 $0.00 $36.58 $57.94 $58.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 427022S SUP HCPCS C1713 427022S - PLATE BN 292MM STRL 22 HL CMPR LCK BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 427069S SUP HCPCS C1713 427069S - PLATE 3MM 115MM SS 9 HOLE 1/3 TBLR SM FRAG IMPL AXSOS BONE BOTH IP/OP $236.80 $175.23 $0.00 $189.20 $106.43 $106.43 $0.00 $0.00 $0.00 $49.36 $175.75 $175.75 $0.00 $0.00 $49.35 $0.00 $140.07 $140.07 $0.00 $118.25 $187.31 $189.20 $0.00 $0.00 $37.01 $0.00 $0.00 $37.65 $0.00 $0.00 $0.00 $0.00 $0.00 4281127B SUP Custom 27803010 4281127B - CAGE SPNL 8D 11MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4281127F SUP Custom 27803010 4281127F - CAGE SPNL 8D 11MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4281327B SUP Custom 27803010 4281327B - CAGE SPNL 8D 13MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4281327F SUP Custom 27803010 4281327F - CAGE SPNL 8D 13MM 27MM WHL BD STNDALN BOTH IP/OP "$4,245.88 " "$3,141.95" $0.00 "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,151.29" "$3,151.29" $0.00 $0.00 $884.84 $0.00 $0.00 $0.00 $0.00 "$2,122.94" "$3,362.74" "$3,396.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4296-78 SUP HCPCS C1900 4296-78 - LEAD PACING 2 CURVE 5.3FR 78CM BIPOL 2 ELECTRODE 2 FIX IS-1 BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43-1001 SUP HCPCS C1713 43-1001 - PLATE BONE SMALL 1MM ANGLED TRAUMAONE GOLD TITANIUM MANDIB 2 BOTH IP/OP "$3,127.50 " "$2,314.35" $0.00 "$2,502.00" "$1,407.38" "$1,407.38" $0.00 $0.00 $0.00 $651.85 "$2,321.23" "$2,321.23" $0.00 $0.00 $651.77 $0.00 "$1,541.86" "$1,541.86" $0.00 "$1,563.75" "$2,476.98" "$2,502.00" $0.00 $0.00 $489.45 $0.00 $0.00 $497.90 $0.00 $0.00 $0.00 $0.00 $0.00 43-1004 SUP HCPCS C1713 43-1004 - PLATE BONE STR 4 HOLE GAP CRANIOMAXILLOFACIAL BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $868.50 $868.50 $0.00 $0.00 $0.00 $402.26 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 "$1,141.60" "$1,141.60" $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $302.05 $0.00 $0.00 $307.26 $0.00 $0.00 $0.00 $0.00 $0.00 43-1005 SUP HCPCS C1713 43-1005 - PLATE BONE 1MM 4 HOLE STR TRAUMAONE GOLD TITANIUM MANDIB BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $868.50 $868.50 $0.00 $0.00 $0.00 $402.26 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 "$1,141.60" "$1,141.60" $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $302.05 $0.00 $0.00 $307.26 $0.00 $0.00 $0.00 $0.00 $0.00 43-1007 SUP HCPCS C1713 43-1007 - PLATE BONE 1.6MM 7 HOLE STR BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" "$1,032.75" "$1,032.75" $0.00 $0.00 $0.00 $478.34 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 "$1,357.49" "$1,357.49" $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $359.17 $0.00 $0.00 $365.36 $0.00 $0.00 $0.00 $0.00 $0.00 43-1008 SUP HCPCS C1713 43-1008 - PLATE BONE THK1.6MM CVD 7 HOLE LORENZ GOLD MANDIB BOTH IP/OP "$3,127.50 " "$2,314.35" $0.00 "$2,502.00" "$1,407.38" "$1,407.38" $0.00 $0.00 $0.00 $651.85 "$2,321.23" "$2,321.23" $0.00 $0.00 $651.77 $0.00 "$1,541.86" "$1,541.86" $0.00 "$1,563.75" "$2,476.98" "$2,502.00" $0.00 $0.00 $489.45 $0.00 $0.00 $497.90 $0.00 $0.00 $0.00 $0.00 $0.00 43-1016 SUP HCPCS C1713 43-1016 - PLATE BONE 1.6MM 16 HOLE STR TRAUMAONE GOLD MANDIB BOTH IP/OP "$3,552.50 " "$2,628.85" $0.00 "$2,842.00" "$1,598.63" "$1,598.63" $0.00 $0.00 $0.00 $740.43 "$2,636.67" "$2,636.67" $0.00 $0.00 $740.34 $0.00 "$1,751.38" "$1,751.38" $0.00 "$1,776.25" "$2,813.58" "$2,842.00" $0.00 $0.00 $555.97 $0.00 $0.00 $565.56 $0.00 $0.00 $0.00 $0.00 $0.00 43-1280 SUP Custom 27203010 43-1280 - KIT RSN REPR 75 PPM CRNPLST CMPLT SET TY 2 PWDR CRNL BOTH IP/OP "$4,296.40 " "$3,179.34" $0.00 "$3,437.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,188.79" "$3,188.79" $0.00 $0.00 $895.37 $0.00 $0.00 $0.00 $0.00 "$2,148.20" "$3,402.75" "$3,437.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 43154-060 SUP Custom 27203010 43154-060 - TUBE ENDOTRAC 6MM NSL/ORL TRK REINF CUF MRPH SIL SS BOTH IP/OP $312.93 $231.57 $0.00 $250.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.47 $247.84 $250.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4324A SUP Custom 27203010 4324A - TRAY PROCEDURE 20GA 3.5IN MYELOGRAM PH WATER SOLUBLE CLEAR BOTH IP/OP $24.70 $18.28 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.33 $18.33 $0.00 $0.00 $5.15 $0.00 $0.00 $0.00 $0.00 $12.54 $19.86 $20.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 433-01 SUP Custom 27203010 433-01 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,064.63 " $787.83 $0.00 $851.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $790.16 $790.16 $0.00 $0.00 $221.87 $0.00 $0.00 $0.00 $0.00 $532.31 $843.19 $851.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 435002S SUP HCPCS C1713 435002S - PLATE 34MM SS 3.5/4MM SCR 2 HOLE BONE LEFT PERIART TIB STRL BOTH IP/OP "$1,113.75 " $824.18 $0.00 $891.00 $501.19 $501.19 $0.00 $0.00 $0.00 $232.13 $826.63 $826.63 $0.00 $0.00 $232.11 $0.00 $658.78 $658.78 $0.00 $556.88 $882.09 $891.00 $0.00 $0.00 $174.30 $0.00 $0.00 $177.31 $0.00 $0.00 $0.00 $0.00 $0.00 435004S SUP HCPCS C1713 435004S - PLATE 60MM SS 3.5/4MM SCR 4 HOLE BONE LEFT PERIART TIB STRL BOTH IP/OP "$1,113.75 " $824.18 $0.00 $891.00 $501.19 $501.19 $0.00 $0.00 $0.00 $232.13 $826.63 $826.63 $0.00 $0.00 $232.11 $0.00 $658.78 $658.78 $0.00 $556.88 $882.09 $891.00 $0.00 $0.00 $174.30 $0.00 $0.00 $177.31 $0.00 $0.00 $0.00 $0.00 $0.00 435006S SUP HCPCS C1713 435006S - PLATE 86MM SS 3.5/4MM SCR 6 HOLE BONE LEFT PERIART TIB STRL BOTH IP/OP "$1,113.75 " $824.18 $0.00 $891.00 $501.19 $501.19 $0.00 $0.00 $0.00 $232.13 $826.63 $826.63 $0.00 $0.00 $232.11 $0.00 $658.78 $658.78 $0.00 $556.88 $882.09 $891.00 $0.00 $0.00 $174.30 $0.00 $0.00 $177.31 $0.00 $0.00 $0.00 $0.00 $0.00 435008S SUP HCPCS C1713 435008S - PLATE 112MM SS 3.5/4MM SCR 8 HOLE BONE LEFT PERIART TIB STRL BOTH IP/OP "$1,113.75 " $824.18 $0.00 $891.00 $501.19 $501.19 $0.00 $0.00 $0.00 $232.13 $826.63 $826.63 $0.00 $0.00 $232.11 $0.00 $658.78 $658.78 $0.00 $556.88 $882.09 $891.00 $0.00 $0.00 $174.30 $0.00 $0.00 $177.31 $0.00 $0.00 $0.00 $0.00 $0.00 435010S SUP HCPCS C1713 435010S - PLATE 138MM SS 3.5/4MM SCR 10 HOLE BONE LEFT PERIART TIB BOTH IP/OP "$1,149.50 " $850.63 $0.00 $919.60 $517.28 $517.28 $0.00 $0.00 $0.00 $239.58 $853.16 $853.16 $0.00 $0.00 $239.56 $0.00 $679.93 $679.93 $0.00 $574.75 $910.40 $919.60 $0.00 $0.00 $179.90 $0.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 435012S SUP HCPCS C1713 435012S - PLATE 164MM SS 3.5/4MM SCR 12 HOLE BONE LEFT PERIART TIB BOTH IP/OP "$1,149.50 " $850.63 $0.00 $919.60 $517.28 $517.28 $0.00 $0.00 $0.00 $239.58 $853.16 $853.16 $0.00 $0.00 $239.56 $0.00 $679.93 $679.93 $0.00 $574.75 $910.40 $919.60 $0.00 $0.00 $179.90 $0.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 435014S SUP HCPCS C1713 435014S - PLATE 190MM SS 3.5/4MM SCR 14 HOLE BONE LEFT PERIART TIB BOTH IP/OP "$1,193.50 " $883.19 $0.00 $954.80 $537.08 $537.08 $0.00 $0.00 $0.00 $248.76 $885.82 $885.82 $0.00 $0.00 $248.73 $0.00 $705.96 $705.96 $0.00 $596.75 $945.25 $954.80 $0.00 $0.00 $186.78 $0.00 $0.00 $190.01 $0.00 $0.00 $0.00 $0.00 $0.00 435022S SUP HCPCS C1713 435022S - PLATE 34MM SS 3.5/4MM SCR 2 HOLE BONE RIGHT PERIART TIB STRL BOTH IP/OP "$1,113.75 " $824.18 $0.00 $891.00 $501.19 $501.19 $0.00 $0.00 $0.00 $232.13 $826.63 $826.63 $0.00 $0.00 $232.11 $0.00 $658.78 $658.78 $0.00 $556.88 $882.09 $891.00 $0.00 $0.00 $174.30 $0.00 $0.00 $177.31 $0.00 $0.00 $0.00 $0.00 $0.00 435024S SUP HCPCS C1713 435024S - PLATE 60MM SS 3.5/4MM SCR 4 HOLE BONE RIGHT PERIART TIB STRL BOTH IP/OP "$1,113.75 " $824.18 $0.00 $891.00 $501.19 $501.19 $0.00 $0.00 $0.00 $232.13 $826.63 $826.63 $0.00 $0.00 $232.11 $0.00 $658.78 $658.78 $0.00 $556.88 $882.09 $891.00 $0.00 $0.00 $174.30 $0.00 $0.00 $177.31 $0.00 $0.00 $0.00 $0.00 $0.00 435026S SUP HCPCS C1713 435026S - PLATE 86MM SS 3.5/4MM SCR 6 HOLE BONE RIGHT PERIART TIB STRL BOTH IP/OP "$1,113.75 " $824.18 $0.00 $891.00 $501.19 $501.19 $0.00 $0.00 $0.00 $232.13 $826.63 $826.63 $0.00 $0.00 $232.11 $0.00 $658.78 $658.78 $0.00 $556.88 $882.09 $891.00 $0.00 $0.00 $174.30 $0.00 $0.00 $177.31 $0.00 $0.00 $0.00 $0.00 $0.00 435028S SUP HCPCS C1713 435028S - PLATE 112MM SS 3.5/4MM SCR 8 HOLE BONE RIGHT PERIART TIB BOTH IP/OP "$1,113.75 " $824.18 $0.00 $891.00 $501.19 $501.19 $0.00 $0.00 $0.00 $232.13 $826.63 $826.63 $0.00 $0.00 $232.11 $0.00 $658.78 $658.78 $0.00 $556.88 $882.09 $891.00 $0.00 $0.00 $174.30 $0.00 $0.00 $177.31 $0.00 $0.00 $0.00 $0.00 $0.00 435030S SUP HCPCS C1713 435030S - PLATE 138MM SS 3.5/4MM SCR 10 HOLE BONE RIGHT PERIART TIB BOTH IP/OP "$1,149.50 " $850.63 $0.00 $919.60 $517.28 $517.28 $0.00 $0.00 $0.00 $239.58 $853.16 $853.16 $0.00 $0.00 $239.56 $0.00 $679.93 $679.93 $0.00 $574.75 $910.40 $919.60 $0.00 $0.00 $179.90 $0.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 435032S SUP HCPCS C1713 435032S - PLATE 164MM SS 3.5/4MM SCR 12 HOLE BONE RIGHT PERIART TIB BOTH IP/OP "$1,149.50 " $850.63 $0.00 $919.60 $517.28 $517.28 $0.00 $0.00 $0.00 $239.58 $853.16 $853.16 $0.00 $0.00 $239.56 $0.00 $679.93 $679.93 $0.00 $574.75 $910.40 $919.60 $0.00 $0.00 $179.90 $0.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 435034S SUP HCPCS C1713 435034S - PLATE 190MM SS 3.5/4MM SCR 14 HOLE BONE RIGHT PERIART TIB BOTH IP/OP "$1,193.50 " $883.19 $0.00 $954.80 $537.08 $537.08 $0.00 $0.00 $0.00 $248.76 $885.82 $885.82 $0.00 $0.00 $248.73 $0.00 $705.96 $705.96 $0.00 $596.75 $945.25 $954.80 $0.00 $0.00 $186.78 $0.00 $0.00 $190.01 $0.00 $0.00 $0.00 $0.00 $0.00 435506S SUP HCPCS C1713 435506S - PLATE SS 6 HL SHFT BONE LEFT PERIART FEM STRL BOTH IP/OP "$1,080.75 " $799.76 $0.00 $864.60 $486.34 $486.34 $0.00 $0.00 $0.00 $225.26 $802.13 $802.13 $0.00 $0.00 $225.23 $0.00 $639.26 $639.26 $0.00 $540.38 $855.95 $864.60 $0.00 $0.00 $169.14 $0.00 $0.00 $172.06 $0.00 $0.00 $0.00 $0.00 $0.00 435508S SUP HCPCS C1713 435508S - PLATE 193MM SS 4.5/6.5MM SCR 8 HOLE BONE LEFT PERIART FEM BOTH IP/OP "$1,080.75 " $799.76 $0.00 $864.60 $486.34 $486.34 $0.00 $0.00 $0.00 $225.26 $802.13 $802.13 $0.00 $0.00 $225.23 $0.00 $639.26 $639.26 $0.00 $540.38 $855.95 $864.60 $0.00 $0.00 $169.14 $0.00 $0.00 $172.06 $0.00 $0.00 $0.00 $0.00 $0.00 435526S SUP HCPCS C1713 435526S - PLATE 157MM SS 4.5/6.5MM SCR 6 HOLE BONE RIGHT PERIART FEM BOTH IP/OP "$1,080.75 " $799.76 $0.00 $864.60 $486.34 $486.34 $0.00 $0.00 $0.00 $225.26 $802.13 $802.13 $0.00 $0.00 $225.23 $0.00 $639.26 $639.26 $0.00 $540.38 $855.95 $864.60 $0.00 $0.00 $169.14 $0.00 $0.00 $172.06 $0.00 $0.00 $0.00 $0.00 $0.00 435528S SUP HCPCS C1713 435528S - PLATE 193MM SS 4.5/6.5MM SCR 8 HOLE BONE RIGHT PERIART FEM BOTH IP/OP "$1,080.75 " $799.76 $0.00 $864.60 $486.34 $486.34 $0.00 $0.00 $0.00 $225.26 $802.13 $802.13 $0.00 $0.00 $225.23 $0.00 $639.26 $639.26 $0.00 $540.38 $855.95 $864.60 $0.00 $0.00 $169.14 $0.00 $0.00 $172.06 $0.00 $0.00 $0.00 $0.00 $0.00 435604S SUP HCPCS C1713 435604S - PLATE 78MM SS 4.5/6.5MM SCR 4 HOLE BONE LEFT PERIART TIB BOTH IP/OP "$1,127.50 " $834.35 $0.00 $902.00 $507.38 $507.38 $0.00 $0.00 $0.00 $235.00 $836.83 $836.83 $0.00 $0.00 $234.97 $0.00 $666.92 $666.92 $0.00 $563.75 $892.98 $902.00 $0.00 $0.00 $176.45 $0.00 $0.00 $179.50 $0.00 $0.00 $0.00 $0.00 $0.00 435606S SUP HCPCS C1713 435606S - PLATE 114MM SS 4.5/6.5MM SCR 6 HOLE BONE LEFT PERIART TIB BOTH IP/OP "$1,056.00 " $781.44 $0.00 $902.00 $507.38 $507.38 $0.00 $0.00 $0.00 $220.10 $783.76 $783.76 $0.00 $0.00 $220.07 $0.00 $624.62 $624.62 $0.00 $563.75 $892.98 $902.00 $0.00 $0.00 $176.45 $0.00 $0.00 $179.50 $0.00 $0.00 $0.00 $0.00 $0.00 435608S SUP HCPCS C1713 435608S - PLATE 150MM SS 4.5/6.5MM SCR 8 HOLE BONE LEFT PERIART TIB BOTH IP/OP "$1,171.50 " $866.91 $0.00 $937.20 $527.18 $527.18 $0.00 $0.00 $0.00 $244.17 $869.49 $869.49 $0.00 $0.00 $244.14 $0.00 $692.94 $692.94 $0.00 $585.75 $927.83 $937.20 $0.00 $0.00 $183.34 $0.00 $0.00 $186.50 $0.00 $0.00 $0.00 $0.00 $0.00 435624S SUP HCPCS C1713 435624S - PLATE 78MM SS 4.5/6.5MM SCR 4 HOLE BONE RIGHT PERIART TIB BOTH IP/OP "$1,127.50 " $834.35 $0.00 $902.00 $507.38 $507.38 $0.00 $0.00 $0.00 $235.00 $836.83 $836.83 $0.00 $0.00 $234.97 $0.00 $666.92 $666.92 $0.00 $563.75 $892.98 $902.00 $0.00 $0.00 $176.45 $0.00 $0.00 $179.50 $0.00 $0.00 $0.00 $0.00 $0.00 435626S SUP HCPCS C1713 435626S - PLATE 114MM SS 4.5/6.5MM SCR 6 HOLE BONE RIGHT PERIART TIB BOTH IP/OP "$1,127.50 " $834.35 $0.00 $902.00 $507.38 $507.38 $0.00 $0.00 $0.00 $235.00 $836.83 $836.83 $0.00 $0.00 $234.97 $0.00 $666.92 $666.92 $0.00 $563.75 $892.98 $902.00 $0.00 $0.00 $176.45 $0.00 $0.00 $179.50 $0.00 $0.00 $0.00 $0.00 $0.00 435628S SUP HCPCS C1713 435628S - PLATE 150MM SS 4.5/6.5MM SCR 8 HOLE BONE RIGHT PERIART TIB BOTH IP/OP "$1,171.50 " $866.91 $0.00 $937.20 $527.18 $527.18 $0.00 $0.00 $0.00 $244.17 $869.49 $869.49 $0.00 $0.00 $244.14 $0.00 $692.94 $692.94 $0.00 $585.75 $927.83 $937.20 $0.00 $0.00 $183.34 $0.00 $0.00 $186.50 $0.00 $0.00 $0.00 $0.00 $0.00 436.504S SUP HCPCS C1713 436.504S - PLATE BONE 4 LCP TITANIUM OLECRANON STERILE 3.5MM SCREWS BOTH IP/OP "$1,865.35 " "$1,380.36" $0.00 "$1,448.82" $814.96 $814.96 $0.00 $0.00 $0.00 $388.79 "$1,384.46" "$1,384.46" $0.00 $0.00 $388.74 $0.00 "$1,103.35" "$1,103.35" $0.00 $905.51 "$1,434.34" "$1,448.82" $0.00 $0.00 $275.17 $0.00 $0.00 $288.32 $0.00 $0.00 $0.00 $0.00 $0.00 436.505S SUP HCPCS C1713 436.505S - PLATE BONE 112MM 4 HOLE LCP TITANIUM LEFT OLECRANON STERILE BOTH IP/OP "$1,865.35 " "$1,380.36" $0.00 "$1,448.82" $814.96 $814.96 $0.00 $0.00 $0.00 $388.79 "$1,384.46" "$1,384.46" $0.00 $0.00 $388.74 $0.00 "$1,103.35" "$1,103.35" $0.00 $905.51 "$1,434.34" "$1,448.82" $0.00 $0.00 $275.17 $0.00 $0.00 $288.32 $0.00 $0.00 $0.00 $0.00 $0.00 436.508S SUP HCPCS C1713 436.508S - PLATE BONE 164MM 8 HOLE LCP TITANIUM RIGHT OLECRANON STERILE BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 436.509S SUP HCPCS C1713 436.509S - PLATE BONE 164MM 8 HOLE LCP TITANIUM LEFT OLECRANON STERILE BOTH IP/OP "$2,015.78 " "$1,491.68" $0.00 "$1,565.64" $880.67 $880.67 $0.00 $0.00 $0.00 $420.14 "$1,496.11" "$1,496.11" $0.00 $0.00 $420.09 $0.00 "$1,192.33" "$1,192.33" $0.00 $978.53 "$1,549.98" "$1,565.64" $0.00 $0.00 $297.36 $0.00 $0.00 $311.56 $0.00 $0.00 $0.00 $0.00 $0.00 436013B SUP HCPCS C1713 436013B - CENTERPIECE 436013B 13MM B-SIZE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436013C SUP HCPCS C1713 436013C - CENTERPIECE 436013C 13MM C-SIZE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436013D SUP HCPCS C1713 436013D - CENTERPIECE 436013D 13MM D-SIZE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436013E SUP HCPCS C1713 436013E - CENTERPIECE 436013E 13MM E-SIZE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436020A SUP HCPCS C1713 436020A - CENTERPIECE 436020A 20MM A-SIZE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436020B SUP HCPCS C1713 436020B - CENTERPIECE 436020B 20MM B-SIZE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436020C SUP HCPCS C1713 436020C - CENTERPIECE 436020C 20MM C-SIZE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436020D SUP HCPCS C1713 436020D - CENTERPIECE 436020D 20MM D-SIZE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436020E SUP HCPCS C1713 436020E - CENTERPIECE 436020E 20MM E-SIZE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436025A SUP HCPCS C1713 436025A - CENTERPIECE 436025A 25MM A-SIZE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436025B SUP HCPCS C1713 436025B - CENTERPIECE 436025B 25MM B-SIZE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436025C SUP HCPCS C1713 436025C - CENTERPIECE 436025C 25MM C-SIZE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436025D SUP HCPCS C1713 436025D - CENTERPIECE 436025D 25MM D-SIZE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436025E SUP HCPCS C1713 436025E - CENTERPIECE 436025E 25MM E-SIZE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436113A SUP HCPCS C1713 436113A - CAGE 436113A 13MM A-SIZE STERILE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436113B SUP HCPCS C1713 436113B - CAGE 436113B 13MM B-SIZE STERILE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436113C SUP HCPCS C1713 436113C - CAGE 436113C 13MM C-SIZE STERILE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436113D SUP HCPCS C1713 436113D - CAGE 436113D 13MM D-SIZE STERILE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436113E SUP HCPCS C1713 436113E - CAGE 436113E 13MM E-SIZE STERILE BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436120A SUP HCPCS C1713 436120A - CAGE 436120A 20MM A-SIZE STERILE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436120B SUP HCPCS C1713 436120B - CAGE 436120B 20MM B-SIZE STERILE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436120C SUP HCPCS C1713 436120C - CAGE 436120C 20MM C-SIZE STERILE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436120D SUP HCPCS C1713 436120D - CAGE 436120D 20MM D-SIZE STERILE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436120E SUP HCPCS C1713 436120E - CAGE 436120E 20MM E-SIZE STERILE BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 436125A SUP HCPCS C1713 436125A - CAGE 436125A 25MM A-SIZE STERILE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436125B SUP HCPCS C1713 436125B - CAGE 436125B 25MM B-SIZE STERILE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436125C SUP HCPCS C1713 436125C - CAGE 436125C 25MM C-SIZE STERILE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436125D SUP HCPCS C1713 436125D - CAGE 436125D 25MM D-SIZE STERILE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436125E SUP HCPCS C1713 436125E - CAGE 436125E 25MM E-SIZE STERILE BOTH IP/OP "$14,500.00 " "$10,730.00" $0.00 "$11,600.00" "$6,525.00" "$6,525.00" $0.00 $0.00 $0.00 "$3,022.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,021.80" $0.00 "$7,148.50" "$7,148.50" $0.00 "$7,250.00" "$11,484.00" "$11,600.00" $0.00 $0.00 "$2,269.25" $0.00 $0.00 "$2,308.40" $0.00 $0.00 $0.00 $0.00 $0.00 436213A SUP HCPCS C1713 436213A - CENTERPIECE 436213A 13MM A-SIZE CERVICAL BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436213B SUP HCPCS C1713 436213B - CENTERPIECE 436213B 13MM B-SIZE CERVICAL BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436213C SUP HCPCS C1713 436213C - CENTERPIECE 436213C 13MM C-SIZE CERVICAL BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436213D SUP HCPCS C1713 436213D - CENTERPIECE 436213D 13MM D-SIZE CERVICAL BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436213E SUP HCPCS C1713 436213E - CENTERPIECE 436213E 13MM E-SIZE CERVICAL BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436313A SUP HCPCS C1713 436313A - CENTERPIECE 436313A 13MM A-SIZE CRV STER BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436313B SUP HCPCS C1713 436313B - CENTERPIECE 436313B 13MM B-SIZE CRV STER BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436313C SUP HCPCS C1713 436313C - CENTERPIECE 436313C 13MM C-SIZE CRV STER BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436313D SUP HCPCS C1713 436313D - CENTERPIECE 436313D 13MM D-SIZE CRV STER BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 436313E SUP HCPCS C1713 436313E - CENTERPIECE 436313E 13MM E-SIZE CRV STER BOTH IP/OP "$11,500.00 " "$8,510.00" $0.00 "$9,200.00" "$5,175.00" "$5,175.00" $0.00 $0.00 $0.00 "$2,396.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,396.60" $0.00 "$5,669.50" "$5,669.50" $0.00 "$5,750.00" "$9,108.00" "$9,200.00" $0.00 $0.00 "$1,799.75" $0.00 $0.00 "$1,830.80" $0.00 $0.00 $0.00 $0.00 $0.00 437.043S SUP HCPCS C1713 437.043S - PLATE BONE 90D 30MM 4 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.044S SUP HCPCS C1713 437.044S - PLATE BONE 90D 40MM 4 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.053S SUP HCPCS C1713 437.053S - PLATE BONE 90D 30MM 5 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.054S SUP HCPCS C1713 437.054S - PLATE BONE 90D 40MM 5 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.063S SUP HCPCS C1713 437.063S - PLATE BONE 90D 30MM 6 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.064S SUP HCPCS C1713 437.064S - PLATE BONE 90D 40MM 6 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.083S SUP HCPCS C1713 437.083S - PLATE BONE 90D 30MM 8 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.084S SUP HCPCS C1713 437.084S - PLATE BONE 90D 40MM 8 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.085S SUP HCPCS C1713 437.085S - PLATE BONE 90D 50MM 8 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.086S SUP HCPCS C1713 437.086S - PLATE BONE 90D 60MM 8 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$1,629.75 " "$1,206.02" $0.00 "$1,303.80" $733.39 $733.39 $0.00 $0.00 $0.00 $339.68 "$1,209.60" "$1,209.60" $0.00 $0.00 $339.64 $0.00 $964.00 $964.00 $0.00 $814.88 "$1,290.76" "$1,303.80" $0.00 $0.00 $255.06 $0.00 $0.00 $259.46 $0.00 $0.00 $0.00 $0.00 $0.00 437.103S SUP HCPCS C1713 437.103S - PLATE BONE 90D 30MM 10 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,126.63 " "$1,573.71" $0.00 "$1,701.30" $956.98 $956.98 $0.00 $0.00 $0.00 $443.24 "$1,578.38" "$1,578.38" $0.00 $0.00 $443.19 $0.00 "$1,257.90" "$1,257.90" $0.00 "$1,063.31" "$1,684.29" "$1,701.30" $0.00 $0.00 $332.82 $0.00 $0.00 $338.56 $0.00 $0.00 $0.00 $0.00 $0.00 437.104S SUP HCPCS C1713 437.104S - PLATE BONE 90D 40MM 10 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,126.63 " "$1,573.71" $0.00 "$1,701.30" $956.98 $956.98 $0.00 $0.00 $0.00 $443.24 "$1,578.38" "$1,578.38" $0.00 $0.00 $443.19 $0.00 "$1,257.90" "$1,257.90" $0.00 "$1,063.31" "$1,684.29" "$1,701.30" $0.00 $0.00 $332.82 $0.00 $0.00 $338.56 $0.00 $0.00 $0.00 $0.00 $0.00 437.105S SUP HCPCS C1713 437.105S - PLATE BONE 90D 50MM 10 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,126.63 " "$1,573.71" $0.00 "$1,701.30" $956.98 $956.98 $0.00 $0.00 $0.00 $443.24 "$1,578.38" "$1,578.38" $0.00 $0.00 $443.19 $0.00 "$1,257.90" "$1,257.90" $0.00 "$1,063.31" "$1,684.29" "$1,701.30" $0.00 $0.00 $332.82 $0.00 $0.00 $338.56 $0.00 $0.00 $0.00 $0.00 $0.00 437.106S SUP HCPCS C1713 437.106S - PLATE BONE 90D 60MM 10 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,126.63 " "$1,573.71" $0.00 "$1,701.30" $956.98 $956.98 $0.00 $0.00 $0.00 $443.24 "$1,578.38" "$1,578.38" $0.00 $0.00 $443.19 $0.00 "$1,257.90" "$1,257.90" $0.00 "$1,063.31" "$1,684.29" "$1,701.30" $0.00 $0.00 $332.82 $0.00 $0.00 $338.56 $0.00 $0.00 $0.00 $0.00 $0.00 437.123S SUP HCPCS C1713 437.123S - PLATE BONE 90D 30MM 12 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,126.63 " "$1,573.71" $0.00 "$1,701.30" $956.98 $956.98 $0.00 $0.00 $0.00 $443.24 "$1,578.38" "$1,578.38" $0.00 $0.00 $443.19 $0.00 "$1,257.90" "$1,257.90" $0.00 "$1,063.31" "$1,684.29" "$1,701.30" $0.00 $0.00 $332.82 $0.00 $0.00 $338.56 $0.00 $0.00 $0.00 $0.00 $0.00 437.124S SUP HCPCS C1713 437.124S - PLATE BONE 90D 40MM 12 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,126.63 " "$1,573.71" $0.00 "$1,701.30" $956.98 $956.98 $0.00 $0.00 $0.00 $443.24 "$1,578.38" "$1,578.38" $0.00 $0.00 $443.19 $0.00 "$1,257.90" "$1,257.90" $0.00 "$1,063.31" "$1,684.29" "$1,701.30" $0.00 $0.00 $332.82 $0.00 $0.00 $338.56 $0.00 $0.00 $0.00 $0.00 $0.00 437.125S SUP HCPCS C1713 437.125S - PLATE BONE 90D 50MM 12 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,126.63 " "$1,573.71" $0.00 "$1,701.30" $956.98 $956.98 $0.00 $0.00 $0.00 $443.24 "$1,578.38" "$1,578.38" $0.00 $0.00 $443.19 $0.00 "$1,257.90" "$1,257.90" $0.00 "$1,063.31" "$1,684.29" "$1,701.30" $0.00 $0.00 $332.82 $0.00 $0.00 $338.56 $0.00 $0.00 $0.00 $0.00 $0.00 437.126S SUP HCPCS C1713 437.126S - PLATE BONE 90D 60MM 12 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,126.63 " "$1,573.71" $0.00 "$1,701.30" $956.98 $956.98 $0.00 $0.00 $0.00 $443.24 "$1,578.38" "$1,578.38" $0.00 $0.00 $443.19 $0.00 "$1,257.90" "$1,257.90" $0.00 "$1,063.31" "$1,684.29" "$1,701.30" $0.00 $0.00 $332.82 $0.00 $0.00 $338.56 $0.00 $0.00 $0.00 $0.00 $0.00 437.143S SUP HCPCS C1713 437.143S - PLATE BONE 90D 30MM 14 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,705.65 " "$2,002.18" $0.00 "$2,164.52" "$1,217.54" "$1,217.54" $0.00 $0.00 $0.00 $563.93 "$2,008.13" "$2,008.13" $0.00 $0.00 $563.86 $0.00 "$1,333.89" "$1,333.89" $0.00 "$1,352.83" "$2,142.87" "$2,164.52" $0.00 $0.00 $423.43 $0.00 $0.00 $430.74 $0.00 $0.00 $0.00 $0.00 $0.00 437.144S SUP HCPCS C1713 437.144S - PLATE BONE 90D 40MM 14 HOLE CANN LC ANGLED TITANIUM BOTH IP/OP "$2,705.65 " "$2,002.18" $0.00 "$2,164.52" "$1,217.54" "$1,217.54" $0.00 $0.00 $0.00 $563.93 "$2,008.13" "$2,008.13" $0.00 $0.00 $563.86 $0.00 "$1,333.89" "$1,333.89" $0.00 "$1,352.83" "$2,142.87" "$2,164.52" $0.00 $0.00 $423.43 $0.00 $0.00 $430.74 $0.00 $0.00 $0.00 $0.00 $0.00 437.146S SUP HCPCS C1713 437.146S - PLATE BONE 90D 256MM 60X11.7MM 14 HOLE CANN LC ANGLED BLADE BOTH IP/OP "$2,705.65 " "$2,002.18" $0.00 "$2,164.52" "$1,217.54" "$1,217.54" $0.00 $0.00 $0.00 $563.93 "$2,008.13" "$2,008.13" $0.00 $0.00 $563.86 $0.00 "$1,333.89" "$1,333.89" $0.00 "$1,352.83" "$2,142.87" "$2,164.52" $0.00 $0.00 $423.43 $0.00 $0.00 $430.74 $0.00 $0.00 $0.00 $0.00 $0.00 4396-78 SUP HCPCS C1900 4396-78 - LEAD PACING STR 4FR 78CM 2 ELECTRODE TINES IS-1 ATTAIN BOTH IP/OP "$3,562.50 " "$2,636.25" $0.00 "$2,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $742.51 "$2,644.09" "$2,644.09" $0.00 $0.00 $742.43 $0.00 "$1,756.31" "$1,756.31" $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4396-88 SUP HCPCS C1900 4396-88 - LEAD PACING STR 4FR 88CM 2 ELECTRODE TINES IS-1 ATTAIN BOTH IP/OP "$3,562.50 " "$2,636.25" $0.00 "$2,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $742.51 "$2,644.09" "$2,644.09" $0.00 $0.00 $742.43 $0.00 "$1,756.31" "$1,756.31" $0.00 "$1,781.25" "$2,821.50" "$2,850.00" $0.00 $0.00 $557.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.072S SUP HCPCS C1713 441.072S - PLATE BONE 12MM 4 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,513.93 " "$1,120.31" $0.00 "$1,175.86" $661.42 $661.42 $0.00 $0.00 $0.00 $315.54 "$1,123.64" "$1,123.64" $0.00 $0.00 $315.50 $0.00 $895.49 $895.49 $0.00 $734.91 "$1,164.11" "$1,175.86" $0.00 $0.00 $223.33 $0.00 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.073S SUP HCPCS C1713 441.073S - PLATE BONE 12MM 4 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,513.93 " "$1,120.31" $0.00 "$1,175.86" $661.42 $661.42 $0.00 $0.00 $0.00 $315.54 "$1,123.64" "$1,123.64" $0.00 $0.00 $315.50 $0.00 $895.49 $895.49 $0.00 $734.91 "$1,164.11" "$1,175.86" $0.00 $0.00 $223.33 $0.00 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.074S SUP HCPCS C1713 441.074S - PLATE BN 15MM 70MM STRL LCP CMBN 4 HL HK PRECONTOUR RND SHFT BOTH IP/OP "$1,513.93 " "$1,120.31" $0.00 "$1,175.86" $661.42 $661.42 $0.00 $0.00 $0.00 $315.54 "$1,123.64" "$1,123.64" $0.00 $0.00 $315.50 $0.00 $895.49 $895.49 $0.00 $734.91 "$1,164.11" "$1,175.86" $0.00 $0.00 $223.33 $0.00 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.075S SUP HCPCS C1713 441.075S - PLATE BONE 15MM 4 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,513.93 " "$1,120.31" $0.00 "$1,175.86" $661.42 $661.42 $0.00 $0.00 $0.00 $315.54 "$1,123.64" "$1,123.64" $0.00 $0.00 $315.50 $0.00 $895.49 $895.49 $0.00 $734.91 "$1,164.11" "$1,175.86" $0.00 $0.00 $223.33 $0.00 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.076S SUP HCPCS C1713 441.076S - PLATE BONE 18MM 4 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,513.93 " "$1,120.31" $0.00 "$1,175.86" $661.42 $661.42 $0.00 $0.00 $0.00 $315.54 "$1,123.64" "$1,123.64" $0.00 $0.00 $315.50 $0.00 $895.49 $895.49 $0.00 $734.91 "$1,164.11" "$1,175.86" $0.00 $0.00 $223.33 $0.00 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.077S SUP HCPCS C1713 441.077S - PLATE BONE 18MM 4 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,513.93 " "$1,120.31" $0.00 "$1,175.86" $661.42 $661.42 $0.00 $0.00 $0.00 $315.54 "$1,123.64" "$1,123.64" $0.00 $0.00 $315.50 $0.00 $895.49 $895.49 $0.00 $734.91 "$1,164.11" "$1,175.86" $0.00 $0.00 $223.33 $0.00 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 441.082S SUP HCPCS C1713 441.082S - PLATE BONE 12MM 5 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 441.083S SUP HCPCS C1713 441.083S - PLATE BONE 12MM 5 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 441.084S SUP HCPCS C1713 441.084S - PLATE BONE 15MM 5 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 441.085S SUP HCPCS C1713 441.085S - PLATE BONE 15MM 5 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 441.086S SUP HCPCS C1713 441.086S - PLATE BONE 18MM 5 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 441.087S SUP HCPCS C1713 441.087S - PLATE BONE 18MM 5 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,584.23 " "$1,172.33" $0.00 "$1,230.46" $692.13 $692.13 $0.00 $0.00 $0.00 $330.19 "$1,175.81" "$1,175.81" $0.00 $0.00 $330.15 $0.00 $937.07 $937.07 $0.00 $769.04 "$1,218.16" "$1,230.46" $0.00 $0.00 $233.70 $0.00 $0.00 $244.86 $0.00 $0.00 $0.00 $0.00 $0.00 441.094S SUP HCPCS C1713 441.094S - PLATE BONE 15MM 6 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,629.20 " "$1,205.61" $0.00 "$1,265.40" $711.79 $711.79 $0.00 $0.00 $0.00 $339.57 "$1,209.19" "$1,209.19" $0.00 $0.00 $339.53 $0.00 $963.67 $963.67 $0.00 $790.88 "$1,252.75" "$1,265.40" $0.00 $0.00 $240.33 $0.00 $0.00 $251.81 $0.00 $0.00 $0.00 $0.00 $0.00 441.095S SUP HCPCS C1713 441.095S - PLATE BONE 15MM 6 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,629.20 " "$1,205.61" $0.00 "$1,265.40" $711.79 $711.79 $0.00 $0.00 $0.00 $339.57 "$1,209.19" "$1,209.19" $0.00 $0.00 $339.53 $0.00 $963.67 $963.67 $0.00 $790.88 "$1,252.75" "$1,265.40" $0.00 $0.00 $240.33 $0.00 $0.00 $251.81 $0.00 $0.00 $0.00 $0.00 $0.00 441.096S SUP HCPCS C1713 441.096S - PLATE BONE 18MM 6 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,629.20 " "$1,205.61" $0.00 "$1,265.40" $711.79 $711.79 $0.00 $0.00 $0.00 $339.57 "$1,209.19" "$1,209.19" $0.00 $0.00 $339.53 $0.00 $963.67 $963.67 $0.00 $790.88 "$1,252.75" "$1,265.40" $0.00 $0.00 $240.33 $0.00 $0.00 $251.81 $0.00 $0.00 $0.00 $0.00 $0.00 441.097S SUP HCPCS C1713 441.097S - PLATE BONE 18MM 6 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,629.20 " "$1,205.61" $0.00 "$1,265.40" $711.79 $711.79 $0.00 $0.00 $0.00 $339.57 "$1,209.19" "$1,209.19" $0.00 $0.00 $339.53 $0.00 $963.67 $963.67 $0.00 $790.88 "$1,252.75" "$1,265.40" $0.00 $0.00 $240.33 $0.00 $0.00 $251.81 $0.00 $0.00 $0.00 $0.00 $0.00 441.104S SUP HCPCS C1713 441.104S - PLATE BONE 15MM 7 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,698.08 " "$1,256.58" $0.00 "$1,318.90" $741.88 $741.88 $0.00 $0.00 $0.00 $353.92 "$1,260.31" "$1,260.31" $0.00 $0.00 $353.88 $0.00 "$1,004.41" "$1,004.41" $0.00 $824.31 "$1,305.71" "$1,318.90" $0.00 $0.00 $250.49 $0.00 $0.00 $262.46 $0.00 $0.00 $0.00 $0.00 $0.00 441.105S SUP HCPCS C1713 441.105S - PLATE BONE 15MM 7 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,698.08 " "$1,256.58" $0.00 "$1,318.90" $741.88 $741.88 $0.00 $0.00 $0.00 $353.92 "$1,260.31" "$1,260.31" $0.00 $0.00 $353.88 $0.00 "$1,004.41" "$1,004.41" $0.00 $824.31 "$1,305.71" "$1,318.90" $0.00 $0.00 $250.49 $0.00 $0.00 $262.46 $0.00 $0.00 $0.00 $0.00 $0.00 441.106S SUP HCPCS C1713 441.106S - PLATE BONE 18MM 7 HOLE HOOK LCP TITANIUM RIGHT CLAVICLE BOTH IP/OP "$1,698.08 " "$1,256.58" $0.00 "$1,318.90" $741.88 $741.88 $0.00 $0.00 $0.00 $353.92 "$1,260.31" "$1,260.31" $0.00 $0.00 $353.88 $0.00 "$1,004.41" "$1,004.41" $0.00 $824.31 "$1,305.71" "$1,318.90" $0.00 $0.00 $250.49 $0.00 $0.00 $262.46 $0.00 $0.00 $0.00 $0.00 $0.00 441.107S SUP HCPCS C1713 441.107S - PLATE BONE 18MM 7 HOLE HOOK LCP TITANIUM LEFT CLAVICLE BOTH IP/OP "$1,698.08 " "$1,256.58" $0.00 "$1,318.90" $741.88 $741.88 $0.00 $0.00 $0.00 $353.92 "$1,260.31" "$1,260.31" $0.00 $0.00 $353.88 $0.00 "$1,004.41" "$1,004.41" $0.00 $824.31 "$1,305.71" "$1,318.90" $0.00 $0.00 $250.49 $0.00 $0.00 $262.46 $0.00 $0.00 $0.00 $0.00 $0.00 44-1001 SUP HCPCS C1713 44-1001 - PLATE BONE LARGE 2MM ANGLED TRAUMAONE BLUE TITANIUM MANDIB 2 BOTH IP/OP "$6,255.00 " "$4,628.70" $0.00 "$5,004.00" "$2,814.75" "$2,814.75" $0.00 $0.00 $0.00 "$1,303.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,303.54" $0.00 "$3,083.72" "$3,083.72" $0.00 "$3,127.50" "$4,953.96" "$5,004.00" $0.00 $0.00 $978.91 $0.00 $0.00 $995.80 $0.00 $0.00 $0.00 $0.00 $0.00 44-1002 SUP HCPCS C1713 44-1002 - PLATE BONE SMALL 2MM 2 ANGLED TRAUMAONE BLUE TITANIUM MANDIB BOTH IP/OP "$7,630.00 " "$5,646.20" $0.00 "$6,104.00" "$3,433.50" "$3,433.50" $0.00 $0.00 $0.00 "$1,590.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,590.09" $0.00 "$3,761.59" "$3,761.59" $0.00 "$3,815.00" "$6,042.96" "$6,104.00" $0.00 $0.00 "$1,194.10" $0.00 $0.00 "$1,214.70" $0.00 $0.00 $0.00 $0.00 $0.00 44-1003 SUP HCPCS C1713 44-1003 - PLATE BONE THK2MM MEDIUM 2 ANGLED LORENZ BLUE MANDIB BOTH IP/OP "$8,075.00 " "$5,975.50" $0.00 "$6,460.00" "$3,633.75" "$3,633.75" $0.00 $0.00 $0.00 "$1,683.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,682.83" $0.00 "$3,980.98" "$3,980.98" $0.00 "$4,037.50" "$6,395.40" "$6,460.00" $0.00 $0.00 "$1,263.74" $0.00 $0.00 "$1,285.54" $0.00 $0.00 $0.00 $0.00 $0.00 44-1005 SUP HCPCS C1713 44-1005 - PLATE BONE LARGE 2.6MM ANGLED TRAUMAONE MAGENTA TITANIUM BOTH IP/OP "$6,727.50 " "$4,978.35" $0.00 "$5,382.00" "$3,027.38" "$3,027.38" $0.00 $0.00 $0.00 "$1,402.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,402.01" $0.00 "$3,316.66" "$3,316.66" $0.00 "$3,363.75" "$5,328.18" "$5,382.00" $0.00 $0.00 "$1,052.85" $0.00 $0.00 "$1,071.02" $0.00 $0.00 $0.00 $0.00 $0.00 44-1012 SUP HCPCS C1713 44-1012 - PLATE BONE 2MM 12 HOLE STR TRAUMAONE BLUE TITANIUM MANDIB 2 BOTH IP/OP "$2,765.00 " "$2,046.10" $0.00 "$2,212.00" "$1,244.25" "$1,244.25" $0.00 $0.00 $0.00 $576.30 "$2,052.18" "$2,052.18" $0.00 $0.00 $576.23 $0.00 "$1,363.15" "$1,363.15" $0.00 "$1,382.50" "$2,189.88" "$2,212.00" $0.00 $0.00 $432.72 $0.00 $0.00 $440.19 $0.00 $0.00 $0.00 $0.00 $0.00 44-1022 SUP HCPCS C1713 44-1022 - PLATE BN MED 2 ANG 2MM BLU TRAUMAONE STRG TI MNDB 2MM/2.3MM BOTH IP/OP "$8,072.50 " "$5,973.65" $0.00 "$4,692.00" "$2,639.25" "$2,639.25" $0.00 $0.00 $0.00 "$1,682.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,682.31" $0.00 "$3,979.74" "$3,979.74" $0.00 "$2,932.50" "$4,645.08" "$4,692.00" $0.00 $0.00 $917.87 $0.00 $0.00 $933.71 $0.00 $0.00 $0.00 $0.00 $0.00 44-1023 SUP HCPCS C1713 44-1023 - PLATE BN LG ANG 2.6MM MAG TRAUMAONE STRG TI MNDB 2MM/2.3MM BOTH IP/OP "$6,727.50 " "$4,978.35" $0.00 "$5,382.00" "$3,027.38" "$3,027.38" $0.00 $0.00 $0.00 "$1,402.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,402.01" $0.00 "$3,316.66" "$3,316.66" $0.00 "$3,363.75" "$5,328.18" "$5,382.00" $0.00 $0.00 "$1,052.85" $0.00 $0.00 "$1,071.02" $0.00 $0.00 $0.00 $0.00 $0.00 44-1024 SUP HCPCS C1713 44-1024 - PLATE BONE 2MM 24 HOLE STR TRAUMAONE BLUE TITANIUM MANDIB 2 BOTH IP/OP "$3,805.00 " "$2,815.70" $0.00 "$3,044.00" "$1,712.25" "$1,712.25" $0.00 $0.00 $0.00 $793.06 "$2,824.07" "$2,824.07" $0.00 $0.00 $792.96 $0.00 "$1,875.87" "$1,875.87" $0.00 "$1,902.50" "$3,013.56" "$3,044.00" $0.00 $0.00 $595.48 $0.00 $0.00 $605.76 $0.00 $0.00 $0.00 $0.00 $0.00 442.458TM SUP HCPCS C1713 442.458TM - PLATE 48MM TI 2.4MM SCR 5 HLE/HD 3 HL SHFT LCP BONE RIGHT BOTH IP/OP "$1,819.53 " "$1,346.45" $0.00 "$1,455.62" $818.79 $818.79 $0.00 $0.00 $0.00 $379.23 "$1,350.45" "$1,350.45" $0.00 $0.00 $379.19 $0.00 "$1,076.25" "$1,076.25" $0.00 $909.76 "$1,441.07" "$1,455.62" $0.00 $0.00 $284.76 $0.00 $0.00 $289.67 $0.00 $0.00 $0.00 $0.00 $0.00 442.459TM SUP HCPCS C1713 442.459TM - PLATE 66MM TI 2.4MM SCR 5 HLE/HD 5 HL SHFT LCP BONE RIGHT BOTH IP/OP "$1,928.98 " "$1,427.45" $0.00 "$1,543.18" $868.04 $868.04 $0.00 $0.00 $0.00 $402.05 "$1,431.69" "$1,431.69" $0.00 $0.00 $402.00 $0.00 "$1,140.99" "$1,140.99" $0.00 $964.49 "$1,527.75" "$1,543.18" $0.00 $0.00 $301.88 $0.00 $0.00 $307.09 $0.00 $0.00 $0.00 $0.00 $0.00 442.461TM SUP HCPCS C1713 442.461TM - PLATE 48MM TI 2.4MM SCR 5X3 HOLE LCP BONE LEFT DISTAL VOLR BOTH IP/OP "$1,819.53 " "$1,346.45" $0.00 "$1,455.62" $818.79 $818.79 $0.00 $0.00 $0.00 $379.23 "$1,350.45" "$1,350.45" $0.00 $0.00 $379.19 $0.00 "$1,076.25" "$1,076.25" $0.00 $909.76 "$1,441.07" "$1,455.62" $0.00 $0.00 $284.76 $0.00 $0.00 $289.67 $0.00 $0.00 $0.00 $0.00 $0.00 442.462TM SUP HCPCS C1713 442.462TM - PLATE 66MM TI 2.4MM SCR 5 HLE/HD 5 HL SHFT LCP BONE LEFT BOTH IP/OP "$1,928.98 " "$1,427.45" $0.00 "$1,543.18" $868.04 $868.04 $0.00 $0.00 $0.00 $402.05 "$1,431.69" "$1,431.69" $0.00 $0.00 $402.00 $0.00 "$1,140.99" "$1,140.99" $0.00 $964.49 "$1,527.75" "$1,543.18" $0.00 $0.00 $301.88 $0.00 $0.00 $307.09 $0.00 $0.00 $0.00 $0.00 $0.00 442.464TM SUP HCPCS C1713 442.464TM - PLATE BN 47X6.3X1.6MM LCP 4 HLE/HD 3 HL SHFT TI RDS RT DIST BOTH IP/OP "$1,819.53 " "$1,346.45" $0.00 "$1,455.62" $818.79 $818.79 $0.00 $0.00 $0.00 $379.23 "$1,350.45" "$1,350.45" $0.00 $0.00 $379.19 $0.00 "$1,076.25" "$1,076.25" $0.00 $909.76 "$1,441.07" "$1,455.62" $0.00 $0.00 $284.76 $0.00 $0.00 $289.67 $0.00 $0.00 $0.00 $0.00 $0.00 442.465TM SUP HCPCS C1713 442.465TM - PLATE 65MM TI 2.4MM SCR 4 HLE/HD 5 HL SHFT LCP BONE RIGHT BOTH IP/OP "$1,928.98 " "$1,427.45" $0.00 "$1,543.18" $868.04 $868.04 $0.00 $0.00 $0.00 $402.05 "$1,431.69" "$1,431.69" $0.00 $0.00 $402.00 $0.00 "$1,140.99" "$1,140.99" $0.00 $964.49 "$1,527.75" "$1,543.18" $0.00 $0.00 $301.88 $0.00 $0.00 $307.09 $0.00 $0.00 $0.00 $0.00 $0.00 442.467TM SUP HCPCS C1713 442.467TM - PLATE 47MM TI 2.4MM SCR 3X4 HOLE LCP BONE LEFT DISTAL EXTART BOTH IP/OP "$1,819.53 " "$1,346.45" $0.00 "$1,455.62" $818.79 $818.79 $0.00 $0.00 $0.00 $379.23 "$1,350.45" "$1,350.45" $0.00 $0.00 $379.19 $0.00 "$1,076.25" "$1,076.25" $0.00 $909.76 "$1,441.07" "$1,455.62" $0.00 $0.00 $284.76 $0.00 $0.00 $289.67 $0.00 $0.00 $0.00 $0.00 $0.00 442.468TM SUP HCPCS C1713 442.468TM - PLATE 65MM TI 4 HOLE LCK LCP BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,928.98 " "$1,427.45" $0.00 "$1,543.18" $868.04 $868.04 $0.00 $0.00 $0.00 $402.05 "$1,431.69" "$1,431.69" $0.00 $0.00 $402.00 $0.00 "$1,140.99" "$1,140.99" $0.00 $964.49 "$1,527.75" "$1,543.18" $0.00 $0.00 $301.88 $0.00 $0.00 $307.09 $0.00 $0.00 $0.00 $0.00 $0.00 442.531S SUP HCPCS C1713 442.531S - PLATE BONE 46MM 7 HOLE LCP TITANIUM DISTAL ULNAR STERILE 2MM BOTH IP/OP "$1,591.25 " "$1,177.53" $0.00 "$1,235.92" $695.21 $695.21 $0.00 $0.00 $0.00 $331.66 "$1,181.03" "$1,181.03" $0.00 $0.00 $331.62 $0.00 $941.22 $941.22 $0.00 $772.45 "$1,223.56" "$1,235.92" $0.00 $0.00 $234.73 $0.00 $0.00 $245.95 $0.00 $0.00 $0.00 $0.00 $0.00 443.61.96 SUP HCPCS C1713 443.61.96 - PLATE BN 39X5X1.2MM NS LCP 7 HL LOPRFL PRECONTOUR TI CNDYL BOTH IP/OP $567.90 $420.25 $0.00 $441.08 $248.11 $248.11 $0.00 $0.00 $0.00 $118.36 $421.50 $421.50 $0.00 $0.00 $118.35 $0.00 $335.91 $335.91 $0.00 $275.68 $436.67 $441.08 $0.00 $0.00 $107.41 $0.00 $0.00 $87.77 $0.00 $0.00 $0.00 $0.00 $0.00 443.62.96 SUP HCPCS C1713 443.62.96 - PLATE BN 39X5X1.2MM NS LCP 7 HL LOPRFL PRECONTOUR TI CNDRL BOTH IP/OP $567.90 $420.25 $0.00 $441.08 $248.11 $248.11 $0.00 $0.00 $0.00 $118.36 $421.50 $421.50 $0.00 $0.00 $118.35 $0.00 $335.91 $335.91 $0.00 $275.68 $436.67 $441.08 $0.00 $0.00 $107.41 $0.00 $0.00 $87.77 $0.00 $0.00 $0.00 $0.00 $0.00 4450M26 SUP Custom 27803010 4450M26 - RING ANNULOPLASTY KIDNEY 26MM 30.7MM 24.9MM FLEXIBLE HOLDER BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4450M28 SUP Custom 27803010 4450M28 - RING ANLPLS 28MM C-E PH BOTH IP/OP "$8,295.00 " "$6,138.30" $0.00 "$6,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,728.68" $0.00 $0.00 $0.00 $0.00 "$4,147.50" "$6,569.64" "$6,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4450M30 SUP Custom 27803010 4450M30 - RING ANLPLS 30MM C-E PH BOTH IP/OP "$8,295.00 " "$6,138.30" $0.00 "$6,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,728.68" $0.00 $0.00 $0.00 $0.00 "$4,147.50" "$6,569.64" "$6,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4450M32 SUP Custom 27803010 4450M32 - RING ANLPLS 32MM C-E PH BOTH IP/OP "$8,295.00 " "$6,138.30" $0.00 "$6,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,728.68" $0.00 $0.00 $0.00 $0.00 "$4,147.50" "$6,569.64" "$6,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4450M34 SUP Custom 27803010 4450M34 - RING ANLPLS 34MM C-E PH BOTH IP/OP "$8,295.00 " "$6,138.30" $0.00 "$6,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,728.68" $0.00 $0.00 $0.00 $0.00 "$4,147.50" "$6,569.64" "$6,636.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4450M36 SUP Custom 27803010 4450M36 - RING ANLPLS KNDY 36MM 41.2MM 34.8MM STRL C-E PH FLXB HLDR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 446.354S SUP HCPCS C1713 446.354S - PLATE BONE 27MM 2 HOLE HEAD 4 HOLE SHAFT ROTATION CORRECTION BOTH IP/OP "$1,544.90 " "$1,143.23" $0.00 "$1,235.92" $695.21 $695.21 $0.00 $0.00 $0.00 $322.00 "$1,146.62" "$1,146.62" $0.00 $0.00 $321.96 $0.00 $913.81 $913.81 $0.00 $772.45 "$1,223.56" "$1,235.92" $0.00 $0.00 $234.73 $0.00 $0.00 $245.95 $0.00 $0.00 $0.00 $0.00 $0.00 446.355S SUP HCPCS C1713 446.355S - PLATE BONE 32MM 2 HOLE HEAD 5 HOLE SHAFT ROTATION CORRECTION BOTH IP/OP "$1,544.90 " "$1,143.23" $0.00 "$1,235.92" $695.21 $695.21 $0.00 $0.00 $0.00 $322.00 "$1,146.62" "$1,146.62" $0.00 $0.00 $321.96 $0.00 $913.81 $913.81 $0.00 $772.45 "$1,223.56" "$1,235.92" $0.00 $0.00 $234.73 $0.00 $0.00 $245.95 $0.00 $0.00 $0.00 $0.00 $0.00 446.63.96 SUP HCPCS C1713 446.63.96 - PLATE BN 36X3.5X.9MM NS LCP 7 HL LOPRFL PRECONTOUR TI CNDYL BOTH IP/OP $539.78 $399.44 $0.00 $419.26 $235.83 $235.83 $0.00 $0.00 $0.00 $112.50 $400.62 $400.62 $0.00 $0.00 $112.49 $0.00 $319.28 $319.28 $0.00 $262.04 $415.07 $419.26 $0.00 $0.00 $79.63 $0.00 $0.00 $83.43 $0.00 $0.00 $0.00 $0.00 $0.00 446.64.96 SUP HCPCS C1713 446.64.96 - PLATE BN 36X3.5X.9MM NS LCP 7 HL LOPRFL PRECONTOUR TI CNDYL BOTH IP/OP $539.78 $399.44 $0.00 $419.26 $235.83 $235.83 $0.00 $0.00 $0.00 $112.50 $400.62 $400.62 $0.00 $0.00 $112.49 $0.00 $319.28 $319.28 $0.00 $262.04 $415.07 $419.26 $0.00 $0.00 $79.63 $0.00 $0.00 $83.43 $0.00 $0.00 $0.00 $0.00 $0.00 447.354S SUP HCPCS C1713 447.354S - PLATE BONE 34MM 2 HOLE HEAD 4 HOLE SHAFT ROTATION CORRECTION BOTH IP/OP "$1,591.25 " "$1,177.53" $0.00 "$1,235.92" $695.21 $695.21 $0.00 $0.00 $0.00 $331.66 "$1,181.03" "$1,181.03" $0.00 $0.00 $331.62 $0.00 $941.22 $941.22 $0.00 $772.45 "$1,223.56" "$1,235.92" $0.00 $0.00 $234.73 $0.00 $0.00 $245.95 $0.00 $0.00 $0.00 $0.00 $0.00 447.355S SUP HCPCS C1713 447.355S - PLATE BONE 40MM 2 HOLE HEAD 2 HOLE SHAFT ROTATION CORRECTION BOTH IP/OP "$1,591.25 " "$1,177.53" $0.00 "$1,235.92" $695.21 $695.21 $0.00 $0.00 $0.00 $331.66 "$1,181.03" "$1,181.03" $0.00 $0.00 $331.62 $0.00 $941.22 $941.22 $0.00 $772.45 "$1,223.56" "$1,235.92" $0.00 $0.00 $234.73 $0.00 $0.00 $245.95 $0.00 $0.00 $0.00 $0.00 $0.00 450.701S SUP HCPCS C1713 450.701S - NAIL INTRAMEDULLARY 9MM 16CM SOLID AQUA TITANIUM FEMUR BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.702S SUP HCPCS C1713 450.702S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 20CM SOLID EXPERT AQUA BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.703S SUP HCPCS C1713 450.703S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 24CM SOLID EXPERT AQUA BOTH IP/OP "$3,299.98 " "$2,441.99" $0.00 "$2,639.98" "$1,484.99" "$1,484.99" $0.00 $0.00 $0.00 $687.80 "$2,449.24" "$2,449.24" $0.00 $0.00 $687.71 $0.00 "$1,626.89" "$1,626.89" $0.00 "$1,649.99" "$2,613.58" "$2,639.98" $0.00 $0.00 $599.36 $0.00 $0.00 $525.36 $0.00 $0.00 $0.00 $0.00 $0.00 450.704S SUP HCPCS C1713 450.704S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 28CM SOLID EXPERT AQUA BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.705S SUP HCPCS C1713 450.705S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 30CM SOLID EXPERT AQUA BOTH IP/OP "$3,299.98 " "$2,441.99" $0.00 "$2,639.98" "$1,484.99" "$1,484.99" $0.00 $0.00 $0.00 $687.80 "$2,449.24" "$2,449.24" $0.00 $0.00 $687.71 $0.00 "$1,626.89" "$1,626.89" $0.00 "$1,649.99" "$2,613.58" "$2,639.98" $0.00 $0.00 $599.36 $0.00 $0.00 $525.36 $0.00 $0.00 $0.00 $0.00 $0.00 450.706S SUP HCPCS C1713 450.706S - NAIL 9MM 32CM DISTAL FEM IM SLD TI STRL BOTH IP/OP "$3,829.78 " "$2,834.04" $0.00 "$3,063.82" "$1,723.40" "$1,723.40" $0.00 $0.00 $0.00 $798.22 "$2,842.46" "$2,842.46" $0.00 $0.00 $798.13 $0.00 "$1,888.08" "$1,888.08" $0.00 "$1,914.89" "$3,033.19" "$3,063.82" $0.00 $0.00 $599.36 $0.00 $0.00 $609.70 $0.00 $0.00 $0.00 $0.00 $0.00 450.707S SUP HCPCS C1713 450.707S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 34CM SOLID EXPERT AQUA BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.708S SUP HCPCS C1713 450.708S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 360MM SOLID ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $506.12 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.709S SUP HCPCS C1713 450.709S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 380MM SOLID ROUND BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.710S SUP HCPCS C1713 450.710S - NAIL 9MM 40CM DISTAL FEM IM SLD TI STRL AQ BOTH IP/OP "$3,829.78 " "$2,834.04" $0.00 "$3,063.82" "$1,723.40" "$1,723.40" $0.00 $0.00 $0.00 $798.22 "$2,842.46" "$2,842.46" $0.00 $0.00 $798.13 $0.00 "$1,888.08" "$1,888.08" $0.00 "$1,914.89" "$3,033.19" "$3,063.82" $0.00 $0.00 $599.36 $0.00 $0.00 $609.70 $0.00 $0.00 $0.00 $0.00 $0.00 450.711S SUP HCPCS C1713 450.711S - NAIL INTRAMEDULLARY 9MM 42CM SOLID AQUA TITANIUM FEMUR BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.712S SUP HCPCS C1713 450.712S - NAIL INTRAMEDULLARY 9MM 44CM SOLID AQUA TITANIUM FEMUR BOTH IP/OP "$3,299.98 " "$2,441.99" $0.00 "$2,639.98" "$1,484.99" "$1,484.99" $0.00 $0.00 $0.00 $687.80 "$2,449.24" "$2,449.24" $0.00 $0.00 $687.71 $0.00 "$1,626.89" "$1,626.89" $0.00 "$1,649.99" "$2,613.58" "$2,639.98" $0.00 $0.00 $599.36 $0.00 $0.00 $525.36 $0.00 $0.00 $0.00 $0.00 $0.00 450.713S SUP HCPCS C1713 450.713S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 460MM SOLID ROUND BARREL BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.714S SUP HCPCS C1713 450.714S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 180MM SOLID ROUND BARREL BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.715S SUP HCPCS C1713 450.715S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 220MM SOLID ROUND BARREL BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.716S SUP HCPCS C1713 450.716S - NAIL INTRAMEDULLARY UNIVERSAL 9MM 260MM SOLID ROUND BARREL BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.781S SUP HCPCS C1713 450.781S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 160MM CANN ROUND BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.782S SUP HCPCS C1713 450.782S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 200MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.783S SUP HCPCS C1713 450.783S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 240MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.784S SUP HCPCS C1713 450.784S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 280MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.785S SUP HCPCS C1713 450.785S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 300MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.786S SUP HCPCS C1713 450.786S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 320MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.787S SUP HCPCS C1713 450.787S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 340MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.788S SUP HCPCS C1713 450.788S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 360MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.789S SUP HCPCS C1713 450.789S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 380MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.790S SUP HCPCS C1713 450.790S - NAIL 10MM 40CM DISTAL FEM IM CANN TI STRL AQ BOTH IP/OP "$3,829.78 " "$2,834.04" $0.00 "$3,063.82" "$1,723.40" "$1,723.40" $0.00 $0.00 $0.00 $798.22 "$2,842.46" "$2,842.46" $0.00 $0.00 $798.13 $0.00 "$1,888.08" "$1,888.08" $0.00 "$1,914.89" "$3,033.19" "$3,063.82" $0.00 $0.00 $599.36 $0.00 $0.00 $609.70 $0.00 $0.00 $0.00 $0.00 $0.00 450.791S SUP HCPCS C1713 450.791S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 420MM CANN ROUND BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.792S SUP HCPCS C1713 450.792S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 440MM CANN ROUND BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.793S SUP HCPCS C1713 450.793S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 460MM CANN ROUND BARREL BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.794S SUP HCPCS C1713 450.794S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 180MM CANN ROUND BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.795S SUP HCPCS C1713 450.795S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 220MM CANN ROUND BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.796S SUP HCPCS C1713 450.796S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 260MM CANN ROUND BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.801S SUP HCPCS C1713 450.801S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 160MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.802S SUP HCPCS C1713 450.802S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 200MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.803S SUP HCPCS C1713 450.803S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 240MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.804S SUP HCPCS C1713 450.804S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 280MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.805S SUP HCPCS C1713 450.805S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 300MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.806S SUP HCPCS C1713 450.806S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 320MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.807S SUP HCPCS C1713 450.807S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 340MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.808S SUP HCPCS C1713 450.808S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 360MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.809S SUP HCPCS C1713 450.809S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 380MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.810S SUP HCPCS C1713 450.810S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 400MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.811S SUP HCPCS C1713 450.811S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 420MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.812S SUP HCPCS C1713 450.812S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 440MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.813S SUP HCPCS C1713 450.813S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 460MM CANN FLUTED BARREL BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.814S SUP HCPCS C1713 450.814S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 180MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.815S SUP HCPCS C1713 450.815S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 220MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.816S SUP HCPCS C1713 450.816S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 260MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.821S SUP HCPCS C1713 450.821S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 160MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.822S SUP HCPCS C1713 450.822S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 200MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.823S SUP HCPCS C1713 450.823S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 240MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.824S SUP HCPCS C1713 450.824S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 280MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.825S SUP HCPCS C1713 450.825S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 30CM CANN EXPERT AQUA BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.826S SUP HCPCS C1713 450.826S - NAIL 12MM 32CM DISTAL FEM IM CANN TI STRL AQ BOTH IP/OP "$3,829.78 " "$2,834.04" $0.00 "$3,063.82" "$1,723.40" "$1,723.40" $0.00 $0.00 $0.00 $798.22 "$2,842.46" "$2,842.46" $0.00 $0.00 $798.13 $0.00 "$1,888.08" "$1,888.08" $0.00 "$1,914.89" "$3,033.19" "$3,063.82" $0.00 $0.00 $599.36 $0.00 $0.00 $609.70 $0.00 $0.00 $0.00 $0.00 $0.00 450.827S SUP HCPCS C1713 450.827S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 340MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.828S SUP HCPCS C1713 450.828S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 360MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.829S SUP HCPCS C1713 450.829S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 380MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.830S SUP HCPCS C1713 450.830S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 400MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.831S SUP HCPCS C1713 450.831S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 420MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.832S SUP HCPCS C1713 450.832S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 440MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.833S SUP HCPCS C1713 450.833S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 460MM CANN FLUTED BARREL BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.834S SUP HCPCS C1713 450.834S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 180MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.835S SUP HCPCS C1713 450.835S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 220MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.836S SUP HCPCS C1713 450.836S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 260MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.841S SUP HCPCS C1713 450.841S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 160MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.842S SUP HCPCS C1713 450.842S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 200MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.843S SUP HCPCS C1713 450.843S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 240MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.844S SUP HCPCS C1713 450.844S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 280MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.845S SUP HCPCS C1713 450.845S - NAIL 13MM 30CM DISTAL FEM IM CANN TI STRL AQ BOTH IP/OP "$3,829.78 " "$2,834.04" $0.00 "$3,063.82" "$1,723.40" "$1,723.40" $0.00 $0.00 $0.00 $798.22 "$2,842.46" "$2,842.46" $0.00 $0.00 $798.13 $0.00 "$1,888.08" "$1,888.08" $0.00 "$1,914.89" "$3,033.19" "$3,063.82" $0.00 $0.00 $599.36 $0.00 $0.00 $609.70 $0.00 $0.00 $0.00 $0.00 $0.00 450.846S SUP HCPCS C1713 450.846S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 320MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.847S SUP HCPCS C1713 450.847S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 340MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.848S SUP HCPCS C1713 450.848S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 360MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.849S SUP HCPCS C1713 450.849S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 380MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.850S SUP HCPCS C1713 450.850S - NAIL 13MM 40CM DISTAL FEM IM CANN TI STRL AQ BOTH IP/OP "$3,829.78 " "$2,834.04" $0.00 "$3,063.82" "$1,723.40" "$1,723.40" $0.00 $0.00 $0.00 $798.22 "$2,842.46" "$2,842.46" $0.00 $0.00 $798.13 $0.00 "$1,888.08" "$1,888.08" $0.00 "$1,914.89" "$3,033.19" "$3,063.82" $0.00 $0.00 $599.36 $0.00 $0.00 $609.70 $0.00 $0.00 $0.00 $0.00 $0.00 450.851S SUP HCPCS C1713 450.851S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 420MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $599.36 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.852S SUP HCPCS C1713 450.852S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 440MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.853S SUP HCPCS C1713 450.853S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 460MM CANN FLUTED BARREL BOTH IP/OP "$3,324.75 " "$2,460.32" $0.00 "$2,659.80" "$1,496.14" "$1,496.14" $0.00 $0.00 $0.00 $692.96 "$2,467.63" "$2,467.63" $0.00 $0.00 $692.88 $0.00 "$1,639.10" "$1,639.10" $0.00 "$1,662.38" "$2,633.20" "$2,659.80" $0.00 $0.00 $520.32 $0.00 $0.00 $529.30 $0.00 $0.00 $0.00 $0.00 $0.00 450.854S SUP HCPCS C1713 450.854S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 180MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.855S SUP HCPCS C1713 450.855S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 220MM CANN FLUTED BARREL BOTH IP/OP "$3,209.90 " "$2,375.33" $0.00 "$2,567.92" "$1,444.46" "$1,444.46" $0.00 $0.00 $0.00 $669.02 "$2,382.39" "$2,382.39" $0.00 $0.00 $668.94 $0.00 "$1,582.48" "$1,582.48" $0.00 "$1,604.95" "$2,542.24" "$2,567.92" $0.00 $0.00 $506.12 $0.00 $0.00 $511.02 $0.00 $0.00 $0.00 $0.00 $0.00 450.856S SUP HCPCS C1713 450.856S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 260MM CANN FLUTED BARREL BOTH IP/OP "$3,234.00 " "$2,393.16" $0.00 "$2,587.20" "$1,455.30" "$1,455.30" $0.00 $0.00 $0.00 $674.05 "$2,400.27" "$2,400.27" $0.00 $0.00 $673.97 $0.00 "$1,594.36" "$1,594.36" $0.00 "$1,617.00" "$2,561.33" "$2,587.20" $0.00 $0.00 $506.12 $0.00 $0.00 $514.85 $0.00 $0.00 $0.00 $0.00 $0.00 450.896S SUP Custom 27803010 450.896S - CAP END DISTAL FEM IM NAIL TI STRL AQ BOTH IP/OP $518.33 $383.56 $0.00 $414.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.70 $384.70 $0.00 $0.00 $108.02 $0.00 $0.00 $0.00 $0.00 $259.16 $410.52 $414.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-0010 SUP Custom 27203010 REAGENT BLOOD LEAD METEXCHANGE KT ANALY BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-0032 SUP Custom 27203010 REAGENT NA CHLOR SOL CHM BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-0058 SUP Custom 27203010 REAGENT PLT SOL LEAD POISONING ANALY BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450120-20 SUP Custom 27203010 CONTROL PRTN IMG VGL LVL 1 5ML IMMUN BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450125-20 SUP Custom 27203010 CONTROL PRTN IMG VGL LVL 2 5ML IMMUN BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450-1329 SUP HCPCS L8699 450-1329 - PROSTHESIS TESTICULAR 4.9X2.9CM INFUS LINE NEEDLE LARGE BOTH IP/OP "$4,622.50 " "$3,420.65" $0.00 "$3,698.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,430.82" "$3,430.82" $0.00 $0.00 $963.33 $0.00 $0.00 $0.00 $0.00 "$2,311.25" "$3,661.02" "$3,698.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450162-20 SUP Custom 27203010 CONTROL ASO CRP RF VIGIL LVL 1 5ML SERO BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450163-20 SUP Custom 27203010 CONTROL ASO CRP RF VIGIL LVL 2 5ML SERO BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450164-20 SUP Custom 27203010 VIGIL SEROLOGY ASO/CRP/RHF CNTRL LEVEL 3 BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-018-E2S SUP Custom 27203010 45-018-E2S - CATHETER INFS 2 2/3FR 45CM CLARIVEIN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-0225 SUP Custom 27203010 CALIBRATOR CHM 68 TST LOW BLOOD METEXCHANGE SA BOTH IP/OP $717.50 $530.95 $0.00 $574.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.75 $568.26 $574.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-0230 SUP Custom 27203010 CALIBRATOR CHM 68 TST HI BLOOD METEXCHANGE SA BOTH IP/OP $717.50 $530.95 $0.00 $574.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.75 $568.26 $574.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-0250A SUP Custom 27203010 CONTROL LINEAR VRF KT TOX BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450-4251-1 SUP Custom 27803010 450-4251-1 - CLAMP SURG HALIFAX SPNL THRD C1 BOTH IP/OP $483.00 $357.42 $0.00 $386.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.48 $358.48 $0.00 $0.00 $100.66 $0.00 $0.00 $0.00 $0.00 $241.50 $382.54 $386.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 450-4253-1 SUP Custom 27803010 450-4253-1 - CLAMP SURG HALIFAX 7MM SPNL THRD BOTH IP/OP $483.00 $357.42 $0.00 $386.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.48 $358.48 $0.00 $0.00 $100.66 $0.00 $0.00 $0.00 $0.00 $241.50 $382.54 $386.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 451514H0 SUP HCPCS C1725 451514H0 - CATHETER ANGIO VERT CRV 5FR .042IN 100CM CRDS TMP RADOPQ BRD BOTH IP/OP $44.85 $33.19 $0.00 $35.88 $24.35 $24.35 $0.00 $0.00 $0.00 $9.35 $33.29 $33.29 $0.00 $0.00 $9.35 $0.00 $26.53 $26.53 $0.00 $22.43 $35.52 $35.88 $0.00 $0.00 $7.02 $0.00 $0.00 $7.14 $0.00 $0.00 $0.00 $0.00 $0.00 45-20005 SUP Custom 27203010 45-20005 - BIT DRILL 1.7MM ASNS MIC AO CPLNG CANN STRL DISP BOTH IP/OP $336.75 $249.20 $0.00 $249.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.94 $249.94 $0.00 $0.00 $70.18 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-20006 SUP Custom 27803010 45-20006 - TAP 2MM MIC CANN AO CPLNG SURG ASNS DISP BOTH IP/OP $333.00 $246.42 $0.00 $247.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.15 $247.15 $0.00 $0.00 $69.40 $0.00 $0.00 $0.00 $0.00 $77.00 $121.97 $123.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-20007 SUP Custom 27203010 45-20007 - CNTRSNK DRILL 2MM ASNS MIC CANN AO CPLNG DISP BOTH IP/OP $419.90 $310.73 $0.00 $350.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.65 $311.65 $0.00 $0.00 $87.51 $0.00 $0.00 $0.00 $0.00 $219.31 $347.39 $350.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-20008 SUP Custom 27203010 45-20008 - SLEEVE DRILL ASNS MIC HLD 2MM SCR BOTH IP/OP $273.63 $202.49 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.08 $203.08 $0.00 $0.00 $57.02 $0.00 $0.00 $0.00 $0.00 $136.81 $216.71 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-20009 SUP Custom 27203010 45-20009 - GUIDE DRILL .8MM 1.7MM ASNS MIC DBL BOTH IP/OP $672.38 $497.56 $0.00 $537.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.04 $499.04 $0.00 $0.00 $140.12 $0.00 $0.00 $0.00 $0.00 $336.19 $532.52 $537.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-20011 SUP Custom 27203010 45-20011 - BIT DRILL 1.7MM ASNS 2MM AO CPLNG SLD NONSTRL BOTH IP/OP $121.55 $89.95 $0.00 $100.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.21 $90.21 $0.00 $0.00 $25.33 $0.00 $0.00 $0.00 $0.00 $62.56 $99.10 $100.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-20014 SUP Custom 27203010 45-20014 - STYLET SURG INSTR .8MM ASNS CLEAN BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-20015 SUP HCPCS C1713 45-20015 - WIRE FX .8MM 100MM NS KRSH DISP 2MM ASNS MIC SCR BOTH IP/OP $68.75 $50.88 $0.00 $51.03 $16.09 $16.09 $0.00 $0.00 $0.00 $14.33 $51.03 $51.03 $0.00 $0.00 $14.33 $0.00 $40.67 $40.67 $0.00 $17.88 $28.31 $28.60 $0.00 $0.00 $5.59 $0.00 $0.00 $5.69 $0.00 $0.00 $0.00 $0.00 $0.00 45-27005 SUP Custom 27803010 45-27005 - TAP 50MM SURG 2.7MM SCR BOTH IP/OP $159.75 $118.22 $0.00 $125.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.57 $118.57 $0.00 $0.00 $33.29 $0.00 $0.00 $0.00 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-27010 SUP Custom 27203010 45-27010 - DRILL TWST 102MM 2MM VARIAX AO SHFT END 50MM NONSTRL BOTH IP/OP $159.75 $118.22 $0.00 $125.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.57 $118.57 $0.00 $0.00 $33.29 $0.00 $0.00 $0.00 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-30005 SUP Custom 27203010 45-30005 - DRILL SRG MIC 2.1MM STRL AO CPLNG CNN HND FT DISP 3MM ASNS BOTH IP/OP $416.50 $308.21 $0.00 $347.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $309.13 $309.13 $0.00 $0.00 $86.80 $0.00 $0.00 $0.00 $0.00 $217.25 $344.12 $347.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-30006 SUP Custom 27803010 45-30006 - TAP 3MM MIC CANN AO CPLNG SURG ASNS DISP BOTH IP/OP $319.50 $236.43 $0.00 $237.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.13 $237.13 $0.00 $0.00 $66.58 $0.00 $0.00 $0.00 $0.00 $80.44 $127.42 $128.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-30007 SUP Custom 27203010 45-30007 - CNTRSNK DRILL 3MM AO CPLNG CANN DISP BOTH IP/OP $391.00 $289.34 $0.00 $324.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.20 $290.20 $0.00 $0.00 $81.48 $0.00 $0.00 $0.00 $0.00 $202.81 $321.26 $324.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-30008 SUP Custom 27203010 45-30008 - SLEEVE DRILL ASNS MIC HLD 3MM SCR BOTH IP/OP $270.88 $200.45 $0.00 $216.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.04 $201.04 $0.00 $0.00 $56.45 $0.00 $0.00 $0.00 $0.00 $135.44 $214.54 $216.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-30009 SUP Custom 27203010 45-30009 - GUIDE DRILL 1.2MM 2.1MM ASNS DBL BOTH IP/OP $334.13 $247.26 $0.00 $267.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.99 $247.99 $0.00 $0.00 $69.63 $0.00 $0.00 $0.00 $0.00 $167.06 $264.63 $267.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-30011 SUP Custom 27203010 45-30011 - BIT DRILL 2.1MM ASNS MIC SLD AO CPLNG NONSTRL BOTH IP/OP $123.25 $91.21 $0.00 $102.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.48 $91.48 $0.00 $0.00 $25.69 $0.00 $0.00 $0.00 $0.00 $63.94 $101.28 $102.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-30014 SUP Custom 27203010 45-30014 - STYLET SURG INSTR 1.2MM ASNS CLEAN BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-30015 SUP HCPCS C1713 45-30015 - WIRE FX 1.2MM 100MM NS KRSH 3MM ASNS MIC SCR BOTH IP/OP $68.75 $50.88 $0.00 $51.03 $17.94 $17.94 $0.00 $0.00 $0.00 $14.33 $51.03 $51.03 $0.00 $0.00 $14.33 $0.00 $40.67 $40.67 $0.00 $19.94 $31.58 $31.90 $0.00 $0.00 $6.24 $0.00 $0.00 $6.35 $0.00 $0.00 $0.00 $0.00 $0.00 45-35001 SUP Custom 27203010 45-35001 - GAUGE DEPTH MSR 3.5 MM SCR BOTH IP/OP $760.38 $562.68 $0.00 $608.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $564.35 $564.35 $0.00 $0.00 $158.46 $0.00 $0.00 $0.00 $0.00 $380.19 $602.22 $608.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-35005 SUP Custom 27803010 45-35005 - TAP 70MM SURG 3.5MM SCR BOTH IP/OP $188.25 $139.31 $0.00 $148.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.72 $139.72 $0.00 $0.00 $39.23 $0.00 $0.00 $0.00 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-35010 SUP Custom 27203010 45-35010 - DRILL TWST 122MM 2.6MM VARIAX AO SHFT END 70MM NONSTRL BOTH IP/OP $188.25 $139.31 $0.00 $148.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.72 $139.72 $0.00 $0.00 $39.23 $0.00 $0.00 $0.00 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-35015 SUP Custom 27203010 45-35015 - BLADE AO FIT ASNS SCRDRVR T10 BOTH IP/OP $297.00 $219.78 $0.00 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.43 $220.43 $0.00 $0.00 $61.89 $0.00 $0.00 $0.00 $0.00 $148.50 $235.22 $237.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-35030 SUP Custom 27203010 45-35030 - SLEEVE DRILL ASNS MIC HLD INSTR 3.5MM SCR BOTH IP/OP $664.13 $491.46 $0.00 $531.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.91 $492.91 $0.00 $0.00 $138.40 $0.00 $0.00 $0.00 $0.00 $332.06 $525.99 $531.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.010S SUP HCPCS C1713 456.010S - SLEEVE LCK 100D 15MM LGHT BLU STRL TI FEM 9-12MM IM NL SPRL BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 456.011S SUP HCPCS C1713 456.011S - SLEEVE LOCKING 110D 15MM LIGHT BLUE TITANIUM FEMUR STERILE BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 456.012S SUP HCPCS C1713 456.012S - SLEEVE LCK 120D 15MM LGHT BLU STRL TI FEM 9-12MM IM NL SPRL BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 456.013S SUP HCPCS C1713 456.013S - SLEEVE LOCKING 130D 15MM PINK TITANIUM FEMUR STERILE SPIRAL BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 456.100S SUP Custom 27803010 456.100S - BLADE FIX 100MM SPIRAL TITANIUM FEMUR STERILE INTRAMEDULLARY BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.105S SUP Custom 27803010 456.105S - BLADE FIX 105MM SPIRAL TITANIUM FEMUR STERILE INTRAMEDULLARY BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.110S SUP Custom 27803010 456.110S - BLADE FIX 110MM SPIRAL TITANIUM FEMUR STERILE INTRAMEDULLARY BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.115S SUP Custom 27803010 456.115S - BLADE FIX 115MM SPIRAL TITANIUM FEMUR STERILE INTRAMEDULLARY BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.120S SUP Custom 27803010 456.120S - BLADE FIX 120MM SPIRAL TITANIUM FEMUR STERILE INTRAMEDULLARY BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.300S SUP Custom 27803010 456.300S - BLADE INTRAMEDULLARY FIX HELIX 11MM 75MM HELICAL GOLD BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.301S SUP Custom 27803010 456.301S - BLADE INTRAMEDULLARY FIX HELIX 11MM 80MM GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.302S SUP Custom 27803010 456.302S - BLADE INTRAMEDULLARY FIX HELIX 11MM 85MM CANN GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.303S SUP Custom 27803010 456.303S - BLADE INTRAMEDULLARY FIX HELIX 11MM 90MM GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.304S SUP Custom 27803010 456.304S - BLADE INTRAMEDULLARY FIX HELIX 11MM 95MM GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.305S SUP Custom 27803010 456.305S - BLADE INTRAMEDULLARY FIX HELIX 11MM 100MM GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.306S SUP HCPCS C1713 456.306S - BLADE INTRAMEDULLARY FIX HELIX 11MM 105MM CANN GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $549.36 $549.36 $0.00 $0.00 $0.00 $262.08 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $743.77 $743.77 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $185.49 $0.00 $0.00 $194.35 $0.00 $0.00 $0.00 $0.00 $0.00 456.307S SUP Custom 27803010 456.307S - BLADE INTRAMEDULLARY FIX HELIX 11MM 110MM CANN GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.308S SUP Custom 27803010 456.308S - BLADE INTRAMEDULLARY FIX HELIX 11MM 115MM GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.309S SUP Custom 27803010 456.309S - BLADE INTRAMEDULLARY FIX HELIX 11MM 120MM GOLD TITANIUM BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.310S SUP Custom 27803010 456.310S - BLADE INTRAMEDULLARY FIX HELIX 11MM 125MM HELICAL GOLD BOTH IP/OP "$1,257.43 " $930.50 $0.00 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.26 $933.26 $0.00 $0.00 $262.05 $0.00 $0.00 $0.00 $0.00 $610.40 $966.87 $976.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.311S SUP Custom 27803010 456.311S - CAP END 0MM GREEN TITANIUM STERILE BOTH IP/OP $404.08 $299.02 $0.00 $313.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.90 $299.90 $0.00 $0.00 $84.21 $0.00 $0.00 $0.00 $0.00 $196.15 $310.70 $313.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.312S SUP Custom 27803010 456.312S - CAP END 5MM EXTEND GREEN TITANIUM TROC STERILE BOTH IP/OP $404.08 $299.02 $0.00 $313.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.90 $299.90 $0.00 $0.00 $84.21 $0.00 $0.00 $0.00 $0.00 $196.15 $310.70 $313.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.313S SUP Custom 27803010 456.313S - CAP END 10MM EXTEND GREEN TITANIUM TROC STERILE CANN BOTH IP/OP $404.08 $299.02 $0.00 $313.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.90 $299.90 $0.00 $0.00 $84.21 $0.00 $0.00 $0.00 $0.00 $196.15 $310.70 $313.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.314S SUP HCPCS C1713 456.314S - NAIL INTRAMEDULLARY 125D SHORT UNIVERSAL 10MM 170MM CANN BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.315S SUP HCPCS C1713 456.315S - NAIL INTRAMEDULLARY 130D SHORT UNIVERSAL 10MM 170MM CANN BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $497.96 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.316S SUP HCPCS C1713 456.316S - NAIL FIX 135D 10MM 17CM CANN GREEN TITANIUM TROCHANTER BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.317S SUP HCPCS C1713 456.317S - NAIL INTRAMEDULLARY 125D SHORT UNIVERSAL 11MM 170MM CANN BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.318S SUP HCPCS C1713 456.318S - NAIL INTRAMEDULLARY 130D SHORT UNIVERSAL 11MM 170MM CANN BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.319S SUP HCPCS C1713 456.319S - NAIL INTRAMEDULLARY 135D SHORT UNIVERSAL 11MM 170MM CANN BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.321S SUP HCPCS C1713 456.321S - NAIL INTRAMEDULLARY 125D SHORT UNIVERSAL 12MM 170MM CANN BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.322S SUP HCPCS C1713 456.322S - NAIL INTRAMEDULLARY 130D SHORT 12MM 170MM CANN STATIC INTLCK BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.323S SUP HCPCS C1713 456.323S - NAIL FIX 135D SHORT 12MM 170MM CANN STATIC INTLCK GREEN BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.324S SUP HCPCS C1713 456.324S - NAIL INTRAMEDULLARY 125D SHORT UNIVERSAL 10MM 235MM CANN BOTH IP/OP "$2,719.08 " "$2,012.12" $0.00 "$2,111.92" "$1,187.96" "$1,187.96" $0.00 $0.00 $0.00 $566.72 "$2,018.10" "$2,018.10" $0.00 $0.00 $566.66 $0.00 "$1,340.50" "$1,340.50" $0.00 "$1,319.95" "$2,090.80" "$2,111.92" $0.00 $0.00 $401.11 $0.00 $0.00 $420.27 $0.00 $0.00 $0.00 $0.00 $0.00 456.325S SUP HCPCS C1713 456.325S - NAIL INTRAMEDULLARY 130D SHORT UNIVERSAL 10MM 235MM CANN BOTH IP/OP "$2,719.08 " "$2,012.12" $0.00 "$2,111.92" "$1,187.96" "$1,187.96" $0.00 $0.00 $0.00 $566.72 "$2,018.10" "$2,018.10" $0.00 $0.00 $566.66 $0.00 "$1,340.50" "$1,340.50" $0.00 "$1,319.95" "$2,090.80" "$2,111.92" $0.00 $0.00 $401.11 $0.00 $0.00 $420.27 $0.00 $0.00 $0.00 $0.00 $0.00 456.326S SUP HCPCS C1713 456.326S - NAIL FIX 135D SHORT 10MM 23.5CM CANN GREEN TITANIUM TROC BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.327S SUP HCPCS C1713 456.327S - NAIL FIX 125D SHORT 11MM 23.5CM CANN GREEN TITANIUM BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.328S SUP HCPCS C1713 456.328S - NAIL INTRAMEDULLARY 130D SHORT UNIVERSAL 11MM 235MM CANN BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.329S SUP HCPCS C1713 456.329S - NAIL FIX 135D SHORT 11MM 23.5CM CANN GREEN TITANIUM BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.330S SUP HCPCS C1713 456.330S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 30CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.331S SUP HCPCS C1713 456.331S - NAIL INTRAMEDULLARY 125D LONG 10MM 30CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.332S SUP HCPCS C1713 456.332S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 32CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.333S SUP HCPCS C1713 456.333S - NAIL INTRAMEDULLARY 125D LONG 10MM 32CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.334S SUP HCPCS C1713 456.334S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 34CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.335S SUP HCPCS C1713 456.335S - NAIL INTRAMEDULLARY 125D LONG 10MM 34CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.336S SUP HCPCS C1713 456.336S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 36CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.337S SUP HCPCS C1713 456.337S - NAIL INTRAMEDULLARY 125D LONG 10MM 36CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.338S SUP HCPCS C1713 456.338S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 38CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.339S SUP HCPCS C1713 456.339S - NAIL INTRAMEDULLARY 125D LONG 10MM 38CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.340S SUP HCPCS C1713 456.340S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 40CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.341S SUP HCPCS C1713 456.341S - NAIL INTRAMEDULLARY 125D LONG 10MM 40CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.342S SUP HCPCS C1713 456.342S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 42CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.343S SUP HCPCS C1713 456.343S - NAIL INTRAMEDULLARY 125D LONG 10MM 42CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.344S SUP HCPCS C1713 456.344S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 44CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.345S SUP HCPCS C1713 456.345S - NAIL INTRAMEDULLARY 125D LONG 10MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.346S SUP HCPCS C1713 456.346S - NAIL INTRAMEDULLARY 125D LONG 17-10MM 46CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.347S SUP HCPCS C1713 456.347S - NAIL INTRAMEDULLARY 125D LONG 10MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.350S SUP HCPCS C1713 456.350S - NAIL INTRAMEDULLARY 130D LONG 17-10MM 30CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.351S SUP HCPCS C1713 456.351S - NAIL INTRAMEDULLARY 130D LONG 10MM 30CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.352S SUP HCPCS C1713 456.352S - NAIL INTRAMEDULLARY 130D LONG 17-10MM 32CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.353S SUP HCPCS C1713 456.353S - NAIL INTRAMEDULLARY 130D LONG 10MM 320MM CANN PREASSEMBLED BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.354S SUP HCPCS C1713 456.354S - NAIL INTRAMEDULLARY 130D LONG 17-10MM 34CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.355S SUP HCPCS C1713 456.355S - NAIL INTRAMEDULLARY 130D 10MM 34CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.356S SUP HCPCS C1713 456.356S - NAIL INTRAMEDULLARY 130D LONG 17-10MM 36CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.357S SUP HCPCS C1713 456.357S - NAIL FIX 130D 10MM 360MM CANN STATIC INTLCK GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.358S SUP HCPCS C1713 456.358S - NAIL INTRAMEDULLARY 130D LONG 10MM 38CM CANN INTERLOCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.359S SUP HCPCS C1713 456.359S - NAIL INTRAMEDULLARY 130D 10MM 380MM CANN STATIC INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.360S SUP HCPCS C1713 456.360S - NAIL INTRAMEDULLARY 130D LONG 17-10MM 40CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.361S SUP HCPCS C1713 456.361S - NAIL INTRAMEDULLARY 130D LONG 10MM 400MM CANN PREASSEMBLED BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.362S SUP HCPCS C1713 456.362S - NAIL INTRAMEDULLARY 130D LONG 17-10MM 42CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.363S SUP HCPCS C1713 456.363S - NAIL INTRAMEDULLARY 130D LONG 10MM 42CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.364S SUP HCPCS C1713 456.364S - NAIL INTRAMEDULLARY 130D LONG 17-10MM 44CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.365S SUP HCPCS C1713 456.365S - NAIL INTRAMEDULLARY 130D LONG 10MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.366S SUP HCPCS C1713 456.366S - NAIL INTRAMEDULLARY 130D LONG 17-10MM 46CM CANN INTLCK GREEN BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.367S SUP HCPCS C1713 456.367S - NAIL INTRAMEDULLARY 130D LONG 10MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.370S SUP HCPCS C1713 456.370S - NAIL INTRAMEDULLARY 135D LONG 10MM 33CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.371S SUP HCPCS C1713 456.371S - NAIL INTRAMEDULLARY 135D LONG 10MM 33CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.372S SUP HCPCS C1713 456.372S - NAIL INTRAMEDULLARY 135D LONG 10MM 320MM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.373S SUP HCPCS C1713 456.373S - NAIL INTRAMEDULLARY 135D LONG 10MM 32CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.374S SUP HCPCS C1713 456.374S - NAIL INTRAMEDULLARY 135D LONG 10MM 34CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.375S SUP HCPCS C1713 456.375S - NAIL INTRAMEDULLARY 135D LONG 10MM 34CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.376S SUP HCPCS C1713 456.376S - NAIL INTRAMEDULLARY 135D LONG 10MM 36CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.377S SUP HCPCS C1713 456.377S - NAIL INTRAMEDULLARY 135D LONG 10MM 36CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.378S SUP HCPCS C1713 456.378S - NAIL INTRAMEDULLARY 135D LONG 10MM 38CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.379S SUP HCPCS C1713 456.379S - NAIL INTRAMEDULLARY 135D LONG 10MM 38CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.380S SUP HCPCS C1713 456.380S - NAIL INTRAMEDULLARY 135D LONG 10MM 40CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.381S SUP HCPCS C1713 456.381S - NAIL INTRAMEDULLARY 135D LONG 10MM 40CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.382S SUP HCPCS C1713 456.382S - NAIL INTRAMEDULLARY 135D LONG 10MM 42CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.383S SUP HCPCS C1713 456.383S - NAIL INTRAMEDULLARY 135D LONG 10MM 42CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.384S SUP HCPCS C1713 456.384S - NAIL INTRAMEDULLARY 135D LONG 10MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.385S SUP HCPCS C1713 456.385S - NAIL INTRAMEDULLARY 135D LONG 10MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.386S SUP HCPCS C1713 456.386S - NAIL INTRAMEDULLARY 135D LONG 10MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.387S SUP HCPCS C1713 456.387S - NAIL INTRAMEDULLARY 135D LONG 10MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,578.28 " "$2,647.93" $0.00 "$2,779.24" "$1,563.32" "$1,563.32" $0.00 $0.00 $0.00 $745.80 "$2,655.80" "$2,655.80" $0.00 $0.00 $745.71 $0.00 "$1,764.09" "$1,764.09" $0.00 "$1,737.03" "$2,751.45" "$2,779.24" $0.00 $0.00 $527.85 $0.00 $0.00 $553.07 $0.00 $0.00 $0.00 $0.00 $0.00 456.390S SUP HCPCS C1713 456.390S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 33CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.391S SUP HCPCS C1713 456.391S - NAIL INTRAMEDULLARY 125D LONG 11MM 33CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.392S SUP HCPCS C1713 456.392S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 32CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.393S SUP HCPCS C1713 456.393S - NAIL INTRAMEDULLARY 125D LONG 11MM 32CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.394S SUP HCPCS C1713 456.394S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 34CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.395S SUP HCPCS C1713 456.395S - NAIL INTRAMEDULLARY 125D LONG 11MM 34CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.396S SUP HCPCS C1713 456.396S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 36CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.397S SUP HCPCS C1713 456.397S - NAIL INTRAMEDULLARY 125D 11MM 36CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.398S SUP HCPCS C1713 456.398S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 38CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.399S SUP HCPCS C1713 456.399S - NAIL INTRAMEDULLARY 125D 11MM 38CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.400S SUP HCPCS C1713 456.400S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 40CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.401S SUP HCPCS C1713 456.401S - NAIL INTRAMEDULLARY 125D 11MM 40CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.402S SUP HCPCS C1713 456.402S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 42CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.403S SUP HCPCS C1713 456.403S - NAIL INTRAMEDULLARY 125D LONG 11MM 42CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.404S SUP HCPCS C1713 456.404S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 44CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.405S SUP HCPCS C1713 456.405S - NAIL INTRAMEDULLARY 125D LONG 11MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.406S SUP HCPCS C1713 456.406S - NAIL INTRAMEDULLARY 125D LONG 17-11MM 46CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.407S SUP HCPCS C1713 456.407S - NAIL INTRAMEDULLARY 125D LONG 11MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.410S SUP HCPCS C1713 456.410S - NAIL INTRAMEDULLARY 130D LONG 11MM 30CM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.411S SUP HCPCS C1713 456.411S - NAIL FIX 130D SHORT 11MM 300MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.412S SUP HCPCS C1713 456.412S - NAIL FIX 130D SHORT 11MM 320MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.413S SUP HCPCS C1713 456.413S - NAIL FIX 130D SHORT 11MM 320MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.414S SUP HCPCS C1713 456.414S - NAIL FIX 130D 11MM 340MM CANN TITANIUM RIGHT TROCHANTER BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.415S SUP HCPCS C1713 456.415S - NAIL FIX 130D SHORT 11MM 340MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.416S SUP HCPCS C1713 456.416S - NAIL FIX 130D SHORT 11MM 360MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.417S SUP HCPCS C1713 456.417S - NAIL FIX 130D SHORT 11MM 360MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.418S SUP HCPCS C1713 456.418S - NAIL FIX 130D SHORT 11MM 380MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.419S SUP HCPCS C1713 456.419S - NAIL FIX 130D SHORT 11MM 380MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.420S SUP HCPCS C1713 456.420S - NAIL FIX 130D SHORT 11MM 400MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.421S SUP HCPCS C1713 456.421S - NAIL FIX 130D SHORT 11MM 400MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.422S SUP HCPCS C1713 456.422S - NAIL FIX 130D SHORT 11MM 420MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.423S SUP HCPCS C1713 456.423S - NAIL FIX 130D SHORT 11MM 420MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.424S SUP HCPCS C1713 456.424S - NAIL FIX 130D SHORT 11MM 440MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.425S SUP HCPCS C1713 456.425S - NAIL INTRAMEDULLARY 130D LONG 11MM 440MM CANN PREASSEMBLED BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.426S SUP HCPCS C1713 456.426S - NAIL FIX 130D LONG 11MM 460MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.427S SUP HCPCS C1713 456.427S - NAIL FIX 130D LONG 11MM 460MM CANN PREASSEMBLED LOCKING BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.430S SUP HCPCS C1713 456.430S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 33CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.431S SUP HCPCS C1713 456.431S - NAIL INTRAMEDULLARY 135D LONG 11MM 33CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.432S SUP HCPCS C1713 456.432S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 32CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.433S SUP HCPCS C1713 456.433S - NAIL INTRAMEDULLARY 135D LONG 11MM 32CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.434S SUP HCPCS C1713 456.434S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 34CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.435S SUP HCPCS C1713 456.435S - NAIL INTRAMEDULLARY 135D 11MM 34CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.436S SUP HCPCS C1713 456.436S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 36CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.437S SUP HCPCS C1713 456.437S - NAIL INTRAMEDULLARY 135D 11MM 36CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.438S SUP HCPCS C1713 456.438S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 38CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.439S SUP HCPCS C1713 456.439S - NAIL INTRAMEDULLARY 135D 11MM 38CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.440S SUP HCPCS C1713 456.440S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 40CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.441S SUP HCPCS C1713 456.441S - NAIL INTRAMEDULLARY 135D 11MM 40CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.442S SUP HCPCS C1713 456.442S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 42CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.443S SUP HCPCS C1713 456.443S - NAIL INTRAMEDULLARY 135D 11MM 42CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.444S SUP HCPCS C1713 456.444S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 44CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.445S SUP HCPCS C1713 456.445S - NAIL INTRAMEDULLARY 135D LONG 11MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.446S SUP HCPCS C1713 456.446S - NAIL INTRAMEDULLARY 135D LONG 17-11MM 46CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.447S SUP HCPCS C1713 456.447S - NAIL INTRAMEDULLARY 135D LONG 11MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.450S SUP HCPCS C1713 456.450S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 30CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.451S SUP HCPCS C1713 456.451S - NAIL INTRAMEDULLARY 125D 12MM 30CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.452S SUP HCPCS C1713 456.452S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 32CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.453S SUP HCPCS C1713 456.453S - NAIL INTRAMEDULLARY 125D LONG 12MM 32CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.454S SUP HCPCS C1713 456.454S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 34CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.455S SUP HCPCS C1713 456.455S - NAIL INTRAMEDULLARY 125D 12MM 34CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.456S SUP HCPCS C1713 456.456S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 36CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.457S SUP HCPCS C1713 456.457S - NAIL INTRAMEDULLARY 125D LONG 12MM 36CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.458S SUP HCPCS C1713 456.458S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 38CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.459S SUP HCPCS C1713 456.459S - NAIL INTRAMEDULLARY 125D LONG 12MM 38CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.460S SUP HCPCS C1713 456.460S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 40CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.461S SUP HCPCS C1713 456.461S - NAIL INTRAMEDULLARY 125D 12MM 40CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.462S SUP HCPCS C1713 456.462S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 42CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.463S SUP HCPCS C1713 456.463S - NAIL INTRAMEDULLARY 125D LONG 12MM 42CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.464S SUP HCPCS C1713 456.464S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 44CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.465S SUP HCPCS C1713 456.465S - NAIL INTRAMEDULLARY 125D LONG 12MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.466S SUP HCPCS C1713 456.466S - NAIL INTRAMEDULLARY 125D LONG 17-12MM 46CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.467S SUP HCPCS C1713 456.467S - NAIL INTRAMEDULLARY 125D LONG 12MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.470S SUP HCPCS C1713 456.470S - NAIL INTRAMEDULLARY 130D LONG 17-12MM 30CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.471S SUP HCPCS C1713 456.471S - NAIL INTRAMEDULLARY 130D 12MM 30CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.472S SUP HCPCS C1713 456.472S - NAIL INTRAMEDULLARY 130D LONG 17-12MM 32CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.473S SUP HCPCS C1713 456.473S - NAIL INTRAMEDULLARY 130D LONG 12MM 32CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.474S SUP HCPCS C1713 456.474S - NAIL INTRAMEDULLARY 130D LONG 12MM 34CM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.475S SUP HCPCS C1713 456.475S - NAIL INTRAMEDULLARY 130D LONG 12MM 34CM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.476S SUP HCPCS C1713 456.476S - NAIL INTRAMEDULLARY 130D LONG 12MM 36CM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.477S SUP HCPCS C1713 456.477S - NAIL INTRAMEDULLARY 130D LONG 12MM 36CM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.478S SUP HCPCS C1713 456.478S - NAIL INTRAMEDULLARY 130D LONG 12MM 380MM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.479S SUP HCPCS C1713 456.479S - NAIL INTRAMEDULLARY 130D LONG 12MM 380MM CANN PREASSEMBLED BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.480S SUP HCPCS C1713 456.480S - NAIL INTRAMEDULLARY 130D LONG 12MM 400MM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.481S SUP HCPCS C1713 456.481S - NAIL INTRAMEDULLARY 130D LONG 12MM 40CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.482S SUP HCPCS C1713 456.482S - NAIL INTRAMEDULLARY 130D LONG 12MM 420MM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.483S SUP HCPCS C1713 456.483S - NAIL INTRAMEDULLARY 130D LONG 12MM 420MM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.484S SUP HCPCS C1713 456.484S - NAIL INTRAMEDULLARY 130D LONG 12MM 440MM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.485S SUP HCPCS C1713 456.485S - NAIL INTRAMEDULLARY 130D 12MM 44CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.486S SUP HCPCS C1713 456.486S - NAIL INTRAMEDULLARY 130D LONG 12MM 460MM CANN PREASSEMBLE BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.487S SUP HCPCS C1713 456.487S - NAIL INTRAMEDULLARY 130D LONG 12MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.490S SUP HCPCS C1713 456.490S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 30CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.491S SUP HCPCS C1713 456.491S - NAIL INTRAMEDULLARY 135D LONG 12MM 33CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.492S SUP HCPCS C1713 456.492S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 32CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.493S SUP HCPCS C1713 456.493S - NAIL INTRAMEDULLARY 135D LONG 12MM 32CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.494S SUP HCPCS C1713 456.494S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 34CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.495S SUP HCPCS C1713 456.495S - NAIL INTRAMEDULLARY 135D 12MM 34CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.496S SUP HCPCS C1713 456.496S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 36CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.497S SUP HCPCS C1713 456.497S - NAIL INTRAMEDULLARY 135D 12MM 36CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.498S SUP HCPCS C1713 456.498S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 38CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.499S SUP HCPCS C1713 456.499S - NAIL INTRAMEDULLARY 135D 12MM 38CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.500S SUP HCPCS C1713 456.500S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 40CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.501S SUP HCPCS C1713 456.501S - NAIL INTRAMEDULLARY 135D LONG 12MM 40CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.502S SUP HCPCS C1713 456.502S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 42CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.503S SUP HCPCS C1713 456.503S - NAIL INTRAMEDULLARY 135D 12MM 42CM CANN TITANIUM LEFT TROC BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.504S SUP HCPCS C1713 456.504S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 44CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.505S SUP HCPCS C1713 456.505S - NAIL INTRAMEDULLARY 135D LONG 12MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.506S SUP HCPCS C1713 456.506S - NAIL INTRAMEDULLARY 135D LONG 17-12MM 46CM CANN INTLCK GREEN BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.507S SUP HCPCS C1713 456.507S - NAIL INTRAMEDULLARY 135D LONG 12MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,461.58 " "$2,561.57" $0.00 "$2,688.60" "$1,512.34" "$1,512.34" $0.00 $0.00 $0.00 $721.48 "$2,569.18" "$2,569.18" $0.00 $0.00 $721.39 $0.00 "$1,706.56" "$1,706.56" $0.00 "$1,680.38" "$2,661.71" "$2,688.60" $0.00 $0.00 $510.64 $0.00 $0.00 $535.03 $0.00 $0.00 $0.00 $0.00 $0.00 456.510S SUP HCPCS C1713 456.510S - NAIL FIX 125D SHORT 12MM 23.5CM CANN PREASSEMBLED LOCKING BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.511S SUP HCPCS C1713 456.511S - NAIL FIX 130D SHORT 12MM 23.5CM CANN PREASSEMBLED LOCKING BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.512S SUP HCPCS C1713 456.512S - NAIL FIX 135D SHORT 12MM 23.5CM CANN GREEN TITANIUM TROC BOTH IP/OP "$2,630.10 " "$1,946.27" $0.00 "$2,042.80" "$1,149.08" "$1,149.08" $0.00 $0.00 $0.00 $548.18 "$1,952.06" "$1,952.06" $0.00 $0.00 $548.11 $0.00 "$1,296.64" "$1,296.64" $0.00 "$1,276.75" "$2,022.37" "$2,042.80" $0.00 $0.00 $387.98 $0.00 $0.00 $406.52 $0.00 $0.00 $0.00 $0.00 $0.00 456.630S SUP HCPCS C1713 456.630S - NAIL INTRAMEDULLARY 130D LONG 14MM 30CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.631S SUP HCPCS C1713 456.631S - NAIL INTRAMEDULLARY 130D LONG 14MM 30CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.632S SUP HCPCS C1713 456.632S - NAIL INTRAMEDULLARY 130D 14MM 32CM CANN GREEN TITANIUM RIGHT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.633S SUP HCPCS C1713 456.633S - NAIL INTRAMEDULLARY 130D 14MM 32CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.634S SUP HCPCS C1713 456.634S - NAIL INTRAMEDULLARY 130D 14MM 130MM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.635S SUP HCPCS C1713 456.635S - NAIL INTRAMEDULLARY 130D LONG 14MM 34CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.636S SUP HCPCS C1713 456.636S - NAIL INTRAMEDULLARY 130D LONG 14MM 36CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.637S SUP HCPCS C1713 456.637S - NAIL INTRAMEDULLARY 130D 14MM 360MM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.638S SUP HCPCS C1713 456.638S - NAIL INTRAMEDULLARY 130D LONG 14MM 38CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.639S SUP HCPCS C1713 456.639S - NAIL INTRAMEDULLARY 130D 14MM 380MM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.640S SUP HCPCS C1713 456.640S - NAIL INTRAMEDULLARY 130D 14MM 40CM CANN GREEN TITANIUM RIGHT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.641S SUP HCPCS C1713 456.641S - NAIL INTRAMEDULLARY 130D 14MM 40CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.642S SUP HCPCS C1713 456.642S - NAIL INTRAMEDULLARY 130D 14MM 42CM CANN GREEN TITANIUM RIGHT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.643S SUP HCPCS C1713 456.643S - NAIL INTRAMEDULLARY 130D 14MM 42CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.644S SUP HCPCS C1713 456.644S - NAIL INTRAMEDULLARY 130D LONG 14MM 44CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.645S SUP HCPCS C1713 456.645S - NAIL INTRAMEDULLARY 130D 14MM 44CM CANN GREEN TITANIUM LEFT BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.646S SUP HCPCS C1713 456.646S - NAIL INTRAMEDULLARY 130D LONG 14MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.647S SUP HCPCS C1713 456.647S - NAIL INTRAMEDULLARY 130D LONG 14MM 46CM CANN GREEN TITANIUM BOTH IP/OP "$3,687.70 " "$2,728.90" $0.00 "$2,864.22" "$1,611.12" "$1,611.12" $0.00 $0.00 $0.00 $768.61 "$2,737.01" "$2,737.01" $0.00 $0.00 $768.52 $0.00 "$1,818.04" "$1,818.04" $0.00 "$1,790.14" "$2,835.58" "$2,864.22" $0.00 $0.00 $543.99 $0.00 $0.00 $569.98 $0.00 $0.00 $0.00 $0.00 $0.00 456.650S SUP Custom 27803010 456.650S - BLADE FIX 11MM 130MM HELICAL TITANIUM TROC STERILE BOTH IP/OP "$1,254.53 " $928.35 $0.00 $974.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $931.11 $931.11 $0.00 $0.00 $261.44 $0.00 $0.00 $0.00 $0.00 $608.99 $964.64 $974.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.70S SUP Custom 27803010 456.70S - BLADE FIX 70MM SPIRAL TITANIUM TROC STERILE INTRAMEDULLARY BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.75S SUP Custom 27803010 456.75S - BLADE INTRAMEDULLARY FIX 75MM SPIRAL TITANIUM FEMUR STERILE BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.80S SUP Custom 27803010 456.80S - BLADE INTRAMEDULLARY FIX 80MM SPIRAL TITANIUM FEMUR STERILE BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.85S SUP Custom 27803010 456.85S - BLADE INTRAMEDULLARY FIX 85MM SPIRAL TITANIUM FEMUR STERILE BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.90S SUP Custom 27803010 456.90S - BLADE INTRAMEDULLARY FIX 90MM SPIRAL TITANIUM FEMUR STERILE BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 456.95S SUP Custom 27803010 456.95S - BLADE INTRAMEDULLARY FIX 95MM SPIRAL TITANIUM FEMUR STERILE BOTH IP/OP "$1,326.88 " $981.89 $0.00 "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.81 $984.81 $0.00 $0.00 $276.52 $0.00 $0.00 $0.00 $0.00 $663.44 "$1,050.89" "$1,061.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-600 SUP HCPCS C1769 45-600 - CATH CEN VEN 5FR 50CM 1 LUM GWIRE VXCL PU .035IN BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 457.010S SUP Custom 27803010 457.010S - CAP END 0MM 15MM FEM XTD IM NAIL SPRL BLDE TI STRL LBLU BOTH IP/OP $542.30 $401.30 $0.00 $433.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $402.50 $402.50 $0.00 $0.00 $113.02 $0.00 $0.00 $0.00 $0.00 $271.15 $429.50 $433.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 457.011S SUP Custom 27803010 457.011S - CAP END 10MM EXTEND LIGHT BLUE TITANIUM FEMUR STERILE SPIRAL BOTH IP/OP $470.25 $347.99 $0.00 $376.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.02 $349.02 $0.00 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $235.13 $372.44 $376.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 457.012S SUP Custom 27803010 457.012S - CAP END 20MM 15MM EXTEND LIGHT BLUE TITANIUM FEMUR STERILE BOTH IP/OP $470.25 $347.99 $0.00 $376.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.02 $349.02 $0.00 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $235.13 $372.44 $376.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 457.210S SUP Custom 27803010 457.210S - CAP END 0MM FEM XTD LCK IM NAIL TI STRL PNK 15MM BOTH IP/OP $513.53 $380.01 $0.00 $410.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $381.14 $381.14 $0.00 $0.00 $107.02 $0.00 $0.00 $0.00 $0.00 $256.76 $406.72 $410.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 457.211S SUP Custom 27803010 457.211S - CAP END 130D 10MM 15MM LOCK PINK TITANIUM FEMUR STERILE BOTH IP/OP $446.88 $330.69 $0.00 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.67 $331.67 $0.00 $0.00 $93.13 $0.00 $0.00 $0.00 $0.00 $223.44 $353.93 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 457.212S SUP Custom 27803010 457.212S - CAP END 130D 20MM 15MM LOCK PINK TITANIUM FEMUR STERILE BOTH IP/OP $446.88 $330.69 $0.00 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.67 $331.67 $0.00 $0.00 $93.13 $0.00 $0.00 $0.00 $0.00 $223.44 $353.93 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 458.10S SUP Custom 27803010 458.10S - CAP END 6MM 15MM EXTEND BLUE TITANIUM TIBIA STERILE SOLID BOTH IP/OP $331.38 $245.22 $0.00 $265.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $245.95 $245.95 $0.00 $0.00 $69.06 $0.00 $0.00 $0.00 $0.00 $165.69 $262.45 $265.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 458.110S SUP Custom 27803010 458.110S - CAP END 15MM 15MM EXTN BLUE TITANIUM TIBIA STERILE SOLID BOTH IP/OP $541.75 $400.90 $0.00 $433.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $402.09 $402.09 $0.00 $0.00 $112.90 $0.00 $0.00 $0.00 $0.00 $270.88 $429.07 $433.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 458.120S SUP Custom 27803010 458.120S - CAP END 8MM 15MM TIB XTD HEX DRV CANN IM NAIL TI STRL GRN 8 BOTH IP/OP $307.65 $227.66 $0.00 $246.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.34 $228.34 $0.00 $0.00 $64.11 $0.00 $0.00 $0.00 $0.00 $153.83 $243.66 $246.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 458.926S SUP HCPCS C1713 458.926S - SCREW BN 3.5MM FT 5MM 8MM 26MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.928S SUP HCPCS C1713 458.928S - SCREW BN 3.5MM FT 5MM 8MM 28MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.930S SUP HCPCS C1713 458.930S - SCREW BN 3.5MM FT 5MM 8MM 30MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.932S SUP HCPCS C1713 458.932S - SCREW BN 3.5MM FT 5MM 8MM 32MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.934S SUP HCPCS C1713 458.934S - SCREW BN 3.5MM FT 5MM 8MM 34MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.936S SUP HCPCS C1713 458.936S - SCREW BN 3.5MM FT 5MM 8MM 36MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.938S SUP HCPCS C1713 458.938S - SCREW BN 3.5MM FT 5MM 8MM 38MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.940S SUP HCPCS C1713 458.940S - SCREW BN 3.5MM FT 5MM 8MM 40MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.942S SUP HCPCS C1713 458.942S - SCREW BN 3.5MM FT 5MM 8MM 42MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.944S SUP HCPCS C1713 458.944S - SCREW BN 3.5MM FT 5MM 8MM 44MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.946S SUP HCPCS C1713 458.946S - SCREW BN 3.5MM FT 5MM 8MM 46MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.948S SUP HCPCS C1713 458.948S - SCREW BN 3.5MM FT 5MM 8MM 48MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.950S SUP HCPCS C1713 458.950S - SCREW BN 3.5MM FT 5MM 8MM 50MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.952S SUP HCPCS C1713 458.952S - SCREW BN 3.5MM FT 5MM 8MM 52MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.954S SUP HCPCS C1713 458.954S - SCREW BN 3.5MM FT 5MM 8MM 54MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.956S SUP HCPCS C1713 458.956S - SCREW BN 3.5MM FT 5MM 8MM 56MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.958S SUP HCPCS C1713 458.958S - SCREW BN 3.5MM FT 5MM 8MM 58MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.960S SUP HCPCS C1713 458.960S - SCREW BN 3.5MM FT 5MM 8MM 60MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.964S SUP HCPCS C1713 458.964S - SCREW BN 3.5MM FT 5MM 8MM 64MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.968S SUP HCPCS C1713 458.968S - SCREW BN 3.5MM FT 5MM 8MM 68MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.972S SUP HCPCS C1713 458.972S - SCREW BN 3.5MM FT 5MM 8MM 72MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.976S SUP HCPCS C1713 458.976S - SCREW BN 3.5MM FT 5MM 8MM 76MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.980S SUP HCPCS C1713 458.980S - SCREW BN 3.5MM FT 5MM 8MM 80MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.985S SUP HCPCS C1713 458.985S - SCREW BN 3.5MM FT 5MM 8MM 85MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.990S SUP HCPCS C1713 458.990S - SCREW BN 3.5MM FT 5MM 8MM 90MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.995S SUP HCPCS C1713 458.995S - SCREW BN 3.5MM FT 5MM 8MM 95MM GRN STRL ST LCK 2 LD HEX TI BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 458.999S SUP HCPCS C1713 458.999S - SCREW BN 5MM 100MM GRN STRL NLEX LCK HEX RCS TI FEM TIB BOTH IP/OP $444.93 $329.25 $0.00 $345.56 $194.38 $194.38 $0.00 $0.00 $0.00 $92.73 $330.22 $330.22 $0.00 $0.00 $92.72 $0.00 $263.17 $263.17 $0.00 $215.98 $342.10 $345.56 $0.00 $0.00 $65.63 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $0.00 45-80001 SUP Custom 27203010 45-80001 - GUIDE DRILL CIRC LCK HOLE BOTH IP/OP $851.13 $629.84 $0.00 $680.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.70 $631.70 $0.00 $0.00 $177.37 $0.00 $0.00 $0.00 $0.00 $425.56 $674.09 $680.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-80005 SUP Custom 27203010 45-80005 - GUIDE DRILL OVL CMPR HOLE BOTH IP/OP $955.63 $707.17 $0.00 $764.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $709.26 $709.26 $0.00 $0.00 $199.15 $0.00 $0.00 $0.00 $0.00 $477.81 $756.86 $764.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 45-80010 SUP HCPCS C1713 45-80010 - PLATE BNDRG PLR BONE BOTH IP/OP $907.50 $671.55 $0.00 $726.00 $408.38 $408.38 $0.00 $0.00 $0.00 $189.15 $673.55 $673.55 $0.00 $0.00 $189.12 $0.00 $536.79 $536.79 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 45-80100 SUP HCPCS C1713 45-80100 - WIRE FX FT 1.6MM 200MM NS KRSH VARIAX FT LCK PLT SYS BOTH IP/OP $69.00 $51.06 $0.00 $51.21 $19.18 $19.18 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $0.00 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $21.31 $33.76 $34.10 $0.00 $0.00 $6.67 $0.00 $0.00 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 45-80200 SUP HCPCS C1713 45-80200 - WIRE FX 1.4MM 100MM NS KRSH SMTH VARIAX FT LCK PLT SYS BOTH IP/OP $29.25 $21.65 $0.00 $22.00 $12.38 $12.38 $0.00 $0.00 $0.00 $6.10 $21.71 $21.71 $0.00 $0.00 $6.10 $0.00 $17.30 $17.30 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $4.30 $0.00 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 45-80300 SUP Custom 27203010 45-80300 - PIN FIX 100MM 2.5MM STNM SS SMTH NONSTRL BOTH IP/OP $55.50 $41.07 $0.00 $41.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.19 $41.19 $0.00 $0.00 $11.57 $0.00 $0.00 $0.00 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 459.012S SUP Custom 27803010 459.012S - CAP END 0MM XTD 9-12MM IM NAIL STD LCK TI STRL GRN 12MM BOTH IP/OP $494.33 $365.80 $0.00 $395.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $366.89 $366.89 $0.00 $0.00 $103.02 $0.00 $0.00 $0.00 $0.00 $247.16 $391.51 $395.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 459.013S SUP Custom 27803010 459.013S - CAP END 10MM 12MM 12MM EXTENDED STANDARD LOCKING GREEN BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $0.00 $0.00 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 459.014S SUP Custom 27803010 459.014S - CAP END 20MM 12MM 12MM EXTENDED STANDARD LOCKING GREEN BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $0.00 $0.00 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.001.01S SUP Custom 27803010 460.001.01S - CLAMP TUBE 13MM CRANIAL FLP TI STRL BOTH IP/OP $940.50 $695.97 $0.00 $752.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $698.04 $698.04 $0.00 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $470.25 $744.88 $752.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.002.01S SUP Custom 27803010 460.002.01S - CLAMP TUBE 18MM CRANIAL FLP TI STRL BOTH IP/OP $974.25 $720.95 $0.00 $779.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.09 $723.09 $0.00 $0.00 $203.03 $0.00 $0.00 $0.00 $0.00 $487.13 $771.61 $779.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.003.01S SUP Custom 27803010 460.003.01S - CLAMP TUBE 22MM CRANIAL FLP TI STRL BOTH IP/OP "$1,010.25 " $747.59 $0.00 $808.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.81 $749.81 $0.00 $0.00 $210.54 $0.00 $0.00 $0.00 $0.00 $505.13 $800.12 $808.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.008.01S SUP Custom 27803010 460.008.01S - CLAMP TUBE 13MM CRANIAL FLP TI TXTR STRL BOTH IP/OP $974.25 $720.95 $0.00 $779.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.09 $723.09 $0.00 $0.00 $203.03 $0.00 $0.00 $0.00 $0.00 $487.13 $771.61 $779.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.009.01S SUP Custom 27803010 460.009.01S - CLAMP TUBE 18MM CRANIAL FLP TI TXTR STRL BOTH IP/OP "$1,010.25 " $747.59 $0.00 $808.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.81 $749.81 $0.00 $0.00 $210.54 $0.00 $0.00 $0.00 $0.00 $505.13 $800.12 $808.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.010.01S SUP Custom 27803010 460.010.01S - CLAMP TUBE 22MM CRANIAL FLP TI TXTR STRL BOTH IP/OP "$1,050.75 " $777.56 $0.00 $840.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $779.87 $779.87 $0.00 $0.00 $218.98 $0.00 $0.00 $0.00 $0.00 $525.38 $832.19 $840.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.022.05S SUP HCPCS C1713 460.022.05S - PIN ER RELS STRNL TI STRL BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $98.10 $98.10 $0.00 $0.00 $0.00 $45.44 $161.80 $161.80 $0.00 $0.00 $45.43 $0.00 $128.95 $128.95 $0.00 $109.00 $172.66 $174.40 $0.00 $0.00 $34.12 $0.00 $0.00 $34.71 $0.00 $0.00 $0.00 $0.00 $0.00 460.100.01S SUP Custom 27803010 460.100.01S - TI CRANIAL FLAP TUBE CLAMP 11MM DIA-STERILE BOTH IP/OP $893.25 $661.01 $0.00 $714.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.97 $662.97 $0.00 $0.00 $186.15 $0.00 $0.00 $0.00 $0.00 $446.63 $707.45 $714.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 460.107.01S SUP Custom 27803010 460.107.01S - TI CRANIAL FLAP TUBE CLAMP TEXTURED 11MM DIA-STERILE BOTH IP/OP $924.75 $684.32 $0.00 $739.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $686.35 $686.35 $0.00 $0.00 $192.72 $0.00 $0.00 $0.00 $0.00 $462.38 $732.40 $739.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-1001T SUP Custom 27203010 46-1001T - TEMPLATE SZ LG ANG PLT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-1002T SUP Custom 27203010 46-1002T - TEMPLATE SZ 2 ANG LCK PLT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-1003T SUP Custom 27203010 46-1003T - TEMPLATE SZ ANG LCK PLT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-1004 SUP Custom 27203010 46-1004 - DRILL TWIST 1.8MM MICRO 26MM 115MM STOP BOTH IP/OP $632.50 $468.05 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.44 $469.44 $0.00 $0.00 $131.81 $0.00 $0.00 $0.00 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-1006 SUP Custom 27203010 46-1006 - BIT DRL 1.6MM 50MM 22MM TWST STP LORENZ TRAUMAONE BOTH IP/OP $632.50 $468.05 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.44 $469.44 $0.00 $0.00 $131.81 $0.00 $0.00 $0.00 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-1007 SUP Custom 27203010 46-1007 - DRILL SURG 1.6MM 115MM 26MM STOP TRAUMAONE MANDIB BOTH IP/OP $632.50 $468.05 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.44 $469.44 $0.00 $0.00 $131.81 $0.00 $0.00 $0.00 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-1024T SUP Custom 27203010 46-1024T - TEMPLATE SZ STRG 24 HL PLT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-123 SUP Custom 27203010 46-123 - DRESSING WOUND LARGE ABSORBENT VEST NONADHERENT MULTILAYER BOTH IP/OP $26.47 $19.59 $0.00 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.65 $19.65 $0.00 $0.00 $5.52 $0.00 $0.00 $0.00 $0.00 $13.30 $21.07 $21.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-130 SUP Custom 27203010 46-130 - DRESSING HYDROCOLLOID XL ABSORBENT LATEX FREE SOFSORB BOTH IP/OP $750.02 $555.01 $0.00 $556.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.66 $556.66 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $25.12 $39.79 $40.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-133 SUP Custom 27203010 46-133 - DRESSING BURN ABSORBENT HIP LEG BOTH IP/OP $52.10 $38.55 $0.00 $51.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.67 $38.67 $0.00 $0.00 $10.86 $0.00 $0.00 $0.00 $0.00 $31.94 $50.60 $51.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-138 SUP Custom 27203010 DRESSING BURN 17 PLY GZE 36X36IN BOTH IP/OP $56.63 $41.91 $0.00 $45.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.31 $44.85 $45.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-152 SUP Custom 27203010 46-152 - DRESSING WOUND XL ABSORBENT VEST HIGH PERFORMANCE BOTH IP/OP $28.03 $20.74 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.80 $20.80 $0.00 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $14.22 $22.52 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-155 SUP Custom 27203010 46-155 - DRESSING WND STRL LF SFSRB ABS STDR LINR ADLT HIP LG BOTH IP/OP $31.02 $22.95 $0.00 $24.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.02 $23.02 $0.00 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $15.51 $24.57 $24.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 462.634S SUP Custom 27803010 462.634S - BLADE FIX 34MM SPIRAL SOLID TITANIUM HUMERUS STERILE BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $0.00 $0.00 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 462.636S SUP Custom 27803010 462.636S - BLADE INTRAMEDULLARY FIX 13MM 36MMX3.9MM SPIRAL CUTTING BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $0.00 $0.00 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 462.638S SUP Custom 27803010 462.638S - BLADE FIX 38MM SPIRAL SOLID TITANIUM HUMERUS STERILE BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $0.00 $0.00 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 462.640S SUP HCPCS C1713 462.640S - NAIL INTRAMEDULLARY 40MM SPIRAL BLADE TITANIUM STERILE BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $535.98 $535.98 $0.00 $0.00 $0.00 $255.70 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $725.65 $725.65 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $180.97 $0.00 $0.00 $189.62 $0.00 $0.00 $0.00 $0.00 $0.00 462.642S SUP HCPCS C1713 462.642S - BLADE INTRAMEDULLARY FIX 13MM 42MMX3.9MM SPIRAL CUTTING BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $535.98 $535.98 $0.00 $0.00 $0.00 $255.70 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $725.65 $725.65 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $180.97 $0.00 $0.00 $189.62 $0.00 $0.00 $0.00 $0.00 $0.00 462.644S SUP HCPCS C1713 462.644S - BLADE INTRAMEDULLARY FIX 44MM SPIRAL GOLD TITANIUM ALUMINUM BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $535.98 $535.98 $0.00 $0.00 $0.00 $255.70 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $725.65 $725.65 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $180.97 $0.00 $0.00 $189.62 $0.00 $0.00 $0.00 $0.00 $0.00 462.646S SUP HCPCS C1713 462.646S - BLADE INTRAMEDULLARY FIX 13MM 46MMX3.9MM SPIRAL CUTTING BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $535.98 $535.98 $0.00 $0.00 $0.00 $255.70 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $725.65 $725.65 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $180.97 $0.00 $0.00 $189.62 $0.00 $0.00 $0.00 $0.00 $0.00 462.648S SUP HCPCS C1713 462.648S - BLADE INTRAMEDULLARY FIX 48MM SPIRAL NAIL-EX TITANIUM BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $535.98 $535.98 $0.00 $0.00 $0.00 $255.70 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $725.65 $725.65 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $180.97 $0.00 $0.00 $189.62 $0.00 $0.00 $0.00 $0.00 $0.00 462.650S SUP HCPCS C1713 462.650S - BLADE INTRAMEDULLARY FIX 50MM SPIRAL GOLD TITANIUM ALUMINUM BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $535.98 $535.98 $0.00 $0.00 $0.00 $255.70 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $725.65 $725.65 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $180.97 $0.00 $0.00 $189.62 $0.00 $0.00 $0.00 $0.00 $0.00 462.652S SUP HCPCS C1713 462.652S - BLADE FIX 52MM CANN SPIRAL SOLID GOLD TITANIUM HUMERUS BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $535.98 $535.98 $0.00 $0.00 $0.00 $255.70 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $725.65 $725.65 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $180.97 $0.00 $0.00 $189.62 $0.00 $0.00 $0.00 $0.00 $0.00 462.654S SUP HCPCS C1713 462.654S - BLADE FIX 54MM CANN SPIRAL NAIL-EX TITANIUM HUMERUS STERILE BOTH IP/OP "$1,226.80 " $907.83 $0.00 $952.86 $535.98 $535.98 $0.00 $0.00 $0.00 $255.70 $910.53 $910.53 $0.00 $0.00 $255.67 $0.00 $725.65 $725.65 $0.00 $595.54 $943.34 $952.86 $0.00 $0.00 $180.97 $0.00 $0.00 $189.62 $0.00 $0.00 $0.00 $0.00 $0.00 462.660S SUP HCPCS C1713 462.660S - CAP END 0MM T25 STARDRIVE RECESS GOLD TITANIUM HUMERUS BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $194.91 $194.91 $0.00 $0.00 $0.00 $90.27 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $256.19 $256.19 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $67.78 $0.00 $0.00 $68.95 $0.00 $0.00 $0.00 $0.00 $0.00 462.665S SUP HCPCS C1713 462.665S - CAP END 5MM HUM XTD IM NAIL SPRL BLDE TI STRL BOTH IP/OP $494.33 $365.80 $0.00 $395.46 $222.45 $222.45 $0.00 $0.00 $0.00 $103.03 $366.89 $366.89 $0.00 $0.00 $103.02 $0.00 $292.39 $292.39 $0.00 $247.16 $391.51 $395.46 $0.00 $0.00 $77.36 $0.00 $0.00 $78.70 $0.00 $0.00 $0.00 $0.00 $0.00 462.666S SUP HCPCS C1713 462.666S - CAP END 10MM 3.5MM HEXAGONAL RECESS GOLD TITANIUM HUMERUS BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $194.91 $194.91 $0.00 $0.00 $0.00 $90.27 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $256.19 $256.19 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $67.78 $0.00 $0.00 $68.95 $0.00 $0.00 $0.00 $0.00 $0.00 462.667S SUP HCPCS C1713 462.667S - CAP END 15MM 3.5MM HEXAGONAL RECESS GOLD TITANIUM HUMERUS BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $194.91 $194.91 $0.00 $0.00 $0.00 $90.27 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $256.19 $256.19 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $67.78 $0.00 $0.00 $68.95 $0.00 $0.00 $0.00 $0.00 $0.00 462.719S SUP HCPCS C1713 462.719S - NAIL INTRAMEDULLARY UNIVERSAL 7.5MM 19CM SOLID ROUND CROSS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.723S SUP HCPCS C1713 462.723S - NAIL 7.5MM 23CM HUM IM SLD TI STRL BOTH IP/OP "$3,802.15 " "$2,813.59" $0.00 "$3,041.72" "$1,710.97" "$1,710.97" $0.00 $0.00 $0.00 $792.46 "$2,821.96" "$2,821.96" $0.00 $0.00 $792.37 $0.00 "$1,874.46" "$1,874.46" $0.00 "$1,901.08" "$3,011.30" "$3,041.72" $0.00 $0.00 $595.04 $0.00 $0.00 $605.30 $0.00 $0.00 $0.00 $0.00 $0.00 462.728S SUP HCPCS C1713 462.728S - NAIL INTRAMEDULLARY 7.5MM 280MM SOLID ROUND CROSS SECTION BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.729S SUP HCPCS C1713 462.729S - NAIL INTRAMEDULLARY 7.5MM 29.5CM SOLID BLUE TITANIUM HUMERUS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.731S SUP HCPCS C1713 462.731S - NAIL INTRAMEDULLARY 7.5MM 31CM SOLID TITANIUM HUMERUS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.732S SUP HCPCS C1713 462.732S - NAIL INTRAMEDULLARY 7.5MM 32.5CM SOLID TITANIUM HUMERUS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.919S SUP HCPCS C1713 462.919S - NAIL INTRAMEDULLARY UNIVERSAL 9.5MM 19CM SOLID FLUTED CROSS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.920S SUP HCPCS C1713 462.920S - NAIL INTRAMEDULLARY UNIVERSAL 9.5MM 20.5CM SOLID FLUTED BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.922S SUP HCPCS C1713 462.922S - NAIL INTRAMEDULLARY UNIVERSAL 9.5MM 22CM SOLID FLUTED CROSS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.923S SUP HCPCS C1713 462.923S - NAIL INTRAMEDULLARY UNIVERSAL 9.5MM 23CM SOLID FLUTED CROSS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.924S SUP HCPCS C1713 462.924S - NAIL INTRAMEDULLARY 9.5MM 240MM SOLID FLUTED CROSS SECTION BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.925S SUP HCPCS C1713 462.925S - NAIL 9.5MM 25CM HUM IM SLD TI STRL BOTH IP/OP "$3,802.15 " "$2,813.59" $0.00 "$3,041.72" "$1,710.97" "$1,710.97" $0.00 $0.00 $0.00 $792.46 "$2,821.96" "$2,821.96" $0.00 $0.00 $792.37 $0.00 "$1,874.46" "$1,874.46" $0.00 "$1,901.08" "$3,011.30" "$3,041.72" $0.00 $0.00 $595.04 $0.00 $0.00 $605.30 $0.00 $0.00 $0.00 $0.00 $0.00 462.927S SUP HCPCS C1713 462.927S - NAIL INTRAMEDULLARY UNIVERSAL 9.5MM 27CM SOLID FLUTED CROSS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.928S SUP HCPCS C1713 462.928S - NAIL INTRAMEDULLARY UNIVERSAL 9.5MM 28CM SOLID FLUTED CROSS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.929S SUP HCPCS C1713 462.929S - NAIL INTRAMEDULLARY UNIVERSAL 9.5MM 29.5CM SOLID FLUTED BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.931S SUP HCPCS C1713 462.931S - NAIL INTRAMEDULLARY 9.5MM 31CM SOLID TITANIUM HUMERUS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.932S SUP HCPCS C1713 462.932S - NAIL INTRAMEDULLARY 9.5MM 32.5CM SOLID TITANIUM HUMERUS BOTH IP/OP "$3,261.50 " "$2,413.51" $0.00 "$2,609.20" "$1,467.68" "$1,467.68" $0.00 $0.00 $0.00 $679.78 "$2,420.69" "$2,420.69" $0.00 $0.00 $679.70 $0.00 "$1,607.92" "$1,607.92" $0.00 "$1,630.75" "$2,583.11" "$2,609.20" $0.00 $0.00 $510.42 $0.00 $0.00 $519.23 $0.00 $0.00 $0.00 $0.00 $0.00 462.950S SUP Custom 27803010 462.950S - CAP END 5MM 2.5MM HEXAGONAL RECESS BLUE TITANIUM HUMERUS BOTH IP/OP $484.00 $358.16 $0.00 $387.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.22 $359.22 $0.00 $0.00 $100.87 $0.00 $0.00 $0.00 $0.00 $242.00 $383.33 $387.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 462.955S SUP Custom 27803010 462.955S - CAP END 5MM HUM XTD IM NAIL TI STRL BOTH IP/OP $559.10 $413.73 $0.00 $447.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $414.96 $414.96 $0.00 $0.00 $116.52 $0.00 $0.00 $0.00 $0.00 $279.55 $442.81 $447.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 462.960S SUP Custom 27803010 462.960S - CAP END HUM SLD IM NAIL TI STRL 10MM BOTH IP/OP $559.10 $413.73 $0.00 $447.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $414.96 $414.96 $0.00 $0.00 $116.52 $0.00 $0.00 $0.00 $0.00 $279.55 $442.81 $447.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 462.965S SUP Custom 27803010 462.965S - CAP END 15MM 3.5MM HEXAGONAL RECESS BLUE TITANIUM HUMERUS BOTH IP/OP $484.00 $358.16 $0.00 $387.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.22 $359.22 $0.00 $0.00 $100.87 $0.00 $0.00 $0.00 $0.00 $242.00 $383.33 $387.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 46-305 SUP HCPCS C1769 46-305 - GWIRE VASC STD .035IN 150CM 3CM ANG TIP STF SHFT GLDWR BOTH IP/OP $118.75 $87.88 $0.00 $95.00 $64.48 $64.48 $0.00 $0.00 $0.00 $24.75 $88.14 $88.14 $0.00 $0.00 $24.75 $0.00 $70.24 $70.24 $0.00 $59.38 $94.05 $95.00 $0.00 $0.00 $18.58 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 464.30S SUP HCPCS C1713 464.30S - NAIL INTRAMEDULLARY 9MM 30CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 464.32S SUP HCPCS C1713 464.32S - NAIL INTRAMEDULLARY 9MM 32CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 464.34S SUP HCPCS C1713 464.34S - NAIL INTRAMEDULLARY 9MM 34CM SOLID TITANIUM FEMUR STERILE BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 464.36S SUP HCPCS C1713 464.36S - NAIL INTRAMEDULLARY 9MM 36CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 464.38S SUP HCPCS C1713 464.38S - NAIL INTRAMEDULLARY 9MM 38CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 464.40S SUP HCPCS C1713 464.40S - NAIL 9MM 40CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 464.42S SUP HCPCS C1713 464.42S - NAIL INTRAMEDULLARY 9MM 420MM CANN SOLID TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 464.44S SUP HCPCS C1713 464.44S - NAIL 9MM 44CM FEM IM SLD TI STRL BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 464.46S SUP HCPCS C1713 464.46S - NAIL INTRAMEDULLARY 9MM 46CM SOLID TITANIUM FEMUR STERILE BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 464.48S SUP HCPCS C1713 464.48S - NAIL INTRAMEDULLARY 9MM 48CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 465.30S SUP HCPCS C1713 465.30S - NAIL 10MM 30CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 465.32S SUP HCPCS C1713 465.32S - NAIL INTRAMEDULLARY 10MM 32CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 465.34S SUP HCPCS C1713 465.34S - NAIL INTRAMEDULLARY 10MM 34CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 465.36S SUP HCPCS C1713 465.36S - NAIL INTRAMEDULLARY 10MM 36CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 465.38S SUP HCPCS C1713 465.38S - NAIL 10MM 380MM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 465.40S SUP HCPCS C1713 465.40S - NAIL INTRAMEDULLARY 10MM 40CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 465.42S SUP HCPCS C1713 465.42S - NAIL INTRAMEDULLARY 10MM 42CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 465.44S SUP HCPCS C1713 465.44S - NAIL INTRAMEDULLARY 10MM 44CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 465.46S SUP HCPCS C1713 465.46S - NAIL 10MM 46CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 465.48S SUP HCPCS C1713 465.48S - NAIL INTRAMEDULLARY 10MM 48CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 465440-20 SUP Custom 27203010 CONTROL CRP SYN VIGIL HI SNS LVL C LOW MDLR DATA RDC 5ML LX BOTH IP/OP $366.68 $271.34 $0.00 $293.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.34 $290.41 $293.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4655-03 SUP HCPCS C1776 4655-03 - HEAD FEM +5 UNV 32MM BOTH IP/OP "$2,607.50 " "$1,929.55" $0.00 "$2,086.00" "$1,173.38" "$1,173.38" $0.00 $0.00 $0.00 $543.47 "$1,935.29" "$1,935.29" $0.00 $0.00 $543.40 $0.00 "$1,285.50" "$1,285.50" $0.00 "$1,303.75" "$2,065.14" "$2,086.00" $0.00 $0.00 $408.07 $0.00 $0.00 $415.11 $0.00 $0.00 $0.00 $0.00 $0.00 466.30S SUP HCPCS C1713 466.30S - NAIL INTRAMEDULLARY 11MM 30CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 466.32S SUP HCPCS C1713 466.32S - NAIL INTRAMEDULLARY 11MM 32CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 466.34S SUP HCPCS C1713 466.34S - NAIL INTRAMEDULLARY 11MM 34CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 466.36S SUP HCPCS C1713 466.36S - NAIL 11MM 36CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 466.38S SUP HCPCS C1713 466.38S - NAIL INTRAMEDULLARY 11MM 38CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 466.40S SUP HCPCS C1713 466.40S - NAIL 11MM 40CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 466.42S SUP HCPCS C1713 466.42S - NAIL INTRAMEDULLARY 11MM 42CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 466.44S SUP HCPCS C1713 466.44S - NAIL INTRAMEDULLARY 11MM 44CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 466.46S SUP HCPCS C1713 466.46S - NAIL INTRAMEDULLARY 11MM 46CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 466.48S SUP HCPCS C1713 466.48S - NAIL INTRAMEDULLARY 11MM 48CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 46-605 SUP HCPCS C1769 46-605 - GWIRE VASC .018IN 260CM 3CM TIP SHRT TPR SPCL PLTN PLUS GLDX BOTH IP/OP $45.18 $33.43 $0.00 $36.14 $24.53 $24.53 $0.00 $0.00 $0.00 $9.42 $33.53 $33.53 $0.00 $0.00 $9.41 $0.00 $26.72 $26.72 $0.00 $22.59 $35.78 $36.14 $0.00 $0.00 $7.07 $0.00 $0.00 $7.19 $0.00 $0.00 $0.00 $0.00 $0.00 466P306A SUP HCPCS C1884 466P306A - FILTER EMBL 55CM LF TRPS CATH SHTH INTRO KT BOTH IP/OP "$3,112.50 " "$2,303.25" $0.00 "$2,490.00" "$1,400.63" "$1,400.63" $0.00 $0.00 $0.00 $648.72 "$2,310.10" "$2,310.10" $0.00 $0.00 $648.65 $0.00 "$1,534.46" "$1,534.46" $0.00 "$1,556.25" "$2,465.10" "$2,490.00" $0.00 $0.00 $487.11 $0.00 $0.00 $495.51 $0.00 $0.00 $0.00 $0.00 $0.00 467.30S SUP HCPCS C1713 467.30S - NAIL 12MM 30CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 467.32S SUP HCPCS C1713 467.32S - NAIL INTRAMEDULLARY 12MM 32CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 467.34S SUP HCPCS C1713 467.34S - NAIL INTRAMEDULLARY 12MM 34CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 467.36S SUP HCPCS C1713 467.36S - NAIL INTRAMEDULLARY 12MM 36CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 467.38S SUP HCPCS C1713 467.38S - NAIL INTRAMEDULLARY 12MM 38CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 467.40S SUP HCPCS C1713 467.40S - NAIL 12MM 40CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 467.42S SUP HCPCS C1713 467.42S - NAIL INTRAMEDULLARY 12MM 420MM SOLID GREEN TITANIUM FEMORAL BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 467.44S SUP HCPCS C1713 467.44S - NAIL INTRAMEDULLARY 12MM 44CM SOLID GREEN TITANIUM FEMUR BOTH IP/OP "$2,054.25 " "$1,520.15" $0.00 "$1,643.40" $924.41 $924.41 $0.00 $0.00 $0.00 $428.16 "$1,524.66" "$1,524.66" $0.00 $0.00 $428.11 $0.00 "$1,215.09" "$1,215.09" $0.00 "$1,027.13" "$1,626.97" "$1,643.40" $0.00 $0.00 $321.49 $0.00 $0.00 $327.04 $0.00 $0.00 $0.00 $0.00 $0.00 467.46S SUP HCPCS C1713 467.46S - NAIL 12MM 46CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 467.48S SUP HCPCS C1713 467.48S - NAIL 12MM 48CM FEM IM SLD TI STRL GRN BOTH IP/OP "$2,344.43 " "$1,734.88" $0.00 "$1,875.54" "$1,054.99" "$1,054.99" $0.00 $0.00 $0.00 $488.64 "$1,740.03" "$1,740.03" $0.00 $0.00 $488.58 $0.00 "$1,386.73" "$1,386.73" $0.00 "$1,172.21" "$1,856.79" "$1,875.54" $0.00 $0.00 $366.90 $0.00 $0.00 $373.23 $0.00 $0.00 $0.00 $0.00 $0.00 46-804 SUP HCPCS C1769 46-804 - GUIDEWIRE TRANSEND EX .014 BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $509.06 $509.06 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 46-806 SUP HCPCS C1769 GUIDEWIRE VASC .014IN 205CM 2CM SHP TIP SFTP TRNSD EX HYDPHI BOTH IP/OP $20.30 $15.02 $0.00 $16.24 $11.02 $11.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.15 $16.08 $16.24 $0.00 $0.00 $3.18 $0.00 $0.00 $3.23 $0.00 $0.00 $0.00 $0.00 $0.00 46B005 SUP HCPCS V2790 46B005 - GRAFT SFT TIS 25X15X15MM PATLR TNDN TIB STRUT WHL BOTH IP/OP "$8,265.00 " "$6,116.10" $0.00 "$6,612.00" "$3,719.25" "$3,719.25" $0.00 $0.00 $0.00 "$1,722.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,722.43" $0.00 "$4,074.65" "$4,074.65" $0.00 "$4,132.50" "$6,545.88" "$6,612.00" $0.00 $0.00 "$1,293.47" $0.00 $0.00 "$1,315.79" $0.00 $0.00 $0.00 $0.00 $0.00 47-2255-008-01 SUP Custom 27203010 47-2255-008-01 - GWIRE ORTH 100CM 3MM SS ANTGRD IM FIX SYS STRL BOTH IP/OP $251.25 $185.93 $0.00 $201.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.48 $186.48 $0.00 $0.00 $52.36 $0.00 $0.00 $0.00 $0.00 $125.63 $198.99 $201.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 47-2483-060-50 SUP HCPCS C1713 47-2483-060-50 - SCREW BONE 3.5MM 5MM 60MM NTR NAIL TI6AL4V ALLOY CORT PTTHRD BOTH IP/OP $381.35 $282.20 $0.00 $305.08 $171.61 $171.61 $0.00 $0.00 $0.00 $79.48 $283.04 $283.04 $0.00 $0.00 $79.47 $0.00 $225.57 $225.57 $0.00 $190.68 $302.03 $305.08 $0.00 $0.00 $59.68 $0.00 $0.00 $60.71 $0.00 $0.00 $0.00 $0.00 $0.00 47-2483-095-60 SUP HCPCS C1713 47-2483-095-60 - SCREW BONE 6MM 3.5MM 95MM NTR NAIL TI6AL4V ALLOY CANC PTTHRD BOTH IP/OP $426.30 $315.46 $0.00 $341.04 $191.84 $191.84 $0.00 $0.00 $0.00 $88.85 $316.40 $316.40 $0.00 $0.00 $88.84 $0.00 $252.16 $252.16 $0.00 $213.15 $337.63 $341.04 $0.00 $0.00 $66.72 $0.00 $0.00 $67.87 $0.00 $0.00 $0.00 $0.00 $0.00 47-2484-042-50 SUP HCPCS C1713 47-2484-042-50 - SCREW BONE 5MM 42.5MM NTR NAIL TI6AL4V ALLOY FULTHD CORT BOTH IP/OP $381.35 $282.20 $0.00 $305.08 $171.61 $171.61 $0.00 $0.00 $0.00 $79.48 $283.04 $283.04 $0.00 $0.00 $79.47 $0.00 $225.57 $225.57 $0.00 $190.68 $302.03 $305.08 $0.00 $0.00 $59.68 $0.00 $0.00 $60.71 $0.00 $0.00 $0.00 $0.00 $0.00 47-2484-045-50 SUP HCPCS C1713 47-2484-045-50 - SCREW BONE 5MM 45MM TI 3.5MM CORT FIXANG HX HD BOTH IP/OP $381.35 $282.20 $0.00 $305.08 $171.61 $171.61 $0.00 $0.00 $0.00 $79.48 $283.04 $283.04 $0.00 $0.00 $79.47 $0.00 $225.57 $225.57 $0.00 $190.68 $302.03 $305.08 $0.00 $0.00 $59.68 $0.00 $0.00 $60.71 $0.00 $0.00 $0.00 $0.00 $0.00 47-2484-070-60 SUP HCPCS C1713 47-2484-070-60 - SCREW BONE 6MM 3.5MM 70MM NTR NAIL TI6AL4V ALLOY CANC FIXANG BOTH IP/OP $395.85 $292.93 $0.00 $316.68 $178.13 $178.13 $0.00 $0.00 $0.00 $82.51 $293.80 $293.80 $0.00 $0.00 $82.50 $0.00 $234.15 $234.15 $0.00 $197.93 $313.51 $316.68 $0.00 $0.00 $61.95 $0.00 $0.00 $63.02 $0.00 $0.00 $0.00 $0.00 $0.00 47-2484-075-50 SUP HCPCS C1713 47-2484-075-50 - SCREW BONE 5MM 3.5MM 75MM NTR NAIL TI6AL4V ALLOY CORT FIXANG BOTH IP/OP $381.35 $282.20 $0.00 $305.08 $171.61 $171.61 $0.00 $0.00 $0.00 $79.48 $283.04 $283.04 $0.00 $0.00 $79.47 $0.00 $225.57 $225.57 $0.00 $190.68 $302.03 $305.08 $0.00 $0.00 $59.68 $0.00 $0.00 $60.71 $0.00 $0.00 $0.00 $0.00 $0.00 47-2484-075-60 SUP HCPCS C1713 47-2484-075-60 - SCREW BONE 6MM 3.5MM 75MM NTR NAIL TI CANC FIXANG HEX HEAD BOTH IP/OP $395.85 $292.93 $0.00 $316.68 $178.13 $178.13 $0.00 $0.00 $0.00 $82.51 $293.80 $293.80 $0.00 $0.00 $82.50 $0.00 $234.15 $234.15 $0.00 $197.93 $313.51 $316.68 $0.00 $0.00 $61.95 $0.00 $0.00 $63.02 $0.00 $0.00 $0.00 $0.00 $0.00 47-2484-095-60 SUP HCPCS C1713 47-2484-095-60 - SCREW BONE 6MM 3.5MM 95MM NTR NAIL TI CANC FIXANG HEX HEAD BOTH IP/OP $395.85 $292.93 $0.00 $316.68 $178.13 $178.13 $0.00 $0.00 $0.00 $82.51 $293.80 $293.80 $0.00 $0.00 $82.50 $0.00 $234.15 $234.15 $0.00 $197.93 $313.51 $316.68 $0.00 $0.00 $61.95 $0.00 $0.00 $63.02 $0.00 $0.00 $0.00 $0.00 $0.00 47-2485-095-10 SUP HCPCS C1713 47-2485-095-10 - SCREW BONE 10.5MM 95MM NTR NAIL TI6AL4V ALLOY LAG BOTH IP/OP "$1,074.45 " $795.09 $0.00 $859.56 $483.50 $483.50 $0.00 $0.00 $0.00 $223.94 $797.46 $797.46 $0.00 $0.00 $223.92 $0.00 $635.54 $635.54 $0.00 $537.23 $850.96 $859.56 $0.00 $0.00 $168.15 $0.00 $0.00 $171.05 $0.00 $0.00 $0.00 $0.00 $0.00 47-2487-001-00 SUP HCPCS C1713 47-2487-001-00 - NAIL FEM IM 0MM ANTGRD CAP BOTH IP/OP $411.80 $304.73 $0.00 $329.44 $185.31 $185.31 $0.00 $0.00 $0.00 $85.83 $305.64 $305.64 $0.00 $0.00 $85.82 $0.00 $243.58 $243.58 $0.00 $205.90 $326.15 $329.44 $0.00 $0.00 $64.45 $0.00 $0.00 $65.56 $0.00 $0.00 $0.00 $0.00 $0.00 47-2487-002-00 SUP HCPCS C1713 47-2487-002-00 - CAP END 0MM CEPHALOMEDULLARY NAIL TI6AL4V ALLOY NTR NAIL BOTH IP/OP $395.85 $292.93 $0.00 $316.68 $178.13 $178.13 $0.00 $0.00 $0.00 $82.51 $293.80 $293.80 $0.00 $0.00 $82.50 $0.00 $234.15 $234.15 $0.00 $197.93 $313.51 $316.68 $0.00 $0.00 $61.95 $0.00 $0.00 $63.02 $0.00 $0.00 $0.00 $0.00 $0.00 47-2487-005-00 SUP HCPCS C1713 47-2487-005-00 - CAP END 0MM TIB Z NTR NAIL BOTH IP/OP $411.80 $304.73 $0.00 $329.44 $185.31 $185.31 $0.00 $0.00 $0.00 $85.83 $305.64 $305.64 $0.00 $0.00 $85.82 $0.00 $243.58 $243.58 $0.00 $205.90 $326.15 $329.44 $0.00 $0.00 $64.45 $0.00 $0.00 $65.56 $0.00 $0.00 $0.00 $0.00 $0.00 47-2487-008-00 SUP HCPCS C1713 47-2487-008-00 - CAP END 0MM FEM RTRGRD TI ALLOY NTR NAIL BOTH IP/OP $411.80 $304.73 $0.00 $329.44 $185.31 $185.31 $0.00 $0.00 $0.00 $85.83 $305.64 $305.64 $0.00 $0.00 $85.82 $0.00 $243.58 $243.58 $0.00 $205.90 $326.15 $329.44 $0.00 $0.00 $64.45 $0.00 $0.00 $65.56 $0.00 $0.00 $0.00 $0.00 $0.00 47-2488-000-01 SUP HCPCS C1713 47-2488-000-01 - NUT ORTH CORT FEM KNEE TI RTRGRD 6 MM CANC SCR NTR NAIL SYS BOTH IP/OP $208.00 $153.92 $0.00 $166.40 $93.60 $93.60 $0.00 $0.00 $0.00 $43.35 $154.38 $154.38 $0.00 $0.00 $43.35 $0.00 $123.03 $123.03 $0.00 $104.00 $164.74 $166.40 $0.00 $0.00 $32.55 $0.00 $0.00 $33.11 $0.00 $0.00 $0.00 $0.00 $0.00 47-2488-000-02 SUP HCPCS C1713 47-2488-000-02 - WASHER CORT NTR NAIL ORTH TI ALLOY STRL BOTH IP/OP $175.50 $129.87 $0.00 $140.40 $78.98 $78.98 $0.00 $0.00 $0.00 $36.58 $130.26 $130.26 $0.00 $0.00 $36.57 $0.00 $103.81 $103.81 $0.00 $87.75 $139.00 $140.40 $0.00 $0.00 $27.47 $0.00 $0.00 $27.94 $0.00 $0.00 $0.00 $0.00 $0.00 47-2491-360-12 SUP HCPCS C1713 47-2491-360-12 - NAIL 12MM 36CM PIRIFORMIS FOSSA FEM NTR NAIL IM UNV ANTGRD BOTH IP/OP "$3,408.95 " "$2,522.62" $0.00 "$2,727.16" "$1,534.03" "$1,534.03" $0.00 $0.00 $0.00 $710.51 "$2,530.12" "$2,530.12" $0.00 $0.00 $710.43 $0.00 "$1,680.61" "$1,680.61" $0.00 "$1,704.48" "$2,699.89" "$2,727.16" $0.00 $0.00 $533.50 $0.00 $0.00 $542.70 $0.00 $0.00 $0.00 $0.00 $0.00 47-2492-360-12 SUP HCPCS C1713 47-2492-360-12 - NAIL 12MM 36CM RIGHT GT IM BOTH IP/OP "$3,408.95 " "$2,522.62" $0.00 "$2,727.16" "$1,534.03" "$1,534.03" $0.00 $0.00 $0.00 $710.51 "$2,530.12" "$2,530.12" $0.00 $0.00 $710.43 $0.00 "$1,680.61" "$1,680.61" $0.00 "$1,704.48" "$2,699.89" "$2,727.16" $0.00 $0.00 $533.50 $0.00 $0.00 $542.70 $0.00 $0.00 $0.00 $0.00 $0.00 47-2493-210-11 SUP HCPCS C1713 47-2493-210-11 - NAIL 11.5MM 21.5CM RIGHT DPHSL CEPHALOMEDULLARY NTR NAIL IM BOTH IP/OP "$2,965.25 " "$2,194.29" $0.00 "$2,372.20" "$1,334.36" "$1,334.36" $0.00 $0.00 $0.00 $618.03 "$2,200.81" "$2,200.81" $0.00 $0.00 $617.96 $0.00 "$1,461.87" "$1,461.87" $0.00 "$1,482.63" "$2,348.48" "$2,372.20" $0.00 $0.00 $464.06 $0.00 $0.00 $472.07 $0.00 $0.00 $0.00 $0.00 $0.00 47-2493-360-11 SUP HCPCS C1713 47-2493-360-11 - NAIL 11.5MM 36CM RIGHT DPHSL CEPHALOMEDULLARY NTR NAIL IM BOTH IP/OP "$4,463.10 " "$3,302.69" $0.00 "$3,570.48" "$2,008.40" "$2,008.40" $0.00 $0.00 $0.00 $930.22 "$3,312.51" "$3,312.51" $0.00 $0.00 $930.11 $0.00 "$2,200.31" "$2,200.31" $0.00 "$2,231.55" "$3,534.78" "$3,570.48" $0.00 $0.00 $698.48 $0.00 $0.00 $710.53 $0.00 $0.00 $0.00 $0.00 $0.00 47-2494-200-11 SUP HCPCS C1713 47-2494-200-11 - NAIL 11.5MM 20CM FEM NTR NAIL IM UNV SHRT RTRGRD TI ALLOY BOTH IP/OP "$4,218.05 " "$3,121.36" $0.00 "$3,374.44" "$1,898.12" "$1,898.12" $0.00 $0.00 $0.00 $879.15 "$3,130.64" "$3,130.64" $0.00 $0.00 $879.04 $0.00 "$2,079.50" "$2,079.50" $0.00 "$2,109.03" "$3,340.70" "$3,374.44" $0.00 $0.00 $660.12 $0.00 $0.00 $671.51 $0.00 $0.00 $0.00 $0.00 $0.00 47-2494-360-11 SUP HCPCS C1713 47-2494-360-11 - NAIL 11.5MM 36CM FEM NTR NAIL IM UNV LNG RTRGRD TI BOTH IP/OP "$4,218.05 " "$3,121.36" $0.00 "$3,374.44" "$1,898.12" "$1,898.12" $0.00 $0.00 $0.00 $879.15 "$3,130.64" "$3,130.64" $0.00 $0.00 $879.04 $0.00 "$2,079.50" "$2,079.50" $0.00 "$2,109.03" "$3,340.70" "$3,374.44" $0.00 $0.00 $660.12 $0.00 $0.00 $671.51 $0.00 $0.00 $0.00 $0.00 $0.00 47-2495-320-12 SUP HCPCS C1713 47-2495-320-12 - NAIL 12MM 32CM TIB NTR NAIL IM UNV TI6AL4V BOTH IP/OP "$3,240.75 " "$2,398.16" $0.00 "$2,592.60" "$1,458.34" "$1,458.34" $0.00 $0.00 $0.00 $675.45 "$2,405.28" "$2,405.28" $0.00 $0.00 $675.37 $0.00 "$1,597.69" "$1,597.69" $0.00 "$1,620.38" "$2,566.67" "$2,592.60" $0.00 $0.00 $507.18 $0.00 $0.00 $515.93 $0.00 $0.00 $0.00 $0.00 $0.00 474.031S SUP HCPCS C1713 474.031S - NAIL 10MM 30CM FEM IM CANN TI STRL GRN BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.032S SUP HCPCS C1713 474.032S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 320MM CANN ROUND BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.034S SUP HCPCS C1713 474.034S - NAIL INTRAMEDULLARY 10MM 34CM CANN GREEN TITANIUM FEMUR BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.036S SUP HCPCS C1713 474.036S - NAIL 10MM 36CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.038S SUP HCPCS C1713 474.038S - NAIL 10MM 38CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.041S SUP HCPCS C1713 474.041S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 400MM CANN ROUND BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.042S SUP HCPCS C1713 474.042S - NAIL 10MM 42CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.044S SUP HCPCS C1713 474.044S - NAIL 10MM 44CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.046S SUP HCPCS C1713 474.046S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 460MM CANN ROUND BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.048S SUP HCPCS C1713 474.048S - NAIL INTRAMEDULLARY UNIVERSAL 10MM 480MM CANN ROUND BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.131S SUP HCPCS C1713 474.131S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 300MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.132S SUP HCPCS C1713 474.132S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 320MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.134S SUP HCPCS C1713 474.134S - NAIL 11MM 34CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.136S SUP HCPCS C1713 474.136S - NAIL 11MM 36CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.138S SUP HCPCS C1713 474.138S - NAIL 11MM 38CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.141S SUP HCPCS C1713 474.141S - NAIL 11MM 41CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.142S SUP HCPCS C1713 474.142S - NAIL 11MM 42CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.144S SUP HCPCS C1713 474.144S - NAIL 11MM 44CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.146S SUP HCPCS C1713 474.146S - NAIL 11MM 46CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.148S SUP HCPCS C1713 474.148S - NAIL INTRAMEDULLARY UNIVERSAL 11MM 480MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.231S SUP HCPCS C1713 474.231S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 300MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.232S SUP HCPCS C1713 474.232S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 320MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.234S SUP HCPCS C1713 474.234S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 340MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.236S SUP HCPCS C1713 474.236S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 360MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.238S SUP HCPCS C1713 474.238S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 380MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.241S SUP HCPCS C1713 474.241S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 400MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.242S SUP HCPCS C1713 474.242S - NAIL 12MM 42CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.244S SUP HCPCS C1713 474.244S - NAIL 12MM 44CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.246S SUP HCPCS C1713 474.246S - NAIL INTRAMEDULLARY 12MM 460MM CANN GREEN TITANIUM FEMUR BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.248S SUP HCPCS C1713 474.248S - NAIL INTRAMEDULLARY UNIVERSAL 12MM 480MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.331S SUP HCPCS C1713 474.331S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 300MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.332S SUP HCPCS C1713 474.332S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 320MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.334S SUP HCPCS C1713 474.334S - NAIL 13MM 34CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.336S SUP HCPCS C1713 474.336S - NAIL 13MM 36CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.338S SUP HCPCS C1713 474.338S - NAIL 13MM 38CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.341S SUP HCPCS C1713 474.341S - NAIL 13MM 40CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.342S SUP HCPCS C1713 474.342S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 420MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.344S SUP HCPCS C1713 474.344S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 440MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.346S SUP HCPCS C1713 474.346S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 460MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.348S SUP HCPCS C1713 474.348S - NAIL INTRAMEDULLARY UNIVERSAL 13MM 480MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.431S SUP HCPCS C1713 474.431S - NAIL 14MM 30CM FEM IM CANN TI STRL GRN BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.432S SUP HCPCS C1713 474.432S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 320MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.434S SUP HCPCS C1713 474.434S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 340MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.436S SUP HCPCS C1713 474.436S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 360MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.438S SUP HCPCS C1713 474.438S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 380MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.441S SUP HCPCS C1713 474.441S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 400MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.442S SUP HCPCS C1713 474.442S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 420MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.444S SUP HCPCS C1713 474.444S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 440MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.446S SUP HCPCS C1713 474.446S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 460MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.448S SUP HCPCS C1713 474.448S - NAIL INTRAMEDULLARY UNIVERSAL 14MM 480MM CANN FLUTED BARREL BOTH IP/OP "$2,492.88 " "$1,844.73" $0.00 "$1,994.30" "$1,121.79" "$1,121.79" $0.00 $0.00 $0.00 $519.58 "$1,850.21" "$1,850.21" $0.00 $0.00 $519.52 $0.00 "$1,474.54" "$1,474.54" $0.00 "$1,246.44" "$1,974.36" "$1,994.30" $0.00 $0.00 $390.13 $0.00 $0.00 $396.87 $0.00 $0.00 $0.00 $0.00 $0.00 474.531S SUP HCPCS C1713 474.531S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 300MM CANN FLUTED BARREL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" "$1,158.30" "$1,158.30" $0.00 $0.00 $0.00 $536.49 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 "$1,268.98" "$1,268.98" $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $402.83 $0.00 $0.00 $409.78 $0.00 $0.00 $0.00 $0.00 $0.00 474.532S SUP HCPCS C1713 474.532S - NAIL 15MM 32CM FEM IM CANN TI STRL GRN BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.534S SUP HCPCS C1713 474.534S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 340MM CANN FLUTED BARREL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" "$1,158.30" "$1,158.30" $0.00 $0.00 $0.00 $536.49 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 "$1,268.98" "$1,268.98" $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $402.83 $0.00 $0.00 $409.78 $0.00 $0.00 $0.00 $0.00 $0.00 474.536S SUP HCPCS C1713 474.536S - NAIL 15MM 36CM FEM IM CANN TI STRL GRN BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.538S SUP HCPCS C1713 474.538S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 380MM CANN FLUTED BARREL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" "$1,158.30" "$1,158.30" $0.00 $0.00 $0.00 $536.49 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 "$1,268.98" "$1,268.98" $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $402.83 $0.00 $0.00 $409.78 $0.00 $0.00 $0.00 $0.00 $0.00 474.541S SUP HCPCS C1713 474.541S - NAIL 15MM 40CM FEM IM CANN TI STRL BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.542S SUP HCPCS C1713 474.542S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 420MM CANN FLUTED BARREL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" "$1,158.30" "$1,158.30" $0.00 $0.00 $0.00 $536.49 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 "$1,268.98" "$1,268.98" $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $402.83 $0.00 $0.00 $409.78 $0.00 $0.00 $0.00 $0.00 $0.00 474.544S SUP HCPCS C1713 474.544S - NAIL 15MM 44CM FEM IM CANN TI STRL GRN BOTH IP/OP "$2,956.30 " "$2,187.66" $0.00 "$2,365.04" "$1,330.34" "$1,330.34" $0.00 $0.00 $0.00 $616.17 "$2,194.17" "$2,194.17" $0.00 $0.00 $616.09 $0.00 "$1,457.46" "$1,457.46" $0.00 "$1,478.15" "$2,341.39" "$2,365.04" $0.00 $0.00 $462.66 $0.00 $0.00 $470.64 $0.00 $0.00 $0.00 $0.00 $0.00 474.546S SUP HCPCS C1713 474.546S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 460MM CANN FLUTED BARREL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" "$1,158.30" "$1,158.30" $0.00 $0.00 $0.00 $536.49 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 "$1,268.98" "$1,268.98" $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $402.83 $0.00 $0.00 $409.78 $0.00 $0.00 $0.00 $0.00 $0.00 474.548S SUP HCPCS C1713 474.548S - NAIL INTRAMEDULLARY UNIVERSAL 15MM 480MM CANN FLUTED BARREL BOTH IP/OP "$2,574.00 " "$1,904.76" $0.00 "$2,059.20" "$1,158.30" "$1,158.30" $0.00 $0.00 $0.00 $536.49 "$1,910.42" "$1,910.42" $0.00 $0.00 $536.42 $0.00 "$1,268.98" "$1,268.98" $0.00 "$1,287.00" "$2,038.61" "$2,059.20" $0.00 $0.00 $402.83 $0.00 $0.00 $409.78 $0.00 $0.00 $0.00 $0.00 $0.00 474.900S SUP HCPCS C1713 474.900S - SLEEVE LCK STD GRN STRL TI FEM 13-15MM NL BOTH IP/OP $669.63 $495.53 $0.00 $535.70 $301.33 $301.33 $0.00 $0.00 $0.00 $139.57 $497.00 $497.00 $0.00 $0.00 $139.55 $0.00 $396.08 $396.08 $0.00 $334.81 $530.35 $535.70 $0.00 $0.00 $104.80 $0.00 $0.00 $106.60 $0.00 $0.00 $0.00 $0.00 $0.00 474.910S SUP HCPCS C1713 474.910S - SLEEVE LOCKING 100D BLUE TITANIUM FEMUR STERILE 13-15MM CANN BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 474.911S SUP HCPCS C1713 474.911S - SLEEVE LOCKING 110D BLUE TITANIUM FEMUR STERILE 13-15MM CANN BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 474.912S SUP HCPCS C1713 474.912S - SLEEVE LOCKING 120D BLUE TITANIUM FEMUR STERILE 13-15MM CANN BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 474.913S SUP HCPCS C1713 474.913S - SLEEVE LOCKING 130D ANTEGRADE PINK TITANIUM FEMUR STERILE BOTH IP/OP $756.25 $559.63 $0.00 $605.00 $340.31 $340.31 $0.00 $0.00 $0.00 $157.62 $561.29 $561.29 $0.00 $0.00 $157.60 $0.00 $447.32 $447.32 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $118.35 $0.00 $0.00 $120.40 $0.00 $0.00 $0.00 $0.00 $0.00 474.920S SUP Custom 27803010 474.920S - CAP END 0MM 15MM EXTEND GREEN TITANIUM FEMUR STERILE 13-15MM BOTH IP/OP $446.88 $330.69 $0.00 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.67 $331.67 $0.00 $0.00 $93.13 $0.00 $0.00 $0.00 $0.00 $223.44 $353.93 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 474.921S SUP Custom 27803010 474.921S - CAP END 10MM 15MM EXTEND GREEN TITANIUM FEMUR STERILE 13-15 BOTH IP/OP $446.88 $330.69 $0.00 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.67 $331.67 $0.00 $0.00 $93.13 $0.00 $0.00 $0.00 $0.00 $223.44 $353.93 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 474.922S SUP Custom 27803010 474.922S - CAP END 20MM 15MM EXTEND GREEN TITANIUM FEMUR STERILE 13-15 BOTH IP/OP $446.88 $330.69 $0.00 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.67 $331.67 $0.00 $0.00 $93.13 $0.00 $0.00 $0.00 $0.00 $223.44 $353.93 $357.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 475.900S SUP Custom 27803010 475.900S - CAP END GREEN TITANIUM STERILE 3-4MM ELAST INTRAMEDULLARY BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $0.00 $0.00 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 475.905S SUP Custom 27803010 475.905S - CAP END ROSE RED TAN STERILE TEN SYSTEM BOTH IP/OP $247.40 $183.08 $0.00 $192.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.62 $183.62 $0.00 $0.00 $51.56 $0.00 $0.00 $0.00 $0.00 $120.10 $190.24 $192.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 475.915S SUP HCPCS C1713 475.915S - NAIL INTRAMEDULLARY 1.5MM 300MM ELAST PURPLE TITANIUM BOTH IP/OP $572.13 $423.38 $0.00 $444.36 $249.95 $249.95 $0.00 $0.00 $0.00 $119.25 $424.63 $424.63 $0.00 $0.00 $119.23 $0.00 $338.41 $338.41 $0.00 $277.73 $439.92 $444.36 $0.00 $0.00 $84.40 $0.00 $0.00 $88.43 $0.00 $0.00 $0.00 $0.00 $0.00 475.920S SUP HCPCS C1713 475.920S - NAIL INTRAMEDULLARY 2MM 440MM ELAST GREEN TITANIUM OLECRANON BOTH IP/OP $604.45 $447.29 $0.00 $469.48 $264.08 $264.08 $0.00 $0.00 $0.00 $125.98 $448.62 $448.62 $0.00 $0.00 $125.97 $0.00 $357.53 $357.53 $0.00 $293.43 $464.79 $469.48 $0.00 $0.00 $89.17 $0.00 $0.00 $93.43 $0.00 $0.00 $0.00 $0.00 $0.00 475.925S SUP HCPCS C1713 475.925S - NAIL INTRAMEDULLARY 2.5MM 440MM ELAST PINK TITANIUM BOTH IP/OP $642.40 $475.38 $0.00 $498.96 $280.67 $280.67 $0.00 $0.00 $0.00 $133.89 $476.79 $476.79 $0.00 $0.00 $133.88 $0.00 $379.98 $379.98 $0.00 $311.85 $493.97 $498.96 $0.00 $0.00 $94.76 $0.00 $0.00 $99.29 $0.00 $0.00 $0.00 $0.00 $0.00 475.930S SUP HCPCS C1713 475.930S - NAIL INTRAMEDULLARY 3MM 440MM ELAST GOLD TITANIUM OLECRANON BOTH IP/OP $674.73 $499.30 $0.00 $524.06 $294.78 $294.78 $0.00 $0.00 $0.00 $140.63 $500.78 $500.78 $0.00 $0.00 $140.61 $0.00 $399.10 $399.10 $0.00 $327.54 $518.82 $524.06 $0.00 $0.00 $99.53 $0.00 $0.00 $104.29 $0.00 $0.00 $0.00 $0.00 $0.00 475.935S SUP HCPCS C1713 475.935S - NAIL INTRAMEDULLARY 3.5MM 440MM ELAST BLUE TITANIUM BOTH IP/OP $707.08 $523.24 $0.00 $549.18 $308.91 $308.91 $0.00 $0.00 $0.00 $147.37 $524.79 $524.79 $0.00 $0.00 $147.35 $0.00 $418.23 $418.23 $0.00 $343.24 $543.69 $549.18 $0.00 $0.00 $104.30 $0.00 $0.00 $109.29 $0.00 $0.00 $0.00 $0.00 $0.00 475.940S SUP HCPCS C1713 475.940S - NAIL INTRAMEDULLARY 4MM 440MM ELAST PURPLE TITANIUM BOTH IP/OP $752.05 $556.52 $0.00 $584.12 $328.57 $328.57 $0.00 $0.00 $0.00 $156.75 $558.17 $558.17 $0.00 $0.00 $156.73 $0.00 $444.84 $444.84 $0.00 $365.08 $578.28 $584.12 $0.00 $0.00 $110.94 $0.00 $0.00 $116.24 $0.00 $0.00 $0.00 $0.00 $0.00 47525P SUP HCPCS C1713 47525P - SCREW BN 4.75MM 25MM SPRL R90D MULTIANGLE LCK TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47525S SUP HCPCS C1713 47525S - SCREW BN STD 4.75MM 25MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47530P SUP HCPCS C1713 47530P - SCREW BN 4.75MM 30MM SPRL R90D MULTIANGLE LCK TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47530S SUP HCPCS C1713 47530S - SCREW BN STD 4.75MM 30MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47535P SUP HCPCS C1713 47535P - SCREW BN 4.75MM 35MM SPRL R90D MULTIANGLE LCK TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47535S SUP HCPCS C1713 47535S - SCREW BN STD 4.75MM 35MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47540P SUP HCPCS C1713 47540P - SCREW BN 4.75MM 40MM SPRL R90D MULTIANGLE LCK TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47540S SUP HCPCS C1713 47540S - SCREW BN STD 4.75MM 40MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47545P SUP HCPCS C1713 47545P - SCREW BN 4.75MM 45MM SPRL R90D MULTIANGLE LCK TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47545S SUP HCPCS C1713 47545S - SCREW BN STD 4.75MM 45MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47550P SUP HCPCS C1713 47550P - SCREW BN 4.75MM 50MM SPRL R90D MULTIANGLE LCK TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47550S SUP HCPCS C1713 47550S - SCREW BN STD 4.75MM 50MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47555P SUP HCPCS C1713 47555P - SCREW BN 4.75MM 55MM SPRL R90D MULTIANGLE LCK TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 47555S SUP HCPCS C1713 47555S - SCREW BN STD 4.75MM 55MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 476.25S SUP HCPCS C1713 476.25S - NAIL INTRAMEDULLARY 10MM 25.5CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.27S SUP HCPCS C1713 476.27S - NAIL INTRAMEDULLARY 10MM 27CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.28S SUP HCPCS C1713 476.28S - NAIL INTRAMEDULLARY 10MM 28.5CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.30S SUP HCPCS C1713 476.30S - NAIL INTRAMEDULLARY 10MM 30CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.31S SUP HCPCS C1713 476.31S - NAIL INTRAMEDULLARY 10MM 31.5CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.33S SUP HCPCS C1713 476.33S - NAIL INTRAMEDULLARY 10MM 33CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.34S SUP HCPCS C1713 476.34S - NAIL INTRAMEDULLARY 10MM 34.5CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.36S SUP HCPCS C1713 476.36S - NAIL INTRAMEDULLARY 10MM 36CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.38S SUP HCPCS C1713 476.38S - NAIL INTRAMEDULLARY 10MM 38CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.40S SUP HCPCS C1713 476.40S - NAIL INTRAMEDULLARY 10MM 40CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 476.42S SUP HCPCS C1713 476.42S - NAIL INTRAMEDULLARY 10MM 42CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 478.25S SUP HCPCS C1713 478.25S - NAIL INTRAMEDULLARY 8MM 25.5CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 478.27S SUP HCPCS C1713 478.27S - NAIL 8MM 27CM TIB IM SLD TI STRL BOTH IP/OP "$2,814.73 " "$2,082.90" $0.00 "$2,251.78" "$1,266.63" "$1,266.63" $0.00 $0.00 $0.00 $586.66 "$2,089.09" "$2,089.09" $0.00 $0.00 $586.59 $0.00 "$1,387.66" "$1,387.66" $0.00 "$1,407.36" "$2,229.27" "$2,251.78" $0.00 $0.00 $440.50 $0.00 $0.00 $448.10 $0.00 $0.00 $0.00 $0.00 $0.00 478.28S SUP HCPCS C1713 478.28S - NAIL INTRAMEDULLARY 8MM 28.5CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 478.30S SUP HCPCS C1713 478.30S - NAIL INTRAMEDULLARY 8MM 30CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 478.31S SUP HCPCS C1713 478.31S - NAIL 8MM 31.5CM TIB IM SLD TI STRL BOTH IP/OP "$2,814.73 " "$2,082.90" $0.00 "$2,251.78" "$1,266.63" "$1,266.63" $0.00 $0.00 $0.00 $586.66 "$2,089.09" "$2,089.09" $0.00 $0.00 $586.59 $0.00 "$1,387.66" "$1,387.66" $0.00 "$1,407.36" "$2,229.27" "$2,251.78" $0.00 $0.00 $440.50 $0.00 $0.00 $448.10 $0.00 $0.00 $0.00 $0.00 $0.00 478.33S SUP HCPCS C1713 478.33S - NAIL 8MM 33CM TIB IM SLD TI STRL BOTH IP/OP "$2,814.73 " "$2,082.90" $0.00 "$2,251.78" "$1,266.63" "$1,266.63" $0.00 $0.00 $0.00 $586.66 "$2,089.09" "$2,089.09" $0.00 $0.00 $586.59 $0.00 "$1,387.66" "$1,387.66" $0.00 "$1,407.36" "$2,229.27" "$2,251.78" $0.00 $0.00 $440.50 $0.00 $0.00 $448.10 $0.00 $0.00 $0.00 $0.00 $0.00 478.34S SUP HCPCS C1713 478.34S - NAIL 8MM 34.5CM TIB IM SLD TI STRL BOTH IP/OP "$2,814.73 " "$2,082.90" $0.00 "$2,251.78" "$1,266.63" "$1,266.63" $0.00 $0.00 $0.00 $586.66 "$2,089.09" "$2,089.09" $0.00 $0.00 $586.59 $0.00 "$1,387.66" "$1,387.66" $0.00 "$1,407.36" "$2,229.27" "$2,251.78" $0.00 $0.00 $440.50 $0.00 $0.00 $448.10 $0.00 $0.00 $0.00 $0.00 $0.00 478.36S SUP HCPCS C1713 478.36S - NAIL 8MM 36CM TIB IM SLD TI STRL BOTH IP/OP "$2,814.73 " "$2,082.90" $0.00 "$2,251.78" "$1,266.63" "$1,266.63" $0.00 $0.00 $0.00 $586.66 "$2,089.09" "$2,089.09" $0.00 $0.00 $586.59 $0.00 "$1,387.66" "$1,387.66" $0.00 "$1,407.36" "$2,229.27" "$2,251.78" $0.00 $0.00 $440.50 $0.00 $0.00 $448.10 $0.00 $0.00 $0.00 $0.00 $0.00 478.38S SUP HCPCS C1713 478.38S - NAIL INTRAMEDULLARY 8MM 38CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 478.40S SUP HCPCS C1713 478.40S - NAIL 8MM 40CM TIB IM SLD TI STRL BOTH IP/OP "$2,814.73 " "$2,082.90" $0.00 "$2,251.78" "$1,266.63" "$1,266.63" $0.00 $0.00 $0.00 $586.66 "$2,089.09" "$2,089.09" $0.00 $0.00 $586.59 $0.00 "$1,387.66" "$1,387.66" $0.00 "$1,407.36" "$2,229.27" "$2,251.78" $0.00 $0.00 $440.50 $0.00 $0.00 $448.10 $0.00 $0.00 $0.00 $0.00 $0.00 478.42S SUP HCPCS C1713 478.42S - NAIL INTRAMEDULLARY 8MM 42CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 479.25S SUP HCPCS C1713 479.25S - NAIL INTRAMEDULLARY 9MM 25.5CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 479.27S SUP HCPCS C1713 479.27S - NAIL INTRAMEDULLARY 9MM 27CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 479.28S SUP HCPCS C1713 479.28S - NAIL INTRAMEDULLARY 9MM 28.5CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 479.30S SUP HCPCS C1713 479.30S - NAIL INTRAMEDULLARY 9MM 30CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 479.31S SUP HCPCS C1713 479.31S - NAIL INTRAMEDULLARY 9MM 315MM SOLID BLUE TITANIUM TIBIAL BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 479.33S SUP HCPCS C1713 479.33S - NAIL INTRAMEDULLARY 9MM 330MM SOLID BLUE TITANIUM TIBIAL BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 479.34S SUP HCPCS C1713 479.34S - NAIL INTRAMEDULLARY 9MM 34.5CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 479.36S SUP HCPCS C1713 479.36S - NAIL INTRAMEDULLARY 9MM 36CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 479.38S SUP HCPCS C1713 479.38S - NAIL INTRAMEDULLARY 9MM 38CM SOLID TITANIUM TIBIA STERILE BOTH IP/OP "$2,450.25 " "$1,813.19" $0.00 "$1,960.20" "$1,102.61" "$1,102.61" $0.00 $0.00 $0.00 $510.69 "$1,818.58" "$1,818.58" $0.00 $0.00 $510.63 $0.00 "$1,449.32" "$1,449.32" $0.00 "$1,225.13" "$1,940.60" "$1,960.20" $0.00 $0.00 $383.46 $0.00 $0.00 $390.08 $0.00 $0.00 $0.00 $0.00 $0.00 479.40S SUP HCPCS C1713 479.40S - NAIL INTRAMEDULLARY 9MM 40CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 479.42S SUP HCPCS C1713 479.42S - NAIL INTRAMEDULLARY 9MM 42CM SOLID BLUE TITANIUM TIBIA BOTH IP/OP "$2,517.63 " "$1,863.05" $0.00 "$2,014.10" "$1,132.93" "$1,132.93" $0.00 $0.00 $0.00 $524.74 "$1,868.58" "$1,868.58" $0.00 $0.00 $524.67 $0.00 "$1,241.19" "$1,241.19" $0.00 "$1,258.81" "$1,993.96" "$2,014.10" $0.00 $0.00 $394.01 $0.00 $0.00 $400.81 $0.00 $0.00 $0.00 $0.00 $0.00 4806-100-20 SUP Custom 27203010 4806-100-20 - BIT DRL 2MM 100MM QCK CNCT BOTH IP/OP $136.85 $101.27 $0.00 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.57 $101.57 $0.00 $0.00 $28.52 $0.00 $0.00 $0.00 $0.00 $68.43 $108.39 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4806-100-27 SUP Custom 27203010 4806-100-27 - BIT DRL 2.7MM BOTH IP/OP $136.85 $101.27 $0.00 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.57 $101.57 $0.00 $0.00 $28.52 $0.00 $0.00 $0.00 $0.00 $68.43 $108.39 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4806-110-25 SUP Custom 27203010 4806-110-25 - BIT DRL 2.5MM 110MM QCK CNCT BOTH IP/OP $136.85 $101.27 $0.00 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.57 $101.57 $0.00 $0.00 $28.52 $0.00 $0.00 $0.00 $0.00 $68.43 $108.39 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4806-110-35 SUP Custom 27203010 4806-110-35 - BIT DRL 3.5MM BOTH IP/OP $136.85 $101.27 $0.00 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.57 $101.57 $0.00 $0.00 $28.52 $0.00 $0.00 $0.00 $0.00 $68.43 $108.39 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4807-180-25 SUP Custom 27203010 4807-180-25 - BIT DRILL 180MM 2.5MM SS QC NONSTRL BOTH IP/OP $136.85 $101.27 $0.00 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.57 $101.57 $0.00 $0.00 $28.52 $0.00 $0.00 $0.00 $0.00 $68.43 $108.39 $109.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4809-27 SUP Custom 27203010 "4809-27 - COUNTERSINK, Q-C, FOR 2.7MM SCREWS" BOTH IP/OP $211.60 $156.58 $0.00 $169.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.05 $157.05 $0.00 $0.00 $44.10 $0.00 $0.00 $0.00 $0.00 $105.80 $167.59 $169.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4811-100-27 SUP Custom 27203010 4811-100-27 - TAP 100MM QC SURG SS PERIART 2.7MM SCR NONSTRL BOTH IP/OP $163.30 $120.84 $0.00 $130.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.20 $121.20 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $81.65 $129.33 $130.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4811-110-35 SUP Custom 27203010 4811-110-35 - TAP 110MM QC SURG SS PERIART 3.5MM SCR NONSTRL BOTH IP/OP $163.30 $120.84 $0.00 $130.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.20 $121.20 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $81.65 $129.33 $130.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4811-110-40 SUP Custom 27203010 4811-110-40 - TAP 110MM QC SURG SS PERIART 4MM SCR NONSTRL BOTH IP/OP $163.30 $120.84 $0.00 $130.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.20 $121.20 $0.00 $0.00 $34.03 $0.00 $0.00 $0.00 $0.00 $81.65 $129.33 $130.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48210-025 SUP Custom 27203010 48210-025 - TAPE DRSG 72YDX.5IN TWL BLCH CTTN WHT BOTH IP/OP $156.02 $115.45 $0.00 $124.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.80 $115.80 $0.00 $0.00 $32.51 $0.00 $0.00 $0.00 $0.00 $78.01 $123.57 $124.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 48230260R SUP Custom 27803010 48230260R - HOOK SPNL XIA 3 TI AL VNDM SCRL RT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0101 SUP HCPCS C1776 4845-0101 - STEM FEM 1 8.5MM 100MM ABG II V40 TMZF HA HIP RT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0102 SUP HCPCS C1776 4845-0102 - STEM FEM 2 8.5MM 100MM ABG II V40 TMZF HA HIP RT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0103 SUP HCPCS C1776 4845-0103 - STEM FEM 3 9MM 110MM ABG II V40 TMZF HA HIP RT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0104 SUP HCPCS C1776 4845-0104 - STEM FEM 4 10MM 115MM ABG II V40 TMZF HA HIP RT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0105 SUP HCPCS C1776 4845-0105 - STEM FEM 5 11MM 120MM ABG II V40 TMZF HA HIP RT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0106 SUP HCPCS C1776 4845-0106 - STEM FEM 6 12MM 125MM ABG II V40 TMZF HA HIP RT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0107 SUP HCPCS C1776 4845-0107 - STEM FEM 7 13MM 135MM ABG II V40 TMZF HA HIP RT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0108 SUP HCPCS C1776 4845-0108 - STEM FEM 8 14MM 145MM ABG II V40 TMZF HA HIP RT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0201 SUP HCPCS C1776 4845-0201 - STEM FEM 1 8.5MM 100MM ABG II V40 TMZF HA HIP LT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0202 SUP HCPCS C1776 4845-0202 - STEM FEM 2 8.5MM 100MM ABG II V40 TMZF HA HIP LT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0203 SUP HCPCS C1776 4845-0203 - STEM FEM 3 9MM 110MM ABG II V40 TMZF HA HIP LT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0204 SUP HCPCS C1776 4845-0204 - STEM FEM 4 10MM 115MM ABG II V40 TMZF HA HIP LT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0205 SUP HCPCS C1776 4845-0205 - STEM FEM 5 11MM 120MM ABG II V40 TMZF HA HIP LT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0206 SUP HCPCS C1776 4845-0206 - STEM FEM 6 12MM 125MM ABG II V40 TMZF HA HIP LT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0207 SUP HCPCS C1776 4845-0207 - STEM FEM 7 13MM 135MM ABG II V40 TMZF HA HIP LT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-0208 SUP HCPCS C1776 4845-0208 - STEM FEM 8 14MM 145MM ABG II V40 TMZF HA HIP LT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-101 SUP HCPCS C1776 4845-7-101 - STEM FEM 130D 1 37MM OFST 99MM STRL ANATO ANTEVERT HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-102 SUP HCPCS C1776 4845-7-102 - STEM FEM 130D 2 39MM OFST 99MM STRL ANATO ANTEVERT HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-103 SUP HCPCS C1776 4845-7-103 - STEM FEM 130D 3 42MM OFST 110MM STRL ANATO ANTEVERT HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-104 SUP HCPCS C1776 4845-7-104 - STEM FEM 130D 4 44MM OFST 115MM STRL ANATO ANTEVERT HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-105 SUP HCPCS C1776 4845-7-105 - STEM FEM 130D 5 44MM OFST 120MM STRL ANATO ANTEVERT HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-106 SUP HCPCS C1776 4845-7-106 - STEM FEM 130D 6 47MM OFST 120MM STRL ANATO ANTEVERT HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-107 SUP HCPCS C1776 4845-7-107 - STEM FEM 130D 7 50MM OFST 120MM STRL ANATO ANTEVERT HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-108 SUP HCPCS C1776 4845-7-108 - STEM FEM 130D 8 53MM OFST 120MM STRL ANATO ANTEVERT HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-111 SUP HCPCS C1776 4845-7-111 - STEM FEM 130D 1 37MM OFST 99MM STRL ANATO HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-112 SUP HCPCS C1776 4845-7-112 - STEM FEM 130D 2 39MM OFST 99MM STRL ANATO HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-114 SUP HCPCS C1776 4845-7-114 - STEM FEM 130D 4 44MM OFST 115MM STRL ANATO HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-115 SUP HCPCS C1776 4845-7-115 - STEM FEM 130D 5 44MM OFST 120MM STRL ANATO HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-116 SUP HCPCS C1776 4845-7-116 - STEM FEM 130D 6 47MM OFST 120MM STRL ANATO HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-117 SUP HCPCS C1776 4845-7-117 - STEM FEM 130D 7 50MM OFST 120MM STRL ANATO HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-118 SUP HCPCS C1776 4845-7-118 - STEM FEM 130D 8 53MM OFST 120MM STRL ANATO HIP RT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-201 SUP HCPCS C1776 4845-7-201 - STEM FEM 130D 1 37MM OFST 99MM STRL ANATO ANTEVERT HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-202 SUP HCPCS C1776 4845-7-202 - STEM FEM 130D 2 39MM OFST 99MM STRL ANATO ANTEVERT HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-203 SUP HCPCS C1776 4845-7-203 - STEM FEM 130D 3 42MM OFST 110MM STRL ANATO ANTEVERT HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-204 SUP HCPCS C1776 4845-7-204 - STEM FEM 130D 4 44MM OFST 115MM STRL ANATO ANTEVERT HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-205 SUP HCPCS C1776 4845-7-205 - STEM FEM 130D 5 44MM OFST 120MM STRL ANATO ANTEVERT HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-206 SUP HCPCS C1776 4845-7-206 - STEM FEM 130D 6 47MM OFST 120MM STRL ANATO ANTEVERT HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-207 SUP HCPCS C1776 4845-7-207 - STEM FEM 130D 7 50MM OFST 120MM STRL ANATO ANTEVERT HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-208 SUP HCPCS C1776 4845-7-208 - STEM FEM 130D 8 53MM OFST 120MM STRL ANATO ANTEVERT HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-211 SUP HCPCS C1776 4845-7-211 - STEM FEM 130D 1 37MM OFST 99MM STRL ANATO HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-212 SUP HCPCS C1776 4845-7-212 - STEM FEM 130D 2 39MM OFST 99MM STRL ANATO HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-213 SUP HCPCS C1776 4845-7-213 - STEM FEM 130D 3 42MM OFST 110MM STRL ANATO HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-214 SUP HCPCS C1776 4845-7-214 - STEM FEM 130D 4 44MM OFST 115MM STRL ANATO HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-215 SUP HCPCS C1776 4845-7-215 - STEM FEM 130D 5 44MM OFST 120MM STRL ANATO HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-216 SUP HCPCS C1776 4845-7-216 - STEM FEM 130D 6 47MM OFST 120MM STRL ANATO HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-217 SUP HCPCS C1776 4845-7-217 - STEM FEM 130D 7 50MM OFST 120MM STRL ANATO HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 4845-7-218 SUP HCPCS C1776 4845-7-218 - STEM FEM 130D 8 53MM OFST 120MM STRL ANATO HIP LT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 48485540XL SUP HCPCS C1713 48485540XL - SCREW BONE 5.5MM 40MM DIAPASON OSS THOR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48485545XL SUP HCPCS C1713 48485545XL - SCREW BONE 5.5MM 45MM DIAPASON OSS THOR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486735XL SUP HCPCS C1713 48486735XL - SCREW BONE 6.7MM 35MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486740XL SUP HCPCS C1713 48486740XL - SCREW BONE 6.7MM 40MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486745XL SUP HCPCS C1713 48486745XL - SCREW BONE 6.7MM 45MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486750XL SUP HCPCS C1713 48486750XL - SCREW BONE 6.7MM 50MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486755XL SUP HCPCS C1713 48486755XL - SCREW BONE 6.7MM 55MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48486760XL SUP HCPCS C1713 48486760XL - SCREW BONE 6.7MM 60MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487740XL SUP HCPCS C1713 48487740XL - SCREW BONE 7.7MM 40MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487745XL SUP HCPCS C1713 48487745XL - SCREW BONE 7.7MM 45MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487750XL SUP HCPCS C1713 48487750XL - SCREW BONE 7.7MM 50MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487755XL SUP HCPCS C1713 48487755XL - SCREW BONE 7.7MM 55MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48487760XL SUP HCPCS C1713 48487760XL - SCREW BONE 7.7MM 60MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48488050XL SUP HCPCS C1713 48488050XL - SCREW BONE 8MM 50MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48488055XL SUP HCPCS C1713 48488055XL - SCREW BONE 8MM 55MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 48488060XL SUP HCPCS C1713 48488060XL - SCREW BONE 8MM 60MM DIAPASON OSS LMBR SPN LNG ARM BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 485.025S SUP HCPCS C1713 485.025S - NAIL INTRAMEDULLARY 10MM 25.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.027S SUP HCPCS C1713 485.027S - NAIL INTRAMEDULLARY 10MM 27CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.028S SUP HCPCS C1713 485.028S - NAIL INTRAMEDULLARY 10MM 28.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.030S SUP HCPCS C1713 485.030S - NAIL INTRAMEDULLARY 10MM 30CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.031S SUP HCPCS C1713 485.031S - NAIL INTRAMEDULLARY 10MM 31.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.033S SUP HCPCS C1713 485.033S - NAIL INTRAMEDULLARY 10MM 33CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.034S SUP HCPCS C1713 485.034S - NAIL INTRAMEDULLARY 10MM 34.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.036S SUP HCPCS C1713 485.036S - NAIL 10MM 36CM TIB IM CANN TI STRL BOTH IP/OP "$2,853.10 " "$2,111.29" $0.00 "$2,282.48" "$1,283.90" "$1,283.90" $0.00 $0.00 $0.00 $594.66 "$2,117.57" "$2,117.57" $0.00 $0.00 $594.59 $0.00 "$1,406.58" "$1,406.58" $0.00 "$1,426.55" "$2,259.66" "$2,282.48" $0.00 $0.00 $446.51 $0.00 $0.00 $454.21 $0.00 $0.00 $0.00 $0.00 $0.00 485.038S SUP HCPCS C1713 485.038S - NAIL INTRAMEDULLARY 10MM 380MM CANN TITANIUM TIBIA STERILE BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.040S SUP HCPCS C1713 485.040S - NAIL INTRAMEDULLARY 10MM 40CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.042S SUP HCPCS C1713 485.042S - NAIL INTRAMEDULLARY 10MM 42CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 485.125S SUP HCPCS C1713 485.125S - NAIL INTRAMEDULLARY 11MM 25.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.127S SUP HCPCS C1713 485.127S - NAIL INTRAMEDULLARY 11MM 27CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.128S SUP HCPCS C1713 485.128S - NAIL INTRAMEDULLARY 11MM 28.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.130S SUP HCPCS C1713 485.130S - NAIL INTRAMEDULLARY 11MM 30CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.131S SUP HCPCS C1713 485.131S - NAIL INTRAMEDULLARY 11MM 315MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.133S SUP HCPCS C1713 485.133S - NAIL INTRAMEDULLARY 11MM 330MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.134S SUP HCPCS C1713 485.134S - NAIL INTRAMEDULLARY 11MM 34.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.136S SUP HCPCS C1713 485.136S - NAIL INTRAMEDULLARY 11MM 360MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.138S SUP HCPCS C1713 485.138S - NAIL INTRAMEDULLARY 11MM 38CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.140S SUP HCPCS C1713 485.140S - NAIL INTRAMEDULLARY 11MM 400MM CANN GREEN TITANIUM TIBIAL BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.142S SUP HCPCS C1713 485.142S - NAIL INTRAMEDULLARY 11MM 42CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 485.225S SUP HCPCS C1713 485.225S - NAIL INTRAMEDULLARY 12MM 25.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 485.227S SUP HCPCS C1713 485.227S - NAIL INTRAMEDULLARY 12MM 27CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 485.228S SUP HCPCS C1713 485.228S - NAIL INTRAMEDULLARY 12MM 285MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 485.230S SUP HCPCS C1713 485.230S - NAIL INTRAMEDULLARY 12MM 30CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.231S SUP HCPCS C1713 485.231S - NAIL INTRAMEDULLARY 12MM 31.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.233S SUP HCPCS C1713 485.233S - NAIL INTRAMEDULLARY 12MM 33CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.234S SUP HCPCS C1713 485.234S - NAIL INTRAMEDULLARY 12MM 34.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.236S SUP HCPCS C1713 485.236S - NAIL INTRAMEDULLARY 12MM 36CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.238S SUP HCPCS C1713 485.238S - NAIL INTRAMEDULLARY 12MM 38CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.240S SUP HCPCS C1713 485.240S - NAIL INTRAMEDULLARY 12MM 40CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.242S SUP HCPCS C1713 485.242S - NAIL INTRAMEDULLARY 12MM 42CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 485.325S SUP HCPCS C1713 485.325S - NAIL INTRAMEDULLARY 13MM 25.5CM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 485.327S SUP HCPCS C1713 485.327S - NAIL 13MM 27CM TIB IM CANN TI STRL BLUE BOTH IP/OP "$2,853.10 " "$2,111.29" $0.00 "$2,282.48" "$1,283.90" "$1,283.90" $0.00 $0.00 $0.00 $594.66 "$2,117.57" "$2,117.57" $0.00 $0.00 $594.59 $0.00 "$1,406.58" "$1,406.58" $0.00 "$1,426.55" "$2,259.66" "$2,282.48" $0.00 $0.00 $446.51 $0.00 $0.00 $454.21 $0.00 $0.00 $0.00 $0.00 $0.00 485.328S SUP HCPCS C1713 485.328S - NAIL INTRAMEDULLARY 13MM 285MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 485.330S SUP HCPCS C1713 485.330S - NAIL INTRAMEDULLARY 13MM 300MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.331S SUP HCPCS C1713 485.331S - NAIL INTRAMEDULLARY 13MM 315MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.333S SUP HCPCS C1713 485.333S - NAIL INTRAMEDULLARY 13MM 330MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.334S SUP HCPCS C1713 485.334S - NAIL INTRAMEDULLARY 13MM 345MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.336S SUP HCPCS C1713 485.336S - NAIL 13MM 36CM TIB IM CANN TI STRL BOTH IP/OP "$2,853.10 " "$2,111.29" $0.00 "$2,282.48" "$1,283.90" "$1,283.90" $0.00 $0.00 $0.00 $594.66 "$2,117.57" "$2,117.57" $0.00 $0.00 $594.59 $0.00 "$1,406.58" "$1,406.58" $0.00 "$1,426.55" "$2,259.66" "$2,282.48" $0.00 $0.00 $446.51 $0.00 $0.00 $454.21 $0.00 $0.00 $0.00 $0.00 $0.00 485.338S SUP HCPCS C1713 485.338S - NAIL INTRAMEDULLARY 13MM 380MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,484.63 " "$1,838.63" $0.00 "$1,987.70" "$1,118.08" "$1,118.08" $0.00 $0.00 $0.00 $517.86 "$1,844.09" "$1,844.09" $0.00 $0.00 $517.80 $0.00 "$1,469.66" "$1,469.66" $0.00 "$1,242.31" "$1,967.83" "$1,987.70" $0.00 $0.00 $388.84 $0.00 $0.00 $395.55 $0.00 $0.00 $0.00 $0.00 $0.00 485.340S SUP HCPCS C1713 485.340S - NAIL 13MM 40CM TIB IM CANN TI STRL BLUE BOTH IP/OP "$2,853.10 " "$2,111.29" $0.00 "$2,282.48" "$1,283.90" "$1,283.90" $0.00 $0.00 $0.00 $594.66 "$2,117.57" "$2,117.57" $0.00 $0.00 $594.59 $0.00 "$1,406.58" "$1,406.58" $0.00 "$1,426.55" "$2,259.66" "$2,282.48" $0.00 $0.00 $446.51 $0.00 $0.00 $454.21 $0.00 $0.00 $0.00 $0.00 $0.00 485.342S SUP HCPCS C1713 485.342S - NAIL INTRAMEDULLARY 13MM 420MM CANN GREEN TITANIUM TIBIA BOTH IP/OP "$2,553.38 " "$1,889.50" $0.00 "$2,042.70" "$1,149.02" "$1,149.02" $0.00 $0.00 $0.00 $532.19 "$1,895.11" "$1,895.11" $0.00 $0.00 $532.12 $0.00 "$1,258.81" "$1,258.81" $0.00 "$1,276.69" "$2,022.28" "$2,042.70" $0.00 $0.00 $399.60 $0.00 $0.00 $406.50 $0.00 $0.00 $0.00 $0.00 $0.00 48551041L SUP HCPCS C1713 48551041L - PLATE BONE 130D PRECONTOUR OASYS TITANIUM SPN LEFT THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551041R SUP HCPCS C1713 48551041R - PLATE BONE 130D PRECONTOUR OASYS TITANIUM SPN RIGHT THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551043L SUP HCPCS C1713 48551043L - PLATE BONE 100D PRECONTOUR OASYS TITANIUM SPN LEFT THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 48551043R SUP HCPCS C1713 48551043R - PLATE BONE 100D PRECONTOUR OASYS TITANIUM SPN RIGHT THORACIC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 4900-40-51 SUP HCPCS C1713 4900-40-51 - WASHER 7MM SM ORTH 2.7-4MM SCR NONSTRL BOTH IP/OP $71.30 $52.76 $0.00 $57.04 $32.09 $32.09 $0.00 $0.00 $0.00 $14.86 $52.92 $52.92 $0.00 $0.00 $14.86 $0.00 $42.17 $42.17 $0.00 $35.65 $56.47 $57.04 $0.00 $0.00 $11.16 $0.00 $0.00 $11.35 $0.00 $0.00 $0.00 $0.00 $0.00 4900T26 SUP Custom 27803010 4900T26 - RING ANLPLS 26MM STRL ED MC3 SEAM 2 WRP TI PLSTR SIL RBR BOTH IP/OP "$7,995.00 " "$5,916.30" $0.00 "$6,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,666.16" $0.00 $0.00 $0.00 $0.00 "$3,997.50" "$6,332.04" "$6,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4900T28 SUP Custom 27803010 4900T28 - RING ANLPLS 28MM STRL ED MC3 SEAM 2 WRP TI PLSTR SIL RBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4900T30 SUP Custom 27803010 4900T30 - RING ANLPLS 30MM STRL ED MC3 1 SEAM 2 WRP ANTM TI SIL RBR BOTH IP/OP "$7,995.00 " "$5,916.30" $0.00 "$6,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,666.16" $0.00 $0.00 $0.00 $0.00 "$3,997.50" "$6,332.04" "$6,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4900T32 SUP Custom 27803010 4900T32 - RING ANLPLS 3D ANG DNWRD 32MM ED MC3 RGD TRCSD BOTH IP/OP "$7,995.00 " "$5,916.30" $0.00 "$6,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,666.16" $0.00 $0.00 $0.00 $0.00 "$3,997.50" "$6,332.04" "$6,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4900T34 SUP Custom 27803010 4900T34 - RING ANLPLS 34MM TRCSD ED MC3 BOTH IP/OP "$7,995.00 " "$5,916.30" $0.00 "$6,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,666.16" $0.00 $0.00 $0.00 $0.00 "$3,997.50" "$6,332.04" "$6,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4900T36 SUP HCPCS C1713 4900T36 - RING ANLPLS 36MM STRL ED MC3 1 SEAM 2 WRP ANTM TI SIL RBR BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" "$3,937.50" "$3,937.50" $0.00 $0.00 $0.00 "$1,823.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 "$4,313.75" "$4,313.75" $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 "$1,369.38" $0.00 $0.00 "$1,393.00" $0.00 $0.00 $0.00 $0.00 $0.00 491B SUP Custom 27203010 491B - PROBE THRMTR SM STAT STRL STRPRB TEMP ESPH RCTM DISP BOTH IP/OP $12.74 $9.43 $0.00 $10.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.37 $10.09 $10.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-0-000 SUP Custom 27203010 4920-0-000 - ROD EXFIX HFMN2 DYN BOTH IP/OP "$3,734.50 " "$2,763.53" $0.00 "$2,987.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,771.75" "$2,771.75" $0.00 $0.00 $778.27 $0.00 $0.00 $0.00 $0.00 "$1,867.25" "$2,957.72" "$2,987.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-0-015 SUP Custom 27203010 4920-0-015 - TUBE XTRNFX STD 40MM HFMN2 CMPR DSTRCT BOTH IP/OP $965.25 $714.29 $0.00 $772.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.41 $716.41 $0.00 $0.00 $201.16 $0.00 $0.00 $0.00 $0.00 $482.63 $764.48 $772.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-1-010 SUP Custom 27203010 4920-1-010 - CLAMP EXFIX HFMN2 STD CARFBR NONMRI SAFE BOTH IP/OP $853.88 $631.87 $0.00 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.75 $633.75 $0.00 $0.00 $177.95 $0.00 $0.00 $0.00 $0.00 $426.94 $676.27 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-1-010R SUP Custom 27203010 4920-1-010R - HOFF2 COUPLING 8/8MM RECERT BOTH IP/OP $853.88 $631.87 $0.00 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.75 $633.75 $0.00 $0.00 $177.95 $0.00 $0.00 $0.00 $0.00 $426.94 $676.27 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-1-020 SUP Custom 27203010 4920-1-020 - CPLNG EXFIX HFMN2 4-5MM 8MM ARTC BOTH IP/OP $853.88 $631.87 $0.00 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.75 $633.75 $0.00 $0.00 $177.95 $0.00 $0.00 $0.00 $0.00 $426.94 $676.27 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-1-020R SUP Custom 27203010 4920-1-020R - HOFF2 ARTIC COUPLING 8/4+5MM BOTH IP/OP $853.88 $631.87 $0.00 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.75 $633.75 $0.00 $0.00 $177.95 $0.00 $0.00 $0.00 $0.00 $426.94 $676.27 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-1-030 SUP Custom 27203010 4920-1-030 - COUPLING XTRNFX 4 5/8MM HFMN2 INVERT PIN TO ROD BOTH IP/OP $853.88 $631.87 $0.00 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.75 $633.75 $0.00 $0.00 $177.95 $0.00 $0.00 $0.00 $0.00 $426.94 $676.27 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-1-030R SUP Custom 27203010 4920-1-030R - HOFF2 INVERT COUPLING 8/4+5MM BOTH IP/OP $853.88 $631.87 $0.00 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.75 $633.75 $0.00 $0.00 $177.95 $0.00 $0.00 $0.00 $0.00 $426.94 $676.27 $683.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-1-100 SUP Custom 27203010 4920-1-100 - COUPLING XTRNFX STD 20MM 8MM HFMN2 TUBE TO ROD DYN BOTH IP/OP $948.75 $702.08 $0.00 $759.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $704.16 $704.16 $0.00 $0.00 $197.72 $0.00 $0.00 $0.00 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-020 SUP Custom 27203010 4920-2-020 - CLAMP EXFIX HFMN2 8MM 4-5MM CARFBR PIN ASMBLY 5 HOLE W/O BOTH IP/OP $900.63 $666.47 $0.00 $720.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $668.44 $668.44 $0.00 $0.00 $187.69 $0.00 $0.00 $0.00 $0.00 $450.31 $713.30 $720.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-060 SUP Custom 27203010 4920-2-060 - CLAMP EXFIX HFMN2 10 HOLE BOTH IP/OP "$1,516.63 " "$1,122.31" $0.00 "$1,213.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.64" "$1,125.64" $0.00 $0.00 $316.06 $0.00 $0.00 $0.00 $0.00 $758.31 "$1,201.17" "$1,213.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-060R SUP Custom 27203010 4920-2-060R - HOFF2 10 HOLE CLAMP BOTH IP/OP "$1,516.63 " "$1,122.31" $0.00 "$1,213.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,125.64" "$1,125.64" $0.00 $0.00 $316.06 $0.00 $0.00 $0.00 $0.00 $758.31 "$1,201.17" "$1,213.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-080 SUP Custom 27203010 4920-2-080 - CLAMP EXFIX HFMN2 PLVC CMPNT 4 MM 5 MM 6 MM PIN BOTH IP/OP "$1,328.25 " $982.91 $0.00 "$1,062.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $985.83 $985.83 $0.00 $0.00 $276.81 $0.00 $0.00 $0.00 $0.00 $664.13 "$1,051.97" "$1,062.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-120 SUP Custom 27203010 4920-2-120 - POST XTRNFX STRG 8MM NS LF HFMN2 CMPNT SS DISP BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-120R SUP Custom 27203010 4920-2-120R - POST XTRNFX STRG 8MM NS LF HFMN2 CMPNT SS DISP REPRO BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-140 SUP Custom 27203010 4920-2-140 - POST XTRNFX 30D HFMN2 AL SS CFBR BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-140R SUP Custom 27203010 4920-2-140R - POST XTRNFX 30D 8MM NS LF HFMN2 CMPNT SS DISP REPRO BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-160 SUP Custom 27203010 4920-2-160 - POST EXFIX HFMN2 90D 8MM SS ANG CMPNT BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-160R SUP Custom 27203010 4920-2-160R - POST XTRNFX 90D NS LF HFMN2 CMPNT SS DISP REPRO BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-2-180 SUP Custom 27203010 4920-2-180 - POST EXFIX HFMN2 MI BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-3-010 SUP Custom 27203010 4920-3-010 - COUPLING XTRNFX ROD TO WRE BOTH IP/OP $936.38 $692.92 $0.00 $749.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $694.98 $694.98 $0.00 $0.00 $195.14 $0.00 $0.00 $0.00 $0.00 $468.19 $741.61 $749.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-9-810 SUP Custom 27203010 4920-9-810 - SET EXFIX HFMN2 ANKL KIT ROD TO ROD CPLNG MLPN CLMP SFT TIS BOTH IP/OP "$6,227.38 " "$4,608.26" $0.00 "$4,981.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,297.78" $0.00 $0.00 $0.00 $0.00 "$3,113.69" "$4,932.08" "$4,981.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-9-830 SUP Custom 27203010 4920-9-830 - SET EXFIX HFMN2 430MMX307MMX65MM TIB KIT ROD TO ROD CPLNG BOTH IP/OP "$6,539.50 " "$4,839.23" $0.00 "$5,231.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.83" $0.00 $0.00 $0.00 $0.00 "$3,269.75" "$5,179.28" "$5,231.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-9-900 SUP Custom 27203010 4920-9-900 - KIT EXFIX HFMN2 STRL BOTH IP/OP "$4,116.75 " "$3,046.40" $0.00 "$3,293.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,055.45" "$3,055.45" $0.00 $0.00 $857.93 $0.00 $0.00 $0.00 $0.00 "$2,058.38" "$3,260.47" "$3,293.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-9-920 SUP Custom 27203010 4920-9-920 - KIT EXFIX HFMN2 STRL BOTH IP/OP "$3,430.63 " "$2,538.67" $0.00 "$2,744.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,546.21" "$2,546.21" $0.00 $0.00 $714.94 $0.00 $0.00 $0.00 $0.00 "$1,715.31" "$2,717.06" "$2,744.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-9-930 SUP Custom 27203010 4920-9-930 - SET EXFIX HFMN2 PLVC KIT ROD TO ROD CPLNG MLPN CLMP SFT TIS BOTH IP/OP "$8,417.75 " "$6,229.14" $0.00 "$6,734.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.26" $0.00 $0.00 $0.00 $0.00 "$4,208.88" "$6,666.86" "$6,734.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4920-9-952 SUP Custom 27203010 4920-9-952 - SET EXFIX HFMN2 KIT MLTR MUL PIN CLMP SLFDRILL APEX PIN ANG BOTH IP/OP "$4,138.75 " "$3,062.68" $0.00 "$3,311.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,071.78" "$3,071.78" $0.00 $0.00 $862.52 $0.00 $0.00 $0.00 $0.00 "$2,069.38" "$3,277.89" "$3,311.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-0-000 SUP Custom 27203010 4921-0-000 - TUBE XTRNFX HFMN 3 DYN MRI SAFE BOTH IP/OP "$4,233.63 " "$3,132.89" $0.00 "$3,386.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,142.20" "$3,142.20" $0.00 $0.00 $882.29 $0.00 $0.00 $0.00 $0.00 "$2,116.81" "$3,353.03" "$3,386.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-0-015 SUP Custom 27203010 4921-0-015 - TUBE XTRNFX 20MM HFMN2 CMPR DSTRCT MRI SAFE BOTH IP/OP $946.00 $700.04 $0.00 $756.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $702.12 $702.12 $0.00 $0.00 $197.15 $0.00 $0.00 $0.00 $0.00 $473.00 $749.23 $756.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-1-010 SUP Custom 27203010 4921-1-010 - CPLNG EXFIX HFMN2 ROD TO ROD BOTH IP/OP $975.88 $722.15 $0.00 "$1,268.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $724.29 $724.29 $0.00 $0.00 $203.37 $0.00 $0.00 $0.00 $0.00 $793.00 "$1,256.11" "$1,268.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-1-020 SUP Custom 27203010 4921-1-020 - CLAMP EXFIX HFMN2 CLR CD REASSEMBLE GOLD HEAD BOLT BOTH IP/OP $909.28 $672.87 $0.00 "$1,182.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $674.86 $674.86 $0.00 $0.00 $189.49 $0.00 $0.00 $0.00 $0.00 $739.00 "$1,170.58" "$1,182.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-1-030 SUP Custom 27203010 4921-1-030 - COUPLING XTRNFX HFMN2 INVERT PIN TO ROD MRI CLR CD 4-5 MM BOTH IP/OP $875.88 $648.15 $0.00 $700.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $650.07 $650.07 $0.00 $0.00 $182.53 $0.00 $0.00 $0.00 $0.00 $437.94 $693.70 $700.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-1-100 SUP Custom 27203010 4921-1-100 - DEVICE EXFIX YLW HFMN2 MRI FRM 6 PIN BOTH IP/OP $875.88 $648.15 $0.00 $700.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $650.07 $650.07 $0.00 $0.00 $182.53 $0.00 $0.00 $0.00 $0.00 $437.94 $693.70 $700.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-1-140 SUP Custom 27203010 4921-1-140 - POST EXFIX 8MM HFMN2 30D MRI SAFE CMPNT GOLD TIP BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-2-020 SUP Custom 27203010 4921-2-020 - CLAMP EXFIX 6MM HFMN2 5 HOLE PIN MRI SAFE BOTH IP/OP "$1,035.08 " $765.96 $0.00 "$1,347.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.23 $768.23 $0.00 $0.00 $215.71 $0.00 $0.00 $0.00 $0.00 $842.00 "$1,333.73" "$1,347.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-2-060 SUP Custom 27203010 4921-2-060 - CLAMP EXFIX HFMN2 C 10 HOLE PIN BOTH IP/OP "$1,379.18 " "$1,020.59" $0.00 "$1,796.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,023.62" "$1,023.62" $0.00 $0.00 $287.42 $0.00 $0.00 $0.00 $0.00 "$1,123.00" "$1,778.83" "$1,796.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-2-080 SUP Custom 27203010 4921-2-080 - CLAMP EXFIX HFMN2 MRI PLVC BOTH IP/OP "$1,496.00 " "$1,107.04" $0.00 "$1,110.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,110.33" "$1,110.33" $0.00 $0.00 $311.77 $0.00 $0.00 $0.00 $0.00 $565.13 $895.16 $904.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-2-120 SUP Custom 27203010 4921-2-120 - POST XTRNFX STRG 8MM HFMN 3 CLR CD MRI SAFE BOTH IP/OP $225.70 $167.02 $0.00 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.51 $167.51 $0.00 $0.00 $47.04 $0.00 $0.00 $0.00 $0.00 $183.00 $289.87 $292.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-2-140 SUP Custom 27203010 4921-2-140 - POST XTRNFX 30D 8MM HFMN2 CLR CD MRI SAFE BOTH IP/OP $172.98 $128.01 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.38 $128.38 $0.00 $0.00 $36.05 $0.00 $0.00 $0.00 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-2-160 SUP Custom 27203010 4921-2-160 - POST XTRNFX 90D 8MM HFMN2 MRI SAFE H BOTH IP/OP $264.55 $195.77 $0.00 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.35 $196.35 $0.00 $0.00 $55.13 $0.00 $0.00 $0.00 $0.00 $217.00 $343.73 $347.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4921-9-985 SUP Custom 27203010 4921-9-985 - BAR XTRNFX 30D HFMN2 STOR LWR BOTH IP/OP $779.63 $576.93 $0.00 $623.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $578.64 $578.64 $0.00 $0.00 $162.47 $0.00 $0.00 $0.00 $0.00 $389.81 $617.47 $623.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-1-010 SUP Custom 27203010 4922-1-010 - COUPLING EXFIX 5MM 8MM ROD TO ROD BOTH IP/OP "$1,360.45 " "$1,006.73" $0.00 "$1,349.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.73" "$1,009.73" $0.00 $0.00 $283.52 $0.00 $0.00 $0.00 $0.00 $843.48 "$1,336.06" "$1,349.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-1-020 SUP Custom 27203010 4922-1-020 - COUPLING EXFIX 5/8IN 4IN 5 HOLE PIN TO ROD APEX PIN CLMP BOTH IP/OP "$1,245.45 " $921.63 $0.00 "$1,349.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.37 $924.37 $0.00 $0.00 $259.55 $0.00 $0.00 $0.00 $0.00 $843.48 "$1,336.06" "$1,349.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-1-030 SUP Custom 27203010 4922-1-030 - COUPLING EXFIX 5MM 8MM PIN TO ROD BOTH IP/OP "$1,360.45 " "$1,006.73" $0.00 "$1,349.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.73" "$1,009.73" $0.00 $0.00 $283.52 $0.00 $0.00 $0.00 $0.00 $843.48 "$1,336.06" "$1,349.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-2-020 SUP Custom 27203010 4922-2-020 - CLAMP EXFIX 4/5/6MM 5 HOLE MULTIPIN MODULAR HOFFMANN III BOTH IP/OP "$1,401.85 " "$1,037.37" $0.00 "$1,416.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,040.45" "$1,040.45" $0.00 $0.00 $292.15 $0.00 $0.00 $0.00 $0.00 $885.06 "$1,401.94" "$1,416.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-2-140 SUP Custom 27203010 4922-2-140 - POST XTRNFX 30D 11MM HFMN 3 BOTH IP/OP $246.10 $182.11 $0.00 $247.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.66 $182.66 $0.00 $0.00 $51.29 $0.00 $0.00 $0.00 $0.00 $154.44 $244.63 $247.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-2-240 SUP Custom 27203010 4922-2-240 - CLAMP EXFIX 30D 11MM 5 HOLE PIN POST MODULAR HOFFMANN III BOTH IP/OP "$1,481.70 " "$1,096.46" $0.00 "$1,566.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,099.72" "$1,099.72" $0.00 $0.00 $308.79 $0.00 $0.00 $0.00 $0.00 $979.11 "$1,550.92" "$1,566.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-8-150 SUP Custom 27203010 4922-8-150 - ROD EXFIX 11MM 150MM CONNCTNG BOTH IP/OP $645.70 $477.82 $0.00 $714.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.24 $479.24 $0.00 $0.00 $134.56 $0.00 $0.00 $0.00 $0.00 $446.49 $707.24 $714.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-8-200 SUP Custom 27203010 4922-8-200 - ROD EXFIX 11MM 200MM CONNCTNG MRI HOFFMANN 3 CARB BOTH IP/OP $662.20 $490.03 $0.00 $734.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $491.48 $491.48 $0.00 $0.00 $138.00 $0.00 $0.00 $0.00 $0.00 $459.36 $727.63 $734.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-8-250 SUP Custom 27203010 4922-8-250 - ROD EXFIX 11MM 250MM CONNCTNG BOTH IP/OP $662.20 $490.03 $0.00 $734.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $491.48 $491.48 $0.00 $0.00 $138.00 $0.00 $0.00 $0.00 $0.00 $459.36 $727.63 $734.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-8-300 SUP Custom 27203010 4922-8-300 - ROD EXFIX 11MM 300MM CONNCTNG MRI SAFE HOFFMANN III CARB BOTH IP/OP $679.80 $503.05 $0.00 $752.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $504.55 $504.55 $0.00 $0.00 $141.67 $0.00 $0.00 $0.00 $0.00 $470.25 $744.88 $752.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-8-350 SUP Custom 27203010 4922-8-350 - ROD EXFIX 11MM 350MM CONNCTNG MRI HOFFMANN 3 CARB BOTH IP/OP $679.80 $503.05 $0.00 $752.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $504.55 $504.55 $0.00 $0.00 $141.67 $0.00 $0.00 $0.00 $0.00 $470.25 $744.88 $752.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-8-400 SUP Custom 27203010 4922-8-400 - ROD EXFIX 11MM 400MM CONNCTNG MRI HOFFMANN 3 CARB BOTH IP/OP $777.70 $575.50 $0.00 $820.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $577.21 $577.21 $0.00 $0.00 $162.07 $0.00 $0.00 $0.00 $0.00 $512.83 $812.31 $820.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4922-8-500 SUP HCPCS C1713 4922-8-500 - ROD EXFIX 11MM 500MM CONNECT MRI SAFE MODULAR HOFFMANN III BOTH IP/OP $887.70 $656.90 $0.00 $902.88 $507.87 $507.87 $0.00 $0.00 $0.00 $185.02 $658.85 $658.85 $0.00 $0.00 $185.00 $0.00 $525.07 $525.07 $0.00 $564.30 $893.85 $902.88 $0.00 $0.00 $176.63 $0.00 $0.00 $179.67 $0.00 $0.00 $0.00 $0.00 $0.00 493.100.01S SUP Custom 27803010 493.100.01S - WIRE FX 26GA 500MM STRL NDL TI BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 493.101.01S SUP Custom 27803010 493.101.01S - WIRE FX 28GA 500MM STRL NDL TI BOTH IP/OP $229.50 $169.83 $0.00 $183.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.33 $170.33 $0.00 $0.00 $47.83 $0.00 $0.00 $0.00 $0.00 $114.75 $181.76 $183.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 493.102.01S SUP Custom 27803010 493.102.01S - WIRE SPINAL .25MM 500MM NEEDLE TITANIUM STERILE BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 493.103.01S SUP Custom 27803010 493.103.01S - WIRE SPINAL .2MM 500MM NEEDLE TITANIUM STERILE BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 493.104.01S SUP Custom 27803010 493.104.01S - WIRE FX 28GA 500MM STRL BRB NDL TI BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $0.00 $0.00 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 49-36-1550 SUP Custom 27203010 PAD FLRMCHN FOAM THK2IN 8IN CMPD MILWAUKEE BOTH IP/OP $42.58 $31.51 $0.00 $34.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.29 $33.72 $34.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 494.771SHA SUP HCPCS C1713 494.771SHA - SCREW BONE 4/3MM 80MM SLFDRILL SCHANZ HYDRXAPT ORTHOPEDIC BOTH IP/OP $337.53 $249.77 $0.00 $262.16 $147.47 $147.47 $0.00 $0.00 $0.00 $70.35 $250.51 $250.51 $0.00 $0.00 $70.34 $0.00 $199.65 $199.65 $0.00 $163.85 $259.54 $262.16 $0.00 $0.00 $49.79 $0.00 $0.00 $52.17 $0.00 $0.00 $0.00 $0.00 $0.00 494.784SHA SUP HCPCS C1713 494.784SHA - SCREW BONE 5MM 150MM SLFDRILL SCHANZ HYDRXAPT ORTHOPEDIC BOTH IP/OP $382.08 $282.74 $0.00 $296.76 $166.93 $166.93 $0.00 $0.00 $0.00 $79.63 $283.58 $283.58 $0.00 $0.00 $79.62 $0.00 $226.00 $226.00 $0.00 $185.48 $293.79 $296.76 $0.00 $0.00 $56.36 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 494.785SHA SUP HCPCS C1713 494.785SHA - SCREW BONE 5MM 175MM SLFDRILL SCHANZ HYDRXAPT ORTHOPEDIC BOTH IP/OP $382.08 $282.74 $0.00 $296.76 $166.93 $166.93 $0.00 $0.00 $0.00 $79.63 $283.58 $283.58 $0.00 $0.00 $79.62 $0.00 $226.00 $226.00 $0.00 $185.48 $293.79 $296.76 $0.00 $0.00 $56.36 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 494.786SHA SUP HCPCS C1713 494.786SHA - SCREW BONE 5MM 200MM SLFDRILL SCHANZ HYDRXAPT ORTHOPEDIC BOTH IP/OP $382.08 $282.74 $0.00 $296.76 $166.93 $166.93 $0.00 $0.00 $0.00 $79.63 $283.58 $283.58 $0.00 $0.00 $79.62 $0.00 $226.00 $226.00 $0.00 $185.48 $293.79 $296.76 $0.00 $0.00 $56.36 $0.00 $0.00 $59.06 $0.00 $0.00 $0.00 $0.00 $0.00 4940-0-015 SUP Custom 27203010 4940-0-015 - TUBE XTRNFX SM 15MM 5MM HFMN2 C CMPR DSTRCT C BOTH IP/OP $844.25 $624.75 $0.00 $675.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $626.60 $626.60 $0.00 $0.00 $175.94 $0.00 $0.00 $0.00 $0.00 $422.13 $668.65 $675.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4940-1-010 SUP Custom 27203010 4940-1-010 - COUPLING XTRNFX NS HFMN2 C ROD TO ROD 5 MM ROD/POST BOTH IP/OP $522.50 $386.65 $0.00 $418.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $387.80 $387.80 $0.00 $0.00 $108.89 $0.00 $0.00 $0.00 $0.00 $261.25 $413.82 $418.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4940-1-015 SUP Custom 27203010 4940-1-015 - CLAMP EXFIX HFMN2 C KNEE CPLNG BOTH IP/OP $584.38 $432.44 $0.00 $467.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $433.72 $433.72 $0.00 $0.00 $121.78 $0.00 $0.00 $0.00 $0.00 $292.19 $462.83 $467.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4940-1-020 SUP Custom 27203010 4940-1-020 - CPLNG EXFIX 5MM HFMN2 C 5MM 3-4MM PIN TO ROD BOTH IP/OP $522.50 $386.65 $0.00 $418.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $387.80 $387.80 $0.00 $0.00 $108.89 $0.00 $0.00 $0.00 $0.00 $261.25 $413.82 $418.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4940-1-058 SUP Custom 27203010 4940-1-058 - CPLNG EXFIX 5MM HFMN2 C 5MM 8-8MM PIN TO ROD BOTH IP/OP $807.13 $597.28 $0.00 $645.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.05 $599.05 $0.00 $0.00 $168.20 $0.00 $0.00 $0.00 $0.00 $403.56 $639.25 $645.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4940-1-100 SUP Custom 27203010 4940-1-100 - DEVICE EXFIX HFMN2 C CMPR DSTRCT ROD TO TUBE CPLNG BOTH IP/OP $522.50 $386.65 $0.00 $418.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $387.80 $387.80 $0.00 $0.00 $108.89 $0.00 $0.00 $0.00 $0.00 $261.25 $413.82 $418.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4940-2-020 SUP Custom 27203010 4940-2-020 - CLAMP EXFIX HFMN2 4 HOLE MLPN BOTH IP/OP "$1,575.90 " "$1,166.17" $0.00 "$1,169.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,169.63" "$1,169.63" $0.00 $0.00 $328.42 $0.00 $0.00 $0.00 $0.00 $308.69 $488.96 $493.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4940-2-120 SUP Custom 27203010 4940-2-120 - POST XTRNFX STRG 5MM HFMN2 C SS BOTH IP/OP $298.70 $221.04 $0.00 $221.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.70 $221.70 $0.00 $0.00 $62.25 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4940-2-140 SUP Custom 27203010 4940-2-140 - POST XTRNFX 30D 5MM HFMN2 C SS BOTH IP/OP $298.70 $221.04 $0.00 $221.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.70 $221.70 $0.00 $0.00 $62.25 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-0-015 SUP Custom 27203010 4941-0-015 - TUBE XTRNFX 15MM 350MM YLW HFMN2 C CMPR DSTRCT MRI SAFE C BOTH IP/OP $737.00 $545.38 $0.00 $589.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.00 $547.00 $0.00 $0.00 $153.59 $0.00 $0.00 $0.00 $0.00 $368.50 $583.70 $589.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-1-010 SUP Custom 27203010 4941-1-010 - CPLNG EXFIX HFMN2 ROD TO ROD CMPCT 5 MM ROD OR POST BOTH IP/OP $514.25 $380.55 $0.00 $411.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $381.68 $381.68 $0.00 $0.00 $107.17 $0.00 $0.00 $0.00 $0.00 $257.13 $407.29 $411.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-1-020 SUP Custom 27203010 4941-1-020 - CLAMP EXFIX HFMN2 MRI PIN TO ROD CPLNG MRI 5 MM ROD OR POST BOTH IP/OP $514.25 $380.55 $0.00 $411.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $381.68 $381.68 $0.00 $0.00 $107.17 $0.00 $0.00 $0.00 $0.00 $257.13 $407.29 $411.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-1-058 SUP Custom 27203010 4941-1-058 - COUPLING XTRNFX HFMN2 C MR SF 5 MM 8 MM ROD BOTH IP/OP $746.63 $552.51 $0.00 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.15 $554.15 $0.00 $0.00 $155.60 $0.00 $0.00 $0.00 $0.00 $373.31 $591.33 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-1-100 SUP Custom 27203010 4941-1-100 - SYSTEM EXFIX 15MM 5MM DSTRCT TUBE ROD CPLNG POSTS BOTH IP/OP $456.50 $337.81 $0.00 $365.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $338.81 $338.81 $0.00 $0.00 $95.13 $0.00 $0.00 $0.00 $0.00 $228.25 $361.55 $365.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-2-020 SUP Custom 27203010 4941-2-020 - CLAMP EXFIX HFMN2 C 4 HOLE PIN 3-4 MM PIN BOTH IP/OP $621.50 $459.91 $0.00 $497.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $461.28 $461.28 $0.00 $0.00 $129.52 $0.00 $0.00 $0.00 $0.00 $310.75 $492.23 $497.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-2-120 SUP Custom 27203010 4941-2-120 - POST XTRNFX 30D STRG AU HFMN2 C MDLR MRI SAFE AL TI BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $0.00 $0.00 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-2-140 SUP Custom 27203010 4941-2-140 - POST XTRNFX 30D HFMN2 C MRI SAFE BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $0.00 $0.00 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4941-2-200 SUP Custom 27203010 4941-2-200 - CLAMP EXFIX HFMN2 MRI PERIART PIN CMPCT BOTH IP/OP $621.50 $459.91 $0.00 $497.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $461.28 $461.28 $0.00 $0.00 $129.52 $0.00 $0.00 $0.00 $0.00 $310.75 $492.23 $497.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-1-010 SUP Custom 27203010 4960-1-010 - CPLNG EXFIX 3MM 3MM HFMN2 ROD TO ROD BOTH IP/OP $841.50 $622.71 $0.00 $624.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $624.56 $624.56 $0.00 $0.00 $175.37 $0.00 $0.00 $0.00 $0.00 $367.13 $581.53 $587.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-1-020 SUP Custom 27203010 4960-1-020 - CPLNG EXFIX 1.65-2MM 3MM HFMN2 MIC HAND PIN TO ROD BOTH IP/OP $734.25 $543.35 $0.00 $587.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $544.96 $544.96 $0.00 $0.00 $153.02 $0.00 $0.00 $0.00 $0.00 $367.13 $581.53 $587.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-1-060 SUP Custom 27203010 4960-1-060 - CPLNG EXFIX 5MM 3MM HFMN2 ROD TO ROD BOTH IP/OP $855.75 $633.26 $0.00 $635.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $635.14 $635.14 $0.00 $0.00 $178.34 $0.00 $0.00 $0.00 $0.00 $373.31 $591.33 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-2-020 SUP Custom 27203010 4960-2-020 - CLAMP EXFIX HFMN2 STR MLPN BOTH IP/OP $855.75 $633.26 $0.00 $635.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $635.14 $635.14 $0.00 $0.00 $178.34 $0.00 $0.00 $0.00 $0.00 $373.31 $591.33 $597.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-3-000 SUP Custom 27203010 4960-3-000 - DEVICE EXFIX HFMN2 MIC LNTHNR BOTH IP/OP "$4,581.00 " "$3,389.94" $0.00 "$3,559.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,400.02" "$3,400.02" $0.00 $0.00 $954.68 $0.00 $0.00 $0.00 $0.00 "$2,224.75" "$3,524.00" "$3,559.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-3-015 SUP Custom 27203010 4960-3-015 - CLAMP EXFIX HFMN2 MIC MLPN LNTHNR CMPNT BOTH IP/OP $64.50 $47.73 $0.00 $47.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.87 $47.87 $0.00 $0.00 $13.44 $0.00 $0.00 $0.00 $0.00 $29.56 $46.83 $47.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-3-020 SUP Custom 27203010 4960-3-020 - CLAMP EXFIX HFMN2 MIC MLPN LNTHNR CMPNT BOTH IP/OP "$1,524.00 " "$1,127.76" $0.00 "$1,131.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,131.11" "$1,131.11" $0.00 $0.00 $317.60 $0.00 $0.00 $0.00 $0.00 $325.88 $516.19 $521.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-3-025 SUP Custom 27203010 4960-3-025 - CLAMP EXFIX HFMN2 PERIART MLPN LNTHNR BOTH IP/OP "$1,524.00 " "$1,127.76" $0.00 "$1,131.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,131.11" "$1,131.11" $0.00 $0.00 $317.60 $0.00 $0.00 $0.00 $0.00 $325.88 $516.19 $521.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4960-3-030 SUP Custom 27203010 4960-3-030 - HII MICRO LENGTHENER THUMBWHEEL BOTH IP/OP $238.50 $176.49 $0.00 $177.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $0.00 $0.00 $0.00 $87.31 $138.31 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 497.668E SUP HCPCS C1713 497.668E - SCREW TI 8MM 2.4MM MANDIB SLFTAP LCK BONE STRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.670E SUP HCPCS C1713 497.670E - SCREW TI 10MM 2.4MM MANDIB SLFTAP LCK BONE STRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.672E SUP HCPCS C1713 497.672E - SCREW TI 12MM 2.4MM MANDIB SLFTAP LCK BONE STRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.674E SUP HCPCS C1713 497.674E - SCREW TI 14MM 2.4MM MANDIB SLFTAP LCK BONE STRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.676E SUP HCPCS C1713 497.676E - SCREW TI 16MM 2.4MM MANDIB SLFTAP LCK BONE STRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.678E SUP HCPCS C1713 497.678E - SCREW TI 18MM 2.4MM MANDIB SLFTAP LCK BONE STRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.680E SUP HCPCS C1713 497.680E - 2.4MM TI LOCKING SCREW 20MM F/LOCKING RECONSTRUCTION PLATE BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 497.682E SUP HCPCS C1713 497.682E - 2.4MM TI LOCKING SCREW 22MM F/LOCKING RECONSTRUCTION PLATE BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 497.684E SUP HCPCS C1713 497.684E - 2.4MM TI LOCKING SCREW 24MM F/LOCKING RECONSTRUCTION PLATE BOTH IP/OP $389.25 $288.05 $0.00 $311.40 $175.16 $175.16 $0.00 $0.00 $0.00 $81.13 $288.90 $288.90 $0.00 $0.00 $81.12 $0.00 $230.24 $230.24 $0.00 $194.63 $308.29 $311.40 $0.00 $0.00 $60.92 $0.00 $0.00 $61.97 $0.00 $0.00 $0.00 $0.00 $0.00 497.689E SUP HCPCS C1713 497.689E - TI BENDING INSERT SCREW F/LOCKING RECONSTRUCTION PLATE BOTH IP/OP $113.63 $84.09 $0.00 $90.90 $51.13 $51.13 $0.00 $0.00 $0.00 $23.68 $84.33 $84.33 $0.00 $0.00 $23.68 $0.00 $67.21 $67.21 $0.00 $56.81 $89.99 $90.90 $0.00 $0.00 $17.78 $0.00 $0.00 $18.09 $0.00 $0.00 $0.00 $0.00 $0.00 497.690E SUP HCPCS C1713 497.690E - SCREW TI 8MM 3MM MANDIB SLFTAP LCK BONE STRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.691E SUP HCPCS C1713 497.691E - SCREW TI 10MM 3MM MANDIB SLFTAP LCK BONE NONSTRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.692E SUP HCPCS C1713 497.692E - SCREW TI 12MM 3MM MANDIB SLFTAP LCK BONE NONSTRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.693E SUP HCPCS C1713 497.693E - SCREW TI 14MM 3MM MANDIB SLFTAP LCK BONE STRL RECON PLT BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.694E SUP HCPCS C1713 497.694E - SCREW BONE 16MM 3MM CRNMXF TI SLFTAP LCK RECON PLT STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.695E SUP HCPCS C1713 497.695E - SCREW BONE 18MM 3MM CRNMXF TI SLFTAP LCK RECON PLT STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.45 $0.45 $0.00 $0.00 $0.00 $0.21 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.59 $0.59 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.16 $0.00 $0.00 $0.16 $0.00 $0.00 $0.00 $0.00 $0.00 497.696E SUP HCPCS C1713 497.696E - SCREW TI 20MM 3MM MANDIB SLFTAP LCK BONE NONSTRL RECON PLT BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 497.697E SUP HCPCS C1713 497.697E - SCREW BONE 3MM 22MM TI ORTH LCK NONSTRL BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 497.698E SUP HCPCS C1713 497.698E - 3.0MM TI LOCKING SCREW 24MM F/LOCKING RECONSTRUCTION PLATE BOTH IP/OP $452.25 $334.67 $0.00 $361.80 $203.51 $203.51 $0.00 $0.00 $0.00 $94.26 $335.66 $335.66 $0.00 $0.00 $94.25 $0.00 $267.51 $267.51 $0.00 $226.13 $358.18 $361.80 $0.00 $0.00 $70.78 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 497.78.98 SUP HCPCS C1713 497.78.98 - SCREW TI 5MM 1.8MM MAXFACL LCK BONE THORP NONSTRL BOTH IP/OP $85.50 $63.27 $0.00 $68.40 $38.48 $38.48 $0.00 $0.00 $0.00 $17.82 $63.46 $63.46 $0.00 $0.00 $17.82 $0.00 $50.57 $50.57 $0.00 $42.75 $67.72 $68.40 $0.00 $0.00 $13.38 $0.00 $0.00 $13.61 $0.00 $0.00 $0.00 $0.00 $0.00 497-670 SUP HCPCS C1713 497-670 - SCREW TI 10MM 2.4MM MANDIB SLFTAP LCK RECON BONE NONSTRL BOTH IP/OP $272.25 $201.47 $0.00 $217.80 $122.51 $122.51 $0.00 $0.00 $0.00 $56.74 $202.06 $202.06 $0.00 $0.00 $56.74 $0.00 $161.04 $161.04 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $42.61 $0.00 $0.00 $43.34 $0.00 $0.00 $0.00 $0.00 $0.00 498.800.01S SUP Custom 27803010 498.800.01S - CABLE ORTHOPEDIC 1MM 750MM CRIMP TITANIUM STERILE BOTH IP/OP $919.33 $680.30 $0.00 $714.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $682.32 $682.32 $0.00 $0.00 $191.59 $0.00 $0.00 $0.00 $0.00 $446.28 $706.90 $714.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 498.803S SUP Custom 27203010 498.803S - POSITIONER IMPLANT 4.5MM THREAD CERCLAGE TITANIUM STERILE BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 498.806S SUP Custom 27803010 498.806S - SYSTEM CABLE STANDARD REATTACHMENT DEVICE TITANIUM COCR BOTH IP/OP "$3,644.95 " "$2,697.26" $0.00 "$2,831.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,705.28" "$2,705.28" $0.00 $0.00 $759.61 $0.00 $0.00 $0.00 $0.00 "$1,769.40" "$2,802.73" "$2,831.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 498.807S SUP Custom 27803010 498.807S - SYSTEM CABLE LONG TITANIUM COCR TROC STERILE REATTACHMENT BOTH IP/OP "$5,251.68 " "$3,886.24" $0.00 "$4,078.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,897.79" "$3,897.79" $0.00 $0.00 "$1,094.45" $0.00 $0.00 $0.00 $0.00 "$2,549.35" "$4,038.17" "$4,078.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 498.821S SUP Custom 27803010 498.821S - CABLE ORTHOPEDIC 1MM 750MM NEEDLE CRIMP TITANIUM STERILE BOTH IP/OP "$1,031.78 " $763.52 $0.00 $801.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $765.78 $765.78 $0.00 $0.00 $215.02 $0.00 $0.00 $0.00 $0.00 $500.86 $793.37 $801.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 498.822S SUP Custom 27803010 498.822S - CABLE ORTHOPEDIC CRIMP TITANIUM STERILE BOTH IP/OP $67.83 $50.19 $0.00 $52.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.34 $50.34 $0.00 $0.00 $14.13 $0.00 $0.00 $0.00 $0.00 $32.93 $52.15 $52.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 498.837S SUP Custom 27203010 498.837S - PIN FIX 3.5MM CERCLAGE POSITION STR TITANIUM ORTHOPEDIC BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 498.838S SUP HCPCS C1713 498.838S - PIN FIX 3.5MM THREADED CERCLAGE POSITIONING TITANIUM BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $149.85 $149.85 $0.00 $0.00 $0.00 $71.49 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $202.88 $202.88 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $50.60 $0.00 $0.00 $53.01 $0.00 $0.00 $0.00 $0.00 $0.00 498.839S SUP Custom 27203010 498.839S - POSITIONER SURG 4.5MM CERCLAGE NONTHREADED PIN TITANIUM BOTH IP/OP $343.00 $253.82 $0.00 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.57 $254.57 $0.00 $0.00 $71.48 $0.00 $0.00 $0.00 $0.00 $166.50 $263.74 $266.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4981-1-010S SUP Custom 27203010 4981-1-010S - CPLNG EXFIX 15/15MM 4 5/15MM HFMN XPRESS UNV STRL BOTH IP/OP $696.50 $515.41 $0.00 $632.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $516.94 $516.94 $0.00 $0.00 $145.15 $0.00 $0.00 $0.00 $0.00 $395.31 $626.18 $632.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4981-1-020S SUP Custom 27203010 4981-1-020S - COUPLING XTRNFX UNV 5MM 6MM BOTH IP/OP $845.63 $625.77 $0.00 $676.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $627.62 $627.62 $0.00 $0.00 $176.23 $0.00 $0.00 $0.00 $0.00 $422.81 $669.74 $676.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4A0002 SUP HCPCS C1725 4A0002 - CATHETER ANGIO JR4 CRV 4FR 100CM STSR BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 4A0004 SUP HCPCS C1887 4A0004 - CATHETER ANGIOGRAPHIC JR5 CURVE 4FR 100CM SITESEER BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 4A001 SUP HCPCS C1725 CATHETER 4FR JR 3.5 BOTH IP/OP $0.80 $0.59 $0.00 $0.64 $0.43 $0.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.40 $0.63 $0.64 $0.00 $0.00 $0.13 $0.00 $0.00 $0.13 $0.00 $0.00 $0.00 $0.00 $0.00 4A0010 SUP HCPCS C1725 4A0010 - CATHETER ANGIOGRAPHIC JL3.5 CURVE 4FR 100CM SITESEER BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 4A0011 SUP HCPCS C1725 4A0011 - CATHETER ANGIO JL4 CRV 4FR 100CM STSR BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 4A0012 SUP HCPCS C1725 4A0012 - CATHETER ANGIOGRAPHIC JL5 CURVE 4FR 100CM SITESEER BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 4A002 SUP HCPCS C1887 4A002 - CATHETER GD JR CRV 4FR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $3.65 $12.99 $12.99 $0.00 $0.00 $3.65 $0.00 $10.35 $10.35 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 4A0022 SUP HCPCS C1725 4A0022 - CATHETER ANGIOGRAPHIC MPA2 CURVE 4FR 100CM 2 SIDEHOLE BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 4A101 SUP Custom 27203010 HAMMER TL 12.25IN 1.25IN NUPLA FBGLS PLMR DEAD BLOW 4IN 16OZ BOTH IP/OP $62.90 $46.55 $0.00 $50.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.45 $49.82 $50.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4DCFN SUP Custom 27203010 4DCFN - TUBE TRCH 4 9.4MM 5MM 62MM STRL LF SHLY CUFLS DISP INR CNN BOTH IP/OP $83.74 $61.97 $0.00 $66.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.15 $62.15 $0.00 $0.00 $17.45 $0.00 $0.00 $0.00 $0.00 $41.87 $66.32 $66.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4DCFS SUP Custom 27203010 4DCFS - TUBE TRCH 4 9.4MM 5MM 62MM STRL LF SHLY CUFLS DISP INR CNN BOTH IP/OP $89.90 $66.53 $0.00 $71.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.95 $71.20 $71.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4DFEN SUP Custom 27203010 4DFEN - TUBE TRCH 4 9.4MM 5MM 62MM STRL LF SHLY CUF DISP INR CNN RND BOTH IP/OP $99.43 $73.58 $0.00 $80.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.79 $73.79 $0.00 $0.00 $20.72 $0.00 $0.00 $0.00 $0.00 $50.46 $79.93 $80.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4MAXC SUP HCPCS C1757 4MAXC - CATHETER REPERFUSION 4MAX BOTH IP/OP "$3,725.00 " "$2,756.50" $0.00 "$4,110.93" $0.00 $0.00 $0.00 $0.00 $0.00 $776.38 "$2,764.70" "$2,764.70" $0.00 $0.00 $776.29 $0.00 "$4,110.93" "$4,110.93" $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4MAXCKIT SUP HCPCS C1757 4MAXCKIT - CATHETER REPERFUSION 4MAX BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4N06A SUP Custom 27803010 4N06A - SUTURE NABSB CV-4 TH-26 36IN WHT 2 ARM MFL GRTX BOTH IP/OP $67.50 $49.95 $0.00 $53.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.10 $50.10 $0.00 $0.00 $14.07 $0.00 $0.00 $0.00 $0.00 $33.23 $52.64 $53.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 4R5126 SUP Custom 27203010 DEVICE HMTP SEG NDL PRTC BLOOD BANK STRL BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50000LTS SUP HCPCS C1713 50000LTS - CAP LCK SPRL R90D TI SPNE WDG LCK CLSR MECH BOTH IP/OP $696.43 $515.36 $0.00 $557.14 $313.39 $313.39 $0.00 $0.00 $0.00 $145.15 $516.89 $516.89 $0.00 $0.00 $145.13 $0.00 $411.94 $411.94 $0.00 $348.21 $551.57 $557.14 $0.00 $0.00 $108.99 $0.00 $0.00 $110.87 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-42A SUP Custom 27803010 500-01-42A - SHELL ACETAB A HEMISPHERICAL 42MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-44B SUP Custom 27803010 500-01-44B - SHELL ACETAB B HEMISPHERICAL 44MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-46C SUP Custom 27803010 500-01-46C - SHELL ACETAB C HEMISPHERICAL 46MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-48D SUP Custom 27803010 500-01-48D - SHELL ACETAB D HEMISPHERICAL 48MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-50D SUP Custom 27803010 500-01-50D - SHELL ACETAB D HEMISPHERICAL 50MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-52E SUP Custom 27803010 500-01-52E - SHELL ACETAB E HEMISPHERICAL 52MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-54E SUP Custom 27803010 500-01-54E - SHELL ACETAB E HEMISPHERICAL 54MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-56F SUP Custom 27803010 500-01-56F - SHELL ACETAB F HEMISPHERICAL 56MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-58F SUP Custom 27803010 500-01-58F - SHELL ACETAB F HEMISPHERICAL 58MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-60G SUP Custom 27803010 500-01-60G - SHELL ACETAB G HEMISPHERICAL 60MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-62G SUP Custom 27803010 500-01-62G - SHELL ACETAB G HEMISPHERICAL 62MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-64H SUP Custom 27803010 500-01-64H - SHELL ACETAB H HEMISPHERICAL 64MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-66H SUP Custom 27803010 500-01-66H - SHELL ACETAB H HEMISPHERICAL 66MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-68I SUP Custom 27803010 500-01-68I - SHELL ACETAB I HEMISPHERICAL 68MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-70I SUP Custom 27803010 500-01-70I - SHELL ACETAB I HEMISPHERICAL 70MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-72J SUP Custom 27803010 500-01-72J - SHELL ACETAB J HEMISPHERICAL 72MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-01-74J SUP Custom 27803010 500-01-74J - SHELL ACETAB J HEMISPHERICAL 74MM SOLID BACK TRIDENT HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-44A SUP Custom 27803010 500-03-44A - SHELL ACETAB A HEMISPHERICAL 44MM SOLID BACK TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-46B SUP Custom 27803010 500-03-46B - SHELL ACETAB B HEMISPHERICAL 46MM SOLID BACK TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-48C SUP Custom 27803010 500-03-48C - SHELL ACETAB C HEMISPHERICAL 48MM SOLID BACK TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-50D SUP Custom 27803010 500-03-50D - SHELL ACETAB D HEMISPHERICAL 50MM SOLID BACK TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-52D SUP Custom 27803010 500-03-52D - SHELL ACETAB D HEMISPHERICAL 52MM SOLID BACK TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-54E SUP Custom 27803010 500-03-54E - SHELL ACETAB E HEMISPHERICAL 54MM SOLID BACK PRIM TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-56E SUP Custom 27803010 500-03-56E - SHELL ACETAB E HEMISPHERICAL 56MM SOLID BACK PRIM TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-58F SUP Custom 27803010 500-03-58F - SHELL ACETAB F HEMISPHERICAL 58MM SOLID BACK PRIM TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-60F SUP Custom 27803010 500-03-60F - SHELL ACETAB F HEMISPHERICAL 60MM SOLID BACK PRIM TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-62G SUP Custom 27803010 500-03-62G - SHELL ACETAB F HEMISPHERICAL 60MM SOLID BACK PRIM TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-64G SUP Custom 27803010 500-03-64G - SHELL ACETAB G HEMISPHERICAL 64MM SOLID BACK PRIM TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-03-66H SUP Custom 27803010 500-03-66H - SHELL ACETAB H HEMISPHERICAL 66MM SOLID BACK PRIM TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5000L SUP Custom 27803010 5000L - CONNECTOR ROD LNG SPRL R90D VAR CX TI SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5000M SUP Custom 27803010 5000M - CONNECTOR ROD MED SPRL R90D VAR CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5000S SUP Custom 27803010 5000S - CONNECTOR ROD SM SPRL R90D VAR CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50010X SUP Custom 27803010 50010X - CONNECTOR ROD 10MM SPRL R90D FX CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-42A SUP Custom 27803010 500-11-42A - SHELL ACETAB A HEMISPHERICAL 42MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-44B SUP Custom 27803010 500-11-44B - SHELL ACETAB B HEMISPHERICAL 44MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-46C SUP Custom 27803010 500-11-46C - SHELL ACETAB C HEMISPHERICAL 46MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-48D SUP Custom 27803010 500-11-48D - SHELL ACETAB D HEMISPHERICAL 48MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-50D SUP Custom 27803010 500-11-50D - SHELL ACETAB D HEMISPHERICAL 50MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-52E SUP Custom 27803010 500-11-52E - SHELL ACETAB E HEMISPHERICAL 52MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-54E SUP Custom 27803010 500-11-54E - SHELL ACETAB E HEMISPHERICAL 54MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-56F SUP Custom 27803010 500-11-56F - SHELL ACETAB F HEMISPHERICAL 56MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-58F SUP Custom 27803010 500-11-58F - SHELL ACETAB F HEMISPHERICAL 58MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-60G SUP Custom 27803010 500-11-60G - SHELL ACETAB G HEMISPHERICAL 60MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-62G SUP Custom 27803010 500-11-62G - SHELL ACETAB G HEMISPHERICAL 62MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-64H SUP Custom 27803010 500-11-64H - SHELL ACETAB H HEMISPHERICAL 64MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-66H SUP Custom 27803010 500-11-66H - SHELL ACETAB H HEMISPHERICAL 66MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-68I SUP Custom 27803010 500-11-68I - SHELL ACETAB I HEMISPHERICAL 68MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-70I SUP Custom 27803010 500-11-70I - SHELL ACETAB I HEMISPHERICAL 70MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-72J SUP Custom 27803010 500-11-72J - SHELL ACETAB J HEMISPHERICAL 72MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-11-74J SUP Custom 27803010 500-11-74J - SHELL ACETAB J HEMISPHERICAL 74MM SOLID BACK TRIDENT METAL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50012X SUP Custom 27803010 50012X - CONNECTOR ROD 12MM SPRL R90D FX CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50014X SUP Custom 27803010 50014X - CONNECTOR ROD 14MM SPRL R90D FX CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50016X SUP Custom 27803010 50016X - CONNECTOR ROD 16MM SPRL R90D FX CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50018X SUP Custom 27803010 50018X - CONNECTOR ROD 18MM SPRL R90D FX CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50020X SUP Custom 27803010 50020X - CONNECTOR ROD 20MM SPRL R90D VAR CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-022-01-07 SUP Custom 27100030 50-022-01-07 - DRILL TWIST 2.7MM 2.2MM 70MM J NOTCH GLIDING 2.7MM SCREW 2.1 BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-022-15-07 SUP Custom 27100030 50-022-15-07 - DRILL TWIST 2.2MM 115MM STERILE BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50022X SUP Custom 27803010 50022X - CONNECTOR ROD 22MM SPRL R90D VAR CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50024X SUP Custom 27803010 50024X - CONNECTOR ROD 24MM SPRL R90D VAR CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50026X SUP Custom 27803010 50026X - CONNECTOR ROD 26MM SPRL R90D CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50028X SUP Custom 27803010 50028X - CONNECTOR ROD 28MM SPRL R90D CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50030X SUP Custom 27803010 50030X - CONNECTOR ROD 30MM SPRL R90D CX TI THORLMBR SPNE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 A SUP Custom 27803010 5005 A - PLATE 18MM TI BONE SPNL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 B SUP Custom 27803010 5005 B - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 C SUP Custom 27803010 5005 C - PLATE 18MM TI BONE SPNL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 E SUP Custom 27803010 5005 E - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 F SUP Custom 27803010 5005 F - PLATE 18MM TI BONE SPNL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 G SUP Custom 27803010 5005 G - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 H SUP Custom 27803010 5005 H - PLATE 18MM TI BONE SPNL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5005 I SUP Custom 27803010 5005 I - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 500-580C-10U SUP Custom 27803010 500-580C-10U - CLIP HMSTS 5FR BMRNG CTLST 2 SYS ART VASC CATH ACCES ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50100-1500 SUP HCPCS C1884 50100-1500 - SHEATH RTRVL 4FR F EZ .014IN BNTP BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 50-12003 SUP HCPCS C1713 50-12003 - SCREW BONE 1.2MM 3MM SELF TAP XPIN HEAD LEIBINGER UNIVERSAL BOTH IP/OP $27.75 $20.54 $0.00 $22.20 $12.49 $12.49 $0.00 $0.00 $0.00 $5.78 $20.60 $20.60 $0.00 $0.00 $5.78 $0.00 $16.41 $16.41 $0.00 $13.88 $21.98 $22.20 $0.00 $0.00 $4.34 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $0.00 50-12004 SUP HCPCS C1713 50-12004 - SCREW BONE 1.2MM 4MM SELF TAP XPIN HEAD LEIBINGER UNIVERSAL BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $57.84 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $164.14 $164.14 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-12005 SUP HCPCS C1713 50-12005 - SCREW BONE 1.2MM 5MM SLFTAP XPIN GOLD TITANIUM UPPERFACIAL BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $57.84 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $164.14 $164.14 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-12006 SUP HCPCS C1713 50-12006 - SCREW BONE 1.2MM 6MM SLFTAP XPIN GOLD TITANIUM UPPERFACIAL BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $57.84 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $164.14 $164.14 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-12007 SUP HCPCS C1713 50-12007 - SCREW BONE 1.2MM 7MM SLFTAP TITANIUM UPPERFACIAL BOTH IP/OP $111.25 $82.33 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $23.19 $82.57 $82.57 $0.00 $0.00 $23.18 $0.00 $65.80 $65.80 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-12008 SUP HCPCS C1713 50-12008 - SCREW BONE 1.2MM 8MM SLFTAP XPIN GOLD TITANIUM UPPERFACIAL BOTH IP/OP $111.25 $82.33 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $23.19 $82.57 $82.57 $0.00 $0.00 $23.18 $0.00 $65.80 $65.80 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-12010 SUP HCPCS C1713 50-12010 - SCREW BONE 1.2MM 10MM SLFTAP XPIN GOLD TITANIUM UPPERFACIAL BOTH IP/OP $111.25 $82.33 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $23.19 $82.57 $82.57 $0.00 $0.00 $23.18 $0.00 $65.80 $65.80 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-12012 SUP HCPCS C1713 50-12012 - SCREW BONE 1.2MM 12MM SLFTAP XPIN GOLD TITANIUM UPPERFACIAL BOTH IP/OP $111.25 $82.33 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $23.19 $82.57 $82.57 $0.00 $0.00 $23.18 $0.00 $65.80 $65.80 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-12903 SUP HCPCS C1713 50-12903 - SCREW BONE 1.2MM 3MM SLFDRILL XPIN HEAD LEIBINGER UNIVERSAL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 50-12904 SUP HCPCS C1713 50-12904 - SCREW BONE 1.2MM 4MM SELF DRILL XPIN TITANIUM UPPERFACIAL BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $28.13 $28.13 $0.00 $0.00 $0.00 $13.03 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $36.97 $36.97 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 5013-2-120S SUP HCPCS C1713 5013-2-120S - PIN 120MM 4MM APEX HA SS SLFTAP DRL THRD SHFT 20MM STRL BOTH IP/OP $228.65 $169.20 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $47.66 $169.70 $169.70 $0.00 $0.00 $47.65 $0.00 $135.25 $135.25 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 5013-3-090S SUP HCPCS C1713 5013-3-090S - PIN 90MM 4MM APEX HA SS SLFTAP DRL THRD SHFT 30MM STRL BOTH IP/OP $228.65 $169.20 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $47.66 $169.70 $169.70 $0.00 $0.00 $47.65 $0.00 $135.25 $135.25 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 50-14003 SUP HCPCS C1713 50-14003 - SCREW BONE 1.4MM 3MM SELF TAP XPIN EMERGENCY TITANIUM BOTH IP/OP $282.50 $209.05 $0.00 $226.00 $127.13 $127.13 $0.00 $0.00 $0.00 $58.88 $209.67 $209.67 $0.00 $0.00 $58.87 $0.00 $167.10 $167.10 $0.00 $141.25 $223.74 $226.00 $0.00 $0.00 $44.21 $0.00 $0.00 $44.97 $0.00 $0.00 $0.00 $0.00 $0.00 50-14005 SUP HCPCS C1713 50-14005 - SCREW BONE 1.4MM 5MM SELF TAP XPIN HEAD EMERGENCY LEIBINGER BOTH IP/OP $282.50 $209.05 $0.00 $226.00 $127.13 $127.13 $0.00 $0.00 $0.00 $58.88 $209.67 $209.67 $0.00 $0.00 $58.87 $0.00 $167.10 $167.10 $0.00 $141.25 $223.74 $226.00 $0.00 $0.00 $44.21 $0.00 $0.00 $44.97 $0.00 $0.00 $0.00 $0.00 $0.00 50-14007 SUP HCPCS C1713 50-14007 - SCREW BONE 1.4MM 7MM SLFTAP XPIN EMERGENCY TITANIUM BOTH IP/OP $120.38 $89.08 $0.00 $226.00 $127.13 $127.13 $0.00 $0.00 $0.00 $25.09 $89.34 $89.34 $0.00 $0.00 $25.09 $0.00 $71.20 $71.20 $0.00 $141.25 $223.74 $226.00 $0.00 $0.00 $44.21 $0.00 $0.00 $44.97 $0.00 $0.00 $0.00 $0.00 $0.00 50-14009 SUP HCPCS C1713 50-14009 - SCREW BONE 1.4MM 9MM SLFTAP XPIN EMERGENCY TITANIUM BOTH IP/OP $120.38 $89.08 $0.00 $226.00 $127.13 $127.13 $0.00 $0.00 $0.00 $25.09 $89.34 $89.34 $0.00 $0.00 $25.09 $0.00 $71.20 $71.20 $0.00 $141.25 $223.74 $226.00 $0.00 $0.00 $44.21 $0.00 $0.00 $44.97 $0.00 $0.00 $0.00 $0.00 $0.00 5014-2-120S SUP HCPCS C1713 5014-2-120S - PIN 6MM SLFTAP/DRL THRD SHFT 120MM APEX HA SS 30MM STRL BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-3-150S SUP HCPCS C1713 5014-3-150S - PIN 6MM SLFTAP/DRL THRD SHFT 150MM APEX HA SS 30MM STRL BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-3-180S SUP HCPCS C1713 5014-3-180S - PIN HALF 180MM 6MM APEX HA SS SLFDRILL SLFTAP THRD SHFT 30MM BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-3-200S SUP HCPCS C1713 5014-3-200S - PIN 6MM SLFTAP/DRL THRD SHFT 200MM APEX HA SS 30MM STRL BOTH IP/OP $268.13 $198.42 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $55.88 $199.00 $199.00 $0.00 $0.00 $55.88 $0.00 $158.60 $158.60 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 5014-4-150S SUP HCPCS C1713 5014-4-150S - PIN 6MM SLFTAP/DRL THRD SHFT 150MM APEX HA SS 40MM STRL BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-4-180S SUP HCPCS C1713 5014-4-180S - PIN 6MM SLFTAP/DRL THRD SHFT 180MM APEX HA SS 40MM STRL BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-4-200S SUP HCPCS C1713 5014-4-200S - PIN 6MM SLFTAP/DRL THRD SHFT 200MM APEX HA SS 40MM STRL BOTH IP/OP $268.13 $198.42 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $55.88 $199.00 $199.00 $0.00 $0.00 $55.88 $0.00 $158.60 $158.60 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 5014-5-150S SUP HCPCS C1713 5014-5-150S - PIN HALF 150MM 6MM APEX HA SS SLFDRILL SLFTAP 50MM FIX SYS BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-5-180S SUP HCPCS C1713 5014-5-180S - PIN HALF 180MM 6MM APEX HA SS SLFDRILL SLFTAP THRD SHFT 50MM BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-5-200S SUP HCPCS C1713 5014-5-200S - PIN 6MM SLFTAP/DRL THRD SHFT 200MM APEX HA SS 50MM STRL BOTH IP/OP $268.13 $198.42 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $55.88 $199.00 $199.00 $0.00 $0.00 $55.88 $0.00 $158.60 $158.60 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 5014-6-150S SUP HCPCS C1713 5014-6-150S - PIN 6MM SLFTAP/DRL THRD SHFT 150MM APEX HA SS 60MM STRL BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-6-180S SUP HCPCS C1713 5014-6-180S - PIN 6MM SLFTAP/DRL THRD SHFT 180MM APEX HA SS 60MM STRL BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-6-200S SUP HCPCS C1713 5014-6-200S - PIN 6MM SLFTAP/DRL THRD SHFT 200MM APEX HA SS 60MM STRL BOTH IP/OP $268.13 $198.42 $0.00 $214.50 $120.66 $120.66 $0.00 $0.00 $0.00 $55.88 $199.00 $199.00 $0.00 $0.00 $55.88 $0.00 $158.60 $158.60 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $41.96 $0.00 $0.00 $42.69 $0.00 $0.00 $0.00 $0.00 $0.00 5014-7-250S SUP HCPCS C1713 5014-7-250S - PIN HALF 250MM 6MM APEX SS HA SLFDRILL SLFTAP THRD 70MM STRL BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 5014-8-150S SUP HCPCS C1713 5014-8-150S - PIN 6MM SLFDRILL SLFTAP THRD SHFT 150MM APEX HA SS 25MM STRL BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5014-8-250S SUP HCPCS C1713 5014-8-250S - PIN 6MM SLFDRILL SLFTAP THRD SHFT 150MM APEX HA SS 80MM STRL BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 5014-9-250S SUP HCPCS C1713 5014-9-250S - PIN 6MM SLFDRILL SLFTAP THRD SHFT 250MM APEX HA SS 90MM STRL BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 50-15006 SUP HCPCS C1713 50-15006 - SCREW BN 1.5MM 6MM ST CROSSPIN TI CRNMXF BOTH IP/OP $140.68 $104.10 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $29.32 $104.41 $104.41 $0.00 $0.00 $29.32 $0.00 $83.21 $83.21 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 5015-3-120 SUP HCPCS C1713 5015-3-120 - SCREW BONE 5MM 120MM 35MM APEX THRD CANC BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 5015-4-150 SUP HCPCS C1713 5015-4-150 - PIN 5MM 150MM CANC APEX TI 40MM BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 5015-5-150 SUP HCPCS C1713 5015-5-150 - SCREW BONE 5MM 150MM 50MM APEX THRD CANC BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 5015-6-180 SUP HCPCS C1713 5015-6-180 - SCREW BONE 5MM 180MM 60MM APEX SS CANC BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 5015-7-250 SUP HCPCS C1713 5015-7-250 - PIN HALF 250MM 5MM APEX HFMN2 CANC SS THRD 70MM BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 50-15904 SUP HCPCS C1713 50-15904 - SCREW BONE 1.5MM 4MM SELF DRILL XPIN HEAD TITANIUM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 50-15905 SUP HCPCS C1713 50-15905 - SCREW BONE 1.5MM 5MM SELF DRILL XPIN HEAD TITANIUM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 5016-5-111 SUP HCPCS C1713 5016-5-111 - PIN HALF HFMN 5MMX120MM 35MM THRD TI SLFDRL ST F/EXFIX BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $95.91 $95.91 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 5016-5-117 SUP HCPCS C1713 5016-5-117 - PIN 5MM SLFDRILL SLFTAP 150MM APEX TI 40MM BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $95.91 $95.91 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 5016-5-118 SUP HCPCS C1713 5016-5-118 - PIN HALF HFMN 50MM 5MMX150MM TI SLFDRL ST F/EXFIX BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $95.91 $95.91 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 5016-5-122 SUP HCPCS C1713 5016-5-122 - PIN HALF HFMN 50MM 5MMX180MM TI SLFDRL ST F/EXFIX BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $95.91 $95.91 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $33.35 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 50-17003 SUP HCPCS C1713 50-17003 - SCREW BONE 1.7MM 3MM SLFTAP XPIN TITANIUM MIDFAC BOTH IP/OP $49.50 $36.63 $0.00 $39.60 $22.28 $22.28 $0.00 $0.00 $0.00 $10.32 $36.74 $36.74 $0.00 $0.00 $10.32 $0.00 $29.28 $29.28 $0.00 $24.75 $39.20 $39.60 $0.00 $0.00 $7.75 $0.00 $0.00 $7.88 $0.00 $0.00 $0.00 $0.00 $0.00 50-17004 SUP HCPCS C1713 50-17004 - SCREW BONE 1.7MM 4MM SLFTAP XPIN TITANIUM MIDFAC BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 50-17006 SUP HCPCS C1713 50-17006 - SCREW BONE 1.7MM 6MM SLFTAP XPIN TITANIUM MIDFAC BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 50-17007 SUP HCPCS C1713 50-17007 - SCREW BONE 1.7MM 7MM SLFTAP XPIN TITANIUM MIDFAC BOTH IP/OP $94.25 $69.75 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $19.64 $69.95 $69.95 $0.00 $0.00 $19.64 $0.00 $55.75 $55.75 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 50-17008 SUP HCPCS C1713 50-17008 - SCREW BONE 1.7MM 8MM SELF TAP XPIN TITANIUM MIDFAC BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 50-17010 SUP HCPCS C1713 50-17010 - SCREW BONE 1.7MM 10MM SELF TAP XPIN TITANIUM MIDFAC BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 50-17012 SUP HCPCS C1713 50-17012 - SCREW BONE 1.7MM 12MM SLFTAP XPIN TITANIUM MIDFAC BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 5017-2-150S SUP HCPCS C1713 5017-2-150S - PIN 5MM SLFDRILL SLFTAP THRD SHFT 150MM APEX HA SS 20MM STRL BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 50-17304 SUP HCPCS C1713 50-17304 - SCREW BN 1.7MM 4MM NS UNV NEURO 2 ST XPN ER CRNMXF BOTH IP/OP $125.70 $93.02 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $26.20 $93.29 $93.29 $0.00 $0.00 $26.20 $0.00 $74.35 $74.35 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 5017-3-150S SUP Custom 27203010 5017-3-150S - PIN XTRNFX 5MM 150MM STRL 30MM APX SLF DRL ST SS HA BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $0.00 $0.00 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5017-3-180S SUP HCPCS C1713 5017-3-180S - PIN HALF 180MM 5MM APEX HA SS SLFDRILL SLFTAP THRD SHFT 30MM BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 50-174-01-09 SUP HCPCS C1713 50-174-01-09 - IMPLANT PRT JNT TI RT CNDYL 3 MM RECON PLT BOTH IP/OP "$3,141.33 " "$2,324.58" $0.00 "$2,513.06" "$1,413.60" "$1,413.60" $0.00 $0.00 $0.00 $654.73 "$2,331.49" "$2,331.49" $0.00 $0.00 $654.65 $0.00 "$1,548.67" "$1,548.67" $0.00 "$1,570.66" "$2,487.93" "$2,513.06" $0.00 $0.00 $491.62 $0.00 $0.00 $500.10 $0.00 $0.00 $0.00 $0.00 $0.00 50-174-03-09 SUP HCPCS C1713 50-174-03-09 - SCREW BN FX XDR TI CNDYL 3 MM RECON PLT BOTH IP/OP "$1,008.13 " $746.02 $0.00 $806.50 $453.66 $453.66 $0.00 $0.00 $0.00 $210.12 $748.23 $748.23 $0.00 $0.00 $210.09 $0.00 $596.31 $596.31 $0.00 $504.06 $798.44 $806.50 $0.00 $0.00 $157.77 $0.00 $0.00 $160.49 $0.00 $0.00 $0.00 $0.00 $0.00 5017-4-150S SUP HCPCS C1713 5017-4-150S - PIN HALF STRL 150MM 5MM APEX SS SLFTAP SLFDRILL 40MM EXFIX BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 5017-4-180S SUP HCPCS C1713 5017-4-180S - PIN HALF 180MM 5MM APEX HYDRXAPT EXFIX BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 50-17504 SUP HCPCS C1713 50-17504 - SCREW BONE 1.7MM 4MM LOCK GRAY TITANIUM MIDFAC BOTH IP/OP $139.70 $103.38 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $29.12 $103.69 $103.69 $0.00 $0.00 $29.11 $0.00 $82.63 $82.63 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 50-17505 SUP HCPCS C1713 50-17505 - SCREW BONE 1.7MM 5MM LOCKING XPIN GRAY TITANIUM MIDFAC BOTH IP/OP $139.70 $103.38 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $29.12 $103.69 $103.69 $0.00 $0.00 $29.11 $0.00 $82.63 $82.63 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 50-17506 SUP HCPCS C1713 50-17506 - SCREW BONE 1.7MM 6MM SLFDRILL SLFTAP LOCKING XPIN TITANIUM BOTH IP/OP $139.70 $103.38 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $29.12 $103.69 $103.69 $0.00 $0.00 $29.11 $0.00 $82.63 $82.63 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 5017-5-150S SUP HCPCS C1713 5017-5-150S - PIN HLF SLFDRL ORTH BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 5017-5-180S SUP HCPCS C1713 5017-5-180S - PIN HALF 180MM 5MM APEX SS HA SLFDRILL SLFTAP THRD 50MM STRL BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 5017-6-150S SUP HCPCS C1713 5017-6-150S - PIN 5MM SLFTAP/DRL THRD SHFT 150MM APEX HA SS 60MM STRL BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 5017-6-200S SUP HCPCS C1713 5017-6-200S - PIN HALF 200MM 5MM APEX ORTH SS SLFTAP SLFDRILL 60MM EXFIX BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5017-7-200S SUP HCPCS C1713 5017-7-200S - PIN HALF 200MM 5MM APEX ORTH SS SLFTAP SLFDRILL 70MM EXFIX BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $116.94 $116.94 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 5017-8-150S SUP HCPCS C1713 5017-8-150S - PIN HALF 150MM 5MM APEX HA SS SLFDRILL SLFTAP THRD SHFT 25MM BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 50-17903 SUP HCPCS C1713 50-17903 - SCREW BONE 1.7MM 3MM SELF DRILL XPIN TITANIUM MIDFAC BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $630.00 $630.00 $0.00 $0.00 $0.00 $291.80 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $828.10 $828.10 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $219.10 $0.00 $0.00 $222.88 $0.00 $0.00 $0.00 $0.00 $0.00 50-17904 SUP HCPCS C1713 50-17904 - SCREW BONE 1.7MM 4MM SELF DRILL XPIN TITANIUM MIDFAC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-17905 SUP HCPCS C1713 50-17905 - SCREW BONE 1.7MM 5MM SLFDRILL XPIN TITANIUM MIDFAC BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $630.00 $630.00 $0.00 $0.00 $0.00 $291.80 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $828.10 $828.10 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $219.10 $0.00 $0.00 $222.88 $0.00 $0.00 $0.00 $0.00 $0.00 50-17906 SUP HCPCS C1713 50-17906 - SCREW BONE 1.7MM 6MM SLFDRILL XPIN TITANIUM MIDFAC BOTH IP/OP $103.40 $76.52 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $21.55 $76.74 $76.74 $0.00 $0.00 $21.55 $0.00 $61.16 $61.16 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 5017-9-120S SUP HCPCS C1713 5017-9-120S - PIN 5MM SLFDRILL SLFTAP THRD SHFT 120MM APEX HA SS 35MM STRL BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 5017-9-150S SUP HCPCS C1713 5017-9-150S - PIN HALF 150MM 5MM APEX HYDRXAPT SLFDRILL EXFIX BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $113.85 $113.85 $0.00 $0.00 $0.00 $52.73 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $149.65 $149.65 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $39.59 $0.00 $0.00 $40.28 $0.00 $0.00 $0.00 $0.00 $0.00 5018-3-120 SUP Custom 27203010 5018-3-120 - PIN HLF 5MM 120MM 30MM APX ST SLFDRL THRD SS FT/ANKL BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018-3-180 SUP HCPCS C1713 5018-3-180 - PIN HALF 180MM 5MM APEX ORTH SS SLFDRILL BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $92.81 $92.81 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 5018-5-120 SUP Custom 27203010 5018-5-120 - PIN HALF 120MM 5MM APEX SS SLFTAP SLFDRILL 35MM EXFIX SYS BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018-5-150 SUP Custom 27203010 5018-5-150 - PIN HALF 150MM 5MM APEX SS SLFTAP SLFDRILL 40MM EXFIX SYS BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018-5-200 SUP Custom 27203010 5018-5-200 - PIN HALF 200MM 5MM APEX SS SLFTAP SLFDRILL 50MM EXFIX SYS BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018-5-250 SUP Custom 27203010 5018-5-250 - PIN HALF 250MM 5MM APEX SS SLFTAP SLFDRILL 50MM EXFIX SYS BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018-6-150 SUP Custom 27203010 5018-6-150 - PIN HALF 150MM 5MM APEX SS SLFTAP SLFDRILL 50MM EXFIX SYS BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018-6-180S SUP HCPCS C1713 5018-6-180S - PIN HALF 180MM 5MM APEX ORTH SS SLFTAP SLFDRILL 50MM STRL BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $98.38 $98.38 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $109.31 $173.15 $174.90 $0.00 $0.00 $34.21 $0.00 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 5018-6-200 SUP Custom 27203010 5018-6-200 - PIN HALF 200MM 5MM APEX SS SLFTAP SLFDRILL 60MM EXFIX SYS BOTH IP/OP $205.70 $152.22 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.67 $152.67 $0.00 $0.00 $42.87 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018-7-250 SUP Custom 27203010 5018-7-250 - PIN HALF 250MM 5MM APEX SS SLFTAP SLFDRILL 70MM EXFIX SYS BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5018-8-180 SUP Custom 27203010 5018-8-180 - PIN HALF 180MM 5MM APEX SS SLFTAP SLFDRILL 60MM EXFIX SYS BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-19003 SUP HCPCS C1713 50-19003 - SCREW BONE 1.9MM 3MM EMERGENCY TITANIUM MIDFAC BOTH IP/OP "$1,362.50 " "$1,008.25" $0.00 "$1,090.00" $613.13 $613.13 $0.00 $0.00 $0.00 $283.98 "$1,011.25" "$1,011.25" $0.00 $0.00 $283.95 $0.00 $805.92 $805.92 $0.00 $681.25 "$1,079.10" "$1,090.00" $0.00 $0.00 $213.23 $0.00 $0.00 $216.91 $0.00 $0.00 $0.00 $0.00 $0.00 50-19005 SUP HCPCS C1713 50-19005 - SCREW BONE 1.9MM 5MM EMERGENCY TITANIUM MIDFAC BOTH IP/OP $54.50 $40.33 $0.00 $43.60 $24.53 $24.53 $0.00 $0.00 $0.00 $11.36 $40.45 $40.45 $0.00 $0.00 $11.36 $0.00 $32.24 $32.24 $0.00 $27.25 $43.16 $43.60 $0.00 $0.00 $8.53 $0.00 $0.00 $8.68 $0.00 $0.00 $0.00 $0.00 $0.00 50-19007 SUP HCPCS C1713 50-19007 - SCREW BONE 1.9MM 7MM SLFTAP XPIN EMERGENCY TITANIUM MAXFACL BOTH IP/OP $106.93 $79.13 $0.00 $218.00 $122.63 $122.63 $0.00 $0.00 $0.00 $22.29 $79.36 $79.36 $0.00 $0.00 $22.28 $0.00 $63.25 $63.25 $0.00 $136.25 $215.82 $218.00 $0.00 $0.00 $42.65 $0.00 $0.00 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 50-19009 SUP HCPCS C1713 50-19009 - SCREW BONE 1.9MM 9MM SLFTAP XPIN EMERGENCY TITANIUM MAXFACL BOTH IP/OP $106.93 $79.13 $0.00 $218.00 $122.63 $122.63 $0.00 $0.00 $0.00 $22.29 $79.36 $79.36 $0.00 $0.00 $22.28 $0.00 $63.25 $63.25 $0.00 $136.25 $215.82 $218.00 $0.00 $0.00 $42.65 $0.00 $0.00 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 5019-1-180 SUP HCPCS C1713 5019-1-180 - PIN HALF 120MM 5MM APEX SS SLFTAP CONTIN THRD 50MM BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $87.86 $87.86 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 5019-7-120 SUP HCPCS C1713 5019-7-120 - PIN HALF 120MM 6MM APEX SS SLFTAP CONTIN THRD 50MM BOTH IP/OP $258.50 $191.29 $0.00 $206.80 $116.33 $116.33 $0.00 $0.00 $0.00 $53.88 $191.86 $191.86 $0.00 $0.00 $53.87 $0.00 $152.90 $152.90 $0.00 $129.25 $204.73 $206.80 $0.00 $0.00 $40.46 $0.00 $0.00 $41.15 $0.00 $0.00 $0.00 $0.00 $0.00 5019-7-150 SUP HCPCS C1713 5019-7-150 - PIN HALF 150MM 6MM APEX SS CONTIN THRD BLNT TIP 50MM EXFIX BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $92.81 $92.81 $0.00 $0.00 $0.00 $49.43 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $140.27 $140.27 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-42A SUP Custom 27803010 502-01-42A - SHELL ACETAB A HEMISPHERICAL 42MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-44B SUP Custom 27803010 502-01-44B - SHELL ACETAB B HEMISPHERICAL 44MM 3 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-46C SUP Custom 27803010 502-01-46C - SHELL ACETAB C HEMISPHERICAL 46MM 3 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-48D SUP Custom 27803010 502-01-48D - SHELL ACETAB 48MM HIP HMSPHR CLSTR TRDNT D BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-50D SUP Custom 27803010 502-01-50D - SHELL ACETAB 50MM HIP HMSPHR CLSTR TRDNT D BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-52E SUP Custom 27803010 502-01-52E - SHELL ACETAB 52MM HIP HMSPHR CLSTR TRDNT E BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-54E SUP Custom 27803010 502-01-54E - SHELL ACETAB 54MM HIP HMSPHR CLSTR TRDNT E BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-56F SUP Custom 27803010 502-01-56F - SHELL ACETAB F HEMISPHERICAL 56MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-58F SUP Custom 27803010 502-01-58F - SHELL ACETAB 58MM HIP HMSPHR CLSTR TRDNT F BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-60G SUP Custom 27803010 502-01-60G - SHELL ACETAB G HEMISPHERICAL 60MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-62G SUP Custom 27803010 502-01-62G - SHELL ACETAB G HEMISPHERICAL 62MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-64H SUP Custom 27803010 502-01-64H - SHELL ACETAB H HEMISPHERICAL 64MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-66H SUP Custom 27803010 502-01-66H - SHELL ACETAB H HEMISPHERICAL 66MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-68I SUP Custom 27803010 502-01-68I - SHELL ACTB I HMSPHR 68MM TRDNT 5 SCR HL CLSTR MTL HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-70I SUP Custom 27803010 502-01-70I - SHELL ACETAB I HEMISPHERICAL 70MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-72J SUP Custom 27803010 502-01-72J - SHELL ACETAB J HEMISPHERICAL 72MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-01-74J SUP Custom 27803010 502-01-74J - SHELL ACETAB J HEMISPHERICAL 74MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-2-150 SUP Custom 27203010 5020-2-150 - PIN HLF 5MM 150MM 20MM APX BLNT BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $0.00 $0.00 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-2-180 SUP Custom 27203010 5020-2-180 - PIN HLF 5MM 180MM 20MM APX BLNT BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $0.00 $0.00 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-2-200 SUP Custom 27203010 5020-2-200 - PIN HLF 5MM 200MM 20MM APX BLNT BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $0.00 $0.00 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-2-250 SUP Custom 27203010 5020-2-250 - PIN HLF 5MM 250MM 20MM APX BLNT BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $0.00 $0.00 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-3-120 SUP Custom 27203010 5020-3-120 - PIN HALF 120MM 5MM APEX SS CONTIN THRD BLNT TIP 30MM EXFIX BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-3-150 SUP Custom 27203010 5020-3-150 - PIN HALF 150MM 5MM APEX SS CONTIN THRD BLNT TIP 40MM EXFIX BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-44A SUP Custom 27803010 502-03-44A - SHELL ACETAB A HEMISPHERICAL 44MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-46B SUP Custom 27803010 502-03-46B - SHELL ACETAB B HEMISPHERICAL 46MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-48C SUP Custom 27803010 502-03-48C - SHELL ACETAB C HEMISPHERICAL 48MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-50D SUP Custom 27803010 502-03-50D - SHELL ACETAB D HEMISPHERICAL 50MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-52D SUP Custom 27803010 502-03-52D - SHELL ACETAB D 52MM PRIM HEMISPHERICAL CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-54E SUP Custom 27803010 502-03-54E - SHELL ACETAB E HEMISPHERICAL 54MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-56E SUP Custom 27803010 502-03-56E - SHELL ACETAB E HEMISPHERICAL 56MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20358 SUP HCPCS C1713 50-20358 - SCREW BN 2MM 8MM NS LEIBINGER UNV 2 MMF SLF DRL XPN LGT WRE BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $252.00 $252.00 $0.00 $0.00 $0.00 $116.72 $415.63 $415.63 $0.00 $0.00 $116.70 $0.00 $331.24 $331.24 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $89.15 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-58F SUP Custom 27803010 502-03-58F - SHELL ACETAB F HEMISPHERICAL 58MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-60F SUP Custom 27803010 502-03-60F - SHELL ACETAB F HEMISPHERICAL 60MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20362 SUP HCPCS C1713 50-20362 - SCREW BONE 2MM 12MM SELF DRILL TITANIUM MANDIB BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $252.00 $252.00 $0.00 $0.00 $0.00 $116.72 $415.63 $415.63 $0.00 $0.00 $116.70 $0.00 $331.24 $331.24 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $89.15 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-62G SUP Custom 27803010 502-03-62G - SHELL ACETAB G 62MM PRIM HEMISPHERICAL CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-64G SUP Custom 27803010 502-03-64G - SHELL ACETAB G HEMISPHERICAL 64MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-03-66H SUP Custom 27803010 502-03-66H - SHELL ACETAB H HEMISPHERICAL 66MM PRIM RIM CLSHOLE TRITANIUM BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 $0.00 $0.00 $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20404 SUP HCPCS C1713 50-20404 - SCREW BONE 2MM 4MM XPIN TITANIUM MAXFACL BOTH IP/OP $125.93 $93.19 $0.00 $100.74 $56.67 $56.67 $0.00 $0.00 $0.00 $26.25 $93.46 $93.46 $0.00 $0.00 $26.24 $0.00 $74.48 $74.48 $0.00 $62.96 $99.74 $100.74 $0.00 $0.00 $19.71 $0.00 $0.00 $20.05 $0.00 $0.00 $0.00 $0.00 $0.00 50-20405 SUP HCPCS C1713 50-20405 - SCREW BONE 2MM 5MM XPIN TITANIUM MAXFACL BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $108.00 $108.00 $0.00 $0.00 $0.00 $50.02 $178.13 $178.13 $0.00 $0.00 $50.02 $0.00 $141.96 $141.96 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 50-20407 SUP HCPCS C1713 50-20407 - SCREW BONE 2MM 7MM XPIN TITANIUM MAXFACL BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $108.00 $108.00 $0.00 $0.00 $0.00 $50.02 $178.13 $178.13 $0.00 $0.00 $50.02 $0.00 $141.96 $141.96 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 50-20408 SUP HCPCS C1713 50-20408 - SCREW BONE 2MM 8MM XPIN TITANIUM MAXFACL BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $108.00 $108.00 $0.00 $0.00 $0.00 $50.02 $178.13 $178.13 $0.00 $0.00 $50.02 $0.00 $141.96 $141.96 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 50-20410 SUP HCPCS C1713 50-20410 - SCREW BN 2MM 10MM AU NS LEIBINGER UNV 2 ST XPN TI MXLFCL BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $108.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 50-20412 SUP HCPCS C1713 50-20412 - SCREW BONE 2MM 12MM XPIN TITANIUM MAXFACL BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $108.00 $108.00 $0.00 $0.00 $0.00 $50.02 $178.13 $178.13 $0.00 $0.00 $50.02 $0.00 $141.96 $141.96 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 50-20414 SUP HCPCS C1713 50-20414 - SCREW BONE 2MM 14MM XPIN TITANIUM MANDIB BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $108.00 $108.00 $0.00 $0.00 $0.00 $50.02 $178.13 $178.13 $0.00 $0.00 $50.02 $0.00 $141.96 $141.96 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 50-20416 SUP HCPCS C1713 50-20416 - SCREW BONE 2MM 16MM XPIN TITANIUM MANDIB BOTH IP/OP $89.60 $66.30 $0.00 $192.00 $108.00 $108.00 $0.00 $0.00 $0.00 $18.67 $66.50 $66.50 $0.00 $0.00 $18.67 $0.00 $53.00 $53.00 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $37.56 $0.00 $0.00 $38.21 $0.00 $0.00 $0.00 $0.00 $0.00 50-20418 SUP HCPCS C1713 50-20418 - SCREW BONE 2MM 18MM XPIN TITANIUM MANDIB BOTH IP/OP $113.30 $83.84 $0.00 $214.00 $120.38 $120.38 $0.00 $0.00 $0.00 $23.61 $84.09 $84.09 $0.00 $0.00 $23.61 $0.00 $67.02 $67.02 $0.00 $133.75 $211.86 $214.00 $0.00 $0.00 $41.86 $0.00 $0.00 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 50-20420 SUP HCPCS C1713 50-20420 - SCREW BONE 2MM 20MM SLFTAP XPIN TITANIUM MANDIB BOTH IP/OP $113.30 $83.84 $0.00 $214.00 $120.38 $120.38 $0.00 $0.00 $0.00 $23.61 $84.09 $84.09 $0.00 $0.00 $23.61 $0.00 $67.02 $67.02 $0.00 $133.75 $211.86 $214.00 $0.00 $0.00 $41.86 $0.00 $0.00 $42.59 $0.00 $0.00 $0.00 $0.00 $0.00 50-20504 SUP HCPCS C1713 50-20504 - SCREW BONE 2MM 4MM LOCKING XPIN TITANIUM MAXFACL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 50-20505 SUP HCPCS C1713 50-20505 - SCREW BN 2MM 5MM GRY NS LEIBINGER UNV 2 LCK XPN TI MXLFCL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 50-20506 SUP HCPCS C1713 50-20506 - SCREW BONE 2MM 6MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 50-20507 SUP HCPCS C1713 50-20507 - SCREW BONE 2MM 7MM LOCKING XPIN TITANIUM MAXFACL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $192.38 $192.38 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 50-20508 SUP HCPCS C1713 50-20508 - SCREW BN 2MM 8MM GRY NS LEIBINGER UNV 2 LCK XPN TI MNDB BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 50-20510 SUP HCPCS C1713 50-20510 - SCREW BONE 2MM 10MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 50-20512 SUP HCPCS C1713 50-20512 - SCREW BONE 2MM 12MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 50-20514 SUP HCPCS C1713 50-20514 - SCREW BONE 2MM 14MM LOCKING XPIN TITANIUM MAXFACL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 5020-5-150 SUP Custom 27203010 5020-5-150 - PIN HALF 150MM 5MM APEX ORTH BLNT TIP 25MM BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20516 SUP HCPCS C1713 50-20516 - SCREW BONE 2MM 16MM LOCKING XPIN LEIBINGER UNIVERSAL 2 BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 50-205-16 SUP Custom 27203010 50-205-16 - FORCEPS SURG UNV PLT HLD 2 BALLS BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20518 SUP HCPCS C1713 50-20518 - SCREW BONE 2MM 18MM LOCKING XPIN TITANIUM MANDIB BOTH IP/OP $162.23 $120.05 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $33.81 $120.40 $120.40 $0.00 $0.00 $33.81 $0.00 $95.96 $95.96 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 50-20520 SUP HCPCS C1713 50-20520 - SCREW BONE 2MM 20MM LOCKING XPIN TITANIUM MAXFACL BOTH IP/OP $162.23 $120.05 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $33.81 $120.40 $120.40 $0.00 $0.00 $33.81 $0.00 $95.96 $95.96 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 50-20596 SUP HCPCS C1713 50-20596 - SCREW BN 2MM 6MM NS LEIBINGER UNV 2 SMARTLOCK SLF DRL LCK TI BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 50-20598 SUP HCPCS C1713 50-20598 - SCREW BN 2MM 8MM NS LEIBINGER UNV 2 SMARTLOCK SLF DRL LCK TI BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 5020-6-120 SUP Custom 27203010 5020-6-120 - PIN HALF 120MM 5MM APEX SS THRD SHFT BLNT PREDRILLING 35MM BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-6-200 SUP Custom 27203010 5020-6-200 - PIN HALF 200MM 5MM APEX SS THRD SHFT BLNT PREDRILLING 60MM BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20704 SUP HCPCS C1713 50-20704 - SCREW BONE 2MM 4MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 50-20705 SUP HCPCS C1713 50-20705 - SCREW BONE 2MM 5MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 50-20706 SUP HCPCS C1713 50-20706 - SCREW BONE 2MM 6MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 50-20708 SUP HCPCS C1713 50-20708 - SCREW BONE 2MM 8MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 50-20710 SUP HCPCS C1713 50-20710 - SCREW BONE 2MM 10MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 50-20712 SUP HCPCS C1713 50-20712 - SCREW BONE 2MM 12MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $87.67 $25.88 $25.88 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $28.75 $45.54 $46.00 $0.00 $0.00 $9.00 $0.00 $0.00 $9.15 $0.00 $0.00 $0.00 $0.00 $0.00 50-20714 SUP HCPCS C1713 50-20714 - SCREW BONE 2MM 14MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $119.93 $67.46 $67.46 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $74.96 $118.74 $119.93 $0.00 $0.00 $23.46 $0.00 $0.00 $23.87 $0.00 $0.00 $0.00 $0.00 $0.00 5020-7-150 SUP Custom 27203010 5020-7-150 - PIN HALF 150MM 5MM APEX SS CONTIN THRD 50MM EXFIX SYS BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20716 SUP HCPCS C1713 50-20716 - SCREW BONE 2MM 16MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 50-20718 SUP HCPCS C1713 50-20718 - SCREW BONE 2MM 18MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 5020-7-180 SUP Custom 27203010 5020-7-180 - PIN HALF 180MM 5MM APEX SS CONTIN THRD 50MM EXFIX SYS BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20720 SUP HCPCS C1713 50-20720 - SCREW BONE 2MM 20MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.13 $87.42 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.62 $87.67 $87.67 $0.00 $0.00 $24.62 $0.00 $69.87 $69.87 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 5020-7-200 SUP Custom 27203010 5020-7-200 - PIN HALF 200MM 5MM APEX SS CONTIN THRD 50MM EXFIX SYS BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-7-250 SUP Custom 27203010 5020-7-250 - PIN HALF 250MM 5MM APEX SS CONTIN THRD 50MM EXFIX SYS BOTH IP/OP $237.15 $175.49 $0.00 $176.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.01 $176.01 $0.00 $0.00 $49.42 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-8-180 SUP Custom 27203010 5020-8-180 - PIN HALF 180MM 5MM APEX SS BLNT TIP 60MM EXFIX SYS BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5020-8-250 SUP Custom 27203010 5020-8-250 - PIN HALF 250MM 5MM APEX SS BLNT TIP 70MM EXFIX SYS BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-20904 SUP HCPCS C1713 50-20904 - SCREW BONE 2MM 4MM SLFDRILL XPIN TITANIUM MAXFACL BOTH IP/OP $144.50 $106.93 $0.00 $274.00 $154.13 $154.13 $0.00 $0.00 $0.00 $30.12 $107.25 $107.25 $0.00 $0.00 $30.11 $0.00 $85.47 $85.47 $0.00 $171.25 $271.26 $274.00 $0.00 $0.00 $53.60 $0.00 $0.00 $54.53 $0.00 $0.00 $0.00 $0.00 $0.00 50-20905 SUP HCPCS C1713 50-20905 - SCREW BONE 2MM 5MM SLFDRILL XPIN TITANIUM MAXFACL BOTH IP/OP $342.50 $253.45 $0.00 $274.00 $154.13 $154.13 $0.00 $0.00 $0.00 $71.39 $254.20 $254.20 $0.00 $0.00 $71.38 $0.00 $202.59 $202.59 $0.00 $171.25 $271.26 $274.00 $0.00 $0.00 $53.60 $0.00 $0.00 $54.53 $0.00 $0.00 $0.00 $0.00 $0.00 50-20906 SUP HCPCS C1713 50-20906 - SCREW BONE 2MM 6MM SLFDRILL XPIN TITANIUM MAXFACL BOTH IP/OP $126.35 $93.50 $0.00 $274.00 $154.13 $154.13 $0.00 $0.00 $0.00 $26.33 $93.78 $93.78 $0.00 $0.00 $26.33 $0.00 $74.74 $74.74 $0.00 $171.25 $271.26 $274.00 $0.00 $0.00 $53.60 $0.00 $0.00 $54.53 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-42A SUP Custom 27803010 502-11-42A - SHELL ACETAB A HEMISPHERICAL 42MM 3 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-44B SUP Custom 27803010 502-11-44B - SHELL ACETAB B HEMISPHERICAL 44MM 3 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-46C SUP Custom 27803010 502-11-46C - SHELL ACETAB C HEMISPHERICAL 46MM 3 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-48D SUP Custom 27803010 502-11-48D - SHELL ACETAB D HEMISPHERICAL 48MM 3 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-50D SUP Custom 27803010 502-11-50D - SHELL ACETAB D HEMISPHERICAL 50MM 3 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-52E SUP Custom 27803010 502-11-52E - SHELL ACETAB E HEMISPHERICAL 52MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-54E SUP Custom 27803010 502-11-54E - SHELL ACETAB E HEMISPHERICAL 54MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-56F SUP Custom 27803010 502-11-56F - SHELL ACTB F HMSPHR 56MM TRDNT CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-58F SUP Custom 27803010 502-11-58F - SHELL ACETAB F HEMISPHERICAL 58MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-60G SUP Custom 27803010 502-11-60G - SHELL ACETAB G HEMISPHERICAL 60MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-62G SUP Custom 27803010 502-11-62G - SHELL ACETAB G HEMISPHERICAL 62MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-64H SUP Custom 27803010 502-11-64H - SHELL ACETAB H HEMISPHERICAL 64MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-66H SUP Custom 27803010 502-11-66H - SHELL ACETAB H HEMISPHERICAL 66MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-68I SUP Custom 27803010 502-11-68I - SHELL ACETAB I HEMISPHERICAL 68MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-70I SUP Custom 27803010 502-11-70I - SHELL ACETAB I HEMISPHERICAL 70MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-72J SUP Custom 27803010 502-11-72J - SHELL ACETAB D HEMISPHERICAL 72MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-74J SUP Custom 27803010 502-11-74J - SHELL ACETAB J HEMISPHERICAL 74MM 5 SCREW HOLE CLUSTER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-80L SUP Custom 27803010 502-11-80L - SHELL ACETAB 80MM HIP CLSHOLE HMSPHR TRDNT L BOTH IP/OP "$2,506.00 " "$1,854.44" $0.00 "$2,004.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.95" "$1,859.95" $0.00 $0.00 $522.25 $0.00 $0.00 $0.00 $0.00 "$1,253.00" "$1,984.75" "$2,004.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 502-11-82L SUP Custom 27803010 502-11-82L - SHELL ACETAB 82MM HIP CLSHOLE HMSPHR TRDNT L BOTH IP/OP "$2,506.00 " "$1,854.44" $0.00 "$2,004.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,859.95" "$1,859.95" $0.00 $0.00 $522.25 $0.00 $0.00 $0.00 $0.00 "$1,253.00" "$1,984.75" "$2,004.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5021-7-150 SUP Custom 27203010 5021-7-150 - PIN HALF 150MM 6MM APEX SS SLFDRILL THRD SHFT SLFTAP 50MM BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $0.00 $0.00 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5021-7-200 SUP Custom 27203010 5021-7-200 - PIN HALF 200MM 6MM APEX SS SLFDRILL THRD 60MM BOTH IP/OP $209.25 $154.85 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.31 $155.31 $0.00 $0.00 $43.61 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5023-1-090 SUP Custom 27203010 5023-1-090 - PIN HALF 90MM 4MM APEX SS SLFTAP SLFDRILL THRD 10MM EXFIX BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5023-2-090 SUP Custom 27203010 5023-2-090 - PIN HALF 90MM 4MM APEX SS SLFTAP SLFDRILL THRD 20MM EXFIX BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5023-3-090 SUP Custom 27203010 5023-3-090 - PIN HALF 90MM 4MM APEX SS SLFTAP SLFDRILL THRD 30MM EXFIX BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5023-3-120 SUP Custom 27203010 5023-3-120 - PIN HALF 120MM 4MM APEX SS SLFDRILL SLFTAP THRD 30MM EXFIX BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-23404 SUP HCPCS C1713 50-23404 - SCREW BONE 2.3MM 4MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-23406 SUP HCPCS C1713 50-23406 - SCREW BONE 2.3MM 6MM SELF TAP XPIN TITANIUM MAXFACL NONSTRL BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-23408 SUP HCPCS C1713 50-23408 - SCREW BONE 2.3MM 8MM SELF TAP XPIN TITANIUM MANDIB BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-23410 SUP HCPCS C1713 50-23410 - SCREW BONE 2.3MM 10MM SELF TAP XPIN HEAD LEIBINGER UNIVERSAL BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-23412 SUP HCPCS C1713 50-23412 - SCREW BONE 2.3MM 12MM SELF TAP XPIN HEAD LEIBINGER UNIVERSAL BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 5023-4-120 SUP Custom 27203010 5023-4-120 - PIN HALF 120MM 4MM APEX ORTH SS 45MM BOTH IP/OP $169.50 $125.43 $0.00 $128.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $80.44 $127.42 $128.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-23414 SUP HCPCS C1713 50-23414 - SCREW TI 14MM 2.3MM MANDIB SLFTAP XPIN BONE BOTH IP/OP $115.50 $85.47 $0.00 $121.54 $68.37 $68.37 $0.00 $0.00 $0.00 $24.07 $85.72 $85.72 $0.00 $0.00 $24.07 $0.00 $68.32 $68.32 $0.00 $75.96 $120.33 $121.54 $0.00 $0.00 $23.78 $0.00 $0.00 $24.19 $0.00 $0.00 $0.00 $0.00 $0.00 50-23416 SUP HCPCS C1713 50-23416 - SCREW BONE 2.3MM 16MM SELF TAP XPIN TITANIUM MANDIB BOTH IP/OP $115.50 $85.47 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $24.07 $85.72 $85.72 $0.00 $0.00 $24.07 $0.00 $68.32 $68.32 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-23418 SUP HCPCS C1713 50-23418 - SCREW BONE 2.3MM 18MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $118.45 $87.65 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.69 $87.91 $87.91 $0.00 $0.00 $24.68 $0.00 $70.06 $70.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 5023-4-180 SUP Custom 27203010 5023-4-180 - PIN HLF 4MM 180MM 40MM HFMN2 APX SLF DRL ST THRD SS FT/ANKL BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-23420 SUP HCPCS C1713 50-23420 - SCREW BONE 2.3MM 20MM SLFTAP XPIN TITANIUM MANDIB BOTH IP/OP $118.45 $87.65 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $24.69 $87.91 $87.91 $0.00 $0.00 $24.68 $0.00 $70.06 $70.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 50-23504 SUP HCPCS C1713 50-23504 - SCREW BONE 2.3MM 4MM LOCKING XPIN TITANIUM MAXFACL BOTH IP/OP "$1,299.22 " $961.42 $0.00 "$1,039.37" $584.65 $584.65 $0.00 $0.00 $0.00 $270.79 $964.28 $964.28 $0.00 $0.00 $270.76 $0.00 $768.49 $768.49 $0.00 $649.61 "$1,028.98" "$1,039.37" $0.00 $0.00 $203.33 $0.00 $0.00 $206.84 $0.00 $0.00 $0.00 $0.00 $0.00 50-23506 SUP HCPCS C1713 50-23506 - SCREW BONE 2.3MM 6MM LOCKING XPIN LEIBINGER UNIVERSAL 2 BOTH IP/OP $197.35 $146.04 $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $41.13 $146.47 $146.47 $0.00 $0.00 $41.13 $0.00 $116.73 $116.73 $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 50-23508 SUP HCPCS C1713 50-23508 - SCREW BONE 2.3MM 8MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 5023-5-090 SUP Custom 27203010 5023-5-090 - PIN HALF 90MM 4MM ORTH MDLR 40MM BOTH IP/OP $192.10 $142.15 $0.00 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.58 $142.58 $0.00 $0.00 $40.03 $0.00 $0.00 $0.00 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-23510 SUP HCPCS C1713 50-23510 - SCREW BONE 2.3MM 10MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 50-23512 SUP HCPCS C1713 50-23512 - SCREW BONE 2.3MM 12MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 5023-5-120 SUP Custom 27203010 5023-5-120 - PIN HALF 120MM 4MM APEX SS SLFTAP SLFDRILL THRD 35MM EXFIX BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-23514 SUP HCPCS C1713 50-23514 - SCREW BONE 2.3MM 14MM LOCKING XPIN LEIBINGER UNIVERSAL 2 BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 5023-5-150 SUP Custom 27203010 5023-5-150 - PIN HALF 150MM 4MM APEX SS SLFTAP SLFDRILL THRD 40MM EXFIX BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-23516 SUP HCPCS C1713 50-23516 - SCREW BONE 2.3MM 16MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 50-23518 SUP HCPCS C1713 50-23518 - SCREW BONE 2.3MM 18MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $197.35 $146.04 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $41.13 $146.47 $146.47 $0.00 $0.00 $41.13 $0.00 $116.73 $116.73 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 50-23520 SUP HCPCS C1713 50-23520 - SCREW BONE 2.3MM 20MM LOCKING XPIN TITANIUM MAXFACL BOTH IP/OP $197.35 $146.04 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $41.13 $146.47 $146.47 $0.00 $0.00 $41.13 $0.00 $116.73 $116.73 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 5023-6-150 SUP Custom 27203010 5023-6-150 - PIN HALF 150MM 4MM APEX SS SLFTAP SLFDRILL THRD 50MM EXFIX BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5023-6-180 SUP Custom 27203010 5023-6-180 - PIN 4MM TROCAR PNT 1 END THRD 180X50MM APEX SS 50MM XTRN BOTH IP/OP $169.50 $125.43 $0.00 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.80 $125.80 $0.00 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $84.56 $133.95 $135.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5023-6-200 SUP Custom 27203010 5023-6-200 - PIN HALF 200MM 4MM APEX HFMN2 ORTH SS MDLR CNT THRD 40MM BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5023-6-250 SUP Custom 27203010 5023-6-250 - PIN HALF 250MM 4MM APEX HFMN2 ORTH SS MDLR CNT THRD 50MM BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-23706 SUP HCPCS C1713 50-23706 - SCREW BONE 2.3MM 6MM SLFTAP XFIT TITANIUM MAXFACL BOTH IP/OP $132.03 $97.70 $0.00 $246.00 $138.38 $138.38 $0.00 $0.00 $0.00 $27.52 $97.99 $97.99 $0.00 $0.00 $27.51 $0.00 $78.09 $78.09 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $48.12 $0.00 $0.00 $48.95 $0.00 $0.00 $0.00 $0.00 $0.00 50-23708 SUP HCPCS C1713 50-23708 - SCREW BONE 2.3MM 8MM SLFTAP XPIN EMERGENCY TITANIUM MAXFACL BOTH IP/OP $132.03 $97.70 $0.00 $246.00 $138.38 $138.38 $0.00 $0.00 $0.00 $27.52 $97.99 $97.99 $0.00 $0.00 $27.51 $0.00 $78.09 $78.09 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $48.12 $0.00 $0.00 $48.95 $0.00 $0.00 $0.00 $0.00 $0.00 50-23710 SUP HCPCS C1713 50-23710 - SCREW BONE 2.3MM 10MM SLFTAP EMERGENCY XPIN TITANIUM MAXFACL BOTH IP/OP $132.03 $97.70 $0.00 $246.00 $138.38 $138.38 $0.00 $0.00 $0.00 $27.52 $97.99 $97.99 $0.00 $0.00 $27.51 $0.00 $78.09 $78.09 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $48.12 $0.00 $0.00 $48.95 $0.00 $0.00 $0.00 $0.00 $0.00 50-23712 SUP HCPCS C1713 50-23712 - SCREW BONE 2.3MM 12MM SLFTAP EMERGENCY XPIN TITANIUM MAXFACL BOTH IP/OP $132.03 $97.70 $0.00 $246.00 $138.38 $138.38 $0.00 $0.00 $0.00 $27.52 $97.99 $97.99 $0.00 $0.00 $27.51 $0.00 $78.09 $78.09 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $48.12 $0.00 $0.00 $48.95 $0.00 $0.00 $0.00 $0.00 $0.00 50-23714 SUP HCPCS C1713 50-23714 - SCREW BONE 2.3MM 14MM SLFTAP EMERGENCY XPIN TITANIUM MAXFACL BOTH IP/OP $132.03 $97.70 $0.00 $246.00 $138.38 $138.38 $0.00 $0.00 $0.00 $27.52 $97.99 $97.99 $0.00 $0.00 $27.51 $0.00 $78.09 $78.09 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $48.12 $0.00 $0.00 $48.95 $0.00 $0.00 $0.00 $0.00 $0.00 50-23716 SUP HCPCS C1713 50-23716 - SCREW BONE 2.3MM 16MM EMERGENCY XPIN TITANIUM MAXFACL BOTH IP/OP $132.03 $97.70 $0.00 $246.00 $138.38 $138.38 $0.00 $0.00 $0.00 $27.52 $97.99 $97.99 $0.00 $0.00 $27.51 $0.00 $78.09 $78.09 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $48.12 $0.00 $0.00 $48.95 $0.00 $0.00 $0.00 $0.00 $0.00 5023-7-250 SUP Custom 27203010 5023-7-250 - PIN HALF 250MM 4MM APEX HFMN2 ORTH SS MDLR CNT THRD 70MM BOTH IP/OP $96.25 $71.23 $0.00 $77.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.44 $71.44 $0.00 $0.00 $20.06 $0.00 $0.00 $0.00 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5027-1-040 SUP Custom 27803010 5027-1-040 - CAP PCTV HFMN XPRESS NONSTRL TIP WHT 4MM 4MM 4MM DISP BOTH IP/OP $69.70 $51.58 $0.00 $58.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.73 $51.73 $0.00 $0.00 $14.53 $0.00 $0.00 $0.00 $0.00 $36.44 $57.72 $58.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5027-1-050 SUP Custom 27803010 5027-1-050 - CAP PCTV TIP BLUE 5MM BOTH IP/OP $72.25 $53.47 $0.00 $59.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.62 $53.62 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $37.13 $58.81 $59.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5027-1-090 SUP Custom 27203010 5027-1-090 - PIN HALF 90MM 4MM APEX SS BLNT TIP 10MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5027-2-090 SUP Custom 27203010 5027-2-090 - PIN HALF 90MM 4MM APEX SS BLNT TIP 20MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5027-3-090 SUP Custom 27203010 5027-3-090 - PIN HALF 90MM 4MM APEX SS BLNT TIP 30MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5027-3-120 SUP Custom 27203010 5027-3-120 - PIN HALF 120MM 4MM APEX SS BLNT TIP 30MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-27405 SUP HCPCS C1713 50-27405 - SCREW BONE 2.7MM 5MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $327.50 $242.35 $0.00 $262.00 $147.38 $147.38 $0.00 $0.00 $0.00 $68.26 $243.07 $243.07 $0.00 $0.00 $68.25 $0.00 $193.72 $193.72 $0.00 $163.75 $259.38 $262.00 $0.00 $0.00 $51.25 $0.00 $0.00 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 50-27408 SUP HCPCS C1713 50-27408 - SCREW BONE 2.7MM 8MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $65.50 $48.47 $0.00 $52.40 $29.48 $29.48 $0.00 $0.00 $0.00 $13.65 $48.61 $48.61 $0.00 $0.00 $13.65 $0.00 $38.74 $38.74 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 50-27410 SUP HCPCS C1713 50-27410 - SCREW BONE 2.7MM 10MM SELF TAP XPIN EMERGENCY TITANIUM BOTH IP/OP $139.88 $103.51 $0.00 $262.00 $147.38 $147.38 $0.00 $0.00 $0.00 $29.15 $103.82 $103.82 $0.00 $0.00 $29.15 $0.00 $82.74 $82.74 $0.00 $163.75 $259.38 $262.00 $0.00 $0.00 $51.25 $0.00 $0.00 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 50-27412 SUP HCPCS C1713 50-27412 - SCREW BONE 2 UNIVERSAL 2.7MM 12MM SELF TAP XPIN EMERGENCY BOTH IP/OP $327.50 $242.35 $0.00 $262.00 $147.38 $147.38 $0.00 $0.00 $0.00 $68.26 $243.07 $243.07 $0.00 $0.00 $68.25 $0.00 $193.72 $193.72 $0.00 $163.75 $259.38 $262.00 $0.00 $0.00 $51.25 $0.00 $0.00 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 5027-4-120 SUP Custom 27203010 5027-4-120 - PIN HALF 120MM 4MM APEX SS BLNT TIP 35MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-27414 SUP HCPCS C1713 50-27414 - SCREW BONE 2.7MM 14MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $327.50 $242.35 $0.00 $262.00 $147.38 $147.38 $0.00 $0.00 $0.00 $68.26 $243.07 $243.07 $0.00 $0.00 $68.25 $0.00 $193.72 $193.72 $0.00 $163.75 $259.38 $262.00 $0.00 $0.00 $51.25 $0.00 $0.00 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 5027-4-150 SUP Custom 27203010 5027-4-150 - PIN HALF 150MM 4MM APEX SS BLNT TIP 40MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-27416 SUP HCPCS C1713 50-27416 - SCREW BONE 2.7MM 16MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $139.88 $103.51 $0.00 $262.00 $147.38 $147.38 $0.00 $0.00 $0.00 $29.15 $103.82 $103.82 $0.00 $0.00 $29.15 $0.00 $82.74 $82.74 $0.00 $163.75 $259.38 $262.00 $0.00 $0.00 $51.25 $0.00 $0.00 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 50-27418 SUP HCPCS C1713 50-27418 - SCREW BONE 2.7MM 18MM SLFTAP XPIN TITANIUM MAXFACL BOTH IP/OP $139.88 $103.51 $0.00 $103.82 $29.48 $29.48 $0.00 $0.00 $0.00 $29.15 $103.82 $103.82 $0.00 $0.00 $29.15 $0.00 $82.74 $82.74 $0.00 $32.75 $51.88 $52.40 $0.00 $0.00 $10.25 $0.00 $0.00 $10.43 $0.00 $0.00 $0.00 $0.00 $0.00 5027-4-180 SUP Custom 27203010 5027-4-180 - PIN HALF 180MM 4MM APEX SS BLNT TIP 40MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-27420 SUP HCPCS C1713 50-27420 - SCREW BONE 2.7MM 20MM XPIN EMERGENCY TITANIUM MAXFACL BOTH IP/OP $139.88 $103.51 $0.00 $262.00 $147.38 $147.38 $0.00 $0.00 $0.00 $29.15 $103.82 $103.82 $0.00 $0.00 $29.15 $0.00 $82.74 $82.74 $0.00 $163.75 $259.38 $262.00 $0.00 $0.00 $51.25 $0.00 $0.00 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 50-27505 SUP HCPCS C1713 50-27505 - SCREW BONE 2.7MM 5MM LOCKING XPIN EMERGENCY TITANIUM MAXFACL BOTH IP/OP $233.85 $173.05 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $48.74 $173.56 $173.56 $0.00 $0.00 $48.73 $0.00 $138.32 $138.32 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-27508 SUP HCPCS C1713 50-27508 - SCREW BONE 2.7MM 8MM LOCKING XPIN EMERGENCY TITANIUM MAXFACL BOTH IP/OP $233.85 $173.05 $0.00 $173.56 $47.25 $47.25 $0.00 $0.00 $0.00 $48.74 $173.56 $173.56 $0.00 $0.00 $48.73 $0.00 $138.32 $138.32 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 50-27510 SUP HCPCS C1713 50-27510 - SCREW BONE 2.7MM 10MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $233.85 $173.05 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $48.74 $173.56 $173.56 $0.00 $0.00 $48.73 $0.00 $138.32 $138.32 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-27512 SUP HCPCS C1713 50-27512 - SCREW BONE 2.7MM 12MM LOCK XPIN HEAD LEIBINGER UNIVERSAL 2 BOTH IP/OP $233.85 $173.05 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $48.74 $173.56 $173.56 $0.00 $0.00 $48.73 $0.00 $138.32 $138.32 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-27514 SUP HCPCS C1713 50-27514 - SCREW BONE 2.7MM 14MM LOCKING XPIN EMERGENCY TITANIUM BOTH IP/OP $233.85 $173.05 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $48.74 $173.56 $173.56 $0.00 $0.00 $48.73 $0.00 $138.32 $138.32 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 5027-5-150 SUP Custom 27203010 5027-5-150 - PIN HALF 150MM 4MM APEX SS BLNT TIP 50MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-27516 SUP HCPCS C1713 50-27516 - SCREW BONE 2.7MM 16MM LOCKING XPIN EMERGENCY TITANIUM BOTH IP/OP $233.85 $173.05 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $48.74 $173.56 $173.56 $0.00 $0.00 $48.73 $0.00 $138.32 $138.32 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 50-27518 SUP HCPCS C1713 50-27518 - SCREW BONE 2.7MM 18MM LOCKING XPIN EMERGENCY TITANIUM BOTH IP/OP $233.85 $173.05 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $48.74 $173.56 $173.56 $0.00 $0.00 $48.73 $0.00 $138.32 $138.32 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 5027-5-180 SUP Custom 27203010 5027-5-180 - PIN HALF 180MM 4MM APEX CONTIN THRD 50MM BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-27520 SUP HCPCS C1713 50-27520 - SCREW BONE 2.7MM 20MM LOCKING XPIN EMERGENCY TITANIUM BOTH IP/OP $233.85 $173.05 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $48.74 $173.56 $173.56 $0.00 $0.00 $48.73 $0.00 $138.32 $138.32 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 5028-7-030 SUP Custom 27203010 5028-7-030 - ROD EXFIX 174MM 8MM HFMN2 CARFBR CONNCTNG BOTH IP/OP $595.10 $440.37 $0.00 $441.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $441.68 $441.68 $0.00 $0.00 $124.02 $0.00 $0.00 $0.00 $0.00 $222.06 $351.75 $355.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5028-8-065 SUP Custom 27203010 5028-8-065 - ROD EXFIX 65MM 8MM HFMN2 CARFBR CONNCTNG BOTH IP/OP $415.50 $307.47 $0.00 $308.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.38 $308.38 $0.00 $0.00 $86.59 $0.00 $0.00 $0.00 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5028-8-100 SUP HCPCS C1713 ROD 100MM 8MM CONNCTNG HFMN2 MRI CARB FBR EXFIXA BOTH IP/OP $312.13 $230.98 $0.00 $249.70 $140.46 $140.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $48.85 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 5028-8-150 SUP Custom 27203010 5028-8-150 - ROD EXFIX 150MM 8MM HFMN2 CARFBR CONNCTNG BOTH IP/OP $415.50 $307.47 $0.00 $308.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.38 $308.38 $0.00 $0.00 $86.59 $0.00 $0.00 $0.00 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5028-8-200 SUP Custom 27203010 5028-8-200 - ROD EXFIX 200MM 8MM HFMN2 CARFBR CONNCTNG BOTH IP/OP $426.75 $315.80 $0.00 $316.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $316.73 $316.73 $0.00 $0.00 $88.93 $0.00 $0.00 $0.00 $0.00 $160.19 $253.74 $256.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5028-8-250 SUP Custom 27203010 5028-8-250 - ROD EXFIX 250MM 8MM HFMN2 CARFBR CONNCTNG BOTH IP/OP $426.75 $315.80 $0.00 $316.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $316.73 $316.73 $0.00 $0.00 $88.93 $0.00 $0.00 $0.00 $0.00 $160.19 $253.74 $256.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5028-8-350 SUP Custom 27203010 5028-8-350 - ROD EXFIX 350MM 8MM HFMN2 CARFBR CONNCTNG BOTH IP/OP $439.50 $325.23 $0.00 $326.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.20 $326.20 $0.00 $0.00 $91.59 $0.00 $0.00 $0.00 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-720 SUP Custom 27203010 5029-8-720 - ROD EXFIX 200MM 8MM HFMN2 CARB CONNCTNG BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $0.00 $0.00 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-725 SUP Custom 27203010 5029-8-725 - ROD EXFIX 250MM 8MM HFMN2 CARB CONNCTNG BOTH IP/OP $253.00 $187.22 $0.00 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.78 $187.78 $0.00 $0.00 $52.73 $0.00 $0.00 $0.00 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-805 SUP Custom 27203010 5029-8-805 - ROD EXFIX 65MM 8MM HFMN2 CARFBR CONNCTNG BRAID BOTH IP/OP $302.25 $223.67 $0.00 $224.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.33 $224.33 $0.00 $0.00 $62.99 $0.00 $0.00 $0.00 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-810 SUP Custom 27203010 5029-8-810 - ROD EXFIX 100MM 8MM HFMN2 CARFBR CONNCTNG BRAID BOTH IP/OP $302.25 $223.67 $0.00 $224.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.33 $224.33 $0.00 $0.00 $62.99 $0.00 $0.00 $0.00 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-815 SUP Custom 27203010 5029-8-815 - ROD EXFIX 150MM 8MM HFMN2 CARFBR CONNCTNG BRAID BOTH IP/OP $302.25 $223.67 $0.00 $224.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.33 $224.33 $0.00 $0.00 $62.99 $0.00 $0.00 $0.00 $0.00 $116.88 $185.13 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-820 SUP Custom 27203010 5029-8-820 - ROD EXFIX 200MM 8MM HFMN2 CARFBR CONNCTNG BRAID BOTH IP/OP $329.25 $243.65 $0.00 $244.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.37 $244.37 $0.00 $0.00 $68.62 $0.00 $0.00 $0.00 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-825 SUP Custom 27203010 5029-8-825 - ROD EXFIX 250MM 8MM HFMN2 CARFBR CONNCTNG BRAID BOTH IP/OP $329.25 $243.65 $0.00 $244.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.37 $244.37 $0.00 $0.00 $68.62 $0.00 $0.00 $0.00 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-830 SUP Custom 27203010 5029-8-830 - ROD EXFIX 300MM 8MM HFMN2 CARFBR CONNCTNG BRAID BOTH IP/OP $329.25 $243.65 $0.00 $244.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.37 $244.37 $0.00 $0.00 $68.62 $0.00 $0.00 $0.00 $0.00 $126.50 $200.38 $202.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-835 SUP Custom 27203010 5029-8-835 - ROD XTRNFX 8MM 350MM HFMN2 CNCT BRD CFBR BOTH IP/OP $353.25 $261.41 $0.00 $262.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.18 $262.18 $0.00 $0.00 $73.62 $0.00 $0.00 $0.00 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-840 SUP Custom 27203010 5029-8-840 - ROD EXFIX 400MM 8MM HFMN2 CARFBR CONNCTNG BOTH IP/OP $353.25 $261.41 $0.00 $262.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.18 $262.18 $0.00 $0.00 $73.62 $0.00 $0.00 $0.00 $0.00 $136.13 $215.62 $217.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-845 SUP Custom 27203010 5029-8-845 - ROD EXFIX 450MM 8MM HFMN2 CARFBR CONNCTNG BRAID BOTH IP/OP $403.50 $298.59 $0.00 $299.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.48 $299.48 $0.00 $0.00 $84.09 $0.00 $0.00 $0.00 $0.00 $156.75 $248.29 $250.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5029-8-850 SUP Custom 27203010 5029-8-850 - ROD EXFIX 500MM 8MM HFMN2 CARFBR CONNCTNG BRAID BOTH IP/OP $403.50 $298.59 $0.00 $299.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.48 $299.48 $0.00 $0.00 $84.09 $0.00 $0.00 $0.00 $0.00 $156.75 $248.29 $250.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-3-200 SUP Custom 27203010 5030-3-200 - PIN HALF 200MM 4MM APEX SS MDLR THRD TRNFX 35MM EXFIX SYS BOTH IP/OP $221.00 $163.54 $0.00 $164.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-3-250 SUP Custom 27203010 5030-3-250 - PIN HALF 250MM 4MM APEX SS MDLR THRD TRNFX 35MM EXFIX SYS BOTH IP/OP $221.00 $163.54 $0.00 $164.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-4-200 SUP Custom 27203010 5030-4-200 - PIN HALF 200MM 4MM APEX SS MDLR THRD TRNFX 40MM EXFIX SYS BOTH IP/OP $221.00 $163.54 $0.00 $164.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-4-250 SUP Custom 27203010 5030-4-250 - PIN HALF 250MM 4MM APEX SS MDLR THRD TRNFX 40MM EXFIX SYS BOTH IP/OP $221.00 $163.54 $0.00 $164.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-4-300 SUP Custom 27203010 5030-4-300 - PIN HLF 5MM 4MM 300MM NS 50MM APX TRNFX ST SLF DRL CNTR THRD BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-5-200 SUP Custom 27203010 5030-5-200 - PIN HALF 200MM 4MM APEX SS MDLR THRD TRNFX 50MM EXFIX SYS BOTH IP/OP $221.00 $163.54 $0.00 $164.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-5-250 SUP HCPCS C1713 5030-5-250 - TRAY STRL MDLR TRNFX 4 MM 250 MM PIN THRD BOTH IP/OP $221.00 $163.54 $0.00 $164.03 $89.10 $89.10 $0.00 $0.00 $0.00 $46.06 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $130.72 $130.72 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $30.99 $0.00 $0.00 $31.52 $0.00 $0.00 $0.00 $0.00 $0.00 5030-5-300 SUP Custom 27203010 5030-5-300 - PIN HLF 5MM 4MM 300MM NS 50MM HFMN2 APX TRNFX ST SLF DRL BOTH IP/OP $221.00 $163.54 $0.00 $204.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $127.88 $202.55 $204.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-6-250 SUP Custom 27203010 5030-6-250 - PIN HALF 250MM 4MM APEX SS MDLR THRD TRNFX 60MM EXFIX SYS BOTH IP/OP $221.00 $163.54 $0.00 $164.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-306-40-04 SUP Custom 27803010 50-306-40-04 - RESORB MESH ORBITAL BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5030-7-300 SUP Custom 27203010 5030-7-300 - PIN FX 5MM 4MM 300MM 70MM APX TRNFX SS FT/ANKL CANC BOTH IP/OP $221.00 $163.54 $0.00 $164.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-310-27-09 SUP Custom 27803010 50-310-27-09 - COVER BURR HOLE 17MM .3MM CNTOUR TITANIUM CRANIUM 1.5MM BOTH IP/OP $465.18 $344.23 $0.00 $372.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.25 $345.25 $0.00 $0.00 $96.94 $0.00 $0.00 $0.00 $0.00 $232.59 $368.42 $372.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-320-08-09 SUP HCPCS C1713 50-320-08-09 - PLATE BONE MINI REGULAR 1MM 8 HOLE RIGID LIGHTWEIGHT BLUE BOTH IP/OP $271.95 $201.24 $0.00 $217.56 $122.38 $122.38 $0.00 $0.00 $0.00 $56.68 $201.84 $201.84 $0.00 $0.00 $56.67 $0.00 $160.86 $160.86 $0.00 $135.98 $215.38 $217.56 $0.00 $0.00 $42.56 $0.00 $0.00 $43.29 $0.00 $0.00 $0.00 $0.00 $0.00 50-321-04-09 SUP HCPCS C1713 50-321-04-09 - PLATE BONE MINI MEDIUM 1MM 4 HOLE RIGID LIGHTWEIGHT BLUE BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 50-322-04-09 SUP HCPCS C1713 50-322-04-09 - PLATE BONE LONG 1MM 4 HOLE RIGID LIGHTWEIGHT BLUE TITANIUM BOTH IP/OP $222.75 $164.84 $0.00 $178.20 $100.24 $100.24 $0.00 $0.00 $0.00 $46.43 $165.33 $165.33 $0.00 $0.00 $46.42 $0.00 $131.76 $131.76 $0.00 $111.38 $176.42 $178.20 $0.00 $0.00 $34.86 $0.00 $0.00 $35.46 $0.00 $0.00 $0.00 $0.00 $0.00 50-325-01-07 SUP Custom 27100030 50-325-01-07 - CLAMP SURG 6IN SHARP STAINLESS STEEL BOTH IP/OP $576.23 $426.41 $0.00 $460.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.67 $427.67 $0.00 $0.00 $120.09 $0.00 $0.00 $0.00 $0.00 $288.11 $456.37 $460.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-330-06-09 SUP HCPCS C1713 50-330-06-09 - PLATE BONE MINI MEDIUM CVD FLAT 1MM 6 HOLE SAGITTAL RIGID BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 50-331-06-09 SUP HCPCS C1713 50-331-06-09 - PLATE BONE LONG CVD FLAT 1MM 6 HOLE SAGITTAL RIGID BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 50-332-06-09 SUP HCPCS C1713 50-332-06-09 - PLATE BONE XLONG CVD FLAT 1MM 6 HOLE SAGITTAL RIGID BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 5036-1-080 SUP Custom 27203010 5036-1-080 - PIN HALF 80MM 3MM APEX SS BLNT TIP 10MM EXFIX SYS BOTH IP/OP $312.00 $230.88 $0.00 $231.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.57 $231.57 $0.00 $0.00 $65.02 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5036-1-110 SUP Custom 27203010 5036-1-110 - PIN HALF 110MM 3MM APEX SS BLNT TIP 10MM EXFIX SYS BOTH IP/OP $312.00 $230.88 $0.00 $231.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.57 $231.57 $0.00 $0.00 $65.02 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5036-1-580 SUP Custom 27203010 5036-1-580 - PIN HALF 80MM 3MM APEX SS BLNT TIP 15MM EXFIX SYS BOTH IP/OP $312.00 $230.88 $0.00 $231.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.57 $231.57 $0.00 $0.00 $65.02 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5036-2-060 SUP Custom 27203010 5036-2-060 - PIN HALF 60MM 3MM APEX SS BLNT TIP 10MM EXFIX SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5036-2-080 SUP Custom 27203010 5036-2-080 - PIN HALF 80MM 3MM APEX SS BLNT TIP 20MM EXFIX SYS BOTH IP/OP $312.00 $230.88 $0.00 $231.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.57 $231.57 $0.00 $0.00 $65.02 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5036-2-110 SUP Custom 27203010 5036-2-110 - PIN HLF 3MM 110MM 25MM HFMN2 APX BLNT TIP SS BOTH IP/OP $312.00 $230.88 $0.00 $231.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.57 $231.57 $0.00 $0.00 $65.02 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-368-16-91 SUP HCPCS C1713 50-368-16-91 - PLATE BONE MINI REGULAR .6MM 16 HOLE LP TITANIUM MANDIB 2MM BOTH IP/OP $323.75 $239.58 $0.00 $259.00 $145.69 $145.69 $0.00 $0.00 $0.00 $67.48 $240.29 $240.29 $0.00 $0.00 $67.47 $0.00 $191.50 $191.50 $0.00 $161.88 $256.41 $259.00 $0.00 $0.00 $50.67 $0.00 $0.00 $51.54 $0.00 $0.00 $0.00 $0.00 $0.00 50-369-06 SUP HCPCS C1713 50-369-06 - X PLATE BOTH IP/OP $348.75 $258.08 $0.00 $279.00 $156.94 $156.94 $0.00 $0.00 $0.00 $72.69 $258.84 $258.84 $0.00 $0.00 $72.68 $0.00 $206.29 $206.29 $0.00 $174.38 $276.21 $279.00 $0.00 $0.00 $54.58 $0.00 $0.00 $55.52 $0.00 $0.00 $0.00 $0.00 $0.00 50-375-04-91 SUP HCPCS C1713 50-375-04-91 - PLATE BN MED MN L .6MM NS THREADLOCK TS 4 HL LOPRFL TI BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-377-04-91 SUP HCPCS C1713 50-377-04-91 - PLATE BN MED MN L .6MM NS THREADLOCK TS 4 HL LOPRFL TI BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-379-04-91 SUP HCPCS C1713 50-379-04-91 - PLATE BN LNG MN L .6MM NS THREADLOCK TS 4 HL LOPRFL TI BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-381-04-91 SUP HCPCS C1713 50-381-04-91 - PLATE BN LNG MN L .6MM NS THREADLOCK TS 4 HL LOPRFL TI BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-381-05-09 SUP HCPCS C1713 50-381-05-09 - PLATE BN LNG MN L .7MM NS THREADLOCK TS 5 HL LOPRFL TI BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 5038-1-080 SUP Custom 27203010 5038-1-080 - PIN 3MM SLFDRILL SLFTAP THRD 80MM APEX SS 10MM BOTH IP/OP $214.83 $158.97 $0.00 $159.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.44 $159.44 $0.00 $0.00 $44.77 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5038-1-110 SUP Custom 27203010 5038-1-110 - PIN HALF 110MM 3MM APEX SS SLFDRILL SLFTAP THRD 10MM EXFIX BOTH IP/OP $214.83 $158.97 $0.00 $159.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.44 $159.44 $0.00 $0.00 $44.77 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5038-2-080 SUP Custom 27203010 5038-2-080 - PIN HALF 80MM 3MM APEX SS SLFDRILL SLFTAP THRD 15MM EXFIX BOTH IP/OP $214.83 $158.97 $0.00 $159.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.44 $159.44 $0.00 $0.00 $44.77 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5038-2-110 SUP Custom 27203010 5038-2-110 - PIN HALF 110MM 3MM APEX SS SLFDRILL SLFTAP THRD 25MM EXFIX BOTH IP/OP $214.83 $158.97 $0.00 $159.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.44 $159.44 $0.00 $0.00 $44.77 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-383-05-09 SUP HCPCS C1713 50-383-05-09 - PLATE BN LNG MN L .7MM NS THREADLOCK TS 5 HL LOPRFL TI BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 5038-5-060 SUP Custom 27203010 5038-5-060 - PIN HALF 60MM 3MM APEX SS SLFDRILL SLFTAP THRD 10MM EXFIX BOTH IP/OP $214.83 $158.97 $0.00 $159.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.44 $159.44 $0.00 $0.00 $44.77 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5038-5-080 SUP Custom 27203010 5038-5-080 - PIN HALF 80MM 3MM APEX SS SLFDRILL SLFTAP THRD 20MM EXFIX BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5038-5-110 SUP Custom 27203010 5038-5-110 - PIN HALF 11CM 3MM APEX HFMN2 ORTH CONTIN THRD 22MM EXFIX SYS BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $0.00 $0.00 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-386-06-91 SUP HCPCS C1713 50-386-06-91 - PLATE BONE T MINI REGULAR .6MM LP TITANIUM MANDIB 2MM SCREW BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-390-05-91 SUP HCPCS C1713 50-390-05-91 - PLATE BN MN SHRT Y .6MM THREADLOCK TS 5 HL LOPRFL TI MXLFCL BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-395-04 SUP HCPCS C1713 50-395-04 - L PLATE RIGHT BOTH IP/OP $325.50 $240.87 $0.00 $260.40 $146.48 $146.48 $0.00 $0.00 $0.00 $67.84 $241.59 $241.59 $0.00 $0.00 $67.83 $0.00 $192.53 $192.53 $0.00 $162.75 $257.80 $260.40 $0.00 $0.00 $50.94 $0.00 $0.00 $51.82 $0.00 $0.00 $0.00 $0.00 $0.00 50-396-06-91 SUP HCPCS C1713 50-396-06-91 - PLATE BONE MINI REGULAR Y LP .6MM 2 TITANIUM MANDIB 2MM BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $174.83 $174.83 $0.00 $0.00 $0.00 $80.97 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $229.80 $229.80 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $60.80 $0.00 $0.00 $61.85 $0.00 $0.00 $0.00 $0.00 $0.00 504-02-54C-L SUP HCPCS C1776 504-02-54C-L - SHELL ACTB 54MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-54C-R SUP HCPCS C1776 504-02-54C-R - SHELL ACTB 54MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-56D-L SUP HCPCS C1776 504-02-56D-L - SHELL ACTB 56MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-56D-R SUP HCPCS C1776 504-02-56D-R - SHELL ACTB 56MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-58D-L SUP HCPCS C1776 504-02-58D-L - SHELL ACTB 58MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-58D-R SUP HCPCS C1776 504-02-58D-R - SHELL ACTB 58MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-60D-L SUP HCPCS C1776 504-02-60D-L - SHELL ACTB 60MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-60D-R SUP HCPCS C1776 504-02-60D-R - SHELL ACTB 60MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-62E-L SUP HCPCS C1776 504-02-62E-L - SHELL ACTB 62MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-62E-R SUP HCPCS C1776 504-02-62E-R - SHELL ACTB 62MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-64E-L SUP HCPCS C1776 504-02-64E-L - SHELL ACTB 64MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-64E-R SUP HCPCS C1776 504-02-64E-R - SHELL ACTB 64MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-66F-L SUP HCPCS C1776 504-02-66F-L - SHELL ACTB 66MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-66F-R SUP HCPCS C1776 504-02-66F-R - SHELL ACTB 66MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-68F-L SUP HCPCS C1776 504-02-68F-L - SHELL ACTB 68MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-68F-R SUP HCPCS C1776 504-02-68F-R - SHELL ACTB 68MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-70G-L SUP HCPCS C1776 504-02-70G-L - SHELL ACTB 70MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-70G-R SUP HCPCS C1776 504-02-70G-R - SHELL ACTB 70MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-72G-L SUP HCPCS C1776 504-02-72G-L - SHELL ACTB 72MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-72G-R SUP HCPCS C1776 504-02-72G-R - SHELL ACTB 72MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-74H-L SUP HCPCS C1776 504-02-74H-L - SHELL ACTB 74MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-74H-R SUP HCPCS C1776 504-02-74H-R - SHELL ACTB 74MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-76H-L SUP HCPCS C1776 504-02-76H-L - SHELL ACTB 76MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-76H-R SUP HCPCS C1776 504-02-76H-R - SHELL ACTB 76MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-78H-L SUP HCPCS C1776 504-02-78H-L - SHELL ACTB 78MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-78H-R SUP HCPCS C1776 504-02-78H-R - SHELL ACTB 78MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-80H-L SUP HCPCS C1776 504-02-80H-L - SHELL ACTB 80MM RSTR ANTM HIP LT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 504-02-80H-R SUP HCPCS C1776 504-02-80H-R - SHELL ACTB 80MM RSTR ANTM HIP RT BOTH IP/OP "$9,457.50 " "$6,998.55" $0.00 "$7,566.00" "$4,255.88" "$4,255.88" $0.00 $0.00 $0.00 "$1,971.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,970.94" $0.00 "$4,662.55" "$4,662.55" $0.00 "$4,728.75" "$7,490.34" "$7,566.00" $0.00 $0.00 "$1,480.10" $0.00 $0.00 "$1,505.63" $0.00 $0.00 $0.00 $0.00 $0.00 50-405-07-09 SUP HCPCS C1713 50-405-07-09 - PLATE BONE 100D L MINI .7MM 7 HOLE TITANIUM MANDIB 2MM SCREW BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-405-09-09 SUP HCPCS C1713 50-405-09-09 - PLATE BONE 100D L MINI .7MM 9 HOLE INSERT FRAC TITANIUM BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-405-12-09 SUP HCPCS C1713 50-405-12-09 - PLATE BN MN .7MM THREADLOCK TS 12 HL LOPRFL TI ORBT FLR 2MM BOTH IP/OP $401.43 $297.06 $0.00 $321.14 $180.64 $180.64 $0.00 $0.00 $0.00 $83.67 $297.94 $297.94 $0.00 $0.00 $83.66 $0.00 $237.44 $237.44 $0.00 $200.71 $317.93 $321.14 $0.00 $0.00 $62.82 $0.00 $0.00 $63.91 $0.00 $0.00 $0.00 $0.00 $0.00 50-405-17-09 SUP HCPCS C1713 50-405-17-09 - PLATE BN MN STRG 1MM NS THREADLOCK TS 20 HL LOPRFL CMPR TI BOTH IP/OP $569.80 $421.65 $0.00 $455.84 $256.41 $256.41 $0.00 $0.00 $0.00 $118.76 $422.91 $422.91 $0.00 $0.00 $118.75 $0.00 $337.04 $337.04 $0.00 $284.90 $451.28 $455.84 $0.00 $0.00 $89.17 $0.00 $0.00 $90.71 $0.00 $0.00 $0.00 $0.00 $0.00 50-406-04-91 SUP HCPCS C1713 50-406-04-91 - PLATE BONE Z MINI 6MM LP TITANIUM LEFT MANDIB 2MM SCREW BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-406-17-09 SUP HCPCS C1713 50-406-17-09 - PLATE BONE STR 1MM 17 HOLE RIGID LIGHTWEIGHT LP BLUE BOTH IP/OP $530.95 $392.90 $0.00 $424.76 $238.93 $238.93 $0.00 $0.00 $0.00 $110.66 $394.07 $394.07 $0.00 $0.00 $110.65 $0.00 $314.06 $314.06 $0.00 $265.48 $420.51 $424.76 $0.00 $0.00 $83.09 $0.00 $0.00 $84.53 $0.00 $0.00 $0.00 $0.00 $0.00 50-407-07-09 SUP HCPCS C1713 50-407-07-09 - PLATE BN MN STRG L .7MM THREADLOCK TS 20 HL LOPRFL TI MXLFCL BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-407-09-09 SUP HCPCS C1713 50-407-09-09 - PLATE BONE 100D L MINI 9 HOLE INSERT FRAC TITANIUM MANDIB 2 BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-408-04-91 SUP HCPCS C1713 50-408-04-91 - PLATE BONE Z LEFT ANGLE LONG .6MM LP FRAC TITANIUM MANDIB BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 50-409-04-91 SUP HCPCS C1713 50-409-04-91 - PLATE BN 100D LNG MN Z .6MM THREADLOCK TS 4 HL LOPRFL TI BOTH IP/OP $362.60 $268.32 $0.00 $290.08 $163.17 $163.17 $0.00 $0.00 $0.00 $75.57 $269.12 $269.12 $0.00 $0.00 $75.57 $0.00 $214.48 $214.48 $0.00 $181.30 $287.18 $290.08 $0.00 $0.00 $56.75 $0.00 $0.00 $57.73 $0.00 $0.00 $0.00 $0.00 $0.00 5045-5-150 SUP Custom 27203010 5045-5-150 - PIN HALF 150MM 3MM APEX SMTH TRNFX EXFIX SYS BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $0.00 $0.00 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5045-5-200 SUP Custom 27203010 5045-5-200 - PIN HLF 3MM 200MM NS APX TRNFX ST SLF DRL THRD SS BOTH IP/OP $207.63 $153.65 $0.00 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.10 $154.10 $0.00 $0.00 $43.27 $0.00 $0.00 $0.00 $0.00 $103.81 $164.44 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-4561 SUP Custom 27203010 BLADE RTRCTR 6X2IN BKWLTR MLBL BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-4567 SUP Custom 27203010 BLADE RTRCTR 6X3IN BKWLTR MLBL BOTH IP/OP "$1,307.50 " $967.55 $0.00 "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $653.75 "$1,035.54" "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 504605A SUP HCPCS C1894 504605A - INTRODUCER SHTH STD HEXACUSPID 5FR 11CM GRY AVNT+ ROT SUT BOTH IP/OP $19.88 $14.71 $0.00 $15.90 $10.79 $10.79 $0.00 $0.00 $0.00 $4.14 $14.75 $14.75 $0.00 $0.00 $4.14 $0.00 $11.76 $11.76 $0.00 $9.94 $15.74 $15.90 $0.00 $0.00 $3.11 $0.00 $0.00 $3.16 $0.00 $0.00 $0.00 $0.00 $0.00 504606A SUP HCPCS C1894 504606A - INTROD SHTH 6FR 11CM W/O MINI GWIRE NO OBT AVNT+ .038IN GRN BOTH IP/OP $99.38 $73.54 $0.00 $79.50 $53.96 $53.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.69 $78.71 $79.50 $0.00 $0.00 $15.55 $0.00 $0.00 $15.82 $0.00 $0.00 $0.00 $0.00 $0.00 504606T SUP HCPCS C1894 504606T - INTRODUCER SHTH MID LGTH 6FR 23CM GRN AVNT+ NO MN GW NO OBT BOTH IP/OP $54.88 $40.61 $0.00 $43.90 $29.80 $29.80 $0.00 $0.00 $0.00 $11.44 $40.73 $40.73 $0.00 $0.00 $11.44 $0.00 $32.46 $32.46 $0.00 $27.44 $43.46 $43.90 $0.00 $0.00 $8.59 $0.00 $0.00 $8.74 $0.00 $0.00 $0.00 $0.00 $0.00 5047-1-030 SUP Custom 27203010 5047-1-030 - CAP END ORTH 3MM DISP BOTH IP/OP $70.55 $52.21 $0.00 $58.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.36 $52.36 $0.00 $0.00 $14.70 $0.00 $0.00 $0.00 $0.00 $36.44 $57.72 $58.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5048-5-065 SUP Custom 27203010 5048-5-065 - ROD EXFIX 65MM 5MM HFMN2 MRI CMPCT CARB CONNCTNG STRL BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5048-5-100 SUP Custom 27203010 5048-5-100 - ROD EXFIX YLW 100MM 5MM HFMN2 C CARB CONNCTNG MRI SAFE BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5048-5-150 SUP Custom 27203010 5048-5-150 - ROD EXFIX YLW 150MM 5MM HFMN2 C CARB CONNCTNG MRI SAFE BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5048-5-200 SUP Custom 27203010 5048-5-200 - ROD EXFIX YLW 200MM 5MM HFMN2 C CARB CONNCTNG MRI SAFE BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5048-5-250 SUP Custom 27203010 5048-5-250 - ROD EXFIX 250MM 5MM HFMN2 MRI CMPCT CONNCTNG MRI SAFE BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5048-5-300 SUP Custom 27203010 5048-5-300 - ROD EXFIX 100MM 8MM HFMN2 C MRI CONNCTNG BOTH IP/OP $200.75 $148.56 $0.00 $160.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.00 $149.00 $0.00 $0.00 $41.84 $0.00 $0.00 $0.00 $0.00 $100.38 $158.99 $160.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5049-5-505 SUP Custom 27203010 5049-5-505 - ROD EXFIX 100MM 5MM HFMN2 C CARFBR CONNCTNG BOTH IP/OP $177.00 $130.98 $0.00 $131.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5049-5-510 SUP Custom 27203010 5049-5-510 - ROD EXFIX 150MM 5MM HFMN2 C CARFBR CONNCTNG BOTH IP/OP $177.00 $130.98 $0.00 $131.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.37 $131.37 $0.00 $0.00 $36.89 $0.00 $0.00 $0.00 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5049-5-515 SUP Custom 27203010 5049-5-515 - ROD EXFIX 150MM 5MM HFMN2 C CARFBR CONNCTNG BOTH IP/OP $199.50 $147.63 $0.00 $148.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.07 $148.07 $0.00 $0.00 $41.58 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5049-5-520 SUP Custom 27203010 5049-5-520 - ROD EXFIX 200MM 5MM HFMN2 C CARFBR CONNCTNG BOTH IP/OP $199.50 $147.63 $0.00 $148.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.07 $148.07 $0.00 $0.00 $41.58 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5049-5-525 SUP Custom 27803010 5049-5-525 - CONCTR ROD 250MM 5MM CMPCT CARB BOTH IP/OP $301.28 $222.95 $0.00 $223.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.61 $223.61 $0.00 $0.00 $62.79 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5049-5-530 SUP Custom 27203010 5049-5-530 - ROD EXFIX 300MM 5MM HFMN2 C CARFBR CONNCTNG BOTH IP/OP $375.95 $278.20 $0.00 $279.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.03 $279.03 $0.00 $0.00 $78.35 $0.00 $0.00 $0.00 $0.00 $62.56 $99.10 $100.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5049-7-018 SUP Custom 27203010 5049-7-018 - ROD EXFIX 111MM HFMN2 C CVD SEM CIR CARFBR BOTH IP/OP $367.13 $271.68 $0.00 $272.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.48 $272.48 $0.00 $0.00 $76.51 $0.00 $0.00 $0.00 $0.00 $95.56 $151.37 $152.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5049-7-020 SUP Custom 27203010 5049-7-020 - ROD EXFIX 146MM HFMN2 C CVD SEM CIR CARFBR BOTH IP/OP $178.75 $132.28 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $0.00 $0.00 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-501-31-07 SUP HCPCS C1713 50-501-31-07 - GUIDE DRILL LONG 2.7MM RECONSTRUCTION THREADLOCK TS BOTH IP/OP $348.13 $257.62 $0.00 $278.50 $156.66 $156.66 $0.00 $0.00 $0.00 $72.56 $258.38 $258.38 $0.00 $0.00 $72.55 $0.00 $205.92 $205.92 $0.00 $174.06 $275.72 $278.50 $0.00 $0.00 $54.48 $0.00 $0.00 $55.42 $0.00 $0.00 $0.00 $0.00 $0.00 50-504-23-07 SUP HCPCS C1713 50-504-23-07 - CUTTER SURG 8.5MM BENDER STAINLESS STEEL 1.5/2/3MM THICK BOTH IP/OP "$2,478.55 " "$1,834.13" $0.00 "$1,982.84" "$1,115.35" "$1,115.35" $0.00 $0.00 $0.00 $516.59 "$1,839.58" "$1,839.58" $0.00 $0.00 $516.53 $0.00 "$1,466.06" "$1,466.06" $0.00 "$1,239.28" "$1,963.01" "$1,982.84" $0.00 $0.00 $387.89 $0.00 $0.00 $394.59 $0.00 $0.00 $0.00 $0.00 $0.00 50-504-24-07 SUP HCPCS C1713 50-504-24-07 - CUTTER SURG 8.5MM BENDER STAINLESS STEEL 1.5/2/3MM THICK BOTH IP/OP "$2,562.08 " "$1,895.94" $0.00 "$2,049.66" "$1,152.93" "$1,152.93" $0.00 $0.00 $0.00 $534.00 "$1,901.57" "$1,901.57" $0.00 $0.00 $533.94 $0.00 "$1,263.10" "$1,263.10" $0.00 "$1,281.04" "$2,029.17" "$2,049.66" $0.00 $0.00 $400.96 $0.00 $0.00 $407.88 $0.00 $0.00 $0.00 $0.00 $0.00 5050-4-300 SUP HCPCS C1713 5050-4-300 - PIN FIX 5/6MM 300MM 40MM SLFDRILL THREAD APEX TRANSFIX BOTH IP/OP $221.00 $163.54 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $46.06 $164.03 $164.03 $0.00 $0.00 $46.06 $0.00 $130.72 $130.72 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 5050-5-250 SUP Custom 27203010 5050-5-250 - PIN HALF 250MM 5MM 4MM APEX SS TRNFX 50MM NONSTRL BOTH IP/OP $262.65 $194.36 $0.00 $206.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.94 $194.94 $0.00 $0.00 $54.74 $0.00 $0.00 $0.00 $0.00 $129.25 $204.73 $206.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5050-5-300 SUP Custom 27203010 5050-5-300 - PIN EXFIX 300MM 5MM HFMN2 THRD TRNFX 50MM NONSTRL BOTH IP/OP $249.05 $184.30 $0.00 $195.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.84 $184.84 $0.00 $0.00 $51.90 $0.00 $0.00 $0.00 $0.00 $122.38 $193.84 $195.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-519-15-07 SUP Custom 27100030 50-519-15-07 - DRILL TWIST 1.9MM 115MM J NOTCH STEEL 2/2.3MM SCREW BOTH IP/OP $290.05 $214.64 $0.00 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.28 $215.28 $0.00 $0.00 $60.45 $0.00 $0.00 $0.00 $0.00 $145.03 $229.72 $232.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-2-001 SUP Custom 27203010 5054-2-001 - INSRTR SURG THDL PIN BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-2-002 SUP Custom 27203010 5054-2-002 - SET EXFIX 2 DRLBT W/O CHK REUSE BOTH IP/OP $804.38 $595.24 $0.00 $643.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $597.01 $597.01 $0.00 $0.00 $167.63 $0.00 $0.00 $0.00 $0.00 $402.19 $637.07 $643.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-3-080 SUP Custom 27203010 5054-3-080 - SLEEVE XTRNFX 3MM 80MM HFMN2 2 TROC BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $0.00 $0.00 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-3-093 SUP Custom 27203010 5054-3-093 - TROCAR 3MM 93MM 2 SLV ASMBLY SURG BOTH IP/OP $378.13 $279.82 $0.00 $302.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.64 $280.64 $0.00 $0.00 $78.80 $0.00 $0.00 $0.00 $0.00 $189.06 $299.48 $302.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-4-120 SUP Custom 27203010 5054-4-120 - SLEEVE XTRNFX 4MM 120MM HFMN2 2 TROC BOTH IP/OP $426.25 $315.43 $0.00 $341.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $316.36 $316.36 $0.00 $0.00 $88.83 $0.00 $0.00 $0.00 $0.00 $213.13 $337.59 $341.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-4-150 SUP Custom 27203010 5054-4-150 - SLEEVE XTRNFX 4MM 150MM HFMN2 2 TROC BOTH IP/OP $422.13 $312.38 $0.00 $337.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.30 $313.30 $0.00 $0.00 $87.97 $0.00 $0.00 $0.00 $0.00 $211.06 $334.33 $337.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-4-180 SUP Custom 27203010 5054-4-180 - SLEEVE XTRNFX 4MM 180MM HFMN2 2 TROC BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-6-120 SUP Custom 27203010 5054-6-120 - SET EXFIX 6MM HFMN2 TROCAR DUAL SLV ASMBLY BOTH IP/OP $479.88 $355.11 $0.00 $383.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.16 $356.16 $0.00 $0.00 $100.01 $0.00 $0.00 $0.00 $0.00 $239.94 $380.06 $383.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-6-150 SUP Custom 27203010 5054-6-150 - TROCAR 6MM 150MM 2 SLV ASMBLY SURG BOTH IP/OP $479.88 $355.11 $0.00 $383.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.16 $356.16 $0.00 $0.00 $100.01 $0.00 $0.00 $0.00 $0.00 $239.94 $380.06 $383.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-6-180 SUP Custom 27203010 5054-6-180 - TROCAR 6MM 180MM 2 SLV ASMBLY SURG BOTH IP/OP $479.88 $355.11 $0.00 $383.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.16 $356.16 $0.00 $0.00 $100.01 $0.00 $0.00 $0.00 $0.00 $239.94 $380.06 $383.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5054-6-200 SUP Custom 27203010 5054-6-200 - TROCAR 6MM 200MM 2 SLV ASMBLY SURG BOTH IP/OP $479.88 $355.11 $0.00 $383.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.16 $356.16 $0.00 $0.00 $100.01 $0.00 $0.00 $0.00 $0.00 $239.94 $380.06 $383.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-0-100 SUP Custom 27203010 5057-0-100 - GUIDE DRILL APEX ASMBLY BOTH IP/OP $173.25 $128.21 $0.00 $138.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.59 $128.59 $0.00 $0.00 $36.11 $0.00 $0.00 $0.00 $0.00 $86.63 $137.21 $138.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-0-200 SUP Custom 27203010 5057-0-200 - ASMBLY DRILL BRC APEX BOTH IP/OP $816.75 $604.40 $0.00 $653.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $606.19 $606.19 $0.00 $0.00 $170.21 $0.00 $0.00 $0.00 $0.00 $408.38 $646.87 $653.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-0-300 SUP Custom 27203010 5057-0-300 - ASMBLY DRILL 3-6MM BRC APEX BOTH IP/OP $765.88 $566.75 $0.00 $612.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $568.43 $568.43 $0.00 $0.00 $159.61 $0.00 $0.00 $0.00 $0.00 $382.94 $606.58 $612.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-1-117 SUP Custom 27203010 5057-1-117 - GUIDE DRILL HFMN2 4 HOLE BLOCK CMPCT BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $0.00 $0.00 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-1-118 SUP Custom 27203010 5057-1-118 - GUIDE DRILL HFMN2 C PERIART 4 HOLE BLOCK CLMP BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $0.00 $0.00 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-1-119 SUP Custom 27203010 5057-1-119 - GUIDE DRILL BLUE RED MNTB TRX APEX 4 HOLE BLOCK BOTH IP/OP $468.88 $346.97 $0.00 $375.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.00 $348.00 $0.00 $0.00 $97.71 $0.00 $0.00 $0.00 $0.00 $234.44 $371.35 $375.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-1-120 SUP Custom 27203010 5057-1-120 - GUIDE DRILL YLW MNTB TRX APEX 2 HOLE BLOCK BOTH IP/OP $468.88 $346.97 $0.00 $375.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.00 $348.00 $0.00 $0.00 $97.71 $0.00 $0.00 $0.00 $0.00 $234.44 $371.35 $375.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-3-000 SUP Custom 27203010 5057-3-000 - ASSEMBLY DRL XSH 3MM PREDRILLING BOTH IP/OP $218.63 $161.79 $0.00 $174.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.26 $162.26 $0.00 $0.00 $45.56 $0.00 $0.00 $0.00 $0.00 $109.31 $173.15 $174.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-3-100 SUP Custom 27203010 5057-3-100 - SLEEVE DRILL 3MM APEX SHRT PREDRILL BOTH IP/OP $511.43 $378.46 $0.00 $379.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.58 $379.58 $0.00 $0.00 $106.58 $0.00 $0.00 $0.00 $0.00 $115.50 $182.95 $184.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-3-200 SUP Custom 27203010 5057-3-200 - SLEEVE DRILL 3MM APEX LNG PREDRILL BOTH IP/OP $511.43 $378.46 $0.00 $379.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.58 $379.58 $0.00 $0.00 $106.58 $0.00 $0.00 $0.00 $0.00 $115.50 $182.95 $184.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-4-000 SUP Custom 27203010 5057-4-000 - GUIDE DRILL 35MM 4MM APEX XSH HYDRXAPT PREDRILLING ASMBLY BOTH IP/OP $235.13 $174.00 $0.00 $188.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.51 $174.51 $0.00 $0.00 $49.00 $0.00 $0.00 $0.00 $0.00 $117.56 $186.22 $188.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-4-100 SUP Custom 27203010 5057-4-100 - SLEEVE DRILL 4MM APEX SHRT PREDRILL BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.45 $171.45 $0.00 $0.00 $48.14 $0.00 $0.00 $0.00 $0.00 $115.50 $182.95 $184.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-4-200 SUP Custom 27203010 5057-4-200 - GUIDE DRILL 100MM 4MM APEX LNG HA PREDRILLING ASMBLY PRTC BOTH IP/OP $231.00 $170.94 $0.00 $184.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.45 $171.45 $0.00 $0.00 $48.14 $0.00 $0.00 $0.00 $0.00 $115.50 $182.95 $184.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-5-000 SUP Custom 27203010 5057-5-000 - ASMBLY DRILL XSH 50MM PREDRILLING PRTC LGTH 5MM BOTH IP/OP $250.25 $185.19 $0.00 $200.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.74 $185.74 $0.00 $0.00 $52.15 $0.00 $0.00 $0.00 $0.00 $125.13 $198.20 $200.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-5-100 SUP Custom 27203010 5057-5-100 - GUIDE 5MM SHRT PREDRILL TROCAR ASMBLY APEX SURG BOTH IP/OP $250.25 $185.19 $0.00 $200.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.74 $185.74 $0.00 $0.00 $52.15 $0.00 $0.00 $0.00 $0.00 $125.13 $198.20 $200.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-5-200 SUP Custom 27203010 5057-5-200 - ASMBLY DRILL LNG 5MM BOTH IP/OP $250.25 $185.19 $0.00 $200.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.74 $185.74 $0.00 $0.00 $52.15 $0.00 $0.00 $0.00 $0.00 $125.13 $198.20 $200.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-6-000 SUP Custom 27203010 5057-6-000 - ASMBLY DRILL XSH 60MM PREDRILLING PRTC LGTH 6MM BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $0.00 $0.00 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-6-100 SUP Custom 27203010 5057-6-100 - ASMBLY DRILL 6MM SHRT PREDRILLING BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $0.00 $0.00 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-6-200 SUP Custom 27203010 5057-6-200 - GUIDE DRILL 120MM 6MM APEX LNG HA PREDRILLING ASMBLY BOTH IP/OP $266.75 $197.40 $0.00 $213.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.98 $197.98 $0.00 $0.00 $55.59 $0.00 $0.00 $0.00 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-6-300 SUP Custom 27203010 5057-6-300 - CUTTER PIN APEX 4-6MM EXTN HNDL BOTH IP/OP "$3,898.13 " "$2,884.62" $0.00 "$3,118.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,893.19" "$2,893.19" $0.00 $0.00 $812.37 $0.00 $0.00 $0.00 $0.00 "$1,949.06" "$3,087.32" "$3,118.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5057-9-900 SUP Custom 27203010 5057-9-900 - TRAY STRL PIN AND INSTRUMENTATION STOR APEX BOTH IP/OP "$3,267.00 " "$2,417.58" $0.00 "$2,613.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,424.77" "$2,424.77" $0.00 $0.00 $680.84 $0.00 $0.00 $0.00 $0.00 "$1,633.50" "$2,587.46" "$2,613.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50638-311 SUP Custom 27203010 50638-311 - BRACE PSTN GTT STOP ECON SPAN+AIDS 300 SER ANKL FT LATEX BOTH IP/OP $37.23 $27.55 $0.00 $30.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.63 $27.63 $0.00 $0.00 $7.76 $0.00 $0.00 $0.00 $0.00 $18.99 $30.07 $30.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5065-3-312 SUP Custom 27203010 5065-3-312 - PIN HALF 12MM 2MM APEX SM BONE SS BLNT SLFTAP CONTIN THRD BOTH IP/OP $111.00 $82.14 $0.00 $82.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5065-3-615 SUP Custom 27203010 5065-3-615 - PIN HALF 36MM 2MM APEX SS BLNT SLFTAP CONTIN THRD 15MM BOTH IP/OP $111.00 $82.14 $0.00 $82.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5065-3-918 SUP Custom 27203010 5065-3-918 - PIN HALF 39MM 2MM APEX SS BLNT SLFTAP CONTIN THRD 18MM BOTH IP/OP $111.00 $82.14 $0.00 $82.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5065-4-520 SUP Custom 27203010 5065-4-520 - PIN HALF 45MM 2MM APEX MINI SS BLNT SLFTAP CONTIN THRD 20MM BOTH IP/OP $111.00 $82.14 $0.00 $82.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5065-5-020 SUP Custom 27203010 5065-5-020 - PIN HALF 50MM 2MM APEX SS BLNT SLFTAP CONTIN THRD 20MM BOTH IP/OP $111.00 $82.14 $0.00 $82.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5065-6-020 SUP Custom 27203010 5065-6-020 - PIN HALF 60MM 2MM APEX SS BLNT SLFTAP CONTIN THRD 20MM BOTH IP/OP $111.00 $82.14 $0.00 $82.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5065-9-015 SUP Custom 27203010 5065-9-015 - PIN HALF 90MM 2MM APEX SS BLNT SLFTAP CONTIN THRD 15MM BOTH IP/OP $111.00 $82.14 $0.00 $82.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-7000B SUP HCPCS A7042 50-7000B - KIT DRAIN 15.5FR PLEURAL CATHETER CHLORAPREP APPLICATOR BOTH IP/OP "$2,412.70 " "$1,785.40" $0.00 "$1,930.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,790.71" "$1,790.71" $0.00 $0.00 $502.81 $0.00 $0.00 $0.00 $0.00 "$1,206.35" "$1,910.87" "$1,930.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5070-3-310 SUP Custom 27203010 5070-3-310 - PIN EXFIX 33MM 2MM TRNFX SS SMTH 10MM BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5070-3-810 SUP Custom 27203010 5070-3-810 - PIN XTRNFX 2MM 38MM 10MM TRNFX SMTH SS BOTH IP/OP $130.63 $96.67 $0.00 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.95 $96.95 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5070-4-312 SUP Custom 27203010 5070-4-312 - PIN EXFIX 43MM 2MM TRNFX SS SMTH 13MM BOTH IP/OP $130.63 $96.67 $0.00 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.95 $96.95 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5070-4-812 SUP Custom 27203010 5070-4-812 - PIN EXFIX 48MM 2MM TRNFX SS SMTH 13MM BOTH IP/OP $130.63 $96.67 $0.00 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.95 $96.95 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5070-5-312 SUP Custom 27203010 5070-5-312 - PIN EXFIX 53MM 2MM TRNFX SS SMTH 13MM BOTH IP/OP $130.63 $96.67 $0.00 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.95 $96.95 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5070-5-815 SUP Custom 27203010 5070-5-815 - PIN EXFIX 58MM 2MM TRNFX SS SMTH 16MM BOTH IP/OP $130.63 $96.67 $0.00 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.95 $96.95 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5070-6-315 SUP Custom 27203010 5070-6-315 - PIN EXFIX 63MM 2MM TRNFX SS SMTH 16MM BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5070-7-820 SUP Custom 27203010 5070-7-820 - PIN EXFIX 78MM 2MM TRNFX SS SMTH 20MM BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-712-04-09 SUP HCPCS C1713 50-712-04-09 - PLATE BONE 28MM 4 HOLE LOCKING FRAC TITANIUM MANDIB STERILE BOTH IP/OP $932.93 $690.37 $0.00 $746.34 $419.82 $419.82 $0.00 $0.00 $0.00 $194.44 $692.42 $692.42 $0.00 $0.00 $194.42 $0.00 $551.83 $551.83 $0.00 $466.46 $738.88 $746.34 $0.00 $0.00 $146.00 $0.00 $0.00 $148.52 $0.00 $0.00 $0.00 $0.00 $0.00 5071-35 SUP HCPCS C1898 5071-35 - LEAD PCNG 6.6FR 35CM IS-1 UNPLR FX SCR SIL MYOCARDIUM BOTH IP/OP $992.50 $734.45 $0.00 $810.00 $455.63 $455.63 $0.00 $0.00 $0.00 $206.86 $736.63 $736.63 $0.00 $0.00 $206.84 $0.00 $587.06 $587.06 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $158.46 $0.00 $0.00 $161.19 $0.00 $0.00 $0.00 $0.00 $0.00 50-714-04-09 SUP HCPCS C1713 50-714-04-09 - PLATE BONE 33MM 4 HOLE FRAC TITANIUM MANDIB STERILE BOTH IP/OP $974.73 $721.30 $0.00 $779.78 $438.63 $438.63 $0.00 $0.00 $0.00 $203.16 $723.44 $723.44 $0.00 $0.00 $203.13 $0.00 $576.55 $576.55 $0.00 $487.36 $771.99 $779.78 $0.00 $0.00 $152.54 $0.00 $0.00 $155.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-716-06-09 SUP HCPCS C1713 50-716-06-09 - PLATE BONE 16MMX1.5IN 6 HOLE FRAC TITANIUM MANDIB BOTH IP/OP "$1,127.88 " $834.63 $0.00 $902.30 $507.54 $507.54 $0.00 $0.00 $0.00 $235.08 $837.11 $837.11 $0.00 $0.00 $235.05 $0.00 $667.14 $667.14 $0.00 $563.94 $893.28 $902.30 $0.00 $0.00 $176.51 $0.00 $0.00 $179.56 $0.00 $0.00 $0.00 $0.00 $0.00 50-722-12-09 SUP HCPCS C1713 50-722-12-09 - PLATE BONE 1.5IN 2X6 HOLE LOCKING FRAC TITANIUM MANDIB BOTH IP/OP "$1,072.18 " $793.41 $0.00 $857.74 $482.48 $482.48 $0.00 $0.00 $0.00 $223.47 $795.77 $795.77 $0.00 $0.00 $223.44 $0.00 $634.19 $634.19 $0.00 $536.09 $849.17 $857.74 $0.00 $0.00 $167.80 $0.00 $0.00 $170.69 $0.00 $0.00 $0.00 $0.00 $0.00 50-723-12-09 SUP HCPCS C1713 50-723-12-09 - PLATE BONE MINI CVD 1MM 12 HOLE LOCKING THREADLOCK TITANIUM BOTH IP/OP "$1,100.03 " $814.02 $0.00 $880.02 $495.01 $495.01 $0.00 $0.00 $0.00 $229.27 $816.44 $816.44 $0.00 $0.00 $229.25 $0.00 $650.66 $650.66 $0.00 $550.01 $871.22 $880.02 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 50-730-04-09 SUP HCPCS C1713 50-730-04-09 - PLATE BONE CVD SHORT 1.5MM LOCKING FRAC TITANIUM MANDIB BOTH IP/OP "$1,281.03 " $947.96 $0.00 "$1,024.82" $576.46 $576.46 $0.00 $0.00 $0.00 $267.00 $950.78 $950.78 $0.00 $0.00 $266.97 $0.00 $757.73 $757.73 $0.00 $640.51 "$1,014.58" "$1,024.82" $0.00 $0.00 $200.48 $0.00 $0.00 $203.94 $0.00 $0.00 $0.00 $0.00 $0.00 50-730-06-09 SUP HCPCS C1713 50-730-06-09 - PLATE BONE CVD MEDIUM 1MM 6 HOLE LOCKING FRAC TITANIUM BOTH IP/OP $877.23 $649.15 $0.00 $701.78 $394.75 $394.75 $0.00 $0.00 $0.00 $182.84 $651.08 $651.08 $0.00 $0.00 $182.81 $0.00 $518.88 $518.88 $0.00 $438.61 $694.77 $701.78 $0.00 $0.00 $137.29 $0.00 $0.00 $139.65 $0.00 $0.00 $0.00 $0.00 $0.00 50-731-06-09 SUP HCPCS C1713 50-731-06-09 - PLATE BN CRV LNG 1MM THREADLOCK TS 6 HL LCK TI MNDB 2MM SCR BOTH IP/OP $877.23 $649.15 $0.00 $701.78 $394.75 $394.75 $0.00 $0.00 $0.00 $182.84 $651.08 $651.08 $0.00 $0.00 $182.81 $0.00 $518.88 $518.88 $0.00 $438.61 $694.77 $701.78 $0.00 $0.00 $137.29 $0.00 $0.00 $139.65 $0.00 $0.00 $0.00 $0.00 $0.00 50-732-04-09 SUP HCPCS C1713 50-732-04-09 - PLATE BONE CVD LONG 1.5MM 6 HOLE LOCKING FRAC TITANIUM BOTH IP/OP "$1,281.03 " $947.96 $0.00 "$1,024.82" $576.46 $576.46 $0.00 $0.00 $0.00 $267.00 $950.78 $950.78 $0.00 $0.00 $266.97 $0.00 $757.73 $757.73 $0.00 $640.51 "$1,014.58" "$1,024.82" $0.00 $0.00 $200.48 $0.00 $0.00 $203.94 $0.00 $0.00 $0.00 $0.00 $0.00 50-732-06-09 SUP HCPCS C1713 50-732-06-09 - PLATE BONE CVD XLONG 1MM 6 HOLE LOCKING FRAC TITANIUM MANDIB BOTH IP/OP $877.23 $649.15 $0.00 $701.78 $394.75 $394.75 $0.00 $0.00 $0.00 $182.84 $651.08 $651.08 $0.00 $0.00 $182.81 $0.00 $518.88 $518.88 $0.00 $438.61 $694.77 $701.78 $0.00 $0.00 $137.29 $0.00 $0.00 $139.65 $0.00 $0.00 $0.00 $0.00 $0.00 50-746-22-09 SUP HCPCS C1713 50-746-22-09 - PLATE SM 2.8MM SMRT BONE RIGHT BOTH IP/OP "$7,531.88 " "$5,573.59" $0.00 "$6,025.50" "$3,389.34" "$3,389.34" $0.00 $0.00 $0.00 "$1,569.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,569.64" $0.00 "$3,713.21" "$3,713.21" $0.00 "$3,765.94" "$5,965.25" "$6,025.50" $0.00 $0.00 "$1,178.74" $0.00 $0.00 "$1,199.07" $0.00 $0.00 $0.00 $0.00 $0.00 50-747-22-09 SUP HCPCS C1713 50-747-22-09 - PLATE BN SM 2.8MM SMRT LT BOTH IP/OP "$7,531.88 " "$5,573.59" $0.00 "$6,025.50" "$3,389.34" "$3,389.34" $0.00 $0.00 $0.00 "$1,569.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,569.64" $0.00 "$3,713.21" "$3,713.21" $0.00 "$3,765.94" "$5,965.25" "$6,025.50" $0.00 $0.00 "$1,178.74" $0.00 $0.00 "$1,199.07" $0.00 $0.00 $0.00 $0.00 $0.00 50-750-06-09 SUP HCPCS C1713 50-750-06-09 - PLATE BONE ANGLED 1.5MM 3X3 HOLE LOCKING FRAC TITANIUM BOTH IP/OP "$1,782.30 " "$1,318.90" $0.00 "$1,425.84" $802.04 $802.04 $0.00 $0.00 $0.00 $371.48 "$1,322.82" "$1,322.82" $0.00 $0.00 $371.43 $0.00 "$1,054.23" "$1,054.23" $0.00 $891.15 "$1,411.58" "$1,425.84" $0.00 $0.00 $278.93 $0.00 $0.00 $283.74 $0.00 $0.00 $0.00 $0.00 $0.00 50-750-08-09 SUP HCPCS C1713 50-750-08-09 - PLATE BONE ANGLED 1.5MM 4X4 HOLE LOCKING FRAC TITANIUM BOTH IP/OP "$1,810.18 " "$1,339.53" $0.00 "$1,448.14" $814.58 $814.58 $0.00 $0.00 $0.00 $377.29 "$1,343.51" "$1,343.51" $0.00 $0.00 $377.24 $0.00 "$1,070.72" "$1,070.72" $0.00 $905.09 "$1,433.66" "$1,448.14" $0.00 $0.00 $283.29 $0.00 $0.00 $288.18 $0.00 $0.00 $0.00 $0.00 $0.00 50-7505 SUP Custom 27203010 50-7505 - DILATOR LARYNGEAL METAL 20F BOTH IP/OP $346.25 $256.23 $0.00 $277.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.13 $274.23 $277.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-7507 SUP Custom 27203010 50-7507 - DILATOR LARYNGEAL METAL 24F BOTH IP/OP $332.60 $246.12 $0.00 $266.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.30 $263.42 $266.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-7509 SUP Custom 27203010 50-7509 - DILATOR LARYNGEAL METAL 28F BOTH IP/OP $374.90 $277.43 $0.00 $299.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.45 $296.92 $299.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-7511 SUP Custom 27203010 50-7511 - DILATOR LARYNGEAL METAL 32F BOTH IP/OP $355.73 $263.24 $0.00 $284.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.86 $281.74 $284.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-7513 SUP Custom 27203010 50-7513 - DILATOR LARYNGEAL METAL 36F BOTH IP/OP $350.88 $259.65 $0.00 $280.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.44 $277.90 $280.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-7515 SUP Custom 27203010 50-7515 - DILATOR LARYNGEAL METAL 40F BOTH IP/OP $337.20 $249.53 $0.00 $269.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.60 $267.06 $269.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-7517 SUP Custom 27203010 50-7517 - DILATOR LARYNGEAL METAL 44F BOTH IP/OP $336.10 $248.71 $0.00 $268.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.05 $266.19 $268.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-754-05-09 SUP HCPCS C1713 50-754-05-09 - PLATE BN MN LNG 110MM THREADLOCK TS LVL 1 4 HL LCK BAR TI BOTH IP/OP $854.95 $632.66 $0.00 $683.96 $384.73 $384.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.48 $677.12 $683.96 $0.00 $0.00 $133.80 $0.00 $0.00 $136.11 $0.00 $0.00 $0.00 $0.00 $0.00 50-760-12-09 SUP HCPCS C1713 50-760-12-09 - PLATE BONE STR 2.5MM LOCK 12 HOLE TITANIUM BOTH IP/OP "$2,796.00 " "$2,069.04" $0.00 "$2,236.80" "$1,258.20" "$1,258.20" $0.00 $0.00 $0.00 $582.76 "$2,075.19" "$2,075.19" $0.00 $0.00 $582.69 $0.00 "$1,378.43" "$1,378.43" $0.00 "$1,398.00" "$2,214.43" "$2,236.80" $0.00 $0.00 $437.57 $0.00 $0.00 $445.12 $0.00 $0.00 $0.00 $0.00 $0.00 50-760-20-09 SUP HCPCS C1713 50-760-20-09 - PLATE BN STRG 2.5MM 20 HL LCK TI BOTH IP/OP "$4,074.25 " "$3,014.95" $0.00 "$3,259.40" "$1,833.41" "$1,833.41" $0.00 $0.00 $0.00 $849.18 "$3,023.91" "$3,023.91" $0.00 $0.00 $849.07 $0.00 "$2,008.61" "$2,008.61" $0.00 "$2,037.13" "$3,226.81" "$3,259.40" $0.00 $0.00 $637.62 $0.00 $0.00 $648.62 $0.00 $0.00 $0.00 $0.00 $0.00 50-764-04-09 SUP HCPCS C1713 50-764-04-09 - LOCKING FRACTURE PLATE 4 HOLE 33MM NON-COMPRESSION 2.0MM BOTH IP/OP "$1,241.75 " $918.90 $0.00 $993.40 $558.79 $558.79 $0.00 $0.00 $0.00 $258.81 $921.63 $921.63 $0.00 $0.00 $258.78 $0.00 $734.50 $734.50 $0.00 $620.88 $983.47 $993.40 $0.00 $0.00 $194.33 $0.00 $0.00 $197.69 $0.00 $0.00 $0.00 $0.00 $0.00 5076-52 SUP HCPCS C1898 5076-52 - LEAD PACING 10MM SPACE SMALL STR 6.2FR 2MM 52CM 20-110CM BOTH IP/OP $992.50 $734.45 $0.00 $810.00 $455.63 $455.63 $0.00 $0.00 $0.00 $206.86 $736.63 $736.63 $0.00 $0.00 $206.84 $0.00 $587.06 $587.06 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $158.46 $0.00 $0.00 $161.19 $0.00 $0.00 $0.00 $0.00 $0.00 5076-58 SUP HCPCS C1898 5076-58 - LEAD PACING 10MM SPACE SMALL STR 6.2FR 2MM 58CM 20-110CM BOTH IP/OP $992.50 $734.45 $0.00 $810.00 $455.63 $455.63 $0.00 $0.00 $0.00 $206.86 $736.63 $736.63 $0.00 $0.00 $206.84 $0.00 $587.06 $587.06 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $158.46 $0.00 $0.00 $161.19 $0.00 $0.00 $0.00 $0.00 $0.00 50-766-06-09 SUP HCPCS C1713 50-766-06-09 - PLATE BN 43MMX2MM NS LVL 1 6 HL LCK TI CRNMXF 2MM SCR BOTH IP/OP "$1,241.75 " $918.90 $0.00 $993.40 $558.79 $558.79 $0.00 $0.00 $0.00 $258.81 $921.63 $921.63 $0.00 $0.00 $258.78 $0.00 $734.50 $734.50 $0.00 $620.88 $983.47 $993.40 $0.00 $0.00 $194.33 $0.00 $0.00 $197.69 $0.00 $0.00 $0.00 $0.00 $0.00 50-771-26-09 SUP HCPCS C1713 50-771-26-09 - PLATE BONE PREBENT ANGLED 2MM 26 HOLE RECONSTRUCTION LOCKING BOTH IP/OP "$3,550.70 " "$2,627.52" $0.00 "$2,840.56" "$1,597.82" "$1,597.82" $0.00 $0.00 $0.00 $740.05 "$2,635.33" "$2,635.33" $0.00 $0.00 $739.97 $0.00 "$1,750.50" "$1,750.50" $0.00 "$1,775.35" "$2,812.15" "$2,840.56" $0.00 $0.00 $555.68 $0.00 $0.00 $565.27 $0.00 $0.00 $0.00 $0.00 $0.00 50-773-26-09 SUP HCPCS C1713 50-773-26-09 - PLATE BONE PREBENT ANGLED 2MM 26 HOLE RECONSTRUCTION LOCKING BOTH IP/OP "$3,550.70 " "$2,627.52" $0.00 "$2,840.56" "$1,597.82" "$1,597.82" $0.00 $0.00 $0.00 $740.05 "$2,635.33" "$2,635.33" $0.00 $0.00 $739.97 $0.00 "$1,750.50" "$1,750.50" $0.00 "$1,775.35" "$2,812.15" "$2,840.56" $0.00 $0.00 $555.68 $0.00 $0.00 $565.27 $0.00 $0.00 $0.00 $0.00 $0.00 50-774-20-09 SUP HCPCS C1713 50-774-20-09 - PLATE BN STRG 2MM THREADLOCK TS 20 HL RECON BRDG LCK TI MNDB BOTH IP/OP "$2,186.13 " "$1,617.74" $0.00 "$1,748.90" $983.76 $983.76 $0.00 $0.00 $0.00 $455.64 "$1,622.54" "$1,622.54" $0.00 $0.00 $455.59 $0.00 "$1,293.09" "$1,293.09" $0.00 "$1,093.06" "$1,731.41" "$1,748.90" $0.00 $0.00 $342.13 $0.00 $0.00 $348.03 $0.00 $0.00 $0.00 $0.00 $0.00 50-775-26-09 SUP HCPCS C1713 50-775-26-09 - PLATE BONE 2MM 26 HOLE PRIM RECONSTRUCTION THREADLOCK GREEN BOTH IP/OP "$3,481.10 " "$2,576.01" $0.00 "$2,784.88" "$1,566.50" "$1,566.50" $0.00 $0.00 $0.00 $725.55 "$2,583.67" "$2,583.67" $0.00 $0.00 $725.46 $0.00 "$1,716.18" "$1,716.18" $0.00 "$1,740.55" "$2,757.03" "$2,784.88" $0.00 $0.00 $544.79 $0.00 $0.00 $554.19 $0.00 $0.00 $0.00 $0.00 $0.00 50-777-26-09 SUP HCPCS C1713 50-777-26-09 - PLATE BONE LEFT ANGLE 2MM 26 HOLE LOCKING RECONSTRUCTION BOTH IP/OP "$3,481.10 " "$2,576.01" $0.00 "$2,784.88" "$1,566.50" "$1,566.50" $0.00 $0.00 $0.00 $725.55 "$2,583.67" "$2,583.67" $0.00 $0.00 $725.46 $0.00 "$1,716.18" "$1,716.18" $0.00 "$1,740.55" "$2,757.03" "$2,784.88" $0.00 $0.00 $544.79 $0.00 $0.00 $554.19 $0.00 $0.00 $0.00 $0.00 $0.00 50-781-76-09 SUP HCPCS C1713 50-781-76-09 - TEMPLATE SIZING PREBENT 26 HOLE RECONSTRUCTION LOCKING BOTH IP/OP $139.25 $103.05 $0.00 $111.40 $62.66 $62.66 $0.00 $0.00 $0.00 $29.02 $103.35 $103.35 $0.00 $0.00 $29.02 $0.00 $82.37 $82.37 $0.00 $69.63 $110.29 $111.40 $0.00 $0.00 $21.79 $0.00 $0.00 $22.17 $0.00 $0.00 $0.00 $0.00 $0.00 50-784-70-09 SUP HCPCS C1713 50-784-70-09 - TEMPLATE BNDRG 20MMX2.3MM LCK PLT BOTH IP/OP $139.25 $103.05 $0.00 $111.40 $62.66 $62.66 $0.00 $0.00 $0.00 $29.02 $103.35 $103.35 $0.00 $0.00 $29.02 $0.00 $82.37 $82.37 $0.00 $69.63 $110.29 $111.40 $0.00 $0.00 $21.79 $0.00 $0.00 $22.17 $0.00 $0.00 $0.00 $0.00 $0.00 50-785-76-09 SUP HCPCS C1713 50-785-76-09 - TEMPLATE BENDING 26 HOLE PRIM PLATE RECONSTRUCTION TITANIUM BOTH IP/OP $139.25 $103.05 $0.00 $111.40 $62.66 $62.66 $0.00 $0.00 $0.00 $29.02 $103.35 $103.35 $0.00 $0.00 $29.02 $0.00 $82.37 $82.37 $0.00 $69.63 $110.29 $111.40 $0.00 $0.00 $21.79 $0.00 $0.00 $22.17 $0.00 $0.00 $0.00 $0.00 $0.00 50-790-06-09 SUP HCPCS C1713 50-790-06-09 - PLATE BN 155D 3MM GRN NS THREADLOCK TS 6 HL RECON CX TI MNDB BOTH IP/OP "$2,339.28 " "$1,731.07" $0.00 "$1,871.42" "$1,052.67" "$1,052.67" $0.00 $0.00 $0.00 $487.56 "$1,736.21" "$1,736.21" $0.00 $0.00 $487.50 $0.00 "$1,383.68" "$1,383.68" $0.00 "$1,169.64" "$1,852.71" "$1,871.42" $0.00 $0.00 $366.10 $0.00 $0.00 $372.41 $0.00 $0.00 $0.00 $0.00 $0.00 5079-1-010 SUP Custom 27203010 5079-1-010 - CLAMP EXFIX HFMN2 MINI SS SWVL BOTH IP/OP "$1,339.50 " $991.23 $0.00 "$1,028.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $994.18 $994.18 $0.00 $0.00 $279.15 $0.00 $0.00 $0.00 $0.00 $642.81 "$1,018.22" "$1,028.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-1-020 SUP Custom 27203010 5079-1-020 - CLAMP EXFIX HFMN MINI SMPL HM20 BOTH IP/OP $970.50 $718.17 $0.00 $759.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $720.31 $720.31 $0.00 $0.00 $202.25 $0.00 $0.00 $0.00 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-791-26-09 SUP HCPCS C1713 50-791-26-09 - PLATE BONE RIGHT ANG 3MM 26 HOLE RECONSTRUCTION TITANIUM BOTH IP/OP "$4,177.30 " "$3,091.20" $0.00 "$3,341.84" "$1,879.79" "$1,879.79" $0.00 $0.00 $0.00 $870.65 "$3,100.39" "$3,100.39" $0.00 $0.00 $870.55 $0.00 "$2,059.41" "$2,059.41" $0.00 "$2,088.65" "$3,308.42" "$3,341.84" $0.00 $0.00 $653.75 $0.00 $0.00 $665.03 $0.00 $0.00 $0.00 $0.00 $0.00 50-791-76-09 SUP HCPCS C1713 50-791-76-09 - TEMPLATE BENDING PREBENT 26 HOLE THREADLOCK TITANIUM MANDIB BOTH IP/OP $139.25 $103.05 $0.00 $111.40 $62.66 $62.66 $0.00 $0.00 $0.00 $29.02 $103.35 $103.35 $0.00 $0.00 $29.02 $0.00 $82.37 $82.37 $0.00 $69.63 $110.29 $111.40 $0.00 $0.00 $21.79 $0.00 $0.00 $22.17 $0.00 $0.00 $0.00 $0.00 $0.00 5079-2-031 SUP Custom 27203010 5079-2-031 - FXTR EXFIX HFMN 31MM MINI HIP INSL VISE SMTH BOTH IP/OP $264.75 $195.92 $0.00 $203.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.50 $196.50 $0.00 $0.00 $55.17 $0.00 $0.00 $0.00 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-2-032 SUP Custom 27203010 5079-2-032 - PIN XTRNFX 32MM MN HFMN INSL BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $0.00 $0.00 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-2-034 SUP Custom 27203010 5079-2-034 - FIXATOR XTRNFX MN HFMN2 INSL BOTH IP/OP $178.75 $132.28 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $0.00 $0.00 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-2-035 SUP Custom 27203010 5079-2-035 - VISE XTRNFX 35MM HFMN2 ROD 3 HL MDLR HM BOTH IP/OP $393.75 $291.38 $0.00 $302.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $0.00 $0.00 $0.00 $189.06 $299.48 $302.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-2-036 SUP Custom 27203010 5079-2-036 - DEVICE EXFIX HFMN2 MINI 3 HOLE VISE 2 ROD BOTH IP/OP $378.13 $279.82 $0.00 $302.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.64 $280.64 $0.00 $0.00 $78.80 $0.00 $0.00 $0.00 $0.00 $189.06 $299.48 $302.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-792-06-09 SUP HCPCS C1713 50-792-06-09 - PLATE BONE 120D 3MM 6 HOLE RECONSTRUCTION THREADLOCK GREEN BOTH IP/OP "$2,339.28 " "$1,731.07" $0.00 "$1,871.42" "$1,052.67" "$1,052.67" $0.00 $0.00 $0.00 $487.56 "$1,736.21" "$1,736.21" $0.00 $0.00 $487.50 $0.00 "$1,383.68" "$1,383.68" $0.00 "$1,169.64" "$1,852.71" "$1,871.42" $0.00 $0.00 $366.10 $0.00 $0.00 $372.41 $0.00 $0.00 $0.00 $0.00 $0.00 50-792-08-09 SUP HCPCS C1713 50-792-08-09 - PLATE BONE 120D 3MM 8 HOLE RECONSTRUCTION THREADLOCK GREEN BOTH IP/OP "$2,422.85 " "$1,792.91" $0.00 "$1,938.28" "$1,090.28" "$1,090.28" $0.00 $0.00 $0.00 $504.98 "$1,798.24" "$1,798.24" $0.00 $0.00 $504.92 $0.00 "$1,433.12" "$1,433.12" $0.00 "$1,211.43" "$1,918.90" "$1,938.28" $0.00 $0.00 $379.18 $0.00 $0.00 $385.72 $0.00 $0.00 $0.00 $0.00 $0.00 5079-2-113 SUP Custom 27203010 5079-2-113 - CPLNG EXFIX 3X3MM HFMN 13MM LCK BOTH IP/OP $787.50 $582.75 $0.00 $605.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $0.00 $0.00 $0.00 $378.13 $598.95 $605.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-2-123 SUP Custom 27203010 5079-2-123 - COUPLING XTRNFX 2MM MN 3MM HFMN ARTC CPL BOTH IP/OP $797.50 $590.15 $0.00 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.90 $591.90 $0.00 $0.00 $166.20 $0.00 $0.00 $0.00 $0.00 $398.75 $631.62 $638.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-3-040 SUP Custom 27203010 5079-3-040 - HOLDER IMPL HFMN2 PIN STR HM40 STRL BOTH IP/OP $273.00 $202.02 $0.00 $209.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.62 $202.62 $0.00 $0.00 $56.89 $0.00 $0.00 $0.00 $0.00 $130.63 $206.91 $209.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-3-041 SUP Custom 27203010 5079-3-041 - HOLDER IMPL HFMN MINI OFFST HM41 BOTH IP/OP $336.88 $249.29 $0.00 $269.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.03 $250.03 $0.00 $0.00 $70.20 $0.00 $0.00 $0.00 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-3-042 SUP Custom 27203010 5079-3-042 - HOLDER IMPL HFMN2 MINI PIN OFFST STR BOTH IP/OP $336.88 $249.29 $0.00 $269.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.03 $250.03 $0.00 $0.00 $70.20 $0.00 $0.00 $0.00 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-793-26-09 SUP HCPCS C1713 50-793-26-09 - PLATE BONE PREBENT ANGLED 3MM 26 HOLE RECONSTRUCTION LOCKING BOTH IP/OP "$4,177.30 " "$3,091.20" $0.00 "$3,341.84" "$1,879.79" "$1,879.79" $0.00 $0.00 $0.00 $870.65 "$3,100.39" "$3,100.39" $0.00 $0.00 $870.55 $0.00 "$2,059.41" "$2,059.41" $0.00 "$2,088.65" "$3,308.42" "$3,341.84" $0.00 $0.00 $653.75 $0.00 $0.00 $665.03 $0.00 $0.00 $0.00 $0.00 $0.00 5079-3-413 SUP Custom 27203010 5079-3-413 - BURR SURG 3MM HFMN MINI SHNK OFST HLD STRL BOTH IP/OP $351.75 $260.30 $0.00 $269.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $261.07 $261.07 $0.00 $0.00 $73.30 $0.00 $0.00 $0.00 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-4-012 SUP Custom 27203010 5079-4-012 - DEVICE EXFIX HFMN2 2MMX3MM MINI PVT LINKING BOTH IP/OP $294.00 $217.56 $0.00 $225.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.21 $218.21 $0.00 $0.00 $61.27 $0.00 $0.00 $0.00 $0.00 $140.94 $223.25 $225.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-4-050 SUP Custom 27203010 5079-4-050 - SOCKET XTRNFX 4MM MN 5MM HFMN INSL BOTH IP/OP $178.75 $132.28 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $0.00 $0.00 $0.00 $89.38 $141.57 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-794-20-09 SUP HCPCS C1713 50-794-20-09 - PLATE BONE STR 3MM 20 HOLE RECONSTRUCTION THREADLOCK GREEN BOTH IP/OP "$2,770.93 " "$2,050.49" $0.00 "$2,216.74" "$1,246.92" "$1,246.92" $0.00 $0.00 $0.00 $577.53 "$2,056.58" "$2,056.58" $0.00 $0.00 $577.46 $0.00 "$1,366.07" "$1,366.07" $0.00 "$1,385.46" "$2,194.58" "$2,216.74" $0.00 $0.00 $433.65 $0.00 $0.00 $441.13 $0.00 $0.00 $0.00 $0.00 $0.00 50-794-70-09 SUP HCPCS C1713 50-794-70-09 - TEMPLATE BENDING STR 20 HOLE THREADLOCK TITANIUM BOTH IP/OP $139.25 $103.05 $0.00 $111.40 $62.66 $62.66 $0.00 $0.00 $0.00 $29.02 $103.35 $103.35 $0.00 $0.00 $29.02 $0.00 $82.37 $82.37 $0.00 $69.63 $110.29 $111.40 $0.00 $0.00 $21.79 $0.00 $0.00 $22.17 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-030 SUP Custom 27203010 5079-5-030 - ROD EXFIX 30MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-040 SUP Custom 27203010 5079-5-040 - ROD EXFIX 40MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-050 SUP Custom 27203010 5079-5-050 - ROD EXFIX 50MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-060 SUP Custom 27203010 5079-5-060 - ROD EXFIX 60MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $68.25 $50.51 $0.00 $50.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.66 $50.66 $0.00 $0.00 $14.22 $0.00 $0.00 $0.00 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-070 SUP Custom 27203010 5079-5-070 - ROD EXFIX 70MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-080 SUP Custom 27203010 5079-5-080 - HM33/80 3MMX80MM BOTH IP/OP $68.25 $50.51 $0.00 $50.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.66 $50.66 $0.00 $0.00 $14.22 $0.00 $0.00 $0.00 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-090 SUP Custom 27203010 5079-5-090 - ROD EXFIX 90MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-120 SUP Custom 27203010 5079-5-120 - ROD EXFIX 120MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-150 SUP Custom 27203010 5079-5-150 - ROD EXFIX 150MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-180 SUP Custom 27203010 5079-5-180 - 3X180MM CONNECTING ROD BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-250 SUP Custom 27203010 5079-5-250 - ROD EXFIX 250MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $78.00 $57.72 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.89 $57.89 $0.00 $0.00 $16.26 $0.00 $0.00 $0.00 $0.00 $37.81 $59.90 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-795-26-09 SUP HCPCS C1713 50-795-26-09 - PLATE BONE RIGHT ANG 3MM 26 HOLE RECONSTRUCTION THREADLOCK BOTH IP/OP "$4,274.75 " "$3,163.32" $0.00 "$3,419.80" "$1,923.64" "$1,923.64" $0.00 $0.00 $0.00 $890.96 "$3,172.72" "$3,172.72" $0.00 $0.00 $890.86 $0.00 "$2,107.45" "$2,107.45" $0.00 "$2,137.38" "$3,385.60" "$3,419.80" $0.00 $0.00 $669.00 $0.00 $0.00 $680.54 $0.00 $0.00 $0.00 $0.00 $0.00 5079-5-300 SUP Custom 27203010 5079-5-300 - ROD EXFIX 300MM 3MM HFMN2 MIC SS CONNCTNG BOTH IP/OP $78.00 $57.72 $0.00 $57.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.89 $57.89 $0.00 $0.00 $16.26 $0.00 $0.00 $0.00 $0.00 $34.38 $54.45 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-795-76-09 SUP Custom 27203010 50-795-76-09 - TEMPLATE BENDING 26 HOLE THREADLOCK TITANIUM MANDIB BOTH IP/OP $139.25 $103.05 $0.00 $111.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.35 $103.35 $0.00 $0.00 $29.02 $0.00 $0.00 $0.00 $0.00 $69.63 $110.29 $111.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-6-030 SUP Custom 27203010 5079-6-030 - ROD EXFIX 30MM 3MM HFMN2 MIC CARB CONNCTNG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $0.00 $0.00 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-6-040 SUP Custom 27203010 5079-6-040 - ROD EXFIX 40MM 3MM HFMN2 MIC CARB CONNCTNG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $0.00 $0.00 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-6-050 SUP Custom 27203010 5079-6-050 - ROD EXFIX 50MM 3MM HFMN2 MIC CARB CONNCTNG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $0.00 $0.00 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-6-060 SUP Custom 27203010 5079-6-060 - ROD EXFIX 60MM 3MM HFMN2 MIC CARB CONNCTNG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $0.00 $0.00 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-796-06-09 SUP HCPCS C1713 50-796-06-09 - PLATE BN STRG 3MM GRN NS THREADLOCK TS 6 HL RECON BAR CX TI BOTH IP/OP "$1,991.18 " "$1,473.47" $0.00 "$1,592.94" $896.03 $896.03 $0.00 $0.00 $0.00 $415.01 "$1,477.85" "$1,477.85" $0.00 $0.00 $414.96 $0.00 "$1,177.78" "$1,177.78" $0.00 $995.59 "$1,577.01" "$1,592.94" $0.00 $0.00 $311.62 $0.00 $0.00 $317.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-6-090 SUP Custom 27203010 5079-6-090 - ROD EXFIX 90MM 3MM HFMN2 MIC CARB CONNCTNG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $0.00 $0.00 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-6-120 SUP Custom 27203010 5079-6-120 - ROD EXFIX 120MM 3MM HFMN2 MIC CARB CONNCTNG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $0.00 $0.00 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5079-6-150 SUP Custom 27203010 5079-6-150 - ROD EXFIX 150MM 3MM HFMN2 MIC CARB CONNCTNG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $0.00 $0.00 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-797-26-09 SUP HCPCS C1713 50-797-26-09 - PLATE BONE 3MM RECONSTRUCTION THREADLOCK GREEN TITANIUM LEFT BOTH IP/OP "$4,274.75 " "$3,163.32" $0.00 "$3,419.80" "$1,923.64" "$1,923.64" $0.00 $0.00 $0.00 $890.96 "$3,172.72" "$3,172.72" $0.00 $0.00 $890.86 $0.00 "$2,107.45" "$2,107.45" $0.00 "$2,137.38" "$3,385.60" "$3,419.80" $0.00 $0.00 $669.00 $0.00 $0.00 $680.54 $0.00 $0.00 $0.00 $0.00 $0.00 50-799-32-09 SUP HCPCS C1713 50-799-32-09 - PLATE BONE 3MM 32 HOLE LOCKING RECONSTRUCTION TITANIUM BOTH IP/OP "$4,748.20 " "$3,513.67" $0.00 "$3,798.56" "$2,136.69" "$2,136.69" $0.00 $0.00 $0.00 $989.64 "$3,524.11" "$3,524.11" $0.00 $0.00 $989.52 $0.00 "$2,340.86" "$2,340.86" $0.00 "$2,374.10" "$3,760.57" "$3,798.56" $0.00 $0.00 $743.09 $0.00 $0.00 $755.91 $0.00 $0.00 $0.00 $0.00 $0.00 50-799-34-09 SUP HCPCS C1713 50-799-34-09 - PLATE BN ANG 3MM LVL 1 34 HL LCK RECON TI CRNMXF 2.7MM SCR BOTH IP/OP "$5,082.38 " "$3,760.96" $0.00 "$4,065.90" "$2,287.07" "$2,287.07" $0.00 $0.00 $0.00 "$1,059.29" "$3,772.14" "$3,772.14" $0.00 $0.00 "$1,059.17" $0.00 "$2,505.61" "$2,505.61" $0.00 "$2,541.19" "$4,025.24" "$4,065.90" $0.00 $0.00 $795.39 $0.00 $0.00 $809.11 $0.00 $0.00 $0.00 $0.00 $0.00 50-8001 SUP Custom 27011340 50-8001 - OXYGEN DELIVERY SYSTEM W/ADLT MASK 10/CS BOTH IP/OP $40.81 $30.20 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.29 $30.29 $0.00 $0.00 $8.50 $0.00 $0.00 $0.00 $0.00 $20.40 $32.32 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5080-1-612 SUP Custom 27203010 5080-1-612 - PIN HALF 12MM 45MM 1.65MM HFMN2 APEX MIC SS SLFDRILL SLFTAP BOTH IP/OP $129.00 $95.46 $0.00 $95.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.74 $95.74 $0.00 $0.00 $26.88 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5080-1-620 SUP Custom 27203010 5080-1-620 - PIN HALF 20MM 45MM 1.65MM HFMN2 APEX MIC SS SLFDRILL SLFTAP BOTH IP/OP $129.00 $95.46 $0.00 $95.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.74 $95.74 $0.00 $0.00 $26.88 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5080-2-012 SUP Custom 27203010 5080-2-012 - PIN HALF 45MM 2MM HFMN2 APEX MIC SS SLFDRILL SLFTAP THRD 12 BOTH IP/OP $129.00 $95.46 $0.00 $95.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.74 $95.74 $0.00 $0.00 $26.88 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5080-2-020 SUP Custom 27203010 5080-2-020 - PIN HALF 45MM 2MM HFMN2 APEX MIC SS SLFDRILL SLFTAP THRD 20 BOTH IP/OP $129.00 $95.46 $0.00 $95.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.74 $95.74 $0.00 $0.00 $26.88 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-42A SUP Custom 27803010 508-11-42A - SHELL ACETAB A HEMISPHERE 42MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-44B SUP Custom 27803010 508-11-44B - SHELL ACETAB B HEMISPHERE 44MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-46C SUP Custom 27803010 508-11-46C - SHELL ACETAB C HEMISPHERE 46MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-48D SUP Custom 27803010 508-11-48D - SHELL ACETAB D HEMISPHERE 48MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-50D SUP Custom 27803010 508-11-50D - SHELL ACETAB D HEMISPHERE 50MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-52E SUP Custom 27803010 508-11-52E - SHELL ACETAB E HEMISPHERE 52MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-54E SUP Custom 27803010 508-11-54E - SHELL ACETAB E HEMISPHERE 54MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-56F SUP Custom 27803010 508-11-56F - SHELL ACETAB F HEMISPHERE 56MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-58F SUP Custom 27803010 508-11-58F - SHELL ACETAB F HEMISPHERE 58MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-60G SUP Custom 27803010 508-11-60G - SHELL ACETAB G HEMISPHERE 60MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-62G SUP Custom 27803010 508-11-62G - SHELL ACETAB G HEMISPHERE 62MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-64H SUP Custom 27803010 508-11-64H - SHELL ACETAB H HEMISPHERE 64MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-66H SUP Custom 27803010 508-11-66H - SHELL ACETAB H HEMISPHERE 66MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-68I SUP Custom 27803010 508-11-68I - SHELL ACETAB I HEMISPHERE 68MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-70I SUP Custom 27803010 508-11-70I - SHELL ACETAB I HEMISPHERE 70MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-72J SUP Custom 27803010 508-11-72J - SHELL ACETAB J HEMISPHERE 72MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 508-11-74J SUP Custom 27803010 508-11-74J - SHELL ACETAB J HEMISPHERE 74MM MULTIHOLE TRIDENT HIP BOTH IP/OP "$4,207.50 " "$3,113.55" $0.00 "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,122.81" "$3,122.81" $0.00 $0.00 $876.84 $0.00 $0.00 $0.00 $0.00 "$2,103.75" "$3,332.34" "$3,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50-820-07-07 SUP Custom 27100030 50-820-07-07 - DRILL TWIST 1.5MM 40MM 7MM HEXAGONAL ATTCH STOP STAINLESS BOTH IP/OP $311.90 $230.81 $0.00 $249.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.49 $231.49 $0.00 $0.00 $65.00 $0.00 $0.00 $0.00 $0.00 $155.95 $247.02 $249.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5082-200 SUP Custom 27203010 5082-200 - BLOOD PRESSURE CONNECTOR/MALE BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5084-1-100 SUP Custom 27203010 5084-1-100 - GUIDE DRILL 1.5-2MM MINI BOTH IP/OP $515.63 $381.57 $0.00 $412.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.70 $382.70 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $257.81 $408.38 $412.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5085-2-015 SUP Custom 27203010 5085-2-015 - BIT DRILL 75MM 1.5MM STRL BOTH IP/OP $86.70 $64.16 $0.00 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.35 $64.35 $0.00 $0.00 $18.07 $0.00 $0.00 $0.00 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5090-2-120 SUP Custom 27203010 5090-2-120 - PIN HALF 120MM 3MM 4MM APEX SLFDRILL BOTH IP/OP $146.20 $108.19 $0.00 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.51 $108.51 $0.00 $0.00 $30.47 $0.00 $0.00 $0.00 $0.00 $103.81 $164.44 $166.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-54E SUP Custom 27803010 509-02-54E - SHELL ACETAB E HEMISPHERE 54MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-56E SUP Custom 27803010 509-02-56E - SHELL ACETAB E HEMISPHERE 56MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-58F SUP Custom 27803010 509-02-58F - SHELL ACETAB F HEMISPHERE 58MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-60F SUP Custom 27803010 509-02-60F - SHELL ACETAB F HEMISPHERE 60MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-62G SUP Custom 27803010 509-02-62G - SHELL ACETAB G HEMISPHERE 62MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-64G SUP Custom 27803010 509-02-64G - SHELL ACETAB G HEMISPHERE 64MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-66H SUP Custom 27803010 509-02-66H - SHELL ACETAB H HEMISPHERE 66MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-68H SUP Custom 27803010 509-02-68H - SHELL ACETAB H HEMISPHERE 68MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-70I SUP Custom 27803010 509-02-70I - SHELL ACETAB I HEMISPHERE 70MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-72I SUP Custom 27803010 509-02-72I - SHELL ACETAB I HEMISPHERE 72MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-74J SUP Custom 27803010 509-02-74J - SHELL ACETAB J HEMISPHERE 74MM MULTIHOLE RIM MDM TRIDENT BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-76J SUP Custom 27803010 509-02-76J - SHELL ACETAB 76MM MULTIHOLE REVISION TRITANIUM BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-78J SUP Custom 27803010 509-02-78J - SHELL ACETAB 78MM MULTIHOLE REVISION TRITANIUM BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-02-80J SUP Custom 27803010 509-02-80J - SHELL ACETAB 80MM MULTIHOLE REVISION TRITANIUM BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 $0.00 $0.00 $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 509-250-605 SUP Custom 27203010 SPECULUM 7X1.75IN GRV 2XL RT OPN VAG LTX BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5094-0-202 SUP Custom 27203010 5094-0-202 - FIXATOR XTRNFX HFMN2 LENGTHEN SS BOTH IP/OP "$4,054.50 " "$3,000.33" $0.00 "$3,179.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,009.25" "$3,009.25" $0.00 $0.00 $844.96 $0.00 $0.00 $0.00 $0.00 "$1,986.88" "$3,147.21" "$3,179.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50960-584 SUP Custom 27203010 MATTRESS OVRLY 72X34X3.5IN FULL SFT SKN COVER LF GM BOTH IP/OP $108.83 $80.53 $0.00 $87.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.41 $86.19 $87.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5096-4615 SUP HCPCS C1776 5096-4615 - AUGMENT ACTB WDG 46MM 15MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-4620 SUP HCPCS C1776 5096-4620 - AUGMENT ACTB WDG 46MM 20MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-5015 SUP HCPCS C1776 5096-5015 - AUGMENT ACTB WDG 50MM 15MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-5020 SUP HCPCS C1776 5096-5020 - AUGMENT ACTB WDG 50MM 20MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-5025 SUP HCPCS C1776 5096-5025 - AUGMENT ACTB WDG 50MM 25MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-5415 SUP HCPCS C1776 5096-5415 - AUGMENT ACTB WDG 54MM 15MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-5815 SUP HCPCS C1776 5096-5815 - AUGMENT ACTB WDG 58MM 15MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-5825 SUP HCPCS C1776 5096-5825 - AUGMENT ACTB WDG 58MM 25MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-6220 SUP HCPCS C1776 5096-6220 - AUGMENT ACTB WDG 62MM 20MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-6225 SUP HCPCS C1776 5096-6225 - AUGMENT ACTB WDG 62MM 25MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-6615 SUP HCPCS C1776 5096-6615 - AUGMENT ACTB WDG 66MM 15MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-6620 SUP HCPCS C1776 5096-6620 - AUGMENT ACTB WDG 66MM 20MM RSTR BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5096-6625 SUP HCPCS C1776 5096-6625 - AUGMENT ACTB WDG 66MM 25MM RSTR HIP BOTH IP/OP "$4,817.50 " "$3,564.95" $0.00 "$3,854.00" "$2,167.88" "$2,167.88" $0.00 $0.00 $0.00 "$1,004.09" "$3,575.55" "$3,575.55" $0.00 $0.00 "$1,003.97" $0.00 "$2,375.03" "$2,375.03" $0.00 "$2,408.75" "$3,815.46" "$3,854.00" $0.00 $0.00 $753.94 $0.00 $0.00 $766.95 $0.00 $0.00 $0.00 $0.00 $0.00 5100-001 SUP HCPCS Q4116 5100-001 - GRAFT SKIN 0-175SQ CM CRYOPRESERVED SPLIT NONMESHED BOTH IP/OP "$1,184.05 " $876.20 $0.00 $878.80 $425.25 $425.25 $0.00 $0.00 $0.00 $246.79 $878.80 $878.80 $0.00 $0.00 $246.76 $0.00 $700.37 $700.37 $0.00 $472.50 $748.44 $756.00 $0.00 $0.00 $147.89 $0.00 $0.00 $150.44 $0.00 $0.00 $0.00 $0.00 $0.00 5100-037-012 SUP Custom 27203010 5100-037-012 - BLADE SAW SHORT LONG MICRO 33.5X.64MM RECIPROCATE TPS BOTH IP/OP $196.10 $145.11 $0.00 $156.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.55 $145.55 $0.00 $0.00 $40.87 $0.00 $0.00 $0.00 $0.00 $98.05 $155.31 $156.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5100-137-233 SUP Custom 27203010 5100-137-233 - BLADE SAW SHORT 27X.38MM RECIPROCATING TAPERED PRECISION BOTH IP/OP $196.10 $145.11 $0.00 $156.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.55 $145.55 $0.00 $0.00 $40.87 $0.00 $0.00 $0.00 $0.00 $98.05 $155.31 $156.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 510038SIM2 SUP HCPCS C1725 510038SIM2 - CATHETER ANGIOGRAPHIC SIDEWINDER SIMMONS TECHNIQUE 2 CURVE 5 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 5101-1-450 SUP HCPCS C1713 5101-1-450 - WIRE XTRNFX 1.5MM 450MM KRSH BOTH IP/OP $103.70 $76.74 $0.00 $86.90 $48.88 $48.88 $0.00 $0.00 $0.00 $21.61 $76.97 $76.97 $0.00 $0.00 $21.61 $0.00 $61.34 $61.34 $0.00 $54.31 $86.03 $86.90 $0.00 $0.00 $17.00 $0.00 $0.00 $17.29 $0.00 $0.00 $0.00 $0.00 $0.00 5101-2-450 SUP HCPCS C1713 5101-2-450 - WIRE XTRNFX 2MM 450MM KRSH BOTH IP/OP $103.70 $76.74 $0.00 $86.90 $48.88 $48.88 $0.00 $0.00 $0.00 $21.61 $76.97 $76.97 $0.00 $0.00 $21.61 $0.00 $61.34 $61.34 $0.00 $54.31 $86.03 $86.90 $0.00 $0.00 $17.00 $0.00 $0.00 $17.29 $0.00 $0.00 $0.00 $0.00 $0.00 5101302P2 SUP HCPCS C1713 5101302P2 - CAGE SPNL 12D 30X10X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5101308P2 SUP HCPCS C1713 5101308P2 - CAGE SPNL 8D 30X10X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5102-1-246 SUP Custom 27203010 5102-1-246 - HOLDER IMPL M-S KWR SPCR KWR BOTH IP/OP $383.63 $283.89 $0.00 $306.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $284.73 $284.73 $0.00 $0.00 $79.95 $0.00 $0.00 $0.00 $0.00 $191.81 $303.83 $306.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5102-1-250 SUP Custom 27203010 5102-1-250 - CLAMP XTRNFX M-S HBRD BOTH IP/OP "$1,218.25 " $901.51 $0.00 $974.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $904.19 $904.19 $0.00 $0.00 $253.88 $0.00 $0.00 $0.00 $0.00 $609.13 $964.85 $974.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5102-1-260 SUP Custom 27203010 5102-1-260 - HOLDER KWR 60MM M-S 2 BOTH IP/OP "$1,215.50 " $899.47 $0.00 $972.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $902.14 $902.14 $0.00 $0.00 $253.31 $0.00 $0.00 $0.00 $0.00 $607.75 $962.68 $972.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5102-1-270 SUP Custom 27203010 5102-1-270 - HOLDER KWR 80MM M-S 2 BOTH IP/OP "$1,215.50 " $899.47 $0.00 $972.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $902.14 $902.14 $0.00 $0.00 $253.31 $0.00 $0.00 $0.00 $0.00 $607.75 $962.68 $972.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5102-1-330 SUP Custom 27203010 5102-1-330 - FIXATOR XTRNFX 70D M-S BALL JNT BOTH IP/OP $803.00 $594.22 $0.00 $642.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $595.99 $595.99 $0.00 $0.00 $167.35 $0.00 $0.00 $0.00 $0.00 $401.50 $635.98 $642.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5102-8-330 SUP Custom 27203010 5102-8-330 - ROD EXFIX 330MM 8MM MNTB CONNCTNG THRD BOTH IP/OP $81.13 $60.04 $0.00 $64.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.21 $60.21 $0.00 $0.00 $16.91 $0.00 $0.00 $0.00 $0.00 $40.56 $64.25 $64.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5102-8-395 SUP Custom 27203010 5102-8-395 - FXTR EXFIX 395MM 8MM M-S CONNCTNG ROD THRD BOTH IP/OP $82.50 $61.05 $0.00 $66.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.23 $61.23 $0.00 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $41.25 $65.34 $66.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 510410R SUP HCPCS C1758 510410R - CATHETER URETHRAL 10FR LATEX ROBINSON RED RUBBER STERILE RRL BOTH IP/OP $10.58 $7.83 $0.00 $8.46 $5.74 $5.74 $0.00 $0.00 $0.00 $2.20 $7.85 $7.85 $0.00 $0.00 $2.20 $0.00 $6.26 $6.26 $0.00 $5.29 $8.38 $8.46 $0.00 $0.00 $1.65 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 510420R SUP HCPCS C1758 510420R - CATHETER URTH RBNSN 20FR 16IN 2 STGR EYLT XRY BOTH IP/OP $10.58 $7.83 $0.00 $8.46 $5.74 $5.74 $0.00 $0.00 $0.00 $2.20 $7.85 $7.85 $0.00 $0.00 $2.20 $0.00 $6.26 $6.26 $0.00 $5.29 $8.38 $8.46 $0.00 $0.00 $1.65 $0.00 $0.00 $1.68 $0.00 $0.00 $0.00 $0.00 $0.00 5104308P2 SUP HCPCS C1713 5104308P2 - CAGE SPNL 8D 30X10X14MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5109302P2 SUP HCPCS C1713 5109302P2 - CAGE SPNL 12D 30X10X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5109308P2 SUP HCPCS C1713 5109308P2 - CAGE SPNL 8D 30X10X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5111302P2 SUP HCPCS C1713 5111302P2 - CAGE SPNL 12D 30X11X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5111308P2 SUP HCPCS C1713 5111308P2 - CAGE SPNL 8D 30X11X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 51114V SUP Custom 27203010 51114V - CLIP INTNL MED LG SMTR VESOLOCK BOTH IP/OP $851.23 $629.91 $0.00 $680.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.78 $631.78 $0.00 $0.00 $177.40 $0.00 $0.00 $0.00 $0.00 $425.61 $674.17 $680.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51-17304 SUP HCPCS C1713 51-17304 - SCREW BONE 1.7MM 4MM EMERGENCY TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-300 SUP Custom 27203010 5118-1-300 - RING XTRNFX SM 147MM BLU M-S .75 HP BOTH IP/OP $642.13 $475.18 $0.00 $513.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $476.59 $476.59 $0.00 $0.00 $133.82 $0.00 $0.00 $0.00 $0.00 $321.06 $508.57 $513.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-301 SUP Custom 27203010 5118-1-301 - RING XTRNFX SM 165MM GRN M-S .75 HP BOTH IP/OP $738.38 $546.40 $0.00 $590.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $548.02 $548.02 $0.00 $0.00 $153.88 $0.00 $0.00 $0.00 $0.00 $369.19 $584.80 $590.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-302 SUP Custom 27203010 5118-1-302 - RING XTRNFX SM 187MM WHT M-S .75 HP BOTH IP/OP $796.13 $589.14 $0.00 $636.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.88 $590.88 $0.00 $0.00 $165.91 $0.00 $0.00 $0.00 $0.00 $398.06 $630.53 $636.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-303 SUP Custom 27203010 5118-1-303 - RING XTRNFX SM 147MM BLU M-S .25 HP BOTH IP/OP $374.00 $276.76 $0.00 $299.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.58 $277.58 $0.00 $0.00 $77.94 $0.00 $0.00 $0.00 $0.00 $187.00 $296.21 $299.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-304 SUP Custom 27203010 5118-1-304 - RING XTRNFX MED 165MM GRN M-S .25 HP BOTH IP/OP $441.38 $326.62 $0.00 $353.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $327.59 $327.59 $0.00 $0.00 $91.98 $0.00 $0.00 $0.00 $0.00 $220.69 $349.57 $353.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-305 SUP Custom 27203010 5118-1-305 - RING XTRNFX LG 187MM WHT M-S .25 HP BOTH IP/OP $566.50 $419.21 $0.00 $453.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.46 $420.46 $0.00 $0.00 $118.06 $0.00 $0.00 $0.00 $0.00 $283.25 $448.67 $453.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-306 SUP Custom 27203010 5118-1-306 - PIN XTRNFX 50MM KRSH M-S RECON CLP WRE HLDR BOTH IP/OP $265.38 $196.38 $0.00 $212.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.96 $196.96 $0.00 $0.00 $55.30 $0.00 $0.00 $0.00 $0.00 $132.69 $210.18 $212.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-307 SUP Custom 27203010 5118-1-307 - PIN EXFIX 100MM CLMP BOTH IP/OP $320.38 $237.08 $0.00 $256.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.78 $237.78 $0.00 $0.00 $66.77 $0.00 $0.00 $0.00 $0.00 $160.19 $253.74 $256.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-308 SUP Custom 27203010 5118-1-308 - CPLNG EXFIX ARTC BOTH IP/OP $735.63 $544.37 $0.00 $588.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.98 $545.98 $0.00 $0.00 $153.30 $0.00 $0.00 $0.00 $0.00 $367.81 $582.62 $588.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-311 SUP Custom 27203010 5118-1-311 - HOLDER XTRNFX KRSH M-S ARTC CPLNG BOTH IP/OP $948.75 $702.08 $0.00 $759.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $704.16 $704.16 $0.00 $0.00 $197.72 $0.00 $0.00 $0.00 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-320 SUP HCPCS C1713 5118-1-320 - WIRE XTRNFX OLV 1.5MM 450MM KRSH STP NUT SS BOTH IP/OP $216.75 $160.40 $0.00 $173.80 $97.76 $97.76 $0.00 $0.00 $0.00 $45.18 $160.87 $160.87 $0.00 $0.00 $45.17 $0.00 $128.21 $128.21 $0.00 $108.63 $172.06 $173.80 $0.00 $0.00 $34.00 $0.00 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-340 SUP HCPCS C1713 5118-1-340 - WIRE XTRNFX OLV 2MM 450MM KRSH STP SS BOTH IP/OP $216.75 $160.40 $0.00 $173.80 $97.76 $97.76 $0.00 $0.00 $0.00 $45.18 $160.87 $160.87 $0.00 $0.00 $45.17 $0.00 $128.21 $128.21 $0.00 $108.63 $172.06 $173.80 $0.00 $0.00 $34.00 $0.00 $0.00 $34.59 $0.00 $0.00 $0.00 $0.00 $0.00 5118-1-350 SUP Custom 27203010 5118-1-350 - HINGE XTRNFX M-S BOTH IP/OP $481.25 $356.13 $0.00 $385.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $357.18 $357.18 $0.00 $0.00 $100.29 $0.00 $0.00 $0.00 $0.00 $240.63 $381.15 $385.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5119302P2 SUP HCPCS C1713 5119302P2 - CAGE SPNL 12D 30X11X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5119308P2 SUP HCPCS C1713 5119308P2 - CAGE SPNL 8D 30X11X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5120-0-010 SUP Custom 27203010 5120-0-010 - RING EXFIX GRY 100MM M-S .75 RING BOTH IP/OP $515.63 $381.57 $0.00 $412.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.70 $382.70 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $257.81 $408.38 $412.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5120-0-040 SUP Custom 27203010 5120-0-040 - RING EXFIX 115MM M-S .25 BOTH IP/OP $323.13 $239.12 $0.00 $258.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.82 $239.82 $0.00 $0.00 $67.34 $0.00 $0.00 $0.00 $0.00 $161.56 $255.92 $258.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5120-0-050 SUP Custom 27203010 5120-0-050 - RING EXFIX 130MM M-S .75 BOTH IP/OP $591.25 $437.53 $0.00 $473.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $438.83 $438.83 $0.00 $0.00 $123.22 $0.00 $0.00 $0.00 $0.00 $295.63 $468.27 $473.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5120-0-060 SUP Custom 27203010 5120-0-060 - RING EXFIX RED 130MM M-S .25 RING BOTH IP/OP $367.13 $271.68 $0.00 $293.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.48 $272.48 $0.00 $0.00 $76.51 $0.00 $0.00 $0.00 $0.00 $183.56 $290.77 $293.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5120-0-070 SUP Custom 27203010 5120-0-070 - RING EXFIX BRNZ 210MM M-S .75 RING BOTH IP/OP $782.38 $578.96 $0.00 $625.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $580.68 $580.68 $0.00 $0.00 $163.05 $0.00 $0.00 $0.00 $0.00 $391.19 $619.64 $625.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5120-0-080 SUP Custom 27203010 5120-0-080 - RING EXFIX BRNZ 210MM M-S .25 RING BOTH IP/OP $622.88 $460.93 $0.00 $498.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.30 $462.30 $0.00 $0.00 $129.81 $0.00 $0.00 $0.00 $0.00 $311.44 $493.32 $498.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5121302P2 SUP HCPCS C1713 5121302P2 - CAGE SPNL 12D 30X12X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5121308P2 SUP HCPCS C1713 5121308P2 - CAGE SPNL 8D 30X12X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5124308P2 SUP HCPCS C1713 5124308P2 - CAGE SPNL 8D 30X12X14MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5128-1220 SUP Custom 27203010 REAGENT MOL BIO HC2 TRNSPT MED 30ML BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5129302P2 SUP HCPCS C1713 5129302P2 - CAGE SPNL 12D 30X12X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5129308P2 SUP HCPCS C1713 5129308P2 - CAGE SPNL 8D 30X12X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5130-080-030 SUP Custom 27203010 5130-080-030 - RASP SURG LONG 3.2MM HELICOIDAL 3.2MM 18.3MM BOTH IP/OP $316.25 $234.03 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.72 $234.72 $0.00 $0.00 $65.91 $0.00 $0.00 $0.00 $0.00 $158.13 $250.47 $253.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5141302P2 SUP HCPCS C1713 5141302P2 - CAGE SPNL 12D 30X14X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5141308P2 SUP HCPCS C1713 5141308P2 - CAGE SPNL 8D 30X14X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5144308P2 SUP HCPCS C1713 5144308P2 - CAGE SPNL 8D 30X14X14MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5149302P2 SUP HCPCS C1713 5149302P2 - CAGE SPNL 12D 30X14X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5149308P2 SUP HCPCS C1713 5149308P2 - CAGE SPNL 8D 30X9X14MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5150-0-400 SUP Custom 27203010 5150-0-400 - TUBE XTRNFX 25MM RD MNTB TRX XTD DYNMC C BOTH IP/OP "$2,083.13 " "$1,541.52" $0.00 "$1,666.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,546.10" "$1,546.10" $0.00 $0.00 $434.12 $0.00 $0.00 $0.00 $0.00 "$1,041.56" "$1,649.84" "$1,666.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-0-410 SUP Custom 27203010 5150-0-410 - TUBE XTRNFX 20MM RD MNTB TRX XTD DYNMC C BOTH IP/OP "$2,186.25 " "$1,617.83" $0.00 "$1,749.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,622.63" "$1,622.63" $0.00 $0.00 $455.61 $0.00 $0.00 $0.00 $0.00 "$1,093.13" "$1,731.51" "$1,749.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-0-420 SUP Custom 27203010 5150-0-420 - TUBE XTRNFX 15MM RD MNTB TRX XTD DYNMC C BOTH IP/OP "$2,186.25 " "$1,617.83" $0.00 "$1,749.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,622.63" "$1,622.63" $0.00 $0.00 $455.61 $0.00 $0.00 $0.00 $0.00 "$1,093.13" "$1,731.51" "$1,749.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-0-465 SUP Custom 27203010 5150-0-465 - TUBE XTRNFX SM 15MM YLW MNTB TRX DYNMC SNPFT C BOTH IP/OP "$2,844.88 " "$2,105.21" $0.00 "$2,275.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,111.47" "$2,111.47" $0.00 $0.00 $592.87 $0.00 $0.00 $0.00 $0.00 "$1,422.44" "$2,253.14" "$2,275.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-0-470 SUP Custom 27203010 5150-0-470 - TUBE XTRNFX MED 20MM BLU MNTB TRX DYNMC C BOTH IP/OP "$2,996.88 " "$2,217.69" $0.00 "$2,409.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,224.28" "$2,224.28" $0.00 $0.00 $624.55 $0.00 $0.00 $0.00 $0.00 "$1,505.63" "$2,384.91" "$2,409.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-0-475 SUP Custom 27203010 5150-0-475 - TUBE XTRNFX 25MM RD MNTB TRX DYNMC C BOTH IP/OP "$3,067.75 " "$2,270.14" $0.00 "$2,465.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,276.88" "$2,276.88" $0.00 $0.00 $639.32 $0.00 $0.00 $0.00 $0.00 "$1,540.69" "$2,440.45" "$2,465.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-0-575 SUP Custom 27203010 5150-0-575 - TUBE XTRNFX 25MM RD MNTB TRX XTD DYNMC C BOTH IP/OP "$3,650.63 " "$2,701.47" $0.00 "$2,920.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,709.49" "$2,709.49" $0.00 $0.00 $760.79 $0.00 $0.00 $0.00 $0.00 "$1,825.31" "$2,891.30" "$2,920.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-2-520 SUP HCPCS C1713 5150-2-520 - CAP END SPR 20MM TUBE MNTB TRX BLUE BOTH IP/OP $88.00 $65.12 $0.00 $70.40 $39.60 $39.60 $0.00 $0.00 $0.00 $18.34 $65.31 $65.31 $0.00 $0.00 $18.34 $0.00 $52.05 $52.05 $0.00 $44.00 $69.70 $70.40 $0.00 $0.00 $13.77 $0.00 $0.00 $14.01 $0.00 $0.00 $0.00 $0.00 $0.00 5150-2-615 SUP Custom 27203010 5150-2-615 - TUBE XTRNFX 15MM YLW MNTB TRX END CAP UNLAT C BOTH IP/OP $38.25 $28.31 $0.00 $28.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.39 $28.39 $0.00 $0.00 $7.97 $0.00 $0.00 $0.00 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-2-620 SUP Custom 27203010 5150-2-620 - SET EXFIX BLUE 20MM CARB TUBE END CAP ASMBLY BOTH IP/OP $35.75 $26.46 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.53 $26.53 $0.00 $0.00 $7.45 $0.00 $0.00 $0.00 $0.00 $17.88 $28.31 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-2-625 SUP Custom 27203010 5150-2-625 - SET EXFIX RED CAP ASMBLY CARB TUBE BOTH IP/OP $38.50 $28.49 $0.00 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.57 $28.57 $0.00 $0.00 $8.02 $0.00 $0.00 $0.00 $0.00 $22.00 $34.85 $35.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-015 SUP Custom 27203010 5150-3-015 - CLAMP SURG 15MM PIN YLW BOTH IP/OP $823.63 $609.49 $0.00 $658.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.29 $611.29 $0.00 $0.00 $171.64 $0.00 $0.00 $0.00 $0.00 $411.81 $652.31 $658.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-020 SUP Custom 27203010 5150-3-020 - CLAMP EXFIX BLUE 20MM MNTB TRX PIN BOTH IP/OP "$1,154.13 " $854.06 $0.00 $926.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $856.59 $856.59 $0.00 $0.00 $240.52 $0.00 $0.00 $0.00 $0.00 $578.88 $916.94 $926.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-025 SUP Custom 27203010 5150-3-025 - CLAMP EXFIX RED 25MM MNTB TRX PIN BOTH IP/OP "$1,273.25 " $942.21 $0.00 "$1,018.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $945.01 $945.01 $0.00 $0.00 $265.35 $0.00 $0.00 $0.00 $0.00 $636.63 "$1,008.41" "$1,018.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-065 SUP Custom 27203010 5150-3-065 - CLAMP EXFIX YLW 15MM MNTB TRX 1 PIN BOTH IP/OP $969.38 $717.34 $0.00 $775.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $719.47 $719.47 $0.00 $0.00 $202.02 $0.00 $0.00 $0.00 $0.00 $484.69 $767.75 $775.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-070 SUP Custom 27203010 5150-3-070 - CLAMP EXFIX BLUE 20MM MNTB TRX 1 PIN BOTH IP/OP "$1,687.00 " "$1,248.38" $0.00 "$1,354.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.09" "$1,252.09" $0.00 $0.00 $351.57 $0.00 $0.00 $0.00 $0.00 $846.31 "$1,340.56" "$1,354.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-075 SUP Custom 27203010 5150-3-075 - CLAMP EXFIX RED 25MM MNTB TRX 1 PIN BOTH IP/OP "$1,992.38 " "$1,474.36" $0.00 "$1,600.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,478.74" "$1,478.74" $0.00 $0.00 $415.21 $0.00 $0.00 $0.00 $0.00 "$1,000.31" "$1,584.50" "$1,600.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-165 SUP Custom 27203010 5150-3-165 - CLAMP EXFIX YLW 15MM MNTB TRX 1 PIN BOTH IP/OP "$1,045.00 " $773.30 $0.00 $836.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.60 $775.60 $0.00 $0.00 $217.78 $0.00 $0.00 $0.00 $0.00 $522.50 $827.64 $836.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-170 SUP Custom 27203010 5150-3-170 - CLAMP EXFIX BLUE 20MM MNTB TRX 1 PIN BOTH IP/OP "$1,069.25 " $791.25 $0.00 $859.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $793.60 $793.60 $0.00 $0.00 $222.83 $0.00 $0.00 $0.00 $0.00 $536.94 $850.51 $859.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-175 SUP Custom 27203010 5150-3-175 - CLAMP EXFIX RED 25MM MNTB TRX 1 PIN BOTH IP/OP "$1,101.63 " $815.21 $0.00 $884.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $817.63 $817.63 $0.00 $0.00 $229.58 $0.00 $0.00 $0.00 $0.00 $552.75 $875.56 $884.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-315 SUP Custom 27203010 5150-3-315 - CLAMP EXFIX YLW MNTB TRX SM T ASMBLY BOTH IP/OP "$1,278.75 " $946.28 $0.00 "$1,023.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $949.09 $949.09 $0.00 $0.00 $266.49 $0.00 $0.00 $0.00 $0.00 $639.38 "$1,012.77" "$1,023.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-320 SUP Custom 27203010 5150-3-320 - T-CLAMP ASSEMBLY MED. (BLUE) BOTH IP/OP "$1,362.63 " "$1,008.35" $0.00 "$1,090.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.34" "$1,011.34" $0.00 $0.00 $283.97 $0.00 $0.00 $0.00 $0.00 $681.31 "$1,079.20" "$1,090.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-415 SUP Custom 27203010 5150-3-415 - CPLNG EXFIX YLW SM TUBE TO TUBE BOTH IP/OP "$1,344.75 " $995.12 $0.00 "$1,075.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $998.07 $998.07 $0.00 $0.00 $280.25 $0.00 $0.00 $0.00 $0.00 $672.38 "$1,065.04" "$1,075.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-420 SUP Custom 27203010 5150-3-420 - CPLNG EXFIX BLUE MED TUBE TO TUBE BOTH IP/OP "$1,393.88 " "$1,031.47" $0.00 "$1,118.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,034.53" "$1,034.53" $0.00 $0.00 $290.48 $0.00 $0.00 $0.00 $0.00 $699.19 "$1,107.52" "$1,118.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-425 SUP Custom 27203010 5150-3-425 - CPLNG EXFIX RED LG TUBE TO TUBE BOTH IP/OP "$1,408.75 " "$1,042.48" $0.00 "$1,131.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,045.57" "$1,045.57" $0.00 $0.00 $293.58 $0.00 $0.00 $0.00 $0.00 $707.44 "$1,120.58" "$1,131.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-435 SUP Custom 27203010 5150-3-435 - CPLNG EXFIX BLUE YLW S/MED TUBE TO TUBE BOTH IP/OP "$1,398.38 " "$1,034.80" $0.00 "$1,118.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.87" "$1,037.87" $0.00 $0.00 $291.42 $0.00 $0.00 $0.00 $0.00 $699.19 "$1,107.52" "$1,118.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-3-445 SUP Custom 27203010 5150-3-445 - CPLNG EXFIX BLUE RED MED LG TUBE TO TUBE BOTH IP/OP "$1,408.75 " "$1,042.48" $0.00 "$1,131.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,045.57" "$1,045.57" $0.00 $0.00 $293.58 $0.00 $0.00 $0.00 $0.00 $707.44 "$1,120.58" "$1,131.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-4-065 SUP Custom 27203010 5150-4-065 - ADAPTER XTRNFX T 15MM YLW MNTB TRX PIN CLP BOTH IP/OP $676.50 $500.61 $0.00 $541.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.10 $502.10 $0.00 $0.00 $140.98 $0.00 $0.00 $0.00 $0.00 $338.25 $535.79 $541.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-4-070 SUP Custom 27203010 5150-4-070 - CLAMP EXFIX BLUE 20MM MNTB TRX T ADPR BOTH IP/OP $694.75 $514.12 $0.00 $562.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $515.64 $515.64 $0.00 $0.00 $144.79 $0.00 $0.00 $0.00 $0.00 $351.31 $556.48 $562.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-4-075 SUP Custom 27203010 5150-4-075 - CLAMP EXFIX RED 25MM MNTB TRX T ADPR BOTH IP/OP $710.50 $525.77 $0.00 $575.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.33 $527.33 $0.00 $0.00 $148.07 $0.00 $0.00 $0.00 $0.00 $359.56 $569.55 $575.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-5-020 SUP Custom 27203010 5150-5-020 - HOLDER XTRNFX 20MM BLU MNTB TRX PIN BOTH IP/OP "$2,864.13 " "$2,119.46" $0.00 "$2,291.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,125.75" "$2,125.75" $0.00 $0.00 $596.88 $0.00 $0.00 $0.00 $0.00 "$1,432.06" "$2,268.39" "$2,291.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-5-025 SUP Custom 27203010 5150-5-025 - HOLDER XTRNFX 25MM RD MNTB TRX PIN BOTH IP/OP "$2,864.13 " "$2,119.46" $0.00 "$2,291.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,125.75" "$2,125.75" $0.00 $0.00 $596.88 $0.00 $0.00 $0.00 $0.00 "$1,432.06" "$2,268.39" "$2,291.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-7-020 SUP Custom 27203010 5150-7-020 - O RING XTRNFX YLW MNTB TRX BOTH IP/OP $24.08 $17.82 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.87 $17.87 $0.00 $0.00 $5.02 $0.00 $0.00 $0.00 $0.00 $12.04 $19.07 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-9-465 SUP Custom 27203010 5150-9-465 - DEVICE CMPR DSTRCT 15MM MNTB TRX YLW BOTH IP/OP "$1,696.75 " "$1,255.60" $0.00 "$1,357.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,259.33" "$1,259.33" $0.00 $0.00 $353.60 $0.00 $0.00 $0.00 $0.00 $848.38 "$1,343.83" "$1,357.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-9-535 SUP Custom 27203010 5150-9-535 - SLEEVE DRILL MNTB SM 3 MMBLOCKS BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-9-545 SUP Custom 27203010 5150-9-545 - SLEEVE DRILL MNTB SM 4 MMBLOCKS BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-9-950 SUP Custom 27203010 5150-9-950 - KIT EXFIX YLW MNTB STRL BOTH IP/OP "$2,715.63 " "$2,009.57" $0.00 "$2,172.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,015.54" "$2,015.54" $0.00 $0.00 $565.94 $0.00 $0.00 $0.00 $0.00 "$1,357.81" "$2,150.78" "$2,172.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5150-9-960 SUP Custom 27203010 5150-9-960 - SET EXFIX YLW 310X130X36MM 15MM MNTB TRX 310MMX130MMX36MM BOTH IP/OP "$2,570.25 " "$1,901.99" $0.00 "$2,007.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,907.64" "$1,907.64" $0.00 $0.00 $535.64 $0.00 $0.00 $0.00 $0.00 "$1,254.69" "$1,987.43" "$2,007.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 515-203 SUP HCPCS C1713 515-203 - PLATE 18MM TI BONE SPNL BOTH IP/OP $91.73 $67.88 $0.00 $73.38 $41.28 $41.28 $0.00 $0.00 $0.00 $19.12 $68.08 $68.08 $0.00 $0.00 $19.12 $0.00 $54.26 $54.26 $0.00 $45.86 $72.65 $73.38 $0.00 $0.00 $14.35 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $0.00 515-204 SUP HCPCS C1713 515-204 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $91.73 $67.88 $0.00 $73.38 $41.28 $41.28 $0.00 $0.00 $0.00 $19.12 $68.08 $68.08 $0.00 $0.00 $19.12 $0.00 $54.26 $54.26 $0.00 $45.86 $72.65 $73.38 $0.00 $0.00 $14.35 $0.00 $0.00 $14.60 $0.00 $0.00 $0.00 $0.00 $0.00 515-205 SUP HCPCS C1713 515-205 - PLATE 18MM TI BONE SPNL BOTH IP/OP $96.33 $71.28 $0.00 $77.06 $43.35 $43.35 $0.00 $0.00 $0.00 $20.08 $71.49 $71.49 $0.00 $0.00 $20.07 $0.00 $56.98 $56.98 $0.00 $48.16 $76.29 $77.06 $0.00 $0.00 $15.07 $0.00 $0.00 $15.33 $0.00 $0.00 $0.00 $0.00 $0.00 515-206 SUP HCPCS C1713 515-206 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 515-633 SUP HCPCS C1781 515-633 - PLATE 18MM TI BONE SPNL BOTH IP/OP $813.88 $602.27 $0.00 $651.10 $366.24 $366.24 $0.00 $0.00 $0.00 $169.63 $604.06 $604.06 $0.00 $0.00 $169.61 $0.00 $481.41 $481.41 $0.00 $406.94 $644.59 $651.10 $0.00 $0.00 $127.37 $0.00 $0.00 $129.57 $0.00 $0.00 $0.00 $0.00 $0.00 5157M/S SUP HCPCS C1786 5157M/S - PACEMAKER CARDIAC THK6MM 52X42MM 1 CHAMBER RATE RESPONSIVE BOTH IP/OP "$7,425.00 " "$5,494.50" $0.00 "$5,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,547.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,547.37" $0.00 "$3,660.53" "$3,660.53" $0.00 "$3,712.50" "$5,880.60" "$5,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51-672-01-09 SUP Custom 27803010 51-672-01-09 - ROD EXFIX FULL PREBENT MANDIB BOTH IP/OP "$1,843.58 " "$1,364.25" $0.00 "$1,474.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.30" "$1,368.30" $0.00 $0.00 $384.20 $0.00 $0.00 $0.00 $0.00 $921.79 "$1,460.12" "$1,474.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51-672-05-09 SUP Custom 27803010 51-672-05-09 - ROD EXFIX .5 PREBENT MANDIB BOTH IP/OP "$1,317.25 " $974.77 $0.00 "$1,053.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $977.66 $977.66 $0.00 $0.00 $274.51 $0.00 $0.00 $0.00 $0.00 $658.63 "$1,043.26" "$1,053.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51-673-09-09 SUP Custom 27803010 51-673-09-09 - PIN XTRNFX 4MM 2.7MM 80MM LF 9MM X-FX THRD TI CRNMXF BOTH IP/OP $543.05 $401.86 $0.00 $434.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $403.05 $403.05 $0.00 $0.00 $113.17 $0.00 $0.00 $0.00 $0.00 $271.53 $430.10 $434.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 51-673-13-09 SUP Custom 27803010 51-673-13-09 - PIN XTRNFX 4MM 2.7MM 80MM LF 13MM X-FX THRD TI CRNMXF BOTH IP/OP $543.05 $401.86 $0.00 $434.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $403.05 $403.05 $0.00 $0.00 $113.17 $0.00 $0.00 $0.00 $0.00 $271.53 $430.10 $434.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 518-032 SUP HCPCS C1887 518-032 - CATH GUID .014IN 6FR 5MM 135CM GWIRE RADIOPQ MRKR STRL QKCRS BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 518-033 SUP HCPCS C1887 518-033 - CATH GUID .018IN 3.4-2.2FR 90CM LOW CX PRFL 3 RADIOPQ MRKR BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 518-034 SUP HCPCS C1887 518-034 - CATH GUID .018IN 3.4-2.3FR 135CM RADIOPQ MRKR GWIRE SHFT BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 518-035 SUP HCPCS C1887 518-035 - CATH GUID .018IN 15MM SPC 1.8FR 150CM RADIOPQ MRKR SMLS LP BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 518-036 SUP HCPCS C1887 518-036 - CATHETER GUID .035IN 4.8-3.7FR 90CM LOW CROSSING PROFILE 3 BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 518-037 SUP HCPCS C1887 518-037 - CATH GUID .035IN 50MM SPC 3.1FR 135CM RADIOPQ MRKR SMLS LP BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 518-038 SUP HCPCS C1887 518-038 - CATHETER GUID .035IN 5MM SPACING 3.1FR 150CM LP TAPERED TIP BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 518-065 SUP HCPCS C1887 518-065 - CATH GUID .014IN 3-1.9FR 150CM 3 RADIOPQ MRKR LOW CX PRFL BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 518-066 SUP HCPCS C1887 518-066 - CATH GUID .035IN 4.8-3.7FR 65CM LOW CX PRFL 3 RADIOPQ MRKR BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $233.49 $233.49 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $67.30 $0.00 $0.00 $68.46 $0.00 $0.00 $0.00 $0.00 $0.00 518-076 SUP HCPCS C1887 518-076 - CATH GUID .035IN 50MM SPC 4.5FR 65CM STR TIP RADIOPQ MRKR BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-077 SUP HCPCS C1887 518-077 - CATH GUID .035IN 4FR 65CM ANG TIP QKCRS BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-078 SUP HCPCS C1887 518-078 - CATH GUID .035IN 50MM SPC 4.5FR 90CM 70CM STR TIP RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-079 SUP HCPCS C1887 518-079 - CATH GUID .035IN 4FR 90CM SPRT ANG TIP QKCRS BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-080 SUP HCPCS C1887 518-080 - CATHETER SPRT .035IN STRG 135CM QKCRS BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-081 SUP HCPCS C1887 518-081 - CATH GUID 45D 50MM SPC LP .052-.059IN 135CM 7MM LV 3 RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-082 SUP HCPCS C1887 518-082 - CATH GUID .035IN 50MM SPC 4.5FR 150CM 130CM STR TIP RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-083 SUP HCPCS C1887 518-083 - CATH GUID .035IN 4FR 150CM 3 RADIOPQ MRKR SPRT ANG TIP BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-084 SUP HCPCS C1887 518-084 - CATHETER GD 15MM SPC 1.9FR 135CM STRL QKCRS XTRM RADOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-085 SUP HCPCS C1887 518-085 - CATH GUID 45D .014IN 15MM SPC 3.2FR 135CM 100CM ANG TIP BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-086 SUP HCPCS C1887 518-086 - CATH GUID .014IN 15MM SPC 3.2FR 150CM 100CM STR TIP RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-087 SUP HCPCS C1887 518-087 - CATH GUID .014IN 150CM 3 RADIOPQ MRKR LOW CX PRFL SPRT QKCRS BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-088 SUP HCPCS C1887 518-088 - CATH GUID .018IN 15MM SPC 3.4FR 90CM 60CM STR TIP RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-089 SUP HCPCS C1887 518-089 - CATH GUID .018IN 15MM SPC 3.4FR 90CM 60CM ANG TIP RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-090 SUP HCPCS C1887 518-090 - CATH GUID .018IN 15MM SPC 3.2FR 135CM 100CM STR TIP RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-091 SUP HCPCS C1887 518-091 - CATH GUID .018IN 15MM SPC 3.4FR 135CM 100CM ANG TIP RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 518-092 SUP HCPCS C1887 518-092 - CATH GUID .018IN 15MM SPC 3.4FR 150CM 100CM STR TIP RADIOPQ BOTH IP/OP $507.50 $375.55 $0.00 $406.00 $275.57 $275.57 $0.00 $0.00 $0.00 $105.78 $376.67 $376.67 $0.00 $0.00 $105.76 $0.00 $300.19 $300.19 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $79.42 $0.00 $0.00 $80.79 $0.00 $0.00 $0.00 $0.00 $0.00 5181302P2 SUP HCPCS C1713 5181302P2 - CAGE SPNL 12D 30X8X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5181308P2 SUP HCPCS C1713 5181308P2 - CAGE SPNL 8D 30X8X11MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 518-203 SUP HCPCS C1713 518-203 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $96.33 $71.28 $0.00 $77.06 $43.35 $43.35 $0.00 $0.00 $0.00 $20.08 $71.49 $71.49 $0.00 $0.00 $20.07 $0.00 $56.98 $56.98 $0.00 $48.16 $76.29 $77.06 $0.00 $0.00 $15.07 $0.00 $0.00 $15.33 $0.00 $0.00 $0.00 $0.00 $0.00 518-205 SUP HCPCS C1713 518-205 - PLATE 18MM TI BONE SPNL BOTH IP/OP $96.33 $71.28 $0.00 $77.06 $43.35 $43.35 $0.00 $0.00 $0.00 $20.08 $71.49 $71.49 $0.00 $0.00 $20.07 $0.00 $56.98 $56.98 $0.00 $48.16 $76.29 $77.06 $0.00 $0.00 $15.07 $0.00 $0.00 $15.33 $0.00 $0.00 $0.00 $0.00 $0.00 518-306 SUP HCPCS C1713 518-306 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $79.70 $58.98 $0.00 $63.76 $35.87 $35.87 $0.00 $0.00 $0.00 $16.61 $59.15 $59.15 $0.00 $0.00 $16.61 $0.00 $47.14 $47.14 $0.00 $39.85 $63.12 $63.76 $0.00 $0.00 $12.47 $0.00 $0.00 $12.69 $0.00 $0.00 $0.00 $0.00 $0.00 5184308P2 SUP HCPCS C1713 5184308P2 - CAGE SPNL 8D 30X8X14MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5189302P2 SUP HCPCS C1713 5189302P2 - CAGE SPNL 12D 30X8X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5189308P2 SUP HCPCS C1713 5189308P2 - CAGE SPNL 8D 30X8X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5190-0-010 SUP Custom 27203010 5190-0-010 - SET ORTH Y BODY ASMBLY BOTH IP/OP "$1,588.13 " "$1,175.22" $0.00 "$1,270.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,178.71" "$1,178.71" $0.00 $0.00 $330.97 $0.00 $0.00 $0.00 $0.00 $794.06 "$1,257.80" "$1,270.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5190-0-020 SUP Custom 27203010 5190-0-020 - CPLNG EXFIX PIN TO ROD BOTH IP/OP $598.13 $442.62 $0.00 $478.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.93 $443.93 $0.00 $0.00 $124.65 $0.00 $0.00 $0.00 $0.00 $299.06 $473.72 $478.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5190-0-110 SUP Custom 27203010 5190-0-110 - SET ORTH STR BODY ASMBLY BOTH IP/OP "$1,051.88 " $778.39 $0.00 $841.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $780.70 $780.70 $0.00 $0.00 $219.21 $0.00 $0.00 $0.00 $0.00 $525.94 $833.09 $841.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5190-0-200 SUP HCPCS C1713 5190-0-200 - PIN STOP COLLAR DSTRCT BOTH IP/OP $240.63 $178.07 $0.00 $192.50 $108.28 $108.28 $0.00 $0.00 $0.00 $50.15 $178.59 $178.59 $0.00 $0.00 $50.15 $0.00 $142.33 $142.33 $0.00 $120.31 $190.58 $192.50 $0.00 $0.00 $37.66 $0.00 $0.00 $38.31 $0.00 $0.00 $0.00 $0.00 $0.00 5190-0-210 SUP Custom 27203010 5190-0-210 - ROD EXFIX STR THRD BOTH IP/OP $130.63 $96.67 $0.00 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.95 $96.95 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5191302P2 SUP HCPCS C1713 5191302P2 - CAGE SPNL 12D 30X11X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5191308P2 SUP HCPCS C1713 5191308P2 - CAGE SPNL 8D 30X11X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5195-000-010 SUP Custom 27203010 5195-000-010 - BODY XTRNFX NS DJD II CMPNT BOTH IP/OP "$3,081.38 " "$2,280.22" $0.00 "$2,465.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,287.00" "$2,287.00" $0.00 $0.00 $642.16 $0.00 $0.00 $0.00 $0.00 "$1,540.69" "$2,440.45" "$2,465.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5195-1-011 SUP Custom 27203010 5195-1-011 - SCREW XTRNFX DJD II GD HUM BOTH IP/OP $70.13 $51.90 $0.00 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.05 $52.05 $0.00 $0.00 $14.61 $0.00 $0.00 $0.00 $0.00 $35.06 $55.54 $56.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5195-1-020 SUP Custom 27203010 5195-1-020 - DRILL SURG OSTEOSTAT STRL BOTH IP/OP $158.13 $117.02 $0.00 $126.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.36 $117.36 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $79.06 $125.24 $126.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5195-1-030 SUP Custom 27203010 5195-1-030 - GUIDE 4MM HING INS DJD 2 SURG DYNMC ELB JNT DISTRCT BOTH IP/OP $158.13 $117.02 $0.00 $126.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.36 $117.36 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $79.06 $125.24 $126.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5195-1-035 SUP Custom 27203010 5195-1-035 - GUIDE FOR HALF-PINS BOTH IP/OP $158.13 $117.02 $0.00 $126.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.36 $117.36 $0.00 $0.00 $32.95 $0.00 $0.00 $0.00 $0.00 $79.06 $125.24 $126.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5199302P2 SUP HCPCS C1713 5199302P2 - CAGE SPNL 12D 30X9X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5199308P2 SUP HCPCS C1713 5199308P2 - CAGE SPNL 8D 30X9X9MM NS CRNT PEEK ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5201300P2 SUP HCPCS C1713 5201300P2 - CAGE SPNL 0D 30X10X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5201302P2 SUP HCPCS C1713 5201302P2 - CAGE SPNL 12D 30X10X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5201308P2 SUP HCPCS C1713 5201308P2 - CAGE SPNL 8D 30X10X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 52-022-01 SUP Custom 27203010 52-022-01 - DRILL BIT 2.7 BOTH IP/OP $260.40 $192.70 $0.00 $208.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.27 $193.27 $0.00 $0.00 $54.27 $0.00 $0.00 $0.00 $0.00 $130.20 $206.24 $208.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5204300P2 SUP HCPCS C1713 5204300P2 - CAGE SPNL 0D 30X10X14MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5204308P2 SUP HCPCS C1713 5204308P2 - CAGE SPNL 8D 30X10X14MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5209300P2 SUP HCPCS C1713 5209300P2 - CAGE SPNL 0D 30X10X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5209302P2 SUP HCPCS C1713 5209302P2 - CAGE SPNL 12D 30X10X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5209308P2 SUP HCPCS C1713 5209308P2 - CAGE SPNL 8D 30X10X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5210-3-165 SUP HCPCS C1713 5210-3-165 - SCREW BONE 5MM 65MM FULTHD BOTH IP/OP $203.50 $150.59 $0.00 $162.80 $91.58 $91.58 $0.00 $0.00 $0.00 $42.41 $151.04 $151.04 $0.00 $0.00 $42.41 $0.00 $120.37 $120.37 $0.00 $101.75 $161.17 $162.80 $0.00 $0.00 $31.85 $0.00 $0.00 $32.40 $0.00 $0.00 $0.00 $0.00 $0.00 5210-3-190 SUP HCPCS C1713 5210-3-190 - SCREW BONE 5MM 90MM FULTHD BOTH IP/OP $203.50 $150.59 $0.00 $162.80 $91.58 $91.58 $0.00 $0.00 $0.00 $42.41 $151.04 $151.04 $0.00 $0.00 $42.41 $0.00 $120.37 $120.37 $0.00 $101.75 $161.17 $162.80 $0.00 $0.00 $31.85 $0.00 $0.00 $32.40 $0.00 $0.00 $0.00 $0.00 $0.00 5211300P2 SUP HCPCS C1713 5211300P2 - CAGE SPNL 0D 30X11X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5211302P2 SUP HCPCS C1713 5211302P2 - CAGE SPNL 12D 30X11X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5211308P2 SUP HCPCS C1713 5211308P2 - CAGE SPNL 8D 30X11X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5213-42 SUP HCPCS C1776 5213-42 - COMPONENT GLENOID 40MM 42MM UHMWPE STERILE BOTH IP/OP "$2,055.08 " "$1,520.76" $0.00 "$1,644.06" $924.78 $924.78 $0.00 $0.00 $0.00 $428.33 "$1,525.28" "$1,525.28" $0.00 $0.00 $428.28 $0.00 "$1,215.58" "$1,215.58" $0.00 "$1,027.54" "$1,627.62" "$1,644.06" $0.00 $0.00 $321.62 $0.00 $0.00 $327.17 $0.00 $0.00 $0.00 $0.00 $0.00 5213-44 SUP HCPCS C1776 5213-44 - SOCKET GLENOID 44MM SHOULDER STERILE BOTH IP/OP "$2,055.08 " "$1,520.76" $0.00 "$1,644.06" $924.78 $924.78 $0.00 $0.00 $0.00 $428.33 "$1,525.28" "$1,525.28" $0.00 $0.00 $428.28 $0.00 "$1,215.58" "$1,215.58" $0.00 "$1,027.54" "$1,627.62" "$1,644.06" $0.00 $0.00 $321.62 $0.00 $0.00 $327.17 $0.00 $0.00 $0.00 $0.00 $0.00 5213-46 SUP HCPCS C1776 5213-46 - COMPONENT GLENOID 46MM UHMWPE STERILE BOTH IP/OP "$2,055.08 " "$1,520.76" $0.00 "$1,644.06" $924.78 $924.78 $0.00 $0.00 $0.00 $428.33 "$1,525.28" "$1,525.28" $0.00 $0.00 $428.28 $0.00 "$1,215.58" "$1,215.58" $0.00 "$1,027.54" "$1,627.62" "$1,644.06" $0.00 $0.00 $321.62 $0.00 $0.00 $327.17 $0.00 $0.00 $0.00 $0.00 $0.00 5213-48 SUP HCPCS C1776 5213-48 - COMPONENT GLENOID 48MM UHMWPE NONSTRL BOTH IP/OP "$2,055.08 " "$1,520.76" $0.00 "$1,644.06" $924.78 $924.78 $0.00 $0.00 $0.00 $428.33 "$1,525.28" "$1,525.28" $0.00 $0.00 $428.28 $0.00 "$1,215.58" "$1,215.58" $0.00 "$1,027.54" "$1,627.62" "$1,644.06" $0.00 $0.00 $321.62 $0.00 $0.00 $327.17 $0.00 $0.00 $0.00 $0.00 $0.00 5213-50 SUP HCPCS C1776 5213-50 - COMPONENT GLENOID 50MM UHMWPE NONSTRL BOTH IP/OP "$2,055.08 " "$1,520.76" $0.00 "$1,644.06" $924.78 $924.78 $0.00 $0.00 $0.00 $428.33 "$1,525.28" "$1,525.28" $0.00 $0.00 $428.28 $0.00 "$1,215.58" "$1,215.58" $0.00 "$1,027.54" "$1,627.62" "$1,644.06" $0.00 $0.00 $321.62 $0.00 $0.00 $327.17 $0.00 $0.00 $0.00 $0.00 $0.00 5213-52 SUP HCPCS C1776 5213-52 - COMPONENT GLENOID 52MM UHMWPE STERILE BOTH IP/OP "$2,055.08 " "$1,520.76" $0.00 "$1,644.06" $924.78 $924.78 $0.00 $0.00 $0.00 $428.33 "$1,525.28" "$1,525.28" $0.00 $0.00 $428.28 $0.00 "$1,215.58" "$1,215.58" $0.00 "$1,027.54" "$1,627.62" "$1,644.06" $0.00 $0.00 $321.62 $0.00 $0.00 $327.17 $0.00 $0.00 $0.00 $0.00 $0.00 5213-54 SUP HCPCS C1776 5213-54 - SOCKET GLENOID 54MM SHOULDER STERILE BOTH IP/OP "$2,094.83 " "$1,550.17" $0.00 "$1,675.86" $942.67 $942.67 $0.00 $0.00 $0.00 $436.61 "$1,554.78" "$1,554.78" $0.00 $0.00 $436.56 $0.00 "$1,239.09" "$1,239.09" $0.00 "$1,047.41" "$1,659.11" "$1,675.86" $0.00 $0.00 $327.84 $0.00 $0.00 $333.50 $0.00 $0.00 $0.00 $0.00 $0.00 5213-56 SUP HCPCS C1776 5213-56 - COMPONENT GLENOID 56MM UHMWPE STERILE BOTH IP/OP "$2,094.83 " "$1,550.17" $0.00 "$1,675.86" $942.67 $942.67 $0.00 $0.00 $0.00 $436.61 "$1,554.78" "$1,554.78" $0.00 $0.00 $436.56 $0.00 "$1,239.09" "$1,239.09" $0.00 "$1,047.41" "$1,659.11" "$1,675.86" $0.00 $0.00 $327.84 $0.00 $0.00 $333.50 $0.00 $0.00 $0.00 $0.00 $0.00 5213-58 SUP HCPCS C1776 5213-58 - COMPONENT GLENOID 58MM UHMWPE STERILE BOTH IP/OP "$2,094.83 " "$1,550.17" $0.00 "$1,675.86" $942.67 $942.67 $0.00 $0.00 $0.00 $436.61 "$1,554.78" "$1,554.78" $0.00 $0.00 $436.56 $0.00 "$1,239.09" "$1,239.09" $0.00 "$1,047.41" "$1,659.11" "$1,675.86" $0.00 $0.00 $327.84 $0.00 $0.00 $333.50 $0.00 $0.00 $0.00 $0.00 $0.00 5219300P2 SUP HCPCS C1713 5219300P2 - CAGE SPNL 0D 30X11X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5219302P2 SUP HCPCS C1713 5219302P2 - CAGE SPNL 12D 30X11X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5219308P2 SUP HCPCS C1713 5219308P2 - CAGE SPNL 8D 30X11X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 52-20358 SUP HCPCS C1713 52-20358 - SCREW BONE 2MM 8MM SLFTAP XFIT TITANIUM INTERMAXILLARY BOTH IP/OP $221.15 $163.65 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $46.09 $164.14 $164.14 $0.00 $0.00 $46.09 $0.00 $130.81 $130.81 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 52-20364 SUP HCPCS C1713 52-20364 - SCREW BONE 2MM 14MM SLFTAP XFIT CROSS-FIT TITANIUM BOTH IP/OP $221.15 $163.65 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $46.09 $164.14 $164.14 $0.00 $0.00 $46.09 $0.00 $130.81 $130.81 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 52-20616 SUP HCPCS C1713 52-20616 - PEG 2MM 16MM DISTAL RADL LCK XPIN TI VARIAX NONSTRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-20618 SUP HCPCS C1713 52-20618 - PEG FIX 2MM 18MM DISTAL RADL LCK VARIAX BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-20618E SUP HCPCS C1713 52-20618E - PEG 2MM 18MM DISTAL RADL LCK XPIN TI VARIAX STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-20620 SUP HCPCS C1713 52-20620 - PEG FIX 2MM 20MM DISTAL RADL LCK VARIAX BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-20622 SUP HCPCS C1713 52-20622 - PEG 2MM 22MM RADL LCK TI BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-20624 SUP HCPCS C1713 52-20624 - PEG 2MM 24MM DISTAL RADL LCK XPIN TI VARIAX NONSTRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-20626 SUP HCPCS C1713 52-20626 - PEG 2MM 26MM RADL LCK TI BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 5221300P2 SUP HCPCS C1713 5221300P2 - CAGE SPNL 0D 30X12X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5221302P2 SUP HCPCS C1713 5221302P2 - CAGE SPNL 12D 30X12X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5221308P2 SUP HCPCS C1713 5221308P2 - CAGE SPNL 8D 30X12X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 52-23010 SUP HCPCS C1713 52-23010 - SCREW BN 2.3MM 10MM VARIAX ST XPN TI DIST RDS LCK PLT SYS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23010E SUP HCPCS C1713 52-23010E - SCREW BONE 2.3MM 10MM VARIAX TI DISTAL RADL HAND XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23012 SUP HCPCS C1713 52-23012 - SCREW BONE 2.3MM 12MM TI RADL SLFTAP XPIN BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23012E SUP HCPCS C1713 52-23012E - SCREW BONE 2.3MM 12MM VARIAX TI DISTAL RADL HAND XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23014 SUP HCPCS C1713 52-23014 - SCREW BONE 2.3MM 14MM SMARTLOCK VARIAX TI DISTAL RADL SLFTAP BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23016 SUP HCPCS C1713 52-23016 - SCREW BONE 2.3MM 16MM VARIAX TI DISTAL RAD XPIN BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23016E SUP HCPCS C1713 52-23016E - SCREW BONE 2.3MM 16MM VARIAX TI DISTAL RADL HAND XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23018 SUP HCPCS C1713 52-23018 - SCREW BONE 2.3MM 18MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23018E SUP HCPCS C1713 52-23018E - SCREW BONE 2.3MM 18MM VARIAX TI DISTAL RADL HAND XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23020E SUP HCPCS C1713 52-23020E - SCREW BONE 2.3MM 20MM VARIAX TI DISTAL RADL HAND XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23022 SUP HCPCS C1713 52-23022 - SCREW BONE 2.3MM 22MM VARIAX TI DISTAL RAD LCK XPIN BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23022E SUP HCPCS C1713 52-23022E - SCREW BONE 2.3MM 22MM VARIAX TI ORTH LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23024 SUP HCPCS C1713 52-23024 - SCREW TI 24MM 2.3MM MAXFACL LCK XPIN BONE VARIAX DISTAL RAD BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23024E SUP HCPCS C1713 52-23024E - SCREW BONE 2.3MM 24MM VARIAX TI LCK STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23026 SUP HCPCS C1713 52-23026 - SCREW BONE 2.3MM 26MM SMARTLOCK TI RADL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23028 SUP HCPCS C1713 52-23028 - SCREW BN 2.3MM 28MM VARIAX LCK TI DIST RADL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23028E SUP HCPCS C1713 52-23028E - SCREW BN XPN BLNT 2.3MM 28MM STRL VARIAX OPTM AX STAB TI RDS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23030 SUP HCPCS C1713 52-23030 - SCREW BONE 2.3MM 30MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23030E SUP HCPCS C1713 52-23030E - SCREW BONE 2.3MM 30MM VARIAX TI LCK STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23032 SUP HCPCS C1713 52-23032 - SCREW BONE 2.3MM 32MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23032E SUP HCPCS C1713 52-23032E - SCREW BONE 2.3MM 32MM VARIAX TI RADL XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23034 SUP HCPCS C1713 52-23034 - SCREW BONE 2.3MM 34MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23034E SUP HCPCS C1713 52-23034E - SCREW BONE 2.3MM 34MM VARIAX TI RADL XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23036 SUP HCPCS C1713 52-23036 - SCREW BONE 2.3MM 36MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23036E SUP HCPCS C1713 52-23036E - SCREW BONE 2.3MM 36MM VARIAX TI RADL XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23038 SUP HCPCS C1713 52-23038 - SCREW BONE 2.3MM 38MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23038E SUP HCPCS C1713 52-23038E - SCREW BONE 2.3MM 38MM VARIAX TI RADL XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-23610 SUP HCPCS C1713 52-23610 - SCREW BONE 2.3MM 10MM SMARTLOCK TI RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23610E SUP HCPCS C1713 52-23610E - SCREW BONE 2.3MM 10MM TI LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23612 SUP HCPCS C1713 52-23612 - SCREW BONE 2.3MM 12MM SMARTLOCK TI RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23612E SUP HCPCS C1713 52-23612E - SCREW BONE 2.3MM 12MM LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23614 SUP HCPCS C1713 52-23614 - SCREW BONE 2.3MM 14MM VARIAX TI DISTAL RADL LCK XPIN BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23614E SUP HCPCS C1713 52-23614E - SCREW BONE 2.3MM 14MM VARIAX TI DISTAL RADL XPIN LCK PLT SYS BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23616 SUP HCPCS C1713 52-23616 - SCREW BONE 2.3MM 16MM SMARTLOCK TI DISTAL RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23616E SUP HCPCS C1713 52-23616E - SCREW BONE 2.3MM 16MM VARIAX TI DISTAL RADL LCK XPIN BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23618 SUP HCPCS C1713 52-23618 - SCREW BONE 2.3MM 18MM VARIAX TI DISTAL RADL LCK XPIN BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23618E SUP HCPCS C1713 52-23618E - SCREW BONE 2.3MM 18MM VARIAX TI DISTAL RADL LCK XPIN BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23620 SUP HCPCS C1713 52-23620 - SCREW BONE 2.3MM 20MM SMARTLOCK VARIAX TI DISTAL RADL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23620E SUP HCPCS C1713 52-23620E - SCREW BONE 2.3MM 20MM VARIAX TI DISTAL RADL XPIN LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23622 SUP HCPCS C1713 52-23622 - SCREW BONE 2.3MM 22MM SMARTLOCK VARIAX TI RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23624 SUP HCPCS C1713 52-23624 - SCREW BONE 2.3MM 24MM SMARTLOCK VARIAX TI RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23626 SUP HCPCS C1713 52-23626 - SCREW BONE 2.3MM 26MM SMARTLOCK TI DISTAL RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23626E SUP HCPCS C1713 52-23626E - SCREW BONE 2.3MM 26MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23628 SUP HCPCS C1713 52-23628 - SCREW BONE 2.3MM 28MM SMARTLOCK VARIAX TI DISTAL RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23628E SUP HCPCS C1713 52-23628E - PLATE 28MM TI LCK SYS VARIAX BONE 2.3MM DISTAL RADL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23630 SUP HCPCS C1713 52-23630 - SCREW BONE 2.3MM 30MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23632 SUP HCPCS C1713 52-23632 - SCREW BONE 2.3MM 32MM SMARTLOCK TI RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23634 SUP HCPCS C1713 52-23634 - SCREW BONE 2.3MM 34MM VARIAX TI DISTAL RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23636 SUP HCPCS C1713 52-23636 - SCREW BONE 2.3MM 36MM TI RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-23638 SUP HCPCS C1713 52-23638 - SCREW BONE 2.3MM 38MM TI RADL LCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 5224300P2 SUP HCPCS C1713 5224300P2 - CAGE SPNL 0D 30X12X14MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5224308P2 SUP HCPCS C1713 5224308P2 - CAGE SPNL 8D 30X12X14MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 52-27010 SUP HCPCS C1713 52-27010 - SCREW BONE 2.7MM 10MM VARIAX TI DISTAL RADL XPIN NONSTRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27010E SUP HCPCS C1713 52-27010E - SCREW BONE 2.7MM 10MM VARIAX TI DISTAL RADL XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27012 SUP HCPCS C1713 52-27012 - SCREW BONE 2.7MM 12MM VARIAX TI DISTAL RADL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27012E SUP HCPCS C1713 52-27012E - SCREW BONE 2.7MM 12MM VARIAX TI DISTAL RADL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27014 SUP HCPCS C1713 52-27014 - SCREW BONE 2.7MM 14MM VARIAX TI DISTAL RADL WR HND XPIN BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27014E SUP HCPCS C1713 52-27014E - SCREW BONE 2.7MM 14MM VARIAX TI DISTAL RADL WR HND XPIN BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27016 SUP HCPCS C1713 52-27016 - 2.7X16MM BONE SCREW_ RADIUS BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27016E SUP HCPCS C1713 52-27016E - SCREW BONE 2.7MM 16MM VARIAX TI DISTAL RADL WR HND XPIN BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27018 SUP HCPCS C1713 52-27018 - SCREW BN 2.7MM 18MM VARIAX LCK TI DIST RADL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27018E SUP HCPCS C1713 52-27018E - SCREW BN 2.7MM 18MM STRL VARIAX XPN NLCKG TI DIST RADL WR BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27020 SUP HCPCS C1713 52-27020 - SCREW BONE 2.7MM 20MM VARIAX TI DISTAL RADL XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27022 SUP HCPCS C1713 52-27022 - SCREW BONE 2.7MM 22MM VARIAX TI DISTAL RADL XPIN NONSTRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27022E SUP HCPCS C1713 52-27022E - SCREW BONE 2.7MM 22MM SMARTLOCK TI CORT RADL LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27024 SUP HCPCS C1713 52-27024 - SCREW BONE 2.7MM 24MM VARIAX TI DISTAL RADL XPIN NONSTRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27024E SUP HCPCS C1713 52-27024E - SCREW BONE 2.7MM 24MM SMARTLOCK TI CORT RADL LCK BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27026 SUP HCPCS C1713 52-27026 - SCREW BONE 2.7MM 26MM SMARTLOCK TI RADL XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27026E SUP HCPCS C1713 52-27026E - SCREW BONE 2.7MM 26MM VARIAX TI DISTAL RADL XPIN STRL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $55.69 $55.69 $0.00 $0.00 $0.00 $25.79 $91.85 $91.85 $0.00 $0.00 $25.79 $0.00 $73.20 $73.20 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 52-27116 SUP HCPCS C1713 52-27116 - SCREW BN 2.7MM 16MM VARIAX LCK P/T TI DIST RADL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27116E SUP HCPCS C1713 52-27116E - SCREW BN P/T 2.7MM 16MM VARIAX NLCKG XPN TI DIST RDS BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27118 SUP HCPCS C1713 52-27118 - SCREW BONE 2.7MM 18MM VARIAX TI DISTAL RADL PTTHRD XPIN BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27120 SUP HCPCS C1713 52-27120 - SCREW BN 2.7MM 20MM VARIAX LCK P/T TI DIST RADL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27120E SUP HCPCS C1713 52-27120E - SCREW BN P/T 2.7MM 20MM VARIAX NLCKG XPN TI DIST RDS BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27122 SUP HCPCS C1713 52-27122 - SCREW BN 2.7MM 22MM VARIAX LCK P/T TI DIST RADL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27122E SUP HCPCS C1713 52-27122E - SCREW BN P/T 2.7MM 22MM VARIAX NLCKG XPN TI DIST RDS BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27124 SUP HCPCS C1713 52-27124 - SCREW BONE 2.7MM 24MM VARIAX TI DISTAL RADL PTTHRD XPIN BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27126 SUP HCPCS C1713 52-27126 - SCREW BONE 2.7MM 26MM VARIAX TI DISTAL RADL PTTHRD XPIN STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27208 SUP HCPCS C1713 52-27208 - SCREW BONE 2.7MM 8MM TI RADL SLFTAP XFIT BOTH IP/OP $132.30 $97.90 $0.00 $104.50 $58.78 $58.78 $0.00 $0.00 $0.00 $27.57 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $78.26 $78.26 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $20.44 $0.00 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 52-27210 SUP HCPCS C1713 52-27210 - SCREW BONE 2.7MM 10MM TI RADL SLFTAP XFIT BOTH IP/OP $132.30 $97.90 $0.00 $104.50 $58.78 $58.78 $0.00 $0.00 $0.00 $27.57 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $78.26 $78.26 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $20.44 $0.00 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 52-27212 SUP HCPCS C1713 52-27212 - SCREW BONE 2.7MM 12MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $132.30 $97.90 $0.00 $104.50 $58.78 $58.78 $0.00 $0.00 $0.00 $27.57 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $78.26 $78.26 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $20.44 $0.00 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 52-27214 SUP HCPCS C1713 52-27214 - SCREW BONE 2.7MM 14MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $132.30 $97.90 $0.00 $104.50 $58.78 $58.78 $0.00 $0.00 $0.00 $27.57 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $78.26 $78.26 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $20.44 $0.00 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 52-27216 SUP HCPCS C1713 52-27216 - SCREW BONE 2.7MM 16MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $132.30 $97.90 $0.00 $104.50 $58.78 $58.78 $0.00 $0.00 $0.00 $27.57 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $78.26 $78.26 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $20.44 $0.00 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 52-27218 SUP HCPCS C1713 52-27218 - SCREW BONE 2.7MM 18MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $151.25 $111.93 $0.00 $121.00 $68.06 $68.06 $0.00 $0.00 $0.00 $31.52 $112.26 $112.26 $0.00 $0.00 $31.52 $0.00 $89.46 $89.46 $0.00 $75.63 $119.79 $121.00 $0.00 $0.00 $23.67 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 52-27220 SUP HCPCS C1713 52-27220 - SCREW BONE 2.7MM 20MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $151.25 $111.93 $0.00 $121.00 $68.06 $68.06 $0.00 $0.00 $0.00 $31.52 $112.26 $112.26 $0.00 $0.00 $31.52 $0.00 $89.46 $89.46 $0.00 $75.63 $119.79 $121.00 $0.00 $0.00 $23.67 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 52-27222 SUP HCPCS C1713 52-27222 - SCREW BONE 2.7MM 22MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $151.25 $111.93 $0.00 $121.00 $68.06 $68.06 $0.00 $0.00 $0.00 $31.52 $112.26 $112.26 $0.00 $0.00 $31.52 $0.00 $89.46 $89.46 $0.00 $75.63 $119.79 $121.00 $0.00 $0.00 $23.67 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 52-27224 SUP HCPCS C1713 52-27224 - SCREW BONE 2.7MM 24MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $151.25 $111.93 $0.00 $121.00 $68.06 $68.06 $0.00 $0.00 $0.00 $31.52 $112.26 $112.26 $0.00 $0.00 $31.52 $0.00 $89.46 $89.46 $0.00 $75.63 $119.79 $121.00 $0.00 $0.00 $23.67 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 52-27226 SUP HCPCS C1713 52-27226 - SCREW BONE 2.7MM 26MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $151.25 $111.93 $0.00 $121.00 $68.06 $68.06 $0.00 $0.00 $0.00 $31.52 $112.26 $112.26 $0.00 $0.00 $31.52 $0.00 $89.46 $89.46 $0.00 $75.63 $119.79 $121.00 $0.00 $0.00 $23.67 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 52-27228 SUP HCPCS C1713 52-27228 - SCREW BONE 2.7MM 28MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $151.25 $111.93 $0.00 $121.00 $68.06 $68.06 $0.00 $0.00 $0.00 $31.52 $112.26 $112.26 $0.00 $0.00 $31.52 $0.00 $89.46 $89.46 $0.00 $75.63 $119.79 $121.00 $0.00 $0.00 $23.67 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 52-27230 SUP HCPCS C1713 52-27230 - SCREW BONE 2.7MM 30MM TI RADL SLFTAP XFIT BOTH IP/OP $151.25 $111.93 $0.00 $121.00 $68.06 $68.06 $0.00 $0.00 $0.00 $31.52 $112.26 $112.26 $0.00 $0.00 $31.52 $0.00 $89.46 $89.46 $0.00 $75.63 $119.79 $121.00 $0.00 $0.00 $23.67 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 52-27232 SUP HCPCS C1713 52-27232 - SCREW BONE 2.7MM 32MM TI RADL SLFTAP XFIT BOTH IP/OP $151.25 $111.93 $0.00 $121.00 $68.06 $68.06 $0.00 $0.00 $0.00 $31.52 $112.26 $112.26 $0.00 $0.00 $31.52 $0.00 $89.46 $89.46 $0.00 $75.63 $119.79 $121.00 $0.00 $0.00 $23.67 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 52-27234 SUP HCPCS C1713 52-27234 - SCREW BONE 2.7MM 34MM MTRX-SMARTLOCK DISTAL RADL SLFTAP BOTH IP/OP $160.65 $118.88 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $33.48 $119.23 $119.23 $0.00 $0.00 $33.48 $0.00 $95.02 $95.02 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 52-27236 SUP HCPCS C1713 52-27236 - SCREW BONE 2.7MM 36MM TI RADL SLFTAP XFIT BOTH IP/OP $160.65 $118.88 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $33.48 $119.23 $119.23 $0.00 $0.00 $33.48 $0.00 $95.02 $95.02 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 52-27238 SUP HCPCS C1713 52-27238 - SCREW BONE 2.7MM 38MM TI RADL SLFTAP XFIT BOTH IP/OP $160.65 $118.88 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $33.48 $119.23 $119.23 $0.00 $0.00 $33.48 $0.00 $95.02 $95.02 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 52-27610 SUP HCPCS C1713 52-27610 - SCREW BONE 2.7MM 10MM VARIAX TI DISTAL RADL PTTHRD LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27610E SUP HCPCS C1713 52-27610E - SCREW BONE 2.7MM 10MM VARIAX TI DISTAL RADL PTTHRD LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27612 SUP HCPCS C1713 52-27612 - SCREW BONE 2.7MM 12MM VARIAX TI DISTAL RADL LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27614 SUP HCPCS C1713 52-27614 - SCREW BONE 2.7MM 14MM VARIAX TI DISTAL RADL XPIN LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27614E SUP HCPCS C1713 52-27614E - SCREW BONE 2.7MM 14MM VARIAX TI DISTAL RADL XPIN LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27616 SUP HCPCS C1713 52-27616 - SCREW BONE 2.7MM 16MM VARIAX TI DISTAL RADL XPIN LCK PLT SYS BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27618 SUP HCPCS C1713 52-27618 - SCREW BN 2.7MM 18MM VARIAX LCK TI DIST RADL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27618E SUP HCPCS C1713 52-27618E - SCREW BN 2.7MM 18MM STRL LCK XPN TI RDS DIST VARIAX LCK PLT BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27620 SUP HCPCS C1713 52-27620 - SCREW BONE 2.7MM 20MM VARIAX TI DISTAL RADL PTTHRD LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27620E SUP HCPCS C1713 52-27620E - SCREW BONE 2.7MM 20MM VARIAX TI DISTAL RADL XPIN LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27622 SUP HCPCS C1713 52-27622 - SCREW BONE 2.7MM 22MM VARIAX TI DISTAL RADL XPIN LCK PLT SYS BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27624 SUP HCPCS C1713 52-27624 - SCREW BONE 2.7MM 24MM VARIAX TI DISTAL RADL XPIN LCK PLT SYS BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27626 SUP HCPCS C1713 52-27626 - SCREW BN 2.7MM 26MM VARIAX LCK TI DIST RADL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27626E SUP HCPCS C1713 52-27626E - SCREW BN 2.7MM 26MM STRL LCK XPN TI RDS DIST VARIAX LCK PLT BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27716 SUP HCPCS C1713 52-27716 - PEG 2.7MM 16MM DISTAL RADL PTTHRD LCK TI VARIAX NONSTRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27716E SUP HCPCS C1713 52-27716E - PEG 2.7MM 16MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27718 SUP HCPCS C1713 52-27718 - PEG 2.7MM 18MM DISTAL RADL PTTHRD LCK TI VARIAX NONSTRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27718E SUP HCPCS C1713 52-27718E - PEG 2.7MM 18MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27720 SUP HCPCS C1713 52-27720 - PEG 2.7MM 20MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27722 SUP HCPCS C1713 52-27722 - PEG 2.7MM 22MM ORTH LCK PTHRD TI SMARTLOCK BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27722E SUP HCPCS C1713 52-27722E - SCREW BONE 2.7MM 22MM VARIAX TI DISTAL RADL PTTHRD LCK STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27724 SUP HCPCS C1713 52-27724 - PEG 2.7MM 24MM DISTAL RADL PTTHRD LCK TI VARIAX NONSTRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27724E SUP HCPCS C1713 52-27724E - PEG 2.7MM 24MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27726 SUP HCPCS C1713 52-27726 - PEG 2.7MM 26MM DISTAL RADL PTTHRD LCK TI VARIAX NONSTRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27726E SUP HCPCS C1713 52-27726E - PEG 2.7MM 24MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $144.38 $106.84 $0.00 $115.50 $64.97 $64.97 $0.00 $0.00 $0.00 $30.09 $107.16 $107.16 $0.00 $0.00 $30.09 $0.00 $85.40 $85.40 $0.00 $72.19 $114.35 $115.50 $0.00 $0.00 $22.59 $0.00 $0.00 $22.98 $0.00 $0.00 $0.00 $0.00 $0.00 52-27844 SUP HCPCS C1713 52-27844 - SCREW BONE 2.7MM 14MM TI FRFT HEX BOTH IP/OP $125.13 $92.60 $0.00 $100.10 $56.31 $56.31 $0.00 $0.00 $0.00 $26.08 $92.87 $92.87 $0.00 $0.00 $26.08 $0.00 $74.01 $74.01 $0.00 $62.56 $99.10 $100.10 $0.00 $0.00 $19.58 $0.00 $0.00 $19.92 $0.00 $0.00 $0.00 $0.00 $0.00 52-27846 SUP HCPCS C1713 52-27846 - SCREW BONE 2.7MM 16MM TI FRFT HEX BOTH IP/OP $125.13 $92.60 $0.00 $100.10 $56.31 $56.31 $0.00 $0.00 $0.00 $26.08 $92.87 $92.87 $0.00 $0.00 $26.08 $0.00 $74.01 $74.01 $0.00 $62.56 $99.10 $100.10 $0.00 $0.00 $19.58 $0.00 $0.00 $19.92 $0.00 $0.00 $0.00 $0.00 $0.00 52-27850 SUP HCPCS C1713 52-27850 - SCREW BONE 2.7MM 20MM TI FRFT HEX BOTH IP/OP $125.13 $92.60 $0.00 $100.10 $56.31 $56.31 $0.00 $0.00 $0.00 $26.08 $92.87 $92.87 $0.00 $0.00 $26.08 $0.00 $74.01 $74.01 $0.00 $62.56 $99.10 $100.10 $0.00 $0.00 $19.58 $0.00 $0.00 $19.92 $0.00 $0.00 $0.00 $0.00 $0.00 52-27852 SUP HCPCS C1713 52-27852 - SCREW BONE 2.7MM 22MM TI FRFT HEX BUN TIAL BOTH IP/OP $121.00 $89.54 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $25.22 $89.81 $89.81 $0.00 $0.00 $25.22 $0.00 $71.57 $71.57 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 5229300P2 SUP HCPCS C1713 5229300P2 - CAGE SPNL 0D 30X12X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5229302P2 SUP HCPCS C1713 5229302P2 - CAGE SPNL 12D 30X12X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5229308P2 SUP HCPCS C1713 5229308P2 - CAGE SPNL 8D 30X12X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 52-30056 SUP HCPCS C1713 52-30056 - SCREW BONE 3MM 16MM TI FRFT HEX BOTH IP/OP $125.13 $92.60 $0.00 $100.10 $56.31 $56.31 $0.00 $0.00 $0.00 $26.08 $92.87 $92.87 $0.00 $0.00 $26.08 $0.00 $74.01 $74.01 $0.00 $62.56 $99.10 $100.10 $0.00 $0.00 $19.58 $0.00 $0.00 $19.92 $0.00 $0.00 $0.00 $0.00 $0.00 52-30308 SUP HCPCS C1713 52-30308 - SCREW BONE 3MM 8MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $165.90 $122.77 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.58 $123.13 $123.13 $0.00 $0.00 $34.57 $0.00 $98.13 $98.13 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 52-30310 SUP HCPCS C1713 52-30310 - SCREW BONE 3MM 10MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 52-30312 SUP HCPCS C1713 52-30312 - SCREW BONE 3MM 12MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 52-30314 SUP HCPCS C1713 52-30314 - SCREW BONE 3MM 14MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 52-30316 SUP HCPCS C1713 52-30316 - SCREW BONE 3MM 16MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 52-30318 SUP HCPCS C1713 52-30318 - SCREW BONE 3MM 18MM CANC BOTH IP/OP $206.25 $152.63 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $42.99 $153.08 $153.08 $0.00 $0.00 $42.98 $0.00 $122.00 $122.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-30320 SUP HCPCS C1713 52-30320 - SCREW BONE 3MM 20MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $206.25 $152.63 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $42.99 $153.08 $153.08 $0.00 $0.00 $42.98 $0.00 $122.00 $122.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-30322 SUP HCPCS C1713 52-30322 - SCREW BONE 3MM 22MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $206.25 $152.63 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $42.99 $153.08 $153.08 $0.00 $0.00 $42.98 $0.00 $122.00 $122.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-30324 SUP HCPCS C1713 52-30324 - SCREW BONE 3MM 24MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $206.25 $152.63 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $42.99 $153.08 $153.08 $0.00 $0.00 $42.98 $0.00 $122.00 $122.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-30326 SUP HCPCS C1713 52-30326 - SCREW BONE 3MM 26MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $199.75 $147.82 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $41.63 $148.25 $148.25 $0.00 $0.00 $41.63 $0.00 $118.15 $118.15 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-30328 SUP HCPCS C1713 52-30328 - SCREW BONE 3MM 28MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $199.75 $147.82 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $41.63 $148.25 $148.25 $0.00 $0.00 $41.63 $0.00 $118.15 $118.15 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-30330 SUP HCPCS C1713 52-30330 - SCREW BONE 3MM 30MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $199.75 $147.82 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $41.63 $148.25 $148.25 $0.00 $0.00 $41.63 $0.00 $118.15 $118.15 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-30332 SUP HCPCS C1713 52-30332 - SCREW BONE 3MM 32MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $199.75 $147.82 $0.00 $165.00 $92.81 $92.81 $0.00 $0.00 $0.00 $41.63 $148.25 $148.25 $0.00 $0.00 $41.63 $0.00 $118.15 $118.15 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $32.28 $0.00 $0.00 $32.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-30334 SUP HCPCS C1713 52-30334 - SCREW BONE 3MM 34MM TI CANC RADL SLFTAP XFIT BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 52-306-23 SUP HCPCS C1781 52-306-23 - MESH SURG 26.2X.6MM PRFL 3ANG RX ORBTL FLR BOTH IP/OP "$1,416.25 " "$1,048.03" $0.00 "$1,133.00" $637.31 $637.31 $0.00 $0.00 $0.00 $295.18 "$1,051.14" "$1,051.14" $0.00 $0.00 $295.15 $0.00 $837.71 $837.71 $0.00 $708.13 "$1,121.67" "$1,133.00" $0.00 $0.00 $221.64 $0.00 $0.00 $225.47 $0.00 $0.00 $0.00 $0.00 $0.00 52-306-23-04 SUP HCPCS C1781 52-306-23-04 - MESH CRNL 3ANG 23MMX.6MM STRL RSRBX PDLLA ORBT FLR BOTH IP/OP "$1,531.68 " "$1,133.44" $0.00 "$1,225.34" $689.25 $689.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $765.84 "$1,213.09" "$1,225.34" $0.00 $0.00 $239.71 $0.00 $0.00 $243.84 $0.00 $0.00 $0.00 $0.00 $0.00 52-306-40-04 SUP HCPCS C1713 52-306-40-04 - MESH SURG 40X40X.6MM RX ORBTL FLOOR BOTH IP/OP "$1,670.93 " "$1,236.49" $0.00 "$1,336.74" $751.92 $751.92 $0.00 $0.00 $0.00 $348.26 "$1,240.16" "$1,240.16" $0.00 $0.00 $348.22 $0.00 $988.35 $988.35 $0.00 $835.46 "$1,323.38" "$1,336.74" $0.00 $0.00 $261.50 $0.00 $0.00 $266.01 $0.00 $0.00 $0.00 $0.00 $0.00 52-306-51-04 SUP HCPCS C1781 52-306-51-04 - MESH DYNAMIC 51X51X.6MM RESORB LARGE GRID FLEXIBLE ROUNDED BOTH IP/OP "$2,227.90 " "$1,648.65" $0.00 "$1,782.32" "$1,002.56" "$1,002.56" $0.00 $0.00 $0.00 $464.35 "$1,653.55" "$1,653.55" $0.00 $0.00 $464.29 $0.00 "$1,317.80" "$1,317.80" $0.00 "$1,113.95" "$1,764.50" "$1,782.32" $0.00 $0.00 $348.67 $0.00 $0.00 $354.68 $0.00 $0.00 $0.00 $0.00 $0.00 52-310-31-04 SUP HCPCS C1713 52-310-31-04 - MESH CRANIAL 106X31X1MM RESORB SMALL GRID RESORB-X SONICWELD BOTH IP/OP "$3,202.60 " "$2,369.92" $0.00 "$2,562.08" "$1,441.17" "$1,441.17" $0.00 $0.00 $0.00 $667.50 "$2,376.97" "$2,376.97" $0.00 $0.00 $667.42 $0.00 "$1,578.88" "$1,578.88" $0.00 "$1,601.30" "$2,536.46" "$2,562.08" $0.00 $0.00 $501.21 $0.00 $0.00 $509.85 $0.00 $0.00 $0.00 $0.00 $0.00 5235-1-846 SUP Custom 27203010 5235-1-846 - BIT DRILL 250MM 4.3MM ALTA TRFLT BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $0.00 $0.00 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5235-1-916 SUP Custom 27203010 5235-1-916 - GUIDE DRILL 4.3MM SLV BOTH IP/OP $468.88 $346.97 $0.00 $375.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.00 $348.00 $0.00 $0.00 $97.71 $0.00 $0.00 $0.00 $0.00 $234.44 $371.35 $375.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5235-7-110 SUP HCPCS C1713 5235-7-110 - SCREW BONE ALTA LAG RMR ASSY BOTH IP/OP "$5,328.13 " "$3,942.82" $0.00 "$4,262.50" "$2,397.66" "$2,397.66" $0.00 $0.00 $0.00 "$1,110.51" "$3,954.53" "$3,954.53" $0.00 $0.00 "$1,110.38" $0.00 "$2,626.77" "$2,626.77" $0.00 "$2,664.06" "$4,219.88" "$4,262.50" $0.00 $0.00 $833.85 $0.00 $0.00 $848.24 $0.00 $0.00 $0.00 $0.00 $0.00 52-400-00 SUP Custom 27203010 52-400-00 - PEN MRKNG TIP HEAT RSRBX BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5241300P2 SUP HCPCS C1713 5241300P2 - CAGE SPNL 0D 30X14X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5241302P2 SUP HCPCS C1713 5241302P2 - CAGE SPNL 12D 30X14X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5241308P2 SUP HCPCS C1713 5241308P2 - CAGE SPNL 8D 30X14X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 52432-U SUP Custom 27203010 SPECULUM OTSCP KLNSPC 2.75MM UNV 2.75MM PLST DX DISP BOTH IP/OP $0.05 $0.04 $0.00 $0.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.03 $0.04 $0.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5244300P2 SUP HCPCS C1713 5244300P2 - CAGE SPNL 0D 30X14X14MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5244308P2 SUP HCPCS C1713 5244308P2 - CAGE SPNL 8D 30X14X14MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5249300P2 SUP HCPCS C1713 5249300P2 - CAGE SPNL 0D 30X14X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5249302P2 SUP HCPCS C1713 5249302P2 - CAGE SPNL 12D 30X14X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5249308P2 SUP HCPCS C1713 5249308P2 - CAGE SPNL 8D 30X14X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5255-1-255 SUP Custom 27203010 5255-1-255 - BIT DRILL 250MM 3.2MM AO BOTH IP/OP $188.38 $139.40 $0.00 $150.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.81 $139.81 $0.00 $0.00 $39.26 $0.00 $0.00 $0.00 $0.00 $94.19 $149.20 $150.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5260-4-000 SUP Custom 27803010 5260-4-000 - SHELL ACETAB HIP SCR PLUG OSTLK APCL BOTH IP/OP $141.00 $104.34 $0.00 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.65 $104.65 $0.00 $0.00 $29.38 $0.00 $0.00 $0.00 $0.00 $70.50 $111.67 $112.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-012 SUP HCPCS C1713 5260-5-012 - SCREW ACETAB 6.5MM 12MM HEXAGON OSTEOLOCK TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-014 SUP HCPCS C1713 5260-5-014 - SCREW ACETAB 6.5MM 14MM HEXAGON OSTEOLOCK TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-016 SUP HCPCS C1713 5260-5-016 - SCREW BN 6.5MM 16MM OSTLK CANC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-018 SUP HCPCS C1713 5260-5-018 - SCREW ACETAB 6.5MM 18MM HEXAGON OSTEOLOCK TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-020 SUP HCPCS C1713 5260-5-020 - SCREW ACETAB 6.5MM 20MM HEXAGON OSTEOLOCK TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-022 SUP HCPCS C1713 5260-5-022 - SCREW ACETAB 6.5MM 22MM HEXAGON OSTEOLOCK TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-024 SUP HCPCS C1713 5260-5-024 - SCREW ACETAB 6.5MM 24MM HEXAGON OSTEOLOCK TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-026 SUP HCPCS C1713 5260-5-026 - SCREW BONE HEXAGON 6.5MM 26MM WEDGE RSTOR OSTEOLOCK TITANIUM BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-028 SUP HCPCS C1713 5260-5-028 - SCREW BONE HEXAGON 6.5MM 28MM WEDGE RSTOR OSTEOLOCK TITANIUM BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-030 SUP HCPCS C1713 5260-5-030 - SCREW BONE HEXAGON 6.5MM 30MM WEDGE RSTOR OSTEOLOCK TITANIUM BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-035 SUP HCPCS C1713 5260-5-035 - SCREW BONE HEXAGON 6.5MM 35MM WEDGE RSTOR OSTEOLOCK TITANIUM BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-040 SUP HCPCS C1713 5260-5-040 - SCREW BONE HEXAGON 6.5MM 40MM WEDGE RSTOR OSTEOLOCK TITANIUM BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-045 SUP HCPCS C1713 5260-5-045 - SCREW BONE HEXAGON 6.5MM 45MM WEDGE RSTOR OSTEOLOCK TITANIUM BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5260-5-050 SUP HCPCS C1713 5260-5-050 - SCREW BONE HEXAGON 6.5MM 50MM WEDGE RSTOR OSTEOLOCK TITANIUM BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5281300P2 SUP HCPCS C1713 5281300P2 - CAGE SPNL 0D 30X8X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5281302P2 SUP HCPCS C1713 5281302P2 - CAGE SPNL 12D 30X8X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5281308P2 SUP HCPCS C1713 5281308P2 - CAGE SPNL 8D 30X8X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5284300P2 SUP HCPCS C1713 5284300P2 - CAGE SPNL 0D 30X8X14MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5284308P2 SUP HCPCS C1713 5284308P2 - CAGE SPNL 8D 30X8X14MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5289300P2 SUP HCPCS C1713 5289300P2 - CAGE SPNL 0D 30X8X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5289302P2 SUP HCPCS C1713 5289302P2 - CAGE SPNL 12D 30X8X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5289308P2 SUP HCPCS C1713 5289308P2 - CAGE SPNL 8D 30X8X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5291300P2 SUP HCPCS C1713 5291300P2 - CAGE SPNL 0D 30X9X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5291302P2 SUP HCPCS C1713 5291302P2 - CAGE SPNL 12D 30X9X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5291308P2 SUP HCPCS C1713 5291308P2 - CAGE SPNL 8D 30X9X11MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5299300P2 SUP HCPCS C1713 5299300P2 - CAGE SPNL 0D 30X9X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5299302P2 SUP HCPCS C1713 5299302P2 - CAGE SPNL 12D 30X9X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5299308P2 SUP HCPCS C1713 5299308P2 - CAGE SPNL 8D 30X9X9MM NS CRNT TI ANT TLIF BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 5300-010-941 SUP Custom 27203010 5300-010-941 - DERMABRADER SURG MEDIUM STR 4MM STR TPS STERILE BOTH IP/OP $190.80 $141.19 $0.00 $152.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.61 $141.61 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $95.40 $151.11 $152.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5300-010-943 SUP Custom 27203010 5300-010-943 - DERMABRADER SURG MEDIUM STR 7MM STR X-CHANGE III BOTH IP/OP $190.80 $141.19 $0.00 $152.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.61 $141.61 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $95.40 $151.11 $152.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5300-010-945 SUP Custom 27203010 5300-010-945 - DERMABRADER SURG MEDIUM STR 12MM 50MM BUR STR TPS STERILE BOTH IP/OP $190.80 $141.19 $0.00 $152.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.61 $141.61 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $95.40 $151.11 $152.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5300-010-947 SUP Custom 27203010 5300-010-947 - DERMABRADER SURG MEDIUM 10MM TAPERED TPS STERILE BOTH IP/OP $190.80 $141.19 $0.00 $152.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.61 $141.61 $0.00 $0.00 $39.76 $0.00 $0.00 $0.00 $0.00 $95.40 $151.11 $152.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 53-00324 SUP HCPCS C1713 53-00324 - PLATE BN 47X29X.3MM UNV NEURO III CLS OUTR FRM TI TMPR 1.5MM BOTH IP/OP "$3,067.50 " "$2,269.95" $0.00 "$2,454.00" "$1,380.38" "$1,380.38" $0.00 $0.00 $0.00 $639.34 "$2,276.70" "$2,276.70" $0.00 $0.00 $639.27 $0.00 "$1,512.28" "$1,512.28" $0.00 "$1,533.75" "$2,429.46" "$2,454.00" $0.00 $0.00 $480.06 $0.00 $0.00 $488.35 $0.00 $0.00 $0.00 $0.00 $0.00 53-00466 SUP HCPCS C1713 53-00466 - PLATE BN LG RND 58MM .4MM NS UNV NEURO III CLS OUTR FRM RGD BOTH IP/OP "$3,675.00 " "$2,719.50" $0.00 "$2,940.00" "$1,653.75" "$1,653.75" $0.00 $0.00 $0.00 $765.96 "$2,727.59" "$2,727.59" $0.00 $0.00 $765.87 $0.00 "$1,811.78" "$1,811.78" $0.00 "$1,837.50" "$2,910.60" "$2,940.00" $0.00 $0.00 $575.14 $0.00 $0.00 $585.06 $0.00 $0.00 $0.00 $0.00 $0.00 53-05164 SUP HCPCS C1713 53-05164 - PLATE BONE STR LP 16 HOLE TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $478.13 $353.82 $0.00 $864.00 $486.00 $486.00 $0.00 $0.00 $0.00 $99.65 $354.86 $354.86 $0.00 $0.00 $99.64 $0.00 $282.81 $282.81 $0.00 $540.00 $855.36 $864.00 $0.00 $0.00 $169.02 $0.00 $0.00 $171.94 $0.00 $0.00 $0.00 $0.00 $0.00 53-05212 SUP HCPCS C1713 53-05212 - PLATE BN 12MM NS UNV NEURO II 2 HL LOPRFL BAR TI CRNMXF 1.5 BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $187.88 $187.88 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 53-05216 SUP HCPCS C1713 53-05216 - PLATE BN 16MM NS UNV NEURO II 2 HL LOPRFL BAR TI CRNMXF 1.5 BOTH IP/OP $205.00 $151.70 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 53-05228 SUP HCPCS C1713 53-05228 - PLATE BN 3D BX 28MM NS UNV NEURO II 2X2 HL LOPRFL TI CRNMXF BOTH IP/OP $327.38 $242.26 $0.00 $544.00 $306.00 $306.00 $0.00 $0.00 $0.00 $68.23 $242.98 $242.98 $0.00 $0.00 $68.22 $0.00 $193.64 $193.64 $0.00 $340.00 $538.56 $544.00 $0.00 $0.00 $106.42 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 53-05240 SUP HCPCS C1713 53-05240 - PLATE BN 3D LG BX 40MM NS UNV NEURO II 2X2 HL LOPRFL TI BOTH IP/OP "$1,012.50 " $749.25 $0.00 $810.00 $455.63 $455.63 $0.00 $0.00 $0.00 $211.03 $751.48 $751.48 $0.00 $0.00 $211.01 $0.00 $598.89 $598.89 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $158.46 $0.00 $0.00 $161.19 $0.00 $0.00 $0.00 $0.00 $0.00 53-05406 SUP HCPCS C1713 53-05406 - PLATE BONE 6MM 4 HOLE LP BAR TITANIUM CRANIUM NONSTRL 1.5MM BOTH IP/OP $199.50 $147.63 $0.00 $364.00 $204.75 $204.75 $0.00 $0.00 $0.00 $41.58 $148.07 $148.07 $0.00 $0.00 $41.58 $0.00 $118.00 $118.00 $0.00 $227.50 $360.36 $364.00 $0.00 $0.00 $71.21 $0.00 $0.00 $72.44 $0.00 $0.00 $0.00 $0.00 $0.00 53-05507 SUP Custom 27803010 53-05507 - COVER BURR HOLE 7MM LP TAB TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $807.50 $597.55 $0.00 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.33 $599.33 $0.00 $0.00 $168.28 $0.00 $0.00 $0.00 $0.00 $403.75 $639.54 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 53-05510 SUP Custom 27803010 53-05510 - COVER BURR HOLE MEDIUM 10MM LP TAB TITANIUM CRANIAL NONSTRL BOTH IP/OP $807.50 $597.55 $0.00 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.33 $599.33 $0.00 $0.00 $168.28 $0.00 $0.00 $0.00 $0.00 $403.75 $639.54 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 53-05514 SUP Custom 27803010 53-05514 - COVER BURR HOLE LP 14MM TAB TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $807.50 $597.55 $0.00 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.33 $599.33 $0.00 $0.00 $168.28 $0.00 $0.00 $0.00 $0.00 $403.75 $639.54 $646.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 53-05520 SUP Custom 27803010 53-05520 - COVER BURR HOLE 20MM LP TAB TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $892.50 $660.45 $0.00 $714.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.41 $662.41 $0.00 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $446.25 $706.86 $714.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 53-05608 SUP HCPCS C1713 53-05608 - PLATE BONE 2Y LP 8MM 6 HOLE GAP TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $965.00 $714.10 $0.00 $772.00 $434.25 $434.25 $0.00 $0.00 $0.00 $201.13 $716.22 $716.22 $0.00 $0.00 $201.11 $0.00 $570.80 $570.80 $0.00 $482.50 $764.28 $772.00 $0.00 $0.00 $151.02 $0.00 $0.00 $153.63 $0.00 $0.00 $0.00 $0.00 $0.00 53-05612 SUP HCPCS C1713 53-05612 - PLATE BONE SMALL LP GAP TITANIUM CRANIOMAXILLOFACIAL NONSTRL BOTH IP/OP $493.53 $365.21 $0.00 $910.00 $511.88 $511.88 $0.00 $0.00 $0.00 $102.86 $366.29 $366.29 $0.00 $0.00 $102.85 $0.00 $291.92 $291.92 $0.00 $568.75 $900.90 $910.00 $0.00 $0.00 $178.02 $0.00 $0.00 $181.09 $0.00 $0.00 $0.00 $0.00 $0.00 53-05622 SUP HCPCS C1713 53-05622 - PLATE BN LG GAP 22MM NS UNV NEURO II LOPRFL TI CRNMXF 1.5MM BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $561.38 $561.38 $0.00 $0.00 $0.00 $260.01 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $737.90 $737.90 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $195.23 $0.00 $0.00 $198.60 $0.00 $0.00 $0.00 $0.00 $0.00 53-05630 SUP HCPCS C1713 53-05630 - PLATE BONE X LP TITANIUM CRANIOMAXILLOFACIAL NONSTRL BOTH IP/OP $965.00 $714.10 $0.00 $772.00 $434.25 $434.25 $0.00 $0.00 $0.00 $201.13 $716.22 $716.22 $0.00 $0.00 $201.11 $0.00 $570.80 $570.80 $0.00 $482.50 $764.28 $772.00 $0.00 $0.00 $151.02 $0.00 $0.00 $153.63 $0.00 $0.00 $0.00 $0.00 $0.00 53-05804 SUP HCPCS C1713 53-05804 - PLATE BONE STR LP 8 HOLE TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 53-06212 SUP HCPCS C1713 53-06212 - PLATE BN 12MM NS UNV NEURO II QUIKFLAP 2 HL BAR X RGD LOPRFL BOTH IP/OP $141.25 $104.53 $0.00 $199.88 $112.43 $112.43 $0.00 $0.00 $0.00 $29.44 $104.84 $104.84 $0.00 $0.00 $29.44 $0.00 $83.55 $83.55 $0.00 $124.93 $197.88 $199.88 $0.00 $0.00 $39.10 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 53-1125 SUP Custom 27203010 RONGUER SURG 9IN LKSL 5MM CURVE REG DBL ACT LMI BOTH IP/OP "$2,175.23 " "$1,609.67" $0.00 "$1,740.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,087.61" "$1,722.78" "$1,740.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 53-17005 SUP HCPCS C1713 53-17005 - SCREW BONE 1.7MM 5MM LCK SLFTAP CROSSPIN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17005E SUP HCPCS C1713 53-17005E - SCREW BONE 1.7MM 5MM VARIAX TI HAND LCK SLFTAP CROSSPIN STRL BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17006E SUP HCPCS C1713 53-17006E - SCREW BONE 1.7MM 6MM HAND LCK SLFTAP CROSSPIN STRL BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17007E SUP HCPCS C1713 53-17007E - SCREW BONE 1.7MM 7MM LCK SLFTAP CROSSPIN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17008E SUP HCPCS C1713 53-17008E - SCREW BONE 1.7MM 8MM CANC HIP LCK SLFTAP CROSSPIN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17009E SUP HCPCS C1713 53-17009E - SCREW BONE 1.7MM 9MM LCK SLFTAP CROSSPIN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17010 SUP HCPCS C1713 53-17010 - 1.7X10MM LOCKING SCREWS_CROSS-PIN_SELF-T BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17010E SUP HCPCS C1713 53-17010E - SCREW BONE 1.7MM 10MM VARIAX HAND SLFTAP LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17011E SUP HCPCS C1713 53-17011E - SCREW BONE 1.7MM 11MM ORTH LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17012E SUP HCPCS C1713 53-17012E - SCREW BONE 1.7MM 12MM LCK SLFTAP CROSSPIN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17013E SUP HCPCS C1713 53-17013E - SCREW BONE 1.7MM 13MM ORTH SLFTAP LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17014E SUP HCPCS C1713 53-17014E - SCREW BONE 1.7MM 14MM LCK SLFTAP CROSSPIN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17015 SUP HCPCS C1713 53-17015 - SCREW BONE 1.7MM 15MM LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17015E SUP HCPCS C1713 53-17015E - SCREW BONE 1.7MM 15MM LCK SLFTAP CROSSPIN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17016 SUP HCPCS C1713 53-17016 - SCREW BONE 1.7MM 16MM LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17016E SUP HCPCS C1713 53-17016E - SCREW BONE 1.7MM 16MM ORTH SLFTAP LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17018 SUP HCPCS C1713 53-17018 - SCREW BONE 1.7MM 18MM LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17018E SUP HCPCS C1713 53-17018E - SCREW BONE 1.7MM 18MM VARIAX HAND SLFTAP LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17020 SUP HCPCS C1713 53-17020 - SCREW BONE 1.7MM 20MM LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17020E SUP HCPCS C1713 53-17020E - SCREW BONE 1.7MM 20MM ORTH SLFTAP LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17022 SUP HCPCS C1713 53-17022 - SCREW BN 1.7MM 22MM NS VARIAX ST LCK XPN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17022E SUP HCPCS C1713 53-17022E - SCREW BONE 1.7MM 22MM ORTH SLFTAP LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17024 SUP HCPCS C1713 53-17024 - SCREW BN 1.7MM 24MM NS VARIAX ST LCK XPN BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-17024E SUP HCPCS C1713 53-17024E - SCREW BONE 1.7MM 24MM ORTH SLFTAP LCK BOTH IP/OP $140.70 $104.12 $0.00 $104.43 $52.59 $52.59 $0.00 $0.00 $0.00 $29.33 $104.43 $104.43 $0.00 $0.00 $29.32 $0.00 $83.22 $83.22 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-20424 SUP HCPCS C1713 53-20424 - SCREW BONE 2MM 24MM SLFTAP XPIN LAG TITANIUM MAXFACL BOTH IP/OP $117.00 $86.58 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $0.00 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 53-20427 SUP HCPCS C1713 53-20427 - SCREW BONE 2MM 27MM SLFTAP XPIN LAG CRANIOMAXILLOFACIAL BOTH IP/OP $117.00 $86.58 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $0.00 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 53-20430 SUP HCPCS C1713 53-20430 - SCREW BONE 2MM 30MM SLFTAP XPIN LAG TITANIUM MAXFACL BOTH IP/OP $117.00 $86.58 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $0.00 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 53-20433 SUP HCPCS C1713 53-20433 - SCREW BONE 2MM 33MM SLFTAP XPIN LAG MAXFACL BOTH IP/OP $117.00 $86.58 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $0.00 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 53-20436 SUP HCPCS C1713 53-20436 - SCREW BONE 2MM 36MM SLFTAP XPIN LAG TITANIUM MAXFACL BOTH IP/OP $117.00 $86.58 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $0.00 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 53-20439 SUP HCPCS C1713 53-20439 - SCREW BONE 2MM 39MM SLFTAP XPIN LAG MANDIB NONSTRL BOTH IP/OP $117.00 $86.58 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $0.00 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 53-20442 SUP HCPCS C1713 53-20442 - SCREW BONE 2MM 42MM SLFTAP XPIN LAG MANDIB NONSTRL BOTH IP/OP $117.00 $86.58 $0.00 $222.00 $124.88 $124.88 $0.00 $0.00 $0.00 $24.39 $86.84 $86.84 $0.00 $0.00 $24.38 $0.00 $69.21 $69.21 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $43.43 $0.00 $0.00 $44.18 $0.00 $0.00 $0.00 $0.00 $0.00 53-20616E SUP HCPCS C1713 53-20616E - SCREW BONE 2MM 16MM TI LCK PG T7 DRV BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $35.82 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $101.66 $101.66 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-20618E SUP HCPCS C1713 53-20618E - SCREW BONE 2MM 18MM TI LCK PG T7 DRV BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $35.82 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $101.66 $101.66 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-20620E SUP HCPCS C1713 53-20620E - SCREW BONE 2MM 20MM TI LCK PG T7 DRV BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $35.82 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $101.66 $101.66 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-20622E SUP HCPCS C1713 53-20622E - SCREW BONE 2MM 22MM TI LCK PG T7 DRV BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $35.82 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $101.66 $101.66 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-20624E SUP HCPCS C1713 53-20624E - SCREW BONE 2MM 24MM TI LCK PG T7 DRV STRL BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $35.82 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $101.66 $101.66 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-20626E SUP HCPCS C1713 53-20626E - SCREW BONE 2MM 26MM TI LCK PG T7 DRV STRL BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $35.82 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $101.66 $101.66 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23006 SUP HCPCS C1713 53-23006 - SCREW BONE 2.3MM 6MM HAND LCK BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23006E SUP HCPCS C1713 53-23006E - SCREW BONE 2.3MM 6MM CANC LCK SLFTAP CROSSPIN BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23008 SUP HCPCS C1713 53-23008 - SCREW BONE 2.3MM 8MM VARIAX HAND SLFTAP XPIN BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23008E SUP HCPCS C1713 53-23008E - SCREW BN 2.3MM 8MM STRL VARIAX ST LCK LOPRFL XPN HD TI HND BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23009 SUP HCPCS C1713 53-23009 - SCREW BN BLNT 2.3MM 9MM LCK ST XPN HD LOPRFL HND BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23009E SUP HCPCS C1713 53-23009E - SCREW BN LOPRFL 2.3MM 9MM NS VARIAX ST LCK XPN HD TI HND BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23010 SUP HCPCS C1713 53-23010 - SCREW BONE 2.3MM 10MM HAND LCK SLFTAP CROSSPIN BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23010E SUP HCPCS C1713 53-23010E - SCREW BN 2.3MM 10MM STRL VARIAX ST LCK LOPRFL XPN HD TI HND BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23011 SUP HCPCS C1713 53-23011 - SCREW BONE 2.3MM 11MM VARIAX HAND SLFTAP XPIN BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23011E SUP HCPCS C1713 53-23011E - SCREW BONE 2.3MM 11MM LCK SLFTAP CROSSPIN BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23012 SUP HCPCS C1713 53-23012 - SCREW BONE 2.3MM 12MM VARIAX HAND LCK XPIN BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23012E SUP HCPCS C1713 53-23012E - SCREW BN 2.3MM 12MM STRL VARIAX ST LCK LOPRFL CROSSPIN HD TI BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23013E SUP HCPCS C1713 53-23013E - SCREW BONE 2.3MM 13MM VARIAX TI HAND LCK SLFTAP CROSSPIN BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23014 SUP HCPCS C1713 53-23014 - SCREW BONE 2.3MM 14MM HAND LCK SLFTAP CROSSPIN BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23015E SUP HCPCS C1713 53-23015E - SCREW BONE 2.3MM 15MM HAND LCK SLFTAP CROSSPIN BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23016 SUP HCPCS C1713 53-23016 - SCREW BONE 2.3MM 16MM HAND LCK SLFTAP CROSSPIN BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23016E SUP HCPCS C1713 53-23016E - SCREW BONE 2.3MM 16MM HAND LCK SLFTAP CROSSPIN BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23018 SUP HCPCS C1713 53-23018 - SCREW BONE 2.3MM 18MM VARIAX HAND LCK SLFTAP XPIN BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23018E SUP HCPCS C1713 53-23018E - SCREW BONE 2.3MM 18MM HAND LCK SLFTAP CROSSPIN BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23020 SUP HCPCS C1713 53-23020 - SCREW BONE 2.3MM 20MM LCK BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23020E SUP HCPCS C1713 53-23020E - SCREW BONE 2.3MM 20MM LCK SLFTAP CROSSPIN BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23022 SUP HCPCS C1713 53-23022 - SCREW BONE 2MM 22MM RADL BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23022E SUP HCPCS C1713 53-23022E - SCREW BONE 2.3MM 22MM VARIAX HAND SLFTAP LCK BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23024 SUP HCPCS C1713 53-23024 - SCREW BN LOPRFL BLNT RND 2.3MM 24MM GRN VARIAX PRFL 1 STP BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23024E SUP HCPCS C1713 53-23024E - SCREW BN 2.3MM 24MM VARIAX LCK ST XPN HD LOPRFL TI WR HND BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23026 SUP HCPCS C1713 53-23026 - SCREW BONE 2.3MM 26MM LCK BOTH IP/OP $145.60 $107.74 $0.00 $108.06 $52.59 $52.59 $0.00 $0.00 $0.00 $30.35 $108.06 $108.06 $0.00 $0.00 $30.34 $0.00 $86.12 $86.12 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23026E SUP HCPCS C1713 53-23026E - SCREW BONE 2.3MM 26MM VARIAX HAND SLFTAP LCK BOTH IP/OP $141.40 $104.64 $0.00 $104.95 $52.59 $52.59 $0.00 $0.00 $0.00 $29.47 $104.95 $104.95 $0.00 $0.00 $29.47 $0.00 $83.64 $83.64 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 53-23210E SUP HCPCS C1713 53-23210E - SCREW BONE 2.3MM 10MM TI LCK PG T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23212E SUP HCPCS C1713 53-23212E - SCREW BONE 2.3MM 12MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23214E SUP HCPCS C1713 53-23214E - SCREW BONE 2.3MM 14MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23216E SUP HCPCS C1713 53-23216E - SCREW BONE 2.3MM 16MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23218E SUP HCPCS C1713 53-23218E - SCREW BONE 2.3MM 18MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23220E SUP HCPCS C1713 53-23220E - SCREW BONE 2.3MM 20MM VARIAX TI DISTAL RADL WR HND NLCKG T7 BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23222E SUP HCPCS C1713 53-23222E - SCREW BONE 2.3MM 22MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23224E SUP HCPCS C1713 53-23224E - SCREW BONE 2.3MM 24MM VARIAX TI DISTAL RADL LCK T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23226E SUP HCPCS C1713 53-23226E - SCREW BONE 2.3MM 26MM VARIAX TI DISTAL RADL NLCKG T7 DRV BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23228E SUP HCPCS C1713 53-23228E - SCREW BONE 2.3MM 28MM VARIAX TI T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23230E SUP HCPCS C1713 53-23230E - SCREW BONE 2.3MM 30MM TI LCK PG T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23232E SUP HCPCS C1713 53-23232E - SCREW BONE 2.3MM 32MM TI LCK PG T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23234E SUP HCPCS C1713 53-23234E - SCREW BONE 2.3MM 34MM TI LCK PG T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23236E SUP HCPCS C1713 53-23236E - SCREW BONE 2.3MM 36MM TI LCK PG T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23238E SUP HCPCS C1713 53-23238E - SCREW BONE 2.3MM 38MM TI LCK PG T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-23610E SUP HCPCS C1713 53-23610E - SCREW BONE 2.3MM 10MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23612E SUP HCPCS C1713 53-23612E - SCREW BONE 2.3MM 12MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23614E SUP HCPCS C1713 53-23614E - SCREW BONE 2.3MM 14MM VARIAX TI DISTAL RADL WR HND LCK T7 BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23616E SUP HCPCS C1713 53-23616E - SCREW BONE 2.3MM 16MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23618E SUP HCPCS C1713 53-23618E - SCREW BONE 2.3MM 18MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23620E SUP HCPCS C1713 53-23620E - SCREW BONE 2.3MM 20MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23622E SUP HCPCS C1713 53-23622E - SCREW BONE 2.3MM 22MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23624E SUP HCPCS C1713 53-23624E - SCREW BONE 2.3MM 24MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23626E SUP HCPCS C1713 53-23626E - SCREW BONE 2.3MM 26MM VARIAX TI LCK T7 DRV STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23628E SUP HCPCS C1713 53-23628E - SCREW BONE 2.3MM 28MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23630E SUP HCPCS C1713 53-23630E - SCREW BONE 2.3MM 30MM TI LCK T7 DRV STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23632E SUP HCPCS C1713 53-23632E - SCREW BONE 2.3MM 32MM TI LCK T7 DRV STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23634E SUP HCPCS C1713 53-23634E - SCREW BONE 2.3MM 34MM TI LCK T7 DRV STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23636E SUP HCPCS C1713 53-23636E - SCREW BONE 2.3MM 36MM TI LCK T7 DRV STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-23638E SUP HCPCS C1713 53-23638E - SCREW BONE 2.3MM 38MM TI LCK T7 DRV STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 532650S SUP HCPCS C1725 532650S - CATHETER ANGIO PGTL CRV 6FR 110CM ST 6 SH BRD PU VNTRC ACPT BOTH IP/OP $105.63 $78.17 $0.00 $84.50 $57.35 $57.35 $0.00 $0.00 $0.00 $22.01 $78.39 $78.39 $0.00 $0.00 $22.01 $0.00 $62.48 $62.48 $0.00 $52.81 $83.66 $84.50 $0.00 $0.00 $16.53 $0.00 $0.00 $16.82 $0.00 $0.00 $0.00 $0.00 $0.00 53-27116E SUP HCPCS C1713 53-27116E - SCREW BONE 2.7MM 16MM VARIAX TI DISTAL RADL PTTHRD T7 DRV BOTH IP/OP $174.25 $128.95 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $36.32 $129.33 $129.33 $0.00 $0.00 $36.31 $0.00 $103.07 $103.07 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27118E SUP HCPCS C1713 53-27118E - SCREW BONE 2.7MM 18MM VARIAX TI DISTAL RADL PTTHRD T7 DRV BOTH IP/OP $174.25 $128.95 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $36.32 $129.33 $129.33 $0.00 $0.00 $36.31 $0.00 $103.07 $103.07 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27120E SUP HCPCS C1713 53-27120E - SCREW BONE 2.7MM 20MM TI PTHRD T7 DRV BOTH IP/OP $174.25 $128.95 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $36.32 $129.33 $129.33 $0.00 $0.00 $36.31 $0.00 $103.07 $103.07 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27122E SUP HCPCS C1713 53-27122E - SCREW BONE 2.7MM 22MM VARIAX TI DISTAL RADL PTTHRD T7 DRV BOTH IP/OP $174.25 $128.95 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $36.32 $129.33 $129.33 $0.00 $0.00 $36.31 $0.00 $103.07 $103.07 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27124E SUP HCPCS C1713 53-27124E - SCREW BONE 2.7MM 24MM VARIAX TI DISTAL RADL PTTHRD T7 DRV BOTH IP/OP $174.25 $128.95 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $36.32 $129.33 $129.33 $0.00 $0.00 $36.31 $0.00 $103.07 $103.07 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27126E SUP HCPCS C1713 53-27126E - SCREW BONE 2.7MM 26MM VARIAX TI DISTAL RADL PTTHRD T7 DRV BOTH IP/OP $174.25 $128.95 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $36.32 $129.33 $129.33 $0.00 $0.00 $36.31 $0.00 $103.07 $103.07 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27210E SUP HCPCS C1713 53-27210E - SCREW BONE 2.7MM 10MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27212E SUP HCPCS C1713 53-27212E - SCREW BONE 2.7MM 12MM VARIAX TI DISTAL RADL WR HND NLCKG T7 BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27214E SUP HCPCS C1713 53-27214E - SCREW BONE 2.7MM 14MM VARIAX TI DISTAL RADL WR HND NLCKG T7 BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27216E SUP HCPCS C1713 53-27216E - SCREW BONE 2.7MM 16MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27218E SUP HCPCS C1713 53-27218E - SCREW BONE 2.7MM 18MM VARIAX TI DISTAL RADL LCK T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27220E SUP HCPCS C1713 53-27220E - SCREW BONE 2.7MM 20MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27222E SUP HCPCS C1713 53-27222E - SCREW BONE 2.7MM 22MM VARIAX TI DISTAL RADL NLCKG T7 DRV BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27224E SUP HCPCS C1713 53-27224E - SCREW BONE 2.7MM 24MM VARIAX TI DISTAL RADL LCK T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27226E SUP HCPCS C1713 53-27226E - SCREW BONE 2.7MM 26MM VARIAX TI DISTAL RADL LCK T7 DRV STRL BOTH IP/OP $134.30 $99.38 $0.00 $137.50 $77.34 $77.34 $0.00 $0.00 $0.00 $27.99 $99.68 $99.68 $0.00 $0.00 $27.99 $0.00 $79.44 $79.44 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $26.90 $0.00 $0.00 $27.36 $0.00 $0.00 $0.00 $0.00 $0.00 53-27610E SUP HCPCS C1713 53-27610E - SCREW BONE 2.7MM 10MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27612E SUP HCPCS C1713 53-27612E - SCREW BONE 2.7MM 12MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27614E SUP HCPCS C1713 53-27614E - SCREW BONE 2.7MM 14MM VARIAX TI DISTAL RADL LCK T7 DRV STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27616E SUP HCPCS C1713 53-27616E - SCREW BONE 2.7MM 16MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27618E SUP HCPCS C1713 53-27618E - SCREW BONE 2.7MM 18MM VARIAX TI DISTAL RADL T7 DRV STRL LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27620E SUP HCPCS C1713 53-27620E - SCREW BONE 2.7MM 20MM VARIAX TI DISTAL RADL LCK T7 DRV STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27622E SUP HCPCS C1713 53-27622E - SCREW BN T7 FT 2.7MM 22MM NS VARIAX LCK TI DIST RDS LCK PLT BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27624E SUP HCPCS C1713 53-27624E - SCREW BONE 2.7MM 24MM VARIAX TI DISTAL RADL T7 DRV LCK BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27626E SUP HCPCS C1713 53-27626E - SCREW BONE 2.7MM 26MM TI T7 DRV BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27716E SUP HCPCS C1713 53-27716E - PEG 2.7MM 16MM PTTHRD LCK TI NONSTRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27718E SUP HCPCS C1713 53-27718E - PEG 2.7MM 18MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27720E SUP HCPCS C1713 53-27720E - PEG 2.7MM 20MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27722E SUP HCPCS C1713 53-27722E - PEG 2.7MM 22MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27724E SUP HCPCS C1713 53-27724E - PEG 2.7MM 24MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 53-27726E SUP HCPCS C1713 53-27726E - PEG 2.7MM 26MM DISTAL RADL PTTHRD LCK TI VARIAX STRL BOTH IP/OP $179.35 $132.72 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $37.38 $133.11 $133.11 $0.00 $0.00 $37.38 $0.00 $106.09 $106.09 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 5331-40/15 SUP HCPCS C1776 5331-40/15 - HEAD HUMERAL 40MM 15MM EPOCA COCR ALLOY SHOULDER STERILE BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-42/15 SUP HCPCS C1776 5331-42/15 - HEAD HUMERAL 42MM 15.75MM COCR SHOULDER NONSTRL BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-44/16 SUP HCPCS C1776 5331-44/16 - HEAD HUM 44MM 16.5MM STRL COCR SHLDR BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-46/17 SUP HCPCS C1776 5331-46/17 - HEAD HUM 46MM 17.25MM STRL COCR SHLDR BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-48/18 SUP HCPCS C1776 5331-48/18 - HEAD HUM 48MM 18MM STRL COCR SHLDR BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-50/18 SUP HCPCS C1776 5331-50/18 - HEAD HUM 50MM 18.75MM STRL COCR SHLDR BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-52/19 SUP HCPCS C1776 5331-52/19 - HEAD HUMERAL 52MM 19.5MM EPOCA COCR SHOULDER STERILE BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-54/20 SUP HCPCS C1776 5331-54/20 - HEAD HUMERAL 54MM 20.25MM COCR SHOULDER NONSTRL BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-56/21 SUP HCPCS C1776 5331-56/21 - HEAD FEMORAL 56MM 21MM COCR HIP STERILE BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 5331-58/22 SUP HCPCS C1776 5331-58/22 - HEAD FEMORAL 58MM 21.75MM COCR HIP STERILE BOTH IP/OP "$4,287.70 " "$3,172.90" $0.00 "$3,430.16" "$1,929.47" "$1,929.47" $0.00 $0.00 $0.00 $893.66 "$3,182.33" "$3,182.33" $0.00 $0.00 $893.56 $0.00 "$2,113.84" "$2,113.84" $0.00 "$2,143.85" "$3,395.86" "$3,430.16" $0.00 $0.00 $671.03 $0.00 $0.00 $682.60 $0.00 $0.00 $0.00 $0.00 $0.00 53-34164 SUP HCPCS C1713 53-34164 - PLATE BN STRG .4MM NS UNV NEURO III 16 HL LOPRFL TI CRNMXF BOTH IP/OP "$1,147.50 " $849.15 $0.00 $918.00 $516.38 $516.38 $0.00 $0.00 $0.00 $239.17 $851.67 $851.67 $0.00 $0.00 $239.14 $0.00 $678.75 $678.75 $0.00 $573.75 $908.82 $918.00 $0.00 $0.00 $179.58 $0.00 $0.00 $182.68 $0.00 $0.00 $0.00 $0.00 $0.00 53-34212 SUP HCPCS C1713 53-34212 - PLATE BN STRG .4MM NS UNV NEURO III 2 HL LOPRFL BAR TAB TI BOTH IP/OP $457.50 $338.55 $0.00 $366.00 $205.88 $205.88 $0.00 $0.00 $0.00 $95.35 $339.56 $339.56 $0.00 $0.00 $95.34 $0.00 $270.61 $270.61 $0.00 $228.75 $362.34 $366.00 $0.00 $0.00 $71.60 $0.00 $0.00 $72.83 $0.00 $0.00 $0.00 $0.00 $0.00 53-34216 SUP HCPCS C1713 53-34216 - PLATE BN DOG 16MMX.4MM NS UNV NEURO III 2 HL LOPRFL BAR TI BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 53-34228 SUP HCPCS C1713 53-34228 - PLATE BN SM BX .4MM NS UNV NEURO III 2X2 HL LOPRFL TI CRNMXF BOTH IP/OP $717.50 $530.95 $0.00 $574.00 $322.88 $322.88 $0.00 $0.00 $0.00 $149.54 $532.53 $532.53 $0.00 $0.00 $149.53 $0.00 $424.40 $424.40 $0.00 $358.75 $568.26 $574.00 $0.00 $0.00 $112.29 $0.00 $0.00 $114.23 $0.00 $0.00 $0.00 $0.00 $0.00 53-34240 SUP HCPCS C1713 53-34240 - PLATE BN LG BX .4MM NS UNV NEURO III 2X2 HL LOPRFL TI CRNMXF BOTH IP/OP "$1,112.50 " $823.25 $0.00 $890.00 $500.63 $500.63 $0.00 $0.00 $0.00 $231.87 $825.70 $825.70 $0.00 $0.00 $231.85 $0.00 $658.04 $658.04 $0.00 $556.25 $881.10 $890.00 $0.00 $0.00 $174.11 $0.00 $0.00 $177.11 $0.00 $0.00 $0.00 $0.00 $0.00 53-34300 SUP HCPCS C1713 53-34300 - PLATE BN RECT .4MM NS UNV NEURO III 2X2 HL LOPRFL TI CRNMXF BOTH IP/OP "$1,092.50 " $808.45 $0.00 $874.00 $491.63 $491.63 $0.00 $0.00 $0.00 $227.70 $810.85 $810.85 $0.00 $0.00 $227.68 $0.00 $646.21 $646.21 $0.00 $546.25 $865.26 $874.00 $0.00 $0.00 $170.98 $0.00 $0.00 $173.93 $0.00 $0.00 $0.00 $0.00 $0.00 53-34406 SUP HCPCS C1713 53-34406 - PLATE BN STRG 6MMX.4MM NS UNV NEURO III 4 HL LOPRFL BAR TI BOTH IP/OP $505.00 $373.70 $0.00 $404.00 $227.25 $227.25 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $252.50 $399.96 $404.00 $0.00 $0.00 $79.03 $0.00 $0.00 $80.40 $0.00 $0.00 $0.00 $0.00 $0.00 53-34507 SUP HCPCS C1713 53-34507 - COVER BUR HL LOPRFL 7MM STRL MDPR TAB TI BOTH IP/OP $915.00 $677.10 $0.00 $732.00 $411.75 $411.75 $0.00 $0.00 $0.00 $190.71 $679.11 $679.11 $0.00 $0.00 $190.69 $0.00 $541.22 $541.22 $0.00 $457.50 $724.68 $732.00 $0.00 $0.00 $143.20 $0.00 $0.00 $145.67 $0.00 $0.00 $0.00 $0.00 $0.00 53-34510 SUP HCPCS C1713 53-34510 - COVER BURR HOLE LP 10MM TAB UNIVERSAL NEURO III BOTH IP/OP $915.00 $677.10 $0.00 $732.00 $411.75 $411.75 $0.00 $0.00 $0.00 $190.71 $679.11 $679.11 $0.00 $0.00 $190.69 $0.00 $541.22 $541.22 $0.00 $457.50 $724.68 $732.00 $0.00 $0.00 $143.20 $0.00 $0.00 $145.67 $0.00 $0.00 $0.00 $0.00 $0.00 53-34514 SUP HCPCS C1713 53-34514 - COVER BURR HOLE LP 14MM TAB UNIVERSAL NEURO III BOTH IP/OP $915.00 $677.10 $0.00 $732.00 $411.75 $411.75 $0.00 $0.00 $0.00 $190.71 $679.11 $679.11 $0.00 $0.00 $190.69 $0.00 $541.22 $541.22 $0.00 $457.50 $724.68 $732.00 $0.00 $0.00 $143.20 $0.00 $0.00 $145.67 $0.00 $0.00 $0.00 $0.00 $0.00 53-34608 SUP HCPCS C1713 53-34608 - PLATE BN 2Y .4MM NS UNV NEURO III 6 HL LOPRFL BAR TI CRNMXF BOTH IP/OP "$1,002.50 " $741.85 $0.00 $802.00 $451.13 $451.13 $0.00 $0.00 $0.00 $208.95 $744.06 $744.06 $0.00 $0.00 $208.92 $0.00 $592.98 $592.98 $0.00 $501.25 $793.98 $802.00 $0.00 $0.00 $156.89 $0.00 $0.00 $159.60 $0.00 $0.00 $0.00 $0.00 $0.00 53-34612 SUP HCPCS C1713 53-34612 - PLATE BN SM GAP .4MM NS UNV NEURO III 6 HL LOPRFL TI CRNMXF BOTH IP/OP "$1,240.00 " $917.60 $0.00 $992.00 $558.00 $558.00 $0.00 $0.00 $0.00 $258.45 $920.33 $920.33 $0.00 $0.00 $258.42 $0.00 $733.46 $733.46 $0.00 $620.00 $982.08 $992.00 $0.00 $0.00 $194.06 $0.00 $0.00 $197.41 $0.00 $0.00 $0.00 $0.00 $0.00 53-34614 SUP HCPCS C1713 53-34614 - COVER BUR HL 14MMX.4MM NS UNV NEURO III LOPRFL SHNT TAB TI BOTH IP/OP "$1,002.50 " $741.85 $0.00 $802.00 $451.13 $451.13 $0.00 $0.00 $0.00 $208.95 $744.06 $744.06 $0.00 $0.00 $208.92 $0.00 $592.98 $592.98 $0.00 $501.25 $793.98 $802.00 $0.00 $0.00 $156.89 $0.00 $0.00 $159.60 $0.00 $0.00 $0.00 $0.00 $0.00 53-34620 SUP HCPCS C1713 53-34620 - COVER BUR HL 20MMX.4MM NS UNV NEURO III LOPRFL SHNT TAB TI BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 53-34622 SUP HCPCS C1713 53-34622 - PLATE BN LG GAP .4MM NS UNV NEURO III 6 HL LOPRFL TI CRNMXF BOTH IP/OP "$1,320.00 " $976.80 $0.00 "$1,056.00" $594.00 $594.00 $0.00 $0.00 $0.00 $275.12 $979.70 $979.70 $0.00 $0.00 $275.09 $0.00 $780.78 $780.78 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $206.58 $0.00 $0.00 $210.14 $0.00 $0.00 $0.00 $0.00 $0.00 53-34804 SUP HCPCS C1713 53-34804 - PLATE BN STRG .4MM NS UNV NEURO III 8 HL LOPRFL TI CRNMXF BOTH IP/OP $655.00 $484.70 $0.00 $524.00 $294.75 $294.75 $0.00 $0.00 $0.00 $136.52 $486.14 $486.14 $0.00 $0.00 $136.50 $0.00 $387.43 $387.43 $0.00 $327.50 $518.76 $524.00 $0.00 $0.00 $102.51 $0.00 $0.00 $104.28 $0.00 $0.00 $0.00 $0.00 $0.00 53-36212 SUP HCPCS C1713 53-36212 - PLATE BN DOG 12MMX.6MM NS UNV NEURO III 2 HL LOPRFL RGD TI BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 5-34-002 SUP Custom 27203010 CHEMICAL ALGAECIDE LQ 4OZ BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5357M/S SUP HCPCS C1785 5357M/S - PACEMAKER CRD 11ML VR XL 2 CHMBR BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 539G SUP Custom 27203010 539G - SUTURE SS 4-0 5-26 TS 14IN MFL DBL ARM BLK NABSB BOTH IP/OP $22.74 $16.83 $0.00 $18.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.88 $16.88 $0.00 $0.00 $4.74 $0.00 $0.00 $0.00 $0.00 $11.37 $18.01 $18.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 54-00261 SUP HCPCS C1713 54-00261 - PLATE BONE 120X60X.1MM MICROMESH TITANIUM BOTH IP/OP "$1,872.65 " "$1,385.76" $0.00 "$2,644.00" "$1,487.25" "$1,487.25" $0.00 $0.00 $0.00 $390.31 "$1,389.88" "$1,389.88" $0.00 $0.00 $390.26 $0.00 "$1,107.67" "$1,107.67" $0.00 "$1,652.50" "$2,617.56" "$2,644.00" $0.00 $0.00 $517.23 $0.00 $0.00 $526.16 $0.00 $0.00 $0.00 $0.00 $0.00 54-00262 SUP HCPCS C1713 54-00262 - MESH DYNAMIC MICRO ULTRA-THIN 60X60X.1MM MALBLE UNIVERSAL BOTH IP/OP "$1,085.40 " $803.20 $0.00 "$1,756.00" $987.75 $987.75 $0.00 $0.00 $0.00 $226.22 $805.58 $805.58 $0.00 $0.00 $226.20 $0.00 $642.01 $642.01 $0.00 "$1,097.50" "$1,738.44" "$1,756.00" $0.00 $0.00 $343.52 $0.00 $0.00 $349.44 $0.00 $0.00 $0.00 $0.00 $0.00 54-00272 SUP HCPCS C1713 54-00272 - MESH CRNL MIC 60X60X.2MM NS UNV NEURO III TI CRNMXF 1.2MM BOTH IP/OP "$1,085.40 " $803.20 $0.00 "$1,756.00" $987.75 $987.75 $0.00 $0.00 $0.00 $226.22 $805.58 $805.58 $0.00 $0.00 $226.20 $0.00 $642.01 $642.01 $0.00 "$1,097.50" "$1,738.44" "$1,756.00" $0.00 $0.00 $343.52 $0.00 $0.00 $349.44 $0.00 $0.00 $0.00 $0.00 $0.00 54-00345 SUP HCPCS C1713 54-00345 - MESH DYNAMIC LP 120X120X.3MM MALBLE BLUE TITANIUM BOTH IP/OP "$10,045.00 " "$7,433.30" $0.00 "$8,036.00" "$4,520.25" "$4,520.25" $0.00 $0.00 $0.00 "$2,093.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,093.38" $0.00 "$4,952.19" "$4,952.19" $0.00 "$5,022.50" "$7,955.64" "$8,036.00" $0.00 $0.00 "$1,572.04" $0.00 $0.00 "$1,599.16" $0.00 $0.00 $0.00 $0.00 $0.00 54-00346 SUP HCPCS C1713 54-00346 - MESH DYNAMIC LP 90X90X.3MM MALBLE BLUE TITANIUM BOTH IP/OP "$2,448.48 " "$1,811.88" $0.00 "$5,100.00" "$2,868.75" "$2,868.75" $0.00 $0.00 $0.00 $510.32 "$1,817.26" "$1,817.26" $0.00 $0.00 $510.26 $0.00 "$1,448.27" "$1,448.27" $0.00 "$3,187.50" "$5,049.00" "$5,100.00" $0.00 $0.00 $997.69 $0.00 $0.00 "$1,014.90" $0.00 $0.00 $0.00 $0.00 $0.00 54-00642 SUP HCPCS C1713 54-00642 - PLATE BONE 90X90X.6MM DYNAMIC MESH TITANIUM BOTH IP/OP "$2,989.85 " "$2,212.49" $0.00 "$5,106.00" "$2,872.13" "$2,872.13" $0.00 $0.00 $0.00 $623.16 "$2,219.07" "$2,219.07" $0.00 $0.00 $623.08 $0.00 "$1,474.00" "$1,474.00" $0.00 "$3,191.25" "$5,054.94" "$5,106.00" $0.00 $0.00 $998.86 $0.00 $0.00 "$1,016.09" $0.00 $0.00 $0.00 $0.00 $0.00 54-00643 SUP HCPCS C1713 54-00643 - PLATE BONE STANDARD 120X120X.6MM DYNAMIC MESH TITANIUM BOTH IP/OP "$5,197.40 " "$3,846.08" $0.00 "$8,292.00" "$4,664.25" "$4,664.25" $0.00 $0.00 $0.00 "$1,083.27" "$3,857.51" "$3,857.51" $0.00 $0.00 "$1,083.14" $0.00 "$2,562.32" "$2,562.32" $0.00 "$5,182.50" "$8,209.08" "$8,292.00" $0.00 $0.00 "$1,622.12" $0.00 $0.00 "$1,650.11" $0.00 $0.00 $0.00 $0.00 $0.00 54-00645 SUP HCPCS C1713 54-00645 - MESH DYNAMIC STANDARD 120X120X.6MM GOLD TITANIUM BOTH IP/OP "$10,365.00 " "$7,670.10" $0.00 "$8,292.00" "$4,664.25" "$4,664.25" $0.00 $0.00 $0.00 "$2,160.33" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,160.07" $0.00 "$5,109.95" "$5,109.95" $0.00 "$5,182.50" "$8,209.08" "$8,292.00" $0.00 $0.00 "$1,622.12" $0.00 $0.00 "$1,650.11" $0.00 $0.00 $0.00 $0.00 $0.00 54-00646 SUP HCPCS C1713 54-00646 - MESH DYNAMIC STANDARD 90X90X.6MM GOLD TITANIUM BOTH IP/OP "$2,448.48 " "$1,811.88" $0.00 "$5,106.00" "$2,872.13" "$2,872.13" $0.00 $0.00 $0.00 $510.32 "$1,817.26" "$1,817.26" $0.00 $0.00 $510.26 $0.00 "$1,448.27" "$1,448.27" $0.00 "$3,191.25" "$5,054.94" "$5,106.00" $0.00 $0.00 $998.86 $0.00 $0.00 "$1,016.09" $0.00 $0.00 $0.00 $0.00 $0.00 54-00647 SUP HCPCS C1713 54-00647 - MESH DYNAMIC STANDARD 200X200X.6MM GOLD TITANIUM BOTH IP/OP "$13,363.95 " "$9,889.32" $0.00 "$23,464.00" "$13,198.50" "$13,198.50" $0.00 $0.00 $0.00 "$2,785.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,785.05" $0.00 "$6,588.43" "$6,588.43" $0.00 "$14,665.00" "$23,229.36" "$23,464.00" $0.00 $0.00 "$4,590.15" $0.00 $0.00 "$4,669.34" $0.00 $0.00 $0.00 $0.00 $0.00 5400-701-000 SUP Custom 27203010 5400-701-000 - MILL BONE BIOP MED BIOP DISP BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-40A SUP Custom 27803010 540-11-40A - SHELL ACETAB A 40MM 41.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-42B SUP Custom 27803010 540-11-42B - SHELL ACETAB B 42MM 43.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-44C SUP Custom 27803010 540-11-44C - SHELL ACETAB C 44MM 45.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-46D SUP Custom 27803010 540-11-46D - SHELL ACETAB D 46MM 47.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-48D SUP Custom 27803010 540-11-48D - SHELL ACETAB D 48MM 49.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-50E SUP Custom 27803010 540-11-50E - SHELL ACETAB E 50MM 51.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-52E SUP Custom 27803010 540-11-52E - SHELL ACETAB E 52MM SOLID BACK DOME HOLE PLUG TRIDENT PSL HA BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-54F SUP Custom 27803010 540-11-54F - SHELL ACETAB F 54MM 55.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-56F SUP Custom 27803010 540-11-56F - SHELL ACETAB F 56MM 57.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-58G SUP Custom 27803010 540-11-58G - SHELL ACETAB G 58MM 59.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-60G SUP Custom 27803010 540-11-60G - SHELL ACETAB G 60MM 61.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-62H SUP Custom 27803010 540-11-62H - SHELL ACETAB H 62MM 63.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-64H SUP Custom 27803010 540-11-64H - SHELL ACETAB H 64MM 65.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-66I SUP Custom 27803010 540-11-66I - SHELL ACETAB I 66MM 67.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-68I SUP Custom 27803010 540-11-68I - SHELL ACETAB I 68MM 69.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-70J SUP Custom 27803010 540-11-70J - SHELL ACETAB J 70MM 71.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 540-11-72J SUP Custom 27803010 540-11-72J - SHELL ACETAB J 72MM 73.8MM SOLID BACK RIM TRIDENT PSL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 54-03000 SUP HCPCS C1713 54-03000 - TEMPLATE SZ SM STD 1.2MM CMBN ORBT PLT BOTH IP/OP $101.80 $75.33 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $21.22 $75.56 $75.56 $0.00 $0.00 $21.22 $0.00 $60.21 $60.21 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 54-03001 SUP HCPCS C1713 54-03001 - PLATE BONE LARGE 39X34X.3MM COMPLEX TITANIUM ORBTL FLOOR 1.2 BOTH IP/OP "$1,618.33 " "$1,197.56" $0.00 "$2,964.00" "$1,667.25" "$1,667.25" $0.00 $0.00 $0.00 $337.30 "$1,201.12" "$1,201.12" $0.00 $0.00 $337.26 $0.00 $957.24 $957.24 $0.00 "$1,852.50" "$2,934.36" "$2,964.00" $0.00 $0.00 $579.83 $0.00 $0.00 $589.84 $0.00 $0.00 $0.00 $0.00 $0.00 54-03002 SUP HCPCS C1713 54-03002 - PLATE BONE MEDIUM .3MM MALBLE BASIC UPPER FACE ORBTL FLOOR BOTH IP/OP "$3,477.50 " "$2,573.35" $0.00 "$2,782.00" "$1,564.88" "$1,564.88" $0.00 $0.00 $0.00 $724.80 "$2,581.00" "$2,581.00" $0.00 $0.00 $724.71 $0.00 "$1,714.41" "$1,714.41" $0.00 "$1,738.75" "$2,754.18" "$2,782.00" $0.00 $0.00 $544.23 $0.00 $0.00 $553.62 $0.00 $0.00 $0.00 $0.00 $0.00 54-03003 SUP HCPCS C1713 54-03003 - PLATE BONE SMALL 20X18X.3MM ISOLATED TITANIUM ORBTL FLOOR BOTH IP/OP "$3,260.00 " "$2,412.40" $0.00 "$2,608.00" "$1,467.00" "$1,467.00" $0.00 $0.00 $0.00 $679.47 "$2,419.57" "$2,419.57" $0.00 $0.00 $679.38 $0.00 "$1,607.18" "$1,607.18" $0.00 "$1,630.00" "$2,581.92" "$2,608.00" $0.00 $0.00 $510.19 $0.00 $0.00 $518.99 $0.00 $0.00 $0.00 $0.00 $0.00 54-04000 SUP HCPCS C1713 54-04000 - TEMPLATE SZ LG STD 1.2MM CMBN ORBT PLT BOTH IP/OP $97.45 $72.11 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $20.31 $72.33 $72.33 $0.00 $0.00 $20.31 $0.00 $57.64 $57.64 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 54-04001 SUP HCPCS C1713 54-04001 - PLATE BONE LARGE 30X32X.4MM COMPLEX TITANIUM ORBTL FLOOR 1.2 BOTH IP/OP "$3,705.00 " "$2,741.70" $0.00 "$2,964.00" "$1,667.25" "$1,667.25" $0.00 $0.00 $0.00 $772.21 "$2,749.85" "$2,749.85" $0.00 $0.00 $772.12 $0.00 "$1,826.57" "$1,826.57" $0.00 "$1,852.50" "$2,934.36" "$2,964.00" $0.00 $0.00 $579.83 $0.00 $0.00 $589.84 $0.00 $0.00 $0.00 $0.00 $0.00 54-04002 SUP HCPCS C1713 54-04002 - PLATE BN MED BSC STD .4MM NS LEIBINGER UNV 2 TI ORBT FLR 1.2 BOTH IP/OP "$1,517.68 " "$1,123.08" $0.00 "$2,782.00" "$1,564.88" "$1,564.88" $0.00 $0.00 $0.00 $316.32 "$1,126.42" "$1,126.42" $0.00 $0.00 $316.28 $0.00 $897.70 $897.70 $0.00 "$1,738.75" "$2,754.18" "$2,782.00" $0.00 $0.00 $544.23 $0.00 $0.00 $553.62 $0.00 $0.00 $0.00 $0.00 $0.00 54-04004 SUP HCPCS C1713 54-04004 - PLATE BONE 3D SMALL PREBENT ORBTL FLOOR RIGHT BOTH IP/OP "$3,482.20 " "$2,576.83" $0.00 "$3,316.00" "$1,865.25" "$1,865.25" $0.00 $0.00 $0.00 $725.78 "$2,584.49" "$2,584.49" $0.00 $0.00 $725.69 $0.00 "$1,716.72" "$1,716.72" $0.00 "$2,072.50" "$3,282.84" "$3,316.00" $0.00 $0.00 $648.69 $0.00 $0.00 $659.88 $0.00 $0.00 $0.00 $0.00 $0.00 54-04007 SUP HCPCS C1713 54-04007 - PLATE BONE 3D LARGE PREBENT ORBTL FLOOR LEFT BOTH IP/OP "$3,482.20 " "$2,576.83" $0.00 "$3,316.00" "$1,865.25" "$1,865.25" $0.00 $0.00 $0.00 $725.78 "$2,584.49" "$2,584.49" $0.00 $0.00 $725.69 $0.00 "$1,716.72" "$1,716.72" $0.00 "$2,072.50" "$3,282.84" "$3,316.00" $0.00 $0.00 $648.69 $0.00 $0.00 $659.88 $0.00 $0.00 $0.00 $0.00 $0.00 54-05100 SUP Custom 27803010 54-05100 - CLIP FIX TITANIUM CRANIAL 1.5 MM 1.7 MM SCREW BOTH IP/OP $351.80 $260.33 $0.00 $281.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $261.10 $261.10 $0.00 $0.00 $73.31 $0.00 $0.00 $0.00 $0.00 $175.90 $278.63 $281.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 54051T SUP HCPCS Q4108 54051T - DRESSING WND THN 5X4IN STRL BVN CLGN GAG DISP BOTH IP/OP $457.19 $338.32 $0.00 $365.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.60 $362.09 $365.75 $0.00 $0.00 $39.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5407FA1015 SUP Custom 27203010 5407FA1015 - ROUTER POWER TAPER 1.5MM 12MM LATEX FREE BOTH IP/OP $301.68 $223.24 $0.00 $241.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.90 $223.90 $0.00 $0.00 $62.87 $0.00 $0.00 $0.00 $0.00 $150.84 $238.93 $241.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5407FA2023 SUP Custom 27203010 5407FA2023 - ROUTER POWER TAPER 2.3MM LATEX FREE BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $0.00 $0.00 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5407FA3030 SUP Custom 27203010 5407FA3030 - BURR SRG TPR 3MM WHT ROUT BOTH IP/OP $288.78 $213.70 $0.00 $231.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.33 $214.33 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.39 $228.71 $231.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5413-20/5 SUP HCPCS C1713 5413-20/5 - COMPONENT HUM STD ECCENTER STRL EPOCA TI SHLDR BOTH IP/OP "$1,004.35 " $743.22 $0.00 $803.48 $451.96 $451.96 $0.00 $0.00 $0.00 $209.33 $745.43 $745.43 $0.00 $0.00 $209.31 $0.00 $594.07 $594.07 $0.00 $502.18 $795.45 $803.48 $0.00 $0.00 $157.18 $0.00 $0.00 $159.89 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-40A SUP Custom 27803010 542-11-40A - SHELL ACETAB A 40MM 41.8MM 3 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-42B SUP Custom 27803010 542-11-42B - SHELL ACETAB B 42MM 43.8MM 3 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-44C SUP Custom 27803010 542-11-44C - SHELL ACETAB C 44MM 45.8MM 3 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-46D SUP Custom 27803010 542-11-46D - SHELL ACETAB D 46MM 47.8MM 3 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-48D SUP Custom 27803010 542-11-48D - SHELL ACETAB D 48MM 49.8MM 3 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-50E SUP Custom 27803010 542-11-50E - SHELL ACETAB E 50MM 51.8MM 5 HOLE CLUSTER TRIDENT PSL BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-52E SUP Custom 27803010 542-11-52E - SHELL ACETAB E 52MM 53.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-54F SUP Custom 27803010 542-11-54F - SHELL ACETAB F 54MM 55.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-56F SUP Custom 27803010 542-11-56F - SHELL ACETAB F 56MM 57.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-58G SUP Custom 27803010 542-11-58G - SHELL ACETAB G 58MM 59.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-60G SUP Custom 27803010 542-11-60G - SHELL ACETAB G 60MM 61.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-62H SUP Custom 27803010 542-11-62H - SHELL ACETAB H 62MM 63.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-64H SUP Custom 27803010 542-11-64H - SHELL ACETAB H 64MM 65.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-66I SUP Custom 27803010 542-11-66I - SHELL ACETAB I 66MM 67.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-68I SUP Custom 27803010 542-11-68I - SHELL ACETAB I 68MM 69.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-70J SUP Custom 27803010 542-11-70J - SHELL ACETAB J 70MM 71.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542-11-72J SUP Custom 27803010 542-11-72J - SHELL ACETAB J 72MM 73.8MM 5 SCREW HOLE CLUSTER RIM TRIDENT BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 54-25240 SUP HCPCS C1713 54-25240 - PLATE SHRT 2.7MM SCR 8 HOLE RECON BONE RIGHT RADL BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $222.75 $222.75 $0.00 $0.00 $0.00 $103.17 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $292.79 $292.79 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $77.47 $0.00 $0.00 $78.80 $0.00 $0.00 $0.00 $0.00 $0.00 54-25241 SUP HCPCS C1713 54-25241 - PLATE SM 2.7MM SCR 8 HOLE RECON BONE RIGHT RADL BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $222.75 $222.75 $0.00 $0.00 $0.00 $103.17 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $292.79 $292.79 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $77.47 $0.00 $0.00 $78.80 $0.00 $0.00 $0.00 $0.00 $0.00 54-25242 SUP HCPCS C1713 54-25242 - PLATE SHRT 2.7MM SCR 8 HOLE RECON BONE LEFT RADL BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $222.75 $222.75 $0.00 $0.00 $0.00 $103.17 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $292.79 $292.79 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $77.47 $0.00 $0.00 $78.80 $0.00 $0.00 $0.00 $0.00 $0.00 54-25243 SUP HCPCS C1713 54-25243 - PLATE SM 2.7MM SCR 8 HOLE RECON BONE LEFT RADL BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $222.75 $222.75 $0.00 $0.00 $0.00 $103.17 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $292.79 $292.79 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $77.47 $0.00 $0.00 $78.80 $0.00 $0.00 $0.00 $0.00 $0.00 54-25244 SUP HCPCS C1713 54-25244 - PLATE LNG 2.7MM SCR 11 HOLE RECON BONE RIGHT RADL BOTH IP/OP $591.25 $437.53 $0.00 $473.00 $266.06 $266.06 $0.00 $0.00 $0.00 $123.23 $438.83 $438.83 $0.00 $0.00 $123.22 $0.00 $349.72 $349.72 $0.00 $295.63 $468.27 $473.00 $0.00 $0.00 $92.53 $0.00 $0.00 $94.13 $0.00 $0.00 $0.00 $0.00 $0.00 54-25246 SUP HCPCS C1713 54-25246 - PLATE LNG 2.7MM SCR 11 HOLE RECON BONE LEFT RADL BOTH IP/OP $591.25 $437.53 $0.00 $473.00 $266.06 $266.06 $0.00 $0.00 $0.00 $123.23 $438.83 $438.83 $0.00 $0.00 $123.22 $0.00 $349.72 $349.72 $0.00 $295.63 $468.27 $473.00 $0.00 $0.00 $92.53 $0.00 $0.00 $94.13 $0.00 $0.00 $0.00 $0.00 $0.00 54-25250 SUP HCPCS C1713 54-25250 - PLATE REG 2.7MM SCR 6 HOLE RECON BONE RIGHT RADL BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $194.91 $194.91 $0.00 $0.00 $0.00 $90.27 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $256.19 $256.19 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $67.78 $0.00 $0.00 $68.95 $0.00 $0.00 $0.00 $0.00 $0.00 54-25251 SUP HCPCS C1713 54-25251 - PLATE REG 2.7MM SCR 6 HOLE RECON BONE LEFT RADL BOTH IP/OP $433.13 $320.52 $0.00 $346.50 $194.91 $194.91 $0.00 $0.00 $0.00 $90.27 $321.47 $321.47 $0.00 $0.00 $90.26 $0.00 $256.19 $256.19 $0.00 $216.56 $343.04 $346.50 $0.00 $0.00 $67.78 $0.00 $0.00 $68.95 $0.00 $0.00 $0.00 $0.00 $0.00 54-25252 SUP HCPCS C1713 54-25252 - PLATE REG 2.7MM SCR 7 HOLE RECON BONE RIGHT RADL BOTH IP/OP $474.38 $351.04 $0.00 $379.50 $213.47 $213.47 $0.00 $0.00 $0.00 $98.87 $352.08 $352.08 $0.00 $0.00 $98.86 $0.00 $280.59 $280.59 $0.00 $237.19 $375.71 $379.50 $0.00 $0.00 $74.24 $0.00 $0.00 $75.52 $0.00 $0.00 $0.00 $0.00 $0.00 54-25253 SUP HCPCS C1713 54-25253 - PLATE REG 2.7MM SCR 7 HOLE RECON BONE LEFT RADL BOTH IP/OP $474.38 $351.04 $0.00 $379.50 $213.47 $213.47 $0.00 $0.00 $0.00 $98.87 $352.08 $352.08 $0.00 $0.00 $98.86 $0.00 $280.59 $280.59 $0.00 $237.19 $375.71 $379.50 $0.00 $0.00 $74.24 $0.00 $0.00 $75.52 $0.00 $0.00 $0.00 $0.00 $0.00 54-25254 SUP HCPCS C1713 54-25254 - PLATE REG 2.7MM SCR 8 HOLE RECON BONE RIGHT RADL BOTH IP/OP $577.50 $427.35 $0.00 $462.00 $259.88 $259.88 $0.00 $0.00 $0.00 $120.37 $428.62 $428.62 $0.00 $0.00 $120.35 $0.00 $341.59 $341.59 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 54-25255 SUP HCPCS C1713 54-25255 - PLATE REG 2.7MM SCR 8 HOLE RECON BONE LEFT RADL BOTH IP/OP $577.50 $427.35 $0.00 $462.00 $259.88 $259.88 $0.00 $0.00 $0.00 $120.37 $428.62 $428.62 $0.00 $0.00 $120.35 $0.00 $341.59 $341.59 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 54-25270 SUP HCPCS C1713 54-25270 - PLATE MED BONE PLMR RADL BOTH IP/OP $790.63 $585.07 $0.00 $632.50 $355.78 $355.78 $0.00 $0.00 $0.00 $164.79 $586.80 $586.80 $0.00 $0.00 $164.77 $0.00 $467.65 $467.65 $0.00 $395.31 $626.18 $632.50 $0.00 $0.00 $123.73 $0.00 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $0.00 54-25271 SUP HCPCS C1713 54-25271 - PLATE MED BONE LEFT DORSAL RADL BOTH IP/OP $790.63 $585.07 $0.00 $632.50 $355.78 $355.78 $0.00 $0.00 $0.00 $164.79 $586.80 $586.80 $0.00 $0.00 $164.77 $0.00 $467.65 $467.65 $0.00 $395.31 $626.18 $632.50 $0.00 $0.00 $123.73 $0.00 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $0.00 54-25272 SUP HCPCS C1713 54-25272 - PLATE MED BONE LEFT DORSAL RADL BOTH IP/OP $790.63 $585.07 $0.00 $632.50 $355.78 $355.78 $0.00 $0.00 $0.00 $164.79 $586.80 $586.80 $0.00 $0.00 $164.77 $0.00 $467.65 $467.65 $0.00 $395.31 $626.18 $632.50 $0.00 $0.00 $123.73 $0.00 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $0.00 54-25273 SUP HCPCS C1713 54-25273 - PLATE LG BONE LEFT DORSAL RADL BOTH IP/OP $790.63 $585.07 $0.00 $632.50 $355.78 $355.78 $0.00 $0.00 $0.00 $164.79 $586.80 $586.80 $0.00 $0.00 $164.77 $0.00 $467.65 $467.65 $0.00 $395.31 $626.18 $632.50 $0.00 $0.00 $123.73 $0.00 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $0.00 54-25274 SUP HCPCS C1713 54-25274 - PLATE MED BONE RIGHT DORSAL RADL BOTH IP/OP $790.63 $585.07 $0.00 $632.50 $355.78 $355.78 $0.00 $0.00 $0.00 $164.79 $586.80 $586.80 $0.00 $0.00 $164.77 $0.00 $467.65 $467.65 $0.00 $395.31 $626.18 $632.50 $0.00 $0.00 $123.73 $0.00 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $0.00 54-25275 SUP HCPCS C1713 54-25275 - PLATE LG BONE RIGHT DORSAL RADL BOTH IP/OP $790.63 $585.07 $0.00 $632.50 $355.78 $355.78 $0.00 $0.00 $0.00 $164.79 $586.80 $586.80 $0.00 $0.00 $164.77 $0.00 $467.65 $467.65 $0.00 $395.31 $626.18 $632.50 $0.00 $0.00 $123.73 $0.00 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $0.00 54-25290 SUP HCPCS C1713 54-25290 - PLATE BN STD VARIAX LCK TI RDS RT DIST DRSL BOTH IP/OP "$1,656.00 " "$1,225.44" $0.00 "$1,229.08" $511.09 $511.09 $0.00 $0.00 $0.00 $345.15 "$1,229.08" "$1,229.08" $0.00 $0.00 $345.11 $0.00 $979.52 $979.52 $0.00 $567.88 $899.51 $908.60 $0.00 $0.00 $177.74 $0.00 $0.00 $180.81 $0.00 $0.00 $0.00 $0.00 $0.00 54-25291 SUP HCPCS C1713 54-25291 - PLATE MED STD ORBTL FLR BONE SMARTLOCK TI BOTH IP/OP "$1,656.00 " "$1,225.44" $0.00 "$1,229.08" $511.09 $511.09 $0.00 $0.00 $0.00 $345.15 "$1,229.08" "$1,229.08" $0.00 $0.00 $345.11 $0.00 $979.52 $979.52 $0.00 $567.88 $899.51 $908.60 $0.00 $0.00 $177.74 $0.00 $0.00 $180.81 $0.00 $0.00 $0.00 $0.00 $0.00 54-25292 SUP HCPCS C1713 54-25292 - PLATE W TI LCK VARIAX BONE RIGHT DISTAL DORSAL RADL BOTH IP/OP "$1,656.00 " "$1,225.44" $0.00 "$1,229.08" $511.09 $511.09 $0.00 $0.00 $0.00 $345.15 "$1,229.08" "$1,229.08" $0.00 $0.00 $345.11 $0.00 $979.52 $979.52 $0.00 $567.88 $899.51 $908.60 $0.00 $0.00 $177.74 $0.00 $0.00 $180.81 $0.00 $0.00 $0.00 $0.00 $0.00 54-25293 SUP HCPCS C1713 54-25293 - PLATE W LCK VARIAX BONE LEFT DISTAL DORSAL RADL BOTH IP/OP "$1,656.00 " "$1,225.44" $0.00 "$1,229.08" $511.09 $511.09 $0.00 $0.00 $0.00 $345.15 "$1,229.08" "$1,229.08" $0.00 $0.00 $345.11 $0.00 $979.52 $979.52 $0.00 $567.88 $899.51 $908.60 $0.00 $0.00 $177.74 $0.00 $0.00 $180.81 $0.00 $0.00 $0.00 $0.00 $0.00 54-25294 SUP HCPCS C1713 54-25294 - PLATE STD XLNG LCK VARIAX BONE RIGHT DISTAL DORSAL RADL BOTH IP/OP "$1,911.00 " "$1,414.14" $0.00 "$1,418.34" $581.01 $581.01 $0.00 $0.00 $0.00 $398.30 "$1,418.34" "$1,418.34" $0.00 $0.00 $398.25 $0.00 "$1,130.36" "$1,130.36" $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25295 SUP HCPCS C1713 54-25295 - PLATE STD XLNG LCK VARIAX BONE LEFT DISTAL DORSAL RADL BOTH IP/OP "$1,911.00 " "$1,414.14" $0.00 "$1,418.34" $581.01 $581.01 $0.00 $0.00 $0.00 $398.30 "$1,418.34" "$1,418.34" $0.00 $0.00 $398.25 $0.00 "$1,130.36" "$1,130.36" $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25296 SUP HCPCS C1713 54-25296 - PLATE XLNG LCK W VARIAX BONE RIGHT DISTAL DORSAL RADL BOTH IP/OP "$1,911.00 " "$1,414.14" $0.00 "$1,418.34" $581.01 $581.01 $0.00 $0.00 $0.00 $398.30 "$1,418.34" "$1,418.34" $0.00 $0.00 $398.25 $0.00 "$1,130.36" "$1,130.36" $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25297 SUP HCPCS C1713 54-25297 - PLATE XLNG LCK W VARIAX BONE LEFT DISTAL DORSAL RADL BOTH IP/OP "$1,911.00 " "$1,414.14" $0.00 "$1,418.34" $581.01 $581.01 $0.00 $0.00 $0.00 $398.30 "$1,418.34" "$1,418.34" $0.00 $0.00 $398.25 $0.00 "$1,130.36" "$1,130.36" $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25374 SUP HCPCS C1713 54-25374 - PLATE NAR LCK PLT SYS ANTM VARIAX BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,206.08" $618.13 $618.13 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25375 SUP HCPCS C1713 54-25375 - PLATE NAR LNG LCK ANTM VARIAX BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,877.00 " "$1,388.98" $0.00 "$1,393.11" $618.13 $618.13 $0.00 $0.00 $0.00 $391.21 "$1,393.11" "$1,393.11" $0.00 $0.00 $391.17 $0.00 "$1,110.25" "$1,110.25" $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25376 SUP HCPCS C1713 54-25376 - PLATE STD LCK SYS ANTM VARIAX BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,206.08" $618.13 $618.13 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25377 SUP HCPCS C1713 54-25377 - PLATE STD LNG LCK PLT SYS ANTM VARIAX BONE LEFT DISTAL VOLR BOTH IP/OP "$1,877.00 " "$1,388.98" $0.00 "$1,393.11" $618.13 $618.13 $0.00 $0.00 $0.00 $391.21 "$1,393.11" "$1,393.11" $0.00 $0.00 $391.17 $0.00 "$1,110.25" "$1,110.25" $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25384 SUP HCPCS C1713 54-25384 - PLATE NAR LCK SYS ANTM VARIAX BONE RIGHT DISTAL VOLR RADL BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,206.08" $618.13 $618.13 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25385 SUP HCPCS C1713 54-25385 - PLATE BN NAR LNG VARIAX ANTM LCK TI RADL RT DIST VOLR BOTH IP/OP "$1,877.00 " "$1,388.98" $0.00 "$1,393.11" $618.13 $618.13 $0.00 $0.00 $0.00 $391.21 "$1,393.11" "$1,393.11" $0.00 $0.00 $391.17 $0.00 "$1,110.25" "$1,110.25" $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25386 SUP HCPCS C1713 54-25386 - PLATE STD LCK SYS ANTM VARIAX BONE RIGHT DISTAL VOLR RADL BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,206.08" $618.13 $618.13 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25387 SUP HCPCS C1713 54-25387 - PLATE STD LNG LCK SYS ANTM VARIAX BONE RIGHT DISTAL VOLR BOTH IP/OP "$1,877.00 " "$1,388.98" $0.00 "$1,393.11" $618.13 $618.13 $0.00 $0.00 $0.00 $391.21 "$1,393.11" "$1,393.11" $0.00 $0.00 $391.17 $0.00 "$1,110.25" "$1,110.25" $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25391 SUP HCPCS C1713 54-25391 - PLATE NAR XLNG UNV TI LCK VARIAX BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,469.00 " "$1,087.06" $0.00 "$1,098.90" $618.13 $618.13 $0.00 $0.00 $0.00 $306.18 "$1,090.29" "$1,090.29" $0.00 $0.00 $306.14 $0.00 $868.91 $868.91 $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25392 SUP HCPCS C1713 54-25392 - PLATE XLNG STD UNV TI LCK VARIAX BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,469.00 " "$1,087.06" $0.00 "$1,098.90" $618.13 $618.13 $0.00 $0.00 $0.00 $306.18 "$1,090.29" "$1,090.29" $0.00 $0.00 $306.14 $0.00 $868.91 $868.91 $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25393 SUP HCPCS C1713 54-25393 - PLATE XLNG UNV TI LCK W VARIAX BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,469.00 " "$1,087.06" $0.00 "$1,098.90" $618.13 $618.13 $0.00 $0.00 $0.00 $306.18 "$1,090.29" "$1,090.29" $0.00 $0.00 $306.14 $0.00 $868.91 $868.91 $0.00 $686.81 "$1,087.91" "$1,098.90" $0.00 $0.00 $214.97 $0.00 $0.00 $218.68 $0.00 $0.00 $0.00 $0.00 $0.00 54-25394 SUP HCPCS C1713 54-25394 - PLATE NAR SHRT TI LCK VARIAX BONE DISTAL VOLR RADL BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,032.90" $581.01 $581.01 $0.00 $0.00 $0.00 $286.17 "$1,019.04" "$1,019.04" $0.00 $0.00 $286.13 $0.00 $812.13 $812.13 $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25395 SUP HCPCS C1713 54-25395 - PLATE NAR LNG UNV TI LCK VARIAX BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,032.90" $581.01 $581.01 $0.00 $0.00 $0.00 $286.17 "$1,019.04" "$1,019.04" $0.00 $0.00 $286.13 $0.00 $812.13 $812.13 $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25396 SUP HCPCS C1713 54-25396 - PLATE UNV STD SHRT LCK VARIAX BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,032.90" $581.01 $581.01 $0.00 $0.00 $0.00 $286.17 "$1,019.04" "$1,019.04" $0.00 $0.00 $286.13 $0.00 $812.13 $812.13 $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25397 SUP HCPCS C1713 54-25397 - PLATE UNV STD LNG LCK VARIAX BONE RADL DISTAL VOLR BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,032.90" $581.01 $581.01 $0.00 $0.00 $0.00 $286.17 "$1,019.04" "$1,019.04" $0.00 $0.00 $286.13 $0.00 $812.13 $812.13 $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25398 SUP HCPCS C1713 54-25398 - PLATE UNV W SHRT LCK VARIAX BONE RADL DISTAL VOLR BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,032.90" $581.01 $581.01 $0.00 $0.00 $0.00 $286.17 "$1,019.04" "$1,019.04" $0.00 $0.00 $286.13 $0.00 $812.13 $812.13 $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25399 SUP HCPCS C1713 54-25399 - PLATE UNV W LNG LCK VARIAX BONE RADL DISTAL VOLR BOTH IP/OP "$1,373.00 " "$1,016.02" $0.00 "$1,032.90" $581.01 $581.01 $0.00 $0.00 $0.00 $286.17 "$1,019.04" "$1,019.04" $0.00 $0.00 $286.13 $0.00 $812.13 $812.13 $0.00 $645.56 "$1,022.57" "$1,032.90" $0.00 $0.00 $202.06 $0.00 $0.00 $205.55 $0.00 $0.00 $0.00 $0.00 $0.00 54-25400 SUP HCPCS C1713 54-25400 - PLATE SHRT TI CLMN FRAG SPC VARIAX BONE RADL BOTH IP/OP "$1,210.00 " $895.40 $0.00 $898.06 $417.66 $417.66 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $464.06 $735.08 $742.50 $0.00 $0.00 $145.25 $0.00 $0.00 $147.76 $0.00 $0.00 $0.00 $0.00 $0.00 54-25401 SUP HCPCS C1713 54-25401 - PLATE LNG TI CLMN SMARTLOCK BONE VOLR RADL BOTH IP/OP "$1,210.00 " $895.40 $0.00 $898.06 $417.66 $417.66 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $464.06 $735.08 $742.50 $0.00 $0.00 $145.25 $0.00 $0.00 $147.76 $0.00 $0.00 $0.00 $0.00 $0.00 54-25402 SUP HCPCS C1713 54-25402 - PLATE SHRT TI CLMN SMARTLOCK BONE RIGHT DISTAL ULN BOTH IP/OP "$1,210.00 " $895.40 $0.00 $898.06 $417.66 $417.66 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $464.06 $735.08 $742.50 $0.00 $0.00 $145.25 $0.00 $0.00 $147.76 $0.00 $0.00 $0.00 $0.00 $0.00 54-25403 SUP HCPCS C1713 54-25403 - PLATE BN SHRT 40MMX1MM VARIAX LCK CLMN TI ULNA LT FRAG SPC BOTH IP/OP "$1,210.00 " $895.40 $0.00 $898.06 $417.66 $417.66 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $464.06 $735.08 $742.50 $0.00 $0.00 $145.25 $0.00 $0.00 $147.76 $0.00 $0.00 $0.00 $0.00 $0.00 54-25404 SUP HCPCS C1713 54-25404 - PLATE LNG LCK CLMN FRAG SPC VARIAX BONE RIGHT RADL DISTAL BOTH IP/OP "$1,210.00 " $895.40 $0.00 $898.06 $417.66 $417.66 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $464.06 $735.08 $742.50 $0.00 $0.00 $145.25 $0.00 $0.00 $147.76 $0.00 $0.00 $0.00 $0.00 $0.00 54-25405 SUP HCPCS C1713 54-25405 - PLATE LNG TI CLMN SMARTLOCK BONE LEFT RADL DISTAL ULN BOTH IP/OP "$1,210.00 " $895.40 $0.00 $898.06 $417.66 $417.66 $0.00 $0.00 $0.00 $252.19 $898.06 $898.06 $0.00 $0.00 $252.16 $0.00 $715.72 $715.72 $0.00 $464.06 $735.08 $742.50 $0.00 $0.00 $145.25 $0.00 $0.00 $147.76 $0.00 $0.00 $0.00 $0.00 $0.00 54-25420S SUP HCPCS C1713 54-25420S - PLATE 2XL THK3MM 189MM 15 HOLE ANTM STND BONE 2.7MM LEFT BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,334.22" "$1,218.94" "$1,218.94" $0.00 $0.00 $0.00 $655.50 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 "$1,550.49" "$1,550.49" $0.00 "$1,354.38" "$2,145.33" "$2,167.00" $0.00 $0.00 $423.92 $0.00 $0.00 $431.23 $0.00 $0.00 $0.00 $0.00 $0.00 54-25422S SUP HCPCS C1713 54-25422S - PLATE 2XL THK3MM 189MM 15 HOLE ANTM STND BONE 2.7MM RIGHT BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,334.22" "$1,218.94" "$1,218.94" $0.00 $0.00 $0.00 $655.50 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 "$1,550.49" "$1,550.49" $0.00 "$1,354.38" "$2,145.33" "$2,167.00" $0.00 $0.00 $423.92 $0.00 $0.00 $431.23 $0.00 $0.00 $0.00 $0.00 $0.00 54-25424S SUP HCPCS C1713 54-25424S - PLATE BN 2XL 189MMX3MM STRL 15 HL ANTM STND RADL RT DIST BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,334.22" "$1,163.25" "$1,163.25" $0.00 $0.00 $0.00 $655.50 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 "$1,550.49" "$1,550.49" $0.00 "$1,292.50" "$2,047.32" "$2,068.00" $0.00 $0.00 $404.55 $0.00 $0.00 $411.53 $0.00 $0.00 $0.00 $0.00 $0.00 54-25426S SUP HCPCS C1713 54-25426S - PLATE STD 145MM 2.7MM SCR 11 HOLE BONE RIGHT DISTAL VOLR BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,334.22" "$1,163.25" "$1,163.25" $0.00 $0.00 $0.00 $655.50 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 "$1,550.49" "$1,550.49" $0.00 "$1,292.50" "$2,047.32" "$2,068.00" $0.00 $0.00 $404.55 $0.00 $0.00 $411.53 $0.00 $0.00 $0.00 $0.00 $0.00 54-25428S SUP HCPCS C1713 54-25428S - PLATE 2XL THK3MM STD 100MM 8 HOLE ANTM BONE LEFT DISTAL VOLR BOTH IP/OP "$2,751.00 " "$2,035.74" $0.00 "$2,041.79" "$1,126.13" "$1,126.13" $0.00 $0.00 $0.00 $573.38 "$2,041.79" "$2,041.79" $0.00 $0.00 $573.31 $0.00 "$1,356.24" "$1,356.24" $0.00 "$1,251.25" "$1,981.98" "$2,002.00" $0.00 $0.00 $391.64 $0.00 $0.00 $398.40 $0.00 $0.00 $0.00 $0.00 $0.00 54-25430S SUP HCPCS C1713 54-25430S - PLATE 2XL STD 100MMX3MM 2.7MM SCR 8 HOLE ANTM BONE RIGHT BOTH IP/OP "$2,751.00 " "$2,035.74" $0.00 "$2,041.79" "$1,126.13" "$1,126.13" $0.00 $0.00 $0.00 $573.38 "$2,041.79" "$2,041.79" $0.00 $0.00 $573.31 $0.00 "$1,356.24" "$1,356.24" $0.00 "$1,251.25" "$1,981.98" "$2,002.00" $0.00 $0.00 $391.64 $0.00 $0.00 $398.40 $0.00 $0.00 $0.00 $0.00 $0.00 54-25432S SUP HCPCS C1713 54-25432S - PLATE 2XL THK3MM 74MM 2.7MM SCR 5 HOLE VARIAX BONE 2.7MM BOTH IP/OP "$2,751.00 " "$2,035.74" $0.00 "$2,041.79" "$1,089.00" "$1,089.00" $0.00 $0.00 $0.00 $573.38 "$2,041.79" "$2,041.79" $0.00 $0.00 $573.31 $0.00 "$1,356.24" "$1,356.24" $0.00 "$1,210.00" "$1,916.64" "$1,936.00" $0.00 $0.00 $378.73 $0.00 $0.00 $385.26 $0.00 $0.00 $0.00 $0.00 $0.00 54-25434S SUP HCPCS C1713 54-25434S - PLATE 2XL THK3MM 74MM 5 HOLE ANTM STND BONE 2.7MM RIGHT VOLR BOTH IP/OP "$2,751.00 " "$2,035.74" $0.00 "$2,041.79" "$1,089.00" "$1,089.00" $0.00 $0.00 $0.00 $573.38 "$2,041.79" "$2,041.79" $0.00 $0.00 $573.31 $0.00 "$1,356.24" "$1,356.24" $0.00 "$1,210.00" "$1,916.64" "$1,936.00" $0.00 $0.00 $378.73 $0.00 $0.00 $385.26 $0.00 $0.00 $0.00 $0.00 $0.00 54-25436S SUP HCPCS C1713 54-25436S - PLATE 2XL THK3MM 189MM 15 HOLE ANTM NAR BONE 2.7MM LEFT VOLR BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,334.22" "$1,188.00" "$1,188.00" $0.00 $0.00 $0.00 $655.50 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 "$1,550.49" "$1,550.49" $0.00 "$1,320.00" "$2,090.88" "$2,112.00" $0.00 $0.00 $413.16 $0.00 $0.00 $420.29 $0.00 $0.00 $0.00 $0.00 $0.00 54-25438S SUP HCPCS C1713 54-25438S - PLATE 2XL THK3MM 189MM 15 HOLE ANTM NAR BONE 2.7MM RIGHT BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,334.22" "$1,188.00" "$1,188.00" $0.00 $0.00 $0.00 $655.50 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 "$1,550.49" "$1,550.49" $0.00 "$1,320.00" "$2,090.88" "$2,112.00" $0.00 $0.00 $413.16 $0.00 $0.00 $420.29 $0.00 $0.00 $0.00 $0.00 $0.00 54-25440S SUP HCPCS C1713 54-25440S - PLATE 2XL THK3MM 145MM 11 HOLE ANTM NAR BONE 2.7MM LEFT VOLR BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,334.22" "$1,132.31" "$1,132.31" $0.00 $0.00 $0.00 $655.50 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 "$1,550.49" "$1,550.49" $0.00 "$1,258.13" "$1,992.87" "$2,013.00" $0.00 $0.00 $393.79 $0.00 $0.00 $400.59 $0.00 $0.00 $0.00 $0.00 $0.00 54-25442S SUP HCPCS C1713 54-25442S - PLATE 2XL 145MMX3MM 2.7MM SCR 11 HOLE ANTM NAR VARIAX BONE BOTH IP/OP "$3,145.00 " "$2,327.30" $0.00 "$2,334.22" "$1,132.31" "$1,132.31" $0.00 $0.00 $0.00 $655.50 "$2,334.22" "$2,334.22" $0.00 $0.00 $655.42 $0.00 "$1,550.49" "$1,550.49" $0.00 "$1,258.13" "$1,992.87" "$2,013.00" $0.00 $0.00 $393.79 $0.00 $0.00 $400.59 $0.00 $0.00 $0.00 $0.00 $0.00 54-25444S SUP HCPCS C1713 54-25444S - PLATE 2XL NAR 2.7MM SCR 8 HOLE ANTM BONE LEFT DISTAL VOLR BOTH IP/OP "$2,751.00 " "$2,035.74" $0.00 "$2,041.79" "$1,095.19" "$1,095.19" $0.00 $0.00 $0.00 $573.38 "$2,041.79" "$2,041.79" $0.00 $0.00 $573.31 $0.00 "$1,356.24" "$1,356.24" $0.00 "$1,216.88" "$1,927.53" "$1,947.00" $0.00 $0.00 $380.88 $0.00 $0.00 $387.45 $0.00 $0.00 $0.00 $0.00 $0.00 54-25446S SUP HCPCS C1713 54-25446S - PLATE 2XL 100MMX3MM 2.7MM SCR 8 HOLE ANTM NAR VARIAX BONE BOTH IP/OP "$2,751.00 " "$2,035.74" $0.00 "$2,041.79" "$1,095.19" "$1,095.19" $0.00 $0.00 $0.00 $573.38 "$2,041.79" "$2,041.79" $0.00 $0.00 $573.31 $0.00 "$1,356.24" "$1,356.24" $0.00 "$1,216.88" "$1,927.53" "$1,947.00" $0.00 $0.00 $380.88 $0.00 $0.00 $387.45 $0.00 $0.00 $0.00 $0.00 $0.00 54-25448S SUP HCPCS C1713 54-25448S - PLATE 2XL NAR 2.7MM SCR 5 HOLE ANTM BONE LEFT DISTAL VOLR BOTH IP/OP "$2,751.00 " "$2,035.74" $0.00 "$2,041.79" "$1,058.06" "$1,058.06" $0.00 $0.00 $0.00 $573.38 "$2,041.79" "$2,041.79" $0.00 $0.00 $573.31 $0.00 "$1,356.24" "$1,356.24" $0.00 "$1,175.63" "$1,862.19" "$1,881.00" $0.00 $0.00 $367.97 $0.00 $0.00 $374.32 $0.00 $0.00 $0.00 $0.00 $0.00 54-25450S SUP HCPCS C1713 54-25450S - PLATE 2XL 74MMX3MM 2.7MM SCR 5 HOLE ANTM NAR VARIAX BONE BOTH IP/OP "$2,751.00 " "$2,035.74" $0.00 "$2,041.79" "$1,058.06" "$1,058.06" $0.00 $0.00 $0.00 $573.38 "$2,041.79" "$2,041.79" $0.00 $0.00 $573.31 $0.00 "$1,356.24" "$1,356.24" $0.00 "$1,175.63" "$1,862.19" "$1,881.00" $0.00 $0.00 $367.97 $0.00 $0.00 $374.32 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-42A SUP Custom 27803010 542T-11-42A - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-44B SUP Custom 27803010 542T-11-44B - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-46C SUP Custom 27803010 542T-11-46C - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-50D SUP Custom 27803010 542T-11-50D - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-54E SUP Custom 27803010 542T-11-54E - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-58F SUP Custom 27803010 542T-11-58F - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-62G SUP Custom 27803010 542T-11-62G - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-66H SUP Custom 27803010 542T-11-66H - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 542T-11-70I SUP Custom 27803010 542T-11-70I - SHELL ACETAB HYDRXAPT TR PSL T BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5444-0-110 SUP HCPCS C1895 5444-0-110 - GRAFT SYNTH TISSUE SMALL CUSTOMIZE MEDPOR BOTH IP/OP "$25,393.75 " "$18,791.38" $0.00 "$25,726.00" "$14,470.88" "$14,470.88" $0.00 $0.00 $0.00 "$5,292.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,292.06" $0.00 "$12,519.12" "$12,519.12" $0.00 "$16,078.75" "$25,468.74" "$25,726.00" $0.00 $0.00 "$5,032.65" $0.00 $0.00 "$5,119.47" $0.00 $0.00 $0.00 $0.00 $0.00 5444-0-210 SUP HCPCS C1895 5444-0-210 - GRAFT SYNTH TISSUE MEDIUM CUSTOMIZE MEDPOR BOTH IP/OP "$38,395.00 " "$28,412.30" $0.00 "$30,716.00" "$17,277.75" "$17,277.75" $0.00 $0.00 $0.00 "$8,002.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,001.52" $0.00 "$18,928.74" "$18,928.74" $0.00 "$19,197.50" "$30,408.84" "$30,716.00" $0.00 $0.00 "$6,008.82" $0.00 $0.00 "$6,112.48" $0.00 $0.00 $0.00 $0.00 $0.00 5444-0-310 SUP HCPCS C1895 5444-0-310 - GRAFT SYNTH TISSUE LARGE CUSTOMIZE MEDPOR BOTH IP/OP "$45,842.50 " "$33,923.45" $0.00 "$36,674.00" "$20,629.13" "$20,629.13" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,553.58" $0.00 "$22,600.35" "$22,600.35" $0.00 "$22,921.25" "$36,307.26" "$36,674.00" $0.00 $0.00 "$7,174.35" $0.00 $0.00 "$7,298.13" $0.00 $0.00 $0.00 $0.00 $0.00 5444-0-410 SUP HCPCS C1895 5444-0-410 - GRAFT SYNTH TISSUE XL CUSTOMIZE MEDPOR BOTH IP/OP "$54,737.50 " "$40,505.75" $0.00 "$43,790.00" "$24,631.88" "$24,631.88" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$11,407.30" $0.00 "$26,985.59" "$26,985.59" $0.00 "$27,368.75" "$43,352.10" "$43,790.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 5444-0-510 SUP HCPCS C1895 5444-0-510 - GRAFT SYNTH TISSUE CUSTOMIZE MEDPOR MIDFAC BOTH IP/OP "$42,120.00 " "$31,168.80" $0.00 "$33,696.00" "$18,954.00" "$18,954.00" $0.00 $0.00 $0.00 "$8,778.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,777.81" $0.00 "$20,765.16" "$20,765.16" $0.00 "$21,060.00" "$33,359.04" "$33,696.00" $0.00 $0.00 "$6,591.78" $0.00 $0.00 "$6,705.50" $0.00 $0.00 $0.00 $0.00 $0.00 5444-0-610 SUP HCPCS C1895 5444-0-610 - GRAFT SYNTH TISSUE CUSTOMIZE AUGMENTATION LATEX FREE MEDPOR BOTH IP/OP "$20,182.50 " "$14,935.05" $0.00 "$16,146.00" "$9,082.13" "$9,082.13" $0.00 $0.00 $0.00 "$4,206.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,206.03" $0.00 "$9,949.97" "$9,949.97" $0.00 "$10,091.25" "$15,984.54" "$16,146.00" $0.00 $0.00 "$3,158.56" $0.00 $0.00 "$3,213.05" $0.00 $0.00 $0.00 $0.00 $0.00 5450-800-315 SUP Custom 27203010 5450-800-315 - TIP ASP LNG 4.6IN STRL LF SPTZLR MIC CLW MIC CLW BN DISP BOTH IP/OP "$8,925.00 " "$6,604.50" $0.00 "$7,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,859.97" $0.00 $0.00 $0.00 $0.00 "$4,462.50" "$7,068.60" "$7,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 55.26.25E SUP Custom 27203010 55.26.25E - PROBE LSR 25GA STRL DRCT XTD DISP BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 55-0001 SUP HCPCS C1713 55-0001 - NAIL HELICAL 20 MM IMPLANT BOTH IP/OP $657.50 $486.55 $0.00 $526.00 $295.88 $295.88 $0.00 $0.00 $0.00 $137.04 $488.00 $488.00 $0.00 $0.00 $137.02 $0.00 $388.91 $388.91 $0.00 $328.75 $520.74 $526.00 $0.00 $0.00 $102.90 $0.00 $0.00 $104.67 $0.00 $0.00 $0.00 $0.00 $0.00 55-0002 SUP HCPCS C1713 55-0002 - NAIL HELICAL 30 MM IMPLANT BOTH IP/OP $657.50 $486.55 $0.00 $526.00 $295.88 $295.88 $0.00 $0.00 $0.00 $137.04 $488.00 $488.00 $0.00 $0.00 $137.02 $0.00 $388.91 $388.91 $0.00 $328.75 $520.74 $526.00 $0.00 $0.00 $102.90 $0.00 $0.00 $104.67 $0.00 $0.00 $0.00 $0.00 $0.00 55-0003 SUP HCPCS C1713 55-0003 - NAIL HELICAL 40 MM IMPLANT BOTH IP/OP $657.50 $486.55 $0.00 $526.00 $295.88 $295.88 $0.00 $0.00 $0.00 $137.04 $488.00 $488.00 $0.00 $0.00 $137.02 $0.00 $388.91 $388.91 $0.00 $328.75 $520.74 $526.00 $0.00 $0.00 $102.90 $0.00 $0.00 $104.67 $0.00 $0.00 $0.00 $0.00 $0.00 550-120 SUP HCPCS C1713 550-120 - PLATE 18MM TI BONE SPNL BOTH IP/OP $242.25 $179.27 $0.00 $193.80 $109.01 $109.01 $0.00 $0.00 $0.00 $50.49 $179.80 $179.80 $0.00 $0.00 $50.48 $0.00 $143.29 $143.29 $0.00 $121.13 $191.86 $193.80 $0.00 $0.00 $37.91 $0.00 $0.00 $38.57 $0.00 $0.00 $0.00 $0.00 $0.00 55-02950 SUP HCPCS C1713 55-02950 - PLATE BN NS HBRD MMF MXLMNDB BOTH IP/OP $870.00 $643.80 $0.00 $696.00 $391.50 $391.50 $0.00 $0.00 $0.00 $181.33 $645.71 $645.71 $0.00 $0.00 $181.31 $0.00 $514.61 $514.61 $0.00 $435.00 $689.04 $696.00 $0.00 $0.00 $136.16 $0.00 $0.00 $138.50 $0.00 $0.00 $0.00 $0.00 $0.00 55-02951 SUP HCPCS C1713 55-02951 - PLATE BONE SMARTLOCK SMALL MAXILLOFACIAL HYBRID BOTH IP/OP $870.00 $643.80 $0.00 $696.00 $391.50 $391.50 $0.00 $0.00 $0.00 $181.33 $645.71 $645.71 $0.00 $0.00 $181.31 $0.00 $514.61 $514.61 $0.00 $435.00 $689.04 $696.00 $0.00 $0.00 $136.16 $0.00 $0.00 $138.50 $0.00 $0.00 $0.00 $0.00 $0.00 55-03731 SUP HCPCS C1713 55-03731 - PLATE BONE 3D LP .55MM 2X2 HOLE MALBLE UNIVERSAL 2 TITANIUM BOTH IP/OP $767.50 $567.95 $0.00 $614.00 $345.38 $345.38 $0.00 $0.00 $0.00 $159.97 $569.64 $569.64 $0.00 $0.00 $159.95 $0.00 $453.98 $453.98 $0.00 $383.75 $607.86 $614.00 $0.00 $0.00 $120.11 $0.00 $0.00 $122.19 $0.00 $0.00 $0.00 $0.00 $0.00 55-03733 SUP HCPCS C1713 55-03733 - PLATE BONE 3D LP .55MM 6X2 HOLE MALBLE UNIVERSAL 2 TITANIUM BOTH IP/OP $947.50 $701.15 $0.00 "$1,576.00" $886.50 $886.50 $0.00 $0.00 $0.00 $197.48 $703.23 $703.23 $0.00 $0.00 $197.46 $0.00 $560.45 $560.45 $0.00 $985.00 "$1,560.24" "$1,576.00" $0.00 $0.00 $308.31 $0.00 $0.00 $313.62 $0.00 $0.00 $0.00 $0.00 $0.00 55-04218 SUP HCPCS C1713 55-04218 - PLATE BONE STR LP .5MM 18 HOLE MALBLE UNIVERSAL 2 TITANIUM BOTH IP/OP $958.35 $709.18 $0.00 "$1,694.00" $952.88 $952.88 $0.00 $0.00 $0.00 $199.74 $711.29 $711.29 $0.00 $0.00 $199.72 $0.00 $566.86 $566.86 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $331.39 $0.00 $0.00 $337.11 $0.00 $0.00 $0.00 $0.00 $0.00 55-04231 SUP HCPCS C1713 55-04231 - PLATE BONE 3D .5MM 2X2 HOLE MALBLE 3D TITANIUM UPPERFACIAL BOTH IP/OP $439.13 $324.96 $0.00 $774.00 $435.38 $435.38 $0.00 $0.00 $0.00 $91.52 $325.92 $325.92 $0.00 $0.00 $91.51 $0.00 $259.74 $259.74 $0.00 $483.75 $766.26 $774.00 $0.00 $0.00 $151.41 $0.00 $0.00 $154.03 $0.00 $0.00 $0.00 $0.00 $0.00 55-04233 SUP HCPCS C1713 55-04233 - PLATE BONE .5MM 6X2 HOLE MALBLE 3D TITANIUM UPPERFACIAL 1.2 BOTH IP/OP $789.25 $584.05 $0.00 "$1,394.00" $784.13 $784.13 $0.00 $0.00 $0.00 $164.50 $585.78 $585.78 $0.00 $0.00 $164.48 $0.00 $466.84 $466.84 $0.00 $871.25 "$1,380.06" "$1,394.00" $0.00 $0.00 $272.70 $0.00 $0.00 $277.41 $0.00 $0.00 $0.00 $0.00 $0.00 55-04235 SUP HCPCS C1713 55-04235 - PLATE BONE 3D .5MM 6X6 HOLE MALBLE 3D UNIVERSAL2 TITANIUM BOTH IP/OP "$1,818.43 " "$1,345.64" $0.00 "$3,208.00" "$1,804.50" "$1,804.50" $0.00 $0.00 $0.00 $379.01 "$1,349.64" "$1,349.64" $0.00 $0.00 $378.96 $0.00 "$1,075.60" "$1,075.60" $0.00 "$2,005.00" "$3,175.92" "$3,208.00" $0.00 $0.00 $627.57 $0.00 $0.00 $638.39 $0.00 $0.00 $0.00 $0.00 $0.00 55-04237 SUP HCPCS C1713 55-04237 - PLATE BONE .5MM 10X10 HOLE MALBLE 3D TITANIUM UPPERFACIAL BOTH IP/OP "$2,480.68 " "$1,835.70" $0.00 "$4,380.00" "$2,463.75" "$2,463.75" $0.00 $0.00 $0.00 $517.03 "$1,841.16" "$1,841.16" $0.00 $0.00 $516.97 $0.00 "$1,467.32" "$1,467.32" $0.00 "$2,737.50" "$4,336.20" "$4,380.00" $0.00 $0.00 $856.84 $0.00 $0.00 $871.62 $0.00 $0.00 $0.00 $0.00 $0.00 55-04240 SUP HCPCS C1713 55-04240 - PLATE BONE 2Y LP .5MM 7 HOLE MALBLE UNIVERSAL 2 TITANIUM BOTH IP/OP $837.50 $619.75 $0.00 $670.00 $376.88 $376.88 $0.00 $0.00 $0.00 $174.56 $621.59 $621.59 $0.00 $0.00 $174.54 $0.00 $495.38 $495.38 $0.00 $418.75 $663.30 $670.00 $0.00 $0.00 $131.07 $0.00 $0.00 $133.33 $0.00 $0.00 $0.00 $0.00 $0.00 55-04250 SUP HCPCS C1713 55-04250 - PLATE BONE CURVE .5MM 10 HOLE MALBLE UNIVERSAL 2 TITANIUM BOTH IP/OP $426.33 $315.48 $0.00 $758.00 $426.38 $426.38 $0.00 $0.00 $0.00 $88.86 $316.42 $316.42 $0.00 $0.00 $88.85 $0.00 $252.17 $252.17 $0.00 $473.75 $750.42 $758.00 $0.00 $0.00 $148.28 $0.00 $0.00 $150.84 $0.00 $0.00 $0.00 $0.00 $0.00 55-04424 SUP HCPCS C1713 55-04424 - PLATE BONE .5MM 24 HOLE STR MALBLE CONDENSED TITANIUM BOTH IP/OP "$1,021.25 " $755.73 $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $212.85 $757.97 $757.97 $0.00 $0.00 $212.83 $0.00 $604.07 $604.07 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 55-04720 SUP HCPCS C1713 55-04720 - PLATE BONE STR .5MM 20 HOLE MALBLE TITANIUM MIDFAC 1.7MM BOTH IP/OP "$1,002.25 " $741.67 $0.00 "$1,798.00" "$1,011.38" "$1,011.38" $0.00 $0.00 $0.00 $208.89 $743.87 $743.87 $0.00 $0.00 $208.87 $0.00 $592.83 $592.83 $0.00 "$1,123.75" "$1,780.02" "$1,798.00" $0.00 $0.00 $351.73 $0.00 $0.00 $357.80 $0.00 $0.00 $0.00 $0.00 $0.00 55-04724 SUP HCPCS C1713 55-04724 - PLATE BONE 24 HOLE STR MALBLE CONDENSED TITANIUM MIDFAC 1.7 BOTH IP/OP "$1,037.18 " $767.51 $0.00 "$1,856.00" "$1,044.00" "$1,044.00" $0.00 $0.00 $0.00 $216.17 $769.79 $769.79 $0.00 $0.00 $216.15 $0.00 $613.49 $613.49 $0.00 "$1,160.00" "$1,837.44" "$1,856.00" $0.00 $0.00 $363.08 $0.00 $0.00 $369.34 $0.00 $0.00 $0.00 $0.00 $0.00 55-04760 SUP HCPCS C1713 55-04760 - PLATE BONE 100D 2MM ADVANCEMENT 5 HOLE L MALBLE TITANIUM BOTH IP/OP $391.20 $289.49 $0.00 $692.00 $389.25 $389.25 $0.00 $0.00 $0.00 $81.54 $290.35 $290.35 $0.00 $0.00 $81.53 $0.00 $231.39 $231.39 $0.00 $432.50 $685.08 $692.00 $0.00 $0.00 $135.37 $0.00 $0.00 $137.71 $0.00 $0.00 $0.00 $0.00 $0.00 55-04761 SUP HCPCS C1713 55-04761 - PLATE BONE 100D 2MM ADVANCEMENT L 5 HOLE MALBLE RIGHT ANGLED BOTH IP/OP $391.20 $289.49 $0.00 $692.00 $389.25 $389.25 $0.00 $0.00 $0.00 $81.54 $290.35 $290.35 $0.00 $0.00 $81.53 $0.00 $231.39 $231.39 $0.00 $432.50 $685.08 $692.00 $0.00 $0.00 $135.37 $0.00 $0.00 $137.71 $0.00 $0.00 $0.00 $0.00 $0.00 55-04762 SUP HCPCS C1713 55-04762 - PLATE BONE 100D LEFT 5MM L 5 HOLE MALBLE TITANIUM MIDFAC 1.7 BOTH IP/OP $402.00 $297.48 $0.00 $712.00 $400.50 $400.50 $0.00 $0.00 $0.00 $83.79 $298.36 $298.36 $0.00 $0.00 $83.78 $0.00 $237.78 $237.78 $0.00 $445.00 $704.88 $712.00 $0.00 $0.00 $139.29 $0.00 $0.00 $141.69 $0.00 $0.00 $0.00 $0.00 $0.00 55-04763 SUP HCPCS C1713 55-04763 - PLATE BONE 100D 5MM ADVANCEMENT L 5 HOLE MALBLE RIGHT ANGLED BOTH IP/OP $402.00 $297.48 $0.00 $712.00 $400.50 $400.50 $0.00 $0.00 $0.00 $83.79 $298.36 $298.36 $0.00 $0.00 $83.78 $0.00 $237.78 $237.78 $0.00 $445.00 $704.88 $712.00 $0.00 $0.00 $139.29 $0.00 $0.00 $141.69 $0.00 $0.00 $0.00 $0.00 $0.00 55-04764 SUP HCPCS C1713 55-04764 - PLATE BONE 100D 8MM ADVANCEMENT 6 HOLE L MALBLE TITANIUM BOTH IP/OP $415.20 $307.25 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $86.54 $308.16 $308.16 $0.00 $0.00 $86.53 $0.00 $245.59 $245.59 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 55-04765 SUP HCPCS C1713 55-04765 - PLATE BONE 100D 8MM L 6 HOLE MALBLE TITANIUM MIDFAC RIGHT BOTH IP/OP $415.20 $307.25 $0.00 $734.00 $412.88 $412.88 $0.00 $0.00 $0.00 $86.54 $308.16 $308.16 $0.00 $0.00 $86.53 $0.00 $245.59 $245.59 $0.00 $458.75 $726.66 $734.00 $0.00 $0.00 $143.59 $0.00 $0.00 $146.07 $0.00 $0.00 $0.00 $0.00 $0.00 55-04766 SUP HCPCS C1713 55-04766 - PLATE BONE 100D 12MM ADVANCEMENT 6 HOLE L MALBLE TITANIUM BOTH IP/OP $426.00 $315.24 $0.00 $754.00 $424.13 $424.13 $0.00 $0.00 $0.00 $88.79 $316.18 $316.18 $0.00 $0.00 $88.78 $0.00 $251.98 $251.98 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $147.50 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $0.00 55-04767 SUP HCPCS C1713 55-04767 - PLATE BONE 100D 12MM ADVANCEMENT 6 HOLE L MALBLE TITANIUM BOTH IP/OP $426.00 $315.24 $0.00 $754.00 $424.13 $424.13 $0.00 $0.00 $0.00 $88.79 $316.18 $316.18 $0.00 $0.00 $88.78 $0.00 $251.98 $251.98 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $147.50 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $0.00 55-05151 SUP HCPCS C1713 55-05151 - PLATE BONE STANDARD Y 4MMX.6MM 5 HOLE BAR UNIVERSAL 2 BOTH IP/OP $329.15 $243.57 $0.00 $596.00 $335.25 $335.25 $0.00 $0.00 $0.00 $68.60 $244.30 $244.30 $0.00 $0.00 $68.59 $0.00 $194.69 $194.69 $0.00 $372.50 $590.04 $596.00 $0.00 $0.00 $116.59 $0.00 $0.00 $118.60 $0.00 $0.00 $0.00 $0.00 $0.00 55-05152 SUP HCPCS C1713 55-05152 - PLATE BONE STANDARD Y 8MMX.6MM 5 HOLE BAR UNIVERSAL 2 BOTH IP/OP $349.63 $258.73 $0.00 $618.00 $347.63 $347.63 $0.00 $0.00 $0.00 $72.87 $259.49 $259.49 $0.00 $0.00 $72.86 $0.00 $206.80 $206.80 $0.00 $386.25 $611.82 $618.00 $0.00 $0.00 $120.90 $0.00 $0.00 $122.98 $0.00 $0.00 $0.00 $0.00 $0.00 55-05164 SUP HCPCS C1713 55-05164 - PLATE BONE UNIVERSAL STANDARD 2Y .6MM 7 HOLE MALBLE TITANIUM BOTH IP/OP $877.50 $649.35 $0.00 $702.00 $394.88 $394.88 $0.00 $0.00 $0.00 $182.89 $651.28 $651.28 $0.00 $0.00 $182.87 $0.00 $519.04 $519.04 $0.00 $438.75 $694.98 $702.00 $0.00 $0.00 $137.33 $0.00 $0.00 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 55-05188 SUP HCPCS C1713 55-05188 - PLATE BONE STANDARD CURVE .6MM 6 HOLE BAR UNIVERSAL 2 BOTH IP/OP $982.50 $727.05 $0.00 $786.00 $442.13 $442.13 $0.00 $0.00 $0.00 $204.78 $729.21 $729.21 $0.00 $0.00 $204.75 $0.00 $581.15 $581.15 $0.00 $491.25 $778.14 $786.00 $0.00 $0.00 $153.76 $0.00 $0.00 $156.41 $0.00 $0.00 $0.00 $0.00 $0.00 55-05716 SUP HCPCS C1713 55-05716 - PLATE BONE 16 HOLE LOCKING TITANIUM MIDFAC 1.7 MM SCREW BOTH IP/OP $730.50 $540.57 $0.00 "$1,332.00" $749.25 $749.25 $0.00 $0.00 $0.00 $152.25 $542.18 $542.18 $0.00 $0.00 $152.24 $0.00 $432.09 $432.09 $0.00 $832.50 "$1,318.68" "$1,332.00" $0.00 $0.00 $260.57 $0.00 $0.00 $265.07 $0.00 $0.00 $0.00 $0.00 $0.00 55-05731 SUP HCPCS C1713 55-05731 - PLATE BONE 3D .8MM 2X2 HOLE LOCK UNIVERSAL 2 TITANIUM MIDFAC BOTH IP/OP $502.08 $371.54 $0.00 $936.00 $526.50 $526.50 $0.00 $0.00 $0.00 $104.64 $372.64 $372.64 $0.00 $0.00 $104.63 $0.00 $296.98 $296.98 $0.00 $585.00 $926.64 $936.00 $0.00 $0.00 $183.11 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $0.00 55-05733 SUP HCPCS C1713 55-05733 - PLATE BONE 2X6 HOLE LOCKING 3D TITANIUM MIDFAC 1.7 MM SCREW BOTH IP/OP "$1,159.48 " $858.02 $0.00 "$2,098.00" "$1,180.13" "$1,180.13" $0.00 $0.00 $0.00 $241.66 $860.56 $860.56 $0.00 $0.00 $241.63 $0.00 $685.83 $685.83 $0.00 "$1,311.25" "$2,077.02" "$2,098.00" $0.00 $0.00 $410.42 $0.00 $0.00 $417.50 $0.00 $0.00 $0.00 $0.00 $0.00 55-05742 SUP HCPCS C1713 55-05742 - PLATE BONE 2Y .8MM 7 HOLE LOCK UNIVERSAL 2 TITANIUM MIDFAC BOTH IP/OP $574.08 $424.82 $0.00 "$1,048.00" $589.50 $589.50 $0.00 $0.00 $0.00 $119.65 $426.08 $426.08 $0.00 $0.00 $119.64 $0.00 $339.57 $339.57 $0.00 $655.00 "$1,037.52" "$1,048.00" $0.00 $0.00 $205.02 $0.00 $0.00 $208.55 $0.00 $0.00 $0.00 $0.00 $0.00 55-05751 SUP HCPCS C1713 55-05751 - PLATE BONE Y 4MMX.8MM 5 HOLE LOCK BAR UNIVERSAL 2 TITANIUM BOTH IP/OP $450.88 $333.65 $0.00 $826.00 $464.63 $464.63 $0.00 $0.00 $0.00 $93.97 $334.64 $334.64 $0.00 $0.00 $93.96 $0.00 $266.69 $266.69 $0.00 $516.25 $817.74 $826.00 $0.00 $0.00 $161.59 $0.00 $0.00 $164.37 $0.00 $0.00 $0.00 $0.00 $0.00 55-05752 SUP HCPCS C1713 55-05752 - PLATE BONE 8MM ADVANCEMENT 8MM 5 HOLE Y LOCKING BAR TITANIUM BOTH IP/OP $450.88 $333.65 $0.00 $826.00 $464.63 $464.63 $0.00 $0.00 $0.00 $93.97 $334.64 $334.64 $0.00 $0.00 $93.96 $0.00 $266.69 $266.69 $0.00 $516.25 $817.74 $826.00 $0.00 $0.00 $161.59 $0.00 $0.00 $164.37 $0.00 $0.00 $0.00 $0.00 $0.00 55-05758 SUP HCPCS C1713 55-05758 - PLATE BONE 8 HOLE CVD LOCKING TITANIUM MIDFAC 1.7 MM SCREW BOTH IP/OP $354.80 $262.55 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $73.95 $263.33 $263.33 $0.00 $0.00 $73.94 $0.00 $209.86 $209.86 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 55-05761 SUP HCPCS C1713 55-05761 - PLATE BONE 2MM ADVANCEMENT 2MMX.8MM 5 HOLE L LOCKING BOTH IP/OP $413.55 $306.03 $0.00 $754.00 $424.13 $424.13 $0.00 $0.00 $0.00 $86.19 $306.94 $306.94 $0.00 $0.00 $86.18 $0.00 $244.61 $244.61 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $147.50 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $0.00 55-05763 SUP HCPCS C1713 55-05763 - PLATE BONE 5MM ADVANCEMENT L 5MMX.8MM 5 HOLE LOCK TITANIUM BOTH IP/OP $439.13 $324.96 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $91.52 $325.92 $325.92 $0.00 $0.00 $91.51 $0.00 $259.74 $259.74 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 55-05765 SUP HCPCS C1713 55-05765 - PLATE BONE 100D L 8MMX.8MM 6 HOLE LOCK BAR UNIVERSAL 2 BOTH IP/OP $463.73 $343.16 $0.00 $844.00 $474.75 $474.75 $0.00 $0.00 $0.00 $96.65 $344.18 $344.18 $0.00 $0.00 $96.64 $0.00 $274.29 $274.29 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 55-05767 SUP HCPCS C1713 55-05767 - PLATE BONE 100D L 12MMX.8MM 6 HOLE LOCK BAR UNIVERSAL 2 BOTH IP/OP $474.80 $351.35 $0.00 $866.00 $487.13 $487.13 $0.00 $0.00 $0.00 $98.96 $352.40 $352.40 $0.00 $0.00 $98.95 $0.00 $280.84 $280.84 $0.00 $541.25 $857.34 $866.00 $0.00 $0.00 $169.41 $0.00 $0.00 $172.33 $0.00 $0.00 $0.00 $0.00 $0.00 55-05779 SUP HCPCS C1713 55-05779 - PLATE BONE Y .8MM 8 HOLE LOCK UNIVERSAL 2 TITANIUM MIDFAC BOTH IP/OP $523.88 $387.67 $0.00 $958.00 $538.88 $538.88 $0.00 $0.00 $0.00 $109.19 $388.82 $388.82 $0.00 $0.00 $109.18 $0.00 $309.87 $309.87 $0.00 $598.75 $948.42 $958.00 $0.00 $0.00 $187.41 $0.00 $0.00 $190.64 $0.00 $0.00 $0.00 $0.00 $0.00 55-06208 SUP HCPCS C1713 55-06208 - PLATE BONE STANDARD STR .6MM 8 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $474.75 $474.75 $0.00 $0.00 $0.00 $219.89 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $624.03 $624.03 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 55-06224 SUP HCPCS C1713 55-06224 - PLATE BONE STANDARD STR .6MM 24 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $883.38 $653.70 $0.00 "$1,576.00" $886.50 $886.50 $0.00 $0.00 $0.00 $184.12 $655.64 $655.64 $0.00 $0.00 $184.10 $0.00 $522.52 $522.52 $0.00 $985.00 "$1,560.24" "$1,576.00" $0.00 $0.00 $308.31 $0.00 $0.00 $313.62 $0.00 $0.00 $0.00 $0.00 $0.00 55-06231 SUP HCPCS C1713 55-06231 - PLATE BONE STANDARD 3D .6MM 2X2 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 55-06233 SUP HCPCS C1713 55-06233 - PLATE BONE STANDARD .6MM 6X2 HOLE 3D TITANIUM UPPERFACIAL BOTH IP/OP $735.58 $544.33 $0.00 "$1,288.00" $724.50 $724.50 $0.00 $0.00 $0.00 $153.31 $545.94 $545.94 $0.00 $0.00 $153.29 $0.00 $435.09 $435.09 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $251.97 $0.00 $0.00 $256.31 $0.00 $0.00 $0.00 $0.00 $0.00 55-06235 SUP HCPCS C1713 55-06235 - PLATE BONE STANDARD 3D .6MM 6X6 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP "$1,788.75 " "$1,323.68" $0.00 "$3,112.00" "$1,750.50" "$1,750.50" $0.00 $0.00 $0.00 $372.82 "$1,327.61" "$1,327.61" $0.00 $0.00 $372.78 $0.00 "$1,058.05" "$1,058.05" $0.00 "$1,945.00" "$3,080.88" "$3,112.00" $0.00 $0.00 $608.79 $0.00 $0.00 $619.29 $0.00 $0.00 $0.00 $0.00 $0.00 55-06237 SUP HCPCS C1713 55-06237 - PLATE BONE 10X10 HOLE 3D TITANIUM UPPERFACIAL 1.2 MM SCREW BOTH IP/OP "$2,420.00 " "$1,790.80" $0.00 "$4,208.00" "$2,367.00" "$2,367.00" $0.00 $0.00 $0.00 $504.39 "$1,796.12" "$1,796.12" $0.00 $0.00 $504.33 $0.00 "$1,431.43" "$1,431.43" $0.00 "$2,630.00" "$4,165.92" "$4,208.00" $0.00 $0.00 $823.19 $0.00 $0.00 $837.39 $0.00 $0.00 $0.00 $0.00 $0.00 55-06240 SUP HCPCS C1713 55-06240 - PLATE BONE STANDARD 2Y .6MM 7 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $760.00 $562.40 $0.00 $608.00 $342.00 $342.00 $0.00 $0.00 $0.00 $158.40 $564.07 $564.07 $0.00 $0.00 $158.38 $0.00 $449.54 $449.54 $0.00 $380.00 $601.92 $608.00 $0.00 $0.00 $118.94 $0.00 $0.00 $120.99 $0.00 $0.00 $0.00 $0.00 $0.00 55-06250 SUP HCPCS C1713 55-06250 - PLATE BONE STANDARD CURVE .6MM 10 HOLE LEIBINGER UNIVERSAL 2 BOTH IP/OP $947.50 $701.15 $0.00 $758.00 $426.38 $426.38 $0.00 $0.00 $0.00 $197.48 $703.23 $703.23 $0.00 $0.00 $197.46 $0.00 $560.45 $560.45 $0.00 $473.75 $750.42 $758.00 $0.00 $0.00 $148.28 $0.00 $0.00 $150.84 $0.00 $0.00 $0.00 $0.00 $0.00 55-06254 SUP HCPCS C1713 55-06254 - PLATE BONE STANDARD CURVE .6MM 4 HOLE LEIBINGER UNIVERSAL 2 BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $211.50 $211.50 $0.00 $0.00 $0.00 $97.96 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $278.01 $278.01 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $73.56 $0.00 $0.00 $74.82 $0.00 $0.00 $0.00 $0.00 $0.00 55-06260 SUP HCPCS C1713 55-06260 - PLATE BONE 90D .6MM 8 HOLE L TITANIUM LEFT UPPERFACIAL 1.2MM BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 55-06261 SUP HCPCS C1713 55-06261 - PLATE BONE 90D STANDARD L .6MM 8 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $331.35 $245.20 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $69.06 $245.93 $245.93 $0.00 $0.00 $69.05 $0.00 $195.99 $195.99 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 55-06270 SUP HCPCS C1713 55-06270 - PLATE BONE STANDARD T .6MM 7 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $336.65 $249.12 $0.00 $598.00 $336.38 $336.38 $0.00 $0.00 $0.00 $70.17 $249.86 $249.86 $0.00 $0.00 $70.16 $0.00 $199.13 $199.13 $0.00 $373.75 $592.02 $598.00 $0.00 $0.00 $116.98 $0.00 $0.00 $119.00 $0.00 $0.00 $0.00 $0.00 $0.00 55-06310 SUP HCPCS C1713 55-06310 - PLATE BONE MINI 3D SQUARE .6MM 2X2 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $398.25 $294.71 $0.00 $770.00 $433.13 $433.13 $0.00 $0.00 $0.00 $83.01 $295.58 $295.58 $0.00 $0.00 $83.00 $0.00 $235.56 $235.56 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 55-06312 SUP HCPCS C1713 55-06312 - PLATE BONE MINI 3D RECTANGLE .6MM 2X2 HOLE UNIVERSAL 2 BOTH IP/OP $398.25 $294.71 $0.00 $770.00 $433.13 $433.13 $0.00 $0.00 $0.00 $83.01 $295.58 $295.58 $0.00 $0.00 $83.00 $0.00 $235.56 $235.56 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 55-06320 SUP HCPCS C1713 55-06320 - PLATE BONE MINI 3D SQUARE .6MM 3X2 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $442.13 $327.18 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $92.15 $328.15 $328.15 $0.00 $0.00 $92.14 $0.00 $261.52 $261.52 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 55-06370 SUP HCPCS C1713 55-06370 - PLATE BONE STANDARD 14MM BURR HOLE COVER TITANIUM MAXFACL BOTH IP/OP $405.25 $299.89 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $84.46 $300.78 $300.78 $0.00 $0.00 $84.45 $0.00 $239.71 $239.71 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 55-06371 SUP HCPCS C1713 55-06371 - PLATE BONE 20MM BURR HOLE COVER MALBLE TITANIUM MAXFACL 1.2 BOTH IP/OP $452.18 $334.61 $0.00 $804.00 $452.25 $452.25 $0.00 $0.00 $0.00 $94.24 $335.60 $335.60 $0.00 $0.00 $94.23 $0.00 $267.46 $267.46 $0.00 $502.50 $795.96 $804.00 $0.00 $0.00 $157.28 $0.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 55-06372 SUP HCPCS C1713 55-06372 - PLATE BONE STANDARD 10MM .6MM BURR HOLE COVER UNIVERSAL 2 BOTH IP/OP $405.25 $299.89 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $84.46 $300.78 $300.78 $0.00 $0.00 $84.45 $0.00 $239.71 $239.71 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 55-06373 SUP HCPCS C1713 55-06373 - PLATE BONE 14MM BURR HOLE COVER MALBLE TITANIUM MAXFACL 1.2 BOTH IP/OP $454.05 $336.00 $0.00 $804.00 $452.25 $452.25 $0.00 $0.00 $0.00 $94.64 $337.00 $337.00 $0.00 $0.00 $94.62 $0.00 $268.57 $268.57 $0.00 $502.50 $795.96 $804.00 $0.00 $0.00 $157.28 $0.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 55-06374 SUP HCPCS C1713 55-06374 - PLATE BONE 10MM BURR HOLE COVER MALBLE TITANIUM MAXFACL 1.2 BOTH IP/OP $454.05 $336.00 $0.00 $804.00 $452.25 $452.25 $0.00 $0.00 $0.00 $94.64 $337.00 $337.00 $0.00 $0.00 $94.62 $0.00 $268.57 $268.57 $0.00 $502.50 $795.96 $804.00 $0.00 $0.00 $157.28 $0.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 55-06375 SUP HCPCS C1713 55-06375 - PLATE BONE STANDARD 7MM BURR HOLE COVER TITANIUM MAXFACL 1.2 BOTH IP/OP $405.25 $299.89 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $84.46 $300.78 $300.78 $0.00 $0.00 $84.45 $0.00 $239.71 $239.71 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 55-06376 SUP HCPCS C1713 55-06376 - PLATE BONE 7MM BURR HOLE COVER MALBLE TITANIUM MAXFACL 1.2MM BOTH IP/OP $450.88 $333.65 $0.00 $770.00 $433.13 $433.13 $0.00 $0.00 $0.00 $93.97 $334.64 $334.64 $0.00 $0.00 $93.96 $0.00 $266.69 $266.69 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 55-06704 SUP HCPCS C1713 55-06704 - PLATE BONE STANDARD STR .55MM 4 HOLE BAR UNIVERSAL 2 BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $222.75 $222.75 $0.00 $0.00 $0.00 $103.17 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $292.79 $292.79 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $77.47 $0.00 $0.00 $78.80 $0.00 $0.00 $0.00 $0.00 $0.00 55-06708 SUP HCPCS C1713 55-06708 - PLATE BONE STANDARD STR 8 HOLE UNIVERSAL 2 TITANIUM MIDFAC BOTH IP/OP "$1,090.00 " $806.60 $0.00 $872.00 $490.50 $490.50 $0.00 $0.00 $0.00 $227.18 $809.00 $809.00 $0.00 $0.00 $227.16 $0.00 $644.74 $644.74 $0.00 $545.00 $863.28 $872.00 $0.00 $0.00 $170.59 $0.00 $0.00 $173.53 $0.00 $0.00 $0.00 $0.00 $0.00 55-06724 SUP HCPCS C1713 55-06724 - PLATE BONE STANDARD .6MM 24 HOLE STR TITANIUM MIDFAC 1.7MM BOTH IP/OP "$2,080.00 " "$1,539.20" $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $433.52 "$1,543.78" "$1,543.78" $0.00 $0.00 $433.47 $0.00 "$1,230.32" "$1,230.32" $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 55-06731 SUP HCPCS C1713 55-06731 - PLATE BONE STANDARD .6MM 2X2 HOLE 3D TITANIUM MIDFAC 1.7MM BOTH IP/OP $480.98 $355.93 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $100.25 $356.98 $356.98 $0.00 $0.00 $100.24 $0.00 $284.50 $284.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 55-06733 SUP HCPCS C1713 55-06733 - PLATE BONE STANDARD .6MM 2X6 HOLE 3D TITANIUM MIDFAC 1.7MM BOTH IP/OP "$1,810.00 " "$1,339.40" $0.00 "$1,448.00" $814.50 $814.50 $0.00 $0.00 $0.00 $377.25 "$1,343.38" "$1,343.38" $0.00 $0.00 $377.20 $0.00 "$1,070.62" "$1,070.62" $0.00 $905.00 "$1,433.52" "$1,448.00" $0.00 $0.00 $283.27 $0.00 $0.00 $288.15 $0.00 $0.00 $0.00 $0.00 $0.00 55-06750 SUP HCPCS C1713 55-06750 - PLATE BONE STANDARD CURVE .6MM 10 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $517.50 $517.50 $0.00 $0.00 $0.00 $239.69 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $680.23 $680.23 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $179.98 $0.00 $0.00 $183.08 $0.00 $0.00 $0.00 $0.00 $0.00 55-06754 SUP HCPCS C1713 55-06754 - PLATE BONE STANDARD 4 HOLE CVD BAR TITANIUM MIDFAC 1.7MM BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $274.50 $274.50 $0.00 $0.00 $0.00 $127.14 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $360.82 $360.82 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $95.47 $0.00 $0.00 $97.11 $0.00 $0.00 $0.00 $0.00 $0.00 55-06760 SUP HCPCS C1713 55-06760 - PLATE BONE 100D STANDARD 2MM ADVANCEMENT 5 HOLE L TITANIUM BOTH IP/OP $349.60 $258.70 $0.00 $636.00 $357.75 $357.75 $0.00 $0.00 $0.00 $72.87 $259.47 $259.47 $0.00 $0.00 $72.86 $0.00 $206.79 $206.79 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $124.42 $0.00 $0.00 $126.56 $0.00 $0.00 $0.00 $0.00 $0.00 55-06761 SUP HCPCS C1713 55-06761 - PLATE BONE 100D STANDARD 2MM ADVANCEMENT 5 HOLE L TITANIUM BOTH IP/OP $349.60 $258.70 $0.00 $636.00 $357.75 $357.75 $0.00 $0.00 $0.00 $72.87 $259.47 $259.47 $0.00 $0.00 $72.86 $0.00 $206.79 $206.79 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $124.42 $0.00 $0.00 $126.56 $0.00 $0.00 $0.00 $0.00 $0.00 55-06762 SUP HCPCS C1713 55-06762 - PLATE BONE 100D 5 HOLE L TITANIUM LEFT MIDFAC BOTH IP/OP $361.10 $267.21 $0.00 $658.00 $370.13 $370.13 $0.00 $0.00 $0.00 $75.26 $268.01 $268.01 $0.00 $0.00 $75.25 $0.00 $213.59 $213.59 $0.00 $411.25 $651.42 $658.00 $0.00 $0.00 $128.72 $0.00 $0.00 $130.94 $0.00 $0.00 $0.00 $0.00 $0.00 55-06763 SUP HCPCS C1713 55-06763 - PLATE BONE 100D STANDARD 5MM 5 HOLE L BAR TITANIUM RIGHT BOTH IP/OP $361.10 $267.21 $0.00 $658.00 $370.13 $370.13 $0.00 $0.00 $0.00 $75.26 $268.01 $268.01 $0.00 $0.00 $75.25 $0.00 $213.59 $213.59 $0.00 $411.25 $651.42 $658.00 $0.00 $0.00 $128.72 $0.00 $0.00 $130.94 $0.00 $0.00 $0.00 $0.00 $0.00 55-06764 SUP HCPCS C1713 55-06764 - PLATE BONE 100D 6 HOLE L TITANIUM LEFT MIDFAC 1.7MM SCREW BOTH IP/OP $384.10 $284.23 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $80.06 $285.08 $285.08 $0.00 $0.00 $80.05 $0.00 $227.20 $227.20 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 55-06765 SUP HCPCS C1713 55-06765 - PLATE BONE 100D 8MM 6 HOLE L TITANIUM RIGHT MAXFACL 1.7MM BOTH IP/OP $384.10 $284.23 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $80.06 $285.08 $285.08 $0.00 $0.00 $80.05 $0.00 $227.20 $227.20 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 55-06766 SUP HCPCS C1713 55-06766 - PLATE BONE 100D STANDARD 12MM ADVANCEMENT 12MM 6 HOLE LEFT L BOTH IP/OP $392.15 $290.19 $0.00 $736.00 $414.00 $414.00 $0.00 $0.00 $0.00 $81.73 $291.05 $291.05 $0.00 $0.00 $81.72 $0.00 $231.96 $231.96 $0.00 $460.00 $728.64 $736.00 $0.00 $0.00 $143.98 $0.00 $0.00 $146.46 $0.00 $0.00 $0.00 $0.00 $0.00 55-06767 SUP HCPCS C1713 55-06767 - PLATE BONE 100D STANDARD 12MM BAR L .6MM 6 HOLE LEIBINGER BOTH IP/OP $392.15 $290.19 $0.00 $736.00 $414.00 $414.00 $0.00 $0.00 $0.00 $81.73 $291.05 $291.05 $0.00 $0.00 $81.72 $0.00 $231.96 $231.96 $0.00 $460.00 $728.64 $736.00 $0.00 $0.00 $143.98 $0.00 $0.00 $146.46 $0.00 $0.00 $0.00 $0.00 $0.00 55-06771 SUP HCPCS C1713 55-06771 - PLATE BONE STANDARD T 5 HOLE T TITANIUM MIDFAC 1.7MM SCREWS BOTH IP/OP $293.25 $217.01 $0.00 $556.00 $312.75 $312.75 $0.00 $0.00 $0.00 $61.12 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $173.46 $173.46 $0.00 $347.50 $550.44 $556.00 $0.00 $0.00 $108.77 $0.00 $0.00 $110.64 $0.00 $0.00 $0.00 $0.00 $0.00 55-07760 SUP HCPCS C1713 55-07760 - PLATE BONE 100D 2MM ADVANCEMENT .6MM 5 HOLE L TITANIUM LEFT BOTH IP/OP $382.30 $282.90 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $79.68 $283.74 $283.74 $0.00 $0.00 $79.67 $0.00 $226.13 $226.13 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 55-07761 SUP HCPCS C1713 55-07761 - PLATE BONE 100D 2MM ADVANCEMENT .6MM 5 HOLE L TITANIUM RIGHT BOTH IP/OP $382.30 $282.90 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $79.68 $283.74 $283.74 $0.00 $0.00 $79.67 $0.00 $226.13 $226.13 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 55-07762 SUP HCPCS C1713 55-07762 - PLATE BONE 100D 5MM ADVANCEMENT .6MM 5 HOLE L TITANIUM LEFT BOTH IP/OP $393.75 $291.38 $0.00 $710.00 $399.38 $399.38 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $443.75 $702.90 $710.00 $0.00 $0.00 $138.89 $0.00 $0.00 $141.29 $0.00 $0.00 $0.00 $0.00 $0.00 55-07763 SUP HCPCS C1713 55-07763 - PLATE BONE 100D 5MM ADVANCEMENT .6MM 5 HOLE L TITANIUM RIGHT BOTH IP/OP $393.75 $291.38 $0.00 $710.00 $399.38 $399.38 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $443.75 $702.90 $710.00 $0.00 $0.00 $138.89 $0.00 $0.00 $141.29 $0.00 $0.00 $0.00 $0.00 $0.00 55-07764 SUP HCPCS C1713 55-07764 - PLATE BONE 100D 8MM ADVANCEMENT .8MM 6 HOLE L TITANIUM LEFT BOTH IP/OP $409.73 $303.20 $0.00 $736.00 $414.00 $414.00 $0.00 $0.00 $0.00 $85.40 $304.10 $304.10 $0.00 $0.00 $85.39 $0.00 $242.35 $242.35 $0.00 $460.00 $728.64 $736.00 $0.00 $0.00 $143.98 $0.00 $0.00 $146.46 $0.00 $0.00 $0.00 $0.00 $0.00 55-07765 SUP HCPCS C1713 55-07765 - PLATE BONE 100D 8MM ADVANCEMENT .8MM 6 HOLE L TITANIUM RIGHT BOTH IP/OP $409.73 $303.20 $0.00 $736.00 $414.00 $414.00 $0.00 $0.00 $0.00 $85.40 $304.10 $304.10 $0.00 $0.00 $85.39 $0.00 $242.35 $242.35 $0.00 $460.00 $728.64 $736.00 $0.00 $0.00 $143.98 $0.00 $0.00 $146.46 $0.00 $0.00 $0.00 $0.00 $0.00 55-07766 SUP HCPCS C1713 55-07766 - PLATE BONE 100D 12MM ADVANCEMENT .55MM 6 HOLE L TITANIUM BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 55-07767 SUP HCPCS C1713 55-07767 - PLATE BONE 100D 12MM ADVANCEMENT .55MM 6 HOLE L TITANIUM BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 55-08203 SUP HCPCS C1713 55-08203 - PLATE BONE MINI STR 4MMX1MM 4 HOLE BAR UNIVERSAL 2 TITANIUM BOTH IP/OP $308.13 $228.02 $0.00 $594.00 $334.13 $334.13 $0.00 $0.00 $0.00 $64.22 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $182.26 $182.26 $0.00 $371.25 $588.06 $594.00 $0.00 $0.00 $116.20 $0.00 $0.00 $118.21 $0.00 $0.00 $0.00 $0.00 $0.00 55-08204 SUP HCPCS C1713 55-08204 - PLATE BONE MINI REGULAR STR 1MM 4 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $255.38 $188.98 $0.00 $508.00 $285.75 $285.75 $0.00 $0.00 $0.00 $53.23 $189.54 $189.54 $0.00 $0.00 $53.22 $0.00 $151.05 $151.05 $0.00 $317.50 $502.92 $508.00 $0.00 $0.00 $99.38 $0.00 $0.00 $101.09 $0.00 $0.00 $0.00 $0.00 $0.00 55-08205 SUP HCPCS C1713 55-08205 - PLATE BONE MINI STR 8MMX1MM 4 HOLE BAR UNIVERSAL 2 TITANIUM BOTH IP/OP $308.13 $228.02 $0.00 $594.00 $334.13 $334.13 $0.00 $0.00 $0.00 $64.22 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $182.26 $182.26 $0.00 $371.25 $588.06 $594.00 $0.00 $0.00 $116.20 $0.00 $0.00 $118.21 $0.00 $0.00 $0.00 $0.00 $0.00 55-08206 SUP HCPCS C1713 55-08206 - PLATE BONE MINI STR 6 HOLE STR TITANIUM LEFT BOTH IP/OP $465.68 $344.60 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $97.06 $345.62 $345.62 $0.00 $0.00 $97.05 $0.00 $275.45 $275.45 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 55-08216 SUP HCPCS C1713 55-08216 - PLATE BONE MINI REGULAR STR 1MM 16 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $905.70 $670.22 $0.00 "$1,664.00" $936.00 $936.00 $0.00 $0.00 $0.00 $188.77 $672.21 $672.21 $0.00 $0.00 $188.75 $0.00 $535.72 $535.72 $0.00 "$1,040.00" "$1,647.36" "$1,664.00" $0.00 $0.00 $325.52 $0.00 $0.00 $331.14 $0.00 $0.00 $0.00 $0.00 $0.00 55-08230 SUP HCPCS C1713 55-08230 - PLATE BONE MINI REGULAR L 1MM 4 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $382.13 $282.78 $0.00 $702.00 $394.88 $394.88 $0.00 $0.00 $0.00 $79.64 $283.61 $283.61 $0.00 $0.00 $79.63 $0.00 $226.03 $226.03 $0.00 $438.75 $694.98 $702.00 $0.00 $0.00 $137.33 $0.00 $0.00 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 55-08231 SUP HCPCS C1713 55-08231 - PLATE BONE MINI REGULAR L 1MM 4 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $382.13 $282.78 $0.00 $702.00 $394.88 $394.88 $0.00 $0.00 $0.00 $79.64 $283.61 $283.61 $0.00 $0.00 $79.63 $0.00 $226.03 $226.03 $0.00 $438.75 $694.98 $702.00 $0.00 $0.00 $137.33 $0.00 $0.00 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 55-08232 SUP HCPCS C1713 55-08232 - PLATE BONE 8MM 4 HOLE L BAR TITANIUM RIGHT BOTH IP/OP $391.00 $289.34 $0.00 $738.00 $415.13 $415.13 $0.00 $0.00 $0.00 $81.49 $290.20 $290.20 $0.00 $0.00 $81.48 $0.00 $231.28 $231.28 $0.00 $461.25 $730.62 $738.00 $0.00 $0.00 $144.37 $0.00 $0.00 $146.86 $0.00 $0.00 $0.00 $0.00 $0.00 55-08233 SUP HCPCS C1713 55-08233 - PLATE BONE 8MM 4 HOLE L BAR TITANIUM LEFT BOTH IP/OP $391.00 $289.34 $0.00 $738.00 $415.13 $415.13 $0.00 $0.00 $0.00 $81.49 $290.20 $290.20 $0.00 $0.00 $81.48 $0.00 $231.28 $231.28 $0.00 $461.25 $730.62 $738.00 $0.00 $0.00 $144.37 $0.00 $0.00 $146.86 $0.00 $0.00 $0.00 $0.00 $0.00 55-08234 SUP HCPCS C1713 55-08234 - PLATE BONE MINI L 4MMX1MM 4 HOLE BAR UNIVERSAL 2 TITANIUM BOTH IP/OP $406.90 $301.11 $0.00 $770.00 $433.13 $433.13 $0.00 $0.00 $0.00 $84.81 $302.00 $302.00 $0.00 $0.00 $84.80 $0.00 $240.68 $240.68 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 55-08235 SUP HCPCS C1713 55-08235 - PLATE BONE 4MM 4 HOLE L BAR TITANIUM LEFT BOTH IP/OP $406.90 $301.11 $0.00 $770.00 $433.13 $433.13 $0.00 $0.00 $0.00 $84.81 $302.00 $302.00 $0.00 $0.00 $84.80 $0.00 $240.68 $240.68 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 55-08236 SUP HCPCS C1713 55-08236 - PLATE BONE MINI L 8MMX1MM 5 HOLE BAR UNIVERSAL 2 TITANIUM BOTH IP/OP $421.83 $312.15 $0.00 $802.00 $451.13 $451.13 $0.00 $0.00 $0.00 $87.92 $313.08 $313.08 $0.00 $0.00 $87.91 $0.00 $249.51 $249.51 $0.00 $501.25 $793.98 $802.00 $0.00 $0.00 $156.89 $0.00 $0.00 $159.60 $0.00 $0.00 $0.00 $0.00 $0.00 55-08237 SUP HCPCS C1713 55-08237 - PLATE BONE MINI L 8MMX1MM 5 HOLE BAR UNIVERSAL 2 TITANIUM BOTH IP/OP $421.83 $312.15 $0.00 $802.00 $451.13 $451.13 $0.00 $0.00 $0.00 $87.92 $313.08 $313.08 $0.00 $0.00 $87.91 $0.00 $249.51 $249.51 $0.00 $501.25 $793.98 $802.00 $0.00 $0.00 $156.89 $0.00 $0.00 $159.60 $0.00 $0.00 $0.00 $0.00 $0.00 55-08240 SUP HCPCS C1713 55-08240 - PLATE BONE MINI REGULAR T 1MM 6 HOLE UNIVERSAL 2 TITANIUM BOTH IP/OP $319.73 $236.60 $0.00 $572.00 $321.75 $321.75 $0.00 $0.00 $0.00 $66.64 $237.30 $237.30 $0.00 $0.00 $66.63 $0.00 $189.12 $189.12 $0.00 $357.50 $566.28 $572.00 $0.00 $0.00 $111.90 $0.00 $0.00 $113.83 $0.00 $0.00 $0.00 $0.00 $0.00 55-08250 SUP HCPCS C1713 55-08250 - PLATE BONE MINI 5 HOLE Y W/O BAR TITANIUM MAXFACL BOTH IP/OP $364.98 $270.09 $0.00 $676.00 $380.25 $380.25 $0.00 $0.00 $0.00 $76.07 $270.88 $270.88 $0.00 $0.00 $76.06 $0.00 $215.88 $215.88 $0.00 $422.50 $669.24 $676.00 $0.00 $0.00 $132.24 $0.00 $0.00 $134.52 $0.00 $0.00 $0.00 $0.00 $0.00 55-08251 SUP HCPCS C1713 55-08251 - PLATE BONE MINI Y 8MMX1MM 5 HOLE BAR UNIVERSAL 2 TITANIUM BOTH IP/OP $364.98 $270.09 $0.00 $676.00 $380.25 $380.25 $0.00 $0.00 $0.00 $76.07 $270.88 $270.88 $0.00 $0.00 $76.06 $0.00 $215.88 $215.88 $0.00 $422.50 $669.24 $676.00 $0.00 $0.00 $132.24 $0.00 $0.00 $134.52 $0.00 $0.00 $0.00 $0.00 $0.00 55-08260 SUP HCPCS C1713 55-08260 - PLATE BONE 2Y 6 HOLE TITANIUM MAXFACL 2MM SCREW BOTH IP/OP $397.25 $293.97 $0.00 $754.00 $424.13 $424.13 $0.00 $0.00 $0.00 $82.80 $294.84 $294.84 $0.00 $0.00 $82.79 $0.00 $234.97 $234.97 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $147.50 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $0.00 55-08262 SUP HCPCS C1713 55-08262 - PLATE BONE MINI 2Y 8MMX1MM 6 HOLE BAR UNIVERSAL 2 TITANIUM BOTH IP/OP $397.25 $293.97 $0.00 $754.00 $424.13 $424.13 $0.00 $0.00 $0.00 $82.80 $294.84 $294.84 $0.00 $0.00 $82.79 $0.00 $234.97 $234.97 $0.00 $471.25 $746.46 $754.00 $0.00 $0.00 $147.50 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $0.00 55-08510 SUP HCPCS C1713 55-08510 - PLATE BONE .75MM 30 HOLE STR LP TITANIUM MAXFACL BOTH IP/OP "$1,029.93 " $762.15 $0.00 "$1,882.00" "$1,058.63" "$1,058.63" $0.00 $0.00 $0.00 $214.66 $764.41 $764.41 $0.00 $0.00 $214.64 $0.00 $609.20 $609.20 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $368.17 $0.00 $0.00 $374.52 $0.00 $0.00 $0.00 $0.00 $0.00 55-08520 SUP HCPCS C1713 55-08520 - PLATE BONE 100D L .75MM 9 HOLE LP RIGHT ANGLED TITANIUM BOTH IP/OP $488.65 $361.60 $0.00 $894.00 $502.88 $502.88 $0.00 $0.00 $0.00 $101.85 $362.68 $362.68 $0.00 $0.00 $101.83 $0.00 $289.04 $289.04 $0.00 $558.75 $885.06 $894.00 $0.00 $0.00 $174.89 $0.00 $0.00 $177.91 $0.00 $0.00 $0.00 $0.00 $0.00 55-08521 SUP HCPCS C1713 55-08521 - PLATE BONE 100D L .75MM 9 HOLE LP LEFT ANGLED TITANIUM BOTH IP/OP $488.65 $361.60 $0.00 $894.00 $502.88 $502.88 $0.00 $0.00 $0.00 $101.85 $362.68 $362.68 $0.00 $0.00 $101.83 $0.00 $289.04 $289.04 $0.00 $558.75 $885.06 $894.00 $0.00 $0.00 $174.89 $0.00 $0.00 $177.91 $0.00 $0.00 $0.00 $0.00 $0.00 55-08542 SUP HCPCS C1713 55-08542 - PLATE BONE .75MM 8 HOLE T LP TITANIUM MAXFACL BOTH IP/OP $480.75 $355.76 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $100.20 $356.81 $356.81 $0.00 $0.00 $100.19 $0.00 $284.36 $284.36 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 55-08579 SUP HCPCS C1713 55-08579 - PLATE BONE .75MM 8 HOLE Y TITANIUM MAXFACL BOTH IP/OP $480.75 $355.76 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $100.20 $356.81 $356.81 $0.00 $0.00 $100.19 $0.00 $284.36 $284.36 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 55-08586 SUP HCPCS C1713 55-08586 - PLATE BONE CURVE .75MM 12 HOLE LP TITANIUM MAXFACL BOTH IP/OP $488.65 $361.60 $0.00 $920.00 $517.50 $517.50 $0.00 $0.00 $0.00 $101.85 $362.68 $362.68 $0.00 $0.00 $101.83 $0.00 $289.04 $289.04 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $179.98 $0.00 $0.00 $183.08 $0.00 $0.00 $0.00 $0.00 $0.00 55-09104 SUP HCPCS C1713 55-09104 - PLATE BONE 4MM BAR TITANIUM CHIN 2MM SCREW BOTH IP/OP $480.75 $355.76 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $100.20 $356.81 $356.81 $0.00 $0.00 $100.19 $0.00 $284.36 $284.36 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 55-09106 SUP HCPCS C1713 55-09106 - PLATE BONE 6MM BAR TITANIUM CHIN BOTH IP/OP $488.65 $361.60 $0.00 $920.00 $517.50 $517.50 $0.00 $0.00 $0.00 $101.85 $362.68 $362.68 $0.00 $0.00 $101.83 $0.00 $289.04 $289.04 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $179.98 $0.00 $0.00 $183.08 $0.00 $0.00 $0.00 $0.00 $0.00 55-09108 SUP HCPCS C1713 55-09108 - PLATE BONE 8MM BAR TITANIUM CHIN 2MM SCREW BOTH IP/OP $527.33 $390.22 $0.00 $968.00 $544.50 $544.50 $0.00 $0.00 $0.00 $109.91 $391.38 $391.38 $0.00 $0.00 $109.89 $0.00 $311.91 $311.91 $0.00 $605.00 $958.32 $968.00 $0.00 $0.00 $189.37 $0.00 $0.00 $192.63 $0.00 $0.00 $0.00 $0.00 $0.00 55-09110 SUP HCPCS C1713 55-09110 - PLATE BONE 10MM BAR TITANIUM CHIN 2MM SCREW BOTH IP/OP $550.78 $407.58 $0.00 $992.00 $558.00 $558.00 $0.00 $0.00 $0.00 $114.80 $408.79 $408.79 $0.00 $0.00 $114.78 $0.00 $325.78 $325.78 $0.00 $620.00 $982.08 $992.00 $0.00 $0.00 $194.06 $0.00 $0.00 $197.41 $0.00 $0.00 $0.00 $0.00 $0.00 55-10503 SUP HCPCS C1713 55-10503 - PLATE BONE LONG 4 HOLE LOCKING STR BAR TITANIUM MANDIB 2MM BOTH IP/OP $595.00 $440.30 $0.00 $476.00 $267.75 $267.75 $0.00 $0.00 $0.00 $124.01 $441.61 $441.61 $0.00 $0.00 $124.00 $0.00 $351.94 $351.94 $0.00 $297.50 $471.24 $476.00 $0.00 $0.00 $93.12 $0.00 $0.00 $94.72 $0.00 $0.00 $0.00 $0.00 $0.00 55-10504 SUP HCPCS C1713 55-10504 - PLATE BN MN STRG 1MM BLU SMRT LCK LEIBINGER UNV 2 4 HL TI BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 55-10505 SUP HCPCS C1713 55-10505 - PLATE BN MN STRG 4MMX1MM BLU SMRT LCK LEIBINGER UNV 2 4 HL BOTH IP/OP $452.50 $334.85 $0.00 $362.00 $203.63 $203.63 $0.00 $0.00 $0.00 $94.31 $335.85 $335.85 $0.00 $0.00 $94.30 $0.00 $267.65 $267.65 $0.00 $226.25 $358.38 $362.00 $0.00 $0.00 $70.82 $0.00 $0.00 $72.04 $0.00 $0.00 $0.00 $0.00 $0.00 55-10506 SUP HCPCS C1713 55-10506 - PLATE BN MN STRG 1MM BLU SMRT LCK LEIBINGER UNV 2 6 HL TI BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 55-10507 SUP HCPCS C1713 55-10507 - PLATE BN MN STRG 8MMX1MM BLU SMRT LCK LEIBINGER UNV 2 6 HL BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 55-10515 SUP HCPCS C1713 55-10515 - PLATE BONE MINI 8MM 16 HOLE STR CONDENSED TITANIUM MANDIB 2 BOTH IP/OP $755.75 $559.26 $0.00 "$1,442.00" $811.13 $811.13 $0.00 $0.00 $0.00 $157.52 $560.92 $560.92 $0.00 $0.00 $157.50 $0.00 $447.03 $447.03 $0.00 $901.25 "$1,427.58" "$1,442.00" $0.00 $0.00 $282.09 $0.00 $0.00 $286.96 $0.00 $0.00 $0.00 $0.00 $0.00 55-10516 SUP HCPCS C1713 55-10516 - PLATE BONE STR MINI 16 HOLE LOCK TITANIUM MAXFACL 2/2.3MM BOTH IP/OP $302.88 $224.13 $0.00 $566.00 $318.38 $318.38 $0.00 $0.00 $0.00 $63.13 $224.79 $224.79 $0.00 $0.00 $63.12 $0.00 $179.15 $179.15 $0.00 $353.75 $560.34 $566.00 $0.00 $0.00 $110.72 $0.00 $0.00 $112.63 $0.00 $0.00 $0.00 $0.00 $0.00 55-10532 SUP HCPCS C1713 55-10532 - PLATE BONE MINI RECTANGLE 3X2 HOLE RECTANGULAR 3D TITANIUM BOTH IP/OP $612.18 $453.01 $0.00 "$1,108.00" $623.25 $623.25 $0.00 $0.00 $0.00 $127.59 $454.36 $454.36 $0.00 $0.00 $127.58 $0.00 $362.10 $362.10 $0.00 $692.50 "$1,096.92" "$1,108.00" $0.00 $0.00 $216.75 $0.00 $0.00 $220.49 $0.00 $0.00 $0.00 $0.00 $0.00 55-10542 SUP HCPCS C1713 55-10542 - PLATE BONE 4X2 HOLE 3D LOCKING TITANIUM MAXFACL 2/2.3 MM BOTH IP/OP $688.55 $509.53 $0.00 "$1,280.00" $720.00 $720.00 $0.00 $0.00 $0.00 $143.51 $511.04 $511.04 $0.00 $0.00 $143.49 $0.00 $407.28 $407.28 $0.00 $800.00 "$1,267.20" "$1,280.00" $0.00 $0.00 $250.40 $0.00 $0.00 $254.72 $0.00 $0.00 $0.00 $0.00 $0.00 55-10562 SUP HCPCS C1713 55-10562 - PLATE BONE MINI CVD 6X2 HOLE 3D LOCKING CVD TITANIUM MAXFACL BOTH IP/OP $769.63 $569.53 $0.00 "$1,394.00" $784.13 $784.13 $0.00 $0.00 $0.00 $160.41 $571.22 $571.22 $0.00 $0.00 $160.39 $0.00 $455.23 $455.23 $0.00 $871.25 "$1,380.06" "$1,394.00" $0.00 $0.00 $272.70 $0.00 $0.00 $277.41 $0.00 $0.00 $0.00 $0.00 $0.00 55-10563 SUP HCPCS C1713 55-10563 - PLATE BONE MINI 4 HOLE REINFORCED BAR TITANIUM MANDIB 2/2.3 BOTH IP/OP $709.10 $524.73 $0.00 "$1,302.00" $732.38 $732.38 $0.00 $0.00 $0.00 $147.79 $526.29 $526.29 $0.00 $0.00 $147.78 $0.00 $419.43 $419.43 $0.00 $813.75 "$1,288.98" "$1,302.00" $0.00 $0.00 $254.70 $0.00 $0.00 $259.10 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-101 SUP HCPCS C1776 5510-F-101 - COMPONENT FEMORAL 1 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-102 SUP HCPCS C1776 5510-F-102 - COMPONENT FEMORAL 1 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-201 SUP HCPCS C1776 5510-F-201 - COMPONENT FEMORAL 2 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-202 SUP HCPCS C1776 5510-F-202 - COMPONENT FEMORAL 2 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-301 SUP HCPCS C1776 5510-F-301 - COMPONENT FEMORAL 3 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-302 SUP HCPCS C1776 5510-F-302 - COMPONENT FEMORAL 3 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-401 SUP HCPCS C1776 5510-F-401 - COMPONENT FEMORAL 4 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-402 SUP HCPCS C1776 5510-F-402 - COMPONENT FEMORAL 4 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-501 SUP HCPCS C1776 5510-F-501 - COMPONENT FEMORAL 5 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-502 SUP HCPCS C1776 5510-F-502 - COMPONENT FEMORAL 5 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-601 SUP HCPCS C1776 5510-F-601 - COMPONENT FEMORAL 6 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-602 SUP HCPCS C1776 5510-F-602 - COMPONENT FEMORAL 6 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-701 SUP HCPCS C1776 5510-F-701 - COMPONENT FEMORAL 7 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-702 SUP HCPCS C1776 5510-F-702 - COMPONENT FEMORAL 7 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-801 SUP HCPCS C1776 5510-F-801 - COMPONENT FEMORAL 8 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5510-F-802 SUP HCPCS C1776 5510-F-802 - COMPONENT FEMORAL 8 CRUCIATE RETAIN CEMENTED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-101 SUP HCPCS C1776 5512-F-101 - COMPONENT FEMORAL 1 TOT STABILIZE TRIATHLON COCR KNEE LEFT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-102 SUP HCPCS C1776 5512-F-102 - COMPONENT FEMORAL 1 TOT STABILIZE TRIATHLON COCR KNEE RIGHT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-201 SUP HCPCS C1776 5512-F-201 - COMPONENT FEMORAL 2 TOT STABILIZE TRIATHLON COCR KNEE LEFT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-202 SUP HCPCS C1776 5512-F-202 - COMPONENT FEMORAL 2 TOT STABILIZE TRIATHLON COCR KNEE RIGHT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-301 SUP HCPCS C1776 5512-F-301 - COMPONENT FEMORAL 3 TOT STABILIZER TRIATHLON COCR KNEE LEFT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-302 SUP HCPCS C1776 5512-F-302 - COMPONENT FEMORAL 3 TOT STABILIZER TRIATHLON COCR KNEE RIGHT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-401 SUP HCPCS C1776 5512-F-401 - COMPONENT FEMORAL 4 TOT STABILIZER TRIATHLON COCR KNEE LEFT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-402 SUP HCPCS C1776 5512-F-402 - COMPONENT FEMORAL 4 TOT STABILIZER TRIATHLON COCR KNEE RIGHT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-501 SUP HCPCS C1776 5512-F-501 - COMPONENT FEMORAL 5 TOT STABILIZE TRIATHLON COCR KNEE LEFT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-502 SUP HCPCS C1776 5512-F-502 - COMPONENT FEMORAL 5 TOT STABILIZER TRIATHLON COCR KNEE RIGHT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-601 SUP HCPCS C1776 5512-F-601 - COMPONENT FEMORAL 6 TOT STABILIZE TRIATHLON COCR KNEE LEFT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-602 SUP HCPCS C1776 5512-F-602 - COMPONENT FEMORAL 6 TOT STABILIZE TRIATHLON COCR KNEE RIGHT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-701 SUP HCPCS C1776 5512-F-701 - COMPONENT FEMORAL 7 TOT STABILIZE TRIATHLON COCR KNEE LEFT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-702 SUP HCPCS C1776 5512-F-702 - COMPONENT FEMORAL 7 TOT STABILIZE TRIATHLON COCR KNEE RIGHT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-801 SUP HCPCS C1776 5512-F-801 - COMPONENT FEMORAL 8 TOT STABILIZE TRIATHLON COCR KNEE LEFT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5512-F-802 SUP HCPCS C1776 5512-F-802 - COMPONENT FEMORAL 8 TOT STABILIZE TRIATHLON COCR KNEE RIGHT BOTH IP/OP "$13,967.50 " "$10,335.95" $0.00 "$11,174.00" "$6,285.38" "$6,285.38" $0.00 $0.00 $0.00 "$2,911.18" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,910.83" $0.00 "$6,885.98" "$6,885.98" $0.00 "$6,983.75" "$11,062.26" "$11,174.00" $0.00 $0.00 "$2,185.91" $0.00 $0.00 "$2,223.63" $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-101 SUP HCPCS C1776 5513-F-101 - COMPONENT FEMORAL 1 CRUCIATE RETAIN BEAD TRIATHLON KNEE LEFT BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-102 SUP HCPCS C1776 5513-F-102 - COMPONENT FEMORAL 1 CRUCIATE RETAIN BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-201 SUP HCPCS C1776 5513-F-201 - COMPONENT FEMORAL 2 CRUCIATE RETAIN BEAD TRIATHLON KNEE LEFT BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-202 SUP HCPCS C1776 5513-F-202 - COMPONENT FEMORAL 2 CRUCIATE RETAIN BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-301 SUP HCPCS C1776 5513-F-301 - COMPONENT FEMORAL 3 CRUCIATE RETAIN BEAD TRIATHLON KNEE LEFT BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-302 SUP HCPCS C1776 5513-F-302 - COMPONENT FEMORAL 3 CRUCIATE RETAIN BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-401 SUP HCPCS C1776 5513-F-401 - COMPONENT FEMORAL 4 CRUCIATE RETAIN BEAD TRIATHLON KNEE LEFT BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-402 SUP HCPCS C1776 5513-F-402 - COMPONENT FEMORAL 4 CRUCIATE RETAIN BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-501 SUP HCPCS C1776 5513-F-501 - COMPONENT FEMORAL 5 CRUCIATE RETAIN BEAD TRIATHLON KNEE LEFT BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-502 SUP HCPCS C1776 5513-F-502 - COMPONENT FEMORAL 5 CRUCIATE RETAIN BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-601 SUP HCPCS C1776 5513-F-601 - COMPONENT FEMORAL 6 CRUCIATE RETAIN BEAD TRIATHLON KNEE LEFT BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-602 SUP HCPCS C1776 5513-F-602 - COMPONENT FEMORAL 6 CRUCIATE RETAIN BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-701 SUP HCPCS C1776 5513-F-701 - COMPONENT FEMORAL 7 CRUCIATE RETAIN BEAD TRIATHLON KNEE LEFT BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-702 SUP HCPCS C1776 5513-F-702 - COMPONENT FEMORAL 7 CRUCIATE RETAIN BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-801 SUP HCPCS C1776 5513-F-801 - COMPONENT FEMORAL 8 CRUCIATE RETAIN BEAD TRIATHLON KNEE LEFT BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5513-F-802 SUP HCPCS C1776 5513-F-802 - COMPONENT FEMORAL 8 CRUCIATE RETAIN BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-101 SUP HCPCS C1776 5514-F-101 - COMPONENT FEMORAL 1 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-102 SUP HCPCS C1776 5514-F-102 - COMPONENT FEMORAL 1 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-201 SUP HCPCS C1776 5514-F-201 - COMPONENT FEMORAL 2 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-202 SUP HCPCS C1776 5514-F-202 - COMPONENT FEMORAL 2 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-301 SUP HCPCS C1776 5514-F-301 - COMPONENT FEMORAL 3 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-302 SUP HCPCS C1776 5514-F-302 - COMPONENT FEMORAL 3 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-401 SUP HCPCS C1776 5514-F-401 - COMPONENT FEMORAL 4 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-402 SUP HCPCS C1776 5514-F-402 - COMPONENT FEMORAL 4 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-501 SUP HCPCS C1776 5514-F-501 - COMPONENT FEMORAL 5 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-502 SUP HCPCS C1776 5514-F-502 - COMPONENT FEMORAL 5 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-601 SUP HCPCS C1776 5514-F-601 - COMPONENT FEMORAL 6 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-602 SUP HCPCS C1776 5514-F-602 - COMPONENT FEMORAL 6 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-701 SUP HCPCS C1776 5514-F-701 - COMPONENT FEMORAL 7 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-702 SUP HCPCS C1776 5514-F-702 - COMPONENT FEMORAL 7 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-801 SUP HCPCS C1776 5514-F-801 - COMPONENT FEMORAL 8 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5514-F-802 SUP HCPCS C1776 5514-F-802 - COMPONENT FEMORAL 8 POSTERIOR STABILIZE BEAD TRIATHLON KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 55-15504 SUP HCPCS C1713 55-15504 - PLATE BONE STR MINI 1.5MM 4 HOLE TITANIUM MAXFACL 2.3MM BOTH IP/OP "$1,600.00 " "$1,184.00" $0.00 "$1,280.00" $720.00 $720.00 $0.00 $0.00 $0.00 $333.48 "$1,187.52" "$1,187.52" $0.00 $0.00 $333.44 $0.00 $946.40 $946.40 $0.00 $800.00 "$1,267.20" "$1,280.00" $0.00 $0.00 $250.40 $0.00 $0.00 $254.72 $0.00 $0.00 $0.00 $0.00 $0.00 55-15505 SUP HCPCS C1713 55-15505 - PLATE BONE 4 HOLE BAR LOCKING TITANIUM MAXFACL BOTH IP/OP "$1,610.00 " "$1,191.40" $0.00 "$1,288.00" $724.50 $724.50 $0.00 $0.00 $0.00 $335.56 "$1,194.94" "$1,194.94" $0.00 $0.00 $335.52 $0.00 $952.32 $952.32 $0.00 $805.00 "$1,275.12" "$1,288.00" $0.00 $0.00 $251.97 $0.00 $0.00 $256.31 $0.00 $0.00 $0.00 $0.00 $0.00 55-15506 SUP HCPCS C1713 55-15506 - PLATE BONE 6 HOLE LOCKING TITANIUM MANDIB 2 MM SCREW BOTH IP/OP "$1,887.50 " "$1,396.75" $0.00 "$1,510.00" $849.38 $849.38 $0.00 $0.00 $0.00 $393.40 "$1,400.90" "$1,400.90" $0.00 $0.00 $393.36 $0.00 "$1,116.46" "$1,116.46" $0.00 $943.75 "$1,494.90" "$1,510.00" $0.00 $0.00 $295.39 $0.00 $0.00 $300.49 $0.00 $0.00 $0.00 $0.00 $0.00 55-15507 SUP HCPCS C1713 55-15507 - PLATE BONE 6 HOLE BAR TITANIUM MANDIB 2.3/2.7 MM SCREW BOTH IP/OP "$2,045.00 " "$1,513.30" $0.00 "$1,636.00" $920.25 $920.25 $0.00 $0.00 $0.00 $426.23 "$1,517.80" "$1,517.80" $0.00 $0.00 $426.18 $0.00 "$1,209.62" "$1,209.62" $0.00 "$1,022.50" "$1,619.64" "$1,636.00" $0.00 $0.00 $320.04 $0.00 $0.00 $325.56 $0.00 $0.00 $0.00 $0.00 $0.00 55-15514 SUP HCPCS C1713 55-15514 - PLATE BONE 14 HOLE LOCKING TITANIUM MAXFACL 2.3/2.7 MM SCREW BOTH IP/OP "$1,270.23 " $939.97 $0.00 "$2,408.00" "$1,354.50" "$1,354.50" $0.00 $0.00 $0.00 $264.75 $942.76 $942.76 $0.00 $0.00 $264.71 $0.00 $751.34 $751.34 $0.00 "$1,505.00" "$2,383.92" "$2,408.00" $0.00 $0.00 $471.07 $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 $0.00 55-15524 SUP HCPCS C1713 55-15524 - PLATE BONE 4 HOLE TITANIUM MAXFACL BOTH IP/OP "$1,710.00 " "$1,265.40" $0.00 "$1,368.00" $769.50 $769.50 $0.00 $0.00 $0.00 $356.41 "$1,269.16" "$1,269.16" $0.00 $0.00 $356.36 $0.00 "$1,011.47" "$1,011.47" $0.00 $855.00 "$1,354.32" "$1,368.00" $0.00 $0.00 $267.62 $0.00 $0.00 $272.23 $0.00 $0.00 $0.00 $0.00 $0.00 55-15526 SUP HCPCS C1713 55-15526 - PLATE BONE 115D 1.5MM 4 HOLE ANGLED TITANIUM MANDIB 2MM BOTH IP/OP "$2,840.00 " "$2,101.60" $0.00 "$2,272.00" "$1,278.00" "$1,278.00" $0.00 $0.00 $0.00 $591.93 "$2,107.85" "$2,107.85" $0.00 $0.00 $591.86 $0.00 "$1,400.12" "$1,400.12" $0.00 "$1,420.00" "$2,249.28" "$2,272.00" $0.00 $0.00 $444.46 $0.00 $0.00 $452.13 $0.00 $0.00 $0.00 $0.00 $0.00 55-15536 SUP HCPCS C1713 55-15536 - PLATE BN 140D 1.5MM NS LEIBINGER UNV 2 6 HL BAR TI MNDB BOTH IP/OP "$2,820.00 " "$2,086.80" $0.00 "$2,256.00" "$1,269.00" "$1,269.00" $0.00 $0.00 $0.00 $587.76 "$2,093.00" "$2,093.00" $0.00 $0.00 $587.69 $0.00 "$1,390.26" "$1,390.26" $0.00 "$1,410.00" "$2,233.44" "$2,256.00" $0.00 $0.00 $441.33 $0.00 $0.00 $448.94 $0.00 $0.00 $0.00 $0.00 $0.00 55-15570 SUP HCPCS C1713 55-15570 - PLATE BONE UNIVERSAL 1.5MM 4 HOLE COMPRESSION TITANIUM BOTH IP/OP $586.33 $433.88 $0.00 "$1,060.00" $596.25 $596.25 $0.00 $0.00 $0.00 $122.20 $435.17 $435.17 $0.00 $0.00 $122.19 $0.00 $346.81 $346.81 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 55-15575 SUP HCPCS C1713 55-15575 - PLATE BONE 4 HOLE COMPRESSION TITANIUM MANDIB 2.3 MM SCREWS BOTH IP/OP $586.33 $433.88 $0.00 "$1,060.00" $596.25 $596.25 $0.00 $0.00 $0.00 $122.20 $435.17 $435.17 $0.00 $0.00 $122.19 $0.00 $346.81 $346.81 $0.00 $662.50 "$1,049.40" "$1,060.00" $0.00 $0.00 $207.36 $0.00 $0.00 $210.94 $0.00 $0.00 $0.00 $0.00 $0.00 55-15580 SUP HCPCS C1713 55-15580 - PLATE BONE STR 6 HOLE COMPRESSION TITANIUM MAXFACL 2MM SCREW BOTH IP/OP $893.03 $660.84 $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $186.13 $662.80 $662.80 $0.00 $0.00 $186.11 $0.00 $528.22 $528.22 $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 55-15585 SUP HCPCS C1713 55-15585 - PLATE BONE 6 HOLE COMPRESSION TITANIUM MANDIB 2.3 MM SCREWS BOTH IP/OP $893.03 $660.84 $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $186.13 $662.80 $662.80 $0.00 $0.00 $186.11 $0.00 $528.22 $528.22 $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 55-15911 SUP HCPCS C1713 55-15911 - PLATE BONE STR 11 HOLE PRIM RECONSTRUCTION TITANIUM MANDIB BOTH IP/OP "$1,365.68 " "$1,010.60" $0.00 "$2,466.00" "$1,387.13" "$1,387.13" $0.00 $0.00 $0.00 $284.64 "$1,013.60" "$1,013.60" $0.00 $0.00 $284.61 $0.00 $807.80 $807.80 $0.00 "$1,541.25" "$2,441.34" "$2,466.00" $0.00 $0.00 $482.41 $0.00 $0.00 $490.73 $0.00 $0.00 $0.00 $0.00 $0.00 55-15917 SUP HCPCS C1713 55-15917 - PLATE BONE STR 17 HOLE PRIM RECONSTRUCTION TEMPLATE TITANIUM BOTH IP/OP "$1,735.33 " "$1,284.14" $0.00 "$3,130.00" "$1,760.63" "$1,760.63" $0.00 $0.00 $0.00 $361.69 "$1,287.96" "$1,287.96" $0.00 $0.00 $361.64 $0.00 "$1,026.44" "$1,026.44" $0.00 "$1,956.25" "$3,098.70" "$3,130.00" $0.00 $0.00 $612.31 $0.00 $0.00 $622.87 $0.00 $0.00 $0.00 $0.00 $0.00 55-15920 SUP HCPCS C1713 55-15920 - PLATE BN HMSPHR 1.5MM AU SMRT LCK LEIBINGER UNV 2 5X17 HL TI BOTH IP/OP "$2,445.23 " "$1,809.47" $0.00 "$4,244.00" "$2,387.25" "$2,387.25" $0.00 $0.00 $0.00 $509.65 "$1,814.85" "$1,814.85" $0.00 $0.00 $509.58 $0.00 "$1,446.35" "$1,446.35" $0.00 "$2,652.50" "$4,201.56" "$4,244.00" $0.00 $0.00 $830.23 $0.00 $0.00 $844.56 $0.00 $0.00 $0.00 $0.00 $0.00 55-15922 SUP HCPCS C1713 55-15922 - PLATE BN HMSPHR 1.5MM SMRT LCK LEIBINGER UNV 2 5X17 HL TI BOTH IP/OP "$2,445.23 " "$1,809.47" $0.00 "$4,244.00" "$2,387.25" "$2,387.25" $0.00 $0.00 $0.00 $509.65 "$1,814.85" "$1,814.85" $0.00 $0.00 $509.58 $0.00 "$1,446.35" "$1,446.35" $0.00 "$2,652.50" "$4,201.56" "$4,244.00" $0.00 $0.00 $830.23 $0.00 $0.00 $844.56 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-101 SUP HCPCS C1776 5515-F-101 - COMPONENT FEMORAL 1 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-102 SUP HCPCS C1776 5515-F-102 - COMPONENT FEMORAL 1 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-201 SUP HCPCS C1776 5515-F-201 - COMPONENT FEMORAL 2 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-202 SUP HCPCS C1776 5515-F-202 - COMPONENT FEMORAL 2 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-301 SUP HCPCS C1776 5515-F-301 - COMPONENT FEMORAL 3 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-302 SUP HCPCS C1776 5515-F-302 - COMPONENT FEMORAL 3 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-401 SUP HCPCS C1776 5515-F-401 - COMPONENT FEMORAL 4 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-402 SUP HCPCS C1776 5515-F-402 - COMPONENT FEMORAL 4 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-501 SUP HCPCS C1776 5515-F-501 - COMPONENT FEMORAL 5 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-502 SUP HCPCS C1776 5515-F-502 - COMPONENT FEMORAL 5 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-601 SUP HCPCS C1776 5515-F-601 - COMPONENT FEMORAL 6 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-602 SUP HCPCS C1776 5515-F-602 - COMPONENT FEMORAL 6 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-701 SUP HCPCS C1776 5515-F-701 - COMPONENT FEMORAL 7 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-702 SUP HCPCS C1776 5515-F-702 - COMPONENT FEMORAL 7 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-801 SUP HCPCS C1776 5515-F-801 - COMPONENT FEMORAL 8 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5515-F-802 SUP HCPCS C1776 5515-F-802 - COMPONENT FEMORAL 8 CEMENTED POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-101 SUP HCPCS C1776 5516-F-101 - COMPONENT FEMORAL 1 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-102 SUP HCPCS C1776 5516-F-102 - COMPONENT FEMORAL 1 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-201 SUP HCPCS C1776 5516-F-201 - COMPONENT FEMORAL 2 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-202 SUP HCPCS C1776 5516-F-202 - COMPONENT FEMORAL 2 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-301 SUP HCPCS C1776 5516-F-301 - COMPONENT FEMORAL 3 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-302 SUP HCPCS C1776 5516-F-302 - COMPONENT FEMORAL 3 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-401 SUP HCPCS C1776 5516-F-401 - COMPONENT FEMORAL 4 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-402 SUP HCPCS C1776 5516-F-402 - COMPONENT FEMORAL 4 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-501 SUP HCPCS C1776 5516-F-501 - COMPONENT FEMORAL 5 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-502 SUP HCPCS C1776 5516-F-502 - COMPONENT FEMORAL 5 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-601 SUP HCPCS C1776 5516-F-601 - COMPONENT FEMORAL 6 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-602 SUP HCPCS C1776 5516-F-602 - COMPONENT FEMORAL 6 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-701 SUP HCPCS C1776 5516-F-701 - COMPONENT FEMORAL 7 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-702 SUP HCPCS C1776 5516-F-702 - COMPONENT FEMORAL 7 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-801 SUP HCPCS C1776 5516-F-801 - COMPONENT FEMORAL 8 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5516-F-802 SUP HCPCS C1776 5516-F-802 - COMPONENT FEMORAL 8 POSTERIOR STABILIZE BEAD TRIATHLON PA BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-101 SUP HCPCS C1776 5517-F-101 - COMPONENT FEMORAL 1 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-102 SUP HCPCS C1776 5517-F-102 - COMPONENT FEMORAL 1 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-201 SUP HCPCS C1776 5517-F-201 - COMPONENT FEMORAL 2 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-202 SUP HCPCS C1776 5517-F-202 - COMPONENT FEMORAL 2 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-301 SUP HCPCS C1776 5517-F-301 - COMPONENT FEMORAL 3 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-302 SUP HCPCS C1776 5517-F-302 - COMPONENT FEMORAL 3 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-401 SUP HCPCS C1776 5517-F-401 - COMPONENT FEMORAL 4 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-402 SUP HCPCS C1776 5517-F-402 - COMPONENT FEMORAL 4 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-501 SUP HCPCS C1776 5517-F-501 - COMPONENT FEMORAL 5 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-502 SUP HCPCS C1776 5517-F-502 - COMPONENT FEMORAL 5 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-601 SUP HCPCS C1776 5517-F-601 - COMPONENT FEMORAL 6 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-602 SUP HCPCS C1776 5517-F-602 - COMPONENT FEMORAL 6 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-701 SUP HCPCS C1776 5517-F-701 - COMPONENT FEMORAL 7 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-702 SUP HCPCS C1776 5517-F-702 - COMPONENT FEMORAL 7 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-801 SUP HCPCS C1776 5517-F-801 - COMPONENT FEMORAL 8 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5517-F-802 SUP HCPCS C1776 5517-F-802 - COMPONENT FEMORAL 8 CRUCIATE RETAIN BEAD TRIATHLON PA KNEE BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 5520-B-100 SUP HCPCS C1776 5520-B-100 - BASEPLATE TIBIAL 1 PRIM CEMENT TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-B-200 SUP HCPCS C1776 5520-B-200 - BASEPLATE TIBIAL 2 PRIM CEMENT TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-B-300 SUP HCPCS C1776 5520-B-300 - BASEPLATE TIB 3 TRTHLN PRM CMNT KN BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-B-400 SUP HCPCS C1776 5520-B-400 - BASEPLATE TIBIAL 4 PRIM CEMENT TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-B-500 SUP HCPCS C1776 5520-B-500 - BASEPLATE TIBIAL 5 PRIM CEMENT TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-B-600 SUP HCPCS C1776 5520-B-600 - BASEPLATE TIBIAL 6 PRIM CEMENT TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-B-700 SUP HCPCS C1776 5520-B-700 - BASEPLATE TIBIAL 7 PRIM CEMENT TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-B-800 SUP HCPCS C1776 5520-B-800 - BASEPLATE TIBIAL 8 PRIM CEMENT TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-M-100 SUP HCPCS C1776 5520-M-100 - BASEPLATE TIBIAL 1 LP TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-M-200 SUP HCPCS C1776 5520-M-200 - BASEPLATE TIBIAL 2 LP TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-M-300 SUP HCPCS C1776 5520-M-300 - BASEPLATE TIBIAL 3 LP TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-M-400 SUP HCPCS C1776 5520-M-400 - BASEPLATE TIBIAL 4 LP TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-M-500 SUP HCPCS C1776 5520-M-500 - BASEPLATE TIBIAL 5 LP TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-M-600 SUP HCPCS C1776 5520-M-600 - BASEPLATE TIBIAL 6 LP TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-M-700 SUP HCPCS C1776 5520-M-700 - BASEPLATE TIBIAL 7 LP TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5520-M-800 SUP HCPCS C1776 5520-M-800 - BASEPLATE TIBIAL 8 LP TRIATHLON KNEE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 5521-B-100 SUP HCPCS C1776 5521-B-100 - BASEPLATE TIB 1 UNV TRTHLN COCR KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5521-B-200 SUP HCPCS C1776 5521-B-200 - BASEPLATE TIB 2 UNV TRTHLN COCR KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5521-B-300 SUP HCPCS C1776 5521-B-300 - BASEPLATE TIB 3 UNV TRTHLN COCR KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5521-B-400 SUP HCPCS C1776 5521-B-400 - BASEPLATE TIB 4 UNV TRTHLN COCR KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5521-B-500 SUP HCPCS C1776 5521-B-500 - BASEPLATE TIB 5 UNV TRTHLN COCR KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5521-B-600 SUP HCPCS C1776 5521-B-600 - BASEPLATE TIB 6 UNV TRTHLN COCR KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5521-B-700 SUP HCPCS C1776 5521-B-700 - BASEPLATE TIB 7 UNV TRTHLN COCR KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5521-B-800 SUP HCPCS C1776 5521-B-800 - BASEPLATE TIB 8 UNV TRTHLN COCR KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5523-B-100 SUP HCPCS C1776 5523-B-100 - BASEPLATE TIBIAL 1 PRIM BEADED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5523-B-200 SUP HCPCS C1776 5523-B-200 - BASEPLATE TIBIAL 2 PRIM BEADED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5523-B-300 SUP HCPCS C1776 5523-B-300 - BASEPLATE TIBIAL 3 PRIM BEADED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5523-B-400 SUP HCPCS C1776 5523-B-400 - BASEPLATE TIBIAL 4 PRIM BEADED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5523-B-500 SUP HCPCS C1776 5523-B-500 - BASEPLATE TIBIAL 5 PRIM BEADED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5523-B-600 SUP HCPCS C1776 5523-B-600 - BASEPLATE TIBIAL 6 PRIM BEADED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5523-B-700 SUP HCPCS C1776 5523-B-700 - BASEPLATE TIBIAL 7 PRIM BEADED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5523-B-800 SUP HCPCS C1776 5523-B-800 - BASEPLATE TIBIAL 8 PRIM BEADED TRIATHLON KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5524-B-100 SUP HCPCS C1776 5524-B-100 - BASEPLATE TIBIAL 1 CEMENTLESS TRIATHLON KNEE SCREW FIX BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5524-B-200 SUP HCPCS C1776 5524-B-200 - BASEPLATE TIBIAL 2 CEMENTLESS TRIATHLON KNEE SCREW FIX BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5524-B-300 SUP HCPCS C1776 5524-B-300 - BASEPLATE TIBIAL 3 BEAD TRIATHLON VITALLIUM KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5524-B-400 SUP HCPCS C1776 5524-B-400 - BASEPLATE TIBIAL 4 CEMENTLESS TRIATHLON KNEE SCREW FIX BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5524-B-500 SUP HCPCS C1776 5524-B-500 - BASEPLATE TIBIAL 5 CEMENTLESS TRIATHLON KNEE SCREW FIX BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5524-B-600 SUP HCPCS C1776 5524-B-600 - BASEPLATE TIBIAL 6 CEMENTLESS TRIATHLON KNEE SCREW FIX BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5524-B-700 SUP HCPCS C1776 5524-B-700 - BASEPLATE TIBIAL 7 CEMENTLESS TRIATHLON KNEE SCREW FIX BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5524-B-800 SUP HCPCS C1776 5524-B-800 - BASEPLATE TIBIAL 8 CEMENTLESS TRIATHLON KNEE SCREW FIX BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5526-B-100 SUP HCPCS C1776 5526-B-100 - BASEPLATE TIBIAL 1 PRIM BEADED TRIATHLON PERIAPT KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5526-B-200 SUP HCPCS C1776 5526-B-200 - BASEPLATE TIBIAL 2 PRIM BEADED TRIATHLON PERIAPT KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5526-B-300 SUP HCPCS C1776 5526-B-300 - BASEPLATE TIBIAL 3 PRIM BEADED TRIATHLON PERIAPT KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5526-B-400 SUP HCPCS C1776 5526-B-400 - BASEPLATE TIBIAL 4 PRIM BEADED TRIATHLON PERIAPT KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5526-B-500 SUP HCPCS C1776 5526-B-500 - BASEPLATE TIBIAL 5 PRIM BEADED TRIATHLON PERIAPT KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5526-B-600 SUP HCPCS C1776 5526-B-600 - BASEPLATE TIBIAL 6 PRIM BEADED TRIATHLON PERIAPT KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5526-B-700 SUP HCPCS C1776 5526-B-700 - BASEPLATE TIBIAL 7 PRIM BEADED TRIATHLON PERIAPT KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5526-B-800 SUP HCPCS C1776 5526-B-800 - BASEPLATE TIBIAL 8 PRIM BEADED TRIATHLON PERIAPT KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5527-B-100 SUP HCPCS C1776 5527-B-100 - BASEPLATE TIBIAL 1 CEMENTLESS TRIATHLON PERIAPT KNEE SCREW BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5527-B-200 SUP HCPCS C1776 5527-B-200 - BASEPLATE TIBIAL 2 CEMENTLESS TRIATHLON PERIAPT KNEE SCREW BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5527-B-300 SUP HCPCS C1776 5527-B-300 - BASEPLATE TIBIAL 3 CEMENTLESS TRIATHLON PERIAPT KNEE SCREW BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5527-B-400 SUP HCPCS C1776 5527-B-400 - BASEPLATE TIBIAL 4 CEMENTLESS TRIATHLON PERIAPT KNEE SCREW BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5527-B-500 SUP HCPCS C1776 5527-B-500 - BASEPLATE TIBIAL 5 CEMENTLESS TRIATHLON PERIAPT KNEE SCREW BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5527-B-600 SUP HCPCS C1776 5527-B-600 - BASEPLATE TIBIAL 6 CEMENTLESS TRIATHLON PERIAPT KNEE SCREW BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5527-B-700 SUP HCPCS C1776 5527-B-700 - BASEPLATE TIBIAL 7 CEMENTLESS TRIATHLON PERIAPT KNEE SCREW BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5527-B-800 SUP HCPCS C1776 5527-B-800 - BASEPLATE TIBIAL 8 CEMENTLESS TRIATHLON PERIAPT KNEE SCREW BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 55-28911 SUP HCPCS C1713 55-28911 - PLATE BONE 11 HOLE RECONSTRUCTION TEMPLATE TITANIUM MAXFACL BOTH IP/OP "$1,609.38 " "$1,190.94" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $335.43 "$1,194.48" "$1,194.48" $0.00 $0.00 $335.39 $0.00 $951.95 $951.95 $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 55-28917 SUP HCPCS C1713 55-28917 - PLATE BONE 17 HOLE RECONSTRUCTION TEMPLATE TITANIUM MAXFACL BOTH IP/OP "$2,167.63 " "$1,604.05" $0.00 "$4,316.00" "$2,427.75" "$2,427.75" $0.00 $0.00 $0.00 $451.79 "$1,608.81" "$1,608.81" $0.00 $0.00 $451.73 $0.00 "$1,282.15" "$1,282.15" $0.00 "$2,697.50" "$4,272.84" "$4,316.00" $0.00 $0.00 $844.32 $0.00 $0.00 $858.88 $0.00 $0.00 $0.00 $0.00 $0.00 55-28920 SUP HCPCS C1713 55-28920 - PLATE BONE 6X17 HOLE RECONSTRUCTION HEMISPHERE TEMPLATE BOTH IP/OP "$2,724.95 " "$2,016.46" $0.00 "$4,726.00" "$2,658.38" "$2,658.38" $0.00 $0.00 $0.00 $567.95 "$2,022.46" "$2,022.46" $0.00 $0.00 $567.88 $0.00 "$1,343.40" "$1,343.40" $0.00 "$2,953.75" "$4,678.74" "$4,726.00" $0.00 $0.00 $924.52 $0.00 $0.00 $940.47 $0.00 $0.00 $0.00 $0.00 $0.00 55-28922 SUP HCPCS C1713 55-28922 - PLATE BONE 6X17 HOLE RECONSTRUCTION HEMISPHERE TEMPLATE BOTH IP/OP "$2,724.95 " "$2,016.46" $0.00 "$4,726.00" "$2,658.38" "$2,658.38" $0.00 $0.00 $0.00 $567.95 "$2,022.46" "$2,022.46" $0.00 $0.00 $567.88 $0.00 "$1,343.40" "$1,343.40" $0.00 "$2,953.75" "$4,678.74" "$4,726.00" $0.00 $0.00 $924.52 $0.00 $0.00 $940.47 $0.00 $0.00 $0.00 $0.00 $0.00 55-28925 SUP HCPCS C1713 55-28925 - PLATE BN HMSPHR 1.5MM SMRT LCK LEIBINGER UNV 2 6X17 HL TI BOTH IP/OP "$5,907.50 " "$4,371.55" $0.00 "$4,726.00" "$2,658.38" "$2,658.38" $0.00 $0.00 $0.00 "$1,231.27" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,231.12" $0.00 "$2,912.40" "$2,912.40" $0.00 "$2,953.75" "$4,678.74" "$4,726.00" $0.00 $0.00 $924.52 $0.00 $0.00 $940.47 $0.00 $0.00 $0.00 $0.00 $0.00 55-28926 SUP HCPCS C1713 55-28926 - PLATE BN HMSPHR 1.5MM SMRT LCK LEIBINGER UNV 2 6X17 HL TI BOTH IP/OP "$5,907.50 " "$4,371.55" $0.00 "$4,726.00" "$2,658.38" "$2,658.38" $0.00 $0.00 $0.00 "$1,231.27" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,231.12" $0.00 "$2,912.40" "$2,912.40" $0.00 "$2,953.75" "$4,678.74" "$4,726.00" $0.00 $0.00 $924.52 $0.00 $0.00 $940.47 $0.00 $0.00 $0.00 $0.00 $0.00 55-28930 SUP HCPCS C1713 55-28930 - PLATE BONE 6+17+6 HOLE FULL TITANIUM MANDIB BOTH IP/OP "$3,495.70 " "$2,586.82" $0.00 "$5,792.00" "$3,258.00" "$3,258.00" $0.00 $0.00 $0.00 $728.59 "$2,594.51" "$2,594.51" $0.00 $0.00 $728.50 $0.00 "$1,723.38" "$1,723.38" $0.00 "$3,620.00" "$5,734.08" "$5,792.00" $0.00 $0.00 "$1,133.06" $0.00 $0.00 "$1,152.61" $0.00 $0.00 $0.00 $0.00 $0.00 55-28932 SUP HCPCS C1713 55-28932 - PLATE BONE 6X15X6 HOLE FULL RECONSTRUCTION TEMPLATE TITANIUM BOTH IP/OP "$3,369.60 " "$2,493.50" $0.00 "$5,582.00" "$3,139.88" "$3,139.88" $0.00 $0.00 $0.00 $702.31 "$2,500.92" "$2,500.92" $0.00 $0.00 $702.22 $0.00 "$1,661.21" "$1,661.21" $0.00 "$3,488.75" "$5,526.18" "$5,582.00" $0.00 $0.00 "$1,091.98" $0.00 $0.00 "$1,110.82" $0.00 $0.00 $0.00 $0.00 $0.00 55-28934 SUP HCPCS C1713 55-28934 - PLATE BONE 6+13+6 HOLE SECONDARY RECONSTRUCTION FULL BOTH IP/OP "$3,304.78 " "$2,445.54" $0.00 "$5,098.00" "$2,867.63" "$2,867.63" $0.00 $0.00 $0.00 $688.80 "$2,452.80" "$2,452.80" $0.00 $0.00 $688.72 $0.00 "$1,629.25" "$1,629.25" $0.00 "$3,186.25" "$5,047.02" "$5,098.00" $0.00 $0.00 $997.30 $0.00 $0.00 "$1,014.50" $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-109 SUP Custom 27803010 5530-G-109 - INSERT TIBIAL 1 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-109-E SUP HCPCS C1776 5530-G-109-E - INSERT TIB 1 9MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-110-E SUP HCPCS C1776 5530-G-110-E - INSERT TIB 1 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-111 SUP Custom 27803010 5530-G-111 - INSERT TIBIAL 1 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-111-E SUP HCPCS C1776 5530-G-111-E - INSERT TIB 1 11MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-112-E SUP HCPCS C1776 5530-G-112-E - INSERT TIB 1 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-113 SUP Custom 27803010 5530-G-113 - INSERT TIBIAL 1 13MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-113-E SUP HCPCS C1776 5530-G-113-E - INSERT TIB 1 13MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-114-E SUP HCPCS C1776 5530-G-114-E - INSERT TIB 1 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-116 SUP Custom 27803010 5530-G-116 - INSERT TIBIAL 1 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-116-E SUP HCPCS C1776 5530-G-116-E - INSERT TIB 1 16MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-119 SUP Custom 27803010 5530-G-119 - INSERT TIBIAL 1 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-119-E SUP HCPCS C1776 5530-G-119-E - INSERT TIB 1 19MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-209 SUP Custom 27803010 5530-G-209 - INSERT TIBIAL 2 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-209-E SUP HCPCS C1776 5530-G-209-E - INSERT TIB 2 9MM STRL TRTHLN BRNG CRCTE RTN CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-210-E SUP HCPCS C1776 5530-G-210-E - INSERT TIB 2 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-211 SUP Custom 27803010 5530-G-211 - INSERT TIBIAL 2 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-211-E SUP HCPCS C1776 5530-G-211-E - INSERT TIB 2 11MM STRL TRTHLN BRNG CRCTE RTN CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-212-E SUP HCPCS C1776 5530-G-212-E - INSERT TIB 2 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-213 SUP Custom 27803010 5530-G-213 - INSERT TIBIAL 2 13MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-213-E SUP HCPCS C1776 5530-G-213-E - INSERT TIB 2 13MM STRL TRTHLN BRNG CRCTE RTN CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-214-E SUP HCPCS C1776 5530-G-214-E - INSERT TIB 2 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-216 SUP Custom 27803010 5530-G-216 - INSERT TIBIAL 2 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-216-E SUP HCPCS C1776 5530-G-216-E - INSERT TIB 2 16MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-219 SUP Custom 27803010 5530-G-219 - INSERT TIBIAL 2 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-219-E SUP HCPCS C1776 5530-G-219-E - INSERT TIB 2 19MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-309 SUP Custom 27803010 5530-G-309 - INSERT TIBIAL 3 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-309-E SUP HCPCS C1776 5530-G-309-E - INSERT TIB 3 9MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-310-E SUP HCPCS C1776 5530-G-310-E - INSERT TIB 3 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-311 SUP Custom 27803010 5530-G-311 - INSERT TIBIAL 3 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-311-E SUP HCPCS C1776 5530-G-311-E - INSERT TIB 3 11MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-312-E SUP HCPCS C1776 5530-G-312-E - INSERT TIB 3 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-313 SUP Custom 27803010 5530-G-313 - INSERT TIBIAL 3 13MM CRUCIATE RETAIN TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-313-E SUP HCPCS C1776 5530-G-313-E - INSERT TIB 3 13MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-314-E SUP HCPCS C1776 5530-G-314-E - INSERT TIB 3 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-316 SUP Custom 27803010 5530-G-316 - INSERT TIBIAL 3 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-316-E SUP HCPCS C1776 5530-G-316-E - INSERT TIB 3 16MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-319 SUP Custom 27803010 5530-G-319 - INSERT TIBIAL 3 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-319-E SUP HCPCS C1776 5530-G-319-E - INSERT TIB 3 19MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-409 SUP Custom 27803010 5530-G-409 - INSERT TIBIAL 4 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-409-E SUP HCPCS C1776 5530-G-409-E - INSERT TIB 4 9MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-410-E SUP HCPCS C1776 5530-G-410-E - INSERT TIB 4 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-411 SUP Custom 27803010 5530-G-411 - INSERT TIBIAL 4 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-411-E SUP HCPCS C1776 5530-G-411-E - INSERT TIB 4 11MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-412-E SUP HCPCS C1776 5530-G-412-E - INSERT TIB 4 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-413 SUP Custom 27803010 5530-G-413 - INSERT TIBIAL 4 13MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-413-E SUP HCPCS C1776 5530-G-413-E - INSERT TIB 4 13MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-414-E SUP HCPCS C1776 5530-G-414-E - INSERT TIB 4 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-416 SUP Custom 27803010 5530-G-416 - INSERT TIBIAL 4 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-416-E SUP HCPCS C1776 5530-G-416-E - INSERT TIB 4 16MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-419 SUP Custom 27803010 5530-G-419 - INSERT TIBIAL 4 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-419-E SUP HCPCS C1776 5530-G-419-E - INSERT TIB 4 19MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-509 SUP Custom 27803010 5530-G-509 - INSERT TIBIAL 5 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-509-E SUP HCPCS C1776 5530-G-509-E - INSERT TIB 5 9MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-510-E SUP HCPCS C1776 5530-G-510-E - INSERT TIB 5 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-511 SUP Custom 27803010 5530-G-511 - INSERT TIBIAL 5 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-511-E SUP HCPCS C1776 5530-G-511-E - INSERT TIB 5 11MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-512-E SUP HCPCS C1776 5530-G-512-E - INSERT TIB 5 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-513 SUP Custom 27803010 5530-G-513 - INSERT TIBIAL 5 13MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-513-E SUP HCPCS C1776 5530-G-513-E - INSERT TIB 5 13MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-514-E SUP HCPCS C1776 5530-G-514-E - INSERT TIB 5 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-516 SUP Custom 27803010 5530-G-516 - INSERT TIBIAL 5 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-516-E SUP HCPCS C1776 5530-G-516-E - INSERT TIB 5 16MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-519 SUP Custom 27803010 5530-G-519 - INSERT TIBIAL 5 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-519-E SUP HCPCS C1776 5530-G-519-E - INSERT TIB 5 19MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-609 SUP Custom 27803010 5530-G-609 - INSERT TIBIAL 6 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-609-E SUP HCPCS C1776 5530-G-609-E - INSERT TIB 6 9MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-610-E SUP HCPCS C1776 5530-G-610-E - INSERT TIB 6 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-611 SUP Custom 27803010 5530-G-611 - INSERT TIBIAL 6 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-611-E SUP HCPCS C1776 5530-G-611-E - INSERT TIB 6 11MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-612-E SUP HCPCS C1776 5530-G-612-E - INSERT TIB 6 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-613 SUP Custom 27803010 5530-G-613 - INSERT TIBIAL 6 13MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-613-E SUP HCPCS C1776 5530-G-613-E - INSERT TIB 6 13MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-614-E SUP HCPCS C1776 5530-G-614-E - INSERT TIB 6 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-616 SUP Custom 27803010 5530-G-616 - INSERT TIBIAL 6 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-616-E SUP HCPCS C1776 5530-G-616-E - INSERT TIB 6 16MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-619 SUP Custom 27803010 5530-G-619 - INSERT TIBIAL 6 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-619-E SUP HCPCS C1776 5530-G-619-E - INSERT TIB 6 19MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-709 SUP Custom 27803010 5530-G-709 - INSERT TIBIAL 7 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-709-E SUP HCPCS C1776 5530-G-709-E - INSERT TIB 7 9MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-710-E SUP HCPCS C1776 5530-G-710-E - INSERT TIB 7 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-711 SUP Custom 27803010 5530-G-711 - INSERT TIBIAL 7 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-711-E SUP HCPCS C1776 5530-G-711-E - INSERT TIB 7 11MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-712-E SUP HCPCS C1776 5530-G-712-E - INSERT TIB 7 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-713 SUP Custom 27803010 5530-G-713 - INSERT TIBIAL 7 13MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-713-E SUP HCPCS C1776 5530-G-713-E - INSERT TIB 7 13MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-714-E SUP HCPCS C1776 5530-G-714-E - INSERT TIB 7 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-716 SUP Custom 27803010 5530-G-716 - INSERT TIBIAL 7 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-716-E SUP HCPCS C1776 5530-G-716-E - INSERT TIB 7 16MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-719 SUP Custom 27803010 5530-G-719 - INSERT TIBIAL 7 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-719-E SUP HCPCS C1776 5530-G-719-E - INSERT TIB 7 19MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-809 SUP Custom 27803010 5530-G-809 - INSERT TIBIAL 8 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-809-E SUP HCPCS C1776 5530-G-809-E - INSERT TIB 8 9MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-810-E SUP HCPCS C1776 5530-G-810-E - INSERT TIB 8 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-811 SUP Custom 27803010 5530-G-811 - INSERT TIBIAL 8 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-811-E SUP HCPCS C1776 5530-G-811-E - INSERT TIB 8 11MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-812-E SUP HCPCS C1776 5530-G-812-E - INSERT TIB 8 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-813 SUP Custom 27803010 5530-G-813 - INSERT TIBIAL 8 13MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-813-E SUP HCPCS C1776 5530-G-813-E - INSERT TIB 8 13MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-814-E SUP HCPCS C1776 5530-G-814-E - INSERT TIB 8 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-816 SUP Custom 27803010 5530-G-816 - INSERT TIBIAL 8 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-816-E SUP HCPCS C1776 5530-G-816-E - INSERT TIB 8 16MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-819 SUP Custom 27803010 5530-G-819 - INSERT TIBIAL 8 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-G-819-E SUP HCPCS C1776 5530-G-819-E - INSERT TIB 8 19MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-109 SUP Custom 27803010 5530-P-109 - INSERT TIBIAL 1 9MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-110 SUP HCPCS C1776 5530-P-110 - INSERT TIB 1 10MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-111 SUP Custom 27803010 5530-P-111 - INSERT TIBIAL 1 11MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-112 SUP HCPCS C1776 5530-P-112 - INSERT TIB 1 12MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-113 SUP Custom 27803010 5530-P-113 - INSERT TIBIAL 1 13MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-114 SUP HCPCS C1776 5530-P-114 - INSERT TIB 1 14MM STRL TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-116 SUP Custom 27803010 5530-P-116 - INSERT TIBIAL 1 P 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-119 SUP Custom 27803010 5530-P-119 - INSERT TIBIAL 1 P 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-209 SUP Custom 27803010 5530-P-209 - INSERT TIBIAL 2 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-210 SUP HCPCS C1776 5530-P-210 - INSERT TIB 2 10MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-211 SUP Custom 27803010 5530-P-211 - INSERT TIBIAL 2 11MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-212 SUP HCPCS C1776 5530-P-212 - INSERT TIB 2 12MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-213 SUP Custom 27803010 5530-P-213 - INSERT TIBIAL 2 13MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-214 SUP HCPCS C1776 5530-P-214 - INSERT TIB 2 14MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-216 SUP Custom 27803010 5530-P-216 - INSERT TIBIAL 2 16MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-219 SUP Custom 27803010 5530-P-219 - INSERT TIBIAL 2 P 19MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-309 SUP Custom 27803010 5530-P-309 - INSERT TIBIAL 3 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-310 SUP HCPCS C1776 5530-P-310 - INSERT TIB 3 10MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-311 SUP Custom 27803010 5530-P-311 - INSERT TIBIAL 3 11MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-312 SUP HCPCS C1776 5530-P-312 - INSERT TIB 3 12MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-313 SUP Custom 27803010 5530-P-313 - INSERT TIBIAL 3 13MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-314 SUP HCPCS C1776 5530-P-314 - INSERT TIB 3 14MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-316 SUP Custom 27803010 5530-P-316 - INSERT TIBIAL 3 16MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-319 SUP Custom 27803010 5530-P-319 - INSERT TIBIAL 3 19MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-409 SUP Custom 27803010 5530-P-409 - INSERT TIBIAL 4 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-410 SUP HCPCS C1776 5530-P-410 - INSERT TIB 4 10MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-411 SUP Custom 27803010 5530-P-411 - INSERT TIBIAL 4 11MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-412 SUP HCPCS C1776 5530-P-412 - INSERT TIB 4 12MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-413 SUP Custom 27803010 5530-P-413 - INSERT TIBIAL 4 13MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-414 SUP HCPCS C1776 5530-P-414 - INSERT TIB 4 14MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-416 SUP Custom 27803010 5530-P-416 - INSERT TIBIAL 4 16MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-419 SUP Custom 27803010 5530-P-419 - INSERT TIBIAL 4 19MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-509 SUP Custom 27803010 5530-P-509 - INSERT TIBIAL 5 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-510 SUP HCPCS C1776 5530-P-510 - INSERT TIB 5 10MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-511 SUP Custom 27803010 5530-P-511 - INSERT TIBIAL 5 11MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-512 SUP HCPCS C1776 5530-P-512 - INSERT TIB 5 12MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-513 SUP Custom 27803010 5530-P-513 - INSERT TIBIAL 5 13MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-514 SUP HCPCS C1776 5530-P-514 - INSERT TIB 5 14MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-516 SUP Custom 27803010 5530-P-516 - INSERT TIBIAL 5 16MM CRUCIATE RETAIN TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-519 SUP Custom 27803010 5530-P-519 - INSERT TIBIAL 5 19MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-609 SUP Custom 27803010 5530-P-609 - INSERT TIBIAL 6 9MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-610 SUP HCPCS C1776 5530-P-610 - INSERT TIB 6 10MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-611 SUP Custom 27803010 5530-P-611 - INSERT TIBIAL 6 11MM CRUC RET TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-612 SUP HCPCS C1776 5530-P-612 - INSERT TIB 6 12MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-613 SUP Custom 27803010 5530-P-613 - INSERT TIBIAL 6 13MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-614 SUP HCPCS C1776 5530-P-614 - INSERT TIB 6 14MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-616 SUP Custom 27803010 5530-P-616 - INSERT TIBIAL 6 16MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-619 SUP Custom 27803010 5530-P-619 - INSERT TIBIAL 6 19MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-709 SUP Custom 27803010 5530-P-709 - INSERT TIBIAL 7 9MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-710 SUP HCPCS C1776 5530-P-710 - INSERT TIB 7 10MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-711 SUP Custom 27803010 5530-P-711 - INSERT TIBIAL 7 11MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-712 SUP HCPCS C1776 5530-P-712 - INSERT TIB 7 12MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-713 SUP Custom 27803010 5530-P-713 - INSERT TIBIAL 7 13MM CRUCIATE RETAIN TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-714 SUP HCPCS C1776 5530-P-714 - INSERT TIB 7 14MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-716 SUP Custom 27803010 5530-P-716 - INSERT TIBIAL 7 16MM CRUCIATE RETAIN TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-719 SUP Custom 27803010 5530-P-719 - INSERT TIBIAL 7 19MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-809 SUP Custom 27803010 5530-P-809 - INSERT TIBIAL 8 9MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-810 SUP HCPCS C1776 5530-P-810 - INSERT TIB 8 10MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-811 SUP Custom 27803010 5530-P-811 - INSERT TIBIAL 8 11MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-812 SUP HCPCS C1776 5530-P-812 - INSERT TIB 8 12MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-813 SUP Custom 27803010 5530-P-813 - INSERT TIBIAL 8 13MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-814 SUP HCPCS C1776 5530-P-814 - INSERT TIB 8 14MM STRL LF TRTHLN BRNG CRCTE RTN KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-816 SUP Custom 27803010 5530-P-816 - INSERT TIBIAL 8 16MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5530-P-819 SUP Custom 27803010 5530-P-819 - INSERT TIBIAL 8 19MM CRUC RET TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-109 SUP Custom 27803010 5531-G-109 - INSERT TIBIAL 1 9MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-109-E SUP HCPCS C1776 5531-G-109-E - INSERT TIB 1 9MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-110-E SUP HCPCS C1776 5531-G-110-E - INSERT TIB 1 10MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-111 SUP Custom 27803010 5531-G-111 - INSERT TIBIAL 1 G 11MM TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-111-E SUP HCPCS C1776 5531-G-111-E - INSERT TIB 1 11MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-112-E SUP HCPCS C1776 5531-G-112-E - INSERT TIB 1 12MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-113 SUP Custom 27803010 5531-G-113 - INSERT TIBIAL 1 13MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-113-E SUP HCPCS C1776 5531-G-113-E - INSERT TIB 1 13MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-114-E SUP HCPCS C1776 5531-G-114-E - INSERT TIB 1 14MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-116 SUP Custom 27803010 5531-G-116 - INSERT TIBIAL 1 16MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-116-E SUP HCPCS C1776 5531-G-116-E - INSERT TIB 1 16MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-119 SUP Custom 27803010 5531-G-119 - INSERT TIBIAL 1 19MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-119-E SUP HCPCS C1776 5531-G-119-E - INSERT TIB 1 19MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-122 SUP Custom 27803010 5531-G-122 - INSERT TIBIAL 1 22MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-122-E SUP HCPCS C1776 5531-G-122-E - INSERT TIB 1 22MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-125 SUP Custom 27803010 5531-G-125 - INSERT TIBIAL 1 25MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-209 SUP Custom 27803010 5531-G-209 - INSERT TIBIAL 2 9MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-209-E SUP HCPCS C1776 5531-G-209-E - INSERT TIB 2 9MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-210-E SUP HCPCS C1776 5531-G-210-E - INSERT TIB 2 10MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-211 SUP Custom 27803010 5531-G-211 - INSERT TIBIAL 2 11MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-211-E SUP HCPCS C1776 5531-G-211-E - INSERT TIB 2 11MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-212-E SUP HCPCS C1776 5531-G-212-E - INSERT TIB 2 12MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-213 SUP Custom 27803010 5531-G-213 - INSERT TIBIAL 2 13MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-213-E SUP HCPCS C1776 5531-G-213-E - INSERT TIB 2 13MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-214-E SUP HCPCS C1776 5531-G-214-E - INSERT TIB 2 14MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-216 SUP Custom 27803010 5531-G-216 - INSERT TIBIAL 2 16MM CRUC SUB REVISION FLEXION TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-216-E SUP HCPCS C1776 5531-G-216-E - INSERT TIB 2 16MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-219 SUP Custom 27803010 5531-G-219 - INSERT TIBIAL 2 19MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-219-E SUP HCPCS C1776 5531-G-219-E - INSERT TIB 2 19MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-222 SUP Custom 27803010 5531-G-222 - INSERT TIBIAL 2 22MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-222-E SUP HCPCS C1776 5531-G-222-E - INSERT TIB 2 22MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-225 SUP Custom 27803010 5531-G-225 - INSERT TIBIAL 2 25MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-309 SUP Custom 27803010 5531-G-309 - INSERT TIBIAL 3 9MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-309-E SUP HCPCS C1776 5531-G-309-E - INSERT TIB 3 9MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-310-E SUP HCPCS C1776 5531-G-310-E - INSERT TIB 3 10MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-311 SUP Custom 27803010 5531-G-311 - INSERT TIBIAL 3 11MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-311-E SUP HCPCS C1776 5531-G-311-E - INSERT TIB 3 11MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-312-E SUP HCPCS C1776 5531-G-312-E - INSERT TIB 3 12MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-313 SUP Custom 27803010 5531-G-313 - INSERT TIBIAL 3 13MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-313-E SUP HCPCS C1776 5531-G-313-E - INSERT TIB 3 13MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-314-E SUP HCPCS C1776 5531-G-314-E - INSERT TIB 3 14MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-316 SUP Custom 27803010 5531-G-316 - INSERT TIBIAL 3 16MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-316-E SUP HCPCS C1776 5531-G-316-E - INSERT TIB 3 16MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-319 SUP Custom 27803010 5531-G-319 - INSERT TIBIAL 3 19MM CNDYLR STABILIZED PRIM TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-319-E SUP HCPCS C1776 5531-G-319-E - INSERT TIB 3 19MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-322 SUP Custom 27803010 5531-G-322 - INSERT TIBIAL 3 22MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-322-E SUP HCPCS C1776 5531-G-322-E - INSERT TIB 3 22MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-325 SUP Custom 27803010 5531-G-325 - INSERT TIBIAL 3 25MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-409 SUP Custom 27803010 5531-G-409 - INSERT TIBIAL 4 9MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-409-E SUP HCPCS C1776 5531-G-409-E - INSERT TIB 4 9MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-410-E SUP HCPCS C1776 5531-G-410-E - INSERT TIB 4 10MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-411 SUP Custom 27803010 5531-G-411 - INSERT TIBIAL 4 11MM CNDYLR STABILIZED PRIM TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-411-E SUP HCPCS C1776 5531-G-411-E - INSERT TIB 4 11MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-412-E SUP HCPCS C1776 5531-G-412-E - INSERT TIB 4 12MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-413 SUP Custom 27803010 5531-G-413 - INSERT TIBIAL 4 13MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-413-E SUP HCPCS C1776 5531-G-413-E - INSERT TIB 4 13MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-414-E SUP HCPCS C1776 5531-G-414-E - INSERT TIB 4 14MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-416 SUP Custom 27803010 5531-G-416 - INSERT TIBIAL 4 16MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-416-E SUP HCPCS C1776 5531-G-416-E - INSERT TIB 4 16MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-419 SUP Custom 27803010 5531-G-419 - INSERT TIBIAL 4 19MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-419-E SUP HCPCS C1776 5531-G-419-E - INSERT TIB 4 19MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-422 SUP Custom 27803010 5531-G-422 - INSERT TIBIAL 4 22MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-422-E SUP HCPCS C1776 5531-G-422-E - INSERT TIB 4 22MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-425 SUP Custom 27803010 5531-G-425 - INSERT TIBIAL 4 25MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-509 SUP Custom 27803010 5531-G-509 - INSERT TIBIAL 5 9MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-509-E SUP HCPCS C1776 5531-G-509-E - INSERT TIB 5 9MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-510-E SUP HCPCS C1776 5531-G-510-E - INSERT TIB 5 10MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-511 SUP Custom 27803010 5531-G-511 - INSERT TIBIAL 5 11MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-511-E SUP HCPCS C1776 5531-G-511-E - INSERT TIB 5 11MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-512-E SUP HCPCS C1776 5531-G-512-E - INSERT TIB 5 12MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-513 SUP Custom 27803010 5531-G-513 - INSERT TIBIAL 5 13MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-513-E SUP HCPCS C1776 5531-G-513-E - INSERT TIB 5 13MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-514-E SUP HCPCS C1776 5531-G-514-E - INSERT TIB 5 14MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-516 SUP Custom 27803010 5531-G-516 - INSERT TIBIAL 5 16MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-516-E SUP HCPCS C1776 5531-G-516-E - INSERT TIB 5 16MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-519 SUP Custom 27803010 5531-G-519 - INSERT TIBIAL 5 19MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-519-E SUP HCPCS C1776 5531-G-519-E - INSERT TIB 5 19MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-522 SUP Custom 27803010 5531-G-522 - INSERT TIBIAL 5 22MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-522-E SUP HCPCS C1776 5531-G-522-E - INSERT TIB 5 22MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-525 SUP Custom 27803010 5531-G-525 - INSERT TIBIAL 5 25MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-609 SUP Custom 27803010 5531-G-609 - INSERT TIBIAL 6 9MM CNDYLR STABILIZED PRIM TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-609-E SUP HCPCS C1776 5531-G-609-E - INSERT TIB 6 9MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-610-E SUP HCPCS C1776 5531-G-610-E - INSERT TIB 6 10MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-611 SUP Custom 27803010 5531-G-611 - INSERT TIBIAL 6 11MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-611-E SUP HCPCS C1776 5531-G-611-E - INSERT TIB 6 11MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-612-E SUP HCPCS C1776 5531-G-612-E - INSERT TIB 6 12MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-613 SUP Custom 27803010 5531-G-613 - INSERT TIBIAL 6 13MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-613-E SUP HCPCS C1776 5531-G-613-E - INSERT TIB 6 13MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-614-E SUP HCPCS C1776 5531-G-614-E - INSERT TIB 6 14MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-616 SUP Custom 27803010 5531-G-616 - INSERT TIBIAL 6 16MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-616-E SUP HCPCS C1776 5531-G-616-E - INSERT TIB 6 16MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-619 SUP Custom 27803010 5531-G-619 - INSERT TIBIAL 6 19MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-619-E SUP HCPCS C1776 5531-G-619-E - INSERT TIB 6 19MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-622 SUP Custom 27803010 5531-G-622 - INSERT TIBIAL 6 22MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-622-E SUP HCPCS C1776 5531-G-622-E - INSERT TIB 6 22MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-625 SUP Custom 27803010 5531-G-625 - INSERT TIBIAL 6 25MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-709 SUP Custom 27803010 5531-G-709 - INSERT TIBIAL 7 9MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-709-E SUP HCPCS C1776 5531-G-709-E - INSERT TIB 7 9MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-710-E SUP HCPCS C1776 5531-G-710-E - INSERT TIB 7 10MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-711 SUP Custom 27803010 5531-G-711 - INSERT TIBIAL 7 11MM CNDYLR STABILIZED PRIM TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-711-E SUP HCPCS C1776 5531-G-711-E - INSERT TIB 7 11MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-712-E SUP HCPCS C1776 5531-G-712-E - INSERT TIB 7 12MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-713 SUP Custom 27803010 5531-G-713 - INSERT TIBIAL 7 13MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-713-E SUP HCPCS C1776 5531-G-713-E - INSERT TIB 7 13MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-714-E SUP HCPCS C1776 5531-G-714-E - INSERT TIB 7 14MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-716 SUP Custom 27803010 5531-G-716 - INSERT TIBIAL 7 16MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-716-E SUP HCPCS C1776 5531-G-716-E - INSERT TIB 7 16MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-719 SUP Custom 27803010 5531-G-719 - INSERT TIBIAL 7 19MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-719-E SUP HCPCS C1776 5531-G-719-E - INSERT TIB 7 19MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-722 SUP Custom 27803010 5531-G-722 - INSERT TIBIAL 7 22MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-722-E SUP HCPCS C1776 5531-G-722-E - INSERT TIB 7 22MM STRL TRTHLN CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-725 SUP Custom 27803010 5531-G-725 - INSERT TIBIAL 7 25MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-809 SUP Custom 27803010 5531-G-809 - INSERT TIBIAL 8 9MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-809-E SUP HCPCS C1776 5531-G-809-E - INSERT TIB 8 9MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-810-E SUP HCPCS C1776 5531-G-810-E - INSERT TIB 8 10MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-811 SUP Custom 27803010 5531-G-811 - INSERT TIBIAL 8 11MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-811-E SUP HCPCS C1776 5531-G-811-E - INSERT TIB 8 11MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-812-E SUP HCPCS C1776 5531-G-812-E - INSERT TIB 8 12MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-813 SUP Custom 27803010 5531-G-813 - INSERT TIBIAL 8 13MM CNDYLR STABILIZED TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-813-E SUP HCPCS C1776 5531-G-813-E - INSERT TIB 8 13MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-814-E SUP HCPCS C1776 5531-G-814-E - INSERT TIB 8 14MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-816 SUP Custom 27803010 5531-G-816 - INSERT TIBIAL 8 16MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-816-E SUP HCPCS C1776 5531-G-816-E - INSERT TIB 8 16MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-819 SUP Custom 27803010 5531-G-819 - INSERT TIBIAL 8 19MM CRUC SUB TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-819-E SUP HCPCS C1776 5531-G-819-E - INSERT TIB 8 19MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-822 SUP Custom 27803010 5531-G-822 - INSERT TIBIAL 8 22MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-822-E SUP HCPCS C1776 5531-G-822-E - INSERT TIB 8 22MM STRL TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5531-G-825 SUP Custom 27803010 5531-G-825 - INSERT TIBIAL 8 25MM CRUC SUB TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-109 SUP Custom 27803010 5531-P-109 - INSERT TIBIAL 1 9MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-110 SUP HCPCS C1776 5531-P-110 - INSERT TIB 1 10MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-111 SUP Custom 27803010 5531-P-111 - INSERT TIBIAL 1 11MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-112 SUP HCPCS C1776 5531-P-112 - INSERT TIB 1 12MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-113 SUP Custom 27803010 5531-P-113 - INSERT TIBIAL 1 13MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-114 SUP HCPCS C1776 5531-P-114 - INSERT TIB 1 14MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-116 SUP Custom 27803010 5531-P-116 - INSERT TIBIAL 1 16MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-119 SUP Custom 27803010 5531-P-119 - INSERT TIBIAL 1 19MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-122 SUP Custom 27803010 5531-P-122 - INSERT TIBIAL 1 22MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-125 SUP Custom 27803010 5531-P-125 - INSERT TIBIAL 1 25MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-209 SUP Custom 27803010 5531-P-209 - INSERT TIBIAL 2 9MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-210 SUP HCPCS C1776 5531-P-210 - INSERT TIB 2 10MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-211 SUP Custom 27803010 5531-P-211 - INSERT TIBIAL 2 11MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-212 SUP HCPCS C1776 5531-P-212 - INSERT TIB 2 12MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-213 SUP Custom 27803010 5531-P-213 - INSERT TIBIAL 2 13MM CRUC SUB TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-214 SUP HCPCS C1776 5531-P-214 - INSERT TIB 2 14MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-216 SUP Custom 27803010 5531-P-216 - INSERT TIBIAL 2 16MM CRUC SUB TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-219 SUP Custom 27803010 5531-P-219 - INSERT TIBIAL 2 19MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-222 SUP Custom 27803010 5531-P-222 - INSERT TIBIAL 2 22MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-225 SUP Custom 27803010 5531-P-225 - INSERT TIBIAL 2 25MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-309 SUP Custom 27803010 5531-P-309 - INSERT TIBIAL 3 8-9MM TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-310 SUP HCPCS C1776 5531-P-310 - INSERT TIB 3 10MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-311 SUP Custom 27803010 5531-P-311 - INSERT TIBIAL 3 11MM BEARING TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-312 SUP HCPCS C1776 5531-P-312 - INSERT TIB 3 13MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-313 SUP Custom 27803010 5531-P-313 - INSERT TIBIAL 3 13MM TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-314 SUP HCPCS C1776 5531-P-314 - INSERT TIB 3 14MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-316 SUP Custom 27803010 5531-P-316 - INSERT TIBIAL 3 16MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-319 SUP Custom 27803010 5531-P-319 - INSERT TIBIAL 3 19MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-322 SUP Custom 27803010 5531-P-322 - INSERT TIBIAL 3 22MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-325 SUP Custom 27803010 5531-P-325 - INSERT TIBIAL 3 25MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-409 SUP Custom 27803010 5531-P-409 - INSERT TIBIAL 4 9MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-410 SUP HCPCS C1776 5531-P-410 - INSERT TIB 4 10MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-411 SUP Custom 27803010 5531-P-411 - INSERT TIBIAL 4 11MM CRUC SUB TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-412 SUP HCPCS C1776 5531-P-412 - INSERT TIB 4 12MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-413 SUP Custom 27803010 5531-P-413 - INSERT TIBIAL 4 13MM CRUC SUB TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-414 SUP HCPCS C1776 5531-P-414 - INSERT TIB 4 14MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-416 SUP Custom 27803010 5531-P-416 - INSERT TIBIAL 4 16MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-419 SUP Custom 27803010 5531-P-419 - INSERT TIBIAL 4 19MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-422 SUP Custom 27803010 5531-P-422 - INSERT TIBIAL 4 22MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-425 SUP Custom 27803010 5531-P-425 - INSERT TIBIAL 4 25MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-509 SUP Custom 27803010 5531-P-509 - INSERT TIBIAL 5 9MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-510 SUP HCPCS C1776 5531-P-510 - INSERT TIB 5 10MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-511 SUP Custom 27803010 5531-P-511 - INSERT TIBIAL 5 11MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-512 SUP HCPCS C1776 5531-P-512 - INSERT TIB 5 12MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-513 SUP Custom 27803010 5531-P-513 - INSERT TIBIAL 5 13MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-514 SUP HCPCS C1776 5531-P-514 - INSERT TIB 5 14MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-516 SUP Custom 27803010 5531-P-516 - INSERT TIBIAL 5 16MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-519 SUP Custom 27803010 5531-P-519 - INSERT TIBIAL 5 19MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-522 SUP Custom 27803010 5531-P-522 - INSERT TIBIAL 5 22MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-525 SUP Custom 27803010 5531-P-525 - INSERT TIBIAL 5 25MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-609 SUP Custom 27803010 5531-P-609 - INSERT TIBIAL 6 9MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-610 SUP HCPCS C1776 5531-P-610 - INSERT TIB 6 10MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-611 SUP Custom 27803010 5531-P-611 - INSERT TIBIAL 6 11MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-612 SUP HCPCS C1776 5531-P-612 - INSERT TIB 6 12MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-613 SUP Custom 27803010 5531-P-613 - INSERT TIBIAL 6 13MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-614 SUP HCPCS C1776 5531-P-614 - INSERT TIB 6 14MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-616 SUP Custom 27803010 5531-P-616 - INSERT TIBIAL 6 16MM CRUC SUB TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-619 SUP Custom 27803010 5531-P-619 - INSERT TIBIAL 6 19MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-622 SUP Custom 27803010 5531-P-622 - INSERT TIBIAL 6 22MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-625 SUP Custom 27803010 5531-P-625 - INSERT TIBIAL 6 25MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-709 SUP Custom 27803010 5531-P-709 - INSERT TIBIAL 7 9MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-710 SUP HCPCS C1776 5531-P-710 - INSERT TIB 7 10MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-711 SUP Custom 27803010 5531-P-711 - INSERT TIBIAL 7 11MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-712 SUP HCPCS C1776 5531-P-712 - INSERT TIB 7 12MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-713 SUP Custom 27803010 5531-P-713 - INSERT TIBIAL 7 13MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-714 SUP HCPCS C1776 5531-P-714 - INSERT TIB 7 14MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-716 SUP Custom 27803010 5531-P-716 - INSERT TIBIAL 7 16MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-719 SUP Custom 27803010 5531-P-719 - INSERT TIBIAL 7 19MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-722 SUP Custom 27803010 5531-P-722 - INSERT TIBIAL 7 22MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-725 SUP Custom 27803010 5531-P-725 - INSERT TIBIAL 7 25MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-809 SUP Custom 27803010 5531-P-809 - INSERT TIBIAL 8 9MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-810 SUP HCPCS C1776 5531-P-810 - INSERT TIB 8 10MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-811 SUP Custom 27803010 5531-P-811 - INSERT TIBIAL 8 11MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-812 SUP HCPCS C1776 5531-P-812 - INSERT TIB 8 12MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-813 SUP Custom 27803010 5531-P-813 - INSERT TIBIAL 8 13MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-814 SUP HCPCS C1776 5531-P-814 - INSERT TIB 8 14MM STRL LF TRTHLN BRNG CNDRL STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-816 SUP Custom 27803010 5531-P-816 - INSERT TIBIAL 8 16MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-819 SUP Custom 27803010 5531-P-819 - INSERT TIBIAL 8 19MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-822 SUP Custom 27803010 5531-P-822 - INSERT TIBIAL 8 22MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5531-P-825 SUP Custom 27803010 5531-P-825 - INSERT TIBIAL 8 25MM STABILIZE TRIATHLON KNEE CONDYLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-109 SUP Custom 27803010 5532-G-109 - INSERT TIBIAL 1 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-109-E SUP HCPCS C1776 5532-G-109-E - INSERT TIB 1 9MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-110-E SUP HCPCS C1776 5532-G-110-E - INSERT TIB 1 10MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-111 SUP Custom 27803010 5532-G-111 - INSERT TIBIAL 1 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-111-E SUP HCPCS C1776 5532-G-111-E - INSERT TIB 1 11MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-112-E SUP HCPCS C1776 5532-G-112-E - INSERT TIB 1 12MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-113 SUP Custom 27803010 5532-G-113 - INSERT TIBIAL 1 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-113-E SUP HCPCS C1776 5532-G-113-E - INSERT TIB 1 13MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-114-E SUP HCPCS C1776 5532-G-114-E - INSERT TIB 1 14MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-116 SUP Custom 27803010 5532-G-116 - INSERT TIBIAL 1 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-116-E SUP HCPCS C1776 5532-G-116-E - INSERT TIB 1 16MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-119 SUP Custom 27803010 5532-G-119 - INSERT TIBIAL 1 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-119-E SUP HCPCS C1776 5532-G-119-E - INSERT TIB 1 19MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-122 SUP Custom 27803010 5532-G-122 - INSERT TIBIAL 1 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-122-E SUP HCPCS C1776 5532-G-122-E - INSERT TIB 1 22MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-125 SUP Custom 27803010 5532-G-125 - INSERT TIBIAL 1 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-209 SUP Custom 27803010 5532-G-209 - INSERT TIBIAL 2 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-209-E SUP HCPCS C1776 5532-G-209-E - INSERT TIB 2 9MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-210-E SUP HCPCS C1776 5532-G-210-E - INSERT TIB 2 10MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-211 SUP Custom 27803010 5532-G-211 - INSERT TIBIAL 2 11MM POSTERIOR STABILIZE TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-211-E SUP HCPCS C1776 5532-G-211-E - INSERT TIB 2 11MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-212-E SUP HCPCS C1776 5532-G-212-E - INSERT TIB 2 12MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-213 SUP Custom 27803010 5532-G-213 - INSERT TIBIAL 2 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-213-E SUP HCPCS C1776 5532-G-213-E - INSERT TIB 2 13MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-214-E SUP HCPCS C1776 5532-G-214-E - INSERT TIB 2 14MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-216 SUP Custom 27803010 5532-G-216 - INSERT TIBIAL 2 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-216-E SUP HCPCS C1776 5532-G-216-E - INSERT TIB 2 16MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-219 SUP Custom 27803010 5532-G-219 - INSERT TIBIAL 2 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-219-E SUP HCPCS C1776 5532-G-219-E - INSERT TIB 2 19MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-222 SUP Custom 27803010 5532-G-222 - INSERT TIBIAL 2 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-222-E SUP HCPCS C1776 5532-G-222-E - INSERT TIB 2 22MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-225 SUP Custom 27803010 5532-G-225 - INSERT TIBIAL 2 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-309 SUP Custom 27803010 5532-G-309 - INSERT TIBIAL 3 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-309-E SUP HCPCS C1776 5532-G-309-E - INSERT TIB 3 9MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-310-E SUP HCPCS C1776 5532-G-310-E - INSERT TIB 3 10MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-311 SUP Custom 27803010 5532-G-311 - INSERT TIBIAL 3 11MM POSTERIOR STABILIZED PRIM TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-311-E SUP HCPCS C1776 5532-G-311-E - INSERT TIB 3 11MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-312-E SUP HCPCS C1776 5532-G-312-E - INSERT TIB 3 12MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-313 SUP Custom 27803010 5532-G-313 - INSERT TIBIAL 3 13MM BEARING POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-313-E SUP HCPCS C1776 5532-G-313-E - INSERT TIB 3 13MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-314-E SUP HCPCS C1776 5532-G-314-E - INSERT TIB 3 14MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-316 SUP Custom 27803010 5532-G-316 - INSERT TIBIAL 3 16MM BEARING POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-316-E SUP HCPCS C1776 5532-G-316-E - INSERT TIB 3 16MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-319 SUP Custom 27803010 5532-G-319 - INSERT TIBIAL 3 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-319-E SUP HCPCS C1776 5532-G-319-E - INSERT TIB 3 19MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-322 SUP Custom 27803010 5532-G-322 - INSERT TIBIAL 3 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-322-E SUP HCPCS C1776 5532-G-322-E - INSERT TIB 3 22MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-325 SUP Custom 27803010 5532-G-325 - INSERT TIBIAL 3 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-409 SUP Custom 27803010 5532-G-409 - INSERT TIBIAL 4 9MM POSTERIOR STABILIZE TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-409-E SUP HCPCS C1776 5532-G-409-E - INSERT TIB 4 9MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-410-E SUP HCPCS C1776 5532-G-410-E - INSERT TIB 4 10MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-411 SUP Custom 27803010 5532-G-411 - INSERT TIBIAL 4 11MM BEARING POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-411-E SUP HCPCS C1776 5532-G-411-E - INSERT TIB 4 11MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-412-E SUP HCPCS C1776 5532-G-412-E - INSERT TIB 4 12MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-413 SUP Custom 27803010 5532-G-413 - INSERT TIBIAL 4 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-413-E SUP HCPCS C1776 5532-G-413-E - INSERT TIB 4 13MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-414-E SUP HCPCS C1776 5532-G-414-E - INSERT TIB 4 14MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-416 SUP Custom 27803010 5532-G-416 - INSERT TIBIAL 4 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-416-E SUP HCPCS C1776 5532-G-416-E - INSERT TIB 4 16MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-419 SUP Custom 27803010 5532-G-419 - INSERT TIBIAL 4 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-419-E SUP HCPCS C1776 5532-G-419-E - INSERT TIB 4 19MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-422 SUP Custom 27803010 5532-G-422 - INSERT TIBIAL 4 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-422-E SUP HCPCS C1776 5532-G-422-E - INSERT TIB 4 22MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-425 SUP Custom 27803010 5532-G-425 - INSERT TIBIAL 4 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-509 SUP Custom 27803010 5532-G-509 - INSERT TIBIAL 5 9MM BEARING POSTERIOR STABILIZE TRIATHLON X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-509-E SUP HCPCS C1776 5532-G-509-E - INSERT TIB 5 9MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-510-E SUP HCPCS C1776 5532-G-510-E - INSERT TIB 5 10MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-511 SUP Custom 27803010 5532-G-511 - INSERT TIBIAL 5 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-511-E SUP HCPCS C1776 5532-G-511-E - INSERT TIB 5 11MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-512-E SUP HCPCS C1776 5532-G-512-E - INSERT TIB 5 12MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-513 SUP Custom 27803010 5532-G-513 - INSERT TIBIAL 5 13MM POSTERIOR STABILIZE BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-513-E SUP HCPCS C1776 5532-G-513-E - INSERT TIB 5 13MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-514-E SUP HCPCS C1776 5532-G-514-E - INSERT TIB 5 14MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-516 SUP Custom 27803010 5532-G-516 - INSERT TIBIAL 5 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-516-E SUP HCPCS C1776 5532-G-516-E - INSERT TIB 5 16MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-519 SUP Custom 27803010 5532-G-519 - INSERT TIBIAL 5 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-519-E SUP HCPCS C1776 5532-G-519-E - INSERT TIB 5 19MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-522 SUP Custom 27803010 5532-G-522 - INSERT TIBIAL 5 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-522-E SUP HCPCS C1776 5532-G-522-E - INSERT TIB 5 22MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-525 SUP Custom 27803010 5532-G-525 - INSERT TIBIAL 5 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-609 SUP Custom 27803010 5532-G-609 - INSERT TIBIAL 6 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-609-E SUP HCPCS C1776 5532-G-609-E - INSERT TIB 6 9MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-610-E SUP HCPCS C1776 5532-G-610-E - INSERT TIB 6 10MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-611 SUP Custom 27803010 5532-G-611 - INSERT TIBIAL 6 11MM BEARING POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-611-E SUP HCPCS C1776 5532-G-611-E - INSERT TIB 6 11MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-612-E SUP HCPCS C1776 5532-G-612-E - INSERT TIB 6 12MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-613 SUP Custom 27803010 5532-G-613 - INSERT TIBIAL 6 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-613-E SUP HCPCS C1776 5532-G-613-E - INSERT TIB 6 13MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-614-E SUP HCPCS C1776 5532-G-614-E - INSERT TIB 6 14MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-616 SUP Custom 27803010 5532-G-616 - INSERT TIBIAL 6 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-616-E SUP HCPCS C1776 5532-G-616-E - INSERT TIB 6 16MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-619 SUP Custom 27803010 5532-G-619 - INSERT TIBIAL 6 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-619-E SUP HCPCS C1776 5532-G-619-E - INSERT TIB 6 19MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-622 SUP Custom 27803010 5532-G-622 - INSERT TIBIAL 6 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-622-E SUP HCPCS C1776 5532-G-622-E - INSERT TIB 6 22MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-625 SUP Custom 27803010 5532-G-625 - INSERT TIBIAL 6 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-709 SUP Custom 27803010 5532-G-709 - INSERT TIBIAL 7 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-709-E SUP HCPCS C1776 5532-G-709-E - INSERT TIB 7 9MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-710-E SUP HCPCS C1776 5532-G-710-E - INSERT TIB 7 10MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-711 SUP Custom 27803010 5532-G-711 - INSERT TIBIAL 7 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-711-E SUP HCPCS C1776 5532-G-711-E - INSERT TIB 7 11MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-712-E SUP HCPCS C1776 5532-G-712-E - INSERT TIB 7 12MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-713 SUP Custom 27803010 5532-G-713 - INSERT TIBIAL 7 13MM POSTERIOR STABILIZE TRIATHLON X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-713-E SUP HCPCS C1776 5532-G-713-E - INSERT TIB 7 13MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-714-E SUP HCPCS C1776 5532-G-714-E - INSERT TIB 7 14MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-716 SUP Custom 27803010 5532-G-716 - INSERT TIBIAL 7 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-716-E SUP HCPCS C1776 5532-G-716-E - INSERT TIB 7 16MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-719 SUP Custom 27803010 5532-G-719 - INSERT TIBIAL 7 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-719-E SUP HCPCS C1776 5532-G-719-E - INSERT TIB 7 19MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-722 SUP Custom 27803010 5532-G-722 - INSERT TIBIAL 7 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-722-E SUP HCPCS C1776 5532-G-722-E - INSERT TIB 7 22MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-725 SUP Custom 27803010 5532-G-725 - INSERT TIBIAL 7 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-809 SUP Custom 27803010 5532-G-809 - INSERT TIBIAL 8 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-809-E SUP HCPCS C1776 5532-G-809-E - INSERT TIB 8 9MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-810-E SUP HCPCS C1776 5532-G-810-E - INSERT TIB 8 10MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-811 SUP Custom 27803010 5532-G-811 - INSERT TIBIAL 8 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-811-E SUP HCPCS C1776 5532-G-811-E - INSERT TIB 8 11MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-812-E SUP HCPCS C1776 5532-G-812-E - INSERT TIB 8 12MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-813 SUP Custom 27803010 5532-G-813 - INSERT TIBIAL 8 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-813-E SUP HCPCS C1776 5532-G-813-E - INSERT TIB 8 13MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-814-E SUP HCPCS C1776 5532-G-814-E - INSERT TIB 8 14MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-816 SUP Custom 27803010 5532-G-816 - INSERT TIBIAL 8 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-816-E SUP HCPCS C1776 5532-G-816-E - INSERT TIB 8 16MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-819 SUP Custom 27803010 5532-G-819 - INSERT TIBIAL 8 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-819-E SUP HCPCS C1776 5532-G-819-E - INSERT TIB 8 19MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-822 SUP Custom 27803010 5532-G-822 - INSERT TIBIAL 8 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-822-E SUP HCPCS C1776 5532-G-822-E - INSERT TIB 8 22MM STRL TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 5532-G-825 SUP Custom 27803010 5532-G-825 - INSERT TIBIAL 8 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-109 SUP Custom 27803010 5532-P-109 - INSERT TIBIAL 1 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-110 SUP HCPCS C1776 5532-P-110 - INSERT TIB 1 10MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-111 SUP Custom 27803010 5532-P-111 - INSERT TIBIAL 1 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-112 SUP HCPCS C1776 5532-P-112 - INSERT TIB 1 12MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-113 SUP Custom 27803010 5532-P-113 - INSERT TIBIAL 1 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-114 SUP HCPCS C1776 5532-P-114 - INSERT TIB 1 14MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-116 SUP Custom 27803010 5532-P-116 - INSERT TIBIAL 1 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-119 SUP Custom 27803010 5532-P-119 - INSERT TIBIAL 1 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-122 SUP Custom 27803010 5532-P-122 - INSERT TIBIAL 1 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-125 SUP Custom 27803010 5532-P-125 - INSERT TIBIAL 1 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-209 SUP Custom 27803010 5532-P-209 - INSERT TIBIAL 2 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-210 SUP HCPCS C1776 5532-P-210 - INSERT TIB 2 10MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-211 SUP Custom 27803010 5532-P-211 - INSERT TIBIAL 2 11MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-212 SUP HCPCS C1776 5532-P-212 - INSERT TIB 2 12MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-213 SUP Custom 27803010 5532-P-213 - INSERT TIBIAL 2 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-214 SUP HCPCS C1776 5532-P-214 - INSERT TIB 2 14MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-216 SUP Custom 27803010 5532-P-216 - INSERT TIBIAL 2 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-219 SUP Custom 27803010 5532-P-219 - INSERT TIBIAL 2 P 19MM POSTERIOR STABILIZE TRIATHLON X3 KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-222 SUP Custom 27803010 5532-P-222 - INSERT TIBIAL 2 22MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-225 SUP Custom 27803010 5532-P-225 - INSERT TIBIAL 2 25MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-309 SUP Custom 27803010 5532-P-309 - INSERT TIBIAL 3 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-310 SUP HCPCS C1776 5532-P-310 - INSERT TIB 3 10MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-311 SUP Custom 27803010 5532-P-311 - INSERT TIBIAL 3 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-312 SUP HCPCS C1776 5532-P-312 - INSERT TIB 3 12MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-313 SUP Custom 27803010 5532-P-313 - INSERT TIBIAL 3 13MM POSTERIOR STABILIZED PRIM TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-314 SUP HCPCS C1776 5532-P-314 - INSERT TIB 3 14MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-316 SUP Custom 27803010 5532-P-316 - INSERT TIBIAL 3 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-319 SUP Custom 27803010 5532-P-319 - INSERT TIBIAL 3 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-322 SUP Custom 27803010 5532-P-322 - INSERT TIBIAL 3 22MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-325 SUP Custom 27803010 5532-P-325 - INSERT TIBIAL 3 25MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-409 SUP Custom 27803010 5532-P-409 - INSERT TIBIAL 4 9MM POSTERIOR STABILIZE BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-410 SUP HCPCS C1776 5532-P-410 - INSERT TIB 4 10MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-411 SUP Custom 27803010 5532-P-411 - INSERT TIBIAL 4 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-412 SUP HCPCS C1776 5532-P-412 - INSERT TIB 4 12MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-413 SUP Custom 27803010 5532-P-413 - INSERT TIBIAL 4 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-416 SUP Custom 27803010 5532-P-416 - INSERT TIBIAL 4 16MM POSTERIOR STABILIZE BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-419 SUP Custom 27803010 5532-P-419 - INSERT TIBIAL 4 19MM POSTERIOR STABILIZE BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-422 SUP Custom 27803010 5532-P-422 - INSERT TIBIAL 4 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-425 SUP Custom 27803010 5532-P-425 - INSERT TIBIAL 4 25MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-509 SUP Custom 27803010 5532-P-509 - INSERT TIBIAL 5 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-510 SUP HCPCS C1776 5532-P-510 - INSERT TIB 5 10MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-511 SUP Custom 27803010 5532-P-511 - INSERT TIBIAL 5 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-512 SUP HCPCS C1776 5532-P-512 - INSERT TIB 5 12MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-513 SUP Custom 27803010 5532-P-513 - INSERT TIBIAL 5 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-514 SUP HCPCS C1776 5532-P-514 - INSERT TIB 5 14MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-516 SUP Custom 27803010 5532-P-516 - INSERT TIBIAL 5 16MM POSTERIOR STABILIZED PRIM TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-519 SUP Custom 27803010 5532-P-519 - INSERT TIBIAL 5 P 19MM POSTERIOR STABILIZE TRIATHLON N2/VAC BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-522 SUP Custom 27803010 5532-P-522 - INSERT TIBIAL 5 22MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-525 SUP Custom 27803010 5532-P-525 - INSERT TIBIAL 5 25MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-609 SUP Custom 27803010 5532-P-609 - INSERT TIBIAL 6 9IN POSTERIOR STABILIZED PLASMA SPRAY BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-610 SUP HCPCS C1776 5532-P-610 - INSERT TIB 6 10MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-611 SUP Custom 27803010 5532-P-611 - INSERT TIBIAL 6 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-612 SUP HCPCS C1776 5532-P-612 - INSERT TIB 6 12MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-613 SUP Custom 27803010 5532-P-613 - INSERT TIBIAL 6 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-614 SUP HCPCS C1776 5532-P-614 - INSERT TIB 6 14MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-616 SUP Custom 27803010 5532-P-616 - INSERT TIBIAL 6 16MM POSTERIOR STABILIZE BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-619 SUP Custom 27803010 5532-P-619 - INSERT TIBIAL 6 19MM POSTERIOR STABILIZE TRIATHLON NONSTRL BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-622 SUP Custom 27803010 5532-P-622 - INSERT TIBIAL 6 22MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-625 SUP Custom 27803010 5532-P-625 - INSERT TIBIAL POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-709 SUP Custom 27803010 5532-P-709 - INSERT TIBIAL 7 9MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-710 SUP HCPCS C1776 5532-P-710 - INSERT TIB 7 10MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-711 SUP Custom 27803010 5532-P-711 - INSERT TIBIAL 7 11MM POSTERIOR STABILIZE BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-712 SUP HCPCS C1776 5532-P-712 - INSERT TIB 7 12MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-713 SUP Custom 27803010 5532-P-713 - INSERT TIBIAL 13MM POSTERIOR STABILIZE TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-714 SUP HCPCS C1776 5532-P-714 - INSERT TIB 7 14MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-716 SUP Custom 27803010 5532-P-716 - INSERT TIBIAL 7 16MM POSTERIOR STABILIZE BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-719 SUP Custom 27803010 5532-P-719 - INSERT TIBIAL 7 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-722 SUP Custom 27803010 5532-P-722 - INSERT TIBIAL 7 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-725 SUP Custom 27803010 5532-P-725 - INSERT TIBIAL 7 25MM POSTERIOR STABILIZE TRIATHLON KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-809 SUP Custom 27803010 5532-P-809 - INSERT TIBIAL 8 9MM POSTERIOR STABILIZE BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-810 SUP HCPCS C1776 5532-P-810 - INSERT TIB 8 10MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-811 SUP Custom 27803010 5532-P-811 - INSERT TIBIAL 8 11MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-812 SUP HCPCS C1776 5532-P-812 - INSERT TIB 8 12MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-813 SUP Custom 27803010 5532-P-813 - INSERT TIBIAL 8 13MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-814 SUP HCPCS C1776 5532-P-814 - INSERT TIB 8 14MM STRL LF TRTHLN BRNG POST STAB KN BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $540.00 $540.00 $0.00 $0.00 $0.00 $250.11 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $709.80 $709.80 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $187.80 $0.00 $0.00 $191.04 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-816 SUP Custom 27803010 5532-P-816 - INSERT TIBIAL 8 16MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-819 SUP Custom 27803010 5532-P-819 - INSERT TIBIAL 8 19MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-822 SUP Custom 27803010 5532-P-822 - INSERT TIBIAL 8 22MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5532-P-825 SUP Custom 27803010 5532-P-825 - INSERT TIBIAL 8 25MM POSTERIOR STABILIZED BEARING TRIATHLON BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-109 SUP HCPCS C1776 5534-A-109 - COMPONENT TIB 1 9MM CRCTE STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-111 SUP HCPCS C1776 5534-A-111 - INSERT TIB 1 11MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-113 SUP HCPCS C1776 5534-A-113 - INSERT TIB 1 13MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-116 SUP HCPCS C1776 5534-A-116 - INSERT TIB 1 16MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-209 SUP HCPCS C1776 5534-A-209 - INSERT TIB 2 9MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-211 SUP HCPCS C1776 5534-A-211 - INSERT TIB 2 11MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-213 SUP HCPCS C1776 5534-A-213 - INSERT TIB 2 13MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-216 SUP HCPCS C1776 5534-A-216 - INSERT TIB 2 16MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-309 SUP HCPCS C1776 5534-A-309 - INSERT TIB 3 9MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-311 SUP HCPCS C1776 5534-A-311 - INSERT TIB 3 11MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-313 SUP HCPCS C1776 5534-A-313 - COMPONENT TIB 3 13MM CRCTE STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-316 SUP HCPCS C1776 5534-A-316 - COMPONENT TIB 3 16MM CRCTE STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-409 SUP HCPCS C1776 5534-A-409 - INSERT TIB 4 9MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-411 SUP HCPCS C1776 5534-A-411 - INSERT TIB 4 11MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-413 SUP HCPCS C1776 5534-A-413 - INSERT TIB 4 13MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-416 SUP HCPCS C1776 5534-A-416 - COMPONENT TIB 4 16MM CRCTE STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-509 SUP HCPCS C1776 5534-A-509 - INSERT TIB 5 9MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-511 SUP HCPCS C1776 5534-A-511 - INSERT TIB 5 11MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-513 SUP HCPCS C1776 5534-A-513 - TRAY TIB 5 13MM STRL TRTHLN CNDRL STAB ALPLY KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-516 SUP HCPCS C1776 5534-A-516 - INSERT TIB 5 16MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-609 SUP HCPCS C1776 5534-A-609 - INSERT TIB 6 9MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-611 SUP HCPCS C1776 5534-A-611 - INSERT TIB 6 11MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-613 SUP HCPCS C1776 5534-A-613 - INSERT TIB 6 13MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-616 SUP HCPCS C1776 5534-A-616 - INSERT TIB 6 16MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-709 SUP HCPCS C1776 5534-A-709 - INSERT TIB 7 9MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-711 SUP HCPCS C1776 5534-A-711 - INSERT TIB 7 11MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-713 SUP HCPCS C1776 5534-A-713 - INSERT TIB 7 13MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-716 SUP HCPCS C1776 5534-A-716 - TRAY TIB 7 16MM STRL TRTHLN CNDRL STAB ALPLY KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-809 SUP HCPCS C1776 5534-A-809 - INSERT TIB 8 9MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-811 SUP HCPCS C1776 5534-A-811 - INSERT TIB 8 11MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-813 SUP HCPCS C1776 5534-A-813 - INSERT TIB 8 13MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5534-A-816 SUP HCPCS C1776 5534-A-816 - INSERT TIB 8 16MM CNDRL STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-109 SUP HCPCS C1776 5535-A-109 - INSERT TIB 1 9MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-111 SUP HCPCS C1776 5535-A-111 - INSERT TIB 1 11MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-113 SUP HCPCS C1776 5535-A-113 - INSERT TIB 1 13MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-116 SUP HCPCS C1776 5535-A-116 - INSERT TIB 1 16MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-209 SUP HCPCS C1776 5535-A-209 - INSERT TIB 2 9MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-211 SUP HCPCS C1776 5535-A-211 - INSERT TIB 2 11MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-213 SUP HCPCS C1776 5535-A-213 - INSERT TIB 2 13MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-216 SUP HCPCS C1776 5535-A-216 - INSERT TIB 2 16MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-309 SUP HCPCS C1776 5535-A-309 - INSERT TIB 3 9MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-311 SUP HCPCS C1776 5535-A-311 - COMPONENT TIB 3 11MM POST STAB PE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-313 SUP HCPCS C1776 5535-A-313 - INSERT TIB 3 13MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-316 SUP HCPCS C1776 5535-A-316 - INSERT TIB 3 16MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-409 SUP HCPCS C1776 5535-A-409 - INSERT TIB 4 9MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-411 SUP HCPCS C1776 5535-A-411 - COMPONENT TIB 4 11MM POST STAB ALPLY KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-413 SUP HCPCS C1776 5535-A-413 - TRAY TIB 4 13MM STRL TRTHLN POST STAB ALPLY KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-416 SUP HCPCS C1776 5535-A-416 - INSERT TIB 4 16MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-509 SUP HCPCS C1776 5535-A-509 - INSERT TIB 5 9MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-511 SUP HCPCS C1776 5535-A-511 - COMPONENT TIB 5 11MM POST STAB ALPLY KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-513 SUP HCPCS C1776 5535-A-513 - INSERT TIB 5 13MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-516 SUP HCPCS C1776 5535-A-516 - INSERT TIB 5 16MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-609 SUP HCPCS C1776 5535-A-609 - COMPONENT TIB 6 9MM POST STAB PE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-611 SUP HCPCS C1776 5535-A-611 - COMPONENT TIB 6 11MM POST STAB PE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-613 SUP HCPCS C1776 5535-A-613 - INSERT TIB 6 13MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-616 SUP HCPCS C1776 5535-A-616 - INSERT TIB 6 16MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-709 SUP HCPCS C1776 5535-A-709 - TRAY TIB 7 9MM STRL TRTHLN POST STAB ALPLY KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-711 SUP HCPCS C1776 5535-A-711 - INSERT TIB 7 11MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-713 SUP HCPCS C1776 5535-A-713 - INSERT TIB 7 13MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-716 SUP HCPCS C1776 5535-A-716 - INSERT TIB 7 16MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-809 SUP HCPCS C1776 5535-A-809 - INSERT TIB 8 9MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-811 SUP HCPCS C1776 5535-A-811 - INSERT TIB 8 11MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-813 SUP HCPCS C1776 5535-A-813 - INSERT TIB 8 13MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5535-A-816 SUP HCPCS C1776 5535-A-816 - INSERT TIB 8 16MM POST STAB ALL PE KN BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 5536-B-100 SUP HCPCS C1776 5536-B-100 - BASEPLATE TIB 1 7MM 40X40MM 61MM TRTHLN 4 CRFRM PG KEEL BOTH IP/OP "$3,602.50 " "$2,665.85" $0.00 "$2,882.00" "$1,621.13" "$1,621.13" $0.00 $0.00 $0.00 $750.85 "$2,673.78" "$2,673.78" $0.00 $0.00 $750.76 $0.00 "$1,776.03" "$1,776.03" $0.00 "$1,801.25" "$2,853.18" "$2,882.00" $0.00 $0.00 $563.79 $0.00 $0.00 $573.52 $0.00 $0.00 $0.00 $0.00 $0.00 5536-B-200 SUP HCPCS C1776 5536-B-200 - COMPONENT TIB 2 STRL LF TRTHLN KN BOTH IP/OP "$3,602.50 " "$2,665.85" $0.00 "$2,882.00" "$1,621.13" "$1,621.13" $0.00 $0.00 $0.00 $750.85 "$2,673.78" "$2,673.78" $0.00 $0.00 $750.76 $0.00 "$1,776.03" "$1,776.03" $0.00 "$1,801.25" "$2,853.18" "$2,882.00" $0.00 $0.00 $563.79 $0.00 $0.00 $573.52 $0.00 $0.00 $0.00 $0.00 $0.00 5536-B-300 SUP HCPCS C1776 5536-B-300 - BASEPLATE TIB 3 TRTHLN TRITANIUM KN BOTH IP/OP "$3,602.50 " "$2,665.85" $0.00 "$2,882.00" "$1,621.13" "$1,621.13" $0.00 $0.00 $0.00 $750.85 "$2,673.78" "$2,673.78" $0.00 $0.00 $750.76 $0.00 "$1,776.03" "$1,776.03" $0.00 "$1,801.25" "$2,853.18" "$2,882.00" $0.00 $0.00 $563.79 $0.00 $0.00 $573.52 $0.00 $0.00 $0.00 $0.00 $0.00 5536-B-400 SUP HCPCS C1776 5536-B-400 - BASEPLATE TIB 4 TRTHLN TRITANIUM KN BOTH IP/OP "$3,602.50 " "$2,665.85" $0.00 "$2,882.00" "$1,621.13" "$1,621.13" $0.00 $0.00 $0.00 $750.85 "$2,673.78" "$2,673.78" $0.00 $0.00 $750.76 $0.00 "$1,776.03" "$1,776.03" $0.00 "$1,801.25" "$2,853.18" "$2,882.00" $0.00 $0.00 $563.79 $0.00 $0.00 $573.52 $0.00 $0.00 $0.00 $0.00 $0.00 5536-B-500 SUP HCPCS C1776 5536-B-500 - BASEPLATE TIB 5 TRTHLN TRITANIUM KN BOTH IP/OP "$3,602.50 " "$2,665.85" $0.00 "$2,882.00" "$1,621.13" "$1,621.13" $0.00 $0.00 $0.00 $750.85 "$2,673.78" "$2,673.78" $0.00 $0.00 $750.76 $0.00 "$1,776.03" "$1,776.03" $0.00 "$1,801.25" "$2,853.18" "$2,882.00" $0.00 $0.00 $563.79 $0.00 $0.00 $573.52 $0.00 $0.00 $0.00 $0.00 $0.00 5536-B-600 SUP HCPCS C1776 5536-B-600 - BASEPLATE TIB 6 TRTHLN TRITANIUM KN BOTH IP/OP "$3,602.50 " "$2,665.85" $0.00 "$2,882.00" "$1,621.13" "$1,621.13" $0.00 $0.00 $0.00 $750.85 "$2,673.78" "$2,673.78" $0.00 $0.00 $750.76 $0.00 "$1,776.03" "$1,776.03" $0.00 "$1,801.25" "$2,853.18" "$2,882.00" $0.00 $0.00 $563.79 $0.00 $0.00 $573.52 $0.00 $0.00 $0.00 $0.00 $0.00 5536-B-700 SUP HCPCS C1776 5536-B-700 - BASEPLATE TIB 7 TRTHLN TRITANIUM KN BOTH IP/OP "$3,602.50 " "$2,665.85" $0.00 "$2,882.00" "$1,621.13" "$1,621.13" $0.00 $0.00 $0.00 $750.85 "$2,673.78" "$2,673.78" $0.00 $0.00 $750.76 $0.00 "$1,776.03" "$1,776.03" $0.00 "$1,801.25" "$2,853.18" "$2,882.00" $0.00 $0.00 $563.79 $0.00 $0.00 $573.52 $0.00 $0.00 $0.00 $0.00 $0.00 5536-B-800 SUP HCPCS C1776 5536-B-800 - BASEPLATE TIB 8 TRTHLN TRITANIUM KN BOTH IP/OP "$3,602.50 " "$2,665.85" $0.00 "$2,882.00" "$1,621.13" "$1,621.13" $0.00 $0.00 $0.00 $750.85 "$2,673.78" "$2,673.78" $0.00 $0.00 $750.76 $0.00 "$1,776.03" "$1,776.03" $0.00 "$1,801.25" "$2,853.18" "$2,882.00" $0.00 $0.00 $563.79 $0.00 $0.00 $573.52 $0.00 $0.00 $0.00 $0.00 $0.00 5537-14/13 SUP HCPCS C1776 5537-14/13 - STEM HUMERAL 14MM 135MM PRESS FIT HUMERAL TITANIUM SHOULDER BOTH IP/OP "$6,566.70 " "$4,859.36" $0.00 "$5,253.36" "$2,955.02" "$2,955.02" $0.00 $0.00 $0.00 "$1,368.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,368.50" $0.00 "$3,237.38" "$3,237.38" $0.00 "$3,283.35" "$5,200.83" "$5,253.36" $0.00 $0.00 "$1,027.69" $0.00 $0.00 "$1,045.42" $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-109 SUP HCPCS C1776 5537-G-109 - INSERT TIBIAL 1 9MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-109-E SUP HCPCS C1776 5537-G-109-E - INSERT TIB 1 9MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-111 SUP HCPCS C1776 5537-G-111 - INSERT TIBIAL 1 11MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-111-E SUP HCPCS C1776 5537-G-111-E - INSERT TIB 1 11MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-113 SUP HCPCS C1776 5537-G-113 - INSERT TIBIAL 1 13MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-113-E SUP HCPCS C1776 5537-G-113-E - INSERT TIB 1 13MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-116 SUP HCPCS C1776 5537-G-116 - INSERT TIBIAL 1 16MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-116-E SUP HCPCS C1776 5537-G-116-E - INSERT TIB 1 16MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-119 SUP HCPCS C1776 5537-G-119 - INSERT TIBIAL 1 19MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-119-E SUP HCPCS C1776 5537-G-119-E - INSERT TIB 1 19MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-122 SUP HCPCS C1776 5537-G-122 - INSERT TIBIAL 1 22MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-122-E SUP HCPCS C1776 5537-G-122-E - INSERT TIB 1 22MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-125 SUP HCPCS C1776 5537-G-125 - INSERT TIBIAL 1 25MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-125-E SUP HCPCS C1776 5537-G-125-E - INSERT TIB 1 25MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-128 SUP HCPCS C1776 5537-G-128 - INSERT TIBIAL 1 28MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-128-E SUP HCPCS C1776 5537-G-128-E - INSERT TIB 1 28MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-131 SUP HCPCS C1776 5537-G-131 - INSERT TIBIAL 1 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-131-E SUP HCPCS C1776 5537-G-131-E - INSERT TIB 1 31MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-209 SUP HCPCS C1776 5537-G-209 - INSERT TIBIAL 2 9MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-209-E SUP HCPCS C1776 5537-G-209-E - INSERT TIB 2 9MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-211 SUP HCPCS C1776 5537-G-211 - INSERT TIBIAL 2 11MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-211-E SUP HCPCS C1776 5537-G-211-E - INSERT TIB 2 11MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-213 SUP HCPCS C1776 5537-G-213 - INSERT TIBIAL 2 13MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-213-E SUP HCPCS C1776 5537-G-213-E - INSERT TIB 2 13MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-216 SUP HCPCS C1776 5537-G-216 - INSERT TIBIAL 2 16MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-216-E SUP HCPCS C1776 5537-G-216-E - INSERT TIB 2 16MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-219 SUP HCPCS C1776 5537-G-219 - INSERT TIBIAL 2 19MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-219-E SUP HCPCS C1776 5537-G-219-E - INSERT TIB 2 19MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-222 SUP HCPCS C1776 5537-G-222 - INSERT TIBIAL 2 22MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-222-E SUP HCPCS C1776 5537-G-222-E - INSERT TIB 2 22MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-225 SUP HCPCS C1776 5537-G-225 - INSERT TIBIAL 2 25MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-225-E SUP HCPCS C1776 5537-G-225-E - INSERT TIB 2 25MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-228 SUP HCPCS C1776 5537-G-228 - INSERT TIBIAL 2 28MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-228-E SUP HCPCS C1776 5537-G-228-E - INSERT TIB 2 28MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-231 SUP HCPCS C1776 5537-G-231 - INSERT TIBIAL 2 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-231-E SUP HCPCS C1776 5537-G-231-E - INSERT TIB 2 31MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-309 SUP HCPCS C1776 5537-G-309 - INSERT TIBIAL 2 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-309-E SUP HCPCS C1776 5537-G-309-E - INSERT TIB 3 9MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-311 SUP HCPCS C1776 5537-G-311 - INSERT TIBIAL 3 11MM TOT STABILIZED PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-311-E SUP HCPCS C1776 5537-G-311-E - INSERT TIB 3 11MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-313 SUP HCPCS C1776 5537-G-313 - INSERT TIBIAL 3 13MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-313-E SUP HCPCS C1776 5537-G-313-E - INSERT TIB 3 13MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-316 SUP HCPCS C1776 5537-G-316 - INSERT TIBIAL 3 16MM TOT STABILIZED PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-316-E SUP HCPCS C1776 5537-G-316-E - INSERT TIB 3 16MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-319 SUP HCPCS C1776 5537-G-319 - INSERT TIBIAL 3 19MM TOT STABILIZED PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-319-E SUP HCPCS C1776 5537-G-319-E - INSERT TIB 3 19MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-322 SUP HCPCS C1776 5537-G-322 - INSERT TIBIAL 3 13MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-322-E SUP HCPCS C1776 5537-G-322-E - INSERT TIB 3 22MM STRL TRTHLN TS + X3 KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-325 SUP HCPCS C1776 5537-G-325 - INSERT TIBIAL 3 25MM TOT STABILIZED PLUS TRIATHLON X3 BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-325-E SUP HCPCS C1776 5537-G-325-E - INSERT TIB 3 25MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-328 SUP HCPCS C1776 5537-G-328 - INSERT TIBIAL 3 28MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-328-E SUP HCPCS C1776 5537-G-328-E - INSERT TIB 3 28MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-331 SUP HCPCS C1776 5537-G-331 - INSERT TIBIAL 3 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-331-E SUP HCPCS C1776 5537-G-331-E - INSERT TIB 3 31MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-409 SUP HCPCS C1776 5537-G-409 - INSERT TIBIAL 4 9MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-409-E SUP HCPCS C1776 5537-G-409-E - INSERT TIB 4 9MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-411 SUP HCPCS C1776 5537-G-411 - INSERT TIBIAL 4 11MM TOT STABILIZED PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-411-E SUP HCPCS C1776 5537-G-411-E - INSERT TIB 4 11MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-413 SUP HCPCS C1776 5537-G-413 - INSERT TIBIAL 4 13MM TOT STABILIZED PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-413-E SUP HCPCS C1776 5537-G-413-E - INSERT TIB 4 13MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-416 SUP HCPCS C1776 5537-G-416 - INSERT TIBIAL 4 16MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-416-E SUP HCPCS C1776 5537-G-416-E - INSERT TIB 4 16MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-419 SUP HCPCS C1776 5537-G-419 - INSERT TIBIAL 4 19MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-419-E SUP HCPCS C1776 5537-G-419-E - INSERT TIB 4 19MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-422 SUP HCPCS C1776 5537-G-422 - INSERT TIBIAL 4 22MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-422-E SUP HCPCS C1776 5537-G-422-E - INSERT TIB 4 22MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-425 SUP HCPCS C1776 5537-G-425 - INSERT TIBIAL 4 25MM TOT STABILIZED PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-425-E SUP HCPCS C1776 5537-G-425-E - INSERT TIB 4 25MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-428 SUP HCPCS C1776 5537-G-428 - INSERT TIBIAL 4 28MM TOT STABILIZED PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-428-E SUP HCPCS C1776 5537-G-428-E - INSERT TIB 4 28MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-431 SUP HCPCS C1776 5537-G-431 - INSERT TIBIAL 4 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-431-E SUP HCPCS C1776 5537-G-431-E - INSERT TIB 4 31MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-509 SUP HCPCS C1776 5537-G-509 - INSERT TIBIAL 5 9MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-509-E SUP HCPCS C1776 5537-G-509-E - INSERT TIB 5 9MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-511 SUP HCPCS C1776 5537-G-511 - INSERT TIBIAL 5 11MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-511-E SUP HCPCS C1776 5537-G-511-E - INSERT TIB 5 11MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-513 SUP HCPCS C1776 5537-G-513 - INSERT TIBIAL 5 13MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-513-E SUP HCPCS C1776 5537-G-513-E - INSERT TIB 5 13MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-516 SUP HCPCS C1776 5537-G-516 - INSERT TIBIAL 5 16MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-516-E SUP HCPCS C1776 5537-G-516-E - INSERT TIB 5 16MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-519 SUP HCPCS C1776 5537-G-519 - INSERT TIBIAL 5 19MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-519-E SUP HCPCS C1776 5537-G-519-E - INSERT TIB 5 19MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-522 SUP HCPCS C1776 5537-G-522 - INSERT TIBIAL 5 22MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-522-E SUP HCPCS C1776 5537-G-522-E - INSERT TIB 5 22MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-525 SUP HCPCS C1776 5537-G-525 - INSERT TIBIAL 5 25MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-525-E SUP HCPCS C1776 5537-G-525-E - INSERT TIB 5 25MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-528 SUP HCPCS C1776 5537-G-528 - INSERT TIBIAL 5 28MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-528-E SUP HCPCS C1776 5537-G-528-E - INSERT TIB 5 28MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-531 SUP HCPCS C1776 5537-G-531 - INSERT TIBIAL 5 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-531-E SUP HCPCS C1776 5537-G-531-E - INSERT TIB 5 31MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-609 SUP HCPCS C1776 5537-G-609 - INSERT TIBIAL 6 9MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-609-E SUP HCPCS C1776 5537-G-609-E - INSERT TIB 6 9MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-611 SUP HCPCS C1776 5537-G-611 - INSERT TIBIAL 6 11MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-611-E SUP HCPCS C1776 5537-G-611-E - INSERT TIB 6 11MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-613 SUP HCPCS C1776 5537-G-613 - INSERT TIBIAL 6 13MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-613-E SUP HCPCS C1776 5537-G-613-E - INSERT TIB 6 13MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-616 SUP HCPCS C1776 5537-G-616 - INSERT TIBIAL 6 16MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-616-E SUP HCPCS C1776 5537-G-616-E - INSERT TIB 6 16MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-619 SUP HCPCS C1776 5537-G-619 - INSERT TIBIAL 6 19MM TOT STABILIZED PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-619-E SUP HCPCS C1776 5537-G-619-E - INSERT TIB 6 19MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-622 SUP HCPCS C1776 5537-G-622 - INSERT TIBIAL 6 22MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-622-E SUP HCPCS C1776 5537-G-622-E - INSERT TIB 6 22MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-625 SUP HCPCS C1776 5537-G-625 - INSERT TIBIAL 6 25MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-625-E SUP HCPCS C1776 5537-G-625-E - INSERT TIB 6 25MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-628 SUP HCPCS C1776 5537-G-628 - INSERT TIBIAL 6 28MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-628-E SUP HCPCS C1776 5537-G-628-E - INSERT TIB 6 28MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-631 SUP HCPCS C1776 5537-G-631 - INSERT TIBIAL 6 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-631-E SUP HCPCS C1776 5537-G-631-E - INSERT TIB 6 31MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-709 SUP HCPCS C1776 5537-G-709 - INSERT TIBIAL 7 9MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-709-E SUP HCPCS C1776 5537-G-709-E - INSERT TIB 7 9MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-711 SUP HCPCS C1776 5537-G-711 - INSERT TIBIAL 7 11MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-711-E SUP HCPCS C1776 5537-G-711-E - INSERT TIB 7 11MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-713 SUP HCPCS C1776 5537-G-713 - INSERT TIBIAL 7 13MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-713-E SUP HCPCS C1776 5537-G-713-E - INSERT TIB 7 13MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-716 SUP HCPCS C1776 5537-G-716 - INSERT TIBIAL 7 16MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-716-E SUP HCPCS C1776 5537-G-716-E - INSERT TIB 7 16MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-719 SUP HCPCS C1776 5537-G-719 - INSERT TIBIAL 7 19MM TOT STABILIZE TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-719-E SUP HCPCS C1776 5537-G-719-E - INSERT TIB 7 19MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-722 SUP HCPCS C1776 5537-G-722 - INSERT TIBIAL 7 22MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-722-E SUP HCPCS C1776 5537-G-722-E - INSERT TIB 7 22MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-725 SUP HCPCS C1776 5537-G-725 - INSERT TIBIAL 7 25MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-725-E SUP HCPCS C1776 5537-G-725-E - INSERT TIB 7 25MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-728 SUP HCPCS C1776 5537-G-728 - INSERT TIBIAL 7 28MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-728-E SUP HCPCS C1776 5537-G-728-E - INSERT TIB 7 28MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-731 SUP HCPCS C1776 5537-G-731 - INSERT TIBIAL 7 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-731-E SUP HCPCS C1776 5537-G-731-E - INSERT TIB 7 31MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-809 SUP HCPCS C1776 5537-G-809 - INSERT TIBIAL 8 9MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-809-E SUP HCPCS C1776 5537-G-809-E - INSERT TIB 8 9MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-811 SUP HCPCS C1776 5537-G-811 - INSERT TIBIAL 8 11MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-811-E SUP HCPCS C1776 5537-G-811-E - INSERT TIB 8 11MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-813 SUP HCPCS C1776 5537-G-813 - INSERT TIBIAL 8 13MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-813-E SUP HCPCS C1776 5537-G-813-E - INSERT TIB 8 13MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-816 SUP HCPCS C1776 5537-G-816 - INSERT TIBIAL 8 16MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-816-E SUP HCPCS C1776 5537-G-816-E - INSERT TIB 8 16MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-819 SUP HCPCS C1776 5537-G-819 - INSERT TIBIAL 8 19MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-819-E SUP HCPCS C1776 5537-G-819-E - INSERT TIB 8 19MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-822 SUP HCPCS C1776 5537-G-822 - INSERT TIBIAL 8 22MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-822-E SUP HCPCS C1776 5537-G-822-E - INSERT TIB 8 22MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-825 SUP HCPCS C1776 5537-G-825 - INSERT TIBIAL 8 25MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-825-E SUP HCPCS C1776 5537-G-825-E - INSERT TIB 8 25MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-828 SUP HCPCS C1776 5537-G-828 - INSERT TIBIAL 8 28MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-828-E SUP HCPCS C1776 5537-G-828-E - INSERT TIB 8 28MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-831 SUP HCPCS C1776 5537-G-831 - INSERT TIBIAL 8 31MM TOT STABILIZE PLUS TRIATHLON X3 KNEE BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5537-G-831-E SUP HCPCS C1776 5537-G-831-E - INSERT TIB 8 31MM STRL TRTHLN TS + KN BOTH IP/OP "$5,255.00 " "$3,888.70" $0.00 "$4,204.00" "$2,364.75" "$2,364.75" $0.00 $0.00 $0.00 "$1,095.27" "$3,900.26" "$3,900.26" $0.00 $0.00 "$1,095.14" $0.00 "$2,590.72" "$2,590.72" $0.00 "$2,627.50" "$4,161.96" "$4,204.00" $0.00 $0.00 $822.41 $0.00 $0.00 $836.60 $0.00 $0.00 $0.00 $0.00 $0.00 5539-91 SUP HCPCS C1725 CATHETER ANGIO .035IN 5FR .052IN 90CM PGTL FLSH 10 SDPRT BOTH IP/OP $33.75 $24.98 $0.00 $27.00 $18.33 $18.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.88 $26.73 $27.00 $0.00 $0.00 $5.28 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 5540-14/13 SUP HCPCS C1776 5540-14/13 - STEM HUMERAL 14MM 135MM PRESS FIT TITANIUM HA STERILE BOTH IP/OP "$6,943.00 " "$5,137.82" $0.00 "$5,554.40" "$3,124.35" "$3,124.35" $0.00 $0.00 $0.00 "$1,447.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,446.92" $0.00 "$3,422.90" "$3,422.90" $0.00 "$3,471.50" "$5,498.86" "$5,554.40" $0.00 $0.00 "$1,086.58" $0.00 $0.00 "$1,105.33" $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-101 SUP Custom 27803010 5540-A-101 - AUGMENT FEMORAL 1 5MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-102 SUP Custom 27803010 5540-A-102 - AUGMENT FEMORAL 1 5MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-201 SUP Custom 27803010 5540-A-201 - AUGMENT FEMORAL 2 5MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-202 SUP Custom 27803010 5540-A-202 - AUGMENT FEMORAL 2 5MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-301 SUP Custom 27803010 5540-A-301 - AUGMENT FEMORAL 3 5MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-302 SUP Custom 27803010 5540-A-302 - AUGMENT FEMORAL 3 5MM TOT STABILIZED TRIATHLON RIGHT DISTAL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-401 SUP Custom 27803010 5540-A-401 - AUGMENT FEMORAL 4 5MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-402 SUP Custom 27803010 5540-A-402 - AUGMENT FEMORAL 4 5MM TOT STABILIZED TRIATHLON RIGHT DISTAL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-501 SUP Custom 27803010 5540-A-501 - AUGMENT FEMORAL 5 5MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-502 SUP Custom 27803010 5540-A-502 - AUGMENT FEMORAL 5 5MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-601 SUP Custom 27803010 5540-A-601 - AUGMENT FEMORAL 6 5MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-602 SUP Custom 27803010 5540-A-602 - AUGMENT FEMORAL 6 5MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-701 SUP Custom 27803010 5540-A-701 - AUGMENT FEMORAL 7 5MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-702 SUP Custom 27803010 5540-A-702 - AUGMENT FEMORAL 7 5MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-801 SUP Custom 27803010 5540-A-801 - AUGMENT FEMORAL 8 5MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5540-A-802 SUP Custom 27803010 5540-A-802 - AUGMENT FEMORAL 8 5MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-101 SUP Custom 27803010 5541-A-101 - AUGMENT FEMORAL 1 10MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-102 SUP Custom 27803010 5541-A-102 - AUGMENT FEMORAL 1 10MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-201 SUP Custom 27803010 5541-A-201 - AUGMENT FEMORAL 2 10MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-202 SUP Custom 27803010 5541-A-202 - AUGMENT FEMORAL 2 10MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-301 SUP Custom 27803010 5541-A-301 - AUGMENT FEMORAL 3 10MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-302 SUP Custom 27803010 5541-A-302 - AUGMENT FEMORAL 3 10MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-401 SUP Custom 27803010 5541-A-401 - AUGMENT FEMORAL 4 10MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-402 SUP Custom 27803010 5541-A-402 - AUGMENT FEMORAL 4 10MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-501 SUP Custom 27803010 5541-A-501 - AUGMENT FEMORAL 5 10MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-502 SUP Custom 27803010 5541-A-502 - AUGMENT FEMORAL 5 10MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-601 SUP Custom 27803010 5541-A-601 - AUGMENT FEMORAL 6 10MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-602 SUP Custom 27803010 5541-A-602 - AUGMENT FEMORAL 6 10MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-701 SUP Custom 27803010 5541-A-701 - AUGMENT FEMORAL 7 10MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-702 SUP Custom 27803010 5541-A-702 - AUGMENT FEMORAL 7 10MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-801 SUP Custom 27803010 5541-A-801 - AUGMENT FEMORAL 8 10MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5541-A-802 SUP Custom 27803010 5541-A-802 - AUGMENT FEMORAL 8 10MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-101 SUP Custom 27803010 5542-A-101 - AUGMENT FEMORAL 1 15MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-102 SUP Custom 27803010 5542-A-102 - AUGMENT FEMORAL 1 15MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-201 SUP Custom 27803010 5542-A-201 - AUGMENT FEMORAL 2 15MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-202 SUP Custom 27803010 5542-A-202 - AUGMENT FEMORAL 2 15MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-301 SUP Custom 27803010 5542-A-301 - AUGMENT FEMORAL 3 15MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-302 SUP Custom 27803010 5542-A-302 - AUGMENT FEMORAL 3 15MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-401 SUP Custom 27803010 5542-A-401 - AUGMENT FEMORAL 4 15MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-402 SUP Custom 27803010 5542-A-402 - AUGMENT FEMORAL 4 15MM TOT STABILIZE TRIATHLON KNEEL RIGHT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-501 SUP Custom 27803010 5542-A-501 - AUGMENT FEMORAL 5 15MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-502 SUP Custom 27803010 5542-A-502 - AUGMENT FEMORAL 5 15MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-601 SUP Custom 27803010 5542-A-601 - AUGMENT FEMORAL 6 15MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-602 SUP Custom 27803010 5542-A-602 - AUGMENT FEMORAL 6 15MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-701 SUP Custom 27803010 5542-A-701 - AUGMENT FEMORAL 7 15MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-702 SUP Custom 27803010 5542-A-702 - AUGMENT FEMORAL 7 15MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-801 SUP Custom 27803010 5542-A-801 - AUGMENT FEMORAL 8 15MM TOT STABILIZE TRIATHLON KNEE LEFT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5542-A-802 SUP Custom 27803010 5542-A-802 - AUGMENT FEMORAL 8 15MM TOT STABILIZE TRIATHLON KNEE RIGHT BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,831.38" "$1,831.38" $0.00 $0.00 $514.23 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5543-A-100 SUP Custom 27803010 5543-A-100 - AUGMENT FEMORAL 1 5MM TOT STABILIZE TRIATHLON KNEE POSTERIOR BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5543-A-200 SUP Custom 27803010 5543-A-200 - AUGMENT FEMORAL 2 5MM TOT STABILIZE TRIATHLON KNEE POSTERIOR BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5543-A-300 SUP Custom 27803010 5543-A-300 - AUGMENT FEMORAL 3 5MM TOT STABILIZED TRIATHLON POSTERIOR BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5543-A-400 SUP Custom 27803010 5543-A-400 - AUGMENT FEMORAL 4 5MM TOT STABILIZE TRIATHLON KNEE POSTERIOR BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5543-A-500 SUP Custom 27803010 5543-A-500 - AUGMENT FEMORAL 5 5MM TOT STABILIZE TRIATHLON KNEE POSTERIOR BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5543-A-600 SUP Custom 27803010 5543-A-600 - AUGMENT FEMORAL 6 5MM TOT STABILIZE TRIATHLON KNEE POSTERIOR BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5543-A-700 SUP Custom 27803010 5543-A-700 - AUGMENT FEMORAL 7 5MM TOT STABILIZE TRIATHLON KNEE POSTERIOR BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5543-A-800 SUP Custom 27803010 5543-A-800 - AUGMENT FEMORAL 8 5MM TOT STABILIZE TRIATHLON KNEE POSTERIOR BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5544-A-100 SUP Custom 27803010 5544-A-100 - AUGMENT FEMORAL 1 10MM TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5544-A-200 SUP Custom 27803010 5544-A-200 - AUGMENT FEMORAL 2 10MM TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5544-A-300 SUP Custom 27803010 5544-A-300 - AUGMENT FEMORAL 3 10MM TOT STABILIZED BACKWARD BLOCK BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5544-A-400 SUP Custom 27803010 5544-A-400 - AUGMENT FEMORAL 4 10MM TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5544-A-500 SUP Custom 27803010 5544-A-500 - AUGMENT FEMORAL 5 10MM TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5544-A-600 SUP Custom 27803010 5544-A-600 - AUGMENT FEMORAL 6 10MM TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5544-A-700 SUP Custom 27803010 5544-A-700 - AUGMENT FEMORAL 7 10MM TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5544-A-800 SUP Custom 27803010 5544-A-800 - AUGMENT FEMORAL 8 10MM TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,352.50 " "$1,740.85" $0.00 "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,746.03" "$1,746.03" $0.00 $0.00 $490.26 $0.00 $0.00 $0.00 $0.00 "$1,176.25" "$1,863.18" "$1,882.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-101 SUP Custom 27803010 5545-A-101 - AUGMENT TIBIAL 1 5MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-102 SUP Custom 27803010 5545-A-102 - AUGMENT TIBIAL 1 5MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-201 SUP Custom 27803010 5545-A-201 - AUGMENT TIBIAL 2 5MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-202 SUP Custom 27803010 5545-A-202 - AUGMENT TIBIAL 2 5MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-301 SUP Custom 27803010 5545-A-301 - AUGMENT TIBIAL 3 5MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-302 SUP Custom 27803010 5545-A-302 - AUGMENT TIBIAL 3 5MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-401 SUP Custom 27803010 5545-A-401 - AUGMENT TIBIAL 4 5MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-402 SUP Custom 27803010 5545-A-402 - AUGMENT TIBIAL 4 5MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-501 SUP Custom 27803010 5545-A-501 - AUGMENT TIBIAL 5 5MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-502 SUP Custom 27803010 5545-A-502 - AUGMENT TIBIAL 5 5MM TRIATHLON RIGHT MEDIAL LEFT LATERAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-601 SUP Custom 27803010 5545-A-601 - AUGMENT TIBIAL 6 5MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-602 SUP Custom 27803010 5545-A-602 - AUGMENT TIBIAL 6 5MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-701 SUP Custom 27803010 5545-A-701 - AUGMENT TIBIAL 7 5MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-702 SUP Custom 27803010 5545-A-702 - AUGMENT TIBIAL 7 5MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-801 SUP Custom 27803010 5545-A-801 - AUGMENT TIBIAL 8 5MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5545-A-802 SUP Custom 27803010 5545-A-802 - AUGMENT TIBIAL 8 5MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 $0.00 $0.00 $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-101 SUP Custom 27803010 5546-A-101 - AUGMENT TIBIAL 1 10MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-102 SUP Custom 27803010 5546-A-102 - AUGMENT TIBIAL 1 10MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-201 SUP Custom 27803010 5546-A-201 - AUGMENT TIBIAL 2 10MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-202 SUP Custom 27803010 5546-A-202 - AUGMENT TIBIAL 2 10MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-301 SUP Custom 27803010 5546-A-301 - AUGMENT TIBIAL 3 10MM TOT STABILIZED FIXING SCREW TRIATHLON BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-302 SUP Custom 27803010 5546-A-302 - AUGMENT TIBIAL 3 10MM TOAL STABILIZED TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-401 SUP Custom 27803010 5546-A-401 - AUGMENT TIBIAL 4 10MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-402 SUP Custom 27803010 5546-A-402 - AUGMENT TIBIAL 4 10MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-501 SUP Custom 27803010 5546-A-501 - AUGMENT TIBIAL 5 10MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-502 SUP Custom 27803010 5546-A-502 - AUGMENT TIBIAL 5 10MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-601 SUP Custom 27803010 5546-A-601 - AUGMENT TIBIAL 6 10MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-602 SUP Custom 27803010 5546-A-602 - AUGMENT TIBIAL 6 10MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-701 SUP Custom 27803010 5546-A-701 - AUGMENT TIBIAL 7 10MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-702 SUP Custom 27803010 5546-A-702 - AUGMENT TIBIAL 7 10MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-801 SUP Custom 27803010 5546-A-801 - AUGMENT TIBIAL 8 10MM TOT STABILIZE TRIATHLON LEFT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5546-A-802 SUP Custom 27803010 5546-A-802 - AUGMENT TIBIAL 8 10MM TOT STABILIZE TRIATHLON RIGHT MEDIAL BOTH IP/OP "$2,095.00 " "$1,550.30" $0.00 "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.91" "$1,554.91" $0.00 $0.00 $436.60 $0.00 $0.00 $0.00 $0.00 "$1,047.50" "$1,659.24" "$1,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-110 SUP HCPCS C1776 5549-A-110 - AUGMENT TIB A CONE STRL LF TRTHLN SMTR TRITANIUM BOTH IP/OP "$8,495.00 " "$6,286.30" $0.00 "$6,796.00" "$3,822.75" "$3,822.75" $0.00 $0.00 $0.00 "$1,770.57" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,770.36" $0.00 "$4,188.04" "$4,188.04" $0.00 "$4,247.50" "$6,728.04" "$6,796.00" $0.00 $0.00 "$1,329.47" $0.00 $0.00 "$1,352.40" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-120 SUP HCPCS C1776 5549-A-120 - AUGMENT TIB B CONE STRL LF TRTHLN SMTR TRITANIUM BOTH IP/OP "$8,495.00 " "$6,286.30" $0.00 "$6,796.00" "$3,822.75" "$3,822.75" $0.00 $0.00 $0.00 "$1,770.57" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,770.36" $0.00 "$4,188.04" "$4,188.04" $0.00 "$4,247.50" "$6,728.04" "$6,796.00" $0.00 $0.00 "$1,329.47" $0.00 $0.00 "$1,352.40" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-140 SUP HCPCS C1776 5549-A-140 - AUGMENT TIB D CONE TRTHLN SMTR REV TRITANIUM KN BOTH IP/OP "$8,495.00 " "$6,286.30" $0.00 "$6,796.00" "$3,822.75" "$3,822.75" $0.00 $0.00 $0.00 "$1,770.57" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,770.36" $0.00 "$4,188.04" "$4,188.04" $0.00 "$4,247.50" "$6,728.04" "$6,796.00" $0.00 $0.00 "$1,329.47" $0.00 $0.00 "$1,352.40" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-150 SUP HCPCS C1776 5549-A-150 - AUGMENT TIB E CONE TRTHLN SMTR REV TRITANIUM KN BOTH IP/OP "$8,495.00 " "$6,286.30" $0.00 "$6,796.00" "$3,822.75" "$3,822.75" $0.00 $0.00 $0.00 "$1,770.57" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,770.36" $0.00 "$4,188.04" "$4,188.04" $0.00 "$4,247.50" "$6,728.04" "$6,796.00" $0.00 $0.00 "$1,329.47" $0.00 $0.00 "$1,352.40" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-221 SUP HCPCS C1776 5549-A-221 - AUGMENT TIB B CONE TRTHLN ASYM TRITANIUM KN LT MDL RL REV BOTH IP/OP "$9,085.00 " "$6,722.90" $0.00 "$7,268.00" "$4,088.25" "$4,088.25" $0.00 $0.00 $0.00 "$1,893.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.31" $0.00 "$4,478.91" "$4,478.91" $0.00 "$4,542.50" "$7,195.32" "$7,268.00" $0.00 $0.00 "$1,421.80" $0.00 $0.00 "$1,446.33" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-222 SUP HCPCS C1776 5549-A-222 - AUGMENT TIB B CONE STRL TRTHLN ASYM TRITANIUM KN RMLL BOTH IP/OP "$9,085.00 " "$6,722.90" $0.00 "$7,268.00" "$4,088.25" "$4,088.25" $0.00 $0.00 $0.00 "$1,893.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.31" $0.00 "$4,478.91" "$4,478.91" $0.00 "$4,542.50" "$7,195.32" "$7,268.00" $0.00 $0.00 "$1,421.80" $0.00 $0.00 "$1,446.33" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-231 SUP HCPCS C1776 5549-A-231 - AUGMENT TIB C CONE TRTHLN ASYM TRITANIUM KN LT MDL RL REV BOTH IP/OP "$9,085.00 " "$6,722.90" $0.00 "$7,268.00" "$4,088.25" "$4,088.25" $0.00 $0.00 $0.00 "$1,893.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.31" $0.00 "$4,478.91" "$4,478.91" $0.00 "$4,542.50" "$7,195.32" "$7,268.00" $0.00 $0.00 "$1,421.80" $0.00 $0.00 "$1,446.33" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-232 SUP HCPCS C1776 5549-A-232 - AUGMENT TIB C CONE TRTHLN ASYM REV TRITANIUM KN RMLL BOTH IP/OP "$9,085.00 " "$6,722.90" $0.00 "$7,268.00" "$4,088.25" "$4,088.25" $0.00 $0.00 $0.00 "$1,893.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.31" $0.00 "$4,478.91" "$4,478.91" $0.00 "$4,542.50" "$7,195.32" "$7,268.00" $0.00 $0.00 "$1,421.80" $0.00 $0.00 "$1,446.33" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-241 SUP HCPCS C1776 5549-A-241 - AUGMENT TIB D CONE TRTHLN ASYM TRITANIUM KN LT MDL RL REV BOTH IP/OP "$9,085.00 " "$6,722.90" $0.00 "$7,268.00" "$4,088.25" "$4,088.25" $0.00 $0.00 $0.00 "$1,893.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.31" $0.00 "$4,478.91" "$4,478.91" $0.00 "$4,542.50" "$7,195.32" "$7,268.00" $0.00 $0.00 "$1,421.80" $0.00 $0.00 "$1,446.33" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-242 SUP HCPCS C1776 5549-A-242 - AUGMENT TIB D CONE TRTHLN ASYM TRITANIUM KN RMLL REV SYS BOTH IP/OP "$9,085.00 " "$6,722.90" $0.00 "$7,268.00" "$4,088.25" "$4,088.25" $0.00 $0.00 $0.00 "$1,893.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.31" $0.00 "$4,478.91" "$4,478.91" $0.00 "$4,542.50" "$7,195.32" "$7,268.00" $0.00 $0.00 "$1,421.80" $0.00 $0.00 "$1,446.33" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-251 SUP HCPCS C1776 5549-A-251 - AUGMENT TIB E CONE TRTHLN ASYM REV TRITANIUM KN LT MDL RL BOTH IP/OP "$9,085.00 " "$6,722.90" $0.00 "$7,268.00" "$4,088.25" "$4,088.25" $0.00 $0.00 $0.00 "$1,893.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.31" $0.00 "$4,478.91" "$4,478.91" $0.00 "$4,542.50" "$7,195.32" "$7,268.00" $0.00 $0.00 "$1,421.80" $0.00 $0.00 "$1,446.33" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-252 SUP HCPCS C1776 5549-A-252 - AUGMENT TIB E CONE TRTHLN ASYM REV TRITANIUM KN RMLL BOTH IP/OP "$9,085.00 " "$6,722.90" $0.00 "$7,268.00" "$4,088.25" "$4,088.25" $0.00 $0.00 $0.00 "$1,893.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.31" $0.00 "$4,478.91" "$4,478.91" $0.00 "$4,542.50" "$7,195.32" "$7,268.00" $0.00 $0.00 "$1,421.80" $0.00 $0.00 "$1,446.33" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-321 SUP HCPCS C1776 5549-A-321 - AUGMENT FEM 1 2 CONE TRTHLN TRITANIUM KN LT REV SYS BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-322 SUP HCPCS C1776 5549-A-322 - AUGMENT FEM 1 2 CONE TRTHLN REV TRITANIUM KN RT BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-331 SUP HCPCS C1776 5549-A-331 - AUGMENT FEM 3 CONE TRTHLN REV TRITANIUM KN LT BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-332 SUP HCPCS C1776 5549-A-332 - AUGMENT FEM 3 CONE TRTHLN TRITANIUM KN RT REV SYS BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-341 SUP HCPCS C1776 5549-A-341 - AUGMENT FEM 4 CONE TRTHLN REV TRITANIUM KN LT BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-342 SUP HCPCS C1776 5549-A-342 - AUGMENT FEM 4 CONE TRTHLN TRITANIUM KN RT REV SYS BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-351 SUP HCPCS C1776 5549-A-351 - AUGMENT FEM 5 CONE TRTHLN TRITANIUM KN LT REV SYS BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-352 SUP HCPCS C1776 5549-A-352 - AUGMENT FEM 5 CONE TRTHLN REV TRITANIUM KN RT BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-361 SUP HCPCS C1776 5549-A-361 - AUGMENT FEM 6 CONE TRTHLN REV TRITANIUM KN LT BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-362 SUP HCPCS C1776 5549-A-362 - AUGMENT FEM 6 CONE TRTHLN REV TRITANIUM KN RT BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-371 SUP HCPCS C1776 5549-A-371 - AUGMENT FEM 7 8 CONE TRTHLN TRITANIUM KN LT REV SYS BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5549-A-372 SUP HCPCS C1776 5549-A-372 - AUGMENT FEM 7 8 CONE TRTHLN REV TRITANIUM KN RT BOTH IP/OP "$9,675.00 " "$7,159.50" $0.00 "$7,740.00" "$4,353.75" "$4,353.75" $0.00 $0.00 $0.00 "$2,016.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,016.27" $0.00 "$4,769.78" "$4,769.78" $0.00 "$4,837.50" "$7,662.60" "$7,740.00" $0.00 $0.00 "$1,514.14" $0.00 $0.00 "$1,540.26" $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-278 SUP Custom 27803010 5550-G-278 - COMPONENT PATLR 27MM 8MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-278-E SUP HCPCS C1776 5550-G-278-E - COMPONENT PTLR 27MM 8MM STRL TRTHLN SMTR KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-298 SUP Custom 27803010 5550-G-298 - COMPONENT PATLR 29MM 8MM SYMMETRIC TRIATHLON X3 TOT KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-298-E SUP HCPCS C1776 5550-G-298-E - COMPONENT PTLR 29MM 8MM STRL TRTHLN SMTR KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-319 SUP Custom 27803010 5550-G-319 - COMPONENT PATLR 31MM 9MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-319-E SUP HCPCS C1776 5550-G-319-E - COMPONENT PTLR 31MM 9MM STRL TRTHLN SMTR KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-339 SUP Custom 27803010 5550-G-339 - COMPONENT PATLR 33MM 9MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-339-E SUP HCPCS C1776 5550-G-339-E - COMPONENT PTLR 33MM 9MM STRL TRTHLN SMTR KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-360 SUP Custom 27803010 5550-G-360 - COMPONENT PATLR 36MM 10MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-360-E SUP HCPCS C1776 5550-G-360-E - COMPONENT PTLR 36MM 10MM STRL TRTHLN SMTR KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-391 SUP Custom 27803010 5550-G-391 - COMPONENT PATLR 39MM 11MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-G-391-E SUP HCPCS C1776 5550-G-391-E - COMPONENT PTLR 39MM 11MM STRL TRTHLN SMTR KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5550-L-278 SUP Custom 27803010 5550-L-278 - COMPONENT PATLR 27MM 8MM SYMMETRIC TRIATHLON KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-L-298 SUP Custom 27803010 5550-L-298 - COMPONENT PATLR 29MM 8MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-L-319 SUP Custom 27803010 5550-L-319 - COMPONENT PATLR 31MM 9MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-L-339 SUP Custom 27803010 5550-L-339 - COMPONENT PATLR 33MM 9MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-L-360 SUP Custom 27803010 5550-L-360 - COMPONENT PATLR 36MM 10MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5550-L-391 SUP Custom 27803010 5550-L-391 - COMPONENT PATLR 39MM 11MM SYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-299 SUP Custom 27803010 5551-G-299 - COMPONENT PATLR ASYMMETRIC 29MM 9MM TRIATHLON X3 TOT KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-299-E SUP HCPCS C1776 5551-G-299-E - COMPONENT PTLR 29MM 9MM STRL TRTHLN ASYM KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-320 SUP Custom 27803010 5551-G-320 - COMPONENT PATLR ASYMMETRIC 32MM 10MM TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-320-E SUP HCPCS C1776 5551-G-320-E - COMPONENT PTLR 32MM 10MM STRL TRTHLN ASYM KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-350 SUP Custom 27803010 5551-G-350 - COMPONENT PATLR 35MM 10MM ASYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-350-E SUP HCPCS C1776 5551-G-350-E - COMPONENT PTLR 35MM 10MM STRL TRTHLN ASYM KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-381 SUP Custom 27803010 5551-G-381 - COMPONENT PATLR 38MM 11MM ASYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-381-E SUP HCPCS C1776 5551-G-381-E - COMPONENT PTLR 38MM 11MM STRL TRTHLN ASYM KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-401 SUP Custom 27803010 5551-G-401 - COMPONENT PATLR 40MM 11MM ASYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-G-401-E SUP HCPCS C1776 5551-G-401-E - COMPONENT PTLR 40MM 11MM STRL TRTHLN ASYM KN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 5551-L-299 SUP Custom 27803010 5551-L-299 - COMPONENT PATLR 29MM 9MM ASYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-L-320 SUP Custom 27803010 5551-L-320 - COMPONENT PATLR 32MM 10MM ASYMMETRIC TRIATHLON KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-L-350 SUP Custom 27803010 5551-L-350 - COMPONENT PATLR 35MM 10MM ASYMMETRIC TRIATHLON KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-L-381 SUP Custom 27803010 5551-L-381 - COMPONENT PATLR 38MM 11MM ASYMMETRIC TRIATHLON BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5551-L-401 SUP Custom 27803010 5551-L-401 - COMPONENT PATLR 40MM 11MM ASYMMETRIC TRIATHLON X3 KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5552-L-299 SUP HCPCS C1776 5552-L-299 - COMPONENT PTLR 29MM 9MM TRITANIUM ASYM MTL KN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5552-L-320 SUP HCPCS C1776 5552-L-320 - COMPONENT PTLR 32MM 10MM ASYM TRITANIUM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5552-L-350 SUP HCPCS C1776 5552-L-350 - COMPONENT PTLR 35MM 10MM ASYM TRITANIUM MTL KN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5552-L-381 SUP HCPCS C1776 5552-L-381 - COMPONENT PTLR 38MM 11MM TRITANIUM ASYM MTL KN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5552-L-401 SUP HCPCS C1776 5552-L-401 - COMPONENT PTLR 40MM 11MM TRITANIUM ASYM MTL KN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5554-L-320 SUP Custom 27803010 5554-L-320 - COMPONENT PATLR 32MM 10MM ASYMMETRIC METAL BACKED BEADED BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5554-L-350 SUP Custom 27803010 5554-L-350 - COMPONENT PATLR 35MM BEAD BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5554-L-381 SUP Custom 27803010 5554-L-381 - COMPONENT PATLR 38MM 11MM ASYMMETRIC METAL BACKED BEADED BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5554-L-401 SUP Custom 27803010 5554-L-401 - COMPONENT PATLR 40MM BEAD TRIATHLON PERI-APATITE KNEE BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-2901 SUP Custom 27203010 5555-2901 - BLOCK CUT TRTHLN PRCS BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $44.50 $70.49 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-2902 SUP Custom 27203010 5555-2902 - BLOCK CUT TRTHLN PRCS BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $44.50 $70.49 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-2903 SUP Custom 27203010 5555-2903 - BLOCK CUT TRTHLN PRCS BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $44.50 $70.49 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-2904 SUP Custom 27203010 5555-2904 - BLOCK CUT TRTHLN PRCS BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $44.50 $70.49 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-2905 SUP Custom 27203010 5555-2905 - BLOCK CUT TRTHLN PRCS BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $44.50 $70.49 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-2906 SUP Custom 27203010 5555-2906 - BLOCK CUT TRTHLN PRCS BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $44.50 $70.49 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-2907 SUP Custom 27203010 5555-2907 - BLOCK CUT TRTHLN PRCS BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $44.50 $70.49 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-2908 SUP Custom 27203010 5555-2908 - BLOCK CUT TRTHLN PRCS BOTH IP/OP $89.00 $65.86 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $44.50 $70.49 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3201 SUP Custom 27203010 5555-3201 - SET TRAUMA FIX TIB KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3202 SUP Custom 27203010 5555-3202 - SET TRAUMA FIX TIB KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3203 SUP Custom 27203010 5555-3203 - SET TRAUMA FIX 3 TIB PRCS PREP KIT CR STD BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3204 SUP Custom 27203010 5555-3204 - SET TRAUMA FIX 4 STD TIB CRUC RET PRCS PREP KIT TRTHLN BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3205 SUP Custom 27203010 5555-3205 - SET ORTH TRTHLN 5 PRP BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3206 SUP Custom 27203010 5555-3206 - KIT PRP TRTHLN 6 PRCS TIB CRUC RET STD BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3207 SUP Custom 27203010 5555-3207 - SET TRAUMA FIX 7 STD TIB CRUC RET PRCS PREP KIT TRTHLN BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3208 SUP HCPCS C1713 5555-3208 - SYSTEM BONE CMNT PRP KIT TIB BIOPREP BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $75.60 $75.60 $0.00 $0.00 $0.00 $35.02 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $99.37 $99.37 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $26.29 $0.00 $0.00 $26.75 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3301 SUP Custom 27203010 5555-3301 - SET TRAUMA FIX TIB KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3302 SUP Custom 27203010 5555-3302 - SET TRAUMA FIX TIB KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3303 SUP Custom 27203010 5555-3303 - SET TRAUMA FIX TIB KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3305 SUP Custom 27203010 5555-3305 - SET ORTH TRTHLN ECT 5 PRP BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3306 SUP Custom 27203010 5555-3306 - SET TRAUMA FIX TIB KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3307 SUP Custom 27203010 5555-3307 - SET TRAUMA FIX TIB KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3308 SUP Custom 27203010 5555-3308 - SET TRAUMA FIX TIB KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $126.00 $93.24 $0.00 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $0.00 $0.00 $0.00 $63.00 $99.79 $100.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3501 SUP Custom 27203010 5555-3501 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.56 $136.56 $0.00 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3502 SUP Custom 27203010 5555-3502 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.56 $136.56 $0.00 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3503 SUP HCPCS C1713 5555-3503 - SYSTEM BONE CMNT PREP KIT TIB 3 BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $82.80 $82.80 $0.00 $0.00 $0.00 $38.35 $136.56 $136.56 $0.00 $0.00 $38.35 $0.00 $108.84 $108.84 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $28.80 $0.00 $0.00 $29.29 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3504 SUP Custom 27203010 5555-3504 - SET TRAUMA FIX 4 STD TIB PS PRCS PREP KIT TRTHLN BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.56 $136.56 $0.00 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3505 SUP Custom 27203010 5555-3505 - SET TRAUMA FIX 5 STD TIB PS PRCS PREP KIT TRTHLN BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.56 $136.56 $0.00 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3506 SUP Custom 27203010 5555-3506 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.56 $136.56 $0.00 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3507 SUP Custom 27203010 5555-3507 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.56 $136.56 $0.00 $0.00 $38.35 $0.00 $0.00 $0.00 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3508 SUP HCPCS C1713 5555-3508 - SYSTEM BONE CMNT PREP KIT TIB 8 BOTH IP/OP $184.00 $136.16 $0.00 $147.20 $82.80 $82.80 $0.00 $0.00 $0.00 $38.35 $136.56 $136.56 $0.00 $0.00 $38.35 $0.00 $108.84 $108.84 $0.00 $92.00 $145.73 $147.20 $0.00 $0.00 $28.80 $0.00 $0.00 $29.29 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3701 SUP Custom 27803010 5555-3701 - CMPNT TIB TRTHLN KNEE PS BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3702 SUP Custom 27803010 5555-3702 - CMPNT TIB TRTHLN KNEE PS BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3703 SUP Custom 27203010 5555-3703 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3704 SUP Custom 27203010 5555-3704 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3705 SUP Custom 27203010 5555-3705 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3706 SUP Custom 27203010 5555-3706 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3707 SUP Custom 27203010 5555-3707 - SET TRAUMA FIX TIB KNEE PS PRCS TRTHLN BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-3708 SUP Custom 27803010 5555-3708 - CMPNT TIB TRTHLN KNEE PS BOTH IP/OP $158.00 $116.92 $0.00 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.27 $117.27 $0.00 $0.00 $32.93 $0.00 $0.00 $0.00 $0.00 $79.00 $125.14 $126.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4201 SUP Custom 27203010 5555-4201 - SET TRAUMA FIX FEM KNEE CRUC RET PRCS TRTHLN BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4202 SUP Custom 27203010 5555-4202 - KIT THR TRTHLN 2 CRUC RET BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4203 SUP Custom 27203010 5555-4203 - SET ORTH TRTHLN 3 FEM PRP BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4204 SUP Custom 27203010 5555-4204 - SET TRAUMA FIX 4 FEM CRUC RET PRCS PREP KIT TRTHLN BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4205 SUP Custom 27203010 5555-4205 - SET ORTH TRTHLN 5 TIB PRP BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4206 SUP Custom 27203010 5555-4206 - SET TRAUMA FIX 6 FEM CRUC RET PRCS PREP KIT TRTHLN BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4207 SUP Custom 27203010 5555-4207 - KIT PRP TRTHLN 7 PRCS FEM CRUC RET STD BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4208 SUP HCPCS C1713 5555-4208 - SYSTEM BONE CMNT PRP KIT FEM BIOPREP BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $141.75 $141.75 $0.00 $0.00 $0.00 $65.65 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $186.32 $186.32 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $49.30 $0.00 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4301 SUP Custom 27203010 5555-4301 - TRIATHLON PS PRECISION FEMORAL PREP KIT SIZE 1 BOTH IP/OP $341.00 $252.34 $0.00 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.09 $253.09 $0.00 $0.00 $71.06 $0.00 $0.00 $0.00 $0.00 $170.50 $270.07 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4302 SUP Custom 27203010 5555-4302 - SET TRAUMA FIX FEM KNEE PS PRCS TRTHLN BOTH IP/OP $341.00 $252.34 $0.00 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.09 $253.09 $0.00 $0.00 $71.06 $0.00 $0.00 $0.00 $0.00 $170.50 $270.07 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4303 SUP HCPCS C1713 5555-4303 - SYSTEM BONE CMNT PREP KIT FEM 3 BOTH IP/OP $341.00 $252.34 $0.00 $272.80 $153.45 $153.45 $0.00 $0.00 $0.00 $71.07 $253.09 $253.09 $0.00 $0.00 $71.06 $0.00 $201.70 $201.70 $0.00 $170.50 $270.07 $272.80 $0.00 $0.00 $53.37 $0.00 $0.00 $54.29 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4304 SUP Custom 27203010 5555-4304 - SET TRAUMA FIX 4 FEM PS PRCS PREP KIT TRTHLN BOTH IP/OP $341.00 $252.34 $0.00 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.09 $253.09 $0.00 $0.00 $71.06 $0.00 $0.00 $0.00 $0.00 $170.50 $270.07 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4305 SUP Custom 27203010 5555-4305 - SET TRAUMA FIX 5 FEM PS PRCS PREP KIT TRTHLN BOTH IP/OP $341.00 $252.34 $0.00 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.09 $253.09 $0.00 $0.00 $71.06 $0.00 $0.00 $0.00 $0.00 $170.50 $270.07 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4306 SUP HCPCS C1713 5555-4306 - SYSTEM BONE CMNT PREP KIT FEM 6 BOTH IP/OP $341.00 $252.34 $0.00 $272.80 $153.45 $153.45 $0.00 $0.00 $0.00 $71.07 $253.09 $253.09 $0.00 $0.00 $71.06 $0.00 $201.70 $201.70 $0.00 $170.50 $270.07 $272.80 $0.00 $0.00 $53.37 $0.00 $0.00 $54.29 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4307 SUP Custom 27203010 5555-4307 - SET TRAUMA FIX FEM KNEE PS PRCS TRTHLN BOTH IP/OP $341.00 $252.34 $0.00 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.09 $253.09 $0.00 $0.00 $71.06 $0.00 $0.00 $0.00 $0.00 $170.50 $270.07 $272.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4308 SUP HCPCS C1713 5555-4308 - SYSTEM BONE CMNT PREP KIT FEM 8 BOTH IP/OP $341.00 $252.34 $0.00 $272.80 $153.45 $153.45 $0.00 $0.00 $0.00 $71.07 $253.09 $253.09 $0.00 $0.00 $71.06 $0.00 $201.70 $201.70 $0.00 $170.50 $270.07 $272.80 $0.00 $0.00 $53.37 $0.00 $0.00 $54.29 $0.00 $0.00 $0.00 $0.00 $0.00 5555-4600 SUP Custom 27203010 5555-4600 - SYSTEM KN TRL 1-8 TRTHLN TIB BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5556-L-319 SUP HCPCS C1776 5556-L-319 - COMPONENT PTLR S 31X9MM STRL LF TRITANIUM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5556-L-339 SUP HCPCS C1776 5556-L-339 - COMPONENT PTLR 33MM 9MM SMTR TRITANIUM KN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5556-L-360 SUP HCPCS C1776 5556-L-360 - COMPONENT PTLR 36MM 10MM TRITANIUM SMTR MTL KN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5556-L-391 SUP HCPCS C1776 5556-L-391 - COMPONENT PTLR 39MM 11MM TRITANIUM SMTR MTL KN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-109 SUP Custom 27803010 5560-S-109 - STEM FEMORAL 9MM 50MM CEMENTED TOT STABILIZE TRIATHLON COCR BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-112 SUP Custom 27803010 5560-S-112 - STEM FEMORAL 12MM 50MM CEMENTED TOT STABILIZED TRIATHLON BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-115 SUP Custom 27803010 5560-S-115 - STEM FEMORAL 15MM 50MM CEMENTED TOT STABILIZE TRIATHLON COCR BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-209 SUP Custom 27803010 5560-S-209 - STEM FEMORAL 9MM 100MM CEMENTED TOT STABILIZE TRIATHLON COCR BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-212 SUP Custom 27803010 5560-S-212 - STEM FEMORAL 12MM 100MM CEMENTED TOT STABILIZED TRIATHLON BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-215 SUP Custom 27803010 5560-S-215 - STEM FEMORAL 15MM 100MM CEMENTED TOT STABILIZE TRIATHLON BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-309 SUP Custom 27803010 5560-S-309 - STEM FEMORAL 9MM 150MM CEMENTED TOT STABILIZE TRIATHLON COCR BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-312 SUP Custom 27803010 5560-S-312 - STEM FEMORAL 12MM 150MM CEMENTED TOT STABILIZE TRIATHLON BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5560-S-315 SUP Custom 27803010 5560-S-315 - STEM FEMORAL 15MM 150MM CEMENTED TOT STABILIZE TRIATHLON BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 556-25890 SUP HCPCS C1887 556-25890 - CATH GUID MPD CURVE 5FR .056IN 90CM PTFE ENV BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $447.98 $447.98 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-010 SUP Custom 27803010 5565-S-010 - STEM FEMORAL 10MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-011 SUP Custom 27803010 5565-S-011 - STEM FEMORAL 11MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-012 SUP Custom 27803010 5565-S-012 - STEM FEMORAL 12MM 100MM CEMENTLESS TOT STABILIZED TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-013 SUP Custom 27803010 5565-S-013 - STEM FEMORAL 13MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-014 SUP Custom 27803010 5565-S-014 - STEM FEMORAL 14MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-015 SUP Custom 27803010 5565-S-015 - STEM FEMORAL 15MM 100MM CEMENTLESS TOT STABILIZED TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-016 SUP Custom 27803010 5565-S-016 - STEM FEMORAL 16MM 105MM CEMENTLESS TOT STABILIZED TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-017 SUP Custom 27803010 5565-S-017 - STEM FEMORAL 17MM 100MM CEMENTLESS TOT STABILIZED TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-018 SUP Custom 27803010 5565-S-018 - STEM FEMORAL 18MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-019 SUP Custom 27803010 5565-S-019 - STEM FEMORAL 19MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-020 SUP Custom 27803010 5565-S-020 - STEM FEMORAL 20MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-021 SUP Custom 27803010 5565-S-021 - STEM FEMORAL 21MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-022 SUP Custom 27803010 5565-S-022 - STEM FEMORAL 22MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-023 SUP Custom 27803010 5565-S-023 - STEM FEMORAL 23MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-024 SUP Custom 27803010 5565-S-024 - STEM FEMORAL 24MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5565-S-025 SUP Custom 27803010 5565-S-025 - STEM FEMORAL 25MM 100MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,530.00 " "$1,872.20" $0.00 "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,877.77" "$1,877.77" $0.00 $0.00 $527.25 $0.00 $0.00 $0.00 $0.00 "$1,265.00" "$2,003.76" "$2,024.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-010 SUP Custom 27803010 5566-S-010 - STEM FEMORAL 20MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-011 SUP Custom 27803010 5566-S-011 - STEM FEMORAL 11MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-012 SUP Custom 27803010 5566-S-012 - STEM FEMORAL 12MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-013 SUP Custom 27803010 5566-S-013 - STEM FEMORAL 13MM 150MM CEMENTLESS TOT STABILIZED TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-014 SUP Custom 27803010 5566-S-014 - STEM FEMORAL 14MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-015 SUP Custom 27803010 5566-S-015 - STEM FEMORAL 15MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-016 SUP Custom 27803010 5566-S-016 - STEM FEMORAL 16MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-017 SUP Custom 27803010 5566-S-017 - STEM FEMORAL 17MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-018 SUP Custom 27803010 5566-S-018 - STEM FEMORAL 18MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-019 SUP Custom 27803010 5566-S-019 - STEM FEMORAL 19MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-020 SUP Custom 27803010 5566-S-020 - STEM FEMORAL 20MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-021 SUP Custom 27803010 5566-S-021 - STEM FEMORAL 21MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-022 SUP Custom 27803010 5566-S-022 - STEM FEMORAL 22MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-023 SUP Custom 27803010 5566-S-023 - STEM FEMORAL 23MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-024 SUP Custom 27803010 5566-S-024 - STEM FEMORAL 24MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5566-S-025 SUP Custom 27803010 5566-S-025 - STEM FEMORAL 25MM 150MM CEMENTLESS TOT STABILIZE TRIATHLON BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 $0.00 $0.00 $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5570-S-020 SUP Custom 27803010 5570-S-020 - ADAPTER FEMORAL 2MM OFFST TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,582.50 " "$1,911.05" $0.00 "$2,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,916.73" "$1,916.73" $0.00 $0.00 $538.19 $0.00 $0.00 $0.00 $0.00 "$1,291.25" "$2,045.34" "$2,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5570-S-040 SUP Custom 27803010 5570-S-040 - ADAPTER FEMORAL 4MM OFFST TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,582.50 " "$1,911.05" $0.00 "$2,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,916.73" "$1,916.73" $0.00 $0.00 $538.19 $0.00 $0.00 $0.00 $0.00 "$1,291.25" "$2,045.34" "$2,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5570-S-060 SUP Custom 27803010 5570-S-060 - ADAPTER FEMORAL 6MM OFFST TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,582.50 " "$1,911.05" $0.00 "$2,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,916.73" "$1,916.73" $0.00 $0.00 $538.19 $0.00 $0.00 $0.00 $0.00 "$1,291.25" "$2,045.34" "$2,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5570-S-080 SUP Custom 27803010 5570-S-080 - ADAPTER FEMORAL 8MM OFFST TOT STABILIZE TRIATHLON KNEE BOTH IP/OP "$2,582.50 " "$1,911.05" $0.00 "$2,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,916.73" "$1,916.73" $0.00 $0.00 $538.19 $0.00 $0.00 $0.00 $0.00 "$1,291.25" "$2,045.34" "$2,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5571-S-025 SUP Custom 27803010 5571-S-025 - EXTENSION STEM 25MM TOT STABILIZE TRIATHLON KNEE FEMUR BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 $0.00 $0.00 $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5571-S-050 SUP Custom 27803010 5571-S-050 - EXTENSION STEM 50MM TOT STABILIZE TRIATHLON KNEE FEMUR BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 $0.00 $0.00 $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5575-X-000 SUP HCPCS C1713 5575-X-000 - PEG FIX MODULAR TRIATHLON DISTAL FEMUR KNEE BOTH IP/OP $880.00 $651.20 $0.00 $704.00 $396.00 $396.00 $0.00 $0.00 $0.00 $183.41 $653.14 $653.14 $0.00 $0.00 $183.39 $0.00 $520.52 $520.52 $0.00 $440.00 $696.96 $704.00 $0.00 $0.00 $137.72 $0.00 $0.00 $140.10 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-48D SUP Custom 27803010 558-10-48D - SHELL ACETAB 48MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT D BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-50D SUP Custom 27803010 558-10-50D - SHELL ACETAB 50MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT D BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-52E SUP Custom 27803010 558-10-52E - SHELL ACETAB 52MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT E BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-54E SUP Custom 27803010 558-10-54E - SHELL ACETAB 54MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT E BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-56F SUP Custom 27803010 558-10-56F - SHELL ACETAB 56MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT F BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-58F SUP Custom 27803010 558-10-58F - SHELL ACETAB 58MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT F BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-60G SUP Custom 27803010 558-10-60G - SHELL ACETAB 60MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT G BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-62G SUP Custom 27803010 558-10-62G - SHELL ACETAB 62MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT G BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-64H SUP Custom 27803010 558-10-64H - SHELL ACETAB 62MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT H BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-66H SUP Custom 27803010 558-10-66H - SHELL ACETAB 66MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT H BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-68I SUP Custom 27803010 558-10-68I - SHELL ACETAB 68MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT 1 BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 558-10-70I SUP Custom 27803010 558-10-70I - SHELL ACETAB 70MM HIP PUREFIX HYDRXAPT ARC-2F TRDNT 1 BOTH IP/OP "$2,409.00 " "$1,782.66" $0.00 "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.96" "$1,787.96" $0.00 $0.00 $502.04 $0.00 $0.00 $0.00 $0.00 "$1,204.50" "$1,907.93" "$1,927.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5583-A3 SUP HCPCS C1725 5583-A3 - CATH ANGIO .035IN VERT CURVE 5FR .044IN 100CM BRAID SFTCH BOTH IP/OP $30.50 $22.57 $0.00 $24.40 $16.56 $16.56 $0.00 $0.00 $0.00 $6.36 $22.64 $22.64 $0.00 $0.00 $6.36 $0.00 $18.04 $18.04 $0.00 $15.25 $24.16 $24.40 $0.00 $0.00 $4.77 $0.00 $0.00 $4.86 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-016 SUP HCPCS C1713 5585-C-016 - SCREW BN 6.5MM 16MM TRTHLN VIT CANC T/K SYS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-020 SUP HCPCS C1713 5585-C-020 - SCREW BASEPLATE 6.5MM 20MM TRIATHLON VITALLIUM KNEE TIBIA BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-025 SUP HCPCS C1713 5585-C-025 - SCREW BASEPLATE 6.5MM 25MM TRIATHLON VITALLIUM KNEE TIBIA BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-030 SUP HCPCS C1713 5585-C-030 - SCREW BASEPLATE 6.5MM 30MM TRIATHLON VITALLIUM KNEE TIBIA BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-035 SUP HCPCS C1713 5585-C-035 - SCREW BASEPLATE 6.5MM 35MM TRIATHLON VITALLIUM KNEE TIBIA BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-040 SUP HCPCS C1713 5585-C-040 - SCREW BASEPLATE 6.5MM 40MM TRIATHLON VITALLIUM KNEE TIBIA BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-045 SUP HCPCS C1713 5585-C-045 - SCREW BASEPLATE 6.5MM 45MM TRIATHLON VITALLIUM KNEE TIBIA BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-050 SUP HCPCS C1713 5585-C-050 - SCREW BASEPLATE 6.5MM 50MM TRIATHLON VITALLIUM KNEE TIBIA BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-055 SUP HCPCS C1713 5585-C-055 - SCREW BN 6.5MM 55MM TRTHLN VIT CANC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5585-C-060 SUP HCPCS C1713 5585-C-060 - SCREW BN 6.5MM 60MM TRTHLN VIT CANC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 5591-B3 SUP HCPCS C1725 5591-B3 - CATHETER ANGIOGRAPHIC MOTARJEME CURVE 5FR .046IN 100CM BRAID BOTH IP/OP $29.65 $21.94 $0.00 $23.72 $16.10 $16.10 $0.00 $0.00 $0.00 $6.18 $22.01 $22.01 $0.00 $0.00 $6.18 $0.00 $17.54 $17.54 $0.00 $14.83 $23.48 $23.72 $0.00 $0.00 $4.64 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 55-969-30-04 SUP HCPCS C1713 55-969-30-04 - TRAY 30CM X30CM W/O LID FOR LEV 1 INST BOTH IP/OP "$2,412.78 " "$1,785.46" $0.00 "$1,930.22" "$1,085.75" "$1,085.75" $0.00 $0.00 $0.00 $502.88 "$1,790.76" "$1,790.76" $0.00 $0.00 $502.82 $0.00 "$1,427.16" "$1,427.16" $0.00 "$1,206.39" "$1,910.92" "$1,930.22" $0.00 $0.00 $377.60 $0.00 $0.00 $384.11 $0.00 $0.00 $0.00 $0.00 $0.00 55-969-98-04 SUP Custom 27803010 55-969-98-04 - LOCK MOD 3 STACK LEFT LEVEL 1 SYSTEM BOTH IP/OP $579.38 $428.74 $0.00 $463.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $430.01 $430.01 $0.00 $0.00 $120.74 $0.00 $0.00 $0.00 $0.00 $289.69 $458.87 $463.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 55-969-99-04 SUP Custom 27803010 55-969-99-04 - LOCK MOD 3 STACK RIGHT LEVEL 1 SYSTEM BOTH IP/OP $579.38 $428.74 $0.00 $463.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $430.01 $430.01 $0.00 $0.00 $120.74 $0.00 $0.00 $0.00 $0.00 $289.69 $458.87 $463.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 56-00400 SUP HCPCS C1713 56-00400 - WASHER SPINAL BICONCAVE 4MM SALZBURG TITANIUM BOTH IP/OP $74.08 $54.82 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $15.44 $54.98 $54.98 $0.00 $0.00 $15.44 $0.00 $43.82 $43.82 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 5601-0-901 SUP HCPCS C1713 5601-0-901 - TRAY STRL ICS SMTB PLT BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 5601-0-902 SUP HCPCS C1713 5601-0-902 - TRAY STRL ICS NAR PLT BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 5601-0-903 SUP HCPCS C1713 5601-0-903 - TRAY STRL ICS BRD PLT BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $136.13 $136.13 $0.00 $0.00 $0.00 $63.05 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $178.93 $178.93 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $47.34 $0.00 $0.00 $48.16 $0.00 $0.00 $0.00 $0.00 $0.00 5601-0-904 SUP Custom 27203010 5601-0-904 - CASE STRL LG SCR BOTH IP/OP $459.25 $339.85 $0.00 $367.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.86 $340.86 $0.00 $0.00 $95.71 $0.00 $0.00 $0.00 $0.00 $229.63 $363.73 $367.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5601-0-908 SUP Custom 27203010 5601-0-908 - TRAY STRL ICS DRILL TAPS BOTH IP/OP $481.25 $356.13 $0.00 $385.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $357.18 $357.18 $0.00 $0.00 $100.29 $0.00 $0.00 $0.00 $0.00 $240.63 $381.15 $385.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5601-0-909 SUP Custom 27203010 5601-0-909 - TRAY STRL ICS DRILL GD BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5601-1-900 SUP Custom 27203010 5601-1-900 - CASE STRL ICS FRAGMENTATION BOTH IP/OP $460.63 $340.87 $0.00 $368.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.88 $341.88 $0.00 $0.00 $95.99 $0.00 $0.00 $0.00 $0.00 $230.31 $364.82 $368.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5601-1-901 SUP Custom 27203010 5601-1-901 - RACK STRL SCR ICS SM BOTH IP/OP $726.00 $537.24 $0.00 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $538.84 $538.84 $0.00 $0.00 $151.30 $0.00 $0.00 $0.00 $0.00 $363.00 $574.99 $580.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5601-1-902 SUP HCPCS C1713 5601-1-902 - TRAY STRL ICS SM PLT BOTH IP/OP $481.25 $356.13 $0.00 $385.00 $216.56 $216.56 $0.00 $0.00 $0.00 $100.30 $357.18 $357.18 $0.00 $0.00 $100.29 $0.00 $284.66 $284.66 $0.00 $240.63 $381.15 $385.00 $0.00 $0.00 $75.32 $0.00 $0.00 $76.62 $0.00 $0.00 $0.00 $0.00 $0.00 5601-1-911 SUP Custom 27203010 5601-1-911 - TRAY STRL ICS SM TAP DRILL SLV BOTH IP/OP $357.50 $264.55 $0.00 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $265.34 $265.34 $0.00 $0.00 $74.50 $0.00 $0.00 $0.00 $0.00 $178.75 $283.14 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5601-1-912 SUP Custom 27203010 5601-1-912 - TRAY STRL ICS FORCEP BOTH IP/OP $357.50 $264.55 $0.00 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $265.34 $265.34 $0.00 $0.00 $74.50 $0.00 $0.00 $0.00 $0.00 $178.75 $283.14 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5601-1-913 SUP Custom 27203010 5601-1-913 - TRAY STRL ICS SM DRILL TAPS BOTH IP/OP $357.50 $264.55 $0.00 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $265.34 $265.34 $0.00 $0.00 $74.50 $0.00 $0.00 $0.00 $0.00 $178.75 $283.14 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-101 SUP HCPCS C1776 5610-F-101 - COMPONENT FEM 1 TRTHLN PRT KN RSRFC KN LT MDL RL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-102 SUP HCPCS C1776 5610-F-102 - COMPONENT FEM 1 TRTHLN RMLL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-201 SUP HCPCS C1776 5610-F-201 - COMPONENT FEM 2 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-202 SUP HCPCS C1776 5610-F-202 - COMPONENT FEM 2 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-301 SUP HCPCS C1776 5610-F-301 - COMPONENT FEM 3 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-302 SUP HCPCS C1776 5610-F-302 - COMPONENT FEM 3 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-401 SUP HCPCS C1776 5610-F-401 - COMPONENT FEM 4 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-402 SUP HCPCS C1776 5610-F-402 - COMPONENT FEM 4 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-501 SUP HCPCS C1776 5610-F-501 - COMPONENT FEM 5 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-502 SUP HCPCS C1776 5610-F-502 - COMPONENT FEM 5 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-601 SUP HCPCS C1776 5610-F-601 - COMPONENT FEM 6 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 5610-F-602 SUP HCPCS C1776 5610-F-602 - COMPONENT FEM 6 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$3,302.50 " "$2,443.85" $0.00 "$2,642.00" "$1,486.13" "$1,486.13" $0.00 $0.00 $0.00 $688.32 "$2,451.12" "$2,451.12" $0.00 $0.00 $688.24 $0.00 "$1,628.13" "$1,628.13" $0.00 "$1,651.25" "$2,615.58" "$2,642.00" $0.00 $0.00 $516.84 $0.00 $0.00 $525.76 $0.00 $0.00 $0.00 $0.00 $0.00 56-15904 SUP HCPCS C1713 56-15904 - SCREW BONE 1.5MM 4MM SELF DRILL UN3 CRANIOMAXILLOFACIAL BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 56-15934 SUP HCPCS C1713 56-15934 - SCREW BN 1.5MM 4MM NS LF UNV NEURO 3 SLF DRL AX STAB BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 56-15935 SUP HCPCS C1713 56-15935 - SCREW BN 1.5MM 5MM NS LF UNV NEURO 3 SLF DRL AX STAB BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 56-17005 SUP HCPCS C1713 56-17005 - SCREW BN 1.7MM 5MM ST AX STAB LWR PRFL BOTH IP/OP $120.38 $89.08 $0.00 $218.00 $122.63 $122.63 $0.00 $0.00 $0.00 $25.09 $89.34 $89.34 $0.00 $0.00 $25.09 $0.00 $71.20 $71.20 $0.00 $136.25 $215.82 $218.00 $0.00 $0.00 $42.65 $0.00 $0.00 $43.38 $0.00 $0.00 $0.00 $0.00 $0.00 56-17904 SUP HCPCS C1713 56-17904 - SCREW BN 1.9MM 5MM ER AX STAB LWR PRFL BOTH IP/OP $135.00 $99.90 $0.00 $244.00 $137.25 $137.25 $0.00 $0.00 $0.00 $28.14 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $79.85 $79.85 $0.00 $152.50 $241.56 $244.00 $0.00 $0.00 $47.73 $0.00 $0.00 $48.56 $0.00 $0.00 $0.00 $0.00 $0.00 56-19005 SUP HCPCS C1713 56-19005 - NAIL IM 11.5MM 36CM STRL TRGN 2M POST BW RT HINDFOOT FSN BOTH IP/OP $132.75 $98.24 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $27.67 $98.53 $98.53 $0.00 $0.00 $27.67 $0.00 $78.52 $78.52 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-101 SUP HCPCS C1776 5620-B-101 - BASEPLATE TIB 1 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-102 SUP HCPCS C1776 5620-B-102 - BASEPLATE TIB 1 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-201 SUP HCPCS C1776 5620-B-201 - BASEPLATE TIB 2 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-202 SUP HCPCS C1776 5620-B-202 - BASEPLATE TIB 2 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-301 SUP HCPCS C1776 5620-B-301 - BASEPLATE TIB 3 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-302 SUP HCPCS C1776 5620-B-302 - BASEPLATE TIB 3 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-401 SUP HCPCS C1776 5620-B-401 - BASEPLATE TIB 4 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-402 SUP HCPCS C1776 5620-B-402 - BASEPLATE TIB 4 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-501 SUP HCPCS C1776 5620-B-501 - BASEPLATE TIB 5 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-502 SUP HCPCS C1776 5620-B-502 - BASEPLATE TIB 5 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-601 SUP HCPCS C1776 5620-B-601 - BASEPLATE TIB 6 TRTHLN PRT KN RSRFC LT MDL RL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5620-B-602 SUP HCPCS C1776 5620-B-602 - BASEPLATE TIB 6 TRTHLN PRT KN RSRFC RMLL BOTH IP/OP "$2,402.50 " "$1,777.85" $0.00 "$1,922.00" "$1,081.13" "$1,081.13" $0.00 $0.00 $0.00 $500.74 "$1,783.14" "$1,783.14" $0.00 $0.00 $500.68 $0.00 "$1,421.08" "$1,421.08" $0.00 "$1,201.25" "$1,902.78" "$1,922.00" $0.00 $0.00 $375.99 $0.00 $0.00 $382.48 $0.00 $0.00 $0.00 $0.00 $0.00 5624-10/16L SUP HCPCS C1776 5624-10/16L - STEM HUMERAL 10MM 165MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$6,511.05 " "$4,818.18" $0.00 "$5,208.84" "$2,929.97" "$2,929.97" $0.00 $0.00 $0.00 "$1,357.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,356.90" $0.00 "$3,209.95" "$3,209.95" $0.00 "$3,255.53" "$5,156.75" "$5,208.84" $0.00 $0.00 "$1,018.98" $0.00 $0.00 "$1,036.56" $0.00 $0.00 $0.00 $0.00 $0.00 5624-10/20XL SUP HCPCS C1776 5624-10/20XL - STEM HUMERAL 10MM 205MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$7,003.95 " "$5,182.92" $0.00 "$5,603.16" "$3,151.78" "$3,151.78" $0.00 $0.00 $0.00 "$1,459.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,459.62" $0.00 "$3,452.95" "$3,452.95" $0.00 "$3,501.98" "$5,547.13" "$5,603.16" $0.00 $0.00 "$1,096.12" $0.00 $0.00 "$1,115.03" $0.00 $0.00 $0.00 $0.00 $0.00 5624-12/17L SUP HCPCS C1776 5624-12/17L - STEM HUMERAL 12MM 170MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$6,511.05 " "$4,818.18" $0.00 "$5,208.84" "$2,929.97" "$2,929.97" $0.00 $0.00 $0.00 "$1,357.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,356.90" $0.00 "$3,209.95" "$3,209.95" $0.00 "$3,255.53" "$5,156.75" "$5,208.84" $0.00 $0.00 "$1,018.98" $0.00 $0.00 "$1,036.56" $0.00 $0.00 $0.00 $0.00 $0.00 5624-12/21XL SUP HCPCS C1776 5624-12/21XL - STEM HUMERAL 12MM 210MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$7,003.95 " "$5,182.92" $0.00 "$5,603.16" "$3,151.78" "$3,151.78" $0.00 $0.00 $0.00 "$1,459.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,459.62" $0.00 "$3,452.95" "$3,452.95" $0.00 "$3,501.98" "$5,547.13" "$5,603.16" $0.00 $0.00 "$1,096.12" $0.00 $0.00 "$1,115.03" $0.00 $0.00 $0.00 $0.00 $0.00 5624-14/13 SUP HCPCS C1776 5624-14/13 - STEM HUMERAL 14 135MM CEMENTED ANATOMICAL COCR STERILE BOTH IP/OP "$5,769.05 " "$4,269.10" $0.00 "$4,615.24" "$2,596.07" "$2,596.07" $0.00 $0.00 $0.00 "$1,202.41" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,202.27" $0.00 "$2,844.14" "$2,844.14" $0.00 "$2,884.53" "$4,569.09" "$4,615.24" $0.00 $0.00 $902.86 $0.00 $0.00 $918.43 $0.00 $0.00 $0.00 $0.00 $0.00 5624-14/17L SUP HCPCS C1776 5624-14/17L - STEM HUMERAL 14MM 175MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$6,511.05 " "$4,818.18" $0.00 "$5,208.84" "$2,929.97" "$2,929.97" $0.00 $0.00 $0.00 "$1,357.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,356.90" $0.00 "$3,209.95" "$3,209.95" $0.00 "$3,255.53" "$5,156.75" "$5,208.84" $0.00 $0.00 "$1,018.98" $0.00 $0.00 "$1,036.56" $0.00 $0.00 $0.00 $0.00 $0.00 5624-14/21XL SUP HCPCS C1776 5624-14/21XL - STEM HUMERAL 14MM 215MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$7,003.95 " "$5,182.92" $0.00 "$5,603.16" "$3,151.78" "$3,151.78" $0.00 $0.00 $0.00 "$1,459.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,459.62" $0.00 "$3,452.95" "$3,452.95" $0.00 "$3,501.98" "$5,547.13" "$5,603.16" $0.00 $0.00 "$1,096.12" $0.00 $0.00 "$1,115.03" $0.00 $0.00 $0.00 $0.00 $0.00 5624-6/15L SUP HCPCS C1776 5624-6/15L - STEM HUMERAL 6MM 155MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$6,511.05 " "$4,818.18" $0.00 "$5,208.84" "$2,929.97" "$2,929.97" $0.00 $0.00 $0.00 "$1,357.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,356.90" $0.00 "$3,209.95" "$3,209.95" $0.00 "$3,255.53" "$5,156.75" "$5,208.84" $0.00 $0.00 "$1,018.98" $0.00 $0.00 "$1,036.56" $0.00 $0.00 $0.00 $0.00 $0.00 5624-6/19XL SUP HCPCS C1776 5624-6/19XL - STEM HUMERAL 6MM 195MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$7,003.95 " "$5,182.92" $0.00 "$5,603.16" "$3,151.78" "$3,151.78" $0.00 $0.00 $0.00 "$1,459.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,459.62" $0.00 "$3,452.95" "$3,452.95" $0.00 "$3,501.98" "$5,547.13" "$5,603.16" $0.00 $0.00 "$1,096.12" $0.00 $0.00 "$1,115.03" $0.00 $0.00 $0.00 $0.00 $0.00 5624-8/16L SUP HCPCS C1776 5624-8/16L - STEM HUMERAL 8MM 160MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$6,511.05 " "$4,818.18" $0.00 "$5,208.84" "$2,929.97" "$2,929.97" $0.00 $0.00 $0.00 "$1,357.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,356.90" $0.00 "$3,209.95" "$3,209.95" $0.00 "$3,255.53" "$5,156.75" "$5,208.84" $0.00 $0.00 "$1,018.98" $0.00 $0.00 "$1,036.56" $0.00 $0.00 $0.00 $0.00 $0.00 5624-8/20XL SUP HCPCS C1776 5624-8/20XL - STEM HUMERAL 8MM 200MM CEMENTED IMPLANT COCR STERILE BOTH IP/OP "$7,003.95 " "$5,182.92" $0.00 "$5,603.16" "$3,151.78" "$3,151.78" $0.00 $0.00 $0.00 "$1,459.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,459.62" $0.00 "$3,452.95" "$3,452.95" $0.00 "$3,501.98" "$5,547.13" "$5,603.16" $0.00 $0.00 "$1,096.12" $0.00 $0.00 "$1,115.03" $0.00 $0.00 $0.00 $0.00 $0.00 56-25000 SUP HCPCS C1713 56-25000 - SCREW BONE FASTENING TITANIUM CONDYLE MANDIB BOTH IP/OP $246.50 $182.41 $0.00 $448.00 $252.00 $252.00 $0.00 $0.00 $0.00 $51.38 $182.95 $182.95 $0.00 $0.00 $51.37 $0.00 $145.80 $145.80 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $89.15 $0.00 $0.00 $0.00 $0.00 $0.00 56-25001 SUP Custom 27803010 56-25001 - PROSTHESIS TEMPORARY MARX CONDYLE LEFT BOTH IP/OP "$2,382.23 " "$1,762.85" $0.00 "$3,816.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,768.09" "$1,768.09" $0.00 $0.00 $496.46 $0.00 $0.00 $0.00 $0.00 "$2,385.00" "$3,777.84" "$3,816.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 56-25002 SUP Custom 27803010 56-25002 - PROSTHESIS TEMPORARY MARX CONDYLE RIGHT BOTH IP/OP "$2,382.23 " "$1,762.85" $0.00 "$3,816.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,768.09" "$1,768.09" $0.00 $0.00 $496.46 $0.00 $0.00 $0.00 $0.00 "$2,385.00" "$3,777.84" "$3,816.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-108 SUP HCPCS C1776 5630-G-108 - INSERT TIB 1 8MM TRTHLN PRT KN RSRFC X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-109 SUP HCPCS C1776 5630-G-109 - INSERT TIB 1 9MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-110 SUP HCPCS C1776 5630-G-110 - INSERT TIB 1 10MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-112 SUP HCPCS C1776 5630-G-112 - INSERT TIB 1 12MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-120 SUP HCPCS C1776 5630-G-120 - INSERT TIB 1 10MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-122 SUP HCPCS C1776 5630-G-122 - INSERT TIB 1 12MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-128 SUP HCPCS C1776 5630-G-128 - INSERT TIB 1 8MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-129 SUP HCPCS C1776 5630-G-129 - INSERT TIB 1 9MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-208 SUP HCPCS C1776 5630-G-208 - INSERT TIB 2 8MM TRTHLN PRT KN RSRFC X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-209 SUP HCPCS C1776 5630-G-209 - INSERT TIB 2 9MM TRTHLN STRG KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-210 SUP HCPCS C1776 5630-G-210 - INSERT TIB 2 10MM TRTHLN PRT KN RSRFC X3 LT MDL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-212 SUP HCPCS C1776 5630-G-212 - INSERT TIB 2 12MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-220 SUP HCPCS C1776 5630-G-220 - INSERT TIB 2 10MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-222 SUP HCPCS C1776 5630-G-222 - INSERT TIB 2 12MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-228 SUP HCPCS C1776 5630-G-228 - INSERT TIB 2 8MM TRTHLN PRT KN RSRFC X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-229 SUP HCPCS C1776 5630-G-229 - INSERT TIB 2 29MM TRTHLN PRT RSRFC X3 KN RT MDL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-308 SUP HCPCS C1776 5630-G-308 - INSERT TIB 3 8MM TRTHLN PRT KN RSRFC X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-309 SUP HCPCS C1776 5630-G-309 - INSERT TIB 3 9MM TRTHLN PRT KN RSRFC X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-310 SUP HCPCS C1776 5630-G-310 - INSERT TIB 3 10MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-312 SUP HCPCS C1776 5630-G-312 - INSERT TIB 3 12MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-320 SUP HCPCS C1776 5630-G-320 - INSERT TIB 3 20MM TRTHLN PRT RSRFC X3 KN RT MDL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-322 SUP HCPCS C1776 5630-G-322 - INSERT TIB 3 12MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-328 SUP HCPCS C1776 5630-G-328 - INSERT TIB 3 8MM TRTHLN PRT KN RSRFC X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-329 SUP HCPCS C1776 5630-G-329 - INSERT TIB 3 29MM TRTHLN PRT RSRFC X3 KN RT MDL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-408 SUP HCPCS C1776 5630-G-408 - INSERT TIB 4 8MM TRTHLN PRT KN RSRFC X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-409 SUP HCPCS C1776 5630-G-409 - INSERT TIB 4 9MM TRTHLN PRT KN RSRFC X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-410 SUP HCPCS C1776 5630-G-410 - INSERT TIB 4 10MM TRTHLN X3 LT MDL RL KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-412 SUP HCPCS C1776 5630-G-412 - INSERT TIB 4 12MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-420 SUP HCPCS C1776 5630-G-420 - INSERT TIB 4 10MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-422 SUP HCPCS C1776 5630-G-422 - INSERT TIB 4 12MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-428 SUP HCPCS C1776 5630-G-428 - INSERT TIB 4 8MM TRTHLN PRT KN RSRFC X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-429 SUP HCPCS C1776 5630-G-429 - INSERT TIB 4 9MM TRTHLN PRT KN RSRFC X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-508 SUP HCPCS C1776 5630-G-508 - INSERT TIB 5 8MM TRTHLN PRT KN RSRFC X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-509 SUP HCPCS C1776 5630-G-509 - INSERT TIB 5 9MM TRTHLN X3 LT MDL RL KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-510 SUP HCPCS C1776 5630-G-510 - INSERT TIB 5 10MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-512 SUP HCPCS C1776 5630-G-512 - INSERT TIB 5 12MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-520 SUP HCPCS C1776 5630-G-520 - INSERT TIB 5 10MM TRTHLN X3 RMLL KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-522 SUP HCPCS C1776 5630-G-522 - INSERT TIB 5 12MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-528 SUP HCPCS C1776 5630-G-528 - INSERT TIB 5 8MM TRTHLN PRT KN RSRFC X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-529 SUP HCPCS C1776 5630-G-529 - INSERT TIB 5 9MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-608 SUP HCPCS C1776 5630-G-608 - INSERT TIB 6 8MM TRTHLN PRT KN RSRFC X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-609 SUP HCPCS C1776 5630-G-609 - INSERT TIB 9 60MM TRTHLN STRG KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-610 SUP HCPCS C1776 5630-G-610 - INSERT TIB 6 10MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-612 SUP HCPCS C1776 5630-G-612 - INSERT TIB 6 12MM TRTHLN X3 LT MDL RL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-620 SUP HCPCS C1776 5630-G-620 - INSERT TIB 62MM TRTHLN STRG KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-622 SUP HCPCS C1776 5630-G-622 - INSERT TIB 6 12MM TRTHLN X3 RMLL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-628 SUP HCPCS C1776 5630-G-628 - INSERT TIB 6 TRTHLN PRT RSRFC X3 KN RT MDL BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5630-G-629 SUP HCPCS C1776 5630-G-629 - INSERT TIB 6 9MM TRTHLN KN BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-010 SUP HCPCS C1713 5639-0-010 - SCREW BONE 4MM 10MM 5MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-012 SUP HCPCS C1713 5639-0-012 - SCREW BONE 4MM 12MM 5MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-014 SUP HCPCS C1713 5639-0-014 - SCREW BONE 4MM 14MM 5MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-016 SUP HCPCS C1713 5639-0-016 - SCREW BONE 4MM 16MM 6MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-018 SUP HCPCS C1713 5639-0-018 - SCREW BONE 4MM 18MM 7MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-020 SUP HCPCS C1713 5639-0-020 - SCREW BONE 4MM 20MM 8MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-022 SUP HCPCS C1713 5639-0-022 - SCREW BONE 4MM 22MM 9MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-024 SUP HCPCS C1713 5639-0-024 - SCREW BONE 4MM 24MM 10MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-026 SUP HCPCS C1713 5639-0-026 - SCREW BONE 4MM 26MM 12MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-028 SUP HCPCS C1713 5639-0-028 - SCREW BONE 4MM 28MM 14MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-030 SUP HCPCS C1713 5639-0-030 - SCREW BONE 4MM 30MM 14MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-035 SUP HCPCS C1713 5639-0-035 - SCREW BONE 4MM 35MM 14MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-040 SUP HCPCS C1713 5639-0-040 - SCREW BONE 4MM 40MM 14MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-045 SUP HCPCS C1713 5639-0-045 - SCREW BONE 4MM 45MM 15MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 5639-0-050 SUP HCPCS C1713 5639-0-050 - SCREW BONE 4MM 50MM 15MM PTHRD CANC HEX HEAD BOTH IP/OP $34.38 $25.44 $0.00 $27.50 $15.47 $15.47 $0.00 $0.00 $0.00 $7.16 $25.51 $25.51 $0.00 $0.00 $7.16 $0.00 $20.33 $20.33 $0.00 $17.19 $27.23 $27.50 $0.00 $0.00 $5.38 $0.00 $0.00 $5.47 $0.00 $0.00 $0.00 $0.00 $0.00 563CAL SUP Custom 27203010 MATTRESS COMPLETE UNIT /5 BOTH IP/OP $712.00 $526.88 $0.00 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $356.00 $563.90 $569.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 56-40281 SUP Custom 27803010 56-40281 - WIRE FX 1.4MM 17MM KRSH OLV STP DIST RDS LCK PLT SYS BOTH IP/OP $45.75 $33.86 $0.00 $33.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.96 $33.96 $0.00 $0.00 $9.53 $0.00 $0.00 $0.00 $0.00 $19.25 $30.49 $30.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5645-0-0160 SUP HCPCS C1713 5645-0-0160 - SCREW BONE 4.5MM 16MM SLFTAP CORTICAL BOTH IP/OP $22.00 $16.28 $0.00 $17.60 $9.90 $9.90 $0.00 $0.00 $0.00 $4.59 $16.33 $16.33 $0.00 $0.00 $4.58 $0.00 $13.01 $13.01 $0.00 $11.00 $17.42 $17.60 $0.00 $0.00 $3.44 $0.00 $0.00 $3.50 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-014 SUP HCPCS C1713 5645-1-014 - SCREW BONE 4.5MM 14MM TI CORTEX ORTH FULTHRD HEX HEAD SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-016 SUP HCPCS C1713 5645-1-016 - SCREW BONE 4.5MM 16MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-018 SUP HCPCS C1713 5645-1-018 - SCREW BONE 4.5MM 18MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-020 SUP HCPCS C1713 5645-1-020 - SCREW BONE 4.5MM 20MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-022 SUP HCPCS C1713 5645-1-022 - SCREW BONE 4.5MM 22MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-024 SUP HCPCS C1713 5645-1-024 - SCREW BONE 4.5MM 24MM FULTHD CORTEX SLFTAP HEX HEAD BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-026 SUP HCPCS C1713 5645-1-026 - SCREW BONE 4.5MM 26MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-028 SUP HCPCS C1713 5645-1-028 - SCREW BONE 4.5MM 28MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-030 SUP HCPCS C1713 5645-1-030 - SCREW BONE 4.5MM 30MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-032 SUP HCPCS C1713 5645-1-032 - SCREW BONE 4.5MM 32MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-034 SUP HCPCS C1713 5645-1-034 - SCREW BONE 4.5MM 34MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-036 SUP HCPCS C1713 5645-1-036 - SCREW BONE 4.5MM 36MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-038 SUP HCPCS C1713 5645-1-038 - SCREW BONE 4.5MM 38MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-040 SUP HCPCS C1713 5645-1-040 - SCREW BONE 4.5MM 40MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-042 SUP HCPCS C1713 5645-1-042 - SCREW BONE 4.5MM 42MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-044 SUP HCPCS C1713 5645-1-044 - SCREW BONE 4.5MM 44MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-046 SUP HCPCS C1713 5645-1-046 - SCREW BONE 4.5MM 46MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-048 SUP HCPCS C1713 5645-1-048 - SCREW BONE 4.5MM 48MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-050 SUP HCPCS C1713 5645-1-050 - SCREW BONE 4.5MM 50MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-052 SUP HCPCS C1713 5645-1-052 - SCREW BONE 4.5MM 52MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-054 SUP HCPCS C1713 5645-1-054 - SCREW BONE 4.5MM 54MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-056 SUP HCPCS C1713 5645-1-056 - SCREW BONE 4.5MM 56MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-058 SUP HCPCS C1713 5645-1-058 - SCREW BONE 4.5MM 58MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-060 SUP HCPCS C1713 5645-1-060 - SCREW BONE 4.5MM 60MM CORT SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-064 SUP HCPCS C1713 5645-1-064 - SCREW BONE 4.5MM 64MM CORTEX HEX HEAD FULTHD SLFTAP BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5645-1-070 SUP HCPCS C1713 5645-1-070 - SCREW BONE 4.5MM 70MM FULTHD CORTEX SLFTAP HEX HEAD BOTH IP/OP $39.20 $29.01 $0.00 $37.40 $21.04 $21.04 $0.00 $0.00 $0.00 $8.17 $29.09 $29.09 $0.00 $0.00 $8.17 $0.00 $23.19 $23.19 $0.00 $23.38 $37.03 $37.40 $0.00 $0.00 $7.32 $0.00 $0.00 $7.44 $0.00 $0.00 $0.00 $0.00 $0.00 5678-1-005 SUP HCPCS C1713 5678-1-005 - PLATE 3.5 MM SCR 5 HOLE BONE CORT BOTH IP/OP $391.88 $289.99 $0.00 $313.50 $176.34 $176.34 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 5678-1-010 SUP HCPCS C1713 5678-1-010 - PLATE 3.5 MM SCR 10 HOLE BONE CORT BOTH IP/OP $156.75 $116.00 $0.00 $125.40 $70.54 $70.54 $0.00 $0.00 $0.00 $32.67 $116.34 $116.34 $0.00 $0.00 $32.67 $0.00 $92.72 $92.72 $0.00 $78.38 $124.15 $125.40 $0.00 $0.00 $24.53 $0.00 $0.00 $24.95 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-025 SUP HCPCS C1713 5680-0-025 - SCREW BONE 6.5MM 25MM 16MM CANC CANC HEX HEAD PTTHRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-030 SUP HCPCS C1713 5680-0-030 - SCREW BONE 6.5MM 30MM 16MM CANC HEX HEAD PTHRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-035 SUP HCPCS C1713 5680-0-035 - SCREW BONE 6.5MM 35MM 16MM CANC HEX HEAD PTTHRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-040 SUP HCPCS C1713 5680-0-040 - SCREW BONE 6.5MM 40MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-045 SUP HCPCS C1713 5680-0-045 - SCREW BONE 6.5MM 45MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-050 SUP HCPCS C1713 5680-0-050 - SCREW BONE 6.5MM 50MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-055 SUP HCPCS C1713 5680-0-055 - SCREW BONE 6.5MM 55MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-060 SUP HCPCS C1713 5680-0-060 - SCREW BONE 6.5MM 60MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-065 SUP HCPCS C1713 5680-0-065 - SCREW BONE 6.5MM 65MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-070 SUP HCPCS C1713 5680-0-070 - SCREW BONE 6.5MM 70MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-075 SUP HCPCS C1713 5680-0-075 - SCREW BONE 6.5MM 75MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-080 SUP HCPCS C1713 5680-0-080 - SCREW BONE 6.5MM 80MM 16MM PTHRD CANC HEX HEAD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-085 SUP HCPCS C1713 5680-0-085 - SCREW BONE 6.5MM 85MM 16MM CANC HX HD PRTL THRED BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-090 SUP HCPCS C1713 5680-0-090 - SCREW BONE 6.5MM 90MM 16MM CANC PTHRD HX HD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-095 SUP HCPCS C1713 5680-0-095 - SCREW BONE 6.5MM 95MM 16MM CANC HEX HEAD PTHRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-100 SUP HCPCS C1713 5680-0-100 - SCREW BONE 6.5MM 110MM 16MM ALTA CANC HEX HEAD PTHRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-105 SUP HCPCS C1713 5680-0-105 - SCREW BONE 6.5MM 105MM 16MM CANC PTHRD HEX THRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5680-0-110 SUP HCPCS C1713 5680-0-110 - SCREW BONE 6.5MM 110MM 16MM TI CANC HEX HEAD PTTHRD STRYK BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-030 SUP HCPCS C1713 5681-0-030 - SCREW BONE 6.5MM 30MM 20MM CANC HX HD PTHRD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-035 SUP HCPCS C1713 5681-0-035 - SCREW BONE 6.5MM 27MM CANC HEX HEAD PRTL THRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-040 SUP HCPCS C1713 5681-0-040 - SCREW BONE 6.5MM 40MM 32MM CANC HX HD PTHRD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-045 SUP HCPCS C1713 5681-0-045 - SCREW BONE 6.5MM 45MM 32MM CANC PTTHRD HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-050 SUP HCPCS C1713 5681-0-050 - SCREW BONE 6.5MM 50MM 32MM CANC CANC HAEXGONAL HEAD PRTL BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-055 SUP HCPCS C1713 5681-0-055 - SCREW BONE 6.5MM 55MM 32MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-060 SUP HCPCS C1713 5681-0-060 - SCREW BONE 6.5MM 60MM 32MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-065 SUP HCPCS C1713 5681-0-065 - SCREW BONE 6.5MM 65MM 32MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-070 SUP HCPCS C1713 5681-0-070 - SCREW BONE 6.5MM 70MM 32MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-075 SUP HCPCS C1713 5681-0-075 - SCREW BONE 6.5MM 75MM 32MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-080 SUP HCPCS C1713 5681-0-080 - SCREW BONE 6.5MM 80MM 32MM PTHRD CANC HEX HEAD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-085 SUP HCPCS C1713 5681-0-085 - SCREW BONE 6.5MM 85MM 32MM CANC HX HD PTHRD BOTH IP/OP $54.40 $40.26 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-090 SUP HCPCS C1713 5681-0-090 - SCREW BONE 6.5MM 90MM 32MM CANC HX HD PTTHRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-095 SUP HCPCS C1713 5681-0-095 - SCREW BONE 6.5MM 95MM 32MM TI CANC PTTHRD HX HD SLFTAP BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-100 SUP HCPCS C1713 5681-0-100 - SCREW BONE 4.2MM 100MM 32MM TI CANC HEX HEAD PTTHRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-105 SUP HCPCS C1713 5681-0-105 - SCREW BONE 6.5MM 32MM 32MM CANC HX HD PRTL THRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 5681-0-110 SUP HCPCS C1713 5681-0-110 - SCREW BONE 6.5MM 110MM 32MM CANC HEX HEAD PTHRD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 57-05101 SUP HCPCS C1713 57-05101 - PLATE XS HYDRXAPT TI 1.2MM SCR 4 HOLE STR PRFL BONE BOTH IP/OP $321.30 $237.76 $0.00 $238.47 $97.14 $97.14 $0.00 $0.00 $0.00 $66.97 $238.47 $238.47 $0.00 $0.00 $66.96 $0.00 $190.05 $190.05 $0.00 $107.94 $170.98 $172.70 $0.00 $0.00 $33.78 $0.00 $0.00 $34.37 $0.00 $0.00 $0.00 $0.00 $0.00 57-05116 SUP HCPCS C1713 57-05116 - PLATE XS .55MM TI 1.2MM SCR 16 HOLE STR PRFL BONE HAND BOTH IP/OP $518.70 $383.84 $0.00 $386.10 $217.18 $217.18 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $241.31 $382.24 $386.10 $0.00 $0.00 $75.53 $0.00 $0.00 $76.83 $0.00 $0.00 $0.00 $0.00 $0.00 57-05140 SUP HCPCS C1713 57-05140 - PLATE XS NAR STD .55MM TI 1.2MM SCR 5 HOLE T PRFL BONE HAND BOTH IP/OP $321.30 $237.76 $0.00 $238.47 $129.32 $129.32 $0.00 $0.00 $0.00 $66.97 $238.47 $238.47 $0.00 $0.00 $66.96 $0.00 $190.05 $190.05 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $44.97 $0.00 $0.00 $45.75 $0.00 $0.00 $0.00 $0.00 $0.00 57-05142 SUP HCPCS C1713 57-05142 - PLATE XS NAR STD .55MM 1.2MM SCR 8 HOLE T PRFL PRFL BONE BOTH IP/OP $371.00 $274.54 $0.00 $278.30 $156.54 $156.54 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $173.94 $275.52 $278.30 $0.00 $0.00 $54.44 $0.00 $0.00 $55.38 $0.00 $0.00 $0.00 $0.00 $0.00 57-05150 SUP HCPCS C1713 57-05150 - PLATE XS STD .55MM TI 1.2MM SCR T 5 HOLE OBLQ PRFL PRFL BONE BOTH IP/OP $371.00 $274.54 $0.00 $275.36 $147.88 $147.88 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 57-05151 SUP HCPCS C1713 57-05151 - PLATE XS STD .55MM TI 1.2MM SCR 5 HOLE T OBLQ PRFL BONE LEFT BOTH IP/OP $371.00 $274.54 $0.00 $275.36 $147.88 $147.88 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 57-05170 SUP HCPCS C1713 57-05170 - PLATE XS STD NAR .55MM TI 1.2MM SCR 5 HOLE Y PRFL BONE HAND BOTH IP/OP $371.00 $274.54 $0.00 $275.36 $138.60 $138.60 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-05190 SUP HCPCS C1713 57-05190 - PLATE XS TI SM FRAG SYS 2X2 HOLE 3D MDLR FIX PRFL BONE HAND BOTH IP/OP $518.70 $383.84 $0.00 $384.98 $165.83 $165.83 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $184.25 $291.85 $294.80 $0.00 $0.00 $57.67 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 57-05191 SUP HCPCS C1713 57-05191 - PLATE XS STD .55MM TI 1.2MM SCR 3D 3X2HOLE PRFL PRFL BONE BOTH IP/OP $554.13 $410.06 $0.00 $443.30 $249.36 $249.36 $0.00 $0.00 $0.00 $115.49 $411.27 $411.27 $0.00 $0.00 $115.48 $0.00 $327.76 $327.76 $0.00 $277.06 $438.87 $443.30 $0.00 $0.00 $86.72 $0.00 $0.00 $88.22 $0.00 $0.00 $0.00 $0.00 $0.00 57-05192 SUP HCPCS C1713 57-05192 - PLATE XS STD .55MM TI 1.2MM SCR 4X2 HOLE 3D PRFL BONE HAND BOTH IP/OP $555.75 $411.26 $0.00 $533.50 $300.09 $300.09 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $333.44 $528.17 $533.50 $0.00 $0.00 $104.37 $0.00 $0.00 $106.17 $0.00 $0.00 $0.00 $0.00 $0.00 57-05195 SUP HCPCS C1713 57-05195 - PLATE XS STD .55MM TI 1.2MM SCR 3D 4X2 HOLE REPLANTATION BOTH IP/OP $555.75 $411.26 $0.00 $500.50 $281.53 $281.53 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $312.81 $495.50 $500.50 $0.00 $0.00 $97.91 $0.00 $0.00 $99.60 $0.00 $0.00 $0.00 $0.00 $0.00 57-05197 SUP HCPCS C1713 57-05197 - PLATE XS TI 1.2MM SCR 2X2+2 HOLE 3D PRFL PRFL BONE HAND WRST BOTH IP/OP $554.13 $410.06 $0.00 $443.30 $249.36 $249.36 $0.00 $0.00 $0.00 $115.49 $411.27 $411.27 $0.00 $0.00 $115.48 $0.00 $327.76 $327.76 $0.00 $277.06 $438.87 $443.30 $0.00 $0.00 $86.72 $0.00 $0.00 $88.22 $0.00 $0.00 $0.00 $0.00 $0.00 57-05201 SUP HCPCS C1713 57-05201 - PLATE SM .55MM TI 1.7MM SCR FRAG SYS 4 HOLE FIX STR MDLR BOTH IP/OP $321.30 $237.76 $0.00 $238.47 $102.09 $102.09 $0.00 $0.00 $0.00 $66.97 $238.47 $238.47 $0.00 $0.00 $66.96 $0.00 $190.05 $190.05 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $35.51 $0.00 $0.00 $36.12 $0.00 $0.00 $0.00 $0.00 $0.00 57-05202 SUP HCPCS C1713 57-05202 - PLATE SM .55MM TI 1.7MM SCR FRAG SYS 4 HOLE FIX STR BAR MDLR BOTH IP/OP $321.30 $237.76 $0.00 $238.47 $102.09 $102.09 $0.00 $0.00 $0.00 $66.97 $238.47 $238.47 $0.00 $0.00 $66.96 $0.00 $190.05 $190.05 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $35.51 $0.00 $0.00 $36.12 $0.00 $0.00 $0.00 $0.00 $0.00 57-05210 SUP HCPCS C1713 57-05210 - PLATE W STD .55MM 1.7MM SCR 8 HOLE T S MOD PRFL BONE HAND BOTH IP/OP $489.00 $361.86 $0.00 $362.94 $167.06 $167.06 $0.00 $0.00 $0.00 $101.92 $362.94 $362.94 $0.00 $0.00 $101.91 $0.00 $289.24 $289.24 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 57-05216 SUP HCPCS C1713 57-05216 - PLATE SM .55MM 1.7MM SCR FRAG SYS 16 HOLE FIX STR MDLR PRFL BOTH IP/OP $518.70 $383.84 $0.00 $393.80 $221.51 $221.51 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $246.13 $389.86 $393.80 $0.00 $0.00 $77.04 $0.00 $0.00 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 57-05220 SUP HCPCS C1713 57-05220 - PLATE 90D REG SM HYDRXAPT TI 1.7MM SCR 6 HOLE RIGHT L PRFL BOTH IP/OP $321.30 $237.76 $0.00 $238.70 $134.27 $134.27 $0.00 $0.00 $0.00 $66.97 $238.47 $238.47 $0.00 $0.00 $66.96 $0.00 $190.05 $190.05 $0.00 $149.19 $236.32 $238.70 $0.00 $0.00 $46.70 $0.00 $0.00 $47.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-05221 SUP HCPCS C1713 57-05221 - PLATE SM .55MM TI 1.7MM SCR FRAG SYS 6 HOLE FIX L MDLR PRFL BOTH IP/OP $321.30 $237.76 $0.00 $238.70 $134.27 $134.27 $0.00 $0.00 $0.00 $66.97 $238.47 $238.47 $0.00 $0.00 $66.96 $0.00 $190.05 $190.05 $0.00 $149.19 $236.32 $238.70 $0.00 $0.00 $46.70 $0.00 $0.00 $47.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-05230 SUP HCPCS C1713 57-05230 - PLATE SM .55MM TI 1.7MM SCR 6 HOLE L OBLQ PRFL BONE RIGHT BOTH IP/OP $366.10 $270.91 $0.00 $271.72 $134.27 $134.27 $0.00 $0.00 $0.00 $76.30 $271.72 $271.72 $0.00 $0.00 $76.30 $0.00 $216.55 $216.55 $0.00 $149.19 $236.32 $238.70 $0.00 $0.00 $46.70 $0.00 $0.00 $47.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-05231 SUP HCPCS C1713 57-05231 - PLATE SM .55MM TI 1.7MM SCR 6 HOLE PRFL BONE LEFT OBLQ BOTH IP/OP $366.10 $270.91 $0.00 $271.72 $134.27 $134.27 $0.00 $0.00 $0.00 $76.30 $271.72 $271.72 $0.00 $0.00 $76.30 $0.00 $216.55 $216.55 $0.00 $149.19 $236.32 $238.70 $0.00 $0.00 $46.70 $0.00 $0.00 $47.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-05240 SUP HCPCS C1713 57-05240 - PLATE SM TI 1.7MM SCR SM FRAG SYS 6 HOLE T MDLR FIX PRFL BOTH IP/OP $328.63 $243.19 $0.00 $262.90 $147.88 $147.88 $0.00 $0.00 $0.00 $68.49 $243.91 $243.91 $0.00 $0.00 $68.49 $0.00 $194.38 $194.38 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 57-05250 SUP HCPCS C1713 57-05250 - PLATE SM TI SM FRAG SYS 6 HOLE T FX MDLR PRFL BONE HAND BOTH IP/OP $371.00 $274.54 $0.00 $275.36 $147.88 $147.88 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 57-05251 SUP HCPCS C1713 57-05251 - PLATE SM NAR TI 1.7MM SCR 6 HOLE T OBLQ PRFL BONE LEFT HAND BOTH IP/OP $371.00 $274.54 $0.00 $275.36 $147.88 $147.88 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 57-05260 SUP HCPCS C1713 57-05260 - PLATE STD TI 1.7MM SCR 7 HOLE T PRFL BONE HAND BOTH IP/OP $371.00 $274.54 $0.00 $275.36 $147.88 $147.88 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $164.31 $260.27 $262.90 $0.00 $0.00 $51.43 $0.00 $0.00 $52.32 $0.00 $0.00 $0.00 $0.00 $0.00 57-05262 SUP HCPCS C1713 57-05262 - PLATE SM STD NAR .55MM TI 1.7MM SCR 10 HOLE T FX PRFL BONE BOTH IP/OP $371.00 $274.54 $0.00 $278.30 $156.54 $156.54 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $173.94 $275.52 $278.30 $0.00 $0.00 $54.44 $0.00 $0.00 $55.38 $0.00 $0.00 $0.00 $0.00 $0.00 57-05270 SUP HCPCS C1713 57-05270 - PLATE SM .55MM TI 1.7MM SCR FRAG SYS 7 HOLE FIX Y MDLR PRFL BOTH IP/OP $371.00 $274.54 $0.00 $288.20 $162.11 $162.11 $0.00 $0.00 $0.00 $77.33 $275.36 $275.36 $0.00 $0.00 $77.32 $0.00 $219.45 $219.45 $0.00 $180.13 $285.32 $288.20 $0.00 $0.00 $56.38 $0.00 $0.00 $57.35 $0.00 $0.00 $0.00 $0.00 $0.00 57-05279 SUP HCPCS C1713 57-05279 - PLATE SM .55MM TI 1.7MM SCR 9 HOLE Z FIX PRFL BONE HAND BOTH IP/OP $518.70 $383.84 $0.00 $384.98 $193.67 $193.67 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $215.19 $340.86 $344.30 $0.00 $0.00 $67.35 $0.00 $0.00 $68.52 $0.00 $0.00 $0.00 $0.00 $0.00 57-05280 SUP HCPCS C1713 57-05280 - PLATE SM RIGHT CNDYLR HAND .55MM TI 1.7MM SCR FRAG SYS 5 BOTH IP/OP $518.70 $383.84 $0.00 $384.98 $156.54 $156.54 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $173.94 $275.52 $278.30 $0.00 $0.00 $54.44 $0.00 $0.00 $55.38 $0.00 $0.00 $0.00 $0.00 $0.00 57-05281 SUP HCPCS C1713 57-05281 - PLATE SM LEFT CNDYLR HAND .55MM TI 1.7MM SCR FRAG SYS 5 HOLE BOTH IP/OP $518.70 $383.84 $0.00 $384.98 $156.54 $156.54 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $173.94 $275.52 $278.30 $0.00 $0.00 $54.44 $0.00 $0.00 $55.38 $0.00 $0.00 $0.00 $0.00 $0.00 57-05282 SUP HCPCS C1713 57-05282 - PLATE SM STD .55MM TI 1.7MM SCR 5 HOLE BLADE PRFL BONE RIGHT BOTH IP/OP $518.70 $383.84 $0.00 $384.98 $156.54 $156.54 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $173.94 $275.52 $278.30 $0.00 $0.00 $54.44 $0.00 $0.00 $55.38 $0.00 $0.00 $0.00 $0.00 $0.00 57-05283 SUP HCPCS C1713 57-05283 - PLATE SM STD .55MM TI 1.7MM SCR 5 HOLE BLADE PRFL BONE LEFT BOTH IP/OP $518.70 $383.84 $0.00 $384.98 $156.54 $156.54 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $173.94 $275.52 $278.30 $0.00 $0.00 $54.44 $0.00 $0.00 $55.38 $0.00 $0.00 $0.00 $0.00 $0.00 57-05285 SUP HCPCS C1713 57-05285 - PLATE SM STD .55MM TI 1.7MM SCR 1 HOLE PR PRFL BONE HAND BOTH IP/OP $518.70 $383.84 $0.00 $384.98 $162.11 $162.11 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $180.13 $285.32 $288.20 $0.00 $0.00 $56.38 $0.00 $0.00 $57.35 $0.00 $0.00 $0.00 $0.00 $0.00 57-05290 SUP HCPCS C1713 57-05290 - PLATE SM HYDRXAPT TI 1.7MM SCR 2X2 HOLE 3D PRFL BONE BOTH IP/OP $518.70 $383.84 $0.00 $384.98 $170.78 $170.78 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $189.75 $300.56 $303.60 $0.00 $0.00 $59.39 $0.00 $0.00 $60.42 $0.00 $0.00 $0.00 $0.00 $0.00 57-05291 SUP HCPCS C1713 57-05291 - PLATE SM STD .55MM TI 1.7MM SCR 3X2 HOLE 3D PRFL BONE HAND BOTH IP/OP $555.75 $411.26 $0.00 $451.00 $253.69 $253.69 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $281.88 $446.49 $451.00 $0.00 $0.00 $88.23 $0.00 $0.00 $89.75 $0.00 $0.00 $0.00 $0.00 $0.00 57-05292 SUP HCPCS C1713 57-05292 - PLATE SM STD .55MM TI 1.7MM SCR 4X2 HOLE 3D PRFL BONE HAND BOTH IP/OP $555.75 $411.26 $0.00 $542.30 $305.04 $305.04 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $338.94 $536.88 $542.30 $0.00 $0.00 $106.09 $0.00 $0.00 $107.92 $0.00 $0.00 $0.00 $0.00 $0.00 57-05295 SUP HCPCS C1713 57-05295 - PLATE SM STD .55MM TI 1.7MM SCR 4X2 HOLE 3D REPLANTATION BOTH IP/OP $555.75 $411.26 $0.00 $542.30 $305.04 $305.04 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $338.94 $536.88 $542.30 $0.00 $0.00 $106.09 $0.00 $0.00 $107.92 $0.00 $0.00 $0.00 $0.00 $0.00 57-05297 SUP HCPCS C1713 57-05297 - PLATE SM STD .55MM TI 1.7MM SCR 2X2+ 2 HOLE 3D PRFL BONE BOTH IP/OP $555.75 $411.26 $0.00 $451.00 $253.69 $253.69 $0.00 $0.00 $0.00 $115.83 $412.48 $412.48 $0.00 $0.00 $115.82 $0.00 $328.73 $328.73 $0.00 $281.88 $446.49 $451.00 $0.00 $0.00 $88.23 $0.00 $0.00 $89.75 $0.00 $0.00 $0.00 $0.00 $0.00 57-08212 SUP HCPCS C1713 57-08212 - PLATE TI 1.7 MM SCR 12 HOLE STR PRFL BONE RIGHT HAND BOTH IP/OP $518.70 $383.84 $0.00 $386.10 $217.18 $217.18 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $241.31 $382.24 $386.10 $0.00 $0.00 $75.53 $0.00 $0.00 $76.83 $0.00 $0.00 $0.00 $0.00 $0.00 57-08213 SUP HCPCS C1713 57-08213 - PLATE TI 1.7 MM SCR 12 HOLE STR PRFL BONE LEFT HAND BOTH IP/OP $518.70 $383.84 $0.00 $386.10 $217.18 $217.18 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $241.31 $382.24 $386.10 $0.00 $0.00 $75.53 $0.00 $0.00 $76.83 $0.00 $0.00 $0.00 $0.00 $0.00 57-08216 SUP HCPCS C1713 57-08216 - PLATE TI 1.7 MM SCR 16 HOLE STR PRFL BONE HAND BOTH IP/OP $518.70 $383.84 $0.00 $402.60 $226.46 $226.46 $0.00 $0.00 $0.00 $108.11 $384.98 $384.98 $0.00 $0.00 $108.10 $0.00 $306.81 $306.81 $0.00 $251.63 $398.57 $402.60 $0.00 $0.00 $78.76 $0.00 $0.00 $80.12 $0.00 $0.00 $0.00 $0.00 $0.00 57-10101 SUP HCPCS C1713 57-10101 - PLATE MED STD 1MM 2.3MM SCR 4 HOLE STR PRFL BONE HAND BOTH IP/OP $459.00 $339.66 $0.00 $340.67 $87.86 $87.86 $0.00 $0.00 $0.00 $95.67 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $271.50 $271.50 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 57-10102 SUP HCPCS C1713 57-10102 - PLATE TI SM FRAG SYS 4 HOLE STR BAR FIX MDLR PRFL BONE HAND BOTH IP/OP $459.00 $339.66 $0.00 $340.67 $87.86 $87.86 $0.00 $0.00 $0.00 $95.67 $340.67 $340.67 $0.00 $0.00 $95.66 $0.00 $271.50 $271.50 $0.00 $97.63 $154.64 $156.20 $0.00 $0.00 $30.56 $0.00 $0.00 $31.08 $0.00 $0.00 $0.00 $0.00 $0.00 57-10116 SUP HCPCS C1713 57-10116 - PLATE MED STD 1MM TI 2.3MM SCR 16 HOLE STR PRFL BONE HAND BOTH IP/OP $741.00 $548.34 $0.00 $549.97 $230.79 $230.79 $0.00 $0.00 $0.00 $154.44 $549.97 $549.97 $0.00 $0.00 $154.42 $0.00 $438.30 $438.30 $0.00 $256.44 $406.20 $410.30 $0.00 $0.00 $80.26 $0.00 $0.00 $81.65 $0.00 $0.00 $0.00 $0.00 $0.00 57-10120 SUP HCPCS C1713 57-10120 - PLATE MED STD 1MM TI 2.3MM SCR 6 HOLE L PRFL PRFL BONE RIGHT BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $134.27 $134.27 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $149.19 $236.32 $238.70 $0.00 $0.00 $46.70 $0.00 $0.00 $47.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-10121 SUP HCPCS C1713 57-10121 - PLATE MED STD 1MM TI 2.3MM SCR 6 HOLE L PRFL BONE LEFT HAND BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $134.27 $134.27 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $149.19 $236.32 $238.70 $0.00 $0.00 $46.70 $0.00 $0.00 $47.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-10130 SUP HCPCS C1713 57-10130 - PLATE MED 1MM 2.3MM SCR SM FRAG SYS 6 HOLE L PRFL BONE HAND BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $134.27 $134.27 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $149.19 $236.32 $238.70 $0.00 $0.00 $46.70 $0.00 $0.00 $47.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-10131 SUP HCPCS C1713 57-10131 - PLATE MED TI 2.3MM SCR 6 HOLE L OBLQ PRFL BONE LEFT HAND BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $134.27 $134.27 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $149.19 $236.32 $238.70 $0.00 $0.00 $46.70 $0.00 $0.00 $47.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-10140 SUP HCPCS C1713 57-10140 - PLATE MED STD NAR 1MM 2.3MM SCR SM FRAG SYS 6 HOLE T PRFL BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $138.60 $138.60 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10150 SUP HCPCS C1713 57-10150 - PLATE MED 1MM 2.3MM SCR SM FRAG SYS 6 HOLE T PRFL BONE HAND BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $138.60 $138.60 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10151 SUP HCPCS C1713 57-10151 - PLATE MED NAR TI 2.3MM SCR 6 HOLE T OBLQ PRFL BONE LEFT HAND BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $138.60 $138.60 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10160 SUP HCPCS C1713 57-10160 - PLATE MED STD 1MM 2.3MM SCR SM FRAG SYS 7 HOLE T PRFL BONE BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $152.83 $152.83 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $169.81 $268.99 $271.70 $0.00 $0.00 $53.15 $0.00 $0.00 $54.07 $0.00 $0.00 $0.00 $0.00 $0.00 57-10161 SUP HCPCS C1713 57-10161 - PLATE MED W STD 1MM 2.3MM SCR 8 HOLE T PRFL PRFL BONE HAND BOTH IP/OP $489.00 $361.86 $0.00 $362.94 $167.06 $167.06 $0.00 $0.00 $0.00 $101.92 $362.94 $362.94 $0.00 $0.00 $101.91 $0.00 $289.24 $289.24 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 57-10170 SUP HCPCS C1713 57-10170 - PLATE MED STD NAR 1MM 2.3MM SCR SM FRAG SYS 7 HOLE Y PRFL BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $175.11 $175.11 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $194.56 $308.19 $311.30 $0.00 $0.00 $60.90 $0.00 $0.00 $61.95 $0.00 $0.00 $0.00 $0.00 $0.00 57-10179 SUP HCPCS C1713 57-10179 - PLATE MED STD NAR 1MM 2.3MM SCR SM FRAG SYS 13 HOLE Z PRFL BOTH IP/OP $741.00 $548.34 $0.00 $549.97 $193.67 $193.67 $0.00 $0.00 $0.00 $154.44 $549.97 $549.97 $0.00 $0.00 $154.42 $0.00 $438.30 $438.30 $0.00 $215.19 $340.86 $344.30 $0.00 $0.00 $67.35 $0.00 $0.00 $68.52 $0.00 $0.00 $0.00 $0.00 $0.00 57-10180 SUP HCPCS C1713 57-10180 - PLATE MED TI OBLQ FRAC M ROT PRFL BONE PHLNG MTCRPL BOTH IP/OP $734.00 $543.16 $0.00 $647.90 $364.44 $364.44 $0.00 $0.00 $0.00 $152.98 $544.77 $544.77 $0.00 $0.00 $152.97 $0.00 $434.16 $434.16 $0.00 $404.94 $641.42 $647.90 $0.00 $0.00 $126.75 $0.00 $0.00 $128.93 $0.00 $0.00 $0.00 $0.00 $0.00 57-10185 SUP HCPCS C1713 57-10185 - PLATE STD MED 1MM 2.3MM SCR 5 HOLE ROT PRFL BONE HAND BOTH IP/OP $944.00 $698.56 $0.00 $700.64 $324.84 $324.84 $0.00 $0.00 $0.00 $196.75 $700.64 $700.64 $0.00 $0.00 $196.73 $0.00 $558.38 $558.38 $0.00 $360.94 $571.73 $577.50 $0.00 $0.00 $112.97 $0.00 $0.00 $114.92 $0.00 $0.00 $0.00 $0.00 $0.00 57-10190 SUP HCPCS C1713 57-10190 - PLATE MED STD 1MM 2.3MM SCR SM FRAG SYS 2X2 HOLE 3D PRFL BOTH IP/OP $530.00 $392.20 $0.00 $393.37 $170.78 $170.78 $0.00 $0.00 $0.00 $110.47 $393.37 $393.37 $0.00 $0.00 $110.45 $0.00 $313.50 $313.50 $0.00 $189.75 $300.56 $303.60 $0.00 $0.00 $59.39 $0.00 $0.00 $60.42 $0.00 $0.00 $0.00 $0.00 $0.00 57-10191 SUP HCPCS C1713 57-10191 - PLATE MED STD 1MM 2.3MM SCR SM FRAG SYS 3X2 HOLE 3D PRFL BOTH IP/OP $741.00 $548.34 $0.00 $549.97 $253.69 $253.69 $0.00 $0.00 $0.00 $154.44 $549.97 $549.97 $0.00 $0.00 $154.42 $0.00 $438.30 $438.30 $0.00 $281.88 $446.49 $451.00 $0.00 $0.00 $88.23 $0.00 $0.00 $89.75 $0.00 $0.00 $0.00 $0.00 $0.00 57-10192 SUP HCPCS C1713 57-10192 - PLATE MED HYDRXAPT TI 2.3MM SCR 4X2 HOLE 3D PRFL BONE BOTH IP/OP $741.00 $548.34 $0.00 $549.97 $305.04 $305.04 $0.00 $0.00 $0.00 $154.44 $549.97 $549.97 $0.00 $0.00 $154.42 $0.00 $438.30 $438.30 $0.00 $338.94 $536.88 $542.30 $0.00 $0.00 $106.09 $0.00 $0.00 $107.92 $0.00 $0.00 $0.00 $0.00 $0.00 57-10193 SUP HCPCS C1713 57-10193 - PLATE MED TI 2.3MM SCR 3D PRFL BONE HAND WRST BOTH IP/OP $741.00 $548.34 $0.00 $549.97 $305.04 $305.04 $0.00 $0.00 $0.00 $154.44 $549.97 $549.97 $0.00 $0.00 $154.42 $0.00 $438.30 $438.30 $0.00 $338.94 $536.88 $542.30 $0.00 $0.00 $106.09 $0.00 $0.00 $107.92 $0.00 $0.00 $0.00 $0.00 $0.00 57-10195 SUP HCPCS C1713 57-10195 - PLATE MED 1MM TI 2.3MM SCR SM FRAG SYS 4X2 HOLE 3D FIX PRFL BOTH IP/OP $741.00 $548.34 $0.00 $549.97 $286.48 $286.48 $0.00 $0.00 $0.00 $154.44 $549.97 $549.97 $0.00 $0.00 $154.42 $0.00 $438.30 $438.30 $0.00 $318.31 $504.21 $509.30 $0.00 $0.00 $99.63 $0.00 $0.00 $101.35 $0.00 $0.00 $0.00 $0.00 $0.00 57-10197 SUP HCPCS C1713 57-10197 - PLATE MED 1MM TI 2.3MM SCR SM FRAG SYS 2X2+ 2 HOLE 3D FIX BOTH IP/OP $741.00 $548.34 $0.00 $549.97 $253.69 $253.69 $0.00 $0.00 $0.00 $154.44 $549.97 $549.97 $0.00 $0.00 $154.42 $0.00 $438.30 $438.30 $0.00 $281.88 $446.49 $451.00 $0.00 $0.00 $88.23 $0.00 $0.00 $89.75 $0.00 $0.00 $0.00 $0.00 $0.00 57-10201 SUP HCPCS C1713 57-10201 - PLATE MED TI 2.3MM SCR 4 HOLE STR CMPR PRFL BONE HAND WRST BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $111.38 $111.38 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 57-10202 SUP HCPCS C1713 57-10202 - PLATE MED TI 2.3MM SCR 4 HOLE STR CMPR BAR PRFL BONE HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $111.38 $111.38 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 57-10204 SUP HCPCS C1713 57-10204 - PLATE MED 1MM TI SM FRAG SYS 5 HOLE CMPR STR PRFL BONE HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $111.38 $111.38 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 57-10207 SUP HCPCS C1713 57-10207 - PLATE MED 1MM TI SM FRAG SYS 6 HOLE CMPR STR PRFL BONE HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $138.60 $138.60 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10208 SUP HCPCS C1713 57-10208 - PLATE MED TI 2.3MM SCR 7 HOLE STR CMPR PRFL BONE HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $138.60 $138.60 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10220 SUP HCPCS C1713 57-10220 - PLATE 90D MED TI 2.3MM SCR 6 HOLE L CMPR PRFL BONE RIGHT BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $138.60 $138.60 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10221 SUP HCPCS C1713 57-10221 - PLATE 90D MED TI 2.3MM SCR 6 HOLE L CMPR PRFL BONE LEFT HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $138.60 $138.60 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10230 SUP HCPCS C1713 57-10230 - PLATE MED TI 2.3MM SCR 6 HOLE L OBLQ CMPR PRFL BONE RIGHT BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $138.60 $138.60 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10231 SUP HCPCS C1713 57-10231 - PLATE MED TI 2.3MM SCR 6 HOLE L OBLQ CMPR PRFL BONE LEFT BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $138.60 $138.60 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-10240 SUP HCPCS C1713 57-10240 - PLATE MED 1MM TI SM FRAG SYS 6 HOLE CMPR T PRFL BONE HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $152.83 $152.83 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $169.81 $268.99 $271.70 $0.00 $0.00 $53.15 $0.00 $0.00 $54.07 $0.00 $0.00 $0.00 $0.00 $0.00 57-10250 SUP HCPCS C1713 57-10250 - PLATE MED NAR TI 2.3MM SCR 6 HOLE T OBLQ CMPR PRFL BONE BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $152.83 $152.83 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $169.81 $268.99 $271.70 $0.00 $0.00 $53.15 $0.00 $0.00 $54.07 $0.00 $0.00 $0.00 $0.00 $0.00 57-10251 SUP HCPCS C1713 57-10251 - PLATE MED NAR TI 2.3MM SCR 6 HOLE T OBLQ CMPR PRFL BONE LEFT BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $152.83 $152.83 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $169.81 $268.99 $271.70 $0.00 $0.00 $53.15 $0.00 $0.00 $54.07 $0.00 $0.00 $0.00 $0.00 $0.00 57-10260 SUP HCPCS C1713 57-10260 - PLATE 90D MED REG TI 2.3MM SCR 7 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $162.11 $162.11 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $180.13 $285.32 $288.20 $0.00 $0.00 $56.38 $0.00 $0.00 $57.35 $0.00 $0.00 $0.00 $0.00 $0.00 57-10262 SUP HCPCS C1713 57-10262 - PLATE 90D REG TI 2.3MM SCR 10 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $180.06 $180.06 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $200.06 $316.90 $320.10 $0.00 $0.00 $62.62 $0.00 $0.00 $63.70 $0.00 $0.00 $0.00 $0.00 $0.00 57-10270 SUP HCPCS C1713 57-10270 - PLATE MED 1MM TI SM FRAG SYS 7 HOLE CMPR Y PRFL BONE HAND BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $180.06 $180.06 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $200.06 $316.90 $320.10 $0.00 $0.00 $62.62 $0.00 $0.00 $63.70 $0.00 $0.00 $0.00 $0.00 $0.00 57-10280 SUP HCPCS C1713 57-10280 - PLATE MED TI 2.3MM SCR 5 HOLE PRFL BONE RIGHT CNDYLR BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $152.83 $152.83 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $169.81 $268.99 $271.70 $0.00 $0.00 $53.15 $0.00 $0.00 $54.07 $0.00 $0.00 $0.00 $0.00 $0.00 57-10281 SUP HCPCS C1713 57-10281 - PLATE MED TI 2.3MM SCR 5 HOLE PRFL BONE LEFT CNDYLR BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $152.83 $152.83 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $169.81 $268.99 $271.70 $0.00 $0.00 $53.15 $0.00 $0.00 $54.07 $0.00 $0.00 $0.00 $0.00 $0.00 57-10282 SUP HCPCS C1713 57-10282 - PLATE MED TI 2.3MM SCR 6 HOLE PRFL BONE RIGHT CNDYLR BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $152.83 $152.83 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $169.81 $268.99 $271.70 $0.00 $0.00 $53.15 $0.00 $0.00 $54.07 $0.00 $0.00 $0.00 $0.00 $0.00 57-10283 SUP HCPCS C1713 57-10283 - PLATE MED TI 2.3MM SCR 6 HOLE PRFL BONE LEFT CNDYLR BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $152.83 $152.83 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $169.81 $268.99 $271.70 $0.00 $0.00 $53.15 $0.00 $0.00 $54.07 $0.00 $0.00 $0.00 $0.00 $0.00 57-10284 SUP HCPCS C1713 57-10284 - PLATE MED TI 2.3MM SCR 6 HOLE LNG PIN PRFL BONE RIGHT CNDYLR BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $175.11 $175.11 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $194.56 $308.19 $311.30 $0.00 $0.00 $60.90 $0.00 $0.00 $61.95 $0.00 $0.00 $0.00 $0.00 $0.00 57-10285 SUP HCPCS C1713 57-10285 - PLATE MED TI 2.3MM SCR 6 HOLE LNG PIN PRFL BONE LEFT CNDYLR BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $175.11 $175.11 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $194.56 $308.19 $311.30 $0.00 $0.00 $60.90 $0.00 $0.00 $61.95 $0.00 $0.00 $0.00 $0.00 $0.00 57-10304 SUP HCPCS C1713 57-10304 - PLATE SM 1MM 1.7MM SCR 4 HOLE STR LCK VARIAX BONE HAND BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $114.47 $114.47 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $127.19 $201.47 $203.50 $0.00 $0.00 $39.81 $0.00 $0.00 $40.50 $0.00 $0.00 $0.00 $0.00 $0.00 57-10310 SUP HCPCS C1713 57-10310 - PLATE SM NAR 1MM 1.7MM SCR 10 HOLE T LCK PRFL VARIAX BONE BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $176.34 $176.34 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $195.94 $310.37 $313.50 $0.00 $0.00 $61.33 $0.00 $0.00 $62.39 $0.00 $0.00 $0.00 $0.00 $0.00 57-10316 SUP HCPCS C1713 57-10316 - PLATE SM 1MM 1.7MM SCR 16 HOLE STR LCK PRFL VARIAX BONE HAND BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $250.59 $250.59 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $278.44 $441.05 $445.50 $0.00 $0.00 $87.15 $0.00 $0.00 $88.65 $0.00 $0.00 $0.00 $0.00 $0.00 57-10320 SUP HCPCS C1713 57-10320 - PLATE SM 1MM 1.7MM SCR 6 HOLE L LCK VARIAX BONE 1.7MM RIGHT BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $151.59 $151.59 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $52.72 $0.00 $0.00 $53.63 $0.00 $0.00 $0.00 $0.00 $0.00 57-10321 SUP HCPCS C1713 57-10321 - PLATE SM 1MM 1.7MM SCR 6 HOLE L LCK VARIAX BONE 1.7MM LEFT BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $151.59 $151.59 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $52.72 $0.00 $0.00 $53.63 $0.00 $0.00 $0.00 $0.00 $0.00 57-10340 SUP HCPCS C1713 57-10340 - PLATE SM NAR 1MM 1.7MM SCR 6 HOLE T LCK PRFL VARIAX BONE BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $167.06 $167.06 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 57-10360 SUP HCPCS C1713 57-10360 - PLATE SM 1MM 1.7MM SCR 7 HOLE T LCK PRFL VARIAX BONE HAND BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $167.06 $167.06 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $58.10 $0.00 $0.00 $59.10 $0.00 $0.00 $0.00 $0.00 $0.00 57-10368 SUP HCPCS C1713 57-10368 - PLATE SM W 1MM 1.7MM SCR 8 HOLE T LCK PRFL VARIAX BONE HAND BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $182.53 $182.53 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $202.81 $321.26 $324.50 $0.00 $0.00 $63.48 $0.00 $0.00 $64.58 $0.00 $0.00 $0.00 $0.00 $0.00 57-10379 SUP HCPCS C1713 57-10379 - PLATE SM NAR 1MM 1.7MM SCR 9 HOLE Z LCK PRFL VARIAX BONE BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $219.66 $219.66 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $244.06 $386.60 $390.50 $0.00 $0.00 $76.39 $0.00 $0.00 $77.71 $0.00 $0.00 $0.00 $0.00 $0.00 57-10380 SUP HCPCS C1713 57-10380 - PLATE SM 1MM 1.7MM SCR 5 HOLE ROT LCK VARIAX BONE HAND BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $343.41 $343.41 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $381.56 $604.40 $610.50 $0.00 $0.00 $119.43 $0.00 $0.00 $121.49 $0.00 $0.00 $0.00 $0.00 $0.00 57-10390 SUP HCPCS C1713 57-10390 - PLATE SM 1MM 1.7MM SCR 2X2 HOLE 3D LCK VARIAX BONE 1.7MM BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $191.81 $191.81 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $213.13 $337.59 $341.00 $0.00 $0.00 $66.71 $0.00 $0.00 $67.86 $0.00 $0.00 $0.00 $0.00 $0.00 57-10391 SUP HCPCS C1713 57-10391 - PLATE 1MM 3X2 HOLE 3D VARIAX BONE 1.7MM HAND WRST BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $284.63 $284.63 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $98.99 $0.00 $0.00 $100.69 $0.00 $0.00 $0.00 $0.00 $0.00 57-10392 SUP HCPCS C1713 57-10392 - PLATE SM 1MM 1.7MM SCR 4X2 HOLE 3D LCK VARIAX BONE 1.7MM BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $343.41 $343.41 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $381.56 $604.40 $610.50 $0.00 $0.00 $119.43 $0.00 $0.00 $121.49 $0.00 $0.00 $0.00 $0.00 $0.00 57-10395 SUP HCPCS C1713 57-10395 - PLATE SM 1MM 1.7MM SCR 8 HOLE 3D LCK PRFL REPLANTATION BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $343.41 $343.41 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $381.56 $604.40 $610.50 $0.00 $0.00 $119.43 $0.00 $0.00 $121.49 $0.00 $0.00 $0.00 $0.00 $0.00 57-10397 SUP HCPCS C1713 57-10397 - PLATE SM 1MM 1.7MM SCR 2X2+2 HOLE 3D LCK VARIAX BONE HAND BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $284.63 $284.63 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $98.99 $0.00 $0.00 $100.69 $0.00 $0.00 $0.00 $0.00 $0.00 57-10402 SUP HCPCS C1713 57-10402 - PLATE MED 1MM 2.3MM SCR 4 HOLE STR CMPR PRFL BONE HAND BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $126.84 $126.84 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $140.94 $223.25 $225.50 $0.00 $0.00 $44.11 $0.00 $0.00 $44.87 $0.00 $0.00 $0.00 $0.00 $0.00 57-10407 SUP HCPCS C1713 57-10407 - PLATE MED 1MM 2.3MM SCR 6 HOLE STR CMPR PRFL PRFL BONE HAND BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $157.78 $157.78 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $54.87 $0.00 $0.00 $55.82 $0.00 $0.00 $0.00 $0.00 $0.00 57-10420 SUP HCPCS C1713 57-10420 - PLATE MED 1MM 2.3MM SCR 6 HOLE L CMPR PRFL BONE RIGHT HAND BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $157.78 $157.78 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $54.87 $0.00 $0.00 $55.82 $0.00 $0.00 $0.00 $0.00 $0.00 57-10421 SUP HCPCS C1713 57-10421 - PLATE MED 1MM 2.3MM SCR 6 HOLE L CMPR PRFL BONE LEFT HAND BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $157.78 $157.78 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $54.87 $0.00 $0.00 $55.82 $0.00 $0.00 $0.00 $0.00 $0.00 57-10440 SUP HCPCS C1713 57-10440 - PLATE MED NAR 1MM 2.3MM SCR 6 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $173.25 $173.25 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 57-10460 SUP HCPCS C1713 57-10460 - PLATE MED 1MM 2.3MM SCR 7 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $182.53 $182.53 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $202.81 $321.26 $324.50 $0.00 $0.00 $63.48 $0.00 $0.00 $64.58 $0.00 $0.00 $0.00 $0.00 $0.00 57-10470 SUP HCPCS C1713 57-10470 - PLATE NAR MED 1MM 2.3MM SCR 7 HOLE Y CMPR PRFL BONE HAND BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $204.19 $204.19 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $226.88 $359.37 $363.00 $0.00 $0.00 $71.01 $0.00 $0.00 $72.24 $0.00 $0.00 $0.00 $0.00 $0.00 57-10482 SUP HCPCS C1713 57-10482 - PLATE MED 1MM 2.3MM SCR 6 HOLE BLADE CMPR PRFL BONE 2.3MM BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $173.25 $173.25 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 57-10483 SUP HCPCS C1713 57-10483 - PLATE MED 1MM 2.3MM SCR 6 HOLE BLADE CMPR PRFL BONE LEFT BOTH IP/OP $630.00 $466.20 $0.00 $467.59 $173.25 $173.25 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 57-13102 SUP HCPCS C1713 57-13102 - PLATE LG 1.3MM TI SM FRAG SYS 4 HOLE STR BAR CMPR PRFL BONE BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $129.32 $129.32 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $44.97 $0.00 $0.00 $45.75 $0.00 $0.00 $0.00 $0.00 $0.00 57-13105 SUP HCPCS C1713 57-13105 - PLATE LG 1.3MM TI SM FRAG SYS 5 HOLE STR BAR CMPR PRFL BONE BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $138.60 $138.60 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 57-13108 SUP HCPCS C1713 57-13108 - PLATE LG 1.3MM TI SM FRAG SYS 6 HOLE STR BAR CMPR PRFL BONE BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $162.11 $162.11 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $180.13 $285.32 $288.20 $0.00 $0.00 $56.38 $0.00 $0.00 $57.35 $0.00 $0.00 $0.00 $0.00 $0.00 57-13109 SUP HCPCS C1713 57-13109 - PLATE LG 1.3MM TI SM FRAG SYS 7 HOLE STR BAR CMPR PRFL BONE BOTH IP/OP $634.00 $469.16 $0.00 $470.55 $175.11 $175.11 $0.00 $0.00 $0.00 $132.14 $470.55 $470.55 $0.00 $0.00 $132.13 $0.00 $375.01 $375.01 $0.00 $194.56 $308.19 $311.30 $0.00 $0.00 $60.90 $0.00 $0.00 $61.95 $0.00 $0.00 $0.00 $0.00 $0.00 57-13110 SUP HCPCS C1713 57-13110 - PLATE LG 1.3MM TI SM FRAG SYS 8 HOLE STR BAR CMPR PRFL BONE BOTH IP/OP $443.80 $328.41 $0.00 $336.60 $189.34 $189.34 $0.00 $0.00 $0.00 $92.50 $329.39 $329.39 $0.00 $0.00 $92.49 $0.00 $262.51 $262.51 $0.00 $210.38 $333.23 $336.60 $0.00 $0.00 $65.85 $0.00 $0.00 $66.98 $0.00 $0.00 $0.00 $0.00 $0.00 57-13120 SUP HCPCS C1713 57-13120 - PLATE LG 1.3MM TI SM FRAG SYS 6 HOLE L CMPR PRFL BONE HAND BOTH IP/OP $443.80 $328.41 $0.00 $329.39 $165.83 $165.83 $0.00 $0.00 $0.00 $92.50 $329.39 $329.39 $0.00 $0.00 $92.49 $0.00 $262.51 $262.51 $0.00 $184.25 $291.85 $294.80 $0.00 $0.00 $57.67 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 57-13121 SUP HCPCS C1713 57-13121 - PLATE LG 1.3MM TI SM FRAG SYS 6 HOLE L CMPR PRFL BONE HAND BOTH IP/OP $443.80 $328.41 $0.00 $329.39 $165.83 $165.83 $0.00 $0.00 $0.00 $92.50 $329.39 $329.39 $0.00 $0.00 $92.49 $0.00 $262.51 $262.51 $0.00 $184.25 $291.85 $294.80 $0.00 $0.00 $57.67 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 57-13140 SUP HCPCS C1713 57-13140 - PLATE LG 1.3MM TI SM FRAG SYS 6 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $443.80 $328.41 $0.00 $329.39 $165.83 $165.83 $0.00 $0.00 $0.00 $92.50 $329.39 $329.39 $0.00 $0.00 $92.49 $0.00 $262.51 $262.51 $0.00 $184.25 $291.85 $294.80 $0.00 $0.00 $57.67 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 57-13142 SUP HCPCS C1713 57-13142 - PLATE LG 1.3MM TI SM FRAG SYS 10 HOLE T BAR CMPR PRFL BONE BOTH IP/OP $443.80 $328.41 $0.00 $329.39 $180.06 $180.06 $0.00 $0.00 $0.00 $92.50 $329.39 $329.39 $0.00 $0.00 $92.49 $0.00 $262.51 $262.51 $0.00 $200.06 $316.90 $320.10 $0.00 $0.00 $62.62 $0.00 $0.00 $63.70 $0.00 $0.00 $0.00 $0.00 $0.00 57-13150 SUP HCPCS C1713 57-13150 - PLATE LG 1.3MM TI SM FRAG SYS 6 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $443.80 $328.41 $0.00 $329.39 $165.83 $165.83 $0.00 $0.00 $0.00 $92.50 $329.39 $329.39 $0.00 $0.00 $92.49 $0.00 $262.51 $262.51 $0.00 $184.25 $291.85 $294.80 $0.00 $0.00 $57.67 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 57-13151 SUP HCPCS C1713 57-13151 - PLATE LG 1.3MM TI SM FRAG SYS 6 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $443.80 $328.41 $0.00 $329.39 $165.83 $165.83 $0.00 $0.00 $0.00 $92.50 $329.39 $329.39 $0.00 $0.00 $92.49 $0.00 $262.51 $262.51 $0.00 $184.25 $291.85 $294.80 $0.00 $0.00 $57.67 $0.00 $0.00 $58.67 $0.00 $0.00 $0.00 $0.00 $0.00 57-13180 SUP HCPCS C1713 57-13180 - PLATE LG TI SM FRAG SET 5 HOLE MDLR ROT PRFL BONE HAND BOTH IP/OP $550.50 $407.37 $0.00 $647.90 $364.44 $364.44 $0.00 $0.00 $0.00 $114.74 $408.58 $408.58 $0.00 $0.00 $114.72 $0.00 $325.62 $325.62 $0.00 $404.94 $641.42 $647.90 $0.00 $0.00 $126.75 $0.00 $0.00 $128.93 $0.00 $0.00 $0.00 $0.00 $0.00 57-13185 SUP HCPCS C1713 57-13185 - PLATE STD W MED 1MM 5 HOLE ROT PRFL PRFL BONE 2.3MM HAND BOTH IP/OP $944.00 $698.56 $0.00 $700.64 $324.84 $324.84 $0.00 $0.00 $0.00 $196.75 $700.64 $700.64 $0.00 $0.00 $196.73 $0.00 $558.38 $558.38 $0.00 $360.94 $571.73 $577.50 $0.00 $0.00 $112.97 $0.00 $0.00 $114.92 $0.00 $0.00 $0.00 $0.00 $0.00 57-13402 SUP HCPCS C1713 57-13402 - PLATE 1.3MM 2.3MM SCR 4 HOLE L CMPR STR PRFL BONE HAND BOTH IP/OP $441.00 $326.34 $0.00 $327.31 $148.50 $148.50 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 57-13405 SUP HCPCS C1713 57-13405 - PLATE 1.3MM 2.3MM SCR 5 HOLE L CMPR STR PRFL BONE HAND BOTH IP/OP $441.00 $326.34 $0.00 $327.31 $157.78 $157.78 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $54.87 $0.00 $0.00 $55.82 $0.00 $0.00 $0.00 $0.00 $0.00 57-13408 SUP HCPCS C1713 57-13408 - PLATE LG 1.3MM 2.3MM SCR 6 HOLE L CMPR STR PRFL BONE 2.3MM BOTH IP/OP $441.00 $326.34 $0.00 $327.31 $182.53 $182.53 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $202.81 $321.26 $324.50 $0.00 $0.00 $63.48 $0.00 $0.00 $64.58 $0.00 $0.00 $0.00 $0.00 $0.00 57-13410 SUP HCPCS C1713 57-13410 - PLATE LG 1.3MM 2.3MM SCR 8 HOLE L CMPR STR PRFL BONE HAND BOTH IP/OP $441.00 $326.34 $0.00 $352.00 $198.00 $198.00 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $220.00 $348.48 $352.00 $0.00 $0.00 $68.86 $0.00 $0.00 $70.05 $0.00 $0.00 $0.00 $0.00 $0.00 57-13420 SUP HCPCS C1713 57-13420 - PLATE LG 1.3MM 2.3MM SCR 6 HOLE L CMPR PRFL BONE RIGHT BOTH IP/OP $441.00 $326.34 $0.00 $335.50 $188.72 $188.72 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $209.69 $332.15 $335.50 $0.00 $0.00 $65.63 $0.00 $0.00 $66.76 $0.00 $0.00 $0.00 $0.00 $0.00 57-13421 SUP HCPCS C1713 57-13421 - PLATE LG 1.3MM 2.3MM SCR 6 HOLE L CMPR PRFL BONE LEFT BOTH IP/OP $441.00 $326.34 $0.00 $335.50 $188.72 $188.72 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $209.69 $332.15 $335.50 $0.00 $0.00 $65.63 $0.00 $0.00 $66.76 $0.00 $0.00 $0.00 $0.00 $0.00 57-13440 SUP HCPCS C1713 57-13440 - PLATE NAR 1.3MM 2.3MM SCR 6 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $441.00 $326.34 $0.00 $335.50 $188.72 $188.72 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $209.69 $332.15 $335.50 $0.00 $0.00 $65.63 $0.00 $0.00 $66.76 $0.00 $0.00 $0.00 $0.00 $0.00 57-13442 SUP HCPCS C1713 57-13442 - PLATE NAR 1.3MM 2.3MM SCR 10 HOLE T CMPR PRFL BONE 2.3MM BOTH IP/OP $453.75 $335.78 $0.00 $363.00 $204.19 $204.19 $0.00 $0.00 $0.00 $94.57 $336.77 $336.77 $0.00 $0.00 $94.56 $0.00 $268.39 $268.39 $0.00 $226.88 $359.37 $363.00 $0.00 $0.00 $71.01 $0.00 $0.00 $72.24 $0.00 $0.00 $0.00 $0.00 $0.00 57-13450 SUP HCPCS C1713 57-13450 - PLATE LG 1.3MM 2.3MM SCR 6 HOLE T CMPR OBLQ PRFL BONE RIGHT BOTH IP/OP $441.00 $326.34 $0.00 $335.50 $188.72 $188.72 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $209.69 $332.15 $335.50 $0.00 $0.00 $65.63 $0.00 $0.00 $66.76 $0.00 $0.00 $0.00 $0.00 $0.00 57-13451 SUP HCPCS C1713 57-13451 - PLATE LG 1.3MM 2.3MM SCR 6 HOLE T CMPR OBLQ PRFL BONE LEFT BOTH IP/OP $441.00 $326.34 $0.00 $335.50 $188.72 $188.72 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $209.69 $332.15 $335.50 $0.00 $0.00 $65.63 $0.00 $0.00 $66.76 $0.00 $0.00 $0.00 $0.00 $0.00 57-13906 SUP HCPCS C1713 57-13906 - PLATE LG 1.3MM 2.3MM SCR 6 HOLE T CMPR PRFL BONE HAND BOTH IP/OP $441.00 $326.34 $0.00 $335.50 $188.72 $188.72 $0.00 $0.00 $0.00 $91.92 $327.31 $327.31 $0.00 $0.00 $91.90 $0.00 $260.85 $260.85 $0.00 $209.69 $332.15 $335.50 $0.00 $0.00 $65.63 $0.00 $0.00 $66.76 $0.00 $0.00 $0.00 $0.00 $0.00 57-15301 SUP HCPCS C1713 57-15301 - PLATE BN MED STRG 1.5MM VARIAX 4 HL LCK PRECONTOUR HND 2.3MM BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $123.75 $123.75 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 57-15302 SUP HCPCS C1713 57-15302 - PLATE MED 1.5MM 2.3MM SCR 4 HOLE LCK STR BAR VARIAX BONE BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $126.84 $126.84 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $140.94 $223.25 $225.50 $0.00 $0.00 $44.11 $0.00 $0.00 $44.87 $0.00 $0.00 $0.00 $0.00 $0.00 57-15316 SUP HCPCS C1713 57-15316 - PLATE MED 1.5MM 2.3MM SCR 16 HOLE LCK STR PRFL VARIAX BONE BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $259.88 $259.88 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $288.75 $457.38 $462.00 $0.00 $0.00 $90.38 $0.00 $0.00 $91.94 $0.00 $0.00 $0.00 $0.00 $0.00 57-15320 SUP HCPCS C1713 57-15320 - PLATE MED RIGHT HAND 1.5MM 2.3MM SCR 6 HOLE L LCK VARIAX BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $151.59 $151.59 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $52.72 $0.00 $0.00 $53.63 $0.00 $0.00 $0.00 $0.00 $0.00 57-15321 SUP HCPCS C1713 57-15321 - PLATE MED LEFT HAND 1.5MM 2.3MM SCR 6 HOLE L LCK VARIAX BONE BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $151.59 $151.59 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $168.44 $266.81 $269.50 $0.00 $0.00 $52.72 $0.00 $0.00 $53.63 $0.00 $0.00 $0.00 $0.00 $0.00 57-15324 SUP HCPCS C1713 57-15324 - PLATE 1.5MM 5 HOLE 5 VARIAX BONE 2.3MM LEFT HAND WRST BOTH IP/OP $979.00 $724.46 $0.00 $731.50 $411.47 $411.47 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $457.19 $724.19 $731.50 $0.00 $0.00 $143.10 $0.00 $0.00 $145.57 $0.00 $0.00 $0.00 $0.00 $0.00 57-15325 SUP HCPCS C1713 57-15325 - PLATE MED 1.5MM 2.3MM SCR 5 HOLE MC5 LCK VARIAX BONE 2.3MM BOTH IP/OP $979.00 $724.46 $0.00 $731.50 $411.47 $411.47 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $457.19 $724.19 $731.50 $0.00 $0.00 $143.10 $0.00 $0.00 $145.57 $0.00 $0.00 $0.00 $0.00 $0.00 57-15340 SUP HCPCS C1713 57-15340 - PLATE BN MED NAR T 1.5MM VARIAX 6 HL LCK PRECONTOUR HND 2.3 BOTH IP/OP $725.00 $536.50 $0.00 $538.10 $157.78 $157.78 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $54.87 $0.00 $0.00 $55.82 $0.00 $0.00 $0.00 $0.00 $0.00 57-15360 SUP HCPCS C1713 57-15360 - PLATE MED 1.5MM 2.3MM SCR 7 HOLE T LCK VARIAX BONE HAND BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $173.25 $173.25 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 57-15361 SUP HCPCS C1713 57-15361 - PLATE MED W 1.5MM 2.3MM SCR 8 HOLE T LCK VARIAX BONE HAND BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $182.53 $182.53 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $202.81 $321.26 $324.50 $0.00 $0.00 $63.48 $0.00 $0.00 $64.58 $0.00 $0.00 $0.00 $0.00 $0.00 57-15370 SUP HCPCS C1713 57-15370 - PLATE BN MED NAR T 1.5MM VARIAX 7 HL LCK PRECONTOUR HND 2.3 BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $198.00 $198.00 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $220.00 $348.48 $352.00 $0.00 $0.00 $68.86 $0.00 $0.00 $70.05 $0.00 $0.00 $0.00 $0.00 $0.00 57-15379 SUP HCPCS C1713 57-15379 - PLATE MED NAR 1.5MM 2.3MM SCR 13 HOLE Z LCK PRFL VARIAX BONE BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $219.66 $219.66 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $244.06 $386.60 $390.50 $0.00 $0.00 $76.39 $0.00 $0.00 $77.71 $0.00 $0.00 $0.00 $0.00 $0.00 57-15385 SUP HCPCS C1713 57-15385 - PLATE MED 1.5MM 2.3MM SCR 5 HOLE LCK ROT PRFL VARIAX BONE BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $408.38 $408.38 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $453.75 $718.74 $726.00 $0.00 $0.00 $142.02 $0.00 $0.00 $144.47 $0.00 $0.00 $0.00 $0.00 $0.00 57-15390 SUP HCPCS C1713 57-15390 - PLATE MED 1.5MM 2.3MM SCR 2X2 HOLE 3D LCK VARIAX BONE 2.3MM BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $266.06 $266.06 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $295.63 $468.27 $473.00 $0.00 $0.00 $92.53 $0.00 $0.00 $94.13 $0.00 $0.00 $0.00 $0.00 $0.00 57-15391 SUP HCPCS C1713 57-15391 - PLATE MED 1.5MM 2.3MM SCR 3X2 HOLE 3D LCK VARIAX BONE 2.3MM BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $284.63 $284.63 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $98.99 $0.00 $0.00 $100.69 $0.00 $0.00 $0.00 $0.00 $0.00 57-15392 SUP HCPCS C1713 57-15392 - PLATE MED 1.5MM 2.3MM SCR 4X2 HOLE 3D LCK PRFL VARIAX BONE BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $343.41 $343.41 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $381.56 $604.40 $610.50 $0.00 $0.00 $119.43 $0.00 $0.00 $121.49 $0.00 $0.00 $0.00 $0.00 $0.00 57-15395 SUP HCPCS C1713 57-15395 - PLATE MED 1.5MM 2.3MM SCR 4X2 HOLE 3D LCK REPLANTATION PRFL BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $321.75 $321.75 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $357.50 $566.28 $572.00 $0.00 $0.00 $111.90 $0.00 $0.00 $113.83 $0.00 $0.00 $0.00 $0.00 $0.00 57-15397 SUP HCPCS C1713 57-15397 - PLATE MED 1.5MM 2.3MM SCR 2X2+ 2 HOLE 3D LCK VARIAX BONE 2.3 BOTH IP/OP $979.00 $724.46 $0.00 $726.61 $284.63 $284.63 $0.00 $0.00 $0.00 $204.05 $726.61 $726.61 $0.00 $0.00 $204.02 $0.00 $579.08 $579.08 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $98.99 $0.00 $0.00 $100.69 $0.00 $0.00 $0.00 $0.00 $0.00 57525P SUP HCPCS C1713 57525P - SCREW BN 5.75MM 25MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57525S SUP HCPCS C1713 57525S - SCREW BN STD 5.75MM 25MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57530P SUP HCPCS C1713 57530P - SCREW BN 5.75MM 30MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57530S SUP HCPCS C1713 57530S - SCREW BN STD 5.75MM 30MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57535P SUP HCPCS C1713 57535P - SCREW BN 5.75MM 35MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57535S SUP HCPCS C1713 57535S - SCREW BN STD 5.75MM 35MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57540P SUP HCPCS C1713 57540P - SCREW BN 5.75MM 40MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57540S SUP HCPCS C1713 57540S - SCREW BN STD 5.75MM 40MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57545P SUP HCPCS C1713 57545P - SCREW BN 5.75MM 45MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57545S SUP HCPCS C1713 57545S - SCREW BN STD 5.75MM 45MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57550P SUP HCPCS C1713 57550P - SCREW BN 5.75MM 50MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57550S SUP HCPCS C1713 57550S - SCREW BN STD 5.75MM 50MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57555P SUP HCPCS C1713 57555P - SCREW BN 5.75MM 55MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57555S SUP HCPCS C1713 57555S - SCREW BN STD 5.75MM 55MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57560P SUP HCPCS C1713 57560P - SCREW BN 5.75MM 60MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 57560S SUP HCPCS C1713 57560S - SCREW BN STD 5.75MM 60MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,233.33 " $912.66 $0.00 $986.66 $555.00 $555.00 $0.00 $0.00 $0.00 $257.06 $915.37 $915.37 $0.00 $0.00 $257.02 $0.00 $729.51 $729.51 $0.00 $616.66 $976.80 $986.66 $0.00 $0.00 $193.02 $0.00 $0.00 $196.35 $0.00 $0.00 $0.00 $0.00 $0.00 57565P SUP HCPCS C1713 57565P - SCREW BN 5.75MM 65MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$1,621.98 " "$1,200.27" $0.00 "$1,297.58" $729.89 $729.89 $0.00 $0.00 $0.00 $338.06 "$1,203.83" "$1,203.83" $0.00 $0.00 $338.02 $0.00 $959.40 $959.40 $0.00 $810.99 "$1,284.61" "$1,297.58" $0.00 $0.00 $253.84 $0.00 $0.00 $258.22 $0.00 $0.00 $0.00 $0.00 $0.00 57565S SUP HCPCS C1713 57565S - SCREW BN STD 5.75MM 65MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,233.33 " $912.66 $0.00 $986.66 $555.00 $555.00 $0.00 $0.00 $0.00 $257.06 $915.37 $915.37 $0.00 $0.00 $257.02 $0.00 $729.51 $729.51 $0.00 $616.66 $976.80 $986.66 $0.00 $0.00 $193.02 $0.00 $0.00 $196.35 $0.00 $0.00 $0.00 $0.00 $0.00 5770-1-000 SUP Custom 27203010 5770-1-000 - SET ORTH 3.2MM DRILL GUIDE BOTH IP/OP $382.25 $282.87 $0.00 $305.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.71 $283.71 $0.00 $0.00 $79.66 $0.00 $0.00 $0.00 $0.00 $191.13 $302.74 $305.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5770-3-000 SUP Custom 27203010 5770-3-000 - SET ORTH 3.2MM DRILL GUIDE NTRL BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5770-4-000 SUP Custom 27203010 5770-4-000 - SET ORTH 3.6MM DRILL GUIDE BOTH IP/OP $493.63 $365.29 $0.00 $394.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $366.37 $366.37 $0.00 $0.00 $102.87 $0.00 $0.00 $0.00 $0.00 $246.81 $390.95 $394.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5770-5-000 SUP Custom 27203010 5770-5-000 - SET ORTH 2MM DRILL GUIDE BOTH IP/OP $422.13 $312.38 $0.00 $337.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.30 $313.30 $0.00 $0.00 $87.97 $0.00 $0.00 $0.00 $0.00 $211.06 $334.33 $337.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5780-0-035 SUP HCPCS C1713 5780-0-035 - SCREW BONE CORT TAP BOTH IP/OP $105.88 $78.35 $0.00 $84.70 $47.64 $47.64 $0.00 $0.00 $0.00 $22.07 $78.58 $78.58 $0.00 $0.00 $22.06 $0.00 $62.63 $62.63 $0.00 $52.94 $83.86 $84.70 $0.00 $0.00 $16.57 $0.00 $0.00 $16.86 $0.00 $0.00 $0.00 $0.00 $0.00 5780-0-045 SUP HCPCS C1713 5780-0-045 - SCREW BONE CORT TAP BOTH IP/OP $411.13 $304.24 $0.00 $328.90 $185.01 $185.01 $0.00 $0.00 $0.00 $85.69 $305.14 $305.14 $0.00 $0.00 $85.68 $0.00 $243.18 $243.18 $0.00 $205.56 $325.61 $328.90 $0.00 $0.00 $64.34 $0.00 $0.00 $65.45 $0.00 $0.00 $0.00 $0.00 $0.00 5780-1-045 SUP Custom 27803010 5780-1-045 - TAP CORTICAL BONE SCREW BOTH IP/OP $411.13 $304.24 $0.00 $328.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.14 $305.14 $0.00 $0.00 $85.68 $0.00 $0.00 $0.00 $0.00 $205.56 $325.61 $328.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5781-0-014 SUP Custom 27203010 5781-0-014 - SLEEVE DRILL 1.4-2MM ICS BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $0.00 $0.00 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5781-0-027 SUP Custom 27203010 5781-0-027 - SLEEVE DRILL 2MM INS BOTH IP/OP $103.13 $76.32 $0.00 $82.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.54 $76.54 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $51.56 $81.68 $82.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5781-0-045 SUP Custom 27203010 5781-0-045 - SLEEVE DRILL 4.5MM TAP BOTH IP/OP $180.13 $133.30 $0.00 $144.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.69 $133.69 $0.00 $0.00 $37.54 $0.00 $0.00 $0.00 $0.00 $90.06 $142.66 $144.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5781-0-480 SUP Custom 27203010 5781-0-480 - SLEEVE DRILL 48MM BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $0.00 $0.00 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5781-0-530 SUP Custom 27203010 5781-0-530 - SLEEVE DRILL 53MM BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $0.00 $0.00 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5781-3-035 SUP Custom 27203010 5781-3-035 - GUIDE DRILL SM PNT BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5781-3-045 SUP Custom 27203010 5781-3-045 - GUIDE DRILL PNT BOTH IP/OP $240.63 $178.07 $0.00 $192.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.59 $178.59 $0.00 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $120.31 $190.58 $192.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5785-0-002 SUP Custom 27203010 5785-0-002 - FORCEP SURG LNG SCR BOTH IP/OP $67.38 $49.86 $0.00 $53.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.01 $50.01 $0.00 $0.00 $14.04 $0.00 $0.00 $0.00 $0.00 $33.69 $53.36 $53.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5785-0-003 SUP Custom 27203010 5785-0-003 - FORCEP SURG ICS PLT BOTH IP/OP $287.38 $212.66 $0.00 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.29 $213.29 $0.00 $0.00 $59.89 $0.00 $0.00 $0.00 $0.00 $143.69 $227.60 $229.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 58-12004E SUP HCPCS C1713 58-12004E - SCREW BONE 1.2MM 4MM HAND WRST STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12005E SUP HCPCS C1713 58-12005E - SCREW BONE 1.2MM 5MM HAND WRST STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12006E SUP HCPCS C1713 58-12006E - SCREW BONE 1.2MM 6MM HAND WRST STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12007E SUP HCPCS C1713 58-12007E - SCREW BONE 1.2MM 7MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12008E SUP HCPCS C1713 58-12008E - SCREW BONE 1.2MM 8MM HAND BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12009E SUP HCPCS C1713 58-12009E - SCREW BONE 1.2MM 9MM STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12010E SUP HCPCS C1713 58-12010E - SCREW BONE 1.2MM 10MM BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12012E SUP HCPCS C1713 58-12012E - SCREW BONE 1.2MM 12MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12014E SUP HCPCS C1713 58-12014E - SCREW BONE 1.2MM 14MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12016E SUP HCPCS C1713 58-12016E - SCREW BONE 1.2MM 16MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12018E SUP HCPCS C1713 58-12018E - SCREW BONE 1.2MM 18MM WR HND NLCKG STR CROSSPIN STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-12020E SUP HCPCS C1713 58-12020E - SCREW BONE 1.2MM 20MM WR HND NLCKG STR CROSSPIN STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-14003E SUP HCPCS C1713 58-14003E - SCREW BONE 1.4MM 3MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-14005E SUP HCPCS C1713 58-14005E - SCREW BONE 1.4MM 5MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-14007E SUP HCPCS C1713 58-14007E - SCREW BONE 1.4MM 7MM WR HND ER NLCKG STR CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-14009E SUP HCPCS C1713 58-14009E - SCREW BONE 1.4MM 9MM IMPL ER STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-17005 SUP HCPCS C1713 58-17005 - SCREW BONE 1.7MM 5MM HAND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17005E SUP HCPCS C1713 58-17005E - SCREW BONE 1.7MM 5MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-17006 SUP HCPCS C1713 58-17006 - SCREW BONE 1.7MM 6MM BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17007 SUP HCPCS C1713 58-17007 - SCREW BN 1.7MM 7MM HND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17008 SUP HCPCS C1713 58-17008 - SCREW BONE 1.7MM 8MM HAND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17008E SUP HCPCS C1713 58-17008E - SCREW BONE 1.7MM 8MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $22.93 $81.64 $81.64 $0.00 $0.00 $22.92 $0.00 $65.07 $65.07 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-17009 SUP HCPCS C1713 58-17009 - SCREW BONE 1.7MM 9MM BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17010 SUP HCPCS C1713 58-17010 - SCREW BONE 1.7MM 10MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17011 SUP HCPCS C1713 58-17011 - SCREW BONE 1.7MM 11MM HAND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17012 SUP HCPCS C1713 58-17012 - SCREW BONE 1.7MM 12MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17013 SUP HCPCS C1713 58-17013 - SCREW BONE 1.7MM 13MM BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17013E SUP HCPCS C1713 58-17013E - SCREW BONE 1.7MM 13MM HAND WRST SLFTAP STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-17014 SUP HCPCS C1713 58-17014 - SCREW BONE 1.7MM 14MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17015 SUP HCPCS C1713 58-17015 - SCREW BONE 1.7MM 15MM XPIN BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17015E SUP HCPCS C1713 58-17015E - SCREW BONE 1.7MM 15MM HAND WRST SLFTAP STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-17016 SUP HCPCS C1713 58-17016 - SCREW BONE 1.7MM 16MM XPIN BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17018 SUP HCPCS C1713 58-17018 - SCREW BONE 1.7MM 18MM HAND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17018E SUP HCPCS C1713 58-17018E - SCREW BONE 1.7MM 18MM HAND WRST SLFTAP STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-17020 SUP HCPCS C1713 58-17020 - SCREW BN 1.7MM 20MM NS VARIAX ST XPN BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17020E SUP HCPCS C1713 58-17020E - SCREW BONE 1.7MM 20MM HAND WRST SLFTAP STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-17022 SUP HCPCS C1713 58-17022 - SCREW BONE 1.7MM 22MM HAND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17022E SUP HCPCS C1713 58-17022E - SCREW BONE 1.7MM 22MM HAND WRST SLFTAP STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-17024 SUP HCPCS C1713 58-17024 - SCREW BONE 1.7MM 24MM BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-17024E SUP HCPCS C1713 58-17024E - SCREW BONE 1.7MM 24MM HAND WRST SLFTAP STRL BOTH IP/OP $116.20 $85.99 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.22 $86.24 $86.24 $0.00 $0.00 $24.22 $0.00 $68.73 $68.73 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-19005 SUP HCPCS C1713 58-19005 - SCREW BONE 1.9MM 5MM ER BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-19005E SUP HCPCS C1713 58-19005E - SCREW BONE 1.9MM 5MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-19008 SUP HCPCS C1713 58-19008 - SCREW BONE 1.9MM 8MM ER BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-19008E SUP HCPCS C1713 58-19008E - SCREW BONE 1.9MM 8MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-19010 SUP HCPCS C1713 58-19010 - SCREW BONE 2.5MM 10MM BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 58-19010E SUP HCPCS C1713 58-19010E - SCREW BONE 1.9MM 10MM CANC WR HND ER NLCKG STR CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-19012 SUP HCPCS C1713 58-19012 - SCREW BONE 1.9MM 12MM ER BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $43.31 $43.31 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 5820-009-030 SUP Custom 27203010 5820-009-030 - BURR SURG 3MM PRECISION BOTH IP/OP $505.88 $374.35 $0.00 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.46 $375.46 $0.00 $0.00 $105.42 $0.00 $0.00 $0.00 $0.00 $252.94 $400.66 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-009-040 SUP Custom 27203010 5820-009-040 - BURR SURG 4MM PRECISION BOTH IP/OP $505.88 $374.35 $0.00 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.46 $375.46 $0.00 $0.00 $105.42 $0.00 $0.00 $0.00 $0.00 $252.94 $400.66 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-009-050 SUP Custom 27203010 5820-009-050 - BURR SURG 5MM PRECISION BOTH IP/OP $505.88 $374.35 $0.00 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $375.46 $375.46 $0.00 $0.00 $105.42 $0.00 $0.00 $0.00 $0.00 $252.94 $400.66 $404.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-010-120 SUP Custom 27203010 5820-010-120 - BURR SURG ROUND FLUTE 2MM 5 NOTCH SOFT TOUCH SMOOTH CUT GOOD BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-010-130 SUP Custom 27203010 5820-010-130 - BURR SURG ROUND FLUTE 3MM 5 NOTCH SOFT TOUCH SMOOTH CUT GOOD BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-010-140 SUP Custom 27203010 5820-010-140 - BURR SURG ROUND 4MM ROUND SOFT TOUCH LATEX FREE ELITE BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-012-030 SUP Custom 27203010 5820-012-030 - BURR SURG ROUND DIAMOND 3MM 5 STEP NOTCH NUMBERED SAFETY BOTH IP/OP $303.78 $224.80 $0.00 $225.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.46 $225.46 $0.00 $0.00 $63.31 $0.00 $0.00 $0.00 $0.00 $132.21 $209.43 $211.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-012-040 SUP Custom 27203010 5820-012-040 - BURR SURG ROUND DIAMOND 4MM 5 NOTCH SMOOTH CUT GOOD CONTROL BOTH IP/OP $303.78 $224.80 $0.00 $243.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.46 $225.46 $0.00 $0.00 $63.31 $0.00 $0.00 $0.00 $0.00 $151.89 $240.59 $243.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-015-050 SUP Custom 27203010 5820-015-050 - BURR 5.0MM EGG BURR BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820-015-060 SUP Custom 27203010 5820-015-060 - BURR 6.0MM EGG BOTH IP/OP $310.50 $229.77 $0.00 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.45 $230.45 $0.00 $0.00 $64.71 $0.00 $0.00 $0.00 $0.00 $155.25 $245.92 $248.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820107430S1 SUP Custom 27203010 5820107430S1 - BIT DRILL 3MM 3.8MM LESS AGGRESSIVE NEURO STERILE BOTH IP/OP $300.30 $222.22 $0.00 $240.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.88 $222.88 $0.00 $0.00 $62.58 $0.00 $0.00 $0.00 $0.00 $150.15 $237.84 $240.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5820107530S3 SUP Custom 27203010 5820107530S3 - BIT DRILL 1.7MM NEURO BOTH IP/OP $288.75 $213.68 $0.00 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.31 $214.31 $0.00 $0.00 $60.18 $0.00 $0.00 $0.00 $0.00 $144.38 $228.69 $231.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 58-23006 SUP HCPCS C1713 58-23006 - SCREW BONE 2.3MM 6MM HAND NLCKG SLFTAP CROSSPIN BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23008 SUP HCPCS C1713 58-23008 - SCREW BONE 2.3MM 8MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23009 SUP HCPCS C1713 58-23009 - SCREW BONE 2.3MM 9MM HAND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23009E SUP HCPCS C1713 58-23009E - SCREW BONE 2.3MM 9MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23010 SUP HCPCS C1713 58-23010 - SCREW BONE 2.3MM 10MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23011 SUP HCPCS C1713 58-23011 - SCREW BONE 2.3MM 11MM HAND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23011E SUP HCPCS C1713 58-23011E - SCREW BONE 2.3MM 11MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23012 SUP HCPCS C1713 58-23012 - SCREW BONE 2.3MM 12MM HAND NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23012E SUP HCPCS C1713 58-23012E - SCREW BN 2.3MM 12MM STRL VARIAX PRFL ST LOPRFL RND XPN HD TI BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23013E SUP HCPCS C1713 58-23013E - SCREW BONE 2.3MM 13MM NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23014 SUP HCPCS C1713 58-23014 - SCREW BONE 2.3MM 14MM NLCKG XPIN BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23014E SUP HCPCS C1713 58-23014E - SCREW BN 2.3MM 14MM STRL VARIAX PRFL ST LOPRFL RND XPN HD TI BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23015 SUP HCPCS C1713 58-23015 - SCREW BONE 2.3MM 15MM NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $22.93 $81.64 $81.64 $0.00 $0.00 $22.92 $0.00 $65.07 $65.07 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23015E SUP HCPCS C1713 58-23015E - SCREW BONE 2.3MM 15MM NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23016 SUP HCPCS C1713 58-23016 - SCREW BONE 2.3MM 16MM NLCKG XPIN BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23016E SUP HCPCS C1713 58-23016E - SCREW BONE 2.3MM 16MM NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23018 SUP HCPCS C1713 58-23018 - SCREW BONE 2.3MM 18MM HAND NLCKG SLFTAP CROSSPIN BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23018E SUP HCPCS C1713 58-23018E - SCREW BONE 2.3MM 18MM NLCKG SLFTAP CROSSPIN BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23020 SUP HCPCS C1713 58-23020 - SCREW BONE 2.3MM 20MM HAND BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23020E SUP HCPCS C1713 58-23020E - SCREW BONE 2.3MM 20MM WR HND NLCKG STR CROSSPIN STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23022 SUP HCPCS C1713 58-23022 - SCREW BONE 2.3MM 22MM ORTH BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23022E SUP HCPCS C1713 58-23022E - SCREW BONE 2.3MM 22MM HAND WRST SLFTAP STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23024 SUP HCPCS C1713 58-23024 - SCREW BONE 2.3MM 24MM BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23024E SUP HCPCS C1713 58-23024E - SCREW BONE 2.3MM 24MM HAND WRST SLFTAP STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23026 SUP HCPCS C1713 58-23026 - SCREW BONE 2.3MM 26MM BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-23026E SUP HCPCS C1713 58-23026E - SCREW BONE 2.3MM 26MM WR HND NLCKG STR CROSSPIN STRL BOTH IP/OP $116.90 $86.51 $0.00 $88.00 $49.50 $49.50 $0.00 $0.00 $0.00 $24.36 $86.76 $86.76 $0.00 $0.00 $24.36 $0.00 $69.15 $69.15 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-25006 SUP HCPCS C1713 58-25006 - SCREW BONE 2.5MM 6MM ER BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-25006E SUP HCPCS C1713 58-25006E - SCREW BONE 2.5MM 6MM CANC WR HND ER NLCKG STR CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-25008 SUP HCPCS C1713 58-25008 - SCREW BONE 2.5MM 8MM ER BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-25008E SUP HCPCS C1713 58-25008E - SCREW BONE 2.5MM 8MM CANC WR HND ER NLCKG STR CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-25010 SUP HCPCS C1713 58-25010 - SCREW BONE 2.5MM 10MM ER BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-25010E SUP HCPCS C1713 58-25010E - SCREW BONE 2.5MM 10MM NLCKG SLFTAP CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 58-25012 SUP HCPCS C1713 58-25012 - SCREW BONE 2.5MM 12MM ER BOTH IP/OP $120.40 $89.10 $0.00 $89.36 $49.50 $49.50 $0.00 $0.00 $0.00 $25.09 $89.36 $89.36 $0.00 $0.00 $25.09 $0.00 $71.22 $71.22 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $17.22 $0.00 $0.00 $17.51 $0.00 $0.00 $0.00 $0.00 $0.00 58-25012E SUP HCPCS C1713 58-25012E - SCREW BONE 2.5MM 12MM CANC WR HND ER NLCKG STR CROSSPIN STRL BOTH IP/OP $116.88 $86.49 $0.00 $93.50 $52.59 $52.59 $0.00 $0.00 $0.00 $24.36 $86.74 $86.74 $0.00 $0.00 $24.36 $0.00 $69.13 $69.13 $0.00 $58.44 $92.57 $93.50 $0.00 $0.00 $18.29 $0.00 $0.00 $18.61 $0.00 $0.00 $0.00 $0.00 $0.00 5858-0-000 SUP Custom 27203010 5858-0-000 - GAUGE DEPTH SCR BOTH IP/OP "$1,024.38 " $758.04 $0.00 $819.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.29 $760.29 $0.00 $0.00 $213.48 $0.00 $0.00 $0.00 $0.00 $512.19 $811.31 $819.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5866-45 SUP Custom 27203010 5866-45 - SLEEVE LEAD ACCES BOTH IP/OP $47.50 $35.15 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.25 $35.25 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5867-3M SUP Custom 27203010 5867-3M - CAP LEAD 4.6-8.4FR 5MM 3.2MM IMPLTABLE PIN LOW PROFILE IS-1 BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 59-12004 SUP HCPCS C1713 59-12004 - SCREW BONE 1.2MM 4MM PRFL TI HAND MDLR SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12005 SUP HCPCS C1713 59-12005 - SCREW BONE 1.2MM 5MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12006 SUP HCPCS C1713 59-12006 - SCREW BONE 1.2MM 6MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12007 SUP HCPCS C1713 59-12007 - SCREW BONE 1.2MM 7MM PRFL TI HAND MDLR SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12008 SUP HCPCS C1713 59-12008 - SCREW BONE 1.2MM 8MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12009 SUP HCPCS C1713 59-12009 - SCREW BONE 1.2MM 9MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12010 SUP HCPCS C1713 59-12010 - SCREW BONE 1.2MM 10MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12011 SUP HCPCS C1713 59-12011 - SCREW BONE 1.2MM 11MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12012 SUP HCPCS C1713 59-12012 - SCREW BONE 1.2MM 12MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12013 SUP HCPCS C1713 59-12013 - SCREW BONE 1.2MM 13MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12014 SUP HCPCS C1713 59-12014 - SCREW BONE 1.2MM 14MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12016 SUP HCPCS C1713 59-12016 - SCREW BONE 1.2MM 16MM PRFL TI HAND WRST SLFTAP XFIT SM FRAG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12018 SUP HCPCS C1713 59-12018 - PLATE 18MM TI SLFTAP XFIT PRFL BONE 1.2MM HAND BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12020 SUP HCPCS C1713 59-12020 - PLATE 20MM TI SLFTAP XFIT PRFL BONE 1.2MM HAND BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-12049 SUP HCPCS C1713 59-12049 - WASHER 1.2MM WRST PRFL ORTH BOTH IP/OP $53.20 $39.37 $0.00 $39.49 $21.66 $21.66 $0.00 $0.00 $0.00 $11.09 $39.49 $39.49 $0.00 $0.00 $11.09 $0.00 $31.47 $31.47 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 59-12049E SUP HCPCS C1713 59-12049E - WASHER FOR 1.2 MM BONE SCREWS BOTH IP/OP $53.20 $39.37 $0.00 $39.49 $18.56 $18.56 $0.00 $0.00 $0.00 $11.09 $39.49 $39.49 $0.00 $0.00 $11.09 $0.00 $31.47 $31.47 $0.00 $20.63 $32.67 $33.00 $0.00 $0.00 $6.46 $0.00 $0.00 $6.57 $0.00 $0.00 $0.00 $0.00 $0.00 59-14003 SUP HCPCS C1713 59-14003 - SCREW BONE 1.4MM 3MM PRFL TI HAND SLFTAP XFIT ER SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-14005 SUP HCPCS C1713 59-14005 - SCREW BONE 1.4MM 5MM PRFL TI HAND SLFTAP XFIT ER SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-14007 SUP HCPCS C1713 59-14007 - SCREW BONE 1.4MM 7MM PRFL TI HAND SLFTAP XFIT ER SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-14009 SUP HCPCS C1713 59-14009 - SCREW BONE 1.4MM 9MM PRFL TI HAND SLFTAP XFIT ER SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-17005 SUP HCPCS C1713 59-17005 - SCREW BONE 1.7MM 5MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17006 SUP HCPCS C1713 59-17006 - SCREW BONE 1.7MM 6MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17007 SUP HCPCS C1713 59-17007 - SCREW BONE 1.7MM 7MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17008 SUP HCPCS C1713 59-17008 - SCREW BONE 1.7MM 8MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17009 SUP HCPCS C1713 59-17009 - SCREW BONE 1.7MM 9MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17010 SUP HCPCS C1713 59-17010 - SCREW BONE 1.7MM 10MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17011 SUP HCPCS C1713 59-17011 - SCREW BONE 1.7MM 11MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17012 SUP HCPCS C1713 59-17012 - SCREW BONE 1.7MM 12MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $112.75 $83.44 $0.00 $90.20 $50.74 $50.74 $0.00 $0.00 $0.00 $23.50 $83.68 $83.68 $0.00 $0.00 $23.50 $0.00 $66.69 $66.69 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17013 SUP HCPCS C1713 59-17013 - SCREW BONE 1.7MM 13MM PRFL TI HAND MDLR BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17014 SUP HCPCS C1713 59-17014 - SCREW BONE 1.7MM 14MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17015 SUP HCPCS C1713 59-17015 - SCREW BONE 1.7MM 15MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $43.31 $43.31 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $48.13 $76.23 $77.00 $0.00 $0.00 $15.06 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $0.00 59-17016 SUP HCPCS C1713 59-17016 - SCREW BONE 1.7MM 16MM PRFL TI HAND MDLR SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17017 SUP HCPCS C1713 59-17017 - SCREW BONE 1.7MM 17MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17018 SUP HCPCS C1713 59-17018 - SCREW BONE 1.7MM 18MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17019 SUP HCPCS C1713 59-17019 - SCREW BONE 1.7MM 19MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17020 SUP HCPCS C1713 59-17020 - SCREW BONE 1.7MM 20MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17021 SUP HCPCS C1713 59-17021 - SCREW BONE 1.7MM 21MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17022 SUP HCPCS C1713 59-17022 - SCREW BONE 1.7MM 22MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17023 SUP HCPCS C1713 59-17023 - SCREW BONE 1.7MM 23MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17024 SUP HCPCS C1713 59-17024 - SCREW BONE 1.7MM 24MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-17049 SUP HCPCS C1713 59-17049 - WASHER 1.7MM PRFL ORTH TI BOTH IP/OP $53.20 $39.37 $0.00 $39.49 $21.66 $21.66 $0.00 $0.00 $0.00 $11.09 $39.49 $39.49 $0.00 $0.00 $11.09 $0.00 $31.47 $31.47 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 59-17049E SUP HCPCS C1713 59-17049E - WASHER HAND WRST ORTH 1.7 MM SCR STRL BOTH IP/OP $53.20 $39.37 $0.00 $39.49 $18.56 $18.56 $0.00 $0.00 $0.00 $11.09 $39.49 $39.49 $0.00 $0.00 $11.09 $0.00 $31.47 $31.47 $0.00 $20.63 $32.67 $33.00 $0.00 $0.00 $6.46 $0.00 $0.00 $6.57 $0.00 $0.00 $0.00 $0.00 $0.00 59-19005 SUP HCPCS C1713 59-19005 - SCREW BONE 1.9MM 5MM PRFL TI HAND XFIT SLFTAP ER SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-19008 SUP HCPCS C1713 59-19008 - SCREW BONE 1.9MM 8MM PRFL TI HAND XFIT SLFTAP ER SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-19010 SUP HCPCS C1713 59-19010 - SCREW BONE 1.9MM 10MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-19012 SUP HCPCS C1713 59-19012 - SCREW BONE 1.9MM 12MM PRFL TI HAND XFIT SLFTAP ER SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-23006 SUP HCPCS C1713 59-23006 - SCREW BONE 2.3MM 6MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23007 SUP HCPCS C1713 59-23007 - SCREW BONE 2.3MM 7MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23008 SUP HCPCS C1713 59-23008 - SCREW BONE 2.3MM 8MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23009 SUP HCPCS C1713 59-23009 - SCREW BONE 2.3MM 9MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23010 SUP HCPCS C1713 59-23010 - SCREW BONE 2.3MM 10MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23011 SUP HCPCS C1713 59-23011 - SCREW BONE 2.3MM 11MM PRFL TI HAND SLFTAP XFIT SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23012 SUP HCPCS C1713 59-23012 - SCREW BONE 2.3MM 12MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23013 SUP HCPCS C1713 59-23013 - SCREW BONE 2.3MM 13MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23014 SUP HCPCS C1713 59-23014 - SCREW BONE 2.3MM 14MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23015 SUP HCPCS C1713 59-23015 - SCREW BONE 2.3MM 15MM PRFL TI HAND SLFTAP XFIT MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23016 SUP HCPCS C1713 59-23016 - SCREW BONE 2.3MM 16MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23017 SUP HCPCS C1713 59-23017 - SCREW BONE 2.3MM 17MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23018 SUP HCPCS C1713 59-23018 - SCREW BONE 2.3MM 18MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23019 SUP HCPCS C1713 59-23019 - SCREW BONE 2.3MM 19MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23020 SUP HCPCS C1713 59-23020 - SCREW BONE 2.3MM 20MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23021 SUP HCPCS C1713 59-23021 - SCREW BONE 2.3MM 21MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23022 SUP HCPCS C1713 59-23022 - SCREW BONE 2.3MM 22MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23023 SUP HCPCS C1713 59-23023 - SCREW BONE 2.3MM 23MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23024 SUP HCPCS C1713 59-23024 - SCREW BONE 2.3MM 24MM PRFL TI HAND SLFTAP XFIT BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23026 SUP HCPCS C1713 59-23026 - SCREW BONE 2.3MM 26MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23028 SUP HCPCS C1713 59-23028 - SCREW BONE 2.3MM 28MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23030 SUP HCPCS C1713 59-23030 - SCREW BONE 2.3MM 30MM PRFL TI HAND XFIT SLFTAP MDLR SM FRAG BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23032 SUP HCPCS C1713 59-23032 - SCREW BONE 2.3MM 32MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23034 SUP HCPCS C1713 59-23034 - SCREW BONE 2.3MM 34MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23036 SUP HCPCS C1713 59-23036 - SCREW BONE 2.3MM 36MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23038 SUP HCPCS C1713 59-23038 - SCREW BONE 2.3MM 38MM PRFL TI HAND WRST SLFTAP XFIT MDLR SM BOTH IP/OP $126.00 $93.24 $0.00 $93.52 $50.74 $50.74 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $56.38 $89.30 $90.20 $0.00 $0.00 $17.65 $0.00 $0.00 $17.95 $0.00 $0.00 $0.00 $0.00 $0.00 59-23049 SUP HCPCS C1713 59-23049 - WASHER 2.3MM PLT PRFL ORTH NONSTRL BOTH IP/OP $53.20 $39.37 $0.00 $39.49 $21.66 $21.66 $0.00 $0.00 $0.00 $11.09 $39.49 $39.49 $0.00 $0.00 $11.09 $0.00 $31.47 $31.47 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 59-23049E SUP HCPCS C1713 59-23049E - WASHER BONE ORTH 2.3 MM SCR STRL BOTH IP/OP $53.20 $39.37 $0.00 $39.49 $18.56 $18.56 $0.00 $0.00 $0.00 $11.09 $39.49 $39.49 $0.00 $0.00 $11.09 $0.00 $31.47 $31.47 $0.00 $20.63 $32.67 $33.00 $0.00 $0.00 $6.46 $0.00 $0.00 $6.57 $0.00 $0.00 $0.00 $0.00 $0.00 59-25006 SUP HCPCS C1713 59-25006 - SCREW BONE 2.5MM 6MM PRFL TI HAND MDLR XFIT SLFTAP ER SM BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-25008 SUP HCPCS C1713 59-25008 - SCREW BONE 2.5MM 8MM PRFL TI HAND ER SM FRAG SYS BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-25010 SUP HCPCS C1713 59-25010 - SCREW BONE 2.5MM 10MM PRFL TI HAND MDLR XFIT SLFTAP ER SM BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 59-25012 SUP HCPCS C1713 59-25012 - SCREW BONE 2.5MM 12MM PRFL TI HAND MDLR XFIT SLFTAP ER SM BOTH IP/OP $126.00 $93.24 $0.00 $96.80 $54.45 $54.45 $0.00 $0.00 $0.00 $26.26 $93.52 $93.52 $0.00 $0.00 $26.26 $0.00 $74.53 $74.53 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 595000S SUP HCPCS C1713 595000S - SCREW BONE OHS OCS ORTH HIP CMPR BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $44.55 $44.55 $0.00 $0.00 $0.00 $20.63 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $58.56 $58.56 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 596001S SUP HCPCS C1713 596001S - SCREW BONE 3MM 32.2MM OMEGA 2 SS ORTH HIP CMPR STRL BOTH IP/OP $116.80 $86.43 $0.00 $104.50 $58.78 $58.78 $0.00 $0.00 $0.00 $24.34 $86.69 $86.69 $0.00 $0.00 $24.34 $0.00 $69.09 $69.09 $0.00 $65.31 $103.46 $104.50 $0.00 $0.00 $20.44 $0.00 $0.00 $20.80 $0.00 $0.00 $0.00 $0.00 $0.00 597002S SUP HCPCS C1713 597002S - PLATE 130D STD BRL 47MM SS 2 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597003S SUP HCPCS C1713 597003S - SCREW BONE 47MM OMEGA 3 130D STD BRL HIP 3 HOLE CMPR KEY BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597004S SUP HCPCS C1713 597004S - PLATE 130D STD BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597005S SUP HCPCS C1713 597005S - PLATE 130D STD BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597006S SUP HCPCS C1713 597006S - PLATE 130D 111MM SS 6 HOLE STD BRL KEY OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597008S SUP HCPCS C1713 597008S - PLATE 130D STD BRL 143MM SS 8 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597010S SUP HCPCS C1713 597010S - PLATE 130D STD BRL 175MM SS 10 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597012S SUP HCPCS C1713 597012S - PLATE 130D STD BRL 207MM SS 12 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597022S SUP HCPCS C1713 597022S - PLATE 135D STD BRL 47MM SS SYS 2 HOLE KEY LP OMEGA3 CHS BONE BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597023S SUP HCPCS C1713 597023S - PLATE 135D STD BRL 63MM SS 3 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597024S SUP HCPCS C1713 597024S - PLATE 130D STD BRL OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597025S SUP HCPCS C1713 597025S - PLATE 135D STD BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597026S SUP HCPCS C1713 597026S - PLATE 135D STD BRL 111MM SS 6 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597028S SUP HCPCS C1713 597028S - PLATE 135D STD BRL 143MM SS 8 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597030S SUP HCPCS C1713 597030S - PLATE 135D STD BRL 175MM SS 10 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597032S SUP HCPCS C1713 597032S - PLATE 135D STD BRL 207MM SS 12 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597042S SUP HCPCS C1713 597042S - PLATE 140D STD BRL 47MM SS 2 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597043S SUP HCPCS C1713 597043S - PLATE 140D STD BRL 63MM SS 3 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597044S SUP HCPCS C1713 597044S - PLATE 140D STD BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597045S SUP HCPCS C1713 597045S - PLATE 140D STD BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597046S SUP HCPCS C1713 597046S - PLATE 140D STD BRL 111MM SS 6 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597048S SUP HCPCS C1713 597048S - PLATE 140D STD BRL 143MM SS 8 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597050S SUP HCPCS C1713 597050S - PLATE 140D STD BRL 175MM SS 10 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597052S SUP HCPCS C1713 597052S - PLATE 140D STD BRL 207MM SS 12 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597062S SUP HCPCS C1713 597062S - PLATE 145D STD BRL 47MM SS 2 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597063S SUP HCPCS C1713 597063S - PLATE 145D STD BRL 63MM SS 3 HOLE ANG KYLS CMPR OMEGA 3 BONE BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597064S SUP HCPCS C1713 597064S - PLATE 145D STD BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597065S SUP HCPCS C1713 597065S - PLATE 145D STD BRL 95MM 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597066S SUP HCPCS C1713 597066S - PLATE 145D STD BRL 111MM SS 6 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597068S SUP HCPCS C1713 597068S - PLATE 145D STD BRL 143MM SS 8 HOLE ANG KYLS CMPR OMEGA 3 BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597070S SUP HCPCS C1713 597070S - PLATE 145D STD BRL 175MM SS 10 HOLE ANG KYLS CMPR OMEGA 3 BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597072S SUP HCPCS C1713 597072S - PLATE 145D STD BRL 207MM SS 12 HOLE ANG KYLS CMPR OMEGA 3 BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597082S SUP HCPCS C1713 597082S - PLATE 150D STD BRL 47MM SS 2 HOLE ANG KYLS CMPR OMEGA 3 BONE BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597083S SUP HCPCS C1713 597083S - PLATE 150D STD BRL 63MM SS 3 HOLE ANG KYLS CMPR OMEGA 3 BONE BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597084S SUP HCPCS C1713 597084S - PLATE 150D STD BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597085S SUP HCPCS C1713 597085S - PLATE 150D STD BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597086S SUP HCPCS C1713 597086S - PLATE 150D STD BRL 111MM SS 6 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597088S SUP HCPCS C1713 597088S - PLATE 150D STD BRL 143MM SS 8 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597090S SUP HCPCS C1713 597090S - PLATE 150D STD BRL 175MM SS 10 HOLE ANG KYLS CMPR OMEGA 3 BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597092S SUP HCPCS C1713 597092S - PLATE 150D STD BRL 207MM SS 12 HOLE ANG KYLS CMPR OMEGA 3 BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597102S SUP HCPCS C1713 597102S - PLATE 130D STD BRL 47MM SS 2 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597103S SUP HCPCS C1713 597103S - PLATE 130D STD BRL SS 3 HOLE OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597104S SUP HCPCS C1713 597104S - PLATE 135D STD BRL 32MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597105S SUP HCPCS C1713 597105S - PLATE 130D STD BRL 95MM SS 5 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597106S SUP HCPCS C1713 597106S - PLATE 130D STD BRL 111MM SS 6 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597108S SUP HCPCS C1713 597108S - PLATE 130D STD BRL 143MM SS 8 HOLE LP KYLS OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597110S SUP HCPCS C1713 597110S - PLATE 130D STD BRL 10 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597112S SUP HCPCS C1713 597112S - PLATE 130D STD BRL 207MM SS 12 HOLE ANG KYLS CMPR OMEGA 3 BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597122S SUP HCPCS C1713 597122S - PLATE 135D STD BRL 47MM SS 2 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597123S SUP HCPCS C1713 597123S - PLATE 135D 3 HOLE OMEGA 3 BONE KNEE STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597124S SUP HCPCS C1713 597124S - PLATE 135D STD BRL 79MM SS 4 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597125S SUP HCPCS C1713 597125S - PLATE 135D 5 HOLE OMEGA 3 BONE STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597126S SUP HCPCS C1713 597126S - PLATE STD BRL KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597128S SUP HCPCS C1713 597128S - PLATE 8 HOLE OMEGA 3 BONE HIP STRL BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597130S SUP HCPCS C1713 597130S - PLATE 135D STD BRL 175MM SS 10 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597132S SUP HCPCS C1713 597132S - PLATE 135D STD BRL 135MM 12 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597142S SUP HCPCS C1713 597142S - PLATE 140D STD BRL 47MM SS 2 HOLE ANG KYLS CMPR OMEGA 3 BONE BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597143S SUP HCPCS C1713 597143S - PLATE 140D STD BRL 63MM SS 3 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597144S SUP HCPCS C1713 597144S - PLATE 140D STD BRL 79MM 4 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597145S SUP HCPCS C1713 597145S - PLATE 140D STD BRL SS 5 HOLE OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597146S SUP HCPCS C1713 597146S - PLATE 140D STD BRL 111MM 6 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597148S SUP HCPCS C1713 597148S - PLATE 140D STD BRL 143MM 8 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597150S SUP HCPCS C1713 597150S - PLATE 140D STD BRL 175MM SS 10 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597152S SUP HCPCS C1713 597152S - PLATE 140D STD BRL 207MM SS 12 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597162S SUP HCPCS C1713 597162S - PLATE 145D STD BRL 47MM SS 2 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597163S SUP HCPCS C1713 597163S - PLATE 145D STD BRL 63MM SS 3 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597164S SUP HCPCS C1713 597164S - PLATE STD BRL 4 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597165S SUP HCPCS C1713 597165S - PLATE 145D STD BRL 95MM SS 5 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597166S SUP HCPCS C1713 597166S - PLATE 145D STD BRL 111MM 6 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597168S SUP HCPCS C1713 597168S - PLATE 145D STD BRL 143MM SS 8 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597170S SUP HCPCS C1713 597170S - PLATE 145D STD BRL 175MM SS 10 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597172S SUP HCPCS C1713 597172S - PLATE 145D STD BRL 207MM SS 12 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597182S SUP HCPCS C1713 597182S - PLATE 150D STD BRL 47MM SS 2 HOLE KYLS OMEGA 3 BONE HIP STRL BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597183S SUP HCPCS C1713 597183S - PLATE 150D STD BARRREL 63MM SS 3 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597184S SUP HCPCS C1713 597184S - PLATE 150D STD BARRREL 79MM SS 4 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597185S SUP HCPCS C1713 597185S - PLATE 150D STD BARRREL 95MM SS 5 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597186S SUP HCPCS C1713 597186S - PLATE 150D STD BRL 111MM 6 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $749.38 $554.54 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $156.19 $556.19 $556.19 $0.00 $0.00 $156.17 $0.00 $443.26 $443.26 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597188S SUP HCPCS C1713 597188S - PLATE 150D STD BARRREL 143MM SS 8 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597190S SUP HCPCS C1713 597190S - PLATE 150D STD BARRREL 175MM SS 10 HOLE KYLS OMEGA 3 BONE BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597192S SUP HCPCS C1713 597192S - PLATE 150D STD BARRREL 207MM SS 12 HOLE KYLS OMEGA 3 BONE BOTH IP/OP $916.00 $677.84 $0.00 $759.00 $426.94 $426.94 $0.00 $0.00 $0.00 $190.92 $679.86 $679.86 $0.00 $0.00 $190.89 $0.00 $541.81 $541.81 $0.00 $474.38 $751.41 $759.00 $0.00 $0.00 $148.48 $0.00 $0.00 $151.04 $0.00 $0.00 $0.00 $0.00 $0.00 597202S SUP HCPCS C1713 597202S - PLATE 130D SHRT BRL 47MM SS 2 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597203S SUP HCPCS C1713 597203S - PLATE 130D SHRT BRL SS 3 HOLE ANG KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597204S SUP HCPCS C1713 597204S - PLATE 130D SHRT BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597205S SUP HCPCS C1713 597205S - PLATE 130D SHRT BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597212S SUP HCPCS C1713 597212S - PLATE 135D SHRT BRL SS 2 HOLE ANG KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597213S SUP HCPCS C1713 597213S - PLATE 135D SHRT BRL SS 3 HOLE ANG KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597214S SUP HCPCS C1713 597214S - PLATE 135D SHRT BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597215S SUP HCPCS C1713 597215S - PLATE 135D SHRT BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597222S SUP HCPCS C1713 597222S - PLATE 140D SHRT BARRREL 47MM SS 2 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597223S SUP HCPCS C1713 597223S - PLATE 140D SHRT BARRREL 63MM SS 3 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597224S SUP HCPCS C1713 597224S - PLATE 140D SHRT BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597225S SUP HCPCS C1713 597225S - PLATE 140D SHRT BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597232S SUP HCPCS C1713 597232S - PLATE 145D SHRT BARRREL 47MM SS 2 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597233S SUP HCPCS C1713 597233S - PLATE 145D SHRT BARRREL 63MM SS 3 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597234S SUP HCPCS C1713 597234S - PLATE 145D SHRT BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597235S SUP HCPCS C1713 597235S - PLATE 145D SHRT BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597242S SUP HCPCS C1713 597242S - PLATE 150D SHRT BARRREL 47MM SS 2 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597243S SUP HCPCS C1713 597243S - PLATE 150D SHRT BARRREL 63MM SS 3 HOLE KEY OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597244S SUP HCPCS C1713 597244S - PLATE 150D SHRT BRL 79MM SS 4 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597245S SUP HCPCS C1713 597245S - PLATE 150D SHRT BRL 95MM SS 5 HOLE KEY OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597254S SUP HCPCS C1713 597254S - PLATE 130D SHRT BRL KYLS BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597255S SUP HCPCS C1713 597255S - PLATE 130D SHRT BRL 95MM SS 5 HOLE KYLS CMPR OMEGA 3 BONE BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597264S SUP HCPCS C1713 597264S - PLATE 135D SHRT BRL 79MM 5 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597265S SUP HCPCS C1713 597265S - PLATE 135D SHRT BRL 95MM SS 5 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597274S SUP HCPCS C1713 597274S - PLATE 140D SHRT BRL SS 4 HOLE OMEGA 3 BONE HIP STRL BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597275S SUP HCPCS C1713 597275S - PLATE 140D SHRT BARRREL 95MM SS 5 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597284S SUP HCPCS C1713 597284S - PLATE 145D SHRT BRL 79MM SS 4 HOLE KYLS LP OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597285S SUP HCPCS C1713 597285S - PLATE 145D SHRT BARRREL 95MM SS 5 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597294S SUP HCPCS C1713 597294S - PLATE 150D SHRT BARRREL 79MM SS 4 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597295S SUP HCPCS C1713 597295S - PLATE 150D SHRT BARRREL 25MM SS 5 HOLE KYLS OMEGA 3 BONE HIP BOTH IP/OP $724.00 $535.76 $0.00 $599.50 $337.22 $337.22 $0.00 $0.00 $0.00 $150.90 $537.35 $537.35 $0.00 $0.00 $150.88 $0.00 $428.25 $428.25 $0.00 $374.69 $593.51 $599.50 $0.00 $0.00 $117.28 $0.00 $0.00 $119.30 $0.00 $0.00 $0.00 $0.00 $0.00 597404S SUP HCPCS C1713 597404S - PLATE 135D 150MM SS 4 HOLE STAB OMEGA 3 BONE HIP STRL BOTH IP/OP "$1,228.00 " $908.72 $0.00 "$1,017.50" $572.34 $572.34 $0.00 $0.00 $0.00 $255.95 $911.42 $911.42 $0.00 $0.00 $255.92 $0.00 $726.36 $726.36 $0.00 $635.94 "$1,007.33" "$1,017.50" $0.00 $0.00 $199.05 $0.00 $0.00 $202.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0002 SUP HCPCS C1725 5A0002 - CATHETER ANGIO JR4 CRV 5FR 100CM STSR BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0007 SUP HCPCS C1725 5A0007 - CATHETER ANGIOGRAPHIC 3DRCB CURVE 5FR 100CM SITESEER BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0018 SUP HCPCS C1725 5A0018 - CATHETER ANGIO AL1 CRV 5FR 100CM STSR BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0021 SUP HCPCS C1725 5A0021 - CATHETER ANGIOGRAPHIC MPA1 CURVE 5FR 100CM SITESEER BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0031 SUP HCPCS C1725 5A0031 - CATHETER ANGIOGRAPHIC IM CURVE 5FR 100CM SITESEER BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0070 SUP HCPCS C1725 5A0070 - CATHETER ANGIOGRAPHIC PIGTAIL 145 CURVE 5FR 110CM 6 SIDEHOLE BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0084 SUP HCPCS C1725 5A0084 - CATHETER ANGIO JL3.5 CRV 5FR 100CM STSR BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0085 SUP HCPCS C1725 5A0085 - CATHETER ANGIOGRAPHIC JL4 CURVE 5FR 100CM SITESEER BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5A0087 SUP HCPCS C1725 5A0087 - CATHETER ANGIOGRAPHIC JL5 CURVE 5FR 100CM SITESEER BOTH IP/OP $21.88 $16.19 $0.00 $17.50 $11.88 $11.88 $0.00 $0.00 $0.00 $4.56 $16.24 $16.24 $0.00 $0.00 $4.56 $0.00 $12.94 $12.94 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 5B5136 SUP Custom 25803010 SOLUTION IV PERITONEAL BOTH IP/OP $123.75 $91.58 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.88 $98.01 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 5MAXACE132 SUP HCPCS C1887 5MAXACE132 - CATHETER REPERFUSION BOTH IP/OP "$5,725.00 " "$4,236.50" $0.00 "$6,189.46" "$3,353.03" "$3,353.03" $0.00 $0.00 $0.00 "$1,193.23" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,193.09" $0.00 "$6,189.46" "$6,189.46" $0.00 "$3,087.50" "$4,890.60" "$4,940.00" $0.00 $0.00 $966.39 $0.00 $0.00 $983.06 $0.00 $0.00 $0.00 $0.00 $0.00 5MAXACE132KIT SUP HCPCS C1887 5MAXACE132KIT - CATHETER REPERFUSION BOTH IP/OP "$6,062.50 " "$4,486.25" $0.00 "$4,850.00" "$3,291.94" "$3,291.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,031.25" "$4,801.50" "$4,850.00" $0.00 $0.00 $948.78 $0.00 $0.00 $965.15 $0.00 $0.00 $0.00 $0.00 $0.00 6 LGT SUP Custom 27203010 6 LGT - TUBE 50MM 11.1MM 6.4MM UNCUF LRNTMY SHLY TRCH 6 STRL LATEX BOTH IP/OP $143.01 $105.83 $0.00 $114.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.51 $113.26 $114.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60.116.521 SUP HCPCS C1713 60.116.521 - PIN PUSH SCREW TYPE VAR ANG LOCKING GRAPHIC CASES NONSTRL BOTH IP/OP $113.25 $83.81 $0.00 $90.60 $50.96 $50.96 $0.00 $0.00 $0.00 $23.60 $84.05 $84.05 $0.00 $0.00 $23.60 $0.00 $66.99 $66.99 $0.00 $56.63 $89.69 $90.60 $0.00 $0.00 $17.72 $0.00 $0.00 $18.03 $0.00 $0.00 $0.00 $0.00 $0.00 60-00120 SUP Custom 27203010 60-00120 - GUIDE DRILL 14.5CM 2 END BOTH IP/OP $646.25 $478.23 $0.00 $517.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.65 $479.65 $0.00 $0.00 $134.68 $0.00 $0.00 $0.00 $0.00 $323.13 $511.83 $517.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000-215 SUP HCPCS C1713 6000-215 - SUB BNGFT 40X15MM PLEXUR 15D BCMPS VOID FILR WDG RESORB BOTH IP/OP "$1,370.00 " "$1,013.80" $0.00 "$1,096.00" $616.50 $616.50 $0.00 $0.00 $0.00 $285.54 "$1,016.81" "$1,016.81" $0.00 $0.00 $285.51 $0.00 $810.36 $810.36 $0.00 $685.00 "$1,085.04" "$1,096.00" $0.00 $0.00 $214.41 $0.00 $0.00 $218.10 $0.00 $0.00 $0.00 $0.00 $0.00 6000BL SUP Custom 27803010 6000BL - HOOK SPNL SPRL R90D LT OBLQ TI BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000BR SUP Custom 27803010 6000BR - HOOK SPNL SPRL R90D RT OBLQ TI BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000LL SUP Custom 27803010 6000LL - HOOK SPNL LG SPRL R90D TI LMR BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000LP SUP Custom 27803010 6000LP - HOOK SPNL LG SPRL R90D TI PDCL BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000ME SUP Custom 27803010 6000ME - HOOK SPNL MED SPRL R90D XTD TI LMR THOR BOTH IP/OP "$1,745.55 " "$1,291.71" $0.00 "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,295.55" "$1,295.55" $0.00 $0.00 $363.77 $0.00 $0.00 $0.00 $0.00 $872.78 "$1,382.48" "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000ML SUP Custom 27803010 6000ML - HOOK SPNL MED SPRL R90D TI LMR BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000MW SUP Custom 27803010 6000MW - HOOK SPNL MED SPRL R90D W TI LMR BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000SE SUP Custom 27803010 6000SE - HOOK SPNL SM SPRL R90D XTD TI LMR BOTH IP/OP "$1,745.55 " "$1,291.71" $0.00 "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,295.55" "$1,295.55" $0.00 $0.00 $363.77 $0.00 $0.00 $0.00 $0.00 $872.78 "$1,382.48" "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000SL SUP Custom 27803010 6000SL - HOOK SPNL SM SPRL R90D TI LMR BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000SP SUP Custom 27803010 6000SP - HOOK SPNL SM SPRL R90D TI PDCL BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000SW SUP Custom 27803010 6000SW - HOOK SPNL SM SPRL R90D W TI LMR BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6000TH SUP Custom 27803010 6000TH - HOOK SPNL SPRL R90D TI LMR THOR BOTH IP/OP "$1,662.43 " "$1,230.20" $0.00 "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.85" "$1,233.85" $0.00 $0.00 $346.45 $0.00 $0.00 $0.00 $0.00 $831.21 "$1,316.64" "$1,329.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-2200 SUP Custom 27803010 6001-2200 - HEAD FEMORAL +0MM C TAPER 22MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-2205 SUP Custom 27803010 6001-2205 - HEAD FEMORAL +5MM C TAPER 22MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-2600 SUP Custom 27803010 6001-2600 - HEAD FEMORAL +0MM C TAPER 26MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-2605 SUP Custom 27803010 6001-2605 - HEAD FEMORAL +5MM C TAPER 26MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-2610 SUP Custom 27803010 6001-2610 - HEAD FEMORAL +10MM C TAPER 26MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-2800 SUP Custom 27803010 6001-2800 - HEAD FEMORAL +0MM C TAPER 28MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-2805 SUP Custom 27803010 6001-2805 - HEAD FEMORAL +5MM C TAPER 28MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-2810 SUP Custom 27803010 6001-2810 - HEAD FEMORAL +10MM C TAPER 28MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-3200 SUP Custom 27803010 6001-3200 - HEAD FEMORAL +0MM C TAPER 32MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-3205 SUP Custom 27803010 6001-3205 - HEAD FEMORAL +5MM C TAPER 32MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-3210 SUP Custom 27803010 6001-3210 - HEAD FEMORAL +10MM C TAPER 32MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6001-3299 SUP Custom 27803010 6001-3299 - HEAD FEMORAL -5MM C TAPER 32MM COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6003-003-090 SUP HCPCS C1713 6003-003-090 - PIN FIX .125IN 3.54IN PRELOADED PINABALL NONSTRL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 6005LO SUP Custom 27803010 6005LO - HOOK SPNL 5MM SPRL R90D LT OFST TI BOTH IP/OP "$1,745.55 " "$1,291.71" $0.00 "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,295.55" "$1,295.55" $0.00 $0.00 $363.77 $0.00 $0.00 $0.00 $0.00 $872.78 "$1,382.48" "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6005RO SUP Custom 27803010 6005RO - HOOK SPNL 5MM SPRL R90D RT OFST TI BOTH IP/OP "$1,745.55 " "$1,291.71" $0.00 "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,295.55" "$1,295.55" $0.00 $0.00 $363.77 $0.00 $0.00 $0.00 $0.00 $872.78 "$1,382.48" "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-09504 SUP Custom 27100030 60-09504 - DRILL TWST .9MM 46MM 4MM STRYK SHFT 1.2MM SCR BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.92 $411.92 $0.00 $0.00 $115.66 $0.00 $0.00 $0.00 $0.00 $277.50 $439.56 $444.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-10115 SUP Custom 27203010 60-10115 - BIT DRILL 83MM 1MM TWST STRL BOTH IP/OP $161.50 $119.51 $0.00 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.87 $119.87 $0.00 $0.00 $33.66 $0.00 $0.00 $0.00 $0.00 $81.81 $129.59 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-10122 SUP Custom 27203010 60-10122 - BIT DRILL 90MM 1MM TWST STOP SHFT END 22MM STRL BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-10315 SUP Custom 27203010 60-10315 - BIT DRILL 76MM 1MM TWST AO STRL BOTH IP/OP $163.63 $121.09 $0.00 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.44 $121.44 $0.00 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $81.81 $129.59 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-10322 SUP Custom 27203010 60-10322 - BIT DRL 22MM AO SHFT QCK 1.2MM SCR BOTH IP/OP $168.30 $124.54 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-10415 SUP Custom 27203010 60-10415 - DRILL DNTL 1MM 16MM BIT TWST STOP BOTH IP/OP $163.63 $121.09 $0.00 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.44 $121.44 $0.00 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $81.81 $129.59 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-10422 SUP Custom 27203010 60-10422 - BIT DRILL 73MM 1MM 22MM STOP TWST DNTL SHFT END STRL BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-10506 SUP Custom 27100030 60-10506 - BIT DRILL TWIST 1MM 50MM 6MM STOP PROFYLE HAND STERILE SMALL BOTH IP/OP $224.18 $165.89 $0.00 $432.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.38 $166.38 $0.00 $0.00 $46.72 $0.00 $0.00 $0.00 $0.00 $270.00 $427.68 $432.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-10512 SUP Custom 27100030 60-10512 - BIT DRILL 12MM STOP 1MM 54MM 12MM TWIST STOP STERILE BOTH IP/OP $224.18 $165.89 $0.00 $444.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.38 $166.38 $0.00 $0.00 $46.72 $0.00 $0.00 $0.00 $0.00 $277.50 $439.56 $444.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6010LO SUP Custom 27803010 6010LO - HOOK SPNL 10MM SPRL R90D LT OFST TI BOTH IP/OP "$1,745.55 " "$1,291.71" $0.00 "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,295.55" "$1,295.55" $0.00 $0.00 $363.77 $0.00 $0.00 $0.00 $0.00 $872.78 "$1,382.48" "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6010RO SUP Custom 27803010 6010RO - HOOK SPNL 10MM SPRL R90D RT OFST TI BOTH IP/OP "$1,745.55 " "$1,291.71" $0.00 "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,295.55" "$1,295.55" $0.00 $0.00 $363.77 $0.00 $0.00 $0.00 $0.00 $872.78 "$1,382.48" "$1,396.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6012-0711 SUP HCPCS C1776 6012-0711 - STEM FEMORAL 7 11MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-0713 SUP HCPCS C1776 6012-0713 - STEM FEMORAL 7 13MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-0812 SUP HCPCS C1776 6012-0812 - STEM FEMORAL 8 12MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-0814 SUP HCPCS C1776 6012-0814 - STEM FEMORAL 8 14MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-0913 SUP HCPCS C1776 6012-0913 - STEM FEMORAL 9 13MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-0915 SUP HCPCS C1776 6012-0915 - STEM FEMORAL 9 15MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-1014 SUP HCPCS C1776 6012-1014 - STEM FEMORAL 10 14MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-1016 SUP HCPCS C1776 6012-1016 - STEM FEMORAL 10 16MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-1115 SUP HCPCS C1776 6012-1115 - STEM FEMORAL 11 15MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-1117 SUP HCPCS C1776 6012-1117 - STEM FEMORAL 11 17MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-1216 SUP HCPCS C1776 6012-1216 - STEM FEMORAL 12 16MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6012-1218 SUP HCPCS C1776 6012-1218 - STEM FEMORAL 12 18MM 155MM RSTOR TITANIUM HA HIP BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 601-251 SUP HCPCS C1887 MICROCATHETER RAPIDTRANSIT 150CM BOTH IP/OP "$1,760.00 " "$1,302.40" $0.00 "$1,408.00" $955.68 $955.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $880.00 "$1,393.92" "$1,408.00" $0.00 $0.00 $275.44 $0.00 $0.00 $280.19 $0.00 $0.00 $0.00 $0.00 $0.00 601251X SUP HCPCS C1751 601251X - MICROCATHETER CRBRVASC 2.3-2.8FR .021IN 150CM 50CM BOTH IP/OP "$1,775.10 " "$1,313.57" $0.00 "$1,420.08" $798.80 $798.80 $0.00 $0.00 $0.00 $369.98 "$1,317.48" "$1,317.48" $0.00 $0.00 $369.93 $0.00 "$1,049.97" "$1,049.97" $0.00 $887.55 "$1,405.88" "$1,420.08" $0.00 $0.00 $277.80 $0.00 $0.00 $282.60 $0.00 $0.00 $0.00 $0.00 $0.00 6013-0812 SUP HCPCS C1776 6013-0812 - STEM FEMORAL 8 12MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-0814 SUP HCPCS C1776 6013-0814 - STEM FEMORAL 8 14MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-0913 SUP HCPCS C1776 6013-0913 - STEM FEMORAL 9 13MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-0915 SUP HCPCS C1776 6013-0915 - STEM FEMORAL 9 15MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1014 SUP HCPCS C1776 6013-1014 - STEM FEMORAL 10 14MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1016 SUP HCPCS C1776 6013-1016 - STEM FEMORAL 10 16MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1115 SUP HCPCS C1776 6013-1115 - STEM FEMORAL 11 15MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1117 SUP HCPCS C1776 6013-1117 - STEM FEMORAL 11 17MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1216 SUP HCPCS C1776 6013-1216 - STEM FEMORAL 12 16MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1218 SUP HCPCS C1776 6013-1218 - STEM FEMORAL 12 18MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1317 SUP HCPCS C1776 6013-1317 - STEM FEMORAL 13 17MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1319 SUP HCPCS C1776 6013-1319 - STEM FEMORAL 13 19MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1418 SUP HCPCS C1776 6013-1418 - STEM FEMORAL 14 18MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 6013-1420 SUP HCPCS C1776 6013-1420 - STEM FEMORAL 14 20MM 205MM RSTOR TITANIUM HA HIP BOTH IP/OP "$12,550.00 " "$9,287.00" $0.00 "$10,040.00" "$5,647.50" "$5,647.50" $0.00 $0.00 $0.00 "$2,615.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,615.42" $0.00 "$6,187.15" "$6,187.15" $0.00 "$6,275.00" "$9,939.60" "$10,040.00" $0.00 $0.00 "$1,964.08" $0.00 $0.00 "$1,997.96" $0.00 $0.00 $0.00 $0.00 $0.00 60-13506 SUP Custom 27100030 60-13506 - BIT DRILL 6MM STOP 1.3MM 50MM 6MM TWIST STOP STERILE BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.21 $408.21 $0.00 $0.00 $114.62 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-13512 SUP Custom 27100030 60-13512 - DRILL TWST 1.3MM 54MM STRL 12MM LEIBINGER UNV 2 12MM SCR BOTH IP/OP $236.25 $174.83 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.34 $175.34 $0.00 $0.00 $49.23 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-13570 SUP Custom 27100030 60-13570 - BIT DRILL 12MM STOP 1.3MM 79MM TWIST STERILE BOTH IP/OP $242.15 $179.19 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.72 $179.72 $0.00 $0.00 $50.46 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-13712 SUP Custom 27100030 60-13712 - BIT DRILL STERILE 12 MM SCREW BOTH IP/OP $272.60 $201.72 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.32 $202.32 $0.00 $0.00 $56.81 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-14008 SUP Custom 27100030 60-14008 - BIT DRILL 1.4MM 8MM TWIST STERILE BOTH IP/OP $254.80 $188.55 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.11 $189.11 $0.00 $0.00 $53.10 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6014-0812L SUP HCPCS C1776 6014-0812L - STEM FEM 255MM 12MM BW RSTOR HYDRXAPT 8 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-0812R SUP HCPCS C1776 6014-0812R - STEM FEM 255MM 12MM RSTOR HYDRXAPT 8 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-0913L SUP HCPCS C1776 6014-0913L - STEM FEM 255MM 13MM BW RSTOR HYDRXAPT 9 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-0913R SUP HCPCS C1776 6014-0913R - STEM FEM 255MM 13MM BW RSTOR HYDRXAPT 9 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1014L SUP HCPCS C1776 6014-1014L - STEM FEM 255MM 14MM BW RSTOR HYDRXAPT 10 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1014R SUP HCPCS C1776 6014-1014R - STEM FEM 255MM 14MM BW RSTOR HYDRXAPT 10 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1115L SUP HCPCS C1776 6014-1115L - STEM FEM 255MM 15MM BW RSTOR HYDRXAPT 11 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1115R SUP HCPCS C1776 6014-1115R - STEM FEM 255MM 15MM BW RSTOR HYDRXAPT 11 RIGHT BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1216L SUP HCPCS C1776 6014-1216L - STEM FEM 255MM 16MM BW RSTOR HA 12 LNG LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1216R SUP HCPCS C1776 6014-1216R - STEM FEM 255MM 16MM BW RSTOR HYDRXAPT 12 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 60-14126 SUP Custom 27203010 60-14126 - BIT DRILL 94MM 1.4MM TWST STOP SHFT END 27MM STRL BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6014-1317L SUP HCPCS C1776 6014-1317L - STEM FEM 255MM 17MM BW RSTOR HYDRXAPT 13 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1317R SUP HCPCS C1776 6014-1317R - STEM FEM 255MM 17MM BW RSTOR HYDRXAPT 13 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1418L SUP HCPCS C1776 6014-1418L - STEM FEM 255MM 18MM BW RSTOR HYDRXAPT 14 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6014-1418R SUP HCPCS C1776 6014-1418R - STEM FEM 255MM 18MM BW RSTOR HYDRXAPT 14 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 60-14326 SUP Custom 27203010 60-14326 - BIT DRILL 87MM 1.4MM TWST AO STRL BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-14426 SUP Custom 27203010 60-14426 - BIT DRILL 77MM 1.4MM 27MM STOP TWST DNTL SHFT END STRL BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-15008 SUP Custom 27100030 60-15008 - BIT DRILL 1.5MM 50MM 8MM TWIST STOP STERILE BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-15020 SUP Custom 27100030 60-15020 - BIT DRILL TWIST 1.5MM 58MM 20MM STOP STERILE 20MM SCREW BOTH IP/OP $265.50 $196.47 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6015-0814L SUP HCPCS C1776 6015-0814L - STEM FEM 205MM 14MM BW RSTOR HYDRXAPT 8 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-0814R SUP HCPCS C1776 6015-0814R - STEM FEM 205MM 14MM BW RSTOR HYDRXAPT 8 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-0915L SUP HCPCS C1776 6015-0915L - STEM FEM 205MM 15MM BW RSTOR HYDRXAPT 9 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-0915R SUP HCPCS C1776 6015-0915R - STEM FEM 205MM 15MM BW RSTOR HYDRXAPT 9 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1016L SUP HCPCS C1776 6015-1016L - STEM FEM 205MM 16MM BW RSTOR HYDRXAPT 10 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1016R SUP HCPCS C1776 6015-1016R - STEM FEM 205MM 16MM BW RSTOR HYDRXAPT 10 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 60-15105 SUP Custom 27100030 60-15105 - BIT DRILL 5MM STOP 1.5MM 50MM 5MM TWIST STERILE 5MM SCREW BOTH IP/OP $265.50 $196.47 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6015-1117L SUP HCPCS C1776 6015-1117L - STEM FEM 205MM 17MM BW RSTOR HYDRXAPT 11 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1117R SUP HCPCS C1776 6015-1117R - STEM FEM 205MM 17MM BW RSTOR HYDRXAPT 11 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1218L SUP HCPCS C1776 6015-1218L - STEM FEM 205MM 18MM BW RSTOR HYDRXAPT 12 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1218R SUP HCPCS C1776 6015-1218R - STEM FEM 205 18MM BW RSTOR HYDRXAPT 12 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1319L SUP HCPCS C1776 6015-1319L - STEM FEM 205MM 19MM BW RSTOR HYDRXAPT 13 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1319R SUP HCPCS C1776 6015-1319R - STEM FEM 205MM 19MM BW RSTOR HYDRXAPT 13 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1420L SUP HCPCS C1776 6015-1420L - STEM FEM 205MM 20MM BW RSTOR HYDRXAPT 14 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6015-1420R SUP HCPCS C1776 6015-1420R - STEM FEM 205MM 20MM BW RSTOR HYDRXAPT 14 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 60-15920 SUP Custom 27100030 60-15920 - BIT DRILL 20MM STOP 1.5MM 107MM TWIST STERILE BOTH IP/OP $334.28 $247.37 $0.00 $610.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.10 $248.10 $0.00 $0.00 $69.66 $0.00 $0.00 $0.00 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-15998 SUP Custom 27203010 60-15998 - DRILL TWST 1.5MM 19MM 8MM BOTH IP/OP $827.50 $612.35 $0.00 $662.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $614.17 $614.17 $0.00 $0.00 $172.45 $0.00 $0.00 $0.00 $0.00 $413.75 $655.38 $662.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16005 SUP Custom 27203010 60-16005 - BIT DRILL 50MM 1.6MM 5MM STOP TWST 5MM STRL BOTH IP/OP $532.50 $394.05 $0.00 $395.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $395.22 $395.22 $0.00 $0.00 $110.97 $0.00 $0.00 $0.00 $0.00 $134.06 $212.36 $214.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16007 SUP Custom 27203010 60-16007 - DRILL TWST 1.6MM 50MM STRL 7MM STP BOTH IP/OP $570.00 $421.80 $0.00 $456.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $423.05 $423.05 $0.00 $0.00 $118.79 $0.00 $0.00 $0.00 $0.00 $285.00 $451.44 $456.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16035 SUP Custom 27100030 60-16035 - BIT DRILL 1.6MM 115MM TWIST NONSTRL 20MM SCREW BOTH IP/OP $642.50 $475.45 $0.00 $514.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $476.86 $476.86 $0.00 $0.00 $133.90 $0.00 $0.00 $0.00 $0.00 $321.25 $508.86 $514.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16050 SUP Custom 27100030 60-16050 - BIT DRILL 1.6MM 125MM PILOT SHAFT END STERILE 50MM SCREW BOTH IP/OP $307.55 $227.59 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.26 $228.26 $0.00 $0.00 $64.09 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16407 SUP Custom 27100030 60-16407 - BIT DRL 1.6MM 50MM NS 7MM DNTL SHFT END 2/2.3MM SCR BOTH IP/OP $255.85 $189.33 $0.00 $474.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.89 $189.89 $0.00 $0.00 $53.32 $0.00 $0.00 $0.00 $0.00 $296.25 $469.26 $474.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16435 SUP Custom 27100030 60-16435 - BIT DRL 1.6MM 115MM NS 20MM DNTL SHFT END 2/2.3MM SCR BOTH IP/OP $296.43 $219.36 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.01 $220.01 $0.00 $0.00 $61.77 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16526 SUP Custom 27203010 60-16526 - BIT DRILL TWIST 1.6MM 58MM 20MM STOP LEIBINGER HAND STERILE BOTH IP/OP $249.38 $184.54 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.09 $185.09 $0.00 $0.00 $51.97 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16535 SUP Custom 27100030 60-16535 - BIT DRILL TWIST 1.6MM 85MM 26MM STOP STERILE 20MM SCREW BOTH IP/OP $258.33 $191.16 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.73 $191.73 $0.00 $0.00 $53.83 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16908 SUP Custom 27100030 60-16908 - BIT DRILL 90D 8MM STOP 1.6MM 19MM 8MM DENTAL END STERILE 8MM BOTH IP/OP $238.75 $176.68 $0.00 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.20 $177.20 $0.00 $0.00 $49.76 $0.00 $0.00 $0.00 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-16918 SUP Custom 27100030 60-16918 - BIT DRL 1.6MM 29MM NS 18MM DNTL SHFT END 2/2.3MM SCR BOTH IP/OP $238.75 $176.68 $0.00 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.20 $177.20 $0.00 $0.00 $49.76 $0.00 $0.00 $0.00 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6017-0425A SUP HCPCS C1776 6017-0425A - STEM FEMORAL 4 25MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-0525A SUP HCPCS C1776 6017-0525A - STEM FEMORAL 5 25MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-0625A SUP HCPCS C1776 6017-0625A - STEM FEMORAL 6 25MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-0730A SUP HCPCS C1776 6017-0730A - STEM FEMORAL 7 30MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-0830A SUP HCPCS C1776 6017-0830A - STEM FEMORAL 8 30MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-0935A SUP HCPCS C1776 6017-0935A - STEM FEMORAL 9 35MM C TAPER OMNIFIT HA HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-1035A SUP HCPCS C1776 6017-1035A - STEM FEMORAL 10 35MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-1140A SUP HCPCS C1776 6017-1140A - STEM FEMORAL 11 40MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-1240A SUP HCPCS C1776 6017-1240A - STEM FEMORAL 12 40MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-1340A SUP HCPCS C1776 6017-1340A - STEM FEMORAL 13 40MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6017-1440A SUP HCPCS C1776 6017-1440A - STEM FEMORAL 14 40MM C TAPER OMNIFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6018-0814 SUP HCPCS C1776 6018-0814 - STEM FEMORAL 1.5 14MM 205MM RSTOR HYDRXAPT CALCAR HIP BOTH IP/OP "$15,140.00 " "$11,203.60" $0.00 "$12,112.00" "$6,813.00" "$6,813.00" $0.00 $0.00 $0.00 "$3,155.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,155.18" $0.00 "$7,464.02" "$7,464.02" $0.00 "$7,570.00" "$11,990.88" "$12,112.00" $0.00 $0.00 "$2,369.41" $0.00 $0.00 "$2,410.29" $0.00 $0.00 $0.00 $0.00 $0.00 6018-0915 SUP HCPCS C1776 6018-0915 - STEM FEMORAL 9 15MM 205MM REPLACEMENT RESECTION LEVEL SYSTEM BOTH IP/OP "$15,140.00 " "$11,203.60" $0.00 "$12,112.00" "$6,813.00" "$6,813.00" $0.00 $0.00 $0.00 "$3,155.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,155.18" $0.00 "$7,464.02" "$7,464.02" $0.00 "$7,570.00" "$11,990.88" "$12,112.00" $0.00 $0.00 "$2,369.41" $0.00 $0.00 "$2,410.29" $0.00 $0.00 $0.00 $0.00 $0.00 6018-1016 SUP HCPCS C1776 6018-1016 - STEM FEMORAL 10 16MM 205MM REPLACEMENT RESECTION LEVEL BOTH IP/OP "$15,140.00 " "$11,203.60" $0.00 "$12,112.00" "$6,813.00" "$6,813.00" $0.00 $0.00 $0.00 "$3,155.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,155.18" $0.00 "$7,464.02" "$7,464.02" $0.00 "$7,570.00" "$11,990.88" "$12,112.00" $0.00 $0.00 "$2,369.41" $0.00 $0.00 "$2,410.29" $0.00 $0.00 $0.00 $0.00 $0.00 6018-1117 SUP HCPCS C1776 6018-1117 - STEM FEMORAL 11 17MM 205MM REVISION RSTOR HYDRXAPT CALCAR BOTH IP/OP "$15,140.00 " "$11,203.60" $0.00 "$12,112.00" "$6,813.00" "$6,813.00" $0.00 $0.00 $0.00 "$3,155.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,155.18" $0.00 "$7,464.02" "$7,464.02" $0.00 "$7,570.00" "$11,990.88" "$12,112.00" $0.00 $0.00 "$2,369.41" $0.00 $0.00 "$2,410.29" $0.00 $0.00 $0.00 $0.00 $0.00 6018-1218 SUP HCPCS C1776 6018-1218 - STEM FEMORAL 12 18MM 205MM RSTOR HYDRXAPT CALCAR HIP BOTH IP/OP "$15,140.00 " "$11,203.60" $0.00 "$12,112.00" "$6,813.00" "$6,813.00" $0.00 $0.00 $0.00 "$3,155.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,155.18" $0.00 "$7,464.02" "$7,464.02" $0.00 "$7,570.00" "$11,990.88" "$12,112.00" $0.00 $0.00 "$2,369.41" $0.00 $0.00 "$2,410.29" $0.00 $0.00 $0.00 $0.00 $0.00 6018-1319 SUP HCPCS C1776 6018-1319 - STEM FEMORAL 13 19MM 205MM REVISION RSTOR HYDRXAPT CALCAR BOTH IP/OP "$15,140.00 " "$11,203.60" $0.00 "$12,112.00" "$6,813.00" "$6,813.00" $0.00 $0.00 $0.00 "$3,155.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,155.18" $0.00 "$7,464.02" "$7,464.02" $0.00 "$7,570.00" "$11,990.88" "$12,112.00" $0.00 $0.00 "$2,369.41" $0.00 $0.00 "$2,410.29" $0.00 $0.00 $0.00 $0.00 $0.00 6018-1420 SUP HCPCS C1776 6018-1420 - STEM FEMORAL 14 20MM 205MM REVISION RSTOR HYDRXAPT CALCAR BOTH IP/OP "$15,140.00 " "$11,203.60" $0.00 "$12,112.00" "$6,813.00" "$6,813.00" $0.00 $0.00 $0.00 "$3,155.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,155.18" $0.00 "$7,464.02" "$7,464.02" $0.00 "$7,570.00" "$11,990.88" "$12,112.00" $0.00 $0.00 "$2,369.41" $0.00 $0.00 "$2,410.29" $0.00 $0.00 $0.00 $0.00 $0.00 60-19035 SUP Custom 27100030 60-19035 - BIT DRILL TWIST 1.9MM 115MM 35MM SHAFT END STOP STERILE BOTH IP/OP $322.43 $238.60 $0.00 $574.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.30 $239.30 $0.00 $0.00 $67.19 $0.00 $0.00 $0.00 $0.00 $358.75 $568.26 $574.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6019-0814 SUP HCPCS C1776 6019-0814 - STEM FEM 205MM 14MM RSTOR HYDRXAPT 3 CLCR HIP BOTH IP/OP "$13,979.88 " "$10,345.11" $0.00 "$11,183.90" "$6,290.94" "$6,290.94" $0.00 $0.00 $0.00 "$2,913.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,913.41" $0.00 "$6,892.08" "$6,892.08" $0.00 "$6,989.94" "$11,072.06" "$11,183.90" $0.00 $0.00 "$2,187.85" $0.00 $0.00 "$2,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 6019-0915 SUP HCPCS C1776 6019-0915 - STEM FEM RSTOR HYDRXAPT 3 CLCR BOTH IP/OP "$13,979.88 " "$10,345.11" $0.00 "$11,183.90" "$6,290.94" "$6,290.94" $0.00 $0.00 $0.00 "$2,913.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,913.41" $0.00 "$6,892.08" "$6,892.08" $0.00 "$6,989.94" "$11,072.06" "$11,183.90" $0.00 $0.00 "$2,187.85" $0.00 $0.00 "$2,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 6019-1016 SUP HCPCS C1776 6019-1016 - STEM FEM 205MM 16MM RSTOR HYDRXAPT 3 CLCR HIP BOTH IP/OP "$13,979.88 " "$10,345.11" $0.00 "$11,183.90" "$6,290.94" "$6,290.94" $0.00 $0.00 $0.00 "$2,913.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,913.41" $0.00 "$6,892.08" "$6,892.08" $0.00 "$6,989.94" "$11,072.06" "$11,183.90" $0.00 $0.00 "$2,187.85" $0.00 $0.00 "$2,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 6019-1117 SUP HCPCS C1776 6019-1117 - STEM FEM 205MM 17MM REV RSTOR HYDRXAPT 11 CLCR HIP BOTH IP/OP "$13,979.88 " "$10,345.11" $0.00 "$11,183.90" "$6,290.94" "$6,290.94" $0.00 $0.00 $0.00 "$2,913.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,913.41" $0.00 "$6,892.08" "$6,892.08" $0.00 "$6,989.94" "$11,072.06" "$11,183.90" $0.00 $0.00 "$2,187.85" $0.00 $0.00 "$2,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 6019-1218 SUP HCPCS C1776 6019-1218 - STEM FEM 205MM 18MM REV RSTOR HYDRXAPT 12 CLCR HIP BOTH IP/OP "$13,979.88 " "$10,345.11" $0.00 "$11,183.90" "$6,290.94" "$6,290.94" $0.00 $0.00 $0.00 "$2,913.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,913.41" $0.00 "$6,892.08" "$6,892.08" $0.00 "$6,989.94" "$11,072.06" "$11,183.90" $0.00 $0.00 "$2,187.85" $0.00 $0.00 "$2,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 60-19126 SUP Custom 27203010 60-19126 - DRILL TWST 1.9MM 27MM STRYK END BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6019-1319 SUP HCPCS C1776 6019-1319 - STEM FEM 205MM 19MM REV RSTOR HYDRXAPT 13 CLCR HIP BOTH IP/OP "$13,979.88 " "$10,345.11" $0.00 "$11,183.90" "$6,290.94" "$6,290.94" $0.00 $0.00 $0.00 "$2,913.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,913.41" $0.00 "$6,892.08" "$6,892.08" $0.00 "$6,989.94" "$11,072.06" "$11,183.90" $0.00 $0.00 "$2,187.85" $0.00 $0.00 "$2,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 60-19140 SUP Custom 27203010 60-19140 - BIT DRILL 108MM 1.9MM VARIAX TWST SHFT END BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6019-1420 SUP HCPCS C1776 6019-1420 - STEM FEM 205MM 20MM REV RSTOR HYDRXAPT 14 CLCR HIP BOTH IP/OP "$13,979.88 " "$10,345.11" $0.00 "$11,183.90" "$6,290.94" "$6,290.94" $0.00 $0.00 $0.00 "$2,913.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,913.41" $0.00 "$6,892.08" "$6,892.08" $0.00 "$6,989.94" "$11,072.06" "$11,183.90" $0.00 $0.00 "$2,187.85" $0.00 $0.00 "$2,225.60" $0.00 $0.00 $0.00 $0.00 $0.00 60-19326 SUP Custom 27203010 60-19326 - BIT DRILL 87MM 1.9MM 27MM STOP TWST AO SHFT END STRL BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-19340 SUP Custom 27203010 60-19340 - BIT DRILL 105MM 1.9MM VARIAX DISTAL AO SHFT END RAD NONSTRL BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-19426 SUP Custom 27203010 60-19426 - BIT DRILL 77MM 1.9MM TWST DNTL SHFT END DISP BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-19435 SUP Custom 27100030 60-19435 - DRILL TWIST 1.9MM 115MM 35MM STOP STERILE 2.3MM SCREW BOTH IP/OP $335.40 $248.20 $0.00 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.93 $248.93 $0.00 $0.00 $69.90 $0.00 $0.00 $0.00 $0.00 $382.50 $605.88 $612.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-19440 SUP Custom 27203010 60-19440 - BIT DRILL 91MM 1.9MM 41MM STOP TWST DNTL SHFT END STRL BOTH IP/OP $168.30 $124.54 $0.00 $148.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $0.00 $0.00 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-19526 SUP Custom 27203010 60-19526 - BIT DRILL 1.9MM 58MM SHAFT END STERILE 20MM SCREW BOTH IP/OP $321.25 $237.73 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.43 $238.43 $0.00 $0.00 $66.95 $0.00 $0.00 $0.00 $0.00 $355.00 $562.32 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-19535 SUP Custom 27100030 60-19535 - BIT DRILL 1.9MM 85MM SHAFT END STERILE 20MM SCREW BOTH IP/OP $245.85 $181.93 $0.00 $442.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.47 $182.47 $0.00 $0.00 $51.24 $0.00 $0.00 $0.00 $0.00 $276.25 $437.58 $442.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-19908 SUP Custom 27100030 60-19908 - BIT DRILL 90D 8MM STOP 1.9MM 19MM DENTAL END STERILE 8MM BOTH IP/OP $238.75 $176.68 $0.00 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.20 $177.20 $0.00 $0.00 $49.76 $0.00 $0.00 $0.00 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-19918 SUP Custom 27100030 60-19918 - BIT DRILL 90D 18MM STOP 1.9MM 29MM DENTAL END STERILE 18MM BOTH IP/OP $238.75 $176.68 $0.00 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.20 $177.20 $0.00 $0.00 $49.76 $0.00 $0.00 $0.00 $0.00 $253.75 $401.94 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0030 SUP HCPCS C1776 6020-0030 - STEM FEMORAL 132D 0 33MM OFFST 86MM 30MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 60-20012 SUP Custom 27100030 60-20012 - BIT DRILL TWIST 2MM 62MM 13MM REPOSITION PIN STOP STERILE BOTH IP/OP $670.00 $495.80 $0.00 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $497.27 $497.27 $0.00 $0.00 $139.63 $0.00 $0.00 $0.00 $0.00 $335.00 $530.64 $536.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0130 SUP HCPCS C1776 6020-0130 - STEM FEMORAL 132D 1 34MM OFFST 110MM 30MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0230 SUP HCPCS C1776 6020-0230 - STEM FEMORAL 130D 2 35MM OFFST 115MM 30MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0335 SUP HCPCS C1776 6020-0335 - STEM FEMORAL 132D 3 39MM OFFST 120MM 35MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0435 SUP HCPCS C1776 6020-0435 - STEM FEMORAL 132D 4 40MM OFFST 125MM 35MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 60-20050 SUP Custom 27100030 60-20050 - BIT DRL 2MM 125MM NS 50MM STRYK SHFT END 2MM LG SCR BOTH IP/OP $368.75 $272.88 $0.00 $628.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.69 $273.69 $0.00 $0.00 $76.85 $0.00 $0.00 $0.00 $0.00 $392.50 $621.72 $628.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0537 SUP HCPCS C1776 6020-0537 - STEM FEMORAL 132D 5 44MM OFFST 130MM 37MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0637 SUP HCPCS C1776 6020-0637 - STEM FEMORAL 132D 6 45MM OFFST 135MM 37MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0740 SUP HCPCS C1776 6020-0740 - STEM FEMORAL 132D 7 48MM OFFST 140MM 40MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6020-0840 SUP HCPCS C1776 6020-0840 - STEM FEMORAL 132D 8 49MM OFFST 145MM 40MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 60-20185 SUP Custom 27203010 60-20185 - BIT DRILL 100MM 2MM 40MM STOP TWST DNTL SHFT END STRL BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6020-2530 SUP HCPCS C1776 6020-2530 - STEM FEMORAL 132D 2.5 36MM OFFST 118MM 30MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6020-3535 SUP HCPCS C1776 6020-3535 - STEM FEMORAL 132D 3.5 39MM OFFST 124MM 35MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 60-20385 SUP Custom 27203010 60-20385 - DRILL TWST 2MM 105MM STRL 40MM AO SHFT END STP DIST VARIAX BOTH IP/OP $166.38 $123.12 $0.00 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.48 $123.48 $0.00 $0.00 $34.67 $0.00 $0.00 $0.00 $0.00 $83.19 $131.77 $133.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6020-4535 SUP HCPCS C1776 6020-4535 - STEM FEMORAL 132D 4.5 41MM OFFST 129MM 35MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 60-20485 SUP Custom 27203010 60-20485 - BIT DRILL 100MM 2MM 40MM STOP TWST DNTL SHFT END STRL BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6020-5537 SUP HCPCS C1776 6020-5537 - STEM FEMORAL 132D 5.5 45MM OFFST 133MM 37MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0030 SUP HCPCS C1776 6021-0030 - STEM FEMORAL 127D 0 37MM OFFST 86MM 30MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0130 SUP HCPCS C1776 6021-0130 - STEM FEMORAL 127D 1 38MM OFFST 110MM 30MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0230 SUP HCPCS C1776 6021-0230 - STEM FEMORAL 127D 2 39MM OFFST 115MM 30MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0335 SUP HCPCS C1776 6021-0335 - STEM FEMORAL 127D 3 43MM OFFST 120MM 35MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0435 SUP HCPCS C1776 6021-0435 - STEM FEMORAL 127D 4 44MM OFFST 125MM 35MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0537 SUP HCPCS C1776 6021-0537 - STEM FEMORAL 127D 5 48MM OFFST 130MM 37MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0637 SUP HCPCS C1776 6021-0637 - STEM FEMORAL 127D 6 49MM OFFST 135MM 37MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0740 SUP HCPCS C1776 6021-0740 - STEM FEMORAL 127D 7 53MM OFFST 140MM 40MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-0840 SUP HCPCS C1776 6021-0840 - STEM FEMORAL 127D 8 54MM OFFST 145MM 40MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-2530 SUP HCPCS C1776 6021-2530 - STEM FEMORAL 127D 2.5 40MM OFFST 118MM 30MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-3535 SUP HCPCS C1776 6021-3535 - STEM FEMORAL 127D 3.5 43MM OFFST 124MM 35MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-4535 SUP HCPCS C1776 6021-4535 - STEM FEMORAL 127D 4.5 45MM OFFST 129MM 35MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6021-5537 SUP HCPCS C1776 6021-5537 - STEM FEMORAL 127D 5.5 49MM OFFST 133MM 37MM CEMENTLESS NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 60-23141 SUP Custom 27203010 60-23141 - DRILL TWST 2.3MM BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-23341 SUP Custom 27203010 60-23341 - DRILL TWST 2.3MM VARIAX DISTAL AO SHFT END RAD STRL BOTH IP/OP $168.30 $124.54 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.91 $124.91 $0.00 $0.00 $35.07 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-23441 SUP Custom 27203010 60-23441 - DRILL TWST 2.3MM DNTL SHFT END BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-25126 SUP Custom 27203010 60-25126 - BIT DRILL 94MM 2.5MM 26MM STOP TWST STRL BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-25326 SUP Custom 27203010 60-25326 - BIT DRILL 87MM 2.5MM PRFL HAND MDLR AO SHFT END 26MM SM FRAG BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-25426 SUP Custom 27203010 60-25426 - DRILL TWST 25MM 27MM WKG LN BOTH IP/OP $159.50 $118.03 $0.00 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.38 $118.38 $0.00 $0.00 $33.24 $0.00 $0.00 $0.00 $0.00 $79.75 $126.32 $127.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 602640S SUP HCPCS C1713 602640S - SCREW BN THRD 6.5MM 40MM STRL 20MM ASNS III CNN THRD TI HIP BOTH IP/OP $391.88 $289.99 $0.00 $483.20 $271.80 $271.80 $0.00 $0.00 $0.00 $81.68 $290.85 $290.85 $0.00 $0.00 $81.67 $0.00 $231.79 $231.79 $0.00 $302.00 $478.37 $483.20 $0.00 $0.00 $94.53 $0.00 $0.00 $96.16 $0.00 $0.00 $0.00 $0.00 $0.00 6033-0425 SUP HCPCS C1776 6033-0425 - STEM FEMORAL 4 25MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-0525 SUP HCPCS C1776 6033-0525 - STEM FEMORAL 5 25MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-0625 SUP HCPCS C1776 6033-0625 - STEM FEMORAL 6 25MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-0730 SUP HCPCS C1776 6033-0730 - STEM FEMORAL 7 30MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-0830 SUP HCPCS C1776 6033-0830 - STEM FEMORAL 8 30MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-0935 SUP HCPCS C1776 6033-0935 - STEM FEMORAL 9 35MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-1035 SUP HCPCS C1776 6033-1035 - STEM FEMORAL 10 35MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-1140 SUP HCPCS C1776 6033-1140 - STEM FEMORAL 11 40MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-1240 SUP HCPCS C1776 6033-1240 - STEM FEMORAL 12 40MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6033-1340 SUP HCPCS C1776 6033-1340 - STEM FEMORAL 13 40MM CEMENTED COLLARLESS NORMALIZE OMNIFIT BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-0425 SUP HCPCS C1776 6034-0425 - STEM FEMORAL 4 25MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-0525 SUP HCPCS C1776 6034-0525 - STEM FEMORAL 5 25MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-0625 SUP HCPCS C1776 6034-0625 - STEM FEMORAL 6 25MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-0730 SUP HCPCS C1776 6034-0730 - STEM FEMORAL 7 30MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-0830 SUP HCPCS C1776 6034-0830 - STEM FEMORAL 8 30MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-0935 SUP HCPCS C1776 6034-0935 - STEM FEMORAL 9 35MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-1035 SUP HCPCS C1776 6034-1035 - STEM FEMORAL 10 35MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-1140 SUP HCPCS C1776 6034-1140 - STEM FEMORAL 11 40MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-1240 SUP HCPCS C1776 6034-1240 - STEM FEMORAL 12 40MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6034-1340 SUP HCPCS C1776 6034-1340 - STEM FEMORAL 13 40MM CEMENTED COLLAR NORMALIZE OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6041-1140 SUP HCPCS C1776 6041-1140 - STEM FEM 40MM OMFT HYDRXAPT 11 HIP BOTH IP/OP "$5,592.00 " "$4,138.08" $0.00 "$4,473.60" "$2,516.40" "$2,516.40" $0.00 $0.00 $0.00 "$1,165.51" "$4,150.38" "$4,150.38" $0.00 $0.00 "$1,165.37" $0.00 "$2,756.86" "$2,756.86" $0.00 "$2,796.00" "$4,428.86" "$4,473.60" $0.00 $0.00 $875.15 $0.00 $0.00 $890.25 $0.00 $0.00 $0.00 $0.00 $0.00 6041-1240 SUP HCPCS C1776 6041-1240 - STEM FEM 40MM 12MM MRS TPR OSTNC HYDRXAPT HIP BOTH IP/OP "$5,592.00 " "$4,138.08" $0.00 "$4,473.60" "$2,516.40" "$2,516.40" $0.00 $0.00 $0.00 "$1,165.51" "$4,150.38" "$4,150.38" $0.00 $0.00 "$1,165.37" $0.00 "$2,756.86" "$2,756.86" $0.00 "$2,796.00" "$4,428.86" "$4,473.60" $0.00 $0.00 $875.15 $0.00 $0.00 $890.25 $0.00 $0.00 $0.00 $0.00 $0.00 6046-0625 SUP HCPCS C1776 6046-0625 - STEM FEM OMFLX HYDRXAPT 6 HIP BOTH IP/OP "$6,546.00 " "$4,844.04" $0.00 "$5,236.80" "$2,945.70" "$2,945.70" $0.00 $0.00 $0.00 "$1,364.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,364.19" $0.00 "$3,227.18" "$3,227.18" $0.00 "$3,273.00" "$5,184.43" "$5,236.80" $0.00 $0.00 "$1,024.45" $0.00 $0.00 "$1,042.12" $0.00 $0.00 $0.00 $0.00 $0.00 6046-0830 SUP HCPCS C1776 6046-0830 - STEM FEM OMFLX HYDRXAPT 8 HIP BOTH IP/OP "$6,546.00 " "$4,844.04" $0.00 "$5,236.80" "$2,945.70" "$2,945.70" $0.00 $0.00 $0.00 "$1,364.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,364.19" $0.00 "$3,227.18" "$3,227.18" $0.00 "$3,273.00" "$5,184.43" "$5,236.80" $0.00 $0.00 "$1,024.45" $0.00 $0.00 "$1,042.12" $0.00 $0.00 $0.00 $0.00 $0.00 6046-1440 SUP HCPCS C1776 6046-1440 - STEM FEM OMFLX HYDRXAPT 14 HIP BOTH IP/OP "$6,546.00 " "$4,844.04" $0.00 "$5,236.80" "$2,945.70" "$2,945.70" $0.00 $0.00 $0.00 "$1,364.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,364.19" $0.00 "$3,227.18" "$3,227.18" $0.00 "$3,273.00" "$5,184.43" "$5,236.80" $0.00 $0.00 "$1,024.45" $0.00 $0.00 "$1,042.12" $0.00 $0.00 $0.00 $0.00 $0.00 6048-58 SUP Custom 27203010 6048-58 - KIT STYLET BLUNT STR .014IN 58CM LEAD KNOB GREEN BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $0.00 $0.00 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6050-0530 SUP HCPCS C1776 6050-0530 - STEM FEMORAL 5 30MM HEAD NECK OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6050-0735 SUP HCPCS C1776 6050-0735 - IMPLANT KN 69 68.9MM ANT/POSTERIORX70.1MM MEDI STRL IB2MKS BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6050-0745 SUP HCPCS C1776 6050-0745 - STEM FEMORAL 7 45MM CEMENTED HEAD/NECK OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6050-0935 SUP HCPCS C1776 6050-0935 - STEM FEMORAL 9 C TAPER 12MM 160MM 35MM OMNIFIT HEAD NECK HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6050-0945 SUP HCPCS C1776 6050-0945 - STEM FEMORAL 9 45MM 160MM CEMENTED HEAD/NECK OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6050-0955 SUP HCPCS C1776 6050-0955 - STEM FEMORAL 55MM 55MM 9MM HEAD NECK OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6050-1135 SUP HCPCS C1776 6050-1135 - STEM FEMORAL 11 CEMENT OMNIFIT HIP BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6051-0425A SUP HCPCS C1776 6051-0425A - STEM FEM 100MM 8.1MM CMNTLS SECFIT HYDRXAPT 4 25MM HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6051-0425S SUP HCPCS C1776 6051-0425S - STEM FEMORAL 132D 4 29MM OFFST 8.1MM 100MM 25MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-0525A SUP HCPCS C1776 6051-0525A - STEM FEM 110MM 8.9MM CMNTLS SECFIT HYDRXAPT 5 25MM HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6051-0525S SUP HCPCS C1776 6051-0525S - STEM FEMORAL 132D 5 29MM OFFST 8.9MM 110MM 25MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-0625A SUP HCPCS C1776 6051-0625A - STEM FEM CMNTLS CTPR CLRLS SECFIT HYDRXAPT 6 25MM HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6051-0625S SUP HCPCS C1776 6051-0625S - STEM FEMORAL 132D 6 30MM OFFST 9.6MM 120MM 25MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-0730A SUP HCPCS C1776 6051-0730A - STEM FEM 7 10.4MM 13CM 30MM SCRFT BS NK DIST TIP HA HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6051-0730S SUP HCPCS C1776 6051-0730S - STEM FEMORAL 132D 7 35MM OFFST 10.4MM 130MM 30MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-0830A SUP HCPCS C1776 6051-0830A - STEM FEM 140MM 11.2MM CMNTLS SECFIT HYDRXAPT 8 30MM HIP STRL BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6051-0830S SUP HCPCS C1776 6051-0830S - STEM FEMORAL 132D 8 36MM OFFST 11.2MM 140MM 30MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-0935A SUP HCPCS C1776 6051-0935A - STEM FEM 11.9MM SECFIT HYDRXAPT 9 35MM HIP STRL BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6051-0935S SUP HCPCS C1776 6051-0935S - STEM FEMORAL 132D 9 40.8MM 11.9MM 15CM 35MM SECFIT MAX HA BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-1035A SUP HCPCS C1776 6051-1035A - STEM FEM 160MM 12.7MM CMNTLS SECFIT HYDRXAPT 10 35MM HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6051-1035S SUP HCPCS C1776 6051-1035S - STEM FEMORAL 132D 10 42MM OFFST 12.7MM 160MM 35MM NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-1140A SUP HCPCS C1776 6051-1140A - STEM FEM 40MM SECFIT MXHYDRXAPT 11 40MM HIP STRL BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6051-1140S SUP HCPCS C1776 6051-1140S - STEM FEMORAL 132D 11 46.5MM 13.5MM 17CM 40MM SECFIT MAX HA BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-1240A SUP HCPCS C1776 6051-1240A - STEM FEM 170MM 14.7MM CMNTLS SECFIT HYDRXAPT 12 40MM HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6051-1240S SUP HCPCS C1776 6051-1240S - STEM FEMORAL 132D 12 47MM OFFST 14.7MM 170MM 40MM NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-1340A SUP HCPCS C1776 6051-1340A - STEM FEM 13 48.2MM OFST 16MM 17CM 40MM SCRFT HA HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6051-1340S SUP HCPCS C1776 6051-1340S - STEM FEM 13 16MM 17CM 40MM SCRFT BS OFST HAP HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6051-1440A SUP HCPCS C1776 6051-1440A - STEM FEM 170MM 17.2MM CMNTLS SECFIT HYDRXAPT 14 40MM HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6051-1440S SUP HCPCS C1776 6051-1440S - STEM FEMORAL 132D 14 49MM OFFST 17.2MM 170MM 40MM NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6052-0625A SUP HCPCS C1776 6052-0625A - STEM FEM CMNTLS SECFIT HYDRXAPT 6 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6052-0625S SUP HCPCS C1776 6052-0625S - STEM FEMORAL 127D 6 33MM OFFST 9.6MM 120MM 25MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6052-0730A SUP HCPCS C1776 6052-0730A - STEM FEM 30MM SECFIT MXHYDRXAPT 7 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6052-0730S SUP HCPCS C1776 6052-0730S - STEM FEMORAL 127D 7 39MM OFFST 10.4MM 130MM 30MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6052-0830A SUP HCPCS C1776 6052-0830A - STEM FEM SECFIT HYDRXAPT 8 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6052-0830S SUP HCPCS C1776 6052-0830S - STEM FEMORAL 127D 8 40MM OFFST 11.2MM 140MM 30MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6052-0935A SUP HCPCS C1776 6052-0935A - STEM FEM SECFIT HYDRXAPT 127D 9 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6052-0935S SUP HCPCS C1776 6052-0935S - STEM FEMORAL 127D 9 45MM OFFST 11.9MM 150MM 35MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6052-1035A SUP HCPCS C1776 6052-1035A - STEM FEM SECFIT HYDRXAPT 127D 10 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6052-1035S SUP HCPCS C1776 6052-1035S - STEM FEMORAL 127D 10 46MM OFFST 12.7MM 160MM 35MM NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6052-1140A SUP HCPCS C1776 6052-1140A - STEM FEM SECFIT HYDRXAPT 127D 11 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6052-1140S SUP HCPCS C1776 6052-1140S - STEM FEMORAL 127D 11 51MM OFFST 13.5MM 170MM 40MM NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6052-1240A SUP HCPCS C1776 6052-1240A - STEM FEM CMNTLS SECFIT HYDRXAPT 127D 12 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6052-1240S SUP HCPCS C1776 6052-1240S - STEM FEMORAL 127D 12 52MM OFFST 14.7MM 170MM 40MM NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6052-1340A SUP HCPCS C1776 6052-1340A - STEM FEM CMNTLS SECFIT HYDRXAPT 127D 13 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6052-1340S SUP HCPCS C1776 6052-1340S - STEM FEMORAL 127D 13 53MM OFFST 16MM 170MM 40MM NECK SECFIT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0509A SUP HCPCS C1776 6054-0509A - STEM FEM 5 32MM OFST 9MM 110MM 25MM SCRFT + PRM HA HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0509S SUP HCPCS C1776 6054-0509S - STEM FEM 127D 5 32MM OFST 9MM 110MM 25MM SCRFT+ MX PLSH NK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0511A SUP HCPCS C1776 6054-0511A - STEM FEM 5 32MM OFST 11MM 110MM 25MM SCRFT + PRM HA HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0511S SUP HCPCS C1776 6054-0511S - STEM FEM 5 11MM STRL SCRFT + HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0610A SUP HCPCS C1776 6054-0610A - STEM FEM 10MM PRIM SECFIT PLUS HYDRXAPT 6 HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0610S SUP HCPCS C1776 6054-0610S - STEM FEMORAL 127D 6 33MM OFFST 10MM 120MM 25MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0612A SUP HCPCS C1776 6054-0612A - STEM FEM 12MM CMNTLS PRIM SECFIT PLUS HYDRXAPT 6 HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0612S SUP HCPCS C1776 6054-0612S - STEM FEMORAL 127D 6 33MM OFFST 12MM 120MM 25MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0711A SUP HCPCS C1776 6054-0711A - STEM FEM 11MM PRIM SECFIT MXHYDRXAPT 7 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0711S SUP HCPCS C1776 6054-0711S - STEM FEMORAL 127D 7 39MM OFFST 11MM 130MM 30MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0713A SUP HCPCS C1776 6054-0713A - STEM FEM 13MM PRIM SECFIT PLUS HYDRXAPT 7 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0713S SUP HCPCS C1776 6054-0713S - STEM FEMORAL 127D 7 39MM OFFST 13MM 130MM 30MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0812A SUP HCPCS C1776 6054-0812A - STEM FEM 12MM PRIM SECFIT PLUS HYDRXAPT 8 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0812S SUP HCPCS C1776 6054-0812S - STEM FEMORAL 127D 8 40MM OFFST 12MM 140MM 30MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0814A SUP HCPCS C1776 6054-0814A - STEM FEM SECFIT PLUS 8 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0814S SUP HCPCS C1776 6054-0814S - STEM FEMORAL 127D 8 40MM OFFST 14MM 140MM 30MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0913A SUP HCPCS C1776 6054-0913A - STEM FEM 13MM PRIM SECFIT MXHYDRXAPT 9 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0913S SUP HCPCS C1776 6054-0913S - STEM FEMORAL 127D 9 45MM OFFST 13MM 150MM 35MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-0915A SUP HCPCS C1776 6054-0915A - STEM FEM PRIM CMNTLS SECFIT PLUS 9 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-0915S SUP HCPCS C1776 6054-0915S - STEM FEMORAL 127D 9 45MM OFFST 15MM 150MM 35MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1014A SUP HCPCS C1776 6054-1014A - STEM FEM 14MM PRIM SECFIT PLUS HYDRXAPT 10 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-1014S SUP HCPCS C1776 6054-1014S - STEM FEMORAL 127D 10 46MM OFFST 14MM 160MM 35MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1016A SUP HCPCS C1776 6054-1016A - STEM FEM 16MM PRIM SECFIT PLUS HYDRXAPT 10 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-1016S SUP HCPCS C1776 6054-1016S - STEM FEMORAL 127D 10 46MM OFFST 16MM 160MM 35MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1115A SUP HCPCS C1776 6054-1115A - STEM FEM 15MM PRIM SECFIT PLUS HYDRXAPT 11 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-1115S SUP HCPCS C1776 6054-1115S - STEM FEMORAL 127D 11 51MM OFFST 15MM 170MM 40MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1117A SUP HCPCS C1776 6054-1117A - STEM FEM 17MM PRIM SECFIT PLUS HYDRXAPT 11 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-1117S SUP HCPCS C1776 6054-1117S - STEM FEMORAL 127D 11 51MM OFFST 17MM 170MM 40MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1216S SUP HCPCS C1776 6054-1216S - STEM FEMORAL 127D 12 52MM OFFST 16MM 170MM 40MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1218A SUP HCPCS C1776 6054-1218A - STEM FEM 18MM CMNTLS PRIM SECFIT PLUS HYDRXAPT 12 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6054-1218S SUP HCPCS C1776 6054-1218S - STEM FEMORAL 127D 12 52MM OFFST 18MM 170MM 40MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1317S SUP HCPCS C1776 6054-1317S - STEM FEMORAL 13 17MM PRIM SECFIT PLUS HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1319S SUP HCPCS C1776 6054-1319S - STEM FEMORAL 127D 13 53MM OFFST 19MM 170MM 40MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1418S SUP HCPCS C1776 6054-1418S - STEM FEMORAL 14 18MM CEMENTLESS PRIM SECFIT PLUS HYDRXAPT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-1420S SUP HCPCS C1776 6054-1420S - STEM FEMORAL 127D 14 54MM OFFST 20MM 170MM 40MM POLISH NECK BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6054-58 SUP HCPCS C1765 6054-58 - STYLET LEAD KT BALL TIP TPR BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $15.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6057-0230D SUP HCPCS C1776 6057-0230D - STEM FEMORAL 127D 2 39MM OFFST 124MM 30MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6057-0335D SUP HCPCS C1776 6057-0335D - STEM FEMORAL 127D 3 43MM OFFST 131MM 35MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6057-0435D SUP HCPCS C1776 6057-0435D - STEM FEMORAL 127D 4 46MM OFFST 137MM 35MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6057-0537D SUP HCPCS C1776 6057-0537D - STEM FEMORAL 127D 5 48MM OFFST 145MM 37MM NECK CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6057-0637D SUP HCPCS C1776 6057-0637D - STEM FEMORAL 127D 6 49MM OFFST 158MM 37MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6057-0740D SUP HCPCS C1776 6057-0740D - STEM FEMORAL 127D 7 52MM OFFST 158MM 40MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6057-52 SUP Custom 27203010 6057-52 - STYLET LEAD STR BALL .014IN 52CM KIT EXTENDED TAPER BLUE BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $0.00 $0.00 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6057-58 SUP HCPCS C1765 6057-58 - STYLET LEAD 58CM .014IN KT BALL TIP BLUE KNOB BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $15.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6058-0230D SUP HCPCS C1776 6058-0230D - STEM FEMORAL 132D 2 35MM OFFST 124MM 30MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6058-0335D SUP HCPCS C1776 6058-0335D - STEM FEMORAL 132D 3 39MM OFFST 131MM 35MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6058-0435D SUP HCPCS C1776 6058-0435D - STEM FEMORAL 132D 4 42MM OFFST 137MM 35MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6058-0537D SUP HCPCS C1776 6058-0537D - STEM FEMORAL 132D 5 44MM OFFST 145MM 37MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6058-0637D SUP HCPCS C1776 6058-0637D - STEM FEMORAL 132D 6 45MM OFFST 158MM 37MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6058-0740D SUP HCPCS C1776 6058-0740D - STEM FEMORAL 132D 4 48MM OFFST 158MM 40MM CEMENTED NECK BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 606-004-103 SUP HCPCS Q4130 606-004-103 - MATRIX TISS THK1MM SEMIOVAL 16X8CM STRL SURGIMEND PRS BOTH IP/OP "$5,760.00 " "$4,262.40" $0.00 "$6,016.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,200.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.38" $0.00 "$2,839.68" "$2,839.68" $0.00 "$3,760.00" "$5,955.84" "$6,016.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-6085-200A SUP Custom 27203010 60-6085-200A - RETRACTOR/ELEVATOR LAPSCP SM 32MM STRL LF VCARE 2 CUP LCK BOTH IP/OP $233.40 $172.72 $0.00 $186.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.23 $173.23 $0.00 $0.00 $48.64 $0.00 $0.00 $0.00 $0.00 $116.70 $184.85 $186.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-6085-201A SUP Custom 27203010 60-6085-201A - RETRACTOR/ELEVATOR LAPSCOP MEDIUM 34MM 2 CUP LOCK SCREW HOLE BOTH IP/OP $233.40 $172.72 $0.00 $186.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.23 $173.23 $0.00 $0.00 $48.64 $0.00 $0.00 $0.00 $0.00 $116.70 $184.85 $186.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-6085-202 SUP Custom 27203010 60-6085-202 - RETRACTOR/ELEVATOR LAPSCOP LARGE 37MM 2 CUP HOLE MANIPULATOR BOTH IP/OP $196.05 $145.08 $0.00 $159.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.51 $145.51 $0.00 $0.00 $40.86 $0.00 $0.00 $0.00 $0.00 $99.50 $157.60 $159.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 606-151X SUP HCPCS C1729 CATHETER INFUS .014IN STRG 2.3-1.9FR .0165IN 150CM 50CM MCTH BOTH IP/OP "$1,747.50 " "$1,293.15" $0.00 "$1,398.00" $948.89 $948.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.75 "$1,384.02" "$1,398.00" $0.00 $0.00 $273.48 $0.00 $0.00 $278.20 $0.00 $0.00 $0.00 $0.00 $0.00 606-200-004 SUP HCPCS C9360 606-200-004 - MATRIX TISSUE SURGIMEND BOVINE COLLAGEN THK2 MM RECTANGLE L1 BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$3,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,003.94" "$2,003.94" $0.00 $0.00 $562.68 $0.00 $0.00 $0.00 $0.00 "$2,070.00" "$3,278.88" "$3,312.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-660-01-04 SUP HCPCS C1713 60-660-01-04 - PLATE BONE CSTM PROPHYLACTIC CRANIAL IRR BOTH IP/OP "$17,487.50 " "$12,940.75" $0.00 "$13,990.00" "$7,869.38" "$7,869.38" $0.00 $0.00 $0.00 "$3,644.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,644.40" $0.00 "$8,621.34" "$8,621.34" $0.00 "$8,743.75" "$13,850.10" "$13,990.00" $0.00 $0.00 "$2,736.79" $0.00 $0.00 "$2,784.01" $0.00 $0.00 $0.00 $0.00 $0.00 606S255MX SUP HCPCS C1725 606S255MX - MICROCATHETER CRBRVASC 90D 2.3-2.8FR .021IN 150CM 5CM PRWLR BOTH IP/OP "$2,175.25 " "$1,609.69" $0.00 "$1,621.84" "$1,100.82" "$1,100.82" $0.00 $0.00 $0.00 $453.38 "$1,614.47" "$1,614.47" $0.00 $0.00 $453.32 $0.00 "$1,286.66" "$1,286.66" $0.00 "$1,013.65" "$1,605.62" "$1,621.84" $0.00 $0.00 $317.27 $0.00 $0.00 $322.75 $0.00 $0.00 $0.00 $0.00 $0.00 606-S255X SUP HCPCS C1729 CATHETER INFUS 2.8-2.3FR .021IN 150CM 5CM MCTH DUAL MRKR BOTH IP/OP "$1,965.00 " "$1,454.10" $0.00 "$1,572.00" "$1,067.00" "$1,067.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $982.50 "$1,556.28" "$1,572.00" $0.00 $0.00 $307.52 $0.00 $0.00 $312.83 $0.00 $0.00 $0.00 $0.00 $0.00 6070-0525A SUP Custom 27803010 6070-0525A - STEM FEMORAL 132D 5 25MM PRIM OMNIFIT HFX HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6070-0625A SUP Custom 27803010 6070-0625A - STEM FEMORAL 132D 6 30MM OFFST 120MM 25MM CEMENTED NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6070-0730A SUP Custom 27803010 6070-0730A - STEM FEMORAL 132D 7 35MM OFFST 130MM 30MM CEMENTED NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6070-0830A SUP Custom 27803010 6070-0830A - STEM FEMORAL 132D 8 36MM OFFST 140MM 30MM CEMENTED NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6070-0935A SUP Custom 27803010 6070-0935A - STEM FEMORAL 132D 9 41MM OFFST 150MM 35MM CEMENTED NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6070-1035A SUP Custom 27803010 6070-1035A - STEM FEMORAL 132D 10 35MM CEMENT OMNIFIT HFX HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6070-1140A SUP Custom 27803010 6070-1140A - STEM FEMORAL 132D 11 46MM OFFST 170MM 40MM CEMENTED NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6072-0625 SUP Custom 27803010 6072-0625 - STEM FEM CMNT ODC-FX 6 HIP BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6072-0730 SUP Custom 27803010 6072-0730 - STEM FEM CMNT ODC-FX 7 HIP BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6072-0830 SUP Custom 27803010 6072-0830 - STEM FEM CMNT ODC-FX 8 HIP BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6072-0935 SUP Custom 27803010 6072-0935 - STEM FEM CMNT ODC-FX 9 HIP BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6072-1035 SUP Custom 27803010 6072-1035 - STEM FEM CMNT OMFT 10 HIP BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6073-0525 SUP Custom 27803010 6073-0525 - STEM FEM ODC HIP BOTH IP/OP "$2,024.00 " "$1,497.76" $0.00 "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,502.21" "$1,502.21" $0.00 $0.00 $421.80 $0.00 $0.00 $0.00 $0.00 "$1,012.00" "$1,603.01" "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6073-0625 SUP Custom 27803010 6073-0625 - STEM FEM ODC HIP BOTH IP/OP "$2,024.00 " "$1,497.76" $0.00 "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,502.21" "$1,502.21" $0.00 $0.00 $421.80 $0.00 $0.00 $0.00 $0.00 "$1,012.00" "$1,603.01" "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6073-0730 SUP Custom 27803010 6073-0730 - STEM FEM ODC HIP BOTH IP/OP "$2,024.00 " "$1,497.76" $0.00 "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,502.21" "$1,502.21" $0.00 $0.00 $421.80 $0.00 $0.00 $0.00 $0.00 "$1,012.00" "$1,603.01" "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6073-0830 SUP Custom 27803010 6073-0830 - STEM FEM ODC HIP BOTH IP/OP "$2,024.00 " "$1,497.76" $0.00 "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,502.21" "$1,502.21" $0.00 $0.00 $421.80 $0.00 $0.00 $0.00 $0.00 "$1,012.00" "$1,603.01" "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6073-0935 SUP Custom 27803010 6073-0935 - STEM FEM ODC HIP BOTH IP/OP "$2,024.00 " "$1,497.76" $0.00 "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,502.21" "$1,502.21" $0.00 $0.00 $421.80 $0.00 $0.00 $0.00 $0.00 "$1,012.00" "$1,603.01" "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6073-1035 SUP Custom 27803010 6073-1035 - STEM FEM ODC HIP BOTH IP/OP "$2,024.00 " "$1,497.76" $0.00 "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,502.21" "$1,502.21" $0.00 $0.00 $421.80 $0.00 $0.00 $0.00 $0.00 "$1,012.00" "$1,603.01" "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6073-1140 SUP Custom 27803010 6073-1140 - STEM FEM ODC HIP BOTH IP/OP "$2,024.00 " "$1,497.76" $0.00 "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,502.21" "$1,502.21" $0.00 $0.00 $421.80 $0.00 $0.00 $0.00 $0.00 "$1,012.00" "$1,603.01" "$1,619.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6076-0525A SUP Custom 27803010 6076-0525A - STEM FEMORAL 127D 5 35MM 110MM 25MM CEMENT HFX OMNIFIT HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6076-0625A SUP Custom 27803010 6076-0625A - STEM FEMORAL 127D 6 120MM 25MM CEMENT OMNIFIT HFX HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6076-0730A SUP Custom 27803010 6076-0730A - STEM FEMORAL 7 OMNIFIT HFX HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6076-0830A SUP Custom 27803010 6076-0830A - STEM FEMORAL 127D 8 135MM 30MM CEMENT OMNIFIT HFX HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6076-0935A SUP Custom 27803010 6076-0935A - STEM FEMORAL 127D 9 140MM 35MM CEMENT OMNIFIT HFX HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6076-1035A SUP Custom 27803010 6076-1035A - STEM FEMORAL 127D 10 145MM 35MM CEMENT OMNIFIT HFX HIP BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6077-0130 SUP Custom 27803010 6077-0130 - STEM FEMORAL 127D 1 38MM OFFST 110MM 30MM CEMENTLESS NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6077-0230 SUP Custom 27803010 6077-0230 - STEM FEMORAL 127D 2 39MM OFFST 115MM 30MM CEMENTLESS NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6077-0335 SUP Custom 27803010 6077-0335 - STEM FEMORAL 127D 3 43MM OFFST 120MM 35MM CEMENTLESS NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6077-0435 SUP Custom 27803010 6077-0435 - STEM FEMORAL 127D 4 44MM OFFST 125MM 35MM CEMENTLESS NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6077-0537 SUP Custom 27803010 6077-0537 - STEM FEMORAL 127D 5 48MM OFFST 130MM 37MM CEMENTLESS NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6077-0637 SUP Custom 27803010 6077-0637 - STEM FEMORAL 127D 6 49MM OFFST 135MM 37MM CEMENTLESS NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6077-0740 SUP Custom 27803010 6077-0740 - STEM FEMORAL 127D 7 53MM OFFST 140MM 40MM CEMENTLESS NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6077-0840 SUP Custom 27803010 6077-0840 - STEM FEMORAL 127D 8 54MM OFFST 145MM 40MM CEMENTLESS NECK BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6080-0530-200L SUP HCPCS C1776 6080-0530-200L - STEM FEM OMFT LNG LEFT HDNK BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0530-200R SUP HCPCS C1776 6080-0530-200R - STEM FEM 200MM 12MM HDNK OMFT 5 LNG 30MM RIGHT BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0735-200L SUP HCPCS C1776 6080-0735-200L - STEM FEM 200MM 14.5MM HDNK PRTCL ADD SYS OMFT 7 LNG 35MM BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0735-200R SUP HCPCS C1776 6080-0735-200R - STEM FEM 200MM 12.4MM CMNT HDNK OMFT 7 LNG 35MM RIGHT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0745-200L SUP HCPCS C1776 6080-0745-200L - STEM FEM 200MM CMNT HDNK OMFT 12.4MM 7 LNG 45MM LEFT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0745-200R SUP HCPCS C1776 6080-0745-200R - STEM FEM 200MM 14.5MM HDNK PRTCL ADD SYS OMFT 7 LNG 45MM BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0935-250L SUP HCPCS C1776 6080-0935-250L - STEM FEM 250MM OMFT 9 LNG 35MM HDNK BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0935-250R SUP HCPCS C1776 6080-0935-250R - STEM FEM 200MM 14MM CMNT HDNK OMFT 9 LNG 35MM RIGHT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0945-250L SUP HCPCS C1776 6080-0945-250L - STEM FEM 250MM 14MM CMNT HDNK OMFT 9 LNG 45MM LEFT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6080-0945-250R SUP HCPCS C1776 6080-0945-250R - STEM FEM 250MM 14MM CMNT HDNK OMFT 9 LNG 45MM RIGHT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 60-80317 SUP Custom 27203010 60-80317 - CNTRSNK DRILL 47 AO SHFT END BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $0.00 $0.00 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60-80323 SUP Custom 27203010 60-80323 - CNTRSNK DRILL 48MM AO SHFT END STRL BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $0.00 $0.00 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6082-52 SUP Custom 27203010 6082-52 - STYLET LEAD .014IN 52CM KIT STR BALL TIP EXTENDED TAPER GRAY BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $0.00 $0.00 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6082-65 SUP Custom 27203010 6082-65 - KIT STY STRG XTD TPR .014IN 65CM GRY BALL TIP KNOB BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.52 $57.52 $0.00 $0.00 $16.15 $0.00 $0.00 $0.00 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6088-0525-200L SUP HCPCS C1776 6088-0525-200L - STEM FEMORAL 5 LONG 10.9MM 200MM 25MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0525-200R SUP HCPCS C1776 6088-0525-200R - STEM FEMORAL 5 LONG 10.9MM 200MM 25MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0525-250L SUP HCPCS C1776 6088-0525-250L - STEM FEMORAL 5 LONG 10.9MM 250MM 25MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0525-250R SUP HCPCS C1776 6088-0525-250R - STEM FEMORAL 5 LONG 250MM CEMENTED REVISION OMNIFIT DISTAL BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0525-300L SUP HCPCS C1776 6088-0525-300L - STEM FEMORAL 5 LONG 10.9MM 300MM 25MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0525-300R SUP HCPCS C1776 6088-0525-300R - STEM FEMORAL 5 LONG 10.9MM 300MM 25MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0525-350L SUP HCPCS C1776 6088-0525-350L - TRIAL SURG 350MM 10.9MM OMFT LNG LEFT STM CMNT IMPL 25MM BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0525-350R SUP HCPCS C1776 6088-0525-350R - STEM FEM 350MM 10.9MM CMNT OMFT 5 LNG 25MM RIGHT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0730-200L SUP HCPCS C1776 6088-0730-200L - STEM FEMORAL 7 LONG 12.4MM 200MM 30MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0730-200R SUP HCPCS C1776 6088-0730-200R - STEM FEMORAL 7 LONG 12.4MM 200MM 30MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0730-250L SUP HCPCS C1776 6088-0730-250L - STEM FEMORAL 7 LONG 12.4MM 250MM 30MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0730-250R SUP HCPCS C1776 6088-0730-250R - STEM FEMORAL 7 LONG 12.4MM 250MM 30MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0730-300L SUP HCPCS C1776 6088-0730-300L - STEM FEMORAL 7 LONG 12.4MM 300MM 30MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0730-300R SUP HCPCS C1776 6088-0730-300R - STEM FEMORAL 7 LONG 12.4MM 300MM 30MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0730-350L SUP HCPCS C1776 6088-0730-350L - STEM FEM 350MM 12.4MM CMNT OMFT 7 LNG 30MM LEFT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0730-350R SUP HCPCS C1776 6088-0730-350R - STEM FEM 350MM 12.4MM CMNT OMFT LNG 30MM HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0935-200L SUP HCPCS C1776 6088-0935-200L - STEM FEMORAL 9 LONG 14MM 200MM 35MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0935-200R SUP HCPCS C1776 6088-0935-200R - STEM FEM 200MM 14MM REV CMNT NECK TRL OMFT 9 LNG 35MM HIP BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0935-250L SUP HCPCS C1776 6088-0935-250L - STEM FEMORAL 9 LONG 14MM 250MM 35MM CEMENT OMNIFIT LEFT HIP BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0935-250R SUP HCPCS C1776 6088-0935-250R - STEM FEMORAL 9 LONG 14MM 250MM 35MM CEMENT OMNIFIT HIP RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0935-300L SUP HCPCS C1776 6088-0935-300L - STEM FEMORAL 9 LONG 14MM 300MM 35MM CEMENT OMNIFIT LEFT HIP BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0935-300R SUP HCPCS C1776 6088-0935-300R - STEM FEMORAL 9 LONG 14MM 300MM 35MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0935-350L SUP HCPCS C1776 6088-0935-350L - STEM FEM 350MM 14MM CMNT OMFT 9 LNG 35MM LEFT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6088-0935-350R SUP HCPCS C1776 6088-0935-350R - STEM FEM 350MM 14MM CMNT OMFT 9 LNG 35MM RIGHT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6088-1140-200L SUP HCPCS C1776 6088-1140-200L - STEM FEMORAL 11 LONG 15.5MM 200MM 40MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-1140-200R SUP HCPCS C1776 6088-1140-200R - STEM FEMORAL 11 LONG 15.5MM 200MM 40MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-1140-250L SUP HCPCS C1776 6088-1140-250L - STEM FEMORAL 11 LONG 15.5MM 250MM 40MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-1140-250R SUP HCPCS C1776 6088-1140-250R - STEM FEMORAL 11 LONG 15.5MM 250MM 40MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-1140-300L SUP HCPCS C1776 6088-1140-300L - STEM FEMORAL 11 LONG 15.5MM 300MM 40MM CEMENT OMNIFIT LEFT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-1140-300R SUP HCPCS C1776 6088-1140-300R - STEM FEMORAL 11 LONG 15.5MM 300MM 40MM CEMENT OMNIFIT RIGHT BOTH IP/OP "$11,872.50 " "$8,785.65" $0.00 "$9,498.00" "$5,342.63" "$5,342.63" $0.00 $0.00 $0.00 "$2,474.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,474.23" $0.00 "$5,853.14" "$5,853.14" $0.00 "$5,936.25" "$9,403.02" "$9,498.00" $0.00 $0.00 "$1,858.05" $0.00 $0.00 "$1,890.10" $0.00 $0.00 $0.00 $0.00 $0.00 6088-1140-350L SUP HCPCS C1776 6088-1140-350L - STEM FEM 350MM CMNT OMFT 11 LNG 40MM HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 6088-1140-350R SUP HCPCS C1776 6088-1140-350R - STEM FEM 350MM 15.5MM CMNT OMFT 11 LNG 40MM RIGHT HIP BOTH IP/OP "$10,099.38 " "$7,473.54" $0.00 "$8,079.50" "$4,544.72" "$4,544.72" $0.00 $0.00 $0.00 "$2,104.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,104.71" $0.00 "$4,978.99" "$4,978.99" $0.00 "$5,049.69" "$7,998.71" "$8,079.50" $0.00 $0.00 "$1,580.55" $0.00 $0.00 "$1,607.82" $0.00 $0.00 $0.00 $0.00 $0.00 60-94120 SUP HCPCS C1713 60-94120 - COUNTERSINK DRILL BICONCAVE WASHER BOTH IP/OP $435.68 $322.40 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $90.81 $323.36 $323.36 $0.00 $0.00 $90.79 $0.00 $257.70 $257.70 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 6097-0425 SUP HCPCS C1776 6097-0425 - STEM FEMORAL 127D 4 33MM OFFST 8.1MM 100MM 25MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6097-0530 SUP HCPCS C1776 6097-0530 - STEM FEMORAL 127D 5 39MM OFFST 8.9MM 110MM 30MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6097-0630 SUP HCPCS C1776 6097-0630 - STEM FEMORAL 127D 6 40MM OFFST 9.6MM 120MM 30MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6097-0735 SUP HCPCS C1776 6097-0735 - STEM FEMORAL 127D 7 45MM OFFST 10.4MM 130MM 35MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6097-0835 SUP HCPCS C1776 6097-0835 - STEM FEMORAL 127D 8 46MM OFFST 11.3MM 135MM 35MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6097-0940 SUP HCPCS C1776 6097-0940 - STEM FEMORAL 127D 9 51MM OFFST 12.6MM 140MM 40MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6097-1040 SUP HCPCS C1776 6097-1040 - STEM FEMORAL 127D 10 52MM OFFST 13.8MM 145MM 40MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6097-1140 SUP HCPCS C1776 6097-1140 - STEM FEMORAL 127D 11 53MM OFFST 14.8MM 150MM 40MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6098-0425 SUP HCPCS C1776 6098-0425 - STEM FEMORAL 132D 4 29MM OFFST 8.1MM 100MM 25MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6098-0530 SUP HCPCS C1776 6098-0530 - STEM FEMORAL 132D 5 35MM OFFST 8.9MM 110MM 30MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6098-0630 SUP HCPCS C1776 6098-0630 - STEM FEMORAL 132D 6 36MM OFFST 9.6MM 120MM 30MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6098-0735 SUP HCPCS C1776 6098-0735 - STEM FEMORAL 132D 7 41MM OFFST 10.4MM 130MM 35MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6098-0835 SUP HCPCS C1776 6098-0835 - STEM FEMORAL 132D 8 42MM OFFST 11.3MM 135MM 35MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6098-0940 SUP HCPCS C1776 6098-0940 - STEM FEMORAL 132D 9 46MM OFFST 12.6MM 140MM 40MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6098-1040 SUP HCPCS C1776 6098-1040 - STEM FEMORAL 132D 10 47MM OFFST 13.8MM 145MM 40MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 6098-1140 SUP HCPCS C1776 6098-1140 - STEM FEMORAL 132D 11 48MM OFFST 14.8MM 150MM 40MM CEMENTED BOTH IP/OP "$4,317.50 " "$3,194.95" $0.00 "$3,454.00" "$1,942.88" "$1,942.88" $0.00 $0.00 $0.00 $899.87 "$3,204.45" "$3,204.45" $0.00 $0.00 $899.77 $0.00 "$2,128.53" "$2,128.53" $0.00 "$2,158.75" "$3,419.46" "$3,454.00" $0.00 $0.00 $675.69 $0.00 $0.00 $687.35 $0.00 $0.00 $0.00 $0.00 $0.00 60XLTCD SUP Custom 27203010 60XLTCD - TUBE TRCH 38MM 49MM 11MM 6MM 95MM STRL LF 8MM SHLY XLT CUF BOTH IP/OP $159.65 $118.14 $0.00 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.49 $118.49 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $81.02 $128.34 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60XLTCP SUP HCPCS A7520 60XLTCP - TUBE TRCH 38MM 34MM 11MM 6MM 95MM STRL LF 23MM SHLY XLT CUF BOTH IP/OP $159.65 $118.14 $0.00 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.49 $118.49 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $81.02 $128.34 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60XLTUD SUP Custom 27203010 60XLTUD - TUBE TRCH 38MM 49MM 11MM 6MM 95MM STRL LF 8MM SHLY XLT CUFLS BOTH IP/OP $159.65 $118.14 $0.00 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.49 $118.49 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $81.02 $128.34 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 60XLTUP SUP Custom 27203010 60XLTUP - TUBE TRCH 38MM 34MM 11MM 6MM 95MM STRL LF 23MM SHLY XLT BOTH IP/OP $159.65 $118.14 $0.00 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.49 $118.49 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $81.02 $128.34 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61.231.017 SUP HCPCS C1713 61.231.017 - GRAPHIC CASE FOR 4.5MM VA-LCP INSTRUMENT AND SCREW SET BOTH IP/OP "$4,703.45 " "$3,480.55" $0.00 "$3,653.16" "$2,054.90" "$2,054.90" $0.00 $0.00 $0.00 $980.32 "$3,490.90" "$3,490.90" $0.00 $0.00 $980.20 $0.00 "$2,318.80" "$2,318.80" $0.00 "$2,283.23" "$3,616.63" "$3,653.16" $0.00 $0.00 $693.83 $0.00 $0.00 $726.98 $0.00 $0.00 $0.00 $0.00 $0.00 611.105.01S SUP Custom 27803010 611.105.01S - CABLE ORTHOPEDIC 1.7MM 750MM TITANIUM CRIMP CERCLAGE COCR BOTH IP/OP $920.73 $681.34 $0.00 $715.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $683.36 $683.36 $0.00 $0.00 $191.88 $0.00 $0.00 $0.00 $0.00 $446.95 $707.97 $715.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61114V SUP Custom 27203010 61114V - CLIP INTNL LG SMTR VESOLOCK BOTH IP/OP $62.41 $46.18 $0.00 $49.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.32 $46.32 $0.00 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $31.20 $49.43 $49.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6-1221 SUP Custom 27803010 6-1221 - CAGE SPNL 12MM 21MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$8,031.25 " "$5,943.13" $0.00 "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,673.71" $0.00 $0.00 $0.00 $0.00 "$4,015.63" "$6,360.75" "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2244 SUP Custom 27803010 61-2244 - CUP ACETAB 44MM 22MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2248 SUP Custom 27803010 61-2248 - CUP ACETAB 48MM 22MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2252 SUP Custom 27803010 61-2252 - CUP ACETAB 52MM 22MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2256 SUP Custom 27803010 61-2256 - CUP ACETAB 56MM 22MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6-1226 SUP Custom 27803010 6-1226 - CAGE SPNL 12MM 26MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$8,031.25 " "$5,943.13" $0.00 "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,673.71" $0.00 $0.00 $0.00 $0.00 "$4,015.63" "$6,360.75" "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2261 SUP Custom 27803010 61-2261 - CUP ACETAB 61MM 22MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2644 SUP Custom 27803010 61-2644 - CUP ACETAB 44MM 26MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2646 SUP Custom 27803010 61-2646 - CUP ACETAB 46MM 26MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2648 SUP Custom 27803010 61-2648 - CUP ACETAB 48MM 26MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2652 SUP Custom 27803010 61-2652 - CUP ACETAB 52MM 26MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2656 SUP Custom 27803010 61-2656 - CUP ACETAB 56MM 26MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2658 SUP Custom 27803010 61-2658 - CUP ACETAB 58MM 26MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2661 SUP Custom 27803010 61-2661 - CUP ACETAB 61MM 26MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2844 SUP Custom 27803010 61-2844 - CUP ACETAB 44MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2846 SUP Custom 27803010 61-2846 - CUP ACETAB 46MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2848 SUP Custom 27803010 61-2848 - CUP ACETAB 48MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2850 SUP Custom 27803010 61-2850 - CUP ACETAB 50MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2852 SUP Custom 27803010 61-2852 - CUP ACETAB 52MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2854 SUP Custom 27803010 61-2854 - CUP ACETAB 54MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2856 SUP Custom 27803010 61-2856 - CUP ACETAB 56MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2858 SUP Custom 27803010 61-2858 - CUP ACETAB 58MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-2861 SUP Custom 27803010 61-2861 - CUP ACETAB 61MM 28MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 613.03.01S SUP HCPCS C1713 613.03.01S - CEMENT BONE NRN CRS FST ST 3ML PTTY STRL BOTH IP/OP "$2,151.00 " "$1,591.74" $0.00 "$1,720.80" $967.95 $967.95 $0.00 $0.00 $0.00 $448.32 "$1,596.47" "$1,596.47" $0.00 $0.00 $448.27 $0.00 "$1,272.32" "$1,272.32" $0.00 "$1,075.50" "$1,703.59" "$1,720.80" $0.00 $0.00 $336.63 $0.00 $0.00 $342.44 $0.00 $0.00 $0.00 $0.00 $0.00 613.05.01S SUP HCPCS C1713 613.05.01S - CEMENT BONE NRN CRS FST ST 5ML PTTY STRL BOTH IP/OP "$3,532.50 " "$2,614.05" $0.00 "$2,826.00" "$1,589.63" "$1,589.63" $0.00 $0.00 $0.00 $736.26 "$2,621.82" "$2,621.82" $0.00 $0.00 $736.17 $0.00 "$1,741.52" "$1,741.52" $0.00 "$1,766.25" "$2,797.74" "$2,826.00" $0.00 $0.00 $552.84 $0.00 $0.00 $562.37 $0.00 $0.00 $0.00 $0.00 $0.00 613.10.01S SUP HCPCS C1713 613.10.01S - CEMENT BONE NRN CRS FST ST 10ML PTTY STRL BOTH IP/OP "$6,945.75 " "$5,139.86" $0.00 "$5,556.60" "$3,125.59" "$3,125.59" $0.00 $0.00 $0.00 "$1,447.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,447.49" $0.00 "$3,424.25" "$3,424.25" $0.00 "$3,472.88" "$5,501.03" "$5,556.60" $0.00 $0.00 "$1,087.01" $0.00 $0.00 "$1,105.76" $0.00 $0.00 $0.00 $0.00 $0.00 613.15.01S SUP HCPCS C1713 613.15.01S - CEMENT BONE NRN CRS FST ST 15ML PTTY STRL BOTH IP/OP "$10,194.75 " "$7,544.12" $0.00 "$8,155.80" "$4,587.64" "$4,587.64" $0.00 $0.00 $0.00 "$2,124.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,124.59" $0.00 "$5,026.01" "$5,026.01" $0.00 "$5,097.38" "$8,074.24" "$8,155.80" $0.00 $0.00 "$1,595.48" $0.00 $0.00 "$1,623.00" $0.00 $0.00 $0.00 $0.00 $0.00 61-3248 SUP Custom 27803010 61-3248 - CUP ACETAB 48MM 32MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-3252 SUP Custom 27803010 61-3252 - CUP ACETAB 52MM 32MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-3254 SUP Custom 27803010 61-3254 - CUP ACETAB 54MM 32MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-3256 SUP Custom 27803010 61-3256 - CUP ACETAB 56MM 32MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-3258 SUP Custom 27803010 61-3258 - CUP ACETAB 58MM 32MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61-3261 SUP Custom 27803010 61-3261 - CUP ACETAB 61MM 32MM CEMENTED UHMWPE HIP BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 614.03.01S SUP HCPCS C1713 614.03.01S - CEMENT BONE NRN CRS 3ML ROTATORY MX STRL BOTH IP/OP "$2,151.00 " "$1,591.74" $0.00 "$1,720.80" $967.95 $967.95 $0.00 $0.00 $0.00 $448.32 "$1,596.47" "$1,596.47" $0.00 $0.00 $448.27 $0.00 "$1,272.32" "$1,272.32" $0.00 "$1,075.50" "$1,703.59" "$1,720.80" $0.00 $0.00 $336.63 $0.00 $0.00 $342.44 $0.00 $0.00 $0.00 $0.00 $0.00 614.05.01S SUP HCPCS C1713 614.05.01S - CEMENT BONE NRN CRS 5ML ROTATORY MX STRL BOTH IP/OP "$3,532.50 " "$2,614.05" $0.00 "$2,826.00" "$1,589.63" "$1,589.63" $0.00 $0.00 $0.00 $736.26 "$2,621.82" "$2,621.82" $0.00 $0.00 $736.17 $0.00 "$1,741.52" "$1,741.52" $0.00 "$1,766.25" "$2,797.74" "$2,826.00" $0.00 $0.00 $552.84 $0.00 $0.00 $562.37 $0.00 $0.00 $0.00 $0.00 $0.00 614.10.01S SUP HCPCS C1713 614.10.01S - CEMENT BONE NRN CRS 10ML ROTATORY MX STRL BOTH IP/OP "$6,945.75 " "$5,139.86" $0.00 "$5,556.60" "$3,125.59" "$3,125.59" $0.00 $0.00 $0.00 "$1,447.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,447.49" $0.00 "$3,424.25" "$3,424.25" $0.00 "$3,472.88" "$5,501.03" "$5,556.60" $0.00 $0.00 "$1,087.01" $0.00 $0.00 "$1,105.76" $0.00 $0.00 $0.00 $0.00 $0.00 6-1426 SUP Custom 27803010 6-1426 - CAGE SPNL 14MM 26MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$8,031.25 " "$5,943.13" $0.00 "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,673.71" $0.00 $0.00 $0.00 $0.00 "$4,015.63" "$6,360.75" "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 615-02 SUP Custom 27203010 615-02 - PLATE 18MM TI BONE SPNL BOTH IP/OP $267.75 $198.14 $0.00 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.72 $198.72 $0.00 $0.00 $55.80 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6154-50-32 SUP HCPCS C1776 6154-50-32 - LINER ACETAB TRLG STD 6.3MM 50/52/54MM 32MM TIV BOTH IP/OP "$7,425.00 " "$5,494.50" $0.00 "$5,940.00" "$3,341.25" "$3,341.25" $0.00 $0.00 $0.00 "$1,547.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,547.37" $0.00 "$3,660.53" "$3,660.53" $0.00 "$3,712.50" "$5,880.60" "$5,940.00" $0.00 $0.00 "$1,162.01" $0.00 $0.00 "$1,182.06" $0.00 $0.00 $0.00 $0.00 $0.00 6-1626 SUP Custom 27803010 6-1626 - CAGE SPNL 16MM 26MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$8,031.25 " "$5,943.13" $0.00 "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,673.71" $0.00 $0.00 $0.00 $0.00 "$4,015.63" "$6,360.75" "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 617-01 SUP Custom 25003010 ANTIBODY CLONE OC 125 LAB BOTH IP/OP "$1,207.50 " $893.55 $0.00 $966.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.75 $956.34 $966.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 617-03 SUP Custom 27203010 617-03 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $274.13 $202.86 $0.00 $219.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.46 $203.46 $0.00 $0.00 $57.13 $0.00 $0.00 $0.00 $0.00 $137.06 $217.11 $219.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 617-12 SUP Custom 27203010 617-12 - PLATE 18MM TI BONE SPNL BOTH IP/OP $267.75 $198.14 $0.00 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.72 $198.72 $0.00 $0.00 $55.80 $0.00 $0.00 $0.00 $0.00 $133.88 $212.06 $214.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6-1821 SUP Custom 27803010 6-1821 - CAGE SPNL 18MM 21MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$8,031.25 " "$5,943.13" $0.00 "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,673.71" $0.00 $0.00 $0.00 $0.00 "$4,015.63" "$6,360.75" "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6-1826 SUP Custom 27803010 6-1826 - CAGE SPNL 18MM 26MM RYTFC UNT THRD CNCT TI PLIF TLIF BOTH IP/OP "$8,031.25 " "$5,943.13" $0.00 "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,673.71" $0.00 $0.00 $0.00 $0.00 "$4,015.63" "$6,360.75" "$6,425.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-2-006 SUP HCPCS C1762 6183-2-006 - SPACER ALGRF 6MM ALLOCRAFT C DBM ACDF BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-2-007 SUP HCPCS C1762 6183-2-007 - SPACER ALGRF 7MM ALLOCRAFT C DBM ACDF BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-2-008 SUP Custom 27803010 6183-2-008 - SPACER ALGRF 8MM ALLOCRAFT C DBM ACDF BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-3-006 SUP HCPCS C1762 6183-3-006 - GRAFT BONE ALLOCRAFT CERV 6MM BOTH IP/OP "$2,625.68 " "$1,943.00" $0.00 "$2,100.54" $0.00 $0.00 $0.00 $0.00 $0.00 $547.26 "$1,948.78" "$1,948.78" $0.00 $0.00 $547.19 $0.00 "$1,294.46" "$1,294.46" $0.00 "$1,312.84" "$2,079.54" "$2,100.54" $0.00 $0.00 $410.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-3-007 SUP HCPCS C1762 6183-3-007 - GRAFT BONE ALLOCRAFT CERV 7MM BOTH IP/OP "$2,625.68 " "$1,943.00" $0.00 "$2,100.54" $0.00 $0.00 $0.00 $0.00 $0.00 $547.26 "$1,948.78" "$1,948.78" $0.00 $0.00 $547.19 $0.00 "$1,294.46" "$1,294.46" $0.00 "$1,312.84" "$2,079.54" "$2,100.54" $0.00 $0.00 $410.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-3-008 SUP HCPCS C1762 6183-3-008 - RNGR SURG 8MM CERV BONE BOTH IP/OP "$2,625.68 " "$1,943.00" $0.00 "$2,100.54" $0.00 $0.00 $0.00 $0.00 $0.00 $547.26 "$1,948.78" "$1,948.78" $0.00 $0.00 $547.19 $0.00 "$1,294.46" "$1,294.46" $0.00 "$1,312.84" "$2,079.54" "$2,100.54" $0.00 $0.00 $410.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-3-010 SUP HCPCS C1762 6183-3-010 - GRAFT BONE ALLOCRAFT DBM SPCR ANT CERV INTRBD FS C-RING 10MM BOTH IP/OP "$2,625.68 " "$1,943.00" $0.00 "$2,100.54" $0.00 $0.00 $0.00 $0.00 $0.00 $547.26 "$1,948.78" "$1,948.78" $0.00 $0.00 $547.19 $0.00 "$1,294.46" "$1,294.46" $0.00 "$1,312.84" "$2,079.54" "$2,100.54" $0.00 $0.00 $410.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-4-006 SUP HCPCS C1762 6183-4-006 - GRAFT BONE ALLOCRAFT CERV 6MM BOTH IP/OP "$3,534.58 " "$2,615.59" $0.00 "$2,827.66" $0.00 $0.00 $0.00 $0.00 $0.00 $736.69 "$2,623.36" "$2,623.36" $0.00 $0.00 $736.61 $0.00 "$1,742.55" "$1,742.55" $0.00 "$1,767.29" "$2,799.39" "$2,827.66" $0.00 $0.00 $553.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-4-007 SUP HCPCS C1762 6183-4-007 - GRAFT BONE ALLOCRAFT CERV 7MM BOTH IP/OP "$3,534.58 " "$2,615.59" $0.00 "$2,827.66" $0.00 $0.00 $0.00 $0.00 $0.00 $736.69 "$2,623.36" "$2,623.36" $0.00 $0.00 $736.61 $0.00 "$1,742.55" "$1,742.55" $0.00 "$1,767.29" "$2,799.39" "$2,827.66" $0.00 $0.00 $553.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-5-005 SUP HCPCS C1762 6183-5-005 - GRAFT BONE 5MM LORDOTIC CERV BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-5-006 SUP HCPCS C1762 6183-5-006 - SPACER ALLOGRAFT 6MM ANTERIOR CERV INTERBODY FUSION LORDOTIC BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-5-007 SUP Custom 27803010 6183-5-007 - SPACER ALLOGRAFT 7MM ANTERIOR CERV INTERBODY FUSION LORDOTIC BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-5-008 SUP Custom 27803010 6183-5-008 - SPACER ALGRF 8MM ALLOCRAFT CL DBM ACDF BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 $0.00 $0.00 $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-5-009 SUP HCPCS C1762 6183-5-009 - SPACER ALLOGRAFT 9MM ANTERIOR CERV INTERBODY FUSION LORDOTIC BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-6-007 SUP HCPCS C1762 6183-6-007 - GRAFT BONE 7MM CERV SPN BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-7-005 SUP HCPCS C1762 6183-7-005 - GRAFT BONE 14X11X5MM LORDOTIC CANCELLOUS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-7-006 SUP HCPCS C1762 6183-7-006 - GRAFT BONE LORDOTIC 14X11X6MM ALLOCRAFT CANCELLOUS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-7-007 SUP HCPCS C1762 6183-7-007 - GRAFT BONE LORDOTIC 14X11X7MM ALLOGRAFT ALLOCRAFT CANCELLOUS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-7-008 SUP HCPCS C1762 6183-7-008 - GRAFT BONE 14X11X8MM LORDOTIC ALLOGRAFT CANCELLOUS CERV BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-7-009 SUP HCPCS C1762 6183-7-009 - GRAFT BONE 14X11X9MM LORDOTIC CANCELLOUS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6183-7-010 SUP HCPCS C1762 6183-7-010 - GRAFT BONE 14X11X10MM LORDOTIC CANCELLOUS BOTH IP/OP "$6,675.00 " "$4,939.50" $0.00 "$5,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,391.07" $0.00 "$3,290.78" "$3,290.78" $0.00 "$3,337.50" "$5,286.60" "$5,340.00" $0.00 $0.00 "$1,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6184-0-025 SUP HCPCS C1713 6184-0-025 - CEMENT BONE BNSRC CALCIUM PHOS HYDRXAPT 2.5GM PST BOTH IP/OP "$1,078.80 " $798.31 $0.00 $863.04 $485.46 $485.46 $0.00 $0.00 $0.00 $224.85 $800.69 $800.69 $0.00 $0.00 $224.82 $0.00 $638.11 $638.11 $0.00 $539.40 $854.41 $863.04 $0.00 $0.00 $168.83 $0.00 $0.00 $171.74 $0.00 $0.00 $0.00 $0.00 $0.00 6184-0-050 SUP HCPCS C1713 6184-0-050 - CEMENT BONE BNSRC CALCIUM PHOS HYDRXAPT 5GM PST BOTH IP/OP "$1,815.83 " "$1,343.71" $0.00 "$1,452.66" $817.12 $817.12 $0.00 $0.00 $0.00 $378.46 "$1,347.71" "$1,347.71" $0.00 $0.00 $378.42 $0.00 "$1,074.06" "$1,074.06" $0.00 $907.91 "$1,438.14" "$1,452.66" $0.00 $0.00 $284.18 $0.00 $0.00 $289.08 $0.00 $0.00 $0.00 $0.00 $0.00 6184-0-100 SUP HCPCS C1713 6184-0-100 - CEMENT BONE BNSRC HYDRXAPT 10GM PST FILR STRL BOTH IP/OP "$3,554.93 " "$2,630.65" $0.00 "$2,843.94" "$1,599.72" "$1,599.72" $0.00 $0.00 $0.00 $740.94 "$2,638.47" "$2,638.47" $0.00 $0.00 $740.85 $0.00 "$1,752.58" "$1,752.58" $0.00 "$1,777.46" "$2,815.50" "$2,843.94" $0.00 $0.00 $556.35 $0.00 $0.00 $565.94 $0.00 $0.00 $0.00 $0.00 $0.00 6184-0-250 SUP HCPCS C1713 6184-0-250 - CEMENT BONE BNSRC HYDRXAPT 25GM PST FILR STRL BOTH IP/OP "$7,616.70 " "$5,636.36" $0.00 "$6,093.36" "$3,427.52" "$3,427.52" $0.00 $0.00 $0.00 "$1,587.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,587.32" $0.00 "$3,755.03" "$3,755.03" $0.00 "$3,808.35" "$6,032.43" "$6,093.36" $0.00 $0.00 "$1,192.01" $0.00 $0.00 "$1,212.58" $0.00 $0.00 $0.00 $0.00 $0.00 6184-0-500 SUP HCPCS C1713 6184-0-500 - CEMENT BONE BNSRC 50GM PST STRL BOTH IP/OP "$12,682.88 " "$9,385.33" $0.00 "$10,146.30" "$5,707.29" "$5,707.29" $0.00 $0.00 $0.00 "$2,643.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,643.11" $0.00 "$6,252.66" "$6,252.66" $0.00 "$6,341.44" "$10,044.84" "$10,146.30" $0.00 $0.00 "$1,984.87" $0.00 $0.00 "$2,019.11" $0.00 $0.00 $0.00 $0.00 $0.00 6184-1-003 SUP HCPCS C1713 6184-1-003 - CEMENT BONE BCMPT INJ OSTCNDC HYDROSET BONE SUB VOID FILR BOTH IP/OP "$2,362.20 " "$1,748.03" $0.00 "$1,889.76" "$1,062.99" "$1,062.99" $0.00 $0.00 $0.00 $492.34 "$1,753.22" "$1,753.22" $0.00 $0.00 $492.28 $0.00 "$1,397.24" "$1,397.24" $0.00 "$1,181.10" "$1,870.86" "$1,889.76" $0.00 $0.00 $369.68 $0.00 $0.00 $376.06 $0.00 $0.00 $0.00 $0.00 $0.00 6184-1-005 SUP HCPCS C1713 6184-1-005 - CEMENT BONE HYDROSET SUB VOID FILR CALCIUM PHOS 5ML ORTH BOTH IP/OP "$3,785.10 " "$2,800.97" $0.00 "$3,028.08" "$1,703.30" "$1,703.30" $0.00 $0.00 $0.00 $788.91 "$2,809.30" "$2,809.30" $0.00 $0.00 $788.81 $0.00 "$1,866.05" "$1,866.05" $0.00 "$1,892.55" "$2,997.80" "$3,028.08" $0.00 $0.00 $592.37 $0.00 $0.00 $602.59 $0.00 $0.00 $0.00 $0.00 $0.00 6184-1-010 SUP HCPCS C1713 6184-1-010 - CEMENT BONE HYDROSET SUB VOID FILR CALCIUM PHOS 10ML INJ BOTH IP/OP "$7,286.55 " "$5,392.05" $0.00 "$5,829.24" "$3,278.95" "$3,278.95" $0.00 $0.00 $0.00 "$1,518.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,518.52" $0.00 "$3,592.27" "$3,592.27" $0.00 "$3,643.28" "$5,770.95" "$5,829.24" $0.00 $0.00 "$1,140.35" $0.00 $0.00 "$1,160.02" $0.00 $0.00 $0.00 $0.00 $0.00 6184-1-015 SUP HCPCS C1713 6184-1-015 - CEMENT BONE INJ BCMPT STRL HYDROSET BONE SUB VOID FILR BOTH IP/OP "$10,460.18 " "$7,740.53" $0.00 "$8,368.14" "$4,707.08" "$4,707.08" $0.00 $0.00 $0.00 "$2,180.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,179.90" $0.00 "$5,156.87" "$5,156.87" $0.00 "$5,230.09" "$8,284.46" "$8,368.14" $0.00 $0.00 "$1,637.02" $0.00 $0.00 "$1,665.26" $0.00 $0.00 $0.00 $0.00 $0.00 6184-5-100 SUP HCPCS C1762 6184-5-100 - BONE STACK 5MM X 100 PELLETS BOTH IP/OP "$1,274.10 " $942.83 $0.00 "$1,019.28" $0.00 $0.00 $0.00 $0.00 $0.00 $265.55 $945.64 $945.64 $0.00 $0.00 $265.52 $0.00 $753.63 $753.63 $0.00 $637.05 "$1,009.09" "$1,019.28" $0.00 $0.00 $199.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6184-5-300 SUP HCPCS C1762 6184-5-300 - BONE STACK 5MM X 300 PELLETS BOTH IP/OP "$2,262.23 " "$1,674.05" $0.00 "$1,809.78" $0.00 $0.00 $0.00 $0.00 $0.00 $471.50 "$1,679.02" "$1,679.02" $0.00 $0.00 $471.45 $0.00 "$1,338.11" "$1,338.11" $0.00 "$1,131.11" "$1,791.69" "$1,809.78" $0.00 $0.00 $354.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6184-9-220 SUP HCPCS C1713 6184-9-220 - CEMENT BONE BONESAVE 4-6MM TCP HYDRXAPT 20ML GRNL BOTH IP/OP "$3,073.65 " "$2,274.50" $0.00 "$2,458.92" "$1,383.14" "$1,383.14" $0.00 $0.00 $0.00 $640.63 "$2,281.26" "$2,281.26" $0.00 $0.00 $640.55 $0.00 "$1,515.31" "$1,515.31" $0.00 "$1,536.83" "$2,434.33" "$2,458.92" $0.00 $0.00 $481.03 $0.00 $0.00 $489.33 $0.00 $0.00 $0.00 $0.00 $0.00 6188-1-001 SUP HCPCS C1713 6188-1-001 - CEMENT BONE RADIOPQ HALF DOSE SIMPLEX P BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $58.50 $58.50 $0.00 $0.00 $0.00 $27.10 $96.49 $96.49 $0.00 $0.00 $27.09 $0.00 $76.90 $76.90 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 6188-1-010 SUP HCPCS C1713 6188-1-010 - CEMENT BONE RADIOPQ HALF DOSE SIMPLEX P STERILE BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $58.50 $58.50 $0.00 $0.00 $0.00 $27.10 $96.49 $96.49 $0.00 $0.00 $27.09 $0.00 $76.90 $76.90 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 6191-1-001 SUP HCPCS C1713 6191-1-001 - CEMENT BONE RADIOPQ FULL DOSE SIMPLEX P BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $76.50 $76.50 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 6191-1-010 SUP HCPCS C1713 6191-1-010 - CEMENT BONE RADIOPQ FULL DOSE SIMPLEX P STERILE BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $76.50 $76.50 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 6192-1-001 SUP HCPCS C1713 6192-1-001 - CEMENT BONE FULL DOSE INDIVIDUAL SIMPLEX P SPEEDSET BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $76.50 $76.50 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 6192-1-010 SUP HCPCS C1713 6192-1-010 - CEMENT BONE SMPX P SPEEDSET FD FST SET STRL BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $76.50 $76.50 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 6194-1-001 SUP HCPCS C1713 6194-1-001 - CEMENT BN SMPX HVISC BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $76.50 $76.50 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 6194-1-010 SUP HCPCS C1713 6194-1-010 - CEMENT BN 20ML STRL SMPX HVISC 40GM BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $76.50 $76.50 $0.00 $0.00 $0.00 $35.43 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $100.56 $100.56 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 6195-1-001 SUP HCPCS C1713 6195-1-001 - CEMENT BN SMPX HVISC GNTA 40GM BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $208.13 $208.13 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 6195-1-010 SUP HCPCS C1713 6195-1-010 - CEMENT BN 20ML STRL SMPX HVISC GNTA 40GM BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $208.13 $208.13 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 6197-9-001 SUP HCPCS C1713 6197-9-001 - CEMENT BONE SMPX P RADIOPQ FD TBR STRL BOTH IP/OP $700.00 $518.00 $0.00 $648.70 $364.89 $364.89 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $405.44 $642.22 $648.70 $0.00 $0.00 $126.90 $0.00 $0.00 $129.09 $0.00 $0.00 $0.00 $0.00 $0.00 6197-9-010 SUP HCPCS C1713 6197-9-010 - CEMENT BONE FULL DOSE RADIOPQ PREBLEND SIMPLEX P TOBRAMYCIN BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2242 SUP Custom 27803010 61C-2242 - CUP ACETAB UHMWPE XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2244 SUP Custom 27803010 61C-2244 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2246 SUP Custom 27803010 61C-2246 - CUP ACETAB UHMWPE XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2248 SUP Custom 27803010 61C-2248 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2250 SUP Custom 27803010 61C-2250 - CUP ACETAB UHMWPE XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2252 SUP Custom 27803010 61C-2252 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2254 SUP Custom 27803010 61C-2254 - CUP ACETAB UHMWPE XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2256 SUP Custom 27803010 61C-2256 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2258 SUP Custom 27803010 61C-2258 - CUP ACETAB UHMWPE XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2261 SUP Custom 27803010 61C-2261 - CUP ACETAB UHMWPE XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2642 SUP Custom 27803010 61C-2642 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2644 SUP Custom 27803010 61C-2644 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2646 SUP Custom 27803010 61C-2646 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2648 SUP Custom 27803010 61C-2648 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2650 SUP Custom 27803010 61C-2650 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2652 SUP Custom 27803010 61C-2652 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2654 SUP Custom 27803010 61C-2654 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2656 SUP Custom 27803010 61C-2656 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2658 SUP Custom 27803010 61C-2658 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2661 SUP Custom 27803010 61C-2661 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2844 SUP Custom 27803010 61C-2844 - CUP ACETAB LOW HIP UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2846 SUP Custom 27803010 61C-2846 - CUP ACETAB UHMWPE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2848 SUP Custom 27803010 61C-2848 - CUP ACETAB ALPLY XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2850 SUP Custom 27803010 61C-2850 - CUP ACETAB ALPLY XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2852 SUP Custom 27803010 61C-2852 - CUP ACETAB ALPLY XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2854 SUP Custom 27803010 61C-2854 - CUP ACETAB ALPLY XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2856 SUP Custom 27803010 61C-2856 - CUP ACETAB ALPLY XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2858 SUP Custom 27803010 61C-2858 - CUP ACETAB ALPLY XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C-2861 SUP Custom 27803010 61C-2861 - CUP ACETAB ALPLY XFIRE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 61C3 SUP Custom 27203010 CONTROL SPHL RPR IMP RPR 1ML SERO BOTH IP/OP $51.20 $37.89 $0.00 $40.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.60 $40.55 $40.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-00-28D SUP Custom 27803010 620-00-28D - INSERT ACETAB 28MM 0D D HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-00-28E SUP Custom 27803010 620-00-28E - INSERT ACETAB 28MM 0D E HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-00-28F SUP Custom 27803010 620-00-28F - INSERT ACETAB 28MM 0D F HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-00-28G SUP Custom 27803010 620-00-28G - INSERT ACETAB 28MM 0D G HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-00-28H SUP Custom 27803010 620-00-28H - INSERT ACETAB 28MM 0D H HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-00-28I SUP Custom 27803010 620-00-28I - INSERT ACETAB 28MM 0D 1 HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-00-28J SUP Custom 27803010 620-00-28J - INSERT ACETAB 28MM 0D J HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-005 SUP HCPCS C1713 620-005 - CEMENT BN 5ML STIMULAN RPD CURE KT BOTH IP/OP "$2,425.00 " "$1,794.50" $0.00 "$1,940.00" "$1,091.25" "$1,091.25" $0.00 $0.00 $0.00 $505.43 "$1,799.84" "$1,799.84" $0.00 $0.00 $505.37 $0.00 "$1,434.39" "$1,434.39" $0.00 "$1,212.50" "$1,920.60" "$1,940.00" $0.00 $0.00 $379.51 $0.00 $0.00 $386.06 $0.00 $0.00 $0.00 $0.00 $0.00 620-010 SUP HCPCS C9359 620-010 - FILLER BN VOID CA SLF BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00146 SUP Custom 27100030 62-00146 - GUIDE DRILL 1.6MM LAG PILOT BOTH IP/OP $914.20 $676.51 $0.00 "$1,458.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $678.52 $678.52 $0.00 $0.00 $190.52 $0.00 $0.00 $0.00 $0.00 $911.25 "$1,443.42" "$1,458.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00148 SUP Custom 27100030 62-00148 - GUIDE DRILL 2MM LAG OVERDRILL BOTH IP/OP $998.50 $738.89 $0.00 "$1,478.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $741.09 $741.09 $0.00 $0.00 $208.09 $0.00 $0.00 $0.00 $0.00 $923.75 "$1,463.22" "$1,478.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-020 SUP HCPCS C1713 620-020 - CEMENT BONE STIMULAN RPD CURE CALCIUM SLF 20ML KIT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 62-00231 SUP Custom 27203010 62-00231 - GUIDE DRILL XS SRR CENTRIC BOTH IP/OP $163.63 $121.09 $0.00 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.44 $121.44 $0.00 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $81.81 $129.59 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00233 SUP Custom 27203010 62-00233 - GUIDE DRILL SM SRR CENTRIC LEIBINGER BOTH IP/OP $163.63 $121.09 $0.00 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.44 $121.44 $0.00 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $81.81 $129.59 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00235 SUP Custom 27203010 62-00235 - GUIDE MED LG DRILL SRR CENTRIC SURG BOTH IP/OP $163.63 $121.09 $0.00 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.44 $121.44 $0.00 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $81.81 $129.59 $130.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00237 SUP Custom 27203010 62-00237 - GUIDE MED DRILL ECNTRC SURG BOTH IP/OP $138.88 $102.77 $0.00 $111.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.07 $103.07 $0.00 $0.00 $28.94 $0.00 $0.00 $0.00 $0.00 $69.44 $109.99 $111.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00239 SUP Custom 27203010 62-00239 - GUIDE LG DRILL ECNTRC SURG BOTH IP/OP $138.88 $102.77 $0.00 $111.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.07 $103.07 $0.00 $0.00 $28.94 $0.00 $0.00 $0.00 $0.00 $69.44 $109.99 $111.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00241 SUP Custom 27203010 62-00241 - GUIDE DRILL 2.7MM ECNTRC BOTH IP/OP $82.50 $61.05 $0.00 $66.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.23 $61.23 $0.00 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $41.25 $65.34 $66.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00249 SUP Custom 27203010 62-00249 - GUIDE DRILL 2.7MM SRR CENTRIC BOTH IP/OP $204.88 $151.61 $0.00 $163.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.06 $152.06 $0.00 $0.00 $42.70 $0.00 $0.00 $0.00 $0.00 $102.44 $162.26 $163.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00254 SUP Custom 27203010 62-00254 - GUIDE DRILL HNDL CENTRIC SURG BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00270 SUP Custom 27203010 62-00270 - GUIDE DRILL REDX BOTH IP/OP $171.88 $127.19 $0.00 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.57 $127.57 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $85.94 $136.13 $137.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-00605 SUP Custom 27803010 62-00605 - SPACER SPNL HBRD MMF BOTH IP/OP $930.00 $688.20 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.25 $690.25 $0.00 $0.00 $193.81 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-10-28D SUP Custom 27803010 620-10-28D - INSERT ACETAB 28MM 10D D HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-10-28E SUP Custom 27803010 620-10-28E - INSERT ACETAB 28MM 10D E HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-10-28F SUP Custom 27803010 620-10-28F - INSERT ACETAB 28MM 10D F HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-10-28G SUP Custom 27803010 620-10-28G - INSERT ACETAB 10D HIP DUR S12 BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-10-28H SUP Custom 27803010 620-10-28H - INSERT ACETAB 28MM 10D H HIP PE TRDNT BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 620-10-28I SUP Custom 27803010 620-10-28I - INSERT ACETAB 10D HIP CNSTRN ECNTRC POLY XFIRE OMFT S12 BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-01245 SUP Custom 27203010 62-01245 - GUIDE DRILL FEM 2.3 MM SCR BOTH IP/OP $534.88 $395.81 $0.00 $427.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.98 $396.98 $0.00 $0.00 $111.47 $0.00 $0.00 $0.00 $0.00 $267.44 $423.62 $427.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-01246 SUP Custom 27203010 62-01246 - GUIDE DRILL FEM 2.7 MM SCR BOTH IP/OP $534.88 $395.81 $0.00 $427.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.98 $396.98 $0.00 $0.00 $111.47 $0.00 $0.00 $0.00 $0.00 $267.44 $423.62 $427.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-01250 SUP Custom 27203010 62-01250 - GUIDE CENTRIC DRILL HNDL SURG BOTH IP/OP $484.00 $358.16 $0.00 $387.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.22 $359.22 $0.00 $0.00 $100.87 $0.00 $0.00 $0.00 $0.00 $242.00 $383.33 $387.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6201FAS SUP HCPCS C1760 6201FAS - TOOL LEAD DELIVERY 15MM 22CM FLEXIBLE FASTAC BOTH IP/OP $935.00 $691.90 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $194.88 $693.96 $693.96 $0.00 $0.00 $194.85 $0.00 $553.05 $553.05 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6208-3-010 SUP HCPCS C1713 6208-3-010 - PLUG BONE CMNT SDL 10MM IM BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 6208-3-016 SUP HCPCS C1713 6208-3-016 - PLUG BONE CMNT SDL 16MM IM BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22A SUP Custom 27803010 621-00-22A - INSERT ACETAB 0D A 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22B SUP Custom 27803010 621-00-22B - INSERT ACETAB 0D B 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22C SUP Custom 27803010 621-00-22C - INSERT ACETAB 0D C 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22D SUP Custom 27803010 621-00-22D - INSERT ACETAB 0D D 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22E SUP Custom 27803010 621-00-22E - INSERT ACETAB 0D E 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22F SUP Custom 27803010 621-00-22F - INSERT ACETAB 0D F 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22G SUP Custom 27803010 621-00-22G - INSERT ACETAB 0D G 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22H SUP Custom 27803010 621-00-22H - INSERT ACETAB 0D H 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22I SUP Custom 27803010 621-00-22I - INSERT ACETAB 0D I 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-22J SUP Custom 27803010 621-00-22J - INSERT ACETAB 0D J 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-26C SUP Custom 27803010 621-00-26C - INSERT ACETAB 0D C 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-26D SUP Custom 27803010 621-00-26D - INSERT ACETAB 0D D 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-26E SUP Custom 27803010 621-00-26E - INSERT ACETAB 0D E 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-26F SUP Custom 27803010 621-00-26F - INSERT ACETAB 0D F 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-26G SUP Custom 27803010 621-00-26G - INSERT ACETAB 0D G 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-26H SUP Custom 27803010 621-00-26H - INSERT ACETAB 0D H 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-26I SUP Custom 27803010 621-00-26I - INSERT ACETAB 0D I 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-26J SUP Custom 27803010 621-00-26J - INSERT ACETAB 0D J 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-28C SUP Custom 27803010 621-00-28C - INSERT ACETAB 0D C 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-28D SUP Custom 27803010 621-00-28D - INSERT ACETAB 0D D 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-28E SUP Custom 27803010 621-00-28E - INSERT ACETAB 0D E 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-28F SUP Custom 27803010 621-00-28F - INSERT ACETAB 0D F 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-28G SUP Custom 27803010 621-00-28G - INSERT ACETAB 0D G 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-28H SUP Custom 27803010 621-00-28H - INSERT ACETAB 0D H 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-28I SUP Custom 27803010 621-00-28I - INSERT ACETAB 0D I 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-28J SUP Custom 27803010 621-00-28J - INSERT ACETAB 0D J 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-32D SUP Custom 27803010 621-00-32D - INSERT ACETAB 0D D 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-32E SUP Custom 27803010 621-00-32E - INSERT ACETAB 0D E 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-32F SUP Custom 27803010 621-00-32F - INSERT ACETAB 0D F 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-32G SUP Custom 27803010 621-00-32G - INSERT ACETAB 0D G 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-32H SUP Custom 27803010 621-00-32H - INSERT ACETAB 0D H 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-32I SUP Custom 27803010 621-00-32I - INSERT ACETAB 0D I 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-32J SUP Custom 27803010 621-00-32J - INSERT ACETAB 0D J 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-36E SUP Custom 27803010 621-00-36E - INSERT ACETAB 0D E 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-36F SUP Custom 27803010 621-00-36F - INSERT ACETAB 0D F 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-36G SUP Custom 27803010 621-00-36G - INSERT ACETAB 0D G 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-36H SUP Custom 27803010 621-00-36H - INSERT ACETAB 0D H 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-36I SUP Custom 27803010 621-00-36I - INSERT ACETAB 0D I 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-00-36J SUP Custom 27803010 621-00-36J - INSERT ACETAB 0D J 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6210-0-710 SUP Custom 27203010 6210-0-710 - OSTEOTOME SURG 12MM 120MM FLEXIBLE GRAY STERILE BOTH IP/OP "$1,422.50 " "$1,052.65" $0.00 "$1,138.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,055.78" "$1,055.78" $0.00 $0.00 $296.45 $0.00 $0.00 $0.00 $0.00 $711.25 "$1,126.62" "$1,138.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6210-0-740 SUP Custom 27203010 6210-0-740 - OSTEOTOME SURG 12MMX93MM FLEXIBLE GRAY STERILE BOTH IP/OP "$1,422.50 " "$1,052.65" $0.00 "$1,138.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,055.78" "$1,055.78" $0.00 $0.00 $296.45 $0.00 $0.00 $0.00 $0.00 $711.25 "$1,126.62" "$1,138.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22A SUP Custom 27803010 621-10-22A - INSERT ACETAB 10D A 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22B SUP Custom 27803010 621-10-22B - INSERT ACETAB 10D B 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22C SUP Custom 27803010 621-10-22C - INSERT ACETAB 10D C 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22D SUP Custom 27803010 621-10-22D - INSERT ACETAB 10D D 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22E SUP Custom 27803010 621-10-22E - INSERT ACETAB 10D E 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22F SUP Custom 27803010 621-10-22F - INSERT ACETAB 10D F 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22G SUP Custom 27803010 621-10-22G - INSERT ACETAB 10D G 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22H SUP Custom 27803010 621-10-22H - INSERT ACETAB 10D H 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22I SUP Custom 27803010 621-10-22I - INSERT ACETAB 10D I 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-22J SUP Custom 27803010 621-10-22J - INSERT ACETAB 10D J 22MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-26C SUP Custom 27803010 621-10-26C - INSERT ACETAB 10D C 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-26D SUP Custom 27803010 621-10-26D - INSERT ACETAB 10D D 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-26E SUP Custom 27803010 621-10-26E - INSERT ACETAB 10D E 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-26F SUP Custom 27803010 621-10-26F - INSERT ACETAB 10D F 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-26G SUP Custom 27803010 621-10-26G - INSERT ACETAB 10D G 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-26H SUP Custom 27803010 621-10-26H - INSERT ACETAB 10D H 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-26I SUP Custom 27803010 621-10-26I - INSERT ACETAB 10D I 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-26J SUP Custom 27803010 621-10-26J - INSERT ACETAB 10D J 26MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-28C SUP Custom 27803010 621-10-28C - INSERT ACETAB 10D C 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-28D SUP Custom 27803010 621-10-28D - INSERT ACETAB 10D D 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-28E SUP Custom 27803010 621-10-28E - INSERT ACETAB 10D E 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-28F SUP Custom 27803010 621-10-28F - INSERT ACETAB 10D F 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-28G SUP Custom 27803010 621-10-28G - INSERT ACETAB 10D G 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-28H SUP Custom 27803010 621-10-28H - INSERT ACETAB 10D H 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-28I SUP Custom 27803010 621-10-28I - INSERT ACETAB 10D I 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-28J SUP Custom 27803010 621-10-28J - INSERT ACETAB 10D J 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-32D SUP Custom 27803010 621-10-32D - INSERT ACETAB 10D D 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-32E SUP Custom 27803010 621-10-32E - INSERT ACETAB 10D E 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-32F SUP Custom 27803010 621-10-32F - INSERT ACETAB 10D F 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-32G SUP Custom 27803010 621-10-32G - INSERT ACETAB 10D G 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-32H SUP HCPCS C1713 621-10-32H - INSERT ACETAB 10D H 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $517.50 $517.50 $0.00 $0.00 $0.00 $239.69 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $680.23 $680.23 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $179.98 $0.00 $0.00 $183.08 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-32I SUP Custom 27803010 621-10-32I - INSERT ACETAB 10D I 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-32J SUP Custom 27803010 621-10-32J - INSERT ACETAB 10D J 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-36E SUP Custom 27803010 621-10-36E - INSERT ACETAB 10D E 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-36F SUP Custom 27803010 621-10-36F - INSERT ACETAB 10D F 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-36G SUP Custom 27803010 621-10-36G - INSERT ACETAB 10D G 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-36H SUP Custom 27803010 621-10-36H - INSERT ACETAB 10D H 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-36I SUP Custom 27803010 621-10-36I - INSERT ACETAB 10D I 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 621-10-36J SUP Custom 27803010 621-10-36J - INSERT ACETAB 10D J 36MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-12002 SUP Custom 27203010 62-12002 - BLADE XFIT DNTL SHFT END 1.2MM SCRDRVR BOTH IP/OP $361.63 $267.61 $0.00 $289.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.40 $268.40 $0.00 $0.00 $75.36 $0.00 $0.00 $0.00 $0.00 $180.81 $286.41 $289.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-12333 SUP Custom 27203010 62-12333 - BLADE 1.2MM XPIN SCRDRVR BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-12335 SUP Custom 27203010 62-12335 - BLADE 1.2MM REM SCRDRVR BOTH IP/OP $309.70 $229.18 $0.00 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.86 $229.86 $0.00 $0.00 $64.54 $0.00 $0.00 $0.00 $0.00 $171.88 $272.25 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-12503 SUP Custom 27803010 62-12503 - TAP SURG 1.2 MM SCR BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6215-5-001 SUP HCPCS C1713 6215-5-001 - PLUG BN CMNT SM 18.5MM STRL IM CNL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 6215-5-011 SUP HCPCS C1713 6215-5-011 - PLUG BN CMNT MED 25MM STRL IM CNL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 6215-5-021 SUP HCPCS C1713 6215-5-021 - PLUG BN CMNT LG 30MM STRL IM CNL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 621573S SUP HCPCS C1713 621573S - PLATE 81MM TI 3.5MM/4MM SCR 3 HOLE SM FRAG SET SHFT BONE FIB BOTH IP/OP $284.00 $210.16 $0.00 $249.70 $140.46 $140.46 $0.00 $0.00 $0.00 $59.19 $210.78 $210.78 $0.00 $0.00 $59.19 $0.00 $167.99 $167.99 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $48.85 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 621574S SUP HCPCS C1713 621574S - PLATE 93MM TI 3.5MM/4MM SCR 4 HOLE SM FRAG SET SHFT BONE FIB BOTH IP/OP $284.00 $210.16 $0.00 $249.70 $140.46 $140.46 $0.00 $0.00 $0.00 $59.19 $210.78 $210.78 $0.00 $0.00 $59.19 $0.00 $167.99 $167.99 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $48.85 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 621575S SUP HCPCS C1713 621575S - PLATE 105MM TI 3.5MM/4MM SCR 5 HOLE SM FRAG SET SHFT BONE BOTH IP/OP $284.00 $210.16 $0.00 $249.70 $140.46 $140.46 $0.00 $0.00 $0.00 $59.19 $210.78 $210.78 $0.00 $0.00 $59.19 $0.00 $167.99 $167.99 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $48.85 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 621576S SUP HCPCS C1713 621576S - PLATE 117MM TI 3.5MM/4MM SCR 6 HOLE SM FRAG SET SHFT BONE BOTH IP/OP $284.00 $210.16 $0.00 $249.70 $140.46 $140.46 $0.00 $0.00 $0.00 $59.19 $210.78 $210.78 $0.00 $0.00 $59.19 $0.00 $167.99 $167.99 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $48.85 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 621577S SUP HCPCS C1713 621577S - PLATE 129MM TI 3.5MM/4MM SCR 7 HOLE SM FRAG SET SHFT BONE BOTH IP/OP $284.00 $210.16 $0.00 $249.70 $140.46 $140.46 $0.00 $0.00 $0.00 $59.19 $210.78 $210.78 $0.00 $0.00 $59.19 $0.00 $167.99 $167.99 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $48.85 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 621578S SUP HCPCS C1713 621578S - PLATE 141MM TI 3.5MM/4MM SCR 8 HOLE SM FRAG SET SHFT BONE BOTH IP/OP $284.00 $210.16 $0.00 $249.70 $140.46 $140.46 $0.00 $0.00 $0.00 $59.19 $210.78 $210.78 $0.00 $0.00 $59.19 $0.00 $167.99 $167.99 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $48.85 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 621579S SUP HCPCS C1713 621579S - PLATE 153MM TI 3.5MM/4MM SCR 9 HOLE SM FRAG SET SHFT BONE BOTH IP/OP $284.00 $210.16 $0.00 $249.70 $140.46 $140.46 $0.00 $0.00 $0.00 $59.19 $210.78 $210.78 $0.00 $0.00 $59.19 $0.00 $167.99 $167.99 $0.00 $156.06 $247.21 $249.70 $0.00 $0.00 $48.85 $0.00 $0.00 $49.69 $0.00 $0.00 $0.00 $0.00 $0.00 62-17005 SUP Custom 27203010 62-17005 - BLADE SCRDRVR 1.7MM XFT BOTH IP/OP $361.63 $267.61 $0.00 $289.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.40 $268.40 $0.00 $0.00 $75.36 $0.00 $0.00 $0.00 $0.00 $180.81 $286.41 $289.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-17333 SUP Custom 27203010 62-17333 - BLADE 1.7MM XPIN SCRDRVR BOTH IP/OP $240.63 $178.07 $0.00 $192.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.59 $178.59 $0.00 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $120.31 $190.58 $192.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-17335 SUP Custom 27203010 62-17335 - BLADE 1.7MM REM SCRDRVR BOTH IP/OP $309.70 $229.18 $0.00 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.86 $229.86 $0.00 $0.00 $64.54 $0.00 $0.00 $0.00 $0.00 $171.88 $272.25 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-17503 SUP Custom 27803010 62-17503 - TAP 1.7MM SURG MAXFACL BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-20125 SUP Custom 27203010 62-20125 - CUTTER SURG PLT BOTH IP/OP "$2,457.00 " "$1,818.18" $0.00 "$1,936.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,823.59" "$1,823.59" $0.00 $0.00 $512.04 $0.00 $0.00 $0.00 $0.00 "$1,210.00" "$1,916.64" "$1,936.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-21723 SUP HCPCS C1713 62-21723 - IRON BNDRG PLT BOTH IP/OP $715.35 $529.36 $0.00 $583.00 $327.94 $327.94 $0.00 $0.00 $0.00 $149.10 $530.93 $530.93 $0.00 $0.00 $149.08 $0.00 $423.13 $423.13 $0.00 $364.38 $577.17 $583.00 $0.00 $0.00 $114.05 $0.00 $0.00 $116.02 $0.00 $0.00 $0.00 $0.00 $0.00 62-23005 SUP Custom 27203010 62-23005 - BLADE 2.3MM XFIT DNTL SHFT END SCRDRVR BOTH IP/OP $361.63 $267.61 $0.00 $289.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.40 $268.40 $0.00 $0.00 $75.36 $0.00 $0.00 $0.00 $0.00 $180.81 $286.41 $289.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-23333 SUP Custom 27203010 62-23333 - BLADE 2.3MM XPIN SCRDRVR BOTH IP/OP $240.63 $178.07 $0.00 $192.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.59 $178.59 $0.00 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $120.31 $190.58 $192.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-23335 SUP HCPCS C1713 62-23335 - SCREW REMOVAL BLADE 2.3 DENTAL BOTH IP/OP $309.70 $229.18 $0.00 $275.00 $154.69 $154.69 $0.00 $0.00 $0.00 $64.55 $229.86 $229.86 $0.00 $0.00 $64.54 $0.00 $183.19 $183.19 $0.00 $171.88 $272.25 $275.00 $0.00 $0.00 $53.80 $0.00 $0.00 $54.73 $0.00 $0.00 $0.00 $0.00 $0.00 62-23503 SUP Custom 27803010 62-23503 - TAP SURG 2.3 MM SCR BOTH IP/OP $213.13 $157.72 $0.00 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.18 $158.18 $0.00 $0.00 $44.42 $0.00 $0.00 $0.00 $0.00 $106.56 $168.80 $170.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-27015 SUP Custom 27203010 62-27015 - BLADE T7 SCRDRVR 2.3MM 2.7MM SCR BOTH IP/OP $501.88 $371.39 $0.00 $401.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.49 $372.49 $0.00 $0.00 $104.59 $0.00 $0.00 $0.00 $0.00 $250.94 $397.49 $401.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6227DEF04 SUP Custom 27203010 6227DEF04 - CATHETER GD 9.9FR 45CM STRL LF ATN PRVL LD DLV SYS DFLC CS BOTH IP/OP "$1,242.50 " $919.45 $0.00 $994.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $922.18 $922.18 $0.00 $0.00 $258.94 $0.00 $0.00 $0.00 $0.00 $621.25 $984.06 $994.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22A SUP Custom 27803010 623-00-22A - LINER ACETAB 0D A 22MM 7.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22B SUP Custom 27803010 623-00-22B - LINER ACETAB 0D B 22MM 8.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22C SUP Custom 27803010 623-00-22C - LINER ACETAB 0D C 22MM 9.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22D SUP Custom 27803010 623-00-22D - LINER ACETAB 0D D 22MM 10.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22E SUP Custom 27803010 623-00-22E - LINER ACETAB 0D E 22MM 12.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22F SUP Custom 27803010 623-00-22F - LINER ACETAB 0D F 22MM 14.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22G SUP Custom 27803010 623-00-22G - LINER ACETAB 0D G 22MM 16.3MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22H SUP Custom 27803010 623-00-22H - LINER ACETAB 0D H 22MM 18.1MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22I SUP Custom 27803010 623-00-22I - LINER ACETAB 0D I 22MM 19.6MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-22J SUP Custom 27803010 623-00-22J - LINER ACETAB 0D J 22MM 21.6MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-26C SUP Custom 27803010 623-00-26C - LINER ACETAB 0D C 26MM 7.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-26D SUP Custom 27803010 623-00-26D - LINER ACETAB 0D D 26MM 8.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-26E SUP Custom 27803010 623-00-26E - LINER ACETAB 0D E 26MM 10.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-26F SUP Custom 27803010 623-00-26F - LINER ACETAB 0D F 26MM 12.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-26G SUP Custom 27803010 623-00-26G - LINER ACETAB 0D G 26MM 14.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-26H SUP Custom 27803010 623-00-26H - LINER ACETAB 0D H 26MM 16.2MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-26I SUP Custom 27803010 623-00-26I - LINER ACETAB 0D I 26MM 17.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-26J SUP Custom 27803010 623-00-26J - LINER ACETAB 0D J 26MM 19.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28A SUP Custom 27803010 623-00-28A - LINER ACETAB 0D A 28MM 4.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28B SUP Custom 27803010 623-00-28B - LINER ACETAB 0D B 28MM 5.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28C SUP Custom 27803010 623-00-28C - LINER ACETAB 0D C 28MM 6.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28D SUP Custom 27803010 623-00-28D - LINER ACETAB 0D D 28MM 7.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28E SUP Custom 27803010 623-00-28E - LINER ACETAB 0D E 28MM 9.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28F SUP Custom 27803010 623-00-28F - LINER ACETAB 0D F 28MM 11.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28G SUP Custom 27803010 623-00-28G - LINER ACETAB 0D G 28MM 13.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28H SUP Custom 27803010 623-00-28H - LINER ACETAB 0D H 28MM 15.2MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28I SUP Custom 27803010 623-00-28I - LINER ACETAB 0D I 28MM 16.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-28J SUP Custom 27803010 623-00-28J - LINER ACETAB 0D J 28MM 18.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32B SUP Custom 27803010 623-00-32B - LINER ACETAB 0D B 32MM 3.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32C SUP Custom 27803010 623-00-32C - LINER ACETAB 0D C 32MM 4.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32D SUP Custom 27803010 623-00-32D - LINER ACETAB 0D D 32MM 5.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32E SUP Custom 27803010 623-00-32E - LINER ACETAB 0D E 32MM 7.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32F SUP Custom 27803010 623-00-32F - LINER ACETAB 0D F 32MM 9.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32G SUP Custom 27803010 623-00-32G - LINER ACETAB 0D G 32MM 11.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32H SUP Custom 27803010 623-00-32H - LINER ACETAB 0D H 32MM 13.2MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32I SUP Custom 27803010 623-00-32I - LINER ACETAB 0D I 32MM 14.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-32J SUP Custom 27803010 623-00-32J - LINER ACETAB 0D J 32MM 16.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-36D SUP Custom 27803010 623-00-36D - LINER ACETAB 0D D 36MM 3.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-36E SUP Custom 27803010 623-00-36E - LINER ACETAB 0D E 36MM 5.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-36F SUP Custom 27803010 623-00-36F - LINER ACETAB 0D F 36MM 7.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-36G SUP Custom 27803010 623-00-36G - LINER ACETAB 0D G 36MM 9.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-36H SUP Custom 27803010 623-00-36H - LINER ACETAB 0D H 36MM 11.2MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-36I SUP Custom 27803010 623-00-36I - LINER ACETAB 0D I 36MM 12.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-36J SUP Custom 27803010 623-00-36J - LINER ACETAB 0D J 36MM 14.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-40E SUP Custom 27803010 623-00-40E - INSERT ACETAB 0D E 40MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-40F SUP Custom 27803010 623-00-40F - LINER ACETAB 0D F 40MM 5.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-40G SUP Custom 27803010 623-00-40G - LINER ACETAB 0D G 40MM 7.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-40H SUP Custom 27803010 623-00-40H - LINER ACETAB 0D H 40MM 9.1MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-40I SUP Custom 27803010 623-00-40I - LINER ACETAB 0D I 40MM 10.6MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-40J SUP Custom 27803010 623-00-40J - LINER ACETAB 0D J 40MM 12.6MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-44F SUP Custom 27803010 623-00-44F - LINER ACETAB 0D B F 44MM 3.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-44G SUP Custom 27803010 623-00-44G - LINER ACETAB 0D G 44MM 5.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-44H SUP Custom 27803010 623-00-44H - LINER ACETAB 0D H 44MM 7.1MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-44I SUP Custom 27803010 623-00-44I - LINER ACETAB 0D I 44MM 8.6MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-00-44J SUP Custom 27803010 623-00-44J - LINER ACETAB 0D J 44MM 10.6MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6230UNI SUP Custom 27203010 6230UNI - SLITTER CATHETER UNIVERSAL UNIVERSAL II BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22A SUP Custom 27803010 623-10-22A - LINER ACETAB 10D A 22MM 7.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22B SUP Custom 27803010 623-10-22B - LINER ACETAB 10D B 22MM 8.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22C SUP Custom 27803010 623-10-22C - LINER ACETAB 10D C 22MM 9.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22D SUP Custom 27803010 623-10-22D - LINER ACETAB 10D D 22MM 10.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22E SUP Custom 27803010 623-10-22E - LINER ACETAB 10D E 22MM 12.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22F SUP Custom 27803010 623-10-22F - LINER ACETAB 10D F 22MM 14.8MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22G SUP Custom 27803010 623-10-22G - LINER ACETAB 10D G 22MM 16.3MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22H SUP Custom 27803010 623-10-22H - LINER ACETAB 10D H 22MM 18.1MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22I SUP Custom 27803010 623-10-22I - LINER ACETAB 10D I 22MM 19.6MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-22J SUP Custom 27803010 623-10-22J - LINER ACETAB 10D J 22MM 21.6MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-26C SUP Custom 27803010 623-10-26C - LINER ACETAB 10D C 26MM 7.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-26D SUP Custom 27803010 623-10-26D - LINER ACETAB 10D D 26MM 8.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-26E SUP Custom 27803010 623-10-26E - LINER ACETAB 10D E 26MM 10.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-26F SUP Custom 27803010 623-10-26F - LINER ACETAB 10D F 26MM 12.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-26G SUP Custom 27803010 623-10-26G - LINER ACETAB 10D G 26MM 14.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-26H SUP Custom 27803010 623-10-26H - LINER ACETAB 10D H 26MM 16.2MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-26I SUP Custom 27803010 623-10-26I - LINER ACETAB 10D I 26MM 17.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-26J SUP Custom 27803010 623-10-26J - LINER ACETAB 10D J 26MM 19.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-28C SUP Custom 27803010 623-10-28C - LINER ACETAB 10D C 28MM 6.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-28D SUP Custom 27803010 623-10-28D - LINER ACETAB 10D D 28MM 7.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-28E SUP Custom 27803010 623-10-28E - LINER ACETAB 10D E 28MM 9.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-28F SUP Custom 27803010 623-10-28F - LINER ACETAB 10D F 28MM 11.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-28G SUP Custom 27803010 623-10-28G - LINER ACETAB 10D G 28MM 13.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-28H SUP Custom 27803010 623-10-28H - LINER ACETAB 10D H 28MM 15.2MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-28I SUP Custom 27803010 623-10-28I - LINER ACETAB 10D I 28MM 16.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-28J SUP Custom 27803010 623-10-28J - LINER ACETAB 10D J 28MM 18.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-32D SUP Custom 27803010 623-10-32D - LINER ACETAB 10D D 32MM 5.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-32E SUP Custom 27803010 623-10-32E - INSERT ACETAB 10D E 32MM PRIM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-32F SUP Custom 27803010 623-10-32F - LINER ACETAB 10D F 32MM 9.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-32G SUP Custom 27803010 623-10-32G - LINER ACETAB 10D G 32MM 11.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-32H SUP Custom 27803010 623-10-32H - LINER ACETAB 10D H 32MM 13.2MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-32I SUP Custom 27803010 623-10-32I - LINER ACETAB 10D I 32MM 14.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-32J SUP Custom 27803010 623-10-32J - LINER ACETAB 10D J 32MM 16.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-36E SUP Custom 27803010 623-10-36E - INSERT ACETAB 10D E 36MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-36F SUP Custom 27803010 623-10-36F - LINER ACETAB 10D F 36MM 7.9MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-36G SUP Custom 27803010 623-10-36G - LINER ACETAB 10D G 36MM 9.4MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-36H SUP Custom 27803010 623-10-36H - LINER ACETAB 10D H 36MM 11.2MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-36I SUP Custom 27803010 623-10-36I - LINER ACETAB 10D I 36MM 12.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 623-10-36J SUP Custom 27803010 623-10-36J - LINER ACETAB 10D J 36MM 14.7MM X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-32440 SUP Custom 27803010 62-32440 - POSITIONER IMPL 3.2MM UNV REPOSITION PIN BOTH IP/OP "$1,892.50 " "$1,400.45" $0.00 "$1,514.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,404.61" "$1,404.61" $0.00 $0.00 $394.40 $0.00 $0.00 $0.00 $0.00 $946.25 "$1,498.86" "$1,514.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6232ADJ SUP Custom 27203010 6232ADJ - SLITTER CATHETER ADJUSTABLE SHEATH BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 624.027S SUP Custom 27203010 624.027S - KIT SURG PEDICLE ACCES SPN REVERE BOTH IP/OP "$2,827.50 " "$2,092.35" $0.00 "$2,262.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,098.57" "$2,098.57" $0.00 $0.00 $589.25 $0.00 $0.00 $0.00 $0.00 "$1,413.75" "$2,239.38" "$2,262.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6248130D02 SUP Custom 27203010 6248130D02 - CATHETER GD 130D 7.1FR 65CM STRL LF ATN SLCT II SUREVALVE BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 624890D02 SUP Custom 27203010 624890D02 - CATHETER GD 90D 7.1FR 65CM STRL LF ATN SLCT II SUREVALVE BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-50201 SUP Custom 27203010 62-50201 - PACK BTRY VARISPEED BOTH IP/OP $780.00 $577.20 $0.00 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $578.92 $578.92 $0.00 $0.00 $162.55 $0.00 $0.00 $0.00 $0.00 $390.00 $617.76 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6250EH02 SUP Custom 27203010 6250EH02 - CATHETER GD EH CRV 9FR 50CM STRL LF ATN CMND SUREVALVE 2 BRD BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6250MB202 SUP Custom 27203010 6250MB202 - CATHETER GD MB2 CRV 9FR 45CM STRL LF ATN CMND SUREVALVE 2 BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 625-0T-28D SUP Custom 27803010 625-0T-28D - INSERT ACETAB D 28MM TRIDENT ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 625-0T-32E SUP Custom 27803010 625-0T-32E - INSERT ACETAB E 32MM TRIDENT ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 625-0T-32F SUP Custom 27803010 625-0T-32F - INSERT ACETAB F 32MM TRIDENT ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 625-0T-36G SUP Custom 27803010 625-0T-36G - INSERT ACETAB G 36MM TRIDENT ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 625-0T-36H SUP Custom 27803010 625-0T-36H - INSERT ACETAB H 36MM TRIDENT ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 625-0T-36I SUP Custom 27803010 625-0T-36I - INSERT ACETAB I 36MM TRIDENT ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-51217 SUP Custom 27203010 62-51217 - GUIDE DRILL 1.2MM 1.7MM STD BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-51723 SUP Custom 27203010 62-51723 - GUIDE DRILL 1.7MM 2.3MM POLYAX LCK BOTH IP/OP $666.88 $493.49 $0.00 $533.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $494.95 $494.95 $0.00 $0.00 $138.98 $0.00 $0.00 $0.00 $0.00 $333.44 $528.17 $533.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-52323 SUP Custom 27203010 62-52323 - GUIDE DRILL 2.3MM CMPR BOTH IP/OP $735.63 $544.37 $0.00 $588.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.98 $545.98 $0.00 $0.00 $153.30 $0.00 $0.00 $0.00 $0.00 $367.81 $582.62 $588.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 62-52325 SUP Custom 27203010 62-52325 - GUIDE DRILL 2.3MM 2.5MM STD BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-080 SUP Custom 27803010 6259-8-080 - CNTRLZR STM 8MM RLNC DISTAL FEM BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-090 SUP Custom 27803010 6259-8-090 - CNTRLZR STM 9MM RLNC DISTAL FEM BOTH IP/OP $168.00 $124.32 $0.00 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.69 $124.69 $0.00 $0.00 $35.01 $0.00 $0.00 $0.00 $0.00 $84.00 $133.06 $134.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-100 SUP Custom 27803010 6259-8-100 - CENTRALIZER STEM 10MM RELIANCE HIP FEMUR FRAC PRODUCTS F R BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-110 SUP HCPCS C1713 6259-8-110 - CENTRALIZER STEM 11MM PRIM RELIANCE HIP FEMUR BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-120 SUP Custom 27803010 6259-8-120 - CENTRALIZER STEM 12MM PRIM RELIANCE DISTAL FEMUR HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-130 SUP HCPCS C1713 6259-8-130 - CENTRALIZER STEM 13MM PRIM RELIANCE HIP FEMUR BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-140 SUP HCPCS C1713 6259-8-140 - CENTRALIZER STEM 14MM RELIANCE HIP FEMUR BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-150 SUP HCPCS C1713 6259-8-150 - CENTRALIZER STEM 15MM RELIANCE HIP FEMUR BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-160 SUP Custom 27803010 6259-8-160 - CENTRALIZER STEM 16MM 16MM ACCESSORIES BONE PLUG CENTRALIZER BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-170 SUP Custom 27803010 6259-8-170 - CENTRALIZER STEM 17MM 17MM BONE PLUGS ACCESSORIES HIP FRAC BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6259-8-180 SUP Custom 27803010 6259-8-180 - CENTRALIZER STEM 18MM RELIANCE HIP FEMUR DISTAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 626-00-36C SUP HCPCS C1776 626-00-36C - LINER ACTB C 36MM MDM COCR HIP 22.2MM FEM HD BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" "$1,056.38" "$1,056.38" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $367.38 $0.00 $0.00 $373.72 $0.00 $0.00 $0.00 $0.00 $0.00 626-00-38D SUP HCPCS C1776 626-00-38D - LINER ACTB D 38MM MDLR 2 MBL COCR HIP BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" "$1,056.38" "$1,056.38" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $367.38 $0.00 $0.00 $373.72 $0.00 $0.00 $0.00 $0.00 $0.00 626-00-42E SUP HCPCS C1776 626-00-42E - LINER ACTB E 42MM MDM 2 MBL MDLR COCR HIP BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" "$1,056.38" "$1,056.38" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $367.38 $0.00 $0.00 $373.72 $0.00 $0.00 $0.00 $0.00 $0.00 626-00-52H SUP HCPCS C1776 626-00-52H - LINER ACTB H 52MM MDM COCR HIP 28MM FEM HD BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" "$1,056.38" "$1,056.38" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $367.38 $0.00 $0.00 $373.72 $0.00 $0.00 $0.00 $0.00 $0.00 626-00-54I SUP HCPCS C1776 626-00-54I - LINER ACTB I 54MM MDM COCR HIP 28MM FEM HD BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" "$1,056.38" "$1,056.38" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $367.38 $0.00 $0.00 $373.72 $0.00 $0.00 $0.00 $0.00 $0.00 626-00-58J SUP HCPCS C1776 626-00-58J - LINER ACTB J 58MM MDM COCR HIP 28MM FEM HD BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" "$1,056.38" "$1,056.38" $0.00 $0.00 $0.00 $489.28 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 "$1,388.55" "$1,388.55" $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $367.38 $0.00 $0.00 $373.72 $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-212 SUP HCPCS C1776 6260-1-212 - STEM FEM 237MM PS BW RSTOR TI 2/12 LNG LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-313 SUP HCPCS C1776 6260-1-313 - STEM FEM 235MM PS BW RSTOR TI 3/13 LNG LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-414 SUP HCPCS C1776 6260-1-414 - STEM FEM 234MM 14MM PS BW RSTOR TI 4 LNG LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-515 SUP HCPCS C1776 6260-1-515 - STEM HUM 15MM 5MM MNBLCK RSTOR TI LNG LEFT T1 BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-616 SUP HCPCS C1776 6260-1-616 - STEM HUM 16MM 6MM MNBLCK RSTOR TI LNG LEFT T1 BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-717 SUP HCPCS C1776 6260-1-717 - STEM FEM 241MM 17MM PS BW RSTOR TI 7 LNG LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-719 SUP HCPCS C1776 6260-1-719 - STEM FEM 251MM 19MM PS BW RSTOR TI 7 LNG LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-818 SUP HCPCS C1776 6260-1-818 - STEM FEM 240MM 18MM PS BW RSTOR TI 8 LNG LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-820 SUP HCPCS C1776 6260-1-820 - STEM FEM 251MM 20MM PS BW RSTOR TI 8 LNG LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-1-921 SUP HCPCS C1776 6260-1-921 - STEM FEM 250MM 21MM PS BW RSTOR TI 9 LNG LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-212 SUP HCPCS C1776 6260-2-212 - STEM HUM 12MM 2MM MNBLCK RSTOR TI LNG LEFT T1 BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-313 SUP HCPCS C1776 6260-2-313 - STEM FEM 235MM 13MM PS BW RSTOR TI LNG RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-414 SUP HCPCS C1776 6260-2-414 - STEM FEM 234MM PS BW RSTOR TI 4/14 LNG RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-515 SUP HCPCS C1776 6260-2-515 - STEM FEM 233MM 15MM PS BW RSTOR TI 5 LNG RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-616 SUP HCPCS C1776 6260-2-616 - STEM FEM 242MM 16MM PS BW RSTOR TI 6 LNG RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-717 SUP HCPCS C1776 6260-2-717 - STEM FEM 241MM PS BW RSTOR TI 7/17 LNG RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-719 SUP HCPCS C1776 6260-2-719 - STEM FEM 251MM 19MM PS BW RSTOR TI 7 LNG RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-818 SUP HCPCS C1776 6260-2-818 - STEM FEM 240MM 18MM PS BW RSTOR TI 8 LNG RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-820 SUP HCPCS C1776 6260-2-820 - STEM FEM 251MM 20MM PS BW RSTOR TI 8 LNG RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-2-921 SUP HCPCS C1776 6260-2-921 - STEM HUM 21MM 9MM MNBLCK RSTOR TI LNG RIGHT T1 BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6260-4-122 SUP Custom 27803010 6260-4-122 - HEAD FEM +0MM 22.2MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-4-222 SUP Custom 27803010 6260-4-222 - HEAD FEM +3MM 22.2MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-4-322 SUP Custom 27803010 6260-4-322 - HEAD FEMORAL +8MM TAPER 22.2MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-026 SUP Custom 27803010 6260-5-026 - HEAD FEMORAL -3MM TAPER 26MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-028 SUP Custom 27803010 6260-5-028 - HEAD FEMORAL -4MM TAPER 28MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-032 SUP Custom 27803010 6260-5-032 - HEAD FEMORAL -4MM TAPER 32MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-126 SUP Custom 27803010 6260-5-126 - HEAD FEMORAL +0MM TAPER 26MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-128 SUP Custom 27803010 6260-5-128 - HEAD FEMORAL +0MM TAPER 28MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-132 SUP Custom 27803010 6260-5-132 - HEAD FEMORAL +0MM TAPER 32MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-226 SUP Custom 27803010 6260-5-226 - HEAD FEMORAL +4MM TAPER 26MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-228 SUP Custom 27803010 6260-5-228 - HEAD FEMORAL +4MM TAPER 28MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-232 SUP Custom 27803010 6260-5-232 - HEAD FEMORAL +4MM TAPER 32MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-326 SUP Custom 27803010 6260-5-326 - HEAD FEMORAL +8MM TAPER 26MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-328 SUP Custom 27803010 6260-5-328 - HEAD FEMORAL +8MM TAPER 28MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-332 SUP Custom 27803010 6260-5-332 - HEAD FEMORAL +8MM TAPER 32MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-426 SUP Custom 27803010 6260-5-426 - HEAD FEMORAL +1MM TAPER 26MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-428 SUP Custom 27803010 6260-5-428 - HEAD FEMORAL +12MM TAPER 28MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-432 SUP Custom 27803010 6260-5-432 - HEAD FEMORAL +12MM TAPER 32MM V40 COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-5-628 SUP Custom 27803010 6260-5-628 - HEAD FEMORAL +6MM TAPER 28MM V40 COCR HIP BOTH IP/OP "$1,302.50 " $963.85 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $966.72 $966.72 $0.00 $0.00 $271.44 $0.00 $0.00 $0.00 $0.00 $651.25 "$1,031.58" "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-111 SUP HCPCS C1776 6260-6-111 - STEM FEMORAL 1 STR 11MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-113 SUP HCPCS C1776 6260-6-113 - STEM FEMORAL 1 STR 13MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-212 SUP HCPCS C1776 6260-6-212 - STEM FEMORAL 2 STR 12MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-214 SUP HCPCS C1776 6260-6-214 - STEM FEMORAL 2 STR 14MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-313 SUP HCPCS C1776 6260-6-313 - STEM FEMORAL 3 STR 13MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-315 SUP HCPCS C1776 6260-6-315 - STEM FEMORAL 3 STR 15MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-414 SUP HCPCS C1776 6260-6-414 - STEM FEMORAL 4 STR 14MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-416 SUP HCPCS C1776 6260-6-416 - STEM FEMORAL 4 STR 16MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-515 SUP HCPCS C1776 6260-6-515 - STEM FEMORAL 5 STR 15MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-517 SUP HCPCS C1776 6260-6-517 - STEM FEMORAL 5 STR 17MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-616 SUP HCPCS C1776 6260-6-616 - STEM FEMORAL 6 STR 16MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-618 SUP HCPCS C1776 6260-6-618 - STEM FEMORAL 6 STR 18MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-717 SUP HCPCS C1776 6260-6-717 - STEM FEMORAL 7 STR 17MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-719 SUP HCPCS C1776 6260-6-719 - STEM FEMORAL 7 STR 19MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-818 SUP HCPCS C1776 6260-6-818 - STEM FEMORAL 8 STR 18MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-820 SUP HCPCS C1776 6260-6-820 - STEM FEMORAL 8 STR 20MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-6-921 SUP HCPCS C1776 6260-6-921 - STEM FEMORAL 9 STR 21MM 165MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-036 SUP Custom 27803010 6260-8-036 - HEAD FEM -4MM 36MM HIP COCR V40 LFIT BOTH IP/OP "$2,035.00 " "$1,505.90" $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,510.38" "$1,510.38" $0.00 $0.00 $424.09 $0.00 $0.00 $0.00 $0.00 "$1,017.50" "$1,611.72" "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-111 SUP HCPCS C1776 6260-8-111 - STEM FEMORAL 1 STR 11MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-113 SUP HCPCS C1776 6260-8-113 - STEM FEMORAL 1 STR 13MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-212 SUP HCPCS C1776 6260-8-212 - STEM FEMORAL 2 STR 12MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-214 SUP HCPCS C1776 6260-8-214 - STEM FEMORAL 2 STR 14MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-236 SUP Custom 27803010 6260-8-236 - HEAD FEM +4MM 36MM HIP COCR V40 LFIT BOTH IP/OP "$2,035.00 " "$1,505.90" $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,510.38" "$1,510.38" $0.00 $0.00 $424.09 $0.00 $0.00 $0.00 $0.00 "$1,017.50" "$1,611.72" "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-313 SUP HCPCS C1776 6260-8-313 - STEM FEMORAL 3 STR 13MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-315 SUP HCPCS C1776 6260-8-315 - STEM FEMORAL 3 STR 15MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-336 SUP Custom 27803010 6260-8-336 - HEAD FEM +8MM 36MM HIP COCR V40 LFIT BOTH IP/OP "$2,035.00 " "$1,505.90" $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,510.38" "$1,510.38" $0.00 $0.00 $424.09 $0.00 $0.00 $0.00 $0.00 "$1,017.50" "$1,611.72" "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-414 SUP HCPCS C1776 6260-8-414 - STEM FEMORAL 4 STR 14MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-416 SUP HCPCS C1776 6260-8-416 - STEM FEMORAL 4 STR 16MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-515 SUP HCPCS C1776 6260-8-515 - STEM FEMORAL 5 STR 15MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-517 SUP HCPCS C1776 6260-8-517 - STEM FEMORAL 5 STR 17MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-616 SUP HCPCS C1776 6260-8-616 - STEM FEMORAL 6 STR 16MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-618 SUP HCPCS C1776 6260-8-618 - STEM FEMORAL 6 STR 18MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-717 SUP HCPCS C1776 6260-8-717 - STEM FEMORAL 7 STR 17MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-719 SUP HCPCS C1776 6260-8-719 - STEM FEMORAL 7 STR 19MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-818 SUP HCPCS C1776 6260-8-818 - STEM FEMORAL 8 STR 18MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-820 SUP HCPCS C1776 6260-8-820 - STEM FEMORAL 8 STR 20MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-8-921 SUP HCPCS C1776 6260-8-921 - STEM FEMORAL 9 STR 21MM 203MM RSTOR TITANIUM PLASMA SPRAY BOTH IP/OP "$13,152.50 " "$9,732.85" $0.00 "$10,522.00" "$5,918.63" "$5,918.63" $0.00 $0.00 $0.00 "$2,741.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,740.98" $0.00 "$6,484.18" "$6,484.18" $0.00 "$6,576.25" "$10,416.78" "$10,522.00" $0.00 $0.00 "$2,058.37" $0.00 $0.00 "$2,093.88" $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-026 SUP Custom 27803010 6260-9-026 - HEAD FEMORAL -3MM OFFST TAPER 26MM PRIM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-028 SUP Custom 27803010 6260-9-028 - HEAD FEM -4MM OFST TPR 28MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-032 SUP Custom 27803010 6260-9-032 - HEAD FEM -4MM OFST 32MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-036 SUP Custom 27803010 6260-9-036 - HEAD FEM -5MM OFST TPR 36MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-040 SUP Custom 27803010 6260-9-040 - HEAD FEM -4MM OFST TPR 40MM V40 LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-044 SUP Custom 27803010 6260-9-044 - HEAD FEM -4MM OFST TPR 44MM V40 LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-122 SUP Custom 27803010 6260-9-122 - HEAD FEM +0MM OFST TPR 22MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-126 SUP Custom 27803010 6260-9-126 - HEAD FEMORAL +0MM OFFST TAPER 26MM PRIM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-128 SUP Custom 27803010 6260-9-128 - HEAD FEM +0MM OFST 28MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-132 SUP Custom 27803010 6260-9-132 - HEAD FEMORAL +0MM OFFST TAPER 32MM PRIM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-136 SUP Custom 27803010 6260-9-136 - HEAD FEMORAL +0MM OFFST TAPER 36MM PRIM ANATOMIC V40 LFIT BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-140 SUP Custom 27803010 6260-9-140 - HEAD FEMORAL +0MM OFFST TAPER 40MM PRIM ANATOMIC V40 LFIT BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-144 SUP Custom 27803010 6260-9-144 - HEAD FEM +0MM OFST TPR 44MM V40 LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-222 SUP Custom 27803010 6260-9-222 - HEAD FEM +3MM OFST 22.2MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-226 SUP Custom 27803010 6260-9-226 - HEAD FEMORAL +4MM OFFST TAPER 26MM PRIM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-228 SUP Custom 27803010 6260-9-228 - HEAD FEM +4MM OFST 28MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-232 SUP Custom 27803010 6260-9-232 - HEAD FEM +4MM OFST TPR 32MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-236 SUP Custom 27803010 6260-9-236 - HEAD FEM +5MM OFST TPR 36MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-240 SUP Custom 27803010 6260-9-240 - HEAD FEMORAL +4MM OFFST TAPER 40MM PRIM ANATOMIC V40 LFIT BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-244 SUP Custom 27803010 6260-9-244 - HEAD FEMORAL +4MM OFFST TAPER 44MM PRIM ANATOMIC V40 LFIT BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-322 SUP Custom 27803010 6260-9-322 - HEAD FEM +8MM OFST TPR 22MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-326 SUP Custom 27803010 6260-9-326 - HEAD FEMORAL +8MM OFFST TAPER 26MM PRIM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-328 SUP Custom 27803010 6260-9-328 - HEAD FEM +8MM OFST TPR 28MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-332 SUP Custom 27803010 6260-9-332 - HEAD FEMORAL +8MM OFFST TAPER 32MM PRIM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-336 SUP Custom 27803010 6260-9-336 - HEAD FEM +10MM OFST TPR 36MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-340 SUP Custom 27803010 6260-9-340 - HEAD FEM +8MM OFST TPR 40MM V40 LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-344 SUP Custom 27803010 6260-9-344 - HEAD FEMORAL +8MM OFFST TAPER 44MM PRIM ANATOMIC V40 LFIT BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-426 SUP Custom 27803010 6260-9-426 - HEAD FEMORAL +12MM OFFST TAPER 26MM PRIM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-428 SUP Custom 27803010 6260-9-428 - HEAD FEM +12MM OFST TPR 28MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-432 SUP Custom 27803010 6260-9-432 - HEAD FEM +12MM OFST TPR 32MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-440 SUP Custom 27803010 6260-9-440 - HEAD FEM +12MM OFST TPR 40MM V40 LFIT COCR HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-444 SUP Custom 27803010 6260-9-444 - HEAD FEMORAL +12MM OFFST TAPER 44MM PRIM ANATOMIC V40 LFIT BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6260-9-628 SUP Custom 27803010 6260-9-628 - HEAD FEMORAL +6MM 28MM V40 LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-001 SUP HCPCS C1776 6261-0-001 - STEM FEM 9MM CMNTLS MRDN PERIAPT 00 HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-002 SUP HCPCS C1776 6261-0-002 - STEM FEM 10MM CMNTLS MRDN PERIAPT HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-003 SUP HCPCS C1776 6261-0-003 - STEM FEM 11MM CMNTLS MRDN PERIAPT 1 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-004 SUP HCPCS C1776 6261-0-004 - STEM FEM 130MM 10MM CMNTLS MRDN PERIAPT 2 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-005 SUP HCPCS C1776 6261-0-005 - STEM FEM 12MM CMNTLS MRDN PERIAPT 2 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-006 SUP HCPCS C1776 6261-0-006 - STEM FEM 11MM CMNTLS MRDN PERIAPT 3 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-007 SUP HCPCS C1776 6261-0-007 - STEM FEM 13MM MRDN PERIAPT 3 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-008 SUP HCPCS C1776 6261-0-008 - STEM FEM 12MM CMNTLS MRDN PERIAPT 4 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-009 SUP HCPCS C1776 6261-0-009 - STEM FEM 14MM CMNTLS MRDN PERIAPT 4 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-010 SUP HCPCS C1776 6261-0-010 - STEM FEM 13MM CMNTLS MRDN PERIAPT 5 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-011 SUP HCPCS C1776 6261-0-011 - STEM FEM 15MM CMNTLS MRDN PERIAPT 5 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-012 SUP HCPCS C1776 6261-0-012 - STEM FEM 14MM CMNTLS MRDN PERIAPT 6 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-013 SUP HCPCS C1776 6261-0-013 - STEM FEM 150MM 16MM MRDN PERIAPT 132D 6 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-014 SUP HCPCS C1776 6261-0-014 - STEM FEM 15MM CMNTLS MRDN PERIAPT 7 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-015 SUP HCPCS C1776 6261-0-015 - STEM FEM 17MM CMNTLS MRDN PERIAPT 7 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-016 SUP HCPCS C1776 6261-0-016 - STEM FEM 16MM CMNTLS MRDN PERIAPT 8 HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-017 SUP HCPCS C1776 6261-0-017 - STEM FEM 18MM CMNTLS MRDN PERIAPT 8 HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6261-0-018 SUP HCPCS C1776 6261-0-018 - STEM FEM 19MM CMNTLS MRDN PERIAPT 9 HIP BOTH IP/OP "$6,861.00 " "$5,077.14" $0.00 "$5,488.80" "$3,087.45" "$3,087.45" $0.00 $0.00 $0.00 "$1,430.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,429.83" $0.00 "$3,382.47" "$3,382.47" $0.00 "$3,430.50" "$5,433.91" "$5,488.80" $0.00 $0.00 "$1,073.75" $0.00 $0.00 "$1,092.27" $0.00 $0.00 $0.00 $0.00 $0.00 6265-0-010 SUP HCPCS C1776 6265-0-010 - STEM FEM 13MM CMNTLS MRDN ST VIT POR 5 HIP BOTH IP/OP "$6,538.00 " "$4,838.12" $0.00 "$5,230.40" "$2,942.10" "$2,942.10" $0.00 $0.00 $0.00 "$1,362.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,362.52" $0.00 "$3,223.23" "$3,223.23" $0.00 "$3,269.00" "$5,178.10" "$5,230.40" $0.00 $0.00 "$1,023.20" $0.00 $0.00 "$1,040.85" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-001 SUP HCPCS C1776 6265-1-001 - STEM FEM 9MM MRDN TMZF 00 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-002 SUP HCPCS C1776 6265-1-002 - STEM FEM 10MM CMNTLS MRDN TMZF 0 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-003 SUP HCPCS C1776 6265-1-003 - STEM FEM 11MM MRDN TMZF 1 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-004 SUP HCPCS C1776 6265-1-004 - STEM FEM 10MM MRDN TMZF 2 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-005 SUP HCPCS C1776 6265-1-005 - STEM FEM 12MM MRDN TMZF 2 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-006 SUP HCPCS C1776 6265-1-006 - STEM FEM 3-11MM BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-007 SUP HCPCS C1776 6265-1-007 - STEM FEM 13MM MRDN TMZF 3 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-008 SUP HCPCS C1776 6265-1-008 - STEM FEM 4-12MM BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-009 SUP HCPCS C1776 6265-1-009 - STEM FEM 14MM MRDN TMZF 4 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-010 SUP HCPCS C1776 6265-1-010 - STEM FEM 13MM MRDN TMZF 5 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-011 SUP HCPCS C1776 6265-1-011 - STEM FEM 15MM CMNTLS MRDN TMZF 5 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-012 SUP HCPCS C1776 6265-1-012 - STEM FEM 14MM MRDN TMZF 6 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-013 SUP HCPCS C1776 6265-1-013 - STEM FEM 16MM MRDN TMZF 6 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-014 SUP HCPCS C1776 6265-1-014 - STEM FEM 15MM CMNTLS MRDN TMZF 7 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-015 SUP HCPCS C1776 6265-1-015 - STEM FEM 17MM CMNTLS MRDN TMZF 7 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-016 SUP HCPCS C1776 6265-1-016 - STEM FEM 16MM CMNTLS MRDN TMZF 8 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-017 SUP HCPCS C1776 6265-1-017 - STEM FEM 18MM CMNTLS MRDN TMZF 8 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6265-1-018 SUP HCPCS C1776 6265-1-018 - STEM FEM 19MM CMNTLS MRDN TMZF 9 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 6265-2-000 SUP Custom 27803010 6265-2-000 - STEM FEMORAL 132D 0 10MM 115MM 31MM COLLAR PRESS FIT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-2-001 SUP Custom 27803010 6265-2-001 - STEM FEMORAL 132D 1 11MM 115MM 31MM COLLAR PRESS FIT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-2-002 SUP Custom 27803010 6265-2-002 - STEM FEMORAL 132D 2 12MM 130MM 32MM COLLAR PRESS FIT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-2-003 SUP Custom 27803010 6265-2-003 - STEM FEMORAL 132D 3 13MM 130MM 34MM COLLAR PRESS FIT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-2-004 SUP Custom 27803010 6265-2-004 - STEM FEMORAL 132D 4 14MM 140MM 35MM COLLAR PRESS FIT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-2-005 SUP Custom 27803010 6265-2-005 - STEM FEMORAL 5 15MM CEMENTED COLLARED PRESS FIT RELIANCE PF BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-2-006 SUP Custom 27803010 6265-2-006 - STEM FEMORAL 132D 6 16MM 150MM 37MM COLLAR PRESS FIT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-2-007 SUP Custom 27803010 6265-2-007 - STEM FEMORAL 132D 7 17MM 150MM 39MM COLLAR PRESS FIT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-099 SUP Custom 27803010 6265-3-099 - STEM FEM CMNT DFN PM 0 HIP BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-100 SUP Custom 27803010 6265-3-100 - STEM FEM CMNT DFN PM 0 HIP BOTH IP/OP "$4,488.00 " "$3,321.12" $0.00 "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,330.99" "$3,330.99" $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 "$2,244.00" "$3,554.50" "$3,590.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-101 SUP Custom 27803010 6265-3-101 - STEM FEM 132D 1 34MM OFST 10MM 115MM 26MM CITN PUREFIX TMZF BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 $0.00 $0.00 $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-102 SUP Custom 27803010 6265-3-102 - STEM FEM CMNT DFN PM 2 HIP BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 $0.00 $0.00 $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-103 SUP Custom 27803010 6265-3-103 - STEM FEM CMNT DFN PM 3 HIP BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 $0.00 $0.00 $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-104 SUP Custom 27803010 6265-3-104 - STEM FEM CMNT DFN PM 4 HIP BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 $0.00 $0.00 $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-105 SUP Custom 27803010 6265-3-105 - STEM FEM CMNT DFN PM 5 HIP BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 $0.00 $0.00 $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-106 SUP Custom 27803010 6265-3-106 - STEM FEM CMNT DFN PM 6 HIP BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 $0.00 $0.00 $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-107 SUP Custom 27803010 6265-3-107 - STEM FEM CMNT DFN PM 7 HIP BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 $0.00 $0.00 $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-111 SUP Custom 27803010 6265-3-111 - STEM FEMORAL 132D 1 34MM OFFST 100MM 31MM BASE HEAD CEMENT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-112 SUP Custom 27803010 6265-3-112 - STEM FEMORAL 132D 2 36MM OFFST 115MM 32MM BASE HEAD CEMENT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-113 SUP Custom 27803010 6265-3-113 - STEM FEMORAL 132D 3 40MM OFFST 115MM 34MM BASE HEAD CEMENT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-114 SUP Custom 27803010 6265-3-114 - STEM FEMORAL 132D 4 44MM OFFST 125MM 35MM BASE HEAD CEMENT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-3-115 SUP Custom 27803010 6265-3-115 - STEM FEMORAL 132D 5 47MM OFFST 125MM 37MM BASE HEAD CEMENT BOTH IP/OP "$2,877.50 " "$2,129.35" $0.00 "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,135.68" "$2,135.68" $0.00 $0.00 $599.67 $0.00 $0.00 $0.00 $0.00 "$1,438.75" "$2,278.98" "$2,302.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-010 SUP Custom 27803010 6265-4-010 - CNTRLZR STM 10MM DFN DISTAL FEM HIP TYPE AA TPR BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-011 SUP Custom 27803010 6265-4-011 - CNTRLZR STM 11MM DFN DISTAL FEM HIP TYPE AA TPR BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-103 SUP HCPCS C1776 6265-4-103 - STEM FEM DFN 3 HIP BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" "$1,855.35" "$1,855.35" $0.00 $0.00 $0.00 $859.34 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 "$2,032.64" "$2,032.64" $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $645.25 $0.00 $0.00 $656.38 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-105 SUP HCPCS C1776 6265-4-105 - STEM FEM DFN 5 HIP BOTH IP/OP "$4,123.00 " "$3,051.02" $0.00 "$3,298.40" "$1,855.35" "$1,855.35" $0.00 $0.00 $0.00 $859.34 "$3,060.09" "$3,060.09" $0.00 $0.00 $859.23 $0.00 "$2,032.64" "$2,032.64" $0.00 "$2,061.50" "$3,265.42" "$3,298.40" $0.00 $0.00 $645.25 $0.00 $0.00 $656.38 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-411 SUP Custom 27803010 6265-4-411 - CNTRLZR STM 11MM DISTAL HIP TYPE A MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-412 SUP Custom 27803010 6265-4-412 - CNTRLZR STM 12MM DISTAL HIP TYPE A MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-413 SUP Custom 27803010 6265-4-413 - CNTRLZR STM 13MM DISTAL HIP TYPE A MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-414 SUP Custom 27803010 6265-4-414 - CNTRLZR STM 14MM DISTAL MOD TYPE A BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-415 SUP Custom 27803010 6265-4-415 - CNTRLZR STM 15MM DISTAL HIP TYPE A MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-416 SUP Custom 27803010 6265-4-416 - CNTRLZR STM 16MM DFN DISTAL FEM HIP MOD TYPE A BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-417 SUP Custom 27803010 6265-4-417 - CNTRLZR STM 17MM DFN DISTAL FEM HIP TYPE A MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-418 SUP Custom 27803010 6265-4-418 - CNTRLZR STM 18MM DFN DISTAL FEM HIP MOD TYPE A BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-515 SUP Custom 27803010 6265-4-515 - CNTRLZR STM 15MM DFN DISTAL FEM HIP TYPE B MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-516 SUP Custom 27803010 6265-4-516 - CNTRLZR STM 16MM MODIFI DISTAL FEM TYPE B BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-517 SUP Custom 27803010 6265-4-517 - CNTRLZR STM 17MM DFN DISTAL FEM HIP TYPE A MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-518 SUP Custom 27803010 6265-4-518 - CNTRLZR STM 18MM DFN DISTAL FEM HIP TYPE B MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-519 SUP Custom 27803010 6265-4-519 - CNTRLZR STM 19MM DFN DISTAL FEM HIP TYPE B MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-520 SUP Custom 27803010 6265-4-520 - CONC CNTRF YLW FLTR COLLECT VL 0.5ML BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-521 SUP Custom 27803010 6265-4-521 - CNTRLZR STM 21MM DFN DISTAL FEM HIP TYPE B MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-4-522 SUP Custom 27803010 6265-4-522 - CNTRLZR STM 22MM DFN DISTAL FEM HIP TYPE B MOD BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $0.00 $0.00 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-100 SUP HCPCS C1776 6265-5-100 - STEM FEMORAL 132D 0 34MM OFFST 9MM 110MM 26MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-101 SUP HCPCS C1776 6265-5-101 - STEM FEMORAL 132D 1 34MM OFFST 10MM 115MM 26MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-102 SUP HCPCS C1776 6265-5-102 - STEM FEMORAL 132D 2 36MM OFFST 11MM 120MM 26MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-103 SUP HCPCS C1776 6265-5-103 - STEM FEMORAL 132D 3 40MM OFFST 12MM 125MM 28MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-104 SUP HCPCS C1776 6265-5-104 - STEM FEMORAL 132D 4 44MM OFFST 13MM 130MM 30MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-105 SUP HCPCS C1776 6265-5-105 - STEM FEMORAL 132D 5 47MM OFFST 14MM 135MM 31MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-106 SUP HCPCS C1776 6265-5-106 - STEM FEMORAL 132D 6 50MM OFFST 15MM 140MM 32MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-107 SUP HCPCS C1776 6265-5-107 - STEM FEMORAL 132D 7 52MM OFFST 16MM 140MM 34MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-108 SUP HCPCS C1776 6265-5-108 - STEM FEMORAL 132D 8 55MM OFFST 17MM 145MM 39MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-109 SUP HCPCS C1776 6265-5-109 - STEM FEMORAL 132D 9 55MM OFFST 18MM 150MM 39MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-110 SUP HCPCS C1776 6265-5-110 - STEM FEMORAL 132D 0 34MM OFFST 9MM 110MM 26MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-111 SUP HCPCS C1776 6265-5-111 - STEM FEMORAL 132D 1 34MM OFFST 10MM 115MM 26MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-112 SUP HCPCS C1776 6265-5-112 - STEM FEMORAL 132D 2 36MM OFFST 11MM 120MM 26MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-113 SUP HCPCS C1776 6265-5-113 - STEM FEMORAL 132D 3 40MM OFFST 12MM 125MM 28MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-114 SUP HCPCS C1776 6265-5-114 - STEM FEMORAL 132D 4 44MM OFFST 13MM 130MM 30MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-115 SUP HCPCS C1776 6265-5-115 - STEM FEMORAL 132D 5 47MM OFFST 14MM 135MM 31MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-116 SUP HCPCS C1776 6265-5-116 - STEM FEMORAL 132D 6 50MM OFFST 15MM 140MM 32MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-117 SUP HCPCS C1776 6265-5-117 - STEM FEMORAL 132D 7 52MM OFFST 16MM 140MM 34MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-118 SUP HCPCS C1776 6265-5-118 - STEM FEMORAL 132D 8 55MM OFFST 17MM 145MM 39MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5-119 SUP HCPCS C1776 6265-5-119 - STEM FEMORAL 132D 9 55MM OFFST 18MM 150MM 39MM CITATION BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5200 SUP HCPCS C1776 6265-5200 - STEM FEMORAL 0 SHORT CITATION TMZF HYDRXAPT LEFT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5201 SUP HCPCS C1776 6265-5201 - STEM FEMORAL 1 SHORT CITATION TMZF HYDRXAPT LEFT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5202 SUP HCPCS C1776 6265-5202 - STEM FEMORAL 2 SHORT CITATION TMZF HYDRXAPT LEFT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5203 SUP HCPCS C1776 6265-5203 - STEM FEMORAL 3 SHORT CITATION TMZF HYDRXAPT LEFT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5204 SUP HCPCS C1776 6265-5204 - STEM FEMORAL 4 SHORT CITATION TMZF HYDRXAPT LEFT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5205 SUP HCPCS C1776 6265-5205 - STEM FEMORAL 5 SHORT CITATION TMZF HYDRXAPT LEFT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5206 SUP HCPCS C1776 6265-5206 - STEM FEMORAL 6 SHORT CITATION TMZF HYDRXAPT LEFT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5207 SUP HCPCS C1776 6265-5207 - STEM FEMORAL 7 SHORT CITATION TMZF HYDRXAPT LEFT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5208 SUP HCPCS C1776 6265-5208 - STEM FEMORAL 8 SHORT CITATION TMZF HYDRXAPT LEFT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5209 SUP HCPCS C1776 6265-5209 - STEM FEMORAL 9 SHORT CITATION TMZF HYDRXAPT LEFT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5210 SUP HCPCS C1776 6265-5210 - STEM FEMORAL 0 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5211 SUP HCPCS C1776 6265-5211 - STEM FEMORAL 1 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5212 SUP HCPCS C1776 6265-5212 - STEM FEMORAL 2 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5213 SUP HCPCS C1776 6265-5213 - STEM FEMORAL 3 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5214 SUP HCPCS C1776 6265-5214 - STEM FEMORAL 4 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5215 SUP HCPCS C1776 6265-5215 - STEM FEMORAL 5 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5216 SUP HCPCS C1776 6265-5216 - STEM FEMORAL 6 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5217 SUP HCPCS C1776 6265-5217 - STEM FEMORAL 7 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5218 SUP HCPCS C1776 6265-5218 - STEM FEMORAL 8 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 6265-5219 SUP HCPCS C1776 6265-5219 - STEM FEMORAL 9 SHORT CITATION TMZF HYDRXAPT RIGHT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 626631US SUP Custom 27803010 626631US - KIT PRESSURE MONITR 14GA BASIC TRANSDUCER TUOHY NEEDLE BOTH IP/OP "$2,043.98 " "$1,512.55" $0.00 "$1,676.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,517.04" "$1,517.04" $0.00 $0.00 $425.96 $0.00 $0.00 $0.00 $0.00 "$1,047.70" "$1,659.56" "$1,676.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6269-1-212 SUP HCPCS C1776 6269-1-212 - STEM FEM 10IN 12MM BW RSTOR TI 2 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-1-414 SUP HCPCS C1776 6269-1-414 - STEM FEM 10IN 14MM BW RSTOR TI 4 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-1-719 SUP HCPCS C1776 6269-1-719 - STEM FEM 10IN 19MM BW RSTOR TI 7 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-1-818 SUP HCPCS C1776 6269-1-818 - STEM FEM 10IN 18MM BW RSTOR TI 8 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-1-820 SUP HCPCS C1776 6269-1-820 - STEM FEM 10IN 20MM BW RSTOR TI 8 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-1-921 SUP HCPCS C1776 6269-1-921 - STEM FEM 10IN 21MM BW RSTOR TI 9 LEFT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-212 SUP HCPCS C1776 6269-2-212 - STEM FEM 10IN 12MM BW RSTOR TI 2 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-313 SUP HCPCS C1776 6269-2-313 - STEM FEM 10IN 13MM BW RSTOR TI 3 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-414 SUP HCPCS C1776 6269-2-414 - STEM FEM 10IN 14MM BW RSTOR TI 4 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-515 SUP HCPCS C1776 6269-2-515 - STEM FEM 10IN 15MM BW RSTOR TI 5 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-616 SUP HCPCS C1776 6269-2-616 - STEM FEM 10IN 16MM BW RSTOR TI 6 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-717 SUP HCPCS C1776 6269-2-717 - STEM FEM 10IN 17MM BW RSTOR TI 7 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-719 SUP HCPCS C1776 6269-2-719 - STEM FEM 10IN 19MM BW RSTOR TI 7 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-818 SUP HCPCS C1776 6269-2-818 - STEM FEM 10IN 18MM BW RSTOR TI 8 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-820 SUP HCPCS C1776 6269-2-820 - STEM FEM 10IN 20MM BW RSTOR TI 8 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-2-921 SUP HCPCS C1776 6269-2-921 - STEM FEM 10IN 21MM BW RSTOR TI 9 RIGHT HIP BOTH IP/OP "$13,745.88 " "$10,171.95" $0.00 "$10,996.70" "$6,185.64" "$6,185.64" $0.00 $0.00 $0.00 "$2,864.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,864.64" $0.00 "$6,776.72" "$6,776.72" $0.00 "$6,872.94" "$10,886.74" "$10,996.70" $0.00 $0.00 "$2,151.23" $0.00 $0.00 "$2,188.34" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-111 SUP HCPCS C1776 6269-3-111 - STEM FEM 8IN 11MM BW RSTOR TI 1 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-113 SUP HCPCS C1776 6269-3-113 - STEM FEM 8IN 13MM BW RSTOR TI 1 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-212 SUP HCPCS C1776 6269-3-212 - STEM FEM 8IN 12MM BW RSTOR TI 2 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-214 SUP HCPCS C1776 6269-3-214 - STEM FEM 8IN 14MM BW RSTOR TI 2 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-313 SUP HCPCS C1776 6269-3-313 - STEM FEM 8IN 13MM BW RSTOR TI 3 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-315 SUP HCPCS C1776 6269-3-315 - STEM FEM 8IN 15MM BW RSTOR TI 3 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-414 SUP HCPCS C1776 6269-3-414 - STEM FEM 8IN 14MM BW RSTOR TI 4 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-416 SUP HCPCS C1776 6269-3-416 - STEM FEM 8IN 16MM BW RSTOR TI 4 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-515 SUP HCPCS C1776 6269-3-515 - STEM FEM 8IN 15MM BW RSTOR TI 5 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-517 SUP HCPCS C1776 6269-3-517 - STEM FEM 8IN 17MM BW RSTOR TI 5 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-616 SUP HCPCS C1776 6269-3-616 - STEM FEM 8IN 16MM BW RSTOR TI 6 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-618 SUP HCPCS C1776 6269-3-618 - STEM FEM 8IN 18MM BW RSTOR TI 6 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-717 SUP HCPCS C1776 6269-3-717 - STEM FEM 8IN 17MM BW RSTOR TI 7 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-818 SUP HCPCS C1776 6269-3-818 - STEM FEM 8IN 18MM BW RSTOR TI 8 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-3-820 SUP HCPCS C1776 6269-3-820 - STEM FEM 8IN 20MM BW RSTOR TI 8 LEFT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-111 SUP HCPCS C1776 6269-4-111 - STEM FEM 8IN 11MM BW RSTOR TI 1 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-113 SUP HCPCS C1776 6269-4-113 - STEM FEM 8IN 13MM BW RSTOR TI 1 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-212 SUP HCPCS C1776 6269-4-212 - STEM FEM 8IN 12MM BW RSTOR TI 2 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-214 SUP HCPCS C1776 6269-4-214 - STEM FEM 8IN 14MM BW RSTOR TI 2 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-313 SUP HCPCS C1776 6269-4-313 - STEM FEM 8IN 13MM BW RSTOR TI 3 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-315 SUP HCPCS C1776 6269-4-315 - STEM FEM 8IN 15MM BW RSTOR TI 3 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-414 SUP HCPCS C1776 6269-4-414 - STEM FEM 8IN 14MM BW PS RSTOR TI 4 RIGHT BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-416 SUP HCPCS C1776 6269-4-416 - STEM FEM 8IN 16MM BW RSTOR TI 4 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-515 SUP HCPCS C1776 6269-4-515 - STEM FEM 8IN 15MM BW RSTOR TI 5 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-517 SUP HCPCS C1776 6269-4-517 - STEM FEM 8IN 17MM BW RSTOR TI 5 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-616 SUP HCPCS C1776 6269-4-616 - STEM FEM 8IN 16MM BW RSTOR TI 6 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-618 SUP HCPCS C1776 6269-4-618 - STEM FEM 8IN 18MM BW RSTOR TI 6 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-717 SUP HCPCS C1776 6269-4-717 - STEM FEM 8IN 17MM BW RSTOR TI 7 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-719 SUP HCPCS C1776 6269-4-719 - STEM FEM 8IN 19MM BW RSTOR TI 7 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-818 SUP HCPCS C1776 6269-4-818 - STEM FEM 8IN 18MM BW RSTOR TI 8 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-820 SUP HCPCS C1776 6269-4-820 - STEM FEM 8IN 20MM BW RSTOR TI 8 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6269-4-921 SUP HCPCS C1776 6269-4-921 - STEM FEM 8IN 21MM BW RSTOR TI 9 RIGHT HIP BOTH IP/OP "$13,281.13 " "$9,828.04" $0.00 "$10,624.90" "$5,976.51" "$5,976.51" $0.00 $0.00 $0.00 "$2,768.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,767.79" $0.00 "$6,547.59" "$6,547.59" $0.00 "$6,640.56" "$10,518.65" "$10,624.90" $0.00 $0.00 "$2,078.50" $0.00 $0.00 "$2,114.36" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-019 SUP HCPCS C1776 6276-1-019 - BODY CONE +0MM STANDARD 19MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-021 SUP HCPCS C1776 6276-1-021 - BODY CONE +0MM STANDARD 21MM MODULAR REVISION BOLT RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-023 SUP HCPCS C1776 6276-1-023 - BODY CONE +0MM STANDARD 23MM 23MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-025 SUP HCPCS C1776 6276-1-025 - BODY CONE +0MM STANDARD 25MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-027 SUP HCPCS C1776 6276-1-027 - BODY CONE +0MM STANDARD 27MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-029 SUP HCPCS C1776 6276-1-029 - BODY CONE +0MM STANDARD 29MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-031 SUP HCPCS C1776 6276-1-031 - BODY CONE +0MM STANDARD 31MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-119 SUP HCPCS C1776 6276-1-119 - BODY CONE +10MM 19MM MODULAR RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-121 SUP HCPCS C1776 6276-1-121 - BODY CONE +10MM 21MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-123 SUP HCPCS C1776 6276-1-123 - BODY CONE +10MM 23MM RSTR MDLR REV TI HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-125 SUP HCPCS C1776 6276-1-125 - BODY CONE +10MM 25MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-127 SUP HCPCS C1776 6276-1-127 - BODY CONE +10MM 27MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-129 SUP HCPCS C1776 6276-1-129 - BODY CONE +10MM 29MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-131 SUP HCPCS C1776 6276-1-131 - BODY CONE +10MM 31MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-219 SUP HCPCS C1776 6276-1-219 - BODY CONE +20MM 19MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-221 SUP HCPCS C1776 6276-1-221 - BODY CONE +20MM 21MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-223 SUP HCPCS C1776 6276-1-223 - BODY CONE +20MM 23MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-225 SUP HCPCS C1776 6276-1-225 - BODY CONE +20MM 25MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-227 SUP HCPCS C1776 6276-1-227 - BODY CONE +20MM 27MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-229 SUP HCPCS C1776 6276-1-229 - BODY CONE +20MM 29MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-231 SUP HCPCS C1776 6276-1-231 - BODY CONE +20MM 31MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-319 SUP HCPCS C1776 6276-1-319 - BODY CONE +30MM 19MM MODULAR RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-321 SUP HCPCS C1776 6276-1-321 - BODY CONE +30MM 21MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-323 SUP HCPCS C1776 6276-1-323 - BODY CONE +30MM 23MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-325 SUP HCPCS C1776 6276-1-325 - BODY CONE +30MM 25MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-327 SUP HCPCS C1776 6276-1-327 - BODY CONE +30MM 27MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-329 SUP HCPCS C1776 6276-1-329 - BODY CONE +30MM 29MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-1-331 SUP HCPCS C1776 6276-1-331 - BODY CONE +30MM 31MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-019 SUP HCPCS C1776 6276-2-019 - BODY MILLED 19MM MODULAR SHALLOW RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-021 SUP HCPCS C1776 6276-2-021 - BODY MILLED 21MM MODULAR SHALLOW RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-023 SUP HCPCS C1776 6276-2-023 - BODY MILLED 23MM MODULAR SHALLOW RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-025 SUP HCPCS C1776 6276-2-025 - BODY MILLED 25MM MODULAR SHALLOW RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-027 SUP HCPCS C1776 6276-2-027 - BODY MILLED 27MM MODULAR SHALLOW RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-029 SUP HCPCS C1776 6276-2-029 - BODY MILLED 29MM MODULAR SHALLOW RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-031 SUP HCPCS C1776 6276-2-031 - BODY MILLED 31MM MODULAR SHALLOW RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-119 SUP HCPCS C1776 6276-2-119 - BODY MILLED 19MM MODULAR DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-121 SUP HCPCS C1776 6276-2-121 - BODY MILLED 21MM MODULAR DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-123 SUP HCPCS C1776 6276-2-123 - BODY MILLED 23MM MODULAR DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-125 SUP HCPCS C1776 6276-2-125 - BODY MILLED 25MM MODULAR DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-127 SUP HCPCS C1776 6276-2-127 - BODY MILLED 27MM MODULAR DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-129 SUP HCPCS C1776 6276-2-129 - BODY MILLED 29MM MODULAR DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-131 SUP HCPCS C1776 6276-2-131 - BODY MILLED 31MM MODULAR DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-227 SUP HCPCS C1776 6276-2-227 - BODY MILLED 27MM MODULAR EXTRA DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-229 SUP HCPCS C1776 6276-2-229 - BODY MILLED 29MM MODULAR EXTRA DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-2-231 SUP HCPCS C1776 6276-2-231 - BODY MILLED 31MM MODULAR EXTRA DEEP RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-3-001 SUP HCPCS C1776 6276-3-001 - BODY BROACHED 1 REVISION MODULAR RSTOR HIP FEMUR PROXIMAL BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-3-002 SUP HCPCS C1776 6276-3-002 - BODY BROACHED 2 REVISION MODULAR RSTOR HIP FEMUR PROXIMAL BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-3-003 SUP HCPCS C1776 6276-3-003 - BODY BROACHED 3 REVISION MODULAR RSTOR HIP FEMUR PROXIMAL BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-3-004 SUP HCPCS C1776 6276-3-004 - BODY BROACHED 4 REVISION MODULAR RSTOR HIP FEMUR PROXIMAL BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-3-005 SUP HCPCS C1776 6276-3-005 - BODY BROACHED 5 REVISION MODULAR RSTOR HIP FEMUR PROXIMAL BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-3-006 SUP HCPCS C1776 6276-3-006 - BODY BROACHED 6 REVISION MODULAR RSTOR HIP FEMUR PROXIMAL BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-3-007 SUP HCPCS C1776 6276-3-007 - BODY BROACHED 7 REVISION MODULAR RSTOR HIP FEMUR BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-3-008 SUP HCPCS C1776 6276-3-008 - BODY BROACHED 8 REVISION MODULAR RSTOR HIP FEMUR PROXIMAL BOTH IP/OP "$9,422.50 " "$6,972.65" $0.00 "$7,538.00" "$4,240.13" "$4,240.13" $0.00 $0.00 $0.00 "$1,963.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,963.65" $0.00 "$4,645.29" "$4,645.29" $0.00 "$4,711.25" "$7,462.62" "$7,538.00" $0.00 $0.00 "$1,474.62" $0.00 $0.00 "$1,500.06" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-119 SUP HCPCS C1776 6276-4-119 - BODY CALCAR +10MM OFFST 19MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-121 SUP HCPCS C1776 6276-4-121 - BODY CALCAR +10MM OFFST 21MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-123 SUP HCPCS C1776 6276-4-123 - BODY CALCAR +10MM OFFST 23MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-125 SUP HCPCS C1776 6276-4-125 - BODY CALCAR +10MM OFFST 25MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-127 SUP HCPCS C1776 6276-4-127 - BODY CALCAR +10MM OFFST 27MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-129 SUP HCPCS C1776 6276-4-129 - BODY CALCAR +10MM OFFST 29MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-131 SUP HCPCS C1776 6276-4-131 - BODY CALCAR +10MM OFFST 31MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-219 SUP HCPCS C1776 6276-4-219 - BODY CALCAR +20MM OFFST 19MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-221 SUP HCPCS C1776 6276-4-221 - BODY CALCAR +20MM OFFST 21MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-223 SUP HCPCS C1776 6276-4-223 - BODY CALCAR +20MM OFFST 23MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-225 SUP HCPCS C1776 6276-4-225 - BODY CALCAR +20MM OFFST 25MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-227 SUP HCPCS C1776 6276-4-227 - BODY CALCAR +20MM OFFST 27MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-229 SUP HCPCS C1776 6276-4-229 - BODY CALCAR +20MM OFFST 29MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-231 SUP HCPCS C1776 6276-4-231 - BODY CALCAR +20MM OFFST 31MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-319 SUP HCPCS C1776 6276-4-319 - BODY CALCAR +30MM OFFST 19MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-321 SUP HCPCS C1776 6276-4-321 - BODY CALCAR +30MM OFFST 21MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-323 SUP HCPCS C1776 6276-4-323 - BODY CALCAR +30MM OFFST 23MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-325 SUP HCPCS C1776 6276-4-325 - BODY CALCAR +30MM OFFST 25MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-327 SUP HCPCS C1776 6276-4-327 - BODY CALCAR +30MM OFFST 27MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-329 SUP HCPCS C1776 6276-4-329 - BODY CALCAR +30MM OFFST 29MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-4-331 SUP HCPCS C1776 6276-4-331 - BODY CALCAR +30MM OFFST 31MM MODULAR RSTOR HIP BOTH IP/OP "$9,827.50 " "$7,272.35" $0.00 "$7,862.00" "$4,422.38" "$4,422.38" $0.00 $0.00 $0.00 "$2,048.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,048.05" $0.00 "$4,844.96" "$4,844.96" $0.00 "$4,913.75" "$7,783.38" "$7,862.00" $0.00 $0.00 "$1,538.00" $0.00 $0.00 "$1,564.54" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-011 SUP HCPCS C1776 6276-5-011 - STEM FEMORAL STR 11MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-012 SUP HCPCS C1776 6276-5-012 - STEM FEMORAL STR 12MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-013 SUP HCPCS C1776 6276-5-013 - STEM FEMORAL STR 13MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-014 SUP HCPCS C1776 6276-5-014 - STEM FEMORAL STR 14MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-015 SUP HCPCS C1776 6276-5-015 - STEM FEMORAL STR 15MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-016 SUP HCPCS C1776 6276-5-016 - STEM FEMORAL STR 16MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-017 SUP HCPCS C1776 6276-5-017 - STEM FEMORAL STR 17MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-018 SUP HCPCS C1776 6276-5-018 - STEM FEMORAL STR 18MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-019 SUP HCPCS C1776 6276-5-019 - STEM FEMORAL STR 19MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-020 SUP HCPCS C1776 6276-5-020 - STEM FEMORAL STR 20MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-021 SUP HCPCS C1776 6276-5-021 - STEM FEMORAL STR 21MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-022 SUP HCPCS C1776 6276-5-022 - STEM FEMORAL STR 22MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-023 SUP HCPCS C1776 6276-5-023 - STEM FEMORAL STR 23MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-024 SUP HCPCS C1776 6276-5-024 - STEM FEMORAL STR 24MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-025 SUP HCPCS C1776 6276-5-025 - STEM FEMORAL STR 25MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-026 SUP HCPCS C1776 6276-5-026 - STEM FEMORAL STR 26MM 127MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-111 SUP HCPCS C1776 6276-5-111 - STEM FEMORAL 11MM 167MM MODULAR STR PLASMA RSTOR DISTAL BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-112 SUP HCPCS C1776 6276-5-112 - STEM FEMORAL STR 12MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-113 SUP HCPCS C1776 6276-5-113 - STEM FEMORAL STR 13MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-114 SUP HCPCS C1776 6276-5-114 - STEM FEMORAL STR 14MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-115 SUP HCPCS C1776 6276-5-115 - STEM FEMORAL STR 15MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-116 SUP HCPCS C1776 6276-5-116 - STEM FEMORAL STR 16MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-117 SUP HCPCS C1776 6276-5-117 - STEM FEMORAL STR 17MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-118 SUP HCPCS C1776 6276-5-118 - STEM FEMORAL STR 18MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-119 SUP HCPCS C1776 6276-5-119 - STEM FEMORAL STR 19MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-120 SUP HCPCS C1776 6276-5-120 - STEM FEMORAL STR 20MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-121 SUP HCPCS C1776 6276-5-121 - STEM FEMORAL STR 21MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-122 SUP HCPCS C1776 6276-5-122 - STEM FEMORAL STR 22MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-123 SUP HCPCS C1776 6276-5-123 - STEM FEMORAL STR 23MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-124 SUP HCPCS C1776 6276-5-124 - STEM FEMORAL STR 24MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-125 SUP HCPCS C1776 6276-5-125 - STEM FEMORAL STR 25MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-126 SUP HCPCS C1776 6276-5-126 - STEM FEMORAL STR 26MM 167MM MODULAR RSTOR HA POROUS PLASMA BOTH IP/OP "$7,417.50 " "$5,488.95" $0.00 "$5,934.00" "$3,337.88" "$3,337.88" $0.00 $0.00 $0.00 "$1,545.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,545.81" $0.00 "$3,656.83" "$3,656.83" $0.00 "$3,708.75" "$5,874.66" "$5,934.00" $0.00 $0.00 "$1,160.84" $0.00 $0.00 "$1,180.87" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-211 SUP HCPCS C1776 6276-5-211 - STEM FEMORAL BOWED 11MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-212 SUP HCPCS C1776 6276-5-212 - STEM FEMORAL BOWED 12MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-213 SUP HCPCS C1776 6276-5-213 - STEM FEMORAL BOWED 13MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-214 SUP HCPCS C1776 6276-5-214 - STEM FEMORAL BOWED 14MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-215 SUP HCPCS C1776 6276-5-215 - STEM FEMORAL BOWED 15MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-216 SUP HCPCS C1776 6276-5-216 - STEM FEMORAL BOWED 16MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-217 SUP HCPCS C1776 6276-5-217 - STEM FEMORAL BOWED 17MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-218 SUP HCPCS C1776 6276-5-218 - STEM FEMORAL BOWED 18MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-219 SUP HCPCS C1776 6276-5-219 - STEM FEMORAL BOWED 19MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-220 SUP HCPCS C1776 6276-5-220 - STEM FEMORAL BOWED 20MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-221 SUP HCPCS C1776 6276-5-221 - STEM FEMORAL BOWED 21MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-222 SUP HCPCS C1776 6276-5-222 - STEM FEMORAL BOWED 22MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-223 SUP HCPCS C1776 6276-5-223 - STEM FEMORAL BOWED 23MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-224 SUP HCPCS C1776 6276-5-224 - STEM FEMORAL BOWED 24MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-225 SUP HCPCS C1776 6276-5-225 - STEM FEMORAL BOWED 25MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-226 SUP HCPCS C1776 6276-5-226 - STEM FEMORAL BOWED 26MM 167MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-411 SUP HCPCS C1776 6276-5-411 - STEM FEMORAL BOWED 11MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-412 SUP HCPCS C1776 6276-5-412 - STEM FEMORAL BOWED 12MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-413 SUP HCPCS C1776 6276-5-413 - STEM FEMORAL BOWED 13MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-414 SUP HCPCS C1776 6276-5-414 - STEM FEMORAL BOWED 14MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-415 SUP HCPCS C1776 6276-5-415 - STEM FEMORAL BOWED 15MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-416 SUP HCPCS C1776 6276-5-416 - STEM FEMORAL BOWED 16MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-417 SUP HCPCS C1776 6276-5-417 - STEM FEMORAL BOWED 17MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-418 SUP HCPCS C1776 6276-5-418 - STEM FEMORAL BOWED 18MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-419 SUP HCPCS C1776 6276-5-419 - STEM FEMORAL BOWED 19MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-420 SUP HCPCS C1776 6276-5-420 - STEM FEMORAL BOWED 20MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-421 SUP HCPCS C1776 6276-5-421 - STEM FEMORAL BOWED 21MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-422 SUP HCPCS C1776 6276-5-422 - STEM FEMORAL BOWED 22MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-423 SUP HCPCS C1776 6276-5-423 - STEM FEMORAL BOWED 23MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-424 SUP HCPCS C1776 6276-5-424 - STEM FEMORAL BOWED 24MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-425 SUP HCPCS C1776 6276-5-425 - STEM FEMORAL BOWED 25MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-426 SUP HCPCS C1776 6276-5-426 - STEM FEMORAL BOWED 26MM 217MM MODULAR PLASMA SPRAYED RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-511 SUP HCPCS C1776 6276-5-511 - STEM FEMORAL 11MM 267MM BOWED PLASMA REVISION MODULAR RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-512 SUP HCPCS C1776 6276-5-512 - STEM FEMORAL 12MM 267MM MODULAR BOWED PLASMA RSTOR DISTAL BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-513 SUP HCPCS C1776 6276-5-513 - STEM FEMORAL 13MM 267MM BOWED PLASMA REVISION MODULAR RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-514 SUP HCPCS C1776 6276-5-514 - STEM FEMORAL 14MM 267MM BOWED PLASMA REVISION MODULAR RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-515 SUP HCPCS C1776 6276-5-515 - STEM FEMORAL 15MM 267MM BOWED PLASMA REVISION MODULAR RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-516 SUP HCPCS C1776 6276-5-516 - STEM FEMORAL 16MM 267MM BOWED PLASMA REVISION MODULAR RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-517 SUP HCPCS C1776 6276-5-517 - STEM FEMORAL 17MM 267MM BOWED PLASMA REVISION MODULAR RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-518 SUP HCPCS C1776 6276-5-518 - STEM FEMORAL 18MM 267MM BOWED PLASMA MODULAR RSTOR DISTAL BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-519 SUP HCPCS C1776 6276-5-519 - STEM FEMORAL 19MM 267MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-520 SUP HCPCS C1776 6276-5-520 - STEM FEMORAL 20MM 267MM BOWED PLASMA MODULAR RSTOR DISTAL BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-521 SUP HCPCS C1776 6276-5-521 - STEM FEMORAL 21MM 267MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-522 SUP HCPCS C1776 6276-5-522 - STEM FEMORAL 22MM 267MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-523 SUP HCPCS C1776 6276-5-523 - STEM FEMORAL 23MM 267MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-524 SUP HCPCS C1776 6276-5-524 - STEM FEMORAL 24MM 267MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-525 SUP HCPCS C1776 6276-5-525 - STEM FEMORAL 25MM 267MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-526 SUP HCPCS C1776 6276-5-526 - STEM FEMORAL 26MM 267MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-611 SUP HCPCS C1776 6276-5-611 - STEM FEMORAL 11MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-612 SUP HCPCS C1776 6276-5-612 - STEM FEMORAL 12MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-613 SUP HCPCS C1776 6276-5-613 - STEM FEMORAL 13MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-614 SUP HCPCS C1776 6276-5-614 - STEM FEMORAL 14MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-615 SUP HCPCS C1776 6276-5-615 - STEM FEMORAL 15MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-616 SUP HCPCS C1776 6276-5-616 - STEM FEMORAL 16MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-617 SUP HCPCS C1776 6276-5-617 - STEM FEMORAL 17MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-618 SUP HCPCS C1776 6276-5-618 - STEM FEMORAL 18MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-619 SUP HCPCS C1776 6276-5-619 - STEM FEMORAL 19MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-620 SUP HCPCS C1776 6276-5-620 - STEM FEMORAL 20MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-621 SUP HCPCS C1776 6276-5-621 - STEM FEMORAL 21MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-622 SUP HCPCS C1776 6276-5-622 - STEM FEMORAL 22MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-623 SUP HCPCS C1776 6276-5-623 - STEM FEMORAL 23MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-624 SUP HCPCS C1776 6276-5-624 - STEM FEMORAL 24MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-625 SUP HCPCS C1776 6276-5-625 - STEM FEMORAL 25MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-5-626 SUP HCPCS C1776 6276-5-626 - STEM FEMORAL 26MM 317MM BOWED PLASMA MODULAR REVISION RSTOR BOTH IP/OP "$8,420.00 " "$6,230.80" $0.00 "$6,736.00" "$3,789.00" "$3,789.00" $0.00 $0.00 $0.00 "$1,754.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,754.73" $0.00 "$4,151.06" "$4,151.06" $0.00 "$4,210.00" "$6,668.64" "$6,736.00" $0.00 $0.00 "$1,317.73" $0.00 $0.00 "$1,340.46" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-011 SUP HCPCS C1776 6276-6-011 - STEM FEMORAL STR FLUTE 11MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-012 SUP HCPCS C1776 6276-6-012 - STEM FEMORAL STR FLUTE 12MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-013 SUP HCPCS C1776 6276-6-013 - STEM FEMORAL STR FLUTE 13MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-014 SUP HCPCS C1776 6276-6-014 - STEM FEMORAL STR FLUTE 14MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-015 SUP HCPCS C1776 6276-6-015 - STEM FEMORAL STR FLUTE 15MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-016 SUP HCPCS C1776 6276-6-016 - STEM FEMORAL STR FLUTE 16MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-017 SUP HCPCS C1776 6276-6-017 - STEM FEMORAL STR FLUTE 17MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-018 SUP HCPCS C1776 6276-6-018 - STEM FEMORAL STR FLUTE 18MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-019 SUP HCPCS C1776 6276-6-019 - STEM FEMORAL STR FLUTE 19MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-020 SUP HCPCS C1776 6276-6-020 - STEM FEMORAL STR FLUTE 20MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-021 SUP HCPCS C1776 6276-6-021 - STEM FEMORAL STR FLUTE 21MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-022 SUP HCPCS C1776 6276-6-022 - STEM FEMORAL STR FLUTE 22MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-023 SUP HCPCS C1776 6276-6-023 - STEM FEMORAL STR FLUTE 23MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-024 SUP HCPCS C1776 6276-6-024 - STEM FEMORAL STR FLUTE 24MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-025 SUP HCPCS C1776 6276-6-025 - STEM FEMORAL STR FLUTE 25MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-026 SUP HCPCS C1776 6276-6-026 - STEM FEMORAL STR FLUTE 26MM 127MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-111 SUP HCPCS C1776 6276-6-111 - STEM FEMORAL STR FLUTE 11MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-112 SUP HCPCS C1776 6276-6-112 - STEM FEMORAL STR FLUTE 12MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-113 SUP HCPCS C1776 6276-6-113 - STEM FEMORAL STR FLUTE 13MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-114 SUP HCPCS C1776 6276-6-114 - STEM FEMORAL STR FLUTE 14MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-115 SUP HCPCS C1776 6276-6-115 - STEM FEMORAL STR FLUTE 15MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-116 SUP HCPCS C1776 6276-6-116 - STEM FEMORAL STR FLUTE 16MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-117 SUP HCPCS C1776 6276-6-117 - STEM FEMORAL STR FLUTE 17MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-118 SUP HCPCS C1776 6276-6-118 - STEM FEMORAL STR FLUTE 18MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-119 SUP HCPCS C1776 6276-6-119 - STEM FEMORAL STR FLUTE 19MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-120 SUP HCPCS C1776 6276-6-120 - STEM FEMORAL STR FLUTE 20MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-121 SUP HCPCS C1776 6276-6-121 - STEM FEMORAL STR FLUTE 21MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-122 SUP HCPCS C1776 6276-6-122 - STEM FEMORAL STR FLUTE 22MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-123 SUP HCPCS C1776 6276-6-123 - STEM FEMORAL STR FLUTE 23MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-124 SUP HCPCS C1776 6276-6-124 - STEM FEMORAL STR FLUTE 24MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-125 SUP HCPCS C1776 6276-6-125 - STEM FEMORAL STR FLUTE 25MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-126 SUP HCPCS C1776 6276-6-126 - STEM FEMORAL STR FLUTE 26MM 167MM MODULAR RSTOR HIP BOTH IP/OP "$5,762.50 " "$4,264.25" $0.00 "$4,610.00" "$2,593.13" "$2,593.13" $0.00 $0.00 $0.00 "$1,201.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,200.91" $0.00 "$2,840.91" "$2,840.91" $0.00 "$2,881.25" "$4,563.90" "$4,610.00" $0.00 $0.00 $901.83 $0.00 $0.00 $917.39 $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-211 SUP HCPCS C1776 6276-6-211 - STEM FEMORAL 11MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-212 SUP HCPCS C1776 6276-6-212 - STEM FEMORAL 12MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-213 SUP HCPCS C1776 6276-6-213 - STEM FEMORAL 13MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-214 SUP HCPCS C1776 6276-6-214 - STEM FEMORAL 14MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-215 SUP HCPCS C1776 6276-6-215 - STEM FEMORAL 15MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-216 SUP HCPCS C1776 6276-6-216 - STEM FEMORAL 16MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-217 SUP HCPCS C1776 6276-6-217 - STEM FEMORAL 17MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-218 SUP HCPCS C1776 6276-6-218 - STEM FEMORAL 18MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-219 SUP HCPCS C1776 6276-6-219 - STEM FEMORAL 19MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-220 SUP HCPCS C1776 6276-6-220 - STEM FEMORAL 20MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-221 SUP HCPCS C1776 6276-6-221 - STEM FEMORAL 21MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-222 SUP HCPCS C1776 6276-6-222 - STEM FEMORAL 22MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-223 SUP HCPCS C1776 6276-6-223 - STEM FEMORAL 23MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-224 SUP HCPCS C1776 6276-6-224 - STEM FEMORAL 24MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-225 SUP HCPCS C1776 6276-6-225 - STEM FEMORAL 25MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-226 SUP HCPCS C1776 6276-6-226 - STEM FEMORAL 26MM 167MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-411 SUP HCPCS C1776 6276-6-411 - STEM FEMORAL 11MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-412 SUP HCPCS C1776 6276-6-412 - STEM FEMORAL 12MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-413 SUP HCPCS C1776 6276-6-413 - STEM FEMORAL 13MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-414 SUP HCPCS C1776 6276-6-414 - STEM FEMORAL 14MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-415 SUP HCPCS C1776 6276-6-415 - STEM FEMORAL 15MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-416 SUP HCPCS C1776 6276-6-416 - STEM FEMORAL 16MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-417 SUP HCPCS C1776 6276-6-417 - STEM FEMORAL 17MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-418 SUP HCPCS C1776 6276-6-418 - STEM FEMORAL 18MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-419 SUP HCPCS C1776 6276-6-419 - STEM FEMORAL 19MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-420 SUP HCPCS C1776 6276-6-420 - STEM FEMORAL 20MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-421 SUP HCPCS C1776 6276-6-421 - STEM FEMORAL 21MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-422 SUP HCPCS C1776 6276-6-422 - STEM FEMORAL 22MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-423 SUP HCPCS C1776 6276-6-423 - STEM FEMORAL 23MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-424 SUP HCPCS C1776 6276-6-424 - STEM FEMORAL 24MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-425 SUP HCPCS C1776 6276-6-425 - STEM FEMORAL 25MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-426 SUP HCPCS C1776 6276-6-426 - STEM FEMORAL 26MM 217MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,760.00 " "$5,742.40" $0.00 "$6,208.00" "$3,492.00" "$3,492.00" $0.00 $0.00 $0.00 "$1,617.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,617.18" $0.00 "$3,825.68" "$3,825.68" $0.00 "$3,880.00" "$6,145.92" "$6,208.00" $0.00 $0.00 "$1,214.44" $0.00 $0.00 "$1,235.39" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-511 SUP HCPCS C1776 6276-6-511 - STEM FEMORAL 11MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-512 SUP HCPCS C1776 6276-6-512 - STEM FEMORAL 12MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-513 SUP HCPCS C1776 6276-6-513 - STEM FEMORAL 13MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-514 SUP HCPCS C1776 6276-6-514 - STEM FEMORAL 14MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-515 SUP HCPCS C1776 6276-6-515 - STEM FEMORAL 15MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-516 SUP HCPCS C1776 6276-6-516 - STEM FEMORAL 16MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-517 SUP HCPCS C1776 6276-6-517 - STEM FEMORAL 17MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-518 SUP HCPCS C1776 6276-6-518 - STEM FEMORAL 18MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-519 SUP HCPCS C1776 6276-6-519 - STEM FEMORAL 19MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-520 SUP HCPCS C1776 6276-6-520 - STEM FEMORAL 20MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-521 SUP HCPCS C1776 6276-6-521 - STEM FEMORAL 21MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-522 SUP HCPCS C1776 6276-6-522 - STEM FEMORAL 22MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-523 SUP HCPCS C1776 6276-6-523 - STEM FEMORAL 23MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-524 SUP HCPCS C1776 6276-6-524 - STEM FEMORAL 24MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-525 SUP HCPCS C1776 6276-6-525 - STEM FEMORAL 25MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-526 SUP HCPCS C1776 6276-6-526 - STEM FEMORAL 26MM 267MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-611 SUP HCPCS C1776 6276-6-611 - STEM FEMORAL 11MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-612 SUP HCPCS C1776 6276-6-612 - STEM FEMORAL 12MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-613 SUP HCPCS C1776 6276-6-613 - STEM FEMORAL 13MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-614 SUP HCPCS C1776 6276-6-614 - STEM FEMORAL 14MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-615 SUP HCPCS C1776 6276-6-615 - STEM FEMORAL 15MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-616 SUP HCPCS C1776 6276-6-616 - STEM FEMORAL 16MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-617 SUP HCPCS C1776 6276-6-617 - STEM FEMORAL 17MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-618 SUP HCPCS C1776 6276-6-618 - STEM FEMORAL 18MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-619 SUP HCPCS C1776 6276-6-619 - STEM FEMORAL 19MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-620 SUP HCPCS C1776 6276-6-620 - STEM FEMORAL 20MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-621 SUP HCPCS C1776 6276-6-621 - STEM FEMORAL 21MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-622 SUP HCPCS C1776 6276-6-622 - STEM FEMORAL 22MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-623 SUP HCPCS C1776 6276-6-623 - STEM FEMORAL 23MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-624 SUP HCPCS C1776 6276-6-624 - STEM FEMORAL 24MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-625 SUP HCPCS C1776 6276-6-625 - STEM FEMORAL 25MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-6-626 SUP HCPCS C1776 6276-6-626 - STEM FEMORAL 26MM 317MM BOWED FLUTED MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-014 SUP HCPCS C1776 6276-7-014 - STEM FEMORAL STR CONE 14MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-015 SUP HCPCS C1776 6276-7-015 - STEM FEMORAL CONICAL 15MM 155MM MODULAR DISTAL HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-016 SUP HCPCS C1776 6276-7-016 - STEM FEMORAL CONICAL 16MM 155MM MODULAR DISTAL HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-017 SUP HCPCS C1776 6276-7-017 - STEM FEMORAL CONICAL 17MM 155MM MODULAR RSTOR HA DISTAL HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-018 SUP HCPCS C1776 6276-7-018 - STEM FEMORAL STR CONE 18MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-019 SUP HCPCS C1776 6276-7-019 - STEM FEMORAL CONICAL 19MM 155MM MODULAR RSTOR HA DISTAL HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-020 SUP HCPCS C1776 6276-7-020 - STEM FEMORAL STR CONE 20MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-021 SUP HCPCS C1776 6276-7-021 - STEM FEMORAL STR CONE 21MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-022 SUP HCPCS C1776 6276-7-022 - STEM FEMORAL STR CONE 22MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-023 SUP HCPCS C1776 6276-7-023 - STEM FEMORAL STR CONE 23MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-024 SUP HCPCS C1776 6276-7-024 - STEM FEMORAL STR CONE 24MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-025 SUP HCPCS C1776 6276-7-025 - STEM FEMORAL STR CONE 25MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-026 SUP HCPCS C1776 6276-7-026 - STEM FEMORAL STR CONE 26MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-027 SUP HCPCS C1776 6276-7-027 - STEM FEMORAL STR CONE 27MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-028 SUP HCPCS C1776 6276-7-028 - STEM FEMORAL STR CONE 28MM 155MM MODULAR RSTOR HA HIP BOTH IP/OP "$6,752.50 " "$4,996.85" $0.00 "$5,402.00" "$3,038.63" "$3,038.63" $0.00 $0.00 $0.00 "$1,407.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,407.22" $0.00 "$3,328.98" "$3,328.98" $0.00 "$3,376.25" "$5,347.98" "$5,402.00" $0.00 $0.00 "$1,056.77" $0.00 $0.00 "$1,075.00" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-114 SUP HCPCS C1776 6276-7-114 - STEM FEMORAL STR CONE 14MM 195MM MODULAR RSTOR HA HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-115 SUP HCPCS C1776 6276-7-115 - STEM FEMORAL STR CONE 15MM 195MM MODULAR RSTOR HA HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-116 SUP HCPCS C1776 6276-7-116 - STEM FEMORAL CONE STR 16MM 195MM MODULAR RSTOR HA HIP DISTAL BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-117 SUP HCPCS C1776 6276-7-117 - STEM FEMORAL STR CONE 17MM 195MM MODULAR RSTOR HA HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-118 SUP HCPCS C1776 6276-7-118 - STEM FEMORAL STR CONE 18MM 195MM MODULAR RSTOR HA HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-119 SUP HCPCS C1776 6276-7-119 - STEM FEMORAL STR CONE 19MM 195MM MODULAR RSTOR HA HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-120 SUP HCPCS C1776 6276-7-120 - STEM FEMORAL STR CONE 20MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-121 SUP HCPCS C1776 6276-7-121 - STEM FEMORAL STR CONE 21MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-122 SUP HCPCS C1776 6276-7-122 - STEM FEMORAL STR CONE 22MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-123 SUP HCPCS C1776 6276-7-123 - STEM FEMORAL STR CONE 23MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-124 SUP HCPCS C1776 6276-7-124 - STEM FEMORAL STR CONE 24MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-125 SUP HCPCS C1776 6276-7-125 - STEM FEMORAL STR CONE 25MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-126 SUP HCPCS C1776 6276-7-126 - STEM FEMORAL STR CONE 26MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-127 SUP HCPCS C1776 6276-7-127 - STEM FEMORAL STR CONE 27MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-128 SUP HCPCS C1776 6276-7-128 - STEM FEMORAL STR CONE 28MM 195MM MODULAR RSTOR HIP BOTH IP/OP "$7,150.00 " "$5,291.00" $0.00 "$5,720.00" "$3,217.50" "$3,217.50" $0.00 $0.00 $0.00 "$1,490.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,490.06" $0.00 "$3,524.95" "$3,524.95" $0.00 "$3,575.00" "$5,662.80" "$5,720.00" $0.00 $0.00 "$1,118.98" $0.00 $0.00 "$1,138.28" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-214 SUP HCPCS C1776 6276-7-214 - STEM FEMORAL CONICAL 14MM 195MM MODULAR RSTOR DISTAL HIP BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-215 SUP HCPCS C1776 6276-7-215 - STEM FEMORAL CONICAL 15MM 195MM BOWED MODULAR RSTOR HIP BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-216 SUP HCPCS C1776 6276-7-216 - STEM FEMORAL BOW CONE 16MM 195MM MODULAR REVISION RSTOR BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-217 SUP HCPCS C1776 6276-7-217 - STEM FEMORAL BOWED CONICAL 17MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-218 SUP HCPCS C1776 6276-7-218 - STEM FEMORAL CONICAL 18MM 195MM BOWED MODULAR RSTOR HA HIP BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-219 SUP HCPCS C1776 6276-7-219 - STEM FEMORAL BOWED CONICAL 19MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-220 SUP HCPCS C1776 6276-7-220 - STEM FEMORAL CONICAL 20MM 195MM BOWED MODULAR RSTOR HIP BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-221 SUP HCPCS C1776 6276-7-221 - STEM FEMORAL BOWED CONICAL 21MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-222 SUP HCPCS C1776 6276-7-222 - STEM FEMORAL BOWED CONICAL 22MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-223 SUP HCPCS C1776 6276-7-223 - STEM FEMORAL BOWED CONICAL 23MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-224 SUP HCPCS C1776 6276-7-224 - STEM FEMORAL BOWED CONICAL 24MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-225 SUP HCPCS C1776 6276-7-225 - STEM FEMORAL CONE 25MM 195MM MODULAR REVISION RSTOR HIP BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-226 SUP HCPCS C1776 6276-7-226 - STEM FEMORAL BOWED CONICAL 26MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-227 SUP HCPCS C1776 6276-7-227 - STEM FEMORAL BOWED CONICAL 27MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-228 SUP HCPCS C1776 6276-7-228 - STEM FEMORAL BOWED CONICAL 28MM 195MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,547.50 " "$5,585.15" $0.00 "$6,038.00" "$3,396.38" "$3,396.38" $0.00 $0.00 $0.00 "$1,573.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,572.90" $0.00 "$3,720.92" "$3,720.92" $0.00 "$3,773.75" "$5,977.62" "$6,038.00" $0.00 $0.00 "$1,181.18" $0.00 $0.00 "$1,201.56" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-314 SUP HCPCS C1776 6276-7-314 - STEM FEMORAL BOWED CONICAL 14MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-315 SUP HCPCS C1776 6276-7-315 - STEM FEMORAL BOWED CONICAL 15MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-316 SUP HCPCS C1776 6276-7-316 - STEM FEMORAL BOWED CONICAL 16MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-317 SUP HCPCS C1776 6276-7-317 - STEM FEMORAL BOWED CONICAL 17MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-318 SUP HCPCS C1776 6276-7-318 - STEM FEMORAL BOWED CONICAL 18MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-319 SUP HCPCS C1776 6276-7-319 - STEM FEMORAL BOWED CONICAL 19MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-320 SUP HCPCS C1776 6276-7-320 - STEM FEMORAL BOWED CONICAL 20MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-321 SUP HCPCS C1776 6276-7-321 - STEM FEMORAL BOWED CONICAL 21MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-322 SUP HCPCS C1776 6276-7-322 - STEM FEMORAL BOWED CONICAL 22MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-323 SUP HCPCS C1776 6276-7-323 - STEM FEMORAL BOWED CONICAL 23MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-324 SUP HCPCS C1776 6276-7-324 - STEM FEMORAL BOWED CONICAL 24MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-325 SUP HCPCS C1776 6276-7-325 - STEM FEMORAL BOWED CONICAL 25MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-326 SUP HCPCS C1776 6276-7-326 - STEM FEMORAL BOWED CONICAL 26MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-327 SUP HCPCS C1776 6276-7-327 - STEM FEMORAL BOWED CONICAL 27MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-7-328 SUP HCPCS C1776 6276-7-328 - STEM FEMORAL BOWED CONICAL 28MM 235MM MODULAR RSTOR DISTAL BOTH IP/OP "$7,942.50 " "$5,877.45" $0.00 "$6,354.00" "$3,574.13" "$3,574.13" $0.00 $0.00 $0.00 "$1,655.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,655.22" $0.00 "$3,915.65" "$3,915.65" $0.00 "$3,971.25" "$6,290.46" "$6,354.00" $0.00 $0.00 "$1,243.00" $0.00 $0.00 "$1,264.45" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-213 SUP HCPCS C1776 6276-8-213 - STEM FEMORAL 13MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-214 SUP HCPCS C1776 6276-8-214 - STEM FEMORAL 14MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-215 SUP HCPCS C1776 6276-8-215 - STEM FEMORAL 15MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-216 SUP HCPCS C1776 6276-8-216 - STEM FEMORAL 16MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-217 SUP HCPCS C1776 6276-8-217 - STEM FEMORAL 17MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-218 SUP HCPCS C1776 6276-8-218 - STEM FEMORAL 18MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-219 SUP HCPCS C1776 6276-8-219 - STEM FEMORAL 19MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-220 SUP HCPCS C1776 6276-8-220 - STEM FEMORAL 20MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-221 SUP HCPCS C1776 6276-8-221 - STEM FEMORAL 21MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-222 SUP HCPCS C1776 6276-8-222 - STEM FEMORAL 22MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-223 SUP HCPCS C1776 6276-8-223 - STEM FEMORAL 23MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-224 SUP HCPCS C1776 6276-8-224 - STEM FEMORAL 24MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-225 SUP HCPCS C1776 6276-8-225 - STEM FEMORAL 25MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-226 SUP HCPCS C1776 6276-8-226 - STEM FEMORAL 26MM 167MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,260.00 " "$6,112.40" $0.00 "$6,608.00" "$3,717.00" "$3,717.00" $0.00 $0.00 $0.00 "$1,721.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,721.38" $0.00 "$4,072.18" "$4,072.18" $0.00 "$4,130.00" "$6,541.92" "$6,608.00" $0.00 $0.00 "$1,292.69" $0.00 $0.00 "$1,314.99" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-413 SUP HCPCS C1776 6276-8-413 - STEM FEMORAL 13MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-414 SUP HCPCS C1776 6276-8-414 - STEM FEMORAL 14MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-415 SUP HCPCS C1776 6276-8-415 - STEM FEMORAL 15MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-416 SUP HCPCS C1776 6276-8-416 - STEM FEMORAL 16MM 1217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-417 SUP HCPCS C1776 6276-8-417 - STEM FEMORAL 17MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-418 SUP HCPCS C1776 6276-8-418 - STEM FEMORAL 18MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-419 SUP HCPCS C1776 6276-8-419 - STEM FEMORAL 19MM 1217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-420 SUP HCPCS C1776 6276-8-420 - STEM FEMORAL 20MM 1217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-421 SUP HCPCS C1776 6276-8-421 - STEM FEMORAL 21MM 1217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-422 SUP HCPCS C1776 6276-8-422 - STEM FEMORAL 22MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-423 SUP HCPCS C1776 6276-8-423 - STEM FEMORAL 23MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-424 SUP HCPCS C1776 6276-8-424 - STEM FEMORAL 24MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-425 SUP HCPCS C1776 6276-8-425 - STEM FEMORAL 25MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-426 SUP HCPCS C1776 6276-8-426 - STEM FEMORAL 26MM 217MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$8,640.00 " "$6,393.60" $0.00 "$6,912.00" "$3,888.00" "$3,888.00" $0.00 $0.00 $0.00 "$1,800.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,800.58" $0.00 "$4,259.52" "$4,259.52" $0.00 "$4,320.00" "$6,842.88" "$6,912.00" $0.00 $0.00 "$1,352.16" $0.00 $0.00 "$1,375.49" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-513 SUP HCPCS C1776 6276-8-513 - STEM FEMORAL 13MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-514 SUP HCPCS C1776 6276-8-514 - STEM FEMORAL 14MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-515 SUP HCPCS C1776 6276-8-515 - STEM FEMORAL 15MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-516 SUP HCPCS C1776 6276-8-516 - STEM FEMORAL 16MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-517 SUP HCPCS C1776 6276-8-517 - STEM FEMORAL 17MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-518 SUP HCPCS C1776 6276-8-518 - STEM FEMORAL 18MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-519 SUP HCPCS C1776 6276-8-519 - STEM FEMORAL 19MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-520 SUP HCPCS C1776 6276-8-520 - STEM FEMORAL 20MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-521 SUP HCPCS C1776 6276-8-521 - STEM FEMORAL 21MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-522 SUP HCPCS C1776 6276-8-522 - STEM FEMORAL 22MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-523 SUP HCPCS C1776 6276-8-523 - STEM FEMORAL 23MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-524 SUP HCPCS C1776 6276-8-524 - STEM FEMORAL 24MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-525 SUP HCPCS C1776 6276-8-525 - STEM FEMORAL 25MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-526 SUP HCPCS C1776 6276-8-526 - STEM FEMORAL 26MM 267MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,027.50 " "$6,680.35" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,881.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,881.33" $0.00 "$4,450.56" "$4,450.56" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-613 SUP HCPCS C1776 6276-8-613 - STEM FEMORAL 13MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-614 SUP HCPCS C1776 6276-8-614 - STEM FEMORAL 14MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-615 SUP HCPCS C1776 6276-8-615 - STEM FEMORAL 15MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-616 SUP HCPCS C1776 6276-8-616 - STEM FEMORAL 16MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-617 SUP HCPCS C1776 6276-8-617 - STEM FEMORAL 17MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-618 SUP HCPCS C1776 6276-8-618 - STEM FEMORAL 18MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-619 SUP HCPCS C1776 6276-8-619 - STEM FEMORAL 19MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-620 SUP HCPCS C1776 6276-8-620 - STEM FEMORAL 20MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-621 SUP HCPCS C1776 6276-8-621 - STEM FEMORAL 21MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-622 SUP HCPCS C1776 6276-8-622 - STEM FEMORAL 22MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-623 SUP HCPCS C1776 6276-8-623 - STEM FEMORAL 23MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-624 SUP HCPCS C1776 6276-8-624 - STEM FEMORAL 24MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-625 SUP HCPCS C1776 6276-8-625 - STEM FEMORAL 25MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6276-8-626 SUP HCPCS C1776 6276-8-626 - STEM FEMORAL 26MM 317MM BOWED SLOTTED PLASMA HIP BOTH IP/OP "$9,410.00 " "$6,963.40" $0.00 "$7,528.00" "$4,234.50" "$4,234.50" $0.00 $0.00 $0.00 "$1,961.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.04" $0.00 "$4,639.13" "$4,639.13" $0.00 "$4,705.00" "$7,452.72" "$7,528.00" $0.00 $0.00 "$1,472.67" $0.00 $0.00 "$1,498.07" $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-036 SUP Custom 27803010 6280-0-036 - HEAD FEM -3MM 36MM PCA OFST BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-126 SUP Custom 27803010 6280-0-126 - HEAD FEMORAL STANDARD OFFST 26MM PCA VITALLIUM HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-128 SUP Custom 27803010 6280-0-128 - HEAD FEM +0MM OFST 28MM STRL PCA VIT HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-132 SUP Custom 27803010 6280-0-132 - HEAD FEM +0MM OFST 32MM STRL PCA VIT HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-136 SUP Custom 27803010 6280-0-136 - HEAD FEM 36MM PCA BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-226 SUP Custom 27803010 6280-0-226 - HEAD FEMORAL +5MM 26MM PCA VITALLIUM HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-228 SUP Custom 27803010 6280-0-228 - HEAD FEM +5MM OFST 28MM STRL PCA VIT HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-232 SUP Custom 27803010 6280-0-232 - HEAD FEM +5MM OFST 32MM STRL PCA VIT HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-236 SUP Custom 27803010 6280-0-236 - HEAD FEM +5MM OFST 36MM STRL PCA VIT HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-326 SUP Custom 27803010 6280-0-326 - HEAD FEMORAL +10MM 26MM PCA VITALLIUM HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-328 SUP Custom 27803010 6280-0-328 - HEAD FEM +10MM OFST 28MM PCA HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-332 SUP Custom 27803010 6280-0-332 - HEAD FEMORAL +10MM TAPER 32MM PCA VITALLIUM HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-336 SUP Custom 27803010 6280-0-336 - HEAD FEM +10MM 36MM HIP OFFST PCA BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-436 SUP Custom 27803010 6280-0-436 - HEAD FEM +15MM 36MM OFFST PCA BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-622 SUP Custom 27803010 6280-0-622 - HEAD FEM +2MM OFST 22.2MM STRL PCA VIT HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-722 SUP Custom 27803010 6280-0-722 - HEAD FEMORAL +5MM 22.2MM PCA VITALLIUM HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-0-822 SUP Custom 27803010 6280-0-822 - HEAD FEMORAL +10MM 22MM PCA VITALLIUM HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6280-3-032 SUP Custom 27803010 6280-3-032 - HEAD FEMORAL +3MM 32MM PCA VITALLIUM HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-012 SUP HCPCS C1713 6290-7-012 - SCREW BONE 6.2MM 12MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-015 SUP HCPCS C1713 6290-7-015 - SCREW BONE 6.2MM 15MM CANC SLFTAP HEX HEAD BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-020 SUP HCPCS C1713 6290-7-020 - SCREW BONE 6.2MM 20MM CANC SLFTAP HEX HEAD BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-025 SUP HCPCS C1713 6290-7-025 - SCREW BONE 6.2MM 25MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-030 SUP HCPCS C1713 6290-7-030 - SCREW BONE 6.2MM 30MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-035 SUP HCPCS C1713 6290-7-035 - SCREW BONE 6.2MM 35MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-040 SUP HCPCS C1713 6290-7-040 - SCREW BONE 6.2MM 40MM CANC SLFTAP HEX HEAD BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-045 SUP HCPCS C1713 6290-7-045 - SCREW BONE 6.2MM 45MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-050 SUP HCPCS C1713 6290-7-050 - SCREW BONE 6.2MM 50MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-055 SUP HCPCS C1713 6290-7-055 - SCREW BONE 6.2MM 55MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-060 SUP HCPCS C1713 6290-7-060 - SCREW BONE 6.2MM 60MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-7-065 SUP HCPCS C1713 6290-7-065 - SCREW BONE 6.2MM 65MM CANC SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6290-8-620 SUP HCPCS C1713 6290-8-620 - WASHER 6.2MM SCR ORTH VIT BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.75 $33.75 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 629210S SUP HCPCS C1713 629210S - PLATE 176MM TI 10 SHFT HOLE LCK VARIAX BONE LEFT DISTAL LAT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $959.06 $959.06 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 629212S SUP HCPCS C1713 629212S - PLATE 203MM TI 12 SHFT HOLE LCK VARIAX BONE LEFT DISTAL LAT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,793.00" "$1,008.56" "$1,008.56" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,120.63" "$1,775.07" "$1,793.00" $0.00 $0.00 $350.76 $0.00 $0.00 $356.81 $0.00 $0.00 $0.00 $0.00 $0.00 629230S SUP HCPCS C1713 629230S - PLATE 176MM TI 10 SHFT HOLE LCK VARIAX BONE RIGHT DISTAL LAT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $959.06 $959.06 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 629232S SUP HCPCS C1713 629232S - PLATE 203MM TI 12 SHFT HOLE REDX CLMP SLFTAP BONE RL STRL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,793.00" "$1,008.56" "$1,008.56" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,120.63" "$1,775.07" "$1,793.00" $0.00 $0.00 $350.76 $0.00 $0.00 $356.81 $0.00 $0.00 $0.00 $0.00 $0.00 629250S SUP HCPCS C1713 629250S - PLATE BN 173MM STRL VARIAX 10 HL TI HUM LT P/L BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $959.06 $959.06 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 629252S SUP HCPCS C1713 629252S - PLATE BN 196MM STRL VARIAX 12 HL TI HUM LT P/L BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,793.00" "$1,008.56" "$1,008.56" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,120.63" "$1,775.07" "$1,793.00" $0.00 $0.00 $350.76 $0.00 $0.00 $356.81 $0.00 $0.00 $0.00 $0.00 $0.00 629254S SUP HCPCS C1713 629254S - DISTAL POSTERIOR LATERAL PLATE 14 HOLE / LEFT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 629270S SUP HCPCS C1713 629270S - PLATE BN 173MM STRL VARIAX 10 HL TI HUM RT P/L BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $959.06 $959.06 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 629272S SUP HCPCS C1713 629272S - PLATE BN 196MM STRL VARIAX 12 HL TI HUM RT P/L BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,793.00" "$1,008.56" "$1,008.56" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,120.63" "$1,775.07" "$1,793.00" $0.00 $0.00 $350.76 $0.00 $0.00 $356.81 $0.00 $0.00 $0.00 $0.00 $0.00 629274S SUP HCPCS C1713 629274S - PLATE BN 218MM STRL VARIAX 14 HL TI HUM RT P/L BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 629290S SUP HCPCS C1713 629290S - PLATE 167MM TI 10 SHFT HOLE LCK XTD VARIAX BONE L/R MDL HUM BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $959.06 $959.06 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 629292S SUP HCPCS C1713 629292S - PLATE 191MM TI 12 HOLE XTD VARIAX BONE MDL ELB STRL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,793.00" "$1,008.56" "$1,008.56" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,120.63" "$1,775.07" "$1,793.00" $0.00 $0.00 $350.76 $0.00 $0.00 $356.81 $0.00 $0.00 $0.00 $0.00 $0.00 629294S SUP HCPCS C1713 629294S - PLATE 215MM TI 14 SHFT HOLE LCK XTD VARIAX BONE L/R MDL HUM BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 6293-0-000 SUP Custom 27803010 6293-0-000 - HEAD FEM STD 32MM HIP PCA BOTH IP/OP "$2,180.00 " "$1,613.20" $0.00 "$1,744.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,618.00" "$1,618.00" $0.00 $0.00 $454.31 $0.00 $0.00 $0.00 $0.00 "$1,090.00" "$1,726.56" "$1,744.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6293-0-005 SUP Custom 27803010 6293-0-005 - HEAD FEM +5 32MM HIP PCA BOTH IP/OP "$2,180.00 " "$1,613.20" $0.00 "$1,744.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,618.00" "$1,618.00" $0.00 $0.00 $454.31 $0.00 $0.00 $0.00 $0.00 "$1,090.00" "$1,726.56" "$1,744.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 629310S SUP HCPCS C1713 629310S - PLATE 175MM TI 10 SHFT HOLE BONE LEFT POST MDL STRL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $959.06 $959.06 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 629312S SUP HCPCS C1713 629312S - PLATE 199MM TI 12 SHFT HOLE LCK VARIAX BONE LEFT POST MDL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,793.00" "$1,008.56" "$1,008.56" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,120.63" "$1,775.07" "$1,793.00" $0.00 $0.00 $350.76 $0.00 $0.00 $356.81 $0.00 $0.00 $0.00 $0.00 $0.00 629330S SUP HCPCS C1713 629330S - PLATE 175MM TI 10 SHFT HOLE LCK VARIAX BONE RIGHT POST MDL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $959.06 $959.06 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 629332S SUP HCPCS C1713 629332S - PLATE 199MM TI 12 HOLE LCK VARIAX BONE RIGHT POST MDL ELB BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,793.00" "$1,008.56" "$1,008.56" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,120.63" "$1,775.07" "$1,793.00" $0.00 $0.00 $350.76 $0.00 $0.00 $356.81 $0.00 $0.00 $0.00 $0.00 $0.00 629350S SUP HCPCS C1713 629350S - PLATE BN 161MM NS VARIAX 10 HL TI OLCRN LT BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $866.25 $866.25 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 629352S SUP HCPCS C1713 629352S - PLATE 184MM TI 12 SHFT HOLE LCK VARIAX BONE LEFT OLCRN ELB BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $909.56 $909.56 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,010.63" "$1,600.83" "$1,617.00" $0.00 $0.00 $316.33 $0.00 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 629370S SUP HCPCS C1713 629370S - PLATE 161MM TI 12 SHFT HOLE LCK VARIAX BONE RIGHT OLCRN ELB BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $866.25 $866.25 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 629372S SUP HCPCS C1713 629372S - PLATE 184MM TI 12 SHFT HOLE LCK VARIAX BONE RIGHT OLCRN ELB BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $909.56 $909.56 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,010.63" "$1,600.83" "$1,617.00" $0.00 $0.00 $316.33 $0.00 $0.00 $321.78 $0.00 $0.00 $0.00 $0.00 $0.00 629390S SUP HCPCS C1713 629390S - PLATE 163MM TI 10 HOLE LCK VARIAX BONE MDL ELB STRL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,769.40" $959.06 $959.06 $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,065.63" "$1,687.95" "$1,705.00" $0.00 $0.00 $333.54 $0.00 $0.00 $339.30 $0.00 $0.00 $0.00 $0.00 $0.00 629392S SUP HCPCS C1713 629392S - PLATE 187MM TI 12 SHFT HOLE LCK VARIAX BONE L/R DISTAL MDL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,793.00" "$1,008.56" "$1,008.56" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,120.63" "$1,775.07" "$1,793.00" $0.00 $0.00 $350.76 $0.00 $0.00 $356.81 $0.00 $0.00 $0.00 $0.00 $0.00 629394S SUP HCPCS C1713 629394S - PLATE 211MM TI 14 SHFT HOLE LCK VARIAX BONE L/R DISTAL MDL BOTH IP/OP "$2,384.00 " "$1,764.16" $0.00 "$1,925.00" "$1,082.81" "$1,082.81" $0.00 $0.00 $0.00 $496.89 "$1,769.40" "$1,769.40" $0.00 $0.00 $496.83 $0.00 "$1,410.14" "$1,410.14" $0.00 "$1,203.13" "$1,905.75" "$1,925.00" $0.00 $0.00 $376.58 $0.00 $0.00 $383.08 $0.00 $0.00 $0.00 $0.00 $0.00 6299-2-403 SUP Custom 27803010 6299-2-403 - INSERT ACETAB 0D NEUTRAL 40-43MM 26MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-2-469 SUP Custom 27803010 6299-2-469 - INSERT ACETAB 0D NEUTRAL 46-49MM 26MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-2-525 SUP Custom 27803010 6299-2-525 - INSERT ACETAB 0D NEUTRAL 52-55MM 26MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-2-581 SUP Custom 27803010 6299-2-581 - INSERT ACETAB 0D NEUTRAL 58-61MM 26MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-3-469 SUP Custom 27803010 6299-3-469 - INSERT ACETAB 0D NEUTRAL 46-49MM 28MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-3-525 SUP Custom 27803010 6299-3-525 - INSERT ACETAB 0D NEUTRAL 52-55MM 28MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-3-581 SUP Custom 27803010 6299-3-581 - INSERT ACETAB 0D NEUTRAL 58-61MM 28MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-3-647 SUP Custom 27803010 6299-3-647 - INSERT ACETAB 0D NEUTRAL 64-67MM 28MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-4-469 SUP Custom 27803010 6299-4-469 - INSERT ACETAB 0D NEUTRAL 46-49MM 32MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-4-525 SUP Custom 27803010 6299-4-525 - INSERT ACETAB 0D NEUTRAL 52-55MM 32MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-4-581 SUP Custom 27803010 6299-4-581 - INSERT ACETAB 0D NEUTRAL 58-61MM 32MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-4-647 SUP Custom 27803010 6299-4-647 - INSERT ACETAB 0D NEUTRAL 64-67MM 32MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-5-403 SUP Custom 27803010 6299-5-403 - INSERT ACETAB 10D 40-43MM 26MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-5-469 SUP Custom 27803010 6299-5-469 - INSERT ACETAB 10D 46-49MM 26MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-5-525 SUP Custom 27803010 6299-5-525 - INSERT ACETAB 10D 52-55MM 26MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-5-581 SUP Custom 27803010 6299-5-581 - INSERT ACETAB 10D 58-61MM 26MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-6-469 SUP Custom 27803010 6299-6-469 - INSERT ACETAB 10D 46-49MM 28MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-6-525 SUP Custom 27803010 6299-6-525 - INSERT ACETAB 10D 52-55MM 28MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-6-581 SUP Custom 27803010 6299-6-581 - INSERT ACETAB 10D 58-61MM 28MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-6-647 SUP Custom 27803010 6299-6-647 - INSERT ACETAB 10D 64-67MM 28MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-7-469 SUP Custom 27803010 6299-7-469 - INSERT ACETAB 10D 46-49MM 32MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-7-525 SUP Custom 27803010 6299-7-525 - INSERT ACETAB 10D 52-55MM 32MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-7-581 SUP Custom 27803010 6299-7-581 - INSERT ACETAB 10D 58-61MM 32MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-7-647 SUP Custom 27803010 6299-7-647 - INSERT ACETAB 10D 64-67MM 32MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-8-403 SUP Custom 27803010 6299-8-403 - INSERT ACETAB 10D 40-43MM 22MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-8-469 SUP Custom 27803010 6299-8-469 - INSERT ACETAB 10D 46-49MM 22MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-8-525 SUP Custom 27803010 6299-8-525 - INSERT ACETAB 10D 52-55MM 22MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-8-581 SUP Custom 27803010 6299-8-581 - INSERT ACETAB 10D 52-55MM 22MM PCA DUR HIP BOTH IP/OP "$2,117.50 " "$1,566.95" $0.00 "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.61" "$1,571.61" $0.00 $0.00 $441.29 $0.00 $0.00 $0.00 $0.00 "$1,058.75" "$1,677.06" "$1,694.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-H-332 SUP Custom 27803010 6299-H-332 - LINER ACETAB PCA 10D C 32MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6299-N-332 SUP Custom 27803010 6299-N-332 - LINER ACETAB PCA NTRL 32MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-012 SUP HCPCS C1713 6302-3-012 - SCREW BONE 6.5MM 12MM VTLK VIT PLUG BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-014 SUP HCPCS C1713 6302-3-014 - SCREW ACETAB 14MM 6.5MM VTLK VITALIUM PLUG BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-016 SUP HCPCS C1713 6302-3-016 - SCREW BONE 6.5MM 16MM VTLK VIT ACETUBULAR PLG VIT BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-018 SUP HCPCS C1713 6302-3-018 - SCREW ACETAB 18MM 6.5MM VTLK VIT PLG BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-020 SUP HCPCS C1713 6302-3-020 - SCREW BONE 6.5MM 20MM VTLK VIT ACETAB SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-022 SUP HCPCS C1713 6302-3-022 - SCREW ACETAB 22MM 6.5MM VTLK VIT PLUG BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-024 SUP HCPCS C1713 6302-3-024 - SCREW BONE 6.5MM 24MM VTLK VIT ACETAB SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-026 SUP HCPCS C1713 6302-3-026 - SCREW BONE 6.5MM 26MM VTLK VIT SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-028 SUP HCPCS C1713 6302-3-028 - SCREW BONE 6.8MM 28MM VTLK VIT PLG BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-030 SUP HCPCS C1713 6302-3-030 - SCREW BONE 6.5MM 30MM VTLK VIT ACETAB SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-035 SUP HCPCS C1713 6302-3-035 - SCREW BONE 6.5MM 35MM VTLK VIT ACETABULLAR SLFTAP BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-040 SUP HCPCS C1713 6302-3-040 - SCREW BONE 6.5MM 40MM VTLK VIT PLUG BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-045 SUP HCPCS C1713 6302-3-045 - SCREW ACETAB 45MM 6.5MM VTLK VIT PLUG BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-3-050 SUP HCPCS C1713 6302-3-050 - SCREW ACETAB 50MM 6.5MM VTLK VIT PLG BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-4-000 SUP HCPCS C1713 6302-4-000 - PLUG DOME HL PRM RECON VIT APCL BOTH IP/OP $152.00 $112.48 $0.00 $121.60 $68.40 $68.40 $0.00 $0.00 $0.00 $31.68 $112.81 $112.81 $0.00 $0.00 $31.68 $0.00 $89.91 $89.91 $0.00 $76.00 $120.38 $121.60 $0.00 $0.00 $23.79 $0.00 $0.00 $24.20 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-000 SUP Custom 27803010 6302-5-000 - INSERT ACETAB 22.2MM 0D P0 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-001 SUP Custom 27803010 6302-5-001 - INSERT ACETAB 22.2MM P1 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-002 SUP Custom 27803010 6302-5-002 - INSERT ACETAB 22.2MM P2 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-003 SUP Custom 27803010 6302-5-003 - INSERT ACETAB 22.2MM P3 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-004 SUP Custom 27803010 6302-5-004 - INSERT ACETAB 22.2MM P4 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-005 SUP Custom 27803010 6302-5-005 - INSERT ACETAB 22.2MM P5 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-006 SUP Custom 27803010 6302-5-006 - INSERT ACETAB 22.2MM P6 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-007 SUP Custom 27803010 6302-5-007 - INSERT ACETAB 22.2MM P7 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-008 SUP Custom 27803010 6302-5-008 - INSERT ACETAB 22.2MM P8 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-009 SUP Custom 27803010 6302-5-009 - INSERT ACETAB 22.2MM P9 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-010 SUP Custom 27803010 6302-5-010 - INSERT ACETAB 22.2MM 10D P0 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-011 SUP Custom 27803010 6302-5-011 - INSERT ACETAB 22.2MM 10D P1 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-012 SUP Custom 27803010 6302-5-012 - INSERT ACETAB 22.2MM 10D P2 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-013 SUP Custom 27803010 6302-5-013 - INSERT ACETAB 22.2MM 10D P3 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-014 SUP Custom 27803010 6302-5-014 - INSERT ACETAB 22.2MM 10D P4 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-015 SUP Custom 27803010 6302-5-015 - INSERT ACETAB 22.2MM 10D P5 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-016 SUP Custom 27803010 6302-5-016 - INSERT ACETAB 22.2MM 10D P6 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-017 SUP Custom 27803010 6302-5-017 - INSERT ACETAB 22.2MM 10D P7 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-018 SUP Custom 27803010 6302-5-018 - INSERT ACETAB 22.2MM 10D P8 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-019 SUP Custom 27803010 6302-5-019 - INSERT ACETAB 22.2MM 10D P9 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-020 SUP Custom 27803010 6302-5-020 - INSERT ACETAB 22.2MM 15D P0 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-021 SUP Custom 27803010 6302-5-021 - INSERT ACETAB 22.2MM 15D P1 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-022 SUP Custom 27803010 6302-5-022 - INSERT ACETAB 22.2MM 15D P2 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-023 SUP Custom 27803010 6302-5-023 - INSERT ACETAB 22.2MM 15D P3 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-024 SUP Custom 27803010 6302-5-024 - INSERT ACETAB 22.2MM 15D P4 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-025 SUP Custom 27803010 6302-5-025 - INSERT ACETAB 22.2MM 15D P5 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-026 SUP Custom 27803010 6302-5-026 - INSERT ACETAB 22.2MM 15D P6 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-027 SUP Custom 27803010 6302-5-027 - INSERT ACETAB 22.2MM 15D P7 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-028 SUP Custom 27803010 6302-5-028 - INSERT ACETAB 22.2MM 15D P8 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-029 SUP Custom 27803010 6302-5-029 - INSERT ACETAB 22.2MM 15D P9 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-030 SUP Custom 27803010 6302-5-030 - INSERT ACETAB 26MM P1 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-032 SUP Custom 27803010 6302-5-032 - INSERT ACETAB 26MM P2 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-033 SUP Custom 27803010 6302-5-033 - INSERT ACETAB 26MM P3 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-034 SUP Custom 27803010 6302-5-034 - INSERT ACETAB 26MM P4 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-035 SUP Custom 27803010 6302-5-035 - INSERT ACETAB 26MM P5 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-036 SUP Custom 27803010 6302-5-036 - INSERT ACETAB 26MM P6 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-037 SUP Custom 27803010 6302-5-037 - INSERT ACETAB 26MM P7 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-038 SUP Custom 27803010 6302-5-038 - INSERT ACETAB 26MM P8 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-039 SUP Custom 27803010 6302-5-039 - INSERT ACETAB 26MM P9 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-040 SUP Custom 27803010 6302-5-040 - INSERT ACETAB 26MM 10D P1 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-042 SUP Custom 27803010 6302-5-042 - INSERT ACETAB 26MM 10D P2 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-043 SUP Custom 27803010 6302-5-043 - INSERT ACETAB 26MM 10D P3 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-044 SUP Custom 27803010 6302-5-044 - INSERT ACETAB 26MM 10D P4 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-045 SUP Custom 27803010 6302-5-045 - INSERT ACETAB 26MM 10D P5 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-046 SUP Custom 27803010 6302-5-046 - INSERT ACETAB 26MM 10D P6 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-047 SUP Custom 27803010 6302-5-047 - INSERT ACETAB 26MM 10D P7 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-048 SUP Custom 27803010 6302-5-048 - INSERT ACETAB 26MM 10D P8 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-049 SUP Custom 27803010 6302-5-049 - INSERT ACETAB 26MM 10D P9 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-050 SUP Custom 27803010 6302-5-050 - INSERT ACETAB 26MM 15D P1 HIP DUR PE S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-052 SUP Custom 27803010 6302-5-052 - INSERT ACETAB 26MM 15D P2 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-053 SUP Custom 27803010 6302-5-053 - INSERT ACETAB 26MM 15D P3 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-054 SUP Custom 27803010 6302-5-054 - INSERT ACETAB 26MM 15D P4 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-055 SUP Custom 27803010 6302-5-055 - INSERT ACETAB 26MM 15D P5 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-056 SUP Custom 27803010 6302-5-056 - INSERT ACETAB 26MM 15D P6 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-057 SUP Custom 27803010 6302-5-057 - INSERT ACETAB 26MM 15D P7 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-058 SUP Custom 27803010 6302-5-058 - INSERT ACETAB 26MM 15D P8 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-059 SUP Custom 27803010 6302-5-059 - INSERT ACETAB 26MM 15D P9 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-062 SUP Custom 27803010 6302-5-062 - INSERT ACETAB 28MM P2 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-063 SUP Custom 27803010 6302-5-063 - INSERT ACETAB 28MM P3 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-064 SUP Custom 27803010 6302-5-064 - INSERT ACETAB 28MM P4 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-065 SUP Custom 27803010 6302-5-065 - INSERT ACETAB 28MM P5 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-066 SUP Custom 27803010 6302-5-066 - INSERT ACETAB 28MM P6 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-067 SUP Custom 27803010 6302-5-067 - INSERT ACETAB 28MM P7 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-068 SUP Custom 27803010 6302-5-068 - INSERT ACETAB 28MM P8 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-069 SUP Custom 27803010 6302-5-069 - INSERT ACETAB 28MM P9 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-072 SUP Custom 27803010 6302-5-072 - INSERT ACETAB 28MM 10D P2 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-073 SUP Custom 27803010 6302-5-073 - INSERT ACETAB 28MM 10D P3 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-074 SUP Custom 27803010 6302-5-074 - INSERT ACETAB 28MM 10D P4 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-075 SUP Custom 27803010 6302-5-075 - INSERT ACETAB 28MM 10D P5 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-076 SUP Custom 27803010 6302-5-076 - INSERT ACETAB 28MM 10D P6 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-077 SUP Custom 27803010 6302-5-077 - INSERT ACETAB 28MM 10D P7 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-078 SUP Custom 27803010 6302-5-078 - INSERT ACETAB 28MM 10D P8 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-079 SUP Custom 27803010 6302-5-079 - INSERT ACETAB 28MM 10D P9 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-082 SUP Custom 27803010 6302-5-082 - INSERT ACETAB 15D P2 28MM SYSTEM 12 OSTEOLOCK DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-083 SUP Custom 27803010 6302-5-083 - INSERT ACETAB 28MM 15D P3 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-084 SUP Custom 27803010 6302-5-084 - INSERT ACETAB 28MM 15D P4 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-085 SUP Custom 27803010 6302-5-085 - INSERT ACETAB 28MM 15D P5 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-086 SUP Custom 27803010 6302-5-086 - INSERT ACETAB 28MM 15D P6 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-087 SUP Custom 27803010 6302-5-087 - INSERT ACETAB 28MM 15D P7 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-088 SUP Custom 27803010 6302-5-088 - INSERT ACETAB 28MM 15D P8 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-089 SUP Custom 27803010 6302-5-089 - INSERT ACETAB 28MM 15D P9 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-093 SUP Custom 27803010 6302-5-093 - INSERT ACETAB 15D P3 32MM SYSTEM 12 OSTEOLOCK DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-094 SUP Custom 27803010 6302-5-094 - INSERT ACETAB 32MM P4 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-095 SUP Custom 27803010 6302-5-095 - INSERT ACETAB 15D P5 32MM SYSTEM 12 OSTEOLOCK DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-096 SUP Custom 27803010 6302-5-096 - INSERT ACETAB 15D P6 32MM SYSTEM 12 OSTEOLOCK DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-097 SUP Custom 27803010 6302-5-097 - INSERT ACETAB 28MM P7 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-098 SUP Custom 27803010 6302-5-098 - INSERT ACETAB 32MM P8 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-099 SUP Custom 27803010 6302-5-099 - INSERT ACETAB 32MM P9 NTRL HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-103 SUP Custom 27803010 6302-5-103 - INSERT ACETAB 10D P3 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-104 SUP Custom 27803010 6302-5-104 - INSERT ACETAB 10D P4 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-105 SUP Custom 27803010 6302-5-105 - INSERT ACETAB 10D P5 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-106 SUP Custom 27803010 6302-5-106 - INSERT ACETAB 32MM 10D P6 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-107 SUP Custom 27803010 6302-5-107 - INSERT ACETAB 10D P7 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-108 SUP Custom 27803010 6302-5-108 - INSERT ACETAB 10D P8 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-109 SUP Custom 27803010 6302-5-109 - INSERT ACETAB 10D P9 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-113 SUP Custom 27803010 6302-5-113 - INSERT ACETAB 10D P3 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-114 SUP Custom 27803010 6302-5-114 - INSERT ACETAB 15D P4 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-115 SUP Custom 27803010 6302-5-115 - INSERT ACETAB 15D P5 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-116 SUP Custom 27803010 6302-5-116 - INSERT ACETAB 15D P6 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-117 SUP Custom 27803010 6302-5-117 - INSERT ACETAB 32MM 15D P7 HIP DUR S12 BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-118 SUP Custom 27803010 6302-5-118 - INSERT ACETAB 15D P8 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-5-119 SUP Custom 27803010 6302-5-119 - INSERT ACETAB 15D P9 32MM SYSTEM 12 DUR HIP BOTH IP/OP "$1,942.50 " "$1,437.45" $0.00 "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.72" "$1,441.72" $0.00 $0.00 $404.82 $0.00 $0.00 $0.00 $0.00 $971.25 "$1,538.46" "$1,554.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-007 SUP Custom 27803010 6302-6-007 - INSERT ACETAB 10D P7 26MM SYSTEM 12 DUR HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-008 SUP Custom 27803010 6302-6-008 - INSERT ACETAB 10D +4MM P8 26MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-009 SUP Custom 27803010 6302-6-009 - INSERT ACETAB 10D +4MM P9 26MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-102 SUP Custom 27803010 6302-6-102 - INSERT ACETAB 10D +4MM P2 28MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-103 SUP Custom 27803010 6302-6-103 - INSERT ACETAB 10D +4MM P3 28MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-104 SUP Custom 27803010 6302-6-104 - INSERT ACETAB 10D +4MM P4 28MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-105 SUP Custom 27803010 6302-6-105 - INSERT ACETAB 10D +4MM P5 28MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-106 SUP Custom 27803010 6302-6-106 - INSERT ACETAB 10D +4MM P6 28MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-107 SUP Custom 27803010 6302-6-107 - INSERT ACETAB 10D +4MM P7 28MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-108 SUP Custom 27803010 6302-6-108 - INSERT ACETAB 10D +4MM P8 28MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-109 SUP Custom 27803010 6302-6-109 - INSERT ACETAB 10D +4MM P9 28MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-220 SUP Custom 27803010 6302-6-220 - INSERT ACETAB 22.2MM 4MM P0 NTRL BOTH IP/OP $928.00 $686.72 $0.00 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $688.76 $688.76 $0.00 $0.00 $193.40 $0.00 $0.00 $0.00 $0.00 $464.00 $734.98 $742.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-303 SUP Custom 27803010 6302-6-303 - INSERT ACETAB 10D +4MM P3 32MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-304 SUP Custom 27803010 6302-6-304 - INSERT ACETAB 10D +4MM P4 32MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-305 SUP Custom 27803010 6302-6-305 - INSERT ACTB 10D P4 32MM S12 LATRILIZING RT BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-306 SUP Custom 27803010 6302-6-306 - INSERT ACETAB 10D +4MM P6 32MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-307 SUP Custom 27803010 6302-6-307 - INSERT ACETAB 10D +4MM P7 32MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-308 SUP Custom 27803010 6302-6-308 - INSERT ACETAB 10D +4MM P8 32MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-6-309 SUP Custom 27803010 6302-6-309 - INSERT ACETAB 10D +4MM P9 32MM SYSTEM 12 HIP BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 $0.00 $0.00 $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-H-328 SUP Custom 27803010 6302-H-328 - LINER ACETAB 10D 28MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-H-428 SUP Custom 27803010 6302-H-428 - LINER ACETAB 10D 28MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-H-432 SUP Custom 27803010 6302-H-432 - LINER ACETAB 10D 32MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-H-528 SUP Custom 27803010 6302-H-528 - LINER ACETAB 10D 28MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-H-532 SUP Custom 27803010 6302-H-532 - LINER ACETAB 10D 32MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-H-628 SUP Custom 27803010 6302-H-628 - LINER ACETAB 10D 28MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-H-632 SUP Custom 27803010 6302-H-632 - LINER ACETAB 10D 32MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-N-222 SUP Custom 27803010 6302-N-222 - LINER ACETAB NTRL 22MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-N-328 SUP Custom 27803010 6302-N-328 - LINER ACETAB TRDNT NTRL 28MM CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-N-426 SUP Custom 27803010 6302-N-426 - LINER ACETAB NTRL 26MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-N-428 SUP Custom 27803010 6302-N-428 - LINER ACETAB NTRL 28MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-N-432 SUP Custom 27803010 6302-N-432 - LINER ACETAB NTRL 32MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-N-532 SUP Custom 27803010 6302-N-532 - LINER ACETAB NTRL 32MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6302-N-632 SUP Custom 27803010 6302-N-632 - LINER ACETAB NTRL 32MM HIP CNSTRN BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 $0.00 $0.00 $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-240 SUP HCPCS C1776 6309-2-240 - CUP ACTB 40MM 22MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-242 SUP HCPCS C1776 6309-2-242 - CUP ACTB 42MM 22MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-244 SUP HCPCS C1776 6309-2-244 - CUP ACTB 44MM 22MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-844 SUP HCPCS C1776 6309-2-844 - CUP ACTB 44MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-846 SUP HCPCS C1776 6309-2-846 - CUP ACTB 46MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-848 SUP HCPCS C1776 6309-2-848 - CUP ACTB 48MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-850 SUP HCPCS C1776 6309-2-850 - CUP ACTB 50MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-852 SUP HCPCS C1776 6309-2-852 - CUP ACTB 52MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-854 SUP HCPCS C1776 6309-2-854 - CUP ACTB 54MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-856 SUP HCPCS C1776 6309-2-856 - CUP ACTB 56MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-858 SUP HCPCS C1776 6309-2-858 - CUP ACTB 58MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-2-860 SUP HCPCS C1776 6309-2-860 - CUP ACTB 60MM 28MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-248 SUP HCPCS C1776 6309-3-248 - CUP ACTB 48MM 32MM EXTR RIMFIT X3 HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-250 SUP HCPCS C1776 6309-3-250 - CUP ACTB 50MM 32MM EXTR RIMFIT X3 HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-252 SUP HCPCS C1776 6309-3-252 - CUP ACTB 52MM 32MM EXTR X3 RIMFIT HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-254 SUP HCPCS C1776 6309-3-254 - CUP ACTB 54MM 32MM EXTR X3 RIMFIT HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-256 SUP HCPCS C1776 6309-3-256 - CUP ACTB 56MM 32MM EXTR X3 RIMFIT HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-258 SUP HCPCS C1776 6309-3-258 - CUP ACTB 58MM 32MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-260 SUP HCPCS C1776 6309-3-260 - CUP ACTB 60MM 32MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-652 SUP HCPCS C1776 6309-3-652 - CUP ACTB 52MM 36MM EXTR RIMFIT X3 HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-654 SUP HCPCS C1776 6309-3-654 - CUP ACTB 54MM 36MM EXTR X3 RIMFIT HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-656 SUP HCPCS C1776 6309-3-656 - CUP ACTB 56MM 36MM EXTR RIMFIT X3 HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-658 SUP HCPCS C1776 6309-3-658 - CUP ACTB 58MM 36MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-3-660 SUP HCPCS C1776 6309-3-660 - CUP ACTB 60MM 36MM EXTR RIMFIT X3 HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-4-056 SUP HCPCS C1776 6309-4-056 - CUP ACTB 56MM 40MM EXTR RIMFIT X3 HIP BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-4-058 SUP HCPCS C1776 6309-4-058 - CUP ACTB 58MM 40MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 6309-4-060 SUP HCPCS C1776 6309-4-060 - CUP ACTB 58MM 60MM STRL EXTR RIMFIT X3 BOTH IP/OP "$2,327.50 " "$1,722.35" $0.00 "$1,862.00" "$1,047.38" "$1,047.38" $0.00 $0.00 $0.00 $485.11 "$1,727.47" "$1,727.47" $0.00 $0.00 $485.05 $0.00 "$1,376.72" "$1,376.72" $0.00 "$1,163.75" "$1,843.38" "$1,862.00" $0.00 $0.00 $364.25 $0.00 $0.00 $370.54 $0.00 $0.00 $0.00 $0.00 $0.00 632.414S SUP Custom 27803010 632.414S - PORT RTRCT BVL 22MM 40MM MRS BOTH IP/OP $897.50 $664.15 $0.00 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $666.12 $666.12 $0.00 $0.00 $187.04 $0.00 $0.00 $0.00 $0.00 $448.75 $710.82 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.415S SUP Custom 27803010 632.415S - PORT RTRCT BVL 22MM 50MM MRS BOTH IP/OP $897.50 $664.15 $0.00 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $666.12 $666.12 $0.00 $0.00 $187.04 $0.00 $0.00 $0.00 $0.00 $448.75 $710.82 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.416S SUP Custom 27803010 "632.416S - 22MM PORT, BEVELED, 60MM" BOTH IP/OP $897.50 $664.15 $0.00 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $666.12 $666.12 $0.00 $0.00 $187.04 $0.00 $0.00 $0.00 $0.00 $448.75 $710.82 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.417S SUP Custom 27803010 632.417S - PORT RTRCT BVL 22MM 70MM MRS BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $0.00 $0.00 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.418S SUP Custom 27803010 632.418S - PORT RTRCT BVL 22MM 80MM MRS BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $0.00 $0.00 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.419S SUP Custom 27803010 632.419S - PORT RTRCT BVL 22MM 90MM MRS BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $0.00 $0.00 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.420S SUP Custom 27803010 632.420S - PORT RTRCT BVL 22MM 100MM MRS BOTH IP/OP "$1,232.50 " $912.05 $0.00 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.76 $914.76 $0.00 $0.00 $256.85 $0.00 $0.00 $0.00 $0.00 $616.25 $976.14 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.421S SUP Custom 27803010 632.421S - PORT RTRCT BVL 22MM 110MM MRS BOTH IP/OP "$1,232.50 " $912.05 $0.00 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.76 $914.76 $0.00 $0.00 $256.85 $0.00 $0.00 $0.00 $0.00 $616.25 $976.14 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.422S SUP Custom 27803010 632.422S - PORT RTRCT BVL 22MM 120MM MRS BOTH IP/OP "$1,232.50 " $912.05 $0.00 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.76 $914.76 $0.00 $0.00 $256.85 $0.00 $0.00 $0.00 $0.00 $616.25 $976.14 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.424S SUP Custom 27803010 632.424S - PORT RTRCT STRG 22MM 40MM MRS BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $0.00 $0.00 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.425S SUP Custom 27803010 "632.425S - 22MM PORT, STRAIGHT, 50MM" BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $0.00 $0.00 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.426S SUP Custom 27803010 "632.426S - 22MM PORT, STRAIGHT, 60MM" BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $0.00 $0.00 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.427S SUP Custom 27803010 632.427S - PORT RTRCT STRG 22MM 70MM BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.65 $723.65 $0.00 $0.00 $203.19 $0.00 $0.00 $0.00 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.428S SUP Custom 27803010 632.428S - PORT RTRCT STRG 22MM 80MM MRS BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.65 $723.65 $0.00 $0.00 $203.19 $0.00 $0.00 $0.00 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.429S SUP Custom 27803010 632.429S - PORT RTRCT STRG 22MM 90MM MRS BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.65 $723.65 $0.00 $0.00 $203.19 $0.00 $0.00 $0.00 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.430S SUP Custom 27803010 632.430S - PORT RTRCT STRG 22MM 100MM MRS BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.431S SUP Custom 27803010 632.431S - PORT RTRCT STRG 22MM 110MM MRS BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.432S SUP Custom 27803010 632.432S - PORT RTRCT STRG 22MM 120MM MRS BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.434S SUP Custom 27803010 632.434S - PORT RTRCT BVL 19MM 40MM MRS BOTH IP/OP $897.50 $664.15 $0.00 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $666.12 $666.12 $0.00 $0.00 $187.04 $0.00 $0.00 $0.00 $0.00 $448.75 $710.82 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.435S SUP Custom 27803010 632.435S - PORT RTRCT BVL 19MM 50MM MRS BOTH IP/OP $897.50 $664.15 $0.00 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $666.12 $666.12 $0.00 $0.00 $187.04 $0.00 $0.00 $0.00 $0.00 $448.75 $710.82 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.436S SUP Custom 27803010 632.436S - PORT RTRCT BVL 19MM 60MM MRS BOTH IP/OP $897.50 $664.15 $0.00 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $666.12 $666.12 $0.00 $0.00 $187.04 $0.00 $0.00 $0.00 $0.00 $448.75 $710.82 $718.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.437S SUP Custom 27803010 632.437S - PORT RTRCT BVL 19MM 70MM MRS BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $0.00 $0.00 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.438S SUP Custom 27803010 632.438S - PORT RTRCT BVL 19MM 80MM MRS BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $0.00 $0.00 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.439S SUP Custom 27803010 "632.439S - 19MM PORT, BEVELED, 90MM" BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $0.00 $0.00 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.440S SUP Custom 27803010 632.440S - PORT RTRCT BVL 19MM 100MM MRS BOTH IP/OP "$1,232.50 " $912.05 $0.00 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.76 $914.76 $0.00 $0.00 $256.85 $0.00 $0.00 $0.00 $0.00 $616.25 $976.14 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.441S SUP Custom 27803010 632.441S - PORT RTRCT BVL 19MM 110MM MRS BOTH IP/OP "$1,232.50 " $912.05 $0.00 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.76 $914.76 $0.00 $0.00 $256.85 $0.00 $0.00 $0.00 $0.00 $616.25 $976.14 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.442S SUP Custom 27803010 632.442S - PORT RTRCT BVL 19MM 120MM MRS BOTH IP/OP "$1,232.50 " $912.05 $0.00 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $914.76 $914.76 $0.00 $0.00 $256.85 $0.00 $0.00 $0.00 $0.00 $616.25 $976.14 $986.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.444S SUP Custom 27803010 632.444S - PORT RTRCT STRG 19MM 40MM MRS BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $0.00 $0.00 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.445S SUP Custom 27803010 632.445S - PORT RTRCT STRG 19MM 50MM MRS BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $0.00 $0.00 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.446S SUP Custom 27803010 632.446S - PORT RTRCT STRG 19MM 60MM BOTH IP/OP $860.00 $636.40 $0.00 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.29 $638.29 $0.00 $0.00 $179.22 $0.00 $0.00 $0.00 $0.00 $430.00 $681.12 $688.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.447S SUP Custom 27803010 632.447S - PORT RTRCT STRG 19MM 70MM MRS BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.65 $723.65 $0.00 $0.00 $203.19 $0.00 $0.00 $0.00 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.448S SUP Custom 27803010 632.448S - PORT RTRCT STRG 19MM 80MM MRS BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.65 $723.65 $0.00 $0.00 $203.19 $0.00 $0.00 $0.00 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.449S SUP Custom 27803010 632.449S - PORT RTRCT STRG 19MM 90MM MRS BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.65 $723.65 $0.00 $0.00 $203.19 $0.00 $0.00 $0.00 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.450S SUP Custom 27803010 632.450S - PORT RTRCT STRG 19MM 100MM MRS BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.451S SUP Custom 27803010 632.451S - PORT RTRCT STRG 19MM 110MM MRS BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.452S SUP Custom 27803010 632.452S - PORT RTRCT STRG 19MM 120MM MRS BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.454S SUP Custom 27803010 632.454S - PORT RTRCT BVL 26MM 40MM MRS BOTH IP/OP "$1,197.50 " $886.15 $0.00 $958.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $888.78 $888.78 $0.00 $0.00 $249.56 $0.00 $0.00 $0.00 $0.00 $598.75 $948.42 $958.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.455S SUP Custom 27803010 632.455S - PORT RTRCT BVL 26MM 50MM MRS BOTH IP/OP "$1,197.50 " $886.15 $0.00 $958.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $888.78 $888.78 $0.00 $0.00 $249.56 $0.00 $0.00 $0.00 $0.00 $598.75 $948.42 $958.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.456S SUP Custom 27803010 632.456S - PORT RTRCT BVL 26MM 60MM MRS BOTH IP/OP "$1,197.50 " $886.15 $0.00 $958.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $888.78 $888.78 $0.00 $0.00 $249.56 $0.00 $0.00 $0.00 $0.00 $598.75 $948.42 $958.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.457S SUP Custom 27803010 632.457S - PORT RTRCT BVL 26MM 70MM MRS BOTH IP/OP "$1,307.50 " $967.55 $0.00 "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.43 $970.43 $0.00 $0.00 $272.48 $0.00 $0.00 $0.00 $0.00 $653.75 "$1,035.54" "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.458S SUP Custom 27803010 632.458S - PORT RTRCT BVL 26MM 80MM MRS BOTH IP/OP "$1,307.50 " $967.55 $0.00 "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.43 $970.43 $0.00 $0.00 $272.48 $0.00 $0.00 $0.00 $0.00 $653.75 "$1,035.54" "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.459S SUP Custom 27803010 632.459S - PORT RTRCT BVL 26MM 90MM MRS BOTH IP/OP "$1,307.50 " $967.55 $0.00 "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.43 $970.43 $0.00 $0.00 $272.48 $0.00 $0.00 $0.00 $0.00 $653.75 "$1,035.54" "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.460S SUP Custom 27803010 632.460S - PORT RTRCT BVL 26MM 100MM MRS BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.461S SUP Custom 27803010 632.461S - PORT RTRCT BVL 26MM 110MM MRS BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.462S SUP Custom 27803010 632.462S - PORT RTRCT BVL 26MM 120MM MRS BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.464S SUP Custom 27803010 632.464S - PORT RTRCT STRG 26MM 40MM MRS BOTH IP/OP "$1,167.50 " $863.95 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $866.52 $866.52 $0.00 $0.00 $243.31 $0.00 $0.00 $0.00 $0.00 $583.75 $924.66 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.465S SUP Custom 27803010 632.465S - PORT RTRCT STRG 26MM 50MM MRS BOTH IP/OP "$1,167.50 " $863.95 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $866.52 $866.52 $0.00 $0.00 $243.31 $0.00 $0.00 $0.00 $0.00 $583.75 $924.66 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.466S SUP Custom 27803010 632.466S - PORT RTRCT STRG 26MM 60MM MRS BOTH IP/OP "$1,167.50 " $863.95 $0.00 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $866.52 $866.52 $0.00 $0.00 $243.31 $0.00 $0.00 $0.00 $0.00 $583.75 $924.66 $934.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.467S SUP Custom 27803010 632.467S - PORT RTRCT STRG 26MM 70MM MRS BOTH IP/OP "$1,307.50 " $967.55 $0.00 "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.43 $970.43 $0.00 $0.00 $272.48 $0.00 $0.00 $0.00 $0.00 $653.75 "$1,035.54" "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.468S SUP Custom 27803010 632.468S - PORT RTRCT STRG 26MM 80MM STRL MRS SPNE BOTH IP/OP "$1,307.50 " $967.55 $0.00 "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.43 $970.43 $0.00 $0.00 $272.48 $0.00 $0.00 $0.00 $0.00 $653.75 "$1,035.54" "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.469S SUP Custom 27803010 632.469S - PORT RTRCT STRG 26MM 90MM MRS BOTH IP/OP "$1,307.50 " $967.55 $0.00 "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.43 $970.43 $0.00 $0.00 $272.48 $0.00 $0.00 $0.00 $0.00 $653.75 "$1,035.54" "$1,046.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.470S SUP Custom 27803010 632.470S - PORT RTRCT STRG 26MM 100MM MRS BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.471S SUP Custom 27803010 632.471S - PORT RTRCT STRG 26MM 110MM MRS BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 632.472S SUP Custom 27803010 632.472S - PORT RTRCT STRG 26MM 120MM MRS BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 633-350 SUP HCPCS C1884 COIL EMBL 6MM TRFL PSH CMPLX SHP BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-062 SUP Custom 27803010 6352-5-062 - INSERT ACETAB 0D P2 46/48MM 28MM LINER CONGRUENT ROBUST LOCK BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-063 SUP Custom 27803010 6352-5-063 - INSERT ACETAB 0D 28MM LINER CONGRUENT ROBUST LOCK SYSTEM 12 BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-064 SUP Custom 27803010 6352-5-064 - INSERT ACETAB 0D 28MM LINER CONGRUENT ROBUST LOCK SYSTEM 12 BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-065 SUP Custom 27803010 6352-5-065 - INSERT ACETAB 0D 28MM LINER CONGRUENT ROBUST LOCK SYSTEM 12 BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-065300 SUP Custom 27803010 6352-5-065300 - INSERT ACETAB 28MM 0D XFIRE S12 BOTH IP/OP "$1,707.00 " "$1,263.18" $0.00 "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.94" "$1,266.94" $0.00 $0.00 $355.74 $0.00 $0.00 $0.00 $0.00 $853.50 "$1,351.94" "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-066 SUP Custom 27803010 6352-5-066 - INSERT ACETAB 0D 28MM LINER CONGRUENT ROBUST LOCK SYSTEM 12 BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-066300 SUP Custom 27803010 6352-5-066300 - INSERT ACETAB 28MM 0D XFIRE S12 BOTH IP/OP "$1,707.00 " "$1,263.18" $0.00 "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.94" "$1,266.94" $0.00 $0.00 $355.74 $0.00 $0.00 $0.00 $0.00 $853.50 "$1,351.94" "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-072 SUP Custom 27803010 6352-5-072 - INSERT ACETAB 0D P2 46/48MM 28MM 5MM LINER CONGRUENT ROBUST BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-073 SUP HCPCS C1776 6352-5-073 - INSERT ACTB 10D P3 50/52MM 28MM S12 LINR CNGR RBST LCK XFR BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" "$1,189.13" "$1,189.13" $0.00 $0.00 $0.00 $550.76 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 "$1,302.75" "$1,302.75" $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $413.55 $0.00 $0.00 $420.69 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-073300 SUP Custom 27803010 6352-5-073300 - INSERT ACETAB 28MM 10D XFIRE S12 BOTH IP/OP "$1,707.00 " "$1,263.18" $0.00 "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.94" "$1,266.94" $0.00 $0.00 $355.74 $0.00 $0.00 $0.00 $0.00 $853.50 "$1,351.94" "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-074 SUP HCPCS C1776 6352-5-074 - INSERT ACTB 10D P4 54/46MM 28MM S12 LINR CNGR RBST LCK XFR BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" "$1,189.13" "$1,189.13" $0.00 $0.00 $0.00 $550.76 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 "$1,302.75" "$1,302.75" $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $413.55 $0.00 $0.00 $420.69 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-074300 SUP Custom 27803010 6352-5-074300 - INSERT ACETAB 28MM 10D HIP XFIRE S12 BOTH IP/OP "$1,707.00 " "$1,263.18" $0.00 "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.94" "$1,266.94" $0.00 $0.00 $355.74 $0.00 $0.00 $0.00 $0.00 $853.50 "$1,351.94" "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-075 SUP Custom 27803010 6352-5-075 - INSERT ACETAB 10D P5 58/60MM 28MM LINER CONGRUENT ROBUST BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-076 SUP HCPCS C1776 6352-5-076 - INSERT ACTB 10D P6 62/64MM 28MM S12 LINR CNGR RBST LCK XFR BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" "$1,189.13" "$1,189.13" $0.00 $0.00 $0.00 $550.76 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 "$1,302.75" "$1,302.75" $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $413.55 $0.00 $0.00 $420.69 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-076300 SUP Custom 27803010 6352-5-076300 - INSERT ACETAB 28MM 10D XFIRE S12 BOTH IP/OP "$1,707.00 " "$1,263.18" $0.00 "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.94" "$1,266.94" $0.00 $0.00 $355.74 $0.00 $0.00 $0.00 $0.00 $853.50 "$1,351.94" "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-093 SUP Custom 27803010 6352-5-093 - INSERT ACETAB 0D P3 50/52MM 32MM LINER CONGRUENT ROBUST LOCK BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-094 SUP Custom 27803010 6352-5-094 - INSERT ACETAB 0D P4 54/46MM 32MM LINER CONGRUENT ROBUST LOCK BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-095 SUP Custom 27803010 6352-5-095 - INSERT ACETAB 0D P5 58/60MM 32MM 8MM LINER CONGRUENT ROBUST BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-096 SUP Custom 27803010 6352-5-096 - INSERT ACETAB 0D 32MM LINER CONGRUENT ROBUST LOCK SYSTEM 12 BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-097 SUP HCPCS C1776 6352-5-097 - INSERT ACTB 0D P7 32MM STRL S12 LINR CNGR RBST LCK XFR HIP BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" "$1,189.13" "$1,189.13" $0.00 $0.00 $0.00 $550.76 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 "$1,302.75" "$1,302.75" $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $413.55 $0.00 $0.00 $420.69 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-097300 SUP Custom 27803010 6352-5-097300 - INSERT ACETAB 32MM 0D HIP XFIRE S12 BOTH IP/OP "$1,707.00 " "$1,263.18" $0.00 "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.94" "$1,266.94" $0.00 $0.00 $355.74 $0.00 $0.00 $0.00 $0.00 $853.50 "$1,351.94" "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-098 SUP HCPCS C1776 6352-5-098 - INSERT ACTB 0D P8 70/72MM 32MM S12 LINR CNGR XFR HIP BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" "$1,189.13" "$1,189.13" $0.00 $0.00 $0.00 $550.76 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 "$1,302.75" "$1,302.75" $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $413.55 $0.00 $0.00 $420.69 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-098300 SUP Custom 27803010 6352-5-098300 - INSERT ACETAB 32MM 0D P8 HIP XFIRE S12 BOTH IP/OP "$1,707.00 " "$1,263.18" $0.00 "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,266.94" "$1,266.94" $0.00 $0.00 $355.74 $0.00 $0.00 $0.00 $0.00 $853.50 "$1,351.94" "$1,365.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-103 SUP Custom 27803010 6352-5-103 - INSERT ACETAB 10D P3 50/52MM 32MM LINER CONGRUENT ROBUST BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-104 SUP Custom 27803010 6352-5-104 - INSERT ACETAB 10D 32MM LINER CONGRUENT ROBUST LOCK SYSTEM 12 BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-105 SUP Custom 27803010 6352-5-105 - INSERT ACETAB 10D P5 58/60MM 32MM LINER CONGRUENT ROBUST BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-106 SUP Custom 27803010 6352-5-106 - INSERT ACETAB 10D P6 62/64MM 32MM LINER CONGRUENT ROBUST BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-107 SUP Custom 27803010 6352-5-107 - INSERT ACETAB 10D 32MM LINER CONGRUENT ROBUST LOCK SYSTEM 12 BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6352-5-108 SUP Custom 27803010 6352-5-108 - INSERT ACETAB 10D P8 70/72MM 32MM LINER CONGRUENT ROBUST BOTH IP/OP "$2,642.50 " "$1,955.45" $0.00 "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.26" "$1,961.26" $0.00 $0.00 $550.70 $0.00 $0.00 $0.00 $0.00 "$1,321.25" "$2,092.86" "$2,114.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-026 SUP Custom 27803010 6364-2-026 - HEAD FEMORAL -3MM 26MM NECK V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-028 SUP Custom 27803010 6364-2-028 - HEAD FEMORAL -4MM 28MM NECK V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-032 SUP Custom 27803010 6364-2-032 - HEAD FEMORAL -4MM 32MM TAPER V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-036 SUP Custom 27803010 6364-2-036 - HEAD FEMORAL -5MM 36MM TAPER V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-122 SUP Custom 27803010 6364-2-122 - HEAD FEMORAL 0MM 22MM V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-126 SUP Custom 27803010 6364-2-126 - HEAD FEMORAL 0MM 26MM TAPER V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-128 SUP Custom 27803010 6364-2-128 - HEAD FEMORAL 0MM 28MM TAPER V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-132 SUP Custom 27803010 6364-2-132 - HEAD FEMORAL 0MM 32MM TAPER V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-136 SUP Custom 27803010 6364-2-136 - HEAD FEMORAL 0MM 36MM V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-226 SUP Custom 27803010 6364-2-226 - HEAD FEMORAL +4MM 26MM NECK V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-228 SUP Custom 27803010 6364-2-228 - HEAD FEMORAL +4MM 28MM TAPER V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-232 SUP Custom 27803010 6364-2-232 - HEAD FEMORAL +4MM TAPER 32MM V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-236 SUP Custom 27803010 6364-2-236 - HEAD FEMORAL +5MM 36MM TAPER V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-322 SUP Custom 27803010 6364-2-322 - HEAD FEMORAL +8MM 22MM V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-326 SUP Custom 27803010 6364-2-326 - HEAD FEMORAL +8MM 26MM NECK V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-328 SUP Custom 27803010 6364-2-328 - HEAD FEMORAL +8MM 28MM V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6364-2-332 SUP Custom 27803010 6364-2-332 - HEAD FEMORAL +8MM 32MM EXETER V40 ORTHINOX HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6366-9-220 SUP HCPCS C1776 6366-9-220 - GUIDE PIN ORTH HMRS AXIS BOTH IP/OP "$2,030.00 " "$1,502.20" $0.00 "$1,624.00" $913.50 $913.50 $0.00 $0.00 $0.00 $423.10 "$1,506.67" "$1,506.67" $0.00 $0.00 $423.05 $0.00 "$1,200.75" "$1,200.75" $0.00 "$1,015.00" "$1,607.76" "$1,624.00" $0.00 $0.00 $317.70 $0.00 $0.00 $323.18 $0.00 $0.00 $0.00 $0.00 $0.00 640301S SUP HCPCS C1713 640301S - SCREW BONE T2 STD CMPR STRL BOTH IP/OP $189.75 $140.42 $0.00 $151.80 $85.39 $85.39 $0.00 $0.00 $0.00 $39.55 $140.83 $140.83 $0.00 $0.00 $39.54 $0.00 $112.24 $112.24 $0.00 $94.88 $150.28 $151.80 $0.00 $0.00 $29.70 $0.00 $0.00 $30.21 $0.00 $0.00 $0.00 $0.00 $0.00 640302S SUP HCPCS C1713 640302S - SCREW BONE T2 2 SPNL CMPR STRL BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $89.72 $89.72 $0.00 $0.00 $0.00 $41.55 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $117.93 $117.93 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $31.20 $0.00 $0.00 $31.74 $0.00 $0.00 $0.00 $0.00 $0.00 640303S SUP HCPCS C1713 640303S - SCREW BONE T2 3 SPNL CMPR STRL BOTH IP/OP $170.50 $126.17 $0.00 $136.40 $76.73 $76.73 $0.00 $0.00 $0.00 $35.54 $126.55 $126.55 $0.00 $0.00 $35.53 $0.00 $100.85 $100.85 $0.00 $85.25 $135.04 $136.40 $0.00 $0.00 $26.68 $0.00 $0.00 $27.14 $0.00 $0.00 $0.00 $0.00 $0.00 640304S SUP HCPCS C1713 640304S - SCREW BONE T2 4 SPNL CMPR STRL BOTH IP/OP $170.50 $126.17 $0.00 $136.40 $76.73 $76.73 $0.00 $0.00 $0.00 $35.54 $126.55 $126.55 $0.00 $0.00 $35.53 $0.00 $100.85 $100.85 $0.00 $85.25 $135.04 $136.40 $0.00 $0.00 $26.68 $0.00 $0.00 $27.14 $0.00 $0.00 $0.00 $0.00 $0.00 640320S SUP HCPCS C1713 640320S - WASHER SCR T2 ORTH STRL BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $27.23 $27.23 $0.00 $0.00 $0.00 $12.61 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $35.79 $35.79 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $9.47 $0.00 $0.00 $9.63 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-28C SUP Custom 27803010 641-00-28C - INSERT ACETAB C 28MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-28D SUP Custom 27803010 641-00-28D - INSERT ACETAB D 28MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-28E SUP Custom 27803010 641-00-28E - INSERT ACETAB E 28MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-28F SUP Custom 27803010 641-00-28F - INSERT ACETAB F 28MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-28G SUP Custom 27803010 641-00-28G - INSERT ACETAB G 28MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-28H SUP Custom 27803010 641-00-28H - INSERT ACETAB H 28MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-28I SUP Custom 27803010 641-00-28I - INSERT ACETAB I 28MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-28J SUP Custom 27803010 641-00-28J - INSERT ACETAB J 28MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-32E SUP Custom 27803010 641-00-32E - INSERT ACETAB 0D E 32MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-32F SUP Custom 27803010 641-00-32F - INSERT ACETAB F 32MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-32G SUP Custom 27803010 641-00-32G - INSERT ACETAB G 32MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-32H SUP Custom 27803010 641-00-32H - INSERT ACETAB H 32MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-32I SUP Custom 27803010 641-00-32I - INSERT ACETAB I 32MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-32J SUP Custom 27803010 641-00-32J - INSERT ACETAB J 32MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-36E SUP Custom 27803010 641-00-36E - INSERT ACETAB E 36MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-36F SUP Custom 27803010 641-00-36F - INSERT ACETAB F 36MM ELEVATED RIM TRIDENT X3 HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-36G SUP Custom 27803010 641-00-36G - INSERT ACETAB G 36MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-36H SUP Custom 27803010 641-00-36H - INSERT ACETAB H 36MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-36I SUP Custom 27803010 641-00-36I - INSERT ACETAB I 36MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 641-00-36J SUP Custom 27803010 641-00-36J - INSERT ACETAB J 36MM ELEVATED RIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 64122-06 SUP Custom 27203010 FIXATIVE B5 HISTOLGY BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6430-0-020 SUP Custom 27803010 6430-0-020 - COMPONENT PATLR SMALL 20MM AVON KNEE BOTH IP/OP "$2,170.00 " "$1,605.80" $0.00 "$1,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,610.57" "$1,610.57" $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 "$1,085.00" "$1,718.64" "$1,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6430-0-030 SUP Custom 27803010 6430-0-030 - COMPONENT PATLR MEDIUM 30MM AVON KNEE BOTH IP/OP "$2,170.00 " "$1,605.80" $0.00 "$1,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,610.57" "$1,610.57" $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 "$1,085.00" "$1,718.64" "$1,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6430-0-040 SUP Custom 27803010 6430-0-040 - COMPONENT PATLR LARGE 40MM AVON KNEE BOTH IP/OP "$2,170.00 " "$1,605.80" $0.00 "$1,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,610.57" "$1,610.57" $0.00 $0.00 $452.23 $0.00 $0.00 $0.00 $0.00 "$1,085.00" "$1,718.64" "$1,736.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6430-0-050 SUP HCPCS C1776 6430-0-050 - COMPONENT FEMORAL XS 50MM AVON KNEE BOTH IP/OP "$9,682.50 " "$7,165.05" $0.00 "$7,746.00" "$4,357.13" "$4,357.13" $0.00 $0.00 $0.00 "$2,018.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,017.83" $0.00 "$4,773.47" "$4,773.47" $0.00 "$4,841.25" "$7,668.54" "$7,746.00" $0.00 $0.00 "$1,515.31" $0.00 $0.00 "$1,541.45" $0.00 $0.00 $0.00 $0.00 $0.00 6430-0-100 SUP HCPCS C1776 6430-0-100 - COMPONENT FEMORAL SMALL AVON KNEE BOTH IP/OP "$9,682.50 " "$7,165.05" $0.00 "$7,746.00" "$4,357.13" "$4,357.13" $0.00 $0.00 $0.00 "$2,018.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,017.83" $0.00 "$4,773.47" "$4,773.47" $0.00 "$4,841.25" "$7,668.54" "$7,746.00" $0.00 $0.00 "$1,515.31" $0.00 $0.00 "$1,541.45" $0.00 $0.00 $0.00 $0.00 $0.00 6430-0-200 SUP HCPCS C1776 6430-0-200 - COMPONENT FEMORAL MEDIUM AVON KNEE BOTH IP/OP "$9,682.50 " "$7,165.05" $0.00 "$7,746.00" "$4,357.13" "$4,357.13" $0.00 $0.00 $0.00 "$2,018.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,017.83" $0.00 "$4,773.47" "$4,773.47" $0.00 "$4,841.25" "$7,668.54" "$7,746.00" $0.00 $0.00 "$1,515.31" $0.00 $0.00 "$1,541.45" $0.00 $0.00 $0.00 $0.00 $0.00 643-00-28C SUP Custom 27803010 643-00-28C - INSERT ACETAB C 28MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-28D SUP Custom 27803010 643-00-28D - INSERT ACETAB D 28MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-28E SUP Custom 27803010 643-00-28E - INSERT ACETAB E 28MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-28F SUP Custom 27803010 643-00-28F - INSERT ACETAB F 28MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-28G SUP Custom 27803010 643-00-28G - INSERT ACETAB G 28MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-28H SUP Custom 27803010 643-00-28H - INSERT ACETAB H 28MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-28I SUP Custom 27803010 643-00-28I - INSERT ACETAB I 28MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-28J SUP Custom 27803010 643-00-28J - INSERT ACETAB J 28MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6430-0-300 SUP HCPCS C1776 6430-0-300 - COMPONENT FEMORAL LARGE AVON KNEE BOTH IP/OP "$9,682.50 " "$7,165.05" $0.00 "$7,746.00" "$4,357.13" "$4,357.13" $0.00 $0.00 $0.00 "$2,018.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,017.83" $0.00 "$4,773.47" "$4,773.47" $0.00 "$4,841.25" "$7,668.54" "$7,746.00" $0.00 $0.00 "$1,515.31" $0.00 $0.00 "$1,541.45" $0.00 $0.00 $0.00 $0.00 $0.00 643-00-32E SUP Custom 27803010 643-00-32E - INSERT ACETAB E 32MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-32F SUP Custom 27803010 643-00-32F - INSERT ACETAB F 32MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-32G SUP Custom 27803010 643-00-32G - INSERT ACETAB G 32MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-32H SUP Custom 27803010 643-00-32H - INSERT ACETAB H 32MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-32I SUP Custom 27803010 643-00-32I - INSERT ACETAB I 32MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-32J SUP Custom 27803010 643-00-32J - INSERT ACETAB J 32MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,130.00 " "$2,316.20" $0.00 "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,323.09" "$2,323.09" $0.00 $0.00 $652.29 $0.00 $0.00 $0.00 $0.00 "$1,565.00" "$2,478.96" "$2,504.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-36E SUP Custom 27803010 643-00-36E - INSERT ACETAB E 36MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,345.00 " "$2,475.30" $0.00 "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,482.66" "$2,482.66" $0.00 $0.00 $697.10 $0.00 $0.00 $0.00 $0.00 "$1,672.50" "$2,649.24" "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-36F SUP Custom 27803010 643-00-36F - INSERT ACETAB F 36MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,345.00 " "$2,475.30" $0.00 "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,482.66" "$2,482.66" $0.00 $0.00 $697.10 $0.00 $0.00 $0.00 $0.00 "$1,672.50" "$2,649.24" "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-36G SUP Custom 27803010 643-00-36G - INSERT ACETAB G 36MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,345.00 " "$2,475.30" $0.00 "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,482.66" "$2,482.66" $0.00 $0.00 $697.10 $0.00 $0.00 $0.00 $0.00 "$1,672.50" "$2,649.24" "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-36H SUP Custom 27803010 643-00-36H - INSERT ACETAB H 36MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,345.00 " "$2,475.30" $0.00 "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,482.66" "$2,482.66" $0.00 $0.00 $697.10 $0.00 $0.00 $0.00 $0.00 "$1,672.50" "$2,649.24" "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-36I SUP Custom 27803010 643-00-36I - INSERT ACETAB I 36MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,345.00 " "$2,475.30" $0.00 "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,482.66" "$2,482.66" $0.00 $0.00 $697.10 $0.00 $0.00 $0.00 $0.00 "$1,672.50" "$2,649.24" "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 643-00-36J SUP Custom 27803010 643-00-36J - INSERT ACETAB J 36MM ELEVATE RIM TRIDENT X3 HIP BOTH IP/OP "$3,345.00 " "$2,475.30" $0.00 "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,482.66" "$2,482.66" $0.00 $0.00 $697.10 $0.00 $0.00 $0.00 $0.00 "$1,672.50" "$2,649.24" "$2,676.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-0-808 SUP Custom 27803010 6471-0-808 - INSERT TIB XS 8MM CNDYLR MDLR K-2 BOTH IP/OP "$2,192.13 " "$1,622.18" $0.00 "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,627.00" "$1,627.00" $0.00 $0.00 $456.84 $0.00 $0.00 $0.00 $0.00 "$1,096.06" "$1,736.17" "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-0-811 SUP Custom 27803010 6471-0-811 - INSERT TIB XS 11MM CNDYLR MDLR K-2 BOTH IP/OP "$2,192.13 " "$1,622.18" $0.00 "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,627.00" "$1,627.00" $0.00 $0.00 $456.84 $0.00 $0.00 $0.00 $0.00 "$1,096.06" "$1,736.17" "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-0-813 SUP Custom 27803010 6471-0-813 - INSERT TIB XS 13MM CNDYLR MDLR K-2 BOTH IP/OP "$2,192.13 " "$1,622.18" $0.00 "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,627.00" "$1,627.00" $0.00 $0.00 $456.84 $0.00 $0.00 $0.00 $0.00 "$1,096.06" "$1,736.17" "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-0-816 SUP Custom 27803010 6471-0-816 - INSERT TIB XS 16MM CNDYLR MDLR K-2 BOTH IP/OP "$2,192.13 " "$1,622.18" $0.00 "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,627.00" "$1,627.00" $0.00 $0.00 $456.84 $0.00 $0.00 $0.00 $0.00 "$1,096.06" "$1,736.17" "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-1-808 SUP Custom 27803010 6471-1-808 - INSERT TIB SM 8MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-1-811 SUP Custom 27803010 6471-1-811 - INSERT TIB SM 11MM CNDYLR MDLR K-2 BOTH IP/OP "$2,283.13 " "$1,689.52" $0.00 "$1,826.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.54" "$1,694.54" $0.00 $0.00 $475.80 $0.00 $0.00 $0.00 $0.00 "$1,141.56" "$1,808.24" "$1,826.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-1-813 SUP Custom 27803010 6471-1-813 - INSERT TIB SM 13MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-1-816 SUP Custom 27803010 6471-1-816 - INSERT TIB SM 16MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-3-808 SUP Custom 27803010 6471-3-808 - INSERT TIB MED 8MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-3-811 SUP Custom 27803010 6471-3-811 - INSERT TIB MED 11MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-3-813 SUP Custom 27803010 6471-3-813 - INSERT TIB MED 13MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-3-816 SUP Custom 27803010 6471-3-816 - INSERT TIB MED 16MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-5-808 SUP Custom 27803010 6471-5-808 - INSERT TIB LG 8MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-5-811 SUP Custom 27803010 6471-5-811 - INSERT TIB LG 11MM CNDYLR MDLR K-2 BOTH IP/OP "$2,283.13 " "$1,689.52" $0.00 "$1,826.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.54" "$1,694.54" $0.00 $0.00 $475.80 $0.00 $0.00 $0.00 $0.00 "$1,141.56" "$1,808.24" "$1,826.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-5-813 SUP Custom 27803010 6471-5-813 - INSERT TIB LG 13MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-5-816 SUP Custom 27803010 6471-5-816 - INSERT TIB LG 16MM CNDYLR MDLR K-2 BOTH IP/OP "$1,509.63 " "$1,117.13" $0.00 "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.44" "$1,120.44" $0.00 $0.00 $314.61 $0.00 $0.00 $0.00 $0.00 $754.81 "$1,195.63" "$1,207.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-6-808 SUP Custom 27803010 6471-6-808 - INSERT TIB XL 8MM CNDYLR KNEE MDLR K-2 BOTH IP/OP "$1,349.00 " $998.26 $0.00 "$1,079.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,001.23" "$1,001.23" $0.00 $0.00 $281.13 $0.00 $0.00 $0.00 $0.00 $674.50 "$1,068.41" "$1,079.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-6-811 SUP Custom 27803010 6471-6-811 - INSERT TIB XL 11MM CNDYLR MDLR K-2 BOTH IP/OP "$2,192.13 " "$1,622.18" $0.00 "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,627.00" "$1,627.00" $0.00 $0.00 $456.84 $0.00 $0.00 $0.00 $0.00 "$1,096.06" "$1,736.17" "$1,753.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-6-813 SUP Custom 27803010 6471-6-813 - INSERT TIB XL 13MM CNDYLR MDLR K-2 BOTH IP/OP "$1,349.00 " $998.26 $0.00 "$1,079.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,001.23" "$1,001.23" $0.00 $0.00 $281.13 $0.00 $0.00 $0.00 $0.00 $674.50 "$1,068.41" "$1,079.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6471-6-816 SUP Custom 27803010 6471-6-816 - INSERT TIB XL 16MM CNDYLR MDLR K-2 BOTH IP/OP "$1,116.00 " $825.84 $0.00 $892.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $828.30 $828.30 $0.00 $0.00 $232.57 $0.00 $0.00 $0.00 $0.00 $558.00 $883.87 $892.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-0-808 SUP Custom 27803010 6472-0-808 - INSERT TIB XS 8MM KNEE STAB MDLR BOTH IP/OP "$1,398.00 " "$1,034.52" $0.00 "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.60" "$1,037.60" $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $699.00 "$1,107.22" "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-0-813 SUP Custom 27803010 6472-0-813 - INSERT TIB XS 13MM KNEE STAB MDLR BOTH IP/OP "$1,398.00 " "$1,034.52" $0.00 "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.60" "$1,037.60" $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $699.00 "$1,107.22" "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-0-816 SUP Custom 27803010 6472-0-816 - INSERT TIB XS 16MM KNEE STAB MDLR BOTH IP/OP "$1,398.00 " "$1,034.52" $0.00 "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.60" "$1,037.60" $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $699.00 "$1,107.22" "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-1-808 SUP Custom 27803010 6472-1-808 - INSERT TIB SM 8MM KNEE STAB MDLR BOTH IP/OP "$1,398.00 " "$1,034.52" $0.00 "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.60" "$1,037.60" $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $699.00 "$1,107.22" "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-1-816 SUP Custom 27803010 6472-1-816 - INSERT TIB SM 16MM KNEE STAB MDLR BOTH IP/OP "$1,398.00 " "$1,034.52" $0.00 "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.60" "$1,037.60" $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $699.00 "$1,107.22" "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-6-808 SUP Custom 27803010 6472-6-808 - INSERT TIB XL 8MM KNEE STAB MDLR BOTH IP/OP "$1,456.00 " "$1,077.44" $0.00 "$1,164.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,080.64" "$1,080.64" $0.00 $0.00 $303.43 $0.00 $0.00 $0.00 $0.00 $728.00 "$1,153.15" "$1,164.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-6-811 SUP Custom 27803010 6472-6-811 - INSERT TIB XL 11MM KNEE STAB MDLR BOTH IP/OP "$1,456.00 " "$1,077.44" $0.00 "$1,164.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,080.64" "$1,080.64" $0.00 $0.00 $303.43 $0.00 $0.00 $0.00 $0.00 $728.00 "$1,153.15" "$1,164.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-6-813 SUP Custom 27803010 6472-6-813 - INSERT TIB XL 13MM KNEE STAB MDLR BOTH IP/OP "$1,456.00 " "$1,077.44" $0.00 "$1,164.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,080.64" "$1,080.64" $0.00 $0.00 $303.43 $0.00 $0.00 $0.00 $0.00 $728.00 "$1,153.15" "$1,164.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6472-6-816 SUP Custom 27803010 6472-6-816 - INSERT TIB XL 16MM KNEE STAB MDLR BOTH IP/OP "$1,398.00 " "$1,034.52" $0.00 "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,037.60" "$1,037.60" $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $699.00 "$1,107.22" "$1,118.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6475-3-933 SUP HCPCS C1776 6475-3-933 - BEARING TIBIAL LONG COMPRESSION ROTATE HINGE MRS MRH KNEE BOTH IP/OP "$5,895.00 " "$4,362.30" $0.00 "$4,716.00" "$2,652.75" "$2,652.75" $0.00 $0.00 $0.00 "$1,228.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,228.52" $0.00 "$2,906.24" "$2,906.24" $0.00 "$2,947.50" "$4,668.84" "$4,716.00" $0.00 $0.00 $922.57 $0.00 $0.00 $938.48 $0.00 $0.00 $0.00 $0.00 $0.00 6475-3-940 SUP Custom 27803010 6475-3-940 - AXLE FEMORAL STANDARD ROTATE HINGE MRS KINEMATIC KNEE BOTH IP/OP "$2,065.00 " "$1,528.10" $0.00 "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,532.64" "$1,532.64" $0.00 $0.00 $430.35 $0.00 $0.00 $0.00 $0.00 "$1,032.50" "$1,635.48" "$1,652.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-100 SUP Custom 27803010 6476-0-100 - WEDGE TIB 10MM KNMX PLUS XS FULL BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-110 SUP Custom 27203010 6476-0-110 - TRIAL SURG BLK 10MM KNMX XS LL/RM HALF BLOCK WDG BOTH IP/OP $776.00 $574.24 $0.00 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.95 $575.95 $0.00 $0.00 $161.72 $0.00 $0.00 $0.00 $0.00 $388.00 $614.59 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-120 SUP Custom 27803010 6476-0-120 - WEDGE TIB 10MM KX+ XS LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-130 SUP Custom 27803010 6476-0-130 - WEDGE TIB 5MM KX+ XS LL/RM BLOCK BOTH IP/OP $776.00 $574.24 $0.00 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.95 $575.95 $0.00 $0.00 $161.72 $0.00 $0.00 $0.00 $0.00 $388.00 $614.59 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-140 SUP Custom 27803010 6476-0-140 - WEDGE TIB 5MM KX+ XS LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $776.00 $574.24 $0.00 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.95 $575.95 $0.00 $0.00 $161.72 $0.00 $0.00 $0.00 $0.00 $388.00 $614.59 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-150 SUP Custom 27803010 6476-0-150 - WEDGE TIB KX+ XS LL/RM FULL ANG BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-160 SUP Custom 27803010 6476-0-160 - WEDGE TIB KX+ XS LEFT MDL RIGHT LAT FULL ANG BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-310 SUP Custom 27803010 6476-0-310 - BSPLT TIB KNMX K2 XS MDLR BOTH IP/OP "$2,274.00 " "$1,682.76" $0.00 "$1,819.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,687.76" "$1,687.76" $0.00 $0.00 $473.90 $0.00 $0.00 $0.00 $0.00 "$1,137.00" "$1,801.01" "$1,819.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-0-400 SUP Custom 27803010 6476-0-400 - BSPLT TIB KMX+ 4 XS KNEE BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-100 SUP Custom 27803010 6476-1-100 - WEDGE TIBIAL 10MM FULL BLOCK KINEMAX PLUS SMALL LEFT MEDIAL BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-110 SUP Custom 27803010 6476-1-110 - WEDGE TIB 10MM KX+ SM LL/RM BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-120 SUP Custom 27803010 6476-1-120 - WEDGE TIB 10MM KX+ SM LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-130 SUP Custom 27803010 6476-1-130 - WEDGE TIB 5MM KX+ SM LL/RM BLOCK BOTH IP/OP $673.00 $498.02 $0.00 $538.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.50 $499.50 $0.00 $0.00 $140.25 $0.00 $0.00 $0.00 $0.00 $336.50 $533.02 $538.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-140 SUP Custom 27803010 6476-1-140 - WEDGE TIB 5MM KX+ SM LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-150 SUP Custom 27803010 6476-1-150 - WEDGE TIB KX+ SM LL/RM FULL ANG BOTH IP/OP "$1,248.00 " $923.52 $0.00 $998.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $926.27 $926.27 $0.00 $0.00 $260.08 $0.00 $0.00 $0.00 $0.00 $624.00 $988.42 $998.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-160 SUP Custom 27803010 6476-1-160 - WEDGE TIB KX+ SM LEFT MDL RIGHT LAT FULL ANG BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-310 SUP Custom 27803010 6476-1-310 - BSPLT TIB KNMX SM REG KNEE STM BOTH IP/OP "$2,146.00 " "$1,588.04" $0.00 "$1,716.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,592.76" "$1,592.76" $0.00 $0.00 $447.23 $0.00 $0.00 $0.00 $0.00 "$1,073.00" "$1,699.63" "$1,716.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-1-400 SUP Custom 27803010 6476-1-400 - BASEPLATE TIBIAL SMALL KINEMAX PLUS KNEE BOTH IP/OP "$4,920.00 " "$3,640.80" $0.00 "$3,936.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,651.62" "$3,651.62" $0.00 $0.00 "$1,025.33" $0.00 $0.00 $0.00 $0.00 "$2,460.00" "$3,896.64" "$3,936.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-100 SUP Custom 27803010 6476-3-100 - WEDGE TIB 10MM KNMX PLUS MED FULL BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-110 SUP Custom 27803010 6476-3-110 - WEDGE TIB 10MM KX+ MED LL/RM BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-120 SUP Custom 27803010 6476-3-120 - WEDGE TIB 10MM KX+ MED LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-130 SUP Custom 27803010 6476-3-130 - WEDGE TIB 5MM KX+ MED LL/RM BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-140 SUP Custom 27803010 6476-3-140 - WEDGE TIB 5MM KX+ MED LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-150 SUP Custom 27803010 6476-3-150 - WEDGE TIB KX+ MED LL/RM FULL ANG BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-160 SUP Custom 27803010 6476-3-160 - WEDGE TIBIAL KINEMAX PLUS MEDIUM FULL ANGLE RIGHT MEDIAL BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-310 SUP Custom 27803010 6476-3-310 - BSPLT TIB KNMX K2 MED KNEE MDLR BOTH IP/OP "$2,146.00 " "$1,588.04" $0.00 "$1,716.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,592.76" "$1,592.76" $0.00 $0.00 $447.23 $0.00 $0.00 $0.00 $0.00 "$1,073.00" "$1,699.63" "$1,716.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-3-400 SUP Custom 27803010 6476-3-400 - BSPLT TIB KMX+ MED KNEE ASMBLY BOTH IP/OP "$2,996.00 " "$2,217.04" $0.00 "$2,396.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,223.63" "$2,223.63" $0.00 $0.00 $624.37 $0.00 $0.00 $0.00 $0.00 "$1,498.00" "$2,372.83" "$2,396.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-100 SUP Custom 27803010 6476-5-100 - WEDGE TIB 10MM KNMX PLUS LG FULL BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-110 SUP Custom 27803010 6476-5-110 - WEDGE TIB 10MM KX+ LG LL/RM BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-120 SUP Custom 27803010 6476-5-120 - WEDGE TIB 10MM KX+ LG LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $673.00 $498.02 $0.00 $538.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.50 $499.50 $0.00 $0.00 $140.25 $0.00 $0.00 $0.00 $0.00 $336.50 $533.02 $538.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-130 SUP Custom 27803010 6476-5-130 - WEDGE TIB 5MM KX+ LG LL/RM BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-140 SUP Custom 27803010 6476-5-140 - WEDGE TIB 5MM KX+ LG LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-150 SUP Custom 27803010 6476-5-150 - WEDGE TIB KX+ LG LL/RM FULL ANG BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-160 SUP Custom 27803010 6476-5-160 - WEDGE TIB KX+ LG LEFT MDL RIGHT LAT FULL ANG BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-310 SUP Custom 27803010 6476-5-310 - BSPLT TIB KNMX LG KNEE MODULLAR BOTH IP/OP "$2,146.00 " "$1,588.04" $0.00 "$1,716.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,592.76" "$1,592.76" $0.00 $0.00 $447.23 $0.00 $0.00 $0.00 $0.00 "$1,073.00" "$1,699.63" "$1,716.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-5-400 SUP Custom 27803010 6476-5-400 - BSPLT TIB KMX+ LG KNEE ASMBLY BOTH IP/OP "$2,996.00 " "$2,217.04" $0.00 "$2,396.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,223.63" "$2,223.63" $0.00 $0.00 $624.37 $0.00 $0.00 $0.00 $0.00 "$1,498.00" "$2,372.83" "$2,396.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-100 SUP Custom 27803010 6476-6-100 - WEDGE TIB 10MM KNMX PLUS XL FULL BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-110 SUP Custom 27803010 6476-6-110 - WEDGE TIB 10MM KX+ XL LL/RM BLOCK BOTH IP/OP $776.00 $574.24 $0.00 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.95 $575.95 $0.00 $0.00 $161.72 $0.00 $0.00 $0.00 $0.00 $388.00 $614.59 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-120 SUP Custom 27803010 6476-6-120 - WEDGE TIB 10MM KX+ XL LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $776.00 $574.24 $0.00 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.95 $575.95 $0.00 $0.00 $161.72 $0.00 $0.00 $0.00 $0.00 $388.00 $614.59 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-130 SUP Custom 27803010 6476-6-130 - WEDGE TIB 5MM KX+ XL LL/RM BLOCK BOTH IP/OP $776.00 $574.24 $0.00 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.95 $575.95 $0.00 $0.00 $161.72 $0.00 $0.00 $0.00 $0.00 $388.00 $614.59 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-140 SUP Custom 27803010 6476-6-140 - WEDGE TIB 5MM KX+ XL LEFT MDL RIGHT LAT BLOCK BOTH IP/OP $776.00 $574.24 $0.00 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.95 $575.95 $0.00 $0.00 $161.72 $0.00 $0.00 $0.00 $0.00 $388.00 $614.59 $620.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-150 SUP Custom 27803010 6476-6-150 - WEDGE TIB KX+ XL LL/RM FULL ANG BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-160 SUP Custom 27803010 6476-6-160 - WEDGE TIB KX+ XL LEFT MDL RIGHT LAT FULL ANG BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-310 SUP Custom 27803010 6476-6-310 - BSPLT TIB KNMX XL KNEE MDLR BOTH IP/OP "$2,274.00 " "$1,682.76" $0.00 "$1,819.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,687.76" "$1,687.76" $0.00 $0.00 $473.90 $0.00 $0.00 $0.00 $0.00 "$1,137.00" "$1,801.01" "$1,819.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-6-400 SUP Custom 27803010 6476-6-400 - BSPLT TIB KMX+ XL ORTH ASMBLY BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 $0.00 $0.00 $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-170 SUP Custom 27803010 6476-8-170 - WEDGE TIB KMX+ FIX SCR BOTH IP/OP $103.00 $76.22 $0.00 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.45 $76.45 $0.00 $0.00 $21.47 $0.00 $0.00 $0.00 $0.00 $51.50 $81.58 $82.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-180 SUP Custom 27803010 6476-8-180 - WEDGE TIB 15MM KNMX PLUS FIX PG BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.80 $161.80 $0.00 $0.00 $45.43 $0.00 $0.00 $0.00 $0.00 $109.00 $172.66 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-242 SUP Custom 27803010 6476-8-242 - STEM FEM 40MM CMNT COCR XS FEM/TIB KNEE BOTH IP/OP "$1,839.50 " "$1,361.23" $0.00 "$1,471.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,365.28" "$1,365.28" $0.00 $0.00 $383.35 $0.00 $0.00 $0.00 $0.00 $919.75 "$1,456.88" "$1,471.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-244 SUP Custom 27803010 6476-8-244 - STEM FEM 80MM CMNT COCR XS TIB KNEE BOTH IP/OP "$1,839.50 " "$1,361.23" $0.00 "$1,471.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,365.28" "$1,365.28" $0.00 $0.00 $383.35 $0.00 $0.00 $0.00 $0.00 $919.75 "$1,456.88" "$1,471.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-246 SUP Custom 27803010 6476-8-246 - STEM FEM 155MM CMNT COCR XS TIB KNEE BOTH IP/OP "$1,860.63 " "$1,376.87" $0.00 "$1,488.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,380.96" "$1,380.96" $0.00 $0.00 $387.75 $0.00 $0.00 $0.00 $0.00 $930.31 "$1,473.62" "$1,488.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-250 SUP Custom 27803010 6476-8-250 - EXTENSION STEM XS 40MM CEMENTED KINEMAX COCR KNEE FEMORAL BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-260 SUP Custom 27803010 6476-8-260 - STEM FEMORAL 80MM CEMENT KINEMAX COCR KNEE BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-270 SUP Custom 27803010 6476-8-270 - EXTENSION STEM XS 155MM CEMENTED KINEMAX COCR KNEE FEMORAL BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-315 SUP Custom 27803010 6476-8-315 - WEDGE TIB KMX+ LG BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6476-8-320 SUP Custom 27803010 6476-8-320 - WEDGE TIB KMX+ XL BOTH IP/OP $808.00 $597.92 $0.00 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.70 $599.70 $0.00 $0.00 $168.39 $0.00 $0.00 $0.00 $0.00 $404.00 $639.94 $646.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-020 SUP Custom 27803010 6478-6-020 - INSERT TIB 20MM KNEE PEG KMX+ BOTH IP/OP $446.00 $330.04 $0.00 $356.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.02 $331.02 $0.00 $0.00 $92.95 $0.00 $0.00 $0.00 $0.00 $223.00 $353.23 $356.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-100 SUP Custom 27803010 6478-6-100 - WEDGE TIB KNMX PLUS SM XS SS BOTH IP/OP $687.00 $508.38 $0.00 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.89 $509.89 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $0.00 $343.50 $544.10 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-110 SUP Custom 27803010 6478-6-110 - WEDGE TIB SM KNEE SS MDLR PLUS KX BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-120 SUP Custom 27803010 6478-6-120 - WEDGE TIB KNMX L+ MED KNEE SS WDG SUP STAB BOTH IP/OP $687.00 $508.38 $0.00 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.89 $509.89 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $0.00 $343.50 $544.10 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-395 SUP Custom 27803010 6478-6-395 - EXTENSION STEM 10MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-396 SUP Custom 27803010 6478-6-396 - EXTENSION STEM 11MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-397 SUP Custom 27803010 6478-6-397 - EXTENSION STEM 12MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-398 SUP Custom 27803010 6478-6-398 - TRIAL KNEE 13MM 80MM 1 AXIS PRESS FIT CEMENTED STEM EXTN BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-399 SUP Custom 27803010 6478-6-399 - EXTENSION STEM 14MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-400 SUP Custom 27803010 6478-6-400 - TRIAL KNEE 15MM 80MM 1 AXIS PRESS FIT CEMENTED STEM EXTN BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-405 SUP Custom 27803010 6478-6-405 - EXTENSION STEM 16MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-410 SUP Custom 27803010 6478-6-410 - EXTENSION STEM 17MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-415 SUP Custom 27803010 6478-6-415 - EXTENSION STEM 18MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-420 SUP Custom 27803010 6478-6-420 - EXTENSION STEM 19MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-425 SUP Custom 27803010 6478-6-425 - EXTENSION STEM 21MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-430 SUP Custom 27803010 6478-6-430 - EXTENSION STEM 23MM 80MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-435 SUP Custom 27803010 6478-6-435 - EXTENSION STEM 10MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-436 SUP Custom 27803010 6478-6-436 - EXTENSION STEM 11MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-437 SUP Custom 27803010 6478-6-437 - TRIAL KNEE 12MM 155MM 1 AXIS PRESS FIT CEMENTED STEM EXTN BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-438 SUP Custom 27803010 6478-6-438 - EXTENSION STEM 13MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-439 SUP Custom 27803010 6478-6-439 - EXTENSION STEM 14MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-440 SUP Custom 27803010 6478-6-440 - EXTENSION STEM 15MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-445 SUP Custom 27803010 6478-6-445 - EXTENSION STEM 16MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-450 SUP Custom 27803010 6478-6-450 - EXTENSION STEM 17MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-455 SUP Custom 27803010 6478-6-455 - EXTENSION STEM 18MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-460 SUP Custom 27803010 6478-6-460 - EXTENSION STEM 19MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-465 SUP Custom 27803010 6478-6-465 - EXTENSION STEM 21MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-470 SUP Custom 27803010 6478-6-470 - EXTENSION STEM 23MM 155MM 1 AXIS PRESS FIT CEMENTED SCORPIO BOTH IP/OP "$1,915.00 " "$1,417.10" $0.00 "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.31" "$1,421.31" $0.00 $0.00 $399.09 $0.00 $0.00 $0.00 $0.00 $957.50 "$1,516.68" "$1,532.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-490 SUP Custom 27803010 6478-6-490 - ADAPTER STEM 4MM OFFST JAM NUT SCORPIO KNEE BOTH IP/OP "$2,220.00 " "$1,642.80" $0.00 "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,647.68" "$1,647.68" $0.00 $0.00 $462.65 $0.00 $0.00 $0.00 $0.00 "$1,110.00" "$1,758.24" "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-495 SUP Custom 27803010 6478-6-495 - ADAPTER STM 6MM OFST SCRP JAM NUT TIB 1 AXIS KN SYS BOTH IP/OP "$2,220.00 " "$1,642.80" $0.00 "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,647.68" "$1,647.68" $0.00 $0.00 $462.65 $0.00 $0.00 $0.00 $0.00 "$1,110.00" "$1,758.24" "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-500 SUP Custom 27803010 6478-6-500 - ADAPTER STM 8MM OFST SCRP JAM NUT TIB 1 AXIS KN SYS BOTH IP/OP "$2,220.00 " "$1,642.80" $0.00 "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,647.68" "$1,647.68" $0.00 $0.00 $462.65 $0.00 $0.00 $0.00 $0.00 "$1,110.00" "$1,758.24" "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-585 SUP Custom 27803010 6478-6-585 - ADAPTER STM 2MM OFST SCRP JAM NUT FEM 1 AXIS KN SYS BOTH IP/OP "$2,220.00 " "$1,642.80" $0.00 "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,647.68" "$1,647.68" $0.00 $0.00 $462.65 $0.00 $0.00 $0.00 $0.00 "$1,110.00" "$1,758.24" "$1,776.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-600 SUP Custom 27803010 6478-6-600 - STEM TIBIAL FLUTE 10MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-605 SUP Custom 27803010 6478-6-605 - STEM TIBIAL FLUTE 11MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-610 SUP Custom 27803010 6478-6-610 - STEM TIBIAL FLUTE 12MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-615 SUP Custom 27803010 6478-6-615 - STEM TIBIAL FLUTE 13MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-620 SUP Custom 27803010 6478-6-620 - STEM TIBIAL FLUTE 14MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-625 SUP Custom 27803010 6478-6-625 - STEM TIBIAL FLUTE 15MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-630 SUP Custom 27803010 6478-6-630 - STEM TIBIAL FLUTE 16MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-635 SUP Custom 27803010 6478-6-635 - STEM TIBIAL FLUTE 17MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-640 SUP Custom 27803010 6478-6-640 - STEM TIBIAL FLUTE 18MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-645 SUP Custom 27803010 6478-6-645 - STEM TIBIAL FLUTE 19MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-655 SUP Custom 27803010 6478-6-655 - STEM TIBIAL FLUTE 21MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-665 SUP Custom 27803010 6478-6-665 - STEM TIBIAL FLUTE 23MM 80MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-680 SUP Custom 27803010 6478-6-680 - STEM TIBIAL FLUTE 10MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-685 SUP Custom 27803010 6478-6-685 - STEM TIBIAL FLUTE 11MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-690 SUP Custom 27803010 6478-6-690 - STEM TIBIAL FLUTE 12MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-695 SUP Custom 27803010 6478-6-695 - STEM TIBIAL FLUTE 13MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-705 SUP Custom 27803010 6478-6-705 - STEM TIBIAL FLUTE 14MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-710 SUP Custom 27803010 6478-6-710 - STEM TIBIAL FLUTE 15MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-715 SUP Custom 27803010 6478-6-715 - STEM TIBIAL FLUTE 16MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-720 SUP Custom 27803010 6478-6-720 - STEM TIBIAL FLUTE 17MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-725 SUP Custom 27803010 6478-6-725 - STEM TIBIAL FLUTE 18MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-730 SUP Custom 27803010 6478-6-730 - STEM TIBIAL FLUTE 19MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-740 SUP Custom 27803010 6478-6-740 - STEM TIBIAL FLUTE 21MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6478-6-750 SUP Custom 27803010 6478-6-750 - STEM TIBIAL FLUTE 23MM 115MM GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$2,342.50 " "$1,733.45" $0.00 "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,738.60" "$1,738.60" $0.00 $0.00 $488.18 $0.00 $0.00 $0.00 $0.00 "$1,171.25" "$1,855.26" "$1,874.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-0-050 SUP HCPCS C1776 6479-0-050 - CMPNT FEM XS CNDYLR KMX+ NPOR BOTH IP/OP "$3,596.00 " "$2,661.04" $0.00 "$2,876.80" "$1,618.20" "$1,618.20" $0.00 $0.00 $0.00 $749.50 "$2,668.95" "$2,668.95" $0.00 $0.00 $749.41 $0.00 "$1,772.83" "$1,772.83" $0.00 "$1,798.00" "$2,848.03" "$2,876.80" $0.00 $0.00 $562.77 $0.00 $0.00 $572.48 $0.00 $0.00 $0.00 $0.00 $0.00 6479-0-100 SUP HCPCS C1776 6479-0-100 - CMPNT FEM SM CNDYLR KMX+ NPOR BOTH IP/OP "$3,467.00 " "$2,565.58" $0.00 "$2,773.60" "$1,560.15" "$1,560.15" $0.00 $0.00 $0.00 $722.61 "$2,573.21" "$2,573.21" $0.00 $0.00 $722.52 $0.00 "$1,709.23" "$1,709.23" $0.00 "$1,733.50" "$2,745.86" "$2,773.60" $0.00 $0.00 $542.59 $0.00 $0.00 $551.95 $0.00 $0.00 $0.00 $0.00 $0.00 6479-0-150 SUP HCPCS C1776 6479-0-150 - CMPNT FEM MED CNDYLR KMX+ NPOR BOTH IP/OP "$3,467.00 " "$2,565.58" $0.00 "$2,773.60" "$1,560.15" "$1,560.15" $0.00 $0.00 $0.00 $722.61 "$2,573.21" "$2,573.21" $0.00 $0.00 $722.52 $0.00 "$1,709.23" "$1,709.23" $0.00 "$1,733.50" "$2,745.86" "$2,773.60" $0.00 $0.00 $542.59 $0.00 $0.00 $551.95 $0.00 $0.00 $0.00 $0.00 $0.00 6479-0-200 SUP HCPCS C1776 6479-0-200 - CMPNT FEM LG CNDYLR KMX+ NPOR BOTH IP/OP "$3,467.00 " "$2,565.58" $0.00 "$2,773.60" "$1,560.15" "$1,560.15" $0.00 $0.00 $0.00 $722.61 "$2,573.21" "$2,573.21" $0.00 $0.00 $722.52 $0.00 "$1,709.23" "$1,709.23" $0.00 "$1,733.50" "$2,745.86" "$2,773.60" $0.00 $0.00 $542.59 $0.00 $0.00 $551.95 $0.00 $0.00 $0.00 $0.00 $0.00 6479-0-250 SUP HCPCS C1776 6479-0-250 - CMPNT FEM XL CNDYLR KMX+ NPOR BOTH IP/OP "$3,467.00 " "$2,565.58" $0.00 "$2,773.60" "$1,560.15" "$1,560.15" $0.00 $0.00 $0.00 $722.61 "$2,573.21" "$2,573.21" $0.00 $0.00 $722.52 $0.00 "$1,709.23" "$1,709.23" $0.00 "$1,733.50" "$2,745.86" "$2,773.60" $0.00 $0.00 $542.59 $0.00 $0.00 $551.95 $0.00 $0.00 $0.00 $0.00 $0.00 6479-0-300 SUP HCPCS C1776 6479-0-300 - CMPNT FEM 2XL CNDYLR KMX+ NPOR BOTH IP/OP "$3,596.00 " "$2,661.04" $0.00 "$2,876.80" "$1,618.20" "$1,618.20" $0.00 $0.00 $0.00 $749.50 "$2,668.95" "$2,668.95" $0.00 $0.00 $749.41 $0.00 "$1,772.83" "$1,772.83" $0.00 "$1,798.00" "$2,848.03" "$2,876.80" $0.00 $0.00 $562.77 $0.00 $0.00 $572.48 $0.00 $0.00 $0.00 $0.00 $0.00 6479-4-900 SUP Custom 27803010 6479-4-900 - CMPNT PATLR SM KMX+ DUR BOTH IP/OP "$1,133.00 " $838.42 $0.00 $906.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $840.91 $840.91 $0.00 $0.00 $236.12 $0.00 $0.00 $0.00 $0.00 $566.50 $897.34 $906.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-4-911 SUP Custom 27803010 6479-4-911 - CMPNT PATLR MED KMX+ DUR BOTH IP/OP "$1,133.00 " $838.42 $0.00 $906.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $840.91 $840.91 $0.00 $0.00 $236.12 $0.00 $0.00 $0.00 $0.00 $566.50 $897.34 $906.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-4-920 SUP Custom 27803010 6479-4-920 - INSERT TIB LG PTLR DUR KX+ BOTH IP/OP "$1,133.00 " $838.42 $0.00 $906.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $840.91 $840.91 $0.00 $0.00 $236.12 $0.00 $0.00 $0.00 $0.00 $566.50 $897.34 $906.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-008 SUP Custom 27803010 6479-5-008 - INSERT TIBIAL XS 65X41X8MM LATERAL STABILIZE CRUCIATE RETAIN BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-010 SUP Custom 27803010 6479-5-010 - INSERT TIBIAL XS 65X41X10MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-012 SUP Custom 27803010 6479-5-012 - INSERT TIBIAL XS 65X41X12MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-015 SUP Custom 27803010 6479-5-015 - INSERT TIBIAL XS 65X41X15MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-018 SUP Custom 27803010 6479-5-018 - INSERT TIBIAL XS 65X41X18MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-021 SUP Custom 27803010 6479-5-021 - INSERT TIBIAL XS 21MM LATERAL STABILIZED CRUC RET KINEMAX BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-025 SUP Custom 27803010 6479-5-025 - INSERT TIBIAL XS 65X41X25MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-108 SUP Custom 27803010 6479-5-108 - INSERT TIBIAL SMALL 8MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-110 SUP Custom 27803010 6479-5-110 - INSERT TIBIAL SMALL 10MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-112 SUP Custom 27803010 6479-5-112 - INSERT TIBIAL SMALL 12MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-115 SUP Custom 27803010 6479-5-115 - INSERT TIBIAL SMALL 15MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-118 SUP Custom 27803010 6479-5-118 - INSERT TIBIAL SMALL 71X44X18MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-121 SUP Custom 27803010 6479-5-121 - INSERT TIBIAL SMALL 21MM LATERAL STABILIZED CRUC RET KINEMAX BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-125 SUP Custom 27803010 6479-5-125 - INSERT TIBIAL SMALL 71X44X25MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-208 SUP Custom 27803010 6479-5-208 - INSERT TIBIAL MEDIUM 8MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-210 SUP Custom 27803010 6479-5-210 - INSERT TIBIAL MEDIUM 76X48X10MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-212 SUP Custom 27803010 6479-5-212 - INSERT TIBIAL MEDIUM 12MM LATERAL STABILIZED KINEMAX PLUS BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-215 SUP Custom 27803010 6479-5-215 - INSERT TIBIAL MEDIUM 15MM LATERAL STABILIZED KINEMAX PLUS BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-218 SUP Custom 27803010 6479-5-218 - INSERT TIBIAL MEDIUM 18MM LATERAL STABILIZED KINEMAX PLUS BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-221 SUP Custom 27803010 6479-5-221 - INSERT TIBIAL MEDIUM 76X48X21MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-225 SUP Custom 27803010 6479-5-225 - INSERT TIBIAL MEDIUM 76X48X25MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-308 SUP Custom 27803010 6479-5-308 - INSERT TIBIAL LARGE 8MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-310 SUP Custom 27803010 6479-5-310 - INSERT TIBIAL LARGE 81X51X10MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-312 SUP Custom 27803010 6479-5-312 - INSERT TIBIAL LARGE 12MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-315 SUP Custom 27803010 6479-5-315 - INSERT TIBIAL LARGE 81X51X15MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-318 SUP Custom 27803010 6479-5-318 - INSERT TIBIAL LARGE 81X51X18MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-321 SUP Custom 27803010 6479-5-321 - INSERT TIBIAL LARGE 81X51X21MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-325 SUP Custom 27803010 6479-5-325 - INSERT TIBIAL LARGE 81X51X25MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-408 SUP Custom 27803010 6479-5-408 - INSERT TIBIAL XL 86X54X8MM LATERAL STABILIZE CRUCIATE RETAIN BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-410 SUP Custom 27803010 6479-5-410 - INSERT TIBIAL XL 86X54X10MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-412 SUP Custom 27803010 6479-5-412 - INSERT TIBIAL XL 86X54X12MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-415 SUP Custom 27803010 6479-5-415 - INSERT TIBIAL XL 86X54X15MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-418 SUP Custom 27803010 6479-5-418 - INSERT TIBIAL XL 86X54X18MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-421 SUP Custom 27803010 6479-5-421 - INSERT TIBIAL XL 86X54X21MM LATERAL STABILIZE CRUCIATE BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-425 SUP Custom 27803010 6479-5-425 - INSERT TIBIAL XL 25MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,265.00 " "$1,676.10" $0.00 "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.08" "$1,681.08" $0.00 $0.00 $472.03 $0.00 $0.00 $0.00 $0.00 "$1,132.50" "$1,793.88" "$1,812.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-508 SUP Custom 27803010 6479-5-508 - INSERT TIBIAL XS 65X41X8MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-510 SUP Custom 27803010 6479-5-510 - INSERT TIBIAL XS 65X41X10MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-512 SUP Custom 27803010 6479-5-512 - INSERT TIBIAL XS 65X41X12MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-515 SUP Custom 27803010 6479-5-515 - INSERT TIBIAL XS 65X41X15MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-518 SUP Custom 27803010 6479-5-518 - INSERT TIBIAL XS 65X41X18MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-521 SUP Custom 27803010 6479-5-521 - INSERT TIBIAL XS 65X41X21MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-525 SUP Custom 27803010 6479-5-525 - INSERT TIBIAL XS 65X41X25MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-608 SUP Custom 27803010 6479-5-608 - INSERT TIBIAL SMALL 70X45X8MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-610 SUP Custom 27803010 6479-5-610 - INSERT TIBIAL SMALL 10MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-612 SUP Custom 27803010 6479-5-612 - INSERT TIBIAL SMALL 12MM LATERAL STABILIZED KINEMAX PLUS DUR BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-615 SUP Custom 27803010 6479-5-615 - INSERT TIBIAL SMALL 70X45X15MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-618 SUP Custom 27803010 6479-5-618 - INSERT TIBIAL SMALL 70X45X18MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-621 SUP Custom 27803010 6479-5-621 - INSERT TIBIAL SMALL 70X45X21MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-625 SUP Custom 27803010 6479-5-625 - INSERT TIBIAL SMALL 70X45X25MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-708 SUP Custom 27803010 6479-5-708 - INSERT TIBIAL MEDIUM 76X48X8MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-710 SUP Custom 27803010 6479-5-710 - INSERT TIBIAL MEDIUM 76X48X10MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-712 SUP Custom 27803010 6479-5-712 - INSERT TIBIAL MEDIUM 76X48X12MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-715 SUP Custom 27803010 6479-5-715 - INSERT TIBIAL MEDIUM 76X48X15MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-718 SUP Custom 27803010 6479-5-718 - INSERT TIBIAL MEDIUM 18MM LATERAL STABILIZED KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-721 SUP Custom 27803010 6479-5-721 - INSERT TIBIAL MEDIUM 76X48X21MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-725 SUP Custom 27803010 6479-5-725 - INSERT TIBIAL MEDIUM 76X48X25MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-808 SUP Custom 27803010 6479-5-808 - INSERT TIBIAL LARGE 81X51X8MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-810 SUP Custom 27803010 6479-5-810 - INSERT TIBIAL LARGE 81X51X10MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-812 SUP Custom 27803010 6479-5-812 - INSERT TIBIAL LARGE 81X51X12MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-815 SUP Custom 27803010 6479-5-815 - INSERT TIBIAL LARGE 81X51X15MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-818 SUP Custom 27803010 6479-5-818 - INSERT TIBIAL LARGE 81X51X18MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-821 SUP Custom 27803010 6479-5-821 - INSERT TIBIAL LARGE 81X51X21MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-825 SUP Custom 27803010 6479-5-825 - INSERT TIBIAL LARGE 81X51X25MM POSTERIOR STABILIZE KINEMAX BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-908 SUP Custom 27803010 6479-5-908 - INSERT TIBIAL XL 86X54X8MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-910 SUP Custom 27803010 6479-5-910 - INSERT TIBIAL XL 86X54X10MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-912 SUP Custom 27803010 6479-5-912 - INSERT TIBIAL XL 86X54X12MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-915 SUP Custom 27803010 6479-5-915 - INSERT TIBIAL XL 86X54X15MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-918 SUP Custom 27803010 6479-5-918 - INSERT TIBIAL XL 86X54X18MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-921 SUP Custom 27803010 6479-5-921 - INSERT TIBIAL XL 86X54X21MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6479-5-925 SUP Custom 27803010 6479-5-925 - INSERT TIBIAL XL 86X54X25MM POSTERIOR STABILIZE KINEMAX PLUS BOTH IP/OP "$2,347.50 " "$1,737.15" $0.00 "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,742.31" "$1,742.31" $0.00 $0.00 $489.22 $0.00 $0.00 $0.00 $0.00 "$1,173.75" "$1,859.22" "$1,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6480-0-050 SUP HCPCS C1776 6480-0-050 - COMPONENT FEMORAL XS STABILIZE KINEMAX PLUS KNEE BOTH IP/OP "$5,787.50 " "$4,282.75" $0.00 "$4,630.00" "$2,604.38" "$2,604.38" $0.00 $0.00 $0.00 "$1,206.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,206.12" $0.00 "$2,853.24" "$2,853.24" $0.00 "$2,893.75" "$4,583.70" "$4,630.00" $0.00 $0.00 $905.74 $0.00 $0.00 $921.37 $0.00 $0.00 $0.00 $0.00 $0.00 6480-0-100 SUP HCPCS C1776 6480-0-100 - COMPONENT FEMORAL SMALL STABILIZE KINEMAX PLUS KNEE BOTH IP/OP "$5,787.50 " "$4,282.75" $0.00 "$4,630.00" "$2,604.38" "$2,604.38" $0.00 $0.00 $0.00 "$1,206.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,206.12" $0.00 "$2,853.24" "$2,853.24" $0.00 "$2,893.75" "$4,583.70" "$4,630.00" $0.00 $0.00 $905.74 $0.00 $0.00 $921.37 $0.00 $0.00 $0.00 $0.00 $0.00 6480-0-150 SUP HCPCS C1776 6480-0-150 - COMPONENT FEMORAL MEDIUM STABILIZE KINEMAX PLUS KNEE BOTH IP/OP "$5,787.50 " "$4,282.75" $0.00 "$4,630.00" "$2,604.38" "$2,604.38" $0.00 $0.00 $0.00 "$1,206.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,206.12" $0.00 "$2,853.24" "$2,853.24" $0.00 "$2,893.75" "$4,583.70" "$4,630.00" $0.00 $0.00 $905.74 $0.00 $0.00 $921.37 $0.00 $0.00 $0.00 $0.00 $0.00 6480-0-200 SUP HCPCS C1776 6480-0-200 - COMPONENT FEMORAL LARGE STABILIZE KINEMAX PLUS KNEE BOTH IP/OP "$5,787.50 " "$4,282.75" $0.00 "$4,630.00" "$2,604.38" "$2,604.38" $0.00 $0.00 $0.00 "$1,206.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,206.12" $0.00 "$2,853.24" "$2,853.24" $0.00 "$2,893.75" "$4,583.70" "$4,630.00" $0.00 $0.00 $905.74 $0.00 $0.00 $921.37 $0.00 $0.00 $0.00 $0.00 $0.00 6480-0-250 SUP HCPCS C1776 6480-0-250 - COMPONENT FEMORAL XL STABILIZE KINEMAX PLUS KNEE BOTH IP/OP "$5,787.50 " "$4,282.75" $0.00 "$4,630.00" "$2,604.38" "$2,604.38" $0.00 $0.00 $0.00 "$1,206.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,206.12" $0.00 "$2,853.24" "$2,853.24" $0.00 "$2,893.75" "$4,583.70" "$4,630.00" $0.00 $0.00 $905.74 $0.00 $0.00 $921.37 $0.00 $0.00 $0.00 $0.00 $0.00 6480-0-300 SUP HCPCS C1776 6480-0-300 - COMPONENT FEMORAL 2XL STABILIZE KINEMAX PLUS KNEE BOTH IP/OP "$5,787.50 " "$4,282.75" $0.00 "$4,630.00" "$2,604.38" "$2,604.38" $0.00 $0.00 $0.00 "$1,206.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,206.12" $0.00 "$2,853.24" "$2,853.24" $0.00 "$2,893.75" "$4,583.70" "$4,630.00" $0.00 $0.00 $905.74 $0.00 $0.00 $921.37 $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-100 SUP HCPCS C1776 6481-1-100 - COMPONENT FEMORAL XS 60X54MM MODULAR ROTATE HINGE KNEE LEFT BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-101 SUP HCPCS C1776 6481-1-101 - COMPONENT FEMORAL XS 60X54MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-110 SUP HCPCS C1776 6481-1-110 - COMPONENT FEMORAL SMALL 65X55MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-111 SUP HCPCS C1776 6481-1-111 - COMPONENT FEMORAL SMALL 65X55MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-120 SUP HCPCS C1776 6481-1-120 - COMPONENT FEMORAL MEDIUM 70X61MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-121 SUP HCPCS C1776 6481-1-121 - COMPONENT FEMORAL MEDIUM 70X61MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-130 SUP HCPCS C1776 6481-1-130 - COMPONENT FEMORAL LARGE 75X64MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-131 SUP HCPCS C1776 6481-1-131 - COMPONENT FEMORAL LARGE 75X64MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-140 SUP HCPCS C1776 6481-1-140 - COMPONENT FEMORAL XL 80X66MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-141 SUP HCPCS C1776 6481-1-141 - COMPONENT FEMORAL XL 80X66MM MODULAR ROTATE HINGE GMRS BOTH IP/OP "$10,780.00 " "$7,977.20" $0.00 "$8,624.00" "$4,851.00" "$4,851.00" $0.00 $0.00 $0.00 "$2,246.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,246.55" $0.00 "$5,314.54" "$5,314.54" $0.00 "$5,390.00" "$8,537.76" "$8,624.00" $0.00 $0.00 "$1,687.07" $0.00 $0.00 "$1,716.18" $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-200 SUP Custom 27803010 6481-1-200 - BLOCK AUGMENTATION XS 10MM GMRS FEMORAL DISTAL BOTH IP/OP "$1,455.00 " "$1,076.70" $0.00 "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.90" "$1,079.90" $0.00 $0.00 $303.22 $0.00 $0.00 $0.00 $0.00 $727.50 "$1,152.36" "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-210 SUP Custom 27803010 6481-1-210 - BLOCK AUGMENTATION SMALL 10MM GMRS FEMORAL DISTAL BOTH IP/OP "$1,455.00 " "$1,076.70" $0.00 "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.90" "$1,079.90" $0.00 $0.00 $303.22 $0.00 $0.00 $0.00 $0.00 $727.50 "$1,152.36" "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-220 SUP Custom 27803010 6481-1-220 - BLOCK AUGMENTATION MEDIUM 10MM GMRS FEMORAL DISTAL BOTH IP/OP "$1,455.00 " "$1,076.70" $0.00 "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.90" "$1,079.90" $0.00 $0.00 $303.22 $0.00 $0.00 $0.00 $0.00 $727.50 "$1,152.36" "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-230 SUP Custom 27803010 6481-1-230 - BLOCK AUGMENTATION LARGE 10MM GMRS FEMORAL DISTAL BOTH IP/OP "$1,455.00 " "$1,076.70" $0.00 "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.90" "$1,079.90" $0.00 $0.00 $303.22 $0.00 $0.00 $0.00 $0.00 $727.50 "$1,152.36" "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-1-240 SUP Custom 27803010 6481-1-240 - BLOCK AUGMENTATION XL 10MM GMRS FEMORAL DISTAL BOTH IP/OP "$1,455.00 " "$1,076.70" $0.00 "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.90" "$1,079.90" $0.00 $0.00 $303.22 $0.00 $0.00 $0.00 $0.00 $727.50 "$1,152.36" "$1,164.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-100 SUP HCPCS C1776 6481-2-100 - COMPONENT TIB XS-XL MNGR MDLR ROT HNG KN BOTH IP/OP "$6,265.00 " "$4,636.10" $0.00 "$5,012.00" "$2,819.25" "$2,819.25" $0.00 $0.00 $0.00 "$1,305.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,305.63" $0.00 "$3,088.65" "$3,088.65" $0.00 "$3,132.50" "$4,961.88" "$5,012.00" $0.00 $0.00 $980.47 $0.00 $0.00 $997.39 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-101 SUP HCPCS C1776 6481-2-101 - COMPONENT TIBIAL LARGE XL MOBILE ROTATE HINGE MRS KNEE BOTH IP/OP "$6,265.00 " "$4,636.10" $0.00 "$5,012.00" "$2,819.25" "$2,819.25" $0.00 $0.00 $0.00 "$1,305.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,305.63" $0.00 "$3,088.65" "$3,088.65" $0.00 "$3,132.50" "$4,961.88" "$5,012.00" $0.00 $0.00 $980.47 $0.00 $0.00 $997.39 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-103 SUP HCPCS C1776 6481-2-103 - COMPONENT TIBIAL XS LONG XL BEARING CROSSOVER MODULAR ROTATE BOTH IP/OP "$6,265.00 " "$4,636.10" $0.00 "$5,012.00" "$2,819.25" "$2,819.25" $0.00 $0.00 $0.00 "$1,305.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,305.63" $0.00 "$3,088.65" "$3,088.65" $0.00 "$3,132.50" "$4,961.88" "$5,012.00" $0.00 $0.00 $980.47 $0.00 $0.00 $997.39 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-104 SUP HCPCS C1776 6481-2-104 - COMPONENT TIBIAL XS XL SHORT BEARING CROSSOVER MODULAR BOTH IP/OP "$6,265.00 " "$4,636.10" $0.00 "$5,012.00" "$2,819.25" "$2,819.25" $0.00 $0.00 $0.00 "$1,305.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,305.63" $0.00 "$3,088.65" "$3,088.65" $0.00 "$3,132.50" "$4,961.88" "$5,012.00" $0.00 $0.00 $980.47 $0.00 $0.00 $997.39 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-107 SUP HCPCS C1776 6481-2-107 - COMPONENT TIBIAL BEARING GMRS ALL POLY PEDIATRIC KNEE BOTH IP/OP "$5,752.50 " "$4,256.85" $0.00 "$4,602.00" "$2,588.63" "$2,588.63" $0.00 $0.00 $0.00 "$1,198.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.82" $0.00 "$2,835.98" "$2,835.98" $0.00 "$2,876.25" "$4,555.98" "$4,602.00" $0.00 $0.00 $900.27 $0.00 $0.00 $915.80 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-108 SUP HCPCS C1776 6481-2-108 - COMPONENT TIBIAL BEARING CROSSOVER MODULAR ROTATE HINGE MRS BOTH IP/OP "$6,265.00 " "$4,636.10" $0.00 "$5,012.00" "$2,819.25" "$2,819.25" $0.00 $0.00 $0.00 "$1,305.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,305.63" $0.00 "$3,088.65" "$3,088.65" $0.00 "$3,132.50" "$4,961.88" "$5,012.00" $0.00 $0.00 $980.47 $0.00 $0.00 $997.39 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-110 SUP Custom 27803010 6481-2-110 - BUSHING FEMORAL MODULAR ROTATE HINGE KNEE BOTH IP/OP $617.50 $456.95 $0.00 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $458.31 $458.31 $0.00 $0.00 $128.69 $0.00 $0.00 $0.00 $0.00 $308.75 $489.06 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-120 SUP Custom 27803010 6481-2-120 - AXLE FEMORAL MODULAR ROTATE HINGE KNEE BOTH IP/OP "$2,122.50 " "$1,570.65" $0.00 "$1,698.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,575.32" "$1,575.32" $0.00 $0.00 $442.33 $0.00 $0.00 $0.00 $0.00 "$1,061.25" "$1,681.02" "$1,698.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-130 SUP Custom 27803010 6481-2-130 - INSERT BUMPER NEUTRAL MODULAR ROTATE HINGE GMRS KNEE BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-133 SUP Custom 27803010 6481-2-133 - INSERT BUMPER 3D MODULAR ROTATE HINGE GMRS KNEE PROXIMAL BOTH IP/OP "$1,272.50 " $941.65 $0.00 "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $944.45 $944.45 $0.00 $0.00 $265.19 $0.00 $0.00 $0.00 $0.00 $636.25 "$1,007.82" "$1,018.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-140 SUP Custom 27203010 6481-2-140 - SLEEVE TIBIAL MODULAR ROTATE HINGE KNEE BOTH IP/OP "$1,065.00 " $788.10 $0.00 $852.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $790.44 $790.44 $0.00 $0.00 $221.95 $0.00 $0.00 $0.00 $0.00 $532.50 $843.48 $852.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-2-150 SUP HCPCS C1776 6481-2-150 - COMPONENT FEMORAL PACK CROSSLINK GMRS POLYETHYLENE KNEE BOTH IP/OP "$3,347.50 " "$2,477.15" $0.00 "$2,678.00" "$1,506.38" "$1,506.38" $0.00 $0.00 $0.00 $697.70 "$2,484.51" "$2,484.51" $0.00 $0.00 $697.62 $0.00 "$1,650.32" "$1,650.32" $0.00 "$1,673.75" "$2,651.22" "$2,678.00" $0.00 $0.00 $523.88 $0.00 $0.00 $532.92 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-110 SUP HCPCS C1776 6481-3-110 - BASEPLATE TIB 1 SM MDLR ROT HNG KN BOTH IP/OP "$6,730.00 " "$4,980.20" $0.00 "$5,384.00" "$3,028.50" "$3,028.50" $0.00 $0.00 $0.00 "$1,402.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,402.53" $0.00 "$3,317.89" "$3,317.89" $0.00 "$3,365.00" "$5,330.16" "$5,384.00" $0.00 $0.00 "$1,053.25" $0.00 $0.00 "$1,071.42" $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-111 SUP HCPCS C1776 6481-3-111 - BASEPLATE TIB 2 SM MDLR ROT HNG KN BOTH IP/OP "$6,730.00 " "$4,980.20" $0.00 "$5,384.00" "$3,028.50" "$3,028.50" $0.00 $0.00 $0.00 "$1,402.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,402.53" $0.00 "$3,317.89" "$3,317.89" $0.00 "$3,365.00" "$5,330.16" "$5,384.00" $0.00 $0.00 "$1,053.25" $0.00 $0.00 "$1,071.42" $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-112 SUP HCPCS C1776 6481-3-112 - BASEPLATE TIB 2 MED MDLR ROT HNG KN BOTH IP/OP "$6,730.00 " "$4,980.20" $0.00 "$5,384.00" "$3,028.50" "$3,028.50" $0.00 $0.00 $0.00 "$1,402.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,402.53" $0.00 "$3,317.89" "$3,317.89" $0.00 "$3,365.00" "$5,330.16" "$5,384.00" $0.00 $0.00 "$1,053.25" $0.00 $0.00 "$1,071.42" $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-113 SUP HCPCS C1776 6481-3-113 - BASEPLATE TIB 2 LG MDLR ROT HNG KN BOTH IP/OP "$6,730.00 " "$4,980.20" $0.00 "$5,384.00" "$3,028.50" "$3,028.50" $0.00 $0.00 $0.00 "$1,402.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,402.53" $0.00 "$3,317.89" "$3,317.89" $0.00 "$3,365.00" "$5,330.16" "$5,384.00" $0.00 $0.00 "$1,053.25" $0.00 $0.00 "$1,071.42" $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-210 SUP Custom 27803010 6481-3-210 - INSERT TIBIAL THK10MM S1 S2 MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-213 SUP Custom 27803010 6481-3-213 - INSERT TIBIAL THK13MM S1 S2 MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-216 SUP Custom 27803010 6481-3-216 - INSERT TIBIAL THK16MM S1 S2 MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-220 SUP Custom 27803010 6481-3-220 - INSERT TIBIAL THK20MM S1 S2 MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-224 SUP Custom 27803010 6481-3-224 - INSERT TIBIAL THK24MM S1 S2 MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-310 SUP Custom 27803010 6481-3-310 - INSERT TIBIAL MEDIUM LARGE M2 2 10MM BEARING MODULAR BOTH IP/OP "$2,387.50 " "$1,766.75" $0.00 "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,772.00" "$1,772.00" $0.00 $0.00 $497.56 $0.00 $0.00 $0.00 $0.00 "$1,193.75" "$1,890.90" "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-313 SUP Custom 27803010 6481-3-313 - INSERT TIBIAL THK13MM M2 2 BEARING MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,387.50 " "$1,766.75" $0.00 "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,772.00" "$1,772.00" $0.00 $0.00 $497.56 $0.00 $0.00 $0.00 $0.00 "$1,193.75" "$1,890.90" "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-316 SUP Custom 27803010 6481-3-316 - INSERT TIBIAL THK16MM M2 2 BEARING MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,387.50 " "$1,766.75" $0.00 "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,772.00" "$1,772.00" $0.00 $0.00 $497.56 $0.00 $0.00 $0.00 $0.00 "$1,193.75" "$1,890.90" "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-320 SUP Custom 27803010 6481-3-320 - INSERT TIBIAL THK20MM M2 2 BEARING MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,387.50 " "$1,766.75" $0.00 "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,772.00" "$1,772.00" $0.00 $0.00 $497.56 $0.00 $0.00 $0.00 $0.00 "$1,193.75" "$1,890.90" "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6481-3-324 SUP Custom 27803010 6481-3-324 - INSERT TIBIAL THK24MM M2 2 BEARING MODULAR ROTATE HINGE GMRS BOTH IP/OP "$2,387.50 " "$1,766.75" $0.00 "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,772.00" "$1,772.00" $0.00 $0.00 $497.56 $0.00 $0.00 $0.00 $0.00 "$1,193.75" "$1,890.90" "$1,910.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-020 SUP HCPCS C1776 6485-0-020 - CMPNT FEM CNDYLR RIGHT MDLR ROT HNG MRS BOTH IP/OP "$14,192.75 " "$10,502.64" $0.00 "$11,354.20" "$6,386.74" "$6,386.74" $0.00 $0.00 $0.00 "$2,958.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.77" $0.00 "$6,997.03" "$6,997.03" $0.00 "$7,096.38" "$11,240.66" "$11,354.20" $0.00 $0.00 "$2,221.17" $0.00 $0.00 "$2,259.49" $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-025 SUP HCPCS C1776 6485-0-025 - STEM FEM 75MM CNDYLR MRH MRS SM LEFT PRD BOTH IP/OP "$14,192.75 " "$10,502.64" $0.00 "$11,354.20" "$6,386.74" "$6,386.74" $0.00 $0.00 $0.00 "$2,958.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.77" $0.00 "$6,997.03" "$6,997.03" $0.00 "$7,096.38" "$11,240.66" "$11,354.20" $0.00 $0.00 "$2,221.17" $0.00 $0.00 "$2,259.49" $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-045 SUP HCPCS C1776 6485-0-045 - CMPNT FEM SM 85MM LEFT CNDYLR MRS BOTH IP/OP "$14,192.75 " "$10,502.64" $0.00 "$11,354.20" "$6,386.74" "$6,386.74" $0.00 $0.00 $0.00 "$2,958.12" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,957.77" $0.00 "$6,997.03" "$6,997.03" $0.00 "$7,096.38" "$11,240.66" "$11,354.20" $0.00 $0.00 "$2,221.17" $0.00 $0.00 "$2,259.49" $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-050 SUP HCPCS C1776 6485-0-050 - CMPNT FEM XS LEFT REV STAB KMX+ BOTH IP/OP "$5,216.00 " "$3,859.84" $0.00 "$4,172.80" "$2,347.20" "$2,347.20" $0.00 $0.00 $0.00 "$1,087.14" "$3,871.32" "$3,871.32" $0.00 $0.00 "$1,087.01" $0.00 "$2,571.49" "$2,571.49" $0.00 "$2,608.00" "$4,131.07" "$4,172.80" $0.00 $0.00 $816.30 $0.00 $0.00 $830.39 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-060 SUP HCPCS C1776 6485-0-060 - CMPNT FEM XS RIGHT REV STAB KNMX PLUS BOTH IP/OP "$5,189.00 " "$3,839.86" $0.00 "$4,151.20" "$2,335.05" "$2,335.05" $0.00 $0.00 $0.00 "$1,081.52" "$3,851.28" "$3,851.28" $0.00 $0.00 "$1,081.39" $0.00 "$2,558.18" "$2,558.18" $0.00 "$2,594.50" "$4,109.69" "$4,151.20" $0.00 $0.00 $812.08 $0.00 $0.00 $826.09 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-075 SUP HCPCS C1776 6485-0-075 - CMPNT FEM SM 95MM RIGHT CNDYLR MRS BOTH IP/OP "$10,856.63 " "$8,033.91" $0.00 "$8,685.30" "$4,885.48" "$4,885.48" $0.00 $0.00 $0.00 "$2,262.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,262.52" $0.00 "$5,352.32" "$5,352.32" $0.00 "$5,428.31" "$8,598.45" "$8,685.30" $0.00 $0.00 "$1,699.06" $0.00 $0.00 "$1,728.37" $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-100 SUP HCPCS C1776 6485-0-100 - CMPNT FEM SM LEFT REV STAB KMX+ BOTH IP/OP "$5,407.00 " "$4,001.18" $0.00 "$4,325.60" "$2,433.15" "$2,433.15" $0.00 $0.00 $0.00 "$1,126.95" "$4,013.08" "$4,013.08" $0.00 $0.00 "$1,126.82" $0.00 "$2,665.65" "$2,665.65" $0.00 "$2,703.50" "$4,282.34" "$4,325.60" $0.00 $0.00 $846.20 $0.00 $0.00 $860.79 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-110 SUP HCPCS C1776 6485-0-110 - CMPNT FEM SM RIGHT REV STAB KMX+ BOTH IP/OP "$5,189.00 " "$3,839.86" $0.00 "$4,151.20" "$2,335.05" "$2,335.05" $0.00 $0.00 $0.00 "$1,081.52" "$3,851.28" "$3,851.28" $0.00 $0.00 "$1,081.39" $0.00 "$2,558.18" "$2,558.18" $0.00 "$2,594.50" "$4,109.69" "$4,151.20" $0.00 $0.00 $812.08 $0.00 $0.00 $826.09 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-150 SUP HCPCS C1776 6485-0-150 - CMPNT FEM MED LEFT REV STAB KMX+ BOTH IP/OP "$5,407.00 " "$4,001.18" $0.00 "$4,325.60" "$2,433.15" "$2,433.15" $0.00 $0.00 $0.00 "$1,126.95" "$4,013.08" "$4,013.08" $0.00 $0.00 "$1,126.82" $0.00 "$2,665.65" "$2,665.65" $0.00 "$2,703.50" "$4,282.34" "$4,325.60" $0.00 $0.00 $846.20 $0.00 $0.00 $860.79 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-160 SUP HCPCS C1776 6485-0-160 - CMPNT FEM MED RIGHT REV STAB KMX+ BOTH IP/OP "$5,407.00 " "$4,001.18" $0.00 "$4,325.60" "$2,433.15" "$2,433.15" $0.00 $0.00 $0.00 "$1,126.95" "$4,013.08" "$4,013.08" $0.00 $0.00 "$1,126.82" $0.00 "$2,665.65" "$2,665.65" $0.00 "$2,703.50" "$4,282.34" "$4,325.60" $0.00 $0.00 $846.20 $0.00 $0.00 $860.79 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-200 SUP HCPCS C1776 6485-0-200 - CMPNT FEM LG LEFT REV STAB KMX+ BOTH IP/OP "$5,407.00 " "$4,001.18" $0.00 "$4,325.60" "$2,433.15" "$2,433.15" $0.00 $0.00 $0.00 "$1,126.95" "$4,013.08" "$4,013.08" $0.00 $0.00 "$1,126.82" $0.00 "$2,665.65" "$2,665.65" $0.00 "$2,703.50" "$4,282.34" "$4,325.60" $0.00 $0.00 $846.20 $0.00 $0.00 $860.79 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-210 SUP HCPCS C1776 6485-0-210 - CMPNT FEM LG RIGHT REV STAB KMX+ BOTH IP/OP "$5,407.00 " "$4,001.18" $0.00 "$4,325.60" "$2,433.15" "$2,433.15" $0.00 $0.00 $0.00 "$1,126.95" "$4,013.08" "$4,013.08" $0.00 $0.00 "$1,126.82" $0.00 "$2,665.65" "$2,665.65" $0.00 "$2,703.50" "$4,282.34" "$4,325.60" $0.00 $0.00 $846.20 $0.00 $0.00 $860.79 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-250 SUP HCPCS C1776 6485-0-250 - CMPNT FEM XL LEFT KNEE MDLR STABLILZED ASMBLY KMX+ LATEX BOTH IP/OP "$5,407.00 " "$4,001.18" $0.00 "$4,325.60" "$2,433.15" "$2,433.15" $0.00 $0.00 $0.00 "$1,126.95" "$4,013.08" "$4,013.08" $0.00 $0.00 "$1,126.82" $0.00 "$2,665.65" "$2,665.65" $0.00 "$2,703.50" "$4,282.34" "$4,325.60" $0.00 $0.00 $846.20 $0.00 $0.00 $860.79 $0.00 $0.00 $0.00 $0.00 $0.00 6485-0-260 SUP HCPCS C1776 6485-0-260 - CMPNT FEM XL RIGHT REV STAB KMX+ BOTH IP/OP "$4,552.00 " "$3,368.48" $0.00 "$3,641.60" "$2,048.40" "$2,048.40" $0.00 $0.00 $0.00 $948.75 "$3,378.49" "$3,378.49" $0.00 $0.00 $948.64 $0.00 "$2,244.14" "$2,244.14" $0.00 "$2,276.00" "$3,605.18" "$3,641.60" $0.00 $0.00 $712.39 $0.00 $0.00 $724.68 $0.00 $0.00 $0.00 $0.00 $0.00 6485-1-915 SUP Custom 27803010 6485-1-915 - COMPONENT PATLR SMALL ROTATE HINGE KRH DUR BOTH IP/OP "$1,705.00 " "$1,261.70" $0.00 "$1,364.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,265.45" "$1,265.45" $0.00 $0.00 $355.32 $0.00 $0.00 $0.00 $0.00 $852.50 "$1,350.36" "$1,364.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-008 SUP HCPCS C1776 6485-2-008 - INSERT TIBIAL XS 8MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-011 SUP HCPCS C1776 6485-2-011 - INSERT TIBIAL XS 11MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-016 SUP HCPCS C1776 6485-2-016 - INSERT TIBIAL XS 16MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-021 SUP HCPCS C1776 6485-2-021 - INSERT TIBIAL XS 21MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-108 SUP HCPCS C1776 6485-2-108 - INSERT TIBIAL SMALL 8MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-111 SUP HCPCS C1776 6485-2-111 - INSERT TIBIAL SMALL 11MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-116 SUP HCPCS C1776 6485-2-116 - INSERT TIBIAL SMALL 16MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-121 SUP HCPCS C1776 6485-2-121 - INSERT TIBIAL SMALL 21MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-208 SUP HCPCS C1776 6485-2-208 - INSERT TIBIAL MEDIUM 8MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-211 SUP HCPCS C1776 6485-2-211 - COMPONENT TIBIAL MEDIUM 11MM ROTATING HINGE KRH ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-216 SUP HCPCS C1776 6485-2-216 - INSERT TIBIAL MEDIUM 16MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-221 SUP HCPCS C1776 6485-2-221 - INSERT TIBIAL MEDIUM 21MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-308 SUP HCPCS C1776 6485-2-308 - INSERT TIBIAL LARGE 8MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-311 SUP HCPCS C1776 6485-2-311 - INSERT TIBIAL LARGE 11MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-316 SUP HCPCS C1776 6485-2-316 - INSERT TIBIAL LARGE 16MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-321 SUP HCPCS C1776 6485-2-321 - INSERT TIBIAL LARGE 21MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-408 SUP HCPCS C1776 6485-2-408 - INSERT TIBIAL XL 8MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-411 SUP HCPCS C1776 6485-2-411 - INSERT TIBIAL XL 11MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-416 SUP HCPCS C1776 6485-2-416 - INSERT TIBIAL XL 16MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-421 SUP HCPCS C1776 6485-2-421 - INSERT TIBIAL XL 21MM GMRS ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-460 SUP Custom 27803010 6485-2-460 - BUSHING FEMORAL STANDARD ROTATE HINGE KINEMATIC DUR BOTH IP/OP $632.50 $468.05 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.44 $469.44 $0.00 $0.00 $131.81 $0.00 $0.00 $0.00 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-465 SUP Custom 27803010 6485-2-465 - BUSHING FEMORAL SMALL ROTATE HINGE KINEMATIC DUR BOTH IP/OP $632.50 $468.05 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.44 $469.44 $0.00 $0.00 $131.81 $0.00 $0.00 $0.00 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-508 SUP HCPCS C1776 6485-2-508 - INSERT TIBIAL 3XS 8MM MRS POLYETHYLENE KNEE BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-511 SUP HCPCS C1776 6485-2-511 - COMPONENT TIBIAL 3XS PT1 11MM MRS MRH KRH DUR BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-608 SUP HCPCS C1776 6485-2-608 - INSERT TIBIAL 2XS 8MM MRS POLYETHYLENE KNEE BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-2-611 SUP HCPCS C1776 6485-2-611 - COMPONENT TIBIAL 2XS PT2 11MM KRH ALL POLY BOTH IP/OP "$3,142.50 " "$2,325.45" $0.00 "$2,514.00" "$1,414.13" "$1,414.13" $0.00 $0.00 $0.00 $654.98 "$2,332.36" "$2,332.36" $0.00 $0.00 $654.90 $0.00 "$1,549.25" "$1,549.25" $0.00 "$1,571.25" "$2,488.86" "$2,514.00" $0.00 $0.00 $491.80 $0.00 $0.00 $500.29 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-000 SUP HCPCS C1776 6485-3-000 - STEM FEMORAL SMALL 10MM 102MM MRS HIP BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-008 SUP HCPCS C1776 6485-3-008 - STEM FEMORAL SMALL 8MM 102MM MRS HIP BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-009 SUP HCPCS C1776 6485-3-009 - STEM FEMORAL SMALL 9MM 102MM MRS HIP BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-010 SUP HCPCS C1776 6485-3-010 - STEM FEMORAL SMALL 10MM 102MM MRS HIP BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-011 SUP HCPCS C1776 6485-3-011 - STEM FEMORAL STANDARD STR 11MM 127MM CEMENTED BODY SECTION BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-013 SUP HCPCS C1776 6485-3-013 - STEM FEMORAL STANDARD STR 13MM 127MM CEMENTED BODY SECTION BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-015 SUP HCPCS C1776 6485-3-015 - STEM FEMORAL STANDARD 15MM 127MM MODULAR ROTATE HINGE MRS BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-017 SUP HCPCS C1776 6485-3-017 - STEM FEMORAL 17MM 127MM CEMENTED BODY SECTION MRS HIP BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-018 SUP HCPCS C1776 6485-3-018 - STEM FEMORAL SMALL 8MM 102MM MRS HIP BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-019 SUP HCPCS C1776 6485-3-019 - STEM FEMORAL SMALL 9MM 102MM MRS HIP BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-111 SUP HCPCS C1776 6485-3-111 - STEM FEMORAL 11MM 127MM MRS KNEE BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-113 SUP HCPCS C1776 6485-3-113 - STEM FEMORAL STR 13MM 127MM CEMENTED BODY SECTION GMRS HIP BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-115 SUP HCPCS C1776 6485-3-115 - STEM FEMORAL STR 15MM 127MM CEMENTED BODY SECTION MRS KNEE BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-117 SUP HCPCS C1776 6485-3-117 - STEM FEMORAL 17MM 127MM MRS KNEE BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-211 SUP HCPCS C1776 6485-3-211 - STEM FEMORAL TAPER 11MM 127MM MRS HIP BOTH IP/OP "$5,275.00 " "$3,903.50" $0.00 "$4,220.00" "$2,373.75" "$2,373.75" $0.00 $0.00 $0.00 "$1,099.44" "$3,915.11" "$3,915.11" $0.00 $0.00 "$1,099.31" $0.00 "$2,600.58" "$2,600.58" $0.00 "$2,637.50" "$4,177.80" "$4,220.00" $0.00 $0.00 $825.54 $0.00 $0.00 $839.78 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-213 SUP HCPCS C1776 6485-3-213 - STEM FEMORAL TAPER 13MM 127MM MRS HIP BOTH IP/OP "$5,275.00 " "$3,903.50" $0.00 "$4,220.00" "$2,373.75" "$2,373.75" $0.00 $0.00 $0.00 "$1,099.44" "$3,915.11" "$3,915.11" $0.00 $0.00 "$1,099.31" $0.00 "$2,600.58" "$2,600.58" $0.00 "$2,637.50" "$4,177.80" "$4,220.00" $0.00 $0.00 $825.54 $0.00 $0.00 $839.78 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-215 SUP HCPCS C1776 6485-3-215 - STEM FEMORAL TAPER 15MM 127MM MRS HIP BOTH IP/OP "$5,275.00 " "$3,903.50" $0.00 "$4,220.00" "$2,373.75" "$2,373.75" $0.00 $0.00 $0.00 "$1,099.44" "$3,915.11" "$3,915.11" $0.00 $0.00 "$1,099.31" $0.00 "$2,600.58" "$2,600.58" $0.00 "$2,637.50" "$4,177.80" "$4,220.00" $0.00 $0.00 $825.54 $0.00 $0.00 $839.78 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-217 SUP HCPCS C1776 6485-3-217 - STEM FEMORAL TAPER 17MM 127MM MRS HIP BOTH IP/OP "$5,275.00 " "$3,903.50" $0.00 "$4,220.00" "$2,373.75" "$2,373.75" $0.00 $0.00 $0.00 "$1,099.44" "$3,915.11" "$3,915.11" $0.00 $0.00 "$1,099.31" $0.00 "$2,600.58" "$2,600.58" $0.00 "$2,637.50" "$4,177.80" "$4,220.00" $0.00 $0.00 $825.54 $0.00 $0.00 $839.78 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-300 SUP HCPCS C1776 6485-3-300 - STEM FEMORAL SMALL CURVE 10MM 102MM MRS HIP BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-308 SUP HCPCS C1776 6485-3-308 - STEM FEMORAL SMALL CURVE 8MM 102MM MRS HIP BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-309 SUP HCPCS C1776 6485-3-309 - STEM FEMORAL SMALL CURVE 9MM 102MM MRS HIP BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-310 SUP HCPCS C1776 6485-3-310 - STEM FEMORAL SMALL CURVE 10MM 102MM MRS KNEE BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-311 SUP HCPCS C1776 6485-3-311 - STEM FEMORAL 11MM 203MM MRS KNEE BOTH IP/OP "$10,430.00 " "$7,718.20" $0.00 "$8,344.00" "$4,693.50" "$4,693.50" $0.00 $0.00 $0.00 "$2,173.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,173.61" $0.00 "$5,141.99" "$5,141.99" $0.00 "$5,215.00" "$8,260.56" "$8,344.00" $0.00 $0.00 "$1,632.30" $0.00 $0.00 "$1,660.46" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-313 SUP HCPCS C1776 6485-3-313 - STEM FEMORAL LONG BOW 13MM 203MM CEMENTED BODY SECTION GMRS BOTH IP/OP "$10,430.00 " "$7,718.20" $0.00 "$8,344.00" "$4,693.50" "$4,693.50" $0.00 $0.00 $0.00 "$2,173.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,173.61" $0.00 "$5,141.99" "$5,141.99" $0.00 "$5,215.00" "$8,260.56" "$8,344.00" $0.00 $0.00 "$1,632.30" $0.00 $0.00 "$1,660.46" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-315 SUP HCPCS C1776 6485-3-315 - STEM FEMORAL LONG BOW 15MM 203MM CEMENTED BODY SECTION GMRS BOTH IP/OP "$10,430.00 " "$7,718.20" $0.00 "$8,344.00" "$4,693.50" "$4,693.50" $0.00 $0.00 $0.00 "$2,173.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,173.61" $0.00 "$5,141.99" "$5,141.99" $0.00 "$5,215.00" "$8,260.56" "$8,344.00" $0.00 $0.00 "$1,632.30" $0.00 $0.00 "$1,660.46" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-317 SUP HCPCS C1776 6485-3-317 - STEM FEMORAL 17MM 203MM MRS KNEE BOTH IP/OP "$10,430.00 " "$7,718.20" $0.00 "$8,344.00" "$4,693.50" "$4,693.50" $0.00 $0.00 $0.00 "$2,173.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,173.61" $0.00 "$5,141.99" "$5,141.99" $0.00 "$5,215.00" "$8,260.56" "$8,344.00" $0.00 $0.00 "$1,632.30" $0.00 $0.00 "$1,660.46" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-318 SUP HCPCS C1776 6485-3-318 - STEM FEMORAL SMALL CURVE 8MM 102MM MRS HIP BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-319 SUP HCPCS C1776 6485-3-319 - STEM FEMORAL SMALL CURVE 9MM 102MM MRS HIP BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-611 SUP HCPCS C1776 6485-3-611 - STEM FEMORAL LONG CURVE 11MM 203MM CEMENTED BODY SECTION BOTH IP/OP "$8,115.00 " "$6,005.10" $0.00 "$6,492.00" "$3,651.75" "$3,651.75" $0.00 $0.00 $0.00 "$1,691.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,691.17" $0.00 "$4,000.70" "$4,000.70" $0.00 "$4,057.50" "$6,427.08" "$6,492.00" $0.00 $0.00 "$1,270.00" $0.00 $0.00 "$1,291.91" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-613 SUP HCPCS C1776 6485-3-613 - STEM FEMORAL LONG CURVE 13MM 203MM CEMENT GMRS HIP DISTAL BOTH IP/OP "$8,115.00 " "$6,005.10" $0.00 "$6,492.00" "$3,651.75" "$3,651.75" $0.00 $0.00 $0.00 "$1,691.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,691.17" $0.00 "$4,000.70" "$4,000.70" $0.00 "$4,057.50" "$6,427.08" "$6,492.00" $0.00 $0.00 "$1,270.00" $0.00 $0.00 "$1,291.91" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-615 SUP HCPCS C1776 6485-3-615 - STEM FEMORAL LONG BOW CURVE 15MM 203MM CEMENTED BODY SECTION BOTH IP/OP "$8,115.00 " "$6,005.10" $0.00 "$6,492.00" "$3,651.75" "$3,651.75" $0.00 $0.00 $0.00 "$1,691.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,691.17" $0.00 "$4,000.70" "$4,000.70" $0.00 "$4,057.50" "$6,427.08" "$6,492.00" $0.00 $0.00 "$1,270.00" $0.00 $0.00 "$1,291.91" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-617 SUP HCPCS C1776 6485-3-617 - STEM FEMORAL LONG BOW 17MM 203MM CEMENTED BODY SECTION GMRS BOTH IP/OP "$8,115.00 " "$6,005.10" $0.00 "$6,492.00" "$3,651.75" "$3,651.75" $0.00 $0.00 $0.00 "$1,691.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,691.17" $0.00 "$4,000.70" "$4,000.70" $0.00 "$4,057.50" "$6,427.08" "$6,492.00" $0.00 $0.00 "$1,270.00" $0.00 $0.00 "$1,291.91" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-711 SUP HCPCS C1776 6485-3-711 - STEM FEMORAL CURVE 11MM 127MM MRS KNEE BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-713 SUP HCPCS C1776 6485-3-713 - STEM FEMORAL CURVE 13MM 127MM MRS KNEE BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-715 SUP HCPCS C1776 6485-3-715 - STEM FEMORAL CURVE 15MM 127MM MRS KNEE BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-717 SUP HCPCS C1776 6485-3-717 - STEM FEMORAL CURVE 17MM 127MM MRS HIP BOTH IP/OP "$7,977.50 " "$5,903.35" $0.00 "$6,382.00" "$3,589.88" "$3,589.88" $0.00 $0.00 $0.00 "$1,662.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,662.51" $0.00 "$3,932.91" "$3,932.91" $0.00 "$3,988.75" "$6,318.18" "$6,382.00" $0.00 $0.00 "$1,248.48" $0.00 $0.00 "$1,270.02" $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-811 SUP HCPCS C1776 6485-3-811 - STEM FEMORAL CURVE 11MM 127MM MRS KNEE BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-813 SUP HCPCS C1776 6485-3-813 - STEM FEMORAL CURVE 13MM 127MM MRS KNEE BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-815 SUP HCPCS C1776 6485-3-815 - STEM FEMORAL CURVE 15MM 127MM MRS HIP BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-817 SUP HCPCS C1776 6485-3-817 - STEM FEMORAL CURVE 17MM 127MM MRS HIP BOTH IP/OP "$5,780.00 " "$4,277.20" $0.00 "$4,624.00" "$2,601.00" "$2,601.00" $0.00 $0.00 $0.00 "$1,204.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,204.55" $0.00 "$2,849.54" "$2,849.54" $0.00 "$2,890.00" "$4,577.76" "$4,624.00" $0.00 $0.00 $904.57 $0.00 $0.00 $920.18 $0.00 $0.00 $0.00 $0.00 $0.00 6485-3-915 SUP Custom 27803010 6485-3-915 - COMPONENT PATLR MEDIUM ROTATE HINGE KRH DUR BOTH IP/OP "$1,705.00 " "$1,261.70" $0.00 "$1,364.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,265.45" "$1,265.45" $0.00 $0.00 $355.32 $0.00 $0.00 $0.00 $0.00 $852.50 "$1,350.36" "$1,364.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-100 SUP Custom 27803010 6485-4-100 - COMPONENT FEMORAL STANDARD 10MM ROTATE HINGE BUMPER BOTH IP/OP "$1,282.50 " $949.05 $0.00 "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.87 $951.87 $0.00 $0.00 $267.27 $0.00 $0.00 $0.00 $0.00 $641.25 "$1,015.74" "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-111 SUP Custom 27803010 6485-4-111 - INSERT TIBIAL SMALL 11MM MRS DUR METASUL KNEE ENCAPSULATE BOTH IP/OP "$3,120.00 " "$2,308.80" $0.00 "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,315.66" "$2,315.66" $0.00 $0.00 $650.21 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$2,471.04" "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-113 SUP Custom 27803010 6485-4-113 - INSERT TIBIAL SMALL 13MM MRS DUR METASUL KNEE ENCAPSULATE BOTH IP/OP "$3,120.00 " "$2,308.80" $0.00 "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,315.66" "$2,315.66" $0.00 $0.00 $650.21 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$2,471.04" "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-116 SUP Custom 27803010 6485-4-116 - INSERT TIBIAL SMALL 16MM MRS DUR KNEE ENCAP BOTH IP/OP "$3,120.00 " "$2,308.80" $0.00 "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,315.66" "$2,315.66" $0.00 $0.00 $650.21 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$2,471.04" "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-121 SUP Custom 27803010 6485-4-121 - INSERT TIBIAL SMALL 21MM MRS DUR KNEE ENCAP BOTH IP/OP "$3,120.00 " "$2,308.80" $0.00 "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,315.66" "$2,315.66" $0.00 $0.00 $650.21 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$2,471.04" "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-125 SUP Custom 27803010 6485-4-125 - INSERT TIBIAL 12.5MM BUMPER KRH DUR KNEE BOTH IP/OP "$1,282.50 " $949.05 $0.00 "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.87 $951.87 $0.00 $0.00 $267.27 $0.00 $0.00 $0.00 $0.00 $641.25 "$1,015.74" "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-145 SUP Custom 27803010 6485-4-145 - INSERT TIBIAL 14.5MM 14.5MM BUMPER MRS MRH KRH DUR BOTH IP/OP "$1,282.50 " $949.05 $0.00 "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.87 $951.87 $0.00 $0.00 $267.27 $0.00 $0.00 $0.00 $0.00 $641.25 "$1,015.74" "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-160 SUP Custom 27803010 6485-4-160 - INSERT TIBIAL 16MM BUMPER KRH DUR KNEE BOTH IP/OP "$1,282.50 " $949.05 $0.00 "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $951.87 $951.87 $0.00 $0.00 $267.27 $0.00 $0.00 $0.00 $0.00 $641.25 "$1,015.74" "$1,026.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-211 SUP Custom 27803010 6485-4-211 - INSERT TIBIAL MEDIUM 11MM MRS DUR KNEE ENCAP BOTH IP/OP "$3,120.00 " "$2,308.80" $0.00 "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,315.66" "$2,315.66" $0.00 $0.00 $650.21 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$2,471.04" "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-213 SUP Custom 27803010 6485-4-213 - INSERT TIBIAL MEDIUM 13MM MRS DUR KNEE ENCAP BOTH IP/OP "$3,120.00 " "$2,308.80" $0.00 "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,315.66" "$2,315.66" $0.00 $0.00 $650.21 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$2,471.04" "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-216 SUP Custom 27803010 6485-4-216 - INSERT TIBIAL MEDIUM 16MM MRS DUR KNEE ENCAP BOTH IP/OP "$3,120.00 " "$2,308.80" $0.00 "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,315.66" "$2,315.66" $0.00 $0.00 $650.21 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$2,471.04" "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-4-221 SUP Custom 27803010 6485-4-221 - INSERT TIBIAL MEDIUM 21MM MRS DUR KNEE ENCAP BOTH IP/OP "$3,120.00 " "$2,308.80" $0.00 "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,315.66" "$2,315.66" $0.00 $0.00 $650.21 $0.00 $0.00 $0.00 $0.00 "$1,560.00" "$2,471.04" "$2,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-010 SUP Custom 27803010 6485-5-010 - SPACER FEM 10MM KMX+ LCK SCR BOTH IP/OP $98.00 $72.52 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.74 $72.74 $0.00 $0.00 $20.42 $0.00 $0.00 $0.00 $0.00 $49.00 $77.62 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-050 SUP Custom 27803010 6485-5-050 - SPACER FEM 5MM KNMX XS LEFT DISTAL MDL BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-051 SUP Custom 27803010 6485-5-051 - SPACER FEM 10MM KNMX XS LEFT DISTAL MDL BOTH IP/OP $687.00 $508.38 $0.00 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.89 $509.89 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $0.00 $343.50 $544.10 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-052 SUP Custom 27803010 6485-5-052 - SPACER FEM 10MM KMX+ XS RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-053 SUP Custom 27803010 6485-5-053 - SPACER FEM 10MM KMX+ XS RIGHT DISTAL MDL BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-060 SUP Custom 27803010 6485-5-060 - SPACER FEM 5MM KNMX XS RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-061 SUP Custom 27803010 6485-5-061 - SPACER FEM 10MM KMX+ XS RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-062 SUP Custom 27803010 6485-5-062 - SPACER FEM 10MM KMX+ MED XS DISTAL KNEE BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-063 SUP Custom 27803010 6485-5-063 - SPACER FEM 10MM KMX+ XS RIGHT DISTAL MDL BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-100 SUP Custom 27803010 6485-5-100 - SPACER FEM 5MM KNMX SM LEFT DISTAL MDL BOTH IP/OP $687.00 $508.38 $0.00 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.89 $509.89 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $0.00 $343.50 $544.10 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-101 SUP Custom 27803010 6485-5-101 - SPACER FEM 10MM KMX+ SM LEFT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-102 SUP Custom 27803010 6485-5-102 - SPACER FEM 10MM KMX+ SM RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-103 SUP Custom 27803010 6485-5-103 - SPACER FEM 10MM KMX+ SM RIGHT DISTAL MDL BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-110 SUP Custom 27803010 6485-5-110 - SPACER FEM 5MM KNMX SM RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-111 SUP Custom 27803010 6485-5-111 - SPACER FEM 10MM KMX+ SM RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-112 SUP Custom 27803010 6485-5-112 - SPACER FEM 10MM KMX+ SM RIGHT DISTAL MDL BOTH IP/OP $687.00 $508.38 $0.00 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.89 $509.89 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $0.00 $343.50 $544.10 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-113 SUP Custom 27803010 6485-5-113 - SPACER FEM 10MM KMX+ SM RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-150 SUP Custom 27803010 6485-5-150 - SPACER FEM 5MM KMX+ MED LEFT DISTAL MDL BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $0.00 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-151 SUP Custom 27803010 6485-5-151 - SPACER FEM 10MM KNMX MED LEFT DISTAL MDL BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $0.00 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-152 SUP Custom 27803010 6485-5-152 - SPACER FEM 10MM KNMX MED RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-153 SUP Custom 27803010 6485-5-153 - SPACER FEM 10MM KMX+ MED RIGHT DISTAL MDL BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $0.00 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-160 SUP Custom 27803010 6485-5-160 - SPACER FEM 5MM KNMX MED RIGHT DISTAL MDL BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $0.00 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-161 SUP Custom 27803010 6485-5-161 - SPACER FEM 10MM KNMX MED RIGHT DISTAL MDL BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $0.00 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-162 SUP Custom 27803010 6485-5-162 - SPACER FEM 10MM KNMX MED RIGHT DISTAL MDL BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $0.00 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-163 SUP Custom 27803010 6485-5-163 - SPACER FEM 10MM KNMX MED RIGHT DISTAL MDL BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $0.00 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-200 SUP Custom 27803010 6485-5-200 - SPACER FEM 5MM KMX+ LG LEFT DISTAL MDL BOTH IP/OP $687.00 $508.38 $0.00 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.89 $509.89 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $0.00 $343.50 $544.10 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-201 SUP Custom 27803010 6485-5-201 - SPACER FEM 10MM KMX+ LG LEFT DISTAL MDL BOTH IP/OP $572.00 $423.28 $0.00 $457.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.54 $424.54 $0.00 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $286.00 $453.02 $457.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-202 SUP Custom 27803010 6485-5-202 - SPACER FEM 10MM KMX+ LG RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-203 SUP Custom 27803010 6485-5-203 - SPACER FEM 10MM KMX+ MED RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-210 SUP Custom 27803010 6485-5-210 - SPACER FEM 5MM KMX+ LG RIGHT DISTAL MDL BOTH IP/OP $572.00 $423.28 $0.00 $457.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.54 $424.54 $0.00 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $286.00 $453.02 $457.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-211 SUP Custom 27803010 6485-5-211 - SPACER FEM 10MM KMX+ MED RIGHT DISTAL MDL BOTH IP/OP $687.00 $508.38 $0.00 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.89 $509.89 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $0.00 $343.50 $544.10 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-212 SUP Custom 27803010 6485-5-212 - SPACER FEM 10MM KMX+ LG RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-213 SUP Custom 27803010 6485-5-213 - SPACER FEM 10MM KMX+ LG RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-250 SUP Custom 27803010 6485-5-250 - SPACER FEM 5MM KMX+ XL LEFT DISTAL MDL BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-251 SUP Custom 27803010 6485-5-251 - SPACER FEM 10MM KMX+ MED XL DISTAL KNEE BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-252 SUP Custom 27803010 6485-5-252 - SPACER FEM 10MM KMX+ XL RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-253 SUP Custom 27803010 6485-5-253 - SPACER FEM 10MM KMX+ XL RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-260 SUP Custom 27803010 6485-5-260 - SPACER FEM 5MM KNMX 2XL RIGHT DISTAL MDL BOTH IP/OP $816.00 $603.84 $0.00 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $605.64 $605.64 $0.00 $0.00 $170.05 $0.00 $0.00 $0.00 $0.00 $408.00 $646.27 $652.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-261 SUP Custom 27803010 6485-5-261 - SPACER FEM 10MM KMX+ XL RIGHT DISTAL MDL BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $0.00 $0.00 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-262 SUP Custom 27803010 6485-5-262 - SPACER FEM 10MM KMX+ XL RIGHT DISTAL MDL BOTH IP/OP $687.00 $508.38 $0.00 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.89 $509.89 $0.00 $0.00 $143.17 $0.00 $0.00 $0.00 $0.00 $343.50 $544.10 $549.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-263 SUP Custom 27803010 6485-5-263 - SPACER FEM 10MM KMX+ XL RIGHT DISTAL MDL BOTH IP/OP $659.00 $487.66 $0.00 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.11 $489.11 $0.00 $0.00 $137.34 $0.00 $0.00 $0.00 $0.00 $329.50 $521.93 $527.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-5-915 SUP Custom 27803010 6485-5-915 - CMPNT PATLR LG KNMTC BOTH IP/OP "$1,639.63 " "$1,213.33" $0.00 "$1,311.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,216.93" "$1,216.93" $0.00 $0.00 $341.70 $0.00 $0.00 $0.00 $0.00 $819.81 "$1,298.59" "$1,311.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-6-409 SUP HCPCS C1776 6485-6-409 - STEM TIBIAL 9MM MRS KNEE BOTH IP/OP "$7,905.00 " "$5,849.70" $0.00 "$6,324.00" "$3,557.25" "$3,557.25" $0.00 $0.00 $0.00 "$1,647.60" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,647.40" $0.00 "$3,897.17" "$3,897.17" $0.00 "$3,952.50" "$6,260.76" "$6,324.00" $0.00 $0.00 "$1,237.13" $0.00 $0.00 "$1,258.48" $0.00 $0.00 $0.00 $0.00 $0.00 6485-6-411 SUP HCPCS C1776 6485-6-411 - STEM TIBIAL 11MM MRS KNEE BOTH IP/OP "$7,905.00 " "$5,849.70" $0.00 "$6,324.00" "$3,557.25" "$3,557.25" $0.00 $0.00 $0.00 "$1,647.60" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,647.40" $0.00 "$3,897.17" "$3,897.17" $0.00 "$3,952.50" "$6,260.76" "$6,324.00" $0.00 $0.00 "$1,237.13" $0.00 $0.00 "$1,258.48" $0.00 $0.00 $0.00 $0.00 $0.00 6485-6-413 SUP HCPCS C1776 6485-6-413 - STEM TIBIAL 13MM MRS KNEE BOTH IP/OP "$7,905.00 " "$5,849.70" $0.00 "$6,324.00" "$3,557.25" "$3,557.25" $0.00 $0.00 $0.00 "$1,647.60" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,647.40" $0.00 "$3,897.17" "$3,897.17" $0.00 "$3,952.50" "$6,260.76" "$6,324.00" $0.00 $0.00 "$1,237.13" $0.00 $0.00 "$1,258.48" $0.00 $0.00 $0.00 $0.00 $0.00 6485-6-509 SUP HCPCS C1776 6485-6-509 - STEM TIBIAL 9MM 127MM MRS KNEE BOTH IP/OP "$5,722.50 " "$4,234.65" $0.00 "$4,578.00" "$2,575.13" "$2,575.13" $0.00 $0.00 $0.00 "$1,192.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,192.57" $0.00 "$2,821.19" "$2,821.19" $0.00 "$2,861.25" "$4,532.22" "$4,578.00" $0.00 $0.00 $895.57 $0.00 $0.00 $911.02 $0.00 $0.00 $0.00 $0.00 $0.00 6485-6-511 SUP HCPCS C1776 6485-6-511 - STEM TIBIAL 11MM 127MM MRS KNEE BOTH IP/OP "$5,722.50 " "$4,234.65" $0.00 "$4,578.00" "$2,575.13" "$2,575.13" $0.00 $0.00 $0.00 "$1,192.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,192.57" $0.00 "$2,821.19" "$2,821.19" $0.00 "$2,861.25" "$4,532.22" "$4,578.00" $0.00 $0.00 $895.57 $0.00 $0.00 $911.02 $0.00 $0.00 $0.00 $0.00 $0.00 6485-6-513 SUP HCPCS C1776 6485-6-513 - STEM TIBIAL 13MM MRS KNEE BOTH IP/OP "$5,722.50 " "$4,234.65" $0.00 "$4,578.00" "$2,575.13" "$2,575.13" $0.00 $0.00 $0.00 "$1,192.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,192.57" $0.00 "$2,821.19" "$2,821.19" $0.00 "$2,861.25" "$4,532.22" "$4,578.00" $0.00 $0.00 $895.57 $0.00 $0.00 $911.02 $0.00 $0.00 $0.00 $0.00 $0.00 6485-8-435 SUP HCPCS C1776 6485-8-435 - COMPONENT TIBIAL SHORT BEARING MRS KNEE BOTH IP/OP "$6,005.00 " "$4,443.70" $0.00 "$4,804.00" "$2,702.25" "$2,702.25" $0.00 $0.00 $0.00 "$1,251.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,251.44" $0.00 "$2,960.47" "$2,960.47" $0.00 "$3,002.50" "$4,755.96" "$4,804.00" $0.00 $0.00 $939.78 $0.00 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 6485-8-450 SUP HCPCS C1776 6485-8-450 - COMPONENT TIBIAL 3XS BEARING KRH KNEE BOTH IP/OP "$6,122.50 " "$4,530.65" $0.00 "$4,898.00" "$2,755.13" "$2,755.13" $0.00 $0.00 $0.00 "$1,276.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,275.93" $0.00 "$3,018.39" "$3,018.39" $0.00 "$3,061.25" "$4,849.02" "$4,898.00" $0.00 $0.00 $958.17 $0.00 $0.00 $974.70 $0.00 $0.00 $0.00 $0.00 $0.00 6485-8-460 SUP HCPCS C1895 6485-8-460 - AXLE FEMORAL SMALL ROTATE HINGE MODULE KINEMATIC KNEE BOTH IP/OP "$2,182.50 " "$1,615.05" $0.00 "$1,746.00" $982.13 $982.13 $0.00 $0.00 $0.00 $454.89 "$1,619.85" "$1,619.85" $0.00 $0.00 $454.83 $0.00 "$1,290.95" "$1,290.95" $0.00 "$1,091.25" "$1,728.54" "$1,746.00" $0.00 $0.00 $341.56 $0.00 $0.00 $347.45 $0.00 $0.00 $0.00 $0.00 $0.00 6487-1-040 SUP HCPCS C1776 6487-1-040 - BODY HUMERAL TAPER 40MM MALE TO FMALE MRS BOTH IP/OP "$5,680.00 " "$4,203.20" $0.00 "$4,544.00" "$2,556.00" "$2,556.00" $0.00 $0.00 $0.00 "$1,183.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,183.71" $0.00 "$2,800.24" "$2,800.24" $0.00 "$2,840.00" "$4,498.56" "$4,544.00" $0.00 $0.00 $888.92 $0.00 $0.00 $904.26 $0.00 $0.00 $0.00 $0.00 $0.00 6487-1-060 SUP HCPCS C1776 6487-1-060 - BODY HUMERAL TAPER 60MM MALE TO FMALE MRS BOTH IP/OP "$5,680.00 " "$4,203.20" $0.00 "$4,544.00" "$2,556.00" "$2,556.00" $0.00 $0.00 $0.00 "$1,183.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,183.71" $0.00 "$2,800.24" "$2,800.24" $0.00 "$2,840.00" "$4,498.56" "$4,544.00" $0.00 $0.00 $888.92 $0.00 $0.00 $904.26 $0.00 $0.00 $0.00 $0.00 $0.00 6487-1-080 SUP HCPCS C1776 6487-1-080 - BODY HUMERAL 80MM MALE/FMALE TAPERED MRS SHOULDER BOTH IP/OP "$5,680.00 " "$4,203.20" $0.00 "$4,544.00" "$2,556.00" "$2,556.00" $0.00 $0.00 $0.00 "$1,183.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,183.71" $0.00 "$2,800.24" "$2,800.24" $0.00 "$2,840.00" "$4,498.56" "$4,544.00" $0.00 $0.00 $888.92 $0.00 $0.00 $904.26 $0.00 $0.00 $0.00 $0.00 $0.00 6487-1-100 SUP HCPCS C1776 6487-1-100 - BODY HUMERAL TAPER 100MM MALE TO FMALE MRS BOTH IP/OP "$5,680.00 " "$4,203.20" $0.00 "$4,544.00" "$2,556.00" "$2,556.00" $0.00 $0.00 $0.00 "$1,183.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,183.71" $0.00 "$2,800.24" "$2,800.24" $0.00 "$2,840.00" "$4,498.56" "$4,544.00" $0.00 $0.00 $888.92 $0.00 $0.00 $904.26 $0.00 $0.00 $0.00 $0.00 $0.00 6487-1-120 SUP HCPCS C1776 6487-1-120 - BODY HUMERAL TAPER 120MM MALE TO FMALE MRS BOTH IP/OP "$5,680.00 " "$4,203.20" $0.00 "$4,544.00" "$2,556.00" "$2,556.00" $0.00 $0.00 $0.00 "$1,183.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,183.71" $0.00 "$2,800.24" "$2,800.24" $0.00 "$2,840.00" "$4,498.56" "$4,544.00" $0.00 $0.00 $888.92 $0.00 $0.00 $904.26 $0.00 $0.00 $0.00 $0.00 $0.00 6487-1-140 SUP HCPCS C1776 6487-1-140 - BODY HUMERAL TAPER 140MM MALE TO FMALE MRS BOTH IP/OP "$5,680.00 " "$4,203.20" $0.00 "$4,544.00" "$2,556.00" "$2,556.00" $0.00 $0.00 $0.00 "$1,183.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,183.71" $0.00 "$2,800.24" "$2,800.24" $0.00 "$2,840.00" "$4,498.56" "$4,544.00" $0.00 $0.00 $888.92 $0.00 $0.00 $904.26 $0.00 $0.00 $0.00 $0.00 $0.00 6487-2-075 SUP HCPCS C1776 6487-2-075 - STEM HUMERAL 7MM 75MM MRS MRH SHOULDER BOTH IP/OP "$7,480.00 " "$5,535.20" $0.00 "$5,984.00" "$3,366.00" "$3,366.00" $0.00 $0.00 $0.00 "$1,559.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,558.83" $0.00 "$3,687.64" "$3,687.64" $0.00 "$3,740.00" "$5,924.16" "$5,984.00" $0.00 $0.00 "$1,170.62" $0.00 $0.00 "$1,190.82" $0.00 $0.00 $0.00 $0.00 $0.00 6487-2-115 SUP HCPCS C1776 6487-2-115 - STEM HUMERAL 7MM 115MM MRS SHOULDER BOTH IP/OP "$7,480.00 " "$5,535.20" $0.00 "$5,984.00" "$3,366.00" "$3,366.00" $0.00 $0.00 $0.00 "$1,559.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,558.83" $0.00 "$3,687.64" "$3,687.64" $0.00 "$3,740.00" "$5,924.16" "$5,984.00" $0.00 $0.00 "$1,170.62" $0.00 $0.00 "$1,190.82" $0.00 $0.00 $0.00 $0.00 $0.00 6487-3-075 SUP HCPCS C1776 6487-3-075 - STEM HUMERAL 9MM 75MM MRS SHOULDER BOTH IP/OP "$7,480.00 " "$5,535.20" $0.00 "$5,984.00" "$3,366.00" "$3,366.00" $0.00 $0.00 $0.00 "$1,559.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,558.83" $0.00 "$3,687.64" "$3,687.64" $0.00 "$3,740.00" "$5,924.16" "$5,984.00" $0.00 $0.00 "$1,170.62" $0.00 $0.00 "$1,190.82" $0.00 $0.00 $0.00 $0.00 $0.00 6487-3-115 SUP HCPCS C1776 6487-3-115 - STEM HUMERAL 9MM 115MM MRS SHOULDER BOTH IP/OP "$7,480.00 " "$5,535.20" $0.00 "$5,984.00" "$3,366.00" "$3,366.00" $0.00 $0.00 $0.00 "$1,559.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,558.83" $0.00 "$3,687.64" "$3,687.64" $0.00 "$3,740.00" "$5,924.16" "$5,984.00" $0.00 $0.00 "$1,170.62" $0.00 $0.00 "$1,190.82" $0.00 $0.00 $0.00 $0.00 $0.00 6487-4-075 SUP HCPCS C1776 6487-4-075 - STEM HUMERAL 11MM 75MM MRS SHOULDER BOTH IP/OP "$7,480.00 " "$5,535.20" $0.00 "$5,984.00" "$3,366.00" "$3,366.00" $0.00 $0.00 $0.00 "$1,559.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,558.83" $0.00 "$3,687.64" "$3,687.64" $0.00 "$3,740.00" "$5,924.16" "$5,984.00" $0.00 $0.00 "$1,170.62" $0.00 $0.00 "$1,190.82" $0.00 $0.00 $0.00 $0.00 $0.00 6487-4-115 SUP HCPCS C1776 6487-4-115 - STEM HUMERAL 11MM 115MM MRS SHOULDER BOTH IP/OP "$7,480.00 " "$5,535.20" $0.00 "$5,984.00" "$3,366.00" "$3,366.00" $0.00 $0.00 $0.00 "$1,559.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,558.83" $0.00 "$3,687.64" "$3,687.64" $0.00 "$3,740.00" "$5,924.16" "$5,984.00" $0.00 $0.00 "$1,170.62" $0.00 $0.00 "$1,190.82" $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-010 SUP HCPCS C1713 6487-5-010 - SCREW BONE INTERCALARY MRS HUMERUS BOTH IP/OP $932.50 $690.05 $0.00 $746.00 $419.63 $419.63 $0.00 $0.00 $0.00 $194.36 $692.10 $692.10 $0.00 $0.00 $194.33 $0.00 $551.57 $551.57 $0.00 $466.25 $738.54 $746.00 $0.00 $0.00 $145.94 $0.00 $0.00 $148.45 $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-040 SUP HCPCS C1776 6487-5-040 - HEAD HUM 40MM STRL MRS SHLDR PROX BOTH IP/OP "$7,317.50 " "$5,414.95" $0.00 "$5,854.00" "$3,292.88" "$3,292.88" $0.00 $0.00 $0.00 "$1,525.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,524.97" $0.00 "$3,607.53" "$3,607.53" $0.00 "$3,658.75" "$5,795.46" "$5,854.00" $0.00 $0.00 "$1,145.19" $0.00 $0.00 "$1,164.95" $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-044 SUP HCPCS C1776 6487-5-044 - HEAD HUM 44MM STRL MRS SHLDR PROX BOTH IP/OP "$7,317.50 " "$5,414.95" $0.00 "$5,854.00" "$3,292.88" "$3,292.88" $0.00 $0.00 $0.00 "$1,525.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,524.97" $0.00 "$3,607.53" "$3,607.53" $0.00 "$3,658.75" "$5,795.46" "$5,854.00" $0.00 $0.00 "$1,145.19" $0.00 $0.00 "$1,164.95" $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-051 SUP HCPCS C1776 6487-5-051 - STEM HUM 50MM BODY MRS 25MM SHLDR BOTH IP/OP "$4,054.38 " "$3,000.24" $0.00 "$3,243.50" "$1,824.47" "$1,824.47" $0.00 $0.00 $0.00 $845.03 "$3,009.16" "$3,009.16" $0.00 $0.00 $844.93 $0.00 "$1,998.81" "$1,998.81" $0.00 "$2,027.19" "$3,211.07" "$3,243.50" $0.00 $0.00 $634.51 $0.00 $0.00 $645.46 $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-075 SUP HCPCS C1776 6487-5-075 - STEM HUMERAL 7MM 75MM MRS SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-076 SUP HCPCS C1776 6487-5-076 - STEM HUMERAL 75MM 25MM BODY MRS MRH SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-101 SUP HCPCS C1776 6487-5-101 - STEM HUMERAL 100MM 25MM BODY MRS SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-115 SUP HCPCS C1776 6487-5-115 - STEM HUMERAL 7MM 115MM MRS BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-5-126 SUP HCPCS C1776 6487-5-126 - STEM HUM 125MM BODY MRS 25MM SHLDR BOTH IP/OP "$4,054.38 " "$3,000.24" $0.00 "$3,243.50" "$1,824.47" "$1,824.47" $0.00 $0.00 $0.00 $845.03 "$3,009.16" "$3,009.16" $0.00 $0.00 $844.93 $0.00 "$1,998.81" "$1,998.81" $0.00 "$2,027.19" "$3,211.07" "$3,243.50" $0.00 $0.00 $634.51 $0.00 $0.00 $645.46 $0.00 $0.00 $0.00 $0.00 $0.00 6487-6-051 SUP HCPCS C1776 6487-6-051 - STEM HUM 50MM BODY MRS 50MM SHLDR BOTH IP/OP "$4,054.38 " "$3,000.24" $0.00 "$3,243.50" "$1,824.47" "$1,824.47" $0.00 $0.00 $0.00 $845.03 "$3,009.16" "$3,009.16" $0.00 $0.00 $844.93 $0.00 "$1,998.81" "$1,998.81" $0.00 "$2,027.19" "$3,211.07" "$3,243.50" $0.00 $0.00 $634.51 $0.00 $0.00 $645.46 $0.00 $0.00 $0.00 $0.00 $0.00 6487-6-075 SUP HCPCS C1776 6487-6-075 - STEM HUMERAL 9MM 75MM MRS BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-6-076 SUP HCPCS C1776 6487-6-076 - STEM HUMERAL 50MM 75MM BODY MRS BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-6-101 SUP HCPCS C1776 6487-6-101 - STEM HUMERAL 50MM 100MM BODY MRS SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-6-115 SUP HCPCS C1776 6487-6-115 - STEM HUMERAL 9MM 115MM MRS SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-6-126 SUP HCPCS C1776 6487-6-126 - STEM HUM 125MM BODY MRS 50MM SHLDR BOTH IP/OP "$4,054.38 " "$3,000.24" $0.00 "$3,243.50" "$1,824.47" "$1,824.47" $0.00 $0.00 $0.00 $845.03 "$3,009.16" "$3,009.16" $0.00 $0.00 $844.93 $0.00 "$1,998.81" "$1,998.81" $0.00 "$2,027.19" "$3,211.07" "$3,243.50" $0.00 $0.00 $634.51 $0.00 $0.00 $645.46 $0.00 $0.00 $0.00 $0.00 $0.00 6487-7-051 SUP HCPCS C1776 6487-7-051 - STEM HUM 50MM BODY MRS 75MM SHLDR BOTH IP/OP "$4,054.38 " "$3,000.24" $0.00 "$3,243.50" "$1,824.47" "$1,824.47" $0.00 $0.00 $0.00 $845.03 "$3,009.16" "$3,009.16" $0.00 $0.00 $844.93 $0.00 "$1,998.81" "$1,998.81" $0.00 "$2,027.19" "$3,211.07" "$3,243.50" $0.00 $0.00 $634.51 $0.00 $0.00 $645.46 $0.00 $0.00 $0.00 $0.00 $0.00 6487-7-075 SUP HCPCS C1776 6487-7-075 - STEM HUMERAL 11MM 75MM MRS SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-7-076 SUP HCPCS C1776 6487-7-076 - STEM HUMERAL 75MM 75MM BODY MRS SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-7-101 SUP HCPCS C1776 6487-7-101 - STEM HUMERAL 100MM 75MM BODY MRS MRH SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-7-115 SUP HCPCS C1776 6487-7-115 - STEM HUMERAL 11MM 115MM BODY MRS SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-8-051 SUP HCPCS C1776 6487-8-051 - STEM HUMERAL 100MM 50MM BODY MRS MRH SHOULDER BOTH IP/OP "$5,420.00 " "$4,010.80" $0.00 "$4,336.00" "$2,439.00" "$2,439.00" $0.00 $0.00 $0.00 "$1,129.66" "$4,022.72" "$4,022.72" $0.00 $0.00 "$1,129.53" $0.00 "$2,672.06" "$2,672.06" $0.00 "$2,710.00" "$4,292.64" "$4,336.00" $0.00 $0.00 $848.23 $0.00 $0.00 $862.86 $0.00 $0.00 $0.00 $0.00 $0.00 6487-9-051 SUP HCPCS C1776 6487-9-051 - CAP END 50MM MRS HUMERAL PROXIMAL BOTH IP/OP "$2,635.00 " "$1,949.90" $0.00 "$2,108.00" "$1,185.75" "$1,185.75" $0.00 $0.00 $0.00 $549.20 "$1,955.70" "$1,955.70" $0.00 $0.00 $549.13 $0.00 "$1,299.06" "$1,299.06" $0.00 "$1,317.50" "$2,086.92" "$2,108.00" $0.00 $0.00 $412.38 $0.00 $0.00 $419.49 $0.00 $0.00 $0.00 $0.00 $0.00 6495-1-001 SUP HCPCS C1776 6495-1-001 - COMPONENT FEMORAL STANDARD NEUTRAL GMRS COCR HIP BOTH IP/OP "$10,355.00 " "$7,662.70" $0.00 "$8,284.00" "$4,659.75" "$4,659.75" $0.00 $0.00 $0.00 "$2,158.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,157.98" $0.00 "$5,105.02" "$5,105.02" $0.00 "$5,177.50" "$8,201.16" "$8,284.00" $0.00 $0.00 "$1,620.56" $0.00 $0.00 "$1,648.52" $0.00 $0.00 $0.00 $0.00 $0.00 6495-1-002 SUP HCPCS C1776 6495-1-002 - COMPONENT FEMORAL NEUTRAL GMRS HIP TROCHANTER BOTH IP/OP "$10,355.00 " "$7,662.70" $0.00 "$8,284.00" "$4,659.75" "$4,659.75" $0.00 $0.00 $0.00 "$2,158.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,157.98" $0.00 "$5,105.02" "$5,105.02" $0.00 "$5,177.50" "$8,201.16" "$8,284.00" $0.00 $0.00 "$1,620.56" $0.00 $0.00 "$1,648.52" $0.00 $0.00 $0.00 $0.00 $0.00 6495-1-101 SUP HCPCS C1776 6495-1-101 - COMPONENT FEMORAL 15D ANTEVERT STANDARD GMRS KNEE LEFT BOTH IP/OP "$10,355.00 " "$7,662.70" $0.00 "$8,284.00" "$4,659.75" "$4,659.75" $0.00 $0.00 $0.00 "$2,158.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,157.98" $0.00 "$5,105.02" "$5,105.02" $0.00 "$5,177.50" "$8,201.16" "$8,284.00" $0.00 $0.00 "$1,620.56" $0.00 $0.00 "$1,648.52" $0.00 $0.00 $0.00 $0.00 $0.00 6495-1-102 SUP HCPCS C1776 6495-1-102 - COMPONENT FEMORAL 15D ANTEVERT GMRS KNEE LEFT TROCHANTER BOTH IP/OP "$10,355.00 " "$7,662.70" $0.00 "$8,284.00" "$4,659.75" "$4,659.75" $0.00 $0.00 $0.00 "$2,158.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,157.98" $0.00 "$5,105.02" "$5,105.02" $0.00 "$5,177.50" "$8,201.16" "$8,284.00" $0.00 $0.00 "$1,620.56" $0.00 $0.00 "$1,648.52" $0.00 $0.00 $0.00 $0.00 $0.00 6495-1-201 SUP HCPCS C1776 6495-1-201 - COMPONENT FEMORAL 15D ANTEVERT STANDARD GMRS KNEE RIGHT BOTH IP/OP "$10,355.00 " "$7,662.70" $0.00 "$8,284.00" "$4,659.75" "$4,659.75" $0.00 $0.00 $0.00 "$2,158.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,157.98" $0.00 "$5,105.02" "$5,105.02" $0.00 "$5,177.50" "$8,201.16" "$8,284.00" $0.00 $0.00 "$1,620.56" $0.00 $0.00 "$1,648.52" $0.00 $0.00 $0.00 $0.00 $0.00 6495-1-202 SUP HCPCS C1776 6495-1-202 - COMPONENT FEMORAL 15D ANTEVERT GMRS KNEE RIGHT TROCHANTER BOTH IP/OP "$10,355.00 " "$7,662.70" $0.00 "$8,284.00" "$4,659.75" "$4,659.75" $0.00 $0.00 $0.00 "$2,158.24" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,157.98" $0.00 "$5,105.02" "$5,105.02" $0.00 "$5,177.50" "$8,201.16" "$8,284.00" $0.00 $0.00 "$1,620.56" $0.00 $0.00 "$1,648.52" $0.00 $0.00 $0.00 $0.00 $0.00 6495-2-010 SUP HCPCS C1776 6495-2-010 - COMPONENT FEMORAL SMALL 65MM GMRS COCR KNEE LEFT BOTH IP/OP "$14,922.50 " "$11,042.65" $0.00 "$11,938.00" "$6,715.13" "$6,715.13" $0.00 $0.00 $0.00 "$3,110.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,109.85" $0.00 "$7,356.79" "$7,356.79" $0.00 "$7,461.25" "$11,818.62" "$11,938.00" $0.00 $0.00 "$2,335.37" $0.00 $0.00 "$2,375.66" $0.00 $0.00 $0.00 $0.00 $0.00 6495-2-020 SUP HCPCS C1776 6495-2-020 - COMPONENT FEMORAL SMALL 65MM GMRS DISTAL RIGHT BOTH IP/OP "$14,922.50 " "$11,042.65" $0.00 "$11,938.00" "$6,715.13" "$6,715.13" $0.00 $0.00 $0.00 "$3,110.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,109.85" $0.00 "$7,356.79" "$7,356.79" $0.00 "$7,461.25" "$11,818.62" "$11,938.00" $0.00 $0.00 "$2,335.37" $0.00 $0.00 "$2,375.66" $0.00 $0.00 $0.00 $0.00 $0.00 6495-2-030 SUP HCPCS C1776 6495-2-030 - COMPONENT FEMORAL STANDARD 65MM GMRS COCR KNEE LEFT BOTH IP/OP "$14,787.50 " "$10,942.75" $0.00 "$11,830.00" "$6,654.38" "$6,654.38" $0.00 $0.00 $0.00 "$3,082.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,081.72" $0.00 "$7,290.24" "$7,290.24" $0.00 "$7,393.75" "$11,711.70" "$11,830.00" $0.00 $0.00 "$2,314.24" $0.00 $0.00 "$2,354.17" $0.00 $0.00 $0.00 $0.00 $0.00 6495-2-040 SUP HCPCS C1776 6495-2-040 - COMPONENT FEMORAL STANDARD 65MM GMRS COCR KNEE RIGHT BOTH IP/OP "$14,787.50 " "$10,942.75" $0.00 "$11,830.00" "$6,654.38" "$6,654.38" $0.00 $0.00 $0.00 "$3,082.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,081.72" $0.00 "$7,290.24" "$7,290.24" $0.00 "$7,393.75" "$11,711.70" "$11,830.00" $0.00 $0.00 "$2,314.24" $0.00 $0.00 "$2,354.17" $0.00 $0.00 $0.00 $0.00 $0.00 6495-2-105 SUP Custom 27803010 6495-2-105 - BUSHING FEMORAL SMALL GMRS KNEE BOTH IP/OP $640.00 $473.60 $0.00 $512.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $475.01 $475.01 $0.00 $0.00 $133.38 $0.00 $0.00 $0.00 $0.00 $320.00 $506.88 $512.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6495-2-115 SUP Custom 27803010 6495-2-115 - AXLE FEMORAL SMALL GMRS KNEE BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6495-3-010 SUP Custom 27803010 6495-3-010 - INSERT TIBIAL SMALL 10MM GMRS PROXIMAL BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6495-3-013 SUP Custom 27803010 6495-3-013 - INSERT TIBIAL SMALL 13MM GMRS PROXIMAL BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6495-3-016 SUP Custom 27803010 6495-3-016 - INSERT TIBIAL SMALL 16MM GMRS PROXIMAL BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6495-3-020 SUP Custom 27803010 6495-3-020 - INSERT TIBIAL SMALL 20MM GMRS PROXIMAL BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6495-3-024 SUP Custom 27803010 6495-3-024 - INSERT TIBIAL SMALL 24MM GMRS PROXIMAL BOTH IP/OP "$2,367.50 " "$1,751.95" $0.00 "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.16" "$1,757.16" $0.00 $0.00 $493.39 $0.00 $0.00 $0.00 $0.00 "$1,183.75" "$1,875.06" "$1,894.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6495-3-101 SUP HCPCS C1776 6495-3-101 - COMPONENT TIBIAL SMALL GMRS PROXIMAL BOTH IP/OP "$14,895.00 " "$11,022.30" $0.00 "$11,916.00" "$6,702.75" "$6,702.75" $0.00 $0.00 $0.00 "$3,104.49" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,104.12" $0.00 "$7,343.24" "$7,343.24" $0.00 "$7,447.50" "$11,796.84" "$11,916.00" $0.00 $0.00 "$2,331.07" $0.00 $0.00 "$2,371.28" $0.00 $0.00 $0.00 $0.00 $0.00 6495-3-102 SUP HCPCS C1776 6495-3-102 - COMPONENT TIBIAL STANDARD GMRS PROXIMAL BOTH IP/OP "$14,895.00 " "$11,022.30" $0.00 "$11,916.00" "$6,702.75" "$6,702.75" $0.00 $0.00 $0.00 "$3,104.49" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,104.12" $0.00 "$7,343.24" "$7,343.24" $0.00 "$7,447.50" "$11,796.84" "$11,916.00" $0.00 $0.00 "$2,331.07" $0.00 $0.00 "$2,371.28" $0.00 $0.00 $0.00 $0.00 $0.00 6495-3-601 SUP HCPCS C1776 6495-3-601 - COMPONENT TIBIAL SMALL ROTATE GMRS TITANIUM KNEE PROXIMAL BOTH IP/OP "$6,122.50 " "$4,530.65" $0.00 "$4,898.00" "$2,755.13" "$2,755.13" $0.00 $0.00 $0.00 "$1,276.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,275.93" $0.00 "$3,018.39" "$3,018.39" $0.00 "$3,061.25" "$4,849.02" "$4,898.00" $0.00 $0.00 $958.17 $0.00 $0.00 $974.70 $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-011 SUP HCPCS C1776 6495-5-011 - STEM FEMORAL STR FLUTE 11MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-012 SUP HCPCS C1776 6495-5-012 - STEM FEMORAL STR FLUTE 12MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-013 SUP HCPCS C1776 6495-5-013 - STEM FEMORAL STR FLUTE 13MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-014 SUP HCPCS C1776 6495-5-014 - STEM FEMORAL STR FLUTE 14MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-015 SUP HCPCS C1776 6495-5-015 - STEM FEMORAL STR FLUTE 15MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-016 SUP HCPCS C1776 6495-5-016 - STEM FEMORAL STR FLUTE 16MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-017 SUP HCPCS C1776 6495-5-017 - STEM FEMORAL STR FLUTE 17MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-018 SUP HCPCS C1776 6495-5-018 - STEM FEMORAL STR FLUTE 18MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-019 SUP HCPCS C1776 6495-5-019 - STEM FEMORAL STR FLUTE 19MM 125MM PRESSFIT GMRS COCR HIP BOTH IP/OP "$9,450.00 " "$6,993.00" $0.00 "$7,560.00" "$4,252.50" "$4,252.50" $0.00 $0.00 $0.00 "$1,969.62" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,969.38" $0.00 "$4,658.85" "$4,658.85" $0.00 "$4,725.00" "$7,484.40" "$7,560.00" $0.00 $0.00 "$1,478.93" $0.00 $0.00 "$1,504.44" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-111 SUP HCPCS C1776 6495-5-111 - STEM FEMORAL LONG BOW 11MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-112 SUP HCPCS C1776 6495-5-112 - STEM FEMORAL LONG BOW 12MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-113 SUP HCPCS C1776 6495-5-113 - STEM FEMORAL LONG BOW 13MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-114 SUP HCPCS C1776 6495-5-114 - STEM FEMORAL LONG BOW 14MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-115 SUP HCPCS C1776 6495-5-115 - STEM FEMORAL LONG BOW 15MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-116 SUP HCPCS C1776 6495-5-116 - STEM FEMORAL LONG BOW 16MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-117 SUP HCPCS C1776 6495-5-117 - STEM FEMORAL LONG BOW 17MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-118 SUP HCPCS C1776 6495-5-118 - STEM FEMORAL LONG BOW 18MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-119 SUP HCPCS C1776 6495-5-119 - STEM FEMORAL LONG BOW 19MM 200MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-211 SUP HCPCS C1776 6495-5-211 - STEM FEMORAL BOW 11MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-212 SUP HCPCS C1776 6495-5-212 - STEM FEMORAL BOW 12MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-213 SUP HCPCS C1776 6495-5-213 - STEM FEMORAL BOW 13MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-214 SUP HCPCS C1776 6495-5-214 - STEM FEMORAL BOW 14MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-215 SUP HCPCS C1776 6495-5-215 - STEM FEMORAL BOW 15MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-216 SUP HCPCS C1776 6495-5-216 - STEM FEMORAL BOW 16MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-217 SUP HCPCS C1776 6495-5-217 - STEM FEMORAL BOW 17MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-218 SUP HCPCS C1776 6495-5-218 - STEM FEMORAL BOW 18MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-5-219 SUP HCPCS C1776 6495-5-219 - STEM FEMORAL BOW 19MM 150MM PRESSFIT GMRS HIP BOTH IP/OP "$9,962.50 " "$7,372.25" $0.00 "$7,970.00" "$4,483.13" "$4,483.13" $0.00 $0.00 $0.00 "$2,076.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.19" $0.00 "$4,911.51" "$4,911.51" $0.00 "$4,981.25" "$7,890.30" "$7,970.00" $0.00 $0.00 "$1,559.13" $0.00 $0.00 "$1,586.03" $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-008 SUP HCPCS C1776 6495-6-008 - COMPONENT FEMORAL 80MM CONCTR GMRS KNEE LEFT BOTH IP/OP "$9,002.50 " "$6,661.85" $0.00 "$7,202.00" "$4,051.13" "$4,051.13" $0.00 $0.00 $0.00 "$1,876.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,876.12" $0.00 "$4,438.23" "$4,438.23" $0.00 "$4,501.25" "$7,129.98" "$7,202.00" $0.00 $0.00 "$1,408.89" $0.00 $0.00 "$1,433.20" $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-009 SUP HCPCS C1776 6495-6-009 - COMPONENT FEMORAL 90MM CONNECT PIECE GMRS KNEE LEFT BOTH IP/OP "$9,002.50 " "$6,661.85" $0.00 "$7,202.00" "$4,051.13" "$4,051.13" $0.00 $0.00 $0.00 "$1,876.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,876.12" $0.00 "$4,438.23" "$4,438.23" $0.00 "$4,501.25" "$7,129.98" "$7,202.00" $0.00 $0.00 "$1,408.89" $0.00 $0.00 "$1,433.20" $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-018 SUP HCPCS C1776 6495-6-018 - COMPONENT FEMORAL 80MM CONNECT PIECE GMRS TITANIUM HIP RIGHT BOTH IP/OP "$9,087.50 " "$6,724.75" $0.00 "$7,270.00" "$4,089.38" "$4,089.38" $0.00 $0.00 $0.00 "$1,894.06" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.84" $0.00 "$4,480.14" "$4,480.14" $0.00 "$4,543.75" "$7,197.30" "$7,270.00" $0.00 $0.00 "$1,422.19" $0.00 $0.00 "$1,446.73" $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-019 SUP HCPCS C1776 6495-6-019 - COMPONENT FEMORAL 90MM CONNECT PIECE GMRS KNEE RIGHT BOTH IP/OP "$9,087.50 " "$6,724.75" $0.00 "$7,270.00" "$4,089.38" "$4,089.38" $0.00 $0.00 $0.00 "$1,894.06" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,893.84" $0.00 "$4,480.14" "$4,480.14" $0.00 "$4,543.75" "$7,197.30" "$7,270.00" $0.00 $0.00 "$1,422.19" $0.00 $0.00 "$1,446.73" $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-030 SUP HCPCS C1776 6495-6-030 - EXTENSION FEMORAL 30MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-040 SUP HCPCS C1776 6495-6-040 - EXTENSION FEMORAL 40MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-050 SUP HCPCS C1776 6495-6-050 - EXTENSION FEMORAL 50MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-060 SUP HCPCS C1776 6495-6-060 - EXTENSION FEMORAL 60MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-070 SUP HCPCS C1776 6495-6-070 - EXTENSION FEMORAL 70MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-080 SUP HCPCS C1776 6495-6-080 - EXTENSION FEMORAL 80MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-100 SUP HCPCS C1776 6495-6-100 - EXTENSION FEMORAL 100MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-120 SUP HCPCS C1776 6495-6-120 - EXTENSION FEMORAL 120MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-140 SUP HCPCS C1776 6495-6-140 - EXTENSION FEMORAL 140MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-160 SUP HCPCS C1776 6495-6-160 - EXTENSION STEM 160MM GMRS COCR KNEE FEMUR BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-180 SUP HCPCS C1776 6495-6-180 - EXTENSION FEMORAL 180MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-200 SUP HCPCS C1776 6495-6-200 - EXTENSION FEMORAL 200MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6495-6-220 SUP HCPCS C1776 6495-6-220 - EXTENSION FEMORAL 220MM GMRS COCR KNEE DISTAL BOTH IP/OP "$6,257.50 " "$4,630.55" $0.00 "$5,006.00" "$2,815.88" "$2,815.88" $0.00 $0.00 $0.00 "$1,304.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,304.06" $0.00 "$3,084.95" "$3,084.95" $0.00 "$3,128.75" "$4,955.94" "$5,006.00" $0.00 $0.00 $979.30 $0.00 $0.00 $996.19 $0.00 $0.00 $0.00 $0.00 $0.00 6500-000-009 SUP Custom 27100030 6500-000-009 - MODEL ANTM CLRVW ADLT SKL BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 $0.00 $0.00 $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65-0003-S SUP Custom 27803010 65-0003-S - FILLER BN VOID 3ML CALLOS BOTH IP/OP "$2,962.50 " "$2,192.25" $0.00 "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,198.77" "$2,198.77" $0.00 $0.00 $617.39 $0.00 $0.00 $0.00 $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65-0005-S SUP Custom 27803010 65-0005-S - SYSTEM BN CMNT 5ML CALLOS INJ BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 $0.00 $0.00 $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65-0010-S SUP Custom 27803010 65-0010-S - FILLER BN VOID 10ML CALLOS BOTH IP/OP "$7,750.00 " "$5,735.00" $0.00 "$6,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,615.10" $0.00 $0.00 $0.00 $0.00 "$3,875.00" "$6,138.00" "$6,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65-0099-S SUP Custom 27203010 65-0099-S - KIT DLV INJ BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $0.00 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 650-1057 SUP HCPCS C1776 650-1057 - HEAD FEM 36MM G7 BLX D OPTN HIP BOTH IP/OP "$10,177.50 " "$7,531.35" $0.00 "$8,142.00" "$4,579.88" "$4,579.88" $0.00 $0.00 $0.00 "$2,121.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,120.99" $0.00 "$5,017.51" "$5,017.51" $0.00 "$5,088.75" "$8,060.58" "$8,142.00" $0.00 $0.00 "$1,592.78" $0.00 $0.00 "$1,620.26" $0.00 $0.00 $0.00 $0.00 $0.00 65-0105-S SUP Custom 27803010 65-0105-S - FILLER BN VOID 5ML CALLOS BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 $0.00 $0.00 $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 650-1066 SUP HCPCS C1776 650-1066 - SLEEVE FEMORAL STANDARD TAPER TYPE 1 OPTION BIOLOX DELTA BOTH IP/OP "$1,030.00 " $762.20 $0.00 $824.00 $463.50 $463.50 $0.00 $0.00 $0.00 $214.68 $764.47 $764.47 $0.00 $0.00 $214.65 $0.00 $609.25 $609.25 $0.00 $515.00 $815.76 $824.00 $0.00 $0.00 $161.20 $0.00 $0.00 $163.98 $0.00 $0.00 $0.00 $0.00 $0.00 65-0110-S SUP Custom 27803010 65-0110-S - FILLER BN VOID 10ML CALLOS BOTH IP/OP "$7,750.00 " "$5,735.00" $0.00 "$6,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,615.10" $0.00 $0.00 $0.00 $0.00 "$3,875.00" "$6,138.00" "$6,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65-018-E4S SUP Custom 27203010 65-018-E4S - CATHETER INFS 4 4/3FR 65CM CLARIVEIN BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65-0199-S SUP Custom 27203010 65-0199-S - SYSTEM BONE CMNT IMPCT KIT CALLOS BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $0.00 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6515-0814L SUP HCPCS C1776 6515-0814L - STEM FEM 205MM 14MM BW RSTOR HYDRXAPT -5MM LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-0814R SUP HCPCS C1776 6515-0814R - STEM FEM 205MM 14MM BW RSTOR HYDRXAPT -5MM RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-0915L SUP HCPCS C1776 6515-0915L - STEM FEM 205MM 15MM BW RSTOR HYDRXAPT -5MM LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-0915R SUP HCPCS C1776 6515-0915R - STEM FEM 205MM 15MM BW RSTOR HYDRXAPT -5MM RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1016L SUP HCPCS C1776 6515-1016L - STEM FEM 205MM 16MM BW RSTOR HYDRXAPT -5MM LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1016R SUP HCPCS C1776 6515-1016R - STEM FEM 205MM 16MM BW RSTOR HYDRXAPT -5MM RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1117L SUP HCPCS C1776 6515-1117L - STEM FEM 205MM 17MM BW RSTOR HYDRXAPT -5MM LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1117R SUP HCPCS C1776 6515-1117R - STEM FEM 205MM 17MM BW RSTOR HYDRXAPT -5MM RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1218L SUP HCPCS C1776 6515-1218L - STEM REV 205MM 18MM RSTOR -5MM LEFT HIP HYDRXAPT BW BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1218R SUP HCPCS C1776 6515-1218R - STEM FEM 205MM 18MM BW RSTOR HYDRXAPT -5MM RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1319L SUP HCPCS C1776 6515-1319L - STEM FEM 205MM 19MM BW RSTOR HYDRXAPT -5MM LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1319R SUP HCPCS C1776 6515-1319R - STEM FEM 205MM 19MM BW RSTOR HYDRXAPT -5MM RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1420L SUP HCPCS C1776 6515-1420L - STEM FEM 205MM 20MM BW RSTOR HYDRXAPT -5MM LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1420R SUP HCPCS C1776 6515-1420R - STEM FEM 205MM 20MM BW RSTOR HYDRXAPT -5MM RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1422L SUP HCPCS C1776 6515-1422L - STEM FEM 205MM 22MM BW RSTOR HYDRXAPT -5MM LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6515-1422R SUP HCPCS C1776 6515-1422R - STEM FEM 205MM 22MM BW RSTOR HYDRXAPT -5MM RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-0814L SUP HCPCS C1776 6516-0814L - STEM FEM 14MM 14MM RED NECK RSTOR HYDRXAPT -5MM 8 HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-0814R SUP HCPCS C1776 6516-0814R - STEM FEM 255MM STR RED NECK RSTOR HYDRXAPT -5MM HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-0915L SUP HCPCS C1776 6516-0915L - NECK FEM 15MM RSTOR LEFT HIP HYDRXAPT RED BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-0915R SUP HCPCS C1776 6516-0915R - STEM FEM 15MM RED NECK RSTOR HYDRXAPT RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1016L SUP HCPCS C1776 6516-1016L - STEM FEM 16MM RED NECK RSTOR HYDRXAPT LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1016R SUP HCPCS C1776 6516-1016R - STEM FEM 16MM RED NECK RSTOR HYDRXAPT RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1117L SUP HCPCS C1776 6516-1117L - STEM FEM 17MM 17MM NO DISTAL SLOT RED NECK SYS RSTOR BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1117R SUP HCPCS C1776 6516-1117R - STEM FEM 17MM RED NECK RSTOR HYDRXAPT RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1218L SUP HCPCS C1776 6516-1218L - STEM FEM 18MM RED RSTOR HYDRXAPT LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1218R SUP HCPCS C1776 6516-1218R - STEM FEM 18MM 18MM RED NECK NO DISTAL SLOT RSTOR HYDRXAPT -5 BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1319L SUP HCPCS C1776 6516-1319L - STEM FEM 19MM RED NECK RSTOR HYDRXAPT LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1319R SUP HCPCS C1776 6516-1319R - STEM FEM 19MM 19MM RED NECK NO DISTAL SLOT RSTOR HYDRXAPT 13 BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1420L SUP HCPCS C1776 6516-1420L - STEM FEM 20MM RED NECK RSTOR HYDRXAPT LEFT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1420R SUP HCPCS C1776 6516-1420R - STEM FEM 20MM RED NECK NO DISTAL SLOT RSTOR HYDRXAPT RIGHT BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1422L SUP HCPCS C1776 6516-1422L - STEM FEM 22MM 22MM NO DISTAL SLOT RED NECK SYS RSTOR BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6516-1422R SUP HCPCS C1776 6516-1422R - STEM FEM 22MM RED NECK RSTOR HYDRXAPT RIGHT HIP BOTH IP/OP "$12,943.13 " "$9,577.92" $0.00 "$10,354.50" "$5,824.41" "$5,824.41" $0.00 $0.00 $0.00 "$2,697.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,697.35" $0.00 "$6,380.96" "$6,380.96" $0.00 "$6,471.56" "$10,250.96" "$10,354.50" $0.00 $0.00 "$2,025.60" $0.00 $0.00 "$2,060.55" $0.00 $0.00 $0.00 $0.00 $0.00 6519-1-028 SUP Custom 27803010 6519-1-028 - HEAD FEM +0MM UNV TPR 28MM STRL BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6519-1-032 SUP Custom 27803010 6519-1-032 - HEAD FEM +0MM UNV TPR 32MM STRL BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6519-1-036 SUP Custom 27803010 6519-1-036 - HEAD FEM +0MM UNV TPR 36MM STRL BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6519-1-040 SUP Custom 27803010 6519-1-040 - HEAD FEM +0MM UNV TPR 40MM STRL BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6519-1-044 SUP Custom 27803010 6519-1-044 - HEAD FEM +0MM UNV TPR 44MM STRL BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6519-T-025 SUP Custom 27803010 6519-T-025 - SLEEVE ADAPTER -2.5MM OFFST UNIVERSAL TAPER V40 TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6519-T-100 SUP Custom 27803010 6519-T-100 - SLEEVE ADAPTER +0MM OFFST UNIVERSAL TAPER V40 TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6519-T-204 SUP Custom 27803010 6519-T-204 - SLEEVE ADAPTER +4MM OFFST UNIVERSAL TAPER V40 TITANIUM HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6522-0509 SUP HCPCS C1776 6522-0509 - STEM FEM 145MM 9MM CTPR RSTOR TI HYDRXAPT HIP BOTH IP/OP "$11,474.13 " "$8,490.86" $0.00 "$9,179.30" "$5,163.36" "$5,163.36" $0.00 $0.00 $0.00 "$2,391.49" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,391.21" $0.00 "$5,656.74" "$5,656.74" $0.00 "$5,737.06" "$9,087.51" "$9,179.30" $0.00 $0.00 "$1,795.70" $0.00 $0.00 "$1,826.68" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0511 SUP HCPCS C1776 6522-0511 - STEM FEM 145MM 11MM CTPR RSTOR TI HYDRXAPT HIP BOTH IP/OP "$11,474.13 " "$8,490.86" $0.00 "$9,179.30" "$5,163.36" "$5,163.36" $0.00 $0.00 $0.00 "$2,391.49" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,391.21" $0.00 "$5,656.74" "$5,656.74" $0.00 "$5,737.06" "$9,087.51" "$9,179.30" $0.00 $0.00 "$1,795.70" $0.00 $0.00 "$1,826.68" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0610 SUP HCPCS C1776 6522-0610 - STEM FEM 145MM 10MM CTPR RSTOR TI HYDRXAPT HIP BOTH IP/OP "$11,474.13 " "$8,490.86" $0.00 "$9,179.30" "$5,163.36" "$5,163.36" $0.00 $0.00 $0.00 "$2,391.49" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,391.21" $0.00 "$5,656.74" "$5,656.74" $0.00 "$5,737.06" "$9,087.51" "$9,179.30" $0.00 $0.00 "$1,795.70" $0.00 $0.00 "$1,826.68" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0612 SUP HCPCS C1776 6522-0612 - STEM FEM 145MM 12MM CTPR RSTOR TI HYDRXAPT HIP BOTH IP/OP "$11,474.13 " "$8,490.86" $0.00 "$9,179.30" "$5,163.36" "$5,163.36" $0.00 $0.00 $0.00 "$2,391.49" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,391.21" $0.00 "$5,656.74" "$5,656.74" $0.00 "$5,737.06" "$9,087.51" "$9,179.30" $0.00 $0.00 "$1,795.70" $0.00 $0.00 "$1,826.68" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0711 SUP HCPCS C1776 6522-0711 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0713 SUP HCPCS C1776 6522-0713 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0812 SUP HCPCS C1776 6522-0812 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0814 SUP HCPCS C1776 6522-0814 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0913 SUP HCPCS C1776 6522-0913 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-0915 SUP HCPCS C1776 6522-0915 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-1014 SUP HCPCS C1776 6522-1014 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-1016 SUP HCPCS C1776 6522-1016 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-1115 SUP HCPCS C1776 6522-1115 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6522-1117 SUP HCPCS C1776 6522-1117 - STEM FEM 145MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$10,684.38 " "$7,906.44" $0.00 "$8,547.50" "$4,807.97" "$4,807.97" $0.00 $0.00 $0.00 "$2,226.89" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.62" $0.00 "$5,267.40" "$5,267.40" $0.00 "$5,342.19" "$8,462.03" "$8,547.50" $0.00 $0.00 "$1,672.10" $0.00 $0.00 "$1,700.95" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0509 SUP HCPCS C1776 6523-0509 - STEM FEM 175MM 9MM CTPR RSTOR TI HYDRXAPT HIP BOTH IP/OP "$12,150.13 " "$8,991.10" $0.00 "$9,720.10" "$5,467.56" "$5,467.56" $0.00 $0.00 $0.00 "$2,532.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,532.09" $0.00 "$5,990.01" "$5,990.01" $0.00 "$6,075.06" "$9,622.90" "$9,720.10" $0.00 $0.00 "$1,901.49" $0.00 $0.00 "$1,934.30" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0511 SUP HCPCS C1776 6523-0511 - STEM FEM 175MM 11MM CTPR RSTOR TI HYDRXAPT HIP BOTH IP/OP "$12,150.13 " "$8,991.10" $0.00 "$9,720.10" "$5,467.56" "$5,467.56" $0.00 $0.00 $0.00 "$2,532.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,532.09" $0.00 "$5,990.01" "$5,990.01" $0.00 "$6,075.06" "$9,622.90" "$9,720.10" $0.00 $0.00 "$1,901.49" $0.00 $0.00 "$1,934.30" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0610 SUP HCPCS C1776 6523-0610 - STEM FEM 175MM 10MM CTPR RSTOR TI HYDRXAPT HIP BOTH IP/OP "$12,150.13 " "$8,991.10" $0.00 "$9,720.10" "$5,467.56" "$5,467.56" $0.00 $0.00 $0.00 "$2,532.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,532.09" $0.00 "$5,990.01" "$5,990.01" $0.00 "$6,075.06" "$9,622.90" "$9,720.10" $0.00 $0.00 "$1,901.49" $0.00 $0.00 "$1,934.30" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0612 SUP HCPCS C1776 6523-0612 - STEM FEM 175MM 12MM CTPR RSTOR TI HYDRXAPT HIP BOTH IP/OP "$12,150.13 " "$8,991.10" $0.00 "$9,720.10" "$5,467.56" "$5,467.56" $0.00 $0.00 $0.00 "$2,532.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,532.09" $0.00 "$5,990.01" "$5,990.01" $0.00 "$6,075.06" "$9,622.90" "$9,720.10" $0.00 $0.00 "$1,901.49" $0.00 $0.00 "$1,934.30" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0711 SUP HCPCS C1776 6523-0711 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0713 SUP HCPCS C1776 6523-0713 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0812 SUP HCPCS C1776 6523-0812 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0814 SUP HCPCS C1776 6523-0814 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0913 SUP HCPCS C1776 6523-0913 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-0915 SUP HCPCS C1776 6523-0915 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-1014 SUP HCPCS C1776 6523-1014 - STEM HUM 205MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-1016 SUP HCPCS C1776 6523-1016 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-1115 SUP HCPCS C1776 6523-1115 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6523-1117 SUP HCPCS C1776 6523-1117 - STEM FEM 175MM CTPR RSTOR HYDRXAPT BOTH IP/OP "$11,313.25 " "$8,371.81" $0.00 "$9,050.60" "$5,090.96" "$5,090.96" $0.00 $0.00 $0.00 "$2,357.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,357.68" $0.00 "$5,577.43" "$5,577.43" $0.00 "$5,656.63" "$8,960.09" "$9,050.60" $0.00 $0.00 "$1,770.52" $0.00 $0.00 "$1,801.07" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0511L SUP HCPCS C1776 6524-0511L - STEM FEM 205MM BW RSTOR HYDRXAPT LEFT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0511R SUP HCPCS C1776 6524-0511R - STEM FEM 205MM BW RSTOR HYDRXAPT RIGHT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0612L SUP HCPCS C1776 6524-0612L - STEM FEM 205MM BW RSTOR HYDRXAPT LEFT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0612R SUP HCPCS C1776 6524-0612R - STEM FEM 205MM BW RSTOR HYDRXAPT RIGHT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0713L SUP HCPCS C1776 6524-0713L - STEM FEM 205MM BW RSTOR HYDRXAPT LEFT BOTH IP/OP "$12,161.50 " "$8,999.51" $0.00 "$9,729.20" "$5,472.68" "$5,472.68" $0.00 $0.00 $0.00 "$2,534.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,534.46" $0.00 "$5,995.62" "$5,995.62" $0.00 "$6,080.75" "$9,631.91" "$9,729.20" $0.00 $0.00 "$1,903.27" $0.00 $0.00 "$1,936.11" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0713R SUP HCPCS C1776 6524-0713R - STEM FEM 205MM BW RSTOR HYDRXAPT RIGHT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0814L SUP HCPCS C1776 6524-0814L - STEM FEM 205MM BW RSTOR HYDRXAPT LEFT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0814R SUP HCPCS C1776 6524-0814R - STEM FEM 205MM BW RSTOR HYDRXAPT RIGHT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0915L SUP HCPCS C1776 6524-0915L - STEM FEM 205MM BW RSTOR HYDRXAPT LEFT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-0915R SUP HCPCS C1776 6524-0915R - STEM FEM 205MM BW RSTOR HYDRXAPT RIGHT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-1016L SUP HCPCS C1776 6524-1016L - STEM FEM 205MM BW RSTOR HYDRXAPT LEFT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-1016R SUP HCPCS C1776 6524-1016R - STEM FEM 205MM BW RSTOR HYDRXAPT RIGHT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-1117L SUP HCPCS C1776 6524-1117L - STEM FEM 205MM BW RSTOR HYDRXAPT LEFT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6524-1117R SUP HCPCS C1776 6524-1117R - STEM FEM 205MM BW RSTOR HYDRXAPT RIGHT BOTH IP/OP "$11,938.88 " "$8,834.77" $0.00 "$9,551.10" "$5,372.49" "$5,372.49" $0.00 $0.00 $0.00 "$2,488.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,488.06" $0.00 "$5,885.87" "$5,885.87" $0.00 "$5,969.44" "$9,455.59" "$9,551.10" $0.00 $0.00 "$1,868.43" $0.00 $0.00 "$1,900.67" $0.00 $0.00 $0.00 $0.00 $0.00 6528-0511 SUP HCPCS C1776 6528-0511 - STEM FEM 175MM RSTOR HYDRXAPT CLCR 1 BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6528-0612 SUP HCPCS C1776 6528-0612 - STEM FEM 175MM RSTOR HYDRXAPT CLCR 1 BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6528-0713 SUP HCPCS C1776 6528-0713 - STEM FEM 175MM RSTOR HYDRXAPT CLCR 1 BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6528-0814 SUP HCPCS C1776 6528-0814 - STEM FEM 175MM RSTOR HYDRXAPT CLCR 1 BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6528-0915 SUP HCPCS C1776 6528-0915 - CMPNT FEM 175MM CLCR 2 RSTOR HYDRXAPT BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6528-1016 SUP HCPCS C1776 6528-1016 - STEM FEM 145MM 15MM RSTOR HYDRXAPT 10/16 CLCR BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6528-1117 SUP HCPCS C1776 6528-1117 - CMPNT FEM 11/17 175MM CLCR 2 RSTOR HYDRXAPT 15MM BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6528-1218 SUP HCPCS C1776 6528-1218 - CMPNT FEM 12/18 175MM CLCR RSTOR HYDRXAPT 15MM BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6529-0511 SUP HCPCS C1776 6529-0511 - STEM FEM 175MM 30MM RSTOR HYDRXAPT 5/11 CLCR 2 BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6529-0612 SUP HCPCS C1776 6529-0612 - CMPNT FEM 6/12 175MM CLCR 2 RSTOR HYDRXAPT 30MM BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6529-0713 SUP HCPCS C1776 6529-0713 - STEM FEM 175MM 30MM RSTOR HYDRXAPT 7/13 CLCR 2 BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6529-0814 SUP HCPCS C1776 6529-0814 - STEM FEM 175MM 30MM RSTOR HYDRXAPT 8/14 CLCR BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6529-0915 SUP HCPCS C1776 6529-0915 - CMPNT FEM 9/15 175MM CLCR 2 RSTOR HYDRXAPT 30MM BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6529-1016 SUP HCPCS C1776 6529-1016 - STEM FEM 175MM 30MM RSTOR HYDRXAPT 10/16 CLCR 2 BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6529-1117 SUP HCPCS C1776 6529-1117 - CMPNT FEM 11/17 175MM CLCR 2 RSTOR HYDRXAPT 30MM BOTH IP/OP "$12,689.63 " "$9,390.33" $0.00 "$10,151.70" "$5,710.33" "$5,710.33" $0.00 $0.00 $0.00 "$2,644.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,644.52" $0.00 "$6,255.99" "$6,255.99" $0.00 "$6,344.81" "$10,050.19" "$10,151.70" $0.00 $0.00 "$1,985.93" $0.00 $0.00 "$2,020.19" $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-028 SUP Custom 27803010 6565-0-028 - HEAD FEMORAL -2.7MM OFFST TAPER 28MM V40 ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-032 SUP Custom 27803010 6565-0-032 - HEAD FEMORAL -4MM OFFST TAPER 32MM V40 ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-036 SUP Custom 27803010 6565-0-036 - HEAD FEMORAL -5MM OFFST TAPER 36MM V40 ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-128 SUP Custom 27803010 6565-0-128 - HEAD FEMORAL +0MM OFFST TAPER 28MM V40 ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-132 SUP Custom 27803010 6565-0-132 - HEAD FEM +0MM OFST TPR 32MM STRL V40 AL CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-136 SUP Custom 27803010 6565-0-136 - HEAD FEMORAL +0MM OFFST TAPER 36MM V40 ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-228 SUP Custom 27803010 6565-0-228 - HEAD FEMORAL +4MM OFFST TAPER 28MM V40 ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-232 SUP Custom 27803010 6565-0-232 - HEAD FEMORAL +4MM OFFST TAPER 32MM V40 ALUM CERAMIC HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6565-0-236 SUP Custom 27803010 6565-0-236 - HEAD FEM +5MM OFST TPR 36MM STRL V40 AL CERM HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65652-512 SUP Custom 27203010 CANISTER SCT 1L CURVE INTNL ON/OFF VLV XTD BKT HLDR REUSE LF BOTH IP/OP $64.00 $47.36 $0.00 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.00 $50.69 $51.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-028 SUP Custom 27803010 6570-0-028 - HEAD FEM -4MM OFST TPR 28MM STRL V40 BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-032 SUP Custom 27803010 6570-0-032 - HEAD FEM -4MM OFST TPR 32MM STRL V40 BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-036 SUP Custom 27803010 6570-0-036 - HEAD FEM -5MM OFST TPR 36MM V40 ANTM BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-128 SUP Custom 27803010 6570-0-128 - HEAD FEMORAL 0MM OFFST TAPER 28MM V40 BIOLOX DELTA HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-132 SUP Custom 27803010 6570-0-132 - HEAD FEM +0MM OFST TPR 32MM V40 BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-136 SUP Custom 27803010 6570-0-136 - HEAD FEM +0MM OFST TPR 36MM V40 ANTM BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-228 SUP Custom 27803010 6570-0-228 - HEAD FEM +4MM OFST TPR 28MM STRL V40 BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-232 SUP Custom 27803010 6570-0-232 - HEAD FEM +4MM OFST TPR 32MM STRL V40 BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-236 SUP Custom 27803010 6570-0-236 - HEAD FEM +5MM OFST TPR 36MM V40 ANTM BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-328 SUP Custom 27803010 6570-0-328 - HEAD FEM -2.7MM OFST TPR 28MM STRL V40 BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-436 SUP Custom 27803010 6570-0-436 - HEAD FEM -2.5MM OFST TPR 36MM V40 ANTM BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-536 SUP Custom 27803010 6570-0-536 - HEAD FEM +2.5MM OFST TPR 36MM V40 ANTM BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6570-0-736 SUP Custom 27803010 6570-0-736 - HEAD FEM +7.5MM OFST TPR 36MM STRL V40 BLX D HIP BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 $0.00 $0.00 $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2240 SUP Custom 27803010 65C-2240 - CUP ACETAB 40MM 22MM 6.4MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2242 SUP Custom 27803010 65C-2242 - CUP ACETAB 42MM 22MM 7.4MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2244 SUP Custom 27803010 65C-2244 - CUP ACETAB 44MM 22MM 7.9MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2246 SUP Custom 27803010 65C-2246 - CUP ACETAB 46MM 22MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2248 SUP Custom 27803010 65C-2248 - CUP ACETAB 48MM 22MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2250 SUP Custom 27803010 65C-2250 - CUP ACETAB 50MM 22MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2252 SUP Custom 27803010 65C-2252 - CUP ACETAB 52MM 22MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2642 SUP Custom 27803010 65C-2642 - CUP ACETAB 42MM 26MM 5.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2644 SUP Custom 27803010 65C-2644 - CUP ACETAB 44MM 26MM 6.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2646 SUP Custom 27803010 65C-2646 - CUP ACETAB 46MM 26MM 7.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2648 SUP Custom 27803010 65C-2648 - CUP ACETAB 48MM 26MM 8MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2650 SUP Custom 27803010 65C-2650 - CUP ACETAB 50MM 26MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2652 SUP Custom 27803010 65C-2652 - CUP ACETAB 52MM 26MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2654 SUP Custom 27803010 65C-2654 - CUP ACETAB 54MM 26MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2844 SUP Custom 27803010 65C-2844 - CUP ACETAB 44MM 28MM 5.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2846 SUP Custom 27803010 65C-2846 - CUP ACETAB 46MM 28MM 6.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2848 SUP Custom 27803010 65C-2848 - CUP ACETAB 48MM 28MM 7.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2850 SUP Custom 27803010 65C-2850 - CUP ACETAB 50MM 28MM 8MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2852 SUP Custom 27803010 65C-2852 - CUP ACETAB 52MM 28MM 8.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2854 SUP Custom 27803010 65C-2854 - CUP ACETAB 54MM 28MM 9.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2856 SUP Custom 27803010 65C-2856 - CUP ACETAB 56MM 28MM 10.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2858 SUP Custom 27803010 65C-2858 - CUP ACETAB 58MM 28MM 11.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2860 SUP Custom 27803010 65C-2860 - CUP ACETAB 60MM 28MM 12.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2863 SUP Custom 27803010 65C-2863 - CUP ACETAB 63MM 28MM 14MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-2866 SUP Custom 27803010 65C-2866 - CUP ACETAB 66MM 28MM 15.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3248 SUP Custom 27803010 65C-3248 - CUP ACETAB 48MM 32MM 5.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3250 SUP Custom 27803010 65C-3250 - CUP ACETAB 50MM 32MM 6.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3252 SUP Custom 27803010 65C-3252 - CUP ACETAB 52MM 32MM 7.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3254 SUP Custom 27803010 65C-3254 - CUP ACETAB 54MM 32MM 8MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3256 SUP Custom 27803010 65C-3256 - CUP ACETAB 56MM 32MM 8.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3258 SUP Custom 27803010 65C-3258 - CUP ACETAB 58MM 32MM 9.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3260 SUP Custom 27803010 65C-3260 - CUP ACETAB 60MM 32MM 10.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3263 SUP Custom 27803010 65C-3263 - CUP ACETAB 63MM 32MM 12MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65C-3266 SUP Custom 27803010 65C-3266 - CUP ACETAB 66MM 32MM 13.5MM TRIDENT XFIRE HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28B SUP Custom 27803010 661-00-28B - INSERT ACETAB 0D B ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28C SUP Custom 27803010 661-00-28C - INSERT ACETAB 0D C ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28D SUP Custom 27803010 661-00-28D - INSERT ACETAB 0D D ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28E SUP Custom 27803010 661-00-28E - INSERT ACETAB 0D E ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28F SUP Custom 27803010 661-00-28F - INSERT ACETAB 0D F ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28G SUP Custom 27803010 661-00-28G - INSERT ACETAB 0D G ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28H SUP Custom 27803010 661-00-28H - INSERT ACETAB 0D H ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28I SUP Custom 27803010 661-00-28I - INSERT ACETAB 0D I ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-28J SUP Custom 27803010 661-00-28J - INSERT ACETAB 0D J ECCENTRIC 28MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-32D SUP Custom 27803010 661-00-32D - INSERT ACETAB 0D D ECCENTRIC 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-32E SUP Custom 27803010 661-00-32E - INSERT ACETAB 0D E ECCENTRIC 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-32F SUP Custom 27803010 661-00-32F - INSERT ACETAB 0D F ECCENTRIC 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-32G SUP Custom 27803010 661-00-32G - INSERT ACETAB 0D G ECCENTRIC 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-32H SUP Custom 27803010 661-00-32H - INSERT ACETAB 0D H ECCENTRIC 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-32I SUP Custom 27803010 661-00-32I - INSERT ACETAB 0D I ECCENTRIC 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-32J SUP Custom 27803010 661-00-32J - INSERT ACETAB 0D J ECCENTRIC 32MM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-36E SUP Custom 27803010 661-00-36E - INSERT ACETAB 0D E 36MM ECCENTRIC TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-36F SUP Custom 27803010 661-00-36F - INSERT ACETAB 0D F 36MM ECCENTRIC TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-36G SUP Custom 27803010 661-00-36G - INSERT ACETAB 0D G 36MM ECCENTRIC TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-36H SUP Custom 27803010 661-00-36H - INSERT ACETAB 0D H 36MM ECCENTRIC TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-36I SUP Custom 27803010 661-00-36I - INSERT ACETAB 0D I 36MM ECCENTRIC TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-00-36J SUP Custom 27803010 661-00-36J - INSERT ACETAB 0D J 36MM ECCENTRIC TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-28C SUP Custom 27803010 661-10-28C - INSERT ACETAB 10D C ECCENTRIC 28MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-28D SUP Custom 27803010 661-10-28D - INSERT ACETAB 10D D ECCENTRIC 28MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-28E SUP Custom 27803010 661-10-28E - INSERT ACETAB 10D E ECCENTRIC 28MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-28F SUP Custom 27803010 661-10-28F - INSERT ACETAB 10D F ECCENTRIC 28MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-28G SUP Custom 27803010 661-10-28G - INSERT ACETAB 10D G ECCENTRIC 28MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-28H SUP Custom 27803010 661-10-28H - INSERT ACETAB 10D H ECCENTRIC 28MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-28I SUP Custom 27803010 661-10-28I - INSERT ACETAB 10D I ECCENTRIC 28MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-28J SUP Custom 27803010 661-10-28J - INSERT ACETAB 10D J ECCENTRIC 28MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-32D SUP Custom 27803010 661-10-32D - INSERT ACETAB 10D D ECCENTRIC 32MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-32E SUP Custom 27803010 661-10-32E - INSERT ACETAB 10D E ECCENTRIC 32MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-32F SUP Custom 27803010 661-10-32F - INSERT ACETAB 10D F ECCENTRIC 32MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-32G SUP Custom 27803010 661-10-32G - INSERT ACETAB 10D G ECCENTRIC 32MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-32H SUP Custom 27803010 661-10-32H - INSERT ACETAB 10D H ECCENTRIC 32MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-32I SUP Custom 27803010 661-10-32I - INSERT ACETAB 10D I ECCENTRIC 32MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-32J SUP Custom 27803010 661-10-32J - INSERT ACETAB 10D J ECCENTRIC 32MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-36E SUP Custom 27803010 661-10-36E - INSERT ACETAB 10D E ECCENTRIC 36MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-36F SUP Custom 27803010 661-10-36F - INSERT ACETAB 10D F ECCENTRIC 36MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-36G SUP Custom 27803010 661-10-36G - INSERT ACETAB 10D G ECCENTRIC 36MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-36H SUP Custom 27803010 661-10-36H - INSERT ACETAB 10D H ECCENTRIC 36MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-36I SUP Custom 27803010 661-10-36I - INSERT ACETAB 10D I ECCENTRIC 36MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 661-10-36J SUP Custom 27803010 661-10-36J - INSERT ACETAB 10D J ECCENTRIC 36MM PRIM TRIDENT XFIRE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-010 SUP HCPCS C1776 6630-0-010 - CMPNT FEM 2XS LEFT KNEE BEADED DRCN BOTH IP/OP "$4,464.00 " "$3,303.36" $0.00 "$3,571.20" "$2,008.80" "$2,008.80" $0.00 $0.00 $0.00 $930.41 "$3,313.18" "$3,313.18" $0.00 $0.00 $930.30 $0.00 "$2,200.75" "$2,200.75" $0.00 "$2,232.00" "$3,535.49" "$3,571.20" $0.00 $0.00 $698.62 $0.00 $0.00 $710.67 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-015 SUP HCPCS C1776 6630-0-015 - CMPNT FEM 1 2XS LEFT KNEE NBD DRCN BOTH IP/OP "$3,525.00 " "$2,608.50" $0.00 "$2,820.00" "$1,586.25" "$1,586.25" $0.00 $0.00 $0.00 $734.70 "$2,616.26" "$2,616.26" $0.00 $0.00 $734.61 $0.00 "$1,737.83" "$1,737.83" $0.00 "$1,762.50" "$2,791.80" "$2,820.00" $0.00 $0.00 $551.66 $0.00 $0.00 $561.18 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-020 SUP HCPCS C1776 6630-0-020 - CMPNT FEM 2XS RIGHT BEADED DRCN BOTH IP/OP "$4,464.00 " "$3,303.36" $0.00 "$3,571.20" "$2,008.80" "$2,008.80" $0.00 $0.00 $0.00 $930.41 "$3,313.18" "$3,313.18" $0.00 $0.00 $930.30 $0.00 "$2,200.75" "$2,200.75" $0.00 "$2,232.00" "$3,535.49" "$3,571.20" $0.00 $0.00 $698.62 $0.00 $0.00 $710.67 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-025 SUP HCPCS C1776 6630-0-025 - CMPNT FEM 1 2XS RIGHT KNEE NBD DRCN BOTH IP/OP "$3,525.00 " "$2,608.50" $0.00 "$2,820.00" "$1,586.25" "$1,586.25" $0.00 $0.00 $0.00 $734.70 "$2,616.26" "$2,616.26" $0.00 $0.00 $734.61 $0.00 "$1,737.83" "$1,737.83" $0.00 "$1,762.50" "$2,791.80" "$2,820.00" $0.00 $0.00 $551.66 $0.00 $0.00 $561.18 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-110 SUP HCPCS C1776 6630-0-110 - CMPNT FEM XS LEFT BEADED DRCN BOTH IP/OP "$4,464.00 " "$3,303.36" $0.00 "$3,571.20" "$2,008.80" "$2,008.80" $0.00 $0.00 $0.00 $930.41 "$3,313.18" "$3,313.18" $0.00 $0.00 $930.30 $0.00 "$2,200.75" "$2,200.75" $0.00 "$2,232.00" "$3,535.49" "$3,571.20" $0.00 $0.00 $698.62 $0.00 $0.00 $710.67 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-115 SUP HCPCS C1776 6630-0-115 - CMPNT FEM 2 XS LEFT KNEE NBD DRCN BOTH IP/OP "$3,525.00 " "$2,608.50" $0.00 "$2,820.00" "$1,586.25" "$1,586.25" $0.00 $0.00 $0.00 $734.70 "$2,616.26" "$2,616.26" $0.00 $0.00 $734.61 $0.00 "$1,737.83" "$1,737.83" $0.00 "$1,762.50" "$2,791.80" "$2,820.00" $0.00 $0.00 $551.66 $0.00 $0.00 $561.18 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-120 SUP HCPCS C1776 6630-0-120 - CMPNT FEM XS RIGHT BEADED DRCN BOTH IP/OP "$4,464.00 " "$3,303.36" $0.00 "$3,571.20" "$2,008.80" "$2,008.80" $0.00 $0.00 $0.00 $930.41 "$3,313.18" "$3,313.18" $0.00 $0.00 $930.30 $0.00 "$2,200.75" "$2,200.75" $0.00 "$2,232.00" "$3,535.49" "$3,571.20" $0.00 $0.00 $698.62 $0.00 $0.00 $710.67 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-125 SUP HCPCS C1776 6630-0-125 - CMPNT FEM XS STD RIGHT KNEE NBD DRCN BOTH IP/OP "$3,525.00 " "$2,608.50" $0.00 "$2,820.00" "$1,586.25" "$1,586.25" $0.00 $0.00 $0.00 $734.70 "$2,616.26" "$2,616.26" $0.00 $0.00 $734.61 $0.00 "$1,737.83" "$1,737.83" $0.00 "$1,762.50" "$2,791.80" "$2,820.00" $0.00 $0.00 $551.66 $0.00 $0.00 $561.18 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-210 SUP HCPCS C1776 6630-0-210 - CMPNT FEM SM LEFT BEADED DRCN BOTH IP/OP "$4,385.00 " "$3,244.90" $0.00 "$3,508.00" "$1,973.25" "$1,973.25" $0.00 $0.00 $0.00 $913.94 "$3,254.55" "$3,254.55" $0.00 $0.00 $913.83 $0.00 "$2,161.81" "$2,161.81" $0.00 "$2,192.50" "$3,472.92" "$3,508.00" $0.00 $0.00 $686.25 $0.00 $0.00 $698.09 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-215 SUP HCPCS C1776 6630-0-215 - CMPNT FEM SM LEFT NBD DRCN BOTH IP/OP "$3,464.00 " "$2,563.36" $0.00 "$2,771.20" "$1,558.80" "$1,558.80" $0.00 $0.00 $0.00 $721.98 "$2,570.98" "$2,570.98" $0.00 $0.00 $721.90 $0.00 "$1,707.75" "$1,707.75" $0.00 "$1,732.00" "$2,743.49" "$2,771.20" $0.00 $0.00 $542.12 $0.00 $0.00 $551.47 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-220 SUP HCPCS C1776 6630-0-220 - CMPNT FEM SM RIGHT BEADED DRCN BOTH IP/OP "$4,385.00 " "$3,244.90" $0.00 "$3,508.00" "$1,973.25" "$1,973.25" $0.00 $0.00 $0.00 $913.94 "$3,254.55" "$3,254.55" $0.00 $0.00 $913.83 $0.00 "$2,161.81" "$2,161.81" $0.00 "$2,192.50" "$3,472.92" "$3,508.00" $0.00 $0.00 $686.25 $0.00 $0.00 $698.09 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-225 SUP HCPCS C1776 6630-0-225 - CMPNT FEM SM RIGHT NBD DRCN BOTH IP/OP "$3,464.00 " "$2,563.36" $0.00 "$2,771.20" "$1,558.80" "$1,558.80" $0.00 $0.00 $0.00 $721.98 "$2,570.98" "$2,570.98" $0.00 $0.00 $721.90 $0.00 "$1,707.75" "$1,707.75" $0.00 "$1,732.00" "$2,743.49" "$2,771.20" $0.00 $0.00 $542.12 $0.00 $0.00 $551.47 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28B SUP Custom 27803010 663-00-28B - INSERT ACETAB 0D B ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28C SUP Custom 27803010 663-00-28C - INSERT ACETAB 0D C ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28D SUP Custom 27803010 663-00-28D - INSERT ACETAB 0D D ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28E SUP Custom 27803010 663-00-28E - INSERT ACETAB 0D E ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28F SUP Custom 27803010 663-00-28F - INSERT ACETAB 0D F ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28G SUP Custom 27803010 663-00-28G - INSERT ACETAB 0D G ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28H SUP Custom 27803010 663-00-28H - INSERT ACETAB 0D H ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28I SUP Custom 27803010 663-00-28I - INSERT ACETAB 0D I ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-28J SUP Custom 27803010 663-00-28J - INSERT ACETAB 0D J ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-310 SUP HCPCS C1776 6630-0-310 - CMPNT FEM MED LEFT BEADED DRCN BOTH IP/OP "$4,385.00 " "$3,244.90" $0.00 "$3,508.00" "$1,973.25" "$1,973.25" $0.00 $0.00 $0.00 $913.94 "$3,254.55" "$3,254.55" $0.00 $0.00 $913.83 $0.00 "$2,161.81" "$2,161.81" $0.00 "$2,192.50" "$3,472.92" "$3,508.00" $0.00 $0.00 $686.25 $0.00 $0.00 $698.09 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-315 SUP HCPCS C1776 6630-0-315 - CMPNT FEM MED LEFT NBD DRCN BOTH IP/OP "$3,464.00 " "$2,563.36" $0.00 "$2,771.20" "$1,558.80" "$1,558.80" $0.00 $0.00 $0.00 $721.98 "$2,570.98" "$2,570.98" $0.00 $0.00 $721.90 $0.00 "$1,707.75" "$1,707.75" $0.00 "$1,732.00" "$2,743.49" "$2,771.20" $0.00 $0.00 $542.12 $0.00 $0.00 $551.47 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-320 SUP HCPCS C1776 6630-0-320 - CMPNT FEM MED RIGHT BEADED DRCN BOTH IP/OP "$4,385.00 " "$3,244.90" $0.00 "$3,508.00" "$1,973.25" "$1,973.25" $0.00 $0.00 $0.00 $913.94 "$3,254.55" "$3,254.55" $0.00 $0.00 $913.83 $0.00 "$2,161.81" "$2,161.81" $0.00 "$2,192.50" "$3,472.92" "$3,508.00" $0.00 $0.00 $686.25 $0.00 $0.00 $698.09 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-325 SUP HCPCS C1776 6630-0-325 - CMPNT FEM MED RIGHT NBD DRCN BOTH IP/OP "$3,464.00 " "$2,563.36" $0.00 "$2,771.20" "$1,558.80" "$1,558.80" $0.00 $0.00 $0.00 $721.98 "$2,570.98" "$2,570.98" $0.00 $0.00 $721.90 $0.00 "$1,707.75" "$1,707.75" $0.00 "$1,732.00" "$2,743.49" "$2,771.20" $0.00 $0.00 $542.12 $0.00 $0.00 $551.47 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-32D SUP Custom 27803010 663-00-32D - INSERT ACETAB 0D D ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-32E SUP Custom 27803010 663-00-32E - INSERT ACETAB 0D E ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-32F SUP Custom 27803010 663-00-32F - INSERT ACETAB 0D F ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-32G SUP Custom 27803010 663-00-32G - INSERT ACETAB 0D G ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-32H SUP Custom 27803010 663-00-32H - INSERT ACETAB 0D H ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-32I SUP Custom 27803010 663-00-32I - INSERT ACETAB 0D I ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-32J SUP Custom 27803010 663-00-32J - INSERT ACETAB 0D J ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-36E SUP Custom 27803010 663-00-36E - INSERT ACETAB 0D E ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$3,830.00 " "$2,834.20" $0.00 "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,842.63" "$2,842.63" $0.00 $0.00 $798.17 $0.00 $0.00 $0.00 $0.00 "$1,915.00" "$3,033.36" "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-36F SUP Custom 27803010 663-00-36F - INSERT ACETAB 0D F ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$3,830.00 " "$2,834.20" $0.00 "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,842.63" "$2,842.63" $0.00 $0.00 $798.17 $0.00 $0.00 $0.00 $0.00 "$1,915.00" "$3,033.36" "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-36G SUP Custom 27803010 663-00-36G - INSERT ACETAB 0D G ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$3,830.00 " "$2,834.20" $0.00 "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,842.63" "$2,842.63" $0.00 $0.00 $798.17 $0.00 $0.00 $0.00 $0.00 "$1,915.00" "$3,033.36" "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-36H SUP Custom 27803010 663-00-36H - INSERT ACETAB 0D H ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$3,830.00 " "$2,834.20" $0.00 "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,842.63" "$2,842.63" $0.00 $0.00 $798.17 $0.00 $0.00 $0.00 $0.00 "$1,915.00" "$3,033.36" "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-36I SUP Custom 27803010 663-00-36I - INSERT ACETAB 0D I ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$3,830.00 " "$2,834.20" $0.00 "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,842.63" "$2,842.63" $0.00 $0.00 $798.17 $0.00 $0.00 $0.00 $0.00 "$1,915.00" "$3,033.36" "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-00-36J SUP Custom 27803010 663-00-36J - INSERT ACETAB 0D J ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$3,830.00 " "$2,834.20" $0.00 "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,842.63" "$2,842.63" $0.00 $0.00 $798.17 $0.00 $0.00 $0.00 $0.00 "$1,915.00" "$3,033.36" "$3,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-410 SUP HCPCS C1776 6630-0-410 - CMPNT FEM MED LG LEFT BEADED DRCN BOTH IP/OP "$4,385.00 " "$3,244.90" $0.00 "$3,508.00" "$1,973.25" "$1,973.25" $0.00 $0.00 $0.00 $913.94 "$3,254.55" "$3,254.55" $0.00 $0.00 $913.83 $0.00 "$2,161.81" "$2,161.81" $0.00 "$2,192.50" "$3,472.92" "$3,508.00" $0.00 $0.00 $686.25 $0.00 $0.00 $698.09 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-415 SUP HCPCS C1776 6630-0-415 - CMPNT FEM MED LG LEFT NBD DRCN BOTH IP/OP "$3,464.00 " "$2,563.36" $0.00 "$2,771.20" "$1,558.80" "$1,558.80" $0.00 $0.00 $0.00 $721.98 "$2,570.98" "$2,570.98" $0.00 $0.00 $721.90 $0.00 "$1,707.75" "$1,707.75" $0.00 "$1,732.00" "$2,743.49" "$2,771.20" $0.00 $0.00 $542.12 $0.00 $0.00 $551.47 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-420 SUP HCPCS C1776 6630-0-420 - CMPNT FEM MED LG RIGHT BEADED DRCN BOTH IP/OP "$4,385.00 " "$3,244.90" $0.00 "$3,508.00" "$1,973.25" "$1,973.25" $0.00 $0.00 $0.00 $913.94 "$3,254.55" "$3,254.55" $0.00 $0.00 $913.83 $0.00 "$2,161.81" "$2,161.81" $0.00 "$2,192.50" "$3,472.92" "$3,508.00" $0.00 $0.00 $686.25 $0.00 $0.00 $698.09 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-425 SUP HCPCS C1776 6630-0-425 - CMPNT FEM MED LG RIGHT NBD DRCN BOTH IP/OP "$3,464.00 " "$2,563.36" $0.00 "$2,771.20" "$1,558.80" "$1,558.80" $0.00 $0.00 $0.00 $721.98 "$2,570.98" "$2,570.98" $0.00 $0.00 $721.90 $0.00 "$1,707.75" "$1,707.75" $0.00 "$1,732.00" "$2,743.49" "$2,771.20" $0.00 $0.00 $542.12 $0.00 $0.00 $551.47 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-510 SUP HCPCS C1776 6630-0-510 - CMPNT FEM LG LEFT BEADED DRCN BOTH IP/OP "$4,385.00 " "$3,244.90" $0.00 "$3,508.00" "$1,973.25" "$1,973.25" $0.00 $0.00 $0.00 $913.94 "$3,254.55" "$3,254.55" $0.00 $0.00 $913.83 $0.00 "$2,161.81" "$2,161.81" $0.00 "$2,192.50" "$3,472.92" "$3,508.00" $0.00 $0.00 $686.25 $0.00 $0.00 $698.09 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-515 SUP HCPCS C1776 6630-0-515 - CMPNT FEM LG LEFT NBD DRCN BOTH IP/OP "$3,464.00 " "$2,563.36" $0.00 "$2,771.20" "$1,558.80" "$1,558.80" $0.00 $0.00 $0.00 $721.98 "$2,570.98" "$2,570.98" $0.00 $0.00 $721.90 $0.00 "$1,707.75" "$1,707.75" $0.00 "$1,732.00" "$2,743.49" "$2,771.20" $0.00 $0.00 $542.12 $0.00 $0.00 $551.47 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-520 SUP HCPCS C1776 6630-0-520 - CMPNT FEM LG RIGHT BEADED DRCN BOTH IP/OP "$4,385.00 " "$3,244.90" $0.00 "$3,508.00" "$1,973.25" "$1,973.25" $0.00 $0.00 $0.00 $913.94 "$3,254.55" "$3,254.55" $0.00 $0.00 $913.83 $0.00 "$2,161.81" "$2,161.81" $0.00 "$2,192.50" "$3,472.92" "$3,508.00" $0.00 $0.00 $686.25 $0.00 $0.00 $698.09 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-525 SUP HCPCS C1776 6630-0-525 - CMPNT FEM LG RIGHT NBD DRCN BOTH IP/OP "$3,464.00 " "$2,563.36" $0.00 "$2,771.20" "$1,558.80" "$1,558.80" $0.00 $0.00 $0.00 $721.98 "$2,570.98" "$2,570.98" $0.00 $0.00 $721.90 $0.00 "$1,707.75" "$1,707.75" $0.00 "$1,732.00" "$2,743.49" "$2,771.20" $0.00 $0.00 $542.12 $0.00 $0.00 $551.47 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-610 SUP HCPCS C1776 6630-0-610 - CMPNT FEM XL LEFT BEADED DRCN BOTH IP/OP "$4,464.00 " "$3,303.36" $0.00 "$3,571.20" "$2,008.80" "$2,008.80" $0.00 $0.00 $0.00 $930.41 "$3,313.18" "$3,313.18" $0.00 $0.00 $930.30 $0.00 "$2,200.75" "$2,200.75" $0.00 "$2,232.00" "$3,535.49" "$3,571.20" $0.00 $0.00 $698.62 $0.00 $0.00 $710.67 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-615 SUP HCPCS C1776 6630-0-615 - CMPNT FEM 1 XL LEFT NBD DRCN BOTH IP/OP "$3,525.00 " "$2,608.50" $0.00 "$2,820.00" "$1,586.25" "$1,586.25" $0.00 $0.00 $0.00 $734.70 "$2,616.26" "$2,616.26" $0.00 $0.00 $734.61 $0.00 "$1,737.83" "$1,737.83" $0.00 "$1,762.50" "$2,791.80" "$2,820.00" $0.00 $0.00 $551.66 $0.00 $0.00 $561.18 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-620 SUP HCPCS C1776 6630-0-620 - CMPNT FEM XL RIGHT BEADED DRCN BOTH IP/OP "$4,464.00 " "$3,303.36" $0.00 "$3,571.20" "$2,008.80" "$2,008.80" $0.00 $0.00 $0.00 $930.41 "$3,313.18" "$3,313.18" $0.00 $0.00 $930.30 $0.00 "$2,200.75" "$2,200.75" $0.00 "$2,232.00" "$3,535.49" "$3,571.20" $0.00 $0.00 $698.62 $0.00 $0.00 $710.67 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-625 SUP HCPCS C1776 6630-0-625 - CMPNT FEM 1 XL RIGHT NBD DRCN BOTH IP/OP "$3,525.00 " "$2,608.50" $0.00 "$2,820.00" "$1,586.25" "$1,586.25" $0.00 $0.00 $0.00 $734.70 "$2,616.26" "$2,616.26" $0.00 $0.00 $734.61 $0.00 "$1,737.83" "$1,737.83" $0.00 "$1,762.50" "$2,791.80" "$2,820.00" $0.00 $0.00 $551.66 $0.00 $0.00 $561.18 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-710 SUP HCPCS C1776 6630-0-710 - CMPNT FEM 2XL STD LEFT KNEE BEADED DRCN BOTH IP/OP "$4,464.00 " "$3,303.36" $0.00 "$3,571.20" "$2,008.80" "$2,008.80" $0.00 $0.00 $0.00 $930.41 "$3,313.18" "$3,313.18" $0.00 $0.00 $930.30 $0.00 "$2,200.75" "$2,200.75" $0.00 "$2,232.00" "$3,535.49" "$3,571.20" $0.00 $0.00 $698.62 $0.00 $0.00 $710.67 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-715 SUP HCPCS C1776 6630-0-715 - CMPNT FEM 2XL LEFT NBD DRCN BOTH IP/OP "$3,525.00 " "$2,608.50" $0.00 "$2,820.00" "$1,586.25" "$1,586.25" $0.00 $0.00 $0.00 $734.70 "$2,616.26" "$2,616.26" $0.00 $0.00 $734.61 $0.00 "$1,737.83" "$1,737.83" $0.00 "$1,762.50" "$2,791.80" "$2,820.00" $0.00 $0.00 $551.66 $0.00 $0.00 $561.18 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-720 SUP HCPCS C1776 6630-0-720 - CMPNT FEM 2XL RIGHT BEADED DRCN BOTH IP/OP "$4,464.00 " "$3,303.36" $0.00 "$3,571.20" "$2,008.80" "$2,008.80" $0.00 $0.00 $0.00 $930.41 "$3,313.18" "$3,313.18" $0.00 $0.00 $930.30 $0.00 "$2,200.75" "$2,200.75" $0.00 "$2,232.00" "$3,535.49" "$3,571.20" $0.00 $0.00 $698.62 $0.00 $0.00 $710.67 $0.00 $0.00 $0.00 $0.00 $0.00 6630-0-725 SUP HCPCS C1776 6630-0-725 - CMPNT FEM 2XL RIGHT NBD DRCN BOTH IP/OP "$3,525.00 " "$2,608.50" $0.00 "$2,820.00" "$1,586.25" "$1,586.25" $0.00 $0.00 $0.00 $734.70 "$2,616.26" "$2,616.26" $0.00 $0.00 $734.61 $0.00 "$1,737.83" "$1,737.83" $0.00 "$1,762.50" "$2,791.80" "$2,820.00" $0.00 $0.00 $551.66 $0.00 $0.00 $561.18 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-105 SUP Custom 27803010 6630-6-105 - WEDGE TIBIAL S1 FLAT 5MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-110 SUP Custom 27803010 6630-6-110 - WEDGE TIBIAL S1 HEMIFLAT 10MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-125 SUP Custom 27803010 6630-6-125 - WEDGE TIBIAL S1 FLAT 5MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-130 SUP Custom 27803010 6630-6-130 - WEDGE TIBIAL S1 FLAT 10MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-150 SUP Custom 27803010 6630-6-150 - WEDGE TIBIAL S2 HEMIFLAT 5MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-155 SUP Custom 27803010 6630-6-155 - WEDGE TIBIAL S2 HEMIFLAT 10MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-170 SUP Custom 27803010 6630-6-170 - WEDGE TIBIAL S2 HEMIFLAT 5MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-175 SUP Custom 27803010 6630-6-175 - WEDGE TIBIAL S2 FLAT 10MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-205 SUP Custom 27803010 6630-6-205 - WEDGE TIBIAL M1 FLAT 5MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-210 SUP Custom 27803010 6630-6-210 - WEDGE TIBIAL M1 FLAT 10MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-225 SUP Custom 27803010 6630-6-225 - WEDGE TIBIAL M1 FLAT 5MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-230 SUP Custom 27803010 6630-6-230 - WEDGE TIBIAL M1 FLAT 10MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-250 SUP Custom 27803010 6630-6-250 - WEDGE TIBIAL M2 HEMIFLAT 5MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-255 SUP Custom 27803010 6630-6-255 - WEDGE TIBIAL M2 HEMIFLAT 10MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-270 SUP Custom 27803010 6630-6-270 - WEDGE TIBIAL M2 HEMIFLAT 5MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-275 SUP Custom 27803010 6630-6-275 - WEDGE TIBIAL M2 HEMIFLAT 10MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-305 SUP Custom 27803010 6630-6-305 - WEDGE TIBIAL 1 FLAT 5MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-310 SUP Custom 27803010 6630-6-310 - WEDGE TIBIAL 1 FLAT 10MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-325 SUP Custom 27803010 6630-6-325 - WEDGE TIBIAL 1 FLAT 5MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-330 SUP Custom 27803010 6630-6-330 - WEDGE TIBIAL 1 FLAT 10MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-350 SUP Custom 27803010 6630-6-350 - WEDGE TIBIAL 2 HEMIFLAT 5MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-355 SUP Custom 27803010 6630-6-355 - WEDGE TIBIAL 2 HEMIFLAT 10MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-370 SUP Custom 27803010 6630-6-370 - WEDGE TIBIAL 2 HEMIFLAT 5MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-375 SUP Custom 27803010 6630-6-375 - WEDGE TIBIAL 2 HEMIFLAT 10MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-405 SUP Custom 27803010 6630-6-405 - WEDGE TIBIAL X1 FLAT 5MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-410 SUP Custom 27803010 6630-6-410 - WEDGE TIBIAL X1 FLAT 10MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-425 SUP Custom 27803010 6630-6-425 - WEDGE TIBIAL X1 FLAT 5MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-430 SUP Custom 27803010 6630-6-430 - WEDGE TIBIAL X1 FLAT 10MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-450 SUP Custom 27803010 6630-6-450 - WEDGE TIBIAL X2 FLAT 5MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-455 SUP Custom 27803010 6630-6-455 - WEDGE TIBIAL X2 FLAT 10MM REVISION DURACON KNEE RIGHT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-470 SUP Custom 27803010 6630-6-470 - WEDGE TIBIAL X2 FLAT 5MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-475 SUP Custom 27803010 6630-6-475 - WEDGE TIBIAL X2 FLAT 10MM REVISION DURACON KNEE LEFT BOTH IP/OP "$1,885.00 " "$1,394.90" $0.00 "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.05" "$1,399.05" $0.00 $0.00 $392.83 $0.00 $0.00 $0.00 $0.00 $942.50 "$1,492.92" "$1,508.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-510 SUP Custom 27803010 6630-6-510 - WEDGE TIBIAL S1 FULL FLAT 10MM REVISION DURACON KNEE BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 $0.00 $0.00 $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-515 SUP Custom 27803010 6630-6-515 - WEDGE TIBIAL S2 FULL 10MM REVISION DURACON KNEE BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 $0.00 $0.00 $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-520 SUP Custom 27803010 6630-6-520 - WEDGE TIBIAL M1 FULL 10MM REVISION DURACON KNEE BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 $0.00 $0.00 $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-525 SUP Custom 27803010 6630-6-525 - WEDGE TIBIAL M2 FULL FLAT 10MM REVISION DURACON KNEE BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 $0.00 $0.00 $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-530 SUP Custom 27803010 6630-6-530 - WEDGE TIBIAL 1 FULL FLAT 10MM REVISION DURACON KNEE BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 $0.00 $0.00 $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-535 SUP Custom 27803010 6630-6-535 - WEDGE TIBIAL 2 FULL FLAT 10MM REVISION DURACON KNEE BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 $0.00 $0.00 $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-545 SUP Custom 27803010 6630-6-545 - WEDGE TIBIAL X1 FULL 10MM REVISION DURACON KNEE BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 $0.00 $0.00 $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-6-550 SUP Custom 27803010 6630-6-550 - WEDGE TIBIAL X2 FULL 10MM REVISION DURACON KNEE BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 $0.00 $0.00 $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-005 SUP HCPCS C1776 6630-8-005 - CMPNT FEM 2XS LEFT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,209.00 " "$3,854.66" $0.00 "$4,167.20" "$2,344.05" "$2,344.05" $0.00 $0.00 $0.00 "$1,085.69" "$3,866.12" "$3,866.12" $0.00 $0.00 "$1,085.56" $0.00 "$2,568.04" "$2,568.04" $0.00 "$2,604.50" "$4,125.53" "$4,167.20" $0.00 $0.00 $815.21 $0.00 $0.00 $829.27 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-010 SUP HCPCS C1776 6630-8-010 - CMPNT FEM 2XS RIGHT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,209.00 " "$3,854.66" $0.00 "$4,167.20" "$2,344.05" "$2,344.05" $0.00 $0.00 $0.00 "$1,085.69" "$3,866.12" "$3,866.12" $0.00 $0.00 "$1,085.56" $0.00 "$2,568.04" "$2,568.04" $0.00 "$2,604.50" "$4,125.53" "$4,167.20" $0.00 $0.00 $815.21 $0.00 $0.00 $829.27 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-015 SUP HCPCS C1776 6630-8-015 - CMPNT FEM XS LEFT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,209.00 " "$3,854.66" $0.00 "$4,167.20" "$2,344.05" "$2,344.05" $0.00 $0.00 $0.00 "$1,085.69" "$3,866.12" "$3,866.12" $0.00 $0.00 "$1,085.56" $0.00 "$2,568.04" "$2,568.04" $0.00 "$2,604.50" "$4,125.53" "$4,167.20" $0.00 $0.00 $815.21 $0.00 $0.00 $829.27 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-020 SUP HCPCS C1776 6630-8-020 - CMPNT FEM XS RIGHT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,209.00 " "$3,854.66" $0.00 "$4,167.20" "$2,344.05" "$2,344.05" $0.00 $0.00 $0.00 "$1,085.69" "$3,866.12" "$3,866.12" $0.00 $0.00 "$1,085.56" $0.00 "$2,568.04" "$2,568.04" $0.00 "$2,604.50" "$4,125.53" "$4,167.20" $0.00 $0.00 $815.21 $0.00 $0.00 $829.27 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-025 SUP HCPCS C1776 6630-8-025 - CMPNT FEM SM LEFT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,167.00 " "$3,823.58" $0.00 "$4,133.60" "$2,325.15" "$2,325.15" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.95" "$3,834.95" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.33" "$2,547.33" $0.00 "$2,583.50" "$4,092.26" "$4,133.60" $0.00 $0.00 $808.64 $0.00 $0.00 $822.59 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-030 SUP HCPCS C1776 6630-8-030 - CMPNT FEM SM RIGHT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,167.00 " "$3,823.58" $0.00 "$4,133.60" "$2,325.15" "$2,325.15" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.95" "$3,834.95" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.33" "$2,547.33" $0.00 "$2,583.50" "$4,092.26" "$4,133.60" $0.00 $0.00 $808.64 $0.00 $0.00 $822.59 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-035 SUP HCPCS C1776 6630-8-035 - CMPNT FEM MED LEFT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,167.00 " "$3,823.58" $0.00 "$4,133.60" "$2,325.15" "$2,325.15" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.95" "$3,834.95" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.33" "$2,547.33" $0.00 "$2,583.50" "$4,092.26" "$4,133.60" $0.00 $0.00 $808.64 $0.00 $0.00 $822.59 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-040 SUP HCPCS C1776 6630-8-040 - CMPNT FEM MED RIGHT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,167.00 " "$3,823.58" $0.00 "$4,133.60" "$2,325.15" "$2,325.15" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.95" "$3,834.95" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.33" "$2,547.33" $0.00 "$2,583.50" "$4,092.26" "$4,133.60" $0.00 $0.00 $808.64 $0.00 $0.00 $822.59 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-045 SUP HCPCS C1776 6630-8-045 - CMPNT FEM MED LG LEFT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,167.00 " "$3,823.58" $0.00 "$4,133.60" "$2,325.15" "$2,325.15" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.95" "$3,834.95" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.33" "$2,547.33" $0.00 "$2,583.50" "$4,092.26" "$4,133.60" $0.00 $0.00 $808.64 $0.00 $0.00 $822.59 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-050 SUP HCPCS C1776 6630-8-050 - CMPNT FEM MED LG RIGHT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,167.00 " "$3,823.58" $0.00 "$4,133.60" "$2,325.15" "$2,325.15" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.95" "$3,834.95" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.33" "$2,547.33" $0.00 "$2,583.50" "$4,092.26" "$4,133.60" $0.00 $0.00 $808.64 $0.00 $0.00 $822.59 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-055 SUP HCPCS C1776 6630-8-055 - CMPNT FEM LG LEFT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,167.00 " "$3,823.58" $0.00 "$4,133.60" "$2,325.15" "$2,325.15" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.95" "$3,834.95" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.33" "$2,547.33" $0.00 "$2,583.50" "$4,092.26" "$4,133.60" $0.00 $0.00 $808.64 $0.00 $0.00 $822.59 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-060 SUP HCPCS C1776 6630-8-060 - BSPLT TIB DRCN LG FEM RIGHT BEADED PERIAPT 28MM BOTH IP/OP "$5,167.00 " "$3,823.58" $0.00 "$4,133.60" "$2,325.15" "$2,325.15" $0.00 $0.00 $0.00 "$1,076.93" "$3,834.95" "$3,834.95" $0.00 $0.00 "$1,076.80" $0.00 "$2,547.33" "$2,547.33" $0.00 "$2,583.50" "$4,092.26" "$4,133.60" $0.00 $0.00 $808.64 $0.00 $0.00 $822.59 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-065 SUP HCPCS C1776 6630-8-065 - CMPNT FEM XL LEFT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,209.00 " "$3,854.66" $0.00 "$4,167.20" "$2,344.05" "$2,344.05" $0.00 $0.00 $0.00 "$1,085.69" "$3,866.12" "$3,866.12" $0.00 $0.00 "$1,085.56" $0.00 "$2,568.04" "$2,568.04" $0.00 "$2,604.50" "$4,125.53" "$4,167.20" $0.00 $0.00 $815.21 $0.00 $0.00 $829.27 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-070 SUP HCPCS C1776 6630-8-070 - CMPNT FEM XL RIGHT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,209.00 " "$3,854.66" $0.00 "$4,167.20" "$2,344.05" "$2,344.05" $0.00 $0.00 $0.00 "$1,085.69" "$3,866.12" "$3,866.12" $0.00 $0.00 "$1,085.56" $0.00 "$2,568.04" "$2,568.04" $0.00 "$2,604.50" "$4,125.53" "$4,167.20" $0.00 $0.00 $815.21 $0.00 $0.00 $829.27 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-075 SUP HCPCS C1776 6630-8-075 - CMPNT FEM 2XL LEFT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,209.00 " "$3,854.66" $0.00 "$4,167.20" "$2,344.05" "$2,344.05" $0.00 $0.00 $0.00 "$1,085.69" "$3,866.12" "$3,866.12" $0.00 $0.00 "$1,085.56" $0.00 "$2,568.04" "$2,568.04" $0.00 "$2,604.50" "$4,125.53" "$4,167.20" $0.00 $0.00 $815.21 $0.00 $0.00 $829.27 $0.00 $0.00 $0.00 $0.00 $0.00 6630-8-080 SUP HCPCS C1776 6630-8-080 - CMPNT FEM 2XL RIGHT KNEE BEADED DRCN PERIAPT BOTH IP/OP "$5,209.00 " "$3,854.66" $0.00 "$4,167.20" "$2,344.05" "$2,344.05" $0.00 $0.00 $0.00 "$1,085.69" "$3,866.12" "$3,866.12" $0.00 $0.00 "$1,085.56" $0.00 "$2,568.04" "$2,568.04" $0.00 "$2,604.50" "$4,125.53" "$4,167.20" $0.00 $0.00 $815.21 $0.00 $0.00 $829.27 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-28C SUP Custom 27803010 663-10-28C - INSERT ACETAB 10D C ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-28D SUP Custom 27803010 663-10-28D - INSERT ACETAB 10D D ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-28E SUP Custom 27803010 663-10-28E - INSERT ACETAB 10D E ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-28F SUP Custom 27803010 663-10-28F - INSERT ACETAB 10D F ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-28G SUP Custom 27803010 663-10-28G - INSERT ACETAB 10D G ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-28H SUP Custom 27803010 663-10-28H - INSERT ACETAB 10D H ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-28I SUP Custom 27803010 663-10-28I - INSERT ACETAB 10D I ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-28J SUP Custom 27803010 663-10-28J - INSERT ACETAB 10D J ECCENTRIC 28MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-32D SUP Custom 27803010 663-10-32D - INSERT ACETAB 10D D ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-32E SUP Custom 27803010 663-10-32E - INSERT ACETAB 10D E ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-32F SUP Custom 27803010 663-10-32F - INSERT ACETAB 10D F ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-32G SUP Custom 27803010 663-10-32G - INSERT ACETAB 10D G ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-32H SUP Custom 27803010 663-10-32H - INSERT ACETAB 10D H ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-32I SUP Custom 27803010 663-10-32I - INSERT ACETAB 10D I ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-32J SUP Custom 27803010 663-10-32J - INSERT ACETAB 10D J ECCENTRIC 32MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-36E SUP Custom 27803010 663-10-36E - INSERT ACETAB 10D E ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-36F SUP Custom 27803010 663-10-36F - INSERT ACETAB 10D F ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-36G SUP Custom 27803010 663-10-36G - INSERT ACETAB 10D G ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-36H SUP Custom 27803010 663-10-36H - INSERT ACETAB 10D H ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-36I SUP Custom 27803010 663-10-36I - INSERT ACETAB 10D I ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 663-10-36J SUP Custom 27803010 663-10-36J - INSERT ACETAB 10D J ECCENTRIC 36MM TRIDENT X3 HIP BOTH IP/OP "$1,440.00 " "$1,065.60" $0.00 "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.77" "$1,068.77" $0.00 $0.00 $300.10 $0.00 $0.00 $0.00 $0.00 $720.00 "$1,140.48" "$1,152.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-208 SUP Custom 27803010 6632-0-208 - STAB SURG XS DRCN POR CMNT MONO FEM LEFT BOTH IP/OP "$5,490.00 " "$4,062.60" $0.00 "$4,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,074.68" "$4,074.68" $0.00 $0.00 "$1,144.12" $0.00 $0.00 $0.00 $0.00 "$2,745.00" "$4,348.08" "$4,392.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-210 SUP HCPCS C1776 6632-0-210 - CMPNT FEM SM LEFT KNEE BEADED STAB MDLR DRCN BOTH IP/OP "$7,057.38 " "$5,222.46" $0.00 "$5,645.90" "$3,175.82" "$3,175.82" $0.00 $0.00 $0.00 "$1,470.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,470.76" $0.00 "$3,479.29" "$3,479.29" $0.00 "$3,528.69" "$5,589.44" "$5,645.90" $0.00 $0.00 "$1,104.48" $0.00 $0.00 "$1,123.53" $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-215 SUP HCPCS C1776 6632-0-215 - CMPNT FEM SM LEFT MDLR NBD ASYM DRCN NONSTRL BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-218 SUP HCPCS C1776 6632-0-218 - CMPNT FEM XS RIGHT KNEE CMNT MONO STAB DRCN POR BOTH IP/OP "$5,490.00 " "$4,062.60" $0.00 "$4,392.00" "$2,470.50" "$2,470.50" $0.00 $0.00 $0.00 "$1,144.25" "$4,074.68" "$4,074.68" $0.00 $0.00 "$1,144.12" $0.00 "$2,706.57" "$2,706.57" $0.00 "$2,745.00" "$4,348.08" "$4,392.00" $0.00 $0.00 $859.19 $0.00 $0.00 $874.01 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-220 SUP HCPCS C1776 6632-0-220 - CMPNT FEM SM RIGHT KNEE CRUC RET MDLR BEADED ASMBLY DRCN BOTH IP/OP "$7,057.38 " "$5,222.46" $0.00 "$5,645.90" "$3,175.82" "$3,175.82" $0.00 $0.00 $0.00 "$1,470.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,470.76" $0.00 "$3,479.29" "$3,479.29" $0.00 "$3,528.69" "$5,589.44" "$5,645.90" $0.00 $0.00 "$1,104.48" $0.00 $0.00 "$1,123.53" $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-225 SUP HCPCS C1776 6632-0-225 - CMPNT FEM SM RIGHT KNEE CRUC RET MDLR NBD ASMBLY DRCN BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-310 SUP HCPCS C1776 6632-0-310 - CMPNT FEM MED LEFT KNEE CRUC RET MDLR BEADED ASMBLY DRCN BOTH IP/OP "$7,057.38 " "$5,222.46" $0.00 "$5,645.90" "$3,175.82" "$3,175.82" $0.00 $0.00 $0.00 "$1,470.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,470.76" $0.00 "$3,479.29" "$3,479.29" $0.00 "$3,528.69" "$5,589.44" "$5,645.90" $0.00 $0.00 "$1,104.48" $0.00 $0.00 "$1,123.53" $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-315 SUP HCPCS C1776 6632-0-315 - CMPNT FEM MED LEFT MDLR NBD ASYM DRCN NONSTRL BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-317 SUP HCPCS C1776 6632-0-317 - CMPNT FEM MED NTRL LEFT KNEE CRUC RET NBD MDLR STAB ASMBLY BOTH IP/OP "$3,314.00 " "$2,452.36" $0.00 "$2,651.20" "$1,491.30" "$1,491.30" $0.00 $0.00 $0.00 $690.72 "$2,459.65" "$2,459.65" $0.00 $0.00 $690.64 $0.00 "$1,633.80" "$1,633.80" $0.00 "$1,657.00" "$2,624.69" "$2,651.20" $0.00 $0.00 $518.64 $0.00 $0.00 $527.59 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-325 SUP HCPCS C1776 6632-0-325 - STEM FEM NBD ASY DRCN MED RIGHT NONSTRL BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-327 SUP HCPCS C1776 6632-0-327 - CMPNT FEM MED NTRL RIGHT KNEE CRUC RET NBD MDLR STAB ASMBLY BOTH IP/OP "$3,314.00 " "$2,452.36" $0.00 "$2,651.20" "$1,491.30" "$1,491.30" $0.00 $0.00 $0.00 $690.72 "$2,459.65" "$2,459.65" $0.00 $0.00 $690.64 $0.00 "$1,633.80" "$1,633.80" $0.00 "$1,657.00" "$2,624.69" "$2,651.20" $0.00 $0.00 $518.64 $0.00 $0.00 $527.59 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-410 SUP HCPCS C1776 6632-0-410 - CMPNT FEM MED LG LEFT KNEE CRUC RET MDLR BEADED ASMBLY DRCN BOTH IP/OP "$7,057.38 " "$5,222.46" $0.00 "$5,645.90" "$3,175.82" "$3,175.82" $0.00 $0.00 $0.00 "$1,470.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,470.76" $0.00 "$3,479.29" "$3,479.29" $0.00 "$3,528.69" "$5,589.44" "$5,645.90" $0.00 $0.00 "$1,104.48" $0.00 $0.00 "$1,123.53" $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-415 SUP HCPCS C1776 6632-0-415 - CMPNT FEM MED LG LEFT KNEE CRUC RET MDLR NBD ASMBLY DRCN BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-425 SUP HCPCS C1776 6632-0-425 - CMPNT FEM MED LG RIGHT MDLR NBD ASMBLY DRCN BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-515 SUP HCPCS C1776 6632-0-515 - CMPNT FEM LG LEFT KNEE NBD ASMBLY MDLR DRCN NPOR BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-525 SUP HCPCS C1776 6632-0-525 - CMPNT FEM LG RIGHT NBD MDLR ASMBLY DRCN BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-610 SUP HCPCS C1776 6632-0-610 - CMPNT FEM XL LEFT BEADED MDLR ASMBLY DRCN BOTH IP/OP "$7,192.25 " "$5,322.27" $0.00 "$5,753.80" "$3,236.51" "$3,236.51" $0.00 $0.00 $0.00 "$1,499.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,498.86" $0.00 "$3,545.78" "$3,545.78" $0.00 "$3,596.13" "$5,696.26" "$5,753.80" $0.00 $0.00 "$1,125.59" $0.00 $0.00 "$1,145.01" $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-615 SUP HCPCS C1776 6632-0-615 - CMPNT FEM XL LEFT MDLR NBD ASMBLY DRCN BOTH IP/OP "$3,499.00 " "$2,589.26" $0.00 "$2,799.20" "$1,574.55" "$1,574.55" $0.00 $0.00 $0.00 $729.28 "$2,596.96" "$2,596.96" $0.00 $0.00 $729.19 $0.00 "$1,725.01" "$1,725.01" $0.00 "$1,749.50" "$2,771.21" "$2,799.20" $0.00 $0.00 $547.59 $0.00 $0.00 $557.04 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-620 SUP HCPCS C1776 6632-0-620 - CMPNT FEM XL RIGHT BEADED MDLR ASMBLY DRCN BOTH IP/OP "$7,192.25 " "$5,322.27" $0.00 "$5,753.80" "$3,236.51" "$3,236.51" $0.00 $0.00 $0.00 "$1,499.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,498.86" $0.00 "$3,545.78" "$3,545.78" $0.00 "$3,596.13" "$5,696.26" "$5,753.80" $0.00 $0.00 "$1,125.59" $0.00 $0.00 "$1,145.01" $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-625 SUP HCPCS C1776 6632-0-625 - CMPNT FEM XL RIGHT KNEE CRUC RET NBD MDLR DRCN BOTH IP/OP "$3,499.00 " "$2,589.26" $0.00 "$2,799.20" "$1,574.55" "$1,574.55" $0.00 $0.00 $0.00 $729.28 "$2,596.96" "$2,596.96" $0.00 $0.00 $729.19 $0.00 "$1,725.01" "$1,725.01" $0.00 "$1,749.50" "$2,771.21" "$2,799.20" $0.00 $0.00 $547.59 $0.00 $0.00 $557.04 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-710 SUP HCPCS C1776 6632-0-710 - CMPNT FEM 2XL LEFT KNEE CRUC RET BEADED MDLR DRCN BOTH IP/OP "$7,192.25 " "$5,322.27" $0.00 "$5,753.80" "$3,236.51" "$3,236.51" $0.00 $0.00 $0.00 "$1,499.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,498.86" $0.00 "$3,545.78" "$3,545.78" $0.00 "$3,596.13" "$5,696.26" "$5,753.80" $0.00 $0.00 "$1,125.59" $0.00 $0.00 "$1,145.01" $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-715 SUP HCPCS C1776 6632-0-715 - CMPNT FEM 2XL LEFT KNEE NBD ASMBLY MDLR DRCN NPOR BOTH IP/OP "$3,499.00 " "$2,589.26" $0.00 "$2,799.20" "$1,574.55" "$1,574.55" $0.00 $0.00 $0.00 $729.28 "$2,596.96" "$2,596.96" $0.00 $0.00 $729.19 $0.00 "$1,725.01" "$1,725.01" $0.00 "$1,749.50" "$2,771.21" "$2,799.20" $0.00 $0.00 $547.59 $0.00 $0.00 $557.04 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-720 SUP HCPCS C1776 6632-0-720 - CMPNT FEM 2XL RIGHT BEADED MDLR ASMBLY DRCN BOTH IP/OP "$7,192.25 " "$5,322.27" $0.00 "$5,753.80" "$3,236.51" "$3,236.51" $0.00 $0.00 $0.00 "$1,499.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,498.86" $0.00 "$3,545.78" "$3,545.78" $0.00 "$3,596.13" "$5,696.26" "$5,753.80" $0.00 $0.00 "$1,125.59" $0.00 $0.00 "$1,145.01" $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-725 SUP HCPCS C1776 6632-0-725 - CMPNT FEM 2XL RIGHT KNEE NBD ASMBLY MDLR DRCN NPOR BOTH IP/OP "$3,499.00 " "$2,589.26" $0.00 "$2,799.20" "$1,574.55" "$1,574.55" $0.00 $0.00 $0.00 $729.28 "$2,596.96" "$2,596.96" $0.00 $0.00 $729.19 $0.00 "$1,725.01" "$1,725.01" $0.00 "$1,749.50" "$2,771.21" "$2,799.20" $0.00 $0.00 $547.59 $0.00 $0.00 $557.04 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-750 SUP HCPCS C1713 6632-0-750 - PEG FIX FEM MDLR REPL BOTH IP/OP $524.00 $387.76 $0.00 $419.20 $235.80 $235.80 $0.00 $0.00 $0.00 $109.21 $388.91 $388.91 $0.00 $0.00 $109.20 $0.00 $309.95 $309.95 $0.00 $262.00 $415.01 $419.20 $0.00 $0.00 $82.01 $0.00 $0.00 $83.42 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-810 SUP HCPCS C1776 6632-0-810 - CMPNT FEM SM LEFT MNLTH STAB DRCN BOTH IP/OP "$3,869.00 " "$2,863.06" $0.00 "$3,095.20" "$1,741.05" "$1,741.05" $0.00 $0.00 $0.00 $806.40 "$2,871.57" "$2,871.57" $0.00 $0.00 $806.30 $0.00 "$1,907.42" "$1,907.42" $0.00 "$1,934.50" "$3,064.25" "$3,095.20" $0.00 $0.00 $605.50 $0.00 $0.00 $615.94 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-811 SUP HCPCS C1776 6632-0-811 - CMPNT FEM SM LEFT KNEE CMNT MNLTH STAB DRCN VIT BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-815 SUP HCPCS C1776 6632-0-815 - CMPNT FEM SM RIGHT MNLTH STAB DRCN VIT BOTH IP/OP "$3,869.00 " "$2,863.06" $0.00 "$3,095.20" "$1,741.05" "$1,741.05" $0.00 $0.00 $0.00 $806.40 "$2,871.57" "$2,871.57" $0.00 $0.00 $806.30 $0.00 "$1,907.42" "$1,907.42" $0.00 "$1,934.50" "$3,064.25" "$3,095.20" $0.00 $0.00 $605.50 $0.00 $0.00 $615.94 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-820 SUP HCPCS C1776 6632-0-820 - CMPNT FEM MED LEFT MONOLITHIX STAB DRCN BOTH IP/OP "$3,869.00 " "$2,863.06" $0.00 "$3,095.20" "$1,741.05" "$1,741.05" $0.00 $0.00 $0.00 $806.40 "$2,871.57" "$2,871.57" $0.00 $0.00 $806.30 $0.00 "$1,907.42" "$1,907.42" $0.00 "$1,934.50" "$3,064.25" "$3,095.20" $0.00 $0.00 $605.50 $0.00 $0.00 $615.94 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-821 SUP HCPCS C1776 6632-0-821 - CMPNT FEM MED LEFT KNEE CMNT MNLTH STAB DRCN VIT BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-825 SUP HCPCS C1776 6632-0-825 - COMPONENT FEM MED DRCN CMNT MNLTH STAB KN RT BOTH IP/OP "$3,869.00 " "$2,863.06" $0.00 "$3,095.20" "$1,741.05" "$1,741.05" $0.00 $0.00 $0.00 $806.40 "$2,871.57" "$2,871.57" $0.00 $0.00 $806.30 $0.00 "$1,907.42" "$1,907.42" $0.00 "$1,934.50" "$3,064.25" "$3,095.20" $0.00 $0.00 $605.50 $0.00 $0.00 $615.94 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-826 SUP HCPCS C1776 6632-0-826 - COMPONENT FEM MED DRCN CMNT MNLTH STAB KN RT BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-830 SUP HCPCS C1776 6632-0-830 - COMPONENT FEM MED LG DRCN CMNT MNLTH STAB KN LT BOTH IP/OP "$3,869.00 " "$2,863.06" $0.00 "$3,095.20" "$1,741.05" "$1,741.05" $0.00 $0.00 $0.00 $806.40 "$2,871.57" "$2,871.57" $0.00 $0.00 $806.30 $0.00 "$1,907.42" "$1,907.42" $0.00 "$1,934.50" "$3,064.25" "$3,095.20" $0.00 $0.00 $605.50 $0.00 $0.00 $615.94 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-831 SUP HCPCS C1776 6632-0-831 - COMPONENT FEM MED LG DRCN CMNT MNLTH STAB KN LT BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-835 SUP HCPCS C1776 6632-0-835 - COMPONENT FEM MED LG DRCN CMNT MNLTH STAB KN RT BOTH IP/OP "$3,869.00 " "$2,863.06" $0.00 "$3,095.20" "$1,741.05" "$1,741.05" $0.00 $0.00 $0.00 $806.40 "$2,871.57" "$2,871.57" $0.00 $0.00 $806.30 $0.00 "$1,907.42" "$1,907.42" $0.00 "$1,934.50" "$3,064.25" "$3,095.20" $0.00 $0.00 $605.50 $0.00 $0.00 $615.94 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-836 SUP HCPCS C1776 6632-0-836 - COMPONENT FEM MED LG DRCN CMNT MNLTH STAB KN RT BOTH IP/OP "$3,437.00 " "$2,543.38" $0.00 "$2,749.60" "$1,546.65" "$1,546.65" $0.00 $0.00 $0.00 $716.36 "$2,550.94" "$2,550.94" $0.00 $0.00 $716.27 $0.00 "$1,694.44" "$1,694.44" $0.00 "$1,718.50" "$2,722.10" "$2,749.60" $0.00 $0.00 $537.89 $0.00 $0.00 $547.17 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-840 SUP HCPCS C1776 6632-0-840 - CMPNT FEM LG LEFT MNLTH STAB DRCN VIT BOTH IP/OP "$3,869.00 " "$2,863.06" $0.00 "$3,095.20" "$1,741.05" "$1,741.05" $0.00 $0.00 $0.00 $806.40 "$2,871.57" "$2,871.57" $0.00 $0.00 $806.30 $0.00 "$1,907.42" "$1,907.42" $0.00 "$1,934.50" "$3,064.25" "$3,095.20" $0.00 $0.00 $605.50 $0.00 $0.00 $615.94 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-845 SUP HCPCS C1776 6632-0-845 - CMPNT FEM LG RIGHT MNLTH STAB DRCN BOTH IP/OP "$3,869.00 " "$2,863.06" $0.00 "$3,095.20" "$1,741.05" "$1,741.05" $0.00 $0.00 $0.00 $806.40 "$2,871.57" "$2,871.57" $0.00 $0.00 $806.30 $0.00 "$1,907.42" "$1,907.42" $0.00 "$1,934.50" "$3,064.25" "$3,095.20" $0.00 $0.00 $605.50 $0.00 $0.00 $615.94 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-855 SUP HCPCS C1776 6632-0-855 - STAB FEM DRCN XL RIGHT MONO BOTH IP/OP "$3,941.00 " "$2,916.34" $0.00 "$3,152.80" "$1,773.45" "$1,773.45" $0.00 $0.00 $0.00 $821.40 "$2,925.01" "$2,925.01" $0.00 $0.00 $821.30 $0.00 "$1,942.91" "$1,942.91" $0.00 "$1,970.50" "$3,121.27" "$3,152.80" $0.00 $0.00 $616.77 $0.00 $0.00 $627.41 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-860 SUP HCPCS C1776 6632-0-860 - CMPNT FEM 2XL LEFT MNLTH STAB DRCN BLK BOTH IP/OP "$3,941.00 " "$2,916.34" $0.00 "$3,152.80" "$1,773.45" "$1,773.45" $0.00 $0.00 $0.00 $821.40 "$2,925.01" "$2,925.01" $0.00 $0.00 $821.30 $0.00 "$1,942.91" "$1,942.91" $0.00 "$1,970.50" "$3,121.27" "$3,152.80" $0.00 $0.00 $616.77 $0.00 $0.00 $627.41 $0.00 $0.00 $0.00 $0.00 $0.00 6632-0-865 SUP HCPCS C1776 6632-0-865 - CMPNT FEM 2XL RIGHT MNLTH STAB DRCN BOTH IP/OP "$3,941.00 " "$2,916.34" $0.00 "$3,152.80" "$1,773.45" "$1,773.45" $0.00 $0.00 $0.00 $821.40 "$2,925.01" "$2,925.01" $0.00 $0.00 $821.30 $0.00 "$1,942.91" "$1,942.91" $0.00 "$1,970.50" "$3,121.27" "$3,152.80" $0.00 $0.00 $616.77 $0.00 $0.00 $627.41 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-301 SUP HCPCS C1776 6632-3-301 - BSPLT TIB DRCN XS1 BEADED CRCIFRM NPOR BOTH IP/OP "$2,891.00 " "$2,139.34" $0.00 "$2,312.80" "$1,300.95" "$1,300.95" $0.00 $0.00 $0.00 $602.56 "$2,145.70" "$2,145.70" $0.00 $0.00 $602.48 $0.00 "$1,425.26" "$1,425.26" $0.00 "$1,445.50" "$2,289.67" "$2,312.80" $0.00 $0.00 $452.44 $0.00 $0.00 $460.25 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-303 SUP HCPCS C1776 6632-3-303 - BSPLT TIB DRCN 2 XS KNEE CRCIFRM BEADED POR BOTH IP/OP "$2,891.00 " "$2,139.34" $0.00 "$2,312.80" "$1,300.95" "$1,300.95" $0.00 $0.00 $0.00 $602.56 "$2,145.70" "$2,145.70" $0.00 $0.00 $602.48 $0.00 "$1,425.26" "$1,425.26" $0.00 "$1,445.50" "$2,289.67" "$2,312.80" $0.00 $0.00 $452.44 $0.00 $0.00 $460.25 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-305 SUP HCPCS C1776 6632-3-305 - BSPLT TIB DRCN 1 SM CRCIFRM BSPLT POR BOTH IP/OP "$2,838.00 " "$2,100.12" $0.00 "$2,270.40" "$1,277.10" "$1,277.10" $0.00 $0.00 $0.00 $591.51 "$2,106.36" "$2,106.36" $0.00 $0.00 $591.44 $0.00 "$1,399.13" "$1,399.13" $0.00 "$1,419.00" "$2,247.70" "$2,270.40" $0.00 $0.00 $444.15 $0.00 $0.00 $451.81 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-310 SUP HCPCS C1776 6632-3-310 - BSPLT TIB DRCN 2 SM KNEE BEADED CRCIFRM POR BOTH IP/OP "$2,838.00 " "$2,100.12" $0.00 "$2,270.40" "$1,277.10" "$1,277.10" $0.00 $0.00 $0.00 $591.51 "$2,106.36" "$2,106.36" $0.00 $0.00 $591.44 $0.00 "$1,399.13" "$1,399.13" $0.00 "$1,419.00" "$2,247.70" "$2,270.40" $0.00 $0.00 $444.15 $0.00 $0.00 $451.81 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-315 SUP HCPCS C1776 6632-3-315 - BSPLT TIB DRCN 1 MED KNEE BEADED CRCIFRM POR BOTH IP/OP "$2,838.00 " "$2,100.12" $0.00 "$2,270.40" "$1,277.10" "$1,277.10" $0.00 $0.00 $0.00 $591.51 "$2,106.36" "$2,106.36" $0.00 $0.00 $591.44 $0.00 "$1,399.13" "$1,399.13" $0.00 "$1,419.00" "$2,247.70" "$2,270.40" $0.00 $0.00 $444.15 $0.00 $0.00 $451.81 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-320 SUP HCPCS C1776 6632-3-320 - BSPLT TIB DRCN 2 MED KNEE CRCIFRM POR BOTH IP/OP "$2,838.00 " "$2,100.12" $0.00 "$2,270.40" "$1,277.10" "$1,277.10" $0.00 $0.00 $0.00 $591.51 "$2,106.36" "$2,106.36" $0.00 $0.00 $591.44 $0.00 "$1,399.13" "$1,399.13" $0.00 "$1,419.00" "$2,247.70" "$2,270.40" $0.00 $0.00 $444.15 $0.00 $0.00 $451.81 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-325 SUP HCPCS C1776 6632-3-325 - BSPLT TIB DRCN 1 LG KNEE BEADED CRCIFRM POR BOTH IP/OP "$2,838.00 " "$2,100.12" $0.00 "$2,270.40" "$1,277.10" "$1,277.10" $0.00 $0.00 $0.00 $591.51 "$2,106.36" "$2,106.36" $0.00 $0.00 $591.44 $0.00 "$1,399.13" "$1,399.13" $0.00 "$1,419.00" "$2,247.70" "$2,270.40" $0.00 $0.00 $444.15 $0.00 $0.00 $451.81 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-330 SUP HCPCS C1776 6632-3-330 - BSPLT TIB DRCN 2 LG KNEE BEADED CRCIFRM POR BOTH IP/OP "$2,838.00 " "$2,100.12" $0.00 "$2,270.40" "$1,277.10" "$1,277.10" $0.00 $0.00 $0.00 $591.51 "$2,106.36" "$2,106.36" $0.00 $0.00 $591.44 $0.00 "$1,399.13" "$1,399.13" $0.00 "$1,419.00" "$2,247.70" "$2,270.40" $0.00 $0.00 $444.15 $0.00 $0.00 $451.81 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-335 SUP HCPCS C1776 6632-3-335 - BSPLT TIB DRCN 1 XL KNEE BEADED CRCIFRM POR BOTH IP/OP "$2,891.00 " "$2,139.34" $0.00 "$2,312.80" "$1,300.95" "$1,300.95" $0.00 $0.00 $0.00 $602.56 "$2,145.70" "$2,145.70" $0.00 $0.00 $602.48 $0.00 "$1,425.26" "$1,425.26" $0.00 "$1,445.50" "$2,289.67" "$2,312.80" $0.00 $0.00 $452.44 $0.00 $0.00 $460.25 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-340 SUP HCPCS C1776 6632-3-340 - BSPLT TIB DRCN 2 XL KNEE BEADED CRCIFRM POR BOTH IP/OP "$2,891.00 " "$2,139.34" $0.00 "$2,312.80" "$1,300.95" "$1,300.95" $0.00 $0.00 $0.00 $602.56 "$2,145.70" "$2,145.70" $0.00 $0.00 $602.48 $0.00 "$1,425.26" "$1,425.26" $0.00 "$1,445.50" "$2,289.67" "$2,312.80" $0.00 $0.00 $452.44 $0.00 $0.00 $460.25 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-401 SUP HCPCS C1776 6632-3-401 - BSPLT TIB DRCN 1 XS NBD CRCIFRM BOTH IP/OP "$1,918.00 " "$1,419.32" $0.00 "$1,534.40" $863.10 $863.10 $0.00 $0.00 $0.00 $399.76 "$1,423.54" "$1,423.54" $0.00 $0.00 $399.71 $0.00 "$1,134.50" "$1,134.50" $0.00 $959.00 "$1,519.06" "$1,534.40" $0.00 $0.00 $300.17 $0.00 $0.00 $305.35 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-403 SUP HCPCS C1776 6632-3-403 - BSPLT TIB DRCN 2 XS NBD CRCIFRM BOTH IP/OP "$2,149.00 " "$1,590.26" $0.00 "$1,719.20" $967.05 $967.05 $0.00 $0.00 $0.00 $447.91 "$1,594.99" "$1,594.99" $0.00 $0.00 $447.85 $0.00 "$1,271.13" "$1,271.13" $0.00 "$1,074.50" "$1,702.01" "$1,719.20" $0.00 $0.00 $336.32 $0.00 $0.00 $342.12 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-405 SUP HCPCS C1776 6632-3-405 - BSPLT TIB DRCN S1 NBD CRCIFRM NPOR BOTH IP/OP "$2,167.00 " "$1,603.58" $0.00 "$1,733.60" $975.15 $975.15 $0.00 $0.00 $0.00 $451.66 "$1,608.35" "$1,608.35" $0.00 $0.00 $451.60 $0.00 "$1,281.78" "$1,281.78" $0.00 "$1,083.50" "$1,716.26" "$1,733.60" $0.00 $0.00 $339.14 $0.00 $0.00 $344.99 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-410 SUP HCPCS C1776 6632-3-410 - BSPLT TIB DRCN S2 NBD CRCIFRM NPOR BOTH IP/OP "$2,167.00 " "$1,603.58" $0.00 "$1,733.60" $975.15 $975.15 $0.00 $0.00 $0.00 $451.66 "$1,608.35" "$1,608.35" $0.00 $0.00 $451.60 $0.00 "$1,281.78" "$1,281.78" $0.00 "$1,083.50" "$1,716.26" "$1,733.60" $0.00 $0.00 $339.14 $0.00 $0.00 $344.99 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-415 SUP HCPCS C1776 6632-3-415 - BSPLT TIB DRCN M1 NBD CRCIFRM NPOR BOTH IP/OP "$2,131.00 " "$1,576.94" $0.00 "$1,704.80" $958.95 $958.95 $0.00 $0.00 $0.00 $444.15 "$1,581.63" "$1,581.63" $0.00 $0.00 $444.10 $0.00 "$1,260.49" "$1,260.49" $0.00 "$1,065.50" "$1,687.75" "$1,704.80" $0.00 $0.00 $333.50 $0.00 $0.00 $339.26 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-420 SUP HCPCS C1776 6632-3-420 - BSPLT TIB DRCN M2 NBD CRCIFRM NPOR BOTH IP/OP "$2,131.00 " "$1,576.94" $0.00 "$1,704.80" $958.95 $958.95 $0.00 $0.00 $0.00 $444.15 "$1,581.63" "$1,581.63" $0.00 $0.00 $444.10 $0.00 "$1,260.49" "$1,260.49" $0.00 "$1,065.50" "$1,687.75" "$1,704.80" $0.00 $0.00 $333.50 $0.00 $0.00 $339.26 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-425 SUP HCPCS C1776 6632-3-425 - BSPLT TIB DRCN 1 NBD CRCIFRM NPOR BOTH IP/OP "$2,131.00 " "$1,576.94" $0.00 "$1,704.80" $958.95 $958.95 $0.00 $0.00 $0.00 $444.15 "$1,581.63" "$1,581.63" $0.00 $0.00 $444.10 $0.00 "$1,260.49" "$1,260.49" $0.00 "$1,065.50" "$1,687.75" "$1,704.80" $0.00 $0.00 $333.50 $0.00 $0.00 $339.26 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-430 SUP HCPCS C1776 6632-3-430 - BSPLT TIB DRCN 2 NBD CRCIFRM NPOR BOTH IP/OP "$2,131.00 " "$1,576.94" $0.00 "$1,704.80" $958.95 $958.95 $0.00 $0.00 $0.00 $444.15 "$1,581.63" "$1,581.63" $0.00 $0.00 $444.10 $0.00 "$1,260.49" "$1,260.49" $0.00 "$1,065.50" "$1,687.75" "$1,704.80" $0.00 $0.00 $333.50 $0.00 $0.00 $339.26 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-435 SUP HCPCS C1776 6632-3-435 - BSPLT TIB DRCN X1 NBD CRCIFRM NPOR BOTH IP/OP "$2,167.00 " "$1,603.58" $0.00 "$1,733.60" $975.15 $975.15 $0.00 $0.00 $0.00 $451.66 "$1,608.35" "$1,608.35" $0.00 $0.00 $451.60 $0.00 "$1,281.78" "$1,281.78" $0.00 "$1,083.50" "$1,716.26" "$1,733.60" $0.00 $0.00 $339.14 $0.00 $0.00 $344.99 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-440 SUP HCPCS C1776 6632-3-440 - BSPLT TIB DRCN 2 XL KNEE NBD CRCIFRM NPOR BOTH IP/OP "$2,167.00 " "$1,603.58" $0.00 "$1,733.60" $975.15 $975.15 $0.00 $0.00 $0.00 $451.66 "$1,608.35" "$1,608.35" $0.00 $0.00 $451.60 $0.00 "$1,281.78" "$1,281.78" $0.00 "$1,083.50" "$1,716.26" "$1,733.60" $0.00 $0.00 $339.14 $0.00 $0.00 $344.99 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-505 SUP HCPCS C1776 6632-3-505 - BSPLT TIB DRCN 1 SM KNEE BEADED CRCIFRM PERIAPT BOTH IP/OP "$3,355.00 " "$2,482.70" $0.00 "$2,684.00" "$1,509.75" "$1,509.75" $0.00 $0.00 $0.00 $699.27 "$2,490.08" "$2,490.08" $0.00 $0.00 $699.18 $0.00 "$1,654.02" "$1,654.02" $0.00 "$1,677.50" "$2,657.16" "$2,684.00" $0.00 $0.00 $525.06 $0.00 $0.00 $534.12 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-510 SUP HCPCS C1776 6632-3-510 - BSPLT TIB DRCN S2 BEADED CRCIFRM PERIAPT BOTH IP/OP "$3,355.00 " "$2,482.70" $0.00 "$2,684.00" "$1,509.75" "$1,509.75" $0.00 $0.00 $0.00 $699.27 "$2,490.08" "$2,490.08" $0.00 $0.00 $699.18 $0.00 "$1,654.02" "$1,654.02" $0.00 "$1,677.50" "$2,657.16" "$2,684.00" $0.00 $0.00 $525.06 $0.00 $0.00 $534.12 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-515 SUP HCPCS C1776 6632-3-515 - BSPLT TIB DRCN M1 BEADED CRCIFRM PERIAPT BOTH IP/OP "$3,339.00 " "$2,470.86" $0.00 "$2,671.20" "$1,502.55" "$1,502.55" $0.00 $0.00 $0.00 $695.93 "$2,478.21" "$2,478.21" $0.00 $0.00 $695.85 $0.00 "$1,646.13" "$1,646.13" $0.00 "$1,669.50" "$2,644.49" "$2,671.20" $0.00 $0.00 $522.55 $0.00 $0.00 $531.57 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-520 SUP HCPCS C1776 6632-3-520 - BSPLT TIB DRCN M2 BEADED CRCIFRM PERIAPT BOTH IP/OP "$3,339.00 " "$2,470.86" $0.00 "$2,671.20" "$1,502.55" "$1,502.55" $0.00 $0.00 $0.00 $695.93 "$2,478.21" "$2,478.21" $0.00 $0.00 $695.85 $0.00 "$1,646.13" "$1,646.13" $0.00 "$1,669.50" "$2,644.49" "$2,671.20" $0.00 $0.00 $522.55 $0.00 $0.00 $531.57 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-525 SUP HCPCS C1776 6632-3-525 - BSPLT TIB DRCN 1 LG KNEE BEADED CRCIFRM PERIAPT BOTH IP/OP "$3,339.00 " "$2,470.86" $0.00 "$2,671.20" "$1,502.55" "$1,502.55" $0.00 $0.00 $0.00 $695.93 "$2,478.21" "$2,478.21" $0.00 $0.00 $695.85 $0.00 "$1,646.13" "$1,646.13" $0.00 "$1,669.50" "$2,644.49" "$2,671.20" $0.00 $0.00 $522.55 $0.00 $0.00 $531.57 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-530 SUP HCPCS C1776 6632-3-530 - BSPLT TIB DRCN 2 LG KNEE BEADED CRCIFRM PERIAPT BOTH IP/OP "$3,339.00 " "$2,470.86" $0.00 "$2,671.20" "$1,502.55" "$1,502.55" $0.00 $0.00 $0.00 $695.93 "$2,478.21" "$2,478.21" $0.00 $0.00 $695.85 $0.00 "$1,646.13" "$1,646.13" $0.00 "$1,669.50" "$2,644.49" "$2,671.20" $0.00 $0.00 $522.55 $0.00 $0.00 $531.57 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-535 SUP HCPCS C1776 6632-3-535 - BSPLT TIB DRCN 1 XL KNEE BEADED CRCIFRM PERIAPT BOTH IP/OP "$3,355.00 " "$2,482.70" $0.00 "$2,684.00" "$1,509.75" "$1,509.75" $0.00 $0.00 $0.00 $699.27 "$2,490.08" "$2,490.08" $0.00 $0.00 $699.18 $0.00 "$1,654.02" "$1,654.02" $0.00 "$1,677.50" "$2,657.16" "$2,684.00" $0.00 $0.00 $525.06 $0.00 $0.00 $534.12 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-540 SUP HCPCS C1776 6632-3-540 - BSPLT TIB DRCN 2 XL KNEE BEADED CRCIFRM PERIAPT BOTH IP/OP "$3,355.00 " "$2,482.70" $0.00 "$2,684.00" "$1,509.75" "$1,509.75" $0.00 $0.00 $0.00 $699.27 "$2,490.08" "$2,490.08" $0.00 $0.00 $699.18 $0.00 "$1,654.02" "$1,654.02" $0.00 "$1,677.50" "$2,657.16" "$2,684.00" $0.00 $0.00 $525.06 $0.00 $0.00 $534.12 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-603 SUP HCPCS C1776 6632-3-603 - BSPLT TIB DRCN 1 MED UNV KNEE NBD CRCIFRM NPOR BOTH IP/OP "$2,169.00 " "$1,605.06" $0.00 "$1,735.20" $976.05 $976.05 $0.00 $0.00 $0.00 $452.07 "$1,609.83" "$1,609.83" $0.00 $0.00 $452.02 $0.00 "$1,282.96" "$1,282.96" $0.00 "$1,084.50" "$1,717.85" "$1,735.20" $0.00 $0.00 $339.45 $0.00 $0.00 $345.30 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-605 SUP HCPCS C1776 6632-3-605 - BSPLT TIB DRCN S1 UNV NBD CRCIFRM NPOR BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-610 SUP HCPCS C1776 6632-3-610 - BSPLT TIB DRCN S2 NBD CRCIFRM NPOR BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-615 SUP HCPCS C1776 6632-3-615 - BSPLT TIB M1 NPOR HWMDC BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-620 SUP HCPCS C1776 6632-3-620 - BSPLT TIB DRCN 2 MED UNV KNEE NBD CRCIFRM NPOR BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-625 SUP HCPCS C1776 6632-3-625 - BSPLT TIB DRCN 1 NBD CRCIFRM NPOR BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-630 SUP HCPCS C1776 6632-3-630 - BSPLT TIB DRCN 2 LG UNV KNEE NBD CRCIFRM NPOR BOTH IP/OP "$2,130.00 " "$1,576.20" $0.00 "$1,704.00" $958.50 $958.50 $0.00 $0.00 $0.00 $443.95 "$1,580.89" "$1,580.89" $0.00 $0.00 $443.89 $0.00 "$1,259.90" "$1,259.90" $0.00 "$1,065.00" "$1,686.96" "$1,704.00" $0.00 $0.00 $333.35 $0.00 $0.00 $339.10 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-635 SUP HCPCS C1776 6632-3-635 - BSPLT TIB DRCN 1 XL UNV KNEE NBD CRCIFRM NPOR BOTH IP/OP "$2,169.00 " "$1,605.06" $0.00 "$1,735.20" $976.05 $976.05 $0.00 $0.00 $0.00 $452.07 "$1,609.83" "$1,609.83" $0.00 $0.00 $452.02 $0.00 "$1,282.96" "$1,282.96" $0.00 "$1,084.50" "$1,717.85" "$1,735.20" $0.00 $0.00 $339.45 $0.00 $0.00 $345.30 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-640 SUP HCPCS C1776 6632-3-640 - BSPLT TIB DRCN X2 NBD CRCIFRM NPOR BOTH IP/OP "$2,169.00 " "$1,605.06" $0.00 "$1,735.20" $976.05 $976.05 $0.00 $0.00 $0.00 $452.07 "$1,609.83" "$1,609.83" $0.00 $0.00 $452.02 $0.00 "$1,282.96" "$1,282.96" $0.00 "$1,084.50" "$1,717.85" "$1,735.20" $0.00 $0.00 $339.45 $0.00 $0.00 $345.30 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-701 SUP HCPCS C1776 6632-3-701 - BSPLT TIB DRCN XS1 UNV KNEE BEADED POR 62X37MM BOTH IP/OP "$2,919.00 " "$2,160.06" $0.00 "$2,335.20" "$1,313.55" "$1,313.55" $0.00 $0.00 $0.00 $608.39 "$2,166.48" "$2,166.48" $0.00 $0.00 $608.32 $0.00 "$1,439.07" "$1,439.07" $0.00 "$1,459.50" "$2,311.85" "$2,335.20" $0.00 $0.00 $456.82 $0.00 $0.00 $464.70 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-703 SUP HCPCS C1776 6632-3-703 - BSPLT TIB DRCN XS2 UNV KNEE BEADED POR 64X39MM BOTH IP/OP "$2,919.00 " "$2,160.06" $0.00 "$2,335.20" "$1,313.55" "$1,313.55" $0.00 $0.00 $0.00 $608.39 "$2,166.48" "$2,166.48" $0.00 $0.00 $608.32 $0.00 "$1,439.07" "$1,439.07" $0.00 "$1,459.50" "$2,311.85" "$2,335.20" $0.00 $0.00 $456.82 $0.00 $0.00 $464.70 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-705 SUP HCPCS C1776 6632-3-705 - BSPLT TIB DRCN S1 UNV KNEE BEADED POR 67X42MM BOTH IP/OP "$2,865.00 " "$2,120.10" $0.00 "$2,292.00" "$1,289.25" "$1,289.25" $0.00 $0.00 $0.00 $597.14 "$2,126.40" "$2,126.40" $0.00 $0.00 $597.07 $0.00 "$1,412.45" "$1,412.45" $0.00 "$1,432.50" "$2,269.08" "$2,292.00" $0.00 $0.00 $448.37 $0.00 $0.00 $456.11 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-710 SUP HCPCS C1776 6632-3-710 - BSPLT TIB DRCN S2 UNV KNEE BEADED POR 69X45MM BOTH IP/OP "$2,865.00 " "$2,120.10" $0.00 "$2,292.00" "$1,289.25" "$1,289.25" $0.00 $0.00 $0.00 $597.14 "$2,126.40" "$2,126.40" $0.00 $0.00 $597.07 $0.00 "$1,412.45" "$1,412.45" $0.00 "$1,432.50" "$2,269.08" "$2,292.00" $0.00 $0.00 $448.37 $0.00 $0.00 $456.11 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-715 SUP HCPCS C1776 6632-3-715 - BSPLT TIB DRCN M1 UNV KNEE BEADED POR 72X48MM BOTH IP/OP "$2,865.00 " "$2,120.10" $0.00 "$2,292.00" "$1,289.25" "$1,289.25" $0.00 $0.00 $0.00 $597.14 "$2,126.40" "$2,126.40" $0.00 $0.00 $597.07 $0.00 "$1,412.45" "$1,412.45" $0.00 "$1,432.50" "$2,269.08" "$2,292.00" $0.00 $0.00 $448.37 $0.00 $0.00 $456.11 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-720 SUP HCPCS C1776 6632-3-720 - BSPLT TIB DRCN M2 BEADED CRCIFRM NPOR BOTH IP/OP "$2,865.00 " "$2,120.10" $0.00 "$2,292.00" "$1,289.25" "$1,289.25" $0.00 $0.00 $0.00 $597.14 "$2,126.40" "$2,126.40" $0.00 $0.00 $597.07 $0.00 "$1,412.45" "$1,412.45" $0.00 "$1,432.50" "$2,269.08" "$2,292.00" $0.00 $0.00 $448.37 $0.00 $0.00 $456.11 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-725 SUP HCPCS C1776 6632-3-725 - BSPLT TIB DRCN UNV KNEE SCR POR 77X53MM HWMDC X 1 BOTH IP/OP "$2,865.00 " "$2,120.10" $0.00 "$2,292.00" "$1,289.25" "$1,289.25" $0.00 $0.00 $0.00 $597.14 "$2,126.40" "$2,126.40" $0.00 $0.00 $597.07 $0.00 "$1,412.45" "$1,412.45" $0.00 "$1,432.50" "$2,269.08" "$2,292.00" $0.00 $0.00 $448.37 $0.00 $0.00 $456.11 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-730 SUP HCPCS C1776 6632-3-730 - BSPLT TIB DRCN X2 UNV KNEE SCR FIX POR 79X55MM BOTH IP/OP "$2,865.00 " "$2,120.10" $0.00 "$2,292.00" "$1,289.25" "$1,289.25" $0.00 $0.00 $0.00 $597.14 "$2,126.40" "$2,126.40" $0.00 $0.00 $597.07 $0.00 "$1,412.45" "$1,412.45" $0.00 "$1,432.50" "$2,269.08" "$2,292.00" $0.00 $0.00 $448.37 $0.00 $0.00 $456.11 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-735 SUP HCPCS C1776 6632-3-735 - BSPLT TIB DRCN X1 UNV KNEE BEADED POR 82X58MM BOTH IP/OP "$2,919.00 " "$2,160.06" $0.00 "$2,335.20" "$1,313.55" "$1,313.55" $0.00 $0.00 $0.00 $608.39 "$2,166.48" "$2,166.48" $0.00 $0.00 $608.32 $0.00 "$1,439.07" "$1,439.07" $0.00 "$1,459.50" "$2,311.85" "$2,335.20" $0.00 $0.00 $456.82 $0.00 $0.00 $464.70 $0.00 $0.00 $0.00 $0.00 $0.00 6632-3-740 SUP HCPCS C1776 6632-3-740 - BSPLT TIB DRCN X2 UNV KNEE SCR FIX POR 85X60MM BOTH IP/OP "$2,919.00 " "$2,160.06" $0.00 "$2,335.20" "$1,313.55" "$1,313.55" $0.00 $0.00 $0.00 $608.39 "$2,166.48" "$2,166.48" $0.00 $0.00 $608.32 $0.00 "$1,439.07" "$1,439.07" $0.00 "$1,459.50" "$2,311.85" "$2,335.20" $0.00 $0.00 $456.82 $0.00 $0.00 $464.70 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-080 SUP Custom 27803010 6632-5-080 - SPACER FEM 5MM LEFT MDL KNEE BOTH IP/OP "$1,794.00 " "$1,327.56" $0.00 "$1,435.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,331.51" "$1,331.51" $0.00 $0.00 $373.87 $0.00 $0.00 $0.00 $0.00 $897.00 "$1,420.85" "$1,435.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-085 SUP Custom 27803010 6632-5-085 - SPACER FEM 5MM RIGHT MDL KNEE BOTH IP/OP "$1,794.00 " "$1,327.56" $0.00 "$1,435.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,331.51" "$1,331.51" $0.00 $0.00 $373.87 $0.00 $0.00 $0.00 $0.00 $897.00 "$1,420.85" "$1,435.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-090 SUP Custom 27803010 6632-5-090 - SPACER FEM 5MM DRCN XS LEFT DISTAL LAT BOTH IP/OP "$1,737.13 " "$1,285.48" $0.00 "$1,389.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.29" "$1,289.29" $0.00 $0.00 $362.02 $0.00 $0.00 $0.00 $0.00 $868.56 "$1,375.81" "$1,389.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-100 SUP Custom 27803010 6632-5-100 - SPACER FEM 5MM DRCN SM LEFT DISTAL MDL VIT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-105 SUP Custom 27803010 6632-5-105 - SPACER FEM 5MM DRCN SM RIGHT DISTAL MDL BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-110 SUP Custom 27803010 6632-5-110 - SPACER FEM 5MM DRCN SM LEFT DISTAL LAT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-115 SUP Custom 27803010 6632-5-115 - SPACER FEM 5MM DRCN SM RIGHT DISTAL LAT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-120 SUP Custom 27803010 6632-5-120 - SPACER FEM 5MM DRCN MED LEFT DISTAL MDL BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-125 SUP Custom 27803010 6632-5-125 - SPACER FEM 5MM DRCN MED RIGHT DISTAL MDL BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-130 SUP Custom 27803010 6632-5-130 - SPACER FEM 5MM DRCN MED LEFT DISTAL LAT VIT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-135 SUP Custom 27803010 6632-5-135 - SPACER FEM 5MM DRCN MED RIGHT DISTAL LAT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-140 SUP Custom 27803010 6632-5-140 - SPACER FEM 5MM DRCN MED LG LEFT DISTAL MDL VIT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-145 SUP Custom 27803010 6632-5-145 - SPACER FEM 5MM DRCN MED LG RIGHT DISTAL MDL VIT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-150 SUP Custom 27803010 6632-5-150 - SPACER FEM 5MM DRCN MED LG LEFT DISTAL LAT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-155 SUP Custom 27803010 6632-5-155 - SPACER FEM 5MM DRCN MED LG RIGHT DISTAL LAT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-160 SUP Custom 27803010 6632-5-160 - SPACER FEM 5MM DRCN LG LEFT DISTAL MDL BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-165 SUP Custom 27803010 6632-5-165 - SPACER FEM 5MM DRCN LG RIGHT DISTAL MDL BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-170 SUP Custom 27803010 6632-5-170 - SPACER FEM 5MM DRCN LG LEFT DISTAL LAT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-175 SUP Custom 27803010 6632-5-175 - SPACER FEM 5MM DRCN LG RIGHT DISTAL LAT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-180 SUP Custom 27803010 6632-5-180 - SPACER FEM 5MM DRCN XL LEFT DISTAL MDL VIT BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-185 SUP Custom 27803010 6632-5-185 - SPACER FEM 5MM DRCN XL RIGHT DISTAL MDL VIT BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-190 SUP Custom 27803010 6632-5-190 - SPACER FEM 5MM DRCN XL LEFT DISTAL LAT BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-195 SUP Custom 27803010 6632-5-195 - SPACER FEM 5MM DRCN XL RIGHT DISTAL LAT VIT BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-450 SUP Custom 27803010 6632-5-450 - STABILIZER SRG S/MED ML DRCN MDLR KN BOTH IP/OP $414.00 $306.36 $0.00 $331.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.27 $307.27 $0.00 $0.00 $86.28 $0.00 $0.00 $0.00 $0.00 $207.00 $327.89 $331.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-5-600 SUP HCPCS C1713 6632-5-600 - SCREW BONE 5MM DRCN VIT DISTAL FEM LCK SMPL BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $54.00 $54.00 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-100 SUP Custom 27803010 6632-6-100 - SPACER FEM SM 10MM DRCN KN LT MDL BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-105 SUP Custom 27803010 6632-6-105 - SPACER FEM 10MM DRCN SM RIGHT MDL DP VIT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-110 SUP Custom 27803010 6632-6-110 - SPACER FEM 10MM DRCN SM L/L DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-115 SUP Custom 27803010 6632-6-115 - SPACER FEM 10MM DRCN SM RIGHT LAT DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-120 SUP Custom 27803010 6632-6-120 - SPACER FEM 10MM DRCN MED LEFT MDL DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-125 SUP Custom 27803010 6632-6-125 - SPACER FEM 10MM DRCN MED RIGHT MDL DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-130 SUP Custom 27803010 6632-6-130 - SPACER FEM 10MM DRCN MED L/L DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-135 SUP Custom 27803010 6632-6-135 - SPACER FEM 10MM DRCN MED RIGHT LAT DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-140 SUP Custom 27803010 6632-6-140 - SPACER FEM 10MM DRCN MED LG LEFT MDL DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-145 SUP Custom 27803010 6632-6-145 - SPACER FEM 10MM DRCN MED LG RIGHT MDL DP VIT BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-150 SUP Custom 27803010 6632-6-150 - SPACER FEM 10MM DRCN MED LG L/L DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-155 SUP Custom 27803010 6632-6-155 - SPACER FEM 10MM DRCN MED LG RIGHT LAT DP VIT SPCR STAB BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-160 SUP Custom 27803010 6632-6-160 - SPACER FEM 10MM DRCN LG LEFT MDL DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-165 SUP Custom 27803010 6632-6-165 - SPACER FEM 10MM DRCN LG RIGHT MDL DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-170 SUP Custom 27803010 6632-6-170 - SPACER FEM 10MM DRCN LG L/L DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-175 SUP Custom 27803010 6632-6-175 - SPACER FEM 10MM DRCN LG RIGHT LAT DP BOTH IP/OP "$1,865.50 " "$1,380.47" $0.00 "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,384.57" "$1,384.57" $0.00 $0.00 $388.77 $0.00 $0.00 $0.00 $0.00 $932.75 "$1,477.48" "$1,492.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-180 SUP Custom 27803010 6632-6-180 - SPACER FEM 10MM DRCN XL LEFT MDL DP BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-185 SUP Custom 27803010 6632-6-185 - SPACER FEM 10MM DRCN XL RIGHT MDL DP BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-190 SUP Custom 27803010 6632-6-190 - SPACER FEM 10MM DRCN XL L/L DP BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-195 SUP Custom 27803010 6632-6-195 - SPACER FEM 10MM DRCN XL RIGHT LAT DP BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-410 SUP Custom 27803010 6632-6-410 - SPACER FEM 10MM DRCN SM POST BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-415 SUP Custom 27803010 6632-6-415 - SPACER FEM 5MM DRCN SM POST BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-420 SUP Custom 27803010 6632-6-420 - SPACER FEM 10MM DRCN MED POST BOTH IP/OP "$1,581.13 " "$1,170.04" $0.00 "$1,264.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,173.51" "$1,173.51" $0.00 $0.00 $329.51 $0.00 $0.00 $0.00 $0.00 $790.56 "$1,252.25" "$1,264.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-425 SUP Custom 27803010 6632-6-425 - SPACER FEM 5MM DRCN MED POST BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-430 SUP Custom 27803010 6632-6-430 - SPACER FEM 10MM DRCN MED LG POST BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-435 SUP Custom 27803010 6632-6-435 - SPACER FEM 5MM DRCN MED LG POST VIT FULL BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-440 SUP Custom 27803010 6632-6-440 - SPACER FEM 10MM DRCN LG POST BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-445 SUP Custom 27803010 6632-6-445 - SPACER FEM 5MM DRCN LG POST BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-450 SUP Custom 27803010 6632-6-450 - SPACER FEM 10MM DRCN XL POST BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-455 SUP Custom 27803010 6632-6-455 - SPACER FEM 5MM DRCN XL POST VIT FULL BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-460 SUP Custom 27803010 6632-6-460 - SPACER FEM 10MM DRCN 2XL POST FULL BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-465 SUP Custom 27803010 6632-6-465 - SPACER FEM 5MM DRCN 2XL POST FULL BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-600 SUP HCPCS C1713 6632-6-600 - SCREW BONE 10MM 10MM DRCN DISTAL FEM LCK BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $54.00 $54.00 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-705 SUP Custom 27803010 6632-6-705 - SPACER FEM 5MM DRCN XS POST HALF BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-710 SUP Custom 27803010 6632-6-710 - SPACER FEM 10MM DRCN SM POST HALF BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-715 SUP Custom 27803010 6632-6-715 - SPACER FEM 5MM DRCN SM POST HALF BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-720 SUP Custom 27803010 6632-6-720 - SPACER FEM 10MM DRCN MED POST HALF BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-725 SUP Custom 27803010 6632-6-725 - SPACER FEM 5MM DRCN MED POST HALF BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-730 SUP Custom 27803010 6632-6-730 - SPACER FEM 10MM DRCN MED LG POST HALF BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-735 SUP Custom 27803010 6632-6-735 - SPACER FEM 5MM DRCN MED LG POST HALF BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-740 SUP Custom 27803010 6632-6-740 - SPACER FEM 10MM DRCN LG POST HALF BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-745 SUP Custom 27803010 6632-6-745 - SPACER FEM 5MM DRCN LG POST HALF BOTH IP/OP "$1,868.75 " "$1,382.88" $0.00 "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.99" "$1,386.99" $0.00 $0.00 $389.45 $0.00 $0.00 $0.00 $0.00 $934.38 "$1,480.05" "$1,495.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-750 SUP Custom 27803010 6632-6-750 - SPACER FEM 10MM DRCN XL POST HALF BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-755 SUP Custom 27803010 6632-6-755 - SPACER FEM XL HLF 5MM DRCN KN POST BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-760 SUP Custom 27803010 6632-6-760 - SPACER FEM 10MM DRCN 2XL POST KNEE HALF BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-6-765 SUP Custom 27803010 6632-6-765 - SPACER FEM 5MM DRCN XL POST HALF BOTH IP/OP "$1,961.38 " "$1,451.42" $0.00 "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,455.73" "$1,455.73" $0.00 $0.00 $408.75 $0.00 $0.00 $0.00 $0.00 $980.69 "$1,553.41" "$1,569.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-800 SUP HCPCS C1776 6632-8-800 - CMPNT FEM XS LEFT TOT STAB BOTH IP/OP "$10,811.13 " "$8,000.24" $0.00 "$8,648.90" "$4,865.01" "$4,865.01" $0.00 $0.00 $0.00 "$2,253.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,253.04" $0.00 "$5,329.88" "$5,329.88" $0.00 "$5,405.56" "$8,562.41" "$8,648.90" $0.00 $0.00 "$1,691.94" $0.00 $0.00 "$1,721.13" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-805 SUP HCPCS C1776 6632-8-805 - CMPNT FEM XS RIGHT KNEE TOT STAB DRCN BOTH IP/OP "$10,811.13 " "$8,000.24" $0.00 "$8,648.90" "$4,865.01" "$4,865.01" $0.00 $0.00 $0.00 "$2,253.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,253.04" $0.00 "$5,329.88" "$5,329.88" $0.00 "$5,405.56" "$8,562.41" "$8,648.90" $0.00 $0.00 "$1,691.94" $0.00 $0.00 "$1,721.13" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-810 SUP HCPCS C1776 6632-8-810 - CMPNT FEM SM LEFT TOT STAB BOTH IP/OP "$10,619.38 " "$7,858.34" $0.00 "$8,495.50" "$4,778.72" "$4,778.72" $0.00 $0.00 $0.00 "$2,213.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,213.08" $0.00 "$5,235.35" "$5,235.35" $0.00 "$5,309.69" "$8,410.55" "$8,495.50" $0.00 $0.00 "$1,661.93" $0.00 $0.00 "$1,690.60" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-815 SUP HCPCS C1776 6632-8-815 - CMPNT FEM SM RIGHT TOT STAB BOTH IP/OP "$10,619.38 " "$7,858.34" $0.00 "$8,495.50" "$4,778.72" "$4,778.72" $0.00 $0.00 $0.00 "$2,213.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,213.08" $0.00 "$5,235.35" "$5,235.35" $0.00 "$5,309.69" "$8,410.55" "$8,495.50" $0.00 $0.00 "$1,661.93" $0.00 $0.00 "$1,690.60" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-820 SUP HCPCS C1776 6632-8-820 - CMPNT FEM MED LEFT TOT STAB BOTH IP/OP "$10,619.38 " "$7,858.34" $0.00 "$8,495.50" "$4,778.72" "$4,778.72" $0.00 $0.00 $0.00 "$2,213.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,213.08" $0.00 "$5,235.35" "$5,235.35" $0.00 "$5,309.69" "$8,410.55" "$8,495.50" $0.00 $0.00 "$1,661.93" $0.00 $0.00 "$1,690.60" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-825 SUP HCPCS C1776 6632-8-825 - CMPNT FEM MED RIGHT TOT STAB BOTH IP/OP "$10,619.38 " "$7,858.34" $0.00 "$8,495.50" "$4,778.72" "$4,778.72" $0.00 $0.00 $0.00 "$2,213.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,213.08" $0.00 "$5,235.35" "$5,235.35" $0.00 "$5,309.69" "$8,410.55" "$8,495.50" $0.00 $0.00 "$1,661.93" $0.00 $0.00 "$1,690.60" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-830 SUP HCPCS C1776 6632-8-830 - CMPNT FEM MED LG LEFT TOT STAB BOTH IP/OP "$10,619.38 " "$7,858.34" $0.00 "$8,495.50" "$4,778.72" "$4,778.72" $0.00 $0.00 $0.00 "$2,213.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,213.08" $0.00 "$5,235.35" "$5,235.35" $0.00 "$5,309.69" "$8,410.55" "$8,495.50" $0.00 $0.00 "$1,661.93" $0.00 $0.00 "$1,690.60" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-835 SUP HCPCS C1776 6632-8-835 - CMPNT FEM MED LG RIGHT TOT STAB BOTH IP/OP "$10,619.38 " "$7,858.34" $0.00 "$8,495.50" "$4,778.72" "$4,778.72" $0.00 $0.00 $0.00 "$2,213.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,213.08" $0.00 "$5,235.35" "$5,235.35" $0.00 "$5,309.69" "$8,410.55" "$8,495.50" $0.00 $0.00 "$1,661.93" $0.00 $0.00 "$1,690.60" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-840 SUP HCPCS C1776 6632-8-840 - CMPNT FEM LG LEFT TOT STAB BOTH IP/OP "$10,619.38 " "$7,858.34" $0.00 "$8,495.50" "$4,778.72" "$4,778.72" $0.00 $0.00 $0.00 "$2,213.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,213.08" $0.00 "$5,235.35" "$5,235.35" $0.00 "$5,309.69" "$8,410.55" "$8,495.50" $0.00 $0.00 "$1,661.93" $0.00 $0.00 "$1,690.60" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-845 SUP HCPCS C1776 6632-8-845 - CMPNT FEM LG RIGHT TOT STAB BOTH IP/OP "$10,619.38 " "$7,858.34" $0.00 "$8,495.50" "$4,778.72" "$4,778.72" $0.00 $0.00 $0.00 "$2,213.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,213.08" $0.00 "$5,235.35" "$5,235.35" $0.00 "$5,309.69" "$8,410.55" "$8,495.50" $0.00 $0.00 "$1,661.93" $0.00 $0.00 "$1,690.60" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-850 SUP HCPCS C1776 6632-8-850 - CMPNT FEM XL LEFT TOT STAB BOTH IP/OP "$10,811.13 " "$8,000.24" $0.00 "$8,648.90" "$4,865.01" "$4,865.01" $0.00 $0.00 $0.00 "$2,253.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,253.04" $0.00 "$5,329.88" "$5,329.88" $0.00 "$5,405.56" "$8,562.41" "$8,648.90" $0.00 $0.00 "$1,691.94" $0.00 $0.00 "$1,721.13" $0.00 $0.00 $0.00 $0.00 $0.00 6632-8-855 SUP HCPCS C1776 6632-8-855 - CMPNT FEM XL RIGHT TOT STAB BOTH IP/OP "$10,811.13 " "$8,000.24" $0.00 "$8,648.90" "$4,865.01" "$4,865.01" $0.00 $0.00 $0.00 "$2,253.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,253.04" $0.00 "$5,329.88" "$5,329.88" $0.00 "$5,405.56" "$8,562.41" "$8,648.90" $0.00 $0.00 "$1,691.94" $0.00 $0.00 "$1,721.13" $0.00 $0.00 $0.00 $0.00 $0.00 6634-0-330 SUP Custom 27803010 6634-0-330 - CMPNT FEM UNV SM LEFT MDL RIGHT LAT DRCN BOTH IP/OP "$1,856.00 " "$1,373.44" $0.00 "$1,484.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,377.52" "$1,377.52" $0.00 $0.00 $386.79 $0.00 $0.00 $0.00 $0.00 $928.00 "$1,469.95" "$1,484.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-009 SUP HCPCS C1776 6637-0-009 - INSERT TIBIAL SMALL 9MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-011 SUP HCPCS C1776 6637-0-011 - INSERT TIBIAL SMALL 11MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-013 SUP HCPCS C1776 6637-0-013 - INSERT TIBIAL SMALL 13MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-016 SUP HCPCS C1776 6637-0-016 - INSERT TIBIAL SMALL 16MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-019 SUP HCPCS C1776 6637-0-019 - INSERT TIBIAL SMALL 19MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-022 SUP HCPCS C1776 6637-0-022 - INSERT TIBIAL SMALL 22MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-025 SUP HCPCS C1776 6637-0-025 - INSERT TIBIAL SMALL 25MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-028 SUP HCPCS C1776 6637-0-028 - INSERT TIBIAL SMALL 28MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-031 SUP HCPCS C1776 6637-0-031 - INSERT TIBIAL SMALL 31MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-109 SUP HCPCS C1776 6637-0-109 - INSERT TIBIAL MEDIUM 9MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-111 SUP HCPCS C1776 6637-0-111 - INSERT TIBIAL MEDIUM 11MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-113 SUP HCPCS C1776 6637-0-113 - INSERT TIBIAL MEDIUM 13MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-116 SUP HCPCS C1776 6637-0-116 - INSERT TIBIAL MEDIUM 16MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-119 SUP HCPCS C1776 6637-0-119 - INSERT TIBIAL MEDIUM 19MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-122 SUP HCPCS C1776 6637-0-122 - INSERT TIBIAL MEDIUM 22MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-125 SUP HCPCS C1776 6637-0-125 - INSERT TIBIAL MEDIUM 25MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-128 SUP HCPCS C1776 6637-0-128 - INSERT TIBIAL MEDIUM 28MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-131 SUP HCPCS C1776 6637-0-131 - INSERT TIBIAL MEDIUM 31MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-209 SUP HCPCS C1776 6637-0-209 - INSERT TIBIAL LARGE 9MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-211 SUP HCPCS C1776 6637-0-211 - INSERT TIBIAL LARGE 11MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-213 SUP HCPCS C1776 6637-0-213 - INSERT TIBIAL LARGE 13MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-216 SUP HCPCS C1776 6637-0-216 - INSERT TIBIAL LARGE 16MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-219 SUP HCPCS C1776 6637-0-219 - INSERT TIBIAL LARGE 19MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-222 SUP HCPCS C1776 6637-0-222 - INSERT TIBIAL LARGE 22MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-225 SUP HCPCS C1776 6637-0-225 - INSERT TIBIAL LARGE 25MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-228 SUP HCPCS C1776 6637-0-228 - INSERT TIBIAL LARGE 28MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-231 SUP HCPCS C1776 6637-0-231 - INSERT TIBIAL LARGE 31MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-309 SUP HCPCS C1776 6637-0-309 - INSERT TIBIAL XL 9MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-311 SUP HCPCS C1776 6637-0-311 - INSERT TIBIAL XL 11MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-313 SUP HCPCS C1776 6637-0-313 - INSERT TIBIAL XL 13MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-316 SUP HCPCS C1776 6637-0-316 - INSERT TIBIAL XL 16MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-319 SUP HCPCS C1776 6637-0-319 - INSERT TIBIAL XL 19MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-322 SUP HCPCS C1776 6637-0-322 - INSERT TIBIAL XL 22MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-325 SUP HCPCS C1776 6637-0-325 - INSERT TIBIAL XL 25MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-328 SUP HCPCS C1776 6637-0-328 - INSERT TIBIAL XL 28MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-331 SUP HCPCS C1776 6637-0-331 - INSERT TIBIAL XL 31MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-609 SUP HCPCS C1776 6637-0-609 - INSERT TIBIAL SMALL 9MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-611 SUP HCPCS C1776 6637-0-611 - INSERT TIBIAL SMALL 11MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-613 SUP HCPCS C1776 6637-0-613 - INSERT TIBIAL SMALL 13MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-616 SUP HCPCS C1776 6637-0-616 - INSERT TIBIAL SMALL 16MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-619 SUP HCPCS C1776 6637-0-619 - INSERT TIBIAL SMALL 19MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-622 SUP HCPCS C1776 6637-0-622 - INSERT TIBIAL SMALL 22MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-625 SUP HCPCS C1776 6637-0-625 - INSERT TIBIAL SMALL 25MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-628 SUP HCPCS C1776 6637-0-628 - INSERT TIBIAL SMALL 28MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-631 SUP HCPCS C1776 6637-0-631 - INSERT TIBIAL SMALL 31MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-709 SUP HCPCS C1776 6637-0-709 - INSERT TIBIAL MEDIUM 9MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-711 SUP HCPCS C1776 6637-0-711 - INSERT TIBIAL MEDIUM 11MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-713 SUP HCPCS C1776 6637-0-713 - INSERT TIBIAL MEDIUM 13MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-716 SUP HCPCS C1776 6637-0-716 - INSERT TIBIAL MEDIUM 16MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-719 SUP HCPCS C1776 6637-0-719 - INSERT TIBIAL MEDIUM 19MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-722 SUP HCPCS C1776 6637-0-722 - INSERT TIBIAL MEDIUM 22MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-725 SUP HCPCS C1776 6637-0-725 - INSERT TIBIAL MEDIUM 25MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-728 SUP HCPCS C1776 6637-0-728 - INSERT TIBIAL MEDIUM 28MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-731 SUP HCPCS C1776 6637-0-731 - INSERT TIBIAL MEDIUM 31MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-809 SUP HCPCS C1776 6637-0-809 - INSERT TIBIAL LARGE 9MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-811 SUP HCPCS C1776 6637-0-811 - INSERT TIBIAL LARGE 11MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-813 SUP HCPCS C1776 6637-0-813 - INSERT TIBIAL LARGE 13MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-816 SUP HCPCS C1776 6637-0-816 - INSERT TIBIAL LARGE 16MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-819 SUP HCPCS C1776 6637-0-819 - INSERT TIBIAL LARGE 16MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-822 SUP HCPCS C1776 6637-0-822 - INSERT TIBIAL LARGE 22MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-825 SUP HCPCS C1776 6637-0-825 - INSERT TIBIAL LARGE 25MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-828 SUP HCPCS C1776 6637-0-828 - INSERT TIBIAL LARGE 28MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-831 SUP HCPCS C1776 6637-0-831 - INSERT TIBIAL LARGE 31MM REVISION PCA DURACON KNEE LEFT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-909 SUP HCPCS C1776 6637-0-909 - INSERT TIBIAL XL 9MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-911 SUP HCPCS C1776 6637-0-911 - INSERT TIBIAL XL 11MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-913 SUP HCPCS C1776 6637-0-913 - INSERT TIBIAL XL 13MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-916 SUP HCPCS C1776 6637-0-916 - INSERT TIBIAL XL 16MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-919 SUP HCPCS C1776 6637-0-919 - INSERT TIBIAL XL 19MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-922 SUP HCPCS C1776 6637-0-922 - INSERT TIBIAL XL 22MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-925 SUP HCPCS C1776 6637-0-925 - INSERT TIBIAL XL 25MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-928 SUP HCPCS C1776 6637-0-928 - INSERT TIBIAL XL 28MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-0-931 SUP HCPCS C1776 6637-0-931 - INSERT TIBIAL XL 31MM REVISION PCA DURACON KNEE RIGHT BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-009 SUP HCPCS C1776 6637-4-009 - INSERT TIBIAL SMALL NEUTRAL 9MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-011 SUP HCPCS C1776 6637-4-011 - INSERT TIBIAL SMALL NEUTRAL 11MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-013 SUP HCPCS C1776 6637-4-013 - INSERT TIBIAL SMALL NEUTRAL 13MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-016 SUP HCPCS C1776 6637-4-016 - INSERT TIBIAL SMALL NEUTRAL 16MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-019 SUP HCPCS C1776 6637-4-019 - INSERT TIBIAL SMALL NEUTRAL 19MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-022 SUP HCPCS C1776 6637-4-022 - INSERT TIBIAL SMALL NEUTRAL 22MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-025 SUP HCPCS C1776 6637-4-025 - INSERT TIBIAL SMALL NEUTRAL 25MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-028 SUP HCPCS C1776 6637-4-028 - INSERT TIBIAL SMALL NEUTRAL 28MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-031 SUP HCPCS C1776 6637-4-031 - INSERT TIBIAL SMALL NEUTRAL 31MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-109 SUP HCPCS C1776 6637-4-109 - INSERT TIBIAL MEDIUM NEUTRAL 9MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-111 SUP HCPCS C1776 6637-4-111 - INSERT TIBIAL MEDIUM NEUTRAL 11MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-113 SUP HCPCS C1776 6637-4-113 - INSERT TIBIAL MEDIUM NEUTRAL 13MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-116 SUP HCPCS C1776 6637-4-116 - INSERT TIBIAL MEDIUM NEUTRAL 16MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-119 SUP HCPCS C1776 6637-4-119 - INSERT TIBIAL MEDIUM NEUTRAL 19MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-122 SUP HCPCS C1776 6637-4-122 - INSERT TIBIAL MEDIUM NEUTRAL 22MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-125 SUP HCPCS C1776 6637-4-125 - INSERT TIBIAL MEDIUM NEUTRAL 25MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-128 SUP HCPCS C1776 6637-4-128 - INSERT TIBIAL MEDIUM NEUTRAL 28MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-131 SUP HCPCS C1776 6637-4-131 - INSERT TIBIAL MEDIUM NEUTRAL 31MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-209 SUP HCPCS C1776 6637-4-209 - INSERT TIBIAL LARGE NEUTRAL 9MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-211 SUP HCPCS C1776 6637-4-211 - INSERT TIBIAL LARGE NEUTRAL 11MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-213 SUP HCPCS C1776 6637-4-213 - INSERT TIBIAL LARGE NEUTRAL 13MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-216 SUP HCPCS C1776 6637-4-216 - INSERT TIBIAL LARGE NEUTRAL 16MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-219 SUP HCPCS C1776 6637-4-219 - INSERT TIBIAL LARGE NEUTRAL 19MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-222 SUP HCPCS C1776 6637-4-222 - INSERT TIBIAL LARGE NEUTRAL 22MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-225 SUP HCPCS C1776 6637-4-225 - INSERT TIBIAL LARGE NEUTRAL 25MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-228 SUP HCPCS C1776 6637-4-228 - INSERT TIBIAL LARGE NEUTRAL 28MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-231 SUP HCPCS C1776 6637-4-231 - INSERT TIBIAL LARGE NEUTRAL 31MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-309 SUP HCPCS C1776 6637-4-309 - INSERT TIBIAL XL NEUTRAL 9MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-311 SUP HCPCS C1776 6637-4-311 - INSERT TIBIAL XL NEUTRAL 11MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-313 SUP HCPCS C1776 6637-4-313 - INSERT TIBIAL XL NEUTRAL 13MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-316 SUP HCPCS C1776 6637-4-316 - INSERT TIBIAL XL NEUTRAL 16MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-319 SUP HCPCS C1776 6637-4-319 - INSERT TIBIAL XL NEUTRAL 19MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-322 SUP HCPCS C1776 6637-4-322 - INSERT TIBIAL XL NEUTRAL 22MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-325 SUP HCPCS C1776 6637-4-325 - INSERT TIBIAL XL NEUTRAL 25MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-328 SUP HCPCS C1776 6637-4-328 - INSERT TIBIAL XL NEUTRAL 28MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6637-4-331 SUP HCPCS C1776 6637-4-331 - INSERT TIBIAL XL NEUTRAL 31MM REVISION PCA DURACON KNEE BOTH IP/OP "$5,517.50 " "$4,082.95" $0.00 "$4,414.00" "$2,482.88" "$2,482.88" $0.00 $0.00 $0.00 "$1,149.98" "$4,095.09" "$4,095.09" $0.00 $0.00 "$1,149.85" $0.00 "$2,720.13" "$2,720.13" $0.00 "$2,758.75" "$4,369.86" "$4,414.00" $0.00 $0.00 $863.49 $0.00 $0.00 $878.39 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-009 SUP Custom 27803010 6642-1-009 - INSERT TIB XS 9MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-011 SUP Custom 27803010 6642-1-011 - INSERT TIB XS 11MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-013 SUP Custom 27803010 6642-1-013 - INSERT TIB XS 13MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-016 SUP Custom 27803010 6642-1-016 - INSERT TIB XS 16MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-109 SUP Custom 27803010 6642-1-109 - INSERT TIB SM 9MM CNDYLR DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-111 SUP Custom 27803010 6642-1-111 - INSERT TIB SM 11MM CNDYLR DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-113 SUP Custom 27803010 6642-1-113 - INSERT TIB SM 13MM CNDYLR DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-116 SUP Custom 27803010 6642-1-116 - INSERT TIB SM 16MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-119 SUP Custom 27803010 6642-1-119 - INSERT TIB SM 19MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-209 SUP Custom 27803010 6642-1-209 - INSERT TIB MED 9MM CNDYLR DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-211 SUP Custom 27803010 6642-1-211 - INSERT TIB MED 11MM CNDYLR DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-213 SUP Custom 27803010 6642-1-213 - INSERT TIB MED 13MM CNDYLR DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-216 SUP Custom 27803010 6642-1-216 - INSERT TIB MED 16MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-219 SUP Custom 27803010 6642-1-219 - INSERT TIB MED 19MM CNDYLR KNEE DUR CNDYLR STAB DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-309 SUP Custom 27803010 6642-1-309 - INSERT TIB LG 9MM CNDYLR DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-311 SUP Custom 27803010 6642-1-311 - INSERT TIB LG 11MM CNDYLR DUR BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-313 SUP Custom 27803010 6642-1-313 - INSERT TIB LG 13MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-316 SUP Custom 27803010 6642-1-316 - INSERT TIB LG 16MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-319 SUP Custom 27803010 6642-1-319 - INSERT TIB LG 19MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,191.00 " $881.34 $0.00 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.96 $883.96 $0.00 $0.00 $248.20 $0.00 $0.00 $0.00 $0.00 $595.50 $943.27 $952.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-409 SUP Custom 27803010 6642-1-409 - INSERT TIB XL 9MM CNDYLR DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-411 SUP Custom 27803010 6642-1-411 - INSERT TIB XL 11MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-413 SUP Custom 27803010 6642-1-413 - INSERT TIB XL 13MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-416 SUP Custom 27803010 6642-1-416 - INSERT TIB XL 16MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-419 SUP Custom 27803010 6642-1-419 - INSERT TIB XL 19MM CNDYLR KNEE DUR DRCN BOTH IP/OP "$1,214.00 " $898.36 $0.00 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.03 $901.03 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $607.00 $961.49 $971.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-509 SUP Custom 27803010 6642-1-509 - INSERT TIBIAL XS 9MM ANTERIOR/POSTERIOR LIPPED DURACON DUR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-511 SUP Custom 27803010 6642-1-511 - INSERT TIBIAL XS 11MM ANTERIOR/POSTERIOR LIPPED DURACON DUR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-513 SUP Custom 27803010 6642-1-513 - INSERT TIBIAL XS 13MM ANTERIOR/POSTERIOR LIPPED DURACON DUR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-516 SUP Custom 27803010 6642-1-516 - INSERT TIBIAL XS 16MM ANTERIOR/POSTERIOR LIPPED DURACON DUR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-609 SUP Custom 27803010 6642-1-609 - INSERT TIBIAL SMALL 9MM DURACON DUR ANTERIOR POSTERIOR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-611 SUP Custom 27803010 6642-1-611 - INSERT TIBIAL SMALL 11MM LIPPED REVISION RECONSTRUCTION BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-613 SUP Custom 27803010 6642-1-613 - INSERT TIBIAL SMALL 13MM DURACON DUR ANTERIOR POSTERIOR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-616 SUP Custom 27803010 6642-1-616 - INSERT TIBIAL SMALL 16MM DURACON DUR ANTERIOR POSTERIOR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-619 SUP Custom 27803010 6642-1-619 - INSERT TIBIAL SMALL 19MM DURACON DUR KNEE ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-622 SUP Custom 27803010 6642-1-622 - INSERT TIBIAL SMALL 22MM LIP DURACON DUR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-625 SUP Custom 27803010 6642-1-625 - INSERT TIBIAL SMALL 25MM DURACON DUR KNEE ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-709 SUP Custom 27803010 6642-1-709 - INSERT TIBIAL MEDIUM 9MM LIPPED DURACON DUR ANTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-711 SUP Custom 27803010 6642-1-711 - INSERT TIBIAL MEDIUM 11MM DURACON DUR ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-713 SUP Custom 27803010 6642-1-713 - INSERT TIBIAL MEDIUM 13MM DURACON DUR ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-716 SUP Custom 27803010 6642-1-716 - INSERT TIBIAL MEDIUM 16MM LIPPED REVISION RECONSTRUCTION BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-719 SUP Custom 27803010 6642-1-719 - INSERT TIBIAL MEDIUM 19MM DURACON DUR ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-722 SUP Custom 27803010 6642-1-722 - INSERT TIBIAL MEDIUM 22MM DURACON DUR KNEE ANTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-725 SUP Custom 27803010 6642-1-725 - INSERT TIBIAL MEDIUM 25MM DURACON DUR KNEE ANTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-809 SUP Custom 27803010 6642-1-809 - INSERT TIBIAL LARGE 9MM DURACON DUR ANTERIOR POSTERIOR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-811 SUP Custom 27803010 6642-1-811 - INSERT TIBIAL LARGE 11MM DURACON DUR ANTERIOR POSTERIOR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-813 SUP Custom 27803010 6642-1-813 - INSERT TIBIAL LARGE 13MM LIPPED REVISION RECONSTRUCTION BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-816 SUP Custom 27803010 6642-1-816 - INSERT TIBIAL LARGE 16MM LIPPED REVISION RECONSTRUCTION BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-819 SUP Custom 27803010 6642-1-819 - INSERT TIBIAL LARGE 19MM DURACON DUR KNEE ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-822 SUP Custom 27803010 6642-1-822 - INSERT TIBIAL LARGE 22MM DURACON DUR KNEE ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-825 SUP Custom 27803010 6642-1-825 - INSERT TIBIAL LARGE 25MM DURACON DUR KNEE ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-909 SUP Custom 27803010 6642-1-909 - INSERT TIBIAL XL 9MM LIPPED REVISION RECONSTRUCTION DURACON BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-911 SUP Custom 27803010 6642-1-911 - INSERT TIBIAL XL 11MM DURACON DUR ANTERIOR POSTERIOR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-913 SUP Custom 27803010 6642-1-913 - INSERT TIBIAL XL 13MM DURACON DUR ANTERIOR POSTERIOR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-916 SUP Custom 27803010 6642-1-916 - INSERT TIBIAL XL 16MM DURACON DUR ANTERIOR POSTERIOR KNEE BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-919 SUP Custom 27803010 6642-1-919 - INSERT TIBIAL XL 19MM DURACON DUR KNEE ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-922 SUP Custom 27803010 6642-1-922 - INSERT TIBIAL XL 22MM DURACON DUR KNEE ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-1-925 SUP Custom 27803010 6642-1-925 - INSERT TIBIAL XL 25MM DURACON DUR KNEE ANTERIOR POSTERIOR BOTH IP/OP "$1,917.50 " "$1,418.95" $0.00 "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,423.17" "$1,423.17" $0.00 $0.00 $399.61 $0.00 $0.00 $0.00 $0.00 $958.75 "$1,518.66" "$1,534.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-040 SUP Custom 27803010 6642-2-040 - COMPONENT PATLR XS 29MM HDPE RESIN KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-050 SUP Custom 27803010 6642-2-050 - COMPONENT PATLR SMALL 32MM HDPE RESIN KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-100 SUP Custom 27803010 6642-2-100 - COMPONENT PATLR MEDIUM 35MM HDPE RESIN KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-140 SUP Custom 27803010 6642-2-140 - CMPNT PATLR 33MM MTLBLK DRCN DUR BOTH IP/OP "$1,316.00 " $973.84 $0.00 "$1,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $976.74 $976.74 $0.00 $0.00 $274.25 $0.00 $0.00 $0.00 $0.00 $658.00 "$1,042.27" "$1,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-145 SUP Custom 27803010 6642-2-145 - CMPNT PATLR 33MM DRCN BOTH IP/OP "$1,571.00 " "$1,162.54" $0.00 "$1,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,166.00" "$1,166.00" $0.00 $0.00 $327.40 $0.00 $0.00 $0.00 $0.00 $785.50 "$1,244.23" "$1,256.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-150 SUP Custom 27803010 6642-2-150 - COMPONENT PATLR LARGE 11MM DURACON DUR ALL POLY KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-200 SUP Custom 27803010 6642-2-200 - COMPONENT PATLR XL 11MM DURACON DUR ALL POLY KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-300 SUP Custom 27803010 6642-2-300 - CMPNT PATLR SM MTLBLK DRCN DUR BOTH IP/OP "$1,316.00 " $973.84 $0.00 "$1,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $976.74 $976.74 $0.00 $0.00 $274.25 $0.00 $0.00 $0.00 $0.00 $658.00 "$1,042.27" "$1,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-350 SUP Custom 27803010 6642-2-350 - CMPNT PATLR MED MTLBLK DRCN DUR BOTH IP/OP "$1,316.00 " $973.84 $0.00 "$1,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $976.74 $976.74 $0.00 $0.00 $274.25 $0.00 $0.00 $0.00 $0.00 $658.00 "$1,042.27" "$1,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-400 SUP Custom 27803010 6642-2-400 - CMPNT PATLR LG ASYM MTLBLK DRCN DUR BOTH IP/OP "$1,316.00 " $973.84 $0.00 "$1,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $976.74 $976.74 $0.00 $0.00 $274.25 $0.00 $0.00 $0.00 $0.00 $658.00 "$1,042.27" "$1,052.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-600 SUP Custom 27803010 6642-2-600 - INSERT TIBIAL 8MM 27MM SYMMETRIC DURACON DUR BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-610 SUP Custom 27803010 6642-2-610 - INSERT TIBIAL 8MM 29MM SYMMETRIC DURACON DUR BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-620 SUP Custom 27803010 6642-2-620 - COMPONENT PATLR 31MM 9MM SYMMETRIC DURACON DUR BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-626 SUP Custom 27203010 6642-2-626 - TRIAL SURG 25MM 10MM INSET DURACON DUR PATELLA BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-627 SUP Custom 27803010 6642-2-627 - COMPONENT PATLR 27MM 10MM SYMMETRIC DURACON DUR KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-629 SUP Custom 27803010 6642-2-629 - COMPONENT PATLR 29MM 10MM INSET DURACON DUR BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-630 SUP Custom 27803010 6642-2-630 - INSERT TIBIAL 9MM 33MM SYMMETRIC DURACON DUR KNEE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-631 SUP Custom 27803010 6642-2-631 - COMPONENT PATLR 31MM 10MM SYMMETRIC DURACON DUR BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-633 SUP Custom 27803010 6642-2-633 - COMPONENT PATLR 33MM 10MM INSET DURACON DUR BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-640 SUP Custom 27803010 6642-2-640 - COMPONENT PATLR 36MM 10MM SYMMETRIC DURACON DUR BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-645 SUP Custom 27803010 6642-2-645 - INSERT TIBIAL 11MM 39MM SYMMETRIC DURACON DUR BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-700 SUP Custom 27803010 6642-2-700 - CMPNT PATLR SM CNVR DRCN DUR BOTH IP/OP "$1,634.00 " "$1,209.16" $0.00 "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,212.75" "$1,212.75" $0.00 $0.00 $340.53 $0.00 $0.00 $0.00 $0.00 $817.00 "$1,294.13" "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-705 SUP Custom 27803010 6642-2-705 - CMPNT PATLR MED CNVR DRCN DUR BOTH IP/OP "$1,634.00 " "$1,209.16" $0.00 "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,212.75" "$1,212.75" $0.00 $0.00 $340.53 $0.00 $0.00 $0.00 $0.00 $817.00 "$1,294.13" "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-710 SUP Custom 27803010 6642-2-710 - CMPNT PATLR LG CNVX DRCN DUR BOTH IP/OP "$1,634.00 " "$1,209.16" $0.00 "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,212.75" "$1,212.75" $0.00 $0.00 $340.53 $0.00 $0.00 $0.00 $0.00 $817.00 "$1,294.13" "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-715 SUP Custom 27803010 6642-2-715 - CMPNT PATLR XL CNVX DRCN DUR UHMWPE BOTH IP/OP "$1,634.00 " "$1,209.16" $0.00 "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,212.75" "$1,212.75" $0.00 $0.00 $340.53 $0.00 $0.00 $0.00 $0.00 $817.00 "$1,294.13" "$1,307.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-720 SUP Custom 27803010 6642-2-720 - INSERT TIB SM 20MM KNEE DUR CNVX DRCN 7MM BOTH IP/OP $677.00 $500.98 $0.00 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.47 $502.47 $0.00 $0.00 $141.09 $0.00 $0.00 $0.00 $0.00 $338.50 $536.18 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-725 SUP Custom 27803010 6642-2-725 - INSERT TIB MED 25MM KNEE DUR CNVX DRCN 7MM BOTH IP/OP $677.00 $500.98 $0.00 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.47 $502.47 $0.00 $0.00 $141.09 $0.00 $0.00 $0.00 $0.00 $338.50 $536.18 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-730 SUP Custom 27803010 6642-2-730 - INSERT TIB LG 30MM KNEE DUR CNVX DRCN 7MM BOTH IP/OP $677.00 $500.98 $0.00 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.47 $502.47 $0.00 $0.00 $141.09 $0.00 $0.00 $0.00 $0.00 $338.50 $536.18 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-735 SUP Custom 27803010 6642-2-735 - INSERT TIB XL 35MM KNEE DUR CNVX DRCN 7MM BOTH IP/OP $677.00 $500.98 $0.00 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.47 $502.47 $0.00 $0.00 $141.09 $0.00 $0.00 $0.00 $0.00 $338.50 $536.18 $541.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-740 SUP Custom 27803010 6642-2-740 - CMPNT PATLR SM DRCN BOTH IP/OP "$1,768.00 " "$1,308.32" $0.00 "$1,414.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,312.21" "$1,312.21" $0.00 $0.00 $368.45 $0.00 $0.00 $0.00 $0.00 $884.00 "$1,400.26" "$1,414.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-745 SUP Custom 27803010 6642-2-745 - CMPNT PATLR MED DRCN BOTH IP/OP "$1,842.00 " "$1,363.08" $0.00 "$1,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,367.13" "$1,367.13" $0.00 $0.00 $383.87 $0.00 $0.00 $0.00 $0.00 $921.00 "$1,458.86" "$1,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-750 SUP Custom 27803010 6642-2-750 - CMPNT PATLR ASYM DUR BOTH IP/OP "$1,842.00 " "$1,363.08" $0.00 "$1,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,367.13" "$1,367.13" $0.00 $0.00 $383.87 $0.00 $0.00 $0.00 $0.00 $921.00 "$1,458.86" "$1,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-2-755 SUP Custom 27803010 6642-2-755 - CMPNT PATLR XL DRCN BOTH IP/OP "$1,842.00 " "$1,363.08" $0.00 "$1,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,367.13" "$1,367.13" $0.00 $0.00 $383.87 $0.00 $0.00 $0.00 $0.00 $921.00 "$1,458.86" "$1,473.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-111 SUP HCPCS C1776 6642-5-111 - INSERT TIBIAL SMALL 11MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-113 SUP HCPCS C1776 6642-5-113 - INSERT TIBIAL SMALL 13MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-116 SUP HCPCS C1776 6642-5-116 - INSERT TIBIAL SMALL 16MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-119 SUP HCPCS C1776 6642-5-119 - INSERT TIBIAL SMALL 19MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-122 SUP HCPCS C1776 6642-5-122 - INSERT TIBIAL SMALL 22MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-125 SUP HCPCS C1776 6642-5-125 - INSERT TIBIAL SMALL 25MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-128 SUP HCPCS C1776 6642-5-128 - INSERT TIBIAL SMALL 28MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-131 SUP HCPCS C1776 6642-5-131 - INSERT TIBIAL SMALL 31MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-211 SUP HCPCS C1776 6642-5-211 - INSERT TIBIAL MEDIUM 11MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-213 SUP HCPCS C1776 6642-5-213 - INSERT TIBIAL MEDIUM 13MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-216 SUP HCPCS C1776 6642-5-216 - INSERT TIBIAL MEDIUM 16MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-219 SUP HCPCS C1776 6642-5-219 - INSERT TIBIAL MEDIUM 19MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-222 SUP HCPCS C1776 6642-5-222 - INSERT TIBIAL MEDIUM 22MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-225 SUP HCPCS C1776 6642-5-225 - INSERT TIBIAL MEDIUM 25MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-228 SUP HCPCS C1776 6642-5-228 - INSERT TIBIAL MEDIUM 28MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-231 SUP HCPCS C1776 6642-5-231 - INSERT TIBIAL MEDIUM 31MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-311 SUP HCPCS C1776 6642-5-311 - INSERT TIBIAL LARGE 11MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-313 SUP HCPCS C1776 6642-5-313 - INSERT TIBIAL LARGE 13MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-316 SUP HCPCS C1776 6642-5-316 - INSERT TIBIAL LARGE 16MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-319 SUP HCPCS C1776 6642-5-319 - INSERT TIBIAL LARGE 19MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-322 SUP HCPCS C1776 6642-5-322 - INSERT TIBIAL LARGE 22MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-325 SUP HCPCS C1776 6642-5-325 - INSERT TIBIAL LARGE 25MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-328 SUP HCPCS C1776 6642-5-328 - INSERT TIBIAL LARGE 28MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-331 SUP HCPCS C1776 6642-5-331 - INSERT TIBIAL LARGE 31MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-411 SUP HCPCS C1776 6642-5-411 - INSERT TIBIAL XL 11MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-413 SUP HCPCS C1776 6642-5-413 - INSERT TIBIAL XL 13MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-416 SUP HCPCS C1776 6642-5-416 - INSERT TIBIAL XL 16MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-419 SUP HCPCS C1776 6642-5-419 - INSERT TIBIAL XL 19MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-422 SUP HCPCS C1776 6642-5-422 - INSERT TIBIAL XL 22MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-425 SUP HCPCS C1776 6642-5-425 - INSERT TIBIAL XL 25MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-428 SUP HCPCS C1776 6642-5-428 - INSERT TIBIAL XL 28MM TOT STABILIZED DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-5-431 SUP HCPCS C1776 6642-5-431 - INSERT TIBIAL XL 31MM TOT STABILIZE DURACON DUR KNEE BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-009 SUP Custom 27803010 6642-9-009 - INSERT TIB XS STD 9MM KNEE DUR DRCN BOTH IP/OP "$2,075.13 " "$1,535.60" $0.00 "$1,660.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,540.16" "$1,540.16" $0.00 $0.00 $432.46 $0.00 $0.00 $0.00 $0.00 "$1,037.56" "$1,643.50" "$1,660.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-011 SUP HCPCS C1776 6642-9-011 - INSERT TIB XS STD 11MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-013 SUP HCPCS C1776 6642-9-013 - INSERT TIB XS STD 13MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-016 SUP HCPCS C1776 6642-9-016 - INSERT TIB XS STD 16MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-019 SUP HCPCS C1776 6642-9-019 - INSERT TIB XS STD 19MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-109 SUP HCPCS C1776 6642-9-109 - INSERT TIB STD SM 9MM KNEE DUR TOT STAB DRCN OTHR BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-111 SUP HCPCS C1776 6642-9-111 - INSERT TIB SM STD 11MM KNEE DUR TOT STAB DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-113 SUP HCPCS C1776 6642-9-113 - INSERT TIB SM STD 13MM KNEE DUR TOT STAB DRCN OTHR BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-116 SUP HCPCS C1776 6642-9-116 - INSERT TIB SM STD 16MM KNEE DUR TOT STAB DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-119 SUP HCPCS C1776 6642-9-119 - INSERT TIB STD SM 19MM KNEE DUR TOT STAB DRCN OTHR BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-209 SUP HCPCS C1776 6642-9-209 - INSERT TIB STD MED 9MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-211 SUP HCPCS C1776 6642-9-211 - INSERT TIB MED 11MM KNEE DUR STD DRCN 11MM BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-213 SUP HCPCS C1776 6642-9-213 - INSERT TIB MED 13MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-216 SUP HCPCS C1776 6642-9-216 - INSERT TIB STD MED 16MM KNEE DUR OTHR INS DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-219 SUP HCPCS C1776 6642-9-219 - INSERT TIB STD 19MM KNEE DUR DRCN 4 016 BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-309 SUP HCPCS C1776 6642-9-309 - INSERT TIB STD 9MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-311 SUP HCPCS C1776 6642-9-311 - INSERT TIB STD 11MM LEG DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-313 SUP HCPCS C1776 6642-9-313 - INSERT TIB LG 13MM KNEE COCR CNDYLR STAB LIP DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-316 SUP HCPCS C1776 6642-9-316 - INSERT TIB STD LG 16MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-319 SUP HCPCS C1776 6642-9-319 - INSERT TIB STD 19MM KNEE DUR DRCN BOTH IP/OP "$5,026.13 " "$3,719.34" $0.00 "$4,020.90" "$2,261.76" "$2,261.76" $0.00 $0.00 $0.00 "$1,047.57" "$3,730.39" "$3,730.39" $0.00 $0.00 "$1,047.44" $0.00 "$2,477.88" "$2,477.88" $0.00 "$2,513.06" "$3,980.69" "$4,020.90" $0.00 $0.00 $786.59 $0.00 $0.00 $800.16 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-609 SUP Custom 27803010 6642-9-609 - INSERT TIBIAL SMALL 9MM CONSTRAIN DURACON DUR KNEE OTHER BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-611 SUP Custom 27803010 6642-9-611 - INSERT TIBIAL SMALL 11MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-613 SUP Custom 27803010 6642-9-613 - INSERT TIBIAL SMALL 13MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-616 SUP Custom 27803010 6642-9-616 - INSERT TIBIAL SMALL 16MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-619 SUP Custom 27803010 6642-9-619 - INSERT TIBIAL SMALL 19MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-622 SUP Custom 27803010 6642-9-622 - INSERT TIBIAL SMALL 22MM CONSTRAIN DURACON DUR KNEE OTHER BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-625 SUP Custom 27803010 6642-9-625 - INSERT TIBIAL SMALL 25MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-709 SUP Custom 27803010 6642-9-709 - INSERT TIBIAL MEDIUM 9MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-711 SUP HCPCS C1776 6642-9-711 - INSERT TIBIAL MEDIUM 11MM CONSTRAIN DURACON DUR KNEE OTHER BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" "$2,286.00" "$2,286.00" $0.00 $0.00 $0.00 "$1,058.80" "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 "$2,504.44" "$2,504.44" $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $795.02 $0.00 $0.00 $808.74 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-713 SUP Custom 27803010 6642-9-713 - INSERT TIBIAL MEDIUM 13MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-716 SUP Custom 27803010 6642-9-716 - INSERT TIBIAL MEDIUM 16MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-719 SUP Custom 27803010 6642-9-719 - INSERT TIBIAL MEDIUM 19MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-722 SUP Custom 27803010 6642-9-722 - INSERT TIBIAL MEDIUM 22MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-725 SUP Custom 27803010 6642-9-725 - INSERT TIBIAL MEDIUM 25MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-809 SUP Custom 27803010 6642-9-809 - INSERT TIBIAL LARGE 9MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-811 SUP Custom 27803010 6642-9-811 - INSERT TIBIAL LARGE 11MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-813 SUP Custom 27803010 6642-9-813 - INSERT TIBIAL LARGE 13MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-816 SUP Custom 27803010 6642-9-816 - INSERT TIBIAL LARGE 16MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-819 SUP Custom 27803010 6642-9-819 - INSERT TIBIAL LARGE 19MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-822 SUP Custom 27803010 6642-9-822 - INSERT TIBIAL LARGE 22MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6642-9-825 SUP Custom 27803010 6642-9-825 - INSERT TIBIAL LARGE 25MM CONSTRAIN DURACON DUR KNEE BOTH IP/OP "$5,080.00 " "$3,759.20" $0.00 "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,770.38" "$3,770.38" $0.00 $0.00 "$1,058.67" $0.00 $0.00 $0.00 $0.00 "$2,540.00" "$4,023.36" "$4,064.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6647-1-018 SUP HCPCS C1776 6647-1-018 - CMPNT FEM CMPR WCHT 18MM BOTH IP/OP "$7,213.38 " "$5,337.90" $0.00 "$5,770.70" "$3,246.02" "$3,246.02" $0.00 $0.00 $0.00 "$1,503.45" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,503.27" $0.00 "$3,556.19" "$3,556.19" $0.00 "$3,606.69" "$5,713.00" "$5,770.70" $0.00 $0.00 "$1,128.89" $0.00 $0.00 "$1,148.37" $0.00 $0.00 $0.00 $0.00 $0.00 6647-2-012 SUP HCPCS C1713 6647-2-012 - NAIL 12MM HUM TIB WCHT IM BOTH IP/OP "$5,000.13 " "$3,700.10" $0.00 "$4,000.10" "$2,250.06" "$2,250.06" $0.00 $0.00 $0.00 "$1,042.15" "$3,711.09" "$3,711.09" $0.00 $0.00 "$1,042.03" $0.00 "$2,465.06" "$2,465.06" $0.00 "$2,500.06" "$3,960.10" "$4,000.10" $0.00 $0.00 $782.52 $0.00 $0.00 $796.02 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-000 SUP HCPCS C1713 6647-3-000 - SCREW BONE WCHT FULTHD KNEE CMPR FSN NAIL BOTH IP/OP "$3,519.75 " "$2,604.62" $0.00 "$2,815.80" "$1,583.89" "$1,583.89" $0.00 $0.00 $0.00 $733.60 "$2,612.36" "$2,612.36" $0.00 $0.00 $733.52 $0.00 "$1,735.24" "$1,735.24" $0.00 "$1,759.88" "$2,787.64" "$2,815.80" $0.00 $0.00 $550.84 $0.00 $0.00 $560.34 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-125 SUP HCPCS C1713 6647-3-125 - SCREW BONE 6MM 25MM WCHT FULTHD ORTH SLFTAP BOTH IP/OP $494.00 $365.56 $0.00 $395.20 $222.30 $222.30 $0.00 $0.00 $0.00 $102.96 $366.65 $366.65 $0.00 $0.00 $102.95 $0.00 $292.20 $292.20 $0.00 $247.00 $391.25 $395.20 $0.00 $0.00 $77.31 $0.00 $0.00 $78.64 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-130 SUP HCPCS C1713 6647-3-130 - SCREW BONE 6MM 30MM WCHT FULTHD KNEE CMPR FSN NAIL BOTH IP/OP $500.50 $370.37 $0.00 $400.40 $225.23 $225.23 $0.00 $0.00 $0.00 $104.32 $371.47 $371.47 $0.00 $0.00 $104.30 $0.00 $296.05 $296.05 $0.00 $250.25 $396.40 $400.40 $0.00 $0.00 $78.33 $0.00 $0.00 $79.68 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-135 SUP HCPCS C1713 6647-3-135 - SCREW BONE 6MM 35MM WCHT FULTHRD IM NAIL BOTH IP/OP $500.50 $370.37 $0.00 $400.40 $225.23 $225.23 $0.00 $0.00 $0.00 $104.32 $371.47 $371.47 $0.00 $0.00 $104.30 $0.00 $296.05 $296.05 $0.00 $250.25 $396.40 $400.40 $0.00 $0.00 $78.33 $0.00 $0.00 $79.68 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-140 SUP HCPCS C1713 6647-3-140 - SCREW BONE 6MM 40MM WCHT FULTHD KNEE CMPR FSN NAIL BOTH IP/OP $500.50 $370.37 $0.00 $400.40 $225.23 $225.23 $0.00 $0.00 $0.00 $104.32 $371.47 $371.47 $0.00 $0.00 $104.30 $0.00 $296.05 $296.05 $0.00 $250.25 $396.40 $400.40 $0.00 $0.00 $78.33 $0.00 $0.00 $79.68 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-145 SUP HCPCS C1713 6647-3-145 - SCREW BONE 6MM 45MM WCHT FULTHD KNEE CMPR FSN NAIL BOTH IP/OP $500.50 $370.37 $0.00 $400.40 $225.23 $225.23 $0.00 $0.00 $0.00 $104.32 $371.47 $371.47 $0.00 $0.00 $104.30 $0.00 $296.05 $296.05 $0.00 $250.25 $396.40 $400.40 $0.00 $0.00 $78.33 $0.00 $0.00 $79.68 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-150 SUP HCPCS C1713 6647-3-150 - SCREW BONE 6MM 50MM WCHT FULTHD KNEE CMPR FSN NAIL BOTH IP/OP $500.50 $370.37 $0.00 $400.40 $225.23 $225.23 $0.00 $0.00 $0.00 $104.32 $371.47 $371.47 $0.00 $0.00 $104.30 $0.00 $296.05 $296.05 $0.00 $250.25 $396.40 $400.40 $0.00 $0.00 $78.33 $0.00 $0.00 $79.68 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-155 SUP HCPCS C1713 6647-3-155 - SCREW BONE 6MM 55MM WCHT FULTHD KNEE FSN NAIL BOTH IP/OP $500.50 $370.37 $0.00 $400.40 $225.23 $225.23 $0.00 $0.00 $0.00 $104.32 $371.47 $371.47 $0.00 $0.00 $104.30 $0.00 $296.05 $296.05 $0.00 $250.25 $396.40 $400.40 $0.00 $0.00 $78.33 $0.00 $0.00 $79.68 $0.00 $0.00 $0.00 $0.00 $0.00 6647-3-160 SUP HCPCS C1713 6647-3-160 - SCREW BONE 6MM 60MM WCHT FULTHD KNEE FSN NAIL BOTH IP/OP $500.50 $370.37 $0.00 $400.40 $225.23 $225.23 $0.00 $0.00 $0.00 $104.32 $371.47 $371.47 $0.00 $0.00 $104.30 $0.00 $296.05 $296.05 $0.00 $250.25 $396.40 $400.40 $0.00 $0.00 $78.33 $0.00 $0.00 $79.68 $0.00 $0.00 $0.00 $0.00 $0.00 670000B SUP HCPCS C1713 670000B - SCREW BONE 6.5MM 30MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670001B SUP HCPCS C1713 670001B - SCREW BONE 6.5MM 35MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670002B SUP HCPCS C1713 670002B - SCREW BONE 6.5MM 40MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670003B SUP HCPCS C1713 670003B - SCREW BONE 6.5MM 45MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670004B SUP HCPCS C1713 670004B - SCREW BONE 6.5MM 50MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670005B SUP HCPCS C1713 670005B - SCREW BONE 7.5MM 35MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670006B SUP HCPCS C1713 670006B - SCREW BONE 7.5MM 40MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670007B SUP HCPCS C1713 670007B - SCREW BONE 7.5MM 45MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670008B SUP HCPCS C1713 670008B - SCREW BONE 7.5MM 50MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670009B SUP HCPCS C1713 670009B - SCREW BONE 7.5MM 55MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670010B SUP HCPCS C1713 670010B - SCREW BONE 7.5MM 60MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670015B SUP HCPCS C1713 670015B - SCREW BONE 6.5MM 55MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670016B SUP HCPCS C1713 670016B - SCREW BONE 6.5MM 60MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670017B SUP HCPCS C1713 670017B - SCREW BONE 7.5MM 30MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670-044-00 SUP HCPCS C1887 CATHETER GUID AL 1ST TIP SHP 6FR .070IN 100CM PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 670061B SUP HCPCS C1713 670061B - SCREW BONE 5.5MM 30MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670062B SUP HCPCS C1713 670062B - SCREW BONE 5.5MM 35MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670063B SUP HCPCS C1713 670063B - SCREW BONE 5.5MM 40MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670070B SUP HCPCS C1713 670070B - SCREW BONE 6.5MM 30MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670071B SUP HCPCS C1713 670071B - SCREW BONE 6.5MM 35MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670072B SUP HCPCS C1713 670072B - SCREW BONE 6.5MM 40MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670073B SUP HCPCS C1713 670073B - SCREW BONE 6.5MM 45MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670074B SUP HCPCS C1713 670074B - SCREW BONE 6.5MM 50MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670075B SUP HCPCS C1713 670075B - SCREW BONE 6.5MM 55MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670076B SUP HCPCS C1713 670076B - SCREW BONE 6.5MM 60MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670080B SUP HCPCS C1713 670080B - SCREW BONE 7.5MM 30MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670081B SUP HCPCS C1713 670081B - SCREW BONE 7.5MM 35MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670082B SUP HCPCS C1713 670082B - SCREW BONE 7.5MM 40MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670083B SUP HCPCS C1713 670083B - SCREW BONE 7.5MM 45MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670084B SUP HCPCS C1713 670084B - SCREW BONE 7.5MM 50MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670086B SUP HCPCS C1713 670086B - SCREW BONE 7.5MM 55MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670087B SUP HCPCS C1713 670087B - SCREW BONE 7.5MM 60MM OPUS LNG SPNL HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670-090-00 SUP HCPCS C1887 CATHETER GUID JR4ST CURVE 6FR .070IN 100CM PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 670110B SUP HCPCS C1713 670110B - SCREW BONE 9MM 30MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670111B SUP HCPCS C1713 670111B - SCREW BONE 9MM 35MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670112B SUP HCPCS C1713 670112B - SCREW BONE 9MM 40MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670113B SUP HCPCS C1713 670113B - SCREW BONE 9MM 45MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670114B SUP HCPCS C1713 670114B - SCREW BONE 9MM 50MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670115B SUP HCPCS C1713 670115B - SCREW BONE 9MM 55MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670116B SUP HCPCS C1713 670116B - SCREW BONE 9MM 60MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670212B SUP HCPCS C1713 670212B - SCREW BONE 5.5MM 30MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670213B SUP HCPCS C1713 670213B - SCREW BONE 5.5MM 35MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670214B SUP HCPCS C1713 670214B - SCREW BONE 5.5MM 40MM OPUS SPNL CYLND BOTH IP/OP "$1,556.83 " "$1,152.05" $0.00 "$1,245.46" $700.57 $700.57 $0.00 $0.00 $0.00 $324.48 "$1,155.48" "$1,155.48" $0.00 $0.00 $324.44 $0.00 $920.86 $920.86 $0.00 $778.41 "$1,233.01" "$1,245.46" $0.00 $0.00 $243.64 $0.00 $0.00 $247.85 $0.00 $0.00 $0.00 $0.00 $0.00 670215B SUP HCPCS C1713 670215B - SCREW BONE 5.5MM 45MM OPUS THOR SPN BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670223C SUP HCPCS C1713 670223C - PLATE SHRT 3 HOLE OPUS BONE SPNL BOTH IP/OP "$2,772.18 " "$2,051.41" $0.00 "$2,217.74" "$1,247.48" "$1,247.48" $0.00 $0.00 $0.00 $577.79 "$2,057.51" "$2,057.51" $0.00 $0.00 $577.72 $0.00 "$1,366.68" "$1,366.68" $0.00 "$1,386.09" "$2,195.57" "$2,217.74" $0.00 $0.00 $433.85 $0.00 $0.00 $441.33 $0.00 $0.00 $0.00 $0.00 $0.00 670-26090 SUP HCPCS C1887 CATHETER GUID STRG ENVOY 6FR .90CM BOTH IP/OP $785.00 $580.90 $0.00 $628.00 $426.26 $426.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $392.50 $621.72 $628.00 $0.00 $0.00 $122.85 $0.00 $0.00 $124.97 $0.00 $0.00 $0.00 $0.00 $0.00 670300B SUP HCPCS C1713 670300B - SCREW BONE 6.5MM 30MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670301B SUP HCPCS C1713 670301B - SCREW BONE 6.5MM 35MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670302B SUP HCPCS C1713 670302B - SCREW BONE 6.5MM 40MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670303B SUP HCPCS C1713 670303B - SCREW BONE 6.5MM 45MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670304B SUP HCPCS C1713 670304B - SCREW BONE 6.5MM 50MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670305B SUP HCPCS C1713 670305B - SCREW BONE 6.5MM 55MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6703-1-018 SUP Custom 27203010 6703-1-018 - WIRE SUT .032IN VIT 6 PER TUBE BOTH IP/OP $50.38 $37.28 $0.00 $40.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.39 $37.39 $0.00 $0.00 $10.50 $0.00 $0.00 $0.00 $0.00 $25.19 $39.90 $40.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 670310B SUP HCPCS C1713 670310B - SCREW BONE 7.5MM 30MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670311B SUP HCPCS C1713 670311B - SCREW BONE 7.5MM 35MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670312B SUP HCPCS C1713 670312B - SCREW BONE 7.5MM 40MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670313B SUP HCPCS C1713 670313B - SCREW BONE 7.5MM 45MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670314B SUP HCPCS C1713 670314B - SCREW BONE 7.5MM 50MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670315B SUP HCPCS C1713 670315B - SCREW BONE 7.5MM 55MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670316B SUP HCPCS C1713 670316B - SCREW BONE 7.5MM 60MM OPUS SPNL LNG TOP CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6703-2-120 SUP Custom 27203010 6703-2-120 - WIRE SUT .032IN VIT BOTH IP/OP $217.75 $161.14 $0.00 $174.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.61 $161.61 $0.00 $0.00 $45.38 $0.00 $0.00 $0.00 $0.00 $108.88 $172.46 $174.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 670370B SUP HCPCS C1713 670370B - SCREW BONE 6.5MM 30MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670371B SUP HCPCS C1713 670371B - SCREW BONE 6.5MM 35MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670372B SUP HCPCS C1713 670372B - SCREW BONE 6.5MM 40MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670373B SUP HCPCS C1713 670373B - SCREW BONE 6.5MM 45MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670374B SUP HCPCS C1713 670374B - SCREW BONE 6.5MM 50MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670375B SUP HCPCS C1713 670375B - SCREW BONE 6.5MM 55MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670376B SUP HCPCS C1713 670376B - SCREW BONE 6.5MM 60MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670380B SUP HCPCS C1713 670380B - SCREW BONE 7.5MM 30MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670381B SUP HCPCS C1713 670381B - SCREW BONE 7.5MM 35MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670382B SUP HCPCS C1713 670382B - SCREW BONE 7.5MM 40MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670383B SUP HCPCS C1713 670383B - SCREW BONE 7.5MM 45MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670384B SUP HCPCS C1713 670384B - SCREW BONE 7.5MM 50MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670385B SUP HCPCS C1713 670385B - SCREW BONE 7.5MM 55MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 670386B SUP HCPCS C1713 670386B - SCREW BONE 7.5MM 60MM OPUS SPNL LNG TOP LNG HEX CYLND BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 6704-0-110 SUP HCPCS C1713 6704-0-110 - CABLE ORTHOPEDIC 2 1.6MM HOMOGENOUS GRIP DALL-MILES BOTH IP/OP "$2,022.50 " "$1,496.65" $0.00 "$1,618.00" $910.13 $910.13 $0.00 $0.00 $0.00 $421.54 "$1,501.10" "$1,501.10" $0.00 $0.00 $421.49 $0.00 "$1,196.31" "$1,196.31" $0.00 "$1,011.25" "$1,601.82" "$1,618.00" $0.00 $0.00 $316.52 $0.00 $0.00 $321.98 $0.00 $0.00 $0.00 $0.00 $0.00 6704-0-210 SUP HCPCS C1713 6704-0-210 - CABLE ORTHOPEDIC 2 2MM HOMOGENOUS GRIP DALL-MILES VITALLIUM BOTH IP/OP "$2,022.50 " "$1,496.65" $0.00 "$1,618.00" $910.13 $910.13 $0.00 $0.00 $0.00 $421.54 "$1,501.10" "$1,501.10" $0.00 $0.00 $421.49 $0.00 "$1,196.31" "$1,196.31" $0.00 "$1,011.25" "$1,601.82" "$1,618.00" $0.00 $0.00 $316.52 $0.00 $0.00 $321.98 $0.00 $0.00 $0.00 $0.00 $0.00 6704-0-310 SUP HCPCS C1713 6704-0-310 - CABLE ORTHOPEDIC 2 LARGE 2MM 22MM GRIP DALL-MILES VITALLIUM BOTH IP/OP "$2,022.50 " "$1,496.65" $0.00 "$1,618.00" $910.13 $910.13 $0.00 $0.00 $0.00 $421.54 "$1,501.10" "$1,501.10" $0.00 $0.00 $421.49 $0.00 "$1,196.31" "$1,196.31" $0.00 "$1,011.25" "$1,601.82" "$1,618.00" $0.00 $0.00 $316.52 $0.00 $0.00 $321.98 $0.00 $0.00 $0.00 $0.00 $0.00 6704-0-410 SUP HCPCS C1713 6704-0-410 - CABLE ORTHOPEDIC 1.6MM SET SLEEVE DALL-MILES VITALLIUM HIP BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $310.50 $310.50 $0.00 $0.00 $0.00 $143.81 $512.12 $512.12 $0.00 $0.00 $143.80 $0.00 $408.14 $408.14 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $107.99 $0.00 $0.00 $109.85 $0.00 $0.00 $0.00 $0.00 $0.00 6704-0-420 SUP HCPCS C1713 6704-0-420 - CABLE ORTHOPEDIC 1.6MM SET SLEEVE BEADED DALL-MILES BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $333.00 $333.00 $0.00 $0.00 $0.00 $154.23 $549.23 $549.23 $0.00 $0.00 $154.22 $0.00 $437.71 $437.71 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $115.81 $0.00 $0.00 $117.81 $0.00 $0.00 $0.00 $0.00 $0.00 6704-0-510 SUP Custom 27803010 6704-0-510 - CABLE ORTHOPEDIC 2 2MM HOMOGENOUS DALL-MILES VITALLIUM HIP BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $512.12 $512.12 $0.00 $0.00 $143.80 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6704-0-520 SUP HCPCS C1713 6704-0-520 - CABLE ORTHOPEDIC 2MM SET SLEEVE BEAD DALL-MILES VITALLIUM BOTH IP/OP $740.00 $547.60 $0.00 $592.00 $333.00 $333.00 $0.00 $0.00 $0.00 $154.23 $549.23 $549.23 $0.00 $0.00 $154.22 $0.00 $437.71 $437.71 $0.00 $370.00 $586.08 $592.00 $0.00 $0.00 $115.81 $0.00 $0.00 $117.81 $0.00 $0.00 $0.00 $0.00 $0.00 6704-1-018 SUP Custom 27203010 6704-1-018 - WIRE SUT .04IN 18IN DLMLS VIT 6 PER TUBE BOTH IP/OP $48.75 $36.08 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.18 $36.18 $0.00 $0.00 $10.16 $0.00 $0.00 $0.00 $0.00 $24.38 $38.61 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6704-2-120 SUP Custom 27203010 6704-2-120 - WIRE FX .04IN SUT VIT BOTH IP/OP $253.50 $187.59 $0.00 $202.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.15 $188.15 $0.00 $0.00 $52.83 $0.00 $0.00 $0.00 $0.00 $126.75 $200.77 $202.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-070 SUP HCPCS C1713 6704-3-070 - GRIP CBL 2MM SM DLMLS 2 CBL VIT HIP TROCH BOTH IP/OP "$2,552.50 " "$1,888.85" $0.00 "$2,042.00" "$1,148.63" "$1,148.63" $0.00 $0.00 $0.00 $532.00 "$1,894.47" "$1,894.47" $0.00 $0.00 $531.94 $0.00 "$1,258.38" "$1,258.38" $0.00 "$1,276.25" "$2,021.58" "$2,042.00" $0.00 $0.00 $399.47 $0.00 $0.00 $406.36 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-080 SUP HCPCS C1713 6704-3-080 - GRIP CABLE 2MM MEDIUM 2MM DALL-MILES VITALLIUM HIP BOTH IP/OP "$2,552.50 " "$1,888.85" $0.00 "$2,042.00" "$1,148.63" "$1,148.63" $0.00 $0.00 $0.00 $532.00 "$1,894.47" "$1,894.47" $0.00 $0.00 $531.94 $0.00 "$1,258.38" "$1,258.38" $0.00 "$1,276.25" "$2,021.58" "$2,042.00" $0.00 $0.00 $399.47 $0.00 $0.00 $406.36 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-081 SUP HCPCS C1713 6704-3-081 - PLATE BONE 2MM MEDIUM 100MM 2 CABLE GRIP DALL-MILES BOTH IP/OP "$2,552.50 " "$1,888.85" $0.00 "$2,042.00" "$1,148.63" "$1,148.63" $0.00 $0.00 $0.00 $532.00 "$1,894.47" "$1,894.47" $0.00 $0.00 $531.94 $0.00 "$1,258.38" "$1,258.38" $0.00 "$1,276.25" "$2,021.58" "$2,042.00" $0.00 $0.00 $399.47 $0.00 $0.00 $406.36 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-082 SUP HCPCS C1713 6704-3-082 - PLATE BN 2MM MED 150MM DLMLS 2 CBL GRP VIT HIP TROCH BOTH IP/OP "$3,325.00 " "$2,460.50" $0.00 "$2,660.00" "$1,496.25" "$1,496.25" $0.00 $0.00 $0.00 $693.01 "$2,467.82" "$2,467.82" $0.00 $0.00 $692.93 $0.00 "$1,639.23" "$1,639.23" $0.00 "$1,662.50" "$2,633.40" "$2,660.00" $0.00 $0.00 $520.36 $0.00 $0.00 $529.34 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-083 SUP HCPCS C1713 6704-3-083 - PLATE BN 2MM MED 200MM DLMLS 2 CBL GRP VIT HIP TROCH BOTH IP/OP "$4,115.00 " "$3,045.10" $0.00 "$3,292.00" "$1,851.75" "$1,851.75" $0.00 $0.00 $0.00 $857.67 "$3,054.15" "$3,054.15" $0.00 $0.00 $857.57 $0.00 "$2,028.70" "$2,028.70" $0.00 "$2,057.50" "$3,259.08" "$3,292.00" $0.00 $0.00 $644.00 $0.00 $0.00 $655.11 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-090 SUP HCPCS C1713 6704-3-090 - GRIP CABLE 2MM LARGE DALL-MILES VITALLIUM HIP BOTH IP/OP "$2,552.50 " "$1,888.85" $0.00 "$2,042.00" "$1,148.63" "$1,148.63" $0.00 $0.00 $0.00 $532.00 "$1,894.47" "$1,894.47" $0.00 $0.00 $531.94 $0.00 "$1,258.38" "$1,258.38" $0.00 "$1,276.25" "$2,021.58" "$2,042.00" $0.00 $0.00 $399.47 $0.00 $0.00 $406.36 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-091 SUP HCPCS C1713 6704-3-091 - PLATE BN 2MM LG 110MM DLMLS 2 CBL GRP VIT HIP TROCH BOTH IP/OP "$2,552.50 " "$1,888.85" $0.00 "$2,042.00" "$1,148.63" "$1,148.63" $0.00 $0.00 $0.00 $532.00 "$1,894.47" "$1,894.47" $0.00 $0.00 $531.94 $0.00 "$1,258.38" "$1,258.38" $0.00 "$1,276.25" "$2,021.58" "$2,042.00" $0.00 $0.00 $399.47 $0.00 $0.00 $406.36 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-092 SUP HCPCS C1713 6704-3-092 - PLATE BONE 2MM LARGE 160MM 2 CABLE GRIP DALL-MILES VITALLIUM BOTH IP/OP "$3,325.00 " "$2,460.50" $0.00 "$2,660.00" "$1,496.25" "$1,496.25" $0.00 $0.00 $0.00 $693.01 "$2,467.82" "$2,467.82" $0.00 $0.00 $692.93 $0.00 "$1,639.23" "$1,639.23" $0.00 "$1,662.50" "$2,633.40" "$2,660.00" $0.00 $0.00 $520.36 $0.00 $0.00 $529.34 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-093 SUP HCPCS C1713 6704-3-093 - PLATE BONE 2MM LARGE 210MM 2 CABLE GRIP DALL-MILES VITALLIUM BOTH IP/OP "$4,115.00 " "$3,045.10" $0.00 "$3,292.00" "$1,851.75" "$1,851.75" $0.00 $0.00 $0.00 $857.67 "$3,054.15" "$3,054.15" $0.00 $0.00 $857.57 $0.00 "$2,028.70" "$2,028.70" $0.00 "$2,057.50" "$3,259.08" "$3,292.00" $0.00 $0.00 $644.00 $0.00 $0.00 $655.11 $0.00 $0.00 $0.00 $0.00 $0.00 6704-3-120 SUP HCPCS C1713 6704-3-120 - WIRE FX .046IN HVY GA VIT BOTH IP/OP $253.50 $187.59 $0.00 $202.80 $114.08 $114.08 $0.00 $0.00 $0.00 $52.84 $188.15 $188.15 $0.00 $0.00 $52.83 $0.00 $149.95 $149.95 $0.00 $126.75 $200.77 $202.80 $0.00 $0.00 $39.67 $0.00 $0.00 $40.36 $0.00 $0.00 $0.00 $0.00 $0.00 6704-4-016 SUP HCPCS C1713 6704-4-016 - SLEEVE CABLE SMALL 1.6MM CRIMP DALL-MILES VITALLIUM HIP BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 6704-4-020 SUP HCPCS C1713 6704-4-020 - SLEEVE CABLE MEDIUM 2MM GRIP CRIMP DALL-MILES VITALLIUM HIP BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 6704-5-016 SUP HCPCS C1713 6704-5-016 - GRIP CABLE SMALL 1.6MM HOLE DALL-MILES VITALLIUM HIP STERILE BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $537.75 $537.75 $0.00 $0.00 $0.00 $249.07 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $706.84 $706.84 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $187.02 $0.00 $0.00 $190.24 $0.00 $0.00 $0.00 $0.00 $0.00 6704-6-020 SUP HCPCS C1713 6704-6-020 - GRIP CABLE MEDIUM 2MM HOLE DALL-MILES VITALLIUM HIP STERILE BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $537.75 $537.75 $0.00 $0.00 $0.00 $249.07 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $706.84 $706.84 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $187.02 $0.00 $0.00 $190.24 $0.00 $0.00 $0.00 $0.00 $0.00 6704-6-110 SUP HCPCS C1713 6704-6-110 - BUTTON FIX GROOVE LOCK DALL-MILES VITALLIUM HIP BOTH IP/OP $647.50 $479.15 $0.00 $518.00 $291.38 $291.38 $0.00 $0.00 $0.00 $134.96 $480.57 $480.57 $0.00 $0.00 $134.94 $0.00 $383.00 $383.00 $0.00 $323.75 $512.82 $518.00 $0.00 $0.00 $101.33 $0.00 $0.00 $103.08 $0.00 $0.00 $0.00 $0.00 $0.00 6704-7-020 SUP Custom 27803010 6704-7-020 - GRIP CABLE LARGE 2MM DALL-MILES VITALLIUM HIP STERILE BOTH IP/OP "$1,195.00 " $884.30 $0.00 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.93 $886.93 $0.00 $0.00 $249.04 $0.00 $0.00 $0.00 $0.00 $597.50 $946.44 $956.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6704-8-030 SUP HCPCS C1713 6704-8-030 - CABLE ORTHOPEDIC MINI SLEEVE DALL-MILES VITALLIUM HIP BOTH IP/OP $555.00 $410.70 $0.00 $444.00 $249.75 $249.75 $0.00 $0.00 $0.00 $115.68 $411.92 $411.92 $0.00 $0.00 $115.66 $0.00 $328.28 $328.28 $0.00 $277.50 $439.56 $444.00 $0.00 $0.00 $86.86 $0.00 $0.00 $88.36 $0.00 $0.00 $0.00 $0.00 $0.00 6704-8-236 SUP HCPCS C1713 6704-8-236 - CABLE ORTHOPEDIC 1.6MM 750MM GRIP DALL-MILES VITALLIUM HIP BOTH IP/OP $622.50 $460.65 $0.00 $498.00 $280.13 $280.13 $0.00 $0.00 $0.00 $129.74 $462.02 $462.02 $0.00 $0.00 $129.73 $0.00 $368.21 $368.21 $0.00 $311.25 $493.02 $498.00 $0.00 $0.00 $97.42 $0.00 $0.00 $99.10 $0.00 $0.00 $0.00 $0.00 $0.00 6704-8-240 SUP HCPCS C1713 6704-8-240 - CABLE ORTHOPEDIC 2MM 750MM GRIP DALL-MILES VITALLIUM HIP BOTH IP/OP $622.50 $460.65 $0.00 $498.00 $280.13 $280.13 $0.00 $0.00 $0.00 $129.74 $462.02 $462.02 $0.00 $0.00 $129.73 $0.00 $368.21 $368.21 $0.00 $311.25 $493.02 $498.00 $0.00 $0.00 $97.42 $0.00 $0.00 $99.10 $0.00 $0.00 $0.00 $0.00 $0.00 6707920P2 SUP HCPCS C1713 6707920P2 - IMPLANT SPNL 4D 20X7X9MM LF CRNT LI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6707926P2 SUP HCPCS C1713 6707926P2 - IMPLANT SPNL 4D 26X7X9MM LF CRNT LI BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708520P2 SUP HCPCS C1713 6708520P2 - CAGE SPNL 15D LG TPR 20X9X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708820P2 SUP HCPCS C1713 6708820P2 - CAGE SPNL 8D LG TPR 20X9X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708920P2 SUP HCPCS C1713 6708920P2 - CAGE SPNL 4D LG IMPCT 20X9X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708926P2 SUP HCPCS C1713 6708926P2 - CAGE SPNL 4D LG IMPCT 26X9X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6708932P2 SUP HCPCS C1713 6708932P2 - CAGE SPNL 4D LG IMPCT 32X9X8MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6709920P2 SUP HCPCS C1713 6709920P2 - CAGE SPNL 4D LG IMPCT 20X9X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6709926P2 SUP HCPCS C1713 6709926P2 - CAGE SPNL 4D LG IMPCT 26X9X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6709932P2 SUP HCPCS C1713 6709932P2 - CAGE SPNL 4D LG IMPCT 32X9X9MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710520P2 SUP HCPCS C1713 6710520P2 - CAGE SPNL 15D LG TPR 20X10X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710820P2 SUP HCPCS C1713 6710820P2 - CAGE SPNL 8D LG TPR 20X10X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710920P2 SUP HCPCS C1713 6710920P2 - CAGE SPNL 4D LG IMPCT 20X10X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710926P2 SUP HCPCS C1713 6710926P2 - CAGE SPNL 4D LG IMPCT 26X10X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6710932P2 SUP HCPCS C1713 6710932P2 - CAGE SPNL 4D LG IMPCT 32X10X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711920P2 SUP HCPCS C1713 6711920P2 - CAGE SPNL 4D LG IMPCT 20X11X9MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711926P2 SUP HCPCS C1713 6711926P2 - CAGE SPNL 4D LG IMPCT 26X11X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6711932P2 SUP HCPCS C1713 6711932P2 - CAGE SPNL 4D LG IMPCT 32X11X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712520P2 SUP HCPCS C1713 6712520P2 - CAGE SPNL 15D LG TPR 20X12X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712820P2 SUP HCPCS C1713 6712820P2 - CAGE SPNL 8D LG TPR 20X12X9MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712920P2 SUP HCPCS C1713 6712920P2 - CAGE SPNL 4D LG IMPCT 20X12X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712926P2 SUP HCPCS C1713 6712926P2 - CAGE SPNL 4D LG IMPCT 26X12X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6712932P2 SUP HCPCS C1713 6712932P2 - CAGE SPNL 4D LG IMPCT 32X12X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713920P2 SUP HCPCS C1713 6713920P2 - CAGE SPNL 4D LG IMPCT LRDTC 20X13X9MM NS LF CRNT PEEK BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713926P2 SUP HCPCS C1713 6713926P2 - CAGE SPNL 4D LG IMPCT 26X13X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6713932P2 SUP HCPCS C1713 6713932P2 - CAGE SPNL 4D LG IMPCT 32X13X9MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714820P2 SUP HCPCS C1713 6714820P2 - CAGE SPNL 8D LG TPR 20X14X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714920P2 SUP HCPCS C1713 6714920P2 - CAGE SPNL 4D LG IMPCT 20X14X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714926P2 SUP HCPCS C1713 6714926P2 - CAGE SPNL 4D LG IMPCT 26X14X9MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6714932P2 SUP HCPCS C1713 6714932P2 - CAGE SPNL 4D LG IMPCT 32X14X9MM NS LF CRNT PEEK-OPTM BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6715920P2 SUP HCPCS C1713 6715920P2 - CAGE SPNL 4D LG IMPCT 20X9X15MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6715926P2 SUP HCPCS C1713 6715926P2 - CAGE SPNL 4D LG IMPCT 26X9X15MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6716920P2 SUP HCPCS C1713 6716920P2 - CAGE SPNL 4D LG IMPCT 20X9X16MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6716926P2 SUP HCPCS C1713 6716926P2 - CAGE SPNL 4D LG IMPCT 26X9X16MM NS LF CRNT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 6720-0027 SUP HCPCS C1776 6720-0027 - STEM FEM 132D 0 28MM STD OFST 93MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0127 SUP HCPCS C1776 6720-0127 - STEM FEM 132D 1 29MM STD OFST 96MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0230 SUP HCPCS C1776 6720-0230 - STEM FEM 132D 2 33MM STD OFST 99MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0330 SUP HCPCS C1776 6720-0330 - STEM FEM 132D 3 35MM STD OFST 102MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0435 SUP HCPCS C1776 6720-0435 - STEM FEM 132D 4 38MM STD OFST 105MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0535 SUP HCPCS C1776 6720-0535 - STEM FEM 132D 5 40MM STD OFST 108MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0635 SUP HCPCS C1776 6720-0635 - STEM FEM 132D 6 41MM STD OFST 111MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0737 SUP HCPCS C1776 6720-0737 - STEM FEM 132D 7 46MM STD OFST 114MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0837 SUP HCPCS C1776 6720-0837 - STEM FEM 132D 8 47MM STD OFST 117MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-0937 SUP HCPCS C1776 6720-0937 - STEM FEM 132D 9 49MM STD OFST 120MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-1040 SUP HCPCS C1776 6720-1040 - STEM FEM 132D 10 51MM STD OFST 123MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6720-1140 SUP HCPCS C1776 6720-1140 - STEM FEM 132D 11 53MM STD OFST 126MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6721-0027 SUP HCPCS C1776 6721-0027 - STEM FEM 127D 0 32MM HI OFST 93MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6721-0330 SUP HCPCS C1776 6721-0330 - STEM FEM ACLD II 3 127D BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6721-0435 SUP HCPCS C1713 6721-0435 - STEM FEM ACLD II 4 127D BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6721-0535 SUP HCPCS C1713 6721-0535 - STEM FEM ACLD II 5 127D BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6721-0635 SUP HCPCS C1776 6721-0635 - STEM FEM 127D 6 TPR 111MM STRL 35MM ACLD MDLR HIP BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6721-0837 SUP HCPCS C1776 6721-0837 - STEM FEM 127D 8 TPR 117MM STRL 37MM ACLD II MDLR HIP BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6721-1140 SUP HCPCS C1776 6721-1140 - STEM FEM 127D 11 58MM HI OFST 126MM STRL ACLD II V40 PRFT BOTH IP/OP "$5,357.50 " "$3,964.55" $0.00 "$4,286.00" "$2,410.88" "$2,410.88" $0.00 $0.00 $0.00 "$1,116.64" "$3,976.34" "$3,976.34" $0.00 $0.00 "$1,116.50" $0.00 "$2,641.25" "$2,641.25" $0.00 "$2,678.75" "$4,243.14" "$4,286.00" $0.00 $0.00 $838.45 $0.00 $0.00 $852.91 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-609 SUP HCPCS C1776 6728-1-609 - INSERT TIBIAL SMALL 9MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-611 SUP HCPCS C1776 6728-1-611 - INSERT TIBIAL SMALL 11MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-613 SUP HCPCS C1776 6728-1-613 - INSERT TIBIAL SMALL 13MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-616 SUP HCPCS C1776 6728-1-616 - INSERT TIBIAL SMALL 16MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-619 SUP HCPCS C1776 6728-1-619 - INSERT TIBIAL SMALL 19MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-622 SUP HCPCS C1776 6728-1-622 - INSERT TIBIAL SMALL 22MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-625 SUP HCPCS C1776 6728-1-625 - INSERT TIBIAL SMALL 25MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-709 SUP HCPCS C1776 6728-1-709 - INSERT TIBIAL SMALL 9MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-711 SUP HCPCS C1776 6728-1-711 - INSERT TIBIAL SMALL 11MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-713 SUP HCPCS C1776 6728-1-713 - INSERT TIBIAL SMALL 13MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-716 SUP HCPCS C1776 6728-1-716 - INSERT TIBIAL SMALL 16MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-719 SUP HCPCS C1776 6728-1-719 - INSERT TIBIAL SMALL 19MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-722 SUP HCPCS C1776 6728-1-722 - INSERT TIBIAL SMALL 22MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-725 SUP HCPCS C1776 6728-1-725 - INSERT TIBIAL SMALL 25MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-1-940 SUP Custom 27803010 6728-1-940 - COMPONENT PATLR SMALL PRIM REVISION CUP PCA KNEE BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 $0.00 $0.00 $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-609 SUP HCPCS C1776 6728-2-609 - INSERT TIBIAL MEDIUM 9MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-611 SUP HCPCS C1776 6728-2-611 - INSERT TIBIAL MEDIUM 11MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-613 SUP HCPCS C1776 6728-2-613 - INSERT TIBIAL MEDIUM 13MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-616 SUP HCPCS C1776 6728-2-616 - INSERT TIBIAL MEDIUM 16MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-619 SUP HCPCS C1776 6728-2-619 - INSERT TIBIAL MEDIUM 19MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-622 SUP HCPCS C1776 6728-2-622 - INSERT TIBIAL MEDIUM 22MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-625 SUP HCPCS C1776 6728-2-625 - INSERT TIBIAL MEDIUM 25MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-709 SUP HCPCS C1776 6728-2-709 - INSERT TIBIAL MEDIUM 9MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-711 SUP HCPCS C1776 6728-2-711 - INSERT TIBIAL MEDIUM 11MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-713 SUP HCPCS C1776 6728-2-713 - INSERT TIBIAL MEDIUM 13MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-716 SUP HCPCS C1776 6728-2-716 - INSERT TIBIAL MEDIUM 16MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-719 SUP HCPCS C1776 6728-2-719 - INSERT TIBIAL MEDIUM 19MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-722 SUP HCPCS C1776 6728-2-722 - INSERT TIBIAL MEDIUM 22MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-725 SUP HCPCS C1776 6728-2-725 - INSERT TIBIAL MEDIUM 25MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-2-940 SUP HCPCS C1776 6728-2-940 - COMPONENT PATLR MEDIUM PRIM REVISION CUP PCA KNEE BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" "$1,633.50" "$1,633.50" $0.00 $0.00 $0.00 $756.58 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 "$1,789.59" "$1,789.59" $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $568.10 $0.00 $0.00 $577.90 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-609 SUP HCPCS C1776 6728-4-609 - INSERT TIBIAL LARGE 9MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-611 SUP HCPCS C1776 6728-4-611 - INSERT TIBIAL LARGE 11MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-613 SUP HCPCS C1776 6728-4-613 - INSERT TIBIAL LARGE 13MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-616 SUP HCPCS C1776 6728-4-616 - INSERT TIBIAL LARGE 16MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-619 SUP HCPCS C1776 6728-4-619 - INSERT TIBIAL LARGE 19MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-622 SUP HCPCS C1776 6728-4-622 - INSERT TIBIAL LARGE 22MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-625 SUP HCPCS C1776 6728-4-625 - INSERT TIBIAL LARGE 25MM REVISION PCA KNEE LEFT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-709 SUP HCPCS C1776 6728-4-709 - INSERT TIBIAL LARGE 9MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-711 SUP HCPCS C1776 6728-4-711 - INSERT TIBIAL LARGE 11MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-713 SUP HCPCS C1776 6728-4-713 - INSERT TIBIAL LARGE 13MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-716 SUP HCPCS C1776 6728-4-716 - INSERT TIBIAL LARGE 16MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-719 SUP HCPCS C1776 6728-4-719 - INSERT TIBIAL LARGE 19MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-722 SUP HCPCS C1776 6728-4-722 - INSERT TIBIAL LARGE 22MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-725 SUP HCPCS C1776 6728-4-725 - INSERT TIBIAL LARGE 25MM REVISION PCA KNEE RIGHT BOTH IP/OP "$5,410.00 " "$4,003.40" $0.00 "$4,328.00" "$2,434.50" "$2,434.50" $0.00 $0.00 $0.00 "$1,127.58" "$4,015.30" "$4,015.30" $0.00 $0.00 "$1,127.44" $0.00 "$2,667.13" "$2,667.13" $0.00 "$2,705.00" "$4,284.72" "$4,328.00" $0.00 $0.00 $846.67 $0.00 $0.00 $861.27 $0.00 $0.00 $0.00 $0.00 $0.00 6728-4-940 SUP Custom 27803010 6728-4-940 - COMPONENT PATLR LARGE PRIM REVISION PCA BOTH IP/OP "$3,630.00 " "$2,686.20" $0.00 "$2,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,694.19" "$2,694.19" $0.00 $0.00 $756.49 $0.00 $0.00 $0.00 $0.00 "$1,815.00" "$2,874.96" "$2,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-109 SUP Custom 27803010 6742-1-109 - INSERT TIBIAL SMALL 9MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-111 SUP Custom 27803010 6742-1-111 - INSERT TIBIAL SMALL 11MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-113 SUP Custom 27803010 6742-1-113 - INSERT TIBIAL SMALL 13MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-116 SUP Custom 27803010 6742-1-116 - INSERT TIBIAL SMALL 16MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-119 SUP Custom 27803010 6742-1-119 - INSERT TIBIAL SMALL 19MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-122 SUP Custom 27803010 6742-1-122 - INSERT TIBIAL SMALL 22MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-125 SUP Custom 27803010 6742-1-125 - INSERT TIBIAL SMALL 25MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-209 SUP Custom 27803010 6742-1-209 - INSERT TIBIAL MEDIUM 9MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-211 SUP Custom 27803010 6742-1-211 - INSERT TIBIAL MEDIUM 11MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-213 SUP Custom 27803010 6742-1-213 - INSERT TIBIAL MEDIUM 13MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-216 SUP Custom 27803010 6742-1-216 - INSERT TIBIAL MEDIUM 16MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-219 SUP Custom 27803010 6742-1-219 - INSERT TIBIAL MEDIUM 19MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-222 SUP Custom 27803010 6742-1-222 - INSERT TIBIAL MEDIUM 12MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-225 SUP Custom 27803010 6742-1-225 - INSERT TIBIAL MEDIUM 25MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-309 SUP Custom 27803010 6742-1-309 - INSERT TIBIAL LARGE 9MM POSTERIOR STABILIZE LIPPED DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-311 SUP Custom 27803010 6742-1-311 - INSERT TIBIAL LARGE 11MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-313 SUP Custom 27803010 6742-1-313 - INSERT TIBIAL LARGE 13MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-316 SUP Custom 27803010 6742-1-316 - INSERT TIBIAL LARGE 16MM POSTERIOR STABILIZE LIP DURACON DUR BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-319 SUP Custom 27803010 6742-1-319 - INSERT TIBIAL LARGE 19MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-322 SUP Custom 27803010 6742-1-322 - INSERT TIBIAL LARGE 22MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-325 SUP Custom 27803010 6742-1-325 - INSERT TIBIAL LARGE 25MM POSTERIOR STABILIZE LIP DURACON BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-409 SUP Custom 27803010 6742-1-409 - INSERT TIBIAL XL 9MM POSTERIOR STABILIZE LIP DURACON KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-411 SUP Custom 27803010 6742-1-411 - INSERT TIBIAL XL 11MM POSTERIOR STABILIZE LIP DURACON KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-413 SUP Custom 27803010 6742-1-413 - INSERT TIBIAL XL 13MM POSTERIOR STABILIZE LIP DURACON KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-416 SUP Custom 27803010 6742-1-416 - INSERT TIBIAL XL 16MM POSTERIOR STABILIZE LIP DURACON KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-419 SUP Custom 27803010 6742-1-419 - INSERT TIBIAL XL 19MM POSTERIOR STABILIZE LIP DURACON KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-422 SUP Custom 27803010 6742-1-422 - INSERT TIBIAL XL 22MM POSTERIOR STABILIZE LIP DURACON KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-1-425 SUP Custom 27803010 6742-1-425 - INSERT TIBIAL XL 25MM POSTERIOR STABILIZE LIP DURACON KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-009 SUP Custom 27803010 6742-4-009 - INSERT TIBIAL XS 9MM STABILIZE LIP DURACON DUR KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-011 SUP Custom 27803010 6742-4-011 - INSERT TIBIAL XS 11MM STABILIZE LIP DURACON DUR KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-013 SUP Custom 27803010 6742-4-013 - INSERT TIBIAL XS 13MM STABILIZE LIP DURACON DUR KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-016 SUP Custom 27803010 6742-4-016 - INSERT TIBIAL XS 16MM STABILIZE LIP DURACON DUR KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-109 SUP Custom 27803010 6742-4-109 - INSERT TIBIAL SMALL 9MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-111 SUP Custom 27803010 6742-4-111 - INSERT TIBIAL SMALL 11MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-113 SUP Custom 27803010 6742-4-113 - INSERT TIBIAL SMALL 13MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-116 SUP Custom 27803010 6742-4-116 - INSERT TIBIAL SMALL 16MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-119 SUP Custom 27803010 6742-4-119 - INSERT TIBIAL SMALL 19MM STABILIZE LIP DURACON DUR KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-122 SUP Custom 27803010 6742-4-122 - INSERT TIBIAL SMALL 22MM STABILIZE LIP DURACON DUR KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-125 SUP Custom 27803010 6742-4-125 - INSERT TIBIAL SMALL 25MM STABILIZE LIP DURACON DUR KNEE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-209 SUP Custom 27803010 6742-4-209 - INSERT TIBIAL MEDIUM 9MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$2,230.00 " "$1,650.20" $0.00 "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,655.11" "$1,655.11" $0.00 $0.00 $464.73 $0.00 $0.00 $0.00 $0.00 "$1,115.00" "$1,766.16" "$1,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-209X SUP Custom 27803010 6742-4-209X - INSERT TIBIAL MEDIUM 9MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-211 SUP Custom 27803010 6742-4-211 - INSERT TIBIAL MEDIUM 11MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-211X SUP Custom 27803010 6742-4-211X - INSERT TIBIAL MEDIUM 11MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-213 SUP Custom 27803010 6742-4-213 - INSERT TIBIAL MEDIUM 13MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-213X SUP Custom 27803010 6742-4-213X - INSERT TIBIAL MEDIUM 13MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-216 SUP Custom 27803010 6742-4-216 - INSERT TIBIAL MEDIUM 16MM STABILIZE DURACON DUR KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-219 SUP Custom 27803010 6742-4-219 - INSERT TIBIAL MEDIUM 19MM STABILIZE DURACON DUR KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-222 SUP Custom 27803010 6742-4-222 - INSERT TIBIAL MEDIUM 22MM STABILIZE LIP DURACON DUR KNEE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-225 SUP Custom 27803010 6742-4-225 - INSERT TIBIAL MEDIUM 25MM STABILIZE DURACON DUR KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-309 SUP Custom 27803010 6742-4-309 - INSERT TIBIAL LARGE 9MM STABILIZE DURACON DUR KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-309X SUP Custom 27803010 6742-4-309X - INSERT TIBIAL LARGE 9MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-311 SUP Custom 27803010 6742-4-311 - INSERT TIBIAL LARGE 11MM STABILIZE DURACON DUR KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-311X SUP Custom 27803010 6742-4-311X - INSERT TIBIAL LARGE 11MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-313 SUP Custom 27803010 6742-4-313 - INSERT TIBIAL LARGE 13MM STABILIZE DURACON DUR KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-313X SUP Custom 27803010 6742-4-313X - INSERT TIBIAL LARGE 13MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-316 SUP Custom 27803010 6742-4-316 - INSERT TIBIAL LARGE 16MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-319 SUP Custom 27803010 6742-4-319 - INSERT TIBIAL LARGE 19MM STABILIZE LIP DURACON DUR KNEE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-322 SUP Custom 27803010 6742-4-322 - INSERT TIBIAL LARGE 22MM STABILIZE LIP DURACON DUR KNEE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-325 SUP Custom 27803010 6742-4-325 - INSERT TIBIAL LARGE 25MM STABILIZE LIP DURACON DUR KNEE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-409 SUP Custom 27803010 6742-4-409 - INSERT TIBIAL XL 9MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-409X SUP Custom 27803010 6742-4-409X - INSERT TIBIAL XL 9MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-411 SUP Custom 27803010 6742-4-411 - INSERT TIBIAL XL 11MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-411X SUP Custom 27803010 6742-4-411X - INSERT TIBIAL XL 11MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-413 SUP Custom 27803010 6742-4-413 - INSERT TIBIAL XL 13MM STABILIZE DURACON KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-413X SUP Custom 27803010 6742-4-413X - INSERT TIBIAL XL 13MM STABILIZE DURACON X3 KNEE CONDYLE BOTH IP/OP "$5,025.00 " "$3,718.50" $0.00 "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,729.56" "$3,729.56" $0.00 $0.00 "$1,047.21" $0.00 $0.00 $0.00 $0.00 "$2,512.50" "$3,979.80" "$4,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-416 SUP Custom 27803010 6742-4-416 - INSERT TIBIAL XL 16MM CNDYLR STABILIZED DURACON RIGHT BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-419 SUP Custom 27803010 6742-4-419 - INSERT TIBIAL XL 19MM CNDYLR STABILIZED DURACON RIGHT BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-422 SUP Custom 27803010 6742-4-422 - INSERT TIBIAL XL 22MM STABILIZE LIP DURACON DUR KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6742-4-425 SUP Custom 27803010 6742-4-425 - INSERT TIBIAL XL 25MM STABILIZE LIP DURACON DUR KNEE CONDYLE BOTH IP/OP "$3,055.00 " "$2,260.70" $0.00 "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,267.42" "$2,267.42" $0.00 $0.00 $636.66 $0.00 $0.00 $0.00 $0.00 "$1,527.50" "$2,419.56" "$2,444.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-111 SUP Custom 27803010 6752-5-111 - INSERT TIB SM 11MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-113 SUP Custom 27803010 6752-5-113 - INSERT TIB SM 13MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-116 SUP Custom 27803010 6752-5-116 - INSERT TIB SM 16MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-119 SUP Custom 27803010 6752-5-119 - INSERT TIB SM 19MM KNEE PS CNSTRN BOTH IP/OP "$1,412.00 " "$1,044.88" $0.00 "$1,129.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,047.99" "$1,047.99" $0.00 $0.00 $294.26 $0.00 $0.00 $0.00 $0.00 $706.00 "$1,118.30" "$1,129.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-122 SUP Custom 27803010 6752-5-122 - INSERT TIB SM 22MM KNEE PS CNSTRN BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-125 SUP Custom 27803010 6752-5-125 - INSERT TIB SM 25MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,381.00 " "$1,021.94" $0.00 "$1,104.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.98" "$1,024.98" $0.00 $0.00 $287.80 $0.00 $0.00 $0.00 $0.00 $690.50 "$1,093.75" "$1,104.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-128 SUP Custom 27803010 6752-5-128 - INSERT TIB SM 28MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-131 SUP Custom 27803010 6752-5-131 - INSERT TIB SM 31MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-211 SUP Custom 27803010 6752-5-211 - INSERT TIB MED 11MM KNEE PS CNSTRN BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-213 SUP Custom 27803010 6752-5-213 - INSERT TIB MED 13MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-216 SUP Custom 27803010 6752-5-216 - INSERT TIB MED 16MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-219 SUP Custom 27803010 6752-5-219 - INSERT TIB MED 19MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-222 SUP Custom 27803010 6752-5-222 - INSERT TIB MED 22MM KNEE PS CNSTRN BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-225 SUP Custom 27803010 6752-5-225 - INSERT TIB MED 25MM KNEE PS CNSTRN BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-228 SUP Custom 27803010 6752-5-228 - INSERT TIB MED 28MM KNEE PS CNSTRN BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-231 SUP Custom 27803010 6752-5-231 - INSERT TIB MED 31MM KNEE PS CNSTRN BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-311 SUP Custom 27803010 6752-5-311 - INSERT TIB LG 11MM KNEE PS CNSTRN BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-313 SUP Custom 27803010 6752-5-313 - INSERT TIB LG 13MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-316 SUP Custom 27803010 6752-5-316 - INSERT TIB LG 16MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-319 SUP Custom 27803010 6752-5-319 - INSERT TIB LG 19MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,412.00 " "$1,044.88" $0.00 "$1,129.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,047.99" "$1,047.99" $0.00 $0.00 $294.26 $0.00 $0.00 $0.00 $0.00 $706.00 "$1,118.30" "$1,129.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-322 SUP Custom 27803010 6752-5-322 - INSERT TIB LG 22MM KNEE PS CNSTRN BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-325 SUP Custom 27803010 6752-5-325 - INSERT TIB LG 25MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-328 SUP Custom 27803010 6752-5-328 - INSERT TIB LG 28MM KNEE PS CNSTRN BOTH IP/OP "$1,381.00 " "$1,021.94" $0.00 "$1,104.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.98" "$1,024.98" $0.00 $0.00 $287.80 $0.00 $0.00 $0.00 $0.00 $690.50 "$1,093.75" "$1,104.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-331 SUP Custom 27803010 6752-5-331 - INSERT TIB LG 31MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,381.00 " "$1,021.94" $0.00 "$1,104.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,024.98" "$1,024.98" $0.00 $0.00 $287.80 $0.00 $0.00 $0.00 $0.00 $690.50 "$1,093.75" "$1,104.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-411 SUP Custom 27803010 6752-5-411 - INSERT TIB XL 11MM KNEE PS CNSTRN BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-413 SUP Custom 27803010 6752-5-413 - INSERT TIB XL 13MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-416 SUP Custom 27803010 6752-5-416 - INSERT TIB XL 16MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-419 SUP Custom 27803010 6752-5-419 - INSERT TIB XL 19MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,763.00 " "$1,304.62" $0.00 "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.50" "$1,308.50" $0.00 $0.00 $367.41 $0.00 $0.00 $0.00 $0.00 $881.50 "$1,396.30" "$1,410.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-422 SUP Custom 27803010 6752-5-422 - INSERT TIB XL 22MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6752-5-425 SUP Custom 27803010 6752-5-425 - INSERT TIB XL 25MM KNEE PS CNSTRN MRS BOTH IP/OP "$1,439.00 " "$1,064.86" $0.00 "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,068.03" "$1,068.03" $0.00 $0.00 $299.89 $0.00 $0.00 $0.00 $0.00 $719.50 "$1,139.69" "$1,151.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 67525P SUP HCPCS C1713 67525P - SCREW BN 6.75MM 25MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67525S SUP HCPCS C1713 67525S - SCREW BN STD 6.75MM 25MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67530P SUP HCPCS C1713 67530P - SCREW BN 6.75MM 30MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67530S SUP HCPCS C1713 67530S - SCREW BN STD 6.75MM 30MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67535P SUP HCPCS C1713 67535P - SCREW BN 6.75MM 35MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67535S SUP HCPCS C1713 67535S - SCREW BN STD 6.75MM 35MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67540P SUP HCPCS C1713 67540P - SCREW BN 6.75MM 40MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67540S SUP HCPCS C1713 67540S - SCREW BN STD 6.75MM 40MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67545P SUP HCPCS C1713 67545P - SCREW BN 6.75MM 45MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67545S SUP HCPCS C1713 67545S - SCREW BN STD 6.75MM 45MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67550P SUP HCPCS C1713 67550P - SCREW BN 6.75MM 50MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67550S SUP HCPCS C1713 67550S - SCREW BN STD 6.75MM 50MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67555P SUP HCPCS C1713 67555P - SCREW BN 6.75MM 55MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67555S SUP HCPCS C1713 67555S - SCREW BN STD 6.75MM 55MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67560P SUP HCPCS C1713 67560P - SCREW BN 6.75MM 60MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67560S SUP HCPCS C1713 67560S - SCREW BN STD 6.75MM 60MM SPRL R90D LCK SPNE THORLMBR BOTH IP/OP "$2,228.53 " "$1,649.11" $0.00 "$1,782.82" "$1,002.84" "$1,002.84" $0.00 $0.00 $0.00 $464.48 "$1,654.01" "$1,654.01" $0.00 $0.00 $464.42 $0.00 "$1,318.17" "$1,318.17" $0.00 "$1,114.26" "$1,765.00" "$1,782.82" $0.00 $0.00 $348.76 $0.00 $0.00 $354.78 $0.00 $0.00 $0.00 $0.00 $0.00 67565P SUP HCPCS C1713 67565P - SCREW BN 6.75MM 65MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 67565S SUP HCPCS C1713 67565S - SCREW BN STD 6.75MM 65MM SPRL R90D LCK SPNE THORLMBR BOTH IP/OP "$1,233.33 " $912.66 $0.00 $986.66 $555.00 $555.00 $0.00 $0.00 $0.00 $257.06 $915.37 $915.37 $0.00 $0.00 $257.02 $0.00 $729.51 $729.51 $0.00 $616.66 $976.80 $986.66 $0.00 $0.00 $193.02 $0.00 $0.00 $196.35 $0.00 $0.00 $0.00 $0.00 $0.00 68-1405 SUP Custom 27203010 FORCEPS SURG DBKY 5MM ATRM CURVE 330 MD BOTH IP/OP "$1,507.50 " "$1,115.55" $0.00 "$1,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.75 "$1,193.94" "$1,206.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 68-1415 SUP Custom 27203010 FORCEPS SURG CLN 30MM 10MM JAW 330 BOTH IP/OP "$1,530.00 " "$1,132.20" $0.00 "$1,224.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $765.00 "$1,211.76" "$1,224.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-00-22D SUP Custom 27803010 690-00-22D - INSERT ACETAB 0D D 40MM 36MM 22MM 5.6MM CONSTRAIN RING LOCK BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-00-22E SUP Custom 27803010 690-00-22E - INSERT ACETAB 0D E 44MM 36MM 22MM 7.5MM CONSTRAIN LOCK RING BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-00-28F SUP Custom 27803010 690-00-28F - INSERT ACETAB 0D F 42MM 28MM CONSTRAIN TRIDENT UHMWPE HIP BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-00-28G SUP Custom 27803010 690-00-28G - INSERT ACETAB 0D G 51.5MM 42MM 28MM 5.6MM CONSTRAIN LOCK BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-00-32H SUP Custom 27803010 690-00-32H - INSERT ACETAB 0D H 55MM 46MM 32MM 7.8MM CONSTRAIN LOCK RING BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-00-32I SUP Custom 27803010 690-00-32I - INSERT ACETAB 0D I 58MM 46MM 32MM CONSTRAIN BIPOL SPLIT RING BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-00-32J SUP Custom 27803010 690-00-32J - INSERT ACETAB 0D J 62MM 46MM 32MM CONSTRAIN BIPOL SPLIT RING BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6900PTFX SUP Custom 27203010 6900PTFX - SIZER VLV 29MM CRP-ED PRIMNT PLUS 33MM PRICRD HRT PRICRD BOTH IP/OP "$20,695.00 " "$15,314.30" $0.00 "$16,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,312.84" $0.00 $0.00 $0.00 $0.00 "$10,347.50" "$16,390.44" "$16,556.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6900PTFX 29 SUP Custom 27803010 6900PTFX 29 - VALVE MTRL 29MM C-E PRM+ BPRTH THERMAFIX TRICENTRIX HLDR BOTH IP/OP "$18,487.50 " "$13,680.75" $0.00 "$14,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,852.80" $0.00 $0.00 $0.00 $0.00 "$9,243.75" "$14,642.10" "$14,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-10-22E SUP Custom 27803010 690-10-22E - INSERT ACETAB 10D E 22MM CONSTRAIN TRIDENT HIP BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-10-22F SUP Custom 27803010 690-10-22F - INSERT ACETAB 10D H 48.4MM 36MM 22MM 9.9MM CONSTRAIN BIPOL BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-10-28G SUP Custom 27803010 690-10-28G - INSERT ACETAB 10D G 51.5MM 42MM 28MM 8.4MM CONSTRAIN BIPOL BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-10-28H SUP Custom 27803010 690-10-28H - INSERT ACETAB 10D H 55MM 42MM 28MM 10.2MM CONSTRAIN BIPOL BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-10-28I SUP Custom 27803010 690-10-28I - INSERT ACETAB 10D I 58MM 42MM 28MM 11.6MM CONSTRAIN RING BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-10-28J SUP Custom 27803010 690-10-28J - INSERT ACETAB 10D J 62MM 42MM 28MM 13.7MM CONSTRAIN RING BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 690-10-28K SUP Custom 27803010 690-10-28K - INSERT ACETAB 10D K 42MM 28MM CONSTRAIN BIPOL SPLIT RING BOTH IP/OP "$6,590.00 " "$4,876.60" $0.00 "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,373.36" $0.00 $0.00 $0.00 $0.00 "$3,295.00" "$5,219.28" "$5,272.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-2244 SUP Custom 27803010 69-2244 - INSERT ACETAB 0D 44MM 36MM 22MM 7.3MM CONSTRAIN SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-2246 SUP Custom 27803010 69-2246 - INSERT ACETAB 0D 46MM 36MM 22MM 8.3MM CONSTRAIN SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-2248 SUP Custom 27803010 69-2248 - INSERT ACETAB 0D 48MM 36MM 22MM CONSTRAIN BIPOL SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-2850 SUP Custom 27803010 69-2850 - INSERT ACETAB 0D 50MM 42MM 28MM 7.3MM CONSTRAIN SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-2852 SUP Custom 27803010 69-2852 - INSERT ACETAB 0D 52MM 42MM 28MM 8.3MM CONSTRAIN SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-2854 SUP Custom 27803010 69-2854 - INSERT ACETAB 0D 54MM 42MM 28MM 9.3MM CONSTRAIN SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-3256 SUP Custom 27803010 69-3256 - INSERT ACETAB 0D 56MM 46MM 32MM 8.3MM CONSTRAIN SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-3258 SUP Custom 27803010 69-3258 - INSERT ACETAB 0D 58MM 46MM 32MM 9.3MM CONSTRAIN SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 69-3260 SUP Custom 27803010 69-3260 - INSERT ACETAB 0D 60MM 46MM 32MM CONSTRAIN BIPOL SPLIT RING BOTH IP/OP "$6,797.50 " "$5,030.15" $0.00 "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,416.60" $0.00 $0.00 $0.00 $0.00 "$3,398.75" "$5,383.62" "$5,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-380 SUP Custom 27803010 6936-0-380 - HEAD FEM 105MM 38MM THMPSN REG HIP ENDOPRSTH FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-400 SUP Custom 27803010 6936-0-400 - HEAD FEM 105MM 40MM THMPSN REG HIP FENST FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-410 SUP Custom 27803010 6936-0-410 - HEAD FEM 41MM HIP ENDOPRSTH UNPLR ZML MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-420 SUP Custom 27803010 6936-0-420 - HEAD FEM 42MM THMPSN HIP ENDOPRSTH FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-430 SUP Custom 27803010 6936-0-430 - STEM FEM 105MM 43MM ENDOPRSTH MOORE ODC OMFT RLNC UHR UNPLR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-440 SUP Custom 27803010 6936-0-440 - HEAD FEM 44MM THMPSN HIP ENDOPRSTH FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-450 SUP Custom 27803010 6936-0-450 - HEAD FEM 105MM 45MM MOORE ODC OMFT RLNC UHR UNTRX REG HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-460 SUP Custom 27803010 6936-0-460 - HEAD FEM 46MM MOORE ODC OMFT RLNC UHR UNTRX HIP ENDOPRSTH FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-470 SUP Custom 27803010 6936-0-470 - HEAD FEM 47MM THMPSN HIP ENDOPRSTH FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-480 SUP Custom 27803010 6936-0-480 - HEAD FEM REG 48MM HIP ENDOPRSTH FRAC PRD FR. THMPSN BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-490 SUP Custom 27803010 6936-0-490 - HEAD FEM 105MM 49MM MOORE ODC OMFT RLNC UHR UNTRX REG HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-500 SUP Custom 27803010 6936-0-500 - STEM FEM 105MM 50MM ENDOPRSTH MOORE ODC OMFT RLNC UHR UNPLR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-510 SUP Custom 27803010 6936-0-510 - STEM FEM 105MM 51MM ENDOPRSTH MOORE ODC OMFT RLNC UHR UNPLR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-520 SUP Custom 27803010 6936-0-520 - HEAD FEM 105MM 52MM MOORE ODC OMFT RLNC UHR UNTRX REG HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-530 SUP Custom 27803010 6936-0-530 - STEM FEM 105MM 53MM ENDOPRSTH MOORE ODC OMFT RLNC UHR UNPLR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-540 SUP Custom 27803010 6936-0-540 - HEAD FEM 105MM 54MM MOORE ODC OMFT RLNC UHR UNTRX REG HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-550 SUP Custom 27803010 6936-0-550 - STEM FEM 105MM 55MM FENST MOORE ODC OMFT RLNC UHR UNPLR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6936-0-570 SUP Custom 27803010 6936-0-570 - HEAD FEM 57MM THMPSN FEM HIP ENDOPRSTH FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-380 SUP Custom 27803010 6939-0-380 - STEM FEM 130MM 38MM CVD FENST A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-400 SUP Custom 27803010 6939-0-400 - STEM FEM 130MM 40MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-410 SUP Custom 27803010 6939-0-410 - STEM FEM 130MM 41MM CVD FENST ENDOPRSTH A-MVIT HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-420 SUP Custom 27803010 6939-0-420 - STEM FEM 130MM 42MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-430 SUP Custom 27803010 6939-0-430 - STEM FEM 43MM CVD FENST ENDOPRSTH MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-440 SUP Custom 27803010 6939-0-440 - STEM FEM 130MM 44MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-450 SUP Custom 27803010 6939-0-450 - STEM FEM 140MM 45MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-460 SUP Custom 27803010 6939-0-460 - STEM FEM 140MM 46MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-470 SUP Custom 27803010 6939-0-470 - STEM FEM 140MM 47MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-480 SUP Custom 27803010 6939-0-480 - STEM FEM 140MM 48MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-490 SUP Custom 27803010 6939-0-490 - STEM FEM 140MM 49MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-500 SUP Custom 27803010 6939-0-500 - STEM FEM 150MM 50MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-510 SUP Custom 27803010 6939-0-510 - STEM FEM 150MM 51MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-520 SUP Custom 27803010 6939-0-520 - STEM FEM 150MM 52MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-530 SUP Custom 27803010 6939-0-530 - STEM FEM 53MM CVD FENST ENDOPRSTH MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-540 SUP Custom 27803010 6939-0-540 - STEM FEM 150MM 54MM CVD FENST A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-550 SUP Custom 27803010 6939-0-550 - HEAD FEM 150MM 55MM A-M FEM HIP FENST CURVE FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-560 SUP Custom 27803010 6939-0-560 - HEAD FEM 56MM HIP FENST CVD MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-570 SUP Custom 27803010 6939-0-570 - STEM FEM 150MM 57MM CVD FENST A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-600 SUP Custom 27803010 6939-0-600 - STEM FEM 60MM 60MM CVD FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-0-630 SUP Custom 27803010 6939-0-630 - STEM FEM 150MM 63MM CVD FENST A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-380 SUP Custom 27803010 6939-1-380 - STEM FEM 135MM 38MM CVD FENST NAR A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-400 SUP Custom 27803010 6939-1-400 - STEM FEM 40MM 40MM CVD FENST ENDOPRSTH A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-410 SUP Custom 27803010 6939-1-410 - STEM FEM 135MM 41MM CVD FENST ENDOPRSTH A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-420 SUP Custom 27803010 6939-1-420 - STEM FEM 135MM 42MM CVD FENST NAR A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-430 SUP Custom 27803010 6939-1-430 - STEM FEM 135MM 43MM CVD FENST NAR A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-440 SUP Custom 27803010 6939-1-440 - STEM FEM 135MM 44MM CVD FENST NAR A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-450 SUP Custom 27803010 6939-1-450 - STEM FEM 135MM 45MM CVD FENST A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-460 SUP Custom 27803010 6939-1-460 - STEM FEM 135MM 46MM CVD FENST A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-470 SUP Custom 27803010 6939-1-470 - STEM FEM 47MM CVD FENST ENDOPRSTH MOORE NAR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-480 SUP Custom 27803010 6939-1-480 - STEM FEM 135MM 48MM CVD FENST A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-490 SUP Custom 27803010 6939-1-490 - STEM FEM 135MM 49MM CVD FENST A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-500 SUP Custom 27803010 6939-1-500 - STEM FEM 135MM 50MM CVD FENST A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-1-510 SUP Custom 27803010 6939-1-510 - STEM FEM 135MM 51MM CVD FENST A-M NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-400 SUP Custom 27803010 6939-5-400 - STEM FEM 40MM MOORE HIP ENDOPRSTH CVD SLD FRAC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-410 SUP Custom 27803010 6939-5-410 - STEM FEM 41MM ENDOPRSTH CVD SLD FRAC MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-420 SUP Custom 27803010 6939-5-420 - STEM FEM 42MM ENDOPRSTH CVD SLD FRAC MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-430 SUP Custom 27803010 6939-5-430 - STEM FEM 43MM SLD CVD MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-440 SUP Custom 27803010 6939-5-440 - STEM FEM 44MM SLD CVD MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-450 SUP Custom 27803010 6939-5-450 - STEM FEM 45MM SLD CVD MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-460 SUP Custom 27803010 6939-5-460 - STEM FEM 46MM CVD SLD ENDOPRSTH MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-470 SUP Custom 27803010 6939-5-470 - STEM FEM 47MM ENDOPRSTH CVD SLD FRAC MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-480 SUP Custom 27803010 6939-5-480 - STEM FEM 48MM CVD SLD ENDOPRSTH MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-490 SUP Custom 27803010 6939-5-490 - STEM FEM 49MM ENDOPRSTH CVD SLD FRAC MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-500 SUP Custom 27803010 6939-5-500 - STEM FEM 50MM CVD SLD ENDOPRSTH MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-510 SUP Custom 27803010 6939-5-510 - STEM FEM 51MM ENDOPRSTH CVD SLD FRAC MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-520 SUP Custom 27803010 6939-5-520 - STEM FEM 52MM ENDOPRSTH MDLR CVD SLD MOORE HIP FRAC PRD BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-530 SUP Custom 27803010 6939-5-530 - STEM FEM 53MM CVD SLD ENDOPRSTH MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-540 SUP Custom 27803010 6939-5-540 - STEM FEM 54MM CVD SLD ENDOPRSTH MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-550 SUP Custom 27803010 6939-5-550 - STEM FEM 55MM SLD CVD ENDOPRSTH MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6939-5-570 SUP Custom 27803010 6939-5-570 - STEM FEM 57MM SLD CVD MOORE HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-380 SUP Custom 27803010 6940-0-380 - STEM FEM 165MM 38MM STR FENST A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-400 SUP Custom 27803010 6940-0-400 - STEM FEM 165MM 40MM STR FENST A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-410 SUP Custom 27803010 6940-0-410 - HEAD UNPLR 165MM 41MM MOORE ODC OMFT RLNC UHR UNTRX FEM HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-420 SUP Custom 27803010 6940-0-420 - HEAD FEM 42MM MOORE FEM HIP FENST STR FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-430 SUP Custom 27803010 6940-0-430 - HEAD FEM 43MM A-M FEM HIP STR FENST FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-440 SUP Custom 27803010 6940-0-440 - STEM FEM 165MM 44MM FENST ENDOPRSTH STR MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-450 SUP Custom 27803010 6940-0-450 - HEAD FEM 165MM 45MM MOORE ODC OMFT RLNC UHR UNTRX HIP STR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-460 SUP Custom 27803010 6940-0-460 - HEAD FEM 165MM 46MM A-M HIP FENST FR STRL BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-470 SUP Custom 27803010 6940-0-470 - HEAD FEM 165MM 43MM MOORE ODC OMFT RLNC UHR UNTRX HIP FENST BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-480 SUP Custom 27803010 6940-0-480 - HEAD FEM 48MM 48MM MOORE FEM HIP PENESTRATED FR STRL BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-490 SUP Custom 27803010 6940-0-490 - HEAD FEM 165MM 49MM A-M FEM HIP STR FENST FR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-500 SUP Custom 27803010 6940-0-500 - STEM FEM 190MM 50MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-510 SUP Custom 27803010 6940-0-510 - STEM FEM 190MM 51MM STR FENST ENDOPRSTH A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-520 SUP Custom 27803010 6940-0-520 - HEAD UNPLR 190MM 52MM MOORE ODC OMFT RLNC UHR UNTRX FEM HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-530 SUP Custom 27803010 6940-0-530 - HEAD UNPLR 190MM 53MM MOORE ODC OMFT RLNC UHR UNTRX FEM HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-540 SUP Custom 27803010 6940-0-540 - HEAD UNPLR 54MM 54MM MOORE ODC OMFT RLNC UHR UNTRX FEM HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-550 SUP Custom 27803010 6940-0-550 - HEAD FEM 190MM 55MM A-M HIP FENST FR STRL BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-570 SUP Custom 27803010 6940-0-570 - HEAD FEM 190MM 57MM A-M HIP FENST STR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-600 SUP Custom 27803010 6940-0-600 - STEM FEM 190MM 60MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-0-630 SUP Custom 27803010 6940-0-630 - STEM FEM 190MM 63MM STR FENST A-M HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-380 SUP Custom 27803010 6940-1-380 - STEM FEM 38MM STR FENST ENDOPRSTH MOORE NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-400 SUP Custom 27803010 6940-1-400 - STEM FEM 40MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-410 SUP Custom 27803010 6940-1-410 - STEM FEM 41MM STR FENST ENDOPRSTH MOORE NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-420 SUP Custom 27803010 6940-1-420 - STEM FEM 42MM STR FENST ENDOPRSTH MOORE NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-430 SUP Custom 27803010 6940-1-430 - STEM FEM 43MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-440 SUP Custom 27803010 6940-1-440 - STEM FEM 44MM STR FENST ENDOPRSTH MOORE NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-450 SUP Custom 27803010 6940-1-450 - STEM FEM 45MM STR FENST ENDOPRSTH MOORE NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-460 SUP Custom 27803010 6940-1-460 - STEM FEM 46MM STR FENST ENDOPRSTH MOORE NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-470 SUP Custom 27803010 6940-1-470 - STEM FEM 47MM STR FENST ENDOPRSTH MOORE NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-480 SUP Custom 27803010 6940-1-480 - STEM FEM 48MM STR FENST ENDOPRSTH MOORE NAR HIP BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-490 SUP Custom 27803010 6940-1-490 - STEM FEM 49MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-500 SUP Custom 27803010 6940-1-500 - STEM FEM 50MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-1-510 SUP Custom 27803010 6940-1-510 - STEM FEM 51MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT RLNC BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-380 SUP Custom 27803010 6940-2-380 - STEM FEM 300MM 38MM ENDOPRSTH STR FENST FRAC MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-400 SUP Custom 27803010 6940-2-400 - STEM FEM 300MM 40MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-410 SUP Custom 27803010 6940-2-410 - STEM FEM 300MM 41MM ENDOPRSTH STR FENST FRAC MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-420 SUP Custom 27803010 6940-2-420 - STEM FEM 300MM 42MM STR FENST ENDOPRSTH A-M ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-450 SUP Custom 27803010 6940-2-450 - STEM FEM 300MM 45MM ENDOPRSTH STR FENST FRAC MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-460 SUP Custom 27803010 6940-2-460 - STEM FEM 300MM 46MM ENDOPRSTH STR FENST FRAC MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-470 SUP Custom 27803010 6940-2-470 - STEM FEM 300MM 47MM ENDOPRSTH STR FENST FRAC MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-480 SUP Custom 27803010 6940-2-480 - STEM FEM 300MM 48MM STR FENST ENDOPRSTH A-M ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-490 SUP Custom 27803010 6940-2-490 - STEM FEM 300MM 49MM STR FENST ENDOPRSTH MOORE BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-500 SUP Custom 27803010 6940-2-500 - STEM FEM 300MM 50MM STR FENST ENDOPRSTH MOORE BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-510 SUP Custom 27803010 6940-2-510 - STEM FEM 300MM 51MM STR FENST ENDOPRSTH MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-520 SUP Custom 27803010 6940-2-520 - STEM FEM 300MM 52MM ENDOPRSTH STR FENST FRAC MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-540 SUP Custom 27803010 6940-2-540 - STEM FEM 300MM 54MM ENDOPRSTH STR FENST FRAC MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-550 SUP Custom 27803010 6940-2-550 - STEM FEM 300MM 55MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-600 SUP Custom 27803010 6940-2-600 - STEM FEM 300MM 60MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-2-630 SUP Custom 27803010 6940-2-630 - STEM FEM 300MM 63MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-400 SUP Custom 27803010 6940-5-400 - HEAD FEM 40MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-410 SUP Custom 27803010 6940-5-410 - HEAD FEM 41MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-420 SUP Custom 27803010 6940-5-420 - HEAD FEM 42MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-430 SUP Custom 27803010 6940-5-430 - HEAD FEM 43MM HIP ENDOPRSTH STR SLD UNPLR MOORE ODC OMFT BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-440 SUP Custom 27803010 6940-5-440 - HEAD FEM 44MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-460 SUP Custom 27803010 6940-5-460 - HEAD FEM 46MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-470 SUP Custom 27803010 6940-5-470 - STEM FEM 47MM SLD ENDOPRSTH A-M STRL BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-490 SUP Custom 27803010 6940-5-490 - HEAD FEM 49MM HIP ENDOPRSTH STR SLD UNPLR MOORE ODC OMFT BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-500 SUP Custom 27803010 6940-5-500 - HEAD FEM 50MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-510 SUP Custom 27803010 6940-5-510 - HEAD FEM 51MM HIP ENDOPRSTH STR SLD UNPLR MOORE ODC OMFT BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-520 SUP Custom 27803010 6940-5-520 - HEAD FEM 52MM HIP ENDOPRSTH STR SLD UNPLR MOORE ODC OMFT BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-530 SUP Custom 27803010 6940-5-530 - STEM FEM 53MM SLD ENDOPRSTH A-M STRL BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-540 SUP Custom 27803010 6940-5-540 - HEAD FEM 54MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-550 SUP Custom 27803010 6940-5-550 - HEAD FEM 55MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-570 SUP Custom 27803010 6940-5-570 - HEAD FEM 57MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-600 SUP Custom 27803010 6940-5-600 - HEAD FEM 60MM HIP ENDOPRSTH STR SLD UNPLR MOORE ODC OMFT BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-5-630 SUP Custom 27803010 6940-5-630 - HEAD FEM 63MM HIP SLD STR MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-6-410 SUP Custom 27803010 6940-6-410 - STEM FEM 41MM ENDOPRSTH STR SLD FRAC MOORE ODC OMFT RLNC UHR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-6-420 SUP Custom 27803010 6940-6-420 - STEM FEM 42MM STR SLD ENDOPRSTH MOORE BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-6-440 SUP Custom 27803010 6940-6-440 - STEM FEM 44MM ENDOPRSTH STR SLD FRAC MOORE ODC OMFT RLNC UHR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-6-450 SUP Custom 27803010 6940-6-450 - STEM FEM 45MM ENDOPRSTH STR SLD FRAC MOORE ODC OMFT RLNC UHR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-6-460 SUP Custom 27803010 6940-6-460 - STEM FEM 46MM ENDOPRSTH STR SLD FRAC MOORE ODC OMFT RLNC UHR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-6-470 SUP Custom 27803010 6940-6-470 - STEM FEM 47MM ENDOPRSTH STR SLD FRAC MOORE ODC OMFT RLNC UHR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-6-480 SUP Custom 27803010 6940-6-480 - STEM FEM 48MM ENDOPRSTH STR SLD FRAC MOORE ODC OMFT RLNC UHR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-6-490 SUP Custom 27803010 6940-6-490 - STEM FEM 49MM ENDOPRSTH STR SLD FRAC MOORE ODC OMFT RLNC UHR BOTH IP/OP "$1,257.00 " $930.18 $0.00 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $932.95 $932.95 $0.00 $0.00 $261.96 $0.00 $0.00 $0.00 $0.00 $628.50 $995.54 "$1,005.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-380 SUP Custom 27803010 6940-8-380 - STEM FEM 200MM 38MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-400 SUP Custom 27803010 6940-8-400 - STEM FEM 200MM 40MM STR FENST ENDOPRSTH MOORE BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-410 SUP Custom 27803010 6940-8-410 - STEM FEM 200MM 41MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-420 SUP Custom 27803010 6940-8-420 - STEM FEM 200MM 42MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-430 SUP Custom 27803010 6940-8-430 - STEM FEM 200MM 43MM ENDOPRSTH A-M HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-440 SUP Custom 27803010 6940-8-440 - STEM FEM 200MM 44MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-450 SUP Custom 27803010 6940-8-450 - STEM FEM 200MM 45MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-460 SUP Custom 27803010 6940-8-460 - STEM FEM 200MM 46MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-470 SUP Custom 27803010 6940-8-470 - STEM FEM 200MM 47MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-500 SUP Custom 27803010 6940-8-500 - STEM FEM 200MM 50MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-510 SUP Custom 27803010 6940-8-510 - STEM FEM 200MM 51MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-530 SUP Custom 27803010 6940-8-530 - STEM FEM 200MM 53MM STR FENST A-M HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-540 SUP Custom 27803010 6940-8-540 - STEM FEM 200MM 54MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-550 SUP Custom 27803010 6940-8-550 - STEM FEM 200MM 55MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-570 SUP Custom 27803010 6940-8-570 - STEM FEM 200MM 57MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-600 SUP Custom 27803010 6940-8-600 - STEM FEM 200MM 60MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-8-630 SUP Custom 27803010 6940-8-630 - STEM FEM 200MM 63MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-380 SUP Custom 27803010 6940-9-380 - STEM FEM 225MM 38MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-410 SUP Custom 27803010 6940-9-410 - STEM FEM 225MM 41MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-440 SUP Custom 27803010 6940-9-440 - STEM FEM 225MM 44MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-460 SUP Custom 27803010 6940-9-460 - STEM FEM 225MM 46MM STR FENST ASTN-MOORE HIP BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-480 SUP Custom 27803010 6940-9-480 - STEM FEM 225MM 48MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-490 SUP Custom 27803010 6940-9-490 - STEM FEM 225MM 49MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-510 SUP Custom 27803010 6940-9-510 - STEM FEM 225MM 51MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-520 SUP Custom 27803010 6940-9-520 - STEM FEM 225MM 52MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-530 SUP Custom 27803010 6940-9-530 - STEM FEM 225MM 53MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-550 SUP Custom 27803010 6940-9-550 - STEM FEM 225MM 55MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-570 SUP Custom 27803010 6940-9-570 - STEM FEM 225MM 57MM ENDOPRSTH STR FENST MOORE ODC OMFT RLNC BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6940-9-630 SUP Custom 27803010 6940-9-630 - STEM FEM 225MM 63MM ENDOPRSTH STR FENST FRAC MOORE ODC OMFT BOTH IP/OP "$1,544.00 " "$1,142.56" $0.00 "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.96" "$1,145.96" $0.00 $0.00 $321.77 $0.00 $0.00 $0.00 $0.00 $772.00 "$1,222.85" "$1,235.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-038 SUP Custom 27803010 6942-5-038 - HEAD UNPLR 38MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-040 SUP Custom 27803010 6942-5-040 - HEAD UNPLR 40MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-041 SUP Custom 27803010 6942-5-041 - HEAD UNPLR 41MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-042 SUP Custom 27803010 6942-5-042 - HEAD UNPLR 42MM UNTRX FEM HIP MDLR ENDOPRSTH FR STRL BOTH IP/OP "$1,150.00 " $851.00 $0.00 $853.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-043 SUP Custom 27803010 6942-5-043 - HEAD UNIPOLAR 43MM MODULAR THOMPSON MOORE ODC OMNIFIT HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-044 SUP Custom 27803010 6942-5-044 - HEAD UNPLR 44MM UNTRX HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-045 SUP Custom 27803010 6942-5-045 - HEAD UNPLR 45MM UNTRX FEM HIP MDLR ENDOPRSTH FR BOTH IP/OP "$1,150.00 " $851.00 $0.00 $853.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-046 SUP Custom 27803010 6942-5-046 - HEAD UNPLR 46MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-047 SUP Custom 27803010 6942-5-047 - HEAD UNIPOLAR 47MM MODULAR UNITRAX HIP FEMORAL EXETER V40 BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-048 SUP Custom 27803010 6942-5-048 - HEAD UNPLR 48MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-049 SUP Custom 27803010 6942-5-049 - HEAD UNPLR 49MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $853.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-050 SUP Custom 27803010 6942-5-050 - HEAD UNPLR 50MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $853.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-051 SUP Custom 27803010 6942-5-051 - HEAD UNPLR 51MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $853.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-052 SUP Custom 27803010 6942-5-052 - HEAD UNPLR 52MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-053 SUP Custom 27803010 6942-5-053 - HEAD UNPLR 53MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-054 SUP Custom 27803010 6942-5-054 - HEAD UNPLR 54MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $853.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-055 SUP Custom 27803010 6942-5-055 - HEAD UNPLR 55MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-056 SUP Custom 27803010 6942-5-056 - HEAD UNPLR 56MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-057 SUP Custom 27803010 6942-5-057 - HEAD UNPLR 57MM UNTRX FEM HIP MDLR ENDOPRSTH BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $406.73 $406.73 $0.00 $0.00 $114.20 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-058 SUP Custom 27803010 6942-5-058 - HEAD UNPLR 58MM STRL UNTRX MDLR EPRSTH HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-060 SUP Custom 27803010 6942-5-060 - HEAD UNPLR 60MM UNTRX FEM HIP MDLR ENDOPRSTH BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $406.73 $406.73 $0.00 $0.00 $114.20 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-061 SUP Custom 27803010 6942-5-061 - HEAD UNIPOLAR 61MM MODULAR UNITRAX HIP FEMORAL EXETER V40 BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-5-063 SUP Custom 27803010 6942-5-063 - HEAD UNPLR 63MM UNTRX FEM HIP MDLR ENDOPRSTH BOTH IP/OP $548.00 $405.52 $0.00 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $406.73 $406.73 $0.00 $0.00 $114.20 $0.00 $0.00 $0.00 $0.00 $274.00 $434.02 $438.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-010 SUP Custom 27803010 6942-6-010 - SLEEVE CENTERING U PCA +0MM FEM HIP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-020 SUP Custom 27803010 6942-6-020 - SLEEVE CENTERING +5MM UNITRAX PCA HIP FEMUR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-030 SUP Custom 27803010 6942-6-030 - SLEEVE CENTERING +10MM UNITRAX PCA HIP FEMUR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-050 SUP Custom 27803010 6942-6-050 - SLEEVE CENTERING -4MM UNITRAX PCA HIP FEMUR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-060 SUP Custom 27803010 6942-6-060 - SLEEVE CENTERING -4MM UNIPOLAR UNITRAX V40 HIP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-065 SUP Custom 27803010 6942-6-065 - SLEEVE CENTERING +0MM TAPER UNIPOLAR UNITRAX V40 EXETER HIP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-070 SUP Custom 27803010 6942-6-070 - SLEEVE CENTERING +4MM TAPER UNIPOLAR UNITRAX V40 EXETER HIP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-075 SUP Custom 27803010 6942-6-075 - SLEEVE CENTERING +8MM TAPER UNIPOLAR UNITRAX V40 EXETER HIP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-6-080 SUP Custom 27803010 6942-6-080 - SLEEVE CENTERING +12MM UNIPOLAR UNITRAX V40 HIP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-7-060 SUP Custom 27803010 6942-7-060 - SLEEVE CENTERING -3MM C TAPER UNITRAX HIP FEMUR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-7-065 SUP Custom 27803010 6942-7-065 - SLEEVE CENTERING +0MM C TAPER UNITRAX HIP FEMUR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-7-075 SUP Custom 27803010 6942-7-075 - SLEEVE CENTERING UNTRX +5MM HIP CTPR NECK BOTH IP/OP $250.00 $185.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $113.00 $178.99 $180.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-7-080 SUP Custom 27803010 6942-7-080 - SLEEVE CENTERING UNTRX 7.5MM CTPR BOTH IP/OP $226.00 $167.24 $0.00 $180.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.74 $167.74 $0.00 $0.00 $47.10 $0.00 $0.00 $0.00 $0.00 $113.00 $178.99 $180.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6942-7-085 SUP Custom 27203010 6942-7-085 - SLEEVE ADJ UNTRX +10MM FEM HIP CTPR BOTH IP/OP $250.00 $185.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $113.00 $178.99 $180.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6951-0-036 SUP Custom 27803010 6951-0-036 - SHELL ACETAB 44MM 40MM HIP VIT BOTH IP/OP "$1,326.00 " $981.24 $0.00 "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.16 $984.16 $0.00 $0.00 $276.34 $0.00 $0.00 $0.00 $0.00 $663.00 "$1,050.19" "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6951-0-040 SUP Custom 27803010 6951-0-040 - SHELL ACETAB 48MM 44MM HIP BOTH IP/OP "$1,326.00 " $981.24 $0.00 "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.16 $984.16 $0.00 $0.00 $276.34 $0.00 $0.00 $0.00 $0.00 $663.00 "$1,050.19" "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6951-0-045 SUP Custom 27803010 6951-0-045 - SHELL ACETAB 53MM 49MM HIP BOTH IP/OP "$1,326.00 " $981.24 $0.00 "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.16 $984.16 $0.00 $0.00 $276.34 $0.00 $0.00 $0.00 $0.00 $663.00 "$1,050.19" "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6951-0-050 SUP Custom 27803010 6951-0-050 - SHELL ACETAB 58MM 54MM HIP PRTRS BOTH IP/OP "$1,326.00 " $981.24 $0.00 "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.16 $984.16 $0.00 $0.00 $276.34 $0.00 $0.00 $0.00 $0.00 $663.00 "$1,050.19" "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6951-0-054 SUP Custom 27803010 6951-0-054 - SHELL ACETAB 62MM 58MM HIP VIT BOTH IP/OP "$1,326.00 " $981.24 $0.00 "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.16 $984.16 $0.00 $0.00 $276.34 $0.00 $0.00 $0.00 $0.00 $663.00 "$1,050.19" "$1,060.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6955975L SUP HCPCS C1713 6955975L - HOOK SPNL 4.5MM NS VRTX MX LT OFST TI LMN RECON SYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6955975R SUP HCPCS C1713 6955975R - HOOK SPNL 4.5MM NS VRTX MX RT OFST TI LMN RECON SYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6955977L SUP HCPCS C1713 6955977L - HOOK SPNL 6MM NS VRTX MX LT OFST TI LMN RECON SYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6955977R SUP HCPCS C1713 6955977R - HOOK SPNL 6MM NS VRTX MX RT OFST TI LMN RECON SYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 6958718PT SUP HCPCS C1713 6958718PT - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958720PT SUP HCPCS C1713 6958720PT - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958722PT SUP HCPCS C1713 6958722PT - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958724PT SUP HCPCS C1713 6958724PT - SCREW BN P/T 3.5MM 24MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958726PT SUP HCPCS C1713 6958726PT - SCREW BN P/T 3.5MM 26MM GRN NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958728PT SUP HCPCS C1713 6958728PT - SCREW BN P/T 3.5MM 28MM GRN NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958730PT SUP HCPCS C1713 6958730PT - SCREW BN P/T 3.5MM 30MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958732PT SUP HCPCS C1713 6958732PT - SCREW BN P/T 3.5MM 32MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958734PT SUP HCPCS C1713 6958734PT - SCREW BN P/T 3.5MM 34MM GRN NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958736PT SUP HCPCS C1713 6958736PT - SCREW BN P/T 3.5MM 36MM GRN NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958738PT SUP HCPCS C1713 6958738PT - SCREW BN P/T 3.5MM 38MM GRN NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958740PT SUP HCPCS C1713 6958740PT - SCREW BN P/T 3.5MM 40MM GRN NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958742PT SUP HCPCS C1713 6958742PT - SCREW BN P/T 3.5MM 42MM VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958744PT SUP HCPCS C1713 6958744PT - SCREW BN P/T 3.5MM 44MM VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958746PT SUP HCPCS C1713 6958746PT - SCREW BN P/T 3.5MM 46MM VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958748PT SUP HCPCS C1713 6958748PT - SCREW BN P/T 3.5MM 48MM VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958750PT SUP HCPCS C1713 6958750PT - SCREW BN P/T 3.5MM 50MM VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958752PT SUP HCPCS C1713 6958752PT - SCREW BN P/T 3.5MM 52MM VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958818PT SUP HCPCS C1713 6958818PT - SCREW BN P/T 4MM 18MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958820PT SUP HCPCS C1713 6958820PT - SCREW BN P/T 4MM 20MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958822PT SUP HCPCS C1713 6958822PT - SCREW BN P/T 4MM 22MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958824PT SUP HCPCS C1713 6958824PT - SCREW BN P/T 4MM 24MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958826PT SUP HCPCS C1713 6958826PT - SCREW BN P/T 4MM 26MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958828PT SUP HCPCS C1713 6958828PT - SCREW BN P/T 4MM 28MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958830PT SUP HCPCS C1713 6958830PT - SCREW BN P/T 4MM 30MM AU 15MM VRTX MX TI SPNE OCPTL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958832PT SUP HCPCS C1713 6958832PT - SCREW BN P/T 4MM 32MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958834PT SUP HCPCS C1713 6958834PT - SCREW BN P/T 4MM 34MM AU NS VRTX MX MA TI SPNE RECON SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958836PT SUP HCPCS C1713 6958836PT - SCREW BN P/T 4MM 36MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958838PT SUP HCPCS C1713 6958838PT - SCREW BN P/T 4MM 38MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958840PT SUP HCPCS C1713 6958840PT - SCREW BN P/T 4MM 40MM AU NS VRTX MX MA TI SPNE THOR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958842PT SUP HCPCS C1713 6958842PT - SCREW BN P/T 4MM 42MM AU VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958844PT SUP HCPCS C1713 6958844PT - SCREW BN P/T 4MM 44MM AU VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958846PT SUP HCPCS C1713 6958846PT - SCREW BN P/T 4MM 46MM AU VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958848PT SUP HCPCS C1713 6958848PT - SCREW BN P/T 4MM 48MM AU VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958850PT SUP HCPCS C1713 6958850PT - SCREW BN P/T 4MM 50MM AU VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6958852PT SUP HCPCS C1713 6958852PT - SCREW BN P/T 4MM 52MM AU VRTX MX MA TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 6959420PT SUP HCPCS C1713 6959420PT - SCREW BN P/T 4MM 20MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959422PT SUP HCPCS C1713 6959422PT - SCREW BN P/T 4MM 22MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959424PT SUP HCPCS C1713 6959424PT - SCREW BN P/T 4MM 24MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959426PT SUP HCPCS C1713 6959426PT - SCREW BN P/T 4MM 26MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959428PT SUP HCPCS C1713 6959428PT - SCREW BN P/T 4MM 28MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959430PT SUP HCPCS C1713 6959430PT - SCREW BN P/T 4MM 30MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959432PT SUP HCPCS C1713 6959432PT - SCREW BN P/T 4MM 32MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959434PT SUP HCPCS C1713 6959434PT - SCREW BN P/T 4MM 34MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959436PT SUP HCPCS C1713 6959436PT - SCREW BN P/T 4MM 36MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959438PT SUP HCPCS C1713 6959438PT - SCREW BN P/T 4MM 38MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6959440PT SUP HCPCS C1713 6959440PT - SCREW BN P/T 4MM 40MM MA CNN TI SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 6971250CK SUP HCPCS C1713 6971250CK - DISC INTVRTB 5MM 12MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971270CK SUP HCPCS C1713 6971270CK - DISC INTVRTB 7MM 12MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971450CK SUP HCPCS C1713 6971450CK - DISC INTVRTB 5MM 14MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971470CK SUP HCPCS C1713 6971470CK - DISC INTVRTB 7MM 14MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971480CK SUP HCPCS C1713 6971480CK - DISC INTVRTB 8MM 14MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971650CK SUP HCPCS C1713 6971650CK - DISC INTVRTB 5MM 16MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971670CK SUP HCPCS C1713 6971670CK - DISC INTVRTB 7MM 16MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971680CK SUP HCPCS C1713 6971680CK - DISC INTVRTB 8MM 16MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971870CK SUP HCPCS C1713 6971870CK - DISC INTVRTB 7MM 18MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 6971880CK SUP HCPCS C1713 6971880CK - DISC INTVRTB 8MM 18MM SPNE CRV BOTH IP/OP "$10,200.00 " "$7,548.00" $0.00 "$8,160.00" "$4,590.00" "$4,590.00" $0.00 $0.00 $0.00 "$2,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,125.68" $0.00 "$5,028.60" "$5,028.60" $0.00 "$5,100.00" "$8,078.40" "$8,160.00" $0.00 $0.00 "$1,596.30" $0.00 $0.00 "$1,623.84" $0.00 $0.00 $0.00 $0.00 $0.00 698.600S SUP Custom 27803010 698.600S - MARS 3V DISPOSABLE KIT BOTH IP/OP "$7,440.00 " "$5,505.60" $0.00 "$5,952.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,550.50" $0.00 $0.00 $0.00 $0.00 "$3,720.00" "$5,892.48" "$5,952.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6980-5-030 SUP Custom 27803010 6980-5-030 - SRFC ARTC 30MM 1STP DISTAL KNEE BOTH IP/OP "$1,817.00 " "$1,344.58" $0.00 "$1,453.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,348.58" "$1,348.58" $0.00 $0.00 $378.66 $0.00 $0.00 $0.00 $0.00 $908.50 "$1,439.06" "$1,453.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6980-5-035 SUP HCPCS C1713 6980-5-035 - STAPLE BONE DISTAL IMPL 35MM DISTAL KNEE 1STP BOTH IP/OP "$1,817.00 " "$1,344.58" $0.00 "$1,453.60" $817.65 $817.65 $0.00 $0.00 $0.00 $378.71 "$1,348.58" "$1,348.58" $0.00 $0.00 $378.66 $0.00 "$1,074.76" "$1,074.76" $0.00 $908.50 "$1,439.06" "$1,453.60" $0.00 $0.00 $284.36 $0.00 $0.00 $289.27 $0.00 $0.00 $0.00 $0.00 $0.00 6980-5-040 SUP HCPCS C1713 6980-5-040 - STAPLE BONE 40MM DISTAL TIB 1STP BOTH IP/OP "$1,817.00 " "$1,344.58" $0.00 "$1,453.60" $817.65 $817.65 $0.00 $0.00 $0.00 $378.71 "$1,348.58" "$1,348.58" $0.00 $0.00 $378.66 $0.00 "$1,074.76" "$1,074.76" $0.00 $908.50 "$1,439.06" "$1,453.60" $0.00 $0.00 $284.36 $0.00 $0.00 $289.27 $0.00 $0.00 $0.00 $0.00 $0.00 6980-5-045 SUP Custom 27803010 6980-5-045 - SRFC ARTC 45MM 1STP DISTAL BOTH IP/OP "$1,817.00 " "$1,344.58" $0.00 "$1,453.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,348.58" "$1,348.58" $0.00 $0.00 $378.66 $0.00 $0.00 $0.00 $0.00 $908.50 "$1,439.06" "$1,453.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6980-5-050 SUP HCPCS C1713 6980-5-050 - STAPLE BONE 50MM DISTAL 1STP BOTH IP/OP "$1,817.00 " "$1,344.58" $0.00 "$1,453.60" $817.65 $817.65 $0.00 $0.00 $0.00 $378.71 "$1,348.58" "$1,348.58" $0.00 $0.00 $378.66 $0.00 "$1,074.76" "$1,074.76" $0.00 $908.50 "$1,439.06" "$1,453.60" $0.00 $0.00 $284.36 $0.00 $0.00 $289.27 $0.00 $0.00 $0.00 $0.00 $0.00 6980-5-055 SUP HCPCS C1713 6980-5-055 - STAPLE BONE 55MM DISTAL TIB 1STP BOTH IP/OP "$1,817.00 " "$1,344.58" $0.00 "$1,453.60" $817.65 $817.65 $0.00 $0.00 $0.00 $378.71 "$1,348.58" "$1,348.58" $0.00 $0.00 $378.66 $0.00 "$1,074.76" "$1,074.76" $0.00 $908.50 "$1,439.06" "$1,453.60" $0.00 $0.00 $284.36 $0.00 $0.00 $289.27 $0.00 $0.00 $0.00 $0.00 $0.00 6980-5-060 SUP HCPCS C1713 6980-5-060 - STAPLE BONE 60MM DISTAL FIRSTSTEP BOTH IP/OP "$1,817.00 " "$1,344.58" $0.00 "$1,453.60" $817.65 $817.65 $0.00 $0.00 $0.00 $378.71 "$1,348.58" "$1,348.58" $0.00 $0.00 $378.66 $0.00 "$1,074.76" "$1,074.76" $0.00 $908.50 "$1,439.06" "$1,453.60" $0.00 $0.00 $284.36 $0.00 $0.00 $289.27 $0.00 $0.00 $0.00 $0.00 $0.00 6980-5-065 SUP HCPCS C1713 6980-5-065 - STAPLE BONE 65MM DISTAL KNEE FIRSTSTEP BOTH IP/OP "$1,817.00 " "$1,344.58" $0.00 "$1,453.60" $817.65 $817.65 $0.00 $0.00 $0.00 $378.71 "$1,348.58" "$1,348.58" $0.00 $0.00 $378.66 $0.00 "$1,074.76" "$1,074.76" $0.00 $908.50 "$1,439.06" "$1,453.60" $0.00 $0.00 $284.36 $0.00 $0.00 $289.27 $0.00 $0.00 $0.00 $0.00 $0.00 6981-5-060 SUP HCPCS C1713 6981-5-060 - STAPLE BONE 60X15MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-5-065 SUP HCPCS C1713 6981-5-065 - STAPLE BONE 65X15MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-5-070 SUP HCPCS C1713 6981-5-070 - STAPLE BONE 70X15MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-5-075 SUP HCPCS C1713 6981-5-075 - STAPLE BONE 75 MMX 15MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-5-080 SUP HCPCS C1713 6981-5-080 - STAPLE BONE 80X15MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-5-085 SUP HCPCS C1713 6981-5-085 - STAPLE BONE 85X15MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-5-090 SUP HCPCS C1713 6981-5-090 - STAPLE BONE 90X15MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-6-060 SUP HCPCS C1713 6981-6-060 - STAPLE BONE 60X10MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-6-065 SUP HCPCS C1713 6981-6-065 - STAPLE BONE 65X10MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-6-070 SUP HCPCS C1713 6981-6-070 - STAPLE BONE 70X10MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-6-075 SUP Custom 27803010 6981-6-075 - SRFC ARTC 75X10MM 1STP PROX BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $0.00 $0.00 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6981-6-080 SUP HCPCS C1713 6981-6-080 - STAPLE BONE 80X10MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-6-085 SUP HCPCS C1713 6981-6-085 - STAPLE BONE 85X10MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-6-090 SUP HCPCS C1713 6981-6-090 - STAPLE BONE 90X10MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-7-060 SUP HCPCS C1713 6981-7-060 - STAPLE BONE 60MMX5MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-7-065 SUP HCPCS C1713 6981-7-065 - STAPLE BONE 65X5MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-7-070 SUP HCPCS C1713 6981-7-070 - STAPLE BONE 70MMX5MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-7-075 SUP HCPCS C1713 6981-7-075 - STAPLE BONE 75MMX5MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-7-080 SUP HCPCS C1713 6981-7-080 - STAPLE BONE 80MMX5MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-7-085 SUP HCPCS C1713 6981-7-085 - STAPLE BONE 85X5MM PROX KNEE 1STP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6981-7-090 SUP HCPCS C1713 6981-7-090 - STAPLE BONE 90X5MM PROX FIRSTSTEP BOTH IP/OP "$1,137.00 " $841.38 $0.00 $909.60 $511.65 $511.65 $0.00 $0.00 $0.00 $236.98 $843.88 $843.88 $0.00 $0.00 $236.95 $0.00 $672.54 $672.54 $0.00 $568.50 $900.50 $909.60 $0.00 $0.00 $177.94 $0.00 $0.00 $181.01 $0.00 $0.00 $0.00 $0.00 $0.00 6985M SUP Custom 27203010 KIT EXTENDER LEAD BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6A0001 SUP HCPCS C1725 CATHETER 6FR JR 3.5 BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $47.51 $47.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 6A0014 SUP HCPCS C1725 CATHETER ANGIO JR6 CURVE 6FR 100CM STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A0019 SUP HCPCS C1725 CATHETER ANGIO AR2 CURVE 6FR 100CM STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A002 SUP HCPCS C1725 CATHETER 6FR JR4 BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $19.01 $19.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 6A0021 SUP HCPCS C1725 CATHETER ANGIO AL2 CURVE 6FR 100CM STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A0024 SUP HCPCS C1725 CATHETER ANGIO 6FR 100CM 2 SH STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A003 SUP HCPCS C1725 CATHETER 6FR JR5 BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A0033 SUP HCPCS C1725 CATHETER ANGIO IMA CURVE 6FR 100CM STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A0034 SUP HCPCS C1725 CATHETER ANGIO LCB CURVE 6FR 100CM STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A0080 SUP HCPCS C1725 CATHETER ANGIO JL3.5 CURVE 6FR 100CM STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A0083 SUP HCPCS C1725 CATHETER ANGIO JL5 CURVE 6FR 100CM STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6A0085 SUP HCPCS C1725 CATHETER ANGIO JL4 CURVE 6FR 100CM STSR BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 6DCFN SUP Custom 27203010 6DCFN - TUBE TRCH 6 10.8MM 6.4MM 74MM STRL LF SHLY CUFLS DISP INR BOTH IP/OP $83.74 $61.97 $0.00 $66.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.15 $62.15 $0.00 $0.00 $17.45 $0.00 $0.00 $0.00 $0.00 $41.87 $66.32 $66.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6DCFS SUP Custom 27203010 6DCFS - TUBE TRCH 6 10.8MM 6.4MM 74MM STRL LF SHLY CUFLS DISP INR BOTH IP/OP $104.53 $77.35 $0.00 $77.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.58 $77.58 $0.00 $0.00 $21.78 $0.00 $0.00 $0.00 $0.00 $44.95 $71.20 $71.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6DCT SUP Custom 27203010 6DCT - TUBE TRCH 6 10.8MM 6.4MM 74MM STRL LF SHLY CUF DISP INR CNN BOTH IP/OP $117.10 $86.65 $0.00 $86.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.91 $86.91 $0.00 $0.00 $24.40 $0.00 $0.00 $0.00 $0.00 $47.54 $75.30 $76.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6DFEN SUP Custom 27203010 6DFEN - TUBE TRCH 6 10.8MM 6.4MM 74MM STRL LF SHLY CUF DISP INR CNN BOTH IP/OP $99.43 $73.58 $0.00 $80.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.79 $73.79 $0.00 $0.00 $20.72 $0.00 $0.00 $0.00 $0.00 $50.46 $79.93 $80.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6E1322 SUP Custom 25803010 SOLUTION IV 0.9% NA CHLOR 250ML AVIVA LF BOTH IP/OP $7.70 $5.70 $0.00 $6.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.85 $6.10 $6.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6L215 SUP Custom 27203010 BELT 5 THK7/16IN 101IN B TYPE WRP 21/32IN BOTH IP/OP $81.35 $60.20 $0.00 $65.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.68 $64.43 $65.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6LGT SUP Custom 27203010 6LGT - TUBE 50MM 11.1MM 6.4MM UNCUF LRNTMY SHLY TRCH 6 STRL LATEX BOTH IP/OP $114.73 $84.90 $0.00 $95.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.15 $85.15 $0.00 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $59.99 $92.23 $95.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6LGT SUP Custom 27203010 TUBE 6.4MM UNCUF LRNTMY SHLY TRCH 6 BOTH IP/OP $114.73 $84.90 $0.00 $95.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.15 $85.15 $0.00 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $59.99 $95.02 $95.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6M02A SUP Custom 27203010 6M02A - SUTURE NONABSORBABLE CV-6 TTC-9 30IN 2 ARM MONOFILAMENT BOTH IP/OP $73.33 $54.26 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.43 $54.43 $0.00 $0.00 $15.28 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 6SCT SUP Custom 27203010 6SCT - TUBE TRCH 6 8.3MM 6MM 67MM LF SHLY CUF SGL CNN RND TIP OBT BOTH IP/OP $71.38 $52.82 $0.00 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.97 $52.97 $0.00 $0.00 $14.87 $0.00 $0.00 $0.00 $0.00 $36.22 $57.38 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-0007 SUP HCPCS C1713 70-0007 - PLATE BN 5 HL 1ST TARSOMETATARSAL BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0008 SUP HCPCS C1713 70-0008 - PLATE BN 4 HL 1ST TARSOMETATARSAL BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0009 SUP HCPCS C1713 70-0009 - PLATE BN 4 HL 2ND AND 3RD TARSOMETATARSAL BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0010 SUP HCPCS C1713 70-0010 - PLATE BN LCK LT PROX MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0011 SUP HCPCS C1713 70-0011 - PLATE BN LCK RT PROX MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0012 SUP HCPCS C1713 70-0012 - PLATE BN LCK FSN LT DRSL 1ST MTP BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0013 SUP HCPCS C1713 70-0013 - PLATE BN LCK FSN RT DRSL 1ST MTP BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0018 SUP HCPCS C1713 70-0018 - PLATE BN REV LCK FSN LT 1ST MTP BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0019 SUP HCPCS C1713 70-0019 - PLATE BN REV LCK FSN RT 1ST MTP BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0022 SUP HCPCS C1713 70-0022 - PLATE SM TI LCK BONE LEFT CALC NONSTRL BOTH IP/OP "$3,520.00 " "$2,604.80" $0.00 "$2,816.00" "$1,584.00" "$1,584.00" $0.00 $0.00 $0.00 $733.66 "$2,612.54" "$2,612.54" $0.00 $0.00 $733.57 $0.00 "$1,735.36" "$1,735.36" $0.00 "$1,760.00" "$2,787.84" "$2,816.00" $0.00 $0.00 $550.88 $0.00 $0.00 $560.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-0023 SUP HCPCS C1713 70-0023 - PLATE SM LCK BONE RIGHT CALC BOTH IP/OP "$3,520.00 " "$2,604.80" $0.00 "$2,816.00" "$1,584.00" "$1,584.00" $0.00 $0.00 $0.00 $733.66 "$2,612.54" "$2,612.54" $0.00 $0.00 $733.57 $0.00 "$1,735.36" "$1,735.36" $0.00 "$1,760.00" "$2,787.84" "$2,816.00" $0.00 $0.00 $550.88 $0.00 $0.00 $560.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-0024 SUP HCPCS C1713 70-0024 - PLATE MED BONE LEFT CALC BOTH IP/OP "$3,520.00 " "$2,604.80" $0.00 "$2,816.00" "$1,584.00" "$1,584.00" $0.00 $0.00 $0.00 $733.66 "$2,612.54" "$2,612.54" $0.00 $0.00 $733.57 $0.00 "$1,735.36" "$1,735.36" $0.00 "$1,760.00" "$2,787.84" "$2,816.00" $0.00 $0.00 $550.88 $0.00 $0.00 $560.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-0025 SUP HCPCS C1713 70-0025 - PLATE BONE RIGHT CALC BOTH IP/OP "$3,520.00 " "$2,604.80" $0.00 "$2,816.00" "$1,584.00" "$1,584.00" $0.00 $0.00 $0.00 $733.66 "$2,612.54" "$2,612.54" $0.00 $0.00 $733.57 $0.00 "$1,735.36" "$1,735.36" $0.00 "$1,760.00" "$2,787.84" "$2,816.00" $0.00 $0.00 $550.88 $0.00 $0.00 $560.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-0026 SUP HCPCS C1713 70-0026 - PLATE LG LCK BONE LEFT CALC NONSTRL BOTH IP/OP "$3,520.00 " "$2,604.80" $0.00 "$2,816.00" "$1,584.00" "$1,584.00" $0.00 $0.00 $0.00 $733.66 "$2,612.54" "$2,612.54" $0.00 $0.00 $733.57 $0.00 "$1,735.36" "$1,735.36" $0.00 "$1,760.00" "$2,787.84" "$2,816.00" $0.00 $0.00 $550.88 $0.00 $0.00 $560.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-0027 SUP HCPCS C1713 70-0027 - PLATE LG LCK BONE CALC RIGHT BOTH IP/OP "$3,520.00 " "$2,604.80" $0.00 "$2,816.00" "$1,584.00" "$1,584.00" $0.00 $0.00 $0.00 $733.66 "$2,612.54" "$2,612.54" $0.00 $0.00 $733.57 $0.00 "$1,735.36" "$1,735.36" $0.00 "$1,760.00" "$2,787.84" "$2,816.00" $0.00 $0.00 $550.88 $0.00 $0.00 $560.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-0036 SUP HCPCS C1713 70-0036 - PLATE BN MPJ 5 HL CMB FSN LCK LT 1ST MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0037 SUP HCPCS C1713 70-0037 - PLATE 5 HOLE PRIM BONE RIGHT MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-42A SUP HCPCS C1776 700-04-42A - SHELL ACTB A 42MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-44B SUP HCPCS C1776 700-04-44B - SHELL ACTB B 44MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-46C SUP HCPCS C1776 700-04-46C - SHELL ACTB C 46MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-48D SUP HCPCS C1776 700-04-48D - SHELL ACTB D 48MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 70-0045 SUP HCPCS C1713 70-0045 - PLATE BN STD NS ACLC LOPRFL LCK SHFT FX ANG SCR HL KWR HL TI BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-50D SUP HCPCS C1776 700-04-50D - SHELL ACTB D 50MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-52E SUP HCPCS C1776 700-04-52E - SHELL ACTB E 52MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-54E SUP HCPCS C1776 700-04-54E - SHELL ACTB E 54MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-56F SUP HCPCS C1776 700-04-56F - SHELL ACTB F 56MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-58F SUP HCPCS C1776 700-04-58F - SHELL ACTB F 58MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 70-0046 SUP HCPCS C1713 70-0046 - PLATE BN STD RT DIST VOLR ULN BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-60G SUP HCPCS C1776 700-04-60G - SHELL ACTB G 60MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-62G SUP HCPCS C1776 700-04-62G - SHELL ACTB G 62MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-64H SUP HCPCS C1776 700-04-64H - SHELL ACTB H 64MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 700-04-66H SUP HCPCS C1776 700-04-66H - SHELL ACTB H 66MM STRL TRDNT II SB TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 70-0047 SUP HCPCS C1713 70-0047 - PLATE BN LNG LG DIST ULN BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 70-0048 SUP HCPCS C1713 70-0048 - PLATE BN LNG NS ACLC LOPRFL LCK SHFT FX ANG SCR HL KWR HL TI BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 70-0049 SUP HCPCS C1713 70-0049 - PLATE 8 HOLE LCK BONE 1ST TARSOMETATARSAL BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-005 SUP HCPCS C1713 70-005 - PLATE STD ACLC BONE DORSAL DISTAL RADL BOTH IP/OP "$2,362.50 " "$1,748.25" $0.00 "$1,890.00" "$1,063.13" "$1,063.13" $0.00 $0.00 $0.00 $492.40 "$1,753.45" "$1,753.45" $0.00 $0.00 $492.35 $0.00 "$1,397.42" "$1,397.42" $0.00 "$1,181.25" "$1,871.10" "$1,890.00" $0.00 $0.00 $369.73 $0.00 $0.00 $376.11 $0.00 $0.00 $0.00 $0.00 $0.00 70-0050 SUP HCPCS C1713 70-0050 - PLATE 7 HOLE LCK BONE 1ST TARSOMETATARSAL BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0051 SUP HCPCS C1713 70-0051 - PLATE 7 HOLE LCK BONE SEC 3RD TARSOMETATARSAL BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0052 SUP HCPCS C1713 70-0052 - PLATE MPJ LOW PROFILE 4 DEGREE L BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0053 SUP HCPCS C1713 70-0053 - PLATE MPJ LOW PROFILE 4 DEGREE R BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0055 SUP HCPCS C1713 70-0055 - PLATE STD TI ACLC BONE LEFT DISTAL DORSAL RADL STRL BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 70-0056 SUP HCPCS C1713 70-0056 - PLATE BN STD ACLC TI RT DRSL BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 70-0057 SUP HCPCS C1713 70-0057 - PLATE BN NAR NS ACLC LOPRFL LCK SHFT FX ANG SCR HL KWR HL TI BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 70-0058 SUP HCPCS C1713 70-0058 - PLATE BN NAR ACLC RT DRSL BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 70-0063 SUP HCPCS C1713 70-0063 - PLATE BN STD STRL ACLC XTD BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 70-0064 SUP HCPCS C1713 70-0064 - PLATE NAR TI ACLC BONE LEFT DISTAL VOLR ULN BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 70-0066 SUP HCPCS C1713 70-0066 - PLATE 80MM 6 HOLE MIDSHAFT ACUMED BONE VOLR RADL STRL BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0067 SUP HCPCS C1713 70-0067 - PLATE TI 8 HOLE MIDSHAFT BONE VOLR RADL BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0068 SUP HCPCS C1713 70-0068 - PLATE 10 HOLE MIDSHAFT ACUMED BONE VOLR RADL STRL BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0069 SUP HCPCS C1713 70-0069 - PLATE 160MM 12 HOLE MIDSHAFT BONE VOLR RADL BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0070 SUP HCPCS C1713 70-0070 - PLATE BN 80MM NS 6 HL MIDSHAFT LOPRFL ULNA BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0071 SUP HCPCS C1713 70-0071 - PLATE BN 100MM NS 8 HL MIDSHAFT LOPRFL ULNA BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0072 SUP HCPCS C1713 70-0072 - PLATE TI 10 HOLE BONE ULN BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0073 SUP HCPCS C1713 70-0073 - PLATE 12 HOLE MIDSHAFT BONE ULN BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0074 SUP HCPCS C1713 70-0074 - PLATE 6 HOLE MIDSHAFT BONE ULN BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0075 SUP HCPCS C1713 70-0075 - PLATE BN 100MM NS 8 HL MIDSHAFT LOPRFL RDS DORSOLATERAL BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0076 SUP HCPCS C1713 70-0076 - PLATE 10 HOLE BONE DORSOLATERAL RADL BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0077 SUP HCPCS C1713 70-0077 - PLATE 12 HOLE BONE DORSOLATERAL RADL BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0078 SUP HCPCS C1713 70-0078 - PLATE MPJ PETIETE 4 DEGREE L BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0079 SUP HCPCS C1713 70-0079 - PLATE MPJ PETIETE 4 DEGREE R BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0097 SUP HCPCS C1713 70-0097 - PLATE BN STD CRVTR 31MM NS 3 HL LCK RADL HD BOTH IP/OP "$2,652.50 " "$1,962.85" $0.00 "$2,122.00" "$1,193.63" "$1,193.63" $0.00 $0.00 $0.00 $552.85 "$1,968.69" "$1,968.69" $0.00 $0.00 $552.78 $0.00 "$1,307.68" "$1,307.68" $0.00 "$1,326.25" "$2,100.78" "$2,122.00" $0.00 $0.00 $415.12 $0.00 $0.00 $422.28 $0.00 $0.00 $0.00 $0.00 $0.00 70-0098 SUP HCPCS C1713 70-0098 - PLATE BN 5 HLE/HD LCK RDS BOTH IP/OP "$2,652.50 " "$1,962.85" $0.00 "$2,122.00" "$1,193.63" "$1,193.63" $0.00 $0.00 $0.00 $552.85 "$1,968.69" "$1,968.69" $0.00 $0.00 $552.78 $0.00 "$1,307.68" "$1,307.68" $0.00 "$1,326.25" "$2,100.78" "$2,122.00" $0.00 $0.00 $415.12 $0.00 $0.00 $422.28 $0.00 $0.00 $0.00 $0.00 $0.00 70-0099 SUP HCPCS C1713 70-0099 - PLATE BN SM CRV 3 HL LCK RDS HD BOTH IP/OP "$2,652.50 " "$1,962.85" $0.00 "$2,122.00" "$1,193.63" "$1,193.63" $0.00 $0.00 $0.00 $552.85 "$1,968.69" "$1,968.69" $0.00 $0.00 $552.78 $0.00 "$1,307.68" "$1,307.68" $0.00 "$1,326.25" "$2,100.78" "$2,122.00" $0.00 $0.00 $415.12 $0.00 $0.00 $422.28 $0.00 $0.00 $0.00 $0.00 $0.00 7000AC SUP Custom 27803010 7000AC - CLAMP SPNL SPRL R90D BOTH IP/OP "$1,615.25 " "$1,195.29" $0.00 "$1,292.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,198.84" "$1,198.84" $0.00 $0.00 $336.62 $0.00 $0.00 $0.00 $0.00 $807.63 "$1,279.28" "$1,292.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7000OC SUP Custom 27803010 7000OC - CLIP FX SPRL R90D OFST CRNL BOTH IP/OP "$2,147.68 " "$1,589.28" $0.00 "$1,718.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,594.00" "$1,594.00" $0.00 $0.00 $447.58 $0.00 $0.00 $0.00 $0.00 "$1,073.84" "$1,700.96" "$1,718.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7000SOL SUP HCPCS C1713 7000SOL - SCREW BN LG SPRL R90D OFST TI THORLMBR SPNE BOTH IP/OP "$1,534.38 " "$1,135.44" $0.00 "$1,227.50" $690.47 $690.47 $0.00 $0.00 $0.00 $319.80 "$1,138.81" "$1,138.81" $0.00 $0.00 $319.76 $0.00 $907.58 $907.58 $0.00 $767.19 "$1,215.23" "$1,227.50" $0.00 $0.00 $240.13 $0.00 $0.00 $244.27 $0.00 $0.00 $0.00 $0.00 $0.00 7000SOS SUP HCPCS C1713 7000SOS - SCREW BN SHRT SPRL R90D OFST TI THORLMBR SPNE BOTH IP/OP "$1,534.38 " "$1,135.44" $0.00 "$1,227.50" $690.47 $690.47 $0.00 $0.00 $0.00 $319.80 "$1,138.81" "$1,138.81" $0.00 $0.00 $319.76 $0.00 $907.58 $907.58 $0.00 $767.19 "$1,215.23" "$1,227.50" $0.00 $0.00 $240.13 $0.00 $0.00 $244.27 $0.00 $0.00 $0.00 $0.00 $0.00 70-0100 SUP HCPCS C1713 70-0100 - PLATE SM 5 HOLE LCK CRVTR BONE RADL HEAD STRL BOTH IP/OP "$2,652.50 " "$1,962.85" $0.00 "$2,122.00" "$1,193.63" "$1,193.63" $0.00 $0.00 $0.00 $552.85 "$1,968.69" "$1,968.69" $0.00 $0.00 $552.78 $0.00 "$1,307.68" "$1,307.68" $0.00 "$1,326.25" "$2,100.78" "$2,122.00" $0.00 $0.00 $415.12 $0.00 $0.00 $422.28 $0.00 $0.00 $0.00 $0.00 $0.00 70-0109 SUP HCPCS C1713 70-0109 - PLATE BONE LEFT TIB MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0110 SUP HCPCS C1713 70-0110 - PLATE BONE RIGHT TIB MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0111 SUP HCPCS C1713 70-0111 - PLATE BN 12 HL LCK LT DIST 3.5 MM SCR BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0112 SUP HCPCS C1713 70-0112 - PLATE BN 12 HL LCK LT DIST 3.5 MM SCR BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0116 SUP HCPCS C1713 70-0116 - PLATE BN 9 HL LCK LT DIST 3.5 MM SCR BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0117 SUP HCPCS C1713 70-0117 - PLATE BN DIST CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0118 SUP HCPCS C1713 70-0118 - PLATE BN 8 HL LAT ANT BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0119 SUP HCPCS C1713 70-0119 - PLATE BN 8 HL LCK ANT MDL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0120 SUP HCPCS C1713 70-0120 - PLATE BN 6 HL LCK ANT MDL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0121 SUP HCPCS C1713 70-0121 - PLATE BN 10 HL ANT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0122 SUP HCPCS C1713 70-0122 - PLATE BN 6 HL LCK ANT LAT BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0123 SUP HCPCS C1713 70-0123 - PLATE BN 16 HL LCK RT DIST 2.3 MM SCR BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0124 SUP HCPCS C1713 70-0124 - PLATE BN 101X11MM NS 16 HL LCK LOPRFL TI CLVCL LT DIST 2.3MM BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0125 SUP HCPCS C1713 70-0125 - PLATE BN 13 HL LCK RT DIST 2.3 MM SCR BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0126 SUP HCPCS C1713 70-0126 - PLATE BN 68X11MM NS 13 HL LCK LOPRFL TI CLVCL LT DIST 2.3MM BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0141 SUP HCPCS C1713 70-0141 - PLATE 4D BONE LEFT MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0142 SUP HCPCS C1713 70-0142 - PLATE 4D BONE RIGHT MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0143 SUP HCPCS C1713 70-0143 - PLATE REV BONE LEFT MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0144 SUP HCPCS C1713 70-0144 - PLATE REV BONE RIGHT MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0145 SUP HCPCS C1713 70-0145 - PLATE 5 HOLE BONE FIB BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0147 SUP HCPCS C1713 70-0147 - PLATE 7 HOLE LCK BONE LAT FIB BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0149 SUP HCPCS C1713 70-0149 - PLATE 9 HOLE LP LCK BONE LAT FIB ANKL BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0151 SUP HCPCS C1713 70-0151 - PLATE 11 HOLE LCK LP TYPE 2 ANODIZE FNSH BONE LAT FIB ANKL BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0153 SUP HCPCS C1713 70-0153 - PLATE 13 HOLE LCK LP BONE LAT FIB ANKL NONSTRL BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0169 SUP HCPCS C1713 70-0169 - PLATE BN STD 9 HL LCK LAT FIB BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0171 SUP HCPCS C1713 70-0171 - PLATE 11 HOLE LCK BONE LAT FIB ANKL NONSTRL BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0173 SUP HCPCS C1713 70-0173 - PLATE 13 HOLE LCK BONE LAT FIB ANKL BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0227 SUP HCPCS C1713 70-0227 - PLATE 7 HOLE LCK LP BONE MDL TIB NONSTRL BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0229 SUP HCPCS C1713 70-0229 - PLATE 9 HOLE BONE MDL TIB BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0245 SUP HCPCS C1713 70-0245 - PLATE 5 HOLE LCK LP BONE ANT TIB NONSTRL BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0247 SUP HCPCS C1713 70-0247 - PLATE 7 HOLE LCK LP BONE ANT TIB NONSTRL BOTH IP/OP "$3,222.50 " "$2,384.65" $0.00 "$2,578.00" "$1,450.13" "$1,450.13" $0.00 $0.00 $0.00 $671.65 "$2,391.74" "$2,391.74" $0.00 $0.00 $671.57 $0.00 "$1,588.69" "$1,588.69" $0.00 "$1,611.25" "$2,552.22" "$2,578.00" $0.00 $0.00 $504.32 $0.00 $0.00 $513.02 $0.00 $0.00 $0.00 $0.00 $0.00 70-0286 SUP HCPCS C1713 70-0286 - PLATE BN 8 HL STRG LOPRFL CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0287 SUP HCPCS C1713 70-0287 - PLATE BN 8 HL LOPRFL STRG RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0288 SUP HCPCS C1713 70-0288 - PLATE BN LNG 8 HL LOPRFL LT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0289 SUP HCPCS C1713 70-0289 - PLATE BN LNG 8 HL LOPRFL RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0290 SUP HCPCS C1713 70-0290 - PLATE BN 8 HL LT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0291 SUP HCPCS C1713 70-0291 - PLATE BN MED 8 HL LOPRFL RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0292 SUP HCPCS C1713 70-0292 - PLATE BN SM 8 HL LOPRFL LT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0293 SUP HCPCS C1713 70-0293 - PLATE BN SM 8 HL LOPRFL RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0294 SUP HCPCS C1713 70-0294 - PLATE BN LG 121X11MM NS 10 HL LCK MIDSHAFT LOPRFL TI CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0295 SUP HCPCS C1713 70-0295 - PLATE BN 10 HL LOPRFL RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0296 SUP HCPCS C1713 70-0296 - PLATE BN 6 HL LT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0297 SUP HCPCS C1713 70-0297 - PLATE BN NAR 6 HL LOPRFL RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0298 SUP HCPCS C1713 70-0298 - PLATE BN 8 HL STRG LT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0299 SUP HCPCS C1713 70-0299 - PLATE BN NAR 8 HL LOPRFL STRG RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0300 SUP HCPCS C1713 70-0300 - PLATE BN 8 HL LT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0301 SUP HCPCS C1713 70-0301 - PLATE BN NAR 8 HL LOPRFL RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0302 SUP HCPCS C1713 70-0302 - PLATE BN STD 65MM NS 3 HL LOPRFL OLCRN LT BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0303 SUP HCPCS C1713 70-0303 - PLATE BN STD 65MM NS 3 HL LOPRFL OLCRN RT BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0304 SUP HCPCS C1713 70-0304 - PLATE BN STD 90MM NS 5 HL LOPRFL OLCRN LT BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0305 SUP HCPCS C1713 70-0305 - PLATE BN STD 90MM NS 5 HL LOPRFL OLCRN RT BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0306 SUP HCPCS C1713 70-0306 - PLATE BN STD 110MM NS 7 HL LOPRFL DIST TPR LMT CNTCT OLCRN BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0307 SUP HCPCS C1713 70-0307 - PLATE BN STD 110MM NS 7 HL LOPRFL OLCRN RT BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0308 SUP HCPCS C1713 70-0308 - PLATE BN STD 150MM NS 11 HL LOPRFL OLCRN LT BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0309 SUP HCPCS C1713 70-0309 - PLATE STD 11 HOLE BONE RIGHT OLCRN BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0310 SUP HCPCS C1713 70-0310 - PLATE 15 HOLE BONE CLVCL BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0311 SUP HCPCS C1713 70-0311 - PLATE STD 190MM 15 HOLE PRECONTOURED LP TAP-LOC TCH ANTM BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0312 SUP HCPCS C1713 70-0312 - PLATE BN 90MM NS 5 HL LOPRFL XTD OLCRN LT BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0313 SUP HCPCS C1713 70-0313 - PLATE BN 90MM NS 5 HL LOPRFL XTD OLCRN RT BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0314 SUP HCPCS C1713 70-0314 - PLATE 9 HOLE EXTN BONE OLCRN BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0315 SUP HCPCS C1713 70-0315 - PLATE 9 HOLE XTD BONE OLCRN BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0316 SUP HCPCS C1713 70-0316 - PLATE NAR 85MM 5 HOLE BONE LEFT OLCRN BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0317 SUP HCPCS C1713 70-0317 - PLATE NAR 85MM 5 HOLE OPTN DISTAL TPR DSGN LMT CNTCT PR BONE BOTH IP/OP "$3,137.50 " "$2,321.75" $0.00 "$2,510.00" "$1,411.88" "$1,411.88" $0.00 $0.00 $0.00 $653.93 "$2,328.65" "$2,328.65" $0.00 $0.00 $653.86 $0.00 "$1,546.79" "$1,546.79" $0.00 "$1,568.75" "$2,484.90" "$2,510.00" $0.00 $0.00 $491.02 $0.00 $0.00 $499.49 $0.00 $0.00 $0.00 $0.00 $0.00 70-0319 SUP HCPCS C1713 70-0319 - PLATE BN J LOPRFL LT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0320 SUP HCPCS C1713 70-0320 - PLATE BN J LOPRFL RT CLVCL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0323 SUP HCPCS C1713 70-0323 - PLATE EXTN OSTMY BONE LEFT BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0324 SUP HCPCS C1713 70-0324 - PLATE EXTN OSTMY BONE RIGHT BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0329 SUP HCPCS C1713 70-0329 - PLATE BN 4D PET LCK MTP LT BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0330 SUP HCPCS C1713 70-0330 - PLATE BN 4D PET MPJ LCK RT MTP BOTH IP/OP "$1,280.00 " $947.20 $0.00 "$1,024.00" $576.00 $576.00 $0.00 $0.00 $0.00 $266.78 $950.02 $950.02 $0.00 $0.00 $266.75 $0.00 $757.12 $757.12 $0.00 $640.00 "$1,013.76" "$1,024.00" $0.00 $0.00 $200.32 $0.00 $0.00 $203.78 $0.00 $0.00 $0.00 $0.00 $0.00 70-0331 SUP HCPCS C1713 70-0331 - PLATE BONE RADL STYLOID BOTH IP/OP "$2,315.00 " "$1,713.10" $0.00 "$1,852.00" "$1,041.75" "$1,041.75" $0.00 $0.00 $0.00 $482.50 "$1,718.19" "$1,718.19" $0.00 $0.00 $482.45 $0.00 "$1,369.32" "$1,369.32" $0.00 "$1,157.50" "$1,833.48" "$1,852.00" $0.00 $0.00 $362.30 $0.00 $0.00 $368.55 $0.00 $0.00 $0.00 $0.00 $0.00 70-0334 SUP HCPCS C1713 70-0334 - PLATE BN NS ACLC 2 SUT RDS LUNATE VOLR DIST BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0335 SUP HCPCS C1713 70-0335 - PLATE BN BTRS NS ACLC 2 RIM RDS RT DIST DRSL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0336 SUP HCPCS C1713 70-0336 - PLATE FRAC SYS BTRS RIM BONE LEFT DISTAL DORSAL RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0337 SUP HCPCS C1713 70-0337 - PLATE FRAC SYS BTRS RIM BONE RIGHT DISTAL DORSAL LUNATE RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0338 SUP HCPCS C1713 70-0338 - PLATE BONE LEFT DORSAL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0350 SUP HCPCS C1713 70-0350 - PLATE BN STD 49X24MM NS ACLC 2 VA RDS LT VOLR DIST 2.3MM SCR BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0351 SUP HCPCS C1713 70-0351 - PLATE BN STD 49X24MM NS ACLC 2 VA RDS RT VOLR DIST 2.3MM SCR BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0352 SUP HCPCS C1713 70-0352 - PLATE LNG NAR ACLC 2 BONE PROX DISTAL VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0353 SUP HCPCS C1713 70-0353 - PLATE ACLC BONE RIGHT DISTAL VOLR PROX BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0354 SUP HCPCS C1713 70-0354 - PLATE BN ACLC 2 W LT PROX BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0355 SUP HCPCS C1713 70-0355 - PLATE BN W ACLC 2 RT PROX DIST VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0356 SUP HCPCS C1713 70-0356 - PLATE BN STD SLVR NS ACLC 2 LT DIST VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0357 SUP HCPCS C1713 70-0357 - PLATE BN STD REG ACLC 2 RT VOLR DIST RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0358 SUP HCPCS C1713 70-0358 - PLATE BN NAR STRL ACLC 2 LT DIST VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0359 SUP HCPCS C1713 70-0359 - PLATE BN NAR STRL ACLC 2 RT DIST VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0360 SUP HCPCS C1713 70-0360 - PLATE BN W STRL ACLC 2 LT DIST VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0361 SUP HCPCS C1713 70-0361 - PLATE BN W ACLC 2 RT VOLR DIST RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0364 SUP HCPCS C1713 70-0364 - PLATE NTRL ACLC 2 BONE PROX DISTAL VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0365 SUP HCPCS C1713 70-0365 - PLATE LNG EXTN ACLC 2 BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0366 SUP HCPCS C1713 70-0366 - PLATE LNG EXTN ACLC 2 BONE RIGHT DISTAL VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0368 SUP HCPCS C1713 70-0368 - PLATE BN LNG STD ACLC 2 LT DIST VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0369 SUP HCPCS C1713 70-0369 - PLATE LNG STD ACLC 2 BONE RIGHT DISTAL RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0370 SUP HCPCS C1713 70-0370 - PLATE LNG NAR ACLC 2 BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0371 SUP HCPCS C1713 70-0371 - PLATE LNG NAR 65MM OPTM DSGN ACLC 2 BONE RIGHT DISTAL VOLR BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0372 SUP HCPCS C1713 70-0372 - PLATE BN LNG STD ACLC 2 LT PROX DIST VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0373 SUP HCPCS C1713 70-0373 - PLATE BN LNG STD ACLC 2 RT PROX DIST VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0374 SUP HCPCS C1713 70-0374 - PLATE 5 HOLE BONE LEFT DISTAL POSTLAT HUM BOTH IP/OP "$3,437.50 " "$2,543.75" $0.00 "$2,750.00" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $716.46 "$2,551.31" "$2,551.31" $0.00 $0.00 $716.38 $0.00 "$1,694.69" "$1,694.69" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 70-0375 SUP HCPCS C1713 70-0375 - PLATE 78MM 5 HOLE BONE RIGHT P/L HUM BOTH IP/OP "$3,437.50 " "$2,543.75" $0.00 "$2,750.00" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $716.46 "$2,551.31" "$2,551.31" $0.00 $0.00 $716.38 $0.00 "$1,694.69" "$1,694.69" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 70-0376 SUP HCPCS C1713 70-0376 - PLATE 103MM 7 HOLE BONE LEFT DISTAL POSTLAT HUM NONSTRL BOTH IP/OP "$3,437.50 " "$2,543.75" $0.00 "$2,750.00" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $716.46 "$2,551.31" "$2,551.31" $0.00 $0.00 $716.38 $0.00 "$1,694.69" "$1,694.69" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 70-0377 SUP HCPCS C1713 70-0377 - PLATE 7 HOLE BONE RIGHT DISTAL POSTLAT HUM BOTH IP/OP "$3,437.50 " "$2,543.75" $0.00 "$2,750.00" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $716.46 "$2,551.31" "$2,551.31" $0.00 $0.00 $716.38 $0.00 "$1,694.69" "$1,694.69" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 70-0378 SUP HCPCS C1713 70-0378 - PLATE 152MM 11 HOLE BONE LEFT DISTAL POSTLAT HUM NONSTRL BOTH IP/OP "$3,437.50 " "$2,543.75" $0.00 "$2,750.00" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $716.46 "$2,551.31" "$2,551.31" $0.00 $0.00 $716.38 $0.00 "$1,694.69" "$1,694.69" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 70-0379 SUP HCPCS C1713 70-0379 - PLATE 152MM 11 HOLE BONE RIGHT DISTAL POSTLAT HUM NONSTRL BOTH IP/OP "$3,437.50 " "$2,543.75" $0.00 "$2,750.00" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $716.46 "$2,551.31" "$2,551.31" $0.00 $0.00 $716.38 $0.00 "$1,694.69" "$1,694.69" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 70-0380 SUP HCPCS C1713 70-0380 - PLATE 203MM 15 HOLE BONE LEFT DISTAL POSTLAT HUM NONSTRL BOTH IP/OP "$3,437.50 " "$2,543.75" $0.00 "$2,750.00" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $716.46 "$2,551.31" "$2,551.31" $0.00 $0.00 $716.38 $0.00 "$1,694.69" "$1,694.69" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 70-0381 SUP HCPCS C1713 70-0381 - PLATE 203MM 15 HOLE BONE RIGHT DISTAL POSTLAT HUM NONSTRL BOTH IP/OP "$3,437.50 " "$2,543.75" $0.00 "$2,750.00" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $716.46 "$2,551.31" "$2,551.31" $0.00 $0.00 $716.38 $0.00 "$1,694.69" "$1,694.69" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 70-0382 SUP HCPCS C1713 70-0382 - PLATE NAR LNG ACLC 2 BONE LEFT PROX DISTAL VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0383 SUP HCPCS C1713 70-0383 - PLATE LNG NAR ACLC 2 BONE LEFT PROX DISTAL VOLR RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70-0386 SUP HCPCS C1713 70-0386 - PLATE MED BONE LEFT ANT CALC BOTH IP/OP "$3,052.50 " "$2,258.85" $0.00 "$2,442.00" "$1,373.63" "$1,373.63" $0.00 $0.00 $0.00 $636.22 "$2,265.57" "$2,265.57" $0.00 $0.00 $636.14 $0.00 "$1,504.88" "$1,504.88" $0.00 "$1,526.25" "$2,417.58" "$2,442.00" $0.00 $0.00 $477.72 $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 70-0387 SUP HCPCS C1713 70-0387 - PLATE MED BONE RIGHT ANT CALC BOTH IP/OP "$3,052.50 " "$2,258.85" $0.00 "$2,442.00" "$1,373.63" "$1,373.63" $0.00 $0.00 $0.00 $636.22 "$2,265.57" "$2,265.57" $0.00 $0.00 $636.14 $0.00 "$1,504.88" "$1,504.88" $0.00 "$1,526.25" "$2,417.58" "$2,442.00" $0.00 $0.00 $477.72 $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 70-0388 SUP HCPCS C1713 70-0388 - PLATE BONE LEFT ANT CALC BOTH IP/OP "$3,052.50 " "$2,258.85" $0.00 "$2,442.00" "$1,373.63" "$1,373.63" $0.00 $0.00 $0.00 $636.22 "$2,265.57" "$2,265.57" $0.00 $0.00 $636.14 $0.00 "$1,504.88" "$1,504.88" $0.00 "$1,526.25" "$2,417.58" "$2,442.00" $0.00 $0.00 $477.72 $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 70-0389 SUP HCPCS C1713 70-0389 - PLATE LG BONE RIGHT ANT CALC BOTH IP/OP "$3,052.50 " "$2,258.85" $0.00 "$2,442.00" "$1,373.63" "$1,373.63" $0.00 $0.00 $0.00 $636.22 "$2,265.57" "$2,265.57" $0.00 $0.00 $636.14 $0.00 "$1,504.88" "$1,504.88" $0.00 "$1,526.25" "$2,417.58" "$2,442.00" $0.00 $0.00 $477.72 $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 70-0394 SUP HCPCS C1713 70-0394 - PLATE LG 5 HOLE TUBE BONE POST CALC BOTH IP/OP "$3,052.50 " "$2,258.85" $0.00 "$2,442.00" "$1,373.63" "$1,373.63" $0.00 $0.00 $0.00 $636.22 "$2,265.57" "$2,265.57" $0.00 $0.00 $636.14 $0.00 "$1,504.88" "$1,504.88" $0.00 "$1,526.25" "$2,417.58" "$2,442.00" $0.00 $0.00 $477.72 $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 70-0395 SUP HCPCS C1713 70-0395 - PLATE 5 HOLE BONE RIGHT POST CALC BOTH IP/OP "$3,052.50 " "$2,258.85" $0.00 "$2,442.00" "$1,373.63" "$1,373.63" $0.00 $0.00 $0.00 $636.22 "$2,265.57" "$2,265.57" $0.00 $0.00 $636.14 $0.00 "$1,504.88" "$1,504.88" $0.00 "$1,526.25" "$2,417.58" "$2,442.00" $0.00 $0.00 $477.72 $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 70-0396 SUP HCPCS C1713 70-0396 - PLATE 6 HOLE BONE LEFT POST CALC BOTH IP/OP "$3,052.50 " "$2,258.85" $0.00 "$2,442.00" "$1,373.63" "$1,373.63" $0.00 $0.00 $0.00 $636.22 "$2,265.57" "$2,265.57" $0.00 $0.00 $636.14 $0.00 "$1,504.88" "$1,504.88" $0.00 "$1,526.25" "$2,417.58" "$2,442.00" $0.00 $0.00 $477.72 $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 70-0397 SUP HCPCS C1713 70-0397 - PLATE 6 HOLE BONE RIGHT POST CALC BOTH IP/OP "$3,052.50 " "$2,258.85" $0.00 "$2,442.00" "$1,373.63" "$1,373.63" $0.00 $0.00 $0.00 $636.22 "$2,265.57" "$2,265.57" $0.00 $0.00 $636.14 $0.00 "$1,504.88" "$1,504.88" $0.00 "$1,526.25" "$2,417.58" "$2,442.00" $0.00 $0.00 $477.72 $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 70-0400 SUP HCPCS C1713 70-0400 - PLATE 8 HOLE BONE LEFT CALC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 70-0401 SUP HCPCS C1713 70-0401 - PLATE MED 8 HOLE COMBO BONE RIGHT CALC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 70-0404 SUP HCPCS C1713 70-0404 - PLATE 8 HOLE COMBO BONE LEFT CLVCL BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 70-0405 SUP HCPCS C1713 70-0405 - PLATE 8 HOLE BONE RL NONSTRL BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 70-0406 SUP HCPCS C1713 70-0406 - PLATE 4 HOLE COMBO BONE LEFT CALC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 70-0407 SUP HCPCS C1713 70-0407 - PLATE LG 9 HOLE COMBO BONE RIGHT CALC BOTH IP/OP "$3,250.00 " "$2,405.00" $0.00 "$2,600.00" "$1,462.50" "$1,462.50" $0.00 $0.00 $0.00 $677.38 "$2,412.15" "$2,412.15" $0.00 $0.00 $677.30 $0.00 "$1,602.25" "$1,602.25" $0.00 "$1,625.00" "$2,574.00" "$2,600.00" $0.00 $0.00 $508.63 $0.00 $0.00 $517.40 $0.00 $0.00 $0.00 $0.00 $0.00 7005-08003 SUP HCPCS C1713 7005-08003 - PLATE BN T .8MM NS LOPRFL TI HND BOTH IP/OP "$1,365.00 " "$1,010.10" $0.00 "$1,092.00" $614.25 $614.25 $0.00 $0.00 $0.00 $284.50 "$1,013.10" "$1,013.10" $0.00 $0.00 $284.47 $0.00 $807.40 $807.40 $0.00 $682.50 "$1,081.08" "$1,092.00" $0.00 $0.00 $213.62 $0.00 $0.00 $217.31 $0.00 $0.00 $0.00 $0.00 $0.00 7005-08006 SUP HCPCS C1713 7005-08006 - PLATE BN .8MM NS 6 HL CMPR TI HND BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $533.25 $533.25 $0.00 $0.00 $0.00 $246.98 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $700.93 $700.93 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $185.45 $0.00 $0.00 $188.65 $0.00 $0.00 $0.00 $0.00 $0.00 7005-13005 SUP HCPCS C1713 7005-13005 - PLATE BN NS ROT CRRT HND 1.3 MM SCR BOTH IP/OP $945.00 $699.30 $0.00 $756.00 $425.25 $425.25 $0.00 $0.00 $0.00 $196.96 $701.38 $701.38 $0.00 $0.00 $196.94 $0.00 $558.97 $558.97 $0.00 $472.50 $748.44 $756.00 $0.00 $0.00 $147.89 $0.00 $0.00 $150.44 $0.00 $0.00 $0.00 $0.00 $0.00 7005-13006 SUP HCPCS C1713 7005-13006 - PLATE BONE 6 HOLE COMPRESSION HAND NONSTRL 1.3 MM SCREW BOTH IP/OP "$1,365.00 " "$1,010.10" $0.00 "$1,092.00" $614.25 $614.25 $0.00 $0.00 $0.00 $284.50 "$1,013.10" "$1,013.10" $0.00 $0.00 $284.47 $0.00 $807.40 $807.40 $0.00 $682.50 "$1,081.08" "$1,092.00" $0.00 $0.00 $213.62 $0.00 $0.00 $217.31 $0.00 $0.00 $0.00 $0.00 $0.00 70-1050 SUP Custom 27203010 ELECTRODE 3010B SER ANALY BOTH IP/OP "$2,600.00 " "$1,924.00" $0.00 "$2,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,300.00" "$2,059.20" "$2,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7014-5927 SUP HCPCS L8613 7014-5927 - PISTON OSS .6MM 4.25MM SMRT RECON OVR CRMP NTNL FLRPLAS BOTH IP/OP $752.40 $556.78 $0.00 $601.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $558.43 $558.43 $0.00 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $376.20 $595.90 $601.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7014-5928 SUP HCPCS L8613 7014-5928 - PISTON OSS .6MM 4.5MM SMRT NTNL FLRPLAS EAR STPS BOTH IP/OP $752.40 $556.78 $0.00 $601.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $558.43 $558.43 $0.00 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $376.20 $595.90 $601.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7016RR SUP Custom 27803010 7016RR - CONNECTOR ROD 16MM SPRL R90D 2 SD TI THORLMBR SPNE BOTH IP/OP "$2,075.80 " "$1,536.09" $0.00 "$1,660.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,540.66" "$1,540.66" $0.00 $0.00 $432.60 $0.00 $0.00 $0.00 $0.00 "$1,037.90" "$1,644.03" "$1,660.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-42A SUP HCPCS C1776 702-04-42A - SHELL ACTB A 42MM STRL TRDNT II 3 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-44B SUP HCPCS C1776 702-04-44B - SHELL ACTB B 44MM STRL TRDNT II 3 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-46C SUP HCPCS C1776 702-04-46C - SHELL ACTB C 46MM STRL TRDNT II 3 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-48D SUP HCPCS C1776 702-04-48D - SHELL ACTB D 48MM STRL TRDNT II 3 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-50D SUP HCPCS C1776 702-04-50D - SHELL ACTB D 50MM STRL TRDNT II 3 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-52E SUP HCPCS C1776 702-04-52E - SHELL ACTB E 52MM STRL TRDNT II 5 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-54E SUP HCPCS C1776 702-04-54E - SHELL ACTB E 54MM STRL TRDNT II 5 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-56F SUP HCPCS C1776 702-04-56F - SHELL ACTB F 56MM STRL TRDNT II 5 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-58F SUP HCPCS C1776 702-04-58F - SHELL ACTB F 58MM STRL TRDNT II 5 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-60G SUP HCPCS C1776 702-04-60G - SHELL ACTB G 60MM STRL TRDNT II 5 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-62G SUP HCPCS C1776 702-04-62G - SHELL ACTB G 62MM STRL TRDNT II 5 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-64H SUP HCPCS C1776 702-04-64H - SHELL ACTB H 64MM STRL TRDNT II 5 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-04-66H SUP HCPCS C1776 702-04-66H - SHELL ACTB H 66MM STRL TRDNT II 5 SCR HL CLSTR TRITANIUM HIP BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-42A SUP HCPCS C1776 702-11-42A - SHELL ACTB A 42MM TRDNT II CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-44B SUP HCPCS C1776 702-11-44B - SHELL ACTB B 44MM TRDNT II CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-46C SUP HCPCS C1776 702-11-46C - SHELL ACTB C 46MM TRDNT II CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-48D SUP HCPCS C1776 702-11-48D - SHELL ACTB D 48MM TRDNT II CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-50D SUP HCPCS C1776 702-11-50D - SHELL ACTB D 50MM TRDNT II CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-52E SUP HCPCS C1776 702-11-52E - SHELL ACTB E 52MM TRDNT II CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-54E SUP HCPCS C1776 702-11-54E - SHELL ACTB E 54MM TRDNT II CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-56F SUP HCPCS C1776 702-11-56F - SHELL ACTB F 56MM TRDNT II CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-58F SUP HCPCS C1776 702-11-58F - SHELL ACTB F 58MM STRL TRDNT II CLSTR 5 HL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-60G SUP HCPCS C1776 702-11-60G - SHELL ACTB G 60MM STRL TRDNT II CLSTR 5 HL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-62G SUP HCPCS C1776 702-11-62G - SHELL ACTB G 62MM STRL TRDNT II CLSTR 5 HL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-64H SUP HCPCS C1776 702-11-64H - SHELL ACTB H 64MM STRL TRDNT II CLSTR 5 HL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702-11-66H SUP HCPCS C1776 702-11-66H - SHELL ACTB H 66MM STRL TRDNT II CLSTR 5 HL HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 702301-5 SUP HCPCS C1713 702301-5 - SCREW BN ALTA CNCT ORTH BOTH IP/OP $185.63 $137.37 $0.00 $148.50 $83.53 $83.53 $0.00 $0.00 $0.00 $38.69 $137.77 $137.77 $0.00 $0.00 $38.68 $0.00 $109.80 $109.80 $0.00 $92.81 $147.02 $148.50 $0.00 $0.00 $29.05 $0.00 $0.00 $29.55 $0.00 $0.00 $0.00 $0.00 $0.00 702336S SUP HCPCS C1769 702336S - GWIRE ORTH 100MM 3MM SS BALL TIP STRL BOTH IP/OP $259.88 $192.31 $0.00 $207.90 $141.11 $141.11 $0.00 $0.00 $0.00 $54.16 $192.88 $192.88 $0.00 $0.00 $54.16 $0.00 $153.72 $153.72 $0.00 $129.94 $205.82 $207.90 $0.00 $0.00 $40.67 $0.00 $0.00 $41.37 $0.00 $0.00 $0.00 $0.00 $0.00 702341-2 SUP Custom 27203010 702341-2 - SLEEVE PRTC REPL BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.21 $408.21 $0.00 $0.00 $114.62 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702460S SUP HCPCS C1769 702460S - GWIRE ORTH 150MM 2MM ASNS 3 FEM HIP THRD 5MM NONSTRL DISP BOTH IP/OP $124.10 $91.83 $0.00 $130.90 $88.85 $88.85 $0.00 $0.00 $0.00 $25.87 $92.11 $92.11 $0.00 $0.00 $25.86 $0.00 $73.41 $73.41 $0.00 $81.81 $129.59 $130.90 $0.00 $0.00 $25.61 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $0.00 702627S SUP HCPCS C1769 702627S - GWIRE ORTH 300MM 3.2MM CLBRT FIT STRL BOTH IP/OP $281.88 $208.59 $0.00 $225.50 $153.06 $153.06 $0.00 $0.00 $0.00 $58.75 $209.21 $209.21 $0.00 $0.00 $58.74 $0.00 $166.73 $166.73 $0.00 $140.94 $223.25 $225.50 $0.00 $0.00 $44.11 $0.00 $0.00 $44.87 $0.00 $0.00 $0.00 $0.00 $0.00 702716-2 SUP HCPCS C1713 702716-2 - SCREW BONE 4MM AXSOS HUM AIM BLOCK LCK PLT SYS BOTH IP/OP $94.88 $70.21 $0.00 $75.90 $42.69 $42.69 $0.00 $0.00 $0.00 $19.77 $70.42 $70.42 $0.00 $0.00 $19.77 $0.00 $56.12 $56.12 $0.00 $47.44 $75.14 $75.90 $0.00 $0.00 $14.85 $0.00 $0.00 $15.10 $0.00 $0.00 $0.00 $0.00 $0.00 702718-2 SUP HCPCS C1713 702718-2 - SCREW BN SET SPR AIM BLCK FEM DIST BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $44.55 $44.55 $0.00 $0.00 $0.00 $20.63 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $58.56 $58.56 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 702720-2 SUP HCPCS C1713 702720-2 - SCREW BONE 4MM AXSOS TIB AIM BLOCK LCK PLT SYS BOTH IP/OP $193.88 $143.47 $0.00 $155.10 $87.24 $87.24 $0.00 $0.00 $0.00 $40.41 $143.89 $143.89 $0.00 $0.00 $40.40 $0.00 $114.68 $114.68 $0.00 $96.94 $153.55 $155.10 $0.00 $0.00 $30.34 $0.00 $0.00 $30.86 $0.00 $0.00 $0.00 $0.00 $0.00 702858-1 SUP Custom 27803010 702858-1 - DRIVER SRG 4MM VARIAX RING HD LCK BOTH IP/OP $570.63 $422.27 $0.00 $456.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $423.52 $423.52 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $285.31 $451.94 $456.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 702970-2 SUP Custom 27803010 702970-2 - SCREW BONE AXSOS SPR SET HUM AIM BLOCK LCK PALTE SYS BOTH IP/OP $199.38 $147.54 $0.00 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.98 $147.98 $0.00 $0.00 $41.55 $0.00 $0.00 $0.00 $0.00 $99.69 $157.91 $159.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-3003L SUP HCPCS C1776 70-3003L - CMPNT FEM 3 LEFT KNEE CMNT CRUC RET BASIC SCRP BOTH IP/OP "$3,074.00 " "$2,274.76" $0.00 "$2,459.20" "$1,383.30" "$1,383.30" $0.00 $0.00 $0.00 $640.70 "$2,281.52" "$2,281.52" $0.00 $0.00 $640.62 $0.00 "$1,515.48" "$1,515.48" $0.00 "$1,537.00" "$2,434.61" "$2,459.20" $0.00 $0.00 $481.08 $0.00 $0.00 $489.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-3003R SUP HCPCS C1776 70-3003R - CMPNT FEM 3 RIGHT KNEE CMNT CRUC RET BASIC SCRP BOTH IP/OP "$3,074.00 " "$2,274.76" $0.00 "$2,459.20" "$1,383.30" "$1,383.30" $0.00 $0.00 $0.00 $640.70 "$2,281.52" "$2,281.52" $0.00 $0.00 $640.62 $0.00 "$1,515.48" "$1,515.48" $0.00 "$1,537.00" "$2,434.61" "$2,459.20" $0.00 $0.00 $481.08 $0.00 $0.00 $489.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-3004L SUP HCPCS C1776 70-3004L - CMPNT FEM 4 LEFT KNEE CMNT CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3004R SUP HCPCS C1776 70-3004R - CMPNT FEM 4 RIGHT KNEE CMNT CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3005L SUP HCPCS C1776 70-3005L - CMPNT FEM 5 LEFT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3005R SUP HCPCS C1776 70-3005R - CMPNT FEM 5 RIGHT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3006L SUP HCPCS C1776 70-3006L - CMPNT FEM 6 LEFT KNEE CMNT CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3006R SUP HCPCS C1776 70-3006R - CMPNT FEM 6 RIGHT KNEE CMNT CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3007L SUP HCPCS C1776 70-3007L - CMPNT FEM 7 LEFT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3007R SUP HCPCS C1776 70-3007R - CMPNT FEM 7 RIGHT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3009L SUP HCPCS C1776 70-3009L - CMPNT FEM 9 LEFT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3009R SUP HCPCS C1776 70-3009R - CMPNT FEM 9 RIGHT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3011L SUP HCPCS C1776 70-3011L - CMPNT FEM 11 LEFT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3011R SUP HCPCS C1776 70-3011R - CMPNT FEM 11 RIGHT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,029.00 " "$2,241.46" $0.00 "$2,423.20" "$1,363.05" "$1,363.05" $0.00 $0.00 $0.00 $631.32 "$2,248.12" "$2,248.12" $0.00 $0.00 $631.24 $0.00 "$1,493.30" "$1,493.30" $0.00 "$1,514.50" "$2,398.97" "$2,423.20" $0.00 $0.00 $474.04 $0.00 $0.00 $482.22 $0.00 $0.00 $0.00 $0.00 $0.00 70-3013L SUP HCPCS C1776 70-3013L - CMPNT FEM 13 LEFT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,074.00 " "$2,274.76" $0.00 "$2,459.20" "$1,383.30" "$1,383.30" $0.00 $0.00 $0.00 $640.70 "$2,281.52" "$2,281.52" $0.00 $0.00 $640.62 $0.00 "$1,515.48" "$1,515.48" $0.00 "$1,537.00" "$2,434.61" "$2,459.20" $0.00 $0.00 $481.08 $0.00 $0.00 $489.38 $0.00 $0.00 $0.00 $0.00 $0.00 70-3013R SUP HCPCS C1776 70-3013R - CMPNT FEM 13 RIGHT KNEE CRUC RET BASIC SCRP BOTH IP/OP "$3,074.00 " "$2,274.76" $0.00 "$2,459.20" "$1,383.30" "$1,383.30" $0.00 $0.00 $0.00 $640.70 "$2,281.52" "$2,281.52" $0.00 $0.00 $640.62 $0.00 "$1,515.48" "$1,515.48" $0.00 "$1,537.00" "$2,434.61" "$2,459.20" $0.00 $0.00 $481.08 $0.00 $0.00 $489.38 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6515 SUP HCPCS C1713 7030-6515 - SCREW BN 6.5MM 15MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6520 SUP HCPCS C1713 7030-6520 - SCREW BN 6.5MM 20MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6525 SUP HCPCS C1713 7030-6525 - SCREW BN 6.5MM 25MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6530 SUP HCPCS C1713 7030-6530 - SCREW BN 6.5MM 30MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6535 SUP HCPCS C1713 7030-6535 - SCREW BN 6.5MM 35MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6540 SUP HCPCS C1713 7030-6540 - SCREW BN 6.5MM 40MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6545 SUP HCPCS C1713 7030-6545 - SCREW BN 6.5MM 45MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6550 SUP HCPCS C1713 7030-6550 - SCREW BN 6.5MM 50MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6555 SUP HCPCS C1713 7030-6555 - SCREW BN 6.5MM 55MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7030-6560 SUP HCPCS C1713 7030-6560 - SCREW BN 6.5MM 60MM STRL TRDNT II LOPRFL HEX BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 703165-20 SUP Custom 27203010 703165-20 - SLEEVE DRILL ANT FEM RTN BOTH IP/OP $559.63 $414.13 $0.00 $447.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $415.35 $415.35 $0.00 $0.00 $116.63 $0.00 $0.00 $0.00 $0.00 $279.81 $443.23 $447.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-3191 SUP Custom 27203010 ELECTRODE ANALY SLVR CHLOR REF WIRE 3010B SER BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-3849 SUP Custom 27203010 CONTROL BLOOD LEAD LVL 1 HMTL BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-3850 SUP Custom 27203010 CONTROL BLOOD LEAD LVL 2 HMTL BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-3851 SUP Custom 27203010 CONTROL CHM HI BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 704001-1 SUP Custom 27203010 704001-1 - IMPCTR SURG OMEGA HIP HEAD BOTH IP/OP $371.25 $274.73 $0.00 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.54 $275.54 $0.00 $0.00 $77.37 $0.00 $0.00 $0.00 $0.00 $185.63 $294.03 $297.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 704005-10 SUP Custom 27203010 704005-10 - REAMER SURG DRILL COMBO BOTH IP/OP $701.25 $518.93 $0.00 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $520.47 $520.47 $0.00 $0.00 $146.14 $0.00 $0.00 $0.00 $0.00 $350.63 $555.39 $561.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 704011S SUP HCPCS C1713 704011S - PIN SURG GUIDE BOTH IP/OP $75.63 $55.97 $0.00 $60.50 $34.03 $34.03 $0.00 $0.00 $0.00 $15.76 $56.13 $56.13 $0.00 $0.00 $15.76 $0.00 $44.73 $44.73 $0.00 $37.81 $59.90 $60.50 $0.00 $0.00 $11.84 $0.00 $0.00 $12.04 $0.00 $0.00 $0.00 $0.00 $0.00 704012S SUP HCPCS C1769 704012S - GWIRE ORTH 230MM 2.8MM THRD TIP QC BOTH IP/OP $226.88 $167.89 $0.00 $181.50 $123.19 $123.19 $0.00 $0.00 $0.00 $47.29 $168.39 $168.39 $0.00 $0.00 $47.28 $0.00 $134.20 $134.20 $0.00 $113.44 $179.69 $181.50 $0.00 $0.00 $35.51 $0.00 $0.00 $36.12 $0.00 $0.00 $0.00 $0.00 $0.00 70-4103L SUP HCPCS C1776 70-4103L - COMPONENT FEMORAL 3 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4103R SUP HCPCS C1776 70-4103R - COMPONENT FEMORAL 3 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4104L SUP HCPCS C1776 70-4104L - COMPONENT FEMORAL 4 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4104R SUP HCPCS C1776 70-4104R - COMPONENT FEMORAL 4 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4105L SUP HCPCS C1776 70-4105L - COMPONENT FEMORAL 5 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4105R SUP HCPCS C1776 70-4105R - COMPONENT FEMORAL 5 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4106L SUP HCPCS C1776 70-4106L - COMPONENT FEMORAL 6 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4106R SUP HCPCS C1776 70-4106R - COMPONENT FEMORAL 6 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4107L SUP HCPCS C1776 70-4107L - COMPONENT FEMORAL 7 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4107R SUP HCPCS C1776 70-4107R - COMPONENT FEMORAL 7 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4109L SUP HCPCS C1776 70-4109L - COMPONENT FEMORAL 9 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4109R SUP HCPCS C1776 70-4109R - COMPONENT FEMORAL 9 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4111L SUP HCPCS C1776 70-4111L - COMPONENT FEMORAL 11 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4111R SUP HCPCS C1776 70-4111R - COMPONENT FEMORAL 11 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4113L SUP HCPCS C1776 70-4113L - COMPONENT FEMORAL 13 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-4113R SUP HCPCS C1776 70-4113R - COMPONENT FEMORAL 13 CRUCIATE RETAIN CEMENTED WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 70-5003L SUP HCPCS C1776 70-5003L - CMPNT FEM 3 LEFT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,906.00 " "$3,630.44" $0.00 "$3,924.80" "$2,207.70" "$2,207.70" $0.00 $0.00 $0.00 "$1,022.53" "$3,641.23" "$3,641.23" $0.00 $0.00 "$1,022.41" $0.00 "$2,418.66" "$2,418.66" $0.00 "$2,453.00" "$3,885.55" "$3,924.80" $0.00 $0.00 $767.79 $0.00 $0.00 $781.04 $0.00 $0.00 $0.00 $0.00 $0.00 70-5003R SUP HCPCS C1776 70-5003R - CMPNT FEM 3 RIGHT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,906.00 " "$3,630.44" $0.00 "$3,924.80" "$2,207.70" "$2,207.70" $0.00 $0.00 $0.00 "$1,022.53" "$3,641.23" "$3,641.23" $0.00 $0.00 "$1,022.41" $0.00 "$2,418.66" "$2,418.66" $0.00 "$2,453.00" "$3,885.55" "$3,924.80" $0.00 $0.00 $767.79 $0.00 $0.00 $781.04 $0.00 $0.00 $0.00 $0.00 $0.00 70-5004L SUP HCPCS C1776 70-5004L - CMPNT FEM 4 LEFT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5004R SUP HCPCS C1776 70-5004R - CMPNT FEM 4 RIGHT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5005L SUP HCPCS C1776 70-5005L - CMPNT FEM 5 LEFT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5005R SUP HCPCS C1776 70-5005R - CMPNT FEM 5 RIGHT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5006L SUP HCPCS C1776 70-5006L - CMPNT FEM 6 LEFT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5006R SUP HCPCS C1776 70-5006R - CMPNT FEM 6 RIGHT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5007L SUP HCPCS C1776 70-5007L - CMPNT FEM 7 LEFT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5007R SUP HCPCS C1776 70-5007R - CMPNT FEM 7 RIGHT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5009L SUP HCPCS C1776 70-5009L - CMPNT FEM 9 LEFT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5009R SUP HCPCS C1776 70-5009R - CMPNT FEM 9 RIGHT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5011L SUP HCPCS C1776 70-5011L - CMPNT FEM 11 LEFT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5011R SUP HCPCS C1776 70-5011R - CMPNT FEM 11 RIGHT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,777.00 " "$3,534.98" $0.00 "$3,821.60" "$2,149.65" "$2,149.65" $0.00 $0.00 $0.00 $995.65 "$3,545.49" "$3,545.49" $0.00 $0.00 $995.53 $0.00 "$2,355.06" "$2,355.06" $0.00 "$2,388.50" "$3,783.38" "$3,821.60" $0.00 $0.00 $747.60 $0.00 $0.00 $760.50 $0.00 $0.00 $0.00 $0.00 $0.00 70-5013L SUP HCPCS C1776 70-5013L - CMPNT FEM 13 LEFT KNEE MCSTRCT CRUC RET NON LFIT SCRP BOTH IP/OP "$4,906.00 " "$3,630.44" $0.00 "$3,924.80" "$2,207.70" "$2,207.70" $0.00 $0.00 $0.00 "$1,022.53" "$3,641.23" "$3,641.23" $0.00 $0.00 "$1,022.41" $0.00 "$2,418.66" "$2,418.66" $0.00 "$2,453.00" "$3,885.55" "$3,924.80" $0.00 $0.00 $767.79 $0.00 $0.00 $781.04 $0.00 $0.00 $0.00 $0.00 $0.00 70-5013R SUP HCPCS C1776 70-5013R - CMPNT FEM 13 RIGHT KNEE CRUC RET MCSTRCT NON LFIT SCRP BOTH IP/OP "$4,906.00 " "$3,630.44" $0.00 "$3,924.80" "$2,207.70" "$2,207.70" $0.00 $0.00 $0.00 "$1,022.53" "$3,641.23" "$3,641.23" $0.00 $0.00 "$1,022.41" $0.00 "$2,418.66" "$2,418.66" $0.00 "$2,453.00" "$3,885.55" "$3,924.80" $0.00 $0.00 $767.79 $0.00 $0.00 $781.04 $0.00 $0.00 $0.00 $0.00 $0.00 70-5103L SUP HCPCS C1776 70-5103L - CMPNT FEM 3 LEFT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,647.00 " "$3,438.78" $0.00 "$3,717.60" "$2,091.15" "$2,091.15" $0.00 $0.00 $0.00 $968.55 "$3,449.00" "$3,449.00" $0.00 $0.00 $968.43 $0.00 "$2,290.97" "$2,290.97" $0.00 "$2,323.50" "$3,680.42" "$3,717.60" $0.00 $0.00 $727.26 $0.00 $0.00 $739.80 $0.00 $0.00 $0.00 $0.00 $0.00 70-5103R SUP HCPCS C1776 70-5103R - CMPNT FEM 3 RIGHT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,647.00 " "$3,438.78" $0.00 "$3,717.60" "$2,091.15" "$2,091.15" $0.00 $0.00 $0.00 $968.55 "$3,449.00" "$3,449.00" $0.00 $0.00 $968.43 $0.00 "$2,290.97" "$2,290.97" $0.00 "$2,323.50" "$3,680.42" "$3,717.60" $0.00 $0.00 $727.26 $0.00 $0.00 $739.80 $0.00 $0.00 $0.00 $0.00 $0.00 70-5104L SUP HCPCS C1776 70-5104L - CMPNT FEM 4 LEFT KNEE CRUC RET MCSTRCT LFIT SCRP BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5104R SUP HCPCS C1776 70-5104R - CMPNT FEM 4 RIGHT KNEE CRUC RET MCSTRCT LFIT SCRP BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5105L SUP HCPCS C1776 70-5105L - CMPNT FEM 5 LEFT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5105R SUP HCPCS C1776 70-5105R - CMPNT FEM 5 RIGHT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5106L SUP HCPCS C1776 70-5106L - CMPNT FEM 6 LEFT KNEE CRUC RET MCSTRCT LFIT SCRP BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5106R SUP HCPCS C1776 70-5106R - CMPNT FEM 6 RIGHT KNEE CRUC RET MCSTRCT LFIT SCRP BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5107L SUP HCPCS C1776 70-5107L - CMPNT FEM 7 LEFT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5107R SUP HCPCS C1776 70-5107R - CMPNT FEM 7 RIGHT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5109L SUP HCPCS C1776 70-5109L - CMPNT FEM 9 LEFT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5109R SUP HCPCS C1776 70-5109R - CMPNT FEM 9 RIGHT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5111L SUP HCPCS C1776 70-5111L - CMPNT FEM 11 LEFT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5111R SUP HCPCS C1776 70-5111R - CMPNT FEM 11 RIGHT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,565.00 " "$3,378.10" $0.00 "$3,652.00" "$2,054.25" "$2,054.25" $0.00 $0.00 $0.00 $951.46 "$3,388.14" "$3,388.14" $0.00 $0.00 $951.35 $0.00 "$2,250.55" "$2,250.55" $0.00 "$2,282.50" "$3,615.48" "$3,652.00" $0.00 $0.00 $714.42 $0.00 $0.00 $726.75 $0.00 $0.00 $0.00 $0.00 $0.00 70-5113L SUP HCPCS C1776 70-5113L - CMPNT FEM 13 LEFT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,647.00 " "$3,438.78" $0.00 "$3,717.60" "$2,091.15" "$2,091.15" $0.00 $0.00 $0.00 $968.55 "$3,449.00" "$3,449.00" $0.00 $0.00 $968.43 $0.00 "$2,290.97" "$2,290.97" $0.00 "$2,323.50" "$3,680.42" "$3,717.60" $0.00 $0.00 $727.26 $0.00 $0.00 $739.80 $0.00 $0.00 $0.00 $0.00 $0.00 70-5113R SUP HCPCS C1776 70-5113R - CMPNT FEM 13 RIGHT KNEE CRUC RET MCSTRCT SCRP LFIT BOTH IP/OP "$4,647.00 " "$3,438.78" $0.00 "$3,717.60" "$2,091.15" "$2,091.15" $0.00 $0.00 $0.00 $968.55 "$3,449.00" "$3,449.00" $0.00 $0.00 $968.43 $0.00 "$2,290.97" "$2,290.97" $0.00 "$2,323.50" "$3,680.42" "$3,717.60" $0.00 $0.00 $727.26 $0.00 $0.00 $739.80 $0.00 $0.00 $0.00 $0.00 $0.00 70-5203L SUP HCPCS C1776 70-5203L - COMPONENT FEMORAL 3 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5203R SUP HCPCS C1776 70-5203R - COMPONENT FEMORAL 3 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5205L SUP HCPCS C1776 70-5205L - COMPONENT FEMORAL 5 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5205R SUP HCPCS C1776 70-5205R - COMPONENT FEMORAL 5 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5207L SUP HCPCS C1776 70-5207L - COMPONENT FEMORAL 7 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5207R SUP HCPCS C1776 70-5207R - COMPONENT FEMORAL 7 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5209L SUP HCPCS C1776 70-5209L - COMPONENT FEMORAL 9 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5209R SUP HCPCS C1776 70-5209R - COMPONENT FEMORAL 9 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5211L SUP HCPCS C1776 70-5211L - COMPONENT FEMORAL 11 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5211R SUP HCPCS C1776 70-5211R - COMPONENT FEMORAL 11 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5213L SUP HCPCS C1776 70-5213L - COMPONENT FEMORAL 13 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 70-5213R SUP HCPCS C1776 70-5213R - COMPONENT FEMORAL 13 CRUCIATE RETAIN MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 7060-0000 SUP HCPCS C1713 7060-0000 - PLUG DOME HL HEX STRL LF TRDNT II DISP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 7066-24 SUP Custom 27203010 SPLINT ORTH UNV 24IN KNEE SUP PRFR FOAM BOTH IP/OP $44.23 $32.73 $0.00 $53.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.82 $32.82 $0.00 $0.00 $9.22 $0.00 $0.00 $0.00 $0.00 $33.43 $52.95 $53.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 709-04-42A SUP HCPCS C1776 709-04-42A - SHELL ACTB A 42MM STRL TRDNT II 8 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-44B SUP HCPCS C1776 709-04-44B - SHELL ACTB B 44MM STRL TRDNT II 8 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-46C SUP HCPCS C1776 709-04-46C - SHELL ACTB C 46MM STRL TRDNT II 8 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-48D SUP HCPCS C1776 709-04-48D - SHELL ACTB D 48MM STRL TRDNT II 9 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-50D SUP HCPCS C1776 709-04-50D - SHELL ACTB D 50MM STRL TRDNT II 9 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-52E SUP HCPCS C1776 709-04-52E - SHELL ACTB E 52MM STRL TRDNT II 11 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-54E SUP HCPCS C1776 709-04-54E - SHELL ACTB E 54MM STRL TRDNT II 11 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-56F SUP HCPCS C1776 709-04-56F - SHELL ACTB F 56MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-58F SUP HCPCS C1776 709-04-58F - SHELL ACTB F 58MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-60G SUP HCPCS C1776 709-04-60G - SHELL ACTB G 60MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-62G SUP HCPCS C1776 709-04-62G - SHELL ACTB G 62MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-64H SUP HCPCS C1776 709-04-64H - SHELL ACTB H 64MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-66H SUP HCPCS C1776 709-04-66H - SHELL ACTB H 66MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-68I SUP HCPCS C1776 709-04-68I - SHELL ACTB I 68MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-70I SUP HCPCS C1776 709-04-70I - SHELL ACTB I 70MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 709-04-72J SUP HCPCS C1776 709-04-72J - SHELL ACTB J 72MM STRL TRDNT II 13 HL TRITANIUM HIP BOTH IP/OP "$6,782.50 " "$5,019.05" $0.00 "$5,426.00" "$3,052.13" "$3,052.13" $0.00 $0.00 $0.00 "$1,413.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,413.47" $0.00 "$3,343.77" "$3,343.77" $0.00 "$3,391.25" "$5,371.74" "$5,426.00" $0.00 $0.00 "$1,061.46" $0.00 $0.00 "$1,079.77" $0.00 $0.00 $0.00 $0.00 $0.00 70-DO55 SUP HCPCS C1713 70-DO55 - PLATE STD BONE LEFT DISTAL RADL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 70XLTCD SUP Custom 27203010 70XLTCD - TUBE TRCH 39MM 49MM 12.3MM 7MM 100MM STRL LF 12MM SHLY XLT BOTH IP/OP $159.65 $118.14 $0.00 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.49 $118.49 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $81.02 $128.34 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 70XLTUP SUP Custom 27203010 70XLTUP - TUBE TRCH 39MM 34MM 12.3MM 7MM 100MM STRL LF 27MM SHLY XLT BOTH IP/OP $159.65 $118.14 $0.00 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.49 $118.49 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $81.02 $128.34 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 710.000.98S SUP HCPCS C1763 710.000.98S - SUBSTITUTE BNGFT XS VOID FILR GRANULES CHRONOS BTCP .5ML BOTH IP/OP $216.25 $160.03 $0.00 $173.00 $97.31 $97.31 $0.00 $0.00 $0.00 $45.07 $160.50 $160.50 $0.00 $0.00 $45.07 $0.00 $127.91 $127.91 $0.00 $108.13 $171.27 $173.00 $0.00 $0.00 $33.84 $0.00 $0.00 $34.43 $0.00 $0.00 $0.00 $0.00 $0.00 710.001.98S SUP HCPCS C1763 710.001.98S - SUBSTITUTE BNGFT SMALL .7-1.4MM VOID FILR GRANULES CHRONOS BOTH IP/OP $216.25 $160.03 $0.00 $173.00 $97.31 $97.31 $0.00 $0.00 $0.00 $45.07 $160.50 $160.50 $0.00 $0.00 $45.07 $0.00 $127.91 $127.91 $0.00 $108.13 $171.27 $173.00 $0.00 $0.00 $33.84 $0.00 $0.00 $34.43 $0.00 $0.00 $0.00 $0.00 $0.00 710.002.98S SUP HCPCS C1713 710.002.98S - CEMENT BONE .7-1.4MM/1CC GRANULES BETA-TRICALCIUM PHOSPHATE BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 710.003.98S SUP HCPCS C1763 710.003.98S - SUBSTITUTE BNGFT SMALL .7-1.4MM VOID FILR GRANULES CHRONOS BOTH IP/OP $887.50 $656.75 $0.00 $710.00 $399.38 $399.38 $0.00 $0.00 $0.00 $184.98 $658.70 $658.70 $0.00 $0.00 $184.96 $0.00 $524.96 $524.96 $0.00 $443.75 $702.90 $710.00 $0.00 $0.00 $138.89 $0.00 $0.00 $141.29 $0.00 $0.00 $0.00 $0.00 $0.00 710.011.98S SUP HCPCS C1763 710.011.98S - SUBSTITUTE BNGFT MEDIUM 1.4-2.8MM VOID FILR GRANULES CHRONOS BOTH IP/OP $887.50 $656.75 $0.00 $710.00 $399.38 $399.38 $0.00 $0.00 $0.00 $184.98 $658.70 $658.70 $0.00 $0.00 $184.96 $0.00 $524.96 $524.96 $0.00 $443.75 $702.90 $710.00 $0.00 $0.00 $138.89 $0.00 $0.00 $141.29 $0.00 $0.00 $0.00 $0.00 $0.00 710.014.98S SUP HCPCS C1763 710.014.98S - SUBSTITUTE BNGFT MEDIUM 1.4-2.8MM VOID FILR GRANULES CHRONOS BOTH IP/OP "$1,242.50 " $919.45 $0.00 $994.00 $559.13 $559.13 $0.00 $0.00 $0.00 $258.97 $922.18 $922.18 $0.00 $0.00 $258.94 $0.00 $734.94 $734.94 $0.00 $621.25 $984.06 $994.00 $0.00 $0.00 $194.45 $0.00 $0.00 $197.81 $0.00 $0.00 $0.00 $0.00 $0.00 710.019.97S SUP HCPCS C1713 710.019.97S - SUBSTITUTE BNGFT 1.4-2.8MM CHRNS MED BTCP VOID BOTH IP/OP "$1,849.95 " "$1,368.96" $0.00 "$1,436.86" $808.23 $808.23 $0.00 $0.00 $0.00 $385.58 "$1,373.03" "$1,373.03" $0.00 $0.00 $385.53 $0.00 "$1,094.25" "$1,094.25" $0.00 $898.04 "$1,422.50" "$1,436.86" $0.00 $0.00 $272.90 $0.00 $0.00 $285.94 $0.00 $0.00 $0.00 $0.00 $0.00 710.021.97S SUP HCPCS C1713 710.021.97S - SUBSTITUTE BNGFT 1.4-2.8MM CHRNS MED BTCP VOID BOTH IP/OP "$2,641.65 " "$1,954.82" $0.00 "$2,051.76" "$1,154.12" "$1,154.12" $0.00 $0.00 $0.00 $550.59 "$1,960.63" "$1,960.63" $0.00 $0.00 $550.52 $0.00 "$1,302.33" "$1,302.33" $0.00 "$1,282.35" "$2,031.24" "$2,051.76" $0.00 $0.00 $389.69 $0.00 $0.00 $408.30 $0.00 $0.00 $0.00 $0.00 $0.00 710.042.98S SUP HCPCS C1763 710.042.98S - SUBSTITUTE BNGFT 10X5X5MM VOID FILR BLOCK CHRONOS BTCP BOTH IP/OP $672.50 $497.65 $0.00 $538.00 $302.63 $302.63 $0.00 $0.00 $0.00 $140.17 $499.13 $499.13 $0.00 $0.00 $140.15 $0.00 $397.78 $397.78 $0.00 $336.25 $532.62 $538.00 $0.00 $0.00 $105.25 $0.00 $0.00 $107.06 $0.00 $0.00 $0.00 $0.00 $0.00 710.045.97S SUP HCPCS C1763 710.045.97S - SUBSTITUTE BNGFT 12.5X12.5X10MM VOID FILR BLOCK BOTH IP/OP $924.98 $684.49 $0.00 $718.42 $404.11 $404.11 $0.00 $0.00 $0.00 $192.79 $686.52 $686.52 $0.00 $0.00 $192.76 $0.00 $547.12 $547.12 $0.00 $449.01 $711.24 $718.42 $0.00 $0.00 $136.45 $0.00 $0.00 $142.97 $0.00 $0.00 $0.00 $0.00 $0.00 710.047.97S SUP HCPCS C1763 710.047.97S - SUBSTITUTE BNGFT 20X20X10MM VOID FILR BLOCK OSTEOCONDUCTIVE BOTH IP/OP "$1,818.13 " "$1,345.42" $0.00 "$1,412.14" $794.33 $794.33 $0.00 $0.00 $0.00 $378.94 "$1,349.41" "$1,349.41" $0.00 $0.00 $378.90 $0.00 "$1,075.42" "$1,075.42" $0.00 $882.59 "$1,398.02" "$1,412.14" $0.00 $0.00 $268.20 $0.00 $0.00 $281.02 $0.00 $0.00 $0.00 $0.00 $0.00 710.047.98S SUP HCPCS C1763 710.047.98S - SUBSTITUTE BNGFT 20X20X10MM VOID FILR BLOCK CHRONOS BETA BOTH IP/OP "$2,355.00 " "$1,742.70" $0.00 "$1,884.00" "$1,059.75" "$1,059.75" $0.00 $0.00 $0.00 $490.84 "$1,747.88" "$1,747.88" $0.00 $0.00 $490.78 $0.00 "$1,392.98" "$1,392.98" $0.00 "$1,177.50" "$1,865.16" "$1,884.00" $0.00 $0.00 $368.56 $0.00 $0.00 $374.92 $0.00 $0.00 $0.00 $0.00 $0.00 710.050.97S SUP HCPCS C1763 710.050.97S - SUBSTITUTE BNGFT 10D RECTANGLE 25X20X6.5MM VOID FILR WEDGE BOTH IP/OP "$1,838.00 " "$1,360.12" $0.00 "$1,427.58" $803.01 $803.01 $0.00 $0.00 $0.00 $383.09 "$1,364.16" "$1,364.16" $0.00 $0.00 $383.04 $0.00 "$1,087.18" "$1,087.18" $0.00 $892.24 "$1,413.31" "$1,427.58" $0.00 $0.00 $271.14 $0.00 $0.00 $284.09 $0.00 $0.00 $0.00 $0.00 $0.00 710.050.98S SUP HCPCS C1713 710.050.98S - SUBSTITUTE BNGFT 10D RECTANGLE 25X20MM WEDGE CHRONOS BTCP BOTH IP/OP "$2,380.00 " "$1,761.20" $0.00 "$1,904.00" "$1,071.00" "$1,071.00" $0.00 $0.00 $0.00 $496.05 "$1,766.44" "$1,766.44" $0.00 $0.00 $495.99 $0.00 "$1,407.77" "$1,407.77" $0.00 "$1,190.00" "$1,884.96" "$1,904.00" $0.00 $0.00 $372.47 $0.00 $0.00 $378.90 $0.00 $0.00 $0.00 $0.00 $0.00 710.051.97S SUP HCPCS C1763 710.051.97S - SUBSTITUTE BNGFT 14D RECTANGLE 25X20X8MM VOID FILR WEDGE BOTH IP/OP "$1,937.48 " "$1,433.74" $0.00 "$1,504.84" $846.47 $846.47 $0.00 $0.00 $0.00 $403.82 "$1,437.99" "$1,437.99" $0.00 $0.00 $403.77 $0.00 "$1,146.02" "$1,146.02" $0.00 $940.53 "$1,489.79" "$1,504.84" $0.00 $0.00 $285.81 $0.00 $0.00 $299.46 $0.00 $0.00 $0.00 $0.00 $0.00 710.052.97S SUP HCPCS C1763 710.052.97S - SUBSTITUTE BNGFT 18D RECTANGULAR 25X20X10MM VOID FILR WEDGE BOTH IP/OP "$2,058.80 " "$1,523.51" $0.00 "$1,599.08" $899.48 $899.48 $0.00 $0.00 $0.00 $429.11 "$1,528.04" "$1,528.04" $0.00 $0.00 $429.05 $0.00 "$1,217.78" "$1,217.78" $0.00 $999.43 "$1,583.09" "$1,599.08" $0.00 $0.00 $303.71 $0.00 $0.00 $318.22 $0.00 $0.00 $0.00 $0.00 $0.00 710.053.97S SUP HCPCS C1763 710.053.97S - SUBSTITUTE BNGFT 22D RECTANGLE 25X20X12MM VOID FILR WEDGE BOTH IP/OP "$2,170.20 " "$1,605.95" $0.00 "$1,685.60" $948.15 $948.15 $0.00 $0.00 $0.00 $452.32 "$1,610.72" "$1,610.72" $0.00 $0.00 $452.27 $0.00 "$1,283.67" "$1,283.67" $0.00 "$1,053.50" "$1,668.74" "$1,685.60" $0.00 $0.00 $320.14 $0.00 $0.00 $335.43 $0.00 $0.00 $0.00 $0.00 $0.00 710.057.97S SUP HCPCS C1763 710.057.97S - SUBSTITUTE BNGFT 7D SEMICIRCLE 35X25X7MM VOID FILR WEDGE BOTH IP/OP "$2,170.20 " "$1,605.95" $0.00 "$1,685.60" $948.15 $948.15 $0.00 $0.00 $0.00 $452.32 "$1,610.72" "$1,610.72" $0.00 $0.00 $452.27 $0.00 "$1,283.67" "$1,283.67" $0.00 "$1,053.50" "$1,668.74" "$1,685.60" $0.00 $0.00 $320.14 $0.00 $0.00 $335.43 $0.00 $0.00 $0.00 $0.00 $0.00 710.057.98S SUP HCPCS C1763 710.057.98S - SUBSTITUTE BNGFT 7D VOID FILR WEDGE SEMICIRCULAR CHRONOS BOTH IP/OP "$2,810.00 " "$2,079.40" $0.00 "$2,248.00" "$1,264.50" "$1,264.50" $0.00 $0.00 $0.00 $585.67 "$2,085.58" "$2,085.58" $0.00 $0.00 $585.60 $0.00 "$1,385.33" "$1,385.33" $0.00 "$1,405.00" "$2,225.52" "$2,248.00" $0.00 $0.00 $439.77 $0.00 $0.00 $447.35 $0.00 $0.00 $0.00 $0.00 $0.00 710.060.97S SUP HCPCS C1763 710.060.97S - SUBSTITUTE BNGFT 10D VOID FILR WEDGE ANGLED SEMICIRCULAR BOTH IP/OP "$2,245.80 " "$1,661.89" $0.00 "$1,744.30" $981.17 $981.17 $0.00 $0.00 $0.00 $468.08 "$1,666.83" "$1,666.83" $0.00 $0.00 $468.02 $0.00 "$1,328.39" "$1,328.39" $0.00 "$1,090.19" "$1,726.86" "$1,744.30" $0.00 $0.00 $331.29 $0.00 $0.00 $347.12 $0.00 $0.00 $0.00 $0.00 $0.00 710.063.97S SUP HCPCS C1763 710.063.97S - SUBSTITUTE BNGFT 13D SEMICIRCLE 35X25X13MM WEDGE BOTH IP/OP "$2,355.20 " "$1,742.85" $0.00 "$1,829.28" "$1,028.97" "$1,028.97" $0.00 $0.00 $0.00 $490.88 "$1,748.03" "$1,748.03" $0.00 $0.00 $490.82 $0.00 "$1,393.10" "$1,393.10" $0.00 "$1,143.30" "$1,810.99" "$1,829.28" $0.00 $0.00 $347.43 $0.00 $0.00 $364.03 $0.00 $0.00 $0.00 $0.00 $0.00 71063108S SUP HCPCS C1713 71063108S - PIN HLF 3MM 10MM JTX TI NTRD BOTH IP/OP $424.00 $313.76 $0.00 $339.20 $190.80 $190.80 $0.00 $0.00 $0.00 $88.37 $314.69 $314.69 $0.00 $0.00 $88.36 $0.00 $250.80 $250.80 $0.00 $212.00 $335.81 $339.20 $0.00 $0.00 $66.36 $0.00 $0.00 $67.50 $0.00 $0.00 $0.00 $0.00 $0.00 71063158S SUP HCPCS C1713 71063158S - PIN HLF 3MM 15MM JTX TI NTRD BOTH IP/OP $424.00 $313.76 $0.00 $339.20 $190.80 $190.80 $0.00 $0.00 $0.00 $88.37 $314.69 $314.69 $0.00 $0.00 $88.36 $0.00 $250.80 $250.80 $0.00 $212.00 $335.81 $339.20 $0.00 $0.00 $66.36 $0.00 $0.00 $67.50 $0.00 $0.00 $0.00 $0.00 $0.00 71063208S SUP HCPCS C1713 71063208S - PIN HLF 3MM 20MM JTX TI NTRD BOTH IP/OP $424.00 $313.76 $0.00 $339.20 $190.80 $190.80 $0.00 $0.00 $0.00 $88.37 $314.69 $314.69 $0.00 $0.00 $88.36 $0.00 $250.80 $250.80 $0.00 $212.00 $335.81 $339.20 $0.00 $0.00 $66.36 $0.00 $0.00 $67.50 $0.00 $0.00 $0.00 $0.00 $0.00 71063258S SUP HCPCS C1713 71063258S - PIN HLF 3MM 25MM JTX TI NTRD BOTH IP/OP $424.00 $313.76 $0.00 $339.20 $190.80 $190.80 $0.00 $0.00 $0.00 $88.37 $314.69 $314.69 $0.00 $0.00 $88.36 $0.00 $250.80 $250.80 $0.00 $212.00 $335.81 $339.20 $0.00 $0.00 $66.36 $0.00 $0.00 $67.50 $0.00 $0.00 $0.00 $0.00 $0.00 71064158S SUP HCPCS C1713 71064158S - PIN HLF 4MM 15MM JTX TI NTRD BOTH IP/OP $456.00 $337.44 $0.00 $364.80 $205.20 $205.20 $0.00 $0.00 $0.00 $95.04 $338.44 $338.44 $0.00 $0.00 $95.03 $0.00 $269.72 $269.72 $0.00 $228.00 $361.15 $364.80 $0.00 $0.00 $71.36 $0.00 $0.00 $72.60 $0.00 $0.00 $0.00 $0.00 $0.00 71064208S SUP HCPCS C1713 71064208S - PIN HLF 4MM 20MM JTX TI NTRD BOTH IP/OP $456.00 $337.44 $0.00 $364.80 $205.20 $205.20 $0.00 $0.00 $0.00 $95.04 $338.44 $338.44 $0.00 $0.00 $95.03 $0.00 $269.72 $269.72 $0.00 $228.00 $361.15 $364.80 $0.00 $0.00 $71.36 $0.00 $0.00 $72.60 $0.00 $0.00 $0.00 $0.00 $0.00 71064258S SUP HCPCS C1713 71064258S - PIN HLF 4MM 25MM JTX TI NTRD BOTH IP/OP $456.00 $337.44 $0.00 $364.80 $205.20 $205.20 $0.00 $0.00 $0.00 $95.04 $338.44 $338.44 $0.00 $0.00 $95.03 $0.00 $269.72 $269.72 $0.00 $228.00 $361.15 $364.80 $0.00 $0.00 $71.36 $0.00 $0.00 $72.60 $0.00 $0.00 $0.00 $0.00 $0.00 71064308S SUP HCPCS C1713 71064308S - PIN HLF 4MM 30MM JTX TI NTRD BOTH IP/OP $456.00 $337.44 $0.00 $364.80 $205.20 $205.20 $0.00 $0.00 $0.00 $95.04 $338.44 $338.44 $0.00 $0.00 $95.03 $0.00 $269.72 $269.72 $0.00 $228.00 $361.15 $364.80 $0.00 $0.00 $71.36 $0.00 $0.00 $72.60 $0.00 $0.00 $0.00 $0.00 $0.00 71064358S SUP HCPCS C1713 71064358S - PIN HLF 4MM 35MM JTX TI NTRD BOTH IP/OP $456.00 $337.44 $0.00 $364.80 $205.20 $205.20 $0.00 $0.00 $0.00 $95.04 $338.44 $338.44 $0.00 $0.00 $95.03 $0.00 $269.72 $269.72 $0.00 $228.00 $361.15 $364.80 $0.00 $0.00 $71.36 $0.00 $0.00 $72.60 $0.00 $0.00 $0.00 $0.00 $0.00 7106-5300 SUP HCPCS C1713 7106-5300 - PIN HLF SHRT 5MM 30MM ORTH BOTH IP/OP $608.00 $449.92 $0.00 $486.40 $273.60 $273.60 $0.00 $0.00 $0.00 $126.72 $451.26 $451.26 $0.00 $0.00 $126.71 $0.00 $359.63 $359.63 $0.00 $304.00 $481.54 $486.40 $0.00 $0.00 $95.15 $0.00 $0.00 $96.79 $0.00 $0.00 $0.00 $0.00 $0.00 71065304S SUP HCPCS C1713 71065304S - PIN HLF XSH 5MM 30MM STRL JTX TI NTRD BOTH IP/OP $584.00 $432.16 $0.00 $467.20 $262.80 $262.80 $0.00 $0.00 $0.00 $121.72 $433.44 $433.44 $0.00 $0.00 $121.71 $0.00 $345.44 $345.44 $0.00 $292.00 $462.53 $467.20 $0.00 $0.00 $91.40 $0.00 $0.00 $92.97 $0.00 $0.00 $0.00 $0.00 $0.00 71065308S SUP HCPCS C1713 71065308S - PIN HLF SHRT 5MM 30MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065309S SUP HCPCS C1713 71065309S - PIN HLF LNG 5MM 30MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065354S SUP HCPCS C1713 71065354S - PIN HLF XSH 5MM 35MM STRL JTX TI NTRD BOTH IP/OP $556.00 $411.44 $0.00 $444.80 $250.20 $250.20 $0.00 $0.00 $0.00 $115.88 $412.66 $412.66 $0.00 $0.00 $115.87 $0.00 $328.87 $328.87 $0.00 $278.00 $440.35 $444.80 $0.00 $0.00 $87.01 $0.00 $0.00 $88.52 $0.00 $0.00 $0.00 $0.00 $0.00 71065358S SUP HCPCS C1713 71065358S - PIN HLF SHRT 5MM 35MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065359S SUP HCPCS C1713 71065359S - PIN HLF LNG 5MM 35MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065404S SUP HCPCS C1713 71065404S - PIN HLF XSH 5MM 40MM STRL JTX TI NTRD BOTH IP/OP $584.00 $432.16 $0.00 $467.20 $262.80 $262.80 $0.00 $0.00 $0.00 $121.72 $433.44 $433.44 $0.00 $0.00 $121.71 $0.00 $345.44 $345.44 $0.00 $292.00 $462.53 $467.20 $0.00 $0.00 $91.40 $0.00 $0.00 $92.97 $0.00 $0.00 $0.00 $0.00 $0.00 71065407S SUP HCPCS C1713 71065407S - PIN HLF XSH 1.6MM 40MM STRL JTX CNN TI NTRD BOTH IP/OP $790.00 $584.60 $0.00 $632.00 $355.50 $355.50 $0.00 $0.00 $0.00 $164.66 $586.34 $586.34 $0.00 $0.00 $164.64 $0.00 $467.29 $467.29 $0.00 $395.00 $625.68 $632.00 $0.00 $0.00 $123.64 $0.00 $0.00 $125.77 $0.00 $0.00 $0.00 $0.00 $0.00 71065408S SUP HCPCS C1713 71065408S - PIN HLF SHRT 5MM 40MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065409S SUP HCPCS C1713 71065409S - PIN HLF LNG 5MM 40MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065454S SUP HCPCS C1713 71065454S - PIN HLF XSH 5MM 45MM STRL JTX TI NTRD BOTH IP/OP $556.00 $411.44 $0.00 $444.80 $250.20 $250.20 $0.00 $0.00 $0.00 $115.88 $412.66 $412.66 $0.00 $0.00 $115.87 $0.00 $328.87 $328.87 $0.00 $278.00 $440.35 $444.80 $0.00 $0.00 $87.01 $0.00 $0.00 $88.52 $0.00 $0.00 $0.00 $0.00 $0.00 71065458S SUP HCPCS C1713 71065458S - PIN HLF SHRT 5MM 45MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065459S SUP HCPCS C1713 71065459S - PIN HLF LNG 5MM 45MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065507S SUP HCPCS C1713 71065507S - PIN HLF 5MM 50MM STRL JTX TRC TI NTRD BOTH IP/OP "$1,132.00 " $837.68 $0.00 $905.60 $509.40 $509.40 $0.00 $0.00 $0.00 $235.94 $840.17 $840.17 $0.00 $0.00 $235.91 $0.00 $669.58 $669.58 $0.00 $566.00 $896.54 $905.60 $0.00 $0.00 $177.16 $0.00 $0.00 $180.21 $0.00 $0.00 $0.00 $0.00 $0.00 71065508S SUP HCPCS C1713 71065508S - PIN HLF SHRT 5MM 50MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065509S SUP HCPCS C1713 71065509S - PIN HLF LNG 5MM 50MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065558S SUP HCPCS C1713 71065558S - PIN HLF SHRT 5MM 55MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065559S SUP HCPCS C1713 71065559S - PIN HLF LNG 5MM 55MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065608S SUP HCPCS C1713 71065608S - PIN HLF SHRT 5MM 60MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065609S SUP HCPCS C1713 71065609S - PIN HLF LNG 5MM 60MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065658S SUP HCPCS C1713 71065658S - PIN HLF SHRT 5MM 65MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065659S SUP HCPCS C1713 71065659S - PIN HLF LNG 5MM 65MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065708S SUP HCPCS C1713 71065708S - PIN HLF SHRT 5MM 70MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71065709S SUP HCPCS C1713 71065709S - PIN HLF LNG 5MM 70MM STRL JTX TI NTRD BOTH IP/OP $618.00 $457.32 $0.00 $494.40 $278.10 $278.10 $0.00 $0.00 $0.00 $128.81 $458.68 $458.68 $0.00 $0.00 $128.79 $0.00 $365.55 $365.55 $0.00 $309.00 $489.46 $494.40 $0.00 $0.00 $96.72 $0.00 $0.00 $98.39 $0.00 $0.00 $0.00 $0.00 $0.00 71066409S SUP HCPCS C1713 71066409S - PIN HLF LNG 6MM 40MM STRL JTX TI NTRD BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71066459S SUP HCPCS C1713 71066459S - PIN HLF LNG 6MM 45MM STRL JTX TI NTRD BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71066509S SUP HCPCS C1713 71066509S - PIN HLF LNG 6MM 50MM STRL JTX TI NTRD BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71066559S SUP HCPCS C1713 71066559S - PIN HLF LNG 6MM 55MM STRL JTX TI NTRD BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 71066609S SUP HCPCS C1713 71066609S - PIN HLF LNG 6MM 60MM JTX TI NTRD BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $143.33 $143.33 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 71070115X SUP Custom 27011340 71070115X - RING EXFIX 180MM FULL CIR FT TLT SP BOTH IP/OP "$3,468.00 " "$2,566.32" $0.00 "$2,774.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,573.95" "$2,573.95" $0.00 $0.00 $722.73 $0.00 $0.00 $0.00 $0.00 "$1,734.00" "$2,746.66" "$2,774.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71071306X SUP HCPCS C1713 71071306X - RING XTRNFX 2/3 155MM BOTH IP/OP "$3,315.00 " "$2,453.10" $0.00 "$2,652.00" "$1,491.75" "$1,491.75" $0.00 $0.00 $0.00 $690.93 "$2,460.39" "$2,460.39" $0.00 $0.00 $690.85 $0.00 "$1,634.30" "$1,634.30" $0.00 "$1,657.50" "$2,625.48" "$2,652.00" $0.00 $0.00 $518.80 $0.00 $0.00 $527.75 $0.00 $0.00 $0.00 $0.00 $0.00 71101545S SUP HCPCS C1713 71101545S - WASHER ORTH 6MM STRL BOTH IP/OP $109.00 $80.66 $0.00 $87.20 $49.05 $49.05 $0.00 $0.00 $0.00 $22.72 $80.90 $80.90 $0.00 $0.00 $22.72 $0.00 $64.47 $64.47 $0.00 $54.50 $86.33 $87.20 $0.00 $0.00 $17.06 $0.00 $0.00 $17.35 $0.00 $0.00 $0.00 $0.00 $0.00 71101690S SUP HCPCS C1713 71101690S - WASHER ORTH 12.7MM RND BOTH IP/OP $132.30 $97.90 $0.00 $105.84 $59.54 $59.54 $0.00 $0.00 $0.00 $27.57 $98.19 $98.19 $0.00 $0.00 $27.57 $0.00 $78.26 $78.26 $0.00 $66.15 $104.78 $105.84 $0.00 $0.00 $20.70 $0.00 $0.00 $21.06 $0.00 $0.00 $0.00 $0.00 $0.00 71101693S SUP HCPCS C1713 71101693S - WASHER ORTH 21.7MM STRL BTRFLY SS LG CNN SCR SYS BOTH IP/OP $219.45 $162.39 $0.00 $175.56 $98.75 $98.75 $0.00 $0.00 $0.00 $45.74 $162.88 $162.88 $0.00 $0.00 $45.73 $0.00 $129.80 $129.80 $0.00 $109.73 $173.80 $175.56 $0.00 $0.00 $34.34 $0.00 $0.00 $34.94 $0.00 $0.00 $0.00 $0.00 $0.00 71103000S SUP HCPCS C1713 71103000S - WASHER ORTH 12.7MM RND TI BOTH IP/OP $77.13 $57.08 $0.00 $61.70 $34.71 $34.71 $0.00 $0.00 $0.00 $16.07 $57.24 $57.24 $0.00 $0.00 $16.07 $0.00 $45.62 $45.62 $0.00 $38.56 $61.09 $61.70 $0.00 $0.00 $12.07 $0.00 $0.00 $12.28 $0.00 $0.00 $0.00 $0.00 $0.00 71103003S SUP HCPCS C1713 71103003S - WASHER ORTH 21.7MM BTRFLY TI BOTH IP/OP $527.10 $390.05 $0.00 $421.68 $237.20 $237.20 $0.00 $0.00 $0.00 $109.86 $391.21 $391.21 $0.00 $0.00 $109.85 $0.00 $311.78 $311.78 $0.00 $263.55 $417.46 $421.68 $0.00 $0.00 $82.49 $0.00 $0.00 $83.91 $0.00 $0.00 $0.00 $0.00 $0.00 71106230S SUP HCPCS C1713 71106230S - SCREW BN FT 6.5MM 30MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106235S SUP HCPCS C1713 71106235S - SCREW BN FT 6.5MM 35MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106240S SUP HCPCS C1713 71106240S - SCREW BN FT 6.5MM 40MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106245S SUP HCPCS C1713 71106245S - SCREW BN FT 6.5MM 45MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106250S SUP HCPCS C1713 71106250S - SCREW BN FT 6.5MM 50MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106255S SUP HCPCS C1713 71106255S - SCREW BN FT 6.5MM 55MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106260S SUP HCPCS C1713 71106260S - SCREW BN FT 6.5MM 60MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106265S SUP HCPCS C1713 71106265S - SCREW BN FT 6.5MM 65MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106270S SUP HCPCS C1713 71106270S - SCREW BN FT 6.5MM 70MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106275S SUP HCPCS C1713 71106275S - SCREW BN FT 6.5MM 75MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106280S SUP HCPCS C1713 71106280S - SCREW BN FT 6.5MM 80MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106285S SUP HCPCS C1713 71106285S - SCREW BN 6.5MM 85MM CNN FT SS BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106290S SUP HCPCS C1713 71106290S - SCREW BN FT 6.5MM 90MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106295S SUP HCPCS C1713 71106295S - SCREW BN FT 6.5MM 95MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106300S SUP HCPCS C1713 71106300S - SCREW BN FT 6.5MM 100MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106305S SUP HCPCS C1713 71106305S - SCREW BN FT 6.5MM 105MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106310S SUP HCPCS C1713 71106310S - SCREW BN FT 6.5MM 110MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106315S SUP HCPCS C1713 71106315S - SCREW BN FT 6.5MM 115MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106320S SUP HCPCS C1713 71106320S - SCREW BN FT 6.5MM 120MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106325S SUP HCPCS C1713 71106325S - SCREW BN FT 6.5MM 125MM STRL CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106330S SUP HCPCS C1713 71106330S - SCREW BN FT 6.5MM 130MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106335S SUP HCPCS C1713 71106335S - SCREW BN FT 6.5MM 135MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106340S SUP HCPCS C1713 71106340S - SCREW BN FT 6.5MM 140MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106345S SUP HCPCS C1713 71106345S - SCREW BN FT 6.5MM 145MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106350S SUP HCPCS C1713 71106350S - SCREW BN FT 6.5MM 150MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106355S SUP HCPCS C1713 71106355S - SCREW BN FT 6.5MM 155MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106360S SUP HCPCS C1713 71106360S - SCREW BN FT 6.5MM 160MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106365S SUP HCPCS C1713 71106365S - SCREW BN FT 6.5MM 165MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106370S SUP HCPCS C1713 71106370S - SCREW BN FT 6.5MM 170MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106375S SUP HCPCS C1713 71106375S - SCREW BN FT 6.5MM 175MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106380S SUP HCPCS C1713 71106380S - SCREW BN FT 6.5MM 180MM STRL CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106530S SUP HCPCS C1713 71106530S - SCREW BN 6.5MM 30MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106535S SUP HCPCS C1713 71106535S - SCREW BN 6.5MM 35MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106540S SUP HCPCS C1713 71106540S - SCREW BN 6.5MM 40MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106545S SUP HCPCS C1713 71106545S - SCREW BN 6.5MM 45MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106550S SUP HCPCS C1713 71106550S - SCREW BN 6.5MM 50MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106555S SUP HCPCS C1713 71106555S - SCREW BN 6.5MM 55MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106560S SUP HCPCS C1713 71106560S - SCREW BN 6.5MM 60MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106565S SUP HCPCS C1713 71106565S - SCREW BN 6.5MM 65MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106570S SUP HCPCS C1713 71106570S - SCREW BN 6.5MM 70MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106575S SUP HCPCS C1713 71106575S - SCREW BN 6.5MM 75MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106580S SUP HCPCS C1713 71106580S - SCREW BN 6.5MM 80MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106585S SUP HCPCS C1713 71106585S - SCREW BN 6.5MM 85MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106590S SUP HCPCS C1713 71106590S - SCREW BN 6.5MM 90MM STRL 22MM CNN SS ORTH BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106595S SUP HCPCS C1713 71106595S - SCREW BN 6.5MM 95MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106600S SUP HCPCS C1713 71106600S - SCREW BN 6.5MM 100MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106605S SUP HCPCS C1713 71106605S - SCREW BN 6.5MM 105MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106610S SUP HCPCS C1713 71106610S - SCREW BN 6.5MM 110MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106615S SUP HCPCS C1713 71106615S - SCREW BN 6.5MM 115MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106620S SUP HCPCS C1713 71106620S - SCREW BN 6.5MM 120MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106625S SUP HCPCS C1713 71106625S - SCREW BN 6.5MM 125MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106630S SUP HCPCS C1713 71106630S - SCREW BN 6.5MM 130MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106635S SUP HCPCS C1713 71106635S - SCREW BN 6.5MM 135MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106640S SUP HCPCS C1713 71106640S - SCREW BN 6.5MM 140MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106645S SUP HCPCS C1713 71106645S - SCREW BN 6.5MM 145MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106650S SUP HCPCS C1713 71106650S - SCREW BN 6.5MM 150MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106655S SUP HCPCS C1713 71106655S - SCREW BN 6.5MM 155MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106660S SUP HCPCS C1713 71106660S - SCREW BN 6.5MM 160MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106665S SUP HCPCS C1713 71106665S - SCREW BN 6.5MM 165MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106670S SUP HCPCS C1713 71106670S - SCREW BN 6.5MM 170MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106675S SUP HCPCS C1713 71106675S - SCREW BN 6.5MM 175MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106680S SUP HCPCS C1713 71106680S - SCREW BN 6.5MM 180MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106755S SUP HCPCS C1713 71106755S - SCREW BN 6.5MM 55MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106760S SUP HCPCS C1713 71106760S - SCREW BN 6.5MM 60MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106765S SUP HCPCS C1713 71106765S - SCREW BN 6.5MM 65MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106770S SUP HCPCS C1713 71106770S - SCREW BN 6.5MM 70MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106775S SUP HCPCS C1713 71106775S - SCREW BN 6.5MM 75MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106780S SUP HCPCS C1713 71106780S - SCREW BN 6.5MM 80MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106785S SUP HCPCS C1713 71106785S - SCREW BN 6.5MM 85MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106790S SUP HCPCS C1713 71106790S - SCREW BN 6.5MM 90MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106795S SUP HCPCS C1713 71106795S - SCREW BN 6.5MM 95MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106800S SUP HCPCS C1713 71106800S - SCREW BN 6.5MM 100MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106805S SUP HCPCS C1713 71106805S - SCREW BN 6.5MM 105MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106810S SUP HCPCS C1713 71106810S - SCREW BN 6.5MM 110MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106815S SUP HCPCS C1713 71106815S - SCREW BN 6.5MM 115MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106820S SUP HCPCS C1713 71106820S - SCREW BN 6.5MM 120MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106825S SUP HCPCS C1713 71106825S - SCREW BN 6.5MM 125MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $435.75 $322.46 $0.00 $348.60 $196.09 $196.09 $0.00 $0.00 $0.00 $90.82 $323.41 $323.41 $0.00 $0.00 $90.81 $0.00 $257.75 $257.75 $0.00 $217.88 $345.11 $348.60 $0.00 $0.00 $68.19 $0.00 $0.00 $69.37 $0.00 $0.00 $0.00 $0.00 $0.00 71106830S SUP HCPCS C1713 71106830S - SCREW BN 6.5MM 130MM STRL 40MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106835S SUP HCPCS C1713 71106835S - SCREW BN 6.5MM 135MM STRL 40MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106840S SUP HCPCS C1713 71106840S - SCREW BN 6.5MM 140MM STRL 40MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106845S SUP HCPCS C1713 71106845S - SCREW BN 6.5MM 145MM STRL 40MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106850S SUP HCPCS C1713 71106850S - SCREW BN 6.5MM 150MM STRL 40MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106855S SUP HCPCS C1713 71106855S - SCREW BN 6.5MM 155MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106860S SUP HCPCS C1713 71106860S - SCREW BN 6.5MM 160MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106865S SUP HCPCS C1713 71106865S - SCREW BN 6.5MM 165MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106870S SUP HCPCS C1713 71106870S - SCREW BN 6.5MM 170MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106875S SUP HCPCS C1713 71106875S - SCREW BN 6.5MM 175MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71106880S SUP HCPCS C1713 71106880S - SCREW BN 6.5MM 180MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $502.95 $372.18 $0.00 $402.36 $226.33 $226.33 $0.00 $0.00 $0.00 $104.83 $373.29 $373.29 $0.00 $0.00 $104.81 $0.00 $297.49 $297.49 $0.00 $251.48 $398.34 $402.36 $0.00 $0.00 $78.71 $0.00 $0.00 $80.07 $0.00 $0.00 $0.00 $0.00 $0.00 71107230S SUP HCPCS C1713 71107230S - SCREW BN 6.5MM 30MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107235S SUP HCPCS C1713 71107235S - SCREW BN 6.5MM 35MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107240S SUP HCPCS C1713 71107240S - SCREW BN 6.5MM 40MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107245S SUP HCPCS C1713 71107245S - SCREW BN 6.5MM 45MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107250S SUP HCPCS C1713 71107250S - SCREW BN 6.5MM 50MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107255S SUP HCPCS C1713 71107255S - SCREW BN 6.5MM 55MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107260S SUP HCPCS C1713 71107260S - SCREW BN 6.5MM 60MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107265S SUP HCPCS C1713 71107265S - SCREW BN 6.5MM 65MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107270S SUP HCPCS C1713 71107270S - SCREW BN 6.5MM 70MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107275S SUP HCPCS C1713 71107275S - SCREW BN 6.5MM 75MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107280S SUP HCPCS C1713 71107280S - SCREW BN 6.5MM 80MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107285S SUP HCPCS C1713 71107285S - SCREW BN 6.5MM 85MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107290S SUP HCPCS C1713 71107290S - SCREW BN 6.5MM 90MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107295S SUP HCPCS C1713 71107295S - SCREW BN 6.5MM 95MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107300S SUP HCPCS C1713 71107300S - SCREW BN 6.5MM 100MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107305S SUP HCPCS C1713 71107305S - SCREW BN 6.5MM 105MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107310S SUP HCPCS C1713 71107310S - SCREW BN 6.5MM 110MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107315S SUP HCPCS C1713 71107315S - SCREW BN 6.5MM 115MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107320S SUP HCPCS C1713 71107320S - SCREW BN 6.5MM 120MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107325S SUP HCPCS C1713 71107325S - SCREW BN FT 6.5MM 125MM CNN SET TI ANKL ASCP ARTHDS BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107330S SUP HCPCS C1713 71107330S - SCREW BN 6.5MM 130MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107335S SUP HCPCS C1713 71107335S - SCREW BN 6.5MM 135MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107340S SUP HCPCS C1713 71107340S - SCREW BN 6.5MM 140MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107345S SUP HCPCS C1713 71107345S - SCREW BN 6.5MM 145MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107350S SUP HCPCS C1713 71107350S - SCREW BN 6.5MM 150MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107355S SUP HCPCS C1713 71107355S - SCREW BN 6.5MM 155MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107360S SUP HCPCS C1713 71107360S - SCREW BN 6.5MM 160MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107365S SUP HCPCS C1713 71107365S - SCREW BN 6.5MM 165MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107370S SUP HCPCS C1713 71107370S - SCREW BN 6.5MM 170MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107375S SUP HCPCS C1713 71107375S - SCREW BN 6.5MM 175MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107380S SUP HCPCS C1713 71107380S - SCREW BN 6.5MM 180MM CNN FT TI BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107530S SUP HCPCS C1713 71107530S - SCREW BN 6.5MM 30MM 20MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107535S SUP HCPCS C1713 71107535S - SCREW BN 6.5MM 35MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107540S SUP HCPCS C1713 71107540S - SCREW BN 6.5MM 40MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107545S SUP HCPCS C1713 71107545S - SCREW BN 6.5MM 45MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107550S SUP HCPCS C1713 71107550S - SCREW BN 6.5MM 50MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107555S SUP HCPCS C1713 71107555S - SCREW BN 6.5MM 55MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107560S SUP HCPCS C1713 71107560S - SCREW BN 6.5MM 60MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107565S SUP HCPCS C1713 71107565S - SCREW BN 6.5MM 65MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107570S SUP HCPCS C1713 71107570S - SCREW BN 6.5MM 70MM 22MM CNN P/T BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107575S SUP HCPCS C1713 71107575S - SCREW BN 6.5MM 75MM 22MM CNN P/T BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107580S SUP HCPCS C1713 71107580S - SCREW BN 6.5MM 80MM 22MM CNN P/T BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107585S SUP HCPCS C1713 71107585S - SCREW BN 6.5MM 85MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107590S SUP HCPCS C1713 71107590S - SCREW BN 6.5MM 90MM 22MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107595S SUP HCPCS C1713 71107595S - SCREW BN 6.5MM 95MM 22MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107600S SUP HCPCS C1713 71107600S - SCREW BN 6.5MM 100MM 22MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107605S SUP HCPCS C1713 71107605S - SCREW BN 6.5MM 105MM 22MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107610S SUP HCPCS C1713 71107610S - SCREW BN 6.5MM 110MM 22MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107615S SUP HCPCS C1713 71107615S - SCREW BN 6.5MM 115MM 22MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107620S SUP HCPCS C1713 71107620S - SCREW BN 6.5MM 120MM 22MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107625S SUP HCPCS C1713 71107625S - SCREW BN 6.5MM 125MM 22MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107630S SUP HCPCS C1713 71107630S - SCREW BN 6.5MM 130MM 22MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107635S SUP HCPCS C1713 71107635S - SCREW BN 6.5MM 135MM 22MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107640S SUP HCPCS C1713 71107640S - SCREW BN 6.5MM 140MM 22MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107645S SUP HCPCS C1713 71107645S - SCREW BN 6.5MM 145MM 22MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107650S SUP HCPCS C1713 71107650S - SCREW BN 6.5MM 150MM 22MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107655S SUP HCPCS C1713 71107655S - SCREW BN 6.5MM 155MM 22MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107660S SUP HCPCS C1713 71107660S - SCREW BN 6.5MM 160MM 22MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107665S SUP HCPCS C1713 71107665S - SCREW BN 6.5MM 165MM 22MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107670S SUP HCPCS C1713 71107670S - SCREW BN 6.5MM 170MM 22MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107675S SUP HCPCS C1713 71107675S - SCREW BN 6.5MM 175MM 22MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107680S SUP HCPCS C1713 71107680S - SCREW BN 6.5MM 180MM 22MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107755S SUP HCPCS C1713 71107755S - SCREW BN 6.5MM 55MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107760S SUP HCPCS C1713 71107760S - SCREW BN 6.5MM 60MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107765S SUP HCPCS C1713 71107765S - SCREW BN 6.5MM 65MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107770S SUP HCPCS C1713 71107770S - SCREW BN 6.5MM 70MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107775S SUP HCPCS C1713 71107775S - SCREW BN 6.5MM 75MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107780S SUP HCPCS C1713 71107780S - SCREW BN 6.5MM 80MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107785S SUP HCPCS C1713 71107785S - SCREW BN 6.5MM 85MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107790S SUP HCPCS C1713 71107790S - SCREW BN 6.5MM 90MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107795S SUP HCPCS C1713 71107795S - SCREW BN 6.5MM 95MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107800S SUP HCPCS C1713 71107800S - SCREW BN 6.5MM 100MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107805S SUP HCPCS C1713 71107805S - SCREW BN 6.5MM 105MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107810S SUP HCPCS C1713 71107810S - SCREW BN 6.5MM 110MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107815S SUP HCPCS C1713 71107815S - SCREW BN 6.5MM 115MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107820S SUP HCPCS C1713 71107820S - SCREW BN 6.5MM 120MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107825S SUP HCPCS C1713 71107825S - SCREW BN 6.5MM 125MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71107830S SUP HCPCS C1713 71107830S - SCREW BN 6.5MM 130MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107835S SUP HCPCS C1713 71107835S - SCREW BN 6.5MM 135MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107840S SUP HCPCS C1713 71107840S - SCREW BN 6.5MM 140MM 46MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107845S SUP HCPCS C1713 71107845S - SCREW BN 6.5MM 145MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107850S SUP HCPCS C1713 71107850S - SCREW BN 6.5MM 150MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107855S SUP HCPCS C1713 71107855S - SCREW BN 6.5MM 155MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107860S SUP HCPCS C1713 71107860S - SCREW BN 6.5MM 160MM 46MM CNN P/T BOTH IP/OP $564.90 $418.03 $0.00 $451.92 $254.21 $254.21 $0.00 $0.00 $0.00 $117.74 $419.27 $419.27 $0.00 $0.00 $117.73 $0.00 $334.14 $334.14 $0.00 $282.45 $447.40 $451.92 $0.00 $0.00 $88.41 $0.00 $0.00 $89.93 $0.00 $0.00 $0.00 $0.00 $0.00 71107865S SUP HCPCS C1713 71107865S - SCREW BN 6.5MM 165MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107870S SUP HCPCS C1713 71107870S - SCREW BN 6.5MM 170MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107875S SUP HCPCS C1713 71107875S - SCREW BN 6.5MM 175MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71107880S SUP HCPCS C1713 71107880S - SCREW BN 6.5MM 180MM 46MM CNN P/T BOTH IP/OP $492.45 $364.41 $0.00 $393.96 $221.60 $221.60 $0.00 $0.00 $0.00 $102.64 $365.50 $365.50 $0.00 $0.00 $102.63 $0.00 $291.28 $291.28 $0.00 $246.23 $390.02 $393.96 $0.00 $0.00 $77.07 $0.00 $0.00 $78.40 $0.00 $0.00 $0.00 $0.00 $0.00 71108240S SUP HCPCS C1713 71108240S - SCREW BN FT 8MM 40MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108245S SUP HCPCS C1713 71108245S - SCREW BN FT 8MM 45MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108250S SUP HCPCS C1713 71108250S - SCREW BN FT 8MM 50MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108255S SUP HCPCS C1713 71108255S - SCREW BN FT 8MM 55MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108260S SUP HCPCS C1713 71108260S - SCREW BN FT 8MM 60MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108265S SUP HCPCS C1713 71108265S - SCREW BN FT 8MM 65MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108270S SUP HCPCS C1713 71108270S - SCREW BN FT 8MM 70MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108275S SUP HCPCS C1713 71108275S - SCREW BN FT 8MM 75MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108280S SUP HCPCS C1713 71108280S - SCREW BN LG FT LOPRFL 8MM 80MM STRL CNN ST SLFDRL REVCT FLUT BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108285S SUP HCPCS C1713 71108285S - SCREW BN FT 8MM 85MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108290S SUP HCPCS C1713 71108290S - SCREW BN FT 8MM 90MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108295S SUP HCPCS C1713 71108295S - SCREW BN FT 8MM 95MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108300S SUP HCPCS C1713 71108300S - SCREW BN LG FT LOPRFL 8MM 100MM STRL CNN ST SLFDRL REVCT BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108305S SUP HCPCS C1713 71108305S - SCREW BN FT 8MM 105MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108310S SUP HCPCS C1713 71108310S - SCREW BN FT 8MM 110MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108315S SUP HCPCS C1713 71108315S - SCREW BN FT 8MM 115MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108320S SUP HCPCS C1713 71108320S - SCREW BN FT 8MM 120MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108325S SUP HCPCS C1713 71108325S - SCREW BN FT 8MM 125MM STRL CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108330S SUP HCPCS C1713 71108330S - SCREW BN FT 8MM 130MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108335S SUP HCPCS C1713 71108335S - SCREW BN FT 8MM 135MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108340S SUP HCPCS C1713 71108340S - SCREW BN FT 8MM 140MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108345S SUP HCPCS C1713 71108345S - SCREW BN FT 8MM 145MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108350S SUP HCPCS C1713 71108350S - SCREW BN FT 8MM 150MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108355S SUP HCPCS C1713 71108355S - SCREW BN 8MM 155MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108360S SUP HCPCS C1713 71108360S - SCREW BN 8MM 160MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108365S SUP HCPCS C1713 71108365S - SCREW BN 8MM 165MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108370S SUP HCPCS C1713 71108370S - SCREW BN 8MM 170MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108375S SUP HCPCS C1713 71108375S - SCREW BN 8MM 175MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108380S SUP HCPCS C1713 71108380S - SCREW BN 8MM 180MM STRL CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108540S SUP HCPCS C1713 71108540S - SCREW BN 8MM 40MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108545S SUP HCPCS C1713 71108545S - SCREW BN 8MM 45MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108550S SUP HCPCS C1713 71108550S - SCREW BN 8MM 50MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108555S SUP HCPCS C1713 71108555S - SCREW BN 8MM 55MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108560S SUP HCPCS C1713 71108560S - SCREW BN 8MM 60MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108565S SUP HCPCS C1713 71108565S - SCREW BN 8MM 65MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108570S SUP HCPCS C1713 71108570S - SCREW BN 8MM 70MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108575S SUP HCPCS C1713 71108575S - SCREW BN 8MM 75MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108580S SUP HCPCS C1713 71108580S - SCREW BN 8MM 80MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108585S SUP HCPCS C1713 71108585S - SCREW BN 8MM 85MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108590S SUP HCPCS C1713 71108590S - SCREW BN 8MM 90MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108595S SUP HCPCS C1713 71108595S - SCREW BN LG P/T LOPRFL 8MM 95MM STRL 22MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108600S SUP HCPCS C1713 71108600S - SCREW BN LG P/T LOPRFL 8MM 100MM STRL 22MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108605S SUP HCPCS C1713 71108605S - SCREW BN 8MM 105MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108610S SUP HCPCS C1713 71108610S - SCREW BN 8MM 110MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108615S SUP HCPCS C1713 71108615S - SCREW BN 8MM 115MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108620S SUP HCPCS C1713 71108620S - SCREW BN 8MM 120MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108625S SUP HCPCS C1713 71108625S - SCREW BN 8MM 125MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108630S SUP HCPCS C1713 71108630S - SCREW BN 8MM 130MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108635S SUP HCPCS C1713 71108635S - SCREW BN 8MM 135MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108640S SUP HCPCS C1713 71108640S - SCREW BN 8MM 140MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108645S SUP HCPCS C1713 71108645S - SCREW BN LG P/T LOPRFL 8MM 145MM STRL 22MM CNN ST SLFDRL BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108650S SUP HCPCS C1713 71108650S - SCREW BN 8MM 150MM STRL 24MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108655S SUP HCPCS C1713 71108655S - SCREW BN 8MM 155MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108660S SUP HCPCS C1713 71108660S - SCREW BN 8MM 160MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108665S SUP HCPCS C1713 71108665S - SCREW BN 8MM 165MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108670S SUP HCPCS C1713 71108670S - SCREW BN 8MM 170MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108675S SUP HCPCS C1713 71108675S - SCREW BN 8MM 175MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108680S SUP HCPCS C1713 71108680S - SCREW BN 8MM 180MM STRL 22MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108755S SUP HCPCS C1713 71108755S - SCREW BN LG P/T LOPRFL 8MM 55MM STRL 46MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108760S SUP HCPCS C1713 71108760S - SCREW BN LG P/T LOPRFL 8MM 60MM STRL 46MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108765S SUP HCPCS C1713 71108765S - SCREW BN 8MM 65MM STRL 40MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108770S SUP HCPCS C1713 71108770S - SCREW BN 8MM 70MM STRL 40MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108775S SUP HCPCS C1713 71108775S - SCREW BN LG P/T LOPRFL 8MM 75MM STRL 46MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108780S SUP HCPCS C1713 71108780S - SCREW BN 8MM 80MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108785S SUP HCPCS C1713 71108785S - SCREW BN P/T 8MM 85MM CNN SS FEM TIB BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108790S SUP HCPCS C1713 71108790S - SCREW BN 8MM 90MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108795S SUP HCPCS C1713 71108795S - SCREW BN LG P/T LOPRFL 8MM 95MM STRL 46MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108800S SUP HCPCS C1713 71108800S - SCREW BN 8MM 100MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108805S SUP HCPCS C1713 71108805S - SCREW BN LG P/T LOPRFL 8MM 105MM STRL 46MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108810S SUP HCPCS C1713 71108810S - SCREW BN 8MM 110MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108815S SUP HCPCS C1713 71108815S - SCREW BN LG P/T LOPRFL 8MM 115MM STRL 46MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108820S SUP HCPCS C1713 71108820S - SCREW BN LG P/T LOPRFL 8MM 120MM STRL 46MM CNN ST SLFDRL BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108825S SUP HCPCS C1713 71108825S - SCREW BN 8MM 125MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $444.15 $328.67 $0.00 $355.32 $199.87 $199.87 $0.00 $0.00 $0.00 $92.57 $329.65 $329.65 $0.00 $0.00 $92.56 $0.00 $262.71 $262.71 $0.00 $222.08 $351.77 $355.32 $0.00 $0.00 $69.51 $0.00 $0.00 $70.71 $0.00 $0.00 $0.00 $0.00 $0.00 71108830S SUP HCPCS C1713 71108830S - SCREW BN 8MM 130MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108835S SUP HCPCS C1713 71108835S - SCREW BN 8MM 135MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108840S SUP HCPCS C1713 71108840S - SCREW BN 8MM 140MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108845S SUP HCPCS C1713 71108845S - SCREW BN 8MM 145MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108850S SUP HCPCS C1713 71108850S - SCREW BN 8MM 150MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108855S SUP HCPCS C1713 71108855S - SCREW BN 8MM 155MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108860S SUP HCPCS C1713 71108860S - SCREW BN 8MM 160MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108865S SUP HCPCS C1713 71108865S - SCREW BN 8MM 165MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108870S SUP HCPCS C1713 71108870S - SCREW BN 8MM 170MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108875S SUP HCPCS C1713 71108875S - SCREW BN 8MM 175MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71108880S SUP HCPCS C1713 71108880S - SCREW BN 8MM 180MM STRL 46MM CNN SS LNG BN SM BN BOTH IP/OP $510.30 $377.62 $0.00 $408.24 $229.64 $229.64 $0.00 $0.00 $0.00 $106.36 $378.74 $378.74 $0.00 $0.00 $106.35 $0.00 $301.84 $301.84 $0.00 $255.15 $404.16 $408.24 $0.00 $0.00 $79.86 $0.00 $0.00 $81.24 $0.00 $0.00 $0.00 $0.00 $0.00 71109240S SUP HCPCS C1713 71109240S - SCREW BN 8MM 40MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109245S SUP HCPCS C1713 71109245S - SCREW BN FT 8MM 45MM CNN SET TI ANKL BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109250S SUP HCPCS C1713 71109250S - SCREW BN 8MM 50MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109255S SUP HCPCS C1713 71109255S - SCREW BN 8MM 55MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109260S SUP HCPCS C1713 71109260S - SCREW BN 8MM 60MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109265S SUP HCPCS C1713 71109265S - SCREW BN 8MM 65MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109270S SUP HCPCS C1713 71109270S - SCREW BN 8MM 70MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109275S SUP HCPCS C1713 71109275S - SCREW BN 8MM 75MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109280S SUP HCPCS C1713 71109280S - SCREW BN 8MM 80MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109285S SUP HCPCS C1713 71109285S - SCREW BN 8MM 85MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109290S SUP HCPCS C1713 71109290S - SCREW BN 8MM 90MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109295S SUP HCPCS C1713 71109295S - SCREW BN 8MM 95MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109300S SUP HCPCS C1713 71109300S - SCREW BN 8MM 100MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109305S SUP HCPCS C1713 71109305S - SCREW BN 8MM 105MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109310S SUP HCPCS C1713 71109310S - SCREW BN 8MM 110MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109315S SUP HCPCS C1713 71109315S - SCREW BN 8MM 115MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109320S SUP HCPCS C1713 71109320S - SCREW BN 8MM 120MM FT CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109325S SUP HCPCS C1713 71109325S - SCREW BN 8MM 125MM CNN FT TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109330S SUP HCPCS C1713 71109330S - SCREW BN 8MM 130MM CNN FT TI BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109335S SUP HCPCS C1713 71109335S - SCREW BN 8MM 135MM CNN FT TI BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109340S SUP HCPCS C1713 71109340S - SCREW BN 8MM 140MM CNN FT TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109345S SUP HCPCS C1713 71109345S - SCREW BN 8MM 145MM CNN FT TI BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109350S SUP HCPCS C1713 71109350S - SCREW BN 8MM 150MM CNN FT TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109355S SUP HCPCS C1713 71109355S - SCREW BN 8MM 155MM CNN FT TI BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109360S SUP HCPCS C1713 71109360S - SCREW BN 8MM 160MM STRL CNN FT TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109365S SUP HCPCS C1713 71109365S - SCREW BN 8MM 165MM STRL CNN FT TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109370S SUP HCPCS C1713 71109370S - SCREW BN 8MM 170MM STRL CNN FT TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109375S SUP HCPCS C1713 71109375S - SCREW BN 8MM 175MM STRL CNN FT TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109380S SUP HCPCS C1713 71109380S - SCREW BN 8MM 180MM STRL CNN FT TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109540S SUP HCPCS C1713 71109540S - SCREW BN 8MM 40MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109545S SUP HCPCS C1713 71109545S - SCREW BN 8MM 45MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109550S SUP HCPCS C1713 71109550S - SCREW BN 8MM 50MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109555S SUP HCPCS C1713 71109555S - SCREW BN 8MM 55MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109560S SUP HCPCS C1713 71109560S - SCREW BN 8MM 60MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109565S SUP HCPCS C1713 71109565S - SCREW BN 8MM 65MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109570S SUP HCPCS C1713 71109570S - SCREW BN 8MM 70MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109575S SUP HCPCS C1713 71109575S - SCREW BN 8MM 75MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109580S SUP HCPCS C1713 71109580S - SCREW BN 8MM 80MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109585S SUP HCPCS C1713 71109585S - SCREW BN 8MM 85MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109590S SUP HCPCS C1713 71109590S - SCREW BN 8MM 90MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109595S SUP HCPCS C1713 71109595S - SCREW BN 8MM 95MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109600S SUP HCPCS C1713 71109600S - SCREW BN 8MM 100MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109605S SUP HCPCS C1713 71109605S - SCREW BN 8MM 105MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109610S SUP HCPCS C1713 71109610S - SCREW BN P/T 8MM 110MM 22MM CNN SLFDRL ST SS HND MIDFOOT BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109615S SUP HCPCS C1713 71109615S - SCREW BN 8MM 115MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109620S SUP HCPCS C1713 71109620S - SCREW BN 8MM 120MM 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109625S SUP HCPCS C1713 71109625S - SCREW BN 8MM 125MM STRL 22MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109630S SUP HCPCS C1713 71109630S - SCREW BN 8MM 130MM STRL 22MM CNN P/T TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109635S SUP HCPCS C1713 71109635S - SCREW BN 8MM 135MM STRL 22MM CNN P/T TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109640S SUP HCPCS C1713 71109640S - SCREW BN 8MM 140MM 22MM CNN P/T TI BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109645S SUP HCPCS C1713 71109645S - SCREW BN 8MM 145MM STRL 22MM CNN P/T TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109650S SUP HCPCS C1713 71109650S - SCREW BN 8MM 150MM STRL 22MM P/T CNN TI BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109655S SUP HCPCS C1713 71109655S - SCREW BN P/T 8MM 155MM 22MM CNN TI ANKL BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109660S SUP HCPCS C1713 71109660S - SCREW BN 8MM 160MM 22MM CNN P/T TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109665S SUP HCPCS C1713 71109665S - SCREW BN 8MM 165MM 22MM CNN P/T TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109670S SUP HCPCS C1713 71109670S - SCREW BN 8MM 170MM 22MM CNN P/T TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109675S SUP HCPCS C1713 71109675S - SCREW BN 8MM 175MM 22MM CNN P/T TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109680S SUP HCPCS C1713 71109680S - SCREW BN 8MM 180MM 22MM CNN P/T TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109755S SUP HCPCS C1713 71109755S - SCREW BN 8MM 55MM 46MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109760S SUP HCPCS C1713 71109760S - SCREW BN 8MM 60MM 46MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109765S SUP HCPCS C1713 71109765S - SCREW BN 8MM 65MM 46MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109770S SUP HCPCS C1713 71109770S - SCREW BN 8MM 70MM 46MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109775S SUP HCPCS C1713 71109775S - SCREW BN 8MM 75MM 46MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109780S SUP HCPCS C1713 71109780S - SCREW BN 6.5MM 80MM CNN BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109785S SUP HCPCS C1713 71109785S - SCREW BN 8MM 85MM 46MM CNN P/T TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109790S SUP HCPCS C1713 71109790S - SCREW BN 8MM 90MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109795S SUP HCPCS C1713 71109795S - SCREW BN 8MM 95MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109800S SUP HCPCS C1713 71109800S - SCREW BN 8MM 100MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109805S SUP HCPCS C1713 71109805S - SCREW BN 8MM 105MM 46MM P/T BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109810S SUP HCPCS C1713 71109810S - SCREW BN 8MM 110MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109815S SUP HCPCS C1713 71109815S - SCREW BN 8MM 115MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109820S SUP HCPCS C1713 71109820S - SCREW BN 8MM 120MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109825S SUP HCPCS C1713 71109825S - SCREW BN 8MM 125MM 46MM P/T CNN TI BOTH IP/OP $540.75 $400.16 $0.00 $432.60 $243.34 $243.34 $0.00 $0.00 $0.00 $112.71 $401.34 $401.34 $0.00 $0.00 $112.69 $0.00 $319.85 $319.85 $0.00 $270.38 $428.27 $432.60 $0.00 $0.00 $84.63 $0.00 $0.00 $86.09 $0.00 $0.00 $0.00 $0.00 $0.00 71109830S SUP HCPCS C1713 71109830S - SCREW BN 8MM 130MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109835S SUP HCPCS C1713 71109835S - SCREW BN 8MM 135MM 46MM P/T CNN TI BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109840S SUP HCPCS C1713 71109840S - SCREW BN 8MM 140MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109845S SUP HCPCS C1713 71109845S - SCREW BN 8MM 145MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109850S SUP HCPCS C1713 71109850S - SCREW BN 8MM 150MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109855S SUP HCPCS C1713 71109855S - SCREW BN 8MM 155MM 46MM P/T CNN TI BOTH IP/OP $513.45 $379.95 $0.00 $410.76 $231.05 $231.05 $0.00 $0.00 $0.00 $107.02 $381.08 $381.08 $0.00 $0.00 $107.00 $0.00 $303.71 $303.71 $0.00 $256.73 $406.65 $410.76 $0.00 $0.00 $80.35 $0.00 $0.00 $81.74 $0.00 $0.00 $0.00 $0.00 $0.00 71109860S SUP HCPCS C1713 71109860S - SCREW BN 8MM 160MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109865S SUP HCPCS C1713 71109865S - SCREW BN 8MM 165MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109870S SUP HCPCS C1713 71109870S - SCREW BN 8MM 170MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109875S SUP HCPCS C1713 71109875S - SCREW BN 8MM 175MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71109880S SUP HCPCS C1713 71109880S - SCREW BN 8MM 180MM 46MM P/T CNN TI BOTH IP/OP $591.15 $437.45 $0.00 $472.92 $266.02 $266.02 $0.00 $0.00 $0.00 $123.21 $438.75 $438.75 $0.00 $0.00 $123.20 $0.00 $349.67 $349.67 $0.00 $295.58 $468.19 $472.92 $0.00 $0.00 $92.51 $0.00 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 71114V SUP Custom 27203010 71114V - CLIP INTNL XLARGE CLIPS (6 CARTRIDGE) ( 14 CARTRIDGES BX)ź BOTH IP/OP $67.77 $50.15 $0.00 $54.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.30 $50.30 $0.00 $0.00 $14.12 $0.00 $0.00 $0.00 $0.00 $33.88 $53.67 $54.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71149308M SUP HCPCS C1713 71149308M - SCREW BN 2MM 4MM 8MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $106.80 $79.03 $0.00 $85.44 $48.06 $48.06 $0.00 $0.00 $0.00 $22.26 $79.27 $79.27 $0.00 $0.00 $22.26 $0.00 $63.17 $63.17 $0.00 $53.40 $84.59 $85.44 $0.00 $0.00 $16.71 $0.00 $0.00 $17.00 $0.00 $0.00 $0.00 $0.00 $0.00 71149310M SUP HCPCS C1713 71149310M - SCREW BN 2MM 4MM 10MM TC100 ST HEX HD SS CORT MN FRAG SYS BOTH IP/OP $106.80 $79.03 $0.00 $85.44 $48.06 $48.06 $0.00 $0.00 $0.00 $22.26 $79.27 $79.27 $0.00 $0.00 $22.26 $0.00 $63.17 $63.17 $0.00 $53.40 $84.59 $85.44 $0.00 $0.00 $16.71 $0.00 $0.00 $17.00 $0.00 $0.00 $0.00 $0.00 $0.00 71149312M SUP HCPCS C1713 71149312M - SCREW BN 2MM 12MM TC100 ST CORT BOTH IP/OP $106.80 $79.03 $0.00 $85.44 $48.06 $48.06 $0.00 $0.00 $0.00 $22.26 $79.27 $79.27 $0.00 $0.00 $22.26 $0.00 $63.17 $63.17 $0.00 $53.40 $84.59 $85.44 $0.00 $0.00 $16.71 $0.00 $0.00 $17.00 $0.00 $0.00 $0.00 $0.00 $0.00 71149314M SUP HCPCS C1713 71149314M - SCREW BN 2MM 14MM TC100 ST CORT BOTH IP/OP $106.80 $79.03 $0.00 $85.44 $48.06 $48.06 $0.00 $0.00 $0.00 $22.26 $79.27 $79.27 $0.00 $0.00 $22.26 $0.00 $63.17 $63.17 $0.00 $53.40 $84.59 $85.44 $0.00 $0.00 $16.71 $0.00 $0.00 $17.00 $0.00 $0.00 $0.00 $0.00 $0.00 71149316M SUP HCPCS C1713 71149316M - SCREW BN 2MM 16MM TC100 ST CORT BOTH IP/OP $106.80 $79.03 $0.00 $85.44 $48.06 $48.06 $0.00 $0.00 $0.00 $22.26 $79.27 $79.27 $0.00 $0.00 $22.26 $0.00 $63.17 $63.17 $0.00 $53.40 $84.59 $85.44 $0.00 $0.00 $16.71 $0.00 $0.00 $17.00 $0.00 $0.00 $0.00 $0.00 $0.00 71149410M SUP HCPCS C1713 71149410M - SCREW BN 2.7MM 5MM 10MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $93.20 $68.97 $0.00 $74.56 $41.94 $41.94 $0.00 $0.00 $0.00 $19.43 $69.17 $69.17 $0.00 $0.00 $19.42 $0.00 $55.13 $55.13 $0.00 $46.60 $73.81 $74.56 $0.00 $0.00 $14.59 $0.00 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $0.00 71149412M SUP HCPCS C1713 71149412M - SCREW BN 2.7MM 5MM 12MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $93.20 $68.97 $0.00 $74.56 $41.94 $41.94 $0.00 $0.00 $0.00 $19.43 $69.17 $69.17 $0.00 $0.00 $19.42 $0.00 $55.13 $55.13 $0.00 $46.60 $73.81 $74.56 $0.00 $0.00 $14.59 $0.00 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $0.00 71149414M SUP HCPCS C1713 71149414M - SCREW BN 2.7MM 5MM 14MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $93.20 $68.97 $0.00 $74.56 $41.94 $41.94 $0.00 $0.00 $0.00 $19.43 $69.17 $69.17 $0.00 $0.00 $19.42 $0.00 $55.13 $55.13 $0.00 $46.60 $73.81 $74.56 $0.00 $0.00 $14.59 $0.00 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $0.00 71149418M SUP HCPCS C1713 71149418M - SCREW BN 2.7MM 5MM 18MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $93.20 $68.97 $0.00 $74.56 $41.94 $41.94 $0.00 $0.00 $0.00 $19.43 $69.17 $69.17 $0.00 $0.00 $19.42 $0.00 $55.13 $55.13 $0.00 $46.60 $73.81 $74.56 $0.00 $0.00 $14.59 $0.00 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $0.00 71149420M SUP HCPCS C1713 71149420M - SCREW BN 2.7MM 5MM 20MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $93.20 $68.97 $0.00 $74.56 $41.94 $41.94 $0.00 $0.00 $0.00 $19.43 $69.17 $69.17 $0.00 $0.00 $19.42 $0.00 $55.13 $55.13 $0.00 $46.60 $73.81 $74.56 $0.00 $0.00 $14.59 $0.00 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $0.00 71149422M SUP HCPCS C1713 71149422M - SCREW BN 2.7MM 5MM 22MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $93.20 $68.97 $0.00 $74.56 $41.94 $41.94 $0.00 $0.00 $0.00 $19.43 $69.17 $69.17 $0.00 $0.00 $19.42 $0.00 $55.13 $55.13 $0.00 $46.60 $73.81 $74.56 $0.00 $0.00 $14.59 $0.00 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $0.00 71149424M SUP HCPCS C1713 71149424M - SCREW BN 2.7MM 5MM 24MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $93.20 $68.97 $0.00 $74.56 $41.94 $41.94 $0.00 $0.00 $0.00 $19.43 $69.17 $69.17 $0.00 $0.00 $19.42 $0.00 $55.13 $55.13 $0.00 $46.60 $73.81 $74.56 $0.00 $0.00 $14.59 $0.00 $0.00 $14.84 $0.00 $0.00 $0.00 $0.00 $0.00 71149510A SUP HCPCS C1713 71149510A - SCREW BN 3.5MM 6MM 10MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149510M SUP HCPCS C1713 71149510M - SCREW BN 3.5MM 6MM 10MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149512A SUP HCPCS C1713 71149512A - SCREW BN 3.5MM 6MM 12MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149514A SUP HCPCS C1713 71149514A - SCREW BN 3.5MM 6MM 14MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149516A SUP HCPCS C1713 71149516A - SCREW BN 3.5MM 6MM 16MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149518A SUP HCPCS C1713 71149518A - SCREW BN 3.5MM 6MM 18MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149520A SUP HCPCS C1713 71149520A - SCREW BN 3.5MM 6MM 20MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149520M SUP HCPCS C1713 71149520M - SCREW BN 3.5MM 6MM 20MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149522A SUP HCPCS C1713 71149522A - SCREW BN 3.5MM 6MM 22MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149522M SUP HCPCS C1713 71149522M - SCREW BN 3.5MM 22MM TC100 ST CORT BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149524A SUP HCPCS C1713 71149524A - SCREW BN 3.5MM 6MM 24MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149526A SUP HCPCS C1713 71149526A - SCREW BN 3.5MM 6MM 26MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149526M SUP HCPCS C1713 71149526M - SCREW BN 3.5MM 6MM 26MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149528A SUP HCPCS C1713 71149528A - SCREW BN 3.5MM 28MM TC100 ST CORT BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149528M SUP HCPCS C1713 71149528M - SCREW BN 3.5MM 6MM 28MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149530M SUP HCPCS C1713 71149530M - SCREW BN 3.5MM 6MM 30MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149532A SUP HCPCS C1713 71149532A - SCREW BN 3.5MM 6MM 32MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149532M SUP HCPCS C1713 71149532M - SCREW BN 3.5MM 32MM TC100 ST CORT BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149534A SUP HCPCS C1713 71149534A - SCREW BN 3.5MM 34MM TC100 ST CORT BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149534M SUP HCPCS C1713 71149534M - SCREW BN 3.5MM 6MM 34MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149536A SUP HCPCS C1713 71149536A - SCREW BN 3.5MM 6MM 36MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149536M SUP HCPCS C1713 71149536M - SCREW BN 3.5MM 36MM TC100 ST CORT BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149538A SUP HCPCS C1713 71149538A - SCREW BN 3.5MM 6MM 38MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149538M SUP HCPCS C1713 71149538M - SCREW BN 3.5MM 38MM TC100 ST CORT BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149540A SUP HCPCS C1713 71149540A - SCREW BN 3.5MM 6MM 40MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149540M SUP HCPCS C1713 71149540M - SCREW BN 3.5MM 40MM TC100 ST CORT BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149545A SUP HCPCS C1713 71149545A - SCREW BN 3.5MM 6MM 45MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149545M SUP HCPCS C1713 71149545M - SCREW BN 3.5MM 6MM 45MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149550A SUP HCPCS C1713 71149550A - SCREW BN 3.5MM 6MM 50MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $86.40 $63.94 $0.00 $69.12 $38.88 $38.88 $0.00 $0.00 $0.00 $18.01 $64.13 $64.13 $0.00 $0.00 $18.01 $0.00 $51.11 $51.11 $0.00 $43.20 $68.43 $69.12 $0.00 $0.00 $13.52 $0.00 $0.00 $13.75 $0.00 $0.00 $0.00 $0.00 $0.00 71149550M SUP HCPCS C1713 71149550M - SCREW BN 3.5MM 6MM 50MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149555M SUP HCPCS C1713 71149555M - SCREW BN 3.5MM 6MM 55MM TC100 ST HEX SCKT SS CORT SM FRAG BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149714M SUP HCPCS C1713 71149714M - SCREW BN 4.5MM 14MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149716M SUP HCPCS C1713 71149716M - SCREW BN 4.5MM 16MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149718M SUP HCPCS C1713 71149718M - SCREW BN 4.5MM 18MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149720M SUP HCPCS C1713 71149720M - SCREW BN 4.5MM 20MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149722M SUP HCPCS C1713 71149722M - SCREW BN 4.5MM 22MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149724M SUP HCPCS C1713 71149724M - SCREW BN 4.5MM 24MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149726M SUP HCPCS C1713 71149726M - SCREW BN 4.5MM 26MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149728M SUP HCPCS C1713 71149728M - SCREW BN 4.5MM 28MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149730M SUP HCPCS C1713 71149730M - SCREW BN 4.5MM 30MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149732M SUP HCPCS C1713 71149732M - SCREW BN 4.5MM 32MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149734M SUP HCPCS C1713 71149734M - SCREW BN 4.5MM 34MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149736M SUP HCPCS C1713 71149736M - SCREW BN 4.5MM 36MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149738M SUP HCPCS C1713 71149738M - SCREW BN 4.5MM 38MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149740M SUP HCPCS C1713 71149740M - SCREW BN 4.5MM 40MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149742M SUP HCPCS C1713 71149742M - SCREW BN 4.5MM 42MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149744M SUP HCPCS C1713 71149744M - SCREW BN 4.5MM 44MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149746M SUP HCPCS C1713 71149746M - SCREW BN 4.5MM 46MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149748M SUP HCPCS C1713 71149748M - SCREW BN 4.5MM 48MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149750M SUP HCPCS C1713 71149750M - SCREW BN 4.5MM 50MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149752M SUP HCPCS C1713 71149752M - SCREW BN 4.5MM 52MM TC100 ST CORT BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149754M SUP HCPCS C1713 71149754M - SCREW BN 4.5MM 54MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149756M SUP HCPCS C1713 71149756M - SCREW BN 4.5MM 56MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149758M SUP HCPCS C1713 71149758M - SCREW BN 4.5MM 58MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149760M SUP HCPCS C1713 71149760M - SCREW BN 4.5MM 60MM TC100 ST CORT BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149762M SUP HCPCS C1713 71149762M - SCREW BN 4.5MM 62MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149764M SUP HCPCS C1713 71149764M - SCREW BN 4.5MM 64MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149766M SUP HCPCS C1713 71149766M - SCREW BN 4.5MM 66MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149768M SUP HCPCS C1713 71149768M - SCREW BN 4.5MM 68MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149770M SUP HCPCS C1713 71149770M - SCREW BN 4.5MM 70MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $101.20 $74.89 $0.00 $80.96 $45.54 $45.54 $0.00 $0.00 $0.00 $21.09 $75.11 $75.11 $0.00 $0.00 $21.09 $0.00 $59.86 $59.86 $0.00 $50.60 $80.15 $80.96 $0.00 $0.00 $15.84 $0.00 $0.00 $16.11 $0.00 $0.00 $0.00 $0.00 $0.00 71149772M SUP HCPCS C1713 71149772M - SCREW BN 4.5MM 72MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $167.20 $123.73 $0.00 $133.76 $75.24 $75.24 $0.00 $0.00 $0.00 $34.85 $124.10 $124.10 $0.00 $0.00 $34.84 $0.00 $98.90 $98.90 $0.00 $83.60 $132.42 $133.76 $0.00 $0.00 $26.17 $0.00 $0.00 $26.62 $0.00 $0.00 $0.00 $0.00 $0.00 71149776M SUP HCPCS C1713 71149776M - SCREW BN 4.5MM 76MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $167.20 $123.73 $0.00 $133.76 $75.24 $75.24 $0.00 $0.00 $0.00 $34.85 $124.10 $124.10 $0.00 $0.00 $34.84 $0.00 $98.90 $98.90 $0.00 $83.60 $132.42 $133.76 $0.00 $0.00 $26.17 $0.00 $0.00 $26.62 $0.00 $0.00 $0.00 $0.00 $0.00 71149780M SUP HCPCS C1713 71149780M - SCREW BN 4.5MM 8MM 80MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $47.25 $47.25 $0.00 $0.00 $0.00 $21.88 $77.93 $77.93 $0.00 $0.00 $21.88 $0.00 $62.11 $62.11 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 71149785M SUP HCPCS C1713 71149785M - SCREW BN 4.5MM 85MM TC100 ST HEX SCKT SS CORT LG FRAG SYS BOTH IP/OP $167.20 $123.73 $0.00 $133.76 $75.24 $75.24 $0.00 $0.00 $0.00 $34.85 $124.10 $124.10 $0.00 $0.00 $34.84 $0.00 $98.90 $98.90 $0.00 $83.60 $132.42 $133.76 $0.00 $0.00 $26.17 $0.00 $0.00 $26.62 $0.00 $0.00 $0.00 $0.00 $0.00 71149790M SUP HCPCS C1713 71149790M - SCREW BN 4.5MM 8MM 90MM TC100 ST HEX SCKT SS METACARPUS BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $47.25 $47.25 $0.00 $0.00 $0.00 $21.88 $77.93 $77.93 $0.00 $0.00 $21.88 $0.00 $62.11 $62.11 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 7115-0003 SUP HCPCS C1776 7115-0003 - COMPONENT TIBIAL TRAY 3 STANDARD CEMENT SCORPIO KNEE 7000 BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 7115-0004 SUP HCPCS C1776 7115-0004 - COMPONENT TIBIAL TRAY STANDARD SERIES 7000 BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 7115-0005 SUP HCPCS C1776 7115-0005 - COMPONENT TIBIAL TRAY 5 1 AXIS PRIM POSTERIOR STABILIZED BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 7115-0006 SUP HCPCS C1776 7115-0006 - COMPONENT TIBIAL TRAY STANDARD 1 AXIS PRIM POSTERIOR BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 7115-0007 SUP HCPCS C1776 7115-0007 - COMPONENT TIBIAL TRAY 7 1 AXIS PRIM POSTERIOR STABILIZE BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 7115-0009 SUP HCPCS C1776 7115-0009 - COMPONENT TIBIAL TRAY 9 1 AXIS PRIM POSTERIOR STABILIZED BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 7115-0011 SUP HCPCS C1776 7115-0011 - COMPONENT TIBIAL TRAY 11 1 AXIS PRIM POSTERIOR STABILIZED BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 7115-0013 SUP HCPCS C1776 7115-0013 - COMPONENT TIBIAL TRAY 13 STANDARD 1 AXIS PRIM POSTERIOR BOTH IP/OP "$2,330.00 " "$1,724.20" $0.00 "$1,864.00" "$1,048.50" "$1,048.50" $0.00 $0.00 $0.00 $485.63 "$1,729.33" "$1,729.33" $0.00 $0.00 $485.57 $0.00 "$1,378.20" "$1,378.20" $0.00 "$1,165.00" "$1,845.36" "$1,864.00" $0.00 $0.00 $364.65 $0.00 $0.00 $370.94 $0.00 $0.00 $0.00 $0.00 $0.00 7120/60 SUP HCPCS C1895 7120/60 - LEAD PCNG 7FR 60CM DURATA TRUE BP ACTFX 2 COIL STRD BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7120/65 SUP HCPCS C1895 7120/65 - LEAD PACING 7FR 65CM 2 COIL DF-4 CONCTR TRUE BIPOL BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7120/75 SUP HCPCS C1895 7120/75 - DURATA+++PMM#:87533 BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 7120Q/52 SUP HCPCS C1895 7120Q/52 - LEAD DEFIBRILLATOR 17CM 7FR 52CM 2 COIL DF-4 CONCTR TRUE BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7120Q/58 SUP HCPCS C1895 7120Q/58 - LEAD ICD 7FR 58CM DURATA OPTIM DF4 CNCT 2 COIL BP BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7120Q/65 SUP HCPCS C1895 7120Q/65 - LEAD PACING 7FR 65CM 2 COIL DF-4 TRUE BIPOL ACTIVE FIX BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7121/60 SUP HCPCS C1895 7121/60 - LEAD DFBR 7FR 60CM 21CM DURATA 2 COIL IS-1 CNCT TRUE BP BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7121/65 SUP HCPCS C1895 7121/65 - LEAD PCNG 7FR 65CM DURATA 2 COIL ACTFX IMPL CARDVRT DFBR BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 71-2100 SUP Custom 27011340 71-2100 - ADPR SCT MTL DISS BOTH IP/OP $144.00 $106.56 $0.00 $115.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.88 $106.88 $0.00 $0.00 $30.01 $0.00 $0.00 $0.00 $0.00 $72.00 $114.05 $115.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7121Q/52 SUP HCPCS C1895 7121Q/52 - LEAD PACING 21CM SPACE 7FR 52CM 2 COIL TRUE BIPOL BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7121Q/58 SUP HCPCS C1895 7121Q/58 - LEAD PACING 21CM SPACE 7FR 58CM 2 COIL TRUE BIPOL BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7121Q/65 SUP HCPCS C1895 7121Q/65 - LEAD PCNG 7FR 65CM DURATA DF4 CNCT TRUE BP ACTFX IMPL BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7122/60 SUP HCPCS C1895 7122/60 - LEAD DFBR 7FR 60CM DURATA 1 COIL DF1 IS-1 CNCT TRUE BP SNS BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7122/65 SUP HCPCS C1895 7122/65 - LEAD PACING 7FR 65CM 1 COIL TRUE BIPOL CARDIOVERTER BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 71222010M SUP HCPCS C1713 71222010M - SCREW BN 3.5MM 6MM 10MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222012M SUP HCPCS C1713 71222012M - SCREW BN 3.5MM 6MM 12MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222016M SUP HCPCS C1713 71222016M - SCREW BN 3.5MM 6MM 16MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222018M SUP HCPCS C1713 71222018M - SCREW BN 3.5MM 6MM 18MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222020M SUP HCPCS C1713 71222020M - SCREW BN 3.5MM 6MM 20MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222022M SUP HCPCS C1713 71222022M - SCREW BN 3.5MM 6MM 22MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222024M SUP HCPCS C1713 71222024M - SCREW BN 3.5MM 6MM 22MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222026M SUP HCPCS C1713 71222026M - SCREW BN 3.5MM 6MM 26MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222028M SUP HCPCS C1713 71222028M - SCREW BN 3.5MM 6MM 28MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222030M SUP HCPCS C1713 71222030M - SCREW BN 3.5MM 6MM 30MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222032M SUP HCPCS C1713 71222032M - SCREW BN 3.5MM 6MM 32MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222034M SUP HCPCS C1713 71222034M - SCREW BN 3.5MM 6MM 34MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222036M SUP HCPCS C1713 71222036M - SCREW BN 3.5MM 6MM 36MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222038M SUP HCPCS C1713 71222038M - SCREW BN 3.5MM 6MM 38MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222040M SUP HCPCS C1713 71222040M - SCREW BN 3.5MM 6MM 40MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71222045M SUP HCPCS C1713 71222045M - SCREW BN 3.5MM 6MM 45MM TC100 SS CORT SM FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71223010M SUP HCPCS C1713 71223010M - SCREW BN FT 4MM 6MM 10MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223012M SUP HCPCS C1713 71223012M - SCREW BN FT 4MM 6MM 12MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223014M SUP HCPCS C1713 71223014M - SCREW BN FT 4MM 6MM 14MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223016M SUP HCPCS C1713 71223016M - SCREW BN FT 4MM 6MM 16MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223018M SUP HCPCS C1713 71223018M - SCREW BN FT 4MM 6MM 18MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223020M SUP HCPCS C1713 71223020M - SCREW BN FT 4MM 6MM 20MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223024M SUP HCPCS C1713 71223024M - SCREW BN FT 4MM 6MM 24MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223026M SUP HCPCS C1713 71223026M - SCREW BN FT 4MM 6MM 26MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223028M SUP HCPCS C1713 71223028M - SCREW BN FT 4MM 6MM 28MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223030M SUP HCPCS C1713 71223030M - SCREW BN FT 4MM 6MM 30MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223032M SUP HCPCS C1713 71223032M - SCREW BN FT 4MM 6MM 32MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223035M SUP HCPCS C1713 71223035M - SCREW BN SM FT 4MM 6MM 35MM TC100 SS CANC BOTH IP/OP $72.40 $53.58 $0.00 $57.92 $32.58 $32.58 $0.00 $0.00 $0.00 $15.09 $53.74 $53.74 $0.00 $0.00 $15.09 $0.00 $42.82 $42.82 $0.00 $36.20 $57.34 $57.92 $0.00 $0.00 $11.33 $0.00 $0.00 $11.53 $0.00 $0.00 $0.00 $0.00 $0.00 71223036M SUP HCPCS C1713 71223036M - SCREW BN FT 4MM 6MM 36MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223040M SUP HCPCS C1713 71223040M - SCREW BN FT 4MM 6MM 40MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223045M SUP HCPCS C1713 71223045M - SCREW BN FT 4MM 6MM 45MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223050M SUP HCPCS C1713 71223050M - SCREW BN FT 4MM 6MM 50MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223055M SUP HCPCS C1713 71223055M - SCREW BN FT 4MM 6MM 55MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223060M SUP HCPCS C1713 71223060M - SCREW BN FT 4MM 6MM 60MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $82.80 $61.27 $0.00 $66.24 $37.26 $37.26 $0.00 $0.00 $0.00 $17.26 $61.45 $61.45 $0.00 $0.00 $17.26 $0.00 $48.98 $48.98 $0.00 $41.40 $65.58 $66.24 $0.00 $0.00 $12.96 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $0.00 71223210M SUP HCPCS C1713 71223210M - SCREW BN P/T 4MM 6MM 10MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223212M SUP HCPCS C1713 71223212M - SCREW BN P/T 4MM 6MM 12MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223214M SUP HCPCS C1713 71223214M - SCREW BN P/T 4MM 6MM 14MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223216M SUP HCPCS C1713 71223216M - SCREW BN P/T 4MM 6MM 16MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223218M SUP HCPCS C1713 71223218M - SCREW BN P/T 4MM 6MM 18MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223220M SUP HCPCS C1713 71223220M - SCREW BN P/T 4MM 6MM 20MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223222M SUP HCPCS C1713 71223222M - SCREW BN P/T 4MM 6MM 22MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223224M SUP HCPCS C1713 71223224M - SCREW BN P/T 4MM 6MM 24MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223226M SUP HCPCS C1713 71223226M - SCREW BN P/T 4MM 6MM 26MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223228M SUP HCPCS C1713 71223228M - SCREW BN P/T 4MM 6MM 28MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223230M SUP HCPCS C1713 71223230M - SCREW BN P/T 4MM 6MM 30MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223235M SUP HCPCS C1713 71223235M - SCREW BN P/T 4MM 6MM 35MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223240M SUP HCPCS C1713 71223240M - SCREW BN P/T 4MM 6MM 40MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223245M SUP HCPCS C1713 71223245M - SCREW BN P/T 4MM 6MM 45MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71223250M SUP HCPCS C1713 71223250M - SCREW BN P/T 4MM 6MM 50MM TC100 SS CANC SM FRAG SYS BOTH IP/OP $80.80 $59.79 $0.00 $64.64 $36.36 $36.36 $0.00 $0.00 $0.00 $16.84 $59.97 $59.97 $0.00 $0.00 $16.84 $0.00 $47.79 $47.79 $0.00 $40.40 $63.99 $64.64 $0.00 $0.00 $12.65 $0.00 $0.00 $12.86 $0.00 $0.00 $0.00 $0.00 $0.00 71225026M SUP HCPCS C1713 71225026M - SCREW BN 4.5MM 8MM 26MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225028M SUP HCPCS C1713 71225028M - SCREW BN 4.5MM 8MM 28MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225030M SUP HCPCS C1713 71225030M - SCREW BN 4.5MM 8MM 30MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225032M SUP HCPCS C1713 71225032M - SCREW BN 4.5MM 8MM 32MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225034M SUP HCPCS C1713 71225034M - SCREW BN 4.5MM 8MM 34MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225036M SUP HCPCS C1713 71225036M - SCREW BN 4.5MM 8MM 36MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225038M SUP HCPCS C1713 71225038M - SCREW BN 4.5MM 8MM 38MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225040M SUP HCPCS C1713 71225040M - SCREW BN 4.5MM 8MM 40MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225042M SUP HCPCS C1713 71225042M - SCREW BN 4.5MM 8MM 42MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225044M SUP HCPCS C1713 71225044M - SCREW BN 4.5MM 8MM 44MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71225046M SUP HCPCS C1713 71225046M - SCREW BN 4.5MM 8MM 46MM TC100 SS CORT LG FRAG SYS BOTH IP/OP $76.80 $56.83 $0.00 $61.44 $34.56 $34.56 $0.00 $0.00 $0.00 $16.01 $57.00 $57.00 $0.00 $0.00 $16.01 $0.00 $45.43 $45.43 $0.00 $38.40 $60.83 $61.44 $0.00 $0.00 $12.02 $0.00 $0.00 $12.23 $0.00 $0.00 $0.00 $0.00 $0.00 71226030M SUP HCPCS C1713 71226030M - SCREW BN P/T 6.5MM 8MM 30MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226035M SUP HCPCS C1713 71226035M - SCREW BN P/T 6.5MM 8MM 35MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226040M SUP HCPCS C1713 71226040M - SCREW BN P/T 6.5MM 8MM 40MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226045M SUP HCPCS C1713 71226045M - SCREW BN P/T 6.5MM 8MM 45MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226055M SUP HCPCS C1713 71226055M - SCREW BN P/T 6.5MM 8MM 55MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226060M SUP HCPCS C1713 71226060M - SCREW BN P/T 6.5MM 8MM 60MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226065M SUP HCPCS C1713 71226065M - SCREW BN P/T 6.5MM 8MM 65MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226070M SUP HCPCS C1713 71226070M - SCREW BN P/T 6.5MM 8MM 70MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226075M SUP HCPCS C1713 71226075M - SCREW BN P/T 6.5MM 8MM 75MM 16MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71226080M SUP HCPCS C1713 71226080M - SCREW BN P/T 6.5MM 80MM 16MM TC100 CANC BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71229075M SUP HCPCS C1713 71229075M - SCREW BN FT 6.5MM 8MM 75MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 71229080M SUP HCPCS C1713 71229080M - SCREW BN FT 6.5MM 8MM 80MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $180.80 $133.79 $0.00 $144.64 $81.36 $81.36 $0.00 $0.00 $0.00 $37.68 $134.19 $134.19 $0.00 $0.00 $37.68 $0.00 $106.94 $106.94 $0.00 $90.40 $143.19 $144.64 $0.00 $0.00 $28.30 $0.00 $0.00 $28.78 $0.00 $0.00 $0.00 $0.00 $0.00 71229085M SUP HCPCS C1713 71229085M - SCREW BN FT 6.5MM 8MM 85MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $180.80 $133.79 $0.00 $144.64 $81.36 $81.36 $0.00 $0.00 $0.00 $37.68 $134.19 $134.19 $0.00 $0.00 $37.68 $0.00 $106.94 $106.94 $0.00 $90.40 $143.19 $144.64 $0.00 $0.00 $28.30 $0.00 $0.00 $28.78 $0.00 $0.00 $0.00 $0.00 $0.00 71229090M SUP HCPCS C1713 71229090M - SCREW BN FT 6.5MM 8MM 90MM TC100 SS CANC LG FRAG SYS BOTH IP/OP $164.80 $121.95 $0.00 $131.84 $74.16 $74.16 $0.00 $0.00 $0.00 $34.35 $122.31 $122.31 $0.00 $0.00 $34.34 $0.00 $97.48 $97.48 $0.00 $82.40 $130.52 $131.84 $0.00 $0.00 $25.79 $0.00 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 7122Q/52 SUP HCPCS C1777 7122Q/52 - LEAD PCNG 11MM SPC 6.8FR 58CM DURATA 1 COIL TRUE BP ACTFX BOTH IP/OP "$8,775.00 " "$6,493.50" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,828.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,828.71" $0.00 "$4,326.08" "$4,326.08" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7122Q/58 SUP HCPCS C1777 7122Q/58 - LEAD PCNG 58CM 6.8FR 11MM SPC ECRDL 1 COIL DFBR ACT FIX TRUE BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 7122Q/65 SUP HCPCS C1777 7122Q/65 - LEAD PACING 11MM SPACING 6.8FR 65CM TRUE BIPOL ACTIVE FIX BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7125-0003 SUP HCPCS C1776 7125-0003 - COMPONENT TIBIAL TRAY STANDARD MICROSTRUCTURED SCORPIO KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7125-0004 SUP HCPCS C1776 7125-0004 - COMPONENT TIBIAL TRAY STANDARD 4MM MICROSTRUCTURED SERIES BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7125-0005 SUP HCPCS C1776 7125-0005 - COMPONENT TIBIAL TRAY 5 STANDARD 66X44MM 30MM STEM WAFFLE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7125-0006 SUP HCPCS C1776 7125-0006 - COMPONENT TIBIAL TRAY 6 STANDARD MICROSTRUCTURED CEMENTED BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7125-0007 SUP HCPCS C1776 7125-0007 - COMPONENT TIBIAL TRAY STANDARD DELTAFIT MICROSTRUCTURE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7125-0009 SUP HCPCS C1776 7125-0009 - COMPONENT TIBIAL TRAY STANDARD DELTAFIT MICROSTRUCTURED BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7125-0011 SUP HCPCS C1776 7125-0011 - COMPONENT TIBIAL TRAY STANDARD DELTAFIT MICROSTRUCTURED BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7125-0013 SUP HCPCS C1776 7125-0013 - COMPONENT TIBIAL TRAY STANDARD MICROSTRUCTURED SCORPIO KNEE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7130/60 SUP HCPCS C1895 7130/60 - LEAD DFBR 6.8FR 60CM STRL LF 17MM DURATA DISP BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7130/65 SUP HCPCS C1895 7130/65 - DURATA+++PMM#:96295 BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 71-3003L SUP HCPCS C1776 71-3003L - CMPNT FEM 3 LEFT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,176.00 " "$2,350.24" $0.00 "$2,540.80" "$1,429.20" "$1,429.20" $0.00 $0.00 $0.00 $661.96 "$2,357.23" "$2,357.23" $0.00 $0.00 $661.88 $0.00 "$1,565.77" "$1,565.77" $0.00 "$1,588.00" "$2,515.39" "$2,540.80" $0.00 $0.00 $497.04 $0.00 $0.00 $505.62 $0.00 $0.00 $0.00 $0.00 $0.00 71-3003R SUP HCPCS C1776 71-3003R - CMPNT FEM 3 RIGHT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,176.00 " "$2,350.24" $0.00 "$2,540.80" "$1,429.20" "$1,429.20" $0.00 $0.00 $0.00 $661.96 "$2,357.23" "$2,357.23" $0.00 $0.00 $661.88 $0.00 "$1,565.77" "$1,565.77" $0.00 "$1,588.00" "$2,515.39" "$2,540.80" $0.00 $0.00 $497.04 $0.00 $0.00 $505.62 $0.00 $0.00 $0.00 $0.00 $0.00 71-3005L SUP HCPCS C1776 71-3005L - CMPNT FEM 5 LEFT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,110.00 " "$2,301.40" $0.00 "$2,488.00" "$1,399.50" "$1,399.50" $0.00 $0.00 $0.00 $648.20 "$2,308.24" "$2,308.24" $0.00 $0.00 $648.12 $0.00 "$1,533.23" "$1,533.23" $0.00 "$1,555.00" "$2,463.12" "$2,488.00" $0.00 $0.00 $486.72 $0.00 $0.00 $495.11 $0.00 $0.00 $0.00 $0.00 $0.00 71-3005R SUP HCPCS C1776 71-3005R - CMPNT FEM 5 RIGHT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,110.00 " "$2,301.40" $0.00 "$2,488.00" "$1,399.50" "$1,399.50" $0.00 $0.00 $0.00 $648.20 "$2,308.24" "$2,308.24" $0.00 $0.00 $648.12 $0.00 "$1,533.23" "$1,533.23" $0.00 "$1,555.00" "$2,463.12" "$2,488.00" $0.00 $0.00 $486.72 $0.00 $0.00 $495.11 $0.00 $0.00 $0.00 $0.00 $0.00 71-3007L SUP HCPCS C1776 71-3007L - CMPNT FEM 7 LEFT KNEE PS CMNT BASIC SCRP NPOR BOTH IP/OP "$3,110.00 " "$2,301.40" $0.00 "$2,488.00" "$1,399.50" "$1,399.50" $0.00 $0.00 $0.00 $648.20 "$2,308.24" "$2,308.24" $0.00 $0.00 $648.12 $0.00 "$1,533.23" "$1,533.23" $0.00 "$1,555.00" "$2,463.12" "$2,488.00" $0.00 $0.00 $486.72 $0.00 $0.00 $495.11 $0.00 $0.00 $0.00 $0.00 $0.00 71-3007R SUP HCPCS C1776 71-3007R - CMPNT FEM 7 RIGHT KNEE PS BASIC SCRP BOTH IP/OP "$3,110.00 " "$2,301.40" $0.00 "$2,488.00" "$1,399.50" "$1,399.50" $0.00 $0.00 $0.00 $648.20 "$2,308.24" "$2,308.24" $0.00 $0.00 $648.12 $0.00 "$1,533.23" "$1,533.23" $0.00 "$1,555.00" "$2,463.12" "$2,488.00" $0.00 $0.00 $486.72 $0.00 $0.00 $495.11 $0.00 $0.00 $0.00 $0.00 $0.00 71-3009L SUP HCPCS C1776 71-3009L - CMPNT FEM 9 LEFT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,110.00 " "$2,301.40" $0.00 "$2,488.00" "$1,399.50" "$1,399.50" $0.00 $0.00 $0.00 $648.20 "$2,308.24" "$2,308.24" $0.00 $0.00 $648.12 $0.00 "$1,533.23" "$1,533.23" $0.00 "$1,555.00" "$2,463.12" "$2,488.00" $0.00 $0.00 $486.72 $0.00 $0.00 $495.11 $0.00 $0.00 $0.00 $0.00 $0.00 71-3009R SUP HCPCS C1776 71-3009R - CMPNT FEM 9 RIGHT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,110.00 " "$2,301.40" $0.00 "$2,488.00" "$1,399.50" "$1,399.50" $0.00 $0.00 $0.00 $648.20 "$2,308.24" "$2,308.24" $0.00 $0.00 $648.12 $0.00 "$1,533.23" "$1,533.23" $0.00 "$1,555.00" "$2,463.12" "$2,488.00" $0.00 $0.00 $486.72 $0.00 $0.00 $495.11 $0.00 $0.00 $0.00 $0.00 $0.00 71-3011L SUP HCPCS C1776 71-3011L - CMPNT FEM 11 LEFT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,110.00 " "$2,301.40" $0.00 "$2,488.00" "$1,399.50" "$1,399.50" $0.00 $0.00 $0.00 $648.20 "$2,308.24" "$2,308.24" $0.00 $0.00 $648.12 $0.00 "$1,533.23" "$1,533.23" $0.00 "$1,555.00" "$2,463.12" "$2,488.00" $0.00 $0.00 $486.72 $0.00 $0.00 $495.11 $0.00 $0.00 $0.00 $0.00 $0.00 71-3011R SUP HCPCS C1776 71-3011R - CMPNT FEM 11 RIGHT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,110.00 " "$2,301.40" $0.00 "$2,488.00" "$1,399.50" "$1,399.50" $0.00 $0.00 $0.00 $648.20 "$2,308.24" "$2,308.24" $0.00 $0.00 $648.12 $0.00 "$1,533.23" "$1,533.23" $0.00 "$1,555.00" "$2,463.12" "$2,488.00" $0.00 $0.00 $486.72 $0.00 $0.00 $495.11 $0.00 $0.00 $0.00 $0.00 $0.00 71-3013L SUP HCPCS C1776 71-3013L - CMPNT FEM 13 LEFT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,176.00 " "$2,350.24" $0.00 "$2,540.80" "$1,429.20" "$1,429.20" $0.00 $0.00 $0.00 $661.96 "$2,357.23" "$2,357.23" $0.00 $0.00 $661.88 $0.00 "$1,565.77" "$1,565.77" $0.00 "$1,588.00" "$2,515.39" "$2,540.80" $0.00 $0.00 $497.04 $0.00 $0.00 $505.62 $0.00 $0.00 $0.00 $0.00 $0.00 71-3013R SUP HCPCS C1776 71-3013R - CMPNT FEM 13 RIGHT KNEE CMNT PS BASIC SCRP BOTH IP/OP "$3,176.00 " "$2,350.24" $0.00 "$2,540.80" "$1,429.20" "$1,429.20" $0.00 $0.00 $0.00 $661.96 "$2,357.23" "$2,357.23" $0.00 $0.00 $661.88 $0.00 "$1,565.77" "$1,565.77" $0.00 "$1,588.00" "$2,515.39" "$2,540.80" $0.00 $0.00 $497.04 $0.00 $0.00 $505.62 $0.00 $0.00 $0.00 $0.00 $0.00 7131/60 SUP HCPCS C1895 7131/60 - LEAD DFBR 60CM STRL LF 21CM DURATA DISP BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 7131/65 SUP HCPCS C1895 7131/65 - LEAD PACING 21MM SPACE 6.8FR 65CM 2 COIL INTEGRATE BIPOL BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 71-4103L SUP HCPCS C1776 71-4103L - CMPNT FEM 3 LEFT KNEE PS WFL POST SCRP LFIT BOTH IP/OP "$3,657.00 " "$2,706.18" $0.00 "$2,925.60" "$1,645.65" "$1,645.65" $0.00 $0.00 $0.00 $762.21 "$2,714.23" "$2,714.23" $0.00 $0.00 $762.12 $0.00 "$1,802.90" "$1,802.90" $0.00 "$1,828.50" "$2,896.34" "$2,925.60" $0.00 $0.00 $572.32 $0.00 $0.00 $582.19 $0.00 $0.00 $0.00 $0.00 $0.00 71-4103R SUP HCPCS C1776 71-4103R - CMPNT FEM 3 RIGHT KNEE PS WFL POST SCRP LFIT BOTH IP/OP "$3,657.00 " "$2,706.18" $0.00 "$2,925.60" "$1,645.65" "$1,645.65" $0.00 $0.00 $0.00 $762.21 "$2,714.23" "$2,714.23" $0.00 $0.00 $762.12 $0.00 "$1,802.90" "$1,802.90" $0.00 "$1,828.50" "$2,896.34" "$2,925.60" $0.00 $0.00 $572.32 $0.00 $0.00 $582.19 $0.00 $0.00 $0.00 $0.00 $0.00 71-4104L SUP HCPCS C1776 71-4104L - CMPNT FEM PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4104R SUP HCPCS C1776 71-4104R - CMPNT FEM PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4105L SUP HCPCS C1776 71-4105L - CMPNT FEM 5 LEFT PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4105R SUP HCPCS C1776 71-4105R - CMPNT FEM 5 RIGHT PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4106L SUP HCPCS C1776 71-4106L - CMPNT FEM PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4106R SUP HCPCS C1776 71-4106R - CMPNT FEM 6 RIGHT PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4107L SUP HCPCS C1776 71-4107L - COMPONENT FEM 7 LFIT SCRP CMNT POST STAB WFL KN LT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4107R SUP HCPCS C1776 71-4107R - COMPONENT FEM 7 LFIT SCRP CMNT POST STAB WFL KN RT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4109L SUP HCPCS C1776 71-4109L - CMPNT FEM 9 LEFT PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4109R SUP HCPCS C1776 71-4109R - CMPNT FEM 9 RIGHT PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4111L SUP HCPCS C1776 71-4111L - CMPNT FEM 11 LEFT PS WFL SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4111R SUP HCPCS C1776 71-4111R - CMPNT FEM 11 RIGHT WFL PS SCRP LFIT BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 71-4113L SUP HCPCS C1776 71-4113L - CMPNT FEM 13 LEFT PS WFL SCRP LFIT BOTH IP/OP "$3,657.00 " "$2,706.18" $0.00 "$2,925.60" "$1,645.65" "$1,645.65" $0.00 $0.00 $0.00 $762.21 "$2,714.23" "$2,714.23" $0.00 $0.00 $762.12 $0.00 "$1,802.90" "$1,802.90" $0.00 "$1,828.50" "$2,896.34" "$2,925.60" $0.00 $0.00 $572.32 $0.00 $0.00 $582.19 $0.00 $0.00 $0.00 $0.00 $0.00 71-4113R SUP HCPCS C1776 71-4113R - CMPNT FEM 13 RIGHT KNEE PS WFL POST SCRP LFIT BOTH IP/OP "$3,657.00 " "$2,706.18" $0.00 "$2,925.60" "$1,645.65" "$1,645.65" $0.00 $0.00 $0.00 $762.21 "$2,714.23" "$2,714.23" $0.00 $0.00 $762.12 $0.00 "$1,802.90" "$1,802.90" $0.00 "$1,828.50" "$2,896.34" "$2,925.60" $0.00 $0.00 $572.32 $0.00 $0.00 $582.19 $0.00 $0.00 $0.00 $0.00 $0.00 7145-0003 SUP HCPCS C1776 7145-0003 - COMPONENT TIBIAL TRAY STANDARD MICROSTRUCTURED PERIAPT BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7145-0005 SUP HCPCS C1776 7145-0005 - COMPONENT TIBIAL TRAY STANDARD MICROSTRUCTURED PERIAPT BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7145-0007 SUP HCPCS C1776 7145-0007 - COMPONENT TIBIAL TRAY STANDARD MICROSTRUCTURED PERIAPT BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7145-0009 SUP HCPCS C1776 7145-0009 - COMPONENT TIBIAL TRAY STANDARD MICROSTRUCTURED PERIAPT BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7145-0011 SUP HCPCS C1776 7145-0011 - COMPONENT TIBIAL TRAY STANDARD MICROSTRUCTURED PERIAPT BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 7145-0013 SUP HCPCS C1776 7145-0013 - COMPONENT TIBIAL TRAY STANDARD MICROSTRUCTURED PERIAPT BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4503L SUP HCPCS C1776 71-4503L - COMPONENT FEMORAL 3 56X35MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4503R SUP HCPCS C1776 71-4503R - COMPONENT FEMORAL 3 56X35MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4504L SUP HCPCS C1776 71-4504L - COMPONENT FEMORAL 4 1 AXIS POSTERIOR STABILIZE WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4504R SUP HCPCS C1776 71-4504R - COMPONENT FEMORAL 4 1 AXIS POSTERIOR STABILIZE WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4505L SUP HCPCS C1776 71-4505L - COMPONENT FEMORAL 5 61X39MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4505R SUP HCPCS C1776 71-4505R - COMPONENT FEMORAL 5 61X39MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4506L SUP HCPCS C1776 71-4506L - COMPONENT FEMORAL 6 1 AXIS POSTERIOR STABILIZE WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4506R SUP HCPCS C1776 71-4506R - COMPONENT FEMORAL 6 1 AXIS POSTERIOR STABILIZE WAFFLE POST BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4507L SUP HCPCS C1776 71-4507L - COMPONENT FEMORAL 7 66X44MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4507R SUP HCPCS C1776 71-4507R - COMPONENT FEMORAL 7 66X44MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4509L SUP HCPCS C1776 71-4509L - COMPONENT FEMORAL 9 71X49MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4509R SUP HCPCS C1776 71-4509R - COMPONENT FEMORAL 9 71X49MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4511L SUP HCPCS C1776 71-4511L - COMPONENT FEMORAL 11 76X53MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4511R SUP HCPCS C1776 71-4511R - COMPONENT FEMORAL 11 76X53MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4513L SUP HCPCS C1776 71-4513L - COMPONENT FEMORAL 13 81X58MM CEMENTED POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-4513R SUP HCPCS C1776 71-4513R - COMPONENT FEMORAL 13 81X58MM 1 AXIS POSTERIOR STABILIZE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-5003L SUP HCPCS C1776 71-5003L - CMPNT FEM 3 LEFT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,199.00 " "$3,847.26" $0.00 "$4,159.20" "$2,339.55" "$2,339.55" $0.00 $0.00 $0.00 "$1,083.60" "$3,858.70" "$3,858.70" $0.00 $0.00 "$1,083.47" $0.00 "$2,563.11" "$2,563.11" $0.00 "$2,599.50" "$4,117.61" "$4,159.20" $0.00 $0.00 $813.64 $0.00 $0.00 $827.68 $0.00 $0.00 $0.00 $0.00 $0.00 71-5003R SUP HCPCS C1776 71-5003R - CMPNT FEM 3 RIGHT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,199.00 " "$3,847.26" $0.00 "$4,159.20" "$2,339.55" "$2,339.55" $0.00 $0.00 $0.00 "$1,083.60" "$3,858.70" "$3,858.70" $0.00 $0.00 "$1,083.47" $0.00 "$2,563.11" "$2,563.11" $0.00 "$2,599.50" "$4,117.61" "$4,159.20" $0.00 $0.00 $813.64 $0.00 $0.00 $827.68 $0.00 $0.00 $0.00 $0.00 $0.00 71-5004L SUP HCPCS C1776 71-5004L - CMPNT FEM 4 LEFT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5004R SUP HCPCS C1776 71-5004R - CMPNT FEM 4 RIGHT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5005L SUP HCPCS C1776 71-5005L - CMPNT FEM 5 LEFT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5005R SUP HCPCS C1776 71-5005R - CMPNT FEM 5 RIGHT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5006L SUP HCPCS C1776 71-5006L - CMPNT FEM 6 LEFT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5006R SUP HCPCS C1776 71-5006R - CMPNT FEM 6 RIGHT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5007L SUP HCPCS C1776 71-5007L - CMPNT FEM 7 LEFT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5007R SUP HCPCS C1776 71-5007R - CMPNT FEM 7 RIGHT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5009L SUP HCPCS C1776 71-5009L - CMPNT FEM 9 LEFT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5009R SUP HCPCS C1776 71-5009R - CMPNT FEM 9 RIGHT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5011L SUP HCPCS C1776 71-5011L - CMPNT FEM 11 LEFT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5011R SUP HCPCS C1776 71-5011R - CMPNT FEM 11 RIGHT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,096.00 " "$3,771.04" $0.00 "$4,076.80" "$2,293.20" "$2,293.20" $0.00 $0.00 $0.00 "$1,062.13" "$3,782.25" "$3,782.25" $0.00 $0.00 "$1,062.01" $0.00 "$2,512.33" "$2,512.33" $0.00 "$2,548.00" "$4,036.03" "$4,076.80" $0.00 $0.00 $797.52 $0.00 $0.00 $811.28 $0.00 $0.00 $0.00 $0.00 $0.00 71-5013L SUP HCPCS C1776 71-5013L - CMPNT FEM 13 LEFT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,199.00 " "$3,847.26" $0.00 "$4,159.20" "$2,339.55" "$2,339.55" $0.00 $0.00 $0.00 "$1,083.60" "$3,858.70" "$3,858.70" $0.00 $0.00 "$1,083.47" $0.00 "$2,563.11" "$2,563.11" $0.00 "$2,599.50" "$4,117.61" "$4,159.20" $0.00 $0.00 $813.64 $0.00 $0.00 $827.68 $0.00 $0.00 $0.00 $0.00 $0.00 71-5013R SUP HCPCS C1776 71-5013R - CMPNT FEM 13 RIGHT KNEE PS MCSTRCT NON LFIT SCRP BOTH IP/OP "$5,199.00 " "$3,847.26" $0.00 "$4,159.20" "$2,339.55" "$2,339.55" $0.00 $0.00 $0.00 "$1,083.60" "$3,858.70" "$3,858.70" $0.00 $0.00 "$1,083.47" $0.00 "$2,563.11" "$2,563.11" $0.00 "$2,599.50" "$4,117.61" "$4,159.20" $0.00 $0.00 $813.64 $0.00 $0.00 $827.68 $0.00 $0.00 $0.00 $0.00 $0.00 71-5103L SUP HCPCS C1776 71-5103L - CMPNT FEM 3 LEFT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,839.00 " "$3,580.86" $0.00 "$3,871.20" "$2,177.55" "$2,177.55" $0.00 $0.00 $0.00 "$1,008.57" "$3,591.51" "$3,591.51" $0.00 $0.00 "$1,008.45" $0.00 "$2,385.63" "$2,385.63" $0.00 "$2,419.50" "$3,832.49" "$3,871.20" $0.00 $0.00 $757.30 $0.00 $0.00 $770.37 $0.00 $0.00 $0.00 $0.00 $0.00 71-5103R SUP HCPCS C1776 71-5103R - CMPNT FEM 3 RIGHT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,839.00 " "$3,580.86" $0.00 "$3,871.20" "$2,177.55" "$2,177.55" $0.00 $0.00 $0.00 "$1,008.57" "$3,591.51" "$3,591.51" $0.00 $0.00 "$1,008.45" $0.00 "$2,385.63" "$2,385.63" $0.00 "$2,419.50" "$3,832.49" "$3,871.20" $0.00 $0.00 $757.30 $0.00 $0.00 $770.37 $0.00 $0.00 $0.00 $0.00 $0.00 71-5104L SUP HCPCS C1776 71-5104L - CMPNT FEM LEFT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5104R SUP HCPCS C1776 71-5104R - CMPNT FEM 4 RIGHT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5105L SUP HCPCS C1776 71-5105L - CMPNT FEM 5 LEFT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5105R SUP HCPCS C1776 71-5105R - CMPNT FEM 5 RIGHT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5106L SUP HCPCS C1776 71-5106L - CMPNT FEM 6 LEFT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5106R SUP HCPCS C1776 71-5106R - CMPNT FEM 6 RIGHT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5107L SUP HCPCS C1776 71-5107L - CMPNT FEM 7 LEFT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5107R SUP HCPCS C1776 71-5107R - CMPNT FEM 7 RIGHT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5109L SUP HCPCS C1776 71-5109L - CMPNT FEM 9 LEFT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5109R SUP HCPCS C1776 71-5109R - CMPNT FEM 9 RIGHT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5111L SUP HCPCS C1776 71-5111L - CMPNT FEM 11 LEFT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5111R SUP HCPCS C1776 71-5111R - CMPNT FEM 11 RIGHT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" "$2,151.00" "$2,151.00" $0.00 $0.00 $0.00 $996.27 "$3,547.72" "$3,547.72" $0.00 $0.00 $996.15 $0.00 "$2,356.54" "$2,356.54" $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $748.07 $0.00 $0.00 $760.98 $0.00 $0.00 $0.00 $0.00 $0.00 71-5113L SUP HCPCS C1776 71-5113L - CMPNT FEM 13 LEFT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,839.00 " "$3,580.86" $0.00 "$3,871.20" "$2,177.55" "$2,177.55" $0.00 $0.00 $0.00 "$1,008.57" "$3,591.51" "$3,591.51" $0.00 $0.00 "$1,008.45" $0.00 "$2,385.63" "$2,385.63" $0.00 "$2,419.50" "$3,832.49" "$3,871.20" $0.00 $0.00 $757.30 $0.00 $0.00 $770.37 $0.00 $0.00 $0.00 $0.00 $0.00 71-5113R SUP HCPCS C1776 71-5113R - CMPNT FEM 13 RIGHT KNEE PS MCSTRCT SCRP LFIT BOTH IP/OP "$4,839.00 " "$3,580.86" $0.00 "$3,871.20" "$2,177.55" "$2,177.55" $0.00 $0.00 $0.00 "$1,008.57" "$3,591.51" "$3,591.51" $0.00 $0.00 "$1,008.45" $0.00 "$2,385.63" "$2,385.63" $0.00 "$2,419.50" "$3,832.49" "$3,871.20" $0.00 $0.00 $757.30 $0.00 $0.00 $770.37 $0.00 $0.00 $0.00 $0.00 $0.00 71511V SUP Custom 27203010 71511V - CLIP INTNL REMOVER MED LARGE - LARGE STRAIGHT 11INźź BOTH IP/OP $412.48 $305.24 $0.00 $329.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.14 $306.14 $0.00 $0.00 $85.96 $0.00 $0.00 $0.00 $0.00 $206.24 $326.68 $329.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71512V SUP Custom 27203010 71512V - APPLIER MED LARGE CURVED 11INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71517V SUP Custom 27203010 71517V - APPLIER MED LARGE 70 DEGREE 11INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71-5203L SUP HCPCS C1776 71-5203L - COMPONENT FEMORAL 3 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5203R SUP HCPCS C1776 71-5203R - COMPONENT FEMORAL 3 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5205L SUP HCPCS C1776 71-5205L - COMPONENT FEMORAL 5 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5205R SUP HCPCS C1776 71-5205R - COMPONENT FEMORAL 5 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5207L SUP HCPCS C1776 71-5207L - COMPONENT FEMORAL 7 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5207R SUP HCPCS C1776 71-5207R - COMPONENT FEMORAL 7 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5209L SUP HCPCS C1776 71-5209L - COMPONENT FEMORAL 9 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5209R SUP HCPCS C1776 71-5209R - COMPONENT FEMORAL 9 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5211L SUP HCPCS C1776 71-5211L - COMPONENT FEMORAL 11 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5211R SUP HCPCS C1776 71-5211R - COMPONENT FEMORAL 11 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5213L SUP HCPCS C1776 71-5213L - COMPONENT FEMORAL 13 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71-5213R SUP HCPCS C1776 71-5213R - COMPONENT FEMORAL 13 POSTERIOR STABILIZE MICROSTRUCTURE PRIM BOTH IP/OP "$4,505.00 " "$3,333.70" $0.00 "$3,604.00" "$2,027.25" "$2,027.25" $0.00 $0.00 $0.00 $938.95 "$3,343.61" "$3,343.61" $0.00 $0.00 $938.84 $0.00 "$2,220.97" "$2,220.97" $0.00 "$2,252.50" "$3,567.96" "$3,604.00" $0.00 $0.00 $705.03 $0.00 $0.00 $717.20 $0.00 $0.00 $0.00 $0.00 $0.00 71582V SUP Custom 27203010 71582V - APPLIER MED LARGE CURVED 8INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71587V SUP Custom 27203010 71587V - APPLIER MED LARGE 70 DEGREE 8INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7160-20 SUP Custom 27203010 7160-20 - KIT PEG 20FR 4X4IN SPONGE FEED TUBE EXTERNAL RETENTION RING BOTH IP/OP $225.15 $166.61 $0.00 $182.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.11 $167.11 $0.00 $0.00 $46.92 $0.00 $0.00 $0.00 $0.00 $114.26 $181.00 $182.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71612V SUP Custom 27203010 71612V - APPLIER LARGE CURVED 11INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71617V SUP Custom 27203010 71617V - APPLIER LARGE 70 DEGREE 11INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71682510L SUP HCPCS C1713 71682510L - NAIL IM 125D STD 10MM 19.5CM IMHS CP SS LT HIP BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71682510R SUP HCPCS C1713 71682510R - NAIL IM 125D STD 10MM 19.5CM IMHS CP SS HIP RT BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71682512L SUP HCPCS C1713 71682512L - NAIL IM 125D STD 12MM 19.5CM IMHS CP SS HIP LT BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71682512R SUP HCPCS C1713 71682512R - NAIL IM 125D STD 12MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71682514L SUP HCPCS C1713 71682514L - NAIL IM 125D STD 14MM 19.5CM IMHS CP SS LT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71682514R SUP HCPCS C1713 71682514R - NAIL IM 125D STD 14MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71682516L SUP HCPCS C1713 71682516L - NAIL IM 125D STD 16MM 19.5CM IMHS CP SS LT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71682516R SUP HCPCS C1713 71682516R - NAIL IM 125D STD 16MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71682532L SUP HCPCS C1713 71682532L - NAIL IM 125D LNG 10MM 32CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682532R SUP HCPCS C1713 71682532R - NAIL IM 125D LNG 10MM 32CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682534L SUP HCPCS C1713 71682534L - NAIL IM 125D LNG 10MM 34CM IMHS CP SS FEM LT BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682534R SUP HCPCS C1713 71682534R - NAIL IM 125D LNG 10MM 34CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682536L SUP HCPCS C1713 71682536L - NAIL IM 125D LNG 10MM 36CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682536R SUP HCPCS C1713 71682536R - NAIL IM 125D LNG 10MM 36CM IMHS CP SS RT BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682538L SUP HCPCS C1713 71682538L - NAIL IM 125D LNG 10MM 38CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682538R SUP HCPCS C1713 71682538R - NAIL IM 125D LNG 10MM 38CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682540L SUP HCPCS C1713 71682540L - NAIL IM 125D LNG 10MM 40CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682540R SUP HCPCS C1713 71682540R - NAIL IM 125D LNG 10MM 40CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682542L SUP HCPCS C1713 71682542L - NAIL IM 125D LNG 10MM 42CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682542R SUP HCPCS C1713 71682542R - NAIL IM 125D LNG 10MM 42CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682544L SUP HCPCS C1713 71682544L - NAIL IM 125D LNG 10MM 44CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682544R SUP HCPCS C1713 71682544R - NAIL IM 125D LNG 10MM 44CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682632L SUP HCPCS C1713 71682632L - NAIL IM 125D LNG 12MM 32CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682632R SUP HCPCS C1713 71682632R - NAIL IM 125D LNG 12MM 32CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682634L SUP HCPCS C1713 71682634L - NAIL IM 125D 12MM 34CM IMHS SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682634R SUP HCPCS C1713 71682634R - NAIL IM 125D LNG 12MM 34CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682636L SUP HCPCS C1713 71682636L - NAIL IM 125D LNG 12MM 36CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682636R SUP HCPCS C1713 71682636R - NAIL IM 125D LNG 12MM 36CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682638L SUP HCPCS C1713 71682638L - NAIL IM 125D LNG 12MM 38CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682638R SUP HCPCS C1713 71682638R - NAIL IM 125D LNG 12MM 38CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682640L SUP HCPCS C1713 71682640L - NAIL IM 125D LNG 12MM 40CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682640R SUP HCPCS C1713 71682640R - NAIL IM 125D LNG 12MM 40CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682642L SUP HCPCS C1713 71682642L - NAIL IM 125D LNG 12MM 42CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682642R SUP HCPCS C1713 71682642R - NAIL IM 125D LNG 12MM 42CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682644L SUP HCPCS C1713 71682644L - NAIL IM 125D LNG 12MM 44CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682644R SUP HCPCS C1713 71682644R - NAIL IM 125D LNG 12MM 44CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682734R SUP HCPCS C1713 71682734R - NAIL IM 125D 14MM 34CM IMHS CP SS RT HIP BOTH IP/OP "$6,269.38 " "$4,639.34" $0.00 "$5,015.50" "$2,821.22" "$2,821.22" $0.00 $0.00 $0.00 "$1,306.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,306.54" $0.00 "$3,090.80" "$3,090.80" $0.00 "$3,134.69" "$4,965.35" "$5,015.50" $0.00 $0.00 $981.16 $0.00 $0.00 $998.08 $0.00 $0.00 $0.00 $0.00 $0.00 71682736L SUP HCPCS C1713 71682736L - NAIL IM 125D 14MM 36CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71682744L SUP HCPCS C1713 71682744L - NAIL IM 125D 14MM 44CM IMHS CP SS LT HIP BOTH IP/OP "$6,269.38 " "$4,639.34" $0.00 "$5,015.50" "$2,821.22" "$2,821.22" $0.00 $0.00 $0.00 "$1,306.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,306.54" $0.00 "$3,090.80" "$3,090.80" $0.00 "$3,134.69" "$4,965.35" "$5,015.50" $0.00 $0.00 $981.16 $0.00 $0.00 $998.08 $0.00 $0.00 $0.00 $0.00 $0.00 71682744R SUP HCPCS C1713 71682744R - NAIL IM 125D 14MM 44CM IMHS CP SS RT HIP BOTH IP/OP "$6,269.38 " "$4,639.34" $0.00 "$5,015.50" "$2,821.22" "$2,821.22" $0.00 $0.00 $0.00 "$1,306.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,306.54" $0.00 "$3,090.80" "$3,090.80" $0.00 "$3,134.69" "$4,965.35" "$5,015.50" $0.00 $0.00 $981.16 $0.00 $0.00 $998.08 $0.00 $0.00 $0.00 $0.00 $0.00 71682V SUP Custom 27203010 71682V - APPLIER LARGE CURVED 8INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71683010L SUP HCPCS C1713 71683010L - NAIL IM 130D 10MM 19.5CM IMHS CP SS HIP LT BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71683012L SUP HCPCS C1713 71683012L - NAIL IM 130D 12MM 19.5CM IMHS SS LT HIP BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71683012R SUP HCPCS C1713 71683012R - NAIL IM 130D STD 12MM 19.5CM IMHS SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683014L SUP HCPCS C1713 71683014L - NAIL IM 130D 14MM 19.5CM IMHS SS LT HIP BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71683014R SUP HCPCS C1713 71683014R - NAIL IM 130D STD 14MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683016L SUP HCPCS C1713 71683016L - NAIL IM 130D STD 16MM 19.5CM IMHS CP SS HIP LT BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683016R SUP HCPCS C1713 71683016R - NAIL IM 130D STD 16MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683032L SUP HCPCS C1713 71683032L - NAIL IM 130D LNG 10MM 32CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683032R SUP HCPCS C1713 71683032R - NAIL IM 130D LNG 10MM 32CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683034L SUP HCPCS C1713 71683034L - NAIL IM 130D LNG 10MM 34CM IMHS CP SS LT BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683034R SUP HCPCS C1713 71683034R - NAIL IM 130D LNG 10MM 34CM IMHS CP SS RT BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683036L SUP HCPCS C1713 71683036L - NAIL IM 130D LNG 10MM 36CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683036R SUP HCPCS C1713 71683036R - NAIL IM 130D LNG 10MM 36CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683038L SUP HCPCS C1713 71683038L - NAIL IM 130D LNG 10MM 38CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683038R SUP HCPCS C1713 71683038R - NAIL IM 130D LNG 10MM 38CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683040L SUP HCPCS C1713 71683040L - NAIL IM 130D LNG 10MM 40CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683040R SUP HCPCS C1713 71683040R - NAIL IM 130D 10MM 40CM IMHS SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683042L SUP HCPCS C1713 71683042L - NAIL IM 130D LNG 10MM 42CM IMHS CP SS HIP LT BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683042R SUP HCPCS C1713 71683042R - NAIL IM 130D LNG 10MM 42CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683044L SUP HCPCS C1713 71683044L - NAIL IM 130D LNG 10MM 44CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683044R SUP HCPCS C1713 71683044R - NAIL IM 130D LNG 10MM 44CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683132L SUP HCPCS C1713 71683132L - NAIL IM 130D LNG 12MM 32CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683132R SUP HCPCS C1713 71683132R - NAIL IM 130D LNG 12MM 32CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683134L SUP HCPCS C1713 71683134L - NAIL IM 130D LNG 12MM 34CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683134R SUP HCPCS C1713 71683134R - NAIL IM 130D 12MM 34CM IMHS CP SS RT BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683136L SUP HCPCS C1713 71683136L - NAIL IM 130D 12MM 36CM IMHS SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683136R SUP HCPCS C1713 71683136R - NAIL IM 130D LNG 12MM 36CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683138L SUP HCPCS C1713 71683138L - NAIL IM 130D LNG 12MM 38CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683138R SUP HCPCS C1713 71683138R - NAIL IM 130D LNG 12MM 38CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683140L SUP HCPCS C1713 71683140L - NAIL IM 130D LNG 12MM 40CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683140R SUP HCPCS C1713 71683140R - NAIL IM 130D LNG 12MM 40CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683142L SUP HCPCS C1713 71683142L - NAIL IM 130D LNG 12MM 42CM IMHS CP SS HIP LT BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683142R SUP HCPCS C1713 71683142R - NAIL IM 130D LNG 12MM 42CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683144L SUP HCPCS C1713 71683144L - NAIL IM 130D LNG 12MM 44CM IMHS CP SS HIP LT BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683144R SUP HCPCS C1713 71683144R - NAIL IM 130D LNG 12MM 44CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683510L SUP HCPCS C1713 71683510L - NAIL IM 135D STD 10MM 19.5CM IMHS CP SS LT HIP BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71683510R SUP HCPCS C1713 71683510R - NAIL IM 135D STD 10MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71683512L SUP HCPCS C1713 71683512L - NAIL IM 135D STD 12MM 19.5CM IMHS CP SS LT HIP BOTH IP/OP "$3,329.38 " "$2,463.74" $0.00 "$2,663.50" "$1,498.22" "$1,498.22" $0.00 $0.00 $0.00 $693.92 "$2,471.06" "$2,471.06" $0.00 $0.00 $693.84 $0.00 "$1,641.38" "$1,641.38" $0.00 "$1,664.69" "$2,636.87" "$2,663.50" $0.00 $0.00 $521.05 $0.00 $0.00 $530.04 $0.00 $0.00 $0.00 $0.00 $0.00 71683512R SUP HCPCS C1713 71683512R - NAIL IM 135D STD 12MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683514L SUP HCPCS C1713 71683514L - NAIL IM 135D STD 14MM 19.5CM IMHS CP SS LT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683514R SUP HCPCS C1713 71683514R - NAIL IM 135D STD 14MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683516L SUP HCPCS C1713 71683516L - NAIL IM 135D 16MM 19.5CM IMHS CP SS LT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683516R SUP HCPCS C1713 71683516R - NAIL IM 135D 16MM 19.5CM IMHS CP SS RT HIP BOTH IP/OP "$3,342.50 " "$2,473.45" $0.00 "$2,674.00" "$1,504.13" "$1,504.13" $0.00 $0.00 $0.00 $696.66 "$2,480.80" "$2,480.80" $0.00 $0.00 $696.58 $0.00 "$1,647.85" "$1,647.85" $0.00 "$1,671.25" "$2,647.26" "$2,674.00" $0.00 $0.00 $523.10 $0.00 $0.00 $532.13 $0.00 $0.00 $0.00 $0.00 $0.00 71683532L SUP HCPCS C1713 71683532L - NAIL IM 135D LNG 10MM 32CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683532R SUP HCPCS C1713 71683532R - NAIL IM 135D LNG 10MM 32CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683534L SUP HCPCS C1713 71683534L - NAIL IM 135D LNG 10MM 34CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683534R SUP HCPCS C1713 71683534R - NAIL IM 135D LNG 10MM 34CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683536L SUP HCPCS C1713 71683536L - NAIL IM 135D LNG 10MM 36CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683536R SUP HCPCS C1713 71683536R - NAIL IM 135D LNG 10MM 36CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683538L SUP HCPCS C1713 71683538L - NAIL IM 135D LNG 10MM 38CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683538R SUP HCPCS C1713 71683538R - NAIL IM 135D LNG 10MM 38CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683540L SUP HCPCS C1713 71683540L - NAIL IM 135D LNG 10MM 40CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683540R SUP HCPCS C1713 71683540R - NAIL IM 135D LNG 10MM 40CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683542L SUP HCPCS C1713 71683542L - NAIL IM 135D LNG 10MM 42CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683542R SUP HCPCS C1713 71683542R - NAIL IM 135D LNG 10MM 42CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683544L SUP HCPCS C1713 71683544L - NAIL IM 135D LNG 10MM 44CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683544R SUP HCPCS C1713 71683544R - NAIL IM 135D LNG 10MM 44CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683632L SUP HCPCS C1713 71683632L - NAIL IM 135D LNG 12MM 32CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683632R SUP HCPCS C1713 71683632R - NAIL IM 135D 12MM 32CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683634L SUP HCPCS C1713 71683634L - NAIL IM 135D LNG 12MM 34CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683634R SUP HCPCS C1713 71683634R - NAIL IM 135D LNG 12MM 34CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683636L SUP HCPCS C1713 71683636L - NAIL IM 135D LNG 12MM 36CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683636R SUP HCPCS C1713 71683636R - NAIL IM 135D LNG 12MM 36CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683638L SUP HCPCS C1713 71683638L - NAIL IM 135D LNG 12MM 38CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683638R SUP HCPCS C1713 71683638R - NAIL IM 135D LNG 12MM 38CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683640L SUP HCPCS C1713 71683640L - NAIL IM 135D LNG 12MM 40CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683640R SUP HCPCS C1713 71683640R - NAIL IM 135D LNG 12MM 40CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683642L SUP HCPCS C1713 71683642L - NAIL IM 135D LNG 12MM 42CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683642R SUP HCPCS C1713 71683642R - NAIL IM 135D LNG 12MM 42CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683644L SUP HCPCS C1713 71683644L - NAIL IM 135D LNG 12MM 44CM IMHS CP SS LT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71683644R SUP HCPCS C1713 71683644R - NAIL IM 135D LNG 12MM 44CM IMHS CP SS RT HIP BOTH IP/OP "$6,671.88 " "$4,937.19" $0.00 "$5,337.50" "$3,002.34" "$3,002.34" $0.00 $0.00 $0.00 "$1,390.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,390.42" $0.00 "$3,289.23" "$3,289.23" $0.00 "$3,335.94" "$5,284.13" "$5,337.50" $0.00 $0.00 "$1,044.15" $0.00 $0.00 "$1,062.16" $0.00 $0.00 $0.00 $0.00 $0.00 71687V SUP Custom 27203010 71687V - APPLIER LARGE 70 DEGREE 8INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71701016L SUP HCPCS C1713 71701016L - NAIL IM 12-10MM 16CM LIME TRGN FSN RND XSECT DC SLOT TI BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701016R SUP HCPCS C1713 71701016R - NAIL IM 10MM 16CM TRGN FSN TI RT HINDFOOT BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701020L SUP HCPCS C1713 71701020L - NAIL INTRAMEDULLARY 10MM 20CM FUSION TRIGEN LEFT HINDFOOT BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701020R SUP HCPCS C1713 71701020R - NAIL IM 12-10MM 20CM ROSE TRGN FSN RND XSECT DC SLOT TI BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701025L SUP HCPCS C1713 71701025L - NAIL IM 10MM 25CM TRGN TI LT HINDFOOT BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701025R SUP HCPCS C1713 71701025R - NAIL IM 10MM 25CM TRGN FSN TI RT HINDFOOT BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701116R SUP HCPCS C1713 71701116R - NAIL INTRAMEDULLARY 11.5MM 16CM FUSION TRIGEN RIGHT HINDFOOT BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701120L SUP HCPCS C1713 71701120L - NAIL INTRAMEDULLARY 11.5MM 20CM FUSION TRIGEN TITANIUM LEFT BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701120R SUP HCPCS C1713 71701120R - NAIL INTRAMEDULLARY 11.5MM 20CM FUSION TRIGEN TITANIUM RIGHT BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701125L SUP HCPCS C1713 71701125L - NAIL IM 11.5MM 25CM TRGN TI HINDFOOT LT BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 71701125R SUP HCPCS C1713 71701125R - TRIGIN HINDFOOT FUSION NAIL (R) 11.5x25CM BOTH IP/OP "$5,613.75 " "$4,154.18" $0.00 "$4,491.00" "$2,526.19" "$2,526.19" $0.00 $0.00 $0.00 "$1,170.05" "$4,166.53" "$4,166.53" $0.00 $0.00 "$1,169.91" $0.00 "$2,767.58" "$2,767.58" $0.00 "$2,806.88" "$4,446.09" "$4,491.00" $0.00 $0.00 $878.55 $0.00 $0.00 $893.71 $0.00 $0.00 $0.00 $0.00 $0.00 7170-20 SUP Custom 27203010 7170-20 - KIT PG 20FR MIC PUSH BOTH IP/OP $229.50 $169.83 $0.00 $183.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.33 $170.33 $0.00 $0.00 $47.83 $0.00 $0.00 $0.00 $0.00 $114.75 $181.76 $183.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7170-24 SUP Custom 27203010 7170-24 - KIT PG 24FR 12ML STRL LF MC SLK PUSH RADOPQ MED PORT SIL BOTH IP/OP $229.50 $169.83 $0.00 $183.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.33 $170.33 $0.00 $0.00 $47.83 $0.00 $0.00 $0.00 $0.00 $114.75 $181.76 $183.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7170Q/52 SUP HCPCS C1895 7170Q/52 - DURATA SJ4 - PASSIVE BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 7170Q/58 SUP HCPCS C1895 7170Q/58 - LEAD PACING 7FR 58CM 17CM TRUE BIPOL ACTIVE FIX 2 COIL BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7170Q/65 SUP HCPCS C1895 7170Q/65 - LEAD DFBR 17CM 65CM DURATA TINE FX 2 COIL DF4 CNCT TRUE BP BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 71711V SUP Custom 27203010 71711V - CLIP INTNL REMOVER LARGE - XLARGE STRAIGHT 11INźź BOTH IP/OP $412.48 $305.24 $0.00 $329.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.14 $306.14 $0.00 $0.00 $85.96 $0.00 $0.00 $0.00 $0.00 $206.24 $326.68 $329.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71712V SUP Custom 27203010 71712V - APPLIER XLARGE CURVED 11INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71717V SUP Custom 27203010 71717V - APPLIER XLARGE 70 DEGREE 11INźź BOTH IP/OP $378.73 $280.26 $0.00 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.09 $281.09 $0.00 $0.00 $78.93 $0.00 $0.00 $0.00 $0.00 $189.36 $299.95 $302.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7171Q/52 SUP HCPCS C1895 7171Q/52 - DURATA SJ4 - PASSIVE BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 7171Q/58 SUP HCPCS C1895 7171Q/58 - LEAD DFBR 7FR 58CM 21CM DURATA 2 COIL DF4 CNCT TRUE BP ACTFX BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7171Q/65 SUP HCPCS C1895 7171Q/65 - LEAD DFBR 65CM DURATA 2 COIL TRUE BP TINE FX DF4 CNCT OPTIM BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 7180025A SUP HCPCS C1713 7180025A - END CAP SPNL 18MM 20-25MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7180027A SUP HCPCS C1713 7180027A - END CAP SPNL 18MM 21-27MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7180033A SUP HCPCS C1713 7180033A - END CAP SPNL 18MM 24-33MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7180041A SUP HCPCS C1713 7180041A - END CAP SPNL 18MM 28-41MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7180055A SUP HCPCS C1713 7180055A - END CAP SPNL 18MM 35-55MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7180067A SUP HCPCS C1713 7180067A - END CAP SPNL 18MM 41-67MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7180079A SUP HCPCS C1713 7180079A - END CAP SPNL 18MM 47-79MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7180-20 SUP Custom 27203010 7180-20 - KIT PG 20FR 4X4IN 12ML STRL LF SECUR-LOK MIC SPNG FDTB XTRN BOTH IP/OP $231.75 $171.50 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $0.00 $0.00 $0.00 $156.30 $247.58 $250.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7180-24 SUP Custom 27203010 7180-24 - KIT PG 24FR 12ML STRL LF MC SLK PUL RADOPQ MED PORT SIL DISP BOTH IP/OP $231.75 $171.50 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.00 $172.00 $0.00 $0.00 $48.30 $0.00 $0.00 $0.00 $0.00 $156.30 $247.58 $250.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71A003 SUP Custom 27804086 71A003 - GRAFT BONE SMALL 40-65MM CORTICAL SEGMENT BOTH IP/OP "$1,617.50 " "$1,196.95" $0.00 "$1,294.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,200.51" "$1,200.51" $0.00 $0.00 $337.09 $0.00 $0.00 $0.00 $0.00 $808.75 "$1,281.06" "$1,294.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71A004 SUP Custom 27804086 71A004 - GRAFT BONE LARGE 66-99MM CORTICAL SEGMENT BOTH IP/OP "$1,707.50 " "$1,263.55" $0.00 "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,267.31" "$1,267.31" $0.00 $0.00 $355.84 $0.00 $0.00 $0.00 $0.00 $853.75 "$1,352.34" "$1,366.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 720088-01 SUP HCPCS C1771 720088-01 - SLING UROLOGICAL ADVANCE MALE BOTH IP/OP "$14,150.00 " "$10,471.00" $0.00 "$11,320.00" "$6,367.50" "$6,367.50" $0.00 $0.00 $0.00 "$2,949.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,948.86" $0.00 "$6,975.95" "$6,975.95" $0.00 "$7,075.00" "$11,206.80" "$11,320.00" $0.00 $0.00 "$2,214.48" $0.00 $0.00 "$2,252.68" $0.00 $0.00 $0.00 $0.00 $0.00 720185-01 SUP HCPCS C1813 720185-01 - PROSTHESIS PENILE PRECONNECT INFLATABLE RESERVOIR AMS 700 MS BOTH IP/OP "$4,672.50 " "$3,457.65" $0.00 "$3,738.00" "$2,102.63" "$2,102.63" $0.00 $0.00 $0.00 $0.00 "$3,467.93" "$3,467.93" $0.00 $0.00 $973.75 $0.00 $0.00 $0.00 $0.00 "$2,336.25" "$3,700.62" "$3,738.00" $0.00 $0.00 $0.00 $0.00 $0.00 $743.86 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0308 SUP Custom 27803010 72-12-0308 - INSERT TIBIAL 3 8MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0310 SUP Custom 27803010 72-12-0310 - INSERT TIBIAL 3 10MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0312 SUP Custom 27803010 72-12-0312 - INSERT TIBIAL 3 12MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0315 SUP Custom 27803010 72-12-0315 - INSERT TIBIAL 3 15MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0318 SUP Custom 27803010 72-12-0318 - INSERT TIBIAL 3 18MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0321 SUP Custom 27803010 72-12-0321 - INSERT TIBIAL 3 21MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0324 SUP Custom 27803010 72-12-0324 - INSERT TIBIAL 3 24MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0508 SUP Custom 27803010 72-12-0508 - INSERT TIBIAL 5 8MM CRUC RET SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0510 SUP Custom 27803010 72-12-0510 - INSERT TIBIAL 5 10MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0512 SUP Custom 27803010 72-12-0512 - INSERT TIBIAL 5 12MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0515 SUP Custom 27803010 72-12-0515 - INSERT TIBIAL 5 15MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0518 SUP Custom 27803010 72-12-0518 - INSERT TIBIAL 5 18MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0521 SUP Custom 27803010 72-12-0521 - INSERT TIBIAL 5 21MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0524 SUP Custom 27803010 72-12-0524 - INSERT TIBIAL 5 24MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0708 SUP Custom 27803010 72-12-0708 - INSERT TIBIAL 7 8MM CRUC RET SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0710 SUP Custom 27803010 72-12-0710 - INSERT TIBIAL 7 10MM CRUC RET SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0712 SUP Custom 27803010 72-12-0712 - INSERT TIBIAL 7 12MM CRUC RET SCORPIO N2/VAC KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0715 SUP Custom 27803010 72-12-0715 - INSERT TIBIAL 7 15MM CRUC RET SCORPIO N2/VAC KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0718 SUP Custom 27803010 72-12-0718 - INSERT TIBIAL 7 18MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0721 SUP Custom 27803010 72-12-0721 - INSERT TIBIAL 7 21MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0724 SUP Custom 27803010 72-12-0724 - INSERT TIBIAL 7 24MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0908 SUP Custom 27803010 72-12-0908 - INSERT TIBIAL 9 8MM CRUC RET SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0910 SUP Custom 27803010 72-12-0910 - INSERT TIBIAL 9 10MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0912 SUP Custom 27803010 72-12-0912 - INSERT TIBIAL 9 12MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0915 SUP Custom 27803010 72-12-0915 - INSERT TIBIAL 9 15MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0918 SUP Custom 27803010 72-12-0918 - INSERT TIBIAL 9 18MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0921 SUP Custom 27803010 72-12-0921 - INSERT TIBIAL 9 21MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-0924 SUP Custom 27803010 72-12-0924 - INSERT TIBIAL 9 24MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-1108 SUP Custom 27803010 72-12-1108 - INSERT TIBIAL 11 8MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-1110 SUP Custom 27803010 72-12-1110 - INSERT TIBIAL 11 10MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-1112 SUP Custom 27803010 72-12-1112 - INSERT TIBIAL 11 12MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-1115 SUP Custom 27803010 72-12-1115 - INSERT TIBIAL 11 15MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-1118 SUP Custom 27803010 72-12-1118 - INSERT TIBIAL 11 18MM CRUC RET SCORPIO POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-1121 SUP Custom 27803010 72-12-1121 - INSERT TIBIAL 11 21MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-12-1124 SUP Custom 27803010 72-12-1124 - INSERT TIBIAL 11 24MM CRUC RET HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0308 SUP Custom 27803010 72-13-0308 - INSERT TIBIAL 3 8MM POSTERIOR STABILIZED HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0310 SUP Custom 27803010 72-13-0310 - INSERT TIBIAL 3 10MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0312 SUP Custom 27803010 72-13-0312 - INSERT TIBIAL 3 12MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0315 SUP Custom 27803010 72-13-0315 - INSERT TIBIAL 3 15MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0318 SUP Custom 27803010 72-13-0318 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0321 SUP Custom 27803010 72-13-0321 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0324 SUP Custom 27803010 72-13-0324 - INSERT TIBIAL 3 24MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0508 SUP Custom 27803010 72-13-0508 - INSERT TIBIAL 5 8MM POSTERIOR STABILIZED HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0510 SUP Custom 27803010 72-13-0510 - INSERT TIBIAL 5 10MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0512 SUP Custom 27803010 72-13-0512 - INSERT TIBIAL 5 12MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0515 SUP Custom 27803010 72-13-0515 - INSERT TIBIAL 5 15MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0518 SUP Custom 27803010 72-13-0518 - INSERT TIBIAL 5 18MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0521 SUP Custom 27803010 72-13-0521 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0524 SUP Custom 27803010 72-13-0524 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0708 SUP Custom 27803010 72-13-0708 - INSERT TIBIAL 7 8MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0710 SUP Custom 27803010 72-13-0710 - INSERT TIBIAL 7 10MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0712 SUP Custom 27803010 72-13-0712 - INSERT TIBIAL 7 12MM POSTERIOR STABILIZE SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0715 SUP Custom 27803010 72-13-0715 - INSERT TIBIAL POSTERIOR STABILIZE SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0718 SUP Custom 27803010 72-13-0718 - INSERT TIBIAL 7 18MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0721 SUP Custom 27803010 72-13-0721 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0724 SUP Custom 27803010 72-13-0724 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0908 SUP Custom 27803010 72-13-0908 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0910 SUP Custom 27803010 72-13-0910 - INSERT TIBIAL 9 10MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0912 SUP Custom 27803010 72-13-0912 - INSERT TIBIAL 9 12MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0915 SUP Custom 27803010 72-13-0915 - INSERT TIBIAL 9 15MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0918 SUP Custom 27803010 72-13-0918 - INSERT TIBIAL 9 18MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0921 SUP Custom 27803010 72-13-0921 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-0924 SUP Custom 27803010 72-13-0924 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-1108 SUP Custom 27803010 72-13-1108 - INSERT TIBIAL 11 8MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-1110 SUP Custom 27803010 72-13-1110 - INSERT TIBIAL 11 10MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-1112 SUP Custom 27803010 72-13-1112 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-1115 SUP Custom 27803010 72-13-1115 - INSERT TIBIAL 11 15MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-1118 SUP Custom 27803010 72-13-1118 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-1121 SUP Custom 27803010 72-13-1121 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-13-1124 SUP Custom 27803010 72-13-1124 - INSERT TIBIAL POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0308 SUP Custom 27803010 72-15-0308 - INSERT TIBIAL 3 8MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0310 SUP Custom 27803010 72-15-0310 - INSERT TIBIAL 3 10MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0312 SUP Custom 27803010 72-15-0312 - INSERT TIBIAL 3 12MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0315 SUP Custom 27803010 72-15-0315 - INSERT TIBIAL 3 15MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0318 SUP Custom 27803010 72-15-0318 - INSERT TIBIAL 3 18MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0321 SUP Custom 27803010 72-15-0321 - INSERT TIBIAL 3 21MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0324 SUP Custom 27803010 72-15-0324 - INSERT TIBIAL 3 24MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0508 SUP Custom 27803010 72-15-0508 - INSERT TIBIAL 5 8MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0510 SUP Custom 27803010 72-15-0510 - INSERT TIBIAL 5 10MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0512 SUP Custom 27803010 72-15-0512 - INSERT TIBIAL 5 12MM POSTERIOR STABILIZED HYPREX SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0515 SUP Custom 27803010 72-15-0515 - INSERT TIBIAL 5 15MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0518 SUP Custom 27803010 72-15-0518 - INSERT TIBIAL 5 18MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0521 SUP Custom 27803010 72-15-0521 - INSERT TIBIAL 5 21MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0524 SUP Custom 27803010 72-15-0524 - INSERT TIBIAL 5 24MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0708 SUP Custom 27803010 72-15-0708 - INSERT TIBIAL 7 8MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0710 SUP Custom 27803010 72-15-0710 - INSERT TIBIAL 7 10MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0712 SUP Custom 27803010 72-15-0712 - INSERT TIBIAL 7 12MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0715 SUP Custom 27803010 72-15-0715 - INSERT TIBIAL 7 15MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0718 SUP Custom 27803010 72-15-0718 - INSERT TIBIAL 7 18MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0721 SUP Custom 27803010 72-15-0721 - INSERT TIBIAL POSTERIOR STABILIZED HYPER EXTN SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0724 SUP Custom 27803010 72-15-0724 - INSERT TIBIAL 7 24MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0908 SUP Custom 27803010 72-15-0908 - INSERT TIBIAL 9 8MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0910 SUP Custom 27803010 72-15-0910 - INSERT TIBIAL 9 10MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0912 SUP Custom 27803010 72-15-0912 - INSERT TIBIAL 9 12MM POSTERIOR STABILIZE SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0915 SUP Custom 27803010 72-15-0915 - INSERT TIBIAL 9 15MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0918 SUP Custom 27803010 72-15-0918 - INSERT TIBIAL 9 18MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0921 SUP Custom 27803010 72-15-0921 - INSERT TIBIAL 9 21MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-0924 SUP Custom 27803010 72-15-0924 - INSERT TIBIAL 9 24MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-1108 SUP Custom 27803010 72-15-1108 - INSERT TIBIAL 11 8MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-1110 SUP Custom 27803010 72-15-1110 - INSERT TIBIAL 11 10MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-1112 SUP Custom 27803010 72-15-1112 - INSERT TIBIAL 11 12MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-1115 SUP Custom 27803010 72-15-1115 - INSERT TIBIAL 11 15MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-1118 SUP Custom 27803010 72-15-1118 - INSERT TIBIAL 11 18MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-1121 SUP Custom 27803010 72-15-1121 - INSERT TIBIAL 11 21MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-15-1124 SUP Custom 27803010 72-15-1124 - INSERT TIBIAL 11 24MM POSTERIOR STABILIZED HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0308 SUP Custom 27803010 72-16-0308 - INSERT TIBIAL CRUC RET HYPER EXTN SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0310 SUP Custom 27803010 72-16-0310 - INSERT TIBIAL CRUC RET HYPER EXTN SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0312 SUP Custom 27803010 72-16-0312 - INSERT TIBIAL CRUC RET HYPER EXTN SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0315 SUP Custom 27803010 72-16-0315 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0318 SUP Custom 27803010 72-16-0318 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0321 SUP Custom 27803010 72-16-0321 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0324 SUP Custom 27803010 72-16-0324 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0508 SUP Custom 27803010 72-16-0508 - INSERT TIBIAL 5 8MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0510 SUP Custom 27803010 72-16-0510 - INSERT TIBIAL 5 10MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0512 SUP Custom 27803010 72-16-0512 - INSERT TIBIAL 5 12MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0515 SUP Custom 27803010 72-16-0515 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0518 SUP Custom 27803010 72-16-0518 - INSERT TIBIAL 5 18MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0521 SUP Custom 27803010 72-16-0521 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0524 SUP Custom 27803010 72-16-0524 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0708 SUP Custom 27803010 72-16-0708 - INSERT TIBIAL 7 8MM CRUC RET SCORPIO KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0710 SUP Custom 27803010 72-16-0710 - INSERT TIBIAL 7 10MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0712 SUP Custom 27803010 72-16-0712 - INSERT TIBIAL 7 12MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0715 SUP Custom 27803010 72-16-0715 - INSERT TIBIAL 7 15MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0718 SUP Custom 27803010 72-16-0718 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0721 SUP Custom 27803010 72-16-0721 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0724 SUP Custom 27803010 72-16-0724 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0908 SUP Custom 27803010 72-16-0908 - INSERT TIBIAL 9 8MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0910 SUP Custom 27803010 72-16-0910 - INSERT TIBIAL 9 10MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0912 SUP Custom 27803010 72-16-0912 - INSERT TIBIAL 9 12MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0915 SUP Custom 27803010 72-16-0915 - INSERT TIBIAL 9 15MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0918 SUP Custom 27803010 72-16-0918 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0921 SUP Custom 27803010 72-16-0921 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0924 SUP Custom 27803010 72-16-0924 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-0924300 SUP Custom 27803010 72-16-0924300 - INSERT TIB CRUC RET HPR EXTN SCRPFLX BOTH IP/OP "$2,013.00 " "$1,489.62" $0.00 "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.05" "$1,494.05" $0.00 $0.00 $419.51 $0.00 $0.00 $0.00 $0.00 "$1,006.50" "$1,594.30" "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-1108 SUP Custom 27803010 72-16-1108 - INSERT TIBIAL 11 8MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-1110 SUP Custom 27803010 72-16-1110 - INSERT TIBIAL 11 10MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-1112 SUP Custom 27803010 72-16-1112 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-1115 SUP Custom 27803010 72-16-1115 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-1118 SUP Custom 27803010 72-16-1118 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-1121 SUP Custom 27803010 72-16-1121 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-16-1124 SUP Custom 27803010 72-16-1124 - INSERT TIBIAL CRUC RET HYPREX SCRPFLX BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7220025A SUP HCPCS C1713 7220025A - END CAP SPNL 22MM 20-25MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7220027A SUP HCPCS C1713 7220027A - END CAP SPNL 22MM 21-27MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7220033A SUP HCPCS C1713 7220033A - END CAP SPNL 22MM 24-33MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7220041A SUP HCPCS C1713 7220041A - END CAP SPNL 22MM 28-41MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7220055A SUP HCPCS C1713 7220055A - END CAP SPNL 22MM 35-55MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7220067A SUP HCPCS C1713 7220067A - END CAP SPNL 22MM 41-67MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7220079A SUP HCPCS C1713 7220079A - END CAP SPNL 22MM 47-79MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 7220121A SUP HCPCS C1713 7220121A - END CAP SPNL 22MM 68-121MM NS X-COR 2 ATLCK TI BOTH IP/OP "$13,962.50 " "$10,332.25" $0.00 "$11,170.00" "$6,283.13" "$6,283.13" $0.00 $0.00 $0.00 "$2,910.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,909.79" $0.00 "$6,883.51" "$6,883.51" $0.00 "$6,981.25" "$11,058.30" "$11,170.00" $0.00 $0.00 "$2,185.13" $0.00 $0.00 "$2,222.83" $0.00 $0.00 $0.00 $0.00 $0.00 72-2049 SUP Custom 27203010 72-2049 - DRILL SURG 1.5MM 5MM STOP HIGH SPEED MANDIB IQ BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $456.45 $456.45 $0.00 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $307.50 $487.08 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-2055 SUP Custom 27203010 72-2055 - DRILL SURG 1.5MM 22MM STOP MANDIB BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $456.45 $456.45 $0.00 $0.00 $128.17 $0.00 $0.00 $0.00 $0.00 $307.50 $487.08 $492.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0308 SUP Custom 27803010 72-25-0308 - INSERT TIBIAL 3 8MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0310 SUP Custom 27803010 72-25-0310 - INSERT TIBIAL 3 10MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0312 SUP HCPCS C1776 72-25-0312 - INSERT TIB 3 12MM SCRPFLX POST STAB PE KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0315 SUP HCPCS C1776 72-25-0315 - INSERT TIB 3 15MM SCRPFLX POST STAB X3 KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0318 SUP HCPCS C1776 72-25-0318 - INSERT TIB 3 18MM SCRPFLX POST STAB X3 KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0321 SUP HCPCS C1776 72-25-0321 - INSERT TIB 3 21MM SCRPFLX POST STAB X3 KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0324 SUP HCPCS C1776 72-25-0324 - INSERT TIB 3 24MM SCRPFLX POST STAB X3 KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0508 SUP Custom 27803010 72-25-0508 - INSERT TIBIAL 5 8MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0510 SUP Custom 27803010 72-25-0510 - INSERT TIBIAL 5 10MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0512 SUP Custom 27803010 72-25-0512 - INSERT TIBIAL 5 12MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0515 SUP Custom 27803010 72-25-0515 - INSERT TIBIAL 5 15MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0518 SUP HCPCS C1776 72-25-0518 - INSERT TIB SCRPFLX POST STAB X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0521 SUP Custom 27803010 72-25-0521 - INSERT TIB 5 21MM SCRP SFLX POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0524 SUP Custom 27803010 72-25-0524 - INSERT TIB 5 24MM SCRPFLX POST STAB X3 ARTC KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0708 SUP Custom 27803010 72-25-0708 - INSERT TIBIAL 7 8MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0710 SUP Custom 27803010 72-25-0710 - INSERT TIBIAL 7 10MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0712 SUP Custom 27803010 72-25-0712 - INSERT TIBIAL 7 12MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0715 SUP Custom 27803010 72-25-0715 - INSERT TIBIAL 7 15MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0718 SUP Custom 27803010 72-25-0718 - INSERT TIBIAL POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0721 SUP Custom 27803010 72-25-0721 - INSERT TIB 7 21MM SCRP SFLX POST STAB KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0724 SUP Custom 27803010 72-25-0724 - INSERT TIB 7 24MM SCRPFLX POST STAB X3 KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0908 SUP Custom 27803010 72-25-0908 - INSERT TIBIAL 9 8MM POSTERIOR STABILIZE SCRPFLX X3 RIGHT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0910 SUP Custom 27803010 72-25-0910 - INSERT TIBIAL 9 10MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0912 SUP Custom 27803010 72-25-0912 - INSERT TIBIAL 9 12MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0915 SUP Custom 27803010 72-25-0915 - INSERT TIBIAL 9 15MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0918 SUP Custom 27803010 72-25-0918 - INSERT TIB 9 18MM SCRPFLX POST STAB X3 ARTC BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0921 SUP Custom 27803010 72-25-0921 - INSERT TIB 9 21MM SCRPFLX POST STAB X3 ARTC KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-0924 SUP Custom 27803010 72-25-0924 - INSERT TIB 9 24MM STRL SCRPFLX POST STAB X3 KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-1108 SUP Custom 27803010 72-25-1108 - INSERT TIBIAL 11 8MM POSTERIOR STABILIZE SCORPIO SUPERFLEX BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-1110 SUP Custom 27803010 72-25-1110 - INSERT TIBIAL 11 10MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-1112 SUP Custom 27803010 72-25-1112 - INSERT TIBIAL 11 12MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-1115 SUP Custom 27803010 72-25-1115 - INSERT TIBIAL 11 15MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-1118 SUP Custom 27803010 72-25-1118 - INSERT TIBIAL 11 18MM POSTERIOR STABILIZE SCRPFLX BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-1121 SUP Custom 27803010 72-25-1121 - INSERT TIBIAL 11 21MM POSTERIOR STABILIZE SCRPFLX X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-25-1124 SUP Custom 27803010 72-25-1124 - INSERT TIBIAL 11 24MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0308 SUP Custom 27803010 72-26-0308 - INSERT TIBIAL 3 8MM CRUC RET SCRPFLX POLYETHYLENE KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0310 SUP Custom 27803010 72-26-0310 - INSERT TIBIAL 3 10MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0312 SUP Custom 27803010 72-26-0312 - INSERT TIBIAL 3 12MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0315 SUP Custom 27803010 72-26-0315 - INSERT TIBIAL 3 15MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0318 SUP Custom 27803010 72-26-0318 - INSERT TIBIAL 3 18MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0321 SUP Custom 27803010 72-26-0321 - INSERT TIBIAL 3 21MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0324 SUP Custom 27803010 72-26-0324 - INSERT TIBIAL 3 24MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0508 SUP Custom 27803010 72-26-0508 - INSERT TIBIAL 5 8MM CRUC RET POSTERIOR STABILIZED SCRPFLX X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0510 SUP Custom 27803010 72-26-0510 - INSERT TIBIAL 5 10MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0512 SUP Custom 27803010 72-26-0512 - INSERT TIBIAL 5 12MM CRUC RET SCRPFLX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0515 SUP Custom 27803010 72-26-0515 - INSERT TIB 5 15MM STRL SCRPFLX CR X3 KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0518 SUP Custom 27803010 72-26-0518 - INSERT TIBIAL 5 18MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0521 SUP Custom 27803010 72-26-0521 - INSERT TIBIAL CRUC RET SCORPIO SUPERFLEX BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0524 SUP Custom 27803010 72-26-0524 - INSERT TIBIAL CRUC RET SCORPIO SUPERFLEX BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0708 SUP Custom 27803010 72-26-0708 - INSERT TIBIAL 7 8MM CRUC RET POSTERIOR STABILIZED SCRPFLX X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0710 SUP Custom 27803010 72-26-0710 - INSERT TIBIAL 7 10MM CRUC RET POSTERIOR STABILIZED SCRPFLX BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0712 SUP Custom 27803010 72-26-0712 - INSERT TIBIAL 7 12MM CRUC RET POSTERIOR STABILIZED SCRPFLX BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0715 SUP Custom 27803010 72-26-0715 - INSERT TIBIAL 7 15MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0718 SUP Custom 27803010 72-26-0718 - INSERT TIBIAL CRUC RET SCORPIO SUPERFLEX BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0721 SUP Custom 27803010 72-26-0721 - INSERT TIBIAL 7 21MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0724 SUP Custom 27803010 72-26-0724 - INSERT TIBIAL 7 24MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0908 SUP Custom 27803010 72-26-0908 - INSERT TIBIAL 9 8MM POSTERIOR STABILIZE SCRPFLX X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0910 SUP Custom 27803010 72-26-0910 - INSERT TIBIAL 9 10MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0912 SUP Custom 27803010 72-26-0912 - INSERT TIBIAL 9 12MM CRUC RET SCORPIO SUPERFLEX POLYETHYLENE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0915 SUP Custom 27803010 72-26-0915 - INSERT TIBIAL 9 15MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0918 SUP Custom 27803010 72-26-0918 - INSERT TIBIAL 9 18MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0921 SUP Custom 27803010 72-26-0921 - INSERT TIBIAL 9 21MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-0924 SUP Custom 27803010 72-26-0924 - INSERT TIBIAL 9 24MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-1108 SUP Custom 27803010 72-26-1108 - INSERT TIBIAL 11 8MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-1110 SUP Custom 27803010 72-26-1110 - INSERT TIB 11 10MM SCRP SFLX CRCTE RTN KN BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-1112 SUP Custom 27803010 72-26-1112 - INSERT TIBIAL 11 12MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-1115 SUP Custom 27803010 72-26-1115 - INSERT TIBIAL CRUC RET SCRPFLX BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-1118 SUP Custom 27803010 72-26-1118 - INSERT TIBIAL 11 18MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-1121 SUP Custom 27803010 72-26-1121 - INSERT TIBIAL 11 21MM CRUCIATE RETAIN SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-26-1124 SUP Custom 27803010 72-26-1124 - INSERT TIBIAL 11 24MM CRUC RET SCORPIO SUPERFLEX KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72402408N SUP HCPCS C1713 72402408N - SCREW BONE 2.4MM 3.8MM 8MM EVOS MINI SS CORT ST T7 BOTH IP/OP $118.75 $87.88 $0.00 $95.00 $53.44 $53.44 $0.00 $0.00 $0.00 $24.75 $88.14 $88.14 $0.00 $0.00 $24.75 $0.00 $70.24 $70.24 $0.00 $59.38 $94.05 $95.00 $0.00 $0.00 $18.58 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 72402409N SUP HCPCS C1713 72402409N - SCREW BONE 2.4MM 3.8MM 9MM EVOS MINI SS CORT ST T7 BOTH IP/OP $118.75 $87.88 $0.00 $95.00 $53.44 $53.44 $0.00 $0.00 $0.00 $24.75 $88.14 $88.14 $0.00 $0.00 $24.75 $0.00 $70.24 $70.24 $0.00 $59.38 $94.05 $95.00 $0.00 $0.00 $18.58 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 72402410N SUP HCPCS C1713 72402410N - SCREW BONE 2.4MM 3.8MM 10MM EVOS MINI SS CORTEX T7 BOTH IP/OP $118.75 $87.88 $0.00 $95.00 $53.44 $53.44 $0.00 $0.00 $0.00 $24.75 $88.14 $88.14 $0.00 $0.00 $24.75 $0.00 $70.24 $70.24 $0.00 $59.38 $94.05 $95.00 $0.00 $0.00 $18.58 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 72402420N SUP HCPCS C1713 72402420N - SCREW BONE 2.4MM 3.8MM 20MM EVOS SS 1.6MM SM BONE BOTH IP/OP $118.75 $87.88 $0.00 $95.00 $53.44 $53.44 $0.00 $0.00 $0.00 $24.75 $88.14 $88.14 $0.00 $0.00 $24.75 $0.00 $70.24 $70.24 $0.00 $59.38 $94.05 $95.00 $0.00 $0.00 $18.58 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0310 SUP Custom 27203010 72-4-0310 - TRIAL SURG 3 10MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0312 SUP Custom 27203010 72-4-0312 - TRIAL SURG 3 12MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0314 SUP Custom 27203010 72-4-0314 - TRIAL SURG 3 14MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0316 SUP Custom 27203010 72-4-0316 - TRIAL SURG 3 16MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0318 SUP Custom 27203010 72-4-0318 - INSERT TIBIAL 3 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0321 SUP Custom 27203010 72-4-0321 - TRIAL SURG 3 21MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0324 SUP HCPCS C1776 72-4-0324 - INSERT TIBIAL 3 24MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0510 SUP Custom 27203010 72-4-0510 - TRIAL SURG 5 10MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0512 SUP Custom 27203010 72-4-0512 - INSERT TIBIAL 5 12MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0514 SUP HCPCS C1776 72-4-0514 - INSERT TIBIAL 5 14MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0516 SUP HCPCS C1776 72-4-0516 - INSERT TIBIAL 5 16MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0518 SUP HCPCS C1776 72-4-0518 - INSERT TIBIAL 5 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0521 SUP HCPCS C1776 72-4-0521 - INSERT TIBIAL 5 21MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0524 SUP Custom 27203010 72-4-0524 - TRIAL SURG 5 24MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0710 SUP HCPCS C1776 72-4-0710 - INSERT TIBIAL 7 10MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0712 SUP HCPCS C1776 72-4-0712 - INSERT TIBIAL 7 12MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0714 SUP HCPCS C1776 72-4-0714 - INSERT TIBIAL 7 14MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0716 SUP HCPCS C1776 72-4-0716 - INSERT TIBIAL 7 16MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0718 SUP HCPCS C1776 72-4-0718 - INSERT TIBIAL 7 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0721 SUP HCPCS C1776 72-4-0721 - INSERT TIBIAL 7 21MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0724 SUP HCPCS C1776 72-4-0724 - INSERT TIBIAL 7 24MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0910 SUP Custom 27203010 72-4-0910 - TRIAL SURG 9 10MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0912 SUP HCPCS C1776 72-4-0912 - INSERT TIBIAL 9 12MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0914 SUP HCPCS C1776 72-4-0914 - INSERT TIBIAL 9 14MM CONSTRAINED TOT STABILIZED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0916 SUP HCPCS C1776 72-4-0916 - INSERT TIBIAL 9 16MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0918 SUP HCPCS C1776 72-4-0918 - INSERT TIBIAL 9 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0921 SUP HCPCS C1776 72-4-0921 - INSERT TIBIAL 9 21MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-0924 SUP Custom 27203010 72-4-0924 - TRIAL SURG 9 24MM INSERT TOT STABILITY CONSTRAINED SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 $0.00 $0.00 $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1110 SUP HCPCS C1776 72-4-1110 - INSERT TIBIAL 11 10MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1112 SUP HCPCS C1776 72-4-1112 - INSERT TIBIAL 11 12MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1114 SUP HCPCS C1776 72-4-1114 - INSERT TIBIAL 11 14MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1116 SUP HCPCS C1776 72-4-1116 - INSERT TIBIAL 11 16MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1118 SUP HCPCS C1776 72-4-1118 - INSERT TIBIAL 11 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1121 SUP HCPCS C1776 72-4-1121 - INSERT TIBIAL 11 21MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1124 SUP HCPCS C1776 72-4-1124 - INSERT TIBIAL 11 24MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72412410N SUP HCPCS C1713 72412410N - SCREW BONE 2.4MM 3.8MM 10MM EVOS SS LNG BONE SM BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $172.13 $172.13 $0.00 $0.00 $0.00 $79.72 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $226.25 $226.25 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $59.86 $0.00 $0.00 $60.89 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1910 SUP HCPCS C1776 72-4-1910 - INSERT TIBIAL 19 10MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1912 SUP HCPCS C1776 72-4-1912 - INSERT TIBIAL 19 12MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1914 SUP HCPCS C1776 72-4-1914 - INSERT TIBIAL 19 14MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1916 SUP HCPCS C1776 72-4-1916 - INSERT TIBIAL 19 16MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1918 SUP HCPCS C1776 72-4-1918 - INSERT TIBIAL 19 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1921 SUP HCPCS C1776 72-4-1921 - INSERT TIBIAL 19 21MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-1924 SUP HCPCS C1776 72-4-1924 - INSERT TIBIAL 19 24MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-5710 SUP HCPCS C1776 72-4-5710 - INSERT TIBIAL 7 10MM TOT STABILIZE SCORPIO POLYETHYLENE KNEE BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-5712 SUP HCPCS C1776 72-4-5712 - INSERT TIBIAL 7 12MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-5714 SUP HCPCS C1776 72-4-5714 - INSERT TIBIAL 7 14MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-5716 SUP HCPCS C1776 72-4-5716 - INSERT TIBIAL 7 16MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-5718 SUP HCPCS C1776 72-4-5718 - INSERT TIBIAL 7 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-5721 SUP HCPCS C1776 72-4-5721 - INSERT TIBIAL 7 21MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-5724 SUP HCPCS C1776 72-4-5724 - INSERT TIBIAL 7 24MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-7512 SUP HCPCS C1776 72-4-7512 - INSERT TIBIAL 7F/5T 12MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-7514 SUP HCPCS C1776 72-4-7514 - INSERT TIBIAL 7F/5T 14MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-7516 SUP HCPCS C1776 72-4-7516 - INSERT TIBIAL 7F/5T 16MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-7518 SUP HCPCS C1776 72-4-7518 - INSERT TIBIAL 7F/5T 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-7521 SUP HCPCS C1776 72-4-7521 - INSERT TIBIAL 7F/5T 21MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-7524 SUP HCPCS C1776 72-4-7524 - INSERT TIBIAL 7F/5T 24MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-9110 SUP HCPCS C1776 72-4-9110 - INSERT TIBIAL 9F/11T 10MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-9112 SUP HCPCS C1776 72-4-9112 - INSERT TIBIAL 9F/11T 12MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-9114 SUP HCPCS C1776 72-4-9114 - INSERT TIBIAL 9F/11T 14MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-9116 SUP HCPCS C1776 72-4-9116 - INSERT TIBIAL 9F/11T 16MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-9118 SUP HCPCS C1776 72-4-9118 - INSERT TIBIAL 9F/11T 18MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-9121 SUP HCPCS C1776 72-4-9121 - INSERT TIBIAL 9F/11T 21MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-4-9124 SUP HCPCS C1776 72-4-9124 - INSERT TIBIAL 9F/11T 24MM CONSTRAIN TOT STABILIZE SCORPIO BOTH IP/OP "$3,492.50 " "$2,584.45" $0.00 "$2,794.00" "$1,571.63" "$1,571.63" $0.00 $0.00 $0.00 $727.92 "$2,592.13" "$2,592.13" $0.00 $0.00 $727.84 $0.00 "$1,721.80" "$1,721.80" $0.00 "$1,746.25" "$2,766.06" "$2,794.00" $0.00 $0.00 $546.58 $0.00 $0.00 $556.01 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0508 SUP Custom 27803010 72-5-0508 - INSERT TIB 5 8MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0510 SUP Custom 27803010 72-5-0510 - INSERT TIB 5 10MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0512 SUP Custom 27803010 72-5-0512 - INSERT TIB 5 12MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0515 SUP Custom 27803010 72-5-0515 - INSERT TIB 5 15MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0518 SUP Custom 27803010 72-5-0518 - INSERT TIB 5 18MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0521 SUP Custom 27803010 72-5-0521 - INSERT TIB 5 21MM KNEE PS SCRP SFLX BOTH IP/OP "$2,013.00 " "$1,489.62" $0.00 "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.05" "$1,494.05" $0.00 $0.00 $419.51 $0.00 $0.00 $0.00 $0.00 "$1,006.50" "$1,594.30" "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0524 SUP Custom 27803010 72-5-0524 - INSERT TIB 5 44X66X24MM SCRPFLX 1 AXIS PS PE KN BOTH IP/OP "$2,013.00 " "$1,489.62" $0.00 "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.05" "$1,494.05" $0.00 $0.00 $419.51 $0.00 $0.00 $0.00 $0.00 "$1,006.50" "$1,594.30" "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0708 SUP Custom 27803010 72-5-0708 - INSERT TIB 7 8MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0710 SUP Custom 27803010 72-5-0710 - INSERT TIB KNEE PS SCRPFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0712 SUP Custom 27803010 72-5-0712 - INSERT TIB 7 12MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0715 SUP Custom 27803010 72-5-0715 - INSERT TIB 7 15MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0718 SUP Custom 27803010 72-5-0718 - INSERT TIB 7 18MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0721 SUP Custom 27803010 72-5-0721 - INSERT TIB 7 21MM SCRP SFLX POST STAB KN BOTH IP/OP "$2,013.00 " "$1,489.62" $0.00 "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.05" "$1,494.05" $0.00 $0.00 $419.51 $0.00 $0.00 $0.00 $0.00 "$1,006.50" "$1,594.30" "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0724 SUP Custom 27803010 72-5-0724 - INSERT TIB 7 24MM SCRPFLX POST STAB X3 KN BOTH IP/OP "$2,013.00 " "$1,489.62" $0.00 "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.05" "$1,494.05" $0.00 $0.00 $419.51 $0.00 $0.00 $0.00 $0.00 "$1,006.50" "$1,594.30" "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0908 SUP HCPCS C1776 72-5-0908 - CMPNT TIB 8MM SCRP 9 KNEE PE PS BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $868.50 $868.50 $0.00 $0.00 $0.00 $402.26 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 "$1,141.60" "$1,141.60" $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $302.05 $0.00 $0.00 $307.26 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0910 SUP Custom 27803010 72-5-0910 - INSERT TIB 9 10MM RIGHT KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0912 SUP Custom 27803010 72-5-0912 - INSERT TIB 9 12MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0915 SUP Custom 27803010 72-5-0915 - INSERT TIB 9 15MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0918 SUP Custom 27803010 72-5-0918 - INSERT TIB 9 18MM SCRP SFLX POST STAB ARTC KN BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0921 SUP Custom 27803010 72-5-0921 - INSERT TIB 9 21MM SCRP SFLX POST STAB ARTC KN BOTH IP/OP "$2,013.00 " "$1,489.62" $0.00 "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.05" "$1,494.05" $0.00 $0.00 $419.51 $0.00 $0.00 $0.00 $0.00 "$1,006.50" "$1,594.30" "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-0924 SUP Custom 27803010 72-5-0924 - INSERT TIB 9 24MM SCRP SFLX POST STAB KN BOTH IP/OP "$2,013.00 " "$1,489.62" $0.00 "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.05" "$1,494.05" $0.00 $0.00 $419.51 $0.00 $0.00 $0.00 $0.00 "$1,006.50" "$1,594.30" "$1,610.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-5-1110 SUP Custom 27803010 72-5-1110 - INSERT TIB 11 10MM KNEE PS SCRP SFLX BOTH IP/OP "$1,930.00 " "$1,428.20" $0.00 "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,432.45" "$1,432.45" $0.00 $0.00 $402.21 $0.00 $0.00 $0.00 $0.00 $965.00 "$1,528.56" "$1,544.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-6-0515 SUP Custom 27803010 72-6-0515 - INSERT TIB 5 15MM SCRP SFLX CRCTE RTN KN BOTH IP/OP "$1,922.00 " "$1,422.28" $0.00 "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,426.51" "$1,426.51" $0.00 $0.00 $400.54 $0.00 $0.00 $0.00 $0.00 $961.00 "$1,522.22" "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-6-0708 SUP Custom 27803010 72-6-0708 - INSERT TIB 7 8MM KNEE CRUC RET SCRP SFLX BOTH IP/OP "$1,922.00 " "$1,422.28" $0.00 "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,426.51" "$1,426.51" $0.00 $0.00 $400.54 $0.00 $0.00 $0.00 $0.00 $961.00 "$1,522.22" "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-6-0710 SUP Custom 27803010 72-6-0710 - INSERT TIB KNEE CRUC RET SCRP SFLX BOTH IP/OP "$1,922.00 " "$1,422.28" $0.00 "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,426.51" "$1,426.51" $0.00 $0.00 $400.54 $0.00 $0.00 $0.00 $0.00 $961.00 "$1,522.22" "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-6-0908 SUP Custom 27803010 72-6-0908 - INSERT TIB 9 8MM KNEE CRUC RET SCRP SFLX BOTH IP/OP "$1,922.00 " "$1,422.28" $0.00 "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,426.51" "$1,426.51" $0.00 $0.00 $400.54 $0.00 $0.00 $0.00 $0.00 $961.00 "$1,522.22" "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72-6-1110 SUP Custom 27803010 72-6-1110 - INSERT TIB 11 10MM SCRP SFLX CRCTE RTN KN BOTH IP/OP "$1,922.00 " "$1,422.28" $0.00 "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,426.51" "$1,426.51" $0.00 $0.00 $400.54 $0.00 $0.00 $0.00 $0.00 $961.00 "$1,522.22" "$1,537.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72821012S SUP HCPCS C1713 72821012S - PLATE BN 20X11MM STRL VLP LT MDL LAT TALUS 2.5MM SCR BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 72821013S SUP HCPCS C1713 72821013S - PLATE BN 20X11MM STRL VLP RT MDL LAT TALUS 2.5MM SCR BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 72821014S SUP HCPCS C1713 72821014S - PLATE BN 22X16MM STRL VLP 3 HL L/L TALUS 2.5MM SCR BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 72821015S SUP HCPCS C1713 72821015S - PLATE BN 22X16MM STRL VLP 3 HL RL TALUS 2.5MM SCR BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 72821016S SUP HCPCS C1713 72821016S - PLATE BN 25X16MM STRL VLP 4 HL L/L TALUS 2.5MM SCR BOTH IP/OP "$2,275.00 " "$1,683.50" $0.00 "$1,820.00" "$1,023.75" "$1,023.75" $0.00 $0.00 $0.00 $474.17 "$1,688.51" "$1,688.51" $0.00 $0.00 $474.11 $0.00 "$1,345.66" "$1,345.66" $0.00 "$1,137.50" "$1,801.80" "$1,820.00" $0.00 $0.00 $356.04 $0.00 $0.00 $362.18 $0.00 $0.00 $0.00 $0.00 $0.00 72821017S SUP HCPCS C1713 72821017S - PLATE BN 25X16MM STRL VLP 4 HL RL TALUS FT 2.5MM SCR BOTH IP/OP "$2,275.00 " "$1,683.50" $0.00 "$1,820.00" "$1,023.75" "$1,023.75" $0.00 $0.00 $0.00 $474.17 "$1,688.51" "$1,688.51" $0.00 $0.00 $474.11 $0.00 "$1,345.66" "$1,345.66" $0.00 "$1,137.50" "$1,801.80" "$1,820.00" $0.00 $0.00 $356.04 $0.00 $0.00 $362.18 $0.00 $0.00 $0.00 $0.00 $0.00 72821018S SUP HCPCS C1713 72821018S - PLATE BN SM 55MM STRL VLP LT CALCANEUS FT 2.7MM SCR PERC BOTH IP/OP "$2,306.25 " "$1,706.63" $0.00 "$1,845.00" "$1,037.81" "$1,037.81" $0.00 $0.00 $0.00 $480.68 "$1,711.70" "$1,711.70" $0.00 $0.00 $480.62 $0.00 "$1,364.15" "$1,364.15" $0.00 "$1,153.13" "$1,826.55" "$1,845.00" $0.00 $0.00 $360.93 $0.00 $0.00 $367.16 $0.00 $0.00 $0.00 $0.00 $0.00 72821019S SUP HCPCS C1713 72821019S - PLATE BN SM 55MM STRL VLP RT CALCANEUS 2.7MM SCR PERC BOTH IP/OP "$2,306.25 " "$1,706.63" $0.00 "$1,845.00" "$1,037.81" "$1,037.81" $0.00 $0.00 $0.00 $480.68 "$1,711.70" "$1,711.70" $0.00 $0.00 $480.62 $0.00 "$1,364.15" "$1,364.15" $0.00 "$1,153.13" "$1,826.55" "$1,845.00" $0.00 $0.00 $360.93 $0.00 $0.00 $367.16 $0.00 $0.00 $0.00 $0.00 $0.00 72821020S SUP HCPCS C1713 72821020S - PLATE BN LG 62 STRL VLP LT CALCANEUS FT 2.7MM SCR PERC BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 72821021S SUP HCPCS C1713 72821021S - PLATE BN LG 62 STRL VLP RT CALCANEUS FT 2.7MM SCR PERC BOTH IP/OP "$2,512.50 " "$1,859.25" $0.00 "$2,010.00" "$1,130.63" "$1,130.63" $0.00 $0.00 $0.00 $523.67 "$1,864.78" "$1,864.78" $0.00 $0.00 $523.61 $0.00 "$1,238.66" "$1,238.66" $0.00 "$1,256.25" "$1,989.90" "$2,010.00" $0.00 $0.00 $393.21 $0.00 $0.00 $399.99 $0.00 $0.00 $0.00 $0.00 $0.00 72821022S SUP HCPCS C1713 72821022S - PLATE BN 67MM STRL 3 HL FSN PRM RT ANT ANKL 3.5MM SCR BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 72821023S SUP HCPCS C1713 72821023S - PLATE BN 67MM STRL 3 HL FSN PRM LT ANT ANKL 3.5MM SCR BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 72821024S SUP HCPCS C1713 72821024S - PLATE BN 92MM STRL 5 HL FSN PRM RT ANT ANKL 3.5MM SCR BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 72821025S SUP HCPCS C1713 72821025S - PLATE BN 92MM STRL 5 HL FSN PRM LT ANT ANKL 3.5MM SCR BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 72821026S SUP HCPCS C1713 72821026S - PLATE BN 79MM STRL 3 HL FSN UTL RT ANKL HINDFOOT 3.5MM SCR BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 72821027S SUP HCPCS C1713 72821027S - PLATE BN 79MM STRL 3 HL FSN UTL LT ANKL HINDFOOT 3.5MM SCR BOTH IP/OP "$2,575.00 " "$1,905.50" $0.00 "$2,060.00" "$1,158.75" "$1,158.75" $0.00 $0.00 $0.00 $536.69 "$1,911.17" "$1,911.17" $0.00 $0.00 $536.63 $0.00 "$1,269.48" "$1,269.48" $0.00 "$1,287.50" "$2,039.40" "$2,060.00" $0.00 $0.00 $402.99 $0.00 $0.00 $409.94 $0.00 $0.00 $0.00 $0.00 $0.00 72821028S SUP HCPCS C1713 72821028S - PLATE BN 5 FSN UTL RT ANKL HINDFOOT 3.5MM SCR BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 72821029S SUP HCPCS C1713 72821029S - PLATE BN 79MM STRL 5 HL FSN UTL LT ANKL HINDFOOT 3.5MM SCR BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 72821030S SUP HCPCS C1713 72821030S - PLATE BN 120MM STRL PRLC FSN RL TIB TALOCALCANEUS ANKL 4.5MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 72821031S SUP HCPCS C1713 72821031S - PLATE BN 120MM STRL PRLC FSN L/L TIB TALOCALCANEUS ANKL 4.5 BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 72821034S SUP HCPCS C1713 72821034S - PLATE BN 80MMX3.8-5.3MM STRL PRLC FSN RT POST ANKL 3.5MM SCR BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 72821035S SUP HCPCS C1713 72821035S - PLATE BN 80MM STRL PRLC FSN LT POST ANKL 3.5MM SCR SM FRAG BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 72821036S SUP HCPCS C1713 72821036S - PLATE BONE MEDIUM 58MM VLP LEFT CALCANEUS FT STERILE 2.7MM BOTH IP/OP "$2,400.00 " "$1,776.00" $0.00 "$1,920.00" "$1,080.00" "$1,080.00" $0.00 $0.00 $0.00 $500.22 "$1,781.28" "$1,781.28" $0.00 $0.00 $500.16 $0.00 "$1,419.60" "$1,419.60" $0.00 "$1,200.00" "$1,900.80" "$1,920.00" $0.00 $0.00 $375.60 $0.00 $0.00 $382.08 $0.00 $0.00 $0.00 $0.00 $0.00 72821037S SUP HCPCS C1713 72821037S - PLATE BN MED 58MM STRL VLP RT CALCANEUS FT 2.7MM SCR PERC BOTH IP/OP "$2,400.00 " "$1,776.00" $0.00 "$1,920.00" "$1,080.00" "$1,080.00" $0.00 $0.00 $0.00 $500.22 "$1,781.28" "$1,781.28" $0.00 $0.00 $500.16 $0.00 "$1,419.60" "$1,419.60" $0.00 "$1,200.00" "$1,900.80" "$1,920.00" $0.00 $0.00 $375.60 $0.00 $0.00 $382.08 $0.00 $0.00 $0.00 $0.00 $0.00 72821040S SUP HCPCS C1713 72821040S - PLATE BN 20X17MM STRL VLP LT MDL LAT TALUS TIB 2.5MM SCR BOTH IP/OP "$2,275.00 " "$1,683.50" $0.00 "$1,820.00" "$1,023.75" "$1,023.75" $0.00 $0.00 $0.00 $474.17 "$1,688.51" "$1,688.51" $0.00 $0.00 $474.11 $0.00 "$1,345.66" "$1,345.66" $0.00 "$1,137.50" "$1,801.80" "$1,820.00" $0.00 $0.00 $356.04 $0.00 $0.00 $362.18 $0.00 $0.00 $0.00 $0.00 $0.00 72821041S SUP HCPCS C1713 72821041S - PLATE BN 20X17MM STRL VLP RT DIST MDL TALUS 2.5MM SCR BOTH IP/OP "$2,275.00 " "$1,683.50" $0.00 "$1,820.00" "$1,023.75" "$1,023.75" $0.00 $0.00 $0.00 $474.17 "$1,688.51" "$1,688.51" $0.00 $0.00 $474.11 $0.00 "$1,345.66" "$1,345.66" $0.00 "$1,137.50" "$1,801.80" "$1,820.00" $0.00 $0.00 $356.04 $0.00 $0.00 $362.18 $0.00 $0.00 $0.00 $0.00 $0.00 72821042S SUP HCPCS C1713 72821042S - PLATE BN 67MM STRL PRLC 3 HL FSN PRM CMPR SLOT ANKL RT ANT BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 72821043S SUP HCPCS C1713 72821043S - PLATE BN 67MM STRL PRLC 3 HL FSN PRM CMPR SLOT ANKL LT ANT BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 72821044S SUP HCPCS C1713 72821044S - PLATE BN 92MM STRL ANCHORAGE 5 HL PRM FSN CMPR RT ANT BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 72821045S SUP HCPCS C1713 72821045S - PLATE BN 92MM STRL PRLC 5 HL FSN PRM CMPR SLOT ANKL LT 3.5MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 72821046S SUP HCPCS C1713 72821046S - PLATE BN 5 FSN UTL CMPR RT ANKL HINDFOOT 3.5MM SCR BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 72821047S SUP HCPCS C1713 72821047S - PLATE BN 104MM STRL PER-LOC 5 HL FSN UTL CMPR SLOT LT BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 72821048S SUP HCPCS C1713 72821048S - PLATE BN XL 68X33.5X1.27MM STRL VLP VA FT LT CALCANEUS PERC BOTH IP/OP "$2,606.25 " "$1,928.63" $0.00 "$2,085.00" "$1,172.81" "$1,172.81" $0.00 $0.00 $0.00 $543.21 "$1,934.36" "$1,934.36" $0.00 $0.00 $543.14 $0.00 "$1,284.88" "$1,284.88" $0.00 "$1,303.13" "$2,064.15" "$2,085.00" $0.00 $0.00 $407.88 $0.00 $0.00 $414.92 $0.00 $0.00 $0.00 $0.00 $0.00 72821049S SUP HCPCS C1713 72821049S - PLATE BN XL 68MM VLP RT CALCANEUS FT 2.7MM SCR PERC BOTH IP/OP "$2,606.25 " "$1,928.63" $0.00 "$2,085.00" "$1,172.81" "$1,172.81" $0.00 $0.00 $0.00 $543.21 "$1,934.36" "$1,934.36" $0.00 $0.00 $543.14 $0.00 "$1,284.88" "$1,284.88" $0.00 "$1,303.13" "$2,064.15" "$2,085.00" $0.00 $0.00 $407.88 $0.00 $0.00 $414.92 $0.00 $0.00 $0.00 $0.00 $0.00 72822206S SUP HCPCS C1713 72822206S - SCREW BN 2.5MM 6MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822208S SUP HCPCS C1713 72822208S - SCREW BN 2.5MM 8MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822210S SUP HCPCS C1713 72822210S - SCREW BN 2.5MM 10MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822212S SUP HCPCS C1713 72822212S - SCREW BN 2.5MM 12MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822214S SUP HCPCS C1713 72822214S - SCREW BN 2.5MM 14MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822216S SUP HCPCS C1713 72822216S - SCREW BN 2.5MM 16MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822218S SUP HCPCS C1713 72822218S - SCREW BN 2.5MM 18MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822220S SUP HCPCS C1713 72822220S - SCREW BN 2.5MM 20MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822222S SUP HCPCS C1713 72822222S - SCREW BN 2.5MM 22MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822224S SUP HCPCS C1713 72822224S - SCREW BN 2.5MM 24MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822226S SUP HCPCS C1713 72822226S - SCREW BN 2.5MM 26MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822228S SUP HCPCS C1713 72822228S - SCREW BN 2.5MM 28MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822230S SUP HCPCS C1713 72822230S - SCREW BN 2.5MM 30MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822232S SUP HCPCS C1713 72822232S - SCREW BN 2.5MM 32MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822234S SUP HCPCS C1713 72822234S - SCREW BN 2.5MM 34MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822236S SUP HCPCS C1713 72822236S - SCREW BN 2.5MM 36MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822238S SUP HCPCS C1713 72822238S - SCREW BN 2.5MM 38MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822240S SUP HCPCS C1713 72822240S - SCREW BN 2.5MM 40MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822245S SUP HCPCS C1713 72822245S - SCREW BN 2.5MM 45MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72822250S SUP HCPCS C1713 72822250S - SCREW BN 2.5MM 50MM STRL VLP ST T7 STRDR RCS FT BOTH IP/OP $286.25 $211.83 $0.00 $229.00 $128.81 $128.81 $0.00 $0.00 $0.00 $59.66 $212.45 $212.45 $0.00 $0.00 $59.65 $0.00 $169.32 $169.32 $0.00 $143.13 $226.71 $229.00 $0.00 $0.00 $44.80 $0.00 $0.00 $45.57 $0.00 $0.00 $0.00 $0.00 $0.00 72823003S SUP HCPCS C1713 72823003S - PLATE BN STRL PRLC VLP 3 HL 1/3 TBLR 3.5 MM SCR BOTH IP/OP $505.00 $373.70 $0.00 $404.00 $227.25 $227.25 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $252.50 $399.96 $404.00 $0.00 $0.00 $79.03 $0.00 $0.00 $80.40 $0.00 $0.00 $0.00 $0.00 $0.00 72823004S SUP HCPCS C1713 72823004S - PLATE BN 1/3 TBLR STRL PRLC VLP 4 HL 3.5MM SCR BOTH IP/OP $505.00 $373.70 $0.00 $404.00 $227.25 $227.25 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $252.50 $399.96 $404.00 $0.00 $0.00 $79.03 $0.00 $0.00 $80.40 $0.00 $0.00 $0.00 $0.00 $0.00 72823106S SUP HCPCS C1713 72823106S - SCREW BN ST 2.7MM 6MM STRL VLP LCK CORT FT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823108S SUP HCPCS C1713 72823108S - SCREW BN ST 2.7MM 8MM STRL VLP ST LCK FT CORT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823110S SUP HCPCS C1713 72823110S - SCREW BN 5MM 38MM VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823112S SUP HCPCS C1713 72823112S - SCREW BN 2.7MM 12MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823114S SUP HCPCS C1713 72823114S - SCREW BN 2.7MM 14MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823116S SUP HCPCS C1713 72823116S - SCREW BN 2.7MM 16MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823118S SUP HCPCS C1713 72823118S - SCREW BN 2.7MM 18MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823120S SUP HCPCS C1713 72823120S - SCREW BN 2.7MM 20MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823122S SUP HCPCS C1713 72823122S - SCREW BN 2.7MM 22MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823124S SUP HCPCS C1713 72823124S - SCREW BN 2.7MM 24MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823126S SUP HCPCS C1713 72823126S - SCREW BN 2.7MM 26MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823128S SUP HCPCS C1713 72823128S - SCREW BN 2.7MM 28MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823130S SUP HCPCS C1713 72823130S - SCREW BN 2.7MM 30MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823132S SUP HCPCS C1713 72823132S - SCREW BN 2.7MM 32MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823134S SUP HCPCS C1713 72823134S - SCREW BN 2.7MM 34MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823136S SUP HCPCS C1713 72823136S - SCREW BN 2.7MM 36MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823138S SUP HCPCS C1713 72823138S - SCREW BN 2.7MM 38MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823140S SUP HCPCS C1713 72823140S - SCREW BN 2.7MM 40MM STRL VLP ST LCK CORT FOREFOOT MIDFOOT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823142S SUP HCPCS C1713 72823142S - SCREW BN 3 FLUT 2.7MM 4.9MM 42MM STRL VLP ST LCK CORT FT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823144S SUP HCPCS C1713 72823144S - SCREW BN 3 FLUT LOPRFL 2.7MM 4.9MM 44MM STRL VLP ST LCK CORT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823146S SUP HCPCS C1713 72823146S - SCREW BN 3 FLUT LOPRFL 2.7MM 4.9MM 46MM STRL VLP ST LCK CORT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823148S SUP HCPCS C1713 72823148S - SCREW BN 3 FLUT LOPRFL 2.7MM 4.9MM 48MM STRL VLP ST LCK CORT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823150S SUP HCPCS C1713 72823150S - SCREW BN 2.7MM 4.9MM 50MM STRL VLP 3 FLT ST LCK FT CORT PERC BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $133.88 $133.88 $0.00 $0.00 $0.00 $62.01 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $175.97 $175.97 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $46.56 $0.00 $0.00 $47.36 $0.00 $0.00 $0.00 $0.00 $0.00 72823206S SUP HCPCS C1713 72823206S - SCREW BN FT 4MM 6MM STRL VLP FT OSTEOPENIA BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 72823208S SUP HCPCS C1713 72823208S - SCREW BN FT 4MM 8MM STRL VLP FT OSTEOPENIA BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 72823210S SUP HCPCS C1713 72823210S - SCREW BN 4MM 10MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823212S SUP HCPCS C1713 72823212S - SCREW BN 4MM 12MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823214S SUP HCPCS C1713 72823214S - SCREW BN 4MM 14MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823216S SUP HCPCS C1713 72823216S - SCREW BN 4MM 16MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823218S SUP HCPCS C1713 72823218S - SCREW BN 4MM 18MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823220S SUP HCPCS C1713 72823220S - SCREW BN 4MM 20MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823222S SUP HCPCS C1713 72823222S - SCREW BN 4MM 22MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823224S SUP HCPCS C1713 72823224S - SCREW BN 4MM 24MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823226S SUP HCPCS C1713 72823226S - SCREW BN 4MM 26MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823228S SUP HCPCS C1713 72823228S - SCREW BN 4MM 28MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823230S SUP HCPCS C1713 72823230S - SCREW BN 4MM 30MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823232S SUP HCPCS C1713 72823232S - SCREW BN 4MM 32MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823234S SUP HCPCS C1713 72823234S - SCREW BN 4MM 34MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823236S SUP HCPCS C1713 72823236S - SCREW BN 4MM 36MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823238S SUP HCPCS C1713 72823238S - SCREW BN FT 4MM 38MM STRL VLP FT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823240S SUP HCPCS C1713 72823240S - SCREW BN 4MM 40MM STRL VLP FT FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823242S SUP HCPCS C1713 72823242S - SCREW BN FT 4MM 5MM 42MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823244S SUP HCPCS C1713 72823244S - SCREW BN FT 4MM 5MM 44MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823246S SUP HCPCS C1713 72823246S - SCREW BN FT LOPRFL 4MM 5MM 46MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823248S SUP HCPCS C1713 72823248S - SCREW BN FT LOPRFL 4MM 5MM 48MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823250S SUP HCPCS C1713 72823250S - SCREW BN FT LOPRFL 4MM 5MM 50MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823326S SUP HCPCS C1713 72823326S - SCREW BN 4MM 26MM STRL VLP P/T FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823328S SUP HCPCS C1713 72823328S - SCREW BN 4MM 28MM STRL VLP P/T FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823330S SUP HCPCS C1713 72823330S - SCREW BN 4MM 30MM STRL VLP P/T FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823332S SUP HCPCS C1713 72823332S - SCREW BN 4MM 32MM STRL VLP P/T FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823334S SUP HCPCS C1713 72823334S - SCREW BN 4MM 34MM STRL VLP P/T FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823336S SUP HCPCS C1713 72823336S - SCREW BN 4MM 36MM STRL VLP P/T FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823338S SUP HCPCS C1713 72823338S - SCREW BN P/T 4MM 5MM 38MMX2.5MM STRL 14MM VLP FOREFOOT BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823340S SUP HCPCS C1713 72823340S - SCREW BN P/T 4MM 5MM 40MMX2.5MM STRL 14MM VLP FOREFOOT BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823342S SUP HCPCS C1713 72823342S - SCREW BN P/T LOPRFL 4MM 5MM 42MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823344S SUP HCPCS C1713 72823344S - SCREW BN P/T LOPRFL 4MM 5MM 44MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823346S SUP HCPCS C1713 72823346S - SCREW BN P/T LOPRFL 4MM 5MM 46MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823348S SUP HCPCS C1713 72823348S - SCREW BN P/T LOPRFL 4MM 5MM 48MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823350S SUP HCPCS C1713 72823350S - SCREW BN P/T LOPRFL 4MM 5MM 50MM STRL VLP FT OSTEOPENIA PERC BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 72823406S SUP HCPCS C1713 72823406S - SCREW BN 4MM 6MM STRL VLP LCK FT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823408S SUP HCPCS C1713 72823408S - SCREW BN 4MM 8MM STRL VLP LCK FT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823410S SUP HCPCS C1713 72823410S - SCREW BN 4MM 10MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823412S SUP HCPCS C1713 72823412S - SCREW BN 4MM 12MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823414S SUP HCPCS C1713 72823414S - SCREW BN 4MM 14MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823416S SUP HCPCS C1713 72823416S - SCREW BN 4MM 16MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823418S SUP HCPCS C1713 72823418S - SCREW BN 4MM 18MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823420S SUP HCPCS C1713 72823420S - SCREW BN 4MM 20MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823422S SUP HCPCS C1713 72823422S - SCREW BN 4MM 22MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823424S SUP HCPCS C1713 72823424S - SCREW BN 4MM 24MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823426S SUP HCPCS C1713 72823426S - SCREW BN 4MM 26MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823428S SUP HCPCS C1713 72823428S - SCREW BN 4MM 28MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823430S SUP HCPCS C1713 72823430S - SCREW BN 4MM 30MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823432S SUP HCPCS C1713 72823432S - SCREW BN 4MM 32MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823434S SUP HCPCS C1713 72823434S - SCREW BN 4MM 34MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823436S SUP HCPCS C1713 72823436S - SCREW BN 4MM 36MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823438S SUP HCPCS C1713 72823438S - SCREW BN 4MM 38MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823440S SUP HCPCS C1713 72823440S - SCREW BN 4MM 40MM STRL VLP LCK FOREFOOT MIDFOOT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823442S SUP HCPCS C1713 72823442S - SCREW BN 4MM 4.9MM 42MM STRL VLP LCK FT OSTEOPENIA PERC BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823444S SUP HCPCS C1713 72823444S - SCREW BN LOPRFL 4MM 4.9MM 44MM STRL VLP LCK FT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823446S SUP HCPCS C1713 72823446S - SCREW BN LOPRFL 4MM 4.9MM 46MM STRL VLP LCK FT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823448S SUP HCPCS C1713 72823448S - SCREW BN LOPRFL 4MM 4.9MM 48MM STRL VLP LCK FT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823450S SUP HCPCS C1713 72823450S - SCREW BN LOPRFL 4MM 4.9MM 50MM STRL VLP LCK FT OSTEOPENIA BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823510S SUP HCPCS C1713 72823510S - SCREW BN 15D 2.5MM 5MM 5.4MM 10MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823512S SUP HCPCS C1713 72823512S - SCREW BN 15D 2.5MM 5MM 5.4MM 12MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823514S SUP HCPCS C1713 72823514S - SCREW BN 15D 2.5MM 5MM 5.4MM 14MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823516S SUP HCPCS C1713 72823516S - SCREW BN 15D 2.5MM 5MM 5.4MM 16MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823518S SUP HCPCS C1713 72823518S - SCREW BN 15D 2.5MM 5MM 5.4MM 18MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823520S SUP HCPCS C1713 72823520S - SCREW BN 15D 2.5MM 5MM 5.4MM 20MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823522S SUP HCPCS C1713 72823522S - SCREW BN 15D 2.5MM 5MM 5.4MM 22MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823524S SUP HCPCS C1713 72823524S - SCREW BN 15D 2.5MM 5MM 5.4MM 24MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823526S SUP HCPCS C1713 72823526S - SCREW BN 15D 2.5MM 5MM 5.4MM 26MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823528S SUP HCPCS C1713 72823528S - SCREW BN 15D 2.5MM 5MM 5.4MM 28MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823530S SUP HCPCS C1713 72823530S - SCREW BN 15D 2.5MM 5MM 5.4MM 30MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823532S SUP HCPCS C1713 72823532S - SCREW BN 15D 2.5MM 5MM 5.4MM 32MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823534S SUP HCPCS C1713 72823534S - SCREW BN 15D 2.5MM 5MM 5.4MM 34MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823536S SUP HCPCS C1713 72823536S - SCREW BN 15D 2.5MM 5MM 5.4MM 36MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823538S SUP HCPCS C1713 72823538S - SCREW BN 15D 2.5MM 5MM 5.4MM 38MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823540S SUP HCPCS C1713 72823540S - SCREW BN 15D 2.5MM 5MM 5.4MM 40MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823542S SUP HCPCS C1713 72823542S - SCREW BN 15D 2.5MM 5MM 5.4MM 42MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823544S SUP HCPCS C1713 72823544S - SCREW BN 15D 2.5MM 5MM 5.4MM 44MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823546S SUP HCPCS C1713 72823546S - SCREW BN 15D 2.5MM 5MM 5.4MM 46MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823548S SUP HCPCS C1713 72823548S - SCREW BN 15D 2.5MM 5MM 5.4MM 48MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823550S SUP HCPCS C1713 72823550S - SCREW BN 15D 2.5MM 5MM 5.4MM 50MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823555S SUP HCPCS C1713 72823555S - SCREW BN 15D 2.5MM 5MM 5.4MM 55MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72823560S SUP HCPCS C1713 72823560S - SCREW BN 15D 2.5MM 5MM 5.4MM 60MMX3.3MM STRL VLP LCK LOPRFL BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 72824001S SUP HCPCS C1713 72824001S - PLATE BN T STRL VLP LCK VA FT 2.7MM SCR BOTH IP/OP "$1,262.50 " $934.25 $0.00 "$1,010.00" $568.13 $568.13 $0.00 $0.00 $0.00 $263.14 $937.03 $937.03 $0.00 $0.00 $263.11 $0.00 $746.77 $746.77 $0.00 $631.25 $999.90 "$1,010.00" $0.00 $0.00 $197.58 $0.00 $0.00 $200.99 $0.00 $0.00 $0.00 $0.00 $0.00 72824002S SUP HCPCS C1713 72824002S - PLATE BN L STRL PRLC VLP SS LT MTP FOREFOOT MIDFOOT 2.7MM BOTH IP/OP "$1,021.25 " $755.73 $0.00 $817.00 $459.56 $459.56 $0.00 $0.00 $0.00 $212.85 $757.97 $757.97 $0.00 $0.00 $212.83 $0.00 $604.07 $604.07 $0.00 $510.63 $808.83 $817.00 $0.00 $0.00 $159.83 $0.00 $0.00 $162.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824003S SUP HCPCS C1713 72824003S - PLATE BN L STRL PRLC VLP SS RT MTP FOREFOOT MIDFOOT 2.7MM BOTH IP/OP "$1,021.25 " $755.73 $0.00 $817.00 $459.56 $459.56 $0.00 $0.00 $0.00 $212.85 $757.97 $757.97 $0.00 $0.00 $212.83 $0.00 $604.07 $604.07 $0.00 $510.63 $808.83 $817.00 $0.00 $0.00 $159.83 $0.00 $0.00 $162.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824004S SUP HCPCS C1713 72824004S - PLATE BN H STRL PRLC VLP 5 HL SS FOREFOOT MIDFOOT 2.7MM SCR BOTH IP/OP "$1,775.00 " "$1,313.50" $0.00 "$1,420.00" $798.75 $798.75 $0.00 $0.00 $0.00 $369.95 "$1,317.41" "$1,317.41" $0.00 $0.00 $369.91 $0.00 "$1,049.91" "$1,049.91" $0.00 $887.50 "$1,405.80" "$1,420.00" $0.00 $0.00 $277.79 $0.00 $0.00 $282.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824005S SUP HCPCS C1713 72824005S - PLATE BN STRL PRLC VLP H 8 HL 2.7 MM SCR BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 72824006S SUP HCPCS C1713 72824006S - PLATE BN .25 TBLR STRL PRLC VLP 3 HL SS FOREFOOT MIDFOOT 2.7 BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $435.94 $435.94 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 72824007S SUP HCPCS C1713 72824007S - PLATE BN STRL PRLC VLP 4 HL QT TBLR MTP 2.7 MM SCR BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $435.94 $435.94 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 72824008S SUP HCPCS C1713 72824008S - PLATE BN .25 TBLR 39.8X8X1.5MM STRL VLP 5 HL FOREFOOT BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $435.94 $435.94 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 72824009S SUP HCPCS C1713 72824009S - PLATE BN STRL PRLC VLP 6 HL QT TBLR MTP 2.7 MM SCR BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $435.94 $435.94 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 72824010S SUP HCPCS C1713 72824010S - PLATE BN STRL PRLC VLP 7 HL QT TBLR MTP 2.7 MM SCR BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $435.94 $435.94 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 72824011S SUP HCPCS C1713 72824011S - PLATE BN .25 TBLR STRL PRLC VLP 8 HL SS FOREFOOT MIDFOOT 2.7 BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $435.94 $435.94 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 72824012S SUP HCPCS C1713 72824012S - PLATE BN .25 TBLR STRL PRLC VLP 3 HL CMPR SS FOREFOOT BOTH IP/OP "$1,518.75 " "$1,123.88" $0.00 "$1,215.00" $683.44 $683.44 $0.00 $0.00 $0.00 $316.55 "$1,127.22" "$1,127.22" $0.00 $0.00 $316.51 $0.00 $898.34 $898.34 $0.00 $759.38 "$1,202.85" "$1,215.00" $0.00 $0.00 $237.68 $0.00 $0.00 $241.79 $0.00 $0.00 $0.00 $0.00 $0.00 72824013S SUP HCPCS C1713 72824013S - PLATE BN STRL PRLC VLP 5 HL QT TBLR CMPR 2.7 MM SCR BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $759.38 $759.38 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $264.09 $0.00 $0.00 $268.65 $0.00 $0.00 $0.00 $0.00 $0.00 72824014S SUP HCPCS C1713 72824014S - PLATE BN .25 TBLR STRL PRLC VLP 7 HL CMPR SS FOREFOOT BOTH IP/OP "$1,775.00 " "$1,313.50" $0.00 "$1,420.00" $798.75 $798.75 $0.00 $0.00 $0.00 $369.95 "$1,317.41" "$1,317.41" $0.00 $0.00 $369.91 $0.00 "$1,049.91" "$1,049.91" $0.00 $887.50 "$1,405.80" "$1,420.00" $0.00 $0.00 $277.79 $0.00 $0.00 $282.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824015S SUP HCPCS C1713 72824015S - PLATE BN STRL PRLC VLP PRM SS LT MTP FOREFOOT MIDFOOT 2.7 MM BOTH IP/OP "$1,775.00 " "$1,313.50" $0.00 "$1,420.00" $798.75 $798.75 $0.00 $0.00 $0.00 $369.95 "$1,317.41" "$1,317.41" $0.00 $0.00 $369.91 $0.00 "$1,049.91" "$1,049.91" $0.00 $887.50 "$1,405.80" "$1,420.00" $0.00 $0.00 $277.79 $0.00 $0.00 $282.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824016S SUP HCPCS C1713 72824016S - PLATE BN 53.1MMX1.27MM STRL 11MM VLP PRM RT MTP FOREFOOT BOTH IP/OP "$1,775.00 " "$1,313.50" $0.00 "$1,420.00" $798.75 $798.75 $0.00 $0.00 $0.00 $369.95 "$1,317.41" "$1,317.41" $0.00 $0.00 $369.91 $0.00 "$1,049.91" "$1,049.91" $0.00 $887.50 "$1,405.80" "$1,420.00" $0.00 $0.00 $277.79 $0.00 $0.00 $282.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824017S SUP HCPCS C1713 72824017S - PLATE BN STRL PRLC VLP REV LT MTP 2.7 MM SCR BOTH IP/OP "$2,262.50 " "$1,674.25" $0.00 "$1,810.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $471.56 "$1,679.23" "$1,679.23" $0.00 $0.00 $471.51 $0.00 "$1,338.27" "$1,338.27" $0.00 "$1,131.25" "$1,791.90" "$1,810.00" $0.00 $0.00 $354.08 $0.00 $0.00 $360.19 $0.00 $0.00 $0.00 $0.00 $0.00 72824018S SUP HCPCS C1713 72824018S - PLATE BN STRL PRLC VLP REV SS RT MTP FOREFOOT MIDFOOT 2.7 MM BOTH IP/OP "$2,262.50 " "$1,674.25" $0.00 "$1,810.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $471.56 "$1,679.23" "$1,679.23" $0.00 $0.00 $471.51 $0.00 "$1,338.27" "$1,338.27" $0.00 "$1,131.25" "$1,791.90" "$1,810.00" $0.00 $0.00 $354.08 $0.00 $0.00 $360.19 $0.00 $0.00 $0.00 $0.00 $0.00 72824019S SUP HCPCS C1713 72824019S - PLATE BN SHRT STRL VLP FSN LCK VA TARSOMETATARSAL FT 2.7MM BOTH IP/OP "$1,775.00 " "$1,313.50" $0.00 "$1,420.00" $798.75 $798.75 $0.00 $0.00 $0.00 $369.95 "$1,317.41" "$1,317.41" $0.00 $0.00 $369.91 $0.00 "$1,049.91" "$1,049.91" $0.00 $887.50 "$1,405.80" "$1,420.00" $0.00 $0.00 $277.79 $0.00 $0.00 $282.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824020S SUP HCPCS C1713 72824020S - PLATE BN LNG STRL PRLC VLP FSN TARSOMETATARSAL 2.7MM SCR BOTH IP/OP "$2,143.75 " "$1,586.38" $0.00 "$1,715.00" $964.69 $964.69 $0.00 $0.00 $0.00 $446.81 "$1,591.09" "$1,591.09" $0.00 $0.00 $446.76 $0.00 "$1,268.03" "$1,268.03" $0.00 "$1,071.88" "$1,697.85" "$1,715.00" $0.00 $0.00 $335.50 $0.00 $0.00 $341.29 $0.00 $0.00 $0.00 $0.00 $0.00 72824021S SUP HCPCS C1713 72824021S - PLATE BN 18.1X7.1X1.5MM STRL VLP BRBL FOREFOOT MIDFOOT 2.7MM BOTH IP/OP "$1,193.75 " $883.38 $0.00 $955.00 $537.19 $537.19 $0.00 $0.00 $0.00 $248.81 $886.00 $886.00 $0.00 $0.00 $248.78 $0.00 $706.10 $706.10 $0.00 $596.88 $945.45 $955.00 $0.00 $0.00 $186.82 $0.00 $0.00 $190.05 $0.00 $0.00 $0.00 $0.00 $0.00 72824022S SUP HCPCS C1713 72824022S - PLATE BN SM 24X18X1.5MM STRL VLP UTL FOREFOOT MIDFOOT 2.7MM BOTH IP/OP "$2,012.50 " "$1,489.25" $0.00 "$1,610.00" $905.63 $905.63 $0.00 $0.00 $0.00 $419.46 "$1,493.68" "$1,493.68" $0.00 $0.00 $419.41 $0.00 "$1,190.39" "$1,190.39" $0.00 "$1,006.25" "$1,593.90" "$1,610.00" $0.00 $0.00 $314.96 $0.00 $0.00 $320.39 $0.00 $0.00 $0.00 $0.00 $0.00 72824023S SUP HCPCS C1713 72824023S - PLATE BN MED STRL PRLC VLP UTL MTP 2.7MM SCR BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 72824024S SUP HCPCS C1713 72824024S - PLATE BN LG STRL PRLC VLP UTL SS FOREFOOT MIDFOOT 2.7MM SCR BOTH IP/OP "$2,262.50 " "$1,674.25" $0.00 "$1,810.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $471.56 "$1,679.23" "$1,679.23" $0.00 $0.00 $471.51 $0.00 "$1,338.27" "$1,338.27" $0.00 "$1,131.25" "$1,791.90" "$1,810.00" $0.00 $0.00 $354.08 $0.00 $0.00 $360.19 $0.00 $0.00 $0.00 $0.00 $0.00 72824025S SUP HCPCS C1713 72824025S - PLATE BN STRL PRLC VLP 3 HL 1/3 TBLR CMPR MTP 3.5 MM SCR BOTH IP/OP "$1,518.75 " "$1,123.88" $0.00 "$1,215.00" $683.44 $683.44 $0.00 $0.00 $0.00 $316.55 "$1,127.22" "$1,127.22" $0.00 $0.00 $316.51 $0.00 $898.34 $898.34 $0.00 $759.38 "$1,202.85" "$1,215.00" $0.00 $0.00 $237.68 $0.00 $0.00 $241.79 $0.00 $0.00 $0.00 $0.00 $0.00 72824026S SUP HCPCS C1713 72824026S - PLATE BN STRL PRLC VLP 5 HL 1/3 TBLR CMPR 3.5 MM SCR BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $759.38 $759.38 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $264.09 $0.00 $0.00 $268.65 $0.00 $0.00 $0.00 $0.00 $0.00 72824027S SUP HCPCS C1713 72824027S - PLATE BN STRL PRLC VLP 7 HL 1/3 TBLR CMPR 3.5 MM SCR BOTH IP/OP "$1,775.00 " "$1,313.50" $0.00 "$1,420.00" $798.75 $798.75 $0.00 $0.00 $0.00 $369.95 "$1,317.41" "$1,317.41" $0.00 $0.00 $369.91 $0.00 "$1,049.91" "$1,049.91" $0.00 $887.50 "$1,405.80" "$1,420.00" $0.00 $0.00 $277.79 $0.00 $0.00 $282.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824028S SUP HCPCS C1713 72824028S - PLATE BN SM STRL PRLC VLP LT CALCANEUS 3.5MM SCR BOTH IP/OP "$2,018.75 " "$1,493.88" $0.00 "$1,615.00" $908.44 $908.44 $0.00 $0.00 $0.00 $420.76 "$1,498.32" "$1,498.32" $0.00 $0.00 $420.71 $0.00 "$1,194.09" "$1,194.09" $0.00 "$1,009.38" "$1,598.85" "$1,615.00" $0.00 $0.00 $315.93 $0.00 $0.00 $321.39 $0.00 $0.00 $0.00 $0.00 $0.00 72824029S SUP HCPCS C1713 72824029S - PLATE BN SM STRL PRLC VLP VA LCK RT CALCANEUS 3.5MM SCR BOTH IP/OP "$2,018.75 " "$1,493.88" $0.00 "$1,615.00" $908.44 $908.44 $0.00 $0.00 $0.00 $420.76 "$1,498.32" "$1,498.32" $0.00 $0.00 $420.71 $0.00 "$1,194.09" "$1,194.09" $0.00 "$1,009.38" "$1,598.85" "$1,615.00" $0.00 $0.00 $315.93 $0.00 $0.00 $321.39 $0.00 $0.00 $0.00 $0.00 $0.00 72824030S SUP HCPCS C1713 72824030S - PLATE BN LG STRL PRLC VLP LT CALCANEUS MIDFOOT HINDFOOT 3.5 BOTH IP/OP "$2,087.50 " "$1,544.75" $0.00 "$1,670.00" $939.38 $939.38 $0.00 $0.00 $0.00 $435.09 "$1,549.34" "$1,549.34" $0.00 $0.00 $435.04 $0.00 "$1,234.76" "$1,234.76" $0.00 "$1,043.75" "$1,653.30" "$1,670.00" $0.00 $0.00 $326.69 $0.00 $0.00 $332.33 $0.00 $0.00 $0.00 $0.00 $0.00 72824031S SUP HCPCS C1713 72824031S - PLATE BN LG STRL PRLC VLP VA LCK SS RT CALCANEUS 3.5MM SCR BOTH IP/OP "$2,087.50 " "$1,544.75" $0.00 "$1,670.00" $939.38 $939.38 $0.00 $0.00 $0.00 $435.09 "$1,549.34" "$1,549.34" $0.00 $0.00 $435.04 $0.00 "$1,234.76" "$1,234.76" $0.00 "$1,043.75" "$1,653.30" "$1,670.00" $0.00 $0.00 $326.69 $0.00 $0.00 $332.33 $0.00 $0.00 $0.00 $0.00 $0.00 72824032S SUP HCPCS C1713 72824032S - PLATE BN STRL PRLC VLP FSN MTP 3.5 MM SCR BOTH IP/OP "$2,012.50 " "$1,489.25" $0.00 "$1,610.00" $905.63 $905.63 $0.00 $0.00 $0.00 $419.46 "$1,493.68" "$1,493.68" $0.00 $0.00 $419.41 $0.00 "$1,190.39" "$1,190.39" $0.00 "$1,006.25" "$1,593.90" "$1,610.00" $0.00 $0.00 $314.96 $0.00 $0.00 $320.39 $0.00 $0.00 $0.00 $0.00 $0.00 72824033S SUP HCPCS C1713 72824033S - PLATE BN LNG STRL PRLC VLP FSN 3.5MM SCR BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 72824034S SUP HCPCS C1713 72824034S - PLATE BN STRL PRLC VLP CLMN FSN 3.5 MM SCR BOTH IP/OP "$2,993.75 " "$2,215.38" $0.00 "$2,395.00" "$1,347.19" "$1,347.19" $0.00 $0.00 $0.00 $623.97 "$2,221.96" "$2,221.96" $0.00 $0.00 $623.90 $0.00 "$1,475.92" "$1,475.92" $0.00 "$1,496.88" "$2,371.05" "$2,395.00" $0.00 $0.00 $468.52 $0.00 $0.00 $476.61 $0.00 $0.00 $0.00 $0.00 $0.00 72824035S SUP HCPCS C1713 72824035S - PLATE BN STRL VLP 6 HL MLT FRAG MIDFOOT HINDFOOT 3.5 MM SCR BOTH IP/OP "$1,775.00 " "$1,313.50" $0.00 "$1,420.00" $798.75 $798.75 $0.00 $0.00 $0.00 $369.95 "$1,317.41" "$1,317.41" $0.00 $0.00 $369.91 $0.00 "$1,049.91" "$1,049.91" $0.00 $887.50 "$1,405.80" "$1,420.00" $0.00 $0.00 $277.79 $0.00 $0.00 $282.58 $0.00 $0.00 $0.00 $0.00 $0.00 72824036S SUP HCPCS C1713 72824036S - PLATE BN STRL PRLC VLP 10 HL MLT FRAG MTP 3.5 MM SCR BOTH IP/OP "$2,443.75 " "$1,808.38" $0.00 "$1,955.00" "$1,099.69" "$1,099.69" $0.00 $0.00 $0.00 $509.34 "$1,813.75" "$1,813.75" $0.00 $0.00 $509.28 $0.00 "$1,445.48" "$1,445.48" $0.00 "$1,221.88" "$1,935.45" "$1,955.00" $0.00 $0.00 $382.45 $0.00 $0.00 $389.05 $0.00 $0.00 $0.00 $0.00 $0.00 72824037S SUP HCPCS C1713 72824037S - PLATE BN STRL PRLC VLP 14 HL MLT FRAG VARAIBLE ANG MIDFOOT BOTH IP/OP "$2,925.00 " "$2,164.50" $0.00 "$2,340.00" "$1,316.25" "$1,316.25" $0.00 $0.00 $0.00 $609.64 "$2,170.94" "$2,170.94" $0.00 $0.00 $609.57 $0.00 "$1,442.03" "$1,442.03" $0.00 "$1,462.50" "$2,316.60" "$2,340.00" $0.00 $0.00 $457.76 $0.00 $0.00 $465.66 $0.00 $0.00 $0.00 $0.00 $0.00 72824038S SUP HCPCS C1713 72824038S - PLATE BN VLP 4 HL MULTIFRAGMENT MIDFOOT HINDFOOT 3.5 MM SCR BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $759.38 $759.38 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $264.09 $0.00 $0.00 $268.65 $0.00 $0.00 $0.00 $0.00 $0.00 72824039S SUP HCPCS C1713 72824039S - PLATE BN MED STRL VLP LT CALCANEUS MIDFOOT HINDFOOT 3.5MM BOTH IP/OP "$2,225.00 " "$1,646.50" $0.00 "$1,780.00" "$1,001.25" "$1,001.25" $0.00 $0.00 $0.00 $463.75 "$1,651.40" "$1,651.40" $0.00 $0.00 $463.69 $0.00 "$1,316.09" "$1,316.09" $0.00 "$1,112.50" "$1,762.20" "$1,780.00" $0.00 $0.00 $348.21 $0.00 $0.00 $354.22 $0.00 $0.00 $0.00 $0.00 $0.00 72824040S SUP HCPCS C1713 72824040S - PLATE BN MED STRL VLP RT CALCANEUS MIDFOOT HINDFOOT 3.5MM BOTH IP/OP "$2,225.00 " "$1,646.50" $0.00 "$1,780.00" "$1,001.25" "$1,001.25" $0.00 $0.00 $0.00 $463.75 "$1,651.40" "$1,651.40" $0.00 $0.00 $463.69 $0.00 "$1,316.09" "$1,316.09" $0.00 "$1,112.50" "$1,762.20" "$1,780.00" $0.00 $0.00 $348.21 $0.00 $0.00 $354.22 $0.00 $0.00 $0.00 $0.00 $0.00 72824041S SUP HCPCS C1713 72824041S - PLATE BN XL STRL VLP LT CALCANEUS MIDFOOT HINDFOOT 3.5MM SCR BOTH IP/OP "$2,331.25 " "$1,725.13" $0.00 "$1,865.00" "$1,049.06" "$1,049.06" $0.00 $0.00 $0.00 $485.89 "$1,730.25" "$1,730.25" $0.00 $0.00 $485.83 $0.00 "$1,378.93" "$1,378.93" $0.00 "$1,165.63" "$1,846.35" "$1,865.00" $0.00 $0.00 $364.84 $0.00 $0.00 $371.14 $0.00 $0.00 $0.00 $0.00 $0.00 72824042S SUP HCPCS C1713 72824042S - PLATE BN XL RT CALC 3.5MM SCR BOTH IP/OP "$2,331.25 " "$1,725.13" $0.00 "$1,865.00" "$1,049.06" "$1,049.06" $0.00 $0.00 $0.00 $485.89 "$1,730.25" "$1,730.25" $0.00 $0.00 $485.83 $0.00 "$1,378.93" "$1,378.93" $0.00 "$1,165.63" "$1,846.35" "$1,865.00" $0.00 $0.00 $364.84 $0.00 $0.00 $371.14 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0108 SUP Custom 27803010 7291-0108 - INSERT TIB 1 8MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.12 $964.12 $0.00 $0.00 $270.71 $0.00 $0.00 $0.00 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0110 SUP Custom 27803010 7291-0110 - INSERT TIB 1 10MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,298.00 " $960.52 $0.00 "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.38 $963.38 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $649.00 "$1,028.02" "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0115 SUP Custom 27803010 7291-0115 - INSERT TIB 1 15MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.12 $964.12 $0.00 $0.00 $270.71 $0.00 $0.00 $0.00 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0118 SUP Custom 27803010 7291-0118 - INSERT TIB 1 18MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,298.00 " $960.52 $0.00 "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.38 $963.38 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $649.00 "$1,028.02" "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0121 SUP Custom 27803010 7291-0121 - INSERT TIB 1 21MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0124 SUP Custom 27803010 7291-0124 - INSERT TIB 1 24MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0308 SUP Custom 27803010 7291-0308 - INSERT TIB 3 8MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0310 SUP Custom 27803010 7291-0310 - INSERT TIB 3 10MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0312 SUP Custom 27803010 7291-0312 - INSERT TIB 3 12MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0315 SUP Custom 27803010 7291-0315 - INSERT TIB 3 15MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0318 SUP Custom 27803010 7291-0318 - INSERT TIB 3 18MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0321 SUP Custom 27803010 7291-0321 - INSERT TIB 3 21MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,298.00 " $960.52 $0.00 "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.38 $963.38 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $649.00 "$1,028.02" "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0324 SUP Custom 27803010 7291-0324 - INSERT TIB 3 24MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0512 SUP Custom 27803010 7291-0512 - INSERT TIB 5 12MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0515 SUP Custom 27803010 7291-0515 - INSERT TIB 5 15MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.12 $964.12 $0.00 $0.00 $270.71 $0.00 $0.00 $0.00 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0518 SUP Custom 27803010 7291-0518 - INSERT TIB 5 18MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.12 $964.12 $0.00 $0.00 $270.71 $0.00 $0.00 $0.00 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0521 SUP Custom 27803010 7291-0521 - INSERT TIB 5 21MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,298.00 " $960.52 $0.00 "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.38 $963.38 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $649.00 "$1,028.02" "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0524 SUP Custom 27803010 7291-0524 - INSERT TIB 5 24MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0708 SUP Custom 27803010 7291-0708 - INSERT TIB 7 8MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.12 $964.12 $0.00 $0.00 $270.71 $0.00 $0.00 $0.00 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0710 SUP Custom 27803010 7291-0710 - INSERT TIB 7 10MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,298.00 " $960.52 $0.00 "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.38 $963.38 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $649.00 "$1,028.02" "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0712 SUP Custom 27803010 7291-0712 - INSERT TIB 7 12MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,298.00 " $960.52 $0.00 "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.38 $963.38 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $649.00 "$1,028.02" "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0718 SUP Custom 27803010 7291-0718 - INSERT TIB 7 18MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,298.00 " $960.52 $0.00 "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.38 $963.38 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $649.00 "$1,028.02" "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0721 SUP Custom 27803010 7291-0721 - INSERT TIB 7 21MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0724 SUP Custom 27803010 7291-0724 - INSERT TIB 7 24MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0908 SUP Custom 27803010 7291-0908 - INSERT TIB 9 8MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,298.00 " $960.52 $0.00 "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.38 $963.38 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $649.00 "$1,028.02" "$1,038.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0910 SUP Custom 27803010 7291-0910 - INSERT TIB 9 10MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.12 $964.12 $0.00 $0.00 $270.71 $0.00 $0.00 $0.00 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0915 SUP Custom 27803010 7291-0915 - INSERT TIB 9 15MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.12 $964.12 $0.00 $0.00 $270.71 $0.00 $0.00 $0.00 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0918 SUP Custom 27803010 7291-0918 - INSERT TIB 9 18MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0921 SUP Custom 27803010 7291-0921 - INSERT TIB 9 21MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,299.00 " $961.26 $0.00 "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.12 $964.12 $0.00 $0.00 $270.71 $0.00 $0.00 $0.00 $0.00 $649.50 "$1,028.81" "$1,039.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7291-0924 SUP Custom 27803010 7291-0924 - INSERT TIB 9 24MM KNEE PS BRNG SER 1 BOTH IP/OP "$1,246.00 " $922.04 $0.00 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $924.78 $924.78 $0.00 $0.00 $259.67 $0.00 $0.00 $0.00 $0.00 $623.00 $986.83 $996.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72A002 SUP Custom 27804086 72A002 - GRAFT BONE SMALL 100-125MM FREEZE DRIED SHAFT CORTICAL BOTH IP/OP "$1,760.00 " "$1,302.40" $0.00 "$1,408.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,306.27" "$1,306.27" $0.00 $0.00 $366.78 $0.00 $0.00 $0.00 $0.00 $880.00 "$1,393.92" "$1,408.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 72B006 SUP HCPCS C1762 72B006 - GRAFT BONE LARGE 126MM FROZEN SHAFT CORTICAL BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $0.00 $0.00 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 730032ADP SUP Custom 27803010 730032ADP - GRAFT CV 42MM 32MM 15CM 32MM GLWV VSLV WVN GELTN AOR ROOT BOTH IP/OP "$6,437.50 " "$4,763.75" $0.00 "$5,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,218.75" "$5,098.50" "$5,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7300TFX25MM SUP Custom 27803010 7300TFX25MM - VALVE MTRL 25MM CRP-ED PRIMNT MAGNA BPRTH EASE HRT BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7300TFX29MM SUP Custom 27803010 7300TFX29MM - VALVE MTRL 29MM CRP-ED PRIMNT MG HRT PRICRD EASE BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7300TFX31MM SUP Custom 27803010 7300TFX31MM - VALVE MITRAL 31MM BIOPROSTHESIS EASE CARPENTIER-EDWARDS BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7300TFX33MM SUP Custom 27803010 7300TFX33MM - VALVE MTRL 33MM CRP-ED PRIMNT MG EASE PRICRD HRT BOTH IP/OP "$22,275.00 " "$16,483.50" $0.00 "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,642.11" $0.00 $0.00 $0.00 $0.00 "$11,137.50" "$17,641.80" "$17,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-0110 SUP Custom 27803010 73-0110 - COMPONENT PATLR 11 10MM MEDIALIZED DOME SCORPIO N2/VAC BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-020S SUP HCPCS C1713 73-020S - SCREW CANNULATED FULLY THREADED 7.3MM X 20MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-025S SUP HCPCS C1713 73-025S - SCREW CANNULATED FULLY THREADED 7.3MM X 25MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-030S SUP HCPCS C1713 73-030S - SCREW CANNULATED FULLY THREADED 7.3MM X 30MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-035S SUP HCPCS C1713 73-035S - SCREW CANNULATED FULLY THREADED 7.3MM X 35MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-040S SUP HCPCS C1713 73-040S - SCREW CANNULATED FULLY THREADED 7.3MM X 40MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-045S SUP HCPCS C1713 73-045S - SCREW CANNULATED FULLY THREADED 7.3MM X 45MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-050S SUP HCPCS C1713 73-050S - SCREW CANNULATED FULLY THREADED 7.3MM X 50MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-0510 SUP Custom 27803010 73-0510 - COMPONENT PATLR 5 1.5MM OFFST 32/35MM 5MM 5MMX10MM MEDIALIZE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-055S SUP HCPCS C1713 73-055S - SCREW CANNULATED FULLY THREADED 7.3MM X 55MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-060S SUP HCPCS C1713 73-060S - SCREW CANNULATED FULLY THREADED 7.3MM X 60MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-065S SUP HCPCS C1713 73-065S - SCREW CANNULATED FULLY THREADED 7.3MM X 65MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-070S SUP HCPCS C1713 73-070S - SCREW CANNULATED FULLY THREADED 7.3MM X 70MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-0710 SUP Custom 27803010 73-0710 - COMPONENT PATLR 7 1.5MM OFFST 34/38MM 5MM 5MMX10MM MEDIALIZE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-075S SUP HCPCS C1713 73-075S - SCREW CANNULATED FULLY THREADED 7.3MM X 75MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-080S SUP HCPCS C1713 73-080S - SCREW CANNULATED FULLY THREADED 7.3MM X 80MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-085S SUP HCPCS C1713 73-085S - SCREW CANNULATED FULLY THREADED 7.3MM X 85MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-090S SUP HCPCS C1713 73-090S - SCREW CANNULATED FULLY THREADED 7.3MM X 90MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-0910 SUP Custom 27803010 73-0910 - COMPONENT PATLR 7 1.5MM OFFST 36/41MM 5MM 5MMX10MM MEDIALIZE BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-095S SUP HCPCS C1713 73-095S - SCREW CANNULATED FULLY THREADED 7.3MM X 95MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-100S SUP HCPCS C1713 73-100S - SCREW CANNULATED FULLY THREADED 7.3MM X 100MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-105S SUP HCPCS C1713 73-105S - SCREW CANNULATED FULLY THREADED 7.3MM X 105MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-110S SUP HCPCS C1713 73-110S - SCREW CANNULATED FULLY THREADED 7.3MM X 110MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-115S SUP HCPCS C1713 73-115S - SCREW CANNULATED FULLY THREADED 7.3MM X 115MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-120S SUP HCPCS C1713 73-120S - SCREW CANNULATED FULLY THREADED 7.3MM X 120MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-125S SUP HCPCS C1713 73-125S - SCREW CANNULATED FULLY THREADED 7.3MM X 125MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-130S SUP HCPCS C1713 73-130S - SCREW CANNULATED FULLY THREADED 7.3MM X 130MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16030S SUP HCPCS C1713 73-16030S - SCREW 7.3MM X 30MM CANNULATED SCREW 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16035S SUP HCPCS C1713 73-16035S - SCREW 7.3MM X 35MM CANNULATED SCREW 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16040S SUP HCPCS C1713 73-16040S - SCREW CANNULATED 7.3MM X 40MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16045S SUP HCPCS C1713 73-16045S - SCREW CANNULATED 7.3MM X 45MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16050S SUP HCPCS C1713 73-16050S - SCREW CANNULATED 7.3MM X 50MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16055S SUP HCPCS C1713 73-16055S - SCREW CANNULATED 7.3MM X 55MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16060S SUP HCPCS C1713 73-16060S - SCREW CANNULATED 7.3MM X 60MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16065S SUP HCPCS C1713 73-16065S - SCREW CANNULATED 7.3MM X 65MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16070S SUP HCPCS C1713 73-16070S - SCREW CANNULATED 7.3MM X 70MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16075S SUP HCPCS C1713 73-16075S - SCREW CANNULATED 7.3MM X 75MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16080S SUP HCPCS C1713 73-16080S - SCREW CANNULATED 7.3MM X 80MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16085S SUP HCPCS C1713 73-16085S - SCREW CANNULATED 7.3MM X 85MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16090S SUP HCPCS C1713 73-16090S - SCREW CANNULATED 7.3MM X 90MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16095S SUP HCPCS C1713 73-16095S - SCREW CANNULATED 7.3MM X 95MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16100S SUP HCPCS C1713 73-16100S - SCREW CANNULATED 7.3MM X 100MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16105S SUP HCPCS C1713 73-16105S - SCREW CANNULATED 7.3MM X 105MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16110S SUP HCPCS C1713 73-16110S - SCREW CANNULATED 7.3MM X 110MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16115S SUP HCPCS C1713 73-16115S - SCREW CANNULATED 7.3MM X 115MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16120S SUP HCPCS C1713 73-16120S - SCREW CANNULATED 7.3MM X 120MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16125S SUP HCPCS C1713 73-16125S - SCREW CANNULATED 7.3MM X 125MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16130S SUP HCPCS C1713 73-16130S - SCREW CANNULATED 7.3MM X 130MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16135S SUP HCPCS C1713 73-16135S - SCREW CANNULATED 7.3MM X 135MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16140S SUP HCPCS C1713 73-16140S - SCREW CANNULATED 7.3MM X 140MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16145S SUP HCPCS C1713 73-16145S - SCREW CANNULATED 7.3MM X 145MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-16150S SUP HCPCS C1713 73-16150S - SCREW CANNULATED 7.3MM X 150MM 16MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-1952 SUP HCPCS C1713 73-1952 - PLATE BN STERNALOCK BLU 8 HL STRG STRNM BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$2,050.00" "$1,153.13" "$1,153.13" $0.00 $0.00 $0.00 $534.09 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 "$1,263.31" "$1,263.31" $0.00 "$1,281.25" "$2,029.50" "$2,050.00" $0.00 $0.00 $401.03 $0.00 $0.00 $407.95 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-0110 SUP Custom 27803010 73-20-0110 - COMPONENT PATLR 1 10MM MEDIALIZED DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-0510 SUP Custom 27803010 73-20-0510 - COMPONENT PATLR 5 10MM MEDIALIZED DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-0710 SUP Custom 27803010 73-20-0710 - COMPONENT PATLR 7 MEDIALIZE DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-0910 SUP Custom 27803010 73-20-0910 - COMPONENT PATLR 9 10MM MEDIALIZED DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-2110 SUP Custom 27803010 73-20-2110 - COMPONENT PATLR 11 10MM CONCENTRIC DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-2510 SUP Custom 27803010 73-20-2510 - COMPONENT PATLR 5 10MM CONCENTRIC DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-2710 SUP Custom 27803010 73-20-2710 - COMPONENT PATLR 7 10MM CONCENTRIC DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-2910 SUP Custom 27803010 73-20-2910 - COMPONENT PATLR 9 10MM CONCENTRIC DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-3110 SUP Custom 27803010 73-20-3110 - COMPONENT PATLR 11 10MM UNIVERSAL DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-3308 SUP Custom 27803010 73-20-3308 - COMPONENT PATLR UNIVERSAL DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-3508 SUP Custom 27803010 73-20-3508 - COMPONENT PATLR 5 8MM UNIVERSAL DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-3708 SUP Custom 27803010 73-20-3708 - COMPONENT PATLR 7 8MM UNIVERSAL DOME SCORPIO X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-3710 SUP Custom 27803010 73-20-3710 - COMPONENT PTLR 7 UNV DOME 34MM 10MM STRL SCRP X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-3910 SUP Custom 27803010 73-20-3910 - COMPONENT PTLR 9 UNV DOME 36MM 10MM STRL SCRP X3 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-4026 SUP Custom 27803010 73-20-4026 - COMPONENT PATLR 26MM RECESSED SCORPIO X3 BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-4028 SUP Custom 27803010 73-20-4028 - COMPONENT PATLR 28MM SCORPIO X3 BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-4030 SUP Custom 27803010 73-20-4030 - COMPONENT PATLR 30MM RECESSED SCORPIO X3 BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-4032 SUP Custom 27803010 73-20-4032 - COMPONENT PATLR 32MM RECESSED SCORPIO X3 BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-5030 SUP Custom 27803010 73-20-5030 - CMPNT PATLR 30MM SCRP X3 BOTH IP/OP "$1,205.00 " $891.70 $0.00 $964.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $894.35 $894.35 $0.00 $0.00 $251.12 $0.00 $0.00 $0.00 $0.00 $602.50 $954.36 $964.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-20-5032 SUP Custom 27803010 73-20-5032 - CMPNT PATLR 32MM INSET SCRP X3 BOTH IP/OP "$1,205.00 " $891.70 $0.00 $964.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $894.35 $894.35 $0.00 $0.00 $251.12 $0.00 $0.00 $0.00 $0.00 $602.50 $954.36 $964.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-2110 SUP Custom 27803010 73-2110 - COMPONENT PATLR 11 10MM CONCENTRIC DOME SCORPIO N2/VAC BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-2408 SUP HCPCS C1713 73-2408 - SCREW BN 2.4MM 8MM AU STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2410 SUP HCPCS C1713 73-2410 - SCREW BN 2.4MM 10MM AU STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2412 SUP HCPCS C1713 73-2412 - SCREW BN 2.4MM 12MM AU STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2414 SUP HCPCS C1713 73-2414 - SCREW BN 2.4MM 14MM AU STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2416 SUP HCPCS C1713 73-2416 - SCREW BN 2.4MM 16MM AU STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2418 SUP HCPCS C1713 73-2418 - SCREW BN 2.4MM 18MM AU STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2420 SUP HCPCS C1713 73-2420 - SCREW BN 2.4MM 20MM AU STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2510 SUP Custom 27803010 73-2510 - COMPONENT PATLR 5 10MM CONCENTRIC DOME SCORPIO N2/VAC BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-2610 SUP Custom 27803010 73-2610 - INSERT TIB 6 10MM PATLR N2 VAC INSET SCRP 26MM BOTH IP/OP $851.00 $629.74 $0.00 $680.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.61 $631.61 $0.00 $0.00 $177.35 $0.00 $0.00 $0.00 $0.00 $425.50 $673.99 $680.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-2622 SUP HCPCS C1713 73-2622 - PLATE BN SQ STERNALOCK BLU 4 HL STRNM BOTH IP/OP "$1,537.50 " "$1,137.75" $0.00 "$1,230.00" $691.88 $691.88 $0.00 $0.00 $0.00 $320.45 "$1,141.13" "$1,141.13" $0.00 $0.00 $320.42 $0.00 $909.43 $909.43 $0.00 $768.75 "$1,217.70" "$1,230.00" $0.00 $0.00 $240.62 $0.00 $0.00 $244.77 $0.00 $0.00 $0.00 $0.00 $0.00 73-2623 SUP HCPCS C1713 73-2623 - PLATE BN STERNALOCK BLU 8 HL STRNM BOTH IP/OP "$2,077.50 " "$1,537.35" $0.00 "$1,662.00" $934.88 $934.88 $0.00 $0.00 $0.00 $433.00 "$1,541.92" "$1,541.92" $0.00 $0.00 $432.95 $0.00 "$1,228.84" "$1,228.84" $0.00 "$1,038.75" "$1,645.38" "$1,662.00" $0.00 $0.00 $325.13 $0.00 $0.00 $330.74 $0.00 $0.00 $0.00 $0.00 $0.00 73-2632 SUP HCPCS C1713 73-2632 - PLATE BN NAR STERNALOCK BLU 12 HL STRNM 2.4MM SCR BOTH IP/OP "$2,175.00 " "$1,609.50" $0.00 "$1,740.00" $978.75 $978.75 $0.00 $0.00 $0.00 $453.32 "$1,614.29" "$1,614.29" $0.00 $0.00 $453.27 $0.00 "$1,286.51" "$1,286.51" $0.00 "$1,087.50" "$1,722.60" "$1,740.00" $0.00 $0.00 $340.39 $0.00 $0.00 $346.26 $0.00 $0.00 $0.00 $0.00 $0.00 73-2634 SUP HCPCS C1713 73-2634 - PLATE BN W STERNALOCK BLU 12 HL STRNM 2.4MM SCR BOTH IP/OP "$2,175.00 " "$1,609.50" $0.00 "$1,740.00" $978.75 $978.75 $0.00 $0.00 $0.00 $453.32 "$1,614.29" "$1,614.29" $0.00 $0.00 $453.27 $0.00 "$1,286.51" "$1,286.51" $0.00 "$1,087.50" "$1,722.60" "$1,740.00" $0.00 $0.00 $340.39 $0.00 $0.00 $346.26 $0.00 $0.00 $0.00 $0.00 $0.00 73-2636 SUP HCPCS C1713 73-2636 - PLATE BN STRG STERNALOCK BLU 4 HL STRNM 2.4MM SCR BOTH IP/OP "$1,537.50 " "$1,137.75" $0.00 "$1,230.00" $691.88 $691.88 $0.00 $0.00 $0.00 $320.45 "$1,141.13" "$1,141.13" $0.00 $0.00 $320.42 $0.00 $909.43 $909.43 $0.00 $768.75 "$1,217.70" "$1,230.00" $0.00 $0.00 $240.62 $0.00 $0.00 $244.77 $0.00 $0.00 $0.00 $0.00 $0.00 73-2643 SUP HCPCS C1713 73-2643 - PLATE BN 100D L STERNALOCK BLU 4 HL STRNM BOTH IP/OP "$1,537.50 " "$1,137.75" $0.00 "$1,230.00" $691.88 $691.88 $0.00 $0.00 $0.00 $320.45 "$1,141.13" "$1,141.13" $0.00 $0.00 $320.42 $0.00 $909.43 $909.43 $0.00 $768.75 "$1,217.70" "$1,230.00" $0.00 $0.00 $240.62 $0.00 $0.00 $244.77 $0.00 $0.00 $0.00 $0.00 $0.00 73-2645 SUP HCPCS C1713 73-2645 - PLATE BN JL STERNALOCK BLU 8 HL STRNM PRM CLSR SYS BOTH IP/OP "$1,945.00 " "$1,439.30" $0.00 "$1,556.00" $875.25 $875.25 $0.00 $0.00 $0.00 $405.39 "$1,443.58" "$1,443.58" $0.00 $0.00 $405.34 $0.00 "$1,150.47" "$1,150.47" $0.00 $972.50 "$1,540.44" "$1,556.00" $0.00 $0.00 $304.39 $0.00 $0.00 $309.64 $0.00 $0.00 $0.00 $0.00 $0.00 73-2708 SUP HCPCS C1713 73-2708 - SCREW BN 2.7MM 8MM MAG STERNALOCK BLU SLF DRL LCK STRNM CANC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2710 SUP HCPCS C1713 73-2710 - COMPONENT PTLR 7 CONC DOME 34/38MM 10MM SCRP N2/VAC BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2712 SUP HCPCS C1713 73-2712 - SCREW BN 2.7MM 12MM MAG STERNALOCK BLU SLF DRL LCK STRNM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2714 SUP HCPCS C1713 73-2714 - SCREW BN 2.7MM 14MM MAG STERNALOCK BLU SLF DRL LCK STRNM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2716 SUP HCPCS C1713 73-2716 - SCREW BN 2.7MM 16MM MAG STERNALOCK BLU SLF DRL LCK STRNM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2718 SUP HCPCS C1713 73-2718 - SCREW BN 2.7MM 18MM MAG STERNALOCK BLU SLF DRL LCK STRNM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2720 SUP HCPCS C1713 73-2720 - SCREW BN 2.7MM 20MM MAG STERNALOCK BLU SLF DRL LCK STRNM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 73-2810 SUP Custom 27803010 73-2810 - CMPNT PATLR 8 10MM 28MM INSET SCRP BOTH IP/OP $851.00 $629.74 $0.00 $680.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.61 $631.61 $0.00 $0.00 $177.35 $0.00 $0.00 $0.00 $0.00 $425.50 $673.99 $680.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73281488/8ARM SUP HCPCS C1768 73281488/8ARM - GRAFT CARDIOVASCULAR PLEXUS 28MM 14X8X8 BOTH IP/OP "$6,612.50 " "$4,893.25" $0.00 "$5,290.00" "$2,975.63" "$2,975.63" $0.00 $0.00 $0.00 "$1,378.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,378.05" $0.00 "$3,259.96" "$3,259.96" $0.00 "$3,306.25" "$5,237.10" "$5,290.00" $0.00 $0.00 "$1,034.86" $0.00 $0.00 "$1,052.71" $0.00 $0.00 $0.00 $0.00 $0.00 73-2910 SUP Custom 27803010 73-2910 - COMPONENT PATLR 9 CONCENTRIC DOME 10MM SCORPIO N2/VAC BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-3010 SUP Custom 27803010 73-3010 - CMPNT PATLR INSET SCRP BOTH IP/OP $851.00 $629.74 $0.00 $680.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.61 $631.61 $0.00 $0.00 $177.35 $0.00 $0.00 $0.00 $0.00 $425.50 $673.99 $680.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73301488/8ARM SUP HCPCS C1768 73301488/8ARM - 4 BRANCH TOTAL ARC GRAFT 30MM BOTH IP/OP "$6,612.50 " "$4,893.25" $0.00 "$5,290.00" "$2,975.63" "$2,975.63" $0.00 $0.00 $0.00 "$1,378.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,378.05" $0.00 "$3,259.96" "$3,259.96" $0.00 "$3,306.25" "$5,237.10" "$5,290.00" $0.00 $0.00 "$1,034.86" $0.00 $0.00 "$1,052.71" $0.00 $0.00 $0.00 $0.00 $0.00 73-3110 SUP Custom 27803010 73-3110 - COMPONENT PATLR 11MM 10MM UNIVERSAL DOME SCORPIO N2/VAC BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-32045S SUP HCPCS C1713 73-32045S - SCREW CANNULATED 7.3MM X 45MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32050S SUP HCPCS C1713 73-32050S - SCREW CANNULATED 7.3MM X 50MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32055S SUP HCPCS C1713 73-32055S - SCREW CANNULATED 7.3MM X 55MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32060S SUP HCPCS C1713 73-32060S - SCREW CANNULATED 7.3MM X 60MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32065S SUP HCPCS C1713 73-32065S - SCREW CANNULATED 7.3MM X 65MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32070S SUP HCPCS C1713 73-32070S - SCREW CANNULATED 7.3MM X 70MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32075S SUP HCPCS C1713 73-32075S - SCREW CANNULATED 7.3MM X 75MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32080S SUP HCPCS C1713 73-32080S - SCREW CANNULATED 7.3MM X 80MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32085S SUP HCPCS C1713 73-32085S - SCREW CANNULATED 7.3MM X 85MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32090S SUP HCPCS C1713 73-32090S - SCREW CANNULATED 7.3MM X 90MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32095S SUP HCPCS C1713 73-32095S - SCREW CANNULATED 7.3MM X 95MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-3210 SUP Custom 27803010 73-3210 - CMPNT PATLR 2 10MM 32MM INSET SCRP BOTH IP/OP $851.00 $629.74 $0.00 $680.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.61 $631.61 $0.00 $0.00 $177.35 $0.00 $0.00 $0.00 $0.00 $425.50 $673.99 $680.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-32100S SUP HCPCS C1713 73-32100S - SCREW CANNULATED 7.3MM X 100MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32105S SUP HCPCS C1713 73-32105S - SCREW CANNULATED 7.3MM X 105MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32110S SUP HCPCS C1713 73-32110S - SCREW CANNULATED 7.3MM X 110MM 32MM THREAD BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32115S SUP HCPCS C1713 73-32115S - SCREW CANNULATED 32MM THREAD 7.3MM X 115MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32120S SUP HCPCS C1713 73-32120S - SCREW CANNULATED 32MM THREAD 7.3MM X 120MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32125S SUP HCPCS C1713 73-32125S - SCREW CANNULATED 32MM THREAD 7.3MM X 125MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32130S SUP HCPCS C1713 73-32130S - SCREW CANNULATED 32MM THREAD 7.3MM X 130MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32135S SUP HCPCS C1713 73-32135S - SCREW CANNULATED 32MM THREAD 7.3MM X 135MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32140S SUP HCPCS C1713 73-32140S - SCREW CANNULATED 32MM THREAD 7.3MM X 140MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32145S SUP HCPCS C1713 73-32145S - SCREW CANNULATED 32MM THREAD 7.3MM X 145MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-32150S SUP HCPCS C1713 73-32150S - SCREW CANNULATED 32MM THREAD 7.3MM X 150MM BOTH IP/OP $235.00 $173.90 $0.00 $188.00 $105.75 $105.75 $0.00 $0.00 $0.00 $48.98 $174.42 $174.42 $0.00 $0.00 $48.97 $0.00 $139.00 $139.00 $0.00 $117.50 $186.12 $188.00 $0.00 $0.00 $36.78 $0.00 $0.00 $37.41 $0.00 $0.00 $0.00 $0.00 $0.00 73-3308 SUP Custom 27803010 73-3308 - COMPONENT PATLR 3 8MM UNIVERSAL DOME SCORPIO N2/VAC BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-3508 SUP Custom 27803010 73-3508 - COMPONENT PATLR 5 32MM 5MM 8MM 4MM UNIVERSAL DOME PEGGED BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-3708 SUP Custom 27803010 73-3708 - COMPONENT PATLR 7 8MM 8MM UNIVERSAL DOME SCORPIO N2/VAC BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-3710 SUP Custom 27803010 73-3710 - COMPONENT PTLR 7 UNV DOME 34MM 10MM SCRP PG N2/VAC 1 AXIS KN BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 73-3910 SUP Custom 27803010 73-3910 - COMPONENT PTLR 5 UNV DOME 36MM 10MM SCRP PG N2/VAC 1 AXIS KN BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $0.00 $0.00 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 734024/8 SUP HCPCS C1768 734024/8 - GRAFT CARDIO 8MM 24MM 8MM 40CM 15CM ANTE-FLO VASCUTEK BOTH IP/OP "$3,225.00 " "$2,386.50" $0.00 "$2,580.00" "$1,451.25" "$1,451.25" $0.00 $0.00 $0.00 $672.17 "$2,393.60" "$2,393.60" $0.00 $0.00 $672.09 $0.00 "$1,589.93" "$1,589.93" $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 $0.00 $504.71 $0.00 $0.00 $513.42 $0.00 $0.00 $0.00 $0.00 $0.00 734026/8 SUP HCPCS C1768 734026/8 - GRAFT CARDIO 8MM 26MM 8MM 40CM 15CM PERFUSION SIDE BRANCH BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 734028/8 SUP HCPCS C1768 734028/8 - GRAFT CARDIO 40CM 28MM 8MM AORTIC ARCH WVN SIDE BRCH GLWV BOTH IP/OP "$3,862.50 " "$2,858.25" $0.00 "$2,866.75" $602.44 $602.44 $0.00 $0.00 $0.00 $0.00 "$2,866.75" "$2,866.75" $0.00 $0.00 $804.95 $0.00 $0.00 $0.00 $0.00 $669.38 "$1,060.29" "$1,071.00" $0.00 $0.00 $209.51 $0.00 $0.00 $213.13 $0.00 $0.00 $0.00 $0.00 $0.00 734030/8 SUP HCPCS C1768 734030/8 - GRAFT CARDIO 30MM 8MM 40CM 15CM ANTEFLO PERFUSION SIDE BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 734032/8 SUP HCPCS C1768 734032/8 - GRAFT CARDIO 32MM 8MM 40CM 15CM PERFUSION SIDE BRANCH GRAFT BOTH IP/OP "$4,050.00 " "$2,997.00" $0.00 "$3,240.00" "$1,822.50" "$1,822.50" $0.00 $0.00 $0.00 $844.12 "$3,005.91" "$3,005.91" $0.00 $0.00 $844.02 $0.00 "$1,996.65" "$1,996.65" $0.00 "$2,025.00" "$3,207.60" "$3,240.00" $0.00 $0.00 $633.83 $0.00 $0.00 $644.76 $0.00 $0.00 $0.00 $0.00 $0.00 734034/8 SUP HCPCS C1768 734034/8 - GRAFT CARDIO 34MM 8MM 40CM 15CM ANTEFLO PERFUSION SIDE BOTH IP/OP "$3,387.50 " "$2,506.75" $0.00 "$2,710.00" "$1,524.38" "$1,524.38" $0.00 $0.00 $0.00 $706.04 "$2,514.20" "$2,514.20" $0.00 $0.00 $705.96 $0.00 "$1,670.04" "$1,670.04" $0.00 "$1,693.75" "$2,682.90" "$2,710.00" $0.00 $0.00 $530.14 $0.00 $0.00 $539.29 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0510 SUP Custom 27803010 74-2-0510 - INSERT TIB 5 10MM KNEE ALPLY CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0512 SUP Custom 27803010 74-2-0512 - INSERT TIB 5 12MM KNEE ALPLY N2 VAC CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0515 SUP HCPCS C1776 74-2-0515 - CMPNT TIB 15MM SCRP 5 KNEE ALPLY CRUC RET BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $643.95 $643.95 $0.00 $0.00 $0.00 $298.26 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $846.44 $846.44 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $223.95 $0.00 $0.00 $227.82 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0710 SUP Custom 27803010 74-2-0710 - INSERT TIB 7 10MM KNEE PE N2 VAC CRUC RET STY SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0712 SUP Custom 27803010 74-2-0712 - INSERT TIB 7 12MM KNEE ALPLY N2 VAC CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0715 SUP Custom 27803010 74-2-0715 - INSERT TIB 7 15MM KNEE ALPLY N2 VAC CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0910 SUP HCPCS C1776 74-2-0910 - CMPNT TIB 10MM SCRP 9 KNEE ALPLY CRUC RET BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $643.95 $643.95 $0.00 $0.00 $0.00 $298.26 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $846.44 $846.44 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $223.95 $0.00 $0.00 $227.82 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0912 SUP Custom 27803010 74-2-0912 - INSERT TIB 9 12MM KNEE ALPLY N2 VAC CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-0915 SUP Custom 27803010 74-2-0915 - INSERT TIB 9 15MM KNEE ALPLY N2 VAC CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-1110 SUP Custom 27803010 74-2-1110 - INSERT TIB 11 10MM KNEE ALPLY N2 VAC CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-1112 SUP Custom 27803010 74-2-1112 - INSERT TIB 11 12MM KNEE ALPLY N2 VAC CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74-2-1115 SUP Custom 27803010 74-2-1115 - INSERT TIB 11 15MM KNEE ALPLY N2 VAC CRUC RET SCRP BOTH IP/OP "$1,431.00 " "$1,058.94" $0.00 "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,062.09" "$1,062.09" $0.00 $0.00 $298.22 $0.00 $0.00 $0.00 $0.00 $715.50 "$1,133.35" "$1,144.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-42A SUP HCPCS C1776 742-11-42A - SHELL ACTB A 42MM STRL TRDNT II PSL 3 HL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-44B SUP HCPCS C1776 742-11-44B - SHELL ACTB B 44MM STRL TRDNT II PSL 3 HL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-46C SUP HCPCS C1776 742-11-46C - SHELL ACTB C 46MM STRL TRDNT II PSL 3 HL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-48D SUP HCPCS C1776 742-11-48D - SHELL ACTB D 48MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-50D SUP HCPCS C1776 742-11-50D - SHELL ACTB D 50MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-52E SUP HCPCS C1776 742-11-52E - SHELL ACTB E 52MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-54E SUP HCPCS C1776 742-11-54E - SHELL ACTB E 54MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-56F SUP HCPCS C1776 742-11-56F - SHELL ACTB F 56MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-58F SUP HCPCS C1776 742-11-58F - SHELL ACTB F 58MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-60G SUP HCPCS C1776 742-11-60G - SHELL ACTB G 60MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-62G SUP HCPCS C1776 742-11-62G - SHELL ACTB G 62MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-64H SUP HCPCS C1776 742-11-64H - SHELL ACTB H 64MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 742-11-66H SUP HCPCS C1776 742-11-66H - SHELL ACTB H 66MM STRL TRDNT II PSL CH HA HIP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0510 SUP HCPCS C1776 74-3-0510 - CMPNT TIB 10MM 5 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0512 SUP HCPCS C1776 74-3-0512 - CMPNT TIB 12MM 5 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0515 SUP HCPCS C1776 74-3-0515 - CMPNT TIB 15MM 5 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0710 SUP HCPCS C1776 74-3-0710 - CMPNT TIB 10MM 7 KNEE ALPLY PS STY BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0712 SUP HCPCS C1776 74-3-0712 - CMPNT TIB 12MM 7 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0715 SUP HCPCS C1776 74-3-0715 - CMPNT TIB 15MM 7 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0910 SUP HCPCS C1776 74-3-0910 - CMPNT TIB 10MM 9 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0912 SUP HCPCS C1776 74-3-0912 - CMPNT TIB 12MM 9 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-0915 SUP HCPCS C1776 74-3-0915 - CMPNT TIB 15MM 9 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-1110 SUP HCPCS C1776 74-3-1110 - CMPNT TIB 10MM 11 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-1112 SUP HCPCS C1776 74-3-1112 - CMPNT TIB 12MM 11 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74-3-1115 SUP HCPCS C1776 74-3-1115 - CMPNT TIB 15MM 11 KNEE ALPLY PS BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $661.50 $661.50 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 74402006N SUP HCPCS C1713 74402006N - SCREW BN T6 2MM 1.4MM 6MM NS VLP MN-MOD ST TI OSTEOPENIA BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402007N SUP HCPCS C1713 74402007N - SCREW BN T6 2MM 1.4MM 7MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402008N SUP HCPCS C1713 74402008N - SCREW BN T6 2MM 1.4MM 8MM NS VLP MN-MOD ST DRV MECH TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402009N SUP HCPCS C1713 74402009N - SCREW BN T6 2MM 1.4MM 9MM NS VLP MN-MOD ST TI OSTEOPENIA BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402010N SUP HCPCS C1713 74402010N - SCREW BN T6 2MM 1.4MM 10MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402011N SUP HCPCS C1713 74402011N - SCREW BN T6 2MM 1.4MM 11MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402012N SUP HCPCS C1713 74402012N - SCREW BN 2MM 1.4MM 12MM PUR NS VLP MN-MOD T6 DRVR ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402013N SUP HCPCS C1713 74402013N - SCREW BN T6 2MM 1.4MM 13MM NS VLP MN-MOD ST TI OSTEOPENIA BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402014N SUP HCPCS C1713 74402014N - SCREW BN 2MM 1.4MM 14MM PUR NS VLP MN-MOD T6 DRVR ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402016N SUP HCPCS C1713 74402016N - SCREW BN 2MM 1.4MM 16MM PUR NS VLP MN-MOD T6 DRVR ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402018N SUP HCPCS C1713 74402018N - SCREW BN 2MM 1.4MM 18MM PUR NS VLP MN-MOD T6 DRVR ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402020N SUP HCPCS C1713 74402020N - SCREW BN 2MM 1.4MM 20MM PUR NS VLP MN-MOD T6 DRVR ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402022N SUP HCPCS C1713 74402022N - SCREW BN T6 2MM 1.4MM 22MM NS VLP MN-MOD ST TI OSTEOPENIA BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402024N SUP HCPCS C1713 74402024N - SCREW BN T6 2MM 1.4MM 24MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402026N SUP HCPCS C1713 74402026N - SCREW BN T6 2MM 1.4MM 26MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402028N SUP HCPCS C1713 74402028N - SCREW BN T6 2MM 1.4MM 28MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402030N SUP HCPCS C1713 74402030N - SCREW BN T6 2MM 1.4MM 30MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402032N SUP HCPCS C1713 74402032N - SCREW BN T6 2MM 1.4MM 32MM NS VLP MN-MOD ST TI OSTEOPENIA BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402034N SUP HCPCS C1713 74402034N - SCREW BN T6 2MM 1.4MM 34MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402036N SUP HCPCS C1713 74402036N - SCREW BN T6 2MM 1.4MM 36MM NS VLP MN-MOD ST TI OSTEOPENIA BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402406N SUP HCPCS C1713 74402406N - SCREW BN T7 2.4MM 1.7MM 6MM NS VLP MN-MOD ST TI OSTEOPENIA BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402407N SUP HCPCS C1713 74402407N - SCREW BN T7 2.4MM 1.7MM 7MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402409N SUP HCPCS C1713 74402409N - SCREW BN T7 2.4MM 1.7MM 9MM GRN NS VLP ST LO HD PRFL TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402410N SUP HCPCS C1713 74402410N - SCREW BN T7 2.4MM 1.7MM 10MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402411N SUP HCPCS C1713 74402411N - SCREW BN T7 2.4MM 1.7MM 11MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402412N SUP HCPCS C1713 74402412N - SCREW BN 2.4MM 1.7MM 12MM GRN NS VLP MN-MOD T7 DRVR ST TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402413N SUP HCPCS C1713 74402413N - SCREW BN T7 2.4MM 1.7MM 13MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402414N SUP HCPCS C1713 74402414N - SCREW BN 2.4MM 1.7MM 14MM GRN NS VLP MN-MOD T7 DRVR ST TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402415N SUP HCPCS C1713 74402415N - SCREW BN 2.4MM 1.7MM 15MM GRN NS VLP MN-MOD T7 DRVR ST TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402416N SUP HCPCS C1713 74402416N - SCREW BN T7 2.4MM 1.7MM 16MM GRN NS VLP ST LOPRFL HD TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402418N SUP HCPCS C1713 74402418N - SCREW BN T7 2.4MM 1.7MM 18MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402420N SUP HCPCS C1713 74402420N - SCREW BN T7 2.4MM 1.7MM 20MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402422N SUP HCPCS C1713 74402422N - SCREW BN T7 2.4MM 1.7MM 22MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402424N SUP HCPCS C1713 74402424N - SCREW BN T7 2.4MM 1.7MM 24MM GRN NS VLP ST LOPRFL HD TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402426N SUP HCPCS C1713 74402426N - SCREW BN T7 2.4MM 26MM NS VLP MN-MOD ST TI CORT BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402428N SUP HCPCS C1713 74402428N - SCREW BN T7 2.4MM 1.7MM 28MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402430N SUP HCPCS C1713 74402430N - SCREW BN T7 2.4MM 1.7MM 30MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402432N SUP HCPCS C1713 74402432N - SCREW BN T7 2.4MM 1.7MM 32MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402434N SUP HCPCS C1713 74402434N - SCREW BN T7 2.4MM 1.7MM 34MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402436N SUP HCPCS C1713 74402436N - SCREW BN T7 2.4MM 1.7MM 36MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402438N SUP HCPCS C1713 74402438N - SCREW BN T7 2.4MM 1.7MM 38MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402440N SUP HCPCS C1713 74402440N - SCREW BN T7 2.4MM 1.7MM 40MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402442N SUP HCPCS C1713 74402442N - SCREW BN T7 2.4MM 1.7MM 42MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402444N SUP HCPCS C1713 74402444N - SCREW BN T7 2.4MM 1.7MM 44MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74402446N SUP HCPCS C1713 74402446N - SCREW BN T7 2.4MM 1.7MM 46MM GRN NS VLP ST LO HD PRFL TI BOTH IP/OP $112.48 $83.24 $0.00 $89.98 $50.61 $50.61 $0.00 $0.00 $0.00 $23.44 $83.48 $83.48 $0.00 $0.00 $23.44 $0.00 $66.53 $66.53 $0.00 $56.24 $89.08 $89.98 $0.00 $0.00 $17.60 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 74412006N SUP HCPCS C1713 74412006N - SCREW BN T6 2MM 1.4MM 6MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412007N SUP HCPCS C1713 74412007N - SCREW BN T6 2MM 1.4MM 7MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412008N SUP HCPCS C1713 74412008N - SCREW BN 2MM 8MM NS VLP LCK ST T6 DRVR TI SM BN BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412009N SUP HCPCS C1713 74412009N - SCREW BN T6 2MM 1.4MM 9MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412010N SUP HCPCS C1713 74412010N - SCREW BN 2MM 10MM NS VLP LCK ST T6 DRVR TI SM BN BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412011N SUP HCPCS C1713 74412011N - SCREW BN 2MM 1.4MM 11MM PUR NS VLP MN-MOD T6 DRVR ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412012N SUP HCPCS C1713 74412012N - SCREW BN 2MM 1.4MM 12MM PUR NS VLP MN-MOD T6 DRVR ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412013N SUP HCPCS C1713 74412013N - SCREW BN T6 2MM 1.4MM 13MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412014N SUP HCPCS C1713 74412014N - SCREW BN 2MM 14MM NS VLP LCK ST T6 DRVR TI SM BN BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412016N SUP HCPCS C1713 74412016N - SCREW BN T6 2MM 1.4MM 16MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412018N SUP HCPCS C1713 74412018N - SCREW BN T6 2MM 1.4MM 18MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412020N SUP HCPCS C1713 74412020N - SCREW BN T6 2MM 1.4MM 20MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412022N SUP HCPCS C1713 74412022N - SCREW BN T6 2MM 1.4MM 22MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412024N SUP HCPCS C1713 74412024N - SCREW BN T6 2MM 1.4MM 24MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412026N SUP HCPCS C1713 74412026N - SCREW BN T6 2MM 1.4MM 26MM PUR NS VLP LCK ST LO HD PRFL TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412028N SUP HCPCS C1713 74412028N - SCREW BN T6 2MM 1.4MM 28MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412030N SUP HCPCS C1713 74412030N - SCREW BN T6 2MM 1.4MM 30MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412032N SUP HCPCS C1713 74412032N - SCREW BN T6 2MM 1.4MM 32MM PUR NS VLP LCK ST LO HD PRFL TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412034N SUP HCPCS C1713 74412034N - SCREW BN T6 2MM 1.4MM 34MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412036N SUP HCPCS C1713 74412036N - SCREW BN T6 2MM 1.4MM 36MM PUR NS VLP LCK ST LOPRFL HD TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412406N SUP HCPCS C1713 74412406N - SCREW BN T7 2.4MM 1.7MM 6MM NS VLP MN-MOD ST LCK TI CORT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412407N SUP HCPCS C1713 74412407N - SCREW BN T7 2.4MM 1.7MM 7MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412408N SUP HCPCS C1713 74412408N - SCREW BN T7 2.4MM 8MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412409N SUP HCPCS C1713 74412409N - SCREW BN T7 2.4MM 1.7MM 9MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412410N SUP HCPCS C1713 74412410N - SCREW BN T7 2.4MM 10MM NS VLP MN-MOD ST LCK LOPRFL HD TI FT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412411N SUP HCPCS C1713 74412411N - SCREW BN T7 2.4MM 1.7MM 11MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412412N SUP HCPCS C1713 74412412N - SCREW BN T7 2.4MM 1.7MM 12MM NS VLP ST LCK TI CORT MN-MOD SM BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412413N SUP HCPCS C1713 74412413N - SCREW BN T7 2.4MM 1.7MM 13MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412414N SUP HCPCS C1713 74412414N - SCREW BN T7 2.4MM 1.7MM 14MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412415N SUP HCPCS C1713 74412415N - SCREW BN T7 2.4MM 1.7MM 15MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412416N SUP HCPCS C1713 74412416N - SCREW BN 2.4MM 1.7MM 16MM GRN NS VLP MN-MOD T7 DRVR ST LCK BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412418N SUP HCPCS C1713 74412418N - SCREW BN T7 2.4MM 18MM NS VLP ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412420N SUP HCPCS C1713 74412420N - SCREW BN T7 2.4MM 1.7MM 20MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412422N SUP HCPCS C1713 74412422N - SCREW BN T7 2.4MM 22MM GRN NS VLP ST DRVR TI FT SM BN PLT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412424N SUP HCPCS C1713 74412424N - SCREW BN T7 2.4MM 24MM GRN NS VLP ST DRVR TI FT SM BN PLT BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412426N SUP HCPCS C1713 74412426N - SCREW BN T7 2.4MM 1.7MM 26MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412428N SUP HCPCS C1713 74412428N - SCREW BN T7 2.4MM 1.7MM 28MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412430N SUP HCPCS C1713 74412430N - SCREW BN T7 2.4MM 1.7MM 30MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412432N SUP HCPCS C1713 74412432N - SCREW BN T7 2.4MM 1.7MM 32MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412434N SUP HCPCS C1713 74412434N - SCREW BN T7 2.4MM 1.7MM 34MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412436N SUP HCPCS C1713 74412436N - SCREW BN T7 2.4MM 1.7MM 36MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412438N SUP HCPCS C1713 74412438N - SCREW BN T7 2.4MM 1.7MM 38MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412440N SUP HCPCS C1713 74412440N - SCREW BN T7 2.4MM 1.7MM 40MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412442N SUP HCPCS C1713 74412442N - SCREW BN T7 2.4MM 1.7MM 42MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412444N SUP HCPCS C1713 74412444N - SCREW BN T7 2.4MM 1.7MM 44MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 74412446N SUP HCPCS C1713 74412446N - SCREW BN T7 2.4MM 1.7MM 46MM NS VLP MN-MOD ST LCK TI BOTH IP/OP $237.88 $176.03 $0.00 $190.30 $107.04 $107.04 $0.00 $0.00 $0.00 $49.58 $176.55 $176.55 $0.00 $0.00 $49.57 $0.00 $140.70 $140.70 $0.00 $118.94 $188.40 $190.30 $0.00 $0.00 $37.23 $0.00 $0.00 $37.87 $0.00 $0.00 $0.00 $0.00 $0.00 746F8 SUP HCPCS C1751 746F8 - CATHETER PA STD 8FR 110CM SG C VIP TD BOTH IP/OP "$1,006.70 " $744.96 $0.00 $805.36 $453.02 $453.02 $0.00 $0.00 $0.00 $209.82 $747.17 $747.17 $0.00 $0.00 $209.80 $0.00 $595.46 $595.46 $0.00 $503.35 $797.31 $805.36 $0.00 $0.00 $157.55 $0.00 $0.00 $160.27 $0.00 $0.00 $0.00 $0.00 $0.00 746HF8 SUP Custom 27203010 746HF8 - CATHETER ART LN 8FR 110CM SG C VIP 7 LUM CCO AMC THRMBSH BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $398.93 $398.93 $0.00 $0.00 $112.02 $0.00 $0.00 $0.00 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 74703-02 SUP Custom 27203010 74703-02 - TUBING PACK BOTH IP/OP $636.25 $470.83 $0.00 $509.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $472.22 $472.22 $0.00 $0.00 $132.59 $0.00 $0.00 $0.00 $0.00 $318.13 $503.91 $509.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0108 SUP Custom 27803010 7492-0108 - BRNG INS PS TIB BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0110 SUP Custom 27803010 7492-0110 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0112 SUP Custom 27803010 7492-0112 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0115 SUP Custom 27803010 7492-0115 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0118 SUP Custom 27803010 7492-0118 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0121 SUP Custom 27803010 7492-0121 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0124 SUP Custom 27803010 7492-0124 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0308 SUP Custom 27803010 7492-0308 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0310 SUP Custom 27803010 7492-0310 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0312 SUP Custom 27803010 7492-0312 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0315 SUP Custom 27803010 7492-0315 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0318 SUP Custom 27803010 7492-0318 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0321 SUP Custom 27803010 7492-0321 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0324 SUP Custom 27803010 7492-0324 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0508 SUP Custom 27803010 7492-0508 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0510 SUP Custom 27803010 7492-0510 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0512 SUP Custom 27803010 7492-0512 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0515 SUP Custom 27803010 7492-0515 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0518 SUP Custom 27803010 7492-0518 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0521 SUP Custom 27803010 7492-0521 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0524 SUP Custom 27803010 7492-0524 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0708 SUP Custom 27803010 7492-0708 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0710 SUP Custom 27803010 7492-0710 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0712 SUP Custom 27803010 7492-0712 - INSERT TIB 7 12MM KNEE BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0715 SUP Custom 27803010 7492-0715 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0718 SUP Custom 27803010 7492-0718 - INSERT TIB KNEE PS 2 BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0721 SUP Custom 27803010 7492-0721 - INSERT TIB PS 2 BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0724 SUP Custom 27803010 7492-0724 - INSERT TIB PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0908 SUP Custom 27803010 7492-0908 - INSERT TIB PS 2 BRNG BOTH IP/OP "$1,347.00 " $996.78 $0.00 "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $999.74 $999.74 $0.00 $0.00 $280.71 $0.00 $0.00 $0.00 $0.00 $673.50 "$1,066.82" "$1,077.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0910 SUP Custom 27803010 7492-0910 - INSERT TIB 9 KNEE 10MM BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0912 SUP Custom 27803010 7492-0912 - INSERT TIB PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0915 SUP Custom 27803010 7492-0915 - INSERT TIB PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0918 SUP Custom 27803010 7492-0918 - INSERT TIB PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0921 SUP Custom 27803010 7492-0921 - INSERT TIB PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7492-0924 SUP Custom 27803010 7492-0924 - INSERT TIB PS 2 BRNG BOTH IP/OP "$1,293.00 " $956.82 $0.00 "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.66 $959.66 $0.00 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $646.50 "$1,024.06" "$1,034.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0108 SUP Custom 27803010 7493-0108 - INSERT TIBIAL 1 8MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0110 SUP Custom 27803010 7493-0110 - INSERT TIBIAL 1 10MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0112 SUP Custom 27803010 7493-0112 - INSERT TIBIAL 1 12MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0115 SUP Custom 27803010 7493-0115 - INSERT TIBIAL 1 15MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0118 SUP Custom 27803010 7493-0118 - INSERT TIBIAL 1 18MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0121 SUP Custom 27803010 7493-0121 - INSERT TIBIAL 1 21MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0124 SUP Custom 27803010 7493-0124 - INSERT TIBIAL 1 24MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0308 SUP Custom 27803010 7493-0308 - INSERT TIBIAL 3 8MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0310 SUP Custom 27803010 7493-0310 - INSERT TIBIAL 3 10MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0312 SUP Custom 27803010 7493-0312 - INSERT TIBIAL 3 12MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0315 SUP Custom 27803010 7493-0315 - INSERT TIBIAL 3 15MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0318 SUP Custom 27803010 7493-0318 - INSERT TIBIAL 3 18MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0321 SUP Custom 27803010 7493-0321 - INSERT TIBIAL 3 21MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0324 SUP Custom 27803010 7493-0324 - INSERT TIBIAL 3 24MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0508 SUP Custom 27803010 7493-0508 - INSERT TIBIAL 5 8MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0510 SUP Custom 27803010 7493-0510 - INSERT TIBIAL 5 10MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0512 SUP Custom 27803010 7493-0512 - INSERT TIBIAL 5 12MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0515 SUP Custom 27803010 7493-0515 - INSERT TIBIAL 5 15MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0518 SUP Custom 27803010 7493-0518 - INSERT TIBIAL 5 18MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0521 SUP Custom 27803010 7493-0521 - INSERT TIBIAL 5 21MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0524 SUP Custom 27803010 7493-0524 - INSERT TIBIAL 5 24MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0708 SUP Custom 27803010 7493-0708 - INSERT TIBIAL 7 8MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0710 SUP Custom 27803010 7493-0710 - INSERT TIBIAL 7 10MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0712 SUP Custom 27803010 7493-0712 - INSERT TIBIAL 7 12MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0715 SUP Custom 27803010 7493-0715 - INSERT TIBIAL 7 15MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0718 SUP Custom 27803010 7493-0718 - INSERT TIBIAL 7 18MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0721 SUP Custom 27803010 7493-0721 - INSERT TIBIAL 7 21MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0724 SUP Custom 27803010 7493-0724 - INSERT TIBIAL 7 24MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0908 SUP Custom 27803010 7493-0908 - INSERT TIBIAL 9 8MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0910 SUP Custom 27803010 7493-0910 - INSERT TIBIAL 9 10MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0912 SUP Custom 27803010 7493-0912 - INSERT TIBIAL 9 12MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0915 SUP Custom 27803010 7493-0915 - INSERT TIBIAL 9 15MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0918 SUP Custom 27803010 7493-0918 - INSERT TIBIAL 9 18MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0921 SUP Custom 27803010 7493-0921 - INSERT TIBIAL 9 21MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7493-0924 SUP Custom 27803010 7493-0924 - INSERT TIBIAL 9 24MM POSTERIOR STABILIZE BEARING KNEE S7000 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0305 SUP Custom 27803010 75-1-0305 - BLOCK AUGMENTATION 3 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0310 SUP Custom 27803010 75-1-0310 - BLOCK AUGMENTATION 3 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0315 SUP Custom 27803010 75-1-0315 - BLOCK AUGMENTATION 3 15MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0405 SUP Custom 27803010 75-1-0405 - BLOCK AUGMENTATION 4 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0410 SUP Custom 27803010 75-1-0410 - BLOCK AUGMENTATION 4 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0415 SUP Custom 27803010 75-1-0415 - BLOCK AUGMENTATION 4 15MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0505 SUP Custom 27803010 75-1-0505 - BLOCK AUGMENTATION 5 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0510 SUP Custom 27803010 75-1-0510 - BLOCK AUGMENTATION 4 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0515 SUP Custom 27803010 75-1-0515 - BLOCK AUGMENTATION 5 15MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0605 SUP Custom 27803010 75-1-0605 - BLOCK AUGMENTATION 6 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0610 SUP Custom 27803010 75-1-0610 - BLOCK AUGMENTATION 6 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0615 SUP Custom 27803010 75-1-0615 - BLOCK AUGMENTATION 6 15MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0705 SUP Custom 27803010 75-1-0705 - BLOCK AUGMENTATION 7 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0710 SUP Custom 27803010 75-1-0710 - BLOCK AUGMENTATION 7 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0715 SUP Custom 27803010 75-1-0715 - BLOCK AUGMENTATION 7 15MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0905 SUP Custom 27803010 75-1-0905 - BLOCK AUGMENTATION 9 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0910 SUP Custom 27803010 75-1-0910 - BLOCK AUGMENTATION 9 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-0915 SUP Custom 27803010 75-1-0915 - BLOCK AUGMENTATION 9 15MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-1105 SUP Custom 27803010 75-1-1105 - BLOCK AUGMENTATION 11 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-1110 SUP Custom 27803010 75-1-1110 - BLOCK AUGMENTATION 11 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-1115 SUP Custom 27803010 75-1-1115 - BLOCK AUGMENTATION 11 15MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-1305 SUP Custom 27803010 75-1-1305 - BLOCK AUGMENTATION 13 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-1310 SUP Custom 27803010 75-1-1310 - BLOCK AUGMENTATION 13 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-1-1315 SUP Custom 27803010 75-1-1315 - BLOCK AUGMENTATION 13 15MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0305 SUP Custom 27803010 75-2-0305 - BLOCK AUGMENTATION 3 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0310 SUP Custom 27803010 75-2-0310 - BLOCK AUGMENTATION 3 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0405 SUP Custom 27803010 75-2-0405 - BLOCK AUGMENTATION 4 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0410 SUP Custom 27803010 75-2-0410 - BLOCK AUGMENTATION 4 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0505 SUP Custom 27803010 75-2-0505 - BLOCK AUGMENTATION 5 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0510 SUP Custom 27803010 75-2-0510 - BLOCK AUGMENTATION 4 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0605 SUP Custom 27803010 75-2-0605 - BLOCK AUGMENTATION 9 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0610 SUP Custom 27803010 75-2-0610 - BLOCK AUGMENTATION 6 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0705 SUP Custom 27803010 75-2-0705 - BLOCK AUGMENTATION 7 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0710 SUP Custom 27803010 75-2-0710 - BLOCK AUGMENTATION 7 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0905 SUP Custom 27803010 75-2-0905 - BLOCK AUGMENTATION 9 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-0910 SUP Custom 27803010 75-2-0910 - BLOCK AUGMENTATION 9 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-1105 SUP Custom 27803010 75-2-1105 - BLOCK AUGMENTATION 11 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-1110 SUP Custom 27803010 75-2-1110 - BLOCK AUGMENTATION 11 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-1305 SUP Custom 27803010 75-2-1305 - BLOCK AUGMENTATION 13 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-2-1310 SUP Custom 27803010 75-2-1310 - BLOCK AUGMENTATION 13 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,292.50 " "$1,696.45" $0.00 "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.49" "$1,701.49" $0.00 $0.00 $477.76 $0.00 $0.00 $0.00 $0.00 "$1,146.25" "$1,815.66" "$1,834.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0305 SUP Custom 27803010 75-3-0305 - BLOCK AUGMENTATION 3 HALF 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0310 SUP Custom 27803010 75-3-0310 - BLOCK AUGMENTATION 3 HALF 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0405 SUP Custom 27203010 75-3-0405 - TRIAL KN 4 5MM SCRP AUG HLF BLCK TIB LT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0410 SUP Custom 27203010 75-3-0410 - TRIAL KN 4 10MM SCRP AUG HLF BLCK TIB LT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0505 SUP Custom 27803010 75-3-0505 - BLOCK AUGMENTATION 5 HALF 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0510 SUP Custom 27203010 75-3-0510 - BLOCK AUGMENTATION 5 HALF 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0605 SUP Custom 27803010 75-3-0605 - BLOCK AUGMENTATION 6 HALF 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0610 SUP Custom 27203010 75-3-0610 - TRIAL KN 6 10MM SCRP AUG HLF BLCK TIB LT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0705 SUP Custom 27803010 75-3-0705 - BLOCK AUGMENTATION 7 HALF 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0710 SUP Custom 27203010 75-3-0710 - BLOCK AUGMENTATION 7 10MM TOT STABILIZED HALF SCORPIO KNEE BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0905 SUP Custom 27803010 75-3-0905 - BLOCK AUGMENTATION 9 HALF 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-0910 SUP Custom 27803010 75-3-0910 - BLOCK AUGMENTATION 9 HALF 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-1105 SUP Custom 27803010 75-3-1105 - BLOCK AUGMENTATION 11 HALF 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-1110 SUP Custom 27203010 75-3-1110 - BLOCK AUGMENTATION 11 HALF 10MM 1 AXIS CRUC RET POSTERIOR BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-1305 SUP Custom 27803010 75-3-1305 - BLOCK AUGMENTATION 13 HALF 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-3-1310 SUP Custom 27803010 75-3-1310 - BLOCK AUGMENTATION 13 HALF 10MM 1 AXIS CRUC RET POSTERIOR BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 $0.00 $0.00 $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-4-0310 SUP Custom 27803010 75-4-0310 - BLOCK AUGMENTATION 3 FULL 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-4-0410 SUP Custom 27803010 75-4-0410 - BLOCK AUGMENTATION 4 10MM FULL SCORPIO TIBIA BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-4-0510 SUP Custom 27803010 75-4-0510 - BLOCK AUGMENTATION 5 FULL 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-4-0610 SUP Custom 27803010 75-4-0610 - BLOCK AUGMENTATION 6 10MM FULL SCORPIO TIBIA BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-4-0710 SUP Custom 27803010 75-4-0710 - BLOCK AUGMENTATION 7 FULL 10MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-4-0910 SUP Custom 27803010 75-4-0910 - BLOCK AUGMENTATION 9 FULL 5MM 1 AXIS CRUC RET POSTERIOR TOT BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-4-1110 SUP Custom 27803010 75-4-1110 - BLOCK AUGMENTATION 11 10MM FULL TOT STABILIZED SCORPIO FEMUR BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-4-1310 SUP Custom 27803010 75-4-1310 - BLOCK AUGMENTATION 13 10MM FULL TOT STABILIZED SCORPIO FEMUR BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-5-0305 SUP Custom 27803010 75-5-0305 - BLOCK AUGMENTATION 5D FULL WEDGE 3MM CRUCIATE RETAIN TOT BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-5-0405 SUP Custom 27803010 75-5-0405 - TRIAL SURG 4.5D FULL WEDGE BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-5-0505 SUP Custom 27803010 75-5-0505 - WEDGE TIBIAL 5D FULL 5 TOT STABILIZE SCORPIO KNEE BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-5-0605 SUP Custom 27203010 75-5-0605 - TRIAL SURG FULL WEDGE 6.5D BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-5-0705 SUP Custom 27803010 75-5-0705 - WEDGE TIBIAL 5D FULL 7 10MM TOT STABILIZE SCORPIO KNEE BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-5-0905 SUP Custom 27803010 75-5-0905 - BLOCK AUGMENTATION 5D FULL WEDGE 9MM CRUCIATE RETAIN TOT BOTH IP/OP "$3,585.00 " "$2,652.90" $0.00 "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,660.79" "$2,660.79" $0.00 $0.00 $747.11 $0.00 $0.00 $0.00 $0.00 "$1,792.50" "$2,839.32" "$2,868.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-5-1105 SUP Custom 27803010 75-5-1105 - WEDGE TIB 11MM SCRP 5D KNEE TOT STAB FULL BOTH IP/OP "$3,445.00 " "$2,549.30" $0.00 "$2,756.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,556.88" "$2,556.88" $0.00 $0.00 $717.94 $0.00 $0.00 $0.00 $0.00 "$1,722.50" "$2,728.44" "$2,756.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75-5-1305 SUP Custom 27803010 75-5-1305 - WEDGE TIB 13MM SCRP 5D KNEE TOT STAB FULL BOTH IP/OP "$3,615.63 " "$2,675.57" $0.00 "$2,892.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,683.52" "$2,683.52" $0.00 $0.00 $753.50 $0.00 $0.00 $0.00 $0.00 "$1,807.81" "$2,863.58" "$2,892.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75AC50 SUP Custom 27203010 75AC50 - PLATE 18MM TI BONE SPNL BOTH IP/OP $303.88 $224.87 $0.00 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.54 $225.54 $0.00 $0.00 $63.33 $0.00 $0.00 $0.00 $0.00 $151.94 $240.67 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75AC60 SUP Custom 27203010 75AC60 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $303.88 $224.87 $0.00 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.54 $225.54 $0.00 $0.00 $63.33 $0.00 $0.00 $0.00 $0.00 $151.94 $240.67 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA05 SUP Custom 27203010 75BA05 - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA05L SUP Custom 27203010 75BA05L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA06DL SUP Custom 27203010 75BA06DL - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA08DL SUP Custom 27203010 75BA08DL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA10 SUP Custom 27203010 75BA10 - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA10D SUP Custom 27203010 75BA10D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA10DC SUP Custom 27203010 75BA10DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA10DCL SUP Custom 27203010 75BA10DCL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA10DL SUP Custom 27203010 75BA10DL - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA10DLF SUP Custom 27203010 75BA10DLF - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA10L SUP Custom 27203010 75BA10L - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA12DL SUP Custom 27203010 75BA12DL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA15 SUP Custom 27203010 75BA15 - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA15D SUP Custom 27203010 75BA15D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA15DC SUP Custom 27203010 75BA15DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA15DCL SUP Custom 27203010 75BA15DCL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA15DL SUP Custom 27203010 75BA15DL - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA15DLF SUP Custom 27203010 75BA15DLF - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA15L SUP Custom 27203010 75BA15L - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20 SUP Custom 27203010 75BA20 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20D SUP Custom 27203010 75BA20D - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20DC SUP Custom 27203010 75BA20DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20DCL SUP Custom 27203010 75BA20DCL - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20DF SUP Custom 27203010 75BA20DF - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20DL SUP Custom 27203010 75BA20DL - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20DLF SUP Custom 27203010 75BA20DLF - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20F SUP Custom 27203010 75BA20F - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20L SUP Custom 27203010 75BA20L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA20LF SUP Custom 27203010 75BA20LF - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25 SUP Custom 27203010 75BA25 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25D SUP Custom 27203010 75BA25D - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25DC SUP Custom 27203010 75BA25DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25DCL SUP Custom 27203010 75BA25DCL - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25DL SUP Custom 27203010 75BA25DL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25DLF SUP Custom 27203010 75BA25DLF - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25F SUP Custom 27203010 75BA25F - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25L SUP Custom 27203010 75BA25L - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA25LF SUP Custom 27203010 75BA25LF - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30 SUP Custom 27203010 75BA30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30D SUP Custom 27203010 75BA30D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30DC SUP Custom 27203010 75BA30DC - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30DCL SUP Custom 27203010 75BA30DCL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30DF SUP Custom 27203010 75BA30DF - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30DL SUP Custom 27203010 75BA30DL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30DLF SUP Custom 27203010 75BA30DLF - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30F SUP Custom 27203010 75BA30F - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30L SUP Custom 27203010 75BA30L - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA30LF SUP Custom 27203010 75BA30LF - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA35 SUP Custom 27203010 75BA35 - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA35D SUP Custom 27203010 75BA35D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA35DCL SUP Custom 27203010 75BA35DCL - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA35DL SUP Custom 27203010 75BA35DL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA35F SUP Custom 27203010 75BA35F - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA35L SUP Custom 27203010 75BA35L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA35LF SUP Custom 27203010 75BA35LF - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA40 SUP Custom 27203010 75BA40 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA40D SUP Custom 27203010 75BA40D - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA40DC SUP Custom 27203010 75BA40DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA40DF SUP Custom 27203010 75BA40DF - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA40DL SUP Custom 27203010 75BA40DL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA40DX SUP Custom 27203010 75BA40DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA40F SUP Custom 27203010 75BA40F - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA40L SUP Custom 27203010 75BA40L - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA50 SUP Custom 27203010 75BA50 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA50D SUP Custom 27203010 75BA50D - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA50DC SUP Custom 27203010 75BA50DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA50DF SUP Custom 27203010 75BA50DF - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA50DX SUP Custom 27203010 75BA50DX - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA50F SUP Custom 27203010 75BA50F - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA60 SUP Custom 27203010 75BA60 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA60D SUP Custom 27203010 75BA60D - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA60DC SUP Custom 27203010 75BA60DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA60DX SUP Custom 27203010 75BA60DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA60F SUP Custom 27203010 75BA60F - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA70 SUP Custom 27203010 75BA70 - PLATE 18MM TI BONE SPNL BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA80 SUP Custom 27203010 75BA80 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $293.25 $217.01 $0.00 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.65 $217.65 $0.00 $0.00 $61.11 $0.00 $0.00 $0.00 $0.00 $146.63 $232.25 $234.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA80D SUP Custom 27203010 75BA80D - PLATE 18MM TI BONE SPNL BOTH IP/OP $316.63 $234.31 $0.00 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.00 $235.00 $0.00 $0.00 $65.98 $0.00 $0.00 $0.00 $0.00 $158.31 $250.77 $253.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75BA80DC SUP Custom 27203010 75BA80DC - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75CY65DX SUP Custom 27203010 75CY65DX - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75MH22 SUP Custom 27203010 75MH22 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $303.88 $224.87 $0.00 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.54 $225.54 $0.00 $0.00 $63.33 $0.00 $0.00 $0.00 $0.00 $151.94 $240.67 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75MH22D SUP Custom 27203010 75MH22D - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75MH30 SUP Custom 27203010 75MH30 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $303.88 $224.87 $0.00 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.54 $225.54 $0.00 $0.00 $63.33 $0.00 $0.00 $0.00 $0.00 $151.94 $240.67 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75MH30D SUP Custom 27203010 75MH30D - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 75OV40 SUP Custom 27203010 75OV40 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $303.88 $224.87 $0.00 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.54 $225.54 $0.00 $0.00 $63.33 $0.00 $0.00 $0.00 $0.00 $151.94 $240.67 $243.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76-0007 SUP HCPCS C1713 76-0007 - SCREW BN 2.4MM 10MM RIBFIX BLU LCK TI STRNM BOTH IP/OP $615.00 $455.10 $0.00 $492.00 $276.75 $276.75 $0.00 $0.00 $0.00 $128.18 $456.45 $456.45 $0.00 $0.00 $128.17 $0.00 $363.77 $363.77 $0.00 $307.50 $487.08 $492.00 $0.00 $0.00 $96.25 $0.00 $0.00 $97.91 $0.00 $0.00 $0.00 $0.00 $0.00 76-0010 SUP HCPCS C1713 76-0010 - SCREW BN 2.4MM 12MM RIBFIX BLU DRL LCK STRNM SCAPULA BOTH IP/OP $605.00 $447.70 $0.00 $484.00 $272.25 $272.25 $0.00 $0.00 $0.00 $126.10 $449.03 $449.03 $0.00 $0.00 $126.08 $0.00 $357.86 $357.86 $0.00 $302.50 $479.16 $484.00 $0.00 $0.00 $94.68 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $0.00 7602-20M SUP HCPCS C1725 7602-20M - CATHETER ANGIOGRAPHIC PIGTAIL CURVE 5FR .052IN 100CM SIZING BOTH IP/OP $226.28 $167.45 $0.00 $181.02 $122.87 $122.87 $0.00 $0.00 $0.00 $47.16 $167.94 $167.94 $0.00 $0.00 $47.16 $0.00 $133.84 $133.84 $0.00 $113.14 $179.21 $181.02 $0.00 $0.00 $35.41 $0.00 $0.00 $36.02 $0.00 $0.00 $0.00 $0.00 $0.00 7602-2M65 SUP HCPCS C1725 7602-2M65 - CATH ANGIO .035IN PGTL CURVE 5FR .052IN 65CM 10 SDPRT 2 BAND BOTH IP/OP $69.13 $51.16 $0.00 $55.30 $37.53 $37.53 $0.00 $0.00 $0.00 $14.41 $51.30 $51.30 $0.00 $0.00 $14.41 $0.00 $40.89 $40.89 $0.00 $34.56 $54.75 $55.30 $0.00 $0.00 $10.82 $0.00 $0.00 $11.00 $0.00 $0.00 $0.00 $0.00 $0.00 7602-51 SUP HCPCS C1725 7602-51 - CATHETER ANGIO PGTL CRV 5FR 90CM STRL PRFM 10 SH RADOPQ BRD BOTH IP/OP $29.65 $21.94 $0.00 $23.72 $16.10 $16.10 $0.00 $0.00 $0.00 $6.18 $22.01 $22.01 $0.00 $0.00 $6.18 $0.00 $17.54 $17.54 $0.00 $14.83 $23.48 $23.72 $0.00 $0.00 $4.64 $0.00 $0.00 $4.72 $0.00 $0.00 $0.00 $0.00 $0.00 76-2001 SUP HCPCS C1713 76-2001 - SCREW BN 2.4MM 34MM X DRV BOTH IP/OP "$1,127.50 " $834.35 $0.00 $902.00 $507.38 $507.38 $0.00 $0.00 $0.00 $235.00 $836.83 $836.83 $0.00 $0.00 $234.97 $0.00 $666.92 $666.92 $0.00 $563.75 $892.98 $902.00 $0.00 $0.00 $176.45 $0.00 $0.00 $179.50 $0.00 $0.00 $0.00 $0.00 $0.00 76-2408 SUP HCPCS C1713 76-2408 - SCREW BN 2.4MM 8MM RIBFIX BLU SLF DRL LCK RB BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $165.38 $165.38 $0.00 $0.00 $0.00 $76.60 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $217.38 $217.38 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-2410 SUP HCPCS C1713 76-2410 - SCREW BN 2.4MM 10MM RIBFIX BLU ST LCK BOTH IP/OP $492.50 $364.45 $0.00 $365.53 $165.38 $165.38 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-2412 SUP HCPCS C1713 76-2412 - Screw S/d-lk 2.4x12mm BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $165.38 $165.38 $0.00 $0.00 $0.00 $76.60 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $217.38 $217.38 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-2414 SUP HCPCS C1713 76-2414 - SCREW BN 2.4MM 14MM RIBFIX BLU ST LCK TI THOR BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $165.38 $165.38 $0.00 $0.00 $0.00 $76.60 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $217.38 $217.38 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-2416 SUP HCPCS C1713 76-2416 - SCREW BN 2.4MM 16MM RIBFIX BLU SLF DRL LCK RB BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $165.38 $165.38 $0.00 $0.00 $0.00 $76.60 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $217.38 $217.38 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-2601 SUP HCPCS C1713 76-2601 - PLATE BN STRG NS RIBFIX BLU 8 HL TI RB BOTH IP/OP "$2,497.50 " "$1,848.15" $0.00 "$1,998.00" "$1,123.88" "$1,123.88" $0.00 $0.00 $0.00 $520.54 "$1,853.64" "$1,853.64" $0.00 $0.00 $520.48 $0.00 "$1,477.27" "$1,477.27" $0.00 "$1,248.75" "$1,978.02" "$1,998.00" $0.00 $0.00 $390.86 $0.00 $0.00 $397.60 $0.00 $0.00 $0.00 $0.00 $0.00 76-2602 SUP HCPCS C1713 76-2602 - SCREW BN PREBNT 2.4MM 14MM SLF DRL LCK TI RB BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 76-2603 SUP HCPCS C1713 76-2603 - PLATE BN PREBNT NS RIBFIX BLU 16 HL TI RB BOTH IP/OP "$3,747.50 " "$2,773.15" $0.00 "$2,998.00" "$1,686.38" "$1,686.38" $0.00 $0.00 $0.00 $781.07 "$2,781.39" "$2,781.39" $0.00 $0.00 $780.98 $0.00 "$1,847.52" "$1,847.52" $0.00 "$1,873.75" "$2,968.02" "$2,998.00" $0.00 $0.00 $586.48 $0.00 $0.00 $596.60 $0.00 $0.00 $0.00 $0.00 $0.00 76-2708 SUP HCPCS C1713 76-2708 - SCREW BN 2.7MM 8MM ER TI RB BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $165.38 $165.38 $0.00 $0.00 $0.00 $76.60 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $217.38 $217.38 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-2710 SUP HCPCS C1713 76-2710 - SCREW BN 2.7MM 10MM ER TI RB BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $165.38 $165.38 $0.00 $0.00 $0.00 $76.60 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $217.38 $217.38 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-2712 SUP HCPCS C1713 76-2712 - SCREW BN 2.7MM 12MM ER RB BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $165.38 $165.38 $0.00 $0.00 $0.00 $76.60 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $217.38 $217.38 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-2714 SUP HCPCS C1713 76-2714 - SCREW BN 2.7MM 14MM ER RB BOTH IP/OP $367.50 $271.95 $0.00 $294.00 $165.38 $165.38 $0.00 $0.00 $0.00 $76.60 $272.76 $272.76 $0.00 $0.00 $76.59 $0.00 $217.38 $217.38 $0.00 $183.75 $291.06 $294.00 $0.00 $0.00 $57.51 $0.00 $0.00 $58.51 $0.00 $0.00 $0.00 $0.00 $0.00 76-4003L SUP HCPCS C1776 76-4003L - CMPNT FEM LEFT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$10,226.13 " "$7,567.34" $0.00 "$8,180.90" "$4,601.76" "$4,601.76" $0.00 $0.00 $0.00 "$2,131.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,131.12" $0.00 "$5,041.48" "$5,041.48" $0.00 "$5,113.06" "$8,099.09" "$8,180.90" $0.00 $0.00 "$1,600.39" $0.00 $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 76-4003R SUP HCPCS C1776 76-4003R - CMPNT FEM RIGHT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$10,226.13 " "$7,567.34" $0.00 "$8,180.90" "$4,601.76" "$4,601.76" $0.00 $0.00 $0.00 "$2,131.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,131.12" $0.00 "$5,041.48" "$5,041.48" $0.00 "$5,113.06" "$8,099.09" "$8,180.90" $0.00 $0.00 "$1,600.39" $0.00 $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 76-4004L SUP HCPCS C1776 76-4004L - CMPNT FEM LEFT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$10,226.13 " "$7,567.34" $0.00 "$8,180.90" "$4,601.76" "$4,601.76" $0.00 $0.00 $0.00 "$2,131.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,131.12" $0.00 "$5,041.48" "$5,041.48" $0.00 "$5,113.06" "$8,099.09" "$8,180.90" $0.00 $0.00 "$1,600.39" $0.00 $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 76-4004R SUP HCPCS C1776 76-4004R - CMPNT FEM RIGHT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$10,226.13 " "$7,567.34" $0.00 "$8,180.90" "$4,601.76" "$4,601.76" $0.00 $0.00 $0.00 "$2,131.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,131.12" $0.00 "$5,041.48" "$5,041.48" $0.00 "$5,113.06" "$8,099.09" "$8,180.90" $0.00 $0.00 "$1,600.39" $0.00 $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 76-4005L SUP HCPCS C1776 76-4005L - CMPNT FEM LEFT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$9,995.38 " "$7,396.58" $0.00 "$7,996.30" "$4,497.92" "$4,497.92" $0.00 $0.00 $0.00 "$2,083.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,083.04" $0.00 "$4,927.72" "$4,927.72" $0.00 "$4,997.69" "$7,916.34" "$7,996.30" $0.00 $0.00 "$1,564.28" $0.00 $0.00 "$1,591.26" $0.00 $0.00 $0.00 $0.00 $0.00 76-4005R SUP HCPCS C1776 76-4005R - CMPNT FEM RIGHT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$9,995.38 " "$7,396.58" $0.00 "$7,996.30" "$4,497.92" "$4,497.92" $0.00 $0.00 $0.00 "$2,083.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,083.04" $0.00 "$4,927.72" "$4,927.72" $0.00 "$4,997.69" "$7,916.34" "$7,996.30" $0.00 $0.00 "$1,564.28" $0.00 $0.00 "$1,591.26" $0.00 $0.00 $0.00 $0.00 $0.00 76-4006L SUP HCPCS C1776 76-4006L - CMPNT FEM LEFT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$10,226.13 " "$7,567.34" $0.00 "$8,180.90" "$4,601.76" "$4,601.76" $0.00 $0.00 $0.00 "$2,131.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,131.12" $0.00 "$5,041.48" "$5,041.48" $0.00 "$5,113.06" "$8,099.09" "$8,180.90" $0.00 $0.00 "$1,600.39" $0.00 $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 76-4006R SUP HCPCS C1776 76-4006R - CMPNT FEM RIGHT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$10,226.13 " "$7,567.34" $0.00 "$8,180.90" "$4,601.76" "$4,601.76" $0.00 $0.00 $0.00 "$2,131.38" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,131.12" $0.00 "$5,041.48" "$5,041.48" $0.00 "$5,113.06" "$8,099.09" "$8,180.90" $0.00 $0.00 "$1,600.39" $0.00 $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 76-4007L SUP HCPCS C1776 76-4007L - CMPNT FEM LEFT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$9,995.38 " "$7,396.58" $0.00 "$7,996.30" "$4,497.92" "$4,497.92" $0.00 $0.00 $0.00 "$2,083.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,083.04" $0.00 "$4,927.72" "$4,927.72" $0.00 "$4,997.69" "$7,916.34" "$7,996.30" $0.00 $0.00 "$1,564.28" $0.00 $0.00 "$1,591.26" $0.00 $0.00 $0.00 $0.00 $0.00 76-4007R SUP HCPCS C1776 76-4007R - CMPNT FEM RIGHT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$9,995.38 " "$7,396.58" $0.00 "$7,996.30" "$4,497.92" "$4,497.92" $0.00 $0.00 $0.00 "$2,083.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,083.04" $0.00 "$4,927.72" "$4,927.72" $0.00 "$4,997.69" "$7,916.34" "$7,996.30" $0.00 $0.00 "$1,564.28" $0.00 $0.00 "$1,591.26" $0.00 $0.00 $0.00 $0.00 $0.00 76-4009L SUP HCPCS C1776 76-4009L - CMPNT FEM LEFT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$9,995.38 " "$7,396.58" $0.00 "$7,996.30" "$4,497.92" "$4,497.92" $0.00 $0.00 $0.00 "$2,083.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,083.04" $0.00 "$4,927.72" "$4,927.72" $0.00 "$4,997.69" "$7,916.34" "$7,996.30" $0.00 $0.00 "$1,564.28" $0.00 $0.00 "$1,591.26" $0.00 $0.00 $0.00 $0.00 $0.00 76-4009R SUP HCPCS C1776 76-4009R - CMPNT FEM RIGHT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$9,995.38 " "$7,396.58" $0.00 "$7,996.30" "$4,497.92" "$4,497.92" $0.00 $0.00 $0.00 "$2,083.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,083.04" $0.00 "$4,927.72" "$4,927.72" $0.00 "$4,997.69" "$7,916.34" "$7,996.30" $0.00 $0.00 "$1,564.28" $0.00 $0.00 "$1,591.26" $0.00 $0.00 $0.00 $0.00 $0.00 76-4011L SUP HCPCS C1776 76-4011L - CMPNT FEM LEFT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$9,995.38 " "$7,396.58" $0.00 "$7,996.30" "$4,497.92" "$4,497.92" $0.00 $0.00 $0.00 "$2,083.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,083.04" $0.00 "$4,927.72" "$4,927.72" $0.00 "$4,997.69" "$7,916.34" "$7,996.30" $0.00 $0.00 "$1,564.28" $0.00 $0.00 "$1,591.26" $0.00 $0.00 $0.00 $0.00 $0.00 76-4011R SUP HCPCS C1776 76-4011R - CMPNT FEM RIGHT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$9,995.38 " "$7,396.58" $0.00 "$7,996.30" "$4,497.92" "$4,497.92" $0.00 $0.00 $0.00 "$2,083.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,083.04" $0.00 "$4,927.72" "$4,927.72" $0.00 "$4,997.69" "$7,916.34" "$7,996.30" $0.00 $0.00 "$1,564.28" $0.00 $0.00 "$1,591.26" $0.00 $0.00 $0.00 $0.00 $0.00 76-4013L SUP HCPCS C1776 76-4013L - CMPNT FEM LEFT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$8,567.00 " "$6,339.58" $0.00 "$6,853.60" "$3,855.15" "$3,855.15" $0.00 $0.00 $0.00 "$1,785.58" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,785.36" $0.00 "$4,223.53" "$4,223.53" $0.00 "$4,283.50" "$6,785.06" "$6,853.60" $0.00 $0.00 "$1,340.74" $0.00 $0.00 "$1,363.87" $0.00 $0.00 $0.00 $0.00 $0.00 76-4013R SUP HCPCS C1776 76-4013R - CMPNT FEM RIGHT KNEE TOT STAB W/O LFIT SCRP BOTH IP/OP "$8,567.00 " "$6,339.58" $0.00 "$6,853.60" "$3,855.15" "$3,855.15" $0.00 $0.00 $0.00 "$1,785.58" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,785.36" $0.00 "$4,223.53" "$4,223.53" $0.00 "$4,283.50" "$6,785.06" "$6,853.60" $0.00 $0.00 "$1,340.74" $0.00 $0.00 "$1,363.87" $0.00 $0.00 $0.00 $0.00 $0.00 76-4103L SUP HCPCS C1776 76-4103L - COMPONENT FEMORAL 3 56X35MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4103R SUP HCPCS C1776 76-4103R - COMPONENT FEMORAL 3 56X35MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4105L SUP HCPCS C1776 76-4105L - COMPONENT FEMORAL 5 61X39MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4105R SUP HCPCS C1776 76-4105R - COMPONENT FEMORAL 5 61X39MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4107L SUP HCPCS C1776 76-4107L - COMPONENT FEMORAL 7 66X44MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4107R SUP HCPCS C1776 76-4107R - COMPONENT FEMORAL 7 66X44MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4109L SUP HCPCS C1776 76-4109L - COMPONENT FEMORAL 9 71X49MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4109R SUP HCPCS C1776 76-4109R - COMPONENT FEMORAL 9 71X49MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4111L SUP HCPCS C1776 76-4111L - COMPONENT FEMORAL 11 76X53MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4111R SUP HCPCS C1776 76-4111R - COMPONENT FEMORAL 11 76X53MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4113L SUP HCPCS C1776 76-4113L - COMPONENT FEMORAL 13 81X58MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 76-4113R SUP HCPCS C1776 76-4113R - COMPONENT FEMORAL 13 81X58MM MODULAR TOT STABILIZE REVISION BOTH IP/OP "$12,130.00 " "$8,976.20" $0.00 "$9,704.00" "$5,458.50" "$5,458.50" $0.00 $0.00 $0.00 "$2,528.20" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,527.89" $0.00 "$5,980.09" "$5,980.09" $0.00 "$6,065.00" "$9,606.96" "$9,704.00" $0.00 $0.00 "$1,898.35" $0.00 $0.00 "$1,931.10" $0.00 $0.00 $0.00 $0.00 $0.00 7650-2038A SUP Custom 27203010 7650-2038A - PIN FIX FLUTE SQUARE 1/8IN 3.5IN STAINLESS STEEL KNEE BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76791-MX SUP HCPCS C1725 THERMOMETER SYSTEM DIAG INTEGRATED 767 BOTH IP/OP "$2,070.45 " "$1,532.13" $0.00 "$1,656.36" "$1,124.25" "$1,124.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,035.23" "$1,639.80" "$1,656.36" $0.00 $0.00 $324.03 $0.00 $0.00 $329.62 $0.00 $0.00 $0.00 $0.00 $0.00 7679922P SUP Custom 27203010 7679922P - REAMER SRG 3.15MM STRL PCM MRC SPNE BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7679925P SUP Custom 27203010 7679925P - REAMER SRG 3.5MM STRL PCM ANS SPNE BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7679926P SUP Custom 27203010 7679926P - REAMER SRG 3.5MM STRL PCM MRL SPNE BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7679927P SUP Custom 27203010 7679927P - REAMER SRG 3.5MM STRL PCM HXL SPNE BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7679930P SUP Custom 27203010 7679930P - REAMER SRG 3.5MM STRL PCM JC SPNE BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7679934P SUP Custom 27203010 7679934P - REAMER SRG 3.5MM STRL PCM TSPE SPNE BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 768G SUP Custom 27203010 768G - SUTURE NONABSORBABLE 7-0 G-6 18IN 2 ARM BRAID NEEDLE BOTH IP/OP $32.63 $24.15 $0.00 $26.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.22 $24.22 $0.00 $0.00 $6.80 $0.00 $0.00 $0.00 $0.00 $16.56 $26.23 $26.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 76-9102 SUP HCPCS C1713 76-9102 - SCREW BN 2.7MM 8MM ER LCK RB BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $83.25 $83.25 $0.00 $0.00 $0.00 $38.56 $137.31 $137.31 $0.00 $0.00 $38.55 $0.00 $109.43 $109.43 $0.00 $92.50 $146.52 $148.00 $0.00 $0.00 $28.95 $0.00 $0.00 $29.45 $0.00 $0.00 $0.00 $0.00 $0.00 76-9103 SUP HCPCS C1713 76-9103 - PLATE BN 16 HL TMPLT RB BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $83.25 $83.25 $0.00 $0.00 $0.00 $38.56 $137.31 $137.31 $0.00 $0.00 $38.55 $0.00 $109.43 $109.43 $0.00 $92.50 $146.52 $148.00 $0.00 $0.00 $28.95 $0.00 $0.00 $29.45 $0.00 $0.00 $0.00 $0.00 $0.00 76-9104 SUP HCPCS C1713 76-9104 - TEMPLATE SZ 16 HL PLT BOTH IP/OP $185.00 $136.90 $0.00 $148.00 $83.25 $83.25 $0.00 $0.00 $0.00 $38.56 $137.31 $137.31 $0.00 $0.00 $38.55 $0.00 $109.43 $109.43 $0.00 $92.50 $146.52 $148.00 $0.00 $0.00 $28.95 $0.00 $0.00 $29.45 $0.00 $0.00 $0.00 $0.00 $0.00 769G SUP Custom 27203010 769G - SUTURE NABSB 6-0 G-6 18IN BLK PRMHND MICROPOINT 2 ARM BRD BOTH IP/OP $32.39 $23.97 $0.00 $26.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.04 $24.04 $0.00 $0.00 $6.75 $0.00 $0.00 $0.00 $0.00 $16.44 $26.03 $26.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77-1003 SUP HCPCS C1776 77-1003 - CMPNT TIBTRY 3MM KNEE LP SCRP BOTH IP/OP "$2,308.00 " "$1,707.92" $0.00 "$1,846.40" "$1,038.60" "$1,038.60" $0.00 $0.00 $0.00 $481.04 "$1,713.00" "$1,713.00" $0.00 $0.00 $480.99 $0.00 "$1,365.18" "$1,365.18" $0.00 "$1,154.00" "$1,827.94" "$1,846.40" $0.00 $0.00 $361.20 $0.00 $0.00 $367.43 $0.00 $0.00 $0.00 $0.00 $0.00 77-1004 SUP HCPCS C1776 77-1004 - CMPNT TIBTRY 4MM KNEE LP SCRP BOTH IP/OP "$2,308.00 " "$1,707.92" $0.00 "$1,846.40" "$1,038.60" "$1,038.60" $0.00 $0.00 $0.00 $481.04 "$1,713.00" "$1,713.00" $0.00 $0.00 $480.99 $0.00 "$1,365.18" "$1,365.18" $0.00 "$1,154.00" "$1,827.94" "$1,846.40" $0.00 $0.00 $361.20 $0.00 $0.00 $367.43 $0.00 $0.00 $0.00 $0.00 $0.00 77-1006 SUP HCPCS C1776 77-1006 - CMPNT TIBTRY 6MM KNEE LP SCRP BOTH IP/OP "$2,308.00 " "$1,707.92" $0.00 "$1,846.40" "$1,038.60" "$1,038.60" $0.00 $0.00 $0.00 $481.04 "$1,713.00" "$1,713.00" $0.00 $0.00 $480.99 $0.00 "$1,365.18" "$1,365.18" $0.00 "$1,154.00" "$1,827.94" "$1,846.40" $0.00 $0.00 $361.20 $0.00 $0.00 $367.43 $0.00 $0.00 $0.00 $0.00 $0.00 77-1007 SUP HCPCS C1776 77-1007 - CMPNT TIBTRY 7MM KNEE LP SCRP BOTH IP/OP "$2,308.00 " "$1,707.92" $0.00 "$1,846.40" "$1,038.60" "$1,038.60" $0.00 $0.00 $0.00 $481.04 "$1,713.00" "$1,713.00" $0.00 $0.00 $480.99 $0.00 "$1,365.18" "$1,365.18" $0.00 "$1,154.00" "$1,827.94" "$1,846.40" $0.00 $0.00 $361.20 $0.00 $0.00 $367.43 $0.00 $0.00 $0.00 $0.00 $0.00 77-1009 SUP HCPCS C1776 77-1009 - CMPNT TIB 9MM SCRP KNEE LP BOTH IP/OP "$2,308.00 " "$1,707.92" $0.00 "$1,846.40" "$1,038.60" "$1,038.60" $0.00 $0.00 $0.00 $481.04 "$1,713.00" "$1,713.00" $0.00 $0.00 $480.99 $0.00 "$1,365.18" "$1,365.18" $0.00 "$1,154.00" "$1,827.94" "$1,846.40" $0.00 $0.00 $361.20 $0.00 $0.00 $367.43 $0.00 $0.00 $0.00 $0.00 $0.00 7717G SUP Custom 27203010 7717G - SUTURE NONABSORBABLE 9-0 TG140-8 12IN 2 ARM MONOFILAMENT BOTH IP/OP $33.76 $24.98 $0.00 $27.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.06 $25.06 $0.00 $0.00 $7.04 $0.00 $0.00 $0.00 $0.00 $17.14 $27.14 $27.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7731G SUP Custom 27203010 7731G - SUTURE NABSB 5-0 S-24 18IN BLK ETH SBLC 2 ARM MFL BOTH IP/OP $33.98 $25.15 $0.00 $27.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.22 $25.22 $0.00 $0.00 $7.08 $0.00 $0.00 $0.00 $0.00 $17.24 $27.32 $27.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 77-4003 SUP HCPCS C1776 77-4003 - TRAY TIBIAL 3 40/61MM 35MM 1 AXIS TOT STABILIZE STEM END CAP BOTH IP/OP "$5,837.50 " "$4,319.75" $0.00 "$4,670.00" "$2,626.88" "$2,626.88" $0.00 $0.00 $0.00 "$1,216.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,216.54" $0.00 "$2,877.89" "$2,877.89" $0.00 "$2,918.75" "$4,623.30" "$4,670.00" $0.00 $0.00 $913.57 $0.00 $0.00 $929.33 $0.00 $0.00 $0.00 $0.00 $0.00 77-4004 SUP HCPCS C1776 77-4004 - TRAY TIBIAL 4 TOT STABILIZE MODULAR SCORPIO KNEE BOTH IP/OP "$5,837.50 " "$4,319.75" $0.00 "$4,670.00" "$2,626.88" "$2,626.88" $0.00 $0.00 $0.00 "$1,216.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,216.54" $0.00 "$2,877.89" "$2,877.89" $0.00 "$2,918.75" "$4,623.30" "$4,670.00" $0.00 $0.00 $913.57 $0.00 $0.00 $929.33 $0.00 $0.00 $0.00 $0.00 $0.00 77-4005 SUP HCPCS C1776 77-4005 - TRAY TIBIAL 5 44/66MM 35MM 1 AXIS TOT STABILIZE STEM END CAP BOTH IP/OP "$5,837.50 " "$4,319.75" $0.00 "$4,670.00" "$2,626.88" "$2,626.88" $0.00 $0.00 $0.00 "$1,216.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,216.54" $0.00 "$2,877.89" "$2,877.89" $0.00 "$2,918.75" "$4,623.30" "$4,670.00" $0.00 $0.00 $913.57 $0.00 $0.00 $929.33 $0.00 $0.00 $0.00 $0.00 $0.00 77-4006 SUP HCPCS C1776 77-4006 - TRAY TIBIAL 6 TOT STABILIZE MODULAR SCORPIO KNEE BOTH IP/OP "$5,837.50 " "$4,319.75" $0.00 "$4,670.00" "$2,626.88" "$2,626.88" $0.00 $0.00 $0.00 "$1,216.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,216.54" $0.00 "$2,877.89" "$2,877.89" $0.00 "$2,918.75" "$4,623.30" "$4,670.00" $0.00 $0.00 $913.57 $0.00 $0.00 $929.33 $0.00 $0.00 $0.00 $0.00 $0.00 77-4007 SUP HCPCS C1776 77-4007 - TRAY TIBIAL 7 47/71MM 37MM 1 AXIS TOT STABILIZE STEM END CAP BOTH IP/OP "$5,837.50 " "$4,319.75" $0.00 "$4,670.00" "$2,626.88" "$2,626.88" $0.00 $0.00 $0.00 "$1,216.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,216.54" $0.00 "$2,877.89" "$2,877.89" $0.00 "$2,918.75" "$4,623.30" "$4,670.00" $0.00 $0.00 $913.57 $0.00 $0.00 $929.33 $0.00 $0.00 $0.00 $0.00 $0.00 77-4009 SUP HCPCS C1776 77-4009 - TRAY TIBIAL 9 51/77MM 37MM 1 AXIS TOT STABILIZE STEM END CAP BOTH IP/OP "$5,837.50 " "$4,319.75" $0.00 "$4,670.00" "$2,626.88" "$2,626.88" $0.00 $0.00 $0.00 "$1,216.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,216.54" $0.00 "$2,877.89" "$2,877.89" $0.00 "$2,918.75" "$4,623.30" "$4,670.00" $0.00 $0.00 $913.57 $0.00 $0.00 $929.33 $0.00 $0.00 $0.00 $0.00 $0.00 77-4011 SUP HCPCS C1776 77-4011 - TRAY TIBIAL 11 54/82MM 43MM 1 AXIS TOT STABILIZE STEM END BOTH IP/OP "$5,837.50 " "$4,319.75" $0.00 "$4,670.00" "$2,626.88" "$2,626.88" $0.00 $0.00 $0.00 "$1,216.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,216.54" $0.00 "$2,877.89" "$2,877.89" $0.00 "$2,918.75" "$4,623.30" "$4,670.00" $0.00 $0.00 $913.57 $0.00 $0.00 $929.33 $0.00 $0.00 $0.00 $0.00 $0.00 77-4013 SUP HCPCS C1776 77-4013 - TRAY TIBIAL 13 58/88MM 43MM 1 AXIS TOT STABILIZE STEM END BOTH IP/OP "$5,837.50 " "$4,319.75" $0.00 "$4,670.00" "$2,626.88" "$2,626.88" $0.00 $0.00 $0.00 "$1,216.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,216.54" $0.00 "$2,877.89" "$2,877.89" $0.00 "$2,918.75" "$4,623.30" "$4,670.00" $0.00 $0.00 $913.57 $0.00 $0.00 $929.33 $0.00 $0.00 $0.00 $0.00 $0.00 7751710EP SUP HCPCS C1713 7751710EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751712EP SUP HCPCS C1713 7751712EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751714EP SUP HCPCS C1713 7751714EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751716EP SUP HCPCS C1713 7751716EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751718EP SUP HCPCS C1713 7751718EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751720EP SUP HCPCS C1713 7751720EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751722EP SUP HCPCS C1713 7751722EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751724EP SUP HCPCS C1713 7751724EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751724PT SUP HCPCS C1713 7751724PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751726PT SUP HCPCS C1713 7751726PT - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751728PT SUP HCPCS C1713 7751728PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751730PT SUP HCPCS C1713 7751730PT - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751732PT SUP HCPCS C1713 7751732PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751734PT SUP HCPCS C1713 7751734PT - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751810EP SUP HCPCS C1713 7751810EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751812EP SUP HCPCS C1713 7751812EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751814EP SUP HCPCS C1713 7751814EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751816EP SUP HCPCS C1713 7751816EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751818EP SUP HCPCS C1713 7751818EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751820EP SUP HCPCS C1713 7751820EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751822EP SUP HCPCS C1713 7751822EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751824EP SUP HCPCS C1713 7751824EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751824PT SUP HCPCS C1713 7751824PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751826EP SUP HCPCS C1713 7751826EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751826PT SUP HCPCS C1713 7751826PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751828EP SUP HCPCS C1713 7751828EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751828PT SUP HCPCS C1713 7751828PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751830EP SUP HCPCS C1713 7751830EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751830PT SUP HCPCS C1713 7751830PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751832EP SUP HCPCS C1713 7751832EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751832PT SUP HCPCS C1713 7751832PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751834EP SUP HCPCS C1713 7751834EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751834PT SUP HCPCS C1713 7751834PT - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751924EP SUP HCPCS C1713 7751924EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751926EP SUP HCPCS C1713 7751926EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751928EP SUP HCPCS C1713 7751928EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751930EP SUP HCPCS C1713 7751930EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751932EP SUP HCPCS C1713 7751932EP - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 7751934EP SUP HCPCS C1713 7751934EP - PLATE 18MM TI BONE SPNL BOTH IP/OP $983.68 $727.92 $0.00 $786.94 $442.65 $442.65 $0.00 $0.00 $0.00 $205.02 $730.08 $730.08 $0.00 $0.00 $205.00 $0.00 $581.84 $581.84 $0.00 $491.84 $779.07 $786.94 $0.00 $0.00 $153.95 $0.00 $0.00 $156.60 $0.00 $0.00 $0.00 $0.00 $0.00 77525P SUP HCPCS C1713 77525P - SCREW BN 7.75MM 25MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77525S SUP HCPCS C1713 77525S - SCREW BN STD 7.75MM 25MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77530P SUP HCPCS C1713 77530P - SCREW BN 7.75MM 30MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77530S SUP HCPCS C1713 77530S - SCREW BN STD 7.75MM 30MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77535P SUP HCPCS C1713 77535P - SCREW BN 7.75MM 35MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77535S SUP HCPCS C1713 77535S - SCREW BN STD 7.75MM 35MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77540P SUP HCPCS C1713 77540P - SCREW BN 7.75MM 40MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77540S SUP HCPCS C1713 77540S - SCREW BN STD 7.75MM 40MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77545P SUP HCPCS C1713 77545P - SCREW BN 7.75MM 45MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77545S SUP HCPCS C1713 77545S - SCREW BN STD 7.75MM 45MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77550P SUP HCPCS C1713 77550P - SCREW BN 7.75MM 50MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77550S SUP HCPCS C1713 77550S - SCREW BN STD 7.75MM 50MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77555P SUP HCPCS C1713 77555P - SCREW BN 7.75MM 55MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77555S SUP HCPCS C1713 77555S - SCREW BN STD 7.75MM 55MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 7756073L SUP HCPCS C1713 7756073L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756073R SUP HCPCS C1713 7756073R - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756074L SUP HCPCS C1713 7756074L - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 7756074R SUP HCPCS C1713 7756074R - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 77560P SUP HCPCS C1713 77560P - SCREW BN 7.75MM 60MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77560S SUP HCPCS C1713 77560S - SCREW BN STD 7.75MM 60MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77565P SUP HCPCS C1713 77565P - SCREW BN 7.75MM 65MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$1,621.98 " "$1,200.27" $0.00 "$1,297.58" $729.89 $729.89 $0.00 $0.00 $0.00 $338.06 "$1,203.83" "$1,203.83" $0.00 $0.00 $338.02 $0.00 $959.40 $959.40 $0.00 $810.99 "$1,284.61" "$1,297.58" $0.00 $0.00 $253.84 $0.00 $0.00 $258.22 $0.00 $0.00 $0.00 $0.00 $0.00 77565S SUP HCPCS C1713 77565S - SCREW BN STD 7.75MM 65MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,233.33 " $912.66 $0.00 $986.66 $555.00 $555.00 $0.00 $0.00 $0.00 $257.06 $915.37 $915.37 $0.00 $0.00 $257.02 $0.00 $729.51 $729.51 $0.00 $616.66 $976.80 $986.66 $0.00 $0.00 $193.02 $0.00 $0.00 $196.35 $0.00 $0.00 $0.00 $0.00 $0.00 77570P SUP HCPCS C1713 77570P - SCREW BN 7.75MM 70MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77580P SUP HCPCS C1713 77580P - SCREW BN 7.75MM 80MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 77590P SUP HCPCS C1713 77590P - SCREW BN 7.75MM 90MM SPRL R90D MULTIANGLE TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 778-014-00 SUP HCPCS C1887 CATHETER GUID JL4ST CURVE 7FR .078IN 100CM PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 778-081-00 SUP HCPCS C1887 CATHETER GUID JR3.5 CURVE 7FR .078IN 100CM SH PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 778-181-00 SUP HCPCS C1887 CATHETER GUID LCB CURVE 7FR .078IN 100CM SH PTFE VSBR BLUE BOTH IP/OP $139.93 $103.55 $0.00 $111.94 $75.98 $75.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.96 $110.82 $111.94 $0.00 $0.00 $21.90 $0.00 $0.00 $22.28 $0.00 $0.00 $0.00 $0.00 $0.00 78-10030 SUP HCPCS C1713 78-10030 - IMPLANT CRNL LG KT CSTM BOTH IP/OP "$30,104.35 " "$22,277.22" $0.00 "$35,102.00" "$19,744.88" "$19,744.88" $0.00 $0.00 $0.00 "$6,274.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,273.75" $0.00 "$14,841.45" "$14,841.45" $0.00 "$21,938.75" "$34,750.98" "$35,102.00" $0.00 $0.00 "$6,866.83" $0.00 $0.00 "$6,985.30" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-000 SUP HCPCS C1776 7850-1-000 - STEM FEM HIPSTAR 135D 0 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-001 SUP HCPCS C1776 7850-1-001 - STEM FEM HIPSTAR 135D 1 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-002 SUP HCPCS C1776 7850-1-002 - STEM FEM HIPSTAR 135D 2 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-003 SUP HCPCS C1776 7850-1-003 - STEM FEM HIPSTAR TMZF 135D 3 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-004 SUP HCPCS C1776 7850-1-004 - STEM FEM HIPSTAR HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-005 SUP HCPCS C1776 7850-1-005 - STEM FEM HIPSTAR TMZF 135D 5 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-006 SUP HCPCS C1776 7850-1-006 - STEM FEM HIPSTAR 135D 6 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-007 SUP HCPCS C1776 7850-1-007 - STEM FEM HIPSTAR 135D 7 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-008 SUP HCPCS C1776 7850-1-008 - STEM FEM HIPSTAR 135D 8 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-009 SUP HCPCS C1776 7850-1-009 - STEM FEM HIPSTAR 135D 9 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-010 SUP HCPCS C1776 7850-1-010 - STEM FEM HIPSTAR 135D 10 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-011 SUP HCPCS C1776 7850-1-011 - STEM FEM HIPSTAR 135D 11 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 7850-1-012 SUP HCPCS C1776 7850-1-012 - STEM FEM HIPSTAR 135D 12 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-000 SUP HCPCS C1776 7850-5-000 - STEM FEM HIPSTAR 127D 0 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-001 SUP HCPCS C1776 7850-5-001 - STEM FEM HIPSTAR 127D 1 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-002 SUP HCPCS C1776 7850-5-002 - STEM FEM HIPSTAR 127D 2 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-003 SUP HCPCS C1776 7850-5-003 - STEM FEM HIPSTAR 127D 3 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-004 SUP HCPCS C1776 7850-5-004 - STEM FEM HIPSTAR 127D 4 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-005 SUP HCPCS C1776 7850-5-005 - STEM FEM HIPSTAR 127D 5 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-006 SUP HCPCS C1776 7850-5-006 - STEM FEM HIPSTAR 127D 6 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-007 SUP HCPCS C1776 7850-5-007 - STEM FEM HIPSTAR 127D 7 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-008 SUP HCPCS C1776 7850-5-008 - STEM FEM HIPSTAR 127D 8 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-009 SUP HCPCS C1776 7850-5-009 - STEM FEM HIPSTAR 127D 9 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-010 SUP HCPCS C1776 7850-5-010 - STEM FEM HIPSTAR 127D 10 HIP BOTH IP/OP "$6,328.00 " "$4,682.72" $0.00 "$5,062.40" "$2,847.60" "$2,847.60" $0.00 $0.00 $0.00 "$1,318.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,318.76" $0.00 "$3,119.70" "$3,119.70" $0.00 "$3,164.00" "$5,011.78" "$5,062.40" $0.00 $0.00 $990.33 $0.00 $0.00 "$1,007.42" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-011 SUP HCPCS C1776 7850-5-011 - STEM FEM HIPSTAR 127D 11 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 7850-5-012 SUP HCPCS C1776 7850-5-012 - STEM FEM HIPSTAR 127D 12 HIP BOTH IP/OP "$6,665.00 " "$4,932.10" $0.00 "$5,332.00" "$2,999.25" "$2,999.25" $0.00 $0.00 $0.00 "$1,389.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,388.99" $0.00 "$3,285.85" "$3,285.85" $0.00 "$3,332.50" "$5,278.68" "$5,332.00" $0.00 $0.00 "$1,043.07" $0.00 $0.00 "$1,061.07" $0.00 $0.00 $0.00 $0.00 $0.00 7925011S SUP HCPCS C1713 7925011S - CABLE SPINAL 2 LOOP 2 CRIMP TITANIUM STERILE BOTH IP/OP "$2,325.00 " "$1,720.50" $0.00 "$1,860.00" "$1,046.25" "$1,046.25" $0.00 $0.00 $0.00 $484.59 "$1,725.62" "$1,725.62" $0.00 $0.00 $484.53 $0.00 "$1,375.24" "$1,375.24" $0.00 "$1,162.50" "$1,841.40" "$1,860.00" $0.00 $0.00 $363.86 $0.00 $0.00 $370.14 $0.00 $0.00 $0.00 $0.00 $0.00 79-43903 SUP HCPCS C1713 79-43903 - CEMENT BONE INJECTABLE BIOCOMPATIBLE OSTEOCONDUCTIVE BOTH IP/OP "$2,314.78 " "$1,712.94" $0.00 "$2,686.00" "$1,510.88" "$1,510.88" $0.00 $0.00 $0.00 $482.46 "$1,718.03" "$1,718.03" $0.00 $0.00 $482.40 $0.00 "$1,369.19" "$1,369.19" $0.00 "$1,678.75" "$2,659.14" "$2,686.00" $0.00 $0.00 $525.45 $0.00 $0.00 $534.51 $0.00 $0.00 $0.00 $0.00 $0.00 79-43905 SUP HCPCS C1713 79-43905 - CEMENT BONE INJECTABLE BIOCOMPATIBLE OSTEOCONDUCTIVE BOTH IP/OP "$3,817.23 " "$2,824.75" $0.00 "$3,053.79" "$1,717.75" "$1,717.75" $0.00 $0.00 $0.00 $795.61 "$2,833.15" "$2,833.15" $0.00 $0.00 $795.51 $0.00 "$1,881.90" "$1,881.90" $0.00 "$1,908.62" "$3,023.25" "$3,053.79" $0.00 $0.00 $597.40 $0.00 $0.00 $607.70 $0.00 $0.00 $0.00 $0.00 $0.00 79-43910 SUP HCPCS C1713 79-43910 - CEMENT BN 10CC STRL LF HYDROSET INJ OSTCNDC CA PHOS VOID FIL BOTH IP/OP "$7,335.12 " "$5,427.99" $0.00 "$5,868.10" "$3,300.80" "$3,300.80" $0.00 $0.00 $0.00 "$1,528.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,528.64" $0.00 "$3,616.21" "$3,616.21" $0.00 "$3,667.56" "$5,809.42" "$5,868.10" $0.00 $0.00 "$1,147.95" $0.00 $0.00 "$1,167.75" $0.00 $0.00 $0.00 $0.00 $0.00 79-43915 SUP HCPCS C1713 79-43915 - CEMENT BONE INJECTABLE OSTEOCONDUCTIVE HYDROSET CALCIUM BOTH IP/OP "$10,553.66 " "$7,809.71" $0.00 "$8,442.93" "$4,749.15" "$4,749.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,276.83" "$8,358.50" "$8,442.93" $0.00 $0.00 "$1,651.65" $0.00 $0.00 "$1,680.14" $0.00 $0.00 $0.00 $0.00 $0.00 79-45903 SUP HCPCS C1713 79-45903 - DIRECT INJECT 3CC BOTH IP/OP "$3,840.00 " "$2,841.60" $0.00 "$3,072.00" "$1,728.00" "$1,728.00" $0.00 $0.00 $0.00 $800.35 "$2,850.05" "$2,850.05" $0.00 $0.00 $800.26 $0.00 "$1,893.12" "$1,893.12" $0.00 "$1,920.00" "$3,041.28" "$3,072.00" $0.00 $0.00 $600.96 $0.00 $0.00 $611.33 $0.00 $0.00 $0.00 $0.00 $0.00 79-45905 SUP HCPCS C1713 79-45905 - DIRECT INJECT 5CC BOTH IP/OP "$6,010.00 " "$4,447.40" $0.00 "$4,808.00" "$2,704.50" "$2,704.50" $0.00 $0.00 $0.00 "$1,252.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,252.48" $0.00 "$2,962.93" "$2,962.93" $0.00 "$3,005.00" "$4,759.92" "$4,808.00" $0.00 $0.00 $940.57 $0.00 $0.00 $956.79 $0.00 $0.00 $0.00 $0.00 $0.00 79-45910 SUP HCPCS C1713 79-45910 - DIRECT INJECT 10CC BOTH IP/OP "$9,277.75 " "$6,865.54" $0.00 "$9,150.00" "$5,146.88" "$5,146.88" $0.00 $0.00 $0.00 "$1,933.72" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,933.48" $0.00 "$4,573.93" "$4,573.93" $0.00 "$5,718.75" "$9,058.50" "$9,150.00" $0.00 $0.00 "$1,789.97" $0.00 $0.00 "$1,820.85" $0.00 $0.00 $0.00 $0.00 $0.00 794G SUP Custom 27203010 794G - SUTURE ABSORBABLE 6-0 G-6 18IN 2 ARM MONOFILAMENT CHROMIC BOTH IP/OP $43.50 $32.19 $0.00 $35.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.28 $32.28 $0.00 $0.00 $9.06 $0.00 $0.00 $0.00 $0.00 $22.08 $34.97 $35.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79-80017 SUP Custom 27203010 SPLINT ORTH LG 16IN KNEE SUP BOTH IP/OP $31.53 $23.33 $0.00 $25.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.76 $24.97 $25.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79-83203 SUP HCPCS L0172 79-83203 - COLLAR CERV SMALL 10-20IN 2IN CHIN REST COMFORT PAD BOTH IP/OP $86.65 $64.12 $0.00 $112.86 $45.85 $45.85 $0.00 $0.00 $0.00 $112.86 $64.31 $64.31 $0.00 $0.00 $18.06 $0.00 $51.25 $51.25 $0.00 $50.94 $80.69 $81.50 $61.13 $61.13 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 79-83205 SUP HCPCS L0172 79-83205 - COLLAR CERV MEDIUM 10-20IN 2.5IN CHIN REST PAD TRACHEAL OPEN BOTH IP/OP $101.88 $75.39 $0.00 $112.86 $45.85 $45.85 $0.00 $0.00 $0.00 $112.86 $75.62 $75.62 $0.00 $0.00 $21.23 $0.00 $60.26 $60.26 $0.00 $50.94 $80.69 $81.50 $61.13 $61.13 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 79-83207 SUP HCPCS L0172 79-83207 - COLLAR CERV LARGE 10-20IN 3IN CHIN REST PAD TRACHEAL OPEN BOTH IP/OP $101.88 $75.39 $0.00 $112.86 $45.85 $45.85 $0.00 $0.00 $0.00 $112.86 $75.62 $75.62 $0.00 $0.00 $21.23 $0.00 $60.26 $60.26 $0.00 $50.94 $80.69 $81.50 $61.13 $61.13 $107.46 $0.00 $0.00 $109.67 $0.00 $0.00 $0.00 $0.00 $0.00 79-83208 SUP Custom 27203010 COLLAR CERV ADLT STOUT 14-24INX1.75IN MI J CHIN REST TRCH BOTH IP/OP $108.68 $80.42 $0.00 $86.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.34 $86.07 $86.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79-94000 SUP Custom 27203010 BRACE ORTH SM UNV PS FOAM KNEERANGER BOTH IP/OP $139.65 $103.34 $0.00 $111.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.83 $110.60 $111.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79-94001 SUP Custom 27203010 BRACE ORTH LG UNV PS FOAM KNEERANGER BOTH IP/OP $139.65 $103.34 $0.00 $111.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.65 $103.65 $0.00 $0.00 $29.10 $0.00 $0.00 $0.00 $0.00 $69.83 $110.60 $111.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79-95413 SUP Custom 27203010 BRACE WLK SM AIR RCKR SOLE MAXTRAX BLK STD HT BOTH IP/OP $93.15 $68.93 $0.00 $74.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.58 $73.77 $74.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79-96018 SUP Custom 27203010 IMMOBILIZER ORTH UNV 18IN 36IN KNEE BSC ELAST ML STAY CNTCT BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $0.00 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79-97957 SUP Custom 27203010 BRACE HUMERAL FX LARGE BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 79-98600 SUP Custom 27203010 CORD TRC 100YD SPL NYL BOTH IP/OP $53.43 $39.54 $0.00 $42.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.71 $42.32 $42.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7AC60-MN SUP Custom 27203010 7AC60-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $0.00 $0.00 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA05 SUP Custom 27203010 7BA05 - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA05L-MN SUP Custom 27203010 7BA05L-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA05-MN SUP Custom 27203010 7BA05-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA06DL-MN SUP Custom 27203010 7BA06DL-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA06D-MN SUP Custom 27203010 7BA06D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA10 SUP Custom 27203010 7BA10 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA10C-MN SUP Custom 27203010 7BA10C-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA10D SUP Custom 27203010 7BA10D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA10-MN SUP Custom 27203010 7BA10-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA15 SUP Custom 27203010 7BA15 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA15D SUP Custom 27203010 7BA15D - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA15DL-MN SUP Custom 27203010 7BA15DL-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA15D-MN SUP Custom 27203010 7BA15D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA15-MN SUP Custom 27203010 7BA15-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA20 SUP Custom 27203010 7BA20 - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA20C-MN SUP Custom 27203010 7BA20C-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA20D SUP Custom 27203010 7BA20D - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA20DC-MN SUP Custom 27203010 7BA20DC-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA20DL-MN SUP Custom 27203010 7BA20DL-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA20-MN SUP Custom 27203010 7BA20-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA25 SUP Custom 27203010 7BA25 - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA25D SUP Custom 27203010 7BA25D - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA25D-MN SUP Custom 27203010 7BA25D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA25-MN SUP Custom 27203010 7BA25-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA30 SUP Custom 27203010 7BA30 - PLATE 18MM TI BONE SPNL BOTH IP/OP $299.63 $221.73 $0.00 $239.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.38 $222.38 $0.00 $0.00 $62.44 $0.00 $0.00 $0.00 $0.00 $149.81 $237.31 $239.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA30C-MN SUP Custom 27203010 7BA30C-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA30D SUP Custom 27203010 7BA30D - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA30DC-MN SUP Custom 27203010 7BA30DC-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA30DL-MN SUP Custom 27203010 7BA30DL-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA30L-MN SUP Custom 27203010 7BA30L-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA30-MN SUP Custom 27203010 7BA30-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA40C-MN SUP Custom 27203010 7BA40C-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA40D SUP Custom 27203010 7BA40D - TOOL DISSECTING BALL 4MM 7CM DIAMOND MIDAS REX LEGEND BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA40DC-MN SUP Custom 27203010 7BA40DC-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA40F-MN SUP Custom 27203010 7BA40F-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA40-MN SUP Custom 27203010 7BA40-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA50C-MN SUP Custom 27203010 7BA50C-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA50DC-MN SUP Custom 27203010 7BA50DC-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA50F-MN SUP Custom 27203010 7BA50F-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA50-MN SUP Custom 27203010 7BA50-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA60C-MN SUP Custom 27203010 7BA60C-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA60D SUP Custom 27203010 7BA60D - PLATE 18MM TI BONE SPNL BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA60DC-MN SUP Custom 27203010 7BA60DC-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $325.13 $240.60 $0.00 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.31 $241.31 $0.00 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $162.56 $257.50 $260.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA60D-MN SUP Custom 27203010 7BA60D-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA60F-MN SUP Custom 27203010 7BA60F-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA60-MN SUP Custom 27203010 7BA60-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA70C-MN SUP Custom 27203010 7BA70C-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA70D-MN SUP Custom 27203010 7BA70D-MN - TOOL DISS MIDAS REX LEGEND MEDNEXT BALL L7 CM OD7 MM STERILE BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA70-MN SUP Custom 27203010 7BA70-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $299.63 $221.73 $0.00 $239.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.38 $222.38 $0.00 $0.00 $62.44 $0.00 $0.00 $0.00 $0.00 $149.81 $237.31 $239.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA80C-MN SUP Custom 27203010 7BA80C-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $306.00 $226.44 $0.00 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.11 $227.11 $0.00 $0.00 $63.77 $0.00 $0.00 $0.00 $0.00 $153.00 $242.35 $244.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA80D-MN SUP Custom 27203010 7BA80D-MN - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7BA80-MN SUP Custom 27203010 7BA80-MN - PLATE 18MM TI BONE SPNL BOTH IP/OP $297.50 $220.15 $0.00 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.80 $220.80 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $148.75 $235.62 $238.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 7SCT SUP Custom 27203010 7SCT - TUBE TRACHEOSTOMY 9.6MM 7MM 80MM 1 CANNU CUFF LOW PRESSURE BOTH IP/OP $71.38 $52.82 $0.00 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.97 $52.97 $0.00 $0.00 $14.87 $0.00 $0.00 $0.00 $0.00 $36.22 $57.38 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 800.604.02S SUP HCPCS C1713 800.604.02S - SCREW BONE 4MM 1.5MM CORT CRNMXF RESORB STRL BOTH IP/OP $373.50 $276.39 $0.00 $298.80 $168.08 $168.08 $0.00 $0.00 $0.00 $77.85 $277.21 $277.21 $0.00 $0.00 $77.84 $0.00 $220.93 $220.93 $0.00 $186.75 $295.81 $298.80 $0.00 $0.00 $58.45 $0.00 $0.00 $59.46 $0.00 $0.00 $0.00 $0.00 $0.00 80-0055 SUP Custom 27203010 80-0055 - DRILL SURG CANN BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0056 SUP Custom 27203010 80-0056 - BIT DRL 5.5MM ACTRK2 BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0100 SUP Custom 27203010 80-0100 - DRILL SRG MIC LNG ACTRK2 BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 800-1003A SUP Custom 27203010 800-1003A - KIT CNTRF 30ML GPS III 1 PLTL CONC DISP BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8001021-3 SUP HCPCS C1781 8001021-3 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,962.25 " "$2,192.07" $0.00 "$2,369.80" "$1,333.01" "$1,333.01" $0.00 $0.00 $0.00 $617.41 "$2,198.58" "$2,198.58" $0.00 $0.00 $617.33 $0.00 "$1,460.39" "$1,460.39" $0.00 "$1,481.13" "$2,346.10" "$2,369.80" $0.00 $0.00 $463.59 $0.00 $0.00 $471.59 $0.00 $0.00 $0.00 $0.00 $0.00 8001021-6 SUP HCPCS C1781 8001021-6 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,962.25 " "$2,192.07" $0.00 "$2,369.80" "$1,333.01" "$1,333.01" $0.00 $0.00 $0.00 $617.41 "$2,198.58" "$2,198.58" $0.00 $0.00 $617.33 $0.00 "$1,460.39" "$1,460.39" $0.00 "$1,481.13" "$2,346.10" "$2,369.80" $0.00 $0.00 $463.59 $0.00 $0.00 $471.59 $0.00 $0.00 $0.00 $0.00 $0.00 80-0148 SUP HCPCS C1713 80-0148 - SCREW BN 3MM 2 TRK TAP DRL CLVCL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $192.38 $192.38 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $66.90 $0.00 $0.00 $68.06 $0.00 $0.00 $0.00 $0.00 $0.00 80-0149 SUP Custom 27203010 80-0149 - SCREW BN 3.8MM 2 TRK TAP DRL CLVCL BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0150 SUP HCPCS C1769 80-0150 - GUIDE STD T ACLC SURG LEFT DORSAL BOTH IP/OP "$2,960.00 " "$2,190.40" $0.00 "$2,368.00" "$1,607.28" "$1,607.28" $0.00 $0.00 $0.00 $616.94 "$2,196.91" "$2,196.91" $0.00 $0.00 $616.86 $0.00 "$1,750.84" "$1,750.84" $0.00 "$1,480.00" "$2,344.32" "$2,368.00" $0.00 $0.00 $463.24 $0.00 $0.00 $471.23 $0.00 $0.00 $0.00 $0.00 $0.00 8001511-3 SUP HCPCS C1781 8001511-3 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,188.75 " "$1,619.68" $0.00 "$1,751.00" $984.94 $984.94 $0.00 $0.00 $0.00 $456.19 "$1,624.49" "$1,624.49" $0.00 $0.00 $456.14 $0.00 "$1,294.65" "$1,294.65" $0.00 "$1,094.38" "$1,733.49" "$1,751.00" $0.00 $0.00 $342.54 $0.00 $0.00 $348.45 $0.00 $0.00 $0.00 $0.00 $0.00 8001511-6 SUP HCPCS C1781 8001511-6 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,188.75 " "$1,619.68" $0.00 "$1,751.00" $984.94 $984.94 $0.00 $0.00 $0.00 $456.19 "$1,624.49" "$1,624.49" $0.00 $0.00 $456.14 $0.00 "$1,294.65" "$1,294.65" $0.00 "$1,094.38" "$1,733.49" "$1,751.00" $0.00 $0.00 $342.54 $0.00 $0.00 $348.45 $0.00 $0.00 $0.00 $0.00 $0.00 8001521-3 SUP HCPCS C1781 8001521-3 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,768.88 " "$2,048.97" $0.00 "$2,215.10" "$1,245.99" "$1,245.99" $0.00 $0.00 $0.00 $577.10 "$2,055.06" "$2,055.06" $0.00 $0.00 $577.03 $0.00 "$1,365.06" "$1,365.06" $0.00 "$1,384.44" "$2,192.95" "$2,215.10" $0.00 $0.00 $433.33 $0.00 $0.00 $440.80 $0.00 $0.00 $0.00 $0.00 $0.00 8001521-6 SUP HCPCS C1781 8001521-6 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,881.50 " "$2,132.31" $0.00 "$2,305.20" "$1,296.68" "$1,296.68" $0.00 $0.00 $0.00 $600.58 "$2,138.65" "$2,138.65" $0.00 $0.00 $600.50 $0.00 "$1,420.58" "$1,420.58" $0.00 "$1,440.75" "$2,282.15" "$2,305.20" $0.00 $0.00 $450.95 $0.00 $0.00 $458.73 $0.00 $0.00 $0.00 $0.00 $0.00 8001523-6 SUP HCPCS C1781 8001523-6 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,881.50 " "$2,132.31" $0.00 "$2,305.20" "$1,296.68" "$1,296.68" $0.00 $0.00 $0.00 $600.58 "$2,138.65" "$2,138.65" $0.00 $0.00 $600.50 $0.00 "$1,420.58" "$1,420.58" $0.00 "$1,440.75" "$2,282.15" "$2,305.20" $0.00 $0.00 $450.95 $0.00 $0.00 $458.73 $0.00 $0.00 $0.00 $0.00 $0.00 8001531-6 SUP HCPCS C1781 8001531-6 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,740.88 " "$3,508.25" $0.00 "$3,792.70" "$2,133.39" "$2,133.39" $0.00 $0.00 $0.00 $988.12 "$3,518.68" "$3,518.68" $0.00 $0.00 $988.00 $0.00 "$2,337.25" "$2,337.25" $0.00 "$2,370.44" "$3,754.78" "$3,792.70" $0.00 $0.00 $741.95 $0.00 $0.00 $754.75 $0.00 $0.00 $0.00 $0.00 $0.00 8001533-6 SUP HCPCS C1781 8001533-6 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,836.50 " "$3,579.01" $0.00 "$3,869.20" "$2,176.43" "$2,176.43" $0.00 $0.00 $0.00 "$1,008.05" "$3,589.65" "$3,589.65" $0.00 $0.00 "$1,007.93" $0.00 "$2,384.39" "$2,384.39" $0.00 "$2,418.25" "$3,830.51" "$3,869.20" $0.00 $0.00 $756.91 $0.00 $0.00 $769.97 $0.00 $0.00 $0.00 $0.00 $0.00 80-018 SUP Custom 27203010 80-018 - BIT DRILL 2MM HEAD BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0180 SUP Custom 27203010 80-0180 - TIP SCRDRVR 1.5MM SLD HEX AO CONNECT DRVR NONSTRL BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $0.00 $0.00 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0205 SUP Custom 27203010 80-0205 - TRPHN ACTRK6/7 SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0206 SUP Custom 27203010 80-0206 - TRPHN ACTRK+ SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0207 SUP Custom 27203010 80-0207 - TRPHN ACTRK 4/5 SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0208 SUP Custom 27203010 80-0208 - TRPHN 20+ MM STD ACTRK SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0209 SUP Custom 27203010 80-0209 - TRPHN 0-20MM STD ACTRK SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0210 SUP Custom 27203010 80-0210 - TRPHN MINI ACTRK SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0211 SUP Custom 27203010 80-0211 - TRPHN STD ACTRK2 SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0212 SUP Custom 27203010 80-0212 - TRPHN MINI ACTRK2 SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0213 SUP Custom 27203010 80-0213 - TRPHN MIC ACTRK2 SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0214 SUP Custom 27203010 80-0214 - TRPHN ACTRK2 SURG 5.5 MM SCR BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0216 SUP Custom 27203010 80-0216 - TRPHN ACTRK2 BRKN SURG 3.5 MM CMPR SCR BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0217 SUP Custom 27203010 80-0217 - TRPHN ACTRK2 BRKN SURG 2.7 MM CMPR SCR BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8002221-6 SUP HCPCS C1781 8002221-6 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,828.38 " "$2,093.00" $0.00 "$2,262.70" "$1,272.77" "$1,272.77" $0.00 $0.00 $0.00 $589.50 "$2,099.22" "$2,099.22" $0.00 $0.00 $589.43 $0.00 "$1,394.39" "$1,394.39" $0.00 "$1,414.19" "$2,240.08" "$2,262.70" $0.00 $0.00 $442.64 $0.00 $0.00 $450.28 $0.00 $0.00 $0.00 $0.00 $0.00 8002231-6 SUP HCPCS C1781 8002231-6 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$4,798.25 " "$3,550.71" $0.00 "$3,838.60" "$2,159.21" "$2,159.21" $0.00 $0.00 $0.00 "$1,000.08" "$3,561.26" "$3,561.26" $0.00 $0.00 $999.96 $0.00 "$2,365.54" "$2,365.54" $0.00 "$2,399.13" "$3,800.21" "$3,838.60" $0.00 $0.00 $750.93 $0.00 $0.00 $763.88 $0.00 $0.00 $0.00 $0.00 $0.00 8002233-6 SUP HCPCS C1781 8002233-6 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$4,798.25 " "$3,550.71" $0.00 "$3,838.60" "$2,159.21" "$2,159.21" $0.00 $0.00 $0.00 "$1,000.08" "$3,561.26" "$3,561.26" $0.00 $0.00 $999.96 $0.00 "$2,365.54" "$2,365.54" $0.00 "$2,399.13" "$3,800.21" "$3,838.60" $0.00 $0.00 $750.93 $0.00 $0.00 $763.88 $0.00 $0.00 $0.00 $0.00 $0.00 80-0248 SUP HCPCS C1713 80-0248 - PLATE SM TACK BONE BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $61.88 $61.88 $0.00 $0.00 $0.00 $28.66 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $81.33 $81.33 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $21.52 $0.00 $0.00 $21.89 $0.00 $0.00 $0.00 $0.00 $0.00 80-0297 SUP Custom 27203010 80-0297 - BIT DRILL 4.6MM 3.1MM ACTRK DNS BOTH IP/OP $805.00 $595.70 $0.00 $644.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $597.47 $597.47 $0.00 $0.00 $167.76 $0.00 $0.00 $0.00 $0.00 $402.50 $637.56 $644.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0298 SUP Custom 27203010 80-0298 - DRILL SURG ACTRK+ CANN DNS QRLSE BOTH IP/OP $805.00 $595.70 $0.00 $644.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $597.47 $597.47 $0.00 $0.00 $167.76 $0.00 $0.00 $0.00 $0.00 $402.50 $637.56 $644.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0302 SUP Custom 27203010 80-0302 - BIT DRILL 2.5MM HEX TIP FLXB BOTH IP/OP "$1,152.50 " $852.85 $0.00 $922.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $855.39 $855.39 $0.00 $0.00 $240.18 $0.00 $0.00 $0.00 $0.00 $576.25 $912.78 $922.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0318 SUP Custom 27203010 80-0318 - BIT DRL 2MM NS ACLC 2 SURGIBIT QRLSE 2.7MM SCR BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 800-3510 SUP Custom 27203010 STRIP UA ATNMX 9 PRMTR REAGENT BOTH IP/OP $86.13 $63.74 $0.00 $68.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.06 $68.21 $68.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0362 SUP Custom 27203010 80-0362 - TAP BN 2.3MM BOTH IP/OP $285.00 $210.90 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.53 $211.53 $0.00 $0.00 $59.39 $0.00 $0.00 $0.00 $0.00 $142.50 $225.72 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0386 SUP Custom 27203010 80-0386 - DRILL SURG QRLSE 2MM BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0387 SUP Custom 27203010 80-0387 - DRILL SRG 2.8MM QRLSE 3.5MM SCR BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0399 SUP Custom 27203010 80-0399 - DRILL SURG 1.5MM ACTRK LEFT HND BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0400 SUP Custom 27203010 80-0400 - DRILL SURG 2MM ACTRK LEFT HND SCR REM BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0401 SUP Custom 27203010 80-0401 - DRILL SURG 2.5MM ACTRK LEFT HND SCR REM BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0402 SUP Custom 27203010 80-0402 - DRILL SURG 3MM ACTRK LEFT HND SCR REM BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0403 SUP Custom 27203010 80-0403 - DRILL SURG 3.5MM ACTRK LEFT HND SCR REM BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0404 SUP Custom 27203010 80-0404 - DRILL SURG 4MM ACTRK LEFT HND SCR REM BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0411 SUP Custom 27803010 80-0411 - PIN TNSNBND SNAPPER BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0413 SUP HCPCS C1769 80-0413 - WIRE FX .062IN KRSH BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $20.36 $20.36 $0.00 $0.00 $0.00 $7.82 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $22.18 $22.18 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $5.87 $0.00 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 80-0465 SUP Custom 27203010 80-0465 - DRILL SRG CNN OLCRN BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0477 SUP Custom 27203010 80-0477 - DRILL SURG 40-65MM ACTRK6/7 CANN QRLSE DNS BOTH IP/OP $805.00 $595.70 $0.00 $644.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $597.47 $597.47 $0.00 $0.00 $167.76 $0.00 $0.00 $0.00 $0.00 $402.50 $637.56 $644.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0478 SUP Custom 27203010 80-0478 - DRILL SURG 70-85MM ACTRK6/7 CANN QRLSE DNS BOTH IP/OP $902.50 $667.85 $0.00 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.84 $669.84 $0.00 $0.00 $188.08 $0.00 $0.00 $0.00 $0.00 $451.25 $714.78 $722.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0479 SUP Custom 27203010 80-0479 - DRILL SURG 90-120MM ACTRK6/7 CANN QRLSE DNS BOTH IP/OP "$1,127.50 " $834.35 $0.00 $902.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $836.83 $836.83 $0.00 $0.00 $234.97 $0.00 $0.00 $0.00 $0.00 $563.75 $892.98 $902.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0569 SUP Custom 27203010 80-0569 - REAMER SURG 16MM CNCV MTP FRFT MIDFT PLT SYS NONSTRL BOTH IP/OP "$1,360.00 " "$1,006.40" $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.39" "$1,009.39" $0.00 $0.00 $283.42 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0570 SUP Custom 27203010 80-0570 - REAMER SURG 16MM CNVX MTP FRFT MIDFT PLT SYS NONSTRL BOTH IP/OP "$1,360.00 " "$1,006.40" $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.39" "$1,009.39" $0.00 $0.00 $283.42 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0571 SUP Custom 27203010 80-0571 - REAMER SURG 18MM MALE SET FT BOTH IP/OP "$1,360.00 " "$1,006.40" $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.39" "$1,009.39" $0.00 $0.00 $283.42 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0572 SUP Custom 27203010 80-0572 - REAMER SURG 18MM FMALE SET FT BOTH IP/OP "$1,360.00 " "$1,006.40" $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.39" "$1,009.39" $0.00 $0.00 $283.42 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0573 SUP Custom 27203010 80-0573 - REAMER SURG 20MM CNCV MTP FRFT MIDFT PLT SYS NONSTRL BOTH IP/OP "$1,360.00 " "$1,006.40" $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.39" "$1,009.39" $0.00 $0.00 $283.42 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0574 SUP Custom 27203010 80-0574 - REAMER SURG 74MM STNLS STELL CNCV SM BONE BOTH IP/OP "$1,360.00 " "$1,006.40" $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.39" "$1,009.39" $0.00 $0.00 $283.42 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0575 SUP Custom 27203010 80-0575 - REAMER SURG 76MM SS CNVX SM BONE BOTH IP/OP "$1,360.00 " "$1,006.40" $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.39" "$1,009.39" $0.00 $0.00 $283.42 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0576 SUP Custom 27203010 80-0576 - REAMER SURG 75MM SS CNCV SM BONE BOTH IP/OP "$1,360.00 " "$1,006.40" $0.00 "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,009.39" "$1,009.39" $0.00 $0.00 $283.42 $0.00 $0.00 $0.00 $0.00 $680.00 "$1,077.12" "$1,088.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0583 SUP Custom 27203010 80-0583 - DRIVER 1.5MM ACTRK QRLSE SLD HEX TIP SURG BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0598 SUP Custom 27203010 80-0598 - XTRT SURG EZOUT QRLSE 1.5MM BOTH IP/OP $307.50 $227.55 $0.00 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.23 $228.23 $0.00 $0.00 $64.08 $0.00 $0.00 $0.00 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0599 SUP Custom 27203010 80-0599 - XTRT SURG ACTRK QRLSE EZOUT 2MM BOTH IP/OP $307.50 $227.55 $0.00 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.23 $228.23 $0.00 $0.00 $64.08 $0.00 $0.00 $0.00 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0600 SUP Custom 27203010 80-0600 - XTRT SURG EZOUT QRLSE 2.5MM BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0601 SUP Custom 27203010 80-0601 - TOOL REM 3MM ACTRK SCR EASYOUT BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0602 SUP Custom 27203010 80-0602 - TOOL REM 3.5MM ACTRK SCR EASYOUT BOTH IP/OP $430.00 $318.20 $0.00 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $0.00 $0.00 $0.00 $215.00 $340.56 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0603 SUP Custom 27203010 80-0603 - TOOL REM 4MM ACTRK SCR EASYOUT BOTH IP/OP $490.00 $362.60 $0.00 $392.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $363.68 $363.68 $0.00 $0.00 $102.12 $0.00 $0.00 $0.00 $0.00 $245.00 $388.08 $392.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0605 SUP Custom 27203010 80-0605 - DRIVER ACTRK HEX TIP IMPCT XTRT 3MM SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0606 SUP Custom 27203010 80-0606 - DRIVER ACTRK HEX TIP IMPCT SCR XTRT 4MM SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0610 SUP Custom 27203010 80-0610 - TIP SCRDRVR ACTRK REM SHFT QRLSE BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0611 SUP Custom 27203010 80-0611 - WRENCH SURG SCR REM TIP ACTRK BOTH IP/OP "$1,837.50 " "$1,359.75" $0.00 "$1,470.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,363.79" "$1,363.79" $0.00 $0.00 $382.94 $0.00 $0.00 $0.00 $0.00 $918.75 "$1,455.30" "$1,470.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0612 SUP Custom 27203010 80-0612 - TIP SCRDRVR ACTRK MIC REM BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0613 SUP Custom 27203010 80-0613 - TOOL REM ACTRK MINI TIP BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0614 SUP Custom 27203010 80-0614 - TOOL REM ACTRK STD TIP BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0615 SUP Custom 27203010 80-0615 - TOOL REM ACTRK LG TIP BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0616 SUP Custom 27203010 80-0616 - TOOL REM ACTRK XL TIP BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $0.00 $0.00 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0625 SUP Custom 27203010 80-0625 - TAP BONE 2.7MM HEXALOBE SCR BOTH IP/OP $307.50 $227.55 $0.00 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.23 $228.23 $0.00 $0.00 $64.08 $0.00 $0.00 $0.00 $0.00 $153.75 $243.54 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0626 SUP Custom 27203010 80-0626 - TAP BN INS CORONOID DISP 3MM NLCKG SCR BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $0.00 $0.00 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0627 SUP Custom 27203010 80-0627 - DRILL SURG QRLSE 2.3MM BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0628 SUP Custom 27203010 80-0628 - GUIDE DRILL 2MM 2.3MM NAR BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0632 SUP Custom 27203010 80-0632 - DRIVER 2MM QRLSE SLD HEX TIP SURG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0633 SUP Custom 27203010 80-0633 - DRIVER 3MM ACTRK QRLSE SLD HEX TIP SURG BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $0.00 $0.00 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0634 SUP Custom 27203010 80-0634 - DRIVER 3.5MM ACTRK QRLSE SLD HEX TIP SURG BOTH IP/OP $597.50 $442.15 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.46 $443.46 $0.00 $0.00 $124.52 $0.00 $0.00 $0.00 $0.00 $298.75 $473.22 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0635 SUP Custom 27203010 80-0635 - DRIVER 4MM ACTRK QRLSE SLD HEX TIP SURG BOTH IP/OP $657.50 $486.55 $0.00 $526.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $488.00 $488.00 $0.00 $0.00 $137.02 $0.00 $0.00 $0.00 $0.00 $328.75 $520.74 $526.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0636 SUP Custom 27203010 80-0636 - DRIVER ACTRK QRLSE CRCIFRM TIP SURG BOTH IP/OP $767.50 $567.95 $0.00 $614.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $569.64 $569.64 $0.00 $0.00 $159.95 $0.00 $0.00 $0.00 $0.00 $383.75 $607.86 $614.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0642 SUP Custom 27203010 80-0642 - ROD XTRNFX 2.8IN DRL FIB BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0659 SUP Custom 27203010 80-0659 - TAP SRG DIST ELB 3 MM SCR BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0661 SUP Custom 27203010 80-0661 - TAP SRG NS HUM DIST 3.5 MM SCR BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0663 SUP Custom 27203010 80-0663 - HANDLE DRVR MED RCHT BOTH IP/OP "$2,275.00 " "$1,683.50" $0.00 "$1,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,688.51" "$1,688.51" $0.00 $0.00 $474.11 $0.00 $0.00 $0.00 $0.00 "$1,137.50" "$1,801.80" "$1,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0664 SUP Custom 27203010 80-0664 - PROBE SURG 2.3MM DEPTH BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0688 SUP Custom 27203010 80-0688 - WIRE FIX .054IN KWIRE GUIDE REUSE BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0724 SUP Custom 27203010 80-0724 - BIT DRILL 2.5MM FRAG-LOC SURG BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $0.00 $0.00 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0728 SUP Custom 27203010 80-0728 - DRIVER 1.5MM HEX TIP LCK GRV 2.3MM SURG BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $0.00 $0.00 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0758 SUP Custom 27203010 80-0758 - GUIDEWIRE ORTHOPEDIC 24IN THREADED INSTR UCSS BOTH IP/OP $805.00 $595.70 $0.00 $644.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $597.47 $597.47 $0.00 $0.00 $167.76 $0.00 $0.00 $0.00 $0.00 $402.50 $637.56 $644.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0759 SUP Custom 27203010 80-0759 - DRIVER SRG T8 MN STICKFIT HEXALOBE QC DRL REUSE BOTH IP/OP $707.50 $523.55 $0.00 $566.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.11 $525.11 $0.00 $0.00 $147.44 $0.00 $0.00 $0.00 $0.00 $353.75 $560.34 $566.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0760 SUP Custom 27203010 80-0760 - DRIVER SRG T15 HEXALOBE SCR STK FIR BOTH IP/OP $707.50 $523.55 $0.00 $566.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.11 $525.11 $0.00 $0.00 $147.44 $0.00 $0.00 $0.00 $0.00 $353.75 $560.34 $566.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0772 SUP HCPCS C1713 80-0772 - SCREW BN 3MM 2 TRK STP DRL CLVCL BOTH IP/OP $547.50 $405.15 $0.00 $438.00 $246.38 $246.38 $0.00 $0.00 $0.00 $114.11 $406.35 $406.35 $0.00 $0.00 $114.10 $0.00 $323.85 $323.85 $0.00 $273.75 $433.62 $438.00 $0.00 $0.00 $85.68 $0.00 $0.00 $87.16 $0.00 $0.00 $0.00 $0.00 $0.00 80-0773 SUP Custom 27203010 80-0773 - SCREW BN 3.8MM 2 TRK STP DRL CLVCL BOTH IP/OP $547.50 $405.15 $0.00 $438.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $406.35 $406.35 $0.00 $0.00 $114.10 $0.00 $0.00 $0.00 $0.00 $273.75 $433.62 $438.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0774 SUP Custom 27203010 80-0774 - REAMER SURG 3MM THDL BOTH IP/OP "$1,287.50 " $952.75 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.58 $955.58 $0.00 $0.00 $268.32 $0.00 $0.00 $0.00 $0.00 $643.75 "$1,019.70" "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0775 SUP Custom 27203010 80-0775 - REAMER SURG 3.8MM THDL DL TRK CLVCL SCR SYS BOTH IP/OP "$1,287.50 " $952.75 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.58 $955.58 $0.00 $0.00 $268.32 $0.00 $0.00 $0.00 $0.00 $643.75 "$1,019.70" "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0783 SUP Custom 27203010 80-0783 - SCREW BN 3MM 2 TRK TAP CLVCL BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $0.00 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-0838 SUP HCPCS C1713 80-0838 - SCREW BONE .75IN 3/32IN BLNK BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $6.75 $6.75 $0.00 $0.00 $0.00 $3.13 $11.13 $11.13 $0.00 $0.00 $3.13 $0.00 $8.87 $8.87 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $2.35 $0.00 $0.00 $2.39 $0.00 $0.00 $0.00 $0.00 $0.00 801 325 100 SUP Custom 27203010 SERACLONE ANTI-A 10X10ML BOTH IP/OP $894.38 $661.84 $0.00 $715.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $447.19 $708.35 $715.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 801 350 100 SUP Custom 27203010 SERACLONE ANTI-B 10X10ML BOTH IP/OP $894.38 $661.84 $0.00 $715.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $447.19 $708.35 $715.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80129-201 SUP HCPCS C1874 80129-201 - STENT ESPH 16FR 18MM 67CM 70MM ALIMAXX-ES FULL CVR PROX SUT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-202 SUP HCPCS C1874 80129-202 - STENT ESPH 18MM 22FR 100CM ALIMAXX-E REM COVERED RADOPQ MTL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-203 SUP HCPCS C1874 80129-203 - STENT ESPH 22FR 18MM 120CM ALIMAXX-E REM COVERED MTL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-204 SUP HCPCS C1874 80129-204 - STENT ESPH 22MM 22FR 70CM ALIMAXX-E REM COVERED RADOPQ MTL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-205 SUP HCPCS C1874 80129-205 - STENT ESPH 22FR 100CM ALIMAXX-E SYS MTL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-206 SUP HCPCS C1874 80129-206 - STENT ESPH 22FR 120CM ALIMAXX-E SLF XPD MTL DISP BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-207 SUP HCPCS C1874 80129-207 - STENT ESPH 12MM 70CM ALIMAXX-ES FLLY COVERED BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-208 SUP HCPCS C1874 80129-208 - STENT ESPH 22MM 100CM ALIMAXX-ES PU CVR ANTIMIGRATION STRUT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-209 SUP HCPCS C1874 80129-209 - STENT ESPH GMTR 12MM 16FR 120MM NS 62CM ALIMAXX-ES FLLY BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-210 SUP HCPCS C1874 80129-210 - STENT ESPH 14MM 70CM ALIMAXX-ES FLLY COVERED BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-211 SUP HCPCS C1874 80129-211 - STENT ESPH 14MM 16FR 100MM 64CM ALIMAXX-ES FLLY COVERED SMTH BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-212 SUP HCPCS C1874 80129-212 - STENT ESPH 14MM 16FR 62CM 120MM ALIMAXX-ES FLLY COVERED GMTR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-213 SUP HCPCS C1874 80129-213 - STENT ESPH GMTR 16MM 70CM ALIMAXX-ES FLLY COVERED PU CVR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-214 SUP HCPCS C1874 80129-214 - STENT ESPH 16MM 16FR 100MM 64CM ALIMAXX-ES FLLY COVERED SMTH BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-215 SUP HCPCS C1874 80129-215 - STENT ESPH 16MM 62CM 120MM ALIMAXX-ES FLLY COVERED GMTR PU BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 80129-406 SUP HCPCS C1769 80129-406 - GUIDEWIRE ENDSCP STR .035IN 260CM SUPER STIFF FLEXIBILITY BOTH IP/OP $750.00 $555.00 $0.00 $556.65 $271.50 $271.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 80-1759 SUP HCPCS C1713 80-1759 - TACK FX .04IN PLT BOTH IP/OP $322.50 $238.65 $0.00 $258.00 $145.13 $145.13 $0.00 $0.00 $0.00 $67.22 $239.36 $239.36 $0.00 $0.00 $67.21 $0.00 $190.76 $190.76 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $50.47 $0.00 $0.00 $51.34 $0.00 $0.00 $0.00 $0.00 $0.00 80-1794 SUP Custom 27203010 80-1794 - DRILL SRG 1.1MM 3.5IN QRLSE STD AO 1.5MM SCR BOTH IP/OP $742.50 $549.45 $0.00 $594.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $551.08 $551.08 $0.00 $0.00 $154.74 $0.00 $0.00 $0.00 $0.00 $371.25 $588.06 $594.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-1796 SUP Custom 27203010 80-1796 - DRILL SURG 2MM 3.5IN QUICK RELEASE STANDARD AO SURGIBIT BOTH IP/OP $742.50 $549.45 $0.00 $594.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $551.08 $551.08 $0.00 $0.00 $154.74 $0.00 $0.00 $0.00 $0.00 $371.25 $588.06 $594.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-1797 SUP Custom 27203010 80-1797 - DRILL SURG 3.5IN CUT INSERTION SURGIBIT MINI 2IN REUSABLE BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 802 042 100 SUP Custom 27203010 SERACLONE ANTI-D 10X10ML BOTH IP/OP $928.13 $686.82 $0.00 $742.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $464.06 $735.08 $742.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 802 336 100 SUP Custom 27203010 SERACLONE ANTI-E 1X5ML BOTH IP/OP $265.50 $196.47 $0.00 $212.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.75 $210.28 $212.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8023 A SUP Custom 27803010 8023 A - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $0.00 $0.00 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8023 B SUP Custom 27803010 8023 B - PLATE 18MM TI BONE SPNL BOTH IP/OP $213.75 $158.18 $0.00 $171.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.65 $158.65 $0.00 $0.00 $44.55 $0.00 $0.00 $0.00 $0.00 $106.88 $169.29 $171.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 803.605.02S SUP HCPCS C1713 803.605.02S - SCREW BONE 1.5MM 5MM CORT RESORB STRL BOTH IP/OP $361.03 $267.16 $0.00 $288.82 $162.46 $162.46 $0.00 $0.00 $0.00 $75.25 $267.95 $267.95 $0.00 $0.00 $75.24 $0.00 $213.55 $213.55 $0.00 $180.51 $285.94 $288.82 $0.00 $0.00 $56.50 $0.00 $0.00 $57.48 $0.00 $0.00 $0.00 $0.00 $0.00 804 175 100 SUP Custom 27203010 AHG ANTI-LGG 10 X 10 ML BOTH IP/OP $463.50 $342.99 $0.00 $370.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.75 $367.09 $370.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 804.006.02S SUP HCPCS C1713 804.006.02S - SCREW BONE 2MM 6MM CORT RESORB MESH STRL BOTH IP/OP $361.03 $267.16 $0.00 $288.82 $162.46 $162.46 $0.00 $0.00 $0.00 $75.25 $267.95 $267.95 $0.00 $0.00 $75.24 $0.00 $213.55 $213.55 $0.00 $180.51 $285.94 $288.82 $0.00 $0.00 $56.50 $0.00 $0.00 $57.48 $0.00 $0.00 $0.00 $0.00 $0.00 80-4403L SUP HCPCS C1776 80-4403L - COMPONENT FEMORAL 3 57X51MM CRUCIATE RETAIN POST PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4403R SUP HCPCS C1776 80-4403R - COMPONENT FEMORAL 3 57X51MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4404L SUP HCPCS C1776 80-4404L - COMPONENT FEMORAL 4 60X53MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4404R SUP HCPCS C1776 80-4404R - COMPONENT FEMORAL 4 60X53MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4405L SUP HCPCS C1776 80-4405L - COMPONENT FEMORAL 5 62X55MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4405R SUP HCPCS C1776 80-4405R - COMPONENT FEMORAL 5 62X55MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4406L SUP HCPCS C1776 80-4406L - COMPONENT FEMORAL 6 65X57MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4406R SUP HCPCS C1776 80-4406R - COMPONENT FEMORAL 6 65X57MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4407L SUP HCPCS C1776 80-4407L - COMPONENT FEMORAL 7 67X60MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4407R SUP HCPCS C1776 80-4407R - COMPONENT FEMORAL 7 67X60MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4408L SUP HCPCS C1776 80-4408L - COMPONENT FEMORAL 8 70X62MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4408R SUP HCPCS C1776 80-4408R - COMPONENT FEMORAL 8 70X62MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4409L SUP HCPCS C1776 80-4409L - COMPONENT FEMORAL 9 72X64MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4409R SUP HCPCS C1776 80-4409R - COMPONENT FEMORAL 9 72X64MM CRUCIATE RETAIN PRIM LUG SCORPIO BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4411L SUP HCPCS C1776 80-4411L - COMPONENT FEMORAL 11 77X69MM CRUCIATE RETAIN PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4411R SUP HCPCS C1776 80-4411R - COMPONENT FEMORAL 11 77X69MM CRUCIATE RETAIN PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4413L SUP HCPCS C1776 80-4413L - COMPONENT FEMORAL 13 82X74MM CRUCIATE RETAIN PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 80-4413R SUP HCPCS C1776 80-4413R - COMPONENT FEMORAL 13 82X74MM CRUCIATE RETAIN PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 805.603.02S SUP HCPCS C1713 805.603.02S - SCREW BN 1.5MM 3MM STRL CRNMXF CORT 2 PK BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 805.604.02S SUP HCPCS C1713 805.604.02S - SCREW BONE RPD RESORB 4MM 1.5MM CORT CRNMXF STRL BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 805.605.02S SUP HCPCS C1713 805.605.02S - SCREW BN 1.5MM 5MM STRL CRNMXF CORT 2 PK BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 805.606.02S SUP HCPCS C1713 805.606.02S - SCREW BN 1.5MM 6MM STRL CRNMXF CORT 2 PK BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 805.608.02S SUP HCPCS C1713 805.608.02S - SCREW BONE 8MM 1.5MM CORT CRNMXF RPD RESORB STRL BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 805.614.02S SUP HCPCS C1713 805.614.02S - TACK FX 1.5MM 4MM STRL RAPIDSORB RSRB CRNMXF BOTH IP/OP $373.50 $276.39 $0.00 $298.80 $168.08 $168.08 $0.00 $0.00 $0.00 $77.85 $277.21 $277.21 $0.00 $0.00 $77.84 $0.00 $220.93 $220.93 $0.00 $186.75 $295.81 $298.80 $0.00 $0.00 $58.45 $0.00 $0.00 $59.46 $0.00 $0.00 $0.00 $0.00 $0.00 806.004.02S SUP HCPCS C1713 806.004.02S - SCREW BONE 4MM 2MM CORT CRNMXF RPD RESORB STRL BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 806.006.02S SUP HCPCS C1713 806.006.02S - SCREW BN 2MM 6MM STRL CRNMXF CORT 2 PK BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 806.008.02S SUP HCPCS C1713 806.008.02S - SCREW BN 2MM 8MM STRL CRNMXF CORT 2 PK BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 806.044.02S SUP HCPCS C1713 806.044.02S - SCREW BONE 4MM 2.5MM CORT CRNMXF RPD RESORB ER STRL BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 806.046.02S SUP HCPCS C1713 806.046.02S - SCREW BONE 6MM 2.5MM CORT CRNMXF RPD RESORB ER STRL BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 806.048.02S SUP HCPCS C1713 806.048.02S - SCREW BONE 8MM 2.5MM CORT CRNMXF RPD RESORB ER STRL BOTH IP/OP $393.75 $291.38 $0.00 $315.00 $177.19 $177.19 $0.00 $0.00 $0.00 $82.07 $292.24 $292.24 $0.00 $0.00 $82.06 $0.00 $232.90 $232.90 $0.00 $196.88 $311.85 $315.00 $0.00 $0.00 $61.62 $0.00 $0.00 $62.69 $0.00 $0.00 $0.00 $0.00 $0.00 808 052 100 SUP Custom 27203010 SERACLONE ANTI-S 1 X 2 MLL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 808 188 100 SUP Custom 27203010 SERACLONE ANTI-FYA 1 X 2 ML BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 808 403 100 SUP Custom 27203010 SERACLONE ANTI-LEA 1X2ML BOTH IP/OP $590.63 $437.07 $0.00 $472.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.31 $467.78 $472.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 808 410 100 SUP Custom 27203010 SERACLONE ANTI-M 1X 2 ML BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 808 415 100 SUP Custom 27203010 SERACLONE ANTI-N 1 X 2 ML BOTH IP/OP $236.25 $174.83 $0.00 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.13 $187.11 $189.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 808-002 SUP HCPCS C1713 808-002 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 808-083 SUP HCPCS C1713 808-083 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 808-105 SUP HCPCS C1713 808-105 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 808-190 SUP HCPCS C1713 808-190 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 808-524 SUP HCPCS C1713 808-524 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,670.00 " "$1,975.80" $0.00 "$2,136.00" "$1,201.50" "$1,201.50" $0.00 $0.00 $0.00 $556.49 "$1,981.67" "$1,981.67" $0.00 $0.00 $556.43 $0.00 "$1,316.31" "$1,316.31" $0.00 "$1,335.00" "$2,114.64" "$2,136.00" $0.00 $0.00 $417.86 $0.00 $0.00 $425.06 $0.00 $0.00 $0.00 $0.00 $0.00 809-DBL SUP HCPCS C1713 809-DBL - PLATE 18MM TI BONE SPNL BOTH IP/OP $97.05 $71.82 $0.00 $77.64 $43.67 $43.67 $0.00 $0.00 $0.00 $20.23 $72.03 $72.03 $0.00 $0.00 $20.23 $0.00 $57.41 $57.41 $0.00 $48.53 $76.86 $77.64 $0.00 $0.00 $15.19 $0.00 $0.00 $15.45 $0.00 $0.00 $0.00 $0.00 $0.00 80CR000022 SUP Custom 27203010 REAGENT TRIS BUFF SAL PH 8 COAG BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80XLTCD SUP Custom 27203010 80XLTCD - TUBE TRCH 40MM 50MM 13.3MM 8MM 105MM STRL LF 15MM SHLY XLT BOTH IP/OP $159.65 $118.14 $0.00 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.49 $118.49 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $81.02 $128.34 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 80XLTCP SUP Custom 27203010 80XLTCP - TUBE TRCH 40MM 35MM 13.3MM 8MM 105MM STRL LF 30MM SHLY XLT BOTH IP/OP $159.65 $118.14 $0.00 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.49 $118.49 $0.00 $0.00 $33.27 $0.00 $0.00 $0.00 $0.00 $81.02 $128.34 $129.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 810041B SUP HCPCS C1781 810041B - MESH TRANSVAGINAL 45X1.1CM TAPE TVT PROLENE BLUE BOTH IP/OP "$1,955.10 " "$1,446.77" $0.00 "$1,564.08" $879.80 $879.80 $0.00 $0.00 $0.00 $407.49 "$1,451.08" "$1,451.08" $0.00 $0.00 $407.44 $0.00 "$1,156.44" "$1,156.44" $0.00 $977.55 "$1,548.44" "$1,564.08" $0.00 $0.00 $305.97 $0.00 $0.00 $311.25 $0.00 $0.00 $0.00 $0.00 $0.00 810-200 SUP HCPCS C1713 810-200 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-201 SUP HCPCS C1713 810-201 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-202 SUP HCPCS C1713 810-202 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-203 SUP HCPCS C1713 810-203 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-205 SUP HCPCS C1713 810-205 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-206 SUP HCPCS C1713 810-206 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-207 SUP HCPCS C1713 810-207 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-208 SUP HCPCS C1713 810-208 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-221 SUP HCPCS C1713 810-221 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-222 SUP HCPCS C1713 810-222 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8103.0201S SUP HCPCS C1713 8103.0201S - SUBSTITUTE BNGFT PLUS XEMPLIFI DEMINERALIZE BONE MATRIX 1ML BOTH IP/OP $570.00 $421.80 $0.00 $456.00 $256.50 $256.50 $0.00 $0.00 $0.00 $118.80 $423.05 $423.05 $0.00 $0.00 $118.79 $0.00 $337.16 $337.16 $0.00 $285.00 $451.44 $456.00 $0.00 $0.00 $89.21 $0.00 $0.00 $90.74 $0.00 $0.00 $0.00 $0.00 $0.00 8103.0203S SUP HCPCS C1713 8103.0203S - SUBSTITUTE BNGFT PLUS XEMPLIFI DEMINERALIZE BONE MATRIX 3ML BOTH IP/OP "$1,485.00 " "$1,098.90" $0.00 "$1,188.00" $668.25 $668.25 $0.00 $0.00 $0.00 $309.51 "$1,102.17" "$1,102.17" $0.00 $0.00 $309.47 $0.00 $878.38 $878.38 $0.00 $742.50 "$1,176.12" "$1,188.00" $0.00 $0.00 $232.40 $0.00 $0.00 $236.41 $0.00 $0.00 $0.00 $0.00 $0.00 810-300 SUP HCPCS C1713 810-300 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-301 SUP HCPCS C1713 810-301 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-302 SUP HCPCS C1713 810-302 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-303 SUP HCPCS C1713 810-303 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-304 SUP HCPCS C1713 810-304 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-305 SUP HCPCS C1713 810-305 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-306 SUP HCPCS C1713 810-306 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-307 SUP HCPCS C1713 810-307 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-308 SUP HCPCS C1713 810-308 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-321 SUP HCPCS C1713 810-321 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-322 SUP HCPCS C1713 810-322 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-323 SUP HCPCS C1713 810-323 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-400 SUP HCPCS C1713 810-400 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-401 SUP HCPCS C1713 810-401 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-402 SUP HCPCS C1713 810-402 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-403 SUP HCPCS C1713 810-403 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-404 SUP HCPCS C1713 810-404 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-405 SUP HCPCS C1713 810-405 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-406 SUP HCPCS C1713 810-406 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-407 SUP HCPCS C1713 810-407 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-408 SUP HCPCS C1713 810-408 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-421 SUP HCPCS C1713 810-421 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-422 SUP HCPCS C1713 810-422 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-423 SUP HCPCS C1713 810-423 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-450 SUP HCPCS C1713 810-450 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 810-451 SUP HCPCS C1713 810-451 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8104528M SUP HCPCS C1713 8104528M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104530M SUP HCPCS C1713 8104530M - PLATE BN 30-34MM X10 XLNK TI SPNE 4.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104534M SUP HCPCS C1713 8104534M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104541M SUP HCPCS C1713 8104541M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8104555M SUP HCPCS C1713 8104555M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 810-A20-1350 SUP Custom 27203010 SCISSORS 4.75IN CRB EDG WIRE CTR SURG LTX BOTH IP/OP $105.33 $77.94 $0.00 $84.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.66 $83.42 $84.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 811-300 SUP HCPCS C1713 811-300 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-301 SUP HCPCS C1713 811-301 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-302 SUP HCPCS C1713 811-302 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-303 SUP HCPCS C1713 811-303 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-304 SUP HCPCS C1713 811-304 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-305 SUP HCPCS C1713 811-305 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-306 SUP HCPCS C1713 811-306 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-307 SUP HCPCS C1713 811-307 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-308 SUP HCPCS C1713 811-308 - PLATE BN 1.5IN STRL XLNK CD HZN LOPRFL TI SPNE 5.5MM ROD BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-313 SUP Custom 27803010 811-313 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 811-321 SUP HCPCS C1713 811-321 - PLATE BN 1.55-1.75IN STRL MLSPN XLNK CD HZN LOPRFL TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-322 SUP HCPCS C1713 811-322 - PLATE BN 1.75-2.15IN STRL MLSPN XLNK CD HZN LOPRFL TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-323 SUP HCPCS C1713 811-323 - PLATE BN 2.15-2.95IN STRL MLSPN XLNK CD HZN LOPRFL TI SPNE BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-324 SUP HCPCS C1713 811-324 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-400 SUP HCPCS C1713 811-400 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-401 SUP HCPCS C1713 811-401 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-402 SUP HCPCS C1713 811-402 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-403 SUP HCPCS C1713 811-403 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-404 SUP HCPCS C1713 811-404 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-405 SUP HCPCS C1713 811-405 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-406 SUP HCPCS C1713 811-406 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-407 SUP HCPCS C1713 811-407 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-408 SUP HCPCS C1713 811-408 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-421 SUP HCPCS C1713 811-421 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-422 SUP HCPCS C1713 811-422 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-423 SUP HCPCS C1713 811-423 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-450 SUP HCPCS C1713 811-450 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 811-451 SUP HCPCS C1713 811-451 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8114528M SUP HCPCS C1713 8114528M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114530M SUP HCPCS C1713 8114530M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114534M SUP HCPCS C1713 8114534M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114541M SUP HCPCS C1713 8114541M - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 8114555M SUP HCPCS C1713 8114555M - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-500 SUP HCPCS C1713 811-500 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-501 SUP HCPCS C1713 811-501 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 811-DBL SUP HCPCS C1713 811-DBL - PLATE 18MM TI BONE SPNL BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 813-DBL SUP HCPCS C1713 813-DBL - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $97.75 $72.34 $0.00 $78.20 $43.99 $43.99 $0.00 $0.00 $0.00 $20.37 $72.55 $72.55 $0.00 $0.00 $20.37 $0.00 $57.82 $57.82 $0.00 $48.88 $77.42 $78.20 $0.00 $0.00 $15.30 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $0.00 81-4403L SUP HCPCS C1776 81-4403L - COMPONENT FEMORAL 3 57X51MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4403R SUP HCPCS C1776 81-4403R - COMPONENT FEMORAL 3 57X51MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4404L SUP HCPCS C1776 81-4404L - COMPONENT FEMORAL 4 60X54MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4404R SUP HCPCS C1776 81-4404R - COMPONENT FEMORAL 4 60X54MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4405L SUP HCPCS C1776 81-4405L - COMPONENT FEMORAL 5 62X56MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4405R SUP HCPCS C1776 81-4405R - COMPONENT FEMORAL 5 62X56MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4406L SUP HCPCS C1776 81-4406L - COMPONENT FEMORAL 6 65X58MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4406R SUP HCPCS C1776 81-4406R - COMPONENT FEMORAL 6 65X58MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4407L SUP HCPCS C1776 81-4407L - COMPONENT FEMORAL 7 67X61MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4407R SUP HCPCS C1776 81-4407R - COMPONENT FEMORAL 7 67X61MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4408L SUP HCPCS C1776 81-4408L - COMPONENT FEMORAL 8 70X63MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4408R SUP HCPCS C1776 81-4408R - COMPONENT FEMORAL 8 70X63MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4409L SUP HCPCS C1776 81-4409L - COMPONENT FEMORAL 9 72X65MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4409R SUP HCPCS C1776 81-4409R - COMPONENT FEMORAL 9 72X65MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4411L SUP HCPCS C1776 81-4411L - COMPONENT FEMORAL 11 77X70MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4411R SUP HCPCS C1776 81-4411R - COMPONENT FEMORAL 11 77X70MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4413L SUP HCPCS C1776 81-4413L - COMPONENT FEMORAL 13 82X75MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81-4413R SUP HCPCS C1776 81-4413R - COMPONENT FEMORAL 13 82X75MM POSTERIOR STABILIZE PRIM LUG BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 81500V SUP Custom 27203010 81500V - APPLIER ENDOSCOPIC MED LARGE STRAIGHT 13INźź BOTH IP/OP "$2,373.73 " "$1,756.56" $0.00 "$1,898.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,761.78" "$1,761.78" $0.00 $0.00 $494.68 $0.00 $0.00 $0.00 $0.00 "$1,186.86" "$1,879.99" "$1,898.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 815-013 SUP HCPCS C1713 815-013 - PLATE 18MM TI BONE SPNL BOTH IP/OP $475.50 $351.87 $0.00 $380.40 $213.98 $213.98 $0.00 $0.00 $0.00 $99.11 $352.92 $352.92 $0.00 $0.00 $99.09 $0.00 $281.26 $281.26 $0.00 $237.75 $376.60 $380.40 $0.00 $0.00 $74.42 $0.00 $0.00 $75.70 $0.00 $0.00 $0.00 $0.00 $0.00 815-015 SUP HCPCS C1713 815-015 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $475.50 $351.87 $0.00 $380.40 $213.98 $213.98 $0.00 $0.00 $0.00 $99.11 $352.92 $352.92 $0.00 $0.00 $99.09 $0.00 $281.26 $281.26 $0.00 $237.75 $376.60 $380.40 $0.00 $0.00 $74.42 $0.00 $0.00 $75.70 $0.00 $0.00 $0.00 $0.00 $0.00 815-017 SUP HCPCS C1713 815-017 - PLATE 18MM TI BONE SPNL BOTH IP/OP $475.50 $351.87 $0.00 $380.40 $213.98 $213.98 $0.00 $0.00 $0.00 $99.11 $352.92 $352.92 $0.00 $0.00 $99.09 $0.00 $281.26 $281.26 $0.00 $237.75 $376.60 $380.40 $0.00 $0.00 $74.42 $0.00 $0.00 $75.70 $0.00 $0.00 $0.00 $0.00 $0.00 81501V SUP Custom 27203010 81501V - CLIP INTNL ENDO REMOVER MED LARGE - LARGE STRAIGHT 13INźź BOTH IP/OP "$2,164.98 " "$1,602.09" $0.00 "$1,731.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,606.84" "$1,606.84" $0.00 $0.00 $451.18 $0.00 $0.00 $0.00 $0.00 "$1,082.49" "$1,714.66" "$1,731.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 816-013 SUP HCPCS C1713 816-013 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $247.05 $247.05 $0.00 $0.00 $0.00 $114.43 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $324.73 $324.73 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $85.92 $0.00 $0.00 $87.40 $0.00 $0.00 $0.00 $0.00 $0.00 816-015 SUP HCPCS C1713 816-015 - PLATE 18MM TI BONE SPNL BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $247.05 $247.05 $0.00 $0.00 $0.00 $114.43 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $324.73 $324.73 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $85.92 $0.00 $0.00 $87.40 $0.00 $0.00 $0.00 $0.00 $0.00 816-017 SUP HCPCS C1713 816-017 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $549.00 $406.26 $0.00 $439.20 $247.05 $247.05 $0.00 $0.00 $0.00 $114.43 $407.47 $407.47 $0.00 $0.00 $114.41 $0.00 $324.73 $324.73 $0.00 $274.50 $434.81 $439.20 $0.00 $0.00 $85.92 $0.00 $0.00 $87.40 $0.00 $0.00 $0.00 $0.00 $0.00 81602V SUP Custom 27203010 81602V - APPLIER ENDOSCOPIC LARGE CURVED 13INźź BOTH IP/OP "$2,373.73 " "$1,756.56" $0.00 "$1,898.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,761.78" "$1,761.78" $0.00 $0.00 $494.68 $0.00 $0.00 $0.00 $0.00 "$1,186.86" "$1,879.99" "$1,898.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8161-35-026 SUP HCPCS C1713 8161-35-026 - SCREW 3.5X26MM CORTICAL LOCKING BOTH IP/OP $402.50 $297.85 $0.00 $322.00 $181.13 $181.13 $0.00 $0.00 $0.00 $83.89 $298.74 $298.74 $0.00 $0.00 $83.88 $0.00 $238.08 $238.08 $0.00 $201.25 $318.78 $322.00 $0.00 $0.00 $62.99 $0.00 $0.00 $64.08 $0.00 $0.00 $0.00 $0.00 $0.00 8161-35-044 SUP HCPCS C1713 8161-35-044 - SCREW BONE 3.5MM 44MM CORT LCK BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $146.25 $146.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 81701V SUP Custom 27203010 81701V - CLIP INTNL ENDO REMOVERźLARGE - XLARGE STRAIGHT 13INźź BOTH IP/OP "$2,249.98 " "$1,664.99" $0.00 "$1,799.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.93" "$1,669.93" $0.00 $0.00 $468.89 $0.00 $0.00 $0.00 $0.00 "$1,124.99" "$1,781.98" "$1,799.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81702V SUP Custom 27203010 81702V - APPLIER ENDOSCOPIC XLARGE CURVED 13INźź BOTH IP/OP "$2,548.73 " "$1,886.06" $0.00 "$2,038.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,891.66" "$1,891.66" $0.00 $0.00 $531.15 $0.00 $0.00 $0.00 $0.00 "$1,274.36" "$2,018.59" "$2,038.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 81B001 SUP HCPCS C1776 81B001 - GRAFT SFT TIS FRZDR ANT TIB TNDN BOTH IP/OP "$5,032.50 " "$3,724.05" $0.00 "$4,026.00" "$2,264.63" "$2,264.63" $0.00 $0.00 $0.00 "$1,048.90" "$3,735.12" "$3,735.12" $0.00 $0.00 "$1,048.77" $0.00 "$2,481.02" "$2,481.02" $0.00 "$2,516.25" "$3,985.74" "$4,026.00" $0.00 $0.00 $787.59 $0.00 $0.00 $801.17 $0.00 $0.00 $0.00 $0.00 $0.00 81B005 SUP HCPCS C1776 81B005 - GRAFT BN GRCLS SEMITENDINOSUS BOTH IP/OP "$5,045.00 " "$3,733.30" $0.00 "$4,036.00" "$2,270.25" "$2,270.25" $0.00 $0.00 $0.00 "$1,051.50" "$3,744.40" "$3,744.40" $0.00 $0.00 "$1,051.38" $0.00 "$2,487.19" "$2,487.19" $0.00 "$2,522.50" "$3,995.64" "$4,036.00" $0.00 $0.00 $789.54 $0.00 $0.00 $803.16 $0.00 $0.00 $0.00 $0.00 $0.00 820-050 SUP HCPCS C1713 820-050 - PLATE 18MM TI BONE SPNL BOTH IP/OP $553.50 $409.59 $0.00 $442.80 $249.08 $249.08 $0.00 $0.00 $0.00 $115.36 $410.81 $410.81 $0.00 $0.00 $115.35 $0.00 $327.40 $327.40 $0.00 $276.75 $438.37 $442.80 $0.00 $0.00 $86.62 $0.00 $0.00 $88.12 $0.00 $0.00 $0.00 $0.00 $0.00 82091-01 SUP HCPCS C1876 82091-01 - STENT VASCULAR TAPER 8-6MM 30MM SELF EXPANDABLE ERGONOMIC BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" "$1,856.25" "$1,856.25" $0.00 $0.00 $0.00 $859.75 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 "$2,033.63" "$2,033.63" $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $645.56 $0.00 $0.00 $656.70 $0.00 $0.00 $0.00 $0.00 $0.00 82-1750 SUP HCPCS C1729 82-1750 - BACTISEAL CLEAR EVD CATHETER ANTIBIOTIC IMPREGNATED CATHETER BOTH IP/OP $386.40 $285.94 $0.00 $309.12 $209.82 $209.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.20 $306.03 $309.12 $0.00 $0.00 $60.47 $0.00 $0.00 $61.51 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0308 SUP Custom 27803010 82-2-0308 - INSERT TIBIAL 3 8MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0310 SUP Custom 27803010 82-2-0310 - INSERT TIBIAL 3 10MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0312 SUP Custom 27803010 82-2-0312 - INSERT TIBIAL 3 12MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0315 SUP Custom 27803010 82-2-0315 - INSERT TIBIAL 3 15MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0318 SUP Custom 27803010 82-2-0318 - INSERT TIBIAL 3 18MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0321 SUP Custom 27803010 82-2-0321 - INSERT TIBIAL 3 21MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0324 SUP Custom 27803010 82-2-0324 - INSERT TIBIAL 3 24MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0508 SUP Custom 27803010 82-2-0508 - INSERT TIBIAL 5 8MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0510 SUP Custom 27803010 82-2-0510 - INSERT TIBIAL 5 10MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0512 SUP Custom 27803010 82-2-0512 - INSERT TIBIAL 5 12MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0515 SUP Custom 27803010 82-2-0515 - INSERT TIBIAL 5 15MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0518 SUP Custom 27803010 82-2-0518 - INSERT TIBIAL 5 18MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0521 SUP Custom 27803010 82-2-0521 - INSERT TIBIAL 5 21MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0524 SUP Custom 27803010 82-2-0524 - INSERT TIBIAL 5 24MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0708 SUP Custom 27803010 82-2-0708 - INSERT TIBIAL 7 BEARING NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0710 SUP Custom 27803010 82-2-0710 - INSERT TIBIAL 7 10MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0712 SUP Custom 27803010 82-2-0712 - INSERT TIBIAL 7 12MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0715 SUP Custom 27803010 82-2-0715 - INSERT TIBIAL 7 15MM SCORPIO NRG CR ANKLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0718 SUP Custom 27803010 82-2-0718 - INSERT TIBIAL 7 18MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0721 SUP Custom 27803010 82-2-0721 - INSERT TIBIAL 7 21MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0724 SUP Custom 27803010 82-2-0724 - INSERT TIBIAL 7 24MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0908 SUP Custom 27803010 82-2-0908 - INSERT TIBIAL 9 8MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0910 SUP Custom 27803010 82-2-0910 - INSERT TIBIAL 9 10MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0912 SUP Custom 27803010 82-2-0912 - INSERT TIBIAL 9 12MM SCORPIO NRG CR ANKLE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0915 SUP Custom 27803010 82-2-0915 - INSERT TIBIAL 9 15MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0918 SUP Custom 27803010 82-2-0918 - INSERT TIBIAL 9 18MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0921 SUP Custom 27803010 82-2-0921 - INSERT TIBIAL 9 21MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-0924 SUP Custom 27803010 82-2-0924 - INSERT TIBIAL 9 24MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-1108 SUP Custom 27803010 82-2-1108 - INSERT TIBIAL 11 8MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-1110 SUP Custom 27803010 82-2-1110 - INSERT TIBIAL 11 10MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-1112 SUP Custom 27803010 82-2-1112 - INSERT TIBIAL 11 12MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-1115 SUP Custom 27803010 82-2-1115 - INSERT TIBIAL 11 15MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-1118 SUP Custom 27803010 82-2-1118 - INSERT TIBIAL 11 18MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-1121 SUP Custom 27803010 82-2-1121 - INSERT TIBIAL 11 21MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-2-1124 SUP Custom 27803010 82-2-1124 - INSERT TIBIAL 11 24MM CRUC RET BEARING SCORPIO NRG KNEE BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 822-230 SUP HCPCS C1713 822-230 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 822-235 SUP HCPCS C1713 822-235 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,209.00 " $894.66 $0.00 $967.20 $544.05 $544.05 $0.00 $0.00 $0.00 $251.99 $897.32 $897.32 $0.00 $0.00 $251.96 $0.00 $715.12 $715.12 $0.00 $604.50 $957.53 $967.20 $0.00 $0.00 $189.21 $0.00 $0.00 $192.47 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0308 SUP Custom 27803010 82-3-0308 - INSERT TIBIAL 3 8MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0310 SUP Custom 27803010 82-3-0310 - INSERT TIBIAL 3 10MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0312 SUP Custom 27803010 82-3-0312 - INSERT TIBIAL 3 12MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0315 SUP Custom 27803010 82-3-0315 - INSERT TIBIAL 3 15MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0318 SUP Custom 27803010 82-3-0318 - INSERT TIBIAL 3 18MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0321 SUP Custom 27803010 82-3-0321 - INSERT TIBIAL 3 21MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0324 SUP Custom 27803010 82-3-0324 - INSERT TIBIAL 3 24MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0508 SUP Custom 27803010 82-3-0508 - INSERT TIBIAL 5 8MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0510 SUP Custom 27803010 82-3-0510 - INSERT TIBIAL 5 10MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0512 SUP Custom 27803010 82-3-0512 - INSERT TIBIAL 5 12MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0515 SUP Custom 27803010 82-3-0515 - INSERT TIBIAL 5 15MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0518 SUP Custom 27803010 82-3-0518 - INSERT TIBIAL 5 18MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0521 SUP Custom 27803010 82-3-0521 - INSERT TIBIAL 5 21MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0524 SUP Custom 27803010 82-3-0524 - INSERT TIBIAL 5 24MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0708 SUP Custom 27803010 82-3-0708 - INSERT TIBIAL 7 8MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0710 SUP Custom 27803010 82-3-0710 - INSERT TIBIAL 7 10MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0712 SUP Custom 27803010 82-3-0712 - INSERT TIBIAL 7 12MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0715 SUP Custom 27803010 82-3-0715 - INSERT TIBIAL 7 15MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0718 SUP Custom 27803010 82-3-0718 - INSERT TIBIAL 7 18MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0721 SUP Custom 27803010 82-3-0721 - INSERT TIBIAL 7 21MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0724 SUP Custom 27803010 82-3-0724 - INSERT TIBIAL 7 24MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0908 SUP Custom 27803010 82-3-0908 - INSERT TIBIAL 9 8MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0910 SUP Custom 27803010 82-3-0910 - INSERT TIBIAL 9 10MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0912 SUP Custom 27803010 82-3-0912 - INSERT TIBIAL 9 12MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0915 SUP Custom 27803010 82-3-0915 - INSERT TIBIAL 9 15MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0918 SUP Custom 27803010 82-3-0918 - INSERT TIBIAL 9 18MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0921 SUP Custom 27803010 82-3-0921 - INSERT TIBIAL 9 21MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-0924 SUP Custom 27803010 82-3-0924 - INSERT TIBIAL 9 24MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-1108 SUP Custom 27803010 82-3-1108 - INSERT TIBIAL 11 8MM POSTERIOR STABILIZE BEARING SCORPIO NRG BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-1110 SUP Custom 27803010 82-3-1110 - INSERT TIBIAL 11 10MM POSTERIOR STABILIZE BEARING SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-1112 SUP Custom 27803010 82-3-1112 - INSERT TIBIAL 11 12MM POSTERIOR STABILIZE BEARING SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-1115 SUP Custom 27803010 82-3-1115 - INSERT TIBIAL 11 15MM POSTERIOR STABILIZE BEARING SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-1118 SUP Custom 27803010 82-3-1118 - INSERT TIBIAL 11 18MM POSTERIOR STABILIZE BEARING SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-1121 SUP Custom 27803010 82-3-1121 - INSERT TIBIAL 11 21MM POSTERIOR STABILIZE BEARING SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3-1124 SUP Custom 27803010 82-3-1124 - INSERT TIBIAL 11 24MM POSTERIOR STABILIZE BEARING SCORPIO BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-3164 SUP Custom 27803010 82-3164 - VALVE SHNT REG STRL STRT2 CSF PRGM FLW CNTRL BALL SPRG MECH BOTH IP/OP "$9,839.45 " "$7,281.19" $0.00 "$7,871.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,919.73" "$7,792.84" "$7,871.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 824-005 SUP HCPCS C1713 824-005 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 824-007 SUP Custom 27803010 824-007 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 824-027 SUP HCPCS C1713 824-027 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 824-028 SUP HCPCS C1713 824-028 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 824-040 SUP HCPCS C1713 824-040 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 824-041 SUP HCPCS C1713 824-041 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 824-042 SUP HCPCS C1713 824-042 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 82-50200 SUP Custom 27203010 ELECTRODE EMG NM RSPN PT SMLTR CBL 15FT 8250200 BOTH IP/OP "$1,802.50 " "$1,333.85" $0.00 "$1,442.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.25 "$1,427.58" "$1,442.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-50600 SUP Custom 27203010 ELECTRODE EMG NM RSPN PT SMLTR CBL 15FT 8250600 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-5472 SUP Custom 27803010 82-5472 - VALVE SHNT REG STRL DLT CSF 1 LVL BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-5474 SUP Custom 27803010 82-5474 - VALVE SHNT REG 40X16.5MM STRL LF 13MM DLT PS MDCL CSF PRFRM BOTH IP/OP "$3,617.13 " "$2,676.68" $0.00 "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,808.56" "$2,864.77" "$2,893.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-011 SUP Custom 27203010 826-011 - PLATE 18MM TI BONE SPNL BOTH IP/OP $828.50 $613.09 $0.00 $662.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $614.91 $614.91 $0.00 $0.00 $172.66 $0.00 $0.00 $0.00 $0.00 $414.25 $656.17 $662.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-012 SUP Custom 27203010 826-012 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $828.50 $613.09 $0.00 $662.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $614.91 $614.91 $0.00 $0.00 $172.66 $0.00 $0.00 $0.00 $0.00 $414.25 $656.17 $662.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-013 SUP Custom 27203010 826-013 - PLATE 18MM TI BONE SPNL BOTH IP/OP $828.50 $613.09 $0.00 $662.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $614.91 $614.91 $0.00 $0.00 $172.66 $0.00 $0.00 $0.00 $0.00 $414.25 $656.17 $662.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-016 SUP Custom 27803010 826-016 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $388.50 $287.49 $0.00 $310.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $288.34 $288.34 $0.00 $0.00 $80.96 $0.00 $0.00 $0.00 $0.00 $194.25 $307.69 $310.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0308 SUP Custom 27803010 82-6-0308 - INSERT TIBIAL 3 8MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0310 SUP Custom 27803010 82-6-0310 - INSERT TIBIAL 3 10MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0312 SUP Custom 27803010 82-6-0312 - INSERT TIBIAL 3 12MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0314 SUP Custom 27803010 82-6-0314 - INSERT TIBIAL 3 14MM CRUC RET SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0315 SUP Custom 27803010 82-6-0315 - INSERT TIBIAL 3 15MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0318 SUP Custom 27803010 82-6-0318 - INSERT TIBIAL 3 18MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0321 SUP Custom 27803010 82-6-0321 - INSERT TIBIAL 3 21MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0324 SUP Custom 27803010 82-6-0324 - INSERT TIBIAL 3 24MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0508 SUP Custom 27803010 82-6-0508 - INSERT TIBIAL 5 8MM KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0510 SUP Custom 27803010 82-6-0510 - INSERT TIBIAL 5 10MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0512 SUP Custom 27803010 82-6-0512 - INSERT TIBIAL 5 12MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0515 SUP Custom 27803010 82-6-0515 - INSERT TIBIAL 5 15MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0518 SUP Custom 27803010 82-6-0518 - INSERT TIBIAL 5 18MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0521 SUP Custom 27803010 82-6-0521 - INSERT TIBIAL 5 21MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0524 SUP Custom 27803010 82-6-0524 - INSERT TIBIAL 5 24MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0708 SUP Custom 27803010 82-6-0708 - INSERT TIBIAL 7 8MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0710 SUP Custom 27803010 82-6-0710 - INSERT TIBIAL 7 10MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0712 SUP Custom 27803010 82-6-0712 - INSERT TIBIAL X3 POLYETHYLENE KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0715 SUP Custom 27803010 82-6-0715 - INSERT TIBIAL 7 15MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0718 SUP Custom 27803010 82-6-0718 - INSERT TIBIAL 7 18MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0721 SUP Custom 27803010 82-6-0721 - INSERT TIBIAL 7 21MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0724 SUP Custom 27803010 82-6-0724 - INSERT TIBIAL 7 24MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0908 SUP Custom 27803010 82-6-0908 - INSERT TIBIAL 9 8MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0910 SUP Custom 27803010 82-6-0910 - INSERT TIBIAL 9 10MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0912 SUP Custom 27803010 82-6-0912 - INSERT TIBIAL 9 12MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0914 SUP Custom 27803010 82-6-0914 - INSERT TIBIAL 9 14MM CRUC RET SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0915 SUP Custom 27803010 82-6-0915 - INSERT TIBIAL 9 15MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0916 SUP Custom 27803010 82-6-0916 - INSERT TIBIAL 9 16MM CRUC RET SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0918 SUP Custom 27803010 82-6-0918 - INSERT TIBIAL 9 18MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0921 SUP Custom 27803010 82-6-0921 - INSERT TIBIAL 9 21MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-0924 SUP Custom 27803010 82-6-0924 - INSERT TIBIAL 9 24MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1108 SUP Custom 27803010 82-6-1108 - INSERT TIBIAL 11 8MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1110 SUP Custom 27803010 82-6-1110 - INSERT TIBIAL 11 10MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1112 SUP Custom 27803010 82-6-1112 - INSERT TIBIAL 11 12MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1114 SUP Custom 27803010 82-6-1114 - INSERT TIBIAL 11 14MM CRUC RET SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1115 SUP Custom 27803010 82-6-1115 - INSERT TIBIAL 11 15MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1116 SUP Custom 27803010 82-6-1116 - INSERT TIBIAL 11 16MM CRUC RET SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1118 SUP Custom 27803010 82-6-1118 - INSERT TIBIAL CRUC RET SCORPIO X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1121 SUP Custom 27803010 82-6-1121 - INSERT TIBIAL 11 21MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6-1124 SUP Custom 27803010 82-6-1124 - INSERT TIBIAL 11 24MM CRUC RET SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-212 SUP Custom 27203010 826-212 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,004.75 " $743.52 $0.00 $803.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $745.73 $745.73 $0.00 $0.00 $209.39 $0.00 $0.00 $0.00 $0.00 $502.38 $795.76 $803.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-213 SUP Custom 27203010 826-213 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,004.75 " $743.52 $0.00 $803.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $745.73 $745.73 $0.00 $0.00 $209.39 $0.00 $0.00 $0.00 $0.00 $502.38 $795.76 $803.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-216 SUP Custom 27803010 826-216 - PLATE 18MM TI BONE SPNL BOTH IP/OP $495.00 $366.30 $0.00 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $367.39 $367.39 $0.00 $0.00 $103.16 $0.00 $0.00 $0.00 $0.00 $247.50 $392.04 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-217 SUP HCPCS C1713 826-217 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $178.50 $132.09 $0.00 $142.80 $80.33 $80.33 $0.00 $0.00 $0.00 $37.20 $132.48 $132.48 $0.00 $0.00 $37.20 $0.00 $105.58 $105.58 $0.00 $89.25 $141.37 $142.80 $0.00 $0.00 $27.94 $0.00 $0.00 $28.42 $0.00 $0.00 $0.00 $0.00 $0.00 826-219 SUP Custom 27203010 826-219 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,004.75 " $743.52 $0.00 $803.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $745.73 $745.73 $0.00 $0.00 $209.39 $0.00 $0.00 $0.00 $0.00 $502.38 $795.76 $803.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826-320 SUP Custom 27203010 826-320 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,004.75 " $743.52 $0.00 $803.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $745.73 $745.73 $0.00 $0.00 $209.39 $0.00 $0.00 $0.00 $0.00 $502.38 $795.76 $803.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 826614 - USE 19994800 SUP Custom 27803010 826614 - USE 19994800 - KIT CRANIOTOMY CRANIAL ACCES CODMAN BOTH IP/OP $721.63 $534.01 $0.00 $577.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $535.59 $535.59 $0.00 $0.00 $150.39 $0.00 $0.00 $0.00 $0.00 $360.81 $571.53 $577.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6638 SUP Custom 27803010 82-6638 - KIT PRSS MONITR MCSNSR .7MM SBDRL INPRENCH SKL BOLT BOTH IP/OP "$1,947.50 " "$1,441.15" $0.00 "$1,558.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,445.43" "$1,445.43" $0.00 $0.00 $405.86 $0.00 $0.00 $0.00 $0.00 $973.75 "$1,542.42" "$1,558.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-6653 SUP Custom 27803010 82-6653 - KIT PRESSURE MONITR 38CM TRANSDUCER CATHETER TUNNELING BOTH IP/OP "$2,027.50 " "$1,500.35" $0.00 "$1,622.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,013.75" "$1,605.78" "$1,622.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0308 SUP Custom 27803010 82-7-0308 - INSERT TIBIAL 3 8MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0310 SUP Custom 27803010 82-7-0310 - INSERT TIBIAL 3 10MM BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0312 SUP Custom 27803010 82-7-0312 - INSERT TIBIAL 3 12MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0314 SUP Custom 27803010 82-7-0314 - INSERT TIBIAL 3 14MM POSTERIOR STABILIZING SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0315 SUP Custom 27803010 82-7-0315 - INSERT TIBIAL 3 15MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0316 SUP Custom 27803010 82-7-0316 - INSERT TIBIAL 3 16MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0318 SUP Custom 27803010 82-7-0318 - INSERT TIBIAL 3 18MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0321 SUP Custom 27803010 82-7-0321 - INSERT TIBIAL 3 21MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0324 SUP Custom 27803010 82-7-0324 - INSERT TIBIAL 3 24MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0508 SUP Custom 27803010 82-7-0508 - INSERT TIBIAL 5 8MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0510 SUP Custom 27803010 82-7-0510 - INSERT TIBIAL 5 10MM BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0512 SUP Custom 27803010 82-7-0512 - INSERT TIBIAL 5 12MM BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0514 SUP Custom 27803010 82-7-0514 - INSERT TIBIAL 5 14MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0515 SUP Custom 27803010 82-7-0515 - INSERT TIBIAL 5 15MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0516 SUP Custom 27803010 82-7-0516 - INSERT TIBIAL 5 16MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0518 SUP Custom 27803010 82-7-0518 - INSERT TIBIAL 3 18MM BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0521 SUP Custom 27803010 82-7-0521 - INSERT TIBIAL 5 21MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0524 SUP Custom 27803010 82-7-0524 - INSERT TIBIAL 5 24MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0708 SUP Custom 27803010 82-7-0708 - INSERT TIBIAL 7 8MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0710 SUP Custom 27803010 82-7-0710 - INSERT TIBIAL 7 10MM BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0712 SUP Custom 27803010 82-7-0712 - INSERT TIBIAL 7 12MM SCORPIO KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0714 SUP Custom 27803010 82-7-0714 - INSERT TIBIAL 7 14MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0715 SUP Custom 27803010 82-7-0715 - INSERT TIBIAL 7 15MM SCORPIO KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0716 SUP Custom 27803010 82-7-0716 - INSERT TIBIAL 7 16MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0718 SUP Custom 27803010 82-7-0718 - INSERT TIBIAL 7 18MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0721 SUP Custom 27803010 82-7-0721 - INSERT TIBIAL 7 21MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0724 SUP Custom 27803010 82-7-0724 - INSERT TIBIAL 7 24MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0908 SUP Custom 27803010 82-7-0908 - INSERT TIBIAL 9 8MM KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0910 SUP Custom 27803010 82-7-0910 - INSERT TIBIAL 10MM KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0912 SUP Custom 27803010 82-7-0912 - INSERT TIBIAL 9 12MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0914 SUP Custom 27803010 82-7-0914 - INSERT TIBIAL 9 14MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0915 SUP Custom 27803010 82-7-0915 - INSERT TIBIAL 9 15MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0916 SUP Custom 27803010 82-7-0916 - INSERT TIBIAL 9 16MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0918 SUP Custom 27803010 82-7-0918 - INSERT TIBIAL 9 18MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0921 SUP Custom 27803010 82-7-0921 - INSERT TIBIAL 9 21MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-0924 SUP Custom 27803010 82-7-0924 - INSERT TIBIAL 9 24MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1108 SUP Custom 27803010 82-7-1108 - INSERT TIBIAL 11 8MM POSTERIOR STABILIZE SCORPIO NRG X3 KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1110 SUP Custom 27803010 82-7-1110 - INSERT TIBIAL 11 10MM POSTERIOR STABILIZE SCORPIO NRG X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1112 SUP Custom 27803010 82-7-1112 - INSERT TIBIAL 11 12MM POSTERIOR STABILIZE SCORPIO NRG X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1114 SUP Custom 27803010 82-7-1114 - INSERT TIBIAL 11 14MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1115 SUP Custom 27803010 82-7-1115 - INSERT TIBIAL 11 15MM POSTERIOR STABILIZE SCORPIO NRG X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1116 SUP Custom 27803010 82-7-1116 - INSERT TIBIAL 11 16MM POSTERIOR STABILIZE SCORPIO NRG KNEE BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1118 SUP Custom 27803010 82-7-1118 - INSERT TIBIAL 11 18MM POSTERIOR STABILIZE SCORPIO NRG X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1121 SUP Custom 27803010 82-7-1121 - INSERT TIBIAL 11 21MM POSTERIOR STABILIZE SCORPIO NRG X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 82-7-1124 SUP Custom 27803010 82-7-1124 - INSERT TIBIAL 11 24MM POSTERIOR STABILIZE SCORPIO NRG X3 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 827-160 SUP HCPCS C1713 827-160 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $129.00 $95.46 $0.00 $103.20 $58.05 $58.05 $0.00 $0.00 $0.00 $26.89 $95.74 $95.74 $0.00 $0.00 $26.88 $0.00 $76.30 $76.30 $0.00 $64.50 $102.17 $103.20 $0.00 $0.00 $20.19 $0.00 $0.00 $20.54 $0.00 $0.00 $0.00 $0.00 $0.00 828-083 SUP HCPCS C1713 828-083 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 828-090 SUP HCPCS C1713 828-090 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 828-105 SUP HCPCS C1713 828-105 - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 828-107 SUP HCPCS C1713 828-107 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 828-135C SUP Custom 27803010 828-135C - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,314.30 " $972.58 $0.00 "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $975.47 $975.47 $0.00 $0.00 $273.90 $0.00 $0.00 $0.00 $0.00 $657.15 "$1,040.93" "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 828-136C SUP Custom 27803010 828-136C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,314.30 " $972.58 $0.00 "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $975.47 $975.47 $0.00 $0.00 $273.90 $0.00 $0.00 $0.00 $0.00 $657.15 "$1,040.93" "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 828-137C SUP Custom 27803010 828-137C - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,314.30 " $972.58 $0.00 "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $975.47 $975.47 $0.00 $0.00 $273.90 $0.00 $0.00 $0.00 $0.00 $657.15 "$1,040.93" "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 828-145 SUP HCPCS C1713 828-145 - SCREW BONE TSRH TI SPNL LCK FLSH BRK 6.35 MM ROD BOTH IP/OP $482.65 $357.16 $0.00 $386.12 $217.19 $217.19 $0.00 $0.00 $0.00 $100.60 $358.22 $358.22 $0.00 $0.00 $100.58 $0.00 $285.49 $285.49 $0.00 $241.33 $382.26 $386.12 $0.00 $0.00 $75.53 $0.00 $0.00 $76.84 $0.00 $0.00 $0.00 $0.00 $0.00 828-190 SUP HCPCS C1713 828-190 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 828-191C SUP Custom 27803010 828-191C - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,314.30 " $972.58 $0.00 "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $975.47 $975.47 $0.00 $0.00 $273.90 $0.00 $0.00 $0.00 $0.00 $657.15 "$1,040.93" "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 828-193 SUP Custom 27803010 828-193 - BOLT SPNL 6.35MM TSRH SM TI T TOP TGHT VA BOTH IP/OP "$2,361.80 " "$1,747.73" $0.00 "$1,889.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,752.93" "$1,752.93" $0.00 $0.00 $492.20 $0.00 $0.00 $0.00 $0.00 "$1,180.90" "$1,870.55" "$1,889.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 828-193C SUP HCPCS C1713 828-193C - BOLT SPNL 6.35MM TSRH SM TI T TOP TGHT CONNCTR BOTH IP/OP "$1,314.30 " $972.58 $0.00 "$1,051.44" $591.44 $591.44 $0.00 $0.00 $0.00 $273.93 $975.47 $975.47 $0.00 $0.00 $273.90 $0.00 $777.41 $777.41 $0.00 $657.15 "$1,040.93" "$1,051.44" $0.00 $0.00 $205.69 $0.00 $0.00 $209.24 $0.00 $0.00 $0.00 $0.00 $0.00 828-349C SUP Custom 27803010 828-349C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,314.30 " $972.58 $0.00 "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $975.47 $975.47 $0.00 $0.00 $273.90 $0.00 $0.00 $0.00 $0.00 $657.15 "$1,040.93" "$1,051.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 828-780 SUP HCPCS C1713 828-780 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-785 SUP HCPCS C1713 828-785 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-790 SUP HCPCS C1713 828-790 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-795 SUP HCPCS C1713 828-795 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828800PL SUP Custom 27803010 828800PL - VALVE SHUNT INLINE CERTAS BOTH IP/OP "$11,722.83 " "$8,674.89" $0.00 "$9,120.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,443.04" $0.00 $0.00 $0.00 $0.00 "$5,700.29" "$9,029.26" "$9,120.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 828-830 SUP HCPCS C1713 828-830 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-835 SUP HCPCS C1713 828-835 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-840 SUP HCPCS C1713 828-840 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-845 SUP HCPCS C1713 828-845 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-850 SUP HCPCS C1713 828-850 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-855 SUP HCPCS C1713 828-855 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-860 SUP HCPCS C1713 828-860 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-930 SUP HCPCS C1713 828-930 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-935 SUP HCPCS C1713 828-935 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-940 SUP HCPCS C1713 828-940 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-945 SUP HCPCS C1713 828-945 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 828-950 SUP HCPCS C1713 828-950 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,194.50 " "$1,623.93" $0.00 "$1,755.60" $987.53 $987.53 $0.00 $0.00 $0.00 $457.39 "$1,628.76" "$1,628.76" $0.00 $0.00 $457.33 $0.00 "$1,298.05" "$1,298.05" $0.00 "$1,097.25" "$1,738.04" "$1,755.60" $0.00 $0.00 $343.44 $0.00 $0.00 $349.36 $0.00 $0.00 $0.00 $0.00 $0.00 830-031 SUP HCPCS C1713 830-031 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-033 SUP HCPCS C1713 830-033 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-035 SUP HCPCS C1713 830-035 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-037 SUP HCPCS C1713 830-037 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-039 SUP HCPCS C1713 830-039 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-041 SUP HCPCS C1713 830-041 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-043 SUP HCPCS C1713 830-043 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-045 SUP HCPCS C1713 830-045 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-050 SUP HCPCS C1713 830-050 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-051 SUP HCPCS C1713 830-051 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8300KITB19A SUP Custom 27803010 8300KITB19A - VALVE AOR 19MM STRL LF EDWRD INTUITY ELT BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 $0.00 $0.00 $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8300KITB21A SUP Custom 27803010 8300KITB21A - VALVE AOR 21MM STRL LF EDWRD INTUITY ELT BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 $0.00 $0.00 $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8300KITB23A SUP Custom 27803010 8300KITB23A - VALVE AOR 23MM STRL LF EDWRD INTUITY ELT BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 $0.00 $0.00 $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8300KITB25A SUP Custom 27803010 8300KITB25A - VALVE AOR 25MM STRL LF EDWRD INTUITY ELT BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 $0.00 $0.00 $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8300KITB27A SUP Custom 27803010 8300KITB27A - VALVE AOR 27MM STRL LF EDWRD INTUITY ELT BOTH IP/OP "$30,000.00 " "$22,200.00" $0.00 "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,252.00" $0.00 $0.00 $0.00 $0.00 "$15,000.00" "$23,760.00" "$24,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8304H SUP Custom 27203010 8304H - SUTURE NABSB 7-0 BV-1 24IN BLU PR VSBLCK 2 ARM MFL BOTH IP/OP $46.76 $34.60 $0.00 $37.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.71 $34.71 $0.00 $0.00 $9.75 $0.00 $0.00 $0.00 $0.00 $23.73 $37.59 $37.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 830-529 SUP HCPCS C1713 830-529 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-531 SUP HCPCS C1713 830-531 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-533 SUP HCPCS C1713 830-533 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-535 SUP HCPCS C1713 830-535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-537 SUP HCPCS C1713 830-537 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-539 SUP HCPCS C1713 830-539 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-541 SUP HCPCS C1713 830-541 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-550 SUP HCPCS C1713 830-550 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 830-551 SUP HCPCS C1713 830-551 - PLATE 18MM TI BONE SPNL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 8305H SUP Custom 27203010 8305H - SUTURE NONABSORBABLE 6-0 BV-1 24IN 2 ARM MONOFILAMENT FIRM BOTH IP/OP $46.66 $34.53 $0.00 $37.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.63 $34.63 $0.00 $0.00 $9.72 $0.00 $0.00 $0.00 $0.00 $23.68 $37.51 $37.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 83545309H SUP HCPCS C1713 83545309H - SCREW BN OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83545359H SUP HCPCS C1713 83545359H - SCREW BN OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83545409H SUP HCPCS C1713 83545409H - SCREW BN 4.5MM 40MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83545459H SUP HCPCS C1713 83545459H - SCREW BN 4.5MM 45MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83545509H SUP HCPCS C1713 83545509H - SCREW BN 4.5MM 50MM TSRH OSTEOGRIP THNLN TI SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83545559H SUP HCPCS C1713 83545559H - SCREW BN 4.5MM 55MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83545609H SUP HCPCS C1713 83545609H - SCREW BN 4.5MM 60MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83555309H SUP HCPCS C1713 83555309H - SCREW BN 5.5MM 30MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83555359H SUP HCPCS C1713 83555359H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83555409H SUP HCPCS C1713 83555409H - SCREW BN 5.5MM 40MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83555459H SUP HCPCS C1713 83555459H - SCREW BN 5.5MM 45MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83555509H SUP HCPCS C1713 83555509H - SCREW BN 5.5MM 50MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83555559H SUP HCPCS C1713 83555559H - SCREW BN 5.5MM 55MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83555609H SUP HCPCS C1713 83555609H - SCREW BN 5.5MM 60MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83565309H SUP HCPCS C1713 83565309H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83565359H SUP HCPCS C1713 83565359H - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83565409H SUP HCPCS C1713 83565409H - SCREW BN 5.5MM 40MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83565459H SUP HCPCS C1713 83565459H - SCREW BN 5.5MM 45MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83565509H SUP HCPCS C1713 83565509H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83565559H SUP HCPCS C1713 83565559H - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83565609H SUP HCPCS C1713 83565609H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83575309H SUP HCPCS C1713 83575309H - SCREW BN 7.5MM 30MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83575359H SUP HCPCS C1713 83575359H - SCREW BN 7.5MM 35MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83575409H SUP HCPCS C1713 83575409H - SCREW BN 7.5MM 40MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83575459H SUP HCPCS C1713 83575459H - SCREW BN 7.5MM 45MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83575509H SUP HCPCS C1713 83575509H - SCREW BN 7.5MM 50MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83575559H SUP HCPCS C1713 83575559H - SCREW BN 7.5MM 55MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83575609H SUP HCPCS C1713 83575609H - SCREW BN 7.5MM 60MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83585309H SUP HCPCS C1713 83585309H - SCREW BN 8.5MM 30MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83585359H SUP HCPCS C1713 83585359H - SCREW BN 8.5MM 35MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83585409H SUP HCPCS C1713 83585409H - SCREW BN 8.5MM 40MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83585459H SUP HCPCS C1713 83585459H - SCREW BN 8.5MM 45MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83585509H SUP HCPCS C1713 83585509H - SCREW BN 8.5MM 50MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83585559H SUP HCPCS C1713 83585559H - SCREW BN 8.5MM 55MM OSTEOGRIP TSRH HA SPNE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 83585609H SUP HCPCS C1713 83585609H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 837-125 SUP HCPCS C1713 837-125 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 837-135 SUP HCPCS C1713 837-135 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 837-230 SUP HCPCS C1713 837-230 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-235 SUP HCPCS C1713 837-235 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-240 SUP HCPCS C1713 837-240 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-245 SUP HCPCS C1713 837-245 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-250 SUP HCPCS C1713 837-250 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-330 SUP HCPCS C1713 837-330 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-335 SUP HCPCS C1713 837-335 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-340 SUP HCPCS C1713 837-340 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-345 SUP HCPCS C1713 837-345 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-350 SUP HCPCS C1713 837-350 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-355 SUP HCPCS C1713 837-355 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-430 SUP HCPCS C1713 837-430 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-435 SUP HCPCS C1713 837-435 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-440 SUP HCPCS C1713 837-440 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-445 SUP HCPCS C1713 837-445 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-450 SUP HCPCS C1713 837-450 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-455 SUP HCPCS C1713 837-455 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-460 SUP HCPCS C1713 837-460 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 837-530 SUP HCPCS C1713 837-530 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-535 SUP HCPCS C1713 837-535 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-540 SUP HCPCS C1713 837-540 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-545 SUP HCPCS C1713 837-545 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-550 SUP HCPCS C1713 837-550 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-630 SUP HCPCS C1713 837-630 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-635 SUP HCPCS C1713 837-635 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-640 SUP HCPCS C1713 837-640 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-645 SUP HCPCS C1713 837-645 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-650 SUP HCPCS C1713 837-650 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-655 SUP HCPCS C1713 837-655 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-730 SUP HCPCS C1713 837-730 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-735 SUP HCPCS C1713 837-735 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-740 SUP HCPCS C1713 837-740 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-745 SUP HCPCS C1713 837-745 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-750 SUP HCPCS C1713 837-750 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-755 SUP HCPCS C1713 837-755 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-760 SUP HCPCS C1713 837-760 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-835 SUP HCPCS C1713 837-835 - PLATE 18MM TI BONE SPNL BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 837-845 SUP HCPCS C1713 837-845 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $984.00 $728.16 $0.00 $787.20 $442.80 $442.80 $0.00 $0.00 $0.00 $205.09 $730.32 $730.32 $0.00 $0.00 $205.07 $0.00 $582.04 $582.04 $0.00 $492.00 $779.33 $787.20 $0.00 $0.00 $154.00 $0.00 $0.00 $156.65 $0.00 $0.00 $0.00 $0.00 $0.00 8379120C SUP Custom 27803010 8379120C - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8379121C SUP Custom 27803010 8379121C - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,165.65 " "$1,602.58" $0.00 "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.35" "$1,607.35" $0.00 $0.00 $451.32 $0.00 $0.00 $0.00 $0.00 "$1,082.83" "$1,715.19" "$1,732.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 838-012 SUP HCPCS C1713 838-012 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 838-855 SUP HCPCS C1713 838-855 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 8400-0611 SUP HCPCS Q4107 8400-0611 - TISSUE SYNTH CALCIUM SLF 5ML OSTST RESORB MINI BEAD KIT FST BOTH IP/OP "$1,637.50 " "$1,211.75" $0.00 "$1,310.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,215.35" "$1,215.35" $0.00 $0.00 $109.65 $0.00 $0.00 $0.00 $0.00 $818.75 "$1,296.90" "$1,310.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84133HT SUP HCPCS C1713 84133HT - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 84154T SUP Custom 27803010 84154T - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,200.50 " "$1,628.37" $0.00 "$1,760.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,633.21" "$1,633.21" $0.00 $0.00 $458.58 $0.00 $0.00 $0.00 $0.00 "$1,100.25" "$1,742.80" "$1,760.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84161HT SUP HCPCS C1713 84161HT - PLATE 18MM TI BONE SPNL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 84181H SUP Custom 27803010 84181H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,991.25 " "$1,473.53" $0.00 "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,477.91" "$1,477.91" $0.00 $0.00 $414.98 $0.00 $0.00 $0.00 $0.00 $995.63 "$1,577.07" "$1,593.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84193H SUP HCPCS C1713 84193H - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 84193HT SUP HCPCS C1713 84193HT - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 8450107030D SUP Custom 27203010 8450107030D - BIT DRILL 3MM 13CM MATCH HEAD DIAMOND BOTH IP/OP $466.35 $345.10 $0.00 $373.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.12 $346.12 $0.00 $0.00 $97.19 $0.00 $0.00 $0.00 $0.00 $233.18 $369.35 $373.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 845-011 SUP HCPCS C1713 845-011 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 84505H SUP Custom 27803010 84505H - CONNECTOR ROD 5.5/5.5MM DMN SPNE BOTH IP/OP "$1,796.58 " "$1,329.47" $0.00 "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.42" "$1,333.42" $0.00 $0.00 $374.41 $0.00 $0.00 $0.00 $0.00 $898.29 "$1,422.89" "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84505HT SUP Custom 27803010 84505HT - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84505LH SUP Custom 27803010 84505LH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,796.58 " "$1,329.47" $0.00 "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.42" "$1,333.42" $0.00 $0.00 $374.41 $0.00 $0.00 $0.00 $0.00 $898.29 "$1,422.89" "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84505QH SUP Custom 27803010 84505QH - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84506H SUP Custom 27803010 84506H - CONNECTOR ROD 5.5/6.35MM CD HZN DMN SS SPNE BOTH IP/OP "$1,796.58 " "$1,329.47" $0.00 "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.42" "$1,333.42" $0.00 $0.00 $374.41 $0.00 $0.00 $0.00 $0.00 $898.29 "$1,422.89" "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84506HT SUP Custom 27803010 84506HT - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84507H SUP Custom 27803010 84507H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,052.75 " "$1,519.04" $0.00 "$1,642.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,523.55" "$1,523.55" $0.00 $0.00 $427.79 $0.00 $0.00 $0.00 $0.00 "$1,026.38" "$1,625.78" "$1,642.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84507HT SUP Custom 27803010 84507HT - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84509H SUP Custom 27803010 84509H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84509HT SUP Custom 27803010 84509HT - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84510H SUP Custom 27803010 84510H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84510HT SUP Custom 27803010 84510HT - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 84511H SUP Custom 27803010 84511H - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 848-011 SUP HCPCS C1713 848-011 - PLATE 18MM TI BONE SPNL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 848-012 SUP HCPCS C1713 848-012 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 848-520 SUP HCPCS C1713 848-520 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-523 SUP HCPCS C1713 848-523 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-525 SUP HCPCS C1713 848-525 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-528 SUP HCPCS C1713 848-528 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-530 SUP HCPCS C1713 848-530 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-533 SUP HCPCS C1713 848-533 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-535 SUP HCPCS C1713 848-535 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-538 SUP HCPCS C1713 848-538 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-540 SUP HCPCS C1713 848-540 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-543 SUP HCPCS C1713 848-543 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-545 SUP HCPCS C1713 848-545 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-548 SUP HCPCS C1713 848-548 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-550 SUP HCPCS C1713 848-550 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-553 SUP HCPCS C1713 848-553 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-555 SUP HCPCS C1713 848-555 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-625 SUP HCPCS C1713 848-625 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-630 SUP HCPCS C1713 848-630 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-635 SUP HCPCS C1713 848-635 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-640 SUP HCPCS C1713 848-640 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-645 SUP HCPCS C1713 848-645 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-725 SUP HCPCS C1713 848-725 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-730 SUP HCPCS C1713 848-730 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-735 SUP HCPCS C1713 848-735 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-740 SUP HCPCS C1713 848-740 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-745 SUP HCPCS C1713 848-745 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$2,352.00 " "$1,740.48" $0.00 "$1,881.60" "$1,058.40" "$1,058.40" $0.00 $0.00 $0.00 $490.22 "$1,745.65" "$1,745.65" $0.00 $0.00 $490.16 $0.00 "$1,391.21" "$1,391.21" $0.00 "$1,176.00" "$1,862.78" "$1,881.60" $0.00 $0.00 $368.09 $0.00 $0.00 $374.44 $0.00 $0.00 $0.00 $0.00 $0.00 848-855 SUP HCPCS C1713 848-855 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 851.002.01S SUP HCPCS C1713 851.002.01S - PLATE BONE CRNMXF 2 HOLE STR RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $315.00 $233.10 $0.00 $252.00 $141.75 $141.75 $0.00 $0.00 $0.00 $65.65 $233.79 $233.79 $0.00 $0.00 $65.65 $0.00 $186.32 $186.32 $0.00 $157.50 $249.48 $252.00 $0.00 $0.00 $49.30 $0.00 $0.00 $50.15 $0.00 $0.00 $0.00 $0.00 $0.00 851.004.01S SUP HCPCS C1713 851.004.01S - PLATE BONE CRNMXF 4 HOLE STR RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $461.25 $341.33 $0.00 $369.00 $207.56 $207.56 $0.00 $0.00 $0.00 $96.14 $342.34 $342.34 $0.00 $0.00 $96.12 $0.00 $272.83 $272.83 $0.00 $230.63 $365.31 $369.00 $0.00 $0.00 $72.19 $0.00 $0.00 $73.43 $0.00 $0.00 $0.00 $0.00 $0.00 851.008.01S SUP HCPCS C1713 851.008.01S - PLATE BONE CRNMXF 8 HOLE ADP RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 851.009.01S SUP HCPCS C1713 851.009.01S - PLATE 1.5 MM SCR 8 HOLE SCLP ADP SCLP RPD RESORB BONE STRL BOTH IP/OP $517.50 $382.95 $0.00 $414.00 $232.88 $232.88 $0.00 $0.00 $0.00 $107.86 $384.09 $384.09 $0.00 $0.00 $107.85 $0.00 $306.10 $306.10 $0.00 $258.75 $409.86 $414.00 $0.00 $0.00 $80.99 $0.00 $0.00 $82.39 $0.00 $0.00 $0.00 $0.00 $0.00 851.020.01S SUP HCPCS C1713 851.020.01S - PLATE BONE CRNMXF 20 HOLE ADP RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $753.75 $557.78 $0.00 $603.00 $339.19 $339.19 $0.00 $0.00 $0.00 $157.10 $559.43 $559.43 $0.00 $0.00 $157.08 $0.00 $445.84 $445.84 $0.00 $376.88 $596.97 $603.00 $0.00 $0.00 $117.96 $0.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 851.021.01S SUP HCPCS C1713 851.021.01S - PLATE 1.5 MM SCR 20 HOLE SCLP ADP SCLP RPD RESORB BONE STRL BOTH IP/OP $753.75 $557.78 $0.00 $603.00 $339.19 $339.19 $0.00 $0.00 $0.00 $157.10 $559.43 $559.43 $0.00 $0.00 $157.08 $0.00 $445.84 $445.84 $0.00 $376.88 $596.97 $603.00 $0.00 $0.00 $117.96 $0.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 851.110.01S SUP HCPCS C1713 851.110.01S - PLATE BONE ORBTL RIM 10 HOLE RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 851.320.01S SUP HCPCS C1713 851.320.01S - PLATE BONE CRNMXF 10 HOLE 2 Y RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 851.343.01S SUP HCPCS C1713 851.343.01S - PLATE BONE CRNMXF 4X3X3 HOLE Y RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 851.344.01S SUP HCPCS C1713 851.344.01S - 1.5MM RAPID RESORB T-PLATE 2 X 3 HOLES-STERILE BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 851.420.01S SUP HCPCS C1713 851.420.01S - PLATE BONE CRNMXF 2X10 HOLE STRUT RPD RESORB 1.5 MM SCR STRL BOTH IP/OP "$1,226.25 " $907.43 $0.00 $981.00 $551.81 $551.81 $0.00 $0.00 $0.00 $255.58 $910.12 $910.12 $0.00 $0.00 $255.55 $0.00 $725.33 $725.33 $0.00 $613.13 $971.19 $981.00 $0.00 $0.00 $191.91 $0.00 $0.00 $195.22 $0.00 $0.00 $0.00 $0.00 $0.00 851.421.01S SUP HCPCS C1713 851.421.01S - PLATE BONE CRNMXF 2X18 HOLE STRUT RPD RESORB 1.5 MM SCR STRL BOTH IP/OP "$1,518.75 " "$1,123.88" $0.00 "$1,215.00" $683.44 $683.44 $0.00 $0.00 $0.00 $316.55 "$1,127.22" "$1,127.22" $0.00 $0.00 $316.51 $0.00 $898.34 $898.34 $0.00 $759.38 "$1,202.85" "$1,215.00" $0.00 $0.00 $237.68 $0.00 $0.00 $241.79 $0.00 $0.00 $0.00 $0.00 $0.00 851.424.01S SUP HCPCS C1713 851.424.01S - PLATE BONE CRNMXF 2X10 HOLE STRUT SCLP RPD RESORB 1.5 MM SCR BOTH IP/OP "$1,228.50 " $909.09 $0.00 $982.80 $552.83 $552.83 $0.00 $0.00 $0.00 $256.05 $911.79 $911.79 $0.00 $0.00 $256.02 $0.00 $726.66 $726.66 $0.00 $614.25 $972.97 $982.80 $0.00 $0.00 $192.26 $0.00 $0.00 $195.58 $0.00 $0.00 $0.00 $0.00 $0.00 851.425.01S SUP HCPCS C1713 851.425.01S - PLATE BONE CRNMXF 2X18 HOLE STRUT SCLP RPD RESORB 1.5 MM SCR BOTH IP/OP "$1,518.75 " "$1,123.88" $0.00 "$1,215.00" $683.44 $683.44 $0.00 $0.00 $0.00 $316.55 "$1,127.22" "$1,127.22" $0.00 $0.00 $316.51 $0.00 $898.34 $898.34 $0.00 $759.38 "$1,202.85" "$1,215.00" $0.00 $0.00 $237.68 $0.00 $0.00 $241.79 $0.00 $0.00 $0.00 $0.00 $0.00 851.436.01S SUP HCPCS C1713 851.436.01S - PLATE 1.5 MM SCR 2X36 HOLE STRUT SCLP RPD RESORB BONE STRL BOTH IP/OP "$3,026.25 " "$2,239.43" $0.00 "$2,421.00" "$1,361.81" "$1,361.81" $0.00 $0.00 $0.00 $630.75 "$2,246.08" "$2,246.08" $0.00 $0.00 $630.67 $0.00 "$1,491.94" "$1,491.94" $0.00 "$1,513.13" "$2,396.79" "$2,421.00" $0.00 $0.00 $473.61 $0.00 $0.00 $481.78 $0.00 $0.00 $0.00 $0.00 $0.00 851.500.01S SUP HCPCS C1713 851.500.01S - 1.5MM RAPID RESORB BOX PLATE 4 HOLES-STERILE BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 851.506.01S SUP Custom 27803010 851.506.01S - COVER BUR HOLE CRNMXF 8 HOLE RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $641.25 $474.53 $0.00 $513.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $475.94 $475.94 $0.00 $0.00 $133.64 $0.00 $0.00 $0.00 $0.00 $320.63 $507.87 $513.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 851.508.01S SUP Custom 27803010 851.508.01S - COVER BUR HOLE CRNMXF 10 HOLE RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $641.25 $474.53 $0.00 $513.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $475.94 $475.94 $0.00 $0.00 $133.64 $0.00 $0.00 $0.00 $0.00 $320.63 $507.87 $513.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 851.510.01S SUP HCPCS C1713 851.510.01S - PLATE BONE 50X50X.5MM CRNMXF MESH RPD RESORB 1.5MM SCR STRL BOTH IP/OP "$3,060.00 " "$2,264.40" $0.00 "$2,448.00" "$1,377.00" "$1,377.00" $0.00 $0.00 $0.00 $637.78 "$2,271.13" "$2,271.13" $0.00 $0.00 $637.70 $0.00 "$1,508.58" "$1,508.58" $0.00 "$1,530.00" "$2,423.52" "$2,448.00" $0.00 $0.00 $478.89 $0.00 $0.00 $487.15 $0.00 $0.00 $0.00 $0.00 $0.00 851.512.01S SUP HCPCS C1713 851.512.01S - PLATE BONE 100X100X.5MM CRNMXF MESH RPD RESORB 1.5MM SCR BOTH IP/OP "$6,525.00 " "$4,828.50" $0.00 "$5,220.00" "$2,936.25" "$2,936.25" $0.00 $0.00 $0.00 "$1,359.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,359.81" $0.00 "$3,216.83" "$3,216.83" $0.00 "$3,262.50" "$5,167.80" "$5,220.00" $0.00 $0.00 "$1,021.16" $0.00 $0.00 "$1,038.78" $0.00 $0.00 $0.00 $0.00 $0.00 851.520.01S SUP HCPCS C1713 851.520.01S - PLATE BONE 50X50X.8MM CRNMXF MESH RPD RESORB 1.5MM SCR STRL BOTH IP/OP "$3,195.00 " "$2,364.30" $0.00 "$2,556.00" "$1,437.75" "$1,437.75" $0.00 $0.00 $0.00 $665.92 "$2,371.33" "$2,371.33" $0.00 $0.00 $665.84 $0.00 "$1,575.14" "$1,575.14" $0.00 "$1,597.50" "$2,530.44" "$2,556.00" $0.00 $0.00 $500.02 $0.00 $0.00 $508.64 $0.00 $0.00 $0.00 $0.00 $0.00 851.521.01S SUP HCPCS C1713 851.521.01S - PLATE BONE 100X100X.8MM CRNMXF MESH RPD RESORB 1.5MM SCR BOTH IP/OP "$7,278.75 " "$5,386.28" $0.00 "$5,823.00" "$3,275.44" "$3,275.44" $0.00 $0.00 $0.00 "$1,517.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,516.89" $0.00 "$3,588.42" "$3,588.42" $0.00 "$3,639.38" "$5,764.77" "$5,823.00" $0.00 $0.00 "$1,139.12" $0.00 $0.00 "$1,158.78" $0.00 $0.00 $0.00 $0.00 $0.00 851.532.01S SUP HCPCS C1713 851.532.01S - PLATE BONE 50X50X.5MM CRNMXF SHT RPD RESORB 1.5MM SCR STRL BOTH IP/OP "$2,256.75 " "$1,670.00" $0.00 "$1,805.40" "$1,015.54" "$1,015.54" $0.00 $0.00 $0.00 $470.36 "$1,674.96" "$1,674.96" $0.00 $0.00 $470.31 $0.00 "$1,334.87" "$1,334.87" $0.00 "$1,128.38" "$1,787.35" "$1,805.40" $0.00 $0.00 $353.18 $0.00 $0.00 $359.27 $0.00 $0.00 $0.00 $0.00 $0.00 851.534.01S SUP HCPCS C1713 851.534.01S - PLATE BONE 50X50X.8MM CRNMXF SHT RPD RESORB 1.5MM SCR STRL BOTH IP/OP "$2,351.25 " "$1,739.93" $0.00 "$1,881.00" "$1,058.06" "$1,058.06" $0.00 $0.00 $0.00 $490.06 "$1,745.10" "$1,745.10" $0.00 $0.00 $490.00 $0.00 "$1,390.76" "$1,390.76" $0.00 "$1,175.63" "$1,862.19" "$1,881.00" $0.00 $0.00 $367.97 $0.00 $0.00 $374.32 $0.00 $0.00 $0.00 $0.00 $0.00 851.540.01S SUP HCPCS C1713 851.540.01S - PLATE BONE TRNS 24X24MM THK.5MM ORBTL FLR RPD REABSORBABLE BOTH IP/OP "$1,890.00 " "$1,398.60" $0.00 "$1,512.00" $850.50 $850.50 $0.00 $0.00 $0.00 $393.92 "$1,402.76" "$1,402.76" $0.00 $0.00 $393.88 $0.00 "$1,117.94" "$1,117.94" $0.00 $945.00 "$1,496.88" "$1,512.00" $0.00 $0.00 $295.79 $0.00 $0.00 $300.89 $0.00 $0.00 $0.00 $0.00 $0.00 851.541.01S SUP HCPCS C1713 851.541.01S - PLATE BONE 30MM MED ORBTL FLR RPD RESORB 1.5MM SCR STRL BOTH IP/OP "$1,968.75 " "$1,456.88" $0.00 "$1,575.00" $885.94 $885.94 $0.00 $0.00 $0.00 $410.34 "$1,461.21" "$1,461.21" $0.00 $0.00 $410.29 $0.00 "$1,164.52" "$1,164.52" $0.00 $984.38 "$1,559.25" "$1,575.00" $0.00 $0.00 $308.11 $0.00 $0.00 $313.43 $0.00 $0.00 $0.00 $0.00 $0.00 851.542.01S SUP HCPCS C1713 851.542.01S - PLATE BONE 35MM LG ORBTL FLR RPD RESORB 1.5MM SCR STRL BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 851.604.01S SUP HCPCS C1713 851.604.01S - PLATE BONE CRNMXF 4 HOLE X RPD RESORB 1.5 MM SCR STRL BOTH IP/OP $663.75 $491.18 $0.00 $531.00 $298.69 $298.69 $0.00 $0.00 $0.00 $138.34 $492.64 $492.64 $0.00 $0.00 $138.33 $0.00 $392.61 $392.61 $0.00 $331.88 $525.69 $531.00 $0.00 $0.00 $103.88 $0.00 $0.00 $105.67 $0.00 $0.00 $0.00 $0.00 $0.00 851.605.01S SUP HCPCS C1713 851.605.01S - 1.5MM RAPID RESORB X-PLATE 8 HOLES-STERILE BOTH IP/OP $663.75 $491.18 $0.00 $531.00 $298.69 $298.69 $0.00 $0.00 $0.00 $138.34 $492.64 $492.64 $0.00 $0.00 $138.33 $0.00 $392.61 $392.61 $0.00 $331.88 $525.69 $531.00 $0.00 $0.00 $103.88 $0.00 $0.00 $105.67 $0.00 $0.00 $0.00 $0.00 $0.00 851.611.01S SUP HCPCS C1713 851.611.01S - 1.5MM RAPID RESORB CONTOURABLE MESH/50X50X0.25MM THK-STERILE BOTH IP/OP "$3,352.50 " "$2,480.85" $0.00 "$2,682.00" "$1,508.63" "$1,508.63" $0.00 $0.00 $0.00 $698.74 "$2,488.23" "$2,488.23" $0.00 $0.00 $698.66 $0.00 "$1,652.78" "$1,652.78" $0.00 "$1,676.25" "$2,655.18" "$2,682.00" $0.00 $0.00 $524.67 $0.00 $0.00 $533.72 $0.00 $0.00 $0.00 $0.00 $0.00 851.612.01S SUP HCPCS C1713 851.612.01S - MESH CRNL 100X100X.25MM STRL RAPIDSORB CNTR RSRB RPD 1.5MM BOTH IP/OP "$7,222.50 " "$5,344.65" $0.00 "$5,778.00" "$3,250.13" "$3,250.13" $0.00 $0.00 $0.00 "$1,505.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.17" $0.00 "$3,560.69" "$3,560.69" $0.00 "$3,611.25" "$5,720.22" "$5,778.00" $0.00 $0.00 "$1,130.32" $0.00 $0.00 "$1,149.82" $0.00 $0.00 $0.00 $0.00 $0.00 851.621.01S SUP HCPCS C1713 851.621.01S - 1.5MM RAPID RESORB CONTOURABLE MESH/50X50X0.5MM THK-STERILE BOTH IP/OP "$3,352.50 " "$2,480.85" $0.00 "$2,682.00" "$1,508.63" "$1,508.63" $0.00 $0.00 $0.00 $698.74 "$2,488.23" "$2,488.23" $0.00 $0.00 $698.66 $0.00 "$1,652.78" "$1,652.78" $0.00 "$1,676.25" "$2,655.18" "$2,682.00" $0.00 $0.00 $524.67 $0.00 $0.00 $533.72 $0.00 $0.00 $0.00 $0.00 $0.00 851.622.01S SUP HCPCS C1713 851.622.01S - PLATE 100X100X.50MM 1.5MM SCR CONTUR MESH RPD RESORB BONE BOTH IP/OP "$7,222.50 " "$5,344.65" $0.00 "$5,778.00" "$3,250.13" "$3,250.13" $0.00 $0.00 $0.00 "$1,505.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.17" $0.00 "$3,560.69" "$3,560.69" $0.00 "$3,611.25" "$5,720.22" "$5,778.00" $0.00 $0.00 "$1,130.32" $0.00 $0.00 "$1,149.82" $0.00 $0.00 $0.00 $0.00 $0.00 851.623.01S SUP HCPCS C1713 851.623.01S - PLATE 150X150X.5MM 1.5MM SCR CONTUR MESH RPD RESORB BONE BOTH IP/OP "$12,172.50 " "$9,007.65" $0.00 "$9,738.00" "$5,477.63" "$5,477.63" $0.00 $0.00 $0.00 "$2,537.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,536.75" $0.00 "$6,001.04" "$6,001.04" $0.00 "$6,086.25" "$9,640.62" "$9,738.00" $0.00 $0.00 "$1,905.00" $0.00 $0.00 "$1,937.86" $0.00 $0.00 $0.00 $0.00 $0.00 851.633.01S SUP HCPCS C1713 851.633.01S - 1.5MM RAPID RESORB CONTOURABLE MESH/150X150X0.8MM THK-STERIL BOTH IP/OP "$12,375.00 " "$9,157.50" $0.00 "$9,900.00" "$5,568.75" "$5,568.75" $0.00 $0.00 $0.00 "$2,579.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,578.95" $0.00 "$6,100.88" "$6,100.88" $0.00 "$6,187.50" "$9,801.00" "$9,900.00" $0.00 $0.00 "$1,936.69" $0.00 $0.00 "$1,970.10" $0.00 $0.00 $0.00 $0.00 $0.00 851.651.01S SUP HCPCS C1713 851.651.01S - PLATE BONE .5MM CRNMXF CONTUR MESH RPD RESORB 1.5MM SCR STRL BOTH IP/OP "$3,352.50 " "$2,480.85" $0.00 "$2,682.00" "$1,508.63" "$1,508.63" $0.00 $0.00 $0.00 $698.74 "$2,488.23" "$2,488.23" $0.00 $0.00 $698.66 $0.00 "$1,652.78" "$1,652.78" $0.00 "$1,676.25" "$2,655.18" "$2,682.00" $0.00 $0.00 $524.67 $0.00 $0.00 $533.72 $0.00 $0.00 $0.00 $0.00 $0.00 851.652.01S SUP HCPCS C1713 851.652.01S - PLATE BONE .5MM 100MM CRNMXF CONTUR MESH RPD RESORB 1.5MM BOTH IP/OP "$7,222.50 " "$5,344.65" $0.00 "$5,778.00" "$3,250.13" "$3,250.13" $0.00 $0.00 $0.00 "$1,505.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,505.17" $0.00 "$3,560.69" "$3,560.69" $0.00 "$3,611.25" "$5,720.22" "$5,778.00" $0.00 $0.00 "$1,130.32" $0.00 $0.00 "$1,149.82" $0.00 $0.00 $0.00 $0.00 $0.00 851.661.01S SUP HCPCS C1713 851.661.01S - PLATE BONE .8MM 50MM CRNMXF CONTUR MESH RPD RESORB 1.5MM SCR BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 851.662.01S SUP HCPCS C1713 851.662.01S - PLATE .8MM 1.5MM SCR CONTUR MESH RESORB RGD BONE 100MM BOTH IP/OP "$7,605.00 " "$5,627.70" $0.00 "$6,084.00" "$3,422.25" "$3,422.25" $0.00 $0.00 $0.00 "$1,585.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,584.88" $0.00 "$3,749.27" "$3,749.27" $0.00 "$3,802.50" "$6,023.16" "$6,084.00" $0.00 $0.00 "$1,190.18" $0.00 $0.00 "$1,210.72" $0.00 $0.00 $0.00 $0.00 $0.00 851.680.01S SUP HCPCS C1713 851.680.01S - 1.5MM RAPID RESORB SELLAR FLR PL 7MMX25MM/0.5MM THK-STERILE BOTH IP/OP $641.25 $474.53 $0.00 $513.00 $288.56 $288.56 $0.00 $0.00 $0.00 $133.65 $475.94 $475.94 $0.00 $0.00 $133.64 $0.00 $379.30 $379.30 $0.00 $320.63 $507.87 $513.00 $0.00 $0.00 $100.36 $0.00 $0.00 $102.09 $0.00 $0.00 $0.00 $0.00 $0.00 851.681.01S SUP HCPCS C1713 851.681.01S - 1.5MM RAPID RESORB SELLAR FLR PL 7MMX25MM/0.8MM THK-STERILE BOTH IP/OP $641.25 $474.53 $0.00 $513.00 $288.56 $288.56 $0.00 $0.00 $0.00 $133.65 $475.94 $475.94 $0.00 $0.00 $133.64 $0.00 $379.30 $379.30 $0.00 $320.63 $507.87 $513.00 $0.00 $0.00 $100.36 $0.00 $0.00 $102.09 $0.00 $0.00 $0.00 $0.00 $0.00 851.689.01S SUP HCPCS C1713 851.689.01S - 1.5MM RAPID RESORB ORBTL FL PL W/BENDING TEMPLATE/24MM-STER BOTH IP/OP "$1,901.25 " "$1,406.93" $0.00 "$1,521.00" $855.56 $855.56 $0.00 $0.00 $0.00 $396.27 "$1,411.11" "$1,411.11" $0.00 $0.00 $396.22 $0.00 "$1,124.59" "$1,124.59" $0.00 $950.63 "$1,505.79" "$1,521.00" $0.00 $0.00 $297.55 $0.00 $0.00 $302.68 $0.00 $0.00 $0.00 $0.00 $0.00 851.690.01S SUP HCPCS C1713 851.690.01S - PLATE BONE 30X30MM ORBTL FLR RPD RESORB BNDRG TMPLT 1.5MM BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" $891.00 $891.00 $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 851.691.01S SUP HCPCS C1713 851.691.01S - PLATE 35X35MM 1.5MM SCR BNDRG TMPLT RPD RESORB BONE ORBTL BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 851.711.01S SUP HCPCS C1713 851.711.01S - PLATE BONE 50X50X.5MM CRNMXF STR ROW MESH RPD RESORB 1.5MM BOTH IP/OP "$3,060.00 " "$2,264.40" $0.00 "$2,448.00" "$1,377.00" "$1,377.00" $0.00 $0.00 $0.00 $637.78 "$2,271.13" "$2,271.13" $0.00 $0.00 $637.70 $0.00 "$1,508.58" "$1,508.58" $0.00 "$1,530.00" "$2,423.52" "$2,448.00" $0.00 $0.00 $478.89 $0.00 $0.00 $487.15 $0.00 $0.00 $0.00 $0.00 $0.00 851.711.97S SUP HCPCS C1713 851.711.97S - PLATE BONE 50X50X.5MM STR ROW MESH RAPID RESORB POLY BOTH IP/OP "$2,846.53 " "$2,106.43" $0.00 "$2,210.90" "$1,243.63" "$1,243.63" $0.00 $0.00 $0.00 $593.29 "$2,112.69" "$2,112.69" $0.00 $0.00 $593.22 $0.00 "$1,403.34" "$1,403.34" $0.00 "$1,381.81" "$2,188.79" "$2,210.90" $0.00 $0.00 $419.91 $0.00 $0.00 $439.97 $0.00 $0.00 $0.00 $0.00 $0.00 851.712.01S SUP HCPCS C1713 851.712.01S - PLATE BONE 100X100X.5MM CRNMXF STR ROW MESH RPD RESORB 1.5MM BOTH IP/OP "$6,525.00 " "$4,828.50" $0.00 "$5,220.00" "$2,936.25" "$2,936.25" $0.00 $0.00 $0.00 "$1,359.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,359.81" $0.00 "$3,216.83" "$3,216.83" $0.00 "$3,262.50" "$5,167.80" "$5,220.00" $0.00 $0.00 "$1,021.16" $0.00 $0.00 "$1,038.78" $0.00 $0.00 $0.00 $0.00 $0.00 851.712.97S SUP HCPCS C1713 851.712.97S - PLATE BONE 100MM RESORB STR ROW MESH ORTHOPEDIC NONSTRL 1MM BOTH IP/OP "$6,071.00 " "$4,492.54" $0.00 "$4,715.34" "$2,652.38" "$2,652.38" $0.00 $0.00 $0.00 "$1,265.35" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,265.20" $0.00 "$2,993.00" "$2,993.00" $0.00 "$2,947.09" "$4,668.19" "$4,715.34" $0.00 $0.00 $895.57 $0.00 $0.00 $938.35 $0.00 $0.00 $0.00 $0.00 $0.00 851.721.01S SUP HCPCS C1713 851.721.01S - PLATE BONE 50X50X.8MM CRNMXF STR ROW MESH RPD RESORB 1.5MM BOTH IP/OP "$3,240.00 " "$2,397.60" $0.00 "$2,592.00" "$1,458.00" "$1,458.00" $0.00 $0.00 $0.00 $675.30 "$2,404.73" "$2,404.73" $0.00 $0.00 $675.22 $0.00 "$1,597.32" "$1,597.32" $0.00 "$1,620.00" "$2,566.08" "$2,592.00" $0.00 $0.00 $507.06 $0.00 $0.00 $515.81 $0.00 $0.00 $0.00 $0.00 $0.00 851.722.01S SUP HCPCS C1713 851.722.01S - PLATE BONE 100X100X.8MM CRNMXF STR ROW MESH RPD RESORB 1.5MM BOTH IP/OP "$7,200.00 " "$5,328.00" $0.00 "$5,760.00" "$3,240.00" "$3,240.00" $0.00 $0.00 $0.00 "$1,500.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,500.48" $0.00 "$3,549.60" "$3,549.60" $0.00 "$3,600.00" "$5,702.40" "$5,760.00" $0.00 $0.00 "$1,126.80" $0.00 $0.00 "$1,146.24" $0.00 $0.00 $0.00 $0.00 $0.00 851.724.01S SUP HCPCS C1713 851.724.01S - 1.5MM RAPID RESORB STRAIGHT ROW MESH/75X75X0.8MM THK-STER BOTH IP/OP "$4,657.50 " "$3,446.55" $0.00 "$3,726.00" "$2,095.88" "$2,095.88" $0.00 $0.00 $0.00 $970.74 "$3,456.80" "$3,456.80" $0.00 $0.00 $970.62 $0.00 "$2,296.15" "$2,296.15" $0.00 "$2,328.75" "$3,688.74" "$3,726.00" $0.00 $0.00 $728.90 $0.00 $0.00 $741.47 $0.00 $0.00 $0.00 $0.00 $0.00 851.801.01S SUP Custom 27803010 851.801.01S - CLAMP TUBE 18MM CRANIAL FLP RPD RESORB STRL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $0.00 $0.00 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 852.002.01S SUP HCPCS C1713 852.002.01S - PLATE BONE CRNMXF 2 HOLE STR RPD RESORB 2 MM SCR STRL BOTH IP/OP $326.25 $241.43 $0.00 $261.00 $146.81 $146.81 $0.00 $0.00 $0.00 $68.00 $242.14 $242.14 $0.00 $0.00 $67.99 $0.00 $192.98 $192.98 $0.00 $163.13 $258.39 $261.00 $0.00 $0.00 $51.06 $0.00 $0.00 $51.94 $0.00 $0.00 $0.00 $0.00 $0.00 852.004.01S SUP HCPCS C1713 852.004.01S - PLATE BONE CRNMXF 4 HOLE STR RPD RESORB 2 MM SCR STRL BOTH IP/OP $483.75 $357.98 $0.00 $387.00 $217.69 $217.69 $0.00 $0.00 $0.00 $100.83 $359.04 $359.04 $0.00 $0.00 $100.81 $0.00 $286.14 $286.14 $0.00 $241.88 $383.13 $387.00 $0.00 $0.00 $75.71 $0.00 $0.00 $77.01 $0.00 $0.00 $0.00 $0.00 $0.00 852.008.01S SUP HCPCS C1713 852.008.01S - PLATE BONE CRNMXF 8 HOLE ADP RPD RESORB 2 MM SCR STRL BOTH IP/OP $540.00 $399.60 $0.00 $432.00 $243.00 $243.00 $0.00 $0.00 $0.00 $112.55 $400.79 $400.79 $0.00 $0.00 $112.54 $0.00 $319.41 $319.41 $0.00 $270.00 $427.68 $432.00 $0.00 $0.00 $84.51 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $0.00 852.020.01S SUP HCPCS C1713 852.020.01S - PLATE BONE 2MM 20 HOLE ADP RPD RESORB STRL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 852.110.01S SUP HCPCS C1713 852.110.01S - PLATE BONE ORBTL RIM 10 HOLE RPD RESORB 2 MM SCR STRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 852.263.01S SUP HCPCS C1713 852.263.01S - PLATE BONE CRNMXF 6X4 HOLE L LEFT OBLQ RPD RESORB 2 MM SCR BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 852.264.01S SUP HCPCS C1713 852.264.01S - PLATE BONE CRNMXF 6X4 HOLE L RIGHT OBLQ RPD RESORB 2 MM SCR BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 852.343.01S SUP HCPCS C1713 852.343.01S - PLATE BONE CRNMXF 4X3X3 HOLE RPD RESORB 2 MM SCR STRL BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $313.88 $313.88 $0.00 $0.00 $0.00 $145.38 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $412.57 $412.57 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 852.420.01S SUP HCPCS C1713 852.420.01S - PLATE BONE CRNMXF 2X10 HOLE STRUT RPD RESORB 2 MM SCR STRL BOTH IP/OP "$1,293.75 " $957.38 $0.00 "$1,035.00" $582.19 $582.19 $0.00 $0.00 $0.00 $269.65 $960.22 $960.22 $0.00 $0.00 $269.62 $0.00 $765.25 $765.25 $0.00 $646.88 "$1,024.65" "$1,035.00" $0.00 $0.00 $202.47 $0.00 $0.00 $205.97 $0.00 $0.00 $0.00 $0.00 $0.00 852.421.01S SUP HCPCS C1713 852.421.01S - PLATE BONE CRNMXF 2X18 HOLE STRUT RPD RESORB 2 MM SCR STRL BOTH IP/OP "$1,597.50 " "$1,182.15" $0.00 "$1,278.00" $718.88 $718.88 $0.00 $0.00 $0.00 $332.96 "$1,185.66" "$1,185.66" $0.00 $0.00 $332.92 $0.00 $944.92 $944.92 $0.00 $798.75 "$1,265.22" "$1,278.00" $0.00 $0.00 $250.01 $0.00 $0.00 $254.32 $0.00 $0.00 $0.00 $0.00 $0.00 852.520.01S SUP HCPCS C1713 852.520.01S - PLATE BONE 48X48X1.2MM CRNMXF MESH RPD RESORB 2MM SCR STRL BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 852.521.01S SUP HCPCS C1713 852.521.01S - PLATE BONE 78X78X1.2MM CRNMXF MESH RPD RESORB 2MM SCR STRL BOTH IP/OP "$5,445.00 " "$4,029.30" $0.00 "$4,356.00" "$2,450.25" "$2,450.25" $0.00 $0.00 $0.00 "$1,134.87" "$4,041.28" "$4,041.28" $0.00 $0.00 "$1,134.74" $0.00 "$2,684.39" "$2,684.39" $0.00 "$2,722.50" "$4,312.44" "$4,356.00" $0.00 $0.00 $852.14 $0.00 $0.00 $866.84 $0.00 $0.00 $0.00 $0.00 $0.00 852.641.01S SUP HCPCS C1713 852.641.01S - PLATE BONE 1.2MM 50MM CRNMXF CONTUR MESH RPD RESORB 2MM SCR BOTH IP/OP "$3,802.50 " "$2,813.85" $0.00 "$3,042.00" "$1,711.13" "$1,711.13" $0.00 $0.00 $0.00 $792.54 "$2,822.22" "$2,822.22" $0.00 $0.00 $792.44 $0.00 "$1,874.63" "$1,874.63" $0.00 "$1,901.25" "$3,011.58" "$3,042.00" $0.00 $0.00 $595.09 $0.00 $0.00 $605.36 $0.00 $0.00 $0.00 $0.00 $0.00 852-000 SUP Custom 27203010 KIT NOW LGNL URN AG MCBLTST 22 TST BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 853008LH SUP HCPCS C1713 853008LH - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853008LW SUP HCPCS C1713 853008LW - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853008WM SUP HCPCS C1713 853008WM - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-010 SUP HCPCS C1713 853-010 - PLATE 10MM TI MLT HOLE OPN DOOR PCUT INTRINSIC STAB CLR CD BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853010LH SUP HCPCS C1713 853010LH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853010LW SUP HCPCS C1713 853010LW - PLATE BN W MTH 10MM CENTERPIECE LAT HL OPN DOOR CLR CD TI BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853010WM SUP HCPCS C1713 853010WM - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-012 SUP HCPCS C1713 853-012 - PLATE 12MM TI MLT HOLE OPN DOOR PCUT INTRINSIC STAB CLR CD BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853012LH SUP HCPCS C1713 853012LH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853012WM SUP HCPCS C1713 853012WM - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-014 SUP HCPCS C1713 853-014 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853014LH SUP HCPCS C1713 853014LH - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853014LW SUP HCPCS C1713 853014LW - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853014WM SUP HCPCS C1713 853014WM - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-016 SUP HCPCS C1713 853-016 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853016LH SUP HCPCS C1713 853016LH - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853016LW SUP HCPCS C1713 853016LW - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853016WM SUP HCPCS C1713 853016WM - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-018 SUP HCPCS C1713 853-018 - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853018LH SUP HCPCS C1713 853018LH - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853018LW SUP HCPCS C1713 853018LW - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853018WM SUP HCPCS C1713 853018WM - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-107 SUP HCPCS C1713 853-107 - PLATE 7MM TI BONE SPNL BOTH IP/OP "$1,657.50 " "$1,226.55" $0.00 "$1,326.00" $745.88 $745.88 $0.00 $0.00 $0.00 $345.46 "$1,230.20" "$1,230.20" $0.00 $0.00 $345.42 $0.00 $980.41 $980.41 $0.00 $828.75 "$1,312.74" "$1,326.00" $0.00 $0.00 $259.40 $0.00 $0.00 $263.87 $0.00 $0.00 $0.00 $0.00 $0.00 853408LH SUP HCPCS C1713 853408LH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-410 SUP HCPCS C1713 853-410 - PLATE BN 10MM NS CENTERPIECE GFT SPNE BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853410LH SUP HCPCS C1713 853410LH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-412 SUP HCPCS C1713 853-412 - PLATE BN 12MM NS CENTERPIECE GFT SPNE BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853412LH SUP HCPCS C1713 853412LH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-414 SUP HCPCS C1713 853-414 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853414LH SUP HCPCS C1713 853414LH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-416 SUP HCPCS C1713 853-416 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853416LH SUP HCPCS C1713 853416LH - SOURCE LGHT 18MM RDN X QDRNT ILUM MTRX X-TUBE RTRCT BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $492.08 $492.08 $0.00 $0.00 $0.00 $227.91 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $646.81 $646.81 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $171.13 $0.00 $0.00 $174.09 $0.00 $0.00 $0.00 $0.00 $0.00 853-418 SUP Custom 27803010 853-418 - PLATE 18MM TI BONE SPNL BOTH IP/OP "$1,093.50 " $809.19 $0.00 $874.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $811.60 $811.60 $0.00 $0.00 $227.89 $0.00 $0.00 $0.00 $0.00 $546.75 $866.05 $874.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 853-465 SUP HCPCS C1713 853-465 - SCREW BONE 2.6MM 5MM CENTERPIECE TI SPNL SLFTAP CLR CD BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 853-467 SUP HCPCS C1713 853-467 - BONE SCREW 853-467 2.6 X 7MM BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 853-469 SUP HCPCS C1713 853-469 - BONE SCREW 853-469 2.6 X 9MM BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 853-471 SUP HCPCS C1713 853-471 - BONE SCREW 853-471 2.6 X 11MM BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 853-505 SUP HCPCS C1713 853-505 - SCREW BONE 3MM 5MM CENTERPIECE TI SPNL SLFTAP CLR CD BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 853-507 SUP HCPCS C1713 853-507 - BONE SCREW 853-507 3.0 X 7MM BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 853-509 SUP HCPCS C1713 853-509 - BONE SCREW 853-509 3.0 X 9MM BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 853-511 SUP HCPCS C1713 853-511 - BONE SCREW 853-511 3.0 X 11MM BOTH IP/OP $171.00 $126.54 $0.00 $136.80 $76.95 $76.95 $0.00 $0.00 $0.00 $35.64 $126.92 $126.92 $0.00 $0.00 $35.64 $0.00 $101.15 $101.15 $0.00 $85.50 $135.43 $136.80 $0.00 $0.00 $26.76 $0.00 $0.00 $27.22 $0.00 $0.00 $0.00 $0.00 $0.00 853-602 SUP Custom 27203010 853-602 - INSTRUMENT 853-602 TRI FLAT DRILL BIT BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8550012L SUP HCPCS C1713 8550012L - ROD 8550012L 5.5MM TI HEX END LINED ROD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 855-011 SUP HCPCS C1713 855-011 - ROD 855-011 5.5 MM HEX-END ROD L20 TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 855011L100 SUP HCPCS C1713 855011L100 - ROD 855011L100 TSRH 5.5X100MM TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 855-012 SUP HCPCS C1713 855-012 - ROD 855-012 TITANIUM ROD CP GRADE IV BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 85-62010 SUP Custom 27203010 85-62010 - STM HNDHLD LCTR VRSTIM3 NRV STD SBDRM BOTH IP/OP $113.00 $83.62 $0.00 $90.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.87 $83.87 $0.00 $0.00 $23.55 $0.00 $0.00 $0.00 $0.00 $56.50 $89.50 $90.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-002 SUP HCPCS C1713 858-002 - HOOK 858-002 5.5 SMALL PEDICLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-010 SUP HCPCS C1713 858-010 - HOOK 858-010 5.5 SMALL WIDE BLADE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-020 SUP HCPCS C1713 858-020 - HOOK 858-020 5.5 SMALL NARROW BLADE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-024 SUP HCPCS C1713 858-024 - HOOK 858-024 5.5 SMALL ANGLED BLADE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-030 SUP HCPCS C1713 858-030 - HOOK 858-030 5.5 SMALL EXTENDED BODY BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-052 SUP HCPCS C1713 858-052 - HOOK 858-052 5.5 SMALL NARROW BLADE RMPD BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-102 SUP HCPCS C1713 858-102 - HOOK 858-102 5.5 PEDICLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-110 SUP HCPCS C1713 858-110 - HOOK 858-110 5.5 WIDE BLADE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-112 SUP HCPCS C1713 858-112 - HOOK 858-112 5.5 WIDE BLADE SMALL GRVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-120 SUP HCPCS C1713 858-120 - HOOK 858-120 5.5 NARROW BLADE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-122 SUP HCPCS C1713 858-122 - HOOK 858-122 NARROW BLADE SMALL GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-124 SUP HCPCS C1713 858-124 - HOOK 858-124 5.5 ANGLED BLADE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-130 SUP HCPCS C1713 858-130 - HOOK 858-130 5.5 EXTENDED BODY BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-140 SUP HCPCS C1713 858-140 - HOOK 858-140 5.5 RIGHT OFFSET BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-142 SUP HCPCS C1713 858-142 - HOOK 858-142 5.5 LEFT OFFSET BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-150 SUP HCPCS C1713 858-150 - HOOK 858-150 5.5 STANDARD BLADE RAMPED BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-152 SUP HCPCS C1713 858-152 - HOOK 858-152 5.5 NARROW BLADE RAMPED BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-160 SUP HCPCS C1713 858-160 - HOOK 858-160 5.5 RIGHT ANGLED BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-162 SUP HCPCS C1713 858-162 - HOOK 858-162 5.5 LEFT ANGLED BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-202 SUP HCPCS C1713 858-202 - HOOK 858-202 5.5 LARGE PEDICLE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-218 SUP HCPCS C1713 858-218 - HOOK 858-218 LARGE GROOVE WIDE BLADE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-220 SUP HCPCS C1713 858-220 - HOOK 858-220 5.5 LARGE GROOVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-230 SUP HCPCS C1713 858-230 - HOOK 858-230 5.5 EXTD BODY LARGE GRVE BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 858-425 SUP HCPCS C1713 858-425 - SCREW 858-425 CDH FIXED ANGLE 4.5 X 25 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-430 SUP HCPCS C1713 858-430 - SCREW 858-430 CDH FIXED ANGLE 4.5 X 30 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-435 SUP HCPCS C1713 858-435 - SCREW 858-435 CDH FIXED ANGLE 4.5 X 35 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-440 SUP HCPCS C1713 858-440 - SCREW 858-440 CDH FIXED ANGLE 4.5 X 40 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-525 SUP HCPCS C1713 858-525 - SCREW 858-525 CDH FIXED ANGLE 5.5 X 25 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-530 SUP HCPCS C1713 858-530 - SCREW 858-530 CDH FIXED ANGLE 5.5 X 30 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-535 SUP HCPCS C1713 858-535 - SCREW 858-535 CDH FIXED ANGLE 5.5 X 35 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-540 SUP HCPCS C1713 858-540 - SCREW 858-540 CDH FIXED ANGLE 5.5 X 40 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-545 SUP HCPCS C1713 858-545 - SCREW 858-545 CDH FIXED ANGLE 5.5 X 45 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-550 SUP HCPCS C1713 858-550 - SCREW 858-550 CDH FIXED ANGLE 5.5 X 50 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-555 SUP HCPCS C1713 858-555 - SCREW BONE 5.5MM 55MM TI SPNL FIXANG BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-630 SUP HCPCS C1713 858-630 - SCREW 858-630 CDH FIXED ANGLE 6.5 X 30 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-635 SUP HCPCS C1713 858-635 - SCREW 858-635 CDH FIXED ANGLE 6.5 X 35 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-640 SUP HCPCS C1713 858-640 - SCREW 858-640 CDH FIXED ANGLE 6.5 X 40 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-645 SUP HCPCS C1713 858-645 - SCREW 858-645 CDH FIXED ANGLE 6.5 X 45 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-650 SUP HCPCS C1713 858-650 - SCREW 858-650 CDH FIXED ANGLE 6.5 X 50 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-655 SUP HCPCS C1713 858-655 - SCREW 858-655 CDH FIXED ANGLE 6.5 X 55 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-730 SUP HCPCS C1713 858-730 - SCREW 858-730 CDH FIXED ANGLE 7.5 X 30 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-735 SUP HCPCS C1713 858-735 - SCREW 858-735 CDH FIXED ANGLE 7.5 X 35 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-740 SUP HCPCS C1713 858-740 - SCREW 858-740 CDH FIXED ANGLE 7.5 X 40 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-745 SUP HCPCS C1713 858-745 - SCREW 858-745 CDH FIXED ANGLE 7.5 X 45 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-750 SUP HCPCS C1713 858-750 - SCREW 858-750 CDH FIXED ANGLE 7.5 X 50 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-755 SUP HCPCS C1713 858-755 - SCREW 858-755 CDH FIXED ANGLE 7.5 X 55 BOTH IP/OP "$1,659.00 " "$1,227.66" $0.00 "$1,327.20" $746.55 $746.55 $0.00 $0.00 $0.00 $345.78 "$1,231.31" "$1,231.31" $0.00 $0.00 $345.74 $0.00 $981.30 $981.30 $0.00 $829.50 "$1,313.93" "$1,327.20" $0.00 $0.00 $259.63 $0.00 $0.00 $264.11 $0.00 $0.00 $0.00 $0.00 $0.00 858-855 SUP HCPCS C1713 858-855 - SCREW SET 8.5MM 55MM HZNM8 BRK OFF SS SPNE 5.5MM ROD BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 859-002 SUP HCPCS C1713 859-002 - HOOK 859-002 5.5 SMALL PEDICLE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 85900P SUP HCPCS C1725 85900P - CATHETER ULTRASOUND 20MHZ STANDARD TAPER 5FR 20MM 150CM BOTH IP/OP "$1,812.50 " "$1,341.25" $0.00 "$1,450.00" $984.19 $984.19 $0.00 $0.00 $0.00 $377.77 "$1,345.24" "$1,345.24" $0.00 $0.00 $377.73 $0.00 "$1,072.09" "$1,072.09" $0.00 $906.25 "$1,435.50" "$1,450.00" $0.00 $0.00 $283.66 $0.00 $0.00 $288.55 $0.00 $0.00 $0.00 $0.00 $0.00 859-010 SUP HCPCS C1713 859-010 - HOOK 859-010 5.5 SMALL WIDE BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-012 SUP HCPCS C1713 859-012 - HOOK 859-012 SV WIDE BLADE SM GROOVE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-020 SUP HCPCS C1713 859-020 - HOOK 859-020 5.5 SM NARROW BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-024 SUP HCPCS C1713 859-024 - HOOK 859-024 5.5 SM ANGLED BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-030 SUP HCPCS C1713 859-030 - HOOK 859-030 5.5 SM EXTEND BODY TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-052 SUP HCPCS C1713 859-052 - HOOK 859-052 5.5 SM NRW BLD RAMPED TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-102 SUP HCPCS C1713 859-102 - HOOK 859-102 5.5 PEDICLE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-110 SUP HCPCS C1713 859-110 - HOOK 859-110 5.5 WIDE BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-112 SUP HCPCS C1713 859-112 - HOOK 859-112 5.5 WIDE BLADE SM GROOVE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-120 SUP HCPCS C1713 859-120 - HOOK 859-120 5.5 NARROW BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-122 SUP HCPCS C1713 859-122 - HOOK 859-122 NARROW BLADE SM GROOVE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-124 SUP HCPCS C1713 859-124 - HOOK 859-124 5.5 ANGLED BLADE TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-130 SUP HCPCS C1713 859-130 - HOOK 859-130 5.5 EXTENDED BOBY TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-140 SUP HCPCS C1713 859-140 - HOOK 859-140 5.5 RIGHT OFFSET TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-142 SUP HCPCS C1713 859-142 - HOOK 859-142 5.5 LEFT OFFSET TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-150 SUP HCPCS C1713 859-150 - HOOK 859-150 5.5 STNDRD BLADE RPD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-152 SUP HCPCS C1713 859-152 - HOOK 859-152 5.5 NARROW BLADE RPD TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-160 SUP HCPCS C1713 859-160 - HOOK 859-160 5.5 RIGHT ANGLED TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-162 SUP HCPCS C1713 859-162 - HOOK 859-162 5.5 LEFT ANGLED TI BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 859-425 SUP HCPCS C1713 859-425 - SCREW 859-425 CDH FIXED ANGLE 4.5 X25 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-430 SUP HCPCS C1713 859-430 - SCREW 859-430 CDH FIXED ANGLE 4.5 X30 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-435 SUP HCPCS C1713 859-435 - SCREW 859-435 CDH FIXED ANGLE 4.5 X35 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-440 SUP HCPCS C1713 859-440 - SCREW 859-440 CDH FIXED ANGLE 4.5 X40 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-445 SUP HCPCS C1713 859-445 - SCREW 859-445 CDH FIXED ANGLE 4.5 X45 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-450 SUP HCPCS C1713 859-450 - SCREW 859-450 CDH FIXED ANGLE 4.5 X50 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-525 SUP HCPCS C1713 859-525 - SCREW 859-525 5.5 FIXED ANGLE 5.5X25 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-530 SUP HCPCS C1713 859-530 - SCREW 859-530 5.5 FIXED ANGLE 5.5X30 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-535 SUP HCPCS C1713 859-535 - SCREW 859-535 5.5 FIXED ANGLE 5.5X35 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-540 SUP HCPCS C1713 859-540 - SCREW 859-540 5.5 FIXED ANGLE 5.5X40 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-545 SUP HCPCS C1713 859-545 - SCREW 859-545 5.5 FIXED ANGLE 5.5X45 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-550 SUP HCPCS C1713 859-550 - SCREW 859-550 5.5 FIXED ANGLE 5.5X50 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-555 SUP HCPCS C1713 859-555 - SCREW 859-555 5.5 FIXED ANGLE 5.5X55 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-630 SUP HCPCS C1713 859-630 - SCREW 859-630 5.5 FIXED ANGLE 6.5X30 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-635 SUP HCPCS C1713 859-635 - SCREW 859-635 5.5 FIXED ANGLE 6.5X35 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-640 SUP HCPCS C1713 859-640 - SCREW 859-640 5.5 FIXED ANGLE 6.5X40 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-645 SUP HCPCS C1713 859-645 - SCREW 859-645 5.5 FIXED ANGLE 6.5X45 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-650 SUP HCPCS C1713 859-650 - SCREW 859-650 5.5 FIXED ANGLE 6.5X50 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-655 SUP HCPCS C1713 859-655 - SCREW 859-655 5.5 FIXED ANGLE 6.5X55 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-730 SUP HCPCS C1713 859-730 - SCREW 859-730 5.5 FIXED ANGLE 7.5X30 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-735 SUP HCPCS C1713 859-735 - SCREW 859-735 5.5 FIXED ANGLE 7.5X35 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-740 SUP HCPCS C1713 859-740 - SCREW 859-740 5.5 FIXED ANGLE 7.5X40 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-745 SUP HCPCS C1713 859-745 - SCREW 859-745 5.5 FIXED ANGLE 7.5X45 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-750 SUP HCPCS C1713 859-750 - SCREW 859-750 5.5 FIXED ANGLE 7.5X50 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-755 SUP HCPCS C1713 859-755 - SCREW 859-755 5.5 FIXED ANGLE 7.5X55 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 859-760 SUP HCPCS C1713 859-760 - SCREW 859-760 5.5 FIXED ANGLE 7.5X60 TI BOTH IP/OP "$1,893.00 " "$1,400.82" $0.00 "$1,514.40" $851.85 $851.85 $0.00 $0.00 $0.00 $394.55 "$1,404.98" "$1,404.98" $0.00 $0.00 $394.50 $0.00 "$1,119.71" "$1,119.71" $0.00 $946.50 "$1,499.26" "$1,514.40" $0.00 $0.00 $296.25 $0.00 $0.00 $301.37 $0.00 $0.00 $0.00 $0.00 $0.00 86-100 SUP HCPCS C1713 86-100 - PLATE BN V NS LF TRITIUM STRNL DISP BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 86-200 SUP HCPCS C1713 86-200 - PLATE BN TRITIUM 8 HL 1 CBL STRNL BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 86-27-08 SUP HCPCS C1713 86-27-08 - SCREW BN 2.7MM 8MM NS TRITIUM STRNL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-27-10 SUP HCPCS C1713 86-27-10 - SCREW BN 2.7MM 10MM NS TRITIUM STRNL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-27-12 SUP HCPCS C1713 86-27-12 - SCREW BN 12MM NS LF TRITIUM STRNL CBL PLT SYS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-27-14 SUP HCPCS C1713 86-27-14 - SCREW BN 14MM NS LF TRITIUM STRNL CBL PLT SYS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-27-16 SUP HCPCS C1713 86-27-16 - SCREW BN 16MM NS TRITIUM STRNL CBL PLT SYS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-300 SUP HCPCS C1713 86-300 - PLATE BN NS TRITIUM 2 CBL STRNL BOTH IP/OP "$1,845.00 " "$1,365.30" $0.00 "$1,476.00" $830.25 $830.25 $0.00 $0.00 $0.00 $384.54 "$1,369.36" "$1,369.36" $0.00 $0.00 $384.50 $0.00 "$1,091.32" "$1,091.32" $0.00 $922.50 "$1,461.24" "$1,476.00" $0.00 $0.00 $288.74 $0.00 $0.00 $293.72 $0.00 $0.00 $0.00 $0.00 $0.00 86-30-08 SUP HCPCS C1713 86-30-08 - SCREW BN NS TRITIUM RSC STRNL CBL PLT SYS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-30-10 SUP HCPCS C1713 86-30-10 - SCREW BN 3MM 10MM NS LF RSC TRITIUM STRNL CBL PLT SYS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-30-12 SUP HCPCS C1713 86-30-12 - SCREW BN 3MM 12MM NS LF RSC TRITIUM STRNL CBL PLT SYS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-30-14 SUP HCPCS C1713 86-30-14 - SCREW BN 3MM 14MM NS LF RSC TRITIUM STRNL CBL PLT SYS BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-30-16 SUP HCPCS C1713 86-30-16 - SCREW BN NS TRITIUM RSC STRNL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 86-350-S SUP HCPCS C1713 86-350-S - DEVICE FX STRL LF TRITIUM 4 HL 2 CBL PLT SHRP NDL STRNL BOTH IP/OP "$1,882.50 " "$1,393.05" $0.00 "$1,506.00" $847.13 $847.13 $0.00 $0.00 $0.00 $392.36 "$1,397.19" "$1,397.19" $0.00 $0.00 $392.31 $0.00 "$1,113.50" "$1,113.50" $0.00 $941.25 "$1,490.94" "$1,506.00" $0.00 $0.00 $294.61 $0.00 $0.00 $299.69 $0.00 $0.00 $0.00 $0.00 $0.00 86-400 SUP HCPCS C1713 86-400 - PLATE BN TRITIUM 5 HL 1 CBL STRNL BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 86-500 SUP HCPCS C1713 86-500 - PLATE BN TRITIUM 4 HL 1 CBL STRNL BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 86-600 SUP HCPCS C1713 86-600 - PLATE BN NS TRITIUM CBL STRNL RB BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 86-700 SUP HCPCS C1713 86-700 - PLATE LADDER TRITIUM SCP 14 HL PRECONTOUR STRNM STRNL CBL BOTH IP/OP "$1,797.50 " "$1,330.15" $0.00 "$1,438.00" $808.88 $808.88 $0.00 $0.00 $0.00 $374.64 "$1,334.10" "$1,334.10" $0.00 $0.00 $374.60 $0.00 "$1,063.22" "$1,063.22" $0.00 $898.75 "$1,423.62" "$1,438.00" $0.00 $0.00 $281.31 $0.00 $0.00 $286.16 $0.00 $0.00 $0.00 $0.00 $0.00 868-011 SUP HCPCS C1713 868-011 - ROD 868-011 LEG 5.5 DIA HEX END SS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 868-021 SUP HCPCS C1713 868-021 - ROD 868-021 LEG 5.5 DIA LINED HEX END SS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 869-011 SUP HCPCS C1713 869-011 - ROD 869-011 LEG 5.5 DIA HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 869-012 SUP HCPCS C1713 869-012 - ROD 869-012 LEG 5.5 DIA HEX END TI BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 869-013 SUP HCPCS C1713 869-013 - ROD SPNL 50MM 5.5MM CD HZN LGC STD TI HEX END IV CP GRAD BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 869-014 SUP HCPCS C1713 869-014 - CP 2 ROD - 5.5MM DIA L=500MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 869-021 SUP HCPCS C1713 869-021 - SCREW BONE 5.5MM 210MM CD HZN LGC TI PDCL MULTIAX STRL 5.5MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 869-022 SUP HCPCS C1713 869-022 - ROD SPNL 50CM 5.5MM CD HZN LGC LNG TI IV HEX END LN CAP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8696G SUP Custom 27203010 8696G - SUTURE NABSB 7-0 P1 18IN BLU PRLN MFL BOTH IP/OP $16.63 $12.31 $0.00 $13.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.34 $12.34 $0.00 $0.00 $3.47 $0.00 $0.00 $0.00 $0.00 $8.32 $13.17 $13.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-000865-01 SUP Custom 27203010 8700-000865-01 - PACK SRG 6FT IVTM COOL LINE SRT UP DISP BOTH IP/OP "$6,725.10 " "$4,976.57" $0.00 "$5,380.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,401.51" $0.00 $0.00 $0.00 $0.00 "$3,362.55" "$5,326.28" "$5,380.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-000866-01 SUP Custom 27203010 8700-000866-01 - PACK SRG 6FT IVTM ICY SRT UP DISP BOTH IP/OP "$9,639.60 " "$7,133.30" $0.00 "$7,711.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,008.89" $0.00 $0.00 $0.00 $0.00 "$4,819.80" "$7,634.56" "$7,711.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-000867-01 SUP Custom 27203010 8700-000867-01 - PACK SRG 6FT IVTM QUATTRO SRT UP DISP BOTH IP/OP "$10,579.20 " "$7,828.61" $0.00 "$8,463.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,204.71" $0.00 $0.00 $0.00 $0.00 "$5,289.60" "$8,378.73" "$8,463.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-0654-01 SUP HCPCS C1751 8700-0654-01 - CATH CEN VEN 9.3FR 22CM 58MM ODS BOTH IP/OP "$1,226.70 " $907.76 $0.00 $981.36 $552.02 $552.02 $0.00 $0.00 $0.00 $255.67 $910.46 $910.46 $0.00 $0.00 $255.64 $0.00 $725.59 $725.59 $0.00 $613.35 $971.55 $981.36 $0.00 $0.00 $191.98 $0.00 $0.00 $195.29 $0.00 $0.00 $0.00 $0.00 $0.00 8700-0657-01 SUP HCPCS C1751 8700-0657-01 - CATHETER CEN VEN .032IN 9.3FR 38CM 75CM 3 INFUS LUMEN EXTN BOTH IP/OP "$1,955.33 " "$1,446.94" $0.00 "$1,564.26" $879.90 $879.90 $0.00 $0.00 $0.00 $407.54 "$1,451.24" "$1,451.24" $0.00 $0.00 $407.49 $0.00 "$1,156.57" "$1,156.57" $0.00 $977.66 "$1,548.62" "$1,564.26" $0.00 $0.00 $306.01 $0.00 $0.00 $311.29 $0.00 $0.00 $0.00 $0.00 $0.00 8700-0660-01 SUP HCPCS C1752 8700-0660-01 - KIT 45CM 9.3FR TRIP CATH QT BOTH IP/OP "$2,190.23 " "$1,620.77" $0.00 "$1,752.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,625.58" "$1,625.58" $0.00 $0.00 $456.44 $0.00 $0.00 $0.00 $0.00 "$1,095.11" "$1,734.66" "$1,752.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-0781-01 SUP Custom 27203010 8700-0781-01 - CATHETER CV 9.3FR 22CM STRL LF CL LN HEAT EXCH KT BOTH IP/OP "$1,287.60 " $952.82 $0.00 "$1,030.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.66 $955.66 $0.00 $0.00 $268.34 $0.00 $0.00 $0.00 $0.00 $643.80 "$1,019.78" "$1,030.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-0782-01 SUP Custom 27203010 8700-0782-01 - KIT CATH 9.3FR 38CM ICY CV BOTH IP/OP "$2,053.20 " "$1,519.37" $0.00 "$1,642.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,523.89" "$1,523.89" $0.00 $0.00 $427.89 $0.00 $0.00 $0.00 $0.00 "$1,026.60" "$1,626.13" "$1,642.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-0783-01 SUP Custom 27203010 8700-0783-01 - KIT CATH 9.3FR 45CM QUATTRO HEAT EXCH 3 LUM LL APPLAUSE HEP BOTH IP/OP "$2,298.98 " "$1,701.25" $0.00 "$1,839.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.30" "$1,706.30" $0.00 $0.00 $479.11 $0.00 $0.00 $0.00 $0.00 "$1,149.49" "$1,820.79" "$1,839.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-0784-01 SUP Custom 27203010 8700-0784-01 - KIT IV CLGRD 3K SRT BOTH IP/OP $454.58 $336.39 $0.00 $363.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.39 $337.39 $0.00 $0.00 $94.73 $0.00 $0.00 $0.00 $0.00 $227.29 $360.03 $363.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8700-0785-01 SUP Custom 27203010 8700-0785-01 - TUBING XTN 9FT BOTH IP/OP $511.13 $378.24 $0.00 $408.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.36 $379.36 $0.00 $0.00 $106.52 $0.00 $0.00 $0.00 $0.00 $255.56 $404.81 $408.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8709H SUP Custom 27203010 8709H - SUTURE NONABSORBABLE 6-0 BV-1 30IN 2 ARM MONOFILAMENT BOTH IP/OP $34.09 $25.23 $0.00 $27.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.30 $25.30 $0.00 $0.00 $7.10 $0.00 $0.00 $0.00 $0.00 $17.04 $27.00 $27.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 873-004 SUP HCPCS C1769 873-004 - GWIRE ORTH 24IN UCSS THRD INSTR BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 873-011 SUP HCPCS C1769 873-011 - GWIRE ORTH 24IN UCSS NTHRD INSTR DISP BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 873-030 SUP HCPCS C1713 873-030 - BONE SCREW 873-030 4.0 CANN CORT L 30MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-032 SUP HCPCS C1713 873-032 - BONE SCREW 873-032 4.0 CANN CORT L 32MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-034 SUP HCPCS C1713 873-034 - BONE SCREW 873-034 4.0 CANN CORT L 34MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-036 SUP HCPCS C1713 873-036 - BONE SCREW 873-036 4.0 CANN CORT L 36MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-038 SUP HCPCS C1713 873-038 - BONE SCREW 873-038 4.0 CANN CORT L 38MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-040 SUP HCPCS C1713 873-040 - SCREW BONE 4MM 40MM UCSS TI CORT CANN BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-042 SUP HCPCS C1713 873-042 - SCREW BONE 4MM 42MM UCSS TI CORT CANN BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-044 SUP HCPCS C1713 873-044 - BONE SCREW 873-044 4.0 CANN CORT L 44MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-046 SUP HCPCS C1713 873-046 - BONE SCREW 873-046 4.0 CANN CORT L 46MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-048 SUP HCPCS C1713 873-048 - BONE SCREW 873-048 4.0 CANN CORT L 48MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-050 SUP HCPCS C1713 873-050 - BONE SCREW 873-050 4.0 CANN CORT L 50MM BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-136 SUP HCPCS C1713 873-136 - SCREW BN P/T 4MM 36MM UCSS LG CNN TI SPNE CORT BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-138 SUP HCPCS C1713 873-138 - BONE SCREW 873-138 4.0 CAN CORT LAG L 38 BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-140 SUP HCPCS C1713 873-140 - BONE SCREW 873-140 4.0 CAN CORT LAG L 40 BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-142 SUP HCPCS C1713 873-142 - BONE SCREW 873-142 4.0 CAN CORT LAG L 42 BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-144 SUP HCPCS C1713 873-144 - BONE SCREW 873-144 4.0 CAN CORT LAG L 44 BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-146 SUP HCPCS C1713 873-146 - BONE SCREW 873-146 4.0 CAN CORT LAG L 46 BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-148 SUP HCPCS C1713 873-148 - BONE SCREW 873-148 4.0 CAN CORT LAG L 48 BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 873-150 SUP HCPCS C1713 873-150 - BONE SCREW 873-150 4.0 CAN CORT LAG L 50 BOTH IP/OP "$1,381.50 " "$1,022.31" $0.00 "$1,105.20" $621.68 $621.68 $0.00 $0.00 $0.00 $287.94 "$1,025.35" "$1,025.35" $0.00 $0.00 $287.90 $0.00 $817.16 $817.16 $0.00 $690.75 "$1,094.15" "$1,105.20" $0.00 $0.00 $216.20 $0.00 $0.00 $219.93 $0.00 $0.00 $0.00 $0.00 $0.00 8747H SUP Custom 27203010 8747H - SUTURE NONABSORBABLE 7-0 BV175-8 24IN 2 ARM MONOFILAMENT BOTH IP/OP $72.38 $53.56 $0.00 $57.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.72 $53.72 $0.00 $0.00 $15.08 $0.00 $0.00 $0.00 $0.00 $36.19 $57.32 $57.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 87525S SUP HCPCS C1713 87525S - SCREW BN STD 8.75MM 25MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$1,233.33 " $912.66 $0.00 $986.66 $555.00 $555.00 $0.00 $0.00 $0.00 $257.06 $915.37 $915.37 $0.00 $0.00 $257.02 $0.00 $729.51 $729.51 $0.00 $616.66 $976.80 $986.66 $0.00 $0.00 $193.02 $0.00 $0.00 $196.35 $0.00 $0.00 $0.00 $0.00 $0.00 87530S SUP HCPCS C1713 87530S - SCREW BN STD 8.75MM 30MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 87535S SUP HCPCS C1713 87535S - SCREW BN STD 8.75MM 35MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 87540S SUP HCPCS C1713 87540S - SCREW BN STD 8.75MM 40MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 87545S SUP HCPCS C1713 87545S - SCREW BN STD 8.75MM 45MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 87550S SUP HCPCS C1713 87550S - SCREW BN STD 8.75MM 50MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 87555S SUP HCPCS C1713 87555S - SCREW BN STD 8.75MM 55MM SPRL R90D LCK TI SPNE THORLMBR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 876-010 SUP HCPCS C1713 876-010 - SCREW 876-010 ATLANTIS CAN FAS 4.0X10MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-011 SUP HCPCS C1713 876-011 - SCREW 876-011 ATLANTIS CAN FAS 4.0X11MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-012 SUP HCPCS C1713 876-012 - SCREW BN 4MM 12MM GRY STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-013 SUP HCPCS C1713 876-013 - SCREW BN 4MM 13MM GRY STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-014 SUP HCPCS C1713 876-014 - SCREW BN 4MM 14MM GRY STRL ATLNTS FX ANG TI SPNE CANC CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-015 SUP HCPCS C1713 876-015 - SCREW BN 4MM 15MM GRY STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-016 SUP HCPCS C1713 876-016 - SCREW BN 4MM 16MM GRY STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-017 SUP HCPCS C1713 876-017 - SCREW BN 4MM 17MM GRY STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-018 SUP HCPCS C1713 876-018 - SCREW BN 4MM 18MM GRY STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-019 SUP HCPCS C1713 876-019 - SCREW 876-019 ATLANTIS CAN FAS 4.0X19MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-020 SUP HCPCS C1713 876-020 - SCREW 876-020 ATLANTIS CAN FAS 4.0X20MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-021 SUP HCPCS C1713 876-021 - SCREW 876-021 ATLANTIS CAN FAS 4.0X21MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-053 SUP HCPCS C1713 876-053 - SCREW BN 4.5MM 13MM BLU STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-055 SUP HCPCS C1713 876-055 - SCREW BN 4.5MM 15MM BLU STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-057 SUP HCPCS C1713 876-057 - SCREW BN 4.5MM 17MM BLU STRL ATLNTS FX ANG TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-119 SUP HCPCS C1713 876-119 - PLATE 876-119 19MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 876-121 SUP HCPCS C1713 876-121 - PLATE 876-121 21MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 876-123 SUP HCPCS C1713 876-123 - PLATE 876-123 23MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 876-125 SUP HCPCS C1713 876-125 - PLATE 876-125 25MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 876-127 SUP HCPCS C1713 876-127 - PLATE 876-127 27.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 876-130 SUP HCPCS C1713 876-130 - PLATE 876-130 30MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-132 SUP HCPCS C1713 876-132 - PLATE 876-132 32.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-135 SUP HCPCS C1713 876-135 - PLATE 876-135 35MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-137 SUP HCPCS C1713 876-137 - PLATE 876-137 37.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-140 SUP HCPCS C1713 876-140 - PLATE 876-140 40MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-142 SUP HCPCS C1713 876-142 - PLATE BN 42.5MM STRL ATLNTS LCK LOPRFL TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-145 SUP HCPCS C1713 876-145 - PLATE 876-145 45MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-147 SUP HCPCS C1713 876-147 - PLATE 876-147 47.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-150 SUP HCPCS C1713 876-150 - PLATE 876-150 50MM ANTERIOR CERVICAL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 876-152 SUP HCPCS C1713 876-152 - PLATE 876-152 52.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 876-155 SUP HCPCS C1713 876-155 - PLATE 876-155 55MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 876-157 SUP HCPCS C1713 876-157 - PLATE 876-157 57.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 876-160 SUP HCPCS C1713 876-160 - PLATE 876-160 60MM ANTERIOR CERVICAL BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 876-162 SUP HCPCS C1713 876-162 - PLATE 876-162 62.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-165 SUP HCPCS C1713 876-165 - PLATE 876-165 65MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-167 SUP HCPCS C1713 876-167 - PLATE 876-167 67.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-170 SUP HCPCS C1713 876-170 - PLATE 876-170 70MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-172 SUP HCPCS C1713 876-172 - PLATE 876-172 72.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-175 SUP HCPCS C1713 876-175 - PLATE 876-175 75MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-177 SUP HCPCS C1713 876-177 - PLATE 876-177 77.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-180 SUP HCPCS C1713 876-180 - PLATE 876-180 80MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-182 SUP HCPCS C1713 876-182 - PLATE 876-182 82.5MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-185 SUP HCPCS C1713 876-185 - PLATE 876-185 85MM ANTERIOR CERVICAL BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 876-187 SUP HCPCS C1713 876-187 - PLATE 876-187 87.5MM ANTERIOR CERVICAL BOTH IP/OP "$4,135.50 " "$3,060.27" $0.00 "$3,308.40" "$1,860.98" "$1,860.98" $0.00 $0.00 $0.00 $861.94 "$3,069.37" "$3,069.37" $0.00 $0.00 $861.84 $0.00 "$2,038.80" "$2,038.80" $0.00 "$2,067.75" "$3,275.32" "$3,308.40" $0.00 $0.00 $647.21 $0.00 $0.00 $658.37 $0.00 $0.00 $0.00 $0.00 $0.00 876-190 SUP HCPCS C1713 876-190 - PLATE 876-190 90MM ANTERIOR CERVICAL BOTH IP/OP "$4,135.50 " "$3,060.27" $0.00 "$3,308.40" "$1,860.98" "$1,860.98" $0.00 $0.00 $0.00 $861.94 "$3,069.37" "$3,069.37" $0.00 $0.00 $861.84 $0.00 "$2,038.80" "$2,038.80" $0.00 "$2,067.75" "$3,275.32" "$3,308.40" $0.00 $0.00 $647.21 $0.00 $0.00 $658.37 $0.00 $0.00 $0.00 $0.00 $0.00 876-195 SUP HCPCS C1713 876-195 - PLATE 876-195 95MM ANTERIOR CERVICAL BOTH IP/OP "$4,135.50 " "$3,060.27" $0.00 "$3,308.40" "$1,860.98" "$1,860.98" $0.00 $0.00 $0.00 $861.94 "$3,069.37" "$3,069.37" $0.00 $0.00 $861.84 $0.00 "$2,038.80" "$2,038.80" $0.00 "$2,067.75" "$3,275.32" "$3,308.40" $0.00 $0.00 $647.21 $0.00 $0.00 $658.37 $0.00 $0.00 $0.00 $0.00 $0.00 876-200 SUP HCPCS C1713 876-200 - PLATE 876-200 100MM ANTERIOR CERVICAL BOTH IP/OP "$4,135.50 " "$3,060.27" $0.00 "$3,308.40" "$1,860.98" "$1,860.98" $0.00 $0.00 $0.00 $861.94 "$3,069.37" "$3,069.37" $0.00 $0.00 $861.84 $0.00 "$2,038.80" "$2,038.80" $0.00 "$2,067.75" "$3,275.32" "$3,308.40" $0.00 $0.00 $647.21 $0.00 $0.00 $658.37 $0.00 $0.00 $0.00 $0.00 $0.00 876-205 SUP HCPCS C1713 876-205 - PLATE 876-205 105MM ANTERIOR CERVICAL BOTH IP/OP "$4,135.50 " "$3,060.27" $0.00 "$3,308.40" "$1,860.98" "$1,860.98" $0.00 $0.00 $0.00 $861.94 "$3,069.37" "$3,069.37" $0.00 $0.00 $861.84 $0.00 "$2,038.80" "$2,038.80" $0.00 "$2,067.75" "$3,275.32" "$3,308.40" $0.00 $0.00 $647.21 $0.00 $0.00 $658.37 $0.00 $0.00 $0.00 $0.00 $0.00 876-210 SUP HCPCS C1713 876-210 - PLATE 876-210 110MM ANTERIOR CERVICAL BOTH IP/OP "$4,135.50 " "$3,060.27" $0.00 "$3,308.40" "$1,860.98" "$1,860.98" $0.00 $0.00 $0.00 $861.94 "$3,069.37" "$3,069.37" $0.00 $0.00 $861.84 $0.00 "$2,038.80" "$2,038.80" $0.00 "$2,067.75" "$3,275.32" "$3,308.40" $0.00 $0.00 $647.21 $0.00 $0.00 $658.37 $0.00 $0.00 $0.00 $0.00 $0.00 8762H SUP Custom 27203010 8762H - SUTURE NABSB 3-0 SH-1 30IN BLU PRLN 2 ARM MFL BOTH IP/OP $554.42 $410.27 $0.00 $443.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.49 $411.49 $0.00 $0.00 $115.54 $0.00 $0.00 $0.00 $0.00 $277.21 $439.10 $443.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 876-310 SUP HCPCS C1713 876-310 - SCREW 876-310 VAS CANCELLOUS 4.0X10MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-311 SUP HCPCS C1713 876-311 - SCREW 876-311 VAS CANCELLOUS 4.0X11MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-312 SUP HCPCS C1713 876-312 - SCREW BN 4MM 12MM GRN STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-313 SUP HCPCS C1713 876-313 - SCREW BN 4MM 13MM GRN STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-314 SUP HCPCS C1713 876-314 - SCREW BN 4MM 14MM GRN STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-315 SUP HCPCS C1713 876-315 - SCREW BN 4MM 15MM GRN STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-316 SUP HCPCS C1713 876-316 - SCREW BN 4MM 16MM GRN STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-317 SUP HCPCS C1713 876-317 - SCREW BN 4MM 17MM GRN STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-318 SUP HCPCS C1713 876-318 - SCREW BN 4MM 18MM GRN STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-319 SUP HCPCS C1713 876-319 - SCREW 876-319 VAS CANCELLOUS 4.0X19MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-320 SUP HCPCS C1713 876-320 - SCREW 876-320 VAS CANCELLOUS 4.0X20MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-321 SUP HCPCS C1713 876-321 - SCREW 876-321 VAS CANCELLOUS 4.0X21MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-353 SUP HCPCS C1713 876-353 - SCREW BN 4.5MM 13MM MAG STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-355 SUP HCPCS C1713 876-355 - SCREW BN 4.5MM 15MM MAG STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-357 SUP HCPCS C1713 876-357 - SCREW BN 4.5MM 17MM MAG STRL ATLNTS VA TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-404 SUP HCPCS C1713 876-404 - PIN HLD ATLNTS ANT CERV SPN PLT INSTR TI STRL BOTH IP/OP $219.00 $162.06 $0.00 $175.20 $98.55 $98.55 $0.00 $0.00 $0.00 $45.65 $162.54 $162.54 $0.00 $0.00 $45.64 $0.00 $129.54 $129.54 $0.00 $109.50 $173.45 $175.20 $0.00 $0.00 $34.27 $0.00 $0.00 $34.86 $0.00 $0.00 $0.00 $0.00 $0.00 876-443 SUP Custom 27203010 876-443 - BIT DRILL 13MM ATLNTS SPNL 3 FLAT STRL DISP BOTH IP/OP $760.00 $562.40 $0.00 $608.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $564.07 $564.07 $0.00 $0.00 $158.38 $0.00 $0.00 $0.00 $0.00 $380.00 $601.92 $608.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 876-455 SUP Custom 27203010 876-455 - BIT DRILL 5MM ATLNTS 3 FLAT ADJ STRL DISP BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $0.00 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 876-612 SUP HCPCS C1713 876-612 - SCREW BN 4MM 12MM STRL ATLNTS VA SLF DRL TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-613 SUP HCPCS C1713 876-613 - SCREW BN 4MM 13MM GRN STRL ATLNTS VA SLF DRL TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-614 SUP HCPCS C1713 876-614 - SCREW BN 4MM 14MM STRL ATLNTS VA SLF DRL NTNL SPNL CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-615 SUP HCPCS C1713 876-615 - SCREW BN 4MM 15MM GRN STRL ATLNTS VA SLF DRL TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-643 SUP HCPCS C1713 876-643 - SCREW BN 4.5MM 13MM MAG STRL ATLNTS VA SLF DRL TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-644 SUP HCPCS C1713 876-644 - SCREW BN 4.5MM 14MM STRL ATLNTS VA SLF DRL NTNL SPNL CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-645 SUP HCPCS C1713 876-645 - SCREW BN 4.5MM 15MM MAG STRL ATLNTS VA SLF DRL TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-710 SUP HCPCS C1713 876-710 - SCREW 876-710 FA SELF TAPPING 4.0X10MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-711 SUP HCPCS C1713 876-711 - SCREW 876-711 FA SELF TAPPING 4.0X11MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-712 SUP HCPCS C1713 876-712 - SCREW BN 4MM 12MM GRY STRL ATLNTS FX ANG ST TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-713 SUP HCPCS C1713 876-713 - SCREW BN 4MM 13MM GRY STRL ATLNTS FX ANG ST TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-714 SUP HCPCS C1713 876-714 - SCREW BONE 4MM 14MM ATLNTS TI CANC ANT CERV SPN FAVORED ANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-715 SUP HCPCS C1713 876-715 - SCREW BN 4MM 15MM GRY STRL ATLNTS FX ANG ST TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-716 SUP HCPCS C1713 876-716 - SCREW BONE 4MM 16MM ATLNTS TI CANC ANT CERV SPNE SLFTAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-717 SUP HCPCS C1713 876-717 - SCREW BONE 4MM 17MM ATLNTS TI CANC ANT CERV SPNE SLFTAP FIX BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-718 SUP HCPCS C1713 876-718 - SCREW BN 4MM 18MM GRY STRL ATLNTS FX ANG ST TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-753 SUP HCPCS C1713 876-753 - SCREW BN 4.5MM 13MM BLU STRL ATLNTS FX ANG ST TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-755 SUP HCPCS C1713 876-755 - SCREW BN 4.5MM 15MM BLU STRL ATLNTS FX ANG ST TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-757 SUP HCPCS C1713 876-757 - SCREW BONE 4.5MM 17MM ATLNTS TI CANC ANT CERV SPNE SLFTAP BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-810 SUP HCPCS C1713 876-810 - SCREW 876-810 VA SELF TAPPING 4.0X10MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-811 SUP HCPCS C1713 876-811 - SCREW 876-811 VA SELF TAPPING 4.0X11MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-812 SUP HCPCS C1713 876-812 - SCREW BN 4MM 12MM GRN STRL ATLNTS VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-813 SUP HCPCS C1713 876-813 - SCREW BN 4MM 13MM GRN STRL ATLNTS VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-814 SUP HCPCS C1713 876-814 - SCREW BONE 4MM 14MM ATLNTS TI SPNL CANC VAR ANG SLFTAP STRL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-815 SUP HCPCS C1713 876-815 - SCREW BN 4MM 15MM GRN STRL ATLNTS VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-816 SUP HCPCS C1713 876-816 - SCREW BONE 4MM 16MM ATLNTS TI SPNL CANC VAR ANG SLFTAP STRL BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-817 SUP HCPCS C1713 876-817 - SCREW BONE 4MM 17MM ATLNTS TI CANC ANT CERV SPNE SLFTAP VA BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-818 SUP HCPCS C1713 876-818 - SCREW BN 4MM 18MM GRN STRL ATLNTS VA ST TI SPNE CRV CANC ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-853 SUP HCPCS C1713 876-853 - SCREW BONE 4.5MM 13MM ATLNTS TI ANT CERV SPN SLFTAP VAR ANG BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-855 SUP HCPCS C1713 876-855 - SCREW BN 4.5MM 15MM MAG STRL ATLNTS VA ST TI SPNE CRV CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-857 SUP HCPCS C1713 876-857 - SCREW BONE 4.5MM 17MM ATLNTS TI CANC ANT CERV SPNE SLFTAP VA BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 876-943 SUP Custom 27203010 876-943 - INSTRUMENT 876-943 ATL NONSTRL 3M DRLBIT BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $0.00 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 876-955 SUP Custom 27203010 876-955 - INSTRUMENT 876-955 ATL NONSTRL ADJ DRLBT BOTH IP/OP $501.00 $370.74 $0.00 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.84 $371.84 $0.00 $0.00 $104.41 $0.00 $0.00 $0.00 $0.00 $250.50 $396.79 $400.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8800500A SUP HCPCS C1713 8800500A - SCREW BN 10.5MM 100MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800510A SUP HCPCS C1713 8800510A - SCREW BN 10.5MM 110MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800520A SUP HCPCS C1713 8800520A - SCREW BN 10.5MM 120MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800525A SUP HCPCS C1713 8800525A - SCREW BN 10.5MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800530A SUP HCPCS C1713 8800530A - SCREW BN 10.5MM 30MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800535A SUP HCPCS C1713 8800535A - SCREW BN 10.5MM 35MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800540A SUP HCPCS C1713 8800540A - SCREW BN 10.5MM 40MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800545A SUP HCPCS C1713 8800545A - SCREW BN 10.5MM 45MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800550A SUP HCPCS C1713 8800550A - SCREW BN 10.5MM 50MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800555A SUP HCPCS C1713 8800555A - SCREW BN 10.5MM 55MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800560A SUP HCPCS C1713 8800560A - SCREW BN 10.5MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800570A SUP HCPCS C1713 8800570A - SCREW BN 10.5MM 70MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800580A SUP HCPCS C1713 8800580A - SCREW BN 10.5MM 80MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8800590A SUP HCPCS C1713 8800590A - SCREW BN 10.5MM 90MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804525A SUP HCPCS C1713 8804525A - SCREW BN 4.5MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804530A SUP HCPCS C1713 8804530A - SCREW BN 4.5MM 30MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804535A SUP HCPCS C1713 8804535A - SCREW BN 4.5MM 35MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804540A SUP HCPCS C1713 8804540A - SCREW BN 4.5MM 40MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804545A SUP HCPCS C1713 8804545A - SCREW BN 4.5MM 45MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804550A SUP HCPCS C1713 8804550A - SCREW BN 4.5MM 50MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804555A SUP HCPCS C1713 8804555A - SCREW BN 4.5MM 55MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8804560A SUP HCPCS C1713 8804560A - SCREW BN 4.5MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805025A SUP HCPCS C1713 8805025A - SCREW BN 5MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805030A SUP HCPCS C1713 8805030A - SCREW BN 5MM 30MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805035A SUP HCPCS C1713 8805035A - SCREW BN 5MM 35MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805040A SUP HCPCS C1713 8805040A - SCREW BN 5MM 40MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805045A SUP HCPCS C1713 8805045A - SCREW BN 5MM 45MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805050A SUP HCPCS C1713 8805050A - SCREW BN 5MM 50MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805055A SUP HCPCS C1713 8805055A - SCREW BN 5MM 55MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805060A SUP HCPCS C1713 8805060A - SCREW BN 5MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805525A SUP HCPCS C1713 8805525A - SCREW BN 5.5MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805530A SUP HCPCS C1713 8805530A - SCREW BN 5.5MM 30MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805535A SUP HCPCS C1713 8805535A - SCREW BN 5.5MM 35MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805540A SUP HCPCS C1713 8805540A - SCREW BONE 40MM POLYAX PRECEPT 5.5MM SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805545A SUP HCPCS C1713 8805545A - SCREW BONE 45MM POLYAX PRECEPT 5.5MM SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805550A SUP HCPCS C1713 8805550A - SCREW BONE 50MM POLYAX PRECEPT 5.5MM SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805555A SUP HCPCS C1713 8805555A - SCREW BN 5.5MM 55MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8805560A SUP HCPCS C1713 8805560A - SCREW BN 5.5MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806025A SUP HCPCS C1713 8806025A - SCREW BN 6MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806030A SUP HCPCS C1713 8806030A - SCREW BN 6MM 30MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806035A SUP HCPCS C1713 8806035A - SCREW BN 6MM 35MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806040A SUP HCPCS C1713 8806040A - SCREW BN 6MM 40MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806045A SUP HCPCS C1713 8806045A - SCREW BN 6MM 45MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806050A SUP HCPCS C1713 8806050A - SCREW BN 6MM 50MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806055A SUP HCPCS C1713 8806055A - SCREW BN 6MM 55MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806060A SUP HCPCS C1713 8806060A - SCREW BN 6MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806500A SUP HCPCS C1713 8806500A - SCREW BN 6.5MM 100MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806510A SUP HCPCS C1713 8806510A - SCREW BN 6.5MM 110MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806520A SUP HCPCS C1713 8806520A - SCREW BN 6.5MM 120MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806525A SUP HCPCS C1713 8806525A - SCREW BN 6.5MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806530A SUP HCPCS C1713 8806530A - SCREW BN 6.5MM 30MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806535A SUP HCPCS C1713 8806535A - SCREW BN 6.5MM 35MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806540A SUP HCPCS C1713 8806540A - SCREW BN 6.5MM 40MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806545A SUP HCPCS C1713 8806545A - SCREW BONE 6.5MM 45MM POLYAX PRECEPT SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806550A SUP HCPCS C1713 8806550A - SCREW BONE 50MM 6.5MM SPN MAS BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806555A SUP HCPCS C1713 8806555A - SCREW BN 6.5MM 55MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806560A SUP HCPCS C1713 8806560A - SCREW BN 6.5MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806570A SUP HCPCS C1713 8806570A - SCREW BN 6.5MM 70MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806580A SUP HCPCS C1713 8806580A - SCREW BN 6.5MM 80MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8806590A SUP HCPCS C1713 8806590A - SCREW BN 6.5MM 90MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807000A SUP HCPCS C1713 8807000A - SCREW BN 7MM 100MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807010A SUP HCPCS C1713 8807010A - SCREW BN 7MM 110MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807020A SUP HCPCS C1713 8807020A - SCREW BN 7MM 120MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807025A SUP HCPCS C1713 8807025A - SCREW BN 7MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807030A SUP HCPCS C1713 8807030A - SCREW BN 7MM 30MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807035A SUP HCPCS C1713 8807035A - SCREW BN 7MM 35MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807040A SUP HCPCS C1713 8807040A - SCREW BN 7MM 40MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807045A SUP HCPCS C1713 8807045A - SCREW BN 7MM 45MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807050A SUP HCPCS C1713 8807050A - SCREW BN 7MM 50MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807060A SUP HCPCS C1713 8807060A - SCREW BN 7MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807070A SUP HCPCS C1713 8807070A - SCREW BN 7MM 70MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807080A SUP HCPCS C1713 8807080A - SCREW BN 7MM 80MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807090A SUP HCPCS C1713 8807090A - SCREW BN 7MM 90MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807500A SUP HCPCS C1713 8807500A - SCREW BN 7.5MM 100MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807510A SUP HCPCS C1713 8807510A - SCREW BN 7.5MM 110MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807520A SUP HCPCS C1713 8807520A - SCREW BN 7.5MM 120MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807525A SUP HCPCS C1713 8807525A - SCREW BN 7.5MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807530A SUP HCPCS C1713 8807530A - SCREW BN 7.5MM 30MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807535A SUP HCPCS C1713 8807535A - SCREW BN 7.5MM 35MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807540A SUP HCPCS C1713 8807540A - SCREW BN 7.5MM 40MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807545A SUP HCPCS C1713 8807545A - SCREW BN 7.5MM 45MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807550A SUP HCPCS C1713 8807550A - SCREW BN 7.5MM 50MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807555A SUP HCPCS C1713 8807555A - SCREW BN 7.5MM 55MM NS PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807560A SUP HCPCS C1713 8807560A - SCREW BN 7.5MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807570A SUP HCPCS C1713 8807570A - SCREW BN 7.5MM 70MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807580A SUP HCPCS C1713 8807580A - SCREW BN 7.5MM 80MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8807590A SUP HCPCS C1713 8807590A - SCREW BN 7.5MM 90MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808500A SUP HCPCS C1713 8808500A - SCREW BN 8.5MM 100MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808510A SUP HCPCS C1713 8808510A - SCREW BN 8.5MM 110MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808520A SUP HCPCS C1713 8808520A - SCREW BN 8.5MM 120MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808525A SUP HCPCS C1713 8808525A - SCREW BN 8.5MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808530A SUP HCPCS C1713 8808530A - SCREW BN 8.5MM 30MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808535A SUP HCPCS C1713 8808535A - SCREW BN 8.5MM 35MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808540A SUP HCPCS C1713 8808540A - SCREW BN 8.5MM 40MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808545A SUP HCPCS C1713 8808545A - SCREW BN 8.5MM 45MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808550A SUP HCPCS C1713 8808550A - SCREW BN 8.5MM 50MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808555A SUP HCPCS C1713 8808555A - SCREW BN 8.5MM 55MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808560A SUP HCPCS C1713 8808560A - SCREW BN 8.5MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808570A SUP HCPCS C1713 8808570A - SCREW BN 8.5MM 70MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808580A SUP HCPCS C1713 8808580A - SCREW BN 8.5MM 80MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8808590A SUP HCPCS C1713 8808590A - SCREW BN 8.5MM 90MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809500A SUP HCPCS C1713 8809500A - SCREW BN 9.5MM 100MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809510A SUP HCPCS C1713 8809510A - SCREW BN 9.5MM 110MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809520A SUP HCPCS C1713 8809520A - SCREW BN 9.5MM 120MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809525A SUP HCPCS C1713 8809525A - SCREW BN 9.5MM 25MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809530A SUP HCPCS C1713 8809530A - SCREW BN 9.5MM 30MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809535A SUP HCPCS C1713 8809535A - SCREW BN 9.5MM 35MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809540A SUP HCPCS C1713 8809540A - SCREW BN 9.5MM 40MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809545A SUP HCPCS C1713 8809545A - SCREW BN 9.5MM 45MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809550A SUP HCPCS C1713 8809550A - SCREW BN 9.5MM 50MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809555A SUP HCPCS C1713 8809555A - SCREW BN 9.5MM 55MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809560A SUP HCPCS C1713 8809560A - SCREW BN 9.5MM 60MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809570A SUP HCPCS C1713 8809570A - SCREW BN 9.5MM 70MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809580A SUP HCPCS C1713 8809580A - SCREW BN 9.5MM 80MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8809590A SUP HCPCS C1713 8809590A - SCREW BN 9.5MM 90MM PRCPT PA SPNE BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 8829-01 SUP Custom 27203010 8829-01 - PADDING CAST 36X21X.25IN ORTHOPEDIC LATEX FREE WHITE FELT BOTH IP/OP $17.45 $12.91 $0.00 $14.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.95 $12.95 $0.00 $0.00 $3.64 $0.00 $0.00 $0.00 $0.00 $8.86 $14.03 $14.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 88-571042 SUP HCPCS C1725 88-571042 - CATH DRAIN 28FR 20IN ARG 6 EYLT RIGHT ANG THRMSNS DEPTH MARK BOTH IP/OP $182.39 $134.97 $0.00 $145.91 $99.04 $99.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.20 $144.45 $145.91 $0.00 $0.00 $28.54 $0.00 $0.00 $29.04 $0.00 $0.00 $0.00 $0.00 $0.00 8872H SUP Custom 27203010 8872H - SUTURE NONABSORBABLE 3-0 RB-1 30IN MONOFILAMENT PROLENE BLUE BOTH IP/OP $337.65 $249.86 $0.00 $274.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.60 $250.60 $0.00 $0.00 $70.37 $0.00 $0.00 $0.00 $0.00 $171.36 $271.43 $274.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8888146044P SUP HCPCS C1750 8888146044P - KIT CATHETER 61CM 44CM SYMMETRICAL TIP PALINDROME PRECISION BOTH IP/OP $500.00 $370.00 $0.00 "$1,144.77" $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 "$1,144.77" $400.00 $0.00 $0.00 $226.21 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 8900-2065 SUP Custom 27203010 ELECTRODE DFBR PED MULFUNC PAD PDPDZ BOTH IP/OP $75.75 $56.06 $0.00 $60.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.88 $59.99 $60.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8900-4003 SUP Custom 27203010 8900-4003 - ELECTRODE DEFIBRILLATOR RECTANGULAR 24IN MULTIFUNCTION CLOSE BOTH IP/OP $72.85 $53.91 $0.00 $58.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.07 $54.07 $0.00 $0.00 $15.18 $0.00 $0.00 $0.00 $0.00 $36.42 $57.70 $58.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-120 SUP Custom 27803010 890-120 - CAGE SPNL 20MMX12MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-125 SUP Custom 27803010 890-125 - CAGE SPNL 25MMX12MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-140 SUP Custom 27803010 890-140 - CAGE SPNL 20MMX14MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-143 SUP Custom 27803010 890-143 - CAGE SPNL 23MMX14MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-146 SUP Custom 27803010 890-146 - CAGE SPNL 26MMX14MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-149 SUP Custom 27803010 890-149 - CAGE SPNL 29MMX14MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-160 SUP Custom 27803010 890-160 - CAGE SPNL 20MMX16MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-163 SUP Custom 27803010 890-163 - CAGE SPNL 23MMX16MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-166 SUP Custom 27803010 890-166 - CAGE SPNL 26MMX16MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-169 SUP Custom 27803010 890-169 - CAGE SPNL 29MMX16MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-180 SUP Custom 27803010 890-180 - CAGE SPNL 20MMX18MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-183 SUP Custom 27803010 890-183 - CAGE SPNL 23MMX18MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-186 SUP Custom 27803010 890-186 - CAGE SPNL 26MMX18MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-189 SUP Custom 27803010 890-189 - CAGE SPNL 29MMX18MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-200 SUP Custom 27803010 890-200 - CAGE SPNL 20MMX20MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-203 SUP Custom 27803010 890-203 - CAGE SPNL 23MMX20MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-206 SUP Custom 27803010 890-206 - CAGE SPNL 26MMX20MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-209 SUP Custom 27803010 890-209 - CAGE SPNL 29MMX20MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-220 SUP Custom 27803010 890-220 - CAGE SPNL 20MMX22MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-223 SUP Custom 27803010 890-223 - CAGE SPNL 23MMX22MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-226 SUP Custom 27803010 890-226 - CAGE SPNL 26MMX22MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-229 SUP Custom 27803010 890-229 - CAGE SPNL 29MMX22MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-240 SUP Custom 27803010 890-240 - CAGE SPNL 24MMX20MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-243 SUP Custom 27803010 890-243 - CAGE SPNL 24MMX23MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-244 SUP HCPCS C1713 890-244 - BONE 890-244 PRESS PLUG 12MM BOTH IP/OP $541.50 $400.71 $0.00 $433.20 $243.68 $243.68 $0.00 $0.00 $0.00 $112.86 $401.90 $401.90 $0.00 $0.00 $112.85 $0.00 $320.30 $320.30 $0.00 $270.75 $428.87 $433.20 $0.00 $0.00 $84.74 $0.00 $0.00 $86.21 $0.00 $0.00 $0.00 $0.00 $0.00 890-246 SUP Custom 27803010 890-246 - CAGE SPNL 26MMX24MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-249 SUP Custom 27803010 890-249 - CAGE SPNL 29MMX24MM LF INTRFX L-CG THRD CNCT TI LMBR INTRBD BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 890-444 SUP HCPCS C1713 890-444 - BONE 890-444 PRESS PLUG 14MM BOTH IP/OP $541.50 $400.71 $0.00 $433.20 $243.68 $243.68 $0.00 $0.00 $0.00 $112.86 $401.90 $401.90 $0.00 $0.00 $112.85 $0.00 $320.30 $320.30 $0.00 $270.75 $428.87 $433.20 $0.00 $0.00 $84.74 $0.00 $0.00 $86.21 $0.00 $0.00 $0.00 $0.00 $0.00 890-999 SUP HCPCS C1713 890-999 - SCREW 890-999 LATERAL EXT. REPLACEMENT BOTH IP/OP $42.00 $31.08 $0.00 $33.60 $18.90 $18.90 $0.00 $0.00 $0.00 $8.75 $31.17 $31.17 $0.00 $0.00 $8.75 $0.00 $24.84 $24.84 $0.00 $21.00 $33.26 $33.60 $0.00 $0.00 $6.57 $0.00 $0.00 $6.69 $0.00 $0.00 $0.00 $0.00 $0.00 89104EH SUP HCPCS C1713 89104EH - SCREW 89104EH BREAK OFF SET T25 BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 89104EHT SUP HCPCS C1713 89104EHT - SET SCR CD HZN M10 BRKOF TI SPNE PDCL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 89-2505 SUP Custom 27203010 89-2505 - KIT SRG OB EMS BOTH IP/OP $19.18 $14.19 $0.00 $15.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.23 $14.23 $0.00 $0.00 $4.00 $0.00 $0.00 $0.00 $0.00 $9.59 $15.19 $15.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941420P SUP Custom 27803010 8941420P - CAGE SPNL 14MM 20X17MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,865.00 " "$5,820.10" $0.00 "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,639.07" $0.00 $0.00 $0.00 $0.00 "$3,932.50" "$6,229.08" "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941423P SUP Custom 27803010 8941423P - CAGE SPNL 14MM 23X17.5MM LTCG PEEK-OPTM LMBR TPR FSN DEV BOTH IP/OP "$7,865.00 " "$5,820.10" $0.00 "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,639.07" $0.00 $0.00 $0.00 $0.00 "$3,932.50" "$6,229.08" "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941620P SUP Custom 27803010 8941620P - CAGE SPNL 16MM 20X19MM LTCG PEEK-OPTM LMBR TPR FSN DEV BOTH IP/OP "$7,865.00 " "$5,820.10" $0.00 "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,639.07" $0.00 $0.00 $0.00 $0.00 "$3,932.50" "$6,229.08" "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941623P SUP Custom 27803010 8941623P - CAGE SPNL 16MM 23X19MM LTCG TI LMBR TPR FSN DEV BOTH IP/OP "$7,865.00 " "$5,820.10" $0.00 "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,639.07" $0.00 $0.00 $0.00 $0.00 "$3,932.50" "$6,229.08" "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941626P SUP Custom 27803010 8941626P - CAGE SPNL 16MM 26X20MM LTCG PEEK-OPTM LMBR TPR FSN DEV BOTH IP/OP "$7,865.00 " "$5,820.10" $0.00 "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,639.07" $0.00 $0.00 $0.00 $0.00 "$3,932.50" "$6,229.08" "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941823P SUP Custom 27803010 8941823P - CAGE SPNL 18MM 23X21.5MM LTCG PEEK-OPTM LMBR TPR FSN DEV BOTH IP/OP "$7,865.00 " "$5,820.10" $0.00 "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,639.07" $0.00 $0.00 $0.00 $0.00 "$3,932.50" "$6,229.08" "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8941826P SUP Custom 27803010 8941826P - CAGE SPNL 18MM 26X22MM LTCG PEEK-OPTM LMBR TPR FSN DEV BOTH IP/OP "$7,865.00 " "$5,820.10" $0.00 "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,639.07" $0.00 $0.00 $0.00 $0.00 "$3,932.50" "$6,229.08" "$6,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 89690E SUP Custom 27203010 89690E - INSTRUMENT 89690E IMP HLDR CURVD REDUCD BOTH IP/OP "$2,295.00 " "$1,698.30" $0.00 "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,703.35" "$1,703.35" $0.00 $0.00 $478.28 $0.00 $0.00 $0.00 $0.00 "$1,147.50" "$1,817.64" "$1,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8AC50 SUP Custom 27203010 8AC50 - TOOL LEGEND 8CM 5MM AC BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8AC60 SUP Custom 27203010 8AC60 - TOOL LEGEND 8CM 6MM AC BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8DCFN SUP Custom 27203010 8DCFN - TUBE TRCH 8 12.2MM 7.6MM 79MM STRL LF SHLY CUFLS DISP INR BOTH IP/OP $83.74 $61.97 $0.00 $66.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.15 $62.15 $0.00 $0.00 $17.45 $0.00 $0.00 $0.00 $0.00 $41.87 $66.32 $66.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8DCFS SUP Custom 27203010 8DCFS - TUBE TRCH 8 12.2MM 7.6MM 79MM STRL LF SHLY CUFLS DISP INR BOTH IP/OP $88.58 $65.55 $0.00 $71.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.74 $65.74 $0.00 $0.00 $18.46 $0.00 $0.00 $0.00 $0.00 $44.95 $71.20 $71.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8DCT SUP Custom 27203010 8DCT - TUBE TRCH 8 12.2MM 7.6MM 79MM STRL LF SHLY CUF DISP INR CNN BOTH IP/OP $117.10 $86.65 $0.00 $76.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.53 $69.53 $0.00 $0.00 $19.52 $0.00 $0.00 $0.00 $0.00 $47.54 $75.30 $76.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8DFEN SUP Custom 27203010 8DFEN - TUBE TRCH 8 12.2MM 7.6MM 79MM STRL LF SHLY CUF DISP INR CNN BOTH IP/OP $99.43 $73.58 $0.00 $80.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.79 $73.79 $0.00 $0.00 $20.72 $0.00 $0.00 $0.00 $0.00 $50.46 $79.93 $80.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8LGT SUP Custom 27203010 8LGT - TUBE TRACHEOSTOMY 8 12.6MM 15MM 7.6MM 50MM CUFFLESS BOTH IP/OP $114.73 $84.90 $0.00 $93.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.15 $85.15 $0.00 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $58.22 $92.23 $93.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8LGT SUP Custom 27203010 TUBE 50MM 7.6MM UNCUF LRNTMY SHLY TRCH 8 STRL LF DISP BOTH IP/OP $114.73 $84.90 $0.00 $95.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.15 $85.15 $0.00 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $58.22 $95.02 $93.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8MH22D SUP Custom 27203010 8MH22D - TOOL LEGEND 8CM 1.7 MH DIAM BOTH IP/OP $295.38 $218.58 $0.00 $236.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.23 $219.23 $0.00 $0.00 $61.56 $0.00 $0.00 $0.00 $0.00 $147.69 $233.94 $236.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8SCT SUP Custom 27203010 8SCT - TUBE TRACHEOSTOMY 8 10.9MM 8MM 89MM 1 CANNU CUFF SMOOTH BOTH IP/OP $71.38 $52.82 $0.00 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.97 $52.97 $0.00 $0.00 $14.87 $0.00 $0.00 $0.00 $0.00 $36.22 $57.38 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TA17 SUP Custom 27203010 8TA17 - TOOL LEGEND 8CM 1.7MM TA BOTH IP/OP $265.63 $196.57 $0.00 $212.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.15 $197.15 $0.00 $0.00 $55.36 $0.00 $0.00 $0.00 $0.00 $132.81 $210.38 $212.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD084 SUP Custom 27203010 8TD084 - TOOL LEGND 8CM 8MM 4MM DEPTH TWST BOTH IP/OP $388.88 $287.77 $0.00 $311.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $288.62 $288.62 $0.00 $0.00 $81.04 $0.00 $0.00 $0.00 $0.00 $194.44 $307.99 $311.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD104 SUP Custom 27203010 8TD104 - TOOL LEGEND 8CM 1MM 4MM DEPTH TD BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD114 SUP Custom 27203010 8TD114 - TOOL LEGEND 8CM 1.1MM 4MM TD BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD116 SUP Custom 27203010 8TD116 - TOOL LEGEND 8CM 1.1MM 6MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD124 SUP Custom 27203010 8TD124 - TOOL LEGEND 8CM 1.2MM 4MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD126 SUP Custom 27203010 8TD126 - TOOL LEGEND 8CM 1.2MM 6MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD134 SUP Custom 27203010 8TD134 - TOOL LEGEND 8CM 1.3MM 4MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD136 SUP Custom 27203010 8TD136 - TOOL LEGEND 8CM 1.3MM 6MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD154 SUP Custom 27203010 8TD154 - TOOL LEGEND 8CM 1.5MM 4MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD156 SUP Custom 27203010 8TD156 - TOOL LEGEND 8CM 1.5MM 6MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD158 SUP Custom 27203010 8TD158 - TOOL LEGEND 8CM 1.5MM 8MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD174 SUP Custom 27203010 8TD174 - TOOL LEGEND 8CM 1.7MM 4MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD176 SUP Custom 27203010 8TD176 - TOOL LEGEND 8CM 1.7MM 6MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD178 SUP Custom 27203010 8TD178 - TOOL LEGEND 8CM 1.7MM 8MM DEPTH BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD204 SUP Custom 27203010 8TD204 - TOOL LEGEND 8CM 2MM 4MM DEPTH TD BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD206 SUP Custom 27203010 8TD206 - TOOL LEGEND 8CM 2MM 6 MM DEPTH TD BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 8TD208 SUP Custom 27203010 8TD208 - TOOL LEGEND 8CM 2MM 8MM DEPTH TD BOTH IP/OP $240.13 $177.70 $0.00 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.22 $178.22 $0.00 $0.00 $50.04 $0.00 $0.00 $0.00 $0.00 $120.06 $190.18 $192.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9001G SUP Custom 27203010 9001G - SUTURE NONABSORBABLE 10-0 CS160-6 6IN 2 ARM MONOFILAMENT BOTH IP/OP $48.64 $35.99 $0.00 $38.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.10 $36.10 $0.00 $0.00 $10.14 $0.00 $0.00 $0.00 $0.00 $24.32 $38.52 $38.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9001-VC-005 SUP Custom 27203010 9001-VC-005 - NEEDLE BAND PRC WRST BOTH IP/OP $275.00 $203.50 $0.00 $204.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9003 B SUP Custom 27803010 9003 B - KIT 9003 B INTL ONLY SHUNT CONT SM ME BOTH IP/OP $859.75 $636.22 $0.00 $687.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.11 $638.11 $0.00 $0.00 $179.17 $0.00 $0.00 $0.00 $0.00 $429.88 $680.92 $687.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900-601 SUP HCPCS C1769 900-601 - GWIRE ORTH 150MM 1.6MM DRILL TIP NONSTRL BOTH IP/OP $108.65 $80.40 $0.00 $86.92 $59.00 $59.00 $0.00 $0.00 $0.00 $22.65 $80.64 $80.64 $0.00 $0.00 $22.64 $0.00 $64.27 $64.27 $0.00 $54.33 $86.05 $86.92 $0.00 $0.00 $17.00 $0.00 $0.00 $17.30 $0.00 $0.00 $0.00 $0.00 $0.00 9007 H SUP Custom 27803010 9007 H - CATH 9007 H C/P STD W/CLOS PRESS-HIGH BOTH IP/OP $605.63 $448.17 $0.00 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.49 $449.49 $0.00 $0.00 $126.21 $0.00 $0.00 $0.00 $0.00 $302.81 $479.66 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9007 L SUP Custom 27803010 9007 L - CATH 9007 L C/P STD W/CLOS PRESS-LOW BOTH IP/OP $605.63 $448.17 $0.00 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.49 $449.49 $0.00 $0.00 $126.21 $0.00 $0.00 $0.00 $0.00 $302.81 $479.66 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9007 M SUP Custom 27803010 9007 M - CATH 9007 M C/P STD W/CLOS PRESS-MED BOTH IP/OP $605.63 $448.17 $0.00 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.49 $449.49 $0.00 $0.00 $126.21 $0.00 $0.00 $0.00 $0.00 $302.81 $479.66 $484.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9009 B-H SUP Custom 27803010 9009 B-H - SHUNT 9009 B-H ASSY SM HI W/PERT OPN-90 BOTH IP/OP "$2,657.63 " "$1,966.65" $0.00 "$2,126.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,972.49" "$1,972.49" $0.00 $0.00 $553.85 $0.00 $0.00 $0.00 $0.00 "$1,328.81" "$2,104.84" "$2,126.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9009 B-L SUP Custom 27803010 9009 B-L - SHUNT 9009 B-L ASSY SM LO W/PERT OPN-90 BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9009 B-M SUP Custom 27803010 9009 B-M - SHNT 9009 B-M ASSY SM MED W/PERT OPN-90 BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 900MR869 SUP Custom 27203010 PROBE DUAL ARWY THRMTR 90D 60IN MR850 HMDF BOTH IP/OP $334.38 $247.44 $0.00 $267.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.19 $264.83 $267.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 901-118 SUP Custom 27803010 901-118 - SHUNT NS INTRO PRTNL BOTH IP/OP $127.00 $93.98 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.26 $94.26 $0.00 $0.00 $26.47 $0.00 $0.00 $0.00 $0.00 $63.50 $100.58 $101.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90129-203 SUP HCPCS C1874 90129-203 - STENT TRCHBR LOPRFL 18MM 22FR 56MM NS AERO OTW FULL CVR FLXB BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-204 SUP HCPCS C1874 90129-204 - STENT TRCHBR GMTR 16MM 22FR 40MM NS 61CM AERO OTW FLLY CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-206 SUP HCPCS C1874 90129-206 - STENT TRCHBR LOPRFL 16MM 22FR 56MM NS AERO OTW FULL CVR FLXB BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-207 SUP HCPCS C1874 90129-207 - STENT TRCHBR GMTR 10MM 16FR 20MM NS 63CM AERO OTW FLLY CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-209 SUP HCPCS C1874 90129-209 - STENT TRCHBR GMTR 10MM 16FR 40MM NS 61CM AERO OTW FLLY CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-210 SUP HCPCS C1874 90129-210 - STENT TRCHBR 12MM 16FR 20MM 63CM AERO FLLY CVR ANTIMIGRATION BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-211 SUP HCPCS C1874 90129-211 - STENT TRCHBR GMTR 12MM 16FR 30MM NS 62CM AERO OTW FLLY CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-213 SUP HCPCS C1874 90129-213 - STENT TRCHBR GMTR 14MM 16FR 20MM NS 63CM AERO OTW FLLY CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-214 SUP HCPCS C1874 90129-214 - STENT TRCHBR GMTR 14MM 16FR 30MM NS 62CM AERO OTW FLLY CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-215 SUP HCPCS C1874 90129-215 - STENT TRCHBR GMTR 14MM 16FR 40MM NS 61CM AERO OTW FLLY CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-216 SUP HCPCS C1874 90129-216 - STENT TRCHBR GMTR 20MM 22FR 40MM NS 61CM AERO OTW FLLY CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-217 SUP HCPCS C1874 90129-217 - STENT TRCHBR 20MM 60MM AERO OTW FLLY COVERED BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-218 SUP HCPCS C1874 90129-218 - STENT TRCH 20MM 80MM AERO FLLY COVERED BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 90129-301 SUP HCPCS C1874 90129-301 - STENT TRCHBR 18MM 40MM AERO DV FLLY COVERED DRCT VIS SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-302 SUP HCPCS C1874 90129-302 - STENT TRCHBR 18MM 60MM AERO DV FLLY COVERED DRCT VIS SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-303 SUP HCPCS C1874 90129-303 - STENT TRCHBR 18MM 80MM AERO DV FLLY COVERED DRCT VSN DLV SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-304 SUP HCPCS C1874 90129-304 - STENT TRCHBR 16MM 30MM 40MM 39MM AERO OTW DRCT VIS NOVEL BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-305 SUP HCPCS C1874 90129-305 - STENT TRCHBR 16MM 60MM AERO FLLY COVERED PURSE STNG DRCT VIS BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-306 SUP HCPCS C1874 90129-306 - STENT TRCHBR 16MM 80MM AERO DV FLLY COVERED DRCT VSN DLV SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-310 SUP HCPCS C1874 90129-310 - STENT TRCHBR 12MM 20MM AERO DV FLLY COVERED DRCT VSN DLV SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-311 SUP HCPCS C1874 90129-311 - STENT TRCHBR GMTR LOPRFL 12MM 28FR 30MM 40CM AERO FULL CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-312 SUP HCPCS C1874 90129-312 - STENT TRCHBR GMTR LOPRFL 28FR 12MM 40MM 39CM AERO FULL CVR BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-313 SUP HCPCS C1874 90129-313 - STENT TRCHBR 14MM 20MM AERO DV FLLY COVERED DRCT VSN DLV SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-314 SUP HCPCS C1874 90129-314 - STENT TRCHBR 14MM 30MM AERO DV FLLY COVERED DRCT VIS SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-315 SUP HCPCS C1874 90129-315 - STENT TRCHBR 14MM 40MM AERO FLLY COVERED PURSE STNG DRCT VIS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-316 SUP HCPCS C1874 90129-316 - STENT TRCHBR 20MM 40MM AERO DV FLLY COVERED DRCT VIS SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-317 SUP HCPCS C1874 90129-317 - STENT TRCHBR 20MM 60MM AERO DV FLLY COVERED DRCT VIS SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-318 SUP HCPCS C1874 90129-318 - STENT TRCHBR 20MM 80MM AERO DV FLLY COVERED DRCT VIS SYS BOTH IP/OP "$5,750.00 " "$4,255.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,198.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,198.30" $0.00 "$2,834.75" "$2,834.75" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 90129-501 SUP HCPCS C1874 90129-501 - SIZER SRG AEROSIZER STNT MSR DEV BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $168.75 $168.75 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9013 A SUP Custom 27803010 9013 A - RESERVOIR 9013 A VENT 12MM CONVT IC 50MM BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9013 B SUP Custom 27803010 9013 B - RESERVOIR 9013 B VENT 12MM CONVT IC 60MM BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9013 F SUP Custom 27803010 9013 F - RESERVOIR 9013 F VENT 12MM CONVT IC 7CM BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9013 G SUP Custom 27803010 9013 G - RESERVOIR 9013 G VENT 12MM CONVT IC 8CM BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $0.00 $0.00 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 903016A SUP HCPCS C1729 903016A - TRAY CATH BDX IC CMP CR 16FR 350ML FOLEY URMTR ANTIINFECTIVE BOTH IP/OP $24.95 $18.46 $0.00 $19.96 $13.55 $13.55 $0.00 $0.00 $0.00 $5.20 $18.52 $18.52 $0.00 $0.00 $5.20 $0.00 $14.76 $14.76 $0.00 $12.48 $19.76 $19.96 $0.00 $0.00 $3.91 $0.00 $0.00 $3.97 $0.00 $0.00 $0.00 $0.00 $0.00 903018A SUP HCPCS C1729 TRAY CATH LBRCTH 18FR 350ML FOLEY URMTR BOTH IP/OP $41.48 $30.70 $0.00 $33.18 $22.52 $22.52 $0.00 $0.00 $0.00 $8.64 $30.78 $30.78 $0.00 $0.00 $8.64 $0.00 $24.53 $24.53 $0.00 $20.74 $32.85 $33.18 $0.00 $0.00 $6.49 $0.00 $0.00 $6.60 $0.00 $0.00 $0.00 $0.00 $0.00 9032G SUP Custom 27203010 9032G - SUTURE NONABSORBABLE 10-0 CS175-8 12IN 2 ARM MONOFILAMENT BOTH IP/OP $42.97 $31.80 $0.00 $34.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.89 $31.89 $0.00 $0.00 $8.95 $0.00 $0.00 $0.00 $0.00 $21.81 $34.54 $34.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9040 R SUP Custom 27803010 9040 R - KIT 9040 R SHUNT CSF BH MED SML CATHS BOTH IP/OP $859.75 $636.22 $0.00 $687.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.11 $638.11 $0.00 $0.00 $179.17 $0.00 $0.00 $0.00 $0.00 $429.88 $680.92 $687.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9042 A SUP HCPCS C1894 9042 A - VAD 9042 A 12MM CONVT 50MM-INTRODUCER BOTH IP/OP "$1,223.13 " $905.12 $0.00 $978.50 $664.16 $664.16 $0.00 $0.00 $0.00 $254.93 $907.80 $907.80 $0.00 $0.00 $254.90 $0.00 $723.48 $723.48 $0.00 $611.56 $968.72 $978.50 $0.00 $0.00 $191.42 $0.00 $0.00 $194.72 $0.00 $0.00 $0.00 $0.00 $0.00 9042 B SUP HCPCS C1894 9042 B - VAD 9042 B 12MM CONVT 60MM-INTRODUCER BOTH IP/OP "$1,223.13 " $905.12 $0.00 $978.50 $664.16 $664.16 $0.00 $0.00 $0.00 $254.93 $907.80 $907.80 $0.00 $0.00 $254.90 $0.00 $723.48 $723.48 $0.00 $611.56 $968.72 $978.50 $0.00 $0.00 $191.42 $0.00 $0.00 $194.72 $0.00 $0.00 $0.00 $0.00 $0.00 9042 D SUP HCPCS C1894 9042 D - VAD 9042 D 12MM CONVT 40MM-INTRODUCER BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $568.72 $568.72 $0.00 $0.00 $0.00 $218.30 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $619.52 $619.52 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $163.91 $0.00 $0.00 $166.74 $0.00 $0.00 $0.00 $0.00 $0.00 9042 G SUP HCPCS C1894 9042 G - VAD 9042 G 12MM CONVT 35MM-INTRODUCER BOTH IP/OP "$1,047.38 " $775.06 $0.00 $837.90 $568.72 $568.72 $0.00 $0.00 $0.00 $218.30 $777.36 $777.36 $0.00 $0.00 $218.27 $0.00 $619.52 $619.52 $0.00 $523.69 $829.52 $837.90 $0.00 $0.00 $163.91 $0.00 $0.00 $166.74 $0.00 $0.00 $0.00 $0.00 $0.00 9046 B-H SUP Custom 27803010 9046 B-H - SHUNT 9046 B-H ASSY REG HIGH PERIT 90CM BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9046 B-L SUP Custom 27803010 9046 B-L - SHUNT 9046 B-L ASSY REG LOW PERIT-90CM BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9046 B-M SUP Custom 27803010 9046 B-M - SHUNT 9046 B-M ASSY REG MED PERIT-90CM BOTH IP/OP "$2,498.50 " "$1,848.89" $0.00 "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,854.39" "$1,854.39" $0.00 $0.00 $520.69 $0.00 $0.00 $0.00 $0.00 "$1,249.25" "$1,978.81" "$1,998.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-101 SUP HCPCS C1781 905-101 - MESH 905-101 PYRM 10MM X 100MM ROUND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 905-103 SUP HCPCS C1781 905-103 - CAGE SPNL RND 10MM 30MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-107 SUP HCPCS C1781 905-107 - MESH 905-107 PYRM 10MM X 70MM ROUND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 905-108 SUP HCPCS C1781 905-108 - CAGE SPNL RND 10MM 8MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-110 SUP HCPCS C1781 905-110 - CAGE SPNL RND 10MM 10MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-112 SUP HCPCS C1781 905-112 - CAGE SPNL RND 10MM 12MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-115 SUP HCPCS C1781 905-115 - CAGE SPNL RND 10MM 15MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-133 SUP HCPCS C1781 905-133 - CAGE SPNL RND 13MM 30MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-137 SUP HCPCS C1781 905-137 - MESH 905-137 PYRM 13MM X 70MM ROUND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 905-139 SUP HCPCS C1781 905-139 - CAGE SPNL RND 13MM 9MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-161 SUP HCPCS C1781 905-161 - CAGE SPNL RND 16MM 10MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-163 SUP HCPCS C1781 905-163 - CAGE SPNL RND 16MM 30MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-166 SUP HCPCS C1781 905-166 - MESH 905-166 PYRM 16MM X 60MM ROUND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 905-194 SUP Custom 27803010 905-194 - CAGE SPNL RND 19MM 40MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 $0.00 $0.00 $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-199 SUP HCPCS C1781 905-199 - CAGE SPNL RND 19MM 90MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 905-251 SUP HCPCS C1781 905-251 - MESH 905-251 PYRM 25MM X 100MM ROUND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 905-255 SUP HCPCS C1781 905-255 - MESH 905-255 PYRM 25MM ROUND X 10X15HGT BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-256 SUP Custom 27803010 905-256 - CAGE SPNL 60MMX25MM PRMSH TI RND MESH BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 $0.00 $0.00 $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-299 SUP HCPCS C1781 905-299 - MESH 905-299 PYRM 19MM X ROUND END CAP BOTH IP/OP $858.00 $634.92 $0.00 $686.40 $386.10 $386.10 $0.00 $0.00 $0.00 $178.83 $636.81 $636.81 $0.00 $0.00 $178.81 $0.00 $507.51 $507.51 $0.00 $429.00 $679.54 $686.40 $0.00 $0.00 $134.28 $0.00 $0.00 $136.59 $0.00 $0.00 $0.00 $0.00 $0.00 905-308 SUP HCPCS C1781 905-308 - CAGE SPNL RND 13MM 8MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-309 SUP HCPCS C1781 905-309 - MESH 905-309 PYRM 25MM X 100MM ROUND BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 905-310 SUP HCPCS C1781 905-310 - CAGE SPNL RND 13MM 10MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-311 SUP HCPCS C1781 905-311 - MESH 905-311 PYRM 13MM X 11MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-312 SUP HCPCS C1781 905-312 - MESH 905-312 PYRM 13MM X 12MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-313 SUP HCPCS C1781 905-313 - MESH 905-313 PYRM 13MM X 13MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-320 SUP HCPCS C1781 905-320 - MESH 905-320 PYRM 13MM X 20MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-399 SUP HCPCS C1781 905-399 - MESH 905-399 PYRM 25MM ROUND END CAP BOTH IP/OP $858.00 $634.92 $0.00 $686.40 $386.10 $386.10 $0.00 $0.00 $0.00 $178.83 $636.81 $636.81 $0.00 $0.00 $178.81 $0.00 $507.51 $507.51 $0.00 $429.00 $679.54 $686.40 $0.00 $0.00 $134.28 $0.00 $0.00 $136.59 $0.00 $0.00 $0.00 $0.00 $0.00 905-401 SUP HCPCS C1781 905-401 - MESH SRG OVOID 14X10X10MM PRMSH BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-403 SUP HCPCS C1781 905-403 - CAGE SPNL OVOID 14X10X30MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-407 SUP HCPCS C1781 905-407 - MESH 905-407 PYRM 10X14X70 OVOID BOTH IP/OP "$12,604.58 " "$9,327.39" $0.00 "$10,083.66" "$5,672.06" "$5,672.06" $0.00 $0.00 $0.00 "$2,627.11" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,626.79" $0.00 "$6,214.06" "$6,214.06" $0.00 "$6,302.29" "$9,982.83" "$10,083.66" $0.00 $0.00 "$1,972.62" $0.00 $0.00 "$2,006.65" $0.00 $0.00 $0.00 $0.00 $0.00 905-408 SUP HCPCS C1781 905-408 - CAGE SPNL OVOID 14X10X8MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-409 SUP HCPCS C1781 905-409 - MESH 905-409 PYRM 10 X 14 OVOID X 9MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-411 SUP HCPCS C1781 905-411 - MESH 905-411 PYRM 10 X 14 OVOID X 11MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-412 SUP HCPCS C1781 905-412 - MESH 905-412 PYRM 10 X 14 OVOID X 12MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-415 SUP HCPCS C1781 905-415 - MESH 905-415 PYRM 10 X 14 OVOID X 15MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-501 SUP HCPCS C1781 905-501 - MESH 905-501 PYRM 13 X17 X 10 OVOID BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-508 SUP HCPCS C1781 905-508 - MESH 905-508 PYRM 13 X 17 OVOID X 8MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-509 SUP HCPCS C1781 905-509 - MESH 905-509 PYRM 13 X 17 OVOID X 9MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-511 SUP HCPCS C1781 905-511 - MESH 905-511 PYRM 13 X 17 OVOID X 11MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-512 SUP HCPCS C1781 905-512 - MESH 905-512 PYRM 13 X 17 OVOID X 12MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-515 SUP HCPCS C1781 905-515 - MESH 905-515 PYRM 13 X 17 OVOID X 15MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-520 SUP HCPCS C1781 905-520 - MESH 905-520 PYRM 13 X 17 OVOID X 20MM BOTH IP/OP "$7,138.60 " "$5,282.56" $0.00 "$5,710.88" "$3,212.37" "$3,212.37" $0.00 $0.00 $0.00 "$1,487.86" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,487.68" $0.00 "$3,519.33" "$3,519.33" $0.00 "$3,569.30" "$5,653.77" "$5,710.88" $0.00 $0.00 "$1,117.19" $0.00 $0.00 "$1,136.47" $0.00 $0.00 $0.00 $0.00 $0.00 905-608 SUP HCPCS C1781 905-608 - MESH 905-608 PYRM 16MM X 8MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-609 SUP HCPCS C1781 905-609 - MESH 905-609 PYRM 16MM X 9MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-611 SUP HCPCS C1781 905-611 - MESH 905-611 PYRM 16MM X 11MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-612 SUP HCPCS C1781 905-612 - MESH 905-612 PYRM 16MM X 12MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-615 SUP HCPCS C1781 905-615 - MESH 905-615 PYRM 16MM X 15MM ROUND BOTH IP/OP "$3,513.85 " "$2,600.25" $0.00 "$2,811.08" "$1,581.23" "$1,581.23" $0.00 $0.00 $0.00 $732.37 "$2,607.98" "$2,607.98" $0.00 $0.00 $732.29 $0.00 "$1,732.33" "$1,732.33" $0.00 "$1,756.93" "$2,782.97" "$2,811.08" $0.00 $0.00 $549.92 $0.00 $0.00 $559.40 $0.00 $0.00 $0.00 $0.00 $0.00 905-800 SUP HCPCS C1781 905-800 - MESH 905-800 PYRM END RING SET SCRW BOTH IP/OP $81.25 $60.13 $0.00 $65.00 $36.56 $36.56 $0.00 $0.00 $0.00 $16.93 $60.30 $60.30 $0.00 $0.00 $16.93 $0.00 $48.06 $48.06 $0.00 $40.63 $64.35 $65.00 $0.00 $0.00 $12.72 $0.00 $0.00 $12.94 $0.00 $0.00 $0.00 $0.00 $0.00 905-810 SUP Custom 27203010 905-810 - INSTRUMENT 905-810 MESH HOLDER STRAIGHT BOTH IP/OP "$1,486.50 " "$1,100.01" $0.00 "$1,189.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,103.28" "$1,103.28" $0.00 $0.00 $309.79 $0.00 $0.00 $0.00 $0.00 $743.25 "$1,177.31" "$1,189.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-815 SUP Custom 27203010 905-815 - INSTRUMENT 905-815 MESH HOLDER SMALL BOTH IP/OP "$1,486.50 " "$1,100.01" $0.00 "$1,189.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,103.28" "$1,103.28" $0.00 $0.00 $309.79 $0.00 $0.00 $0.00 $0.00 $743.25 "$1,177.31" "$1,189.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-820 SUP Custom 27203010 905-820 - INSTRUMENT 905-820 MESH ACTOR STRAIGHT BOTH IP/OP "$1,461.00 " "$1,081.14" $0.00 "$1,168.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,084.35" "$1,084.35" $0.00 $0.00 $304.47 $0.00 $0.00 $0.00 $0.00 $730.50 "$1,157.11" "$1,168.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-825 SUP Custom 27203010 905-825 - INSTRUMENT 905-825 ANGLED MESH IMPACTOR BOTH IP/OP "$1,461.00 " "$1,081.14" $0.00 "$1,168.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,084.35" "$1,084.35" $0.00 $0.00 $304.47 $0.00 $0.00 $0.00 $0.00 $730.50 "$1,157.11" "$1,168.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-830 SUP Custom 27203010 905-830 - INSTRUMENT 905-830 MESH TRIMMER BOTH IP/OP "$2,518.50 " "$1,863.69" $0.00 "$2,014.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,869.23" "$1,869.23" $0.00 $0.00 $524.86 $0.00 $0.00 $0.00 $0.00 "$1,259.25" "$1,994.65" "$2,014.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-880 SUP Custom 27203010 905-880 - INSTRUMENT 905-880 END RING DRVR BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 905-901 SUP HCPCS C1781 905-901 - MESH 905-901 PYRM 13MM X 130MM CURVED BOTH IP/OP "$16,827.60 " "$12,452.42" $0.00 "$13,462.08" "$7,572.42" "$7,572.42" $0.00 $0.00 $0.00 "$3,507.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,506.87" $0.00 "$8,296.01" "$8,296.01" $0.00 "$8,413.80" "$13,327.46" "$13,462.08" $0.00 $0.00 "$2,633.52" $0.00 $0.00 "$2,678.95" $0.00 $0.00 $0.00 $0.00 $0.00 905-902 SUP HCPCS C1781 905-902 - MESH 905-902 PYRM 10X14 OVOIDX130MM CRV BOTH IP/OP "$16,827.60 " "$12,452.42" $0.00 "$13,462.08" "$7,572.42" "$7,572.42" $0.00 $0.00 $0.00 "$3,507.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,506.87" $0.00 "$8,296.01" "$8,296.01" $0.00 "$8,413.80" "$13,327.46" "$13,462.08" $0.00 $0.00 "$2,633.52" $0.00 $0.00 "$2,678.95" $0.00 $0.00 $0.00 $0.00 $0.00 905-903 SUP HCPCS C1781 905-903 - CAGE SPNL ANG 19MM 150MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$16,827.60 " "$12,452.42" $0.00 "$13,462.08" "$7,572.42" "$7,572.42" $0.00 $0.00 $0.00 "$3,507.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,506.87" $0.00 "$8,296.01" "$8,296.01" $0.00 "$8,413.80" "$13,327.46" "$13,462.08" $0.00 $0.00 "$2,633.52" $0.00 $0.00 "$2,678.95" $0.00 $0.00 $0.00 $0.00 $0.00 905-904 SUP HCPCS C1781 905-904 - CAGE SPNL ANG 25MM 150MM PRMSH MESH TI LMBR INTRBD FS BOTH IP/OP "$16,827.60 " "$12,452.42" $0.00 "$13,462.08" "$7,572.42" "$7,572.42" $0.00 $0.00 $0.00 "$3,507.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,506.87" $0.00 "$8,296.01" "$8,296.01" $0.00 "$8,413.80" "$13,327.46" "$13,462.08" $0.00 $0.00 "$2,633.52" $0.00 $0.00 "$2,678.95" $0.00 $0.00 $0.00 $0.00 $0.00 907-1080011 SUP Custom 27203010 BRACE ORTH BGE 10.5IN SM RT WRST SPRT 11425-55 BOTH IP/OP $27.50 $20.35 $0.00 $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 909-145 SUP Custom 27203010 909-145 - PIN 14MM DSTRCT BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $0.00 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9091G SUP Custom 27203010 9091G - SUTURE NABSB 10-0 CTC-6L 4IN BLU PRLN HMSL ULT 2 ARM MFL BOTH IP/OP $73.45 $54.35 $0.00 $59.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.51 $54.51 $0.00 $0.00 $15.31 $0.00 $0.00 $0.00 $0.00 $37.27 $59.04 $59.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91-1504 SUP HCPCS C1713 91-1504 - SCREW BONE 1.5MM 4MM SLFTAP HIGH TORQUE CROSS DRIVE GOLD BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 91-1505 SUP HCPCS C1713 91-1505 - SCREW BONE 1.5MM 5MM SLFTAP HIGH TORQUE CROSS DRIVE GOLD BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 91-1506 SUP HCPCS C1713 91-1506 - SCREW BONE 1.5MM 6MM HIGH TORQUE CROSS DRIVE CENTRE DRIVE BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 91-1507 SUP HCPCS C1713 91-1507 - SCREW BONE 1.5MM 7MM HIGH TORQUE CROSS DRIVE CENTRE DRIVE BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 91-1508 SUP HCPCS C1713 91-1508 - SCREW TI 8MM 1.5MM MANDIB XDR HTORQ BONE CD BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $63.00 $63.00 $0.00 $0.00 $0.00 $29.18 $103.91 $103.91 $0.00 $0.00 $29.18 $0.00 $82.81 $82.81 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $21.91 $0.00 $0.00 $22.29 $0.00 $0.00 $0.00 $0.00 $0.00 91-1509 SUP HCPCS C1713 91-1509 - SCREW BONE 1.5MM 9MM HIGH TORQUE CROSS DRIVE CENTRE DRIVE BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 91-1511 SUP HCPCS C1713 91-1511 - SCREW BONE 1.5MM 11MM HIGH TORQUE CROSS DRIVE TITANIUM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 91-1513 SUP HCPCS C1713 91-1513 - SCREW BONE 1.5MM 13MM HIGH TORQUE CROSS DRIVE CENTRE DRIVE BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 91-1515 SUP HCPCS C1713 91-1515 - SCREW BONE 1.5MM 15MM HIGH TORQUE CROSS DRIVE TITANIUM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 91-1805 SUP HCPCS C1713 91-1805 - SCREW BONE 1.8MM 5MM EMERGENCY SELF TAP HIGH TORQUE CROSS BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $110.25 $110.25 $0.00 $0.00 $0.00 $51.06 $181.84 $181.84 $0.00 $0.00 $51.06 $0.00 $144.92 $144.92 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 91-1807 SUP HCPCS C1713 91-1807 - SCREW BONE 1.8MM 7MM EMERGENCY HIGH TORQUE CROSS DRIVE BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $110.25 $110.25 $0.00 $0.00 $0.00 $51.06 $181.84 $181.84 $0.00 $0.00 $51.06 $0.00 $144.92 $144.92 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 91-1809 SUP HCPCS C1713 91-1809 - SCREW TI 9MM 1.8MM MANDIB ER XDR HTORQ BONE CD BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $63.00 $63.00 $0.00 $0.00 $0.00 $29.18 $103.91 $103.91 $0.00 $0.00 $29.18 $0.00 $82.81 $82.81 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $21.91 $0.00 $0.00 $22.29 $0.00 $0.00 $0.00 $0.00 $0.00 91500V SUP Custom 27203010 91500V - APPLIER ENDOSCOPIC MED LARGE STRAIGHT 18INźź BOTH IP/OP "$2,773.73 " "$2,052.56" $0.00 "$2,218.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,058.66" "$2,058.66" $0.00 $0.00 $578.04 $0.00 $0.00 $0.00 $0.00 "$1,386.86" "$2,196.79" "$2,218.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91501V SUP Custom 27203010 91501V - CLIP INTNL ENDO REMOVER MED LARGE - LARGE STRAIGHT 18INźź BOTH IP/OP "$2,249.98 " "$1,664.99" $0.00 "$1,799.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.93" "$1,669.93" $0.00 $0.00 $468.89 $0.00 $0.00 $0.00 $0.00 "$1,124.99" "$1,781.98" "$1,799.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 915-3100 SUP Custom 27803010 915-3100 - PIN FIX HEAT CONTOURING PEN LACTOSORB STERILE BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91-5607 SUP HCPCS C1713 91-5607 - SCREW BONE 2MM 7MM SELF DRILL TRAUMAONE LORENZ BLUE MANDIB BOTH IP/OP $435.00 $321.90 $0.00 $348.00 $195.75 $195.75 $0.00 $0.00 $0.00 $90.66 $322.86 $322.86 $0.00 $0.00 $90.65 $0.00 $257.30 $257.30 $0.00 $217.50 $344.52 $348.00 $0.00 $0.00 $68.08 $0.00 $0.00 $69.25 $0.00 $0.00 $0.00 $0.00 $0.00 91-5609 SUP HCPCS C1713 91-5609 - SCREW BONE 2MM 9MM SLFDRILL LORENZ TRAUMAONE BLUE MANDIB BOTH IP/OP $435.00 $321.90 $0.00 $348.00 $195.75 $195.75 $0.00 $0.00 $0.00 $90.66 $322.86 $322.86 $0.00 $0.00 $90.65 $0.00 $257.30 $257.30 $0.00 $217.50 $344.52 $348.00 $0.00 $0.00 $68.08 $0.00 $0.00 $69.25 $0.00 $0.00 $0.00 $0.00 $0.00 91-5611 SUP HCPCS C1713 91-5611 - SCREW BONE 2MM 11MM SLFDRILL LORENZ TRAUMAONE BLUE MANDIB BOTH IP/OP $435.00 $321.90 $0.00 $348.00 $195.75 $195.75 $0.00 $0.00 $0.00 $90.66 $322.86 $322.86 $0.00 $0.00 $90.65 $0.00 $257.30 $257.30 $0.00 $217.50 $344.52 $348.00 $0.00 $0.00 $68.08 $0.00 $0.00 $69.25 $0.00 $0.00 $0.00 $0.00 $0.00 91-5707 SUP HCPCS C1713 91-5707 - SCREW BONE 2MM 7MM SELF DRILL TEMPORARY ANCHOR CROSS DRIVE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 91602V SUP Custom 27203010 91602V - APPLIER ENDOSCOPIC LARGE CURVED 18INźź BOTH IP/OP "$2,773.73 " "$2,052.56" $0.00 "$2,218.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,058.66" "$2,058.66" $0.00 $0.00 $578.04 $0.00 $0.00 $0.00 $0.00 "$1,386.86" "$2,196.79" "$2,218.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91-6103 SUP HCPCS C1713 91-6103 - SCREW BONE 1.5MM 3.5MM SELF DRILL HIGH TORQUE CROSS DRIVE BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $110.25 $110.25 $0.00 $0.00 $0.00 $51.06 $181.84 $181.84 $0.00 $0.00 $51.06 $0.00 $144.92 $144.92 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 91-6104 SUP HCPCS C1713 91-6104 - SCREW BONE 1.5MM 4MM SELF DRILL HIGH TORQUE CROSS DRIVE BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $110.25 $110.25 $0.00 $0.00 $0.00 $51.06 $181.84 $181.84 $0.00 $0.00 $51.06 $0.00 $144.92 $144.92 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 91-6105 SUP HCPCS C1713 91-6105 - SCREW BONE 1.5MM 5MM SELF DRILL HIGH TORQUE CROSS DRIVE BOTH IP/OP $245.00 $181.30 $0.00 $196.00 $110.25 $110.25 $0.00 $0.00 $0.00 $51.06 $181.84 $181.84 $0.00 $0.00 $51.06 $0.00 $144.92 $144.92 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $38.34 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 91-6106 SUP HCPCS C1713 91-6106 - SCREW BN 1.5MM 6MM GRN SLF DRL XDR TI MDFC LORENZ TRAUMAONE BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 91-6107 SUP HCPCS C1713 91-6107 - SCREW BN 1.5MM 7MM GRN SLF DRL XDR TI MDFC LORENZ TRAUMAONE BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $68.63 $68.63 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 91-6703 SUP HCPCS C1713 91-6703 - SCREW BONE 1.5MM 3.5MM SELF DRILL CROSS DRIVE THINFLAP BOTH IP/OP $260.00 $192.40 $0.00 $208.00 $117.00 $117.00 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $0.00 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $130.00 $205.92 $208.00 $0.00 $0.00 $40.69 $0.00 $0.00 $41.39 $0.00 $0.00 $0.00 $0.00 $0.00 91-6704 SUP HCPCS C1713 91-6704 - SCREW BONE 1.5MM 4MM SELF DRILL CROSS DRIVE THINFLAP BOTH IP/OP $260.00 $192.40 $0.00 $208.00 $117.00 $117.00 $0.00 $0.00 $0.00 $54.19 $192.97 $192.97 $0.00 $0.00 $54.18 $0.00 $153.79 $153.79 $0.00 $130.00 $205.92 $208.00 $0.00 $0.00 $40.69 $0.00 $0.00 $41.39 $0.00 $0.00 $0.00 $0.00 $0.00 91701V SUP Custom 27203010 91701V - CLIP INTNL ENDO REMOVER LARGE - XLARGE STRAIGHT 18INźź BOTH IP/OP "$2,364.98 " "$1,750.09" $0.00 "$1,891.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,755.28" "$1,755.28" $0.00 $0.00 $492.86 $0.00 $0.00 $0.00 $0.00 "$1,182.49" "$1,873.06" "$1,891.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 91702V SUP Custom 27203010 91702V - APPLIER ENDOSCOPIC XLARGE CURVED 18INźź BOTH IP/OP "$2,773.73 " "$2,052.56" $0.00 "$2,218.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,058.66" "$2,058.66" $0.00 $0.00 $578.04 $0.00 $0.00 $0.00 $0.00 "$1,386.86" "$2,196.79" "$2,218.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-00646 SUP HCPCS C1713 92-00646 - PLATE BONE 90X90MM MESH PREFORMED TITANIUM BOTH IP/OP "$17,716.88 " "$13,110.49" $0.00 "$19,800.00" "$11,137.50" "$11,137.50" $0.00 $0.00 $0.00 "$3,692.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,692.20" $0.00 "$8,734.42" "$8,734.42" $0.00 "$12,375.00" "$19,602.00" "$19,800.00" $0.00 $0.00 "$3,873.38" $0.00 $0.00 "$3,940.20" $0.00 $0.00 $0.00 $0.00 $0.00 92-00647 SUP HCPCS C1713 92-00647 - PLATE BONE 190X140MM MESH PREFORMED TITANIUM BOTH IP/OP "$68,617.50 " "$50,776.95" $0.00 "$54,894.00" "$30,877.88" "$30,877.88" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$14,299.89" $0.00 "$33,828.43" "$33,828.43" $0.00 "$34,308.75" "$54,345.06" "$54,894.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 92-03210 SUP HCPCS C1713 92-03210 - PLATE BN NS UNV NEURO II 2 HL LOPRFL TAB BOTH IP/OP $227.50 $168.35 $0.00 $432.00 $243.00 $243.00 $0.00 $0.00 $0.00 $47.42 $168.85 $168.85 $0.00 $0.00 $47.41 $0.00 $134.57 $134.57 $0.00 $270.00 $427.68 $432.00 $0.00 $0.00 $84.51 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $0.00 92-03510 SUP Custom 27803010 92-03510 - COVER BURR HOLE 10MM LP CRANIUM 3MM SCREW BOTH IP/OP $461.25 $341.33 $0.00 $842.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.34 $342.34 $0.00 $0.00 $96.12 $0.00 $0.00 $0.00 $0.00 $526.25 $833.58 $842.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-03514 SUP Custom 27803010 92-03514 - COVER BURR HOLE LP 14MM CRANIUM 3MM SCREW BOTH IP/OP $461.25 $341.33 $0.00 $842.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.34 $342.34 $0.00 $0.00 $96.12 $0.00 $0.00 $0.00 $0.00 $526.25 $833.58 $842.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-03608 SUP HCPCS C1713 92-03608 - PLATE BONE 2Y MICRO LP 8MM 6 HOLE BAR CRANIUM BOTH IP/OP $639.00 $472.86 $0.00 $936.00 $526.50 $526.50 $0.00 $0.00 $0.00 $133.18 $474.27 $474.27 $0.00 $0.00 $133.17 $0.00 $377.97 $377.97 $0.00 $585.00 $926.64 $936.00 $0.00 $0.00 $183.11 $0.00 $0.00 $186.26 $0.00 $0.00 $0.00 $0.00 $0.00 92-05228 SUP HCPCS C1713 92-05228 - PLATE BONE LARGE LP BOX TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $498.18 $368.65 $0.00 $756.00 $425.25 $425.25 $0.00 $0.00 $0.00 $103.83 $369.75 $369.75 $0.00 $0.00 $103.82 $0.00 $294.67 $294.67 $0.00 $472.50 $748.44 $756.00 $0.00 $0.00 $147.89 $0.00 $0.00 $150.44 $0.00 $0.00 $0.00 $0.00 $0.00 92-07211 SUP Custom 27203010 92-07211 - SLEEVE LAPSCP TWN FX BLDE BOTH IP/OP $525.25 $388.69 $0.00 $420.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.84 $389.84 $0.00 $0.00 $109.46 $0.00 $0.00 $0.00 $0.00 $262.63 $416.00 $420.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-07230 SUP Custom 27203010 92-07230 - BIT DRILL 200MM 3.4MM CANN BOTH IP/OP $463.25 $342.81 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.82 $343.82 $0.00 $0.00 $96.54 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-10504 SUP HCPCS C1713 92-10504 - PLATE BN MN 4 HL TI 1.25MM BOTH IP/OP "$1,857.50 " "$1,374.55" $0.00 "$1,486.00" $835.88 $835.88 $0.00 $0.00 $0.00 $387.15 "$1,378.64" "$1,378.64" $0.00 $0.00 $387.10 $0.00 "$1,098.71" "$1,098.71" $0.00 $928.75 "$1,471.14" "$1,486.00" $0.00 $0.00 $290.70 $0.00 $0.00 $295.71 $0.00 $0.00 $0.00 $0.00 $0.00 92-10505 SUP HCPCS C1713 92-10505 - PLATE BONE MINI 1.5MM 4 HOLE BAR TITANIUM MAXFACL BOTH IP/OP "$1,374.23 " "$1,016.93" $0.00 "$1,680.00" $945.00 $945.00 $0.00 $0.00 $0.00 $286.42 "$1,019.95" "$1,019.95" $0.00 $0.00 $286.39 $0.00 $812.85 $812.85 $0.00 "$1,050.00" "$1,663.20" "$1,680.00" $0.00 $0.00 $328.65 $0.00 $0.00 $334.32 $0.00 $0.00 $0.00 $0.00 $0.00 92-10506 SUP HCPCS C1713 92-10506 - PLATE BONE MINI 6 HOLE CUSTOM MAXFACL BOTH IP/OP "$2,555.00 " "$1,890.70" $0.00 "$2,044.00" "$1,149.75" "$1,149.75" $0.00 $0.00 $0.00 $532.53 "$1,896.32" "$1,896.32" $0.00 $0.00 $532.46 $0.00 "$1,259.62" "$1,259.62" $0.00 "$1,277.50" "$2,023.56" "$2,044.00" $0.00 $0.00 $399.86 $0.00 $0.00 $406.76 $0.00 $0.00 $0.00 $0.00 $0.00 92-10507 SUP HCPCS C1713 92-10507 - PLATE BONE 2MM 6 HOLE BARMAND LOCK CRANIOMAXILLOFACIAL BOTH IP/OP "$1,702.73 " "$1,260.02" $0.00 "$2,140.00" "$1,203.75" "$1,203.75" $0.00 $0.00 $0.00 $354.89 "$1,263.76" "$1,263.76" $0.00 $0.00 $354.85 $0.00 "$1,007.16" "$1,007.16" $0.00 "$1,337.50" "$2,118.60" "$2,140.00" $0.00 $0.00 $418.64 $0.00 $0.00 $425.86 $0.00 $0.00 $0.00 $0.00 $0.00 92-10516 SUP HCPCS C1713 92-10516 - PLATE BN 1.5MM MN 16 HL MXLFCL BOTH IP/OP "$2,850.00 " "$2,109.00" $0.00 "$2,280.00" "$1,282.50" "$1,282.50" $0.00 $0.00 $0.00 $594.01 "$2,115.27" "$2,115.27" $0.00 $0.00 $593.94 $0.00 "$1,405.05" "$1,405.05" $0.00 "$1,425.00" "$2,257.20" "$2,280.00" $0.00 $0.00 $446.03 $0.00 $0.00 $453.72 $0.00 $0.00 $0.00 $0.00 $0.00 92-10562 SUP HCPCS C1713 92-10562 - PLATE BN STRUT TROCH BOTH IP/OP "$2,850.00 " "$2,109.00" $0.00 "$2,280.00" "$1,282.50" "$1,282.50" $0.00 $0.00 $0.00 $594.01 "$2,115.27" "$2,115.27" $0.00 $0.00 $593.94 $0.00 "$1,405.05" "$1,405.05" $0.00 "$1,425.00" "$2,257.20" "$2,280.00" $0.00 $0.00 $446.03 $0.00 $0.00 $453.72 $0.00 $0.00 $0.00 $0.00 $0.00 92-15514 SUP HCPCS C1713 92-15514 - PLATE BONE 2MM STR FRAC BOTH IP/OP "$3,907.50 " "$2,891.55" $0.00 "$3,126.00" "$1,758.38" "$1,758.38" $0.00 $0.00 $0.00 $814.42 "$2,900.15" "$2,900.15" $0.00 $0.00 $814.32 $0.00 "$1,926.40" "$1,926.40" $0.00 "$1,953.75" "$3,094.74" "$3,126.00" $0.00 $0.00 $611.52 $0.00 $0.00 $622.07 $0.00 $0.00 $0.00 $0.00 $0.00 92-15904 SUP HCPCS C1713 92-15904 - SCREW BONE 1.5MM 4MM SELF DRILL TITANIUM CRANIOMAXILLOFACIAL BOTH IP/OP $100.95 $74.70 $0.00 $80.76 $45.43 $45.43 $0.00 $0.00 $0.00 $21.04 $74.93 $74.93 $0.00 $0.00 $21.04 $0.00 $59.71 $59.71 $0.00 $50.48 $79.95 $80.76 $0.00 $0.00 $15.80 $0.00 $0.00 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 92-15905 SUP HCPCS C1713 92-15905 - SCREW BONE 5MM 1.5MM MAXFACL TI SLFDRILL XPIN BOTH IP/OP $100.95 $74.70 $0.00 $80.76 $45.43 $45.43 $0.00 $0.00 $0.00 $21.04 $74.93 $74.93 $0.00 $0.00 $21.04 $0.00 $59.71 $59.71 $0.00 $50.48 $79.95 $80.76 $0.00 $0.00 $15.80 $0.00 $0.00 $16.07 $0.00 $0.00 $0.00 $0.00 $0.00 92-15920 SUP HCPCS C1713 92-15920 - PLATE BONE 20MM HEMI RECONSTRUCTION TITANIUM MANDIB BOTH IP/OP "$10,292.50 " "$7,616.45" $0.00 "$8,234.00" "$4,631.63" "$4,631.63" $0.00 $0.00 $0.00 "$2,145.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,144.96" $0.00 "$5,074.20" "$5,074.20" $0.00 "$5,146.25" "$8,151.66" "$8,234.00" $0.00 $0.00 "$1,610.78" $0.00 $0.00 "$1,638.57" $0.00 $0.00 $0.00 $0.00 $0.00 92-15922 SUP HCPCS C1713 92-15922 - PLATE BONE 22MM HEMI RECONSTRUCTION TITANIUM MANDIB BOTH IP/OP "$10,292.50 " "$7,616.45" $0.00 "$8,234.00" "$4,631.63" "$4,631.63" $0.00 $0.00 $0.00 "$2,145.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,144.96" $0.00 "$5,074.20" "$5,074.20" $0.00 "$5,146.25" "$8,151.66" "$8,234.00" $0.00 $0.00 "$1,610.78" $0.00 $0.00 "$1,638.57" $0.00 $0.00 $0.00 $0.00 $0.00 92-16035 SUP Custom 27100030 92-16035 - BIT DRILL 1.6MM 35MM 7MM TWIST STOP BOTH IP/OP $468.58 $346.75 $0.00 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.78 $347.78 $0.00 $0.00 $97.65 $0.00 $0.00 $0.00 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-16135 SUP Custom 27203010 92-16135 - DRILL SRG 1.6MM 115MM NS LF 35MM CLR CD DISP BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $0.00 $0.00 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-17126 SUP Custom 27203010 92-17126 - BIT DRL TWST BOTH IP/OP $160.65 $118.88 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.23 $119.23 $0.00 $0.00 $33.48 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-19035 SUP Custom 27100030 92-19035 - BIT DRILL 1.9MM 35MM TWIST BOTH IP/OP $736.88 $545.29 $0.00 $802.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.91 $546.91 $0.00 $0.00 $153.56 $0.00 $0.00 $0.00 $0.00 $501.25 $793.98 $802.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-23126 SUP Custom 27203010 92-23126 - BIT DRL 23MM BOTH IP/OP $160.65 $118.88 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.23 $119.23 $0.00 $0.00 $33.48 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-25290 SUP HCPCS C1713 92-25290 - PLATE STD LNG BONE RIGHT DORSAL RADL BOTH IP/OP $893.75 $661.38 $0.00 $715.00 $402.19 $402.19 $0.00 $0.00 $0.00 $186.28 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $528.65 $528.65 $0.00 $446.88 $707.85 $715.00 $0.00 $0.00 $139.87 $0.00 $0.00 $142.29 $0.00 $0.00 $0.00 $0.00 $0.00 92-25291 SUP HCPCS C1713 92-25291 - PLATE STD LNG BONE LEFT DORSAL RADL BOTH IP/OP $893.75 $661.38 $0.00 $715.00 $402.19 $402.19 $0.00 $0.00 $0.00 $186.28 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $528.65 $528.65 $0.00 $446.88 $707.85 $715.00 $0.00 $0.00 $139.87 $0.00 $0.00 $142.29 $0.00 $0.00 $0.00 $0.00 $0.00 92-25292 SUP HCPCS C1713 92-25292 - PLATE LNG W BONE RIGHT DORSAL RADL BOTH IP/OP $893.75 $661.38 $0.00 $715.00 $402.19 $402.19 $0.00 $0.00 $0.00 $186.28 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $528.65 $528.65 $0.00 $446.88 $707.85 $715.00 $0.00 $0.00 $139.87 $0.00 $0.00 $142.29 $0.00 $0.00 $0.00 $0.00 $0.00 92-25293 SUP HCPCS C1713 92-25293 - PLATE LNG W BONE LEFT DORSAL RADL BOTH IP/OP $893.75 $661.38 $0.00 $715.00 $402.19 $402.19 $0.00 $0.00 $0.00 $186.28 $663.34 $663.34 $0.00 $0.00 $186.26 $0.00 $528.65 $528.65 $0.00 $446.88 $707.85 $715.00 $0.00 $0.00 $139.87 $0.00 $0.00 $142.29 $0.00 $0.00 $0.00 $0.00 $0.00 92-25395 SUP HCPCS C1713 92-25395 - PLATE NAR XLNG BONE VOLR RADL BOTH IP/OP "$1,216.88 " $900.49 $0.00 $973.50 $547.59 $547.59 $0.00 $0.00 $0.00 $253.63 $903.16 $903.16 $0.00 $0.00 $253.60 $0.00 $719.78 $719.78 $0.00 $608.44 $963.77 $973.50 $0.00 $0.00 $190.44 $0.00 $0.00 $193.73 $0.00 $0.00 $0.00 $0.00 $0.00 92-25397 SUP HCPCS C1713 92-25397 - PLATE STD XLNG BONE VOLR RADL BOTH IP/OP "$1,216.88 " $900.49 $0.00 $973.50 $547.59 $547.59 $0.00 $0.00 $0.00 $253.63 $903.16 $903.16 $0.00 $0.00 $253.60 $0.00 $719.78 $719.78 $0.00 $608.44 $963.77 $973.50 $0.00 $0.00 $190.44 $0.00 $0.00 $193.73 $0.00 $0.00 $0.00 $0.00 $0.00 92-25399 SUP HCPCS C1713 92-25399 - PLATE W XLNG BONE VOLR RADL BOTH IP/OP "$1,216.88 " $900.49 $0.00 $973.50 $547.59 $547.59 $0.00 $0.00 $0.00 $253.63 $903.16 $903.16 $0.00 $0.00 $253.60 $0.00 $719.78 $719.78 $0.00 $608.44 $963.77 $973.50 $0.00 $0.00 $190.44 $0.00 $0.00 $193.73 $0.00 $0.00 $0.00 $0.00 $0.00 92-25403 SUP HCPCS C1713 92-25403 - PLATE BN SHRT T BOTH IP/OP "$1,271.00 " $940.54 $0.00 $943.34 $506.14 $506.14 $0.00 $0.00 $0.00 $264.91 $943.34 $943.34 $0.00 $0.00 $264.88 $0.00 $751.80 $751.80 $0.00 $562.38 $890.80 $899.80 $0.00 $0.00 $176.02 $0.00 $0.00 $179.06 $0.00 $0.00 $0.00 $0.00 $0.00 92-25405 SUP HCPCS C1713 92-25405 - PLATE LNG 7 HOLE T CLMN BONE ULN BOTH IP/OP "$1,271.00 " $940.54 $0.00 $943.34 $506.14 $506.14 $0.00 $0.00 $0.00 $264.91 $943.34 $943.34 $0.00 $0.00 $264.88 $0.00 $751.80 $751.80 $0.00 $562.38 $890.80 $899.80 $0.00 $0.00 $176.02 $0.00 $0.00 $179.06 $0.00 $0.00 $0.00 $0.00 $0.00 92-27007 SUP Custom 27203010 92-27007 - HOLDER INSTR SHFT PLT BOTH IP/OP $434.50 $321.53 $0.00 $347.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.49 $322.49 $0.00 $0.00 $90.55 $0.00 $0.00 $0.00 $0.00 $217.25 $344.12 $347.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-40281 SUP HCPCS C1713 92-40281 - WIRE FX 1.4MM 160MM KRSH STP BOTH IP/OP $41.25 $30.53 $0.00 $33.00 $18.56 $18.56 $0.00 $0.00 $0.00 $8.60 $30.62 $30.62 $0.00 $0.00 $8.60 $0.00 $24.40 $24.40 $0.00 $20.63 $32.67 $33.00 $0.00 $0.00 $6.46 $0.00 $0.00 $6.57 $0.00 $0.00 $0.00 $0.00 $0.00 92-40283 SUP HCPCS C1713 92-40283 - WIRE FX .062IN 160MM KRSH BOTH IP/OP $48.13 $35.62 $0.00 $38.50 $21.66 $21.66 $0.00 $0.00 $0.00 $10.03 $35.72 $35.72 $0.00 $0.00 $10.03 $0.00 $28.47 $28.47 $0.00 $24.06 $38.12 $38.50 $0.00 $0.00 $7.53 $0.00 $0.00 $7.66 $0.00 $0.00 $0.00 $0.00 $0.00 92-53514 SUP Custom 27803010 92-53514 - COVER BURR HOLE 14MM LP BOTH IP/OP $520.05 $384.84 $0.00 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $385.98 $385.98 $0.00 $0.00 $108.38 $0.00 $0.00 $0.00 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-55005 SUP HCPCS C1713 92-55005 - PLATE BONE SHORT 4 HOLE PREBENT CRANIOMAXILLOFACIAL LEFT BOTH IP/OP "$1,222.50 " $904.65 $0.00 $978.00 $550.13 $550.13 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $611.25 $968.22 $978.00 $0.00 $0.00 $191.32 $0.00 $0.00 $194.62 $0.00 $0.00 $0.00 $0.00 $0.00 92-55007 SUP HCPCS C1713 92-55007 - PLATE BONE SHORT 4 HOLE PREBENT CRANIOMAXILLOFACIAL RIGHT BOTH IP/OP "$1,222.50 " $904.65 $0.00 $978.00 $550.13 $550.13 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $611.25 $968.22 $978.00 $0.00 $0.00 $191.32 $0.00 $0.00 $194.62 $0.00 $0.00 $0.00 $0.00 $0.00 92-55011 SUP HCPCS C1713 92-55011 - PLATE BN 2.5MM 11 HL MNDB BOTH IP/OP "$7,835.00 " "$5,797.90" $0.00 "$6,268.00" "$3,525.75" "$3,525.75" $0.00 $0.00 $0.00 "$1,633.01" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,632.81" $0.00 "$3,862.66" "$3,862.66" $0.00 "$3,917.50" "$6,205.32" "$6,268.00" $0.00 $0.00 "$1,226.18" $0.00 $0.00 "$1,247.33" $0.00 $0.00 $0.00 $0.00 $0.00 92-55066 SUP HCPCS C1713 92-55066 - PLATE BONE 100D L BAR CRANIOMAXILLOFACIAL RIGHT BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $517.50 $517.50 $0.00 $0.00 $0.00 $239.69 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $680.23 $680.23 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $179.98 $0.00 $0.00 $183.08 $0.00 $0.00 $0.00 $0.00 $0.00 92-55067 SUP HCPCS C1713 92-55067 - PLATE BONE 100D L BAR CRANIOMAXILLOFACIAL LEFT BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $517.50 $517.50 $0.00 $0.00 $0.00 $239.69 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $680.23 $680.23 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $179.98 $0.00 $0.00 $183.08 $0.00 $0.00 $0.00 $0.00 $0.00 92-55159 SUP HCPCS C1713 92-55159 - PLATE BN 2MM 11 HL CRNMXF BOTH IP/OP "$6,960.00 " "$5,150.40" $0.00 "$5,568.00" "$3,132.00" "$3,132.00" $0.00 $0.00 $0.00 "$1,450.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,450.46" $0.00 "$3,431.28" "$3,431.28" $0.00 "$3,480.00" "$5,512.32" "$5,568.00" $0.00 $0.00 "$1,089.24" $0.00 $0.00 "$1,108.03" $0.00 $0.00 $0.00 $0.00 $0.00 92-55161 SUP HCPCS C1713 92-55161 - PLATE BONE 2MM 17 HOLE PRIM RECONSTRUCTION TEMPLATE MANDIB BOTH IP/OP "$8,477.50 " "$6,273.35" $0.00 "$6,782.00" "$3,814.88" "$3,814.88" $0.00 $0.00 $0.00 "$1,766.92" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,766.71" $0.00 "$4,179.41" "$4,179.41" $0.00 "$4,238.75" "$6,714.18" "$6,782.00" $0.00 $0.00 "$1,326.73" $0.00 $0.00 "$1,349.62" $0.00 $0.00 $0.00 $0.00 $0.00 92-55506 SUP HCPCS C1713 92-55506 - PLATE BONE 4 HOLE PREBENT TITANIUM LEFT MAXFACL BOTH IP/OP "$1,082.50 " $801.05 $0.00 $866.00 $487.13 $487.13 $0.00 $0.00 $0.00 $225.62 $803.43 $803.43 $0.00 $0.00 $225.59 $0.00 $640.30 $640.30 $0.00 $541.25 $857.34 $866.00 $0.00 $0.00 $169.41 $0.00 $0.00 $172.33 $0.00 $0.00 $0.00 $0.00 $0.00 92-55922 SUP HCPCS C1713 92-55922 - PLATE BN 2MM HEMI PRM LT 2 BOTH IP/OP "$6,475.00 " "$4,791.50" $0.00 "$5,180.00" "$2,913.75" "$2,913.75" $0.00 $0.00 $0.00 "$1,349.55" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,349.39" $0.00 "$3,192.18" "$3,192.18" $0.00 "$3,237.50" "$5,128.20" "$5,180.00" $0.00 $0.00 "$1,013.34" $0.00 $0.00 "$1,030.82" $0.00 $0.00 $0.00 $0.00 $0.00 92-57262 SUP HCPCS C1713 92-57262 - PLATE BN FX 1.7 MM SCR BOTH IP/OP $584.38 $432.44 $0.00 $467.50 $262.97 $262.97 $0.00 $0.00 $0.00 $121.80 $433.72 $433.72 $0.00 $0.00 $121.78 $0.00 $345.66 $345.66 $0.00 $292.19 $462.83 $467.50 $0.00 $0.00 $91.45 $0.00 $0.00 $93.03 $0.00 $0.00 $0.00 $0.00 $0.00 92-60090 SUP Custom 27203010 92-60090 - TWIST DRILL DIA.0.9X66MM TWIST LENGTH 22MM AO SHAFT BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-60130 SUP Custom 27203010 92-60130 - TWIST DRILL DIA.1.3X66MM TWIST LENGTH 22MM AO SHAFT BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-60165 SUP Custom 27100030 92-60165 - BIT DRILL 35MM COLOR CODED BOTH IP/OP $406.70 $300.96 $0.00 $620.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.85 $301.85 $0.00 $0.00 $84.76 $0.00 $0.00 $0.00 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-60170 SUP Custom 27203010 92-60170 - DRILL TWST 1.7MM 66MM BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-60190 SUP Custom 27203010 92-60190 - TWIST DRILL DIA.1.9X82MM TWIST LENGTH 39MM AO SHAFT BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-60199 SUP Custom 27100030 92-60199 - DRILL TWIST 1.9MM STOP 35MM 115MM BOTH IP/OP $491.18 $363.47 $0.00 $702.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $364.55 $364.55 $0.00 $0.00 $102.36 $0.00 $0.00 $0.00 $0.00 $438.75 $694.98 $702.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-60230 SUP Custom 27203010 92-60230 - DRILL TWST 2.3MM 82MM BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-62254 SUP Custom 27203010 92-62254 - GUIDE DRL 1.2MM 1.7MM FUSED BOTH IP/OP "$1,175.63 " $869.97 $0.00 $940.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $872.55 $872.55 $0.00 $0.00 $245.00 $0.00 $0.00 $0.00 $0.00 $587.81 $931.10 $940.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-62255 SUP Custom 27203010 92-62255 - GUIDE DRL 2.3MM LG FUSED CMPR BOTH IP/OP "$1,117.88 " $827.23 $0.00 $894.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $829.69 $829.69 $0.00 $0.00 $232.97 $0.00 $0.00 $0.00 $0.00 $558.94 $885.36 $894.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-62256 SUP Custom 27203010 92-62256 - GUIDE DRL 2.3MM 2.5MM FUSED CENTRIC BOTH IP/OP "$1,227.88 " $908.63 $0.00 $982.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $911.33 $911.33 $0.00 $0.00 $255.89 $0.00 $0.00 $0.00 $0.00 $613.94 $972.48 $982.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 92-62270 SUP Custom 27803010 92-62270 - TAP FOR 2.7MM SCREW BOTH IP/OP $570.63 $422.27 $0.00 $456.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $423.52 $423.52 $0.00 $0.00 $118.92 $0.00 $0.00 $0.00 $0.00 $285.31 $451.94 $456.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 931HF75 SUP HCPCS C1887 CATHETER ART 7.5FR 110CM 5 LUM TD SG HEP BOTH IP/OP $210.25 $155.59 $0.00 $168.20 $114.17 $114.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.13 $166.52 $168.20 $0.00 $0.00 $32.90 $0.00 $0.00 $33.47 $0.00 $0.00 $0.00 $0.00 $0.00 93-9268 SUP HCPCS C1762 93-9268 - GRAFT SKIN 8X6CM DEHYDRATED GAMA IRRADIATED AXIS TUTOPLAST BOTH IP/OP "$3,847.50 " "$2,847.15" $0.00 "$3,078.00" $0.00 $0.00 $0.00 $0.00 $0.00 $801.92 "$2,855.61" "$2,855.61" $0.00 $0.00 $801.82 $0.00 "$1,896.82" "$1,896.82" $0.00 "$1,923.75" "$3,047.22" "$3,078.00" $0.00 $0.00 $602.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 94107CE SUP HCPCS C1713 94107CE - CROSSLINK 94107CE DTT4 FOR COMPRESS L60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 94107DE SUP HCPCS C1713 94107DE - CROSSLINK 94107DE DTT4 FOR DISTRACT L60 BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 94-202 SUP Custom 27203010 REAGENT LUPOTEK DETECTIN ANALY BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9450002E SUP Custom 27203010 9450002E - DISPOSABLE 9450002E ELECTRO LOWIMPED22MM BOTH IP/OP $669.00 $495.06 $0.00 $535.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $496.53 $496.53 $0.00 $0.00 $139.42 $0.00 $0.00 $0.00 $0.00 $334.50 $529.85 $535.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DMA1002 SUP Custom 27203010 945DMA1002 - ELECTRODE 945DMA1002 AD GOLDFOIL EAR CAN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DMA1004 SUP Custom 27203010 945DMA1004 - ELECTRODE 945DMA1004 PED GOLDFOIL EARCAN BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.68 $6.68 $0.00 $0.00 $1.88 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DME1001 SUP Custom 27203010 945DME1001 - ELECTRODE 945DME1001 1.2M CORKSCREW BOTH IP/OP $82.50 $61.05 $0.00 $66.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.23 $61.23 $0.00 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $41.25 $65.34 $66.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DME1004 SUP Custom 27203010 945DME1004 - ELECTRODE 945DME1004 3.5X5CM 2M SING GR BOTH IP/OP $25.50 $18.87 $0.00 $20.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.93 $18.93 $0.00 $0.00 $5.31 $0.00 $0.00 $0.00 $0.00 $12.75 $20.20 $20.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DME2002 SUP Custom 27203010 945DME2002 - ELECTRODE 945DME2002 48IN 1.2M CORKSCREW BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSE1115 SUP Custom 27203010 945DSE1115 - ELECTRODE 945DSE1115 1.5X2CM 1.5M SINGLE BOTH IP/OP $12.00 $8.88 $0.00 $9.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.91 $8.91 $0.00 $0.00 $2.50 $0.00 $0.00 $0.00 $0.00 $6.00 $9.50 $9.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSE1125 SUP Custom 27203010 945DSE1125 - ELECTRODE 945DSE1125 1.5X2CM 2.5M SINGLE BOTH IP/OP $18.00 $13.32 $0.00 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.36 $13.36 $0.00 $0.00 $3.75 $0.00 $0.00 $0.00 $0.00 $9.00 $14.26 $14.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSE2115 SUP Custom 27203010 945DSE2115 - ELECTRODE 945DSE2115 2X2.7CM 1.5M SINGLE BOTH IP/OP $12.00 $8.88 $0.00 $9.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.91 $8.91 $0.00 $0.00 $2.50 $0.00 $0.00 $0.00 $0.00 $6.00 $9.50 $9.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSE2125 SUP Custom 27203010 945DSE2125 - ELECTRODE 945DSE2125 2X2.7CM 2.5M SINGLE BOTH IP/OP $15.00 $11.10 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.13 $11.13 $0.00 $0.00 $3.13 $0.00 $0.00 $0.00 $0.00 $7.50 $11.88 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSE3115 SUP Custom 27203010 945DSE3115 - ELECTRODE 945DSE3115 1.5X2CM 1.5M DUAL BOTH IP/OP $43.50 $32.19 $0.00 $34.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.29 $32.29 $0.00 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $21.75 $34.45 $34.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSE3125 SUP Custom 27203010 945DSE3125 - ELECTRODE 945DSE3125 1.5X2CM 2.5M DUAL BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $0.00 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSE4115 SUP Custom 27203010 945DSE4115 - ELECTRODE 945DSE4115 2X2.7CM 1.5M DUAL BOTH IP/OP $43.50 $32.19 $0.00 $34.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.29 $32.29 $0.00 $0.00 $9.07 $0.00 $0.00 $0.00 $0.00 $21.75 $34.45 $34.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSE4125 SUP Custom 27203010 945DSE4125 - ELECTRODE 945DSE4125 2X2.7CM 2.5M DUAL BOTH IP/OP $63.00 $46.62 $0.00 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.76 $46.76 $0.00 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $31.50 $49.90 $50.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSN1260 SUP Custom 27203010 945DSN1260 - ELECTRODE 945DSN1260 13MM 27G 1.5M SING BOTH IP/OP $22.50 $16.65 $0.00 $18.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.70 $16.70 $0.00 $0.00 $4.69 $0.00 $0.00 $0.00 $0.00 $11.25 $17.82 $18.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSN1299 SUP Custom 27203010 945DSN1299 - ELECTRODE 945DSN1299 13MM 27G 2.5M SING BOTH IP/OP $22.50 $16.65 $0.00 $18.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.70 $16.70 $0.00 $0.00 $4.69 $0.00 $0.00 $0.00 $0.00 $11.25 $17.82 $18.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSN2260 SUP Custom 27203010 945DSN2260 - ELECTRODE 945DSN2260 13MM 27G 1.5M DUAL BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSN2280 SUP Custom 27203010 945DSN2280 - ELECTRODE 945DSN2280 13MM 27G 2.0M DUAL BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DSN2299 SUP Custom 27203010 945DSN2299 - ELECTRODE 945DSN2299 13MM 27G 2.5M DUAL BOTH IP/OP $61.50 $45.51 $0.00 $49.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.65 $45.65 $0.00 $0.00 $12.82 $0.00 $0.00 $0.00 $0.00 $30.75 $48.71 $49.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DTE0001 SUP HCPCS C1898 945DTE0001 - LEAD 945DTE0001 0.6M RED CLIP BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $20.25 $20.25 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 945DTE0002 SUP HCPCS C1898 945DTE0002 - LEAD 945DTE0002 0.6 GREEN CLIP BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $20.25 $20.25 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 945DTE0003 SUP HCPCS C1898 945DTE0003 - LEAD 945DTE0003 0.6M BLACK CLIP BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $20.25 $20.25 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 945DTE1002 SUP Custom 27203010 945DTE1002 - ELECTRODE 945DTE1002 1.27X1.9CMPREGELTAB BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.49 $24.49 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945DTE1003 SUP Custom 27203010 945DTE1003 - ELECTRODE 945DTE1003 2.54X2.54CMPRETAB BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.49 $24.49 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945MEP1001 SUP Custom 27203010 945MEP1001 - ELECTRODE 945MEP1001 KEYED CORKSCREW BOTH IP/OP $624.00 $461.76 $0.00 $499.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.13 $463.13 $0.00 $0.00 $130.04 $0.00 $0.00 $0.00 $0.00 $312.00 $494.21 $499.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945NRE1003 SUP Custom 27203010 945NRE1003 - ELECTRODE 945NRE1003 SD NEEDLE RECORDING BOTH IP/OP $891.00 $659.34 $0.00 $712.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $661.30 $661.30 $0.00 $0.00 $185.68 $0.00 $0.00 $0.00 $0.00 $445.50 $705.67 $712.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945NRE1004 SUP Custom 27203010 945NRE1004 - ELECTRODE 945NRE1004 NEEDLE WITH RING BOTH IP/OP "$1,320.00 " $976.80 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $979.70 $979.70 $0.00 $0.00 $275.09 $0.00 $0.00 $0.00 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945POC1002 SUP HCPCS C1713 945POC1002 - CLIP 945POC1002 SD PULSE OX BOTH IP/OP $223.50 $165.39 $0.00 $178.80 $100.58 $100.58 $0.00 $0.00 $0.00 $46.58 $165.88 $165.88 $0.00 $0.00 $46.58 $0.00 $132.20 $132.20 $0.00 $111.75 $177.01 $178.80 $0.00 $0.00 $34.98 $0.00 $0.00 $35.58 $0.00 $0.00 $0.00 $0.00 $0.00 945PXC2002 SUP HCPCS C1713 945PXC2002 - CLIP 945PXC2002 1MLEAD PULSEOX FING/TOE BOTH IP/OP $82.50 $61.05 $0.00 $66.00 $37.13 $37.13 $0.00 $0.00 $0.00 $17.20 $61.23 $61.23 $0.00 $0.00 $17.19 $0.00 $48.80 $48.80 $0.00 $41.25 $65.34 $66.00 $0.00 $0.00 $12.91 $0.00 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $0.00 945RMA1016 SUP Custom 27203010 945RMA1016 - TUBE 945RMA1016 REPLACEMENT BOTH IP/OP $22.50 $16.65 $0.00 $18.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.70 $16.70 $0.00 $0.00 $4.69 $0.00 $0.00 $0.00 $0.00 $11.25 $17.82 $18.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945RMA1019 SUP Custom 27203010 945RMA1019 - ELECTRODE 945RMA1019 10-7.5MMLARYNGEAL BOTH IP/OP $289.50 $214.23 $0.00 $231.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.87 $214.87 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $144.75 $229.28 $231.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945RMA1019S SUP Custom 27203010 945RMA1019S - ELECTRODE 945RMA1019S 7-6MM LARYNGEAL BOTH IP/OP $289.50 $214.23 $0.00 $231.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.87 $214.87 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $144.75 $229.28 $231.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945RMA1019SP SUP Custom 27203010 945RMA1019SP - ELECTRODE 945RMA1019SP 5.5-2MMLARYNGEAL BOTH IP/OP $289.50 $214.23 $0.00 $231.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.87 $214.87 $0.00 $0.00 $60.33 $0.00 $0.00 $0.00 $0.00 $144.75 $229.28 $231.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945RMA2029 SUP Custom 27203010 945RMA2029 - ELECTRODE 945RMA2029 LARGE LARYNGEAL BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945RMA2029SP SUP Custom 27203010 945RMA2029SP - ELECTRODE 945RMA2029SP MEDIUM LARYNGEAL BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $0.00 $0.00 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 945SRE1002 SUP Custom 27203010 945SRE1002 - ELECTRODE 945SRE1002 SD SURFACERECORDING BOTH IP/OP $891.00 $659.34 $0.00 $712.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $661.30 $661.30 $0.00 $0.00 $185.68 $0.00 $0.00 $0.00 $0.00 $445.50 $705.67 $712.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9461-217 SUP Custom 27203010 TUBING BP RECT SCR CONNCTR LF 12FT PED ADLT GRY EGL 3K DASH BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95-1318BIO SUP Custom 27203010 BAG 18X13IN BHZR LOGO SPGRD SPEC BOTH IP/OP $0.40 $0.30 $0.00 $0.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.20 $0.32 $0.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95-201 SUP Custom 27203010 REAGENT LUPOTEK CORRECTIN ANALY BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9529- SUP Custom 27203010 9529- - SLEEVE CMPR MED KN LGTH 21- IN NS LF KDL SCD EXP ADJ CRCMF BOTH IP/OP $34.45 $25.49 $0.00 $27.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.49 $27.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96004-N SUP Custom 27203010 PACIFIER NBN SIL STH 1 PC DSGN LF NTR BOTH IP/OP $2.58 $1.91 $0.00 $2.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.29 $2.04 $2.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96505H SUP Custom 27803010 96505H - CONNECTOR ROD 6.35/6.35MM DMN SPNE BOTH IP/OP "$1,796.58 " "$1,329.47" $0.00 "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.42" "$1,333.42" $0.00 $0.00 $374.41 $0.00 $0.00 $0.00 $0.00 $898.29 "$1,422.89" "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96505HT SUP Custom 27803010 96505HT - CONNECTOR 96505HT DOM DIA 6.35-6.35 TI BOTH IP/OP "$1,831.18 " "$1,355.07" $0.00 "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,359.10" "$1,359.10" $0.00 $0.00 $381.62 $0.00 $0.00 $0.00 $0.00 $915.59 "$1,450.29" "$1,464.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96507H SUP Custom 27803010 96507H - CONNECTOR 96507H CDH DOMINO 6.35-7MM BOTH IP/OP "$1,796.58 " "$1,329.47" $0.00 "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.42" "$1,333.42" $0.00 $0.00 $374.41 $0.00 $0.00 $0.00 $0.00 $898.29 "$1,422.89" "$1,437.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96509H SUP Custom 27803010 96509H - CONNECTOR 96509H AXIAL 6.35- 6.35 BOTH IP/OP "$2,118.45 " "$1,567.65" $0.00 "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,572.31" "$1,572.31" $0.00 $0.00 $441.48 $0.00 $0.00 $0.00 $0.00 "$1,059.23" "$1,677.81" "$1,694.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96509HT SUP Custom 27803010 96509HT - CONNECTOR 96509HT AXIAL 6.35- 6.35TI BOTH IP/OP "$2,346.10 " "$1,736.11" $0.00 "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,741.28" "$1,741.28" $0.00 $0.00 $488.93 $0.00 $0.00 $0.00 $0.00 "$1,173.05" "$1,858.11" "$1,876.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 968-021 SUP HCPCS C1713 968-021 - ROD 968-021 WITH LINE SS BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 96880-021 SUP Custom 27803010 96880-021 - CANNULA PRFSN 60CM 21FR FEM PERC VN ADLT 3/8IN 1 BOTH IP/OP $986.86 $730.28 $0.00 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.45 $732.45 $0.00 $0.00 $205.66 $0.00 $0.00 $0.00 $0.00 $530.00 $839.52 $848.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 96880-025 SUP Custom 27203010 96880-025 - CANNULA PERFUSION 3/8IN 25FR 60CM 1 PIECE KINK RESISTANT BOTH IP/OP $986.86 $730.28 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.45 $732.45 $0.00 $0.00 $205.66 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 969-012 SUP HCPCS C1713 969-012 - ROD 969-012 SEA FOAM GREEN CP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 969-022 SUP HCPCS C1713 969-022 - ROD 969-022 SEA FOAM GREEN CP W/LINE BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 976-119 SUP HCPCS C1713 976-119 - PLATE BN 19MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 976-121 SUP HCPCS C1713 976-121 - PLATE 21MM TI LCK ATL VS BONE ANT CERV SPNE STRL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 976-123 SUP HCPCS C1713 976-123 - PLATE 23MM TI LCK ATL VS BONE ANT CERV SPN STRL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 976-125 SUP HCPCS C1713 976-125 - PLATE 25MM TI LCK ATL VS BONE ANT CERV SPN STRL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 976-127 SUP HCPCS C1713 976-127 - PLATE 27.5MM TI ATLNTS BONE ANT CERV SPN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 976-130 SUP HCPCS C1713 976-130 - PLATE BN 30MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 976-132 SUP HCPCS C1713 976-132 - PLATE BN 32.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 976-135 SUP HCPCS C1713 976-135 - PLATE BN 35MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 976-137 SUP HCPCS C1713 976-137 - PLATE BN 37.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 976-140 SUP HCPCS C1713 976-140 - PLATE BN 40MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 976-142 SUP HCPCS C1713 976-142 - PLATE 42.5MM TI ALLOY LCK ATL VS BONE ANT CERV SPN STRL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 976-145 SUP HCPCS C1713 976-145 - PLATE 45MM TI ATLNTS BONE ANT CERV SPN BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 976-147 SUP HCPCS C1713 976-147 - PLATE BN 47.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 976-150 SUP HCPCS C1713 976-150 - PLATE BN 50MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 976-152 SUP HCPCS C1713 976-152 - PLATE BN 52.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-155 SUP HCPCS C1713 976-155 - PLATE BN 55MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-157 SUP HCPCS C1713 976-157 - PLATE BN 57.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-160 SUP HCPCS C1713 976-160 - PLATE BN 60MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-162 SUP HCPCS C1713 976-162 - PLATE BN 62.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-165 SUP HCPCS C1713 976-165 - PLATE BN 65MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-167 SUP HCPCS C1713 976-167 - PLATE BN 67.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-170 SUP HCPCS C1713 976-170 - PLATE BN 70MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-172 SUP HCPCS C1713 976-172 - PLATE BN 72.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 976-175 SUP HCPCS C1713 976-175 - PLATE BN 75MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 976-177 SUP HCPCS C1713 976-177 - PLATE BN 77.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 976-180 SUP HCPCS C1713 976-180 - PLATE BN 80MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 976-182 SUP HCPCS C1713 976-182 - PLATE BN 82.5MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 976-185 SUP HCPCS C1713 976-185 - PLATE BN 85MM STRL ATL VS LCK TI SPNE CRV ANT BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 976-187 SUP HCPCS C1713 976-187 - PLATE 87.5MM TI LCK ATL VS BONE ANT CERV SPN STRL BOTH IP/OP "$4,278.00 " "$3,165.72" $0.00 "$3,422.40" "$1,925.10" "$1,925.10" $0.00 $0.00 $0.00 $891.64 "$3,175.13" "$3,175.13" $0.00 $0.00 $891.54 $0.00 "$2,109.05" "$2,109.05" $0.00 "$2,139.00" "$3,388.18" "$3,422.40" $0.00 $0.00 $669.51 $0.00 $0.00 $681.06 $0.00 $0.00 $0.00 $0.00 $0.00 976-190 SUP HCPCS C1713 976-190 - PLATE 90MM TI ATL VS BONE ANT CERV SPN BOTH IP/OP "$4,278.00 " "$3,165.72" $0.00 "$3,422.40" "$1,925.10" "$1,925.10" $0.00 $0.00 $0.00 $891.64 "$3,175.13" "$3,175.13" $0.00 $0.00 $891.54 $0.00 "$2,109.05" "$2,109.05" $0.00 "$2,139.00" "$3,388.18" "$3,422.40" $0.00 $0.00 $669.51 $0.00 $0.00 $681.06 $0.00 $0.00 $0.00 $0.00 $0.00 976-195 SUP HCPCS C1713 976-195 - PLATE 95MM TI LCK ATL VS BONE ANT CERV SPN STRL BOTH IP/OP "$4,278.00 " "$3,165.72" $0.00 "$3,422.40" "$1,925.10" "$1,925.10" $0.00 $0.00 $0.00 $891.64 "$3,175.13" "$3,175.13" $0.00 $0.00 $891.54 $0.00 "$2,109.05" "$2,109.05" $0.00 "$2,139.00" "$3,388.18" "$3,422.40" $0.00 $0.00 $669.51 $0.00 $0.00 $681.06 $0.00 $0.00 $0.00 $0.00 $0.00 976-200 SUP HCPCS C1713 976-200 - PLATE 100MM TI LCK ATL VS BONE ANT CERV SPN STRL BOTH IP/OP "$4,278.00 " "$3,165.72" $0.00 "$3,422.40" "$1,925.10" "$1,925.10" $0.00 $0.00 $0.00 $891.64 "$3,175.13" "$3,175.13" $0.00 $0.00 $891.54 $0.00 "$2,109.05" "$2,109.05" $0.00 "$2,139.00" "$3,388.18" "$3,422.40" $0.00 $0.00 $669.51 $0.00 $0.00 $681.06 $0.00 $0.00 $0.00 $0.00 $0.00 976-205 SUP HCPCS C1713 976-205 - PLATE 105MM TI LCK ATL VS BONE ANT CERV SPN STRL BOTH IP/OP "$4,278.00 " "$3,165.72" $0.00 "$3,422.40" "$1,925.10" "$1,925.10" $0.00 $0.00 $0.00 $891.64 "$3,175.13" "$3,175.13" $0.00 $0.00 $891.54 $0.00 "$2,109.05" "$2,109.05" $0.00 "$2,139.00" "$3,388.18" "$3,422.40" $0.00 $0.00 $669.51 $0.00 $0.00 $681.06 $0.00 $0.00 $0.00 $0.00 $0.00 976-210 SUP HCPCS C1713 976-210 - PLATE 110MM TI LCK ATL VS BONE ANT CERV SPN STRL BOTH IP/OP "$4,278.00 " "$3,165.72" $0.00 "$3,422.40" "$1,925.10" "$1,925.10" $0.00 $0.00 $0.00 $891.64 "$3,175.13" "$3,175.13" $0.00 $0.00 $891.54 $0.00 "$2,109.05" "$2,109.05" $0.00 "$2,139.00" "$3,388.18" "$3,422.40" $0.00 $0.00 $669.51 $0.00 $0.00 $681.06 $0.00 $0.00 $0.00 $0.00 $0.00 976-612 SUP HCPCS C1713 976-612 - SCREW BN 4MM 12MM STRL ATL VS FX ANG SLF DRL TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 976-613 SUP HCPCS C1713 976-613 - SCREW BN 4MM 13MM STRL ATL VS FX ANG SLF DRL TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 976-614 SUP HCPCS C1713 976-614 - SCREW BN 4MM 14MM STRL ATL VS FX ANG SLF DRL TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 976-615 SUP HCPCS C1713 976-615 - SCREW BN 4MM 15MM STRL ATL VS FX ANG SLF DRL TI SPNE CRV ANT BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 976-643 SUP HCPCS C1713 976-643 - SCREW BN 4.5MM 13MM STRL ATL VS FX ANG SLF DRL TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 976-644 SUP HCPCS C1713 976-644 - SCREW BN 4.5MM 14MM STRL ATL VS FX ANG SLF DRL TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 976-645 SUP HCPCS C1713 976-645 - SCREW BN 4.5MM 15MM STRL ATL VS FX ANG SLF DRL TI SPNE CRV BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 9789- SUP Custom 27203010 9789- - SLEEVE CMPR LG KN LGTH 26- IN NS LF KDL SCD EXP ADJ CRCMF BOTH IP/OP $45.05 $33.34 $0.00 $35.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.57 $35.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 995FR19 SUP Custom 27803010 995FR19 - FREESTYLE ROOT VALVE 19 MM BOTH IP/OP "$15,330.00 " "$11,344.20" $0.00 "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,194.77" $0.00 $0.00 $0.00 $0.00 "$7,665.00" "$12,141.36" "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 995FR21 SUP Custom 27803010 995FR21 - FREESTYLE ROOT VALVE 21 MM BOTH IP/OP "$15,330.00 " "$11,344.20" $0.00 "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,194.77" $0.00 $0.00 $0.00 $0.00 "$7,665.00" "$12,141.36" "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 995FR23 SUP Custom 27803010 995FR23 - FREESTYLE ROOT VALVE 23 MM BOTH IP/OP "$15,330.00 " "$11,344.20" $0.00 "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,194.77" $0.00 $0.00 $0.00 $0.00 "$7,665.00" "$12,141.36" "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 995FR25 SUP Custom 27803010 995FR25 - FREESTYLE ROOT VALVE 25 MM BOTH IP/OP "$15,330.00 " "$11,344.20" $0.00 "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,194.77" $0.00 $0.00 $0.00 $0.00 "$7,665.00" "$12,141.36" "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 995FR29 SUP Custom 27803010 995FR29 - FREESTYLE ROOT VALVE 29 MM BOTH IP/OP "$15,330.00 " "$11,344.20" $0.00 "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,194.77" $0.00 $0.00 $0.00 $0.00 "$7,665.00" "$12,141.36" "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99-7284 SUP HCPCS C1713 99-7284 - SCREW BONE 1.5MM 4MM SELF DRILL CENTRE-DRIVE TITANIUM MANDIB BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $63.00 $63.00 $0.00 $0.00 $0.00 $29.18 $103.91 $103.91 $0.00 $0.00 $29.18 $0.00 $82.81 $82.81 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $21.91 $0.00 $0.00 $22.29 $0.00 $0.00 $0.00 $0.00 $0.00 999-LG SUP HCPCS L3702 999-LG - SPLINT ORTH LG BCKL VLCR CLSR PVC KODEL POST ELB BOTH IP/OP $66.03 $48.86 $0.00 $208.54 $29.71 $29.71 $0.00 $0.00 $198.92 $208.54 $49.00 $49.00 $0.00 $0.00 $13.76 $0.00 $39.05 $39.05 $0.00 $33.01 $52.30 $52.82 $39.62 $39.62 $198.56 $0.00 $0.00 $202.65 $0.00 $0.00 $0.00 $0.00 $0.00 999-MED SUP HCPCS L3702 999-MED - SPLINT ORTH MED BCKL VLCR CLSR PVC KODEL POST ELB BOTH IP/OP $66.03 $48.86 $0.00 $208.54 $29.71 $29.71 $0.00 $0.00 $198.92 $208.54 $49.00 $49.00 $0.00 $0.00 $13.76 $0.00 $39.05 $39.05 $0.00 $33.01 $52.30 $52.82 $39.62 $39.62 $198.56 $0.00 $0.00 $202.65 $0.00 $0.00 $0.00 $0.00 $0.00 9AC50 SUP Custom 27203010 9AC50 - TOOL LEGEND 9CM 5MM AC BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9AC60 SUP Custom 27203010 9AC60 - TOOL LEGEND 9CM 6MM AC BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9AC75 SUP Custom 27203010 9AC75 - TOOL LEGEND 9CM 7.5MM AC BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9AC90 SUP Custom 27203010 9AC90 - TOOL LEGEND 9CM 9MM AC BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA30 SUP Custom 27203010 9BA30 - TOOL LEGEND 9CM 3MM BA BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA30D SUP Custom 27203010 9BA30D - TOOL LEGEND 9CM 3MM BA DIAM BOTH IP/OP $380.38 $281.48 $0.00 $304.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.31 $282.31 $0.00 $0.00 $79.27 $0.00 $0.00 $0.00 $0.00 $190.19 $301.26 $304.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA30DC SUP Custom 27203010 9BA30DC - TOOL LEGEND 9CM 3MM BA DIAM CRS BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA40 SUP Custom 27203010 9BA40 - TOOL LEGEND 9CM 4MM BA FLUTED BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA40D SUP Custom 27203010 9BA40D - TOOL LEGEND 9CM 4MM BA DIAM BOTH IP/OP $380.38 $281.48 $0.00 $304.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.31 $282.31 $0.00 $0.00 $79.27 $0.00 $0.00 $0.00 $0.00 $190.19 $301.26 $304.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA40DC SUP Custom 27203010 9BA40DC - TOOL LEGEND 9CM 4MM BA DIAM CRS BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA40DX SUP Custom 27203010 9BA40DX - TOOL LEGEND 9CM 4MM DIAM X CRS BOTH IP/OP $378.25 $279.91 $0.00 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.74 $280.74 $0.00 $0.00 $78.83 $0.00 $0.00 $0.00 $0.00 $189.13 $299.57 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA50DC SUP Custom 27203010 9BA50DC - TOOL LEGEND 9CM 5MM BA DIAM CRS BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA50DX SUP Custom 27203010 9BA50DX - TOOL LEGEND 9CM 5MM DIAM X CRS BOTH IP/OP $378.25 $279.91 $0.00 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.74 $280.74 $0.00 $0.00 $78.83 $0.00 $0.00 $0.00 $0.00 $189.13 $299.57 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA60DC SUP Custom 27203010 9BA60DC - TOOL LEGEND 9CM 6MM BA DIAM CRS BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $283.89 $283.89 $0.00 $0.00 $79.71 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA60DX SUP Custom 27203010 9BA60DX - TOOL LEGEND 9CM 6MM DIAM X CRS BOTH IP/OP $378.25 $279.91 $0.00 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.74 $280.74 $0.00 $0.00 $78.83 $0.00 $0.00 $0.00 $0.00 $189.13 $299.57 $302.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA75D SUP Custom 27203010 9BA75D - TOOL LEGEND 9CM 7.5MM BA DIAM BOTH IP/OP $380.38 $281.48 $0.00 $304.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.31 $282.31 $0.00 $0.00 $79.27 $0.00 $0.00 $0.00 $0.00 $190.19 $301.26 $304.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9BA90 SUP Custom 27203010 9BA90 - TOOL LEGEND 9CM 9MM BA BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9CY50 SUP Custom 27203010 9CY50 - TOOL LEGEND 9CM 5MM CY BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9CY60 SUP Custom 27203010 9CY60 - TOOL LEGEND 9CM 6MM CY BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9CY75 SUP Custom 27203010 9CY75 - TOOL LEGEND 9CM 7.5MM CY BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9HM100 SUP Custom 27203010 9HM100 - TOOL LEGEND 9CM 10MM HOLE MAKER BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9HM126 SUP Custom 27203010 9HM126 - TOOL LEGEND 9CM 12.6MM HOLE MAKER BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9HM95 SUP Custom 27203010 9HM95 - TOOL LEGEND 9CM 9.5MM HOLE MAKER BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9HS108 SUP Custom 27203010 9HS108 - TOOL LEGEND 9CM 10.8MM ID HS BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9HS135 SUP Custom 27203010 9HS135 - TOOL LEGEND 9CM 13.5MM ID HS BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9MH30DC SUP Custom 27203010 9MH30DC - TOOL LEGEND 9CM 3MM MH DIAM CRS BOTH IP/OP $367.63 $272.05 $0.00 $294.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.85 $272.85 $0.00 $0.00 $76.61 $0.00 $0.00 $0.00 $0.00 $183.81 $291.16 $294.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9OV55 SUP Custom 27203010 9OV55 - TOOL LEGEND 9CM 5.5MM OVAL BOTH IP/OP $323.00 $239.02 $0.00 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.73 $239.73 $0.00 $0.00 $67.31 $0.00 $0.00 $0.00 $0.00 $161.50 $255.82 $258.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9SCT SUP Custom 27203010 9SCT - TUBE TRACHEOSTOMY 12.1MM 9MM 99MM 1 CANNU CUFF LATEX FREE BOTH IP/OP $71.38 $52.82 $0.00 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.97 $52.97 $0.00 $0.00 $14.87 $0.00 $0.00 $0.00 $0.00 $36.22 $57.38 $57.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 9TA30 SUP Custom 27203010 9TA30 - TOOL LEGEND 9CM 3MM TA BOTH IP/OP $337.88 $250.03 $0.00 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.77 $250.77 $0.00 $0.00 $70.41 $0.00 $0.00 $0.00 $0.00 $168.94 $267.60 $270.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A0082 SUP Custom 25003010 ANTIBODY VWF 8 RBT IGG ANHMN 2ML LAB BOTH IP/OP $708.10 $523.99 $0.00 $566.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.05 $560.82 $566.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A1-0014 SUP HCPCS C1713 A1-0014 - SCREW BONE 14MM ACUTWIST BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 A1-0016 SUP HCPCS C1713 A1-0016 - SCREW BONE 16MM ACUTWIST BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 A1-0020 SUP HCPCS C1713 A1-0020 - SCREW BONE 20MM ACUTWIST BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 A1-0022 SUP HCPCS C1713 A1-0022 - SCREW BONE 22MM ACUTWIST BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 A10230592 SUP Custom 27803010 A10230592 - VALVE AORTIC 21MM EP SUP THV BOTH IP/OP "$23,350.00 " "$17,279.00" $0.00 "$18,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,866.14" $0.00 $0.00 $0.00 $0.00 "$11,675.00" "$18,493.20" "$18,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A10235766 SUP Custom 27803010 A10235766 - VALVE MTRL 25MM 23MM EP 3 PIG LEAFLETS STNT LINX AC TCH LP BOTH IP/OP "$23,350.00 " "$17,279.00" $0.00 "$18,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,866.14" $0.00 $0.00 $0.00 $0.00 "$11,675.00" "$18,493.20" "$18,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A1072 SUP Custom 27203010 A1072 - PIN SKL STRL MYFLD WNG GRV PLS ADLT CRNM DISP BOTH IP/OP $27.27 $20.18 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.24 $20.24 $0.00 $0.00 $5.68 $0.00 $0.00 $0.00 $0.00 $13.64 $21.60 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A-1083 SUP HCPCS C1713 A-1083 - PIN SKULL 13MM RED O RING SECURE FIT RIGID FIX MAYFIELD BOTH IP/OP $102.50 $75.85 $0.00 $82.00 $46.13 $46.13 $0.00 $0.00 $0.00 $21.36 $76.08 $76.08 $0.00 $0.00 $21.36 $0.00 $60.63 $60.63 $0.00 $51.25 $81.18 $82.00 $0.00 $0.00 $16.04 $0.00 $0.00 $16.32 $0.00 $0.00 $0.00 $0.00 $0.00 A14208 SUP Custom 27203010 REAGENT FOL ACCES SYN 100 TST ANALY BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A16793 SUP Custom 27203010 REAGENT ANALY UNCL DSL WSH BUFF 10L 800 SER BOTH IP/OP $77.50 $57.35 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.75 $61.38 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A16953 SUP Custom 27203010 CALIBRATOR INTC PTH UNICEL IMMUN BOTH IP/OP $382.50 $283.05 $0.00 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.25 $302.94 $306.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A16972 SUP Custom 27203010 REAGENT INTC PTH ACCES 100 TST ANALY NEO BOTH IP/OP $690.00 $510.60 $0.00 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.00 $546.48 $552.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A16P4 SUP Custom 27203010 CHEMICAL LAB ACTN POLY BTL 4L HST GRAD BOTH IP/OP $196.40 $145.34 $0.00 $157.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.20 $155.55 $157.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A16S-4 SUP Custom 27203010 CHEMICAL LAB ACTN SAFETIN 4L HST GRAD BOTH IP/OP $264.35 $195.62 $0.00 $211.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.18 $209.37 $211.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A18/20 SUP Custom 27203010 NEEDLE BIOP 18GA 20CM ACHV COAX AUTO PRGM SFT TIS DISP BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.50 $97.42 $98.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A1815 SUP Custom 27203010 NEEDLE BIOP 18GA 15CM ACHV COAX AUTO PRGM SFT TIS DISP BOTH IP/OP $92.50 $68.45 $0.00 $86.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.65 $68.65 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $54.00 $85.54 $86.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A189 SUP Custom 27203010 NEEDLE BIOP 18GA 9CM ACHV COAX AUTO PRGM SFT TIS DISP BOTH IP/OP $106.95 $79.14 $0.00 $85.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.48 $84.70 $85.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A19611 SUP Custom 27203010 REAGENT LI SYN INFNT 18ML 130 TST ANALY BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A200S SUP Custom 27203010 REAGENT SHTH FLUID A MLTLY BTL ANALY BOTH IP/OP $107.53 $79.57 $0.00 $86.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.76 $85.16 $86.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A2015-020 SUP HCPCS C1725 A2015-020 - CATHETER BLNDIL 1.5MM 150CM 20MM ARMADA FLXB MRKR STREAMLINE BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $115.39 $115.39 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 A2020 SUP Custom 27203010 NEEDLE BIOP 20GA 20CM ACHV COAX AUTO PRGM SFT TIS DISP BOTH IP/OP $116.03 $85.86 $0.00 $92.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.01 $91.90 $92.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A2020-200 SUP HCPCS C1725 A2020-200 - CATHETER BLNDIL 2MM 150CM 200MM ARMADA FLXB MRKR STREAMLINE BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $115.39 $115.39 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 A2030-080 SUP HCPCS C1725 A2030-080 - CATHETER BLNDIL 3MM 150CM 80MM ARMADA FLXB MRKR STREAMLINE BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $115.39 $115.39 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 A21101 SUP Custom 27203010 REAGENT ANA 2 A MLTLY ANALY BOTH IP/OP "$3,008.98 " "$2,226.65" $0.00 "$2,407.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,504.49" "$2,383.11" "$2,407.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A2552 25 SUP Custom 27203010 TRAY EPDRL NRV BLCK A2552 25 BOTH IP/OP $37.33 $27.62 $0.00 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.66 $29.57 $29.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A-3434 SUP Custom 27203010 A-3434 - BIT DRILL 86MM AO SHAFT TWIST STOP 30MM 1.6MM 2MM SCREW BOTH IP/OP $290.00 $214.60 $0.00 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $0.00 $0.00 $0.00 $145.00 $229.68 $232.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A3524 SUP Custom 25003010 ANTIBODY TDT RBT PLYCLN .5ML LAB BOTH IP/OP "$3,400.00 " "$2,516.00" $0.00 "$2,720.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,700.00" "$2,692.80" "$2,720.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A368LL SUP HCPCS L1930 A368LL - SPLINT ORTHOPEDIC 9-10.5 LARGE 20.5IN 7.75IN POSTERIOR LEAF BOTH IP/OP $74.98 $55.49 $0.00 $59.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.65 $55.65 $0.00 $0.00 $15.62 $0.00 $0.00 $0.00 $0.00 $37.49 $59.38 $59.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A368LM SUP HCPCS L1930 A368LM - SPLINT ORTHOPEDIC 7-9 MEDIUM 19.5IN 7IN POSTERIOR LEAF BOTH IP/OP $74.98 $55.49 $0.00 $59.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.65 $55.65 $0.00 $0.00 $15.62 $0.00 $0.00 $0.00 $0.00 $37.49 $59.38 $59.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A368LX SUP HCPCS L1930 A368LX - SPLINT ORTHOPEDIC 11-12.5 XL 21.5IN 8.5IN POSTERIOR LEAF BOTH IP/OP $80.58 $59.63 $0.00 $64.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.80 $59.80 $0.00 $0.00 $16.79 $0.00 $0.00 $0.00 $0.00 $40.29 $63.82 $64.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A368RL SUP HCPCS L1930 A368RL - SPLINT ORTHOPEDIC 9-11 LARGE 20.5IN 7.75IN POSTERIOR LEAF BOTH IP/OP $74.98 $55.49 $0.00 $59.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.65 $55.65 $0.00 $0.00 $15.62 $0.00 $0.00 $0.00 $0.00 $37.49 $59.38 $59.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A368RM SUP HCPCS L1930 A368RM - SPLINT ORTHOPEDIC 7-9 MEDIUM 19.5IN 7IN POSTERIOR LEAF BOTH IP/OP $74.98 $55.49 $0.00 $59.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.65 $55.65 $0.00 $0.00 $15.62 $0.00 $0.00 $0.00 $0.00 $37.49 $59.38 $59.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A368RX SUP HCPCS L1930 A368RX - SPLINT ORTHOPEDIC 11-12.5 XL 21.5IN 8.5IN POSTERIOR LEAF BOTH IP/OP $80.58 $59.63 $0.00 $64.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.80 $59.80 $0.00 $0.00 $16.79 $0.00 $0.00 $0.00 $0.00 $40.29 $63.82 $64.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A38-212 SUP Custom 27203010 CHEMICAL GLAC ACETCID 2.5L GLS BTL ACS GRAD LAB BOTH IP/OP $267.70 $198.10 $0.00 $214.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.85 $212.02 $214.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A390014 SUP HCPCS C1713 A390014 - WASHER ORTH 8MM 4MM BOTH IP/OP $35.70 $26.42 $0.00 $28.56 $16.07 $16.07 $0.00 $0.00 $0.00 $7.44 $26.50 $26.50 $0.00 $0.00 $7.44 $0.00 $21.12 $21.12 $0.00 $17.85 $28.27 $28.56 $0.00 $0.00 $5.59 $0.00 $0.00 $5.68 $0.00 $0.00 $0.00 $0.00 $0.00 A3SR01 SUP HCPCS C1786 A3SR01 - PACEMAKER CRD ADVISA SR MR SURESCAN 1 CHMBR UNPLR BOTH IP/OP "$7,595.00 " "$5,620.30" $0.00 "$6,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,582.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,582.80" $0.00 "$3,744.34" "$3,744.34" $0.00 "$3,875.00" "$6,138.00" "$6,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.01 SUP HCPCS C1713 A-4300.01 - PLATE BN STRG 18MMX.6MM APTUS 4 HL FX TI HND 1.2/1.5MM SCR BOTH IP/OP $580.13 $429.30 $0.00 $464.10 $261.06 $261.06 $0.00 $0.00 $0.00 $120.91 $430.57 $430.57 $0.00 $0.00 $120.90 $0.00 $343.14 $343.14 $0.00 $290.06 $459.46 $464.10 $0.00 $0.00 $90.79 $0.00 $0.00 $92.36 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.03 SUP HCPCS C1713 A-4300.03 - PLATE 6 HOLE BONE BOTH IP/OP $580.13 $429.30 $0.00 $464.10 $261.06 $261.06 $0.00 $0.00 $0.00 $120.91 $430.57 $430.57 $0.00 $0.00 $120.90 $0.00 $343.14 $343.14 $0.00 $290.06 $459.46 $464.10 $0.00 $0.00 $90.79 $0.00 $0.00 $92.36 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.04 SUP HCPCS C1713 A-4300.04 - PLATE 1.5MM 16 HOLE STR BONE 1.2MM BOTH IP/OP $784.88 $580.81 $0.00 $627.90 $353.19 $353.19 $0.00 $0.00 $0.00 $163.59 $582.53 $582.53 $0.00 $0.00 $163.57 $0.00 $464.25 $464.25 $0.00 $392.44 $621.62 $627.90 $0.00 $0.00 $122.83 $0.00 $0.00 $124.95 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.05 SUP HCPCS C1713 A-4300.05 - PLATE BN CRV 69MMX.6MM APTUS 16 HL FX TI HND 1.2/1.5MM SCR BOTH IP/OP $784.88 $580.81 $0.00 $627.90 $353.19 $353.19 $0.00 $0.00 $0.00 $163.59 $582.53 $582.53 $0.00 $0.00 $163.57 $0.00 $464.25 $464.25 $0.00 $392.44 $621.62 $627.90 $0.00 $0.00 $122.83 $0.00 $0.00 $124.95 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.06 SUP HCPCS C1713 A-4300.06 - PLATE BN OFST 51MMX.6MM APTUS 16 HL FX TI HND 1.2/1.5MM SCR BOTH IP/OP $784.88 $580.81 $0.00 $627.90 $353.19 $353.19 $0.00 $0.00 $0.00 $163.59 $582.53 $582.53 $0.00 $0.00 $163.57 $0.00 $464.25 $464.25 $0.00 $392.44 $621.62 $627.90 $0.00 $0.00 $122.83 $0.00 $0.00 $124.95 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.10 SUP HCPCS C1713 A-4300.10 - PLATE BN T 27MMX.6MM APTUS 2X5 HL FX TI HND 1.2/1.5MM SCR BOTH IP/OP $690.38 $510.88 $0.00 $552.30 $310.67 $310.67 $0.00 $0.00 $0.00 $143.89 $512.40 $512.40 $0.00 $0.00 $143.87 $0.00 $408.36 $408.36 $0.00 $345.19 $546.78 $552.30 $0.00 $0.00 $108.04 $0.00 $0.00 $109.91 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.11 SUP HCPCS C1713 A-4300.11 - PLATE T 27X10X.6MM TI 1.2-1.5MM SCR 3X5 HOLE FIX APTUS BONE BOTH IP/OP $690.38 $510.88 $0.00 $552.30 $310.67 $310.67 $0.00 $0.00 $0.00 $143.89 $512.40 $512.40 $0.00 $0.00 $143.87 $0.00 $408.36 $408.36 $0.00 $345.19 $546.78 $552.30 $0.00 $0.00 $108.04 $0.00 $0.00 $109.91 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.13 SUP HCPCS C1713 A-4300.13 - PLATE BN 1.2MM 1.5MM Y 2.4 HL BOTH IP/OP $690.38 $510.88 $0.00 $552.30 $310.67 $310.67 $0.00 $0.00 $0.00 $143.89 $512.40 $512.40 $0.00 $0.00 $143.87 $0.00 $408.36 $408.36 $0.00 $345.19 $546.78 $552.30 $0.00 $0.00 $108.04 $0.00 $0.00 $109.91 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.20 SUP HCPCS C1713 A-4300.20 - PLATE BN 1.2MM 1.5MM L 2-3 HL LT BOTH IP/OP $690.38 $510.88 $0.00 $552.30 $310.67 $310.67 $0.00 $0.00 $0.00 $143.89 $512.40 $512.40 $0.00 $0.00 $143.87 $0.00 $408.36 $408.36 $0.00 $345.19 $546.78 $552.30 $0.00 $0.00 $108.04 $0.00 $0.00 $109.91 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.21 SUP HCPCS C1713 A-4300.21 - PLATE BN L RT 18MMX.6MM APTUS 2X3 HL FX TI HND 1.2/1.5MM SCR BOTH IP/OP $690.38 $510.88 $0.00 $552.30 $310.67 $310.67 $0.00 $0.00 $0.00 $143.89 $512.40 $512.40 $0.00 $0.00 $143.87 $0.00 $408.36 $408.36 $0.00 $345.19 $546.78 $552.30 $0.00 $0.00 $108.04 $0.00 $0.00 $109.91 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.50 SUP HCPCS C1713 A-4300.50 - PLATE BN RECT 9MMX.6MM APTUS 2X2 HL GRID FX TI HND 1.2/1.5MM BOTH IP/OP $711.38 $526.42 $0.00 $569.10 $320.12 $320.12 $0.00 $0.00 $0.00 $148.27 $527.98 $527.98 $0.00 $0.00 $148.25 $0.00 $420.78 $420.78 $0.00 $355.69 $563.41 $569.10 $0.00 $0.00 $111.33 $0.00 $0.00 $113.25 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.51 SUP HCPCS C1713 A-4300.51 - PLATE 1.2 MM 1.5 MM SCR LEAN MESH BONE BOTH IP/OP $711.38 $526.42 $0.00 $569.10 $320.12 $320.12 $0.00 $0.00 $0.00 $148.27 $527.98 $527.98 $0.00 $0.00 $148.25 $0.00 $420.78 $420.78 $0.00 $355.69 $563.41 $569.10 $0.00 $0.00 $111.33 $0.00 $0.00 $113.25 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.54 SUP HCPCS C1713 A-4300.54 - PLATE 1.2-1.5 MM SCR MESH TRP 2X2 HOLE BONE BOTH IP/OP $711.38 $526.42 $0.00 $569.10 $320.12 $320.12 $0.00 $0.00 $0.00 $148.27 $527.98 $527.98 $0.00 $0.00 $148.25 $0.00 $420.78 $420.78 $0.00 $355.69 $563.41 $569.10 $0.00 $0.00 $111.33 $0.00 $0.00 $113.25 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.55 SUP HCPCS C1713 A-4300.55 - PLATE BN RECT 15MMX.6MM APTUS 3X2 HL GRID FX TI HND 1.2/1.5 BOTH IP/OP $771.75 $571.10 $0.00 $617.40 $347.29 $347.29 $0.00 $0.00 $0.00 $160.85 $572.79 $572.79 $0.00 $0.00 $160.83 $0.00 $456.49 $456.49 $0.00 $385.88 $611.23 $617.40 $0.00 $0.00 $120.78 $0.00 $0.00 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.56 SUP HCPCS C1713 A-4300.56 - PLATE BN TRPZD BOTH IP/OP $771.75 $571.10 $0.00 $617.40 $347.29 $347.29 $0.00 $0.00 $0.00 $160.85 $572.79 $572.79 $0.00 $0.00 $160.83 $0.00 $456.49 $456.49 $0.00 $385.88 $611.23 $617.40 $0.00 $0.00 $120.78 $0.00 $0.00 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.58 SUP HCPCS C1713 A-4300.58 - PLATE 1.2-1.5 MM SCR MESH TRP 3X2 HOLE BONE LEFT BOTH IP/OP $771.75 $571.10 $0.00 $617.40 $347.29 $347.29 $0.00 $0.00 $0.00 $160.85 $572.79 $572.79 $0.00 $0.00 $160.83 $0.00 $456.49 $456.49 $0.00 $385.88 $611.23 $617.40 $0.00 $0.00 $120.78 $0.00 $0.00 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.59 SUP HCPCS C1713 A-4300.59 - PLATE BN TRPZD RT 17MMX.6MM APTUS 3X2 HL GRID FX TI HND BOTH IP/OP $771.75 $571.10 $0.00 $617.40 $347.29 $347.29 $0.00 $0.00 $0.00 $160.85 $572.79 $572.79 $0.00 $0.00 $160.83 $0.00 $456.49 $456.49 $0.00 $385.88 $611.23 $617.40 $0.00 $0.00 $120.78 $0.00 $0.00 $122.86 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.60 SUP HCPCS C1713 A-4300.60 - PLATE BN ANG LT 17MMX.6MM APTUS 3X3 HL GRID FX TI HND BOTH IP/OP $800.63 $592.47 $0.00 $640.50 $360.28 $360.28 $0.00 $0.00 $0.00 $166.87 $594.22 $594.22 $0.00 $0.00 $166.85 $0.00 $473.57 $473.57 $0.00 $400.31 $634.10 $640.50 $0.00 $0.00 $125.30 $0.00 $0.00 $127.46 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.61 SUP HCPCS C1713 A-4300.61 - PLATE BN ANG RT 17MMX.6MM APTUS 3X3 HL GRID FX TI HND BOTH IP/OP $800.63 $592.47 $0.00 $640.50 $360.28 $360.28 $0.00 $0.00 $0.00 $166.87 $594.22 $594.22 $0.00 $0.00 $166.85 $0.00 $473.57 $473.57 $0.00 $400.31 $634.10 $640.50 $0.00 $0.00 $125.30 $0.00 $0.00 $127.46 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.62 SUP HCPCS C1713 A-4300.62 - PLATE BN TRPZD 21MMX.6MM APTUS 4X2 HL GRID FX TI HND 1.2/1.5 BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $363.83 $363.83 $0.00 $0.00 $0.00 $168.51 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $478.23 $478.23 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $126.53 $0.00 $0.00 $128.71 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.64 SUP HCPCS C1713 A-4300.64 - PLATE BN ANG LT 20MMX.6MM APTUS 4X2 HL GRID FX TI HND BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $363.83 $363.83 $0.00 $0.00 $0.00 $168.51 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $478.23 $478.23 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $126.53 $0.00 $0.00 $128.71 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.65 SUP HCPCS C1713 A-4300.65 - PLATE BN ANG RT 20MMX.6MM APTUS 4X2 HL GRID FX TI HND BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $363.83 $363.83 $0.00 $0.00 $0.00 $168.51 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $478.23 $478.23 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $126.53 $0.00 $0.00 $128.71 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.66 SUP HCPCS C1713 A-4300.66 - PLATE BN ANG LT 27MMX.6MM APTUS 5X2 HL GRID FX TI HND BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $363.83 $363.83 $0.00 $0.00 $0.00 $168.51 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $478.23 $478.23 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $126.53 $0.00 $0.00 $128.71 $0.00 $0.00 $0.00 $0.00 $0.00 A-4300.67 SUP HCPCS C1713 A-4300.67 - PLATE BN TRPZD 33MMX.6MM APTUS 6X2 HL GRID FX TI HND 1.2/1.5 BOTH IP/OP $808.50 $598.29 $0.00 $646.80 $363.83 $363.83 $0.00 $0.00 $0.00 $168.51 $600.07 $600.07 $0.00 $0.00 $168.49 $0.00 $478.23 $478.23 $0.00 $404.25 $640.33 $646.80 $0.00 $0.00 $126.53 $0.00 $0.00 $128.71 $0.00 $0.00 $0.00 $0.00 $0.00 A43102 SUP Custom 27804086 A43102 - FILLER BN VOID 1ML GRFTN ALGRF PTTY JR DBM BOTH IP/OP $540.00 $399.60 $0.00 $432.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $400.79 $400.79 $0.00 $0.00 $112.54 $0.00 $0.00 $0.00 $0.00 $270.00 $427.68 $432.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A43103 SUP Custom 27804086 A43103 - GRAFT BN 2.5ML GRFTN PTTY JR DBM BOTH IP/OP "$1,190.00 " $880.60 $0.00 $952.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.22 $883.22 $0.00 $0.00 $248.00 $0.00 $0.00 $0.00 $0.00 $595.00 $942.48 $952.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A433F-1GAL SUP Custom 27203010 CHEMICAL METHNL 1GL F STY POLY BTL HST GRAD LAB BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A433P4 SUP Custom 27203010 CHEMICAL METHNL 4L POLY BTL HST GRAD LAB BOTH IP/OP $67.45 $49.91 $0.00 $53.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.73 $53.42 $53.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A-4340.11 SUP HCPCS C1713 A-4340.11 - PLATE BN T OFST 35X10X.6MM APTUS 3X8 HL 2 HK CMPR TI HND BOTH IP/OP $879.38 $650.74 $0.00 $703.50 $395.72 $395.72 $0.00 $0.00 $0.00 $183.28 $652.67 $652.67 $0.00 $0.00 $183.26 $0.00 $520.15 $520.15 $0.00 $439.69 $696.47 $703.50 $0.00 $0.00 $137.62 $0.00 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 A-4340.12 SUP HCPCS C1713 A-4340.12 - PLATE BN T OFST 35X13X.6MM APTUS 4X8 HL CMPR TI HND 1.2/1.5 BOTH IP/OP $879.38 $650.74 $0.00 $703.50 $395.72 $395.72 $0.00 $0.00 $0.00 $183.28 $652.67 $652.67 $0.00 $0.00 $183.26 $0.00 $520.15 $520.15 $0.00 $439.69 $696.47 $703.50 $0.00 $0.00 $137.62 $0.00 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 A-4340.30 SUP HCPCS C1713 A-4340.30 - PLATE 30MM 1.5MM SCR 4X8 HOLE GRID ANG CMPR BONE TRPZD BOTH IP/OP $950.25 $703.19 $0.00 $760.20 $427.61 $427.61 $0.00 $0.00 $0.00 $198.06 $705.28 $705.28 $0.00 $0.00 $198.03 $0.00 $562.07 $562.07 $0.00 $475.13 $752.60 $760.20 $0.00 $0.00 $148.71 $0.00 $0.00 $151.28 $0.00 $0.00 $0.00 $0.00 $0.00 A-4340.31 SUP HCPCS C1713 A-4340.31 - PLATE 5 HOLE CMPR PIN BONE RIGHT BOTH IP/OP $950.25 $703.19 $0.00 $760.20 $427.61 $427.61 $0.00 $0.00 $0.00 $198.06 $705.28 $705.28 $0.00 $0.00 $198.03 $0.00 $562.07 $562.07 $0.00 $475.13 $752.60 $760.20 $0.00 $0.00 $148.71 $0.00 $0.00 $151.28 $0.00 $0.00 $0.00 $0.00 $0.00 A-4340.32 SUP HCPCS C1713 A-4340.32 - PLATE BN .6MM APTUS 1 HL 2 HK CMPR TI HND 1.2/1.5MM SCR BOTH IP/OP $879.38 $650.74 $0.00 $703.50 $395.72 $395.72 $0.00 $0.00 $0.00 $183.28 $652.67 $652.67 $0.00 $0.00 $183.26 $0.00 $520.15 $520.15 $0.00 $439.69 $696.47 $703.50 $0.00 $0.00 $137.62 $0.00 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.01 SUP HCPCS C1713 A-4350.01 - PLATE STR 19MMX.8MM TI 1.5MM SCR 4 HOLE APTUS TRLK BONE BOTH IP/OP "$1,141.88 " $844.99 $0.00 $913.50 $513.84 $513.84 $0.00 $0.00 $0.00 $238.00 $847.50 $847.50 $0.00 $0.00 $237.97 $0.00 $675.42 $675.42 $0.00 $570.94 $904.37 $913.50 $0.00 $0.00 $178.70 $0.00 $0.00 $181.79 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.14 SUP HCPCS C1713 A-4350.14 - PLATE T 25X11X.8MM TI 1.5MM SCR 8 HOLE APTUS TRLK BONE BOTH IP/OP "$1,218.00 " $901.32 $0.00 $974.40 $548.10 $548.10 $0.00 $0.00 $0.00 $253.86 $904.00 $904.00 $0.00 $0.00 $253.83 $0.00 $720.45 $720.45 $0.00 $609.00 $964.66 $974.40 $0.00 $0.00 $190.62 $0.00 $0.00 $193.91 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.23 SUP HCPCS C1713 A-4350.23 - PLATE 23X9X.8MM TI 1.5MM SCR 6 HOLE ROT APTUS TRLK BONE BOTH IP/OP "$1,241.63 " $918.81 $0.00 $993.30 $558.73 $558.73 $0.00 $0.00 $0.00 $258.79 $921.53 $921.53 $0.00 $0.00 $258.75 $0.00 $734.42 $734.42 $0.00 $620.81 $983.37 $993.30 $0.00 $0.00 $194.31 $0.00 $0.00 $197.67 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.41 SUP HCPCS C1713 A-4350.41 - PLATE T 24X11X.8MM TI 1.5MM SCR 9 HOLE 2 ROW APTUS TRLK BONE BOTH IP/OP "$1,262.63 " $934.35 $0.00 "$1,010.10" $568.18 $568.18 $0.00 $0.00 $0.00 $263.16 $937.12 $937.12 $0.00 $0.00 $263.13 $0.00 $746.84 $746.84 $0.00 $631.31 "$1,000.00" "$1,010.10" $0.00 $0.00 $197.60 $0.00 $0.00 $201.01 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.50 SUP HCPCS C1713 A-4350.50 - PLATE RECT 9MMX.8MM TI 1.5MM SCR 4 HOLE GRID APTUS TRLK BONE BOTH IP/OP "$1,372.88 " "$1,015.93" $0.00 "$1,098.30" $617.79 $617.79 $0.00 $0.00 $0.00 $286.14 "$1,018.95" "$1,018.95" $0.00 $0.00 $286.11 $0.00 $812.06 $812.06 $0.00 $686.44 "$1,087.32" "$1,098.30" $0.00 $0.00 $214.85 $0.00 $0.00 $218.56 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.56 SUP HCPCS C1713 A-4350.56 - PLATE TRPZD 15MMX.8MM TI 1.5MM SCR 6X2 HOLE GRID APTUS TRLK BOTH IP/OP "$1,420.13 " "$1,050.90" $0.00 "$1,136.10" $639.06 $639.06 $0.00 $0.00 $0.00 $295.99 "$1,054.02" "$1,054.02" $0.00 $0.00 $295.95 $0.00 $840.00 $840.00 $0.00 $710.06 "$1,124.74" "$1,136.10" $0.00 $0.00 $222.25 $0.00 $0.00 $226.08 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.62 SUP HCPCS C1713 A-4350.62 - PLATE TRPZD 21MMX.8MM TI 1.5MM SCR 4X2 HOLE GRID APTUS TRLK BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.66 SUP HCPCS C1713 A-4350.66 - PLATE TRPZD 27MMX.8MM TI 1.5MM SCR 5X2 HOLE GRID APTUS TRLK BOTH IP/OP "$1,530.38 " "$1,132.48" $0.00 "$1,224.30" $688.67 $688.67 $0.00 $0.00 $0.00 $318.97 "$1,135.84" "$1,135.84" $0.00 $0.00 $318.93 $0.00 $905.22 $905.22 $0.00 $765.19 "$1,212.06" "$1,224.30" $0.00 $0.00 $239.50 $0.00 $0.00 $243.64 $0.00 $0.00 $0.00 $0.00 $0.00 A-4350.80 SUP HCPCS C1713 A-4350.80 - PLATE SCPHD 17MMX.8MM TI 1.5MM SCR 6 HOLE APTUS TRLK BONE BOTH IP/OP "$1,496.25 " "$1,107.23" $0.00 "$1,197.00" $673.31 $673.31 $0.00 $0.00 $0.00 $311.86 "$1,110.52" "$1,110.52" $0.00 $0.00 $311.82 $0.00 $885.03 $885.03 $0.00 $748.13 "$1,185.03" "$1,197.00" $0.00 $0.00 $234.16 $0.00 $0.00 $238.20 $0.00 $0.00 $0.00 $0.00 $0.00 A4502 SUP Custom 25003010 ANTIBODY CD117 PLYCLN RBT ANHMN .2 1ML LAB BOTH IP/OP "$1,399.23 " "$1,035.43" $0.00 "$1,119.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $699.61 "$1,108.19" "$1,119.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A45-10020 SUP HCPCS C1713 A45-10020 - SCREW BONE 4.5/3.5MM 100MM 20MM DNFX SS CORT TPR BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.01 SUP HCPCS C1713 A-4645.01 - PLATE BN STRG 29MMX1.3MM APTUS 4 HL CMPR TI MTCRPL 2/2.3MM BOTH IP/OP $816.38 $604.12 $0.00 $653.10 $367.37 $367.37 $0.00 $0.00 $0.00 $170.15 $605.91 $605.91 $0.00 $0.00 $170.13 $0.00 $482.89 $482.89 $0.00 $408.19 $646.57 $653.10 $0.00 $0.00 $127.76 $0.00 $0.00 $129.97 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.02 SUP HCPCS C1713 A-4645.02 - PLATE BN STRG 36MMX1.3MM APTUS 5 HL CMPR TI MTCRPL 2/2.3MM BOTH IP/OP $816.38 $604.12 $0.00 $653.10 $367.37 $367.37 $0.00 $0.00 $0.00 $170.15 $605.91 $605.91 $0.00 $0.00 $170.13 $0.00 $482.89 $482.89 $0.00 $408.19 $646.57 $653.10 $0.00 $0.00 $127.76 $0.00 $0.00 $129.97 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.03 SUP HCPCS C1713 A-4645.03 - PLATE BN STRG 42MMX1.3MM APTUS 6 HL CMPR TI MTCRPL 2/2.3MM BOTH IP/OP $816.38 $604.12 $0.00 $653.10 $367.37 $367.37 $0.00 $0.00 $0.00 $170.15 $605.91 $605.91 $0.00 $0.00 $170.13 $0.00 $482.89 $482.89 $0.00 $408.19 $646.57 $653.10 $0.00 $0.00 $127.76 $0.00 $0.00 $129.97 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.08 SUP HCPCS C1713 A-4645.08 - PLATE STR 2-2.3MM SCR 8 HOLE 4 CRNR FSN CMPR APTUS BONE BOTH IP/OP $918.75 $679.88 $0.00 $735.00 $413.44 $413.44 $0.00 $0.00 $0.00 $191.49 $681.90 $681.90 $0.00 $0.00 $191.47 $0.00 $543.44 $543.44 $0.00 $459.38 $727.65 $735.00 $0.00 $0.00 $143.78 $0.00 $0.00 $146.27 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.10 SUP HCPCS C1713 A-4645.10 - PLATE BN T 35MMX1.3MM APTUS 2X4 HL CMPR TI MTCRPL 2/2.3MM BOTH IP/OP $737.63 $545.85 $0.00 $590.10 $331.93 $331.93 $0.00 $0.00 $0.00 $153.74 $547.47 $547.47 $0.00 $0.00 $153.72 $0.00 $436.31 $436.31 $0.00 $368.81 $584.20 $590.10 $0.00 $0.00 $115.44 $0.00 $0.00 $117.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.16 SUP HCPCS C1713 A-4645.16 - PLATE BN T 60MMX1.3MM APTUS 2X8 HL CMPR TI MTCRPL 2/2.3MM BOTH IP/OP $997.50 $738.15 $0.00 $798.00 $448.88 $448.88 $0.00 $0.00 $0.00 $207.90 $740.34 $740.34 $0.00 $0.00 $207.88 $0.00 $590.02 $590.02 $0.00 $498.75 $790.02 $798.00 $0.00 $0.00 $156.11 $0.00 $0.00 $158.80 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.20 SUP HCPCS C1713 A-4645.20 - PLATE BN L LT 37MMX1.3MM APTUS 2X4 HL CMPR TI MTCRPL 2/2.3MM BOTH IP/OP $737.63 $545.85 $0.00 $590.10 $331.93 $331.93 $0.00 $0.00 $0.00 $153.74 $547.47 $547.47 $0.00 $0.00 $153.72 $0.00 $436.31 $436.31 $0.00 $368.81 $584.20 $590.10 $0.00 $0.00 $115.44 $0.00 $0.00 $117.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.21 SUP HCPCS C1713 A-4645.21 - PLATE BN L RT 37MMX1.3MM APTUS 2X4 HL CMPR TI MTCRPL 2/2.3MM BOTH IP/OP $737.63 $545.85 $0.00 $590.10 $331.93 $331.93 $0.00 $0.00 $0.00 $153.74 $547.47 $547.47 $0.00 $0.00 $153.72 $0.00 $436.31 $436.31 $0.00 $368.81 $584.20 $590.10 $0.00 $0.00 $115.44 $0.00 $0.00 $117.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.22 SUP HCPCS C1713 A-4645.22 - PLATE BN L LT 63MMX1.3MM APTUS 2X8 HL CMPR TI MTCRPL 2/2.3MM BOTH IP/OP $997.50 $738.15 $0.00 $798.00 $448.88 $448.88 $0.00 $0.00 $0.00 $207.90 $740.34 $740.34 $0.00 $0.00 $207.88 $0.00 $590.02 $590.02 $0.00 $498.75 $790.02 $798.00 $0.00 $0.00 $156.11 $0.00 $0.00 $158.80 $0.00 $0.00 $0.00 $0.00 $0.00 A-4645.23 SUP HCPCS C1713 A-4645.23 - PLATE RIGHT ANG 63MMX1.3MM 2-2.3MM SCR 2X8 HOLE CMPR BAR BOTH IP/OP $997.50 $738.15 $0.00 $798.00 $448.88 $448.88 $0.00 $0.00 $0.00 $207.90 $740.34 $740.34 $0.00 $0.00 $207.88 $0.00 $590.02 $590.02 $0.00 $498.75 $790.02 $798.00 $0.00 $0.00 $156.11 $0.00 $0.00 $158.80 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.03 SUP HCPCS C1713 A-4650.03 - PLATE BN STRG 33MMX1MM APTUS TRLK 6 HL TI HND 2/2.3MM SCR BOTH IP/OP "$1,186.50 " $878.01 $0.00 $949.20 $533.93 $533.93 $0.00 $0.00 $0.00 $247.30 $880.62 $880.62 $0.00 $0.00 $247.27 $0.00 $701.81 $701.81 $0.00 $593.25 $939.71 $949.20 $0.00 $0.00 $185.69 $0.00 $0.00 $188.89 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.10 SUP HCPCS C1713 A-4650.10 - PLATE BN T 29MMX1MM APTUS TRLK 2X4 HL TI HND 2/2.3MM SCR BOTH IP/OP "$1,228.50 " $909.09 $0.00 $982.80 $552.83 $552.83 $0.00 $0.00 $0.00 $256.05 $911.79 $911.79 $0.00 $0.00 $256.02 $0.00 $726.66 $726.66 $0.00 $614.25 $972.97 $982.80 $0.00 $0.00 $192.26 $0.00 $0.00 $195.58 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.11 SUP HCPCS C1713 A-4650.11 - PLATE BN T 29X13X1MM APTUS TRLK 3X4 HL TI HND 2/2.3MM SCR BOTH IP/OP "$1,286.25 " $951.83 $0.00 "$1,029.00" $578.81 $578.81 $0.00 $0.00 $0.00 $268.09 $954.65 $954.65 $0.00 $0.00 $268.05 $0.00 $760.82 $760.82 $0.00 $643.13 "$1,018.71" "$1,029.00" $0.00 $0.00 $201.30 $0.00 $0.00 $204.77 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.13 SUP HCPCS C1713 A-4650.13 - PLATE BN Y 35MMX1MM APTUS TRLK 2X5 HL TI HND 2/2.3MM SCR BOTH IP/OP "$1,265.25 " $936.29 $0.00 "$1,012.20" $569.36 $569.36 $0.00 $0.00 $0.00 $263.71 $939.07 $939.07 $0.00 $0.00 $263.68 $0.00 $748.40 $748.40 $0.00 $632.63 "$1,002.08" "$1,012.20" $0.00 $0.00 $198.01 $0.00 $0.00 $201.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.20 SUP HCPCS C1713 A-4650.20 - PLATE 20MM 2MM SCR 4 HOLE L LCK GRID CMPR BONE TRPZD BOTH IP/OP "$1,218.00 " $901.32 $0.00 $974.40 $548.10 $548.10 $0.00 $0.00 $0.00 $253.86 $904.00 $904.00 $0.00 $0.00 $253.83 $0.00 $720.45 $720.45 $0.00 $609.00 $964.66 $974.40 $0.00 $0.00 $190.62 $0.00 $0.00 $193.91 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.21 SUP HCPCS C1713 A-4650.21 - PLATE BN L RT 32MMX1MM APTUS TRLK 2X4 HL TI HND 2/2.3MM SCR BOTH IP/OP "$1,218.00 " $901.32 $0.00 $974.40 $548.10 $548.10 $0.00 $0.00 $0.00 $253.86 $904.00 $904.00 $0.00 $0.00 $253.83 $0.00 $720.45 $720.45 $0.00 $609.00 $964.66 $974.40 $0.00 $0.00 $190.62 $0.00 $0.00 $193.91 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.51 SUP HCPCS C1713 A-4650.51 - PLATE BN RECT 13MMX1MM APTUS TRLK 2X2 HL GRID TI HND 2/2.3MM BOTH IP/OP "$1,428.00 " "$1,056.72" $0.00 "$1,142.40" $642.60 $642.60 $0.00 $0.00 $0.00 $297.63 "$1,059.86" "$1,059.86" $0.00 $0.00 $297.60 $0.00 $844.66 $844.66 $0.00 $714.00 "$1,130.98" "$1,142.40" $0.00 $0.00 $223.48 $0.00 $0.00 $227.34 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.56 SUP HCPCS C1713 A-4650.56 - PLATE 56MM 2MM SCR 6 HOLE LCK GRID CMPR BONE TRPZD BOTH IP/OP "$1,475.25 " "$1,091.69" $0.00 "$1,180.20" $663.86 $663.86 $0.00 $0.00 $0.00 $307.48 "$1,094.93" "$1,094.93" $0.00 $0.00 $307.44 $0.00 $872.61 $872.61 $0.00 $737.63 "$1,168.40" "$1,180.20" $0.00 $0.00 $230.88 $0.00 $0.00 $234.86 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.58 SUP HCPCS C1713 A-4650.58 - PLATE 2 MM 2.3 MM SCR 3X2 HOLE LCK GRID BONE TRPZD LEFT BOTH IP/OP "$1,556.63 " "$1,151.91" $0.00 "$1,245.30" $700.48 $700.48 $0.00 $0.00 $0.00 $324.44 "$1,155.33" "$1,155.33" $0.00 $0.00 $324.40 $0.00 $920.74 $920.74 $0.00 $778.31 "$1,232.85" "$1,245.30" $0.00 $0.00 $243.61 $0.00 $0.00 $247.81 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.59 SUP HCPCS C1713 A-4650.59 - PLATE BN TRPZD RT 23MMX1MM APTUS TRLK 3X2 HL GRID TI HND BOTH IP/OP "$1,556.63 " "$1,151.91" $0.00 "$1,245.30" $700.48 $700.48 $0.00 $0.00 $0.00 $324.44 "$1,155.33" "$1,155.33" $0.00 $0.00 $324.40 $0.00 $920.74 $920.74 $0.00 $778.31 "$1,232.85" "$1,245.30" $0.00 $0.00 $243.61 $0.00 $0.00 $247.81 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.62 SUP HCPCS C1713 A-4650.62 - PLATE BN TRPZD 29MMX1MM APTUS TRLK 4X2 HL GRID TI HND 2/2.3 BOTH IP/OP "$1,556.63 " "$1,151.91" $0.00 "$1,245.30" $700.48 $700.48 $0.00 $0.00 $0.00 $324.44 "$1,155.33" "$1,155.33" $0.00 $0.00 $324.40 $0.00 $920.74 $920.74 $0.00 $778.31 "$1,232.85" "$1,245.30" $0.00 $0.00 $243.61 $0.00 $0.00 $247.81 $0.00 $0.00 $0.00 $0.00 $0.00 A-4650.67 SUP HCPCS C1713 A-4650.67 - PLATE BN TRPZD 45MMX1MM APTUS TRLK 6X2 HL GRID TI HND 2/2.3 BOTH IP/OP "$1,622.25 " "$1,200.47" $0.00 "$1,297.80" $730.01 $730.01 $0.00 $0.00 $0.00 $338.12 "$1,204.03" "$1,204.03" $0.00 $0.00 $338.08 $0.00 $959.56 $959.56 $0.00 $811.13 "$1,284.82" "$1,297.80" $0.00 $0.00 $253.88 $0.00 $0.00 $258.26 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.01 SUP HCPCS C1713 A-4655.01 - PLATE STR 27MMX1.3MM TI 2-2.3MM SCR 4 HOLE LCK GRID APTUS BOTH IP/OP "$1,572.50 " "$1,163.65" $0.00 "$1,258.00" $707.63 $707.63 $0.00 $0.00 $0.00 $327.75 "$1,167.11" "$1,167.11" $0.00 $0.00 $327.71 $0.00 $930.13 $930.13 $0.00 $786.25 "$1,245.42" "$1,258.00" $0.00 $0.00 $246.10 $0.00 $0.00 $250.34 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.02 SUP HCPCS C1713 A-4655.02 - PLATE STR 32MMX1.3MM TI 2-2.3MM SCR 5 HOLE LCK GRID APTUS BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.03 SUP HCPCS C1713 A-4655.03 - PLATE STR 38MMX1.3MM TI 2-2.3MM SCR 6 HOLE LCK GRID APTUS BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.08 SUP HCPCS C1713 A-4655.08 - PLATE 1.3MM 2MM 2.3MM SCR 8 HOLE LCK CVD BONE TRPZD BOTH IP/OP "$1,922.50 " "$1,422.65" $0.00 "$1,538.00" $865.13 $865.13 $0.00 $0.00 $0.00 $400.70 "$1,426.88" "$1,426.88" $0.00 $0.00 $400.65 $0.00 "$1,137.16" "$1,137.16" $0.00 $961.25 "$1,522.62" "$1,538.00" $0.00 $0.00 $300.87 $0.00 $0.00 $306.06 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.10 SUP HCPCS C1713 A-4655.10 - PLATE 1.3MM 2MM 2.3MM SCR 2-4 HOLE T LCK BONE TRPZD BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.16 SUP HCPCS C1713 A-4655.16 - PLATE T 56MMX1.3MM TI 2-2.3MM SCR 2X8 HOLE LCK GRID APTUS BOTH IP/OP "$1,922.50 " "$1,422.65" $0.00 "$1,538.00" $865.13 $865.13 $0.00 $0.00 $0.00 $400.70 "$1,426.88" "$1,426.88" $0.00 $0.00 $400.65 $0.00 "$1,137.16" "$1,137.16" $0.00 $961.25 "$1,522.62" "$1,538.00" $0.00 $0.00 $300.87 $0.00 $0.00 $306.06 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.20 SUP HCPCS C1713 A-4655.20 - PLATE L LEFT ANG 35MMX1.3MM TI 2-2.3MM SCR 2X6 HOLE LCK GRID BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.21 SUP HCPCS C1713 A-4655.21 - PLATE L RIGHT ANG 35MMX1.3MM TI 2-2.3MM SCR 4 HOLE LCK GRID BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.22 SUP HCPCS C1713 A-4655.22 - PLATE L LEFT ANG 58MMX1.3MM TI 2-2.3MM SCR 2X8 HOLE LCK GRID BOTH IP/OP "$1,922.50 " "$1,422.65" $0.00 "$1,538.00" $865.13 $865.13 $0.00 $0.00 $0.00 $400.70 "$1,426.88" "$1,426.88" $0.00 $0.00 $400.65 $0.00 "$1,137.16" "$1,137.16" $0.00 $961.25 "$1,522.62" "$1,538.00" $0.00 $0.00 $300.87 $0.00 $0.00 $306.06 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.23 SUP HCPCS C1713 A-4655.23 - PLATE L RIGHT ANG 58MMX1.3MM TI 2-2.3MM SCR 10 HOLE LCK GRID BOTH IP/OP "$1,922.50 " "$1,422.65" $0.00 "$1,538.00" $865.13 $865.13 $0.00 $0.00 $0.00 $400.70 "$1,426.88" "$1,426.88" $0.00 $0.00 $400.65 $0.00 "$1,137.16" "$1,137.16" $0.00 $961.25 "$1,522.62" "$1,538.00" $0.00 $0.00 $300.87 $0.00 $0.00 $306.06 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.51 SUP HCPCS C1713 A-4655.51 - PLATE 1.3MM 2MM 2.3MM SCR 2X2 HOLE LCK GRID SQ BONE TRPZD BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.56 SUP HCPCS C1713 A-4655.56 - PLATE 3X2 HOLE MESH LCK TRP BONE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.62 SUP HCPCS C1713 A-4655.62 - PLATE 1.3MM 2MM 2.3MM SCR 4X2 HOLE T LCK GRID BONE TRPZD BOTH IP/OP "$1,970.00 " "$1,457.80" $0.00 "$1,576.00" $886.50 $886.50 $0.00 $0.00 $0.00 $410.60 "$1,462.13" "$1,462.13" $0.00 $0.00 $410.55 $0.00 "$1,165.26" "$1,165.26" $0.00 $985.00 "$1,560.24" "$1,576.00" $0.00 $0.00 $308.31 $0.00 $0.00 $313.62 $0.00 $0.00 $0.00 $0.00 $0.00 A-4655.66 SUP HCPCS C1713 A-4655.66 - PLATE TRPZD 42MMX1.3MM TI 2-2.3MM SCR 5X2 HOLE LCK GRID BOTH IP/OP "$2,057.50 " "$1,522.55" $0.00 "$1,646.00" $925.88 $925.88 $0.00 $0.00 $0.00 $428.83 "$1,527.08" "$1,527.08" $0.00 $0.00 $428.78 $0.00 "$1,217.01" "$1,217.01" $0.00 "$1,028.75" "$1,629.54" "$1,646.00" $0.00 $0.00 $322.00 $0.00 $0.00 $327.55 $0.00 $0.00 $0.00 $0.00 $0.00 A-5040.21/1 SUP Custom 27203010 A-5040.21/1 - WIRE FX 1.2MM 150MM NS KRSH APTUS TROC TIP SS BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $0.00 $0.00 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.04/1 SUP HCPCS C1713 A-5100.04/1 - SCREW 4MM 1.2MM 4MM HEAD CORT BONE BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.05/1 SUP HCPCS C1713 A-5100.05/1 - SCREW BONE 1.2MM 5MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.06/1 SUP HCPCS C1713 A-5100.06/1 - SCREW BONE 1.2MM 6MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.07/1 SUP HCPCS C1713 A-5100.07/1 - SCREW BONE 1.2MM 7MM APTUS TI 4MM HEAD CORTEX HAND HEXADRIVE BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.08/1 SUP HCPCS C1713 A-5100.08/1 - SCREW BONE 1.2MM 08MM CORT HD4 1-PKG BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.09/1 SUP HCPCS C1713 A-5100.09/1 - SCREW BONE 1.2MM 9MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.10/1 SUP HCPCS C1713 A-5100.10/1 - SCREW BONE 10MM 1.2MM 4MM HEAD CORT BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.12/1 SUP HCPCS C1713 A-5100.12/1 - SCREW BONE 1.2MM 12MM 4MM HEAD CORTEX HAND HEXADRIVE 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.14/1 SUP HCPCS C1713 A-5100.14/1 - SCREW BONE 1.2MM 14MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5100.16/1 SUP HCPCS C1713 A-5100.16/1 - SCREW BONE 1.2MM 16MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.04/1 SUP HCPCS C1713 A-5200.04/1 - SCREW BONE 1.5MM 4MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.05/1 SUP HCPCS C1713 A-5200.05/1 - SCREW BONE 1.5MM 5MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.06 SUP HCPCS C1713 A-5200.06 - SCREW BONE 6MM 1.5MM CORTICAL BOTH IP/OP $218.50 $161.69 $0.00 $174.80 $98.33 $98.33 $0.00 $0.00 $0.00 $45.54 $162.17 $162.17 $0.00 $0.00 $45.54 $0.00 $129.24 $129.24 $0.00 $109.25 $173.05 $174.80 $0.00 $0.00 $34.20 $0.00 $0.00 $34.79 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.06/1 SUP HCPCS C1713 A-5200.06/1 - SCREW BONE 1.5MM 6MM APTUS TI HAND CORT HEXADRIVE 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.07/1 SUP HCPCS C1713 A-5200.07/1 - SCREW BONE 1.5MM 7MM APTUS TI HAND CORT HEXADRIVE 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.08 SUP HCPCS C1713 A-5200.08 - SCREW BONE 8MM HEXADRIVE 4 APTUS TITANIUM 1.5MM CORTICAL BOTH IP/OP $218.50 $161.69 $0.00 $174.80 $98.33 $98.33 $0.00 $0.00 $0.00 $45.54 $162.17 $162.17 $0.00 $0.00 $45.54 $0.00 $129.24 $129.24 $0.00 $109.25 $173.05 $174.80 $0.00 $0.00 $34.20 $0.00 $0.00 $34.79 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.08/1 SUP HCPCS C1713 A-5200.08/1 - SCREW BONE 1.5MM 8MM APTUS TI CORTEX HAND GRN BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.09/1 SUP HCPCS C1713 A-5200.09/1 - SCREW BONE 1.5MM 9MM APTUS TI HAND CORT HEXADRIVE 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.10 SUP HCPCS C1713 A-5200.10 - SCREW BONE 10MM WASHER TWIST DRILL HEXADRIVE 4 APTUS GREEN BOTH IP/OP $218.50 $161.69 $0.00 $174.80 $98.33 $98.33 $0.00 $0.00 $0.00 $45.54 $162.17 $162.17 $0.00 $0.00 $45.54 $0.00 $129.24 $129.24 $0.00 $109.25 $173.05 $174.80 $0.00 $0.00 $34.20 $0.00 $0.00 $34.79 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.10/1 SUP HCPCS C1713 A-5200.10/1 - SCREW BONE 1.5MM 10MM APTUS TI HAND CORT HEXADRIVE 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.11/1 SUP HCPCS C1713 A-5200.11/1 - SCREW BONE 1.5MM 11MM APTUS TI 4MM HEAD CORTEX ELB HAND BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.12/1 SUP HCPCS C1713 A-5200.12/1 - SCREW BONE 1.5MM 12MM APTUS TI 4MM HEAD CORTEX HAND 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.13/1 SUP HCPCS C1713 A-5200.13/1 - SCREW BONE 1.5MM 13MM APTUS TI 4MM HEAD CORTEX ELB HAND BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.14/1 SUP HCPCS C1713 A-5200.14/1 - SCREW BONE 1.5MM 14MM APTUS TI HAND CORT HEXADRIVE 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.15/1 SUP HCPCS C1713 A-5200.15/1 - SCREW BONE 1.5MM 15MM APTUS TI CORTEX HAND HEXADRIVE 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.16/1 SUP HCPCS C1713 A-5200.16/1 - SCREW BN 1.5MM 16MM 4 HNDL CORT BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.17/1 SUP HCPCS C1713 A-5200.17/1 - SCREW BN 1.5MM 17MM 4 HNDL CORT BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.18/1 SUP HCPCS C1713 A-5200.18/1 - SCREW BONE 1.5MM 18MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.19/1 SUP HCPCS C1713 A-5200.19/1 - SCREW BONE 1.5MM 19MM APTUS CORT BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.20/1 SUP HCPCS C1713 A-5200.20/1 - SCREW BONE 1.5MM 20MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.21/1 SUP HCPCS C1713 A-5200.21/1 - SCREW BONE 1.5MM 21MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.22/1 SUP HCPCS C1713 A-5200.22/1 - SCREW BONE 1.5MM 22MM APTUS CORT BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.23/1 SUP HCPCS C1713 A-5200.23/1 - SCREW BN 1.5MM 23MM APTUS CORT BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5200.24/1 SUP HCPCS C1713 A-5200.24/1 - SCREW BONE 1.5MM 24MM APTUS TI CORTEX HAND HEXADRIVE 4 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.04/1 SUP HCPCS C1713 A-5250.04/1 - SCREW BONE 1.5MM 4MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.05/1 SUP HCPCS C1713 A-5250.05/1 - SCREW BONE 1.5MM 5MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.06/1 SUP HCPCS C1713 A-5250.06/1 - SCREW BONE 1.5MM 6MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.07 SUP HCPCS C1713 A-5250.07 - SCREW BONE 7MM 2 THREADED HEXADRIVE 4 OPTIMAL SELF RETAINING BOTH IP/OP $218.50 $161.69 $0.00 $174.80 $98.33 $98.33 $0.00 $0.00 $0.00 $45.54 $162.17 $162.17 $0.00 $0.00 $45.54 $0.00 $129.24 $129.24 $0.00 $109.25 $173.05 $174.80 $0.00 $0.00 $34.20 $0.00 $0.00 $34.79 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.07/1 SUP HCPCS C1713 A-5250.07/1 - SCREW BONE 1.5MM 7MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.08 SUP HCPCS C1713 A-5250.08 - SCREW BONE 8MM 2 THREAD HEXADRIVE 4 ATRAUMATIC TIP LOCKING BOTH IP/OP $305.00 $225.70 $0.00 $244.00 $137.25 $137.25 $0.00 $0.00 $0.00 $63.57 $226.37 $226.37 $0.00 $0.00 $63.56 $0.00 $180.41 $180.41 $0.00 $152.50 $241.56 $244.00 $0.00 $0.00 $47.73 $0.00 $0.00 $48.56 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.08/1 SUP HCPCS C1713 A-5250.08/1 - SCREW BONE 1.5MM 8MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.09/1 SUP HCPCS C1713 A-5250.09/1 - SCREW BONE 1.5MM 9MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.10/1 SUP HCPCS C1713 A-5250.10/1 - SCREW BONE 1.5MM 10MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.11/1 SUP HCPCS C1713 A-5250.11/1 - SCREW BONE 1.5MM 11MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.12/1 SUP HCPCS C1713 A-5250.12/1 - SCREW BONE 1.5MM 12MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250.13/1 SUP HCPCS C1713 A-5250.13/1 - SCREW BONE 1.5MM 13MM APTUS TRLK TI PHLNG HAND HEXADRIVE 4 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5250-11 SUP HCPCS C1713 A-5250-11 - SCREW BONE 11MM LOCK 1.5MM CORTICAL BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 A-5300.06/1 SUP HCPCS C1713 A-5300.06/1 - SCREW BONE 1.8MM 6MM CORT 4 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5300.10/1 SUP HCPCS C1713 A-5300.10/1 - SCREW BONE 1.8MM 10MM APTUS TI 4MM HEAD CORTEX HAND ER BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.04/1 SUP HCPCS C1713 A-5400.04/1 - SCREW BONE 2MM 4MM APTUS TI CORTEX HAND HEXADRIVE 6 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.05 SUP HCPCS C1713 A-5400.05 - SCREW BONE 5MM 6MM HEAD 2MM CORTICAL BOTH IP/OP $437.00 $323.38 $0.00 $349.60 $196.65 $196.65 $0.00 $0.00 $0.00 $91.08 $324.34 $324.34 $0.00 $0.00 $91.07 $0.00 $258.49 $258.49 $0.00 $218.50 $346.10 $349.60 $0.00 $0.00 $68.39 $0.00 $0.00 $69.57 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.05/1 SUP HCPCS C1713 A-5400.05/1 - SCREW BONE 2MM 5MM APTUS TI CORTEX HAND HEXADRIVE 6 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.06/1 SUP HCPCS C1713 A-5400.06/1 - SCREW BONE 2MM 6MM APTUS TI CORTEX HAND HEXADRIVE 6 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.07/1 SUP HCPCS C1713 A-5400.07/1 - SCREW BONE 2MM 7MM APTUS TI TPR HAND WRST CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.08 SUP HCPCS C1713 A-5400.08 - SCREW BONE 8MM SLFTAP SELF RETAINING ATRAUMATIC TIP BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.08/1 SUP HCPCS C1713 A-5400.08/1 - SCREW BONE 2MM 8MM APTUS TI TPR HAND ELB WRST CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.09/1 SUP HCPCS C1713 A-5400.09/1 - SCREW BONE 2MM 9MM APTUS TI 6MM HEAD CORTEX HAND LCK BLUE BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.10/1 SUP HCPCS C1713 A-5400.10/1 - SCREW BONE 2MM 10MM APTUS TI 6MM HEAD CORTEX WRST ELB HAND BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.11 SUP HCPCS C1713 A-5400.11 - SCREW BONE 11MM SLFTAP SELF RETAINING ATRAUMATIC TIP BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.11/1 SUP HCPCS C1713 A-5400.11/1 - SCREW BONE 2MM 11MM APTUS TI CORTEX WRST ELB HAND FT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.12 SUP HCPCS C1713 A-5400.12 - SCREW BONE 12MM 6MM HEAD 2MM CORTICAL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.12/1 SUP HCPCS C1713 A-5400.12/1 - SCREW BONE 2MM 12MM APTUS TI TPR HAND ELB WRST CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.13 SUP HCPCS C1713 A-5400.13 - SCREW BONE 13MM 2MM CORTICAL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.13/1 SUP HCPCS C1713 A-5400.13/1 - SCREW BONE 2MM 13MM APTUS TI TPR HAND WRST CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.14 SUP HCPCS C1713 A-5400.14 - SCREW BONE 14MM SLFTAP SELF RETAINING ATRAUMATIC TIP BOTH IP/OP $218.50 $161.69 $0.00 $174.80 $98.33 $98.33 $0.00 $0.00 $0.00 $45.54 $162.17 $162.17 $0.00 $0.00 $45.54 $0.00 $129.24 $129.24 $0.00 $109.25 $173.05 $174.80 $0.00 $0.00 $34.20 $0.00 $0.00 $34.79 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.14/1 SUP HCPCS C1713 A-5400.14/1 - SCREW BONE 2MM 14MM APTUS TI CORTEX HAND HEXADRIVE 6 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.15/1 SUP HCPCS C1713 A-5400.15/1 - SCREW BONE 2MM 15MM APTUS TI CORTEX HAND BLUE BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.16/1 SUP HCPCS C1713 A-5400.16/1 - SCREW BONE 2MM 16MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.17 SUP HCPCS C1713 A-5400.17 - SCREW BONE 17MM APTUS BLUE TITANIUM 2MM HAND CORTICAL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.17/1 SUP HCPCS C1713 A-5400.17/1 - SCREW BONE 2MM 17MM APTUS TI CORTEX HAND BLUE BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.18/1 SUP HCPCS C1713 A-5400.18/1 - SCREW BONE 2MM 18MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.19/1 SUP HCPCS C1713 A-5400.19/1 - SCREW BONE 2MM 19MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.20 SUP HCPCS C1713 A-5400.20 - SCREW BONE 20MM 6MM HEAD 2MM CORTICAL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.20/1 SUP HCPCS C1713 A-5400.20/1 - SCREW BONE 2MM 20MM APTUS TRLK TI MIDFT HEXADRIVE 6 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.21/1 SUP HCPCS C1713 A-5400.21/1 - SCREW BONE 2MM 21MM APTUS TI CORTEX HEXADRIVE 6 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.22/1 SUP HCPCS C1713 A-5400.22/1 - SCREW BONE 2MM 22MM APTUS TI CORTEX HEXADRIVE 6 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.23/1 SUP HCPCS C1713 A-5400.23/1 - SCREW BONE 2MM 23MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5400.24/1 SUP HCPCS C1713 A-5400.24/1 - SCREW BONE 2MM 24MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.06/1 SUP HCPCS C1713 A-5450.06/1 - SCREW BONE 2MM 6MM APTUS TRLK TI FT HAND ELB WRST CORT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.07/1 SUP HCPCS C1713 A-5450.07/1 - SCREW BONE 2MM 7MM APTUS TRLK TI FT HAND WRST CORT HEXADRIVE BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.08/1 SUP HCPCS C1713 A-5450.08/1 - SCREW BONE 2MM 8MM APTUS TRLK TI FT HAND ELB WRST CORT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.09 SUP HCPCS C1713 A-5450.09 - SCREW BONE 9MM LOCK APTUS BLUE TITANIUM 2MM HAND CORTICAL BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.09/1 SUP HCPCS C1713 A-5450.09/1 - SCREW BONE 2MM 9MM APTUS TI 6MM CORTEX WRST 2 THRD TRLK BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.10 SUP HCPCS C1713 A-5450.10 - SCREW BONE 10MM TRILOCK LOCKING TECHNOLOGY SLFTAP VAR ANG BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.10/1 SUP HCPCS C1713 A-5450.10/1 - SCREW BONE 2MM 10MM APTUS TI 6MM HEAD WRST ELB HAND FT 2 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.11 SUP HCPCS C1713 A-5450.11 - SCREW BONE 11MM LOCKING HEXADRIVE 6 APTUS TRILOCK BLUE BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.11/1 SUP HCPCS C1713 A-5450.11/1 - SCREW BONE 2MM 11MM APTUS TRLK TI FT HAND WRST CORT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.12 SUP HCPCS C1713 A-5450.12 - SCREW BONE 12MM TRILOCK LOCKING TECHNOLOGY SLFTAP VAR ANG BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.12/1 SUP HCPCS C1713 A-5450.12/1 - SCREW BONE 2MM 12MM APTUS TRLK TI CORTEX FRFT MIDFT LCK BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.13/1 SUP HCPCS C1713 A-5450.13/1 - SCREW BONE 2MM 13MM APTUS TI 6MM HEAD CORTEX WRST ELB HAND BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.14/1 SUP HCPCS C1713 A-5450.14/1 - SCREW BONE 2MM 14MM APTUS TI 6MM HEAD CORTEX HAND LCK BLUE BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.16 SUP HCPCS C1713 A-5450.16 - SCREW BONE 16MM LOCKING HEXAGONAL DRIVE 2MM BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.16/1 SUP HCPCS C1713 A-5450.16/1 - SCREW BONE 2MM 16MM APTUS TRLK TI MIDFT HEXADRIVE 6 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.18/1 SUP HCPCS C1713 A-5450.18/1 - SCREW BONE 2MM 18MM APTUS TRLK TI FT HAND ELB WRST CORT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5450.20/1 SUP HCPCS C1713 A-5450.20/1 - SCREW BONE 2MM 20MM APTUS TI 6MM HEAD WRST ELB HAND FT 2 BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $151.88 $151.88 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.05/1 SUP HCPCS C1713 A-5500.05/1 - SCREW 5MM 2.3MM 6MM HEAD CORT BONE BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.06/1 SUP HCPCS C1713 A-5500.06/1 - SCREW BONE 2.3MM 6MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.07/1 SUP HCPCS C1713 A-5500.07/1 - SCREW BONE 2.3MM 7MM APTUS CORT BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.08/1 SUP HCPCS C1713 A-5500.08/1 - SCREW BONE 2.3MM 8MM APTUS TI TPR ATRM CORTEX WRST ELB HAND BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.09/1 SUP HCPCS C1713 A-5500.09/1 - SCREW BONE 2.3MM 9MM APTUS TI TPR FT HAND CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.10/1 SUP HCPCS C1713 A-5500.10/1 - SCREW BONE 2.3MM 10MM APTUS TI TPR FT HAND ELB WRST CORT 2 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.11/1 SUP HCPCS C1713 A-5500.11/1 - SCREW BONE 2.3MM 11MM APTUS TI CORTEX HAND BROWN BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.12/1 SUP HCPCS C1713 A-5500.12/1 - SCREW BONE 2.3MM 12MM APTUS TI TPR ATRM CORTEX WRST ELB HAND BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.13/1 SUP HCPCS C1713 A-5500.13/1 - SCREW BONE 2.3MM 13MM APTUS TI TPR FT HAND CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.14/1 SUP HCPCS C1713 A-5500.14/1 - SCREW BONE 2.3MM 14MM APTUS TI TPR ATRM CORTEX WRST ELB HAND BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.15/1 SUP HCPCS C1713 A-5500.15/1 - SCREW BONE 2.3MM 15MM APTUS TI TPR FT HAND CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.16/1 SUP HCPCS C1713 A-5500.16/1 - SCREW BONE 2.3MM 16MM APTUS TI TPR FT HAND ELB WRST CORT 2 BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.17/1 SUP HCPCS C1713 A-5500.17/1 - SCREW BONE 2.3MM 17MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.18/1 SUP HCPCS C1713 A-5500.18/1 - SCREW BONE 2.3MM 18MM APTUS TI TPR FT HAND CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.19/1 SUP HCPCS C1713 A-5500.19/1 - SCREW BONE 2.3MM 19MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.20/1 SUP HCPCS C1713 A-5500.20/1 - SCREW BONE 2.3MM 20MM APTUS TI TPR FT HAND CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.21/1 SUP HCPCS C1713 A-5500.21/1 - SCREW BONE 2.3MM 21MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.22/1 SUP HCPCS C1713 A-5500.22/1 - SCREW BONE 2.3MM 22MM CORT 6 HNDL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.23/1 SUP HCPCS C1713 A-5500.23/1 - SCREW BONE 2.3MM 23MM APTUS TI CORT HAND BROWN BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A-5500.24/1 SUP HCPCS C1713 A-5500.24/1 - SCREW BONE 2.3MM 24MM APTUS TI TPR FT HAND CORT 2 THRD BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $94.50 $94.50 $0.00 $0.00 $0.00 $43.77 $155.86 $155.86 $0.00 $0.00 $43.76 $0.00 $124.22 $124.22 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 A60-15030 SUP HCPCS C1713 A60-15030 - SCREW BONE 6/5MM 150MM 30MM VSN 6MM SHNK CORT ANKL THRD TPR BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 AAE21 SUP Custom 27203010 AAE21 - DST SERIES EEA 21 BX /3 BOTH IP/OP "$2,445.20 " "$1,809.45" $0.00 "$1,956.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,222.60" "$1,936.60" "$1,956.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1000 SUP Custom 27203010 ABS-1000 - SYSTEM BN CMNT 3ML DLV MX ABS BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $0.00 $0.00 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1000-L SUP Custom 27203010 ABS-1000-L - SYSTEM BN CMNT LG MX DLV APL BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1000-S SUP Custom 27203010 ABS-1000-S - SYSTEM BN CMNT STRL ARTHX DLV MX SM APL BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1001 SUP Custom 27203010 ABS-1001 - NEEDLE EPDRL TUO OBT BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.91 $103.91 $0.00 $0.00 $29.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1002 SUP Custom 27203010 ABS-1002 - NEEDLE EPDRL STRG TUO OBT BOTH IP/OP $140.00 $103.60 $0.00 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.91 $103.91 $0.00 $0.00 $29.18 $0.00 $0.00 $0.00 $0.00 $70.00 $110.88 $112.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-10020 SUP Custom 27203010 ABS-10020 - CENTRIFUGE BNCHTP 110V ACP HETTICH ROTOFIX 32 SWNG OUT RTR BOTH IP/OP "$10,750.00 " "$7,955.00" $0.00 "$8,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,240.30" $0.00 $0.00 $0.00 $0.00 "$5,375.00" "$8,514.00" "$8,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-10023 SUP HCPCS C1713 ABS-10023 - CAP CNTRF ACP HETTICH REPL BCKT ABS-10023 BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1003 SUP Custom 27203010 ABS-1003 - SYSTEM BN CMNT FNL BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-10050 SUP Custom 27203010 ABS-10050 - APPLICATOR SRG XLNG BLNT BVL 10CM VISCOGEL EZ TO FIL HVISC BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-10051 SUP Custom 27203010 ABS-10051 - APPLICATOR SRG XLNG BLNT BVL 3CM VSC SPRY EZ TO FIL LVISC MX BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS10055 SUP Custom 27203010 ABS10055 - KIT SRG STRL TULIP GEMS CELLFRIENDLY SUPERLUERLOK ADIPOSE BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1007-BC SUP HCPCS C1762 ABS-1007-BC - MATRIX TISS .75CC BIOCARTILAGE BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1010-BC SUP HCPCS C1762 ABS-1010-BC - FILLER BN VOID 1CC BIOCARTILAGE BOTH IP/OP "$2,450.00 " "$1,813.00" $0.00 "$1,960.00" $0.00 $0.00 $0.00 $0.00 $0.00 $510.64 "$1,818.39" "$1,818.39" $0.00 $0.00 $510.58 $0.00 "$1,449.18" "$1,449.18" $0.00 "$1,225.00" "$1,940.40" "$1,960.00" $0.00 $0.00 $383.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1102-19 SUP HCPCS L8699 ABS-1102-19 - GRAFT BN 19X12MM CARTIFORM BOTH IP/OP "$15,625.00 " "$11,562.50" $0.00 "$12,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,256.25" $0.00 $0.00 $0.00 $0.00 "$7,812.50" "$12,375.00" "$12,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-1102-25 SUP HCPCS L8699 ABS-1102-25 - GRAFT BN 25X20MM CARTIFORM BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 $0.00 $0.00 $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-20000 SUP Custom 27203010 ABS-20000 - NEEDLE SPNL 17GA 14.63CM 1.27CM 8 HL FENESTRATE HUB BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2001-01 SUP HCPCS C1713 ABS-2001-01 - FILLER BN VOID 1CC STIMUBLAST PTTY BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2001-02 SUP HCPCS C1713 ABS-2001-02 - FILLER BN VOID 2.5CC STIMUBLAST PTTY BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $495.00 $495.00 $0.00 $0.00 $0.00 $229.27 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $650.65 $650.65 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $172.15 $0.00 $0.00 $175.12 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2001-05 SUP HCPCS C1713 ABS-2001-05 - FILLER BN VOID 5ML STIMUBLAST PTTY RVRS PHS MED DBM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2002-05 SUP HCPCS C1713 ABS-2002-05 - FILLER BN VOID 5CC NS STIMUBLAST ARTHX GEL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2002-10 SUP HCPCS C1713 ABS-2002-10 - FILLER BN VOID 10ML STIMUBLAST GEL RVRS PHS MED DBM BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2003-05 SUP HCPCS C1713 ABS-2003-05 - FILLER BN VOID 5ML STIMUBLAST PTTY RVRS PHS MED CANC DBM BOTH IP/OP "$2,050.00 " "$1,517.00" $0.00 "$1,640.00" $922.50 $922.50 $0.00 $0.00 $0.00 $427.27 "$1,521.51" "$1,521.51" $0.00 $0.00 $427.22 $0.00 "$1,212.58" "$1,212.58" $0.00 "$1,025.00" "$1,623.60" "$1,640.00" $0.00 $0.00 $320.83 $0.00 $0.00 $326.36 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2003-10 SUP HCPCS C1713 ABS-2003-10 - FILLER BN VOID 10ML STIMUBLAST PTTY RVRS PHS MED CANC DBM BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2004-01 SUP HCPCS C1713 ABS-2004-01 - FILLER BN VOID 1ML STIMUBLAST PTTY RVRS PHS MED CANC DBM BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2004-03 SUP HCPCS C1713 ABS-2004-03 - FILLER BN VOID 3ML STIMUBLAST PST RVRS PHS MED CANC DBM BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2004-08 SUP HCPCS C1713 ABS-2004-08 - FILLER BN VOID 8ML STIMUBLAST PST RVRS PHS MED CANC DBM BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,119.38" "$1,119.38" $0.00 $0.00 $0.00 $518.46 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 "$1,471.36" "$1,471.36" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2009-02 SUP HCPCS L8699 ABS-2009-02 - GRAFT BN 2.5CC ARTHROCELL BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-2009-05 SUP HCPCS L8699 ABS-2009-05 - GRAFT BN 5CC ARTHROCELL BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-21000 SUP Custom 27203010 ABS-21000 - NEEDLE EPDRL 17GA 6IN TUO DLV BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-30001S SUP HCPCS L8699 ABS-30001S - GRAFT SFT TIS THK 5X5CM STRL HDRT RTU REINF DRML XCLR MTRX BOTH IP/OP "$4,125.00 " "$3,052.50" $0.00 "$3,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,061.58" "$3,061.58" $0.00 $0.00 $859.65 $0.00 $0.00 $0.00 $0.00 "$2,062.50" "$3,267.00" "$3,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-30002S SUP HCPCS L8699 ABS-30002S - GRAFT SFT TIS THK 8X6CM STRL HDRT RTU REINF DRML XCLR MTRX BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4003 SUP Custom 27203010 ABS-4003 - DRESSING WND 3X3IN JUMPSTART ANMC BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.98 $25.98 $0.00 $0.00 $7.29 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4004 SUP Custom 27203010 ABS-4004 - DRESSING WND 4X4IN JUMPSTART ANMC BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4005 SUP Custom 27203010 ABS-4005 - DRESSING WND 1.5IN 8IN JUMPSTART ANMC BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $0.00 $0.00 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4008 SUP Custom 27203010 ABS-4008 - DRESSING WND 8X8IN JUMPSTART ANMC BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4012 SUP Custom 27203010 ABS-4012 - DRESSING WND 12X12IN JUMPSTART 1 LYR DOT MTRX PTRN ANMC LSR BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4025 SUP Custom 27203010 ABS-4025 - DRESSING WND 2X5IN JUMPSTART ANMC BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4053 SUP Custom 27203010 ABS-4053 - DRESSING WND 4X4IN 2X2IN JUMPSTART COMP ADH BRDR PD ANMC BOTH IP/OP $82.50 $61.05 $0.00 $66.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.23 $61.23 $0.00 $0.00 $17.19 $0.00 $0.00 $0.00 $0.00 $41.25 $65.34 $66.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4054 SUP Custom 27203010 ABS-4054 - DRESSING WND 2.5IN 1IN JUMPSTART COMP ADH BRDR PD ANMC BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4056 SUP Custom 27203010 ABS-4056 - DRESSING WND 4IN 2IN JUMPSTART COMP ADH BRDR PD ANMC BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.12 $24.12 $0.00 $0.00 $6.77 $0.00 $0.00 $0.00 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4100-022 SUP HCPCS L8699 ABS-4100-022 - MATRIX TISS THN 2X2CM ARTHX AMNION BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 $0.00 $0.00 $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4100-023 SUP HCPCS L8699 ABS-4100-023 - MATRIX TISS THN 3X2CM ARTHX AMNION BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 $0.00 $0.00 $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4100-033 SUP HCPCS L8699 ABS-4100-033 - MATRIX TISS THN 3X3CM AMNION BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 $0.00 $0.00 $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4100-044 SUP HCPCS L8699 ABS-4100-044 - MATRIX TISS THN 4X4CM ARTHX AMNION BOTH IP/OP "$5,562.50 " "$4,116.25" $0.00 "$4,450.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,128.49" "$4,128.49" $0.00 $0.00 "$1,159.23" $0.00 $0.00 $0.00 $0.00 "$2,781.25" "$4,405.50" "$4,450.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4100-046 SUP HCPCS L8699 ABS-4100-046 - MATRIX TISS THN 6X4CM ALGRF AMNION BOTH IP/OP "$7,562.50 " "$5,596.25" $0.00 "$6,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,576.03" $0.00 $0.00 $0.00 $0.00 "$3,781.25" "$5,989.50" "$6,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4100-048 SUP HCPCS L8699 ABS-4100-048 - MATRIX TISS THN 8X4CM ARTHX AMNION BOTH IP/OP "$9,312.50 " "$6,891.25" $0.00 "$7,450.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,940.73" $0.00 $0.00 $0.00 $0.00 "$4,656.25" "$7,375.50" "$7,450.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4100-077 SUP HCPCS L8699 ABS-4100-077 - MATRIX TISS THN 7X7CM ARTHX AMNION BOTH IP/OP "$12,312.50 " "$9,111.25" $0.00 "$9,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,565.93" $0.00 $0.00 $0.00 $0.00 "$6,156.25" "$9,751.50" "$9,850.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4100-212 SUP HCPCS L8699 ABS-4100-212 - MATRIX TISS THN 12X2CM ARTHX AMNION BOTH IP/OP "$7,562.50 " "$5,596.25" $0.00 "$6,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,576.03" $0.00 $0.00 $0.00 $0.00 "$3,781.25" "$5,989.50" "$6,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4200-022 SUP HCPCS L8699 ABS-4200-022 - MATRIX TISS THK 2X2CM ALGRF AMNION BOTH IP/OP "$2,956.25 " "$2,187.63" $0.00 "$2,365.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,194.13" "$2,194.13" $0.00 $0.00 $616.08 $0.00 $0.00 $0.00 $0.00 "$1,478.13" "$2,341.35" "$2,365.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4200-023 SUP HCPCS L8699 ABS-4200-023 - MATRIX TISS THK 8X3CM ARTHX AMNION BOTH IP/OP "$4,250.00 " "$3,145.00" $0.00 "$3,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,154.35" "$3,154.35" $0.00 $0.00 $885.70 $0.00 $0.00 $0.00 $0.00 "$2,125.00" "$3,366.00" "$3,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4200-033 SUP HCPCS L8699 ABS-4200-033 - MATRIX TISS THK 3X3CM ALGRF AMNION BOTH IP/OP "$6,125.00 " "$4,532.50" $0.00 "$4,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,276.45" $0.00 $0.00 $0.00 $0.00 "$3,062.50" "$4,851.00" "$4,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4200-034 SUP HCPCS L8699 ABS-4200-034 - MATRIX TISS THK 4X3CM ARTHX AMNION BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 $0.00 $0.00 $0.00 "$3,500.00" "$5,544.00" "$5,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4200-036 SUP HCPCS L8699 ABS-4200-036 - MATRIX TISS THK 4X3CM AMNION BOTH IP/OP "$9,250.00 " "$6,845.00" $0.00 "$7,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,927.70" $0.00 $0.00 $0.00 $0.00 "$4,625.00" "$7,326.00" "$7,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4200-038 SUP HCPCS L8699 ABS-4200-038 - MATRIX TISS THK 8X3CM ARTHX AMNION BOTH IP/OP "$11,000.00 " "$8,140.00" $0.00 "$8,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,292.40" $0.00 $0.00 $0.00 $0.00 "$5,500.00" "$8,712.00" "$8,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4300-050 SUP HCPCS L8699 ABS-4300-050 - MATRIX TISS .5CC ARTHX ALGRF FLW AMNION BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4300-100 SUP HCPCS L8699 ABS-4300-100 - MATRIX TISS 1CC ARTHX AMNION FLW BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABS-4300-200 SUP HCPCS L8699 ABS-4300-200 - MATRIX TISS 2CC ARTHX AMNION FLW BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABSTACK15 SUP Custom 27203010 ABSTACK15 - DEVICE FIX 5MM 15 TACK RATCHET HANDLE PISTOL GRIP NO SHARP BOTH IP/OP $627.03 $464.00 $0.00 $501.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $465.38 $465.38 $0.00 $0.00 $130.67 $0.00 $0.00 $0.00 $0.00 $313.51 $496.61 $501.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ABSTACK30 SUP Custom 27203010 ABSTACK30 - DEVICE FIX 5MM 30 TACK RATCHET HANDLE PISTOL GRIP NO SHARP BOTH IP/OP "$2,104.35 " "$1,557.22" $0.00 "$1,561.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,561.85" "$1,561.85" $0.00 $0.00 $438.55 $0.00 $0.00 $0.00 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AC003 SUP Custom 27203010 AC003 - SET SPNL ADPR BRMR HL MYFLD BOTH IP/OP "$2,077.78 " "$1,537.56" $0.00 "$1,662.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,542.12" "$1,542.12" $0.00 $0.00 $433.01 $0.00 $0.00 $0.00 $0.00 "$1,038.89" "$1,645.60" "$1,662.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AC018 SUP HCPCS C1713 AC018 - PIN BRMR HL SKL STRL BOTH IP/OP $116.25 $86.03 $0.00 $93.00 $52.31 $52.31 $0.00 $0.00 $0.00 $24.23 $86.28 $86.28 $0.00 $0.00 $24.23 $0.00 $68.76 $68.76 $0.00 $58.13 $92.07 $93.00 $0.00 $0.00 $18.19 $0.00 $0.00 $18.51 $0.00 $0.00 $0.00 $0.00 $0.00 AC020 SUP HCPCS C1713 AC020 - PIN BRMR HL SKL STRL BOTH IP/OP $100.50 $74.37 $0.00 $80.40 $45.23 $45.23 $0.00 $0.00 $0.00 $20.95 $74.59 $74.59 $0.00 $0.00 $20.94 $0.00 $59.45 $59.45 $0.00 $50.25 $79.60 $80.40 $0.00 $0.00 $15.73 $0.00 $0.00 $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 AC3930A SUP Custom 27203010 AC3930A - CATHETER ANGEL BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 $0.00 $0.00 $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ACH140 SUP HCPCS C1760 ACH140 - DEVICE CLOSURE STANDARD 40MM EXCLUSION SYSTEM ATRICLIP BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,041.05" "$1,119.38" "$1,119.38" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 ACTR10 SUP Custom 27803010 ACTR10 - RING CPSLR TNSN THK.15MM 10-12.3MM STRL REFORM PMMA BOTH IP/OP $492.53 $364.47 $0.00 $394.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.55 $365.55 $0.00 $0.00 $102.64 $0.00 $0.00 $0.00 $0.00 $246.26 $390.08 $394.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ACTR11 SUP Custom 27803010 ACTR11 - RING CPSLR FX THK.17MM 11-13MM STRL REFORM PMMA BOTH IP/OP $492.53 $364.47 $0.00 $394.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.55 $365.55 $0.00 $0.00 $102.64 $0.00 $0.00 $0.00 $0.00 $246.26 $390.08 $394.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ACTR12 SUP Custom 27803010 ACTR12 - RING CPSLR TNSN THK.2MM 12-14.5MM STRL REFORM PMMA BOTH IP/OP $492.53 $364.47 $0.00 $394.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.55 $365.55 $0.00 $0.00 $102.64 $0.00 $0.00 $0.00 $0.00 $246.26 $390.08 $394.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ACU0T0.300 SUP HCPCS V2632 ACU0T0.300 - LENS IOL +30 DIOP STRL LF ACRSF ULTRASERT 1 PC FLD UV BLU BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 ACX2200 SUP Custom 27203010 NEUTRALIZER SOL GLUTEX 2 GLUT AND OPA BOTH IP/OP $13.03 $9.64 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.51 $10.32 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AD03 SUP Custom 27203010 AD03 - CHUCK DRL 1000 RPM MDSRX LGN JCB PRFR DRVR BOTH IP/OP "$7,528.10 " "$5,570.79" $0.00 "$6,022.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,568.86" $0.00 $0.00 $0.00 $0.00 "$3,764.05" "$5,962.26" "$6,022.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AD-5230 SUP HCPCS V2790 AD-5230 - GRAFT HUM TIS 3X2CM AMBIODRY2 AMNIO MEMBR DHDR STRL DISP BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 ADAPTADRK2 SUP HCPCS C2619 ADAPTADRK2 - PACEMAKER CARDIAC THK7.5MM 47.9X44.7MM IMPLTABLE 2 CHAMBER BOTH IP/OP "$8,355.00 " "$6,182.70" $0.00 "$6,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,741.18" $0.00 $0.00 $0.00 $0.00 "$4,262.50" "$6,751.80" "$6,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ADAPTALGDRK2 SUP HCPCS C2619 ADAPTALGDRK2 - KIT PCMKR LG ADAPTA 2 CHMBR 2 LD BOTH IP/OP "$8,355.00 " "$6,182.70" $0.00 "$6,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,741.18" $0.00 $0.00 $0.00 $0.00 "$4,262.50" "$6,751.80" "$6,820.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ADAPTASRK2 SUP HCPCS C2619 ADAPTASRK2 - PACEMAKER CARDIAC IMPLTABLE 1 CHAMBER RATE RESPONSIVE BOTH IP/OP "$6,382.50 " "$4,723.05" $0.00 "$5,210.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,330.11" $0.00 $0.00 $0.00 $0.00 "$3,256.25" "$5,157.90" "$5,210.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ADDR01 SUP HCPCS C1785 ADDR01 - PACEMAKER CRD 12.1CC ADAPTA DR 2 CHMBR IS-1 CNCT GNTR 27.1GM BOTH IP/OP "$6,370.00 " "$4,713.80" $0.00 "$5,200.00" "$2,925.00" "$2,925.00" $0.00 $0.00 $0.00 "$1,327.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,327.51" $0.00 "$3,140.41" "$3,140.41" $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 $0.00 "$1,017.25" $0.00 $0.00 "$1,034.80" $0.00 $0.00 $0.00 $0.00 $0.00 ADDRL1 SUP HCPCS C2619 ADDRL1 - PACEMAKER CARDIAC THK7.5MM 45.4X52.3MM 2 CHAMBER UNIPOLAR BOTH IP/OP "$6,370.00 " "$4,713.80" $0.00 "$5,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,327.51" $0.00 $0.00 $0.00 $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ADDRS1 SUP Custom 27203010 ADDRS1 - PACEMAKER CARDIAC THK7.5MM 42.9X44.7MM 2 CHAMBER UNIPOLAR BOTH IP/OP "$6,370.00 " "$4,713.80" $0.00 "$5,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,327.51" $0.00 $0.00 $0.00 $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ADP215790C SUP Custom 27011340 ADP215790C - KIT SURG PED BOTH IP/OP $29.73 $22.00 $0.00 $23.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.06 $22.06 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $14.86 $23.55 $23.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ADS201844 SUP Custom 27203010 ADS201844 - SEALANT HEMOSTATIC NEEDLE FREE ADAPTER FLOSEAL MATRIX 10ML BOTH IP/OP $339.22 $251.02 $0.00 $766.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.77 $251.77 $0.00 $0.00 $70.69 $0.00 $0.00 $0.00 $0.00 $310.31 $766.85 $496.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ADS201845 SUP Custom 27203010 ADS201845 - SEALANT HEMOSTATIC NEEDLE FREE ADAPTER FLOSEAL MATRIX 5ML BOTH IP/OP $620.62 $459.26 $0.00 $774.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $460.62 $460.62 $0.00 $0.00 $129.34 $0.00 $0.00 $0.00 $0.00 $484.13 $491.53 $774.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AF02 SUP Custom 27203010 AF02 - ATTCH TL FT MDSRX LGN 2.4MM F2 BOTH IP/OP "$2,133.10 " "$1,578.49" $0.00 "$1,706.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,583.19" "$1,583.19" $0.00 $0.00 $444.54 $0.00 $0.00 $0.00 $0.00 "$1,066.55" "$1,689.42" "$1,706.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AF101 SUP Custom 27011340 AF101 - HALTER TRC 28-38IN HALO AIRFLO SHRT HDNK VST SYS EXFIX BOTH IP/OP "$2,812.50 " "$2,081.25" $0.00 "$2,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,087.44" "$2,087.44" $0.00 $0.00 $586.13 $0.00 $0.00 $0.00 $0.00 "$1,406.25" "$2,227.50" "$2,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AF-101 SUP Custom 27203010 AF-101 - HALTER TRC 28-38IN HALO AIRFLO SHRT HDNK VST SYS EXFIX BOTH IP/OP "$3,002.13 " "$2,221.58" $0.00 "$2,401.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,228.18" "$2,228.18" $0.00 $0.00 $625.64 $0.00 $0.00 $0.00 $0.00 "$1,501.06" "$2,377.69" "$2,401.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AF102 SUP Custom 27011340 AF102 - HALTER TRC 30-44IN BREMER AIRFLO LG HDNK VST HALO BOTH IP/OP "$2,812.50 " "$2,081.25" $0.00 "$2,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,087.44" "$2,087.44" $0.00 $0.00 $586.13 $0.00 $0.00 $0.00 $0.00 "$1,406.25" "$2,227.50" "$2,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AF-1230 SUP HCPCS V2790 AF-1230 - GRAFT SFT TIS THN 3X2CM OPQ AMBIODRY5 LTWT AMNIO MEMBR BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $759.38 $759.38 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $264.09 $0.00 $0.00 $268.65 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX100 SUP HCPCS Q4125 AFLEX100 - GRAFT SFT TIS THK1.5MM 35X35MM STRL ARTHROFLEX FLEXIGRAFT BOTH IP/OP "$5,942.50 " "$4,397.45" $0.00 "$4,546.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,238.42" $0.00 $0.00 $0.00 $0.00 "$2,841.25" "$4,500.54" "$4,546.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX101 SUP HCPCS Q4125 AFLEX101 - GRAFT SFT TIS THK1.5MM 40X70MM STRL MATRACELL ARTHROFLEX BOTH IP/OP "$7,065.00 " "$5,228.10" $0.00 "$5,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,472.35" $0.00 $0.00 $0.00 $0.00 "$3,377.50" "$5,349.96" "$5,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX103 SUP HCPCS Q4125 AFLEX103 - GRAFT SFT TIS THK1.5MM 90X50MM STRL MATRACELL ARTHROFLEX BOTH IP/OP "$9,502.50 " "$7,031.85" $0.00 "$7,342.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,980.32" $0.00 $0.00 $0.00 $0.00 "$4,588.75" "$7,268.58" "$7,342.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX150 SUP HCPCS Q4125 AFLEX150 - GRAFT SFT TIS THK1.5MM 140X15MM STRL MATRACELL ARTHROFLEX BOTH IP/OP "$5,360.00 " "$3,966.40" $0.00 "$4,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,978.19" "$3,978.19" $0.00 $0.00 "$1,117.02" $0.00 $0.00 $0.00 $0.00 "$2,550.00" "$4,039.20" "$4,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX200 SUP HCPCS Q4125 AFLEX200 - GRAFT SFT TIS THK2MM 35X35MM STRL MATRACELL ARTHROFLEX BOTH IP/OP "$7,932.50 " "$5,870.05" $0.00 "$6,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,653.13" $0.00 $0.00 $0.00 $0.00 "$3,831.25" "$6,068.70" "$6,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX201 SUP HCPCS Q4125 AFLEX201 - GRAFT SFT TIS THK2MM 70X40MM STRL MATRACELL ARTHROFLEX BOTH IP/OP "$9,505.00 " "$7,033.70" $0.00 "$7,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,980.84" $0.00 $0.00 $0.00 $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX301 SUP HCPCS Q4125 AFLEX301 - GRAFT SFT TIS THK3MM 70X40MM DECELLULARIZE DERM BOTH IP/OP "$9,965.00 " "$7,374.10" $0.00 "$7,778.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,076.71" $0.00 $0.00 $0.00 $0.00 "$4,861.25" "$7,700.22" "$7,778.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX400 SUP HCPCS Q4125 AFLEX400 - GRAFT SFT TIS 40X40X1MM DECELLUARIZE DERM BOTH IP/OP "$5,495.00 " "$4,066.30" $0.00 "$4,182.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,078.39" "$4,078.39" $0.00 $0.00 "$1,145.16" $0.00 $0.00 $0.00 $0.00 "$2,613.75" "$4,140.18" "$4,182.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX401 SUP HCPCS Q4125 AFLEX401 - GRAFT SFT TIS 70X40X1MM DECELLULARIZE DERM BOTH IP/OP "$6,700.00 " "$4,958.00" $0.00 "$5,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,396.28" $0.00 $0.00 $0.00 $0.00 "$3,187.50" "$5,049.00" "$5,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AFLEX500 SUP HCPCS Q4125 AFLEX500 - GRAFT SFT TIS THK.5MM 40X30MM DECELLULARIZE DERM BOTH IP/OP "$3,107.50 " "$2,299.55" $0.00 "$2,354.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,306.39" "$2,306.39" $0.00 $0.00 $647.60 $0.00 $0.00 $0.00 $0.00 "$1,471.25" "$2,330.46" "$2,354.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AG0340 SUP HCPCS C1763 AG0340 - PROTECTOR NERVE 3.5MM 40MM REINFORCED WRAP AXOGUARD PIG BOTH IP/OP "$5,787.50 " "$4,282.75" $0.00 "$4,280.00" "$2,407.50" "$2,407.50" $0.00 $0.00 $0.00 "$1,206.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,206.12" $0.00 "$2,853.24" "$2,853.24" $0.00 "$2,675.00" "$4,237.20" "$4,280.00" $0.00 $0.00 $837.28 $0.00 $0.00 $851.72 $0.00 $0.00 $0.00 $0.00 $0.00 AG0740 SUP HCPCS C1763 AG0740 - PROTECTOR TISSUE 7MM 40MM AXOGUARD PIG EXTRACELLULAR MATRIX BOTH IP/OP "$5,935.00 " "$4,391.90" $0.00 "$4,300.00" "$2,418.75" "$2,418.75" $0.00 $0.00 $0.00 "$1,237.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,236.85" $0.00 "$2,925.96" "$2,925.96" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 $0.00 $841.19 $0.00 $0.00 $855.70 $0.00 $0.00 $0.00 $0.00 $0.00 AG1040 SUP HCPCS C1763 AG1040 - PROTECTOR NERVE 10MM 40MM MULTILAMINAR AXOGUARD BOTH IP/OP "$5,935.00 " "$4,391.90" $0.00 "$4,390.00" "$2,469.38" "$2,469.38" $0.00 $0.00 $0.00 "$1,237.00" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,236.85" $0.00 "$2,925.96" "$2,925.96" $0.00 "$2,743.75" "$4,346.10" "$4,390.00" $0.00 $0.00 $858.79 $0.00 $0.00 $873.61 $0.00 $0.00 $0.00 $0.00 $0.00 AG-2015 SUP HCPCS V2790 AG-2015 - GRAFT SOFT TISSUE B THK50-100UM 2X1.5IN ALLOGRAFT BOTH IP/OP "$1,722.50 " "$1,274.65" $0.00 "$1,340.00" $753.75 $753.75 $0.00 $0.00 $0.00 $359.01 "$1,278.44" "$1,278.44" $0.00 $0.00 $358.97 $0.00 "$1,018.86" "$1,018.86" $0.00 $837.50 "$1,326.60" "$1,340.00" $0.00 $0.00 $262.14 $0.00 $0.00 $266.66 $0.00 $0.00 $0.00 $0.00 $0.00 AGX215 SUP HCPCS C1763 AGX215 - CONNECTOR NERVE 2MM 15MM COAPTATION AID AXOGUARD PIG BOTH IP/OP "$3,730.00 " "$2,760.20" $0.00 "$2,768.41" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $777.43 "$2,768.41" "$2,768.41" $0.00 $0.00 $777.33 $0.00 "$1,838.89" "$1,838.89" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $571.13 $0.00 $0.00 $0.00 $0.00 $0.00 AGX310 SUP HCPCS C1763 AGX310 - CONNECTOR NERVE 3MM 10MM COAPTATION AID AXOGUARD PIG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AGX415 SUP HCPCS C1763 AGX415 - CONNECTOR NERVE 4MM 15MM COAPTATION AID AXOGUARD PIG BOTH IP/OP "$3,730.00 " "$2,760.20" $0.00 "$2,768.41" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $777.43 "$2,768.41" "$2,768.41" $0.00 $0.00 $777.33 $0.00 "$1,838.89" "$1,838.89" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $571.13 $0.00 $0.00 $0.00 $0.00 $0.00 AGX515 SUP HCPCS C1763 AGX515 - CONNECTOR NERVE 5MM 15MM COAPTATION AID AXOGUARD PIG BOTH IP/OP "$3,730.00 " "$2,760.20" $0.00 "$2,768.41" "$1,552.50" "$1,552.50" $0.00 $0.00 $0.00 $777.43 "$2,768.41" "$2,768.41" $0.00 $0.00 $777.33 $0.00 "$1,838.89" "$1,838.89" $0.00 "$1,725.00" "$2,732.40" "$2,760.00" $0.00 $0.00 $539.93 $0.00 $0.00 $571.13 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0010-S SUP HCPCS C1713 AI-0010-S - SCREW BONE 10MM ACUTWIST ACTRK CALC CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0012-S SUP HCPCS C1713 AI-0012-S - SCREW BONE 12MM ACUTWIST SS CALC CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0014-S SUP HCPCS C1713 AI-0014-S - SCREW BONE 14MM ACUTWIST SS FT HAND CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0016 SUP HCPCS C1713 AI-0016 - SCREW BONE 16MM ACUTWIST TI ORTH CMPR NONSTRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0016-S SUP HCPCS C1713 AI-0016-S - SCREW BONE 16MM ACUTWIST ACTRK CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0018-S SUP HCPCS C1713 AI-0018-S - SCREW BONE 18MM ACUTWIST ACTRK CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0020 SUP HCPCS C1713 AI-0020 - SCREW BONE 20MM ACUTWIST BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0020-S SUP HCPCS C1713 AI-0020-S - SCREW BONE 20MM ACUTWIST SS FT HAND CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0022-S SUP HCPCS C1713 AI-0022-S - SCREW BONE 22MM ACUTWIST ACTRK TI FULTHD HAND FT CMPR HDLS BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0024 SUP HCPCS C1713 AI-0024 - SCREW BONE 24MM ACUTWIST TI ORTH NONSTRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0024-S SUP HCPCS C1713 AI-0024-S - SCREW BONE 24MM ACUTWIST ACTRK TI ORTH CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0026 SUP HCPCS C1713 AI-0026 - SCREW BONE 26MM ACTRK ACUTWIST CMPR NONSTRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0026-S SUP HCPCS C1713 AI-0026-S - SCREW BONE 26MM ACUTWIST ACTRK ORTH CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0028-S SUP HCPCS C1713 AI-0028-S - SCREW BONE 28MM ACUTWIST ACTRK FT HAND CMPR STRL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-0030-S SUP HCPCS C1713 AI-0030-S - SCREW BONE 30MM ACUTWIST ACTRK PERIART WRST ANKL HAND FT BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AI-07127 SUP HCPCS C1725 CATHETER ANGIO 7FR 110CM 2 LUM WDG PRSS PED BOTH IP/OP $113.68 $84.12 $0.00 $90.94 $61.73 $61.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.84 $90.03 $90.94 $0.00 $0.00 $17.79 $0.00 $0.00 $18.10 $0.00 $0.00 $0.00 $0.00 $0.00 AI-EX20 SUP HCPCS C1713 AI-EX20 - SCREW BONE ACTRK ACUTWIST CMPNT XTRT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AI-NG30 SUP HCPCS C1713 AI-NG30 - SCREW BONE 30MM ACTRK ACUTWIST TI ORTH TAP NONSTRL BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 AK-01000 SUP Custom 27203010 AK-01000 - KIT THORACENTESIS 8FR 22GA 7.5IN 1.5IN 3 WAY STOPCOCK BOTH IP/OP $140.00 $103.60 $0.00 $218.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.91 $103.91 $0.00 $0.00 $29.18 $0.00 $0.00 $0.00 $0.00 $66.99 $218.12 $107.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AK-04212 SUP HCPCS C1751 AK-04212 - KIT CATHETER .032IN 16GA 18GA 20CM 2.5IN CATHETER GWIRE BOTH IP/OP $41.70 $30.86 $0.00 $33.36 $22.65 $22.65 $0.00 $0.00 $0.00 $8.69 $30.95 $30.95 $0.00 $0.00 $8.69 $0.00 $24.67 $24.67 $0.00 $20.85 $33.03 $33.36 $0.00 $0.00 $6.53 $0.00 $0.00 $6.64 $0.00 $0.00 $0.00 $0.00 $0.00 AK-09000 SUP HCPCS C1729 AK-09000 - KIT PERITONEAL LAVAGE .035IN 8FR 18GA 9.25IN 17.75IN BOTH IP/OP $58.02 $42.93 $0.00 $68.13 $46.25 $46.25 $0.00 $0.00 $0.00 $12.09 $43.06 $43.06 $0.00 $0.00 $12.09 $0.00 $34.32 $34.32 $0.00 $42.58 $67.45 $68.13 $0.00 $0.00 $13.33 $0.00 $0.00 $13.56 $0.00 $0.00 $0.00 $0.00 $0.00 AK-09601 SUP HCPCS C1894 INTRODUCER SHTH 6FR 10CM INTGR HMSTS VLV SDPRT TISS DILAT BOTH IP/OP $78.75 $58.28 $0.00 $63.00 $42.76 $42.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.38 $62.37 $63.00 $0.00 $0.00 $12.32 $0.00 $0.00 $12.54 $0.00 $0.00 $0.00 $0.00 $0.00 AK-15703-ASP SUP Custom 27203010 TRAY CATH 7FR 8IN CEN VEN A-H BL FLX 3 LUM RADIOPQ SPRG BOTH IP/OP $131.08 $97.00 $0.00 $104.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.28 $97.28 $0.00 $0.00 $27.32 $0.00 $0.00 $0.00 $0.00 $65.54 $103.82 $104.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AK-16553 SUP HCPCS C1769 KIT PED 5 1/8IN 5.5FR .018IN 3 LUM RADIOPQ SPRG GUIDEWIRE BOTH IP/OP $126.85 $93.87 $0.00 $101.48 $68.88 $68.88 $0.00 $0.00 $0.00 $26.44 $94.15 $94.15 $0.00 $0.00 $26.44 $0.00 $75.03 $75.03 $0.00 $63.43 $100.47 $101.48 $0.00 $0.00 $19.85 $0.00 $0.00 $20.19 $0.00 $0.00 $0.00 $0.00 $0.00 AK-16702 SUP HCPCS C1769 KIT 8IN 7FR .032IN 2 LUM RADIOPQ SPRG GUIDEWIRE INTROD NDL BOTH IP/OP $95.50 $70.67 $0.00 $76.40 $51.86 $51.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.75 $75.64 $76.40 $0.00 $0.00 $14.95 $0.00 $0.00 $15.20 $0.00 $0.00 $0.00 $0.00 $0.00 AK-22702 SUP HCPCS C1729 KIT CATH 6 5/16IN 7FR BLUFLTP ARWG+A BL .025IN CEN VEN PU 2 BOTH IP/OP $130.25 $96.39 $0.00 $104.20 $70.73 $70.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.13 $103.16 $104.20 $0.00 $0.00 $20.38 $0.00 $0.00 $20.74 $0.00 $0.00 $0.00 $0.00 $0.00 AK-24703-A SUP HCPCS C1729 CATHETER KIT CENTRAL VENOUS ARROWGUARD 7FR X 12IN MULTI LUM BOTH IP/OP $960.00 $710.40 $0.00 $768.00 $521.28 $521.28 $0.00 $0.00 $0.00 $200.09 $712.51 $712.51 $0.00 $0.00 $200.06 $0.00 $567.84 $567.84 $0.00 $480.00 $760.32 $768.00 $0.00 $0.00 $150.24 $0.00 $0.00 $152.83 $0.00 $0.00 $0.00 $0.00 $0.00 AK-42854-SK SUP HCPCS C1769 KIT 6IN 8.5FR .032IN 4 LUM RADIOPQ SPRG GUIDEWIRE INTROD NDL BOTH IP/OP $194.61 $144.01 $0.00 $155.69 $105.67 $105.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.31 $154.13 $155.69 $0.00 $0.00 $30.46 $0.00 $0.00 $30.98 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0025S SUP HCPCS C1713 AM-0025S - SCREW BONE 4/5MM 25MM ACTRK FIXAT STRL BOTH IP/OP $769.78 $569.64 $0.00 $615.82 $346.40 $346.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.89 $609.67 $615.82 $0.00 $0.00 $120.47 $0.00 $0.00 $122.55 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0025-S SUP HCPCS C1713 AM-0025-S - SCREW BONE 4/5MM 25MM ACTRK TI FULTHD ORTH SLFTAP CANN CMPR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0030S SUP HCPCS C1713 AM-0030S - SCREW BONE 4/5MM 30MM ACTRK FIXAT STRL BOTH IP/OP $769.78 $569.64 $0.00 $615.82 $346.40 $346.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.89 $609.67 $615.82 $0.00 $0.00 $120.47 $0.00 $0.00 $122.55 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0030-S SUP HCPCS C1713 AM-0030-S - SCREW BONE 4/5MM 30MM ACTRK TI FULTHD HINDFOOT ANKL FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0035S SUP HCPCS C1713 AM-0035S - SCREW BONE 35MM ACTRK 4/5 ACUMED FIXAT STRL BOTH IP/OP $769.78 $569.64 $0.00 $615.82 $346.40 $346.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.89 $609.67 $615.82 $0.00 $0.00 $120.47 $0.00 $0.00 $122.55 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0035-S SUP HCPCS C1713 AM-0035-S - SCREW BONE 4/5MM 35MM ACTRK TI FULTHD HINDFOOT ANKL SLFTAP BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0040S SUP HCPCS C1713 AM-0040S - SCREW BONE 40MM ACTRK 4/5 ACUMED FIXAT STRL BOTH IP/OP $769.78 $569.64 $0.00 $615.82 $346.40 $346.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.89 $609.67 $615.82 $0.00 $0.00 $120.47 $0.00 $0.00 $122.55 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0040-S SUP HCPCS C1713 AM-0040-S - SCREW BONE 4MM 5MM 40MM ACTRK TI FULTHD ORTH FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0045S SUP HCPCS C1713 AM-0045S - SCREW BONE 4/5MM 45MM ACTRK FIXAT STRL BOTH IP/OP $769.78 $569.64 $0.00 $615.82 $346.40 $346.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.89 $609.67 $615.82 $0.00 $0.00 $120.47 $0.00 $0.00 $122.55 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0045-S SUP HCPCS C1713 AM-0045-S - SCREW BN FT 4-5MM 45MM STRL ACTRK ST CNN CMPR HDLS TPR TI BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0050S SUP HCPCS C1713 AM-0050S - SCREW BONE 4/5MM 50MM ACTRK FIXAT STRL BOTH IP/OP $769.78 $569.64 $0.00 $615.82 $346.40 $346.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.89 $609.67 $615.82 $0.00 $0.00 $120.47 $0.00 $0.00 $122.55 $0.00 $0.00 $0.00 $0.00 $0.00 AM-0050-S SUP HCPCS C1713 AM-0050-S - SCREW BONE 4/5MM 50MM ACTRK TI FULTHD HINDFOOT ANKL FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AM2184 SUP Custom 27203010 STRIP UA URSTX GLUC PRTN REAGENT BOTH IP/OP $48.45 $35.85 $0.00 $38.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.23 $38.37 $38.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AM2190 SUP Custom 27203010 STRIP UA HEMASTIX URN BLOOD REAGENT BOTH IP/OP $37.98 $28.11 $0.00 $30.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.99 $30.08 $30.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AM-5010 SUP Custom 27203010 AM-5010 - BIT DRILL 4MM 5MM ACTRK STD CANN NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AM-5014 SUP Custom 27203010 AM-5014 - DRILL SRG 4/5MM ACTRK DNS CNN BN BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AMP 225 210 152 SUP HCPCS C1725 AMP 225 210 152 - CATHETER BLNDIL 2-2.5MM 150CM 210MM AM DP OTW LOPRFL TPR BRD BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $536.21 $536.21 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AM-TA25 SUP HCPCS C1713 AM-TA25 - SCREW BONE 25MM ACTRK 4/5 FT ANKL TPR NONSTRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AN04318 SUP HCPCS C1769 INTRODUCER CATH 18GA 2.5IN SPRG GUIDEWIRE BOTH IP/OP $5.38 $3.98 $0.00 $4.30 $2.92 $2.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.69 $4.26 $4.30 $0.00 $0.00 $0.84 $0.00 $0.00 $0.86 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0035-S SUP HCPCS C1713 AP-0035-S - SCREW BONE 5/6.5MM 35MM ACTRK+ TI ORTH FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0040-S SUP HCPCS C1713 AP-0040-S - SCREW BONE 5/6.5MM 40MM ACTRK+ TI HINDFOOT ANKL FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0045-S SUP HCPCS C1713 AP-0045-S - SCREW BONE 5/6.5MM 45MM ACTRK+ TI ORTH CANN STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0050-S SUP HCPCS C1713 AP-0050-S - SCREW BONE 5/6.5MM 50MM ACTRK+ TI HINDFOOT ANKL FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0055-S SUP HCPCS C1713 AP-0055-S - SCREW BONE 5/6.5MM 55MM ACTRK+ TI ORTH FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0060-S SUP HCPCS C1713 AP-0060-S - SCREW BONE 5/6.5MM 60MM ACTRK+ TI HINDFOOT ANKL FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0065-S SUP HCPCS C1713 AP-0065-S - SCREW BONE 5/6.5MM 65MM ACTRK+ TI HINDFOOT ANKL FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0070-S SUP HCPCS C1713 AP-0070-S - SCREW BONE 5/6.5MM 70MM ACMD/TRK PLUS TI ORTH FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0075-S SUP HCPCS C1713 AP-0075-S - SCREW BONE 5/6.5MM 75MM ACMD/TRK PLUS TI ORTH FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0080-S SUP HCPCS C1713 AP-0080-S - SCREW BONE 5/6.5MM 80MM ACTRK+ TI HINDFOOT ANKL FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-010 SUP Custom 27203010 AP-010 - BIT DRILL CANN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0100 SUP Custom 27203010 AP-0100 - DRILL SURG TAPER CANN ACUTRAK PLUS TITANIUM BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0104 SUP Custom 27203010 AP-0104 - DRILL SRG ACTRK+ DNS BN BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-0110 SUP Custom 27203010 AP-0110 - BIT DRL NS ACTRK+ CNN GRV SPNE BOTH IP/OP $785.00 $580.90 $0.00 $628.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $582.63 $582.63 $0.00 $0.00 $163.59 $0.00 $0.00 $0.00 $0.00 $392.50 $621.72 $628.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67008 SUP Custom 27203010 AP-67008 - DEVICE REM 4MM SCR BOTH IP/OP $747.50 $553.15 $0.00 $598.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.79 $554.79 $0.00 $0.00 $155.78 $0.00 $0.00 $0.00 $0.00 $373.75 $592.02 $598.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67011 SUP Custom 27203010 AP-67011 - DRILL SURG SM 40-120MM CANN ACTRK 6-7MM STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67012 SUP Custom 27203010 AP-67012 - DRILL SURG MED 70-85MM CANN DNS ACTRK 6-7MM STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67013 SUP Custom 27203010 AP-67013 - DRILL SURG LG 90-120MM CANN ACTRK 6-7MM NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67014 SUP Custom 27203010 AP-67014 - BIT DRILL 40-65MM 6MM 7MM ACTRK SM CANN DNS STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67015 SUP Custom 27203010 AP-67015 - DRILL HAND RED 70-85MM ACTRK MED CANN DNS 6/7 SCR SYS STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67016 SUP Custom 27203010 AP-67016 - DRILL SURG REG 40-120MM CANN ACTRK 6-7MM STRL YLW ACUTRACK BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67100-S SUP HCPCS C1713 AP-67100-S - SCREW BONE 6-7MM 100MM ACTRK TI SM BONE NONSTRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67105-S SUP HCPCS C1713 AP-67105-S - SCREW BONE 6-7MM 105MM ACTRK FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67110-S SUP HCPCS C1713 AP-67110-S - SCREW BONE 6-7MM 110MM ACTRK FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67115-S SUP HCPCS C1713 AP-67115-S - SCREW BONE 6/7MM 115MM ACTRK FIX BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-67120-S SUP HCPCS C1713 AP-67120-S - SCREW BONE 6/7MM 120MM ACTRK FIX BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6740-S SUP HCPCS C1713 AP-6740-S - SCREW BONE 6/7MM 40MM ACTRK TI FULTHD ORTH SLFTAP CANN STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6745-S SUP HCPCS C1713 AP-6745-S - SCREW BONE 6/7MM 45MM ACTRK TI FULTHD ORTH SLFTAP CANN CMPR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6750-S SUP HCPCS C1713 AP-6750-S - SCREW BONE 6/7MM 50MM ACTRK TI UPR XTRMT FRFT FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6755-S SUP HCPCS C1713 AP-6755-S - SCREW BONE 6/7MM 55MM ACTRK TI UPR XTRMT FRFT FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6760-S SUP HCPCS C1713 AP-6760-S - SCREW BONE 6/7MM 60MM ACTRK TI FULTHD ORTH SLFTAP CANN CMPR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6765-S SUP HCPCS C1713 AP-6765-S - SCREW BONE 6/7MM 65MM ACTRK TI ORTH FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6770-S SUP HCPCS C1713 AP-6770-S - SCREW BONE 6/7MM 70MM ACTRK TI ORTH FIX STRL 6 7 SCR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6775-S SUP HCPCS C1713 AP-6775-S - SCREW BONE 6/7MM 75MM ACTRK TI FULTHD ORTH SLFTAP CANN CMPR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6780-S SUP HCPCS C1713 AP-6780-S - SCREW BN .094IN 6/7MM 4MM 80MM STRL ACTRK FX TI BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6785-S SUP HCPCS C1713 AP-6785-S - SCREW BONE 6/7MM 85MM ACTRK TI UPR XTRMT FRFT FIX STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6790-S SUP HCPCS C1713 AP-6790-S - SCREW BONE 6-7MM 90MM ACTRK TI SM BONE STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AP-6795-S SUP HCPCS C1713 AP-6795-S - SCREW BONE 6/7MM 95MM ACTRK TI ORTH STRL BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AQL-110 SUP HCPCS C1713 AQL-110 - SET TBG AQUILEX FL CNTRL INFL BOTH IP/OP $397.50 $294.15 $0.00 $730.00 $410.63 $410.63 $0.00 $0.00 $0.00 $0.00 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $0.00 $0.00 $0.00 $456.25 $722.70 $730.00 $0.00 $0.00 $142.81 $0.00 $0.00 $145.27 $0.00 $0.00 $0.00 $0.00 $0.00 AQL-111 SUP Custom 27203010 AQL-111 - SET TBG AQUILEX FL CNTRL OFLW BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-005-AC00 SUP Custom 27203010 AR-005-AC00 - CLAMP XTRNFX IBALANCE ANKL UNCNDL KN ARTHOPLASTY BOTH IP/OP "$1,700.00 " "$1,258.00" $0.00 "$1,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,261.74" "$1,261.74" $0.00 $0.00 $354.28 $0.00 $0.00 $0.00 $0.00 $850.00 "$1,346.40" "$1,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1000 SUP Custom 27203010 AR-1000 - PASSER SUT TRANSOSSEOUS BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1006 SUP HCPCS C1713 AR-1006 - STAPLE BN SPK 20X6MM STRL COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $88.88 $88.88 $0.00 $0.00 $0.00 $41.16 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $116.82 $116.82 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $30.91 $0.00 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1006M SUP HCPCS C1713 AR-1006M - STAPLE BN 20X6MM STRL COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $88.88 $88.88 $0.00 $0.00 $0.00 $41.16 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $116.82 $116.82 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $30.91 $0.00 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1006MNS SUP Custom 27803010 AR-1006MNS - STAPLE BN 20X6MM NS COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1006NS SUP Custom 27803010 AR-1006NS - STAPLE BN SPK 20X6MM NS COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1008 SUP HCPCS C1713 AR-1008 - STAPLE BN SPK 20X8MM STRL LOPRFL LGMNT COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $88.88 $88.88 $0.00 $0.00 $0.00 $41.16 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $116.82 $116.82 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $30.91 $0.00 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1008NS SUP Custom 27803010 AR-1008NS - STAPLE BN SPK 20X8MM NS COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1011 SUP HCPCS C1713 AR-1011 - STAPLE BN SPK 20X11MM STRL COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $88.88 $88.88 $0.00 $0.00 $0.00 $41.16 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $116.82 $116.82 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $30.91 $0.00 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1011NS SUP Custom 27803010 AR-1011NS - STAPLE BN SPK LOPRFL 20X11MM NS COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1016 SUP HCPCS C1713 AR-1016 - STAPLE BN SPK 20X16MM STRL COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $88.88 $88.88 $0.00 $0.00 $0.00 $41.16 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $116.82 $116.82 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $30.91 $0.00 $0.00 $31.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1016NS SUP Custom 27803010 AR-1016NS - STAPLE BN SPK LOPRFL 20X16MM NS COCR ACL PCL BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1201.7D SUP Custom 27203010 AR-1201.7D - BIT DRL SM LOPRFL 1.7MM 20X25IN AMERPAK FRM 100 AO CNCT PLT BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1201-7DC SUP Custom 27203010 AR-1201-7DC - BIT DRL 1.7MM CNN AO CNCT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1202-3D SUP Custom 27203010 AR-1202-3D - BIT DRL 2.3MM SM FRAG SCR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-12040 SUP Custom 27203010 AR-12040 - PUNCH ARTHRO 3.5MM STR SER 1 DSGN WIDEBITER 3.4MM BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 $0.00 $0.00 $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-100 SUP Custom 27203010 AR-1204AF-100 - CUTTER ASCP 10MM BLU STRL LF FLIPCUTTER II DRL PIN FEM SCKT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-105 SUP Custom 27203010 AR-1204AF-105 - CUTTER ARTHRO RTRGRD LP 10.5MM DRILL PIN FEMORAL SOCKET BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-110 SUP Custom 27203010 AR-1204AF-110 - CUTTER ARTHRO RTRGRD LP 11MM DRILL PIN FEMORAL SOCKET BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-115 SUP Custom 27203010 AR-1204AF-115 - CUTTER ASCP 11.5MM FLIPCUTTER II RETROCONSTRUCTION DRL PIN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-120 SUP Custom 27203010 AR-1204AF-120 - CUTTER ASCP 12MM FLIPCUTTER II RETROCONSTRUCTION DRL PIN RMR BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-125 SUP Custom 27203010 AR-1204AF-125 - CUTTER ASCP RTRGD LOPRFL 12.5MM BLU STRL LF FLIPCUTTER II BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-130 SUP Custom 27203010 AR-1204AF-130 - CUTTER ASCP RTRGD LOPRFL 13MM BLU STRL LF FLIPCUTTER II DRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-50 SUP Custom 27203010 AR-1204AF-50 - CUTTER ASCP RTRGD LOPRFL 5MM BLU STRL LF FLIPCUTTER II DRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-55 SUP Custom 27203010 AR-1204AF-55 - CUTTER ASCP 5MM FLIPCUTTER II BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-60 SUP Custom 27203010 AR-1204AF-60 - CUTTER ASCP RTRGD LOPRFL 6MM BLU STRL LF FLIPCUTTER II DRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-65 SUP Custom 27203010 AR-1204AF-65 - CUTTER ASCP RTRGD LOPRFL 6.5MM BLU STRL LF FLIPCUTTER II DRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-70 SUP Custom 27203010 AR-1204AF-70 - CUTTER ASCP RTRGD LOPRFL 7MM BLU STRL LF FLIPCUTTER II DRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-75 SUP Custom 27203010 AR-1204AF-75 - CUTTER ASCP RTRGD 7.5MM BLU STRL LF FLIPCUTTER II DRL PIN BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-80 SUP Custom 27203010 AR-1204AF-80 - CUTTER ASCP 8MM BLU STRL LF FLIPCUTTER II DRL PIN FEM SCKT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-85 SUP Custom 27203010 AR-1204AF-85 - CUTTER ASCP 8.5MM BLU STRL LF FLIPCUTTER II DRL PIN FEM SCKT BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-90 SUP Custom 27203010 AR-1204AF-90 - CUTTER ASCP RTRGD 9MM BLU STRL LF FLIPCUTTER II DRL PIN FEM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AF-95 SUP Custom 27203010 AR-1204AF-95 - CUTTER ASCP RTRGD LOPRFL 9.5MM BLU STRL LF FLIPCUTTER II DRL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-105 SUP Custom 27203010 AR-1204AS-105 - CUTTER ASCP SHRT 10.5MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-110 SUP Custom 27203010 AR-1204AS-110 - CUTTER ASCP SHRT 11MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-120 SUP Custom 27203010 AR-1204AS-120 - CUTTER ASCP SHRT 12MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-50 SUP Custom 27203010 AR-1204AS-50 - CUTTER ASCP SHRT 5MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-55 SUP Custom 27203010 AR-1204AS-55 - CUTTER ASCP SHRT 5.5MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-60 SUP Custom 27203010 AR-1204AS-60 - CUTTER ASCP SHRT 6MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-65 SUP Custom 27203010 AR-1204AS-65 - CUTTER ASCP SHRT 6.5MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-70 SUP Custom 27203010 AR-1204AS-70 - CUTTER ASCP SHRT 7MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-75 SUP Custom 27203010 AR-1204AS-75 - CUTTER ASCP SHRT 7.5MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-80 SUP Custom 27203010 AR-1204AS-80 - CUTTER ASCP SHRT 8MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-85 SUP Custom 27203010 AR-1204AS-85 - CUTTER ASCP SHRT 8.5MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-90 SUP Custom 27203010 AR-1204AS-90 - CUTTER ARTHRO ANTM SCKT FLIPCUTTER II SHRT KNEE 9 BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204AS-95 SUP Custom 27203010 AR-1204AS-95 - CUTTER ASCP SHRT 9.5MM FLIPCUTTER II ANTM SCKT KN 3.5MM BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204D SUP Custom 27203010 AR-1204D - DRILL SURG BIT SCREW BIO-TENODESIS 4MM BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-055S SUP Custom 27203010 AR-1204R-055S - CUTTER ASCP 5.5MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-05S SUP Custom 27203010 AR-1204R-05S - CUTTER ASCP 5MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM TIB BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-065S SUP Custom 27203010 AR-1204R-065S - CUTTER ASCP 6.5MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-06S SUP Custom 27203010 AR-1204R-06S - CUTTER ASCP 6MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM TIB BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-075S SUP Custom 27203010 AR-1204R-075S - CUTTER ASCP 7.5MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-07S SUP Custom 27203010 AR-1204R-07S - CUTTER ASCP 7MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM TIB BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-08S SUP Custom 27203010 AR-1204R-08S - CUTTER ASCP 8MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM TIB BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-095S SUP Custom 27203010 AR-1204R-095S - CUTTER ASCP 9.5MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-09S SUP Custom 27203010 AR-1204R-09S - CUTTER ASCP 9MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM TIB BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-105S SUP Custom 27203010 AR-1204R-105S - CUTTER ASCP 10.5MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1204R-12S SUP Custom 27203010 AR-1204R-12S - CUTTER ASCP 12MM STRL RETROCUTTER ANTM SCKT FLXB TNL FEM TIB BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-100 SUP Custom 27203010 AR-1218-100 - DRILL SURG FULL THICK 10MM CALIBRATE DEPTH MARK CANN ACL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-105 SUP Custom 27203010 AR-1218-105 - DRILL SRG 10.5MM STRL CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-115 SUP Custom 27203010 AR-1218-115 - DRILL SRG 11.5MM STRL CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-120 SUP Custom 27203010 AR-1218-120 - DRILL SRG 12MM STRL CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-150 SUP Custom 27203010 AR-1218-150 - DRILL SRG 15MM STRL CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-40 SUP Custom 27203010 AR-1218-40 - DRILL SRG FULL THK 4MM STRL CLBRT D MRK CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-50 SUP Custom 27203010 AR-1218-50 - DRILL SRG FULL THK 5MM STRL CLBRT D MRK CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-55 SUP Custom 27203010 AR-1218-55 - DRILL SRG CNN 5.5 MM SCR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-60 SUP Custom 27203010 AR-1218-60 - DRILL SRG FULL THK 6MM STRL CLBRT D MRK CNN ACL HAZ BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-65 SUP Custom 27203010 AR-1218-65 - DRILL SRG 6.5MM STRL CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-70 SUP Custom 27203010 AR-1218-70 - DRILL SRG 7MM STRL CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-75 SUP Custom 27203010 AR-1218-75 - DRILL SURG 7.5MM CANN STERILE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-80 SUP Custom 27203010 AR-1218-80 - DRILL SRG FULL THK 8MM STRL CLBRT D MRK CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-90 SUP Custom 27203010 AR-1218-90 - DRILL SURG FULL THICK 9MM CALIBRATE DEPTH MARK CANN ACL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1218-95 SUP Custom 27203010 AR-1218-95 - DRILL SURG FULL THK CLBRT DEPTH MARK CANN ACL 9.5 BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1220S SUP Custom 27203010 AR-1220S - REAMER SRG 7MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1222S SUP Custom 27203010 AR-1222S - REAMER SRG 8MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1223S SUP Custom 27203010 AR-1223S - REAMER SRG 9MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1224S SUP Custom 27203010 AR-1224S - REAMER SRG 10MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1226S SUP Custom 27203010 AR-1226S - REAMER SRG 11MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1227S SUP Custom 27203010 AR-1227S - REAMER SRG 12MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1229S SUP Custom 27203010 AR-1229S - REAMER SRG 13MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1231S SUP Custom 27203010 AR-1231S - REAMER SRG 14MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1246-1 SUP Custom 27203010 AR-1246-1 - GUIDE DRL OFST 3MM BOTH IP/OP $780.00 $577.20 $0.00 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $578.92 $578.92 $0.00 $0.00 $162.55 $0.00 $0.00 $0.00 $0.00 $390.00 $617.76 $624.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1250 SUP Custom 27203010 AR-1250 - DRILL SRG 25-30MM 2MM 12IN STRL SEMIFIX D MRK NTNL TIB DISP BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1250F SUP Custom 27203010 AR-1250F - GUIDE PIN ORTH 3.5MM 30CM STRL PREDRILL ACL DISP FLIPCUTTER BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.64 $81.64 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1250L SUP Custom 27203010 AR-1250L - GUIDE PIN ORTH 2.4MM 30CM STRL PREDRILL ACL DISP BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1250LT SUP Custom 27203010 AR-1250LT - DRILL SRG 2.4MM STP 3MM SUT TK BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1250LTC SUP Custom 27203010 AR-1250LTC - DRILL SRG 3MM STP 3MM SUT TK HRD BN BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1252 SUP Custom 27203010 AR-1252 - DRILL SRG THK SPD 3MM SUT TK BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1254 SUP Custom 27203010 AR-1254 - GUIDE PIN ORTH 25/30MM 2MM STRL D MRK NTNL 6MM SCR BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1256 SUP Custom 27203010 AR-1256 - DRILL SRG SHRT SPD STRL BSUT TK NDL DISP SUT TK BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1257 SUP Custom 27203010 AR-1257 - DRILL SRG SPD STRL BSUT TK DISP 3MM SUT TK BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1259 SUP Custom 27203010 AR-1259 - PASSER SUT RETROPASSER NTNL ASCP BOTH IP/OP $310.00 $229.40 $0.00 $248.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.08 $230.08 $0.00 $0.00 $64.60 $0.00 $0.00 $0.00 $0.00 $155.00 $245.52 $248.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1267 SUP HCPCS C1713 AR-1267 - CAP PCTV POPLITEUM PCL BOTH IP/OP $840.00 $621.60 $0.00 $672.00 $378.00 $378.00 $0.00 $0.00 $0.00 $175.08 $623.45 $623.45 $0.00 $0.00 $175.06 $0.00 $496.86 $496.86 $0.00 $420.00 $665.28 $672.00 $0.00 $0.00 $131.46 $0.00 $0.00 $133.73 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1270 SUP Custom 27203010 AR-1270 - GUIDE DRL LNG NS RETROBUTTON D BOTH IP/OP $872.50 $645.65 $0.00 $698.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $647.57 $647.57 $0.00 $0.00 $181.83 $0.00 $0.00 $0.00 $0.00 $436.25 $691.02 $698.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-100 SUP HCPCS C1713 AR-1288-100 - SYSTEM FX SHRT 10MM TGHTRP RT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-105 SUP HCPCS C1713 AR-1288-105 - SYSTEM FX SHRT 10.5MM TGHTRP RT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-110 SUP HCPCS C1713 AR-1288-110 - SYSTEM FX 11MM TGHTRP RT SHRT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-70 SUP HCPCS C1713 AR-1288-70 - SYSTEM FX SHRT 7MM TGHTRP RT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-75 SUP HCPCS C1713 AR-1288-75 - SYSTEM FX SHRT 7.5MM TGHTRP RT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-80 SUP HCPCS C1713 AR-1288-80 - SYSTEM FX SHRT 8MM TGHTRP RT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-85 SUP HCPCS C1713 AR-1288-85 - SYSTEM FX SHRT 8.5MM TGHTRP RT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-90 SUP HCPCS C1713 AR-1288-90 - SYSTEM FX SHRT 9MM TGHTRP RT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288-95 SUP HCPCS C1713 AR-1288-95 - SYSTEM FX SHRT 9.5MM TGHTRP RT FLIPCUTTER II 2 LD BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288BTB-100 SUP HCPCS C1713 AR-1288BTB-100 - KIT FX 10MM SHRT TGHTRP FLIPCUTTER 2 LD BN TNDN BN BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288BTB-110 SUP HCPCS C1713 AR-1288BTB-110 - KIT FX 11MM SHRT TGHTRP FLIPCUTTER 2 LD BN TNDN BN BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288BTB-70 SUP HCPCS C1713 AR-1288BTB-70 - KIT FX 7MM SHRT TGHTRP FLIPCUTTER 2 LD BN TNDN BN BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288BTB-75 SUP HCPCS C1713 AR-1288BTB-75 - KIT FX 7.5MM SHRT TGHTRP FLIPCUTTER 2 LD BN TNDN BN BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288BTB-80 SUP HCPCS C1713 AR-1288BTB-80 - KIT FX 8MM SHRT TGHTRP FLIPCUTTER 2 LD BN TNDN BN BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288BTB-85 SUP HCPCS C1713 AR-1288BTB-85 - KIT FX 8.5MM SHRT TGHTRP FLIPCUTTER 2 LD BN TNDN BN BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288BTB-90 SUP HCPCS C1713 AR-1288BTB-90 - SYSTEM FX 9MM STRL LF ARTHX TGHTRP BTB J DISP FLPCTR IIS BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1288BTB-95 SUP HCPCS C1713 AR-1288BTB-95 - SYSTEM FX 9.5MM STRL LF ARTHX TGHTRP BTB J DISP FLPCTR IIS BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" $866.25 $866.25 $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1291-4 SUP Custom 27203010 AR-1291-4 - NEEDLE SUT STRL GFT PREP DISP BOTH IP/OP $925.00 $684.50 $0.00 $740.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $686.54 $686.54 $0.00 $0.00 $192.77 $0.00 $0.00 $0.00 $0.00 $462.50 $732.60 $740.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1297 SUP Custom 27203010 AR-1297 - GUIDE PIN ORTH BALL 1.7MM ACL BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $0.00 $0.00 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1297L SUP Custom 27203010 AR-1297L - GUIDE PIN ORTH 2.4MM 50CM STRL SUT EYE ACL DISP PCL REPR BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $0.00 $0.00 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-12990N SUP Custom 27203010 AR-12990N - NEEDLE SUT SCRPN KN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100-05.0 SUP HCPCS C1713 AR-13100-05.0 - PLATE BN 5MM STRL SS KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100-07.5 SUP HCPCS C1713 AR-13100-07.5 - PLATE BN 7.5MM STRL SS KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100-09.0 SUP HCPCS C1713 AR-13100-09.0 - PLATE BN 9MM STRL SS KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100-10.0 SUP HCPCS C1713 AR-13100-10.0 - PLATE BN 10MM STRL SS KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100-11.0 SUP HCPCS C1713 AR-13100-11.0 - PLATE BN 11MM STRL SS KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100-12.5 SUP HCPCS C1713 AR-13100-12.5 - PLATE BN 12.5MM STRL SS KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100-15.0 SUP HCPCS C1713 AR-13100-15.0 - PLATE BN 15MM STRL SS KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100-17.5 SUP HCPCS C1713 AR-13100-17.5 - PLATE BN 17.5MM STRL SS KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100T-05.0 SUP HCPCS C1713 AR-13100T-05.0 - PLATE BN 5MM STRL TI KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100T-07.5 SUP HCPCS C1713 AR-13100T-07.5 - PLATE BN 7.5MM STRL TI KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100T-09.0 SUP HCPCS C1713 AR-13100T-09.0 - PLATE BN 9MM STRL TI KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100T-10.0 SUP HCPCS C1713 AR-13100T-10.0 - PLATE BN 10MM STRL TI KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100T-11.0 SUP HCPCS C1713 AR-13100T-11.0 - PLATE BN 11MM STRL TI KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100T-12.5 SUP HCPCS C1713 AR-13100T-12.5 - PLATE BN 12.5MM STRL TI KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100T-15.0 SUP HCPCS C1713 AR-13100T-15.0 - PLATE BN 15MM STRL TI KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13100T-17.5 SUP HCPCS C1713 AR-13100T-17.5 - PLATE BN 17.5MM STRL TI KN FEM 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120G-2 SUP Custom 27203010 AR-13120G-2 - GUIDE DRL MN LOPRFL D 2.4MM SCR BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-10 SUP HCPCS C1713 AR-13120T-10 - SCREW BN 1.5MM FT HEX 2.3MM 10MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-10C SUP HCPCS C1713 AR-13120T-10C - SCREW BN 1.5MM P/T HEX 2.3MM 10MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-10S SUP HCPCS C1713 AR-13120T-10S - SCREW BN 2.3MM 10MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-11 SUP HCPCS C1713 AR-13120T-11 - SCREW BN 1.5MM HEX FT 2.3MM 11MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-11S SUP HCPCS C1713 AR-13120T-11S - SCREW BN 2.3MM 11MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-12 SUP HCPCS C1713 AR-13120T-12 - SCREW BN 1.5MM FT HEX 2.3MM 12MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-12C SUP HCPCS C1713 AR-13120T-12C - SCREW BN 1.5MM P/T HEX 2.3MM 12MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-12S SUP HCPCS C1713 AR-13120T-12S - SCREW BN 2.3MM 12MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-13 SUP HCPCS C1713 AR-13120T-13 - SCREW BN 1.5MM HEX FT 2.3MM 13MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-13S SUP HCPCS C1713 AR-13120T-13S - SCREW BN 2.3MM 13MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-14 SUP HCPCS C1713 AR-13120T-14 - SCREW BN 1.5MM FT HEX 2.3MM 14MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-14C SUP HCPCS C1713 AR-13120T-14C - SCREW BN 1.5MM P/T HEX 2.3MM 14MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-14S SUP HCPCS C1713 AR-13120T-14S - SCREW BN 2.3MM 14MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-15 SUP HCPCS C1713 AR-13120T-15 - SCREW BN 1.5MM HEX FT 2.3MM 15MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-15S SUP HCPCS C1713 AR-13120T-15S - SCREW BN 2.3MM 15MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-16 SUP HCPCS C1713 AR-13120T-16 - SCREW BN 1.5MM FT HEX 2.3MM 16MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-16C SUP HCPCS C1713 AR-13120T-16C - SCREW BN 1.5MM P/T HEX 2.3MM 16MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-16S SUP HCPCS C1713 AR-13120T-16S - SCREW BN 2.3MM 16MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-17 SUP HCPCS C1713 AR-13120T-17 - SCREW BN 1.5MM HEX FT 2.3MM 17MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-17S SUP HCPCS C1713 AR-13120T-17S - SCREW BN 2.3MM 17MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-18 SUP HCPCS C1713 AR-13120T-18 - SCREW BN 1.5MM FT HEX 2.3MM 18MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-18C SUP HCPCS C1713 AR-13120T-18C - SCREW BN 1.5MM P/T HEX 2.3MM 18MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-18S SUP HCPCS C1713 AR-13120T-18S - SCREW BN 2.3MM 18MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-19 SUP HCPCS C1713 AR-13120T-19 - SCREW BN 1.5MM HEX FT 2.3MM 19MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-19S SUP HCPCS C1713 AR-13120T-19S - SCREW BN 2.3MM 19MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-20 SUP HCPCS C1713 AR-13120T-20 - SCREW BN 1.5MM FT HEX 2.3MM 20MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-20C SUP HCPCS C1713 AR-13120T-20C - SCREW BN 1.5MM P/T HEX 2.3MM 20MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-20S SUP HCPCS C1713 AR-13120T-20S - SCREW BN 2.3MM 20MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-21 SUP HCPCS C1713 AR-13120T-21 - SCREW BN 1.5MM HEX FT 2.3MM 21MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-21S SUP HCPCS C1713 AR-13120T-21S - SCREW BN 2.3MM 21MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-22 SUP HCPCS C1713 AR-13120T-22 - SCREW BN 1.5MM FT HEX 2.3MM 22MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-22C SUP HCPCS C1713 AR-13120T-22C - SCREW BN 1.5MM P/T HEX 2.3MM 22MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-22S SUP HCPCS C1713 AR-13120T-22S - SCREW BN 2.3MM 22MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-23 SUP HCPCS C1713 AR-13120T-23 - SCREW BN 1.5MM HEX FT 2.3MM 23MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-23S SUP HCPCS C1713 AR-13120T-23S - SCREW BN 2.3MM 23MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-24 SUP HCPCS C1713 AR-13120T-24 - SCREW BN 1.5MM FT HEX 2.3MM 24MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-24C SUP HCPCS C1713 AR-13120T-24C - SCREW BN 1.5MM P/T HEX 2.3MM 24MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-24S SUP HCPCS C1713 AR-13120T-24S - SCREW BN 2.3MM 24MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-25 SUP HCPCS C1713 AR-13120T-25 - SCREW BN 1.5MM HEX FT 2.3MM 25MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-25S SUP HCPCS C1713 AR-13120T-25S - SCREW BN 2.3MM 25MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-26 SUP HCPCS C1713 AR-13120T-26 - SCREW BN 1.5MM FT HEX 2.3MM 26MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-26C SUP HCPCS C1713 AR-13120T-26C - SCREW BN 1.5MM P/T HEX 2.3MM 26MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-26S SUP HCPCS C1713 AR-13120T-26S - SCREW BN 2.3MM 26MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-27 SUP HCPCS C1713 AR-13120T-27 - SCREW BN 1.5MM HEX FT 2.3MM 27MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-27S SUP HCPCS C1713 AR-13120T-27S - SCREW BN 2.3MM 27MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-28 SUP HCPCS C1713 AR-13120T-28 - SCREW BN 1.5MM FT HEX 2.3MM 28MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-28C SUP HCPCS C1713 AR-13120T-28C - SCREW BN 1.5MM P/T HEX 2.3MM 28MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-28S SUP HCPCS C1713 AR-13120T-28S - SCREW BN 2.3MM 28MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-29 SUP HCPCS C1713 AR-13120T-29 - SCREW BN 1.5MM HEX FT 2.3MM 29MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-29S SUP HCPCS C1713 AR-13120T-29S - SCREW BN 2.3MM 29MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-30 SUP HCPCS C1713 AR-13120T-30 - SCREW BN 1.5MM FT HEX 2.3MM 30MM STRL LOPRFL SCR SLF DRL ST BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-30C SUP HCPCS C1713 AR-13120T-30C - SCREW BN 1.5MM P/T HEX 2.3MM 30MM STRL LOPRFL SCR LG CNN ST BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13120T-30S SUP HCPCS C1713 AR-13120T-30S - SCREW BN 2.3MM 30MM STRL ARTHX LOPRFL CORT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-08 SUP HCPCS C1713 AR-13123-08 - SCREW BN 2.3MM 8MM SS CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-10 SUP HCPCS C1713 AR-13123-10 - SCREW BN 2.3MM 10MM STRL LOPRFL SCR SLD SS SM BN CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-12 SUP HCPCS C1713 AR-13123-12 - SCREW BN 2.3MM 12MM STRL LOPRFL SCR SLD SS SM BN CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-14 SUP HCPCS C1713 AR-13123-14 - SCREW BN 2.3MM 14MM STRL LOPRFL SCR SLD SS SM BN CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-16 SUP HCPCS C1713 AR-13123-16 - SCREW BN 2.3MM 16MM STRL LOPRFL SCR SLD SS SM BN CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-18 SUP HCPCS C1713 AR-13123-18 - SCREW BN 2.3MM 18MM STRL LOPRFL SCR SLD SS SM BN CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-20 SUP HCPCS C1713 AR-13123-20 - SCREW BN 2.3MM 20MM STRL LOPRFL SCR SLD SS SM BN CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-22 SUP HCPCS C1713 AR-13123-22 - SCREW BN 2.3MM 22MM STRL LOPRFL SCR SLD SS SM BN CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13123-24 SUP HCPCS C1713 AR-13123-24 - SCREW BN 2.3MM 24MM SS CORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1318FT SUP HCPCS C1713 AR-1318FT - ANCHOR SUTURE 2-0 3/8 CIR MICRO FULTHD TAPER 2.2MM 4MM 17.9 BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1318FT-40 SUP HCPCS C1713 AR-1318FT-40 - ANCHOR SUTURE 4-0 3/8 CIR MICRO FULTHD TAPER 2.2MM 4MM 12.3 BOTH IP/OP $712.50 $527.25 $0.00 $816.00 $459.00 $459.00 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $510.00 $807.84 $816.00 $0.00 $0.00 $159.63 $0.00 $0.00 $162.38 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1319FT SUP HCPCS C1713 AR-1319FT - ANCHOR SUTURE 2-0 3/8 CIR MINI FULTHD TAPER 2.7MM 7MM 17.9MM BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-03.0 SUP HCPCS C1713 AR-13200-03.0 - PLATE BN 3MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-03.0S SUP HCPCS C1713 AR-13200-03.0S - PLATE BN 3MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-05.0 SUP HCPCS C1713 AR-13200-05.0 - PLATE BN 5MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-05.0S SUP HCPCS C1713 AR-13200-05.0S - PLATE BN 5MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-06.0 SUP HCPCS C1713 AR-13200-06.0 - PLATE BN 6MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-06.0S SUP HCPCS C1713 AR-13200-06.0S - PLATE BN 6MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-07.5 SUP HCPCS C1713 AR-13200-07.5 - PLATE BN 7.5MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-07.5S SUP HCPCS C1713 AR-13200-07.5S - PLATE BN 7.5MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-09.0 SUP HCPCS C1713 AR-13200-09.0 - PLATE BN 9MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-09.0S SUP HCPCS C1713 AR-13200-09.0S - PLATE BN 9MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-10.0 SUP HCPCS C1713 AR-13200-10.0 - PLATE BN 10MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-10.0S SUP HCPCS C1713 AR-13200-10.0S - PLATE BN 10MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-11.0 SUP HCPCS C1713 AR-13200-11.0 - PLATE BN 11MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-11.0S SUP HCPCS C1713 AR-13200-11.0S - PLATE BN 11MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-12.5 SUP HCPCS C1713 AR-13200-12.5 - PLATE BN 12.5MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-12.5S SUP HCPCS C1713 AR-13200-12.5S - PLATE BN 12.5MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-13.5 SUP HCPCS C1713 AR-13200-13.5 - PLATE BN 13.5MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-13.5S SUP HCPCS C1713 AR-13200-13.5S - PLATE BN 13.5MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-15.0 SUP HCPCS C1713 AR-13200-15.0 - PLATE BN 15MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-15.0S SUP HCPCS C1713 AR-13200-15.0S - PLATE BN 15MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-16.0 SUP HCPCS C1713 AR-13200-16.0 - PLATE BN 16MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-16.0S SUP HCPCS C1713 AR-13200-16.0S - PLATE BN 16MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-17.5 SUP HCPCS C1713 AR-13200-17.5 - PLATE BN 17.5MM STRL SS TIB OPN WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200-17.5S SUP HCPCS C1713 AR-13200-17.5S - PLATE BN 17.5MM STRL ARTHX TIB OPN WDG OSTM BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $155.25 $155.25 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200D-05 SUP HCPCS C1713 AR-13200D-05 - PLATE BN LOPRFL 5MM STRL SS TIB DIST 3.5-4MM SCR OPN WDG BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200D-06 SUP HCPCS C1713 AR-13200D-06 - PLATE BN LOPRFL 6MM STRL SS TIB DIST 3.5-4MM SCR OPN WDG BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200D-07 SUP HCPCS C1713 AR-13200D-07 - PLATE BN LOPRFL 7MM STRL SS TIB DIST 3.5-4MM SCR OPN WDG BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200D-08 SUP HCPCS C1713 AR-13200D-08 - PLATE BN LOPRFL 8MM STRL SS TIB DIST 3.5-4MM SCR OPN WDG BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200D-09 SUP HCPCS C1713 AR-13200D-09 - PLATE BN LOPRFL 9MM STRL SS TIB DIST 3.5-4MM SCR OPN WDG BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200D-10 SUP HCPCS C1713 AR-13200D-10 - PLATE BN LOPRFL 10MM STRL SS TIB DIST 3.5-4MM SCR OPN WDG BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200DC SUP HCPCS C1713 AR-13200DC - PLATE BN LOPRFL SS TIB DIST 3.5/4MM SCR CLS WDG OSTM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M SUP HCPCS C1713 AR-13200M - PLATE BN L FLT TI METATARSUS 2.4MM SCR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-025L SUP HCPCS C1713 AR-13200M-025L - PLATE BN L LOPRFL 2.5MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-025R SUP HCPCS C1713 AR-13200M-025R - PLATE BN L LOPRFL 2.5MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-02L SUP HCPCS C1713 AR-13200M-02L - PLATE BN L LOPRFL 2MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-02R SUP HCPCS C1713 AR-13200M-02R - PLATE BN L LOPRFL 2MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-035L SUP HCPCS C1713 AR-13200M-035L - PLATE BN L LOPRFL 3.5MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-035R SUP HCPCS C1713 AR-13200M-035R - PLATE BN L LOPRFL 3.5MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-03L SUP HCPCS C1713 AR-13200M-03L - PLATE BN L LOPRFL 3MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-03R SUP HCPCS C1713 AR-13200M-03R - PLATE BN L LOPRFL 3MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-045L SUP HCPCS C1713 AR-13200M-045L - PLATE BN L LOPRFL 4.5MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-045R SUP HCPCS C1713 AR-13200M-045R - PLATE BN L LOPRFL 4.5MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-04L SUP HCPCS C1713 AR-13200M-04L - PLATE BN L LOPRFL 4MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-04R SUP HCPCS C1713 AR-13200M-04R - PLATE BN L LOPRFL 4MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-055L SUP HCPCS C1713 AR-13200M-055L - PLATE BN L LOPRFL 5.5MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-055R SUP HCPCS C1713 AR-13200M-055R - PLATE BN L LOPRFL 5.5MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-05L SUP HCPCS C1713 AR-13200M-05L - PLATE BN L LOPRFL 5MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-05R SUP HCPCS C1713 AR-13200M-05R - PLATE BN L LOPRFL 5MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-065L SUP HCPCS C1713 AR-13200M-065L - PLATE BN L LOPRFL 6.5MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-065R SUP HCPCS C1713 AR-13200M-065R - PLATE BN L LOPRFL 6.5MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-06L SUP HCPCS C1713 AR-13200M-06L - PLATE BN L LOPRFL 6MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-06R SUP HCPCS C1713 AR-13200M-06R - PLATE BN L LOPRFL 6MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-075L SUP HCPCS C1713 AR-13200M-075L - PLATE BN 32219095 7.5MM NS ARTHX LOPRFL OPN WDG TI BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-075R SUP HCPCS C1713 AR-13200M-075R - PLATE BN 7.5MM NS ARTHX LOPRFL OPN WDG TI METATARSUS RT BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-07L SUP HCPCS C1713 AR-13200M-07L - PLATE BN L LOPRFL 7MM TI METATARSUS LT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200M-07R SUP HCPCS C1713 AR-13200M-07R - PLATE BN L LOPRFL 7MM TI METATARSUS RT 2.4MM SCR OPN WDG BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-05.0 SUP HCPCS C1713 AR-13200PA-05.0 - PLATE BN 5MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-06.0 SUP HCPCS C1713 AR-13200PA-06.0 - PLATE BN 6MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-07.5 SUP HCPCS C1713 AR-13200PA-07.5 - PLATE BN 7.5MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-09.0 SUP HCPCS C1713 AR-13200PA-09.0 - PLATE BN 9MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-10.0 SUP HCPCS C1713 AR-13200PA-10.0 - PLATE BN 10MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-11.0 SUP HCPCS C1713 AR-13200PA-11.0 - PLATE BN 11MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-12.5 SUP HCPCS C1713 AR-13200PA-12.5 - PLATE BN 12.5MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-13.5 SUP HCPCS C1713 AR-13200PA-13.5 - PLATE BN 13.5MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-15.0 SUP HCPCS C1713 AR-13200PA-15.0 - PLATE BN 15MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-16.0 SUP HCPCS C1713 AR-13200PA-16.0 - PLATE BN 16MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200PA-17.5 SUP HCPCS C1713 AR-13200PA-17.5 - PLATE BN 17.5MM ANTEROPOSTERIOR SLOP SS TIB 6.5MM CANC 4.5MM BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200ST-05.0 SUP HCPCS C1713 AR-13200ST-05.0 - PLATE BN LOPRFL 5MM ANTEROPOSTERIOR SLOP TI TIB 6.5MM CANC BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200ST-07.5 SUP HCPCS C1713 AR-13200ST-07.5 - PLATE BN LOPRFL 7.5MM ANTEROPOSTERIOR SLOP TI TIB 6.5MM CANC BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200ST-09.0 SUP HCPCS C1713 AR-13200ST-09.0 - PLATE BN LOPRFL 9MM ANTEROPOSTERIOR SLOP TI TIB 6.5MM CANC BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200ST-10.0 SUP HCPCS C1713 AR-13200ST-10.0 - PLATE BN LOPRFL 10MM ANTEROPOSTERIOR SLOP TI TIB 6.5MM CANC BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200ST-11.0 SUP HCPCS C1713 AR-13200ST-11.0 - PLATE BN LOPRFL 11MM ANTEROPOSTERIOR SLOP TI TIB 6.5MM CANC BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200ST-12.5 SUP HCPCS C1713 AR-13200ST-12.5 - PLATE BN LOPRFL 12.5MM ANTEROPOSTERIOR SLOP TI TIB 6.5MM BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200ST-15.0 SUP HCPCS C1713 AR-13200ST-15.0 - PLATE BN LOPRFL 15MM ANTEROPOSTERIOR SLOP TI TIB 6.5MM CANC BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200ST-17.5 SUP HCPCS C1713 AR-13200ST-17.5 - PLATE BN LOPRFL 17.5MM ANTEROPOSTERIOR SLOP TI TIB 6.5MM BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200T-05.0 SUP HCPCS C1713 AR-13200T-05.0 - PLATE BN LOPRFL 5MM TI TIB 6.5MM CANC 4.5MM CORT SCR OPN WDG BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200T-07.5 SUP HCPCS C1713 AR-13200T-07.5 - PLATE BN LOPRFL 7.5MM TI TIB 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200T-09.0 SUP HCPCS C1713 AR-13200T-09.0 - PLATE BN LOPRFL 9MM TI TIB 6.5MM CANC 4.5MM CORT SCR OPN WDG BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200T-10.0 SUP HCPCS C1713 AR-13200T-10.0 - PLATE BN 10MM LOPRFL TI TIB 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200T-11.0 SUP HCPCS C1713 AR-13200T-11.0 - PLATE BN LOPRFL 11MM TI TIB 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200T-12.5 SUP HCPCS C1713 AR-13200T-12.5 - PLATE BN LOPRFL 12.5MM TI TIB 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200T-15.0 SUP HCPCS C1713 AR-13200T-15.0 - PLATE BN LOPRFL 15MM TI TIB 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13200T-17.5 SUP HCPCS C1713 AR-13200T-17.5 - PLATE BN LOPRFL 17.5MM TI TIB 6.5MM CANC 4.5MM CORT SCR OPN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1320BCNF SUP HCPCS C1713 AR-1320BCNF - ANCHOR SUT MIC NS DISP BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1320BCNF-40 SUP HCPCS C1713 AR-1320BCNF-40 - ANCHOR SUT 4-0 MIC 2 TPR 2.4MM 6.5MM NS SUT TK FBRWR BCMPS BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1320DSC SUP Custom 27203010 AR-1320DSC - KIT INST MIC 1.8MM 2MM STRL SUT TK BIT DRL GD PNCH SHLDR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13215 SUP HCPCS C1713 AR-13215 - PLATE BN 30MM STRL 2 HL SPRT KN OSTM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13217 SUP Custom 27203010 AR-13217 - KIT INST CUT BLCK PIN DISP T3 AMZ BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13220 SUP Custom 27203010 AR-13220 - DRILL BIT CNTRSNK 2.3MM AO CNCT BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13220C SUP Custom 27203010 AR-13220C - DRILL BIT CNTRSNK 2.3MM AO CNCT CNN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13220DG SUP Custom 27203010 AR-13220DG - GUIDE DRL LOPRFL PLT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1322-752SF SUP HCPCS C1713 AR-1322-752SF - ANCHOR SUT 2-0 SM 2.4MM 7.5MM STRL FSTK2 FWR BABSR HNDL BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $208.13 $208.13 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1322BCNF SUP HCPCS C1713 AR-1322BCNF - ANCHOR SUT 2-0 MIC STRG FWD TPR 2.4MM 8.5MM LF BSUT TK FBRWR BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1322D-18 SUP Custom 27203010 AR-1322D-18 - DRILL SRG MN 1.8MM SUT TK BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1322D-20 SUP Custom 27203010 AR-1322D-20 - DRILL SRG MN 2MM SUT TK BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1322DSC SUP Custom 27203010 AR-1322DSC - KIT ESCP INST 2-0 MN 2.4MM 8.5MM STRL LF BSUT TK ANCH DRLBT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1322SXF SUP HCPCS C1713 AR-1322SXF - ANCHOR SUT 2 2.4MM 11.7MM STRL FSTK FWR BRD CNN INSRTR ST TI BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1324B SUP HCPCS C1713 AR-1324B - ANCHOR SUT 2 3MM 14MM STRL BFSTK TVDK BRD EYLT HNDL INSRTR BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1324BF SUP HCPCS C1713 AR-1324BF - ANCHOR SUT 2 3MM 14MM STRL BFSTK FWR BRD EYLT HNDL INSRTR BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $275.63 $275.63 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1324BF-2 SUP HCPCS C1713 AR-1324BF-2 - ANCHOR SUT 2 3MM 11MM STRL BFSTK FWR BRD EYLT HNDL INSRTR BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $292.50 $292.50 $0.00 $0.00 $0.00 $135.48 $482.43 $482.43 $0.00 $0.00 $135.46 $0.00 $384.48 $384.48 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $101.73 $0.00 $0.00 $103.48 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1324D SUP Custom 27203010 AR-1324D - DRILL SRG SPR 2.8MM FSTK II CNN TI SHLDR BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1324HF SUP HCPCS C1713 AR-1324HF - ANCHOR SUT 2 2.8MM 11.7MM STRL FSTK2 FWR HNDL TI KN BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $202.50 $202.50 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1324SF SUP HCPCS C1713 AR-1324SF - ANCHOR SUT 2 2.8MM 11.7MM STRL FSTK2 FWR CNN INSRTR TI BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13280-35 SUP HCPCS C1713 AR-13280-35 - SCREW BN 6.5MM 35MM TI TIB CANC OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13280-40 SUP HCPCS C1713 AR-13280-40 - SCREW BN 6.5MM 40MM TI TIB CANC OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13280-45 SUP HCPCS C1713 AR-13280-45 - SCREW BN 6.5MM 45MM TI TIB CANC OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13280-50 SUP HCPCS C1713 AR-13280-50 - SCREW BN 6.5MM 50MM TI TIB CANC OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13280-55 SUP HCPCS C1713 AR-13280-55 - SCREW BN 6.5MM 55MM TI TIB CANC OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13280-60 SUP HCPCS C1713 AR-13280-60 - SCREW BN 6.5MM 60MM TI TIB CANC OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13280-65 SUP HCPCS C1713 AR-13280-65 - SCREW BN 6.5MM 65MM TI TIB CANC OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13280-70 SUP HCPCS C1713 AR-13280-70 - SCREW BN 6.5MM 70MM TI TIB CANC OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13303-2.4 SUP Custom 27203010 AR-13303-2.4 - GUIDE PIN ORTH 2.4MM BRKWY FEM OSTM BOTH IP/OP $92.50 $68.45 $0.00 $74.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.65 $68.65 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $46.25 $73.26 $74.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13303-3.0 SUP Custom 27203010 AR-13303-3.0 - GUIDE PIN ORTH 3MM BRKWY FEM OSTM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13319 SUP Custom 27203010 AR-13319 - DRILL SRG HTO TI SCR BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13320 SUP Custom 27203010 AR-13320 - GUIDE DRL OPN WDG OSTM HTO PLT BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13321 SUP Custom 27203010 AR-13321 - GUIDE DRL OPN WDG OSTM HTO TI PLT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13370-2 SUP HCPCS C1713 AR-13370-2 - FILLER BN VOID 30X10MM STRL OPTM PORE DIA RGD FX DEV TRM WDG BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13370-3 SUP HCPCS C1713 AR-13370-3 - FILLER BN VOID 35X12MM STRL OPTM PORE DIA RGD FX DEV TRM WDG BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13370-4 SUP HCPCS C1713 AR-13370-4 - FILLER BN VOID 35X15MM STRL OPTM PORE DIA RGD FX DEV TRM WDG BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13372-1 SUP HCPCS C1713 AR-13372-1 - FILLER BN VOID 75D THK7MM TRPZD 25X8MM OSFERION BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13372-2 SUP HCPCS C1713 AR-13372-2 - FILLER BN VOID 75D THK7MM TRPZD 25X9MM OSFERION BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13372-3 SUP HCPCS C1713 AR-13372-3 - FILLER BN VOID 75D THK7MM TRPZD 25X10MM OSFERION BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-26 SUP HCPCS C1713 AR-13380-26 - SCREW BN 4.5MM 26MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-28 SUP HCPCS C1713 AR-13380-28 - SCREW BN 4.5MM 28MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-30 SUP HCPCS C1713 AR-13380-30 - SCREW BN 4.5MM 30MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-32 SUP HCPCS C1713 AR-13380-32 - SCREW BN 4.5MM 32MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-34 SUP HCPCS C1713 AR-13380-34 - SCREW BN 4.5MM 34MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-36 SUP HCPCS C1713 AR-13380-36 - SCREW BN 4.5MM 36MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-38 SUP HCPCS C1713 AR-13380-38 - SCREW BN 4.5MM 38MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-40 SUP HCPCS C1713 AR-13380-40 - SCREW BN 4.5MM 40MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-42 SUP HCPCS C1713 AR-13380-42 - SCREW BN 4.5MM 42MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-44 SUP HCPCS C1713 AR-13380-44 - SCREW BN 4.5MM 44MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-46 SUP HCPCS C1713 AR-13380-46 - SCREW BN 4.5MM 46MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-48 SUP HCPCS C1713 AR-13380-48 - SCREW BN 4.5MM 48MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-50 SUP HCPCS C1713 AR-13380-50 - SCREW BN 4.5MM 50MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-52 SUP HCPCS C1713 AR-13380-52 - SCREW BN 4.5MM 52MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-54 SUP HCPCS C1713 AR-13380-54 - SCREW BN 4.5MM 54MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-56 SUP HCPCS C1713 AR-13380-56 - SCREW BN 4.5MM 56MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-58 SUP HCPCS C1713 AR-13380-58 - SCREW BN 4.5MM 58MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13380-60 SUP HCPCS C1713 AR-13380-60 - SCREW BN 4.5MM 60MM TI TIB CORT OPN WDG OSTM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-05 SUP Custom 27803010 AR-13400L-05 - WEDGE TIB 5D LG IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-06 SUP Custom 27803010 AR-13400L-06 - WEDGE TIB 6D 7D LG XL IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-07 SUP Custom 27803010 AR-13400L-07 - WEDGE TIB 6D 7D LG XL IBALANCE PEEK KN HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-08 SUP Custom 27803010 AR-13400L-08 - WEDGE TIB 7D 8D LG XL IBALANCE KN HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-09 SUP Custom 27803010 AR-13400L-09 - WEDGE TIB 8D 9D LG XL IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-10 SUP Custom 27803010 AR-13400L-10 - WEDGE TIB 9D 10D LG XL IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-11 SUP Custom 27803010 AR-13400L-11 - WEDGE TIB 10D 11D LG XL IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-12 SUP Custom 27803010 AR-13400L-12 - WEDGE TIB 11D 12D LG XL IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-13 SUP Custom 27803010 AR-13400L-13 - WEDGE TIB 12D 13D LG XL IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-14 SUP Custom 27803010 AR-13400L-14 - WEDGE TIB 13D 14D LG XL IBALANCE PEEK HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400L-15 SUP Custom 27803010 AR-13400L-15 - WEDGE TIB 15D LG IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-05 SUP Custom 27803010 AR-13400M-05 - WEDGE TIB 5D 6D S/MED IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-06 SUP Custom 27803010 AR-13400M-06 - WEDGE TIB 6D MED IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-07 SUP Custom 27803010 AR-13400M-07 - WEDGE TIB 7D 8D S/MED IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-08 SUP Custom 27803010 AR-13400M-08 - WEDGE TIB 8D 9D S/MED IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-09 SUP Custom 27803010 AR-13400M-09 - WEDGE TIB 9D 10D S/MED IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-10 SUP Custom 27803010 AR-13400M-10 - WEDGE TIB 10D 11D S/MED IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-11 SUP Custom 27803010 AR-13400M-11 - WEDGE TIB 13D 11D S/MED IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-12 SUP Custom 27803010 AR-13400M-12 - WEDGE TIB 12D 14D S/MED IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-13 SUP Custom 27803010 AR-13400M-13 - WEDGE TIB 15D 13D S/MED IBALANCE KN HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-14 SUP Custom 27803010 AR-13400M-14 - WEDGE TIB 14D MED IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400M-15 SUP Custom 27803010 AR-13400M-15 - WEDGE TIB 15D MED IBALANCE HTO BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13400S-12 SUP Custom 27803010 AR-13400S-12 - WEDGE TIB 12D SM IBALANCE PEEK KN HTO PLT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 $0.00 $0.00 $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13401-20 SUP HCPCS C1713 AR-13401-20 - ANCHOR SUT 6.5MM 20MM IBALANCE CANC HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13401-22 SUP HCPCS C1713 AR-13401-22 - ANCHOR SUT 6.5MM 22MM IBALANCE CANC HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13401-24 SUP HCPCS C1713 AR-13401-24 - ANCHOR SUT 6.5MM 24MM IBALANCE CANC HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13401-26 SUP HCPCS C1713 AR-13401-26 - ANCHOR SUT 6.5MM 26MM IBALANCE CANC HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13401-28 SUP HCPCS C1713 AR-13401-28 - ANCHOR SUT 6.5MM 28MM IBALANCE CANC HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13401-30 SUP HCPCS C1713 AR-13401-30 - ANCHOR SUT 6.5MM 30MM IBALANCE CANC HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13401-32 SUP HCPCS C1713 AR-13401-32 - ANCHOR SUT 6.5MM 32MM IBALANCE CANC HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-24 SUP HCPCS C1713 AR-13402-24 - ANCHOR SUT 4.5MM 24MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-26 SUP HCPCS C1713 AR-13402-26 - ANCHOR SUT 4.5MM 26MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-28 SUP HCPCS C1713 AR-13402-28 - ANCHOR SUT 4.5MM 28MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-30 SUP HCPCS C1713 AR-13402-30 - ANCHOR SUT 4.5MM 30MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-32 SUP HCPCS C1713 AR-13402-32 - ANCHOR SUT 4.5MM 32MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-34 SUP HCPCS C1713 AR-13402-34 - ANCHOR SUT 4.5MM 34MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-36 SUP HCPCS C1713 AR-13402-36 - ANCHOR SUT 4.5MM 36MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-38 SUP HCPCS C1713 AR-13402-38 - ANCHOR SUT 4.5MM 38MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-40 SUP HCPCS C1713 AR-13402-40 - ANCHOR SUT 4.5MM 40MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-42 SUP HCPCS C1713 AR-13402-42 - ANCHOR SUT 4.5MM 42MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-44 SUP HCPCS C1713 AR-13402-44 - ANCHOR SUT 4.5MM 44MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-46 SUP HCPCS C1713 AR-13402-46 - ANCHOR SUT 4.5MM 46MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-48 SUP HCPCS C1713 AR-13402-48 - ANCHOR SUT 4.5MM 48MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-50 SUP HCPCS C1713 AR-13402-50 - ANCHOR SUT 4.5MM 50MM IBALANCE CORT HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13402-52 SUP HCPCS C1713 AR-13402-52 - ANCHOR SUT 4.5MM 52MM IBALANCE HTO BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13413 SUP HCPCS C1713 AR-13413 - WASHER ORTH FSTN LCK BOTH IP/OP $177.45 $131.31 $0.00 $141.96 $79.85 $79.85 $0.00 $0.00 $0.00 $36.99 $131.70 $131.70 $0.00 $0.00 $36.98 $0.00 $104.96 $104.96 $0.00 $88.73 $140.54 $141.96 $0.00 $0.00 $27.77 $0.00 $0.00 $28.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13417L SUP Custom 27203010 AR-13417L - GUIDE DRL LG FREECUT KYHL HTO IBALANCE BOTH IP/OP "$2,697.50 " "$1,996.15" $0.00 "$2,158.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,002.08" "$2,002.08" $0.00 $0.00 $562.16 $0.00 $0.00 $0.00 $0.00 "$1,348.75" "$2,136.42" "$2,158.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13417M SUP Custom 27203010 AR-13417M - GUIDE DRL MED FREECUT KYHL HTO IBALANCE BOTH IP/OP "$2,697.50 " "$1,996.15" $0.00 "$2,158.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,002.08" "$2,002.08" $0.00 $0.00 $562.16 $0.00 $0.00 $0.00 $0.00 "$1,348.75" "$2,136.42" "$2,158.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13433 SUP Custom 27203010 AR-13433 - GUIDE DRL IBALANCE ANCH HTO BOTH IP/OP $632.40 $467.98 $0.00 $505.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.37 $469.37 $0.00 $0.00 $131.79 $0.00 $0.00 $0.00 $0.00 $316.20 $500.86 $505.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1349 SUP Custom 27803010 AR-1349 - WASHER 14MM SPK LP ORTH TI CANC SCR STRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1349L SUP Custom 27803010 AR-1349L - WASHER ORTH 18MM STRL SPK LOPRFL TI CANC SCR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1349LM SUP Custom 27803010 AR-1349LM - WASHER ORTH 18MM STRL SUT TI ACL DISP CANC SCR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1349LMNS SUP Custom 27803010 AR-1349LMNS - WASHER ORTH LOPRFL 18MM NS SUT TI ACL PCL CANC SCR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1349LNS SUP Custom 27803010 AR-1349LNS - WASHER 18MM ACL PCL SPK LP ORTH TI CANC SCR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1349M SUP Custom 27803010 AR-1349M - WASHER ORTH 14MM STRL TI CANC SCR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1349MNS SUP Custom 27803010 AR-1349MNS - WASHER 14MM ACL PCL SUTURE LP ORTH TI CANC SCR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1349NS SUP Custom 27803010 AR-1349NS - WASHER ORTH SPK LOPRFL 14MM NS TI ACL PCL CANC SCR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351 SUP HCPCS C1713 AR-1351 - PIN FX 3MM 40MM STRL TRNFX SLF CUT ST TI ACL BOTH IP/OP $395.00 $292.30 $0.00 $316.00 $177.75 $177.75 $0.00 $0.00 $0.00 $82.33 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $233.64 $233.64 $0.00 $197.50 $312.84 $316.00 $0.00 $0.00 $61.82 $0.00 $0.00 $62.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351B SUP HCPCS C1713 AR-1351B - IMPLANT FX 5MM 40MM STRL BTRNSF 1 XPN AMRPH BABSR PUL OUT BOTH IP/OP $722.50 $534.65 $0.00 $578.00 $325.13 $325.13 $0.00 $0.00 $0.00 $150.59 $536.24 $536.24 $0.00 $0.00 $150.57 $0.00 $427.36 $427.36 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $113.07 $0.00 $0.00 $115.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351BK-CP SUP HCPCS C1713 AR-1351BK-CP - SET IMPL 40MM BTRNSF PK ACL BOTH IP/OP "$1,102.50 " $815.85 $0.00 $882.00 $496.13 $496.13 $0.00 $0.00 $0.00 $229.79 $818.28 $818.28 $0.00 $0.00 $229.76 $0.00 $652.13 $652.13 $0.00 $551.25 $873.18 $882.00 $0.00 $0.00 $172.54 $0.00 $0.00 $175.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351BT SUP HCPCS C1713 AR-1351BT - IMPLANT FX 3MM 40MM STRL BTRNSF 1 XPN AMRPH BABSR PUL OUT BOTH IP/OP $722.50 $534.65 $0.00 $578.00 $325.13 $325.13 $0.00 $0.00 $0.00 $150.59 $536.24 $536.24 $0.00 $0.00 $150.57 $0.00 $427.36 $427.36 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $113.07 $0.00 $0.00 $115.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351C-01 SUP HCPCS C1713 AR-1351C-01 - SCREW INTFR 5MM 40MM STRL TRNFX STRNG BCMPS KN BOTH IP/OP $997.50 $738.15 $0.00 $798.00 $448.88 $448.88 $0.00 $0.00 $0.00 $207.90 $740.34 $740.34 $0.00 $0.00 $207.88 $0.00 $590.02 $590.02 $0.00 $498.75 $790.02 $798.00 $0.00 $0.00 $156.11 $0.00 $0.00 $158.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351C-02 SUP HCPCS C1713 AR-1351C-02 - SCREW INTFR 5MM 50MM STRL TRNFX STRNG BCMPS KN BOTH IP/OP $997.50 $738.15 $0.00 $798.00 $448.88 $448.88 $0.00 $0.00 $0.00 $207.90 $740.34 $740.34 $0.00 $0.00 $207.88 $0.00 $590.02 $590.02 $0.00 $498.75 $790.02 $798.00 $0.00 $0.00 $156.11 $0.00 $0.00 $158.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351K-CP SUP HCPCS C1713 AR-1351K-CP - SET IMPL 40MM TRNFX2 PK ACL BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $348.75 $348.75 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351L SUP HCPCS C1713 AR-1351L - IMPLANT FX 3MM 50MM STRL TRNFX SLF CUT ST TI ACL BOTH IP/OP $395.00 $292.30 $0.00 $316.00 $177.75 $177.75 $0.00 $0.00 $0.00 $82.33 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $233.64 $233.64 $0.00 $197.50 $312.84 $316.00 $0.00 $0.00 $61.82 $0.00 $0.00 $62.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351LB SUP HCPCS C1713 AR-1351LB - IMPLANT FX 5MM 50MM STRL BTRNSF 1 XPN AMRPH BABSR PUL OUT BOTH IP/OP $722.50 $534.65 $0.00 $578.00 $325.13 $325.13 $0.00 $0.00 $0.00 $150.59 $536.24 $536.24 $0.00 $0.00 $150.57 $0.00 $427.36 $427.36 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $113.07 $0.00 $0.00 $115.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351LBK-CP SUP HCPCS C1713 AR-1351LBK-CP - SET IMPL 50MM BTRNSF PK ACL BOTH IP/OP "$1,102.50 " $815.85 $0.00 $882.00 $496.13 $496.13 $0.00 $0.00 $0.00 $229.79 $818.28 $818.28 $0.00 $0.00 $229.76 $0.00 $652.13 $652.13 $0.00 $551.25 $873.18 $882.00 $0.00 $0.00 $172.54 $0.00 $0.00 $175.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351LBT SUP HCPCS C1713 AR-1351LBT - IMPLANT FX 3MM 50MM STRL BTRNSF 1 XPN AMRPH BABSR PUL OUT BOTH IP/OP $722.50 $534.65 $0.00 $578.00 $325.13 $325.13 $0.00 $0.00 $0.00 $150.59 $536.24 $536.24 $0.00 $0.00 $150.57 $0.00 $427.36 $427.36 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $113.07 $0.00 $0.00 $115.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1351LK-CP SUP HCPCS C1713 AR-1351LK-CP - SET IMPL 50MM TRNFX PK ACL BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $348.75 $348.75 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1355 SUP HCPCS C1713 AR-1355 - SCREW BONE GROOVE LP 6.5MM 25MM DEPTH MARK STEP DRILL BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1355D SUP Custom 27203010 AR-1355D - DRILL SRG 25MM LSR D MRK STP KN LOPRFL CANC SCR BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1355NS SUP HCPCS C1713 AR-1355NS - SCREW BN LOPRFL 6.5MM 25MM NS SMTH SHNK TI ACL PCL CANC BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1356 SUP HCPCS C1713 AR-1356 - SCREW BN GRV LOPRFL 6.5MM 30MM STRL D MRK STP DRL TI ACL/PCL BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1356NS SUP HCPCS C1713 AR-1356NS - SCREW BN LOPRFL 6.5MM 30MM NS SMTH SHNK TI ACL PCL CANC BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1357 SUP HCPCS C1713 AR-1357 - SCREW BN GRV LOPRFL 6.5MM 35MM STRL D MRK STP DRL TI ACL/PCL BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1357B SUP HCPCS C1713 AR-1357B - POST FX 6.25MM 35MM STRL BPST WSHR POLY L LAC ACD ACL DISP BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1357NS SUP HCPCS C1713 AR-1357NS - SCREW BN LOPRFL 6.5MM 35MM NS SMTH SHNK TI ACL PCL CANC BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1358 SUP HCPCS C1713 AR-1358 - SCREW BN GRV LOPRFL 6.5MM 40MM STRL D MRK STP DRL TI ACL/PCL BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1358NS SUP HCPCS C1713 AR-1358NS - SCREW BN LOPRFL 6.5MM 40MM NS SMTH SHNK TI ACL PCL CANC BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $100.13 $100.13 $0.00 $0.00 $0.00 $46.37 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $131.61 $131.61 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $34.82 $0.00 $0.00 $35.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1360B SUP HCPCS C1713 AR-1360B - SCREW INTFR 6MM 23MM STRL BIOINTF CNN SHTH POLY L LAC ACD BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1360C SUP HCPCS C1713 AR-1360C - SCREW INTFR 6MM 23MM STRL CNN RDC HD BCMPS ACL PCL BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1360C-CP SUP HCPCS C1713 AR-1360C-CP - SET IMPL 4.5MM 6MM CNN DRL GDPN INTFR SCR RMR TMPLT MPFL PK BOTH IP/OP "$3,717.50 " "$2,750.95" $0.00 "$2,974.00" "$1,672.88" "$1,672.88" $0.00 $0.00 $0.00 $774.82 "$2,759.13" "$2,759.13" $0.00 $0.00 $774.73 $0.00 "$1,832.73" "$1,832.73" $0.00 "$1,858.75" "$2,944.26" "$2,974.00" $0.00 $0.00 $581.79 $0.00 $0.00 $591.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1360CST-CP SUP HCPCS C1713 AR-1360CST-CP - SET IMPL 1.1MM 3.5IN CNN CLS EYLT DRL PIN RMR TMPLT MPFL PK BOTH IP/OP "$4,217.50 " "$3,120.95" $0.00 "$3,374.00" "$1,897.88" "$1,897.88" $0.00 $0.00 $0.00 $879.03 "$3,130.23" "$3,130.23" $0.00 $0.00 $878.93 $0.00 "$2,079.23" "$2,079.23" $0.00 "$2,108.75" "$3,340.26" "$3,374.00" $0.00 $0.00 $660.04 $0.00 $0.00 $671.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1360E SUP HCPCS C1713 AR-1360E - SCREW INTFR 6MM 20MM STRL CNN SHTH TI ACL PCL ACPT 2MM NTNL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1360P SUP HCPCS C1713 AR-1360P - SCREW INTFR 6MM 23MM STRL THRD PTRN PEEK-OPTM ACL PCL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1363 SUP HCPCS C1713 AR-1363 - SCREW INTFR 3MM 40MM STRL TRNFX SLF CUT ST TI ACL BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1363L SUP HCPCS C1713 AR-1363L - SCREW INTFR 3MM 50MM STRL TRNFX SLF CUT ST TI ACL BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-25 SUP HCPCS C1713 AR-1365-25 - POST FIX LP 4.5MM 25MM SELF TAP THREAD TITANIUM KNEE BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-275 SUP Custom 27203010 AR-1365-275 - POST FX LOPRFL 4.5MM 27.5MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-30 SUP Custom 27203010 AR-1365-30 - POST FX LOPRFL 4.5MM 30MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-325 SUP Custom 27203010 AR-1365-325 - POST FX LOPRFL 4.5MM 32.5MM ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-375 SUP Custom 27203010 AR-1365-375 - POST FX LOPRFL 4.5MM 37.5MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-40 SUP Custom 27203010 AR-1365-40 - POST FX LOPRFL 4.5MM 40MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-425 SUP Custom 27203010 AR-1365-425 - POST FX LOPRFL 4.5MM 42.5MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-45 SUP Custom 27203010 AR-1365-45 - POST FX LOPRFL 4.5MM 45MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-475 SUP Custom 27203010 AR-1365-475 - POST FX LOPRFL 4.5MM 47.5MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-50 SUP Custom 27203010 AR-1365-50 - POST FX LOPRFL 4.5MM 50MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-525 SUP Custom 27203010 AR-1365-525 - POST FX LOPRFL 4.5MM 52.5MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-55 SUP Custom 27203010 AR-1365-55 - POST FX LOPRFL 4.5MM 55MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-575 SUP Custom 27203010 AR-1365-575 - POST FX LOPRFL 4.5MM 57.5MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365-60 SUP Custom 27203010 AR-1365-60 - POST FX LOPRFL 4.5MM 60MM STRL ST THRD TI KN BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-25 SUP Custom 27203010 AR-1365NS-25 - POST FX LOPRFL 4.5MM 25MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-275 SUP Custom 27203010 AR-1365NS-275 - POST FX LOPRFL 4.5MM 27.5MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-30 SUP Custom 27203010 AR-1365NS-30 - POST FX LOPRFL 4.5MM 30MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-325 SUP Custom 27203010 AR-1365NS-325 - POST FX LOPRFL 4.5MM 32.5MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-35 SUP Custom 27203010 AR-1365NS-35 - POST FX LOPRFL 4.5MM 35MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-375 SUP Custom 27203010 AR-1365NS-375 - POST FX LOPRFL 4.5MM 37.5MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-40 SUP Custom 27203010 AR-1365NS-40 - POST FX LOPRFL 4.5MM 40MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-425 SUP Custom 27203010 AR-1365NS-425 - POST FX LOPRFL 4.5MM 42.5MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-45 SUP Custom 27203010 AR-1365NS-45 - POST FX LOPRFL 4.5MM 45MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-475 SUP Custom 27203010 AR-1365NS-475 - POST FX LOPRFL 4.5MM 47.5MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-50 SUP Custom 27203010 AR-1365NS-50 - POST FX LOPRFL 4.5MM 50MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-525 SUP Custom 27203010 AR-1365NS-525 - POST FX LOPRFL 4.5MM 52.5MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-55 SUP Custom 27203010 AR-1365NS-55 - POST FX LOPRFL 4.5MM 55MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-575 SUP Custom 27203010 AR-1365NS-575 - POST FX LOPRFL 4.5MM 57.5MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1365NS-60 SUP Custom 27203010 AR-1365NS-60 - POST FX LOPRFL 4.5MM 60MM NS TI ACL PCL BCORT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-30 SUP Custom 27203010 AR-1366-30 - POST FX LOPRFL 6.5MM 30MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-32 SUP Custom 27203010 AR-1366-32 - POST FX LOPRFL 6.5MM 32MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-34 SUP Custom 27203010 AR-1366-34 - POST FX LOPRFL 6.5MM 34MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-36 SUP Custom 27203010 AR-1366-36 - POST FX LOPRFL 6.5MM 36MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-38 SUP Custom 27203010 AR-1366-38 - POST FX LOPRFL 6.5MM 38MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-40 SUP Custom 27203010 AR-1366-40 - POST FX LOPRFL 6.5MM 40MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-42 SUP Custom 27203010 AR-1366-42 - POST FX LOPRFL 6.5MM 42MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-44 SUP Custom 27203010 AR-1366-44 - POST FX LOPRFL 6.5MM 44MM ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-46 SUP Custom 27203010 AR-1366-46 - POST FX LOPRFL 6.5MM 46MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-48 SUP Custom 27203010 AR-1366-48 - POST FX LOPRFL 6.5MM 48MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-50 SUP Custom 27203010 AR-1366-50 - POST FX LOPRFL 6.5MM 50MM ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366-52 SUP Custom 27203010 AR-1366-52 - POST FX LOPRFL 6.5MM 52MM STRL ST THRD TI KN BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-30 SUP Custom 27203010 AR-1366NS-30 - POST FX LOPRFL 6.5MM 30MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-32 SUP Custom 27203010 AR-1366NS-32 - POST FX LOPRFL 6.5MM 32MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-34 SUP Custom 27203010 AR-1366NS-34 - POST FX LOPRFL 6.5MM 34MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-36 SUP Custom 27203010 AR-1366NS-36 - POST FX LOPRFL 6.5MM 36MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-38 SUP Custom 27203010 AR-1366NS-38 - POST FX LOPRFL 6.5MM 38MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-40 SUP Custom 27203010 AR-1366NS-40 - POST FX LOPRFL 6.5MM 40MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-42 SUP Custom 27203010 AR-1366NS-42 - POST FX LOPRFL 6.5MM 42MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-44 SUP Custom 27203010 AR-1366NS-44 - POST FX LOPRFL 6.5MM 44MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-46 SUP Custom 27203010 AR-1366NS-46 - POST FX LOPRFL 6.5MM 46MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-48 SUP Custom 27203010 AR-1366NS-48 - POST FX LOPRFL 6.5MM 48MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1366NS-50 SUP Custom 27203010 AR-1366NS-50 - POST FX LOPRFL 6.5MM 50MM NS TI ACL PCL BCORT BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1367D SUP Custom 27203010 AR-1367D - BIT DRL 4.8MM 6.5MM POST BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370 SUP HCPCS C1713 "AR-1370 - SCREW, CANNULATED INTERFERENCE" BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370B SUP HCPCS C1713 AR-1370B - SCREW INTFR 7MM 23MM STRL BIOINTF CNN SHTH POLY L LAC ACD BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370C SUP HCPCS C1713 AR-1370C - SCREW INTERFERENCE 7MM 23MM CANN REDUCE HEAD BIOCOMPOSITE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370E SUP HCPCS C1713 AR-1370E - SCREW INTFR 7MM 20MM STRL CNN DISP SHTH TI ACL PCL ACPT 2MM BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370H-25 SUP HCPCS C1713 AR-1370H-25 - SCREW INTFR BLNT RND 7MM 25MM STRL CNN SFT TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370H-30 SUP HCPCS C1713 AR-1370H-30 - SCREW INTFR BLNT RND 7MM 30MM STRL CNN SFT TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370P SUP HCPCS C1713 AR-1370P - SCREW INTFR 7MM 23MM STRL PEEK-OPTM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370T SUP HCPCS C1713 AR-1370T - SCREW INTFR FT RND 7MM 20MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370TB SUP HCPCS C1713 AR-1370TB - SCREW INTFR FT 7MM 28MM STRL BIOINTF CNN POLY L LAC ACD ACL BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1370TC SUP HCPCS C1713 AR-1370TC - SCREW INTFR FT STP TPR 7MM 28MM STRL CNN FULL SEAT RDC HD BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1371 SUP HCPCS C1713 AR-1371 - SCREW INTFR 7MM 25MM STRL CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-03.0 SUP HCPCS C1713 AR-13710-03.0 - PLATE BN STRG 3MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-05.0 SUP HCPCS C1713 AR-13710-05.0 - PLATE BN STRG 5MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-07.5 SUP HCPCS C1713 AR-13710-07.5 - PLATE BN STRG 7.5MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-09.0 SUP HCPCS C1713 AR-13710-09.0 - PLATE BN STRG 9MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-10.0 SUP HCPCS C1713 AR-13710-10.0 - PLATE BN STRG 10MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-11.0 SUP HCPCS C1713 AR-13710-11.0 - PLATE BN STRG 11MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-12.5 SUP HCPCS C1713 AR-13710-12.5 - PLATE BN STRG 12.5MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-15.0 SUP HCPCS C1713 AR-13710-15.0 - PLATE BN STRG 15MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13710-17.5 SUP HCPCS C1713 AR-13710-17.5 - PLATE BN STRG 17.5MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-03.0 SUP HCPCS C1713 AR-13715-03.0 - PLATE BN STRG 3MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-05.0 SUP HCPCS C1713 AR-13715-05.0 - PLATE BN STRG 5MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-07.5 SUP HCPCS C1713 AR-13715-07.5 - PLATE BN STRG 7.5MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-09.0 SUP HCPCS C1713 AR-13715-09.0 - PLATE BN STRG 9MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-10.0 SUP HCPCS C1713 AR-13715-10.0 - PLATE BN STRG 10MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-11.0 SUP HCPCS C1713 AR-13715-11.0 - PLATE BN STRG 11MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-12.5 SUP HCPCS C1713 AR-13715-12.5 - PLATE BN STRG 12.5MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-15.0 SUP HCPCS C1713 AR-13715-15.0 - PLATE BN STRG 15MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13715-17.5 SUP HCPCS C1713 AR-13715-17.5 - PLATE BN STRG 17.5MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1371E SUP HCPCS C1713 AR-1371E - SCREW INTFR 7MM 25MM STRL CNN SHTH TI ACL PCL ACPT 2MM NTNL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1371T SUP HCPCS C1713 AR-1371T - SCREW INTFR FT RND 7MM 25MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1372 SUP HCPCS C1713 AR-1372 - SCREW INTFR 7MM 30MM STRL BIOINTF CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13720-05.0 SUP HCPCS C1713 AR-13720-05.0 - PLATE BN 5MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13720-07.5 SUP HCPCS C1713 AR-13720-07.5 - PLATE BN 7.5MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13720-09.0 SUP HCPCS C1713 AR-13720-09.0 - PLATE BN 9MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13720-10.0 SUP HCPCS C1713 AR-13720-10.0 - PLATE BN 10MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13720-11.0 SUP HCPCS C1713 AR-13720-11.0 - PLATE BN 11MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13720-12.5 SUP HCPCS C1713 AR-13720-12.5 - PLATE BN 12.5MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13720-15.0 SUP HCPCS C1713 AR-13720-15.0 - PLATE BN 15MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13720-17.5 SUP HCPCS C1713 AR-13720-17.5 - PLATE BN 17.5MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13725-05.0 SUP HCPCS C1713 AR-13725-05.0 - PLATE BN 5MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13725-07.5 SUP HCPCS C1713 AR-13725-07.5 - PLATE BN 7.5MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13725-09.0 SUP HCPCS C1713 AR-13725-09.0 - PLATE BN 9MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13725-10.0 SUP HCPCS C1713 AR-13725-10.0 - PLATE BN 10MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13725-11.0 SUP HCPCS C1713 AR-13725-11.0 - PLATE BN 11MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13725-12.5 SUP HCPCS C1713 AR-13725-12.5 - PLATE BN 12.5MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13725-15.0 SUP HCPCS C1713 AR-13725-15.0 - PLATE BN 15MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR SLOP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13725-17.5 SUP HCPCS C1713 AR-13725-17.5 - PLATE BN 17.5MM STRL CONTOURLOCK HTO PLT ANTEROPOSTERIOR BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1372E SUP HCPCS C1713 AR-1372E - SCREW INTFR 7MM 30MM STRL CNN SHTH TI ACL PCL ACPT 2MM NTNL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1372T SUP HCPCS C1713 AR-1372T - SCREW INTFR FT RND 7MM 30MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13730-01 SUP HCPCS C1713 AR-13730-01 - PLATE BN FLT 67MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13730-02 SUP HCPCS C1713 AR-13730-02 - PLATE BN FLT 71MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13730-03 SUP HCPCS C1713 AR-13730-03 - PLATE BN FLT 84MM STRL CONTOURLOCK HTO PLT TIB LT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13735-01 SUP HCPCS C1713 AR-13735-01 - PLATE BN FLT 67MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13735-02 SUP HCPCS C1713 AR-13735-02 - PLATE BN FLT 71MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13735-03 SUP HCPCS C1713 AR-13735-03 - PLATE BN FLT 84MM STRL CONTOURLOCK HTO PLT TIB RT OPN WDG BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1375E SUP HCPCS C1713 AR-1375E - SCREW INTFR 7MM 15MM STRL CNN SHTH TI ACL PCL ACPT 2MM NTNL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380 SUP HCPCS C1713 AR-1380 - SCREW INTFR 8MM 20MM STRL BIOINTF CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380B SUP HCPCS C1713 AR-1380B - SCREW INTFR 8MM 23MM STRL BIOINTF CNN SHTH POLY L LAC ACD BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380E SUP HCPCS C1713 AR-1380E - SCREW INTERFERENCE 8MM 20MM CANN SHEATH TITANIUM ACL PCL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380H-25 SUP HCPCS C1713 AR-1380H-25 - SCREW INTFR BLNT RND 8MM 25MM STRL CNN SFT TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380H-30 SUP HCPCS C1713 AR-1380H-30 - SCREW INTFR BLNT RND 8MM 30MM STRL CNN SFT TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380H-35 SUP HCPCS C1713 AR-1380H-35 - SCREW INTFR BLNT RND 8MM 35MM STRL CNN SFT TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380HLU-25 SUP HCPCS C1713 AR-1380HLU-25 - SCREW SOFT CANN LFT HAND THD 8X25MM TI BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380P SUP HCPCS C1713 AR-1380P - SCREW INTFR 8MM 23MM STRL PEEK-OPTM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380T SUP HCPCS C1713 AR-1380T - SCREW INTFR FT RND 8MM 20MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380TB SUP HCPCS C1713 AR-1380TB - SCREW INTFR FT 8MM 28MM STRL BIOINTF CNN POLY L LAC ACD ACL BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1380TC SUP HCPCS C1713 AR-1380TC - SCREW INTFR BLNT FT STP TPR 8MM 28MM STRL CNN FULL SEAT RDC BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1381 SUP HCPCS C1713 AR-1381 - SCREW INTFR 8MM 25MM STRL BIOINTF CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1381T SUP HCPCS C1713 AR-1381T - SCREW INTFR FT RND 8MM 25MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1382 SUP HCPCS C1713 AR-1382 - SCREW INTFR 8MM 30MM STRL BIOINTF CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1382T SUP HCPCS C1713 AR-1382T - SCREW INTFR FT RND 8MM 30MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1390 SUP HCPCS C1713 AR-1390 - SCREW INTFR 9MM 20MM STRL BIOINTF CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1390B SUP HCPCS C1713 AR-1390B - SCREW INTFR 9MM 23MM STRL BIOINTF CNN SHTH POLY L LAC ACD BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1390E SUP HCPCS C1713 AR-1390E - SCREW INTFR 20MM 9MM KNEE CANN SHTH STRL DISP BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1390H-35 SUP HCPCS C1713 AR-1390H-35 - SCREW INTFR BLNT RND 9MM 35MM STRL CNN SFT TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1390P SUP HCPCS C1713 AR-1390P - SCREW INTFR 9MM 23MM STRL PEEK-OPTM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1390T SUP HCPCS C1713 AR-1390T - SCREW INTFR FT RND 9MM 20MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1390TB SUP HCPCS C1713 AR-1390TB - SCREW INTFR FT 9MM 28MM STRL BIOINTF CNN POLY L LAC ACD ACL BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1390TC SUP HCPCS C1713 AR-1390TC - SCREW INTERFERENCE BLUNT FULTHD STEP TAPER 9MM 28MM CANN BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1391 SUP HCPCS C1713 AR-1391 - SCREW INTFR 9MM 25MM STRL BIOINTF CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1391E SUP HCPCS C1713 AR-1391E - SCREW INTFR 9MM 25MM STRL CNN DISP SHTH TI ACL PCL ACPT 2MM BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1391T SUP HCPCS C1713 AR-1391T - SCREW INTFR FT RND 9MM 25MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1392 SUP HCPCS C1713 AR-1392 - SCREW INTFR RND 9MM 30MM STRL CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1392E SUP HCPCS C1713 AR-1392E - SCREW INTFR 9MM 30MM STRL CNN SHTH TI ACL PCL ACPT 2MM NTNL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1392T SUP HCPCS C1713 AR-1392T - SCREW INTFR FT RND 9MM 30MM STRL CNN RECON TI ACL PCL ACPT 2 BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13991N SUP Custom 27203010 AR-13991N - NEEDLE SUTURE SCORPION SUREFIRE ROTATOR CUFF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-13995N SUP Custom 27203010 AR-13995N - NEEDLE SUT MF SCRPN BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400 SUP HCPCS C1713 AR-1400 - SCREW INTFR 10MM 20MM STRL BIOINTF CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14003 SUP HCPCS C1713 AR-14003 - PLATE BN STRL SUTUREPLATE 3 HL HUM BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14005 SUP HCPCS C1713 AR-14005 - PLATE BN STRL SUTUREPLATE 5 HL HUM BOTH IP/OP "$3,987.50 " "$2,950.75" $0.00 "$3,190.00" "$1,794.38" "$1,794.38" $0.00 $0.00 $0.00 $831.09 "$2,959.52" "$2,959.52" $0.00 $0.00 $831.00 $0.00 "$1,965.84" "$1,965.84" $0.00 "$1,993.75" "$3,158.10" "$3,190.00" $0.00 $0.00 $624.04 $0.00 $0.00 $634.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400B SUP HCPCS C1713 AR-1400B - SCREW INTFR 10MM 23MM STRL BIOINTF CNN SHTH POLY L LAC ACD BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400H-25 SUP HCPCS C1713 AR-1400H-25 - SCREW INTFR BLNT RND 10MM 25MM STRL CNN SFT TI ACL PCL ACPT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400H-30 SUP HCPCS C1713 AR-1400H-30 - SCREW INTFR BLNT RND 10MM 30MM STRL CNN SFT TI ACL PCL ACPT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400H-35 SUP HCPCS C1713 AR-1400H-35 - SCREW INTFR BLNT RND 10MM 35MM STRL CNN SFT TI ACL PCL ACPT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400P SUP HCPCS C1713 AR-1400P - SCREW INTFR 10MM 23MM STRL PEEK-OPTM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400T SUP HCPCS C1713 AR-1400T - SCREW INTFR FT RND 10MM 28MM STRL CNN RECON TI ACL PCL ACPT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400TB SUP HCPCS C1713 AR-1400TB - SCREW INTFR FT 10MM 28MM STRL BIOINTF CNN POLY L LAC ACD ACL BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1400TC SUP HCPCS C1713 AR-1400TC - SCREW INTFR BLNT FT STP TPR 10MM 28MM STRL CNN FULL SEAT RDC BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1401 SUP HCPCS C1713 AR-1401 - SCREW INTFR 10MM 25MM STRL CNN TI ACL PCL DISP BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14012 SUP Custom 27203010 AR-14012 - GUIDE DRL 2.5MM SUTUREPLATE THRD BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $0.00 $0.00 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1401T SUP HCPCS C1713 AR-1401T - SCREW INTFR FT RND 10MM 25MM STRL CNN RECON TI ACL PCL ACPT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1402 SUP HCPCS C1713 AR-1402 - SCREW INTFR 10MM 30MM STRL BIOINTF CNN TI ACL PCL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14029 SUP Custom 27203010 AR-14029 - GUIDE DRL 2.5MM BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $0.00 $0.00 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1402T SUP HCPCS C1713 AR-1402T - SCREW INTFR FT RND 10MM 30MM STRL CNN RECON TI ACL PCL ACPT BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1403TB SUP HCPCS C1713 AR-1403TB - SCREW INTFR FT 11MM 28MM STRL BIOINTF CNN BLNT POLY L LAC BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1403TC SUP HCPCS C1713 AR-1403TC - SCREW INTFR FT STP TPR 11MM 28MM STRL CNN SEAT RDC HD BLNT BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1404TB SUP HCPCS C1713 AR-1404TB - SCREW INTFR FT 12MM 28MM STRL BIOINTF CNN BLNT POLY L LAC BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1405LP SUP Custom 27203010 AR-1405LP - REAMER SRG LOPRFL 5MM STRL CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1405LP-50 SUP Custom 27203010 AR-1405LP-50 - REAMER SURG LP 5.5MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1406LP SUP Custom 27203010 AR-1406LP - REAMER SRG LOPRFL 6MM STRL CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1406LP-50 SUP Custom 27203010 AR-1406LP-50 - REAMER SRG LOPRFL 6.5MM STRL CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1407LP SUP Custom 27203010 AR-1407LP - REAMER SURG LP 7MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1407LP-50 SUP Custom 27203010 AR-1407LP-50 - REAMER SURG LP 7.5MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1408LP SUP Custom 27203010 AR-1408LP - REAMER SURG LP 8MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1408LP-50 SUP Custom 27203010 AR-1408LP-50 - REAMER SURG LP 8.5MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1408LPF SUP Custom 27203010 AR-1408LPF - REAMER SRG LOPRFL 8MM LOW PROFILE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1408LPF-50 SUP Custom 27203010 AR-1408LPF-50 - REAMER SRG LOPRFL 8.5MM LOW PROFILE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1409LP SUP Custom 27203010 AR-1409LP - REAMER SURG LP 9MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1409LP-50 SUP Custom 27203010 AR-1409LP-50 - REAMER SURG LP 9.5MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1409LPF SUP Custom 27203010 AR-1409LPF - REAMER SRG LOPRFL 9MM LOW PROFILE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1409LPF-50 SUP Custom 27203010 AR-1409LPF-50 - REAMER SRG LOPRFL 9.5MM LOW PROFILE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1410LP SUP Custom 27203010 AR-1410LP - REAMER SURG LP 10MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1410LP-50 SUP Custom 27203010 AR-1410LP-50 - REAMER SURG LP 10.5MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1410LPF SUP Custom 27203010 AR-1410LPF - REAMER SRG LOPRFL 10MM LOW PROFILE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1410LPF-50 SUP Custom 27203010 AR-1410LPF-50 - REAMER SRG LOPRFL 10.5MM LOW PROFILE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14116 SUP HCPCS C1713 AR-14116 - SCREW BN LOPRFL 3.5MM 16MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14116NL SUP HCPCS C1713 AR-14116NL - SCREW BN LOPRFL 3.5MM 16MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14118 SUP HCPCS C1713 AR-14118 - SCREW BN LOPRFL 3.5MM 18MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14118NL SUP HCPCS C1713 AR-14118NL - SCREW BN LOPRFL 3.5MM 18MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1411LP SUP Custom 27203010 AR-1411LP - REAMER SURG LP 11MM CANN ACL STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1411LP-50 SUP Custom 27203010 AR-1411LP-50 - REAMER SRG LOPRFL 11.5MM STRL CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1411LPF SUP Custom 27203010 AR-1411LPF - REAMER SRG LOPRFL 11MM LOW PROFILE BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14120 SUP HCPCS C1713 AR-14120 - SCREW BN LOPRFL 3.5MM 20MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14120NL SUP HCPCS C1713 AR-14120NL - SCREW BN LOPRFL 3.5MM 20MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14122 SUP HCPCS C1713 AR-14122 - SCREW BN LOPRFL 3.5MM 22MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14122NL SUP HCPCS C1713 AR-14122NL - SCREW BN LOPRFL 3.5MM 22MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14124 SUP HCPCS C1713 AR-14124 - SCREW BN LOPRFL 3.5MM 24MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14124NL SUP HCPCS C1713 AR-14124NL - SCREW BN LOPRFL 3.5MM 24MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14126 SUP HCPCS C1713 AR-14126 - SCREW BN LOPRFL 3.5MM 26MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14126NL SUP HCPCS C1713 AR-14126NL - SCREW BN LOPRFL 3.5MM 26MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14128 SUP HCPCS C1713 AR-14128 - SCREW BN LOPRFL 3.5MM 28MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14128NL SUP HCPCS C1713 AR-14128NL - SCREW BN LOPRFL 3.5MM 28MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1412LP SUP Custom 27203010 AR-1412LP - REAMER SRG LOPRFL 12MM STRL CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1412LP-50 SUP Custom 27203010 AR-1412LP-50 - REAMER SRG LOPRFL 12.5MM STRL CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14130 SUP HCPCS C1713 AR-14130 - SCREW BN LOPRFL 3.5MM 30MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14130NL SUP HCPCS C1713 AR-14130NL - SCREW BN LOPRFL 3.5MM 30MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14132 SUP HCPCS C1713 AR-14132 - SCREW BN LOPRFL 3.5MM 32MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14132NL SUP HCPCS C1713 AR-14132NL - SCREW BN LOPRFL 3.5MM 32MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14134 SUP HCPCS C1713 AR-14134 - SCREW BN LOPRFL 3.5MM 34MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14134NL SUP HCPCS C1713 AR-14134NL - SCREW BN LOPRFL 3.5MM 34MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14136 SUP HCPCS C1713 AR-14136 - SCREW BN LOPRFL 3.5MM 36MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14136NL SUP HCPCS C1713 AR-14136NL - SCREW BN LOPRFL 3.5MM 36MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14138 SUP HCPCS C1713 AR-14138 - SCREW BN LOPRFL 3.5MM 38MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14138NL SUP HCPCS C1713 AR-14138NL - SCREW BN LOPRFL 3.5MM 38MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1413LP SUP Custom 27203010 AR-1413LP - REAMER SRG LOPRFL 13MM STRL CNN ACL DISP BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14140 SUP HCPCS C1713 AR-14140 - SCREW BN LOPRFL 3.5MM 40MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14140NL SUP HCPCS C1713 AR-14140NL - SCREW BN LOPRFL 3.5MM 40MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14145 SUP HCPCS C1713 AR-14145 - SCREW BN LOPRFL 3.5MM 45MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14145NL SUP HCPCS C1713 AR-14145NL - SCREW BN LOPRFL 3.5MM 45MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14150 SUP HCPCS C1713 AR-14150 - SCREW BN LOPRFL 3.5MM 50MM SUTUREPLATE LCK TI SHLDR CORT BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14150NL SUP HCPCS C1713 AR-14150NL - SCREW BN LOPRFL 3.5MM 50MM SUTUREPLATE TI SHLDR CORT ARTHPL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14224 SUP HCPCS C1713 AR-14224 - SCREW BN LOPRFL 4MM 24MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14226 SUP HCPCS C1713 AR-14226 - SCREW BN LOPRFL 4MM 26MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14228 SUP HCPCS C1713 AR-14228 - SCREW BN LOPRFL 4MM 28MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14230 SUP HCPCS C1713 AR-14230 - SCREW BN LOPRFL 4MM 30MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14232 SUP HCPCS C1713 AR-14232 - SCREW BN LOPRFL 4MM 32MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14234 SUP HCPCS C1713 AR-14234 - SCREW BN LOPRFL 4MM 34MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14236 SUP HCPCS C1713 AR-14236 - SCREW BN LOPRFL 4MM 36MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14238 SUP HCPCS C1713 AR-14238 - SCREW BN LOPRFL 4MM 38MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14240 SUP HCPCS C1713 AR-14240 - SCREW BN LOPRFL 4MM 40MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14242 SUP HCPCS C1713 AR-14242 - SCREW BN LOPRFL 4MM 42MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14244 SUP HCPCS C1713 AR-14244 - SCREW BN LOPRFL 4MM 44MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14246 SUP HCPCS C1713 AR-14246 - SCREW BN LOPRFL 4MM 46MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14248 SUP HCPCS C1713 AR-14248 - SCREW BN LOPRFL 4MM 48MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14250 SUP HCPCS C1713 AR-14250 - SCREW BN 4MM 50MM SUTUREPLATE LCK HUM CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14252 SUP HCPCS C1713 AR-14252 - SCREW BN LOPRFL 4MM 52MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14254 SUP HCPCS C1713 AR-14254 - SCREW BN LOPRFL 4MM 54MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-14256 SUP HCPCS C1713 AR-14256 - SCREW BN LOPRFL 4MM 56MM SUTUREPLATE LCK TI SHLDR CANC BOTH IP/OP $280.00 $207.20 $0.00 $224.00 $126.00 $126.00 $0.00 $0.00 $0.00 $58.36 $207.82 $207.82 $0.00 $0.00 $58.35 $0.00 $165.62 $165.62 $0.00 $140.00 $221.76 $224.00 $0.00 $0.00 $43.82 $0.00 $0.00 $44.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1450 SUP Custom 27203010 AR-1450 - REAMER SRG 6MM STRL PILT HD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1451 SUP Custom 27203010 AR-1451 - REAMER SURG 6.5MM PILOT HEAD STERILE BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1452 SUP Custom 27203010 AR-1452 - REAMER SRG 7MM STRL PILT HD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1453 SUP Custom 27203010 AR-1453 - REAMER SRG 7.5MM STRL PILT HD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1454 SUP Custom 27203010 AR-1454 - REAMER SRG 8MM STRL PILT HD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1455 SUP Custom 27203010 AR-1455 - REAMER SRG 8.5MM STRL PILT HD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1456 SUP Custom 27203010 AR-1456 - REAMER SRG 9MM STRL PILT HD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1457 SUP Custom 27203010 AR-1457 - REAMER SRG 9.5MM STRL PILT HD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1458 SUP Custom 27203010 AR-1458 - REAMER SRG 10MM STRL PILT HD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1502 SUP Custom 27203010 AR-1502 - INSERT PSTN CSHN FM LG HLDR BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $0.00 $0.00 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1510FL SUP Custom 27203010 AR-1510FL - GUIDE DRL RETROCONSTRUCTION SET ADJ C RING FTPRNT SLV FEM LT BOTH IP/OP "$1,365.00 " "$1,010.10" $0.00 "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,013.10" "$1,013.10" $0.00 $0.00 $284.47 $0.00 $0.00 $0.00 $0.00 $682.50 "$1,081.08" "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1510FLS SUP Custom 27203010 AR-1510FLS - GUIDE DRL ANG SM RETROCONSTRUCTION FTPRNT FEM LT ACL BOTH IP/OP "$2,433.75 " "$1,800.98" $0.00 "$1,947.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,806.33" "$1,806.33" $0.00 $0.00 $507.19 $0.00 $0.00 $0.00 $0.00 "$1,216.88" "$1,927.53" "$1,947.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1510FPL SUP Custom 27203010 AR-1510FPL - GUIDE DRL 7MM OFST RETROCONSTRUCTION FTPRNT FEM LT ACL BOTH IP/OP "$1,365.00 " "$1,010.10" $0.00 "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,013.10" "$1,013.10" $0.00 $0.00 $284.47 $0.00 $0.00 $0.00 $0.00 $682.50 "$1,081.08" "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1510FPR SUP Custom 27203010 AR-1510FPR - GUIDE DRL 7MM OFST RETROCONSTRUCTION FTPRNT FEM RT ACL BOTH IP/OP "$1,365.00 " "$1,010.10" $0.00 "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,013.10" "$1,013.10" $0.00 $0.00 $284.47 $0.00 $0.00 $0.00 $0.00 $682.50 "$1,081.08" "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1510FR SUP Custom 27203010 AR-1510FR - GUIDE DRL RETROCONSTRUCTION SET ADJ C RING FTPRNT SLV FEM RT BOTH IP/OP "$1,365.00 " "$1,010.10" $0.00 "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,013.10" "$1,013.10" $0.00 $0.00 $284.47 $0.00 $0.00 $0.00 $0.00 $682.50 "$1,081.08" "$1,092.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1510FRS SUP Custom 27203010 AR-1510FRS - GUIDE DRL ANG SM RETROCONSTRUCTION FTPRNT FEM RT ACL BOTH IP/OP "$2,433.75 " "$1,800.98" $0.00 "$1,947.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,806.33" "$1,806.33" $0.00 $0.00 $507.19 $0.00 $0.00 $0.00 $0.00 "$1,216.88" "$1,927.53" "$1,947.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1530BC SUP HCPCS C1713 AR-1530BC - SCREW INTFR 3MM 8MM STRL TENODESIS HNDL INSRTR BCMPS SFT TIS BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1530C-25 SUP Custom 27203010 AR-1530C-25 - BIT DRL 2.5MM CNN BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1530DS SUP Custom 27203010 AR-1530DS - KIT INST 2-0 .041IN 2.5MM BTNDS FWR NDL CNN DRL SUT PASS WRE BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1530P-CP SUP HCPCS C1713 AR-1530P-CP - SYSTEM IMPL STRL INTERNALBRACE PEEK FOREFOOT BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1530PS SUP HCPCS C1713 AR-1530PS - SCREW INTFR 3MM 8MM STRL TENODESIS HNDL INSRTR VNT PEEK-OPTM BOTH IP/OP $912.50 $675.25 $0.00 $730.00 $410.63 $410.63 $0.00 $0.00 $0.00 $190.19 $677.26 $677.26 $0.00 $0.00 $190.17 $0.00 $539.74 $539.74 $0.00 $456.25 $722.70 $730.00 $0.00 $0.00 $142.81 $0.00 $0.00 $145.27 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1540B SUP HCPCS C1713 AR-1540B - SCREW INTFR 4MM 10MM STRL BTNDS RECON POLY L LAC ACD ACL PCL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1540BC SUP HCPCS C1713 AR-1540BC - SCREW INTFR 4MM 10MM STRL TENODESIS BCMPS ACL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1540CDS SUP HCPCS C1713 AR-1540CDS - SCREW INTFR 4MM 10MM TENODESIS SCR DISP DRVR PK BCMPS BOTH IP/OP "$4,812.50 " "$3,561.25" $0.00 "$3,850.00" "$2,165.63" "$2,165.63" $0.00 $0.00 $0.00 "$1,003.05" "$3,571.84" "$3,571.84" $0.00 $0.00 "$1,002.93" $0.00 "$2,372.56" "$2,372.56" $0.00 "$2,406.25" "$3,811.50" "$3,850.00" $0.00 $0.00 $753.16 $0.00 $0.00 $766.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1540PS SUP HCPCS C1713 AR-1540PS - SCREW INTFR 4MM 10MM STRL TENODESIS VNT PEEK-OPTM FT/ANKL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1547BC SUP HCPCS C1713 AR-1547BC - SCREW INTFR 4.75MM 15MM STRL TENODESIS BCMPS ACL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1547CDS SUP HCPCS C1713 AR-1547CDS - SCREW INTFR 4.75MM 15MM TENODESIS SCR DISP DRVR PK BCMPS BOTH IP/OP "$4,812.50 " "$3,561.25" $0.00 "$3,850.00" "$2,165.63" "$2,165.63" $0.00 $0.00 $0.00 "$1,003.05" "$3,571.84" "$3,571.84" $0.00 $0.00 "$1,002.93" $0.00 "$2,372.56" "$2,372.56" $0.00 "$2,406.25" "$3,811.50" "$3,850.00" $0.00 $0.00 $753.16 $0.00 $0.00 $766.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1547PS SUP HCPCS C1713 AR-1547PS - SCREW INTFR 4.75MM 15MM STRL TENODESIS VNT PEEK-OPTM FT/ANKL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1555BC SUP HCPCS C1713 AR-1555BC - SCREW INTFR 5.5MM 15MM STRL TENODESIS BCMPS ACL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1555CDS-1 SUP HCPCS C1713 AR-1555CDS-1 - SCREW BN 5.5MM 15MM STRL ARTHX DISP DRVR BCMPS TENODESIS BOTH IP/OP $962.50 $712.25 $0.00 $770.00 $433.13 $433.13 $0.00 $0.00 $0.00 $200.61 $714.37 $714.37 $0.00 $0.00 $200.59 $0.00 $569.32 $569.32 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1555PS SUP HCPCS C1713 AR-1555PS - SCREW INTFR 5.5MM 15MM STRL TENODESIS VNT PEEK-OPTM FT/ANKL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1562BC SUP HCPCS C1713 AR-1562BC - SCREW INTFR 6.25MM 15MM STRL TENODESIS BCMPS ACL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1562CDS SUP HCPCS C1713 AR-1562CDS - SCREW INTFR 6.25MM 15MM TENODESIS SCR DISP DRVR PK BCMPS BOTH IP/OP "$4,812.50 " "$3,561.25" $0.00 "$3,850.00" "$2,165.63" "$2,165.63" $0.00 $0.00 $0.00 "$1,003.05" "$3,571.84" "$3,571.84" $0.00 $0.00 "$1,002.93" $0.00 "$2,372.56" "$2,372.56" $0.00 "$2,406.25" "$3,811.50" "$3,850.00" $0.00 $0.00 $753.16 $0.00 $0.00 $766.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1562PS SUP HCPCS C1713 AR-1562PS - SCREW INTFR 6.25MM 15MM STRL TENODESIS VNT PEEK-OPTM FT/ANKL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1570BC SUP HCPCS C1713 AR-1570BC - SCREW INTFR 7MM 23MM STRL TENODESIS BCMPS ACL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1570PS SUP HCPCS C1713 AR-1570PS - SCREW INTFR 7MM 23MM STRL TENODESIS VNT PEEK-OPTM FT/ANKL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1580BC SUP HCPCS C1713 AR-1580BC - SCREW INTFR 8MM 23MM STRL TENODESIS BCMPS ACL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1580PS SUP HCPCS C1713 AR-1580PS - SCREW INTFR 8MM 23MM STRL TENODESIS VNT PEEK-OPTM FT/ANKL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586FR-07 SUP HCPCS C1713 AR-1586FR-07 - SCREW INTFR 7MM 20MM STRL RETROSCREW 2 BNDL RECON RVRS THRD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586FR-08 SUP HCPCS C1713 AR-1586FR-08 - SCREW INTFR 8MM 20MM STRL RETROSCREW 2 BNDL RECON RVRS THRD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586FR-09 SUP HCPCS C1713 AR-1586FR-09 - SCREW INTFR 9MM 20MM STRL RETROSCREW 2 BNDL RECON RVRS THRD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586FR-10 SUP HCPCS C1713 AR-1586FR-10 - SCREW INTFR 10MM 20MM STRL RETROSCREW 2 BNDL RECON RVRS THRD BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586FRB-07 SUP HCPCS C1713 AR-1586FRB-07 - SCREW INTFR 7MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586FRB-08 SUP HCPCS C1713 AR-1586FRB-08 - SCREW INTFR 8MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586FRB-09 SUP HCPCS C1713 AR-1586FRB-09 - SCREW INTFR 9MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586FRB-10 SUP HCPCS C1713 AR-1586FRB-10 - SCREW INTFR 10MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586LB-08 SUP HCPCS C1713 AR-1586LB-08 - SCREW INTFR 8MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586LB-09 SUP HCPCS C1713 AR-1586LB-09 - SCREW INTFR 9MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586LB-10 SUP HCPCS C1713 AR-1586LB-10 - SCREW INTFR 10MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586R-08 SUP HCPCS C1713 AR-1586R-08 - SCREW INTFR 8MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN TI BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586R-09 SUP HCPCS C1713 AR-1586R-09 - SCREW INTFR 9MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN TI BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586R-10 SUP HCPCS C1713 AR-1586R-10 - SCREW INTFR 10MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RB-06 SUP HCPCS C1713 AR-1586RB-06 - SCREW INTFR 6MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RB-07 SUP HCPCS C1713 AR-1586RB-07 - SCREW INTFR 7MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RB-08 SUP HCPCS C1713 AR-1586RB-08 - SCREW INTFR 8MM 20MM STRL RETROSCREW RECON RVRS THRD POLY L BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RB-09 SUP HCPCS C1713 AR-1586RB-09 - SCREW INTFR 9MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RB-10 SUP HCPCS C1713 AR-1586RB-10 - SCREW INTFR 10MM 20MM STRL RETROSCREW RECON RVRS THRD DSGN BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RC-07 SUP HCPCS C1713 AR-1586RC-07 - SCREW INTFR 20MM 7MM STRL RETROSCREW RVRS THRD DSGN BCMPS BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RC-08 SUP HCPCS C1713 AR-1586RC-08 - SCREW INTFR 20MM 8MM STRL RETROSCREW RVRS THRD DSGN BCMPS BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RC-09 SUP HCPCS C1713 AR-1586RC-09 - SCREW INTFR 20MM 9MM STRL RETROSCREW RVRS THRD DSGN BCMPS BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1586RC-10 SUP HCPCS C1713 AR-1586RC-10 - SCREW INTFR 10MM 20MM STRL RETROSCREW ACL RVRS THRD DSGN BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1587S SUP Custom 27203010 AR-1587S - KIT INST STRL ALL INSD ACL DISP BOTH IP/OP "$1,182.50 " $875.05 $0.00 $946.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $877.65 $877.65 $0.00 $0.00 $246.43 $0.00 $0.00 $0.00 $0.00 $591.25 $936.54 $946.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-15 SUP HCPCS C1763 AR-1588-15 - BUTTON FX 12MM STRL 15MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-25 SUP HCPCS C1763 AR-1588-25 - BUTTON FX 12MM STRL 25MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-25BT SUP HCPCS C1763 AR-1588-25BT - BUTTON FX 12MM STRL 25MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-30BT SUP HCPCS C1763 AR-1588-30BT - BUTTON FX 12MM STRL 30MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-35 SUP HCPCS C1763 AR-1588-35 - BUTTON FX 12MM STRL 35MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-35BT SUP HCPCS C1763 AR-1588-35BT - BUTTON FX 12MM STRL 35MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-40 SUP HCPCS C1763 AR-1588-40 - BUTTON FX 12MM STRL 40MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-45 SUP HCPCS C1763 AR-1588-45 - BUTTON FX 12MM STRL 45MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-50 SUP HCPCS C1763 AR-1588-50 - BUTTON FX 12MM STRL 50MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-55 SUP HCPCS C1763 AR-1588-55 - BUTTON FX 12MM STRL 55MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-55BT SUP HCPCS C1763 "AR-1588-55BT - BUTTON BTB RETROBUTTON, 12MM X 55MM LOOP" BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-60 SUP HCPCS C1763 AR-1588-60 - BUTTON FX 12MM STRL 60MM RETROBUTTON LOOP SLF FLP TI UHMWPE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588-60BT SUP HCPCS C1763 "AR-1588-60BT - BUTTON BTB 12MM RETROBUTTON, 60MM LOOP" BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588BTB SUP HCPCS C1713 AR-1588BTB - DEVICE FIX SMALL 10MM 4 POINT LOCK ADJUSTABLE LOOP DRILL BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588BTB-J SUP HCPCS C1713 AR-1588BTB-J - DEVICE FX TGHTRP DEPLOYING SUT BOTH IP/OP "$1,112.50 " $823.25 $0.00 $890.00 $500.63 $500.63 $0.00 $0.00 $0.00 $231.87 $825.70 $825.70 $0.00 $0.00 $231.85 $0.00 $658.04 $658.04 $0.00 $556.25 $881.10 $890.00 $0.00 $0.00 $174.11 $0.00 $0.00 $177.11 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588RT SUP HCPCS C1713 AR-1588RT - KIT ENDSCP INSTR LATEX FREE TIGHTROPE TITANIUM UHMWPE ACL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588RT-07 SUP Custom 27203010 AR-1588RT-07 - KIT ASCP FX 8MM LF TGHTRP FLIPCUTTER II TIB RT ACL BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $0.00 $0.00 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588RT-13 SUP Custom 27203010 AR-1588RT-13 - KIT ASCP FX 11MM LF TGHTRP FLIPCUTTER II TIB RT ACL BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $0.00 $0.00 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588RT-18 SUP Custom 27203010 AR-1588RT-18 - KIT ASCP FX 9MM LF TGHTRP FLIPCUTTER II TIB RT ACL BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $0.00 $0.00 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588RT-J SUP HCPCS C1713 AR-1588RT-J - DEVICE FX TGHTRP 2 LD PASS SUT ACL RT BOTH IP/OP $925.00 $684.50 $0.00 $740.00 $416.25 $416.25 $0.00 $0.00 $0.00 $192.79 $686.54 $686.54 $0.00 $0.00 $192.77 $0.00 $547.14 $547.14 $0.00 $462.50 $732.60 $740.00 $0.00 $0.00 $144.76 $0.00 $0.00 $147.26 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588RTS SUP HCPCS C1713 AR-1588RTS - KIT ARTHRO FIX DELIVERY SYSTEM DRILL PIN TIGHTROPE ACL RIGHT BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588T SUP Custom 27203010 AR-1588T - KIT ASCP FX STRL TGHTRP REPR ACL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TB SUP HCPCS C1763 AR-1588TB - BUTTON FX 12MM 8MM TGHTRP ATCH SLOT ACL BOTH IP/OP $357.50 $264.55 $0.00 $286.00 $160.88 $160.88 $0.00 $0.00 $0.00 $74.51 $265.34 $265.34 $0.00 $0.00 $74.50 $0.00 $211.46 $211.46 $0.00 $178.75 $283.14 $286.00 $0.00 $0.00 $55.95 $0.00 $0.00 $56.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TB-1 SUP HCPCS C1763 AR-1588TB-1 - BUTTON FIXATION TIGHTROPE ROUND OD14 MM ACL ATTACHABLE BOTH IP/OP $535.00 $395.90 $0.00 $428.00 $240.75 $240.75 $0.00 $0.00 $0.00 $111.51 $397.08 $397.08 $0.00 $0.00 $111.49 $0.00 $316.45 $316.45 $0.00 $267.50 $423.72 $428.00 $0.00 $0.00 $83.73 $0.00 $0.00 $85.17 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TB-2 SUP HCPCS C1763 AR-1588TB-2 - BUTTON FX OBLNG 13MMXW 3.4MM TGHTRP ATCH SLOT ACL BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $226.13 $226.13 $0.00 $0.00 $0.00 $104.73 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $297.23 $297.23 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $78.64 $0.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TB-3 SUP HCPCS C1763 AR-1588TB-3 - BUTTON FX RND CNCV 11MM TGHTRP ATCH BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $252.00 $252.00 $0.00 $0.00 $0.00 $116.72 $415.63 $415.63 $0.00 $0.00 $116.70 $0.00 $331.24 $331.24 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $89.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TB-4 SUP HCPCS C1763 AR-1588TB-4 - BUTTON FX RND CNCV 14MM TGHTRP ATCH BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $252.00 $252.00 $0.00 $0.00 $0.00 $116.72 $415.63 $415.63 $0.00 $0.00 $116.70 $0.00 $331.24 $331.24 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $89.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TB-5 SUP HCPCS C1763 AR-1588TB-5 - BUTTON FX RND 20MM 9MM TGHTRP COLR ABS BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $252.00 $252.00 $0.00 $0.00 $0.00 $116.72 $415.63 $415.63 $0.00 $0.00 $116.70 $0.00 $331.24 $331.24 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $89.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TDB-7 SUP HCPCS C1713 AR-1588TDB-7 - DEVICE FX 7MM TGHTRP DLV SYS ACL DISP BOTH IP/OP "$1,162.50 " $860.25 $0.00 $930.00 $523.13 $523.13 $0.00 $0.00 $0.00 $242.29 $862.81 $862.81 $0.00 $0.00 $242.27 $0.00 $687.62 $687.62 $0.00 $581.25 $920.70 $930.00 $0.00 $0.00 $181.93 $0.00 $0.00 $185.07 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TDB-7S SUP HCPCS C1713 AR-1588TDB-7S - DEVICE FX TGHTRP DLV SYS ACL BOTH IP/OP "$1,475.00 " "$1,091.50" $0.00 "$1,180.00" $663.75 $663.75 $0.00 $0.00 $0.00 $307.43 "$1,094.75" "$1,094.75" $0.00 $0.00 $307.39 $0.00 $872.46 $872.46 $0.00 $737.50 "$1,168.20" "$1,180.00" $0.00 $0.00 $230.84 $0.00 $0.00 $234.82 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TN SUP HCPCS C1713 AR-1588TN - DEVICE TGHTRP ACL UHMWPE ATCH BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TN-1 SUP HCPCS C1713 AR-1588TN-1 - DEVICE FX TGHTRP ATCH OPN UHMWPE ACL BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1588TP SUP Custom 27203010 AR-1588TP - KIT ASCP FX TGHTRP PCL BOTH IP/OP $872.50 $645.65 $0.00 $698.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $647.57 $647.57 $0.00 $0.00 $181.83 $0.00 $0.00 $0.00 $0.00 $436.25 $691.02 $698.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1589-15 SUP HCPCS C1763 AR-1589-15 - BUTTON FX LNG 15MM STRL 15MM RETROBUTTON LOOP SLF FLP TI BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1589-20 SUP HCPCS C1763 AR-1589-20 - BUTTON FX LNG 15MM STRL 20MM RETROBUTTON LOOP SLF FLP TI BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1589-25 SUP HCPCS C1763 AR-1589-25 - BUTTON FX LNG 15MM STRL 25MM RETROBUTTON LOOP SLF FLP TI BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1589-30 SUP HCPCS C1763 AR-1589-30 - BUTTON FX LNG 15MM STRL 30MM RETROBUTTON LOOP SLF FLP TI BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1589-35 SUP HCPCS C1763 AR-1589-35 - BUTTON FX LNG 15MM STRL 35MM RETROBUTTON LOOP SLF FLP TI BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1589-40 SUP HCPCS C1763 AR-1589-40 - BUTTON FX LNG 15MM STRL 40MM RETROBUTTON LOOP SLF FLP TI BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1589RT SUP HCPCS C1763 AR-1589RT - BUTTON SUT LG 20X5MM TGHTRP XTD FTPRNT BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1590BC SUP HCPCS C1713 AR-1590BC - SCREW INTFR 9MM 23MM STRL TENODESIS BCMPS ACL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1590PS SUP HCPCS C1713 AR-1590PS - SCREW INTFR 9MM 23MM STRL TENODESIS VNT PEEK-OPTM FT/ANKL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1592 SUP HCPCS C1763 AR-1592 - BUTTON FX XL 11MM 20MM STRL RETROBUTTON ASYM LOOP RECON STF BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $298.13 $298.13 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1593 SUP Custom 27203010 AR-1593 - SYSTEM FX ACL BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1595 SUP HCPCS C1763 AR-1595 - PIN DRILL RETROBUTTON KNEE ACL STERILE DISPOSABLE BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1595TC SUP HCPCS C1763 AR-1595TC - PIN DRL 4MM STRL RETROBUTTON TGHTRP CLS EYLT KN ACL DISP BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1605S SUP HCPCS C1713 AR-1605S - HOOK SCR STOR WLMNT 2 HK 2 BOLT DRL BOTH IP/OP $47.50 $35.15 $0.00 $38.00 $21.38 $21.38 $0.00 $0.00 $0.00 $9.90 $35.25 $35.25 $0.00 $0.00 $9.90 $0.00 $28.10 $28.10 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $7.43 $0.00 $0.00 $7.56 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1606 SUP Custom 27203010 AR-1606 - DEVICE PSTN STRL CBN STAR SLV LAT TRC ROT STRAP FM FRARM BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1606C SUP Custom 27203010 AR-1606C - DEVICE PSTN STRL CBN STAR SLV CMPCT LAT TRC ROT STRAP SFT FM BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1606LV SUP Custom 27203010 AR-1606LV - DEVICE PSTN XLNG STRL STAR SLV VLCR FM ARM DISP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1606SV SUP Custom 27203010 AR-1606SV - DEVICE PSTN SM STRL STAR SLV VLCR LMB DISP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1606V SUP Custom 27203010 AR-1606V - DEVICE POSITIONING TRACTION SLING STAR SLEEVE VELCRO FOAM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1627-06 SUP Custom 27203010 AR-1627-06 - KIT PSTN UNV HD STRL DISP BOTH IP/OP $49.75 $36.82 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.92 $36.92 $0.00 $0.00 $10.37 $0.00 $0.00 $0.00 $0.00 $24.88 $39.40 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1627-11 SUP Custom 27203010 AR-1627-11 - CLAMP OP TBL CLRK RAIL BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1644 SUP Custom 27203010 AR-1644 - KIT POSITIONING BEACH CHAIR DRAPE HOLDER LIGHTWEIGHT TRIMANO BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1648 SUP Custom 27203010 AR-1648 - COVER PSTN STRL TRIMANO DRP BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1650-07 SUP Custom 27203010 AR-1650-07 - CLAMP OP TBL CLRK RAIL SHLDR SPNS SYS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1655PS SUP HCPCS C1713 AR-1655PS - SCREW INTFR 5.5MM 8MM STRL BTNDS RECON PEEK-OPTM ACL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1655PS-10 SUP HCPCS C1713 AR-1655PS-10 - SCREW INTFR 5.5MM 10MM STRL BTNDS RECON PEEK-OPTM ACL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1655PS-12 SUP HCPCS C1713 AR-1655PS-12 - SCREW INTFR 5.5MM 12MM STRL BTNDS RECON PEEK-OPTM ACL BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662B SUP HCPCS C1713 AR-1662B - ANCHOR SUT 6.25MM 19.1MM SWIVELOCK BICEPS TENODESIS SYS BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $427.50 $427.50 $0.00 $0.00 $0.00 $198.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $561.93 $561.93 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $148.68 $0.00 $0.00 $151.24 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662BC SUP HCPCS C1713 AR-1662BC - ANCHOR SUT 6.25MM 19.1MM STRL SWIVELOCK TENODESIS CLS EYLT BOTH IP/OP "$1,025.00 " $758.50 $0.00 $820.00 $461.25 $461.25 $0.00 $0.00 $0.00 $213.64 $760.76 $760.76 $0.00 $0.00 $213.61 $0.00 $606.29 $606.29 $0.00 $512.50 $811.80 $820.00 $0.00 $0.00 $160.41 $0.00 $0.00 $163.18 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662BC-7 SUP HCPCS C1713 AR-1662BC-7 - ANCHOR SUT SWVLK TENO BIO-COMP 7X 19.5MM BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662BC-8 SUP HCPCS C1713 AR-1662BC-8 - ANCHOR SUTURE 8MM 19.5MM FORK EYELET SWIVELOCK TENODESIS BOTH IP/OP "$1,087.50 " $804.75 $0.00 "$1,244.00" $699.75 $699.75 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $777.50 "$1,231.56" "$1,244.00" $0.00 $0.00 $243.36 $0.00 $0.00 $247.56 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662BC-9 SUP HCPCS C1713 AR-1662BC-9 - ANCHOR SUT 9MM 19.5MM STRL SWIVELOCK TENODESIS FRK EYLT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662BCC-7 SUP HCPCS C1713 AR-1662BCC-7 - ANCHOR SUT 7MM 19.1MM STRL SWIVELOCK TENODESIS CLS EYLT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662BCC-8 SUP HCPCS C1713 AR-1662BCC-8 - ANCHOR SUT 8MM 19.1MM STRL SWIVELOCK TENODESIS CLS EYLT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662BCC-9 SUP HCPCS C1713 AR-1662BCC-9 - ANCHOR SUT 9MM 19.1MM STRL SWIVELOCK TENODESIS CLS EYLT BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662PSL-7 SUP HCPCS C1713 AR-1662PSL-7 - ANCHOR SUT 7MM 19.5MM STRL SWIVELOCK TENODESIS FRK EYLT PEEK BOTH IP/OP "$1,012.50 " $749.25 $0.00 $810.00 $455.63 $455.63 $0.00 $0.00 $0.00 $211.03 $751.48 $751.48 $0.00 $0.00 $211.01 $0.00 $598.89 $598.89 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $158.46 $0.00 $0.00 $161.19 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662PSL-8 SUP HCPCS C1713 AR-1662PSL-8 - ANCHOR SUT 8MM 19.5MM STRL SWIVELOCK TENODESIS FRK EYLT PEEK BOTH IP/OP "$1,012.50 " $749.25 $0.00 "$1,158.00" $651.38 $651.38 $0.00 $0.00 $0.00 $211.03 $751.48 $751.48 $0.00 $0.00 $211.01 $0.00 $598.89 $598.89 $0.00 $723.75 "$1,146.42" "$1,158.00" $0.00 $0.00 $226.53 $0.00 $0.00 $230.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1662PSL-9 SUP HCPCS C1713 AR-1662PSL-9 - ANCHOR SUT 9MM 19.5MM STRL SWIVELOCK TENODESIS FRK EYLT PEEK BOTH IP/OP "$1,012.50 " $749.25 $0.00 $810.00 $455.63 $455.63 $0.00 $0.00 $0.00 $211.03 $751.48 $751.48 $0.00 $0.00 $211.01 $0.00 $598.89 $598.89 $0.00 $506.25 $801.90 $810.00 $0.00 $0.00 $158.46 $0.00 $0.00 $161.19 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1670BC SUP HCPCS C1713 AR-1670BC - SCREW INTFR 7MM 10MM STRL TENODESIS BCMPS ACL BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1670PS SUP HCPCS C1713 AR-1670PS - SCREW INTFR 7MM 10MM STRL TENODESIS PEEK-OPTM ACL BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1675BC-CP SUP HCPCS C1713 AR-1675BC-CP - SET IMPL BCMPS SCRDRVR RECON SYS BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1676DS SUP Custom 27203010 AR-1676DS - KIT INSTR BIOABSORBABLE BIO-TENODESIS STERILE DISPOSABLE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1676-DS SUP HCPCS C1713 KIT ARTHRO FIXAT BTNDS BABSR STRL DISP BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1677BC-CP SUP HCPCS C1713 AR-1677BC-CP - SET IMPL 4MM CNN DRL GDPN RLR SCR TNDN SHTL CMC LGMNT RECON BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1678-01 SUP Custom 27203010 AR-1678-01 - GUIDE DRL LF TTH FT BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 $0.00 $0.00 $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1678-02 SUP Custom 27203010 AR-1678-02 - BIT DRL 3.5MM SWIVELOCK BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1678-05 SUP Custom 27203010 AR-1678-05 - BIT DRL 3.5MM SWIVELOCK BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1678-CP SUP HCPCS C1713 AR-1678-CP - SET IMPL 3.5MM INTERNALBRACE SWIVELOCK FIBERTAPE 2 2 NDL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1680B SUP HCPCS C1713 AR-1680B - SCREW BABSR 12MM 8MM BTNDS ACL PLLA RECON STRL DISP BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1680PS SUP HCPCS C1713 AR-1680PS - TENODESIS SCREW 8X12MM BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1688-CP SUP Custom 27203010 AR-1688-CP - KIT ASCP FX INTERNALBRACE FIBERTAPE CLGN LGMNT AUG REPR BOTH IP/OP "$2,687.50 " "$1,988.75" $0.00 "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,994.66" "$1,994.66" $0.00 $0.00 $560.08 $0.00 $0.00 $0.00 $0.00 "$1,343.75" "$2,128.50" "$2,150.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-16991N SUP Custom 27203010 AR-16991N - NEEDLE SUT RND GRV LOPRFL SCRPN FBRWR 1 PRTL SMTH JAW MN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-16992N SUP Custom 27203010 AR-16992N - NEEDLE SUT SCRPN CAPSULECLOSE BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1713-03 SUP Custom 27203010 AR-1713-03 - CLAMP BDRL DSTRCT SET STRL ANKL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1801 SUP Custom 27203010 AR-1801 - GUIDE DRL OFST 7MM AU FEM ACL TRNTB DISP 7-8MM HL BOTH IP/OP "$2,087.50 " "$1,544.75" $0.00 "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.34" "$1,549.34" $0.00 $0.00 $435.04 $0.00 $0.00 $0.00 $0.00 "$1,043.75" "$1,653.30" "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1802D SUP Custom 27203010 AR-1802D - CANNULA ASCP 9-12MM STRL TNL SIL TIB DISP BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $0.00 $0.00 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1803 SUP Custom 27203010 AR-1803 - GUIDE DRL OFST 5MM RD FEM ACL TRNTB DISP 7-8MM HL BOTH IP/OP "$2,087.50 " "$1,544.75" $0.00 "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.34" "$1,549.34" $0.00 $0.00 $435.04 $0.00 $0.00 $0.00 $0.00 "$1,043.75" "$1,653.30" "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1804 SUP Custom 27203010 AR-1804 - GUIDE DRL OFST 6MM GRN FEM ACL TRNTB DISP 8-9MM HL BOTH IP/OP "$2,087.50 " "$1,544.75" $0.00 "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.34" "$1,549.34" $0.00 $0.00 $435.04 $0.00 $0.00 $0.00 $0.00 "$1,043.75" "$1,653.30" "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1805 SUP Custom 27203010 AR-1805 - GUIDE DRL OFST 8MM BLU FEM ACL TRNTB DISP 12-13MM HL BOTH IP/OP "$2,087.50 " "$1,544.75" $0.00 "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.34" "$1,549.34" $0.00 $0.00 $435.04 $0.00 $0.00 $0.00 $0.00 "$1,043.75" "$1,653.30" "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1806 SUP Custom 27203010 AR-1806 - GUIDE DRL OFST 4MM PUR FEM ACL TRNTB DISP 6-7MM HL BOTH IP/OP "$2,087.50 " "$1,544.75" $0.00 "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,549.34" "$1,549.34" $0.00 $0.00 $435.04 $0.00 $0.00 $0.00 $0.00 "$1,043.75" "$1,653.30" "$1,670.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1822 SUP Custom 27203010 AR-1822 - BIT DRL LNG 2MM STRL D STP GFT HRVT BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1861 SUP Custom 27203010 AR-1861 - CANNULA ASCP 11MM GFT PASS BOTH IP/OP $732.50 $542.05 $0.00 $586.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.66 $543.66 $0.00 $0.00 $152.65 $0.00 $0.00 $0.00 $0.00 $366.25 $580.14 $586.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1875 SUP Custom 27203010 AR-1875 - GUIDE DRL ADAPTEUR C RING ACL BOTH IP/OP "$3,545.00 " "$2,623.30" $0.00 "$2,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,631.10" "$2,631.10" $0.00 $0.00 $738.78 $0.00 $0.00 $0.00 $0.00 "$1,772.50" "$2,807.64" "$2,836.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1897S SUP Custom 27203010 AR-1897S - KIT INST HALL SW BLDE ACL DISP TRNTB BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-18985 SUP HCPCS C1713 AR-18985 - KIT INST ACL TRNTB DISP BOTH IP/OP $520.00 $384.80 $0.00 $416.00 $234.00 $234.00 $0.00 $0.00 $0.00 $108.38 $385.94 $385.94 $0.00 $0.00 $108.37 $0.00 $307.58 $307.58 $0.00 $260.00 $411.84 $416.00 $0.00 $0.00 $81.38 $0.00 $0.00 $82.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1902SF SUP HCPCS C1713 AR-1902SF - ANCHOR SUT 2 5MM 15.5MM STRL CSCR2 FWR 2 EYLT ST TI ROTR CUF BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $241.88 $241.88 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $0.00 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1907H-3.5 SUP Custom 27203010 AR-1907H-3.5 - GUIDE DRL 3.5MM ANCH CNN TROC SDL HIP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1911 SUP Custom 27203010 AR-1911 - DRILL SRG SPD 1 STP 3.5MM PUSHLOCK BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1912 SUP Custom 27203010 AR-1912 - DRILL SRG LG 1 STP 3.5MM PUSHLOCK BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1913 SUP Custom 27203010 AR-1913 - BIT DRL 3.5MM BCMPS PUSHLOCK BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1915FT-2 SUP HCPCS C1713 AR-1915FT-2 - ANCHOR SUT 1 2.3MM .5 CRC 2 DMD PT FT 3.5MM 2.5MM 26.5MM BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1915S SUP HCPCS C1713 AR-1915S - ANCHOR SUT 2 3.5MM 12MM STRL CRKSCR BABSR ST TI ROTR CUF BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $202.50 $202.50 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1915SF SUP HCPCS C1713 AR-1915SF - ANCHOR SUT 2 3.5MM 12MM STRL CSCR FWR ST SUT EYLT TI ROTR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1915SNF SUP HCPCS C1713 AR-1915SNF - ANCHOR SUTURE 2.3MM 0 SHORT .5 CIR 2 DIAMOND POINT 3.5MM BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1920BF SUP HCPCS C1713 AR-1920BF - BIOCRKSCRW SUTR ANCH 5MM W/2 #2 FW BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $292.50 $292.50 $0.00 $0.00 $0.00 $135.48 $482.43 $482.43 $0.00 $0.00 $135.46 $0.00 $384.48 $384.48 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $101.73 $0.00 $0.00 $103.48 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1920BFT SUP HCPCS C1713 AR-1920BFT - ANCHOR SUT 2 5MM 17.9MM STRL BCSCR TGRL BABSR BRD HNDL BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1920BNF SUP HCPCS C1713 AR-1920BNF - ANCHOR SUT 2 3/8 CRC 5MM 26MM STRL 17.9MM BCSCR FWR BABSR BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1920NSF SUP HCPCS C1713 AR-1920NSF - ANCHOR SUT 2 5MM 15.5MM STRL CSCR FWR BRD NDL ROTR CUF DISP BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $241.88 $241.88 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $0.00 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1920S SUP HCPCS C1713 AR-1920S - ANCHOR SUT 2 5MM 15.5MM STRL CRKSCR BRD HNDL INSRTR TI ROTR BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $202.50 $202.50 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1920SF SUP HCPCS C1713 AR-1920SF - ANCHOR SUT 2 5MM 15.5MM STRL CSCR FWR HNDL INSRTR TI ROTR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1920SNF SUP HCPCS C1713 AR-1920SNF - ANCHOR SUT 2 5MM 15MM STRL CSCR FWR BABSR HNDL INSRTR NDL BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1922BC SUP HCPCS C1713 AR-1922BC - ANCHOR SUT 4.5MM 24MM STRL PUSHLOCK BCMPS DISP BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1922BCM SUP HCPCS C1713 AR-1922BCM - ANCHOR SUT 4.5MM 28MM STRL PUSHLOCK SLF PNCH BCMPS DISP BOTH IP/OP "$1,037.50 " $767.75 $0.00 $830.00 $466.88 $466.88 $0.00 $0.00 $0.00 $216.24 $770.03 $770.03 $0.00 $0.00 $216.22 $0.00 $613.68 $613.68 $0.00 $518.75 $821.70 $830.00 $0.00 $0.00 $162.37 $0.00 $0.00 $165.17 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1922BM SUP HCPCS C1713 AR-1922BM - ANCHOR SUT 4.5MM 28MM STRL BIO-PUSHLOCK SLF PNCH DISP BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $438.75 $438.75 $0.00 $0.00 $0.00 $203.21 $723.65 $723.65 $0.00 $0.00 $203.19 $0.00 $576.71 $576.71 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $152.59 $0.00 $0.00 $155.22 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1922PS SUP HCPCS C1713 AR-1922PS - ANCHOR SUT 4.5MM 24MM STRL PUSHLOCK PEEK SHLDR DISP BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1922PSM SUP HCPCS C1713 AR-1922PSM - ANCHOR SUT 4.5MM 28MM STRL PUSHLOCK SLF PNCH PEEK DISP BOTH IP/OP $975.00 $721.50 $0.00 $780.00 $438.75 $438.75 $0.00 $0.00 $0.00 $203.21 $723.65 $723.65 $0.00 $0.00 $203.19 $0.00 $576.71 $576.71 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $152.59 $0.00 $0.00 $155.22 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923BC SUP HCPCS C1713 AR-1923BC - ANCHOR SUTURE 2.9MM 15.5MM PUSHLOCK BIOCOMPOSITE STERILE BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923BCH SUP HCPCS C1713 AR-1923BCH - ANCHOR SUT PUSHLOCK BCMPS HIP BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923BNF SUP HCPCS C1713 AR-1923BNF - ANCHOR SUT 3/8 CRC DMD 3.7MM 17.9MM STRL 22.2MM BCSCR FWR BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $292.50 $292.50 $0.00 $0.00 $0.00 $135.48 $482.43 $482.43 $0.00 $0.00 $135.46 $0.00 $384.48 $384.48 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $101.73 $0.00 $0.00 $103.48 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923D SUP Custom 27203010 AR-1923D - DRILL SRG 2.9 MM PUSHLOCK HRD BN BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923DH SUP Custom 27203010 AR-1923DH - DRILL SRG HIP 2.9 MM PUSHLOCK BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923DHS SUP Custom 27203010 AR-1923DHS - KIT INST 2.9MM DISP 2.9MM PUSHLOCK BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923DHT SUP Custom 27203010 AR-1923DHT - DRILL SRG HIP HRD BN 2.9 MM PUSHLOCK BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923DS SUP HCPCS C1713 AR-1923DS - KIT INSTR 2.9MM DRILL SPEAR METAL STERILE DISPOSABLE 2.9MM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923D-ST SUP Custom 27203010 AR-1923D-ST - DRILL SRG STRL 2.9 MM PUSHLOCK BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923DT SUP Custom 27203010 AR-1923DT - DRILL SRG 2.9 MM SHRT PUSHLOCK HRD BN BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923DT-ST SUP Custom 27203010 AR-1923DT-ST - DRILL SRG STRL 2.9 MM PUSHLOCK BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923MC SUP Custom 27203010 AR-1923MC - CANNULA ASCP FT 2.9MM 4.5MM PUSHLOCK CRKSCR MTL REUSE BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $0.00 $0.00 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923MCS SUP Custom 27203010 AR-1923MCS - CANNULA ASCP 2.9MM 4.5MM PUSHLOCK CRKSCR SET MTL REUSE BOTH IP/OP "$1,412.50 " "$1,045.25" $0.00 "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,048.36" "$1,048.36" $0.00 $0.00 $294.37 $0.00 $0.00 $0.00 $0.00 $706.25 "$1,118.70" "$1,130.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923PHS SUP HCPCS C1713 AR-1923PHS - ANCHOR SUT 2.9MM 15.5MM STRL PUSHLOCK PEEK HIP DISP BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923PK SUP Custom 27203010 AR-1923PK - KIT ENDSCP INSTR 1.1MM 17GA 2.9MM CANNU DRILL NEEDLE PORTAL BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.21 $408.21 $0.00 $0.00 $114.62 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1923SD SUP Custom 27203010 AR-1923SD - DRILL SRG SPD STRL 2.9MM PUSHLOCK BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1925BF SUP HCPCS C1713 AR-1925BF - ANCHOR SUT 2 FT 6.5MM 17.9MM STRL BCSCR 2 BABSR ROTR CUF BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $292.50 $292.50 $0.00 $0.00 $0.00 $135.48 $482.43 $482.43 $0.00 $0.00 $135.46 $0.00 $384.48 $384.48 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $101.73 $0.00 $0.00 $103.48 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1925BNF SUP HCPCS C1713 AR-1925BNF - ANCHOR SUT 2 6.5MM 17.9MM STRL BCSCR FWR 2 BRD BABSR MLD BOTH IP/OP $675.00 $499.50 $0.00 $540.00 $303.75 $303.75 $0.00 $0.00 $0.00 $140.69 $500.99 $500.99 $0.00 $0.00 $140.67 $0.00 $399.26 $399.26 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $105.64 $0.00 $0.00 $107.46 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1925SF SUP HCPCS C1713 AR-1925SF - ANCHOR SUT 2 6.5MM 15.5MM STRL CSCR FWR 2 BABSR HNDL INSRTR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1926BC SUP HCPCS C1713 AR-1926BC - ANCHOR SUT 3.5MM 19.5MM STRL PUSHLOCK BCMPS DISP BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1926BH SUP HCPCS C1713 AR-1926BH - ANCHOR SUT 3.5MM 19.5MM STRL BIO-PUSHLOCK HIP DISP BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1926DHS SUP Custom 27203010 AR-1926DHS - KIT INST DISP 3.5MM PUSHLOCK BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1926DS-2 SUP Custom 27203010 AR-1926DS-2 - KIT INST OFST DRL GD 3.5MM PUSHLOCK BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $0.00 $0.00 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1926MC SUP Custom 27203010 AR-1926MC - CANNULA ASCP PUSHLOCK MTL BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.43 $482.43 $0.00 $0.00 $135.46 $0.00 $0.00 $0.00 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1926PHS SUP HCPCS C1713 AR-1926PHS - ANCHOR SUT 3.5MM 19.5MM STRL BIO-PUSHLOCK HIP DISP BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1926PS SUP HCPCS C1713 AR-1926PS - ANCHOR SUT 3.5MM 19.5MM STRL PUSHLOCK PEEK ROTR CUF DISP BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCF SUP HCPCS C1713 AR-1927BCF - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL CSCR FWR TIGERWIRE 2 DRV BOTH IP/OP "$4,062.50 " "$3,006.25" $0.00 "$3,250.00" "$1,828.13" "$1,828.13" $0.00 $0.00 $0.00 $846.73 "$3,015.19" "$3,015.19" $0.00 $0.00 $846.63 $0.00 "$2,002.81" "$2,002.81" $0.00 "$2,031.25" "$3,217.50" "$3,250.00" $0.00 $0.00 $635.78 $0.00 $0.00 $646.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCF-3 SUP HCPCS C1713 AR-1927BCF-3 - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL CSCR FWR 3 BCMPS DISP BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $382.50 $382.50 $0.00 $0.00 $0.00 $177.16 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $502.78 $502.78 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $133.03 $0.00 $0.00 $135.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCF-45 SUP HCPCS C1713 AR-1927BCF-45 - ANCHOR SUT 2 FT 4.5MM 14MM STRL CSCR FWR 2 BCMPS DISP BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCF-65 SUP HCPCS C1713 AR-1927BCF-65 - ANCHOR SUT 2 FT 6.5MM 14.7MM STRL CSCR FWR 2 VNT BCMPS DISP BOTH IP/OP $837.50 $619.75 $0.00 $670.00 $376.88 $376.88 $0.00 $0.00 $0.00 $174.56 $621.59 $621.59 $0.00 $0.00 $174.54 $0.00 $495.38 $495.38 $0.00 $418.75 $663.30 $670.00 $0.00 $0.00 $131.07 $0.00 $0.00 $133.33 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCFT SUP HCPCS C1713 AR-1927BCFT - ANCHOR SUTURE 2 SQUARE FULTHD 5.5MM 14.7MM DRIVE MECHANISM BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCFT-45 SUP HCPCS C1713 AR-1927BCFT-45 - ANCHOR SUT 2 SQ FT 4.5MM 14.7MM STRL CRKSCR TGTL DRV MECH BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $388.13 $388.13 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCNF SUP HCPCS C1713 AR-1927BCNF - ANCHOR SUTURE 2 FULTHD 5.5MM 14.7MM 2 4 NEEDLE CORKSCREW BOTH IP/OP $837.50 $619.75 $0.00 $958.00 $538.88 $538.88 $0.00 $0.00 $0.00 $174.56 $621.59 $621.59 $0.00 $0.00 $174.54 $0.00 $495.38 $495.38 $0.00 $598.75 $948.42 $958.00 $0.00 $0.00 $187.41 $0.00 $0.00 $190.64 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCNF-45 SUP HCPCS C1713 AR-1927BCNF-45 - ANCHOR SUT 4.5MM BCMPS CRKSCR FT NDL BOTH IP/OP $837.50 $619.75 $0.00 $670.00 $376.88 $376.88 $0.00 $0.00 $0.00 $174.56 $621.59 $621.59 $0.00 $0.00 $174.54 $0.00 $495.38 $495.38 $0.00 $418.75 $663.30 $670.00 $0.00 $0.00 $131.07 $0.00 $0.00 $133.33 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BCT SUP HCPCS C1713 AR-1927BCT - ANCHOR SUT FT 1.3MM 5.5MM 14.7MM BLK BLU WHT CRKSCR BOTH IP/OP "$4,437.50 " "$3,283.75" $0.00 "$3,550.00" "$1,996.88" "$1,996.88" $0.00 $0.00 $0.00 $924.89 "$3,293.51" "$3,293.51" $0.00 $0.00 $924.78 $0.00 "$2,187.69" "$2,187.69" $0.00 "$2,218.75" "$3,514.50" "$3,550.00" $0.00 $0.00 $694.47 $0.00 $0.00 $706.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BF SUP HCPCS C1713 AR-1927BF - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL BCSCR FWR 2 POLY L LACTD BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BF-3 SUP HCPCS C1713 AR-1927BF-3 - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL BCSCR FWR 3 PLAY BABSR VNT BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BF-45 SUP HCPCS C1713 AR-1927BF-45 - ANCHOR SUT 2 FT 4.5MM 14MM STRL BCSCR FWR 2 POLY L LACTD CO BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BF-65 SUP HCPCS C1713 AR-1927BF-65 - ANCHOR SUT 2 FT 6.5MM 14.7MM STRL BCSCR FWR 2 POLY L LACTD BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BFC SUP HCPCS C1713 AR-1927BFC - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL BCSCR FWR FIBERCHAIN BABSR BOTH IP/OP $787.50 $582.75 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $164.13 $584.48 $584.48 $0.00 $0.00 $164.12 $0.00 $465.81 $465.81 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BFS SUP HCPCS C1713 AR-1927BFS - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL BCSCR SCRPN BABSR NDL DISP BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BFT-45 SUP HCPCS C1713 AR-1927BFT-45 - ANCHOR SUT 2 FT 4.5MM 14MM STRL BCSCR TGRL POLY L LACTD CO D BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BNF SUP HCPCS C1713 AR-1927BNF - ANCHOR SUT 2 .5 CRC FT 5.5MM 14.7MM STRL 26MM BCSCR FWR 2 4 BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927BNF-45 SUP HCPCS C1713 AR-1927BNF-45 - ANCHOR SUT 2 .5 CRC FT 4.5MM 14MM STRL 26MM BCSCR FWR 2 4 BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927PBS SUP HCPCS C1713 AR-1927PBS - PUNCH ARTHRO STERILE DISPOSABLE 5.5 CORKSCREW FULTHD BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927PNF SUP HCPCS C1713 AR-1927PNF - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL CSCR FWR 2 BRD 4 NDL PEEK BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927PNF-45 SUP HCPCS C1713 AR-1927PNF-45 - ANCHOR SUT 2 FT 4.5MM 14MM BLU W/B STRL CSCR FWR 2 BRD 4 NDL BOTH IP/OP $737.50 $545.75 $0.00 $547.37 $226.13 $226.13 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $78.64 $0.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927PSF SUP HCPCS C1713 AR-1927PSF - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL CSCR FWR 2 PEEK DISP BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927PSF-3 SUP HCPCS C1713 AR-1927PSF-3 - ANCHOR SUT 2 FT 5.5MM 14.7MM STRL CSCR FWR 3 PEEK SHLDR DISP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927PSF-45 SUP HCPCS C1713 AR-1927PSF-45 - ANCHOR SUT 2 FT 4.5MM 14MM BLK BLU WHT STRL CSCR FWR 2 PEEK BOTH IP/OP $712.50 $527.25 $0.00 $656.00 $369.00 $369.00 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $410.00 $649.44 $656.00 $0.00 $0.00 $128.33 $0.00 $0.00 $130.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1927PSF-65 SUP HCPCS C1713 AR-1927PSF-65 - ANCHOR SUT 2 FT 6.5MM STRL CSCR FWR 2 PEEK DISP BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1928SF SUP HCPCS C1713 AR-1928SF - ANCHOR SUT 2 FT 5.5MM 15MM STRL CSCR2 FWR BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $258.75 $258.75 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1928SF-2 SUP HCPCS C1713 AR-1928SF-2 - ANCHOR SUT 2 FT 5.5MM 16.3MM STRL CSCR2 FWR TI DISP BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $258.75 $258.75 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1928SF-3 SUP HCPCS C1713 AR-1928SF-3 - ANCHOR SUT 2 FT 5.5MM 16.3MM STRL CSCR2 FWR 3 TI DISP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $275.63 $275.63 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1928SF-45 SUP HCPCS C1713 AR-1928SF-45 - ANCHOR SUT 2 FT 4.5MM 14MM STRL CSCR2 FWR 2 TI DISP BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $258.75 $258.75 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1928SFT-2 SUP HCPCS C1713 AR-1928SFT-2 - ANCHOR SUT 2 FT 5.5MM 16.3MM STRL CRKSCR II TGTL TI BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1928SNF SUP HCPCS C1713 AR-1928SNF - ANCHOR SUT 2 5.5MM 26MM STRL CSCR FWR TI ROTR CUF DISP BOTH IP/OP $637.50 $471.75 $0.00 $510.00 $286.88 $286.88 $0.00 $0.00 $0.00 $132.87 $473.15 $473.15 $0.00 $0.00 $132.86 $0.00 $377.08 $377.08 $0.00 $318.75 $504.90 $510.00 $0.00 $0.00 $99.77 $0.00 $0.00 $101.49 $0.00 $0.00 $0.00 $0.00 $0.00 AR1928SNF-2 SUP HCPCS C1713 AR1928SNF-2 - ANCHOR SUT 5.5MM 2 .5 CRC FT DMD CSCR2 FWR ROTR CUF 2 KNT BOTH IP/OP $637.50 $471.75 $0.00 $510.00 $286.88 $286.88 $0.00 $0.00 $0.00 $132.87 $473.15 $473.15 $0.00 $0.00 $132.86 $0.00 $377.08 $377.08 $0.00 $318.75 $504.90 $510.00 $0.00 $0.00 $99.77 $0.00 $0.00 $101.49 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1928SNF-2 SUP HCPCS C1713 AR-1928SNF-2 - ANCHOR SUTURE 2 .5 CIR FULTHD DIAMOND 5.5MM 16MM 26MM 2 KNOT BOTH IP/OP $637.50 $471.75 $0.00 $510.00 $286.88 $286.88 $0.00 $0.00 $0.00 $132.87 $473.15 $473.15 $0.00 $0.00 $132.86 $0.00 $377.08 $377.08 $0.00 $318.75 $504.90 $510.00 $0.00 $0.00 $99.77 $0.00 $0.00 $101.49 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1929SF-3 SUP HCPCS C1713 "AR-1929SF-3 - SUTURE ANCHOR, CORKSCREW FT III" BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $275.63 $275.63 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1931S SUP Custom 27203010 AR-1931S - REAMER SRG 14MM STRL CNN COLR PIN SET COR DISP BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934-20DS SUP Custom 27203010 AR-1934-20DS - KIT INST 2MM SUT TK ANCH DRL SPR TROC DISP BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934-24DS SUP Custom 27203010 AR-1934-24DS - KIT ESCP INST 2.4MM BSUT TK ANCH SPR STP DRL DISP ASCP BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BCF SUP HCPCS C1713 AR-1934BCF - ANCHOR SUT 2 3MM 14.5MM STRL SUT TK FBRWR BCMPS DISP BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BCF-2 SUP HCPCS C1713 AR-1934BCF-2 - ANCHOR SUT 2 3MM 14.5MM STRL SUT TK TIGERWIRE FBRWR BCMPS BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BCF-20 SUP HCPCS C1713 AR-1934BCF-20 - ANCHOR SUT 1 MN 2MM 12MM STRL SUT TK FBRWR BCMPS BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BCF-24 SUP HCPCS C1713 AR-1934BCF-24 - ANCHOR SUT 2 2.4MM 12MM STRL SUT TK FBRWR BCMPS DISP BOTH IP/OP $762.50 $564.25 $0.00 $610.00 $343.13 $343.13 $0.00 $0.00 $0.00 $158.92 $565.93 $565.93 $0.00 $0.00 $158.91 $0.00 $451.02 $451.02 $0.00 $381.25 $603.90 $610.00 $0.00 $0.00 $119.33 $0.00 $0.00 $121.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BCF-24-2 SUP HCPCS C1713 AR-1934BCF-24-2 - ANCHOR SUT 2 2.4MM 12MM STRL SUT TK FBRWR BCMPS DISP BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BCFT SUP HCPCS C1713 AR-1934BCFT - ANCHOR SUTURE 2 3MM 14.5MM SUTURETAK TIGERTAIL BIOCOMPOSITE BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BCFT-2 SUP HCPCS C1713 AR-1934BCFT-2 - ANCHOR SUT 2 3MM 14.5MM STRL SUT TK TGTL BCMPS DISP BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $382.50 $382.50 $0.00 $0.00 $0.00 $177.16 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $502.78 $502.78 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $133.03 $0.00 $0.00 $135.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BF SUP HCPCS C1713 AR-1934BF - ANCHOR SUT 2 3MM 14.5MM STRL BSUT TK FBRWR BABSR PUSH IN BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $275.63 $275.63 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934BFT SUP HCPCS C1713 AR-1934BFT - ANCHOR SUTURE 3MM 2 BSUT TK TGTL ROTR CUF BABSR ARTHRO 14MM BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $298.13 $298.13 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934D-20 SUP Custom 27203010 AR-1934D-20 - DRILL SRG 2 MM SUT TK BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934D-20-1 SUP Custom 27203010 AR-1934D-20-1 - DRILL SRG 2 MM SUT TK HRD BN BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934D-24 SUP Custom 27203010 AR-1934D-24 - DRILL SRG STP DISP 2.4MM SUT TK BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934D-24-1 SUP Custom 27203010 AR-1934D-24-1 - DRILL SRG 2.6MM 2.4MM SUT TK BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934D-24-2 SUP Custom 27203010 AR-1934D-24-2 - DRILL SRG 2.6MM 2.4MM SUT TK BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934DHS-2 SUP Custom 27203010 AR-1934DHS-2 - KIT INST HIP DISP 3MM SUT TK BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934DS-2 SUP Custom 27203010 AR-1934DS-2 - KIT INST STRL GD SPR STP DRL TROC DISP 3MM SUT TK BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934PF-20 SUP HCPCS C1713 AR-1934PF-20 - ANCHOR SUT 1 2MM 12MM STRL SUT TK FBRWR PEEK BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934PF-24 SUP HCPCS C1713 AR-1934PF-24 - ANCHOR SUT 2 2.4MM 12MM STRL SUT TK FBRWR PEEK BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934PI SUP Custom 27203010 AR-1934PI - KIT INS 1.1MM 17GA 2.4MM BSUT TK DRL NDL PERC INS PRTL DIL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934PI-20 SUP Custom 27203010 AR-1934PI-20 - KIT INS 1.1MM 17GA 2MM SUT TK DRL PRTL DIL SPR SPNL NDL WRE BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934PI-30 SUP Custom 27203010 AR-1934PI-30 - KIT INSERTION 1.1MM 17GA 3MM STEP DRILL PORTAL DILAT SPEAR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934PRK SUP Custom 27203010 AR-1934PRK - KIT ASCP FX 2.4MM 4.5MM SUT TK SWIVELOCK SPR NDL GW DIL BOTH IP/OP "$2,962.50 " "$2,192.25" $0.00 "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,198.77" "$2,198.77" $0.00 $0.00 $617.39 $0.00 $0.00 $0.00 $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934PS SUP HCPCS C1713 AR-1934PS - ANCHOR SUT 2 3MM 12.4MM BSUT TK FBRWR PEEK BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1934PS-2 SUP HCPCS C1713 AR-1934PS-2 - ANCHOR SUT 2 3MM 12.2MM SUT TK FBRWR PEEK ROTR CUF BOTH IP/OP $637.50 $471.75 $0.00 $510.00 $286.88 $286.88 $0.00 $0.00 $0.00 $132.87 $473.15 $473.15 $0.00 $0.00 $132.86 $0.00 $377.08 $377.08 $0.00 $318.75 $504.90 $510.00 $0.00 $0.00 $99.77 $0.00 $0.00 $101.49 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1938BC SUP HCPCS C1713 AR-1938BC - ANCHOR SUT 2 3MM 12.7MM SUT TK FBRWR KNTLS BCMPS BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1938D SUP Custom 27203010 AR-1938D - DRILL SRG 2.6MM 3MM SUT TK BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1938PS SUP HCPCS C1713 AR-1938PS - ANCHOR SUT 2 3MM 12.7MM KNTLS SUT TK FBRWR PEEK BOTH IP/OP $962.50 $712.25 $0.00 $770.00 $433.13 $433.13 $0.00 $0.00 $0.00 $200.61 $714.37 $714.37 $0.00 $0.00 $200.59 $0.00 $569.32 $569.32 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1938PS-PL SUP HCPCS C1713 AR-1938PS-PL - SUTRE ANCH PEEK S-TAK KNOTLESS 3X12.7M BOTH IP/OP $962.50 $712.25 $0.00 $770.00 $433.13 $433.13 $0.00 $0.00 $0.00 $200.61 $714.37 $714.37 $0.00 $0.00 $200.59 $0.00 $569.32 $569.32 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1949H-2.4 SUP Custom 27203010 AR-1949H-2.4 - GUIDE DRL 2.4MM ANCH CNN SDL TROC HIP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1949H-3.0 SUP Custom 27203010 AR-1949H-3.0 - GUIDE DRL 3MM ANCH CNN SDL TROC HIP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1965 SUP Custom 27203010 AR-1965 - GUIDE DRL ALGTR MNSCL ALGRF BOTH IP/OP "$5,120.00 " "$3,788.80" $0.00 "$4,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,800.06" "$3,800.06" $0.00 $0.00 "$1,067.01" $0.00 $0.00 $0.00 $0.00 "$2,560.00" "$4,055.04" "$4,096.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1965G SUP Custom 27203010 AR-1965G - GUIDE DRL DVTL TIB BOTH IP/OP "$7,250.00 " "$5,365.00" $0.00 "$5,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,510.90" $0.00 $0.00 $0.00 $0.00 "$3,625.00" "$5,742.00" "$5,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1966DS SUP Custom 27203010 AR-1966DS - KIT INST ALGRF DISP BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 $0.00 $0.00 $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1967A SUP Custom 27203010 AR-1967A - CLAMP SRG ADJ SFT TIS BOTH IP/OP "$1,510.00 " "$1,117.40" $0.00 "$1,208.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.72" "$1,120.72" $0.00 $0.00 $314.68 $0.00 $0.00 $0.00 $0.00 $755.00 "$1,195.92" "$1,208.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1967F SUP Custom 27203010 AR-1967F - CLAMP SRG FX SFT TIS BOTH IP/OP "$1,510.00 " "$1,117.40" $0.00 "$1,208.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,120.72" "$1,120.72" $0.00 $0.00 $314.68 $0.00 $0.00 $0.00 $0.00 $755.00 "$1,195.92" "$1,208.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1974 SUP Custom 27203010 AR-1974 - DRILL SRG 5MM ACL 3MM PIN TRNFX BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1974L SUP Custom 27203010 AR-1974L - DRILL SRG LNG 5MM STRL 2MM GDPN TRNFX2 BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1975 SUP Custom 27203010 AR-1975 - GUIDE DRL ACL RECON TIB TRNFX2 BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 $0.00 $0.00 $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1980-05S SUP Custom 27203010 AR-1980-05S - SET GFT HRVT 6MM 5MM STRL OATS COLR PIN TUBE ACL DISP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1980-06S SUP Custom 27203010 AR-1980-06S - SET GFT HRVT 7MM 6MM STRL OATS COLR PIN TUBE ACL DISP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1980-07S SUP Custom 27203010 AR-1980-07S - SET GFT HRVT 8MM 7MM STRL OATS COLR PIN TUBE ACL DISP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1980-08S SUP Custom 27203010 AR-1980-08S - SET GFT HRVT 9MM 8MM STRL OATS COLR PIN TUBE ACL DISP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1980-09S SUP Custom 27203010 AR-1980-09S - SET GFT HRVT 10MM 9MM STRL OATS COLR PIN TUBE ACL DISP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1980-10S SUP Custom 27203010 AR-1980-10S - SET GFT HRVT 11MM 10MM STRL OATS COLR PIN TUBE ACL DISP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1980-12SU SUP Custom 27203010 AR-1980-12SU - SET GFT HRVT 12MM 11MM STRL OATS COLR PIN TUBE ACL DISP BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1981-04S SUP Custom 27203010 AR-1981-04S - SET GFT HRVT 4.75MM STRL OATS ALGN ROD COR XTRDR DLV TUBE BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1981-06H SUP Custom 27203010 AR-1981-06H - SET GFT HRVT 6MM STRL OATS ALGN ROD COR XTRDR DLV TUBE TAMP BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1981-06S SUP Custom 27203010 AR-1981-06S - SET GFT HRVT 7MM 6MM STRL OATS ALGN ROD COR XTRDR DLV TUBE BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1981-08H SUP Custom 27203010 AR-1981-08H - SET GFT HRVT 8MM STRL OATS ALGN ROD COR XTRDR DLV TUBE TAMP BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1981-08S SUP Custom 27203010 AR-1981-08S - SET GFT HRVT 9MM 8MM STRL OATS ALGN ROD COR XTRDR DLV TUBE BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1981-10H SUP Custom 27203010 AR-1981-10H - SET GFT HRVT 10MM STRL OATS ALGN ROD COR XTRDR DLV TUBE TAMP BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1982-08S SUP Custom 27203010 AR-1982-08S - SET GFT HRVT RTRGD 8MM STRL OATS DISP BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 $0.00 $0.00 $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1982-10S SUP Custom 27203010 AR-1982-10S - SET GFT HRVT RTRGD 10MM STRL OATS DISP BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 $0.00 $0.00 $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1983 SUP HCPCS C1713 AR-1983 - CAP PCTV OATS CRTLG ACL BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $348.75 $348.75 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 AR-1991 SUP HCPCS C1713 AR-1991 - CALIBRATOR PIN OATS BOTH IP/OP $327.50 $242.35 $0.00 $262.00 $147.38 $147.38 $0.00 $0.00 $0.00 $68.26 $243.07 $243.07 $0.00 $0.00 $68.25 $0.00 $193.72 $193.72 $0.00 $163.75 $259.38 $262.00 $0.00 $0.00 $51.25 $0.00 $0.00 $52.14 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2236B SUP HCPCS C1763 AR-2236B - BUTTON FX 6.5MM 1MM TISSUEBUTTON HNDL INSRTR PRELD POLY L BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2238B SUP HCPCS C1763 AR-2238B - BUTTON FX 8MM 1MM STRL TISSUEBUTTON BABSR POLY L LAC ACD SFT BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2240B SUP HCPCS C1763 AR-2240B - BUTTON FX 5MM 10MM STRL TISSUEBUTTON POLY L LAC ACD ROTR CUF BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2253L SUP Custom 27203010 AR-2253L - GUIDE DRL ARM LT ACJT ACJT RECON SYS BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2253R SUP Custom 27203010 AR-2253R - GUIDE DRL ARM RT ACJT ACJT RECON SYS BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2255CG SUP Custom 27203010 AR-2255CG - GUIDE DRL CNST ACJT BOTH IP/OP "$4,912.50 " "$3,635.25" $0.00 "$3,930.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,646.06" "$3,646.06" $0.00 $0.00 "$1,023.77" $0.00 $0.00 $0.00 $0.00 "$2,456.25" "$3,890.70" "$3,930.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2257-01 SUP HCPCS C1763 AR-2257-01 - BUTTON FX CLVCL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2257-02 SUP HCPCS C1763 AR-2257-02 - BUTTON FX CORACOID BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2257D-24 SUP Custom 27203010 AR-2257D-24 - DRILL SRG 2.4MM CNN ACML REPR BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2257D-30 SUP Custom 27203010 AR-2257D-30 - DRILL SRG 3MM CNN AC REPR BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2258-03 SUP Custom 27803010 AR-2258-03 - WASHER ORTH CLVCL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2260 SUP Custom 27203010 AR-2260 - KIT ASCP FX STRL BTN DRL PIN INSRTR SCR BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2261 SUP HCPCS C1763 AR-2261 - BUTTON SUT 12MM STRL BICEPS BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2263 SUP HCPCS C1763 AR-2263 - PIN DRL 3.2MM STRL BISCEPSBUTTON DIST DISP BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2264 SUP HCPCS C1713 AR-2264 - DEVICE FX STRL TGHTRP TWN TAIL ACJT BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2266 SUP HCPCS C1763 AR-2266 - BUTTON FX 2.6MM 10.9MM TI SHLDR PECTORALIS MN OPN REPR BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2267 SUP HCPCS C1763 AR-2267 - BUTTON FX LF INSRTR LG EYLT PECTORALIS BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2270 SUP HCPCS C1763 AR-2270 - BUTTON FX DOG BN BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2271 SUP Custom 27203010 AR-2271 - KIT ASCP FX 2MM 3MM TIGERTAPE SUTLSO 2 DOG BN BTN CNN DRL BOTH IP/OP "$2,812.50 " "$2,081.25" $0.00 "$2,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,087.44" "$2,087.44" $0.00 $0.00 $586.13 $0.00 $0.00 $0.00 $0.00 "$1,406.25" "$2,227.50" "$2,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2273 SUP Custom 27203010 AR-2273 - GUIDE DRL ACJT ACJT RECON SYS BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2274 SUP Custom 27203010 AR-2274 - CANNULA ESCP 4.7MM SLOT BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2280 SUP HCPCS C1763 AR-2280 - BUTTON INSERTER/SUTURE KIT BOTH IP/OP "$1,975.00 " "$1,461.50" $0.00 "$1,580.00" $888.75 $888.75 $0.00 $0.00 $0.00 $411.64 "$1,465.85" "$1,465.85" $0.00 $0.00 $411.59 $0.00 "$1,168.21" "$1,168.21" $0.00 $987.50 "$1,564.20" "$1,580.00" $0.00 $0.00 $309.09 $0.00 $0.00 $314.42 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2281 SUP HCPCS C1763 AR-2281 - 12MM BUTTON/SUTURE CONSTRUCT BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2290 SUP HCPCS C1713 AR-2290 - SET IMPLANT PROXIMAL TENODESIS BUTTON FIBERLOOP DRILL PIN BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,350.00" $759.38 $759.38 $0.00 $0.00 $0.00 $351.72 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $998.16 $998.16 $0.00 $843.75 "$1,336.50" "$1,350.00" $0.00 $0.00 $264.09 $0.00 $0.00 $268.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2291 SUP HCPCS C1763 AR-2291 - BUTTON FX 0 BICEPS PROX TENODESIS BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323BCC SUP HCPCS C1713 AR-2323BCC - ANCHOR SUTURE 5.5MM 19.1MM CLOSE EYELET VENT SWIVELOCK C BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323BCM SUP HCPCS C1713 AR-2323BCM - ANCHOR SUT 5.5MM 24.5MM STRL SWIVELOCK SP SLF PNCH VNT BCMPS BOTH IP/OP "$1,050.00 " $777.00 $0.00 $840.00 $472.50 $472.50 $0.00 $0.00 $0.00 $218.85 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $621.08 $621.08 $0.00 $525.00 $831.60 $840.00 $0.00 $0.00 $164.33 $0.00 $0.00 $167.16 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323BCT-2 SUP HCPCS C1713 AR-2323BCT-2 - ANCHOR SUT 2 5.5MM 22MM BLK BLU WHT FIBERTAK SWIVELOCK C BOTH IP/OP "$5,312.50 " "$3,931.25" $0.00 "$4,250.00" "$2,390.63" "$2,390.63" $0.00 $0.00 $0.00 "$1,107.26" "$3,942.94" "$3,942.94" $0.00 $0.00 "$1,107.13" $0.00 "$2,619.06" "$2,619.06" $0.00 "$2,656.25" "$4,207.50" "$4,250.00" $0.00 $0.00 $831.41 $0.00 $0.00 $845.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323BSL SUP HCPCS C1713 AR-2323BSL - ANCHOR SUT 5.5MM 20MM STRL BIO-SWIVELOCK SLF PNCH VNT DISP BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323BSLC SUP HCPCS C1713 AR-2323BSLC - ANCHOR SUT 5.5MM 19.1MM STRL BIO-SWIVELOCK C CLS EYLT VNT BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323BSLM SUP HCPCS C1713 AR-2323BSLM - ANCHOR SUT 5.5MM 24.5MM STRL BIO-SWIVELOCK SLF PNCH VNT DISP BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323PSL SUP HCPCS C1713 AR-2323PSL - ANCHOR SUT 5.5MM 20MM SWIVELOCK PEEK BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323PSLC SUP HCPCS C1713 AR-2323PSLC - ANCHOR SUTURE 5.5MM 19.1MM CLOSE EYELET SWIVELOCK C BOTH IP/OP $937.50 $693.75 $0.00 "$1,072.00" $603.00 $603.00 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $670.00 "$1,061.28" "$1,072.00" $0.00 $0.00 $209.71 $0.00 $0.00 $213.33 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323PSLC-2 SUP HCPCS C1713 AR-2323PSLC-2 - ANCHOR SUT 5.5MM STRL LF ARTHX SWIVELOCK 2 LD PEEK BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323PSLM SUP HCPCS C1713 AR-2323PSLM - ANCHOR SUT 5.5MM 24.5MM STRL BIO-SWIVELOCK SLF PNCH DISP BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2323SLM SUP HCPCS C1713 AR-2323SLM - ANCHOR SUT 5.5MM 24.5MM STRL SWIVELOCK SLF PNCH DISP BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BCC SUP HCPCS C1713 AR-2324BCC - ANCHOR SUTURE 4.75MM 19.1MM CLOSE EYELET VENT SWIVELOCK C BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BCC-2 SUP HCPCS C1713 AR-2324BCC-2 - ANCHOR SUT 4.75MM STRL SWIVELOCK TIGERWIRE ARTHX 2 LD 2 TIP BOTH IP/OP "$1,042.50 " $771.45 $0.00 $834.00 $469.13 $469.13 $0.00 $0.00 $0.00 $217.28 $773.74 $773.74 $0.00 $0.00 $217.26 $0.00 $616.64 $616.64 $0.00 $521.25 $825.66 $834.00 $0.00 $0.00 $163.15 $0.00 $0.00 $165.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BCC-CP SUP HCPCS C1713 AR-2324BCC-CP - SET IMPL FULL 4.75MM 19.1MM SWIVELOCK C CLS EYLT VNT KN BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$2,050.00" "$1,153.13" "$1,153.13" $0.00 $0.00 $0.00 $534.09 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 "$1,263.31" "$1,263.31" $0.00 "$1,281.25" "$2,029.50" "$2,050.00" $0.00 $0.00 $401.03 $0.00 $0.00 $407.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BCCS SUP HCPCS C1713 AR-2324BCCS - SYSTEM ENDSCP FIX 4.75MM NEEDLE MULTIFIRE SCORPION SWIVELOCK BOTH IP/OP "$1,600.00 " "$1,184.00" $0.00 "$1,280.00" $720.00 $720.00 $0.00 $0.00 $0.00 $333.48 "$1,187.52" "$1,187.52" $0.00 $0.00 $333.44 $0.00 $946.40 $946.40 $0.00 $800.00 "$1,267.20" "$1,280.00" $0.00 $0.00 $250.40 $0.00 $0.00 $254.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BCCT SUP HCPCS C1713 AR-2324BCCT - ANCHOR SUTURE 4.75MM 19.1MM CLOSE EYELET TAPE LOOP VENT BOTH IP/OP "$1,175.00 " $869.50 $0.00 "$1,286.00" $723.38 $723.38 $0.00 $0.00 $0.00 $244.90 $872.09 $872.09 $0.00 $0.00 $244.87 $0.00 $695.01 $695.01 $0.00 $803.75 "$1,273.14" "$1,286.00" $0.00 $0.00 $251.57 $0.00 $0.00 $255.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BCCTT SUP HCPCS C1713 AR-2324BCCTT - ANCHOR SUTURE 4.75MM 19.1MM CLOSE EYELET VENT SWIVELOCK C BOTH IP/OP "$1,175.00 " $869.50 $0.00 "$1,080.00" $607.50 $607.50 $0.00 $0.00 $0.00 $244.90 $872.09 $872.09 $0.00 $0.00 $244.87 $0.00 $695.01 $695.01 $0.00 $675.00 "$1,069.20" "$1,080.00" $0.00 $0.00 $211.28 $0.00 $0.00 $214.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BCM SUP HCPCS C1713 AR-2324BCM - ANCHOR SUTURE 4.75MM 24.5MM SELF PUNCH VENT SWIVELOCK BOTH IP/OP "$1,050.00 " $777.00 $0.00 "$1,144.00" $643.50 $643.50 $0.00 $0.00 $0.00 $218.85 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $621.08 $621.08 $0.00 $715.00 "$1,132.56" "$1,144.00" $0.00 $0.00 $223.80 $0.00 $0.00 $227.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BCT-2 SUP HCPCS C1713 AR-2324BCT-2 - ANCHOR SUT 2 4.75MM 22MM BLK BLU WHT SWIVELOCK C FIBERTAK BOTH IP/OP "$5,312.50 " "$3,931.25" $0.00 "$4,250.00" "$2,390.63" "$2,390.63" $0.00 $0.00 $0.00 "$1,107.26" "$3,942.94" "$3,942.94" $0.00 $0.00 "$1,107.13" $0.00 "$2,619.06" "$2,619.06" $0.00 "$2,656.25" "$4,207.50" "$4,250.00" $0.00 $0.00 $831.41 $0.00 $0.00 $845.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BSL SUP HCPCS C1713 AR-2324BSL - ANCHOR SUT 4.75MM 20MM STRL BIO-SWIVELOCK DISP BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324BSLC SUP HCPCS C1713 AR-2324BSLC - ANCHOR SUT 4.75MM 19.1MM STRL BIO-SWIVELOCK C CLS EYLT VNT BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324PCT SUP HCPCS C1713 AR-2324PCT - ANCHOR SUT 4.75MM 19.1MM BLU STRL SWIVELOCK C FIBERTAPE CLS BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324PCTT SUP HCPCS C1713 AR-2324PCTT - ANCHOR SUT 4.75MM 19.1MM B/W STRL SWIVELOCK C TIGERTAPE CLS BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324PSLC SUP HCPCS C1713 AR-2324PSLC - ANCHOR SUTURE 4.75MM 19.1MM CLOSE EYELET VENT SWIVELOCK PEEK BOTH IP/OP $937.50 $693.75 $0.00 "$1,072.00" $603.00 $603.00 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $670.00 "$1,061.28" "$1,072.00" $0.00 $0.00 $209.71 $0.00 $0.00 $213.33 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324PSLC-2 SUP HCPCS C1713 AR-2324PSLC-2 - ANCHOR SUT 4.75MM STRL LF ARTHX SWIVELOCK 2 LD PEEK BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324PSLM SUP HCPCS C1713 AR-2324PSLM - ANCHOR SUT 4.75MM 24.5MM STRL SWIVELOCK SLF PNCH VNT PEEK BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2324SLM SUP HCPCS C1713 AR-2324SLM - ANCHOR SUT 4.75MM 24.5MM STRL SWIVELOCK SLF PNCH VNT TI DISP BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2325BCC SUP HCPCS C1713 AR-2325BCC - BIO-COMP SWVLK 3.5X 15.8MM BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2325D SUP Custom 27203010 AR-2325D - DRILL SRG 3.5 MM SWIVELLOCK BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2325D-ST SUP Custom 27203010 AR-2325D-ST - DRILL SRG STRL 3.5 MM LABRAL SWIVELOCK BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2325PSLC SUP HCPCS C1713 AR-2325PSLC - ANCHOR SUT 3.5MM 14.8MM SWIVELOCK VNT PEEK-OPTM BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2374 SUP Custom 27203010 AR-2374 - 5.1MM CANNULATED REAMER WITH STOP BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2511 SUP Custom 27203010 AR-2511 - GUIDE DRL SHLDR PERC REUSE PNG SYS BOTH IP/OP "$1,937.50 " "$1,433.75" $0.00 "$1,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,438.01" "$1,438.01" $0.00 $0.00 $403.78 $0.00 $0.00 $0.00 $0.00 $968.75 "$1,534.50" "$1,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2512 SUP Custom 27203010 AR-2512 - GUIDE DRL PRLL SHLDR PERC REUSE PNG SYS BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 $0.00 $0.00 $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2528 SUP Custom 27203010 AR-2528 - DRILL SRG 3.2MM CNN SHLDR PERC DISP PNG SYS BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2600SBS-6 SUP HCPCS C1713 AR-2600SBS-6 - SYSTEM FX 4.75MM BLK BLU WHT SPEEDBRIDGE SWIVELOCK FIBERTAPE BOTH IP/OP "$4,000.00 " "$2,960.00" $0.00 "$3,200.00" "$1,800.00" "$1,800.00" $0.00 $0.00 $0.00 $833.70 "$2,968.80" "$2,968.80" $0.00 $0.00 $833.60 $0.00 "$1,972.00" "$1,972.00" $0.00 "$2,000.00" "$3,168.00" "$3,200.00" $0.00 $0.00 $626.00 $0.00 $0.00 $636.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2622DL SUP HCPCS C1713 AR-2622DL - PLATE BN 22MM CLVCL LT DIST BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2622DR SUP HCPCS C1713 AR-2622DR - PLATE BN 22D STRL ARTHX CLVCL RT DIST BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2650CL SUP HCPCS C1713 AR-2650CL - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2650CR SUP HCPCS C1713 AR-2650CR - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2651CL SUP HCPCS C1713 AR-2651CL - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2651CR SUP HCPCS C1713 AR-2651CR - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2652CL SUP HCPCS C1713 AR-2652CL - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2652CR SUP HCPCS C1713 AR-2652CR - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2653CL SUP HCPCS C1713 AR-2653CL - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2653CR SUP HCPCS C1713 AR-2653CR - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2654CL SUP HCPCS C1713 AR-2654CL - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2654CR SUP HCPCS C1713 AR-2654CR - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2655CL SUP HCPCS C1713 AR-2655CL - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2655CR SUP HCPCS C1713 AR-2655CR - PLATE BN PRECONTOUR STRL CNTR 3RD CMPR SLOT LCK HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2656DL SUP HCPCS C1713 AR-2656DL - PLATE BN SHRT PRECONTOUR STRL CHMFR SUT EYLT CMPR SLOT THRD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2656DR SUP HCPCS C1713 AR-2656DR - PLATE BN SHRT PRECONTOUR LOPRFL LCK CMPR HL SS CLVCL RT DIST BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2657DL SUP HCPCS C1713 AR-2657DL - PLATE BN SHRT PRECONTOUR STRL CHMFR SUT EYLT CMPR SLOT THRD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2657DR SUP HCPCS C1713 AR-2657DR - PLATE BN SHRT PRECONTOUR STRL CHMFR SUT EYLT CMPR SLOT THRD BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2658 SUP HCPCS C1713 AR-2658 - BUTTON FX CMPR SLOT PLT SEAT FLSH SS CLVCL DIST BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $393.75 $393.75 $0.00 $0.00 $0.00 $182.37 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $517.56 $517.56 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $136.94 $0.00 $0.00 $139.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2664L SUP Custom 27203010 AR-2664L - GUIDE DRL PLT SCR CLVCL LT DIST BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2664R SUP Custom 27203010 AR-2664R - GUIDE DRL PLT SCR CLVCL RT DIST BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2665-10H SUP HCPCS C1713 AR-2665-10H - SCREW BN HEXALOBE 2.5MM 10MM HRBRT 2 PTCH SS ELB SHLDR SM BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2665-12H SUP HCPCS C1713 AR-2665-12H - SCREW BN HEXALOBE 2.5MM 12MM HRBRT 2 PTCH SS ELB SHLDR SM BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2665-14H SUP HCPCS C1713 AR-2665-14H - SCREW BN HEXALOBE 2.5MM 14MM HRBRT 2 PTCH SS ELB SHLDR SM BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2665-16H SUP HCPCS C1713 AR-2665-16H - SCREW BN HEXALOBE 2.5MM 16MM HRBRT 2 PTCH SS ELB SHLDR SM BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2665-18H SUP HCPCS C1713 AR-2665-18H - SCREW BN HEXALOBE 2.5MM 18MM HRBRT 2 PTCH SS ELB SHLDR SM BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2665-20H SUP HCPCS C1713 AR-2665-20H - SCREW BN HEXALOBE 2.5MM 20MM HRBRT 2 PTCH SS ELB SHLDR SM BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2665-22H SUP HCPCS C1713 AR-2665-22H - SCREW BN HEXALOBE 2.5MM 22MM HRBRT 2 PTCH SS ELB SHLDR SM BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2665-24H SUP HCPCS C1713 AR-2665-24H - SCREW BN HEXALOBE 2.5MM 24MM HRBRT 2 PTCH SS ELB SHLDR SM BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2668 SUP Custom 27203010 AR-2668 - GUIDE DRL LCK SLV 2.7 MM SCR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2669 SUP Custom 27203010 AR-2669 - GUIDE DRL LCK DIST 2.7 MM SCR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2680ST SUP HCPCS C1713 AR-2680ST - PLATE BN PRECONTOUR FX 7 HL SS CLVCL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2685DR-10 SUP HCPCS C1713 AR-2685DR-10 - PLATE BN 10 HL LOPRFL PRECONTOUR CMPR SLOT SS CLVCL RT DIST BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,577.18" $618.75 $618.75 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2810-20 SUP Custom 27203010 AR-2810-20 - PARTIAL ECLIPSE HUMERAL REAMER BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2810-25 SUP Custom 27203010 AR-2810-25 - PARTIAL ECLIPSE HUMERAL REAMER BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2810F-18-5 SUP Custom 27203010 AR-2810F-18-5 - PARTIAL ECLIPSE GLENOID REAMER BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2810F-20-5 SUP Custom 27203010 AR-2810F-20-5 - PARTIAL ECLIPSE GLENOID REAMER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2810F-22-5 SUP Custom 27203010 AR-2810F-22-5 - PARTIAL ECLIPSE GLENOID REAMER BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2810R-20-5 SUP Custom 27203010 AR-2810R-20-5 - ALLOGRAFT PARTIAL ECLIPSE HUMERAL REAMER BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2810R-25-5 SUP Custom 27203010 AR-2810R-25-5 - ALLOGRAFT PARTIAL ECLIPSE HUMERAL REAMER BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2810R-30-5 SUP Custom 27203010 AR-2810R-30-5 - ALLOGRAFT PARTIAL ECLIPSE HUMERAL REAMER BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2820 SUP Custom 27203010 AR-2820 - GUIDE DRL PRT ECLPS STEMLESS SHLDR ARTHPL BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2922BC SUP HCPCS C1713 AR-2922BC - ANCHOR SUT 2.4MM 11.3MM PUSHLOCK BCMPS 1 FBRWR 2 FIBERLINK BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2922D-24-1 SUP Custom 27203010 AR-2922D-24-1 - DRILL SRG 2.4 MM PUSHLOCK BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2922PS SUP HCPCS C1713 AR-2922PS - ANCHOR SUT 2.4MM 14MM STRL PUSHLOCK CNN EYLT HNDL INSRTR BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923BC SUP HCPCS C1713 AR-2923BC - ANCHOR SUTURE SHORT 2.9MM 12.5MM CANN EYELET HANDLE INSERTER BOTH IP/OP "$1,000.00 " $740.00 $0.00 "$1,144.00" $643.50 $643.50 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $715.00 "$1,132.56" "$1,144.00" $0.00 $0.00 $223.80 $0.00 $0.00 $227.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923BCH SUP HCPCS C1713 AR-2923BCH - SUTR ANCH HIP BIO-COMP P-LCK 2.9X12.5MM BOTH IP/OP "$1,050.00 " $777.00 $0.00 $840.00 $472.50 $472.50 $0.00 $0.00 $0.00 $218.85 $779.31 $779.31 $0.00 $0.00 $218.82 $0.00 $621.08 $621.08 $0.00 $525.00 $831.60 $840.00 $0.00 $0.00 $164.33 $0.00 $0.00 $167.16 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923D SUP Custom 27203010 AR-2923D - DRILL SRG BCMPS 2.9 MM SHRT PUSHLOCK BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923DHT SUP Custom 27203010 AR-2923DHT - DRILL SRG HIP SHRT 2.9 MM PUSHLOCK HRD BN BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923D-ST SUP Custom 27203010 AR-2923D-ST - DRILL SRG STRL ELB SHLDR 2.9 MM SHRT PUSHLOCK BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923DT SUP Custom 27203010 AR-2923DT - DRILL SRG 2.9 MM SHRT PUSHLOCK HRD BN BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923DT-ST SUP Custom 27203010 AR-2923DT-ST - DRILL SRG STRL 2.9 MM SHRT PUSHLOCK HRD BN BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923PHS SUP HCPCS C1713 AR-2923PHS - ANCHOR SUT SHRT 2.9MM 12.5MM PUSHLOCK PEEK HIP BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $427.50 $427.50 $0.00 $0.00 $0.00 $198.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $561.93 $561.93 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $148.68 $0.00 $0.00 $151.24 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2923PS SUP HCPCS C1713 AR-2923PS - ANCHOR SUT SHRT 2.9MM 12.5MM STRL PUSHLOCK CNN PEEK BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2950SC SUP Custom 27203010 AR-2950SC - CLAMP SRG GRAFTPRO SFT TIS BOTH IP/OP "$1,492.50 " "$1,104.45" $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,107.73" "$1,107.73" $0.00 $0.00 $311.04 $0.00 $0.00 $0.00 $0.00 $746.25 "$1,182.06" "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-2962 SUP Custom 27203010 AR-2962 - GUIDE DRL DVTL ALGRF MNSCS BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 $0.00 $0.00 $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3400H-4.5 SUP Custom 27203010 AR-3400H-4.5 - CANNULA ASCP HIP LGTH TPR 4.5MM BLNT FENESTRATE QCK CNCT LCK BOTH IP/OP $869.55 $643.47 $0.00 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $645.38 $645.38 $0.00 $0.00 $181.21 $0.00 $0.00 $0.00 $0.00 $434.78 $688.68 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3400H-5.0 SUP Custom 27203010 AR-3400H-5.0 - CANNULA ASCP HIP LGTH TPR 5MM BLNT FENESTRATE QCK CNCT LCK BOTH IP/OP $869.55 $643.47 $0.00 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $645.38 $645.38 $0.00 $0.00 $181.21 $0.00 $0.00 $0.00 $0.00 $434.78 $688.68 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3400H-5.5 SUP Custom 27203010 AR-3400H-5.5 - CANNULA ASCP HIP LGTH TPR 5.5MM BLNT FENESTRATE QCK CNCT LCK BOTH IP/OP $869.55 $643.47 $0.00 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $645.38 $645.38 $0.00 $0.00 $181.21 $0.00 $0.00 $0.00 $0.00 $434.78 $688.68 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3400H-6.5 SUP Custom 27203010 AR-3400H-6.5 - CANNULA ASCP HIP LGTH TPR 6.5MM BLNT FENESTRATE QCK CNCT LCK BOTH IP/OP $869.55 $643.47 $0.00 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $645.38 $645.38 $0.00 $0.00 $181.21 $0.00 $0.00 $0.00 $0.00 $434.78 $688.68 $695.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3490HQC SUP Custom 27203010 AR-3490HQC - CANNULA ASCP STD HIP LGTH HUB QCK CNCT BOTH IP/OP $670.73 $496.34 $0.00 $536.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $497.81 $497.81 $0.00 $0.00 $139.78 $0.00 $0.00 $0.00 $0.00 $335.36 $531.22 $536.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3600-2 SUP HCPCS C1713 AR-3600-2 - ANCHOR SUT 2 FIBERTAK FBRWR CLS EYLT BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $382.50 $382.50 $0.00 $0.00 $0.00 $177.16 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $502.78 $502.78 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $133.03 $0.00 $0.00 $135.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3600D-1 SUP Custom 27203010 AR-3600D-1 - DRILL SRG 1.6MM FIBERTAK BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3600DS SUP HCPCS C1713 AR-3600DS - ANCHOR SUT STRL LF ARTHX FIBERTAK DRL SPR OBT DISP BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $585.00 $585.00 $0.00 $0.00 $0.00 $270.95 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $768.95 $768.95 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3600ND-3 SUP Custom 27203010 AR-3600ND-3 - DRILL SRG 1.7MM FLXB FIBERTAK BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3601 SUP HCPCS C1713 "AR-3601 - KNOTLESS FIBERTAK SUTURE ANCHOR, 1.5MM" BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3602-2 SUP HCPCS C1713 AR-3602-2 - ANCHOR SUT 1.3MM BLU WHT FIBERTAK SUTURETAPE 2 LD BOTH IP/OP $925.00 $684.50 $0.00 $740.00 $416.25 $416.25 $0.00 $0.00 $0.00 $192.79 $686.54 $686.54 $0.00 $0.00 $192.77 $0.00 $547.14 $547.14 $0.00 $462.50 $732.60 $740.00 $0.00 $0.00 $144.76 $0.00 $0.00 $147.26 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3603-2 SUP HCPCS C1713 AR-3603-2 - ANCHOR SUT 2 FIBERTAK TGTL 2 LD BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $382.50 $382.50 $0.00 $0.00 $0.00 $177.16 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $502.78 $502.78 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $133.03 $0.00 $0.00 $135.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3651T SUP HCPCS C1713 AR-3651T - ANCHOR SUT 2 BLK GRN/WHT FIBERTAK TGTL LABRALTAPE 2 ROW BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-3651TT SUP HCPCS C1713 AR-3651TT - ANCHOR SUT 2 BLK BLU WHT FIBERTAK TGTL LABRALTAPE 2 ROW BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4007JS SUP Custom 27203010 AR-4007JS - SET GFT PREP MNS DRT JSTK BOTH IP/OP "$1,300.00 " $962.00 $0.00 "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $964.86 $964.86 $0.00 $0.00 $270.92 $0.00 $0.00 $0.00 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4008 SUP Custom 27203010 AR-4008 - PROBE ASCP STRL MNS DRT MSR DISP BOTH IP/OP $117.50 $86.95 $0.00 $94.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.21 $87.21 $0.00 $0.00 $24.49 $0.00 $0.00 $0.00 $0.00 $58.75 $93.06 $94.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4045 SUP Custom 27203010 AR-4045 - CANNULA ASCP STRL MNS DRT OBT DISP BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4065-45L SUP Custom 27203010 AR-4065-45L - PASSER SUT 45D CRV LT STRL CRKSCR SUTLSO DISP ASCP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4065-45R SUP Custom 27203010 AR-4065-45R - PASSER SUT 45D RT CRV STRL CRKSCR SUTLSO DISP ASCP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4065-90S SUP Custom 27203010 AR-4065-90S - PASSER SUT 90D 2.3MM STRL SUTLSO NTNL ELB SHLDR DISP ASCP BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4065-90W SUP Custom 27203010 AR-4065-90W - PASSER SUT 90D 2.3MM STRL SUTLSO WRE LOOP NTNL ELB SHLDR BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4065B SUP Custom 27203010 AR-4065B - PASSER SUT UNV BNA 2.3MM STRL SUTLSO ROTR CUF NTNL DISP ASCP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4065H SUP HCPCS C1713 AR-4065H - ANCHOR SUT 45D LASSO HIP BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4065S SUP Custom 27203010 AR-4065S - PASSER SUT 45D CRV STRL SUTLSO NTNL DISP ASCP BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4065W SUP Custom 27203010 AR-4065W - PASSER SUT 45D 2.3MM STRL SUTLSO WRE LOOP NTNL DISP ASCP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-05SD SUP Custom 27203010 AR-4068-05SD - PASSER SUT 1.8MM 3.8MM STRL SUTLSO SD WIRELOOP NTNL ASCP BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-25TL SUP Custom 27203010 AR-4068-25TL - PASSER SUTURE 25D TIGHT LEFT CURVE 1.8MM 3.8MM SUTURELASSO BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-25TLF SUP Custom 27203010 AR-4068-25TLF - PASSER SUT 25D TIGHT LT CRV 1.8MM 3.8MM STRL SUTLSO SD BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $0.00 $0.00 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-25TR SUP Custom 27203010 AR-4068-25TR - PASSER SUT 25D TIGHT RT CRV 1.8MM 3.8MM STRL SUTLSO SD THB BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-25TRF SUP Custom 27203010 AR-4068-25TRF - PASSER SUT 25D TIGHT RT CRV 1.8MM 3.8MM STRL SUTLSO SD BOTH IP/OP $445.00 $329.30 $0.00 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.28 $330.28 $0.00 $0.00 $92.74 $0.00 $0.00 $0.00 $0.00 $222.50 $352.44 $356.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-30 SUP Custom 27203010 AR-4068-30 - PASSER SUT 30D STRG 1.8MM 3.8MM STRL SUTLSO SD THB PD NTNL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-45L SUP Custom 27203010 AR-4068-45L - PASSER SUTURE 45D LEFT CURVE 1.8MM 3.8MM THUMB PAD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-45LH SUP Custom 27203010 AR-4068-45LH - PASSER SUT 45D LT CRV STRL SUTLSO DISP HIP ASCP BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-45R SUP Custom 27203010 AR-4068-45R - PASSER SUTURE 45D RIGHT CURVE 1.8MM 3.8MM THUMB PAD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-45RH SUP Custom 27203010 AR-4068-45RH - PASSER SUT 45D RT CRV STRL SUTLSO DISP HIP ASCP BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-90 SUP Custom 27203010 AR-4068-90 - PASSER SUTURE 90D UP STR 1.8MM 3.8MM THUMB PAD SUTURELASSO BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-90H SUP Custom 27203010 AR-4068-90H - PASSER SUT 90D STRG STRL SUTLSO DISP HIP ASCP BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-90L SUP Custom 27203010 AR-4068-90L - PASSER SUTURE 90D LEFT CURVE 1.8MM 3.8MM THUMB PAD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068-90R SUP Custom 27203010 AR-4068-90R - PASSER SUTURE 90D RIGHT CURVE 1.8MM 3.8MM THUMB PAD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068C SUP Custom 27203010 AR-4068C - PASSER SUTURE SMALL CRESCENT 1.8MM 3.8MM THUMB PAD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4068CH SUP Custom 27203010 AR-4068CH - PASSER SUT CRSNT STRL SUTLSO DISP HIP ASCP BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4070-01 SUP Custom 27203010 AR-4070-01 - PROBE ASCP 60D 220MM MSR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4070-70S SUP Custom 27203010 AR-4070-70S - PROBE ASCP 70D STRL MSR MP KN DISP BOTH IP/OP $395.00 $292.30 $0.00 $316.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $0.00 $0.00 $0.00 $197.50 $312.84 $316.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4151B SUP HCPCS C1713 AR-4151B - PIN DRL 1.5MM 100MM STRL TRMIT DISP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4151DS SUP HCPCS C1713 AR-4151DS - KIT INST 1.5MM 100MM STRL TRMIT DRL PIN KRSH BN TAMP GD SLV BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4152B SUP HCPCS C1713 AR-4152B - PIN DRL 2MM 100MM STRL TRMIT DISP BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4152DS SUP HCPCS C1713 AR-4152DS - KIT INST 2MM 100MM STRL TRMIT DRL PIN KRSH BN TAMP GD SLV BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4152MS SUP HCPCS C1713 AR-4152MS - PIN DRL 2MM 100MM STRL TRMIT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4154P-3010 SUP HCPCS C1713 AR-4154P-3010 - KIT TRMA FX 10D 2.5MM 30MM STRL PIP DART RDLCNT INSRTR DRL BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4154PS-3000 SUP HCPCS C1713 AR-4154PS-3000 - KIT TRMA FX STRG 2.5MM 30MM STRL PIP DART INSRTR DRL GW TROC BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4154PS-3010 SUP HCPCS C1713 AR-4154PS-3010 - KIT TRMA FX 10D 2.5MM 30MM STRL PIP DART INSRTR DRL GW BRB BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4155P-3010 SUP HCPCS C1713 AR-4155P-3010 - KIT TRMA FX 10D 3MM 30MM STRL PIP DART RDLCNT INSRTR DRL GW BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4155PS-3010 SUP HCPCS C1713 AR-4155PS-3010 - KIT TRMA FX 10D 3MM 30MM STRL PIP DART INSRTR DRL GW TROC BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4156DS SUP HCPCS C1713 AR-4156DS - KIT INST 2MM 100MM STRL TRMIT DRL PIN KRSH BN TAMP GD SLV BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-20 SUP Custom 27203010 AR-4160-20 - BIT DRL 2MM TRMIT BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-24 SUP Custom 27203010 AR-4160-24 - BIT DRL 2.4MM TRMIT BOTH IP/OP $487.50 $360.75 $0.00 $361.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-25 SUP Custom 27203010 AR-4160-25 - BIT DRL 2.5MM TRMIT BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-26 SUP Custom 27203010 AR-4160-26 - BIT DRL 2.6MM TRMIT BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-27 SUP Custom 27203010 AR-4160-27 - BIT DRL 2.7MM TRMIT BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-34 SUP Custom 27203010 AR-4160-34 - BIT DRL 3.4MM TRMIT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-35 SUP Custom 27203010 AR-4160-35 - BIT DRL 3.5MM TRMIT BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-40 SUP Custom 27203010 AR-4160-40 - BIT DRL 4MM TRMIT BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4160-45 SUP Custom 27203010 AR-4160-45 - BIT DRL 4.5MM TRMIT BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4161 SUP Custom 27203010 AR-4161 - DRILL BIT CNTRSNK 2.7MM TRMIT BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4161B SUP HCPCS C1713 AR-4161B - SCREW INTFR HEX 2.7MM 30MM STRL TRMIT CNN POLY L LAC ACD ACL BOTH IP/OP $482.50 $357.05 $0.00 $386.00 $217.13 $217.13 $0.00 $0.00 $0.00 $100.57 $358.11 $358.11 $0.00 $0.00 $100.55 $0.00 $285.40 $285.40 $0.00 $241.25 $382.14 $386.00 $0.00 $0.00 $75.51 $0.00 $0.00 $76.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4161G SUP Custom 27203010 AR-4161G - GUIDE DRL 2MM 2.7MM TRMIT BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4162B SUP HCPCS C1713 AR-4162B - SCREW INTFR HEX 3.5MM 40MM STRL TRMIT CNN POLY L LAC ACD ACL BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4163 SUP Custom 27203010 AR-4163 - DRILL BIT CNTRSNK 4MM BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4163B SUP HCPCS C1713 AR-4163B - SCREW INTFR HEX 4MM 50MM STRL TRMIT CNN POLY L LAC ACD ACL BOTH IP/OP $525.00 $388.50 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $109.42 $389.66 $389.66 $0.00 $0.00 $109.41 $0.00 $310.54 $310.54 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4163G SUP Custom 27203010 AR-4163G - GUIDE DRL 2.4MM 4MM TRMIT BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4164 SUP Custom 27203010 AR-4164 - DRILL BIT CNTRSNK 4.5MM BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4164B SUP HCPCS C1713 AR-4164B - SCREW INTFR FT HEX 4.5MM 60MM STRL TRMIT CNN POLY L LAC ACD BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $348.75 $348.75 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4164G SUP Custom 27203010 AR-4164G - GUIDE DRL 3.4MM 4.5MM TRMIT BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4207-12 SUP Custom 27203010 AR-4207-12 - COMPONENT SUBTALAR CNCV 7MM 12MM STRL PROSTOP BABSR TI POLY BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,773.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 $0.00 $0.00 $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4208-14 SUP Custom 27203010 AR-4208-14 - COMPONENT SUBTALAR CNCV 8MM 14MM STRL PROSTOP BABSR TI POLY BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,773.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 $0.00 $0.00 $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4208B-14 SUP Custom 27203010 AR-4208B-14 - COMPONENT SUBTALAR CNCV 8MM 14MM STRL PROSTOP + BABSR TI BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 $0.00 $0.00 $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4209-14 SUP Custom 27203010 AR-4209-14 - COMPONENT SUBTALAR CNCV 9MM 14MM STRL PROSTOP BABSR TI POLY BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,773.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 $0.00 $0.00 $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4209B-14 SUP Custom 27203010 AR-4209B-14 - COMPONENT SUBTALAR CNCV 9MM 14MM STRL PROSTOP + BABSR TI BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 $0.00 $0.00 $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4210-14 SUP Custom 27203010 AR-4210-14 - COMPONENT SUBTALAR CNCV 10MM 14MM STRL PROSTOP BABSR TI POLY BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,773.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 $0.00 $0.00 $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4210B-14 SUP Custom 27203010 AR-4210B-14 - COMPONENT SUBTALAR CNCV 10MM 14MM STRL PROSTOP + BABSR TI BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 $0.00 $0.00 $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4211-16 SUP Custom 27203010 AR-4211-16 - COMPONENT SUBTALAR CNCV 11MM 16MM STRL PROSTOP BABSR TI POLY BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,773.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 $0.00 $0.00 $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4211B-16 SUP Custom 27203010 AR-4211B-16 - COMPONENT SUBTALAR CNCV 11MM 16MM STRL PROSTOP + BABSR TI BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 $0.00 $0.00 $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4212-16 SUP Custom 27203010 AR-4212-16 - COMPONENT SUBTALAR CNCV 12MM 16MM STRL PROSTOP BABSR TI POLY BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,773.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 $0.00 $0.00 $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4212B-16 SUP Custom 27203010 AR-4212B-16 - COMPONENT SUBTALAR CNCV 12MM 16MM STRL PROSTOP + BABSR TI BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 $0.00 $0.00 $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4502 SUP HCPCS C1713 AR-4502 - NEEDLE SUT 2-0 CRV SPEEDCINCH FBRWR PEEK BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4515 SUP Custom 27203010 AR-4515 - CUTTER SUTURE REMOVAL KNOT PUSHER MENISCAL CINCH STERILE BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-4520 SUP Custom 27203010 AR-4520 - CUTTER SUT REM TGHTRP RECON SUT ACL ASCP BOTH IP/OP $395.00 $292.30 $0.00 $316.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $293.17 $293.17 $0.00 $0.00 $82.32 $0.00 $0.00 $0.00 $0.00 $197.50 $312.84 $316.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5010AB SUP HCPCS C1713 AR-5010AB - SCREW INTFR 50D 10MM 17MM STRL BCRTCL BCK END FLSH POLY L BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5010BB SUP HCPCS C1713 AR-5010BB - SCREW INTFR 10MM 20MM STRL BCRTCL BCK END FLSH POLY L LAC BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5011AB SUP HCPCS C1713 AR-5011AB - SCREW INTFR 50D 11MM 17MM STRL BCRTCL BCK END FLSH POLY L BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBA0 SUP HCPCS C1713 AR-501-TBA0 - BEARING TIB 1 10MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBA1 SUP HCPCS C1713 AR-501-TBA1 - BEARING TIB 1 11MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBA2 SUP HCPCS C1713 AR-501-TBA2 - BEARING TIB 1 12MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBA4 SUP HCPCS C1713 AR-501-TBA4 - BEARING TIB 1 14MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBA8 SUP HCPCS C1713 AR-501-TBA8 - BEARING TIB 1 8MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBA9 SUP HCPCS C1713 AR-501-TBA9 - BEARING TIB 1 9MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBB0 SUP HCPCS C1713 AR-501-TBB0 - BEARING TIB 2 10MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBB1 SUP HCPCS C1713 AR-501-TBB1 - BEARING TIB 2 11MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBB2 SUP HCPCS C1713 AR-501-TBB2 - BEARING TIB 2 12MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBB4 SUP HCPCS C1713 AR-501-TBB4 - BEARING TIB 2 14MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBB8 SUP HCPCS C1713 AR-501-TBB8 - BEARING TIB 2 8MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBB9 SUP HCPCS C1713 AR-501-TBB9 - BEARING TIB 2 9MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBC0 SUP HCPCS C1713 AR-501-TBC0 - BEARING TIB 3 10MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBC1 SUP HCPCS C1713 AR-501-TBC1 - BEARING TIB 3 11MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBC2 SUP HCPCS C1713 AR-501-TBC2 - BEARING TIB 3 12MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBC4 SUP HCPCS C1713 AR-501-TBC4 - BEARING TIB 3 14MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBC8 SUP HCPCS C1713 AR-501-TBC8 - BEARING TIB 3 8MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBC9 SUP HCPCS C1713 AR-501-TBC9 - BEARING TIB 3 9MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBD0 SUP HCPCS C1713 AR-501-TBD0 - BEARING TIB 4 10MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBD1 SUP HCPCS C1713 AR-501-TBD1 - BEARING TIB 4 11MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBD2 SUP HCPCS C1713 AR-501-TBD2 - BEARING TIB 4 12MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBD4 SUP HCPCS C1713 AR-501-TBD4 - BEARING TIB 4 14MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBD8 SUP HCPCS C1713 AR-501-TBD8 - BEARING TIB 4 8MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBD9 SUP HCPCS C1713 AR-501-TBD9 - BEARING TIB D 9MM UNCMP BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBE0 SUP HCPCS C1713 AR-501-TBE0 - BEARING TIB 5 10MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBE1 SUP HCPCS C1713 AR-501-TBE1 - BEARING TIB 5 11MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBE2 SUP HCPCS C1713 AR-501-TBE2 - BEARING TIB 5 12MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBE4 SUP HCPCS C1713 AR-501-TBE4 - BEARING TIB 5 14MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBE8 SUP HCPCS C1713 AR-501-TBE8 - BEARING TIB 5 8MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBE9 SUP HCPCS C1713 AR-501-TBE9 - BEARING TIB 5 9MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBF0 SUP HCPCS C1713 AR-501-TBF0 - BEARING TIB 6 10MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBF1 SUP HCPCS C1713 AR-501-TBF1 - BEARING TIB 6 11MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBF2 SUP HCPCS C1713 AR-501-TBF2 - BEARING TIB 6 12MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBF4 SUP HCPCS C1713 AR-501-TBF4 - BEARING TIB 6 14MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBF8 SUP HCPCS C1713 AR-501-TBF8 - BEARING TIB 6 8MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TBF9 SUP HCPCS C1713 AR-501-TBF9 - BEARING TIB 6 9MM IBALANCE ANTM DSGN RSRFC PE KN UNCNDL BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTLA SUP Custom 27203010 AR-501-TTLA - TRAY TIB 1 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTLB SUP Custom 27203010 AR-501-TTLB - TRAY TIB 2 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTLC SUP Custom 27203010 AR-501-TTLC - TRAY TIB 3 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTLD SUP HCPCS C1776 AR-501-TTLD - COMPONENT TIBTRY D UNCMP LT BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTLE SUP Custom 27203010 AR-501-TTLE - TRAY TIB 5 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTLF SUP Custom 27203010 AR-501-TTLF - TRAY TIB 6 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTRA SUP Custom 27203010 AR-501-TTRA - TRAY TIB 1 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTRB SUP Custom 27203010 AR-501-TTRB - TRAY TIB 2 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTRC SUP Custom 27203010 AR-501-TTRC - TRAY TIB 3 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTRD SUP Custom 27203010 AR-501-TTRD - TRAY TIB 4 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTRE SUP Custom 27203010 AR-501-TTRE - TRAY TIB 5 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-TTRF SUP Custom 27203010 AR-501-TTRF - TRAY TIB 6 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 $0.00 $0.00 $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFLA SUP HCPCS C1776 AR-501-UFLA - COMPONENT FEM 1 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFLB SUP HCPCS C1776 AR-501-UFLB - COMPONENT FEM 2 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFLC SUP HCPCS C1776 AR-501-UFLC - COMPONENT FEM 3 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFLD SUP HCPCS C1776 AR-501-UFLD - COMPONENT FEM 4 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFLE SUP HCPCS C1776 AR-501-UFLE - COMPONENT FEM E KN LT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFLF SUP HCPCS C1776 AR-501-UFLF - COMPONENT FEM 6 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL LT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFRA SUP HCPCS C1776 AR-501-UFRA - COMPONENT FEM 1 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFRB SUP HCPCS C1776 AR-501-UFRB - COMPONENT FEM 2 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFRC SUP HCPCS C1776 AR-501-UFRC - COMPONENT FEM 3 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFRD SUP HCPCS C1776 AR-501-UFRD - COMPONENT FEM 4 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFRE SUP HCPCS C1776 AR-501-UFRE - COMPONENT FEM 5 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-501-UFRF SUP HCPCS C1776 AR-501-UFRF - COMPONENT FEM 6 IBALANCE ANTM DSGN CMNT RSRFC KN UNCNDL RT BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-502-1L SUP HCPCS C1776 AR-502-1L - COMPONENT FEM 1 IBALANCE PTLFEM LT BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" "$5,355.00" "$5,355.00" $0.00 $0.00 $0.00 "$2,480.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,479.96" $0.00 "$5,866.70" "$5,866.70" $0.00 "$5,950.00" "$9,424.80" "$9,520.00" $0.00 $0.00 "$1,862.35" $0.00 $0.00 "$1,894.48" $0.00 $0.00 $0.00 $0.00 $0.00 AR-502-1R SUP HCPCS C1776 AR-502-1R - COMPONENT FEM 1 IBALANCE PTLFEM RT BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" "$5,355.00" "$5,355.00" $0.00 $0.00 $0.00 "$2,480.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,479.96" $0.00 "$5,866.70" "$5,866.70" $0.00 "$5,950.00" "$9,424.80" "$9,520.00" $0.00 $0.00 "$1,862.35" $0.00 $0.00 "$1,894.48" $0.00 $0.00 $0.00 $0.00 $0.00 AR-502-2L SUP HCPCS C1776 AR-502-2L - COMPONENT FEM 2 IBALANCE PTLFEM LT BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" "$5,355.00" "$5,355.00" $0.00 $0.00 $0.00 "$2,480.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,479.96" $0.00 "$5,866.70" "$5,866.70" $0.00 "$5,950.00" "$9,424.80" "$9,520.00" $0.00 $0.00 "$1,862.35" $0.00 $0.00 "$1,894.48" $0.00 $0.00 $0.00 $0.00 $0.00 AR-502-2R SUP HCPCS C1776 AR-502-2R - COMPONENT FEM 2 IBALANCE PTLFEM RT BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" "$5,355.00" "$5,355.00" $0.00 $0.00 $0.00 "$2,480.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,479.96" $0.00 "$5,866.70" "$5,866.70" $0.00 "$5,950.00" "$9,424.80" "$9,520.00" $0.00 $0.00 "$1,862.35" $0.00 $0.00 "$1,894.48" $0.00 $0.00 $0.00 $0.00 $0.00 AR-502-3L SUP HCPCS C1776 AR-502-3L - COMPONENT FEM 3 IBALANCE PTLFEM LT BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" "$5,355.00" "$5,355.00" $0.00 $0.00 $0.00 "$2,480.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,479.96" $0.00 "$5,866.70" "$5,866.70" $0.00 "$5,950.00" "$9,424.80" "$9,520.00" $0.00 $0.00 "$1,862.35" $0.00 $0.00 "$1,894.48" $0.00 $0.00 $0.00 $0.00 $0.00 AR-502-3R SUP HCPCS C1776 AR-502-3R - COMPONENT FEM 3 IBALANCE PTLFEM RT BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" "$5,355.00" "$5,355.00" $0.00 $0.00 $0.00 "$2,480.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,479.96" $0.00 "$5,866.70" "$5,866.70" $0.00 "$5,950.00" "$9,424.80" "$9,520.00" $0.00 $0.00 "$1,862.35" $0.00 $0.00 "$1,894.48" $0.00 $0.00 $0.00 $0.00 $0.00 AR-502-4L SUP HCPCS C1776 AR-502-4L - COMPONENT FEM 4 IBALANCE PTLFEM LT BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" "$5,355.00" "$5,355.00" $0.00 $0.00 $0.00 "$2,480.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,479.96" $0.00 "$5,866.70" "$5,866.70" $0.00 "$5,950.00" "$9,424.80" "$9,520.00" $0.00 $0.00 "$1,862.35" $0.00 $0.00 "$1,894.48" $0.00 $0.00 $0.00 $0.00 $0.00 AR-502-4R SUP HCPCS C1776 AR-502-4R - COMPONENT FEM 4 IBALANCE PTLFEM RT BOTH IP/OP "$11,900.00 " "$8,806.00" $0.00 "$9,520.00" "$5,355.00" "$5,355.00" $0.00 $0.00 $0.00 "$2,480.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,479.96" $0.00 "$5,866.70" "$5,866.70" $0.00 "$5,950.00" "$9,424.80" "$9,520.00" $0.00 $0.00 "$1,862.35" $0.00 $0.00 "$1,894.48" $0.00 $0.00 $0.00 $0.00 $0.00 AR-5024TDA SUP Custom 27203010 AR-5024TDA - BIT DRL CMPR SCR TPR ASCP BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5024TDP SUP Custom 27203010 AR-5024TDP - BIT DRL CMPR SCR TPR PERC BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025B-16 SUP HCPCS C1713 AR-5025B-16 - SCREW INTFR TPR 3-3.7MM 16MM STRL BIO-CMPR SCR CNN SLF CMPR BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025B-18 SUP HCPCS C1713 AR-5025B-18 - SCREW INTFR TPR 3-3.7MM 18MM STRL BIO-CMPR SCR CNN SLF CMPR BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025B-20 SUP HCPCS C1713 AR-5025B-20 - SCREW INTFR TPR 2.7-3.7MM 20MM STRL BIO-CMPR SCR CNN SLF BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025B-22 SUP HCPCS C1713 AR-5025B-22 - SCREW INTFR TPR 3-3.7MM 22MM STRL BIO-CMPR SCR CNN SLF CMPR BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025B-24 SUP HCPCS C1713 AR-5025B-24 - SCREW INTFR TPR 3-3.7MM 24MM STRL BIO-CMPR SCR CNN SLF CMPR BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025B-26 SUP HCPCS C1713 AR-5025B-26 - SCREW INTFR TPR 3-3.7MM 26MM STRL BIO-CMPR SCR CNN SLF CMPR BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025ETDC-26 SUP Custom 27203010 AR-5025ETDC-26 - BIT DRL 26MM CNN BIO-CMPR SCR BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $0.00 $0.00 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025TD SUP Custom 27203010 AR-5025TD - BIT DRL 2.7MM 20MM CNN BIO-CMPR SCR BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025TDC SUP Custom 27203010 AR-5025TDC - BIT DRL CNN BIO-CMPR SCR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025TDC-16 SUP Custom 27203010 AR-5025TDC-16 - BIT DRL 16MM CNN BIO-CMPR SCR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025TDC-18 SUP Custom 27203010 AR-5025TDC-18 - BIT DRL 18MM CNN BIO-CMPR SCR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025TDC-22 SUP Custom 27203010 AR-5025TDC-22 - BIT DRL 22MM CNN BIO-CMPR SCR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025TDC-24 SUP Custom 27203010 AR-5025TDC-24 - BIT DRL 24MM CNN BIO-CMPR SCR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5025TDC-26 SUP Custom 27203010 AR-5025TDC-26 - BIT DRL 26MM CNN BIO-CMPR SCR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-16 SUP HCPCS C1713 AR-5026B-16 - SCREW INTFR TPR 3.5-4.4MM 16MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-18 SUP HCPCS C1713 AR-5026B-18 - SCREW INTFR TPR 3.5-4.5MM 18MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-20 SUP HCPCS C1713 AR-5026B-20 - SCREW INTFR TPR 3.5-4.6MM 20MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-22 SUP HCPCS C1713 AR-5026B-22 - SCREW INTFR TPR 3.5-4.7MM 22MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-24 SUP HCPCS C1713 AR-5026B-24 - SCREW INTFR TPR 3.5-4.8MM 24MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-26 SUP HCPCS C1713 AR-5026B-26 - SCREW INTFR TPR 3.5-4.9MM 26MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-28 SUP HCPCS C1713 AR-5026B-28 - SCREW INTFR TPR 3.5-5-5MM 28MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-30 SUP HCPCS C1713 AR-5026B-30 - SCREW INTFR TPR 3.5-5.1MM 30MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026B-32 SUP HCPCS C1713 AR-5026B-32 - SCREW INTFR TPR 3.5-3.5MM 32MM BIO-CMPR SCR CNN SLF CMPR STP BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $444.38 $444.38 $0.00 $0.00 $0.00 $205.82 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $584.11 $584.11 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $154.54 $0.00 $0.00 $157.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026G SUP Custom 27203010 AR-5026G - 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BIT DRL TPR 3.5MM 30MM BIO-CMPR SCR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5026TDC-32 SUP Custom 27203010 AR-5026TDC-32 - BIT DRL TPR 3.5MM 32MM BIO-CMPR SCR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5028B-08 SUP HCPCS C1713 AR-5028B-08 - SCREW INTFR DLT TPR 8MM 28MM STRL 6.5MM BIOINTF POLY L LAC BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5028B-09 SUP HCPCS C1713 AR-5028B-09 - SCREW INTFR DLT TPR 9MM 28MM STRL 7.5MM BIOINTF POLY L LAC BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5028B-10 SUP HCPCS C1713 AR-5028B-10 - 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SCREW INTERFERENCE DELTA TAPER 10MM 28MM BIOCOMPOSITE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5028C-11 SUP HCPCS C1713 AR-5028C-11 - SCREW INTERFERENCE DELTA TAPER 11MM 28MM BIOCOMPOSITE BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5028P-07 SUP HCPCS C1713 AR-5028P-07 - SCREW INTFR DLT TPR 7MM 28MM STRL RECON SHTH THRD PTRN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5028P-08 SUP HCPCS C1713 AR-5028P-08 - 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SCREW INTFR DLT TPR 12MM 28MM STRL RECON SHTH THRD PTRN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5035P-09 SUP HCPCS C1713 AR-5035P-09 - SCREW INTFR DLT TPR 9MM 35MM STRL CNN DRVR RECON PEEK-OPTM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5035P-10 SUP HCPCS C1713 AR-5035P-10 - SCREW INTFR DLT TPR 10MM 35MM STRL CNN DRVR RECON PEEK-OPTM BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5035P-11 SUP HCPCS C1713 AR-5035P-11 - 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SCREW INTFR DLT TPR 8.5-10MM 35MM STRL BIOINTF CNN POLY L BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5035TB-11 SUP HCPCS C1713 AR-5035TB-11 - SCREW INTFR DLT TPR 9.5-11MM 35MM STRL BIOINTF CNN POLY L BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5035TB-12 SUP HCPCS C1713 AR-5035TB-12 - SCREW INTFR DLT TPR 10.5-12MM 35MM STRL BIOINTF CNN POLY L BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5035TC-09 SUP HCPCS C1713 AR-5035TC-09 - SCREW INTFR DLT 9MM 35MM STRL CNN BCMPS ACL BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5035TC-10 SUP HCPCS C1713 AR-5035TC-10 - SCREW INTFR DLT 10MM 35MM STRL CNN BCMPS ACL BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5035TC-12 SUP HCPCS C1713 AR-5035TC-12 - SCREW INTFR BCMPS 35MM 12MM DLT ACL CANN STRL BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1008 SUP HCPCS C1776 "AR-503-A1008 - CR PLUS TIBIAL BEARING, SIZE 10, 8MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1009 SUP HCPCS C1776 "AR-503-A1009 - CR PLUS TIBIAL BEARING, SIZE 10, 9MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1010 SUP HCPCS C1776 "AR-503-A1010 - CR PLUS TIBIAL BEARING, SIZE 10, 10MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1011 SUP HCPCS C1776 "AR-503-A1011 - CR PLUS TIBIAL BEARING, SIZE 10, 11MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1012 SUP HCPCS C1776 "AR-503-A1012 - CR PLUS TIBIAL BEARING, SIZE 10, 12MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1013 SUP HCPCS C1776 "AR-503-A1013 - CR PLUS TIBIAL BEARING, SIZE 10, 13MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1014 SUP HCPCS C1776 "AR-503-A1014 - CR PLUS TIBIAL BEARING, SIZE 10, 14MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1016 SUP HCPCS C1776 "AR-503-A1016 - CR PLUS TIBIAL BEARING, SIZE 10, 16MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A1018 SUP HCPCS C1776 "AR-503-A1018 - CR PLUS TIBIAL BEARING, SIZE 10, 18MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A908 SUP HCPCS C1776 "AR-503-A908 - CR PLUS TIBIAL BEARING, SIZE 9, 8MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A909 SUP HCPCS C1776 "AR-503-A909 - CR PLUS TIBIAL BEARING, SIZE 9, 9MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A910 SUP HCPCS C1776 "AR-503-A910 - CR PLUS TIBIAL BEARING, SIZE 9, 10MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A911 SUP HCPCS C1776 "AR-503-A911 - CR PLUS TIBIAL BEARING, SIZE 9, 11MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A912 SUP HCPCS C1776 "AR-503-A912 - CR PLUS TIBIAL BEARING, SIZE 9, 12MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A913 SUP HCPCS C1776 "AR-503-A913 - CR PLUS TIBIAL BEARING, SIZE 9, 13MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A914 SUP HCPCS C1776 "AR-503-A914 - CR PLUS TIBIAL BEARING, SIZE 9, 14MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A916 SUP HCPCS C1776 "AR-503-A916 - CR PLUS TIBIAL BEARING, SIZE 9, 16MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-A918 SUP HCPCS C1776 "AR-503-A918 - CR PLUS TIBIAL BEARING, SIZE 9, 18MM" BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-503-PSRA SUP HCPCS C1776 AR-503-PSRA - COMPONENT FEM IBALANCE CMNT POST STAB KN RT BOTH IP/OP "$7,750.00 " "$5,735.00" $0.00 "$6,200.00" "$3,487.50" "$3,487.50" $0.00 $0.00 $0.00 "$1,615.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,615.10" $0.00 "$3,820.75" "$3,820.75" $0.00 "$3,875.00" "$6,138.00" "$6,200.00" $0.00 $0.00 "$1,212.88" $0.00 $0.00 "$1,233.80" $0.00 $0.00 $0.00 $0.00 $0.00 AR-504-PSA8 SUP HCPCS C1776 AR-504-PSA8 - COMPONENT PTLR DOME 27MM 8MM IBALANCE BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" $984.38 $984.38 $0.00 $0.00 $0.00 $455.93 "$1,623.56" "$1,623.56" $0.00 $0.00 $455.88 $0.00 "$1,293.91" "$1,293.91" $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-504-PSB8 SUP HCPCS C1776 AR-504-PSB8 - COMPONENT PTLR DOME 30MM 8MM IBALANCE BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" $984.38 $984.38 $0.00 $0.00 $0.00 $455.93 "$1,623.56" "$1,623.56" $0.00 $0.00 $455.88 $0.00 "$1,293.91" "$1,293.91" $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-504-PSE0 SUP HCPCS C1776 AR-504-PSE0 - COMPONENT PTLR THK10MM 3 DOME 40MM IBALANCE 3 PG BOTH IP/OP "$2,187.50 " "$1,618.75" $0.00 "$1,750.00" $984.38 $984.38 $0.00 $0.00 $0.00 $455.93 "$1,623.56" "$1,623.56" $0.00 $0.00 $455.88 $0.00 "$1,293.91" "$1,293.91" $0.00 "$1,093.75" "$1,732.50" "$1,750.00" $0.00 $0.00 $342.34 $0.00 $0.00 $348.25 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5050-05 SUP Custom 27203010 AR-5050-05 - CLAMP SRG 2X SM WEBER LNG THROW PTLR FX SYS BOTH IP/OP $442.50 $327.45 $0.00 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.42 $328.42 $0.00 $0.00 $92.22 $0.00 $0.00 $0.00 $0.00 $221.25 $350.46 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5050-07 SUP Custom 27203010 AR-5050-07 - GUIDE DRL 2MM 1.6MM BOTH IP/OP "$1,117.50 " $826.95 $0.00 $894.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $829.41 $829.41 $0.00 $0.00 $232.89 $0.00 $0.00 $0.00 $0.00 $558.75 $885.06 $894.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5050-11 SUP Custom 27203010 AR-5050-11 - GUIDE DRL PRLL PTLR FX BOTH IP/OP "$1,402.50 " "$1,037.85" $0.00 "$1,122.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,040.94" "$1,040.94" $0.00 $0.00 $292.28 $0.00 $0.00 $0.00 $0.00 $701.25 "$1,110.78" "$1,122.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5050K-2 SUP Custom 27203010 AR-5050K-2 - CANNULA ASCP 7MM 7CM STRL OBT THRD SHLDR DISP BOTH IP/OP $97.50 $72.15 $0.00 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.36 $72.36 $0.00 $0.00 $20.32 $0.00 $0.00 $0.00 $0.00 $48.75 $77.22 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-24 SUP HCPCS C1713 AR-5051-24 - SCREW BN 4MM 24MM CNN BLNT TIP LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-26 SUP HCPCS C1713 AR-5051-26 - SCREW BN 4MM 26MM CNN BLNT TIP LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-28 SUP HCPCS C1713 AR-5051-28 - SCREW BN 4MM 28MM CNN BLNT TIP LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-30 SUP HCPCS C1713 AR-5051-30 - SCREW BN 4MM 30MM CNN BLNT TIP LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-32 SUP HCPCS C1713 AR-5051-32 - SCREW BN 4MM 32MM BLNT TIP CNN LG BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-34 SUP HCPCS C1713 AR-5051-34 - SCREW BN 4MM 34MM BLNT TIP CNN LG BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-36 SUP HCPCS C1713 AR-5051-36 - SCREW BN 4MM 36MM CNN BLNT TIP LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-38 SUP HCPCS C1713 AR-5051-38 - SCREW BN 4MM 38MM CNN BLNT TIP LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-40 SUP HCPCS C1713 AR-5051-40 - SCREW BN 4MM 40MM BLNT TIP CNN LG BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-42 SUP HCPCS C1713 AR-5051-42 - SCREW BN 4MM 42MM BLNT TIP CNN LG BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-44 SUP HCPCS C1713 AR-5051-44 - SCREW BN 4MM 44MM CNN BLNT LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-46 SUP HCPCS C1713 AR-5051-46 - SCREW BN 4MM 46MM CNN BLNT LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-48 SUP HCPCS C1713 AR-5051-48 - SCREW BN 4MM 48MM CNN BLNT TIP LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-50 SUP HCPCS C1713 AR-5051-50 - SCREW BN 4MM 50MM CNN LOPRFL BLNT TIP BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-55 SUP HCPCS C1713 AR-5051-55 - SCREW BN 4MM 55MM CNN BLNT LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5051-60 SUP HCPCS C1713 AR-5051-60 - SCREW BN 4MM 60MM CNN BLNT LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-25TL SUP Custom 27203010 AR-5068-25TL - PASSER SUT 25D SUTLSO SD CRV LT SHFT TIGHT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-25TR SUP Custom 27203010 AR-5068-25TR - PASSER SUT 25D SUTLSO SD CRV RT SHFT TIGHT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-30 SUP Custom 27203010 AR-5068-30 - PASSER SUT 30D SUTLSO SD STRG SHFT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-45L SUP Custom 27203010 AR-5068-45L - PASSER SUT 45D SUTLSO SD CRV LT SHFT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-45R SUP Custom 27203010 AR-5068-45R - PASSER SUT 45D SUTLSO SD CRV RT SHFT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-90 SUP Custom 27203010 AR-5068-90 - PASSER SUT 90D SUTLSO SD STRG SHFT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-90L SUP Custom 27203010 AR-5068-90L - PASSER SUT 90D SUTLSO SD CRV LT SHFT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-90R SUP Custom 27203010 AR-5068-90R - PASSER SUT 90D SUTLSO SD CRV RT SHFT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068-90T SUP Custom 27203010 AR-5068-90T - PASSER SUT 90D 2 SUTLSO SD SHFT STRG RT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068C SUP Custom 27203010 AR-5068C - PASSER SUT SUTLSO SD CRSNT SHFT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5068H SUP Custom 27203010 AR-5068H - PASSER SUT SUTLSO HNDL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5080AB SUP HCPCS C1713 AR-5080AB - SCREW INTFR 50D 8MM 17MM STRL BCRTCL BCK END FLSH POLY L LAC BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5080BB SUP HCPCS C1713 AR-5080BB - SCREW INTFR 8MM 20MM STRL BCRTCL BCK END FLSH POLY L LAC ACD BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5090AB SUP HCPCS C1713 AR-5090AB - SCREW INTFR 50D 9MM 17MM STRL BCRTCL BCK END FLSH POLY L LAC BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5090BB SUP HCPCS C1713 AR-5090BB - SCREW INTFR 9MM 20MM STRL BCRTCL BCK END FLSH POLY L LAC ACD BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-10100 SUP HCPCS C1776 AR-513-10100 - EXTENSION STM 10MM 100MM IBALANCE SCR TIB BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-1050 SUP HCPCS C1776 AR-513-1050 - STEM XTN 10MM 50MM IBALANCE TKA SCR TIB BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-12100 SUP HCPCS C1776 AR-513-12100 - EXTENSION STM 12MM 100MM IBALANCE SCR TIB BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-1250 SUP HCPCS C1776 AR-513-1250 - COMPONENT FEM 12MM 50MM STRL IBALANCE ARTHX STM XTN CMNT T/K BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-14100 SUP HCPCS C1776 AR-513-14100 - EXTENSION STM 14MM 100MM IBALANCE SCR TIB BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-1450 SUP HCPCS C1776 AR-513-1450 - COMPONENT FEM 14MM 50MM STRL IBALANCE ARTHX STM XTN CMNT T/K BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL1010 SUP HCPCS C1713 AR-513-RL1010 - AUGMENT TIB 10 10MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL105 SUP HCPCS C1713 AR-513-RL105 - AUGMENT TIB 10 5MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL110 SUP HCPCS C1713 AR-513-RL110 - AUGMENT TIB 1 10MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL15 SUP HCPCS C1713 AR-513-RL15 - AUGMENT TIB 1 5MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL210 SUP HCPCS C1713 AR-513-RL210 - AUGMENT TIB 2 10MM IBALANCE SCR LT MDL RL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL25 SUP HCPCS C1713 AR-513-RL25 - AUGMENT TIB 2 5MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL310 SUP HCPCS C1713 AR-513-RL310 - AUGMENT TIB 3 10MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL35 SUP HCPCS C1713 AR-513-RL35 - AUGMENT TIB 3 5MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL410 SUP HCPCS C1713 AR-513-RL410 - AUGMENT TIB 4 10MM IBALANCE SCR LT MDL RL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL45 SUP HCPCS C1713 AR-513-RL45 - AUGMENT TIB 4 5MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL510 SUP HCPCS C1713 AR-513-RL510 - AUGMENT TIB 5 10MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL55 SUP HCPCS C1713 AR-513-RL55 - AUGMENT TIB 5 5MM IBALANCE SCR LT MDL RL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL610 SUP HCPCS C1713 AR-513-RL610 - AUGMENT TIB 6 10MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL65 SUP HCPCS C1713 AR-513-RL65 - AUGMENT TIB 5 5MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL710 SUP HCPCS C1713 AR-513-RL710 - AUGMENT TIB 7 10MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL75 SUP HCPCS C1713 AR-513-RL75 - AUGMENT TIB 7 5MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL810 SUP HCPCS C1713 AR-513-RL810 - AUGMENT TIB 8 10MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL85 SUP HCPCS C1713 AR-513-RL85 - AUGMENT TIB 8 5MM IBALANCE SCR LT MDL RL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL910 SUP HCPCS C1713 AR-513-RL910 - AUGMENT TIB 9 10MM IBALANCE SCR LT MDL RL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RL95 SUP HCPCS C1713 AR-513-RL95 - AUGMENT TIB 9 5MM IBALANCE SCR RL/LM TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM1010 SUP HCPCS C1713 AR-513-RM1010 - AUGMENT TIB 10 10MM IBALANCE SCR LT MDL RL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM105 SUP HCPCS C1713 AR-513-RM105 - AUGMENT TIB 10 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM110 SUP HCPCS C1713 AR-513-RM110 - AUGMENT TIB 1 10MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM15 SUP HCPCS C1713 AR-513-RM15 - AUGMENT TIB 1 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM210 SUP HCPCS C1713 AR-513-RM210 - AUGMENT TIB 2 10MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM25 SUP HCPCS C1713 AR-513-RM25 - AUGMENT TIB 2 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM310 SUP HCPCS C1713 AR-513-RM310 - AUGMENT TIB 3 10MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM35 SUP HCPCS C1713 AR-513-RM35 - AUGMENT TIB 3 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM410 SUP HCPCS C1713 AR-513-RM410 - AUGMENT TIB 4 10MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM45 SUP HCPCS C1713 AR-513-RM45 - AUGMENT TIB 4 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM510 SUP HCPCS C1713 AR-513-RM510 - AUGMENT TIB 5 10MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM55 SUP HCPCS C1713 AR-513-RM55 - AUGMENT TIB 5 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM610 SUP HCPCS C1713 AR-513-RM610 - AUGMENT TIB 6 10MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM65 SUP HCPCS C1713 AR-513-RM65 - AUGMENT TIB 6 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM710 SUP HCPCS C1713 AR-513-RM710 - AUGMENT TIB 7 10MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM75 SUP HCPCS C1713 AR-513-RM75 - AUGMENT TIB 7 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM810 SUP HCPCS C1713 AR-513-RM810 - AUGMENT TIB 8 10MM IBALANCE SCR LT MDL RL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM85 SUP HCPCS C1713 AR-513-RM85 - AUGMENT TIB 8 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM910 SUP HCPCS C1713 AR-513-RM910 - AUGMENT TIB 9 10MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-RM95 SUP HCPCS C1713 AR-513-RM95 - AUGMENT TIB 9 5MM IBALANCE SCR RMLL TKA BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-T1 SUP HCPCS C1713 AR-513-T1 - COMPONENT TIBTRY 1 STRL IBALANCE ARTHX MDLR T/K ARTHPL BOTH IP/OP "$6,175.00 " "$4,569.50" $0.00 "$4,940.00" "$2,778.75" "$2,778.75" $0.00 $0.00 $0.00 "$1,287.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,286.87" $0.00 "$3,044.28" "$3,044.28" $0.00 "$3,087.50" "$4,890.60" "$4,940.00" $0.00 $0.00 $966.39 $0.00 $0.00 $983.06 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-T2 SUP HCPCS C1713 AR-513-T2 - COMPONENT TIBTRY 2 STRL IBALANCE ARTHX MDLR T/K ARTHPL BOTH IP/OP "$6,175.00 " "$4,569.50" $0.00 "$4,940.00" "$2,778.75" "$2,778.75" $0.00 $0.00 $0.00 "$1,287.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,286.87" $0.00 "$3,044.28" "$3,044.28" $0.00 "$3,087.50" "$4,890.60" "$4,940.00" $0.00 $0.00 $966.39 $0.00 $0.00 $983.06 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-T5 SUP HCPCS C1713 AR-513-T5 - COMPONENT TIBTRY 5 STRL IBALANCE ARTHX MDLR T/K ARTHPL BOTH IP/OP "$6,175.00 " "$4,569.50" $0.00 "$4,940.00" "$2,778.75" "$2,778.75" $0.00 $0.00 $0.00 "$1,287.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,286.87" $0.00 "$3,044.28" "$3,044.28" $0.00 "$3,087.50" "$4,890.60" "$4,940.00" $0.00 $0.00 $966.39 $0.00 $0.00 $983.06 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-T7 SUP HCPCS C1713 AR-513-T7 - COMPONENT TIBTRY 7 STRL IBALANCE ARTHX MDLR T/K ARTHPL BOTH IP/OP "$6,175.00 " "$4,569.50" $0.00 "$4,940.00" "$2,778.75" "$2,778.75" $0.00 $0.00 $0.00 "$1,287.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,286.87" $0.00 "$3,044.28" "$3,044.28" $0.00 "$3,087.50" "$4,890.60" "$4,940.00" $0.00 $0.00 $966.39 $0.00 $0.00 $983.06 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-T8 SUP HCPCS C1713 AR-513-T8 - COMPONENT TIBTRY 8 STRL IBALANCE ARTHX MDLR T/K ARTHPL BOTH IP/OP "$6,175.00 " "$4,569.50" $0.00 "$4,940.00" "$2,778.75" "$2,778.75" $0.00 $0.00 $0.00 "$1,287.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,286.87" $0.00 "$3,044.28" "$3,044.28" $0.00 "$3,087.50" "$4,890.60" "$4,940.00" $0.00 $0.00 $966.39 $0.00 $0.00 $983.06 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-T9 SUP HCPCS C1713 AR-513-T9 - COMPONENT TIBTRY 9 STRL IBALANCE ARTHX MDLR T/K ARTHPL BOTH IP/OP "$6,175.00 " "$4,569.50" $0.00 "$4,940.00" "$2,778.75" "$2,778.75" $0.00 $0.00 $0.00 "$1,287.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,286.87" $0.00 "$3,044.28" "$3,044.28" $0.00 "$3,087.50" "$4,890.60" "$4,940.00" $0.00 $0.00 $966.39 $0.00 $0.00 $983.06 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-TL10 SUP HCPCS C1713 AR-513-TL10 - AUGMENT TIB 10MM LCK SCR BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-513-TL5 SUP HCPCS C1713 AR-513-TL5 - AUGMENT TIB 5MM LCK SCR KN BOTH IP/OP $167.50 $123.95 $0.00 $134.00 $75.38 $75.38 $0.00 $0.00 $0.00 $34.91 $124.32 $124.32 $0.00 $0.00 $34.91 $0.00 $99.08 $99.08 $0.00 $83.75 $132.66 $134.00 $0.00 $0.00 $26.21 $0.00 $0.00 $26.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-516-5R SUP HCPCS C1776 AR-516-5R - COMPONENT FEM 5 IBALANCE CMNT POST STAB KN RT T/K ARTHPL BOTH IP/OP "$7,750.00 " "$5,735.00" $0.00 "$6,200.00" "$3,487.50" "$3,487.50" $0.00 $0.00 $0.00 "$1,615.29" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,615.10" $0.00 "$3,820.75" "$3,820.75" $0.00 "$3,875.00" "$6,138.00" "$6,200.00" $0.00 $0.00 "$1,212.88" $0.00 $0.00 "$1,233.80" $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1008 SUP HCPCS C1776 "AR-523-B1008 - PS TIBIAL BEARING, SIZE 10, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1009 SUP HCPCS C1776 "AR-523-B1009 - PS TIBIAL BEARING, SIZE 10, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1010 SUP HCPCS C1776 "AR-523-B1010 - PS TIBIAL BEARING, SIZE 10, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1011 SUP HCPCS C1776 "AR-523-B1011 - PS TIBIAL BEARING, SIZE 10, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1012 SUP HCPCS C1776 "AR-523-B1012 - PS TIBIAL BEARING, SIZE 10, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1013 SUP HCPCS C1776 "AR-523-B1013 - PS TIBIAL BEARING, SIZE 10, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1014 SUP HCPCS C1776 "AR-523-B1014 - PS TIBIAL BEARING, SIZE 10, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1016 SUP HCPCS C1776 "AR-523-B1016 - PS TIBIAL BEARING, SIZE 10, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1018 SUP HCPCS C1776 "AR-523-B1018 - PS TIBIAL BEARING, SIZE 10, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B1020 SUP HCPCS C1776 "AR-523-B1020 - PS TIBIAL BEARING, SIZE 10, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B108 SUP HCPCS C1776 "AR-523-B108 - PS TIBIAL BEARING, SIZE 1, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B109 SUP HCPCS C1776 "AR-523-B109 - PS TIBIAL BEARING, SIZE 1, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B110 SUP HCPCS C1776 "AR-523-B110 - PS TIBIAL BEARING, SIZE 1, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B111 SUP HCPCS C1776 "AR-523-B111 - PS TIBIAL BEARING, SIZE 1, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B112 SUP HCPCS C1776 "AR-523-B112 - PS TIBIAL BEARING, SIZE 1, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B113 SUP HCPCS C1776 "AR-523-B113 - PS TIBIAL BEARING, SIZE 1, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B114 SUP HCPCS C1776 "AR-523-B114 - PS TIBIAL BEARING, SIZE 1, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B116 SUP HCPCS C1776 "AR-523-B116 - PS TIBIAL BEARING, SIZE 1, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B118 SUP HCPCS C1776 "AR-523-B118 - PS TIBIAL BEARING, SIZE 1, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B120 SUP HCPCS C1776 "AR-523-B120 - PS TIBIAL BEARING, SIZE 1, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B208 SUP HCPCS C1776 "AR-523-B208 - PS TIBIAL BEARING, SIZE 2, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B209 SUP HCPCS C1776 "AR-523-B209 - PS TIBIAL BEARING, SIZE 2, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B210 SUP HCPCS C1776 "AR-523-B210 - PS TIBIAL BEARING, SIZE 2, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B211 SUP HCPCS C1776 "AR-523-B211 - PS TIBIAL BEARING, SIZE 2, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B212 SUP HCPCS C1776 "AR-523-B212 - PS TIBIAL BEARING, SIZE 2, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B213 SUP HCPCS C1776 "AR-523-B213 - PS TIBIAL BEARING, SIZE 2, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B214 SUP HCPCS C1776 "AR-523-B214 - PS TIBIAL BEARING, SIZE 2, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B216 SUP HCPCS C1776 "AR-523-B216 - PS TIBIAL BEARING, SIZE 2, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B218 SUP HCPCS C1776 "AR-523-B218 - PS TIBIAL BEARING, SIZE 2, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B220 SUP HCPCS C1776 "AR-523-B220 - PS TIBIAL BEARING, SIZE 2, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B308 SUP HCPCS C1776 "AR-523-B308 - PS TIBIAL BEARING, SIZE 3, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B309 SUP HCPCS C1776 "AR-523-B309 - PS TIBIAL BEARING, SIZE 3, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B310 SUP HCPCS C1776 "AR-523-B310 - PS TIBIAL BEARING, SIZE 3, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B311 SUP HCPCS C1776 "AR-523-B311 - PS TIBIAL BEARING, SIZE 3, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B312 SUP HCPCS C1776 "AR-523-B312 - PS TIBIAL BEARING, SIZE 3, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B313 SUP HCPCS C1776 "AR-523-B313 - PS TIBIAL BEARING, SIZE 3, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B314 SUP HCPCS C1776 "AR-523-B314 - PS TIBIAL BEARING, SIZE 3, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B316 SUP HCPCS C1776 "AR-523-B316 - PS TIBIAL BEARING, SIZE 3, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B318 SUP HCPCS C1776 "AR-523-B318 - PS TIBIAL BEARING, SIZE 3, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B320 SUP HCPCS C1776 "AR-523-B320 - PS TIBIAL BEARING, SIZE 3, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B408 SUP HCPCS C1776 "AR-523-B408 - PS TIBIAL BEARING, SIZE 4, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B409 SUP HCPCS C1776 "AR-523-B409 - PS TIBIAL BEARING, SIZE 4, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B410 SUP HCPCS C1776 "AR-523-B410 - PS TIBIAL BEARING, SIZE 4, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B411 SUP HCPCS C1776 "AR-523-B411 - PS TIBIAL BEARING, SIZE 4, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B412 SUP HCPCS C1776 "AR-523-B412 - PS TIBIAL BEARING, SIZE 4, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B413 SUP HCPCS C1776 "AR-523-B413 - PS TIBIAL BEARING, SIZE 4, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B414 SUP HCPCS C1776 "AR-523-B414 - PS TIBIAL BEARING, SIZE 4, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B416 SUP HCPCS C1776 "AR-523-B416 - PS TIBIAL BEARING, SIZE 4, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B418 SUP HCPCS C1776 "AR-523-B418 - PS TIBIAL BEARING, SIZE 4, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B420 SUP HCPCS C1776 "AR-523-B420 - PS TIBIAL BEARING, SIZE 4, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B508 SUP HCPCS C1776 "AR-523-B508 - PS TIBIAL BEARING, SIZE 5, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B509 SUP HCPCS C1776 "AR-523-B509 - PS TIBIAL BEARING, SIZE 5, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B510 SUP HCPCS C1776 "AR-523-B510 - PS TIBIAL BEARING, SIZE 5, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B511 SUP HCPCS C1776 "AR-523-B511 - PS TIBIAL BEARING, SIZE 5, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B512 SUP HCPCS C1776 "AR-523-B512 - PS TIBIAL BEARING, SIZE 5, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B513 SUP HCPCS C1776 "AR-523-B513 - PS TIBIAL BEARING, SIZE 5, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B514 SUP HCPCS C1776 "AR-523-B514 - PS TIBIAL BEARING, SIZE 5, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B516 SUP HCPCS C1776 "AR-523-B516 - PS TIBIAL BEARING, SIZE 5, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B518 SUP HCPCS C1776 "AR-523-B518 - PS TIBIAL BEARING, SIZE 5, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B520 SUP HCPCS C1776 "AR-523-B520 - PS TIBIAL BEARING, SIZE 5, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B608 SUP HCPCS C1776 "AR-523-B608 - PS TIBIAL BEARING, SIZE 6, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B609 SUP HCPCS C1776 "AR-523-B609 - PS TIBIAL BEARING, SIZE 6, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B610 SUP HCPCS C1776 "AR-523-B610 - PS TIBIAL BEARING, SIZE 6, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B611 SUP HCPCS C1776 "AR-523-B611 - PS TIBIAL BEARING, SIZE 6, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B612 SUP HCPCS C1776 "AR-523-B612 - PS TIBIAL BEARING, SIZE 6, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B613 SUP HCPCS C1776 "AR-523-B613 - PS TIBIAL BEARING, SIZE 6, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B614 SUP HCPCS C1776 "AR-523-B614 - PS TIBIAL BEARING, SIZE 6, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B616 SUP HCPCS C1776 "AR-523-B616 - PS TIBIAL BEARING, SIZE 6, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B618 SUP HCPCS C1776 "AR-523-B618 - PS TIBIAL BEARING, SIZE 6, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B620 SUP HCPCS C1776 "AR-523-B620 - PS TIBIAL BEARING, SIZE 6, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B708 SUP HCPCS C1776 "AR-523-B708 - PS TIBIAL BEARING, SIZE 7, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B709 SUP HCPCS C1776 "AR-523-B709 - PS TIBIAL BEARING, SIZE 7, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B710 SUP HCPCS C1776 "AR-523-B710 - PS TIBIAL BEARING, SIZE 7, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B711 SUP HCPCS C1776 "AR-523-B711 - PS TIBIAL BEARING, SIZE 7, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B712 SUP HCPCS C1776 "AR-523-B712 - PS TIBIAL BEARING, SIZE 7, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B713 SUP HCPCS C1776 "AR-523-B713 - PS TIBIAL BEARING, SIZE 7, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B714 SUP HCPCS C1776 "AR-523-B714 - PS TIBIAL BEARING, SIZE 7, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B716 SUP HCPCS C1776 "AR-523-B716 - PS TIBIAL BEARING, SIZE 7, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B718 SUP HCPCS C1776 "AR-523-B718 - PS TIBIAL BEARING, SIZE 7, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B720 SUP HCPCS C1776 "AR-523-B720 - PS TIBIAL BEARING, SIZE 7, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B808 SUP HCPCS C1776 "AR-523-B808 - PS TIBIAL BEARING, SIZE 8, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B809 SUP HCPCS C1776 "AR-523-B809 - PS TIBIAL BEARING, SIZE 8, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B810 SUP HCPCS C1776 "AR-523-B810 - PS TIBIAL BEARING, SIZE 8, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B811 SUP HCPCS C1776 "AR-523-B811 - PS TIBIAL BEARING, SIZE 8, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B812 SUP HCPCS C1776 "AR-523-B812 - PS TIBIAL BEARING, SIZE 8, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B813 SUP HCPCS C1776 "AR-523-B813 - PS TIBIAL BEARING, SIZE 8, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B814 SUP HCPCS C1776 "AR-523-B814 - PS TIBIAL BEARING, SIZE 8, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B816 SUP HCPCS C1776 "AR-523-B816 - PS TIBIAL BEARING, SIZE 8, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B818 SUP HCPCS C1776 "AR-523-B818 - PS TIBIAL BEARING, SIZE 8, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B820 SUP HCPCS C1776 "AR-523-B820 - PS TIBIAL BEARING, SIZE 8, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B908 SUP HCPCS C1776 "AR-523-B908 - PS TIBIAL BEARING, SIZE 9, 8MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B909 SUP HCPCS C1776 "AR-523-B909 - PS TIBIAL BEARING, SIZE 9, 9MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B910 SUP HCPCS C1776 "AR-523-B910 - PS TIBIAL BEARING, SIZE 9, 10MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B911 SUP HCPCS C1776 "AR-523-B911 - PS TIBIAL BEARING, SIZE 9, 11MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B912 SUP HCPCS C1776 "AR-523-B912 - PS TIBIAL BEARING, SIZE 9, 12MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B913 SUP HCPCS C1776 "AR-523-B913 - PS TIBIAL BEARING, SIZE 9, 13MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B914 SUP HCPCS C1776 "AR-523-B914 - PS TIBIAL BEARING, SIZE 9, 14MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B916 SUP HCPCS C1776 "AR-523-B916 - PS TIBIAL BEARING, SIZE 9, 16MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B918 SUP HCPCS C1776 "AR-523-B918 - PS TIBIAL BEARING, SIZE 9, 18MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-523-B920 SUP HCPCS C1776 "AR-523-B920 - PS TIBIAL BEARING, SIZE 9, 20MM, VIT E" BOTH IP/OP "$5,085.00 " "$3,762.90" $0.00 "$4,068.00" "$2,288.25" "$2,288.25" $0.00 $0.00 $0.00 "$1,059.84" "$3,774.09" "$3,774.09" $0.00 $0.00 "$1,059.71" $0.00 "$2,506.91" "$2,506.91" $0.00 "$2,542.50" "$4,027.32" "$4,068.00" $0.00 $0.00 $795.80 $0.00 $0.00 $809.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-524-PS328 SUP HCPCS C1713 AR-524-PS328 - DOME PTLR 32MM 8MM STRL LF ARTHX VIT E KN BOTH IP/OP "$2,967.50 " "$2,195.95" $0.00 "$2,374.00" "$1,335.38" "$1,335.38" $0.00 $0.00 $0.00 $618.50 "$2,202.48" "$2,202.48" $0.00 $0.00 $618.43 $0.00 "$1,462.98" "$1,462.98" $0.00 "$1,483.75" "$2,350.26" "$2,374.00" $0.00 $0.00 $464.41 $0.00 $0.00 $472.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-524-PSA8 SUP HCPCS C1713 AR-524-PSA8 - DOME PTLR 27MM 8MM STRL LF ARTHX VIT E KN BOTH IP/OP "$2,967.50 " "$2,195.95" $0.00 "$2,374.00" "$1,335.38" "$1,335.38" $0.00 $0.00 $0.00 $618.50 "$2,202.48" "$2,202.48" $0.00 $0.00 $618.43 $0.00 "$1,462.98" "$1,462.98" $0.00 "$1,483.75" "$2,350.26" "$2,374.00" $0.00 $0.00 $464.41 $0.00 $0.00 $472.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-524-PSB8 SUP HCPCS C1713 AR-524-PSB8 - DOME PTLR 30MM 8MM STRL LF ARTHX VIT E KN BOTH IP/OP "$2,967.50 " "$2,195.95" $0.00 "$2,374.00" "$1,335.38" "$1,335.38" $0.00 $0.00 $0.00 $618.50 "$2,202.48" "$2,202.48" $0.00 $0.00 $618.43 $0.00 "$1,462.98" "$1,462.98" $0.00 "$1,483.75" "$2,350.26" "$2,374.00" $0.00 $0.00 $464.41 $0.00 $0.00 $472.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-524-PSC9 SUP HCPCS C1713 AR-524-PSC9 - DOME PTLR 34MM 9MM STRL LF ARTHX VIT E BOTH IP/OP "$2,967.50 " "$2,195.95" $0.00 "$2,374.00" "$1,335.38" "$1,335.38" $0.00 $0.00 $0.00 $618.50 "$2,202.48" "$2,202.48" $0.00 $0.00 $618.43 $0.00 "$1,462.98" "$1,462.98" $0.00 "$1,483.75" "$2,350.26" "$2,374.00" $0.00 $0.00 $464.41 $0.00 $0.00 $472.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-524-PSD0 SUP HCPCS C1713 AR-524-PSD0 - DOME PTLR 37MM 10MM STRL LF ARTHX VIT E BOTH IP/OP "$2,967.50 " "$2,195.95" $0.00 "$2,374.00" "$1,335.38" "$1,335.38" $0.00 $0.00 $0.00 $618.50 "$2,202.48" "$2,202.48" $0.00 $0.00 $618.43 $0.00 "$1,462.98" "$1,462.98" $0.00 "$1,483.75" "$2,350.26" "$2,374.00" $0.00 $0.00 $464.41 $0.00 $0.00 $472.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-524-PSE0 SUP HCPCS C1713 AR-524-PSE0 - DOME PTLR 40MM 10MM STRL LF ARTHX VIT E KN BOTH IP/OP "$2,967.50 " "$2,195.95" $0.00 "$2,374.00" "$1,335.38" "$1,335.38" $0.00 $0.00 $0.00 $618.50 "$2,202.48" "$2,202.48" $0.00 $0.00 $618.43 $0.00 "$1,462.98" "$1,462.98" $0.00 "$1,483.75" "$2,350.26" "$2,374.00" $0.00 $0.00 $464.41 $0.00 $0.00 $472.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5503 SUP Custom 27203010 AR-5503 - GUIDE DRL PIN PRLL BOTH IP/OP "$1,390.30 " "$1,028.82" $0.00 "$1,112.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,031.88" "$1,031.88" $0.00 $0.00 $289.74 $0.00 $0.00 $0.00 $0.00 $695.15 "$1,101.12" "$1,112.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5511-CP SUP HCPCS C1713 AR-5511-CP - KIT ARTHRO FIX INTERNALBRACE FIBERTAPE SWIVELOCK BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5600-01 SUP Custom 27203010 AR-5600-01 - GUIDE DRL OFST CRDL FISH MTH 4MM CHONDROGUARD NOVEL TIP XTN BOTH IP/OP "$1,497.50 " "$1,108.15" $0.00 "$1,198.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,111.44" "$1,111.44" $0.00 $0.00 $312.08 $0.00 $0.00 $0.00 $0.00 $748.75 "$1,186.02" "$1,198.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-5600-02 SUP Custom 27203010 AR-5600-02 - GUIDE DRL OFST CRDL FISH MTH 6MM CHONDROGUARD NOVEL TIP XTN BOTH IP/OP "$1,497.50 " "$1,108.15" $0.00 "$1,198.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,111.44" "$1,111.44" $0.00 $0.00 $312.08 $0.00 $0.00 $0.00 $0.00 $748.75 "$1,186.02" "$1,198.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-601-BBS0 SUP Custom 27203010 AR-601-BBS0 - BIT DRL 2.7MM TRMIT CNN SLF CMPR THRD PTCH BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $0.00 $0.00 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-601-SB06 SUP Custom 27203010 AR-601-SB06 - INSERT TIB 6MM IBALANCE SPCR BLCK KN UNCNDL BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $0.00 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-601-SB07 SUP Custom 27203010 AR-601-SB07 - INSERT TIB 7MM IBALANCE SPCR BLCK KN UNCNDL BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $0.00 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-601-SB08 SUP Custom 27203010 AR-601-SB08 - INSERT TIB 8MM IBALANCE SPCR BLCK KN UNCNDL BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $0.00 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-601-SB09 SUP Custom 27203010 AR-601-SB09 - INSERT TIB 9MM IBALANCE SPCR BLCK KN UNCNDL BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $0.00 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-601-SB10 SUP Custom 27203010 AR-601-SB10 - INSERT TIB 10MM IBALANCE SPCR BLCK KN UNCNDL BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $0.00 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-602-44 SUP Custom 27203010 AR-602-44 - GUIDE DRL 27MM IBALANCE PTLR BOTH IP/OP $617.50 $456.95 $0.00 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $458.31 $458.31 $0.00 $0.00 $128.69 $0.00 $0.00 $0.00 $0.00 $308.75 $489.06 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-602-45 SUP Custom 27203010 AR-602-45 - GUIDE DRL 30MM IBALANCE PTLR BOTH IP/OP $617.50 $456.95 $0.00 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $458.31 $458.31 $0.00 $0.00 $128.69 $0.00 $0.00 $0.00 $0.00 $308.75 $489.06 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-602-46 SUP Custom 27203010 AR-602-46 - GUIDE DRL 34MM IBALANCE PTLR BOTH IP/OP $617.50 $456.95 $0.00 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $458.31 $458.31 $0.00 $0.00 $128.69 $0.00 $0.00 $0.00 $0.00 $308.75 $489.06 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-602-47 SUP Custom 27203010 AR-602-47 - GUIDE DRL 37MM IBALANCE PTLR BOTH IP/OP $617.50 $456.95 $0.00 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $458.31 $458.31 $0.00 $0.00 $128.69 $0.00 $0.00 $0.00 $0.00 $308.75 $489.06 $494.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-602-49 SUP Custom 27203010 AR-602-49 - GUIDE DRL IBALANCE CMBN PTLR BOTH IP/OP $915.00 $677.10 $0.00 $732.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $679.11 $679.11 $0.00 $0.00 $190.69 $0.00 $0.00 $0.00 $0.00 $457.50 $724.68 $732.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-603-85 SUP Custom 27203010 AR-603-85 - CLAMP SRG IBALANCE CMNT TMPLT PTLR BOTH IP/OP "$3,712.50 " "$2,747.25" $0.00 "$2,970.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,755.42" "$2,755.42" $0.00 $0.00 $773.69 $0.00 $0.00 $0.00 $0.00 "$1,856.25" "$2,940.30" "$2,970.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-25TL SUP Custom 27203010 AR-6068-25TL - PASSER SUTURE 25D SMALL TIGHT LEFT CURVE 8.25MM CANNU BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-25TR SUP Custom 27203010 AR-6068-25TR - PASSER SUT 25D SM TIGHT RT CRV 8.25MM STRL QUICKPASS SUTLSO BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-30 SUP Custom 27203010 AR-6068-30 - PASSER SUT 30D SM STRG 7MM STRL QUICKPASS SUTLSO CNN ERG BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-45L SUP Custom 27203010 AR-6068-45L - PASSER SUT 45D SM LT CRV 7MM STRL QUICKPASS SUTLSO CNN ERG BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-45R SUP Custom 27203010 AR-6068-45R - PASSER SUT 45D CRV QUICKPASS SUTLSO RT BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-90 SUP Custom 27203010 AR-6068-90 - PASSER SUTURE 90D SMALL STR 7MM CANNU ERGONOMIC HANDLE BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-90L SUP Custom 27203010 AR-6068-90L - PASSER SUT 90D SM LT CRV 8.25MM STRL QUICKPASS SUTLSO CNN BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-90R SUP Custom 27203010 AR-6068-90R - PASSER SUT 90D SM RT CRV 8.25MM STRL QUICKPASS SUTLSO CNN BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6068-90T SUP Custom 27203010 AR-6068-90T - PASSER SUT 90D SM TC 7MM STRL QUICKPASS SUTLSO CNN ERG HNDL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6069-45L SUP Custom 27203010 AR-6069-45L - PASSER SUT 45D 1 LT CRV 1.5MM 10YD BLU SUTLSO ERG HNDL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6069-45R SUP Custom 27203010 AR-6069-45R - PASSER SUT 45D 1 RT CRV 1.5MM 10YD BLU SUTLSO ERG HNDL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6069-90 SUP Custom 27203010 AR-6069-90 - PASSER SUT 90D STRG CRV SUTLSO REELPASS BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6506 SUP Custom 27203010 AR-6506 - CANNULA ASCP OPN BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6507 SUP Custom 27203010 AR-6507 - CANNULA ASCP BLNT OPN BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6507-01 SUP Custom 27203010 AR-6507-01 - CANNULA ASCP TPR OPN SHRP PLYCRB BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6507-02 SUP Custom 27203010 AR-6507-02 - CANNULA ASCP BLNT OPN SHRP PLYCRB BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6507-03 SUP Custom 27203010 AR-6507-03 - CANNULA ASCP TPR DTCH HNDL OPN MTL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6507-04 SUP Custom 27203010 AR-6507-04 - CANNULA ASCP BLNT DTCH HNDL OPN MTL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6520-15 SUP Custom 27203010 AR-6520-15 - STICK SWH LNG ACR CNN DTCH HNDL HIP BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $0.00 $0.00 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6520-16 SUP Custom 27203010 AR-6520-16 - STICK SWH LNG 3.5MM 15IN CNN BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $0.00 $0.00 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6521 SUP Custom 27203010 AR-6521 - NEEDLE ESCP STRL PIN REPL DISP PRTL DILATION SET ASCP BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6523 SUP Custom 27203010 AR-6523 - NEEDLE ESCP BLNT STRL DISP PRTL DILATION SET ASCP BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6526S SUP Custom 27203010 AR-6526S - KIT ENDSCP INSTR MSTR 1.5MM 14GA GWIRE KNF BLADE BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6527S SUP Custom 27203010 AR-6527S - KIT ESCP INST CRV BNA 14GA 1.5MM 35ML BLDE KNF PIN SYR NTNL BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6528-07 SUP Custom 27203010 AR-6528-07 - PROBE ASCP 220MM NAV-X RND ABLT MNPLR STRBL COAG HIP BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6529-07 SUP Custom 27203010 AR-6529-07 - POST OP TBL PERI HDS BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6530 SUP Custom 27203010 AR-6530 - CANNU ARTHRO 7CM THRD TWST IN STRL DISP 8.25MM BOTH IP/OP $62.50 $46.25 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6530N SUP Custom 27203010 AR-6530N - CANNU ARTHRO 7CM NTCH TWST IN STRL DISP 8.25MM BOTH IP/OP $62.50 $46.25 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6532 SUP Custom 27203010 AR-6532 - CANNULA ASCP 5.5MM 9CM STRL OBT THRD SHLDR DISP BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6535 SUP Custom 27203010 AR-6535 - CANNULA ARTHRO 6MM 7CM OBTURATOR THREAD TWIST-IN TRANSLUCENT BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6535TD SUP Custom 27203010 AR-6535TD - CANNULA ASCP 6MM 7CM TWST-IN 3 DAM SDPRT LL CNCT VLV SWH BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6545 SUP Custom 27203010 AR-6545 - CANNULA ASCP 6MM 9CM TRNLU STRL TWST-IN OBT THRD SHLDR DISP BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6548 SUP Custom 27203010 AR-6548 - CANNULA ARTHRO LP OBTURATOR THREAD PUSHLOCK SHOULDER STERILE BOTH IP/OP $62.50 $46.25 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6550TD SUP Custom 27203010 AR-6550TD - CANNULA ASCP 7MM 7CM TWST-IN 3 DAM SDPRT LL CNCT VLV SWH BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6551L SUP Custom 27203010 AR-6551L - CANNULA ASCP SM 6MM 7.75CM BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6560 SUP Custom 27203010 AR-6560 - CANNULA ASCP BRL 5.75MM 7CM TRNLU STRL CRYS DIST RING RTNT BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6560F SUP Custom 27203010 AR-6560F - CANNULA ASCP BRL 5.75MM 7CM TRNLU STRL CRYS DIST RING FLXB BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6562 SUP Custom 27203010 AR-6562 - CANNULA ASCP BRL 5.75MM 7CM TRNLU STRL CRYS RTNT BWL SMTH BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6564 SUP Custom 27203010 AR-6564 - CANNULA ASCP P/T BRL 5.75MM 7CM TRNLU STRL CRYS RTNT BWL BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6565 SUP Custom 27203010 AR-6565 - CANNULA ASCP 6MM 9CM STRL SHOHN LNGTDNL SLOT OBT SHLDR DISP BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6566 SUP Custom 27203010 AR-6566 - CANNULA ASCP P/T 8.25MM 7CM TRNLU STRL FLXB OBT THRD ROTR BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6568 SUP Custom 27203010 AR-6568 - CANNULA ASCP SHRT P/T 5.75MM 5CM TRNLU CRYS BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6570 SUP Custom 27203010 AR-6570 - CANNULA ARTHRO 7MM 7CM OBTURATOR TWIST-IN TRANSLUCENT BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6570F SUP Custom 27203010 AR-6570F - CANNULA ASCP 7MM 7CM TRNLU STRL TWST-IN FLXB OBT SHLDR DISP BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $0.00 $0.00 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6570TD SUP Custom 27203010 AR-6570TD - CANNULA ASCP 7MM 7CM TWST-IN 3 DAM SDPRT LL CNCT VLV SWH BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6570TDNV SUP Custom 27203010 AR-6570TDNV - CANNULA ASCP 6MM 7CM TWST-IN 3 DAM SDPRT LL CNCT NO VLV BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6572 SUP Custom 27203010 AR-6572 - CANNULA ARTHRO LP 8.25MM 9CM SELF RETAINING SYSTEM GEMINI SR BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6575-09 SUP Custom 27203010 AR-6575-09 - CANNULA ASCP P/T 8.25MM 9CM TRNLU STRL OBT DISP BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6575-11 SUP Custom 27203010 AR-6575-11 - CANNULA ASCP P/T 8.25MM 11CM TRNLU STRL OBT DISP BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6576S-C SUP Custom 27203010 AR-6576S-C - SYSTEM ESCP XL ASCP C MNT HIP BOTH IP/OP "$69,755.00 " "$51,618.70" $0.00 "$54,824.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$14,536.94" $0.00 $0.00 $0.00 $0.00 "$34,265.00" "$54,275.76" "$54,824.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6576S-E SUP Custom 27203010 AR-6576S-E - SYSTEM ESCP XL ASCP EYE PC HIP BOTH IP/OP "$62,280.00 " "$46,087.20" $0.00 "$48,844.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$12,979.15" $0.00 $0.00 $0.00 $0.00 "$30,527.50" "$48,355.56" "$48,844.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6577-09 SUP Custom 27203010 AR-6577-09 - CANNULA ARTHRO PTHRD 7MM 9CM HIP STERILE BOTH IP/OP $62.50 $46.25 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6577-11 SUP Custom 27203010 AR-6577-11 - CANNULA ASCP P/T 7MM 11CM STRL HIP BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6580 SUP Custom 27203010 AR-6580 - CANNULA ASCP 3.75MM 3 DAM BOTH IP/OP $343.75 $254.38 $0.00 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.13 $255.13 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $171.88 $272.25 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6590 SUP Custom 27203010 AR-6590 - CANNULA ASCP TRMIT CSTM HIP BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6590DT SUP Custom 27203010 AR-6590DT - CANNULA ASCP TRMIT DTCH OBT BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.43 $482.43 $0.00 $0.00 $135.46 $0.00 $0.00 $0.00 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6590ST SUP Custom 27203010 AR-6590ST - STICK SWH 4MM TRMIT CNN CNN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592 SUP Custom 27203010 AR-6592 - CANNULA BTN CRV LOPRFL STRL LF PSPRT 1 PC MLD 2 DAM DSGN 2 BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-06-20 SUP Custom 27203010 AR-6592-06-20 - CANNULA BTN CRV LOPRFL 6MM 2CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-06-30 SUP Custom 27203010 AR-6592-06-30 - CANNULA BTN CRV LOPRFL 6MM 3CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-06-40 SUP Custom 27203010 AR-6592-06-40 - CANNULA BTN CRV LOPRFL 6MM 4CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-06-50 SUP Custom 27203010 AR-6592-06-50 - CANNULA BTN CRV LOPRFL 6MM 5CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-08-20 SUP Custom 27203010 AR-6592-08-20 - CANNULA BTN CRV LOPRFL 8MM 2CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-08-40 SUP Custom 27203010 AR-6592-08-40 - CANNULA BTN CRV LOPRFL 8MM 4CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-08-50 SUP Custom 27203010 AR-6592-08-50 - CANNULA BTN CRV LOPRFL 8MM 5CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-08-60 SUP Custom 27203010 AR-6592-08-60 - CANNULA BTN CRV LOPRFL 8MM 6CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-08-90 SUP Custom 27203010 AR-6592-08-90 - CANNULA BTN CRV LOPRFL 9MM 9CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-10-20 SUP Custom 27203010 AR-6592-10-20 - CANNULA BTN CRV LOPRFL 10MM 2CM STRL LF PSPRT 1 PC MLD 2 DAM BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-10-30 SUP Custom 27203010 AR-6592-10-30 - CANNU 3CM 10MM CANNU BTN PSPRT DISP STRL BOTH IP/OP $80.00 $59.20 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $57.50 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-10-40 SUP Custom 27203010 AR-6592-10-40 - CANNULA BUTTON CURVE LP 10MM 4CM 1 PIECE MOLD 2 DAM DESIGN 2 BOTH IP/OP $80.00 $59.20 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $57.50 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6592-10-50 SUP Custom 27203010 AR-6592-10-50 - CANNULA BUTTON CURVE LP 10MM 5CM 1 PIECE MOLD 2 DAM DESIGN 2 BOTH IP/OP $80.00 $59.20 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $57.50 $91.08 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-6955 SUP HCPCS C1713 AR-6955 - SET IMPL 2.7MM TRMIT TNL INSTRUMENTATION SET BOTH IP/OP "$4,917.50 " "$3,638.95" $0.00 "$3,934.00" "$2,212.88" "$2,212.88" $0.00 $0.00 $0.00 "$1,024.93" "$3,649.77" "$3,649.77" $0.00 $0.00 "$1,024.81" $0.00 "$2,424.33" "$2,424.33" $0.00 "$2,458.75" "$3,894.66" "$3,934.00" $0.00 $0.00 $769.59 $0.00 $0.00 $782.87 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-03 SUP Custom 27203010 AR-7000-03 - GUIDE DRL 4MM PRLL BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-04 SUP Custom 27203010 AR-7000-04 - GUIDE DRL 6MM PRLL BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-05 SUP Custom 27203010 AR-7000-05 - GUIDE DRL 8MM PRLL BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-07 SUP Custom 27203010 AR-7000-07 - GUIDE DRL CORACOID BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-14 SUP Custom 27203010 AR-7000-14 - DRILL SURG MINI .066IN 2.75MM CANN OPEN REPAIR BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-15 SUP Custom 27803010 AR-7000-15 - WASHER ORTHOPEDIC CANN SELF COMPRESS THREAD PITCH TITANIUM BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-16 SUP Custom 27203010 AR-7000-16 - GUIDE DRL PRLL BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $0.00 $0.00 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-17 SUP Custom 27203010 AR-7000-17 - GUIDE DRL SHLW CORACOID BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-18T SUP Custom 27803010 AR-7000-18T - WASHER ESCP 2 CRV FBRWR NDL SUT TI ASCP BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-26 SUP HCPCS C1713 AR-7000-26 - SCREW BN P/T 3.75MM 26MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-26FT SUP HCPCS C1713 AR-7000-26FT - SCREW BN FT 3.75MM 26MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-28 SUP HCPCS C1713 AR-7000-28 - SCREW BN P/T 3.75MM 28MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-28FT SUP HCPCS C1713 AR-7000-28FT - SCREW BN FT 3.75MM 28MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-30 SUP HCPCS C1713 AR-7000-30 - SCREW BN P/T 3.75MM 30MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-30FT SUP HCPCS C1713 AR-7000-30FT - SCREW BN FT 3.75MM 30MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-32 SUP HCPCS C1713 AR-7000-32 - SCREW BONE PTHRD 3.75MM 32MM SELF DRILL SELF TAP CANN BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-32FT SUP HCPCS C1713 AR-7000-32FT - SCREW BN FT 3.75MM 32MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-34 SUP HCPCS C1713 AR-7000-34 - SCREW BN P/T 3.75MM 34MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-34FT SUP HCPCS C1713 AR-7000-34FT - SCREW BONE 3.75MM 34MM TI FULTHD SHLDR GLND SLF BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-36 SUP HCPCS C1713 AR-7000-36 - SCREW BONE PTHRD 3.75MM 36MM SELF DRILL SELF TAP CANN BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-36FT SUP HCPCS C1713 AR-7000-36FT - SCREW BN FT 3.75MM 36MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-38 SUP HCPCS C1713 AR-7000-38 - SCREW BN P/T 3.75MM 38MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-38FT SUP HCPCS C1713 AR-7000-38FT - SCREW BN FT 3.75MM 38MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-40 SUP HCPCS C1713 AR-7000-40 - SCREW BONE PTHRD 3.75MM 40MM SELF DRILL SELF TAP CANN BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-40FT SUP HCPCS C1713 AR-7000-40FT - SCREW BN FT 3.75MM 40MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-42 SUP HCPCS C1713 AR-7000-42 - SCREW BONE PTHRD 3.75MM 42MM SELF DRILL SELF TAP CANN BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7000-42FT SUP HCPCS C1713 AR-7000-42FT - SCREW BN FT 3.75MM 42MM SLF DRL ST CNN TI SHLDR GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7199 SUP Custom 27203010 AR-7199 - DEVICE PSTN BLU WHT FINGERSHIELD LT OPN TIP MRKR PCTV RADOPQ BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7200 SUP Custom 27803010 AR-7200 - SUTURE NABSB 2 T-5 38IN BLU FBRWR MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7200B SUP Custom 27803010 AR-7200B - SUTURE NABSB 2 TPR 38IN FBRWR BRD TIE MS LWR KNT PRFL NDL BOTH IP/OP $97.50 $72.15 $0.00 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.36 $72.36 $0.00 $0.00 $20.32 $0.00 $0.00 $0.00 $0.00 $48.75 $77.22 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7201 SUP Custom 27803010 AR-7201 - SUTURE NABSB 2 .5 CRC STRG DMD PT RVRS CUT 38IN BLK BLU WHT BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7202 SUP Custom 27803010 AR-7202 - SUTURE NABSB 2 C-13 38IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7203 SUP Custom 27203010 AR-7203 - SUTURE NABSB 2 38IN B/W TIGERWIRE BRD BOTH IP/OP $57.50 $42.55 $0.00 $46.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.68 $42.68 $0.00 $0.00 $11.98 $0.00 $0.00 $0.00 $0.00 $28.75 $45.54 $46.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7204 SUP Custom 27803010 AR-7204 - SUTURE NABSB 2 STRG 26IN GRN 10MM FBRWR BRD MS CLS LOOP LWR BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7205 SUP Custom 27803010 AR-7205 - SUTURE NABSB 2 T-5 38IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7205T SUP Custom 27203010 AR-7205T - SUTURE NABSB 2 T-5 38IN B/W FVR TGRWR 2 ARM BRD TIE MS LWR BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7206 SUP Custom 27803010 AR-7206 - SUTURE NABSB 2 T-8 38IN BLU FBRWR 2 ARM BRD MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7207 SUP Custom 27803010 AR-7207 - SUTURE NABSB 2 38IN BLU 10MM FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7208 SUP Custom 27803010 AR-7208 - SUTURE NABSB 2 T-5 38IN BLK BLU WHT FBRWR BRD TIE MS LWR KNT BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $0.00 $0.00 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7209 SUP Custom 27803010 AR-7209 - SUTURE NABSB 2 50IN 12IN FBSTK FBRWR 1 END STIFFEN BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7209T SUP HCPCS C1713 AR-7209T - SUTURE NONABSORBABLE 2 50IN 12IN 1 END STIFFEN MONOFILAMENT BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7210 SUP Custom 27803010 AR-7210 - SUTURE NABSB 5 38IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7211 SUP Custom 27203010 AR-7211 - SUTURE NABSB 5 CCS-1 38IN BLU FBRWR MS LWR KNT PRFL BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7212 SUP Custom 27803010 AR-7212 - SUTURE NABSB 5 .5 CRC 38IN BLK BLU WHT 48MM FBRWR CNV CUT BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7213 SUP Custom 27803010 AR-7213 - SUTURE NONABSORBABLE 5 T-5 CCS-1 38IN 48MM BRAID TIES BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $0.00 $0.00 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7216 SUP Custom 27803010 AR-7216 - SUTURE NABSB 1 38IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7217 SUP Custom 27803010 AR-7217 - SUTURE NABSB 2 .5 CRC RVRS CUT 38IN BLK BLU WHT 36.6MM FBRWR BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $0.00 $0.00 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7220 SUP Custom 27203010 AR-7220 - SUTURE NABSB 2-0 T-13 18IN BLU FBRWR MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $40.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $24.38 $38.61 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7221 SUP Custom 27803010 "AR-7221 - FIBERWIRE, BRAIDED PB 2-0 SUTURE, BLUE" BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7222 SUP Custom 27803010 AR-7222 - SUTURE NABSB 2-0 50IN BLU 12IN FBRWR FBSTK 1 END STIFFEN BRD BOTH IP/OP $105.00 $77.70 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.93 $77.93 $0.00 $0.00 $21.88 $0.00 $0.00 $0.00 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7223SM SUP Custom 27803010 AR-7223SM - SUTURE NABSB 2-0 SM STRL FBRWR BRD SWEDGE LO KNT PRFL MNSCS BOTH IP/OP $180.00 $133.20 $0.00 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $103.13 $163.35 $165.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7227-01 SUP Custom 27803010 AR-7227-01 - SUTURE NABSB 3-0 T-43 18IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7227-02 SUP Custom 27803010 AR-7227-02 - SUTURE NABSB 3-0 C-22 18IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7228 SUP Custom 27803010 AR-7228 - SUTURE NABSB 4-0 DE-10 18IN BLU FBRWR BRD TIE MS LWR KNT BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7229-12 SUP Custom 27203010 AR-7229-12 - SUTURE NABSB 4-0 T-13 12IN BLU FIBERLOOP MS BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7229-20 SUP Custom 27203010 AR-7229-20 - SUTURE NABSB 4-0 3/8 CRC 10IN BLU 17.9MM FIBERLOOP TPR NDL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7230-01 SUP Custom 27803010 AR-7230-01 - SUTURE NABSB 4-0 T-12 18IN BLU FBRWR MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7230-02 SUP Custom 27803010 AR-7230-02 - SUTURE NABSB 4-0 C-17 18IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7232-01 SUP Custom 27203010 AR-7232-01 - SUTURE NABSB 2-0 D-17 60IN BLU FIBERLOOP 2 ARM MS BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7232-02 SUP Custom 27203010 AR-7232-02 - SUTURE NABSB 2-0 D-14 24IN BLU FIBERLOOP 2 ARM MS BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7232-03 SUP Custom 27203010 AR-7232-03 - SUTURE NABSB 2-0 SD-2 13IN BLU FIBERLOOP 2 ARM MS BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7232-05 SUP Custom 27203010 AR-7232-05 - SUTURE NABSB 2-0 3/8 CRC TPR PNT 14IN 17.9MM FIBERLOOP LOOP BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7233 SUP Custom 27803010 AR-7233 - SUTURE NABSB 2 38IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7234 SUP Custom 27203010 AR-7234 - SUTURE NONABSORBABLE 2 7MM STR 20IN 76MM BRAID MULTISTRAND BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7234-01 SUP Custom 27203010 AR-7234-01 - SUTURE NABSB 2 7MM STRG 20IN WHT 76MM FIBERLOOP BRD MS NDL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7234B SUP Custom 27203010 AR-7234B - SUTURE NABSB 2 STRG 20IN BLU 76MM FIBERLOOP BRD MS NDL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7234C SUP Custom 27203010 AR-7234C - SUTURE NONABSORBABLE 2 .5 CIR CURVE 20IN BRAID MULTISTRAND BOTH IP/OP $125.00 $92.50 $0.00 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $80.63 $127.71 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7234T SUP Custom 27203010 AR-7234T - SUTURE NONABSORBABLE 2 STR 20IN 3IN BRAID MULTISTRAND NEEDLE BOTH IP/OP $125.00 $92.50 $0.00 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $80.63 $127.71 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7235 SUP Custom 27203010 AR-7235 - SUTURE NONABSORBABLE 2 26IN 1.5IN BRAID TIES MULTISTRAND BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7235T SUP Custom 27203010 AR-7235T - SUTURE NABSB 2 26IN B/W TIGERLINK FBRWR CLS LOOP BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $102.05 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7237 SUP Custom 27803010 AR-7237 - SUTURE NABSB 2 TPR 54IN BLU 36INX2MM FIBERTAPE FBRWR BRD BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $0.00 $0.00 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7237-17LN SUP Custom 27803010 AR-7237-17LN - SUTURE NABSB 2MM STRG 17IN BLU FIBERTAPE BRD BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7237-17N SUP Custom 27803010 AR-7237-17N - SUTURE NABSB 2 .5 CRC TPR 17IN BLU 26.5MM FIBERTAPE FBRWR BOTH IP/OP $190.00 $140.60 $0.00 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.02 $141.02 $0.00 $0.00 $39.60 $0.00 $0.00 $0.00 $0.00 $95.00 $150.48 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7237-7 SUP Custom 27803010 AR-7237-7 - SUTURE NONABSORBABLE 2 TAPER 7INX2MM BRAID FIBERTAPE BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7237-7T SUP Custom 27203010 AR-7237-7T - SUTURE NABSB 2 TPR 7INX2MM B/W TIGERTAPE TIGERWIRE BRD BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7240 SUP Custom 27803010 AR-7240 - SUTURE NONABSORBABLE 2 38IN BRAID 2 STRAND LOWER KNOT BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7242 SUP Custom 27203010 AR-7242 - SUTURE NABSB 2-0 T-5 18IN BLU TIGERTAPE FBRWR BRD TIE MS BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7246 SUP Custom 27803010 AR-7246 - SUTURE NABSB 2 STRG DMD 38IN BLU 26.5MM FBRWR 1 END NDL BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7246-02 SUP Custom 27803010 AR-7246-02 - SUTURE NABSB 2 STRG DMD 38IN BLU 64MM FBRWR 1 END 2 NDL BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.64 $81.64 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7248 SUP Custom 27803010 AR-7248 - SUTURE NABSB 4-0 T-22 18IN WHT FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7249-12 SUP Custom 27203010 AR-7249-12 - SUTURE NABSB 4-0 T-22 6IN WHT FIBERLOOP MS BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7249-20 SUP Custom 27203010 AR-7249-20 - SUTURE NABSB 4-0 T-22 10IN WHT FIBERLOOP MS BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7250 SUP Custom 27803010 AR-7250 - SUTURE NABSB 0 T-4 38IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7251 SUP Custom 27803010 AR-7251 - SUTURE NABSB 0 D-10 38IN BLU FBRWR BRD TIE MS LWR KNT PRFL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7253 SUP Custom 27203010 AR-7253 - SUTURE NABSB 0 7MM STRG 13IN BLU 76MM FIBERLOOP BRD MS BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7253T SUP Custom 27203010 AR-7253T - SUTURE NABSB 0 7MM STRG 13IN B/W 76MM FIBERLOOP TIGERLOOP BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7254 SUP Custom 27803010 AR-7254 - SUTURE NABSB 0 FBRWR BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7255 SUP Custom 27803010 AR-7255 - SUTURE NABSB 0 38IN WHT FBRWR LWR KNT PRFL SMTH TIE ABL SUP BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $0.00 $0.00 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7258 SUP Custom 27203010 AR-7258 - SUTURE NABSB 0 36IN BLU 1.5IN FIBERLINK LOOP BOTH IP/OP "$1,950.00 " "$1,443.00" $0.00 "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,447.29" "$1,447.29" $0.00 $0.00 $406.38 $0.00 $0.00 $0.00 $0.00 $975.00 "$1,544.40" "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7258T SUP Custom 27203010 AR-7258T - SUTURE NABSB 0 36IN 1.5IN TIGERLINK LOOP BOTH IP/OP "$1,950.00 " "$1,443.00" $0.00 "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,447.29" "$1,447.29" $0.00 $0.00 $406.38 $0.00 $0.00 $0.00 $0.00 $975.00 "$1,544.40" "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7264 SUP Custom 27803010 AR-7264 - SUTURE NABSB 2 FIBERTAG SPEEDWHIP FIBERLOOP BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7270 SUP Custom 27803010 AR-7270 - SUTURE NABSB 2 10 LNG LOOP 7MM FBRWR FIBERCHAIN BRD BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7272 SUP Custom 27803010 AR-7272 - FIBERWIRE CL WHITE BLUE 38IN BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $0.00 $0.00 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7272T SUP Custom 27203010 AR-7272T - TIGERWIRE CL WHITE BLACK 38IN W NDL BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $0.00 $0.00 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7275 SUP Custom 27803010 AR-7275 - SUTURE NONABSORBABLE 2 2MM 8IN 24IN FIBERTAPE FIBERWIRE BLUE BOTH IP/OP $175.00 $129.50 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7275T SUP Custom 27203010 AR-7275T - SUTURE NONABSORBABLE 2 2MM 8IN 24IN TIGERTAPE TIGERWIRE BLUE BOTH IP/OP $175.00 $129.50 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7276 SUP Custom 27203010 AR-7276 - SUTURE NABSB 1.5MM 36IN WHT LABRALTAPE BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7276T SUP Custom 27203010 AR-7276T - SUTURE NONABSORBABLE 1.5MM 36IN LABRALTAPE BLACK WHITE BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7280 SUP Custom 27203010 AR-7280 - NEEDLE SUT C-13 .5 CRC RVRS CUT 36.6MM LOOP NTNL BOTH IP/OP $47.50 $35.15 $0.00 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.25 $35.25 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7281 SUP Custom 27203010 AR-7281 - NEEDLE SUT T-5 .5 CRC TPR 26.5MM BTNDS LOOP NTNL DISP BOTH IP/OP $47.50 $35.15 $0.00 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.25 $35.25 $0.00 $0.00 $9.90 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7282 SUP Custom 27203010 AR-7282 - PASSER SUT 1 FBRWR LOOP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7284 SUP Custom 27203010 AR-7284 - SUTURE NABSB 2 FIBERLOOP SWAGE STRG NDL BOTH IP/OP "$1,950.00 " "$1,443.00" $0.00 "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,447.29" "$1,447.29" $0.00 $0.00 $406.38 $0.00 $0.00 $0.00 $0.00 $975.00 "$1,544.40" "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7300DS SUP Custom 27203010 AR-7300DS - BLADE SHVR 3MM 7CM STRL COOLCUT ASCP DSCT S JNT DISP BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7300OBT SUP Custom 27203010 AR-7300OBT - BURR SHVR 10 FLUT OVL3MM S JNT BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7324PSL SUP HCPCS C1713 AR-7324PSL - ANCHOR SUT SWIVELOCK TENODESIS PEEK BOTH IP/OP "$1,087.50 " $804.75 $0.00 $870.00 $489.38 $489.38 $0.00 $0.00 $0.00 $226.66 $807.14 $807.14 $0.00 $0.00 $226.64 $0.00 $643.26 $643.26 $0.00 $543.75 $861.30 $870.00 $0.00 $0.00 $170.19 $0.00 $0.00 $173.13 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7400TD SUP Custom 27203010 AR-7400TD - BLADE SHVR 4MM 7CM TORPEDO COOLCUT OVIOD OUTR WDW SMTH CUT BOTH IP/OP $252.50 $186.85 $0.00 $202.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.41 $187.41 $0.00 $0.00 $52.62 $0.00 $0.00 $0.00 $0.00 $126.25 $199.98 $202.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7500 SUP Custom 27203010 AR-7500 - SUTURE NABSB 1.3MM 36IN WHT BLU STRL SUTURETAPE .5 CRC TPR BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7710 SUP Custom 27203010 AR-7710 - BIT DRL 5MM 15MM SCKT HUM TNL ULN COLLATERAL LGMNT BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7710-4.5 SUP Custom 27203010 AR-7710-4.5 - BIT DRL 4.5MM HUM TNL ULN COLLATERAL LGMNT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7710-5.0 SUP Custom 27203010 AR-7710-5.0 - BIT DRL 5MM HUM TNL ULN COLLATERAL LGMNT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7711 SUP Custom 27203010 AR-7711 - BIT DRL 4.5MM 15MM SCKT HUM TNL ULN COLLATERAL LGMNT BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7715-4.5 SUP Custom 27203010 AR-7715-4.5 - KIT INST 2 MIC CRV 6IN STRL TIGERLOOP FIBERLOOP SUTLSO NDL BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 $0.00 $0.00 $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7720-2.0 SUP Custom 27203010 AR-7720-2.0 - DRILL SRG 2MM RECON ELB HUM ULN COLLATERAL LGMNT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7720-2.7 SUP Custom 27203010 AR-7720-2.7 - DRILL SRG 2.7MM HUM BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7720-3.2 SUP Custom 27203010 AR-7720-3.2 - DRILL SRG 3.2MM HUM BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7720-3.5 SUP Custom 27203010 AR-7720-3.5 - DRILL SRG 3.5MM RECON ELB HUM ULN COLLATERAL LGMNT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7720-4.0 SUP Custom 27203010 AR-7720-4.0 - DRILL SRG 4MM RECON ELB HUM ULN COLLATERAL LGMNT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7750-3.5 SUP Custom 27203010 AR-7750-3.5 - GUIDE DRL V 3.5MM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7750-55 SUP Custom 27203010 AR-7750-55 - GUIDE DRL 55D V ULNA BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7750-55M SUP Custom 27203010 AR-7750-55M - GUIDE DRL 55D V PRT ULNA BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7752 SUP Custom 27203010 AR-7752 - GUIDE DRL 3.5MM BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-7755 SUP Custom 27203010 AR-7755 - GUIDE DRL OFST 7MM ULNA BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8003-10 SUP HCPCS C1713 AR-8003-10 - STAPLE BN 10X10MM CMPR SS BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8003-15 SUP HCPCS C1713 AR-8003-15 - STAPLE BN 15X10MM CMPR SS BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8004-10 SUP HCPCS C1713 AR-8004-10 - STAPLE BN 10X15MM CMPR SS BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8004-15 SUP HCPCS C1713 AR-8004-15 - STAPLE BN 15X15MM CMPR SS DISP BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8005-20 SUP HCPCS C1713 AR-8005-20 - STAPLE BN 20X20MM CMPR SS DISP BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8005D-20 SUP Custom 27203010 AR-8005D-20 - BIT DRL 2MM 120MM CNN BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $0.00 $0.00 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8005D-30 SUP Custom 27203010 AR-8005D-30 - BIT DRL 3MM 120MM CNN BOTH IP/OP $347.50 $257.15 $0.00 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.91 $257.91 $0.00 $0.00 $72.42 $0.00 $0.00 $0.00 $0.00 $173.75 $275.22 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8006-20 SUP HCPCS C1713 AR-8006-20 - PLATE BN 20MM 2 CMPR 2 HL SS FT/ANKL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8006-25 SUP HCPCS C1713 AR-8006-25 - PLATE BN 25MM 2 CMPR 2 HL SS FT/ANKL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8006-30 SUP HCPCS C1713 AR-8006-30 - PLATE BN 30MM 2 CMPR 2 HL SS FT/ANKL BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8006C SUP Custom 27203010 AR-8006C - BIT DRL 2.4MM TRMIT CNN SLF CMPR THRD PTCH BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 $0.00 $0.00 $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8006S SUP Custom 27203010 AR-8006S - BIT DRL 2.5MM LAPIDUS CNN SLF CMPR THRD PTCH MIDFOOT BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 $0.00 $0.00 $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8006T SUP HCPCS C1713 AR-8006T - PLATE BN TRL 2 HL 2 CMPR BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8007-20 SUP HCPCS C1713 AR-8007-20 - PLATE BN 20MM 2 CMPR 3 HL SS FT/ANKL BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,119.38" "$1,119.38" $0.00 $0.00 $0.00 $518.46 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 "$1,471.36" "$1,471.36" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8007-25 SUP HCPCS C1713 AR-8007-25 - PLATE BN 25MM 2 CMPR 3 HL SS FT/ANKL BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,119.38" "$1,119.38" $0.00 $0.00 $0.00 $518.46 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 "$1,471.36" "$1,471.36" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8007-30 SUP HCPCS C1713 AR-8007-30 - PLATE BN 30MM 2 CMPR 3 HL SS FT/ANKL BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,119.38" "$1,119.38" $0.00 $0.00 $0.00 $518.46 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 "$1,471.36" "$1,471.36" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8007C-1 SUP HCPCS C1713 AR-8007C-1 - CASE INST 2 CMPR BOTH IP/OP "$4,737.50 " "$3,505.75" $0.00 "$3,790.00" "$2,131.88" "$2,131.88" $0.00 $0.00 $0.00 $987.41 "$3,516.17" "$3,516.17" $0.00 $0.00 $987.30 $0.00 "$2,335.59" "$2,335.59" $0.00 "$2,368.75" "$3,752.10" "$3,790.00" $0.00 $0.00 $741.42 $0.00 $0.00 $754.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8007T SUP HCPCS C1713 AR-8007T - TRIAL TRMA 3 HL 2 CMPR PLT BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8008-20 SUP HCPCS C1713 AR-8008-20 - PLATE BN STRG 20MM 2 CMPR 4 HL SS FT/ANKL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8008-25 SUP HCPCS C1713 AR-8008-25 - PLATE BN STRG 25MM 2 CMPR 4 HL SS FT/ANKL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8008-30 SUP HCPCS C1713 AR-8008-30 - PLATE BN STRG 30MM 2 CMPR 4 HL SS FT/ANKL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8009-20 SUP HCPCS C1713 AR-8009-20 - PLATE BN SQ 20MM 2 CMPR 4 HL SS FT/ANKL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8009-25 SUP HCPCS C1713 AR-8009-25 - PLATE BN SQ 25MM 2 CMPR 4 HL SS FT/ANKL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8009-30 SUP HCPCS C1713 AR-8009-30 - PLATE BN SQ 30MM 2 CMPR 4 HL SS FT/ANKL BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8400CSS SUP Custom 27203010 AR-8400CSS - BURR SHVR 6 FLUT 4MM 13CM STRL CLRCT COOLCUT SLAP BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8400EX SUP Custom 27203010 AR-8400EX - BLADE SHVR 4MM 13CM STRL EXCLBR COOLCUT DISP BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8400OBE SUP Custom 27203010 AR-8400OBE - BURR SHVR 8 FLUT OVL 4MM 13CM STRL COOLCUT DISP BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8500BC SUP Custom 27203010 AR-8500BC - CUTTER BN CUT 5MM 13CM STRL COOLCUT DISP BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8500EX SUP Custom 27203010 AR-8500EX - BLADE SHVR 5MM 13CM STRL EXCLBR COOLCUT DISP BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8500OBE SUP Custom 27203010 AR-8500OBE - BURR SHVR 8 FLUT OVL 5MM 13CM STRL COOLCUT DISP BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-16 SUP HCPCS C1713 AR-8545-16 - SCREW BN LOPRFL 4.5MM 16MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-18 SUP HCPCS C1713 AR-8545-18 - SCREW BN LOPRFL 4.5MM 18MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-20 SUP HCPCS C1713 AR-8545-20 - SCREW BN LOPRFL 4.5MM 20MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-22 SUP HCPCS C1713 AR-8545-22 - SCREW BN LOPRFL 4.5MM 22MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-24 SUP HCPCS C1713 AR-8545-24 - SCREW BN LOPRFL 4.5MM 24MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-26 SUP HCPCS C1713 AR-8545-26 - SCREW BN LOPRFL 4.5MM 26MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-28 SUP HCPCS C1713 AR-8545-28 - SCREW BN LOPRFL 4.5MM 28MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-30 SUP HCPCS C1713 AR-8545-30 - SCREW BN LOPRFL 4.5MM 30MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-32 SUP HCPCS C1713 AR-8545-32 - SCREW BN LOPRFL 4.5MM 32MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-34 SUP HCPCS C1713 AR-8545-34 - SCREW BN LOPRFL 4.5MM 34MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-36 SUP HCPCS C1713 AR-8545-36 - SCREW BN LOPRFL 4.5MM 36MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-38 SUP HCPCS C1713 AR-8545-38 - SCREW BN LOPRFL 4.5MM 38MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-40 SUP HCPCS C1713 AR-8545-40 - SCREW BN LOPRFL 4.5MM 40MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-42 SUP HCPCS C1713 AR-8545-42 - SCREW BN 4.5MM 42MM NS ARTHX LOPRFL TI BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-45 SUP HCPCS C1713 AR-8545-45 - SCREW BN LOPRFL 4.5MM 45MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-48 SUP HCPCS C1713 AR-8545-48 - SCREW BN 4.5MM 48MM LOPRFL TI BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-50 SUP HCPCS C1713 AR-8545-50 - SCREW BN LOPRFL 4.5MM 50MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-55 SUP HCPCS C1713 AR-8545-55 - SCREW BN LOPRFL 4.5MM 55MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-60 SUP HCPCS C1713 AR-8545-60 - SCREW BN LOPRFL 4.5MM 60MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545-65 SUP HCPCS C1713 AR-8545-65 - SCREW BN LOPRFL 4.5MM 65MM ANKL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-16 SUP HCPCS C1713 AR-8545L-16 - SCREW BN LOPRFL 4.5MM 16MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-18 SUP HCPCS C1713 AR-8545L-18 - SCREW BN LOPRFL 4.5MM 18MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-20 SUP HCPCS C1713 AR-8545L-20 - SCREW BN LOPRFL 4.5MM 20MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-22 SUP HCPCS C1713 AR-8545L-22 - SCREW BN LOPRFL 4.5MM 22MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-24 SUP HCPCS C1713 AR-8545L-24 - SCREW BN LOPRFL 4.5MM 24MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-26 SUP HCPCS C1713 AR-8545L-26 - SCREW BN LOPRFL 4.5MM 26MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-28 SUP HCPCS C1713 AR-8545L-28 - SCREW BN LOPRFL 4.5MM 28MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-30 SUP HCPCS C1713 AR-8545L-30 - SCREW BN LOPRFL 4.5MM 30MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-32 SUP HCPCS C1713 AR-8545L-32 - SCREW BN LOPRFL 4.5MM 32MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-34 SUP HCPCS C1713 AR-8545L-34 - SCREW BN LOPRFL 4.5MM 34MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-36 SUP HCPCS C1713 AR-8545L-36 - SCREW BN LOPRFL 4.5MM 36MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-38 SUP HCPCS C1713 AR-8545L-38 - SCREW BN LOPRFL 4.5MM 38MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-40 SUP HCPCS C1713 AR-8545L-40 - SCREW BN LOPRFL 4.5MM 40MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-44 SUP HCPCS C1713 AR-8545L-44 - SCREW BN 4.5MM 44MM NS ARTHX LCK LOPRFL TI BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-50 SUP HCPCS C1713 AR-8545L-50 - SCREW BN LOPRFL 4.5MM 50MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-50S SUP HCPCS C1713 AR-8545L-50S - SCREW BN 4.5MM 50MM STRL ARTHX LOPRFL LCK BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-52 SUP HCPCS C1713 AR-8545L-52 - SCREW BN 4.5MM 52MM LOPRFL LCK BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-54 SUP HCPCS C1713 AR-8545L-54 - SCREW BN 4.5MM 54MM LOPRFL LCK BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-55 SUP HCPCS C1713 AR-8545L-55 - SCREW BN LOPRFL 4.5MM 55MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-56 SUP HCPCS C1713 AR-8545L-56 - SCREW BN 4.5MM 56MM LOPRFL LCK BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-58 SUP HCPCS C1713 AR-8545L-58 - SCREW BN 4.5MM 58MM LOPRFL LCK BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-60 SUP HCPCS C1713 AR-8545L-60 - SCREW BN LOPRFL 4.5MM 60MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8545L-65 SUP HCPCS C1713 AR-8545L-65 - SCREW BN LOPRFL 4.5MM 65MM LCK ANKL BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-20 SUP HCPCS C1713 AR-8555-20 - SCREW BN LOPRFL 5.5MM 20MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-25 SUP HCPCS C1713 AR-8555-25 - SCREW BN LOPRFL 5.5MM 25MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-30 SUP HCPCS C1713 AR-8555-30 - SCREW BN LOPRFL 5.5MM 30MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-35 SUP HCPCS C1713 AR-8555-35 - SCREW BN LOPRFL 5.5MM 35MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-40 SUP HCPCS C1713 AR-8555-40 - SCREW BN LOPRFL 5.5MM 40MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-45 SUP HCPCS C1713 AR-8555-45 - SCREW BN LOPRFL 5.5MM 45MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-50 SUP HCPCS C1713 AR-8555-50 - SCREW BN LOPRFL 5.5MM 50MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-55 SUP HCPCS C1713 AR-8555-55 - SCREW BN LOPRFL 5.5MM 55MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-60 SUP HCPCS C1713 AR-8555-60 - SCREW BN LOPRFL 5.5MM 60MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-65 SUP HCPCS C1713 AR-8555-65 - SCREW BN LOPRFL 5.5MM 65MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-70 SUP HCPCS C1713 AR-8555-70 - SCREW BN LOPRFL 5.5MM 70MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8555-75 SUP HCPCS C1713 AR-8555-75 - SCREW BN LOPRFL 5.5MM 75MM ANKL CANC BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610DB-25 SUP Custom 27203010 "AR-8610DB-25 - DRILL BIT, CANNULATED, 1.7MM" BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610DB-25C SUP Custom 27203010 AR-8610DB-25C - BIT DRL 1.7MM CNN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610DB-30 SUP Custom 27203010 "AR-8610DB-30 - DRILL BIT, CANNULATED, 2.0MM" BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610DB-30C SUP Custom 27203010 AR-8610DB-30C - BIT DRL 2MM CNN VTRN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610DB-43 SUP Custom 27203010 "AR-8610DB-43 - DRILL BIT, CANNULATED, 3.0MM" BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610DB-43C SUP Custom 27203010 AR-8610DB-43C - BIT DRL 3MM CNN DISP 4.3MM HDLS CMPR SCR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610DB-65 SUP Custom 27203010 "AR-8610DB-65 - DRILL BIT, CANNULATED, 4.3MM" BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610DB-65C SUP Custom 27203010 AR-8610DB-65C - BIT DRL 4.3MM CNN DISP 6.5MM HDLS CMPR P/T SCR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610S-01 SUP HCPCS C1713 AR-8610S-01 - HEADLESS COMPRESSION SCREW SYSTEM2.5/3.0 BOTH IP/OP "$34,412.50 " "$25,465.25" $0.00 "$27,530.00" "$15,485.63" "$15,485.63" $0.00 $0.00 $0.00 "$7,172.43" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,171.57" $0.00 "$16,965.36" "$16,965.36" $0.00 "$17,206.25" "$27,254.70" "$27,530.00" $0.00 $0.00 "$5,385.56" $0.00 $0.00 "$5,478.47" $0.00 $0.00 $0.00 $0.00 $0.00 AR-8610S-02 SUP HCPCS C1713 AR-8610S-02 - HEADLESS COMPRESSION SCREW SYSTEM4.3/6.5 BOTH IP/OP "$29,750.00 " "$22,015.00" $0.00 "$23,800.00" "$13,387.50" "$13,387.50" $0.00 $0.00 $0.00 "$6,200.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,199.90" $0.00 "$14,666.75" "$14,666.75" $0.00 "$14,875.00" "$23,562.00" "$23,800.00" $0.00 $0.00 "$4,655.88" $0.00 $0.00 "$4,736.20" $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-08 SUP HCPCS C1713 AR-8625-08 - HEADLESS COMPR SCRW 2.5X 8 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-10 SUP HCPCS C1713 AR-8625-10 - HEADLESS COMPR SCRW 2.5X 10 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-12 SUP HCPCS C1713 AR-8625-12 - HEADLESS COMPR SCRW 2.5X 12 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-14 SUP HCPCS C1713 AR-8625-14 - HEADLESS COMPR SCRW 2.5X 14 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-16 SUP HCPCS C1713 AR-8625-16 - HEADLESS COMPR SCRW 2.5X 16 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-18 SUP HCPCS C1713 AR-8625-18 - HEADLESS COMPR SCRW 2.5X 18 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-20 SUP HCPCS C1713 AR-8625-20 - SCREW BN T15 FT HEXALOBE 3.5MM 20MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-22 SUP HCPCS C1713 AR-8625-22 - HEADLESS COMPR SCRW 2.5X 22 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-24 SUP HCPCS C1713 AR-8625-24 - HEADLESS COMPR SCRW 2.5X 24 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-26 SUP HCPCS C1713 AR-8625-26 - HEADLESS COMPR SCRW 2.5X 26 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-28 SUP HCPCS C1713 AR-8625-28 - HEADLESS COMPR SCRW 2.5X 28 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-30 SUP HCPCS C1713 AR-8625-30 - HEADLESS COMPR SCRW 2.5X 30 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-32 SUP HCPCS C1713 AR-8625-32 - HEADLESS COMPR SCRW 2.5X 32 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8625-34 SUP HCPCS C1713 AR-8625-34 - HEADLESS COMPR SCRW 2.5X 34 MMCANN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-10 SUP HCPCS C1713 "AR-8630-10 - HEDLESS COMPR SCRW,3.0X 10 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-12 SUP HCPCS C1713 "AR-8630-12 - HEDLESS COMPR SCRW,3.0X 12 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-14 SUP HCPCS C1713 "AR-8630-14 - HEDLESS COMPR SCRW,3.0X 14 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-16 SUP HCPCS C1713 "AR-8630-16 - HEDLESS COMPR SCRW,3.0X 16 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-18 SUP HCPCS C1713 "AR-8630-18 - HEDLESS COMPR SCRW,3.0X 18 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-20 SUP HCPCS C1713 "AR-8630-20 - HEDLESS COMPR SCRW,3.0X 20 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-22 SUP HCPCS C1713 "AR-8630-22 - HEDLESS COMPR SCRW,3.0X 22 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-24 SUP HCPCS C1713 AR-8630-24 - SCREW BN 3MM 24MM NS ARTHX CMPR CNN HDLS BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-26 SUP HCPCS C1713 "AR-8630-26 - HEDLESS COMPR SCRW,3.0X 26 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-28 SUP HCPCS C1713 "AR-8630-28 - HEDLESS COMPR SCRW,3.0X 28 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-30 SUP HCPCS C1713 "AR-8630-30 - HEDLESS COMPR SCRW,3.0X 30 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-32 SUP HCPCS C1713 "AR-8630-32 - HEDLESS COMPR SCRW,3.0X 32 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-34 SUP HCPCS C1713 "AR-8630-34 - HEDLESS COMPR SCRW,3.0X 34 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8630-36 SUP HCPCS C1713 "AR-8630-36 - HEDLESS COMPR SCRW,3.0X 36 MMCANN" BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-14 SUP HCPCS C1713 "AR-8643-14 - HEDLESS COMPR SCRW,4.3X 14 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-16 SUP HCPCS C1713 "AR-8643-16 - HEDLESS COMPR SCRW,4.3X 16 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-18 SUP HCPCS C1713 "AR-8643-18 - HEDLESS COMPR SCRW,4.3X 18 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-20 SUP HCPCS C1713 "AR-8643-20 - HEDLESS COMPR SCRW,4.3X 20 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-22 SUP HCPCS C1713 "AR-8643-22 - HEDLESS COMPR SCRW,4.3X 22 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-24 SUP HCPCS C1713 "AR-8643-24 - HEDLESS COMPR SCRW,4.3X 24 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-26 SUP HCPCS C1713 "AR-8643-26 - HEDLESS COMPR SCRW,4.3X 26 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-28 SUP HCPCS C1713 "AR-8643-28 - HEDLESS COMPR SCRW,4.3X 28 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-30 SUP HCPCS C1713 "AR-8643-30 - HEDLESS COMPR SCRW,4.3X 30 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-32 SUP HCPCS C1713 "AR-8643-32 - HEDLESS COMPR SCRW,4.3X 32 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-34 SUP HCPCS C1713 "AR-8643-34 - HEDLESS COMPR SCRW,4.3X 34 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-36 SUP HCPCS C1713 "AR-8643-36 - HEDLESS COMPR SCRW,4.3X 36 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-38 SUP HCPCS C1713 "AR-8643-38 - HEDLESS COMPR SCRW,4.3X 38 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-40 SUP HCPCS C1713 "AR-8643-40 - HEDLESS COMPR SCRW,4.3X 40 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-42 SUP HCPCS C1713 "AR-8643-42 - HEDLESS COMPR SCRW,4.3X 42 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-44 SUP HCPCS C1713 "AR-8643-44 - HEDLESS COMPR SCRW,4.3X 44 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-46 SUP HCPCS C1713 "AR-8643-46 - HEDLESS COMPR SCRW,4.3X 46 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-48 SUP HCPCS C1713 "AR-8643-48 - HEDLESS COMPR SCRW,4.3X 48 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-50 SUP HCPCS C1713 "AR-8643-50 - HEDLESS COMPR SCRW,4.3X 50 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-55 SUP HCPCS C1713 "AR-8643-55 - HEDLESS COMPR SCRW,4.3X 55 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-60 SUP HCPCS C1713 "AR-8643-60 - HEDLESS COMPR SCRW,4.3X 60 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-65 SUP HCPCS C1713 "AR-8643-65 - HEDLESS COMPR SCRW,4.3X 65 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-70 SUP HCPCS C1713 "AR-8643-70 - HEDLESS COMPR SCRW,4.3X 70 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-75 SUP HCPCS C1713 "AR-8643-75 - HEDLESS COMPR SCRW,4.3X 75 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8643-80 SUP HCPCS C1713 "AR-8643-80 - HEDLESS COMPR SCRW,4.3X 80 MMCANN" BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8655-13 SUP Custom 27203010 AR-8655-13 - GUIDE DRL ANKL BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8656G SUP Custom 27203010 AR-8656G - GUIDE DRL GPS TRGT BOTH IP/OP "$4,987.50 " "$3,690.75" $0.00 "$3,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,701.72" "$3,701.72" $0.00 $0.00 "$1,039.40" $0.00 $0.00 $0.00 $0.00 "$2,493.75" "$3,950.10" "$3,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8656G-04 SUP Custom 27203010 AR-8656G-04 - CANNULA ASCP GPS 1.1/1.6/2.4 MM BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-100 SUP HCPCS C1713 AR-8665-100 - HEDLESS COMPR SCRW 6.5X 100 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-105 SUP HCPCS C1713 AR-8665-105 - HEDLESS COMPR SCRW 6.5X 105 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-110 SUP HCPCS C1713 AR-8665-110 - HEDLESS COMPR SCRW 6.5X 110MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-115 SUP HCPCS C1713 AR-8665-115 - HEDLESS COMPR SCRW 6.5X 115 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-120 SUP HCPCS C1713 AR-8665-120 - HEDLESS COMPR SCRW 6.5X 120 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-18100 SUP HCPCS C1713 AR-8665-18100 - SCREW BN ST 6.5MM 100MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-18105 SUP HCPCS C1713 AR-8665-18105 - SCREW BN ST 6.5MM 105MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-18110 SUP HCPCS C1713 AR-8665-18110 - SCREW BN ST 6.5MM 110MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-18115 SUP HCPCS C1713 AR-8665-18115 - SCREW BN ST 6.5MM 115MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-18120 SUP HCPCS C1713 AR-8665-18120 - SCREW BN ST 6.5MM 120MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1830 SUP HCPCS C1713 AR-8665-1830 - SCREW BN ST 6.5MM 30MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1835 SUP HCPCS C1713 AR-8665-1835 - SCREW BN ST 6.5MM 35MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1850 SUP HCPCS C1713 AR-8665-1850 - SCREW BN P/T 6.5MM 50MM CMPR HDLS BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1855 SUP HCPCS C1713 AR-8665-1855 - SCREW BN ST 6.5MM 55MM CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1860 SUP HCPCS C1713 AR-8665-1860 - SCREW BN ST 6.5MM 60MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1865 SUP HCPCS C1713 AR-8665-1865 - SCREW BN ST 6.5MM 65MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1880 SUP HCPCS C1713 AR-8665-1880 - SCREW BN P/T 6.5MM 80MM CMPR HDLS BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1885 SUP HCPCS C1713 AR-8665-1885 - SCREW BN P/T 6.5MM 85MM CMPR HDLS BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1890 SUP HCPCS C1713 AR-8665-1890 - SCREW BN ST 6.5MM 90MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-1895 SUP HCPCS C1713 AR-8665-1895 - SCREW BN ST 6.5MM 95MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-28100 SUP HCPCS C1713 AR-8665-28100 - SCREW BN L/T 6.5MM 100MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-28105 SUP HCPCS C1713 AR-8665-28105 - SCREW BN L/T 6.5MM 105MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-28110 SUP HCPCS C1713 AR-8665-28110 - SCREW BN L/T 6.5MM 110MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-28115 SUP HCPCS C1713 AR-8665-28115 - SCREW BN L/T 6.5MM 115MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-28120 SUP HCPCS C1713 AR-8665-28120 - SCREW BN L/T 6.5MM 120MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-2860 SUP HCPCS C1713 AR-8665-2860 - SCREW BN L/T 6.5MM 60MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-2865 SUP HCPCS C1713 AR-8665-2865 - SCREW BN L/T 6.5MM 65MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-2870 SUP HCPCS C1713 AR-8665-2870 - SCREW BN L/T 6.5MM 70MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-2875 SUP HCPCS C1713 AR-8665-2875 - SCREW BN L/T 6.5MM 75MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-2880 SUP HCPCS C1713 AR-8665-2880 - SCREW BN L/T 6.5MM 80MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-2885 SUP HCPCS C1713 AR-8665-2885 - SCREW BN L/T 6.5MM 85MM NS ARTHX CMPR HDLS BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-2890 SUP HCPCS C1713 AR-8665-2890 - SCREW BN L/T 6.5MM 90MM CMPR CNN HDLS VTRN BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-2895 SUP HCPCS C1713 AR-8665-2895 - SCREW BN L/T 6.5MM 95MM NS ARTHX CMPR HDLS BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $646.88 $646.88 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-30 SUP HCPCS C1713 AR-8665-30 - HEDLESS COMPR SCRW 6.5X 30 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-35 SUP HCPCS C1713 AR-8665-35 - HEDLESS COMPR SCRW 6.5X 35 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-40 SUP HCPCS C1713 AR-8665-40 - HEDLESS COMPR SCRW 6.5X 40 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-45 SUP HCPCS C1713 AR-8665-45 - HEDLESS COMPR SCRW 6.5X 45 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-50 SUP HCPCS C1713 AR-8665-50 - HEDLESS COMPR SCRW 6.5X 50 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-55 SUP HCPCS C1713 AR-8665-55 - HEDLESS COMPR SCRW 6.5X 55 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-60 SUP HCPCS C1713 AR-8665-60 - HEDLESS COMPR SCRW 6.5X 60 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-65 SUP HCPCS C1713 AR-8665-65 - HEDLESS COMPR SCRW 6.5X 65 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-70 SUP HCPCS C1713 AR-8665-70 - HEDLESS COMPR SCRW 6.5X 70 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-75 SUP HCPCS C1713 AR-8665-75 - HEDLESS COMPR SCRW 6.5X 75 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-80 SUP HCPCS C1713 AR-8665-80 - SCREW BN 6.5MM 80MM NS ARTHX CMPR CNN HDLS BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-85 SUP HCPCS C1713 AR-8665-85 - HEDLESS COMPR SCRW 6.5X 85 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-90 SUP HCPCS C1713 AR-8665-90 - SCREW BN 6.5MM 90MM NS ARTHX CMPR CNN HDLS BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8665-95 SUP HCPCS C1713 AR-8665-95 - HEDLESS COMPR SCRW 6.5X 95 MMCANN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8690DS SUP HCPCS C1713 AR-8690DS - SYSTEM FX CPR MN SCRPN DX BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,031.77" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8692DS SUP Custom 27203010 AR-8692DS - SYSTEM FX CPR VPR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,031.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 $0.00 $0.00 $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8701 SUP Custom 27203010 AR-8701 - PASSER SUTURE MICRO SMALL CURVE BENT 1.25MM 6IN BRAID EASIER BOTH IP/OP $350.00 $259.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8703 SUP Custom 27203010 AR-8703 - PASSER SUTLSO MIC STR SUTURE STRL DISP BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8704 SUP Custom 27203010 AR-8704 - PASSER SUT 70D MIC SHRT BNT 3ANG STRL SUTLSO FIBROCARTILAGE BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8708 SUP HCPCS C1713 AR-8708 - STAPLE BN SM 8MM SUT SS BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8708S SUP HCPCS C1713 AR-8708S - STAPLE BN SM QFIX BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" "$2,531.25" "$2,531.25" $0.00 $0.00 $0.00 "$1,172.39" "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 "$2,773.13" "$2,773.13" $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $880.31 $0.00 $0.00 $895.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8710 SUP HCPCS C1713 AR-8710 - STAPLE BN SM 10MM QFIX SS BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8714 SUP HCPCS C1713 AR-8714 - PLATE BN LOPRFL 12MM PLAPLE SS DIAPHYSIS BOTH IP/OP "$1,062.50 " $786.25 $0.00 $788.59 $433.13 $433.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8715 SUP HCPCS C1713 AR-8715 - PLATE BN LOPRFL 15MM PLAPLE SS SM BN 2.3MM CORT SCR BOTH IP/OP "$1,062.50 " $786.25 $0.00 $788.59 $433.13 $433.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8716 SUP HCPCS C1713 AR-8716 - PLATE BN LOPRFL 20MM PLAPLE SS SM BN 2.3MM CORT SCR BOTH IP/OP "$1,062.50 " $786.25 $0.00 $788.59 $433.13 $433.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $481.25 $762.30 $770.00 $0.00 $0.00 $150.63 $0.00 $0.00 $153.23 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-08PT SUP HCPCS C1713 AR-8720-08PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 8MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-10PT SUP HCPCS C1713 AR-8720-10PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 10MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-12PT SUP HCPCS C1713 AR-8720-12PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 12MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-14PT SUP HCPCS C1713 AR-8720-14PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 14MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-16PT SUP HCPCS C1713 AR-8720-16PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 16MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-18PT SUP HCPCS C1713 AR-8720-18PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 18MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-20PT SUP HCPCS C1713 AR-8720-20PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 20MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-22PT SUP HCPCS C1713 AR-8720-22PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 22MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-24PT SUP HCPCS C1713 AR-8720-24PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 24MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-26PT SUP HCPCS C1713 AR-8720-26PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 26MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-28PT SUP HCPCS C1713 AR-8720-28PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2MM 28MM QFIX SLF DRL ST CNN BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8720-30PT SUP HCPCS C1713 AR-8720-30PT - SCREW BN P/T 2MM 30MM QFIX CNN TI BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-08 SUP HCPCS C1713 AR-8724-08 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 8MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-08PT SUP HCPCS C1713 AR-8724-08PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 8MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-10 SUP HCPCS C1713 AR-8724-10 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 10MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-10PT SUP HCPCS C1713 AR-8724-10PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 10MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-12 SUP HCPCS C1713 AR-8724-12 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 12MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-12PT SUP HCPCS C1713 AR-8724-12PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 12MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-14 SUP HCPCS C1713 AR-8724-14 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 14MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-14PT SUP HCPCS C1713 AR-8724-14PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 14MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-16 SUP HCPCS C1713 AR-8724-16 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 16MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-16PT SUP HCPCS C1713 AR-8724-16PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 16MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-18PT SUP HCPCS C1713 AR-8724-18PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 18MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-20 SUP HCPCS C1713 AR-8724-20 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 20MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-20PT SUP HCPCS C1713 AR-8724-20PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 20MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-22 SUP HCPCS C1713 AR-8724-22 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 22MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-22PT SUP HCPCS C1713 AR-8724-22PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 22MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-24PT SUP HCPCS C1713 AR-8724-24PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 24MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-26PT SUP HCPCS C1713 AR-8724-26PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 26MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-28 SUP HCPCS C1713 AR-8724-28 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 28MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-28PT SUP HCPCS C1713 AR-8724-28PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 28MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-30 SUP HCPCS C1713 AR-8724-30 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 30MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-30PT SUP HCPCS C1713 AR-8724-30PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 30MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-32 SUP HCPCS C1713 AR-8724-32 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 32MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-32PT SUP HCPCS C1713 AR-8724-32PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 32MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-34 SUP HCPCS C1713 AR-8724-34 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 34MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-34PT SUP HCPCS C1713 AR-8724-34PT - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 34MM QFIX SLF DRL ST BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-36 SUP HCPCS C1713 AR-8724-36 - SCREW BN T8 P/T HEXALOBE LOPRFL 2.4MM 36MM QFIX SLF DRL ST BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-36PT SUP HCPCS C1713 AR-8724-36PT - SCREW BN P/T 2.4MM 36MM QFIX CNN TI BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $163.13 $163.13 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-38 SUP HCPCS C1713 AR-8724-38 - SCREW BN 2.4MM 38MM LOPRFL TI FT/ANKL CORT BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724-40 SUP HCPCS C1713 AR-8724-40 - SCREW BN 2.4MM 40MM LOPRFL TI FT/ANKL CORT BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724GV SUP Custom 27203010 AR-8724GV - GUIDE DRL 2.4MM VA BOTH IP/OP "$1,187.50 " $878.75 $0.00 $881.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $0.00 $0.00 $0.00 $518.75 $821.70 $830.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-08 SUP HCPCS C1713 AR-8724L-08 - SCREW BN 2.4MM 8MM LCK LOPRFL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-10 SUP HCPCS C1713 AR-8724L-10 - SCREW BN T8 FT HEXALOBE 2.4MM 10MM SLF DRL SLD LCK TI SM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-12 SUP HCPCS C1713 AR-8724L-12 - SCREW BN T8 FT HEXALOBE 2.4MM 12MM SLF DRL SLD LCK TI SM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-14 SUP HCPCS C1713 AR-8724L-14 - SCREW BN T8 FT HEXALOBE 2.4MM 14MM SLF DRL SLD LCK TI SM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-16 SUP HCPCS C1713 AR-8724L-16 - SCREW BN T8 FT HEXALOBE 2.4MM 16MM SLF DRL SLD LCK TI SM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-18 SUP HCPCS C1713 AR-8724L-18 - SCREW BN T8 FT HEXALOBE 2.4MM 18MM SLF DRL SLD LCK TI SM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-20 SUP HCPCS C1713 AR-8724L-20 - SCREW BN T8 FT HEXALOBE 2.4MM 20MM SLF DRL SLD LCK TI SM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-22 SUP HCPCS C1713 AR-8724L-22 - SCREW BN LOPRFL 2.4MM 22MM LCK ST SLD TI FT BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-24 SUP HCPCS C1713 AR-8724L-24 - SCREW BN LOPRFL 2.4MM 24MM LCK ST SLD TI FT BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-26 SUP HCPCS C1713 AR-8724L-26 - SCREW BN 2.4MM 26MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-28 SUP HCPCS C1713 AR-8724L-28 - SCREW BN 2.4MM 28MM LOPRFL LCK TI BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-30 SUP HCPCS C1713 AR-8724L-30 - SCREW BN 2.4MM 30MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-32 SUP HCPCS C1713 AR-8724L-32 - SCREW BN 2.4MM 32MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-34 SUP HCPCS C1713 AR-8724L-34 - SCREW BN T8 FT HEXALOBE 2.4MM 34MM LCK SLF DRL SLD TI SM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-36 SUP HCPCS C1713 AR-8724L-36 - SCREW BN T8 FT HEXALOBE 2.4MM 36MM LCK SLF DRL SLD TI SM BN BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-38 SUP HCPCS C1713 AR-8724L-38 - SCREW BN 2.4MM 38MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724L-40 SUP HCPCS C1713 AR-8724L-40 - SCREW BN 2.4MM 40MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-08 SUP HCPCS C1713 AR-8724V-08 - SCREW BN LOPRFL 2.4MM 8MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-10 SUP HCPCS C1713 AR-8724V-10 - SCREW BN LOPRFL 2.4MM 10MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-12 SUP HCPCS C1713 AR-8724V-12 - SCREW BN LOPRFL 2.4MM 12MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-14 SUP HCPCS C1713 AR-8724V-14 - SCREW BN LOPRFL 2.4MM 14MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-16 SUP HCPCS C1713 AR-8724V-16 - SCREW BN LOPRFL 2.4MM 16MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-18 SUP HCPCS C1713 AR-8724V-18 - SCREW BN LOPRFL 2.4MM 18MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-20 SUP HCPCS C1713 AR-8724V-20 - SCREW BN LOPRFL 2.4MM 20MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-22 SUP HCPCS C1713 AR-8724V-22 - SCREW BN LOPRFL 2.4MM 22MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-24 SUP HCPCS C1713 AR-8724V-24 - SCREW BN LOPRFL 2.4MM 24MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-26 SUP HCPCS C1713 AR-8724V-26 - SCREW BN LOPRFL 2.4MM 26MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-28 SUP HCPCS C1713 AR-8724V-28 - SCREW BN LOPRFL 2.4MM 28MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-30 SUP HCPCS C1713 AR-8724V-30 - SCREW BN LOPRFL 2.4MM 30MM VA ST SLD LCK TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-32 SUP HCPCS C1713 AR-8724V-32 - SCREW BN LOPRFL 2.4MM 32MM LCK ST SLD VA TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-34 SUP HCPCS C1713 AR-8724V-34 - SCREW BN LOPRFL 2.4MM 34MM LCK ST SLD VA TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-36 SUP HCPCS C1713 AR-8724V-36 - SCREW BN LOPRFL 2.4MM 32MM LCK ST SLD VA TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-38 SUP HCPCS C1713 AR-8724V-38 - SCREW BN LOPRFL 2.4MM 38MM LCK ST SLD VA TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724V-40 SUP HCPCS C1713 AR-8724V-40 - SCREW BN LOPRFL 2.4MM 40MM LCK ST SLD VA TI FT HND ANKL WRST BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8724W SUP HCPCS C1713 AR-8724W - WASHER ORTH 6MM TI 2/2.4MM QFIX SCR BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-08H SUP HCPCS C1713 AR-8725-08H - SCREW BN 1.5MM MIC FT HEX 2.5MM 8MM QFIX SLF DRL ST CNN CMPR BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-09H SUP HCPCS C1713 AR-8725-09H - SCREW BN 1.5MM MIC FT HEX 2.5MM 9MM QFIX SLF DRL ST CNN CMPR BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-10H SUP HCPCS C1713 AR-8725-10H - SCREW BN 1.5MM MIC FT HEX 2.5MM 10MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-11H SUP HCPCS C1713 AR-8725-11H - SCREW BN 1.5MM MIC FT HEX 2.5MM 11MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-12H SUP HCPCS C1713 AR-8725-12H - SCREW BN 1.5MM MIC FT HEX 2.5MM 12MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-13H SUP HCPCS C1713 AR-8725-13H - SCREW BN 1.5MM MIC FT HEX 2.5MM 13MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-14H SUP HCPCS C1713 AR-8725-14H - SCREW BN 1.5MM MIC FT 2.5MM 14MM QFIX SLF DRL ST CNN CMPR TI BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-16H SUP HCPCS C1713 AR-8725-16H - SCREW BN 1.5MM MIC FT HEX 2.5MM 16MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-18H SUP HCPCS C1713 AR-8725-18H - SCREW BN 1.5MM MIC FT HEX 2.5MM 18MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-20H SUP HCPCS C1713 AR-8725-20H - SCREW BN 1.5MM MIC FT HEX 2.5MM 20MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-22H SUP HCPCS C1713 AR-8725-22H - SCREW BN 1.5MM MIC FT HEX 2.5MM 22MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-24H SUP HCPCS C1713 AR-8725-24H - SCREW BN 1.5MM MIC FT HEX 2.5MM 24MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-26H SUP HCPCS C1713 AR-8725-26H - SCREW BN 1.5MM MIC FT HEX 2.5MM 26MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-28H SUP HCPCS C1713 AR-8725-28H - SCREW BN 1.5MM MIC FT HEX 2.5MM 28MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8725-30H SUP HCPCS C1713 AR-8725-30H - SCREW BN 1.5MM MIC FT HEX 2.5MM 30MM QFIX SLF DRL ST CNN BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-10PT SUP HCPCS C1713 AR-8730-10PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 10MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-12H SUP HCPCS C1713 AR-8730-12H - SCREW BN MN FT 3.6MM 12MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-12PT SUP HCPCS C1713 AR-8730-12PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 12MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-14H SUP HCPCS C1713 AR-8730-14H - SCREW BN MN FT 3.6MM 14MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-14PT SUP HCPCS C1713 AR-8730-14PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 14MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-16H SUP HCPCS C1713 AR-8730-16H - SCREW BN MN FT 3.6MM 16MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-16PT SUP HCPCS C1713 AR-8730-16PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 16MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-18H SUP HCPCS C1713 AR-8730-18H - SCREW BN MN FT 3.6MM 18MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-18PT SUP HCPCS C1713 AR-8730-18PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 18MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-20H SUP HCPCS C1713 AR-8730-20H - SCREW BN MN FT 3.6MM 20MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-20PT SUP HCPCS C1713 AR-8730-20PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 20MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-22H SUP HCPCS C1713 AR-8730-22H - SCREW BN MN FT 3.5MM 22MM QFIX CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-22PT SUP HCPCS C1713 AR-8730-22PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 22MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-24H SUP HCPCS C1713 AR-8730-24H - SCREW BN MN FT 3.6MM 24MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-24PT SUP HCPCS C1713 AR-8730-24PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 24MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-26H SUP HCPCS C1713 AR-8730-26H - SCREW BN MN FT 3.6MM 26MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-26PT SUP HCPCS C1713 AR-8730-26PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 26MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-28H SUP HCPCS C1713 AR-8730-28H - SCREW BN MN FT 3.6MM 28MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-28PT SUP HCPCS C1713 AR-8730-28PT - SCREW BN P/T 3MM 28MM QFIX TI CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-30H SUP HCPCS C1713 AR-8730-30H - SCREW BN MN FT 3.6MM 30MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-30PT SUP HCPCS C1713 AR-8730-30PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 30MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-32H SUP HCPCS C1713 AR-8730-32H - SCREW BN MN FT 3.6MM 32MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-32PT SUP HCPCS C1713 AR-8730-32PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 32MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-34H SUP HCPCS C1713 AR-8730-34H - SCREW BN MN FT 3.6MM 34MM QFIX CNN CMPR TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-34PT SUP HCPCS C1713 AR-8730-34PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 34MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-36PT SUP HCPCS C1713 AR-8730-36PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 36MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-38PT SUP HCPCS C1713 AR-8730-38PT - SCREW BN P/T 3MM 38MM QFIX TI CANC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-40PT SUP HCPCS C1713 AR-8730-40PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 40MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-42PT SUP HCPCS C1713 AR-8730-42PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 42MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-44PT SUP HCPCS C1713 AR-8730-44PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 44MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-46PT SUP HCPCS C1713 AR-8730-46PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 46MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-48PT SUP HCPCS C1713 AR-8730-48PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 48MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730-50PT SUP HCPCS C1713 AR-8730-50PT - SCREW BN T10 P/T HEXALOBE LOPRFL 3MM 50MM QFIX SLF DRL ST BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8730W SUP HCPCS C1713 AR-8730W - WASHER ORTH 6.5MM TI 3MM QFIX SCR BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-03 SUP Custom 27203010 AR-8737-03 - GUIDE DRL .86MM 1.7MM BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $0.00 $0.00 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-06 SUP Custom 27203010 AR-8737-06 - GUIDE DRL 3MM 4MM BOTH IP/OP $850.00 $629.00 $0.00 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $630.87 $630.87 $0.00 $0.00 $177.14 $0.00 $0.00 $0.00 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-09 SUP Custom 27203010 AR-8737-09 - BIT DRL 2.5MM QFIX CNN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-11 SUP Custom 27203010 AR-8737-11 - BIT DRL 4MM QFIX CNN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-17 SUP Custom 27203010 AR-8737-17 - BIT DRL 1.7MM QFIX CNN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-23 SUP Custom 27203010 AR-8737-23 - DRILL BIT CNTRSNK 2-2.4MM QFIX CNN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-24 SUP Custom 27203010 AR-8737-24 - DRILL BIT CNTRSNK 3MM QFIX CNN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-34 SUP Custom 27203010 AR-8737-34 - BIT DRL STRG 2MM CNN DISP MIC CMPR FT SCR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-35 SUP Custom 27203010 AR-8737-35 - BIT DRL STRG 2.7MM CNN 3.5MM MN CMPR FT SCR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-43 SUP Custom 27203010 AR-8737-43 - GUIDE DRL PERC CMPR FT SCR SYS SET BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 $0.00 $0.00 $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-48 SUP Custom 27203010 AR-8737-48 - GUIDE DRL PRLL MIC CMPR FT SCR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-49 SUP Custom 27203010 AR-8737-49 - GUIDE DRL PRLL MN CMPR FT SCR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-50 SUP Custom 27203010 AR-8737-50 - BIT DRL STRG 2.7MM CLBRT CNN STD CMPR FT 4MM SCR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-55 SUP Custom 27203010 AR-8737-55 - GUIDE DRL PRLL 4 MM STD CMPR FT SCR BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $0.00 $0.00 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-57 SUP Custom 27203010 AR-8737-57 - CLAMP XTRNFX PIN PERC CMPR FT SCR SYS SET BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737-58 SUP Custom 27203010 AR-8737-58 - BIT DRL STRG 2.2MM CNN 2.5MM CMPR FT SCR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737C-SC-01 SUP HCPCS C1713 AR-8737C-SC-01 - PLATE STRL QFIX CADDY TOP CNN SCR SYS BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8737H-2 SUP HCPCS C1713 AR-8737H-2 - SET TRMA FX UPGRD CMPR FT SCR BOTH IP/OP "$15,587.50 " "$11,534.75" $0.00 "$12,470.00" "$7,014.38" "$7,014.38" $0.00 $0.00 $0.00 "$3,248.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,248.44" $0.00 "$7,684.64" "$7,684.64" $0.00 "$7,793.75" "$12,345.30" "$12,470.00" $0.00 $0.00 "$2,439.44" $0.00 $0.00 "$2,481.53" $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-14PTS SUP HCPCS C1713 AR-8740-14PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 14MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-16H SUP HCPCS C1713 AR-8740-16H - SCREW BN STD FT 4.6MM 16MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-16PTS SUP HCPCS C1713 AR-8740-16PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 16MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-18H SUP HCPCS C1713 AR-8740-18H - SCREW BN STD FT 4.6MM 18MM QFIX CNN CMPR TI ANKL/FT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-18PTS SUP HCPCS C1713 AR-8740-18PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 18MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-20H SUP HCPCS C1713 AR-8740-20H - SCREW BN STD FT 4.6MM 20MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-20PTS SUP HCPCS C1713 AR-8740-20PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 20MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-22H SUP HCPCS C1713 AR-8740-22H - SCREW BN STD FT 4MM 22MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-22PTS SUP HCPCS C1713 AR-8740-22PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 22MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-24H SUP HCPCS C1713 AR-8740-24H - SCREW BN STD FT 4.6MM 24MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-24PTS SUP HCPCS C1713 AR-8740-24PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 24MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-26H SUP HCPCS C1713 AR-8740-26H - SCREW BN STD FT 4.6MM 26MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-26PTS SUP HCPCS C1713 AR-8740-26PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 26MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-28H SUP HCPCS C1713 AR-8740-28H - SCREW BN STD FT 4.6MM 28MM QFIX CNN CMPR TI ANKL/FT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-28PTS SUP HCPCS C1713 AR-8740-28PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 28MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-30H SUP HCPCS C1713 AR-8740-30H - SCREW BN STD FT 4MM 30MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-30PTL SUP HCPCS C1713 AR-8740-30PTL - SCREW BN LNG P/T LOPRFL 4MM 30MM SLF DRL ST CNN TI SHLDR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-30PTS SUP HCPCS C1713 AR-8740-30PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 30MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-32H SUP HCPCS C1713 AR-8740-32H - SCREW BN STD FT 4.6MM 32MM QFIX CNN CMPR TI ANKL/FT BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-32PTL SUP HCPCS C1713 AR-8740-32PTL - SCREW BN LNG P/T LOPRFL 4MM 32MM SLF DRL ST CNN TI SHLDR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-32PTS SUP HCPCS C1713 AR-8740-32PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 32MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-34H SUP HCPCS C1713 AR-8740-34H - SCREW BN STD FT 4MM 34MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-34PTL SUP HCPCS C1713 AR-8740-34PTL - SCREW BN LNG P/T LOPRFL 4MM 34MM SLF DRL ST CNN TI SHLDR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-34PTS SUP HCPCS C1713 AR-8740-34PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 34MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-36H SUP HCPCS C1713 AR-8740-36H - SCREW BN STD FT 4MM 36MM CNN CMPR VAR STP PTCH TI FT/ANKL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-36PTL SUP HCPCS C1713 AR-8740-36PTL - SCREW BN LNG P/T LOPRFL 4MM 36MM SLF DRL ST CNN TI SHLDR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-36PTS SUP HCPCS C1713 AR-8740-36PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 36MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-38H SUP HCPCS C1713 AR-8740-38H - SCREW BN STD FT 4MM 38MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-38PTL SUP HCPCS C1713 AR-8740-38PTL - SCREW BN LNG P/T LOPRFL 4MM 38MM SLF DRL ST CNN TI SHLDR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-38PTS SUP HCPCS C1713 AR-8740-38PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 38MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-40H SUP HCPCS C1713 AR-8740-40H - SCREW BN STD FT 4MM 40MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-40PTS SUP HCPCS C1713 AR-8740-40PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 40MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-42H SUP HCPCS C1713 AR-8740-42H - SCREW BN STD FT 4.6MM 42MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-42PTS SUP HCPCS C1713 AR-8740-42PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 42MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-44H SUP HCPCS C1713 AR-8740-44H - SCREW BN STD FT 4.6MM 44MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-44PTS SUP HCPCS C1713 AR-8740-44PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 44MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-46H SUP HCPCS C1713 AR-8740-46H - SCREW BN STD FT 4.6MM 46MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-46PTS SUP HCPCS C1713 AR-8740-46PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 46MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-48H SUP HCPCS C1713 AR-8740-48H - SCREW BN STD FT 4.6MM 48MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-48PTS SUP HCPCS C1713 AR-8740-48PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 48MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-50H SUP HCPCS C1713 AR-8740-50H - SCREW BN STD FT 4.6MM 50MM CNN CMPR VAR STP PTCH TI FT HND BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-50PTS SUP HCPCS C1713 AR-8740-50PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 50MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-52PTLS SUP HCPCS C1713 AR-8740-52PTLS - SCREW BN P/T 4MM 52MM STRL ARTHX LOPRFL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-52PTS SUP HCPCS C1713 AR-8740-52PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 52MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-54PTS SUP HCPCS C1713 AR-8740-54PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 54MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-56PTS SUP HCPCS C1713 AR-8740-56PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 56MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-58PTS SUP HCPCS C1713 AR-8740-58PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 58MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740-60PTS SUP HCPCS C1713 AR-8740-60PTS - SCREW BN SHRT P/T T15 HEXALOBE LOPRFL 4MM 60MM QFIX BCMPT BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8740W SUP HCPCS C1713 AR-8740W - WASHER ORTH 7MM TI 4MM QFIX SCR BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8801 SUP Custom 27203010 AR-8801 - SHEATH ASCP GD SLOT BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8825B SUP HCPCS C1713 AR-8825B - ANCHOR SUT MN 2.5MM 8MM STRL BIO-PUSHLOCK BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8825CP SUP Custom 27203010 AR-8825CP - KIT INST 3ANG FIBROCARTILAGE CMPLX DISP BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8825P SUP HCPCS C1713 AR-8825P - ANCHOR SUT MN 2.5MM 8MM STRL PUSHLOCK PEEK BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8826G SUP Custom 27203010 AR-8826G - GUIDE DRL C RING GFT ANCH BOTH IP/OP "$7,187.50 " "$5,318.75" $0.00 "$5,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,497.88" $0.00 $0.00 $0.00 $0.00 "$3,593.75" "$5,692.50" "$5,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-10 SUP HCPCS C1713 AR-8827-10 - SCREW BN 2.7MM 10MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-12 SUP HCPCS C1713 AR-8827-12 - SCREW BN 2.7MM 12MM LOPRFL SCR NONLOCK SS CORT ANKL FX MGMT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-14 SUP HCPCS C1713 AR-8827-14 - SCREW BN 2.7MM 14MM LOPRFL SCR NONLOCK SS CORT ANKL FX MGMT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-16 SUP HCPCS C1713 AR-8827-16 - SCREW BN 2.7MM 16MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-18 SUP HCPCS C1713 AR-8827-18 - SCREW BN 2.7MM 18MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-20 SUP HCPCS C1713 AR-8827-20 - SCREW BN 2.7MM 20MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-22 SUP HCPCS C1713 AR-8827-22 - SCREW BN 2.7MM 22MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-24 SUP HCPCS C1713 AR-8827-24 - SCREW BN 2.7MM 24MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-26 SUP HCPCS C1713 AR-8827-26 - SCREW BN 2.7MM 26MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-28 SUP HCPCS C1713 AR-8827-28 - SCREW BN 2.7MM 28MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-30 SUP HCPCS C1713 AR-8827-30 - SCREW BN 2.7MM 30MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-32 SUP HCPCS C1713 AR-8827-32 - SCREW BN 2.7MM 32MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-34 SUP HCPCS C1713 AR-8827-34 - SCREW BN 2.7MM 34MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-36 SUP HCPCS C1713 AR-8827-36 - SCREW BN 2.7MM 36MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-38 SUP HCPCS C1713 AR-8827-38 - SCREW BN 2.7MM 38MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-40 SUP HCPCS C1713 AR-8827-40 - SCREW BN 2.7MM 40MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-42 SUP HCPCS C1713 AR-8827-42 - SCREW BN 2.7MM 42MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-44 SUP HCPCS C1713 AR-8827-44 - SCREW BN 2.7MM 44MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-46 SUP HCPCS C1713 AR-8827-46 - SCREW BN 2.7MM 46MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-48 SUP HCPCS C1713 AR-8827-48 - SCREW BN 2.7MM 48MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-50 SUP HCPCS C1713 AR-8827-50 - SCREW BN 2.7MM 50MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-52 SUP HCPCS C1713 AR-8827-52 - SCREW BN 2.7MM 52MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-54 SUP HCPCS C1713 AR-8827-54 - SCREW BN 2.7MM 54MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-56 SUP HCPCS C1713 AR-8827-56 - SCREW BN 2.7MM 56MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-58 SUP HCPCS C1713 AR-8827-58 - SCREW BN 2.7MM 56MM NONLOCK LOPRFL ANKL CORT FX MGMT SYS BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827-60 SUP HCPCS C1713 AR-8827-60 - SCREW BN 2.7MM 60MM LOPRFL SCR SLD SHFT SS FT/ANKL CORT BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827D-01 SUP Custom 27203010 AR-8827D-01 - BIT DRL 2.7MM 2.7/3MM SCR ANKL FX MGMT SYS BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827D-02 SUP Custom 27203010 AR-8827D-02 - GUIDE DRL 2.7MM 2MM BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-08 SUP HCPCS C1713 AR-8827L-08 - SCREW BN T10 HEXALOBE FT 2.7MM 8MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-10 SUP HCPCS C1713 AR-8827L-10 - SCREW BN FT T10 HEXALOBE 2.7MM 10MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-12 SUP HCPCS C1713 AR-8827L-12 - SCREW BN FT T10 HEXALOBE 2.7MM 12MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-14 SUP HCPCS C1713 AR-8827L-14 - SCREW BN FT T10 HEXALOBE 2.7MM 14MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-16 SUP HCPCS C1713 AR-8827L-16 - SCREW BN FT T10 HEXALOBE 2.7MM 16MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-18 SUP HCPCS C1713 AR-8827L-18 - SCREW BN FT T10 HEXALOBE 2.7MM 18MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-20 SUP HCPCS C1713 AR-8827L-20 - SCREW BN FT T10 HEXALOBE 2.7MM 20MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-22 SUP HCPCS C1713 AR-8827L-22 - SCREW BN FT T10 HEXALOBE 2.7MM 22MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-24 SUP HCPCS C1713 AR-8827L-24 - SCREW BN FT T10 HEXALOBE 2.7MM 24MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-26 SUP HCPCS C1713 AR-8827L-26 - SCREW BN FT T10 HEXALOBE 2.7MM 26MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-28 SUP HCPCS C1713 AR-8827L-28 - SCREW BN T10 HEXALOBE FT 2.7MM 28MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-30 SUP HCPCS C1713 AR-8827L-30 - SCREW BN 2.7MM 30MM LOPRFL LCK ANKL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-34 SUP HCPCS C1713 AR-8827L-34 - SCREW BN 2.7MM 34MM NS LF LPR ARTHX LCK SS BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-36 SUP HCPCS C1713 AR-8827L-36 - SCREW BN 2.7MM 36MM NS LF LPR ARTHX LCK SS BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-38 SUP HCPCS C1713 AR-8827L-38 - SCREW BN 2.7MM 38MM NS LF LPR ARTHX LCK SS BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-40 SUP HCPCS C1713 AR-8827L-40 - SCREW BN 2.7MM 40MM NS LF LPR ARTHX LCK SS BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-42 SUP HCPCS C1713 AR-8827L-42 - SCREW BN 2.7MM 42MM STRL LOPRFL SCR LCK ANKL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-44 SUP HCPCS C1713 AR-8827L-44 - SCREW BN 2.7MM 44MM LOPRFL SCR LCK BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-46 SUP HCPCS C1713 AR-8827L-46 - SCREW BN 2.7MM 46MM STRL LOPRFL SCR LCK ANKL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-48 SUP HCPCS C1713 AR-8827L-48 - SCREW BN 2.7MM 48MM STRL LOPRFL SCR LCK BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-50 SUP HCPCS C1713 AR-8827L-50 - SCREW BN 2.7MM 50MM LOPRFL SCR LCK ANKL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-52 SUP HCPCS C1713 AR-8827L-52 - SCREW BN 2.7MM 52MM LOPRFL SCR LCK ANKL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-54 SUP HCPCS C1713 AR-8827L-54 - SCREW BN 2.7MM 54MM ARTHX LOPRFL SCR LCK BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-56 SUP HCPCS C1713 AR-8827L-56 - SCREW BN 2.7MM 56MM LOPRFL SCR LCK ANKL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-58 SUP HCPCS C1713 AR-8827L-58 - SCREW BN 2.7MM 58MM ARTHX LOPRFL SCR LCK BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8827L-60 SUP HCPCS C1713 AR-8827L-60 - SCREW BN 2.7MM 60MM LOPRFL SCR LCK ANKL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-10 SUP HCPCS C1713 AR-8830-10 - SCREW BN FT T10 HEXALOBE 3MM 10MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-12 SUP HCPCS C1713 AR-8830-12 - SCREW BN FT T10 HEXALOBE 3MM 12MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-14 SUP HCPCS C1713 AR-8830-14 - SCREW BN FT T10 HEXALOBE 3MM 14MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-16 SUP HCPCS C1713 AR-8830-16 - SCREW BN FT T10 HEXALOBE 3MM 16MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-18 SUP HCPCS C1713 AR-8830-18 - SCREW BN FT T10 HEXALOBE 3MM 18MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-20 SUP HCPCS C1713 AR-8830-20 - SCREW BN FT T10 HEXALOBE 3MM 20MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-22 SUP HCPCS C1713 AR-8830-22 - SCREW BN FT T10 HEXALOBE 3MM 22MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-24 SUP HCPCS C1713 AR-8830-24 - SCREW BN FT T10 HEXALOBE 3MM 24MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-26 SUP HCPCS C1713 AR-8830-26 - SCREW BN FT T10 HEXALOBE 3MM 26MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-28 SUP HCPCS C1713 AR-8830-28 - SCREW BN FT T10 HEXALOBE 3MM 28MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8830-30 SUP HCPCS C1713 AR-8830-30 - SCREW BN FT T10 HEXALOBE 3MM 30MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-08 SUP HCPCS C1713 AR-8835-08 - SCREW BN T15 HEXALOBE FT 3.5MM 8MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-08S SUP HCPCS C1713 AR-8835-08S - SCREW BN 3.5MM 8MM STRL ARTHX LOPRFL CORT BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-10 SUP HCPCS C1713 AR-8835-10 - SCREW BN T15 FT HEXALOBE 3.5MM 10MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-12 SUP HCPCS C1713 AR-8835-12 - SCREW BN T15 FT HEXALOBE 3.5MM 12MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-14 SUP HCPCS C1713 AR-8835-14 - SCREW BN T15 FT HEXALOBE 3.5MM 14MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-16 SUP HCPCS C1713 AR-8835-16 - SCREW BN T15 FT HEXALOBE 3.5MM 16MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-18 SUP HCPCS C1713 AR-8835-18 - SCREW BN T15 FT HEXALOBE 3.5MM 18MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-20 SUP HCPCS C1713 AR-8835-20 - SCREW BN T15 FT HEXALOBE 3.5MM 20MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-22 SUP HCPCS C1713 AR-8835-22 - SCREW BN T15 FT HEXALOBE 3.5MM 22MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-24 SUP HCPCS C1713 AR-8835-24 - SCREW BN T15 FT HEXALOBE 3.5MM 24MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-26 SUP HCPCS C1713 AR-8835-26 - SCREW BN T15 FT HEXALOBE 3.5MM 26MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-28 SUP HCPCS C1713 AR-8835-28 - SCREW BN T15 FT HEXALOBE 3.5MM 28MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-30 SUP HCPCS C1713 AR-8835-30 - SCREW BN T15 HEXALOBE FT 3.5MM 30MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-32 SUP HCPCS C1713 AR-8835-32 - SCREW BN T15 HEXALOBE FT 3.5MM 32MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-34 SUP HCPCS C1713 AR-8835-34 - SCREW BN T15 HEXALOBE FT 3.5MM 34MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-35 SUP HCPCS C1713 AR-8835-35 - SCREW BN T15 FT HEXALOBE 3.5MM 35MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-36 SUP HCPCS C1713 AR-8835-36 - SCREW BN T15 HEXALOBE FT 3.5MM 36MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-38 SUP HCPCS C1713 AR-8835-38 - SCREW BN T15 HEXALOBE FT 3.5MM 38MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-40 SUP HCPCS C1713 AR-8835-40 - SCREW BN T15 FT HEXALOBE 3.5MM 40MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-42 SUP HCPCS C1713 AR-8835-42 - SCREW BN T15 HEXALOBE FT 3.5MM 42MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-44 SUP HCPCS C1713 AR-8835-44 - SCREW BN T15 FT HEXALOBE 3.5MM 44MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-45 SUP HCPCS C1713 AR-8835-45 - SCREW BN T15 FT HEXALOBE 3.5MM 45MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-46 SUP HCPCS C1713 AR-8835-46 - SCREW BN T15 HEXALOBE FT 3.5MM 46MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-48 SUP HCPCS C1713 AR-8835-48 - SCREW BN T15 HEXALOBE FT 3.5MM 48MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-50 SUP HCPCS C1713 AR-8835-50 - SCREW BN T15 FT HEXALOBE 3.5MM 50MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-55 SUP HCPCS C1713 AR-8835-55 - SCREW BN T15 FT HEXALOBE 3.5MM 55MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-60 SUP HCPCS C1713 AR-8835-60 - SCREW BN T15 FT HEXALOBE 3.5MM 60MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-65 SUP HCPCS C1713 AR-8835-65 - SCREW BN HEXALOBE FT 3.5MM 65MM LOPRFL SCR T15 SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-70 SUP HCPCS C1713 AR-8835-70 - SCREW BN HEXALOBE FT 3.5MM 70MM LOPRFL SCR T15 SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-75 SUP HCPCS C1713 AR-8835-75 - SCREW BN HEXALOBE FT 3.5MM 75MM LOPRFL SCR T15 SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835-80 SUP HCPCS C1713 AR-8835-80 - SCREW BN 3.5MM 80MM ARTHX LOPRFL SCR CORT BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-08 SUP HCPCS C1713 AR-8835L-08 - SCREW BN T15 HEXALOBE FT 3.5MM 8MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-10 SUP HCPCS C1713 AR-8835L-10 - SCREW BN T15 FT HEXALOBE 3.5MM 10MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-12 SUP HCPCS C1713 AR-8835L-12 - SCREW BN T15 FT HEXALOBE 3.5MM 12MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-14 SUP HCPCS C1713 AR-8835L-14 - SCREW BN T15 FT HEXALOBE 3.5MM 14MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-16 SUP HCPCS C1713 AR-8835L-16 - SCREW BN T15 FT HEXALOBE 3.5MM 16MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-18 SUP HCPCS C1713 AR-8835L-18 - SCREW BN T15 FT HEXALOBE 3.5MM 18MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-20 SUP HCPCS C1713 AR-8835L-20 - SCREW BN T15 FT HEXALOBE 3.5MM 20MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-22 SUP HCPCS C1713 AR-8835L-22 - SCREW BN T15 FT HEXALOBE 3.5MM 22MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-24 SUP HCPCS C1713 AR-8835L-24 - SCREW BN T15 HEXALOBE FT 3.5MM 24MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-26 SUP HCPCS C1713 AR-8835L-26 - SCREW BN T15 HEXALOBE FT 3.5MM 26MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-28 SUP HCPCS C1713 AR-8835L-28 - SCREW BN T15 HEXALOBE FT 3.5MM 28MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-30 SUP HCPCS C1713 AR-8835L-30 - SCREW BN T15 FT HEXALOBE 3.5MM 30MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-32 SUP HCPCS C1713 AR-8835L-32 - SCREW BN T15 HEXALOBE FT 3.5MM 32MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-34 SUP HCPCS C1713 AR-8835L-34 - SCREW BN T15 HEXALOBE FT 3.5MM 34MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-36 SUP HCPCS C1713 AR-8835L-36 - SCREW BN T15 HEXALOBE FT 3.5MM 36MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-38 SUP HCPCS C1713 AR-8835L-38 - SCREW BN T15 HEXALOBE FT 3.5MM 38MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-40 SUP HCPCS C1713 AR-8835L-40 - SCREW BN T15 FT HEXALOBE 3.5MM 40MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-42 SUP HCPCS C1713 AR-8835L-42 - SCREW BN T15 FT HEXALOBE 3.5MM 42MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-44 SUP HCPCS C1713 AR-8835L-44 - SCREW BN T15 FT HEXALOBE 3.5MM 44MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-45 SUP HCPCS C1713 AR-8835L-45 - SCREW BN T15 FT HEXALOBE 3.5MM 45MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-46 SUP HCPCS C1713 AR-8835L-46 - SCREW BN T15 FT HEXALOBE 3.5MM 46MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-48 SUP HCPCS C1713 AR-8835L-48 - SCREW BN T15 FT HEXALOBE 3.5MM 48MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8835L-50 SUP HCPCS C1713 AR-8835L-50 - SCREW BN T15 HEXALOBE FT 3.5MM 50MM LOPRFL SCR LCK MDLR SLF BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-10 SUP HCPCS C1713 AR-8840-10 - SCREW BN T15 FT HEXALOBE 4MM 10MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-10S SUP HCPCS C1713 AR-8840-10S - SCREW BN 4MM 10MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-12 SUP HCPCS C1713 AR-8840-12 - SCREW BN T15 FT HEXALOBE 4MM 12MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-12S SUP HCPCS C1713 AR-8840-12S - SCREW BN 4MM 12MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-14 SUP HCPCS C1713 AR-8840-14 - SCREW BN T15 FT HEXALOBE 4MM 14MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-16 SUP HCPCS C1713 AR-8840-16 - SCREW BN T15 FT HEXALOBE 4MM 16MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-16S SUP HCPCS C1713 AR-8840-16S - SCREW BN 4MM 16MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-18 SUP HCPCS C1713 AR-8840-18 - SCREW BN T15 FT HEXALOBE 4MM 18MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-18S SUP HCPCS C1713 AR-8840-18S - SCREW BN 4MM 18MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-20 SUP HCPCS C1713 AR-8840-20 - SCREW BN T15 FT HEXALOBE 4MM 20MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-20S SUP HCPCS C1713 AR-8840-20S - SCREW BN 4MM 20MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-22 SUP HCPCS C1713 AR-8840-22 - SCREW BN T15 FT HEXALOBE 4MM 22MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-22S SUP HCPCS C1713 AR-8840-22S - SCREW BN 4MM 22MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-24 SUP HCPCS C1713 AR-8840-24 - SCREW BN T15 FT HEXALOBE 4MM 24MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-26 SUP HCPCS C1713 AR-8840-26 - SCREW BN T15 FT HEXALOBE 4MM 26MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-26S SUP HCPCS C1713 AR-8840-26S - SCREW BN 4MM 26MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-28 SUP HCPCS C1713 AR-8840-28 - SCREW BN T15 FT HEXALOBE 4MM 28MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-28S SUP HCPCS C1713 AR-8840-28S - SCREW BN 4MM 28MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-30 SUP HCPCS C1713 AR-8840-30 - SCREW BN T15 FT HEXALOBE 4MM 30MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-32 SUP HCPCS C1713 AR-8840-32 - SCREW BN T15 FT HEXALOBE 4MM 32MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-32S SUP HCPCS C1713 AR-8840-32S - SCREW BN 4MM 32MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-34 SUP HCPCS C1713 AR-8840-34 - SCREW BN T15 FT HEXALOBE 4MM 34MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-34S SUP HCPCS C1713 AR-8840-34S - SCREW BN 4MM 34MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-36 SUP HCPCS C1713 AR-8840-36 - SCREW BN T15 HEXALOBE FT 4MM 36MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-36S SUP HCPCS C1713 AR-8840-36S - SCREW BN 4MM 36MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-38 SUP HCPCS C1713 AR-8840-38 - SCREW BN T15 FT HEXALOBE 4MM 38MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-38S SUP HCPCS C1713 AR-8840-38S - SCREW BN 4MM 38MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-40 SUP HCPCS C1713 AR-8840-40 - SCREW BN T15 FT HEXALOBE 4MM 40MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-40S SUP HCPCS C1713 AR-8840-40S - SCREW BN 4MM 40MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-42 SUP HCPCS C1713 AR-8840-42 - SCREW BN T15 FT HEXALOBE 4MM 42MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-44 SUP HCPCS C1713 AR-8840-44 - SCREW BN T15 HEXALOBE FT 4MM 44MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-45 SUP HCPCS C1713 AR-8840-45 - SCREW BN T15 FT HEXALOBE 4MM 45MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-46 SUP HCPCS C1713 AR-8840-46 - SCREW BN T15 HEXALOBE FT 4MM 46MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-48 SUP HCPCS C1713 AR-8840-48 - SCREW BN T15 HEXALOBE FT 4MM 48MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-50 SUP HCPCS C1713 AR-8840-50 - SCREW BN T15 HEXALOBE FT 4MM 50MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-50S SUP HCPCS C1713 AR-8840-50S - SCREW BN 4MM 50MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-55 SUP HCPCS C1713 AR-8840-55 - SCREW BN T15 FT HEXALOBE 4MM 55MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-55S SUP HCPCS C1713 AR-8840-55S - SCREW BN 4MM 55MM STRL ARTHX LOPRFL CANC BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840-60 SUP HCPCS C1713 AR-8840-60 - SCREW BN T15 HEXALOBE FT 4MM 60MM LOPRFL SCR MDLR SLF DRL BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-30 SUP HCPCS C1713 AR-8840C-30 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 30MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-32 SUP HCPCS C1713 AR-8840C-32 - SCREW BN ST 4MM 32MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-34 SUP HCPCS C1713 AR-8840C-34 - SCREW BN ST 4MM 34MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-35 SUP HCPCS C1713 AR-8840C-35 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 35MM LOPRFL SCR MDLR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-36 SUP HCPCS C1713 AR-8840C-36 - SCREW BN ST 4MM 36MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-38 SUP HCPCS C1713 AR-8840C-38 - SCREW BN ST 4MM 38MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-40 SUP HCPCS C1713 AR-8840C-40 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 40MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-42 SUP HCPCS C1713 AR-8840C-42 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 42MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-44 SUP HCPCS C1713 AR-8840C-44 - SCREW BN ST 4MM 44MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-45 SUP HCPCS C1713 AR-8840C-45 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 45MM LOPRFL SCR MDLR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-46 SUP HCPCS C1713 AR-8840C-46 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 46MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-48 SUP HCPCS C1713 AR-8840C-48 - SCREW BN ST 4MM 48MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-50 SUP HCPCS C1713 AR-8840C-50 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 50MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-55 SUP HCPCS C1713 AR-8840C-55 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 55MM LOPRFL SCR MDLR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840C-60 SUP HCPCS C1713 AR-8840C-60 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 60MM LOPRFL SCR MDLR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-30 SUP HCPCS C1713 AR-8840CL-30 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 30MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-32 SUP HCPCS C1713 AR-8840CL-32 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 32MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-34 SUP HCPCS C1713 AR-8840CL-34 - SCREW BN L/T 4MM 34MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-35 SUP HCPCS C1713 AR-8840CL-35 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 35MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-36 SUP HCPCS C1713 AR-8840CL-36 - SCREW BN L/T 4MM 36MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-38 SUP HCPCS C1713 AR-8840CL-38 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 38MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-40 SUP HCPCS C1713 AR-8840CL-40 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 40MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-42 SUP HCPCS C1713 AR-8840CL-42 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 42MM LOPRFL SCR MDLR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-44 SUP HCPCS C1713 AR-8840CL-44 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 44MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-45 SUP HCPCS C1713 AR-8840CL-45 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 45MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-46 SUP HCPCS C1713 AR-8840CL-46 - SCREW BN L/T 4MM 46MM LOPRFL SCR CNN SS ANKL FX MGMT SYS BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-48 SUP HCPCS C1713 AR-8840CL-48 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 48MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-50 SUP HCPCS C1713 AR-8840CL-50 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 50MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-55 SUP HCPCS C1713 AR-8840CL-55 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 55MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840CL-60 SUP HCPCS C1713 AR-8840CL-60 - SCREW BN LNG .5 LGTH T15 HEXALOBE 4MM 60MM LOPRFL SCR SLF BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-30 SUP HCPCS C1713 AR-8840P-30 - SCREW BN ST 4MM 30MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-32 SUP HCPCS C1713 AR-8840P-32 - SCREW BN ST 4MM 32MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-34 SUP HCPCS C1713 AR-8840P-34 - SCREW BN ST 4MM 34MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-36 SUP HCPCS C1713 AR-8840P-36 - SCREW BN ST 4MM 36MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-38 SUP HCPCS C1713 AR-8840P-38 - SCREW BN ST 4MM 38MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-40 SUP HCPCS C1713 AR-8840P-40 - SCREW BN SHRT 1/3 LGTH T15 HEXALOBE 4MM 40MM LOPRFL SCR SLF BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-42 SUP HCPCS C1713 AR-8840P-42 - SCREW BN ST 4MM 42MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-44 SUP HCPCS C1713 AR-8840P-44 - SCREW BN ST 4MM 44MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-46 SUP HCPCS C1713 AR-8840P-46 - SCREW BN ST 4MM 46MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-48 SUP HCPCS C1713 AR-8840P-48 - SCREW BN ST 4MM 48MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-50 SUP HCPCS C1713 AR-8840P-50 - SCREW BN ST 4MM 50MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-55 SUP HCPCS C1713 AR-8840P-55 - SCREW BN ST 4MM 55MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840P-60 SUP HCPCS C1713 AR-8840P-60 - SCREW BN ST 4MM 60MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-30 SUP HCPCS C1713 AR-8840PL-30 - SCREW BN L/T 4MM 30MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-32 SUP HCPCS C1713 AR-8840PL-32 - SCREW BN L/T 4MM 32MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-34 SUP HCPCS C1713 AR-8840PL-34 - SCREW BN L/T 4MM 34MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-36 SUP HCPCS C1713 AR-8840PL-36 - SCREW BN L/T 4MM 36MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-38 SUP HCPCS C1713 AR-8840PL-38 - SCREW BN LNG 1/3 LGTH T15 HEXALOBE 4MM 38MM LOPRFL SCR MDLR BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-40 SUP HCPCS C1713 AR-8840PL-40 - SCREW BN L/T 4MM 40MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-42 SUP HCPCS C1713 AR-8840PL-42 - SCREW BN L/T 4MM 42MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-44 SUP HCPCS C1713 AR-8840PL-44 - SCREW BN L/T 4MM 44MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-46 SUP HCPCS C1713 AR-8840PL-46 - SCREW BN LNG 1/3 LGTH T15 HEXALOBE 4MM 46MM LOPRFL SCR MDLR BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-48 SUP HCPCS C1713 AR-8840PL-48 - SCREW BN LNG 1/3 LGTH T15 HEXALOBE 4MM 48MM LOPRFL SCR MDLR BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-50 SUP HCPCS C1713 AR-8840PL-50 - SCREW BN L/T 4MM 50MM LOPRFL SS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-55 SUP HCPCS C1713 AR-8840PL-55 - SCREW BN L/T 4MM 55MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8840PL-60 SUP HCPCS C1713 AR-8840PL-60 - SCREW BN L/T 4MM 60MM LOPRFL SCR SS ANKL FX MGMT SYS BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8870W SUP HCPCS C1713 AR-8870W - WASHER ORTH 7MM BOTH IP/OP $80.25 $59.39 $0.00 $64.20 $36.11 $36.11 $0.00 $0.00 $0.00 $16.73 $59.56 $59.56 $0.00 $0.00 $16.72 $0.00 $47.47 $47.47 $0.00 $40.13 $63.56 $64.20 $0.00 $0.00 $12.56 $0.00 $0.00 $12.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8911DC SUP Custom 27203010 AR-8911DC - BIT DRL CNN MN TGHTRP BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8911DS SUP HCPCS C1713 AR-8911DS - KIT ESCP INST .45IN MN RND 2.7MM 1.6MM STRL TGHTRP BTN CNN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8911G-05 SUP Custom 27203010 AR-8911G-05 - GUIDE DRL KRSH WRE MN TGHTRP BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8912DS SUP HCPCS C1713 AR-8912DS - KIT ESCP INST MN FT STRL TGHTRP BCSCR CNN DRLBT CUP BTN DRVR BOTH IP/OP "$1,700.00 " "$1,258.00" $0.00 "$1,360.00" $765.00 $765.00 $0.00 $0.00 $0.00 $354.32 "$1,261.74" "$1,261.74" $0.00 $0.00 $354.28 $0.00 "$1,005.55" "$1,005.55" $0.00 $850.00 "$1,346.40" "$1,360.00" $0.00 $0.00 $266.05 $0.00 $0.00 $270.64 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8913DS SUP HCPCS C1713 AR-8913DS - BUTTON FX MN TGHTRP INSRTR BOTH IP/OP "$1,512.50 " "$1,119.25" $0.00 "$1,210.00" $680.63 $680.63 $0.00 $0.00 $0.00 $315.24 "$1,122.58" "$1,122.58" $0.00 $0.00 $315.21 $0.00 $894.64 $894.64 $0.00 $756.25 "$1,197.90" "$1,210.00" $0.00 $0.00 $236.71 $0.00 $0.00 $240.79 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8914P SUP HCPCS C1713 AR-8914P - PLATE BN MN TGHTRP BTRS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-05 SUP Custom 27203010 AR-8916-05 - GUIDE DRL 1.7MM 2.5MM BOTH IP/OP $937.50 $693.75 $0.00 $695.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-06 SUP Custom 27203010 AR-8916-06 - BIT DRL 2.5MM CLBRT GRAD 3.5MM LCK CORT SCR BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.17 $126.17 $0.00 $0.00 $35.43 $0.00 $0.00 $0.00 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-07 SUP Custom 27203010 AR-8916-07 - GUIDE DRL 3.5MM 30MM THRD WRST PLT SYS BOTH IP/OP $720.00 $532.80 $0.00 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $534.38 $534.38 $0.00 $0.00 $150.05 $0.00 $0.00 $0.00 $0.00 $360.00 $570.24 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-09 SUP Custom 27203010 AR-8916-09 - GUIDE DRL 2.4MM AIM WRST PLT SYS BOTH IP/OP $790.00 $584.60 $0.00 $632.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.34 $586.34 $0.00 $0.00 $164.64 $0.00 $0.00 $0.00 $0.00 $395.00 $625.68 $632.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-16 SUP HCPCS C1713 AR-8916-16 - SCREW BN ATCH RDS RT DIST VOLR BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-17 SUP HCPCS C1713 AR-8916-17 - SCREW BN ATCH RDS LT DIST VOLR BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-21 SUP Custom 27203010 AR-8916-21 - GUIDE DRL 2.4MM VAL DRP WRST PLT SYS BOTH IP/OP $610.00 $451.40 $0.00 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $452.74 $452.74 $0.00 $0.00 $127.12 $0.00 $0.00 $0.00 $0.00 $305.00 $483.12 $488.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-23 SUP Custom 27203010 AR-8916-23 - GUIDE DRL 2.5MM 1.7MM BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-26 SUP Custom 27203010 AR-8916-26 - GUIDE DRL PRLL Y 1.7MM PLT PERIPROSTHETIC BOTH IP/OP $950.00 $703.00 $0.00 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.09 $705.09 $0.00 $0.00 $197.98 $0.00 $0.00 $0.00 $0.00 $475.00 $752.40 $760.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916-28 SUP Custom 27203010 AR-8916-28 - BIT DRL SHRT 1.7MM GRAD 2.4MM VA LCK CORT SCR BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916CX24-18 SUP HCPCS C1713 AR-8916CX24-18 - SCREW BN 2.4MM CORT BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916DNL-04 SUP HCPCS C1713 AR-8916DNL-04 - PLATE BN NAR 4 HL RDS LT DIST DRSL BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916DNR-04 SUP HCPCS C1713 AR-8916DNR-04 - PLATE BN NAR 4 HL RDS RT DIST DRSL BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916DSL-04 SUP HCPCS C1713 AR-8916DSL-04 - PLATE BN 4 HL RDS LT DIST DRSL BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916DSR-04 SUP HCPCS C1713 AR-8916DSR-04 - PLATE BN STD 4 HL RDS RT DRSL DIST BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916FS SUP HCPCS C1713 AR-8916FS - MODULE INST FRAG SPC SYS BOTH IP/OP "$5,662.50 " "$4,190.25" $0.00 "$4,530.00" "$2,548.13" "$2,548.13" $0.00 $0.00 $0.00 "$1,180.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,180.07" $0.00 "$2,791.61" "$2,791.61" $0.00 "$2,831.25" "$4,484.70" "$4,530.00" $0.00 $0.00 $886.18 $0.00 $0.00 $901.47 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916RSTY-05 SUP HCPCS C1713 AR-8916RSTY-05 - PLATE BN 5 HL WRST RDS 2.4 MM SCR STYLOID BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916SPN SUP HCPCS C1713 AR-8916SPN - PLATE BN 9 HL SPAN TI WRST BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VH-04 SUP HCPCS C1713 AR-8916VH-04 - PLATE BN 4 HL HK RDS VOLR BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VH-06 SUP HCPCS C1713 AR-8916VH-06 - PLATE BN 6 HL HK TI WRST VOLR BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-08 SUP HCPCS C1713 AR-8916VNC-08 - SCREW BN P/T LOPRFL 2.4MM 8MM AU LCK SMTH VA TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-10 SUP HCPCS C1713 AR-8916VNC-10 - SCREW BN P/T LOPRFL 2.4MM 10MM AU LCK SMTH VA TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-12 SUP HCPCS C1713 AR-8916VNC-12 - SCREW BN P/T LOPRFL 2.4MM 12MM AU LCK SMTH VA TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-14 SUP HCPCS C1713 AR-8916VNC-14 - SCREW BN P/T LOPRFL 2.4MM 14MM AU VA LCK SMTH TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-16 SUP HCPCS C1713 AR-8916VNC-16 - SCREW BN P/T LOPRFL 2.4MM 16MM AU VA LCK SMTH TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-18 SUP HCPCS C1713 AR-8916VNC-18 - SCREW BN P/T LOPRFL 2.4MM 18MM AU VA LCK SMTH TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-20 SUP HCPCS C1713 AR-8916VNC-20 - SCREW BN P/T LOPRFL 2.4MM 20MM AU VA LCK SMTH TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-22 SUP HCPCS C1713 AR-8916VNC-22 - SCREW BN P/T LOPRFL 2.4MM 22MM AU VA LCK SMTH TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-24 SUP HCPCS C1713 AR-8916VNC-24 - SCREW BN P/T LOPRFL 2.4MM 24MM AU VA LCK SMTH TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-26 SUP HCPCS C1713 AR-8916VNC-26 - SCREW BN P/T LOPRFL 2.4MM 26MM AU LCK SMTH VA TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-28 SUP HCPCS C1713 AR-8916VNC-28 - SCREW BN P/T LOPRFL 2.4MM 28MM AU LCK SMTH VA TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-30 SUP HCPCS C1713 AR-8916VNC-30 - SCREW BN P/T LOPRFL 2.4MM 30MM AU LCK SMTH VA TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-32 SUP HCPCS C1713 AR-8916VNC-32 - SCREW BN P/T LOPRFL 2.4MM 32MM AU LCK SMTH VA TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNC-34 SUP HCPCS C1713 AR-8916VNC-34 - SCREW BN P/T LOPRFL 2.4MM 34MM AU LCK SMTH VA TI RDS CORT BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNL-03 SUP HCPCS C1713 AR-8916VNL-03 - PLATE BN NAR CNTR 3 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNL-05 SUP HCPCS C1713 AR-8916VNL-05 - PLATE BN NAR CNTR 5 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNL-07 SUP HCPCS C1713 AR-8916VNL-07 - PLATE BN NAR CNTR 7 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNR-03 SUP HCPCS C1713 AR-8916VNR-03 - PLATE BN NAR CNTR 3 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNR-05 SUP HCPCS C1713 AR-8916VNR-05 - PLATE BN NAR CNTR 5 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VNR-07 SUP HCPCS C1713 AR-8916VNR-07 - PLATE BN NAR CNTR 7 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VSL-03 SUP HCPCS C1713 AR-8916VSL-03 - PLATE BN STD CNTR 3 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VSL-05 SUP HCPCS C1713 AR-8916VSL-05 - PLATE BN STD CNTR 5 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VSL-07 SUP HCPCS C1713 AR-8916VSL-07 - PLATE BN STD CNTR 7 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VSL-09 SUP HCPCS C1713 AR-8916VSL-09 - PLATE BN STD CNTR 9 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VSR-03 SUP HCPCS C1713 AR-8916VSR-03 - PLATE BN STD CNTR 3 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VSR-05 SUP HCPCS C1713 AR-8916VSR-05 - PLATE BN STD CNTR 5 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VSR-07 SUP HCPCS C1713 AR-8916VSR-07 - PLATE BN STD CNTR 7 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VSR-09 SUP HCPCS C1713 AR-8916VSR-09 - PLATE BN STD CNTR 9 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VWL-03 SUP HCPCS C1713 AR-8916VWL-03 - PLATE BN W CNTR 3 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VWL-05 SUP HCPCS C1713 AR-8916VWL-05 - PLATE BN W CNTR 5 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VWL-07 SUP HCPCS C1713 AR-8916VWL-07 - PLATE BN W CNTR 7 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VWL-09 SUP HCPCS C1713 AR-8916VWL-09 - PLATE BN W CNTR 9 HL ANTM GFT WDW TI RDS LT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VWR-03 SUP HCPCS C1713 AR-8916VWR-03 - PLATE BN W CNTR 3 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VWR-05 SUP HCPCS C1713 AR-8916VWR-05 - PLATE BN W CNTR 5 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VWR-07 SUP HCPCS C1713 AR-8916VWR-07 - PLATE BN W CNTR 7 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8916VWR-09 SUP HCPCS C1713 AR-8916VWR-09 - PLATE BN W CNTR 9 HL ANTM GFT WDW TI RDS RT WRST VOLR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8917DS SUP HCPCS C1713 AR-8917DS - KIT ESCP INST MN FT 3.5MM STRL TGHTRP DRL GW HNDL INSRTR BOTH IP/OP "$1,575.00 " "$1,165.50" $0.00 "$1,260.00" $708.75 $708.75 $0.00 $0.00 $0.00 $328.27 "$1,168.97" "$1,168.97" $0.00 $0.00 $328.23 $0.00 $931.61 $931.61 $0.00 $787.50 "$1,247.40" "$1,260.00" $0.00 $0.00 $246.49 $0.00 $0.00 $250.74 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8919DS SUP Custom 27203010 AR-8919DS - KIT ASCP FX MN 1.1MM TGHTRP KRSH BTN ANCH SUT CMC BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8920 SUP HCPCS C1763 AR-8920 - BUTTON SUT 3.5MM STRL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8920CDS SUP Custom 27203010 AR-8920CDS - KIT ESCP INST STRL TGHTRP CNN FLXB TI DISP SYNDESMOSIS REPR BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $0.00 $0.00 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8920DC SUP Custom 27203010 AR-8920DC - BIT DRL 3.5MM CNN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8921CDS SUP HCPCS C1769 AR-8921CDS - TIGHTROPE AR-8921CDS BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $712.69 $712.69 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8922 SUP HCPCS C1763 AR-8922 - BUTTON SUT 12MM STRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8923BC SUP HCPCS C1713 AR-8923BC - ANCHOR SUT SHRT MED 2.9MM 2.3MM 12.5MM STRL PUSHLOCK BCMPS BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8923DSC SUP Custom 27203010 AR-8923DSC - KIT INST SHRT DRLBT DRL GD DISP 2.9/12.5MM BCMPS PUSHLOCK BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8926SS SUP Custom 27203010 AR-8926SS - KIT ESCP INST STRL TGHTRP CNN SS SYNDESMOSIS REPR ASCP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8926T SUP Custom 27203010 AR-8926T - KIT ESCP INST STRL TGHTRP SUT TI DESMOSIS REPR ASCP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 $0.00 $0.00 $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8927BC SUP HCPCS C1713 AR-8927BC - ANCHOR SUT 1 LG FT TPR 3.4MM 15MM CSCR FWR TIGERWIRE BRD NDL BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $365.63 $365.63 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $127.16 $0.00 $0.00 $129.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8927BCNF-CP SUP HCPCS C1713 AR-8927BCNF-CP - SET IMPL STRL LF ARTHX SUTUREBRIDGE BCMPS DISP AHLS PK BOTH IP/OP "$3,987.50 " "$2,950.75" $0.00 "$3,190.00" "$1,794.38" "$1,794.38" $0.00 $0.00 $0.00 $831.09 "$2,959.52" "$2,959.52" $0.00 $0.00 $831.00 $0.00 "$1,965.84" "$1,965.84" $0.00 "$1,993.75" "$3,158.10" "$3,190.00" $0.00 $0.00 $624.04 $0.00 $0.00 $634.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8927BNF SUP HCPCS C1713 AR-8927BNF - ANCHOR SUT 1 LG FT TPR 5.5MM 15MM BCSCR FWR BRD NDL POLY L BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8927BNF-CP SUP HCPCS C1713 AR-8927BNF-CP - SET IMPL LG TPR SUTUREBRIDGE ANCH DRL GD NDL PNCH TAP AHLS BOTH IP/OP "$3,100.00 " "$2,294.00" $0.00 "$2,480.00" "$1,395.00" "$1,395.00" $0.00 $0.00 $0.00 $646.12 "$2,300.82" "$2,300.82" $0.00 $0.00 $646.04 $0.00 "$1,528.30" "$1,528.30" $0.00 "$1,550.00" "$2,455.20" "$2,480.00" $0.00 $0.00 $485.15 $0.00 $0.00 $493.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8927DSC SUP Custom 27203010 AR-8927DSC - KIT INST DISP 4.5/14MM BCMPS CRKSCR BOTH IP/OP $437.50 $323.75 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8927P-CP SUP HCPCS C1713 AR-8927P-CP - SET IMPL SUTUREBRIDGE DRL GD PNCH PUSHLOCK TAP PEEK AHLS PK BOTH IP/OP "$3,100.00 " "$2,294.00" $0.00 "$2,480.00" "$1,395.00" "$1,395.00" $0.00 $0.00 $0.00 $646.12 "$2,300.82" "$2,300.82" $0.00 $0.00 $646.04 $0.00 "$1,528.30" "$1,528.30" $0.00 "$1,550.00" "$2,455.20" "$2,480.00" $0.00 $0.00 $485.15 $0.00 $0.00 $493.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8928BC-CP SUP HCPCS C1713 AR-8928BC-CP - SET IMPL SUTUREBRIDGE ANCH DRILL GUIDE PNCH TAP BOTH IP/OP "$4,350.00 " "$3,219.00" $0.00 "$3,480.00" "$1,957.50" "$1,957.50" $0.00 $0.00 $0.00 $906.65 "$3,228.57" "$3,228.57" $0.00 $0.00 $906.54 $0.00 "$2,144.55" "$2,144.55" $0.00 "$2,175.00" "$3,445.20" "$3,480.00" $0.00 $0.00 $680.78 $0.00 $0.00 $692.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8928BCJ-CP SUP HCPCS C1713 AR-8928BCJ-CP - SYSTEM FX STRL SPEEDBRIDGE JUMPSTART BCMPS AHLS BOTH IP/OP "$4,987.50 " "$3,690.75" $0.00 "$3,990.00" "$2,244.38" "$2,244.38" $0.00 $0.00 $0.00 "$1,039.52" "$3,701.72" "$3,701.72" $0.00 $0.00 "$1,039.40" $0.00 "$2,458.84" "$2,458.84" $0.00 "$2,493.75" "$3,950.10" "$3,990.00" $0.00 $0.00 $780.54 $0.00 $0.00 $794.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8928P-CP SUP HCPCS C1713 AR-8928P-CP - SET IMPL SUTUREBRIDGE ANCH DRL GD PNCH TAP PEEK AHLS PK BOTH IP/OP "$4,350.00 " "$3,219.00" $0.00 "$3,480.00" "$1,957.50" "$1,957.50" $0.00 $0.00 $0.00 $906.65 "$3,228.57" "$3,228.57" $0.00 $0.00 $906.54 $0.00 "$2,144.55" "$2,144.55" $0.00 "$2,175.00" "$3,445.20" "$3,480.00" $0.00 $0.00 $680.78 $0.00 $0.00 $692.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8928PJ-CP SUP HCPCS C1713 AR-8928PJ-CP - SYSTEM IMPL STRL ARTHX SPEEDBRIDGE JUMPSTART AHLS BOTH IP/OP "$4,987.50 " "$3,690.75" $0.00 "$3,990.00" "$2,244.38" "$2,244.38" $0.00 $0.00 $0.00 "$1,039.52" "$3,701.72" "$3,701.72" $0.00 $0.00 "$1,039.40" $0.00 "$2,458.84" "$2,458.84" $0.00 "$2,493.75" "$3,950.10" "$3,990.00" $0.00 $0.00 $780.54 $0.00 $0.00 $794.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8930-10 SUP HCPCS C1713 AR-8930-10 - SCREW BN FT 2MM 10MM SLVR QFIX 3 PR SLF DRL ST SNPOF SLD TI BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8930-11 SUP HCPCS C1713 AR-8930-11 - SCREW BN FT 2MM 11MM MAG QFIX 3 PR SLF DRL ST SNPOF SLD TI BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8930-12 SUP HCPCS C1713 AR-8930-12 - SCREW BN FT 2MM 12MM BLU QFIX 3 PR SLF DRL ST SNPOF SLD TI BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8930-13 SUP HCPCS C1713 AR-8930-13 - SCREW BN FT 2MM 13MM GRN QFIX 3 PR SLF DRL ST SNPOF SLD TI BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8930-14 SUP HCPCS C1713 AR-8930-14 - SCREW BN FT 2MM 14MM PUR QFIX 3 PR SLF DRL ST SNPOF SLD TI BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8930D-13 SUP Custom 27203010 AR-8930D-13 - BIT DRL 1.3MM 2MM QFIX SCR BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8930MC SUP Custom 27203010 AR-8930MC - CLAMP SRG QFIX WEIL OSTM BOTH IP/OP "$3,987.50 " "$2,950.75" $0.00 "$2,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.52" "$2,959.52" $0.00 $0.00 $831.00 $0.00 $0.00 $0.00 $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8930MCS SUP Custom 27203010 AR-8930MCS - CLAMP SRG QFIX INST SET BOTH IP/OP "$4,737.50 " "$3,505.75" $0.00 "$3,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,516.17" "$3,516.17" $0.00 $0.00 $987.30 $0.00 $0.00 $0.00 $0.00 "$2,368.75" "$3,752.10" "$3,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8931-13 SUP HCPCS C1713 AR-8931-13 - SCREW BN FT 3MM 13MM YLW QFIX 3 PR SLF DRL SNPOF TI FT HND BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8931-15 SUP HCPCS C1713 AR-8931-15 - SCREW BN FT 3MM 15MM LGHT BLU QFIX 3 PR SLF DRL SNPOF TI FT BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8931-17 SUP HCPCS C1713 AR-8931-17 - SCREW BN FT 3MM 17MM AQ QFIX 3 PR SLF DRL SNPOF TI FT HND BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8931-17S SUP HCPCS C1713 AR-8931-17S - SCREW BN 3MM 17MM STRL ARTHX QFIX BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8931-19 SUP HCPCS C1713 AR-8931-19 - SCREW BN FT 3MM 19MM BRNZ QFIX 3 PR SLF DRL SNPOF TI FT HND BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-10 SUP HCPCS C1713 AR-8933-10 - SCREW BN FT T10 HEXALOBE 3MM 10MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-10PT SUP HCPCS C1713 AR-8933-10PT - SCREW BN 2.5MM HEX P/T 3MM 10MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-12 SUP HCPCS C1713 AR-8933-12 - SCREW BN FT T10 HEXALOBE 3MM 12MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-12PT SUP HCPCS C1713 AR-8933-12PT - SCREW BN 2.5MM P/T HEX 3MM 12MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-14 SUP HCPCS C1713 AR-8933-14 - SCREW BN FT T10 HEXALOBE 3MM 14MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-14PT SUP HCPCS C1713 AR-8933-14PT - SCREW BN 2.5MM P/T HEX 3MM 14MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-16 SUP HCPCS C1713 AR-8933-16 - SCREW BN FT T10 HEXALOBE 3MM 16MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-16PT SUP HCPCS C1713 AR-8933-16PT - SCREW BN 2.5MM P/T HEX 3MM 16MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-18 SUP HCPCS C1713 AR-8933-18 - SCREW BN T10 HEXALOBE FT 3MM 18MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-18PT SUP HCPCS C1713 AR-8933-18PT - SCREW BN 2.5MM P/T HEX 3MM 18MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-18PTS SUP HCPCS C1713 AR-8933-18PTS - SCREW BN P/T 3MM 18MM STRL ARTHX LOPRFL SCR CNN TI BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-20 SUP HCPCS C1713 AR-8933-20 - SCREW BN FT T10 HEXALOBE 3MM 20MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-20C SUP Custom 27203010 AR-8933-20C - BIT DRL 2MM CNN AO BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-20PT SUP HCPCS C1713 AR-8933-20PT - SCREW BN 2.5MM P/T HEX 3MM 20MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-20PTS SUP HCPCS C1713 AR-8933-20PTS - SCREW BN P/T 3MM 20MM STRL ARTHX LOPRFL SCR CNN TI BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-22 SUP HCPCS C1713 AR-8933-22 - SCREW BN FT T10 HEXALOBE 3MM 22MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-22PT SUP HCPCS C1713 AR-8933-22PT - SCREW BN 2.5MM P/T HEX 3MM 22MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-24 SUP HCPCS C1713 AR-8933-24 - SCREW BN FT T10 HEXALOBE 3MM 24MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-24PT SUP HCPCS C1713 AR-8933-24PT - SCREW BN 2.5MM P/T HEX 3MM 24MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-26 SUP HCPCS C1713 AR-8933-26 - SCREW BN T10 HEXALOBE FT 3MM 26MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-26PT SUP HCPCS C1713 AR-8933-26PT - SCREW BN 2.5MM P/T HEX 3MM 26MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-28 SUP HCPCS C1713 AR-8933-28 - SCREW BN FT T10 HEXALOBE 3MM 28MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-28PT SUP HCPCS C1713 AR-8933-28PT - SCREW BN 2.5MM P/T HEX 3MM 28MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-30 SUP HCPCS C1713 AR-8933-30 - SCREW BN T10 HEXALOBE FT 3MM 30MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-30C SUP Custom 27203010 AR-8933-30C - BIT DRL 3MM CNN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-30PT SUP HCPCS C1713 AR-8933-30PT - SCREW BN 2.5MM P/T HEX 3MM 30MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-30PTS SUP HCPCS C1713 AR-8933-30PTS - SCREW BN P/T 3MM 30MM STRL ARTHX LOPRFL SCR CNN TI BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $39.38 $39.38 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-32PT SUP HCPCS C1713 AR-8933-32PT - SCREW BN 2.5MM P/T HEX 3MM 32MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-34 SUP HCPCS C1713 AR-8933-34 - SCREW BN T10 HEXALOBE FT 3MM 34MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-34PT SUP HCPCS C1713 AR-8933-34PT - SCREW BN 2.5MM HEX P/T 3MM 34MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-36 SUP HCPCS C1713 AR-8933-36 - SCREW BN T10 HEXALOBE FT 3MM 36MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-36PT SUP HCPCS C1713 AR-8933-36PT - SCREW BN 2.5MM P/T HEX 3MM 36MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-38 SUP HCPCS C1713 AR-8933-38 - SCREW BN T10 HEXALOBE FT 3MM 38MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-38PT SUP HCPCS C1713 AR-8933-38PT - SCREW BN 2.5MM P/T HEX 3MM 38MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-40 SUP HCPCS C1713 AR-8933-40 - SCREW BN T10 HEXALOBE FT 3MM 40MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $123.75 $123.75 $0.00 $0.00 $0.00 $57.32 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $162.66 $162.66 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933-40PT SUP HCPCS C1713 AR-8933-40PT - SCREW BN 2.5MM P/T HEX 3MM 40MM LOPRFL SCR SLF DRL ST CNN TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933G SUP Custom 27203010 AR-8933G - GUIDE DRL LOPRFL 1.1-2MM BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $0.00 $0.00 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933GV SUP Custom 27203010 AR-8933GV - GUIDE DRL 3MM VA BOTH IP/OP "$1,037.50 " $767.75 $0.00 $830.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $770.03 $770.03 $0.00 $0.00 $216.22 $0.00 $0.00 $0.00 $0.00 $518.75 $821.70 $830.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-10 SUP HCPCS C1713 AR-8933L-10 - SCREW BN FT T10 HEXALOBE 3MM 10MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-12 SUP HCPCS C1713 AR-8933L-12 - SCREW BN FT T10 HEXALOBE 3MM 12MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-14 SUP HCPCS C1713 AR-8933L-14 - SCREW BN FT T10 HEXALOBE 3MM 14MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-16 SUP HCPCS C1713 AR-8933L-16 - SCREW BN FT T10 HEXALOBE 3MM 16MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-18 SUP HCPCS C1713 AR-8933L-18 - SCREW BN T10 HEXALOBE FT 3MM 18MM SLF DRL SLD LCK LOPRFL TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-20 SUP HCPCS C1713 AR-8933L-20 - SCREW BN FT T10 3MM 20MM SLF DRL SLD LCK LOPRFL TI FOREFOOT BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-22 SUP HCPCS C1713 AR-8933L-22 - SCREW BN FT T10 HEXALOBE 3MM 22MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-24 SUP HCPCS C1713 AR-8933L-24 - SCREW BN FT T10 HEXALOBE 3MM 24MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-26 SUP HCPCS C1713 AR-8933L-26 - SCREW BN T10 HEXALOBE FT 3MM 26MM LCK SLF DRL SLD TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-28 SUP HCPCS C1713 AR-8933L-28 - SCREW BN 3MM 28MM LCK LOPRFL TI FT HND ANKL WRST BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-30 SUP HCPCS C1713 AR-8933L-30 - SCREW BN 3MM 30MM LCK LOPRFL TI FT HND ANKL WRST BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-32 SUP HCPCS C1713 AR-8933L-32 - SCREW BN 3MM 32MM LCK TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-36 SUP HCPCS C1713 AR-8933L-36 - SCREW BN 3MM 36MM LOPRFL LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-38 SUP HCPCS C1713 AR-8933L-38 - SCREW BN 3MM 38MM LCK TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933L-40 SUP HCPCS C1713 AR-8933L-40 - SCREW BN 3MM 40MM LCK TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $123.75 $123.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-10 SUP HCPCS C1713 AR-8933V-10 - SCREW BN 3MM 10MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-12 SUP HCPCS C1713 AR-8933V-12 - SCREW BN 3MM 12MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-14 SUP HCPCS C1713 AR-8933V-14 - SCREW BN 3MM 14MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-16 SUP HCPCS C1713 AR-8933V-16 - SCREW BN 3MM 16MM VA LCK TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-18 SUP HCPCS C1713 AR-8933V-18 - SCREW BN 3MM 18MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-20 SUP HCPCS C1713 AR-8933V-20 - SCREW BN 3MM 20MM VA LCK TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-22 SUP HCPCS C1713 AR-8933V-22 - SCREW BN 3MM 22MM VA LCK TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-24 SUP HCPCS C1713 AR-8933V-24 - SCREW BN 3MM 24MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-26 SUP HCPCS C1713 AR-8933V-26 - SCREW BN 3MM 26MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-28 SUP HCPCS C1713 AR-8933V-28 - SCREW BN 3MM 28MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-30 SUP HCPCS C1713 AR-8933V-30 - SCREW BN 3MM 30MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-32 SUP HCPCS C1713 AR-8933V-32 - SCREW BN 3MM 32MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-34 SUP HCPCS C1713 AR-8933V-34 - SCREW BN 3MM 34MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-36 SUP HCPCS C1713 AR-8933V-36 - SCREW BN 3MM 36MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-38 SUP HCPCS C1713 AR-8933V-38 - SCREW BN 3MM 38MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8933V-40 SUP HCPCS C1713 AR-8933V-40 - SCREW BN 3MM 40MM LCK VA TI FT BOTH IP/OP $437.50 $323.75 $0.00 $324.71 $157.50 $157.50 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8934BCNF SUP HCPCS C1713 AR-8934BCNF - ANCHOR SUTURE 1 .5 CIR 2 DIAMOND 26.2MM NEEDLE SUTURETAK BOTH IP/OP $812.50 $601.25 $0.00 $930.00 $523.13 $523.13 $0.00 $0.00 $0.00 $169.35 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $480.59 $480.59 $0.00 $581.25 $920.70 $930.00 $0.00 $0.00 $181.93 $0.00 $0.00 $185.07 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8934BCNF-00 SUP HCPCS C1713 AR-8934BCNF-00 - ANCHOR SUT 0 .5 CRC 4 DMD 22.2MM SUT TK FBRWR NDL BCMPS S BOTH IP/OP "$4,062.50 " "$3,006.25" $0.00 "$3,250.00" "$1,828.13" "$1,828.13" $0.00 $0.00 $0.00 $846.73 "$3,015.19" "$3,015.19" $0.00 $0.00 $846.63 $0.00 "$2,002.81" "$2,002.81" $0.00 "$2,031.25" "$3,217.50" "$3,250.00" $0.00 $0.00 $635.78 $0.00 $0.00 $646.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8934DSC SUP Custom 27203010 AR-8934DSC - KIT INSTR 2.4MM DRILL GUIDE STEP DRILL DISPOSABLE SMALL BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-10 SUP HCPCS C1713 AR-8935-10 - SCREW BN T15 HEXALOBE FT 3.5MM 10MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-11 SUP HCPCS C1713 AR-8935-11 - SCREW BN T15 HEXALOBE FT 3.5MM 11MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-12 SUP HCPCS C1713 AR-8935-12 - SCREW BN T15 FT HEXALOBE 3.5MM 12MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-13 SUP HCPCS C1713 AR-8935-13 - SCREW BN T15 FT HEXALOBE 3.5MM 13MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-14 SUP HCPCS C1713 AR-8935-14 - SCREW BN T15 FT HEXALOBE 3.5MM 14MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-16 SUP HCPCS C1713 AR-8935-16 - SCREW BN T15 FT HEXALOBE 3.5MM 16MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-18 SUP HCPCS C1713 AR-8935-18 - SCREW BN T15 FT HEXALOBE 3.5MM 18MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-20 SUP HCPCS C1713 AR-8935-20 - SCREW BN T15 FT HEXALOBE 3.5MM 20MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-22 SUP HCPCS C1713 AR-8935-22 - SCREW BN T15 FT HEXALOBE 3.5MM 22MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-28 SUP HCPCS C1713 AR-8935-28 - SCREW BN T15 FT HEXALOBE 3.5MM 28MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-30 SUP HCPCS C1713 AR-8935-30 - SCREW BN T15 FT HEXALOBE 3.5MM 30MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-34 SUP HCPCS C1713 AR-8935-34 - SCREW BN T15 FT HEXALOBE 3.5MM 34MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-36 SUP HCPCS C1713 AR-8935-36 - SCREW BN T15 FT HEXALOBE 3.5MM 36MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-38 SUP HCPCS C1713 AR-8935-38 - SCREW BN T15 FT HEXALOBE 3.5MM 38MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-40 SUP HCPCS C1713 AR-8935-40 - SCREW BN T15 FT HEXALOBE 3.5MM 40MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-42 SUP HCPCS C1713 AR-8935-42 - SCREW BN T15 FT HEXALOBE 3.5MM 42MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-44 SUP HCPCS C1713 AR-8935-44 - SCREW BN T15 FT HEXALOBE 3.5MM 44MM LOPRFL SCR SLF DRL SLD BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-46 SUP HCPCS C1713 AR-8935-46 - SCREW BN 3.5MM 46MM LOPRFL TI FT/ANKL CORT BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-48 SUP HCPCS C1713 AR-8935-48 - SCREW BN 3.5MM 48MM LOPRFL TI CORT BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-50 SUP HCPCS C1713 AR-8935-50 - SCREW BN 3.5MM 50MM LOPRFL TI FT/ANKL CORT BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-52 SUP HCPCS C1713 AR-8935-52 - SCREW BN 3.5MM 52MM LOPRFL TI CORT BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-54 SUP HCPCS C1713 AR-8935-54 - SCREW BN 3.5MM 54MM LOPRFL TI FT/ANKL CORT BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-56 SUP HCPCS C1713 AR-8935-56 - SCREW BN 3.5MM 56MM LOPRFL TI FT/ANKL CORT BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-58 SUP HCPCS C1713 AR-8935-58 - SCREW BN 3.5MM 58MM LOPRFL TI FT/ANKL CORT BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935-60 SUP HCPCS C1713 AR-8935-60 - SCREW BN 3.5MM 60MM LOPRFL TI FT/ANKL CORT BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935G SUP Custom 27203010 AR-8935G - GUIDE DRL 3.5MM 4MM BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935GV SUP Custom 27203010 AR-8935GV - GUIDE DRL 3.5MM VA BOTH IP/OP "$1,037.50 " $767.75 $0.00 $830.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $770.03 $770.03 $0.00 $0.00 $216.22 $0.00 $0.00 $0.00 $0.00 $518.75 $821.70 $830.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935GVN SUP Custom 27203010 AR-8935GVN - GUIDE DRL 3.5MM LCK VA BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-10 SUP HCPCS C1713 AR-8935L-10 - SCREW BN 3.5MM 10MM LOPRFL LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-12 SUP HCPCS C1713 AR-8935L-12 - SCREW BN 3.5MM 12MM LCK LOPRFL TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-14 SUP HCPCS C1713 AR-8935L-14 - SCREW BN T15 FT HEXALOBE 3.5MM 14MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-16 SUP HCPCS C1713 AR-8935L-16 - SCREW BN 3.5MM 16MM LCK TI MIDFOOT CORT BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-20 SUP HCPCS C1713 AR-8935L-20 - SCREW BN T15 FT HEXALOBE 3.5MM 20MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-22 SUP HCPCS C1713 AR-8935L-22 - SCREW BN T15 FT HEXALOBE 3.5MM 22MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-24 SUP HCPCS C1713 AR-8935L-24 - SCREW BN T15 FT HEXALOBE 3.5MM 24MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-26 SUP HCPCS C1713 AR-8935L-26 - SCREW BN T15 FT HEXALOBE 3.5MM 26MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-28 SUP HCPCS C1713 AR-8935L-28 - SCREW BN T15 FT HEXALOBE 3.5MM 28MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-30 SUP HCPCS C1713 AR-8935L-30 - SCREW BN T15 FT HEXALOBE 3.5MM 30MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-32 SUP HCPCS C1713 AR-8935L-32 - SCREW BN T15 FT HEXALOBE 3.5MM 32MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-34 SUP HCPCS C1713 AR-8935L-34 - SCREW BN T15 FT HEXALOBE 3.5MM 34MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-36 SUP HCPCS C1713 AR-8935L-36 - SCREW BN T15 FT HEXALOBE 3.5MM 36MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-38 SUP HCPCS C1713 AR-8935L-38 - SCREW BN T15 FT HEXALOBE 3.5MM 38MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-40 SUP HCPCS C1713 AR-8935L-40 - SCREW BN T15 FT HEXALOBE 3.5MM 40MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-42 SUP HCPCS C1713 AR-8935L-42 - SCREW BN T15 FT HEXALOBE 3.5MM 42MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-44 SUP HCPCS C1713 AR-8935L-44 - SCREW BN T15 FT HEXALOBE 3.5MM 44MM SLF DRL SLD LCK TI BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-46 SUP HCPCS C1713 AR-8935L-46 - SCREW BN 3.5MM 46MM LCK LOPRFL TI HND ANKL LNG BN BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-48 SUP HCPCS C1713 AR-8935L-48 - SCREW BN 3.5MM 48MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-50 SUP HCPCS C1713 AR-8935L-50 - SCREW BN 3.5MM 50MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-52 SUP HCPCS C1713 AR-8935L-52 - SCREW BN 3.5MM 52MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-54 SUP HCPCS C1713 AR-8935L-54 - SCREW BN 3.5MM 54MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-56 SUP HCPCS C1713 AR-8935L-56 - SCREW BN 3.5MM 56MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-58 SUP HCPCS C1713 AR-8935L-58 - SCREW BN 3.5MM 58MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8935L-60 SUP HCPCS C1713 AR-8935L-60 - SCREW BN 3.5MM 60MM LCK LOPRFL TI FT/ANKL BOTH IP/OP $375.00 $277.50 $0.00 $278.33 $95.63 $95.63 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8936BC-CP SUP HCPCS C1713 AR-8936BC-CP - KIT ESCP INST CNN STP DRL DRL GD OBT BROSTROM ASCP BOTH IP/OP "$3,625.00 " "$2,682.50" $0.00 "$2,900.00" "$1,631.25" "$1,631.25" $0.00 $0.00 $0.00 $755.54 "$2,690.48" "$2,690.48" $0.00 $0.00 $755.45 $0.00 "$1,787.13" "$1,787.13" $0.00 "$1,812.50" "$2,871.00" "$2,900.00" $0.00 $0.00 $567.31 $0.00 $0.00 $577.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8938P SUP HCPCS C1713 AR-8938P - KIT INST RD YLW 2 EYLT CNVR LCK DRVR SMPL SNP SUT LDR PEEK BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $219.38 $219.38 $0.00 $0.00 $0.00 $101.61 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $288.36 $288.36 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-14 SUP HCPCS C1713 AR-8940-14 - SCREW BN T15 FT HEXALOBE 4MM 14MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-16 SUP HCPCS C1713 AR-8940-16 - SCREW BN T15 FT HEXALOBE 4MM 16MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-16S SUP HCPCS C1713 AR-8940-16S - SCREW BN 4MM 16MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-18 SUP HCPCS C1713 AR-8940-18 - SCREW BN T15 FT HEXALOBE 4MM 18MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-18S SUP HCPCS C1713 AR-8940-18S - SCREW BN 4MM 18MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-20 SUP HCPCS C1713 AR-8940-20 - SCREW BN T15 FT HEXALOBE 4MM 20MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-20S SUP HCPCS C1713 AR-8940-20S - SCREW BN 4MM 20MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-22 SUP HCPCS C1713 AR-8940-22 - SCREW BN T15 FT HEXALOBE 4MM 22MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-22S SUP HCPCS C1713 AR-8940-22S - SCREW BN 4MM 22MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-24 SUP HCPCS C1713 AR-8940-24 - SCREW BN T15 FT HEXALOBE 4MM 24MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-26 SUP HCPCS C1713 AR-8940-26 - SCREW BN T15 FT HEXALOBE 4MM 26MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-28 SUP HCPCS C1713 AR-8940-28 - SCREW BN T15 FT HEXALOBE 4MM 28MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-28S SUP HCPCS C1713 AR-8940-28S - SCREW BN 4MM 28MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-30 SUP HCPCS C1713 AR-8940-30 - SCREW BN T15 FT HEXALOBE 4MM 30MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-30S SUP HCPCS C1713 AR-8940-30S - SCREW BN 4MM 30MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-32 SUP HCPCS C1713 AR-8940-32 - SCREW BN T15 FT HEXALOBE 4MM 32MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-32S SUP HCPCS C1713 AR-8940-32S - SCREW BN 4MM 32MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-34 SUP HCPCS C1713 AR-8940-34 - SCREW BN T15 FT HEXALOBE 4MM 34MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-36 SUP HCPCS C1713 AR-8940-36 - SCREW BN T15 FT HEXALOBE 4MM 36MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-38 SUP HCPCS C1713 AR-8940-38 - SCREW BN T15 FT HEXALOBE 4MM 38MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-40 SUP HCPCS C1713 AR-8940-40 - SCREW BN T15 FT HEXALOBE 4MM 40MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-40S SUP HCPCS C1713 AR-8940-40S - SCREW BN 4MM 40MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-42 SUP HCPCS C1713 AR-8940-42 - SCREW BN T15 FT HEXALOBE 4MM 42MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-42S SUP HCPCS C1713 AR-8940-42S - SCREW BN 4MM 42MM STRL ARTHX LOPRFL SCR TI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-44 SUP HCPCS C1713 AR-8940-44 - SCREW BN T15 FT HEXALOBE 4MM 44MM LOPRFL SCR SLF DRL SLD TI BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-46 SUP HCPCS C1713 AR-8940-46 - SCREW BN 4MM 46MM LOPRFL TI FT/ANKL CANC BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-48 SUP HCPCS C1713 AR-8940-48 - SCREW BN 4MM 48MM LOPRFL TI FT/ANKL CANC BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-50 SUP HCPCS C1713 AR-8940-50 - SCREW BN 4MM 50MM LOPRFL TI HND ANKL LNG BN BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-52 SUP HCPCS C1713 AR-8940-52 - SCREW BN 4MM 52MM LOPRFL TI FT/ANKL CANC BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-54 SUP HCPCS C1713 AR-8940-54 - SCREW BN 4MM 54MM LOPRFL TI FT/ANKL CANC BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-56 SUP HCPCS C1713 AR-8940-56 - SCREW BN 4MM 56MM LOPRFL TI FT/ANKL CANC BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-58 SUP HCPCS C1713 AR-8940-58 - SCREW BN 4MM 58MM LOPRFL TI FT/ANKL CANC BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8940-60 SUP HCPCS C1713 AR-8940-60 - SCREW BN 4MM 60MM LOPRFL TI FT/ANKL CANC BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8941-6 SUP HCPCS C1769 AR-8941-6 - WIRE FIX .062IN .062IN 6IN KWIRE BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $54.30 $54.30 $0.00 $0.00 $0.00 $20.84 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8941-7 SUP HCPCS C1769 AR-8941-7 - WIRE FIX .062IN .062IN 7IN KWIRE BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $54.30 $54.30 $0.00 $0.00 $0.00 $20.84 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8941G SUP Custom 27203010 AR-8941G - GUIDE DRL 3.5/4 MM MTL SCR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8941GL SUP Custom 27203010 AR-8941GL - GUIDE DRL D LCK BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8941L SUP HCPCS C1713 AR-8941L - PLATE BN LNG LOPRFL FT/ANKL LAPIDUS LISFRANC BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $731.25 $731.25 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8941PLS SUP HCPCS C1713 AR-8941PLS - PLATE BN SHRT LOPRFL PRECONTOUR TI PLNTR LT LAPIDUS BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8941PR SUP HCPCS C1713 AR-8941PR - PLATE BN PLNTR RT LAPIDUS BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8941PRS SUP HCPCS C1713 AR-8941PRS - PLATE BN SHRT PLNTR RT LAPIDUS BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942-02 SUP Custom 27203010 AR-8942-02 - BIT DRL WDG 1.7MM EVANS DISP BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942-03 SUP Custom 27203010 AR-8942-03 - GUIDE DRL 1.7MM EVANS WDG BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942L-06 SUP HCPCS C1713 AR-8942L-06 - PLATE BN H WDG LOPRFL 34X16X6MM TI MIDFOOT LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $731.25 $731.25 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942L-08 SUP HCPCS C1713 AR-8942L-08 - PLATE BN H WDG LOPRFL 36X16X8MM TI MIDFOOT LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $731.25 $731.25 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942L-10 SUP HCPCS C1713 AR-8942L-10 - PLATE BN H WDG LOPRFL 36X16X10MM TI MIDFOOT LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $731.25 $731.25 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942L-L SUP HCPCS C1713 AR-8942L-L - PLATE BN LG H FLT LOPRFL 38X16MM TI MIDFOOT LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $675.00 $675.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942L-M SUP HCPCS C1713 AR-8942L-M - PLATE BN MED H FLT LOPRFL 34X16MM TI MIDFOOT LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $675.00 $675.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942L-S SUP HCPCS C1713 AR-8942L-S - PLATE BN SM H FLT LOPRFL 28X16MM TI MIDFOOT LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $675.00 $675.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942R-06 SUP HCPCS C1713 AR-8942R-06 - PLATE BN H WDG LOPRFL 34X16X6MM TI MIDFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $731.25 $731.25 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942R-08 SUP HCPCS C1713 AR-8942R-08 - PLATE BN H WDG LOPRFL 34X16X8MM TI MIDFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $731.25 $731.25 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942R-10 SUP HCPCS C1713 AR-8942R-10 - PLATE BN H WDG LOPRFL 36X16X10MM TI MIDFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $731.25 $731.25 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942R-L SUP HCPCS C1713 AR-8942R-L - PLATE BN LG H FLT LOPRFL 38X16MM TI MIDFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $675.00 $675.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942R-M SUP HCPCS C1713 AR-8942R-M - PLATE BN MED H FLT LOPRFL 34X16MM TI MIDFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $675.00 $675.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8942R-S SUP HCPCS C1713 AR-8942R-S - PLATE BN SM H FLT LOPRFL 28X16MM TI MIDFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $675.00 $675.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-02 SUP Custom 27203010 AR-8943-02 - BIT DRL 2.6MM 160MM CNN 4MM LPS P/T SCR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-03 SUP Custom 27203010 AR-8943-03 - GUIDE DRL 1.35-2.6MM 4MM LPS P/T SCR BOTH IP/OP $937.50 $693.75 $0.00 $695.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-05 SUP Custom 27203010 AR-8943-05 - DRILL BIT CNTRSNK 4MM QFIX CNN 4MM LPS P/T SCR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-13 SUP Custom 27203010 AR-8943-13 - BIT DRL 2.5MM CLBRT GRAD BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-14 SUP Custom 27203010 AR-8943-14 - GUIDE DRL 3.5MM 2.5MM 3.5MM CORT 4MM CANC SCR LCK BOTH IP/OP "$1,687.50 " "$1,248.75" $0.00 "$1,252.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.46" "$1,252.46" $0.00 $0.00 $351.68 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-16 SUP Custom 27203010 AR-8943-16 - BIT DRL 2MM CLBRT GRAD 2.7/3MM SCR BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-17 SUP Custom 27203010 AR-8943-17 - GUIDE DRL LOPRFL 2.7MM THRD 2.7/3MM SCR BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-24 SUP Custom 27203010 AR-8943-24 - CLAMP SRG WEBER BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-26 SUP Custom 27203010 AR-8943-26 - GUIDE DRL LOPRFL 3.5MM THRD BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-30 SUP Custom 27203010 AR-8943-30 - BIT DRL 2.5MM 110MM ANKL 3.5MM CORT 4MM CANC SCR LCK BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-31 SUP Custom 27203010 AR-8943-31 - GUIDE DRL 3MM 2MM ANKL 2.7/3MM SCR BOTH IP/OP "$1,062.50 " $786.25 $0.00 $788.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-36 SUP Custom 27203010 AR-8943-36 - BIT DRL 3MM ANKL 2.7/3MM SCR BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-37 SUP HCPCS C1713 AR-8943-37 - SCREW BN REPL ATCH ANKL FX MGMT BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-40 SUP Custom 27203010 AR-8943-40 - BIT DRL 2MM CNN BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-41 SUP Custom 27203010 AR-8943-41 - GUIDE DRL 2.6MM 1.35MM PRLL 4MM LPS P/T SCR BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-43 SUP Custom 27203010 AR-8943-43 - GUIDE DRL 3.5MM BIT FX LCK VA FT/ANKL 3.5MM CORT 4MM CANC BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943-44 SUP Custom 27203010 AR-8943-44 - CLAMP SRG SYNDESMOSIS BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BL-04 SUP HCPCS C1713 AR-8943BL-04 - PLATE BN LOPRFL 4 HL LCK MDLR SS FIB LT DIST BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BL-05 SUP HCPCS C1713 AR-8943BL-05 - PLATE BN LOPRFL 5 HL LCK MDLR SS FIB LT DIST BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BL-06 SUP HCPCS C1713 AR-8943BL-06 - PLATE BN LOPRFL 6 HL LCK MDLR SS FIB LT DIST BOTH IP/OP "$1,812.50 " "$1,341.25" $0.00 "$1,450.00" $815.63 $815.63 $0.00 $0.00 $0.00 $377.77 "$1,345.24" "$1,345.24" $0.00 $0.00 $377.73 $0.00 "$1,072.09" "$1,072.09" $0.00 $906.25 "$1,435.50" "$1,450.00" $0.00 $0.00 $283.66 $0.00 $0.00 $288.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BL-08 SUP HCPCS C1713 AR-8943BL-08 - PLATE BN LOPRFL 8 HL LCK MDLR SS FIB LT DIST BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BLS-10 SUP HCPCS C1713 AR-8943BLS-10 - PLATE BN STRL 10 HL LCK FIB LT DIST BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BLS-12 SUP HCPCS C1713 AR-8943BLS-12 - PLATE BN STRL 12 HL LCK FIB LT DIST BOTH IP/OP "$2,150.00 " "$1,591.00" $0.00 "$1,720.00" $967.50 $967.50 $0.00 $0.00 $0.00 $448.11 "$1,595.73" "$1,595.73" $0.00 $0.00 $448.06 $0.00 "$1,271.73" "$1,271.73" $0.00 "$1,075.00" "$1,702.80" "$1,720.00" $0.00 $0.00 $336.48 $0.00 $0.00 $342.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BLS-14 SUP HCPCS C1713 AR-8943BLS-14 - PLATE BN STRL 14 HL LCK FIB LT DIST BOTH IP/OP "$2,175.00 " "$1,609.50" $0.00 "$1,740.00" $978.75 $978.75 $0.00 $0.00 $0.00 $453.32 "$1,614.29" "$1,614.29" $0.00 $0.00 $453.27 $0.00 "$1,286.51" "$1,286.51" $0.00 "$1,087.50" "$1,722.60" "$1,740.00" $0.00 $0.00 $340.39 $0.00 $0.00 $346.26 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BR-04 SUP HCPCS C1713 AR-8943BR-04 - PLATE BN LOPRFL 4 HL LCK MDLR SS ANKL RT FIB BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BR-05 SUP HCPCS C1713 AR-8943BR-05 - PLATE BN LOPRFL 5 HL LCK MDLR SS ANKL RT FIB BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BR-06 SUP HCPCS C1713 AR-8943BR-06 - PLATE BN LOPRFL 6 HL LCK MDLR SS ANKL RT FIB BOTH IP/OP "$1,812.50 " "$1,341.25" $0.00 "$1,450.00" $815.63 $815.63 $0.00 $0.00 $0.00 $377.77 "$1,345.24" "$1,345.24" $0.00 $0.00 $377.73 $0.00 "$1,072.09" "$1,072.09" $0.00 $906.25 "$1,435.50" "$1,450.00" $0.00 $0.00 $283.66 $0.00 $0.00 $288.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BR-08 SUP HCPCS C1713 AR-8943BR-08 - PLATE BN LOPRFL 8 HL LCK MDLR SS ANKL RT FIB BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BRS-10 SUP HCPCS C1713 AR-8943BRS-10 - PLATE BN STRL 10 HL LCK FIB RT DIST BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BRS-12 SUP HCPCS C1713 AR-8943BRS-12 - PLATE BN STRL 12 HL LCK FIB RT DIST BOTH IP/OP "$2,150.00 " "$1,591.00" $0.00 "$1,720.00" $967.50 $967.50 $0.00 $0.00 $0.00 $448.11 "$1,595.73" "$1,595.73" $0.00 $0.00 $448.06 $0.00 "$1,271.73" "$1,271.73" $0.00 "$1,075.00" "$1,702.80" "$1,720.00" $0.00 $0.00 $336.48 $0.00 $0.00 $342.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943BRS-14 SUP HCPCS C1713 AR-8943BRS-14 - PLATE BN STRL 12 HL LCK FIB RT DIST BOTH IP/OP "$2,175.00 " "$1,609.50" $0.00 "$1,740.00" $978.75 $978.75 $0.00 $0.00 $0.00 $453.32 "$1,614.29" "$1,614.29" $0.00 $0.00 $453.27 $0.00 "$1,286.51" "$1,286.51" $0.00 "$1,087.50" "$1,722.60" "$1,740.00" $0.00 $0.00 $340.39 $0.00 $0.00 $346.26 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943C-04 SUP HCPCS C1713 AR-8943C-04 - PLATE BN STRG 55MM 4 HL LCK SS ANKL BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943C-06 SUP HCPCS C1713 AR-8943C-06 - PLATE BN STRG 80MM 6 HL LCK SS ANKL BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $534.38 $534.38 $0.00 $0.00 $0.00 $247.50 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $702.41 $702.41 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $185.84 $0.00 $0.00 $189.05 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943C-07 SUP HCPCS C1713 AR-8943C-07 - PLATE BN STRG 93MM 7 HL LCK SS ANKL BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943C-08 SUP HCPCS C1713 AR-8943C-08 - PLATE BN STRG 106MM 8 HL LCK SS ANKL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943C-10 SUP HCPCS C1713 AR-8943C-10 - PLATE BN STRG 131MM 10 HL LCK SS ANKL BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943C-12 SUP HCPCS C1713 AR-8943C-12 - PLATE BN STRG 156MM 12 HL LCK SS ANKL BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943H-03 SUP HCPCS C1713 AR-8943H-03 - PLATE BN 61MM 3 HL HK LCK SS ANKL MLLE MDL BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943H-05 SUP HCPCS C1713 AR-8943H-05 - PLATE BN 79MM 5 HL HK LCK SS FT/ANKL MDL BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943H-07 SUP HCPCS C1713 AR-8943H-07 - PLATE BN 97MM 7 HL HK LCK SS FT/ANKL MDL BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943I SUP HCPCS C1713 AR-8943I - SET IMPL ANKL FX SYS BOTH IP/OP "$112,500.00 " "$83,250.00" $0.00 "$90,000.00" "$50,625.00" "$50,625.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$23,445.00" $0.00 "$55,462.50" "$55,462.50" $0.00 "$56,250.00" "$89,100.00" "$90,000.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943T-04 SUP HCPCS C1713 AR-8943T-04 - PLATE BN 1/3 TUBE 47MM 4 HL LCK SS ANKL BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943T-05 SUP HCPCS C1713 AR-8943T-05 - PLATE BN 1/3 TUBE 59MM 5 HL LCK SS ANKL BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943T-06 SUP HCPCS C1713 AR-8943T-06 - PLATE BN 1/3 TUBE 72MM 6 HL LCK SS ANKL BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943T-07 SUP HCPCS C1713 AR-8943T-07 - PLATE BN 1/3 TUBE 85MM 7 HL LCK SS ANKL BOTH IP/OP $637.50 $471.75 $0.00 $510.00 $286.88 $286.88 $0.00 $0.00 $0.00 $132.87 $473.15 $473.15 $0.00 $0.00 $132.86 $0.00 $377.08 $377.08 $0.00 $318.75 $504.90 $510.00 $0.00 $0.00 $99.77 $0.00 $0.00 $101.49 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943T-08 SUP HCPCS C1713 AR-8943T-08 - PLATE BN 1/3 TUBE 98MM 8 HL LCK SS ANKL BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $298.13 $298.13 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943T-10 SUP HCPCS C1713 AR-8943T-10 - PLATE BN 1/3 TUBE 123MM 10 HL LCK SS ANKL BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943T-12 SUP HCPCS C1713 AR-8943T-12 - PLATE BN 1/3 TUBE 148MM 12 HL LCK SS ANKL BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943TH-03 SUP HCPCS C1713 AR-8943TH-03 - PLATE BN 72MM 3 HL AVULSION HK LCK SS ANKL LAT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943TH-05 SUP HCPCS C1713 AR-8943TH-05 - PLATE BN 98MM 5 HL AVULSION HK LCK SS ANKL LAT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8943TH-07 SUP HCPCS C1713 AR-8943TH-07 - PLATE BN 123MM 7 HL AVULSION HK LCK SS ANKL LAT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944-10S SUP HCPCS C1713 AR-8944-10S - PLATE BN 10D STD LOPRFL MTP VLGS BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944-22 SUP Custom 27203010 AR-8944-22 - BIT DRL 2MM AO CNCT LCK 3MM SCR BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944C-10S SUP HCPCS C1713 AR-8944C-10S - PLATE BN 10D STD DFLXN MTP VLGS BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944CL-L SUP HCPCS C1713 AR-8944CL-L - PLATE BN LNG CNTR LOPRFL MTP PLT FSN MOD TI FOREFOOT LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $900.00 $900.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944CL-P SUP HCPCS C1713 AR-8944CL-P - PLATE BN SHRT CNTR FSN MOD TI FOREFOOT 1ST MTP LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $900.00 $900.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944CL-S SUP HCPCS C1713 AR-8944CL-S - PLATE BN STD CNTR LOPRFL MTP PLT FSN MOD TI FOREFOOT LT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $900.00 $900.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944CR-L SUP HCPCS C1713 AR-8944CR-L - PLATE BN LNG CNTR LOPRFL MTP PLT FSN MOD TI FOREFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $900.00 $900.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944CR-P SUP HCPCS C1713 AR-8944CR-P - PLATE BN SHRT CNTR LOPRFL MTP PLT FSN MOD TI FOREFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $900.00 $900.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944CR-S SUP HCPCS C1713 AR-8944CR-S - PLATE BN STD CNTR LOPRFL MTP PLT FSN MOD TI FOREFOOT RT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $900.00 $900.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944-L SUP HCPCS C1713 AR-8944-L - PLATE BN LNG STRG LOPRFL MTP PLT FSN MOD TI FOREFOOT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $900.00 $900.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8944-P SUP HCPCS C1713 AR-8944-P - PLATE BN SHRT STRG LOPRFL MTP PLT FSN MOD TI FOREFOOT BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,660.67" $900.00 $900.00 $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-20FT SUP HCPCS C1713 AR-8945-20FT - SCREW BN .062IN 3.5MM FT HEX LOPRFL 4.5MM 20MM SLF DRL ST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-20PT SUP HCPCS C1713 AR-8945-20PT - SCREW BN .062IN 3.5MM 1/3 FT HEX LOPRFL 4.5MM 20MM SLF DRL BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-22FT SUP HCPCS C1713 AR-8945-22FT - SCREW BN FT HEX 4.5MM 22MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-22PT SUP HCPCS C1713 AR-8945-22PT - SCREW BN P/T LOPRFL 4.5MM 22MM CNN TI MLR CORT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-24FT SUP HCPCS C1713 AR-8945-24FT - SCREW BN FT HEX 4.5MM 24MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-24PT SUP HCPCS C1713 AR-8945-24PT - SCREW BN P/T HEX 4.5MM 24MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-26FT SUP HCPCS C1713 AR-8945-26FT - SCREW BN FT HEX 4.5MM 26MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-26PT SUP HCPCS C1713 AR-8945-26PT - SCREW BN P/T LOPRFL 4.5MM 26MM CNN TI MLR CORT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-28FT SUP HCPCS C1713 AR-8945-28FT - SCREW BN FT HEX 4.5MM 28MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-28PT SUP HCPCS C1713 AR-8945-28PT - SCREW BN P/T HEX 4.5MM 28MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-30C SUP Custom 27203010 AR-8945-30C - BIT DRL MN 3MM 120MM CNN 4.5MM SCR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-30FT SUP HCPCS C1713 AR-8945-30FT - SCREW BN FT HEX 4.5MM 30MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-30PT SUP HCPCS C1713 AR-8945-30PT - SCREW BN P/T HEX 4.5MM 30MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-32FT SUP HCPCS C1713 AR-8945-32FT - SCREW BN FT HEX 4.5MM 32MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-32PT SUP HCPCS C1713 AR-8945-32PT - SCREW BN P/T HEX 4.5MM 32MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-34FT SUP HCPCS C1713 AR-8945-34FT - SCREW BN FT HEX 4.5MM 34MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-34PT SUP HCPCS C1713 AR-8945-34PT - SCREW BN P/T HEX 4.5MM 34MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-35FT SUP HCPCS C1713 AR-8945-35FT - SCREW BN FT HEX 4.5MM 35MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-35PT SUP HCPCS C1713 AR-8945-35PT - SCREW BN P/T HEX 4.5MM 35MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-36FT SUP HCPCS C1713 AR-8945-36FT - SCREW BN FT HEX 4.5MM 36MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-36PT SUP HCPCS C1713 AR-8945-36PT - SCREW BN P/T HEX 4.5MM 36MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-38FT SUP HCPCS C1713 AR-8945-38FT - SCREW BN FT HEX 4.5MM 38MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-38PT SUP HCPCS C1713 AR-8945-38PT - SCREW BN P/T HEX 4.5MM 38MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-40FT SUP HCPCS C1713 AR-8945-40FT - SCREW BN FT HEX 4.5MM 40MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-40PT SUP HCPCS C1713 AR-8945-40PT - SCREW BN P/T HEX 4.5MM 40MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-45C SUP Custom 27203010 AR-8945-45C - BIT DRL 4.5MM HDSN CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-45FT SUP HCPCS C1713 AR-8945-45FT - SCREW BN FT HEX 4.5MM 45MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-45PT SUP HCPCS C1713 AR-8945-45PT - SCREW BN P/T HEX 4.5MM 45MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-50FT SUP HCPCS C1713 AR-8945-50FT - SCREW BN FT HEX 4.5MM 50MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-50PT SUP HCPCS C1713 AR-8945-50PT - SCREW BN P/T HEX 4.5MM 50MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-55FT SUP HCPCS C1713 AR-8945-55FT - SCREW BN FT HEX 4.5MM 55MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-55PT SUP HCPCS C1713 AR-8945-55PT - SCREW BN P/T HEX 4.5MM 55MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-60FT SUP HCPCS C1713 AR-8945-60FT - SCREW BN FT HEX 4.5MM 60MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-60PT SUP HCPCS C1713 AR-8945-60PT - SCREW BN P/T HEX 4.5MM 60MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-65FT SUP HCPCS C1713 AR-8945-65FT - SCREW BN FT HEX 4.5MM 65MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-65PT SUP HCPCS C1713 AR-8945-65PT - SCREW BN P/T HEX 4.5MM 65MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-70FT SUP HCPCS C1713 AR-8945-70FT - SCREW BN FT HEX 4.5MM 70MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-70PT SUP HCPCS C1713 AR-8945-70PT - SCREW BN P/T HEX 4.5MM 70MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-75FT SUP HCPCS C1713 AR-8945-75FT - SCREW BN FT HEX 4.5MM 75MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-75PT SUP HCPCS C1713 AR-8945-75PT - SCREW BN P/T HEX 4.5MM 75MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-80FT SUP HCPCS C1713 AR-8945-80FT - SCREW BN FT HEX 4.5MM 80MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945-80PT SUP HCPCS C1713 AR-8945-80PT - SCREW BN P/T HEX 4.5MM 80MM LOPRFL SCR SLF DRL ST CNN LG TI BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945CS SUP Custom 27203010 AR-8945CS - DRILL BIT CNTRSNK CNN FX HNDL 4.5/6 MM BOTH IP/OP $550.00 $407.00 $0.00 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.21 $408.21 $0.00 $0.00 $114.62 $0.00 $0.00 $0.00 $0.00 $275.00 $435.60 $440.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945CSF SUP Custom 27203010 AR-8945CSF - COUNTERSINK DRL CNN 4.5 MM SCR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8945W SUP HCPCS C1713 AR-8945W - WASHER ORTH 10MM CNN TI BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8947DS SUP HCPCS C1713 AR-8947DS - PLATE BN BTRS TGHTRP IMPL DLV ANKL SYNDESMOSIS BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$2,050.00" "$1,153.13" "$1,153.13" $0.00 $0.00 $0.00 $534.09 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 "$1,263.31" "$1,263.31" $0.00 "$1,281.25" "$2,029.50" "$2,050.00" $0.00 $0.00 $401.03 $0.00 $0.00 $407.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8948-00 SUP HCPCS C1713 AR-8948-00 - PLATE BN FLT LOPRFL TI CTTN FT/ANKL 2.4MM SCR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8948-02 SUP HCPCS C1713 AR-8948-02 - PLATE BN LOPRFL 2MM TI CTTN FT/ANKL 2.4MM SCR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8948-06 SUP HCPCS C1713 AR-8948-06 - PLATE BN LOPRFL 6MM TI CTTN FT/ANKL 2.4MM SCR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8948-08 SUP HCPCS C1713 AR-8948-08 - PLATE BN LOPRFL 8MM TI CTTN FT/ANKL 2.4MM SCR BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8949-050 SUP HCPCS C1713 AR-8949-050 - PLATE BN 5MM STP CALCANEUS BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,031.77" "$1,102.50" "$1,102.50" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,225.00" "$1,940.40" "$1,960.00" $0.00 $0.00 $383.43 $0.00 $0.00 $390.04 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8949-075 SUP HCPCS C1713 AR-8949-075 - PLATE BN 7.5MM STP CALCANEUS BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,031.77" "$1,102.50" "$1,102.50" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,225.00" "$1,940.40" "$1,960.00" $0.00 $0.00 $383.43 $0.00 $0.00 $390.04 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8949-100 SUP HCPCS C1713 AR-8949-100 - PLATE BN 10MM STP CALCANEUS BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,031.77" "$1,102.50" "$1,102.50" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,225.00" "$1,940.40" "$1,960.00" $0.00 $0.00 $383.43 $0.00 $0.00 $390.04 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8949DG SUP Custom 27203010 AR-8949DG - GUIDE DRL CMPR HL BOTH IP/OP "$1,200.00 " $888.00 $0.00 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $890.64 $890.64 $0.00 $0.00 $250.08 $0.00 $0.00 $0.00 $0.00 $600.00 $950.40 $960.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8949S SUP HCPCS C1713 AR-8949S - PLATE BN 5MM 7.5MM 10MM STP CALCANEUS BOTH IP/OP "$5,625.00 " "$4,162.50" $0.00 "$4,500.00" "$2,531.25" "$2,531.25" $0.00 $0.00 $0.00 "$1,172.39" "$4,174.88" "$4,174.88" $0.00 $0.00 "$1,172.25" $0.00 "$2,773.13" "$2,773.13" $0.00 "$2,812.50" "$4,455.00" "$4,500.00" $0.00 $0.00 $880.31 $0.00 $0.00 $895.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950-01 SUP Custom 27203010 AR-8950-01 - COUNTERSINK DRL 2.4MM BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950-02 SUP Custom 27203010 AR-8950-02 - COUNTERSINK DRL 3MM BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950-03 SUP Custom 27203010 AR-8950-03 - COUNTERSINK DRL 3.5 4 MM SCR BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950-05 SUP Custom 27203010 AR-8950-05 - BIT DRL 3MM BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950-08 SUP Custom 27203010 AR-8950-08 - GUIDE DRL BNT 2.4MM LCK BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950-09 SUP Custom 27203010 AR-8950-09 - GUIDE DRL BNT 3MM LCK BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950C-14 SUP Custom 27203010 AR-8950C-14 - INSERT TRY CMPRH FT SYS BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 $0.00 $0.00 $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950JD-1 SUP HCPCS C1713 AR-8950JD-1 - DISTRACTOR SRG MN 16MM TRC SCR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950JD-2 SUP HCPCS C1713 AR-8950JD-2 - SCREW DSTRCT 20MM MN JNT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8950S-V1 SUP HCPCS C1713 AR-8950S-V1 - SET SCR VA CMPRH FT SYS BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-8951LL SUP HCPCS C1713 AR-8951LL - PLATE BN LG CNTR LOPRFL 1.4MM TI LISFRANC LT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8951LR SUP HCPCS C1713 AR-8951LR - PLATE BN LG CNTR LOPRFL 1.4MM TI LISFRANC RT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8951ML SUP HCPCS C1713 AR-8951ML - PLATE BN MED CNTR LOPRFL 1.4MM TI LISFRANC LT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8951MR SUP HCPCS C1713 AR-8951MR - PLATE BN MED CNTR LOPRFL 1.4MM TI LISFRANC RT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8951SL SUP HCPCS C1713 AR-8951SL - PLATE BN SM CNTR LOPRFL 1.4MM TI LISFRANC LT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8951SR SUP HCPCS C1713 AR-8951SR - PLATE BN SM CNTR LOPRFL 1.4MM TI LISFRANC RT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MC-LL SUP HCPCS C1713 AR-8952MC-LL - PLATE BN LG LOPRFL CLMN FT LT MDL 3.5MM SCR BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MC-LR SUP HCPCS C1713 AR-8952MC-LR - PLATE BN LG LOPRFL CLMN FT RT MDL 3.5MM SCR BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MC-ML SUP HCPCS C1713 AR-8952MC-ML - PLATE BN MED LOPRFL CLMN FT LT MDL 3.5MM SCR BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MC-MR SUP HCPCS C1713 AR-8952MC-MR - PLATE BN MED LOPRFL CLMN FT RT MDL 3.5MM SCR BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MC-SL SUP HCPCS C1713 AR-8952MC-SL - PLATE BN SM LOPRFL CLMN FT LT MDL 3.5MM SCR BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MC-SR SUP HCPCS C1713 AR-8952MC-SR - PLATE BN SM LOPRFL CLMN FT RT MDL 3.5MM SCR BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952ML-05L SUP HCPCS C1713 AR-8952ML-05L - PLATE BN 5 HL TI WRST LT 2.4 MM SCR BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952ML-05R SUP HCPCS C1713 AR-8952ML-05R - PLATE BN L 2 HLE/HD 5 HL SHFT TI RT 2.4MM SCR BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MS-04 SUP HCPCS C1713 AR-8952MS-04 - PLATE BN STRG LOPRFL 2.4MM 4 HL FT BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MS-05 SUP HCPCS C1713 AR-8952MS-05 - PLATE BN STRG LOPRFL 2.4MM 5 HL FT BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MS-06 SUP HCPCS C1713 AR-8952MS-06 - PLATE BN STRG LOPRFL 2.4MM 6 HL FT BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MS-07 SUP HCPCS C1713 AR-8952MS-07 - PLATE BN STRG LOPRFL 2.4MM 7 HL FT BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MS-08 SUP HCPCS C1713 AR-8952MS-08 - PLATE BN STRG 8 HL LOPRFL 2.4MM SCR BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MT-03 SUP HCPCS C1713 AR-8952MT-03 - PLATE BN T 3 HL LOPRFL 2.4MM SCR BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MT-04 SUP HCPCS C1713 AR-8952MT-04 - PLATE BN T LOPRFL 4 HL FT 2.4MM SCR BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MT-05 SUP HCPCS C1713 AR-8952MT-05 - PLATE BN T LOPRFL 2.4MM 5 HL FT BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MT-06 SUP HCPCS C1713 AR-8952MT-06 - PLATE BN T LOPRFL 2.4MM 6 HL FT BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MT-07 SUP HCPCS C1713 AR-8952MT-07 - PLATE BN T 2.4MM 7 HL LOPRFL BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MT-08 SUP HCPCS C1713 AR-8952MT-08 - PLATE BN T 8 HL LOPRFL 2.4MM SCR BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952MT-09 SUP HCPCS C1713 AR-8952MT-09 - PLATE BN T LOPRFL 9 HL 2.4MM SCR BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952TS-02 SUP HCPCS C1713 AR-8952TS-02 - PLATE BN STRG LOPRFL 2 HL TI FT 3MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952TS-04 SUP HCPCS C1713 AR-8952TS-04 - PLATE BN STRG 3MM LOPRFL 4 HL TI BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952TS-05 SUP HCPCS C1713 AR-8952TS-05 - PLATE BN STRG 5 HL LOPRFL TI 3MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952TT-03 SUP HCPCS C1713 AR-8952TT-03 - PLATE BN T LOPRFL 3MM 3 HL TI FT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952TT-04 SUP HCPCS C1713 AR-8952TT-04 - PLATE BN T 4 HL LOPRFL TI 3MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952XL SUP HCPCS C1713 AR-8952XL - PLATE BN LG X 2 HL TI FT 3MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952XM SUP HCPCS C1713 AR-8952XM - PLATE BN MED X TI 3MM SCR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8952XP SUP HCPCS C1713 AR-8952XP - PLATE BN SM X TI 2.4MM SCR BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-00 SUP HCPCS C1713 AR-8953-00 - PLATE BN FLT LCK POW TI FT/ANKL PROX 3MM SCR OPN WDG OSTM BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-02 SUP HCPCS C1713 AR-8953-02 - PLATE BN LOPRFL 2MM LCK POW TI FT/ANKL PROX 3MM SCR OPN WDG BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-025 SUP HCPCS C1713 AR-8953-025 - PLATE BN LOPRFL 2.5MM LCK POW TI FT/ANKL PROX 3MM SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-03 SUP HCPCS C1713 AR-8953-03 - PLATE BN LOPRFL 3MM LCK POW TI FT/ANKL PROX 3MM SCR OPN WDG BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-035 SUP HCPCS C1713 AR-8953-035 - PLATE BN LOPRFL 3.5MM LCK POW TI FT/ANKL PROX 3MM SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-04 SUP HCPCS C1713 AR-8953-04 - PLATE BN 4MM LCK POW LOPRFL TI FT/ANKL PROX 3MM SCR OPN WDG BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-045 SUP HCPCS C1713 AR-8953-045 - PLATE BN LOPRFL 4.5MM LCK POW TI FT/ANKL PROX 3MM SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-05 SUP HCPCS C1713 AR-8953-05 - PLATE BN LOPRFL 5MM LCK POW TI FT/ANKL PROX 3MM SCR OPN WDG BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-055 SUP HCPCS C1713 AR-8953-055 - PLATE BN LOPRFL 5.5MM LCK POW TI FT/ANKL PROX 3MM SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-06 SUP HCPCS C1713 AR-8953-06 - PLATE BN LOPRFL 6MM LCK POW TI FT/ANKL PROX 3MM SCR OPN WDG BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-065 SUP HCPCS C1713 AR-8953-065 - PLATE BN LOPRFL 6.5MM LCK POW TI FT/ANKL PROX 3MM SCR OPN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8953-07 SUP HCPCS C1713 AR-8953-07 - PLATE BN LOPRFL 7MM LCK POW TI FT/ANKL PROX 3MM SCR OPN WDG BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954-07 SUP Custom 27203010 AR-8954-07 - GUIDE DRL BNT 3.5MM LCK BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954ML-L SUP HCPCS C1713 AR-8954ML-L - PLATE BN LNG LOPRFL TPR LCK CALCANEUS LT ANT ATCH GD PERC BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954ML-S SUP HCPCS C1713 AR-8954ML-S - PLATE BN STD LOPRFL TPR LCK CALCANEUS LT ANT ATCH GD PERC BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954MR-L SUP HCPCS C1713 AR-8954MR-L - PLATE BN LNG LOPRFL TPR LCK CALCANEUS RT ANT ATCH GD PERC BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954MR-S SUP HCPCS C1713 AR-8954MR-S - PLATE BN STD LOPRFL TPR LCK CALCANEUS RT ANT ATCH GD PERC BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954MT SUP HCPCS C1713 AR-8954MT - PLATE BN T LOPRFL 4 HL FT 3.5MM SCR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954PL-L SUP HCPCS C1713 AR-8954PL-L - PLATE BN LG PRIMTR CALC FX LT BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954PL-M SUP HCPCS C1713 AR-8954PL-M - PLATE BN MED LOPRFL LCK PRIMTR TI CALCANEUS LT 3.5/4MM SCR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954PL-S SUP HCPCS C1713 AR-8954PL-S - PLATE BN SM LOPRFL LCK PRIMTR TI CALCANEUS LT 3.5/4MM SCR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954PL-XS SUP HCPCS C1713 AR-8954PL-XS - PLATE BN XS LOPRFL LCK PRIMTR TI CALCANEUS LT 3.5/4MM SCR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954PR-L SUP HCPCS C1713 AR-8954PR-L - PLATE BN LG LOPRFL LCK PRIMTR TI CALCANEUS RT 3.5/4MM SCR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954PR-M SUP HCPCS C1713 AR-8954PR-M - PLATE BN MED LOPRFL LCK PRIMTR TI CALCANEUS RT 3.5/4MM SCR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954PR-S SUP HCPCS C1713 AR-8954PR-S - PLATE BN SM LOPRFL LCK PRIMTR TI CALCANEUS RT 3.5/4MM SCR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954PR-XS SUP HCPCS C1713 AR-8954PR-XS - PLATE BN XS LOPRFL LCK PRIMTR TI CALCANEUS RT 3.5/4MM SCR BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954YL-L SUP HCPCS C1713 AR-8954YL-L - PLATE BN LNG LOPRFL TPR LCK CALCANEUS LT ANT POST ATCH GD BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954YL-S SUP HCPCS C1713 AR-8954YL-S - PLATE BN STD LOPRFL TPR LCK CALCANEUS LT ANT POST ATCH GD BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954YR-L SUP HCPCS C1713 AR-8954YR-L - PLATE BN LNG LOPRFL TPR LCK CALCANEUS RT ANT POST ATCH GD BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8954YR-S SUP HCPCS C1713 AR-8954YR-S - PLATE BN STD LOPRFL TPR LCK CALCANEUS RT ANT POST ATCH GD BOTH IP/OP "$2,737.50 " "$2,025.75" $0.00 "$2,190.00" "$1,231.88" "$1,231.88" $0.00 $0.00 $0.00 $570.56 "$2,031.77" "$2,031.77" $0.00 $0.00 $570.50 $0.00 "$1,349.59" "$1,349.59" $0.00 "$1,368.75" "$2,168.10" "$2,190.00" $0.00 $0.00 $428.42 $0.00 $0.00 $435.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8955-60PT SUP HCPCS C1713 AR-8955-60PT - SCREW BN 3.5MM P/T HEX 5.5MM 60MM LOPRFL SCR SLF DRL SLD LG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8955-65PT SUP HCPCS C1713 AR-8955-65PT - SCREW BN 3.5MM P/T HEX 5.5MM 65MM LOPRFL SCR SLF DRL SLD LG BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8955G SUP Custom 27203010 AR-8955G - GUIDE DRL LOPRFL 4MM 1.6MM 4.5MM SCR BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8955T SUP HCPCS C1713 AR-8955T - SCREW BN LOPRFL 5.5MM TAP JNS FX BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8956-01 SUP HCPCS C1713 AR-8956-01 - PLATE BN UNV HK METATARSUS FIFTH MTRSL FX SYS BOTH IP/OP "$2,312.50 " "$1,711.25" $0.00 "$1,850.00" "$1,040.63" "$1,040.63" $0.00 $0.00 $0.00 $481.98 "$1,716.34" "$1,716.34" $0.00 $0.00 $481.93 $0.00 "$1,367.84" "$1,367.84" $0.00 "$1,156.25" "$1,831.50" "$1,850.00" $0.00 $0.00 $361.91 $0.00 $0.00 $368.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8956-08 SUP HCPCS C1713 AR-8956-08 - PLATE BN HK TAMP METATARSUS FIFTH MTRSL FX SYS BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8956L-02 SUP HCPCS C1713 AR-8956L-02 - PLATE BN LNG HK METATARSUS LT FIFTH MTRSL FX SYS BOTH IP/OP "$3,187.50 " "$2,358.75" $0.00 "$2,550.00" "$1,434.38" "$1,434.38" $0.00 $0.00 $0.00 $664.35 "$2,365.76" "$2,365.76" $0.00 $0.00 $664.28 $0.00 "$1,571.44" "$1,571.44" $0.00 "$1,593.75" "$2,524.50" "$2,550.00" $0.00 $0.00 $498.84 $0.00 $0.00 $507.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8956R-03 SUP HCPCS C1713 AR-8956R-03 - PLATE BN LNG 7 HL HK LOPRFL 5TH MTRSL RT 2.4MM SCR BOTH IP/OP "$3,187.50 " "$2,358.75" $0.00 "$2,550.00" "$1,434.38" "$1,434.38" $0.00 $0.00 $0.00 $664.35 "$2,365.76" "$2,365.76" $0.00 $0.00 $664.28 $0.00 "$1,571.44" "$1,571.44" $0.00 "$1,593.75" "$2,524.50" "$2,550.00" $0.00 $0.00 $498.84 $0.00 $0.00 $507.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8958-01 SUP HCPCS C1713 AR-8958-01 - PLATE BN TGHTRP 2 HL SS SYNDESMOSIS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8958-01S SUP HCPCS C1713 AR-8958-01S - PLATE BN STRL TGHTRP 2 HL SS SYNDESMOSIS BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8958-02 SUP HCPCS C1713 AR-8958-02 - PLATE BN TGHTRP 2 HL TI SYNDESMOSIS BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8958-02S SUP HCPCS C1713 AR-8958-02S - PLATE BN STRL TGHTRP 2 HL TI SYNDESMOSIS BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8958TDS SUP HCPCS C1713 AR-8958TDS - SYSTEM FX TGHTRP BB-TAK 2 BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963-05 SUP Custom 27203010 AR-8963-05 - BIT DRL LNG 2MM CLBRT TIB DIST BOTH IP/OP $275.00 $203.50 $0.00 $204.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963-08 SUP Custom 27203010 AR-8963-08 - GUIDE DRL 2.7MM 10-60MM THRD BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963A-03 SUP HCPCS C1713 AR-8963A-03 - PLATE BN 62MM 3 HL 2 ROW CONSTRUCT TPR TIP TIB DIST ANT 2.7 BOTH IP/OP "$2,312.50 " "$1,711.25" $0.00 "$1,850.00" "$1,040.63" "$1,040.63" $0.00 $0.00 $0.00 $481.98 "$1,716.34" "$1,716.34" $0.00 $0.00 $481.93 $0.00 "$1,367.84" "$1,367.84" $0.00 "$1,156.25" "$1,831.50" "$1,850.00" $0.00 $0.00 $361.91 $0.00 $0.00 $368.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963A-05 SUP HCPCS C1713 AR-8963A-05 - PLATE BN 84MM 5 HL TIB DIST ANT BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963A-07 SUP HCPCS C1713 AR-8963A-07 - PLATE BN 107MM 7 HL 2 ROW CONSTRUCT TPR TIP TIB DIST ANT 2.7 BOTH IP/OP "$2,450.00 " "$1,813.00" $0.00 "$1,960.00" "$1,102.50" "$1,102.50" $0.00 $0.00 $0.00 $510.64 "$1,818.39" "$1,818.39" $0.00 $0.00 $510.58 $0.00 "$1,449.18" "$1,449.18" $0.00 "$1,225.00" "$1,940.40" "$1,960.00" $0.00 $0.00 $383.43 $0.00 $0.00 $390.04 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963A-09 SUP HCPCS C1713 AR-8963A-09 - PLATE BN 130MM 9 HL 2 ROW CONSTRUCT TPR TIP TIB DIST ANT 2.7 BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AL-04 SUP HCPCS C1713 AR-8963AL-04 - PLATE BN CNTR 66MM 4 HL TPR TIP LOPRFL TIB LT DIST ALAT 2.7 BOTH IP/OP "$4,550.00 " "$3,367.00" $0.00 "$3,640.00" "$2,047.50" "$2,047.50" $0.00 $0.00 $0.00 $948.33 "$3,377.01" "$3,377.01" $0.00 $0.00 $948.22 $0.00 "$2,243.15" "$2,243.15" $0.00 "$2,275.00" "$3,603.60" "$3,640.00" $0.00 $0.00 $712.08 $0.00 $0.00 $724.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AL-06 SUP HCPCS C1713 AR-8963AL-06 - PLATE BN OBLNG 91MM 6 HL TPR TIP LOPRFL TIB LT DIST ALAT BOTH IP/OP "$4,600.00 " "$3,404.00" $0.00 "$3,680.00" "$2,070.00" "$2,070.00" $0.00 $0.00 $0.00 $958.76 "$3,414.12" "$3,414.12" $0.00 $0.00 $958.64 $0.00 "$2,267.80" "$2,267.80" $0.00 "$2,300.00" "$3,643.20" "$3,680.00" $0.00 $0.00 $719.90 $0.00 $0.00 $732.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AL-08 SUP HCPCS C1713 AR-8963AL-08 - PLATE BN 117MM 8 HL TIB LT DIST ALAT BOTH IP/OP "$4,650.00 " "$3,441.00" $0.00 "$3,720.00" "$2,092.50" "$2,092.50" $0.00 $0.00 $0.00 $969.18 "$3,451.23" "$3,451.23" $0.00 $0.00 $969.06 $0.00 "$2,292.45" "$2,292.45" $0.00 "$2,325.00" "$3,682.80" "$3,720.00" $0.00 $0.00 $727.73 $0.00 $0.00 $740.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AL-10 SUP HCPCS C1713 AR-8963AL-10 - PLATE BN 142MM 10 HL TIB LT DIST ALAT BOTH IP/OP "$4,700.00 " "$3,478.00" $0.00 "$3,760.00" "$2,115.00" "$2,115.00" $0.00 $0.00 $0.00 $979.60 "$3,488.34" "$3,488.34" $0.00 $0.00 $979.48 $0.00 "$2,317.10" "$2,317.10" $0.00 "$2,350.00" "$3,722.40" "$3,760.00" $0.00 $0.00 $735.55 $0.00 $0.00 $748.24 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AL-12 SUP HCPCS C1713 AR-8963AL-12 - PLATE BN 168MM 12 HL TIB LT DIST ALAT BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AL-14 SUP HCPCS C1713 AR-8963AL-14 - PLATE BN 193MM 14 HL TPR TIP OBLNG HL LOPRFL TIB LT DIST BOTH IP/OP "$4,800.00 " "$3,552.00" $0.00 "$3,840.00" "$2,160.00" "$2,160.00" $0.00 $0.00 $0.00 "$1,000.44" "$3,562.56" "$3,562.56" $0.00 $0.00 "$1,000.32" $0.00 "$2,366.40" "$2,366.40" $0.00 "$2,400.00" "$3,801.60" "$3,840.00" $0.00 $0.00 $751.20 $0.00 $0.00 $764.16 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AL-16 SUP HCPCS C1713 AR-8963AL-16 - PLATE BN 218MM 16 HL TPR TIP OBLNG HL LOPRFL TIB LT DIST BOTH IP/OP "$4,850.00 " "$3,589.00" $0.00 "$3,880.00" "$2,182.50" "$2,182.50" $0.00 $0.00 $0.00 "$1,010.86" "$3,599.67" "$3,599.67" $0.00 $0.00 "$1,010.74" $0.00 "$2,391.05" "$2,391.05" $0.00 "$2,425.00" "$3,841.20" "$3,880.00" $0.00 $0.00 $759.03 $0.00 $0.00 $772.12 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AL-18 SUP HCPCS C1713 AR-8963AL-18 - PLATE BN BTRS 244MM 18 HL OBLNG HL TPR TIP LOPRFL TIB LT BOTH IP/OP "$4,900.00 " "$3,626.00" $0.00 "$3,920.00" "$2,205.00" "$2,205.00" $0.00 $0.00 $0.00 "$1,021.28" "$3,636.78" "$3,636.78" $0.00 $0.00 "$1,021.16" $0.00 "$2,415.70" "$2,415.70" $0.00 "$2,450.00" "$3,880.80" "$3,920.00" $0.00 $0.00 $766.85 $0.00 $0.00 $780.08 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963APLL-04 SUP HCPCS C1713 AR-8963APLL-04 - PLATE BN 75MM 4 HL TPR TIP LOPRFL FIB LT DIST P/L 2.7MM LCK BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963APLL-06 SUP HCPCS C1713 AR-8963APLL-06 - PLATE BN 126MM ANTM 6 HL SS FIB LT DIST P/L BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963APLL-08 SUP HCPCS C1713 AR-8963APLL-08 - PLATE BN 151MM 8 HL ANTM TPR TIP CUT OUT FIB LT DIST P/L BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963APLL-10 SUP HCPCS C1713 AR-8963APLL-10 - PLATE BN 10 HL ANTM TPR TIP CUT OUT FIB LT DIST P/L BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963APLR-04 SUP HCPCS C1713 AR-8963APLR-04 - PLATE BN 75MM JUMPSTART 4 HL FIB RT DIST P/L BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963APLR-06 SUP HCPCS C1713 AR-8963APLR-06 - PLATE BN LOPRFL SS FIB RT P/L DIST BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $599.22 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 "$1,417.38" "$1,417.38" $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963APLR-08 SUP HCPCS C1713 AR-8963APLR-08 - PLATE BN 151MM 8 HL FIB RT DIST P/L BOTH IP/OP "$3,000.00 " "$2,220.00" $0.00 "$2,400.00" "$1,350.00" "$1,350.00" $0.00 $0.00 $0.00 $625.28 "$2,226.60" "$2,226.60" $0.00 $0.00 $625.20 $0.00 "$1,479.00" "$1,479.00" $0.00 "$1,500.00" "$2,376.00" "$2,400.00" $0.00 $0.00 $469.50 $0.00 $0.00 $477.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963APLR-10 SUP HCPCS C1713 AR-8963APLR-10 - PLATE BN 10 HL FIB RT DIST P/L BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AR-04 SUP HCPCS C1713 AR-8963AR-04 - PLATE BN BTRS 66MM 4 HL OBLNG HL TPR TIP LOPRFL TIB RT DIST BOTH IP/OP "$4,550.00 " "$3,367.00" $0.00 "$3,640.00" "$2,047.50" "$2,047.50" $0.00 $0.00 $0.00 $948.33 "$3,377.01" "$3,377.01" $0.00 $0.00 $948.22 $0.00 "$2,243.15" "$2,243.15" $0.00 "$2,275.00" "$3,603.60" "$3,640.00" $0.00 $0.00 $712.08 $0.00 $0.00 $724.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AR-06 SUP HCPCS C1713 AR-8963AR-06 - PLATE BN BTRS 91MM 6 HL OBLNG HL TPR TIP LOPRFL TIB RT DIST BOTH IP/OP "$4,600.00 " "$3,404.00" $0.00 "$3,680.00" "$2,070.00" "$2,070.00" $0.00 $0.00 $0.00 $958.76 "$3,414.12" "$3,414.12" $0.00 $0.00 $958.64 $0.00 "$2,267.80" "$2,267.80" $0.00 "$2,300.00" "$3,643.20" "$3,680.00" $0.00 $0.00 $719.90 $0.00 $0.00 $732.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AR-08 SUP HCPCS C1713 AR-8963AR-08 - PLATE BN 117MM 8 HL TIB RT DIST ALAT BOTH IP/OP "$4,650.00 " "$3,441.00" $0.00 "$3,720.00" "$2,092.50" "$2,092.50" $0.00 $0.00 $0.00 $969.18 "$3,451.23" "$3,451.23" $0.00 $0.00 $969.06 $0.00 "$2,292.45" "$2,292.45" $0.00 "$2,325.00" "$3,682.80" "$3,720.00" $0.00 $0.00 $727.73 $0.00 $0.00 $740.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AR-10 SUP HCPCS C1713 AR-8963AR-10 - PLATE BN 142MM 10 HL TIB RT DIST ALAT BOTH IP/OP "$4,700.00 " "$3,478.00" $0.00 "$3,760.00" "$2,115.00" "$2,115.00" $0.00 $0.00 $0.00 $979.60 "$3,488.34" "$3,488.34" $0.00 $0.00 $979.48 $0.00 "$2,317.10" "$2,317.10" $0.00 "$2,350.00" "$3,722.40" "$3,760.00" $0.00 $0.00 $735.55 $0.00 $0.00 $748.24 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AR-14 SUP HCPCS C1713 AR-8963AR-14 - PLATE BN 193MM 14 HL TIB RT DIST ALAT BOTH IP/OP "$4,800.00 " "$3,552.00" $0.00 "$3,840.00" "$2,160.00" "$2,160.00" $0.00 $0.00 $0.00 "$1,000.44" "$3,562.56" "$3,562.56" $0.00 $0.00 "$1,000.32" $0.00 "$2,366.40" "$2,366.40" $0.00 "$2,400.00" "$3,801.60" "$3,840.00" $0.00 $0.00 $751.20 $0.00 $0.00 $764.16 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AR-16 SUP HCPCS C1713 AR-8963AR-16 - PLATE BN 218MM 16 HL TPR TIP OBLNG HL LOPRFL TIB RT DIST BOTH IP/OP "$4,850.00 " "$3,589.00" $0.00 "$3,880.00" "$2,182.50" "$2,182.50" $0.00 $0.00 $0.00 "$1,010.86" "$3,599.67" "$3,599.67" $0.00 $0.00 "$1,010.74" $0.00 "$2,391.05" "$2,391.05" $0.00 "$2,425.00" "$3,841.20" "$3,880.00" $0.00 $0.00 $759.03 $0.00 $0.00 $772.12 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963AR-18 SUP HCPCS C1713 AR-8963AR-18 - PLATE BN BTRS 244MM 18 HL OBLNG HL TPR TIP LOPRFL TIB RT BOTH IP/OP "$4,900.00 " "$3,626.00" $0.00 "$3,920.00" "$2,205.00" "$2,205.00" $0.00 $0.00 $0.00 "$1,021.28" "$3,636.78" "$3,636.78" $0.00 $0.00 "$1,021.16" $0.00 "$2,415.70" "$2,415.70" $0.00 "$2,450.00" "$3,880.80" "$3,920.00" $0.00 $0.00 $766.85 $0.00 $0.00 $780.08 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963ML-04 SUP HCPCS C1713 AR-8963ML-04 - PLATE BN 103MM 4 HL TIB LT DIST MDL BOTH IP/OP "$4,300.00 " "$3,182.00" $0.00 "$3,440.00" "$1,935.00" "$1,935.00" $0.00 $0.00 $0.00 $896.23 "$3,191.46" "$3,191.46" $0.00 $0.00 $896.12 $0.00 "$2,119.90" "$2,119.90" $0.00 "$2,150.00" "$3,405.60" "$3,440.00" $0.00 $0.00 $672.95 $0.00 $0.00 $684.56 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963ML-06 SUP HCPCS C1713 AR-8963ML-06 - PLATE BN 128MM 6 HL TIB LT DIST MDL BOTH IP/OP "$4,350.00 " "$3,219.00" $0.00 "$3,480.00" "$1,957.50" "$1,957.50" $0.00 $0.00 $0.00 $906.65 "$3,228.57" "$3,228.57" $0.00 $0.00 $906.54 $0.00 "$2,144.55" "$2,144.55" $0.00 "$2,175.00" "$3,445.20" "$3,480.00" $0.00 $0.00 $680.78 $0.00 $0.00 $692.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963ML-10 SUP HCPCS C1713 AR-8963ML-10 - PLATE BN 179MM 10 HL TPR TIP OBLNG HL LOPRFL TIB LT DIST MDL BOTH IP/OP "$4,450.00 " "$3,293.00" $0.00 "$3,560.00" "$2,002.50" "$2,002.50" $0.00 $0.00 $0.00 $927.49 "$3,302.79" "$3,302.79" $0.00 $0.00 $927.38 $0.00 "$2,193.85" "$2,193.85" $0.00 "$2,225.00" "$3,524.40" "$3,560.00" $0.00 $0.00 $696.43 $0.00 $0.00 $708.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963ML-14 SUP HCPCS C1713 AR-8963ML-14 - PLATE BN 230MM 14 HL TIB LT DIST MDL BOTH IP/OP "$4,550.00 " "$3,367.00" $0.00 "$3,640.00" "$2,047.50" "$2,047.50" $0.00 $0.00 $0.00 $948.33 "$3,377.01" "$3,377.01" $0.00 $0.00 $948.22 $0.00 "$2,243.15" "$2,243.15" $0.00 "$2,275.00" "$3,603.60" "$3,640.00" $0.00 $0.00 $712.08 $0.00 $0.00 $724.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963ML-16 SUP HCPCS C1713 AR-8963ML-16 - PLATE BN 278MM 16 HL TPR TIP OBLNG HL LOPRFL TIB LT DIST MDL BOTH IP/OP "$4,600.00 " "$3,404.00" $0.00 "$3,680.00" "$2,070.00" "$2,070.00" $0.00 $0.00 $0.00 $958.76 "$3,414.12" "$3,414.12" $0.00 $0.00 $958.64 $0.00 "$2,267.80" "$2,267.80" $0.00 "$2,300.00" "$3,643.20" "$3,680.00" $0.00 $0.00 $719.90 $0.00 $0.00 $732.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963MR-04 SUP HCPCS C1713 AR-8963MR-04 - PLATE BN 4 HL LOPRFL SS TIB RT DIST MDL 2.7 MM SCR BOTH IP/OP "$4,300.00 " "$3,182.00" $0.00 "$3,440.00" "$1,935.00" "$1,935.00" $0.00 $0.00 $0.00 $896.23 "$3,191.46" "$3,191.46" $0.00 $0.00 $896.12 $0.00 "$2,119.90" "$2,119.90" $0.00 "$2,150.00" "$3,405.60" "$3,440.00" $0.00 $0.00 $672.95 $0.00 $0.00 $684.56 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963MR-06 SUP HCPCS C1713 AR-8963MR-06 - PLATE BN CNTR 128MM 6 HL TPR TIP LOPRFL TIB RT DIST MDL 2.7 BOTH IP/OP "$4,350.00 " "$3,219.00" $0.00 "$3,480.00" "$1,957.50" "$1,957.50" $0.00 $0.00 $0.00 $906.65 "$3,228.57" "$3,228.57" $0.00 $0.00 $906.54 $0.00 "$2,144.55" "$2,144.55" $0.00 "$2,175.00" "$3,445.20" "$3,480.00" $0.00 $0.00 $680.78 $0.00 $0.00 $692.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963MR-08 SUP HCPCS C1713 AR-8963MR-08 - PLATE BN 154MM 8 HL TPR TIP OBLNG HL LOPRFL TIB RT DIST MDL BOTH IP/OP "$4,400.00 " "$3,256.00" $0.00 "$3,520.00" "$1,980.00" "$1,980.00" $0.00 $0.00 $0.00 $917.07 "$3,265.68" "$3,265.68" $0.00 $0.00 $916.96 $0.00 "$2,169.20" "$2,169.20" $0.00 "$2,200.00" "$3,484.80" "$3,520.00" $0.00 $0.00 $688.60 $0.00 $0.00 $700.48 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963MR-10 SUP HCPCS C1713 AR-8963MR-10 - PLATE BN CNTR 179MM 10 HL LOPRFL TPR TIP TIB RT DIST MDL BOTH IP/OP "$4,450.00 " "$3,293.00" $0.00 "$3,560.00" "$2,002.50" "$2,002.50" $0.00 $0.00 $0.00 $927.49 "$3,302.79" "$3,302.79" $0.00 $0.00 $927.38 $0.00 "$2,193.85" "$2,193.85" $0.00 "$2,225.00" "$3,524.40" "$3,560.00" $0.00 $0.00 $696.43 $0.00 $0.00 $708.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963MR-12 SUP HCPCS C1713 AR-8963MR-12 - PLATE BN 204MM 12 HL TPR TIP OBLNG HL LOPRFL TIB RT DIST MDL BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963MR-14 SUP HCPCS C1713 AR-8963MR-14 - PLATE BN 230MM 14 HL TPR TIP OBLNG HL LOPRFL TIB RT DIST MDL BOTH IP/OP "$4,550.00 " "$3,367.00" $0.00 "$3,640.00" "$2,047.50" "$2,047.50" $0.00 $0.00 $0.00 $948.33 "$3,377.01" "$3,377.01" $0.00 $0.00 $948.22 $0.00 "$2,243.15" "$2,243.15" $0.00 "$2,275.00" "$3,603.60" "$3,640.00" $0.00 $0.00 $712.08 $0.00 $0.00 $724.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963MR-16 SUP HCPCS C1713 AR-8963MR-16 - PLATE BN 278MM 16 HL TPR TIP OBLNG HL LOPRFL TIB RT DIST MDL BOTH IP/OP "$4,600.00 " "$3,404.00" $0.00 "$3,680.00" "$2,070.00" "$2,070.00" $0.00 $0.00 $0.00 $958.76 "$3,414.12" "$3,414.12" $0.00 $0.00 $958.64 $0.00 "$2,267.80" "$2,267.80" $0.00 "$2,300.00" "$3,643.20" "$3,680.00" $0.00 $0.00 $719.90 $0.00 $0.00 $732.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963P-03 SUP HCPCS C1713 AR-8963P-03 - PLATE BN 57MM ARTHX 3 HL TIB DP BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,119.38" "$1,119.38" $0.00 $0.00 $0.00 $518.46 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 "$1,471.36" "$1,471.36" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963P-05 SUP HCPCS C1713 AR-8963P-05 - PLATE BN 77MM 5 HL TIB DP BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,119.38" "$1,119.38" $0.00 $0.00 $0.00 $518.46 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 "$1,471.36" "$1,471.36" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963P-07 SUP HCPCS C1713 AR-8963P-07 - PLATE BN 7 HL TIB DP BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,041.05" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963P-09 SUP HCPCS C1713 AR-8963P-09 - PLATE BN 118MM 9 HL TIB DP BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963PLL-04 SUP HCPCS C1713 AR-8963PLL-04 - PLATE BN 75MM 4 HL FIB DIST P/L BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963PLL-05 SUP HCPCS C1713 AR-8963PLL-05 - PLATE BN STD 88MM 5 HL TPR TIP FIB DIST P/L 2.7MM LCK BOTH IP/OP "$2,050.00 " "$1,517.00" $0.00 "$1,640.00" $922.50 $922.50 $0.00 $0.00 $0.00 $427.27 "$1,521.51" "$1,521.51" $0.00 $0.00 $427.22 $0.00 "$1,212.58" "$1,212.58" $0.00 "$1,025.00" "$1,623.60" "$1,640.00" $0.00 $0.00 $320.83 $0.00 $0.00 $326.36 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963PLL-06 SUP HCPCS C1713 AR-8963PLL-06 - PLATE BN 100MM 6 HL TPR TIP CUT OUT SCLP FIB DIST P/L BOTH IP/OP "$2,100.00 " "$1,554.00" $0.00 "$1,680.00" $945.00 $945.00 $0.00 $0.00 $0.00 $437.69 "$1,558.62" "$1,558.62" $0.00 $0.00 $437.64 $0.00 "$1,242.15" "$1,242.15" $0.00 "$1,050.00" "$1,663.20" "$1,680.00" $0.00 $0.00 $328.65 $0.00 $0.00 $334.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963PLL-08 SUP HCPCS C1713 AR-8963PLL-08 - PLATE BN STD 126MM 8 HL TPR TIP FIB DIST P/L 2.7MM LCK BOTH IP/OP "$2,150.00 " "$1,591.00" $0.00 "$1,720.00" $967.50 $967.50 $0.00 $0.00 $0.00 $448.11 "$1,595.73" "$1,595.73" $0.00 $0.00 $448.06 $0.00 "$1,271.73" "$1,271.73" $0.00 "$1,075.00" "$1,702.80" "$1,720.00" $0.00 $0.00 $336.48 $0.00 $0.00 $342.28 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963RM-02 SUP HCPCS C1713 AR-8963RM-02 - PLATE BN STRG 16MM 2 HL OBLNG HL TPR TIP LOPRFL 2.7MM SCR BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963RM-03 SUP HCPCS C1713 AR-8963RM-03 - PLATE BN STRG 16MM 3 HL OBLNG HL TPR TIP LOPRFL 2.7MM SCR BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963RM-04 SUP HCPCS C1713 AR-8963RM-04 - PLATE BN STRG 16MM 4 HL OBLNG HL TPR TIP LOPRFL 2.7MM SCR BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $320.63 $320.63 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8963RM-05 SUP HCPCS C1713 AR-8963RM-05 - PLATE BN STRG 40MM 5 HL 2.7MM SCR BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-01 SUP HCPCS C1713 AR-8964-01 - SCREW BN 4MM 125MM SCHNZ BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-02 SUP HCPCS C1713 AR-8964-02 - SCREW BN 4MM 125MM SCHNZ BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-03 SUP HCPCS C1713 AR-8964-03 - SCREW BN 5MM 175MM SCHNZ BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-04 SUP HCPCS C1713 AR-8964-04 - SCREW BN 5MM 200MM SCHNZ BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-05 SUP HCPCS C1713 AR-8964-05 - PIN FX 6MM 225MM TRNFX BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-06 SUP HCPCS C1713 AR-8964-06 - PIN FX 6MM 300MM TRNFX BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-07 SUP Custom 27203010 AR-8964-07 - CLAMP XTRNFX LG CMBN BOTH IP/OP "$1,240.00 " $917.60 $0.00 $992.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $920.33 $920.33 $0.00 $0.00 $258.42 $0.00 $0.00 $0.00 $0.00 $620.00 $982.08 $992.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-08 SUP Custom 27203010 AR-8964-08 - CLAMP XTRNFX LG MLPN BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-09 SUP Custom 27203010 AR-8964-09 - CLAMP XTRNFX LG MLPN ROD ATCH BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $0.00 $0.00 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-10 SUP Custom 27203010 AR-8964-10 - BIT DRL 3.5MM 195MM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-22 SUP HCPCS C1713 AR-8964-22 - CAP END NS LF ARTHX SCR BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $562.50 $562.50 $0.00 $0.00 $0.00 $260.53 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $739.38 $739.38 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964-24 SUP HCPCS C1713 AR-8964-24 - SCREW BN 5MM 250MM SCHNZ BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $140.63 $140.63 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-100 SUP HCPCS C1713 AR-8964R-100 - ROD XTRNFX 11MM 100MM ARTHROFX RDLCNT LTWT CFBR BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-150 SUP HCPCS C1713 AR-8964R-150 - ROD XTRNFX 11MM 150MM CFBR BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-200 SUP HCPCS C1713 AR-8964R-200 - ROD XTRNFX 11MM 200MM ARTHROFX CFBR BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-250 SUP HCPCS C1713 AR-8964R-250 - ROD XTRNFX 11MM 250MM CFBR BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $190.13 $190.13 $0.00 $0.00 $0.00 $88.06 $313.58 $313.58 $0.00 $0.00 $88.05 $0.00 $249.91 $249.91 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-300 SUP HCPCS C1713 AR-8964R-300 - ROD XTRNFX 11MM 300MM CFBR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-350 SUP HCPCS C1713 AR-8964R-350 - ROD XTRNFX 11MM 350MM CFBR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-400 SUP HCPCS C1713 AR-8964R-400 - ROD XTRNFX 11MM 400MM CFBR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-450 SUP HCPCS C1713 AR-8964R-450 - ROD XTRNFX 11MM 450MM CFBR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964R-500 SUP HCPCS C1713 AR-8964R-500 - ROD XTRNFX 11MM 500MM ARTHROFX RDLCNT LTWT CFBR BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8964S SUP Custom 27203010 AR-8964S - SYSTEM XTRNFX ARTHROFX BOTH IP/OP "$35,000.00 " "$25,900.00" $0.00 "$28,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,294.00" $0.00 $0.00 $0.00 $0.00 "$17,500.00" "$27,720.00" "$28,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-100FT SUP HCPCS C1713 AR-8967-100FT - SCREW BN FT 6.7MM 100MM LOPRFL SCR SLF DRL ST CNN MTL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-105FT SUP HCPCS C1713 AR-8967-105FT - SCREW BN FT 6.7MM 105MM LOPRFL SCR SLF DRL ST CNN MTL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-110FT SUP HCPCS C1713 AR-8967-110FT - SCREW BN FT 6.7MM 110MM LOPRFL SCR SLF DRL ST CNN MTL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-115FT SUP HCPCS C1713 AR-8967-115FT - SCREW BN FT 6.7MM 115MM LOPRFL SCR SLF DRL ST CNN MTL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-120FT SUP HCPCS C1713 AR-8967-120FT - SCREW BN FT 6.7MM 120MM LOPRFL SCR SLF DRL ST CNN MTL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-18100 SUP HCPCS C1713 AR-8967-18100 - SCREW BN LOPRFL 6.7MM 100MM 18MM CNN TI FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-18105 SUP HCPCS C1713 AR-8967-18105 - SCREW BN LOPRFL 6.7MM 105MM 18MM CNN TI FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-18110 SUP HCPCS C1713 AR-8967-18110 - SCREW BN LOPRFL 6.7MM 110MM 18MM CNN TI FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-18115 SUP HCPCS C1713 AR-8967-18115 - SCREW BN LOPRFL 6.7MM 115MM 18MM CNN TI FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-18120 SUP HCPCS C1713 AR-8967-18120 - SCREW BN LOPRFL 6.7MM 120MM 18MM CNN TI FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1840 SUP HCPCS C1713 AR-8967-1840 - SCREW BN 3.5MM HEX 6.7MM 40MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1845 SUP HCPCS C1713 AR-8967-1845 - SCREW BN 3.5MM HEX 6.7MM 45MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1850 SUP HCPCS C1713 AR-8967-1850 - SCREW BN 3.5MM HEX 6.7MM 50MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1855 SUP HCPCS C1713 AR-8967-1855 - SCREW BN 3.5MM HEX 6.7MM 55MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1860 SUP HCPCS C1713 AR-8967-1860 - SCREW BN 3.5MM HEX 6.7MM 60MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1865 SUP HCPCS C1713 AR-8967-1865 - SCREW BN 3.5MM HEX 6.7MM 65MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1865S SUP HCPCS C1713 AR-8967-1865S - SCREW BN P/T 6.7MM 65MM STRL ARTHX LOPRFL SCR CNN TI BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1870 SUP HCPCS C1713 AR-8967-1870 - SCREW BN 3.5MM HEX 6.7MM 70MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1875 SUP HCPCS C1713 AR-8967-1875 - SCREW BN 3.5MM HEX 6.7MM 75MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1880 SUP HCPCS C1713 AR-8967-1880 - SCREW BN 3.5MM HEX 6.7MM 80MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1880S SUP HCPCS C1713 AR-8967-1880S - SCREW BN P/T 6.7MM 80MM STRL ARTHX LOPRFL SCR CNN TI BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1885 SUP HCPCS C1713 AR-8967-1885 - SCREW BN 3.5MM HEX 6.7MM 85MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1890 SUP HCPCS C1713 AR-8967-1890 - SCREW BN 3.5MM HEX 6.7MM 90MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1890S SUP HCPCS C1713 AR-8967-1890S - SCREW BN P/T 6.7MM 90MM STRL ARTHX LOPRFL SCR CNN TI BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-1895 SUP HCPCS C1713 AR-8967-1895 - SCREW BN 3.5MM HEX 6.7MM 95MM 18MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-28100 SUP HCPCS C1713 AR-8967-28100 - SCREW BN 3.5MM HEX 6.7MM 100MM 18MM LOPRFL SCR SLF DRL ST BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-28105 SUP HCPCS C1713 AR-8967-28105 - SCREW BN 3.5MM HEX 6.7MM 105MM 18MM LOPRFL SCR SLF DRL ST BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-28110 SUP HCPCS C1713 AR-8967-28110 - SCREW BN 3.5MM HEX 6.7MM 110MM 18MM LOPRFL SCR SLF DRL ST BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-28115 SUP HCPCS C1713 AR-8967-28115 - SCREW BN 3.5MM HEX 6.7MM 115MM 18MM LOPRFL SCR SLF DRL ST BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-28120 SUP HCPCS C1713 AR-8967-28120 - SCREW BN 3.5MM HEX 6.7MM 120MM 18MM LOPRFL SCR SLF DRL ST BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2840 SUP HCPCS C1713 AR-8967-2840 - SCREW BN 3.5MM HEX 6.7MM 40MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2845 SUP HCPCS C1713 AR-8967-2845 - SCREW BN 3.5MM HEX 6.7MM 45MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2850 SUP HCPCS C1713 AR-8967-2850 - SCREW BN 3.5MM HEX 6.7MM 50MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2855 SUP HCPCS C1713 AR-8967-2855 - SCREW BN 3.5MM HEX 6.7MM 55MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2860 SUP HCPCS C1713 AR-8967-2860 - SCREW BN 3.5MM HEX 6.7MM 60MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2865 SUP HCPCS C1713 AR-8967-2865 - SCREW BN 3.5MM HEX 6.7MM 65MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2870 SUP HCPCS C1713 AR-8967-2870 - SCREW BN 3.5MM HEX 6.7MM 70MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2875 SUP HCPCS C1713 AR-8967-2875 - SCREW BN 3.5MM HEX 6.7MM 75MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2880 SUP HCPCS C1713 AR-8967-2880 - SCREW BN 3.5MM HEX 6.7MM 80MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2885 SUP HCPCS C1713 AR-8967-2885 - SCREW BN 3.5MM HEX 6.7MM 85MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2890 SUP HCPCS C1713 AR-8967-2890 - SCREW BN 3.5MM HEX 6.7MM 90MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-2895 SUP HCPCS C1713 AR-8967-2895 - SCREW BN 3.5MM HEX 6.7MM 95MM 28MM LOPRFL SCR SLF DRL ST CNN BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-40C SUP Custom 27203010 AR-8967-40C - BIT DRL 4MM 120MM CNN 6.7MM SCR BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-40FT SUP HCPCS C1713 AR-8967-40FT - SCREW BN FT 6.7MM 40MM LOPRFL SCR CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-45FT SUP HCPCS C1713 AR-8967-45FT - SCREW BN FT 6.7MM 45MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-50FT SUP HCPCS C1713 AR-8967-50FT - SCREW BN FT 6.7MM 50MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-55FT SUP HCPCS C1713 AR-8967-55FT - SCREW BN FT 6.7MM 55MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-60FT SUP HCPCS C1713 AR-8967-60FT - SCREW BN FT 6.7MM 60MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-65FT SUP HCPCS C1713 AR-8967-65FT - SCREW BN FT 6.7MM 65MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-67C SUP Custom 27203010 AR-8967-67C - BIT DRL MN 6.7MM HDSN CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-70FT SUP HCPCS C1713 AR-8967-70FT - SCREW BN FT 6.7MM 70MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-75FT SUP HCPCS C1713 AR-8967-75FT - SCREW BN FT 6.7MM 75MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-80FT SUP HCPCS C1713 AR-8967-80FT - SCREW BN FT 6.7MM 80MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-85FT SUP HCPCS C1713 AR-8967-85FT - SCREW BN FT 6.7MM 85MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-90FT SUP HCPCS C1713 AR-8967-90FT - SCREW BN FT 6.7MM 90MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967-95FT SUP HCPCS C1713 AR-8967-95FT - SCREW BN FT 6.7MM 95MM LOPRFL SCR SLF DRL ST CNN MTL FT/ANKL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967C SUP HCPCS C1713 AR-8967C - SCREW BN LOPRFL 7MM PLT INS SM BN BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967CSF SUP Custom 27203010 AR-8967CSF - COUNTERSINK DRL CNN 6.7 MM SCR BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967G SUP Custom 27203010 AR-8967G - GUIDE DRL 6.7MM 4MM CNN BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967S SUP HCPCS C1713 AR-8967S - MODULE INST 6.7 MM TENODESIS LOPRFL SCR BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8967W SUP HCPCS C1713 AR-8967W - WASHER ORTH 13MM TI BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $90.00 $90.00 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970-01 SUP Custom 27203010 AR-8970-01 - GUIDE DRL 4.5 MM LCK SCR BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970-02 SUP Custom 27203010 AR-8970-02 - GUIDE DRL 3 4.5 MM SCR BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $0.00 $0.00 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970-30 SUP Custom 27203010 AR-8970-30 - BIT DRL 3MM CLBRT BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970-30C SUP Custom 27203010 AR-8970-30C - BIT DRL 3MM CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970-40C SUP Custom 27203010 AR-8970-40C - BIT DRL 4MM CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970-45 SUP Custom 27203010 AR-8970-45 - BIT DRL 4.5MM BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970-55 SUP Custom 27203010 AR-8970-55 - BIT DRL 5.5MM BOTH IP/OP $197.50 $146.15 $0.00 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.58 $146.58 $0.00 $0.00 $41.16 $0.00 $0.00 $0.00 $0.00 $98.75 $156.42 $158.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970AL SUP HCPCS C1713 AR-8970AL - PLATE BN ANKL LT ANT BOTH IP/OP "$5,187.50 " "$3,838.75" $0.00 "$4,150.00" "$2,334.38" "$2,334.38" $0.00 $0.00 $0.00 "$1,081.20" "$3,850.16" "$3,850.16" $0.00 $0.00 "$1,081.08" $0.00 "$2,557.44" "$2,557.44" $0.00 "$2,593.75" "$4,108.50" "$4,150.00" $0.00 $0.00 $811.84 $0.00 $0.00 $825.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970AR SUP HCPCS C1713 AR-8970AR - PLATE BN ANKL RT ANT BOTH IP/OP "$5,187.50 " "$3,838.75" $0.00 "$4,150.00" "$2,334.38" "$2,334.38" $0.00 $0.00 $0.00 "$1,081.20" "$3,850.16" "$3,850.16" $0.00 $0.00 "$1,081.08" $0.00 "$2,557.44" "$2,557.44" $0.00 "$2,593.75" "$4,108.50" "$4,150.00" $0.00 $0.00 $811.84 $0.00 $0.00 $825.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970PL SUP HCPCS C1713 AR-8970PL - PLATE BN ANKL LT TIBIOTALOCALCANEAL POST BOTH IP/OP "$5,687.50 " "$4,208.75" $0.00 "$4,550.00" "$2,559.38" "$2,559.38" $0.00 $0.00 $0.00 "$1,185.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,185.28" $0.00 "$2,803.94" "$2,803.94" $0.00 "$2,843.75" "$4,504.50" "$4,550.00" $0.00 $0.00 $890.09 $0.00 $0.00 $905.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970PR SUP HCPCS C1713 AR-8970PR - PLATE BN ANKL RT POST TIBIOTALOCALCANEAL BOTH IP/OP "$5,687.50 " "$4,208.75" $0.00 "$4,550.00" "$2,559.38" "$2,559.38" $0.00 $0.00 $0.00 "$1,185.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,185.28" $0.00 "$2,803.94" "$2,803.94" $0.00 "$2,843.75" "$4,504.50" "$4,550.00" $0.00 $0.00 $890.09 $0.00 $0.00 $905.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970S SUP HCPCS C1713 AR-8970S - SCREW BN ANKL FSN PLT SYS BOTH IP/OP "$36,250.00 " "$26,825.00" $0.00 "$29,000.00" "$16,312.50" "$16,312.50" $0.00 $0.00 $0.00 "$7,555.41" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,554.50" $0.00 "$17,871.25" "$17,871.25" $0.00 "$18,125.00" "$28,710.00" "$29,000.00" $0.00 $0.00 "$5,673.13" $0.00 $0.00 "$5,771.00" $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970TT SUP HCPCS C1713 AR-8970TT - PLATE BN FSN ANKL TIBIOTALAR LAT BOTH IP/OP "$5,187.50 " "$3,838.75" $0.00 "$4,150.00" "$2,334.38" "$2,334.38" $0.00 $0.00 $0.00 "$1,081.20" "$3,850.16" "$3,850.16" $0.00 $0.00 "$1,081.08" $0.00 "$2,557.44" "$2,557.44" $0.00 "$2,593.75" "$4,108.50" "$4,150.00" $0.00 $0.00 $811.84 $0.00 $0.00 $825.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8970TTC SUP HCPCS C1713 AR-8970TTC - PLATE BN FSN ANKL LAT TIBIOTALOCALCANEAL BOTH IP/OP "$5,437.50 " "$4,023.75" $0.00 "$4,350.00" "$2,446.88" "$2,446.88" $0.00 $0.00 $0.00 "$1,133.31" "$4,035.71" "$4,035.71" $0.00 $0.00 "$1,133.18" $0.00 "$2,680.69" "$2,680.69" $0.00 "$2,718.75" "$4,306.50" "$4,350.00" $0.00 $0.00 $850.97 $0.00 $0.00 $865.65 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8978DS SUP Custom 27203010 AR-8978DS - KIT ASCP FX 3.5MM 8.5MM STRL ARTHX DX SWIVELOCK SL BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8978P SUP HCPCS C1713 AR-8978P - ANCHOR SUT 3.5MM STRL DX SWIVELOCK SL8.5MM FRK EYLT BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8981-06S SUP Custom 27203010 AR-8981-06S - SET GFT HRVT 6MM STRL OATS DISP S JNT BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8981-08S SUP Custom 27203010 AR-8981-08S - SET GFT HRVT 8MM STRL OATS DISP S JNT BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8981-10S SUP Custom 27203010 AR-8981-10S - SET GFT HRVT 10MM STRL OATS DISP S JNT BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-8999N SUP Custom 27203010 AR-8999N - NEEDLE SUT MN SCRPN DX BOTH IP/OP "$4,937.50 " "$3,653.75" $0.00 "$3,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,664.61" "$3,664.61" $0.00 $0.00 "$1,028.98" $0.00 $0.00 $0.00 $0.00 "$2,468.75" "$3,910.50" "$3,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9045-40PT SUP HCPCS C1713 AR-9045-40PT - SCREW BN P/T LOPRFL 4.5MM 40MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9045-45PT SUP HCPCS C1713 AR-9045-45PT - SCREW BN P/T 4.5MM 45MM LOPRFL HD ST TI METATARSUS BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9045-50PT SUP HCPCS C1713 AR-9045-50PT - SCREW BN P/T LOPRFL 4.5MM 50MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9045-55PT SUP HCPCS C1713 AR-9045-55PT - SCREW BN P/T LOPRFL 4.5MM 55MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9045-60PT SUP HCPCS C1713 AR-9045-60PT - SCREW BN P/T LOPRFL 4.5MM 60MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9045-65PT SUP HCPCS C1713 AR-9045-65PT - SCREW BN P/T LOPRFL 4.5MM 65MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9055-40PT SUP HCPCS C1713 AR-9055-40PT - SCREW BN P/T LOPRFL 5.5MM 40MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9055-45PT SUP HCPCS C1713 AR-9055-45PT - SCREW BN P/T 5.5MM 45MM SOLINULLD LOPRFL ST TI METATARSUS BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9055-50PT SUP HCPCS C1713 AR-9055-50PT - SCREW BN P/T LOPRFL 5.5MM 50MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9055-55PT SUP HCPCS C1713 AR-9055-55PT - SCREW BN P/T 5.5MM 55MM LOPRFL HD ST TI METATARSUS BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9055-60PT SUP HCPCS C1713 AR-9055-60PT - SCREW BN P/T LOPRFL 5.5MM 60MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9055-65PT SUP HCPCS C1713 AR-9055-65PT - SCREW BN P/T LOPRFL 5.5MM 65MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9060-40PT SUP HCPCS C1713 AR-9060-40PT - SCREW BN P/T LOPRFL 6MM 40MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9060-45PT SUP HCPCS C1713 AR-9060-45PT - SCREW BN P/T LOPRFL 6MM 45MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9060-50PT SUP HCPCS C1713 AR-9060-50PT - SCREW BN P/T LOPRFL 6MM 50MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9060-55PT SUP HCPCS C1713 AR-9060-55PT - SCREW BN P/T LOPRFL 6MM 55MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9060-60PT SUP HCPCS C1713 AR-9060-60PT - SCREW BN P/T LOPRFL 6MM 60MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9060-65PT SUP HCPCS C1713 AR-9060-65PT - SCREW BN P/T LOPRFL 6MM 65MM SLD TI METATARSUS JNS FX BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-05P SUP HCPCS C1776 AR-9100-05P - STEM HUM 5MM 105MM STRL BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-05S SUP HCPCS C1776 AR-9100-05S - STEM HUM 132.5D 5MM 60MM UNIVERS APX BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-06P SUP HCPCS C1776 AR-9100-06P - STEM HUM 6MM 115MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-06S SUP HCPCS C1776 AR-9100-06S - STEM HUM RECT 6MM 60MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-07 SUP HCPCS C1776 AR-9100-07 - STEM HUM 7MM UNIVERS SHLDR BOTH IP/OP "$5,987.50 " "$4,430.75" $0.00 "$4,790.00" "$2,694.38" "$2,694.38" $0.00 $0.00 $0.00 "$1,247.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.80" $0.00 "$2,951.84" "$2,951.84" $0.00 "$2,993.75" "$4,742.10" "$4,790.00" $0.00 $0.00 $937.04 $0.00 $0.00 $953.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-07P SUP HCPCS C1776 AR-9100-07P - STEM HUM 7MM 140MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-07S SUP HCPCS C1776 AR-9100-07S - STEM HUM RECT 7MM 60MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-08 SUP HCPCS C1776 AR-9100-08 - STEM HUM 8MM UNIVERS SHLDR BOTH IP/OP "$5,987.50 " "$4,430.75" $0.00 "$4,790.00" "$2,694.38" "$2,694.38" $0.00 $0.00 $0.00 "$1,247.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.80" $0.00 "$2,951.84" "$2,951.84" $0.00 "$2,993.75" "$4,742.10" "$4,790.00" $0.00 $0.00 $937.04 $0.00 $0.00 $953.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-08F SUP HCPCS C1776 AR-9100-08F - STEM HUM 8MM 158MM STRL UNIVERS ADJ HT SHLDR BOTH IP/OP "$6,812.50 " "$5,041.25" $0.00 "$5,450.00" "$3,065.63" "$3,065.63" $0.00 $0.00 $0.00 "$1,419.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,419.73" $0.00 "$3,358.56" "$3,358.56" $0.00 "$3,406.25" "$5,395.50" "$5,450.00" $0.00 $0.00 "$1,066.16" $0.00 $0.00 "$1,084.55" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-08P SUP HCPCS C1776 AR-9100-08P - STEM HUM 8MM 143MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-08S SUP HCPCS C1776 AR-9100-08S - STEM HUM RECT 8MM 60MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-09 SUP HCPCS C1776 AR-9100-09 - STEM HUM 9MM UNIVERS SHLDR BOTH IP/OP "$5,987.50 " "$4,430.75" $0.00 "$4,790.00" "$2,694.38" "$2,694.38" $0.00 $0.00 $0.00 "$1,247.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.80" $0.00 "$2,951.84" "$2,951.84" $0.00 "$2,993.75" "$4,742.10" "$4,790.00" $0.00 $0.00 $937.04 $0.00 $0.00 $953.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-09F SUP HCPCS C1776 AR-9100-09F - STEM HUM 9MM 173MM STRL UNIVERS ADJ HT SHLDR BOTH IP/OP "$6,812.50 " "$5,041.25" $0.00 "$5,450.00" "$3,065.63" "$3,065.63" $0.00 $0.00 $0.00 "$1,419.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,419.73" $0.00 "$3,358.56" "$3,358.56" $0.00 "$3,406.25" "$5,395.50" "$5,450.00" $0.00 $0.00 "$1,066.16" $0.00 $0.00 "$1,084.55" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-09P SUP HCPCS C1776 AR-9100-09P - STEM HUM 9MM 146MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-09S SUP HCPCS C1776 AR-9100-09S - STEM HUM RECT 9MM 60MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-10F SUP HCPCS C1776 AR-9100-10F - STEM HUM 10MM 180MM STRL UNIVERS ADJ HT FX SHLDR BOTH IP/OP "$6,812.50 " "$5,041.25" $0.00 "$5,450.00" "$3,065.63" "$3,065.63" $0.00 $0.00 $0.00 "$1,419.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,419.73" $0.00 "$3,358.56" "$3,358.56" $0.00 "$3,406.25" "$5,395.50" "$5,450.00" $0.00 $0.00 "$1,066.16" $0.00 $0.00 "$1,084.55" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-10P SUP HCPCS C1776 AR-9100-10P - STEM HUM 10MM 148MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-10S SUP HCPCS C1776 AR-9100-10S - STEM HUM RECT 10MM 60MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-11 SUP HCPCS C1776 AR-9100-11 - STEM HUM 11MM UNIVERS SHLDR BOTH IP/OP "$5,987.50 " "$4,430.75" $0.00 "$4,790.00" "$2,694.38" "$2,694.38" $0.00 $0.00 $0.00 "$1,247.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.80" $0.00 "$2,951.84" "$2,951.84" $0.00 "$2,993.75" "$4,742.10" "$4,790.00" $0.00 $0.00 $937.04 $0.00 $0.00 $953.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-11F SUP HCPCS C1776 AR-9100-11F - STEM HUM 11MM 187MM STRL UNIVERS ADJ HT SHLDR BOTH IP/OP "$6,812.50 " "$5,041.25" $0.00 "$5,450.00" "$3,065.63" "$3,065.63" $0.00 $0.00 $0.00 "$1,419.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,419.73" $0.00 "$3,358.56" "$3,358.56" $0.00 "$3,406.25" "$5,395.50" "$5,450.00" $0.00 $0.00 "$1,066.16" $0.00 $0.00 "$1,084.55" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-11P SUP HCPCS C1776 AR-9100-11P - STEM HUM 11MM 151MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-11S SUP HCPCS C1776 AR-9100-11S - STEM HUM RECT 11MM 60MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-12 SUP HCPCS C1776 AR-9100-12 - STEM HUM 12MM UNIVERS SHLDR BOTH IP/OP "$5,987.50 " "$4,430.75" $0.00 "$4,790.00" "$2,694.38" "$2,694.38" $0.00 $0.00 $0.00 "$1,247.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.80" $0.00 "$2,951.84" "$2,951.84" $0.00 "$2,993.75" "$4,742.10" "$4,790.00" $0.00 $0.00 $937.04 $0.00 $0.00 $953.21 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-12F SUP HCPCS C1776 AR-9100-12F - STEM HUM 12MM 195MM STRL UNIVERS ADJ HT SHLDR BOTH IP/OP "$6,812.50 " "$5,041.25" $0.00 "$5,450.00" "$3,065.63" "$3,065.63" $0.00 $0.00 $0.00 "$1,419.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,419.73" $0.00 "$3,358.56" "$3,358.56" $0.00 "$3,406.25" "$5,395.50" "$5,450.00" $0.00 $0.00 "$1,066.16" $0.00 $0.00 "$1,084.55" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-12P SUP HCPCS C1776 AR-9100-12P - STEM HUM 12MM 151MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-12S SUP HCPCS C1776 AR-9100-12S - STEM HUM RECT 12MM 60MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-13F SUP HCPCS C1776 AR-9100-13F - STEM HUM 13MM 204MM STRL UNIVERS ADJ HT SHLDR FX BOTH IP/OP "$6,812.50 " "$5,041.25" $0.00 "$5,450.00" "$3,065.63" "$3,065.63" $0.00 $0.00 $0.00 "$1,419.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,419.73" $0.00 "$3,358.56" "$3,358.56" $0.00 "$3,406.25" "$5,395.50" "$5,450.00" $0.00 $0.00 "$1,066.16" $0.00 $0.00 "$1,084.55" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-13P SUP HCPCS C1776 AR-9100-13P - STEM HUM 13MM UNIVERS SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-13S SUP HCPCS C1776 AR-9100-13S - STEM HUM RECT 13MM 65MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-14P SUP HCPCS C1776 AR-9100-14P - STEM HUM 14MM 151MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-14S SUP HCPCS C1776 AR-9100-14S - STEM HUM RECT 14MM 65MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-15P SUP HCPCS C1776 AR-9100-15P - STEM HUM 15MM 151MM STRL UNIVERS II SHLDR BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-15S SUP HCPCS C1776 AR-9100-15S - STEM HUM RECT 15MM 65MM UNIVERS APX PRFT REM TRUNION SUT HL BOTH IP/OP "$10,437.50 " "$7,723.75" $0.00 "$8,350.00" "$4,696.88" "$4,696.88" $0.00 $0.00 $0.00 "$2,175.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,175.18" $0.00 "$5,145.69" "$5,145.69" $0.00 "$5,218.75" "$8,266.50" "$8,350.00" $0.00 $0.00 "$1,633.47" $0.00 $0.00 "$1,661.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-21 SUP Custom 27203010 AR-9100-21 - KIT ASCP FX UNV TRUNNION BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-22 SUP HCPCS C1776 AR-9100-22 - COMPONENT GLND 3 USP UNIVERS REPL TRUNION KT BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9100-24 SUP HCPCS C1776 AR-9100-24 - COMPONENT GLND 5 USP UNIVERS REPL TRUNION KT BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9104-01 SUP HCPCS C1776 AR-9104-01 - COMPONENT GLND SM STRL UNIVERS II CMNT KEEL PE SHLDR BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9104-02 SUP HCPCS C1776 AR-9104-02 - COMPONENT GLND MED STRL UNIVERS II CMNT KEEL PE SHLDR BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9104-03 SUP HCPCS C1776 AR-9104-03 - COMPONENT GLND LG STRL UNIVERS II CMNT KEEL PE SHLDR BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9104-04 SUP HCPCS C1776 AR-9104-04 - COMPONENT GLND XL STRL UNIVERS II CMNT KEEL PE SHLDR BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9105-01 SUP HCPCS C1776 AR-9105-01 - COMPONENT GLND SM STRL UNIVERS II CMNT PG PE SHLDR BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9105-02 SUP HCPCS C1776 AR-9105-02 - COMPONENT GLND MED STRL UNIVERS II CMNT PG PE SHLDR BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9105-03 SUP HCPCS C1776 AR-9105-03 - COMPONENT GLND LG STRL UNIVERS II CMNT PG PE SHLDR BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9105-04 SUP HCPCS C1776 AR-9105-04 - COMPONENT GLND XL STRL UNIVERS II CMNT PG PE SHLDR BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9106-01 SUP HCPCS C1713 AR-9106-01 - COMPONENT GLND SM STRL LF UNIVERS VAULTLOCK DISP BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9106-02 SUP HCPCS C1776 AR-9106-02 - COMPONENT GLND MED STRL ARTHX UNIVERS VAULTLOCK BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9106-04 SUP HCPCS C1776 AR-9106-04 - COMPONENT GLND XL STRL ARTHX UNIVERS VAULTLOCK BOTH IP/OP "$3,937.50 " "$2,913.75" $0.00 "$3,150.00" "$1,771.88" "$1,771.88" $0.00 $0.00 $0.00 $820.67 "$2,922.41" "$2,922.41" $0.00 $0.00 $820.58 $0.00 "$1,941.19" "$1,941.19" $0.00 "$1,968.75" "$3,118.50" "$3,150.00" $0.00 $0.00 $616.22 $0.00 $0.00 $626.85 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9120-01 SUP HCPCS C1713 AR-9120-01 - BASEPLATE GLND SM UNV SHLDR BOTH IP/OP "$4,287.50 " "$3,172.75" $0.00 "$3,430.00" "$1,929.38" "$1,929.38" $0.00 $0.00 $0.00 $893.62 "$3,182.18" "$3,182.18" $0.00 $0.00 $893.52 $0.00 "$2,113.74" "$2,113.74" $0.00 "$2,143.75" "$3,395.70" "$3,430.00" $0.00 $0.00 $670.99 $0.00 $0.00 $682.57 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9125-1 SUP Custom 27203010 AR-9125-1 - GUIDE DRL -10D 5D SM GLND BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9125-10 SUP Custom 27203010 AR-9125-10 - GUIDE DRL -20D 15D 0D SM GLND BOTH IP/OP "$1,787.50 " "$1,322.75" $0.00 "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,326.68" "$1,326.68" $0.00 $0.00 $372.52 $0.00 $0.00 $0.00 $0.00 $893.75 "$1,415.70" "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9125-2 SUP Custom 27203010 AR-9125-2 - GUIDE DRL -10D 5D MED GLND BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9125-20 SUP Custom 27203010 AR-9125-20 - GUIDE DRL -20D 15D 0D MED GLND BOTH IP/OP "$1,787.50 " "$1,322.75" $0.00 "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,326.68" "$1,326.68" $0.00 $0.00 $372.52 $0.00 $0.00 $0.00 $0.00 $893.75 "$1,415.70" "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9125-3 SUP Custom 27203010 AR-9125-3 - GUIDE DRL -10D 5D LG GLND BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 $0.00 $0.00 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9125-30 SUP Custom 27203010 AR-9125-30 - GUIDE DRL -20D 15D 0D LG GLND BOTH IP/OP "$1,787.50 " "$1,322.75" $0.00 "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,326.68" "$1,326.68" $0.00 $0.00 $372.52 $0.00 $0.00 $0.00 $0.00 $893.75 "$1,415.70" "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9140-14 SUP HCPCS C1776 AR-9140-14 - HEAD HUM 40MM 14MM UNIVERS 3D MTL SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9140-17P SUP HCPCS C1776 AR-9140-17P - HEAD HUM 40MM 17MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9142-17CA SUP HCPCS C1776 "AR-9142-17CA - UNIVERS CA HUMERAL HEAD, 42/17" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9142-17P SUP HCPCS C1776 AR-9142-17P - HEAD HUM 42MM 17MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9143-15 SUP HCPCS C1776 AR-9143-15 - HEAD HUM 43MM 15MM SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9143-15F SUP HCPCS C1776 AR-9143-15F - HEAD HUM 43MM 15MM SHLDR BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9144-17CA SUP HCPCS C1776 "AR-9144-17CA - UNIVERS CA HUMERAL HEAD, 44/17" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9144-17P SUP HCPCS C1776 AR-9144-17P - HEAD HUM 44MM 17MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9144-19CA SUP HCPCS C1776 "AR-9144-19CA - UNIVERS CA HUMERAL HEAD, 44/19" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9144-19P SUP HCPCS C1776 AR-9144-19P - HEAD HUM 44MM 19MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-15 SUP HCPCS C1776 AR-9145-15 - HEAD HUM 45MM 15MM MTL SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-24 SUP HCPCS C1713 AR-9145-24 - SCREW BN 18D 4.5MM 24MM UNIVERS REVERS LCK VA SHLDR GLND BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-24NL SUP HCPCS C1713 AR-9145-24NL - SCREW BN 4.5MM 24MM UNIVERS REVERS NONLOCK PERI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-30 SUP HCPCS C1713 AR-9145-30 - SCREW BONE 4.5MM 30MM UNIVERS REVERS 18D SHLDR BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-30NL SUP HCPCS C1713 "AR-9145-30NL - PERIPHERAL SCREW, NL, UNI REV, 4.5X30MM" BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-36 SUP HCPCS C1713 AR-9145-36 - SCREW BONE 4.5MM 36MM UNIVERS REVERS 18D SHLDR BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-36NL SUP HCPCS C1713 AR-9145-36NL - SCREW BN 4.5MM 36MM UNIVERS REVERS NONLOCK PERI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-42 SUP HCPCS C1713 AR-9145-42 - SCREW BN 18D 4.5MM 42MM UNIVERS REVERS LCK VA SHLDR GLND BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-42NL SUP HCPCS C1713 AR-9145-42NL - SCREW BN 4.5MM 42MM UNIVERS REVERS NONLOCK PERI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-48 SUP HCPCS C1713 AR-9145-48 - SCREW BN 18D 4.5MM 48MM UNIVERS REVERS LCK VA SHLDR GLND BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145-48NL SUP HCPCS C1713 AR-9145-48NL - SCREW BN 4.5MM 48MM UNIVERS REVERS NONLOCK PERI BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $135.00 $135.00 $0.00 $0.00 $0.00 $62.53 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $177.45 $177.45 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $46.95 $0.00 $0.00 $47.76 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9145DG SUP Custom 27203010 AR-9145DG - GUIDE DRL 45MM UNIVERS REVERS GLND BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 $0.00 $0.00 $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9146-17 SUP HCPCS C1776 AR-9146-17 - HEAD HUM 46MM 17MM STRL UNIVERS ADJ HT ANTM REFIXATION BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9146-17F SUP HCPCS C1776 AR-9146-17F - HEAD HUM 46MM 17MM STRL UNIVERS ADJ HT ANTM REFIXATION BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9146-18CA SUP HCPCS C1776 "AR-9146-18CA - UNIVERS CA HUMERAL HEAD, 46/18" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9146-18P SUP HCPCS C1776 AR-9146-18P - HEAD HUM 46MM 18MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9146-20CA SUP HCPCS C1776 "AR-9146-20CA - UNIVERS CA HUMERAL HEAD, 46/20" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9146-20P SUP HCPCS C1776 AR-9146-20P - HEAD HUM 46MM 20MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9148-17 SUP HCPCS C1776 AR-9148-17 - HEAD HUM 48MM 17MM STRL UNIVERS ADJ HT ECNTRC SET MTL SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9148-17F SUP HCPCS C1776 AR-9148-17F - HEAD HUM 48MM 17MM STRL UNIVERS ADJ HT ECNTRC SET MTL SHLDR BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9148-18 SUP HCPCS C1776 AR-9148-18 - HEAD HUM 3D BOTH IP/OP "$2,987.50 " "$2,210.75" $0.00 "$2,390.00" "$1,344.38" "$1,344.38" $0.00 $0.00 $0.00 $622.67 "$2,217.32" "$2,217.32" $0.00 $0.00 $622.60 $0.00 "$1,472.84" "$1,472.84" $0.00 "$1,493.75" "$2,366.10" "$2,390.00" $0.00 $0.00 $467.54 $0.00 $0.00 $475.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9148-19CA SUP HCPCS C1776 "AR-9148-19CA - UNIVERS CA HUMERAL HEAD, 48/19" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9148-19P SUP HCPCS C1776 AR-9148-19P - HEAD HUM 48MM 19MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9148-21CA SUP HCPCS C1776 "AR-9148-21CA - UNIVERS CA HUMERAL HEAD, 48/21" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9148-21P SUP HCPCS C1776 AR-9148-21P - HEAD HUM 48MM 21MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9150-19 SUP HCPCS C1776 AR-9150-19 - HEAD HUM 50MM 19MM STRL UNIVERS ADJ HT ECNTRC SET MTL SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9150-19CA SUP HCPCS C1776 "AR-9150-19CA - UNIVERS CA HUMERAL HEAD, 50/19" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9150-19F SUP HCPCS C1776 AR-9150-19F - HEAD HUM 50MM 19MM STRL UNIVERS ADJ HT ANTM REFIXATION BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9150-19P SUP HCPCS C1776 AR-9150-19P - HEAD HUM 50MM 19MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9150-21CA SUP HCPCS C1776 "AR-9150-21CA - UNIVERS CA HUMERAL HEAD, 50/21" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9150-21P SUP HCPCS C1776 AR-9150-21P - HEAD HUM 50MM 21MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9151-22 SUP HCPCS C1776 AR-9151-22 - HEAD HUM 51MM 22MM STRL UNIVERS ADJ HT ECNTRC SET MTL SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9151-22F SUP HCPCS C1776 AR-9151-22F - HEAD HUM 51MM 22MM STRL UNIVERS ADJ HT ANTM REFIXATION BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9152-20CA SUP HCPCS C1776 "AR-9152-20CA - UNIVERS CA HUMERAL HEAD, 52/20" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9152-20P SUP HCPCS C1776 AR-9152-20P - HEAD HUM 52MM 20MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9152-22CA SUP HCPCS C1776 "AR-9152-22CA - UNIVERS CA HUMERAL HEAD, 52/22" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9152-22P SUP HCPCS C1776 AR-9152-22P - HEAD HUM 52MM 22MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9153-19 SUP HCPCS C1776 AR-9153-19 - HEAD HUM 53MM 19MM UNIVERS 3D SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9153-19F SUP HCPCS C1776 AR-9153-19F - HEAD HUM 53MM 19MM STRL UNIVERS ADJ HT ANTM REFIXATION BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9153-23 SUP HCPCS C1776 AR-9153-23 - HEAD HUM 53MM 23MM UNIVERS 3D SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9154-21CA SUP HCPCS C1776 "AR-9154-21CA - UNIVERS CA HUMERAL HEAD, 54/21" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9154-21P SUP HCPCS C1776 AR-9154-21P - HEAD HUM 54MM 21MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9154-23CA SUP HCPCS C1776 "AR-9154-23CA - UNIVERS CA HUMERAL HEAD, 54/23" BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9154-23P SUP HCPCS C1776 AR-9154-23P - HEAD HUM 54MM 23MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9156-22CA SUP HCPCS C1776 AR-9156-22CA - HEAD HUM 56MM 22MM UNIVERS CA BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9156-22P SUP HCPCS C1776 AR-9156-22P - HEAD HUM 56MM 22MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9156-24CA SUP HCPCS C1776 AR-9156-24CA - HEAD HUM 56MM 24MM UNIVERS CA BOTH IP/OP "$5,875.00 " "$4,347.50" $0.00 "$4,700.00" "$2,643.75" "$2,643.75" $0.00 $0.00 $0.00 "$1,224.50" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,224.35" $0.00 "$2,896.38" "$2,896.38" $0.00 "$2,937.50" "$4,653.00" "$4,700.00" $0.00 $0.00 $919.44 $0.00 $0.00 $935.30 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9156-24P SUP HCPCS C1776 AR-9156-24P - HEAD HUM 56MM 24MM STRL UNIVERS II ANTM RSTR VAR ADJ SHLDR BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165-15 SUP HCPCS C1713 AR-9165-15 - SCREW BN 6.5MM 15MM UNIVERS REVERS VA SHLDR GLND CNTR BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165-15NL SUP HCPCS C1713 AR-9165-15NL - SCREW BN 6.5MM 15MM UNIVERS REVERS VA SHLDR GLND CNTR NONLOC BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165-20 SUP HCPCS C1713 AR-9165-20 - SCREW BN 6.5MM 20MM UNIVERS REVERS VA SHLDR GLND CNTR BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165-20NL SUP HCPCS C1713 AR-9165-20NL - SCREW BONE 6.5MM 20MM UNIVERS REVERS BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165-25 SUP HCPCS C1713 AR-9165-25 - SCREW BN 6.5MM 25MM UNIVERS REVERS VA SHLDR GLND CNTR BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165-25NL SUP HCPCS C1713 AR-9165-25NL - SCREW BN 6.5MM 25MM UNIVERS REVERS CNTR NONLOCK BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165-30NL SUP HCPCS C1713 AR-9165-30NL - SCREW BN 6.5MM 30MM UNIVERS REVERS CNTR NONLOCK BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165-35NL SUP HCPCS C1713 AR-9165-35NL - SCREW BN 6.5MM 35MM UNIVERS REVERS CNTR NONLOCK BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $191.25 $191.25 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9165DDG SUP HCPCS C1713 AR-9165DDG - SCREW BN UNIVERS REVERS CNTR UNV BSPLT IMPCTR BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9202-16 SUP HCPCS C1776 AR-9202-16 - CONNECTOR XTRNFX UNIVERS 3D TRL HD BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $258.75 $258.75 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9204-02 SUP HCPCS C1776 AR-9204-02 - STEM HUM UNIVERS XTRT SHLDR SHLDR FX BOTH IP/OP "$2,100.00 " "$1,554.00" $0.00 "$1,680.00" $945.00 $945.00 $0.00 $0.00 $0.00 $437.69 "$1,558.62" "$1,558.62" $0.00 $0.00 $437.64 $0.00 "$1,242.15" "$1,242.15" $0.00 "$1,050.00" "$1,663.20" "$1,680.00" $0.00 $0.00 $328.65 $0.00 $0.00 $334.32 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9207S SUP HCPCS C1776 AR-9207S - SET SPNL UNIVERS II STRL BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-1-01 SUP Custom 27203010 AR-9215-1-01 - GUIDE DRL 6.5IN HNDL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-1-02 SUP Custom 27203010 AR-9215-1-02 - GUIDE DRL LNG UNIVERS II HNDL GLND BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-2 SUP Custom 27203010 AR-9215-2 - GUIDE DRL 1 SM GLND BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-3 SUP Custom 27203010 AR-9215-3 - GUIDE DRL 2 SM KEEL GLND BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-4 SUP Custom 27203010 AR-9215-4 - GUIDE DRL 1 MED KEEL GLND BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-5 SUP Custom 27203010 AR-9215-5 - GUIDE DRL 2 MED KEEL GLND BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-6 SUP Custom 27203010 AR-9215-6 - GUIDE DRL 1 LG KEEL GLND BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-7 SUP Custom 27203010 AR-9215-7 - GUIDE DRL 2 LG KEEL GLND BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-8 SUP Custom 27203010 AR-9215-8 - GUIDE DRL 1 XL GLND BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9215-9 SUP Custom 27203010 AR-9215-9 - GUIDE DRL 2 XL KEEL GLND BOTH IP/OP $875.00 $647.50 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.43 $649.43 $0.00 $0.00 $182.35 $0.00 $0.00 $0.00 $0.00 $437.50 $693.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9216-1 SUP Custom 27203010 AR-9216-1 - GUIDE DRL 6MM UNIVERS II GLND BOTH IP/OP $812.50 $601.25 $0.00 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $406.25 $643.50 $650.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9216-2 SUP Custom 27203010 AR-9216-2 - GUIDE DRL UNIVERS II GLV PRTC GLND BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9216-4 SUP Custom 27203010 AR-9216-4 - GUIDE DRL UNIVERS II GLV PRTC GLND BOTH IP/OP $420.00 $310.80 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $0.00 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9231-01 SUP Custom 27203010 AR-9231-01 - GUIDE DRL 2 SM UNIVERS II PG GLND BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9231-01PP SUP Custom 27203010 AR-9231-01PP - GUIDE DRL SM UNIVERS VAULTLOCK GLND BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9231-02 SUP Custom 27203010 AR-9231-02 - GUIDE DRL 2 MED UNIVERS II PG GLND BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9231-02PP SUP Custom 27203010 AR-9231-02PP - GUIDE DRL MED UNIVERS VAULTLOCK GLND BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9231-03 SUP Custom 27203010 AR-9231-03 - GUIDE DRL 2 LG UNIVERS II PG GLND BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9231-03PP SUP Custom 27203010 AR-9231-03PP - GUIDE DRL LG UNIVERS VAULTLOCK GLND BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9231-04 SUP Custom 27203010 AR-9231-04 - GUIDE DRL 2 XL UNIVERS II PG GLND BOTH IP/OP "$1,250.00 " $925.00 $0.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.75 $927.75 $0.00 $0.00 $260.50 $0.00 $0.00 $0.00 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9231-04PP SUP Custom 27203010 AR-9231-04PP - GUIDE DRL XL UNIVERS VAULTLOCK GLND BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500-170 SUP HCPCS C1776 AR-9500-170 - JOINT TOE 17MM STRL ANATOEMIC PILT PNCH COCR PHALANX BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500-185 SUP HCPCS C1776 AR-9500-185 - JOINT TOE 18.5MM STRL ANATOEMIC PILT PNCH COCR PHALANX BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500-200 SUP HCPCS C1776 AR-9500-200 - JOINT TOE 20MM STRL ANATOEMIC PILT PNCH COCR PHALANX BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500-215 SUP HCPCS C1776 AR-9500-215 - JOINT TOE 21.5MM STRL ANATOEMIC PILT PNCH COCR PHALANX BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500-230 SUP HCPCS C1776 AR-9500-230 - JOINT TOE 23MM STRL ANATOEMIC PILT PNCH COCR PHALANX BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500T-170 SUP HCPCS C1776 AR-9500T-170 - TRIAL ANKL 17MM ANATOEMIC PHALANX BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500T-185 SUP HCPCS C1776 AR-9500T-185 - TRIAL ANKL 18.5MM ANATOEMIC PHALANX BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500T-200 SUP HCPCS C1776 AR-9500T-200 - TRIAL ANKL 20MM ANATOEMIC PHALANX BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500T-215 SUP HCPCS C1776 AR-9500T-215 - TRIAL ANKL 21.5MM ANATOEMIC PHALANX BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9500T-230 SUP HCPCS C1776 AR-9500T-230 - TRIAL ANKL 23MM ANATOEMIC PHALANX BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-05-135CPC SUP HCPCS C1776 AR-9501-05-135CPC - STEM HUM 135D 5 95MM STRL UNIVERS REVERS SET SPL MNBLCK PROX BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-05-155CPC SUP HCPCS C1776 AR-9501-05-155CPC - STEM HUM 155D 5 95MM STRL UNIVERS REVERS SET SPL MNBLCK PROX BOTH IP/OP "$9,187.50 " "$6,798.75" $0.00 "$7,350.00" "$4,134.38" "$4,134.38" $0.00 $0.00 $0.00 "$1,914.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,914.68" $0.00 "$4,529.44" "$4,529.44" $0.00 "$4,593.75" "$7,276.50" "$7,350.00" $0.00 $0.00 "$1,437.84" $0.00 $0.00 "$1,462.65" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-06CPC SUP HCPCS C1776 AR-9501-06CPC - STEM HUM 6 111MM STRL UNIVERS REVERS COR SET PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-06RCPC SUP HCPCS C1776 AR-9501-06RCPC - STEM HUM 6 LNG 150MM STRL UNIVERS REVERS PROX FIL REV CA BOTH IP/OP "$7,437.50 " "$5,503.75" $0.00 "$5,950.00" "$3,346.88" "$3,346.88" $0.00 $0.00 $0.00 "$1,550.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,549.98" $0.00 "$3,666.69" "$3,666.69" $0.00 "$3,718.75" "$5,890.50" "$5,950.00" $0.00 $0.00 "$1,163.97" $0.00 $0.00 "$1,184.05" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-07CPC SUP HCPCS C1776 AR-9501-07CPC - STEM HUM 115MM CORE SET PROX FIL UNIVERS REVERS BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-08CPC SUP HCPCS C1776 AR-9501-08CPC - STEM HUM 8 119MM STRL UNIVERS REVERS COR SET PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-09CPC SUP HCPCS C1776 AR-9501-09CPC - STEM HUM 9 123MM STRL UNIVERS REVERS COR SET PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-09RCPC SUP HCPCS C1776 AR-9501-09RCPC - STEM HUM 9 LNG 180MM STRL UNIVERS REVERS PROX FIL REV CA BOTH IP/OP "$7,437.50 " "$5,503.75" $0.00 "$5,950.00" "$3,346.88" "$3,346.88" $0.00 $0.00 $0.00 "$1,550.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,549.98" $0.00 "$3,666.69" "$3,666.69" $0.00 "$3,718.75" "$5,890.50" "$5,950.00" $0.00 $0.00 "$1,163.97" $0.00 $0.00 "$1,184.05" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-10CPC SUP HCPCS C1776 AR-9501-10CPC - STEM HUM 10 127MM STRL UNIVERS REVERS COR SET PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-11CPC SUP HCPCS C1776 AR-9501-11CPC - STEM HUM 11 131MM STRL UNIVERS REVERS COR SET PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-12CPC SUP HCPCS C1776 AR-9501-12CPC - STEM HUM 12 135MM STRL UNIVERS REVERS COR SET PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-12RCPC SUP HCPCS C1776 AR-9501-12RCPC - STEM HUM 12 LNG 180MM STRL UNIVERS REVERS PROX FIL REV CA BOTH IP/OP "$7,437.50 " "$5,503.75" $0.00 "$5,950.00" "$3,346.88" "$3,346.88" $0.00 $0.00 $0.00 "$1,550.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,549.98" $0.00 "$3,666.69" "$3,666.69" $0.00 "$3,718.75" "$5,890.50" "$5,950.00" $0.00 $0.00 "$1,163.97" $0.00 $0.00 "$1,184.05" $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-13CPC SUP HCPCS C1776 AR-9501-13CPC - STEM HUM 13 139MM STRL UNIVERS REVERS SET SPL PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-14CPC SUP HCPCS C1776 AR-9501-14CPC - STEM HUM 14 143MM STRL UNIVERS REVERS SET SPL PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9501-15CPC SUP HCPCS C1776 AR-9501-15CPC - STEM HUM 15 146MM STRL UNIVERS REVERS SET SPL PROX FIL CA BOTH IP/OP "$6,212.50 " "$4,597.25" $0.00 "$4,970.00" "$2,795.63" "$2,795.63" $0.00 $0.00 $0.00 "$1,294.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.69" $0.00 "$3,062.76" "$3,062.76" $0.00 "$3,106.25" "$4,920.30" "$4,970.00" $0.00 $0.00 $972.26 $0.00 $0.00 $989.03 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-36ARCA SUP HCPCS C1776 AR-9502-36ARCA - ADAPTER HD 36MM STRL ARTHX RVRS CUF ARTHROPATHY BOTH IP/OP "$5,375.00 " "$3,977.50" $0.00 "$4,300.00" "$2,418.75" "$2,418.75" $0.00 $0.00 $0.00 "$1,120.28" "$3,989.33" "$3,989.33" $0.00 $0.00 "$1,120.15" $0.00 "$2,649.88" "$2,649.88" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 $0.00 $841.19 $0.00 $0.00 $855.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-36CPC SUP Custom 27803010 AR-9502-36CPC - CUP HUM NTRL 36MM STRL UNIVERS REVERS CA PHOS SHLDR ARTHPL BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-36LCPC SUP Custom 27803010 AR-9502-36LCPC - CUP HUM +2MM OFST 36MM STRL UNIVERS REVERS CA PHOS SHLDR LT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-36RCPC SUP Custom 27803010 AR-9502-36RCPC - CUP HUM +2MM OFST 36MM STRL UNIVERS REVERS CA PHOS SHLDR RT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-39ARCA SUP HCPCS C1776 AR-9502-39ARCA - ADAPTER HD 39MM STRL ARTHX RVRS BOTH IP/OP "$5,375.00 " "$3,977.50" $0.00 "$4,300.00" "$2,418.75" "$2,418.75" $0.00 $0.00 $0.00 "$1,120.28" "$3,989.33" "$3,989.33" $0.00 $0.00 "$1,120.15" $0.00 "$2,649.88" "$2,649.88" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 $0.00 $841.19 $0.00 $0.00 $855.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-39CPC SUP Custom 27803010 AR-9502-39CPC - CUP HUM NTRL 39MM STRL UNIVERS REVERS CA PHOS SHLDR ARTHPL BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-39LCPC SUP Custom 27803010 AR-9502-39LCPC - CUP HUM +2MM OFST 39MM STRL UNIVERS REVERS CA PHOS SHLDR LT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-39RCPC SUP Custom 27803010 AR-9502-39RCPC - CUP HUM +2MM OFST 39MM STRL UNIVERS REVERS CA PHOS SHLDR RT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-42ARCA SUP HCPCS C1776 AR-9502-42ARCA - ADAPTER HD 42MM STRL ARTHX RVRS BOTH IP/OP "$5,375.00 " "$3,977.50" $0.00 "$4,300.00" "$2,418.75" "$2,418.75" $0.00 $0.00 $0.00 "$1,120.28" "$3,989.33" "$3,989.33" $0.00 $0.00 "$1,120.15" $0.00 "$2,649.88" "$2,649.88" $0.00 "$2,687.50" "$4,257.00" "$4,300.00" $0.00 $0.00 $841.19 $0.00 $0.00 $855.70 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-42CPC SUP Custom 27803010 AR-9502-42CPC - CUP HUM NTRL 42MM STRL UNIVERS REVERS CA PHOS SHLDR ARTHPL BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-42LCPC SUP Custom 27803010 AR-9502-42LCPC - CUP HUM +2MM OFST 42MM STRL UNIVERS REVERS CA PHOS SHLDR LT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502-42RCPC SUP Custom 27803010 AR-9502-42RCPC - CUP HUM +2MM OFST 42MM STRL UNIVERS REVERS CA PHOS SHLDR RT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502F-36CPC SUP HCPCS C1776 AR-9502F-36CPC - CUP HUM 36MM STRL LF ARTHX UNIVERS REVERS SUT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" "$2,008.13" "$2,008.13" $0.00 $0.00 $0.00 $930.10 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 "$2,200.01" "$2,200.01" $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $698.38 $0.00 $0.00 $710.43 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502F-36LCPC SUP Custom 27803010 AR-9502F-36LCPC - CUP HUM +2 36MM UNIVERS REVERS SUT SHLDR LT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502F-36RCPC SUP Custom 27803010 AR-9502F-36RCPC - CUP HUM +2 36MM UNIVERS REVERS SUT SHLDR RT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502F-39LCPC SUP Custom 27803010 AR-9502F-39LCPC - CUP HUM +2 39MM UNIVERS REVERS SUT SHLDR LT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502F-39RCPC SUP Custom 27803010 AR-9502F-39RCPC - CUP HUM +2 39MM UNIVERS REVERS SUT SHLDR RT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9502F-42RCPC SUP Custom 27803010 AR-9502F-42RCPC - CUP HUM +2 42MM UNIVERS REVERS SUT SHLDR RT BOTH IP/OP "$4,462.50 " "$3,302.25" $0.00 "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,312.07" "$3,312.07" $0.00 $0.00 $929.99 $0.00 $0.00 $0.00 $0.00 "$2,231.25" "$3,534.30" "$3,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503L-03 SUP HCPCS C1776 AR-9503L-03 - INSERT HUM +3MM LG 42MM STRL UNIVERS REVERS SHLDR ARTHPL BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503L-03C SUP HCPCS C1776 AR-9503L-03C - INSERT HUM +3MM LG 42MM STRL UNIVERS REVERS CNSTRN SHLDR BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503L-06 SUP HCPCS C1776 AR-9503L-06 - INSERT HUM +6MM LG 42MM STRL UNIVERS REVERS SHLDR ARTHPL BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503L-06C SUP HCPCS C1776 AR-9503L-06C - INSERT HUM +6MM LG 42MM STRL UNIVERS REVERS CNSTRN SHLDR BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503M-03 SUP HCPCS C1776 AR-9503M-03 - INSERT HUM +3MM MED 39MM STRL UNIVERS REVERS SHLDR ARTHPL BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503M-03C SUP HCPCS C1776 AR-9503M-03C - INSERT HUM +3MM MED 39MM STRL UNIVERS REVERS CNSTRN SHLDR BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503M-06 SUP HCPCS C1776 AR-9503M-06 - INSERT HUM +6MM MED 39MM STRL UNIVERS REVERS SHLDR ARTHPL BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503M-06C SUP HCPCS C1776 AR-9503M-06C - INSERT HUM +6MM MED 39MM STRL UNIVERS REVERS CNSTRN SHLDR BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503S-03 SUP HCPCS C1776 AR-9503S-03 - INSERT HUM 36MM UNIVERS REVERS +3MM SM SHLDR BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503S-03C SUP HCPCS C1776 AR-9503S-03C - INSERT HUM +3MM SM 36MM STRL UNIVERS REVERS CNSTRN SHLDR BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503S-06 SUP HCPCS C1776 AR-9503S-06 - INSERT HUM +6MM SM 36MM STRL UNIVERS REVERS SHLDR ARTHPL BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9503S-06C SUP HCPCS C1776 AR-9503S-06C - INSERT HUM +6MM SM 36MM STRL UNIVERS REVERS CNSTRN SHLDR BOTH IP/OP "$2,537.50 " "$1,877.75" $0.00 "$2,030.00" "$1,141.88" "$1,141.88" $0.00 $0.00 $0.00 $528.88 "$1,883.33" "$1,883.33" $0.00 $0.00 $528.82 $0.00 "$1,250.99" "$1,250.99" $0.00 "$1,268.75" "$2,009.70" "$2,030.00" $0.00 $0.00 $397.12 $0.00 $0.00 $403.97 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504L SUP HCPCS C1776 AR-9504L - HEAD GLND LG UNV 42MM STRL UNIVERS REVERS GLENOSPHERE VA CA BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504L-04 SUP HCPCS C1776 AR-9504L-04 - HEAD GLND +4MM LG UNV LAT OFST 42MM STRL UNIVERS REVERS BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504M SUP HCPCS C1776 AR-9504M - HEAD GLND MED UNV 39MM STRL UNIVERS REVERS GLENOSPHERE VA CA BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504M-02 SUP HCPCS C1776 AR-9504M-02 - HEAD GLND +2.5MM MED UNV INFR OFST 42MM STRL UNIVERS REVERS BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504M-04 SUP HCPCS C1776 AR-9504M-04 - HEAD GLND +4MM MED UNV LAT OFST 39MM STRL UNIVERS REVERS BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504S SUP HCPCS C1776 AR-9504S - HEAD GLND SM UNV 36MM STRL UNIVERS REVERS GLENOSPHERE VA CA BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504S-02 SUP HCPCS C1776 AR-9504S-02 - HEAD GLND +2.5MM SM UNV INFR OFST 36MM STRL UNIVERS REVERS BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504S-04 SUP HCPCS C1776 AR-9504S-04 - HEAD GLND 36MM UNIVERS REVERS +4MM SM UNV LAT BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9504S-INF SUP HCPCS C1776 AR-9504S-INF - HEAD GLND +2.5MM INFR OFST 36MM STRL UNIVERS REVERS BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9505-06 SUP HCPCS C1776 AR-9505-06 - SPACER HUM +6MM 39MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9505-09 SUP HCPCS C1776 AR-9505-09 - SPACER HUM +9MM 36MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9505-12 SUP HCPCS C1776 AR-9505-12 - SPACER HUM +12MM 39MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9505-15 SUP HCPCS C1776 AR-9505-15 - SPACER HUM +15MM 39MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-06 SUP HCPCS C1776 AR-9510-06 - RASP SRG 6 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,262.50 " "$2,414.25" $0.00 "$2,610.00" "$1,468.13" "$1,468.13" $0.00 $0.00 $0.00 $679.99 "$2,421.43" "$2,421.43" $0.00 $0.00 $679.91 $0.00 "$1,608.41" "$1,608.41" $0.00 "$1,631.25" "$2,583.90" "$2,610.00" $0.00 $0.00 $510.58 $0.00 $0.00 $519.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-07 SUP HCPCS C1776 AR-9510-07 - RASP SRG 7 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,262.50 " "$2,414.25" $0.00 "$2,610.00" "$1,468.13" "$1,468.13" $0.00 $0.00 $0.00 $679.99 "$2,421.43" "$2,421.43" $0.00 $0.00 $679.91 $0.00 "$1,608.41" "$1,608.41" $0.00 "$1,631.25" "$2,583.90" "$2,610.00" $0.00 $0.00 $510.58 $0.00 $0.00 $519.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-08 SUP HCPCS C1776 AR-9510-08 - RASP SRG 8 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,262.50 " "$2,414.25" $0.00 "$2,610.00" "$1,468.13" "$1,468.13" $0.00 $0.00 $0.00 $679.99 "$2,421.43" "$2,421.43" $0.00 $0.00 $679.91 $0.00 "$1,608.41" "$1,608.41" $0.00 "$1,631.25" "$2,583.90" "$2,610.00" $0.00 $0.00 $510.58 $0.00 $0.00 $519.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-09 SUP HCPCS C1776 AR-9510-09 - RASP SRG 9 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,262.50 " "$2,414.25" $0.00 "$2,610.00" "$1,468.13" "$1,468.13" $0.00 $0.00 $0.00 $679.99 "$2,421.43" "$2,421.43" $0.00 $0.00 $679.91 $0.00 "$1,608.41" "$1,608.41" $0.00 "$1,631.25" "$2,583.90" "$2,610.00" $0.00 $0.00 $510.58 $0.00 $0.00 $519.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-09R SUP HCPCS C1776 AR-9510-09R - RASP SRG 9 LNG 180MM UNIVERS REVERS REV STM TRL SHLDR ARTHPL BOTH IP/OP "$3,612.50 " "$2,673.25" $0.00 "$2,890.00" "$1,625.63" "$1,625.63" $0.00 $0.00 $0.00 $752.94 "$2,681.20" "$2,681.20" $0.00 $0.00 $752.85 $0.00 "$1,780.96" "$1,780.96" $0.00 "$1,806.25" "$2,861.10" "$2,890.00" $0.00 $0.00 $565.36 $0.00 $0.00 $575.11 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-10 SUP HCPCS C1776 AR-9510-10 - RASP SRG 10 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,262.50 " "$2,414.25" $0.00 "$2,610.00" "$1,468.13" "$1,468.13" $0.00 $0.00 $0.00 $679.99 "$2,421.43" "$2,421.43" $0.00 $0.00 $679.91 $0.00 "$1,608.41" "$1,608.41" $0.00 "$1,631.25" "$2,583.90" "$2,610.00" $0.00 $0.00 $510.58 $0.00 $0.00 $519.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-11 SUP HCPCS C1776 AR-9510-11 - RASP SRG 11 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,262.50 " "$2,414.25" $0.00 "$2,610.00" "$1,468.13" "$1,468.13" $0.00 $0.00 $0.00 $679.99 "$2,421.43" "$2,421.43" $0.00 $0.00 $679.91 $0.00 "$1,608.41" "$1,608.41" $0.00 "$1,631.25" "$2,583.90" "$2,610.00" $0.00 $0.00 $510.58 $0.00 $0.00 $519.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-12 SUP HCPCS C1776 AR-9510-12 - RASP SRG 12 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,262.50 " "$2,414.25" $0.00 "$2,610.00" "$1,468.13" "$1,468.13" $0.00 $0.00 $0.00 $679.99 "$2,421.43" "$2,421.43" $0.00 $0.00 $679.91 $0.00 "$1,608.41" "$1,608.41" $0.00 "$1,631.25" "$2,583.90" "$2,610.00" $0.00 $0.00 $510.58 $0.00 $0.00 $519.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-12R SUP HCPCS C1776 AR-9510-12R - RASP SRG 12 LNG 180MM UNIVERS REVERS REV STM TRL SHLDR BOTH IP/OP "$3,612.50 " "$2,673.25" $0.00 "$2,890.00" "$1,625.63" "$1,625.63" $0.00 $0.00 $0.00 $752.94 "$2,681.20" "$2,681.20" $0.00 $0.00 $752.85 $0.00 "$1,780.96" "$1,780.96" $0.00 "$1,806.25" "$2,861.10" "$2,890.00" $0.00 $0.00 $565.36 $0.00 $0.00 $575.11 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-13 SUP HCPCS C1776 AR-9510-13 - RASP SRG 13 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,262.50 " "$2,414.25" $0.00 "$2,610.00" "$1,468.13" "$1,468.13" $0.00 $0.00 $0.00 $679.99 "$2,421.43" "$2,421.43" $0.00 $0.00 $679.91 $0.00 "$1,608.41" "$1,608.41" $0.00 "$1,631.25" "$2,583.90" "$2,610.00" $0.00 $0.00 $510.58 $0.00 $0.00 $519.39 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-14 SUP HCPCS C1776 AR-9510-14 - RASP SRG 14 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,412.50 " "$2,525.25" $0.00 "$2,730.00" "$1,535.63" "$1,535.63" $0.00 $0.00 $0.00 $711.25 "$2,532.76" "$2,532.76" $0.00 $0.00 $711.17 $0.00 "$1,682.36" "$1,682.36" $0.00 "$1,706.25" "$2,702.70" "$2,730.00" $0.00 $0.00 $534.06 $0.00 $0.00 $543.27 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9510-15 SUP HCPCS C1776 AR-9510-15 - RASP SRG 15 UNIVERS REVERS STM TRL SHLDR ARTHPL BOTH IP/OP "$3,412.50 " "$2,525.25" $0.00 "$2,730.00" "$1,535.63" "$1,535.63" $0.00 $0.00 $0.00 $711.25 "$2,532.76" "$2,532.76" $0.00 $0.00 $711.17 $0.00 "$1,682.36" "$1,682.36" $0.00 "$1,706.25" "$2,702.70" "$2,730.00" $0.00 $0.00 $534.06 $0.00 $0.00 $543.27 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9550-06 SUP HCPCS C1776 AR-9550-06 - SPACER HUM +6MM 42MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9550-09 SUP HCPCS C1776 AR-9550-09 - SPACER HUM +9MM 42MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9550-12 SUP HCPCS C1776 AR-9550-12 - SPACER HUM +12MM 42MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9550-15 SUP HCPCS C1776 AR-9550-15 - SPACER HUM +15MM 42MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9555-06 SUP HCPCS C1776 AR-9555-06 - SPACER HUM 36MM UNIVERS REVERS +6MM SHLDR TI BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9555-09 SUP HCPCS C1776 AR-9555-09 - SPACER HUM +9MM 36MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9555-12 SUP HCPCS C1776 AR-9555-12 - SPACER HUM +12MM 36MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9555-15 SUP HCPCS C1776 AR-9555-15 - SPACER HUM +15MM 36MM STRL UNIVERS REVERS TI SHLDR ARTHPL BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $551.25 $551.25 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9703A-90 SUP Custom 27203010 AR-9703A-90 - PROBE ESURG 90D LOPRFL 3MM STRL OPES ASPIRATE ABLT DISP BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9704A-90 SUP Custom 27203010 AR-9704A-90 - PROBE ESURG 90D LOPRFL 4MM STRL OPES ASPIRATE ABLT DISP BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9705-90 SUP Custom 27203010 AR-9705-90 - PROBE ESURG 90D LOPRFL STRL OPES ABLT TTHBRSH DISP BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $0.00 $0.00 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9705A-90 SUP Custom 27203010 AR-9705A-90 - PROBE ESURG 90D LOPRFL STRL OPES ASPIRATE ABLT TTHBRSH DISP BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $0.00 $0.00 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9802M-45 SUP Custom 27203010 AR-9802M-45 - ELECTRODE ESURG 45D STRL COOLCUT ABLATOR MNSCTM BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9802M-90 SUP Custom 27203010 AR-9802M-90 - ELECTRODE ESURG 90D COOLCUT ABLATOR MNSCTM BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9803-30 SUP Custom 27203010 AR-9803-30 - PROBE ESURG 30D 3MM STRL COOLCUT ABLT RF WND BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9803-50 SUP Custom 27203010 AR-9803-50 - ELECTRODE ESURG 50D 3MM COOLCUT 50 ABLATOR 50NA BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9803-90 SUP Custom 27203010 AR-9803-90 - PROBE ESURG 90D 3MM STRL COOLCUT ABLT RF WND BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9803A-30 SUP Custom 27203010 AR-9803A-30 - PROBE ESURG 30D 3MM STRL COOLCUT ASPIRATE ABLT RF WND BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9803A-50 SUP Custom 27203010 AR-9803A-50 - PROBE ESURG 50D 3MM STRL COOLCUT ASPIRATE ABLT RF WND BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9803A-90 SUP Custom 27203010 AR-9803A-90 - PROBE ESURG 3MM COOLCUT 90D ASPIRATE ABLT RF WND BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9808 SUP Custom 27203010 AR-9808 - ELECTRODE ESURG BALL STRL COOLCUT ABLT RF WND S JNT BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9808-45 SUP Custom 27203010 AR-9808-45 - ELECTRODE ESURG 45D COOLCUT BALL ASCP BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9808SJ SUP Custom 27203010 AR-9808SJ - ELECTRODE ESURG BALL STRL COOLCUT ABLT RF WND S JNT BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9808SJ-45 SUP Custom 27203010 AR-9808SJ-45 - ELECTRODE ESURG 45D BALL STRL COOLCUT ABLT RF WND S JNT BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9809SJ-45 SUP Custom 27203010 AR-9809SJ-45 - ELECTRODE ESURG 45D BALL STRL COOLCUT ABLT RF WND S JNT BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9809SJ-90 SUP Custom 27203010 AR-9809SJ-90 - ELECTRODE ESURG 90D BALL STRL COOLCUT ABLT RF WND S JNT BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9811 SUP Custom 27203010 AR-9811 - PROBE ESURG 90D APLO RF ML PRT BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $0.00 $0.00 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-992 SUP Custom 27203010 AR-992 - KIT ARTHRO FIX TRNFX2 SCR CANN DILAT ROTR CUF STRL DISP BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BL-04 SUP HCPCS C1713 AR-9943BL-04 - PLATE BN 4 HL LCK TI FIB LT DIST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BL-05 SUP HCPCS C1713 AR-9943BL-05 - PLATE BN 5 HL LCK TI FIB LT DIST BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BL-06 SUP HCPCS C1713 AR-9943BL-06 - PLATE BN 6 HL LCK TI FIB LT DIST BOTH IP/OP "$1,937.50 " "$1,433.75" $0.00 "$1,550.00" $871.88 $871.88 $0.00 $0.00 $0.00 $403.82 "$1,438.01" "$1,438.01" $0.00 $0.00 $403.78 $0.00 "$1,146.03" "$1,146.03" $0.00 $968.75 "$1,534.50" "$1,550.00" $0.00 $0.00 $303.22 $0.00 $0.00 $308.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BL-08 SUP HCPCS C1713 AR-9943BL-08 - PLATE BN ARTHX 8 HL LCK TI FIB LT DIST BOTH IP/OP "$2,112.50 " "$1,563.25" $0.00 "$1,690.00" $950.63 $950.63 $0.00 $0.00 $0.00 $440.30 "$1,567.90" "$1,567.90" $0.00 $0.00 $440.25 $0.00 "$1,249.54" "$1,249.54" $0.00 "$1,056.25" "$1,673.10" "$1,690.00" $0.00 $0.00 $330.61 $0.00 $0.00 $336.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BL-10 SUP HCPCS C1713 AR-9943BL-10 - PLATE BN ARTHX 10 HL LCK TI FIB LT DIST BOTH IP/OP "$2,325.00 " "$1,720.50" $0.00 "$1,860.00" "$1,046.25" "$1,046.25" $0.00 $0.00 $0.00 $484.59 "$1,725.62" "$1,725.62" $0.00 $0.00 $484.53 $0.00 "$1,375.24" "$1,375.24" $0.00 "$1,162.50" "$1,841.40" "$1,860.00" $0.00 $0.00 $363.86 $0.00 $0.00 $370.14 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BL-12 SUP HCPCS C1713 AR-9943BL-12 - PLATE BN ARTHX 12 HL LCK TI FIB LT DIST BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" "$1,057.50" "$1,057.50" $0.00 $0.00 $0.00 $489.80 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 "$1,390.03" "$1,390.03" $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $367.78 $0.00 $0.00 $374.12 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BL-14 SUP HCPCS C1713 AR-9943BL-14 - PLATE BN ARTHX 14 HL LCK TI FIB LT DIST BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BR-04 SUP HCPCS C1713 AR-9943BR-04 - PLATE BN 4 HL LCK TI FIB DIST BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BR-06 SUP HCPCS C1713 AR-9943BR-06 - PLATE BN 6 HL LCK TI FIB RT DIST BOTH IP/OP "$1,937.50 " "$1,433.75" $0.00 "$1,550.00" $871.88 $871.88 $0.00 $0.00 $0.00 $403.82 "$1,438.01" "$1,438.01" $0.00 $0.00 $403.78 $0.00 "$1,146.03" "$1,146.03" $0.00 $968.75 "$1,534.50" "$1,550.00" $0.00 $0.00 $303.22 $0.00 $0.00 $308.45 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BR-08 SUP HCPCS C1713 AR-9943BR-08 - PLATE BN ARTHX 8 HL LCK TI FIB RT DIST BOTH IP/OP "$2,112.50 " "$1,563.25" $0.00 "$1,690.00" $950.63 $950.63 $0.00 $0.00 $0.00 $440.30 "$1,567.90" "$1,567.90" $0.00 $0.00 $440.25 $0.00 "$1,249.54" "$1,249.54" $0.00 "$1,056.25" "$1,673.10" "$1,690.00" $0.00 $0.00 $330.61 $0.00 $0.00 $336.31 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BR-10 SUP HCPCS C1713 AR-9943BR-10 - PLATE BN ARTHX 10 HL LCK TI FIB RT DIST BOTH IP/OP "$2,325.00 " "$1,720.50" $0.00 "$1,860.00" "$1,046.25" "$1,046.25" $0.00 $0.00 $0.00 $484.59 "$1,725.62" "$1,725.62" $0.00 $0.00 $484.53 $0.00 "$1,375.24" "$1,375.24" $0.00 "$1,162.50" "$1,841.40" "$1,860.00" $0.00 $0.00 $363.86 $0.00 $0.00 $370.14 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BR-12 SUP HCPCS C1713 AR-9943BR-12 - PLATE BN NS ARTHX 12 HL LCK TI FIB RT DIST BOTH IP/OP "$2,350.00 " "$1,739.00" $0.00 "$1,880.00" "$1,057.50" "$1,057.50" $0.00 $0.00 $0.00 $489.80 "$1,744.17" "$1,744.17" $0.00 $0.00 $489.74 $0.00 "$1,390.03" "$1,390.03" $0.00 "$1,175.00" "$1,861.20" "$1,880.00" $0.00 $0.00 $367.78 $0.00 $0.00 $374.12 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943BR-14 SUP HCPCS C1713 AR-9943BR-14 - PLATE BN ARTHX 14 HL LCK TI FIB RT DIST BOTH IP/OP "$2,375.00 " "$1,757.50" $0.00 "$1,900.00" "$1,068.75" "$1,068.75" $0.00 $0.00 $0.00 $495.01 "$1,762.73" "$1,762.73" $0.00 $0.00 $494.95 $0.00 "$1,404.81" "$1,404.81" $0.00 "$1,187.50" "$1,881.00" "$1,900.00" $0.00 $0.00 $371.69 $0.00 $0.00 $378.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943C-04 SUP HCPCS C1713 AR-9943C-04 - PLATE BN STRG 4 HL LCK TI BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943C-06 SUP HCPCS C1713 AR-9943C-06 - PLATE BN STRG 6 HL LCK TI BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $534.38 $534.38 $0.00 $0.00 $0.00 $247.50 $881.36 $881.36 $0.00 $0.00 $247.48 $0.00 $702.41 $702.41 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $185.84 $0.00 $0.00 $189.05 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943C-07 SUP HCPCS C1713 AR-9943C-07 - PLATE BN STRG 7 HL LCK TI BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $273.56 $974.14 $974.14 $0.00 $0.00 $273.53 $0.00 $776.34 $776.34 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943C-08 SUP HCPCS C1713 AR-9943C-08 - PLATE BN STRG 8 HL LCK TI ANKL BOTH IP/OP "$1,375.00 " "$1,017.50" $0.00 "$1,100.00" $618.75 $618.75 $0.00 $0.00 $0.00 $286.58 "$1,020.53" "$1,020.53" $0.00 $0.00 $286.55 $0.00 $813.31 $813.31 $0.00 $687.50 "$1,089.00" "$1,100.00" $0.00 $0.00 $215.19 $0.00 $0.00 $218.90 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943C-10 SUP HCPCS C1713 AR-9943C-10 - PLATE BN STRG 10 HL LCK TI BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943C-12 SUP HCPCS C1713 AR-9943C-12 - PLATE BN STRG 12 HL LCK TI BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $362.14 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 "$1,027.73" "$1,027.73" $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943T-04 SUP HCPCS C1713 AR-9943T-04 - PLATE BN 1/3 TBLR 4 HL LCK TI BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943T-05 SUP HCPCS C1713 AR-9943T-05 - PLATE BN 1/3 TBLR 5 HL LCK TI BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943T-06 SUP HCPCS C1713 AR-9943T-06 - PLATE BN 1/3 TUBE 6 HL LCK TI BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $270.00 $270.00 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943T-07 SUP HCPCS C1713 AR-9943T-07 - PLATE BN 3 TBLR 7 HL LCK TI BOTH IP/OP $637.50 $471.75 $0.00 $510.00 $286.88 $286.88 $0.00 $0.00 $0.00 $132.87 $473.15 $473.15 $0.00 $0.00 $132.86 $0.00 $377.08 $377.08 $0.00 $318.75 $504.90 $510.00 $0.00 $0.00 $99.77 $0.00 $0.00 $101.49 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943T-08 SUP HCPCS C1713 AR-9943T-08 - PLATE BN 1/3 TBLR 8 HL LCK TI BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $298.13 $298.13 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943T-10 SUP HCPCS C1713 AR-9943T-10 - PLATE BN 1/3 TBLR 10 HL LCK TI ANKL BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 AR-9943T-12 SUP HCPCS C1713 AR-9943T-12 - PLATE BN 1/3 TBLR 12 HL LCK TI BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 AS09 SUP Custom 27203010 AS09 - ATTACHMENT TL STRG 3.2MM 9CM MDSRX LGN LG BORE BOTH IP/OP "$2,133.10 " "$1,578.49" $0.00 "$1,706.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,583.19" "$1,583.19" $0.00 $0.00 $444.54 $0.00 $0.00 $0.00 $0.00 "$1,066.55" "$1,689.42" "$1,706.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AS10 SUP Custom 27203010 AS10 - ATTCH TL 10CM STR SM BORE MDSRX LGN 2.4MM BOTH IP/OP "$1,823.93 " "$1,349.71" $0.00 "$1,459.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,353.72" "$1,353.72" $0.00 $0.00 $380.11 $0.00 $0.00 $0.00 $0.00 $911.96 "$1,444.55" "$1,459.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AS74180-06 SUP Custom 27203010 AS74180-06 - PACK VITRECTOMY 23GA BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT-0225-S SUP HCPCS C1713 AT-0225-S - SCREW BONE 22.5MM ACTRK STD BOTH IP/OP $775.00 $573.50 $0.00 $620.00 $348.75 $348.75 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $387.50 $613.80 $620.00 $0.00 $0.00 $121.29 $0.00 $0.00 $123.38 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1032 SUP Custom 27203010 AT-1032 - BIT DRILL ACTRK CANN BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1125-S SUP HCPCS C1713 AT-1125-S - SCREW BONE 3.3-4.6MM 12.5MM ACTRK TI STD FULTHD ORTH SLFTAP BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1150-S SUP HCPCS C1713 AT-1150-S - SCREW BN STD 15MM BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1175-S SUP HCPCS C1713 AT-1175-S - SCREW BN STD 3.3-4.6MM 17.5MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1200-S SUP HCPCS C1713 AT-1200-S - SCREW BN STD 3.3-4.6MM 20MM STRL ACTRK SLF CUT CNN VAR PTCH BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1225-S SUP HCPCS C1713 AT-1225-S - SCREW BN STD 3.3-4.6MM 22.5MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1250-S SUP HCPCS C1713 AT-1250-S - SCREW BN STD 3.3-4.6MM 25MM STRL ACTRK SLF CUT CNN VAR PTCH BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1275-S SUP HCPCS C1713 AT-1275-S - SCREW BN STD 3.3-4.6MM 27.5MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AT-1300-S SUP HCPCS C1713 AT-1300-S - SCREW BN STD 3.3-4.6MM 30MM STRL ACTRK SLF CUT CNN VAR PTCH BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-1509 SUP Custom 27203010 AT2-1509 - BIT DRL 2 MIC ACUTRAL BOTH IP/OP $567.50 $419.95 $0.00 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.20 $421.20 $0.00 $0.00 $118.27 $0.00 $0.00 $0.00 $0.00 $283.75 $449.46 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-2515 SUP Custom 27203010 AT2-2515 - BIT DRL STD ACTRK2 BOTH IP/OP $567.50 $419.95 $0.00 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.20 $421.20 $0.00 $0.00 $118.27 $0.00 $0.00 $0.00 $0.00 $283.75 $449.46 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-3500 SUP HCPCS C1769 AT2-3500 - GUIDEWIRE ORTH .035IN PRLL BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $325.80 $325.80 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-4500 SUP HCPCS C1769 AT2-4500 - GWIRE ORTH .045IN PRLL BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $304.08 $304.08 $0.00 $0.00 $0.00 $116.72 $415.63 $415.63 $0.00 $0.00 $116.70 $0.00 $331.24 $331.24 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $89.15 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-520-S SUP HCPCS C1713 AT2-520-S - SCREW BONE 20MM ACTRK2 STD STRL BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $221.45 $788.59 $788.59 $0.00 $0.00 $221.43 $0.00 $628.47 $628.47 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-5400 SUP HCPCS C1769 AT2-5400 - GWIRE ORTH .054IN PRLL BOTH IP/OP $560.00 $414.40 $0.00 $448.00 $304.08 $304.08 $0.00 $0.00 $0.00 $116.72 $415.63 $415.63 $0.00 $0.00 $116.70 $0.00 $331.24 $331.24 $0.00 $280.00 $443.52 $448.00 $0.00 $0.00 $87.64 $0.00 $0.00 $89.15 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C08-S SUP HCPCS C1713 AT2-C08-S - SCREW BN MIC 8MM FUSHIA BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C09-S SUP HCPCS C1713 AT2-C09-S - SCREW BN MIC 9MM FUSHIA BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C10-S SUP HCPCS C1713 AT2-C10-S - SCREW BN MIC 10MM FUSHIA BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C11-S SUP HCPCS C1713 AT2-C11-S - SCREW BONE 2MM 11MM ACTRK TI MIC FULTHD ORTH SLFTAP CANN BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C12-S SUP HCPCS C1713 AT2-C12-S - SCREW BN MIC 12MM FUSHIA BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C13-S SUP HCPCS C1713 AT2-C13-S - SCREW BONE 2MM 13MM ACTRK2 TI MIC FULTHD ORTH SLFTAP CANN BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C14-S SUP HCPCS C1713 AT2-C14-S - SCREW BN MIC 14MM FUSHIA BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C16-S SUP HCPCS C1713 AT2-C16-S - SCREW BN MIC 16MM FUSHIA BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C18-S SUP HCPCS C1713 AT2-C18-S - SCREW BN MIC 18MM FUSHIA BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-C20-S SUP HCPCS C1713 AT2-C20-S - SCREW BN MIC FT 2.5-2.8MM 20MM STRL ACTRK2 SLF CUT CNN VAR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2L1813 SUP Custom 27203010 AT2L1813 - BIT DRILL ACTRK2 MINI BOTH IP/OP $567.50 $419.95 $0.00 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.20 $421.20 $0.00 $0.00 $118.27 $0.00 $0.00 $0.00 $0.00 $283.75 $449.46 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-L2515 SUP HCPCS C1713 AT2-L2515 - BIT DRL LNG ACTRK2 BOTH IP/OP $567.50 $419.95 $0.00 $454.00 $255.38 $255.38 $0.00 $0.00 $0.00 $118.28 $421.20 $421.20 $0.00 $0.00 $118.27 $0.00 $335.68 $335.68 $0.00 $283.75 $449.46 $454.00 $0.00 $0.00 $88.81 $0.00 $0.00 $90.35 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-M16-S SUP HCPCS C1713 AT2-M16-S - SCREW BN MN FT 3.5-3.6MM 16MM STRL ACTRK2 SLF CUT CNN VAR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2M-1813 SUP Custom 27203010 AT2M-1813 - BIT DRILL 2MM ACTRK2 MINI PRFL 3.5-4MM SCR NONSTRL BOTH IP/OP $567.50 $419.95 $0.00 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.20 $421.20 $0.00 $0.00 $118.27 $0.00 $0.00 $0.00 $0.00 $283.75 $449.46 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-M18-S SUP HCPCS C1713 AT2-M18-S - SCREW BN MN 18MM STRL ACTRK2 TI ORTH BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-M20-S SUP HCPCS C1713 AT2-M20-S - SCREW BN MN 20MM STRL ACTRK2 TI ORTH BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-M22-S SUP HCPCS C1713 AT2-M22-S - SCREW BN MN FT 3.5-3.6MM 22MM STRL ACTRK2 SLF CUT CNN VAR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-M24-S SUP HCPCS C1713 AT2-M24-S - SCREW BN MN 24MM STRL ACTRK2 TI ORTH BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2M-26S SUP HCPCS C1713 AT2M-26S - SCREW BONE 26MM ACTRK2 MINI STRL BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-M26-S SUP HCPCS C1713 AT2-M26-S - SCREW BN MN FT 3.5-3.6MM 26MM STRL ACTRK2 SLF CUT CNN VAR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2M-28S SUP HCPCS C1713 AT2M-28S - SCREW BONE 28MM ACTRK2 MINI STRL BOTH IP/OP "$1,062.50 " $786.25 $0.00 $850.00 $478.13 $478.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $531.25 $841.50 $850.00 $0.00 $0.00 $166.28 $0.00 $0.00 $169.15 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-M28-S SUP HCPCS C1713 AT2-M28-S - SCREW BN MN FT 3.5-3.6MM 28MM STRL ACTRK2 SLF CUT CNN VAR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-M30-S SUP HCPCS C1713 AT2-M30-S - SCREW 30.0MM MINI ACUTRAK 2 BONE BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2M-L1813 SUP Custom 27203010 AT2M-L1813 - BIT DRL MN BOTH IP/OP $567.50 $419.95 $0.00 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.20 $421.20 $0.00 $0.00 $118.27 $0.00 $0.00 $0.00 $0.00 $283.75 $449.46 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-ML1813 SUP Custom 27203010 BIT DRILL ACTRK2 MINI LNG INSTR BOTH IP/OP $467.50 $345.95 $0.00 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.75 $370.26 $374.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT2ML1816 SUP Custom 27203010 AT2ML1816 - BIT DRILL BOTH IP/OP $567.50 $419.95 $0.00 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.20 $421.20 $0.00 $0.00 $118.27 $0.00 $0.00 $0.00 $0.00 $283.75 $449.46 $454.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S16-S SUP HCPCS C1713 AT2-S16-S - SCREW BN STD 2MM 16MM ACTRK2 BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S18-S SUP HCPCS C1713 AT2-S18-S - SCREW BN STD FT 4-4.1MM 18MM STRL ACTRK2 SLF CUT CNN VAR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S20-S SUP HCPCS C1713 AT2-S20-S - SCREW BN STD FT 4-4.1MM 20MM STRL ACTRK2 SLF CUT CNN VAR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S22-S SUP HCPCS C1713 AT2-S22-S - SCREW BN STD FT 4-4.1MM 22MM STRL ACTRK2 SLF CUT CNN VAR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S24-S SUP HCPCS C1713 AT2-S24-S - SCREW BN 24MM STRL BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S26-S SUP HCPCS C1713 AT2-S26-S - SCREW BN STD FT 4-4.1MM 26MM STRL ACTRK2 SLFCT CNN CMPR HEX BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S28-S SUP HCPCS C1713 AT2-S28-S - SCREW BN STD 2MM 28MM ACTRK2 BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S30-S SUP HCPCS C1713 AT2-S30-S - SCREW BONE 2MM 30MM ACTRK2 TI STD HINDFOOT ANKL SLFTAP CANN BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S32-S SUP HCPCS C1713 AT2-S32-S - SCREW BONE 2MM 32MM ACTRK2 TI STD FT HAND SLFTAP CANN CMPR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT2-S34-S SUP HCPCS C1713 AT2-S34-S - SCREW BONE 2MM 34MM ACTRK2 TI STD FT HAND SLFTAP CANN CMPR BOTH IP/OP "$1,160.00 " $858.40 $0.00 $928.00 $522.00 $522.00 $0.00 $0.00 $0.00 $241.77 $860.95 $860.95 $0.00 $0.00 $241.74 $0.00 $686.14 $686.14 $0.00 $580.00 $918.72 $928.00 $0.00 $0.00 $181.54 $0.00 $0.00 $184.67 $0.00 $0.00 $0.00 $0.00 $0.00 AT-7032 SUP Custom 27203010 AT-7032 - BIT DRL STD TPR 2.5MM 4.7MM STRL ACTRK CNN TI BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AT-7044 SUP Custom 27203010 AT-7044 - BIT DRILL ACTRK STD BONE CANN DNS STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-024 SUP Custom 27203010 ATF-024 - DRILL SRG 24MM ACTRK FSN BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-032 SUP Custom 27203010 ATF-032 - BIT DRILL 32MM ACTRK FSN STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-037 SUP Custom 27203010 ATF-037 - BIT DRILL 37MM ACTRK FSN STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-140-S SUP HCPCS C1713 ATF-140-S - SCREW BN 14MM ACTRK FSN BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-160-S SUP HCPCS C1713 ATF-160-S - SCREW BN 16MM ACTRK FSN BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-180-S SUP HCPCS C1713 ATF-180-S - SCREW BN 18MM ACTRK FSN BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-200-S SUP HCPCS C1713 ATF-200-S - SCREW BN 20MM ACTRK FSN BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-220-S SUP HCPCS C1713 ATF-220-S - SCREW BN 22MM ACTRK FSN BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-240-S SUP HCPCS C1713 ATF-240-S - SCREW BN FT 2-2.5MM 24MM STRL ACTRK SLF CUT CNN FSN HDLS TI BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-270-S SUP HCPCS C1713 ATF-270-S - SCREW BN FT 2.8-3.5MM 27MM STRL ACTRK SLF CUT CNN FSN HDLS BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-320-S SUP HCPCS C1713 ATF-320-S - SCREW BONE 32MM ACTRK TI HAND FT STRL BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $364.50 $364.50 $0.00 $0.00 $0.00 $168.82 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $479.12 $479.12 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $126.77 $0.00 $0.00 $128.95 $0.00 $0.00 $0.00 $0.00 $0.00 ATF-370-S SUP Custom 27803010 ATF-370-S - FUSION DEVICE 37.0MM ACUTRAK BOTH IP/OP $810.00 $599.40 $0.00 $648.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $601.18 $601.18 $0.00 $0.00 $168.80 $0.00 $0.00 $0.00 $0.00 $405.00 $641.52 $648.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-008-S SUP HCPCS C1713 ATM-008-S - SCREW BN 8MM ACTRK BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-078 SUP Custom 27203010 ATM-078 - BIT DRILL MN ACTRK SHRT CANN STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-099 SUP Custom 27203010 ATM-099 - BIT DRILL ACTRK LNG CANN TIP TPR STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-100-S SUP HCPCS C1713 ATM-100-S - SCREW BN MN 10MM ACTRK FX BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-120-S SUP HCPCS C1713 ATM-120-S - SCREW BN MN FT 2.8-3.6MM 12MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-140-S SUP HCPCS C1713 ATM-140-S - SCREW BN MN FT 2.8-3.6MM 14MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-160-S SUP HCPCS C1713 ATM-160-S - SCREW BN MN FT 2.8-3.6MM 16MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-180-S SUP HCPCS C1713 ATM-180-S - SCREW BN MN FT 2.8-3.6MM 18MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-200-S SUP HCPCS C1713 ATM-200-S - SCREW BN MN FT 2.8-3.6MM 20MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-220-S SUP HCPCS C1713 ATM-220-S - SCREW BN MN FT 2.8-3.6MM 22MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-240-S SUP HCPCS C1713 ATM-240-S - SCREW BN MN 24MM ACTRK FX BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 ATM-260-S SUP HCPCS C1713 ATM-260-S - SCREW BN MN FT 2.8-3.6MM 26MM STRL ACTRK SLF CUT CNN VAR BOTH IP/OP $940.00 $695.60 $0.00 $752.00 $423.00 $423.00 $0.00 $0.00 $0.00 $195.92 $697.67 $697.67 $0.00 $0.00 $195.90 $0.00 $556.01 $556.01 $0.00 $470.00 $744.48 $752.00 $0.00 $0.00 $147.11 $0.00 $0.00 $149.65 $0.00 $0.00 $0.00 $0.00 $0.00 AU00T0 SUP HCPCS V2632 AU00T0 - LENS IOL 0D PLANAR 6MM 30MM ACRSF IQ STABLEFORCE ULTRASERT BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $241.88 $241.88 $0.00 $0.00 $0.00 $112.03 $398.93 $398.93 $0.00 $0.00 $112.02 $0.00 $317.93 $317.93 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $84.12 $0.00 $0.00 $85.57 $0.00 $0.00 $0.00 $0.00 $0.00 AVM851 SUP Custom 27803010 AVM851 - CLIP INTNL SM STRL LF FLSH SFLN UPR JAW SIL TI FLLPN TUBE BOTH IP/OP $223.95 $165.72 $0.00 $179.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.22 $166.22 $0.00 $0.00 $46.67 $0.00 $0.00 $0.00 $0.00 $111.98 $177.37 $179.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AVSM10060 SUP HCPCS C2625 AVSM10060 - STENT VASCULAR COVERA COVERED 10MM X 60MM 80CM DELIVERY STR BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 AW-04018 SUP HCPCS C1769 GUIDEWIRE VASC .018IN 25CM STRG SFTP SPRG BOTH IP/OP $15.50 $11.47 $0.00 $12.40 $8.42 $8.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.75 $12.28 $12.40 $0.00 $0.00 $2.43 $0.00 $0.00 $2.47 $0.00 $0.00 $0.00 $0.00 $0.00 AW04432 SUP HCPCS C1769 GUIDEWIRE VASC .032IN 60CM JTP STRG SFTP DUAL END SPRG ARW BOTH IP/OP $23.50 $17.39 $0.00 $18.80 $12.76 $12.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.75 $18.61 $18.80 $0.00 $0.00 $3.68 $0.00 $0.00 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 AW-04432 SUP HCPCS C1769 GUIDEWIRE VASC .032IN 60CM JTP STRG SFTP DUAL END SPRG ARW BOTH IP/OP $58.75 $43.48 $0.00 $47.00 $31.90 $31.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.38 $46.53 $47.00 $0.00 $0.00 $9.19 $0.00 $0.00 $9.35 $0.00 $0.00 $0.00 $0.00 $0.00 AW-14735 SUP HCPCS C1769 GUIDEWIRE VASC .35IN 65CM SPRG JTP 2 END STRG ARW ADV SS BOTH IP/OP $40.15 $29.71 $0.00 $37.71 $12.81 $12.81 $0.00 $0.00 $0.00 $8.37 $29.80 $29.80 $0.00 $0.00 $8.37 $0.00 $37.71 $37.71 $0.00 $11.80 $18.69 $18.88 $0.00 $0.00 $3.69 $0.00 $0.00 $3.76 $0.00 $0.00 $0.00 $0.00 $0.00 AX100 SUP Custom 27203010 CALIBRATOR A MLTLY 5ML IMMUN BOTH IP/OP "$1,452.78 " "$1,075.06" $0.00 "$1,162.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $726.39 "$1,150.60" "$1,162.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 AX9001 SUP Custom 27203010 REAGENT A MLTLY DLY MNTN ANALY BOTH IP/OP $460.95 $341.10 $0.00 $368.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.48 $365.07 $368.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B000-0185 SUP HCPCS C1713 B000-0185 - RESTRICTOR CEMENT SMALL UNIVERSAL 18.5MM REVISION PLUG HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B000-0200 SUP HCPCS C1713 B000-0200 - PLUG BONE CMNT MED UNV 20MM BOTH IP/OP $188.00 $139.12 $0.00 $150.40 $84.60 $84.60 $0.00 $0.00 $0.00 $39.18 $139.53 $139.53 $0.00 $0.00 $39.18 $0.00 $111.20 $111.20 $0.00 $94.00 $148.90 $150.40 $0.00 $0.00 $29.42 $0.00 $0.00 $29.93 $0.00 $0.00 $0.00 $0.00 $0.00 B000-0240 SUP HCPCS C1713 B000-0240 - RSTRC CMNT MED UNV 24MM HIP REV BOTH IP/OP $112.50 $83.25 $0.00 $146.40 $82.35 $82.35 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $91.50 $144.94 $146.40 $0.00 $0.00 $28.64 $0.00 $0.00 $29.13 $0.00 $0.00 $0.00 $0.00 $0.00 B000-0300 SUP HCPCS C1713 B000-0300 - RESTRICTOR CEMENT XL UNIVERSAL 30MM REVISION HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B000-1185 SUP HCPCS C1713 B000-1185 - RESTRICTOR CEMENT SMALL UNIVERSAL DISPOSABLE INSERTER DISTAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B000-1240 SUP HCPCS C1713 B000-1240 - RESTRICTOR CEMENT MEDIUM UNIVERSAL DISPOSABLE INSERTER BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B000-1300 SUP HCPCS C1713 B000-1300 - RESTRICTOR CEMENT UNIVERSAL DISPOSABLE INSERTER BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B001-0110 SUP HCPCS C1713 B001-0110 - PLUG BONE CEMENT 1 11MM UHMWPE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B002-0125 SUP HCPCS C1713 B002-0125 - PLUG BONE CEMENT 2 12.5MM UHMWPE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B003-0140 SUP HCPCS C1713 B003-0140 - PLUG BONE CEMENT 3 17.5MM UHMWPE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B004-0155 SUP HCPCS C1713 B004-0155 - PLUG BONE CEMENT 4 23MM UHMWPE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B005-0170 SUP HCPCS C1713 B005-0170 - PLUG BONE CEMENT 5 17MM UHMWPE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B006-0185 SUP HCPCS C1713 B006-0185 - PLUG BONE CEMENT 6 18MM UHMWPE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B007-0200 SUP HCPCS C1713 B007-0200 - PLUG BONE CEMENT 7 20MM UHMWPE HIP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B008-0215 SUP HCPCS C1713 B008-0215 - PLUG BONE CEMENT 8 21.5MM UHMWPE BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $50.63 $50.63 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 B1000729BL SUP Custom 27203010 CASSETTE TISS BLUE SHDN EMBD DISP BOTH IP/OP $288.18 $213.25 $0.00 $230.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.09 $228.24 $230.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1000729DRD SUP Custom 27203010 CASSETTE TISS ANTM PTH 2 BOTH IP/OP $328.35 $242.98 $0.00 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.18 $260.05 $262.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1000729OR SUP Custom 27203010 CASSETTE TISS ORNG SHDN EMBD 2 DISP BOTH IP/OP $262.25 $194.07 $0.00 $209.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.13 $207.70 $209.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1000729PK SUP Custom 27203010 CASSETTE TISS PNK SHDN EMBD DISP BOTH IP/OP $326.50 $241.61 $0.00 $261.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.25 $258.59 $261.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1000729WH SUP Custom 27203010 CASSETTE TISS/BIOP WHT EMBD SM SLOT ACTL PLMR BOTH IP/OP $262.25 $194.07 $0.00 $209.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.13 $207.70 $209.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B10-27A-00 SUP Custom 27803010 B10-27A-00 - VALVE AORTIC 17MM 27MM BIOCOR PIG STNT LP FLEXFIT STENT BOTH IP/OP "$19,200.00 " "$14,208.00" $0.00 "$15,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,001.28" $0.00 $0.00 $0.00 $0.00 "$9,600.00" "$15,206.40" "$15,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1036-1 SUP Custom 27203010 KIT PR RTCLN RVIR EIA DIR AG DTCT MICROTITRATION VIR TST 48 BOTH IP/OP $789.23 $584.03 $0.00 $631.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $394.61 $625.07 $631.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1046-23 SUP Custom 27203010 KIT IMMUN TST GNGN 2 N GC 24 TST BOTH IP/OP $181.90 $134.61 $0.00 $145.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.95 $144.06 $145.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1055-16A SUP Custom 27203010 REAGENT MYCL CALCOFLUOR WHT DRPR .5ML BOTH IP/OP $135.93 $100.59 $0.00 $108.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.96 $107.66 $108.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1055-4 SUP Custom 27203010 REAGENT MCBL INDOPHENOL OXDS DRPR CRUSHABLE AMPULE BBL .5ML BOTH IP/OP $1.28 $0.95 $0.00 $1.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.64 $1.01 $1.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B1076-1B SUP Custom 25003010 DISK NITROCEFIN B LCTMS DTCT BBL ID BOTH IP/OP $125.60 $92.94 $0.00 $100.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.80 $99.48 $100.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B12LT SUP Custom 27203010 B12LT - TROCAR LAPSCOP 12MM 100MM STABILITY SLEEVE OPTICAL TIP BOTH IP/OP $475.45 $351.83 $0.00 $380.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.88 $352.88 $0.00 $0.00 $99.08 $0.00 $0.00 $0.00 $0.00 $237.73 $376.56 $380.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B12XT SUP Custom 27203010 B12XT - TROCAR LAPSCOP 12MM 150MM STABILITY SLEEVE OPTICAL OBTURATOR BOTH IP/OP $536.91 $397.31 $0.00 $429.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $398.49 $398.49 $0.00 $0.00 $111.89 $0.00 $0.00 $0.00 $0.00 $268.45 $425.23 $429.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B2996-60 SUP HCPCS C1760 CLOSURE TUBE UNV NTR WHT XTRN SL CLR CD VRSSCLSR 10-16MM BOTH IP/OP $0.10 $0.07 $0.00 $0.08 $0.05 $0.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.05 $0.08 $0.08 $0.00 $0.00 $0.02 $0.00 $0.00 $0.02 $0.00 $0.00 $0.00 $0.00 $0.00 B40826 SUP Custom 27203010 REAGENT MCBL COAG PLSM EDTA RBT LYPH BBL 15ML BOTH IP/OP $581.23 $430.11 $0.00 $464.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.61 $460.33 $464.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B4340863 SUP Custom 27203010 KIT MYCTST MYCOPREP NAOH NA CHLOR PHOS BUFF DCNT DGST 150ML BOTH IP/OP $447.88 $331.43 $0.00 $358.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.94 $354.72 $358.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5016 SUP HCPCS C1713 B500-5016 - SCREW BONE 5MM 16MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5020 SUP HCPCS C1713 B500-5020 - SCREW BONE 5MM 20MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5024 SUP HCPCS C1713 B500-5024 - SCREW BONE 5MM 24MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5028 SUP HCPCS C1713 B500-5028 - SCREW BONE 5MM 28MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5032 SUP HCPCS C1713 B500-5032 - SCREW BONE 5MM 32MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5034 SUP HCPCS C1713 B500-5034 - SCREW BONE 5MM 34MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5036 SUP HCPCS C1713 B500-5036 - SCREW BONE 5MM 36MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5038 SUP HCPCS C1713 B500-5038 - SCREW BONE 5MM 38MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5040 SUP HCPCS C1713 B500-5040 - SCREW BONE 5MM 40MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5042 SUP HCPCS C1713 B500-5042 - SCREW BONE 5MM 42MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5044 SUP HCPCS C1713 B500-5044 - SCREW BONE 5MM 44MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5046 SUP HCPCS C1713 B500-5046 - SCREW BONE 5MM 46MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5048 SUP HCPCS C1713 B500-5048 - SCREW BONE 5MM 48MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5050 SUP HCPCS C1713 B500-5050 - SCREW BONE 5MM 50MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5052 SUP HCPCS C1713 B500-5052 - SCREW BONE 5MM 52MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5054 SUP HCPCS C1713 B500-5054 - SCREW BONE 5MM 54MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B500-5056 SUP HCPCS C1713 B500-5056 - SCREW BONE 5MM 56MM CORT BOTH IP/OP $89.38 $66.14 $0.00 $71.50 $40.22 $40.22 $0.00 $0.00 $0.00 $18.63 $66.33 $66.33 $0.00 $0.00 $18.63 $0.00 $52.87 $52.87 $0.00 $44.69 $70.79 $71.50 $0.00 $0.00 $13.99 $0.00 $0.00 $14.23 $0.00 $0.00 $0.00 $0.00 $0.00 B56030 SUP Custom 27203010 KIT DRCGN EZ RSV CNTRL REAGENT TUBE TIP VIR TST 30 TST BOTH IP/OP $355.50 $263.07 $0.00 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.75 $281.56 $284.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B5LT SUP Custom 27203010 B5LT - TROCAR LAPSCOP 5MM 100MM STABILITY SLEEVE CANNU XCEL BOTH IP/OP $349.76 $258.82 $0.00 $279.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.59 $259.59 $0.00 $0.00 $72.89 $0.00 $0.00 $0.00 $0.00 $174.88 $277.01 $279.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B5STF SUP Custom 27203010 B5STF - TROCAR LAPSCP STD 5MM STRL LF VERSAONE FX CNN BLDE DISP BOTH IP/OP $72.88 $53.93 $0.00 $59.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.09 $54.09 $0.00 $0.00 $15.19 $0.00 $0.00 $0.00 $0.00 $36.98 $58.58 $59.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B5XT SUP Custom 27203010 B5XT - TROCAR LAPSCOP 5MM 100MM STABILITY SLEEVE XCEL ENDOPATH BOTH IP/OP $405.73 $300.24 $0.00 $324.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.13 $301.13 $0.00 $0.00 $84.55 $0.00 $0.00 $0.00 $0.00 $202.86 $321.34 $324.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B6940-20 SUP Custom 27203010 CONTROL RPR BBL MACV CRD 1.5ML IMMUN BOTH IP/OP $46.10 $34.11 $0.00 $36.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.05 $36.51 $36.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B6940-21 SUP Custom 27203010 DEVICE DISPENSTIRS RPR CRD IMMUN TST BOTH IP/OP $79.23 $58.63 $0.00 $63.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.61 $62.75 $63.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B6940-4 SUP Custom 27203010 KIT MACV RPR QUAL SPOT CRD SERTST 10 TST BOTH IP/OP $243.75 $180.38 $0.00 $195.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.88 $193.05 $195.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B6944-19 SUP Custom 27203010 KIT DRCGN RSV LAT FLW CLIA WVD VIR TST 30 TST BOTH IP/OP $994.50 $735.93 $0.00 $795.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $497.25 $787.64 $795.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 B9990800 SUP Custom 27203010 REAGENT CYTO RD CYRCH COLLECT FLUID ALC BS 3.8L BOTH IP/OP $278.58 $206.15 $0.00 $222.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.29 $220.64 $222.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BA22-40/I13-40 SUP Custom 27803010 BA22-40/I13-40 - GRAFT STNT 2 BRCH 22MM 13MM 40MM STRL LF 40MM AFX STRATA BOTH IP/OP "$28,950.00 " "$21,423.00" $0.00 "$23,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,033.18" $0.00 $0.00 $0.00 $0.00 "$14,475.00" "$22,928.40" "$23,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BA22-60/I13-40 SUP Custom 27803010 BA22-60/I13-40 - GRAFT STNT BFUR 22-13MM 17FR 60MM 40MM AFX ACTIVESEAL STRATA BOTH IP/OP "$28,025.00 " "$20,738.50" $0.00 "$22,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,840.41" $0.00 $0.00 $0.00 $0.00 "$14,012.50" "$22,195.80" "$22,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BA22-70/I16-30 SUP Custom 27803010 BA22-70/I16-30 - GRAFT STNT 2 BRCH 22MM 16MM 70MM STRL 30MM AFX LMB XTN PTFE BOTH IP/OP "$28,950.00 " "$21,423.00" $0.00 "$23,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,033.18" $0.00 $0.00 $0.00 $0.00 "$14,475.00" "$22,928.40" "$23,160.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BA25-70/I16-30 SUP Custom 27803010 BA25-70/I16-30 - GRAFT STENT 70MM SELF EXPANDABLE MAIN BODY POLYPRO SUTURE BOTH IP/OP "$28,025.00 " "$20,738.50" $0.00 "$22,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,840.41" $0.00 $0.00 $0.00 $0.00 "$14,012.50" "$22,195.80" "$22,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BA25-80/I16-40 SUP Custom 27803010 BA25-80/I16-40 - GRAFT STENT 80MM SELF EXPAND MAIN BODY AFX ACTIVESEAL STRATA BOTH IP/OP "$28,025.00 " "$20,738.50" $0.00 "$22,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,840.41" $0.00 $0.00 $0.00 $0.00 "$14,012.50" "$22,195.80" "$22,420.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BA28-70/I16-30 SUP Custom 27803010 BA28-70/I16-30 - GRAFT STNT BFUR 28-16MM 17FR 70MM 30MM AFX ACTIVESEAL STRATA BOTH IP/OP "$28,237.50 " "$20,895.75" $0.00 "$22,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,884.70" $0.00 $0.00 $0.00 $0.00 "$14,118.75" "$22,364.10" "$22,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BC585049 SUP Custom 27203010 BC585049 - CYSTOTOME IRR 50MM 45D ANG TIP BOTH IP/OP $95.65 $70.78 $0.00 $76.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.83 $75.75 $76.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BCK9015 SUP Custom 27804086 BCK9015 - SYSTEM BONE CMNT 15CM DLV NDL HNDL KT 11GA STRL AVTX BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BE1234 SUP HCPCS C1713 "BE1234 - ROD, PEEK, 200MM" BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 BE6055 SUP HCPCS L8613 BE6055 - SET ET 14GA 26IN STRL 24IN BLM-SNG INTRO NDL SHTH CATH PNCT BOTH IP/OP $589.50 $436.23 $0.00 $471.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $437.53 $437.53 $0.00 $0.00 $122.85 $0.00 $0.00 $0.00 $0.00 $294.75 $466.88 $471.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BEA22-70/I16-30 SUP Custom 27803010 BEA22-70/I16-30 - GRAFT STNT 2 BRCH 22MM 16MM 70MM STRL LF 30MM AFX2 MAIN BD BOTH IP/OP "$34,997.50 " "$25,898.15" $0.00 "$27,998.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$17,498.75" "$27,718.02" "$27,998.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG101-350 SUP HCPCS C1783 BG101-350 - DRAIN GLAUCOMA IMNPLANT BAERVELDT SILICONE ANTER CHAM BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $312.64 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $887.25 $887.25 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 BG3510-5-US SUP HCPCS A4364 BG3510-5-US - ADH SURG BIOGL SFT TIS BSA GLUT PREFL SYR 10ML STRL LATEX BOTH IP/OP "$1,725.00 " "$1,276.50" $0.00 "$1,380.00" $936.68 $936.68 $0.00 $0.00 $0.00 $359.53 "$1,280.30" "$1,280.30" $0.00 $0.00 $359.49 $0.00 "$1,020.34" "$1,020.34" $0.00 $862.50 "$1,366.20" "$1,380.00" $0.00 $0.00 $269.96 $0.00 $0.00 $274.62 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8006-S SUP Custom 27203010 BG-8006-S - BIT DRILL 6MM BNGFT BNGFT SYS STRL BOTH IP/OP $965.00 $714.10 $0.00 $772.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.22 $716.22 $0.00 $0.00 $201.11 $0.00 $0.00 $0.00 $0.00 $482.50 $764.28 $772.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8010-S SUP Custom 27203010 BG-8010-S - BIT DRILL 8MM BNGFT BNGFT SYS STRL BOTH IP/OP $965.00 $714.10 $0.00 $772.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.22 $716.22 $0.00 $0.00 $201.11 $0.00 $0.00 $0.00 $0.00 $482.50 $764.28 $772.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8020-S SUP Custom 27203010 BG-8020-S - BIT DRILL 10MM BNGFT BNGFT SYS STRL BOTH IP/OP $965.00 $714.10 $0.00 $772.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.22 $716.22 $0.00 $0.00 $201.11 $0.00 $0.00 $0.00 $0.00 $482.50 $764.28 $772.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8030-S SUP Custom 27203010 BG-8030-S - BIT DRILL 12MM BNGFT BNGFT SYS STRL BOTH IP/OP $965.00 $714.10 $0.00 $772.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.22 $716.22 $0.00 $0.00 $201.11 $0.00 $0.00 $0.00 $0.00 $482.50 $764.28 $772.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8040 SUP Custom 27203010 BG-8040 - ADPR TBG HDSN FIT BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $0.00 $0.00 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8043 SUP Custom 27203010 BG-8043 - HANDLE RCHT T BNGFT BOTH IP/OP "$2,287.50 " "$1,692.75" $0.00 "$1,830.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,697.78" "$1,697.78" $0.00 $0.00 $476.72 $0.00 $0.00 $0.00 $0.00 "$1,143.75" "$1,811.70" "$1,830.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8044 SUP Custom 27203010 BG-8044 - ADPR CHK JCB BOTH IP/OP $572.50 $423.65 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.91 $424.91 $0.00 $0.00 $119.31 $0.00 $0.00 $0.00 $0.00 $286.25 $453.42 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8060 SUP Custom 27203010 BG-8060 - EXTRACTOR SRG G S GFT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8064 SUP Custom 27203010 BG-8064 - EXTRACTOR SRG 6MM G S BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BG-8080 SUP Custom 27203010 BG-8080 - PUNCH SRG GFT TROC BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BI-2030 SUP Custom 27203010 BI-2030 - CIRCUIT BREATHING 9X8X3IN TRANSPORT TEST CAP PORTABLE BOTH IP/OP $73.61 $54.47 $0.00 $58.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.63 $54.63 $0.00 $0.00 $15.34 $0.00 $0.00 $0.00 $0.00 $36.80 $58.30 $58.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BK406 SUP Custom 27203010 BK406 - PROTECTOR STUMP ROOKE BKA BOTH IP/OP $622.50 $460.65 $0.00 $498.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.02 $462.02 $0.00 $0.00 $129.73 $0.00 $0.00 $0.00 $0.00 $311.25 $493.02 $498.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BL5115-2 SUP Custom 27203010 BL5115-2 - PACK SRG STD NS LF ADP FLUIDICS DISP BOTH IP/OP $160.00 $118.40 $0.00 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.75 $118.75 $0.00 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $80.00 $126.72 $128.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BM200 SUP Custom 27203010 BM200 - BONE MILL BM200 LEGEND PNEU DISPOSABLE BOTH IP/OP $627.75 $464.54 $0.00 $502.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $465.92 $465.92 $0.00 $0.00 $130.82 $0.00 $0.00 $0.00 $0.00 $313.88 $497.18 $502.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BMW2021 SUP HCPCS Q4108 BMW2021 - DRESSING BIO 2X2IN STRL LF INTGR BL MX BVN CLGN GAG BOTH IP/OP "$5,171.98 " "$3,827.27" $0.00 "$4,701.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,838.64" "$3,838.64" $0.00 $0.00 $41.87 $0.00 $0.00 $0.00 $0.00 "$2,938.63" "$4,654.78" "$4,701.80" $0.00 $0.00 $39.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BMW8101 SUP HCPCS Q4104 BMW8101 - DRESSING BIOLOGICAL 10X8IN ADHERENT BILAYER MATRIX FLEXIBLE BOTH IP/OP "$23,893.18 " "$17,680.95" $0.00 "$21,721.06" "$12,218.10" "$12,218.10" $0.00 $0.00 $0.00 "$4,979.93" "$17,733.51" "$17,733.51" $0.00 $0.00 $38.02 $0.00 "$11,779.34" "$11,779.34" $0.00 "$13,575.66" "$21,503.85" "$21,721.06" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,322.49" $0.00 $0.00 $0.00 $0.00 $0.00 BP10405 SUP Custom 27803010 BP10405 - BP SUTURABLE GRAFT 4CM X 5CM BOTH IP/OP $850.28 $629.21 $0.00 $782.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $631.07 $631.07 $0.00 $0.00 $177.20 $0.00 $0.00 $0.00 $0.00 $489.13 $774.77 $782.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BP10608 SUP Custom 27803010 BP10608 - BP SUTURABLE GRAFT 6CM X 8CM BOTH IP/OP "$1,097.98 " $812.51 $0.00 "$1,011.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.92 $814.92 $0.00 $0.00 $228.82 $0.00 $0.00 $0.00 $0.00 $632.45 "$1,001.80" "$1,011.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BP10812 SUP Custom 27803010 BP10812 - BP SUTURABLE GRAFT 8CM X 12CM BOTH IP/OP "$1,811.00 " "$1,340.14" $0.00 "$1,667.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,344.12" "$1,344.12" $0.00 $0.00 $377.41 $0.00 $0.00 $0.00 $0.00 "$1,041.95" "$1,650.45" "$1,667.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BP11216 SUP Custom 27803010 BP11216 - GRAFT SFT TIS 12X16CM STRL TTPLST RSRB SUTURABLE BOTH IP/OP "$3,613.63 " "$2,674.09" $0.00 "$3,107.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,682.03" "$2,682.03" $0.00 $0.00 $753.08 $0.00 $0.00 $0.00 $0.00 "$1,942.40" "$3,076.76" "$3,107.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BRC000410-00 SUP HCPCS C1725 BRC000410-00 - CATHETER BLNOCC 4MM 10MM ASCNT CMPT SYS MCIOL NRVSC ANRSM BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,582.85" "$1,582.85" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,724.22" "$1,724.22" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 BRC000415-00 SUP HCPCS C1725 BRC000415-00 - CATHETER BLNOCC 4MM 15MM ASCNT REMODEL BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,582.85" "$1,582.85" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,724.22" "$1,724.22" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 BRS000609-00 SUP HCPCS C1725 BRS000609-00 - CATHETER BLNOCC 6MM 9MM ASCNT REMODEL BOTH IP/OP "$2,915.00 " "$2,157.10" $0.00 "$2,332.00" "$1,582.85" "$1,582.85" $0.00 $0.00 $0.00 $607.56 "$2,163.51" "$2,163.51" $0.00 $0.00 $607.49 $0.00 "$1,724.22" "$1,724.22" $0.00 "$1,457.50" "$2,308.68" "$2,332.00" $0.00 $0.00 $456.20 $0.00 $0.00 $464.07 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351304100 SUP Custom 27203010 BSCLX351304100 - CATHETER BLNDIL 4MM 130CM LF 100MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351304120 SUP Custom 27203010 BSCLX351304120 - CATHETER BLNDIL 4MM 130CM LF 120MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351304150 SUP Custom 27203010 BSCLX351304150 - CATHETER BLNDIL 4MM 130CM LF 150MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130440 SUP Custom 27203010 BSCLX35130440 - CATHETER BLNDIL 4MM 130CM LF 40MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130460 SUP Custom 27203010 BSCLX35130460 - CATHETER BLNDIL 4MM 130CM LF 60MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130480 SUP Custom 27203010 BSCLX35130480 - CATHETER BLNDIL 4MM 130CM LF 80MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351305100 SUP Custom 27203010 BSCLX351305100 - CATHETER BLNDIL 5MM 130CM LF 100MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351305120 SUP Custom 27203010 BSCLX351305120 - CATHETER BLNDIL 5MM 130CM LF 120MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351305150 SUP Custom 27203010 BSCLX351305150 - CATHETER BLNDIL 5MM 130CM LF 150MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130540 SUP Custom 27203010 BSCLX35130540 - CATHETER BLNDIL 5MM 130CM LF 40MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130560 SUP Custom 27203010 BSCLX35130560 - CATHETER BLNDIL 5MM 130CM LF 60MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130580 SUP Custom 27203010 BSCLX35130580 - CATHETER BLNDIL 5MM 130CM LF 80MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351306100 SUP Custom 27203010 BSCLX351306100 - CATHETER BLNDIL 6MM 130CM LF 100MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351306120 SUP Custom 27203010 BSCLX351306120 - CATHETER BALDILAT 6FR 6MM 130CM 120MM PCLTXL BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX351306150 SUP Custom 27203010 BSCLX351306150 - CATHETER BLNDIL 6MM 130CM LF 150MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130640 SUP Custom 27203010 BSCLX35130640 - CATHETER BLNDIL 6MM 130CM LF 40MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130660 SUP Custom 27203010 BSCLX35130660 - CATHETER BLNDIL 6MM 130CM LF 60MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BSCLX35130680 SUP Custom 27203010 BSCLX35130680 - CATHETER BLNDIL 6MM 130CM LF 80MM LUTONIX 035 PCLTXL ACPT BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 $0.00 $0.00 $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BTC-100 SUP HCPCS C1758 CATHETER URET BT-CATH TEMPONADE BOTH IP/OP $290.00 $214.60 $0.00 $215.24 $144.85 $144.85 $0.00 $0.00 $0.00 $0.00 $215.24 $215.24 $0.00 $0.00 $60.44 $0.00 $157.78 $157.78 $0.00 $133.38 $211.27 $213.40 $0.00 $0.00 $41.75 $0.00 $0.00 $42.47 $0.00 $0.00 $0.00 $0.00 $0.00 BTE1000 SUP Custom 27803010 BTE1000 - EXPANDER TISSUE P8-10.2CM RECTANGLE 17X8CM REMOTE PORT BOTH IP/OP "$1,337.50 " $989.75 $0.00 "$1,070.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $992.69 $992.69 $0.00 $0.00 $278.74 $0.00 $0.00 $0.00 $0.00 $668.75 "$1,059.30" "$1,070.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BTE750 SUP Custom 27803010 BTE750 - EXPANDER TISSUE P7-9CM RECTANGLE 15X7.5CM REMOTE PORT SMOOTH BOTH IP/OP "$1,337.50 " $989.75 $0.00 "$1,070.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $992.69 $992.69 $0.00 $0.00 $278.74 $0.00 $0.00 $0.00 $0.00 $668.75 "$1,059.30" "$1,070.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BW012 SUP Custom 27803010 BW012 - WAX BN STRL LF OSTENE HMST AGNT ALK OXD 2.5GM DISP BOTH IP/OP $192.05 $142.12 $0.00 $153.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.54 $142.54 $0.00 $0.00 $40.02 $0.00 $0.00 $0.00 $0.00 $96.03 $152.10 $153.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BW-012 SUP Custom 27203010 OSTENE-A WATER-SOLUBLE BONE HEMOSTASIS MATERIALS BOTH IP/OP $165.63 $122.57 $0.00 $132.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.81 $131.18 $132.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BX00711052 SUP Custom 27203010 BX00711052 - NET SPEC RTRVL 230CM 2.5MM RTHNT STD STRNG REINF NT X SCR BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $0.00 $0.00 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BX-1000 SUP Custom 27203010 BX-1000 - KIT ASCP ARTHROBOX BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 BXA073901A SUP HCPCS C1874 BXA073901A - STENT EPRSTH .035IN 7MM 11MM 7FR 39MM 80CM GORE VBHN BLN BOTH IP/OP "$8,935.00 " "$6,611.90" $0.00 "$7,008.00" "$3,942.00" "$3,942.00" $0.00 $0.00 $0.00 "$1,862.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,862.05" $0.00 "$4,404.96" "$4,404.96" $0.00 "$4,380.00" "$6,937.92" "$7,008.00" $0.00 $0.00 "$1,370.94" $0.00 $0.00 "$1,394.59" $0.00 $0.00 $0.00 $0.00 $0.00 BXA075901A SUP HCPCS C1874 BXA075901A - STENT EPRSTH .035IN 7MM 11MM 7FR 59MM 80CM GORE VBHN BLN BOTH IP/OP "$8,935.00 " "$6,611.90" $0.00 "$7,008.00" "$3,942.00" "$3,942.00" $0.00 $0.00 $0.00 "$1,862.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,862.05" $0.00 "$4,404.96" "$4,404.96" $0.00 "$4,380.00" "$6,937.92" "$7,008.00" $0.00 $0.00 "$1,370.94" $0.00 $0.00 "$1,394.59" $0.00 $0.00 $0.00 $0.00 $0.00 BXA082901A SUP HCPCS C1874 BXA082901A - STENT EPRSTH .035IN 8MM 11MM 7FR 29MM 80CM GORE VBHN BLN BOTH IP/OP "$8,935.00 " "$6,611.90" $0.00 "$7,008.00" "$3,942.00" "$3,942.00" $0.00 $0.00 $0.00 "$1,862.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,862.05" $0.00 "$4,404.96" "$4,404.96" $0.00 "$4,380.00" "$6,937.92" "$7,008.00" $0.00 $0.00 "$1,370.94" $0.00 $0.00 "$1,394.59" $0.00 $0.00 $0.00 $0.00 $0.00 BXA083901A SUP HCPCS C1874 BXA083901A - STENT EPRSTH .035IN 8MM 11MM 7FR 39MM 80CM GORE VBHN BLN BOTH IP/OP "$8,935.00 " "$6,611.90" $0.00 "$7,008.00" "$3,942.00" "$3,942.00" $0.00 $0.00 $0.00 "$1,862.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,862.05" $0.00 "$4,404.96" "$4,404.96" $0.00 "$4,380.00" "$6,937.92" "$7,008.00" $0.00 $0.00 "$1,370.94" $0.00 $0.00 "$1,394.59" $0.00 $0.00 $0.00 $0.00 $0.00 BXA085901A SUP HCPCS C1874 BXA085901A - STENT EPRSTH .035IN 8MM 11MM 7FR 59MM 80CM GORE VBHN BLN BOTH IP/OP "$8,935.00 " "$6,611.90" $0.00 "$7,008.00" "$3,942.00" "$3,942.00" $0.00 $0.00 $0.00 "$1,862.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,862.05" $0.00 "$4,404.96" "$4,404.96" $0.00 "$4,380.00" "$6,937.92" "$7,008.00" $0.00 $0.00 "$1,370.94" $0.00 $0.00 "$1,394.59" $0.00 $0.00 $0.00 $0.00 $0.00 C021D SUP Custom 27203010 C021D - SUTURE NONABSORBABLE 0 CT-1 18IN CONTROL RELEASE BRAID 8 BOTH IP/OP $285.50 $211.27 $0.00 $231.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.90 $211.90 $0.00 $0.00 $59.50 $0.00 $0.00 $0.00 $0.00 $144.89 $229.51 $231.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C-028 SUP HCPCS C1713 C-028 - GUARD PIN YLW .028IN PINCAP .028IN POST SURG KWR STNM PIN BOTH IP/OP $4.58 $3.39 $0.00 $3.67 $2.06 $2.06 $0.00 $0.00 $0.00 $0.96 $3.40 $3.40 $0.00 $0.00 $0.96 $0.00 $2.71 $2.71 $0.00 $2.29 $3.63 $3.67 $0.00 $0.00 $0.72 $0.00 $0.00 $0.73 $0.00 $0.00 $0.00 $0.00 $0.00 C-045 SUP HCPCS C1713 C-045 - CAP PCTV PINCAP STRL WHT .045IN 1.1MM .045IN BOTH IP/OP $4.58 $3.39 $0.00 $3.67 $2.06 $2.06 $0.00 $0.00 $0.00 $0.96 $3.40 $3.40 $0.00 $0.00 $0.96 $0.00 $2.71 $2.71 $0.00 $2.29 $3.63 $3.67 $0.00 $0.00 $0.72 $0.00 $0.00 $0.73 $0.00 $0.00 $0.00 $0.00 $0.00 C-062 SUP HCPCS C1713 C-062 - CAP PCTV .062IN KWR PINCAP STRL POST SURG KWR STNM PIN GRN BOTH IP/OP $2.75 $2.04 $0.00 $2.20 $1.24 $1.24 $0.00 $0.00 $0.00 $0.57 $2.04 $2.04 $0.00 $0.00 $0.57 $0.00 $1.63 $1.63 $0.00 $1.38 $2.18 $2.20 $0.00 $0.00 $0.43 $0.00 $0.00 $0.44 $0.00 $0.00 $0.00 $0.00 $0.00 C-078 SUP HCPCS C1713 C-078 - GUARD PIN PNK .078IN .035IN KWR STNM STRL BOTH IP/OP $5.00 $3.70 $0.00 $4.00 $2.25 $2.25 $0.00 $0.00 $0.00 $1.04 $3.71 $3.71 $0.00 $0.00 $1.04 $0.00 $2.96 $2.96 $0.00 $2.50 $3.96 $4.00 $0.00 $0.00 $0.78 $0.00 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 C0L-3140 SUP HCPCS C1713 C0L-3140 - SCREW BONE 3.5MM 14MM ACUMED ACLC CORT ORTH LCK STRL BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 C0L-3160 SUP HCPCS C1713 C0L-3160 - SCREW BONE 3.5MM 16MM TI DISTAL RADL CORT CLVCL WR HND LCK BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 C141 SUP HCPCS C1713 C141 - COVER PIN .141IN KWR BOTH IP/OP $5.00 $3.70 $0.00 $4.00 $2.25 $2.25 $0.00 $0.00 $0.00 $1.04 $3.71 $3.71 $0.00 $0.00 $1.04 $0.00 $2.96 $2.96 $0.00 $2.50 $3.96 $4.00 $0.00 $0.00 $0.78 $0.00 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 C156 SUP HCPCS C1713 C156 - COVER PIN .156IN KWR BOTH IP/OP $5.00 $3.70 $0.00 $4.00 $2.25 $2.25 $0.00 $0.00 $0.00 $1.04 $3.71 $3.71 $0.00 $0.00 $1.04 $0.00 $2.96 $2.96 $0.00 $2.50 $3.96 $4.00 $0.00 $0.00 $0.78 $0.00 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 C1712 SUP HCPCS C1713 C1712 - SCREW BONE 1.7MM 12MM CANN LBLU BOTH IP/OP $825.00 $610.50 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 C1713 SUP HCPCS C1713 C1713 - SCREW BONE 13MM CANN LIGHT BLUE 1.7MM BOTH IP/OP $825.00 $610.50 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 C1714 SUP HCPCS C1713 C1714 - SCREW BONE 9MM CANN COMPRESSION LIGHT BLUE 1.7MM ORTHOPEDIC BOTH IP/OP $825.00 $610.50 $0.00 $630.00 $354.38 $354.38 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $123.24 $0.00 $0.00 $125.37 $0.00 $0.00 $0.00 $0.00 $0.00 C2314 SUP HCPCS C1713 C2314 - SCREW BONE L14 MM OD2.3 MM ORTHOPEDIC LOCK BLUE BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C2316 SUP HCPCS C1713 C2316 - SCREW BN 2.3MM 16MM BLU CNN CMPR BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C2318 SUP HCPCS C1713 "C2318 - CANNULATED SCREW 2.3MM, 18MM" BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C2320 SUP HCPCS C1713 C2320 - SCREW BONE 20MM LOCK BLUE 2.3MM ORTHOPEDIC BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C2322 SUP HCPCS C1713 C2322 - SCREW BONE 22MM CANN COMPRESSION BLUE 2.3MM BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C2324 SUP HCPCS C1713 C2324 - SCREW BN 2.3MM 24MM BLU CNN CMPR BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C2326 SUP HCPCS C1713 C2326 - SCREW BONE 26MM CANN COMPRESSION BLUE 2.3MM BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C2328 SUP HCPCS C1713 C2328 - SCREW BONE 28MM CANN COMPRESSION BLUE 2.3MM BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C2TR01 SUP HCPCS C2621 C2TR01 - PACEMAKER CARDIAC THK6MM 57X59MM 2 CHAMBER RATE RESPONSIVE BOTH IP/OP "$14,700.00 " "$10,878.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,063.48" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C3.5-20 SUP HCPCS C1713 C3.5-20 - SCREW BONE 20MM CANN ORANGE 3.5MM ORTHOPEDIC BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C3018 SUP HCPCS C1713 C3018 - SCREW BONE 18MM CANN COMPRESSION YELLOW 3MM BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C3020 SUP HCPCS C1713 C3020 - SCREW BONE 20MM CANN COMPRESSION YELLOW 3MM BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C3022 SUP HCPCS C1713 C3022 - SCREW BONE 22MM CANN YELLOW 3MM BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C3024 SUP HCPCS C1713 C3024 - SCREW BONE 24MM COMPRESSION 3MM BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C3026 SUP HCPCS C1713 C3026 - SCREW BONE 26MM CANN COMPRESSION YELLOW 3MM BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C3524 SUP HCPCS C1713 C3524 - SCREW BONE 24MM CANN COMPRESSION ORANGE 3.5MM ORTHOPEDIC BOTH IP/OP $775.00 $573.50 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $161.53 $575.21 $575.21 $0.00 $0.00 $161.51 $0.00 $458.41 $458.41 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 C3RL01-B:US SUP HCPCS Q4100 C3RL01-B:US - DEVICE CELL HRVT RECELL ATLGS BOTH IP/OP "$16,687.50 " "$12,348.75" $0.00 "$13,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,477.68" $0.00 $0.00 $0.00 $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C4120 SUP Custom 27203010 C4120 - CARTRIDGE GRSPR 5MM 38CM STRL 20MM D DR ATRM DISP BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C4319-5B SUP Custom 27203010 C4319-5B - ADPR SCT 15MM 15MM BLUE SWVL TRCHCR CLOSE SCT SYS TRCHCR BOTH IP/OP $86.68 $64.14 $0.00 $69.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.34 $68.65 $69.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C4330 SUP Custom 27203010 CHEMICAL LAB XYLN CLR AGNT POLY BTL 1GL HST GRAD BOTH IP/OP $35.93 $26.59 $0.00 $28.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.96 $28.46 $28.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C46145 SUP Custom 27203010 C46145 - CUSA CURVED EXTENDED STD TIPS 8/BX BOTH IP/OP "$1,219.38 " $902.34 $0.00 $975.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.02 $905.02 $0.00 $0.00 $254.12 $0.00 $0.00 $0.00 $0.00 $609.69 $965.75 $975.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C514D SUP Custom 27203010 C514D - SUTURE NONABSORBABLE 4-0 SH 18IN CONTROL RELEASE BRAID 8 BOTH IP/OP $30.13 $22.30 $0.00 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.36 $22.36 $0.00 $0.00 $6.28 $0.00 $0.00 $0.00 $0.00 $15.07 $23.86 $24.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C554D SUP Custom 27203010 C554D - SUTURE NRLN 4-0 RB1 18IN BRAID CR MPK BLK NABSB BOTH IP/OP $35.34 $26.15 $0.00 $28.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.23 $26.23 $0.00 $0.00 $7.36 $0.00 $0.00 $0.00 $0.00 $17.67 $27.99 $28.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C584D SUP Custom 27203010 C584D - SUTURE NABSB 4-0 TF 18IN BLK NRLN CR BRD 8 STRN NYL 6 6 BOTH IP/OP $39.86 $29.50 $0.00 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.58 $29.58 $0.00 $0.00 $8.31 $0.00 $0.00 $0.00 $0.00 $20.23 $32.04 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C8402 SUP Custom 27203010 C8402 - RETRACTOR SURG MEDIUM RING ATRAUMATIC SELF RETAIN WOUND BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C8403 SUP Custom 27203010 C8403 - RETRACTOR SURG LARGE RIGID RETRACTION RING ALEXIS O 9-14CM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C8404 SUP Custom 27203010 C8404 - RETRACTOR SURG XL 11-17CM WOUND LATEX FREE ALEXIS 11-17CM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C8584 SUP Custom 27203010 C8584 - BIT DRILL 9IN TAPERED HEAD TUNNEL DEPTH ECCENTRIC MONOFLUTED BOTH IP/OP "$1,751.00 " "$1,295.74" $0.00 "$1,400.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,299.59" "$1,299.59" $0.00 $0.00 $364.91 $0.00 $0.00 $0.00 $0.00 $875.50 "$1,386.79" "$1,400.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C8XX2 SUP Custom 27203010 C8XX2 - PORT HND ACC 120MM LF ALEXIS GLPRT WND RTRCTR LAPSCP MRK PEN BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C8XX2NONCE SUP Custom 27203010 PORT HND ACCES GLPRT ALEXIS O RTRCTR LAPSCOP BOTH IP/OP "$1,264.65 " $935.84 $0.00 "$1,011.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.33 "$1,001.60" "$1,011.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C8XXX2N SUP Custom 27203010 C8XXX2N - GELPORT BOTH IP/OP "$1,264.65 " $935.84 $0.00 "$1,011.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.33 "$1,001.60" "$1,011.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C-99999-13 SUP Custom 27203010 CAP TUBE BLK PHNL SCR ON RBR LINR DISP BOTH IP/OP $0.25 $0.19 $0.00 $0.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.13 $0.20 $0.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CA0304 SUP Custom 27803010 CA0304 - GRAFT SFT TISSUE AVIVE HUMAN UMBILICAL CORD MEMBRANE 3CMX4CM BOTH IP/OP "$6,000.00 " "$4,440.00" $0.00 "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,250.40" $0.00 $0.00 $0.00 $0.00 "$3,000.00" "$4,752.00" "$4,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CA2011 SUP HCPCS C1894 DEVICE BIOP 11CM 20GA ACHV SFT TIS COAX AUTO INTROD THNWL BOTH IP/OP $149.10 $110.33 $0.00 $119.28 $80.96 $80.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.55 $118.09 $119.28 $0.00 $0.00 $23.33 $0.00 $0.00 $23.74 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4120 SUP HCPCS C1713 CA-4120 - SCREW BN 4MM 12MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4140 SUP HCPCS C1713 CA-4140 - SCREW BN 4MM 14MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4160 SUP HCPCS C1713 CA-4160 - SCREW BN 4MM 16MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4180 SUP HCPCS C1713 CA-4180 - SCREW BN 4MM 18MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4200 SUP HCPCS C1713 CA-4200 - SCREW BN 4MM 20MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4220 SUP HCPCS C1713 CA-4220 - SCREW BN 4MM 22MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4225 SUP HCPCS C1713 CA-4225 - SCREW BONE 4MM 22.5MM TI CANC NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4240 SUP HCPCS C1713 CA-4240 - SCREW BN 4MM 24MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4250 SUP HCPCS C1713 CA-4250 - SCREW BONE 4MM 25MM TI CANC NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4260 SUP HCPCS C1713 CA-4260 - SCREW BN 4MM 26MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4275 SUP HCPCS C1713 CA-4275 - SCREW BONE 4MM 27.5MM CANC NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4280 SUP HCPCS C1713 CA-4280 - SCREW BN 4MM 28MM CNN BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4300 SUP HCPCS C1713 CA-4300 - SCREW BN 4MM 30MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4340 SUP HCPCS C1713 CA-4340 - SCREW BONE 4MM 34MM TI CANC NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4350 SUP HCPCS C1713 CA-4350 - SCREW BONE 4MM 35MM TI CANC NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4400 SUP HCPCS C1713 CA-4400 - SCREW BONE 4MM 40MM TI CANC NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4450 SUP HCPCS C1713 CA-4450 - SCREW BONE 4MM 45MM TI CANC NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4500 SUP HCPCS C1713 CA-4500 - SCREW BONE 4MM 50MM TI CANC NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4550 SUP HCPCS C1713 CA-4550 - SCREW BN 4MM 55MM CNN BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CA-4600 SUP HCPCS C1713 CA-4600 - SCREW BN 4MM 60MM NS HEX TI CANC BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CAB3.8-12 SUP HCPCS C1713 CAB3.8-12 - SCREW BONE 3.8MM 12MM CANCELLOUS BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 CAB3.8-16 SUP HCPCS C1713 CAB3.8-16 - SCREW BONE 3.8MM 16MM CANCELLOUS BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 CAB3.8-20 SUP HCPCS C1713 CAB3.8-20 - SCREW BONE 3.8MM 20MM CANCELLOUS ANKLE FIX SYSTEM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 CAB3.8-24 SUP HCPCS C1713 CAB3.8-24 - SCREW BN 3.8MM 24MM CANC ANKL FX SYS BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 CAB3.8-26 SUP HCPCS C1713 CAB3.8-26 - SCREW BONE 3.8MM 26MM CANCELLOUS ANKLE FIX SYSTEM BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB25 SUP HCPCS C1713 CA-PHB25 - SCREW BONE 4.5MM 25MM TI ORTH LCK BTRS NONSTRL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB275 SUP HCPCS C1713 CA-PHB275 - SCREW BONE 27.5MM CANC PROX HUM BTRS BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB30 SUP HCPCS C1713 CA-PHB30 - SCREW BONE 4.5MM 30MM TI ORTH LCK BTRS NONSTRL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB325 SUP HCPCS C1713 CA-PHB325 - SCREW BONE 4.5MM 32.5MM TI ORTH LCK BTRS NONSTRL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB35 SUP HCPCS C1713 CA-PHB35 - SCREW BONE 4.5MM 35MM TI ORTH LCK BTRS NONSTRL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB375 SUP HCPCS C1713 CA-PHB375 - SCREW BONE 4.5MM 37.5MM TI CANC LCK BTRS NONSTRL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB40 SUP HCPCS C1713 CA-PHB40 - SCREW BN 4.5MM 40MM NS CORT BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB45 SUP HCPCS C1713 CA-PHB45 - SCREW BN 4.5MM 45MM LCK BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB50 SUP HCPCS C1713 CA-PHB50 - SCREW BONE 4.5MM 50MM TI PROX HUM BTRS NONSTRL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CA-PHB55 SUP HCPCS C1713 CA-PHB55 - SCREW BONE 4.5MM 55MM TI PROX HUM PLT BTRS NONSTRL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $180.00 $180.00 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 CAR500 SUP Custom 27203010 CARTRIDGE HMDIAL DISP CAR-500 BOTH IP/OP "$3,225.00 " "$2,386.50" $0.00 "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CAT00241 SUP Custom 27203010 CAT00241 - KIT ARTHRO 17GA HIP NTNL PRTL ENTRY 2 SPNL NDL SYR BOTH IP/OP $822.50 $608.65 $0.00 $658.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.46 $610.46 $0.00 $0.00 $171.41 $0.00 $0.00 $0.00 $0.00 $411.25 $651.42 $658.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB09BA10 SUP Custom 27203010 CB09BA10 - CURVEDBUR CB09BA10 09CMX1MM BALL BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB09BA10D SUP Custom 27203010 CB09BA10D - CURVEDBUR CB09BA10D 09CMX1MM BALL DIAMND BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB09BA20 SUP Custom 27203010 CB09BA20 - CURVEDBUR CB09BA20 09CMX2MM BALL BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB09BA20D SUP Custom 27203010 CB09BA20D - CURVEDBUR CB09BA20D 09CMX2MM BALL DIAMND BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB09BA30 SUP Custom 27203010 CB09BA30 - CURVEDBUR CB09BA30 09CMX3MM BALL BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB09BA30D SUP Custom 27203010 CB09BA30D - CURVEDBUR CB09BA30D 09CMX1MM BALL DIAMND BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB09BA40 SUP Custom 27203010 CB09BA40 - CURVEDBUR CB09BA40 09CMX4MM BALL BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB09BA40D SUP Custom 27203010 CB09BA40D - CURVEDBUR CB09BA40D 09CMX4MM BALL DIAMND BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB11BA10 SUP Custom 27203010 CB11BA10 - CURVEDBUR CB11BA10 11CMX1MM BALL BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB11BA10D SUP Custom 27203010 CB11BA10D - CURVEDBUR CB11BA10D 11CMX1MM BALL DIAMND BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB11BA20 SUP Custom 27203010 CB11BA20 - CURVEDBUR CB11BA20 11CMX2MM BALL BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB11BA20D SUP Custom 27203010 CB11BA20D - CURVEDBUR CB11BA20D 11CMX2MM BALL DIAMND BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB11BA30 SUP Custom 27203010 CB11BA30 - CURVEDBUR CB11BA30 11CMX3MM BALL BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB11BA30D SUP Custom 27203010 CB11BA30D - CURVEDBUR CB11BA30D 11CMX1MM BALL DIAMND BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB11BA40 SUP Custom 27203010 CB11BA40 - CURVEDBUR CB11BA40 11CMX4MM BALL BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CB11BA40D SUP Custom 27203010 CB11BA40D - CURVEDBUR CB11BA40D 11CMX4MM BALL DIAMND BOTH IP/OP $711.00 $526.14 $0.00 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.70 $527.70 $0.00 $0.00 $148.17 $0.00 $0.00 $0.00 $0.00 $355.50 $563.11 $568.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CBO33010 SUP HCPCS C1726 CBO33010 - CATHETER BLNDIL 3MM 10MM ANGPLSTY BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 CC-2300 SUP Custom 27203010 CC-2300 - CONNECTOR DIALYSIS TITANIUM 2 PART FLEX-NECK CATHETER STERIL BOTH IP/OP $377.50 $279.35 $0.00 $302.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.18 $280.18 $0.00 $0.00 $78.67 $0.00 $0.00 $0.00 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C-CAE-14.0-100-DLT-EF SUP HCPCS C1729 CATHETER ARWYEX 14FR 100CM 2 LUM ENDOTRAC TUBE XFRM RPFT BOTH IP/OP $114.05 $84.40 $0.00 $91.24 $61.93 $61.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.03 $90.33 $91.24 $0.00 $0.00 $17.85 $0.00 $0.00 $18.16 $0.00 $0.00 $0.00 $0.00 $0.00 CCH1910 SUP Custom 27203010 COAXIAL INTRODUCER NEEDLE 19GA 10CM BOTH IP/OP $33.75 $24.98 $0.00 $27.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.88 $26.73 $27.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CD1231-40 SUP HCPCS C1722 CD1231-40 - DEFIBRILLATOR CARDIAC THK14MM 40J 40X73MM 1 CHAMBER IS-1 BOTH IP/OP "$32,250.00 " "$23,865.00" $0.00 "$25,800.00" "$14,512.50" "$14,512.50" $0.00 $0.00 $0.00 "$6,721.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,720.90" $0.00 "$15,899.25" "$15,899.25" $0.00 "$16,125.00" "$25,542.00" "$25,800.00" $0.00 $0.00 "$5,047.13" $0.00 $0.00 "$5,134.20" $0.00 $0.00 $0.00 $0.00 $0.00 CD1231-40Q SUP HCPCS C1722 CD1231-40Q - DEFIBRILLATOR CARDIAC THK14MM 40J 40X71MM 1 CHAMBER DF-4 RF BOTH IP/OP "$32,250.00 " "$23,865.00" $0.00 "$25,800.00" "$14,512.50" "$14,512.50" $0.00 $0.00 $0.00 "$6,721.71" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,720.90" $0.00 "$15,899.25" "$15,899.25" $0.00 "$16,125.00" "$25,542.00" "$25,800.00" $0.00 $0.00 "$5,047.13" $0.00 $0.00 "$5,134.20" $0.00 $0.00 $0.00 $0.00 $0.00 CD2231-40 SUP HCPCS C1721 CD2231-40 - DEFIBRILLATOR CARDIAC THK14MM 40J 40X74MM 2 CHAMBER 2DF-1 BOTH IP/OP "$33,075.00 " "$24,475.50" $0.00 "$26,460.00" "$14,883.75" "$14,883.75" $0.00 $0.00 $0.00 "$6,893.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,892.83" $0.00 "$16,305.98" "$16,305.98" $0.00 "$16,537.50" "$26,195.40" "$26,460.00" $0.00 $0.00 "$5,176.24" $0.00 $0.00 "$5,265.54" $0.00 $0.00 $0.00 $0.00 $0.00 CD2231-40Q SUP HCPCS C1721 CD2231-40Q - DEFIBRILLATOR CARDIAC THK14MM 40J 40X71MM 2 CHAMBER 2DF-4 BOTH IP/OP "$33,075.00 " "$24,475.50" $0.00 "$26,460.00" "$14,883.75" "$14,883.75" $0.00 $0.00 $0.00 "$6,893.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,892.83" $0.00 "$16,305.98" "$16,305.98" $0.00 "$16,537.50" "$26,195.40" "$26,460.00" $0.00 $0.00 "$5,176.24" $0.00 $0.00 "$5,265.54" $0.00 $0.00 $0.00 $0.00 $0.00 CD2257-40 SUP HCPCS C1721 CD2257-40 - DEFIBRILLATOR CARDIAC THK14MM 40J 40X74MM 2 CHAMBER 2DF-1 BOTH IP/OP "$33,075.00 " "$24,475.50" $0.00 "$26,460.00" "$14,883.75" "$14,883.75" $0.00 $0.00 $0.00 "$6,893.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,892.83" $0.00 "$16,305.98" "$16,305.98" $0.00 "$16,537.50" "$26,195.40" "$26,460.00" $0.00 $0.00 "$5,176.24" $0.00 $0.00 "$5,265.54" $0.00 $0.00 $0.00 $0.00 $0.00 CD2257-40Q SUP HCPCS C1721 CD2257-40Q - DEFIBRILLATOR CRD THK14MM 40J 40X71MM 35CC STRL LF FORTIFY BOTH IP/OP "$33,075.00 " "$24,475.50" $0.00 "$26,460.00" "$14,883.75" "$14,883.75" $0.00 $0.00 $0.00 "$6,893.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,892.83" $0.00 "$16,305.98" "$16,305.98" $0.00 "$16,537.50" "$26,195.40" "$26,460.00" $0.00 $0.00 "$5,176.24" $0.00 $0.00 "$5,265.54" $0.00 $0.00 $0.00 $0.00 $0.00 CD2311-36 SUP HCPCS C1721 CD2311-36 - DEFIBRILLATOR CARDIAC THK12MM 36J 51X69MM 1 CHAMBER 1IS-1 1 BOTH IP/OP "$33,075.00 " "$24,475.50" $0.00 "$26,460.00" "$14,883.75" "$14,883.75" $0.00 $0.00 $0.00 "$6,893.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,892.83" $0.00 "$16,305.98" "$16,305.98" $0.00 "$16,537.50" "$26,195.40" "$26,460.00" $0.00 $0.00 "$5,176.24" $0.00 $0.00 "$5,265.54" $0.00 $0.00 $0.00 $0.00 $0.00 CD2311-36Q SUP HCPCS C1721 CD2311-36Q - DEFIBRILLATOR CRD THK12MM 36J 51X70MM 31ML ELLIPSE 2 CHMBR 1 BOTH IP/OP "$33,075.00 " "$24,475.50" $0.00 "$26,460.00" "$14,883.75" "$14,883.75" $0.00 $0.00 $0.00 "$6,893.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,892.83" $0.00 "$16,305.98" "$16,305.98" $0.00 "$16,537.50" "$26,195.40" "$26,460.00" $0.00 $0.00 "$5,176.24" $0.00 $0.00 "$5,265.54" $0.00 $0.00 $0.00 $0.00 $0.00 CD3231-40 SUP HCPCS C1721 CD3231-40 - DEFIBRILLATOR CRD THK14MM 2.5V 40X79MM 36ML UNIFY CRT-D QHR BOTH IP/OP "$45,500.00 " "$33,670.00" $0.00 "$36,400.00" "$20,475.00" "$20,475.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,482.20" $0.00 "$22,431.50" "$22,431.50" $0.00 "$22,750.00" "$36,036.00" "$36,400.00" $0.00 $0.00 "$7,120.75" $0.00 $0.00 "$7,243.60" $0.00 $0.00 $0.00 $0.00 $0.00 CD3231-40Q SUP HCPCS C1721 CD3231-40Q - DEFIBRILLATOR CARDIAC THK14MM 2.5V 500OHM 60 PPM 40X73MM 2 BOTH IP/OP "$39,825.00 " "$29,470.50" $0.00 "$31,860.00" "$17,921.25" "$17,921.25" $0.00 $0.00 $0.00 "$8,300.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,299.53" $0.00 "$19,633.73" "$19,633.73" $0.00 "$19,912.50" "$31,541.40" "$31,860.00" $0.00 $0.00 "$6,232.61" $0.00 $0.00 "$6,340.14" $0.00 $0.00 $0.00 $0.00 $0.00 CD3257-40 SUP HCPCS C1882 CD3257-40 - DEFIBRILLATOR CRD THK14MM 40J 40X79MM 36CC UNIFY ASR CRT-D 2 BOTH IP/OP "$39,825.00 " "$29,470.50" $0.00 "$31,860.00" "$17,921.25" "$17,921.25" $0.00 $0.00 $0.00 "$8,300.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,299.53" $0.00 "$19,633.73" "$19,633.73" $0.00 "$19,912.50" "$31,541.40" "$31,860.00" $0.00 $0.00 "$6,232.61" $0.00 $0.00 "$6,340.14" $0.00 $0.00 $0.00 $0.00 $0.00 CD3257-40Q SUP HCPCS C1882 CD3257-40Q - DEFIBRILLATOR CRD THK14MM 40J 40X73MM 36CC UNIFY ASR BOTH IP/OP "$39,825.00 " "$29,470.50" $0.00 "$31,860.00" "$17,921.25" "$17,921.25" $0.00 $0.00 $0.00 "$8,300.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,299.53" $0.00 "$19,633.73" "$19,633.73" $0.00 "$19,912.50" "$31,541.40" "$31,860.00" $0.00 $0.00 "$6,232.61" $0.00 $0.00 "$6,340.14" $0.00 $0.00 $0.00 $0.00 $0.00 CD3265-40 SUP HCPCS C1882 CD3265-40 - DEFIBRILLATOR CARDIAC THK14MM 40J 41X83MM 2 CHAMBER 1IS-1 1 BOTH IP/OP "$42,750.00 " "$31,635.00" $0.00 "$34,200.00" "$19,237.50" "$19,237.50" $0.00 $0.00 $0.00 "$8,910.17" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,909.10" $0.00 "$21,075.75" "$21,075.75" $0.00 "$21,375.00" "$33,858.00" "$34,200.00" $0.00 $0.00 "$6,690.38" $0.00 $0.00 "$6,805.80" $0.00 $0.00 $0.00 $0.00 $0.00 CD3265-40Q SUP HCPCS C1882 CD3265-40Q - DEFIBRILLATOR CRD THK14MM 40J 41X76MM 38CC QD ASR BOTH IP/OP "$42,750.00 " "$31,635.00" $0.00 "$34,200.00" "$19,237.50" "$19,237.50" $0.00 $0.00 $0.00 "$8,910.17" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,909.10" $0.00 "$21,075.75" "$21,075.75" $0.00 "$21,375.00" "$33,858.00" "$34,200.00" $0.00 $0.00 "$6,690.38" $0.00 $0.00 "$6,805.80" $0.00 $0.00 $0.00 $0.00 $0.00 CDSLM57 SUP Custom 27803010 CDSLM57 - PATCH DURAL 7X5IN LATEX FREE DURAMATRIX-ONLAY BOTH IP/OP "$4,337.03 " "$3,209.40" $0.00 "$4,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,218.94" "$3,218.94" $0.00 $0.00 $903.84 $0.00 $0.00 $0.00 $0.00 "$3,032.50" "$4,803.48" "$4,852.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CDSM33 SUP Custom 27803010 CDSM33 - PATCH DURA 3X3IN DRMTRX IMPL FLXB STRNG CLGN MTRX BOTH IP/OP "$1,731.00 " "$1,280.94" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.75" "$1,284.75" $0.00 $0.00 $360.74 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CF7-3-60 SUP HCPCS C1888 CF7-3-60 - CATHETER INTERVENTIONAL .025IN 7FR 60CM 3CM RADIOFREQUENCY BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 $0.00 $0.00 $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CFF03 SUP Custom 27203010 CFF03 - TROCAR LAPSCP 5MM 100MM LF KII FIOS ADV FX SLV RPD INSFL 1ST BOTH IP/OP $225.00 $166.50 $0.00 "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $675.00 "$1,069.20" "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CFF71 SUP Custom 27203010 CFF71 - TROCAR LAPSCP 12MM 150MM LF KII FIOS 1ST ENTRY ADV FX SLV BOTH IP/OP $250.00 $185.00 $0.00 $185.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CG409 SUP HCPCS C1725 CG409 - CATHETER ANGIO CBR 2 CRV 4FR .041IN 65CM 15CM GLDCATH GLD BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG415 SUP HCPCS C1725 CG415 - CATHETER ANGIOGRAPHIC ANGLE 4FR .041IN 65CM 15CM 2 BRAID BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG416 SUP HCPCS C1887 CG416 - CATHETER ANGIOGRAPHIC ANGLE 4FR .041IN 100CM 15CM 2 BRAID BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG502 SUP HCPCS C1725 CG502 - CATHETER ANGIO CBR 2 CRV 5FR .047IN 65CM 25CM GLDCATH GLD BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG506 SUP HCPCS C1725 CG506 - CATHETER ANGIO STRG TPR 5FR .047IN 100CM GLDCATH GLD TCH BRD BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG507 SUP HCPCS C1725 CG507 - CATHETER ANGIOGRAPHIC ANGLE 5FR .047IN 65CM 25CM 1 BRAID BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG508 SUP HCPCS C1725 CG508 - CATHETER ANGIOGRAPHIC ANGLE 5FR .047IN 100CM 25CM 1 BRAID BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG511 SUP HCPCS C1725 CG511 - CATHETER ANGIOGRAPHIC SIMMONS 2 CURVE 5FR .047IN 100CM 1 BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG513 SUP HCPCS C1725 CG513 - CATHETER ANGIO HDHNTR 1 CRV 5FR .047IN 100CM 25CM GLDCATH BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CG514 SUP HCPCS C1725 CG514 - CATHETER ANGIO BNTSN 1 CRV 5FR .047IN 100CM 25CM GLDCATH GLD BOTH IP/OP $132.95 $98.38 $0.00 $98.68 $65.91 $65.91 $0.00 $0.00 $0.00 $27.71 $98.68 $98.68 $0.00 $0.00 $27.71 $0.00 $78.64 $78.64 $0.00 $60.69 $96.13 $97.10 $0.00 $0.00 $19.00 $0.00 $0.00 $19.32 $0.00 $0.00 $0.00 $0.00 $0.00 CL-07735 SUP HCPCS C1894 INTRODUCER SHTH 7FR 8FR 13.75IN INTGR HMSTS VLV SDPRT BOTH IP/OP $149.00 $110.26 $0.00 $119.20 $80.91 $80.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.50 $118.01 $119.20 $0.00 $0.00 $23.32 $0.00 $0.00 $23.72 $0.00 $0.00 $0.00 $0.00 $0.00 CL-07765 SUP HCPCS C1894 INTRODUCER SHTH 7FR 65CM INTGR HMSTS VLV SDPRT TISS DILAT 3W BOTH IP/OP $233.45 $172.75 $0.00 $186.76 $126.76 $126.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.73 $184.89 $186.76 $0.00 $0.00 $36.53 $0.00 $0.00 $37.17 $0.00 $0.00 $0.00 $0.00 $0.00 CM105C SUP Custom 25003010 ANTIBODY CK 5 CK 6 CLONE CK5/6.007 MS IGG1 1ML LAB BOTH IP/OP "$1,257.50 " $930.55 $0.00 "$1,006.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $628.75 $995.94 "$1,006.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CM1520 SUP HCPCS Q4116 CM1520 - MATRIX TISS THK.4-1.6MM MED CNTR 19.3X9.6CM ALDRM SLCT ALGRF BOTH IP/OP "$9,007.50 " "$6,665.55" $0.00 "$11,178.00" "$6,287.63" "$6,287.63" $0.00 $0.00 $0.00 "$1,877.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,877.16" $0.00 "$4,440.70" "$4,440.70" $0.00 "$6,986.25" "$11,066.22" "$11,178.00" $0.00 $0.00 "$2,186.70" $0.00 $0.00 "$2,224.42" $0.00 $0.00 $0.00 $0.00 $0.00 CM630147S SUP HCPCS C1713 CM630147S - NAIL 11MM 32CM HIP RIGHT GAMMA3 IM 130D LNG STRL BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM640047S SUP HCPCS C1713 CM640047S - NAIL 11MM 32CM LEFT HIP GAMA IM 130D LNG STRL BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM640048S SUP HCPCS C1713 CM640048S - NAIL 11MM 28CM LEFT HIP GAMA IM 130D LNG BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM640060S SUP HCPCS C1713 CM640060S - NAIL 11MM 300MM HIP LEFT GAMMA3 IM 135D LNG BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM640106S SUP HCPCS C1713 CM640106S - NAIL 11MM 32CM LEFT ORTH GAMA IM 135D LNG STRL BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM640113S SUP HCPCS C1713 CM640113S - NAIL 11MM 30CM HIP LEFT FEM GAMMA3 IM 130D LNG TI STRL BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM644004S SUP HCPCS C1713 CM644004S - NAIL 11MM 28CM LEFT HIP GAMA IM 135D LNG BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM645050S SUP HCPCS C1713 CM645050S - NAIL RIGHT GAMA IM LNG BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM645051S SUP HCPCS C1713 CM645051S - NAIL 11MM 280MM HIP RIGHT GAMMA3 IM 135D LNG BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM645059S SUP HCPCS C1713 CM645059S - NAIL 11MM 30CM RIGHT ORTH GAMA IM 135D LNG STRL BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM645092S SUP HCPCS C1713 CM645092S - NAIL RIGHT GAMA IM LNG BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CM645107S SUP HCPCS C1713 CM645107S - NAIL 11MM 30CM HIP RIGHT FEM GAMMA3 IM 130D LNG TI STRL BOTH IP/OP "$1,947.00 " "$1,440.78" $0.00 "$1,557.60" $876.15 $876.15 $0.00 $0.00 $0.00 $405.80 "$1,445.06" "$1,445.06" $0.00 $0.00 $405.75 $0.00 "$1,151.65" "$1,151.65" $0.00 $973.50 "$1,542.02" "$1,557.60" $0.00 $0.00 $304.71 $0.00 $0.00 $309.96 $0.00 $0.00 $0.00 $0.00 $0.00 CMRM6122 SUP Custom 27503206 CMRM6122 - ENVELOPE DFBR MED 2.5X2.75IN AIGISRX PCMKR ANBCTRL KNTD DISP BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,289.57" "$1,289.57" $0.00 $0.00 $362.10 $0.00 $0.00 $0.00 $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CMRM6133 SUP Custom 27503206 CMRM6133 - ENVELOPE DFBR 3.35X3IN AIGISRX RSRB MINOCYCLINE RFMPN PP BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 $0.00 $0.00 $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CMW-18-190 SUP HCPCS C1769 CMW-18-190 - GUIDEWIRE VASCULAR MICRO .018IN 190CM SHAPEABLE TIP APPROACH BOTH IP/OP $167.03 $123.60 $0.00 $133.62 $90.69 $90.69 $0.00 $0.00 $0.00 $34.81 $123.97 $123.97 $0.00 $0.00 $34.81 $0.00 $98.80 $98.80 $0.00 $83.51 $132.29 $133.62 $0.00 $0.00 $26.14 $0.00 $0.00 $26.59 $0.00 $0.00 $0.00 $0.00 $0.00 CO201037 SUP HCPCS C1760 CO201037 - CLIP SURG HEMOSTATIC TEMPORARY NEUROLOGICAL RANEY PLST SCALP BOTH IP/OP $42.14 $31.18 $0.00 $33.72 $18.96 $18.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.07 $33.37 $33.72 $0.00 $0.00 $6.60 $0.00 $0.00 $6.71 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2324 SUP HCPCS C1713 CO-2324 - SCREW BONE 2.3MM 24MM TI CORT NONSTRL BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2326 SUP HCPCS C1713 CO-2326 - SCREW BONE 2.3MM 26MM TI CORT NONSTRL BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 CO261230 SUP Custom 27203010 CO261230 - KIT CRANIOTOMY BOTH IP/OP "$1,025.00 " $758.50 $0.00 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.76 $760.76 $0.00 $0.00 $213.61 $0.00 $0.00 $0.00 $0.00 $512.50 $811.80 $820.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2706 SUP HCPCS C1713 CO-2706 - SCREW BONE 2MM 7MM 6MM CORT DORSAL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2708 SUP HCPCS C1713 CO-2708 - SCREW BN 2.7MM 8MM CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2710 SUP HCPCS C1713 CO-2710 - SCREW BN 2.7MM 10MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2712 SUP HCPCS C1713 CO-2712 - SCREW BN 2.7MM 12MM NS CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2714 SUP HCPCS C1713 CO-2714 - SCREW BN 2.7MM 14MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2716 SUP HCPCS C1713 CO-2716 - SCREW BN 2.7MM 16MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2718 SUP HCPCS C1713 CO-2718 - SCREW BN 2.7MM 18MM NS CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2720 SUP HCPCS C1713 CO-2720 - SCREW BN 2.7MM 20MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2722 SUP HCPCS C1713 CO-2722 - SCREW BN 2.7MM 22MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-27225 SUP HCPCS C1713 CO-27225 - SCREW BONE 2.7MM 22.5MM TI CORT ELB NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2724 SUP HCPCS C1713 CO-2724 - SCREW BN 2.7MM 24MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2725 SUP HCPCS C1713 CO-2725 - SCREW BN 2.7MM 25MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2726 SUP HCPCS C1713 CO-2726 - SCREW BN 2.7MM 26MM CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-27275 SUP HCPCS C1713 CO-27275 - SCREW BONE 2.7MM 27.5MM TI CORT ELB NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2728 SUP HCPCS C1713 CO-2728 - SCREW BN 2.7MM 28MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2730 SUP HCPCS C1713 CO-2730 - SCREW BN 2.7MM 30MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2732 SUP HCPCS C1713 CO-2732 - SCREW BN 2.7MM 32MM CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2734 SUP HCPCS C1713 CO-2734 - SCREW BN 2.7MM 34MM CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2735 SUP HCPCS C1713 CO-2735 - SCREW BONE 2.7MM 35MM TI CORT ELB NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2736 SUP HCPCS C1713 CO-2736 - SCREW BN 2.7MM 36MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-27375 SUP HCPCS C1713 CO-27375 - SCREW BONE 2.7MM 37.5MM CORT NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2738 SUP HCPCS C1713 CO-2738 - SCREW BN 2.7MM 38MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2740 SUP HCPCS C1713 CO-2740 - SCREW BN 2.7MM 40MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2745 SUP HCPCS C1713 CO-2745 - SCREW BONE 2.7MM 45MM TI CORT NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2750 SUP HCPCS C1713 CO-2750 - SCREW BN 2.7MM 50MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2755 SUP HCPCS C1713 CO-2755 - SCREW BN 2.7MM 55MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2760 SUP HCPCS C1713 CO-2760 - SCREW BN 2.7MM 60MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-2765 SUP HCPCS C1713 CO-2765 - SCREW BONE 2.7MM 65MM TI CORT ORTH LCK NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3060 SUP HCPCS C1713 CO-3060 - SCREW BONE 3.5MM 6MM CORT NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3080 SUP HCPCS C1713 CO-3080 - SCREW BN 3.5MM 8MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3100 SUP HCPCS C1713 CO-3100 - SCREW BN 3.5MM 10MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3110 SUP HCPCS C1713 CO-3110 - SCREW BN 3.5MM 10MM NS NLCKG CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3120 SUP HCPCS C1713 CO-3120 - SCREW BN 3.5MM 12MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3140 SUP HCPCS C1713 CO-3140 - SCREW BN 3.5MM 14MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3150-S SUP HCPCS C1713 CO-3150-S - SCREW BONE 3.5MM 15MM ACUMED TI CORT WR HND STRL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3160 SUP HCPCS C1713 CO-3160 - SCREW BN 3.5MM 16MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3175-S SUP HCPCS C1713 CO-3175-S - SCREW BONE 3.5MM 17.5MM ACUMED TI CORT WR HND STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3180 SUP HCPCS C1713 CO-3180 - SCREW BN 3.5MM 18MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3200 SUP HCPCS C1713 CO-3200 - SCREW BN 3.5MM 20MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3200-S SUP HCPCS C1713 CO-3200-S - SCREW BONE 3.5MM 20MM CORT STRL BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3220 SUP HCPCS C1713 CO-3220 - SCREW BN 3.5MM 22MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3225 SUP HCPCS C1713 CO-3225 - SCREW BN 3.5MM 22.5MM CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3240 SUP HCPCS C1713 CO-3240 - SCREW BN 3.5MM 24MM CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3250 SUP HCPCS C1713 CO-3250 - SCREW BONE 3.5MM 25MM TI CORT NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3250-S SUP HCPCS C1713 CO-3250-S - SCREW BONE L25 MM OD3.5 MM CORTICAL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3260 SUP HCPCS C1713 CO-3260 - SCREW BN 3.5MM 26MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3275 SUP HCPCS C1713 CO-3275 - SCREW BONE 3.5MM 27.5MM TI CORT ELB NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3280 SUP HCPCS C1713 CO-3280 - SCREW BN 3.5MM 28MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO3300 SUP HCPCS C1713 CO3300 - SCREW BONE 3.5MM 30MM TI CORT ORTH STRL BOTH IP/OP $135.85 $100.53 $0.00 $108.68 $61.13 $61.13 $0.00 $0.00 $0.00 $28.31 $100.83 $100.83 $0.00 $0.00 $28.31 $0.00 $80.36 $80.36 $0.00 $67.93 $107.59 $108.68 $0.00 $0.00 $21.26 $0.00 $0.00 $21.63 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3300 SUP HCPCS C1713 CO-3300 - SCREW BN 3.5MM 30MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3300-S SUP HCPCS C1713 CO-3300-S - SCREW BONE 3.5MM 30MM ACUMED TI CORT WR HND STRL BOTH IP/OP $165.00 $122.10 $0.00 $132.00 $74.25 $74.25 $0.00 $0.00 $0.00 $34.39 $122.46 $122.46 $0.00 $0.00 $34.39 $0.00 $97.60 $97.60 $0.00 $82.50 $130.68 $132.00 $0.00 $0.00 $25.82 $0.00 $0.00 $26.27 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3320 SUP HCPCS C1713 CO-3320 - SCREW BN 3.5MM 32MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3325 SUP HCPCS C1713 CO-3325 - SCREW BN 3.5MM 32.5MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3340 SUP HCPCS C1713 CO-3340 - SCREW BONE 3.5MM 34MM TI CORT CLVCL SHLDR ANKL FT LCK BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3350 SUP HCPCS C1713 CO-3350 - SCREW BONE 3.5MM 35MM TI CORT ELB NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3360 SUP HCPCS C1713 CO-3360 - SCREW BN 3.5MM 36MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3375 SUP HCPCS C1713 CO-3375 - SCREW BONE 3.5MM 37.5MM TI CORT NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3380 SUP HCPCS C1713 CO-3380 - SCREW BN 3.5MM 38MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3400 SUP HCPCS C1713 CO-3400 - SCREW BN 3.5MM 40MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3450 SUP HCPCS C1713 CO-3450 - SCREW BN 3.5MM 45MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3500 SUP HCPCS C1713 CO-3500 - SCREW BONE 3.5MM 50MM TI CORT FIB NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3550 SUP HCPCS C1713 CO-3550 - SCREW BN 3.5MM 55MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3600 SUP HCPCS C1713 CO-3600 - SCREW BN 3.5MM 60MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-3650 SUP HCPCS C1713 CO-3650 - SCREW BN 3.5MM 65MM NS TI CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO431022 SUP HCPCS C1713 CO431022 - PLATE BONE 150X150MM MESH TITANIUM CRANFCL BOTH IP/OP "$2,950.00 " "$2,183.00" $0.00 "$2,360.00" "$1,327.50" "$1,327.50" $0.00 $0.00 $0.00 $614.85 "$2,189.49" "$2,189.49" $0.00 $0.00 $614.78 $0.00 "$1,454.35" "$1,454.35" $0.00 "$1,475.00" "$2,336.40" "$2,360.00" $0.00 $0.00 $461.68 $0.00 $0.00 $469.64 $0.00 $0.00 $0.00 $0.00 $0.00 CO431050 SUP HCPCS C1713 KIT CRANIOPLASTY 2 BAG POWDER 2 VIAL LIQUID 2 MATRIX BAG BOTH IP/OP "$2,879.26 " "$2,130.65" $0.00 "$2,303.41" "$1,295.67" "$1,295.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,439.63" "$2,280.37" "$2,303.41" $0.00 $0.00 $450.60 $0.00 $0.00 $458.38 $0.00 $0.00 $0.00 $0.00 $0.00 CODA-2-10.0-35-120-32 SUP HCPCS C2628 CODA-2-10.0-35-120-32 - CATH BALDILAT .035IN 10FR OD 32MM 120CM BALLON VASC PROS BOTH IP/OP "$1,042.50 " $771.45 $0.00 $834.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $521.25 $825.66 $834.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CODA-2-10.0-35-120-40 SUP HCPCS C2628 CODA-2-10.0-35-120-40 - CATH BALDILAT .035IN 10FR 40MM 120CM CODA 40ML BOTH IP/OP "$1,042.50 " $771.45 $0.00 $834.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.28 $773.74 $773.74 $0.00 $0.00 $217.26 $0.00 $616.64 $616.64 $0.00 $521.25 $825.66 $834.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2106 SUP HCPCS C1713 CO-F2106 - SCREW BONE 2.1MM 6MM TI CORT WR HND CRCIFRM RECESS NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2108 SUP HCPCS C1713 CO-F2108 - SCREW BN 2.1MM 8MM NLCKG TI BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2110 SUP HCPCS C1713 CO-F2110 - SCREW BN 2.1MM 10MM NLCKG TI BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2112 SUP HCPCS C1713 CO-F2112 - SCREW BN 2.1MM 12MM NLCKG TI BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2114 SUP HCPCS C1713 CO-F2114 - SCREW BONE 2.1MM 14MM TI WR HND CRCIFRM NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2116 SUP HCPCS C1713 CO-F2116 - SCREW BN 2.1MM 16MM NLCKG TI BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2118 SUP HCPCS C1713 CO-F2118 - SCREW BONE 2.1MM 18MM TI CORT LCK NONSTRL MDLR HAND SYS BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2120 SUP HCPCS C1713 CO-F2120 - SCREW BONE 2.1MM 20MM CORT NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2122 SUP HCPCS C1713 CO-F2122 - SCREW BONE 2.1MM 22MM TI ORTH NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2124 SUP HCPCS C1713 CO-F2124 - SCREW BONE 2.1MM 24MM TI CORT CRCIFRM RECESS NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2126 SUP HCPCS C1713 CO-F2126 - SCREW BONE 2.1MM 26MM TI CORT CRCIFRM RECESS NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2128 SUP HCPCS C1713 CO-F2128 - SCREW BONE 2.1MM 28MM TI CORT CRCIFRM RECESS NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2706 SUP HCPCS C1713 CO-F2706 - SCREW BN 2.7MM 6MM NS CRFRM TI CORT MDLR HND SYS BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2708 SUP HCPCS C1713 CO-F2708 - SCREW BN 2.7MM 8MM NS CRFRM TI CORT MDLR HND SYS BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2710 SUP HCPCS C1713 CO-F2710 - SCREW BN 2.7MM 10MM NS CRFRM TI CORT MDLR HND SYS BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2712 SUP HCPCS C1713 CO-F2712 - SCREW BN 2.7MM 12MM NS CRFRM TI CORT MDLR HND SYS BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2714 SUP HCPCS C1713 CO-F2714 - SCREW BN 2.7MM 14MM CRFRM CORT BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2716 SUP HCPCS C1713 CO-F2716 - SCREW BONE 2.7MM 16MM TI ORTH CRCIFRM NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2718 SUP HCPCS C1713 CO-F2718 - SCREW BONE 2.7MM 18MM TI CORT LCK NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2720 SUP HCPCS C1713 CO-F2720 - SCREW BONE 2.7MM 20MM TI CORT LCK NSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2722 SUP HCPCS C1713 CO-F2722 - SCREW BONE 2.7MM 22MM TI CORT LCK NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2724 SUP HCPCS C1713 CO-F2724 - SCREW BONE 2.7MM 24MM TI CORT LCK NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2726 SUP HCPCS C1713 CO-F2726 - SCREW BONE 2.7MM 26MM ACUMED TI RADL ELB CRCIFRM STRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-F2728 SUP HCPCS C1713 CO-F2728 - SCREW BONE 2.7MM 28MM TI CORT CRCIFRM NONSTRL BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $81.00 $81.00 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 CO-FA2736 SUP HCPCS C1713 CO-FA2736 - SCREW BONE 2.7MM 36MM TAP-LOC ACUMED CORT ELB STRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 CO-FA3545 SUP HCPCS C1713 CO-FA3545 - SCREW BONE 3.5MM 45MM TAP-LOC ACUMED ELB STRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 CO-FA3555 SUP HCPCS C1713 CO-FA3555 - SCREW BONE 3.5MM 55MM TAP-LOC ACUMED ELB STRL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2080 SUP HCPCS C1713 COL-2080 - SCREW BN 2.7MM 8MM LCK CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2100 SUP HCPCS C1713 COL-2100 - SCREW BONE 2.7MM 10MM TI CORT ELB LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2120 SUP HCPCS C1713 COL-2120 - SCREW BN 2.7MM 12MM LCK CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2140 SUP HCPCS C1713 COL-2140 - SCREW BN 2.7MM 14MM NS LCK HEX TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2160 SUP HCPCS C1713 COL-2160 - SCREW BN 2.7MM 16MM NS LCK HEX TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2180 SUP HCPCS C1713 COL-2180 - SCREW BN 2.7MM 18MM NS LCK HEX TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2200 SUP HCPCS C1713 COL-2200 - SCREW BN 2.7MM 20MM LCK CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2220 SUP HCPCS C1713 COL-2220 - SCREW BN 2.7MM 22MM NS LCK HEX TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2240 SUP HCPCS C1713 COL-2240 - SCREW BONE 2.7MM 24MM TI CORT ELB LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2250 SUP HCPCS C1713 COL-2250 - SCREW BONE 2.7MM 25MM CORT SCAPULAR LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2260 SUP HCPCS C1713 COL-2260 - SCREW BONE 2.7MM 26MM TI CORT ELB LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2280 SUP HCPCS C1713 COL-2280 - SCREW BONE 2.7MM 28MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2300 SUP HCPCS C1713 COL-2300 - SCREW BONE 2.7MM 30MM CORT LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2320 SUP HCPCS C1713 COL-2320 - SCREW BONE 2.7MM 32MM CORT LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2340 SUP HCPCS C1713 COL-2340 - SCREW BONE 2.7MM 34MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2360 SUP HCPCS C1713 COL-2360 - SCREW BONE 2.7MM 36MM CORT LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2380 SUP HCPCS C1713 COL-2380 - SCREW BONE 2.7MM 38MM TI FULTHD CORT LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2400 SUP HCPCS C1713 COL-2400 - SCREW BONE 2.7MM 40MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2450 SUP HCPCS C1713 COL-2450 - SCREW BONE 2.7MM 45MM CORT SCAPULAR LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2500 SUP HCPCS C1713 COL-2500 - SCREW BONE 2.7MM 50MM CORT SCAPULAR LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2550 SUP HCPCS C1713 COL-2550 - SCREW BONE 2.7MM 55MM CORT SCAPULAR LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2600 SUP HCPCS C1713 COL-2600 - SCREW BN 2.7MM 60MM NS LCK HEX TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2650 SUP HCPCS C1713 COL-2650 - SCREW BONE 2.7MM 65MM CORT SCAPULAR LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2718 SUP HCPCS C1713 COL-2718 - SCREW BONE 2.7MM 18MM CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2720 SUP HCPCS C1713 COL-2720 - SCREW BONE 2.7MM 20MM CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-2722 SUP HCPCS C1713 COL-2722 - SCREW BONE 2.7MM 22MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3060 SUP HCPCS C1713 COL-3060 - SCREW BONE 3.5MM 6MM CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3080 SUP HCPCS C1713 COL-3080 - SCREW BONE 3.5MM 8MM TI DISTAL RADL CORT CLVCL WR HND LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3100 SUP HCPCS C1713 COL-3100 - SCREW BONE 3.5MM 10MM TI DISTAL RADL CORT CLVCL WR HND LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3120 SUP HCPCS C1713 COL-3120 - SCREW BONE 3.5MM 12MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 CO-L3120 SUP HCPCS C1713 CO-L3120 - SCREW BONE 3.5MM 12MM CORT LCK NSTRL BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3140 SUP HCPCS C1713 COL-3140 - SCREW BONE 3.5MM 14MM TI DISTAL RADL CORT CLVCL WR HND LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 CO-L3140 SUP HCPCS C1713 CO-L3140 - SCREW BONE 3.5MM 14MM ACUMED ACLC CORT ORTH LCK STRL BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3160 SUP HCPCS C1713 COL-3160 - SCREW BONE 3.5MM 16MM TI DISTAL RADL CORT CLVCL WR HND LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3180 SUP HCPCS C1713 COL-3180 - SCREW BONE 3.5MM 18MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 CO-L3180 SUP HCPCS C1713 CO-L3180 - SCREW BONE 3.5MM 18MM ACLC ACUMED CORT ORTH LCK STRL BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3200 SUP HCPCS C1713 COL-3200 - SCREW BONE 3.5MM 20MM TI DISTAL RADL CORT CLVCL WR HND LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3220 SUP HCPCS C1713 COL-3220 - SCREW BONE 3.5MM 22MM TI DISTAL RADL CORT CLVCL WR HND LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3225 SUP HCPCS C1713 COL-3225 - SCREW BONE 3.5MM 22.5MM CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3240 SUP HCPCS C1713 COL-3240 - SCREW BONE 3.5MM 24MM ACUMED TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3250 SUP HCPCS C1713 COL-3250 - SCREW BONE 3.5MM 25MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3260 SUP HCPCS C1713 COL-3260 - SCREW BONE 3.5MM 26MM ACUMED TI DISTAL RADL CORT CLVCL WR BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3275 SUP HCPCS C1713 COL-3275 - SCREW BONE 3.5MM 27.5MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3280 SUP HCPCS C1713 COL-3280 - SCREW BONE 3.5MM 28MM TI DISTAL RADL CORT CLVCL WR HND LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3300 SUP HCPCS C1713 COL-3300 - SCREW BN 3.5MM 30MM NS TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3320 SUP HCPCS C1713 COL-3320 - SCREW BN 3.5MM 32MM NS LCK TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3340 SUP HCPCS C1713 COL-3340 - SCREW BONE 3.5MM 34MM TI CORT LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3360 SUP HCPCS C1713 COL-3360 - SCREW BN 3.5MM 36MM NS LCK TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3380 SUP HCPCS C1713 COL-3380 - SCREW BN 3.5MM 38MM LCK CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3400 SUP HCPCS C1713 COL-3400 - SCREW BN 3.5MM 40MM NS LCK TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3450 SUP HCPCS C1713 COL-3450 - SCREW BN 3.5MM 45MM NS LCK TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3500 SUP HCPCS C1713 COL-3500 - SCREW BN 3.5MM 50MM NS LCK TI CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3550 SUP HCPCS C1713 COL-3550 - SCREW BN 3.5MM 55MM LCK CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3600 SUP HCPCS C1713 COL-3600 - SCREW BN 3.5MM 60MM LCK CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COL-3650 SUP HCPCS C1713 COL-3650 - SCREW BN 3.5MM 65MM LCK CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35080-TS SUP HCPCS C1713 COLS-35080-TS - SCREW BN 3.5MM 8MM LCK TI RDS CORT DIST BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35090-TS SUP HCPCS C1713 COLS-35090-TS - SCREW BN 3.5MM 9MM LCK TI RDS CORT DIST BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35100-TS SUP HCPCS C1713 COLS-35100-TS - SCREW BN 3.5MM 10MM NS GEMINUS LCK TI DIST CORT VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35110-TS SUP HCPCS C1713 COLS-35110-TS - SCREW BN 3.5MM 11MM BRNZ NS GEMINUS LCK TI CORT VOLR DIST BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35120-TS SUP HCPCS C1713 COLS-35120-TS - SCREW BN 3.5MM 12MM NS GEMINUS LCK TI DIST CORT VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35130-TS SUP HCPCS C1713 COLS-35130-TS - SCREW BN 3.5MM 13MM NS GEMINUS LCK TI DIST CORT VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35140-TS SUP HCPCS C1713 COLS-35140-TS - SCREW BN 3.5MM 14MM NS GEMINUS LCK TI DIST CORT VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35150-TS SUP HCPCS C1713 COLS-35150-TS - SCREW BN 3.5MM 15MM NS GEMINUS LCK TI DIST CORT VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35160-TS SUP HCPCS C1713 COLS-35160-TS - SCREW BN 3.5MM 16MM NS GEMINUS LCK TI DIST CORT VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 COLS-35180-TS SUP HCPCS C1713 COLS-35180-TS - SCREW BN 3.5MM 18MM NS GEMINUS LCK TI DIST CORT VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2308 SUP HCPCS C1713 CO-N2308 - SCREW BN 2.3MM 8MM NONTOGGLING BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2310 SUP HCPCS C1713 CO-N2310 - SCREW BN 2.3MM 10MM NONTOGGLING CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2312 SUP HCPCS C1713 CO-N2312 - SCREW BN 2.3MM 12MM NLCKG BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2314 SUP HCPCS C1713 CO-N2314 - SCREW BN 2.3MM 14MM SLVR NS NONTOGGLE HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2316 SUP HCPCS C1713 CO-N2316 - SCREW BN 2.3MM 16MM SLVR NS NONTOGGLE HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2318 SUP HCPCS C1713 CO-N2318 - SCREW BN 2.3MM 18MM SLVR NS NONTOGGLE HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2320 SUP HCPCS C1713 CO-N2320 - SCREW BN 2.3MM 20MM SLVR NS NONTOGGLE HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2322 SUP HCPCS C1713 CO-N2322 - SCREW BN 2.3MM 22MM SLVR NS NONTOGGLE HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2324 SUP HCPCS C1713 CO-N2324 - SCREW BONE 2.3MM 24MM ACLC ACUMED TI DISTAL RADL WR HND BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CON-2326 SUP HCPCS C1713 CON-2326 - SCREW BONE 2.3MM 26MM ACLC ACUMED DISTAL RADL WR HND BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2326 SUP HCPCS C1713 CO-N2326 - SCREW BONE 2.3MM 26MM ACLC ACUMED TI THRD DISTAL RADL WR HND BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2328 SUP HCPCS C1713 CO-N2328 - SCREW 2.3MM X 28MM NON-TOGGLING CORTICAL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2330 SUP HCPCS C1713 CO-N2330 - SCREW BONE 2.3MM 30MM ACLC ACUMED TI THRD DISTAL RADL WR HND BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2332 SUP HCPCS C1713 CO-N2332 - SCREW BN 2.3MM 32MM STRL NONTOGGLING CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2334 SUP HCPCS C1713 CO-N2334 - SCREW BONE 2.3MM 34MM ACLC 2 DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2336 SUP HCPCS C1713 CO-N2336 - SCREW BONE 2.3MM 36MM ACLC 2 DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2338 SUP HCPCS C1713 CO-N2338 - SCREW BONE 2.3MM 38MM ACLC 2 DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2340 SUP HCPCS C1713 CO-N2340 - SCREW BONE 2.3MM 40MM ACLC 2 DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2342 SUP HCPCS C1713 CO-N2342 - SCREW BONE 2.3MM 42MM ACLC 2 DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2344 SUP HCPCS C1713 CO-N2344 - SCREW BONE 2.3MM 44MM ACLC 2 DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-N2346 SUP HCPCS C1713 CO-N2346 - SCREW BONE 2.3MM 46MM ACLC 2 DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CONSULTAMMAM SUP HCPCS C2621 CONSULTAMMAM - CONSULTA CRT-D ADVANCED SYSTEM BOTH IP/OP "$60,500.00 " "$44,770.00" $0.00 "$48,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$12,608.20" $0.00 $0.00 $0.00 $0.00 "$30,250.00" "$47,916.00" "$48,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2112 SUP HCPCS C1713 CO-S2112 - SCREW BONE 2.1MM 12MM CORT LP STRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2114 SUP HCPCS C1713 CO-S2114 - SCREW BONE 2.1MM 14MM CORT LP STRL BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2308 SUP Custom 27803010 CO-S2308 - PEG FIX 2.3MM 8MM CORT LCK ACUMED STRL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2310 SUP HCPCS C1713 CO-S2310 - PEG FX 2.3MM 10MM LCK SMTH BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2312 SUP Custom 27203010 CO-S2312 - PEG FIX 2.3MM 12MM CORT LCK STRL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2314 SUP Custom 27803010 CO-S2314 - PEG 2.3MM 14MM CORT LCK TI NONSTRL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2316 SUP Custom 27803010 CO-S2316 - PEG FX 2.3MM 16MM SMTH LCK CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2318 SUP Custom 27803010 CO-S2318 - PEG 2.3MM 18MM DISTAL RADL WR HND LCK SMTH TI NONSTRL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2320 SUP Custom 27803010 CO-S2320 - PEG BONE 20MM 2.3MM CORT SMTH LCK STRL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2322 SUP Custom 27803010 CO-S2322 - PEG BONE 22MM 2.3MM ACLC CORT SMTH LCK BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2324 SUP Custom 27803010 CO-S2324 - PEG 2.3MM 24MM DISTAL RADL WR HND LCK SMTH TI ACUMED STRL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2326 SUP Custom 27803010 CO-S2326 - PEG 2.3MM 26MM WR HND LCK SMTH TI ACUMED STRL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2328 SUP HCPCS C1713 CO-S2328 - PEG FX 2.3MM 28MM SMTH LCK CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-S2714 SUP HCPCS C1713 CO-S2714 - SCREW BONE 2.7MM 14MM CORT LP STRL BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $65.25 $65.25 $0.00 $0.00 $0.00 $30.22 $107.62 $107.62 $0.00 $0.00 $30.22 $0.00 $85.77 $85.77 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $22.69 $0.00 $0.00 $23.08 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2308 SUP HCPCS C1713 CO-T2308 - SCREW BN FT 2.3MM 8MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2310 SUP HCPCS C1713 CO-T2310 - SCREW BN FT 2.3MM 10MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2312 SUP HCPCS C1713 CO-T2312 - SCREW BN FT 2.3MM 12MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 COT-2314 SUP HCPCS C1713 COT-2314 - SCREW BONE 2.3MM 14MM CORT LCK NSTRL BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2314 SUP HCPCS C1713 CO-T2314 - SCREW BN FT 2.3MM 14MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2316 SUP HCPCS C1713 CO-T2316 - SCREW BN FT 2.3MM 16MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2318 SUP HCPCS C1713 CO-T2318 - SCREW BN FT 2.3MM 18MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2320 SUP HCPCS C1713 CO-T2320 - SCREW BN FT 2.3MM 20MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2322 SUP HCPCS C1713 CO-T2322 - SCREW BN FT 2.3MM 22MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2324 SUP HCPCS C1713 CO-T2324 - SCREW BN FT 2.3MM 24MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2326 SUP HCPCS C1713 CO-T2326 - SCREW BN FT 2.3MM 26MM AU NS LCK HEX TI CORT BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2328 SUP HCPCS C1713 CO-T2328 - SCREW BONE 2.3MM 28MM ACUMED TI THRD DISTAL RADL CORT WR HND BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2330 SUP HCPCS C1713 CO-T2330 - SCREW CORTICAL LOCK 2.3MM X 30MM BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2332 SUP HCPCS C1713 CO-T2332 - SCREW BONE 2.3MM 32MM ACLC 2 FULTHD DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2334 SUP HCPCS C1713 CO-T2334 - SCREW BONE 2.3MM 34MM CORT LCK BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2336 SUP HCPCS C1713 CO-T2336 - SCREW BONE 2.3MM 36MM CORT LCK BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2338 SUP HCPCS C1713 CO-T2338 - SCREW BONE 2.3MM 38MM ACLC 2 FULTHD DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2340 SUP HCPCS C1713 CO-T2340 - SCREW BONE 2.3MM 24MM TI CORT ELB LCK NONSTRL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2342 SUP HCPCS C1713 CO-T2342 - SCREW BONE 2.3MM 42MM ACLC 2 FULTHD DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2344 SUP HCPCS C1713 CO-T2344 - SCREW BONE 2.3MM 44MM ACLC 2 FULTHD DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CO-T2346 SUP HCPCS C1713 CO-T2346 - SCREW BONE 2.3MM 46MM ACLC 2 FULTHD DISTAL VOLR CORT RADL BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $99.00 $99.00 $0.00 $0.00 $0.00 $45.85 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $130.13 $130.13 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $34.43 $0.00 $0.00 $35.02 $0.00 $0.00 $0.00 $0.00 $0.00 CP320340 SUP HCPCS C1713 CP320340 - CUSTOM KNEE ARTHRODESIS NAIL 11.5X880MM BOTH IP/OP "$16,225.00 " "$12,006.50" $0.00 "$12,980.00" "$7,301.25" "$7,301.25" $0.00 $0.00 $0.00 "$3,381.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,381.29" $0.00 "$7,998.93" "$7,998.93" $0.00 "$8,112.50" "$12,850.20" "$12,980.00" $0.00 $0.00 "$2,539.21" $0.00 $0.00 "$2,583.02" $0.00 $0.00 $0.00 $0.00 $0.00 CP326963 SUP HCPCS C1713 CP326963 - ASNIS SCREW 8.0 X 160MM BOTH IP/OP "$1,097.25 " $811.97 $0.00 $877.80 $493.76 $493.76 $0.00 $0.00 $0.00 $228.69 $814.38 $814.38 $0.00 $0.00 $228.67 $0.00 $649.02 $649.02 $0.00 $548.63 $869.02 $877.80 $0.00 $0.00 $171.72 $0.00 $0.00 $174.68 $0.00 $0.00 $0.00 $0.00 $0.00 CP326981 SUP HCPCS C1713 CP326981 - ASNIS SCREW 8.0 X 180MM BOTH IP/OP "$1,097.25 " $811.97 $0.00 $877.80 $493.76 $493.76 $0.00 $0.00 $0.00 $228.69 $814.38 $814.38 $0.00 $0.00 $228.67 $0.00 $649.02 $649.02 $0.00 $548.63 $869.02 $877.80 $0.00 $0.00 $171.72 $0.00 $0.00 $174.68 $0.00 $0.00 $0.00 $0.00 $0.00 CP390009 SUP HCPCS C1713 CP390009 - WASHER 26MM BOTH IP/OP $140.25 $103.79 $0.00 $112.20 $63.11 $63.11 $0.00 $0.00 $0.00 $29.23 $104.09 $104.09 $0.00 $0.00 $29.23 $0.00 $82.96 $82.96 $0.00 $70.13 $111.08 $112.20 $0.00 $0.00 $21.95 $0.00 $0.00 $22.33 $0.00 $0.00 $0.00 $0.00 $0.00 CP425737 SUP HCPCS C1713 CP425737 - CUSTOM CLAVICLE PLATE BOTH IP/OP "$4,400.00 " "$3,256.00" $0.00 "$3,520.00" "$1,980.00" "$1,980.00" $0.00 $0.00 $0.00 $917.07 "$3,265.68" "$3,265.68" $0.00 $0.00 $916.96 $0.00 "$2,169.20" "$2,169.20" $0.00 "$2,200.00" "$3,484.80" "$3,520.00" $0.00 $0.00 $688.60 $0.00 $0.00 $700.48 $0.00 $0.00 $0.00 $0.00 $0.00 CP427181 SUP HCPCS C1713 CP427181 - AXSOS CUSTOM-MADE DEVICE_ HUMERUS PLATE 8-HOLES BOTH IP/OP "$4,812.50 " "$3,561.25" $0.00 "$3,850.00" "$2,165.63" "$2,165.63" $0.00 $0.00 $0.00 "$1,003.05" "$3,571.84" "$3,571.84" $0.00 $0.00 "$1,002.93" $0.00 "$2,372.56" "$2,372.56" $0.00 "$2,406.25" "$3,811.50" "$3,850.00" $0.00 $0.00 $753.16 $0.00 $0.00 $766.15 $0.00 $0.00 $0.00 $0.00 $0.00 CP427182 SUP HCPCS C1713 CP427182 - AXSOS CUSTOM-MADE DEVICE - HUMERUS PLATE 6 HOLES BOTH IP/OP "$9,625.00 " "$7,122.50" $0.00 "$7,700.00" "$4,331.25" "$4,331.25" $0.00 $0.00 $0.00 "$2,006.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,005.85" $0.00 "$4,745.13" "$4,745.13" $0.00 "$4,812.50" "$7,623.00" "$7,700.00" $0.00 $0.00 "$1,506.31" $0.00 $0.00 "$1,532.30" $0.00 $0.00 $0.00 $0.00 $0.00 CP461006 SUP Custom 27803010 CP461006 - TRIAL SURG 4CM OSS DPHSL IMPL BOTH IP/OP "$2,500,000.00 " "$1,850,000.00" $0.00 "$2,000,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$521,000.00" $0.00 $0.00 $0.00 $0.00 "$1,250,000.00" "$1,980,000.00" "$2,000,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CP5080-2-112 SUP Custom 27203010 CP5080-2-112 - APEX PIN DIA 2MM_ LENGTH 100MM_ THREAD LENGTH 12MM BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CP5080-2-120 SUP Custom 27203010 CP5080-2-120 - APEX PIN DIA 2MM_ LENGTH 100MM_ THREAD LENGTH 20MM BOTH IP/OP $220.00 $162.80 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.28 $163.28 $0.00 $0.00 $45.85 $0.00 $0.00 $0.00 $0.00 $110.00 $174.24 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CP5080-2-212 SUP Custom 27203010 CP5080-2-212 - CUSTOM-MADE DEVICE APEX DIA 2MM 100 X 12MM BOTH IP/OP $364.38 $269.64 $0.00 $291.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.44 $270.44 $0.00 $0.00 $75.94 $0.00 $0.00 $0.00 $0.00 $182.19 $288.59 $291.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CP5080-2-220 SUP Custom 27203010 CP5080-2-220 - CUSTOM-MADE DEVICE APEX DIA 2MM 100 X 20MM BOTH IP/OP $364.38 $269.64 $0.00 $291.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.44 $270.44 $0.00 $0.00 $75.94 $0.00 $0.00 $0.00 $0.00 $182.19 $288.59 $291.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CP5150-2-864 SUP Custom 27803010 CP5150-2-864 - MONOTUBE TRIAX DIA 20 X 640MM BOTH IP/OP "$3,118.50 " "$2,307.69" $0.00 "$2,494.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,314.55" "$2,314.55" $0.00 $0.00 $649.90 $0.00 $0.00 $0.00 $0.00 "$1,559.25" "$2,469.85" "$2,494.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CP606155 SUP Custom 27803010 CP606155 - ASNIS III DIA 6.5 X 155MM - CUSTOM MADE DEVICE BOTH IP/OP "$1,080.75 " $799.76 $0.00 $864.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $802.13 $802.13 $0.00 $0.00 $225.23 $0.00 $0.00 $0.00 $0.00 $540.38 $855.95 $864.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CP606160 SUP Custom 27803010 CP606160 - ASNIS III DIA 6.5 X 160MM - CUSTOM MADE DEVICE BOTH IP/OP "$1,080.75 " $799.76 $0.00 $864.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $802.13 $802.13 $0.00 $0.00 $225.23 $0.00 $0.00 $0.00 $0.00 $540.38 $855.95 $864.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CP910 SUP HCPCS L8614 CP910 - PROCESSOR SOUND EARHOOK INDICATOR LIGHT RECHARGABLE BATTERY BOTH IP/OP "$23,250.00 " "$17,205.00" $0.00 "$18,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,845.30" $0.00 $0.00 $0.00 $0.00 "$11,625.00" "$18,414.00" "$18,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CPO-6 SUP Custom 27011340 CPO-6 - CATHETER SURG 6FR PNEUMO COLPOTOMY LATEX FREE COLPO-PNEUMO BOTH IP/OP $109.68 $81.16 $0.00 $87.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.40 $81.40 $0.00 $0.00 $22.86 $0.00 $0.00 $0.00 $0.00 $54.84 $86.87 $87.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C-PTISY-100-HC-PERC8 SUP HCPCS C1769 C-PTISY-100-HC-PERC8 - INTROD TUBE 24-28FR CGL BRHN 8 PERC HYDPHI INTROD SHLY DILAT BOTH IP/OP $905.05 $669.74 $0.00 $724.04 $491.44 $491.44 $0.00 $0.00 $0.00 $188.64 $671.73 $671.73 $0.00 $0.00 $188.61 $0.00 $535.34 $535.34 $0.00 $452.53 $716.80 $724.04 $0.00 $0.00 $141.64 $0.00 $0.00 $144.08 $0.00 $0.00 $0.00 $0.00 $0.00 CQ75102 SUP HCPCS C1725 CQ75102 - CATHETER BLNDIL 10MM 75CM 2CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $359.74 $359.74 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 CQ75104 SUP HCPCS C1725 CQ75104 - CATHETER BLNDIL 10MM 75CM 4CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 CQ75122 SUP HCPCS C1725 CQ75122 - CATHETER BLNDIL 12MM 75CM LF 2CM CONQ RPD INFL SHTHLS ENTRY BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 CQ75124 SUP HCPCS C1725 CQ75124 - CATHETER BLNDIL 12MM 75CM 4CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 CQ7552 SUP HCPCS C1725 CQ7552 - CATHETER BLNDIL 5MM 75CM 2CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 CQ7554 SUP HCPCS C1725 CQ7554 - CATHETER BLNDIL 5MM 75CM 4CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 CQ7562 SUP HCPCS C1725 CQ7562 - CATHETER BLNDIL 6MM 75CM 2CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $359.74 $359.74 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 CQ7564 SUP HCPCS C1725 CQ7564 - CATHETER BLNDIL 6MM 75CM 4CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 CQ7572 SUP HCPCS C1725 CQ7572 - CATHETER BLNDIL 7MM 75CM 2CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $359.74 $359.74 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 CQ7574 SUP HCPCS C1725 CQ7574 - CATHETER BLNDIL 7MM 75CM 4CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $662.50 $490.25 $0.00 $530.00 $359.74 $359.74 $0.00 $0.00 $0.00 $138.08 $491.71 $491.71 $0.00 $0.00 $138.07 $0.00 $391.87 $391.87 $0.00 $331.25 $524.70 $530.00 $0.00 $0.00 $103.68 $0.00 $0.00 $105.47 $0.00 $0.00 $0.00 $0.00 $0.00 CQ7582 SUP HCPCS C1725 CQ7582 - CATHETER BLNDIL 8MM 75CM LF 2CM CONQ RPD INFL SHTHLS ENTRY BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 CQ7584 SUP HCPCS C1725 CQ7584 - CATHETER BLNDIL 8MM 75CM 4CM CONQ RADOPQ RPD INFL SHTHLS BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $251.14 $251.14 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.100 SUP HCPCS V2632 CR5BU0.100 - LENS IOL +10 DIOP 13.5MM 7MM PSTCHBR BICNVX 1 PC PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.105 SUP HCPCS V2632 CR5BU0.105 - LENS IOL +10.5 DIOP 13.5MM 7MM PSTCHBR BICNVX 1 PC PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.110 SUP HCPCS V2632 CR5BU0.110 - LENS INTRAOCULAR PMMA 11.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.115 SUP HCPCS V2632 CR5BU0.115 - LENS INTRAOCULAR PMMA 11.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.120 SUP HCPCS V2632 CR5BU0.120 - LENS INTRAOCULAR PMMA 12.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.125 SUP HCPCS V2632 CR5BU0.125 - LENS INTRAOCULAR PMMA 12.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.130 SUP HCPCS V2632 CR5BU0.130 - LENS INTRAOCULAR PMMA 13.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.135 SUP HCPCS V2632 CR5BU0.135 - LENS INTRAOCULAR PMMA 13.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.140 SUP HCPCS V2632 CR5BU0.140 - LENS INTRAOCULAR PMMA 14.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.145 SUP HCPCS V2632 CR5BU0.145 - LENS INTRAOCULAR PMMA 14.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.150 SUP HCPCS V2632 CR5BU0.150 - LENS INTRAOCULAR PMMA 15.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.155 SUP HCPCS V2632 CR5BU0.155 - LENS INTRAOCULAR PMMA 15.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.160 SUP HCPCS V2632 CR5BU0.160 - LENS INTRAOCULAR PMMA 16.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.165 SUP HCPCS V2632 CR5BU0.165 - LENS INTRAOCULAR PMMA 16.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.170 SUP HCPCS V2632 CR5BU0.170 - LENS INTRAOCULAR PMMA 17.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.175 SUP HCPCS V2632 CR5BU0.175 - LENS INTRAOCULAR PMMA 17.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.180 SUP HCPCS V2632 CR5BU0.180 - LENS INTRAOCULAR PMMA 18.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.185 SUP HCPCS V2632 CR5BU0.185 - LENS INTRAOCULAR PMMA 18.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.190 SUP HCPCS V2632 CR5BU0.190 - LENS INTRAOCULAR PMMA 19.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.195 SUP HCPCS V2632 CR5BU0.195 - LENS INTRAOCULAR PMMA 19.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.200 SUP HCPCS V2632 CR5BU0.200 - LENS INTRAOCULAR PMMA 20.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.205 SUP HCPCS V2632 CR5BU0.205 - LENS INTRAOCULAR PMMA 20.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.210 SUP HCPCS V2632 CR5BU0.210 - LENS INTRAOCULAR PMMA 21.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.215 SUP HCPCS V2632 CR5BU0.215 - LENS INTRAOCULAR PMMA 21.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.220 SUP HCPCS V2632 CR5BU0.220 - LENS INTRAOCULAR PMMA 22.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.225 SUP HCPCS V2632 CR5BU0.225 - LENS INTRAOCULAR PMMA 22.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.230 SUP HCPCS V2632 CR5BU0.230 - LENS INTRAOCULAR PMMA 23.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.235 SUP HCPCS V2632 CR5BU0.235 - LENS INTRAOCULAR PMMA 23.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.240 SUP HCPCS V2632 CR5BU0.240 - LENS INTRAOCULAR PMMA 24.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.245 SUP HCPCS V2632 CR5BU0.245 - LENS INTRAOCULAR PMMA 24.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.250 SUP HCPCS V2632 CR5BU0.250 - LENS INTRAOCULAR PMMA 25.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.255 SUP HCPCS V2632 CR5BU0.255 - LENS INTRAOCULAR PMMA 25.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.260 SUP HCPCS V2632 CR5BU0.260 - LENS INTRAOCULAR PMMA 26.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.265 SUP HCPCS V2632 CR5BU0.265 - LENS INTRAOCULAR PMMA 26.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.270 SUP HCPCS V2632 CR5BU0.270 - LENS INTRAOCULAR PMMA 27.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.275 SUP HCPCS V2632 CR5BU0.275 - LENS INTRAOCULAR PMMA 27.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.280 SUP HCPCS V2632 CR5BU0.280 - LENS INTRAOCULAR PMMA 28.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.285 SUP HCPCS V2632 CR5BU0.285 - LENS INTRAOCULAR PMMA 28.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.290 SUP HCPCS V2632 CR5BU0.290 - LENS INTRAOCULAR PMMA 29.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.295 SUP HCPCS V2632 CR5BU0.295 - LENS INTRAOCULAR PMMA 29.5 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR5BU0.300 SUP HCPCS V2632 CR5BU0.300 - LENS INTRAOCULAR PMMA 30.0 DIOPTER L13.5 MM OD7 MM BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.040 SUP HCPCS V2632 CR70BU.040 - LENS IOL 10 D +4 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV ABS BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.045 SUP HCPCS V2632 CR70BU.045 - LENS IOL 10 D +4.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.050 SUP HCPCS V2632 CR70BU.050 - LENS IOL 10 D +5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV ABS BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.055 SUP HCPCS V2632 CR70BU.055 - LENS IOL 10 D +5.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.060 SUP HCPCS V2632 CR70BU.060 - LENS IOL 10 D +6 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV ABS BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.065 SUP HCPCS V2632 CR70BU.065 - LENS IOL 10 D +6.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.070 SUP HCPCS V2632 CR70BU.070 - LENS IOL 10 D +7 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV ABS BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.075 SUP HCPCS V2632 CR70BU.075 - LENS IOL 10 D +7.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.080 SUP HCPCS V2632 CR70BU.080 - LENS IOL 10 D +8 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV ABS BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.085 SUP HCPCS V2632 CR70BU.085 - LENS IOL 10 D +8.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.090 SUP HCPCS V2632 CR70BU.090 - LENS IOL 10 D +9 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV ABS BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.095 SUP HCPCS V2632 CR70BU.095 - LENS IOL 10 D +9.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.100 SUP HCPCS V2632 CR70BU.100 - LENS IOL 10 D +10 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.105 SUP HCPCS V2632 CR70BU.105 - LENS IOL 10 D +10.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.110 SUP HCPCS V2632 CR70BU.110 - LENS IOL 10 D +11 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.115 SUP HCPCS V2632 CR70BU.115 - LENS IOL 10 D +11.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.120 SUP HCPCS V2632 CR70BU.120 - LENS IOL 10 D +12 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.125 SUP HCPCS V2632 CR70BU.125 - LENS IOL 10 D +12.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.130 SUP HCPCS V2632 CR70BU.130 - LENS IOL 10 D +13 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.135 SUP HCPCS V2632 CR70BU.135 - LENS IOL 10 D +13.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.140 SUP HCPCS V2632 CR70BU.140 - LENS IOL 10 D +14 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.145 SUP HCPCS V2632 CR70BU.145 - LENS IOL 10 D +14.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.150 SUP HCPCS V2632 CR70BU.150 - LENS IOL 10 D +15 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.155 SUP HCPCS V2632 CR70BU.155 - LENS IOL 10 D +15.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.160 SUP HCPCS V2632 CR70BU.160 - LENS IOL 10 D +16 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.165 SUP HCPCS V2632 CR70BU.165 - LENS IOL 10 D +16.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.170 SUP HCPCS V2632 CR70BU.170 - LENS IOL 10 D +17 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.175 SUP HCPCS V2632 CR70BU.175 - LENS IOL 10 D +17.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.180 SUP HCPCS V2632 CR70BU.180 - LENS IOL 10 D +18 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.185 SUP HCPCS V2632 CR70BU.185 - LENS IOL 10 D +18.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.190 SUP HCPCS V2632 CR70BU.190 - LENS IOL 10 D +19 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.195 SUP HCPCS V2632 CR70BU.195 - LENS IOL 10 D +19.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.200 SUP HCPCS V2632 CR70BU.200 - LENS IOL 10 D +20 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.205 SUP HCPCS V2632 CR70BU.205 - LENS IOL 10 D +20.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.210 SUP HCPCS V2632 CR70BU.210 - LENS IOL 10 D +21 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.215 SUP HCPCS V2632 CR70BU.215 - LENS IOL 10 D +21.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.220 SUP HCPCS V2632 CR70BU.220 - LENS IOL 10 D +22 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.225 SUP HCPCS V2632 CR70BU.225 - LENS IOL 10 D +22.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.230 SUP HCPCS V2632 CR70BU.230 - LENS IOL 10 D +23 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.235 SUP HCPCS V2632 CR70BU.235 - LENS IOL 10 D +23.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.240 SUP HCPCS V2632 CR70BU.240 - LENS IOL 10 D +24 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.245 SUP HCPCS V2632 CR70BU.245 - LENS IOL 10 D +24.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.250 SUP HCPCS V2632 CR70BU.250 - LENS IOL 10 D +25 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.255 SUP HCPCS V2632 CR70BU.255 - LENS IOL 10 D +25.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.260 SUP HCPCS V2632 CR70BU.260 - LENS IOL 10 D +26 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.265 SUP HCPCS V2632 CR70BU.265 - LENS IOL 10 D +26.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.270 SUP HCPCS V2632 CR70BU.270 - LENS IOL 10 D +27 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.275 SUP HCPCS V2632 CR70BU.275 - LENS IOL 10 D +27.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.280 SUP HCPCS V2632 CR70BU.280 - LENS IOL 10 D +28 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.285 SUP HCPCS V2632 CR70BU.285 - LENS IOL 10 D +28.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.290 SUP HCPCS V2632 CR70BU.290 - LENS IOL 10 D +29 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.295 SUP HCPCS V2632 CR70BU.295 - LENS IOL 10 D +29.5 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CR70BU.300 SUP HCPCS V2632 CR70BU.300 - LENS IOL 10 D +30 DIOP BCNVX 7MM 13.5MM ACRSF 1 PC FLD UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CS-01701 SUP HCPCS C1726 CS-01701 - KIT CHLGM 4FR 10FR 60CM 1.25ML 21.4CM 2 LUM 3W STPCK CATH BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 CS-12 SUP HCPCS C1713 CS-12 - SCREW BONE 3.5MM 12MM DVR TI DISTAL RADL VOLR CORT BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 CS-16 SUP HCPCS C1713 CS-16 - SCREW BONE 3.5MM 16MM DVR TI DISTAL RADL VOLR CORT BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 CS-18 SUP HCPCS C1713 CS-18 - SCREW BONE 3.5MM 18MM DVR TI DISTAL RADL VOLR CORT BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 CS220-ICC SUP Custom 27203010 DRESSING NADH VAC GFM FOAM ABD BOTH IP/OP $801.14 $592.84 $0.00 $640.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $594.61 $594.61 $0.00 $0.00 $166.96 $0.00 $0.00 $0.00 $0.00 $400.57 $634.50 $640.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CS-362 SUP Custom 27203010 CS-362 - CATHETER DIALYSIS FLEX-NECK ADULT SMALL L62 CM W6-14 CM OD5. BOTH IP/OP $222.50 $164.65 $0.00 $178.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.14 $165.14 $0.00 $0.00 $46.37 $0.00 $0.00 $0.00 $0.00 $111.25 $176.22 $178.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CS40G SUP Custom 27203010 CS40G - STAPLER INTERNAL CURVE 40MMX4.7MM 2MM 6 FIRING 4 ROW LINEAR BOTH IP/OP "$1,625.51 " "$1,202.88" $0.00 "$1,300.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,206.45" "$1,206.45" $0.00 $0.00 $338.76 $0.00 $0.00 $0.00 $0.00 $812.75 "$1,287.40" "$1,300.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CSOFT6 SUP Custom 27203010 CSOFT6 - CLIP SURG FGRTY SFJW 6MM SPRG ATRM OCL STRL BOTH IP/OP $33.23 $24.59 $0.00 $258.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.66 $24.66 $0.00 $0.00 $6.92 $0.00 $0.00 $0.00 $0.00 $161.25 $255.42 $258.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CSP243 SUP Custom 27203010 PACK HAEMONETICS BASIC HI BOTH IP/OP $170.00 $125.80 $0.00 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CTI-512N SUP Custom 27203010 CTI-512N - DEVICE CLOSURE 5MM 10/12MM SUTURE PASSER CARTER-THOMASON BOTH IP/OP $278.10 $205.79 $0.00 $222.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.41 $206.41 $0.00 $0.00 $57.96 $0.00 $0.00 $0.00 $0.00 $139.05 $220.26 $222.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C-TP-1507 SUP Custom 27803010 C-TP-1507 - DEVICE CLSR ANG TIGERPAW SYS II 7 CNCT UNQ FSTNR ZERO BLD BOTH IP/OP "$3,375.00 " "$2,497.50" $0.00 "$2,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,504.93" "$2,504.93" $0.00 $0.00 $703.35 $0.00 $0.00 $0.00 $0.00 "$1,687.50" "$2,673.00" "$2,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 C-TP-1509 SUP Custom 27803010 C-TP-1509 - DEVICE CLSR ANG TIGERPAW SYS II 9 CNCT UNQ FSTNR ZERO BLD BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CTP200-FLS SUP Custom 27203010 SYRINGE INJEC 60IN VSTRN CT LP TBG QKFL TUBE FRN LD 200ML BOTH IP/OP $865.00 $640.10 $0.00 $692.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $432.50 $685.08 $692.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CTR11R SUP Custom 27803010 CTR11R - RING TENSION FORTIFEYE PMMA 13 MM 11 MM CAPSULAR RIGHT PRELO BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CUSTOM IMPLANT SUP HCPCS C1763 CUSTOM IMPLANT - TISSUE SYNTH PE POR MEDPOR IMPL CSTM CRANIAL BOTH IP/OP "$12,000.00 " "$8,880.00" $0.00 "$9,600.00" "$5,400.00" "$5,400.00" $0.00 $0.00 $0.00 "$2,501.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,500.80" $0.00 "$5,916.00" "$5,916.00" $0.00 "$6,000.00" "$9,504.00" "$9,600.00" $0.00 $0.00 "$1,878.00" $0.00 $0.00 "$1,910.40" $0.00 $0.00 $0.00 $0.00 $0.00 CX30D SUP Custom 27203010 CX30D - SUTURE NABSB 1 CTX 18IN GRN EBND CR BRD 8 STRN BOTH IP/OP $355.28 $262.91 $0.00 $288.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.69 $263.69 $0.00 $0.00 $74.04 $0.00 $0.00 $0.00 $0.00 $180.30 $285.60 $288.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CX41D SUP Custom 27203010 CX41D - SUTURE NONABSORBABLE 0 MO-7 18IN CONTROL RELEASE BRAID 8 BOTH IP/OP $35.29 $26.11 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.19 $26.19 $0.00 $0.00 $7.35 $0.00 $0.00 $0.00 $0.00 $17.91 $28.37 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 CXI-4.0-35-150-P-NS-0 SUP HCPCS C1887 CXI-4.0-35-150-P-NS-0 - CATH GUID .035IN 4FR 150CM SPRT STR TIP LP RADIOPQ BRAID SS BOTH IP/OP $422.50 $312.65 $0.00 $338.00 $229.42 $229.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.25 $334.62 $338.00 $0.00 $0.00 $66.12 $0.00 $0.00 $67.26 $0.00 $0.00 $0.00 $0.00 $0.00 CXS08300 SUP HCPCS C1874 CXS08300 - STENT CORON 3MM 8MM 137CM .014IN OTW SLF XPD RAPEX RAPTORAIL BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" "$2,925.00" "$2,925.00" $0.00 $0.00 $0.00 "$1,354.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,354.60" $0.00 "$3,204.50" "$3,204.50" $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 $0.00 "$1,017.25" $0.00 $0.00 "$1,034.80" $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.100 SUP HCPCS V2632 CZ70BD.100 - LENS IOL +10 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.105 SUP HCPCS V2632 CZ70BD.105 - LENS IOL +10.5 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.110 SUP HCPCS V2632 CZ70BD.110 - LENS IOL +11 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.115 SUP HCPCS V2632 CZ70BD.115 - LENS IOL +11.5 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.120 SUP HCPCS V2632 CZ70BD.120 - LENS IOL +12 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.125 SUP HCPCS V2632 CZ70BD.125 - LENS IOL +12.5 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.130 SUP HCPCS V2632 CZ70BD.130 - LENS IOL +13 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.135 SUP HCPCS V2632 CZ70BD.135 - LENS IOL +13.5 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.140 SUP HCPCS V2632 CZ70BD.140 - LENS IOL +14 DIOP 12.5MM 7MM PSTCHBR BICNVX EYLT 1 PC PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.145 SUP HCPCS V2632 CZ70BD.145 - LENS IOL +14.5 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.150 SUP HCPCS V2632 CZ70BD.150 - LENS IOL +15 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.155 SUP HCPCS V2632 CZ70BD.155 - LENS IOL +15.5 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.160 SUP HCPCS V2632 CZ70BD.160 - LENS IOL +16 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.165 SUP HCPCS V2632 CZ70BD.165 - LENS IOL +16.5 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.170 SUP HCPCS V2632 CZ70BD.170 - LENS IOL +17 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.175 SUP HCPCS V2632 CZ70BD.175 - LENS IOL +17.5 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.180 SUP HCPCS V2632 CZ70BD.180 - LENS IOL 5 D +18 DIOP 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.185 SUP HCPCS V2632 CZ70BD.185 - LENS IOL +18.5 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.190 SUP HCPCS V2632 CZ70BD.190 - LENS IOL +19 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.195 SUP HCPCS V2632 CZ70BD.195 - LENS IOL +19.5 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.200 SUP HCPCS V2632 CZ70BD.200 - LENS IOL 5 D +20 DIOPTER BICNVX 7MM 12.5MM 1 PIECE UV BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $56.25 $56.25 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.205 SUP HCPCS V2632 CZ70BD.205 - LENS IOL +20.5 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.210 SUP HCPCS V2632 CZ70BD.210 - LENS IOL +21 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.215 SUP HCPCS V2632 CZ70BD.215 - LENS IOL +21.5 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.220 SUP HCPCS V2632 CZ70BD.220 - LENS IOL 5 D +22 DIOP 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.225 SUP HCPCS V2632 CZ70BD.225 - LENS IOL +22.5 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.230 SUP HCPCS V2632 CZ70BD.230 - LEN INTRAOCULAR CZ70BD 23.0D BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.235 SUP HCPCS V2632 CZ70BD.235 - LENS IOL 5 D +23.5 DIOP 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.240 SUP HCPCS V2632 CZ70BD.240 - LENS IOL +24 DIOP 5 D 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.245 SUP HCPCS V2632 CZ70BD.245 - LENS IOL +24.5 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.250 SUP HCPCS V2632 CZ70BD.250 - LENS IOL 5 D +25 DIOP 12.5MM 7MM PSTCHBR 1 PC BICNVX EYLT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.255 SUP HCPCS V2632 CZ70BD.255 - LENS IOL +25.5 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.260 SUP HCPCS V2632 CZ70BD.260 - LENS IOL +26 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.265 SUP HCPCS V2632 CZ70BD.265 - LENS IOL +26.5 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.270 SUP HCPCS V2632 CZ70BD.270 - LENS IOL +27 DIOP 12.5MM 7MM PSTCHBR BICNVX 1 PC EYLT PMMA BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.275 SUP HCPCS V2632 CZ70BD.275 - LENS IOL 5 D +27.5 DIOP MOD C BCNVX 7MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.280 SUP HCPCS V2632 CZ70BD.280 - LENS IOL 5 D +28 DIOP MOD C BCNVX 7MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.285 SUP HCPCS V2632 CZ70BD.285 - LENS IOL 5 D +28.5 DIOP MOD C BCNVX 7MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.290 SUP HCPCS V2632 CZ70BD.290 - LENS IOL 5 D +29 DIOP MOD C BCNVX 7MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.295 SUP HCPCS V2632 CZ70BD.295 - LENS IOL 5 D +29.5 DIOP MOD C BCNVX 7MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 CZ70BD.300 SUP HCPCS V2632 CZ70BD.300 - LENS IOL 5 D +30 DIOP MOD C BCNVX 7MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 D204DRM SUP HCPCS C1721 D204DRM - ICD D204DRM SECURA DR DF4 US BOTH IP/OP "$38,750.00 " "$28,675.00" $0.00 "$31,000.00" "$17,437.50" "$17,437.50" $0.00 $0.00 $0.00 "$8,076.47" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,075.50" $0.00 "$19,103.75" "$19,103.75" $0.00 "$19,375.00" "$30,690.00" "$31,000.00" $0.00 $0.00 "$6,064.38" $0.00 $0.00 "$6,169.00" $0.00 $0.00 $0.00 $0.00 $0.00 D204TRM SUP HCPCS C2621 D204TRM - DEFIBRILLATOR CARDIAC THK15MM 51X66MM 2 CHAMBER 2IS-1 1DF-4 BOTH IP/OP "$69,920.00 " "$51,740.80" $0.00 "$55,936.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$14,571.33" $0.00 $0.00 $0.00 $0.00 "$34,960.00" "$55,376.64" "$55,936.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D204VRM SUP HCPCS C1721 D204VRM - ICD D204VRM SECURA VR DF4 US BOTH IP/OP "$33,750.00 " "$24,975.00" $0.00 "$27,000.00" "$15,187.50" "$15,187.50" $0.00 $0.00 $0.00 "$7,034.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,033.50" $0.00 "$16,638.75" "$16,638.75" $0.00 "$16,875.00" "$26,730.00" "$27,000.00" $0.00 $0.00 "$5,281.88" $0.00 $0.00 "$5,373.00" $0.00 $0.00 $0.00 $0.00 $0.00 D224DRG SUP HCPCS C1721 D224DRG - ICD D224DRG SECURA DR BOTH IP/OP "$38,750.00 " "$28,675.00" $0.00 "$31,000.00" "$17,437.50" "$17,437.50" $0.00 $0.00 $0.00 "$8,076.47" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,075.50" $0.00 "$19,103.75" "$19,103.75" $0.00 "$19,375.00" "$30,690.00" "$31,000.00" $0.00 $0.00 "$6,064.38" $0.00 $0.00 "$6,169.00" $0.00 $0.00 $0.00 $0.00 $0.00 D224TRK SUP HCPCS C1882 D224TRK - DEFIBRILLATOR CARDIAC THK.59IN 2.01X2.72IN IMPLTABLE BOTH IP/OP "$69,920.00 " "$51,740.80" $0.00 "$55,936.00" "$31,464.00" "$31,464.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$14,571.33" $0.00 "$34,470.56" "$34,470.56" $0.00 "$34,960.00" "$55,376.64" "$55,936.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 D25L SUP Custom 27203010 SENSOR ADLT NC OXSNSR 2 36IN OXM PLS ADH STRAP CBL DISP BOTH IP/OP $38.43 $28.44 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.21 $30.44 $30.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D284DRG SUP HCPCS C1721 D284DRG - DEFIBRILLATOR CARD MXMO 2 IMPLTABLE 2 CHMBR DR MODL BOTH IP/OP "$38,750.00 " "$28,675.00" $0.00 "$31,000.00" "$17,437.50" "$17,437.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$19,375.00" "$30,690.00" "$31,000.00" $0.00 $0.00 "$6,064.38" $0.00 $0.00 "$6,169.00" $0.00 $0.00 $0.00 $0.00 $0.00 D284VRC SUP HCPCS C1721 D284VRC - DEFIBRILLATOR CARD MXMO 2 IMPLTABLE 1 CHMBR VR MODL BOTH IP/OP "$32,500.00 " "$24,050.00" $0.00 "$26,000.00" "$14,625.00" "$14,625.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$16,250.00" "$25,740.00" "$26,000.00" $0.00 $0.00 "$5,086.25" $0.00 $0.00 "$5,174.00" $0.00 $0.00 $0.00 $0.00 $0.00 D-2871-600 SUP Custom 27203010 FILTER INCBTR OHMD BOTH IP/OP $27.68 $20.48 $0.00 $22.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.84 $21.92 $22.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D300 SUP Custom 27203010 SYSTEM BLOOD WRM ADM SET NRMTH LVL 1 DISP 1000ML/MIN STRL LF BOTH IP/OP $269.20 $199.21 $0.00 $215.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.60 $213.21 $215.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D334DRG SUP HCPCS C1721 D334DRG - ICD D334DRG PROTECTA DR IS-1/DF-1 US BOTH IP/OP "$38,750.00 " "$28,675.00" $0.00 "$31,000.00" "$17,437.50" "$17,437.50" $0.00 $0.00 $0.00 "$8,076.47" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,075.50" $0.00 "$19,103.75" "$19,103.75" $0.00 "$19,375.00" "$30,690.00" "$31,000.00" $0.00 $0.00 "$6,064.38" $0.00 $0.00 "$6,169.00" $0.00 $0.00 $0.00 $0.00 $0.00 D334DRM SUP HCPCS C1721 D334DRM - ICD D334DRM PROTECTA DR DF4 US BOTH IP/OP "$38,750.00 " "$28,675.00" $0.00 "$31,000.00" "$17,437.50" "$17,437.50" $0.00 $0.00 $0.00 "$8,076.47" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,075.50" $0.00 "$19,103.75" "$19,103.75" $0.00 "$19,375.00" "$30,690.00" "$31,000.00" $0.00 $0.00 "$6,064.38" $0.00 $0.00 "$6,169.00" $0.00 $0.00 $0.00 $0.00 $0.00 D334TRG SUP HCPCS C1721 D334TRG - CRT-D D334TRG PROTECTA IS-1/DF-1 US BOTH IP/OP "$45,500.00 " "$33,670.00" $0.00 "$36,400.00" "$20,475.00" "$20,475.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,482.20" $0.00 "$22,431.50" "$22,431.50" $0.00 "$22,750.00" "$36,036.00" "$36,400.00" $0.00 $0.00 "$7,120.75" $0.00 $0.00 "$7,243.60" $0.00 $0.00 $0.00 $0.00 $0.00 D334TRM SUP HCPCS C1721 D334TRM - CRT-D D334TRM PROTECTA DF4 US BOTH IP/OP "$45,500.00 " "$33,670.00" $0.00 "$36,400.00" "$20,475.00" "$20,475.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,482.20" $0.00 "$22,431.50" "$22,431.50" $0.00 "$22,750.00" "$36,036.00" "$36,400.00" $0.00 $0.00 "$7,120.75" $0.00 $0.00 "$7,243.60" $0.00 $0.00 $0.00 $0.00 $0.00 D4295 SUP Custom 27203010 D4295 - SUTURE PRLN 4-0 TF 36IN MFL CSTM BLUE NABSB BOTH IP/OP $120.03 $88.82 $0.00 $96.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.08 $89.08 $0.00 $0.00 $25.01 $0.00 $0.00 $0.00 $0.00 $60.01 $95.06 $96.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D5961 SUP Custom 27203010 D5961 - SUTURE ABSORBABLE 2 BP-1 27IN BRAID COATED CUSTOM VICRYL BOTH IP/OP $375.79 $278.08 $0.00 $286.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.91 $278.91 $0.00 $0.00 $78.32 $0.00 $0.00 $0.00 $0.00 $178.80 $283.22 $286.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D7933 SUP Custom 27203010 D7933 - SUTURE ABS 4-0 SH 36IN VIOL PDS2 2 ARM MFL BOTH IP/OP $97.96 $72.49 $0.00 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.71 $72.71 $0.00 $0.00 $20.42 $0.00 $0.00 $0.00 $0.00 $48.98 $77.58 $78.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D900VP8HS SUP Custom 27203010 PROBE DPLR 2.9X5.5IN MN DPL 8 MHZ MINI BOTH IP/OP "$1,846.28 " "$1,366.25" $0.00 "$1,370.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,370.31" "$1,370.31" $0.00 $0.00 $384.76 $0.00 $0.00 $0.00 $0.00 $640.41 "$1,014.42" "$1,024.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D9311 SUP Custom 27203010 D9311 - KIT SUTURE 3-0 EBND EXC CSTM D SPCL BOTH IP/OP $179.13 $132.56 $0.00 $132.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.95 $132.95 $0.00 $0.00 $37.33 $0.00 $0.00 $0.00 $0.00 $47.29 $74.91 $75.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 D98100H SUP Custom 27203010 D98100H - PROBE PCNG 135CM 2.4FR CHND TRNLMN 5 PCNG PCPRT CATH BOTH IP/OP $481.83 $356.55 $0.00 $385.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.91 $381.61 $385.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DB2.5 SUP Custom 27203010 BIT DRILL 2.5MM FAST STRL DISP BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DB-2.5 SUP Custom 27203010 DB-2.5 - BIT DRILL 2.5MM STRL DISP BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DCE-110 SUP Custom 27203010 ELECTRODE ESURG 23MM 15MM CLTZ LG CNZTN DISP BOTH IP/OP $52.25 $38.67 $0.00 $41.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DCE-115 SUP Custom 27203010 ELECTRODE ESURG 18X11MM CLTZ MED CNZTN CNTOUR BOTH IP/OP $52.25 $38.67 $0.00 $41.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.13 $41.38 $41.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DFS100210-20 SUP Custom 27803010 DFS100210-20 - COIL EMBL 2MM 10CM DELTAPAQ DELTAWIND 10 MCIOL STRCH RS DTCH BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 $0.00 $0.00 $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DFS100250-20 SUP Custom 27803010 DFS100250-20 - COIL EMBL 2.5MM 10CM DELTAPAQ DELTAWIND 10 MCIOL STRCH RS BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 $0.00 $0.00 $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DFS100310-20 SUP Custom 27803010 DFS100310-20 - MICROCOIL PLATINUM DELTAPAQ 3MMX10CM BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 $0.00 $0.00 $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DFS100406-20 SUP Custom 27803010 DFS100406-20 - COIL EMBL 4MM 6CM DELTAPAQ DELTAWIND 10 MCIOL STRCH RS DTCH BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 $0.00 $0.00 $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DFS100408-20 SUP Custom 27803010 DFS100408-20 - COIL EMBL 4MM 8CM DELTAPAQ DELTAWIND 10 MCIOL STRCH RS DTCH BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 $0.00 $0.00 $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DFS100410-20 SUP Custom 27803010 DFS100410-20 - COIL EMBL 4MM 10CM DELTAPAQ DELTAWIND 10 MCIOL STRCH RS DTCH BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 $0.00 $0.00 $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DFS100510-20 SUP Custom 27803010 DFS100510-20 - COIL EMBL 5MM 10CM DELTAPAQ DELTAWIND 10 MCIOL STRCH RS DTCH BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 $0.00 $0.00 $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DFS100515-20 SUP Custom 27803010 DFS100515-20 - COIL EMBL 5MM 15CM DELTAPAQ DELTAWIND 10 MCIOL STRCH RS DTCH BOTH IP/OP "$2,294.25 " "$1,697.75" $0.00 "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.79" "$1,702.79" $0.00 $0.00 $478.12 $0.00 $0.00 $0.00 $0.00 "$1,147.13" "$1,817.05" "$1,835.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DIN1515X SUP Custom 27203010 NEEDLE IO 3/8-1 7/8IN 15GA BN MRW LNCT PNT ADJ FLNG STY BOTH IP/OP $31.73 $23.48 $0.00 $25.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.86 $25.13 $25.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DJ4008X SUP Custom 27203010 DJ4008X - NEEDLE BIOP STANDARD TAPER 8GA 4IN LIGHTWEIGHT HANDLE DISTAL BOTH IP/OP $55.13 $40.80 $0.00 $44.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.92 $40.92 $0.00 $0.00 $11.49 $0.00 $0.00 $0.00 $0.00 $27.98 $34.71 $44.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DJ4011X SUP Custom 27203010 NEEDLE BIOP 11GA 4IN JMSHD STD HNDL TPR DISTAL TIP BN MRW BOTH IP/OP $51.00 $37.74 $0.00 $43.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.85 $37.85 $0.00 $0.00 $10.63 $0.00 $0.00 $0.00 $0.00 $26.93 $42.65 $43.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DJ6011X SUP Custom 27203010 DJ6011X - NEEDLE BIOP 11GA 6IN TAPER DISTAL SHARP BEVEL TIP ADAPTER BOTH IP/OP $39.36 $29.13 $0.00 $31.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.21 $29.21 $0.00 $0.00 $8.20 $0.00 $0.00 $0.00 $0.00 $19.68 $31.17 $31.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DL900F SUP HCPCS C1880 DL900F - FILTER EMBOLIZATION DELIVERY KIT DENALI NITINOL FEMORAL VENA BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" "$1,687.50" "$1,687.50" $0.00 $0.00 $0.00 $781.59 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 "$1,848.75" "$1,848.75" $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $586.88 $0.00 $0.00 $597.00 $0.00 $0.00 $0.00 $0.00 $0.00 DLP-B11 SUP Custom 27203010 ELECTRODE ESURG TN 11CM LETZ SF-T-GA UTAHLOOP RND LOOP SHAFT BOTH IP/OP $35.63 $26.37 $0.00 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $28.22 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DLS-7083-01S SUP Custom 27203010 DLS-7083-01S - NEEDLE BN CMNT 8GA 10CM STRL DLV BOTH IP/OP $151.18 $111.87 $0.00 $117.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.20 $112.20 $0.00 $0.00 $31.50 $0.00 $0.00 $0.00 $0.00 $73.39 $116.25 $117.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DLS-7083-05S SUP Custom 27203010 DLS-7083-05S - NEEDLE BONE CEMENT 8GA 10CM DELIVERY NORIAN SRS STERILE BOTH IP/OP $114.38 $84.64 $0.00 $91.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.89 $84.89 $0.00 $0.00 $23.84 $0.00 $0.00 $0.00 $0.00 $57.19 $90.59 $91.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DLS-7103-01S SUP Custom 27804086 DLS-7103-01S - SYSTEM BONE CEMENT 10GA 10CM DELIVERY NEEDLE NORIAN SRS BOTH IP/OP $151.18 $111.87 $0.00 $117.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.20 $112.20 $0.00 $0.00 $31.50 $0.00 $0.00 $0.00 $0.00 $73.39 $116.25 $117.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DLS-7103-05S SUP Custom 27203010 DLS-7103-05S - NEEDLE BONE CEMENT 10GA 10CM NORIAN SRS STERILE DISPOSABLE BOTH IP/OP $606.70 $448.96 $0.00 $471.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $450.29 $450.29 $0.00 $0.00 $126.44 $0.00 $0.00 $0.00 $0.00 $294.51 $466.51 $471.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DNX12 SUP HCPCS A4364 DNX12 - ADH SKNCLS 2 OCTYL CYNCRLT DRMBND ADV EZ TO USE APL TOP .7ML BOTH IP/OP $49.98 $36.99 $0.00 $39.98 $27.14 $27.14 $0.00 $0.00 $0.00 $10.42 $37.09 $37.09 $0.00 $0.00 $10.41 $0.00 $29.56 $29.56 $0.00 $24.99 $39.58 $39.98 $0.00 $0.00 $7.82 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $0.00 DPL 100151-20 SUP Custom 27803010 DPL 100151-20 - COIL EMBL 1MM 1.5CM DELTAPLUSH PLTN BOTH IP/OP "$2,544.60 " "$1,883.00" $0.00 "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.60" "$1,888.60" $0.00 $0.00 $530.29 $0.00 $0.00 $0.00 $0.00 "$1,272.30" "$2,015.32" "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DPL 100152-20 SUP Custom 27803010 DPL 100152-20 - COIL EMBL 1.5MM 2CM DELTAPLUSH PLTN BOTH IP/OP "$2,544.60 " "$1,883.00" $0.00 "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.60" "$1,888.60" $0.00 $0.00 $530.29 $0.00 $0.00 $0.00 $0.00 "$1,272.30" "$2,015.32" "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DPL 100153-20 SUP Custom 27803010 DPL 100153-20 - COIL EMBL MIC 1.5MM 3CM DELTAPLUSH BOTH IP/OP "$2,544.60 " "$1,883.00" $0.00 "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.60" "$1,888.60" $0.00 $0.00 $530.29 $0.00 $0.00 $0.00 $0.00 "$1,272.30" "$2,015.32" "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DPL 100202-20 SUP Custom 27803010 DPL 100202-20 - COIL EMBL 2MM 2CM DELTAPLUSH PLTN BOTH IP/OP "$2,544.60 " "$1,883.00" $0.00 "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.60" "$1,888.60" $0.00 $0.00 $530.29 $0.00 $0.00 $0.00 $0.00 "$1,272.30" "$2,015.32" "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DPL 100203-20 SUP Custom 27803010 DPL 100203-20 - COIL EMBL 2MM 3CM DELTAPLUSH PLTN BOTH IP/OP "$2,544.60 " "$1,883.00" $0.00 "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.60" "$1,888.60" $0.00 $0.00 $530.29 $0.00 $0.00 $0.00 $0.00 "$1,272.30" "$2,015.32" "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DPL 100204-20 SUP Custom 27803010 DPL 100204-20 - COIL EMBL 2MM 4CM DELTAPLUSH PLTN BOTH IP/OP "$2,544.60 " "$1,883.00" $0.00 "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.60" "$1,888.60" $0.00 $0.00 $530.29 $0.00 $0.00 $0.00 $0.00 "$1,272.30" "$2,015.32" "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DPL 100206-20 SUP Custom 27803010 DPL 100206-20 - COIL EMBL 2MM 6CM DELTAPLUSH PLTN BOTH IP/OP "$2,544.60 " "$1,883.00" $0.00 "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.60" "$1,888.60" $0.00 $0.00 $530.29 $0.00 $0.00 $0.00 $0.00 "$1,272.30" "$2,015.32" "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DPL10020120 SUP Custom 27803010 DPL10020120 - COIL EMBL 2MM 1CM DELTAPLUSH PLTN BOTH IP/OP "$2,544.60 " "$1,883.00" $0.00 "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,888.60" "$1,888.60" $0.00 $0.00 $530.29 $0.00 $0.00 $0.00 $0.00 "$1,272.30" "$2,015.32" "$2,035.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRB1015 SUP Custom 27203010 DRB1015 - BIT DRILL 10MM BUD NONSTRL BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRB1115 SUP Custom 27203010 DRB1115 - DRILL SURG 11MM IMPL FIX BUD STRL BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL BIT SUP HCPCS C1713 DRILL BIT - DRILL BIT 2.4MM QUICK COUPLING W/65MM STOP BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $208.13 $208.13 $0.00 $0.00 $0.00 $96.40 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $273.57 $273.57 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $72.38 $0.00 $0.00 $73.63 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-1.6CL SUP Custom 27203010 DRILL-1.6CL - BIT DRILL TWISTED 1.6MM BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-1.75L SUP Custom 27203010 DRILL-1.75L - BIT DRL 1.75IN TWST BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.00 SUP Custom 27203010 DRILL-2.00 - DRILL TWIST REGULAR 2MM BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.00CL SUP Custom 27203010 DRILL-2.00CL - BIT DRILL CANN TWIST LONG 3.2MM 2MM BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.00L SUP Custom 27203010 DRILL-2.00L - DRILL TWIST LONG 2MM BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.1/110C SUP Custom 27203010 DRILL-2.1/110C - DRILL SRG 2.1MM 110MM CNN TI BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.1CL SUP Custom 27203010 DRILL-2.1CL - BIT DRILL SMALL HEADLESS SCREWS 2.1MM BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.3 SUP Custom 27203010 DRILL-2.3 - BIT DRL 2.3MM STRL BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.3/080 SUP Custom 27203010 DRILL-2.3/080 - DRILL SRG 2.3MM 80MM NS LF REUSE BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.30 SUP Custom 27203010 DRILL-2.30 - BIT DRILL TWIST 2.3MM BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.30L SUP Custom 27203010 DRILL-2.30L - BIT DRILL LONG TWIST 2.3MM BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-2.4CL SUP Custom 27203010 DRILL-2.4CL - BIT DRILL 2.4MM GS BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRILL-3.20L SUP Custom 27203010 DRILL-3.20L - DRILL TWIST NONCANNULATED 3.2MM BOTH IP/OP $300.00 $222.00 $0.00 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.66 $222.66 $0.00 $0.00 $62.52 $0.00 $0.00 $0.00 $0.00 $150.00 $237.60 $240.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRLL-PLS-20 SUP HCPCS C1713 DRLL-PLS-20 - DRILL SRG 2MM 40MM GEMINUS CNN PA LCK SCR BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 DRLL-SSC-20040 SUP Custom 27203010 DRLL-SSC-20040 - DRILL SURG 2MM 40MM SOLID SIDE CUT GEMINUS NONSTRL BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRLL-SSC-23040 SUP Custom 27203010 "DRLL-SSC-23040 - DRILL, 2.3MM X 40MM" BOTH IP/OP "$2,755.00 " "$2,038.70" $0.00 "$2,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,044.76" "$2,044.76" $0.00 $0.00 $574.14 $0.00 $0.00 $0.00 $0.00 "$1,377.50" "$2,181.96" "$2,204.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRLL-SSC-25040 SUP Custom 27203010 DRLL-SSC-25040 - DRILL SURG 2.5MM 40MM SOLID SIDE CUT GEMINUS NONSTRL BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRM600 SUP Custom 27203010 HEMOCYTOMETER SPERM CNT 2 CHMBR SLD COVERLIP GRID ETCH CLVU BOTH IP/OP $399.20 $295.41 $0.00 $319.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.60 $316.17 $319.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRV22508UX SUP HCPCS C1874 STENT CORON 2.25MM 8MM RAPEX MDRVR DRV22508UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV22512UX SUP HCPCS C1874 STENT CORON 2.25MM 12MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV22514UX SUP HCPCS C1874 STENT CORON 2.25MM 14MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV22518UX SUP HCPCS C1874 STENT CORON 2.25MM 18MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV22524UX SUP HCPCS C1874 STENT CORON 2.25MM 24MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV25008UX SUP HCPCS C1874 STENT CORON 2.5MM 8MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV25012UX SUP HCPCS C1874 STENT CORON 2.25MM 8MM RAPEX MDRVR DRV25012UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV25014UX SUP HCPCS C1874 STENT CORON 2.5MM 14MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV25018UX SUP HCPCS C1874 STENT CORON 2.5MM 18MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV25024UX SUP HCPCS C1874 STENT CORON 2.5MM 24MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV27508UX SUP HCPCS C1874 STENT CORON 2.75MM 8MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV27512UX SUP HCPCS C1874 STENT CORON 2.75MM 12MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV27514UX SUP HCPCS C1874 STENT CORON 2.75MM 14MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV27518UX SUP HCPCS C1874 STENT CORON 2.75MM 18MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV27524UX SUP HCPCS C1874 STENT CORON 2.75MM 24MM RAPEX MDRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV30012UX SUP HCPCS C1874 STENT CORON 3MM 12MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV30015UX SUP HCPCS C1874 STENT CORON 3MM 15MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV30018UX SUP HCPCS C1874 STENT CORON 3MM 18MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV30024UX SUP HCPCS C1874 STENT CORON 3MM 24MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV30030UX SUP HCPCS C1874 STENT CORON 3MM 30MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV35009UX SUP HCPCS C1874 STENT CORON 3.5MM 9MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV35012UX SUP HCPCS C1874 STENT CORON 3.5MM 12MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV35015UX SUP HCPCS C1874 STENT CORON 3.5MM 15MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV35018UX SUP HCPCS C1874 STENT CORON 3.5MM 18MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV35024UX SUP HCPCS C1874 STENT CORON 3.5MM 24MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV35030UX SUP HCPCS C1874 STENT CORON 3.5MM 30MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV40009UX SUP HCPCS C1874 STENT CORON 4MM 9MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV40012UX SUP HCPCS C1874 STENT CORON 4MM 12MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV40015UX SUP HCPCS C1874 STENT CORON 4MM 15MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV40018UX SUP HCPCS C1874 STENT CORON 4MM 18MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV40024UX SUP HCPCS C1874 STENT CORON 4MM 24MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRV40030UX SUP HCPCS C1874 STENT CORON 4MM 30MM RAPEX DRVR BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 DRVR-AOS-PLS SUP Custom 27203010 DRVR-AOS-PLS - DRIVER SRG GEMINUS PA LCK SCR AO CNCT DISP BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $0.00 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRVR-AOS-S20 SUP Custom 27203010 DRVR-AOS-S20 - DRIVER SRG 2MM NS GEMINUS SQ TIP AO CNCT DISP BOTH IP/OP $207.50 $153.55 $0.00 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.01 $154.01 $0.00 $0.00 $43.24 $0.00 $0.00 $0.00 $0.00 $103.75 $164.34 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DRVR-UQC-T10 SUP Custom 27203010 DRVR-UQC-T10 - DRIVER SRG 2MM NS GEMINUS T10 UNV QCK CNCT DISP BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DS100A-1 SUP Custom 27203010 SENSOR ADLT DRSNSR 24IN FNGR OXM CLIP DGT MEM CHP NSTRL BOTH IP/OP $210.63 $155.87 $0.00 $168.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.31 $166.82 $168.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DS2A003 SUP Custom 27203010 DS2A003 - SLITTER CATH UNV CPS ERG DSGN ACPT 4-6FR LD BOTH IP/OP $80.00 $59.20 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $59.38 $0.00 $0.00 $16.67 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DS2C002 SUP HCPCS C1893 DS2C002 - CATHETER GD 115D 9FR 47CM CPS DRCT SL II DRCT-TO-TRGT BRD BOTH IP/OP $450.00 $333.00 $0.00 "$1,000.00" $678.75 $678.75 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $625.00 $990.00 "$1,000.00" $0.00 $0.00 $195.63 $0.00 $0.00 $199.00 $0.00 $0.00 $0.00 $0.00 $0.00 DS2N021/59 SUP HCPCS C1893 DS2N021/59 - CATHETER GD ACUTE CRV 7FR 59CM CPS AIM SL DRCT-TO-TRGT BOTH IP/OP $427.50 $316.35 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 DS2N021/65 SUP HCPCS C1887 DS2N021/65 - CATHETER GD ACUTE CRV 7FR 65CM CPS AIM SL DRCT-TO-TRGT BOTH IP/OP $427.50 $316.35 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 DS2N022/59 SUP HCPCS C1887 DS2N022/59 - CPS AIM SL BOTH IP/OP $427.50 $316.35 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 DS2N022/65 SUP HCPCS C1887 DS2N022/65 - CATHETER GD 90D 7FR 65CM CPS AIM SL DRCT-TO-TRGT SLITTABLE BOTH IP/OP $427.50 $316.35 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 DS2N023/59 SUP HCPCS C1887 DS2N023/59 - CATHETER GD OBTUSE CRV 7FR 59CM CPS AIM SL DRCT-TO-TRGT BOTH IP/OP $427.50 $316.35 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 DS2N023/65 SUP HCPCS C1887 DS2N023/65 - CPS AIM SL BOTH IP/OP $427.50 $316.35 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 DS2N024/65 SUP HCPCS C1887 DS2N024/65 - CATHETER GD CSL CRV 7FR 65CM CPS AIM SL DRCT-TO-TRGT BOTH IP/OP $427.50 $316.35 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 DS2N025/65 SUP HCPCS C1887 DS2N025/65 - CATHETER GD ASII CRV 7FR 65CM CPS AIM SL DRCT-TO-TRGT BOTH IP/OP $427.50 $316.35 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $89.10 $317.29 $317.29 $0.00 $0.00 $89.09 $0.00 $252.87 $252.87 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 DSF1833 SUP HCPCS C1894 DSF1833 - SHEATH INTRO 18FR 6.7MM 6MM 33CM GORE DRYSEAL FLX HDRPH BOTH IP/OP "$1,657.50 " "$1,226.55" $0.00 "$1,230.20" $819.93 $819.93 $0.00 $0.00 $0.00 $345.46 "$1,230.20" "$1,230.20" $0.00 $0.00 $345.42 $0.00 $980.41 $980.41 $0.00 $755.00 "$1,195.92" "$1,208.00" $0.00 $0.00 $236.32 $0.00 $0.00 $240.39 $0.00 $0.00 $0.00 $0.00 $0.00 DSL1228 SUP HCPCS C1894 DSL1228 - SHEATH INTRO 12FR 5MM 4.1MM 28CM DRYSEAL DIL VLV INFL SYR BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 DSL1628 SUP HCPCS C1894 DSL1628 - SHEATH INTRO 16FR 6.2MM 5.3MM 28CM DRYSEAL DIL VLV INFL SYR BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 DSL2628 SUP HCPCS C1894 DSL2628 - SHEATH INTROD 28CM DRYSEAL DILAT VALVE INFLAT SYRINGE BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $468.34 $468.34 $0.00 $0.00 $0.00 $179.77 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $510.17 $510.17 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $134.98 $0.00 $0.00 $137.31 $0.00 $0.00 $0.00 $0.00 $0.00 DUET4535A SUP Custom 27203010 DUET4535A - RELOAD STPLR 45MMX3.5MM STRL LF 1.5MM DUET TRS ARTC TISS BOTH IP/OP "$1,718.23 " "$1,271.49" $0.00 "$1,374.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,275.27" "$1,275.27" $0.00 $0.00 $358.08 $0.00 $0.00 $0.00 $0.00 $859.11 "$1,360.84" "$1,374.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUET4548A SUP Custom 27203010 DUET4548A - RELOAD STPLR 45MMX4.8MM STRL LF 2MM DUET TRS ARTC TISS DISP BOTH IP/OP "$1,909.14 " "$1,412.76" $0.00 "$1,527.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,416.97" "$1,416.97" $0.00 $0.00 $397.87 $0.00 $0.00 $0.00 $0.00 $954.57 "$1,512.04" "$1,527.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUET6035A SUP Custom 27203010 DUET6035A - RELOAD STPLR 60MMX3.5MM STRL LF 1.5MM DUET TRS ARTC TISS BOTH IP/OP "$1,867.59 " "$1,382.02" $0.00 "$1,494.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,386.13" "$1,386.13" $0.00 $0.00 $389.21 $0.00 $0.00 $0.00 $0.00 $933.80 "$1,479.13" "$1,494.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUET6048A SUP Custom 27203010 DUET6048A - RELOAD STPLR 60MMX4.8MM STRL LF 2MM DUET TRS ARTC TISS DISP BOTH IP/OP "$11,205.54 " "$8,292.10" $0.00 "$8,964.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,335.23" $0.00 $0.00 $0.00 $0.00 "$5,602.77" "$8,874.79" "$8,964.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUR1000D SUP Custom 27011340 DUR1000D - LASER FIBER_ 1000 MICRON BOTH IP/OP "$2,794.28 " "$2,067.77" $0.00 "$2,235.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,073.92" "$2,073.92" $0.00 $0.00 $582.33 $0.00 $0.00 $0.00 $0.00 "$1,397.14" "$2,213.07" "$2,235.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUR270D SUP Custom 27011340 DUR270D - LASER FIBER_ 270 MICRON BOTH IP/OP "$1,266.67 " $937.34 $0.00 "$1,013.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $940.12 $940.12 $0.00 $0.00 $263.97 $0.00 $0.00 $0.00 $0.00 $633.33 "$1,003.20" "$1,013.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUR400D SUP Custom 27011340 DUR400D - LASER FIBER_ 400 MICRON BOTH IP/OP "$1,266.67 " $937.34 $0.00 "$1,013.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $940.12 $940.12 $0.00 $0.00 $263.97 $0.00 $0.00 $0.00 $0.00 $633.33 "$1,003.20" "$1,013.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUR400DBX SUP Custom 27011340 DUR400DBX - FIBER LSR 400UM STRL DUR HO DISP LTHTRP BOTH IP/OP "$1,074.28 " $794.97 $0.00 $859.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $797.33 $797.33 $0.00 $0.00 $223.88 $0.00 $0.00 $0.00 $0.00 $537.14 $850.83 $859.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUR600D SUP Custom 27011340 DUR600D - LASER FIBER_ 600 MICRON BOTH IP/OP "$1,475.00 " "$1,091.50" $0.00 "$1,180.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,094.75" "$1,094.75" $0.00 $0.00 $307.39 $0.00 $0.00 $0.00 $0.00 $737.50 "$1,168.20" "$1,180.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DUR600DBX SUP Custom 27011340 DUR600DBX - FIBER LSR 600UM STRL DUR HO DISP LTHTRP BOTH IP/OP "$1,254.17 " $928.09 $0.00 "$1,003.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $930.84 $930.84 $0.00 $0.00 $261.37 $0.00 $0.00 $0.00 $0.00 $627.08 $993.30 "$1,003.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DVR-AXXL SUP HCPCS C1713 DVR-AXXL - PLATE X XTD DVR BONE LEFT DISTAL VOLR RADL STRL BOTH IP/OP "$3,865.00 " "$2,860.10" $0.00 "$3,092.00" "$1,739.25" "$1,739.25" $0.00 $0.00 $0.00 $805.56 "$2,868.60" "$2,868.60" $0.00 $0.00 $805.47 $0.00 "$1,905.45" "$1,905.45" $0.00 "$1,932.50" "$3,061.08" "$3,092.00" $0.00 $0.00 $604.87 $0.00 $0.00 $615.31 $0.00 $0.00 $0.00 $0.00 $0.00 DWB172 SUP HCPCS C1776 DWB172 - STEM HUM 130MM 9MM BONE GRW AQLS CMNT 25IN NECK FRAC BOTH IP/OP "$10,685.00 " "$7,906.90" $0.00 "$8,548.00" "$4,808.25" "$4,808.25" $0.00 $0.00 $0.00 "$2,227.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.75" $0.00 "$5,267.71" "$5,267.71" $0.00 "$5,342.50" "$8,462.52" "$8,548.00" $0.00 $0.00 "$1,672.20" $0.00 $0.00 "$1,701.05" $0.00 $0.00 $0.00 $0.00 $0.00 DWB173 SUP HCPCS C1776 DWB173 - HEAD HUM 130MM 12MM SHLDR FRAC AQLS COCR 130D BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 DWB243 SUP HCPCS C1776 DWB243 - HEAD HUM CALOTTE HUMERALE BOTH IP/OP "$4,215.00 " "$3,119.10" $0.00 "$3,372.00" "$1,896.75" "$1,896.75" $0.00 $0.00 $0.00 $878.51 "$3,128.37" "$3,128.37" $0.00 $0.00 $878.41 $0.00 "$2,078.00" "$2,078.00" $0.00 "$2,107.50" "$3,338.28" "$3,372.00" $0.00 $0.00 $659.65 $0.00 $0.00 $671.03 $0.00 $0.00 $0.00 $0.00 $0.00 DWB252 SUP HCPCS C1776 DWB252 - HEAD HUM 52MM 19MM AQLS CMNT PVRS TI SHLDR BOTH IP/OP "$17,125.00 " "$12,672.50" $0.00 "$13,700.00" "$7,706.25" "$7,706.25" $0.00 $0.00 $0.00 "$3,569.28" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,568.85" $0.00 "$8,442.63" "$8,442.63" $0.00 "$8,562.50" "$13,563.00" "$13,700.00" $0.00 $0.00 "$2,680.06" $0.00 $0.00 "$2,726.30" $0.00 $0.00 $0.00 $0.00 $0.00 DWB253 SUP HCPCS C1776 DWB253 - HEAD HUM 23MM 52MM SHLDR CMNT PVRS AQLS TI BOTH IP/OP "$10,685.00 " "$7,906.90" $0.00 "$8,548.00" "$4,808.25" "$4,808.25" $0.00 $0.00 $0.00 "$2,227.02" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,226.75" $0.00 "$5,267.71" "$5,267.71" $0.00 "$5,342.50" "$8,462.52" "$8,548.00" $0.00 $0.00 "$1,672.20" $0.00 $0.00 "$1,701.05" $0.00 $0.00 $0.00 $0.00 $0.00 DWD020 SUP HCPCS C1713 DWD020 - SCREW BSPLT 20MM 4.5MM AQLS GLND TI LOCK MLDIR ST BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 DWD023 SUP HCPCS C1713 DWD023 - SCREW BSPLT 23MM 4.5MM AQLS GLND TI LOCK MLDIR ST BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 DWD029 SUP HCPCS C1713 DWD029 - SCREW BSPLT 29MM 4.5MM AQLS GLND TI LOCK MLDIR ST BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 DWD055 SUP Custom 27203010 DWD055 - BIT DRL 3MM STRL DISP BOTH IP/OP $342.50 $253.45 $0.00 $274.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.20 $254.20 $0.00 $0.00 $71.38 $0.00 $0.00 $0.00 $0.00 $171.25 $271.26 $274.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DWD180 SUP HCPCS C1776 DWD180 - SPHERE GLND 36MM AQLS CRCO RVRS CNTR 25MM BSPLT BOTH IP/OP "$8,312.50 " "$6,151.25" $0.00 "$6,650.00" "$3,740.63" "$3,740.63" $0.00 $0.00 $0.00 "$1,732.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,732.33" $0.00 "$4,098.06" "$4,098.06" $0.00 "$4,156.25" "$6,583.50" "$6,650.00" $0.00 $0.00 "$1,300.91" $0.00 $0.00 "$1,323.35" $0.00 $0.00 $0.00 $0.00 $0.00 DWD860 SUP HCPCS C1776 DWD860 - INSERT HUM 36MM AQLS 6MM SHLDR LAT PVRS ADPR FRAC BOTH IP/OP "$4,507.50 " "$3,335.55" $0.00 "$3,606.00" "$2,028.38" "$2,028.38" $0.00 $0.00 $0.00 $939.48 "$3,345.47" "$3,345.47" $0.00 $0.00 $939.36 $0.00 "$2,222.20" "$2,222.20" $0.00 "$2,253.75" "$3,569.94" "$3,606.00" $0.00 $0.00 $705.42 $0.00 $0.00 $717.59 $0.00 $0.00 $0.00 $0.00 $0.00 DWD861 SUP HCPCS C1776 DWD861 - INSERT HUM 36MM AQLS +9MM LAT RVRS ADPR FRAC PRIM BOTH IP/OP "$4,507.50 " "$3,335.55" $0.00 "$3,606.00" "$2,028.38" "$2,028.38" $0.00 $0.00 $0.00 $939.48 "$3,345.47" "$3,345.47" $0.00 $0.00 $939.36 $0.00 "$2,222.20" "$2,222.20" $0.00 "$2,253.75" "$3,569.94" "$3,606.00" $0.00 $0.00 $705.42 $0.00 $0.00 $717.59 $0.00 $0.00 $0.00 $0.00 $0.00 DWD901 SUP HCPCS C1776 DWD901 - STEM HUM 130MM 7MM PVRS FRAC AQLS SHLDR BOTH IP/OP "$13,975.00 " "$10,341.50" $0.00 "$11,180.00" "$6,288.75" "$6,288.75" $0.00 $0.00 $0.00 "$2,912.74" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,912.39" $0.00 "$6,889.68" "$6,889.68" $0.00 "$6,987.50" "$11,068.20" "$11,180.00" $0.00 $0.00 "$2,187.09" $0.00 $0.00 "$2,224.82" $0.00 $0.00 $0.00 $0.00 $0.00 DX-22-100 SUP Custom 27203010 DX-22-100 - SYSTEM SPNL FX DTRAX BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 $0.00 $0.00 $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 DYND13522 SUP HCPCS A4351 DYND13522 - CATHETER URTH RBNSN 22FR 16IN SMTH TIP 2 OVL EYE RADIOPQ FNL BOTH IP/OP $1.65 $1.22 $0.00 $1.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.34 $1.22 $1.22 $0.00 $0.00 $0.34 $0.00 $0.98 $0.98 $0.00 $1.03 $1.64 $1.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E05021 SUP Custom 27203010 E05021 - ADAPTER ESURG UNV STRL VLAB MNPLR FTSWTCH DISP ACPT 3.2- MM BOTH IP/OP $97.83 $72.39 $0.00 $78.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.61 $72.61 $0.00 $0.00 $20.39 $0.00 $0.00 $0.00 $0.00 $48.91 $77.48 $78.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E0570 SUP Custom 27203010 RETRACTOR STRG NRV ROOT SURG BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-21A-00 SUP Custom 27803010 E100-21A-00 - VALVE AORTIC 21MM EP BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-23A-00 SUP Custom 27803010 E100-23A-00 - VALVE AOR 23MM 21MM 15MM EP LINX BPRTH STNT SW CUF PLSTR SUP BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-25A-00 SUP Custom 27803010 E100-25A-00 - VALVE AORTIC 25MM EP BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-25M-00 SUP Custom 27803010 E100-25M-00 - VALVE MTRL 25MM 23MM 16MM EP FLEXFIT BPRTH STNT HLDR LOPRFL BOTH IP/OP "$23,350.00 " "$17,279.00" $0.00 "$18,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,866.14" $0.00 $0.00 $0.00 $0.00 "$11,675.00" "$18,493.20" "$18,680.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-27A-00 SUP Custom 27803010 E100-27A-00 - VALVE AOR 27MM 25MM 17MM EP LINX BPRTH STNT SW CUF PLSTR SUP BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-27M-00 SUP Custom 27803010 E100-27M-00 - VALVE MTRL LOPRFL 25MM 23MM 16MM EP FLEXFIT BPRTH STNT HLDR BOTH IP/OP "$15,500.00 " "$11,470.00" $0.00 "$12,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,230.20" $0.00 $0.00 $0.00 $0.00 "$7,750.00" "$12,276.00" "$12,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-29A-00 SUP Custom 27803010 E100-29A-00 - VALVE AORTIC 29MM EP THV BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-29M-00 SUP Custom 27803010 E100-29M-00 - VALVE MTRL 29MM 27MM 19MM LF 10MM EP LINX BIOCOR FLEXFIT BOTH IP/OP "$15,500.00 " "$11,470.00" $0.00 "$12,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,230.20" $0.00 $0.00 $0.00 $0.00 "$7,750.00" "$12,276.00" "$12,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-31M-00 SUP Custom 27803010 E100-31M-00 - VALVE MTRL 31MM 29MM 20MM STRL LF EP FLEXFIT BPRTH STNT HLDR BOTH IP/OP "$15,500.00 " "$11,470.00" $0.00 "$12,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,230.20" $0.00 $0.00 $0.00 $0.00 "$7,750.00" "$12,276.00" "$12,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E100-33M-00 SUP Custom 27803010 E100-33M-00 - VALVE MTRL 33MM 41MM 31MM 20MM STRL EP FLEXFIT BPRTH STNT BOTH IP/OP "$15,500.00 " "$11,470.00" $0.00 "$12,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,230.20" $0.00 $0.00 $0.00 $0.00 "$7,750.00" "$12,276.00" "$12,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E1457 SUP Custom 27203010 E1457 - ELECTRODE ELECTROSURGICAL 45D 178MM NEEDLE SLEEVE BOTH IP/OP $282.50 $209.05 $0.00 $226.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $209.67 $209.67 $0.00 $0.00 $58.87 $0.00 $0.00 $0.00 $0.00 $141.25 $223.74 $226.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E2505-10FR SUP Custom 27203010 E2505-10FR - COAG SCT 6IN 10FR LECTROVAC FTSWTCH ACT SHFT STRL DISP BOTH IP/OP $19.33 $14.30 $0.00 $15.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.66 $15.31 $15.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E2530-6 SUP Custom 27203010 E2530-6 - ELECTRODE ELECTROSURGICAL 6IN HANDSET COAGULATION FLEXIBLE BOTH IP/OP $649.00 $480.26 $0.00 $519.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $481.69 $481.69 $0.00 $0.00 $135.25 $0.00 $0.00 $0.00 $0.00 $324.50 $514.01 $519.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E-3F SUP Custom 27203010 PROBE LTHTRP 120CM 3FR ELHDR STRL AEH2 3 BOTH IP/OP $446.68 $330.54 $0.00 $357.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.34 $353.77 $357.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E5211-6K SUP Custom 27203010 E5211-6K - BIT DRILL 7.4MM 150MM BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $0.00 $0.00 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E5211-6L SUP Custom 27203010 E5211-6L - BIT DRILL 7.4MM 200MM BOTH IP/OP $291.50 $215.71 $0.00 $233.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.35 $216.35 $0.00 $0.00 $60.75 $0.00 $0.00 $0.00 $0.00 $145.75 $230.87 $233.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 E-70-0045 SUP HCPCS C1713 E-70-0045 - PLATE ACUMED BONE LEFT DISTAL ULN BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 EA100 SUP Custom 27203010 EA100 - INSTRUMENT TRAY EA100 LEGEND EHS STYLUS BOTH IP/OP "$1,258.00 " $930.92 $0.00 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $933.69 $933.69 $0.00 $0.00 $262.17 $0.00 $0.00 $0.00 $0.00 $629.00 $996.34 "$1,006.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EAW2827 SUP Custom 27203010 REGULATOR FLOW 1 DISS OXYGEN CYLINDER BOTH IP/OP $240.00 $177.60 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.00 $190.08 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EB0101 SUP Custom 27203010 EB0101 - RSTRC CMNT LTD 8-15MM ELB BOTH IP/OP $420.00 $310.80 $0.00 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.72 $311.72 $0.00 $0.00 $87.53 $0.00 $0.00 $0.00 $0.00 $210.00 $332.64 $336.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EB2S103 SUP HCPCS C1884 EB2S103 - PARTICLES EMBL 100-300UM 2ML YLW BDBL MCSPH CMPR PVA BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 EB2S305 SUP Custom 27803010 EB2S305 - PARTICLES EMBL 300-500UM 2ML BLU BDBL CMPR MCSPH PVA BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $0.00 $0.00 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EB2S507 SUP HCPCS C1884 EB2S507 - PARTICLES EMBL 500-700UM 2ML RD BDBL CMPR PRECISELY CLBRT BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 EB2S709 SUP HCPCS C1884 EB2S709 - PARTICLES EMBL 700-900UM 2ML GRN BDBL CMPR PRECISELY CLBRT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 EB2S912 SUP HCPCS C1884 EB2S912 - PARTICLES EMBL 900-1200UM 2ML PUR BDBL CMPR PRECISELY CLBRT BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 ECATCH15 SUP Custom 27203010 ECATCH15 - POUCH SPEC RTRVL 15MM 34.5CM LF 29.5CM E-CTCH II FLXB ERG BOTH IP/OP $283.90 $210.09 $0.00 $227.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.71 $210.71 $0.00 $0.00 $59.16 $0.00 $0.00 $0.00 $0.00 $141.95 $224.85 $227.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ECH060040A SUP HCPCS C1768 ECH060040A - GRAFT VASCULAR 6CM 40CM 3 LAYER ACUSEAL PTFE BOTH IP/OP "$3,225.00 " "$2,386.50" $0.00 "$2,580.00" "$1,451.25" "$1,451.25" $0.00 $0.00 $0.00 $672.17 "$2,393.60" "$2,393.60" $0.00 $0.00 $672.09 $0.00 "$1,589.93" "$1,589.93" $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 $0.00 $504.71 $0.00 $0.00 $513.42 $0.00 $0.00 $0.00 $0.00 $0.00 ECH470045A SUP HCPCS C1768 ECH470045A - GRAFT VASCULAR 4-7MM 45CM TAPER GORE ACUSEAL STERILE BOTH IP/OP "$3,700.00 " "$2,738.00" $0.00 "$2,960.00" "$1,665.00" "$1,665.00" $0.00 $0.00 $0.00 $771.17 "$2,746.14" "$2,746.14" $0.00 $0.00 $771.08 $0.00 "$1,824.10" "$1,824.10" $0.00 "$1,850.00" "$2,930.40" "$2,960.00" $0.00 $0.00 $579.05 $0.00 $0.00 $589.04 $0.00 $0.00 $0.00 $0.00 $0.00 ECHO-1-22 SUP Custom 27203102 SHEATH BLUE 22G (STIFFER) BOTH IP/OP $669.30 $495.28 $0.00 $535.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.65 $530.09 $535.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ECHO--19 SUP Custom 27203105 NEEDLE 19G BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ECHO-19-CB SUP Custom 27203106 CYTOLOGY BRUSH (ECHO-19) BOTH IP/OP $20.13 $14.90 $0.00 $16.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.06 $15.94 $16.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ECHO-20-CPN SUP Custom 27203104 CELIAC PLEXUS NEUROLYSIS NEEDLE 20G BOTH IP/OP $272.58 $201.71 $0.00 $218.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.29 $215.88 $218.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ECHO-25 SUP Custom 27203590 NEEDLE BX 25G BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ECHO-3-22 SUP Custom 27203103 GREEN SPRING COIL SHEATH 22G BOTH IP/OP $669.30 $495.28 $0.00 $535.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.65 $530.09 $535.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EDI-3180 SUP Custom 27203010 PAD DFBR PADPRO RDTRNS ADLT 2516 LF BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EDI-3183 SUP Custom 27203010 PAD DFBR PADPRO RDTRNS INF 2603 LF BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EEA2835 SUP Custom 27203010 EEA2835 - STAPLER INTERNAL 3.5MM CIRCULAR 28MM 22CM SHAFT LARGE BOTH IP/OP $746.73 $552.58 $0.00 $597.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.22 $554.22 $0.00 $0.00 $155.62 $0.00 $0.00 $0.00 $0.00 $373.36 $591.41 $597.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EGIA60CTAMT SUP Custom 27203010 EGIA60CTAMT - RELOAD STPLR 60MM PUR STRL LF ARTC CRV TIP INTRO MED THKTIS BOTH IP/OP "$4,321.80 " "$3,198.13" $0.00 "$3,457.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,207.64" "$3,207.64" $0.00 $0.00 $900.66 $0.00 $0.00 $0.00 $0.00 "$2,160.90" "$3,422.87" "$3,457.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EGIARADXT SUP Custom 27203010 EGIARADXT - RELOAD STPLR 15MM BLK STRL LF EGIA RADL TI X THKTIS DISP BOTH IP/OP "$6,411.75 " "$4,744.70" $0.00 "$5,129.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,336.21" $0.00 $0.00 $0.00 $0.00 "$3,205.88" "$5,078.11" "$5,129.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EL21L SUP Custom 27203010 EL21L - SUTURE ABSORBABLE 0 3.9MM 21IN BRAID COATED LIGATE LOOP BOTH IP/OP $54.25 $40.15 $0.00 $44.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.26 $40.26 $0.00 $0.00 $11.31 $0.00 $0.00 $0.00 $0.00 $27.53 $43.61 $44.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ELAFIXP2P744 SUP HCPCS C1893 ELAFIXP2P744 - LEAD PCNG ELAPASS PSV FX ART VNTRC BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $610.88 $610.88 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 ELAFIXP2P752 SUP HCPCS C1893 ELAFIXP2P752 - LEAD PCNG 52CM SCR IN BP ATRERY BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $610.88 $610.88 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 ELAFIXP2P758 SUP HCPCS C1893 ELAFIXP2P758 - LEAD SRG 10MM 7FR 58CM SCR IN IS 1 BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $610.88 $610.88 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 ELAFIXS2J748 SUP HCPCS C1898 ELAFIXS2J748 - LEAD PCNG JTP ATR BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 ELAFIXS2J752 SUP HCPCS C1898 ELAFIXS2J752 - LEAD PCNG JTP ATR BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 ELAPASSP752 SUP HCPCS C1898 ELAPASSP752 - LEAD PCNG ELAPASS TN VNTRC BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 ELAPASSP758 SUP HCPCS C1898 ELAPASSP758 - LEAD PCNG 58CM BP STRG VNTRC BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 ELAPASSPJ744 SUP HCPCS C1898 ELAPASSPJ744 - LEAD PCNG 7FR 44CM ELAPASS P BP ATR BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 ELAPASSPJ752 SUP HCPCS C1898 ELAPASSPJ752 - LEAD PACING J 52CM BIPOL PREFORMED TINED LOW VOLTAGE ELAPASS BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $234.48 $834.98 $834.98 $0.00 $0.00 $234.45 $0.00 $665.44 $665.44 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 EMP-FBX1000HS SUP Custom 27203010 EMP-FBX1000HS - LASER SURGICAL 1000 MH FIBER SINGLE USE BOTH IP/OP "$1,937.50 " "$1,433.75" $0.00 "$1,620.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,438.01" "$1,438.01" $0.00 $0.00 $403.78 $0.00 $0.00 $0.00 $0.00 "$1,013.07" "$1,604.70" "$1,620.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EMP-FBX272HS-C SUP Custom 27203010 "EMP-FBX272HS-C - LASER SURGICAL 272 MH FIBER SINGLE USE, COMPATIBLE" BOTH IP/OP $725.95 $537.20 $0.00 $538.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $538.80 $538.80 $0.00 $0.00 $151.29 $0.00 $0.00 $0.00 $0.00 $320.31 $507.37 $512.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EMP-FBX365HS SUP Custom 27203010 EMP-FBX365HS - LASER SURGICAL 365 MH FIBER SINGLE USE BOTH IP/OP $874.75 $647.32 $0.00 $649.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.24 $649.24 $0.00 $0.00 $182.30 $0.00 $0.00 $0.00 $0.00 $320.31 $507.37 $512.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EMP-FBX550HS SUP Custom 27203010 EMP-FBX550HS - LASER SURGICAL 550 MH FIBER SINGLE USE BOTH IP/OP "$1,070.50 " $792.17 $0.00 $867.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $794.53 $794.53 $0.00 $0.00 $223.09 $0.00 $0.00 $0.00 $0.00 $542.34 $859.07 $867.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EN2006015-C SUP HCPCS C1757 EN2006015-C - SNARE VASC STD 9-15MM 6FR 120CM 100CM ENSNR 3 PREFRM LOOP BOTH IP/OP $827.50 $612.35 $0.00 $662.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.47 $614.17 $614.17 $0.00 $0.00 $172.45 $0.00 $489.47 $489.47 $0.00 $413.75 $655.38 $662.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EN2007030 SUP Custom 27203010 EN2007030 - SNARE VASC STD 18-30MM 7FR 120CM 100CM ENSNR 3 INTERLACE BOTH IP/OP $827.50 $612.35 $0.00 $662.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.75 $655.38 $662.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EN2007045 SUP Custom 27203010 EN2007045 - SNARE VASCULAR 120CM 3 PREFORM LOOP WIRE KINK RESISTANT BOTH IP/OP "$1,100.00 " $814.00 $0.00 $880.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $816.42 $816.42 $0.00 $0.00 $229.24 $0.00 $0.00 $0.00 $0.00 $550.00 $871.20 $880.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ENBD-7 SUP HCPCS C1725 CATHETER DRAIN 7FR 250CM 5 SDPRT LCK PGTL ENDSCP BIL NSL BOTH IP/OP $286.15 $211.75 $0.00 $228.92 $155.38 $155.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.08 $226.63 $228.92 $0.00 $0.00 $44.78 $0.00 $0.00 $45.56 $0.00 $0.00 $0.00 $0.00 $0.00 ENDO-014 SUP HCPCS C1769 ENDO-014 - GUIDEWIRE ENDOVASCULAR L260 CM OD.014 IN ANCILLARY BOTH IP/OP $450.00 $333.00 $0.00 $360.00 $244.35 $244.35 $0.00 $0.00 $0.00 $93.79 $333.99 $333.99 $0.00 $0.00 $93.78 $0.00 $266.18 $266.18 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 ENF402300 SUP HCPCS C1874 ENF402300 - STENT VASCULAR 4.5MM 22MM W/O DISTAL TIP ENTERPRISE NITINOL BOTH IP/OP "$14,899.20 " "$11,025.41" $0.00 "$11,919.36" "$6,704.64" "$6,704.64" $0.00 $0.00 $0.00 "$3,105.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,104.99" $0.00 "$7,345.31" "$7,345.31" $0.00 "$7,449.60" "$11,800.17" "$11,919.36" $0.00 $0.00 "$2,331.72" $0.00 $0.00 "$2,371.95" $0.00 $0.00 $0.00 $0.00 $0.00 ENF402312 SUP HCPCS C1874 ENF402312 - STENT VASC 4.5MM 22MM ENTRP RECON DEV SLF EXPANDABLE DLV SYS BOTH IP/OP "$14,899.20 " "$11,025.41" $0.00 "$11,919.36" "$6,704.64" "$6,704.64" $0.00 $0.00 $0.00 "$3,105.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,104.99" $0.00 "$7,345.31" "$7,345.31" $0.00 "$7,449.60" "$11,800.17" "$11,919.36" $0.00 $0.00 "$2,331.72" $0.00 $0.00 "$2,371.95" $0.00 $0.00 $0.00 $0.00 $0.00 ENF403000 SUP HCPCS C1874 ENF403000 - STENT VASCULAR 4.5MM 28MM W/O DISTAL TIP ENTERPRISE NITINOL BOTH IP/OP "$14,899.20 " "$11,025.41" $0.00 "$11,919.36" "$6,704.64" "$6,704.64" $0.00 $0.00 $0.00 "$3,105.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,104.99" $0.00 "$7,345.31" "$7,345.31" $0.00 "$7,449.60" "$11,800.17" "$11,919.36" $0.00 $0.00 "$2,331.72" $0.00 $0.00 "$2,371.95" $0.00 $0.00 $0.00 $0.00 $0.00 ENF403012 SUP HCPCS C1874 ENF403012 - STENT VASC 4.5MM 28MM ENTRP RECON DEV SLF EXPANDABLE DLV SYS BOTH IP/OP "$14,899.20 " "$11,025.41" $0.00 "$11,919.36" "$6,704.64" "$6,704.64" $0.00 $0.00 $0.00 "$3,105.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,104.99" $0.00 "$7,345.31" "$7,345.31" $0.00 "$7,449.60" "$11,800.17" "$11,919.36" $0.00 $0.00 "$2,331.72" $0.00 $0.00 "$2,371.95" $0.00 $0.00 $0.00 $0.00 $0.00 ENF403900 SUP HCPCS C1874 ENF403900 - STENT VASCULAR 4.5MM 37MM W/O DISTAL TIP ENTERPRISE NITINOL BOTH IP/OP "$14,899.20 " "$11,025.41" $0.00 "$11,919.36" "$6,704.64" "$6,704.64" $0.00 $0.00 $0.00 "$3,105.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,104.99" $0.00 "$7,345.31" "$7,345.31" $0.00 "$7,449.60" "$11,800.17" "$11,919.36" $0.00 $0.00 "$2,331.72" $0.00 $0.00 "$2,371.95" $0.00 $0.00 $0.00 $0.00 $0.00 ENF403912 SUP HCPCS C1874 ENF403912 - STENT VASC 4.5MM 37MM ENTRP RECON DEV SLF EXPANDABLE DLV SYS BOTH IP/OP "$14,899.20 " "$11,025.41" $0.00 "$11,919.36" "$6,704.64" "$6,704.64" $0.00 $0.00 $0.00 "$3,105.37" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,104.99" $0.00 "$7,345.31" "$7,345.31" $0.00 "$7,449.60" "$11,800.17" "$11,919.36" $0.00 $0.00 "$2,331.72" $0.00 $0.00 "$2,371.95" $0.00 $0.00 $0.00 $0.00 $0.00 ENSP25008UX SUP HCPCS C1874 STENT CORON 8MM 25MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP25012UX SUP HCPCS C1874 STENT CORON 2.5MM 12MM DRUG ELUDING ENDVR SPRNT BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP25014UX SUP HCPCS C1874 STENT CORON 2.5MM 14MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP25018UX SUP HCPCS C1874 STENT CORON 2.5MM 18MM DRUG ELUDING ENDVR SPRNT BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP25024UX SUP HCPCS C1874 STENT CORON 2.5MM 24MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP25030UX SUP HCPCS C1874 STENT CORON 2.5MM 30MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP30009UX SUP HCPCS C1874 STENT CORON 3MM 9MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP30012UX SUP HCPCS C1874 STENT CORON 3MM 12MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP30015UX SUP HCPCS C1874 STENT CORON 3MM 15MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP30018UX SUP HCPCS C1874 STENT CORON 3MM 18MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP30024UX SUP HCPCS C1874 STENT CORON 3MM 24MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP30030UX SUP HCPCS C1874 STENT CORON 3MM 30MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP35009UX SUP HCPCS C1874 STENT CORON 3.5MM 9MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP35012UX SUP HCPCS C1874 STENT CORON 3.5MM 12MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP35015UX SUP HCPCS C1874 STENT CORON 3.5MM 15MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP35018UX SUP HCPCS C1874 STENT CORON 3.5MM 18MM DRUG ELUDING ENDVR SPRNT BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP35024UX SUP HCPCS C1874 STENT CORON 3.5MM 24MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ENSP35030UX SUP HCPCS C1874 STENT CORON 3.5MM 30MM DRUG ELUDING ENDVR BOTH IP/OP "$4,312.50 " "$3,191.25" $0.00 "$3,450.00" "$1,940.63" "$1,940.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,156.25" "$3,415.50" "$3,450.00" $0.00 $0.00 $674.91 $0.00 $0.00 $686.55 $0.00 $0.00 $0.00 $0.00 $0.00 ER7232A SUP HCPCS C2628 ER7232A - ER-REBOA CATHETER BOTH IP/OP "$5,437.50 " "$4,023.75" $0.00 "$4,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,133.31" "$4,035.71" "$4,035.71" $0.00 $0.00 "$1,133.18" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,718.75" "$4,306.50" "$4,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ES3352 SUP HCPCS C1729 CATHETER INTRAVENOUS PROTECTIV ACUVANCE 16G X 2IN SAFETY STR BOTH IP/OP $4.10 $3.03 $0.00 $3.28 $2.23 $2.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.05 $3.25 $3.28 $0.00 $0.00 $0.64 $0.00 $0.00 $0.65 $0.00 $0.00 $0.00 $0.00 $0.00 ESCDH33 SUP Custom 27203010 ESCDH33 - STAPLER INTNL CRV CRC 33MM 5.5MM STRL LF 1-2.5MM PRX LNR CTR BOTH IP/OP "$3,588.47 " "$2,655.47" $0.00 "$2,870.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,663.36" "$2,663.36" $0.00 $0.00 $747.84 $0.00 $0.00 $0.00 $0.00 "$1,794.24" "$2,842.07" "$2,870.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESEJ10G SUP Custom 27203010 ESEJ10G - SUTURE ABSORBABLE 0 18IN BRAID TIES COATED VICRYL ENDOLOOP BOTH IP/OP $376.17 $278.37 $0.00 $300.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.19 $279.19 $0.00 $0.00 $78.39 $0.00 $0.00 $0.00 $0.00 $188.09 $297.93 $300.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP100-21-00 SUP Custom 27803010 ESP100-21-00 - VALVE AORTIC 21MM EP SUP THV BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP100-23-00 SUP Custom 27803010 ESP100-23-00 - VALVE AOR 23MM 16MM EP FLEXFIT BPRTH STNT SCLP INFL EDG HLDR BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP100-25-00 SUP Custom 27803010 ESP100-25-00 - VALVE AORTIC 25MM EP SUP THV BOTH IP/OP "$19,700.00 " "$14,578.00" $0.00 "$15,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,105.48" $0.00 $0.00 $0.00 $0.00 "$9,850.00" "$15,602.40" "$15,760.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP100-27-00 SUP Custom 27803010 ESP100-27-00 - VALVE AORTIC 27MM EP SUP THV BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP1955 SUP Custom 27011340 ESP1955 - SPLINTS YELLOW JACKET BOTH IP/OP $65.63 $48.57 $0.00 $52.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.71 $48.71 $0.00 $0.00 $13.68 $0.00 $0.00 $0.00 $0.00 $32.81 $51.98 $52.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP3075 SUP Custom 27203010 ESP3075 - KIT SPLINT NEOPRENE DURABLE NONABSORBENT EASY FRACTURE MANAG BOTH IP/OP $437.38 $323.66 $0.00 $349.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.62 $324.62 $0.00 $0.00 $91.15 $0.00 $0.00 $0.00 $0.00 $218.69 $346.40 $349.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP-3100 SUP Custom 27203010 SPLINT TRACTION 4 LEG ADULT BOTH IP/OP $412.38 $305.16 $0.00 $329.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.19 $326.60 $329.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP3101 SUP Custom 27203010 SPLINT TRACTION 3 LEG PEDIATRIC BOTH IP/OP $412.38 $305.16 $0.00 $329.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.19 $326.60 $329.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESP-3119 SUP Custom 27203010 SPLINT TRACTION SINGLE SAGER FORM III BOTH IP/OP $686.25 $507.83 $0.00 $549.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.13 $543.51 $549.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ESU-501 SUP Custom 27203010 FILTER SMKEVC PK FINESSE BOTH IP/OP $83.13 $61.52 $0.00 $66.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.56 $65.84 $66.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ETBF3216C166E SUP Custom 27803010 ETBF3216C166E - GRAFT STNT 2 BRCH 32-16MM 20FR 166MM ENDURANT II DLV SYS C BOTH IP/OP "$24,937.50 " "$18,453.75" $0.00 "$19,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,196.98" $0.00 $0.00 $0.00 $0.00 "$12,468.75" "$19,750.50" "$19,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ETDPP6 SUP Custom 27203010 ETDPP6 - ADHESIVE SKNCLS 2 OCTYL CYNCRLT DRMBND VL TOP LQ HVISC PRPN BOTH IP/OP $64.42 $47.67 $0.00 $51.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.81 $47.81 $0.00 $0.00 $13.43 $0.00 $0.00 $0.00 $0.00 $32.21 $51.02 $51.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ETLW1616C82E SUP Custom 27803010 ETLW1616C82E - GRAFT STNT 16-16MM 14FR 82MM ENDURANT II DLV SYS C DIST BOTH IP/OP "$11,187.50 " "$8,278.75" $0.00 "$8,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,331.48" $0.00 $0.00 $0.00 $0.00 "$5,593.75" "$8,860.50" "$8,950.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ETLW1620C156E SUP Custom 27803010 ETLW1620C156E - GRAFT STNT 16-20MM 16FR 156MM ENDURANT II DLV SYS C DIST BOTH IP/OP "$16,000.00 " "$11,840.00" $0.00 "$12,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,334.40" $0.00 $0.00 $0.00 $0.00 "$8,000.00" "$12,672.00" "$12,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ETLW1628C93E SUP HCPCS C2625 ETLW1628C93E - GRAFT STNT 16-28MM 16FR 93MM ENDURANT II DLV SYS C DIST BOTH IP/OP "$12,312.50 " "$9,111.25" $0.00 "$9,850.00" "$5,540.63" "$5,540.63" $0.00 $0.00 $0.00 "$2,566.23" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,565.93" $0.00 "$6,070.06" "$6,070.06" $0.00 "$6,156.25" "$9,751.50" "$9,850.00" $0.00 $0.00 "$1,926.91" $0.00 $0.00 "$1,960.15" $0.00 $0.00 $0.00 $0.00 $0.00 ETVKMM SUP HCPCS C1781 ETVKMM - MESH SURG 6X6IN ABS KNTD WVN VCL PLGC 910 BOTH IP/OP $791.30 $585.56 $0.00 $633.04 $356.09 $356.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $395.65 $626.71 $633.04 $0.00 $0.00 $123.84 $0.00 $0.00 $125.97 $0.00 $0.00 $0.00 $0.00 $0.00 EUSCFS-070026-14-13 SUP HCPCS C1768 EUSCFS-070026-14-13 - SET STENT 26CM 7-14FR CFLX URET EURTM RELS SLV PSTNR 13CM BOTH IP/OP $297.06 $219.82 $0.00 $237.65 $133.68 $133.68 $0.00 $0.00 $0.00 $61.92 $220.48 $220.48 $0.00 $0.00 $61.91 $0.00 $175.71 $175.71 $0.00 $148.53 $235.27 $237.65 $0.00 $0.00 $46.49 $0.00 $0.00 $47.29 $0.00 $0.00 $0.00 $0.00 $0.00 EUSN-19-QC SUP Custom 27203105 NEEDLE BX 19G BOTH IP/OP $359.88 $266.31 $0.00 $287.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.94 $285.02 $287.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EX70410 SUP HCPCS A4364 EX70410 - ADHESIVE SKNCLS 1ML EXOFIN BOTH IP/OP $25.00 $18.50 $0.00 $18.56 $1.36 $1.36 $0.00 $0.00 $0.00 $5.21 $18.56 $18.56 $0.00 $0.00 $5.21 $0.00 $14.79 $14.79 $0.00 $1.25 $1.98 $2.00 $0.00 $0.00 $0.39 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 EXPORTAP SUP HCPCS C1757 EXPORTAP - CATHETER THROMBECTOMY FULL WALL 6FR .07IN 140CM BRAID BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EZ15-15-15 SUP HCPCS C1713 EZ15-15-15 - STAPLE BONE 2MM 15X15X1.8-1.3MM MONOCORTICAL SUPERELASTIC LP BOTH IP/OP "$3,208.50 " "$2,374.29" $0.00 "$2,474.16" "$1,391.72" "$1,391.72" $0.00 $0.00 $0.00 $668.73 "$2,381.35" "$2,381.35" $0.00 $0.00 $668.65 $0.00 "$1,581.79" "$1,581.79" $0.00 "$1,546.35" "$2,449.42" "$2,474.16" $0.00 $0.00 $484.01 $0.00 $0.00 $492.36 $0.00 $0.00 $0.00 $0.00 $0.00 EZF21TA SUP Custom 27203010 EZF21TA - CANNULA PERFUSION 3/8IN 21FR 14.8IN CURVE TIP SUTURE FLANGE BOTH IP/OP $110.68 $81.90 $0.00 $88.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.14 $82.14 $0.00 $0.00 $23.06 $0.00 $0.00 $0.00 $0.00 $55.34 $87.66 $88.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EZS24TA SUP Custom 27203010 EZS24TA - CANNULA PERFUSION 3/8IN STR 24FR 14IN AUTO DILATE TIP SUTURE BOTH IP/OP $93.30 $69.04 $0.00 $74.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.25 $69.25 $0.00 $0.00 $19.44 $0.00 $0.00 $0.00 $0.00 $46.65 $73.89 $74.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 F1/8TA15S SUP Custom 27203010 F1/8TA15S - TOOL LEGEND 8 CM 1.5MM SPIRAL BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 F1006 SUP HCPCS C1768 F1006 - GRAFT VASC 10CM 6MM IMPR CBFL PTFE PERI BYPS FLX BOTH IP/OP $891.48 $659.70 $0.00 $713.18 $401.16 $401.16 $0.00 $0.00 $0.00 $185.81 $661.65 $661.65 $0.00 $0.00 $185.78 $0.00 $527.31 $527.31 $0.00 $445.74 $706.05 $713.18 $0.00 $0.00 $139.52 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $0.00 F1010 SUP HCPCS C1768 F1010 - GRAFT VASC 10CM 10MM IMPR CBFL PTFE PERI BYPS FLX BOTH IP/OP $891.48 $659.70 $0.00 $713.18 $401.16 $401.16 $0.00 $0.00 $0.00 $185.81 $661.65 $661.65 $0.00 $0.00 $185.78 $0.00 $527.31 $527.31 $0.00 $445.74 $706.05 $713.18 $0.00 $0.00 $139.52 $0.00 $0.00 $141.92 $0.00 $0.00 $0.00 $0.00 $0.00 F2/8TA23S SUP Custom 27203010 F2/8TA23S - TOOL LEGEND 8CM 2.3MM SPIRAL BOTH IP/OP $269.88 $199.71 $0.00 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.30 $200.30 $0.00 $0.00 $56.24 $0.00 $0.00 $0.00 $0.00 $134.94 $213.74 $215.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 F-30 SUP Custom 27203010 FILTER TRNSF GAS VNT REPL LKCYT RBC 40UM BOTH IP/OP $51.75 $38.30 $0.00 $41.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.88 $40.99 $41.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 F6008 SUP HCPCS C1768 F6008 - GRAFT VASC 60CM 8MM IMPR CBFL PTFE PERI BYPS FLX BOTH IP/OP "$2,160.88 " "$1,599.05" $0.00 "$1,728.70" $972.39 $972.39 $0.00 $0.00 $0.00 $450.38 "$1,603.80" "$1,603.80" $0.00 $0.00 $450.33 $0.00 "$1,278.16" "$1,278.16" $0.00 "$1,080.44" "$1,711.42" "$1,728.70" $0.00 $0.00 $338.18 $0.00 $0.00 $344.01 $0.00 $0.00 $0.00 $0.00 $0.00 F7006 SUP HCPCS C1768 F7006 - GRAFT VASC 70CM 6MM IMPR CBFL PTFE PERI BYPS FLX BOTH IP/OP "$2,570.28 " "$1,902.01" $0.00 "$2,056.22" "$1,156.62" "$1,156.62" $0.00 $0.00 $0.00 $535.71 "$1,907.66" "$1,907.66" $0.00 $0.00 $535.65 $0.00 "$1,267.15" "$1,267.15" $0.00 "$1,285.14" "$2,035.66" "$2,056.22" $0.00 $0.00 $402.25 $0.00 $0.00 $409.19 $0.00 $0.00 $0.00 $0.00 $0.00 F7008 SUP HCPCS C1768 F7008 - GRAFT VASC STRG 8MM 70CM IMPRA FLX SM BEAD EPTFE BOTH IP/OP "$2,570.28 " "$1,902.01" $0.00 "$2,056.22" "$1,156.62" "$1,156.62" $0.00 $0.00 $0.00 $535.71 "$1,907.66" "$1,907.66" $0.00 $0.00 $535.65 $0.00 "$1,267.15" "$1,267.15" $0.00 "$1,285.14" "$2,035.66" "$2,056.22" $0.00 $0.00 $402.25 $0.00 $0.00 $409.19 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0140 SUP HCPCS C1713 FA-0140 - SCREW BN 3.5MM 14MM CNN XTRMT BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $253.13 $253.13 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0160 SUP HCPCS C1713 FA-0160 - SCREW BN 3.5MM 16MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0180 SUP HCPCS C1713 FA-0180 - SCREW BN 3.5MM 18MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0200 SUP HCPCS C1713 FA-0200 - SCREW BN 3.5MM 20MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0220 SUP HCPCS C1713 FA-0220 - SCREW BN 3.5MM 22MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0240 SUP HCPCS C1713 FA-0240 - SCREW BN 3.5MM 24MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0260 SUP HCPCS C1713 FA-0260 - SCREW BN 3.5MM 26MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0280 SUP HCPCS C1713 FA-0280 - SCREW BN 3.5MM 28MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0300 SUP HCPCS C1713 FA-0300 - SCREW BN 3.5MM 30MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0320 SUP HCPCS C1713 FA-0320 - SCREW BN 3.5MM 32MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0340 SUP HCPCS C1713 FA-0340 - SCREW BN 3.5MM 34MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0360 SUP HCPCS C1713 FA-0360 - SCREW BN 3.5MM 36MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0380 SUP HCPCS C1713 FA-0380 - SCREW BN 3.5MM 38MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0400 SUP HCPCS C1713 FA-0400 - SCREW BN 3.5MM 40MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-04020 SUP Custom 27203010 FA-04020 - KIT ARTERIAL LINE .018IN 20GA 22GA 1.75IN CATHETER RADIOPQ BOTH IP/OP $34.40 $25.46 $0.00 $45.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.53 $25.53 $0.00 $0.00 $7.17 $0.00 $0.00 $0.00 $0.00 $28.52 $45.18 $45.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FA-0420 SUP HCPCS C1713 FA-0420 - SCREW BN 3.5MM 42MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4014 SUP HCPCS C1713 FA-4014 - SCREW BN 4MM 14MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4016 SUP HCPCS C1713 FA-4016 - SCREW BN 4MM 16MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4018 SUP HCPCS C1713 FA-4018 - SCREW BN 4MM 18MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4020 SUP HCPCS C1713 FA-4020 - SCREW BN 4MM 20MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4022 SUP HCPCS C1713 FA-4022 - SCREW BN 4MM 22MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4024 SUP HCPCS C1713 FA-4024 - SCREW BN 4MM 24MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4026 SUP HCPCS C1713 FA-4026 - SCREW BN 4MM 26MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4028 SUP HCPCS C1713 FA-4028 - SCREW BN 4MM 28MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4030 SUP HCPCS C1713 FA-4030 - SCREW BN 4MM 30MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4032 SUP HCPCS C1713 FA-4032 - SCREW BN 4MM 32MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4034 SUP HCPCS C1713 FA-4034 - SCREW BN 4MM 34MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4036 SUP HCPCS C1713 FA-4036 - SCREW BN 4MM 36MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4038 SUP HCPCS C1713 FA-4038 - SCREW BN 4MM 38MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4040 SUP HCPCS C1713 FA-4040 - SCREW BN 4MM 40MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-4042 SUP HCPCS C1713 FA-4042 - SCREW BN 4MM 42MM CNN XTRMT BOTH IP/OP $492.50 $364.45 $0.00 $394.00 $221.63 $221.63 $0.00 $0.00 $0.00 $102.65 $365.53 $365.53 $0.00 $0.00 $102.64 $0.00 $291.31 $291.31 $0.00 $246.25 $390.06 $394.00 $0.00 $0.00 $77.08 $0.00 $0.00 $78.41 $0.00 $0.00 $0.00 $0.00 $0.00 FA-55150-1030 SUP HCPCS C2628 FA-55150-1030 - CATH INFUS MIC 2.8FR 3.2FR .027IN 150CM 10CM MARKSMAN BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$2,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FA-88810-20 SUP Custom 27203010 FA-88810-20 - DEVICE RTRVL 2MM ALGTR NRVSC FB ATRM DSGN SF RELS BOTH IP/OP "$6,562.50 " "$4,856.25" $0.00 "$5,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,367.63" $0.00 $0.00 $0.00 $0.00 "$3,281.25" "$5,197.50" "$5,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FA-88810-30 SUP Custom 27203010 FA-88810-30 - ALLIGATOR RETRIEVAL-30 BOTH IP/OP "$6,562.50 " "$4,856.25" $0.00 "$5,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,367.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,367.63" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,281.25" "$5,197.50" "$5,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FA-88810-40 SUP Custom 27203010 FA-88810-40 - DEVICE RTRVL ALGTR 4MM FB ATRM DSGN SF RELS BOTH IP/OP "$6,562.50 " "$4,856.25" $0.00 "$5,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,367.63" $0.00 $0.00 $0.00 $0.00 "$3,281.25" "$5,197.50" "$5,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FA-88810-50 SUP HCPCS C1773 FA-88810-50 - DEVICE SPEC RTRVL ALGTR 5MM NRVSC 4 INTLCK PLTN JAW BOTH IP/OP "$6,562.50 " "$4,856.25" $0.00 "$5,250.00" "$3,563.44" "$3,563.44" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,367.63" $0.00 $0.00 $0.00 $0.00 "$3,281.25" "$5,197.50" "$5,250.00" $0.00 $0.00 "$1,027.03" $0.00 $0.00 "$1,044.75" $0.00 $0.00 $0.00 $0.00 $0.00 FA-9020 SUP HCPCS C1713 FA-9020 - DRILL SRG XTRMT 3.5 MM SCR BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $159.75 $159.75 $0.00 $0.00 $0.00 $73.99 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $209.98 $209.98 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $55.56 $0.00 $0.00 $56.52 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO2736 SUP HCPCS C1713 FA-CO2736 - SCREW BONE 2.7MM 36MM TAP-LOC ACUMED TI ELB TAP STRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO2738 SUP HCPCS C1713 FA-CO2738 - SCREW BONE 2.7MM 38MM TI CORT TAP NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO2740 SUP HCPCS C1713 FA-CO2740 - SCREW BONE 2.7MM 40MM ACUMED TI CORT TAP NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO2745 SUP HCPCS C1713 FA-CO2745 - SCREW BONE 2.7MM 45MM TI ELB LCK TAP STRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO2750 SUP HCPCS C1713 FA-CO2750 - SCREW BONE 2.7MM 50MM TAP-LOC TI CORT ELB LCK NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO2755 SUP HCPCS C1713 FA-CO2755 - SCREW BONE 2.7MM 55MM TAP-LOC ACUMED TI ELB TAP STRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO2760 SUP HCPCS C1713 FA-CO2760 - SCREW BONE 2.7MM 60MM TAP-LOC ACUMED TI ELB TPR STRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO3536 SUP HCPCS C1713 FA-CO3536 - SCREW BONE 3.5MM 36MM TAP-LOC TI CORT LCK TAP NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO3538 SUP HCPCS C1713 FA-CO3538 - SCREW BN 3.5MM 38MM TAP LCK BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO3540 SUP HCPCS C1713 FA-CO3540 - SCREW BONE 3.5MM 40MM TAP-LOC TI ELB LCK TAP NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO3545 SUP HCPCS C1713 FA-CO3545 - SCREW BONE 3.5MM 45MM TI CORT LCK TAP NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO3550 SUP HCPCS C1713 FA-CO3550 - SCREW BN 3.5MM 50MM NS TPRLK CORT BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO3555 SUP HCPCS C1713 FA-CO3555 - SCREW BN 3.5MM 55MM NS LCK TAP TI ELB PLT SYS BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FA-CO3560 SUP HCPCS C1713 FA-CO3560 - SCREW BN 3.5MM 60MM NS LCK TAP TI ELB PLT SYS BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $104.63 $104.63 $0.00 $0.00 $0.00 $48.46 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $137.52 $137.52 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $36.39 $0.00 $0.00 $37.01 $0.00 $0.00 $0.00 $0.00 $0.00 FBRC SUP HCPCS C1884 FBRC - SYSTEM REM .035IN 10FR 75CM RCVR CN WRE BSKT RADOPQ PEBAX BOTH IP/OP "$1,593.45 " "$1,179.15" $0.00 "$1,274.76" $717.05 $717.05 $0.00 $0.00 $0.00 $332.11 "$1,182.66" "$1,182.66" $0.00 $0.00 $332.07 $0.00 $942.52 $942.52 $0.00 $796.72 "$1,262.01" "$1,274.76" $0.00 $0.00 $249.37 $0.00 $0.00 $253.68 $0.00 $0.00 $0.00 $0.00 $0.00 FCROF2005 SUP Custom 27203010 FILTER 20.5UM BOTH IP/OP $31.58 $23.37 $0.00 $25.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.79 $25.01 $25.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FD-410LR SUP Custom 27203010 FD-410LR - FORCEPS MNPLR 2.75MM 2.8MM 165X5MM STRL COAGRASPER HMSTS BOTH IP/OP $463.53 $343.01 $0.00 $370.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $344.03 $344.03 $0.00 $0.00 $96.60 $0.00 $0.00 $0.00 $0.00 $231.76 $367.12 $370.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FD-411UR SUP Custom 27203010 FD-411UR - FORCEPS MNPLR 2.75MM 3.2MM 230X4MM STRL COAGRASPER HMSTS BOTH IP/OP $588.85 $435.75 $0.00 $471.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $437.04 $437.04 $0.00 $0.00 $122.72 $0.00 $0.00 $0.00 $0.00 $294.43 $466.37 $471.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FD-412LR SUP Custom 27203010 FD-412LR - FORCEPS ESCP 2.8MM 2.75MM 165CM COAGRASPER HMST GRSPR MNPLR BOTH IP/OP $463.53 $343.01 $0.00 $370.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $344.03 $344.03 $0.00 $0.00 $96.60 $0.00 $0.00 $0.00 $0.00 $231.76 $367.12 $370.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FDB2.0 SUP Custom 27203010 BIT DRILL 2MM STRL DISP DB20 BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FE660K SUP Custom 27803010 FE660K - CLIP ANEURYSM STANDARD 10.3MM OPENING 5MM 12MM STR FENST BOTH IP/OP "$1,013.59 " $750.06 $0.00 $752.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $752.28 $752.28 $0.00 $0.00 $211.23 $0.00 $0.00 $0.00 $0.00 $460.48 $729.39 $736.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FE664K SUP Custom 27803010 FE664K - CLIP ANEURYSM 5.5MM OPEN STANDARD 5MM 10/6.4MM PERMANENT BOTH IP/OP "$1,013.59 " $750.06 $0.00 $752.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $752.28 $752.28 $0.00 $0.00 $211.23 $0.00 $0.00 $0.00 $0.00 $460.48 $729.39 $736.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FE776K SUP Custom 27803010 FE776K - CLIP ANEURYSM STANDARD 5MM OPENING 5MM 10MM CVD DOWN FENST BOTH IP/OP "$1,013.59 " $750.06 $0.00 $752.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $752.28 $752.28 $0.00 $0.00 $211.23 $0.00 $0.00 $0.00 $0.00 $460.48 $729.39 $736.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FE779K SUP Custom 27803010 FE779K - CLIP ANEURYSM STANDARD 5MM OPENING 5MM 10MM CVD UP FENST BOTH IP/OP "$1,013.59 " $750.06 $0.00 $752.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $752.28 $752.28 $0.00 $0.00 $211.23 $0.00 $0.00 $0.00 $0.00 $460.48 $729.39 $736.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FEM08040 SUP HCPCS C1876 FEM08040 - GRAFT STNT 8MM 9FR 40MM 80CM FLN + 2 LYR KINK RST INR CATH BOTH IP/OP "$7,857.50 " "$5,814.55" $0.00 "$6,286.00" "$3,535.88" "$3,535.88" $0.00 $0.00 $0.00 "$1,637.70" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,637.50" $0.00 "$3,873.75" "$3,873.75" $0.00 "$3,928.75" "$6,223.14" "$6,286.00" $0.00 $0.00 "$1,229.70" $0.00 $0.00 "$1,250.91" $0.00 $0.00 $0.00 $0.00 $0.00 FEMII016AS SUP Custom 27203010 FEMII016AS - FEM-FLEX II CANNULA 16 FR BOTH IP/OP $592.30 $438.30 $0.00 $473.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $439.61 $439.61 $0.00 $0.00 $123.44 $0.00 $0.00 $0.00 $0.00 $296.15 $469.10 $473.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FEMII018AS SUP Custom 27203010 FEMII018AS - FEM-FLEX II CANNULA 18 FR BOTH IP/OP $592.30 $438.30 $0.00 $473.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $439.61 $439.61 $0.00 $0.00 $123.44 $0.00 $0.00 $0.00 $0.00 $296.15 $469.10 $473.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FEMII020AS SUP Custom 27203010 FEMII020AS - FEM-FLEX II CANNULA 20 FR BOTH IP/OP $592.30 $438.30 $0.00 $473.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $439.61 $439.61 $0.00 $0.00 $123.44 $0.00 $0.00 $0.00 $0.00 $296.15 $469.10 $473.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FG-0201 SUP Custom 27203010 FG-0201 - DEVICE TISS REM 3.6MM SYMPHION RESCT BOTH IP/OP "$4,120.00 " "$3,048.80" $0.00 "$3,296.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,057.86" "$3,057.86" $0.00 $0.00 $858.61 $0.00 $0.00 $0.00 $0.00 "$2,060.00" "$3,263.04" "$3,296.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FG-0202 SUP Custom 27203010 FG-0202 - TISSUE REMOVAL SYSTEM FLUID MANAGEMENT ACCESSORIES BOTH IP/OP "$1,284.93 " $950.85 $0.00 "$1,027.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $953.67 $953.67 $0.00 $0.00 $267.78 $0.00 $0.00 $0.00 $0.00 $642.46 "$1,017.66" "$1,027.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FG-44NR-1 SUP Custom 27203010 FG-44NR-1 - FORCEP SPEC RTRVL 180CM 2.8MM BRNCHL FB ROT ALGTR JAW RAT BOTH IP/OP "$1,163.58 " $861.05 $0.00 $930.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $863.61 $863.61 $0.00 $0.00 $242.49 $0.00 $0.00 $0.00 $0.00 $581.79 $921.56 $930.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FGL07560 SUP HCPCS L8699 FGL07560 - GRAFT SFT TIS 7.5MM 60MM FLEXIGRAFT GRAFTLINK ALGRF FRZN BOTH IP/OP "$6,160.00 " "$4,558.40" $0.00 "$4,832.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,283.74" $0.00 $0.00 $0.00 $0.00 "$3,020.00" "$4,783.68" "$4,832.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FLT08040 SUP HCPCS C1768 STENT TRACHEOBRONCHIAL FLUENCY 8MM X 40MM SELF EXPANDING COV BOTH IP/OP "$5,737.50 " "$4,245.75" $0.00 "$4,590.00" "$2,581.88" "$2,581.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,868.75" "$4,544.10" "$4,590.00" $0.00 $0.00 $897.92 $0.00 $0.00 $913.41 $0.00 $0.00 $0.00 $0.00 $0.00 FP-07.24.0 SUP HCPCS C1713 FP-07.24.0 - CAGE SPNL 24MMX7MM FUSE 0D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-08.24.0 SUP HCPCS C1713 FP-08.24.0 - CAGE SPNL 24MMX8MM FUSE 0D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-09.24.4 SUP HCPCS C1713 FP-09.24.4 - CAGE SPNL 24MMX9MM FUSE 4D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-09.24.8 SUP HCPCS C1713 FP-09.24.8 - CAGE SPNL 24MMX9MM FUSE 8D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-10.24.4 SUP HCPCS C1713 FP-10.24.4 - CAGE SPNL 24MMX10MM FUSE 4D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-10.24.8 SUP HCPCS C1713 FP-10.24.8 - CAGE SPNL 24MMX10MM FUSE 8D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-11.24.4 SUP HCPCS C1713 FP-11.24.4 - CAGE SPNL 24MMX11MM FUSE 4D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-11.24.8 SUP HCPCS C1713 FP-11.24.8 - CAGE SPNL 24MMX11MM FUSE 8D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-12.24.4 SUP HCPCS C1713 FP-12.24.4 - CAGE SPNL 24MMX12MM FUSE 4D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-12.24.8 SUP HCPCS C1713 FP-12.24.8 - CAGE SPNL 24MMX12MM FUSE 8D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-13.24.4 SUP HCPCS C1713 FP-13.24.4 - CAGE SPNL 24MMX13MM FUSE 4D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-13.24.8 SUP HCPCS C1713 FP-13.24.8 - CAGE SPNL 24MMX13MM FUSE 8D PLIF BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" "$3,375.00" "$3,375.00" $0.00 $0.00 $0.00 "$1,563.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 "$3,697.50" "$3,697.50" $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 "$1,173.75" $0.00 $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 FP-14 SUP HCPCS C1713 FP-14 - PEG FIX 2.5MM 14MM FULTHD BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 FP-16 SUP HCPCS C1713 FP-16 - PEG FIX 2.5MM 16MM FULTHD BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 FP-20 SUP HCPCS C1713 FP-20 - PEG FIX 2.5MM 20MM FULTHD BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 FP-26 SUP HCPCS C1713 FP-26 - PEG FIX 2.5MM 26MM FULTHD BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 FP-7 SUP HCPCS C1783 FP-7 - DRAIN GLAUCOMA THK.9MM BLUNT TAPER .635MM .305MM 16X13MM 25 BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 FR995-27 SUP Custom 27803010 FR995-27 - VALVE AOR 27MM 34MM STRL 3MM FRSTL BPRTH PRCN ROOT BOTH IP/OP "$23,125.00 " "$17,112.50" $0.00 "$18,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,819.25" $0.00 $0.00 $0.00 $0.00 "$11,562.50" "$18,315.00" "$18,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FR995-29 SUP Custom 27803010 FR995-29 - FREESTYLE ROOT VALVE 29 MM BOTH IP/OP "$15,330.00 " "$11,344.20" $0.00 "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,665.00" "$12,141.36" "$12,264.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FS0808 SUP HCPCS C1781 FS0808 - GRAFT SNTH TISS 8X8CM BIO-A BABSR REINF SCFLD TISS BOTH IP/OP "$1,022.50 " $756.65 $0.00 $818.00 $460.13 $460.13 $0.00 $0.00 $0.00 $213.11 $758.90 $758.90 $0.00 $0.00 $213.09 $0.00 $604.81 $604.81 $0.00 $511.25 $809.82 $818.00 $0.00 $0.00 $160.02 $0.00 $0.00 $162.78 $0.00 $0.00 $0.00 $0.00 $0.00 FS0915 SUP HCPCS C1781 FS0915 - GRAFT SNTH TISS 15X9CM GORE BIO-A BABSR SCFLD BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $821.25 $821.25 $0.00 $0.00 $0.00 $380.38 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 "$1,079.49" "$1,079.49" $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $285.61 $0.00 $0.00 $290.54 $0.00 $0.00 $0.00 $0.00 $0.00 FS1030 SUP HCPCS C1781 FS1030 - MESH SRG 30X10CM BIO-ASNTH BABSR REINF SCFLD TRM TISS BOTH IP/OP "$5,027.50 " "$3,720.35" $0.00 "$4,022.00" "$2,262.38" "$2,262.38" $0.00 $0.00 $0.00 "$1,047.86" "$3,731.41" "$3,731.41" $0.00 $0.00 "$1,047.73" $0.00 "$2,478.56" "$2,478.56" $0.00 "$2,513.75" "$3,981.78" "$4,022.00" $0.00 $0.00 $786.80 $0.00 $0.00 $800.38 $0.00 $0.00 $0.00 $0.00 $0.00 FS2020 SUP HCPCS C1781 FS2020 - GRAFT SNTH TISS 20X20CM BIO-A BABSR REINF SCFLD TISS BOTH IP/OP "$6,712.50 " "$4,967.25" $0.00 "$5,370.00" "$3,020.63" "$3,020.63" $0.00 $0.00 $0.00 "$1,399.05" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,398.89" $0.00 "$3,309.26" "$3,309.26" $0.00 "$3,356.25" "$5,316.30" "$5,370.00" $0.00 $0.00 "$1,050.51" $0.00 $0.00 "$1,068.63" $0.00 $0.00 $0.00 $0.00 $0.00 FS2030 SUP HCPCS C1781 FS2030 - MESH SRG 30X20CM BIO-A BABSR REINF SCFLD TISS BOTH IP/OP "$10,080.00 " "$7,459.20" $0.00 "$8,064.00" "$4,536.00" "$4,536.00" $0.00 $0.00 $0.00 "$2,100.92" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,100.67" $0.00 "$4,969.44" "$4,969.44" $0.00 "$5,040.00" "$7,983.36" "$8,064.00" $0.00 $0.00 "$1,577.52" $0.00 $0.00 "$1,604.74" $0.00 $0.00 $0.00 $0.00 $0.00 FSR100201-20 SUP Custom 27803010 FSR100201-20 - COIL EMBL HLCL 2MM 1CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,165.95 " "$1,602.80" $0.00 "$1,732.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,607.57" "$1,607.57" $0.00 $0.00 $451.38 $0.00 $0.00 $0.00 $0.00 "$1,082.98" "$1,715.43" "$1,732.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100202-20 SUP Custom 27803010 FSR100202-20 - COIL EMBL HLCL 2MM 2CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,195.23 " "$1,624.47" $0.00 "$1,756.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,629.30" "$1,629.30" $0.00 $0.00 $457.48 $0.00 $0.00 $0.00 $0.00 "$1,097.61" "$1,738.62" "$1,756.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100203-20 SUP Custom 27803010 FSR100203-20 - COIL EMBL HLCL 2MM 3CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,224.50 " "$1,646.13" $0.00 "$1,779.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,651.02" "$1,651.02" $0.00 $0.00 $463.59 $0.00 $0.00 $0.00 $0.00 "$1,112.25" "$1,761.80" "$1,779.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100204-20 SUP Custom 27803010 FSR100204-20 - COIL EMBL HLCL 2MM 4CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,224.50 " "$1,646.13" $0.00 "$1,779.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,651.02" "$1,651.02" $0.00 $0.00 $463.59 $0.00 $0.00 $0.00 $0.00 "$1,112.25" "$1,761.80" "$1,779.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100206-20 SUP Custom 27803010 FSR100206-20 - COIL EMBL HLCL 2MM 6CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,253.78 " "$1,667.80" $0.00 "$1,803.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,672.75" "$1,672.75" $0.00 $0.00 $469.69 $0.00 $0.00 $0.00 $0.00 "$1,126.89" "$1,784.99" "$1,803.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100208-20 SUP Custom 27803010 FSR100208-20 - COIL EMBL HLX 2MM 8CM ULTIPAQ 10 MCIOL STRCH RS HLCL LOOP BOTH IP/OP "$2,283.05 " "$1,689.46" $0.00 "$1,826.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.48" "$1,694.48" $0.00 $0.00 $475.79 $0.00 $0.00 $0.00 $0.00 "$1,141.53" "$1,808.18" "$1,826.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100252-20 SUP Custom 27803010 FSR100252-20 - COIL EMBL HLX 2.5MM 2CM ULTIPAQ 10 MCIOL STRCH RS HLCL LOOP BOTH IP/OP "$2,195.23 " "$1,624.47" $0.00 "$1,756.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,629.30" "$1,629.30" $0.00 $0.00 $457.48 $0.00 $0.00 $0.00 $0.00 "$1,097.61" "$1,738.62" "$1,756.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100254-20 SUP Custom 27803010 FSR100254-20 - COIL EMBL HLCL 2.5MM 4CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,224.50 " "$1,646.13" $0.00 "$1,779.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,651.02" "$1,651.02" $0.00 $0.00 $463.59 $0.00 $0.00 $0.00 $0.00 "$1,112.25" "$1,761.80" "$1,779.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100256-20 SUP Custom 27803010 FSR100256-20 - COIL EMBL HLCL 2.5MM 6CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,253.78 " "$1,667.80" $0.00 "$1,803.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,672.75" "$1,672.75" $0.00 $0.00 $469.69 $0.00 $0.00 $0.00 $0.00 "$1,126.89" "$1,784.99" "$1,803.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100258-20 SUP Custom 27803010 FSR100258-20 - COIL EMBL 2.5MM 8CM ULTIPAQ 10 MCIOL STRCH RS HLCL LOOP DTCH BOTH IP/OP "$2,283.05 " "$1,689.46" $0.00 "$1,826.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.48" "$1,694.48" $0.00 $0.00 $475.79 $0.00 $0.00 $0.00 $0.00 "$1,141.53" "$1,808.18" "$1,826.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100306-20 SUP Custom 27803010 FSR100306-20 - COIL EMBL HLCL 3MM 6CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,253.78 " "$1,667.80" $0.00 "$1,803.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,672.75" "$1,672.75" $0.00 $0.00 $469.69 $0.00 $0.00 $0.00 $0.00 "$1,126.89" "$1,784.99" "$1,803.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100308-20 SUP Custom 27803010 FSR100308-20 - COIL EMBL 3MM 8CM ULTIPAQ 10 MCIOL HLCL LOOP DTCH SFT STRCH BOTH IP/OP "$2,283.05 " "$1,689.46" $0.00 "$1,826.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.48" "$1,694.48" $0.00 $0.00 $475.79 $0.00 $0.00 $0.00 $0.00 "$1,141.53" "$1,808.18" "$1,826.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100406-20 SUP Custom 27803010 FSR100406-20 - COIL EMBL HLCL 4MM 6CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,253.78 " "$1,667.80" $0.00 "$1,803.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,672.75" "$1,672.75" $0.00 $0.00 $469.69 $0.00 $0.00 $0.00 $0.00 "$1,126.89" "$1,784.99" "$1,803.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FSR100408-20 SUP Custom 27803010 FSR100408-20 - COIL EMBL HLCL 4MM 8CM ULTIPAQ 10 MCIOL STRCH RS LOOP DTCH BOTH IP/OP "$2,283.05 " "$1,689.46" $0.00 "$1,826.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,694.48" "$1,694.48" $0.00 $0.00 $475.79 $0.00 $0.00 $0.00 $0.00 "$1,141.53" "$1,808.18" "$1,826.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT-1100 SUP Custom 27203010 FT-1100 - TROCAR SURGICAL FALLER DIALYSIS CATHETER BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT-12100 SUP Custom 27803010 FT-12100 - CORONARY SHUNT 1.00 MM BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.14 $129.14 $0.00 $0.00 $36.26 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT12125 SUP Custom 27803010 FT12125 - SHUNT CARDIO BULB TAPER 1.25MM 18MM RADIOPQ FLEXIBLE BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT-12125 SUP Custom 27803010 FT-12125 - CORONARY SHUNT 1.25 MM BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.14 $129.14 $0.00 $0.00 $36.26 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT-12150 SUP Custom 27803010 FT-12150 - CORONARY SHUNT 1.50 MM BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.14 $129.14 $0.00 $0.00 $36.26 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT-12175 SUP Custom 27803010 FT-12175 - CORONARY SHUNT 1.75 MM BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.14 $129.14 $0.00 $0.00 $36.26 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT-12200 SUP Custom 27803010 FT-12200 - CORONARY SHUNT 2.00 MM BOTH IP/OP $184.60 $136.60 $0.00 $147.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.01 $137.01 $0.00 $0.00 $38.47 $0.00 $0.00 $0.00 $0.00 $92.30 $146.20 $147.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT-12225 SUP Custom 27803010 FT-12225 - CORONARY SHUNT 2.25 MM BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.14 $129.14 $0.00 $0.00 $36.26 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT12250 SUP Custom 27803010 FT12250 - SHUNT CARDIO 2.5MM 18MM FLO-THRU INTRALUMINAL BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.14 $129.14 $0.00 $0.00 $36.26 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT-12250 SUP Custom 27803010 FT-12250 - CORONARY SHUNT 2.20 MM BOTH IP/OP $174.00 $128.76 $0.00 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.00 $137.81 $139.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT180T SUP Custom 27803010 FT180T - CLIP ANEURYSM MINI 3.3MM OPENING 3MM STR TEMPORARY NARROW BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT190T SUP Custom 27803010 FT190T - CLIP ANEURYSM MINI 4MM OPENING 5MM STR NARROW TEMPORARY BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT220T SUP Custom 27803010 FT220T - CLIP ANEURYSM MINI 4.6MM OPENING 7MM STR TEMPORARY LATEX BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT222T SUP Custom 27803010 FT222T - CLIP ANEURYSM MINI 4.4MM OPENING 6.6MM CVD SLIGHTLY BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT224T SUP Custom 27803010 FT224T - CLIP ANEURYSM MINI 4MM OPENING 5MM CVD TEMPORARY LATEX FREE BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT250T SUP Custom 27803010 FT250T - CLIP ANEURYSM 7MM OPEN STANDARD 9MM TEMPORARY SPRING BOTH IP/OP $975.25 $721.69 $0.00 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.83 $723.83 $0.00 $0.00 $203.24 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT252T SUP Custom 27803010 FT252T - CLIP ANEURYSM STANDARD 6.8MM OPENING 8.3MM CVD SLIGHTLY BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT254T SUP Custom 27803010 FT254T - CLIP ANEURYSM STANDARD 6.1MM OPENING 6.4MM CVD TEMPORARY BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT280T SUP Custom 27803010 FT280T - CLIP ANEURYSM 9.2MM OPENING STANDARD 15MM TEMPORARY MRI BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT290T SUP Custom 27803010 FT290T - CLIP ANEURYSM STANDARD 11.4MM OPENING 20MM STR TEMPORARY BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT620T SUP Custom 27803010 FT620T - CLIP ANEURYSM STANDARD 9.6MM OPENING 3.5MM 12MM STR FENST BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT623T SUP Custom 27803010 FT623T - CLIP ANEURYSM 7.8MM OPENING STANDARD 10.6MM PERMANENT MRI BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT640T SUP Custom 27803010 FT640T - CLIP ANEURYSM STANDARD 7.9MM OPENING 5MM 6MM STR FENST BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT680T SUP Custom 27803010 FT680T - CLIP ANEURYSM MINI 3.3MM OPENING 3MM STR NARROW PERMANENT BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT690T SUP Custom 27803010 FT690T - CLIP ANEURYSM MINI 4MM OPENING 5MM STR NARROW PERMANENT BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT700T SUP Custom 27803010 FT700T - CLIP ANEURYSM MINI 3.5MM OPENING 3MM SLIGHTLY CVD PERMANENT BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT710T SUP Custom 27803010 FT710T - CLIP ANEURYSM MINI 4MM OPENING 5MM STR PERMANENT LATEX FREE BOTH IP/OP $975.25 $721.69 $0.00 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.83 $723.83 $0.00 $0.00 $203.24 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT712T SUP Custom 27803010 FT712T - CLIP ANEURYSM MINI 3.8MM OPENING 4.7MM CVD SLIGHTLY BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT714T SUP Custom 27803010 FT714T - CLIP ANEURYSM MINI 3.5MM OPENING 3.9MM SLIGHTLY CVD BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT720T SUP Custom 27803010 FT720T - CLIP ANEURYSM MINI 4.6MM OPENING 7MM STR PERMANENT LATEX BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT722T SUP Custom 27803010 FT722T - CLIP ANEURYSM MINI 4.4MM OPENING 6.6MM CVD SLIGHTLY BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT724T SUP Custom 27803010 FT724T - CLIP ANEURYSM MINI 4MM OPENING 5MM CVD PERMANENT LATEX FREE BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT726T SUP Custom 27803010 FT726T - CLIP ANEURYSM MINI 4MM OPENING 5.2MM SLIGHTLY CVD PERMANENT BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT727T SUP Custom 27803010 FT727T - CLIP ANEURYSM MINI 7MM OPENING 4MM BAYONET PERMANENT LATEX BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT728D SUP Custom 27803010 FT728D - CLIP ANEURYSM MINI 5.7MM OPENING 7MM BAYONET PERMANENT LATEX BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT740T SUP Custom 27803010 FT740T - CLIP ANEURYSM 6.2MM OPENING STANDARD 7MM PERMANENT MRI BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT742T SUP Custom 27803010 FT742T - CLIP ANEURYSM STANDARD 6MM OPENING 6.5MM SLIGHTLY CVD BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT744T SUP Custom 27803010 FT744T - CLIP ANEURYSM STANDARD 5.5MM OPENING 5.4MM CVD PERMANENT BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT746T SUP Custom 27803010 FT746T - CLIP ANEURYSM STANDARD 5.7MM OPENING 7MM LATERAL ANGLED BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT747T SUP Custom 27803010 FT747T - CLIP ANEURYSM 7MM OPENING STANDARD 8.6MM PERMANENT MRI BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT750T SUP Custom 27803010 FT750T - CLIP ANEURYSM STANDARD 7MM OPENING 9MM STR PERMANENT LATEX BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT752T SUP Custom 27803010 FT752T - CLIP ANEURYSM STANDARD 6.8MM OPENING 8.3MM SLIGHTLY CVD BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT754T SUP Custom 27803010 FT754T - CLIP ANEURYSM STANDARD 6.1MM OPENING 6.4MM CVD PERMANENT BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT760T SUP Custom 27803010 FT760T - CLIP ANEURYSM STANDARD 7.8MM OPENING 11MM STR PERMANENT BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT762T SUP Custom 27803010 FT762T - CLIP ANEURYSM 7.5MM OPENING STANDARD 10.2MM PERMANENT MRI BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT780D SUP Custom 27803010 FT780D - CLIP ANEURYSM 9.2MM OPENING STANDARD 15MM PERMANENT MRI BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT782T SUP Custom 27803010 FT782T - CLIP ANEURYSM STANDARD 8.7MM OPENING 13.7MM PERMANENT CVD BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT786T SUP Custom 27803010 FT786T - CLIP ANEURYSM STANDARD 9.8MM OPENING 15.3MM CVD SLIGHTLY BOTH IP/OP $975.25 $721.69 $0.00 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.83 $723.83 $0.00 $0.00 $203.24 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT790D SUP Custom 27803010 FT790D - CLIP ANEURYSM STANDARD 11.4MM OPENING 20MM STR PERMANENT BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT806T SUP Custom 27803010 FT806T - CLIP ANEURYSM MINI 4.5MM OPENING 7MM ANGLED FORWARD BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT810T SUP Custom 27803010 FT810T - CLIP ANEURYSM STANDARD 6.5MM OPENING 9MM ANGLED FORWARD BOTH IP/OP "$1,084.23 " $802.33 $0.00 $804.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.71 $804.71 $0.00 $0.00 $225.95 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FT820T SUP Custom 27803010 FT820T - CLIP ANEURYSM STANDARD 4.5MM OPENING 7MM ANGLED RIGHT BOTH IP/OP $975.25 $721.69 $0.00 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $723.83 $723.83 $0.00 $0.00 $203.24 $0.00 $0.00 $0.00 $0.00 $487.63 $772.40 $780.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FTL10040 SUP HCPCS C1876 FTL10040 - STENT TRCHBR 10MM 9FR 40MM STRL 117CM FLN + PUZZLE GFT BOTH IP/OP "$7,482.50 " "$5,537.05" $0.00 "$5,986.00" "$3,367.13" "$3,367.13" $0.00 $0.00 $0.00 "$1,559.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,559.35" $0.00 "$3,688.87" "$3,688.87" $0.00 "$3,741.25" "$5,926.14" "$5,986.00" $0.00 $0.00 "$1,171.01" $0.00 $0.00 "$1,191.21" $0.00 $0.00 $0.00 $0.00 $0.00 FTM06040 SUP HCPCS C1876 FTM06040 - STENT TRCHBR 6MM 40MM 80CM .035IN SLF XPD DLV SYS FLN PLUS BOTH IP/OP "$7,482.50 " "$5,537.05" $0.00 "$5,986.00" "$3,367.13" "$3,367.13" $0.00 $0.00 $0.00 "$1,559.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,559.35" $0.00 "$3,688.87" "$3,688.87" $0.00 "$3,741.25" "$5,926.14" "$5,986.00" $0.00 $0.00 "$1,171.01" $0.00 $0.00 "$1,191.21" $0.00 $0.00 $0.00 $0.00 $0.00 FX-4001-S SUP Custom 27203010 FX-4001-S - KIT XTRNFX STRL STABLELOC LTWT RDLCNT WRST BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 $0.00 $0.00 $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FX-4004-S SUP Custom 27203010 FX-4004-S - PIN FIX 3.2MM SLFDRILL 30MM ORTH STABLELOC STRL BOTH IP/OP $707.50 $523.55 $0.00 $566.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.11 $525.11 $0.00 $0.00 $147.44 $0.00 $0.00 $0.00 $0.00 $353.75 $560.34 $566.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 FX-4054-S SUP Custom 27203010 FX-4054-S - PIN FIX 2.7MM SLFDRILL 25MM BOTH IP/OP $707.50 $523.55 $0.00 $566.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.11 $525.11 $0.00 $0.00 $147.44 $0.00 $0.00 $0.00 $0.00 $353.75 $560.34 $566.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G00130 SUP HCPCS C1725 G00130 - CATH ANGIO .035IN 5FR 65CM STR FLXB PE BOTH IP/OP $65.00 $48.10 $0.00 $48.24 $17.65 $17.65 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $5.09 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 G00164 SUP Custom 27203010 G00164 - STOPCOCK IV .95IN CLR STRL 1 WY F TO M LL ROT ADPR LP PLS BOTH IP/OP $14.38 $10.64 $0.00 $11.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.67 $10.67 $0.00 $0.00 $3.00 $0.00 $0.00 $0.00 $0.00 $7.19 $11.39 $11.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G00165 SUP HCPCS C1770 G00165 - COIL EMBL 5CM 5MM 3.2 LOOP FBR OCL SPRG .035IN SS A/V STRL BOTH IP/OP $65.89 $48.76 $0.00 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.90 $48.90 $0.00 $0.00 $13.73 $0.00 $0.00 $0.00 $0.00 $32.94 $52.18 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G00314 SUP HCPCS C1769 G00314 - GUIDEWIRE VASC 3MM .038IN 100CM STRL SFTJ JTP HVYDTY CRV BOTH IP/OP $25.50 $18.87 $0.00 $20.40 $13.85 $13.85 $0.00 $0.00 $0.00 $5.31 $18.93 $18.93 $0.00 $0.00 $5.31 $0.00 $15.08 $15.08 $0.00 $12.75 $20.20 $20.40 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 G00321 SUP HCPCS C1769 G00321 - GUIDEWIRE VASC STRG .038IN 145CM LNDRQS RING TRQ SS PTFE BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G00331 SUP HCPCS C1769 G00331 - SET STNT .035IN 2 PGTL CRV 4.7FR 28CM STRL PSTNR GW SFLX BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G00511 SUP HCPCS C1769 G00511 - GUIDEWIRE VASCULAR CURVE TAPER .035IN 145CM 3CM FLEXIBLE TIP BOTH IP/OP $36.87 $27.28 $0.00 $28.50 $19.34 $19.34 $0.00 $0.00 $0.00 $7.69 $27.37 $27.37 $0.00 $0.00 $7.68 $0.00 $21.81 $21.81 $0.00 $17.81 $28.22 $28.50 $0.00 $0.00 $5.58 $0.00 $0.00 $5.67 $0.00 $0.00 $0.00 $0.00 $0.00 G00529 SUP HCPCS C1769 G00529 - GUIDEWIRE VASCULAR CURVE TAPER .035IN 80CM 3CM FLEXIBLE TIP BOTH IP/OP $33.10 $24.49 $0.00 $25.58 $17.36 $17.36 $0.00 $0.00 $0.00 $6.90 $24.56 $24.56 $0.00 $0.00 $6.90 $0.00 $19.58 $19.58 $0.00 $15.99 $25.33 $25.58 $0.00 $0.00 $5.00 $0.00 $0.00 $5.09 $0.00 $0.00 $0.00 $0.00 $0.00 G00593 SUP HCPCS C1769 G00593 - GUIDEWIRE VASCULAR STR TAPER .018IN 50CM FLEXIBLE TIP FIX BOTH IP/OP $32.03 $23.70 $0.00 $24.76 $16.81 $16.81 $0.00 $0.00 $0.00 $6.68 $23.77 $23.77 $0.00 $0.00 $6.68 $0.00 $18.95 $18.95 $0.00 $15.48 $24.51 $24.76 $0.00 $0.00 $4.84 $0.00 $0.00 $4.93 $0.00 $0.00 $0.00 $0.00 $0.00 G00631 SUP HCPCS C1769 G00631 - GUIDEWIRE VASC STRG .038IN 145CM FX COR SS BOTH IP/OP $45.70 $33.82 $0.00 $36.56 $24.82 $24.82 $0.00 $0.00 $0.00 $9.53 $33.92 $33.92 $0.00 $0.00 $9.52 $0.00 $27.03 $27.03 $0.00 $22.85 $36.19 $36.56 $0.00 $0.00 $7.15 $0.00 $0.00 $7.28 $0.00 $0.00 $0.00 $0.00 $0.00 G00666 SUP HCPCS C1769 G00666 - GUIDEWIRE VASC .035IN 145CM 8CM AMPTZ 2 FLX TP XSTIF SS BOTH IP/OP $52.55 $38.89 $0.00 $42.04 $28.53 $28.53 $0.00 $0.00 $0.00 $10.95 $39.00 $39.00 $0.00 $0.00 $10.95 $0.00 $31.08 $31.08 $0.00 $26.28 $41.62 $42.04 $0.00 $0.00 $8.22 $0.00 $0.00 $8.37 $0.00 $0.00 $0.00 $0.00 $0.00 G00683 SUP HCPCS C1769 G00683 - GUIDEWIRE VASC STRG TPR .028IN 145CM STRL FX COR SS PTFE BOTH IP/OP $43.38 $32.10 $0.00 $34.70 $23.55 $23.55 $0.00 $0.00 $0.00 $9.04 $32.19 $32.19 $0.00 $0.00 $9.04 $0.00 $25.66 $25.66 $0.00 $21.69 $34.36 $34.70 $0.00 $0.00 $6.79 $0.00 $0.00 $6.91 $0.00 $0.00 $0.00 $0.00 $0.00 G00691 SUP HCPCS C1769 G00691 - GWIRE VASC .035IN 145CM 20CM STR FLEXIBILE TIP FLPY BNTSN LG BOTH IP/OP $49.97 $36.98 $0.00 $39.00 $26.47 $26.47 $0.00 $0.00 $0.00 $10.41 $37.09 $37.09 $0.00 $0.00 $10.41 $0.00 $29.56 $29.56 $0.00 $24.38 $38.61 $39.00 $0.00 $0.00 $7.63 $0.00 $0.00 $7.76 $0.00 $0.00 $0.00 $0.00 $0.00 G00693 SUP HCPCS C1769 G00693 - GUIDEWIRE VASCULAR STR BENTSON CURVE .038IN 145CM 20CM BOTH IP/OP $61.88 $45.79 $0.00 $49.50 $33.60 $33.60 $0.00 $0.00 $0.00 $12.90 $45.92 $45.92 $0.00 $0.00 $12.89 $0.00 $36.60 $36.60 $0.00 $30.94 $49.01 $49.50 $0.00 $0.00 $9.68 $0.00 $0.00 $9.85 $0.00 $0.00 $0.00 $0.00 $0.00 G00785 SUP HCPCS C1769 G00785 - GUIDEWIRE VASC .045IN 145CM STRL STRG TPR FXCR SS PTFE DISP BOTH IP/OP $44.10 $32.63 $0.00 $35.28 $23.95 $23.95 $0.00 $0.00 $0.00 $9.19 $32.73 $32.73 $0.00 $0.00 $9.19 $0.00 $26.09 $26.09 $0.00 $22.05 $34.93 $35.28 $0.00 $0.00 $6.90 $0.00 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $0.00 G00852 SUP Custom 27203010 G00852 - NEEDLE BIOP 22GA 10CM CHIBA STERILE DISPOSABLE ASPIRAT BOTH IP/OP $26.58 $19.67 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.72 $19.72 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $13.29 $21.05 $21.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01035 SUP Custom 27203010 COIL 38-2-3 EMBOLIZATION MWCE BOTH IP/OP $145.00 $107.30 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.50 $114.84 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01095 SUP HCPCS C1769 G01095 - GWIRE VASC 6CM .035IN 200CM 20CM BNTSN STR ATRM TIP LG DIA BOTH IP/OP $52.53 $38.87 $0.00 $41.00 $27.83 $27.83 $0.00 $0.00 $0.00 $10.95 $38.99 $38.99 $0.00 $0.00 $10.95 $0.00 $31.07 $31.07 $0.00 $25.63 $40.59 $41.00 $0.00 $0.00 $8.02 $0.00 $0.00 $8.16 $0.00 $0.00 $0.00 $0.00 $0.00 G01184 SUP HCPCS C1770 G01184 - COIL EMBL 4CM 3MM 4.3 LOOP .038IN SS VASC STRL DISP BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01185 SUP HCPCS C1770 G01185 - COIL EMBL .038IN 5MM 5CM STRL 3.2 LOOP SS VASC BOTH IP/OP $65.89 $48.76 $0.00 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.90 $48.90 $0.00 $0.00 $13.73 $0.00 $0.00 $0.00 $0.00 $32.94 $52.18 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G011LF SUP Custom 27203010 GUIDE PRB 11GA MAMTM BRST BIOP LORAD FSCHR STRL DISP BOTH IP/OP $18.38 $13.60 $0.00 $14.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.19 $14.56 $14.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01212 SUP HCPCS C1892 G01212 - DILATOR SURG STANDARD 16FR 20CM RADIOPQ VESSEL STERILE BOTH IP/OP $19.91 $14.73 $0.00 $14.78 $9.96 $9.96 $0.00 $0.00 $0.00 $4.15 $14.78 $14.78 $0.00 $0.00 $4.15 $0.00 $11.78 $11.78 $0.00 $9.18 $14.53 $14.68 $0.00 $0.00 $2.87 $0.00 $0.00 $2.92 $0.00 $0.00 $0.00 $0.00 $0.00 G01232 SUP HCPCS C1770 G01232 - COIL EMBOLIZATION 15MM 8CM 1.7 LOOP LOAD CARTRIDGE STAINLESS BOTH IP/OP $65.89 $48.76 $0.00 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.90 $48.90 $0.00 $0.00 $13.73 $0.00 $0.00 $0.00 $0.00 $32.94 $52.18 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01261 SUP HCPCS C1769 G01261 - GUIDEWIRE VASCULAR J ROSEN CURVE .035IN 145CM 1.5CM HEAVY BOTH IP/OP $36.93 $27.33 $0.00 $28.00 $19.01 $19.01 $0.00 $0.00 $0.00 $7.70 $27.41 $27.41 $0.00 $0.00 $7.70 $0.00 $21.84 $21.84 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 G01292 SUP HCPCS C1770 G01292 - COIL EMBL .038IN 10MM 5CM STRL 1.6 LOOP SS VASC BOTH IP/OP $65.89 $48.76 $0.00 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.90 $48.90 $0.00 $0.00 $13.73 $0.00 $0.00 $0.00 $0.00 $32.94 $52.18 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01371 SUP HCPCS C1769 G01371 - GUIDEWIRE VASC .038IN 145CM AMPTZ MOV COR TPR STRG PTFE BOTH IP/OP $45.70 $33.82 $0.00 $36.56 $24.82 $24.82 $0.00 $0.00 $0.00 $9.53 $33.92 $33.92 $0.00 $0.00 $9.52 $0.00 $27.03 $27.03 $0.00 $22.85 $36.19 $36.56 $0.00 $0.00 $7.15 $0.00 $0.00 $7.28 $0.00 $0.00 $0.00 $0.00 $0.00 G01384 SUP HCPCS C1725 G01384 - CATHETER BLNDIL 80CM 4.5CM V ANDL TPR TIP ILC FEM POPLT ART BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $32.58 $32.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $9.39 $0.00 $0.00 $9.55 $0.00 $0.00 $0.00 $0.00 $0.00 G01471 SUP Custom 27203010 G01471 - DILATOR VASCULAR STANDARD 20FR 20CM RADIOPQ STERILE BOTH IP/OP $36.95 $27.34 $0.00 $27.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.42 $27.42 $0.00 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $17.03 $26.97 $27.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01472 SUP Custom 27203010 G01472 - DILATOR VASCULAR .038IN 22FR 20CM RADIOPQ GWIRE STERILE BOTH IP/OP $36.95 $27.34 $0.00 $27.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.42 $27.42 $0.00 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $17.03 $26.97 $27.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01616 SUP HCPCS C1769 G01616 - GUIDEWIRE VASC .038IN 260CM BNTSN STRG FXCR SS PTFE CRBRL BOTH IP/OP $121.25 $89.73 $0.00 $97.00 $65.84 $65.84 $0.00 $0.00 $0.00 $25.27 $89.99 $89.99 $0.00 $0.00 $25.27 $0.00 $71.72 $71.72 $0.00 $60.63 $96.03 $97.00 $0.00 $0.00 $18.98 $0.00 $0.00 $19.30 $0.00 $0.00 $0.00 $0.00 $0.00 G01618 SUP Custom 27203010 G01618 - NEEDLE PROCEDURE 21GA 7CM 1 PART ENTRY THIN WALL BOTH IP/OP $8.23 $6.09 $0.00 $6.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.11 $6.52 $6.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G01729 SUP HCPCS C1769 G01729 - GUIDEWIRE VASC STD STRG .035IN 145CM 3CM 2 FLXB SS PTFE BOTH IP/OP $39.33 $29.10 $0.00 $31.46 $21.35 $21.35 $0.00 $0.00 $0.00 $8.20 $29.19 $29.19 $0.00 $0.00 $8.20 $0.00 $23.26 $23.26 $0.00 $19.66 $31.15 $31.46 $0.00 $0.00 $6.15 $0.00 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 G01884 SUP Custom 27203010 G01884 - DILATOR VASCULAR .038IN STANDARD 24FR 20CM STANDARD RADIOPQ BOTH IP/OP $36.95 $27.34 $0.00 $27.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.42 $27.42 $0.00 $0.00 $7.70 $0.00 $0.00 $0.00 $0.00 $17.03 $26.97 $27.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G02295 SUP HCPCS C1769 G02295 - CATHETER URET UNV 4FR 70CM RTNR WDG BOTH IP/OP $4.30 $3.18 $0.00 $3.44 $2.34 $2.34 $0.00 $0.00 $0.00 $0.90 $3.19 $3.19 $0.00 $0.00 $0.90 $0.00 $2.54 $2.54 $0.00 $2.15 $3.41 $3.44 $0.00 $0.00 $0.67 $0.00 $0.00 $0.68 $0.00 $0.00 $0.00 $0.00 $0.00 G02760 SUP HCPCS C1770 G02760 - COIL EMBL 4CM 3MM 4.3 LOOP .035IN SS STRL DISP BOTH IP/OP $65.89 $48.76 $0.00 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.90 $48.90 $0.00 $0.00 $13.73 $0.00 $0.00 $0.00 $0.00 $32.94 $52.18 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G03031 SUP HCPCS C1769 G03031 - GUIDEWIRE VASCULAR STR FLOPPY TAPER .038IN 145CM FLEXIBLE BOTH IP/OP $64.58 $47.79 $0.00 $51.66 $35.06 $35.06 $0.00 $0.00 $0.00 $13.46 $47.93 $47.93 $0.00 $0.00 $13.46 $0.00 $38.20 $38.20 $0.00 $32.29 $51.15 $51.66 $0.00 $0.00 $10.11 $0.00 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 G03037 SUP HCPCS C1769 G03037 - GUIDEWIRE VASC .038IN 100CM STRL STRG TPR FXCR SS PTFE DISP BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $29.87 $29.87 $0.00 $0.00 $0.00 $11.46 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $32.53 $32.53 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $8.61 $0.00 $0.00 $8.76 $0.00 $0.00 $0.00 $0.00 $0.00 G03095 SUP HCPCS C1769 G03095 - GUIDEWIRE VASCULAR 3CM STR TAPER .035IN 145CM 7CM FLEXIBLE BOTH IP/OP $67.16 $49.70 $0.00 $51.66 $35.06 $35.06 $0.00 $0.00 $0.00 $14.00 $49.84 $49.84 $0.00 $0.00 $14.00 $0.00 $39.72 $39.72 $0.00 $32.29 $51.15 $51.66 $0.00 $0.00 $10.11 $0.00 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 G03211 SUP HCPCS C1769 G03211 - GUIDEWIRE VASC .038IN 145CM STRL STRG MOV COR SS PTFE DISP BOTH IP/OP $51.93 $38.43 $0.00 $41.54 $28.20 $28.20 $0.00 $0.00 $0.00 $10.82 $38.54 $38.54 $0.00 $0.00 $10.82 $0.00 $30.71 $30.71 $0.00 $25.96 $41.13 $41.54 $0.00 $0.00 $8.13 $0.00 $0.00 $8.27 $0.00 $0.00 $0.00 $0.00 $0.00 G03301 SUP HCPCS C1729 G03301 - SET DRAIN 29CM 9FR PTFE THOR 20 SDPRT 1 WY STPCK CATH NDL BOTH IP/OP $458.70 $339.44 $0.00 $340.45 $208.32 $208.32 $0.00 $0.00 $0.00 $95.60 $340.45 $340.45 $0.00 $0.00 $95.59 $0.00 $271.32 $271.32 $0.00 $191.83 $303.85 $306.92 $0.00 $0.00 $60.04 $0.00 $0.00 $61.08 $0.00 $0.00 $0.00 $0.00 $0.00 G03445 SUP HCPCS C1769 G03445 - GUIDEWIRE URO STD STRG .038IN 145CM STRL 3CM 2 FLX TP FXCR BOTH IP/OP $55.00 $40.70 $0.00 $44.00 $29.87 $29.87 $0.00 $0.00 $0.00 $11.46 $40.82 $40.82 $0.00 $0.00 $11.46 $0.00 $32.53 $32.53 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $8.61 $0.00 $0.00 $8.76 $0.00 $0.00 $0.00 $0.00 $0.00 G03522 SUP HCPCS C1769 G03522 - GUIDEWIRE VASC STRG TPR .035IN 145CM STRL AMPTZ MOV COR SS BOTH IP/OP $50.10 $37.07 $0.00 $40.08 $27.20 $27.20 $0.00 $0.00 $0.00 $10.44 $37.18 $37.18 $0.00 $0.00 $10.44 $0.00 $29.63 $29.63 $0.00 $25.05 $39.68 $40.08 $0.00 $0.00 $7.84 $0.00 $0.00 $7.98 $0.00 $0.00 $0.00 $0.00 $0.00 G03562 SUP HCPCS C1769 G03562 - GUIDEWIRE VASCULAR STR .035IN 260CM EXTRA STIFF SHAFT COIL BOTH IP/OP $70.20 $51.95 $0.00 $54.00 $36.65 $36.65 $0.00 $0.00 $0.00 $14.63 $52.10 $52.10 $0.00 $0.00 $14.63 $0.00 $41.52 $41.52 $0.00 $33.75 $53.46 $54.00 $0.00 $0.00 $10.56 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 G03579 SUP HCPCS C1769 G03579 - GUIDEWIRE VASCULAR STR .038IN 300CM EXTRA STIFF SHAFT BOTH IP/OP $67.50 $49.95 $0.00 $54.00 $36.65 $36.65 $0.00 $0.00 $0.00 $14.07 $50.10 $50.10 $0.00 $0.00 $14.07 $0.00 $39.93 $39.93 $0.00 $33.75 $53.46 $54.00 $0.00 $0.00 $10.56 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 G03831 SUP HCPCS C2628 G03831 - CATHETER BLNDIL 32MM 120CM CODA PU ACPT .035IN GW 12FR INTRO BOTH IP/OP "$1,042.50 " $771.45 $0.00 $834.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.28 $773.74 $773.74 $0.00 $0.00 $217.26 $0.00 $616.64 $616.64 $0.00 $521.25 $825.66 $834.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G04001 SUP HCPCS C1769 G04001 - GUIDEWIRE VASCULAR STR .035IN 300CM FLEXIBLE TIP EXTRA STIFF BOTH IP/OP $105.30 $77.92 $0.00 $81.00 $54.98 $54.98 $0.00 $0.00 $0.00 $21.95 $78.15 $78.15 $0.00 $0.00 $21.94 $0.00 $62.28 $62.28 $0.00 $50.63 $80.19 $81.00 $0.00 $0.00 $15.85 $0.00 $0.00 $16.12 $0.00 $0.00 $0.00 $0.00 $0.00 G04044 SUP HCPCS C1770 G04044 - COIL EMBL 2CM 3MM 2.1 LOOP .035IN SS STRL DISP BOTH IP/OP $65.89 $48.76 $0.00 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.90 $48.90 $0.00 $0.00 $13.73 $0.00 $0.00 $0.00 $0.00 $32.94 $52.18 $52.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G04096 SUP HCPCS C1892 G04096 - INTRODUCER SHEATH LARGE 22FR 13CM 20CM GWIRE DILAT PEEL-AWAY BOTH IP/OP $114.85 $84.99 $0.00 $90.52 $61.44 $61.44 $0.00 $0.00 $0.00 $23.94 $85.24 $85.24 $0.00 $0.00 $23.93 $0.00 $67.93 $67.93 $0.00 $56.58 $89.61 $90.52 $0.00 $0.00 $17.71 $0.00 $0.00 $18.01 $0.00 $0.00 $0.00 $0.00 $0.00 G04267 SUP HCPCS C1894 G04267 - SET ACC NEFF PERC BOTH IP/OP $208.90 $154.59 $0.00 $163.84 $111.21 $111.21 $0.00 $0.00 $0.00 $43.54 $155.04 $155.04 $0.00 $0.00 $43.53 $0.00 $123.56 $123.56 $0.00 $102.40 $162.20 $163.84 $0.00 $0.00 $32.05 $0.00 $0.00 $32.60 $0.00 $0.00 $0.00 $0.00 $0.00 G04636 SUP HCPCS C1894 G04636 - INTROD SHTH 4FR 10CM 40CM COAX CATH MPNCH SS .018IN BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $37.47 $37.47 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $0.00 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $10.80 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $0.00 G05021 SUP Custom 27203010 G05021 - COIL EMBOLIZATION .035IN X 10MM X 5CM SPRING METAL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G05060 SUP HCPCS C1725 G05060 - CATH ANGIO .035IN STD PGTL CURVE 4FR 70CM 10 SDPRT HFLO NYL BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $17.65 $17.65 $0.00 $0.00 $0.00 $6.77 $24.12 $24.12 $0.00 $0.00 $6.77 $0.00 $19.22 $19.22 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $5.09 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 G05183 SUP HCPCS C1769 G05183 - GUIDEWIRE VASCULAR ANGLED .018IN 60CM 7CM SOFT COPE MANDRIL BOTH IP/OP $97.83 $72.39 $0.00 $75.62 $51.33 $51.33 $0.00 $0.00 $0.00 $20.39 $72.61 $72.61 $0.00 $0.00 $20.39 $0.00 $57.87 $57.87 $0.00 $47.26 $74.87 $75.62 $0.00 $0.00 $14.79 $0.00 $0.00 $15.05 $0.00 $0.00 $0.00 $0.00 $0.00 G05189 SUP HCPCS C1725 G05189 - CATHETER ANGIOGRAPHIC PIGTAIL CURVE 5FR 70CM SIZING 10 BOTH IP/OP $57.75 $42.74 $0.00 $44.00 $29.87 $29.87 $0.00 $0.00 $0.00 $12.04 $42.86 $42.86 $0.00 $0.00 $12.04 $0.00 $34.16 $34.16 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $8.61 $0.00 $0.00 $8.76 $0.00 $0.00 $0.00 $0.00 $0.00 G05641 SUP Custom 27203010 G05641 - ADAPTER TUBING MALE LUER LOCK LOCK TO TUOHY BORST STOPCOCK BOTH IP/OP $25.20 $18.65 $0.00 $20.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.70 $18.70 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $12.60 $19.96 $20.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G05839 SUP Custom 27203010 G05839 - SET JJNSTM 80CM 16.5FR 24FR CR-ALZT-CNS 2 LUM 2 CATH SDPRT BOTH IP/OP $825.80 $611.09 $0.00 $660.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $612.91 $612.91 $0.00 $0.00 $172.10 $0.00 $0.00 $0.00 $0.00 $412.90 $654.03 $660.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G06299 SUP Custom 27203010 G06299 - ADAPTER CATHETER 9FR LARGE BORE SIDE ARM ROTATING MALE INFUS BOTH IP/OP $53.00 $39.22 $0.00 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.34 $39.34 $0.00 $0.00 $11.05 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G06444 SUP HCPCS C1892 G06444 - SET INTROD 18FR 15.5CM PEEL-AWAY PERCUTANEOUS STERILE BOTH IP/OP $114.85 $84.99 $0.00 $90.52 $61.44 $61.44 $0.00 $0.00 $0.00 $23.94 $85.24 $85.24 $0.00 $0.00 $23.93 $0.00 $67.93 $67.93 $0.00 $56.58 $89.61 $90.52 $0.00 $0.00 $17.71 $0.00 $0.00 $18.01 $0.00 $0.00 $0.00 $0.00 $0.00 G06445 SUP HCPCS C1892 G06445 - INTRODUCER SHEATH LARGE 20FR 13CM 20CM PEEL-AWAY BOTH IP/OP $114.85 $84.99 $0.00 $90.52 $61.44 $61.44 $0.00 $0.00 $0.00 $23.94 $85.24 $85.24 $0.00 $0.00 $23.93 $0.00 $67.93 $67.93 $0.00 $56.58 $89.61 $90.52 $0.00 $0.00 $17.71 $0.00 $0.00 $18.01 $0.00 $0.00 $0.00 $0.00 $0.00 G06446 SUP HCPCS C1892 G06446 - INTRODUCER SHEATH .038IN LARGE 24FR 13CM 20CM PEEL-AWAY BOTH IP/OP $114.85 $84.99 $0.00 $90.52 $61.44 $61.44 $0.00 $0.00 $0.00 $23.94 $85.24 $85.24 $0.00 $0.00 $23.93 $0.00 $67.93 $67.93 $0.00 $56.58 $89.61 $90.52 $0.00 $0.00 $17.71 $0.00 $0.00 $18.01 $0.00 $0.00 $0.00 $0.00 $0.00 G06447 SUP HCPCS C1892 G06447 - INTRODUCER SHEATH .038IN LARGE 26FR 13CM 20CM W/O GWIRE BOTH IP/OP $114.85 $84.99 $0.00 $90.52 $61.44 $61.44 $0.00 $0.00 $0.00 $23.94 $85.24 $85.24 $0.00 $0.00 $23.93 $0.00 $67.93 $67.93 $0.00 $56.58 $89.61 $90.52 $0.00 $0.00 $17.71 $0.00 $0.00 $18.01 $0.00 $0.00 $0.00 $0.00 $0.00 G06451 SUP HCPCS C1880 G06451 - SYSTEM EMBOLIZATION .038IN 11FR 12FR 40CM EMERGENCY CHRONIC BOTH IP/OP "$4,010.63 " "$2,967.87" $0.00 "$2,976.69" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $835.91 "$2,976.69" "$2,976.69" $0.00 $0.00 $835.81 $0.00 "$1,977.24" "$1,977.24" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 G06452 SUP HCPCS C1880 G06452 - FILTER EMBOLIZATION .038IN 40MM 11FR 75CM CATHETER GWIRE BOTH IP/OP "$4,010.63 " "$2,967.87" $0.00 "$2,976.69" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $835.91 "$2,976.69" "$2,976.69" $0.00 $0.00 $835.81 $0.00 "$1,977.24" "$1,977.24" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 G06491 SUP HCPCS C1892 G06491 - SET INTROD .038IN 11FR 15.5CM PEEL-AWAY PERCUTANEOUS STERILE BOTH IP/OP $114.85 $84.99 $0.00 $90.52 $61.44 $61.44 $0.00 $0.00 $0.00 $23.94 $85.24 $85.24 $0.00 $0.00 $23.93 $0.00 $67.93 $67.93 $0.00 $56.58 $89.61 $90.52 $0.00 $0.00 $17.71 $0.00 $0.00 $18.01 $0.00 $0.00 $0.00 $0.00 $0.00 G06492 SUP HCPCS C1892 G06492 - SET INTROD .038IN 12FR 15.5CM PEEL-AWAY PERCUTANEOUS STERILE BOTH IP/OP $114.85 $84.99 $0.00 $90.52 $61.44 $61.44 $0.00 $0.00 $0.00 $23.94 $85.24 $85.24 $0.00 $0.00 $23.93 $0.00 $67.93 $67.93 $0.00 $56.58 $89.61 $90.52 $0.00 $0.00 $17.71 $0.00 $0.00 $18.01 $0.00 $0.00 $0.00 $0.00 $0.00 G06541 SUP HCPCS C1894 G06541 - SET INTERVENTIONAL 9FR 16GA 38.5CM 50.5CM INTROD SHEATH BOTH IP/OP "$1,215.25 " $899.29 $0.00 $972.20 $659.88 $659.88 $0.00 $0.00 $0.00 $253.29 $901.96 $901.96 $0.00 $0.00 $253.26 $0.00 $718.82 $718.82 $0.00 $607.63 $962.48 $972.20 $0.00 $0.00 $190.19 $0.00 $0.00 $193.47 $0.00 $0.00 $0.00 $0.00 $0.00 G06929 SUP Custom 27203010 G06929 - SET INTERVENTIONAL .038IN 10FR 40CM 62.5CM CATHETER CANNU BOTH IP/OP "$1,101.30 " $814.96 $0.00 $881.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $817.38 $817.38 $0.00 $0.00 $229.51 $0.00 $0.00 $0.00 $0.00 $550.65 $872.23 $881.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G07090 SUP HCPCS C1729 G07090 - TRAY DRAIN 14FR 41CM 4 SIDEPORT RADIOPQ ENTRY NEEDLE SCALPEL BOTH IP/OP $424.90 $314.43 $0.00 $315.36 $205.24 $205.24 $0.00 $0.00 $0.00 $88.56 $315.36 $315.36 $0.00 $0.00 $88.55 $0.00 $251.33 $251.33 $0.00 $188.99 $299.36 $302.38 $0.00 $0.00 $59.15 $0.00 $0.00 $60.17 $0.00 $0.00 $0.00 $0.00 $0.00 G07429 SUP HCPCS C1894 G07429 - SET INTROD 6FR 13CM 20CM SIDEARM FITTING SIDE CONNECT LINE BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $27.15 $27.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $7.83 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $0.00 G07465 SUP HCPCS C1894 G07465 - INTRODUCER SHEATH 9FR 30CM SMALL VALVE ASMBLY RADIOPQ BAND BOTH IP/OP $177.63 $131.45 $0.00 $140.00 $95.03 $95.03 $0.00 $0.00 $0.00 $37.02 $131.83 $131.83 $0.00 $0.00 $37.02 $0.00 $105.07 $105.07 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 G07914 SUP HCPCS C1769 G07914 - GUIDEWIRE VASCULAR TAPER .035IN 145CM RADIOPQ FLOPPY TIP BOTH IP/OP $97.50 $72.15 $0.00 $75.00 $50.91 $50.91 $0.00 $0.00 $0.00 $20.32 $72.36 $72.36 $0.00 $0.00 $20.32 $0.00 $57.67 $57.67 $0.00 $46.88 $74.25 $75.00 $0.00 $0.00 $14.67 $0.00 $0.00 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 G07937 SUP HCPCS C1769 G07937 - GUIDEWIRE VASCULAR ANGLE TAPER .035IN 180CM 9CM RADIOPQ BOTH IP/OP $97.50 $72.15 $0.00 $75.00 $50.91 $50.91 $0.00 $0.00 $0.00 $20.32 $72.36 $72.36 $0.00 $0.00 $20.32 $0.00 $57.67 $57.67 $0.00 $46.88 $74.25 $75.00 $0.00 $0.00 $14.67 $0.00 $0.00 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 G08113 SUP Custom 27203010 G08113 - CATHETER ANGIOGRAPHIC SLIP-CATH BEACON TIP HYDROPHILIC OD18 BOTH IP/OP $313.20 $231.77 $0.00 $250.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.46 $232.46 $0.00 $0.00 $65.27 $0.00 $0.00 $0.00 $0.00 $156.60 $248.05 $250.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G08259 SUP Custom 27203010 G08259 - COIL EMBOLIZATION .018IN 6-2MM 7CM SOFT MICROCOIL TORNADO BOTH IP/OP $275.33 $203.74 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.35 $204.35 $0.00 $0.00 $57.38 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G08261 SUP HCPCS C1770 G08261 - COIL EMBL 2CM 3-2MM TRND MCIOL MLFRM SFT .018IN PLTN BOTH IP/OP $275.33 $203.74 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.35 $204.35 $0.00 $0.00 $57.38 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G08283 SUP Custom 27203010 G08283 - SET BIOP 60CM 18GA 7FR Q COR CHK FLO VLV ADPR HVDTY FRNG BOTH IP/OP "$1,075.00 " $795.50 $0.00 $860.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $797.87 $797.87 $0.00 $0.00 $224.03 $0.00 $0.00 $0.00 $0.00 $537.50 $851.40 $860.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G08417 SUP HCPCS C1729 G08417 - SET GSTRM 14FR 1 LUM 6 SDPRT CATH GWIRE NDL LOOP W-O 30CM BOTH IP/OP $301.63 $223.21 $0.00 $241.30 $163.78 $163.78 $0.00 $0.00 $0.00 $62.87 $223.87 $223.87 $0.00 $0.00 $62.86 $0.00 $178.41 $178.41 $0.00 $150.81 $238.89 $241.30 $0.00 $0.00 $47.20 $0.00 $0.00 $48.02 $0.00 $0.00 $0.00 $0.00 $0.00 G08421 SUP HCPCS C1725 G08421 - CATHETER ANGIOGRAPHIC HEADHUNTER 1 CURVE 5FR 100CM TORCON NB BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G08422 SUP HCPCS C1725 G08422 - CATHETER ANGIOGRAPHIC ANGLE SIMMONS 2 CURVE 5FR 100CM BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G08427 SUP HCPCS C1769 G08427 - GUIDEWIRE VASCULAR ANGLE TAPER .018IN 60CM SOFT TIP COPE BOTH IP/OP $119.34 $88.31 $0.00 $92.24 $62.61 $62.61 $0.00 $0.00 $0.00 $24.87 $88.57 $88.57 $0.00 $0.00 $24.87 $0.00 $70.59 $70.59 $0.00 $57.65 $91.32 $92.24 $0.00 $0.00 $18.04 $0.00 $0.00 $18.36 $0.00 $0.00 $0.00 $0.00 $0.00 G08441 SUP HCPCS C1725 G08441 - CATHETER ANGIOGRAPHIC C1 CURVE ANGLE 5FR 65CM MULTPUR TORCON BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G08442 SUP HCPCS C1725 G08442 - CATH ANGIO .035IN C2 CURVE 5FR 65CM VSCR ANG MULTPUR NYL SS BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $17.65 $17.65 $0.00 $0.00 $0.00 $6.77 $24.12 $24.12 $0.00 $0.00 $6.77 $0.00 $19.22 $19.22 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $5.09 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 G08471 SUP HCPCS C1725 G08471 - CATHETER ANGIOGRAPHIC SIMMONS 1 CURVE 5FR 100CM TORCON NB BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G08515 SUP HCPCS C1725 G08515 - CATH ANGIO .035IN NEFF CURVE 5FR 80CM 8 SDPRT NYL SS TRNB AD BOTH IP/OP $40.55 $30.01 $0.00 $32.44 $22.02 $22.02 $0.00 $0.00 $0.00 $8.45 $30.10 $30.10 $0.00 $0.00 $8.45 $0.00 $23.99 $23.99 $0.00 $20.28 $32.12 $32.44 $0.00 $0.00 $6.35 $0.00 $0.00 $6.46 $0.00 $0.00 $0.00 $0.00 $0.00 G08581 SUP HCPCS C1884 G08581 - CATHETER ANGIOGRAPHIC DAV CURVE ANGLE 5FR 100CM MULTPUR BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $28.13 $28.13 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G08597 SUP HCPCS C1725 G08597 - CATHETER ANGIOGRAPHIC SIMMONS 3 CURVE 5FR 100CM TORCON NB BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G08686 SUP HCPCS C1894 G08686 - SET INTRO 10FR 3.3MM 30CM STRL 41CM CKFL DISP ACPT .038IN GW BOTH IP/OP $111.80 $82.73 $0.00 $86.00 $58.37 $58.37 $0.00 $0.00 $0.00 $23.30 $82.98 $82.98 $0.00 $0.00 $23.30 $0.00 $66.13 $66.13 $0.00 $53.75 $85.14 $86.00 $0.00 $0.00 $16.82 $0.00 $0.00 $17.11 $0.00 $0.00 $0.00 $0.00 $0.00 G08699 SUP Custom 27203010 G08699 - CATHETER ANGIOGRAPHIC DAV CURVE ANGLE 5FR 100CM MULTPUR BOTH IP/OP $325.00 $240.50 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G08777 SUP HCPCS C1769 G08777 - GUIDEWIRE VASCULAR ANGLE SPRING COIL .014IN 180CM HEAVY DUTY BOTH IP/OP $282.30 $208.90 $0.00 $222.50 $151.02 $151.02 $0.00 $0.00 $0.00 $58.84 $209.52 $209.52 $0.00 $0.00 $58.83 $0.00 $166.98 $166.98 $0.00 $139.06 $220.28 $222.50 $0.00 $0.00 $43.53 $0.00 $0.00 $44.28 $0.00 $0.00 $0.00 $0.00 $0.00 G08801 SUP HCPCS C1769 G08801 - GUIDEWIRE VASCULAR TAPER FLOPPY ANGLE SPRING COIL .014IN 300 BOTH IP/OP $310.85 $230.03 $0.00 $245.00 $166.29 $166.29 $0.00 $0.00 $0.00 $64.79 $230.71 $230.71 $0.00 $0.00 $64.78 $0.00 $183.86 $183.86 $0.00 $153.13 $242.55 $245.00 $0.00 $0.00 $47.93 $0.00 $0.00 $48.76 $0.00 $0.00 $0.00 $0.00 $0.00 G08943 SUP HCPCS C1725 G08943 - CATH ANGIO .038IN 7FR 100CM PULM 4 SDPRT MONT1 TIP GW FLXB BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $17.65 $17.65 $0.00 $0.00 $0.00 $6.77 $24.12 $24.12 $0.00 $0.00 $6.77 $0.00 $19.22 $19.22 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $5.09 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 G08957 SUP HCPCS C1894 G08957 - SET INTROD .038IN 14FR 30CM 41CM RADIOPQ DILAT SIDEARM FIT BOTH IP/OP $330.20 $244.35 $0.00 $254.00 $172.40 $172.40 $0.00 $0.00 $0.00 $68.82 $245.07 $245.07 $0.00 $0.00 $68.81 $0.00 $195.31 $195.31 $0.00 $158.75 $251.46 $254.00 $0.00 $0.00 $49.69 $0.00 $0.00 $50.55 $0.00 $0.00 $0.00 $0.00 $0.00 G09215 SUP HCPCS C1770 G09215 - COIL EMBOLIZATION .018IN 8-4MM 9.5CM MICROCOIL SOFT SPACED BOTH IP/OP $275.33 $203.74 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.35 $204.35 $0.00 $0.00 $57.38 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G09409 SUP HCPCS C1725 G09409 - CATH ANGIO .035IN 4FR 70CM 10 SDPRT STR HFLO ATRM TIP DSGN BOTH IP/OP $46.88 $34.69 $0.00 $37.50 $25.45 $25.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 G09411 SUP HCPCS C1725 G09411 - CATH ANGIO .035IN 5FR 70CM 10 SDPRT STR HFLO ATRM TIP DSGN BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $17.65 $17.65 $0.00 $0.00 $0.00 $6.77 $24.12 $24.12 $0.00 $0.00 $6.77 $0.00 $19.22 $19.22 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $5.09 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 G09469 SUP HCPCS C1725 G09469 - CATHETER ANGIOGRAPHIC ANGLE KMP CURVE TAPER 5FR 65CM LP BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G09479 SUP HCPCS C1894 G09479 - INTRODUCER CATHETER .038IN 7FR 40CM BALKIN UP AND OVER BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 G09497 SUP HCPCS C1729 G09497 - CATHETER DRAIN 8.5FR 40CM 32 SIDEPORT RADIOPQ BAND MAC-LOC BOTH IP/OP $253.65 $187.70 $0.00 $199.92 $135.70 $135.70 $0.00 $0.00 $0.00 $52.87 $188.26 $188.26 $0.00 $0.00 $52.86 $0.00 $150.03 $150.03 $0.00 $124.95 $197.92 $199.92 $0.00 $0.00 $39.11 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 G09498 SUP HCPCS C1729 G09498 - CATHETER DRAIN 10.2FR 40CM 32 SIDEPORT RADIOPQ BAND MAC-LOC BOTH IP/OP $253.65 $187.70 $0.00 $199.92 $135.70 $135.70 $0.00 $0.00 $0.00 $52.87 $188.26 $188.26 $0.00 $0.00 $52.86 $0.00 $150.03 $150.03 $0.00 $124.95 $197.92 $199.92 $0.00 $0.00 $39.11 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 G09499 SUP HCPCS C1729 G09499 - CATHETER DRAIN 12FR 40CM 32 SIDEPORT RADIOPQ BAND MAC-LOC BOTH IP/OP $253.65 $187.70 $0.00 $199.92 $135.70 $135.70 $0.00 $0.00 $0.00 $52.87 $188.26 $188.26 $0.00 $0.00 $52.86 $0.00 $150.03 $150.03 $0.00 $124.95 $197.92 $199.92 $0.00 $0.00 $39.11 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 G09500 SUP HCPCS C1729 G09500 - CATHETER DRAIN 14FR 40CM 8CM 32 SIDEPORT LOCK MECHANISM BOTH IP/OP $253.65 $187.70 $0.00 $199.92 $135.70 $135.70 $0.00 $0.00 $0.00 $52.87 $188.26 $188.26 $0.00 $0.00 $52.86 $0.00 $150.03 $150.03 $0.00 $124.95 $197.92 $199.92 $0.00 $0.00 $39.11 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 G09501 SUP HCPCS C1729 G09501 - CATHETER DRAIN 8.5FR 25CM 6 SIDEPORT TROCAR MULTPUR RADIOPQ BOTH IP/OP $254.90 $188.63 $0.00 $199.92 $135.70 $135.70 $0.00 $0.00 $0.00 $53.13 $189.18 $189.18 $0.00 $0.00 $53.12 $0.00 $150.77 $150.77 $0.00 $124.95 $197.92 $199.92 $0.00 $0.00 $39.11 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 G09502 SUP HCPCS C1729 G09502 - CATHETER DRAIN 10.2FR 25CM 6 SIDEPORT LOCK LOOP RADIOPQ BAND BOTH IP/OP $254.90 $188.63 $0.00 $199.92 $135.70 $135.70 $0.00 $0.00 $0.00 $53.13 $189.18 $189.18 $0.00 $0.00 $53.12 $0.00 $150.77 $150.77 $0.00 $124.95 $197.92 $199.92 $0.00 $0.00 $39.11 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 G09503 SUP HCPCS C1729 G09503 - CATHETER DRAIN .038IN 12FR 25CM 6 SIDEPORT MAC LOC LOCKING BOTH IP/OP $254.90 $188.63 $0.00 $199.92 $135.70 $135.70 $0.00 $0.00 $0.00 $53.13 $189.18 $189.18 $0.00 $0.00 $53.12 $0.00 $150.77 $150.77 $0.00 $124.95 $197.92 $199.92 $0.00 $0.00 $39.11 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 G09504 SUP HCPCS C1729 G09504 - CATHETER DRAIN .038IN 14FR 25CM 6 SIDEPORT MAC-LOC LOCKING BOTH IP/OP $254.90 $188.63 $0.00 $199.92 $135.70 $135.70 $0.00 $0.00 $0.00 $53.13 $189.18 $189.18 $0.00 $0.00 $53.12 $0.00 $150.77 $150.77 $0.00 $124.95 $197.92 $199.92 $0.00 $0.00 $39.11 $0.00 $0.00 $39.78 $0.00 $0.00 $0.00 $0.00 $0.00 G09607 SUP HCPCS C1769 G09607 - GUIDEWIRE VASCULAR .035IN 145CM ANGLE SHORT TAPER FLEXIBLE BOTH IP/OP $97.50 $72.15 $0.00 $75.00 $50.91 $50.91 $0.00 $0.00 $0.00 $20.32 $72.36 $72.36 $0.00 $0.00 $20.32 $0.00 $57.67 $57.67 $0.00 $46.88 $74.25 $75.00 $0.00 $0.00 $14.67 $0.00 $0.00 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 G09691 SUP HCPCS C1892 G09691 - INTRODUCER SHEATH .038IN LARGE 16FR 30CM 42CM RADIOPQ BAND BOTH IP/OP $328.61 $243.17 $0.00 $254.00 $172.40 $172.40 $0.00 $0.00 $0.00 $68.49 $243.90 $243.90 $0.00 $0.00 $68.48 $0.00 $194.37 $194.37 $0.00 $158.75 $251.46 $254.00 $0.00 $0.00 $49.69 $0.00 $0.00 $50.55 $0.00 $0.00 $0.00 $0.00 $0.00 G09751 SUP HCPCS C1725 G09751 - CATHETER ANGIOGRAPHIC KMP CURVE 5FR 40CM TORCON NB ADVANTAGE BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G09954 SUP HCPCS C1769 G09954 - GUIDEWIRE VASCULAR STR .035IN 145CM FLEXIBLE TIP ULTRA-STIFF BOTH IP/OP $67.16 $49.70 $0.00 $51.66 $35.06 $35.06 $0.00 $0.00 $0.00 $14.00 $49.84 $49.84 $0.00 $0.00 $14.00 $0.00 $39.72 $39.72 $0.00 $32.29 $51.15 $51.66 $0.00 $0.00 $10.11 $0.00 $0.00 $10.28 $0.00 $0.00 $0.00 $0.00 $0.00 G09956 SUP HCPCS C1769 G09956 - GUIDEWIRE VASCULAR STR .035IN 180CM FLEXIBLE TIP ULTRA-STIFF BOTH IP/OP $89.70 $66.38 $0.00 $69.00 $46.83 $46.83 $0.00 $0.00 $0.00 $18.70 $66.58 $66.58 $0.00 $0.00 $18.69 $0.00 $53.06 $53.06 $0.00 $43.13 $68.31 $69.00 $0.00 $0.00 $13.50 $0.00 $0.00 $13.73 $0.00 $0.00 $0.00 $0.00 $0.00 G10205 SUP Custom 27203010 G10205 - DILATOR VASCULAR .025IN 4FR 20CM DECREASED FRICTION RADIOPQ BOTH IP/OP $26.75 $19.80 $0.00 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.38 $21.19 $21.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G10210 SUP Custom 27203010 G10210 - TRAY PERICARDIOCENTESIS PIGTAIL CURVE 8.3FR 18GA 40CM 15CM 6 BOTH IP/OP $473.75 $350.58 $0.00 $379.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.62 $351.62 $0.00 $0.00 $98.73 $0.00 $0.00 $0.00 $0.00 $236.88 $375.21 $379.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G10292 SUP HCPCS C1758 G10292 - DILATOR VASCULAR 12FR 20CM RADIOPQ HYDPHI STERILE DISPOSABLE BOTH IP/OP $29.03 $21.48 $0.00 $21.54 $14.53 $14.53 $0.00 $0.00 $0.00 $6.05 $21.54 $21.54 $0.00 $0.00 $6.05 $0.00 $17.17 $17.17 $0.00 $13.38 $21.19 $21.40 $0.00 $0.00 $4.19 $0.00 $0.00 $4.26 $0.00 $0.00 $0.00 $0.00 $0.00 G10383 SUP HCPCS C1894 G10383 - INTRODUCER SHEATH 6FR 40CM OVER CONTRALATERAL RADIOPQ BAND BOTH IP/OP $194.06 $143.60 $0.00 $150.00 $101.81 $101.81 $0.00 $0.00 $0.00 $40.45 $144.03 $144.03 $0.00 $0.00 $40.44 $0.00 $114.79 $114.79 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G10405 SUP HCPCS C1894 G10405 - INTROD SHTH 7FR 40CM BLK U-O CNTRLT DSGN RADIOPQ BAND W/O BOTH IP/OP $154.70 $114.48 $0.00 $123.76 $84.00 $84.00 $0.00 $0.00 $0.00 $32.24 $114.82 $114.82 $0.00 $0.00 $32.24 $0.00 $91.51 $91.51 $0.00 $77.35 $122.52 $123.76 $0.00 $0.00 $24.21 $0.00 $0.00 $24.63 $0.00 $0.00 $0.00 $0.00 $0.00 G10414 SUP HCPCS C1770 G10414 - COIL EMBOLIZATION .035IN STANDARD SMALL 4-3MM 2.6CM TORNADO BOTH IP/OP $275.33 $203.74 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.35 $204.35 $0.00 $0.00 $57.38 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G10415 SUP HCPCS C1770 G10415 - COIL EMBOLIZATION .035IN STANDARD SMALL 5-3MM 4.1CM SOFT BOTH IP/OP $275.33 $203.74 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.35 $204.35 $0.00 $0.00 $57.38 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G10417 SUP HCPCS C1770 G10417 - COIL EMBOLIZATION 7-3MM 8CM TORNADO PLATINUM ARTERIOVENOUS BOTH IP/OP $275.33 $203.74 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.35 $204.35 $0.00 $0.00 $57.38 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G10455 SUP HCPCS C1725 G10455 - CATHETER ANGIOGRAPHIC MPA CURVE 5FR 65CM TORCON NB ADVANTAGE BOTH IP/OP $60.00 $44.40 $0.00 $44.53 $29.87 $29.87 $0.00 $0.00 $0.00 $12.51 $44.53 $44.53 $0.00 $0.00 $12.50 $0.00 $35.49 $35.49 $0.00 $27.50 $43.56 $44.00 $0.00 $0.00 $8.61 $0.00 $0.00 $8.76 $0.00 $0.00 $0.00 $0.00 $0.00 G10460 SUP HCPCS C1894 G10460 - SET ACCES 15CM 6FR 22GA 4FR NEFF .018IN PERC HYDPHI CHBA NDL BOTH IP/OP $249.38 $184.54 $0.00 $199.50 $135.41 $135.41 $0.00 $0.00 $0.00 $51.98 $185.09 $185.09 $0.00 $0.00 $51.97 $0.00 $147.51 $147.51 $0.00 $124.69 $197.51 $199.50 $0.00 $0.00 $39.03 $0.00 $0.00 $39.70 $0.00 $0.00 $0.00 $0.00 $0.00 G10554 SUP Custom 27203010 G10554 - SET INTUBATION .038IN 3MM 14FR 70CM 110CM RTRGRD RADIOPQ BOTH IP/OP $383.33 $283.66 $0.00 $284.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $284.50 $284.50 $0.00 $0.00 $79.88 $0.00 $0.00 $0.00 $0.00 $158.13 $250.47 $253.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G10722 SUP Custom 27203010 G10722 - NEEDLE INTRAOSSEOUS 15.5GA 3CM 2 OPPOSE SIDEPORT INFUS BOTH IP/OP $111.25 $82.33 $0.00 $89.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.57 $82.57 $0.00 $0.00 $23.18 $0.00 $0.00 $0.00 $0.00 $55.63 $88.11 $89.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G10992 SUP Custom 27203010 G10992 - CATH IU DISP HSG BOTH IP/OP $299.49 $221.62 $0.00 $239.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.74 $237.20 $239.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G11017 SUP HCPCS C1894 G11017 - INTROD CATH 40CM 8FR .038IN CHK-FLO PRFRMR BLK U-O CNTRLT BOTH IP/OP $337.50 $249.75 $0.00 $270.00 $183.26 $183.26 $0.00 $0.00 $0.00 $70.34 $250.49 $250.49 $0.00 $0.00 $70.34 $0.00 $199.63 $199.63 $0.00 $168.75 $267.30 $270.00 $0.00 $0.00 $52.82 $0.00 $0.00 $53.73 $0.00 $0.00 $0.00 $0.00 $0.00 G11189 SUP HCPCS C1892 G11189 - CATHETER ANGIOGRAPHIC VISCERAL 1 CURVE 5FR 80CM TORCON NB BOTH IP/OP $65.00 $48.10 $0.00 $48.24 $25.45 $25.45 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 G11240 SUP HCPCS C1894 G11240 - SET INTROD .038IN 11FR 70CM RADIOPQ BAND CHK-FLO PERFORMER BOTH IP/OP $247.00 $182.78 $0.00 $190.00 $128.96 $128.96 $0.00 $0.00 $0.00 $51.48 $183.32 $183.32 $0.00 $0.00 $51.47 $0.00 $146.10 $146.10 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 G11667 SUP HCPCS C1769 G11667 - GUIDEWIRE VASC CRV .035IN 260CM STRL 2MM RDRR PC THE FIRM BOTH IP/OP $122.50 $90.65 $0.00 $90.92 $50.91 $50.91 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $46.88 $74.25 $75.00 $0.00 $0.00 $14.67 $0.00 $0.00 $14.93 $0.00 $0.00 $0.00 $0.00 $0.00 G11672 SUP HCPCS C1894 G11672 - INTRODUCER SHEATH .038IN LARGE 18FR 30CM 42CM RADIOPQ BAND BOTH IP/OP $328.61 $243.17 $0.00 $254.00 $172.40 $172.40 $0.00 $0.00 $0.00 $68.49 $243.90 $243.90 $0.00 $0.00 $68.48 $0.00 $194.37 $194.37 $0.00 $158.75 $251.46 $254.00 $0.00 $0.00 $49.69 $0.00 $0.00 $50.55 $0.00 $0.00 $0.00 $0.00 $0.00 G11916 SUP HCPCS C1884 G11916 - CATHETER ANGIO PGTL CRV 5FR 100CM AUROUS 10 SDPRT RADOPQ SZ BOTH IP/OP $343.13 $253.92 $0.00 $274.50 $154.41 $154.41 $0.00 $0.00 $0.00 $71.52 $254.67 $254.67 $0.00 $0.00 $71.51 $0.00 $202.96 $202.96 $0.00 $171.56 $271.76 $274.50 $0.00 $0.00 $53.70 $0.00 $0.00 $54.63 $0.00 $0.00 $0.00 $0.00 $0.00 G12016 SUP HCPCS C1769 G12016 - GUIDEWIRE VASC .018IN 8FR 6.5FR 20CM STRL 15CM JEFFREY SET BOTH IP/OP $324.31 $239.99 $0.00 $254.36 $172.65 $172.65 $0.00 $0.00 $0.00 $67.59 $240.70 $240.70 $0.00 $0.00 $67.59 $0.00 $191.83 $191.83 $0.00 $158.98 $251.82 $254.36 $0.00 $0.00 $49.76 $0.00 $0.00 $50.62 $0.00 $0.00 $0.00 $0.00 $0.00 G12082 SUP HCPCS C1884 G12082 - CATHETER ANGIO VTK CRBRL CRV 5FR 125CM SCTH BTP BRD RADOPQ BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 G12168 SUP HCPCS C1884 G12168 - CATH ANGIO .038IN VERT CURVE 5FR 125CM RADIOPQ LUB SRFC BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $55.13 $55.13 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 G12170 SUP HCPCS C1725 G12170 - CATHETER ANGIOGRAPHIC .038IN VERT CURVE 5FR 125CM LP RADIOPQ BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G12179 SUP Custom 27203010 G12179 - CATH ANGIO .038IN TEGT CURVE 5FR 65CM HYDPHI SCTH BTP BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $0.00 $0.00 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G12266 SUP HCPCS C1894 G12266 - SHEATH GUID 6FR 2.2MM 90CM CHK-FLO VALVE SOFT TIP RADIOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $101.81 $101.81 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G12423 SUP HCPCS C1894 G12423 - SET INTROD .018IN 6FR 20CM 13CM ACCES NEEDLE PLATINUM TIP BOTH IP/OP $104.50 $77.33 $0.00 $77.56 $51.59 $51.59 $0.00 $0.00 $0.00 $21.78 $77.56 $77.56 $0.00 $0.00 $21.78 $0.00 $61.81 $61.81 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $14.87 $0.00 $0.00 $15.12 $0.00 $0.00 $0.00 $0.00 $0.00 G12513 SUP Custom 27203010 G12513 - TRAY TRCH 24-28FR CGL BRHN STD HYDPHI SHLY PERC TUBE DILAT BOTH IP/OP $800.00 $592.00 $0.00 $670.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $0.00 $0.00 $0.00 $419.21 $664.04 $670.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G12560 SUP HCPCS C1894 G12560 - SET INTROD 10CM 4FR MPNCH PSH+ .018IN GWIRE PLTN TIP CATH 40 BOTH IP/OP $122.93 $90.97 $0.00 $98.34 $66.75 $66.75 $0.00 $0.00 $0.00 $25.62 $91.23 $91.23 $0.00 $0.00 $25.62 $0.00 $72.71 $72.71 $0.00 $61.46 $97.36 $98.34 $0.00 $0.00 $19.24 $0.00 $0.00 $19.57 $0.00 $0.00 $0.00 $0.00 $0.00 G12565 SUP HCPCS C1894 G12565 - TRAY TRCH 8FR STRL SHLY CGL BLU RHINO JTP NDL GD CATH RADOPQ BOTH IP/OP "$1,096.10 " $811.11 $0.00 "$1,305.12" $885.85 $885.85 $0.00 $0.00 $0.00 $228.45 $813.53 $813.53 $0.00 $0.00 $228.43 $0.00 $648.34 $648.34 $0.00 $815.70 "$1,292.07" "$1,305.12" $0.00 $0.00 $255.31 $0.00 $0.00 $259.72 $0.00 $0.00 $0.00 $0.00 $0.00 G12580 SUP HCPCS C1763 G12580 - GRAFT SFT TIS 10X7CM 4 SHT FRZDR SIS ES PIG ACLR CLGN MTRX BOTH IP/OP "$2,262.50 " "$1,674.25" $0.00 "$1,810.00" "$1,018.13" "$1,018.13" $0.00 $0.00 $0.00 $471.56 "$1,679.23" "$1,679.23" $0.00 $0.00 $471.51 $0.00 "$1,338.27" "$1,338.27" $0.00 "$1,131.25" "$1,791.90" "$1,810.00" $0.00 $0.00 $354.08 $0.00 $0.00 $360.19 $0.00 $0.00 $0.00 $0.00 $0.00 G12831 SUP HCPCS C1894 G12831 - INTRODUCER SHEATH 25CM DILAT NONTAPER CLOSE CHK-FLO XL AQ 41 BOTH IP/OP $847.50 $627.15 $0.00 $678.00 $460.19 $460.19 $0.00 $0.00 $0.00 $176.64 $629.01 $629.01 $0.00 $0.00 $176.62 $0.00 $501.30 $501.30 $0.00 $423.75 $671.22 $678.00 $0.00 $0.00 $132.63 $0.00 $0.00 $134.92 $0.00 $0.00 $0.00 $0.00 $0.00 G12835 SUP HCPCS C1894 G12835 - INTRODUCER CATHETER 7FR 2.5MM 90CM TUOHY BORST SIDEARM DILAT BOTH IP/OP $390.71 $289.13 $0.00 $302.00 $204.98 $204.98 $0.00 $0.00 $0.00 $81.43 $289.99 $289.99 $0.00 $0.00 $81.42 $0.00 $231.11 $231.11 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 G12847 SUP HCPCS C1763 G12847 - GUIDEWIRE ESCP STRG .038IN 145CM 2 FLX TP BOTH IP/OP $872.83 $645.89 $0.00 $698.26 $392.77 $392.77 $0.00 $0.00 $0.00 $181.92 $647.81 $647.81 $0.00 $0.00 $181.90 $0.00 $516.28 $516.28 $0.00 $436.41 $691.28 $698.26 $0.00 $0.00 $136.60 $0.00 $0.00 $138.95 $0.00 $0.00 $0.00 $0.00 $0.00 G12848 SUP HCPCS C1763 G12848 - GRAFT SFT TIS 10X7CM SURGISIS 1 LYR SHT PEEL OPN DRY PRCN BOTH IP/OP "$2,391.50 " "$1,769.71" $0.00 "$1,913.20" "$1,076.18" "$1,076.18" $0.00 $0.00 $0.00 $498.45 "$1,774.97" "$1,774.97" $0.00 $0.00 $498.39 $0.00 "$1,414.57" "$1,414.57" $0.00 "$1,195.75" "$1,894.07" "$1,913.20" $0.00 $0.00 $374.27 $0.00 $0.00 $380.73 $0.00 $0.00 $0.00 $0.00 $0.00 G13032 SUP HCPCS C1894 G13032 - INTRODUCER CATHETER .038IN 10IN 30CM LARGE VALVE ASMBLY BOTH IP/OP $192.85 $142.71 $0.00 $152.00 $103.17 $103.17 $0.00 $0.00 $0.00 $40.19 $143.13 $143.13 $0.00 $0.00 $40.19 $0.00 $114.07 $114.07 $0.00 $95.00 $150.48 $152.00 $0.00 $0.00 $29.74 $0.00 $0.00 $30.25 $0.00 $0.00 $0.00 $0.00 $0.00 G13033 SUP HCPCS C1894 G13033 - INTRODUCER SHEATH .038IN 10FR 80CM LARGE VALVE ASMBLY BOTH IP/OP $268.98 $199.05 $0.00 $212.00 $143.90 $143.90 $0.00 $0.00 $0.00 $56.06 $199.63 $199.63 $0.00 $0.00 $56.05 $0.00 $159.10 $159.10 $0.00 $132.50 $209.88 $212.00 $0.00 $0.00 $41.47 $0.00 $0.00 $42.19 $0.00 $0.00 $0.00 $0.00 $0.00 G13081 SUP HCPCS C1894 G13081 - INTRODUCER CATHETER .035IN 10FR 38.5CM CHK FLO VALVE RADIOPQ BOTH IP/OP $214.23 $158.53 $0.00 $171.38 $116.32 $116.32 $0.00 $0.00 $0.00 $44.65 $159.00 $159.00 $0.00 $0.00 $44.64 $0.00 $126.71 $126.71 $0.00 $107.11 $169.67 $171.38 $0.00 $0.00 $33.53 $0.00 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $0.00 G13116 SUP HCPCS C1763 G13116 - GRAFT SFT TIS 20X7CM SURGISIS BIODESIGN 4 PLY SHT PRCN ACLR BOTH IP/OP "$1,309.23 " $968.83 $0.00 "$1,047.38" $589.15 $589.15 $0.00 $0.00 $0.00 $272.88 $971.71 $971.71 $0.00 $0.00 $272.84 $0.00 $774.41 $774.41 $0.00 $654.61 "$1,036.91" "$1,047.38" $0.00 $0.00 $204.89 $0.00 $0.00 $208.43 $0.00 $0.00 $0.00 $0.00 $0.00 G13166 SUP HCPCS C1769 G13166 - TRAY TRCH STRL SHLY CGL BLU RHINO PERC DISP BOTH IP/OP "$1,096.10 " $811.11 $0.00 "$1,406.18" $954.44 $954.44 $0.00 $0.00 $0.00 $228.45 $813.53 $813.53 $0.00 $0.00 $228.43 $0.00 $648.34 $648.34 $0.00 $878.86 "$1,392.11" "$1,406.18" $0.00 $0.00 $275.08 $0.00 $0.00 $279.83 $0.00 $0.00 $0.00 $0.00 $0.00 G13287 SUP HCPCS C1773 G13287 - SET RETRIEVAL 6.3FR 11FR 80CM 60CM LOOP CATHETER GUNTHER BOTH IP/OP $879.37 $650.73 $0.00 $652.67 $339.38 $339.38 $0.00 $0.00 $0.00 $183.28 $652.67 $652.67 $0.00 $0.00 $183.26 $0.00 $520.15 $520.15 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 G13338 SUP HCPCS C1894 G13338 - INTRODUCER SHEATH 7FR .1IN 80CM TUOHY BORST SIDEARM RADIOPQ BOTH IP/OP $390.71 $289.13 $0.00 $302.00 $204.98 $204.98 $0.00 $0.00 $0.00 $81.43 $289.99 $289.99 $0.00 $0.00 $81.42 $0.00 $231.11 $231.11 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 G13389 SUP HCPCS C1876 G13389 - STENT VASC 6MM 40MM 80CM .035IN SLF XPD DLV SYS ZL NTNL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 G13398 SUP HCPCS C1876 G13398 - STENT VASC 8MM 30MM 80CM SLF XPD DLV SYS ZL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 G13399 SUP HCPCS C1876 G13399 - STENT BIL 9MM 7FR 40MM 80CM .035IN SLF XPD PRELD DLV SYS ZL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 G13400 SUP HCPCS C1876 G13400 - STENT BIL 8MM 6CM 80CM .035IN SLF XPD PRELD DLV SYS ZL NTNL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 G13404 SUP HCPCS C1876 G13404 - STENT VASC 9MM 40MM 80CM SLF XPD DLV SYS ZL BOTH IP/OP $2.50 $1.85 $0.00 $2.00 $1.13 $1.13 $0.00 $0.00 $0.00 $0.52 $1.86 $1.86 $0.00 $0.00 $0.52 $0.00 $1.48 $1.48 $0.00 $1.25 $1.98 $2.00 $0.00 $0.00 $0.39 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 G13539 SUP HCPCS C1894 G13539 - INTRODUCER SHEATH .038IN 6FR .087IN 80CM GWIRE FLEXOR BOTH IP/OP $390.71 $289.13 $0.00 $302.00 $204.98 $204.98 $0.00 $0.00 $0.00 $81.43 $289.99 $289.99 $0.00 $0.00 $81.42 $0.00 $231.11 $231.11 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 G13559 SUP HCPCS C1725 G13559 - CATH ANGIO .038IN CHG-A CURVE 5FR 80CM VSCR NYL SS TRNB AD BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $47.51 $47.51 $0.00 $0.00 $0.00 $18.24 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $51.76 $51.76 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 G13561 SUP HCPCS C1725 G13561 - CATHETER ANGIOGRAPHIC CHUANG C CURVE 5FR 80CM TORCON NB BOTH IP/OP $65.00 $48.10 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.55 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $38.45 $38.45 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 G13793 SUP Custom 27203010 G13793 - CATHETER ANGIOGRAPHIC 65CM MULTPUR TORCON NB ADVANTAGE BOTH IP/OP $65.00 $48.10 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.24 $48.24 $0.00 $0.00 $13.55 $0.00 $0.00 $0.00 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G13806 SUP HCPCS C1763 G13806 - GRAFT SFT TIS 7X4CM SURGISIS BIODESIGN 4 PLY PRCN ACLR CLGN BOTH IP/OP "$1,870.33 " "$1,384.04" $0.00 "$1,496.26" $841.65 $841.65 $0.00 $0.00 $0.00 $389.82 "$1,388.16" "$1,388.16" $0.00 $0.00 $389.78 $0.00 "$1,106.30" "$1,106.30" $0.00 $935.16 "$1,481.30" "$1,496.26" $0.00 $0.00 $292.71 $0.00 $0.00 $297.76 $0.00 $0.00 $0.00 $0.00 $0.00 G13807 SUP HCPCS C1763 G13807 - GRAFT SFT TIS 10X7CM SURGISIS BIODESIGN 4 PLY PRCN ACLR CLGN BOTH IP/OP $897.75 $664.34 $0.00 $718.20 $403.99 $403.99 $0.00 $0.00 $0.00 $187.11 $666.31 $666.31 $0.00 $0.00 $187.09 $0.00 $531.02 $531.02 $0.00 $448.88 $711.02 $718.20 $0.00 $0.00 $140.50 $0.00 $0.00 $142.92 $0.00 $0.00 $0.00 $0.00 $0.00 G13808 SUP HCPCS C1763 G13808 - GRAFT SFT TIS 3.5X5CM SURGISIS BIODESIGN 4 PLY PRCN ACLR BOTH IP/OP $993.60 $735.26 $0.00 $794.88 $447.12 $447.12 $0.00 $0.00 $0.00 $207.09 $737.45 $737.45 $0.00 $0.00 $207.07 $0.00 $587.71 $587.71 $0.00 $496.80 $786.93 $794.88 $0.00 $0.00 $155.50 $0.00 $0.00 $158.18 $0.00 $0.00 $0.00 $0.00 $0.00 G13816 SUP HCPCS C1769 G13816 - GUIDEWIRE ENDSCP STR STANDARD .035IN 480CM PURPLE STERILE BOTH IP/OP $192.50 $142.45 $0.00 $154.00 $104.53 $104.53 $0.00 $0.00 $0.00 $40.12 $142.87 $142.87 $0.00 $0.00 $40.12 $0.00 $113.86 $113.86 $0.00 $96.25 $152.46 $154.00 $0.00 $0.00 $30.13 $0.00 $0.00 $30.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14014 SUP HCPCS C1758 G14014 - GRAFT SFT TIS 2X3CM SURGISIS BIODESIGN FRZDR PRCN ACLR CLGN BOTH IP/OP $276.25 $204.43 $0.00 $221.00 $150.00 $150.00 $0.00 $0.00 $0.00 $57.58 $205.03 $205.03 $0.00 $0.00 $57.57 $0.00 $163.40 $163.40 $0.00 $138.13 $218.79 $221.00 $0.00 $0.00 $43.23 $0.00 $0.00 $43.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14015 SUP HCPCS C1758 G14015 - CATHETER URET 3FR 70CM FLXTP CLS END RT BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14016 SUP HCPCS C1758 G14016 - CATHETER URET 4FR 70CM LF FLXTP CLS END FLX TP RT BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14017 SUP HCPCS C1758 G14017 - CATHETER URET 5FR 70CM LF FLXTP CLS END RT BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14018 SUP HCPCS C1758 G14018 - CATHETER URET 6FR 70CM LF FLXTP CLS END FLX TP RT BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14019 SUP HCPCS C1758 G14019 - CATHETER URET 7FR 70CM FLXTP CLS END RT BOTH IP/OP $31.77 $23.51 $0.00 $25.42 $17.25 $17.25 $0.00 $0.00 $0.00 $6.62 $23.58 $23.58 $0.00 $0.00 $6.62 $0.00 $18.79 $18.79 $0.00 $15.89 $25.16 $25.42 $0.00 $0.00 $4.97 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 G14022 SUP HCPCS C1758 G14022 - CATHETER URET 8FR 70CM LF FLXTP CLS END FLX TP RT BOTH IP/OP $31.77 $23.51 $0.00 $25.42 $17.25 $17.25 $0.00 $0.00 $0.00 $6.62 $23.58 $23.58 $0.00 $0.00 $6.62 $0.00 $18.79 $18.79 $0.00 $15.89 $25.16 $25.42 $0.00 $0.00 $4.97 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 G14023 SUP HCPCS C1758 G14023 - CATHETER URET 3FR 70CM FLXTP CLS END FLX TP LT BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14024 SUP HCPCS C1758 G14024 - CATHETER URET 4FR 70CM FLXTP CLS END FLX TP LT BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14025 SUP HCPCS C1758 G14025 - CATHETER URET 5FR 70CM LF FLXTP CLS END FLX TP LT BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14026 SUP HCPCS C1758 G14026 - CATHETER URET 6FR 70CM FLXTP CLS END LT BOTH IP/OP $31.77 $23.51 $0.00 $25.42 $17.25 $17.25 $0.00 $0.00 $0.00 $6.62 $23.58 $23.58 $0.00 $0.00 $6.62 $0.00 $18.79 $18.79 $0.00 $15.89 $25.16 $25.42 $0.00 $0.00 $4.97 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 G14027 SUP HCPCS C1758 G14027 - CATHETER URET 7FR 70CM FLXTP CLS END LT BOTH IP/OP $31.77 $23.51 $0.00 $25.42 $17.25 $17.25 $0.00 $0.00 $0.00 $6.62 $23.58 $23.58 $0.00 $0.00 $6.62 $0.00 $18.79 $18.79 $0.00 $15.89 $25.16 $25.42 $0.00 $0.00 $4.97 $0.00 $0.00 $5.06 $0.00 $0.00 $0.00 $0.00 $0.00 G14034 SUP HCPCS C1758 G14034 - CATHETER URET 8FR 70CM WHSTLTP RT BOTH IP/OP $2.78 $2.06 $0.00 $2.23 $1.51 $1.51 $0.00 $0.00 $0.00 $0.58 $2.07 $2.07 $0.00 $0.00 $0.58 $0.00 $1.65 $1.65 $0.00 $1.39 $2.20 $2.23 $0.00 $0.00 $0.44 $0.00 $0.00 $0.44 $0.00 $0.00 $0.00 $0.00 $0.00 G14035 SUP HCPCS C1758 G14035 - CATHETER URET 9FR 70CM WHSTLTP RT BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14040 SUP HCPCS C1758 G14040 - CATHETER URET 6FR 70CM WHSTLTP LT BOTH IP/OP $26.88 $19.89 $0.00 $21.51 $14.60 $14.60 $0.00 $0.00 $0.00 $5.60 $19.95 $19.95 $0.00 $0.00 $5.60 $0.00 $15.90 $15.90 $0.00 $13.44 $21.29 $21.51 $0.00 $0.00 $4.21 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $0.00 G14041 SUP HCPCS C1758 G14041 - CATHETER URET WHSTL 7FR 70CM LT BOTH IP/OP $26.88 $19.89 $0.00 $21.51 $14.60 $14.60 $0.00 $0.00 $0.00 $5.60 $19.95 $19.95 $0.00 $0.00 $5.60 $0.00 $15.90 $15.90 $0.00 $13.44 $21.29 $21.51 $0.00 $0.00 $4.21 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $0.00 G14046 SUP HCPCS C1758 G14046 - CATHETER URET 6FR 70CM RND TIP LT BOTH IP/OP $26.88 $19.89 $0.00 $21.51 $14.60 $14.60 $0.00 $0.00 $0.00 $5.60 $19.95 $19.95 $0.00 $0.00 $5.60 $0.00 $15.90 $15.90 $0.00 $13.44 $21.29 $21.51 $0.00 $0.00 $4.21 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $0.00 G14047 SUP HCPCS C1758 G14047 - CATHETER URET 7FR 70CM RND TIP LT BOTH IP/OP $26.88 $19.89 $0.00 $21.51 $14.60 $14.60 $0.00 $0.00 $0.00 $5.60 $19.95 $19.95 $0.00 $0.00 $5.60 $0.00 $15.90 $15.90 $0.00 $13.44 $21.29 $21.51 $0.00 $0.00 $4.21 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $0.00 G14048 SUP HCPCS C1758 G14048 - CATHETER URET 8FR 70CM RND TIP LT BOTH IP/OP $2.78 $2.06 $0.00 $2.23 $1.51 $1.51 $0.00 $0.00 $0.00 $0.58 $2.07 $2.07 $0.00 $0.00 $0.58 $0.00 $1.65 $1.65 $0.00 $1.39 $2.20 $2.23 $0.00 $0.00 $0.44 $0.00 $0.00 $0.44 $0.00 $0.00 $0.00 $0.00 $0.00 G14049 SUP HCPCS C1758 G14049 - CATHETER URET 9FR 70CM RND TIP LT BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14050 SUP HCPCS C1758 G14050 - CATHETER URET 10FR 70CM RND TIP LT BOTH IP/OP $26.88 $19.89 $0.00 $21.51 $14.60 $14.60 $0.00 $0.00 $0.00 $5.60 $19.95 $19.95 $0.00 $0.00 $5.60 $0.00 $15.90 $15.90 $0.00 $13.44 $21.29 $21.51 $0.00 $0.00 $4.21 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $0.00 G14053 SUP HCPCS C1758 G14053 - CATHETER URET RND 5FR 70CM STY NTCH PORT LT BOTH IP/OP $26.88 $19.89 $0.00 $21.51 $14.60 $14.60 $0.00 $0.00 $0.00 $5.60 $19.95 $19.95 $0.00 $0.00 $5.60 $0.00 $15.90 $15.90 $0.00 $13.44 $21.29 $21.51 $0.00 $0.00 $4.21 $0.00 $0.00 $4.28 $0.00 $0.00 $0.00 $0.00 $0.00 G14054 SUP HCPCS C1758 G14054 - CATHETER URET RND 6FR 70CM STY NTCH PORT LT BOTH IP/OP $2.78 $2.06 $0.00 $2.23 $1.51 $1.51 $0.00 $0.00 $0.00 $0.58 $2.07 $2.07 $0.00 $0.00 $0.58 $0.00 $1.65 $1.65 $0.00 $1.39 $2.20 $2.23 $0.00 $0.00 $0.44 $0.00 $0.00 $0.44 $0.00 $0.00 $0.00 $0.00 $0.00 G14055 SUP HCPCS C1758 G14055 - CATHETER URET 7FR 70CM RND TIP RT BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14056 SUP HCPCS C1758 G14056 - CATHETER URET PGTL CRV 4.7FR 45CM DRETLER MTLNTH BOTH IP/OP $276.25 $204.43 $0.00 $221.00 $150.00 $150.00 $0.00 $0.00 $0.00 $57.58 $205.03 $205.03 $0.00 $0.00 $57.57 $0.00 $163.40 $163.40 $0.00 $138.13 $218.79 $221.00 $0.00 $0.00 $43.23 $0.00 $0.00 $43.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14057 SUP HCPCS C1758 G14057 - CATHETER URET RND 8FR 70CM STY NTCH PORT RT BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14099 SUP HCPCS C2627 G14099 - CATH SPBC STAMEY 14FR 25CM OBT CONNCTNG TUBE STPCK PERC STRL BOTH IP/OP $95.63 $70.77 $0.00 $76.50 $51.92 $51.92 $0.00 $0.00 $0.00 $0.00 $70.97 $70.97 $0.00 $0.00 $19.93 $0.00 $0.00 $0.00 $0.00 $47.81 $75.74 $76.50 $0.00 $0.00 $14.97 $0.00 $0.00 $15.22 $0.00 $0.00 $0.00 $0.00 $0.00 G14120 SUP HCPCS C1729 G14120 - TUBE CONNCTNG STANDARD 14FR 50CM MALE LUER LOCK LOCK LOCK BOTH IP/OP $40.70 $30.12 $0.00 $32.56 $22.10 $22.10 $0.00 $0.00 $0.00 $8.48 $30.21 $30.21 $0.00 $0.00 $8.48 $0.00 $24.07 $24.07 $0.00 $20.35 $32.23 $32.56 $0.00 $0.00 $6.37 $0.00 $0.00 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 G14121 SUP HCPCS C1729 G14121 - TUBE CNCT 14FR 30CM T-B 2 F LL Y 1 DRN BG CNCT ADPR BOTH IP/OP $40.70 $30.12 $0.00 $32.56 $22.10 $22.10 $0.00 $0.00 $0.00 $8.48 $30.21 $30.21 $0.00 $0.00 $8.48 $0.00 $24.07 $24.07 $0.00 $20.35 $32.23 $32.56 $0.00 $0.00 $6.37 $0.00 $0.00 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 G14127 SUP HCPCS C1773 G14127 - STOPCOCK IV 3W 2 F TO 1 M LL PLS PERC BOTH IP/OP $398.45 $294.85 $0.00 $318.76 $216.36 $216.36 $0.00 $0.00 $0.00 $83.05 $295.73 $295.73 $0.00 $0.00 $83.04 $0.00 $235.68 $235.68 $0.00 $199.23 $315.57 $318.76 $0.00 $0.00 $62.36 $0.00 $0.00 $63.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14133 SUP HCPCS C2627 G14133 - DISK RTNT 14FR PERC BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14134 SUP HCPCS C2627 G14134 - DILATOR URTH 6FR 20CM PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14135 SUP HCPCS C2627 G14135 - DILATOR URTH 7FR 20CM STRL PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14136 SUP HCPCS C2627 G14136 - DILATOR URTH 7FR 20CM STRL PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14137 SUP HCPCS C2627 G14137 - DILATOR URTH 9FR 20CM PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14138 SUP HCPCS C2627 G14138 - DILATOR URTH 10FR 20CM PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14139 SUP HCPCS C2627 G14139 - DILATOR URTH 12FR 20CM PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14140 SUP HCPCS C2627 G14140 - DILATOR URTH 14FR 20CM PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14141 SUP HCPCS C2627 G14141 - DILATOR URTH 16FR 20CM PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14143 SUP HCPCS C1758 G14143 - DILATOR URTH 18FR 20CM STRL PE FSCA BOTH IP/OP $123.83 $91.63 $0.00 $99.06 $67.24 $67.24 $0.00 $0.00 $0.00 $25.81 $91.90 $91.90 $0.00 $0.00 $25.81 $0.00 $73.24 $73.24 $0.00 $61.91 $98.07 $99.06 $0.00 $0.00 $19.38 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $0.00 G14144 SUP HCPCS C1758 G14144 - SET CATH .025IN PGTL CRV 4FR 70CM STRL 145CM SDPRT GW PU RT BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14145 SUP HCPCS C1758 G14145 - SET CATH PGTL CRV 5FR .38IN 70CM STRL 145CM SDPRT GW RT BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14146 SUP HCPCS C1758 G14146 - SET CATH .038IN PGTL CRV 5FR 70CM 145CM SDPRT GW LFRIC SRFC BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14147 SUP HCPCS C1758 G14147 - SET CATH PGTL CRV 7FR .045IN 70CM STRL 145CM SDPRT GW RT BOTH IP/OP $123.83 $91.63 $0.00 $99.06 $67.24 $67.24 $0.00 $0.00 $0.00 $25.81 $91.90 $91.90 $0.00 $0.00 $25.81 $0.00 $73.24 $73.24 $0.00 $61.91 $98.07 $99.06 $0.00 $0.00 $19.38 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $0.00 G14148 SUP HCPCS C1758 G14148 - SET CATH .025IN PGTL CRV 4FR 70CM 145CM SDPRT GW LFRIC SRFC BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14149 SUP HCPCS C1758 G14149 - SET CATH .038IN PGTL CRV 5FR 70CM 145CM SDPRT GW LFRIC SRFC BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14150 SUP HCPCS C1758 G14150 - SET CATH .038IN PGTL CRV 6FR 70CM 145CM SDPRT GW LFRIC SRFC BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14151 SUP HCPCS C1758 G14151 - SET CATH .045IN PGTL CRV 7FR 70CM 145CM SDPRT GW LFRIC SRFC BOTH IP/OP $123.83 $91.63 $0.00 $99.06 $67.24 $67.24 $0.00 $0.00 $0.00 $25.81 $91.90 $91.90 $0.00 $0.00 $25.81 $0.00 $73.24 $73.24 $0.00 $61.91 $98.07 $99.06 $0.00 $0.00 $19.38 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $0.00 G14152 SUP HCPCS C1758 G14152 - SET CATH .025IN PGTL CRV 4FR 70CM STRL 145CM SDPRT GW ALONG BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14153 SUP HCPCS C1758 G14153 - SET CATH .038IN PGTL CRV 6FR 70CM STRL 145CM SDPRT GW ALONG BOTH IP/OP $123.83 $91.63 $0.00 $99.06 $67.24 $67.24 $0.00 $0.00 $0.00 $25.81 $91.90 $91.90 $0.00 $0.00 $25.81 $0.00 $73.24 $73.24 $0.00 $61.91 $98.07 $99.06 $0.00 $0.00 $19.38 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $0.00 G14155 SUP HCPCS C1758 G14155 - SET CATH .045IN PGTL CRV 7FR 70CM 145CM SDPRT GW ALONG SHFT BOTH IP/OP $123.83 $91.63 $0.00 $99.06 $67.24 $67.24 $0.00 $0.00 $0.00 $25.81 $91.90 $91.90 $0.00 $0.00 $25.81 $0.00 $73.24 $73.24 $0.00 $61.91 $98.07 $99.06 $0.00 $0.00 $19.38 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $0.00 G14156 SUP HCPCS C1758 G14156 - SET CATH .038IN PGTL CRV 5FR 70CM STRL 145CM SDPRT GW ALONG BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14157 SUP HCPCS C1758 G14157 - SET CATH .038IN PGTL CRV 6FR 70CM 145CM SDPRT GW ALONG SHFT BOTH IP/OP $123.83 $91.63 $0.00 $99.06 $67.24 $67.24 $0.00 $0.00 $0.00 $25.81 $91.90 $91.90 $0.00 $0.00 $25.81 $0.00 $73.24 $73.24 $0.00 $61.91 $98.07 $99.06 $0.00 $0.00 $19.38 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $0.00 G14158 SUP HCPCS C1758 G14158 - SET CATH .045IN PGTL CRV 7FR 70CM 145CM SDPRT GW ALONG SHFT BOTH IP/OP $108.45 $80.25 $0.00 $86.76 $58.89 $58.89 $0.00 $0.00 $0.00 $22.60 $80.49 $80.49 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.89 $86.76 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 G14173 SUP HCPCS C2627 G14173 - SET CATH .038IN PGTL CRV 5FR 70CM 145CM SDPRT GW ALONG SHFT BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14174 SUP HCPCS C2627 G14174 - DILATOR URTH 24FR 20CM PE FSCA BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14175 SUP HCPCS C2627 G14175 - DILATOR URTH 20FR 20CM STRL PE FSCA DISP BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14177 SUP HCPCS C2627 G14177 - DILATOR URTH 22FR 20CM STRL PE FSCA DISP BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $0.00 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G14178 SUP Custom 27203010 G14178 - DILATOR URTH 5FR 20CM STRL PE FSCA DISP BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14185 SUP HCPCS C1769 G14185 - SHEATH ACC 12FR 13CM LF FLXR PRLL RPD RELS WKG CHNL LFRIC BOTH IP/OP $510.95 $378.10 $0.00 $408.76 $277.45 $277.45 $0.00 $0.00 $0.00 $106.49 $379.23 $379.23 $0.00 $0.00 $106.48 $0.00 $302.23 $302.23 $0.00 $255.48 $404.67 $408.76 $0.00 $0.00 $79.96 $0.00 $0.00 $81.34 $0.00 $0.00 $0.00 $0.00 $0.00 G14186 SUP HCPCS C2627 G14186 - STYLET NPHSTM 14FR FLXB BOTH IP/OP $63.25 $46.81 $0.00 $50.60 $34.34 $34.34 $0.00 $0.00 $0.00 $0.00 $46.94 $46.94 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $31.63 $50.09 $50.60 $0.00 $0.00 $9.90 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 G14187 SUP HCPCS C2627 G14187 - DILATOR URTH 8FR 37CM STRL PE FSCA DISP BOTH IP/OP $63.25 $46.81 $0.00 $50.60 $34.34 $34.34 $0.00 $0.00 $0.00 $0.00 $46.94 $46.94 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $31.63 $50.09 $50.60 $0.00 $0.00 $9.90 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 G14188 SUP HCPCS C2627 G14188 - DILATOR URTH 10FR 37CM STRL PE FSCA DISP BOTH IP/OP $63.25 $46.81 $0.00 $50.60 $34.34 $34.34 $0.00 $0.00 $0.00 $0.00 $46.94 $46.94 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $31.63 $50.09 $50.60 $0.00 $0.00 $9.90 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 G14189 SUP HCPCS C2627 G14189 - DILATOR URTH 12FR 37CM STRL PE FSCA DISP BOTH IP/OP $63.25 $46.81 $0.00 $50.60 $34.34 $34.34 $0.00 $0.00 $0.00 $0.00 $46.94 $46.94 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $31.63 $50.09 $50.60 $0.00 $0.00 $9.90 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 G14190 SUP HCPCS C2627 G14190 - DILATOR URTH 14FR 37CM STRL PE FSCA DISP BOTH IP/OP $63.25 $46.81 $0.00 $50.60 $34.34 $34.34 $0.00 $0.00 $0.00 $0.00 $46.94 $46.94 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $31.63 $50.09 $50.60 $0.00 $0.00 $9.90 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 G14191 SUP HCPCS C2627 G14191 - DILATOR URTH 16FR 37CM PE FSCA BOTH IP/OP $63.25 $46.81 $0.00 $50.60 $34.34 $34.34 $0.00 $0.00 $0.00 $0.00 $46.94 $46.94 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $31.63 $50.09 $50.60 $0.00 $0.00 $9.90 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 G14192 SUP HCPCS C2627 G14192 - DILATOR URTH 20FR 37CM PE FSCA BOTH IP/OP $63.25 $46.81 $0.00 $50.60 $34.34 $34.34 $0.00 $0.00 $0.00 $0.00 $46.94 $46.94 $0.00 $0.00 $13.18 $0.00 $0.00 $0.00 $0.00 $31.63 $50.09 $50.60 $0.00 $0.00 $9.90 $0.00 $0.00 $10.07 $0.00 $0.00 $0.00 $0.00 $0.00 G14193 SUP HCPCS C2627 G14193 - DILATOR URTH 22FR 37CM STRL DISP BOTH IP/OP $72.73 $53.82 $0.00 $58.18 $39.49 $39.49 $0.00 $0.00 $0.00 $0.00 $53.98 $53.98 $0.00 $0.00 $15.16 $0.00 $0.00 $0.00 $0.00 $36.36 $57.60 $58.18 $0.00 $0.00 $11.38 $0.00 $0.00 $11.58 $0.00 $0.00 $0.00 $0.00 $0.00 G14194 SUP HCPCS C2627 G14194 - DILATOR URTH 24FR 37CM STRL DISP BOTH IP/OP $75.28 $55.71 $0.00 $60.22 $40.87 $40.87 $0.00 $0.00 $0.00 $0.00 $55.87 $55.87 $0.00 $0.00 $15.69 $0.00 $0.00 $0.00 $0.00 $37.64 $59.62 $60.22 $0.00 $0.00 $11.78 $0.00 $0.00 $11.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14195 SUP HCPCS C2627 G14195 - DILATOR URTH 8FR 37CM SDPRT PE FSCA BOTH IP/OP $65.45 $48.43 $0.00 $52.36 $35.54 $35.54 $0.00 $0.00 $0.00 $0.00 $48.58 $48.58 $0.00 $0.00 $13.64 $0.00 $0.00 $0.00 $0.00 $32.73 $51.84 $52.36 $0.00 $0.00 $10.24 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 G14196 SUP HCPCS C2627 G14196 - DILATOR URTH 10FR 37CM STRL SDPRT DISP BOTH IP/OP $65.45 $48.43 $0.00 $52.36 $35.54 $35.54 $0.00 $0.00 $0.00 $0.00 $48.58 $48.58 $0.00 $0.00 $13.64 $0.00 $0.00 $0.00 $0.00 $32.73 $51.84 $52.36 $0.00 $0.00 $10.24 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 G14197 SUP HCPCS C2627 G14197 - DILATOR URTH 12FR 37CM SDPRT PE FSCA BOTH IP/OP $65.45 $48.43 $0.00 $52.36 $35.54 $35.54 $0.00 $0.00 $0.00 $0.00 $48.58 $48.58 $0.00 $0.00 $13.64 $0.00 $0.00 $0.00 $0.00 $32.73 $51.84 $52.36 $0.00 $0.00 $10.24 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 G14198 SUP HCPCS C2627 G14198 - DILATOR URTH 14FR 37CM STRL SDPRT DISP BOTH IP/OP $65.45 $48.43 $0.00 $52.36 $35.54 $35.54 $0.00 $0.00 $0.00 $0.00 $48.58 $48.58 $0.00 $0.00 $13.64 $0.00 $0.00 $0.00 $0.00 $32.73 $51.84 $52.36 $0.00 $0.00 $10.24 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 G14199 SUP HCPCS C2627 G14199 - DILATOR URTH 16FR 37CM SDPRT PE FSCA BOTH IP/OP $65.45 $48.43 $0.00 $52.36 $35.54 $35.54 $0.00 $0.00 $0.00 $0.00 $48.58 $48.58 $0.00 $0.00 $13.64 $0.00 $0.00 $0.00 $0.00 $32.73 $51.84 $52.36 $0.00 $0.00 $10.24 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 G14200 SUP HCPCS C2627 G14200 - DILATOR URTH 18FR 37CM STRL SDPRT DISP BOTH IP/OP $65.45 $48.43 $0.00 $52.36 $35.54 $35.54 $0.00 $0.00 $0.00 $0.00 $48.58 $48.58 $0.00 $0.00 $13.64 $0.00 $0.00 $0.00 $0.00 $32.73 $51.84 $52.36 $0.00 $0.00 $10.24 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 G14201 SUP HCPCS C2627 G14201 - DILATOR URTH 20FR 37CM STRL SDPRT DISP BOTH IP/OP $65.45 $48.43 $0.00 $52.36 $35.54 $35.54 $0.00 $0.00 $0.00 $0.00 $48.58 $48.58 $0.00 $0.00 $13.64 $0.00 $0.00 $0.00 $0.00 $32.73 $51.84 $52.36 $0.00 $0.00 $10.24 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 G14202 SUP HCPCS C2627 G14202 - DILATOR URTH 22FR 37CM STRL SDPRT DISP BOTH IP/OP $65.45 $48.43 $0.00 $52.36 $35.54 $35.54 $0.00 $0.00 $0.00 $0.00 $48.58 $48.58 $0.00 $0.00 $13.64 $0.00 $0.00 $0.00 $0.00 $32.73 $51.84 $52.36 $0.00 $0.00 $10.24 $0.00 $0.00 $10.42 $0.00 $0.00 $0.00 $0.00 $0.00 G14211 SUP HCPCS C1773 G14211 - DILATOR URTH 24FR 37CM STRL SDPRT DISP BOTH IP/OP $398.45 $294.85 $0.00 $318.76 $216.36 $216.36 $0.00 $0.00 $0.00 $83.05 $295.73 $295.73 $0.00 $0.00 $83.04 $0.00 $235.68 $235.68 $0.00 $199.23 $315.57 $318.76 $0.00 $0.00 $62.36 $0.00 $0.00 $63.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14214 SUP HCPCS C2627 G14214 - FORCEPS GRSP 5FR 20MM 60CM 3 PR BOTH IP/OP $510.95 $378.10 $0.00 $408.76 $277.45 $277.45 $0.00 $0.00 $0.00 $0.00 $379.23 $379.23 $0.00 $0.00 $106.48 $0.00 $0.00 $0.00 $0.00 $255.48 $404.67 $408.76 $0.00 $0.00 $79.96 $0.00 $0.00 $81.34 $0.00 $0.00 $0.00 $0.00 $0.00 G14220 SUP Custom 27203010 G14220 - NEEDLE ENDSCP 35CM 23GA 8MM URTH CSCP INJEC PRC WMS BOTH IP/OP $47.30 $35.00 $0.00 $37.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.65 $37.46 $37.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14231 SUP HCPCS C1769 G14231 - TUBE DRN STD 14FR 30CM STRL LF 1 WY STPCK CNCT DISP BOTH IP/OP $33.80 $25.01 $0.00 $27.04 $18.35 $18.35 $0.00 $0.00 $0.00 $7.04 $25.09 $25.09 $0.00 $0.00 $7.04 $0.00 $19.99 $19.99 $0.00 $16.90 $26.77 $27.04 $0.00 $0.00 $5.29 $0.00 $0.00 $5.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14254 SUP Custom 27203010 G14254 - PUNCH SRG 14FR 3MM NS FL CATH TIP REUSE CUT .118IN RND HL BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.49 $24.49 $0.00 $0.00 $6.88 $0.00 $0.00 $0.00 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14255 SUP Custom 27203010 G14255 - NEEDLE PRC 22GA 20CM SKNY CHBA TIP PERC NPHSTM BOTH IP/OP $35.75 $26.46 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.53 $26.53 $0.00 $0.00 $7.45 $0.00 $0.00 $0.00 $0.00 $17.88 $28.31 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14256 SUP Custom 27203010 G14256 - NEEDLE PRC STD 18GA 20CM ECHTP 2 PRT TROC DISP NPHSTM BOTH IP/OP $35.75 $26.46 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.53 $26.53 $0.00 $0.00 $7.45 $0.00 $0.00 $0.00 $0.00 $17.88 $28.31 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14257 SUP Custom 27203010 G14257 - NEEDLE PRC 18GA 11CM MTPLK PERC BOTH IP/OP $74.65 $55.24 $0.00 $59.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.41 $55.41 $0.00 $0.00 $15.56 $0.00 $0.00 $0.00 $0.00 $37.33 $59.12 $59.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14259 SUP Custom 27203010 G14259 - NEEDLE PRC STD 18GA 25CM 2 PRT TROC DISP BOTH IP/OP $95.70 $70.82 $0.00 $76.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.03 $71.03 $0.00 $0.00 $19.94 $0.00 $0.00 $0.00 $0.00 $47.85 $75.79 $76.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14260 SUP HCPCS C1769 G14260 - NEEDLE BX STD 18GA 25CM TFE SHTH TROC STY RNL BOTH IP/OP $91.25 $67.53 $0.00 $73.00 $49.55 $49.55 $0.00 $0.00 $0.00 $19.02 $67.73 $67.73 $0.00 $0.00 $19.02 $0.00 $53.97 $53.97 $0.00 $45.63 $72.27 $73.00 $0.00 $0.00 $14.28 $0.00 $0.00 $14.53 $0.00 $0.00 $0.00 $0.00 $0.00 G14261 SUP HCPCS C1726 G14261 - GUIDEWIRE URO STD .038IN 80CM STRL LF 3MM SFTJ FX COR STRG BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $179.19 $179.19 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 G14263 SUP Custom 27203010 G14263 - DILATOR URTH 18FR 37CM STRL DISP BOTH IP/OP $525.20 $388.65 $0.00 $420.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.80 $389.80 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $262.60 $415.96 $420.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14270 SUP HCPCS C1894 G14270 - SET NDL 18-22GA 14-22CM MTPLK COAX PERC BOTH IP/OP $128.70 $95.24 $0.00 $102.96 $69.88 $69.88 $0.00 $0.00 $0.00 $26.82 $95.52 $95.52 $0.00 $0.00 $26.82 $0.00 $76.13 $76.13 $0.00 $64.35 $101.93 $102.96 $0.00 $0.00 $20.14 $0.00 $0.00 $20.49 $0.00 $0.00 $0.00 $0.00 $0.00 G14275 SUP HCPCS C2627 G14275 - TUBE CNCT STD 14FR 135CM M LL DRN BG BOTH IP/OP $578.13 $427.82 $0.00 $462.50 $313.92 $313.92 $0.00 $0.00 $0.00 $0.00 $429.08 $429.08 $0.00 $0.00 $120.48 $0.00 $0.00 $0.00 $0.00 $289.06 $457.88 $462.50 $0.00 $0.00 $90.48 $0.00 $0.00 $92.04 $0.00 $0.00 $0.00 $0.00 $0.00 G14276 SUP Custom 27203010 G14276 - SET DIL 26-36FR 37CM STRL PE FSCA DISP BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14277 SUP Custom 27203010 G14277 - DILATOR URTH 26FR 37CM PE FSCA BOTH IP/OP $90.20 $66.75 $0.00 $72.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.95 $66.95 $0.00 $0.00 $18.80 $0.00 $0.00 $0.00 $0.00 $45.10 $71.44 $72.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14278 SUP Custom 27203010 G14278 - DILATOR URTH 28FR 37CM STRL PE FSCA DISP BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14279 SUP Custom 27203010 G14279 - DILATOR URTH 30FR 37CM STRL DISP BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14280 SUP Custom 27203010 G14280 - DILATOR URTH 32FR 37CM PE FSCA BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14281 SUP Custom 27203010 G14281 - DILATOR URTH 34FR 37CM PE FSCA BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14282 SUP HCPCS C1729 G14282 - DILATOR URTH 36FR 37CM PE FSCA BOTH IP/OP $404.80 $299.55 $0.00 $323.84 $219.81 $219.81 $0.00 $0.00 $0.00 $84.37 $300.44 $300.44 $0.00 $0.00 $84.36 $0.00 $239.44 $239.44 $0.00 $202.40 $320.60 $323.84 $0.00 $0.00 $63.35 $0.00 $0.00 $64.44 $0.00 $0.00 $0.00 $0.00 $0.00 G14283 SUP HCPCS C1729 G14283 - SET NPHSTM STD 10FR 19.5CM LTX COPE LOOP NDL GW CATH CNN DIL BOTH IP/OP $188.10 $139.19 $0.00 $150.48 $102.14 $102.14 $0.00 $0.00 $0.00 $39.20 $139.61 $139.61 $0.00 $0.00 $39.20 $0.00 $111.26 $111.26 $0.00 $94.05 $148.98 $150.48 $0.00 $0.00 $29.44 $0.00 $0.00 $29.95 $0.00 $0.00 $0.00 $0.00 $0.00 G14284 SUP HCPCS C1894 G14284 - SET NPHSTM 10FR 18GA 19.5CM STRL LTX 35CM CK RADOPQ CATH CNN BOTH IP/OP $216.70 $160.36 $0.00 $173.36 $117.67 $117.67 $0.00 $0.00 $0.00 $45.17 $160.83 $160.83 $0.00 $0.00 $45.16 $0.00 $128.18 $128.18 $0.00 $108.35 $171.63 $173.36 $0.00 $0.00 $33.91 $0.00 $0.00 $34.50 $0.00 $0.00 $0.00 $0.00 $0.00 G14285 SUP HCPCS C1769 G14285 - SET NPHSTM 6-16FR 20CM COPE LOOP NDL GW CATH CNN DIL PERC BOTH IP/OP $33.80 $25.01 $0.00 $27.04 $18.35 $18.35 $0.00 $0.00 $0.00 $7.04 $25.09 $25.09 $0.00 $0.00 $7.04 $0.00 $19.99 $19.99 $0.00 $16.90 $26.77 $27.04 $0.00 $0.00 $5.29 $0.00 $0.00 $5.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14287 SUP Custom 27203010 G14287 - GUIDEWIRE VASC 39CM STD STRG .038IN 80CM STRL 1CM FXCR FLX BOTH IP/OP $50.60 $37.44 $0.00 $40.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.56 $37.56 $0.00 $0.00 $10.55 $0.00 $0.00 $0.00 $0.00 $25.30 $40.08 $40.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14297 SUP HCPCS C1769 G14297 - ADAPTER INST 3-6FR 1 WY STPCK SDARM Y FIT M LL BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $179.19 $179.19 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 G14298 SUP HCPCS C2627 G14298 - SET DIL 6-18FR 60CM PE URETER BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14299 SUP HCPCS C2627 G14299 - DILATOR URET 8FR 60CM STRL PE DISP BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14300 SUP HCPCS C2627 G14300 - DILATOR URET 9FR 60CM STRL PE DISP BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14301 SUP HCPCS C2627 G14301 - DILATOR URET 10FR 60CM STRL PE BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14302 SUP HCPCS C2627 G14302 - DILATOR URET 12FR 60CM STRL PE BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14303 SUP HCPCS C2627 G14303 - DILATOR URET 14FR 60CM STRL PE BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14304 SUP HCPCS C2627 G14304 - DILATOR URET 16FR 60CM STRL PE BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14305 SUP HCPCS C1726 G14305 - DILATOR URET 16FR 60CM PE FSCA BOTH IP/OP $51.15 $37.85 $0.00 $40.92 $27.77 $27.77 $0.00 $0.00 $0.00 $10.66 $37.96 $37.96 $0.00 $0.00 $10.66 $0.00 $30.26 $30.26 $0.00 $25.58 $40.51 $40.92 $0.00 $0.00 $8.00 $0.00 $0.00 $8.14 $0.00 $0.00 $0.00 $0.00 $0.00 G14306 SUP HCPCS C1894 G14306 - CATHETER BLNDIL 8FR 84CM STRL AMPTZ GD RNL BOTH IP/OP $86.90 $64.31 $0.00 $69.52 $47.19 $47.19 $0.00 $0.00 $0.00 $18.11 $64.50 $64.50 $0.00 $0.00 $18.11 $0.00 $51.40 $51.40 $0.00 $43.45 $68.82 $69.52 $0.00 $0.00 $13.60 $0.00 $0.00 $13.83 $0.00 $0.00 $0.00 $0.00 $0.00 G14307 SUP HCPCS C1769 G14307 - SET INTRO .038IN 50CM 12FR 5FR 100CM STRL 22CM GW RADOPQ BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $21.11 $21.11 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $6.08 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 G14309 SUP HCPCS C1769 G14309 - GUIDEWIRE ESCP STD CDE .038IN 145CM FXCR BOTH IP/OP $33.80 $25.01 $0.00 $27.04 $18.35 $18.35 $0.00 $0.00 $0.00 $7.04 $25.09 $25.09 $0.00 $0.00 $7.04 $0.00 $19.99 $19.99 $0.00 $16.90 $26.77 $27.04 $0.00 $0.00 $5.29 $0.00 $0.00 $5.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14311 SUP HCPCS C1892 G14311 - GUIDEWIRE VASC STD STRG .038IN 145CM STRL 3CM FLX TP FXCR SS BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $77.65 $77.65 $0.00 $0.00 $0.00 $29.80 $106.13 $106.13 $0.00 $0.00 $29.80 $0.00 $84.58 $84.58 $0.00 $71.50 $113.26 $114.40 $0.00 $0.00 $22.38 $0.00 $0.00 $22.77 $0.00 $0.00 $0.00 $0.00 $0.00 G14320 SUP HCPCS C1758 G14320 - SET INTRO STD 9FR 65CM 60CM PLWY SHTH GW URET BOTH IP/OP $352.00 $260.48 $0.00 $281.60 $191.14 $191.14 $0.00 $0.00 $0.00 $73.37 $261.25 $261.25 $0.00 $0.00 $73.36 $0.00 $208.21 $208.21 $0.00 $176.00 $278.78 $281.60 $0.00 $0.00 $55.09 $0.00 $0.00 $56.04 $0.00 $0.00 $0.00 $0.00 $0.00 G14323 SUP HCPCS C1769 G14323 - DILATOR URET 7FR 6MM 65CM 4CM BLN CATH BOTH IP/OP $37.40 $27.68 $0.00 $29.92 $20.31 $20.31 $0.00 $0.00 $0.00 $7.80 $27.76 $27.76 $0.00 $0.00 $7.79 $0.00 $22.12 $22.12 $0.00 $18.70 $29.62 $29.92 $0.00 $0.00 $5.85 $0.00 $0.00 $5.95 $0.00 $0.00 $0.00 $0.00 $0.00 G14326 SUP HCPCS C1769 G14326 - GUIDEWIRE URO .038IN 145CM 3CM FX COR STRG FLX TP HVDTY SS BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $21.11 $21.11 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $6.08 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 G14328 SUP Custom 27203010 G14328 - GUIDEWIRE VASC STD .038IN 100CM FXCR SS BOTH IP/OP $572.00 $423.28 $0.00 $457.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.54 $424.54 $0.00 $0.00 $119.20 $0.00 $0.00 $0.00 $0.00 $286.00 $453.02 $457.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14335 SUP HCPCS C1773 G14335 - SET NPHSTM 7FR 82CM STRL LAWSON RTRGD GW PNCT PERC DISP BOTH IP/OP $398.45 $294.85 $0.00 $318.76 $216.36 $216.36 $0.00 $0.00 $0.00 $83.05 $295.73 $295.73 $0.00 $0.00 $83.04 $0.00 $235.68 $235.68 $0.00 $199.23 $315.57 $318.76 $0.00 $0.00 $62.36 $0.00 $0.00 $63.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14337 SUP HCPCS C2628 G14337 - FORCEPS GRSP 4.5FR 65CM 15MM 3WR COAX SHTH BOTH IP/OP $319.00 $236.06 $0.00 $255.20 $0.00 $0.00 $0.00 $0.00 $0.00 $66.49 $236.76 $236.76 $0.00 $0.00 $66.48 $0.00 $188.69 $188.69 $0.00 $159.50 $252.65 $255.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14343 SUP HCPCS C1729 G14343 - CATHETER BLNOCC 6FR 75CM STRL REM ADPR RADOPQ SIL UPJ DISP BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $197.11 $197.11 $0.00 $0.00 $0.00 $75.66 $269.42 $269.42 $0.00 $0.00 $75.65 $0.00 $214.71 $214.71 $0.00 $181.50 $287.50 $290.40 $0.00 $0.00 $56.81 $0.00 $0.00 $57.79 $0.00 $0.00 $0.00 $0.00 $0.00 G14344 SUP HCPCS C1758 G14344 - CATHETER NPHSTM 17FR 12MM 25CM 15CM KAYE TMPND BLN RADOPQ BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $179.19 $179.19 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 G14363 SUP HCPCS C2617 G14363 - DILATOR SRG 7FR 6MM 65CM STRL 10CM BLN CATH RADOPQ PINVISE BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G14364 SUP HCPCS C2617 G14364 - SET STNT .035IN 50CM SM 2 PGTL CRV STRG 5FR 8CM GRN STRL 70 BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G14365 SUP HCPCS C2617 G14365 - SET STNT .035IN 50CM SM 2 PGTL CRV STRG 5FR 10CM GRN STRL 70 BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G14366 SUP HCPCS C2617 G14366 - SET STNT .035IN 50CM SM 2 PGTL CRV STRG 5FR 12CM GRN STRL 70 BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G14367 SUP HCPCS C2617 G14367 - SET STNT .035IN 50CM SM 2 PGTL CRV STRG 5FR 14CM GRN STRL 70 BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G14405 SUP HCPCS C1892 G14405 - SET STNT .035IN 50CM SM 2 PGTL CRV 5FR 16CM GRN STRL 70CM BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $77.65 $77.65 $0.00 $0.00 $0.00 $29.80 $106.13 $106.13 $0.00 $0.00 $29.80 $0.00 $84.58 $84.58 $0.00 $71.50 $113.26 $114.40 $0.00 $0.00 $22.38 $0.00 $0.00 $22.77 $0.00 $0.00 $0.00 $0.00 $0.00 G14408 SUP HCPCS C1758 G14408 - SET INTRO 14FR 60CM 65CM PLWY CATH 2 KNOB GW SHTH URET BOTH IP/OP $60.38 $44.68 $0.00 $48.30 $32.78 $32.78 $0.00 $0.00 $0.00 $12.58 $44.81 $44.81 $0.00 $0.00 $12.58 $0.00 $35.71 $35.71 $0.00 $30.19 $47.82 $48.30 $0.00 $0.00 $9.45 $0.00 $0.00 $9.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14420 SUP HCPCS C2627 G14420 - TUBE CNCT LG 24FR 30CM LF M LL TO BG DRN BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14421 SUP HCPCS C2627 G14421 - DILATOR URET 6FR 60CM STRL LFRIC SRFC PE DISP BOTH IP/OP $165.73 $122.64 $0.00 $132.58 $89.99 $89.99 $0.00 $0.00 $0.00 $0.00 $123.00 $123.00 $0.00 $0.00 $34.54 $0.00 $0.00 $0.00 $0.00 $82.86 $131.26 $132.58 $0.00 $0.00 $25.94 $0.00 $0.00 $26.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14422 SUP HCPCS C1758 G14422 - SET NPHSTM 5FR 75CM 15CM KAYE TMPND BLN CATH STY STNT PERC BOTH IP/OP $352.00 $260.48 $0.00 $281.60 $191.14 $191.14 $0.00 $0.00 $0.00 $73.37 $261.25 $261.25 $0.00 $0.00 $73.36 $0.00 $208.21 $208.21 $0.00 $176.00 $278.78 $281.60 $0.00 $0.00 $55.09 $0.00 $0.00 $56.04 $0.00 $0.00 $0.00 $0.00 $0.00 G14423 SUP HCPCS C1729 G14423 - DILATOR URET .038IN 5FR 5MM 65CM STRL 4CM INFL BLN RADOPQ BOTH IP/OP $466.40 $345.14 $0.00 $373.12 $253.26 $253.26 $0.00 $0.00 $0.00 $97.21 $346.16 $346.16 $0.00 $0.00 $97.20 $0.00 $275.88 $275.88 $0.00 $233.20 $369.39 $373.12 $0.00 $0.00 $72.99 $0.00 $0.00 $74.25 $0.00 $0.00 $0.00 $0.00 $0.00 G14426 SUP HCPCS C1892 G14426 - SET NPHSTM 17FR 12MM 25CM 10ML STRL LF 15CM KAYE TMPND BLN BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $77.65 $77.65 $0.00 $0.00 $0.00 $29.80 $106.13 $106.13 $0.00 $0.00 $29.80 $0.00 $84.58 $84.58 $0.00 $71.50 $113.26 $114.40 $0.00 $0.00 $22.38 $0.00 $0.00 $22.77 $0.00 $0.00 $0.00 $0.00 $0.00 G14427 SUP HCPCS C1892 G14427 - SET INTRO STD 12FR 65CM 60CM PLWY GW 2 KNOB URET BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $77.65 $77.65 $0.00 $0.00 $0.00 $29.80 $106.13 $106.13 $0.00 $0.00 $29.80 $0.00 $84.58 $84.58 $0.00 $71.50 $113.26 $114.40 $0.00 $0.00 $22.38 $0.00 $0.00 $22.77 $0.00 $0.00 $0.00 $0.00 $0.00 G14428 SUP HCPCS C1892 G14428 - SET INTRO STD 11FR 65CM 60CM PLWY GW 2 KNOB URET BOTH IP/OP $143.00 $105.82 $0.00 $114.40 $77.65 $77.65 $0.00 $0.00 $0.00 $29.80 $106.13 $106.13 $0.00 $0.00 $29.80 $0.00 $84.58 $84.58 $0.00 $71.50 $113.26 $114.40 $0.00 $0.00 $22.38 $0.00 $0.00 $22.77 $0.00 $0.00 $0.00 $0.00 $0.00 G14431 SUP HCPCS C1729 G14431 - CATHETER URET .025IN 4FR 70CM STRL OP-EN PVC DISP BOTH IP/OP $18.59 $13.76 $0.00 $14.87 $10.09 $10.09 $0.00 $0.00 $0.00 $3.87 $13.80 $13.80 $0.00 $0.00 $3.87 $0.00 $11.00 $11.00 $0.00 $9.30 $14.72 $14.87 $0.00 $0.00 $2.91 $0.00 $0.00 $2.96 $0.00 $0.00 $0.00 $0.00 $0.00 G14432 SUP HCPCS C1892 G14432 - SET NPHSTM 7-18FR 20-30CM STRL MLCT CATH STNT STY RTNT DISK BOTH IP/OP $164.45 $121.69 $0.00 $131.56 $89.30 $89.30 $0.00 $0.00 $0.00 $34.28 $122.05 $122.05 $0.00 $0.00 $34.27 $0.00 $97.27 $97.27 $0.00 $82.23 $130.24 $131.56 $0.00 $0.00 $25.74 $0.00 $0.00 $26.18 $0.00 $0.00 $0.00 $0.00 $0.00 G14433 SUP HCPCS C1892 G14433 - SET INTRO .038IN STD STRG 16FR 65CM 60CM PLWY 2 KNOB GW SHTH BOTH IP/OP $164.45 $121.69 $0.00 $131.56 $89.30 $89.30 $0.00 $0.00 $0.00 $34.28 $122.05 $122.05 $0.00 $0.00 $34.27 $0.00 $97.27 $97.27 $0.00 $82.23 $130.24 $131.56 $0.00 $0.00 $25.74 $0.00 $0.00 $26.18 $0.00 $0.00 $0.00 $0.00 $0.00 G14434 SUP HCPCS C2627 G14434 - SET INTRO STD 18FR 65CM 60CM PLWY GW SHTH 2 KNOB URET BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G14437 SUP HCPCS C1729 G14437 - DILATOR URET 11FR 60CM SET PE BOTH IP/OP $185.90 $137.57 $0.00 $148.72 $100.94 $100.94 $0.00 $0.00 $0.00 $38.75 $137.97 $137.97 $0.00 $0.00 $38.74 $0.00 $109.96 $109.96 $0.00 $92.95 $147.23 $148.72 $0.00 $0.00 $29.09 $0.00 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 G14440 SUP HCPCS C1892 G14440 - SET NPHSTM 22FR 35CM MLCT CATH STY RTNT DISK CNCT TUBE PU BOTH IP/OP $118.80 $87.91 $0.00 $95.04 $64.51 $64.51 $0.00 $0.00 $0.00 $24.76 $88.17 $88.17 $0.00 $0.00 $24.76 $0.00 $70.27 $70.27 $0.00 $59.40 $94.09 $95.04 $0.00 $0.00 $18.59 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 G14441 SUP HCPCS C1892 G14441 - SET INTRO STD 9FR 37CM 32CM PLWY 2 KNOB SHTH GW BOTH IP/OP $118.80 $87.91 $0.00 $95.04 $64.51 $64.51 $0.00 $0.00 $0.00 $24.76 $88.17 $88.17 $0.00 $0.00 $24.76 $0.00 $70.27 $70.27 $0.00 $59.40 $94.09 $95.04 $0.00 $0.00 $18.59 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 G14442 SUP HCPCS C1892 G14442 - SET INTRO STD 10FR 37CM 32CM PLWY GW 2 KNOB SHTH URET BOTH IP/OP $118.80 $87.91 $0.00 $95.04 $64.51 $64.51 $0.00 $0.00 $0.00 $24.76 $88.17 $88.17 $0.00 $0.00 $24.76 $0.00 $70.27 $70.27 $0.00 $59.40 $94.09 $95.04 $0.00 $0.00 $18.59 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 G14443 SUP HCPCS C1892 G14443 - SET INTRO STD 12FR 37CM 32CM PLWY 2 KNOB SHTH GW URETER BOTH IP/OP $118.80 $87.91 $0.00 $95.04 $64.51 $64.51 $0.00 $0.00 $0.00 $24.76 $88.17 $88.17 $0.00 $0.00 $24.76 $0.00 $70.27 $70.27 $0.00 $59.40 $94.09 $95.04 $0.00 $0.00 $18.59 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 G14444 SUP HCPCS C1892 G14444 - SET INTRO STD 14FR 37CM 32CM PLWY 2 KNOB SHTH GW BOTH IP/OP $118.80 $87.91 $0.00 $95.04 $64.51 $64.51 $0.00 $0.00 $0.00 $24.76 $88.17 $88.17 $0.00 $0.00 $24.76 $0.00 $70.27 $70.27 $0.00 $59.40 $94.09 $95.04 $0.00 $0.00 $18.59 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 G14445 SUP HCPCS C1892 G14445 - SET INTRO STD 16FR 37CM 32CM PLWY GW 2 KNOB SHTH URET BOTH IP/OP $118.80 $87.91 $0.00 $95.04 $64.51 $64.51 $0.00 $0.00 $0.00 $24.76 $88.17 $88.17 $0.00 $0.00 $24.76 $0.00 $70.27 $70.27 $0.00 $59.40 $94.09 $95.04 $0.00 $0.00 $18.59 $0.00 $0.00 $18.91 $0.00 $0.00 $0.00 $0.00 $0.00 G14454 SUP HCPCS C1729 G14454 - LINE INJ 7FR 30CM CNRST STD FIT BOTH IP/OP $185.90 $137.57 $0.00 $148.72 $100.94 $100.94 $0.00 $0.00 $0.00 $38.75 $137.97 $137.97 $0.00 $0.00 $38.74 $0.00 $109.96 $109.96 $0.00 $92.95 $147.23 $148.72 $0.00 $0.00 $29.09 $0.00 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 G14457 SUP Custom 27203010 G14457 - CATHETER URET .038IN 8FR 70CM STRL OP-EN DISP BOTH IP/OP $11.01 $8.15 $0.00 $8.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.17 $8.17 $0.00 $0.00 $2.29 $0.00 $0.00 $0.00 $0.00 $5.50 $8.72 $8.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14461 SUP Custom 27203010 G14461 - NEEDLE PRC STD 18GA 15CM ECHTP TROC STY SHTH PTFE RNL BOTH IP/OP $35.75 $26.46 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.53 $26.53 $0.00 $0.00 $7.45 $0.00 $0.00 $0.00 $0.00 $17.88 $28.31 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14463 SUP HCPCS C1758 G14463 - NEEDLE PRC 18GA 15CM STRL ECHTP 2 PRT TROC DISP NPHSTM BOTH IP/OP $404.80 $299.55 $0.00 $323.84 $219.81 $219.81 $0.00 $0.00 $0.00 $84.37 $300.44 $300.44 $0.00 $0.00 $84.36 $0.00 $239.44 $239.44 $0.00 $202.40 $320.60 $323.84 $0.00 $0.00 $63.35 $0.00 $0.00 $64.44 $0.00 $0.00 $0.00 $0.00 $0.00 G14485 SUP HCPCS C1726 G14485 - ADAPTER CATH F LL TO LG FIT BOTH IP/OP $510.95 $378.10 $0.00 $408.76 $277.45 $277.45 $0.00 $0.00 $0.00 $106.49 $379.23 $379.23 $0.00 $0.00 $106.48 $0.00 $302.23 $302.23 $0.00 $255.48 $404.67 $408.76 $0.00 $0.00 $79.96 $0.00 $0.00 $81.34 $0.00 $0.00 $0.00 $0.00 $0.00 G14500 SUP Custom 27203010 G14500 - STYLET NPHSTM 8.5FR FLXB MLCT CATH REM BOTH IP/OP $147.40 $109.08 $0.00 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.40 $109.40 $0.00 $0.00 $30.72 $0.00 $0.00 $0.00 $0.00 $73.70 $116.74 $117.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14501 SUP HCPCS C1729 G14501 - APPROXIMATOR SRG WILLSCHER SET VASC BOTH IP/OP $185.90 $137.57 $0.00 $148.72 $100.94 $100.94 $0.00 $0.00 $0.00 $38.75 $137.97 $137.97 $0.00 $0.00 $38.74 $0.00 $109.96 $109.96 $0.00 $92.95 $147.23 $148.72 $0.00 $0.00 $29.09 $0.00 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 G14504 SUP HCPCS C1726 G14504 - SET NPHSTM 5FR 20CM MLCT CATH LL STY RTNT DISK CNCT TUBE PU BOTH IP/OP $587.60 $434.82 $0.00 $470.08 $319.07 $319.07 $0.00 $0.00 $0.00 $122.47 $436.12 $436.12 $0.00 $0.00 $122.46 $0.00 $347.57 $347.57 $0.00 $293.80 $465.38 $470.08 $0.00 $0.00 $91.96 $0.00 $0.00 $93.55 $0.00 $0.00 $0.00 $0.00 $0.00 G14508 SUP HCPCS C1729 G14508 - SET DIL 6-30FR 30CM 19CM AMPTZ MOD RADOPQ SHTH RNL BOTH IP/OP $363.00 $268.62 $0.00 $290.40 $197.11 $197.11 $0.00 $0.00 $0.00 $75.66 $269.42 $269.42 $0.00 $0.00 $75.65 $0.00 $214.71 $214.71 $0.00 $181.50 $287.50 $290.40 $0.00 $0.00 $56.81 $0.00 $0.00 $57.79 $0.00 $0.00 $0.00 $0.00 $0.00 G14510 SUP HCPCS C1729 G14510 - SET NPHSTM PGTL CRV 6FR 7CM STRL 3 DIL 2 NDL CATH CNCT TUBE BOTH IP/OP $185.90 $137.57 $0.00 $148.72 $100.94 $100.94 $0.00 $0.00 $0.00 $38.75 $137.97 $137.97 $0.00 $0.00 $38.74 $0.00 $109.96 $109.96 $0.00 $92.95 $147.23 $148.72 $0.00 $0.00 $29.09 $0.00 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 G14511 SUP HCPCS C1758 G14511 - SET NPHSTM 7FR 20CM MLCT CATH STNT LL RTNT DISK PU BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14513 SUP HCPCS C2625 G14513 - CATHETER URET 10FR 70CM OP-EN ACPT .038IN GW BOTH IP/OP $123.00 $91.02 $0.00 $98.40 $55.35 $55.35 $0.00 $0.00 $0.00 $25.64 $91.29 $91.29 $0.00 $0.00 $25.63 $0.00 $72.75 $72.75 $0.00 $61.50 $97.42 $98.40 $0.00 $0.00 $19.25 $0.00 $0.00 $19.58 $0.00 $0.00 $0.00 $0.00 $0.00 G14514 SUP HCPCS C2625 G14514 - SET STNT .025IN PGTL CRV STRG 3.7FR 125CM BLU STRL 145CM BOTH IP/OP $141.45 $104.67 $0.00 $113.16 $63.65 $63.65 $0.00 $0.00 $0.00 $29.48 $104.98 $104.98 $0.00 $0.00 $29.48 $0.00 $83.67 $83.67 $0.00 $70.73 $112.03 $113.16 $0.00 $0.00 $22.14 $0.00 $0.00 $22.52 $0.00 $0.00 $0.00 $0.00 $0.00 G14515 SUP HCPCS C2628 G14515 - SET STNT .035IN PGTL CRV STRG 4.7FR 125CM BLU STRL 145CM BOTH IP/OP $319.00 $236.06 $0.00 $255.20 $0.00 $0.00 $0.00 $0.00 $0.00 $66.49 $236.76 $236.76 $0.00 $0.00 $66.48 $0.00 $188.69 $188.69 $0.00 $159.50 $252.65 $255.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14519 SUP Custom 27203010 G14519 - PROBE LTHTRP 1MM 605MM LMA STONEBREAKER PNEUM KT DISP BOTH IP/OP $15.62 $11.56 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.59 $11.59 $0.00 $0.00 $3.26 $0.00 $0.00 $0.00 $0.00 $7.81 $12.37 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14521 SUP HCPCS C1758 G14521 - SET DRN 300ML NS PCH 1 CNCT BOTH IP/OP $276.25 $204.43 $0.00 $221.00 $150.00 $150.00 $0.00 $0.00 $0.00 $57.58 $205.03 $205.03 $0.00 $0.00 $57.57 $0.00 $163.40 $163.40 $0.00 $138.13 $218.79 $221.00 $0.00 $0.00 $43.23 $0.00 $0.00 $43.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14526 SUP HCPCS C1729 G14526 - STYLET NPHSTM 5FR FLXB 10FR MLCT CATH REM BOTH IP/OP $185.90 $137.57 $0.00 $148.72 $100.94 $100.94 $0.00 $0.00 $0.00 $38.75 $137.97 $137.97 $0.00 $0.00 $38.74 $0.00 $109.96 $109.96 $0.00 $92.95 $147.23 $148.72 $0.00 $0.00 $29.09 $0.00 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 G14544 SUP HCPCS C1769 G14544 - DEVICE SPEC RTRVL 5FR 5MM 65CM 4CM RTNR 4WR OCL STON BLN BOTH IP/OP $33.80 $25.01 $0.00 $27.04 $18.35 $18.35 $0.00 $0.00 $0.00 $7.04 $25.09 $25.09 $0.00 $0.00 $7.04 $0.00 $19.99 $19.99 $0.00 $16.90 $26.77 $27.04 $0.00 $0.00 $5.29 $0.00 $0.00 $5.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14547 SUP Custom 27203010 G14547 - GUIDEWIRE URO STD STRG .035IN 145CM STRL 3CM FLX TP FX COR BOTH IP/OP $604.00 $446.96 $0.00 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.29 $448.29 $0.00 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $302.00 $478.37 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14551 SUP HCPCS C1769 G14551 - EXTRACTOR STON 5FR 6MM 65CM 4CM RTNR 4WR HLCL BLNDIL FLFRM BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $21.11 $21.11 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $6.08 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 G14554 SUP HCPCS C1769 G14554 - GUIDEWIRE ESCP STD .028IN 145CM LD EXTR RDRR PC FXCR DFLC BOTH IP/OP $33.80 $25.01 $0.00 $27.04 $18.35 $18.35 $0.00 $0.00 $0.00 $7.04 $25.09 $25.09 $0.00 $0.00 $7.04 $0.00 $19.99 $19.99 $0.00 $16.90 $26.77 $27.04 $0.00 $0.00 $5.29 $0.00 $0.00 $5.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14565 SUP HCPCS C2627 G14565 - GUIDEWIRE ESCP STD STRG .038IN 145CM STRL 1CM FXCR FLX TP SS BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $56.32 $56.32 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $16.23 $0.00 $0.00 $16.51 $0.00 $0.00 $0.00 $0.00 $0.00 G14566 SUP HCPCS C2627 G14566 - DILATOR URTH 6FR 37CM SET PTFE FSCA BOTH IP/OP $90.20 $66.75 $0.00 $72.16 $48.98 $48.98 $0.00 $0.00 $0.00 $0.00 $66.95 $66.95 $0.00 $0.00 $18.80 $0.00 $0.00 $0.00 $0.00 $45.10 $71.44 $72.16 $0.00 $0.00 $14.12 $0.00 $0.00 $14.36 $0.00 $0.00 $0.00 $0.00 $0.00 G14567 SUP HCPCS C2627 G14567 - DILATOR URTH 8FR 37CM SET PTFE FSCA BOTH IP/OP $90.20 $66.75 $0.00 $72.16 $48.98 $48.98 $0.00 $0.00 $0.00 $0.00 $66.95 $66.95 $0.00 $0.00 $18.80 $0.00 $0.00 $0.00 $0.00 $45.10 $71.44 $72.16 $0.00 $0.00 $14.12 $0.00 $0.00 $14.36 $0.00 $0.00 $0.00 $0.00 $0.00 G14568 SUP HCPCS C2627 G14568 - DILATOR URTH 10FR 37CM SET TFE FSCA BOTH IP/OP $90.20 $66.75 $0.00 $72.16 $48.98 $48.98 $0.00 $0.00 $0.00 $0.00 $66.95 $66.95 $0.00 $0.00 $18.80 $0.00 $0.00 $0.00 $0.00 $45.10 $71.44 $72.16 $0.00 $0.00 $14.12 $0.00 $0.00 $14.36 $0.00 $0.00 $0.00 $0.00 $0.00 G14569 SUP HCPCS C2627 G14569 - DILATOR URTH 12FR 37CM PTFE FSCA BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $56.32 $56.32 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $16.23 $0.00 $0.00 $16.51 $0.00 $0.00 $0.00 $0.00 $0.00 G14570 SUP HCPCS C2627 G14570 - DILATOR URTH 14FR 37CM SET TFE FSCA BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $56.32 $56.32 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $16.23 $0.00 $0.00 $16.51 $0.00 $0.00 $0.00 $0.00 $0.00 G14571 SUP HCPCS C2627 G14571 - DILATOR URTH 16FR 37CM SET PTFE FSCA BOTH IP/OP $103.73 $76.76 $0.00 $82.98 $56.32 $56.32 $0.00 $0.00 $0.00 $0.00 $76.98 $76.98 $0.00 $0.00 $21.62 $0.00 $0.00 $0.00 $0.00 $51.86 $82.15 $82.98 $0.00 $0.00 $16.23 $0.00 $0.00 $16.51 $0.00 $0.00 $0.00 $0.00 $0.00 G14572 SUP HCPCS C2627 G14572 - DILATOR URTH 18FR 37CM SET PTFE FSCA BOTH IP/OP $721.05 $533.58 $0.00 $576.84 $391.53 $391.53 $0.00 $0.00 $0.00 $0.00 $535.16 $535.16 $0.00 $0.00 $150.27 $0.00 $0.00 $0.00 $0.00 $360.53 $571.07 $576.84 $0.00 $0.00 $112.84 $0.00 $0.00 $114.79 $0.00 $0.00 $0.00 $0.00 $0.00 G14574 SUP HCPCS C1769 G14574 - DILATOR URET 6-18FR 37CM SET PTFE FSCA BOTH IP/OP $638.00 $472.12 $0.00 $510.40 $346.43 $346.43 $0.00 $0.00 $0.00 $132.98 $473.52 $473.52 $0.00 $0.00 $132.96 $0.00 $377.38 $377.38 $0.00 $319.00 $505.30 $510.40 $0.00 $0.00 $99.85 $0.00 $0.00 $101.57 $0.00 $0.00 $0.00 $0.00 $0.00 G14575 SUP HCPCS C2627 G14575 - DILATOR URET 6-18FR 60CM SET GW LFRIC SRFC PTFE FSCA BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G14576 SUP HCPCS C2627 G14576 - DILATOR URET 6FR 60CM SET PTFE DISP BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G14577 SUP HCPCS C2627 G14577 - DILATOR URET 8FR 60CM SET PTFE FSCA BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G14578 SUP HCPCS C2627 G14578 - DILATOR URET 10FR 60CM SET PTFE DISP BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G14579 SUP HCPCS C2627 G14579 - DILATOR URET 12FR 60CM SET PTFE DISP BOTH IP/OP $113.85 $84.25 $0.00 $91.08 $61.82 $61.82 $0.00 $0.00 $0.00 $0.00 $84.50 $84.50 $0.00 $0.00 $23.73 $0.00 $0.00 $0.00 $0.00 $56.93 $90.17 $91.08 $0.00 $0.00 $17.82 $0.00 $0.00 $18.12 $0.00 $0.00 $0.00 $0.00 $0.00 G14580 SUP HCPCS C2627 G14580 - DILATOR URET 14FR 60CM SET PTFE FSCA BOTH IP/OP $113.85 $84.25 $0.00 $91.08 $61.82 $61.82 $0.00 $0.00 $0.00 $0.00 $84.50 $84.50 $0.00 $0.00 $23.73 $0.00 $0.00 $0.00 $0.00 $56.93 $90.17 $91.08 $0.00 $0.00 $17.82 $0.00 $0.00 $18.12 $0.00 $0.00 $0.00 $0.00 $0.00 G14581 SUP HCPCS C2627 G14581 - DILATOR URET 16FR 60CM SET TFE FSCA BOTH IP/OP $113.85 $84.25 $0.00 $91.08 $61.82 $61.82 $0.00 $0.00 $0.00 $0.00 $84.50 $84.50 $0.00 $0.00 $23.73 $0.00 $0.00 $0.00 $0.00 $56.93 $90.17 $91.08 $0.00 $0.00 $17.82 $0.00 $0.00 $18.12 $0.00 $0.00 $0.00 $0.00 $0.00 G14587 SUP HCPCS C1758 G14587 - DILATOR URET 18FR 60CM SET PTFE FSCA BOTH IP/OP $72.60 $53.72 $0.00 $58.08 $39.42 $39.42 $0.00 $0.00 $0.00 $15.13 $53.88 $53.88 $0.00 $0.00 $15.13 $0.00 $42.94 $42.94 $0.00 $36.30 $57.50 $58.08 $0.00 $0.00 $11.36 $0.00 $0.00 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 G14589 SUP HCPCS C1769 G14589 - CATHETER URET 20D .035IN TPR STRG 6FR 70CM 145CM GW BOTH IP/OP $52.08 $38.54 $0.00 $41.66 $28.28 $28.28 $0.00 $0.00 $0.00 $10.85 $38.65 $38.65 $0.00 $0.00 $10.85 $0.00 $30.80 $30.80 $0.00 $26.04 $41.25 $41.66 $0.00 $0.00 $8.15 $0.00 $0.00 $8.29 $0.00 $0.00 $0.00 $0.00 $0.00 G14590 SUP HCPCS C1769 G14590 - GUIDEWIRE VASC STRG .038IN 145CM STRL 15CM BNTSN FLX TP FX BOTH IP/OP $52.08 $38.54 $0.00 $41.66 $28.28 $28.28 $0.00 $0.00 $0.00 $10.85 $38.65 $38.65 $0.00 $0.00 $10.85 $0.00 $30.80 $30.80 $0.00 $26.04 $41.25 $41.66 $0.00 $0.00 $8.15 $0.00 $0.00 $8.29 $0.00 $0.00 $0.00 $0.00 $0.00 G14592 SUP HCPCS C1758 G14592 - GUIDEWIRE VASC .035IN 145CM STRL 15CM BNTSN BNTSN FLX TP BOTH IP/OP $27.50 $20.35 $0.00 $22.00 $14.93 $14.93 $0.00 $0.00 $0.00 $5.73 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $16.27 $16.27 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $4.30 $0.00 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14593 SUP HCPCS C1758 G14593 - CATHETER URET 4FR 70CM RND TIP STY LT BOTH IP/OP $27.50 $20.35 $0.00 $22.00 $14.93 $14.93 $0.00 $0.00 $0.00 $5.73 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $16.27 $16.27 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $4.30 $0.00 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14595 SUP HCPCS C1773 G14595 - CATHETER URET 5FR 70CM RND TIP STY LT BOTH IP/OP $398.45 $294.85 $0.00 $318.76 $216.36 $216.36 $0.00 $0.00 $0.00 $83.05 $295.73 $295.73 $0.00 $0.00 $83.04 $0.00 $235.68 $235.68 $0.00 $199.23 $315.57 $318.76 $0.00 $0.00 $62.36 $0.00 $0.00 $63.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14596 SUP HCPCS C1773 G14596 - FORCEPS SPEC RTRVL 3.2FR 10MM 65CM STRL 3WR GRSP COAX SHTH BOTH IP/OP $398.45 $294.85 $0.00 $318.76 $216.36 $216.36 $0.00 $0.00 $0.00 $83.05 $295.73 $295.73 $0.00 $0.00 $83.04 $0.00 $235.68 $235.68 $0.00 $199.23 $315.57 $318.76 $0.00 $0.00 $62.36 $0.00 $0.00 $63.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14597 SUP HCPCS C1758 G14597 - FORCEPS ESCP 14MM 3.5FR 65CM STRL GRSP BOTH IP/OP $83.50 $61.79 $0.00 $66.80 $45.34 $45.34 $0.00 $0.00 $0.00 $17.40 $61.97 $61.97 $0.00 $0.00 $17.40 $0.00 $49.39 $49.39 $0.00 $41.75 $66.13 $66.80 $0.00 $0.00 $13.07 $0.00 $0.00 $13.29 $0.00 $0.00 $0.00 $0.00 $0.00 G14598 SUP HCPCS C1758 G14598 - CATHETER URET 20D .028IN TPR STRG 4FR 70CM 145CM GW BOTH IP/OP $72.60 $53.72 $0.00 $58.08 $39.42 $39.42 $0.00 $0.00 $0.00 $15.13 $53.88 $53.88 $0.00 $0.00 $15.13 $0.00 $42.94 $42.94 $0.00 $36.30 $57.50 $58.08 $0.00 $0.00 $11.36 $0.00 $0.00 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 G14599 SUP HCPCS C1758 G14599 - CATHETER URET 20D .035IN 5FR 70CM FLXB ANG TIP TPR END GW BOTH IP/OP $83.50 $61.79 $0.00 $66.80 $45.34 $45.34 $0.00 $0.00 $0.00 $17.40 $61.97 $61.97 $0.00 $0.00 $17.40 $0.00 $49.39 $49.39 $0.00 $41.75 $66.13 $66.80 $0.00 $0.00 $13.07 $0.00 $0.00 $13.29 $0.00 $0.00 $0.00 $0.00 $0.00 G14600 SUP HCPCS C1758 G14600 - CATHETER URET 20D .028IN BVL STRG 4FR 70CM 145CM GW BOTH IP/OP $72.60 $53.72 $0.00 $58.08 $39.42 $39.42 $0.00 $0.00 $0.00 $15.13 $53.88 $53.88 $0.00 $0.00 $15.13 $0.00 $42.94 $42.94 $0.00 $36.30 $57.50 $58.08 $0.00 $0.00 $11.36 $0.00 $0.00 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 G14606 SUP HCPCS C2617 G14606 - CATHETER URET 20D .035IN 5FR 70CM 145CM ANG TIP BVL END GW BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14608 SUP HCPCS C1758 G14608 - SET STNT .025IN 50CM SM 2 PGTL CRV STRG 3.7FR 26CM GRN STRL BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $179.19 $179.19 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 G14619 SUP HCPCS C1769 G14619 - TROCAR SRG STD 18GA 11CM DISP BOTH IP/OP $52.08 $38.54 $0.00 $41.66 $28.28 $28.28 $0.00 $0.00 $0.00 $10.85 $38.65 $38.65 $0.00 $0.00 $10.85 $0.00 $30.80 $30.80 $0.00 $26.04 $41.25 $41.66 $0.00 $0.00 $8.15 $0.00 $0.00 $8.29 $0.00 $0.00 $0.00 $0.00 $0.00 G14631 SUP HCPCS C1769 G14631 - GUIDEWIRE ESCP .038IN 145CM STRL CNS BNTSN MOV COR SS PTFE BOTH IP/OP $71.38 $52.82 $0.00 $57.10 $38.76 $38.76 $0.00 $0.00 $0.00 $14.88 $52.97 $52.97 $0.00 $0.00 $14.87 $0.00 $42.22 $42.22 $0.00 $35.69 $56.53 $57.10 $0.00 $0.00 $11.17 $0.00 $0.00 $11.36 $0.00 $0.00 $0.00 $0.00 $0.00 G14639 SUP HCPCS C2617 G14639 - GUIDEWIRE VASC STRG .038IN 145CM AMPTZ FLXB FXCR BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14650 SUP HCPCS C2627 G14650 - SET NPHSTM .038IN 22GA 18GA 80CM 20CM SFTJ 2 NDL ENTRY GW BOTH IP/OP $306.13 $226.54 $0.00 $244.90 $166.23 $166.23 $0.00 $0.00 $0.00 $0.00 $227.21 $227.21 $0.00 $0.00 $63.80 $0.00 $0.00 $0.00 $0.00 $153.06 $242.45 $244.90 $0.00 $0.00 $47.91 $0.00 $0.00 $48.74 $0.00 $0.00 $0.00 $0.00 $0.00 G14658 SUP HCPCS C1769 G14658 - SET NPHSTM 300ML STRL 2 CNCT DRN PCH SFT ELC BELT REED VLV BOTH IP/OP $465.53 $344.49 $0.00 $372.42 $252.78 $252.78 $0.00 $0.00 $0.00 $97.03 $345.51 $345.51 $0.00 $0.00 $97.02 $0.00 $275.36 $275.36 $0.00 $232.76 $368.70 $372.42 $0.00 $0.00 $72.85 $0.00 $0.00 $74.11 $0.00 $0.00 $0.00 $0.00 $0.00 G14659 SUP HCPCS C1758 G14659 - SET NPHSTM 8.2FR 19.5CM LTX COPE LOOP CATH NDL GW STPCK BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G14663 SUP HCPCS C1758 G14663 - CATHETER URETERAL 4.8FR 8FR 70CM CONE TIP BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14665 SUP HCPCS C1758 G14665 - CATHETER URET .038IN 5FR 70CM FLXTP OP-EN GW MOD BOTH IP/OP $27.63 $20.45 $0.00 $221.00 $150.00 $150.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $138.13 $218.79 $221.00 $0.00 $0.00 $43.23 $0.00 $0.00 $43.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14667 SUP HCPCS C1758 G14667 - CATHETER URETERAL CONE 7FR 12FR 70CM BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14669 SUP HCPCS C1758 G14669 - CATHETER URET 6FR 10FR 70CM CONE TIP BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14671 SUP HCPCS C1758 G14671 - CATHETER URET 8FR 14FR 70CM CONE TIP BOTH IP/OP $3.29 $2.43 $0.00 $2.63 $1.79 $1.79 $0.00 $0.00 $0.00 $0.69 $2.44 $2.44 $0.00 $0.00 $0.69 $0.00 $1.95 $1.95 $0.00 $1.65 $2.61 $2.63 $0.00 $0.00 $0.51 $0.00 $0.00 $0.52 $0.00 $0.00 $0.00 $0.00 $0.00 G14674 SUP HCPCS C1773 G14674 - CATHETER URET 5FR 70CM ANG TIP TPR END MOD BOTH IP/OP $313.45 $231.95 $0.00 $250.76 $170.20 $170.20 $0.00 $0.00 $0.00 $65.33 $232.64 $232.64 $0.00 $0.00 $65.32 $0.00 $185.41 $185.41 $0.00 $156.73 $248.25 $250.76 $0.00 $0.00 $49.05 $0.00 $0.00 $49.90 $0.00 $0.00 $0.00 $0.00 $0.00 G14676 SUP Custom 27203010 G14676 - FORCEPS GRASPING 10MM 3.2FR 115MM COAXIAL SHEATH HANDLE BOTH IP/OP $398.45 $294.85 $0.00 $318.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.73 $295.73 $0.00 $0.00 $83.04 $0.00 $0.00 $0.00 $0.00 $199.23 $315.57 $318.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14677 SUP HCPCS C1773 G14677 - RETRIEVER SRG 3FR 115CM STRL FLTWR LOOP URET BOTH IP/OP $398.45 $294.85 $0.00 $318.76 $216.36 $216.36 $0.00 $0.00 $0.00 $83.05 $295.73 $295.73 $0.00 $0.00 $83.04 $0.00 $235.68 $235.68 $0.00 $199.23 $315.57 $318.76 $0.00 $0.00 $62.36 $0.00 $0.00 $63.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14681 SUP Custom 27203010 G14681 - SYRINGE ASP 5ML VAC BOTH IP/OP $604.00 $446.96 $0.00 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.29 $448.29 $0.00 $0.00 $125.87 $0.00 $0.00 $0.00 $0.00 $302.00 $478.37 $483.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14685 SUP HCPCS C1769 G14685 - DEVICE SPEC RTRVL 5CM 5MM 5FR 4CM 65CM RTNR 3WR STON HLCL BOTH IP/OP $52.08 $38.54 $0.00 $41.66 $28.28 $28.28 $0.00 $0.00 $0.00 $10.85 $38.65 $38.65 $0.00 $0.00 $10.85 $0.00 $30.80 $30.80 $0.00 $26.04 $41.25 $41.66 $0.00 $0.00 $8.15 $0.00 $0.00 $8.29 $0.00 $0.00 $0.00 $0.00 $0.00 G14686 SUP HCPCS C1758 G14686 - GUIDEWIRE VASC .035IN 145CM CNS BNTSN MOV COR DSGN FLXB BOTH IP/OP $27.50 $20.35 $0.00 $22.00 $14.93 $14.93 $0.00 $0.00 $0.00 $5.73 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $16.27 $16.27 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $4.30 $0.00 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14687 SUP HCPCS C1758 G14687 - CATHETER URET 4FR 70CM RND TIP STY RT BOTH IP/OP $27.50 $20.35 $0.00 $22.00 $14.93 $14.93 $0.00 $0.00 $0.00 $5.73 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $16.27 $16.27 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $4.30 $0.00 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 G14688 SUP HCPCS C1894 G14688 - CATHETER URET 5FR 70CM RND TIP STY LT BOTH IP/OP $86.90 $64.31 $0.00 $69.52 $47.19 $47.19 $0.00 $0.00 $0.00 $18.11 $64.50 $64.50 $0.00 $0.00 $18.11 $0.00 $51.40 $51.40 $0.00 $43.45 $68.82 $69.52 $0.00 $0.00 $13.60 $0.00 $0.00 $13.83 $0.00 $0.00 $0.00 $0.00 $0.00 G14693 SUP HCPCS C1769 G14693 - STRAINER SPEC NS STON DISP BOTH IP/OP $1.40 $1.04 $0.00 $1.12 $0.76 $0.76 $0.00 $0.00 $0.00 $0.29 $1.04 $1.04 $0.00 $0.00 $0.29 $0.00 $0.83 $0.83 $0.00 $0.70 $1.11 $1.12 $0.00 $0.00 $0.22 $0.00 $0.00 $0.22 $0.00 $0.00 $0.00 $0.00 $0.00 G14694 SUP HCPCS C1729 G14694 - GUIDEWIRE VASC .035IN 145CM 8CM AMPTZ FLX TP XSTIF SS BOTH IP/OP $188.10 $139.19 $0.00 $150.48 $102.14 $102.14 $0.00 $0.00 $0.00 $39.20 $139.61 $139.61 $0.00 $0.00 $39.20 $0.00 $111.26 $111.26 $0.00 $94.05 $148.98 $150.48 $0.00 $0.00 $29.44 $0.00 $0.00 $29.95 $0.00 $0.00 $0.00 $0.00 $0.00 G14700 SUP HCPCS C2617 G14700 - CATHETER NPHSTM 8.2FR 19.5CM STRL LTX COPE LOOP CNN PERC BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14705 SUP HCPCS C1729 G14705 - SET STNT .025IN SM 2 PGTL CRV STRG 3.7FR 14CM GRN STRL 70CM BOTH IP/OP $188.10 $139.19 $0.00 $150.48 $102.14 $102.14 $0.00 $0.00 $0.00 $39.20 $139.61 $139.61 $0.00 $0.00 $39.20 $0.00 $111.26 $111.26 $0.00 $94.05 $148.98 $150.48 $0.00 $0.00 $29.44 $0.00 $0.00 $29.95 $0.00 $0.00 $0.00 $0.00 $0.00 G14706 SUP HCPCS C1758 G14706 - SET NPHSTM 12FR 19.5CM CK CNN GW COPE TY LOOP BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G14714 SUP HCPCS C1729 G14714 - CATHETER URET 6FR 70CM ANG TIP TPR END BOTH IP/OP $404.80 $299.55 $0.00 $323.84 $219.81 $219.81 $0.00 $0.00 $0.00 $84.37 $300.44 $300.44 $0.00 $0.00 $84.36 $0.00 $239.44 $239.44 $0.00 $202.40 $320.60 $323.84 $0.00 $0.00 $63.35 $0.00 $0.00 $64.44 $0.00 $0.00 $0.00 $0.00 $0.00 G14717 SUP HCPCS C1758 G14717 - SET NPHSTM THNWL 12FR 21GA 19.5CM STRL 15CM COPE LOOP 1 WY BOTH IP/OP $28.60 $21.16 $0.00 $22.88 $15.53 $15.53 $0.00 $0.00 $0.00 $5.96 $21.23 $21.23 $0.00 $0.00 $5.96 $0.00 $16.92 $16.92 $0.00 $14.30 $22.65 $22.88 $0.00 $0.00 $4.48 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 G14731 SUP HCPCS C1769 G14731 - CATHETER URET 4.8FR 8FR 70CM CONE TIP OP-EN BOTH IP/OP $3.38 $2.50 $0.00 $2.70 $1.84 $1.84 $0.00 $0.00 $0.00 $0.70 $2.51 $2.51 $0.00 $0.00 $0.70 $0.00 $2.00 $2.00 $0.00 $1.69 $2.68 $2.70 $0.00 $0.00 $0.53 $0.00 $0.00 $0.54 $0.00 $0.00 $0.00 $0.00 $0.00 G14732 SUP Custom 27203010 G14732 - GUIDEWIRE URO STD STRG .038IN 145CM STRL LF 3CM FX COR FLX BOTH IP/OP $61.25 $45.33 $0.00 $49.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.46 $45.46 $0.00 $0.00 $12.76 $0.00 $0.00 $0.00 $0.00 $30.63 $48.51 $49.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14738 SUP HCPCS C1758 G14738 - ADAPTER CATH Y 3-6FR M LL SDARM T-B BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14742 SUP HCPCS C2617 G14742 - FILIFORM URTH 7FR 10IN MLBL TIP THRD BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14744 SUP Custom 27203010 G14744 - SET STNT .035IN 70CM SM 2 PGTL CRV STRG 3.7FR 24CM GRN STRL BOTH IP/OP $366.85 $271.47 $0.00 $293.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.28 $272.28 $0.00 $0.00 $76.45 $0.00 $0.00 $0.00 $0.00 $183.43 $290.55 $293.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14748 SUP Custom 27203010 G14748 - ADAPTER CATHETER 3-6FR FOLEY SIDEARM TUOHY-BORST STERILE BOTH IP/OP $50.60 $37.44 $0.00 $40.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.56 $37.56 $0.00 $0.00 $10.55 $0.00 $0.00 $0.00 $0.00 $25.30 $40.08 $40.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14772 SUP HCPCS C1729 G14772 - DISK RTNT 12FR STAB INDWL PERC CATH TIE BOTH IP/OP $185.90 $137.57 $0.00 $148.72 $100.94 $100.94 $0.00 $0.00 $0.00 $38.75 $137.97 $137.97 $0.00 $0.00 $38.74 $0.00 $109.96 $109.96 $0.00 $92.95 $147.23 $148.72 $0.00 $0.00 $29.09 $0.00 $0.00 $29.60 $0.00 $0.00 $0.00 $0.00 $0.00 G14779 SUP HCPCS C2625 G14779 - SET NPHSTM 7-12FR 30CM 20CM MLCT CATH STNT LL CNCT TUBE STY BOTH IP/OP $139.40 $103.16 $0.00 $111.52 $62.73 $62.73 $0.00 $0.00 $0.00 $29.05 $103.46 $103.46 $0.00 $0.00 $29.05 $0.00 $82.46 $82.46 $0.00 $69.70 $110.40 $111.52 $0.00 $0.00 $21.82 $0.00 $0.00 $22.19 $0.00 $0.00 $0.00 $0.00 $0.00 G14780 SUP HCPCS C2617 G14780 - SET STNT .038IN 5MM PGTL CRV 7FR 75CM STRL 100CM BNDR CATH BOTH IP/OP $139.40 $103.16 $0.00 $111.52 $62.73 $62.73 $0.00 $0.00 $0.00 $29.05 $103.46 $103.46 $0.00 $0.00 $29.05 $0.00 $82.46 $82.46 $0.00 $69.70 $110.40 $111.52 $0.00 $0.00 $21.82 $0.00 $0.00 $22.19 $0.00 $0.00 $0.00 $0.00 $0.00 G14782 SUP HCPCS C1769 G14782 - SET STNT .038IN 5MM PGTL CRV 7FR 75CM STRL 100CM BNDR CATH BOTH IP/OP $404.80 $299.55 $0.00 $323.84 $219.81 $219.81 $0.00 $0.00 $0.00 $84.37 $300.44 $300.44 $0.00 $0.00 $84.36 $0.00 $239.44 $239.44 $0.00 $202.40 $320.60 $323.84 $0.00 $0.00 $63.35 $0.00 $0.00 $64.44 $0.00 $0.00 $0.00 $0.00 $0.00 G14787 SUP HCPCS C2617 G14787 - DILATOR URET 7FR 6MM 65CM 4CM SET BLN RADOPQ GW BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14788 SUP HCPCS C2617 G14788 - SET STNT 50CM 70CM SM 2 PGTL CRV STRG 3.7FR 16CM STRL 145CM BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14789 SUP HCPCS C2617 G14789 - SET STNT .038IN 40CM J 2 PGTL CRV STRG 10FR 10FR 26CM STRL BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14790 SUP HCPCS C2617 G14790 - SET STNT .038IN 40CM J 2 PGTL CRV STRG 10FR 10FR 24CM STRL BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14791 SUP HCPCS C2628 G14791 - CATHETER BLNOCC 5.3FR 75CM STRL REM ADPR RADOPQ SIL UPJ DISP BOTH IP/OP $319.00 $236.06 $0.00 $255.20 $0.00 $0.00 $0.00 $0.00 $0.00 $66.49 $236.76 $236.76 $0.00 $0.00 $66.48 $0.00 $188.69 $188.69 $0.00 $159.50 $252.65 $255.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14794 SUP HCPCS C2617 G14794 - SET STNT .038IN 40CM J 2 PGTL CRV STRG 10FR 10FR 22CM STRL BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14796 SUP HCPCS C2627 G14796 - SET STNT 50CM 70CM SM 2 PGTL CRV STRG 3.7FR 8CM STRL 145CM BOTH IP/OP $36.70 $27.16 $0.00 $29.36 $19.93 $19.93 $0.00 $0.00 $0.00 $0.00 $27.24 $27.24 $0.00 $0.00 $7.65 $0.00 $0.00 $0.00 $0.00 $18.35 $29.07 $29.36 $0.00 $0.00 $5.74 $0.00 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $0.00 G14798 SUP HCPCS C1758 G14798 - DILATOR URTH 11FR 20CM PE FSCA BOTH IP/OP $28.60 $21.16 $0.00 $22.88 $15.53 $15.53 $0.00 $0.00 $0.00 $5.96 $21.23 $21.23 $0.00 $0.00 $5.96 $0.00 $16.92 $16.92 $0.00 $14.30 $22.65 $22.88 $0.00 $0.00 $4.48 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 G14799 SUP HCPCS C2617 G14799 - CATHETER URET 5FR 110CM FLXTP CLS END RT BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14803 SUP HCPCS C1758 G14803 - SET STNT 50CM 70CM SM 2 PGTL CRV STRG 3.7FR 18CM STRL 145CM BOTH IP/OP $123.83 $91.63 $0.00 $99.06 $67.24 $67.24 $0.00 $0.00 $0.00 $25.81 $91.90 $91.90 $0.00 $0.00 $25.81 $0.00 $73.24 $73.24 $0.00 $61.91 $98.07 $99.06 $0.00 $0.00 $19.38 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $0.00 G14804 SUP HCPCS C1758 G14804 - CATHETER URET .045IN PGTL CRV 8FR 70CM SDPRT GW RT BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14808 SUP HCPCS C1758 G14808 - CATHETER URET .038IN 5FR 115CM OP-EN GW MOD BOTH IP/OP $276.25 $204.43 $0.00 $221.00 $150.00 $150.00 $0.00 $0.00 $0.00 $57.58 $205.03 $205.03 $0.00 $0.00 $57.57 $0.00 $163.40 $163.40 $0.00 $138.13 $218.79 $221.00 $0.00 $0.00 $43.23 $0.00 $0.00 $43.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14809 SUP HCPCS C1758 G14809 - CATHETER URET STD 6FR 70CM FLXTP OP-EN FLX TP ACPT .038IN GW BOTH IP/OP $27.63 $20.45 $0.00 $22.10 $15.00 $15.00 $0.00 $0.00 $0.00 $5.76 $20.50 $20.50 $0.00 $0.00 $5.76 $0.00 $16.34 $16.34 $0.00 $13.81 $21.88 $22.10 $0.00 $0.00 $4.32 $0.00 $0.00 $4.40 $0.00 $0.00 $0.00 $0.00 $0.00 G14822 SUP HCPCS C2625 G14822 - CATHETER URET 3FR 70CM OP-EN ACPT .018IN GW BOTH IP/OP $139.40 $103.16 $0.00 $111.52 $62.73 $62.73 $0.00 $0.00 $0.00 $29.05 $103.46 $103.46 $0.00 $0.00 $29.05 $0.00 $82.46 $82.46 $0.00 $69.70 $110.40 $111.52 $0.00 $0.00 $21.82 $0.00 $0.00 $22.19 $0.00 $0.00 $0.00 $0.00 $0.00 G14823 SUP HCPCS C2625 G14823 - SET STNT .038IN 5MM PGTL CRV 7FR 70CM WHT STRL 145CM BNDR BOTH IP/OP $139.40 $103.16 $0.00 $111.52 $62.73 $62.73 $0.00 $0.00 $0.00 $29.05 $103.46 $103.46 $0.00 $0.00 $29.05 $0.00 $82.46 $82.46 $0.00 $69.70 $110.40 $111.52 $0.00 $0.00 $21.82 $0.00 $0.00 $22.19 $0.00 $0.00 $0.00 $0.00 $0.00 G14832 SUP HCPCS C2617 G14832 - SET STNT .018IN SM 2 PGTL CRV CDE 4.7FR 4FR 12CM STRL CP BOTH IP/OP $253.25 $187.41 $0.00 $202.60 $113.96 $113.96 $0.00 $0.00 $0.00 $52.78 $187.96 $187.96 $0.00 $0.00 $52.78 $0.00 $149.80 $149.80 $0.00 $126.63 $200.57 $202.60 $0.00 $0.00 $39.63 $0.00 $0.00 $40.32 $0.00 $0.00 $0.00 $0.00 $0.00 G14834 SUP HCPCS C2617 G14834 - SET STNT .038IN 5MM PGTL CRV 7FR 70CM WHT STRL 145CM BNDR BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14836 SUP HCPCS C2625 G14836 - SET STNT SM 2 PGTL CRV 3.7FR AST LGTH STRL CATH RADOPQ PSTNR BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14837 SUP HCPCS C2625 G14837 - SET STNT .038IN 3CM 40CM 70CM 6FR 22-32CM STRL 145CM KWART BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14840 SUP HCPCS C2617 G14840 - SET STNT .038IN 3CM 40CM 70CM .038IN 7FR 22-32CM STRL 145CM BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14843 SUP HCPCS C2617 G14843 - SET STNT .018IN SM 2 PGTL CRV 4.7FR 4FR 16CM STRL CP MDRL BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14844 SUP HCPCS C2625 G14844 - SET STNT .038IN 40CM 2 PGTL CRV STRG 12FR 12FR 26CM STRL 145 BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14854 SUP HCPCS C2617 G14854 - SET STNT .038IN 8.2FR 22-32CM STRL KWART RETRO-INJ STNT BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14857 SUP HCPCS C1758 G14857 - SET STNT .038IN 40CM 2 PGTL CRV STRG 12FR 12FR 24CM STRL 145 BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14859 SUP HCPCS C2627 G14859 - CATHETER URET .038IN 5FR 95CM OP-EN GW MOD BOTH IP/OP $66.43 $49.16 $0.00 $53.14 $36.07 $36.07 $0.00 $0.00 $0.00 $0.00 $49.30 $49.30 $0.00 $0.00 $13.84 $0.00 $0.00 $0.00 $0.00 $33.21 $52.61 $53.14 $0.00 $0.00 $10.40 $0.00 $0.00 $10.57 $0.00 $0.00 $0.00 $0.00 $0.00 G14861 SUP HCPCS C2627 G14861 - DILATOR URTH 26FR 20CM PE FSCA BOTH IP/OP $66.43 $49.16 $0.00 $53.14 $36.07 $36.07 $0.00 $0.00 $0.00 $0.00 $49.30 $49.30 $0.00 $0.00 $13.84 $0.00 $0.00 $0.00 $0.00 $33.21 $52.61 $53.14 $0.00 $0.00 $10.40 $0.00 $0.00 $10.57 $0.00 $0.00 $0.00 $0.00 $0.00 G14865 SUP HCPCS C2617 G14865 - DILATOR URTH 30FR 20CM PE FSCA BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14866 SUP HCPCS C2617 G14866 - SET STNT .018IN SM 2 PGTL CRV CDE 6FR 4FR 16CM STRL CP MDRL BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14867 SUP HCPCS C2617 G14867 - SET STNT .018IN SM 2 PGTL CRV CDE 6FR 4FR 14CM STRL CP MDRL BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14870 SUP HCPCS C1758 G14870 - SET STNT .018IN SM 2 PGTL CRV 6FR 4FR 12CM STRL CP MDRL BOTH IP/OP $36.70 $27.16 $0.00 $29.36 $19.93 $19.93 $0.00 $0.00 $0.00 $7.65 $27.24 $27.24 $0.00 $0.00 $7.65 $0.00 $21.71 $21.71 $0.00 $18.35 $29.07 $29.36 $0.00 $0.00 $5.74 $0.00 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $0.00 G14873 SUP HCPCS C1758 G14873 - CATHETER URET 3.8FR 70CM LSR BOTH IP/OP $276.25 $204.43 $0.00 $221.00 $150.00 $150.00 $0.00 $0.00 $0.00 $57.58 $205.03 $205.03 $0.00 $0.00 $57.57 $0.00 $163.40 $163.40 $0.00 $138.13 $218.79 $221.00 $0.00 $0.00 $43.23 $0.00 $0.00 $43.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14885 SUP HCPCS C2625 G14885 - SET STNT 3CM 6FR 22CM STRL 145CM KWART RETRO-INJ RADOPQ BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G14886 SUP HCPCS C2625 G14886 - CATHETER URET 5FR 70CM SPRL TIP SDPRT ACC ACPT .038IN GW BOTH IP/OP $26.14 $19.34 $0.00 $20.91 $11.76 $11.76 $0.00 $0.00 $0.00 $5.45 $19.40 $19.40 $0.00 $0.00 $5.45 $0.00 $15.46 $15.46 $0.00 $13.07 $20.70 $20.91 $0.00 $0.00 $4.09 $0.00 $0.00 $4.16 $0.00 $0.00 $0.00 $0.00 $0.00 G14887 SUP HCPCS C2625 G14887 - SET STNT .038IN 2 PGTL CRV 6FR 26CM STRL KWART RETRO-INJ BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14890 SUP HCPCS C1758 G14890 - SET STNT .038IN 40CM 70CM 2 PGTL CRV STRG 6FR 24CM STRL 145 BOTH IP/OP $36.70 $27.16 $0.00 $29.36 $19.93 $19.93 $0.00 $0.00 $0.00 $7.65 $27.24 $27.24 $0.00 $0.00 $7.65 $0.00 $21.71 $21.71 $0.00 $18.35 $29.07 $29.36 $0.00 $0.00 $5.74 $0.00 $0.00 $5.84 $0.00 $0.00 $0.00 $0.00 $0.00 G14891 SUP HCPCS C2627 G14891 - SET CATH 16FR 25CM SET SPBC STM MLCT BOTH IP/OP $95.63 $70.77 $0.00 $76.50 $51.92 $51.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.81 $75.74 $76.50 $0.00 $0.00 $14.97 $0.00 $0.00 $15.22 $0.00 $0.00 $0.00 $0.00 $0.00 G14893 SUP HCPCS C1894 G14893 - CATHETER URET 3FR 70CM LSR ACPT .010IN GW BOTH IP/OP $451.00 $333.74 $0.00 $360.80 $244.89 $244.89 $0.00 $0.00 $0.00 $94.00 $334.73 $334.73 $0.00 $0.00 $93.99 $0.00 $266.77 $266.77 $0.00 $225.50 $357.19 $360.80 $0.00 $0.00 $70.58 $0.00 $0.00 $71.80 $0.00 $0.00 $0.00 $0.00 $0.00 G14897 SUP HCPCS C2617 G14897 - DILATOR URTH RING 8-26FR 50CM LTX RADOPQ PTFE TRQ GW RADOPQ BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14898 SUP HCPCS C2617 G14898 - SET STNT 50CM 70CM SM 2 PGTL CRV STRG 3.7FR 22CM STRL 145CM BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14900 SUP Custom 27203010 G14900 - SET STNT .018IN SM 2 PGTL CRV CDE 4.7FR 4FR 14CM STRL CP BOTH IP/OP $26.58 $19.67 $0.00 $21.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.72 $19.72 $0.00 $0.00 $5.54 $0.00 $0.00 $0.00 $0.00 $13.29 $21.05 $21.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14905 SUP HCPCS C2625 G14905 - DEVICE SCR 16FR STRL RTNT DISK SIL DISP ACPT 16FR BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14906 SUP HCPCS C2617 G14906 - SET STNT .018IN SM 2 PGTL CRV CDE 4.7FR 10CM STRL RADOPQ BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14910 SUP HCPCS C2625 G14910 - SET STNT .038IN 2 PGTL CRV 6FR 28CM STRL KWART RETRO-INJ BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14911 SUP HCPCS C2625 G14911 - SET STNT .038IN 40CM 70CM 2 PGTL CRV STRG 7FR 26CM STRL 145 BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14912 SUP HCPCS C2625 G14912 - SET STNT .038IN 40CM 70CM 2 PGTL CRV 7FR 24CM STRL 145CM BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14916 SUP HCPCS C2625 G14916 - SET STNT .038IN 40CM 70CM 2 PGTL CRV STRG 7FR 28CM STRL 145 BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14917 SUP HCPCS C1729 G14917 - SET STNT .038IN 3CM 40CM 70CM STRG 4.7FR 22-32CM STRL 145CM BOTH IP/OP $404.80 $299.55 $0.00 $323.84 $219.81 $219.81 $0.00 $0.00 $0.00 $84.37 $300.44 $300.44 $0.00 $0.00 $84.36 $0.00 $239.44 $239.44 $0.00 $202.40 $320.60 $323.84 $0.00 $0.00 $63.35 $0.00 $0.00 $64.44 $0.00 $0.00 $0.00 $0.00 $0.00 G14919 SUP Custom 27203010 G14919 - SET NPHSTM .038IN THNWL CRV 14FR 19.5CM STRL 30CM COPE LOOP BOTH IP/OP $185.60 $137.34 $0.00 $148.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.75 $137.75 $0.00 $0.00 $38.68 $0.00 $0.00 $0.00 $0.00 $92.80 $147.00 $148.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G14920 SUP HCPCS C2627 G14920 - BRUSH CYTO 3.2FR 115CM BX SET STRG TIP OCL URET BOTH IP/OP $144.10 $106.63 $0.00 $115.28 $78.25 $78.25 $0.00 $0.00 $0.00 $0.00 $106.95 $106.95 $0.00 $0.00 $30.03 $0.00 $0.00 $0.00 $0.00 $72.05 $114.13 $115.28 $0.00 $0.00 $22.55 $0.00 $0.00 $22.94 $0.00 $0.00 $0.00 $0.00 $0.00 G14921 SUP HCPCS C1773 G14921 - GUIDEWIRE ESCP .035IN 145CM 3CM FLX TP STD BD SS URET BOTH IP/OP $664.55 $491.77 $0.00 $531.64 $360.85 $360.85 $0.00 $0.00 $0.00 $138.51 $493.23 $493.23 $0.00 $0.00 $138.49 $0.00 $393.08 $393.08 $0.00 $332.28 $526.32 $531.64 $0.00 $0.00 $104.00 $0.00 $0.00 $105.80 $0.00 $0.00 $0.00 $0.00 $0.00 G14922 SUP HCPCS C1773 G14922 - SET CATH 16FR 14FR 22CM 3CC LTX 30CM RTNR BLN NDL OBT CNCT BOTH IP/OP $664.55 $491.77 $0.00 $531.64 $360.85 $360.85 $0.00 $0.00 $0.00 $138.51 $493.23 $493.23 $0.00 $0.00 $138.49 $0.00 $393.08 $393.08 $0.00 $332.28 $526.32 $531.64 $0.00 $0.00 $104.00 $0.00 $0.00 $105.80 $0.00 $0.00 $0.00 $0.00 $0.00 G14925 SUP HCPCS C1758 G14925 - FORCEPS SPEC RTRVL 3.3FR 115CM STRL 1 JAW STON FLXB SHFT BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G14935 SUP HCPCS C1773 G14935 - CATHETER URET STD 8FR 70CM PLLK OP-EN FLX TP ACPT .038IN GW BOTH IP/OP $664.55 $491.77 $0.00 $531.64 $360.85 $360.85 $0.00 $0.00 $0.00 $138.51 $493.23 $493.23 $0.00 $0.00 $138.49 $0.00 $393.08 $393.08 $0.00 $332.28 $526.32 $531.64 $0.00 $0.00 $104.00 $0.00 $0.00 $105.80 $0.00 $0.00 $0.00 $0.00 $0.00 G14936 SUP HCPCS C1773 G14936 - FORCEPS SPEC RTRVL 3.3FR 65CM STRL LF ALGTR TTH FLXB SHFT BOTH IP/OP $764.25 $565.55 $0.00 $611.40 $414.99 $414.99 $0.00 $0.00 $0.00 $159.29 $567.23 $567.23 $0.00 $0.00 $159.27 $0.00 $452.05 $452.05 $0.00 $382.13 $605.29 $611.40 $0.00 $0.00 $119.61 $0.00 $0.00 $121.67 $0.00 $0.00 $0.00 $0.00 $0.00 G14938 SUP HCPCS C1758 G14938 - FORCEPS SPEC RTRVL 3.3FR 65CM 1 JAW RAT TTH URO BOTH IP/OP $28.60 $21.16 $0.00 $22.88 $15.53 $15.53 $0.00 $0.00 $0.00 $5.96 $21.23 $21.23 $0.00 $0.00 $5.96 $0.00 $16.92 $16.92 $0.00 $14.30 $22.65 $22.88 $0.00 $0.00 $4.48 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 G14941 SUP HCPCS C1758 G14941 - CATHETER URET .038IN 5FR 70CM PLLK OP-EN GW MOD FLX TP BOTH IP/OP $28.60 $21.16 $0.00 $22.88 $15.53 $15.53 $0.00 $0.00 $0.00 $5.96 $21.23 $21.23 $0.00 $0.00 $5.96 $0.00 $16.92 $16.92 $0.00 $14.30 $22.65 $22.88 $0.00 $0.00 $4.48 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 G14943 SUP HCPCS C2617 G14943 - CATHETER URET SPRL 6FR 70CM LG SDPRT ACPT .038IN GW BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14951 SUP HCPCS C2617 G14951 - SET STNT .038IN 40CM 2 PGTL CRV STRG 12FR 22CM STRL 145CM BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14952 SUP HCPCS C1758 G14952 - SET STNT .018IN SM 2 PGTL CRV CDE 7FR 4FR 12CM STRL CP MDRL BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14955 SUP HCPCS C2625 G14955 - CATHETER URET 5FR 70CM WHSTLTP MOD BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G14975 SUP HCPCS C1769 G14975 - SET STNT .038IN 40CM 70CM 2 PGTL CRV STRG 4.7FR 24CM STRL BOTH IP/OP $69.98 $51.79 $0.00 $55.98 $38.00 $38.00 $0.00 $0.00 $0.00 $14.58 $51.94 $51.94 $0.00 $0.00 $14.58 $0.00 $41.39 $41.39 $0.00 $34.99 $55.42 $55.98 $0.00 $0.00 $10.95 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 G14980 SUP HCPCS C1758 G14980 - GUIDEWIRE URO .035IN 145CM 8CM AMPTZ STRG FLX TP SS BOTH IP/OP $109.48 $81.02 $0.00 $87.58 $59.44 $59.44 $0.00 $0.00 $0.00 $22.82 $81.25 $81.25 $0.00 $0.00 $22.81 $0.00 $64.75 $64.75 $0.00 $54.74 $86.71 $87.58 $0.00 $0.00 $17.13 $0.00 $0.00 $17.43 $0.00 $0.00 $0.00 $0.00 $0.00 G14991 SUP HCPCS C2617 G14991 - SET CATH .038IN PGTL CRV 7FR 90CM STRL 145CM PSTNR SDPRT GW BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G14992 SUP HCPCS C2617 G14992 - SET STNT .038IN 40CM 2 PGTL CRV STRG 10FR 28CM STRL 145CM BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15000 SUP HCPCS C2617 G15000 - SET STNT .038IN 40CM 2 PGTL CRV STRG 10FR 20CM STRL 145CM BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15003 SUP HCPCS C2617 G15003 - SET STNT .018IN SM 2 PGTL CRV CDE 6FR 4FR 8CM STRL CP MDRL BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15015 SUP HCPCS C2625 G15015 - SET STNT .018IN SM 2 PGTL CRV CDE 6FR 4FR 10CM STRL CP MDRL BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G15016 SUP HCPCS C2625 G15016 - SET STNT .038IN 40CM 70CM 2 PGTL CRV STRG 8.2FR 24CM STRL BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G15020 SUP HCPCS C1758 G15020 - SET STNT .038IN 40CM 70CM 2 PGTL CRV STRG 4.7FR 26CM STRL BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $6.65 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $18.87 $18.87 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G15030 SUP Custom 27203010 G15030 - CATHETER URET 3FR 115CM LSR FBR HNDL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $0.00 $0.00 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15034 SUP HCPCS C1729 G15034 - ADAPTER CATH 14FR 15CM GOLDBERG FL DRN BG URET BOTH IP/OP $155.60 $115.14 $0.00 $124.48 $84.49 $84.49 $0.00 $0.00 $0.00 $32.43 $115.49 $115.49 $0.00 $0.00 $32.43 $0.00 $92.04 $92.04 $0.00 $77.80 $123.24 $124.48 $0.00 $0.00 $24.35 $0.00 $0.00 $24.77 $0.00 $0.00 $0.00 $0.00 $0.00 G15035 SUP HCPCS C1729 G15035 - SET NPHSTM PGTL CRV 8.2FR 15CM 5CM MOD CATH STNT CNCT TUBE BOTH IP/OP $155.60 $115.14 $0.00 $124.48 $84.49 $84.49 $0.00 $0.00 $0.00 $32.43 $115.49 $115.49 $0.00 $0.00 $32.43 $0.00 $92.04 $92.04 $0.00 $77.80 $123.24 $124.48 $0.00 $0.00 $24.35 $0.00 $0.00 $24.77 $0.00 $0.00 $0.00 $0.00 $0.00 G15037 SUP HCPCS C1758 G15037 - SET NPHSTM PGTL CRV 8.2FR 15CM 7CM MOD CATH STNT CNCT TUBE BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G15038 SUP HCPCS C2617 G15038 - CATHETER URET .038IN 5FR 115CM PLLK OP-EN GW MOD FLX TP BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15040 SUP HCPCS C1758 G15040 - SET STNT .038IN 2 PGTL CRV CDE 7FR 10CM STRL RADOPQ GW SFLX BOTH IP/OP $276.25 $204.43 $0.00 $221.00 $150.00 $150.00 $0.00 $0.00 $0.00 $57.58 $205.03 $205.03 $0.00 $0.00 $57.57 $0.00 $163.40 $163.40 $0.00 $138.13 $218.79 $221.00 $0.00 $0.00 $43.23 $0.00 $0.00 $43.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15042 SUP HCPCS C2617 G15042 - CATHETER URET STD 4FR 70CM LF FLXTP PLCK OP-EN ACPT .028IN BOTH IP/OP $6.66 $4.93 $0.00 $5.33 $3.00 $3.00 $0.00 $0.00 $0.00 $1.39 $4.94 $4.94 $0.00 $0.00 $1.39 $0.00 $3.94 $3.94 $0.00 $3.33 $5.27 $5.33 $0.00 $0.00 $1.04 $0.00 $0.00 $1.06 $0.00 $0.00 $0.00 $0.00 $0.00 G15045 SUP Custom 27203010 G15045 - STENT URTH 10FR 30CM STRL FRLT KLG SUT BLB SIL DISP BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15047 SUP HCPCS C2617 G15047 - SET BX 3.2FR 115CM BRSH DFLC RADOPQ URET BOTH IP/OP $66.63 $49.31 $0.00 $53.30 $29.98 $29.98 $0.00 $0.00 $0.00 $13.89 $49.45 $49.45 $0.00 $0.00 $13.88 $0.00 $39.41 $39.41 $0.00 $33.31 $52.77 $53.30 $0.00 $0.00 $10.43 $0.00 $0.00 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 G15049 SUP HCPCS C2617 G15049 - STENT URTH 8FR 30CM STRL FRLT KLG SIL DISP HYPOSPADIAS BOTH IP/OP $66.63 $49.31 $0.00 $53.30 $29.98 $29.98 $0.00 $0.00 $0.00 $13.89 $49.45 $49.45 $0.00 $0.00 $13.88 $0.00 $39.41 $39.41 $0.00 $33.31 $52.77 $53.30 $0.00 $0.00 $10.43 $0.00 $0.00 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 G15050 SUP HCPCS C2617 G15050 - STENT URTH 8FR 12CM STRL ZAONTZ DISP HYPOSPADIAS EPISPADIAS BOTH IP/OP $66.63 $49.31 $0.00 $53.30 $29.98 $29.98 $0.00 $0.00 $0.00 $13.89 $49.45 $49.45 $0.00 $0.00 $13.88 $0.00 $39.41 $39.41 $0.00 $33.31 $52.77 $53.30 $0.00 $0.00 $10.43 $0.00 $0.00 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 G15054 SUP Custom 27203010 G15054 - FORCEPS ENDSCP 3.3FR 115CM FLEXIBLE OVAL BIOP CUP TISSUE BOTH IP/OP $781.00 $577.94 $0.00 $624.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $579.66 $579.66 $0.00 $0.00 $162.76 $0.00 $0.00 $0.00 $0.00 $390.50 $618.55 $624.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15056 SUP Custom 27203010 G15056 - STENT URTH 10FR 12CM STRL ZAONTZ DISP HYPOSPADIAS OR BOTH IP/OP $45.55 $33.71 $0.00 $36.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.81 $33.81 $0.00 $0.00 $9.49 $0.00 $0.00 $0.00 $0.00 $22.78 $36.08 $36.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15061 SUP HCPCS C1726 G15061 - CARRIER SUT 30D 16CM PEREYRA RAZ LGT REUSE BOTH IP/OP $385.00 $284.90 $0.00 $308.00 $209.06 $209.06 $0.00 $0.00 $0.00 $80.24 $285.75 $285.75 $0.00 $0.00 $80.23 $0.00 $227.73 $227.73 $0.00 $192.50 $304.92 $308.00 $0.00 $0.00 $60.25 $0.00 $0.00 $61.29 $0.00 $0.00 $0.00 $0.00 $0.00 G15062 SUP HCPCS C1726 G15062 - CATHETER URTH 7FR 30CM STRL M DISP BOTH IP/OP $442.75 $327.64 $0.00 $354.20 $240.41 $240.41 $0.00 $0.00 $0.00 $92.28 $328.61 $328.61 $0.00 $0.00 $92.27 $0.00 $261.89 $261.89 $0.00 $221.38 $350.66 $354.20 $0.00 $0.00 $69.29 $0.00 $0.00 $70.49 $0.00 $0.00 $0.00 $0.00 $0.00 G15067 SUP HCPCS C1769 G15067 - CATHETER BLNDIL SET F URET BOTH IP/OP $37.40 $27.68 $0.00 $29.92 $20.31 $20.31 $0.00 $0.00 $0.00 $7.80 $27.76 $27.76 $0.00 $0.00 $7.79 $0.00 $22.12 $22.12 $0.00 $18.70 $29.62 $29.92 $0.00 $0.00 $5.85 $0.00 $0.00 $5.95 $0.00 $0.00 $0.00 $0.00 $0.00 G15070 SUP HCPCS C2627 G15070 - GUIDEWIRE ESCP STRG STD .038IN 80CM STRL 3CM FLX TP FXCR SS BOTH IP/OP $144.10 $106.63 $0.00 $115.28 $78.25 $78.25 $0.00 $0.00 $0.00 $0.00 $106.95 $106.95 $0.00 $0.00 $30.03 $0.00 $0.00 $0.00 $0.00 $72.05 $114.13 $115.28 $0.00 $0.00 $22.55 $0.00 $0.00 $22.94 $0.00 $0.00 $0.00 $0.00 $0.00 G15076 SUP HCPCS C2617 G15076 - SET CATH 10FR 22CM 3ML STRL LTX 30CM RTNR BLN SS NDL OBT BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15077 SUP HCPCS C2617 G15077 - SET DRN 8FR 6-10FR 30CM 20CM CATH DIL LOOP BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15079 SUP HCPCS C1892 G15079 - SET STNT .018IN SM 2 PGTL CRV CDE 4.7FR 8CM STRL RADOPQ BOTH IP/OP $103.53 $76.61 $0.00 $82.82 $56.21 $56.21 $0.00 $0.00 $0.00 $21.58 $76.84 $76.84 $0.00 $0.00 $21.57 $0.00 $61.24 $61.24 $0.00 $51.76 $82.00 $82.82 $0.00 $0.00 $16.20 $0.00 $0.00 $16.48 $0.00 $0.00 $0.00 $0.00 $0.00 G15088 SUP HCPCS C2627 G15088 - CATHETER URO 8FR 8.5FR 88CM 30CM CK SET GW 810 STNT PLC BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $22.70 $22.70 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $6.54 $0.00 $0.00 $6.65 $0.00 $0.00 $0.00 $0.00 $0.00 G15089 SUP HCPCS C2627 G15089 - DILATOR URET 7FR 60CM SET PE BOTH IP/OP $187.00 $138.38 $0.00 $149.60 $101.54 $101.54 $0.00 $0.00 $0.00 $0.00 $138.79 $138.79 $0.00 $0.00 $38.97 $0.00 $0.00 $0.00 $0.00 $93.50 $148.10 $149.60 $0.00 $0.00 $29.27 $0.00 $0.00 $29.77 $0.00 $0.00 $0.00 $0.00 $0.00 G15093 SUP HCPCS C2617 G15093 - CATHETER SPBC 16FR 12CM OB PLWY ACC INTRO SET GW TROC NDL BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15108 SUP Custom 27203010 G15108 - SET STNT .018IN 2 PGTL CRV CDE 7FR 16CM STRL RADOPQ PSTNR GW BOTH IP/OP $75.90 $56.17 $0.00 $60.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.33 $56.33 $0.00 $0.00 $15.82 $0.00 $0.00 $0.00 $0.00 $37.95 $60.11 $60.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15109 SUP Custom 27203010 G15109 - DILATOR URTH 8FR 35.5CM DIST TIP BOTH IP/OP $75.90 $56.17 $0.00 $60.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.33 $56.33 $0.00 $0.00 $15.82 $0.00 $0.00 $0.00 $0.00 $37.95 $60.11 $60.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15116 SUP HCPCS C1758 G15116 - CATHETER URET 4FR 70CM WHSTLTP MOD BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G15120 SUP HCPCS C2617 G15120 - CATHETER URET 4FR 115CM FLXTP CLS END RT BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15121 SUP HCPCS C1758 G15121 - SET STNT .038IN 2 PGTL CRV 7FR 24CM BLK STRL 145CM RADOPQ BOTH IP/OP $83.50 $61.79 $0.00 $66.80 $45.34 $45.34 $0.00 $0.00 $0.00 $17.40 $61.97 $61.97 $0.00 $0.00 $17.40 $0.00 $49.39 $49.39 $0.00 $41.75 $66.13 $66.80 $0.00 $0.00 $13.07 $0.00 $0.00 $13.29 $0.00 $0.00 $0.00 $0.00 $0.00 G15123 SUP HCPCS C2617 G15123 - CATHETER URET 20D .035IN 7FR 70CM 145CM ANG TIP TPR END GW BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15124 SUP HCPCS C2617 G15124 - SET STNT .038IN 2 PGTL CRV FLFRM 7FR 22CM BLK STRL 145CM BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15125 SUP HCPCS C2617 G15125 - SET STNT .038IN 2 PGTL CRV 7FR 26CM BLK STRL 145CM RADOPQ BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15126 SUP HCPCS C2617 G15126 - SET STNT .038IN 2 PGTL CRV 7FR 28CM BLK STRL 145CM RADOPQ BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15127 SUP HCPCS C2617 G15127 - SET STNT .038IN 2 PGTL CRV STRG FLFRM 7FR 30CM BLK STRL 145 BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15128 SUP HCPCS C2617 G15128 - SET STNT .038IN 2 PGTL CRV STRG FLFRM 8.5FR 22CM BLK STRL BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15129 SUP HCPCS C2617 G15129 - SET STNT .038IN 2 PGTL CRV 8.5FR 24CM BLK STRL 145CM RADOPQ BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15130 SUP HCPCS C2617 G15130 - SET STNT .038IN 2 PGTL CRV 8.5FR 28CM BLK STRL 145CM RADOPQ BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15133 SUP Custom 27203010 G15133 - SET NPHSTM 500ML STRL 1 CNCT DRN PCH SFT ELC BELT REED VLV BOTH IP/OP $71.25 $52.73 $0.00 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.88 $52.88 $0.00 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $35.63 $56.43 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15134 SUP Custom 27203010 G15134 - SET STNT .038IN 2 PGTL CRV STRG FLFRM 8.5FR 26CM BLK STRL BOTH IP/OP $71.25 $52.73 $0.00 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.88 $52.88 $0.00 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $35.63 $56.43 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15136 SUP Custom 27203010 G15136 - SET NPHSTM 500ML STRL DRN PCH SFT ELC BELT REED VLV MECH BOTH IP/OP $71.25 $52.73 $0.00 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.88 $52.88 $0.00 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $35.63 $56.43 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15137 SUP Custom 27203010 G15137 - SET NPHSTM 500ML NS CK 1 CNCT DRN PCH SFT ELC BELT DISP BOTH IP/OP $71.25 $52.73 $0.00 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.88 $52.88 $0.00 $0.00 $14.85 $0.00 $0.00 $0.00 $0.00 $35.63 $56.43 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15138 SUP HCPCS C2617 G15138 - SET NPHSTM 500ML NS 2 CNCT DRN PCH SFT ELC BELT REED VLV BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15144 SUP HCPCS C2617 G15144 - SET STNT .018IN SM 2 PGTL CRV 7FR 14CM STRL RADOPQ PSTNR GW BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15145 SUP HCPCS C2617 G15145 - SET STNT .038IN 2 PGTL CRV FLFRM 6FR 22CM BLK STRL 145CM BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15146 SUP HCPCS C2617 G15146 - SET STNT .038IN 2 PGTL CRV FLFRM 6FR 24CM BLK STRL 145CM BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15147 SUP HCPCS C2617 G15147 - SET STNT .038IN 2 PGTL CRV FLFRM 6FR 26CM BLK STRL 145CM BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15148 SUP HCPCS C2617 G15148 - SET STNT .038IN 2 PGTL CRV 6FR 28CM BLK STRL 145CM RADOPQ BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15149 SUP HCPCS C2627 G15149 - SET STNT .038IN 2 PGTL CRV STRG FLFRM 6FR 30CM BLK STRL 145 BOTH IP/OP $137.90 $102.05 $0.00 $110.32 $74.88 $74.88 $0.00 $0.00 $0.00 $0.00 $102.35 $102.35 $0.00 $0.00 $28.74 $0.00 $0.00 $0.00 $0.00 $68.95 $109.22 $110.32 $0.00 $0.00 $21.58 $0.00 $0.00 $21.95 $0.00 $0.00 $0.00 $0.00 $0.00 G15150 SUP HCPCS C2617 G15150 - SET CATH LOOP 14FR 23CM BLU SFLX 1 WY STPCK NDL OBT CNCT BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15167 SUP Custom 27203010 G15167 - DILATOR URTH 6-10FR MEATUS BOTH IP/OP $35.43 $26.22 $0.00 $28.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.29 $26.29 $0.00 $0.00 $7.38 $0.00 $0.00 $0.00 $0.00 $17.71 $28.06 $28.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15168 SUP HCPCS C2625 G15168 - CATHETER URO 8-14FR SPRT SFT LOPRFL NKNK CRV PERC BOTH IP/OP $141.45 $104.67 $0.00 $113.16 $63.65 $63.65 $0.00 $0.00 $0.00 $29.48 $104.98 $104.98 $0.00 $0.00 $29.48 $0.00 $83.67 $83.67 $0.00 $70.73 $112.03 $113.16 $0.00 $0.00 $22.14 $0.00 $0.00 $22.52 $0.00 $0.00 $0.00 $0.00 $0.00 G15170 SUP Custom 27203010 G15170 - SET NPHSTM PGTL CRV 8.2FR 125CM DRETLER STNT GW BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $0.00 $0.00 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15172 SUP HCPCS C1758 G15172 - CATHETER URTH 22-24FR RTNR FL TRC TEMP TRC BOTH IP/OP $31.63 $23.41 $0.00 $25.30 $17.17 $17.17 $0.00 $0.00 $0.00 $6.59 $23.47 $23.47 $0.00 $0.00 $6.59 $0.00 $18.71 $18.71 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 G15193 SUP HCPCS C2617 G15193 - CATHETER URET 3FR 70CM RND TIP STY RT BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15195 SUP HCPCS C1758 G15195 - SET STNT .038IN 2 PGTL CRV STRG FLFRM 6FR 20CM BLK STRL 145 BOTH IP/OP $31.90 $23.61 $0.00 $25.52 $17.32 $17.32 $0.00 $0.00 $0.00 $6.65 $23.68 $23.68 $0.00 $0.00 $6.65 $0.00 $18.87 $18.87 $0.00 $15.95 $25.26 $25.52 $0.00 $0.00 $4.99 $0.00 $0.00 $5.08 $0.00 $0.00 $0.00 $0.00 $0.00 G15196 SUP HCPCS C2627 G15196 - CATHETER URET 2FR 115CM LSR ADPR BOTH IP/OP $256.80 $190.03 $0.00 $205.44 $139.44 $139.44 $0.00 $0.00 $0.00 $0.00 $190.60 $190.60 $0.00 $0.00 $53.52 $0.00 $0.00 $0.00 $0.00 $128.40 $203.39 $205.44 $0.00 $0.00 $40.19 $0.00 $0.00 $40.88 $0.00 $0.00 $0.00 $0.00 $0.00 G15211 SUP HCPCS C1773 G15211 - FOLLOWER URTH 10FR 35.5CM PHLPS DIL DIST TIP THRD WO SDPRT BOTH IP/OP $664.55 $491.77 $0.00 $531.64 $360.85 $360.85 $0.00 $0.00 $0.00 $138.51 $493.23 $493.23 $0.00 $0.00 $138.49 $0.00 $393.08 $393.08 $0.00 $332.28 $526.32 $531.64 $0.00 $0.00 $104.00 $0.00 $0.00 $105.80 $0.00 $0.00 $0.00 $0.00 $0.00 G15214 SUP HCPCS C1729 G15214 - FORCEPS SPEC RTRVL 3.3FR 115CM MS TTH FLXB SHFT BOTH IP/OP $188.10 $139.19 $0.00 $150.48 $102.14 $102.14 $0.00 $0.00 $0.00 $39.20 $139.61 $139.61 $0.00 $0.00 $39.20 $0.00 $111.26 $111.26 $0.00 $94.05 $148.98 $150.48 $0.00 $0.00 $29.44 $0.00 $0.00 $29.95 $0.00 $0.00 $0.00 $0.00 $0.00 G15216 SUP HCPCS C1758 G15216 - SET NPHSTM 14FR 19.5CM STRL LTX CK CATH CNN COPE LOOP NTR BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G15219 SUP Custom 27203010 G15219 - CATHETER URET .038IN 5FR 70CM OP-EN MOD BOTH IP/OP $25.30 $18.72 $0.00 $20.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.78 $18.78 $0.00 $0.00 $5.27 $0.00 $0.00 $0.00 $0.00 $12.65 $20.04 $20.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15221 SUP HCPCS C1892 G15221 - ADAPTER CATH 7-10FR T-B M LL LD TM BOTH IP/OP $136.63 $101.11 $0.00 $109.30 $74.19 $74.19 $0.00 $0.00 $0.00 $28.48 $101.40 $101.40 $0.00 $0.00 $28.47 $0.00 $80.81 $80.81 $0.00 $68.31 $108.21 $109.30 $0.00 $0.00 $21.38 $0.00 $0.00 $21.75 $0.00 $0.00 $0.00 $0.00 $0.00 G15223 SUP HCPCS C2625 G15223 - SET INTRO STD 20FR 37CM 32CM PLWY 2 KNOB SHTH GW BOTH IP/OP $160.30 $118.62 $0.00 $128.24 $72.14 $72.14 $0.00 $0.00 $0.00 $33.41 $118.97 $118.97 $0.00 $0.00 $33.41 $0.00 $94.82 $94.82 $0.00 $80.15 $126.96 $128.24 $0.00 $0.00 $25.09 $0.00 $0.00 $25.52 $0.00 $0.00 $0.00 $0.00 $0.00 G15224 SUP HCPCS C2625 G15224 - SET STNT .038IN 5MM PGTL CRV 6FR 75CM BLK STRL 100CM BNDR BOTH IP/OP $160.30 $118.62 $0.00 $128.24 $72.14 $72.14 $0.00 $0.00 $0.00 $33.41 $118.97 $118.97 $0.00 $0.00 $33.41 $0.00 $94.82 $94.82 $0.00 $80.15 $126.96 $128.24 $0.00 $0.00 $25.09 $0.00 $0.00 $25.52 $0.00 $0.00 $0.00 $0.00 $0.00 G15225 SUP HCPCS C1769 G15225 - SET STNT .038IN 5MM PGTL CRV 6FR 75CM BLK STRL 100CM BNDR BOTH IP/OP $38.88 $28.77 $0.00 $31.10 $21.11 $21.11 $0.00 $0.00 $0.00 $8.10 $28.85 $28.85 $0.00 $0.00 $8.10 $0.00 $22.99 $22.99 $0.00 $19.44 $30.79 $31.10 $0.00 $0.00 $6.08 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $0.00 G15227 SUP HCPCS C2625 G15227 - SET STNT 3CM 2 PGTL CRV 7FR 22CM STRL 145CM KWART RETRO-INJ BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G15230 SUP Custom 27203010 G15230 - FORCEP SPEC RTRVL 65CM 5.2FR 1 JAW ALGTR TOOTH FLXB SHFT BOTH IP/OP $646.00 $478.04 $0.00 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $323.00 $511.63 $516.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15233 SUP HCPCS C2617 G15233 - GUIDEWIRE ESCP STD .035IN 145CM FXCR SS BOTH IP/OP $66.63 $49.31 $0.00 $53.30 $29.98 $29.98 $0.00 $0.00 $0.00 $13.89 $49.45 $49.45 $0.00 $0.00 $13.88 $0.00 $39.41 $39.41 $0.00 $33.31 $52.77 $53.30 $0.00 $0.00 $10.43 $0.00 $0.00 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 G15240 SUP HCPCS C1729 G15240 - TUBE CNCT 10FR 30CM M LL DRN BG BOTH IP/OP $150.55 $111.41 $0.00 $120.44 $81.75 $81.75 $0.00 $0.00 $0.00 $31.38 $111.74 $111.74 $0.00 $0.00 $31.37 $0.00 $89.05 $89.05 $0.00 $75.28 $119.24 $120.44 $0.00 $0.00 $23.56 $0.00 $0.00 $23.97 $0.00 $0.00 $0.00 $0.00 $0.00 G15248 SUP HCPCS C1769 G15248 - SET NPHSTM 10FR 19.5CM COPE LOOP CATH CNN GW BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $0.00 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 G15252 SUP HCPCS C1769 G15252 - GUIDEWIRE VASC STD STRG .028IN 145CM STRL 3CM FXCR FLX TP SS BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $0.00 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 G15256 SUP HCPCS C1769 G15256 - GUIDEWIRE VASC STD STRG .035IN 145CM STRL 3CM FX COR FLX TP BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $0.00 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 G15261 SUP HCPCS C2627 G15261 - CUFF CONTINENCE 10ML NS TEMP INTOP CAP SYR SIL M REUSE BOTH IP/OP $144.10 $106.63 $0.00 $115.28 $78.25 $78.25 $0.00 $0.00 $0.00 $0.00 $106.95 $106.95 $0.00 $0.00 $30.03 $0.00 $0.00 $0.00 $0.00 $72.05 $114.13 $115.28 $0.00 $0.00 $22.55 $0.00 $0.00 $22.94 $0.00 $0.00 $0.00 $0.00 $0.00 G15262 SUP Custom 27203010 G15262 - GUIDEWIRE URO STD STRG .038IN 145CM STRL 3CM FLX TP FXCR SS BOTH IP/OP $177.10 $131.05 $0.00 $141.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.44 $131.44 $0.00 $0.00 $36.91 $0.00 $0.00 $0.00 $0.00 $88.55 $140.26 $141.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15276 SUP Custom 27203010 G15276 - ADAPTER CATH 2 M LL BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $0.00 $0.00 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15279 SUP Custom 27203010 G15279 - NEEDLE ESCP 25GA 5FR 35CM 8MM WMS CSCP BOTH IP/OP $46.83 $34.65 $0.00 $37.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.75 $34.75 $0.00 $0.00 $9.76 $0.00 $0.00 $0.00 $0.00 $23.41 $37.09 $37.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15280 SUP HCPCS C1769 G15280 - NEEDLE ESCP 14FR 20CM HATTER ASP CSCP FLXB BOTH IP/OP $51.00 $37.74 $0.00 $40.80 $27.69 $27.69 $0.00 $0.00 $0.00 $10.63 $37.85 $37.85 $0.00 $0.00 $10.63 $0.00 $30.17 $30.17 $0.00 $25.50 $40.39 $40.80 $0.00 $0.00 $7.98 $0.00 $0.00 $8.12 $0.00 $0.00 $0.00 $0.00 $0.00 G15284 SUP HCPCS C1758 G15284 - GUIDEWIRE VASC STD .035IN 145CM STRL MOV COR SS SLIP-COAT BOTH IP/OP $40.70 $30.12 $0.00 $32.56 $22.10 $22.10 $0.00 $0.00 $0.00 $8.48 $30.21 $30.21 $0.00 $0.00 $8.48 $0.00 $24.07 $24.07 $0.00 $20.35 $32.23 $32.56 $0.00 $0.00 $6.37 $0.00 $0.00 $6.48 $0.00 $0.00 $0.00 $0.00 $0.00 G15290 SUP Custom 27203010 G15290 - CATHETER ESCP 2FR 3CM SILBER ASP BOTH IP/OP $37.40 $27.68 $0.00 $29.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.76 $27.76 $0.00 $0.00 $7.79 $0.00 $0.00 $0.00 $0.00 $18.70 $29.62 $29.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15291 SUP Custom 27203010 G15291 - NEEDLE PRC 22GA 20CM STRL SKNY ECHTP CHBA TIP PERC US IMG BOTH IP/OP $41.80 $30.93 $0.00 $33.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.02 $31.02 $0.00 $0.00 $8.71 $0.00 $0.00 $0.00 $0.00 $20.90 $33.11 $33.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15292 SUP Custom 27203010 G15292 - NEEDLE PRC TROC 18GA 20CM STRL ECHTP 2 PRT DISP US IMG BOTH IP/OP $93.50 $69.19 $0.00 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.40 $69.40 $0.00 $0.00 $19.49 $0.00 $0.00 $0.00 $0.00 $46.75 $74.05 $74.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15293 SUP Custom 27203010 G15293 - NEEDLE PRC 18GA 22GA 14-22CM MTPLK ECHTP COAX PERC BOTH IP/OP $79.70 $58.98 $0.00 $63.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.15 $59.15 $0.00 $0.00 $16.61 $0.00 $0.00 $0.00 $0.00 $39.85 $63.12 $63.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15296 SUP Custom 27203010 G15296 - NEEDLE TROC STD 18GA 25CM ECHTP 2 PRT DISP BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $0.00 $0.00 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15299 SUP HCPCS C1758 G15299 - NEEDLE ESCP 23GA 3.7FR 35CM WMS CSCP BOTH IP/OP $29.70 $21.98 $0.00 $23.76 $16.13 $16.13 $0.00 $0.00 $0.00 $6.19 $22.04 $22.04 $0.00 $0.00 $6.19 $0.00 $17.57 $17.57 $0.00 $14.85 $23.52 $23.76 $0.00 $0.00 $4.65 $0.00 $0.00 $4.73 $0.00 $0.00 $0.00 $0.00 $0.00 G15300 SUP HCPCS C1758 G15300 - ADAPTER ESCP ANG STRL LF SCHOBORG LSR FBR CATH URET DISP BOTH IP/OP $83.50 $61.79 $0.00 $66.80 $45.34 $45.34 $0.00 $0.00 $0.00 $17.40 $61.97 $61.97 $0.00 $0.00 $17.40 $0.00 $49.39 $49.39 $0.00 $41.75 $66.13 $66.80 $0.00 $0.00 $13.07 $0.00 $0.00 $13.29 $0.00 $0.00 $0.00 $0.00 $0.00 G15301 SUP HCPCS C1758 G15301 - CATHETER URET 40D .035IN TPR STRG 5FR 70CM 145CM SF GW NYL BOTH IP/OP $72.60 $53.72 $0.00 $58.08 $39.42 $39.42 $0.00 $0.00 $0.00 $15.13 $53.88 $53.88 $0.00 $0.00 $15.13 $0.00 $42.94 $42.94 $0.00 $36.30 $57.50 $58.08 $0.00 $0.00 $11.36 $0.00 $0.00 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 G15302 SUP HCPCS C1758 G15302 - CATHETER URET 40D .035IN TPR 6FR 70CM 145CM GW BOTH IP/OP $72.60 $53.72 $0.00 $58.08 $39.42 $39.42 $0.00 $0.00 $0.00 $15.13 $53.88 $53.88 $0.00 $0.00 $15.13 $0.00 $42.94 $42.94 $0.00 $36.30 $57.50 $58.08 $0.00 $0.00 $11.36 $0.00 $0.00 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 G15397 SUP HCPCS C2617 G15397 - CATHETER URET 40D .035IN 5FR 70CM 145CM FLXB ANG TIP BVL END BOTH IP/OP $215.55 $159.51 $0.00 $172.44 $97.00 $97.00 $0.00 $0.00 $0.00 $44.93 $159.98 $159.98 $0.00 $0.00 $44.92 $0.00 $127.50 $127.50 $0.00 $107.78 $170.72 $172.44 $0.00 $0.00 $33.73 $0.00 $0.00 $34.32 $0.00 $0.00 $0.00 $0.00 $0.00 G15422 SUP Custom 27203010 G15422 - FORCEP SPEC RTRVL 65CM 5.2FR 2 JAW ALGTR TOOTH BOTH IP/OP $675.28 $499.71 $0.00 $524.80 $0.00 $0.00 $0.00 $0.00 $0.00 $140.74 $501.19 $501.19 $0.00 $0.00 $140.73 $0.00 $399.43 $399.43 $0.00 $328.00 $519.55 $524.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15424 SUP HCPCS C1758 G15424 - STENT URET 2 PGTL CRV 4.7FR 8CM STRL SFLX PED DISP ACPT .035 BOTH IP/OP $31.63 $23.41 $0.00 $25.30 $17.17 $17.17 $0.00 $0.00 $0.00 $6.59 $23.47 $23.47 $0.00 $0.00 $6.59 $0.00 $18.71 $18.71 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 G15425 SUP HCPCS C1758 G15425 - CATHETER URET .018IN 3FR 70CM OP-EN GW MOD BOTH IP/OP $31.63 $23.41 $0.00 $25.30 $17.17 $17.17 $0.00 $0.00 $0.00 $6.59 $23.47 $23.47 $0.00 $0.00 $6.59 $0.00 $18.71 $18.71 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 G15429 SUP HCPCS C1726 G15429 - CATHETER URET .025IN 4FR 70CM OP-EN GW MOD BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $24.44 $24.44 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 G15434 SUP HCPCS C1726 G15434 - DEVICE SUT 10D 17CM PEREYRA LGT CR REUSE BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $24.44 $24.44 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 G15435 SUP HCPCS C1726 G15435 - CATHETER URDY 7FR 38CM STRL 2 LUM URETER DISP BOTH IP/OP $54.23 $40.13 $0.00 $43.38 $29.44 $29.44 $0.00 $0.00 $0.00 $11.30 $40.25 $40.25 $0.00 $0.00 $11.30 $0.00 $32.07 $32.07 $0.00 $27.11 $42.95 $43.38 $0.00 $0.00 $8.49 $0.00 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 G15443 SUP HCPCS C2617 G15443 - CATHETER URDY 7.4FR 30CM 3 LUM BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15444 SUP HCPCS C2617 G15444 - SET STNT .038IN 2 PGTL CRV STRG FLFRM 8.5FR 20CM BLK STRL BOTH IP/OP $287.00 $212.38 $0.00 $229.60 $129.15 $129.15 $0.00 $0.00 $0.00 $59.82 $213.01 $213.01 $0.00 $0.00 $59.81 $0.00 $169.76 $169.76 $0.00 $143.50 $227.30 $229.60 $0.00 $0.00 $44.92 $0.00 $0.00 $45.69 $0.00 $0.00 $0.00 $0.00 $0.00 G15469 SUP HCPCS C1769 G15469 - SET STNT .038IN 2 PGTL CRV STRG FLFRM 7FR 20CM BLK STRL 145 BOTH IP/OP $207.90 $153.85 $0.00 $166.32 $112.89 $112.89 $0.00 $0.00 $0.00 $43.33 $154.30 $154.30 $0.00 $0.00 $43.33 $0.00 $122.97 $122.97 $0.00 $103.95 $164.66 $166.32 $0.00 $0.00 $32.54 $0.00 $0.00 $33.10 $0.00 $0.00 $0.00 $0.00 $0.00 G15473 SUP HCPCS C2625 G15473 - SET INTRO .035IN STRG 8-14FR 18GA 14CM STRL 10CM SP TUBE NDL BOTH IP/OP $160.30 $118.62 $0.00 $128.24 $72.14 $72.14 $0.00 $0.00 $0.00 $33.41 $118.97 $118.97 $0.00 $0.00 $33.41 $0.00 $94.82 $94.82 $0.00 $80.15 $126.96 $128.24 $0.00 $0.00 $25.09 $0.00 $0.00 $25.52 $0.00 $0.00 $0.00 $0.00 $0.00 G15475 SUP Custom 27203010 G15475 - SET STNT .038IN 5MM PGTL CRV 8.2FR 75CM STRL 100CM BNDR CATH BOTH IP/OP $29.70 $21.98 $0.00 $23.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.04 $22.04 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $14.85 $23.52 $23.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15476 SUP Custom 27203010 G15476 - ADAPTER CATH 9FR STRL CKFL SDARM STPCK F LL PEEL OPN DISP BOTH IP/OP $27.50 $20.35 $0.00 $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $0.00 $0.00 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15495 SUP HCPCS C2625 G15495 - SET STNT 3CM 145CM STRL KWART RETRO-INJ INSRTR TETH RELS SLV BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G15500 SUP HCPCS C1758 G15500 - ADAPTER CATH 9FR STRL CKFL SLF SL F LL DISP BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G15513 SUP Custom 27203010 G15513 - CATHETER URET 4FR 70CM SPRL TIP ACC LG SDPRT ACPT .028IN GW BOTH IP/OP $115.13 $85.20 $0.00 $92.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.45 $85.45 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $57.56 $91.18 $92.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15514 SUP HCPCS C2617 G15514 - NEEDLE PRC 18GA 25CM ECHTP TROC STY SHTH TFE RNL BOTH IP/OP $215.55 $159.51 $0.00 $172.44 $97.00 $97.00 $0.00 $0.00 $0.00 $44.93 $159.98 $159.98 $0.00 $0.00 $44.92 $0.00 $127.50 $127.50 $0.00 $107.78 $170.72 $172.44 $0.00 $0.00 $33.73 $0.00 $0.00 $34.32 $0.00 $0.00 $0.00 $0.00 $0.00 G15530 SUP HCPCS C1769 G15530 - STENT URET 2 PGTL CRV 7FR 20CM STRL SFLX DISP ACPT .038IN GW BOTH IP/OP $58.65 $43.40 $0.00 $46.92 $31.85 $31.85 $0.00 $0.00 $0.00 $12.22 $43.53 $43.53 $0.00 $0.00 $12.22 $0.00 $34.69 $34.69 $0.00 $29.33 $46.45 $46.92 $0.00 $0.00 $9.18 $0.00 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 G15532 SUP HCPCS C2617 G15532 - GUIDEWIRE ESCP STD .028IN 145CM FXCR HDRPH BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G15540 SUP HCPCS C1726 G15540 - SET STNT .025IN 3.7FR 21-32CM STRL CATH RADOPQ MTLNTH PSTNR BOTH IP/OP $97.18 $71.91 $0.00 $77.74 $52.77 $52.77 $0.00 $0.00 $0.00 $20.25 $72.12 $72.12 $0.00 $0.00 $20.25 $0.00 $57.48 $57.48 $0.00 $48.59 $76.97 $77.74 $0.00 $0.00 $15.21 $0.00 $0.00 $15.47 $0.00 $0.00 $0.00 $0.00 $0.00 G15579 SUP HCPCS C1758 G15579 - CATHETER URDY 7.4FR 30CM 3 LUM BLN BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G15600 SUP HCPCS C1769 G15600 - CATHETER URET .028IN 4FR 115CM FLXTP OP-EN GW MOD FLX TP BOTH IP/OP $58.65 $43.40 $0.00 $46.92 $31.85 $31.85 $0.00 $0.00 $0.00 $12.22 $43.53 $43.53 $0.00 $0.00 $12.22 $0.00 $34.69 $34.69 $0.00 $29.33 $46.45 $46.92 $0.00 $0.00 $9.18 $0.00 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 G15602 SUP HCPCS C1769 G15602 - GUIDEWIRE ESCP STD .035IN 145CM FXCR HDRPH BOTH IP/OP $58.65 $43.40 $0.00 $46.92 $31.85 $31.85 $0.00 $0.00 $0.00 $12.22 $43.53 $43.53 $0.00 $0.00 $12.22 $0.00 $34.69 $34.69 $0.00 $29.33 $46.45 $46.92 $0.00 $0.00 $9.18 $0.00 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 G15603 SUP HCPCS C1726 G15603 - GUIDEWIRE URO BNTSN CRV STRG .035IN 145CM STRL 15CM FXCR FLX BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $24.44 $24.44 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 G15606 SUP HCPCS C2617 G15606 - CATHETER URDY 10FR 39CM 2 LUM BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15607 SUP HCPCS C2617 G15607 - SET STNT .018IN 2 PGTL CRV CDE 3FR 4FR 8CM GRY STRL CATH BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15608 SUP HCPCS C2617 G15608 - SET STNT .018IN 2 PGTL CRV CDE 3FR 4FR 10CM GRY STRL CATH BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15610 SUP HCPCS C2617 G15610 - SET STNT .018IN 2 PGTL CRV CDE 3FR 4FR 12CM GRY STRL CATH BOTH IP/OP $215.55 $159.51 $0.00 $172.44 $97.00 $97.00 $0.00 $0.00 $0.00 $44.93 $159.98 $159.98 $0.00 $0.00 $44.92 $0.00 $127.50 $127.50 $0.00 $107.78 $170.72 $172.44 $0.00 $0.00 $33.73 $0.00 $0.00 $34.32 $0.00 $0.00 $0.00 $0.00 $0.00 G15621 SUP Custom 27203010 G15621 - STENT URET 2 PGTL CRV 4.7FR 10CM STRL SFLX PED DISP ACPT BOTH IP/OP $48.08 $35.58 $0.00 $38.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.68 $35.68 $0.00 $0.00 $10.02 $0.00 $0.00 $0.00 $0.00 $24.04 $38.08 $38.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15624 SUP HCPCS C2617 G15624 - NEEDLE PRC STD 18GA 11CM ECHTP 2 PRT TROC DISP BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15632 SUP HCPCS C2627 G15632 - SET STNT .018IN SM 2 PGTL CRV CDE 3FR 7FR 6CM STRL RADOPQ GW BOTH IP/OP $258.05 $190.96 $0.00 $206.44 $140.12 $140.12 $0.00 $0.00 $0.00 $0.00 $191.52 $191.52 $0.00 $0.00 $53.78 $0.00 $0.00 $0.00 $0.00 $129.03 $204.38 $206.44 $0.00 $0.00 $40.38 $0.00 $0.00 $41.08 $0.00 $0.00 $0.00 $0.00 $0.00 G15636 SUP HCPCS C1758 G15636 - SET DIL 6-12FR 60CM WO GW PE HDRPH URET BOTH IP/OP $47.30 $35.00 $0.00 $37.84 $25.68 $25.68 $0.00 $0.00 $0.00 $9.86 $35.11 $35.11 $0.00 $0.00 $9.86 $0.00 $27.98 $27.98 $0.00 $23.65 $37.46 $37.84 $0.00 $0.00 $7.40 $0.00 $0.00 $7.53 $0.00 $0.00 $0.00 $0.00 $0.00 G15637 SUP HCPCS C1758 G15637 - CATHETER URET 5FR 70CM ECHTP OP-EN ACPT .038IN GW BOTH IP/OP $54.40 $40.26 $0.00 $43.52 $29.54 $29.54 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $27.20 $43.08 $43.52 $0.00 $0.00 $8.51 $0.00 $0.00 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 G15638 SUP HCPCS C1758 G15638 - CATHETER URET .038IN 6FR 70CM ECHTP OP-EN GW BOTH IP/OP $54.40 $40.26 $0.00 $43.52 $29.54 $29.54 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $27.20 $43.08 $43.52 $0.00 $0.00 $8.51 $0.00 $0.00 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 G15639 SUP HCPCS C1758 G15639 - CATHETER URET .038IN 7FR 70CM ECHTP OP-EN GW BOTH IP/OP $54.40 $40.26 $0.00 $43.52 $29.54 $29.54 $0.00 $0.00 $0.00 $11.34 $40.38 $40.38 $0.00 $0.00 $11.34 $0.00 $32.18 $32.18 $0.00 $27.20 $43.08 $43.52 $0.00 $0.00 $8.51 $0.00 $0.00 $8.66 $0.00 $0.00 $0.00 $0.00 $0.00 G15650 SUP Custom 27203010 G15650 - CATHETER URET .038IN 8FR 70CM ECHTP OP-EN GW BOTH IP/OP $29.70 $21.98 $0.00 $23.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.04 $22.04 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $14.85 $23.52 $23.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15670 SUP HCPCS C1758 G15670 - ADAPTER CATH UNV 9FR STRL CKFL F LL DISP BOTH IP/OP $150.68 $111.50 $0.00 $120.54 $81.82 $81.82 $0.00 $0.00 $0.00 $31.40 $111.83 $111.83 $0.00 $0.00 $31.40 $0.00 $89.12 $89.12 $0.00 $75.34 $119.34 $120.54 $0.00 $0.00 $23.58 $0.00 $0.00 $23.99 $0.00 $0.00 $0.00 $0.00 $0.00 G15731 SUP HCPCS C1769 G15731 - GUIDEWIRE VASC .032IN 145CM AMPTZ MOV COR STRG TPR BOTH IP/OP $69.98 $51.79 $0.00 $55.98 $38.00 $38.00 $0.00 $0.00 $0.00 $14.58 $51.94 $51.94 $0.00 $0.00 $14.58 $0.00 $41.39 $41.39 $0.00 $34.99 $55.42 $55.98 $0.00 $0.00 $10.95 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 G15732 SUP HCPCS C1769 G15732 - CATHETER URET .045IN PGTL CRV 8FR 70CM 145CM SDPRT SHFT GW BOTH IP/OP $69.98 $51.79 $0.00 $55.98 $38.00 $38.00 $0.00 $0.00 $0.00 $14.58 $51.94 $51.94 $0.00 $0.00 $14.58 $0.00 $41.39 $41.39 $0.00 $34.99 $55.42 $55.98 $0.00 $0.00 $10.95 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 G15733 SUP HCPCS C1892 G15733 - GUIDEWIRE VASC .038IN 145CM LF 3CM AMPTZ 2 FLXB STF SS BOTH IP/OP $136.63 $101.11 $0.00 $109.30 $74.19 $74.19 $0.00 $0.00 $0.00 $28.48 $101.40 $101.40 $0.00 $0.00 $28.47 $0.00 $80.81 $80.81 $0.00 $68.31 $108.21 $109.30 $0.00 $0.00 $21.38 $0.00 $0.00 $21.75 $0.00 $0.00 $0.00 $0.00 $0.00 G15739 SUP HCPCS C1726 G15739 - POUCH SPEC RTRVL 5X2IN YLW LAPSAC SRG REM MORCELLATION INTGR BOTH IP/OP $54.23 $40.13 $0.00 $43.38 $29.44 $29.44 $0.00 $0.00 $0.00 $11.30 $40.25 $40.25 $0.00 $0.00 $11.30 $0.00 $32.07 $32.07 $0.00 $27.11 $42.95 $43.38 $0.00 $0.00 $8.49 $0.00 $0.00 $8.63 $0.00 $0.00 $0.00 $0.00 $0.00 G15753 SUP HCPCS C2627 G15753 - TUBE CNCT 14FR 11CM M LL DRN BG T-B ADPR BOTH IP/OP $72.73 $53.82 $0.00 $58.18 $39.49 $39.49 $0.00 $0.00 $0.00 $0.00 $53.98 $53.98 $0.00 $0.00 $15.16 $0.00 $0.00 $0.00 $0.00 $36.36 $57.60 $58.18 $0.00 $0.00 $11.38 $0.00 $0.00 $11.58 $0.00 $0.00 $0.00 $0.00 $0.00 G15764 SUP HCPCS C2627 G15764 - DILATOR URTH 6FR 37CM PE FSCA BOTH IP/OP $29.70 $21.98 $0.00 $23.76 $16.13 $16.13 $0.00 $0.00 $0.00 $0.00 $22.04 $22.04 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $14.85 $23.52 $23.76 $0.00 $0.00 $4.65 $0.00 $0.00 $4.73 $0.00 $0.00 $0.00 $0.00 $0.00 G15766 SUP Custom 27203010 G15766 - CATHETER URDY 4FR 60CM PRSS BLDR BOTH IP/OP $70.40 $52.10 $0.00 $56.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.25 $52.25 $0.00 $0.00 $14.67 $0.00 $0.00 $0.00 $0.00 $35.20 $55.76 $56.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15771 SUP Custom 27203010 G15771 - CATHETER URDY 12FR 36CM STRL LTX 5CM PRSS BLN SIL RCTL DISP BOTH IP/OP $626.88 $463.89 $0.00 $501.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $465.27 $465.27 $0.00 $0.00 $130.64 $0.00 $0.00 $0.00 $0.00 $313.44 $496.49 $501.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15789 SUP HCPCS C1729 G15789 - INTRODUCER ESCP 25.5CM 5X8IN LAPSAC LGR ACC PORT HNDL SS AL BOTH IP/OP $465.53 $344.49 $0.00 $372.42 $252.78 $252.78 $0.00 $0.00 $0.00 $97.03 $345.51 $345.51 $0.00 $0.00 $97.02 $0.00 $275.36 $275.36 $0.00 $232.76 $368.70 $372.42 $0.00 $0.00 $72.85 $0.00 $0.00 $74.11 $0.00 $0.00 $0.00 $0.00 $0.00 G15792 SUP HCPCS C1758 G15792 - SET NPHSTM 12FR 30CM STRL LTX 20CM COPE LOOP NDL GW DIL CNCT BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G15803 SUP HCPCS C1758 G15803 - CATHETER URET .038IN 5FR 120CM FLXTP OP-EN GW MOD BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G15821 SUP HCPCS C1758 G15821 - CATHETER URET 9FR 15CM WHSTLTP MOD LT BOTH IP/OP $31.63 $23.41 $0.00 $25.30 $17.17 $17.17 $0.00 $0.00 $0.00 $6.59 $23.47 $23.47 $0.00 $0.00 $6.59 $0.00 $18.71 $18.71 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 G15859 SUP HCPCS C1758 G15859 - CATHETER URET 3FR 125CM RND TIP STY LT BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G15864 SUP Custom 27203010 G15864 - CATHETER URET 4FR 90CM WHSTLTP MOD RT BOTH IP/OP $69.58 $51.49 $0.00 $55.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.64 $51.64 $0.00 $0.00 $14.50 $0.00 $0.00 $0.00 $0.00 $34.79 $55.11 $55.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G15871 SUP HCPCS C1758 G15871 - NEEDLE INJ 20GA 5FR 35CM 7MM WMS CSCP BOTH IP/OP $100.25 $74.19 $0.00 $80.20 $54.44 $54.44 $0.00 $0.00 $0.00 $20.89 $74.41 $74.41 $0.00 $0.00 $20.89 $0.00 $59.30 $59.30 $0.00 $50.13 $79.40 $80.20 $0.00 $0.00 $15.69 $0.00 $0.00 $15.96 $0.00 $0.00 $0.00 $0.00 $0.00 G15873 SUP HCPCS C1726 G15873 - CATHETER URET PGTL CRV 8.2FR 56CM SFLX BOTH IP/OP $49.10 $36.33 $0.00 $39.28 $26.66 $26.66 $0.00 $0.00 $0.00 $10.23 $36.44 $36.44 $0.00 $0.00 $10.23 $0.00 $29.04 $29.04 $0.00 $24.55 $38.89 $39.28 $0.00 $0.00 $7.68 $0.00 $0.00 $7.82 $0.00 $0.00 $0.00 $0.00 $0.00 G15875 SUP HCPCS C2625 G15875 - CATHETER URDY 7.4FR 30CM 3 LUM BOTH IP/OP $259.33 $191.90 $0.00 $207.46 $116.70 $116.70 $0.00 $0.00 $0.00 $54.05 $192.47 $192.47 $0.00 $0.00 $54.04 $0.00 $153.39 $153.39 $0.00 $129.66 $205.39 $207.46 $0.00 $0.00 $40.58 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 G15876 SUP HCPCS C2625 G15876 - SET STNT .038IN 5MM PGTL CRV 8.4FR 90CM STRL 125CM BNDR CATH BOTH IP/OP $225.50 $166.87 $0.00 $180.40 $101.48 $101.48 $0.00 $0.00 $0.00 $47.00 $167.37 $167.37 $0.00 $0.00 $46.99 $0.00 $133.38 $133.38 $0.00 $112.75 $178.60 $180.40 $0.00 $0.00 $35.29 $0.00 $0.00 $35.90 $0.00 $0.00 $0.00 $0.00 $0.00 G15877 SUP HCPCS C2625 G15877 - SET STNT .038IN 5MM PGTL CRV 7.2FR 90CM STRL 125CM BNDR CATH BOTH IP/OP $259.33 $191.90 $0.00 $207.46 $116.70 $116.70 $0.00 $0.00 $0.00 $54.05 $192.47 $192.47 $0.00 $0.00 $54.04 $0.00 $153.39 $153.39 $0.00 $129.66 $205.39 $207.46 $0.00 $0.00 $40.58 $0.00 $0.00 $41.28 $0.00 $0.00 $0.00 $0.00 $0.00 G15878 SUP HCPCS C2625 G15878 - SET STNT .038IN 5MM PGTL CRV 8.4FR 90CM STRL 125CM BNDR CATH BOTH IP/OP $225.50 $166.87 $0.00 $180.40 $101.48 $101.48 $0.00 $0.00 $0.00 $47.00 $167.37 $167.37 $0.00 $0.00 $46.99 $0.00 $133.38 $133.38 $0.00 $112.75 $178.60 $180.40 $0.00 $0.00 $35.29 $0.00 $0.00 $35.90 $0.00 $0.00 $0.00 $0.00 $0.00 G15885 SUP HCPCS C1758 G15885 - SET STNT .038IN 5MM PGTL CRV 7.2FR 90CM STRL 125CM BNDR CATH BOTH IP/OP $36.30 $26.86 $0.00 $29.04 $19.71 $19.71 $0.00 $0.00 $0.00 $7.57 $26.94 $26.94 $0.00 $0.00 $7.56 $0.00 $21.47 $21.47 $0.00 $18.15 $28.75 $29.04 $0.00 $0.00 $5.68 $0.00 $0.00 $5.78 $0.00 $0.00 $0.00 $0.00 $0.00 G15889 SUP HCPCS C1758 G15889 - CATHETER URET 3FR 70CM STF STY PED BOTH IP/OP $39.95 $29.56 $0.00 $31.96 $21.69 $21.69 $0.00 $0.00 $0.00 $8.33 $29.65 $29.65 $0.00 $0.00 $8.33 $0.00 $23.63 $23.63 $0.00 $19.98 $31.64 $31.96 $0.00 $0.00 $6.25 $0.00 $0.00 $6.36 $0.00 $0.00 $0.00 $0.00 $0.00 G15899 SUP HCPCS C1726 G15899 - CATHETER URET .038IN 5FR 70CM FLXTP OP-EN GW MOD BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $24.44 $24.44 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 G15924 SUP HCPCS C2617 G15924 - POUCH DRN 300ML STRL SFT ELC BELT REED VLV MECH REUSE BOTH IP/OP $76.63 $56.71 $0.00 $61.30 $34.48 $34.48 $0.00 $0.00 $0.00 $15.97 $56.87 $56.87 $0.00 $0.00 $15.97 $0.00 $45.32 $45.32 $0.00 $38.31 $60.69 $61.30 $0.00 $0.00 $11.99 $0.00 $0.00 $12.20 $0.00 $0.00 $0.00 $0.00 $0.00 G15925 SUP HCPCS C1729 G15925 - STENT URTH 8FR 40CM STRL FRLT KLG CNTR BLB SIL DISP BOTH IP/OP $404.80 $299.55 $0.00 $323.84 $219.81 $219.81 $0.00 $0.00 $0.00 $84.37 $300.44 $300.44 $0.00 $0.00 $84.36 $0.00 $239.44 $239.44 $0.00 $202.40 $320.60 $323.84 $0.00 $0.00 $63.35 $0.00 $0.00 $64.44 $0.00 $0.00 $0.00 $0.00 $0.00 G15929 SUP HCPCS C2617 G15929 - SET NPHSTM 10FR 19.5CM LTX COPE LOOP MOD CATH GW RTNT DISK BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G15934 SUP HCPCS C1769 G15934 - SET STNT .018IN 2 PGTL CRV CDE 3FR 4FR 14CM STRL CP MDRL BOTH IP/OP $58.65 $43.40 $0.00 $46.92 $31.85 $31.85 $0.00 $0.00 $0.00 $12.22 $43.53 $43.53 $0.00 $0.00 $12.22 $0.00 $34.69 $34.69 $0.00 $29.33 $46.45 $46.92 $0.00 $0.00 $9.18 $0.00 $0.00 $9.34 $0.00 $0.00 $0.00 $0.00 $0.00 G15935 SUP HCPCS C1769 G15935 - GUIDEWIRE ESCP STD STRG .025IN 145CM 3CM FLX TP FXCR SS BOTH IP/OP $52.08 $38.54 $0.00 $41.66 $28.28 $28.28 $0.00 $0.00 $0.00 $10.85 $38.65 $38.65 $0.00 $0.00 $10.85 $0.00 $30.80 $30.80 $0.00 $26.04 $41.25 $41.66 $0.00 $0.00 $8.15 $0.00 $0.00 $8.29 $0.00 $0.00 $0.00 $0.00 $0.00 G16019 SUP HCPCS C2617 G16019 - TUBE CNCT 14FR 30CM STRL 2 DRN PCH BOTH IP/OP $253.45 $187.55 $0.00 $202.76 $114.05 $114.05 $0.00 $0.00 $0.00 $52.83 $188.11 $188.11 $0.00 $0.00 $52.82 $0.00 $149.92 $149.92 $0.00 $126.73 $200.73 $202.76 $0.00 $0.00 $39.66 $0.00 $0.00 $40.35 $0.00 $0.00 $0.00 $0.00 $0.00 G16020 SUP HCPCS C2617 G16020 - SET STNT .035IN SM 2 PGTL CRV 4.7FR 4FR 10CM STRL CATH BOTH IP/OP $253.45 $187.55 $0.00 $202.76 $114.05 $114.05 $0.00 $0.00 $0.00 $52.83 $188.11 $188.11 $0.00 $0.00 $52.82 $0.00 $149.92 $149.92 $0.00 $126.73 $200.73 $202.76 $0.00 $0.00 $39.66 $0.00 $0.00 $40.35 $0.00 $0.00 $0.00 $0.00 $0.00 G16021 SUP HCPCS C2617 G16021 - SET STNT .035IN SM 2 PGTL CRV 4.7FR 4FR 14CM STRL CATH BOTH IP/OP $253.45 $187.55 $0.00 $202.76 $114.05 $114.05 $0.00 $0.00 $0.00 $52.83 $188.11 $188.11 $0.00 $0.00 $52.82 $0.00 $149.92 $149.92 $0.00 $126.73 $200.73 $202.76 $0.00 $0.00 $39.66 $0.00 $0.00 $40.35 $0.00 $0.00 $0.00 $0.00 $0.00 G16035 SUP HCPCS C2617 G16035 - SET STNT .035IN SM 2 PGTL CRV 4.7FR 4FR 16CM STRL CATH BOTH IP/OP $253.45 $187.55 $0.00 $202.76 $114.05 $114.05 $0.00 $0.00 $0.00 $52.83 $188.11 $188.11 $0.00 $0.00 $52.82 $0.00 $149.92 $149.92 $0.00 $126.73 $200.73 $202.76 $0.00 $0.00 $39.66 $0.00 $0.00 $40.35 $0.00 $0.00 $0.00 $0.00 $0.00 G16040 SUP HCPCS C2617 G16040 - SET STNT .038IN SM 2 PGTL CRV 7FR 4FR 12CM STRL CATH RADOPQ BOTH IP/OP $253.45 $187.55 $0.00 $202.76 $114.05 $114.05 $0.00 $0.00 $0.00 $52.83 $188.11 $188.11 $0.00 $0.00 $52.82 $0.00 $149.92 $149.92 $0.00 $126.73 $200.73 $202.76 $0.00 $0.00 $39.66 $0.00 $0.00 $40.35 $0.00 $0.00 $0.00 $0.00 $0.00 G16112 SUP Custom 27203010 G16112 - SET STNT .038IN SM 2 PGTL CRV 6FR 4FR 14CM STRL CATH RADOPQ BOTH IP/OP $69.58 $51.49 $0.00 $55.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.64 $51.64 $0.00 $0.00 $14.50 $0.00 $0.00 $0.00 $0.00 $34.79 $55.11 $55.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G16116 SUP HCPCS C1726 G16116 - NEEDLE INJ 23GA 5FR 45CM 8MM WMS CSCP BOTH IP/OP $587.60 $434.82 $0.00 $470.08 $319.07 $319.07 $0.00 $0.00 $0.00 $122.47 $436.12 $436.12 $0.00 $0.00 $122.46 $0.00 $347.57 $347.57 $0.00 $293.80 $465.38 $470.08 $0.00 $0.00 $91.96 $0.00 $0.00 $93.55 $0.00 $0.00 $0.00 $0.00 $0.00 G16120 SUP HCPCS C2627 G16120 - SET DIL 6-30FR 30CM 16CM AMPTZ MOD RADOPQ SHTH RNL BOTH IP/OP $215.05 $159.14 $0.00 $172.04 $116.77 $116.77 $0.00 $0.00 $0.00 $0.00 $159.61 $159.61 $0.00 $0.00 $44.82 $0.00 $0.00 $0.00 $0.00 $107.53 $170.32 $172.04 $0.00 $0.00 $33.66 $0.00 $0.00 $34.24 $0.00 $0.00 $0.00 $0.00 $0.00 G16121 SUP HCPCS C1769 G16121 - INTRODUCER NPHSTM 18FR 12CM OB PLWY ACC SET GW TROC NDL SPBC BOTH IP/OP $215.05 $159.14 $0.00 $172.04 $116.77 $116.77 $0.00 $0.00 $0.00 $44.82 $159.61 $159.61 $0.00 $0.00 $44.82 $0.00 $127.20 $127.20 $0.00 $107.53 $170.32 $172.04 $0.00 $0.00 $33.66 $0.00 $0.00 $34.24 $0.00 $0.00 $0.00 $0.00 $0.00 G16122 SUP HCPCS C1769 G16122 - SET CATH TROC 20FR 12CM OB PLWY INTRO NDL GW SPBC BOTH IP/OP $215.05 $159.14 $0.00 $172.04 $116.77 $116.77 $0.00 $0.00 $0.00 $44.82 $159.61 $159.61 $0.00 $0.00 $44.82 $0.00 $127.20 $127.20 $0.00 $107.53 $170.32 $172.04 $0.00 $0.00 $33.66 $0.00 $0.00 $34.24 $0.00 $0.00 $0.00 $0.00 $0.00 G16123 SUP HCPCS C1769 G16123 - INTRODUCER NPHSTM 22FR 12CM PLWY ACC SET GW TROC NDL BOTH IP/OP $215.05 $159.14 $0.00 $172.04 $116.77 $116.77 $0.00 $0.00 $0.00 $44.82 $159.61 $159.61 $0.00 $0.00 $44.82 $0.00 $127.20 $127.20 $0.00 $107.53 $170.32 $172.04 $0.00 $0.00 $33.66 $0.00 $0.00 $34.24 $0.00 $0.00 $0.00 $0.00 $0.00 G16187 SUP HCPCS C2625 G16187 - POUCH DRN STRL BELT PLS ADJ REUSE BOTH IP/OP $160.30 $118.62 $0.00 $128.24 $72.14 $72.14 $0.00 $0.00 $0.00 $33.41 $118.97 $118.97 $0.00 $0.00 $33.41 $0.00 $94.82 $94.82 $0.00 $80.15 $126.96 $128.24 $0.00 $0.00 $25.09 $0.00 $0.00 $25.52 $0.00 $0.00 $0.00 $0.00 $0.00 G16198 SUP HCPCS C2627 G16198 - CATHETER URET .038IN 5FR 120CM OP-EN GW MOD BOTH IP/OP $165.73 $122.64 $0.00 $132.58 $89.99 $89.99 $0.00 $0.00 $0.00 $0.00 $123.00 $123.00 $0.00 $0.00 $34.54 $0.00 $0.00 $0.00 $0.00 $82.86 $131.26 $132.58 $0.00 $0.00 $25.94 $0.00 $0.00 $26.38 $0.00 $0.00 $0.00 $0.00 $0.00 G16226 SUP HCPCS C2617 G16226 - SET CATH 10FR 22CM RTNR BLN SPBC BOTH IP/OP $317.75 $235.14 $0.00 $254.20 $142.99 $142.99 $0.00 $0.00 $0.00 $66.23 $235.83 $235.83 $0.00 $0.00 $66.22 $0.00 $187.95 $187.95 $0.00 $158.88 $251.66 $254.20 $0.00 $0.00 $49.73 $0.00 $0.00 $50.59 $0.00 $0.00 $0.00 $0.00 $0.00 G16227 SUP HCPCS C2617 G16227 - SET STNT 5FR 8-20CM GRN GW CATH PSTNR RNL TRNSPLNT BOTH IP/OP $317.75 $235.14 $0.00 $254.20 $142.99 $142.99 $0.00 $0.00 $0.00 $66.23 $235.83 $235.83 $0.00 $0.00 $66.22 $0.00 $187.95 $187.95 $0.00 $158.88 $251.66 $254.20 $0.00 $0.00 $49.73 $0.00 $0.00 $50.59 $0.00 $0.00 $0.00 $0.00 $0.00 G16228 SUP HCPCS C2617 G16228 - SET STNT .028IN 6FR 8-20CM GRN STRL 145CM GRN CATH MTLNTH BOTH IP/OP $365.43 $270.42 $0.00 $292.34 $164.44 $164.44 $0.00 $0.00 $0.00 $76.16 $271.22 $271.22 $0.00 $0.00 $76.15 $0.00 $216.15 $216.15 $0.00 $182.71 $289.42 $292.34 $0.00 $0.00 $57.19 $0.00 $0.00 $58.18 $0.00 $0.00 $0.00 $0.00 $0.00 G16229 SUP HCPCS C2617 G16229 - SET STNT 6FR 22-32CM GRN GW CATH PSTNR RNL TRNSPLNT BOTH IP/OP $317.75 $235.14 $0.00 $254.20 $142.99 $142.99 $0.00 $0.00 $0.00 $66.23 $235.83 $235.83 $0.00 $0.00 $66.22 $0.00 $187.95 $187.95 $0.00 $158.88 $251.66 $254.20 $0.00 $0.00 $49.73 $0.00 $0.00 $50.59 $0.00 $0.00 $0.00 $0.00 $0.00 G16230 SUP HCPCS C2617 G16230 - SET STNT 7FR 8-20CM GRN GW CATH PSTNR RNL TRNSPLNT BOTH IP/OP $317.75 $235.14 $0.00 $254.20 $142.99 $142.99 $0.00 $0.00 $0.00 $66.23 $235.83 $235.83 $0.00 $0.00 $66.22 $0.00 $187.95 $187.95 $0.00 $158.88 $251.66 $254.20 $0.00 $0.00 $49.73 $0.00 $0.00 $50.59 $0.00 $0.00 $0.00 $0.00 $0.00 G16658 SUP HCPCS C1769 G16658 - SET STNT 8.5FR 8-20CM GRN GW CATH PSTNR RNL TRNSPLNT BOTH IP/OP $465.53 $344.49 $0.00 $372.42 $252.78 $252.78 $0.00 $0.00 $0.00 $97.03 $345.51 $345.51 $0.00 $0.00 $97.02 $0.00 $275.36 $275.36 $0.00 $232.76 $368.70 $372.42 $0.00 $0.00 $72.85 $0.00 $0.00 $74.11 $0.00 $0.00 $0.00 $0.00 $0.00 G16672 SUP Custom 27203010 G16672 - SET NPHSTM 12FR 19.5CM LTX COPE LOOP MOD CATH GW RTNT DISK BOTH IP/OP $482.33 $356.92 $0.00 $385.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $357.98 $357.98 $0.00 $0.00 $100.52 $0.00 $0.00 $0.00 $0.00 $241.16 $382.01 $385.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G16684 SUP Custom 27203010 G16684 - EXTRACTOR STON FLT 3FR 115CM 4WR BSKT LSR PLMD BOTH IP/OP $60.50 $44.77 $0.00 $48.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.90 $44.90 $0.00 $0.00 $12.61 $0.00 $0.00 $0.00 $0.00 $30.25 $47.92 $48.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G16695 SUP Custom 27203010 G16695 - NEEDLE INJ 23GA 3.7FR 35CM 8MM WMS CSCP BOTH IP/OP $73.15 $54.13 $0.00 $58.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.29 $54.29 $0.00 $0.00 $15.24 $0.00 $0.00 $0.00 $0.00 $36.58 $57.93 $58.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G16696 SUP HCPCS C2627 G16696 - CATHETER PRSS 12FR 36CM 2CM BLN SIL RCTL BOTH IP/OP $166.10 $122.91 $0.00 $132.88 $90.19 $90.19 $0.00 $0.00 $0.00 $0.00 $123.28 $123.28 $0.00 $0.00 $34.62 $0.00 $0.00 $0.00 $0.00 $83.05 $131.55 $132.88 $0.00 $0.00 $25.99 $0.00 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $0.00 G16699 SUP HCPCS C2627 G16699 - SET CATH TROC 8FR 54CM STRL DRN ADPR SPBC CYSTOSTOMY BOTH IP/OP $166.10 $122.91 $0.00 $132.88 $90.19 $90.19 $0.00 $0.00 $0.00 $0.00 $123.28 $123.28 $0.00 $0.00 $34.62 $0.00 $0.00 $0.00 $0.00 $83.05 $131.55 $132.88 $0.00 $0.00 $25.99 $0.00 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $0.00 G16702 SUP HCPCS C1773 G16702 - SET CATH LOPRFL STD 10FR 54CM STRL TROC STY PLS DRN ADPR BOTH IP/OP $397.80 $294.37 $0.00 $318.24 $216.01 $216.01 $0.00 $0.00 $0.00 $82.91 $295.25 $295.25 $0.00 $0.00 $82.90 $0.00 $235.30 $235.30 $0.00 $198.90 $315.06 $318.24 $0.00 $0.00 $62.26 $0.00 $0.00 $63.33 $0.00 $0.00 $0.00 $0.00 $0.00 G16705 SUP HCPCS C1726 G16705 - FORCEPS SPEC RTRVL 2.5FR 10MM 115CM COAX SHTH GRSP BOTH IP/OP $98.20 $72.67 $0.00 $78.56 $53.32 $53.32 $0.00 $0.00 $0.00 $20.47 $72.88 $72.88 $0.00 $0.00 $20.46 $0.00 $58.09 $58.09 $0.00 $49.10 $77.77 $78.56 $0.00 $0.00 $15.37 $0.00 $0.00 $15.63 $0.00 $0.00 $0.00 $0.00 $0.00 G16708 SUP HCPCS C1758 G16708 - CATHETER URDY 7FR 43CM STRL 2 LUM LOOP URETHRA DISP BOTH IP/OP $28.60 $21.16 $0.00 $22.88 $15.53 $15.53 $0.00 $0.00 $0.00 $5.96 $21.23 $21.23 $0.00 $0.00 $5.96 $0.00 $16.92 $16.92 $0.00 $14.30 $22.65 $22.88 $0.00 $0.00 $4.48 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 G16731 SUP HCPCS C2617 G16731 - CATHETER URET .038IN 6FR 10CM FLXTP OP-EN GW MOD BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G16740 SUP HCPCS C2627 G16740 - SET CATH 12FR 16GA 30CM UNIVERSA MLCT 1 WY STPCK CNCT TUBE BOTH IP/OP $166.10 $122.91 $0.00 $132.88 $90.19 $90.19 $0.00 $0.00 $0.00 $0.00 $123.28 $123.28 $0.00 $0.00 $34.62 $0.00 $0.00 $0.00 $0.00 $83.05 $131.55 $132.88 $0.00 $0.00 $25.99 $0.00 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $0.00 G16758 SUP HCPCS C2617 G16758 - SET STNT .038IN CDE 3FR 4FR 8-12CM STRL CATH RADOPQ MTLNTH BOTH IP/OP $66.63 $49.31 $0.00 $53.30 $29.98 $29.98 $0.00 $0.00 $0.00 $13.89 $49.45 $49.45 $0.00 $0.00 $13.88 $0.00 $39.41 $39.41 $0.00 $33.31 $52.77 $53.30 $0.00 $0.00 $10.43 $0.00 $0.00 $10.61 $0.00 $0.00 $0.00 $0.00 $0.00 G16775 SUP Custom 27203010 G16775 - STENT URTH 6FR 12CM STRL ZAONTZ PS DRN DISP HYPOSPADIAS BOTH IP/OP $78.10 $57.79 $0.00 $62.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.97 $57.97 $0.00 $0.00 $16.28 $0.00 $0.00 $0.00 $0.00 $39.05 $61.86 $62.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G16780 SUP HCPCS C1726 G16780 - NEEDLE ESCP 4.5MM 18GA 10CM INCISING RNL FSCA BOTH IP/OP $49.10 $36.33 $0.00 $39.28 $26.66 $26.66 $0.00 $0.00 $0.00 $10.23 $36.44 $36.44 $0.00 $0.00 $10.23 $0.00 $29.04 $29.04 $0.00 $24.55 $38.89 $39.28 $0.00 $0.00 $7.68 $0.00 $0.00 $7.82 $0.00 $0.00 $0.00 $0.00 $0.00 G16783 SUP HCPCS C1758 G16783 - CATHETER URDY 7FR 30CM 2 LUM BOTH IP/OP $31.63 $23.41 $0.00 $25.30 $17.17 $17.17 $0.00 $0.00 $0.00 $6.59 $23.47 $23.47 $0.00 $0.00 $6.59 $0.00 $18.71 $18.71 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 G16784 SUP HCPCS C1758 G16784 - CATHETER URET 4FR 110CM RND TIP RT BOTH IP/OP $31.63 $23.41 $0.00 $25.30 $17.17 $17.17 $0.00 $0.00 $0.00 $6.59 $23.47 $23.47 $0.00 $0.00 $6.59 $0.00 $18.71 $18.71 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 G16791 SUP HCPCS C2627 G16791 - CATHETER URET 3FR 70CM RND TIP STY PORT LT BOTH IP/OP $50.60 $37.44 $0.00 $40.48 $27.48 $27.48 $0.00 $0.00 $0.00 $0.00 $37.56 $37.56 $0.00 $0.00 $10.55 $0.00 $0.00 $0.00 $0.00 $25.30 $40.08 $40.48 $0.00 $0.00 $7.92 $0.00 $0.00 $8.06 $0.00 $0.00 $0.00 $0.00 $0.00 G16792 SUP HCPCS C1758 G16792 - CATHETER SPBC 8FR 54CM CYSTOSTOMY SFT LOPRFL BOTH IP/OP $35.43 $26.22 $0.00 $28.34 $19.24 $19.24 $0.00 $0.00 $0.00 $7.38 $26.29 $26.29 $0.00 $0.00 $7.38 $0.00 $20.95 $20.95 $0.00 $17.71 $28.06 $28.34 $0.00 $0.00 $5.54 $0.00 $0.00 $5.64 $0.00 $0.00 $0.00 $0.00 $0.00 G16816 SUP HCPCS C1729 G16816 - CATHETER URET .038IN 5FR 70CM FLXTP OP-EN GW MOD BOTH IP/OP $216.33 $160.08 $0.00 $173.06 $117.46 $117.46 $0.00 $0.00 $0.00 $45.09 $160.56 $160.56 $0.00 $0.00 $45.08 $0.00 $127.96 $127.96 $0.00 $108.16 $171.33 $173.06 $0.00 $0.00 $33.85 $0.00 $0.00 $34.44 $0.00 $0.00 $0.00 $0.00 $0.00 G16817 SUP HCPCS C2625 G16817 - SET NPHSTM 12FR 40CM COPE LOOP MOD NDL GW CNN DIL BOTH IP/OP $139.40 $103.16 $0.00 $111.52 $62.73 $62.73 $0.00 $0.00 $0.00 $29.05 $103.46 $103.46 $0.00 $0.00 $29.05 $0.00 $82.46 $82.46 $0.00 $69.70 $110.40 $111.52 $0.00 $0.00 $21.82 $0.00 $0.00 $22.19 $0.00 $0.00 $0.00 $0.00 $0.00 G16818 SUP HCPCS C2625 G16818 - SET STNT .038IN 5MM 6FR 75CM STRL 100CM BNDR CATH RADOPQ BOTH IP/OP $139.40 $103.16 $0.00 $111.52 $62.73 $62.73 $0.00 $0.00 $0.00 $29.05 $103.46 $103.46 $0.00 $0.00 $29.05 $0.00 $82.46 $82.46 $0.00 $69.70 $110.40 $111.52 $0.00 $0.00 $21.82 $0.00 $0.00 $22.19 $0.00 $0.00 $0.00 $0.00 $0.00 G16820 SUP HCPCS C2617 G16820 - SET STNT .038IN 5MM 6FR 75CM STRL 100CM BNDR CATH RADOPQ BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G16821 SUP HCPCS C2617 G16821 - SET STNT .018IN SM 2 PGTL CRV CDE 3FR 16CM STRL CP MDRL CATH BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G16876 SUP HCPCS C1769 G16876 - SET STNT .018IN SM 2 PGTL CRV CDE 3FR 20CM STRL CP MDRL CATH BOTH IP/OP $39.33 $29.10 $0.00 $31.46 $21.35 $21.35 $0.00 $0.00 $0.00 $8.20 $29.19 $29.19 $0.00 $0.00 $8.20 $0.00 $23.26 $23.26 $0.00 $19.66 $31.15 $31.46 $0.00 $0.00 $6.15 $0.00 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $0.00 G16880 SUP HCPCS C2617 G16880 - GUIDEWIRE ESCP 70CM STD STRG .038IN 145CM STRL 3CM FXCR FLX BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G16881 SUP HCPCS C2617 G16881 - SET STNT .018IN SM 2 PGTL CRV CDE 3FR 22CM STRL CP MDRL CATH BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G16890 SUP HCPCS C1758 G16890 - SET STNT .018IN SM 2 PGTL CRV CDE 3FR 24CM STRL CP MDRL CATH BOTH IP/OP $182.45 $135.01 $0.00 $145.96 $99.07 $99.07 $0.00 $0.00 $0.00 $38.03 $135.41 $135.41 $0.00 $0.00 $38.02 $0.00 $107.92 $107.92 $0.00 $91.23 $144.50 $145.96 $0.00 $0.00 $28.55 $0.00 $0.00 $29.05 $0.00 $0.00 $0.00 $0.00 $0.00 G16893 SUP HCPCS C1726 G16893 - SET CATH 7.5FR 25CM DEWAN URDY NDL SF WRE PLWY SHTH DIL SPBC BOTH IP/OP $510.95 $378.10 $0.00 $408.76 $277.45 $277.45 $0.00 $0.00 $0.00 $106.49 $379.23 $379.23 $0.00 $0.00 $106.48 $0.00 $302.23 $302.23 $0.00 $255.48 $404.67 $408.76 $0.00 $0.00 $79.96 $0.00 $0.00 $81.34 $0.00 $0.00 $0.00 $0.00 $0.00 G16919 SUP HCPCS C2627 G16919 - SYSTEM IRR URTSCP BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16920 SUP HCPCS C2627 G16920 - CATHETER SPBC 8FR 20CM STRL MLCT SIL DISP BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16921 SUP HCPCS C2627 G16921 - CATHETER SPBC 10FR 20CM MLCT WNG SFT SIL BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16922 SUP HCPCS C2627 G16922 - CATHETER SPBC 12FR 20CM STRL MLCT SIL DISP BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16923 SUP HCPCS C2627 G16923 - CATHETER SPBC 14FR 25CM STRL MLCT WNG SIL DISP BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16924 SUP HCPCS C2627 G16924 - CATHETER SPBC 16FR 25CM STRL MLCT WNG SIL DISP BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16925 SUP HCPCS C2627 G16925 - CATHETER SPBC 18FR 25CM MLCT WNG SFT SIL BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16926 SUP HCPCS C2627 G16926 - CATHETER SPBC 20FR 25CM STRL MLCT WNG SIL DISP BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16927 SUP HCPCS C2627 G16927 - CATHETER SPBC 22FR 25CM STRL MLCT WNG SIL DISP BOTH IP/OP $205.38 $151.98 $0.00 $164.30 $111.52 $111.52 $0.00 $0.00 $0.00 $0.00 $152.43 $152.43 $0.00 $0.00 $42.80 $0.00 $0.00 $0.00 $0.00 $102.69 $162.66 $164.30 $0.00 $0.00 $32.14 $0.00 $0.00 $32.70 $0.00 $0.00 $0.00 $0.00 $0.00 G16938 SUP HCPCS C2625 G16938 - CATHETER SPBC 24FR 25CM STRL MLCT WNG SFT SIL BOTH IP/OP $160.30 $118.62 $0.00 $128.24 $72.14 $72.14 $0.00 $0.00 $0.00 $33.41 $118.97 $118.97 $0.00 $0.00 $33.41 $0.00 $94.82 $94.82 $0.00 $80.15 $126.96 $128.24 $0.00 $0.00 $25.09 $0.00 $0.00 $25.52 $0.00 $0.00 $0.00 $0.00 $0.00 G16939 SUP Custom 27203010 G16939 - SET STNT .038IN 5MM PGTL CRV TPR 7FR 75CM STRL 100CM BNDR BOTH IP/OP $266.20 $196.99 $0.00 $212.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.57 $197.57 $0.00 $0.00 $55.48 $0.00 $0.00 $0.00 $0.00 $133.10 $210.83 $212.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G16940 SUP Custom 27203010 G16940 - SET NPHSTM 16.8CM NDL GW PERC BOTH IP/OP $306.13 $226.54 $0.00 $244.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.21 $227.21 $0.00 $0.00 $63.80 $0.00 $0.00 $0.00 $0.00 $153.06 $242.45 $244.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G16987 SUP HCPCS C1726 G16987 - SET NPHSTM NDL SHTH PERC BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $60.27 $60.27 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 G16989 SUP HCPCS C1758 G16989 - CATHETER URDY 7.4FR 30CM 3 LUM CDE OVL PORT BLN BOTH IP/OP $31.63 $23.41 $0.00 $25.30 $17.17 $17.17 $0.00 $0.00 $0.00 $6.59 $23.47 $23.47 $0.00 $0.00 $6.59 $0.00 $18.71 $18.71 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 G16992 SUP HCPCS C2625 G16992 - CATHETER URET .038IN 5FR 70CM OP-EN GW BOTH IP/OP $235.75 $174.46 $0.00 $188.60 $106.09 $106.09 $0.00 $0.00 $0.00 $49.14 $174.97 $174.97 $0.00 $0.00 $49.13 $0.00 $139.45 $139.45 $0.00 $117.88 $186.71 $188.60 $0.00 $0.00 $36.89 $0.00 $0.00 $37.53 $0.00 $0.00 $0.00 $0.00 $0.00 G16993 SUP HCPCS C2625 G16993 - SET STNT .038IN 5MM PGTL CRV 4.7FR 75CM STRL 100CM BNDR CATH BOTH IP/OP $379.25 $280.65 $0.00 $303.40 $170.66 $170.66 $0.00 $0.00 $0.00 $79.05 $281.48 $281.48 $0.00 $0.00 $79.04 $0.00 $224.33 $224.33 $0.00 $189.63 $300.37 $303.40 $0.00 $0.00 $59.35 $0.00 $0.00 $60.38 $0.00 $0.00 $0.00 $0.00 $0.00 G16994 SUP HCPCS C2625 G16994 - SET STNT .038IN 5MM PGTL CRV 8.4FR 90CM STRL 125CM BNDR CATH BOTH IP/OP $379.25 $280.65 $0.00 $303.40 $170.66 $170.66 $0.00 $0.00 $0.00 $79.05 $281.48 $281.48 $0.00 $0.00 $79.04 $0.00 $224.33 $224.33 $0.00 $189.63 $300.37 $303.40 $0.00 $0.00 $59.35 $0.00 $0.00 $60.38 $0.00 $0.00 $0.00 $0.00 $0.00 G16995 SUP HCPCS C2625 G16995 - SET STENT .038IN 5MM PIGTAIL CURVE 8.2FR 75CM 100CM CATHETER BOTH IP/OP $235.75 $174.46 $0.00 $188.60 $106.09 $106.09 $0.00 $0.00 $0.00 $49.14 $174.97 $174.97 $0.00 $0.00 $49.13 $0.00 $139.45 $139.45 $0.00 $117.88 $186.71 $188.60 $0.00 $0.00 $36.89 $0.00 $0.00 $37.53 $0.00 $0.00 $0.00 $0.00 $0.00 G16996 SUP HCPCS C2625 G16996 - SET STNT .038IN 5MM PGTL CRV 7.2FR 90CM STRL 125CM BNDR CATH BOTH IP/OP $235.75 $174.46 $0.00 $188.60 $106.09 $106.09 $0.00 $0.00 $0.00 $49.14 $174.97 $174.97 $0.00 $0.00 $49.13 $0.00 $139.45 $139.45 $0.00 $117.88 $186.71 $188.60 $0.00 $0.00 $36.89 $0.00 $0.00 $37.53 $0.00 $0.00 $0.00 $0.00 $0.00 G16997 SUP HCPCS C2625 G16997 - SET STNT .038IN 5MM PGTL CRV 7FR 75CM STRL 100CM BNDR CATH BOTH IP/OP $235.75 $174.46 $0.00 $188.60 $106.09 $106.09 $0.00 $0.00 $0.00 $49.14 $174.97 $174.97 $0.00 $0.00 $49.13 $0.00 $139.45 $139.45 $0.00 $117.88 $186.71 $188.60 $0.00 $0.00 $36.89 $0.00 $0.00 $37.53 $0.00 $0.00 $0.00 $0.00 $0.00 G17013 SUP HCPCS C1758 G17013 - CATHETER URET .05IN 10FR 50CM STRL LF 2 INJ LUM TPR TIP BOTH IP/OP $79.20 $58.61 $0.00 $63.36 $43.01 $43.01 $0.00 $0.00 $0.00 $16.51 $58.78 $58.78 $0.00 $0.00 $16.51 $0.00 $46.85 $46.85 $0.00 $39.60 $62.73 $63.36 $0.00 $0.00 $12.39 $0.00 $0.00 $12.61 $0.00 $0.00 $0.00 $0.00 $0.00 G17018 SUP Custom 27203010 G17018 - SET STNT .038IN 5MM PGTL CRV 6FR 75CM STRL 100CM BNDR CATH BOTH IP/OP $89.10 $65.93 $0.00 $71.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.13 $66.13 $0.00 $0.00 $18.57 $0.00 $0.00 $0.00 $0.00 $44.55 $70.57 $71.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17043 SUP HCPCS C1726 G17043 - TUBE CNCT 5FR 10CM M TO F LL MOD BOTH IP/OP $73.60 $54.46 $0.00 $58.88 $39.96 $39.96 $0.00 $0.00 $0.00 $15.34 $54.63 $54.63 $0.00 $0.00 $15.34 $0.00 $43.53 $43.53 $0.00 $36.80 $58.29 $58.88 $0.00 $0.00 $11.52 $0.00 $0.00 $11.72 $0.00 $0.00 $0.00 $0.00 $0.00 G17051 SUP HCPCS C1758 G17051 - CATHETER URDY 7FR 38CM CLR JSPH 2 LUM NRDOP BOTH IP/OP $28.60 $21.16 $0.00 $22.88 $15.53 $15.53 $0.00 $0.00 $0.00 $5.96 $21.23 $21.23 $0.00 $0.00 $5.96 $0.00 $16.92 $16.92 $0.00 $14.30 $22.65 $22.88 $0.00 $0.00 $4.48 $0.00 $0.00 $4.55 $0.00 $0.00 $0.00 $0.00 $0.00 G17083 SUP HCPCS C1758 G17083 - ADAPTER CATH STD TLR LL SYR BOTH IP/OP $56.10 $41.51 $0.00 $44.88 $30.46 $30.46 $0.00 $0.00 $0.00 $11.69 $41.64 $41.64 $0.00 $0.00 $11.69 $0.00 $33.18 $33.18 $0.00 $28.05 $44.43 $44.88 $0.00 $0.00 $8.78 $0.00 $0.00 $8.93 $0.00 $0.00 $0.00 $0.00 $0.00 G17104 SUP Custom 27203010 G17104 - CATHETER URET .028IN 4FR 70CM FLXTP OP-EN GW MOD BOTH IP/OP $306.13 $226.54 $0.00 $244.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.21 $227.21 $0.00 $0.00 $63.80 $0.00 $0.00 $0.00 $0.00 $153.06 $242.45 $244.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17111 SUP Custom 27203010 G17111 - CATH URTH 6FR 25CM 2W FOLEY CLOSE END RND SIL 1.5ML BOTH IP/OP $48.76 $36.08 $0.00 $39.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.38 $38.62 $39.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17128 SUP HCPCS C1769 G17128 - SET NPHSTM 6-12FR NDL GW DIL PERC BOTH IP/OP $248.30 $183.74 $0.00 $198.64 $134.83 $134.83 $0.00 $0.00 $0.00 $51.75 $184.29 $184.29 $0.00 $0.00 $51.75 $0.00 $146.87 $146.87 $0.00 $124.15 $196.65 $198.64 $0.00 $0.00 $38.86 $0.00 $0.00 $39.53 $0.00 $0.00 $0.00 $0.00 $0.00 G17130 SUP HCPCS C2617 G17130 - SET STNT .038IN 2 PGTL CRV 6FR 10CM STRL CATH RADOPQ PSTNR BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17131 SUP HCPCS C2617 G17131 - SET STNT 2 PGTL CRV 7-14FR 30CM 13CM RELS SLV PSTNR ULTHNE BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17132 SUP HCPCS C2617 G17132 - SET STNT .038IN 2 PGTL CRV 7-14FR 13CM STRL 28CM RADOPQ BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17133 SUP HCPCS C2617 G17133 - SET STNT BCNTP 7-14FR 26CM STRL 13CM RELS SLV PSTNR ULTHNE BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17135 SUP HCPCS C2617 G17135 - SET STNT 2 PGTL CRV 7-14FR 24CM 13CM RELS SLV PSTNR ULTHNE BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17136 SUP HCPCS C2617 G17136 - SET STNT 2 PGTL CRV 7-14FR 22CM 13CM RELS SLV PSTNR ULTHNE BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17138 SUP HCPCS C2617 G17138 - SET STNT .038IN 2 PGTL CRV 7-14FR 13CM STRL 20CM RADOPQ BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17139 SUP HCPCS C2617 G17139 - SET STNT .038IN 2 PGTL CRV 6-9.5FR 13CM STRL 30CM RADOPQ BOTH IP/OP $271.63 $201.01 $0.00 $217.30 $122.23 $122.23 $0.00 $0.00 $0.00 $56.61 $201.60 $201.60 $0.00 $0.00 $56.61 $0.00 $160.67 $160.67 $0.00 $135.81 $215.13 $217.30 $0.00 $0.00 $42.51 $0.00 $0.00 $43.24 $0.00 $0.00 $0.00 $0.00 $0.00 G17140 SUP HCPCS C2617 G17140 - STENT URET THNWL PGTL CRV 7-14FR 26CM STRL LF RTRMX+ PSTNR BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17141 SUP HCPCS C2617 G17141 - SET STNT .038IN 2 PGTL CRV 6-9.5FR 13CM STRL 28CM RADOPQ BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17142 SUP HCPCS C2617 G17142 - SET STNT .038IN 2 PGTL CRV 6-9.5FR 13CM STRL 24CM RADOPQ BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17143 SUP HCPCS C2617 G17143 - SET STNT 2 PGTL CRV 6-9.5FR 22CM 13CM RELS SLV PSTNR ULTHNE BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17144 SUP HCPCS C2617 G17144 - SET STNT .038IN 2 PGTL CRV 6-9.5FR 13CM STRL 20CM RADOPQ BOTH IP/OP $312.38 $231.16 $0.00 $249.90 $140.57 $140.57 $0.00 $0.00 $0.00 $65.11 $231.84 $231.84 $0.00 $0.00 $65.10 $0.00 $184.77 $184.77 $0.00 $156.19 $247.40 $249.90 $0.00 $0.00 $48.89 $0.00 $0.00 $49.73 $0.00 $0.00 $0.00 $0.00 $0.00 G17145 SUP HCPCS C1758 G17145 - SET STNT .038IN 2 PGTL CRV 6-9.5FR 13CM STRL 18CM RADOPQ BOTH IP/OP $85.80 $63.49 $0.00 $68.64 $46.59 $46.59 $0.00 $0.00 $0.00 $17.88 $63.68 $63.68 $0.00 $0.00 $17.88 $0.00 $50.75 $50.75 $0.00 $42.90 $67.95 $68.64 $0.00 $0.00 $13.43 $0.00 $0.00 $13.66 $0.00 $0.00 $0.00 $0.00 $0.00 G17150 SUP HCPCS C2625 G17150 - CATHETER URET .04IN 6/10FR 50CM LF FLXTP 2 LUM GW AQ BOTH IP/OP $292.13 $216.18 $0.00 $233.70 $131.46 $131.46 $0.00 $0.00 $0.00 $60.89 $216.82 $216.82 $0.00 $0.00 $60.88 $0.00 $172.79 $172.79 $0.00 $146.06 $231.37 $233.70 $0.00 $0.00 $45.72 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $0.00 G17151 SUP HCPCS C2625 G17151 - SET STNT .038IN 3CM STRG 4.7FR 22-32CM STRL 145CM KWART BOTH IP/OP $292.13 $216.18 $0.00 $233.70 $131.46 $131.46 $0.00 $0.00 $0.00 $60.89 $216.82 $216.82 $0.00 $0.00 $60.88 $0.00 $172.79 $172.79 $0.00 $146.06 $231.37 $233.70 $0.00 $0.00 $45.72 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $0.00 G17152 SUP HCPCS C2625 G17152 - SET STNT .038IN 3CM STRG 6FR 22-32CM STRL 145CM KWART BOTH IP/OP $292.13 $216.18 $0.00 $233.70 $131.46 $131.46 $0.00 $0.00 $0.00 $60.89 $216.82 $216.82 $0.00 $0.00 $60.88 $0.00 $172.79 $172.79 $0.00 $146.06 $231.37 $233.70 $0.00 $0.00 $45.72 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $0.00 G17153 SUP HCPCS C2625 G17153 - SET STNT 7FR 22-32CM KWART RETRO-INJ SFLX MTLNTH RELS SLV GW BOTH IP/OP $292.13 $216.18 $0.00 $233.70 $131.46 $131.46 $0.00 $0.00 $0.00 $60.89 $216.82 $216.82 $0.00 $0.00 $60.88 $0.00 $172.79 $172.79 $0.00 $146.06 $231.37 $233.70 $0.00 $0.00 $45.72 $0.00 $0.00 $46.51 $0.00 $0.00 $0.00 $0.00 $0.00 G17155 SUP HCPCS C2627 G17155 - SET STNT .038IN 3CM STRG 8.2FR 22-32CM STRL 145CM KWART BOTH IP/OP $444.40 $328.86 $0.00 $355.52 $241.31 $241.31 $0.00 $0.00 $0.00 $0.00 $329.83 $329.83 $0.00 $0.00 $92.61 $0.00 $0.00 $0.00 $0.00 $222.20 $351.96 $355.52 $0.00 $0.00 $69.55 $0.00 $0.00 $70.75 $0.00 $0.00 $0.00 $0.00 $0.00 G17156 SUP HCPCS C1769 G17156 - SET NPHSTM 8.5FR 25CM STRL 2 GW CNN DIL MCLC CATH ULTHNE BOTH IP/OP $444.40 $328.86 $0.00 $355.52 $241.31 $241.31 $0.00 $0.00 $0.00 $92.62 $329.83 $329.83 $0.00 $0.00 $92.61 $0.00 $262.86 $262.86 $0.00 $222.20 $351.96 $355.52 $0.00 $0.00 $69.55 $0.00 $0.00 $70.75 $0.00 $0.00 $0.00 $0.00 $0.00 G17157 SUP HCPCS C2627 G17157 - SET NPHSTM 10.2FR 25CM STRL MCLC 2 GW CNN DIL CNCT TUBE BOTH IP/OP $511.05 $378.18 $0.00 $408.84 $277.50 $277.50 $0.00 $0.00 $0.00 $0.00 $379.30 $379.30 $0.00 $0.00 $106.50 $0.00 $0.00 $0.00 $0.00 $255.53 $404.75 $408.84 $0.00 $0.00 $79.98 $0.00 $0.00 $81.36 $0.00 $0.00 $0.00 $0.00 $0.00 G17158 SUP HCPCS C2627 G17158 - SET NPHSTM 12FR 25CM 2 GW CNN DIL CNCT TUBE MC LC LCK LOOP BOTH IP/OP $511.05 $378.18 $0.00 $408.84 $277.50 $277.50 $0.00 $0.00 $0.00 $0.00 $379.30 $379.30 $0.00 $0.00 $106.50 $0.00 $0.00 $0.00 $0.00 $255.53 $404.75 $408.84 $0.00 $0.00 $79.98 $0.00 $0.00 $81.36 $0.00 $0.00 $0.00 $0.00 $0.00 G17160 SUP HCPCS C1758 G17160 - SET NPHSTM 14FR 25CM 2 GW CNN DIL CNCT TUBE MC LC LCK LOOP BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G17185 SUP HCPCS C2625 G17185 - DRAIN INCS .25IN 12IN STRL LF PNRS SIL DISP OPN WND BOTH IP/OP $235.75 $174.46 $0.00 $188.60 $106.09 $106.09 $0.00 $0.00 $0.00 $49.14 $174.97 $174.97 $0.00 $0.00 $49.13 $0.00 $139.45 $139.45 $0.00 $117.88 $186.71 $188.60 $0.00 $0.00 $36.89 $0.00 $0.00 $37.53 $0.00 $0.00 $0.00 $0.00 $0.00 G17186 SUP HCPCS C2625 G17186 - SET STNT 8.2FR 75CM BNDR SFLX OP-EN DVRSN URETER BOTH IP/OP $235.75 $174.46 $0.00 $188.60 $106.09 $106.09 $0.00 $0.00 $0.00 $49.14 $174.97 $174.97 $0.00 $0.00 $49.13 $0.00 $139.45 $139.45 $0.00 $117.88 $186.71 $188.60 $0.00 $0.00 $36.89 $0.00 $0.00 $37.53 $0.00 $0.00 $0.00 $0.00 $0.00 G17214 SUP HCPCS C1769 G17214 - CATHETER URTH 18FR 34CM 5ML UNIVERSA 2W FL CLS END RND TIP BOTH IP/OP $8.59 $6.36 $0.00 $6.88 $4.67 $4.67 $0.00 $0.00 $0.00 $1.79 $6.38 $6.38 $0.00 $0.00 $1.79 $0.00 $5.08 $5.08 $0.00 $4.30 $6.80 $6.88 $0.00 $0.00 $1.34 $0.00 $0.00 $1.37 $0.00 $0.00 $0.00 $0.00 $0.00 G17230 SUP HCPCS C1726 G17230 - SET CATH .021IN 6FR 25CM 1ML UNIVERSA 2W FL OP-EN GW SIL PED BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $24.44 $24.44 $0.00 $0.00 $0.00 $9.38 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $26.62 $26.62 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $7.04 $0.00 $0.00 $7.16 $0.00 $0.00 $0.00 $0.00 $0.00 G17237 SUP HCPCS C1758 G17237 - CATHETER URDY 7FR 38CM 2 LUM CDE BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G17239 SUP HCPCS C1729 G17239 - CATHETER URET 5FR 110CM RND TIP RT BOTH IP/OP $311.20 $230.29 $0.00 $248.96 $168.98 $168.98 $0.00 $0.00 $0.00 $64.86 $230.97 $230.97 $0.00 $0.00 $64.85 $0.00 $184.07 $184.07 $0.00 $155.60 $246.47 $248.96 $0.00 $0.00 $48.70 $0.00 $0.00 $49.54 $0.00 $0.00 $0.00 $0.00 $0.00 G17252 SUP HCPCS C1726 G17252 - CATHETER XTRN 1.3IN NS NADH CNDM SIL M REUSE BOTH IP/OP $51.15 $37.85 $0.00 $40.92 $27.77 $27.77 $0.00 $0.00 $0.00 $10.66 $37.96 $37.96 $0.00 $0.00 $10.66 $0.00 $30.26 $30.26 $0.00 $25.58 $40.51 $40.92 $0.00 $0.00 $8.00 $0.00 $0.00 $8.14 $0.00 $0.00 $0.00 $0.00 $0.00 G17262 SUP HCPCS C1758 G17262 - TUBING URDY INF ST VNT BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G17306 SUP HCPCS C2617 G17306 - ADAPTER CATH TLR LL SYR PED BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G17310 SUP HCPCS C1769 G17310 - SET STNT .025IN 3.7FR 8-30CM STRL CATH RADOPQ MTLNTH PSTNR BOTH IP/OP $396.00 $293.04 $0.00 $316.80 $215.03 $215.03 $0.00 $0.00 $0.00 $82.54 $293.91 $293.91 $0.00 $0.00 $82.53 $0.00 $234.23 $234.23 $0.00 $198.00 $313.63 $316.80 $0.00 $0.00 $61.97 $0.00 $0.00 $63.04 $0.00 $0.00 $0.00 $0.00 $0.00 G17318 SUP HCPCS C1726 G17318 - SET DIL 6-18FR 60CM AQ PE URET BOTH IP/OP $48.08 $35.58 $0.00 $38.46 $26.10 $26.10 $0.00 $0.00 $0.00 $10.02 $35.68 $35.68 $0.00 $0.00 $10.02 $0.00 $28.44 $28.44 $0.00 $24.04 $38.08 $38.46 $0.00 $0.00 $7.52 $0.00 $0.00 $7.65 $0.00 $0.00 $0.00 $0.00 $0.00 G17320 SUP HCPCS C1726 G17320 - CATHETER SUPRAPUBIC 14FR 22CM 30CM SET NEEDLE OBTURATOR BOTH IP/OP $144.10 $106.63 $0.00 $115.28 $78.25 $78.25 $0.00 $0.00 $0.00 $30.03 $106.95 $106.95 $0.00 $0.00 $30.03 $0.00 $85.24 $85.24 $0.00 $72.05 $114.13 $115.28 $0.00 $0.00 $22.55 $0.00 $0.00 $22.94 $0.00 $0.00 $0.00 $0.00 $0.00 G17322 SUP HCPCS C1726 G17322 - CATHETER URDY 5FR 30CM 2 LUM BOTH IP/OP $657.80 $486.77 $0.00 $526.24 $357.19 $357.19 $0.00 $0.00 $0.00 $137.10 $488.22 $488.22 $0.00 $0.00 $137.09 $0.00 $389.09 $389.09 $0.00 $328.90 $520.98 $526.24 $0.00 $0.00 $102.95 $0.00 $0.00 $104.72 $0.00 $0.00 $0.00 $0.00 $0.00 G17323 SUP HCPCS C1758 G17323 - SET DIL 6-30FR 30CM 16CM AMPTZ RADOPQ SHTH HDRPH RNL BOTH IP/OP $97.18 $71.91 $0.00 $77.74 $52.77 $52.77 $0.00 $0.00 $0.00 $20.25 $72.12 $72.12 $0.00 $0.00 $20.25 $0.00 $57.48 $57.48 $0.00 $48.59 $76.97 $77.74 $0.00 $0.00 $15.21 $0.00 $0.00 $15.47 $0.00 $0.00 $0.00 $0.00 $0.00 G17330 SUP HCPCS C1758 G17330 - CATHETER URET .05IN 6/10FR .04IN 50CM STRL LF FLXTP 2 LUM AQ BOTH IP/OP $103.33 $76.46 $0.00 $82.66 $56.11 $56.11 $0.00 $0.00 $0.00 $21.54 $76.69 $76.69 $0.00 $0.00 $21.53 $0.00 $61.12 $61.12 $0.00 $51.66 $81.84 $82.66 $0.00 $0.00 $16.17 $0.00 $0.00 $16.45 $0.00 $0.00 $0.00 $0.00 $0.00 G17354 SUP HCPCS C2627 G17354 - CATHETER URTH 16FR 34CM 5ML UNIVERSA 2W FL OP-EN SIL BOTH IP/OP $4.85 $3.59 $0.00 $3.88 $2.63 $2.63 $0.00 $0.00 $0.00 $0.00 $3.60 $3.60 $0.00 $0.00 $1.01 $0.00 $0.00 $0.00 $0.00 $2.43 $3.84 $3.88 $0.00 $0.00 $0.76 $0.00 $0.00 $0.77 $0.00 $0.00 $0.00 $0.00 $0.00 G17355 SUP HCPCS C2627 G17355 - DILATOR URET 8FR 60CM PE HDRPH BOTH IP/OP $58.20 $43.07 $0.00 $46.56 $31.60 $31.60 $0.00 $0.00 $0.00 $0.00 $43.20 $43.20 $0.00 $0.00 $12.13 $0.00 $0.00 $0.00 $0.00 $29.10 $46.09 $46.56 $0.00 $0.00 $9.11 $0.00 $0.00 $9.27 $0.00 $0.00 $0.00 $0.00 $0.00 G17477 SUP HCPCS C2627 G17477 - STOPCOCK CSCP SAN ANTONIO MOD FIT BOTH IP/OP $58.20 $43.07 $0.00 $46.56 $31.60 $31.60 $0.00 $0.00 $0.00 $0.00 $43.20 $43.20 $0.00 $0.00 $12.13 $0.00 $0.00 $0.00 $0.00 $29.10 $46.09 $46.56 $0.00 $0.00 $9.11 $0.00 $0.00 $9.27 $0.00 $0.00 $0.00 $0.00 $0.00 G17515 SUP HCPCS C2627 G17515 - CATHETER URTH 18FR 34CM 5ML UNIVERSA 2W OP-EN BLN FL SIL DOD BOTH IP/OP $15.92 $11.78 $0.00 $12.74 $8.64 $8.64 $0.00 $0.00 $0.00 $0.00 $11.81 $11.81 $0.00 $0.00 $3.32 $0.00 $0.00 $0.00 $0.00 $7.96 $12.61 $12.74 $0.00 $0.00 $2.49 $0.00 $0.00 $2.53 $0.00 $0.00 $0.00 $0.00 $0.00 G17520 SUP Custom 27203010 G17520 - CATHETER SPBC 8FR 54CM CYSTOSTOMY MOD TROC STY DRN ADPR PUL BOTH IP/OP $302.83 $224.09 $0.00 $242.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.76 $224.76 $0.00 $0.00 $63.11 $0.00 $0.00 $0.00 $0.00 $151.41 $239.84 $242.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17521 SUP HCPCS C1758 G17521 - EXTRACTOR STON 4.5FR 2CM 65CM STRL NCRCL TPLS UNDX HNDL WRE BOTH IP/OP $100.25 $74.19 $0.00 $80.20 $54.44 $54.44 $0.00 $0.00 $0.00 $20.89 $74.41 $74.41 $0.00 $0.00 $20.89 $0.00 $59.30 $59.30 $0.00 $50.13 $79.40 $80.20 $0.00 $0.00 $15.69 $0.00 $0.00 $15.96 $0.00 $0.00 $0.00 $0.00 $0.00 G17539 SUP HCPCS C1769 G17539 - CATHETER URET .038IN PGTL CRV 6FR 70CM SDPRT GW BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G17540 SUP HCPCS C1769 G17540 - GUIDEWIRE VASC STRG .038IN 145CM STRL 3CM RDRR PC STD BD BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G17541 SUP HCPCS C1769 G17541 - GUIDEWIRE VASC ANG STD .035IN 145CM 3CM RDRR PC TRQ CNTRL BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G17542 SUP HCPCS C1769 G17542 - GUIDEWIRE VASC ANG .038IN 145CM STRL 3CM RDRR PC STD BD NTNL BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G17558 SUP Custom 27203010 G17558 - CATH IU NOVY 5FR 40CM SET CVD CANNULATION 55CM DISP BOTH IP/OP $243.48 $180.18 $0.00 $196.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.71 $180.71 $0.00 $0.00 $50.74 $0.00 $0.00 $0.00 $0.00 $123.01 $194.85 $196.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17560 SUP HCPCS C1758 G17560 - POSITIONER STNT 6FR 50CM RADOPQ URET BOTH IP/OP $111.00 $82.14 $0.00 $88.80 $60.27 $60.27 $0.00 $0.00 $0.00 $23.14 $82.38 $82.38 $0.00 $0.00 $23.13 $0.00 $65.66 $65.66 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 G17571 SUP HCPCS C2625 G17571 - CATHETER URET .03IN 4FR 70CM SFLX OP-EN GW BOTH IP/OP $141.45 $104.67 $0.00 $113.16 $63.65 $63.65 $0.00 $0.00 $0.00 $29.48 $104.98 $104.98 $0.00 $0.00 $29.48 $0.00 $83.67 $83.67 $0.00 $70.73 $112.03 $113.16 $0.00 $0.00 $22.14 $0.00 $0.00 $22.52 $0.00 $0.00 $0.00 $0.00 $0.00 G17578 SUP HCPCS C2627 G17578 - CATHETER URET .05IN 5/10FR .04IN 50CM FLXTP 2 LUM AQ BOTH IP/OP $58.20 $43.07 $0.00 $46.56 $31.60 $31.60 $0.00 $0.00 $0.00 $0.00 $43.20 $43.20 $0.00 $0.00 $12.13 $0.00 $0.00 $0.00 $0.00 $29.10 $46.09 $46.56 $0.00 $0.00 $9.11 $0.00 $0.00 $9.27 $0.00 $0.00 $0.00 $0.00 $0.00 G17601 SUP HCPCS C1892 G17601 - DILATOR URET 14FR 60CM PE HDRPH BOTH IP/OP $164.45 $121.69 $0.00 $131.56 $89.30 $89.30 $0.00 $0.00 $0.00 $34.28 $122.05 $122.05 $0.00 $0.00 $34.27 $0.00 $97.27 $97.27 $0.00 $82.23 $130.24 $131.56 $0.00 $0.00 $25.74 $0.00 $0.00 $26.18 $0.00 $0.00 $0.00 $0.00 $0.00 G17618 SUP Custom 27203010 G17618 - INTRODUCER NPHSTM 14FR 65CM 60CM PLWY PERC BOTH IP/OP $390.50 $288.97 $0.00 $312.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.83 $289.83 $0.00 $0.00 $81.38 $0.00 $0.00 $0.00 $0.00 $195.25 $309.28 $312.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17627 SUP Custom 27203010 G17627 - NEEDLE BRCHTX 18GA 20CM ECHTP SET BOTH IP/OP $462.20 $342.03 $0.00 $369.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.04 $343.04 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $231.10 $366.06 $369.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17639 SUP HCPCS C2625 G17639 - DILATOR URET LNG TPR 6-12FR 60CM STRL LFRIC SRFC AQ BOTH IP/OP $141.45 $104.67 $0.00 $113.16 $63.65 $63.65 $0.00 $0.00 $0.00 $29.48 $104.98 $104.98 $0.00 $0.00 $29.48 $0.00 $83.67 $83.67 $0.00 $70.73 $112.03 $113.16 $0.00 $0.00 $22.14 $0.00 $0.00 $22.52 $0.00 $0.00 $0.00 $0.00 $0.00 G17648 SUP HCPCS C2617 G17648 - POSITIONER STNT 4FR 25CM BOTH IP/OP $76.63 $56.71 $0.00 $61.30 $34.48 $34.48 $0.00 $0.00 $0.00 $15.97 $56.87 $56.87 $0.00 $0.00 $15.97 $0.00 $45.32 $45.32 $0.00 $38.31 $60.69 $61.30 $0.00 $0.00 $11.99 $0.00 $0.00 $12.20 $0.00 $0.00 $0.00 $0.00 $0.00 G17666 SUP HCPCS C2617 G17666 - STENT URTH 8FR 24FR 30CM STRL FRLT KLG SDPRT SUT BLB DISP BOTH IP/OP $117.88 $87.23 $0.00 $94.30 $53.04 $53.04 $0.00 $0.00 $0.00 $24.57 $87.49 $87.49 $0.00 $0.00 $24.57 $0.00 $69.72 $69.72 $0.00 $58.94 $93.36 $94.30 $0.00 $0.00 $18.45 $0.00 $0.00 $18.77 $0.00 $0.00 $0.00 $0.00 $0.00 G17667 SUP HCPCS C2617 G17667 - SET STNT 6FR 50CM STRL KL DPR URETHRA DISP BOTH IP/OP $92.25 $68.27 $0.00 $73.80 $41.51 $41.51 $0.00 $0.00 $0.00 $19.23 $68.47 $68.47 $0.00 $0.00 $19.22 $0.00 $54.57 $54.57 $0.00 $46.13 $73.06 $73.80 $0.00 $0.00 $14.44 $0.00 $0.00 $14.69 $0.00 $0.00 $0.00 $0.00 $0.00 G17668 SUP HCPCS C2617 G17668 - STENT URTH 6FR 50CM KL DPR BOTH IP/OP $102.50 $75.85 $0.00 $82.00 $46.13 $46.13 $0.00 $0.00 $0.00 $21.36 $76.08 $76.08 $0.00 $0.00 $21.36 $0.00 $60.63 $60.63 $0.00 $51.25 $81.18 $82.00 $0.00 $0.00 $16.04 $0.00 $0.00 $16.32 $0.00 $0.00 $0.00 $0.00 $0.00 G17669 SUP HCPCS C2617 G17669 - SET STNT 8FR 50CM STRL KL DPR URETHRA DISP BOTH IP/OP $92.25 $68.27 $0.00 $73.80 $41.51 $41.51 $0.00 $0.00 $0.00 $19.23 $68.47 $68.47 $0.00 $0.00 $19.22 $0.00 $54.57 $54.57 $0.00 $46.13 $73.06 $73.80 $0.00 $0.00 $14.44 $0.00 $0.00 $14.69 $0.00 $0.00 $0.00 $0.00 $0.00 G17671 SUP HCPCS C2617 G17671 - STENT URTH 8FR 50CM STRL KL DPR DISP BOTH IP/OP $300.60 $222.44 $0.00 $240.48 $135.27 $135.27 $0.00 $0.00 $0.00 $62.65 $223.11 $223.11 $0.00 $0.00 $62.65 $0.00 $177.80 $177.80 $0.00 $150.30 $238.08 $240.48 $0.00 $0.00 $47.04 $0.00 $0.00 $47.86 $0.00 $0.00 $0.00 $0.00 $0.00 G17676 SUP HCPCS C2617 G17676 - SET STNT .025IN SM 2 PGTL CRV STRG 3.7FR 6CM STRL RADOPQ BOTH IP/OP $253.45 $187.55 $0.00 $202.76 $114.05 $114.05 $0.00 $0.00 $0.00 $52.83 $188.11 $188.11 $0.00 $0.00 $52.82 $0.00 $149.92 $149.92 $0.00 $126.73 $200.73 $202.76 $0.00 $0.00 $39.66 $0.00 $0.00 $40.35 $0.00 $0.00 $0.00 $0.00 $0.00 G17793 SUP HCPCS C2617 G17793 - POSITIONER STNT 5FR 50CM BOTH IP/OP $288.80 $213.71 $0.00 $231.04 $129.96 $129.96 $0.00 $0.00 $0.00 $60.19 $214.35 $214.35 $0.00 $0.00 $60.19 $0.00 $170.83 $170.83 $0.00 $144.40 $228.73 $231.04 $0.00 $0.00 $45.20 $0.00 $0.00 $45.98 $0.00 $0.00 $0.00 $0.00 $0.00 G17794 SUP HCPCS C2627 G17794 - SET STNT .018IN 2 PGTL CRV CDE 3FR 4FR 4CM STRL CP MDRL CATH BOTH IP/OP $72.60 $53.72 $0.00 $58.08 $39.42 $39.42 $0.00 $0.00 $0.00 $0.00 $53.88 $53.88 $0.00 $0.00 $15.13 $0.00 $0.00 $0.00 $0.00 $36.30 $57.50 $58.08 $0.00 $0.00 $11.36 $0.00 $0.00 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 G17795 SUP HCPCS C1726 G17795 - DILATOR URTH 6-12FR 30CM LNG TPR FSCA BOTH IP/OP $72.60 $53.72 $0.00 $58.08 $39.42 $39.42 $0.00 $0.00 $0.00 $15.13 $53.88 $53.88 $0.00 $0.00 $15.13 $0.00 $42.94 $42.94 $0.00 $36.30 $57.50 $58.08 $0.00 $0.00 $11.36 $0.00 $0.00 $11.56 $0.00 $0.00 $0.00 $0.00 $0.00 G17797 SUP HCPCS C1758 G17797 - DILATOR URTH LNG TPR 18FR 30CM AQ BOTH IP/OP $42.90 $31.75 $0.00 $34.32 $23.29 $23.29 $0.00 $0.00 $0.00 $8.94 $31.84 $31.84 $0.00 $0.00 $8.94 $0.00 $25.38 $25.38 $0.00 $21.45 $33.98 $34.32 $0.00 $0.00 $6.71 $0.00 $0.00 $6.83 $0.00 $0.00 $0.00 $0.00 $0.00 G17819 SUP HCPCS C1758 G17819 - DEVICE TRQ STRL OLCOTT DISP ACPT .014-.045IN GW RDRR BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G17842 SUP HCPCS C1726 G17842 - CATHETER URET .040IN 7FR 70CM SFLX OP-EN GW BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $143.35 $143.35 $0.00 $0.00 $0.00 $55.02 $195.94 $195.94 $0.00 $0.00 $55.02 $0.00 $156.16 $156.16 $0.00 $132.00 $209.09 $211.20 $0.00 $0.00 $41.32 $0.00 $0.00 $42.03 $0.00 $0.00 $0.00 $0.00 $0.00 G17843 SUP HCPCS C1726 G17843 - CATHETER URTH 9FR 8.7MM 29CM 18CM CDE BLN BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $143.35 $143.35 $0.00 $0.00 $0.00 $55.02 $195.94 $195.94 $0.00 $0.00 $55.02 $0.00 $156.16 $156.16 $0.00 $132.00 $209.09 $211.20 $0.00 $0.00 $41.32 $0.00 $0.00 $42.03 $0.00 $0.00 $0.00 $0.00 $0.00 G17844 SUP HCPCS C1726 G17844 - CATHETER URTH FLFRM 9FR 8.7MM 29CM 18CM BLN BOTH IP/OP $264.00 $195.36 $0.00 $211.20 $143.35 $143.35 $0.00 $0.00 $0.00 $55.02 $195.94 $195.94 $0.00 $0.00 $55.02 $0.00 $156.16 $156.16 $0.00 $132.00 $209.09 $211.20 $0.00 $0.00 $41.32 $0.00 $0.00 $42.03 $0.00 $0.00 $0.00 $0.00 $0.00 G17852 SUP HCPCS C2617 G17852 - CATHETER URTH 7FR 8.7MM 29CM 18CM OPN TIP BLN BOTH IP/OP $251.13 $185.84 $0.00 $200.90 $113.01 $113.01 $0.00 $0.00 $0.00 $52.34 $186.38 $186.38 $0.00 $0.00 $52.33 $0.00 $148.54 $148.54 $0.00 $125.56 $198.89 $200.90 $0.00 $0.00 $39.30 $0.00 $0.00 $39.98 $0.00 $0.00 $0.00 $0.00 $0.00 G17866 SUP HCPCS C1769 G17866 - SET STNT .035IN 4.7FR 21-32CM STRL CATH RADOPQ MTLNTH PSTNR BOTH IP/OP $107.85 $79.81 $0.00 $86.28 $58.56 $58.56 $0.00 $0.00 $0.00 $22.48 $80.05 $80.05 $0.00 $0.00 $22.48 $0.00 $63.79 $63.79 $0.00 $53.93 $85.42 $86.28 $0.00 $0.00 $16.88 $0.00 $0.00 $17.17 $0.00 $0.00 $0.00 $0.00 $0.00 G17898 SUP HCPCS C1769 G17898 - KIT PRC 11FR MNPRC ENTRY PED PERC BOTH IP/OP $108.75 $80.48 $0.00 $87.00 $59.05 $59.05 $0.00 $0.00 $0.00 $22.67 $80.71 $80.71 $0.00 $0.00 $22.66 $0.00 $64.33 $64.33 $0.00 $54.38 $86.13 $87.00 $0.00 $0.00 $17.02 $0.00 $0.00 $17.31 $0.00 $0.00 $0.00 $0.00 $0.00 G17913 SUP HCPCS C1758 G17913 - FILIFORM URTH 18FR 12.5IN INTGR BOTH IP/OP $27.50 $20.35 $0.00 $22.00 $14.93 $14.93 $0.00 $0.00 $0.00 $5.73 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $16.27 $16.27 $0.00 $13.75 $21.78 $22.00 $0.00 $0.00 $4.30 $0.00 $0.00 $4.38 $0.00 $0.00 $0.00 $0.00 $0.00 G17915 SUP HCPCS C1758 G17915 - CATHETER URET .038IN 7FR 15CM FLXTP OP-EN GW MOD BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G17940 SUP Custom 27203010 G17940 - SET DRN 200ML NS BG PED DISP BOTH IP/OP $478.13 $353.82 $0.00 $382.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.86 $354.86 $0.00 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $239.06 $378.68 $382.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17941 SUP Custom 27203010 G17941 - EXTRACTOR STON 3.2FR 115CM 5CM NFORCE DWR 3WR BSKT HLCL OCL BOTH IP/OP $478.13 $353.82 $0.00 $382.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.86 $354.86 $0.00 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $239.06 $378.68 $382.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G17948 SUP HCPCS C1726 G17948 - EXTRACTOR SRG 3.2FR 115CM 7CM NFORCE HLCL STON SET NTNL URO BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17949 SUP HCPCS C1726 G17949 - DILATOR URTH 12FR 30CM AMPTZ RNL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17950 SUP HCPCS C1726 G17950 - DILATOR URTH 14FR 30CM AMPTZ RNL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17951 SUP HCPCS C1892 G17951 - DILATOR URET 16FR 30CM AMPTZ RNL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17952 SUP HCPCS C1892 G17952 - DILATOR URTH 18FR 30CM AMPTZ RNL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17953 SUP HCPCS C1726 G17953 - DILATOR URET 20FR 30CM AMPTZ RNL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17954 SUP HCPCS C1726 G17954 - DILATOR URET 22FR 30CM AMPTZ RNL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17955 SUP HCPCS C1726 G17955 - DILATOR SRG 24FR 30CM AMPTZ NPHSTM TRACT DILATION BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17956 SUP HCPCS C1726 G17956 - DILATOR URET 26FR 30CM AMPTZ RNL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17957 SUP HCPCS C1726 G17957 - DILATOR URET 28FR 30CM AMPTZ RNL BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $32.25 $32.25 $0.00 $0.00 $0.00 $12.38 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $35.14 $35.14 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 G17963 SUP HCPCS C1894 G17963 - DILATOR URTH 30FR 30CM AMPTZ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17964 SUP HCPCS C1892 G17964 - SHEATH DIL 22FR 16CM AMPTZ OPQ RNL BOTH IP/OP $61.60 $45.58 $0.00 $49.28 $33.45 $33.45 $0.00 $0.00 $0.00 $12.84 $45.72 $45.72 $0.00 $0.00 $12.84 $0.00 $36.44 $36.44 $0.00 $30.80 $48.79 $49.28 $0.00 $0.00 $9.64 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 G17965 SUP HCPCS C1894 G17965 - SHEATH ACC 24FR 16CM AMPTZ OPQ RNL BOTH IP/OP $61.60 $45.58 $0.00 $49.28 $33.45 $33.45 $0.00 $0.00 $0.00 $12.84 $45.72 $45.72 $0.00 $0.00 $12.84 $0.00 $36.44 $36.44 $0.00 $30.80 $48.79 $49.28 $0.00 $0.00 $9.64 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 G17966 SUP HCPCS C1894 G17966 - SHEATH DIL 26FR 16CM AMPTZ OPQ RNL BOTH IP/OP $61.60 $45.58 $0.00 $49.28 $33.45 $33.45 $0.00 $0.00 $0.00 $12.84 $45.72 $45.72 $0.00 $0.00 $12.84 $0.00 $36.44 $36.44 $0.00 $30.80 $48.79 $49.28 $0.00 $0.00 $9.64 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 G17967 SUP HCPCS C1894 G17967 - SHEATH DIL 28FR 16CM AMPTZ OPQ RNL BOTH IP/OP $61.60 $45.58 $0.00 $49.28 $33.45 $33.45 $0.00 $0.00 $0.00 $12.84 $45.72 $45.72 $0.00 $0.00 $12.84 $0.00 $36.44 $36.44 $0.00 $30.80 $48.79 $49.28 $0.00 $0.00 $9.64 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 G17968 SUP HCPCS C1894 G17968 - SHEATH DIL 30FR 16CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17969 SUP HCPCS C1894 G17969 - SHEATH DIL 24FR 20CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17970 SUP HCPCS C1894 G17970 - SHEATH DIL 26FR 20CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17971 SUP HCPCS C1894 G17971 - SHEATH DIL 28FR 20CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17973 SUP HCPCS C1894 G17973 - SHEATH DIL 30FR 20CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17975 SUP HCPCS C1894 G17975 - SHEATH DIL 30FR 19CM AMPTZ OPQ RNL BOTH IP/OP $61.60 $45.58 $0.00 $49.28 $33.45 $33.45 $0.00 $0.00 $0.00 $12.84 $45.72 $45.72 $0.00 $0.00 $12.84 $0.00 $36.44 $36.44 $0.00 $30.80 $48.79 $49.28 $0.00 $0.00 $9.64 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 G17976 SUP HCPCS C1894 G17976 - SHEATH DIL 28FR 30CM OPQ AMPTZ RNL BOTH IP/OP $61.60 $45.58 $0.00 $49.28 $33.45 $33.45 $0.00 $0.00 $0.00 $12.84 $45.72 $45.72 $0.00 $0.00 $12.84 $0.00 $36.44 $36.44 $0.00 $30.80 $48.79 $49.28 $0.00 $0.00 $9.64 $0.00 $0.00 $9.81 $0.00 $0.00 $0.00 $0.00 $0.00 G17980 SUP HCPCS C1894 G17980 - SHEATH DIL 30FR 30CM AMPTZ OPQ BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17981 SUP HCPCS C1894 G17981 - SHEATH DIL 30FR 24CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17982 SUP HCPCS C1894 G17982 - SHEATH DIL 12FR 16CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17983 SUP HCPCS C1894 G17983 - SHEATH DIL 14FR 16CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17984 SUP HCPCS C1894 G17984 - SHEATH DIL 16FR 16CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17985 SUP HCPCS C1894 G17985 - SHEATH DIL 18FR 16CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17986 SUP HCPCS C1894 G17986 - SHEATH DIL 20FR 16CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17997 SUP HCPCS C1894 G17997 - SHEATH DIL 30FR 25CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17998 SUP HCPCS C1894 G17998 - SHEATH DIL 30FR 22CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G17999 SUP HCPCS C1894 G17999 - SHEATH DIL 32FR 16CM AMPTZ OPQ RNL BOTH IP/OP $70.85 $52.43 $0.00 $56.68 $38.47 $38.47 $0.00 $0.00 $0.00 $14.77 $52.58 $52.58 $0.00 $0.00 $14.77 $0.00 $41.91 $41.91 $0.00 $35.43 $56.11 $56.68 $0.00 $0.00 $11.09 $0.00 $0.00 $11.28 $0.00 $0.00 $0.00 $0.00 $0.00 G18001 SUP HCPCS C1892 G18001 - SHEATH DIL 34FR 16CM AMPTZ OPQ RNL BOTH IP/OP $80.85 $59.83 $0.00 $64.68 $43.90 $43.90 $0.00 $0.00 $0.00 $16.85 $60.01 $60.01 $0.00 $0.00 $16.85 $0.00 $47.82 $47.82 $0.00 $40.43 $64.03 $64.68 $0.00 $0.00 $12.65 $0.00 $0.00 $12.87 $0.00 $0.00 $0.00 $0.00 $0.00 G18002 SUP HCPCS C1894 G18002 - INTRODUCER NPHSTM 24FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $80.85 $59.83 $0.00 $64.68 $43.90 $43.90 $0.00 $0.00 $0.00 $16.85 $60.01 $60.01 $0.00 $0.00 $16.85 $0.00 $47.82 $47.82 $0.00 $40.43 $64.03 $64.68 $0.00 $0.00 $12.65 $0.00 $0.00 $12.87 $0.00 $0.00 $0.00 $0.00 $0.00 G18003 SUP HCPCS C1892 G18003 - INTRODUCER NPHSTM 26FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $80.85 $59.83 $0.00 $64.68 $43.90 $43.90 $0.00 $0.00 $0.00 $16.85 $60.01 $60.01 $0.00 $0.00 $16.85 $0.00 $47.82 $47.82 $0.00 $40.43 $64.03 $64.68 $0.00 $0.00 $12.65 $0.00 $0.00 $12.87 $0.00 $0.00 $0.00 $0.00 $0.00 G18004 SUP HCPCS C1894 G18004 - INTRODUCER NPHSTM 28FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $80.85 $59.83 $0.00 $64.68 $43.90 $43.90 $0.00 $0.00 $0.00 $16.85 $60.01 $60.01 $0.00 $0.00 $16.85 $0.00 $47.82 $47.82 $0.00 $40.43 $64.03 $64.68 $0.00 $0.00 $12.65 $0.00 $0.00 $12.87 $0.00 $0.00 $0.00 $0.00 $0.00 G18005 SUP HCPCS C1892 G18005 - INTRODUCER NPHSTM 30FR 16CM 30CM AMPTZ DIL SHTH RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18006 SUP HCPCS C1892 G18006 - INTRODUCER NPHSTM 28FR 20CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18007 SUP HCPCS C1892 G18007 - INTRODUCER NPHSTM 30FR 20CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18008 SUP HCPCS C1892 G18008 - INTRODUCER NPHSTM 22FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18009 SUP HCPCS C1892 G18009 - INTRODUCER NPHSTM 24FR 24CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18010 SUP HCPCS C1892 G18010 - INTRODUCER NPHSTM 26FR 24CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18011 SUP HCPCS C1892 G18011 - INTRODUCER NPHSTM 28FR 24CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18012 SUP HCPCS C1892 G18012 - INTRODUCER NPHSTM 30FR 24CM 30CM AMPTZ DIL SHTH RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18013 SUP HCPCS C1892 G18013 - INTRODUCER NPHSTM 16FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18014 SUP HCPCS C1892 G18014 - INTRODUCER NPHSTM 18FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18015 SUP HCPCS C1892 G18015 - INTRODUCER NPHSTM 20FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18016 SUP HCPCS C1892 G18016 - INTRODUCER NPHSTM 28FR 30CM 40CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18017 SUP HCPCS C1892 G18017 - INTRODUCER NPHSTM 30FR 25CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18018 SUP HCPCS C1892 G18018 - INTRODUCER NPHSTM 30FR 28CM 32CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18019 SUP HCPCS C1892 G18019 - INTRODUCER NPHSTM 30FR 30CM 40CM AMPTZ DIL RNL BOTH IP/OP $80.85 $59.83 $0.00 $64.68 $43.90 $43.90 $0.00 $0.00 $0.00 $16.85 $60.01 $60.01 $0.00 $0.00 $16.85 $0.00 $47.82 $47.82 $0.00 $40.43 $64.03 $64.68 $0.00 $0.00 $12.65 $0.00 $0.00 $12.87 $0.00 $0.00 $0.00 $0.00 $0.00 G18020 SUP HCPCS C1892 G18020 - INTRODUCER NPHSTM 32FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $80.85 $59.83 $0.00 $64.68 $43.90 $43.90 $0.00 $0.00 $0.00 $16.85 $60.01 $60.01 $0.00 $0.00 $16.85 $0.00 $47.82 $47.82 $0.00 $40.43 $64.03 $64.68 $0.00 $0.00 $12.65 $0.00 $0.00 $12.87 $0.00 $0.00 $0.00 $0.00 $0.00 G18021 SUP HCPCS C1892 G18021 - INTRODUCER NPHSTM 34FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18063 SUP HCPCS C1892 G18063 - INTRODUCER NPHSTM 36FR 16CM 30CM AMPTZ DIL RNL BOTH IP/OP $103.53 $76.61 $0.00 $82.82 $56.21 $56.21 $0.00 $0.00 $0.00 $21.58 $76.84 $76.84 $0.00 $0.00 $21.57 $0.00 $61.24 $61.24 $0.00 $51.76 $82.00 $82.82 $0.00 $0.00 $16.20 $0.00 $0.00 $16.48 $0.00 $0.00 $0.00 $0.00 $0.00 G18067 SUP HCPCS C1726 G18067 - SET INTRO 8FR 10FR 70CM 30CM DSLT HFMN SHTH CATH RADOPQ BAND BOTH IP/OP $58.83 $43.53 $0.00 $47.06 $31.94 $31.94 $0.00 $0.00 $0.00 $12.26 $43.66 $43.66 $0.00 $0.00 $12.26 $0.00 $34.79 $34.79 $0.00 $29.41 $46.59 $47.06 $0.00 $0.00 $9.21 $0.00 $0.00 $9.36 $0.00 $0.00 $0.00 $0.00 $0.00 G18070 SUP HCPCS C2625 G18070 - CATHETER GD .038IN 5FR 100CM AMPTZ RADOPQ TFE SHTH RNL BOTH IP/OP $235.75 $174.46 $0.00 $188.60 $106.09 $106.09 $0.00 $0.00 $0.00 $49.14 $174.97 $174.97 $0.00 $0.00 $49.13 $0.00 $139.45 $139.45 $0.00 $117.88 $186.71 $188.60 $0.00 $0.00 $36.89 $0.00 $0.00 $37.53 $0.00 $0.00 $0.00 $0.00 $0.00 G18127 SUP HCPCS C2617 G18127 - SET STENT 26CM 7-14FR CFLX URET EURTM RELS SLV PSTNR 13CM BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G18131 SUP HCPCS C2617 G18131 - SET STNT .038IN 5MM PGTL CRV 7FR 75CM STRL 100MM BNDR 2 CATH BOTH IP/OP $235.75 $174.46 $0.00 $188.60 $106.09 $106.09 $0.00 $0.00 $0.00 $49.14 $174.97 $174.97 $0.00 $0.00 $49.13 $0.00 $139.45 $139.45 $0.00 $117.88 $186.71 $188.60 $0.00 $0.00 $36.89 $0.00 $0.00 $37.53 $0.00 $0.00 $0.00 $0.00 $0.00 G18140 SUP HCPCS C2617 G18140 - SET STNT .038IN 2 PGTL CRV 6-10FR 13CM STRL 26CM RADOPQ BOTH IP/OP $155.40 $115.00 $0.00 $124.32 $69.93 $69.93 $0.00 $0.00 $0.00 $32.39 $115.34 $115.34 $0.00 $0.00 $32.39 $0.00 $91.92 $91.92 $0.00 $77.70 $123.08 $124.32 $0.00 $0.00 $24.32 $0.00 $0.00 $24.74 $0.00 $0.00 $0.00 $0.00 $0.00 G18142 SUP HCPCS C1769 G18142 - SET CATH .038IN PGTL CRV 6FR 70CM 145CM SDPRT SHFT GW MOD BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G18143 SUP HCPCS C1769 G18143 - GUIDEWIRE VASC STRG .035IN 145CM STRL 7CM RDRR PC STD BD BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G18144 SUP HCPCS C1769 G18144 - GUIDEWIRE VASC ANG STD .035IN 145CM STRL 7CM RDRR PC STF BD BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G18145 SUP HCPCS C1769 G18145 - GUIDEWIRE VASC STRG STD .038IN 145CM STRL 7CM RDRR PC STF BD BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G18153 SUP HCPCS C1769 G18153 - GUIDEWIRE VASC STD ANG .038IN 145CM STRL 7CM RDRR PC NTNL BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G18154 SUP HCPCS C1769 G18154 - GUIDEWIRE VASC STRG .035IN 145CM 8CM RDRR PC STF BD LFRIC BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G18155 SUP HCPCS C1769 G18155 - GUIDEWIRE VASC .035IN 145CM STRL 8CM RDRR PC STF BD ANG TIP BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G18156 SUP HCPCS C1769 G18156 - GUIDEWIRE VASC STRG .038IN 145CM 8CM RDRR PC 1 TO 1 TRQ BOTH IP/OP $94.58 $69.99 $0.00 $75.66 $51.35 $51.35 $0.00 $0.00 $0.00 $19.71 $70.19 $70.19 $0.00 $0.00 $19.71 $0.00 $55.94 $55.94 $0.00 $47.29 $74.91 $75.66 $0.00 $0.00 $14.80 $0.00 $0.00 $15.06 $0.00 $0.00 $0.00 $0.00 $0.00 G18162 SUP HCPCS C2617 G18162 - GUIDEWIRE URO STRG .038IN 145CM STRL 5CM AMPTZ FLX TP FX COR BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $14.81 $14.81 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G18189 SUP HCPCS C2627 G18189 - SET STNT 4FR 12-18CM STRL SALLE CATH MTLNTH PSTNR CNCT GW BOTH IP/OP $198.63 $146.99 $0.00 $158.90 $107.85 $107.85 $0.00 $0.00 $0.00 $0.00 $147.42 $147.42 $0.00 $0.00 $41.39 $0.00 $0.00 $0.00 $0.00 $99.31 $157.31 $158.90 $0.00 $0.00 $31.08 $0.00 $0.00 $31.62 $0.00 $0.00 $0.00 $0.00 $0.00 G18191 SUP Custom 27203010 G18191 - SET CATH 8FR 54CM CYSTOSTOMY MOD TROC STY DRN ADPR SPBC BOTH IP/OP $462.20 $342.03 $0.00 $369.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.04 $343.04 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $231.10 $366.06 $369.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18193 SUP Custom 27203010 G18193 - EXTRACTOR STON HLX 3FR 1CM 115CM NCRCL FLXB SHTH NTNL MEM BOTH IP/OP $302.83 $224.09 $0.00 $242.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.76 $224.76 $0.00 $0.00 $63.11 $0.00 $0.00 $0.00 $0.00 $151.41 $239.84 $242.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18201 SUP HCPCS C1892 G18201 - CATHETER XTRN 1.53IN NS NADH CNDM SIL M DISP BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18622 SUP HCPCS C2617 G18622 - INTRODUCER NPHSTM 30FR 22CM 30CM AMPTZ DIL RNL BOTH IP/OP $285.83 $211.51 $0.00 $228.66 $128.62 $128.62 $0.00 $0.00 $0.00 $59.57 $212.14 $212.14 $0.00 $0.00 $59.57 $0.00 $169.07 $169.07 $0.00 $142.91 $226.38 $228.66 $0.00 $0.00 $44.73 $0.00 $0.00 $45.50 $0.00 $0.00 $0.00 $0.00 $0.00 G18624 SUP HCPCS C2625 G18624 - SET STNT .038IN 2 PGTL CRV 7FR 20CM BLU STRL CATH RADOPQ BOTH IP/OP $271.13 $200.64 $0.00 $216.90 $122.01 $122.01 $0.00 $0.00 $0.00 $56.51 $201.23 $201.23 $0.00 $0.00 $56.50 $0.00 $160.37 $160.37 $0.00 $135.56 $214.73 $216.90 $0.00 $0.00 $42.43 $0.00 $0.00 $43.16 $0.00 $0.00 $0.00 $0.00 $0.00 G18629 SUP HCPCS C1769 G18629 - SET STNT .038IN 5MM PGTL CRV 4.7FR 75CM STRL 100MM BNDR 2 BOTH IP/OP $107.85 $79.81 $0.00 $86.28 $58.56 $58.56 $0.00 $0.00 $0.00 $22.48 $80.05 $80.05 $0.00 $0.00 $22.48 $0.00 $63.79 $63.79 $0.00 $53.93 $85.42 $86.28 $0.00 $0.00 $16.88 $0.00 $0.00 $17.17 $0.00 $0.00 $0.00 $0.00 $0.00 G18639 SUP HCPCS C2617 G18639 - GUIDEWIRE ESCP STRG .035IN 145CM STRL 3CM RDRR PC 1-1 TRQ BOTH IP/OP $285.83 $211.51 $0.00 $228.66 $128.62 $128.62 $0.00 $0.00 $0.00 $59.57 $212.14 $212.14 $0.00 $0.00 $59.57 $0.00 $169.07 $169.07 $0.00 $142.91 $226.38 $228.66 $0.00 $0.00 $44.73 $0.00 $0.00 $45.50 $0.00 $0.00 $0.00 $0.00 $0.00 G18671 SUP Custom 27203010 G18671 - SET STNT .038IN 2 PGTL CRV 7FR 24CM BLU STRL CATH RADOPQ BOTH IP/OP $84.70 $62.68 $0.00 $67.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.86 $62.86 $0.00 $0.00 $17.65 $0.00 $0.00 $0.00 $0.00 $42.35 $67.08 $67.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18702 SUP Custom 27203010 G18702 - NEEDLE BRCHTX 18GA 20CM ECHTP LOC BOTH IP/OP $94.60 $70.00 $0.00 $75.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.21 $70.21 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $47.30 $74.92 $75.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18705 SUP Custom 27203010 G18705 - NEEDLE BX 14GA 15CM STRL Q COR 1 HNDCNTL LTWT SFT TIS DISP BOTH IP/OP $94.60 $70.00 $0.00 $75.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.21 $70.21 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $47.30 $74.92 $75.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18707 SUP Custom 27203010 G18707 - NEEDLE BX 18GA 15CM STRL Q COR 1 HND CNTRL LTWT SFT TIS DISP BOTH IP/OP $94.60 $70.00 $0.00 $75.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.21 $70.21 $0.00 $0.00 $19.71 $0.00 $0.00 $0.00 $0.00 $47.30 $74.92 $75.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18725 SUP HCPCS C1892 G18725 - NEEDLE BX 18GA 20CM STRL Q COR 1 HND CNTRL LTWT SFT TIS DISP BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $50.49 $50.49 $0.00 $0.00 $0.00 $19.38 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $54.99 $54.99 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $14.55 $0.00 $0.00 $14.80 $0.00 $0.00 $0.00 $0.00 $0.00 G18758 SUP HCPCS C1758 G18758 - INTRODUCER NPHSTM 26FR 20CM 32CM AMPTZ DIL RNL BOTH IP/OP $39.95 $29.56 $0.00 $31.96 $21.69 $21.69 $0.00 $0.00 $0.00 $8.33 $29.65 $29.65 $0.00 $0.00 $8.33 $0.00 $23.63 $23.63 $0.00 $19.98 $31.64 $31.96 $0.00 $0.00 $6.25 $0.00 $0.00 $6.36 $0.00 $0.00 $0.00 $0.00 $0.00 G18777 SUP Custom 27203010 G18777 - CATHETER URET .038IN 5FR 85CM FLXTP OP-EN GW MOD BOTH IP/OP $462.20 $342.03 $0.00 $369.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.04 $343.04 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $231.10 $366.06 $369.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18778 SUP Custom 27203010 G18778 - EXTRACTOR STON 2.2FR 2CM 115CM NCRCL TPLS MOD BSKT NTNL BOTH IP/OP $462.20 $342.03 $0.00 $369.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.04 $343.04 $0.00 $0.00 $96.32 $0.00 $0.00 $0.00 $0.00 $231.10 $366.06 $369.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18790 SUP HCPCS C1758 G18790 - EXTRACTOR STON 2.2FR 1CM 115CM STRL NCRCL NTNL URO DISP BOTH IP/OP $32.90 $24.35 $0.00 $26.32 $17.86 $17.86 $0.00 $0.00 $0.00 $6.86 $24.42 $24.42 $0.00 $0.00 $6.86 $0.00 $19.46 $19.46 $0.00 $16.45 $26.06 $26.32 $0.00 $0.00 $5.15 $0.00 $0.00 $5.24 $0.00 $0.00 $0.00 $0.00 $0.00 G18792 SUP HCPCS C1769 G18792 - CATHETER URET .038IN 5FR 110CM FLXTP OP-EN GW MOD BOTH IP/OP $108.38 $80.20 $0.00 $86.70 $58.85 $58.85 $0.00 $0.00 $0.00 $22.59 $80.44 $80.44 $0.00 $0.00 $22.59 $0.00 $64.10 $64.10 $0.00 $54.19 $85.84 $86.70 $0.00 $0.00 $16.96 $0.00 $0.00 $17.25 $0.00 $0.00 $0.00 $0.00 $0.00 G18803 SUP HCPCS C1892 G18803 - GUIDEWIRE URO .035IN 145CM STRL RDRR PC 2 FLX TP AQ DISP BOTH IP/OP $164.45 $121.69 $0.00 $131.56 $89.30 $89.30 $0.00 $0.00 $0.00 $34.28 $122.05 $122.05 $0.00 $0.00 $34.27 $0.00 $97.27 $97.27 $0.00 $82.23 $130.24 $131.56 $0.00 $0.00 $25.74 $0.00 $0.00 $26.18 $0.00 $0.00 $0.00 $0.00 $0.00 G18813 SUP Custom 27203010 G18813 - INTRODUCER NPHSTM 12FR 65CM 60CM PLWY 2 KNOB BOTH IP/OP $59.40 $43.96 $0.00 $47.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.09 $44.09 $0.00 $0.00 $12.38 $0.00 $0.00 $0.00 $0.00 $29.70 $47.04 $47.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18827 SUP HCPCS C2627 G18827 - ADAPTER CATH 6FR STRL T-B SDARM URET DISP BOTH IP/OP $102.50 $75.85 $0.00 $82.00 $55.66 $55.66 $0.00 $0.00 $0.00 $0.00 $76.08 $76.08 $0.00 $0.00 $21.36 $0.00 $0.00 $0.00 $0.00 $51.25 $81.18 $82.00 $0.00 $0.00 $16.04 $0.00 $0.00 $16.32 $0.00 $0.00 $0.00 $0.00 $0.00 G18845 SUP HCPCS C1758 G18845 - STENT URTH 6FR 50CM STRL 26CM KL DPR INK MRK DISP BOTH IP/OP $85.80 $63.49 $0.00 $68.64 $46.59 $46.59 $0.00 $0.00 $0.00 $17.88 $63.68 $63.68 $0.00 $0.00 $17.88 $0.00 $50.75 $50.75 $0.00 $42.90 $67.95 $68.64 $0.00 $0.00 $13.43 $0.00 $0.00 $13.66 $0.00 $0.00 $0.00 $0.00 $0.00 G18876 SUP HCPCS C1758 G18876 - CATHETER URET STD 6/10FR 24CM FLXTP 2 LUM ACC HDRPH BOTH IP/OP $27.83 $20.59 $0.00 $22.26 $15.11 $15.11 $0.00 $0.00 $0.00 $5.80 $20.65 $20.65 $0.00 $0.00 $5.80 $0.00 $16.46 $16.46 $0.00 $13.91 $22.04 $22.26 $0.00 $0.00 $4.35 $0.00 $0.00 $4.43 $0.00 $0.00 $0.00 $0.00 $0.00 G18882 SUP Custom 27203010 G18882 - GRASPER ENDSCP 3.2FR 10MM 115CM 3 PRONG DELTA WIRE STAINLESS BOTH IP/OP $472.83 $349.89 $0.00 $378.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.93 $350.93 $0.00 $0.00 $98.54 $0.00 $0.00 $0.00 $0.00 $236.41 $374.48 $378.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G18883 SUP HCPCS C1758 G18883 - CATHETER URET 5FR 100CM RND TIP LT BOTH IP/OP $49.35 $36.52 $0.00 $39.48 $26.80 $26.80 $0.00 $0.00 $0.00 $10.29 $36.63 $36.63 $0.00 $0.00 $10.28 $0.00 $29.19 $29.19 $0.00 $24.68 $39.09 $39.48 $0.00 $0.00 $7.72 $0.00 $0.00 $7.86 $0.00 $0.00 $0.00 $0.00 $0.00 G18884 SUP HCPCS C1758 G18884 - CATHETER URET .05IN 7.1FR 40CM SFLX NTPR TIP LSR BOTH IP/OP $104.35 $77.22 $0.00 $83.48 $56.66 $56.66 $0.00 $0.00 $0.00 $21.75 $77.45 $77.45 $0.00 $0.00 $21.75 $0.00 $61.72 $61.72 $0.00 $52.18 $82.65 $83.48 $0.00 $0.00 $16.33 $0.00 $0.00 $16.61 $0.00 $0.00 $0.00 $0.00 $0.00 G18909 SUP HCPCS C1758 G18909 - CATHETER URET PGTL CRV 8.2FR 56CM SFLX HDRPH BOTH IP/OP $31.63 $23.41 $0.00 $25.30 $17.17 $17.17 $0.00 $0.00 $0.00 $6.59 $23.47 $23.47 $0.00 $0.00 $6.59 $0.00 $18.71 $18.71 $0.00 $15.81 $25.05 $25.30 $0.00 $0.00 $4.95 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 G18996 SUP HCPCS C1758 G18996 - CATHETER URET 3FR 100CM RND TIP STY LT BOTH IP/OP $104.35 $77.22 $0.00 $83.48 $56.66 $56.66 $0.00 $0.00 $0.00 $21.75 $77.45 $77.45 $0.00 $0.00 $21.75 $0.00 $61.72 $61.72 $0.00 $52.18 $82.65 $83.48 $0.00 $0.00 $16.33 $0.00 $0.00 $16.61 $0.00 $0.00 $0.00 $0.00 $0.00 G18997 SUP HCPCS C1758 G18997 - CATHETER URET PGTL CRV 10FR 56CM SFLX HDRPH BOTH IP/OP $119.20 $88.21 $0.00 $95.36 $64.73 $64.73 $0.00 $0.00 $0.00 $24.84 $88.47 $88.47 $0.00 $0.00 $24.84 $0.00 $70.51 $70.51 $0.00 $59.60 $94.41 $95.36 $0.00 $0.00 $18.65 $0.00 $0.00 $18.98 $0.00 $0.00 $0.00 $0.00 $0.00 G19002 SUP HCPCS C1758 G19002 - CATHETER URET PGTL CRV 7FR 56CM SFLX HDRPH BOTH IP/OP $53.13 $39.32 $0.00 $42.50 $28.85 $28.85 $0.00 $0.00 $0.00 $11.07 $39.43 $39.43 $0.00 $0.00 $11.07 $0.00 $31.42 $31.42 $0.00 $26.56 $42.08 $42.50 $0.00 $0.00 $8.31 $0.00 $0.00 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 G19030 SUP Custom 27203010 G19030 - CATHETER URET .038IN 7FR 70CM OP-EN GW MOD BOTH IP/OP $43.00 $31.82 $0.00 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.91 $31.91 $0.00 $0.00 $8.96 $0.00 $0.00 $0.00 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G19032 SUP Custom 27203010 G19032 - NEEDLE ESCP 18GA 20CM SKNY ECHTP CHBA TIP BOTH IP/OP $29.70 $21.98 $0.00 $23.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.04 $22.04 $0.00 $0.00 $6.19 $0.00 $0.00 $0.00 $0.00 $14.85 $23.52 $23.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G19055 SUP HCPCS C1758 G19055 - ADAPTER CATH 9FR CKFL 3W STPCK SDARM SLF SL BOTH IP/OP $53.13 $39.32 $0.00 $42.50 $28.85 $28.85 $0.00 $0.00 $0.00 $11.07 $39.43 $39.43 $0.00 $0.00 $11.07 $0.00 $31.42 $31.42 $0.00 $26.56 $42.08 $42.50 $0.00 $0.00 $8.31 $0.00 $0.00 $8.46 $0.00 $0.00 $0.00 $0.00 $0.00 G19069 SUP HCPCS C2617 G19069 - CATHETER URET .038IN 7FR 70CM OP-EN GW MOD BOTH IP/OP $261.38 $193.42 $0.00 $209.10 $117.62 $117.62 $0.00 $0.00 $0.00 $54.48 $193.99 $193.99 $0.00 $0.00 $54.47 $0.00 $154.60 $154.60 $0.00 $130.69 $207.01 $209.10 $0.00 $0.00 $40.91 $0.00 $0.00 $41.61 $0.00 $0.00 $0.00 $0.00 $0.00 G19072 SUP Custom 27203010 G19072 - SET STNT 5FR 8-20CM STRL GRN CATH RADOPQ MTLNTH PSTNR BOTH IP/OP $478.13 $353.82 $0.00 $382.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.86 $354.86 $0.00 $0.00 $99.64 $0.00 $0.00 $0.00 $0.00 $239.06 $378.68 $382.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G19073 SUP Custom 27203010 G19073 - EXTRACTOR STON 2.2FR 115CM 5CM NFORCE 3WR HLCL OCL NTNL BOTH IP/OP $549.85 $406.89 $0.00 $439.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.10 $408.10 $0.00 $0.00 $114.59 $0.00 $0.00 $0.00 $0.00 $274.93 $435.48 $439.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G19089 SUP HCPCS C1729 G19089 - SET NPHSTM ECHTP NDL GW DIL PERC BOTH IP/OP $417.45 $308.91 $0.00 $333.96 $226.68 $226.68 $0.00 $0.00 $0.00 $87.01 $309.83 $309.83 $0.00 $0.00 $87.00 $0.00 $246.92 $246.92 $0.00 $208.73 $330.62 $333.96 $0.00 $0.00 $65.33 $0.00 $0.00 $66.46 $0.00 $0.00 $0.00 $0.00 $0.00 G19097 SUP HCPCS C1894 G19097 - SET NPHSTM PGTL CRV 6FR 7CM ECHTP NDL GW CATH DIL CNCT TUBE BOTH IP/OP $254.28 $188.17 $0.00 $203.42 $138.07 $138.07 $0.00 $0.00 $0.00 $53.00 $188.72 $188.72 $0.00 $0.00 $52.99 $0.00 $150.40 $150.40 $0.00 $127.14 $201.39 $203.42 $0.00 $0.00 $39.79 $0.00 $0.00 $40.48 $0.00 $0.00 $0.00 $0.00 $0.00 G19098 SUP HCPCS C1769 G19098 - SET NPHSTM COPE LOOP ECHTP NDL GW CATH CNN PERC BOTH IP/OP $465.53 $344.49 $0.00 $372.42 $252.78 $252.78 $0.00 $0.00 $0.00 $97.03 $345.51 $345.51 $0.00 $0.00 $97.02 $0.00 $275.36 $275.36 $0.00 $232.76 $368.70 $372.42 $0.00 $0.00 $72.85 $0.00 $0.00 $74.11 $0.00 $0.00 $0.00 $0.00 $0.00 G19110 SUP Custom 27203010 G19110 - SET NPHSTM 10FR 19.5CM LTX COPE LOOP ECHTP NDL STPCK CNN BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G19111 SUP Custom 27203010 G19111 - EXTRACTOR STON 3ANG 2.4FR 1CM 115CM STRL NCR DWR TPLS BSKT BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G19119 SUP HCPCS C1758 G19119 - EXTRACTOR STON 2.4FR 2CM 115CM NCR DWR TPLS MOD BSKT NTNL BOTH IP/OP $225.50 $166.87 $0.00 $180.40 $122.45 $122.45 $0.00 $0.00 $0.00 $47.00 $167.37 $167.37 $0.00 $0.00 $46.99 $0.00 $133.38 $133.38 $0.00 $112.75 $178.60 $180.40 $0.00 $0.00 $35.29 $0.00 $0.00 $35.90 $0.00 $0.00 $0.00 $0.00 $0.00 G19168 SUP HCPCS C1894 G19168 - SHEATH ACCES 12FR 35CM DILATION CONTIN WORKING CHANNEL BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G19169 SUP HCPCS C1894 G19169 - SET STNT ANTGRD 2 PGTL CRV 6FR 50CM GRN STRL 32CM SEIDMON BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G19172 SUP HCPCS C1894 G19172 - SHEATH ACCES 12FR DILATION CONTIN WKG CHNL FLXR BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G19173 SUP HCPCS C1894 G19173 - SHEATH ACC 12FR 55CM STRL LTX FLXR DILATION CNT WRK CHNL BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G19174 SUP HCPCS C1894 G19174 - SHEATH ACCES 9.5FR TPR DILAT CONTIN WRK CHNL LOCK BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G19175 SUP HCPCS C1894 G19175 - SHEATH ACC 12FR 20CM STRL LTX FLXR DILATION CNT WRK CHNL BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G19176 SUP HCPCS C1894 G19176 - SHEATH ACCES 9.5FR TPR DILAT CONTIN WRK CHNL LOCK BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G19177 SUP HCPCS C1894 G19177 - SHEATH ACC FNL 9.5FR 55CM STRL FLXR WKG CHNL LFRIC SRFC DIL BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G19191 SUP Custom 27203010 G19191 - NEEDLE ENDSCP 22GA 25CM SKINNY NEEDLE CHIBA ECHOTIP BOTH IP/OP $28.60 $21.16 $0.00 $22.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.23 $21.23 $0.00 $0.00 $5.96 $0.00 $0.00 $0.00 $0.00 $14.30 $22.65 $22.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G21363 SUP Custom 27203010 G21363 - PROBE DPLR IMPLTABLE FLW 20MHZ STRL CKSWTZ BOTH IP/OP "$1,240.00 " $917.60 $0.00 $920.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $920.33 $920.33 $0.00 $0.00 $258.42 $0.00 $0.00 $0.00 $0.00 $503.19 $797.05 $805.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G21421 SUP HCPCS C1729 G21421 - CATHETER ENDSCP 7FR 250CM 5 SIDEPORT LATEX FREE BILIARY BOTH IP/OP $207.50 $153.55 $0.00 $166.00 $112.67 $112.67 $0.00 $0.00 $0.00 $43.25 $154.01 $154.01 $0.00 $0.00 $43.24 $0.00 $122.74 $122.74 $0.00 $103.75 $164.34 $166.00 $0.00 $0.00 $32.47 $0.00 $0.00 $33.03 $0.00 $0.00 $0.00 $0.00 $0.00 G21509 SUP HCPCS C2617 G21509 - STENT PANCREATIC 7FR 15CM DRAIN OBSTRUCTED POSITIONING BOTH IP/OP $177.50 $131.35 $0.00 $142.00 $79.88 $79.88 $0.00 $0.00 $0.00 $37.00 $131.74 $131.74 $0.00 $0.00 $36.99 $0.00 $104.99 $104.99 $0.00 $88.75 $140.58 $142.00 $0.00 $0.00 $27.78 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $0.00 G21586 SUP HCPCS C1729 G21586 - SET DRAIN PUR 250CM 7FR .035IN PGTL CURVE NSBIL 5 SDPRT CATH BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $190.05 $190.05 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 G21962 SUP HCPCS C1769 G21962 - GUIDEWIRE ENDSCP 250CM PROGRESSIVELY FLEXIBLE TIP BOTH IP/OP $415.00 $307.10 $0.00 $332.00 $225.35 $225.35 $0.00 $0.00 $0.00 $86.50 $308.01 $308.01 $0.00 $0.00 $86.49 $0.00 $245.47 $245.47 $0.00 $207.50 $328.68 $332.00 $0.00 $0.00 $64.95 $0.00 $0.00 $66.07 $0.00 $0.00 $0.00 $0.00 $0.00 G21978 SUP HCPCS C1769 G21978 - GUIDEWIRE ENDSCP 360CM SAVARY-GILLIARD NONSTRL REUSABLE BOTH IP/OP $480.00 $355.20 $0.00 $384.00 $260.64 $260.64 $0.00 $0.00 $0.00 $100.04 $356.26 $356.26 $0.00 $0.00 $100.03 $0.00 $283.92 $283.92 $0.00 $240.00 $380.16 $384.00 $0.00 $0.00 $75.12 $0.00 $0.00 $76.42 $0.00 $0.00 $0.00 $0.00 $0.00 G22102 SUP HCPCS C2617 G22102 - STENT PANCREATIC 5FR 153CM DRAIN OBSTRUCTED POSITIONING BOTH IP/OP $177.50 $131.35 $0.00 $142.00 $79.88 $79.88 $0.00 $0.00 $0.00 $37.00 $131.74 $131.74 $0.00 $0.00 $36.99 $0.00 $104.99 $104.99 $0.00 $88.75 $140.58 $142.00 $0.00 $0.00 $27.78 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $0.00 G22139 SUP HCPCS C1769 G22139 - GUIDEWIRE ENDSCP 200CM FLEXIBLE TIP SAVARY-GILLIARD BOTH IP/OP $345.00 $255.30 $0.00 $276.00 $187.34 $187.34 $0.00 $0.00 $0.00 $71.91 $256.06 $256.06 $0.00 $0.00 $71.90 $0.00 $204.07 $204.07 $0.00 $172.50 $273.24 $276.00 $0.00 $0.00 $53.99 $0.00 $0.00 $54.92 $0.00 $0.00 $0.00 $0.00 $0.00 G22409 SUP Custom 27203010 G22409 - BRUSH CYTOLOGY 5FR 2MM 180CM GASTROSCOPE GREEN BOTH IP/OP $46.25 $34.23 $0.00 $37.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.33 $34.33 $0.00 $0.00 $9.64 $0.00 $0.00 $0.00 $0.00 $23.13 $36.63 $37.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23239 SUP HCPCS C2617 G23239 - LASER SRG 115V 20AMP RHPSD H-30 BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23240 SUP HCPCS C2617 G23240 - SET STNT .038IN 3CM PGTL CRV 7FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $137.05 $101.42 $0.00 $109.64 $61.67 $61.67 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $68.53 $108.54 $109.64 $0.00 $0.00 $21.45 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 G23241 SUP HCPCS C2617 G23241 - STENT URET 2 PGTL CRV 5FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23242 SUP HCPCS C2617 G23242 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22-32CM STRL 145CM BOTH IP/OP $137.05 $101.42 $0.00 $109.64 $61.67 $61.67 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $68.53 $108.54 $109.64 $0.00 $0.00 $21.45 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 G23243 SUP HCPCS C2617 G23243 - STENT URET 2 PGTL CRV 5FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23244 SUP HCPCS C2617 G23244 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23312 SUP HCPCS C2617 G23312 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22-32CM STRL 145CM BOTH IP/OP $137.05 $101.42 $0.00 $109.64 $61.67 $61.67 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $68.53 $108.54 $109.64 $0.00 $0.00 $21.45 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 G23313 SUP HCPCS C2617 G23313 - SET STNT 2 PGTL CRV 5FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23314 SUP HCPCS C2617 G23314 - SET STNT 2 PGTL CRV 6FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23315 SUP HCPCS C2617 G23315 - SET STNT 2 PGTL CRV 7FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23316 SUP HCPCS C2617 G23316 - SET STNT 2 PGTL CRV 8FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23317 SUP HCPCS C2617 G23317 - SET STNT 2 PGTL CRV 6FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23318 SUP HCPCS C2617 G23318 - SET STNT 2 PGTL CRV 7FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23319 SUP HCPCS C2617 G23319 - SET STNT 2 PGTL CRV 8FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23320 SUP HCPCS C2617 G23320 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23326 SUP HCPCS C2617 G23326 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23327 SUP HCPCS C2617 G23327 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23328 SUP HCPCS C2617 G23328 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23329 SUP HCPCS C2617 G23329 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23330 SUP HCPCS C2617 G23330 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23331 SUP HCPCS C2617 G23331 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23332 SUP HCPCS C2617 G23332 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23333 SUP HCPCS C2617 G23333 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22-32CM STRL 145CM BOTH IP/OP $137.05 $101.42 $0.00 $109.64 $61.67 $61.67 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $68.53 $108.54 $109.64 $0.00 $0.00 $21.45 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 G23334 SUP HCPCS C2617 G23334 - SET STNT 2 PGTL CRV 5FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23335 SUP HCPCS C2617 G23335 - SET STNT 2 PGTL CRV 6FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23336 SUP HCPCS C2617 G23336 - SET STNT 2 PGTL CRV 7FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23337 SUP HCPCS C2617 G23337 - SET STNT 2 PGTL CRV 8FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23338 SUP HCPCS C2617 G23338 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23339 SUP HCPCS C2617 G23339 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23340 SUP HCPCS C2617 G23340 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23341 SUP HCPCS C2617 G23341 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23342 SUP HCPCS C2617 G23342 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23343 SUP HCPCS C2617 G23343 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23344 SUP HCPCS C2617 G23344 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23345 SUP HCPCS C2617 G23345 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23346 SUP HCPCS C2617 G23346 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23347 SUP HCPCS C2617 G23347 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23348 SUP HCPCS C2617 G23348 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23349 SUP HCPCS C2617 G23349 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23350 SUP HCPCS C2617 G23350 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23351 SUP HCPCS C2617 G23351 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23352 SUP HCPCS C2617 G23352 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23353 SUP HCPCS C2617 G23353 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23354 SUP HCPCS C2617 G23354 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23355 SUP HCPCS C2617 G23355 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23356 SUP HCPCS C2617 G23356 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23357 SUP HCPCS C2617 G23357 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23358 SUP HCPCS C2617 G23358 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23359 SUP HCPCS C2617 G23359 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23360 SUP HCPCS C2617 G23360 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23361 SUP HCPCS C2617 G23361 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23362 SUP HCPCS C2617 G23362 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23363 SUP HCPCS C2617 G23363 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23365 SUP HCPCS C2617 G23365 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $137.05 $101.42 $0.00 $109.64 $61.67 $61.67 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $68.53 $108.54 $109.64 $0.00 $0.00 $21.45 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 G23366 SUP HCPCS C2617 G23366 - SET STNT 2 PGTL CRV 5FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23367 SUP HCPCS C2617 G23367 - SET STNT 2 PGTL CRV 5FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23368 SUP HCPCS C2617 G23368 - SET STNT 2 PGTL CRV 5FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23369 SUP HCPCS C2617 G23369 - SET STNT 2 PGTL CRV 5FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23370 SUP HCPCS C2617 G23370 - SET STNT 2 PGTL CRV 5FR 28CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23371 SUP HCPCS C2617 G23371 - SET STNT 2 PGTL CRV 5FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23372 SUP HCPCS C2617 G23372 - SET STNT 2 PGTL CRV 6FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23373 SUP HCPCS C2617 G23373 - SET STNT 2 PGTL CRV 6FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23374 SUP HCPCS C2617 G23374 - SET STNT 2 PGTL CRV 6FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23376 SUP HCPCS C2617 G23376 - SET STNT 2 PGTL CRV 6FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23377 SUP HCPCS C2617 G23377 - SET STNT 2 PGTL CRV 6FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23378 SUP HCPCS C2617 G23378 - SET STNT 2 PGTL CRV 6FR 28CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23379 SUP HCPCS C2617 G23379 - SET STNT 2 PGTL CRV 6FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23380 SUP HCPCS C2617 G23380 - SET STNT 2 PGTL CRV 7FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23381 SUP HCPCS C2617 G23381 - SET STNT 2 PGTL CRV 7FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23382 SUP HCPCS C2617 G23382 - SET STNT 2 PGTL CRV 7FR 22CM STRL UNIVERSA RADOPQ GRAD PSTNR BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23383 SUP HCPCS C2617 G23383 - STENT URET 2 PGTL CRV 7FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23384 SUP HCPCS C2617 G23384 - STENT URET 2 PGTL CRV 7FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23385 SUP HCPCS C2617 G23385 - SET STNT 2 PGTL CRV 7FR 28CM STRL UNIVERSA RADOPQ GRAD PSTNR BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23386 SUP HCPCS C2617 G23386 - SET STNT 2 PGTL CRV 7FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23387 SUP HCPCS C2617 G23387 - SET STNT 2 PGTL CRV 8FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23388 SUP HCPCS C2617 G23388 - SET STNT 2 PGTL CRV 8FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23389 SUP HCPCS C2617 G23389 - SET STNT 2 PGTL CRV 8FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23390 SUP HCPCS C2617 G23390 - SET STNT 2 PGTL CRV 8FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23391 SUP HCPCS C2617 G23391 - SET STNT 2 PGTL CRV 8FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23392 SUP HCPCS C2617 G23392 - SET STNT 2 PGTL CRV 8FR 28CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23395 SUP HCPCS C2617 G23395 - SET STNT 2 PGTL CRV 8FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23396 SUP HCPCS C2617 G23396 - STENT URET 5FR 20CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23397 SUP HCPCS C2617 G23397 - SET STNT 2 PGTL CRV 5FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23398 SUP HCPCS C2617 G23398 - SET STNT 2 PGTL CRV 5FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23399 SUP HCPCS C2617 G23399 - STENT URET 5FR 26CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23400 SUP HCPCS C2617 G23400 - STENT URET 5FR 28CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23401 SUP HCPCS C2617 G23401 - SET STNT 2 PGTL CRV 5FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23402 SUP HCPCS C2617 G23402 - SET STNT 2 PGTL CRV 6FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23404 SUP HCPCS C2617 G23404 - SET STNT 2 PGTL CRV 6FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23405 SUP HCPCS C2617 G23405 - STENT URET 6FR 22CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23406 SUP HCPCS C2617 G23406 - SET STNT 2 PGTL CRV 6FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23407 SUP HCPCS C2617 G23407 - STENT URET 6FR 26CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23408 SUP HCPCS C2617 G23408 - STENT URET 6FR 28CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23411 SUP HCPCS C2617 G23411 - STENT URET 6FR 30CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23412 SUP HCPCS C2617 G23412 - SET STNT 2 PGTL CRV 7FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23413 SUP HCPCS C2617 G23413 - SET STNT 2 PGTL CRV 7FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23415 SUP HCPCS C2617 G23415 - SET STNT 2 PGTL CRV 7FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23416 SUP HCPCS C2617 G23416 - STENT URET 7FR 24CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23417 SUP HCPCS C2617 G23417 - STENT URET 7FR 26CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23418 SUP HCPCS C2617 G23418 - STENT URET 7FR 28CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23419 SUP HCPCS C2617 G23419 - SET STNT 2 PGTL CRV 7FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23420 SUP HCPCS C2617 G23420 - SET STNT 2 PGTL CRV 8FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23421 SUP HCPCS C2617 G23421 - SET STNT 2 PGTL CRV 8FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23422 SUP HCPCS C2617 G23422 - SET STNT 2 PGTL CRV 8FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23423 SUP HCPCS C2617 G23423 - STENT URET 8FR 24CM STRL UNIVERSA FIRM PSTNR NO GW MFL TETH BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23424 SUP HCPCS C2617 G23424 - SET STNT 2 PGTL CRV 8FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23425 SUP HCPCS C2617 G23425 - SET STNT 2 PGTL CRV 8FR 28CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23428 SUP HCPCS C2617 G23428 - SET STNT 2 PGTL CRV 8FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23429 SUP HCPCS C2617 G23429 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23430 SUP HCPCS C2617 G23430 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23431 SUP HCPCS C2617 G23431 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23432 SUP HCPCS C2617 G23432 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23433 SUP HCPCS C2617 G23433 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23434 SUP HCPCS C2617 G23434 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23435 SUP HCPCS C2617 G23435 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23436 SUP HCPCS C2617 G23436 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23437 SUP HCPCS C2617 G23437 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23438 SUP HCPCS C2617 G23438 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23439 SUP HCPCS C2617 G23439 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23440 SUP HCPCS C2617 G23440 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23441 SUP HCPCS C2617 G23441 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23442 SUP HCPCS C2617 G23442 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23443 SUP HCPCS C2617 G23443 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23444 SUP HCPCS C2617 G23444 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23445 SUP HCPCS C2617 G23445 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23446 SUP HCPCS C2617 G23446 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23447 SUP HCPCS C2617 G23447 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23448 SUP HCPCS C2617 G23448 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23449 SUP HCPCS C2617 G23449 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23450 SUP HCPCS C2617 G23450 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23451 SUP HCPCS C2617 G23451 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23452 SUP HCPCS C2617 G23452 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23453 SUP HCPCS C2617 G23453 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23454 SUP HCPCS C2617 G23454 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23455 SUP HCPCS C2617 G23455 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $137.05 $101.42 $0.00 $109.64 $61.67 $61.67 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $68.53 $108.54 $109.64 $0.00 $0.00 $21.45 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 G23456 SUP HCPCS C2617 G23456 - SET STNT 2 PGTL CRV 5FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23457 SUP HCPCS C2617 G23457 - SET STNT 2 PGTL CRV 5FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23458 SUP HCPCS C2617 G23458 - SET STNT 2 PGTL CRV 5FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23459 SUP HCPCS C2617 G23459 - SET STNT 2 PGTL CRV 5FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23460 SUP HCPCS C2617 G23460 - SET STNT 2 PGTL CRV 5FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23461 SUP HCPCS C2617 G23461 - SET STNT 2 PGTL CRV 5FR 28CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23462 SUP HCPCS C2617 G23462 - SET STNT 2 PGTL CRV 5FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23463 SUP HCPCS C2617 G23463 - SET STNT 2 PGTL CRV 6FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23464 SUP HCPCS C2617 G23464 - SET STNT 2 PGTL CRV 6FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23465 SUP HCPCS C2617 G23465 - SET STNT 2 PGTL CRV 6FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23466 SUP HCPCS C2617 G23466 - SET STNT 2 PGTL CRV 6FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23467 SUP HCPCS C2617 G23467 - SET STNT 2 PGTL CRV 6FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23468 SUP HCPCS C2617 G23468 - SET STNT 2 PGTL CRV 6FR 28CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23469 SUP HCPCS C2617 G23469 - SET STNT 2 PGTL CRV 6FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23470 SUP HCPCS C2617 G23470 - SET STNT 2 PGTL CRV 7FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23471 SUP HCPCS C2617 G23471 - SET STNT 2 PGTL CRV 7FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23472 SUP HCPCS C2617 G23472 - SET STNT 2 PGTL CRV 7FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23473 SUP HCPCS C2617 G23473 - SET STNT 2 PGTL CRV 7FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23474 SUP HCPCS C2617 G23474 - SET STNT 2 PGTL CRV 7FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23475 SUP HCPCS C2617 G23475 - SET STNT 2 PGTL CRV 7FR 28CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23476 SUP HCPCS C2617 G23476 - SET STNT 2 PGTL CRV 7FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23477 SUP HCPCS C2617 G23477 - SET STNT 2 PGTL CRV 8FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23478 SUP HCPCS C2617 G23478 - SET STNT 2 PGTL CRV 8FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23479 SUP HCPCS C2617 G23479 - SET STNT 2 PGTL CRV 8FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23480 SUP HCPCS C2617 G23480 - SET STNT 2 PGTL CRV 8FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23481 SUP HCPCS C2617 G23481 - SET STNT 2 PGTL CRV 8FR 26CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23482 SUP HCPCS C2617 G23482 - SET STNT 2 PGTL CRV 8FR 28CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $148.75 $110.08 $0.00 $119.00 $66.94 $66.94 $0.00 $0.00 $0.00 $31.00 $110.40 $110.40 $0.00 $0.00 $31.00 $0.00 $87.99 $87.99 $0.00 $74.38 $117.81 $119.00 $0.00 $0.00 $23.28 $0.00 $0.00 $23.68 $0.00 $0.00 $0.00 $0.00 $0.00 G23483 SUP HCPCS C2617 G23483 - SET STNT .038IN 2 PGTL CRV 8FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23484 SUP HCPCS C2617 G23484 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23485 SUP HCPCS C2617 G23485 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23486 SUP HCPCS C2617 G23486 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23487 SUP HCPCS C2617 G23487 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23488 SUP HCPCS C2617 G23488 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23489 SUP HCPCS C2617 G23489 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23490 SUP HCPCS C2617 G23490 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23491 SUP HCPCS C2617 G23491 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23492 SUP HCPCS C2617 G23492 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23493 SUP HCPCS C2617 G23493 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23494 SUP HCPCS C2617 G23494 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23495 SUP HCPCS C2617 G23495 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23496 SUP HCPCS C2617 G23496 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23497 SUP HCPCS C2617 G23497 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23498 SUP HCPCS C2617 G23498 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23499 SUP HCPCS C2617 G23499 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23500 SUP HCPCS C2617 G23500 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23501 SUP HCPCS C2617 G23501 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23502 SUP HCPCS C2617 G23502 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23503 SUP HCPCS C2617 G23503 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23504 SUP HCPCS C2617 G23504 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23505 SUP HCPCS C2617 G23505 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23506 SUP HCPCS C2617 G23506 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23507 SUP HCPCS C2617 G23507 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23508 SUP HCPCS C2617 G23508 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23509 SUP HCPCS C2617 G23509 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23510 SUP HCPCS C2617 G23510 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23511 SUP HCPCS C2617 G23511 - SET STNT .038IN 2 PGTL CRV 8FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $137.05 $101.42 $0.00 $109.64 $61.67 $61.67 $0.00 $0.00 $0.00 $28.56 $101.72 $101.72 $0.00 $0.00 $28.56 $0.00 $81.07 $81.07 $0.00 $68.53 $108.54 $109.64 $0.00 $0.00 $21.45 $0.00 $0.00 $21.82 $0.00 $0.00 $0.00 $0.00 $0.00 G23512 SUP HCPCS C2617 G23512 - SET STNT 2 PGTL CRV 5FR 22-32CM STRL 145CM UNIVERSA RADOPQ BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G23523 SUP Custom 27803010 G23523 - COIL EMBOLIZATION 3MM 7CM 7.4 LOOP NESTER PLATINUM SYNTH BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23552 SUP Custom 27203010 G23552 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 22-32CM STRL 145CM BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23553 SUP Custom 27203010 G23553 - FIBER LSR 20W 365UM RD STRL SMARTSYNC CNCT HO DISP RHPSD BOTH IP/OP "$2,367.30 " "$1,751.80" $0.00 "$1,893.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.01" "$1,757.01" $0.00 $0.00 $493.35 $0.00 $0.00 $0.00 $0.00 "$1,183.65" "$1,874.90" "$1,893.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23665 SUP Custom 27203010 G23665 - LASER SRG 230V 10AMP RHPSD H-30 HL-30B BOTH IP/OP "$2,231.25 " "$1,651.13" $0.00 "$1,785.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,656.03" "$1,656.03" $0.00 $0.00 $464.99 $0.00 $0.00 $0.00 $0.00 "$1,115.63" "$1,767.15" "$1,785.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23666 SUP Custom 27203010 G23666 - FIBER LSR 940UM CK HO BOTH IP/OP "$1,168.75 " $864.88 $0.00 $935.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $867.45 $867.45 $0.00 $0.00 $243.57 $0.00 $0.00 $0.00 $0.00 $584.38 $925.65 $935.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23667 SUP Custom 27203010 G23667 - FIBER LSR 550UM CK HO BOTH IP/OP "$1,009.38 " $746.94 $0.00 $807.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.16 $749.16 $0.00 $0.00 $210.35 $0.00 $0.00 $0.00 $0.00 $504.69 $799.43 $807.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23668 SUP Custom 27203010 G23668 - FIBER LSR 365UM CK HO BOTH IP/OP "$1,593.75 " "$1,179.38" $0.00 "$1,275.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,182.88" "$1,182.88" $0.00 $0.00 $332.14 $0.00 $0.00 $0.00 $0.00 $796.88 "$1,262.25" "$1,275.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23731 SUP Custom 27203010 G23731 - FIBER LSR 273UM CK HO BOTH IP/OP "$2,921.25 " "$2,161.73" $0.00 "$2,337.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,168.15" "$2,168.15" $0.00 $0.00 $608.79 $0.00 $0.00 $0.00 $0.00 "$1,460.63" "$2,313.63" "$2,337.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23733 SUP Custom 27203010 G23733 - FIBER LSR 150UM CK HO BOTH IP/OP $849.10 $628.33 $0.00 $679.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $630.20 $630.20 $0.00 $0.00 $176.95 $0.00 $0.00 $0.00 $0.00 $424.55 $672.49 $679.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23734 SUP Custom 27203010 G23734 - FIBER LSR 200UM RD STRL SMARTSYNC CNCT HO DISP RHPSD H-30 BOTH IP/OP $953.25 $705.41 $0.00 $762.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $707.50 $707.50 $0.00 $0.00 $198.66 $0.00 $0.00 $0.00 $0.00 $476.63 $754.97 $762.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G23735 SUP Custom 27203010 G23735 - FIBER LSR 550UM RD STRL SMARTSYNC CNCT HO DISP RHPSD H-30 BOTH IP/OP "$1,578.50 " "$1,168.09" $0.00 "$1,262.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,171.56" "$1,171.56" $0.00 $0.00 $328.96 $0.00 $0.00 $0.00 $0.00 $789.25 "$1,250.17" "$1,262.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G24129 SUP HCPCS C1769 G24129 - SET INTRO .018IN .087IN 5.5CM GW SUBMANDIBULAR SLVA DCT BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $210.41 $210.41 $0.00 $0.00 $0.00 $80.76 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $229.21 $229.21 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $60.64 $0.00 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $0.00 G24132 SUP HCPCS C1769 G24132 - SET INTRO .018IN .074IN 5.5CM GW SUBMANDIBULAR SLVA DCT BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $210.41 $210.41 $0.00 $0.00 $0.00 $80.76 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $229.21 $229.21 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $60.64 $0.00 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $0.00 G24889 SUP HCPCS C1874 G24889 - STENT VASCULAR 60MM DRUG ELUTING OTW DELIVERY SYSTEM ZILVER BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 G24890 SUP HCPCS C1874 G24890 - STENT VASCULAR 80MM DRUG ELUTING SELF EXPANDING GWIRE ZILVER BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 G24894 SUP HCPCS C1874 G24894 - STENT VASCULAR 60MM DRUG ELUTING OTW DELIVERY SYSTEM ZILVER BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 G24895 SUP HCPCS C1874 G24895 - STENT VASC .035IN 7MM 6FR 80MM 125CM ZL PTX DRG ELUT SLF XPD BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 G24935 SUP HCPCS C1874 G24935 - STENT VASCULAR 100MM DRUG ELUTING OTW SELF EXPAND ZILVER PTX BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 G24937 SUP HCPCS C1874 G24937 - STENT VASCULAR 100MM DRUG ELUTING OTW DELIVERY SYSTEM ZILVER BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 G25292 SUP Custom 27203010 G25292 - SYSTEM LTHTRP UNV 11.6FR 5FR 38CM STRL LITHASSIST TUO 2 LUM BOTH IP/OP "$2,666.15 " "$1,972.95" $0.00 "$2,132.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,978.82" "$1,978.82" $0.00 $0.00 $555.63 $0.00 $0.00 $0.00 $0.00 "$1,333.08" "$2,111.59" "$2,132.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25293 SUP Custom 27203010 G25293 - FIBER LSR CK HO DISP BOTH IP/OP $802.58 $593.91 $0.00 $642.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $595.67 $595.67 $0.00 $0.00 $167.26 $0.00 $0.00 $0.00 $0.00 $401.29 $635.64 $642.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25294 SUP Custom 27203010 G25294 - FIBER LSR 200UM CK HO DISP BOTH IP/OP $659.25 $487.85 $0.00 $527.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.30 $489.30 $0.00 $0.00 $137.39 $0.00 $0.00 $0.00 $0.00 $329.63 $522.13 $527.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25295 SUP Custom 27203010 G25295 - FIBER LSR HO HO DISP BOTH IP/OP $659.25 $487.85 $0.00 $527.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.30 $489.30 $0.00 $0.00 $137.39 $0.00 $0.00 $0.00 $0.00 $329.63 $522.13 $527.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25296 SUP Custom 27203010 G25296 - FIBER LSR 365UM RD SMARTSYNC HO DISP STD SMA CNCT BOTH IP/OP $857.93 $634.87 $0.00 $686.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $636.75 $636.75 $0.00 $0.00 $178.79 $0.00 $0.00 $0.00 $0.00 $428.96 $679.48 $686.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25297 SUP Custom 27203010 G25297 - FIBER LSR 550UM CK HO DISP BOTH IP/OP "$1,420.65 " "$1,051.28" $0.00 "$1,136.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,054.41" "$1,054.41" $0.00 $0.00 $296.06 $0.00 $0.00 $0.00 $0.00 $710.33 "$1,125.15" "$1,136.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25298 SUP Custom 27203010 G25298 - FIBER LSR 940UM RD SMARTSYNC HO DISP STD SMA CNCT BOTH IP/OP $531.25 $393.13 $0.00 $425.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $394.29 $394.29 $0.00 $0.00 $110.71 $0.00 $0.00 $0.00 $0.00 $265.63 $420.75 $425.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25299 SUP Custom 27203010 G25299 - FIBER LSR 273UM CK MU HO BOTH IP/OP "$1,009.38 " $746.94 $0.00 $807.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.16 $749.16 $0.00 $0.00 $210.35 $0.00 $0.00 $0.00 $0.00 $504.69 $799.43 $807.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25300 SUP Custom 27203010 G25300 - FIBER LSR 365UM CK MU HO BOTH IP/OP "$1,168.75 " $864.88 $0.00 $935.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $867.45 $867.45 $0.00 $0.00 $243.57 $0.00 $0.00 $0.00 $0.00 $584.38 $925.65 $935.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25301 SUP Custom 27203010 G25301 - FIBER LSR 550UM CK MU HO BOTH IP/OP "$2,231.25 " "$1,651.13" $0.00 "$1,785.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,656.03" "$1,656.03" $0.00 $0.00 $464.99 $0.00 $0.00 $0.00 $0.00 "$1,115.63" "$1,767.15" "$1,785.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25507 SUP Custom 27203010 G25507 - NEEDLE ENDSCP 0-8CM 19GA 5.2FR 138-140CM SFT TIS US SHTH Q BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.43 $482.43 $0.00 $0.00 $135.46 $0.00 $0.00 $0.00 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25668 SUP Custom 27203010 G25668 - LGTR 15MM SHORTSHOT SA HMRHD 4 BAND NONSTRL DISP ENDSCP BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G25981 SUP HCPCS C1894 G25981 - BUNDLE FO 150CM VUEOPTIC BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $95.57 $95.57 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 G26124 SUP Custom 27203010 G26124 - INTRODUCER SPBC 10FR 14FR 17CM 20CM 1STP DRN CATH DIL TROC BOTH IP/OP $536.58 $397.07 $0.00 $429.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $398.25 $398.25 $0.00 $0.00 $111.82 $0.00 $0.00 $0.00 $0.00 $268.29 $424.97 $429.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G26574 SUP HCPCS C1726 G26574 - SET SPINAL MICROCOMPRESSION BROWN 4FR TRIGEMINAL GANGLION BOTH IP/OP "$1,027.00 " $759.98 $0.00 $821.60 $557.66 $557.66 $0.00 $0.00 $0.00 $214.05 $762.24 $762.24 $0.00 $0.00 $214.03 $0.00 $607.47 $607.47 $0.00 $513.50 $813.38 $821.60 $0.00 $0.00 $160.73 $0.00 $0.00 $163.50 $0.00 $0.00 $0.00 $0.00 $0.00 G26642 SUP HCPCS C1894 G26642 - EXTRACTOR STON 5CM 7FR 6MM 65CM 4CM RTNR 3WR HLCL BLN BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $95.57 $95.57 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 G26648 SUP HCPCS C1894 G26648 - INTRODUCER SPBC 10FR 16FR 17CM 20CM 1STP DRN CATH DIL TROC BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $95.57 $95.57 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 G26655 SUP HCPCS C1894 G26655 - INTRODUCER SPBC 12FR 18FR 17CM 20CM 1STP DRN CATH DIL TROC BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $95.57 $95.57 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 G26666 SUP HCPCS C1894 G26666 - INTRODUCER SPBC 16FR 20- FR 17CM 20CM PLWY 1 STP DIL TROC BOTH IP/OP $176.00 $130.24 $0.00 $140.80 $95.57 $95.57 $0.00 $0.00 $0.00 $36.68 $130.63 $130.63 $0.00 $0.00 $36.68 $0.00 $104.10 $104.10 $0.00 $88.00 $139.39 $140.80 $0.00 $0.00 $27.54 $0.00 $0.00 $28.02 $0.00 $0.00 $0.00 $0.00 $0.00 G26891 SUP HCPCS C1725 G26891 - CATHETER BLNDIL 4MM 80CM STRL 2CM ATB ADV 2 LUM XPD RADOPQ BOTH IP/OP $277.75 $205.54 $0.00 $220.00 $149.33 $149.33 $0.00 $0.00 $0.00 $57.89 $206.15 $206.15 $0.00 $0.00 $57.88 $0.00 $164.29 $164.29 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $43.04 $0.00 $0.00 $43.78 $0.00 $0.00 $0.00 $0.00 $0.00 G26908 SUP HCPCS C1726 G26908 - SET ENDSCP INSTR BILE DUCT ADPR CATH STON XTRT XPLR STRL BOTH IP/OP "$1,980.00 " "$1,465.20" $0.00 "$1,584.00" "$1,075.14" "$1,075.14" $0.00 $0.00 $0.00 $412.68 "$1,469.56" "$1,469.56" $0.00 $0.00 $412.63 $0.00 "$1,171.17" "$1,171.17" $0.00 $990.00 "$1,568.16" "$1,584.00" $0.00 $0.00 $309.87 $0.00 $0.00 $315.22 $0.00 $0.00 $0.00 $0.00 $0.00 G26957 SUP HCPCS C1769 G26957 - GUIDEWIRE VASCULAR 10MM RAD .035IN 110CM REUTER TIP BOTH IP/OP $215.63 $159.57 $0.00 $160.04 $101.81 $101.81 $0.00 $0.00 $0.00 $44.94 $160.04 $160.04 $0.00 $0.00 $44.94 $0.00 $127.54 $127.54 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G26973 SUP HCPCS C1725 G26973 - CATH ANGIO 5FR .35IN 90CM VSCR SUP VIS GRADUAL TRNS OF BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $17.65 $17.65 $0.00 $0.00 $0.00 $6.77 $24.12 $24.12 $0.00 $0.00 $6.77 $0.00 $19.22 $19.22 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $5.09 $0.00 $0.00 $5.17 $0.00 $0.00 $0.00 $0.00 $0.00 G26986 SUP HCPCS C1770 G26986 - COIL EMBOLIZATION .018IN 10MM 14CM 4.5 LOOP SOFT RADIOPACITY BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G26989 SUP HCPCS C1770 G26989 - COIL EMBOLIZATION .018IN 6MM 14CM 7.4 LOOP SOFT RADIOPACITY BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G26990 SUP HCPCS C1770 G26990 - COIL EMBOLIZATION .018IN 8MM 14CM 5.6 LOOP SOFT RADIOPACITY BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G26991 SUP Custom 27203010 G26991 - COIL EMBOLIZATION .035IN 10MM 14CM 4.5 LOOP SOFT NESTER BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G26994 SUP Custom 27803010 G26994 - COIL EMBOLIZATION .035IN 7.4 LOOP 6MM 14CM SOFT CATHETER BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G26995 SUP HCPCS C1770 G26995 - COIL EMBOLIZATION .035IN 5.6 LOOPS 8MM 14CM SOFT CATHETER BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G27035 SUP HCPCS C1769 G27035 - GUIDEWIRE VASCULAR STR .035IN 260CM FLEXIBLE TIP STIFF SHAFT BOTH IP/OP $89.70 $66.38 $0.00 $69.00 $46.83 $46.83 $0.00 $0.00 $0.00 $18.70 $66.58 $66.58 $0.00 $0.00 $18.69 $0.00 $53.06 $53.06 $0.00 $43.13 $68.31 $69.00 $0.00 $0.00 $13.50 $0.00 $0.00 $13.73 $0.00 $0.00 $0.00 $0.00 $0.00 G27047 SUP Custom 27203010 G27047 - CATH JJNSTM 80CM 16.5FR CR-ALZT-CNS 2 LUM REPL STRL DISP BOTH IP/OP $180.35 $133.46 $0.00 $144.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.86 $133.86 $0.00 $0.00 $37.58 $0.00 $0.00 $0.00 $0.00 $90.18 $142.84 $144.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G27059 SUP HCPCS C2617 G27059 - INTRODUCER SPBC 18FR 22FR 17CM 20CM 1STP DRN CATH DIL TROC BOTH IP/OP $253.45 $187.55 $0.00 $202.76 $114.05 $114.05 $0.00 $0.00 $0.00 $52.83 $188.11 $188.11 $0.00 $0.00 $52.82 $0.00 $149.92 $149.92 $0.00 $126.73 $200.73 $202.76 $0.00 $0.00 $39.66 $0.00 $0.00 $40.35 $0.00 $0.00 $0.00 $0.00 $0.00 G27061 SUP HCPCS C1729 G27061 - SET STNT 2 PGTL CRV 8.2FR 40CM RADOPQ PSTNR SFLX URETER BOTH IP/OP $150.55 $111.41 $0.00 $120.44 $81.75 $81.75 $0.00 $0.00 $0.00 $31.38 $111.74 $111.74 $0.00 $0.00 $31.37 $0.00 $89.05 $89.05 $0.00 $75.28 $119.24 $120.44 $0.00 $0.00 $23.56 $0.00 $0.00 $23.97 $0.00 $0.00 $0.00 $0.00 $0.00 G27063 SUP HCPCS C2617 G27063 - SET NPHSTM 12FR 30CM COPE LOOP MOD NDL GW CNN DIL BOTH IP/OP $365.43 $270.42 $0.00 $292.34 $164.44 $164.44 $0.00 $0.00 $0.00 $76.16 $271.22 $271.22 $0.00 $0.00 $76.15 $0.00 $216.15 $216.15 $0.00 $182.71 $289.42 $292.34 $0.00 $0.00 $57.19 $0.00 $0.00 $58.18 $0.00 $0.00 $0.00 $0.00 $0.00 G27161 SUP HCPCS C2617 G27161 - STENT PANCREATIC 5FR 14CM DRAIN OBSTRUCTED POSITIONING BOTH IP/OP $177.50 $131.35 $0.00 $142.00 $79.88 $79.88 $0.00 $0.00 $0.00 $37.00 $131.74 $131.74 $0.00 $0.00 $36.99 $0.00 $104.99 $104.99 $0.00 $88.75 $140.58 $142.00 $0.00 $0.00 $27.78 $0.00 $0.00 $28.26 $0.00 $0.00 $0.00 $0.00 $0.00 G27234 SUP Custom 27203010 G27234 - DEVICE STNT RTRVL 4.5FR 65CM NSNARE FLXB NTNL WRE CNSTRCT BOTH IP/OP $289.10 $213.93 $0.00 $231.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.57 $214.57 $0.00 $0.00 $60.25 $0.00 $0.00 $0.00 $0.00 $144.55 $228.97 $231.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G27887 SUP HCPCS C1769 G27887 - GUIDEWIRE VASC STRG .028IN 145CM FX COR SS BOTH IP/OP $64.83 $47.97 $0.00 $51.86 $35.20 $35.20 $0.00 $0.00 $0.00 $13.51 $48.11 $48.11 $0.00 $0.00 $13.51 $0.00 $38.34 $38.34 $0.00 $32.41 $51.35 $51.86 $0.00 $0.00 $10.15 $0.00 $0.00 $10.32 $0.00 $0.00 $0.00 $0.00 $0.00 G28999 SUP HCPCS C1894 G28999 - INTRODUCER CATHETER 25CM SET CHK-FLO 20FR BOTH IP/OP $847.50 $627.15 $0.00 $678.00 $460.19 $460.19 $0.00 $0.00 $0.00 $176.64 $629.01 $629.01 $0.00 $0.00 $176.62 $0.00 $501.30 $501.30 $0.00 $423.75 $671.22 $678.00 $0.00 $0.00 $132.63 $0.00 $0.00 $134.92 $0.00 $0.00 $0.00 $0.00 $0.00 G29965 SUP HCPCS C1769 GUIDE WIRE .035IN X 80CM X 10CM REFLECTOR REUTER TIP DEFLECT BOTH IP/OP $161.00 $119.14 $0.00 $128.80 $87.42 $87.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.50 $127.51 $128.80 $0.00 $0.00 $25.20 $0.00 $0.00 $25.63 $0.00 $0.00 $0.00 $0.00 $0.00 G29982 SUP HCPCS C1894 G29982 - SHEATH GUID .018/.038IN ANL1 CURVE 6FR .087IN 45CM RADIOPQ BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G29983 SUP HCPCS C1894 G29983 - SHEATH GUID .018/.038IN ANL2 CURVE 6FR .087IN 45CM RADIOPQ BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G29985 SUP HCPCS C1894 G29985 - SHEATH GUID ANL1 CURVE 7FR .100IN 45CM UNIQUELY FABRICATED BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G29986 SUP HCPCS C1894 G29986 - SHEATH GUID .018/.038IN ANL2 CURVE 7FR .1IN 45CM RADIOPQ BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G29989 SUP HCPCS C1894 G29989 - SHEATH GUID .018-.038IN ANL2 CURVE 6FR .087IN 90CM RADIOPQ BOTH IP/OP $392.60 $290.52 $0.00 $302.00 $204.98 $204.98 $0.00 $0.00 $0.00 $81.83 $291.39 $291.39 $0.00 $0.00 $81.82 $0.00 $232.22 $232.22 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 G30117 SUP HCPCS C1894 G30117 - INTRODUCER SHEATH .018 .038IN ANL2 CURVE 5FR .074IN 45CM BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G30357 SUP HCPCS C1726 G30357 - POUCH DRN 300ML NS ELC BELT ADJ 1 CNCT 2 TUBE REED VLV MECH BOTH IP/OP $618.80 $457.91 $0.00 $495.04 $336.01 $336.01 $0.00 $0.00 $0.00 $128.97 $459.27 $459.27 $0.00 $0.00 $128.96 $0.00 $366.02 $366.02 $0.00 $309.40 $490.09 $495.04 $0.00 $0.00 $96.84 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 G30358 SUP HCPCS C1726 G30358 - EXTRACTOR SRG 12FR 38CM STRL PRC NC STON TPLS ATRM NTNL DISP BOTH IP/OP $519.35 $384.32 $0.00 $415.48 $282.01 $282.01 $0.00 $0.00 $0.00 $108.25 $385.46 $385.46 $0.00 $0.00 $108.23 $0.00 $307.20 $307.20 $0.00 $259.68 $411.33 $415.48 $0.00 $0.00 $81.28 $0.00 $0.00 $82.68 $0.00 $0.00 $0.00 $0.00 $0.00 G30360 SUP HCPCS C1773 G30360 - CATHETER NPHSTM 10MM 15CM CLR ULTRX TRNS TPR BLN RADOPQ STRP BOTH IP/OP $419.70 $310.58 $0.00 $335.76 $227.90 $227.90 $0.00 $0.00 $0.00 $87.48 $311.50 $311.50 $0.00 $0.00 $87.47 $0.00 $248.25 $248.25 $0.00 $209.85 $332.40 $335.76 $0.00 $0.00 $65.68 $0.00 $0.00 $66.82 $0.00 $0.00 $0.00 $0.00 $0.00 G30361 SUP HCPCS C1773 G30361 - FORCEPS SPEC RTRVL 15MM 3.2FR 115CM STRL CPTR 3 PR STON FB BOTH IP/OP $419.70 $310.58 $0.00 $335.76 $227.90 $227.90 $0.00 $0.00 $0.00 $87.48 $311.50 $311.50 $0.00 $0.00 $87.47 $0.00 $248.25 $248.25 $0.00 $209.85 $332.40 $335.76 $0.00 $0.00 $65.68 $0.00 $0.00 $66.82 $0.00 $0.00 $0.00 $0.00 $0.00 G30362 SUP HCPCS C1773 G30362 - GRASPER ESCP 2.8FR 15MM 115CM CPTR 3 PR OPN WD MICROTHROW BOTH IP/OP $419.70 $310.58 $0.00 $335.76 $227.90 $227.90 $0.00 $0.00 $0.00 $87.48 $311.50 $311.50 $0.00 $0.00 $87.47 $0.00 $248.25 $248.25 $0.00 $209.85 $332.40 $335.76 $0.00 $0.00 $65.68 $0.00 $0.00 $66.82 $0.00 $0.00 $0.00 $0.00 $0.00 G30364 SUP HCPCS C1726 G30364 - CATHETER NEPHROSTOMY 20 ATM 10MM 15CM INFLATE BALLOON SHEATH BOTH IP/OP $519.35 $384.32 $0.00 $415.48 $282.01 $282.01 $0.00 $0.00 $0.00 $108.25 $385.46 $385.46 $0.00 $0.00 $108.23 $0.00 $307.20 $307.20 $0.00 $259.68 $411.33 $415.48 $0.00 $0.00 $81.28 $0.00 $0.00 $82.68 $0.00 $0.00 $0.00 $0.00 $0.00 G30365 SUP HCPCS C1726 G30365 - SET NEPHROSTOMY 10MM 15CM CATHETER RADIOPQ BALLOON SHEATH BOTH IP/OP $618.80 $457.91 $0.00 $495.04 $336.01 $336.01 $0.00 $0.00 $0.00 $128.97 $459.27 $459.27 $0.00 $0.00 $128.96 $0.00 $366.02 $366.02 $0.00 $309.40 $490.09 $495.04 $0.00 $0.00 $96.84 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 G30375 SUP HCPCS C1773 G30375 - FORCEPS SPEC RTRVL 15MM 3.2FR 90CM STRL CPTR 3 PR STON FB BOTH IP/OP $482.65 $357.16 $0.00 $386.12 $262.08 $262.08 $0.00 $0.00 $0.00 $100.60 $358.22 $358.22 $0.00 $0.00 $100.58 $0.00 $285.49 $285.49 $0.00 $241.33 $382.26 $386.12 $0.00 $0.00 $75.53 $0.00 $0.00 $76.84 $0.00 $0.00 $0.00 $0.00 $0.00 G30389 SUP HCPCS C1894 G30389 - SHEATH ACCES 14FR 35CM DILATION CONTIN WORKING CHANNEL BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G30390 SUP HCPCS C1894 G30390 - FORCEPS SPEC RTRVL 15MM 2.8FR 115CM STRL CPTR 3 PR STON FB BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G30391 SUP HCPCS C1894 G30391 - SHEATH ACC 14FR 55CM STRL FLXR DILATION CNT WRK CHNL AQ URET BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G30393 SUP HCPCS C1894 G30393 - SHEATH ACC 14FR 20CM FLXR DILATION CNT WKG CHNL URET BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G30403 SUP HCPCS C2627 G30403 - SHEATH ACC 14FR 28CM FLXR DILATION CNT WKG CHNL LFRIC SM BOTH IP/OP $166.10 $122.91 $0.00 $132.88 $90.19 $90.19 $0.00 $0.00 $0.00 $0.00 $123.28 $123.28 $0.00 $0.00 $34.62 $0.00 $0.00 $0.00 $0.00 $83.05 $131.55 $132.88 $0.00 $0.00 $25.99 $0.00 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $0.00 G30404 SUP HCPCS C2627 G30404 - SET CATH 8.5FR 25CM MCLC NDL OBT CNN CNCT TUBE ULTHNE SPBC BOTH IP/OP $166.10 $122.91 $0.00 $132.88 $90.19 $90.19 $0.00 $0.00 $0.00 $0.00 $123.28 $123.28 $0.00 $0.00 $34.62 $0.00 $0.00 $0.00 $0.00 $83.05 $131.55 $132.88 $0.00 $0.00 $25.99 $0.00 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $0.00 G30405 SUP HCPCS C2627 G30405 - SET CATH 12FR 25CM MCLC NDL OBT CNN CNCT TUBE ULTHNE SPBC BOTH IP/OP $166.10 $122.91 $0.00 $132.88 $90.19 $90.19 $0.00 $0.00 $0.00 $0.00 $123.28 $123.28 $0.00 $0.00 $34.62 $0.00 $0.00 $0.00 $0.00 $83.05 $131.55 $132.88 $0.00 $0.00 $25.99 $0.00 $0.00 $26.44 $0.00 $0.00 $0.00 $0.00 $0.00 G30470 SUP HCPCS C1769 G30470 - SET CATH 14FR 25CM MCLC NDL OBT CNN CNCT TUBE LCK LOOP BOTH IP/OP $595.83 $440.91 $0.00 $476.66 $323.53 $323.53 $0.00 $0.00 $0.00 $124.18 $442.22 $442.22 $0.00 $0.00 $124.17 $0.00 $352.43 $352.43 $0.00 $297.91 $471.90 $476.66 $0.00 $0.00 $93.25 $0.00 $0.00 $94.86 $0.00 $0.00 $0.00 $0.00 $0.00 G30471 SUP HCPCS C1769 G30471 - GUIDEWIRE VASCULAR .038IN 150CM 3CM STIFF ANGLED TIP CORE BOTH IP/OP $119.17 $88.19 $0.00 $95.33 $64.71 $64.71 $0.00 $0.00 $0.00 $24.84 $88.44 $88.44 $0.00 $0.00 $24.83 $0.00 $70.49 $70.49 $0.00 $59.58 $94.38 $95.33 $0.00 $0.00 $18.65 $0.00 $0.00 $18.97 $0.00 $0.00 $0.00 $0.00 $0.00 G30472 SUP HCPCS C1769 G30472 - GUIDEWIRE VASC STRG TPR .038IN 150CM STRL 3CM HIWIRE 1-1 TRQ BOTH IP/OP $75.84 $56.12 $0.00 $60.67 $41.18 $41.18 $0.00 $0.00 $0.00 $15.81 $56.28 $56.28 $0.00 $0.00 $15.80 $0.00 $44.86 $44.86 $0.00 $37.92 $60.07 $60.67 $0.00 $0.00 $11.87 $0.00 $0.00 $12.07 $0.00 $0.00 $0.00 $0.00 $0.00 G30473 SUP HCPCS C1769 G30473 - GUIDEWIRE VASCULAR STANDARD STR TAPER .038IN 150CM 3CM ONE BOTH IP/OP $74.80 $55.35 $0.00 $59.84 $40.61 $40.61 $0.00 $0.00 $0.00 $15.59 $55.51 $55.51 $0.00 $0.00 $15.59 $0.00 $44.24 $44.24 $0.00 $37.40 $59.24 $59.84 $0.00 $0.00 $11.71 $0.00 $0.00 $11.91 $0.00 $0.00 $0.00 $0.00 $0.00 G30474 SUP HCPCS C1769 G30474 - GUIDEWIRE VASC STRG TPR .038IN 150CM STRL 3CM HIWIRE 1-1 TRQ BOTH IP/OP $119.17 $88.19 $0.00 $95.33 $64.71 $64.71 $0.00 $0.00 $0.00 $24.84 $88.44 $88.44 $0.00 $0.00 $24.83 $0.00 $70.49 $70.49 $0.00 $59.58 $94.38 $95.33 $0.00 $0.00 $18.65 $0.00 $0.00 $18.97 $0.00 $0.00 $0.00 $0.00 $0.00 G30475 SUP HCPCS C1769 G30475 - GUIDEWIRE VASCULAR ANGLE TAPER .035IN 150CM 3CM 1TO 1 TORQUE BOTH IP/OP $119.17 $88.19 $0.00 $95.33 $64.71 $64.71 $0.00 $0.00 $0.00 $24.84 $88.44 $88.44 $0.00 $0.00 $24.83 $0.00 $70.49 $70.49 $0.00 $59.58 $94.38 $95.33 $0.00 $0.00 $18.65 $0.00 $0.00 $18.97 $0.00 $0.00 $0.00 $0.00 $0.00 G30476 SUP HCPCS C1769 G30476 - GUIDEWIRE VASCULAR STANDARD STR TAPER .035IN 150CM 3CM 1TO 1 BOTH IP/OP $74.80 $55.35 $0.00 $59.84 $40.61 $40.61 $0.00 $0.00 $0.00 $15.59 $55.51 $55.51 $0.00 $0.00 $15.59 $0.00 $44.24 $44.24 $0.00 $37.40 $59.24 $59.84 $0.00 $0.00 $11.71 $0.00 $0.00 $11.91 $0.00 $0.00 $0.00 $0.00 $0.00 G30477 SUP HCPCS C1769 G30477 - GUIDEWIRE VASC STRG TPR .035IN 150CM 3CM HIWIRE STF BD 1 TO BOTH IP/OP $119.17 $88.19 $0.00 $95.33 $64.71 $64.71 $0.00 $0.00 $0.00 $24.84 $88.44 $88.44 $0.00 $0.00 $24.83 $0.00 $70.49 $70.49 $0.00 $59.58 $94.38 $95.33 $0.00 $0.00 $18.65 $0.00 $0.00 $18.97 $0.00 $0.00 $0.00 $0.00 $0.00 G30478 SUP HCPCS C1769 G30478 - GUIDEWIRE VASC TPR .025IN 150CM STRL 3MM HIWIRE STF BD STRG BOTH IP/OP $119.17 $88.19 $0.00 $95.33 $64.71 $64.71 $0.00 $0.00 $0.00 $24.84 $88.44 $88.44 $0.00 $0.00 $24.83 $0.00 $70.49 $70.49 $0.00 $59.58 $94.38 $95.33 $0.00 $0.00 $18.65 $0.00 $0.00 $18.97 $0.00 $0.00 $0.00 $0.00 $0.00 G30479 SUP HCPCS C1769 G30479 - GUIDEWIRE VASC TPR .025IN 150CM STRL 3MM HIWIRE STF BD ANG BOTH IP/OP $75.84 $56.12 $0.00 $60.67 $41.18 $41.18 $0.00 $0.00 $0.00 $15.81 $56.28 $56.28 $0.00 $0.00 $15.80 $0.00 $44.86 $44.86 $0.00 $37.92 $60.07 $60.67 $0.00 $0.00 $11.87 $0.00 $0.00 $12.07 $0.00 $0.00 $0.00 $0.00 $0.00 G30480 SUP HCPCS C1769 G30480 - GUIDEWIRE VASC ANG TPR .025IN 150CM STRL 3CM HIWIRE STD BD BOTH IP/OP $75.84 $56.12 $0.00 $60.67 $41.18 $41.18 $0.00 $0.00 $0.00 $15.81 $56.28 $56.28 $0.00 $0.00 $15.80 $0.00 $44.86 $44.86 $0.00 $37.92 $60.07 $60.67 $0.00 $0.00 $11.87 $0.00 $0.00 $12.07 $0.00 $0.00 $0.00 $0.00 $0.00 G30481 SUP HCPCS C1769 G30481 - GUIDEWIRE VASCULAR STANDARD ANGLE TAPER .035IN 150CM 3CM 1TO BOTH IP/OP $379.18 $280.59 $0.00 $303.34 $205.89 $205.89 $0.00 $0.00 $0.00 $79.03 $281.42 $281.42 $0.00 $0.00 $79.02 $0.00 $224.28 $224.28 $0.00 $189.59 $300.31 $303.34 $0.00 $0.00 $59.34 $0.00 $0.00 $60.36 $0.00 $0.00 $0.00 $0.00 $0.00 G31027 SUP Custom 27203010 G31027 - DEVICE SPHR 20ML EZTRD ERGONOMICAL QRLSE LOCK LVR INFLAT 30 BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G31138 SUP HCPCS C1894 G31138 - INTRODUCER SHEATH .038IN 6FR .087IN 90CM TUOHY BORST SIDEARM BOTH IP/OP $401.06 $296.78 $0.00 $310.00 $210.41 $210.41 $0.00 $0.00 $0.00 $83.59 $297.67 $297.67 $0.00 $0.00 $83.58 $0.00 $237.23 $237.23 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $60.64 $0.00 $0.00 $61.69 $0.00 $0.00 $0.00 $0.00 $0.00 G31215 SUP Custom 27203010 G31215 - CATH ANGIO .035IN PGTL 5FR 70CM SZ 10 SDPRT RADIOPQ MRKR NYL BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $0.00 $0.00 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G31216 SUP HCPCS C1884 G31216 - CATH ANGIO .035IN PGTL 5FR 100CM SZ 10 SDPRT RADIOPQ MRKR BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 G31221 SUP HCPCS C1884 G31221 - CATH ANGIO .035IN VCF CURVE 5FR 100CM 10 SDPRT RADIOPQ MRKR BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 G31518 SUP Custom 27203010 G31518 - NEEDLE ENDSCP 22GA 5.2FR 8- CM ULTRASOUND BALL TIP ADJUST BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G31519 SUP Custom 27203010 G31519 - NEEDLE ENDSCP 25GA 5.2FR 0-8CM ULTRASOUND CNTOUR HANDLE BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G31520 SUP Custom 27203010 G31520 - NEEDLE ENDSCP 19GA 5.2-4.2FR 0-8CM ULTRASOUND CNTOUR HANDLE BOTH IP/OP $730.00 $540.20 $0.00 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $541.81 $541.81 $0.00 $0.00 $152.13 $0.00 $0.00 $0.00 $0.00 $365.00 $578.16 $584.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G31550 SUP HCPCS C1894 G31550 - CATHETER PSH .035IN 5FR STRL LF FSN GW BIL DCT DISP ESCP BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $97.74 $97.74 $0.00 $0.00 $0.00 $37.52 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $106.47 $106.47 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $28.17 $0.00 $0.00 $28.66 $0.00 $0.00 $0.00 $0.00 $0.00 G31551 SUP Custom 27203010 G31551 - CATHETER ENDSCP 7FR 3.2MM 170CM DOME TIP FUSION PURPLE BOTH IP/OP $180.00 $133.20 $0.00 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.60 $133.60 $0.00 $0.00 $37.51 $0.00 $0.00 $0.00 $0.00 $90.00 $142.56 $144.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32011 SUP HCPCS C1876 G32011 - STENT BIL 6MM 6FR 30MM 80CM SLF XPD FLXB FLXR INTROD GOLD BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 G32233 SUP HCPCS C1894 G32233 - INTRODUCER SHEATH .038IN LONG 10FR 40CM LARGE VALVE ASMBLY BOTH IP/OP $192.85 $142.71 $0.00 $152.00 $103.17 $103.17 $0.00 $0.00 $0.00 $40.19 $143.13 $143.13 $0.00 $0.00 $40.19 $0.00 $114.07 $114.07 $0.00 $95.00 $150.48 $152.00 $0.00 $0.00 $29.74 $0.00 $0.00 $30.25 $0.00 $0.00 $0.00 $0.00 $0.00 G32500 SUP HCPCS C1874 G32500 - GRAFT EVAS 2 BRCH 12MM 106MM STRL 28MM H&L-B 1-SHOT ZNTH BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32501 SUP HCPCS C1874 G32501 - GRAFT EVAS 2 BRCH 12MM 7.7MM 20FR 121MM 28MM ZNTH H&L-B BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32502 SUP HCPCS C1874 G32502 - GRAFT EVAS 24MM 7.7MM 20FR 76MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32503 SUP HCPCS C1874 G32503 - GRAFT EVAS 26MM 7.7MM 20FR 76MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32504 SUP HCPCS C1874 G32504 - GRAFT EVAS 28MM 7.7MM 20FR 76MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32505 SUP HCPCS C1874 G32505 - GRAFT EVAS 30MM 7.7MM 20FR 76MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32506 SUP HCPCS C1874 G32506 - GRAFT EVAS 32MM 7.7MM 20FR 76MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32507 SUP HCPCS C1874 G32507 - GRAFT EVAS 24MM 7.7MM 20FR 91MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32508 SUP HCPCS C1874 G32508 - GRAFT EVAS 26MM 7.7MM 20FR 91MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32509 SUP HCPCS C1874 G32509 - GRAFT EVAS 28MM 7.7MM 20FR 91MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32510 SUP HCPCS C1874 G32510 - GRAFT EVAS 30MM 7.7MM 20FR 91MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32511 SUP HCPCS C1874 G32511 - GRAFT EVAS 32MM 7.7MM 20FR 91MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32512 SUP HCPCS C1874 G32512 - GRAFT EVAS 24MM 7.7MM 20FR 106MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32513 SUP HCPCS C1874 G32513 - GRAFT EVAS 26MM 7.7MM 20FR 106MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32514 SUP HCPCS C1874 G32514 - GRAFT EVAS 28MM 7.7MM 20FR 106MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32515 SUP HCPCS C1874 G32515 - GRAFT EVAS 30MM 7.7MM 20FR 106MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32516 SUP HCPCS C1874 G32516 - GRAFT EVAS 32MM 7.7MM 20FR 106MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32517 SUP HCPCS C1874 G32517 - GRAFT EVAS 24MM 7.7MM 20FR 121MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32518 SUP HCPCS C1874 G32518 - GRAFT EVAS 26MM 7.7MM 20FR 121MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32519 SUP HCPCS C1874 G32519 - GRAFT EVAS 28MM 7.7MM 20FR 121MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32520 SUP HCPCS C1874 G32520 - GRAFT EVAS 30MM 7.7MM 20FR 121MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32521 SUP HCPCS C1874 G32521 - GRAFT EVAS 32MM 7.7MM 20FR 121MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32522 SUP HCPCS C1874 G32522 - GRAFT EVAS 34MM 7.7MM 20FR 84MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32523 SUP HCPCS C1874 G32523 - GRAFT EVAS 36MM 8.5MM 20FR 84MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32524 SUP HCPCS C1874 G32524 - GRAFT EVAS 34MM 7.7MM 20FR 99MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32525 SUP HCPCS C1874 G32525 - GRAFT EVAS 36MM 8.5MM 20FR 99MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32526 SUP HCPCS C1874 G32526 - GRAFT EVAS 34MM 7.7MM 20FR 114MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32527 SUP HCPCS C1874 G32527 - GRAFT EVAS 36MM 8.5MM 20FR 114MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32528 SUP HCPCS C1874 G32528 - GRAFT EVAS 34MM 7.7MM 20FR 129MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32529 SUP HCPCS C1874 G32529 - GRAFT EVAS 36MM 8.5MM 20FR 129MM ZNTH H&L-B 1-SHOT 1 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32530 SUP HCPCS C1874 G32530 - GRAFT EVAS 24MM 7.7MM 20FR 94MM ZNTH H&L-B 1-SHOT 2 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32531 SUP HCPCS C1874 G32531 - GRAFT EVAS 26MM 7.7MM 20FR 94MM ZNTH H&L-B 1-SHOT 2 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32532 SUP HCPCS C1874 G32532 - GRAFT EVAS 20FR 94MM 28MM ZNTH VSCR FEN PROX BFUR BD AAA BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32533 SUP HCPCS C1874 G32533 - GRAFT EVAS 30MM 7.7MM 20FR 94MM ZNTH H&L-B 1-SHOT 2 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32534 SUP HCPCS C1874 G32534 - GRAFT EVAS 32MM 7.7MM 20FR 94MM ZNTH H&L-B 1-SHOT 2 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32535 SUP HCPCS C1874 G32535 - GRAFT EVAS 24MM 7.7MM 20FR 109MM ZNTH H&L-B 1-SHOT 2 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32536 SUP HCPCS C1874 G32536 - GRAFT EVAS 26MM 109MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32537 SUP HCPCS C1874 G32537 - GRAFT EVAS 28MM 109MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32538 SUP HCPCS C1874 G32538 - GRAFT EVAS 30MM 109MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32539 SUP HCPCS C1874 G32539 - GRAFT EVAS 32MM 109MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32540 SUP HCPCS C1874 G32540 - GRAFT EVAS 24MM 7.7MM 20FR 124MM ZNTH H&L-B 1-SHOT 2 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32541 SUP HCPCS C1874 G32541 - GRAFT EVAS 12FR 124MM 91MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32542 SUP HCPCS C1874 G32542 - GRAFT EVAS 2FR 124MM 28MM ZNTH FEN PROX BD AAA BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32543 SUP HCPCS C1874 G32543 - GRAFT EVAS 30MM 124MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32544 SUP HCPCS C1874 G32544 - GRAFT EVAS 32MM 124MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32545 SUP HCPCS C1874 G32545 - GRAFT EVAS 34MM 107MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32546 SUP HCPCS C1874 G32546 - GRAFT EVAS 36MM 107MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32547 SUP HCPCS C1874 G32547 - GRAFT EVAS 34MM 20FR 122MM STRL H L-B 1-SHOT ZNTH 2 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32548 SUP HCPCS C1874 G32548 - GRAFT EVAS 36MM 8.5MM 22FR 122MM ZNTH H&L-B 1-SHOT 2 PROX BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32549 SUP HCPCS C1874 G32549 - GRAFT EVAS 34MM 137MM STRL H&L-B 1-SHOT ZNTH 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32550 SUP HCPCS C1874 G32550 - GRAFT EVAS 36MM 137MM STRL ZNTH H&L-B 1-SHOT 2 PROX INTNL BOTH IP/OP "$27,500.00 " "$20,350.00" $0.00 "$22,000.00" "$12,375.00" "$12,375.00" $0.00 $0.00 $0.00 "$5,731.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,731.00" $0.00 "$13,557.50" "$13,557.50" $0.00 "$13,750.00" "$21,780.00" "$22,000.00" $0.00 $0.00 "$4,303.75" $0.00 $0.00 "$4,378.00" $0.00 $0.00 $0.00 $0.00 $0.00 G32551 SUP HCPCS C1874 G32551 - GRAFT EVAS 12FR 76MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32552 SUP HCPCS C1874 G32552 - GRAFT EVAS 16FR 76MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32553 SUP HCPCS C1874 G32553 - GRAFT EVAS 20FR 76MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32554 SUP HCPCS C1874 G32554 - GRAFT EVAS 12FR 91MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32555 SUP HCPCS C1874 G32555 - GRAFT EVAS 16FR 91MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32556 SUP HCPCS C1874 G32556 - GRAFT EVAS 20FR 91MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32557 SUP HCPCS C1874 G32557 - GRAFT EVAS 16FR 106MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32558 SUP HCPCS C1874 G32558 - GRAFT EVAS 20FR 106MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32559 SUP HCPCS C1874 G32559 - GRAFT EVAS 16FR 121MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32560 SUP HCPCS C1874 G32560 - GRAFT EVAS 20FR 121MM 28MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32561 SUP HCPCS C1874 G32561 - GRAFT EVAS 12FR 76MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32562 SUP HCPCS C1874 G32562 - GRAFT EVAS 16FR 76MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32563 SUP HCPCS C1874 G32563 - GRAFT EVAS 20FR 76MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32564 SUP HCPCS C1874 G32564 - GRAFT EVAS 24FR 76MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32565 SUP HCPCS C1874 G32565 - GRAFT EVAS 12FR 91MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32566 SUP HCPCS C1874 G32566 - GRAFT EVAS 16FR 91MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32567 SUP HCPCS C1874 G32567 - GRAFT EVAS 20FR 91MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32568 SUP HCPCS C1874 G32568 - GRAFT EVAS 24FR 91MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32569 SUP HCPCS C1874 G32569 - GRAFT EVAS 12FR 106MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32570 SUP HCPCS C1874 G32570 - GRAFT EVAS 16FR 106MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32571 SUP HCPCS C1874 G32571 - GRAFT EVAS 2 BRCH 20FR 106MM 45MM ZNTH H&L-B 1-SHOT VSCR FEN BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32572 SUP HCPCS C1874 G32572 - GRAFT EVAS 24FR 106MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32573 SUP HCPCS C1874 G32573 - GRAFT EVAS 12FR 121MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32574 SUP HCPCS C1874 G32574 - GRAFT EVAS 16FR 121MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32575 SUP HCPCS C1874 G32575 - GRAFT EVAS 20FR 121MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32576 SUP HCPCS C1874 G32576 - GRAFT EVAS 24FR 121MM 45MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32577 SUP HCPCS C1874 G32577 - GRAFT EVAS 12FR 76MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32578 SUP HCPCS C1874 G32578 - GRAFT EVAS 2 BRCH 20MM 8.1MM 20FR 76MM STRL 62MM ZNTH DIST BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32579 SUP HCPCS C1874 G32579 - GRAFT EVAS 24FR 76MM 62MM ZNTH 1-SHOT 2 BRCH VSCR FENESTRATE BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32580 SUP HCPCS C1874 G32580 - GRAFT EVAS 12FR 91MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32581 SUP HCPCS C1874 G32581 - GRAFT EVAS 16FR 91MM 62MM ZNTH FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32582 SUP HCPCS C1874 G32582 - GRAFT EVAS 20FR 91MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32583 SUP HCPCS C1874 G32583 - GRAFT EVAS 24FR 91MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32584 SUP HCPCS C1874 G32584 - GRAFT EVAS 12FR 106MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32585 SUP HCPCS C1874 G32585 - GRAFT EVAS 16FR 106MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32586 SUP HCPCS C1874 G32586 - GRAFT EVAS 20FR 106MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32587 SUP HCPCS C1874 G32587 - GRAFT EVAS 24FR 106MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32588 SUP HCPCS C1874 G32588 - GRAFT EVAS 12FR 121MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32589 SUP HCPCS C1874 G32589 - GRAFT EVAS 16FR 121MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32590 SUP HCPCS C1874 G32590 - GRAFT EVAS 20FR 121MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32591 SUP HCPCS C1874 G32591 - GRAFT EVAS 24FR 121MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32592 SUP HCPCS C1874 G32592 - GRAFT EVAS 16FR 76MM 62MM ZNTH VSCR FEN DIST BFUR BD AAA BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" "$4,171.50" "$4,171.50" $0.00 $0.00 $0.00 "$1,932.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 "$4,570.11" "$4,570.11" $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 "$1,450.76" $0.00 $0.00 "$1,475.78" $0.00 $0.00 $0.00 $0.00 $0.00 G32701 SUP Custom 27203010 G32701 - GUIDEWIRE VASC TPR STRG .025IN 150CM 3CM HIWIRE 1 TO 1 TRQ BOTH IP/OP $103.07 $76.27 $0.00 $82.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.49 $76.49 $0.00 $0.00 $21.48 $0.00 $0.00 $0.00 $0.00 $51.53 $81.63 $82.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32702 SUP Custom 27203010 G32702 - EXTRACTOR STON 2.4FR 1CM 115CM STRL NCOMPASS NCRCL 16 4WR BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32724 SUP Custom 27203010 G32724 - EXTRACTOR STON 7MM 2.8FR 145MM NTRAP UMRL DSGN ENTRAPMENT BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32727 SUP Custom 27203010 G32727 - CATHETER URTH 26FR 34CM UNIVERSA 2W FL CLS END RND TIP SIL BOTH IP/OP $33.94 $25.12 $0.00 $27.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.19 $25.19 $0.00 $0.00 $7.07 $0.00 $0.00 $0.00 $0.00 $16.97 $26.88 $27.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32730 SUP Custom 27203010 G32730 - EXTRACTOR STON HLX 3FR 3.2FR 115CM STRL CPTR 4WR OCL BSKT BOTH IP/OP $473.25 $350.21 $0.00 $378.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.25 $351.25 $0.00 $0.00 $98.63 $0.00 $0.00 $0.00 $0.00 $236.63 $374.81 $378.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32733 SUP Custom 27203010 G32733 - EXTRACTOR STONE 3FR 3.2FR 115CM 3 WIRE HELICAL OCCLUSIVE BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32734 SUP Custom 27203010 G32734 - EXTRACTOR STON 3FR 3.2FR 115CM 5CM ATLS WR 4WR FLFRM BSKT BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32739 SUP Custom 27203010 G32739 - EXTRACTOR STON 1.1FR 1.7FR 115CM STRL ATLS WR 4WR OCL BSKT BOTH IP/OP $281.55 $208.35 $0.00 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.97 $208.97 $0.00 $0.00 $58.68 $0.00 $0.00 $0.00 $0.00 $140.78 $222.99 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32740 SUP Custom 27203010 G32740 - EXTRACTOR STON 4.5FR 65CM CPTR 4WR OCL BSKT SHTH SS BOTH IP/OP $281.55 $208.35 $0.00 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.97 $208.97 $0.00 $0.00 $58.68 $0.00 $0.00 $0.00 $0.00 $140.78 $222.99 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32742 SUP Custom 27203010 G32742 - EXTRACTOR STON 4.5FR 65CM 5CM CPTR 4WR HLCL FLFRM BSKT SHTH BOTH IP/OP $281.55 $208.35 $0.00 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.97 $208.97 $0.00 $0.00 $58.68 $0.00 $0.00 $0.00 $0.00 $140.78 $222.99 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32746 SUP Custom 27203010 G32746 - EXTRACTOR STON 4.5FR 65CM 5CM CPTR 5WR HLCL FLFRM BSKT SHTH BOTH IP/OP $281.55 $208.35 $0.00 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.97 $208.97 $0.00 $0.00 $58.68 $0.00 $0.00 $0.00 $0.00 $140.78 $222.99 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32749 SUP Custom 27203010 G32749 - EXTRACTOR STON HLX 4.5FR 65CM CPTR 4WR HLCL OCL BSKT SHTH SS BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32750 SUP Custom 27203010 G32750 - EXTRACTOR STON HLCL 3FR 3.2FR 115CM STRL CPTR 5WR OCL SHTH BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32756 SUP Custom 27203010 G32756 - EXTRACTOR STON 3FR 3.2FR 115CM 5CM CPTR 4WR HLCL FLFRM BSKT BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32757 SUP Custom 27203010 G32757 - EXTRACTOR STON 2.5FR 115CM CPTR 4WR HLCL OCL URO SS BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32773 SUP HCPCS C2625 G32773 - CATHETER URTH 26FR 34CM UNIVERSA 2W FL OP-EN OPN TIP SIL BOTH IP/OP $17.08 $12.64 $0.00 $13.67 $7.69 $7.69 $0.00 $0.00 $0.00 $3.56 $12.68 $12.68 $0.00 $0.00 $3.56 $0.00 $10.10 $10.10 $0.00 $8.54 $13.53 $13.67 $0.00 $0.00 $2.67 $0.00 $0.00 $2.72 $0.00 $0.00 $0.00 $0.00 $0.00 G32774 SUP HCPCS C2625 G32774 - SET NPHSTM 4FR .025IN 12-18CM 145CM SALLE SFLX GW STY SS PU BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $92.25 $92.25 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 G32779 SUP Custom 27203010 G32779 - EXTRACTOR STONE 1.7FR 115CM 3 WIRE HELICAL OCCLUSIVE BASKET BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32781 SUP Custom 27203010 G32781 - SET STNT .038IN 4.7FR 12-18CM STRL 145CM SALLE INTOP GW STY BOTH IP/OP $281.55 $208.35 $0.00 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.97 $208.97 $0.00 $0.00 $58.68 $0.00 $0.00 $0.00 $0.00 $140.78 $222.99 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32784 SUP Custom 27203010 G32784 - EXTRACTOR STON 4.5FR 65CM 5CM CPTR 6WR HLCL OCL BSKT SHTH SS BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32786 SUP Custom 27203010 G32786 - EXTRACTOR STON 5CM 3.2FR 3FR 115CM CPTR 3WR HLCL FLFRM SS BOTH IP/OP $281.55 $208.35 $0.00 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.97 $208.97 $0.00 $0.00 $58.68 $0.00 $0.00 $0.00 $0.00 $140.78 $222.99 $225.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32788 SUP Custom 27203010 G32788 - EXTRACTOR STON HLX 4.5FR 65CM 5CM CPTR 4WR HLCL FLFRM BSKT BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32789 SUP HCPCS C1726 G32789 - SET DILAT 8-20FR 37CM SIDEPORT LOW FRICTION SLIPPERY SURFACE BOTH IP/OP $451.00 $333.74 $0.00 $360.80 $244.89 $244.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.50 $357.19 $360.80 $0.00 $0.00 $70.58 $0.00 $0.00 $71.80 $0.00 $0.00 $0.00 $0.00 $0.00 G32824 SUP Custom 27203010 G32824 - EXTRACTOR STONE 3.2FR 3FR 115CM 4 WIRE SHEATH TIP OCCLUSIVE BOTH IP/OP $407.30 $301.40 $0.00 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.30 $302.30 $0.00 $0.00 $84.88 $0.00 $0.00 $0.00 $0.00 $203.65 $322.58 $325.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32831 SUP HCPCS C1758 G32831 - CATH URET .038IN 5FR 6MM 4CM TPR TIP PLTN BAND GWIRE BOTH IP/OP $433.88 $321.07 $0.00 $347.10 $235.59 $235.59 $0.00 $0.00 $0.00 $90.43 $322.02 $322.02 $0.00 $0.00 $90.42 $0.00 $256.64 $256.64 $0.00 $216.94 $343.63 $347.10 $0.00 $0.00 $67.90 $0.00 $0.00 $69.07 $0.00 $0.00 $0.00 $0.00 $0.00 G32833 SUP HCPCS C1758 G32833 - CATH URET .038IN 5FR 6MM 10CM TPR TIP PLTN BAND GWIRE BOTH IP/OP $433.88 $321.07 $0.00 $347.10 $235.59 $235.59 $0.00 $0.00 $0.00 $90.43 $322.02 $322.02 $0.00 $0.00 $90.42 $0.00 $256.64 $256.64 $0.00 $216.94 $343.63 $347.10 $0.00 $0.00 $67.90 $0.00 $0.00 $69.07 $0.00 $0.00 $0.00 $0.00 $0.00 G32840 SUP HCPCS C1758 G32840 - SET CATH ASCND BALDILAT INFLAT DEV TPR TIP PLTN BAND GWIRE 5 BOTH IP/OP $511.88 $378.79 $0.00 $409.50 $277.95 $277.95 $0.00 $0.00 $0.00 $106.69 $379.91 $379.91 $0.00 $0.00 $106.67 $0.00 $302.77 $302.77 $0.00 $255.94 $405.41 $409.50 $0.00 $0.00 $80.11 $0.00 $0.00 $81.49 $0.00 $0.00 $0.00 $0.00 $0.00 G32842 SUP HCPCS C1758 G32842 - SET CATH ASCND BALDILAT INFLAT DEV TPR TIP PLTN BAND GWIRE 5 BOTH IP/OP $511.88 $378.79 $0.00 $409.50 $277.95 $277.95 $0.00 $0.00 $0.00 $106.69 $379.91 $379.91 $0.00 $0.00 $106.67 $0.00 $302.77 $302.77 $0.00 $255.94 $405.41 $409.50 $0.00 $0.00 $80.11 $0.00 $0.00 $81.49 $0.00 $0.00 $0.00 $0.00 $0.00 G32852 SUP HCPCS C1894 G32852 - EXTRACTOR STON 2.5FR 2.8FR 115CM CPTR 4WR OCL BSKT SHTH SS BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G32853 SUP HCPCS C1894 G32853 - SHEATH ACC 12FR 13CM FLXR DILATION CNT WRK CHNL PRTC PED BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G32855 SUP HCPCS C2627 G32855 - SHEATH ACC 9.5FR 13CM FLXR DILATION CNT WKG CHNL PRTC PED BOTH IP/OP $223.98 $165.75 $0.00 $179.18 $121.62 $121.62 $0.00 $0.00 $0.00 $0.00 $166.23 $166.23 $0.00 $0.00 $46.68 $0.00 $0.00 $0.00 $0.00 $111.99 $177.39 $179.18 $0.00 $0.00 $35.05 $0.00 $0.00 $35.66 $0.00 $0.00 $0.00 $0.00 $0.00 G32862 SUP Custom 27203010 G32862 - STENT URET 8.5FR 65CM WHT STRL PATERSON-FORRESTER DISP URN BOTH IP/OP $289.10 $213.93 $0.00 $231.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $214.57 $214.57 $0.00 $0.00 $60.25 $0.00 $0.00 $0.00 $0.00 $144.55 $228.97 $231.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G32863 SUP Custom 27203010 G32863 - EXTRACTOR STON 10FR 2CM 38CM PRC NC BSKT RPD ATRM TPLS NTNL BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G33016 SUP HCPCS C1880 G33016 - SYSTEM EMBOLIC PROTECTION 30MM 8.5FR 50MM 65CM DILAT COAXIAL BOTH IP/OP "$3,050.00 " "$2,257.00" $0.00 "$2,440.00" "$1,372.50" "$1,372.50" $0.00 $0.00 $0.00 $635.70 "$2,263.71" "$2,263.71" $0.00 $0.00 $635.62 $0.00 "$1,503.65" "$1,503.65" $0.00 "$1,525.00" "$2,415.60" "$2,440.00" $0.00 $0.00 $477.33 $0.00 $0.00 $485.56 $0.00 $0.00 $0.00 $0.00 $0.00 G33017 SUP HCPCS C1880 G33017 - FILTER EMBOLIZATION 30MM 8.5FR 50MM 65CM 3 WAY STOPCOCK BOTH IP/OP "$3,050.00 " "$2,257.00" $0.00 "$2,440.00" "$1,372.50" "$1,372.50" $0.00 $0.00 $0.00 $635.70 "$2,263.71" "$2,263.71" $0.00 $0.00 $635.62 $0.00 "$1,503.65" "$1,503.65" $0.00 "$1,525.00" "$2,415.60" "$2,440.00" $0.00 $0.00 $477.33 $0.00 $0.00 $485.56 $0.00 $0.00 $0.00 $0.00 $0.00 G34038 SUP Custom 27203010 G34038 - BRUSH CYTO 1MM 5MM SHFT US CYSTIC ECHOBRUSH ECHTP STRL DISP BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $0.00 $0.00 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G34176 SUP HCPCS C2625 G34176 - EXTRACTOR STON 1.5CM 2.4FR 115CM 1.5CM NCOMPASS 4/16 WRE MOD BOTH IP/OP "$2,245.75 " "$1,661.86" $0.00 "$1,796.60" "$1,010.59" "$1,010.59" $0.00 $0.00 $0.00 $468.07 "$1,666.80" "$1,666.80" $0.00 $0.00 $468.01 $0.00 "$1,328.36" "$1,328.36" $0.00 "$1,122.88" "$1,778.63" "$1,796.60" $0.00 $0.00 $351.46 $0.00 $0.00 $357.52 $0.00 $0.00 $0.00 $0.00 $0.00 G34309 SUP HCPCS C1880 G34309 - FILTER EMBL 65CM 30MM 7FR 49MM STRL 71CM CELECT NAVALIGN BOTH IP/OP "$3,522.38 " "$2,606.56" $0.00 "$2,614.31" "$1,040.63" "$1,040.63" $0.00 $0.00 $0.00 $734.15 "$2,614.31" "$2,614.31" $0.00 $0.00 $734.06 $0.00 "$1,736.53" "$1,736.53" $0.00 "$1,156.25" "$1,831.50" "$1,850.00" $0.00 $0.00 $361.91 $0.00 $0.00 $368.15 $0.00 $0.00 $0.00 $0.00 $0.00 G34311 SUP Custom 27203010 G34311 - STENT URET 6FR 30CM RSNCE PSTN MTL ADLT URETER BOTH IP/OP $45.00 $33.30 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.40 $33.40 $0.00 $0.00 $9.38 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G34502 SUP HCPCS C1880 G34502 - FILTER EMBOLIZATION 65CM 30MM 7FR 49MM 79CM RADIOPQ PRELOAD BOTH IP/OP "$3,522.38 " "$2,606.56" $0.00 "$2,614.31" "$1,040.63" "$1,040.63" $0.00 $0.00 $0.00 $734.15 "$2,614.31" "$2,614.31" $0.00 $0.00 $734.06 $0.00 "$1,736.53" "$1,736.53" $0.00 "$1,156.25" "$1,831.50" "$1,850.00" $0.00 $0.00 $361.91 $0.00 $0.00 $368.15 $0.00 $0.00 $0.00 $0.00 $0.00 G34870 SUP HCPCS C1894 G34870 - ADAPTER L/S NS VUELITE ACMI SCP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G34871 SUP HCPCS C1894 G34871 - SHEATH ACC 10.7FR 13CM RPD RELS PRLL FLXR CNT CHNL URETER BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G34872 SUP HCPCS C1894 G34872 - SHEATH ACC 10.7FR 20CM RPD RELS PRLL FLXR CNT CHNL URETER BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G34873 SUP HCPCS C1894 G34873 - SHEATH ACC 10.7FR 28CM RPD RELS PRLL FLXR CNT CHNL URETER BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G34874 SUP HCPCS C1894 G34874 - SHEATH ACC 10.7FR 35CM RPD RELS PRLL FLXR CNT CHNL URETER BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G34875 SUP HCPCS C1894 G34875 - SHEATH ACC 10.7FR 45CM RPD RELS PRLL FLXR CNT CHNL URETER BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G34876 SUP HCPCS C1894 G34876 - SHEATH ACC 10.7FR 55CM RPD RELS PRLL FLXR CNT CHNL URETER BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G34877 SUP HCPCS C1894 G34877 - SHEATH ACC 10.7FR 13CM FLXR DILATION CNT WRK CHNL URETER BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G34878 SUP HCPCS C1894 G34878 - SHEATH ACCES SM TPR FNL 10.7FR DILAT LOCK HUB FLXB BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G34879 SUP HCPCS C1894 G34879 - SHEATH ACCES 10.7FR DILATION CONTIN WRK CHNL FLXR BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G34880 SUP HCPCS C1894 G34880 - SHEATH ACCES 10.7FR DILATION CONTIN WRK CHNL FLXR BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G34881 SUP HCPCS C1894 G34881 - SHEATH ACC 10.7FR 20CM FLXR DILATION CNT WRK CHNL URETER BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G34931 SUP Custom 27203010 G34931 - SHEATH ACC 10.7FR 55CM FLXR DILATION CNT WRK CHNL URETER BOTH IP/OP $462.50 $342.25 $0.00 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.27 $343.27 $0.00 $0.00 $96.39 $0.00 $0.00 $0.00 $0.00 $231.25 $366.30 $370.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G35129 SUP Custom 27203010 G35129 - LIGATOR ENDSCP MINI HEXAGON 9.5-13MM 5FR 2.8MM 6 BAND SNARE BOTH IP/OP $795.00 $588.30 $0.00 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.05 $590.05 $0.00 $0.00 $165.68 $0.00 $0.00 $0.00 $0.00 $397.50 $629.64 $636.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G36022 SUP HCPCS C1876 G36022 - STENT BILIARY .035IN 5MM 6FR 80MM 125CM SELF EXPANDING BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G36226 SUP HCPCS C1763 G36226 - GRAFT SFT TIS 9.5X.6CM ANAL FSTL PLUS SIS AFP PIG STRL DISP BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 G36229 SUP HCPCS C1876 G36229 - STENT BIL 12MM 6FR 40MM 80CM .035IN SLF XPD FLXB FLXR INTROD BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G36231 SUP HCPCS C1876 G36231 - STENT BIL 12MM 6FR 80MM 80CM .035IN SLF XPD FLXB FLXR INTROD BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G36239 SUP HCPCS C1876 G36239 - STENT BIL 12MM 40MM STRL 125CM ZL 635 FLXR SLF XPD RADOPQ BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G36240 SUP HCPCS C1876 G36240 - STENT BIL .035IN 12MM 6FR 60MM STRL 125CM ZL 635 SLF XPD BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G36245 SUP HCPCS C1876 G36245 - STENT BIL 14MM 6FR 60MM 125CM .035IN SLF XPD FLXB FLXR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G36321 SUP Custom 27803010 G36321 - CATH ANGIO SLIP-CATH HYDROPHILIC .038 IN 160 D TIGHT CURVE BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $0.00 $0.00 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G36333 SUP HCPCS C1894 G36333 - SET INTROD .018IN 5FR 21GA 10CM 40CM COAXIAL CATHETER GWIRE BOTH IP/OP $101.50 $75.11 $0.00 $80.00 $54.30 $54.30 $0.00 $0.00 $0.00 $21.16 $75.33 $75.33 $0.00 $0.00 $21.15 $0.00 $60.04 $60.04 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 G36359 SUP HCPCS C1725 G36359 - CATH ANGIO .035IN VTK CURVE 5.5FR 125CM SHTH GWIRE RADIOPQ BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $105.89 $105.89 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 G36360 SUP HCPCS C1725 G36360 - CATH ANGIO .035IN SIM2 CURVE 5.5FR 125CM SHTH GWIRE RADIOPQ BOTH IP/OP $195.00 $144.30 $0.00 $156.00 $105.89 $105.89 $0.00 $0.00 $0.00 $40.64 $144.73 $144.73 $0.00 $0.00 $40.64 $0.00 $115.34 $115.34 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 G36405 SUP HCPCS C1770 G36405 - COIL EMBOLIZATION .035IN 5MM 5CM 3.1 LOOP MREYE PLATINUM BOTH IP/OP $264.07 $195.41 $0.00 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.99 $195.99 $0.00 $0.00 $55.03 $0.00 $0.00 $0.00 $0.00 $125.15 $198.24 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G38463 SUP HCPCS C1874 G38463 - STENT VASCULAR 6MM 40MM 125CM DRUG ELUTE OTW DELIVERY SYSTEM BOTH IP/OP "$2,937.50 " "$2,173.75" $0.00 "$2,350.00" "$1,321.88" "$1,321.88" $0.00 $0.00 $0.00 $612.25 "$2,180.21" "$2,180.21" $0.00 $0.00 $612.18 $0.00 "$1,448.19" "$1,448.19" $0.00 "$1,468.75" "$2,326.50" "$2,350.00" $0.00 $0.00 $459.72 $0.00 $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 $0.00 G38479 SUP HCPCS C1874 G38479 - STENT VASCULAR 6MM 60MM 125CM DRUG ELUTE OTW DELIVERY SYSTEM BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 G38480 SUP HCPCS C1874 G38480 - STENT VASCULAR 6MM 80MM 125CM DRUG ELUTE OTW DELIVERY SYSTEM BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 G38481 SUP HCPCS C1874 G38481 - STENT VASCULAR 125CM 6FR 80MM 100MM OTW ZILVER PTX BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 G38482 SUP HCPCS C1874 G38482 - STENT VASCULAR 6MM 120MM 125CM DRUG ELUTE OTW DELIVERY BOTH IP/OP "$4,987.50 " "$3,690.75" $0.00 "$3,990.00" "$2,244.38" "$2,244.38" $0.00 $0.00 $0.00 "$1,039.52" "$3,701.72" "$3,701.72" $0.00 $0.00 "$1,039.40" $0.00 "$2,458.84" "$2,458.84" $0.00 "$2,493.75" "$3,950.10" "$3,990.00" $0.00 $0.00 $780.54 $0.00 $0.00 $794.01 $0.00 $0.00 $0.00 $0.00 $0.00 G38486 SUP HCPCS C1874 G38486 - STENT VASCULAR 7MM 40MM 125CM DRUG ELUTE OTW DELIVERY SYSTEM BOTH IP/OP "$2,937.50 " "$2,173.75" $0.00 "$2,350.00" "$1,321.88" "$1,321.88" $0.00 $0.00 $0.00 $612.25 "$2,180.21" "$2,180.21" $0.00 $0.00 $612.18 $0.00 "$1,448.19" "$1,448.19" $0.00 "$1,468.75" "$2,326.50" "$2,350.00" $0.00 $0.00 $459.72 $0.00 $0.00 $467.65 $0.00 $0.00 $0.00 $0.00 $0.00 G38487 SUP HCPCS C1874 G38487 - STENT VASCULAR 7MM 60MM 125CM DRUG ELUTE OTW DELIVERY SYSTEM BOTH IP/OP "$3,737.50 " "$2,765.75" $0.00 "$2,990.00" "$1,681.88" "$1,681.88" $0.00 $0.00 $0.00 $778.99 "$2,773.97" "$2,773.97" $0.00 $0.00 $778.90 $0.00 "$1,842.59" "$1,842.59" $0.00 "$1,868.75" "$2,960.10" "$2,990.00" $0.00 $0.00 $584.92 $0.00 $0.00 $595.01 $0.00 $0.00 $0.00 $0.00 $0.00 G38488 SUP HCPCS C1874 G38488 - STENT VASCULAR 7MM 80MM 125CM DRUG ELUTE OTW DELIVERY SYSTEM BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 G38489 SUP HCPCS C1874 G38489 - STENT VASCULAR 7MM 100MM 125CM DRUG ELUTE OTW DELIVERY BOTH IP/OP "$4,487.50 " "$3,320.75" $0.00 "$3,590.00" "$2,019.38" "$2,019.38" $0.00 $0.00 $0.00 $935.31 "$3,330.62" "$3,330.62" $0.00 $0.00 $935.20 $0.00 "$2,212.34" "$2,212.34" $0.00 "$2,243.75" "$3,554.10" "$3,590.00" $0.00 $0.00 $702.29 $0.00 $0.00 $714.41 $0.00 $0.00 $0.00 $0.00 $0.00 G38490 SUP HCPCS C1874 G38490 - STENT VASCULAR 7MM 120MM 125CM DRUG ELUTE OTW DELIVERY BOTH IP/OP "$4,987.50 " "$3,690.75" $0.00 "$3,990.00" "$2,244.38" "$2,244.38" $0.00 $0.00 $0.00 "$1,039.52" "$3,701.72" "$3,701.72" $0.00 $0.00 "$1,039.40" $0.00 "$2,458.84" "$2,458.84" $0.00 "$2,493.75" "$3,950.10" "$3,990.00" $0.00 $0.00 $780.54 $0.00 $0.00 $794.01 $0.00 $0.00 $0.00 $0.00 $0.00 G38532 SUP HCPCS C1874 G38532 - STENT VASCULAR 8MM 120MM 125CM OTW DRUG ELUTE DELIVERY BOTH IP/OP "$4,987.50 " "$3,690.75" $0.00 "$3,990.00" "$2,244.38" "$2,244.38" $0.00 $0.00 $0.00 "$1,039.52" "$3,701.72" "$3,701.72" $0.00 $0.00 "$1,039.40" $0.00 "$2,458.84" "$2,458.84" $0.00 "$2,493.75" "$3,950.10" "$3,990.00" $0.00 $0.00 $780.54 $0.00 $0.00 $794.01 $0.00 $0.00 $0.00 $0.00 $0.00 G38589 SUP Custom 27803010 G38589 - GRAFT EVAS 2 BRCH 20MM 7.7MM 20FR 109MM 45MM ZNTH FENESTRATE BOTH IP/OP "$9,270.00 " "$6,859.80" $0.00 "$7,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,931.87" $0.00 $0.00 $0.00 $0.00 "$4,635.00" "$7,341.84" "$7,416.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G42409 SUP Custom 27803010 G42409 - COIL EMBOLIZATION .035IN 4MM 3CM 2.4 LOOP MREYE PLATINUM BOTH IP/OP $264.07 $195.41 $0.00 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.99 $195.99 $0.00 $0.00 $55.03 $0.00 $0.00 $0.00 $0.00 $125.15 $198.24 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G42410 SUP HCPCS C1770 G42410 - COIL EMBOLIZATION 5MM 3CM 1.9 LOOP STAINLESS STEEL SYNTH BOTH IP/OP $264.07 $195.41 $0.00 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.99 $195.99 $0.00 $0.00 $55.03 $0.00 $0.00 $0.00 $0.00 $125.15 $198.24 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G42419 SUP HCPCS C1770 G42419 - COIL EMBOLIZATION .035IN 3MM 5CM 5.3 LOOP STAINLESS STEEL BOTH IP/OP $264.07 $195.41 $0.00 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.99 $195.99 $0.00 $0.00 $55.03 $0.00 $0.00 $0.00 $0.00 $125.15 $198.24 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G42423 SUP HCPCS C1770 G42423 - COIL EMBOLIZATION .035IN 8MM 5CM 2 LOOP MREYE PLATINUM BOTH IP/OP $264.07 $195.41 $0.00 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.99 $195.99 $0.00 $0.00 $55.03 $0.00 $0.00 $0.00 $0.00 $125.15 $198.24 $200.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G43821 SUP HCPCS C1876 G43821 - STENT VASCULAR .035IN 6MM 6FR 40MM 125CM SELF EXPANDING BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43823 SUP HCPCS C1876 G43823 - STENT VASCULAR 6MM 6FR 80MM 125CM SELF EXPAND INTROD OTW BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43831 SUP HCPCS C1876 G43831 - STENT VASC 8MM 6FR 40MM 125CM .035IN SLF EXPANDABLE DLV SYS BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G43833 SUP HCPCS C1876 G43833 - STENT VASC 8MM 6FR 80MM 125CM .035IN SLF XPD FLXB FLXR BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G43845 SUP HCPCS C1877 G43845 - STENT VASC 6MM 6FR 30MM 80CM .035IN SLF XPD FLXB FLXR INTROD BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G43846 SUP HCPCS C1876 G43846 - STENT VASCULAR 6MM 40MM 80CM SELF EXPAND OTW INTROD RADIOPQ BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43850 SUP HCPCS C1876 G43850 - STENT VASC 7MM 6FR 30MM 80CM .035IN SLF XPD FLXB FLXR INTROD BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G43851 SUP HCPCS C1876 G43851 - STENT VASCULAR 7MM 6FR 40MM 80CM SELF EXPAND FLEXIBLE SLOT BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43855 SUP HCPCS C1876 G43855 - STENT VASCULAR .035IN 8MM 6FR 30MM 80CM SELF EXPANDING BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43856 SUP HCPCS C1876 G43856 - STENT VASCULAR .035IN 8MM 6FR 40MM 80CM SELF EXPANDING BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43857 SUP HCPCS C1876 G43857 - STENT VASCULAR .035IN 8MM 6FR 60MM 80CM SELF EXPANDING BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43861 SUP HCPCS C1876 G43861 - STENT VASCULAR 9MM 6FR 40MM 80CM SELF EXPAND INTROD OTW BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43863 SUP HCPCS C1876 G43863 - STENT VASC 9MM 6FR 80MM 80CM .035IN SLF XPD FLXB FLXR INTROD BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G43865 SUP HCPCS C1876 G43865 - STENT VASCULAR .035IN 10MM 6FR 30MM 80CM SELF EXPANDING BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43866 SUP HCPCS C1876 G43866 - STENT VASCULAR .035IN 10MM 6FR 40MM 80CM SELF EXPANDING BOTH IP/OP "$2,283.75 " "$1,689.98" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $475.99 "$1,695.00" "$1,695.00" $0.00 $0.00 $475.93 $0.00 "$1,350.84" "$1,350.84" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 G43868 SUP HCPCS C1876 G43868 - STENT VASC 10MM 6FR 80MM 80CM .035IN SLF EXPANDABLE DLV SYS BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G43870 SUP HCPCS C1894 G43870 - SET INTROD 40CM 5FR MPNCH .018IN NTNL GWIRE 10CM VLNK STRL BOTH IP/OP $69.00 $51.06 $0.00 $55.20 $37.47 $37.47 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $0.00 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $34.50 $54.65 $55.20 $0.00 $0.00 $10.80 $0.00 $0.00 $10.98 $0.00 $0.00 $0.00 $0.00 $0.00 G44153 SUP HCPCS C1894 G44153 - SHEATH GUID .018-.038IN ANL0 CURVE 5FR .074IN 45CM INTROD BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G44154 SUP HCPCS C1894 G44154 - SHEATH GUID .018-.038IN ANL0 CURVE 6FR .087IN 45CM INTROD BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G44155 SUP HCPCS C1894 G44155 - SHEATH GUID .018/.038IN ANL0 CURVE 7FR .1IN 45CM INTROD BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G44846 SUP HCPCS C1769 G44846 - GUIDEWIRE URO STRG .035IN 150CM 3CM MTN HBRD FLXB BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 G44848 SUP HCPCS C1769 G44848 - GUIDEWIRE URO .035IN 150CM 3CM MTN HBRD FLXB STRG TIP BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 G44849 SUP HCPCS C1769 G44849 - GUIDEWIRE URO .038IN 150CM 3CM MTN HBRD FLXB STRG TIP BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 G44855 SUP HCPCS C1769 G44855 - GUIDEWIRE URO .038IN 150CM 3CM MTN HBRD FLXB ANG TIP BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 G45208 SUP HCPCS C1769 G45208 - GUIDEWIRE VASCULAR CURVE .035IN 260CM 2 END FLEXIBLE TIP BOTH IP/OP "$1,432.50 " "$1,060.05" $0.00 "$1,146.00" $777.85 $777.85 $0.00 $0.00 $0.00 $298.57 "$1,063.20" "$1,063.20" $0.00 $0.00 $298.53 $0.00 $847.32 $847.32 $0.00 $716.25 "$1,134.54" "$1,146.00" $0.00 $0.00 $224.19 $0.00 $0.00 $228.05 $0.00 $0.00 $0.00 $0.00 $0.00 G45352 SUP HCPCS C1769 G45352 - GUIDEWIRE VASC STRG .035IN 300CM 4CM LNDRQS XSTF FLX TP PTFE BOTH IP/OP "$1,169.05 " $865.10 $0.00 $935.24 $634.79 $634.79 $0.00 $0.00 $0.00 $243.66 $867.67 $867.67 $0.00 $0.00 $243.63 $0.00 $691.49 $691.49 $0.00 $584.53 $925.89 $935.24 $0.00 $0.00 $182.96 $0.00 $0.00 $186.11 $0.00 $0.00 $0.00 $0.00 $0.00 G46023 SUP HCPCS C1726 G46023 - GUIDEWIRE URO .035IN 150CM 3CM MTN HBRD FLXB ANG TIP BOTH IP/OP $103.87 $76.86 $0.00 $83.10 $56.40 $56.40 $0.00 $0.00 $0.00 $21.65 $77.09 $77.09 $0.00 $0.00 $21.65 $0.00 $61.44 $61.44 $0.00 $51.94 $82.27 $83.10 $0.00 $0.00 $16.26 $0.00 $0.00 $16.54 $0.00 $0.00 $0.00 $0.00 $0.00 G46024 SUP HCPCS C1726 G46024 - CATHETER NPHSTM 6MM 15CM CLR ULTRX INFL BLN SHRT TRNS TPR BOTH IP/OP $618.80 $457.91 $0.00 $495.04 $336.01 $336.01 $0.00 $0.00 $0.00 $128.97 $459.27 $459.27 $0.00 $0.00 $128.96 $0.00 $366.02 $366.02 $0.00 $309.40 $490.09 $495.04 $0.00 $0.00 $96.84 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 G46027 SUP Custom 27203010 G46027 - SET NPHSTM 8MM 15CM CLR ULTRX INFL BLN SHRT TRNS TPR RADOPQ BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46028 SUP HCPCS C1894 G46028 - EXTRACTOR STON 1.7FR 1CM 115CM NCOMPASS 4/16 WRE BSKT MOD BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46029 SUP HCPCS C1894 G46029 - SHEATH ACC 3FR 9.5FR 55CM FLXR 2 CNT WRK CHNL 2 LUM DILATION BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46030 SUP HCPCS C2627 G46030 - SHEATH ACC 3FR 12FR 13CM FLXR 2 CNT WRK CHNL 2 LUM DILATION BOTH IP/OP $117.15 $86.69 $0.00 $93.72 $63.61 $63.61 $0.00 $0.00 $0.00 $0.00 $86.95 $86.95 $0.00 $0.00 $24.41 $0.00 $0.00 $0.00 $0.00 $58.58 $92.78 $93.72 $0.00 $0.00 $18.33 $0.00 $0.00 $18.65 $0.00 $0.00 $0.00 $0.00 $0.00 G46031 SUP HCPCS C2627 G46031 - SHEATH ACC 18FR 17CM CLR AMPTZ RADOPQ STRP RNL BOTH IP/OP $117.15 $86.69 $0.00 $93.72 $63.61 $63.61 $0.00 $0.00 $0.00 $0.00 $86.95 $86.95 $0.00 $0.00 $24.41 $0.00 $0.00 $0.00 $0.00 $58.58 $92.78 $93.72 $0.00 $0.00 $18.33 $0.00 $0.00 $18.65 $0.00 $0.00 $0.00 $0.00 $0.00 G46032 SUP HCPCS C2627 G46032 - SHEATH ACC 24FR 17CM CLR AMPTZ RADOPQ STRP RNL BOTH IP/OP $117.15 $86.69 $0.00 $93.72 $63.61 $63.61 $0.00 $0.00 $0.00 $0.00 $86.95 $86.95 $0.00 $0.00 $24.41 $0.00 $0.00 $0.00 $0.00 $58.58 $92.78 $93.72 $0.00 $0.00 $18.33 $0.00 $0.00 $18.65 $0.00 $0.00 $0.00 $0.00 $0.00 G46033 SUP HCPCS C1726 G46033 - SHEATH ACC 30FR 17CM CLR AMPTZ RADOPQ STRP RNL BOTH IP/OP $519.35 $384.32 $0.00 $415.48 $282.01 $282.01 $0.00 $0.00 $0.00 $108.25 $385.46 $385.46 $0.00 $0.00 $108.23 $0.00 $307.20 $307.20 $0.00 $259.68 $411.33 $415.48 $0.00 $0.00 $81.28 $0.00 $0.00 $82.68 $0.00 $0.00 $0.00 $0.00 $0.00 G46034 SUP HCPCS C1726 G46034 - CATHETER NPHSTM 6MM 15CM ULTRX INFL BLN SHRT TRNS TPR RADOPQ BOTH IP/OP $519.35 $384.32 $0.00 $415.48 $282.01 $282.01 $0.00 $0.00 $0.00 $108.25 $385.46 $385.46 $0.00 $0.00 $108.23 $0.00 $307.20 $307.20 $0.00 $259.68 $411.33 $415.48 $0.00 $0.00 $81.28 $0.00 $0.00 $82.68 $0.00 $0.00 $0.00 $0.00 $0.00 G46035 SUP HCPCS C1726 G46035 - CATHETER NPHSTM 8MM 15CM ULTRX INFL BLN SHRT TRNS TPR RADOPQ BOTH IP/OP $519.35 $384.32 $0.00 $415.48 $282.01 $282.01 $0.00 $0.00 $0.00 $108.25 $385.46 $385.46 $0.00 $0.00 $108.23 $0.00 $307.20 $307.20 $0.00 $259.68 $411.33 $415.48 $0.00 $0.00 $81.28 $0.00 $0.00 $82.68 $0.00 $0.00 $0.00 $0.00 $0.00 G46036 SUP HCPCS C1726 G46036 - CATHETER NPHSTM 8MM 15CM CLR ULTRX INFL BLN SHRT TRNS TPR BOTH IP/OP $618.80 $457.91 $0.00 $495.04 $336.01 $336.01 $0.00 $0.00 $0.00 $128.97 $459.27 $459.27 $0.00 $0.00 $128.96 $0.00 $366.02 $366.02 $0.00 $309.40 $490.09 $495.04 $0.00 $0.00 $96.84 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 G46037 SUP HCPCS C1726 G46037 - SET NPHSTM 6MM 15CM ULTRX INFL BLN SHRT TRNS TPR RADOPQ STRP BOTH IP/OP $618.80 $457.91 $0.00 $495.04 $336.01 $336.01 $0.00 $0.00 $0.00 $128.97 $459.27 $459.27 $0.00 $0.00 $128.96 $0.00 $366.02 $366.02 $0.00 $309.40 $490.09 $495.04 $0.00 $0.00 $96.84 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 G46038 SUP HCPCS C1726 G46038 - SET NPHSTM 6MM 15CM CLR ULTRX INFL BLN SHRT TRNS TPR RADOPQ BOTH IP/OP $618.80 $457.91 $0.00 $495.04 $336.01 $336.01 $0.00 $0.00 $0.00 $128.97 $459.27 $459.27 $0.00 $0.00 $128.96 $0.00 $366.02 $366.02 $0.00 $309.40 $490.09 $495.04 $0.00 $0.00 $96.84 $0.00 $0.00 $98.51 $0.00 $0.00 $0.00 $0.00 $0.00 G46041 SUP HCPCS C1726 G46041 - CATHETER NPHSTM 10MM 15CM ULTRX BOTH IP/OP $519.35 $384.32 $0.00 $415.48 $282.01 $282.01 $0.00 $0.00 $0.00 $108.25 $385.46 $385.46 $0.00 $0.00 $108.23 $0.00 $307.20 $307.20 $0.00 $259.68 $411.33 $415.48 $0.00 $0.00 $81.28 $0.00 $0.00 $82.68 $0.00 $0.00 $0.00 $0.00 $0.00 G46042 SUP HCPCS C1726 G46042 - CATHETER NPHSTM 6MM 15CM ULTRX BOTH IP/OP $519.35 $384.32 $0.00 $415.48 $282.01 $282.01 $0.00 $0.00 $0.00 $108.25 $385.46 $385.46 $0.00 $0.00 $108.23 $0.00 $307.20 $307.20 $0.00 $259.68 $411.33 $415.48 $0.00 $0.00 $81.28 $0.00 $0.00 $82.68 $0.00 $0.00 $0.00 $0.00 $0.00 G46043 SUP HCPCS C1726 G46043 - EXTRACTOR STON 2.2FR 11MM 115CM STRL NGAGE NTNL URETER BOTH IP/OP $519.35 $384.32 $0.00 $415.48 $282.01 $282.01 $0.00 $0.00 $0.00 $108.25 $385.46 $385.46 $0.00 $0.00 $108.23 $0.00 $307.20 $307.20 $0.00 $259.68 $411.33 $415.48 $0.00 $0.00 $81.28 $0.00 $0.00 $82.68 $0.00 $0.00 $0.00 $0.00 $0.00 G46044 SUP Custom 27203010 G46044 - SET NPHSTM 8MM 15CM CLR ULTRX INFL BLN SHRT TRNS TPR RADOPQ BOTH IP/OP $814.00 $602.36 $0.00 $651.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $604.15 $604.15 $0.00 $0.00 $169.64 $0.00 $0.00 $0.00 $0.00 $407.00 $644.69 $651.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46071 SUP Custom 27203010 G46071 - DEVICE BX BX KNDY REUSE BOTH IP/OP $814.00 $602.36 $0.00 $651.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $604.15 $604.15 $0.00 $0.00 $169.64 $0.00 $0.00 $0.00 $0.00 $407.00 $644.69 $651.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46072 SUP HCPCS C1894 G46072 - NEEDLE BX 18GA 25CM STRL HUB ECHGN TIP SMPL NTCH DISP BOTH IP/OP $20.35 $15.06 $0.00 $16.28 $11.05 $11.05 $0.00 $0.00 $0.00 $4.24 $15.10 $15.10 $0.00 $0.00 $4.24 $0.00 $12.04 $12.04 $0.00 $10.18 $16.12 $16.28 $0.00 $0.00 $3.18 $0.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 G46073 SUP HCPCS C1894 G46073 - SHEATH ACC 3FR 9.5FR 13CM FLXR DL 2 CNT WRK CHNL 2 LUM BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46074 SUP HCPCS C1894 G46074 - SHEATH ACC 3FR 9.5FR 20CM FLXR DL 2 CNT WRK CHNL 2 LUM BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46075 SUP HCPCS C1894 G46075 - SHEATH ACC 3FR 9.5FR 28CM FLXR DL 2 CNT WRK CHNL 2 LUM BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46076 SUP HCPCS C1894 G46076 - SHEATH ACC 3FR 9.5FR 35CM FLXR DL 2 CNT WRK CHNL 2 LUM BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46077 SUP HCPCS C1894 G46077 - SHEATH ACC 3FR 9.5FR 45CM FLXR DL 2 CNT WRK CHNL 2 LUM BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46078 SUP HCPCS C1894 G46078 - SHEATH ACC 3FR 12FR 20CM FLXR 2 CNT WRK CHNL 2 LUM DILATION BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46079 SUP HCPCS C1894 G46079 - SHEATH ACC 3FR 12FR 28CM FLXR 2 CNT WRK CHNL 2 LUM DILATION BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46080 SUP HCPCS C1894 G46080 - SHEATH ACC 3FR 12FR 35CM FLXR DL 2 CNT WRK CHNL 2 LUM BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46081 SUP HCPCS C1894 G46081 - SHEATH ACC 3FR 12FR 45CM FLXR DL 2 CNT WRK CHNL 2 LUM BOTH IP/OP $407.00 $301.18 $0.00 $325.60 $221.00 $221.00 $0.00 $0.00 $0.00 $84.83 $302.08 $302.08 $0.00 $0.00 $84.82 $0.00 $240.74 $240.74 $0.00 $203.50 $322.34 $325.60 $0.00 $0.00 $63.70 $0.00 $0.00 $64.79 $0.00 $0.00 $0.00 $0.00 $0.00 G46137 SUP HCPCS C1769 G46137 - SHEATH ACC 3FR 12FR 55CM FLXR 2 CNT WRK CHNL 2 LUM DILATION BOTH IP/OP $669.38 $495.34 $0.00 $535.50 $363.47 $363.47 $0.00 $0.00 $0.00 $139.51 $496.81 $496.81 $0.00 $0.00 $139.50 $0.00 $395.94 $395.94 $0.00 $334.69 $530.15 $535.50 $0.00 $0.00 $104.76 $0.00 $0.00 $106.56 $0.00 $0.00 $0.00 $0.00 $0.00 G46138 SUP HCPCS C1769 G46138 - GUIDEWIRE ESCP ANG STRG TPR .038IN 150CM STRL 3CM BIWIRE 1-1 BOTH IP/OP $133.88 $99.07 $0.00 $107.10 $72.69 $72.69 $0.00 $0.00 $0.00 $27.90 $99.36 $99.36 $0.00 $0.00 $27.90 $0.00 $79.19 $79.19 $0.00 $66.94 $106.03 $107.10 $0.00 $0.00 $20.95 $0.00 $0.00 $21.31 $0.00 $0.00 $0.00 $0.00 $0.00 G46139 SUP HCPCS C1769 G46139 - GUIDEWIRE ESCP ANG .035IN 150CM STRL 3CM BIWIRE 1TO 1 TRQ BOTH IP/OP $133.88 $99.07 $0.00 $107.10 $72.69 $72.69 $0.00 $0.00 $0.00 $27.90 $99.36 $99.36 $0.00 $0.00 $27.90 $0.00 $79.19 $79.19 $0.00 $66.94 $106.03 $107.10 $0.00 $0.00 $20.95 $0.00 $0.00 $21.31 $0.00 $0.00 $0.00 $0.00 $0.00 G46140 SUP HCPCS C1769 G46140 - GUIDEWIRE VASC STRG ANG TPR .025IN 150CM 3CM BIWIRE 1TO 1 BOTH IP/OP $111.38 $82.42 $0.00 $89.10 $60.48 $60.48 $0.00 $0.00 $0.00 $23.21 $82.66 $82.66 $0.00 $0.00 $23.21 $0.00 $65.88 $65.88 $0.00 $55.69 $88.21 $89.10 $0.00 $0.00 $17.43 $0.00 $0.00 $17.73 $0.00 $0.00 $0.00 $0.00 $0.00 G46141 SUP HCPCS C1769 G46141 - GUIDEWIRE URO ANG STRG TPR .038IN 150CM STRL 3CM BIWIRE 1-1 BOTH IP/OP $111.38 $82.42 $0.00 $89.10 $60.48 $60.48 $0.00 $0.00 $0.00 $23.21 $82.66 $82.66 $0.00 $0.00 $23.21 $0.00 $65.88 $65.88 $0.00 $55.69 $88.21 $89.10 $0.00 $0.00 $17.43 $0.00 $0.00 $17.73 $0.00 $0.00 $0.00 $0.00 $0.00 G46142 SUP HCPCS C1769 G46142 - GUIDEWIRE VASC STD STRG .035IN 150CM 3CM BIWIRE 1TO 1 TRQ BOTH IP/OP $111.38 $82.42 $0.00 $89.10 $60.48 $60.48 $0.00 $0.00 $0.00 $23.21 $82.66 $82.66 $0.00 $0.00 $23.21 $0.00 $65.88 $65.88 $0.00 $55.69 $88.21 $89.10 $0.00 $0.00 $17.43 $0.00 $0.00 $17.73 $0.00 $0.00 $0.00 $0.00 $0.00 G46167 SUP HCPCS C1894 G46167 - SHEATH ACCES 9.5FR CONTIN WKG CHNL FLXB SCP BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G46168 SUP HCPCS C1894 G46168 - SHEATH ACCES 12FR CONTIN WOR CHNL TPR DILAT LOCK BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G46169 SUP HCPCS C1894 G46169 - GUIDEWIRE URO ANG STRG TPR .025IN 150CM 3CM BIWIRE STD BD BOTH IP/OP $308.00 $227.92 $0.00 $246.40 $167.24 $167.24 $0.00 $0.00 $0.00 $64.19 $228.60 $228.60 $0.00 $0.00 $64.19 $0.00 $182.18 $182.18 $0.00 $154.00 $243.94 $246.40 $0.00 $0.00 $48.20 $0.00 $0.00 $49.03 $0.00 $0.00 $0.00 $0.00 $0.00 G46199 SUP Custom 27203010 G46199 - RETRIEVER STNT 2.4FR 115CM NSNARE FLXB NTNL BOTH IP/OP $796.88 $589.69 $0.00 $637.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.44 $591.44 $0.00 $0.00 $166.07 $0.00 $0.00 $0.00 $0.00 $398.44 $631.13 $637.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46200 SUP Custom 27203010 G46200 - ELECTRODE ESURG .014IN 27FR CUT LOOP FIT 27FR STRZ 1 STM BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46202 SUP Custom 27203010 G46202 - KNIFE ESCP STRL COLLINGS DISP FIT 24/27FR 1 STM RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46203 SUP Custom 27203010 G46203 - ELECTRODE ESURG 3MM RLLR BRL FIT 24/26/28FR ACMI USA/ELT BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46204 SUP Custom 27203010 G46204 - ELECTRODE ESURG .014IN CUT LOOP GW FIT 24FR STRZ 2 STM RSSCP BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46205 SUP Custom 27203010 G46205 - ELECTRODE ESURG PRFR RESCT COAG FIT 24 FR ACMI USA/ELT RSSCP BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46206 SUP Custom 27203010 G46206 - EXTRACTOR STONE 1.5FR 1CM 115CM 4 WIRE TIPLESS BASKET BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46209 SUP Custom 27203010 G46209 - KNIFE ESCP COLLINGS FIT 24/26/28 FR ACMI USA/ELT RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46210 SUP Custom 27203010 G46210 - ELECTRODE ESURG .012IN CUT LOOP GW FIT 24FR ACMI USA/ELT BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46211 SUP Custom 27203010 G46211 - ELECTRODE ESURG .015IN CUT LOOP GW FIT 24FR ACMI USA/ELT BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46212 SUP Custom 27203010 G46212 - ELECTRODE ESURG .012IN CUT LOOP GW FIT 26FR ACMI USA/ELT BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46213 SUP Custom 27203010 G46213 - ELECTRODE ESURG .015IN CUT LOOP GW FIT 26FR ACMI USA/ELT BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46214 SUP Custom 27203010 G46214 - ELECTRODE ESURG .012IN CUT LOOP GW FIT 28FR ACMI USA/ELT BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46215 SUP Custom 27203010 G46215 - ELECTRODE ESURG .015IN LOOP GW URO FIT 28FR ACMI USA/ELT BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46216 SUP Custom 27203010 G46216 - ELECTRODE ESURG PRFR RESCT COAG FIT 28 FR ACMI USA/ELT RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46217 SUP Custom 27203010 G46217 - ELECTRODE ESURG 3MM RLLR BALL FIT 24/26/28FR ACMI USA/ELT BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46218 SUP Custom 27203010 G46218 - ELECTRODE ESURG 5MM RLLR BALL FIT 24/26/28FR ACMI USA/ELT BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46219 SUP Custom 27203010 G46219 - ELECTRODE ESURG .012IN CUT LOOP GW FIT 24FR STRZ 1 STM RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46220 SUP Custom 27203010 G46220 - ELECTRODE MNPLR .014IN CUT LOOP GW FIT 24FR STRZ 1 STM RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46221 SUP Custom 27203010 G46221 - ELECTRODE ESURG .012IN LOOP GW URO FIT 27FR STRZ SGL STM BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46222 SUP Custom 27203010 G46222 - ELECTRODE ESURG PRFR RESCT COAG FIT 24 FR STRZ 1 STM RSSCP BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46223 SUP Custom 27203010 G46223 - ELECTRODE ESURG PRFR RESCT COAG FIT 27 FR STRZ 1 STM RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46224 SUP Custom 27203010 G46224 - ELECTRODE MNPLR 3MM CK RLLR BALL DISP FIT 24/27FR STRZ 1 STM BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46225 SUP Custom 27203010 G46225 - ELECTRODE ESURG 5MM RLLR BALL FIT 24/27FR STRZ 1 STM RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46226 SUP Custom 27203010 G46226 - ELECTRODE ESURG 3MM RLLR BRL FIT 24/27FR STRZ 1 STM RSSCP BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46228 SUP Custom 27203010 G46228 - KNIFE ESCP COLLINGS 24/26/28 FR RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46229 SUP Custom 27203010 G46229 - ELECTRODE ESURG 12D .012IN CUT LOOP GW FIT 24FR OL OES RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46230 SUP Custom 27203010 G46230 - ELECTRODE ESURG 30D 24FR .012IN CUT LOOP WRE OL OES RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46231 SUP Custom 27203010 G46231 - ELECTRODE ESURG 12D .012IN CUT LOOP GW FIT 26FR OL OES RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46232 SUP Custom 27203010 G46232 - ELECTRODE ESURG 30D .012IN 26FR LOOP CUT WRE FIT 26FR OL OES BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46233 SUP Custom 27203010 G46233 - ELECTRODE ESURG 12D .012IN CUT LOOP GW FIT 28FR OL OES RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46234 SUP Custom 27203010 G46234 - ELECTRODE ESURG 30D .012IN CUT LOOP GW FIT 28FR OL OES RSSCP BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46235 SUP Custom 27203010 G46235 - ELECTRODE ESURG PRFR RESCT COAG FIT 24 FR OL OES RSSCP BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46236 SUP Custom 27203010 G46236 - ELECTRODE ESURG PRFR RESCT COAG FIT 26 FR OL OES RSSCP BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46237 SUP Custom 27203010 G46237 - ELECTRODE ESURG PRFR RESCT COAG FIT 28 FR OL OES RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46238 SUP Custom 27203010 G46238 - ELECTRODE ESURG 5MM RLLR BALL FIT 24/26/28FR OL OES RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46239 SUP Custom 27203010 G46239 - ELECTRODE ESURG 3MM RLLR BALL FIT 24/26/28FR OL OES RSSCP BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46240 SUP Custom 27203010 G46240 - ELECTRODE ESURG 3MM DIMPLED TIP VPR RLLR BALL FIT 24/26/28FR BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46241 SUP Custom 27203010 G46241 - ELECTRODE ESURG .014IN CUT LOOP GW FIT 27FR STRZ 2 STM BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46242 SUP Custom 27203010 G46242 - ELECTRODE ESURG PRFR RESCT COAG FIT 24 FR STRZ 2 STM RSSCP BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46243 SUP Custom 27203010 G46243 - ELECTRODE ESURG PRFR RESCT COAG FIT 27 FR STRZ 2 STM RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46244 SUP Custom 27203010 G46244 - ELECTRODE ESURG 3MM RLLR BALL FIT 24/27FR STRZ 2 STM RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46245 SUP Custom 27203010 G46245 - ELECTRODE ESURG 5MM RLLR BALL FIT 24/27FR STRZ 2 STM RSSCP BOTH IP/OP $159.38 $117.94 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.29 $118.29 $0.00 $0.00 $33.21 $0.00 $0.00 $0.00 $0.00 $79.69 $126.23 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46246 SUP Custom 27203010 G46246 - ELECTRODE ESURG 3MM RLLR BALL FIT 24/27FR STRZ 2 STM RSSCP BOTH IP/OP $308.13 $228.02 $0.00 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.69 $228.69 $0.00 $0.00 $64.21 $0.00 $0.00 $0.00 $0.00 $154.06 $244.04 $246.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46247 SUP Custom 27203010 G46247 - ELECTRODE ESURG 3MM DIMPLED TIP VPR RLLR BALL FIT 24/27FR BOTH IP/OP $350.63 $259.47 $0.00 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $260.23 $260.23 $0.00 $0.00 $73.07 $0.00 $0.00 $0.00 $0.00 $175.31 $277.70 $280.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G46612 SUP HCPCS C1763 G46612 - GRAFT SFT TIS 13X8CM PLVC FLR INS SIS ES PIG ACLR CLGN MTRX BOTH IP/OP "$2,487.50 " "$1,840.75" $0.00 "$1,990.00" "$1,119.38" "$1,119.38" $0.00 $0.00 $0.00 $518.46 "$1,846.22" "$1,846.22" $0.00 $0.00 $518.40 $0.00 "$1,471.36" "$1,471.36" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 G47325 SUP HCPCS C1770 G47325 - COIL EMBL 10MM 14CM NST MCIOL PLTN .018IN CATH BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47329 SUP HCPCS C1770 G47329 - COIL EMBL 6MM 14CM NST MCIOL PLTN .018IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47330 SUP HCPCS C1770 G47330 - COIL EMBL 8MM 14CM NST MCIOL PLTN .018IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47338 SUP HCPCS Q4107 G47338 - COIL EMBL 3MM 7CM NST MCIOL PLTN .018IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47339 SUP Custom 27805113 G47339 - COIL EMBL 4MM 7CM NST MCIOL PLTN .018IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47345 SUP HCPCS C1770 G47345 - COIL EMBL 10MM 14CM NST MCIOL PLTN .035IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47354 SUP Custom 27803010 G47354 - COIL EMBL 6MM 14CM NST MCIOL PLTN .035IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47355 SUP HCPCS C1770 G47355 - COIL EMBL 8MM 14CM NST MCIOL PLTN .035IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47365 SUP Custom 27803010 G47365 - COIL EMBL 10MM 7CM NST MCIOL PLTN .035IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47371 SUP Custom 27803010 G47371 - COIL EMBL 3MM 7IN NST PLTN ACPT .035IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47372 SUP Custom 27803010 G47372 - COIL EMBL 4MM 7CM NST MCIOL PLTN .035IN CATH BOTH IP/OP $278.73 $206.26 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.87 $206.87 $0.00 $0.00 $58.09 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47416 SUP HCPCS C1770 G47416 - COIL EMBL 3-2MM TRND MCIOL PLTN .018IN CATH BOTH IP/OP $275.33 $203.74 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47419 SUP HCPCS C1770 G47419 - COIL EMBL 6-2MM TRND MCIOL PLTN .018IN CATH BOTH IP/OP $290.47 $214.95 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.58 $215.58 $0.00 $0.00 $60.53 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47421 SUP HCPCS C1770 G47421 - COIL EMBL 8-4MM 9.5CM TRND MCL PRELD CRTDG PLTN SNTH FBR BOTH IP/OP $290.47 $214.95 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.58 $215.58 $0.00 $0.00 $60.53 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47519 SUP HCPCS C1770 G47519 - COIL EMBL 4-3MM TRND PLTN .035IN CATH BOTH IP/OP $290.47 $214.95 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.58 $215.58 $0.00 $0.00 $60.53 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47520 SUP HCPCS C1770 G47520 - COIL EMBL 5-3MM TRND PLTN .035IN CATH BOTH IP/OP $290.47 $214.95 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.58 $215.58 $0.00 $0.00 $60.53 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47522 SUP HCPCS C1770 G47522 - COIL EMBL 7-3MM TRND PLTN .035IN CATH BOTH IP/OP $290.47 $214.95 $0.00 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.58 $215.58 $0.00 $0.00 $60.53 $0.00 $0.00 $0.00 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47654 SUP HCPCS C1763 G47654 - DILATOR URTH 26FR 37CM S-CRV SDPRT HDRPH BOTH IP/OP $985.03 $728.92 $0.00 $788.02 $443.26 $443.26 $0.00 $0.00 $0.00 $205.30 $731.09 $731.09 $0.00 $0.00 $205.28 $0.00 $582.64 $582.64 $0.00 $492.51 $780.14 $788.02 $0.00 $0.00 $154.16 $0.00 $0.00 $156.82 $0.00 $0.00 $0.00 $0.00 $0.00 G47655 SUP HCPCS C1763 G47655 - GRAFT SFT TIS STD SURGISIS BIODESIGN STRTH FLXB RST TO INFCT BOTH IP/OP "$1,457.50 " "$1,078.55" $0.00 "$1,166.00" $655.88 $655.88 $0.00 $0.00 $0.00 $303.78 "$1,081.76" "$1,081.76" $0.00 $0.00 $303.74 $0.00 $862.11 $862.11 $0.00 $728.75 "$1,154.34" "$1,166.00" $0.00 $0.00 $228.10 $0.00 $0.00 $232.03 $0.00 $0.00 $0.00 $0.00 $0.00 G47700 SUP HCPCS C1892 G47700 - INTRODUCER SHEATH .035IN ANL1 CURVE 11.4FR 10FR 45CM HIGH BOTH IP/OP $212.00 $156.88 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $44.19 $157.35 $157.35 $0.00 $0.00 $44.18 $0.00 $125.40 $125.40 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 G47701 SUP HCPCS C1892 G47701 - INTRODUCER SHEATH .035IN ANL1 CURVE 13.4FR 12FR 45CM HIGH BOTH IP/OP $212.00 $156.88 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $44.19 $157.35 $157.35 $0.00 $0.00 $44.18 $0.00 $125.40 $125.40 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 G47732 SUP HCPCS C1769 G47732 - GUIDEWIRE VASCULAR .014IN 135CM SHAPEABLE TIP KINK BOTH IP/OP $167.03 $123.60 $0.00 $133.62 $90.69 $90.69 $0.00 $0.00 $0.00 $34.81 $123.97 $123.97 $0.00 $0.00 $34.81 $0.00 $98.80 $98.80 $0.00 $83.51 $132.29 $133.62 $0.00 $0.00 $26.14 $0.00 $0.00 $26.59 $0.00 $0.00 $0.00 $0.00 $0.00 G47733 SUP HCPCS C1769 G47733 - GUIDEWIRE VASC .014IN 190CM APRCH SHP TIP KINK RST MNVBL LNR BOTH IP/OP $204.00 $150.96 $0.00 $163.20 $110.77 $110.77 $0.00 $0.00 $0.00 $42.52 $151.41 $151.41 $0.00 $0.00 $42.51 $0.00 $120.67 $120.67 $0.00 $102.00 $161.57 $163.20 $0.00 $0.00 $31.93 $0.00 $0.00 $32.48 $0.00 $0.00 $0.00 $0.00 $0.00 G47734 SUP HCPCS C1769 G47734 - GUIDEWIRE VASC .014IN 300CM APRCH SHP TIP KINK RST MNVBL LNR BOTH IP/OP $204.00 $150.96 $0.00 $163.20 $110.77 $110.77 $0.00 $0.00 $0.00 $42.52 $151.41 $151.41 $0.00 $0.00 $42.51 $0.00 $120.67 $120.67 $0.00 $102.00 $161.57 $163.20 $0.00 $0.00 $31.93 $0.00 $0.00 $32.48 $0.00 $0.00 $0.00 $0.00 $0.00 G47804 SUP HCPCS C1729 G47804 - GRAFT SFT TIS LG SURGISIS BIODESIGN STRTH FLXB RST TO INFCT BOTH IP/OP $244.20 $180.71 $0.00 $195.36 $132.60 $132.60 $0.00 $0.00 $0.00 $50.90 $181.25 $181.25 $0.00 $0.00 $50.89 $0.00 $144.44 $144.44 $0.00 $122.10 $193.41 $195.36 $0.00 $0.00 $38.22 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $0.00 G47805 SUP HCPCS C1729 G47805 - SET CATH CRC NPHSTM SPBC BOTH IP/OP $244.20 $180.71 $0.00 $195.36 $132.60 $132.60 $0.00 $0.00 $0.00 $50.90 $181.25 $181.25 $0.00 $0.00 $50.89 $0.00 $144.44 $144.44 $0.00 $122.10 $193.41 $195.36 $0.00 $0.00 $38.22 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $0.00 G47806 SUP HCPCS C1729 G47806 - SET CATH CRC NPHSTM SPBC BOTH IP/OP $244.20 $180.71 $0.00 $195.36 $132.60 $132.60 $0.00 $0.00 $0.00 $50.90 $181.25 $181.25 $0.00 $0.00 $50.89 $0.00 $144.44 $144.44 $0.00 $122.10 $193.41 $195.36 $0.00 $0.00 $38.22 $0.00 $0.00 $38.88 $0.00 $0.00 $0.00 $0.00 $0.00 G47833 SUP HCPCS C1769 G47833 - TRAY CENTRAL LINE INSERTION WITH BIOPATCH BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $378.74 $378.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $109.16 $0.00 $0.00 $111.04 $0.00 $0.00 $0.00 $0.00 $0.00 G47858 SUP Custom 27203010 G47858 - SET CATH CRC NPHSTM SPBC BOTH IP/OP "$1,034.00 " $765.16 $0.00 $827.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $767.43 $767.43 $0.00 $0.00 $215.49 $0.00 $0.00 $0.00 $0.00 $517.00 $818.93 $827.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47859 SUP Custom 27203010 G47859 - NEEDLE BX 18GA 20CM PAT HUB ECHGN TIP SMPL NTCH PRCS PSTN BOTH IP/OP $51.70 $38.26 $0.00 $41.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.37 $38.37 $0.00 $0.00 $10.77 $0.00 $0.00 $0.00 $0.00 $25.85 $40.95 $41.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47868 SUP HCPCS C1770 G47868 - COIL EMBL MREYE STRT KIT VRSTL MCIOL PLTN STRL DISP BOTH IP/OP "$8,750.00 " "$6,475.00" $0.00 "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,823.50" $0.00 $0.00 $0.00 $0.00 "$4,375.00" "$6,930.00" "$7,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G47942 SUP HCPCS C1894 G47942 - SET INTROD .018IN 4FR 21GA 40CM 10CM SILHOUETTE BOTH IP/OP $106.58 $78.87 $0.00 $84.00 $57.02 $57.02 $0.00 $0.00 $0.00 $22.21 $79.10 $79.10 $0.00 $0.00 $22.21 $0.00 $63.04 $63.04 $0.00 $52.50 $83.16 $84.00 $0.00 $0.00 $16.43 $0.00 $0.00 $16.72 $0.00 $0.00 $0.00 $0.00 $0.00 G48003 SUP HCPCS C1894 G48003 - SET INTROD .018IN 4FR 40CM 10CM TRANSITIONLESS STIFFENED BOTH IP/OP $172.55 $127.69 $0.00 $136.00 $92.31 $92.31 $0.00 $0.00 $0.00 $35.96 $128.07 $128.07 $0.00 $0.00 $35.96 $0.00 $102.06 $102.06 $0.00 $85.00 $134.64 $136.00 $0.00 $0.00 $26.61 $0.00 $0.00 $27.06 $0.00 $0.00 $0.00 $0.00 $0.00 G48007 SUP HCPCS C1894 G48007 - INTRODUCER SHTH 5FR 10CM 40CM TRNSTLS STF MPNCH NTNL .018IN BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $47.51 $47.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $13.69 $0.00 $0.00 $13.93 $0.00 $0.00 $0.00 $0.00 $0.00 G48008 SUP HCPCS C1894 G48008 - SET INTROD .018IN 5FR 21GA 40CM 10CM COAXIAL CATHETER GWIRE BOTH IP/OP $175.09 $129.57 $0.00 $138.00 $93.67 $93.67 $0.00 $0.00 $0.00 $36.49 $129.95 $129.95 $0.00 $0.00 $36.49 $0.00 $103.56 $103.56 $0.00 $86.25 $136.62 $138.00 $0.00 $0.00 $27.00 $0.00 $0.00 $27.46 $0.00 $0.00 $0.00 $0.00 $0.00 G48031 SUP HCPCS C1876 G48031 - STENT ESOPHAGEAL 20MM 25MM 10CM 8MM PARTIALLY COVERED BOTH IP/OP "$4,705.00 " "$3,481.70" $0.00 "$3,764.00" "$2,117.25" "$2,117.25" $0.00 $0.00 $0.00 $980.64 "$3,492.05" "$3,492.05" $0.00 $0.00 $980.52 $0.00 "$2,319.57" "$2,319.57" $0.00 "$2,352.50" "$3,726.36" "$3,764.00" $0.00 $0.00 $736.33 $0.00 $0.00 $749.04 $0.00 $0.00 $0.00 $0.00 $0.00 G48186 SUP HCPCS C1894 G48186 - SHEATH GUID .018-.035IN ANL0 CURVE 4FR 1.5IN 45CM RADIOPQ BOTH IP/OP $202.50 $149.85 $0.00 $156.00 $105.89 $105.89 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $97.50 $154.44 $156.00 $0.00 $0.00 $30.52 $0.00 $0.00 $31.04 $0.00 $0.00 $0.00 $0.00 $0.00 G48188 SUP HCPCS C1894 G48188 - SHEATH GUID .018/.035IN ANL0 CURVE 4FR .059IN 90CM RADIOPQ BOTH IP/OP $392.60 $290.52 $0.00 $302.00 $204.98 $204.98 $0.00 $0.00 $0.00 $81.83 $291.39 $291.39 $0.00 $0.00 $81.82 $0.00 $232.22 $232.22 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 G48189 SUP HCPCS C1894 G48189 - SHEATH GUID ANL0 CURVE STR 5FR .074IN 90CM CHK-FLO VALVE BOTH IP/OP $392.60 $290.52 $0.00 $302.00 $204.98 $204.98 $0.00 $0.00 $0.00 $81.83 $291.39 $291.39 $0.00 $0.00 $81.82 $0.00 $232.22 $232.22 $0.00 $188.75 $298.98 $302.00 $0.00 $0.00 $59.08 $0.00 $0.00 $60.10 $0.00 $0.00 $0.00 $0.00 $0.00 G48240 SUP Custom 27203010 G48240 - FORCEPS BIOP 2.4FR 115CM 1 BITE COLLECT BACKLOAD BIGOPSY BOTH IP/OP $880.00 $651.20 $0.00 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $653.14 $653.14 $0.00 $0.00 $183.39 $0.00 $0.00 $0.00 $0.00 $440.00 $696.96 $704.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48294 SUP Custom 27203010 G48294 - EXTRACTOR STONE 1.7FR 8MM 115CM PATENTED NGAGE NITINOL BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48295 SUP Custom 27203010 G48295 - NEEDLE BX 20GA 20CM PAT HUB ECHGN TIP SMPL NTCH PRCS PSTN BOTH IP/OP $25.77 $19.07 $0.00 $20.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.12 $19.12 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $12.88 $20.41 $20.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48296 SUP Custom 27203010 G48296 - SET NPHSTM 10MM 30FR 15CM CLR 17CM ULTRX RADOPQ STRP BLN BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48297 SUP Custom 27203010 G48297 - EXTRACTOR STONE 2.2FR 8MM 115CM NGAGE NITINOL KIDNEY URETER BOTH IP/OP $515.33 $381.34 $0.00 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.47 $382.47 $0.00 $0.00 $107.39 $0.00 $0.00 $0.00 $0.00 $257.66 $408.14 $412.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48373 SUP HCPCS C1880 G48373 - FILTER EMBOLIZATION 30MM 8.5FR 48MM 65CM 3 WAY STOPCOCK BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $573.17 "$2,041.05" "$2,041.05" $0.00 $0.00 $573.10 $0.00 "$1,355.75" "$1,355.75" $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 G48402 SUP HCPCS C1874 G48402 - GRAFT EVAS 2 BRCH 22MM 18FR 82MM STRL Z-TRK ZNTH FLX SLF BOTH IP/OP "$21,145.00 " "$15,647.30" $0.00 "$16,916.00" "$9,515.25" "$9,515.25" $0.00 $0.00 $0.00 "$4,407.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,406.62" $0.00 "$10,424.49" "$10,424.49" $0.00 "$10,572.50" "$16,746.84" "$16,916.00" $0.00 $0.00 "$3,309.19" $0.00 $0.00 "$3,366.28" $0.00 $0.00 $0.00 $0.00 $0.00 G48422 SUP HCPCS C1874 G48422 - GRAFT EVAS BFUR 30MM 7.7MM 20FR 82MM ZNTH FLX Z-TRK SLF XPD BOTH IP/OP "$21,145.00 " "$15,647.30" $0.00 "$16,916.00" "$9,515.25" "$9,515.25" $0.00 $0.00 $0.00 "$4,407.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,406.62" $0.00 "$10,424.49" "$10,424.49" $0.00 "$10,572.50" "$16,746.84" "$16,916.00" $0.00 $0.00 "$3,309.19" $0.00 $0.00 "$3,366.28" $0.00 $0.00 $0.00 $0.00 $0.00 G48424 SUP Custom 27803010 G48424 - GRAFT EVAS 2 BRCH 30MM 20FR 111MM ZNTH FLX Z-TRK SLF BOTH IP/OP "$21,145.00 " "$15,647.30" $0.00 "$16,916.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,406.62" $0.00 $0.00 $0.00 $0.00 "$10,572.50" "$16,746.84" "$16,916.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48429 SUP HCPCS C1874 G48429 - GRAFT EVAS 2 BRCH 32MM 20FR 111MM ZNTH FLX Z-TRK SLF BOTH IP/OP "$21,145.00 " "$15,647.30" $0.00 "$16,916.00" "$9,515.25" "$9,515.25" $0.00 $0.00 $0.00 "$4,407.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,406.62" $0.00 "$10,424.49" "$10,424.49" $0.00 "$10,572.50" "$16,746.84" "$16,916.00" $0.00 $0.00 "$3,309.19" $0.00 $0.00 "$3,366.28" $0.00 $0.00 $0.00 $0.00 $0.00 G48431 SUP HCPCS C1874 G48431 - GRAFT EVAS BFUR 32MM 20FR 140MM ZNTH FLX Z-TRK SLF XPD WVN BOTH IP/OP "$21,145.00 " "$15,647.30" $0.00 "$16,916.00" "$9,515.25" "$9,515.25" $0.00 $0.00 $0.00 "$4,407.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,406.62" $0.00 "$10,424.49" "$10,424.49" $0.00 "$10,572.50" "$16,746.84" "$16,916.00" $0.00 $0.00 "$3,309.19" $0.00 $0.00 "$3,366.28" $0.00 $0.00 $0.00 $0.00 $0.00 G48522 SUP Custom 27203010 G48522 - EXTRACTOR STON 1.7FR 11MM 115CM NGAGE NTNL KNDY URETER BOTH IP/OP "$1,615.00 " "$1,195.10" $0.00 "$1,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,198.65" "$1,198.65" $0.00 $0.00 $336.57 $0.00 $0.00 $0.00 $0.00 $807.50 "$1,279.08" "$1,292.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48526 SUP Custom 27203010 G48526 - FIBER LSR 273UM GRN OPTILITE FLT TIP CNCT HO REUSE STD SMA BOTH IP/OP "$2,329.80 " "$1,724.05" $0.00 "$1,863.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,729.18" "$1,729.18" $0.00 $0.00 $485.53 $0.00 $0.00 $0.00 $0.00 "$1,164.90" "$1,845.20" "$1,863.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48611 SUP Custom 27203010 G48611 - FIBER LSR 273UM FLT BLK OPTILITE CNCT HO DISP STD SMA CNCT BOTH IP/OP $538.33 $398.36 $0.00 $430.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $399.55 $399.55 $0.00 $0.00 $112.19 $0.00 $0.00 $0.00 $0.00 $269.17 $426.36 $430.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48612 SUP Custom 27203010 G48612 - FIBER LSR 273UM GRN OPTILITE FLT TIP CNCT HO REUSE CNVGNT BOTH IP/OP "$4,735.50 " "$3,504.27" $0.00 "$3,788.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,514.69" "$3,514.69" $0.00 $0.00 $986.88 $0.00 $0.00 $0.00 $0.00 "$2,367.75" "$3,750.52" "$3,788.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48613 SUP Custom 27203010 G48613 - FIBER LSR 940UM BLK OPTILITE FLT TIP CNCT HO DISP STD SMA BOTH IP/OP $336.46 $248.98 $0.00 $269.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.72 $249.72 $0.00 $0.00 $70.12 $0.00 $0.00 $0.00 $0.00 $168.23 $266.48 $269.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48614 SUP Custom 27203010 G48614 - FIBER LSR 365UM BLU OPTILITE FLT TIP CNCT HO REUSE CNVGNT BOTH IP/OP "$2,367.30 " "$1,751.80" $0.00 "$1,893.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.01" "$1,757.01" $0.00 $0.00 $493.35 $0.00 $0.00 $0.00 $0.00 "$1,183.65" "$1,874.90" "$1,893.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48615 SUP Custom 27203010 G48615 - FIBER LSR 273UM RD OPTILITE FLT TIP CNCT HO DISP CNVGNT LSR BOTH IP/OP $389.58 $288.29 $0.00 $311.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.15 $289.15 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $194.79 $308.55 $311.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48616 SUP Custom 27203010 G48616 - FIBER LSR 550UM VIOL OPTILITE FLT TIP CNCT HO REUSE CNVGNT BOTH IP/OP "$2,152.50 " "$1,592.85" $0.00 "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,597.59" "$1,597.59" $0.00 $0.00 $448.58 $0.00 $0.00 $0.00 $0.00 "$1,076.25" "$1,704.78" "$1,722.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48617 SUP Custom 27203010 G48617 - FIBER LSR 365UM FLT RD OPTILITE CNCT HO DISP CNVGNT LSR SYS BOTH IP/OP $743.75 $550.38 $0.00 $595.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.01 $552.01 $0.00 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $371.88 $589.05 $595.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48618 SUP Custom 27203010 G48618 - FIBER LSR 940UM ORNG OPTILITE FLT TIP CNCT HO REUSE CNVGNT BOTH IP/OP "$1,009.38 " $746.94 $0.00 $807.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.16 $749.16 $0.00 $0.00 $210.35 $0.00 $0.00 $0.00 $0.00 $504.69 $799.43 $807.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48619 SUP Custom 27203010 G48619 - FIBER LSR 365UM FLT BLU OPTILITE FLXB CNCT HO REUSE STD SMA BOTH IP/OP "$1,168.75 " $864.88 $0.00 $935.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $867.45 $867.45 $0.00 $0.00 $243.57 $0.00 $0.00 $0.00 $0.00 $584.38 $925.65 $935.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48620 SUP Custom 27203010 G48620 - FIBER LSR 550UM RD OPTILITE FLT TIP CNCT HO REUSE STD SMA BOTH IP/OP "$2,859.75 " "$2,116.22" $0.00 "$2,287.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,122.51" "$2,122.51" $0.00 $0.00 $595.97 $0.00 $0.00 $0.00 $0.00 "$1,429.88" "$2,264.92" "$2,287.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48621 SUP Custom 27203010 G48621 - FIBER LSR 550UM FLT RD OPTILITE CNCT HO DISP CNVGNT LSR SYS BOTH IP/OP $743.75 $550.38 $0.00 $595.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.01 $552.01 $0.00 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $371.88 $589.05 $595.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48622 SUP Custom 27203010 G48622 - FIBER LSR 940UM ORNG OPTILITE FLT TIP CNCT HO REUSE STD SMA BOTH IP/OP "$4,735.50 " "$3,504.27" $0.00 "$3,788.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,514.69" "$3,514.69" $0.00 $0.00 $986.88 $0.00 $0.00 $0.00 $0.00 "$2,367.75" "$3,750.52" "$3,788.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48623 SUP Custom 27203010 G48623 - FIBER LSR 940UM FLT 940UM RD OPTILITE RD CNCT HO DISP CNVGNT BOTH IP/OP $891.75 $659.90 $0.00 $713.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $661.86 $661.86 $0.00 $0.00 $185.84 $0.00 $0.00 $0.00 $0.00 $445.88 $706.27 $713.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48624 SUP Custom 27203010 G48624 - FIBER LSR 273UM BLK OPTILITE FLT TIP CNCT HO DISP TRMDN LSR BOTH IP/OP $973.75 $720.58 $0.00 $779.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $722.72 $722.72 $0.00 $0.00 $202.93 $0.00 $0.00 $0.00 $0.00 $486.88 $771.21 $779.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48625 SUP Custom 27203010 G48625 - FIBER LSR 150UM BLK OPTILITE FLT TIP CNCT HO DISP STD SMA BOTH IP/OP $891.75 $659.90 $0.00 $713.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $661.86 $661.86 $0.00 $0.00 $185.84 $0.00 $0.00 $0.00 $0.00 $445.88 $706.27 $713.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48626 SUP Custom 27203010 G48626 - FIBER LSR 200UM BLK OPTILITE FLT TIP CNCT HO DISP STD SMA BOTH IP/OP $717.50 $530.95 $0.00 $574.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $532.53 $532.53 $0.00 $0.00 $149.53 $0.00 $0.00 $0.00 $0.00 $358.75 $568.26 $574.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G48627 SUP Custom 27203010 G48627 - FIBER LSR FLT 365UM BLK OPTILITE CNCT EXTREMELY FLXB HO DISP BOTH IP/OP $953.25 $705.41 $0.00 $762.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $707.50 $707.50 $0.00 $0.00 $198.66 $0.00 $0.00 $0.00 $0.00 $476.63 $754.97 $762.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G49044 SUP HCPCS C1894 G49044 - INTRODUCER SHEATH .035IN ANL1 CURVE 8.8FR 7FR 110CM GUIDE BOTH IP/OP $502.50 $371.85 $0.00 $402.00 $272.86 $272.86 $0.00 $0.00 $0.00 $104.73 $372.96 $372.96 $0.00 $0.00 $104.72 $0.00 $297.23 $297.23 $0.00 $251.25 $397.98 $402.00 $0.00 $0.00 $78.64 $0.00 $0.00 $80.00 $0.00 $0.00 $0.00 $0.00 $0.00 G49099 SUP HCPCS C1894 G49099 - SHEATH GUID .018/.038IN ANL0 CURVE 8FR .113IN 45CM RADIOPQ BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49100 SUP HCPCS C1894 G49100 - INTRODUCER CATHETER .018/.038IN ANL1 CURVE 8FR .113IN 45CM BOTH IP/OP $202.50 $149.85 $0.00 $150.30 $101.81 $101.81 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49257 SUP Custom 27203010 G49257 - NEEDLE ESCP 20GA 6FR 8- CM STRL ECHTP ULT US CONE TIP SH CLC BOTH IP/OP $697.50 $516.15 $0.00 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $517.68 $517.68 $0.00 $0.00 $145.36 $0.00 $0.00 $0.00 $0.00 $348.75 $552.42 $558.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G49333 SUP HCPCS C1877 G49333 - STENT VASC 10MM 5FR 80MM 125CM .018IN SLF XPD FLXB FLXR BOTH IP/OP "$3,062.50 " "$2,266.25" $0.00 "$2,450.00" "$1,378.13" "$1,378.13" $0.00 $0.00 $0.00 $638.30 "$2,272.99" "$2,272.99" $0.00 $0.00 $638.23 $0.00 "$1,509.81" "$1,509.81" $0.00 "$1,531.25" "$2,425.50" "$2,450.00" $0.00 $0.00 $479.28 $0.00 $0.00 $487.55 $0.00 $0.00 $0.00 $0.00 $0.00 G49472 SUP HCPCS C1892 G49472 - SET INTROD .018IN LONG 5FR 70CM 30CM COAXIAL CATHETER PEEL BOTH IP/OP $151.93 $112.43 $0.00 $118.00 $80.09 $80.09 $0.00 $0.00 $0.00 $31.66 $112.76 $112.76 $0.00 $0.00 $31.66 $0.00 $89.86 $89.86 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $23.08 $0.00 $0.00 $23.48 $0.00 $0.00 $0.00 $0.00 $0.00 G49473 SUP HCPCS C1894 G49473 - SET INTROD .018IN LONG 5FR 21GA 100CM 45CM NEEDLE WIRE GUIDE BOTH IP/OP $151.93 $112.43 $0.00 $118.00 $80.09 $80.09 $0.00 $0.00 $0.00 $31.66 $112.76 $112.76 $0.00 $0.00 $31.66 $0.00 $89.86 $89.86 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $23.08 $0.00 $0.00 $23.48 $0.00 $0.00 $0.00 $0.00 $0.00 G49620 SUP Custom 27203010 G49620 - FIBER LSR 550UM FLT BLK OPTILITE CNCT HO DISP STD SMA CNCT BOTH IP/OP $154.07 $114.01 $0.00 $123.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.35 $114.35 $0.00 $0.00 $32.11 $0.00 $0.00 $0.00 $0.00 $77.03 $122.02 $123.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G49762 SUP HCPCS C2617 G49762 - MICROSCOPE SRG NS INSP FO SAFE EFCT CMPLT BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49862 SUP HCPCS C2617 G49862 - SET STNT .038IN 2 PGTL CRV 5FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49863 SUP HCPCS C2617 G49863 - SET STNT .038IN 2 PGTL CRV 5FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49864 SUP HCPCS C2617 G49864 - SET STNT .038IN 2 PGTL CRV 5FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49865 SUP HCPCS C2617 G49865 - SET STNT .038IN 2 PGTL CRV 5FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49866 SUP HCPCS C2617 G49866 - SET STNT .038IN 2 PGTL CRV 5FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49867 SUP HCPCS C2617 G49867 - SET STNT .038IN 2 PGTL CRV 5FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49868 SUP HCPCS C2617 G49868 - SET STNT .038IN 2 PGTL CRV 5FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49869 SUP HCPCS C2617 G49869 - SET STNT .038IN 2 PGTL CRV 5FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49870 SUP HCPCS C2617 G49870 - SET STNT .038IN 2 PGTL CRV 5FR 22-32CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49871 SUP HCPCS C2617 G49871 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49872 SUP HCPCS C2617 G49872 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49873 SUP HCPCS C2617 G49873 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49874 SUP HCPCS C2617 G49874 - SET STENT .038IN 3CM 2 PIGTAIL CURVE 6FR 26CM 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49875 SUP HCPCS C2617 G49875 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49876 SUP HCPCS C2617 G49876 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49877 SUP HCPCS C2617 G49877 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49878 SUP HCPCS C2617 G49878 - SET STNT 3CM 2 PGTL CRV 6FR 22-32CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49879 SUP HCPCS C2617 G49879 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49880 SUP HCPCS C2617 G49880 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49881 SUP HCPCS C2617 G49881 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49882 SUP HCPCS C2617 G49882 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49883 SUP HCPCS C2617 G49883 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49884 SUP HCPCS C2617 G49884 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49885 SUP HCPCS C2617 G49885 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49886 SUP HCPCS C2617 G49886 - SET STNT 3CM 2 PGTL CRV 7FR 22-32CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49887 SUP HCPCS C2617 G49887 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49888 SUP HCPCS C2617 G49888 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49889 SUP HCPCS C2617 G49889 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49890 SUP HCPCS C2617 G49890 - SET STNT 3CM 2 PGTL CRV 8FR 24CM STRL 145CM UNIVERSA FIRM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49891 SUP HCPCS C2617 G49891 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49892 SUP HCPCS C2617 G49892 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49893 SUP HCPCS C2617 G49893 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49894 SUP HCPCS C2617 G49894 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22-32CM STRL 145CM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49895 SUP HCPCS C2625 G49895 - SET STENT 2 PIGTAIL CURVE 5FR 20CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49896 SUP HCPCS C2625 G49896 - SET STENT 2 PIGTAIL CURVE 5FR 22CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49897 SUP HCPCS C2625 G49897 - SET STENT 2 PIGTAIL CURVE 5FR 24CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49898 SUP HCPCS C2625 G49898 - SET STENT 2 PIGTAIL CURVE 5FR 26CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49899 SUP HCPCS C2625 G49899 - SET STENT 2 PIGTAIL CURVE 5FR 28CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49900 SUP HCPCS C2617 G49900 - SET STNT 2 PGTL CRV 5FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49901 SUP HCPCS C2617 G49901 - SET STNT 2 PGTL CRV 5FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49902 SUP HCPCS C2617 G49902 - SET STNT 2 PGTL CRV 5FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49903 SUP HCPCS C2625 G49903 - SET STENT 2 PIGTAIL CURVE 6FR 20CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49904 SUP HCPCS C2625 G49904 - SET STENT 2 PIGTAIL CURVE 6FR 22CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49906 SUP HCPCS C2625 G49906 - STENT URETERAL 6FR 26CM POSITIONER BRAID TETHER STRAIGHTENER BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49907 SUP HCPCS C2625 G49907 - STENT URETERAL 6FR 28CM POSITIONER SET BRAID TETHER RADIOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49908 SUP HCPCS C2617 G49908 - SET STNT 2 PGTL CRV 6FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49909 SUP HCPCS C2617 G49909 - SET STNT 2 PGTL CRV 6FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49910 SUP HCPCS C2617 G49910 - STENT URET 6FR 22-32CM UNIVERSA PSTNR SET BRD TETH RADOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49911 SUP HCPCS C2617 G49911 - SET STNT 2 PGTL CRV 7FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49912 SUP HCPCS C2625 G49912 - SET STENT 2 PIGTAIL CURVE 7FR 22CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49913 SUP HCPCS C2625 G49913 - SET STENT PIGTAIL 7FR 24CM RADIOPQ TIP STRAIGHTENER BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49914 SUP HCPCS C2625 G49914 - SET STENT PIGTAIL 7FR 26CM RADIOPQ TIP STRAIGHTENER BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49915 SUP HCPCS C2625 G49915 - SET STENT 2 PIGTAIL CURVE 7FR 28CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49916 SUP HCPCS C2617 G49916 - SET STNT 2 PGTL CRV 7FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49917 SUP HCPCS C2617 G49917 - STENT URET 2 PGTL CRV 7FR 30CM UNIVERSA FIRM GRAD MRK RADOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49918 SUP HCPCS C2617 G49918 - SET STNT PGTL 7FR 22-32CM STRL UNIVERSA RADOPQ TIP BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49919 SUP HCPCS C2617 G49919 - SET STNT 2 PGTL CRV 8FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49920 SUP HCPCS C2625 G49920 - SET STENT 2 PIGTAIL CURVE 8FR 22CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49921 SUP HCPCS C2625 G49921 - SET STENT 2 PIGTAIL CURVE 8FR 24CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49922 SUP HCPCS C2625 G49922 - SET STENT 2 PIGTAIL CURVE 8FR 26CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49923 SUP HCPCS C2625 G49923 - SET STENT 2 PIGTAIL CURVE 8FR 28CM RADIOPQ GRADUATE MARK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49924 SUP HCPCS C2617 G49924 - SET STNT 2 PGTL CRV 8FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49925 SUP HCPCS C2617 G49925 - SET STNT 2 PGTL CRV 8FR 30CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49931 SUP HCPCS C2617 G49931 - SET STNT 2 PGTL CRV 8FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49932 SUP HCPCS C2617 G49932 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49933 SUP HCPCS C2617 G49933 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49934 SUP HCPCS C2617 G49934 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49935 SUP HCPCS C2617 G49935 - SET STNT .038IN 2 PGTL CRV 3CM 5FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49936 SUP HCPCS C2617 G49936 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49937 SUP HCPCS C2617 G49937 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49938 SUP HCPCS C2617 G49938 - SET STNT .038IN 3CM 2 PGTL CRV 5FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49939 SUP HCPCS C2617 G49939 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49940 SUP HCPCS C2617 G49940 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49941 SUP HCPCS C2617 G49941 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49942 SUP HCPCS C2617 G49942 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49943 SUP HCPCS C2617 G49943 - SET STNT .038IN 3CM PGTL CRV 5FR 22-32CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49944 SUP HCPCS C2617 G49944 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49945 SUP HCPCS C2617 G49945 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49946 SUP HCPCS C2617 G49946 - SET STNT .038IN 3CM 2 PGTL CRV 6FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49947 SUP HCPCS C2617 G49947 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49948 SUP HCPCS C2617 G49948 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49949 SUP HCPCS C2617 G49949 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49950 SUP HCPCS C2617 G49950 - SET STNT 3CM 2 PGTL CRV 7FR 24CM STRL 145CM UNIVERSA SFT BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49951 SUP HCPCS C2617 G49951 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49952 SUP HCPCS C2617 G49952 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49953 SUP HCPCS C2617 G49953 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49954 SUP HCPCS C2617 G49954 - SET STNT .038IN 3CM 2 PGTL CRV 7FR 22-32CM STRL 145CM BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49955 SUP HCPCS C2617 G49955 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49956 SUP HCPCS C2617 G49956 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49957 SUP HCPCS C2617 G49957 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49958 SUP HCPCS C2617 G49958 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49959 SUP HCPCS C2617 G49959 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49960 SUP HCPCS C2617 G49960 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49961 SUP HCPCS C2617 G49961 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G49962 SUP HCPCS C2617 G49962 - SET STNT .038IN 3CM 2 PGTL CRV 8FR 22-32CM STRL 145CM BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49963 SUP HCPCS C2617 G49963 - SET STNT 2 PGTL CRV 5FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49964 SUP HCPCS C2617 G49964 - SET STNT 2 PGTL CRV 5FR 20CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49965 SUP HCPCS C2617 G49965 - SET STNT 2 PGTL CRV 5FR 22CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49966 SUP HCPCS C2617 G49966 - SET STNT 2 PGTL CRV 5FR 24CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49967 SUP HCPCS C2617 G49967 - SET STNT 2 PGTL CRV 5FR 26CM UNIVERSA SFT GRAD MRK RADOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49968 SUP HCPCS C2617 G49968 - SET STNT 2 PGTL CRV 5FR 28CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49969 SUP HCPCS C2617 G49969 - SET STNT 2 PGTL CRV 5FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49970 SUP HCPCS C2617 G49970 - STENT URET 2 PGTL CRV 5FR 30CM UNIVERSA SFT GRAD MRK RADOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49971 SUP HCPCS C2617 G49971 - SET STNT 2 PGTL CRV 6FR 18CM STRL UNIVERSA RADOPQ GRAD MRK BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49972 SUP HCPCS C2617 G49972 - SET STNT PGTL 6FR 20CM STRL UNIVERSA RADOPQ TIP PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49973 SUP HCPCS C2617 G49973 - SET STNT PGTL 6FR 22CM STRL UNIVERSA RADOPQ TIP PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49974 SUP HCPCS C2617 G49974 - SET STNT 2 PGTL CRV 6FR 24CM STRL UNIVERSA RADOPQ PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49975 SUP HCPCS C2617 G49975 - SET STNT 2 PGTL CRV 6FR 26CM STRL UNIVERSA RADOPQ PSTNR BRD BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49976 SUP HCPCS C2617 G49976 - SET STNT 2 PGTL CRV 6FR 28CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49977 SUP HCPCS C2617 G49977 - STENT URET 2 PGTL CRV 6FR 30CM UNIVERSA SFT GRAD MRK RADOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49978 SUP HCPCS C2617 G49978 - SET STNT 2 PGTL CRV 6FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49979 SUP HCPCS C2617 G49979 - SET STNT 2 PGTL CRV 7FR 18CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49980 SUP HCPCS C2617 G49980 - SET STNT 2 PGTL CRV 7FR 20CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49981 SUP HCPCS C2617 G49981 - SET STNT 2 PGTL CRV 7FR 22CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49982 SUP HCPCS C2617 G49982 - SET STNT 2 PGTL CRV 7FR 24CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49983 SUP HCPCS C2617 G49983 - SET STNT 2 PGTL CRV 7FR 26CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49984 SUP HCPCS C2617 G49984 - SET STNT 2 PGTL CRV 7FR 28CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49985 SUP HCPCS C2617 G49985 - SET STNT 2 PGTL CRV 7FR 30CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49986 SUP HCPCS C2617 G49986 - SET STNT 2 PGTL CRV 7FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49987 SUP HCPCS C2617 G49987 - SET STNT 2 PGTL CRV 8FR 18CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49988 SUP HCPCS C2617 G49988 - SET STNT 2 PGTL CRV 8FR 20CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49989 SUP HCPCS C2617 G49989 - SET STNT 2 PGTL CRV 8FR 22CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49990 SUP HCPCS C2617 G49990 - SET STNT 2 PGTL CRV 8FR 24CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49991 SUP HCPCS C2617 G49991 - SET STNT 2 PGTL CRV 8FR 26CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49992 SUP HCPCS C2617 G49992 - SET STNT 2 PGTL CRV 8FR 28CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G49993 SUP HCPCS C2617 G49993 - SET STNT 2 PGTL CRV 8FR 30CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G50001 SUP HCPCS C1887 G50001 - CATHETER GUID .018IN 2.6FR 150CM DEPTH MARKER RADIOPQ BOTH IP/OP $545.56 $403.71 $0.00 $404.92 $264.71 $264.71 $0.00 $0.00 $0.00 $113.71 $404.92 $404.92 $0.00 $0.00 $113.70 $0.00 $322.70 $322.70 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 G50003 SUP HCPCS C1887 G50003 - CATHETER GUID 2.6FR 150CM BRAID KINK RESISTANT RADIOPQ BOTH IP/OP $545.56 $403.71 $0.00 $404.92 $264.71 $264.71 $0.00 $0.00 $0.00 $113.71 $404.92 $404.92 $0.00 $0.00 $113.70 $0.00 $322.70 $322.70 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 G50010 SUP Custom 27203010 G50010 - FIBER LSR 550UM NS STRP TL BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.11 $204.11 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G50122 SUP HCPCS C1876 G50122 - STENT BIL 6MM 6FR 140MM 80CM .035IN SLF EXPANDABLE DLV SYS BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 G50131 SUP HCPCS C1876 G50131 - STENT BIL 7MM 6FR 140MM 80CM .035IN SLF EXPANDABLE DLV SYS BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 G50168 SUP HCPCS C1876 G50168 - STENT BIL 7MM 6FR 100MM 125CM .035IN SLF EXPANDABLE DLV SYS BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 G50171 SUP HCPCS C1876 G50171 - STENT BIL 8MM 6FR 100MM 125CM .035IN SLF EXPANDABLE DLV SYS BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 G50214 SUP Custom 27203010 G50214 - GLASSES SF NS HO LSR BOTH IP/OP $95.70 $70.82 $0.00 $76.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.03 $71.03 $0.00 $0.00 $19.94 $0.00 $0.00 $0.00 $0.00 $47.85 $75.79 $76.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G50319 SUP HCPCS C1725 G50319 - CATHETER BLNDIL 2MM 170CM STRL LF 20CM ADV LOPRFL KINK RST BOTH IP/OP "$1,351.50 " "$1,000.11" $0.00 "$1,081.20" $733.86 $733.86 $0.00 $0.00 $0.00 $281.69 "$1,003.08" "$1,003.08" $0.00 $0.00 $281.65 $0.00 $799.41 $799.41 $0.00 $675.75 "$1,070.39" "$1,081.20" $0.00 $0.00 $211.51 $0.00 $0.00 $215.16 $0.00 $0.00 $0.00 $0.00 $0.00 G50333 SUP HCPCS C1725 G50333 - CATHETER BLNDIL 3MM 170CM STRL LF 20CM ADV LOPRFL KINK RST BOTH IP/OP "$1,351.50 " "$1,000.11" $0.00 "$1,081.20" $733.86 $733.86 $0.00 $0.00 $0.00 $281.69 "$1,003.08" "$1,003.08" $0.00 $0.00 $281.65 $0.00 $799.41 $799.41 $0.00 $675.75 "$1,070.39" "$1,081.20" $0.00 $0.00 $211.51 $0.00 $0.00 $215.16 $0.00 $0.00 $0.00 $0.00 $0.00 G50337 SUP HCPCS C1725 G50337 - CATHETER BLNDIL 4MM 170CM STRL LF 8CM ADV LOPRFL KINK RST BOTH IP/OP "$1,351.50 " "$1,000.11" $0.00 "$1,081.20" $733.86 $733.86 $0.00 $0.00 $0.00 $281.69 "$1,003.08" "$1,003.08" $0.00 $0.00 $281.65 $0.00 $799.41 $799.41 $0.00 $675.75 "$1,070.39" "$1,081.20" $0.00 $0.00 $211.51 $0.00 $0.00 $215.16 $0.00 $0.00 $0.00 $0.00 $0.00 G50686 SUP HCPCS C1880 G50686 - SYSTEM EMBOLIC PROTECTION .038IN 12FR 40MM 11FR 75CM GWIRE BOTH IP/OP "$3,953.13 " "$2,925.32" $0.00 "$2,934.01" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $823.93 "$2,934.01" "$2,934.01" $0.00 $0.00 $823.83 $0.00 "$1,948.89" "$1,948.89" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 G50687 SUP HCPCS C1880 G50687 - SYSTEM EMBOLIC PROTECTION .038IN 12FR 40MM 11FR 45CM GWIRE BOTH IP/OP "$3,953.13 " "$2,925.32" $0.00 "$2,934.01" "$1,546.88" "$1,546.88" $0.00 $0.00 $0.00 $823.93 "$2,934.01" "$2,934.01" $0.00 $0.00 $823.83 $0.00 "$1,948.89" "$1,948.89" $0.00 "$1,718.75" "$2,722.50" "$2,750.00" $0.00 $0.00 $537.97 $0.00 $0.00 $547.25 $0.00 $0.00 $0.00 $0.00 $0.00 G50784 SUP HCPCS C1769 G50784 - GUIDEWIRE VASCULAR TAPER .014IN 135CM APPROACH STAINLESS BOTH IP/OP $416.88 $308.49 $0.00 $333.50 $226.36 $226.36 $0.00 $0.00 $0.00 $86.89 $309.40 $309.40 $0.00 $0.00 $86.88 $0.00 $246.58 $246.58 $0.00 $208.44 $330.17 $333.50 $0.00 $0.00 $65.24 $0.00 $0.00 $66.37 $0.00 $0.00 $0.00 $0.00 $0.00 G50785 SUP HCPCS C1769 G50785 - GUIDEWIRE VASCULAR TAPER .014IN 135CM APPROACH STAINLESS BOTH IP/OP $416.88 $308.49 $0.00 $333.50 $226.36 $226.36 $0.00 $0.00 $0.00 $86.89 $309.40 $309.40 $0.00 $0.00 $86.88 $0.00 $246.58 $246.58 $0.00 $208.44 $330.17 $333.50 $0.00 $0.00 $65.24 $0.00 $0.00 $66.37 $0.00 $0.00 $0.00 $0.00 $0.00 G50788 SUP HCPCS C1769 G50788 - GUIDEWIRE VASCULAR TAPER .014IN 190CM APPROACH STAINLESS BOTH IP/OP $423.13 $313.12 $0.00 $333.50 $226.36 $226.36 $0.00 $0.00 $0.00 $88.19 $314.05 $314.05 $0.00 $0.00 $88.18 $0.00 $250.28 $250.28 $0.00 $208.44 $330.17 $333.50 $0.00 $0.00 $65.24 $0.00 $0.00 $66.37 $0.00 $0.00 $0.00 $0.00 $0.00 G50789 SUP HCPCS C1769 G50789 - GUIDEWIRE VASCULAR TAPER .014IN 190CM APPROACH STAINLESS BOTH IP/OP $423.13 $313.12 $0.00 $333.50 $226.36 $226.36 $0.00 $0.00 $0.00 $88.19 $314.05 $314.05 $0.00 $0.00 $88.18 $0.00 $250.28 $250.28 $0.00 $208.44 $330.17 $333.50 $0.00 $0.00 $65.24 $0.00 $0.00 $66.37 $0.00 $0.00 $0.00 $0.00 $0.00 G50791 SUP HCPCS C1769 G50791 - GUIDEWIRE VASCULAR TAPER .014IN 300CM 12GM TIP LOAD APPROACH BOTH IP/OP $423.13 $313.12 $0.00 $333.50 $226.36 $226.36 $0.00 $0.00 $0.00 $88.19 $314.05 $314.05 $0.00 $0.00 $88.18 $0.00 $250.28 $250.28 $0.00 $208.44 $330.17 $333.50 $0.00 $0.00 $65.24 $0.00 $0.00 $66.37 $0.00 $0.00 $0.00 $0.00 $0.00 G50792 SUP HCPCS C1769 G50792 - GUIDEWIRE VASCULAR TAPER .014IN 300CM 18GM TIP LOAD APPROACH BOTH IP/OP $423.13 $313.12 $0.00 $333.50 $226.36 $226.36 $0.00 $0.00 $0.00 $88.19 $314.05 $314.05 $0.00 $0.00 $88.18 $0.00 $250.28 $250.28 $0.00 $208.44 $330.17 $333.50 $0.00 $0.00 $65.24 $0.00 $0.00 $66.37 $0.00 $0.00 $0.00 $0.00 $0.00 G50793 SUP HCPCS C1769 G50793 - GUIDEWIRE VASCULAR TAPER .014IN 300CM 25GM TIP LOAD APPROACH BOTH IP/OP $423.13 $313.12 $0.00 $333.50 $226.36 $226.36 $0.00 $0.00 $0.00 $88.19 $314.05 $314.05 $0.00 $0.00 $88.18 $0.00 $250.28 $250.28 $0.00 $208.44 $330.17 $333.50 $0.00 $0.00 $65.24 $0.00 $0.00 $66.37 $0.00 $0.00 $0.00 $0.00 $0.00 G50972 SUP HCPCS C1894 G50972 - NEEDLE PRC SHTH TFE BOTH IP/OP "$5,118.75 " "$3,787.88" $0.00 "$4,095.00" "$2,779.48" "$2,779.48" $0.00 $0.00 $0.00 "$1,066.88" "$3,799.14" "$3,799.14" $0.00 $0.00 "$1,066.75" $0.00 "$3,027.74" "$3,027.74" $0.00 "$2,559.38" "$4,054.05" "$4,095.00" $0.00 $0.00 $801.08 $0.00 $0.00 $814.91 $0.00 $0.00 $0.00 $0.00 $0.00 G50973 SUP HCPCS C1894 G50973 - SHEATH ACC FLXR DFLC VSN URETER BOTH IP/OP "$1,023.75 " $757.58 $0.00 $819.00 $555.90 $555.90 $0.00 $0.00 $0.00 $213.38 $759.83 $759.83 $0.00 $0.00 $213.35 $0.00 $605.55 $605.55 $0.00 $511.88 $810.81 $819.00 $0.00 $0.00 $160.22 $0.00 $0.00 $162.98 $0.00 $0.00 $0.00 $0.00 $0.00 G50974 SUP HCPCS C1894 G50974 - SHEATH ACC 180D FLXR DFLC VSN URETER BOTH IP/OP "$1,023.75 " $757.58 $0.00 $819.00 $555.90 $555.90 $0.00 $0.00 $0.00 $213.38 $759.83 $759.83 $0.00 $0.00 $213.35 $0.00 $605.55 $605.55 $0.00 $511.88 $810.81 $819.00 $0.00 $0.00 $160.22 $0.00 $0.00 $162.98 $0.00 $0.00 $0.00 $0.00 $0.00 G51183 SUP HCPCS C1874 G51183 - STENT ESOPHAGEAL 23MM 18MM 12CM 2 LASSO LOOP CONTROL RELEASE BOTH IP/OP "$4,705.00 " "$3,481.70" $0.00 "$3,764.00" "$2,117.25" "$2,117.25" $0.00 $0.00 $0.00 $980.64 "$3,492.05" "$3,492.05" $0.00 $0.00 $980.52 $0.00 "$2,319.57" "$2,319.57" $0.00 "$2,352.50" "$3,726.36" "$3,764.00" $0.00 $0.00 $736.33 $0.00 $0.00 $749.04 $0.00 $0.00 $0.00 $0.00 $0.00 G51574 SUP HCPCS C1887 G51574 - CATHETER GUID .014IN 3-1.9FR 150CM SUPPORT CORSSCATH BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $196.84 $196.84 $0.00 $0.00 $0.00 $75.55 $269.05 $269.05 $0.00 $0.00 $75.55 $0.00 $214.42 $214.42 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $56.73 $0.00 $0.00 $57.71 $0.00 $0.00 $0.00 $0.00 $0.00 G51954 SUP HCPCS C1769 G51954 - GUIDEWIRE VASCULAR MICRO .018IN 190CM SHAPEABLE TIP APPROACH BOTH IP/OP $167.03 $123.60 $0.00 $133.62 $90.69 $90.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.51 $132.29 $133.62 $0.00 $0.00 $26.14 $0.00 $0.00 $26.59 $0.00 $0.00 $0.00 $0.00 $0.00 G51956 SUP HCPCS C1769 G51956 - GUIDEWIRE VASCULAR MICRO .018IN 300CM SHAPEABLE TIP APPROACH BOTH IP/OP $218.68 $161.82 $0.00 $174.94 $118.74 $118.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.34 $173.19 $174.94 $0.00 $0.00 $34.22 $0.00 $0.00 $34.81 $0.00 $0.00 $0.00 $0.00 $0.00 G52226 SUP HCPCS C1874 G52226 - STENT ESOPHAGEAL 25MM 20MM 12CM CONTROLLED RELEASE FULLY BOTH IP/OP "$4,705.00 " "$3,481.70" $0.00 "$3,764.00" "$2,117.25" "$2,117.25" $0.00 $0.00 $0.00 $980.64 "$3,492.05" "$3,492.05" $0.00 $0.00 $980.52 $0.00 "$2,319.57" "$2,319.57" $0.00 "$2,352.50" "$3,726.36" "$3,764.00" $0.00 $0.00 $736.33 $0.00 $0.00 $749.04 $0.00 $0.00 $0.00 $0.00 $0.00 G52247 SUP HCPCS C1725 G52247 - CATHETER BLNDIL 3MM 135CM STRL LF 8CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52249 SUP HCPCS C1725 G52249 - CATHETER BLNDIL 3MM 135CM STRL LF 12CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52253 SUP HCPCS C1725 G52253 - CATHETER BLNDIL 4MM 135CM STRL LF 8CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52260 SUP HCPCS C1725 G52260 - CATHETER BLNDIL 5MM 135CM STRL LF 8CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52263 SUP HCPCS C1725 G52263 - CATHETER BLNDIL 5MM 135CM STRL LF 14CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52267 SUP HCPCS C1725 G52267 - CATHETER BLNDIL 6MM 135CM STRL LF 8CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52270 SUP HCPCS C1725 G52270 - CATHETER BLNDIL 6MM 135CM STRL LF 14CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52274 SUP HCPCS C1725 G52274 - CATHETER BLNDIL 7MM 135CM STRL LF 8CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52277 SUP HCPCS C1725 G52277 - CATHETER BLNDIL 7MM 135CM STRL LF 14CM ADV 2 LUM LOPRFL BOTH IP/OP $600.00 $444.00 $0.00 $480.00 $325.80 $325.80 $0.00 $0.00 $0.00 $125.06 $445.32 $445.32 $0.00 $0.00 $125.04 $0.00 $354.90 $354.90 $0.00 $300.00 $475.20 $480.00 $0.00 $0.00 $93.90 $0.00 $0.00 $95.52 $0.00 $0.00 $0.00 $0.00 $0.00 G52349 SUP HCPCS C1725 G52349 - CATHETER BLNDIL 6MM 80CM STRL LF 12CM ADV 2 LUM LOPRFL BOTH IP/OP $612.00 $452.88 $0.00 $489.60 $332.32 $332.32 $0.00 $0.00 $0.00 $127.56 $454.23 $454.23 $0.00 $0.00 $127.54 $0.00 $362.00 $362.00 $0.00 $306.00 $484.70 $489.60 $0.00 $0.00 $95.78 $0.00 $0.00 $97.43 $0.00 $0.00 $0.00 $0.00 $0.00 G52542 SUP HCPCS C1887 G52542 - CATHETER GUID .035IN 4FR 135CM SUPPORT STR TIP LP RADIOPQ BOTH IP/OP $494.81 $366.16 $0.00 $390.00 $264.71 $264.71 $0.00 $0.00 $0.00 $103.13 $367.25 $367.25 $0.00 $0.00 $103.12 $0.00 $292.68 $292.68 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 G52543 SUP HCPCS C1887 G52543 - CATHETER SPRT DAV CRV 4FR 135CM STRL CXI RADOPQ BRD LOPRFL BOTH IP/OP $494.81 $366.16 $0.00 $390.00 $264.71 $264.71 $0.00 $0.00 $0.00 $103.13 $367.25 $367.25 $0.00 $0.00 $103.12 $0.00 $292.68 $292.68 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 G52545 SUP HCPCS C1887 G52545 - CATHETER GUID .035IN 4FR 150CM SUPPORT ANGLED TIP LP RADIOPQ BOTH IP/OP $494.81 $366.16 $0.00 $390.00 $264.71 $264.71 $0.00 $0.00 $0.00 $103.13 $367.25 $367.25 $0.00 $0.00 $103.12 $0.00 $292.68 $292.68 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $76.29 $0.00 $0.00 $77.61 $0.00 $0.00 $0.00 $0.00 $0.00 G52599 SUP Custom 27203010 G52599 - SHEATH ACC VUE FLXR DFLC UT ESCP SYS BOTH IP/OP $64.13 $47.46 $0.00 $51.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.59 $47.59 $0.00 $0.00 $13.36 $0.00 $0.00 $0.00 $0.00 $32.06 $50.79 $51.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52603 SUP Custom 27203010 G52603 - CARTRIDGE CO2 LITHOTRIPTER PNEUMATIC KIT LMA STONEBREAKER BOTH IP/OP $35.63 $26.37 $0.00 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.44 $26.44 $0.00 $0.00 $7.42 $0.00 $0.00 $0.00 $0.00 $17.81 $28.22 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52605 SUP Custom 27203010 G52605 - CATHETER URTH 10FR 25CM 3ML UNIVERSA 2W OP-EN BLN FL SIL DOD BOTH IP/OP $192.19 $142.22 $0.00 $153.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.64 $142.64 $0.00 $0.00 $40.05 $0.00 $0.00 $0.00 $0.00 $96.09 $152.21 $153.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52606 SUP Custom 27203010 G52606 - PROBE LITHOTRIPTER 1.6MM 500MM PNEUMATIC KIT LMA BOTH IP/OP $461.25 $341.33 $0.00 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.34 $342.34 $0.00 $0.00 $96.12 $0.00 $0.00 $0.00 $0.00 $230.63 $365.31 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52607 SUP Custom 27203010 G52607 - PROBE LITHOTRIPTER 1MM 500MM PNEUMATIC KIT LMA STONEBREAKER BOTH IP/OP $461.25 $341.33 $0.00 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.34 $342.34 $0.00 $0.00 $96.12 $0.00 $0.00 $0.00 $0.00 $230.63 $365.31 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52608 SUP Custom 27203010 G52608 - PROBE LITHOTRIPTER 2MM 425MM PNEUMATIC KIT STONEBREAKER BOTH IP/OP $461.25 $341.33 $0.00 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.34 $342.34 $0.00 $0.00 $96.12 $0.00 $0.00 $0.00 $0.00 $230.63 $365.31 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52609 SUP Custom 27203010 G52609 - LITHOTRIPTER SRG LMA STONEBREAKER XHST LN STRL PRB CAP PORT BOTH IP/OP "$2,306.25 " "$1,706.63" $0.00 "$1,845.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,711.70" "$1,711.70" $0.00 $0.00 $480.62 $0.00 $0.00 $0.00 $0.00 "$1,153.13" "$1,826.55" "$1,845.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52736 SUP HCPCS Q4107 G52736 - COIL EMBOLIZATION 7CM 3MM NESTER 7.4 LOOP SOFT ENHANCED RADI BOTH IP/OP $249.30 $184.48 $0.00 $199.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.03 $185.03 $0.00 $0.00 $51.95 $0.00 $0.00 $0.00 $0.00 $124.65 $197.45 $199.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52737 SUP Custom 27805113 G52737 - COIL EMBOLIZATION .018IN 4MM 7CM 5.6 LOOP SOFT ENHANCED BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52742 SUP Custom 27803010 G52742 - COIL EMBOLIZATION .035IN 4MM 7CM 5.6 LOOP SOFT ENHANCED BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52745 SUP Custom 27803010 G52745 - COIL EMBOLIZATION .035IN 10MM 7CM 2.2 LOOP SOFT ENHANCED BOTH IP/OP $264.20 $195.51 $0.00 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.09 $196.09 $0.00 $0.00 $55.06 $0.00 $0.00 $0.00 $0.00 $132.10 $209.25 $211.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52753 SUP Custom 27803010 G52753 - COIL EMBOLIZATION .035IN 18MM 14CM 2.5 LOOP SOFT ENHANCED BOTH IP/OP $303.83 $224.83 $0.00 $243.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.50 $225.50 $0.00 $0.00 $63.32 $0.00 $0.00 $0.00 $0.00 $151.91 $240.63 $243.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52754 SUP Custom 27803010 G52754 - COIL EMBOLIZATION .035IN 20MM 14CM 2.2 LOOP SOFT ENHANCED BOTH IP/OP $303.83 $224.83 $0.00 $243.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.50 $225.50 $0.00 $0.00 $63.32 $0.00 $0.00 $0.00 $0.00 $151.91 $240.63 $243.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52756 SUP Custom 27803010 G52756 - COIL EMBOLIZATION .035IN 20MM 20CM 3.2 LOOP SOFT ENHANCED BOTH IP/OP $325.28 $240.71 $0.00 $260.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.42 $241.42 $0.00 $0.00 $67.79 $0.00 $0.00 $0.00 $0.00 $162.64 $257.62 $260.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G52909 SUP HCPCS C1880 G52909 - FILTER EMBOLIZATION 30MM 7FR 48MM 65CM NAVALIGN DELIVERY BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 G52914 SUP HCPCS C1880 G52914 - SYSTEM EMBL PRTC 30MM 7FR 48MM 65CM CELECT NAVALIGN DLV BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,569.38" "$1,569.38" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$1,719.34" "$1,719.34" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 G53030 SUP HCPCS C1758 G53030 - PROBE LTHTRP 1.6MM 605MM LMA STONEBREAKER PNEUM KT DISP BOTH IP/OP $63.75 $47.18 $0.00 $51.00 $34.62 $34.62 $0.00 $0.00 $0.00 $13.29 $47.32 $47.32 $0.00 $0.00 $13.29 $0.00 $37.71 $37.71 $0.00 $31.88 $50.49 $51.00 $0.00 $0.00 $9.98 $0.00 $0.00 $10.15 $0.00 $0.00 $0.00 $0.00 $0.00 G53145 SUP HCPCS C2617 G53145 - CATHETER URTH 16FR 34CM 30ML UNIVERSA 3W FL RND BLDR SIL BOTH IP/OP $20.25 $14.99 $0.00 $16.20 $9.11 $9.11 $0.00 $0.00 $0.00 $4.22 $15.03 $15.03 $0.00 $0.00 $4.22 $0.00 $11.98 $11.98 $0.00 $10.13 $16.04 $16.20 $0.00 $0.00 $3.17 $0.00 $0.00 $3.22 $0.00 $0.00 $0.00 $0.00 $0.00 G53146 SUP HCPCS C2617 G53146 - SET STNT .038IN 3CM PGTL CRV 5FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53179 SUP HCPCS C1769 G53179 - TRAY TRACHEOSTOMY 2 CANNU TUBE SHILEY CUFFED PLIANT TIP BOTH IP/OP "$1,142.50 " $845.45 $0.00 $975.16 $661.89 $661.89 $0.00 $0.00 $0.00 $238.13 $847.96 $847.96 $0.00 $0.00 $238.10 $0.00 $675.79 $675.79 $0.00 $609.48 $965.41 $975.16 $0.00 $0.00 $190.77 $0.00 $0.00 $194.06 $0.00 $0.00 $0.00 $0.00 $0.00 G53211 SUP HCPCS C1769 G53211 - SET STNT 2 PGTL CRV 8FR 22-32CM STRL UNIVERSA RADOPQ SFT BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53235 SUP HCPCS C1758 G53235 - CATHETER URTH 26FR 34CM 30ML UNIVERSA 2W FL RND TIP CLS END BOTH IP/OP $26.56 $19.65 $0.00 $21.25 $14.42 $14.42 $0.00 $0.00 $0.00 $5.54 $19.71 $19.71 $0.00 $0.00 $5.54 $0.00 $15.71 $15.71 $0.00 $13.28 $21.04 $21.25 $0.00 $0.00 $4.16 $0.00 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 G53236 SUP HCPCS C1758 G53236 - CATHETER URTH 18FR 34CM 30ML UNIVERSA 3W FL RND TIP CLS END BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53237 SUP HCPCS C1758 G53237 - CATHETER URTH 20FR 34CM 30ML UNIVERSA 3W FL RND TIP CLS END BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53238 SUP HCPCS C1758 G53238 - CATHETER URTH 22FR 34CM 30ML UNIVERSA 3W FL RND TIP CLS END BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53240 SUP HCPCS C1758 G53240 - CATHETER URTH 24FR 34CM 30ML UNIVERSA 3W FL RND TIP CLS END BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53241 SUP HCPCS C1758 G53241 - CATHETER URTH 26FR 34CM 30ML UNIVERSA 3W FL RND TIP CLS END BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53242 SUP HCPCS C1758 G53242 - CATHETER URTH 16FR 34CM 30ML UNIVERSA 3W FL OP-EN SIL BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53243 SUP HCPCS C1758 G53243 - CATHETER URTH 18FR 34CM 30ML UNIVERSA 3W FL OP-EN SIL BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53244 SUP HCPCS C1758 G53244 - CATHETER URTH 20FR 34CM 30ML UNIVERSA 3W FL OP-EN SIL BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53245 SUP HCPCS C1758 G53245 - CATHETER URTH 22FR 34CM 30ML UNIVERSA 3W FL OP-EN SIL BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53246 SUP HCPCS C1758 G53246 - CATHETER URTH 24FR 34CM 30ML UNIVERSA 3W FL OP-EN SIL BOTH IP/OP $31.88 $23.59 $0.00 $25.50 $17.31 $17.31 $0.00 $0.00 $0.00 $6.64 $23.66 $23.66 $0.00 $0.00 $6.64 $0.00 $18.85 $18.85 $0.00 $15.94 $25.25 $25.50 $0.00 $0.00 $4.99 $0.00 $0.00 $5.07 $0.00 $0.00 $0.00 $0.00 $0.00 G53421 SUP HCPCS C1874 G53421 - GRAFT EVAS BFUR 30MM 20FR 120MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" "$13,605.75" "$13,605.75" $0.00 $0.00 $0.00 "$6,301.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 "$14,905.86" "$14,905.86" $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 "$4,731.78" $0.00 $0.00 "$4,813.41" $0.00 $0.00 $0.00 $0.00 $0.00 G53422 SUP Custom 27803010 G53422 - GRAFT EVAS BFUR 30MM 20FR 140MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53423 SUP Custom 27803010 G53423 - GRAFT EVAS 30MM 20FR 200MM ZNTH TX2 DIST CMPNT PRFRM Z TRK + BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53424 SUP Custom 27803010 G53424 - GRAFT EVAS BFUR 32MM 20FR 120MM ZNTH TX2 PRFRM Z-TRK + PROX BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53426 SUP HCPCS C1874 G53426 - GRAFT EVAS 2 BRCH 32MM 20FR 200MM ZNTH TX2 PROX PRFRM Z-TRK BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" "$13,605.75" "$13,605.75" $0.00 $0.00 $0.00 "$6,301.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 "$14,905.86" "$14,905.86" $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 "$4,731.78" $0.00 $0.00 "$4,813.41" $0.00 $0.00 $0.00 $0.00 $0.00 G53427 SUP HCPCS C1874 G53427 - GRAFT EVAS 2 BRCH CYL 34MM 20FR 127MM STRL PRFRM Z-TRK + BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" "$13,605.75" "$13,605.75" $0.00 $0.00 $0.00 "$6,301.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 "$14,905.86" "$14,905.86" $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 "$4,731.78" $0.00 $0.00 "$4,813.41" $0.00 $0.00 $0.00 $0.00 $0.00 G53428 SUP Custom 27803010 G53428 - GRAFT EVAS BFUR 34MM 20FR 152MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53429 SUP Custom 27803010 G53429 - GRAFT EVAS BFUR 34MM 20FR 202MM ZNTH TX2 PRFRM Z-TRK + PROX BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53430 SUP Custom 27803010 G53430 - GRAFT EVAS BFUR 36MM 22FR 127MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53433 SUP HCPCS C1874 G53433 - GRAFT EVAS 2 BRCH 38MM 22FR 127MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" "$13,605.75" "$13,605.75" $0.00 $0.00 $0.00 "$6,301.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 "$14,905.86" "$14,905.86" $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 "$4,731.78" $0.00 $0.00 "$4,813.41" $0.00 $0.00 $0.00 $0.00 $0.00 G53434 SUP Custom 27803010 G53434 - GRAFT EVAS BFUR 38MM 22FR 152MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53435 SUP Custom 27803010 G53435 - GRAFT EVAS BFUR 38MM 22FR 202MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53436 SUP Custom 27803010 G53436 - GRAFT EVAS BFUR 40MM 22FR 135MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53440 SUP Custom 27803010 G53440 - GRAFT EVAS BFUR 42MM 22FR 162MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53441 SUP Custom 27803010 G53441 - GRAFT EVAS BFUR 42MM 22FR 216MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53442 SUP Custom 27803010 G53442 - GRAFT EVAS BFUR 32MM 20FR 160MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53446 SUP Custom 27803010 G53446 - GRAFT EVAS BFUR 36MM 22FR 157MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53449 SUP HCPCS C1874 G53449 - GRAFT EVAS CYL TPR 38-34MM 8.5MM 22FR 202MM STRL PRFRM Z-TRK BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" "$13,605.75" "$13,605.75" $0.00 $0.00 $0.00 "$6,301.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 "$14,905.86" "$14,905.86" $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 "$4,731.78" $0.00 $0.00 "$4,813.41" $0.00 $0.00 $0.00 $0.00 $0.00 G53450 SUP Custom 27803010 G53450 - GRAFT EVAS 40MM 22FR 158MM ZNTH TX2 PROX TPR CMPNT PRFRM BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 $0.00 $0.00 $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53454 SUP Custom 27803010 G53454 - GRAFT EVAS 28MM 20FR 80MM ZNTH TX2 TBE CMPNT PROX XTN PRFRM BOTH IP/OP "$12,996.03 " "$9,617.06" $0.00 "$10,396.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.37" $0.00 $0.00 $0.00 $0.00 "$6,498.01" "$10,292.86" "$10,396.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53455 SUP Custom 27803010 G53455 - GRAFT EVAS BFUR 30MM 20FR 80MM ZNTH TX2 PRFRM Z-TRK + PROX BOTH IP/OP "$12,995.00 " "$9,616.30" $0.00 "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.16" $0.00 $0.00 $0.00 $0.00 "$6,497.50" "$10,292.04" "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53456 SUP Custom 27803010 G53456 - GRAFT EVAS BFUR 32MM 20FR 80MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$12,995.00 " "$9,616.30" $0.00 "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.16" $0.00 $0.00 $0.00 $0.00 "$6,497.50" "$10,292.04" "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53457 SUP Custom 27803010 G53457 - GRAFT EVAS 34MM 20FR 77MM ZNTH TX2 DIST XTN TBE CMPNT PRFRM BOTH IP/OP "$12,995.00 " "$9,616.30" $0.00 "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.16" $0.00 $0.00 $0.00 $0.00 "$6,497.50" "$10,292.04" "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53458 SUP Custom 27803010 G53458 - GRAFT EVAS 36MM 22FR 77MM ZNTH TX2 PROX XTN Z-TRK + TAA BOTH IP/OP "$12,995.00 " "$9,616.30" $0.00 "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.16" $0.00 $0.00 $0.00 $0.00 "$6,497.50" "$10,292.04" "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53459 SUP Custom 27803010 G53459 - GRAFT EVAS 38MM 22FR 77MM ZNTH TX2 PROX XTN PRFRM Z TRK + BOTH IP/OP "$12,995.00 " "$9,616.30" $0.00 "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.16" $0.00 $0.00 $0.00 $0.00 "$6,497.50" "$10,292.04" "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53460 SUP Custom 27803010 G53460 - GRAFT EVAS BFUR 40MM 22FR 81MM ZNTH TX2 PRFRM Z-TRK + SLF BOTH IP/OP "$12,995.00 " "$9,616.30" $0.00 "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.16" $0.00 $0.00 $0.00 $0.00 "$6,497.50" "$10,292.04" "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53461 SUP Custom 27803010 G53461 - GRAFT EVAS 42MM 22FR 81MM ZNTH TX2 PROX XTN PRFRM Z-TRK + BOTH IP/OP "$12,995.00 " "$9,616.30" $0.00 "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.16" $0.00 $0.00 $0.00 $0.00 "$6,497.50" "$10,292.04" "$10,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53463 SUP HCPCS C1874 G53463 - GRAFT EVAS 30MM 7.7MM 20FR 80MM STRL ZNTH TX2 PRFRM ESBE BOTH IP/OP "$12,995.00 " "$9,616.30" $0.00 "$10,396.00" "$5,847.75" "$5,847.75" $0.00 $0.00 $0.00 "$2,708.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,708.16" $0.00 "$6,406.54" "$6,406.54" $0.00 "$6,497.50" "$10,292.04" "$10,396.00" $0.00 $0.00 "$2,033.72" $0.00 $0.00 "$2,068.80" $0.00 $0.00 $0.00 $0.00 $0.00 G53486 SUP Custom 27803010 G53486 - GRAFT EVAS 42MM 22FR 144MM ZNTH TX2 PRFRM Z TRK + INTRO SYS BOTH IP/OP "$16,442.50 " "$12,167.45" $0.00 "$13,154.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,426.62" $0.00 $0.00 $0.00 $0.00 "$8,221.25" "$13,022.46" "$13,154.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G53556 SUP HCPCS C1769 G53556 - CATHETER URTH 26FR 34CM 30ML UNIVERSA 3W FL OP-EN SIL BOTH IP/OP $6.76 $5.00 $0.00 $5.41 $3.67 $3.67 $0.00 $0.00 $0.00 $1.41 $5.02 $5.02 $0.00 $0.00 $1.41 $0.00 $4.00 $4.00 $0.00 $3.38 $5.35 $5.41 $0.00 $0.00 $1.06 $0.00 $0.00 $1.08 $0.00 $0.00 $0.00 $0.00 $0.00 G53557 SUP HCPCS C1769 G53557 - GUIDEWIRE VASC STRG .038IN 145CM STRL 5CM AMPTZ FLXB STF BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53558 SUP HCPCS C1769 G53558 - GUIDEWIRE VASC STRG .038IN 145CM STRL 5CM AMPTZ 2 FLXB STF BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53559 SUP HCPCS C1769 G53559 - GUIDEWIRE ESCP STRG .025IN 145CM STRL 5CM AMPTZ XSTF FXCR BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53560 SUP HCPCS C1769 G53560 - CATHETER NPHSTM 8MM 15CM ULTRX BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53561 SUP HCPCS C1769 G53561 - GUIDEWIRE ESCP .035IN STRG 145CM 5CM AMPTZ FLX TP FXCR XSTF BOTH IP/OP $88.13 $65.22 $0.00 $70.50 $47.85 $47.85 $0.00 $0.00 $0.00 $18.37 $65.41 $65.41 $0.00 $0.00 $18.37 $0.00 $52.13 $52.13 $0.00 $44.06 $69.80 $70.50 $0.00 $0.00 $13.79 $0.00 $0.00 $14.03 $0.00 $0.00 $0.00 $0.00 $0.00 G53562 SUP HCPCS C1769 G53562 - GUIDEWIRE ESCP STRG .035IN 260CM STRL 5CM AMPTZ XSTF FXCR BOTH IP/OP $88.13 $65.22 $0.00 $70.50 $47.85 $47.85 $0.00 $0.00 $0.00 $18.37 $65.41 $65.41 $0.00 $0.00 $18.37 $0.00 $52.13 $52.13 $0.00 $44.06 $69.80 $70.50 $0.00 $0.00 $13.79 $0.00 $0.00 $14.03 $0.00 $0.00 $0.00 $0.00 $0.00 G53563 SUP HCPCS C1769 G53563 - GUIDEWIRE ESCP STRG .038IN 260CM STRL 5CM AMPTZ XSTF FXCR BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53564 SUP HCPCS C1769 G53564 - GUIDEWIRE VASC STRG .035IN 145CM STRL 5CM AMPTZ 2 FLX TP BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53566 SUP HCPCS C1769 G53566 - GUIDEWIRE URO STRG .038IN 145CM 5CM AMPTZ 2 FLX TP FX COR BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53567 SUP HCPCS C1769 G53567 - GUIDEWIRE VASC STRG .035IN 145CM 5CM AMPTZ 2 FLX TP FXCR ULT BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53568 SUP HCPCS C1769 G53568 - GUIDEWIRE VASC STRG .038IN 145CM STRL 5CM AMPTZ FLXB ULT STF BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53569 SUP HCPCS C1769 G53569 - GUIDEWIRE VASC STRG .035IN 145CM STRL 5CM AMPTZ 2 FLXB ULT BOTH IP/OP $67.58 $50.01 $0.00 $54.06 $36.69 $36.69 $0.00 $0.00 $0.00 $14.08 $50.15 $50.15 $0.00 $0.00 $14.08 $0.00 $39.97 $39.97 $0.00 $33.79 $53.52 $54.06 $0.00 $0.00 $10.58 $0.00 $0.00 $10.76 $0.00 $0.00 $0.00 $0.00 $0.00 G53672 SUP HCPCS C2617 G53672 - GUIDEWIRE VASC STRG .038IN 145CM STRL 5CM AMPTZ 2 FLXB ULT BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53674 SUP HCPCS C2617 G53674 - SET STNT .038IN 3CM PGTL CRV 5FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53675 SUP HCPCS C2617 G53675 - SET STNT .038IN 3CM PGTL CRV 5FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53676 SUP HCPCS C2617 G53676 - SET STNT 3CM PGTL CRV 5FR 22CM STRL 145CM UNIVERSA RADOPQ BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53677 SUP HCPCS C2617 G53677 - SET STNT .038IN 3CM PGTL CRV 5FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53678 SUP HCPCS C2617 G53678 - SET STNT .038IN 3CM PGTL CRV 5FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53680 SUP HCPCS C2617 G53680 - SET STNT .038IN 3CM PGTL CRV 5FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53681 SUP HCPCS C2617 G53681 - SET STNT 2 PGTL CRV 5FR 18CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53682 SUP HCPCS C2617 G53682 - SET STNT 2 PGTL CRV 5FR 20CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53683 SUP HCPCS C2617 G53683 - SET STNT 2 PGTL CRV 5FR 22CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53684 SUP HCPCS C2617 G53684 - SET STNT 2 PGTL CRV 5FR 24CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53685 SUP HCPCS C2617 G53685 - SET STNT 2 PGTL CRV 5FR 26CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53686 SUP HCPCS C2617 G53686 - SET STNT 2 PGTL CRV 5FR 28CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53687 SUP HCPCS C2617 G53687 - SET STNT 2 PGTL CRV 5FR 30CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53688 SUP HCPCS C2617 G53688 - SET STNT .038IN 3CM PGTL CRV 5FR 22-32CM STRL 145CM UNIVERSA BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53689 SUP HCPCS C2617 G53689 - SET STNT 2 PGTL CRV 5FR 22-32CM STRL UNIVERSA PSTNR BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53690 SUP HCPCS C2617 G53690 - SET STNT 2 PGTL CRV 6FR 18CM UNIVERSA SFT GRAD MRK BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53691 SUP HCPCS C2617 G53691 - SET STNT PGTL CRV 6FR 20CM UNIVERSA SFT GRAD MRK BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53692 SUP HCPCS C2617 G53692 - SET STNT 2 PGTL CRV 6FR 22CM UNIVERSA SFT GRAD MRK BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53693 SUP HCPCS C2617 G53693 - SET STNT .038IN 3CM PGTL CRV 6FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53694 SUP HCPCS C2617 G53694 - SET STNT .038IN 3CM PGTL CRV 6FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53695 SUP HCPCS C2617 G53695 - SET STNT PGTL CRV 6FR 28CM UNIVERSA GW SFT GRAD MRK BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53696 SUP HCPCS C2617 G53696 - SET STNT .038IN 3CM PGTL CRV 6FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53697 SUP HCPCS C2617 G53697 - SET STNT 2 PGTL CRV 6FR 18CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53698 SUP HCPCS C2617 G53698 - SET STNT 6FR 22CM STRL LF UNIVERSA PSTNR GW BRD TETH RADOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53699 SUP HCPCS C2617 G53699 - SET STNT 2 PGTL CRV 6FR 20CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53700 SUP HCPCS C2617 G53700 - SET STNT 6FR 26CM STRL LF UNIVERSA PSTNR GW BRD TETH RADOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53701 SUP HCPCS C2617 G53701 - SET STNT 6FR 24CM STRL LF UNIVERSA PSTNR GW BRD TETH RADOPQ BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53702 SUP HCPCS C2617 G53702 - SET STNT 2 PGTL CRV 6FR 28CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53703 SUP HCPCS C2617 G53703 - SET STNT 2 PGTL CRV 6FR 30CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53704 SUP HCPCS C2617 G53704 - SET STNT .038IN 3CM PGTL CRV 6FR 22-32CM STRL 145CM UNIVERSA BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53706 SUP HCPCS C2617 G53706 - SET STNT 2 PGTL CRV 6FR 22-32CM STRL UNIVERSA RADOPQ MTLNTH BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53707 SUP HCPCS C2617 G53707 - SET STNT 3CM PGTL CRV 7FR 22-32CM STRL LF 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53708 SUP HCPCS C2617 G53708 - SET STNT .038IN 3CM PGTL CRV 7FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53709 SUP HCPCS C2617 G53709 - SET STNT .038IN 3CM PGTL CRV 7FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53710 SUP HCPCS C2617 G53710 - SET STNT .038IN 3CM PGTL CRV 7FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53711 SUP HCPCS C2617 G53711 - SET STNT .038IN 3CM PGTL CRV 7FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53712 SUP HCPCS C2617 G53712 - SET STNT .038IN 3CM PGTL CRV 7FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53713 SUP HCPCS C2617 G53713 - SET STNT .038IN 3CM PGTL CRV 7FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53714 SUP HCPCS C2617 G53714 - SET STNT .038IN 3CM PGTL CRV 7FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53715 SUP HCPCS C2617 G53715 - SET STNT 2 PGTL CRV 7FR 18CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53716 SUP HCPCS C2617 G53716 - SET STNT 2 PGTL CRV 7FR 20CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53717 SUP HCPCS C2617 G53717 - SET STNT 2 PGTL CRV 7FR 22CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53718 SUP HCPCS C2617 G53718 - SET STNT 2 PGTL CRV 7FR 24CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53719 SUP HCPCS C2617 G53719 - SET STNT 2 PGTL CRV 7FR 26CM STRL LF UNIVERSA RADOPQ SFT BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53720 SUP HCPCS C2617 G53720 - SET STNT 2 PGTL CRV 7FR 28CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53721 SUP HCPCS C2617 G53721 - SET STNT 2 PGTL CRV 7FR 30CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53722 SUP HCPCS C2617 G53722 - SET STNT .038IN 3CM PGTL CRV 8FR 22-32CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53723 SUP HCPCS C2617 G53723 - SET STNT .038IN 3CM PGTL CRV 8FR 18CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53724 SUP HCPCS C2617 G53724 - SET STNT .038IN 3CM PGTL CRV 8FR 20CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53725 SUP HCPCS C2617 G53725 - SET STNT .038IN 3CM PGTL CRV 8FR 22CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53726 SUP HCPCS C2617 G53726 - SET STNT .038IN 3CM PGTL CRV 8FR 24CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53727 SUP HCPCS C2617 G53727 - SET STNT .038IN 3CM PGTL CRV 8FR 26CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53728 SUP HCPCS C2617 G53728 - SET STNT .038IN 3CM PGTL CRV 8FR 28CM STRL 145CM UNIVERSA BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $91.13 $91.13 $0.00 $0.00 $0.00 $42.21 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $119.78 $119.78 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $31.69 $0.00 $0.00 $32.24 $0.00 $0.00 $0.00 $0.00 $0.00 G53729 SUP HCPCS C2617 G53729 - SET STNT .038IN 3CM PGTL CRV 8FR 30CM STRL 145CM UNIVERSA BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53731 SUP HCPCS C2617 G53731 - SET STNT 2 PGTL CRV 8FR 18CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53732 SUP HCPCS C2617 G53732 - SET STNT 2 PGTL CRV 8FR 20CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53734 SUP HCPCS C2617 G53734 - SET STNT 2 PGTL CRV 8FR 22CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53735 SUP HCPCS C2617 G53735 - SET STNT 2 PGTL CRV 8FR 24CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53736 SUP HCPCS C2617 G53736 - SET STNT 2 PGTL CRV 8FR 26CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G53737 SUP HCPCS C2617 G53737 - SET STNT 2 PGTL CRV 8FR 28CM STRL UNIVERSA RADOPQ SFT PSTNR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G54613 SUP HCPCS C1763 G54613 - GRAFT SOFT TISSUE .4CM SET PLUG BUTTON BIODESIGN SURGISIS BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G54614 SUP HCPCS C1763 G54614 - GRAFT ENDOVASCULAR .7CM SET PLUG BUTTON BIODESIGN SURGISIS BOTH IP/OP "$2,612.50 " "$1,933.25" $0.00 "$2,090.00" "$1,175.63" "$1,175.63" $0.00 $0.00 $0.00 $544.51 "$1,939.00" "$1,939.00" $0.00 $0.00 $544.45 $0.00 "$1,287.96" "$1,287.96" $0.00 "$1,306.25" "$2,069.10" "$2,090.00" $0.00 $0.00 $408.86 $0.00 $0.00 $415.91 $0.00 $0.00 $0.00 $0.00 $0.00 G55230 SUP HCPCS C1874 G55230 - GRAFT EVAS 2 BRCH 13MM 5.4MM 14FR 39MM STRL ZNTH SPRLZ Z-TRK BOTH IP/OP "$7,712.50 " "$5,707.25" $0.00 "$6,170.00" "$3,470.63" "$3,470.63" $0.00 $0.00 $0.00 "$1,607.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,607.29" $0.00 "$3,802.26" "$3,802.26" $0.00 "$3,856.25" "$6,108.30" "$6,170.00" $0.00 $0.00 "$1,207.01" $0.00 $0.00 "$1,227.83" $0.00 $0.00 $0.00 $0.00 $0.00 G55231 SUP HCPCS C1874 G55231 - GRAFT EVAS 2 BRCH 13MM 5.4MM 14FR 56MM STRL ZNTH SPRLZ Z-TRK BOTH IP/OP "$7,712.50 " "$5,707.25" $0.00 "$6,170.00" "$3,470.63" "$3,470.63" $0.00 $0.00 $0.00 "$1,607.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,607.29" $0.00 "$3,802.26" "$3,802.26" $0.00 "$3,856.25" "$6,108.30" "$6,170.00" $0.00 $0.00 "$1,207.01" $0.00 $0.00 "$1,227.83" $0.00 $0.00 $0.00 $0.00 $0.00 G55236 SUP HCPCS C1874 G55236 - GRAFT EVAS 2 BRCH 16MM 14FR 39MM SPRLZ ZNTH Z-TRK SLF XPD LG BOTH IP/OP "$7,712.50 " "$5,707.25" $0.00 "$6,170.00" "$3,470.63" "$3,470.63" $0.00 $0.00 $0.00 "$1,607.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,607.29" $0.00 "$3,802.26" "$3,802.26" $0.00 "$3,856.25" "$6,108.30" "$6,170.00" $0.00 $0.00 "$1,207.01" $0.00 $0.00 "$1,227.83" $0.00 $0.00 $0.00 $0.00 $0.00 G55237 SUP HCPCS C1874 G55237 - GRAFT EVAS BFUR 16MM 5.4MM 14FR 56MM ZNTH SPRLZ ANCLRY BOTH IP/OP "$7,712.50 " "$5,707.25" $0.00 "$6,170.00" "$3,470.63" "$3,470.63" $0.00 $0.00 $0.00 "$1,607.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,607.29" $0.00 "$3,802.26" "$3,802.26" $0.00 "$3,856.25" "$6,108.30" "$6,170.00" $0.00 $0.00 "$1,207.01" $0.00 $0.00 "$1,227.83" $0.00 $0.00 $0.00 $0.00 $0.00 G55242 SUP HCPCS C1874 G55242 - GRAFT EVAS 2 BRCH 20MM 6MM 16FR 74MM ZNTH SPRLZ ILC LG BOTH IP/OP "$7,712.50 " "$5,707.25" $0.00 "$6,170.00" "$3,470.63" "$3,470.63" $0.00 $0.00 $0.00 "$1,607.48" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,607.29" $0.00 "$3,802.26" "$3,802.26" $0.00 "$3,856.25" "$6,108.30" "$6,170.00" $0.00 $0.00 "$1,207.01" $0.00 $0.00 "$1,227.83" $0.00 $0.00 $0.00 $0.00 $0.00 G55243 SUP Custom 27803010 G55243 - GRAFT EVAS 2 BRCH 20MM 16FR 90MM SPRLZ ZNTH Z-TRK SLF XPD LG BOTH IP/OP "$7,712.50 " "$5,707.25" $0.00 "$6,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,607.29" $0.00 $0.00 $0.00 $0.00 "$3,856.25" "$6,108.30" "$6,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G55245 SUP Custom 27803010 G55245 - GRAFT EVAS 24MM 6MM 5.3MM 56MM 71CM ZNTH SPRLZ ILC LG CAPTOR BOTH IP/OP "$9,412.50 " "$6,965.25" $0.00 "$7,530.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,961.57" $0.00 $0.00 $0.00 $0.00 "$4,706.25" "$7,454.70" "$7,530.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G55246 SUP Custom 27803010 G55246 - GRAFT EVAS BFUR 24MM 16FR 74MM ZNTH SPRLZ Z-TRK SLF XPD WVN BOTH IP/OP "$7,712.50 " "$5,707.25" $0.00 "$6,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,607.29" $0.00 $0.00 $0.00 $0.00 "$3,856.25" "$6,108.30" "$6,170.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G55247 SUP HCPCS C1874 G55247 - GRAFT EVAS 24MM 6MM 16FR 90MM ZNTH SPRLZ ANCLRY CNTRLT/IPSL BOTH IP/OP $385.63 $285.37 $0.00 $308.50 $173.53 $173.53 $0.00 $0.00 $0.00 $80.37 $286.21 $286.21 $0.00 $0.00 $80.36 $0.00 $228.10 $228.10 $0.00 $192.81 $305.42 $308.50 $0.00 $0.00 $60.35 $0.00 $0.00 $61.39 $0.00 $0.00 $0.00 $0.00 $0.00 G55800 SUP HCPCS C1729 G55800 - SET DRN 14FR 6-16FR 30CM 20CM UNIVERSA ECHTP SFTJ LOOP CATH BOTH IP/OP $350.68 $259.50 $0.00 $280.54 $190.42 $190.42 $0.00 $0.00 $0.00 $73.09 $260.27 $260.27 $0.00 $0.00 $73.08 $0.00 $207.42 $207.42 $0.00 $175.34 $277.74 $280.54 $0.00 $0.00 $54.88 $0.00 $0.00 $55.83 $0.00 $0.00 $0.00 $0.00 $0.00 G55801 SUP HCPCS C1729 G55801 - SET DRN 6FR 5-8FR 15CM 20CM CATH DIL LOOP BOTH IP/OP $350.68 $259.50 $0.00 $280.54 $190.42 $190.42 $0.00 $0.00 $0.00 $73.09 $260.27 $260.27 $0.00 $0.00 $73.08 $0.00 $207.42 $207.42 $0.00 $175.34 $277.74 $280.54 $0.00 $0.00 $54.88 $0.00 $0.00 $55.83 $0.00 $0.00 $0.00 $0.00 $0.00 G55802 SUP HCPCS C1729 G55802 - SHIELD SPLSH ELLIPSE 9X12IN LTX BRR RBR BOTH IP/OP $350.68 $259.50 $0.00 $280.54 $190.42 $190.42 $0.00 $0.00 $0.00 $73.09 $260.27 $260.27 $0.00 $0.00 $73.08 $0.00 $207.42 $207.42 $0.00 $175.34 $277.74 $280.54 $0.00 $0.00 $54.88 $0.00 $0.00 $55.83 $0.00 $0.00 $0.00 $0.00 $0.00 G55803 SUP HCPCS C1729 G55803 - SET DRN 12FR 6-14FR 30CM 20CM UNIVERSA DIL LOOP CATH INTRO BOTH IP/OP $350.68 $259.50 $0.00 $280.54 $190.42 $190.42 $0.00 $0.00 $0.00 $73.09 $260.27 $260.27 $0.00 $0.00 $73.08 $0.00 $207.42 $207.42 $0.00 $175.34 $277.74 $280.54 $0.00 $0.00 $54.88 $0.00 $0.00 $55.83 $0.00 $0.00 $0.00 $0.00 $0.00 G55804 SUP HCPCS C1729 G55804 - SET DRN 10FR 6-12FR 30CM 20CM CATH DIL LOOP BOTH IP/OP $350.68 $259.50 $0.00 $280.54 $190.42 $190.42 $0.00 $0.00 $0.00 $73.09 $260.27 $260.27 $0.00 $0.00 $73.08 $0.00 $207.42 $207.42 $0.00 $175.34 $277.74 $280.54 $0.00 $0.00 $54.88 $0.00 $0.00 $55.83 $0.00 $0.00 $0.00 $0.00 $0.00 G55821 SUP HCPCS C2627 G55821 - SET CATH 14FR 15GA 30CM UNIVERSA MLCT 1 WY STPCK CNCT TUBE BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G55822 SUP HCPCS C2627 G55822 - CATHETER SPBC 12FR 14FR 22CM 3CC STRL LTX 30CM RTNR SET NDL BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G55823 SUP HCPCS C2627 G55823 - SET CATH 10FR 18GA 30CM UNIVERSA MLCT DRN SPBC BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G55824 SUP HCPCS C2627 G55824 - SET CATH 12FR 54CM TROC STY DRN ADPR SPBC CYSTOSTOMY BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $0.00 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $0.00 $0.00 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G55825 SUP HCPCS C1729 G55825 - INSERTER SRG 1.91IN STRL DISP ACPT 3.1FR BOTH IP/OP $3.96 $2.93 $0.00 $3.17 $2.15 $2.15 $0.00 $0.00 $0.00 $0.83 $2.94 $2.94 $0.00 $0.00 $0.83 $0.00 $2.34 $2.34 $0.00 $1.98 $3.14 $3.17 $0.00 $0.00 $0.62 $0.00 $0.00 $0.63 $0.00 $0.00 $0.00 $0.00 $0.00 G56219 SUP HCPCS C1894 G56219 - INTRODUCER SHEATH .035IN 4FR .059IN 70CM ANL0 CURVE STR TIP BOTH IP/OP $238.50 $176.49 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $49.71 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $141.07 $141.07 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56220 SUP HCPCS C1894 G56220 - INTRODUCER SHEATH .035IN 5FR .074IN 70CM ANL0 CURVE STR TIP BOTH IP/OP $238.50 $176.49 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $49.71 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $141.07 $141.07 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56221 SUP HCPCS C1894 G56221 - INTRODUCER SHEATH .035IN 6FR .087IN 70CM ANL0 CURVE STR TIP BOTH IP/OP $238.50 $176.49 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $49.71 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $141.07 $141.07 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56222 SUP HCPCS C1894 G56222 - INTRODUCER SHEATH .035IN 7FR .1IN 70CM ANL0 CURVE STR TIP BOTH IP/OP $238.50 $176.49 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $49.71 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $141.07 $141.07 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56224 SUP HCPCS C1894 G56224 - INTRODUCER SHEATH .035IN 4FR .059IN 70CM ANL1 CURVE MULTPUR BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56225 SUP HCPCS C1894 G56225 - INTRODUCER SHEATH .035IN 5FR .074IN 70CM ANL1 CURVE MULTPUR BOTH IP/OP $238.50 $176.49 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $49.71 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $141.07 $141.07 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56226 SUP HCPCS C1894 G56226 - INTRODUCER SHEATH .035IN 6FR .087IN 70CM ANL1 CURVE MULTPUR BOTH IP/OP $238.50 $176.49 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $49.71 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $141.07 $141.07 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56227 SUP HCPCS C1894 G56227 - INTRODUCER SHEATH .035IN 7FR .1IN 70CM ANL1 CURVE MULTPUR BOTH IP/OP $238.50 $176.49 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $49.71 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $141.07 $141.07 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56228 SUP HCPCS C1894 G56228 - INTRODUCER SHEATH .035IN 8FR .113IN 70CM ANL1 CURVE MULTPUR BOTH IP/OP $238.50 $176.49 $0.00 $180.00 $122.18 $122.18 $0.00 $0.00 $0.00 $49.71 $177.01 $177.01 $0.00 $0.00 $49.70 $0.00 $141.07 $141.07 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 G56277 SUP HCPCS C1751 G56277 - TRAY CATHETER CEN VEN STERILE BOTH IP/OP $463.00 $342.62 $0.00 $370.39 $251.40 $251.40 $0.00 $0.00 $0.00 $96.50 $343.64 $343.64 $0.00 $0.00 $96.49 $0.00 $273.86 $273.86 $0.00 $231.50 $366.69 $370.39 $0.00 $0.00 $72.46 $0.00 $0.00 $73.71 $0.00 $0.00 $0.00 $0.00 $0.00 G56278 SUP HCPCS C1892 G56278 - INTRODUCER SHEATH .035IN 10FR .134IN 45CM ANL0 CURVE STR TIP BOTH IP/OP $212.00 $156.88 $0.00 $157.35 $101.81 $101.81 $0.00 $0.00 $0.00 $44.19 $157.35 $157.35 $0.00 $0.00 $44.18 $0.00 $125.40 $125.40 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 G56279 SUP HCPCS C1892 G56279 - INTRODUCER SHEATH .035IN 12FR .162IN 45CM ANL0 CURVE STR TIP BOTH IP/OP $212.00 $156.88 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $44.19 $157.35 $157.35 $0.00 $0.00 $44.18 $0.00 $125.40 $125.40 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 G56334 SUP HCPCS C1729 G56334 - CATHETER DRN 16FR 15GA 30CM UNIVERSA MLCT NDL BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $20.63 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $58.56 $58.56 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G56335 SUP HCPCS C1729 G56335 - CATHETER DRN 8FR 19GA 15CM UNIVERSA MLCT NDL BOTH IP/OP $99.00 $73.26 $0.00 $79.20 $53.76 $53.76 $0.00 $0.00 $0.00 $20.63 $73.48 $73.48 $0.00 $0.00 $20.63 $0.00 $58.56 $58.56 $0.00 $49.50 $78.41 $79.20 $0.00 $0.00 $15.49 $0.00 $0.00 $15.76 $0.00 $0.00 $0.00 $0.00 $0.00 G56401 SUP Custom 27203010 G56401 - CATHETER DRN 10FR 18GA 15CM UNIVERSA MLCT NDL BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 G56428 SUP HCPCS C1894 G56428 - EXTRACTOR STON STD 10FR 1.5CM 38CM PERC NGAGE BSKT NTNL SS BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56429 SUP HCPCS C1894 G56429 - SHEATH ESCP 9.5FR 20CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56430 SUP HCPCS C1894 G56430 - SHEATH ESCP 9.5FR 28CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56431 SUP HCPCS C1894 G56431 - SHEATH ESCP 9.5FR 35CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56432 SUP HCPCS C1894 G56432 - SHEATH ESCP 9.5FR 45CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56433 SUP HCPCS C1894 G56433 - SHEATH ESCP 9.5FR 55CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56434 SUP HCPCS C1894 G56434 - SHEATH ESCP 12FR 20CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56435 SUP HCPCS C1894 G56435 - SHEATH ACC 12FR 28CM RPD RELS PRLL FLXR CNT CHNL HDRPH URET BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56436 SUP HCPCS C1894 G56436 - SHEATH ACC 12FR 35CM RPD RELS PRLL FLXR CNT CHNL HDRPH URET BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56438 SUP HCPCS C1894 G56438 - SHEATH ESCP 12FR 45CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56439 SUP HCPCS C1894 G56439 - SHEATH ESCP 12FR 55CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56440 SUP HCPCS C1894 G56440 - SHEATH ESCP 14FR 20CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56441 SUP HCPCS C1894 G56441 - SHEATH ACC 14FR 28CM RPD RELS PRLL FLXR CNT CHNL HDRPH URET BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56442 SUP HCPCS C1894 G56442 - SHEATH ACC 14FR 35CM RPD RELS PRLL FLXR CNT CHNL HDRPH URET BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56443 SUP HCPCS C1894 G56443 - SHEATH ESCP 14FR 45CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56445 SUP HCPCS C1894 G56445 - SHEATH ESCP 14FR 55CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56446 SUP HCPCS C1894 G56446 - SHEATH ESCP 9.5FR 13CM STRL PRLL FLXR DIL HDRPH URETER DISP BOTH IP/OP $325.00 $240.50 $0.00 $260.00 $176.48 $176.48 $0.00 $0.00 $0.00 $67.74 $241.22 $241.22 $0.00 $0.00 $67.73 $0.00 $192.24 $192.24 $0.00 $162.50 $257.40 $260.00 $0.00 $0.00 $50.86 $0.00 $0.00 $51.74 $0.00 $0.00 $0.00 $0.00 $0.00 G56537 SUP Custom 27203010 G56537 - TRAY SURG 14FR 18GA 29CM 5CM 19 SIDEPORT CATHETER ECHOGENIC BOTH IP/OP $450.38 $333.28 $0.00 $663.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.27 $334.27 $0.00 $0.00 $93.86 $0.00 $0.00 $0.00 $0.00 $414.99 $657.34 $663.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GA3501 SUP HCPCS C1769 GA3501 - GUIDEWIRE VASC ANG .035IN 180CM 25CM GLDWR ADV PTFE NTNL BOTH IP/OP $400.00 $296.00 $0.00 $320.00 $217.20 $217.20 $0.00 $0.00 $0.00 $83.37 $296.88 $296.88 $0.00 $0.00 $83.36 $0.00 $236.60 $236.60 $0.00 $200.00 $316.80 $320.00 $0.00 $0.00 $62.60 $0.00 $0.00 $63.68 $0.00 $0.00 $0.00 $0.00 $0.00 GA3502 SUP HCPCS C1769 GA3502 - GUIDEWIRE VASCULAR ANGLED .035IN 260CM 25CM GLIDEWIRE BOTH IP/OP $575.00 $425.50 $0.00 $426.77 $244.35 $244.35 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $225.00 $356.40 $360.00 $0.00 $0.00 $70.43 $0.00 $0.00 $71.64 $0.00 $0.00 $0.00 $0.00 $0.00 GD-1115-100 SUP Custom 27203010 GD-1115-100 - CANNULA ASCP 10CM OSTEOPRECISION VNT BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 $0.00 $0.00 $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GEM1521 SUP Custom 27203010 GEM1521 - CLIP HEMOSTATIC 30 CARTRIDGE SUPERFINE GEM BLUE TITANIUM BOTH IP/OP $29.17 $21.59 $0.00 $23.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.65 $21.65 $0.00 $0.00 $6.08 $0.00 $0.00 $0.00 $0.00 $14.58 $23.10 $23.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GEM2431 SUP Custom 27203010 GEM2431 - CLIP INTNL MIC GM CRTDG TI HMST BOTH IP/OP $25.83 $19.11 $0.00 $20.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.17 $19.17 $0.00 $0.00 $5.38 $0.00 $0.00 $0.00 $0.00 $12.92 $20.46 $20.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GEM2751 SUP Custom 27803010 GEM2751 - COUPLER ANSTM 1.5MM STRL GM MCVSC ANSTM DISP BOTH IP/OP $645.83 $477.91 $0.00 $516.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.34 $479.34 $0.00 $0.00 $134.59 $0.00 $0.00 $0.00 $0.00 $322.92 $511.50 $516.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GEM2752 SUP Custom 27803010 GEM2752 - COUPLER ANSTM 20MHZ 2MM STRL LF GM RING PIN US DPLR SS DISP BOTH IP/OP $770.83 $570.41 $0.00 $598.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.11 $572.11 $0.00 $0.00 $160.64 $0.00 $0.00 $0.00 $0.00 $373.96 $592.35 $598.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GEM2753 SUP Custom 27803010 GEM2753 - COUPLER ANSTM 20MHZ 2.5MM STRL LF GM RING PIN US DPLR SS BOTH IP/OP $770.83 $570.41 $0.00 $598.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.11 $572.11 $0.00 $0.00 $160.64 $0.00 $0.00 $0.00 $0.00 $373.96 $592.35 $598.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GEM2754 SUP Custom 27803010 GEM2754 - COUPLER ANSTM 3MM STRL GM MCVSC DISP BOTH IP/OP $770.83 $570.41 $0.00 $598.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.11 $572.11 $0.00 $0.00 $160.64 $0.00 $0.00 $0.00 $0.00 $373.96 $592.35 $598.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GEM2756 SUP Custom 27803010 GEM2756 - COUPLER ANSTM 4MM STRL GM MCVSC ANSTM DISP BOTH IP/OP $770.83 $570.41 $0.00 $598.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.11 $572.11 $0.00 $0.00 $160.64 $0.00 $0.00 $0.00 $0.00 $373.96 $592.35 $598.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GEZ6200US7B SUP HCPCS C1757 GEZ6200US7B - CATHETER THROMBECTOMY 7FR .08IN 145CM ASPIRAT FULL-WALL BOTH IP/OP "$1,425.00 " "$1,054.50" $0.00 "$1,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $297.01 "$1,057.64" "$1,057.64" $0.00 $0.00 $296.97 $0.00 $842.89 $842.89 $0.00 $712.50 "$1,128.60" "$1,140.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GFS-10A SUP Custom 27203010 GFS-10A - PASSER SUT STRL LF GAB/FRAT GD ORG VLV IMPL BOTH IP/OP $950.18 $703.13 $0.00 $760.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.22 $705.22 $0.00 $0.00 $198.02 $0.00 $0.00 $0.00 $0.00 $475.09 $752.54 $760.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GFS-1A SUP Custom 27203010 GFS-1A - PASSER SUTURE GUIDE ORGANIZER LATEX FREE GABBAY-FRATER VALVE BOTH IP/OP $403.53 $298.61 $0.00 $322.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.50 $299.50 $0.00 $0.00 $84.09 $0.00 $0.00 $0.00 $0.00 $201.76 $319.60 $322.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GH-05501 SUP HCPCS C1729 KIT EPDRL 9.84CM 17GA CATH BOTH IP/OP $90.80 $67.19 $0.00 $72.64 $49.30 $49.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.40 $71.91 $72.64 $0.00 $0.00 $14.21 $0.00 $0.00 $14.46 $0.00 $0.00 $0.00 $0.00 $0.00 GIA10038L SUP Custom 27203010 GIA10038L - RELOAD STPLR 100MMX3.8MM BLU STRL LF 1.5MM DST GIA 4 ROW LNR BOTH IP/OP $268.10 $198.39 $0.00 $217.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.98 $198.98 $0.00 $0.00 $55.87 $0.00 $0.00 $0.00 $0.00 $136.06 $215.52 $217.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA10038S SUP Custom 27203010 GIA10038S - STAPLER INTERNAL 100MMX3.8MM 1.5MM 2 STAGGER ROW STAPLE LOAD BOTH IP/OP $514.53 $380.75 $0.00 $417.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $381.88 $381.88 $0.00 $0.00 $107.23 $0.00 $0.00 $0.00 $0.00 $261.12 $413.61 $417.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA10048L SUP Custom 27203010 GIA10048L - RELOAD STPLR 100MMX4.8MM GRN STRL LF 2MM DST GIA 4 ROW LNR BOTH IP/OP $268.10 $198.39 $0.00 $220.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.98 $198.98 $0.00 $0.00 $55.87 $0.00 $0.00 $0.00 $0.00 $137.52 $217.83 $220.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA10048S SUP Custom 27203010 GIA10048S - STAPLER INTERNAL 104MMX4.8MM 2MM 2 STAGGER ROW STAPLE LOAD BOTH IP/OP $564.67 $417.86 $0.00 $451.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $419.10 $419.10 $0.00 $0.00 $117.68 $0.00 $0.00 $0.00 $0.00 $282.34 $447.22 $451.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA6025L SUP Custom 27203010 GIA6025L - RELOAD STPLR 60MMX2.5MM WHT STRL LF 1MM DST GIA 4 ROW LNR BOTH IP/OP $128.02 $94.73 $0.00 $102.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.01 $95.01 $0.00 $0.00 $26.68 $0.00 $0.00 $0.00 $0.00 $64.01 $101.39 $102.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA6038L SUP Custom 27203010 GIA6038L - RELOAD STPLR 60MMX3.8MM BLU STRL LF 1.5MM DST GIA 4 ROW LNR BOTH IP/OP $117.10 $86.65 $0.00 $95.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.91 $86.91 $0.00 $0.00 $24.40 $0.00 $0.00 $0.00 $0.00 $59.43 $94.14 $95.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA6038S SUP Custom 27203010 GIA6038S - STAPLER INTERNAL TEARDROP 60MMX3.8MM 1.5MM 4 ROW 2 STAGGER BOTH IP/OP $222.80 $164.87 $0.00 $180.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.36 $165.36 $0.00 $0.00 $46.43 $0.00 $0.00 $0.00 $0.00 $113.07 $179.10 $180.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA6048L SUP Custom 27203010 GIA6048L - RELOAD STPLR 60MMX4.8MM GRN STRL LF 2MM DST GIA 4 ROW LNR BOTH IP/OP $115.40 $85.40 $0.00 $93.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.65 $85.65 $0.00 $0.00 $24.05 $0.00 $0.00 $0.00 $0.00 $58.57 $92.77 $93.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA6048S SUP Custom 27203010 GIA6048S - STAPLER INTERNAL TEARDROP 60MMX4.8MM 2MM 4 ROW 2 STAGGER BOTH IP/OP $228.58 $169.15 $0.00 $182.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.65 $169.65 $0.00 $0.00 $47.64 $0.00 $0.00 $0.00 $0.00 $114.29 $181.04 $182.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA8038L SUP Custom 27203010 GIA8038L - RELOAD STPLR 80MMX3.8MM BLU STRL LF 1.5MM DST GIA 4 ROW LNR BOTH IP/OP $171.20 $126.69 $0.00 $139.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.06 $127.06 $0.00 $0.00 $35.68 $0.00 $0.00 $0.00 $0.00 $86.88 $137.63 $139.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA8038S SUP Custom 27203010 GIA8038S - STAPLER INTERNAL TEARDROP 80MMX3.8MM 1.5MM 4 ROW 2 STAGGER BOTH IP/OP $328.33 $242.96 $0.00 $266.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $243.68 $243.68 $0.00 $0.00 $68.42 $0.00 $0.00 $0.00 $0.00 $166.63 $263.93 $266.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA8048L SUP Custom 27203010 GIA8048L - RELOAD STPLR 80MMX4.8MM GRN STRL LF 2MM DST GIA 4 ROW LNR BOTH IP/OP $171.20 $126.69 $0.00 $139.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.06 $127.06 $0.00 $0.00 $35.68 $0.00 $0.00 $0.00 $0.00 $86.88 $137.63 $139.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GIA8048S SUP Custom 27203010 GIA8048S - STAPLER INTERNAL TEARDROP 80MMX4.8MM 2MM 4 ROW 2 STAGGER BOTH IP/OP $336.83 $249.25 $0.00 $269.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.99 $249.99 $0.00 $0.00 $70.19 $0.00 $0.00 $0.00 $0.00 $168.41 $266.77 $269.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GJ44 SUP HCPCS Q4107 GJ44 - GRAFT SKIN 4CMX4CMX.38-1.02MM GRAFTJACKET THK.4-.8MM REGENER BOTH IP/OP "$4,302.50 " "$3,183.85" $0.00 "$3,442.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,193.32" "$3,193.32" $0.00 $0.00 $109.65 $0.00 $0.00 $0.00 $0.00 "$2,151.25" "$3,407.58" "$3,442.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GJ48 SUP HCPCS Q4107 GJ48 - GRAFT SKIN 8CMX4CMX.38-1.02MM GRAFTJACKET THK.4-.8MM REGENER BOTH IP/OP "$7,570.20 " "$5,601.95" $0.00 "$6,056.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,618.60" "$5,618.60" $0.00 $0.00 $109.65 $0.00 $0.00 $0.00 $0.00 "$3,785.10" "$5,995.60" "$6,056.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GJX SUP HCPCS Q4113 GJX - GRAFT SKN 2ML GTJKT XPRESS SFT TIS SCFLD FLW ACLR DRML MTRX BOTH IP/OP "$4,840.00 " "$3,581.60" $0.00 "$3,872.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,592.25" "$3,592.25" $0.00 $0.00 "$1,008.66" $0.00 $0.00 $0.00 $0.00 "$2,420.00" "$3,833.28" "$3,872.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GLU-50122 SUP HCPCS A6196 GLU-50122 - DRESSING WND 12X5IN STRL LF GLUCAN II B GLUCAN CLGN DISP BOTH IP/OP $170.71 $126.33 $0.00 $136.57 $92.69 $92.69 $0.00 $0.00 $0.00 $0.00 $126.70 $126.70 $0.00 $0.00 $35.58 $0.00 $0.00 $0.00 $0.00 $85.35 $135.20 $136.57 $0.00 $0.00 $26.72 $0.00 $0.00 $27.18 $0.00 $0.00 $0.00 $0.00 $0.00 GM1253-1720 SUP Custom 27203010 GM1253-1720 - SET 3 NEEDLES W/MARKER 1.2X5MM BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GM1601 SUP HCPCS C1769 GM1601 - GWIRE VASC 45D .016IN 180CM 2MM ANG FLX TP TRQ DEV GLDWR GL BOTH IP/OP $725.00 $536.50 $0.00 $580.00 $393.68 $393.68 $0.00 $0.00 $0.00 $151.11 $538.10 $538.10 $0.00 $0.00 $151.09 $0.00 $428.84 $428.84 $0.00 $362.50 $574.20 $580.00 $0.00 $0.00 $113.46 $0.00 $0.00 $115.42 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-DSP-160 SUP HCPCS C1713 "GMN-DSP-160 - PLATE DORSAL SPANNING, SHORT" BOTH IP/OP "$2,990.00 " "$2,212.60" $0.00 "$2,392.00" "$1,345.50" "$1,345.50" $0.00 $0.00 $0.00 $623.19 "$2,219.18" "$2,219.18" $0.00 $0.00 $623.12 $0.00 "$1,474.07" "$1,474.07" $0.00 "$1,495.00" "$2,368.08" "$2,392.00" $0.00 $0.00 $467.94 $0.00 $0.00 $476.01 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-DSP-210 SUP HCPCS C1713 GMN-DSP-210 - PLATE DORSAL SPANNING BOTH IP/OP "$2,990.00 " "$2,212.60" $0.00 "$2,392.00" "$1,345.50" "$1,345.50" $0.00 $0.00 $0.00 $623.19 "$2,219.18" "$2,219.18" $0.00 $0.00 $623.12 $0.00 "$1,474.07" "$1,474.07" $0.00 "$1,495.00" "$2,368.08" "$2,392.00" $0.00 $0.00 $467.94 $0.00 $0.00 $476.01 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-HP SUP HCPCS C1713 GMN-HP - PLATE BN GEMINUS HK VOLR BOTH IP/OP $990.00 $732.60 $0.00 $792.00 $445.50 $445.50 $0.00 $0.00 $0.00 $206.34 $734.78 $734.78 $0.00 $0.00 $206.32 $0.00 $585.59 $585.59 $0.00 $495.00 $784.08 $792.00 $0.00 $0.00 $154.94 $0.00 $0.00 $157.61 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-HP-SCRW SUP HCPCS C1713 GMN-HP-SCRW - PLATE BN GEMINUS HK SCR VOLR BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-LTN-3HL SUP HCPCS C1713 GMN-LTN-3HL - PLATE BN NAR NS GEMINUS 3 HL TI LT DIST VOLR RDS FOSSA BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-LTN-4HL SUP HCPCS C1713 GMN-LTN-4HL - PLATE BN NAR NS GEMINUS 4 HL TI LT DIST VOLR RDS FOSSA BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-LTS-3HL SUP HCPCS C1713 GMN-LTS-3HL - PLATE BN STD NS GEMINUS 3 HL TI RDS LT VOLR DIST BOTH IP/OP "$2,237.50 " "$1,655.75" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $466.35 "$1,660.67" "$1,660.67" $0.00 $0.00 $466.30 $0.00 "$1,323.48" "$1,323.48" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-LTS-4HL SUP HCPCS C1713 GMN-LTS-4HL - PLATE BN STD NS GEMINUS 4 HL TI LT DIST VOLR RDS FOSSA BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-LTS-7HL SUP HCPCS C1713 GMN-LTS-7HL - PLATE BN STD NS GEMINUS 7 HL TI LT DIST VOLR RDS FOSSA BOTH IP/OP "$2,190.00 " "$1,620.60" $0.00 "$1,752.00" $985.50 $985.50 $0.00 $0.00 $0.00 $456.45 "$1,625.42" "$1,625.42" $0.00 $0.00 $456.40 $0.00 "$1,295.39" "$1,295.39" $0.00 "$1,095.00" "$1,734.48" "$1,752.00" $0.00 $0.00 $342.74 $0.00 $0.00 $348.65 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-LTW-4HL SUP HCPCS C1713 GMN-LTW-4HL - PLATE BN W NS GEMINUS 4 HL TI LT DIST VOLR RDS FOSSA BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-RTN-3HL SUP HCPCS C1713 GMN-RTN-3HL - PLATE BN NAR NS GEMINUS 3 HL TI RT DIST VOLR RDS FOSSA BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-RTN-4HL SUP HCPCS C1713 GMN-RTN-4HL - PLATE BN NAR NS GEMINUS 4 HL TI RT DIST VOLR RDS FOSSA BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-RTS-3HL SUP HCPCS C1713 GMN-RTS-3HL - PLATE BN STD NS GEMINUS 3 HL TI RT DIST VOLR RDS BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-RTS-4HL SUP HCPCS C1713 GMN-RTS-4HL - PLATE BN STD NS GEMINUS 4 HL TI RT DIST VOLR RDS FOSSA BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-RTS-7HL SUP HCPCS C1713 GMN-RTS-7HL - PLATE BN STD NS GEMINUS 7 HL TI RDS RT FOSSA DIST BOTH IP/OP "$2,190.00 " "$1,620.60" $0.00 "$1,752.00" $985.50 $985.50 $0.00 $0.00 $0.00 $456.45 "$1,625.42" "$1,625.42" $0.00 $0.00 $456.40 $0.00 "$1,295.39" "$1,295.39" $0.00 "$1,095.00" "$1,734.48" "$1,752.00" $0.00 $0.00 $342.74 $0.00 $0.00 $348.65 $0.00 $0.00 $0.00 $0.00 $0.00 GMN-RTW-4HL SUP HCPCS C1713 GMN-RTW-4HL - PLATE BN W NS GEMINUS 4 HL TI RDS RT DIST FOSSA BOTH IP/OP "$1,990.00 " "$1,472.60" $0.00 "$1,592.00" $895.50 $895.50 $0.00 $0.00 $0.00 $414.77 "$1,476.98" "$1,476.98" $0.00 $0.00 $414.72 $0.00 "$1,177.09" "$1,177.09" $0.00 $995.00 "$1,576.08" "$1,592.00" $0.00 $0.00 $311.44 $0.00 $0.00 $316.81 $0.00 $0.00 $0.00 $0.00 $0.00 GN1000 SUP Custom 27803010 GN1000 - KIT SNR 10MM 4FR 120CM 102CM AGN CATH PREFORM LOOP RADOPQ BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $0.00 $0.00 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GN1500 SUP Custom 27203010 GN1500 - KIT VASC 120CM 15MM 6FR AGN NTNL GOLD TUNG LOOP CATH NTNL BOTH IP/OP $800.00 $592.00 $0.00 $593.76 $0.00 $0.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GN2500 SUP Custom 27803010 GN2500 - KIT SNR 25MM 6FR 120CM 102CM AGN CATH PREFORM LOOP RADOPQ BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $0.00 $0.00 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GN500 SUP Custom 27803010 GN500 - KIT SNR 5MM 4FR 120CM 102CM AGN CATH PREFORM LOOP RADOPQ BOTH IP/OP $747.25 $552.97 $0.00 $554.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.61 $554.61 $0.00 $0.00 $155.73 $0.00 $0.00 $0.00 $0.00 $337.50 $534.60 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GOLD-18 SUP HCPCS L8610 GOLD-18 - WEIGHT EYELID 3 SUTURE HOLE SUTUREGROOVE GOLD 1.8GM STERILE BOTH IP/OP $800.00 $592.00 $0.00 $640.00 $360.00 $360.00 $0.00 $0.00 $0.00 $166.74 $593.76 $593.76 $0.00 $0.00 $166.72 $0.00 $473.20 $473.20 $0.00 $400.00 $633.60 $640.00 $0.00 $0.00 $125.20 $0.00 $0.00 $127.36 $0.00 $0.00 $0.00 $0.00 $0.00 GPSL SUP HCPCS C1781 GPSL - MESH SURG GYNMSH 6X4IN PLVC NABSB SFT KNTD LTWT STRL POLYPRO BOTH IP/OP $847.00 $626.78 $0.00 $677.60 $381.15 $381.15 $0.00 $0.00 $0.00 $176.54 $628.64 $628.64 $0.00 $0.00 $176.51 $0.00 $501.00 $501.00 $0.00 $423.50 $670.82 $677.60 $0.00 $0.00 $132.56 $0.00 $0.00 $134.84 $0.00 $0.00 $0.00 $0.00 $0.00 GPSXL3 SUP HCPCS C1781 GPSXL3 - MESH SURG 25X25CM SOFT KNIT NONABSORBABLE GYNECARE GYNEMESH BOTH IP/OP "$4,367.00 " "$3,231.58" $0.00 "$3,493.60" "$1,965.15" "$1,965.15" $0.00 $0.00 $0.00 $910.19 "$3,241.19" "$3,241.19" $0.00 $0.00 $910.08 $0.00 "$2,152.93" "$2,152.93" $0.00 "$2,183.50" "$3,458.66" "$3,493.60" $0.00 $0.00 $683.44 $0.00 $0.00 $695.23 $0.00 $0.00 $0.00 $0.00 $0.00 GR1807 SUP HCPCS C1769 GR1807 - GUIDEWIRE VASCULAR ANGLE .018IN 260CM 3CM GLIDEWIRE HYDPHI BOTH IP/OP "$1,010.63 " $747.87 $0.00 $780.00 $529.43 $529.43 $0.00 $0.00 $0.00 $210.64 $750.09 $750.09 $0.00 $0.00 $210.61 $0.00 $597.78 $597.78 $0.00 $487.50 $772.20 $780.00 $0.00 $0.00 $152.59 $0.00 $0.00 $155.22 $0.00 $0.00 $0.00 $0.00 $0.00 GR3501 SUP HCPCS C1769 GR3501 - GUIDEWIRE VASC STRG .035IN 150CM 3CM GLDWR STF SHFT HDRPH BOTH IP/OP $80.45 $59.53 $0.00 $59.71 $39.37 $39.37 $0.00 $0.00 $0.00 $16.77 $59.71 $59.71 $0.00 $0.00 $16.77 $0.00 $47.59 $47.59 $0.00 $36.25 $57.42 $58.00 $0.00 $0.00 $11.35 $0.00 $0.00 $11.54 $0.00 $0.00 $0.00 $0.00 $0.00 GR3503 SUP HCPCS C1769 GR3503 - GUIDEWIRE VASCULAR STANDARD STR .035IN 180CM 3CM JACKET CORE BOTH IP/OP $108.00 $79.92 $0.00 $80.16 $53.89 $53.89 $0.00 $0.00 $0.00 $22.51 $80.16 $80.16 $0.00 $0.00 $22.51 $0.00 $63.88 $63.88 $0.00 $49.63 $78.61 $79.40 $0.00 $0.00 $15.53 $0.00 $0.00 $15.80 $0.00 $0.00 $0.00 $0.00 $0.00 GR3504 SUP HCPCS C1769 GR3504 - GUIDEWIRE VASCULAR STANDARD STR .035IN 260CM 3CM JACKET CORE BOTH IP/OP $120.75 $89.36 $0.00 $89.62 $60.27 $60.27 $0.00 $0.00 $0.00 $25.17 $89.62 $89.62 $0.00 $0.00 $25.16 $0.00 $71.42 $71.42 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 GR3508 SUP HCPCS C1769 GR3508 - GUIDEWIRE VASCULAR ANGLE STANDARD .035IN 180CM 3CM JACKET BOTH IP/OP $108.00 $79.92 $0.00 $80.16 $53.89 $53.89 $0.00 $0.00 $0.00 $22.51 $80.16 $80.16 $0.00 $0.00 $22.51 $0.00 $63.88 $63.88 $0.00 $49.63 $78.61 $79.40 $0.00 $0.00 $15.53 $0.00 $0.00 $15.80 $0.00 $0.00 $0.00 $0.00 $0.00 GR3509 SUP HCPCS C1769 GUIDEWIRE VASC .035IN 260CM 3CM ANG FLX TP STD GLDWR GR3509 BOTH IP/OP $120.75 $89.36 $0.00 $94.88 $64.40 $64.40 $0.00 $0.00 $0.00 $25.17 $89.62 $89.62 $0.00 $0.00 $25.16 $0.00 $71.42 $71.42 $0.00 $59.30 $93.93 $94.88 $0.00 $0.00 $18.56 $0.00 $0.00 $18.88 $0.00 $0.00 $0.00 $0.00 $0.00 GR3807 SUP HCPCS C1769 GR3807 - GUIDEWIRE VASCULAR ANGLED .038IN 150CM 8CM GLIDEWIRE HYDPHI BOTH IP/OP $89.00 $65.86 $0.00 $66.06 $44.39 $44.39 $0.00 $0.00 $0.00 $18.55 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $52.64 $52.64 $0.00 $40.88 $64.75 $65.40 $0.00 $0.00 $12.79 $0.00 $0.00 $13.01 $0.00 $0.00 $0.00 $0.00 $0.00 GR3808 SUP HCPCS C1769 GR3808 - GUIDEWIRE VASCULAR ANGLED .038IN 180CM 3CM GLIDEWIRE HYDPHI BOTH IP/OP $108.00 $79.92 $0.00 $80.16 $53.89 $53.89 $0.00 $0.00 $0.00 $22.51 $80.16 $80.16 $0.00 $0.00 $22.51 $0.00 $63.88 $63.88 $0.00 $49.63 $78.61 $79.40 $0.00 $0.00 $15.53 $0.00 $0.00 $15.80 $0.00 $0.00 $0.00 $0.00 $0.00 GR3809 SUP HCPCS C1769 GR3809 - GUIDEWIRE VASCULAR ANGLED .038IN 260CM 3CM GLIDEWIRE HYDPHI BOTH IP/OP $120.75 $89.36 $0.00 $89.62 $60.27 $60.27 $0.00 $0.00 $0.00 $25.17 $89.62 $89.62 $0.00 $0.00 $25.16 $0.00 $71.42 $71.42 $0.00 $55.50 $87.91 $88.80 $0.00 $0.00 $17.37 $0.00 $0.00 $17.67 $0.00 $0.00 $0.00 $0.00 $0.00 GR74089-02 SUP Custom 27203010 GR74089-02 - BAG TISS CLSR 7.5CM DRAIN WL DFCT 7.5CM SILO STRL DISP SIL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GRAD0026-06 SUP HCPCS C1751 GRAD0026-06 - TRAY SRG STRL PICC CTH LB RAD BOTH IP/OP $88.91 $65.79 $0.00 $71.13 $48.28 $48.28 $0.00 $0.00 $0.00 $18.53 $65.99 $65.99 $0.00 $0.00 $18.53 $0.00 $52.59 $52.59 $0.00 $44.46 $70.42 $71.13 $0.00 $0.00 $13.92 $0.00 $0.00 $14.16 $0.00 $0.00 $0.00 $0.00 $0.00 GRAD0027-05 SUP Custom 27203010 GRAD0027-05 - TRAY SRG STRL VNS ACC CTH LB RAD BOTH IP/OP $117.73 $87.12 $0.00 $94.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.38 $87.38 $0.00 $0.00 $24.54 $0.00 $0.00 $0.00 $0.00 $58.87 $93.24 $94.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GRAD0058-03 SUP Custom 27203010 GRAD0058-03 - TRAY NEURO ANGIO BOTH IP/OP $131.43 $97.26 $0.00 $105.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.54 $97.54 $0.00 $0.00 $27.39 $0.00 $0.00 $0.00 $0.00 $65.71 $104.09 $105.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GRAD0059-03 SUP Custom 27203010 GRAD0059-03 - TRAY BX STRL LF AVID TRUCUSTOM DISP BOTH IP/OP $52.27 $38.68 $0.00 $41.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.80 $38.80 $0.00 $0.00 $10.89 $0.00 $0.00 $0.00 $0.00 $26.14 $41.40 $41.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GS3503 SUP HCPCS C1769 GS3503 - GUIDEWIRE VASCULAR STR .035IN 180CM 3CM STIFF SHAFT BOTH IP/OP $116.75 $86.40 $0.00 $93.40 $63.40 $63.40 $0.00 $0.00 $0.00 $24.33 $86.65 $86.65 $0.00 $0.00 $24.33 $0.00 $69.06 $69.06 $0.00 $58.38 $92.47 $93.40 $0.00 $0.00 $18.27 $0.00 $0.00 $18.59 $0.00 $0.00 $0.00 $0.00 $0.00 GS3504 SUP HCPCS C1769 GS3504 - GUIDEWIRE VASCULAR STR .035IN 260CM 3CM STIFF SHAFT FLEXIBLE BOTH IP/OP $135.58 $100.33 $0.00 $100.62 $67.67 $67.67 $0.00 $0.00 $0.00 $28.26 $100.62 $100.62 $0.00 $0.00 $28.25 $0.00 $80.19 $80.19 $0.00 $62.31 $98.71 $99.70 $0.00 $0.00 $19.50 $0.00 $0.00 $19.84 $0.00 $0.00 $0.00 $0.00 $0.00 GS3506 SUP HCPCS C1769 GS3506 - GUIDEWIRE VASCULAR ANGLE .035IN 150CM 3CM FLEXIBLE TIP STIFF BOTH IP/OP $122.85 $90.91 $0.00 $91.18 $61.29 $61.29 $0.00 $0.00 $0.00 $25.61 $91.18 $91.18 $0.00 $0.00 $25.60 $0.00 $72.67 $72.67 $0.00 $56.44 $89.40 $90.30 $0.00 $0.00 $17.66 $0.00 $0.00 $17.97 $0.00 $0.00 $0.00 $0.00 $0.00 GS3508 SUP HCPCS C1769 GS3508 - GUIDEWIRE VASCULAR ANGLE .035IN 180CM 3CM STIFF SHAFT BOTH IP/OP $127.18 $94.11 $0.00 $94.39 $63.40 $63.40 $0.00 $0.00 $0.00 $26.51 $94.39 $94.39 $0.00 $0.00 $26.50 $0.00 $75.22 $75.22 $0.00 $58.38 $92.47 $93.40 $0.00 $0.00 $18.27 $0.00 $0.00 $18.59 $0.00 $0.00 $0.00 $0.00 $0.00 GS3509 SUP HCPCS C1769 GS3509 - GUIDEWIRE VASCULAR ANGLE .035IN 260CM 3CM STIFF SHAFT BOTH IP/OP $135.58 $100.33 $0.00 $100.62 $67.67 $67.67 $0.00 $0.00 $0.00 $28.26 $100.62 $100.62 $0.00 $0.00 $28.25 $0.00 $80.19 $80.19 $0.00 $62.31 $98.71 $99.70 $0.00 $0.00 $19.50 $0.00 $0.00 $19.84 $0.00 $0.00 $0.00 $0.00 $0.00 GS3807 SUP HCPCS C1769 GS3807 - GUIDEWIRE VASCULAR ANGLE .038IN 180CM 3CM STIFF SHAFT BOTH IP/OP $127.18 $94.11 $0.00 $94.39 $63.40 $63.40 $0.00 $0.00 $0.00 $26.51 $94.39 $94.39 $0.00 $0.00 $26.50 $0.00 $75.22 $75.22 $0.00 $58.38 $92.47 $93.40 $0.00 $0.00 $18.27 $0.00 $0.00 $18.59 $0.00 $0.00 $0.00 $0.00 $0.00 GSLM-14 SUP HCPCS L8610 GSLM-14 - WEIGHT EYELID SLIM SUTUREGROOVE THK.75MM GOLD 1.4GM STERILE BOTH IP/OP $700.00 $518.00 $0.00 $560.00 $315.00 $315.00 $0.00 $0.00 $0.00 $145.90 $519.54 $519.54 $0.00 $0.00 $145.88 $0.00 $414.05 $414.05 $0.00 $350.00 $554.40 $560.00 $0.00 $0.00 $109.55 $0.00 $0.00 $111.44 $0.00 $0.00 $0.00 $0.00 $0.00 GSLM-16 SUP HCPCS L8610 GSLM-16 - WEIGHT EYELID SLIM SUTUREGROOVE THK.75MM GOLD 1.6GM STERILE BOTH IP/OP $750.00 $555.00 $0.00 $600.00 $337.50 $337.50 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $117.38 $0.00 $0.00 $119.40 $0.00 $0.00 $0.00 $0.00 $0.00 GST45B SUP Custom 27203010 GST45B - RELOAD STPLR 45MMX3.6MM BLU STRL LF 1.5MM ECHLN EPTH ECHLN BOTH IP/OP $877.84 $649.60 $0.00 $712.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $651.53 $651.53 $0.00 $0.00 $182.94 $0.00 $0.00 $0.00 $0.00 $445.50 $705.67 $712.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GST45G SUP Custom 27203010 GST45G - RELOAD STPLR 45MMX4.1MM GRN STRL LF 2MM ECHLN EPTH ECHLN FLX BOTH IP/OP $877.84 $649.60 $0.00 "$8,427.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $651.53 $651.53 $0.00 $0.00 $182.94 $0.00 $0.00 $0.00 $0.00 "$5,267.01" "$8,342.95" "$8,427.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GST45W SUP Custom 27203010 GST45W - RELOAD STPLR 45MMX2.6MM WHT STRL LF 1MM ECHLN EPTH ECHLN FLX BOTH IP/OP $877.84 $649.60 $0.00 $702.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $651.53 $651.53 $0.00 $0.00 $182.94 $0.00 $0.00 $0.00 $0.00 $438.92 $695.25 $702.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GST60G SUP Custom 27203010 GST60G - RELOAD STPLR 60MMX4.1MM GRN STRL LF 2MM ECHLN EPTH ECHLN FLX BOTH IP/OP $949.21 $702.42 $0.00 $759.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $704.50 $704.50 $0.00 $0.00 $197.82 $0.00 $0.00 $0.00 $0.00 $474.60 $751.77 $759.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GST60W SUP Custom 27203010 GST60W - RELOAD STPLR 60MMX2.6MM WHT STRL LF 1MM ECHLN EPTH ECHLN FLX BOTH IP/OP $949.21 $702.42 $0.00 $759.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $704.50 $704.50 $0.00 $0.00 $197.82 $0.00 $0.00 $0.00 $0.00 $474.60 $751.77 $759.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GTK14 SUP Custom 27203010 GTK14 - SYSTEM XTRT 14CM ALEXIS KII SPEC CNTN BG BLN BLNT TPGRD BOTH IP/OP $812.50 $601.25 $0.00 $603.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GTK17 SUP Custom 27203010 GTK17 - SYSTEM XTRT 12X100MM 6500ML ALEXIS BLN BLNT TIP CNTN BOTH IP/OP $812.50 $601.25 $0.00 $603.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.04 $603.04 $0.00 $0.00 $169.33 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GYN-0480 SUP Custom 27203010 KIT SRPTH PK LAB CYTO 480 TST BOTH IP/OP "$7,380.00 " "$5,461.20" $0.00 "$5,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,690.00" "$5,844.96" "$5,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 GYN-0500-B SUP Custom 27203010 BRUSH CYTO BLUE BRM HNDL BOTH IP/OP $10.90 $8.07 $0.00 $8.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.45 $8.63 $8.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H1058 SUP Custom 27203010 MASK O2 PED NREB BOTH IP/OP $8.00 $5.92 $0.00 $6.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.00 $6.34 $6.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H312-4 SUP Custom 27203010 CHEMICAL LAB 3% H2O2 AMBR GLS BTL 4L BOTH IP/OP $460.25 $340.59 $0.00 $368.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.13 $364.52 $368.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H470045A SUP HCPCS C1768 H470045A - GRAFT VASCULAR STANDARD WALL TAPER 4-7MM 45CM STRETCH COATED BOTH IP/OP "$3,147.50 " "$2,329.15" $0.00 "$2,518.00" "$1,416.38" "$1,416.38" $0.00 $0.00 $0.00 $656.02 "$2,336.07" "$2,336.07" $0.00 $0.00 $655.94 $0.00 "$1,551.72" "$1,551.72" $0.00 "$1,573.75" "$2,492.82" "$2,518.00" $0.00 $0.00 $492.58 $0.00 $0.00 $501.08 $0.00 $0.00 $0.00 $0.00 $0.00 H74912100012 SUP HCPCS C1769 H74912100012 - GUIDEWIRE VASCULAR STR FLOPPY SPRING COIL .014IN 300CM BOTH IP/OP $159.25 $117.85 $0.00 $127.40 $86.47 $86.47 $0.00 $0.00 $0.00 $33.19 $118.20 $118.20 $0.00 $0.00 $33.19 $0.00 $94.20 $94.20 $0.00 $79.63 $126.13 $127.40 $0.00 $0.00 $24.92 $0.00 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 H74912118012 SUP HCPCS C1769 H74912118012 - GUIDEWIRE VASCULAR STR SPRING COIL .014IN 300CM 3CM MODERATE BOTH IP/OP $796.25 $589.23 $0.00 $637.00 $432.36 $432.36 $0.00 $0.00 $0.00 $165.96 $590.98 $590.98 $0.00 $0.00 $165.94 $0.00 $470.98 $470.98 $0.00 $398.13 $630.63 $637.00 $0.00 $0.00 $124.61 $0.00 $0.00 $126.76 $0.00 $0.00 $0.00 $0.00 $0.00 H74912119012 SUP HCPCS C1769 H74912119012 - GUIDEWIRE VASCULAR STR SPRING COIL .014IN 300CM EXTRA BOTH IP/OP $159.25 $117.85 $0.00 $127.40 $86.47 $86.47 $0.00 $0.00 $0.00 $33.19 $118.20 $118.20 $0.00 $0.00 $33.19 $0.00 $94.20 $94.20 $0.00 $79.63 $126.13 $127.40 $0.00 $0.00 $24.92 $0.00 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 H74912154012 SUP HCPCS C1769 H74912154012 - GUIDEWIRE VASCULAR STR FLOPPY INTERMEDIATE .014IN 300CM 35CM BOTH IP/OP $159.25 $117.85 $0.00 $127.40 $86.47 $86.47 $0.00 $0.00 $0.00 $33.19 $118.20 $118.20 $0.00 $0.00 $33.19 $0.00 $94.20 $94.20 $0.00 $79.63 $126.13 $127.40 $0.00 $0.00 $24.92 $0.00 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 H74912155012 SUP HCPCS C1769 H74912155012 - GUIDEWIRE VASCULAR STR .014IN 300CM EXTRA SUPPORT BOTH IP/OP $159.25 $117.85 $0.00 $127.40 $86.47 $86.47 $0.00 $0.00 $0.00 $33.19 $118.20 $118.20 $0.00 $0.00 $33.19 $0.00 $94.20 $94.20 $0.00 $79.63 $126.13 $127.40 $0.00 $0.00 $24.92 $0.00 $0.00 $25.35 $0.00 $0.00 $0.00 $0.00 $0.00 H74914090100 SUP HCPCS C1876 H74914090100 - STENT EPRSTH 14MM 90MM 100MM VICI VNS STNT CATH NTNL ACPT BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 H74916060100 SUP HCPCS C1876 H74916060100 - STENT EPRSTH 16MM 60MM 100MM VICI VNS STNT CATH NTNL ACPT BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" "$2,250.00" "$2,250.00" $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $782.50 $0.00 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74916090100 SUP HCPCS C1876 H74916090100 - STENT EPRSTH 16MM 90MM 100MM VICI VNS STNT CATH NTNL ACPT BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 H74917521 SUP HCPCS C1769 H74917521 - GUIDEWIRE VASCULAR STR SPRING COIL .014IN 300CM 5CM SUPER BOTH IP/OP $477.75 $353.54 $0.00 $382.20 $259.42 $259.42 $0.00 $0.00 $0.00 $99.58 $354.59 $354.59 $0.00 $0.00 $99.56 $0.00 $282.59 $282.59 $0.00 $238.88 $378.38 $382.20 $0.00 $0.00 $74.77 $0.00 $0.00 $76.06 $0.00 $0.00 $0.00 $0.00 $0.00 H749201001900 SUP HCPCS C1884 H749201001900 - SYSTEM EMBOLIC PROTECTION .014IN 110UM 3.2FR 6FR 3.5-5.5MM BOTH IP/OP "$3,001.25 " "$2,220.93" $0.00 "$2,401.00" "$1,350.56" "$1,350.56" $0.00 $0.00 $0.00 $625.54 "$2,227.53" "$2,227.53" $0.00 $0.00 $625.46 $0.00 "$1,479.62" "$1,479.62" $0.00 "$1,500.63" "$2,376.99" "$2,401.00" $0.00 $0.00 $469.70 $0.00 $0.00 $477.80 $0.00 $0.00 $0.00 $0.00 $0.00 H749201003000 SUP HCPCS C1884 H749201003000 - SYSTEM EMBOLIC PROTECTION .014IN 110UM 3.2FR 6FR 3.5-5.5MM BOTH IP/OP "$3,001.25 " "$2,220.93" $0.00 "$2,401.00" "$1,350.56" "$1,350.56" $0.00 $0.00 $0.00 $625.54 "$2,227.53" "$2,227.53" $0.00 $0.00 $625.46 $0.00 "$1,479.62" "$1,479.62" $0.00 "$1,500.63" "$2,376.99" "$2,401.00" $0.00 $0.00 $469.70 $0.00 $0.00 $477.80 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062009150 SUP HCPCS C1726 H7492062009150 - CATH BALDILAT .014IN 3.2-2.3FR 1.5MM 135CM 9MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062009200 SUP HCPCS C1726 H7492062009200 - CATH BALDILAT .014IN 3.2-2.3FR 2MM 135CM 9MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062009250 SUP HCPCS C1726 H7492062009250 - CATH BALDILAT .014IN 3.2-2.4FR 2.5MM 135CM 9MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062009300 SUP HCPCS C1726 H7492062009300 - CATH BALDILAT .014IN 3.2-2.4FR 3MM 135CM 9MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062009350 SUP HCPCS C1726 H7492062009350 - CATH BALDILAT .014IN 3.5MM 135CM 9MM CORON OTW TRK TIP MAV BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062015150 SUP HCPCS C1726 H7492062015150 - CATH BALDILAT .014IN 3.2-2.3FR 1.5MM 135CM 15MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062015200 SUP HCPCS C1726 H7492062015200 - CATH BALDILAT .014IN 3.2-2.3FR 2MM 135CM 15MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062015250 SUP HCPCS C1726 H7492062015250 - CATH BALDILAT .014IN 3.2-2.4FR 2.5MM 135CM 15MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062015270 SUP HCPCS C1726 H7492062015270 - CATH BALDILAT .014IN 2.75MM 135CM 15MM CORON OTW TRK TIP MAV BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062015300 SUP HCPCS C1726 H7492062015300 - CATH BALDILAT .014IN 3.2-2.4FR 3MM 135CM 15MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062015350 SUP HCPCS C1726 H7492062015350 - CATH BALDILAT .014IN 3.2-2.7FR 3.5MM 135CM 15MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062020150 SUP HCPCS C1726 H7492062020150 - CATH BALDILAT .014IN 3.2-2.3FR 1.5MM 135CM 20MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062020200 SUP HCPCS C1726 H7492062020200 - CATH BALDILAT .014IN 3.2-2.3FR 2MM 135CM 20MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062020250 SUP HCPCS C1726 H7492062020250 - CATH BALDILAT .014IN 3.2-2.4FR 2.5MM 135CM 20MM PTCA OTW TRK BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7492062020300 SUP HCPCS C1726 H7492062020300 - CATH BALDILAT .014IN 3MM 135CM 20MM CORON OTW TRK TIP MAV BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H749364560 SUP HCPCS C1753 H749364560 - CATHETER ULTRASOUND 95CM OTW ATLANTIS PV 15MHZ 8FR BOTH IP/OP "$1,925.00 " "$1,424.50" $0.00 "$1,540.00" "$1,045.28" "$1,045.28" $0.00 $0.00 $0.00 $401.22 "$1,428.74" "$1,428.74" $0.00 $0.00 $401.17 $0.00 "$1,138.64" "$1,138.64" $0.00 $962.50 "$1,524.60" "$1,540.00" $0.00 $0.00 $301.26 $0.00 $0.00 $306.46 $0.00 $0.00 $0.00 $0.00 $0.00 H74937911415150 SUP HCPCS C1877 H74937911415150 - STENT BILIARY 4MM 15MM 150CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937911415900 SUP HCPCS C1877 H74937911415900 - STENT BILIARY 4MM 15MM 90CM PREMOUNT BALLOON EXPAND CATHETER BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937911515150 SUP HCPCS C1877 H74937911515150 - STENT BILIARY 5MM 15MM 150CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937911515900 SUP HCPCS C2617 H74937911515900 - STENT BILIARY SMALL 5MM 15MM 90CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937911614150 SUP HCPCS C1877 H74937911614150 - STENT BILIARY 6MM 14MM 150CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937911614900 SUP HCPCS C2617 H74937911614900 - STENT BILIARY SMALL 6MM 16MM 90CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937911715150 SUP HCPCS C1877 H74937911715150 - STENT BILIARY 7MM 15MM 150CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937911715900 SUP HCPCS C1877 H74937911715900 - STENT BILIARY SMALL 7MM 15MM 90CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937912419150 SUP HCPCS C1877 H74937912419150 - STENT BILIARY 4MM 19MM 150CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937912419900 SUP HCPCS C1877 H74937912419900 - STENT BILIARY 4MM 19MM 90CM PREMOUNTED BALLOON EXPANDING BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937912519150 SUP HCPCS C1877 H74937912519150 - STENT BILIARY 5MM 19MM 150CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937912519900 SUP HCPCS C2617 H74937912519900 - STENT BILIARY SMALL 5MM 19MM 90CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937912618150 SUP HCPCS C1877 H74937912618150 - STENT BILIARY 6MM 18MM 150CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937912618900 SUP HCPCS C2617 H74937912618900 - STENT BILIARY SMALL 6MM 18MM 90CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937912719150 SUP HCPCS C1877 H74937912719150 - STENT BILIARY 7MM 19MM 150CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74937912719900 SUP HCPCS C1877 H74937912719900 - STENT BILIARY SMALL 7MM 19MM 90CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H7493791540200 SUP HCPCS C1725 H7493791540200 - CATHETER BALDILAT 4MM 90CM 2CM SV RAPEX ULSF SV ANGIOPLST BOTH IP/OP "$1,162.50 " $860.25 $0.00 $930.00 $631.24 $631.24 $0.00 $0.00 $0.00 $242.29 $862.81 $862.81 $0.00 $0.00 $242.27 $0.00 $687.62 $687.62 $0.00 $581.25 $920.70 $930.00 $0.00 $0.00 $181.93 $0.00 $0.00 $185.07 $0.00 $0.00 $0.00 $0.00 $0.00 H7493791550200 SUP HCPCS C1726 H7493791550200 - CATHETER BLNDIL 3.1FR 5MM 90CM 2CM ULSF SV PTA RX NONLASER BOTH IP/OP "$1,055.00 " $780.70 $0.00 $844.00 $572.87 $572.87 $0.00 $0.00 $0.00 $219.89 $783.02 $783.02 $0.00 $0.00 $219.86 $0.00 $624.03 $624.03 $0.00 $527.50 $835.56 $844.00 $0.00 $0.00 $165.11 $0.00 $0.00 $167.96 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046102070 SUP HCPCS C1877 H74938046102070 - STENT BILIARY 30MM 10MM 25MM 75CM OTW PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046104070 SUP HCPCS C1877 H74938046104070 - STENT BILIARY 40MM 10MM 37MM 75CM OTW PREMOUNT CATHETER BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046106070 SUP HCPCS C1877 H74938046106070 - STENT BILIARY 60MM 10MM 57MM 75CM OTW PREMOUNT CATHETER BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046520750 SUP HCPCS C1877 H74938046520750 - STENT BILIARY 5MM 17MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046530750 SUP HCPCS C1877 H74938046530750 - STENT BILIARY 30MM 5MM 27MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046540750 SUP HCPCS C1877 H74938046540750 - STENT BILIARY 5MM 37MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046560750 SUP HCPCS C1877 H74938046560750 - STENT BILIARY 5MM 57MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046620750 SUP HCPCS C1877 H74938046620750 - STENT BILIARY 6MM 17MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046630750 SUP HCPCS C1877 H74938046630750 - STENT BILIARY 6MM 30MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046640750 SUP HCPCS C1877 H74938046640750 - STENT BILIARY 40MM 6MM 37MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046660750 SUP HCPCS C1877 H74938046660750 - STENT BILIARY 60MM 6MM 57MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046720750 SUP HCPCS C1877 H74938046720750 - STENT BILIARY 7MM 17MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046730750 SUP HCPCS C1877 H74938046730750 - STENT BILIARY 30MM 7MM 27MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046740750 SUP HCPCS C1877 H74938046740750 - STENT BILIARY 40MM 7MM 37MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046760750 SUP HCPCS C1877 H74938046760750 - STENT BILIARY 60MM 7MM 57MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046820750 SUP HCPCS C1877 H74938046820750 - STENT BILIARY 8MM 17MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046830750 SUP HCPCS C1877 H74938046830750 - STENT BILIARY 8MM 27MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046840750 SUP HCPCS C1877 H74938046840750 - STENT BILIARY 40MM 8MM 37MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046860750 SUP HCPCS C1877 H74938046860750 - STENT BILIARY 60MM 8MM 57MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046920750 SUP HCPCS C1877 H74938046920750 - STENT BILIARY 30MM 9MM 25MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046940750 SUP HCPCS C1877 H74938046940750 - STENT BILIARY 40MM 9MM 37MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938046960750 SUP HCPCS C1877 H74938046960750 - STENT BILIARY 60MM 9MM 57MM 75CM OTW PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047120130 SUP HCPCS C1877 H74938047120130 - STENT BILIARY 30MM 10MM 25MM 135CM OTW PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047140130 SUP HCPCS C1877 H74938047140130 - STENT BILIARY 10MM 7FR 37MM 135CM BALLOON EXPANDABLE BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $67.50 $67.50 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047160130 SUP HCPCS C1877 H74938047160130 - STENT BILIARY 10MM 7FR 57MM 135CM BALLOON EXPANDABLE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047520130 SUP HCPCS C1877 H74938047520130 - STENT BILIARY .035IN 5MM 17MM 75CM CATHETER BALLOON INFLAT BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047530130 SUP HCPCS C1877 H74938047530130 - STENT BILIARY 5MM 27MM 135CM OTW BALLOON EXPAND PREMOUNT BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047540130 SUP HCPCS C1877 H74938047540130 - STENT BILIARY 5MM 40MM 135CM OTW BALLOON EXPAND PREMOUNT BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047560130 SUP HCPCS C1877 H74938047560130 - STENT BILIARY 5MM 6FR 60MM 135CM BALLOON EXPANDING BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047620130 SUP HCPCS C1877 H74938047620130 - STENT BILIARY 6MM 6FR 17MM 135CM PREMOUNTED BALLOON EXPRESS BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047630130 SUP HCPCS C1877 H74938047630130 - STENT BILIARY 30MM 6MM 27MM 135CM OTW PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047640130 SUP HCPCS C1877 H74938047640130 - STENT BILIARY 40MM 6MM 37MM 135CM OTW PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047660130 SUP HCPCS C1877 H74938047660130 - STENT BILIARY 9MM 6MM 57MM 135CM PREMOUNT BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047720130 SUP HCPCS C1877 H74938047720130 - STENT BILIARY 20MM 7MM 17MM 135CM OTW BALLOON EXPAND BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047730130 SUP HCPCS C1877 H74938047730130 - STENT BILIARY 30MM 7MM 27MM 135CM OTW PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047740130 SUP HCPCS C1877 H74938047740130 - STENT BILIARY 9MM 7MM 6FR 37MM 135CM BALLOON EXPANDABLE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047760130 SUP HCPCS C1877 H74938047760130 - STENT BILIARY 9MM 7MM 6FR 57MM 135CM BALLOON EXPANDABLE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047820130 SUP HCPCS C1877 H74938047820130 - STENT BILIARY 8MM 6FR 17MM 135CM BALLOON EXPANDABLE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047830130 SUP HCPCS C1877 H74938047830130 - STENT BILIARY 30MM 8MM 27MM 135CM OTW PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047840130 SUP HCPCS C1877 H74938047840130 - STENT BILIARY 8MM 37MM 135CM BALLOON EXPAND PREMOUNT EXPRESS BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047860130 SUP HCPCS C1877 H74938047860130 - STENT BILIARY 8MM 7IN 57MM 135CM OTW PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047920130 SUP HCPCS C1877 H74938047920130 - STENT BILIARY 30MM 9MM 25MM 135CM OTW PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047940130 SUP HCPCS C1877 H74938047940130 - STENT BILIARY 9MM 7FR 37MM 135CM BALLOON EXPANDABLE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74938047960130 SUP HCPCS C1877 H74938047960130 - STENT BILIARY 11MM 9MM 7FR 57MM 135CM PREMOUNT BALLOON BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808012200 SUP HCPCS C1726 H7493808012200 - CATH BALDILAT .014IN 2MM 12MM PCTA RAPEX LP TPR TIP Q M BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808012250 SUP HCPCS C1726 H7493808012250 - CATH BALDILAT 1.8-2.7FR 2.5MM 135CM 12MM PTCA RAPEX LP TPR BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808012300 SUP HCPCS C1726 H7493808012300 - CATH BALDILAT 3MM 135CM 12MM PCTA RAPEX LP TPR TIP Q M BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808012350 SUP HCPCS C1726 H7493808012350 - CATH BALDILAT .014IN 1.8-2.7FR 3.5MM 135CM 12MM PTCA RAPEX BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808012400 SUP HCPCS C1726 H7493808012400 - CATH BALDILAT .014IN 1.8-2.7FR 4MM 135CM 12MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808012450 SUP HCPCS C1726 H7493808012450 - CATH BALDILAT .014IN 2-2.7FR 4.5MM 135CM 12MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H749380801250 SUP HCPCS C1726 H749380801250 - CATH BALDILAT .014IN 2-2.7FR 5MM 135CM 12MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808015250 SUP HCPCS C1726 H7493808015250 - CATH BALDILAT .014IN 2.5MM 15MM PTCA RAPEX Q M BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808015300 SUP HCPCS C1726 H7493808015300 - CATH BALDILAT 3MM 135CM 15MM CORON PCTA RAPEX LP TPR TIP Q M BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808015350 SUP HCPCS C1726 H7493808015350 - CATH BALDILAT .014IN 3.5MM 15MM PTCA RAPEX Q M BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808015400 SUP HCPCS C1726 H7493808015400 - CATH BALDILAT .014IN 1.8-2.7FR 4MM 135CM 15MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808015450 SUP HCPCS C1726 H7493808015450 - CATH BALDILAT .014IN 2-2.7FR 4.5MM 135CM 15MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808015500 SUP HCPCS C1726 H7493808015500 - CATH BALDILAT .014IN 2-2.7FR 5MM 135CM 15MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808020250 SUP HCPCS C1726 H7493808020250 - CATH BALDILAT .014IN 1.8-2.7FR 2.5MM 135CM 20MM PTCA RAPEX BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808020300 SUP HCPCS C1726 H7493808020300 - CATH BALDILAT .014IN 1.8-2.7FR 3MM 135CM 20MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808020350 SUP HCPCS C1726 H7493808020350 - CATH BALDILAT .014IN 1.8-2.7FR 3.5MM 135CM 20MM PTCA RAPEX BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493808020400 SUP HCPCS C1726 H7493808020400 - CATH BALDILAT .014IN 2-2.7FR 4MM 135CM 20MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892809200 SUP HCPCS C1726 H7493892809200 - CATHETER BLNDIL 2MM 142CM 9MM MAVERICK2 MNRL TRAKTIP TPR BOTH IP/OP $269.50 $199.43 $0.00 $215.60 $146.34 $146.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.75 $213.44 $215.60 $0.00 $0.00 $42.18 $0.00 $0.00 $42.90 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892809250 SUP HCPCS C1725 H7493892809250 - CATHETER BLNDIL 2.5MM 142CM 9MM MAVERICK2 MNRL TRAKTIP TPR BOTH IP/OP $269.50 $199.43 $0.00 $215.60 $146.34 $146.34 $0.00 $0.00 $0.00 $56.17 $200.02 $200.02 $0.00 $0.00 $56.16 $0.00 $159.41 $159.41 $0.00 $134.75 $213.44 $215.60 $0.00 $0.00 $42.18 $0.00 $0.00 $42.90 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892809300 SUP HCPCS C1725 H7493892809300 - CATHETER BLNDIL 3MM 142CM 9MM MAVERICK2 MNRL TRAKTIP TPR BOTH IP/OP $269.50 $199.43 $0.00 $215.60 $146.34 $146.34 $0.00 $0.00 $0.00 $56.17 $200.02 $200.02 $0.00 $0.00 $56.16 $0.00 $159.41 $159.41 $0.00 $134.75 $213.44 $215.60 $0.00 $0.00 $42.18 $0.00 $0.00 $42.90 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892809350 SUP HCPCS C1726 H7493892809350 - CATH BALDILAT .014IN 1.8-2.7FR 3.5MM 135CM 9MM PTCA RAPEX LP BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892815150 SUP HCPCS C1726 H7493892815150 - CATH BALDILAT .014IN 1.8-2.6-2.3FR 1.5MM 135CM 15MM PTCA BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892815200 SUP HCPCS C1726 H7493892815200 - CATHETER BLNDIL 2MM 142CM 15MM MAVERICK2 MNRL TRAKTIP TPR BOTH IP/OP $269.50 $199.43 $0.00 $215.60 $146.34 $146.34 $0.00 $0.00 $0.00 $56.17 $200.02 $200.02 $0.00 $0.00 $56.16 $0.00 $159.41 $159.41 $0.00 $134.75 $213.44 $215.60 $0.00 $0.00 $42.18 $0.00 $0.00 $42.90 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892815250 SUP HCPCS C1726 H7493892815250 - CATH BALDILAT .014IN 1.8-2.6-2.4FR 2.5MM 135CM 15MM PTCA BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892815300 SUP HCPCS C1726 H7493892815300 - CATH BALDILAT .014IN 1.8-2.6-2.4FR 3MM 135CM 15MM PTCA RAPEX BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892815350 SUP HCPCS C1726 H7493892815350 - CATH BALDILAT .014IN 1.8-2.7FR 3.5MM 135CM 15MM PTCA RAPEX BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892820200 SUP HCPCS C1726 H7493892820200 - CATH BALDILAT .014IN 1.8-2.6-2.3FR 2MM 135CM 20MM PTCA RAPEX BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892820250 SUP HCPCS C1726 H7493892820250 - CATH BALDILAT .014IN 1.8-2.6-2.4FR 2.5MM 135CM 20MM PTCA BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493892820300 SUP HCPCS C1726 H7493892820300 - CATH BALDILAT .014IN 1.8-2.6-2.4FR 3MM 135CM 20MM PTCA RAPEX BOTH IP/OP $612.50 $453.25 $0.00 $490.00 $332.59 $332.59 $0.00 $0.00 $0.00 $127.66 $454.60 $454.60 $0.00 $0.00 $127.65 $0.00 $362.29 $362.29 $0.00 $306.25 $485.10 $490.00 $0.00 $0.00 $95.86 $0.00 $0.00 $97.51 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894812010 SUP HCPCS C1876 H7493894812010 - STENT BILIARY 21MM SELF EXPANDING SENTINOL NITINOL 135CM 10 BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894812070 SUP HCPCS C1876 H7493894812070 - STENT BILIARY 21MM SELF EXPANDING NONCOATED NONCOVERED BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894814010 SUP HCPCS C1876 H7493894814010 - STENT BILIARY 40MM SELF EXPANDING SENTINOL NITINOL 135CM 10 BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894814070 SUP HCPCS C1876 H7493894814070 - STENT BILIARY 41MM SELF EXPANDING SHEATH CATHETER SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894816010 SUP HCPCS C1876 H7493894816010 - STENT BILIARY 59MM SELF EXPANDABLE SENTINOL NITINOL 135CM 10 BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894818010 SUP HCPCS C1876 H7493894818010 - STENT BILIARY 80MM SELF EXPANDING SENTINOL NITINOL 135CM 10 BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894852010 SUP HCPCS C1876 H7493894852010 - STENT BILIARY 21MM SELF EXPANDING SENTINOL NITINOL 135CM 5MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894852070 SUP HCPCS C1876 H7493894852070 - STENT BILIARY 21MM SELF EXPANDING SENTINOL NITINOL 75CM 5MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894854010 SUP HCPCS C1876 H7493894854010 - STENT BILIARY 40MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894854070 SUP HCPCS C1876 H7493894854070 - STENT BILIARY 40MM SELF EXPANDING NONCOATED NONCOVERED BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894856010 SUP HCPCS C1876 H7493894856010 - STENT BILIARY 60MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894856070 SUP HCPCS C1876 H7493894856070 - STENT BILIARY 60MM SELF EXPANDING NONCOATED NONCOVERED BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894862010 SUP HCPCS C1876 H7493894862010 - STENT BILIARY 20MM SELF EXPANDING SENTINOL NITINOL 135CM 6MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894862070 SUP HCPCS C1876 H7493894862070 - STENT BILIARY 20MM SELF EXPANDING SENTINOL NITINOL 75CM 6MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894864010 SUP HCPCS C1876 H7493894864010 - STENT BILIARY 40MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894864070 SUP HCPCS C1876 H7493894864070 - STENT BILIARY 40MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894866010 SUP HCPCS C1876 H7493894866010 - STENT BILIARY 59MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894866070 SUP HCPCS C1876 H7493894866070 - STENT BILIARY 59MM SELF EXPANDING SENTINOL NITINOL 75CM 6MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894868010 SUP HCPCS C1876 H7493894868010 - STENT BILIARY 79MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894868070 SUP HCPCS C1876 H7493894868070 - STENT BILIARY 79MM SELF EXPANDING SENTINOL NITINOL 75CM 6MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894872010 SUP HCPCS C1876 H7493894872010 - STENT BILIARY 1350MM SELF EXPANDING CATHETER DELIVERY SYSTEM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894872070 SUP HCPCS C1876 H7493894872070 - STENT BILIARY 20MM SELF EXPANDING SENTINOL NITINOL 75CM 7MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894874010 SUP HCPCS C1876 H7493894874010 - STENT BILIARY 39MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894874070 SUP HCPCS C1876 H7493894874070 - STENT BILIARY 39MM SELF EXPANDABLE SENTINOL NITINOL 75CM 7MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894876010 SUP HCPCS C1876 H7493894876010 - STENT BILIARY 59MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894876070 SUP HCPCS C1876 H7493894876070 - STENT BILIARY 59MM SELF EXPANDING SENTINOL NITINOL 75CM 7MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894878010 SUP HCPCS C1876 H7493894878010 - STENT BILIARY 78MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894878070 SUP HCPCS C1876 H7493894878070 - STENT BILIARY 78MM SELF EXPANDING SENTINOL NITINOL 75CM 7MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894882010 SUP HCPCS C1876 H7493894882010 - STENT BILIARY 21MM SELF EXPANDING SENTINOL NITINOL 135CM 8MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894882070 SUP HCPCS C1876 H7493894882070 - STENT BILIARY 21MM SELF EXPANDING SENTINOL NITINOL 75CM 8MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894884010 SUP HCPCS C1876 H7493894884010 - STENT BILIARY 42MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894884070 SUP HCPCS C1876 H7493894884070 - STENT BILIARY 42MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894886010 SUP HCPCS C1876 H7493894886010 - STENT BILIARY 60MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894886070 SUP HCPCS C1876 H7493894886070 - STENT BILIARY 60MM SELF EXPAND DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894888010 SUP HCPCS C1876 H7493894888010 - STENT BILIARY 81MM SELF EXPANDING DELIVERY SYSTEM SENTINOL BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894892010 SUP HCPCS C1876 H7493894892010 - STENT BILIARY 21MM SELF EXPANDING SENTINOL NITINOL 135CM 9MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894892070 SUP HCPCS C1876 H7493894892070 - STENT BILIARY 21MM SELF EXPANDING SENTINOL NITINOL 75CM 9MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894894010 SUP HCPCS C1876 H7493894894010 - STENT BILIARY 42MM SELF EXPANDING SENTINOL NITINOL 135CM 9MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894894070 SUP HCPCS C1876 H7493894894070 - STENT BILIARY 750MM SELF EXPANDING CATHETER DELIVERY SYSTEM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894896010 SUP HCPCS C1876 H7493894896010 - STENT BILIARY 60MM SELF EXPANDING SENTINOL NITINOL 135CM 9MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894896070 SUP HCPCS C1876 H7493894896070 - STENT BILIARY 60MM SELF EXPANDING SENTINOL NITINOL 75CM 9MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894898010 SUP HCPCS C1876 H7493894898010 - STENT BILIARY 80MM SELF EXPANDING SENTINOL NITINOL 135CM 9MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493894898070 SUP HCPCS C1876 H7493894898070 - STENT BILIARY 80MM SELF EXPANDING SENTINOL NITINOL 75CM 9MM BOTH IP/OP "$2,437.50 " "$1,803.75" $0.00 "$1,950.00" "$1,096.88" "$1,096.88" $0.00 $0.00 $0.00 $508.04 "$1,809.11" "$1,809.11" $0.00 $0.00 $507.98 $0.00 "$1,441.78" "$1,441.78" $0.00 "$1,218.75" "$1,930.50" "$1,950.00" $0.00 $0.00 $381.47 $0.00 $0.00 $388.05 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897008250 SUP HCPCS C2617 H7493897008250 - STENT CORON 2.5MM 8MM RAPEX BLN XPD TAXUS XPR2 MNRL 8.8% BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897008300 SUP HCPCS C2617 H7493897008300 - STENT CORON 3MM 8MM RAPEX BLN EXPANDABLE TAXUS XPR2 MNRL BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" "$2,925.00" "$2,925.00" $0.00 $0.00 $0.00 "$1,354.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,354.60" $0.00 "$3,204.50" "$3,204.50" $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 $0.00 "$1,017.25" $0.00 $0.00 "$1,034.80" $0.00 $0.00 $0.00 $0.00 $0.00 H7493897008350 SUP HCPCS C2617 H7493897008350 - STENT CORON 3.5MM 8MM RAPEX BLN XPD TAXUS XPR2 MNRL PCLTXL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897012250 SUP HCPCS C2617 H7493897012250 - STENT CORON 2.50MM 12MM XPR TAXUS XPR2 MNRL PCLTXL ELUT RX BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897012300 SUP HCPCS C2617 H7493897012300 - STENT CORON 3MM 12MM RAPEX BLN XPD TAXUS XPR2 MNRL 8.8% BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897012350 SUP HCPCS C2617 H7493897012350 - STENT CORON 3.5MM 12MM RAPEX BLN XPD TAXUS XPR2 MNRL PCLTXL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897016250 SUP HCPCS C2617 H7493897016250 - STENT CORON 2.5MM 16MM SYS ART TAXUS XPR2 MNRL 8.8% PCLTXL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897016300 SUP HCPCS C2617 H7493897016300 - STENT CORONARY ARTERY EXPRESS 2 TAXUS 3 X 16MM 8.8% PACLITAX BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897016350 SUP HCPCS C2617 H7493897016350 - STENT CORON 3.5MM 16MM RAPEX BLN EXPANDABLE TAXUS XPR2 MNRL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897020250 SUP HCPCS C2617 H7493897020250 - STENT CORON 2.5MM 20MM TAXUS XPR2 MNRL 8.8% PCLTXL ELUT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897020300 SUP HCPCS C2617 H7493897020300 - STENT CORON 3MM 20MM RAPEX BLN EXPANDABLE TAXUS XPR2 MNRL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897020350 SUP HCPCS C2617 H7493897020350 - STENT CORON 3.5MM 20MM RAPEX BLN XPD XPR RX PCLTXL ELUT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897028300 SUP HCPCS C2617 H7493897028300 - STENT CORON 3MM 28MM RAPEX BLN XPD TAXUS XPR2 MNRL 8.8% BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897028350 SUP HCPCS C2617 H7493897028350 - STENT CORON 3.5MM 28MM RAPEX BLN XPD TAXUS XPR2 MNRL 8.8% BOTH IP/OP "$6,500.00 " "$4,810.00" $0.00 "$5,200.00" "$2,925.00" "$2,925.00" $0.00 $0.00 $0.00 "$1,354.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,354.60" $0.00 "$3,204.50" "$3,204.50" $0.00 "$3,250.00" "$5,148.00" "$5,200.00" $0.00 $0.00 "$1,017.25" $0.00 $0.00 "$1,034.80" $0.00 $0.00 $0.00 $0.00 $0.00 H7493897032300 SUP HCPCS C2617 H7493897032300 - STENT CORON 3MM 32MM RAPEX BLN XPD TAXUS XPR2 MNRL PCLTXL BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7493897032350 SUP HCPCS C2617 H7493897032350 - STENT CORON 3.5MM 32MM RAPEX BLN XPD XPR RX PCLTXL ELUT BOTH IP/OP "$6,250.00 " "$4,625.00" $0.00 "$5,000.00" "$2,812.50" "$2,812.50" $0.00 $0.00 $0.00 "$1,302.66" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,302.50" $0.00 "$3,081.25" "$3,081.25" $0.00 "$3,125.00" "$4,950.00" "$5,000.00" $0.00 $0.00 $978.13 $0.00 $0.00 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031302010 SUP HCPCS C1725 H74939031302010 - CATHETER BLNDIL 3MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031303010 SUP HCPCS C1725 H74939031303010 - CATHETER BLNDIL 3MM 135CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031304010 SUP HCPCS C1725 H74939031304010 - CATHETER BLNDIL 3MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031306010 SUP HCPCS C1725 H74939031306010 - CATHETER BLNDIL 3MM 135CM 60MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031352010 SUP HCPCS C1725 H74939031352010 - CATHETER BLNDIL 3.5MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031353010 SUP HCPCS C1725 H74939031353010 - CATHETER BLNDIL 3.5MM 135CM 30MM STRLG MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031354010 SUP HCPCS C1725 H74939031354010 - CATHETER BLNDIL 3.5MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031401080 SUP HCPCS C1725 H74939031401080 - CATHETER BLNDIL 4MM 80CM 10MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031401580 SUP HCPCS C1725 H74939031401580 - CATHETER BLNDIL 4MM 80CM 15MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031402010 SUP HCPCS C1725 H74939031402010 - CATHETER BLNDIL 4MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031402080 SUP HCPCS C1725 H74939031402080 - CATHETER BLNDIL 4MM 80CM 20MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031403010 SUP HCPCS C1725 H74939031403010 - CATHETER BLNDIL 4MM 135CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031403080 SUP HCPCS C1725 H74939031403080 - CATHETER BLNDIL 4MM 80CM 30MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031404010 SUP HCPCS C1725 H74939031404010 - CATHETER BLNDIL 4MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031404080 SUP HCPCS C1725 H74939031404080 - CATHETER BLNDIL 4MM 80CM 40MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031406010 SUP HCPCS C1725 H74939031406010 - CATHETER BLNDIL 4MM 135CM 60MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031451580 SUP HCPCS C1725 H74939031451580 - CATHETER BLNDIL 4.5MM 80CM 15MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031452010 SUP HCPCS C1725 H74939031452010 - CATHETER BLNDIL 4.5MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031452080 SUP HCPCS C1725 H74939031452080 - CATHETER BLNDIL 4.5MM 80CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031453010 SUP HCPCS C1725 H74939031453010 - CATHETER BLNDIL 4.5MM 135CM 30MM STRLG MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031453080 SUP HCPCS C1725 H74939031453080 - CATHETER BLNDIL 4.5MM 80CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031454010 SUP HCPCS C1725 H74939031454010 - CATHETER BLNDIL 4.5MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031454080 SUP HCPCS C1725 H74939031454080 - CATHETER BLNDIL 4.5MM 80CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031501080 SUP HCPCS C1725 H74939031501080 - CATHETER BLNDIL 5MM 80CM 10MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031501580 SUP HCPCS C1725 H74939031501580 - CATHETER BLNDIL 5MM 80CM 15MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031502010 SUP HCPCS C1725 H74939031502010 - CATHETER BLNDIL 5MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031502080 SUP HCPCS C1725 H74939031502080 - CATHETER BLNDIL 5MM 80CM 20MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031503010 SUP HCPCS C1725 H74939031503010 - CATHETER BLNDIL 5MM 135CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031503080 SUP HCPCS C1725 H74939031503080 - CATHETER BLNDIL 5MM 80CM 30MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031504010 SUP HCPCS C1725 H74939031504010 - CATHETER BLNDIL 5MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031504080 SUP HCPCS C1725 H74939031504080 - CATHETER BLNDIL 5MM 80CM 40MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031506010 SUP HCPCS C1725 H74939031506010 - CATHETER BLNDIL 5MM 135CM 60MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031551580 SUP HCPCS C1725 H74939031551580 - CATHETER BLNDIL 5.5MM 80CM 15MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031552010 SUP HCPCS C1725 H74939031552010 - CATHETER BLNDIL 5.5MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031552080 SUP HCPCS C1725 H74939031552080 - CATHETER BLNDIL 5.5MM 80CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031553010 SUP HCPCS C1725 H74939031553010 - CATHETER BLNDIL 5.5MM 135CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031553080 SUP HCPCS C1725 H74939031553080 - CATHETER BLNDIL 5.5MM 80CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031554010 SUP HCPCS C1725 H74939031554010 - CATHETER BLNDIL 5.5MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031554080 SUP HCPCS C1725 H74939031554080 - CATHETER BLNDIL 5.5MM 80CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031601080 SUP HCPCS C1725 H74939031601080 - CATHETER BLNDIL 6MM 80CM 10MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031601580 SUP HCPCS C1725 H74939031601580 - CATHETER BLNDIL 6MM 80CM 15MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031602010 SUP HCPCS C1725 H74939031602010 - CATHETER BLNDIL 6MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031602080 SUP HCPCS C1725 H74939031602080 - CATHETER BLNDIL 6MM 80CM 20MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031603010 SUP HCPCS C1725 H74939031603010 - CATHETER BLNDIL 6MM 135CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031603080 SUP HCPCS C1725 H74939031603080 - CATHETER BLNDIL 6MM 80CM 30MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031604010 SUP HCPCS C1725 H74939031604010 - CATHETER BLNDIL 6MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031604080 SUP HCPCS C1725 H74939031604080 - CATHETER BLNDIL 6MM 80CM 40MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031606010 SUP HCPCS C1725 H74939031606010 - CATHETER BLNDIL 6MM 135CM 60MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031651580 SUP HCPCS C1725 H74939031651580 - CATHETER BLNDIL 6.5MM 80CM 15MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031652010 SUP HCPCS C1725 H74939031652010 - CATHETER BLNDIL 6.5MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031652080 SUP HCPCS C1725 H74939031652080 - CATHETER BLNDIL 6.5MM 80CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031653010 SUP HCPCS C1725 H74939031653010 - CATHETER BLNDIL 6.5MM 135CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031653080 SUP HCPCS C1725 H74939031653080 - CATHETER BLNDIL 6.5MM 80CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031654010 SUP HCPCS C1725 H74939031654010 - CATHETER BLNDIL 6.5MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031654080 SUP HCPCS C1725 H74939031654080 - CATHETER BLNDIL 6.5MM 80CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031701080 SUP HCPCS C1725 H74939031701080 - CATHETER BLNDIL 7MM 80CM 10MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031701580 SUP HCPCS C1725 H74939031701580 - CATHETER BLNDIL 7MM 80CM 15MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031702010 SUP HCPCS C1725 H74939031702010 - CATHETER BLNDIL 7MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031702080 SUP HCPCS C1725 H74939031702080 - CATHETER BLNDIL 7MM 80CM 20MM STRLG MNRL RX INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031703010 SUP HCPCS C1725 H74939031703010 - CATHETER BLNDIL 7MM 135CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031703080 SUP HCPCS C1725 H74939031703080 - CATHETER BLNDIL 7MM 80CM 30MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031704010 SUP HCPCS C1725 H74939031704010 - CATHETER BLNDIL 7MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031704080 SUP HCPCS C1725 H74939031704080 - CATHETER BLNDIL 7MM 80CM 40MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031706010 SUP HCPCS C1725 H74939031706010 - CATHETER BLNDIL 7MM 135CM 60MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031801080 SUP HCPCS C1725 H74939031801080 - CATHETER BLNDIL 8MM 80CM 10MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031801580 SUP HCPCS C1725 H74939031801580 - CATHETER BLNDIL 8MM 80CM 15MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031802010 SUP HCPCS C1725 H74939031802010 - CATHETER BLNDIL 8MM 135CM 20MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031802080 SUP HCPCS C1725 H74939031802080 - CATHETER BLNDIL 8MM 80CM 20MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031803010 SUP HCPCS C1725 H74939031803010 - CATHETER BLNDIL 8MM 135CM 30MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031803080 SUP HCPCS C1725 H74939031803080 - CATHETER BLNDIL 8MM 80CM 30MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031804010 SUP HCPCS C1725 H74939031804010 - CATHETER BLNDIL 8MM 135CM 40MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031804080 SUP HCPCS C1725 H74939031804080 - CATHETER BLNDIL 8MM 80CM 40MM STRLG MNRL TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939031806010 SUP HCPCS C1725 H74939031806010 - CATHETER BLNDIL 8MM 135CM 60MM STRLG MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032102010 SUP HCPCS C1753 H74939032102010 - CATHETER BLNDIL 10MM 135CM 20MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032102080 SUP HCPCS C1753 H74939032102080 - CATHETER BLNDIL 10MM 80CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032103010 SUP HCPCS C1753 H74939032103010 - CATHETER BLNDIL 10MM 135CM 30MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032103080 SUP HCPCS C1753 H74939032103080 - CATHETER BLNDIL 10MM 80CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032104010 SUP HCPCS C1753 H74939032104010 - CATHETER BLNDIL 10MM 135CM 40MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032104080 SUP HCPCS C1753 H74939032104080 - CATHETER BLNDIL 10MM 80CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032106010 SUP HCPCS C1753 H74939032106010 - CATHETER BLNDIL 10MM 135CM 60MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032106080 SUP HCPCS C1753 H74939032106080 - CATHETER BLNDIL 10MM 80CM 60MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032108010 SUP HCPCS C1753 H74939032108010 - CATHETER BLNDIL 10MM 135CM 80MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032108080 SUP HCPCS C1753 H74939032108080 - CATHETER BLNDIL 10MM 80CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032401010 SUP HCPCS C1753 H74939032401010 - CATHETER BLNDIL 4MM 135CM 100MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032401080 SUP HCPCS C1753 H74939032401080 - CATHETER BLNDIL 4MM 80CM 100MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032402010 SUP HCPCS C1726 H74939032402010 - CATHETER BLNDIL 4MM 135CM 20MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032402040 SUP HCPCS C1753 H74939032402040 - CATHETER BLNDIL 4MM 40CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032402080 SUP HCPCS C1753 H74939032402080 - CATHETER BLNDIL 4MM 80CM 20MM STRLG OTW INFL PORT LOPRFL TPR BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032403010 SUP HCPCS C1753 H74939032403010 - CATHETER BLNDIL 4MM 135CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032403080 SUP HCPCS C1753 H74939032403080 - CATHETER BLNDIL 4MM 80CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032404010 SUP HCPCS C1726 H74939032404010 - CATHETER BLNDIL 4MM 135CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032404040 SUP HCPCS C1753 H74939032404040 - CATHETER BLNDIL 4MM 40CM 40MM STRLG OTW INFL PORT LOPRFL TPR BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032404080 SUP HCPCS C1753 H74939032404080 - CATHETER BLNDIL 4MM 80CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032406010 SUP HCPCS C1753 H74939032406010 - CATHETER BLNDIL 4MM 135CM 60MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032406080 SUP HCPCS C1753 H74939032406080 - CATHETER BLNDIL 4MM 80CM 60MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032408010 SUP HCPCS C1753 H74939032408010 - CATHETER BLNDIL 4MM 135CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032408080 SUP HCPCS C1753 H74939032408080 - CATHETER BLNDIL 4MM 80CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032501010 SUP HCPCS C1753 H74939032501010 - CATHETER BLNDIL 5MM 135CM 100MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032501080 SUP HCPCS C1726 H74939032501080 - CATHETER BLNDIL 5MM 80CM 100MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032501510 SUP HCPCS C1725 H74939032501510 - CATHETER BLNDIL 5MM 150CM 150MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032502010 SUP HCPCS C1753 H74939032502010 - CATHETER BLNDIL 5MM 135CM 20MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032502040 SUP HCPCS C1753 H74939032502040 - CATHETER BLNDIL 5MM 40CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032502080 SUP HCPCS C1726 H74939032502080 - CATHETER BLNDIL 5MM 80CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032502110 SUP HCPCS C1725 H74939032502110 - CATHETER BLNDIL 5MM 150CM 200MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032503010 SUP HCPCS C1753 H74939032503010 - CATHETER BLNDIL 5MM 135CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032503080 SUP HCPCS C1753 H74939032503080 - CATHETER BLNDIL 5MM 80CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032504010 SUP HCPCS C1726 H74939032504010 - CATHETER BLNDIL 5MM 135CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032504040 SUP HCPCS C1753 H74939032504040 - CATHETER BLNDIL 5MM 40CM 40MM STRLG OTW INFL PORT LOPRFL TPR BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032504080 SUP HCPCS C1726 H74939032504080 - CATHETER BLNDIL 5MM 80CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032506010 SUP HCPCS C1753 H74939032506010 - CATHETER BLNDIL 5MM 135CM 60MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032506080 SUP HCPCS C1726 H74939032506080 - CATHETER BLNDIL 5MM 80CM 60MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032508010 SUP HCPCS C1753 H74939032508010 - CATHETER BLNDIL 5MM 135CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032508080 SUP HCPCS C1726 H74939032508080 - CATHETER BLNDIL 5MM 80CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032601010 SUP HCPCS C1753 H74939032601010 - CATHETER BLNDIL 6MM 135CM 100MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032601080 SUP HCPCS C1753 H74939032601080 - CATHETER BLNDIL 6MM 80CM 100MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032601510 SUP HCPCS C1725 H74939032601510 - CATHETER BLNDIL 6MM 150CM 150MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032602010 SUP HCPCS C1726 H74939032602010 - CATHETER BLNDIL 6MM 135CM 20MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032602040 SUP HCPCS C1753 H74939032602040 - CATHETER BLNDIL 6MM 40CM 20MM STRLG OTW INFL PORT LOPRFL TPR BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032602080 SUP HCPCS C1726 H74939032602080 - CATHETER BLNDIL 6MM 80CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032602210 SUP HCPCS C1725 H74939032602210 - CATHETER BLNDIL 6MM 150CM 220MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032603010 SUP HCPCS C1753 H74939032603010 - CATHETER BLNDIL 6MM 135CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032603080 SUP HCPCS C1753 H74939032603080 - CATHETER BLNDIL 6MM 80CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032604010 SUP HCPCS C1726 H74939032604010 - CATHETER BLNDIL 6MM 135CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032604040 SUP HCPCS C1753 H74939032604040 - CATHETER BLNDIL 6MM 40CM 40MM STRLG OTW INFL PORT LOPRFL TPR BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032604080 SUP HCPCS C1726 H74939032604080 - CATHETER BLNDIL 6MM 80CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032606010 SUP HCPCS C1726 H74939032606010 - CATHETER BLNDIL 6MM 135CM 60MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032606080 SUP HCPCS C1726 H74939032606080 - CATHETER BLNDIL 6MM 80CM 60MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032608010 SUP HCPCS C1726 H74939032608010 - CATHETER BLNDIL 6MM 135CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032608080 SUP HCPCS C1753 H74939032608080 - CATHETER BLNDIL 6MM 80CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032701010 SUP HCPCS C1753 H74939032701010 - CATHETER BLNDIL 7MM 135CM 100MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032701080 SUP HCPCS C1753 H74939032701080 - CATHETER BLNDIL 7MM 80CM 100MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032701210 SUP HCPCS C1725 H74939032701210 - CATHETER BLNDIL 7MM 150CM 120MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032701510 SUP HCPCS C1725 H74939032701510 - CATHETER BLNDIL 7MM 150CM 150MM STRLG OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032702010 SUP HCPCS C1726 H74939032702010 - CATHETER BLNDIL 7MM 135CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032702040 SUP HCPCS C1753 H74939032702040 - CATHETER BLNDIL 7MM 40CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032702080 SUP HCPCS C1726 H74939032702080 - CATHETER BLNDIL 7MM 80CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032702110 SUP HCPCS C1725 H74939032702110 - CATHETER BLNDIL 7MM 150CM 200MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032702210 SUP HCPCS C1725 H74939032702210 - CATHETER BLNDIL 7MM 150CM 220MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032703010 SUP HCPCS C1753 H74939032703010 - CATHETER BLNDIL 7MM 135CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032703080 SUP HCPCS C1753 H74939032703080 - CATHETER BLNDIL 7MM 80CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032704010 SUP HCPCS C1726 H74939032704010 - CATHETER BLNDIL 7MM 135CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032704040 SUP HCPCS C1753 H74939032704040 - CATHETER BLNDIL 7MM 40CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032704080 SUP HCPCS C1726 H74939032704080 - CATHETER BLNDIL 7MM 80CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032706010 SUP HCPCS C1726 H74939032706010 - CATHETER BLNDIL 7MM 135CM 60MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032706080 SUP HCPCS C1726 H74939032706080 - CATHETER BLNDIL 7MM 80CM 60MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032708010 SUP HCPCS C1753 H74939032708010 - CATHETER BLNDIL 7MM 135CM 80MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032708080 SUP HCPCS C1726 H74939032708080 - CATHETER BLNDIL 7MM 80CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032802010 SUP HCPCS C1726 H74939032802010 - CATHETER BLNDIL 8MM 135CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032802040 SUP HCPCS C1753 H74939032802040 - CATHETER BLNDIL 8MM 40CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032802080 SUP HCPCS C1726 H74939032802080 - CATHETER BLNDIL 8MM 80CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032803010 SUP HCPCS C1753 H74939032803010 - CATHETER BLNDIL 8MM 135CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032803080 SUP HCPCS C1753 H74939032803080 - CATHETER BLNDIL 8MM 80CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032804010 SUP HCPCS C1726 H74939032804010 - CATHETER BLNDIL 8MM 135CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032804040 SUP HCPCS C1753 H74939032804040 - CATHETER BLNDIL 8MM 40CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032804080 SUP HCPCS C1726 H74939032804080 - CATHETER BLNDIL 8MM 80CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032806010 SUP HCPCS C1726 H74939032806010 - CATHETER BLNDIL 8MM 135CM 40MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032806080 SUP HCPCS C1726 H74939032806080 - CATHETER BLNDIL 8MM 80CM 60MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $81.45 $81.45 $0.00 $0.00 $0.00 $31.26 $111.33 $111.33 $0.00 $0.00 $31.26 $0.00 $88.73 $88.73 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $23.48 $0.00 $0.00 $23.88 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032808010 SUP HCPCS C1726 H74939032808010 - CATHETER BLNDIL 8MM 135CM 80MM STRLG OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032808080 SUP HCPCS C1753 H74939032808080 - CATHETER BLNDIL 8MM 80CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032902010 SUP HCPCS C1753 H74939032902010 - CATHETER BLNDIL 9MM 135CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032902080 SUP HCPCS C1753 H74939032902080 - CATHETER BLNDIL 9MM 80CM 20MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032903010 SUP HCPCS C1753 H74939032903010 - CATHETER BLNDIL 9MM 135CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032903080 SUP HCPCS C1753 H74939032903080 - CATHETER BLNDIL 9MM 80CM 30MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032904010 SUP HCPCS C1726 H74939032904010 - CATHETER BLNDIL 9MM 135CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032904080 SUP HCPCS C1726 H74939032904080 - CATHETER BLNDIL 9MM 80CM 40MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032906010 SUP HCPCS C1753 H74939032906010 - CATHETER BLNDIL 9MM 135CM 60MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032906080 SUP HCPCS C1753 H74939032906080 - CATHETER BLNDIL 9MM 80CM 60MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032908010 SUP HCPCS C1753 H74939032908010 - CATHETER BLNDIL 9MM 135CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939032908080 SUP HCPCS C1753 H74939032908080 - CATHETER BLNDIL 9MM 80CM 80MM STRLG OTW TPR TIP LOPRFL INFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134152010 SUP HCPCS C1726 H74939134152010 - CATHETER BLNDIL 1.5MM 142CM 20MM CYTE ES OTW ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134202010 SUP HCPCS C1726 H74939134202010 - CATHETER BLNDIL 2MM 142CM 20MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134203010 SUP HCPCS C1753 H74939134203010 - CATHETER BLNDIL 2MM 143CM 30MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134204010 SUP HCPCS C1726 H74939134204010 - CATHETER BLNDIL 2MM 144CM 40MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134252010 SUP HCPCS C1753 H74939134252010 - CATHETER BLNDIL 2.5MM 143CM 20MM CYTE ES OTW ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134253010 SUP HCPCS C1753 H74939134253010 - CATHETER BLNDIL 2.5MM 144CM 30MM CYTE ES OTW ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134254010 SUP HCPCS C1726 H74939134254010 - CATHETER BLNDIL 2.5MM 145CM 40MM CYTE ES OTW ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134302010 SUP HCPCS C1726 H74939134302010 - CATHETER BLNDIL 3MM 143CM 20MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134303010 SUP HCPCS C1753 H74939134303010 - CATHETER BLNDIL 3MM 144CM 30MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134304010 SUP HCPCS C1726 H74939134304010 - CATHETER BLNDIL 3MM 145CM 40MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134352010 SUP HCPCS C1753 H74939134352010 - CATHETER BLNDIL 3.5MM 143CM 20MM CYTE ES OTW ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134353010 SUP HCPCS C1753 H74939134353010 - CATHETER BLNDIL 3.5MM 144CM 30MM CYTE ES OTW ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134354010 SUP HCPCS C1753 H74939134354010 - CATHETER BLNDIL 3.5MM 145CM 40MM CYTE ES OTW ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134402010 SUP HCPCS C1726 H74939134402010 - CATHETER BLNDIL 4MM 143CM 20MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134403010 SUP HCPCS C1753 H74939134403010 - CATHETER BLNDIL 4MM 144CM 30MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939134404010 SUP HCPCS C1726 H74939134404010 - CATHETER BLNDIL 4MM 145CM 40MM CYTE ES OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135152010 SUP HCPCS C1753 H74939135152010 - CATHETER BLNDIL 1.5MM 143CM 20MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135202010 SUP HCPCS C1753 H74939135202010 - CATHETER BLNDIL 2MM 143CM 20MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135203010 SUP HCPCS C1753 H74939135203010 - CATHETER BLNDIL 2MM 144CM 30MM CYTE ES MNRL ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135204010 SUP HCPCS C1753 H74939135204010 - CATHETER BLNDIL 2MM 145CM 40MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135252010 SUP HCPCS C1753 H74939135252010 - CATHETER BLNDIL 2.5MM 144CM 20MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135253010 SUP HCPCS C1753 H74939135253010 - CATHETER BLNDIL 2.5MM 145CM 30MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135254010 SUP HCPCS C1753 H74939135254010 - CATHETER BLNDIL 2.5MM 145CM 40MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135302010 SUP HCPCS C1753 H74939135302010 - CATHETER BLNDIL 3MM 144CM 20MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135303010 SUP HCPCS C1753 H74939135303010 - CATHETER BLNDIL 3MM 145CM 30MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135304010 SUP HCPCS C1753 H74939135304010 - CATHETER BLNDIL 3MM 146CM 40MM CYTE ES MNRL ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135352010 SUP HCPCS C1753 H74939135352010 - CATHETER BLNDIL 3.5MM 144CM 20MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135353010 SUP HCPCS C1753 H74939135353010 - CATHETER BLNDIL 3.5MM 145CM 30MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135354010 SUP HCPCS C1753 H74939135354010 - CATHETER BLNDIL 3.5MM 145CM 40MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135402010 SUP HCPCS C1753 H74939135402010 - CATHETER BLNDIL 4MM 144CM 20MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135403010 SUP HCPCS C1753 H74939135403010 - CATHETER BLNDIL 4MM 145CM 30MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939135404010 SUP HCPCS C1753 H74939135404010 - CATHETER BLNDIL 4MM 145CM 40MM CYTE ES MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147201010 SUP HCPCS C1725 H74939147201010 - CATHETER BLNDIL 2MM 150CM 100MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147201090 SUP HCPCS C1725 H74939147201090 - CATHETER BLNDIL 2MM 90CM 100MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147201210 SUP HCPCS C1725 H74939147201210 - CATHETER BLNDIL 2MM 150CM 120MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147201290 SUP HCPCS C1725 H74939147201290 - CATHETER BLNDIL 2MM 90CM 120MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147201510 SUP HCPCS C1725 H74939147201510 - CATHETER BLNDIL 2MM 150CM 150MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147201590 SUP HCPCS C1725 H74939147201590 - CATHETER BLNDIL 2MM 90CM 150MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147208010 SUP HCPCS C1725 H74939147208010 - CATHETER BLNDIL 2MM 150CM 80MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147208090 SUP HCPCS C1725 H74939147208090 - CATHETER BLNDIL 2MM 90CM 80MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147251010 SUP HCPCS C1725 H74939147251010 - CATHETER BLNDIL 2.5MM 150CM 100MM STRLG SL OTW TPR TIP BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147251090 SUP HCPCS C1725 H74939147251090 - CATHETER BLNDIL 2.5MM 90CM 100MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147251210 SUP HCPCS C1725 H74939147251210 - CATHETER BLNDIL 2.5MM 150CM 120MM STRLG SL MNRL TPR TIP BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147251290 SUP HCPCS C1725 H74939147251290 - CATHETER BLNDIL 2.5MM 90CM 120MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147251510 SUP HCPCS C1725 H74939147251510 - CATHETER BLNDIL 2.5MM 150CM 150MM STRLG SL MNRL TPR TIP BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147251590 SUP HCPCS C1725 H74939147251590 - CATHETER BLNDIL 2.5MM 90CM 150MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147258010 SUP HCPCS C1725 H74939147258010 - CATHETER BLNDIL 2.5MM 150CM 80MM STRLG SL MNRL TPR TIP BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147258090 SUP HCPCS C1725 H74939147258090 - CATHETER BLNDIL 2.5MM 90CM 80MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147301010 SUP HCPCS C1725 H74939147301010 - CATHETER BLNDIL 3MM 150CM 100MM STRLG SL MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147301090 SUP HCPCS C1725 H74939147301090 - CATHETER BLNDIL 3MM 90CM 100MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147301210 SUP HCPCS C1725 H74939147301210 - CATHETER BLNDIL 3MM 150CM 120MM STRLG SL MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147301290 SUP HCPCS C1725 H74939147301290 - CATHETER BLNDIL 3MM 90CM 120MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147301510 SUP HCPCS C1725 H74939147301510 - CATHETER BLNDIL 3MM 150CM 150MM STRLG SL MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147301590 SUP HCPCS C1725 H74939147301590 - CATHETER BLNDIL 3MM 90CM 150MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147308010 SUP HCPCS C1725 H74939147308010 - CATHETER BLNDIL 3MM 150CM 80MM STRLG SL MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147308090 SUP HCPCS C1725 H74939147308090 - CATHETER BLNDIL 3MM 90CM 80MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147351010 SUP HCPCS C1725 H74939147351010 - CATHETER BLNDIL 3.5MM 150CM 100MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147351090 SUP HCPCS C1725 H74939147351090 - CATHETER BLNDIL 3.5MM 90CM 100MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147351210 SUP HCPCS C1725 H74939147351210 - CATHETER BLNDIL 3.5MM 150CM 120MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147351290 SUP HCPCS C1725 H74939147351290 - CATHETER BLNDIL 3.5MM 90CM 120MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147351510 SUP HCPCS C1725 H74939147351510 - CATHETER BLNDIL 3.5MM 150CM 150MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147351590 SUP HCPCS C1725 H74939147351590 - CATHETER BLNDIL 3.5MM 90CM 150MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147358010 SUP HCPCS C1725 H74939147358010 - CATHETER BLNDIL 3.5MM 150CM 80MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147358090 SUP HCPCS C1725 H74939147358090 - CATHETER BLNDIL 3.5MM 90CM 80MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147401010 SUP HCPCS C1725 H74939147401010 - CATHETER BLNDIL 4MM 150CM 100MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147401090 SUP HCPCS C1725 H74939147401090 - CATHETER BLNDIL 4MM 90CM 100MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147401210 SUP HCPCS C1725 H74939147401210 - CATHETER BLNDIL 4MM 150CM 120MM STRLG SL MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147401290 SUP HCPCS C1725 H74939147401290 - CATHETER BLNDIL 4MM 90CM 120MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147401510 SUP HCPCS C1725 H74939147401510 - CATHETER BLNDIL 4MM 150CM 150MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147401590 SUP HCPCS C1725 H74939147401590 - CATHETER BLNDIL 4MM 90CM 150MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147408010 SUP HCPCS C1725 H74939147408010 - CATHETER BLNDIL 4MM 150CM 80MM STRLG SL MNRL TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939147408090 SUP HCPCS C1725 H74939147408090 - CATHETER BLNDIL 4MM 90CM 80MM STRLG SL MNRL RX INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148201010 SUP HCPCS C1726 H74939148201010 - CATHETER BLNDIL 2MM 150CM 100MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148201090 SUP HCPCS C1753 H74939148201090 - CATHETER BLNDIL 2MM 100CM 90MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148201210 SUP HCPCS C1726 H74939148201210 - CATHETER BLNDIL 2MM 150CM 120MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148201290 SUP HCPCS C1725 H74939148201290 - CATHETER BLNDIL 2MM 90CM 120MM STRLG SL OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148201510 SUP HCPCS C1726 H74939148201510 - CATHETER BLNDIL 2MM 150CM 150MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148201590 SUP HCPCS C1725 H74939148201590 - CATHETER BLNDIL 2MM 90CM 150MM STRLG SL OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148208010 SUP HCPCS C1726 H74939148208010 - CATHETER BLNDIL 2MM 150CM 80MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148208090 SUP HCPCS C1753 H74939148208090 - CATHETER BLNDIL 2MM 90CM 80MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148251010 SUP HCPCS C1753 H74939148251010 - CATHETER BLNDIL 2.5MM 150CM 100MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148251090 SUP HCPCS C1753 H74939148251090 - CATHETER BLNDIL 2.5MM 90CM 100MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148251210 SUP HCPCS C1725 H74939148251210 - CATHETER BLNDIL 2.5MM 150CM 120MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148251290 SUP HCPCS C1725 H74939148251290 - CATHETER BLNDIL 2.5MM 90CM 120MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148251510 SUP HCPCS C1725 H74939148251510 - CATHETER BLNDIL 2.5MM 150CM 150MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148251590 SUP HCPCS C1725 H74939148251590 - CATHETER BLNDIL 2.5MM 90CM 150MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148258010 SUP HCPCS C1753 H74939148258010 - CATHETER BLNDIL 2.5MM 150CM 80MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148258090 SUP HCPCS C1753 H74939148258090 - CATHETER BLNDIL 2.5MM 90CM 80MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148301010 SUP HCPCS C1726 H74939148301010 - CATHETER BLNDIL 3MM 150CM 100MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148301090 SUP HCPCS C1753 H74939148301090 - CATHETER BLNDIL 3MM 90CM 100MM STRLG SL OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148301210 SUP HCPCS C1726 H74939148301210 - CATHETER BLNDIL 3MM 150CM 120MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148301290 SUP HCPCS C1725 H74939148301290 - CATHETER BLNDIL 3MM 90CM 120MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148301510 SUP HCPCS C1726 H74939148301510 - CATHETER BLNDIL 3MM 150CM 150MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148301590 SUP HCPCS C1725 H74939148301590 - CATHETER BLNDIL 3MM 90CM 150MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148308010 SUP HCPCS C1726 H74939148308010 - CATHETER BLNDIL 3MM 150CM 80MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148308090 SUP HCPCS C1753 H74939148308090 - CATHETER BLNDIL 3MM 90CM 80MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148351010 SUP HCPCS C1753 H74939148351010 - CATHETER BLNDIL 3.5MM 150CM 100MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148351090 SUP HCPCS C1753 H74939148351090 - CATHETER BLNDIL 3.5MM 90CM 100MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148351210 SUP HCPCS C1725 H74939148351210 - CATHETER BLNDIL 3.5MM 150CM 120MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148351290 SUP HCPCS C1725 H74939148351290 - CATHETER BLNDIL 3.5MM 90CM 120MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148351510 SUP HCPCS C1725 H74939148351510 - CATHETER BLNDIL 3.5MM 150CM 150MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148351590 SUP HCPCS C1725 H74939148351590 - CATHETER BLNDIL 3.5MM 90CM 150MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148358010 SUP HCPCS C1753 H74939148358010 - CATHETER BLNDIL 3.5MM 150CM 80MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148358090 SUP HCPCS C1753 H74939148358090 - CATHETER BLNDIL 3.5MM 90CM 80MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148401010 SUP HCPCS C1753 H74939148401010 - CATHETER BLNDIL 4MM 150CM 100MM STRLG SL OTW INFL PORT BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148401210 SUP HCPCS C1725 H74939148401210 - CATHETER BLNDIL 4MM 150CM 120MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148401290 SUP HCPCS C1725 H74939148401290 - CATHETER BLNDIL 4MM 90CM 120MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148401510 SUP HCPCS C1726 H74939148401510 - CATHETER BLNDIL 4MM 150CM 150MM STRLG SL OTW TPR TIP LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148401590 SUP HCPCS C1725 H74939148401590 - CATHETER BLNDIL 4MM 90CM 150MM STRLG SL OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939148408010 SUP HCPCS C1726 H74939148408010 - CATHETER BLNDIL 4MM 150CM 80MM STRLG SL OTW INFL PORT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030210 SUP HCPCS C1753 H74939171030210 - CATHETER BALDILAT LP 5.3FR 3MM 135CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030240 SUP HCPCS C1753 H74939171030240 - CATHETER BLNDIL 3MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030270 SUP HCPCS C1753 H74939171030270 - CATHETER BALDILAT LP 5.3FR 3MM 75CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030310 SUP HCPCS C1753 H74939171030310 - CATHETER BALDILAT .035IN 5FR 3MM 135CM 30MM PTA LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030340 SUP HCPCS C1753 H74939171030340 - CATHETER BLNDIL 3MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030370 SUP HCPCS C1753 H74939171030370 - CATHETER BLNDIL 3MM 75CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030410 SUP HCPCS C1753 H74939171030410 - CATHETER BALDILAT LP 5.3FR 3MM 135CM 40MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030440 SUP HCPCS C1753 H74939171030440 - CATHETER BLNDIL 3MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030470 SUP HCPCS C1753 H74939171030470 - CATHETER BALDILAT LP 5.3FR 3MM 75CM 40MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030610 SUP HCPCS C1753 H74939171030610 - CATHETER BALDILAT LP 5.3FR 3MM 135CM 60MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030640 SUP HCPCS C1753 H74939171030640 - CATHETER BLNDIL 3MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030670 SUP HCPCS C1753 H74939171030670 - CATHETER BALDILAT LP 5.3FR 3MM 75CM 60MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030810 SUP HCPCS C1753 H74939171030810 - CATHETER BLNDIL 3MM 135CM 80MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030840 SUP HCPCS C1753 H74939171030840 - CATHETER BLNDIL 3MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171030870 SUP HCPCS C1753 H74939171030870 - CATHETER BLNDIL 3MM 75CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031010 SUP HCPCS C1753 H74939171031010 - CATHETER BALDILAT .035IN 3MM 135CM 100MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031040 SUP HCPCS C1753 H74939171031040 - CATHETER BLNDIL 3MM 40CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031070 SUP HCPCS C1753 H74939171031070 - CATHETER BLNDIL 3MM 75CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031210 SUP HCPCS C1753 H74939171031210 - CATHETER BLNDIL 3MM 135CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031270 SUP HCPCS C1753 H74939171031270 - CATHETER BLNDIL 3MM 75CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031510 SUP HCPCS C1753 H74939171031510 - CATHETER BALDILAT LP 5.3FR 3MM 135CM 150MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031570 SUP HCPCS C1753 H74939171031570 - CATHETER BLNDIL 3MM 75CM 150MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031810 SUP HCPCS C1753 H74939171031810 - CATHETER BALDILAT .035IN 5FR 3MM 135CM 180MM PTA LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171031870 SUP HCPCS C1753 H74939171031870 - CATHETER BLNDIL 3MM 75CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171032010 SUP HCPCS C1753 H74939171032010 - CATHETER BALDILAT LP 5.3FR 3MM 135CM 200MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171032070 SUP HCPCS C1753 H74939171032070 - CATHETER BLNDIL 3MM 75CM 200MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040210 SUP HCPCS C1725 H74939171040210 - CATHETER BALDILAT .035IN 4MM 135CM 20MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040240 SUP HCPCS C1753 H74939171040240 - CATHETER BLNDIL 4MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040270 SUP HCPCS C1726 H74939171040270 - CATHETER BALDILAT LP 5.3FR 4MM 75CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040310 SUP HCPCS C1753 H74939171040310 - CATHETER BALDILAT 4MM 135CM 30MM HIGH PRESSURE LP INFLAT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040340 SUP HCPCS C1753 H74939171040340 - CATHETER BLNDIL 4MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040370 SUP HCPCS C1753 H74939171040370 - CATHETER BLNDIL 4MM 75CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040410 SUP HCPCS C1726 H74939171040410 - CATHETER BALDILAT LP 5.3FR 4MM 135CM 40MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040440 SUP HCPCS C1753 H74939171040440 - CATHETER BLNDIL 4MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040470 SUP HCPCS C1726 H74939171040470 - CATHETER BALDILAT LP 5.3FR 4MM 75CM 40MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040610 SUP HCPCS C1753 H74939171040610 - CATHETER BALDILAT LP 5.3FR 4MM 135CM 60MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040640 SUP HCPCS C1753 H74939171040640 - CATHETER BLNDIL 4MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040670 SUP HCPCS C1753 H74939171040670 - CATHETER BALDILAT LP 5.3FR 4MM 75CM 60MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040810 SUP HCPCS C1753 H74939171040810 - CATHETER BALDILAT LP 5.3FR 4MM 135CM 80MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040840 SUP HCPCS C1753 H74939171040840 - CATHETER BLNDIL 4MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171040870 SUP HCPCS C1753 H74939171040870 - CATHETER BLNDIL 4MM 75CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041010 SUP HCPCS C1753 H74939171041010 - CATHETER BALDILAT .035IN 4MM 135CM 100MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041040 SUP HCPCS C1753 H74939171041040 - CATHETER BLNDIL 4MM 40CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041070 SUP HCPCS C1753 H74939171041070 - CATHETER BLNDIL 4MM 75CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041210 SUP HCPCS C1726 H74939171041210 - CATHETER BLNDIL 4MM 135CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041270 SUP HCPCS C1753 H74939171041270 - CATHETER BLNDIL 4MM 75CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041510 SUP HCPCS C1753 H74939171041510 - CATHETER BALDILAT LP 5.3FR 4MM 135CM 150MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041570 SUP HCPCS C1753 H74939171041570 - CATHETER BLNDIL 4MM 75CM 150MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041810 SUP HCPCS C1753 H74939171041810 - CATHETER BLNDIL 4MM 135CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171041870 SUP HCPCS C1753 H74939171041870 - CATHETER BLNDIL 4MM 75CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171042010 SUP HCPCS C1725 H74939171042010 - CATHETER BALDILAT .035IN 4MM 135CM 200MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171042070 SUP HCPCS C1753 H74939171042070 - CATHETER BLNDIL 4MM 75CM 200MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050210 SUP HCPCS C1726 H74939171050210 - CATHETER BALDILAT .035IN 5MM 135CM 20MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050240 SUP HCPCS C1753 H74939171050240 - CATHETER BLNDIL 5MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050270 SUP HCPCS C1725 H74939171050270 - CATHETER BALDILAT LP 5.3FR 5MM 75CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050310 SUP HCPCS C1753 H74939171050310 - CATHETER BALDILAT LP 5FR 5MM 135CM 30MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050340 SUP HCPCS C1753 H74939171050340 - CATHETER BLNDIL 5MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050370 SUP HCPCS C1753 H74939171050370 - CATHETER BLNDIL 5MM 75CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050410 SUP HCPCS C1726 H74939171050410 - CATHETER BALDILAT 5FR 5MM 135CM 40MM HIGH PRESSURE LP INFLAT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050440 SUP HCPCS C1726 H74939171050440 - CATHETER BLNDIL 5MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050470 SUP HCPCS C1726 H74939171050470 - CATHETER BALDILAT .035IN 5MM 75CM 40MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050610 SUP HCPCS C1753 H74939171050610 - CATHETER BALDILAT .035IN 5MM 135CM 60MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050640 SUP HCPCS C1753 H74939171050640 - CATHETER BLNDIL 5MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050670 SUP HCPCS C1753 H74939171050670 - CATHETER BALDILAT .035IN 5MM 75CM 60MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050810 SUP HCPCS C1753 H74939171050810 - CATHETER BALDILAT LP 5.3FR 5MM 135CM 80MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050840 SUP HCPCS C1753 H74939171050840 - CATHETER BLNDIL 5MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171050870 SUP HCPCS C1753 H74939171050870 - CATHETER BLNDIL 5MM 75CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051010 SUP HCPCS C1725 H74939171051010 - CATHETER BALDILAT LP 5.3FR 5MM 135CM 100MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051040 SUP HCPCS C1753 H74939171051040 - CATHETER BLNDIL 5MM 40CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051070 SUP HCPCS C1753 H74939171051070 - CATHETER BLNDIL 5MM 75CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051210 SUP HCPCS C1753 H74939171051210 - CATHETER BALDILAT LP 5.3FR 5MM 135CM 120MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051240 SUP HCPCS C1753 H74939171051240 - CATHETER BLNDIL 5MM 40CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051270 SUP HCPCS C1753 H74939171051270 - CATHETER BLNDIL 5MM 75CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051510 SUP HCPCS C1726 H74939171051510 - CATHETER BALDILAT LP 5.3FR 5MM 135CM 150MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051570 SUP HCPCS C1753 H74939171051570 - CATHETER BLNDIL 5MM 75CM 150MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051810 SUP HCPCS C1753 H74939171051810 - CATHETER BLNDIL 5MM 135CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171051870 SUP HCPCS C1753 H74939171051870 - CATHETER BLNDIL 5MM 75CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171052010 SUP HCPCS C1726 H74939171052010 - CATHETER BALDILAT LP 5.3FR 5MM 135CM 200MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171052070 SUP HCPCS C1753 H74939171052070 - CATHETER BLNDIL 5MM 75CM 200MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060210 SUP HCPCS C1726 H74939171060210 - CATHETER BALDILAT .035IN 6MM 135CM 20MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060240 SUP HCPCS C1753 H74939171060240 - CATHETER BLNDIL 6MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060270 SUP HCPCS C1726 H74939171060270 - CATHETER BALDILAT .035IN 6MM 75CM 20MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060310 SUP HCPCS C1753 H74939171060310 - CATHETER BLNDIL 6MM 135CM 30MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060340 SUP HCPCS C1753 H74939171060340 - CATHETER BLNDIL 6MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060370 SUP HCPCS C1753 H74939171060370 - CATHETER BLNDIL 6MM 75CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060410 SUP HCPCS C1726 H74939171060410 - CATHETER BALDILAT LP 5.3FR 6MM 135CM 40MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060440 SUP HCPCS C1726 H74939171060440 - CATHETER BLNDIL 6MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060470 SUP HCPCS C1726 H74939171060470 - CATHETER BALDILAT 6MM 75CM 40MM HIGH PRESSURE LP INFLAT PORT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060610 SUP HCPCS C1753 H74939171060610 - CATHETER BALDILAT LP 5.3FR 6MM 135CM 60MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060640 SUP HCPCS C1753 H74939171060640 - CATHETER BLNDIL 6MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060670 SUP HCPCS C1753 H74939171060670 - CATHETER BALDILAT .035IN 6MM 75CM 60MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060810 SUP HCPCS C1753 H74939171060810 - CATHETER BALDILAT LP 5.3FR 6MM 135CM 80MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060840 SUP HCPCS C1753 H74939171060840 - CATHETER BLNDIL 6MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171060870 SUP HCPCS C1753 H74939171060870 - CATHETER BALDILAT .035IN 6MM 75CM 80MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061010 SUP HCPCS C1726 H74939171061010 - CATHETER BALDILAT LP 5.3FR 6MM 135CM 100MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061040 SUP HCPCS C1753 H74939171061040 - CATHETER BLNDIL 6MM 40CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061070 SUP HCPCS C1726 H74939171061070 - CATHETER BALDILAT LP 5.3FR 6MM 75CM 100MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061210 SUP HCPCS C1753 H74939171061210 - CATHETER BALDILAT LP 5.3FR 6MM 135CM 120MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061240 SUP HCPCS C1753 H74939171061240 - CATHETER BLNDIL 6MM 40CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061270 SUP HCPCS C1753 H74939171061270 - CATHETER BLNDIL 6MM 75CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061510 SUP HCPCS C1726 H74939171061510 - CATHETER BALDILAT LP 5.3FR 6MM 135CM 150MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061570 SUP HCPCS C1753 H74939171061570 - CATHETER BLNDIL 6MM 75CM 150MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061810 SUP HCPCS C1753 H74939171061810 - CATHETER BLNDIL 6MM 135CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171061870 SUP HCPCS C1753 H74939171061870 - CATHETER BLNDIL 6MM 75CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171062010 SUP HCPCS C1726 H74939171062010 - CATHETER BALDILAT 6MM 135CM 200MM HIGH PRESSURE LP INFLAT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171062070 SUP HCPCS C1753 H74939171062070 - CATHETER BLNDIL 6MM 75CM 200MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070210 SUP HCPCS C1753 H74939171070210 - CATHETER BALDILAT .035IN 7MM 135CM 20MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070240 SUP HCPCS C1753 H74939171070240 - CATHETER BLNDIL 7MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070270 SUP HCPCS C1726 H74939171070270 - CATHETER BALDILAT LP 5.3FR 7MM 75CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070310 SUP HCPCS C1753 H74939171070310 - CATHETER BALDILAT LP 5.3FR 7MM 135CM 30MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070340 SUP HCPCS C1753 H74939171070340 - CATHETER BLNDIL 7MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070370 SUP HCPCS C1753 H74939171070370 - CATHETER BLNDIL 7MM 75CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070410 SUP HCPCS C1726 H74939171070410 - CATHETER BALDILAT .035IN 7MM 135CM 40MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070440 SUP HCPCS C1726 H74939171070440 - CATHETER BLNDIL 7MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070470 SUP HCPCS C1726 H74939171070470 - CATHETER BALDILAT .035IN 7MM 75CM 40MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070610 SUP HCPCS C1753 H74939171070610 - CATHETER BALDILAT LP 5.3FR 7MM 135CM 60MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070640 SUP HCPCS C1753 H74939171070640 - CATHETER BLNDIL 7MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070670 SUP HCPCS C1753 H74939171070670 - CATHETER BALDILAT .035IN 7MM 75CM 60MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070810 SUP HCPCS C1753 H74939171070810 - CATHETER BALDILAT LP 5.3FR 7MM 135CM 80MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070840 SUP HCPCS C1753 H74939171070840 - CATHETER BLNDIL 7MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171070870 SUP HCPCS C1753 H74939171070870 - CATHETER BLNDIL 7MM 75CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071010 SUP HCPCS C1725 H74939171071010 - CATHETER BALDILAT LP 5.3FR 7MM 135CM 100MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071040 SUP HCPCS C1753 H74939171071040 - CATHETER BLNDIL 7MM 40CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071070 SUP HCPCS C1753 H74939171071070 - CATHETER BLNDIL 7MM 75CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071210 SUP HCPCS C1753 H74939171071210 - CATHETER BALDILAT LP 5.3FR 7MM 135CM 120MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071270 SUP HCPCS C1753 H74939171071270 - CATHETER BLNDIL 7MM 75CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071510 SUP HCPCS C1753 H74939171071510 - CATHETER BALDILAT LP 5.3FR 7MM 135CM 150MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071570 SUP HCPCS C1753 H74939171071570 - CATHETER BLNDIL 7MM 75CM 150MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071810 SUP HCPCS C1753 H74939171071810 - CATHETER BLNDIL 7MM 135CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171071870 SUP HCPCS C1753 H74939171071870 - CATHETER BLNDIL 7MM 75CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171072010 SUP HCPCS C1753 H74939171072010 - CATHETER BALDILAT LP 5.3FR 7MM 135CM 200MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171072070 SUP HCPCS C1753 H74939171072070 - CATHETER BLNDIL 7MM 75CM 200MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080210 SUP HCPCS C1753 H74939171080210 - CATHETER BALDILAT LP 5.3FR 8MM 135CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080240 SUP HCPCS C1753 H74939171080240 - CATHETER BLNDIL 8MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080270 SUP HCPCS C1725 H74939171080270 - CATHETER BALDILAT LP 5.3FR 8MM 75CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080310 SUP HCPCS C1753 H74939171080310 - CATHETER BALDILAT LP 5.3FR 8MM 135CM 30MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080340 SUP HCPCS C1753 H74939171080340 - CATHETER BLNDIL 8MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080370 SUP HCPCS C1753 H74939171080370 - CATHETER BALDILAT LP 5.3FR 8MM 75CM 30MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080410 SUP HCPCS C1726 H74939171080410 - CATHETER BALDILAT 8MM 135CM 40MM HIGH PRESSURE LP INFLAT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080440 SUP HCPCS C1726 H74939171080440 - CATHETER BLNDIL 8MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080470 SUP HCPCS C1726 H74939171080470 - CATHETER BALDILAT .035IN 8MM 75CM 40MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080610 SUP HCPCS C1753 H74939171080610 - CATHETER BALDILAT LP 5.3FR 8MM 135CM 60MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080640 SUP HCPCS C1753 H74939171080640 - CATHETER BLNDIL 8MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080670 SUP HCPCS C1753 H74939171080670 - CATHETER BALDILAT .035IN 8MM 75CM 60MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080810 SUP HCPCS C1753 H74939171080810 - CATHETER BALDILAT LP 5.3FR 8MM 135CM 80MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080840 SUP HCPCS C1753 H74939171080840 - CATHETER BLNDIL 8MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171080870 SUP HCPCS C1725 H74939171080870 - CATHETER BALDILAT .035IN 8MM 75CM 80MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081010 SUP HCPCS C1726 H74939171081010 - CATHETER BALDILAT LP 5.3FR 8MM 135CM 100MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081040 SUP HCPCS C1753 H74939171081040 - CATHETER BLNDIL 8MM 40CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081070 SUP HCPCS C1726 H74939171081070 - CATHETER BLNDIL 8MM 75CM 100MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081210 SUP HCPCS C1753 H74939171081210 - CATHETER BLNDIL 8MM 135CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081270 SUP HCPCS C1753 H74939171081270 - CATHETER BLNDIL 8MM 75CM 120MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081510 SUP HCPCS C1753 H74939171081510 - CATHETER BLNDIL 8MM 135CM 150MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081570 SUP HCPCS C1753 H74939171081570 - CATHETER BLNDIL 8MM 75CM 150MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081810 SUP HCPCS C1753 H74939171081810 - CATHETER BALDILAT .035IN 5FR 8MM 135CM 180MM PTA LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171081870 SUP HCPCS C1753 H74939171081870 - CATHETER BLNDIL 8MM 75CM 180MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171082010 SUP HCPCS C1753 H74939171082010 - CATHETER BALDILAT .035IN 5FR 8MM 135CM 200MM PTA LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171082070 SUP HCPCS C1753 H74939171082070 - CATHETER BALDILAT LP 5.3FR 8MM 75CM 200MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171086070 SUP HCPCS C1725 "H74939171086070 - MUSTANG 8X 60, 75" BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090210 SUP HCPCS C1753 H74939171090210 - CATHETER BALDILAT 18 ATM LP TAPER 5.8FR 9MM 135CM 20MM 2 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090240 SUP HCPCS C1753 H74939171090240 - CATHETER BLNDIL 9MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090270 SUP HCPCS C1753 H74939171090270 - CATHETER BALDILAT LP 5.3FR 9MM 75CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090310 SUP HCPCS C1753 H74939171090310 - CATHETER BLNDIL 9MM 135CM 30MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090340 SUP HCPCS C1753 H74939171090340 - CATHETER BLNDIL 9MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090370 SUP HCPCS C1753 H74939171090370 - CATHETER BLNDIL 9MM 75CM 30MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090410 SUP HCPCS C1753 H74939171090410 - CATHETER BALDILAT LP 5.8FR 9MM 135CM 40MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090440 SUP HCPCS C1753 H74939171090440 - CATHETER BLNDIL 9MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090470 SUP HCPCS C1725 H74939171090470 - CATHETER BALDILAT .035IN 9MM 75CM 40MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090610 SUP HCPCS C1753 H74939171090610 - CATHETER BLNDIL 9MM 135CM 60MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090640 SUP HCPCS C1753 H74939171090640 - CATHETER BLNDIL 9MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090670 SUP HCPCS C1726 H74939171090670 - CATHETER BLNDIL 9MM 75CM 60MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090810 SUP HCPCS C1753 H74939171090810 - CATHETER BLNDIL 9MM 135CM 80MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090840 SUP HCPCS C1753 H74939171090840 - CATHETER BLNDIL 9MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171090870 SUP HCPCS C1753 H74939171090870 - CATHETER BLNDIL 9MM 75CM 80MM MUSTANG HI-PRS NYBAX ACPT .035 BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100210 SUP HCPCS C1753 H74939171100210 - CATHETER BALDILAT LP 5.8FR 10MM 135CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100240 SUP HCPCS C1753 H74939171100240 - CATHETER BLNDIL 10MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100270 SUP HCPCS C1726 H74939171100270 - CATHETER BALDILAT 10MM 75CM 20MM HIGH PRESSURE LP INFLAT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100310 SUP HCPCS C1753 H74939171100310 - CATHETER BLNDIL 10MM 135CM 30MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100340 SUP HCPCS C1753 H74939171100340 - CATHETER BLNDIL 10MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100370 SUP HCPCS C1753 H74939171100370 - CATHETER BALDILAT LP 5.8FR 10MM 75CM 30MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100410 SUP HCPCS C1753 H74939171100410 - CATHETER BALDILAT LP 5.8FR 10MM 135CM 40MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100440 SUP HCPCS C1753 H74939171100440 - CATHETER BLNDIL 10MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100470 SUP HCPCS C1726 H74939171100470 - CATHETER BALDILAT 10MM 75CM 40MM HIGH PRESSURE LP MUSTANG BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100610 SUP HCPCS C1753 H74939171100610 - CATHETER BLNDIL 10MM 135CM 60MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100640 SUP HCPCS C1753 H74939171100640 - CATHETER BLNDIL 10MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100670 SUP HCPCS C1725 H74939171100670 - CATHETER BALDILAT 5.8FR 10MM 75CM 60MM HIGH PRESSURE LP BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100810 SUP HCPCS C1753 H74939171100810 - CATHETER BLNDIL 10MM 135CM 80MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100840 SUP HCPCS C1753 H74939171100840 - CATHETER BLNDIL 10MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171100870 SUP HCPCS C1753 H74939171100870 - CATHETER BALDILAT LP 5.8FR 10MM 75CM 80MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120210 SUP HCPCS C1753 H74939171120210 - CATHETER BALDILAT LP 5.8FR 12MM 135CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120240 SUP HCPCS C1753 H74939171120240 - CATHETER BLNDIL 12MM 40CM 20MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120270 SUP HCPCS C1753 H74939171120270 - CATHETER BALDILAT LP 5.8FR 12MM 75CM 20MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120310 SUP HCPCS C1753 H74939171120310 - CATHETER BLNDIL 12MM 135CM 30MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120340 SUP HCPCS C1753 H74939171120340 - CATHETER BLNDIL 12MM 40CM 30MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120370 SUP HCPCS C1753 H74939171120370 - CATHETER BALDILAT LP 5.8FR 12MM 75CM 30MM HIGH PRESSURE BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120410 SUP HCPCS C1753 H74939171120410 - CATHETER BLNDIL 12MM 135CM 40MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120440 SUP HCPCS C1753 H74939171120440 - CATHETER BLNDIL 12MM 40CM 40MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120470 SUP HCPCS C1726 H74939171120470 - CATHETER BALDILAT 12MM 75CM 40MM HIGH PRESSURE LP MUSTANG BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120610 SUP HCPCS C1753 H74939171120610 - CATHETER BLNDIL 12MM 135CM 60MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120640 SUP HCPCS C1753 H74939171120640 - CATHETER BLNDIL 12MM 40CM 60MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120670 SUP HCPCS C1753 H74939171120670 - CATHETER BLNDIL 12MM 75CM 60MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120810 SUP HCPCS C1753 H74939171120810 - CATHETER BLNDIL 12MM 135CM 80MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120840 SUP HCPCS C1753 H74939171120840 - CATHETER BLNDIL 12MM 40CM 80MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939171120870 SUP HCPCS C1753 H74939171120870 - CATHETER BLNDIL 12MM 75CM 80MM MUSTANG HI-PRS NYBAX ACPT BOTH IP/OP $430.00 $318.20 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $89.62 $319.15 $319.15 $0.00 $0.00 $89.61 $0.00 $254.35 $254.35 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185150410 SUP HCPCS C1725 H74939185150410 - CATHETER BLNDIL 1.5MM 150CM 40MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185201210 SUP HCPCS C1725 H74939185201210 - CATHETER BLNDIL 2MM 150CM 120MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185201290 SUP HCPCS C1725 H74939185201290 - CATHETER BLNDIL 2MM 90CM 120MM CYTE MNRL RX ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185201510 SUP HCPCS C1725 H74939185201510 - CATHETER BLNDIL 2MM 150CM 150MM CYTE MNRL ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185201590 SUP HCPCS C1725 H74939185201590 - CATHETER BLNDIL 2MM 90CM 150MM CYTE MNRL RX ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185251210 SUP HCPCS C1725 H74939185251210 - CATHETER BLNDIL 2.5MM 150CM 120MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185251290 SUP HCPCS C1725 H74939185251290 - CATHETER BLNDIL 2.5MM 90CM 120MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185251510 SUP HCPCS C1725 H74939185251510 - CATHETER BLNDIL 2.5MM 150CM 150MM CYTE MNRL ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185251590 SUP HCPCS C1725 H74939185251590 - CATHETER BLNDIL 2.5MM 90CM 150MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185301210 SUP HCPCS C1725 H74939185301210 - CATHETER BLNDIL 3MM 150CM 120MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185301290 SUP HCPCS C1725 H74939185301290 - CATHETER BLNDIL 3MM 90CM 120MM CYTE MNRL RX ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185301510 SUP HCPCS C1725 H74939185301510 - CATHETER BLNDIL 3MM 150CM 150MM CYTE MNRL ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185301590 SUP HCPCS C1725 H74939185301590 - CATHETER BLNDIL 3MM 90CM 150MM CYTE MNRL RX ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185351210 SUP HCPCS C1725 H74939185351210 - CATHETER BLNDIL 3.5MM 150CM 120MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185351290 SUP HCPCS C1725 H74939185351290 - CATHETER BLNDIL 3.5MM 90CM 120MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185351510 SUP HCPCS C1725 H74939185351510 - CATHETER BLNDIL 3.5MM 150CM 150MM CYTE MNRL ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185351590 SUP HCPCS C1725 H74939185351590 - CATHETER BLNDIL 3.5MM 90CM 150MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185401210 SUP HCPCS C1725 H74939185401210 - CATHETER BLNDIL 4MM 150CM 120MM CYTE MNRL RX ULT LOPRFL BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185401290 SUP HCPCS C1725 H74939185401290 - CATHETER BLNDIL 4MM 90CM 120MM CYTE MNRL RX ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185401510 SUP HCPCS C1725 H74939185401510 - CATHETER BLNDIL 4MM 150CM 150MM CYTE MNRL ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939185401590 SUP HCPCS C1725 H74939185401590 - CATHETER BLNDIL 4MM 90CM 150MM CYTE MNRL RX ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186150410 SUP HCPCS C1726 H74939186150410 - CATHETER BLNDIL 1.5MM 150CM 40MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186150490 SUP HCPCS C1753 H74939186150490 - CATHETER BLNDIL 1.5MM 90CM 40MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186200610 SUP HCPCS C1753 H74939186200610 - CATHETER BLNDIL 2MM 150CM 60MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186200690 SUP HCPCS C1753 H74939186200690 - CATHETER BLNDIL 2MM 90CM 60MM CYTE OTW ULT LOPRFL NYBAX BSLD BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186200810 SUP HCPCS C1753 H74939186200810 - CATHETER BLNDIL 2MM 150CM 80MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186200890 SUP HCPCS C1753 H74939186200890 - CATHETER BLNDIL 2MM 90CM 80MM CYTE OTW ULT LOPRFL NYBAX BSLD BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186201010 SUP HCPCS C1726 H74939186201010 - CATHETER BLNDIL 2MM 150CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186201090 SUP HCPCS C1753 H74939186201090 - CATHETER BLNDIL 2MM 90CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186201210 SUP HCPCS C1726 H74939186201210 - CATHETER BLNDIL 2MM 150CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186201290 SUP HCPCS C1753 H74939186201290 - CATHETER BLNDIL 2MM 90CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186201510 SUP HCPCS C1726 H74939186201510 - CATHETER BLNDIL 2MM 150CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186201590 SUP HCPCS C1753 H74939186201590 - CATHETER BLNDIL 2MM 90CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186202210 SUP HCPCS C1726 H74939186202210 - CATHETER BLNDIL 2MM 150CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186202290 SUP HCPCS C1753 H74939186202290 - CATHETER BLNDIL 2MM 90CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186250610 SUP HCPCS C1725 H74939186250610 - CATHETER BLNDIL 2.5MM 150CM 60MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186250690 SUP HCPCS C1753 H74939186250690 - CATHETER BLNDIL 2.5MM 90CM 60MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186250810 SUP HCPCS C1753 H74939186250810 - CATHETER BLNDIL 2.5MM 150CM 80MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186250890 SUP HCPCS C1753 H74939186250890 - CATHETER BLNDIL 2.5MM 90CM 80MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186251010 SUP HCPCS C1753 H74939186251010 - CATHETER BLNDIL 2.5MM 150CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186251090 SUP HCPCS C1753 H74939186251090 - CATHETER BLNDIL 2.5MM 90CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186251210 SUP HCPCS C1726 H74939186251210 - CATHETER BLNDIL 2.5MM 150CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186251290 SUP HCPCS C1753 H74939186251290 - CATHETER BLNDIL 2.5MM 90CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186251510 SUP HCPCS C1753 H74939186251510 - CATHETER BLNDIL 2.5MM 150CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186251590 SUP HCPCS C1753 H74939186251590 - CATHETER BLNDIL 2.5MM 90CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186252210 SUP HCPCS C1726 H74939186252210 - CATHETER BLNDIL 2.5MM 150CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186252290 SUP HCPCS C1753 H74939186252290 - CATHETER BLNDIL 2.5MM 90CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186300610 SUP HCPCS C1753 H74939186300610 - CATHETER BLNDIL 3MM 150CM 60MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186300690 SUP HCPCS C1753 H74939186300690 - CATHETER BLNDIL 3MM 90CM 60MM CYTE OTW ULT LOPRFL NYBAX BSLD BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186300810 SUP HCPCS C1753 H74939186300810 - CATHETER BLNDIL 3MM 150CM 80MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186300890 SUP HCPCS C1753 H74939186300890 - CATHETER BLNDIL 3MM 90CM 80MM CYTE OTW ULT LOPRFL NYBAX BSLD BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186301010 SUP HCPCS C1726 H74939186301010 - CATHETER BLNDIL 3MM 150CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186301090 SUP HCPCS C1753 H74939186301090 - CATHETER BLNDIL 3MM 90CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186301210 SUP HCPCS C1726 H74939186301210 - CATHETER BLNDIL 3MM 150CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186301290 SUP HCPCS C1753 H74939186301290 - CATHETER BLNDIL 3MM 90CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186301510 SUP HCPCS C1726 H74939186301510 - CATHETER BLNDIL 3MM 150CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186301590 SUP HCPCS C1753 H74939186301590 - CATHETER BLNDIL 3MM 90CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186302210 SUP HCPCS C1726 H74939186302210 - CATHETER BLNDIL 3MM 150CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186302290 SUP HCPCS C1753 H74939186302290 - CATHETER BLNDIL 3MM 90CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186350610 SUP HCPCS C1753 H74939186350610 - CATHETER BLNDIL 3.5MM 150CM 60MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186350690 SUP HCPCS C1753 H74939186350690 - CATHETER BLNDIL 3.5MM 90CM 60MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186350810 SUP HCPCS C1753 H74939186350810 - CATHETER BLNDIL 3.5MM 150CM 80MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186350890 SUP HCPCS C1753 H74939186350890 - CATHETER BLNDIL 3.5MM 90CM 80MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186351010 SUP HCPCS C1753 H74939186351010 - CATHETER BLNDIL 3.5MM 150CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186351090 SUP HCPCS C1753 H74939186351090 - CATHETER BLNDIL 3.5MM 90CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186351210 SUP HCPCS C1753 H74939186351210 - CATHETER BLNDIL 3.5MM 150CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186351290 SUP HCPCS C1753 H74939186351290 - CATHETER BLNDIL 3.5MM 90CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186351510 SUP HCPCS C1753 H74939186351510 - CATHETER BLNDIL 3.5MM 150CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186351590 SUP HCPCS C1753 H74939186351590 - CATHETER BLNDIL 3.5MM 90CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186352210 SUP HCPCS C1753 H74939186352210 - CATHETER BLNDIL 3.5MM 150CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186352290 SUP HCPCS C1753 H74939186352290 - CATHETER BLNDIL 3.5MM 90CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186400610 SUP HCPCS C1753 H74939186400610 - CATHETER BLNDIL 4MM 150CM 60MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186400690 SUP HCPCS C1753 H74939186400690 - CATHETER BLNDIL 4MM 90CM 60MM CYTE OTW ULT LOPRFL NYBAX BSLD BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186400810 SUP HCPCS C1753 H74939186400810 - CATHETER BLNDIL 4MM 150CM 80MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186400890 SUP HCPCS C1753 H74939186400890 - CATHETER BLNDIL 4MM 90CM 80MM CYTE OTW ULT LOPRFL NYBAX BSLD BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186401010 SUP HCPCS C1726 H74939186401010 - CATHETER BLNDIL 4MM 150CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186401090 SUP HCPCS C1753 H74939186401090 - CATHETER BLNDIL 4MM 90CM 100MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186401210 SUP HCPCS C1726 H74939186401210 - CATHETER BLNDIL 4MM 150CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186401290 SUP HCPCS C1753 H74939186401290 - CATHETER BLNDIL 4MM 90CM 120MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186401510 SUP HCPCS C1753 H74939186401510 - CATHETER BLNDIL 4MM 150CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186401590 SUP HCPCS C1753 H74939186401590 - CATHETER BLNDIL 4MM 90CM 150MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186402210 SUP HCPCS C1726 H74939186402210 - CATHETER BLNDIL 4MM 150CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939186402290 SUP HCPCS C1753 H74939186402290 - CATHETER BLNDIL 4MM 90CM 220MM CYTE OTW ULT LOPRFL NYBAX BOTH IP/OP $417.50 $308.95 $0.00 $334.00 $226.70 $226.70 $0.00 $0.00 $0.00 $87.02 $309.87 $309.87 $0.00 $0.00 $87.01 $0.00 $246.95 $246.95 $0.00 $208.75 $330.66 $334.00 $0.00 $0.00 $65.34 $0.00 $0.00 $66.47 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200061020 SUP HCPCS C1876 H74939200061020 - STENT VASCULAR .035IN 6MM 100MM 120CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200061070 SUP HCPCS C1876 H74939200061070 - STENT VASCULAR 6MM 100MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200061220 SUP HCPCS C1876 H74939200061220 - STENT VASCULAR 6MM 120MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200061270 SUP HCPCS C1876 H74939200061270 - STENT VASCULAR .035IN 6MM 120MM 75CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200062020 SUP HCPCS C1876 H74939200062020 - STENT VASCULAR 6MM 20MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200062070 SUP HCPCS C1876 H74939200062070 - STENT VASCULAR 6MM 20MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200063020 SUP HCPCS C1876 H74939200063020 - STENT VASCULAR 6MM 30MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200063070 SUP HCPCS C1876 H74939200063070 - STENT VASCULAR 6MM 30MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200064020 SUP HCPCS C1876 H74939200064020 - STENT VASCULAR 6MM 40MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200064070 SUP HCPCS C1876 H74939200064070 - STENT VASCULAR .035IN 6MM 40MM 75CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200065020 SUP HCPCS C1876 H74939200065020 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 120CM 6MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200065070 SUP HCPCS C1876 H74939200065070 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 75CM 6MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200066020 SUP HCPCS C1876 H74939200066020 - STENT VASCULAR .035IN 6MM 60MM 120CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200066070 SUP HCPCS C1876 H74939200066070 - STENT VASCULAR 6MM 60MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200067020 SUP HCPCS C1876 H74939200067020 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 120CM 6MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200067070 SUP HCPCS C1876 H74939200067070 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 75CM 6MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200068020 SUP HCPCS C1876 H74939200068020 - STENT VASCULAR 6MM 80MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200068070 SUP HCPCS C1876 H74939200068070 - STENT VASCULAR 6MM 80MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200071020 SUP HCPCS C1876 H74939200071020 - STENT VASCULAR .035IN 7MM 100MM 120CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200071070 SUP HCPCS C1876 H74939200071070 - STENT VASCULAR 7MM 100MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200071220 SUP HCPCS C1876 H74939200071220 - STENT VASCULAR 7MM 120MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200071270 SUP HCPCS C1876 H74939200071270 - STENT VASCULAR 7MM 120MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200072020 SUP HCPCS C1876 H74939200072020 - STENT VASCULAR 7MM 20MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200072070 SUP HCPCS C1876 H74939200072070 - STENT VASCULAR 7MM 20MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200073020 SUP HCPCS C1876 H74939200073020 - STENT VASCULAR 7MM 30MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200073070 SUP HCPCS C1876 H74939200073070 - STENT VASCULAR .035IN 7MM 30MM 75CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200074020 SUP HCPCS C1876 H74939200074020 - STENT VASCULAR .035IN 7MM 40MM 120CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200074070 SUP HCPCS C1876 H74939200074070 - STENT VASCULAR .035IN 7MM 40MM 75CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200075020 SUP HCPCS C1876 H74939200075020 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 120CM 7MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200075070 SUP HCPCS C1876 H74939200075070 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 75CM 7MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200076020 SUP HCPCS C1876 H74939200076020 - STENT VASCULAR 7MM 60MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200076070 SUP HCPCS C1876 H74939200076070 - STENT VASCULAR 7MM 60MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200077020 SUP HCPCS C1876 H74939200077020 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 120CM 7MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200077070 SUP HCPCS C1876 H74939200077070 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 75CM 7MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200078020 SUP HCPCS C1876 H74939200078020 - STENT VASCULAR 7MM 80MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200078070 SUP HCPCS C1876 H74939200078070 - STENT VASCULAR 7MM 80MM 75CM SELF EXPAND EPIC NITINOL ILIUM BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200081020 SUP HCPCS C1876 H74939200081020 - STENT VASCULAR 8MM 100MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200081070 SUP HCPCS C1876 H74939200081070 - STENT VASCULAR 8MM 100MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200081220 SUP HCPCS C1876 H74939200081220 - STENT VASCULAR .035IN 8MM 120MM 120CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200081270 SUP HCPCS C1876 H74939200081270 - STENT VASCULAR 8MM 120MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200082020 SUP HCPCS C1876 H74939200082020 - STENT VASCULAR 8MM 20MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200082070 SUP HCPCS C1876 H74939200082070 - STENT VASCULAR 8MM 20MM 75CM SELF EXPAND EPIC NITINOL ILIUM BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200083020 SUP HCPCS C1876 H74939200083020 - STENT VASCULAR 8MM 30MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200083070 SUP HCPCS C1876 H74939200083070 - STENT VASCULAR .035IN 8MM 30MM 75CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200084020 SUP HCPCS C1876 H74939200084020 - STENT VASCULAR 8MM 40MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200085020 SUP HCPCS C1876 H74939200085020 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 120CM 8MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200085070 SUP HCPCS C1876 H74939200085070 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 75CM 8MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200086020 SUP HCPCS C1876 H74939200086020 - STENT VASCULAR 8MM 60MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200086070 SUP HCPCS C1876 H74939200086070 - STENT VASCULAR 8MM 6FR 60MM 75CM SELF EXPAND SHEATH EPIC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200087020 SUP HCPCS C1876 H74939200087020 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 120CM 8MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200087070 SUP HCPCS C1876 H74939200087070 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 75CM 8MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200088020 SUP HCPCS C1876 H74939200088020 - STENT VASCULAR 8MM 80MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200088070 SUP HCPCS C1876 H74939200088070 - STENT VASCULAR 8MM 80MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200091020 SUP HCPCS C1876 H74939200091020 - STENT VASCULAR .035IN 8MM 100MM 120CM SELF EXPAND OTW GWIRE BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200091070 SUP HCPCS C1876 H74939200091070 - STENT VASCULAR 9MM 100MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200092020 SUP HCPCS C1876 H74939200092020 - STENT VASCULAR 9MM 20MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200092070 SUP HCPCS C1876 H74939200092070 - STENT VASCULAR 9MM 20MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200093020 SUP HCPCS C1876 H74939200093020 - STENT VASCULAR 9MM 30MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200093070 SUP HCPCS C1876 H74939200093070 - STENT VASCULAR 9MM 30MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200094020 SUP HCPCS C1876 H74939200094020 - STENT VASCULAR 9MM 40MM 120CM SELF EXPAND EPIC METAL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200094070 SUP HCPCS C1876 H74939200094070 - STENT VASCULAR 9MM 40MM 75CM SELF EXPAND EPIC NITINOL ILIUM BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200095020 SUP HCPCS C1876 H74939200095020 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 120CM 9MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200095070 SUP HCPCS C1876 H74939200095070 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 75CM 9MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200096020 SUP HCPCS C1876 H74939200096020 - STENT VASCULAR 9MM 60MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200096070 SUP HCPCS C1876 H74939200096070 - STENT VASCULAR 9MM 60MM 75CM SELF EXPAND EPIC NITINOL ILIUM BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200097020 SUP HCPCS C1876 H74939200097020 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 120CM 9MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200097070 SUP HCPCS C1876 H74939200097070 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 75CM 9MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200098020 SUP HCPCS C1876 H74939200098020 - STENT VASCULAR 9MM 80MM 120CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200098070 SUP HCPCS C1876 H74939200098070 - STENT VASCULAR 9MM 80MM 75CM SELF EXPAND EPIC NITINOL ILIUM BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200101020 SUP HCPCS C1876 H74939200101020 - STENT VASCULAR 9MM 100MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200101070 SUP HCPCS C1876 H74939200101070 - STENT VASCULAR 10MM 100MM 75CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200102020 SUP HCPCS C1876 H74939200102020 - STENT VASCULAR 10MM 20MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200102070 SUP HCPCS C1876 H74939200102070 - STENT VASCULAR 10MM 20MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200103020 SUP HCPCS C1876 H74939200103020 - STENT VASCULAR 10MM 30MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200103070 SUP HCPCS C1876 H74939200103070 - STENT VASCULAR 10MM 30MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200104020 SUP HCPCS C1876 H74939200104020 - STENT VASCULAR 10MM 40MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200104070 SUP HCPCS C1876 H74939200104070 - STENT VASCULAR 10MM 40MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200105020 SUP HCPCS C1876 H74939200105020 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 120CM 10MM BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200105070 SUP HCPCS C1876 H74939200105070 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 75CM 10MM ILIAC BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200106020 SUP HCPCS C1876 H74939200106020 - STENT VASCULAR 10MM 60MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200106070 SUP HCPCS C1876 H74939200106070 - STENT VASCULAR 10MM 60MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200107020 SUP HCPCS C1876 H74939200107020 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 120CM 10MM BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200107070 SUP HCPCS C1876 H74939200107070 - STENT VASCULAR 70MM SELF EXPAND EPIC NITINOL 75CM 10MM ILIUM BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200108020 SUP HCPCS C1876 H74939200108020 - STENT VASCULAR 10MM 80MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200108070 SUP HCPCS C1876 H74939200108070 - STENT VASCULAR 10MM 80MM 75CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200123020 SUP HCPCS C1876 H74939200123020 - STENT VASCULAR 12MM 30MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200123070 SUP HCPCS C1876 H74939200123070 - STENT VASCULAR 12MM 30MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200124020 SUP HCPCS C1876 H74939200124020 - STENT VASCULAR 12MM 40MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200124070 SUP HCPCS C1876 H74939200124070 - STENT VASCULAR 12MM 40MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200125020 SUP HCPCS C1876 H74939200125020 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 120CM 12MM BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200125070 SUP HCPCS C1876 H74939200125070 - STENT VASCULAR 50MM SELF EXPAND EPIC NITINOL 75CM 12MM ILIUM BOTH IP/OP "$2,500.00 " "$1,850.00" $0.00 "$2,000.00" "$1,125.00" "$1,125.00" $0.00 $0.00 $0.00 $521.06 "$1,855.50" "$1,855.50" $0.00 $0.00 $521.00 $0.00 "$1,478.75" "$1,478.75" $0.00 "$1,250.00" "$1,980.00" "$2,000.00" $0.00 $0.00 $391.25 $0.00 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200126020 SUP HCPCS C1876 H74939200126020 - STENT VASCULAR 12MM 60MM 120CM SELF EXPAND EPIC NITINOL BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939200126070 SUP HCPCS C1876 H74939200126070 - STENT VASCULAR 12MM 60MM 75CM SELF EXPAND EPIC NITINOL ILIAC BOTH IP/OP "$1,462.50 " "$1,082.25" $0.00 "$1,170.00" $658.13 $658.13 $0.00 $0.00 $0.00 $304.82 "$1,085.47" "$1,085.47" $0.00 $0.00 $304.79 $0.00 $865.07 $865.07 $0.00 $731.25 "$1,158.30" "$1,170.00" $0.00 $0.00 $228.88 $0.00 $0.00 $232.83 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206030210 SUP HCPCS C1753 H74939206030210 - CATHETER BLNDIL 3MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206030270 SUP HCPCS C1753 H74939206030270 - CATHETER BLNDIL 3MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206030370 SUP HCPCS C1753 H74939206030370 - CATHETER BLNDIL 3MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206030410 SUP HCPCS C1753 H74939206030410 - CATHETER BLNDIL 3MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206030470 SUP HCPCS C1753 H74939206030470 - CATHETER BLNDIL 3MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206030670 SUP HCPCS C1753 H74939206030670 - CATHETER BLNDIL 3MM 75CM 60MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206030810 SUP HCPCS C1753 H74939206030810 - CATHETER BLNDIL 3MM 135CM 80MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206031010 SUP HCPCS C1753 H74939206031010 - CATHETER BLNDIL 3MM 135CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206031210 SUP HCPCS C1753 H74939206031210 - CATHETER BLNDIL 3MM 135CM 120MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206031510 SUP HCPCS C1753 H74939206031510 - CATHETER BLNDIL 3MM 135CM 150MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206031810 SUP HCPCS C1753 H74939206031810 - CATHETER BLNDIL 3MM 135CM 180MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206032010 SUP HCPCS C1753 H74939206032010 - CATHETER BLNDIL 3MM 135CM 200MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040210 SUP HCPCS C1753 H74939206040210 - CATHETER BLNDIL 4MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040270 SUP HCPCS C1753 H74939206040270 - CATHETER BLNDIL 4MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040370 SUP HCPCS C1753 H74939206040370 - CATHETER BLNDIL 4MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040410 SUP HCPCS C1753 H74939206040410 - CATHETER BLNDIL 4MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040470 SUP HCPCS C1753 H74939206040470 - CATHETER BLNDIL 4MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040610 SUP HCPCS C1753 H74939206040610 - CATHETER BLNDIL 4MM 135CM 60MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040670 SUP HCPCS C1753 H74939206040670 - CATHETER BLNDIL 4MM 75CM 60MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040810 SUP HCPCS C1753 H74939206040810 - CATHETER BLNDIL 4MM 135CM 80MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206040870 SUP HCPCS C1753 H74939206040870 - CATHETER BLNDIL 4MM 75CM 80MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206041010 SUP HCPCS C1753 H74939206041010 - CATHETER BLNDIL 4MM 135CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206041070 SUP HCPCS C1753 H74939206041070 - CATHETER BLNDIL 4MM 75CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206041210 SUP HCPCS C1753 H74939206041210 - CATHETER BLNDIL 4MM 135CM 120MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206041510 SUP HCPCS C1753 H74939206041510 - CATHETER BLNDIL 4MM 135CM 150MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206041810 SUP HCPCS C1753 H74939206041810 - CATHETER BLNDIL 4MM 135CM 180MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206042010 SUP HCPCS C1753 H74939206042010 - CATHETER BLNDIL 4MM 135CM 200MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050210 SUP HCPCS C1753 H74939206050210 - CATHETER BLNDIL 5MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050270 SUP HCPCS C1753 H74939206050270 - CATHETER BLNDIL 5MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050370 SUP HCPCS C1753 H74939206050370 - CATHETER BLNDIL 5MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050410 SUP HCPCS C1753 H74939206050410 - CATHETER BLNDIL 5MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050470 SUP HCPCS C1753 H74939206050470 - CATHETER BLNDIL 5MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050610 SUP HCPCS C1753 H74939206050610 - CATHETER BLNDIL 5MM 135CM 60MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050670 SUP HCPCS C1753 H74939206050670 - CATHETER BLNDIL 5MM 75CM 60MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050810 SUP HCPCS C1753 H74939206050810 - CATHETER BLNDIL 5MM 135CM 80MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206050870 SUP HCPCS C1753 H74939206050870 - CATHETER BLNDIL 5MM 75CM 80MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206051010 SUP HCPCS C1753 H74939206051010 - CATHETER BLNDIL 5MM 135CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206051070 SUP HCPCS C1753 H74939206051070 - CATHETER BLNDIL 5MM 75CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206051210 SUP HCPCS C1753 H74939206051210 - CATHETER BLNDIL 5MM 135CM 120MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206051510 SUP HCPCS C1753 H74939206051510 - CATHETER BLNDIL 5MM 135CM 150MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206051810 SUP HCPCS C1753 H74939206051810 - CATHETER BLNDIL 5MM 135CM 180MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206052010 SUP HCPCS C1753 H74939206052010 - CATHETER BLNDIL 5MM 135CM 200MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060210 SUP HCPCS C1753 H74939206060210 - CATHETER BLNDIL 6MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060270 SUP HCPCS C1753 H74939206060270 - CATHETER BLNDIL 6MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060370 SUP HCPCS C1753 H74939206060370 - CATHETER BLNDIL 6MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060410 SUP HCPCS C1753 H74939206060410 - CATHETER BLNDIL 6MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060470 SUP HCPCS C1753 H74939206060470 - CATHETER BLNDIL 6MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060610 SUP HCPCS C1753 H74939206060610 - CATHETER BLNDIL 6MM 135CM 60MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060670 SUP HCPCS C1753 H74939206060670 - CATHETER BLNDIL 6MM 75CM 60MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060810 SUP HCPCS C1753 H74939206060810 - CATHETER BLNDIL 6MM 135CM 80MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206060870 SUP HCPCS C1753 H74939206060870 - CATHETER BLNDIL 6MM 75CM 80MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206061010 SUP HCPCS C1753 H74939206061010 - CATHETER BLNDIL 6MM 135CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206061070 SUP HCPCS C1753 H74939206061070 - CATHETER BLNDIL 6MM 75CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206061210 SUP HCPCS C1753 H74939206061210 - CATHETER BLNDIL 6MM 135CM 120MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206061510 SUP HCPCS C1753 H74939206061510 - CATHETER BLNDIL 6MM 135CM 150MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206061810 SUP HCPCS C1753 H74939206061810 - CATHETER BLNDIL 6MM 135CM 180MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206062010 SUP HCPCS C1753 H74939206062010 - CATHETER BLNDIL 6MM 135CM 200MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070210 SUP HCPCS C1753 H74939206070210 - CATHETER BLNDIL 7MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070270 SUP HCPCS C1753 H74939206070270 - CATHETER BLNDIL 7MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070370 SUP HCPCS C1753 H74939206070370 - CATHETER BLNDIL 7MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070410 SUP HCPCS C1753 H74939206070410 - CATHETER BLNDIL 7MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070470 SUP HCPCS C1753 H74939206070470 - CATHETER BLNDIL 7MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070610 SUP HCPCS C1753 "H74939206070610 - BALLOON CATHETER CHARGER 7.0 x60, 135cm" BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070670 SUP HCPCS C1753 H74939206070670 - CATHETER BLNDIL 7MM 75CM 60MM CHRGR OTW 2 LUM TPR TIP LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070810 SUP HCPCS C1753 H74939206070810 - CATHETER BLNDIL 7MM 135CM 80MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206070870 SUP HCPCS C1753 H74939206070870 - CATHETER BLNDIL 7MM 75CM 80MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206071010 SUP HCPCS C1753 H74939206071010 - CATHETER BLNDIL 7MM 135CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206071070 SUP HCPCS C1753 H74939206071070 - CATHETER BLNDIL 7MM 75CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206071210 SUP HCPCS C1753 H74939206071210 - CATHETER BLNDIL 7MM 135CM 120MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206071510 SUP HCPCS C1753 H74939206071510 - CATHETER BLNDIL 7MM 135CM 150MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206071810 SUP HCPCS C1753 H74939206071810 - CATHETER BLNDIL 7MM 135CM 180MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206072010 SUP HCPCS C1753 H74939206072010 - CATHETER BLNDIL 7MM 135CM 200MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206080210 SUP HCPCS C1753 H74939206080210 - CATHETER BLNDIL 8MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206080270 SUP HCPCS C1753 H74939206080270 - CATHETER BLNDIL 8MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206080370 SUP HCPCS C1753 H74939206080370 - CATHETER BLNDIL 8MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206080410 SUP HCPCS C1753 H74939206080410 - CATHETER BLNDIL 8MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206080470 SUP HCPCS C1753 H74939206080470 - CATHETER BLNDIL 8MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206080670 SUP HCPCS C1753 H74939206080670 - CATHETER BLNDIL 8MM 75CM 60MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206080810 SUP HCPCS C1753 H74939206080810 - CATHETER BLNDIL 8MM 135CM 80MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206080870 SUP HCPCS C1753 H74939206080870 - CATHETER BLNDIL 8MM 75CM 80MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206081010 SUP HCPCS C1753 H74939206081010 - CATHETER BLNDIL 8MM 135CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206081070 SUP HCPCS C1753 H74939206081070 - CATHETER BLNDIL 8MM 75CM 100MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206081210 SUP HCPCS C1753 H74939206081210 - CATHETER BLNDIL 8MM 135CM 120MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206081510 SUP HCPCS C1753 H74939206081510 - CATHETER BLNDIL 8MM 135CM 150MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206081810 SUP HCPCS C1753 H74939206081810 - CATHETER BLNDIL 8MM 135CM 180MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206082010 SUP HCPCS C1753 H74939206082010 - CATHETER BLNDIL 8MM 135CM 200MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206090210 SUP HCPCS C1753 H74939206090210 - CATHETER BLNDIL 9MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206090270 SUP HCPCS C1753 H74939206090270 - CATHETER BLNDIL 9MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206090370 SUP HCPCS C1753 H74939206090370 - CATHETER BLNDIL 9MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206090410 SUP HCPCS C1753 H74939206090410 - CATHETER BLNDIL 9MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206090470 SUP HCPCS C1753 H74939206090470 - CATHETER BLNDIL 9MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206090670 SUP HCPCS C1753 H74939206090670 - CATHETER BLNDIL 9MM 75CM 60MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206090870 SUP HCPCS C1753 H74939206090870 - CATHETER BLNDIL 9MM 75CM 80MM CHRGR OTW NC 2 LUM SHFT LOPRFL BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206100210 SUP HCPCS C1753 H74939206100210 - CATHETER BLNDIL 10MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206100270 SUP HCPCS C1753 H74939206100270 - CATHETER BLNDIL 10MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206100370 SUP HCPCS C1753 H74939206100370 - CATHETER BLNDIL 10MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206100410 SUP HCPCS C1753 H74939206100410 - CATHETER BLNDIL 10MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206100470 SUP HCPCS C1753 H74939206100470 - CATHETER BLNDIL 10MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206100670 SUP HCPCS C1753 H74939206100670 - CATHETER BLNDIL 10MM 75CM 60MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206100870 SUP HCPCS C1753 H74939206100870 - CATHETER BLNDIL 10MM 75CM 80MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206120210 SUP HCPCS C1753 H74939206120210 - CATHETER BLNDIL 12MM 135CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206120270 SUP HCPCS C1753 H74939206120270 - CATHETER BLNDIL 12MM 75CM 20MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206120370 SUP HCPCS C1753 H74939206120370 - CATHETER BLNDIL 12MM 75CM 30MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206120410 SUP HCPCS C1753 H74939206120410 - CATHETER BLNDIL 12MM 135CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206120470 SUP HCPCS C1753 H74939206120470 - CATHETER BLNDIL 12MM 75CM 40MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206120670 SUP HCPCS C1753 H74939206120670 - CATHETER BLNDIL 12MM 75CM 60MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939206120870 SUP HCPCS C1753 H74939206120870 - CATHETER BLNDIL 12MM 75CM 80MM CHRGR OTW NC 2 LUM SHFT BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $108.60 $108.60 $0.00 $0.00 $0.00 $41.69 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $118.30 $118.30 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $31.30 $0.00 $0.00 $31.84 $0.00 $0.00 $0.00 $0.00 $0.00 H74939208001601 SUP HCPCS C1769 H74939208001601 - WIRE CATHETER .017IN .018IN 165CM 300CM SHAPABLE DISTAL TIP BOTH IP/OP $205.80 $152.29 $0.00 $164.64 $111.75 $111.75 $0.00 $0.00 $0.00 $42.89 $152.74 $152.74 $0.00 $0.00 $42.89 $0.00 $121.73 $121.73 $0.00 $102.90 $162.99 $164.64 $0.00 $0.00 $32.21 $0.00 $0.00 $32.76 $0.00 $0.00 $0.00 $0.00 $0.00 H74939208181650 SUP HCPCS C2628 H74939208181650 - CATHETER ATHERECTOMY .017IN .018IN 165CM SHAPABLE DISTAL TIP BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$2,318.68" "$2,318.68" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H74939212014131 SUP HCPCS C1887 H74939212014131 - CATHETER SPRT 15MM SPC 3.4FR 135CM CLR PUR RUBICON 14 RADOPQ BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H74939212014151 SUP HCPCS C1887 H74939212014151 - CATHETER GUID .018IN 150CM RADIOPQ ULTRA LP ROBUST BALLOON BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H74939216718210 SUP HCPCS C1769 H74939216718210 - GUIDEWIRE VASCULAR STR SHORT TAPER .014IN 182CM 8CM ROBUST BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 H74939216718220 SUP HCPCS C1769 H74939216718220 - GUIDEWIRE VASCULAR ANGLE SHORT TAPER .014IN 182CM 8CM ROBUST BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 H74939216730010 SUP HCPCS C1769 H74939216730010 - GUIDEWIRE VASCULAR STR SHORT TAPER .014IN 300CM 8CM ROBUST BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 H74939216730020 SUP HCPCS C1769 H74939216730020 - GUIDEWIRE VASCULAR ANGLE SHORT TAPER .014IN 300CM 8CM ROBUST BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 H74939216918210 SUP HCPCS C1769 H74939216918210 - GUIDEWIRE VASCULAR STR LONG TAPER .014IN 182CM 11CM ROBUST BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 H74939216918220 SUP HCPCS C1769 H74939216918220 - GUIDEWIRE VASCULAR ANGLE LONG TAPER .014IN 182CM 11CM ROBUST BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 H74939216930010 SUP HCPCS C1769 H74939216930010 - GUIDEWIRE VASCULAR STR LONG TAPER .014IN 300CM 11CM ROBUST BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 H74939216930020 SUP HCPCS C1769 H74939216930020 - GUIDEWIRE VASCULAR ANGLE LONG TAPER .014IN 300CM 11CM ROBUST BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 H74939239018091 SUP HCPCS C1887 H74939239018091 - CATHETER SPRT 15MM SPC 4FR 90CM CLR PUR RUBICON 18 RADOPQ BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H74939239018131 SUP HCPCS C1887 H74939239018131 - CATHETER SPRT 15MM SPC 4FR 135CM CLR PUR RUBICON 18 RADOPQ BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H74939239018151 SUP HCPCS C1887 H74939239018151 - CATHETER SPRT 15MM SPC 4FR 150CM CLR PUR RUBICON 18 RADOPQ BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H74939240035061 SUP HCPCS C1887 H74939240035061 - CATHETER SPRT 50MM SPC 5.1FR 65CM CLR PUR RUBICON 35 RADOPQ BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H74939240035091 SUP HCPCS C1887 H74939240035091 - CATHETER SPRT 50MM SPC 5.1FR 90CM CLR PUR RUBICON 35 RADOPQ BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H74939240035131 SUP HCPCS C1887 H74939240035131 - CATHETER SPRT 50MM SPC 5.1FR 135CM CLR PUR RUBICON 35 RADOPQ BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H74939240035151 SUP HCPCS C1887 H74939240035151 - CATHETER SPRT 50MM SPC 5.1FR 150CM CLR PUR RUBICON 35 RADOPQ BOTH IP/OP "$1,470.00 " "$1,087.80" $0.00 "$1,176.00" $798.21 $798.21 $0.00 $0.00 $0.00 $306.38 "$1,091.03" "$1,091.03" $0.00 $0.00 $306.35 $0.00 $869.51 $869.51 $0.00 $735.00 "$1,164.24" "$1,176.00" $0.00 $0.00 $230.06 $0.00 $0.00 $234.02 $0.00 $0.00 $0.00 $0.00 $0.00 H749501001500 SUP Custom 27203010 H749501001500 - SHEATH RTRVL 150CM 4FR F EZ .014IN BNTP BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H749CBO3200100 SUP HCPCS C1726 H749CBO3200100 - CATHETER BLNDIL 2MM 137CM 10MM F CBLN OTW INFL PORT GW PORT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" "$1,086.00" "$1,086.00" $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 H749CBO3200150 SUP HCPCS C1726 H749CBO3200150 - CATHETER BLNDIL 2MM 137CM 15MM F CBLN OTW INFL PORT GW PORT BOTH IP/OP "$1,715.00 " "$1,269.10" $0.00 "$1,372.00" $931.25 $931.25 $0.00 $0.00 $0.00 $357.45 "$1,272.87" "$1,272.87" $0.00 $0.00 $357.41 $0.00 "$1,014.42" "$1,014.42" $0.00 $857.50 "$1,358.28" "$1,372.00" $0.00 $0.00 $268.40 $0.00 $0.00 $273.03 $0.00 $0.00 $0.00 $0.00 $0.00 H749CBO3250100 SUP HCPCS C1726 H749CBO3250100 - CATHETER BLNDIL 2.5MM 137CM 10MM F CBLN OTW INFL PORT GW BOTH IP/OP "$1,715.00 " "$1,269.10" $0.00 "$1,372.00" $931.25 $931.25 $0.00 $0.00 $0.00 $357.45 "$1,272.87" "$1,272.87" $0.00 $0.00 $357.41 $0.00 "$1,014.42" "$1,014.42" $0.00 $857.50 "$1,358.28" "$1,372.00" $0.00 $0.00 $268.40 $0.00 $0.00 $273.03 $0.00 $0.00 $0.00 $0.00 $0.00 H749CBO3250150 SUP HCPCS C1726 H749CBO3250150 - CATHETER BLNDIL 2.5MM 137CM 15MM F CBLN OTW INFL PORT GW BOTH IP/OP "$1,715.00 " "$1,269.10" $0.00 "$1,372.00" $931.25 $931.25 $0.00 $0.00 $0.00 $357.45 "$1,272.87" "$1,272.87" $0.00 $0.00 $357.41 $0.00 "$1,014.42" "$1,014.42" $0.00 $857.50 "$1,358.28" "$1,372.00" $0.00 $0.00 $268.40 $0.00 $0.00 $273.03 $0.00 $0.00 $0.00 $0.00 $0.00 H7587-58 SUP Custom 27203010 REAGENT B-OHB R1 R2 50ML ANALY BOTH IP/OP $854.13 $632.06 $0.00 $683.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.06 $676.47 $683.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H7587-CTL SUP Custom 27203010 CONTROL CHM 5ML SET B-OHB BOTH IP/OP $723.00 $535.02 $0.00 $578.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.50 $572.62 $578.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H787107140145 SUP HCPCS C1713 H787107140145 - CATHETER ANGIO ANG KMP CRV 4FR 65CM SFVU RADOPQ SLCT HTORQ BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $15.75 $15.75 $0.00 $0.00 $0.00 $7.29 $25.98 $25.98 $0.00 $0.00 $7.29 $0.00 $20.70 $20.70 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 H787107322055 SUP HCPCS C1887 H787107322055 - CATHETER ANGIO OM CRV 5FR 100CM SFVU RADOPQ FLSH HTORQ SHFT BOTH IP/OP $35.00 $25.90 $0.00 $28.00 $19.01 $19.01 $0.00 $0.00 $0.00 $7.29 $25.98 $25.98 $0.00 $0.00 $7.29 $0.00 $20.70 $20.70 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 H965100510 SUP HCPCS C1887 H965100510 - CATHETER GD STRG 7FR 90CM STRL GDR SFTP XF 2X2 RND BRD X BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 H965251850 SUP Custom 27203010 H965251850 - CANNULA PRFSN ANGIOVAC DIL FNL TIP RADOPQ COIL REINF DISP BOTH IP/OP "$28,750.00 " "$21,275.00" $0.00 "$23,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,991.50" $0.00 $0.00 $0.00 $0.00 "$14,375.00" "$22,770.00" "$23,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965251860 SUP Custom 27203010 H965251860 - CANNULA PRFSN 20D ANGIOVAC DIL FNL TIP RADOPQ COIL REINF BOTH IP/OP "$28,750.00 " "$21,275.00" $0.00 "$23,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,991.50" $0.00 $0.00 $0.00 $0.00 "$14,375.00" "$22,770.00" "$23,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965251870 SUP Custom 27203010 H965251870 - SYSTEM PRFSN ANGIOVAC CRCT PMP HD BBL TRP BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965251880 SUP Custom 27203010 H965251880 - SYSTEM PRFSN ANGIOVAC CRCT BBL TRP BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965251900 SUP Custom 27203010 H965251900 - CANNULA PRFSN ANGIOVAC STRG DIL CRCT BBL TRP COIL REINF DISP BOTH IP/OP "$32,500.00 " "$24,050.00" $0.00 "$26,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,773.00" $0.00 $0.00 $0.00 $0.00 "$16,250.00" "$25,740.00" "$26,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965251910 SUP Custom 27203010 H965251910 - CANNULA PRFSN 20D ANGIOVAC DIL CRCT PMP HD BBL TRP DISP BOTH IP/OP "$32,500.00 " "$24,050.00" $0.00 "$26,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,773.00" $0.00 $0.00 $0.00 $0.00 "$16,250.00" "$25,740.00" "$26,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965251990 SUP Custom 27203010 H965251990 - SYSTEM PRFSN ANGIOVAC CRCT BOTH IP/OP "$3,750.00 " "$2,775.00" $0.00 "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,783.25" "$2,783.25" $0.00 $0.00 $781.50 $0.00 $0.00 $0.00 $0.00 "$1,875.00" "$2,970.00" "$3,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965402100 SUP HCPCS C1877 H965402100 - STENT ENDOPRSTH 100CM 12MM 20MM 75CM UNCONSTRAIN FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965402110 SUP HCPCS C1877 H965402110 - STENT ENDOPRSTH 12MM 8FR 40MM 100CM FLEXIBLE RECONSTRAINABLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965402120 SUP HCPCS C2617 H965402120 - STENT ENDOPRSTH 100CM 12MM 8FR 60MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965402130 SUP HCPCS C2617 H965402130 - STENT ENDOPRSTH 100CM 12MM 8FR 90MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965403100 SUP HCPCS C1877 H965403100 - STENT ENDOPRSTH 100CM 14MM 20MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965403110 SUP HCPCS C1877 H965403110 - STENT ENDOPRSTH 100CM 14MM 40MM 75CM UNCONSTRAIN FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965403120 SUP HCPCS C1877 H965403120 - STENT ENDOPRSTH 100CM 14MM 9FR 60MM 75CM CATHETER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965403130 SUP HCPCS C1877 H965403130 - STENT ENDOPRSTH 100CM 14MM 9FR 90MM 75CM CATHETER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965403300 SUP HCPCS C1877 H965403300 - STENT ENDOPRSTH 160CM 16MM 9FR 20MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965403310 SUP HCPCS C1877 H965403310 - STENT ENDOPRSTH 100CM 16MM 9FR 40MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965403320 SUP HCPCS C1877 H965403320 - STENT ENDOPRSTH 100CM 16MM 9FR 60MM 75CM CATHETER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965403330 SUP HCPCS C2617 H965403330 - STENT ENDOPRSTH 100CM 16MM 9FR 90MM 75CM CATHETER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404110 SUP HCPCS C1877 H965404110 - STENT ENDOPRSTH 100CM 18MM 10FR 40MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404120 SUP HCPCS C1877 H965404120 - STENT ENDOPRSTH 100CM 18MM 10FR 60MM 75CM CATHETER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404130 SUP HCPCS C1877 H965404130 - STENT ENDOPRSTH 100CM 18MM 10FR 90MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404300 SUP HCPCS C1877 H965404300 - STENT ENDOPRSTH 100CM 20MM 10FR 40MM 75CM CATHETER BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404310 SUP HCPCS C1877 H965404310 - STENT ENDOPRSTH 100CM 20MM 10FR 55MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404320 SUP HCPCS C1877 H965404320 - STENT ENDOPRSTH 100CM 20MM 10FR 80MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404500 SUP HCPCS C1877 H965404500 - STENT ENDOPRSTH 100CM 22MM 10FR 35MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404510 SUP HCPCS C1877 H965404510 - STENT ENDOPRSTH 100CM 22MM 10FR 45MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965404520 SUP HCPCS C1877 H965404520 - STENT ENDOPRSTH 100CM 22MM 10FR 70MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965405100 SUP HCPCS C1877 H965405100 - STENT ENDOPRSTH 100CM 24MM 11FR 35MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965405110 SUP HCPCS C1877 H965405110 - STENT ENDOPRSTH 100CM 24MM 12FR 45MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965405120 SUP HCPCS C1877 H965405120 - STENT ENDOPRSTH 100CM 24MM 11FR 70MM 75CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965412000 SUP HCPCS C1877 H965412000 - STENT ENDOPRSTH 160CM 12MM 9FR 20MM 135CM FLEXIBLE DELIVERY BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965412010 SUP HCPCS C1877 H965412010 - STENT ENDOPRSTH 160CM 12MM 8FR 40MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965412020 SUP HCPCS C1877 H965412020 - STENT ENDOPRSTH 160CM 12MM 8FR 60MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965412030 SUP HCPCS C1877 H965412030 - STENT ENDOPRSTH 160CM 12MM 8FR 90MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 H965700150021 SUP Custom 27203010 H965700150021 - STOPCOCK ANGIO 200 PSI NAMIC 3W ROT M COLR RT PORT PRTC BOTH IP/OP $2.32 $1.72 $0.00 $1.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.72 $1.72 $0.00 $0.00 $0.48 $0.00 $0.00 $0.00 $0.00 $1.16 $1.84 $1.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965700150151 SUP Custom 27203010 H965700150151 - STOPCOCK ANGIO 200 PSI NAMIC 1 WY ROT M COLR PORT PRTC BOTH IP/OP $2.16 $1.60 $0.00 $1.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.60 $1.60 $0.00 $0.00 $0.45 $0.00 $0.00 $0.00 $0.00 $1.08 $1.58 $1.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965914000211 SUP Custom 27203010 H965914000211 - ADAPTER ANGIO 200 PSI 5/16IN 28 THRD ORG Y .1IN STRL NAMIC BOTH IP/OP $16.05 $11.88 $0.00 $12.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.91 $11.91 $0.00 $0.00 $3.34 $0.00 $0.00 $0.00 $0.00 $8.03 $12.71 $12.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 H965SCH306011 SUP HCPCS C1769 H965SCH306011 - GUIDEWIRE VASCULAR C .035IN 300CM 10CM FLEXIBLE MEIER WIRE BOTH IP/OP $391.15 $289.45 $0.00 $312.92 $212.39 $212.39 $0.00 $0.00 $0.00 $81.53 $290.31 $290.31 $0.00 $0.00 $81.52 $0.00 $231.37 $231.37 $0.00 $195.58 $309.79 $312.92 $0.00 $0.00 $61.21 $0.00 $0.00 $62.27 $0.00 $0.00 $0.00 $0.00 $0.00 HARH36 SUP Custom 27203010 HARH36 - SHEARS ESURG CRV 5MM 36CM STRL LF HRMN A +7 ADV HMSTS 3 BOTH IP/OP $756.33 $559.68 $0.00 "$7,368.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,605.60" "$7,295.27" "$7,368.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HC0002 SUP Custom 27203010 HEMOSTASE MPH 5G 5-PACK BOTH IP/OP $669.50 $495.43 $0.00 $535.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.75 $530.24 $535.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HC7001GAL SUP Custom 27203010 REAGENT XYLN HSTPRP 1GL SLVT HISTOLGY BOTH IP/OP $58.70 $43.44 $0.00 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.35 $46.49 $46.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5125 SUP HCPCS C1713 HCA-5125 - SCREW BONE 5MM 25MM TI CANC LCK NONSTRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5127 SUP HCPCS C1713 HCA-5127 - SCREW BONE 5MM 27.5MM CANC BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5130 SUP HCPCS C1713 HCA-5130 - SCREW BONE 5MM 30MM TI CANC NONSTRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5132 SUP HCPCS C1713 HCA-5132 - SCREW BONE 5MM 32.5MM TI CANC NONSTRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5135 SUP HCPCS C1713 HCA-5135 - SCREW BN 5MM 35MM NLCKG ORTH BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5137 SUP HCPCS C1713 HCA-5137 - SCREW BONE 5MM 37.5MM PLRS TI CANC HUM LCK NONSTRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5140 SUP HCPCS C1713 HCA-5140 - SCREW BN 5MM 40MM CANC BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5145 SUP HCPCS C1713 HCA-5145 - SCREW BONE 5MM 45MM CANC BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5150 SUP HCPCS C1713 HCA-5150 - SCREW BONE 5MM 50MM TI CANC NONSTRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-5155 SUP HCPCS C1713 HCA-5155 - SCREW BN 5MM 55MM CANC BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5200-S SUP HCPCS C1713 HCA5200-S - SCREW BONE 5MM 20MM PLRS TI CANC HUM STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5250-S SUP HCPCS C1713 HCA5250-S - SCREW BONE 5MM 25MM PLRS TI CANC STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5275-S SUP HCPCS C1713 HCA5275-S - SCREW BONE 5MM 27.5MM PLRS RADL ULN HUM FIB CANC STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5300-S SUP HCPCS C1713 HCA5300-S - SCREW BONE 5MM 30MM PLRS TI CANC HUM STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5325-S SUP HCPCS C1713 HCA5325-S - SCREW BONE 5MM 32.5MM CANC STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5350-S SUP HCPCS C1713 HCA5350-S - SCREW BONE 5MM 35MM PLRS TI CANC HUM LCK STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5375-S SUP HCPCS C1713 HCA5375-S - SCREW BONE 5MM 37.5MM PLRS RADL ULN HUM FIB CANC STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5400-S SUP HCPCS C1713 HCA5400-S - SCREW BONE 5MM 40MM PLRS TI CANC STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5425-S SUP HCPCS C1713 HCA5425-S - SCREW BONE 5MM 42.5MM PLRS RADL ULN HUM FIB CANC STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5450-S SUP HCPCS C1713 HCA5450-S - SCREW BONE 5MM 45MM PLRS TI CANC STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5500-S SUP HCPCS C1713 HCA5500-S - SCREW BONE 5MM 50MM PLRS TI CANC STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA5550-S SUP HCPCS C1713 HCA5550-S - SCREW BONE 5MM 50MM PLRS TI CANC HUM LCK STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-L5325-S SUP HCPCS C1713 HCA-L5325-S - SCREW BN 5.3MM 25MM STRL PLRS LCK TI CANC HUM BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-L5330-S SUP HCPCS C1713 HCA-L5330-S - SCREW BONE 5.3MM 30MM PLRS TI ORTH LCK STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-L5335-S SUP HCPCS C1713 HCA-L5335-S - SCREW BONE 5.3MM 35MM TI CANC LCK STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-L5340-S SUP HCPCS C1713 HCA-L5340-S - SCREW BONE 5.3MM 40MM PLRS TI ORTH LCK STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCA-L5345-S SUP HCPCS C1713 HCA-L5345-S - SCREW BN 5.3MM 45MM STRL LCK TI CANC BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27100-TS SUP HCPCS C1713 HCLP-27100-TS - PEG FX 2.7MM 10MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27120-TS SUP HCPCS C1713 HCLP-27120-TS - PEG FX 2.7MM 12MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27140-TS SUP HCPCS C1713 HCLP-27140-TS - PEG FX 2.7MM 14MM NS GEMINUS HI CMPR LCK TI RDS DIST VOLR BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27160-TS SUP HCPCS C1713 HCLP-27160-TS - PEG FIX 2.7MM 16MM HIGH COMPRESSION LOCKING GEMINUS TITANIUM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27180-TS SUP HCPCS C1713 HCLP-27180-TS - PEG FX 2.7MM 18MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27190-TS SUP HCPCS C1713 HCLP-27190-TS - PEG FX 2.7MM 19MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27200-TS SUP HCPCS C1713 HCLP-27200-TS - PEG FIX 2.7MM 20MM HIGH COMPRESSION LOCKING GEMINUS TITANIUM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27210-TS SUP HCPCS C1713 HCLP-27210-TS - PEG FX 2.7MM 21MM NS GEMINUS HI CMPR LCK TI RDS DIST VOLR BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27220-TS SUP HCPCS C1713 HCLP-27220-TS - PEG FX 2.7MM 22MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27230-TS SUP HCPCS C1713 HCLP-27230-TS - PEG FX 2.7MM 23MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27240-TS SUP HCPCS C1713 HCLP-27240-TS - PEG FX 2.7MM 24MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27260-TS SUP HCPCS C1713 HCLP-27260-TS - PEG FX 2.7MM 26MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27280-TS SUP HCPCS C1713 HCLP-27280-TS - PEG FX 2.7MM 28MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27300-TS SUP HCPCS C1713 HCLP-27300-TS - PEG FX 2.7MM 30MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCLP-27320-TS SUP HCPCS C1713 HCLP-27320-TS - PEG FX 2.7MM 32MM NS GEMINUS HI CMPR LCK TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 HCO-3150-S SUP HCPCS C1713 HCO-3150-S - SCREW BONE 3.5MM 15MM CORT BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3175-S SUP HCPCS C1713 HCO3175-S - SCREW BONE 3.5MM 17.5MM PLRS TI CORT SHLDR STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3200-S SUP HCPCS C1713 HCO3200-S - SCREW BONE 3.5MM 20MM PLRS TI CORT HUM INTLCK STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3225-S SUP HCPCS C1713 HCO3225-S - SCREW BN 3.5MM 22.5MM STRL CORT BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3250-S SUP HCPCS C1713 HCO3250-S - SCREW BONE 3.5MM 25MM PLRS TI CORT HUM SHLDR STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3275-S SUP HCPCS C1713 HCO3275-S - SCREW BONE 3.5MM 27.5MM PLRS CORT HUM SHLDR STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3300-S SUP HCPCS C1713 HCO3300-S - SCREW BONE 3.5MM 30MM PLRS TI CORT HUM INTLCK STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3325-S SUP HCPCS C1713 HCO3325-S - SCREW BONE 3.5MM 32.5MM PLRS TI CORT HUM STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3350-S SUP HCPCS C1713 HCO3350-S - SCREW BONE 3.5MM 35MM ACUMED TI CORT SHLDR STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3375-S SUP HCPCS C1713 HCO3375-S - SCREW BONE 3.5MM 37.5MM TI CORT STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3400-S SUP HCPCS C1713 HCO3400-S - SCREW BONE 3.5MM 40MM PLRS TI CORT HUM STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3450-S SUP HCPCS C1713 HCO3450-S - SCREW BONE 3.5MM 45MM PLRS TI CORT STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3500-S SUP HCPCS C1713 HCO3500-S - SCREW BONE 3.5MM 50MM PLRS TI CORT HUM SHLDR STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3550-S SUP HCPCS C1713 HCO3550-S - SCREW BONE 3.5MM 55MM PLRS TI CORT HUM STRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HCO35WA SUP Custom 27803010 HCO35WA - WASHER ORTH 3.5MM NS PLRS TI CORT SCR BOTH IP/OP $92.50 $68.45 $0.00 $74.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.65 $68.65 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $46.25 $73.26 $74.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HCO3600-S SUP HCPCS C1713 HCO3600-S - SCREW BONE 3.5MM 60MM PLRS TI CORT NONSTRL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HD-1500 SUP Custom 27203010 HD-1500 - DRIVER HEX SLD 1.5MM SURG BOTH IP/OP $301.88 $223.39 $0.00 $241.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.05 $224.05 $0.00 $0.00 $62.91 $0.00 $0.00 $0.00 $0.00 $150.94 $239.09 $241.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-1509 SUP Custom 27203010 HD-1509 - DRIVER CANN HEX ASMBLY 1.5MM SURG BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-2000 SUP Custom 27203010 HD-2000 - DRIVER 2MM SLD SURG BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-2011 SUP Custom 27203010 HD-2011 - DRIVER SRG 2MM HEX CNN BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-2500 SUP Custom 27203010 HD-2500 - DRIVER SURG 2.5MM HEX SLD ASMBLY 2.5MM BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-2515 SUP Custom 27203010 HD-2515 - SCRDRVR 2.5MM CANN HEX 2.5MM SURG BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-2516 SUP Custom 27203010 HD-2516 - DRIVER CANN HEX ASMBLY 2.5MM SURG BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-3016 SUP Custom 27203010 HD-3016 - DRIVER CANN ASMBLY 3MM SURG BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-3500 SUP Custom 27203010 HD-3500 - SCRDRVR SLD ASMBLY 3.5MM SURG BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HD-3725 SUP Custom 27203010 HD-3725 - DRIVER PLRS CANN HDSN FIT 3MM SURG NONSTRL BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HDF-1500 SUP Custom 27203010 HDF-1500 - DRIVER 1.5MM ACTRK FSN SLD 1.5MM SURG MINI SCR BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HDL-2000 SUP Custom 27203010 HDL-2000 - SCREWDRIVER SRG 2MM SLD BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HDL-2500 SUP Custom 27203010 HDL-2500 - SCRDRVR 2.5MM HEX SLD SURG BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HDM-1500 SUP Custom 27203010 HDM-1500 - DRIVER 1.5MM SLD SURG BOTH IP/OP $682.50 $505.05 $0.00 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.55 $506.55 $0.00 $0.00 $142.23 $0.00 $0.00 $0.00 $0.00 $341.25 $540.54 $546.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL180620-20 SUP Custom 27803010 HEL180620-20 - COIL EMBL HLCL 6MM 20CM HELIPAQ 18 MCIOL LOOP DTCH STRCH RS BOTH IP/OP "$1,268.93 " $939.01 $0.00 "$1,015.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $941.80 $941.80 $0.00 $0.00 $264.44 $0.00 $0.00 $0.00 $0.00 $634.46 "$1,004.99" "$1,015.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL180730-20 SUP Custom 27803010 HEL180730-20 - COIL EMBL HLCL 7MM 30CM HELIPAQ 18 MCIOL LOOP DTCH STRCH RS BOTH IP/OP "$1,358.30 " "$1,005.14" $0.00 "$1,086.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,008.13" "$1,008.13" $0.00 $0.00 $283.07 $0.00 $0.00 $0.00 $0.00 $679.15 "$1,075.77" "$1,086.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL180830-20 SUP Custom 27803010 HEL180830-20 - COIL EMBL HLCL 8MM 30CM HELIPAQ 18 MCIOL LOOP DTCH STRCH RS BOTH IP/OP "$1,358.30 " "$1,005.14" $0.00 "$1,086.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,008.13" "$1,008.13" $0.00 $0.00 $283.07 $0.00 $0.00 $0.00 $0.00 $679.15 "$1,075.77" "$1,086.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL18093020 SUP Custom 27803010 HEL18093020 - COIL EMBL HLCL 9MM 30CM HELIPAQ 18 MCIOL LOOP DTCH STRCH RS BOTH IP/OP "$1,358.30 " "$1,005.14" $0.00 "$1,086.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,008.13" "$1,008.13" $0.00 $0.00 $283.07 $0.00 $0.00 $0.00 $0.00 $679.15 "$1,075.77" "$1,086.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL181030-20 SUP Custom 27803010 HEL181030-20 - COIL EMBL HLCL 10MM 30CM HELIPAQ 18 MCIOL LOOP DTCH STRCH RS BOTH IP/OP "$1,358.30 " "$1,005.14" $0.00 "$1,086.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,008.13" "$1,008.13" $0.00 $0.00 $283.07 $0.00 $0.00 $0.00 $0.00 $679.15 "$1,075.77" "$1,086.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL181230-20 SUP Custom 27803010 HEL181230-20 - COIL EMBL 12MM 30CM HELIPAQ 18 MCIOL HLCL LOOP DTCH STRCH RS BOTH IP/OP "$1,429.78 " "$1,058.04" $0.00 "$1,143.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,061.18" "$1,061.18" $0.00 $0.00 $297.97 $0.00 $0.00 $0.00 $0.00 $714.89 "$1,132.39" "$1,143.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL181430-20 SUP Custom 27803010 HEL181430-20 - COIL EMBL 14MM 30CM HELIPAQ 18 MCIOL HLCL LOOP DTCH STRCH RS BOTH IP/OP "$1,429.78 " "$1,058.04" $0.00 "$1,143.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,061.18" "$1,061.18" $0.00 $0.00 $297.97 $0.00 $0.00 $0.00 $0.00 $714.89 "$1,132.39" "$1,143.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL181630-20 SUP Custom 27803010 HEL181630-20 - COIL EMBL 16MM 30CM HELIPAQ 18 MCIOL HLCL LOOP DTCH STRCH RS BOTH IP/OP "$1,268.93 " $939.01 $0.00 "$1,015.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $941.80 $941.80 $0.00 $0.00 $264.44 $0.00 $0.00 $0.00 $0.00 $634.46 "$1,004.99" "$1,015.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL181830-20 SUP Custom 27803010 HEL181830-20 - COIL EMBL 18MM 30CM HELIPAQ 18 MCIOL HLCL LOOP DTCH STRCH RS BOTH IP/OP "$1,501.28 " "$1,110.95" $0.00 "$1,201.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,114.25" "$1,114.25" $0.00 $0.00 $312.87 $0.00 $0.00 $0.00 $0.00 $750.64 "$1,189.01" "$1,201.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEL182030-20 SUP Custom 27803010 HEL182030-20 - COIL EMBL 20MM 30CM HELIPAQ 18 MCIOL HLCL LOOP DTCH STRCH RS BOTH IP/OP "$1,501.28 " "$1,110.95" $0.00 "$1,201.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,114.25" "$1,114.25" $0.00 $0.00 $312.87 $0.00 $0.00 $0.00 $0.00 $750.64 "$1,189.01" "$1,201.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HERO 1003 SUP Custom 27203010 HERO 1003 - KIT HEMODIALYSIS 16FR Y 10FR 12FR DELIVERY STYLET DILAT BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $0.00 $0.00 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HEX2.7-12 SUP HCPCS C1713 HEX2.7-12 - SCREW BN 2.7MM 12MM SS CORT TRIMED CLVCL FX SYS BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX2.7-14 SUP HCPCS C1713 HEX2.7-14 - SCREW BN 2.7MM 14MM SS CORT TRIMED CLVCL FX SYS BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-08 SUP HCPCS C1713 HEX3.2-08 - SCREW BONE 3.2MM 8MM HEXAGONAL HEAD CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-10 SUP HCPCS C1713 HEX3.2-10 - SCREW BN 3.2MM 10MM HEX CORT ANKL FX SYS BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-11 SUP HCPCS C1713 HEX3.2-11 - SCREW BONE 3.2MM 11MM HEXAGONAL HEAD CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-12 SUP HCPCS C1713 HEX3.2-12 - SCREW BN 3.2MM 12MM HEX CORT ANKL FX SYS BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-13 SUP HCPCS C1713 HEX3.2-13 - SCREW BN 3.2MM 13MM HEX CORT ANKL FX SYS BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-14 SUP HCPCS C1713 HEX3.2-14 - SCREW BN 3.2MM 14MM HEX CORT ANKL FX SYS BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-15 SUP HCPCS C1713 HEX3.2-15 - SCREW BONE 3.2MM 15MM HEXAGONAL HEAD CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-16 SUP HCPCS C1713 HEX3.2-16 - SCREW BN 3.2MM 16MM HEX CORT ANKL FX SYS BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-18 SUP HCPCS C1713 HEX3.2-18 - SCREW BN 3.2MM 18MM HEX CORT ANKL FX SYS BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-20 SUP HCPCS C1713 HEX3.2-20 - SCREW BONE 3.2MM 20MM HEXAGONAL HEAD CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-22 SUP HCPCS C1713 HEX3.2-22 - SCREW BONE 3.2MM 22MM HEXAGONAL HEAD CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-24 SUP HCPCS C1713 HEX3.2-24 - SCREW BONE 3.2MM 24MM HEXAGONAL HEAD CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-26 SUP HCPCS C1713 HEX3.2-26 - SCREW BONE 3.2MM 26MM HEXAGONAL HEAD CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-28 SUP HCPCS C1713 HEX3.2-28 - SCREW BONE 3.2MM 28MM HEXAGON CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HEX3.2-30 SUP HCPCS C1713 HEX3.2-30 - SCREW BN 3.2MM 30MM HEX CORT BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 HF0200DSSM SUP Custom 27011340 HF0200DSSM - FIBER LSR 270UM HO 1 WL STRL DISP BOTH IP/OP "$1,074.28 " $794.97 $0.00 $859.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $797.33 $797.33 $0.00 $0.00 $223.88 $0.00 $0.00 $0.00 $0.00 $537.14 $850.83 $859.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HH0710 SUP HCPCS C1781 HH0710 - MESH SRG 10X7CM GORE BIO-ASNTH REINF TISS HIATAL HRN REPR BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 HIC135 SUP HCPCS C1729 EMBOCATHETER INFUSION SEGWAY BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $339.38 $339.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 HLFDBX0270C SUP Custom 27203010 HLFDBX0270C - LASER SRG 270MH DISP BOTH IP/OP $710.67 $525.90 $0.00 $568.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.46 $527.46 $0.00 $0.00 $148.10 $0.00 $0.00 $0.00 $0.00 $355.33 $562.85 $568.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HLFDBX0400C SUP Custom 27203010 HLFDBX0400C - LASER SRG 400MH DISP BOTH IP/OP $848.67 $628.02 $0.00 $678.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $629.88 $629.88 $0.00 $0.00 $176.86 $0.00 $0.00 $0.00 $0.00 $424.33 $672.15 $678.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HLFDBX0600C SUP Custom 27011340 HLFDBX0600C - FIBER LSR 600UM STRL DUR HO DISP LTHTRP BOTH IP/OP $848.67 $628.02 $0.00 $678.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.33 $672.15 $678.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HLFDBX1000C SUP Custom 27203010 HLFDBX1000C - LASER SURGICAL 1000 MH DISPOSABLE BOTH IP/OP "$2,193.09 " "$1,622.89" $0.00 "$1,627.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,627.71" "$1,627.71" $0.00 $0.00 $457.04 $0.00 $0.00 $0.00 $0.00 $955.80 "$1,513.99" "$1,529.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HLS1007M SUP HCPCS C1894 HLS1007M - INTRODUCER SHTH 7FR 13CM 20CM SFSHTH HMSTS VLV TRAW SDPRT BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $70.59 $70.59 $0.00 $0.00 $0.00 $27.10 $96.49 $96.49 $0.00 $0.00 $27.09 $0.00 $76.90 $76.90 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 HLS10095M SUP HCPCS C1894 HLS10095M - INTRODUCER SHEATH 9.5FR 13CM 20CM HEMOSTASIS VALVE TEAR AWAY BOTH IP/OP $146.25 $108.23 $0.00 $117.00 $79.41 $79.41 $0.00 $0.00 $0.00 $30.48 $108.55 $108.55 $0.00 $0.00 $30.48 $0.00 $86.51 $86.51 $0.00 $73.13 $115.83 $117.00 $0.00 $0.00 $22.89 $0.00 $0.00 $23.28 $0.00 $0.00 $0.00 $0.00 $0.00 HLS1009M SUP HCPCS C1894 HLS1009M - INTRODUCER LEAD 13CM 9FR SFSHTH HMSTS VLV TRAW SDPRT 20CM BOTH IP/OP $650.00 $481.00 $0.00 $520.00 $352.95 $352.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.00 $514.80 $520.00 $0.00 $0.00 $101.73 $0.00 $0.00 $103.48 $0.00 $0.00 $0.00 $0.00 $0.00 HLS10105M SUP HCPCS C1894 HLS10105M - INTRODUCER SHEATH 10.5FR 13CM 20CM HEMOSTASIS VALVE TEAR BOTH IP/OP $130.00 $96.20 $0.00 $104.00 $70.59 $70.59 $0.00 $0.00 $0.00 $27.10 $96.49 $96.49 $0.00 $0.00 $27.09 $0.00 $76.90 $76.90 $0.00 $65.00 $102.96 $104.00 $0.00 $0.00 $20.35 $0.00 $0.00 $20.70 $0.00 $0.00 $0.00 $0.00 $0.00 HLS2509M SUP HCPCS C1894 HLS2509M - INTRODUCER LEAD LONG 9FR 25CM 31.5CM HEMOSTASIS VALVE TEAR BOTH IP/OP $146.00 $108.04 $0.00 $116.80 $79.28 $79.28 $0.00 $0.00 $0.00 $30.43 $108.36 $108.36 $0.00 $0.00 $30.43 $0.00 $86.36 $86.36 $0.00 $73.00 $115.63 $116.80 $0.00 $0.00 $22.85 $0.00 $0.00 $23.24 $0.00 $0.00 $0.00 $0.00 $0.00 HN1200 SUP HCPCS C1776 HN1200 - SLEEVE CENTERING 38.1IN 9MM 12.7IN IMHS CP SET SCR IM HIP BOTH IP/OP $831.25 $615.13 $0.00 $665.00 $374.06 $374.06 $0.00 $0.00 $0.00 $173.25 $616.95 $616.95 $0.00 $0.00 $173.23 $0.00 $491.68 $491.68 $0.00 $415.63 $658.35 $665.00 $0.00 $0.00 $130.09 $0.00 $0.00 $132.34 $0.00 $0.00 $0.00 $0.00 $0.00 HN1202 SUP HCPCS C1713 HN1202 - SCREW SET IMHS CENTERING SLV HIP BOTH IP/OP $533.75 $394.98 $0.00 $427.00 $240.19 $240.19 $0.00 $0.00 $0.00 $111.25 $396.15 $396.15 $0.00 $0.00 $111.23 $0.00 $315.71 $315.71 $0.00 $266.88 $422.73 $427.00 $0.00 $0.00 $83.53 $0.00 $0.00 $84.97 $0.00 $0.00 $0.00 $0.00 $0.00 HNR4.0-35-70-P-10S-0 SUP HCPCS C1725 HNR4.0-35-70-P-10S-0 - CATH ANGIO .035IN 4FR 70CM 10 SDPRT STR HFLO ATRM TIP DSGN BOTH IP/OP $46.88 $34.69 $0.00 $37.50 $25.45 $25.45 $0.00 $0.00 $0.00 $9.77 $34.79 $34.79 $0.00 $0.00 $9.77 $0.00 $27.73 $27.73 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 HOOK-L4 SUP HCPCS C1713 HOOK-L4 - PLATE BONE 4 HOLE HOOK LEFT ELBOW BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 HOOK-R6 SUP HCPCS C1713 HOOK-R6 - PLATE BONE 6 HOLE HOOK ORTHOPEDIC BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $416.85 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 "$1,183.00" "$1,183.00" $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 HP01 SUP HCPCS C1781 HP01 - PLUG SURG BIOABSORBABLE BIO-A HERN REPAIR BOTH IP/OP "$1,260.00 " $932.40 $0.00 "$1,008.00" $567.00 $567.00 $0.00 $0.00 $0.00 $262.62 $935.17 $935.17 $0.00 $0.00 $262.58 $0.00 $745.29 $745.29 $0.00 $630.00 $997.92 "$1,008.00" $0.00 $0.00 $197.19 $0.00 $0.00 $200.59 $0.00 $0.00 $0.00 $0.00 $0.00 HP-2515 SUP Custom 27203010 HP-2515 - DRIVER 2.5MM PWR TIP CANN SURG BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HP3000 SUP Custom 27203010 HP3000 - POSITIONER SRG STRFSH EVO MULTIAPPENDAGE SIL SCT CUP LOPRFL BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 $0.00 $0.00 $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HP-3016 SUP Custom 27203010 HP-3016 - DRIVER CANN PWR TIP 3MM SURG OPTN INST BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HPC-0015 SUP Custom 27203010 HPC-0015 - DRIVER 1.5MM SM HEX TIP SHFT 1.5MM SURG STRL DISP BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HPC-0025 SUP Custom 27203010 HPC-0025 - DRIVER 2.5MM QRLSE 2.5MM SURG BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HPC-0035 SUP Custom 27203010 HPC-0035 - DRIVER HEX QRLSE 3.5MM SURG BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0001-S SUP HCPCS C1713 HR-0001-S - CAP END ORTH SCR ASMBLY IM NAIL STRL PLRS BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $171.00 $171.00 $0.00 $0.00 $0.00 $79.20 $282.04 $282.04 $0.00 $0.00 $79.19 $0.00 $224.77 $224.77 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $59.47 $0.00 $0.00 $60.50 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0024-S SUP HCPCS C1713 HR-0024-S - CAP END 4MM STRL PLRS SCR ASMB BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $340.88 $340.88 $0.00 $0.00 $0.00 $157.88 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $448.06 $448.06 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $118.55 $0.00 $0.00 $120.59 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0028-S SUP HCPCS C1713 HR-0028-S - CAP END 8MM STRL PLRS SCR ASMB BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $340.88 $340.88 $0.00 $0.00 $0.00 $157.88 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $448.06 $448.06 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $118.55 $0.00 $0.00 $120.59 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0050-S SUP HCPCS C1713 HR-0050-S - CAP END PLRS SCR ASMB INS DEV BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $340.88 $340.88 $0.00 $0.00 $0.00 $157.88 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $448.06 $448.06 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $118.55 $0.00 $0.00 $120.59 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0054-S SUP HCPCS C1713 HR-0054-S - CAP END 4MM STRL PLRS SCR ASMB BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $340.88 $340.88 $0.00 $0.00 $0.00 $157.88 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $448.06 $448.06 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $118.55 $0.00 $0.00 $120.59 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0058-S SUP HCPCS C1713 HR-0058-S - CAP END 8MM STRL PLRS SCR ASMB BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $340.88 $340.88 $0.00 $0.00 $0.00 $157.88 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $448.06 $448.06 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $118.55 $0.00 $0.00 $120.59 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0105 SUP Custom 27203010 HR-0105 - BIT DRILL 2.7MM PLRS TAP BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $0.00 $0.00 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0820-S SUP HCPCS C1713 HR-0820-S - ROD ORTH 200MM 8MM PLRS PLUS HUM SHLDR TI HUM IM IMPL STRL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0822-S SUP HCPCS C1713 HR-0822-S - ROD ORTH 220MM 8MM PLRS PLUS HUM SHLDR TI HUM IM IMPL STRL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0824-S SUP HCPCS C1713 HR-0824-S - ROD ORTH 240MM 8MM PLRS PLUS HUM TI IM IMPL STRL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0826-S SUP HCPCS C1713 HR-0826-S - ROD ORTH 260MM 8MM PLRS PLUS HUM SHLDR TI HUM IM IMPL STRL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HR-0828-S SUP HCPCS C1713 HR-0828-S - ROD ORTH 280MM 8MM PLRS PLUS HUM SHLDR TI HUM IM IMPL STRL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HR-3106 SUP Custom 27203010 HR-3106 - DRILL SRG WITNESS HL CLRNC BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HR-3107 SUP Custom 27203010 HR-3107 - TAP SRG 3.5 MM SCR BOTH IP/OP $930.00 $688.20 $0.00 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.25 $690.25 $0.00 $0.00 $193.81 $0.00 $0.00 $0.00 $0.00 $465.00 $736.56 $744.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HR-4D1055-S SUP HCPCS C1713 HR-4D1055-S - ROD XTRNFX 2-4D 5.5MM 150MM STRL 10MM ANT POST BOTH IP/OP "$3,817.50 " "$2,824.95" $0.00 "$3,054.00" "$1,717.88" "$1,717.88" $0.00 $0.00 $0.00 $795.66 "$2,833.35" "$2,833.35" $0.00 $0.00 $795.57 $0.00 "$1,882.03" "$1,882.03" $0.00 "$1,908.75" "$3,023.46" "$3,054.00" $0.00 $0.00 $597.44 $0.00 $0.00 $607.75 $0.00 $0.00 $0.00 $0.00 $0.00 HRA-1055-S SUP HCPCS C1713 HRA-1055-S - ROD XTRNFX 2-4D STD 5.5MM 150MM STRL 10MM BOTH IP/OP "$5,422.50 " "$4,012.65" $0.00 "$4,338.00" "$2,440.13" "$2,440.13" $0.00 $0.00 $0.00 "$1,130.18" "$4,024.58" "$4,024.58" $0.00 $0.00 "$1,130.05" $0.00 "$2,673.29" "$2,673.29" $0.00 "$2,711.25" "$4,294.62" "$4,338.00" $0.00 $0.00 $848.62 $0.00 $0.00 $863.26 $0.00 $0.00 $0.00 $0.00 $0.00 HR-D105 SUP Custom 27203010 HR-D105 - BIT DRILL 35MM .109MM PLRS LNG TAP STRL BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HRH-0820-S SUP HCPCS C1713 HRH-0820-S - ROD XTRNFX 8MM 200MM STRL PLRS + SPCL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HRH-0822-S SUP HCPCS C1713 HRH-0822-S - ROD XTRNFX 8MM 220MM PLRS + HUM PROX BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HRH-0824-S SUP HCPCS C1713 HRH-0824-S - ROD XTRNFX 8MM 240MM PLRS + SPCL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HRH-0826-S SUP HCPCS C1713 HRH-0826-S - ROD XTRNFX 8MM 260MM STRL PLRS + SPCL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HRH-0828-S SUP HCPCS C1713 HRH-0828-S - ROD XTRNFX 8MM 280MM NS PLRS + SPCL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HR-L1115-S SUP HCPCS C1713 HR-L1115-S - NAIL 11MM 15CM HUM PLRS IM LCK TI STRL BOTH IP/OP "$4,107.50 " "$3,039.55" $0.00 "$3,286.00" "$1,848.38" "$1,848.38" $0.00 $0.00 $0.00 $856.11 "$3,048.59" "$3,048.59" $0.00 $0.00 $856.00 $0.00 "$2,025.00" "$2,025.00" $0.00 "$2,053.75" "$3,253.14" "$3,286.00" $0.00 $0.00 $642.82 $0.00 $0.00 $653.91 $0.00 $0.00 $0.00 $0.00 $0.00 HRSD105 SUP Custom 27203010 HRSD105 - BIT DRILL 2.8MM PLRS SHRT TAP STRL BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.51 $70.51 $0.00 $0.00 $19.80 $0.00 $0.00 $0.00 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HR-WC50-S SUP Custom 27203010 HR-WC50-S - WASHER XTRNFX 5MM STRL CIRC CLEATED FIB BOTH IP/OP $132.50 $98.05 $0.00 $106.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.34 $98.34 $0.00 $0.00 $27.61 $0.00 $0.00 $0.00 $0.00 $66.25 $104.94 $106.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HS007 SUP Custom 27011340 HS007 - SPRT ORTH HALO SSTRC TLSO 14 BOTH IP/OP "$1,860.55 " "$1,376.81" $0.00 "$1,488.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,380.90" "$1,380.90" $0.00 $0.00 $387.74 $0.00 $0.00 $0.00 $0.00 $930.28 "$1,473.56" "$1,488.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HS765-010 SUP HCPCS C1713 SPACER MDI OPTHLR HLD CHMBR HNDHLD BOTH IP/OP $13.30 $9.84 $0.00 $10.64 $5.99 $5.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.65 $10.53 $10.64 $0.00 $0.00 $2.08 $0.00 $0.00 $2.12 $0.00 $0.00 $0.00 $0.00 $0.00 HS80010-010 SUP HCPCS C1713 SPACER MDI OPTCH ADV VLV HLD CHMBR HNDHLD RPD BRTHG ALRM WO BOTH IP/OP $8.55 $6.33 $0.00 $6.84 $3.85 $3.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.28 $6.77 $6.84 $0.00 $0.00 $1.34 $0.00 $0.00 $1.36 $0.00 $0.00 $0.00 $0.00 $0.00 HSK-3038 SUP Custom 27203010 HSK-3038 - SYSTEM PROX SL 3.8MM HRTSTR III DLV DEV LDR AOR CTR BOTH IP/OP "$1,650.00 " "$1,221.00" $0.00 "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.00 "$1,306.80" "$1,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT036 SUP Custom 27011340 HT036 - HALTER TRC LG HLCRWN VST XTRNFXTR ADLT HDNK BOTH IP/OP "$1,492.50 " "$1,104.45" $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,107.73" "$1,107.73" $0.00 $0.00 $311.04 $0.00 $0.00 $0.00 $0.00 $746.25 "$1,182.06" "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT036HI SUP Custom 27011340 HT036HI - SET HLCRWN PIN LG SKL TRC BOTH IP/OP "$1,492.50 " "$1,104.45" $0.00 "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,107.73" "$1,107.73" $0.00 $0.00 $311.04 $0.00 $0.00 $0.00 $0.00 $746.25 "$1,182.06" "$1,194.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT064050A SUP HCPCS C1768 HT064050A - GRAFT VASCULAR THIN WALL 6MM 50CM 40CM REMOVABLE RING BOTH IP/OP "$4,527.50 " "$3,350.35" $0.00 "$3,622.00" "$2,037.38" "$2,037.38" $0.00 $0.00 $0.00 $943.64 "$3,360.31" "$3,360.31" $0.00 $0.00 $943.53 $0.00 "$2,232.06" "$2,232.06" $0.00 "$2,263.75" "$3,585.78" "$3,622.00" $0.00 $0.00 $708.55 $0.00 $0.00 $720.78 $0.00 $0.00 $0.00 $0.00 $0.00 HT067090A SUP HCPCS C1768 HT067090A - GRAFT VASCULAR THIN WALL 6MM 90CM 70CM REMOVABLE RING BOTH IP/OP "$7,437.50 " "$5,503.75" $0.00 "$5,950.00" "$3,346.88" "$3,346.88" $0.00 $0.00 $0.00 "$1,550.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,549.98" $0.00 "$3,666.69" "$3,666.69" $0.00 "$3,718.75" "$5,890.50" "$5,950.00" $0.00 $0.00 "$1,163.97" $0.00 $0.00 "$1,184.05" $0.00 $0.00 $0.00 $0.00 $0.00 HT084050A SUP HCPCS C1768 HT084050A - GRAFT VASCULAR THIN WALL 8MM 50CM 40CM REMOVABLE RING BOTH IP/OP "$4,527.50 " "$3,350.35" $0.00 "$3,622.00" "$2,037.38" "$2,037.38" $0.00 $0.00 $0.00 $943.64 "$3,360.31" "$3,360.31" $0.00 $0.00 $943.53 $0.00 "$2,232.06" "$2,232.06" $0.00 "$2,263.75" "$3,585.78" "$3,622.00" $0.00 $0.00 $708.55 $0.00 $0.00 $720.78 $0.00 $0.00 $0.00 $0.00 $0.00 HT087090A SUP HCPCS C1768 HT087090A - GRAFT VASCULAR THINWALL 8MM 90CM 70CM REMOVABLE RING STRETCH BOTH IP/OP "$7,437.50 " "$5,503.75" $0.00 "$5,950.00" "$3,346.88" "$3,346.88" $0.00 $0.00 $0.00 "$1,550.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,549.98" $0.00 "$3,666.69" "$3,666.69" $0.00 "$3,718.75" "$5,890.50" "$5,950.00" $0.00 $0.00 "$1,163.97" $0.00 $0.00 "$1,184.05" $0.00 $0.00 $0.00 $0.00 $0.00 HT-0915 SUP Custom 27203010 HT-0915 - DRIVER SRG 1.5MM HEX BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $0.00 $0.00 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT-1120 SUP Custom 27203010 HT-1120 - DRIVER SRG 2MM HEX BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $0.00 $0.00 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT-1725 SUP Custom 27203010 HT-1725 - DRIVER SRG 2.5MM HEX BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $0.00 $0.00 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT-2502 SUP Custom 27203010 HT-2502 - TIP SCRDRVR 6IN 2.5MM QRLSE SLD BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT-3010 SUP HCPCS C1713 HT-3010 - SCREW BN ACUTRAC DRVR CNN TIP BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $211.50 $211.50 $0.00 $0.00 $0.00 $97.96 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $278.01 $278.01 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $73.56 $0.00 $0.00 $74.82 $0.00 $0.00 $0.00 $0.00 $0.00 HT-3012 SUP Custom 27203010 HT-3012 - TIP SCRDRVR 3MM QRLSE SLD HEX BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT-4000 SUP Custom 27203010 HT-4000 - DRIVER SRG 4MM CNN BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.82 $361.82 $0.00 $0.00 $101.60 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HT-4001 SUP Custom 27203010 HT-4001 - TIP SCRDRVR 4MM SLD HEX BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HW-0034 SUP HCPCS C1713 HW-0034 - SCREW BN .25IN 8-32IN DRL HNDL SET BOTH IP/OP $2.50 $1.85 $0.00 $2.00 $1.13 $1.13 $0.00 $0.00 $0.00 $0.52 $1.86 $1.86 $0.00 $0.00 $0.52 $0.00 $1.48 $1.48 $0.00 $1.25 $1.98 $2.00 $0.00 $0.00 $0.39 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 I20 SUP Custom 27203010 SENSOR INF OXSNR 2 OXM ADH BOTH IP/OP $30.80 $22.79 $0.00 $24.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.40 $24.39 $24.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 I20-13/C70F SUP Custom 27803010 I20-13/C70F - GRAFT STNT STRG 20-13MM 17FR 70MM AFX ACTIVESEAL STRATA SLF BOTH IP/OP "$8,237.50 " "$6,095.75" $0.00 "$6,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,716.70" $0.00 $0.00 $0.00 $0.00 "$4,118.75" "$6,524.10" "$6,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 I20-13/C88F SUP Custom 27803010 I20-13/C88F - GRAFT STNT STRG 20-13MM 17FR 88MM AFX ACTIVESEAL STRATA SLF BOTH IP/OP "$8,187.50 " "$6,058.75" $0.00 "$6,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,706.28" $0.00 $0.00 $0.00 $0.00 "$4,093.75" "$6,484.50" "$6,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 I20-13/C88F SA SUP Custom 27803010 I20-13/C88F SA - GRAFT STNT 20-13MM 88MM STRL LF AFX STRATA ILC LMB AAA BOTH IP/OP "$8,187.50 " "$6,058.75" $0.00 "$6,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,706.28" $0.00 $0.00 $0.00 $0.00 "$4,093.75" "$6,484.50" "$6,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 I20-20/C55F SUP Custom 27803010 I20-20/C55F - GRAFT STNT STRG 20MM 17FR 55MM AFX ACTIVESEAL STRATA SLF BOTH IP/OP "$6,700.00 " "$4,958.00" $0.00 "$5,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,396.28" $0.00 $0.00 $0.00 $0.00 "$3,350.00" "$5,306.40" "$5,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IAB05830-LWS SUP HCPCS C1714 IAB05830-LWS - CATH IAB .025IN 8FR 25.3IN 6IN GWIRE NYL PU CARDIOTHANE 2 BOTH IP/OP "$3,451.70 " "$2,554.26" $0.00 "$2,761.36" "$1,874.27" "$1,874.27" $0.00 $0.00 $0.00 $0.00 "$2,561.85" "$2,561.85" $0.00 $0.00 $719.33 $0.00 $0.00 $0.00 $0.00 "$1,725.85" "$2,733.75" "$2,761.36" $0.00 $0.00 $540.19 $0.00 $0.00 $549.51 $0.00 $0.00 $0.00 $0.00 $0.00 IAB-05830-LWS SUP Custom 27203010 CATHETER IAB 8FR FIBEROPTIX 30ML LF BOTH IP/OP "$2,560.00 " "$1,894.40" $0.00 "$2,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,280.00" "$2,027.52" "$2,048.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IAB-05840-LWS SUP HCPCS C1714 IAB-05840-LWS - CATH IAB .025IN 8FR 27.3IN 6IN GWIRE NYL PU CARDIOTHANE 2 BOTH IP/OP "$3,451.70 " "$2,554.26" $0.00 "$2,761.36" "$1,874.27" "$1,874.27" $0.00 $0.00 $0.00 $0.00 "$2,561.85" "$2,561.85" $0.00 $0.00 $719.33 $0.00 $0.00 $0.00 $0.00 "$1,725.85" "$2,733.75" "$2,761.36" $0.00 $0.00 $540.19 $0.00 $0.00 $549.51 $0.00 $0.00 $0.00 $0.00 $0.00 IAB-06830-LWS SUP HCPCS C1725 CATHETER IAB 7.5FR FIBEROPTIX FLXB 30ML LF BOTH IP/OP "$2,087.50 " "$1,544.75" $0.00 "$1,670.00" "$1,133.51" "$1,133.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,043.75" "$1,653.30" "$1,670.00" $0.00 $0.00 $326.69 $0.00 $0.00 $332.33 $0.00 $0.00 $0.00 $0.00 $0.00 IAS5-120LP SUP Custom 27203010 IAS5-120LP - PORT ACC 5MM 120MM AIRSEAL 2 WL CNN LOPRFL OBT BLDLS OPTC BOTH IP/OP $291.67 $215.84 $0.00 $233.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.48 $216.48 $0.00 $0.00 $60.78 $0.00 $0.00 $0.00 $0.00 $145.83 $231.00 $233.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IBI-85641 SUP Custom 27203010 IBI-85641 - CABLE CATH 8FT STRL LF REUSE BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IBI-85931 SUP Custom 27203010 IBI-85931 - CABLE CATH 150CM INQ 24 PIN CNCT DX BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IBI-87008 SUP HCPCS C1731 IBI-87008 - CATHETER EP 4MM SPC 7FR 20MM 110CM INQ AFOCUS II 20 ELTRD MP BOTH IP/OP "$3,800.00 " "$2,812.00" $0.00 "$3,040.00" "$2,063.40" "$2,063.40" $0.00 $0.00 $0.00 $792.02 "$2,820.36" "$2,820.36" $0.00 $0.00 $791.92 $0.00 "$2,247.70" "$2,247.70" $0.00 "$1,900.00" "$3,009.60" "$3,040.00" $0.00 $0.00 $594.70 $0.00 $0.00 $604.96 $0.00 $0.00 $0.00 $0.00 $0.00 ICV1102 SUP HCPCS C1785 ICV1102 - PACEMAKER CRD REPLY 2 CHMBR BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 ICV1102 SYSTEM SUP HCPCS C1785 ICV1102 SYSTEM - REPLY DR V2 SYSTEM BOTH IP/OP "$12,500.00 " "$9,250.00" $0.00 "$10,000.00" "$5,625.00" "$5,625.00" $0.00 $0.00 $0.00 "$2,605.31" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,605.00" $0.00 "$6,162.50" "$6,162.50" $0.00 "$6,250.00" "$9,900.00" "$10,000.00" $0.00 $0.00 "$1,956.25" $0.00 $0.00 "$1,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 ICV1116 SUP HCPCS C1786 ICV1116 - PACEMAKER CRD ESPRT DR BOTH IP/OP "$9,125.00 " "$6,752.50" $0.00 "$7,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,901.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,901.65" $0.00 "$4,498.63" "$4,498.63" $0.00 "$4,562.50" "$7,227.00" "$7,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ICV1116 SYSTEM SUP HCPCS C1785 ICV1116 SYSTEM - ESPRIT DR SYSTEM BOTH IP/OP "$11,610.00 " "$8,591.40" $0.00 "$9,288.00" "$5,224.50" "$5,224.50" $0.00 $0.00 $0.00 "$2,419.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,419.52" $0.00 "$5,723.73" "$5,723.73" $0.00 "$5,805.00" "$9,195.12" "$9,288.00" $0.00 $0.00 "$1,816.97" $0.00 $0.00 "$1,848.31" $0.00 $0.00 $0.00 $0.00 $0.00 ICV1122 SUP HCPCS C1786 ICV1122 - PACEMAKER CRD REPLY 1 CHMBR BOTH IP/OP "$8,250.00 " "$6,105.00" $0.00 "$6,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,719.51" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,719.30" $0.00 "$4,067.25" "$4,067.25" $0.00 "$4,125.00" "$6,534.00" "$6,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ICV1122 SYSTEM SUP HCPCS C1786 ICV1122 SYSTEM - REPLY SR V2 SYSTEM BOTH IP/OP "$9,500.00 " "$7,030.00" $0.00 "$7,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,980.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,979.80" $0.00 "$4,683.50" "$4,683.50" $0.00 "$4,750.00" "$7,524.00" "$7,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ICV1127 SUP HCPCS C1786 ICV1127 - PACEMAKER CRD ESPRT SR BOTH IP/OP "$6,962.50 " "$5,152.25" $0.00 "$5,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,451.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,450.99" $0.00 "$3,432.51" "$3,432.51" $0.00 "$3,481.25" "$5,514.30" "$5,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ICV1127 SYSTEM SUP HCPCS C1786 ICV1127 SYSTEM - ESPRIT SR SYSTEM BOTH IP/OP "$8,205.00 " "$6,071.70" $0.00 "$6,564.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,710.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,709.92" $0.00 "$4,045.07" "$4,045.07" $0.00 "$4,102.50" "$6,498.36" "$6,564.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ICV1179 SUP HCPCS C1882 ICV1179 - DEFIBRILLATOR CRD PARADYM CRT ICD BOTH IP/OP "$44,412.50 " "$32,865.25" $0.00 "$35,530.00" "$19,985.63" "$19,985.63" $0.00 $0.00 $0.00 "$9,256.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,255.57" $0.00 "$21,895.36" "$21,895.36" $0.00 "$22,206.25" "$35,174.70" "$35,530.00" $0.00 $0.00 "$6,950.56" $0.00 $0.00 "$7,070.47" $0.00 $0.00 $0.00 $0.00 $0.00 ICV1179 SYSTEM SUP HCPCS C1882 ICV1179 SYSTEM - PARADYM CRT-D 8750 SYSTEM BOTH IP/OP "$58,187.50 " "$43,058.75" $0.00 "$46,550.00" "$26,184.38" "$26,184.38" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$12,126.28" $0.00 "$28,686.44" "$28,686.44" $0.00 "$29,093.75" "$46,084.50" "$46,550.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 ICV1199 SUP HCPCS C1722 ICV1199 - DEFIBRILLATOR CRD PARADYM VR ICD BOTH IP/OP "$36,575.00 " "$27,065.50" $0.00 "$29,260.00" "$16,458.75" "$16,458.75" $0.00 $0.00 $0.00 "$7,623.14" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,622.23" $0.00 "$18,031.48" "$18,031.48" $0.00 "$18,287.50" "$28,967.40" "$29,260.00" $0.00 $0.00 "$5,723.99" $0.00 $0.00 "$5,822.74" $0.00 $0.00 $0.00 $0.00 $0.00 ICV1200 SUP HCPCS C1721 ICV1200 - DEFIBRILLATOR CRD PARADYM DR ICD BOTH IP/OP "$42,512.50 " "$31,459.25" $0.00 "$34,010.00" "$19,130.63" "$19,130.63" $0.00 $0.00 $0.00 "$8,860.67" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,859.61" $0.00 "$20,958.66" "$20,958.66" $0.00 "$21,256.25" "$33,669.90" "$34,010.00" $0.00 $0.00 "$6,653.21" $0.00 $0.00 "$6,767.99" $0.00 $0.00 $0.00 $0.00 $0.00 ICV1258 SUP HCPCS C1785 ICV1258 - REPLY DR BOTH IP/OP "$9,125.00 " "$6,752.50" $0.00 "$7,300.00" "$4,106.25" "$4,106.25" $0.00 $0.00 $0.00 "$1,901.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,901.65" $0.00 "$4,498.63" "$4,498.63" $0.00 "$4,562.50" "$7,227.00" "$7,300.00" $0.00 $0.00 "$1,428.06" $0.00 $0.00 "$1,452.70" $0.00 $0.00 $0.00 $0.00 $0.00 ICV1258 SYSTEM SUP HCPCS C1785 ICV1258 SYSTEM - REPLY DR SYSTEM BOTH IP/OP "$11,610.00 " "$8,591.40" $0.00 "$9,288.00" "$5,224.50" "$5,224.50" $0.00 $0.00 $0.00 "$2,419.81" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,419.52" $0.00 "$5,723.73" "$5,723.73" $0.00 "$5,805.00" "$9,195.12" "$9,288.00" $0.00 $0.00 "$1,816.97" $0.00 $0.00 "$1,848.31" $0.00 $0.00 $0.00 $0.00 $0.00 ID-1-5 SUP Custom 27203010 ID-1-5 - ACTU PNEUM LRS AXIUM 3D DTCH HLCL BOTH IP/OP $57.75 $42.74 $0.00 $107.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.86 $42.86 $0.00 $0.00 $12.04 $0.00 $0.00 $0.00 $0.00 $67.25 $106.52 $107.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ID3305 SUP Custom 27803010 ID3305 - GRAFT SOFT TISSUE 3X3IN PATCH RESORB SUTURABLE DURAGEN BOTH IP/OP "$2,068.76 " "$1,530.88" $0.00 "$1,804.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,535.43" "$1,535.43" $0.00 $0.00 $431.13 $0.00 $0.00 $0.00 $0.00 "$1,127.85" "$1,786.51" "$1,804.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IJ27U SUP HCPCS C1898 IJ27U - LEAD PACING 58CM ACTIVE FIX ISOLINE BOTH IP/OP "$10,000.00 " "$7,400.00" $0.00 "$8,000.00" "$4,500.00" "$4,500.00" $0.00 $0.00 $0.00 "$2,084.25" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,084.00" $0.00 "$4,930.00" "$4,930.00" $0.00 "$5,000.00" "$7,920.00" "$8,000.00" $0.00 $0.00 "$1,565.00" $0.00 $0.00 "$1,592.00" $0.00 $0.00 $0.00 $0.00 $0.00 IM3ST SUP Custom 27803010 IM3ST - BRAIN TISSUE MONITERING KIT BOTH IP/OP "$3,115.00 " "$2,305.10" $0.00 "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,311.95" "$2,311.95" $0.00 $0.00 $649.17 $0.00 $0.00 $0.00 $0.00 "$1,557.50" "$2,467.08" "$2,492.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 INS5010 SUP HCPCS C1729 INS5010 - CATHETER DRN 1.5MM .7MM 80CM STRL LF HRMTC TUO CLS TIP LL BOTH IP/OP $635.93 $470.59 $0.00 $471.98 $308.45 $308.45 $0.00 $0.00 $0.00 $132.54 $471.98 $471.98 $0.00 $0.00 $132.53 $0.00 $376.15 $376.15 $0.00 $284.03 $449.90 $454.44 $0.00 $0.00 $88.90 $0.00 $0.00 $90.43 $0.00 $0.00 $0.00 $0.00 $0.00 INS8401 SUP Custom 27803010 INS8401 - SYSTEM DRN 35CM 700ML BLU STRL LF BE2 MNTR TRNDCR ATCH VNTRC BOTH IP/OP $763.85 $565.25 $0.00 $784.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $566.93 $566.93 $0.00 $0.00 $159.19 $0.00 $0.00 $0.00 $0.00 $490.00 $776.16 $784.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 INS-8420 SUP Custom 27803010 INS-8420 - KIT XTRN DRN 1.9MM VNTRC BOTH IP/OP $361.25 $267.33 $0.00 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.63 $286.11 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 INS8700 SUP Custom 27011340 INS8700 - BAG XTRN DRN 700ML EDS 3 CSF CLT BOTH IP/OP $824.38 $610.04 $0.00 $630.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $611.85 $611.85 $0.00 $0.00 $171.80 $0.00 $0.00 $0.00 $0.00 $393.75 $623.70 $630.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 INSHITHRZN SUP Custom 27803010 INSHITHRZN - KIT CRNTMY 25GA 5/8IN STRL RZR NDL DRP BOTH IP/OP $700.60 $518.44 $0.00 $560.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.30 $554.88 $560.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 INT-105-19 SUP HCPCS C1894 INT-105-19 - INTRODUCER SHTH 16FR 15CM PTFE BOTH IP/OP $52.50 $38.85 $0.00 $42.00 $28.51 $28.51 $0.00 $0.00 $0.00 $10.94 $38.97 $38.97 $0.00 $0.00 $10.94 $0.00 $31.05 $31.05 $0.00 $26.25 $41.58 $42.00 $0.00 $0.00 $8.22 $0.00 $0.00 $8.36 $0.00 $0.00 $0.00 $0.00 $0.00 INT-105-45 SUP HCPCS C1894 INT-105-45 - INTRODUCER TEAR AWAY 120F X 30CM BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $26.05 $92.78 $92.78 $0.00 $0.00 $26.05 $0.00 $73.94 $73.94 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 INT22508UX SUP HCPCS C1876 STENT METAL BARE INT22508UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT22512UX SUP HCPCS C1876 INT22512UX - SYSTEM COR STNT 2.25MM 12MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT22514UX SUP HCPCS C1876 STENT METAL BARE INT22514UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT22518UX SUP HCPCS C1876 STENT METAL BARE INT22518UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT22522UX SUP HCPCS C1874 INT22522UX - SYSTEM COR STNT 2.25MM 22MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT22526UX SUP HCPCS C1874 INT22526UX - SYSTEM COR STNT 2.25MM 26MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 INT25008UX SUP HCPCS C1877 INT25008UX - SYSTEM COR STNT 2.5MM 8MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT25012UX SUP HCPCS C1874 INT25012UX - SYSTEM COR STNT 2.5MM 12MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT25014UX SUP HCPCS C1874 INT25014UX - SYSTEM COR STNT 2.5MM 14MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT25018UX SUP HCPCS C1876 STENT METAL BARE INT25018UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT25022UX SUP HCPCS C1874 INT25022UX - SYSTEM COR STNT 2.5MM 22MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 INT25026UX SUP HCPCS C1874 INT25026UX - SYSTEM COR STNT 2.5MM 26MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT27508UX SUP HCPCS C1874 INT27508UX - SYSTEM COR STNT 2.75MM 8MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT27512UX SUP HCPCS C1874 INT27512UX - SYSTEM COR STNT 2.75MM 12MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT27514UX SUP HCPCS C1874 INT27514UX - SYSTEM COR STNT 2.75MM 14MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT27518UX SUP HCPCS C1874 INT27518UX - SYSTEM COR STNT 2.75MM 18MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 INT27526UX SUP HCPCS C1876 INT27526UX - STENT CORON 2.75MM 26MM 1 STRN RAPEX SINUSOID OPTM BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT30009UX SUP HCPCS C1876 INT30009UX - SYSTEM COR STNT 3MM 9MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT30012UX SUP HCPCS C1874 INT30012UX - SYSTEM COR STNT 3MM 12MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT30018UX SUP HCPCS C1874 INT30018UX - SYSTEM COR STNT 3MM 18MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT30022UX SUP HCPCS C1874 INT30022UX - SYSTEM COR STNT 3MM 22MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT30026UX SUP HCPCS C1874 INT30026UX - SYSTEM COR STNT 3MM 26MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $338.69 "$1,206.08" "$1,206.08" $0.00 $0.00 $338.65 $0.00 $961.19 $961.19 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 INT30030UX SUP HCPCS C1876 STENT METAL BARE INT30030UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT35009UX SUP HCPCS C1876 STENT METAL BARE INT35009UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT35012UX SUP HCPCS C1876 STENT METAL BARE INT35012UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT35015UX SUP HCPCS C1876 STENT METAL BARE INT35015UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT35018UX SUP HCPCS C1876 STENT METAL BARE INT35018UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT35022UX SUP HCPCS C1876 STENT METAL BARE INT35022UX BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $900.00 $900.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $313.00 $0.00 $0.00 $318.40 $0.00 $0.00 $0.00 $0.00 $0.00 INT35026UX SUP HCPCS C1874 INT35026UX - SYSTEM COR STNT 3.5MM 26MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT35030UX SUP HCPCS C1874 INT35030UX - SYSTEM COR STNT 3.5MM 30MM INTGR MICROTRAC RX 1 STRN INTGR BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT40009UX SUP HCPCS C1874 INT40009UX - SYSTEM COR STNT 4MM 9MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT40012UX SUP HCPCS C1876 INT40012UX - SYSTEM COR STNT 4MM 12MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT40015UX SUP HCPCS C1874 INT40015UX - SYSTEM COR STNT 4MM 15MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT40018UX SUP HCPCS C1874 INT40018UX - SYSTEM COR STNT 4MM 18MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT40022UX SUP HCPCS C1874 INT40022UX - SYSTEM COR STNT 4MM 22MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT40026UX SUP HCPCS C1874 INT40026UX - SYSTEM COR STNT 4MM 26MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 INT40030UX SUP HCPCS C1874 INT40030UX - SYSTEM COR STNT 4MM 30MM INTGR MICROTRAC RX 1 STRN INTGR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $787.50 $787.50 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 IPC-5000E SUP Custom 27203010 IPC-5000E - CATHETER PRESSURE 3.5MM 5MM 82CM 2CM SENSOR TIP EXTERNAL BOTH IP/OP $56.88 $42.09 $0.00 $46.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.21 $42.21 $0.00 $0.00 $11.85 $0.00 $0.00 $0.00 $0.00 $28.86 $45.72 $46.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRC115 SUP Custom 27203010 IRC115 - CONSOLE LEGEND EHS IRRIGATION BOTH IP/OP "$4,710.00 " "$3,485.40" $0.00 "$3,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,495.76" "$3,495.76" $0.00 $0.00 $981.56 $0.00 $0.00 $0.00 $0.00 "$2,355.00" "$3,730.32" "$3,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRC230 SUP Custom 27203010 IRC230 - CONSOLE LEGEND IRRIGATION EHS EU BOTH IP/OP "$4,710.00 " "$3,485.40" $0.00 "$3,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,495.76" "$3,495.76" $0.00 $0.00 $981.56 $0.00 $0.00 $0.00 $0.00 "$2,355.00" "$3,730.32" "$3,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRC400 SUP Custom 27203010 IRC400 - CABLE SIGNAL IRRIGATION SYSTEM BOTH IP/OP $254.00 $187.96 $0.00 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.52 $188.52 $0.00 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $127.00 $201.17 $203.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRC500 SUP Custom 27203010 IRC500 - IV POLE IRC500 EHS IRRIGATION SYSTEM BOTH IP/OP $218.00 $161.32 $0.00 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.80 $161.80 $0.00 $0.00 $45.43 $0.00 $0.00 $0.00 $0.00 $109.00 $172.66 $174.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRD200 SUP Custom 27203010 IRD200 - DISPOSABLE IRD200 IRRIGATION CONTROL BOTH IP/OP $162.00 $119.88 $0.00 $129.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.24 $120.24 $0.00 $0.00 $33.76 $0.00 $0.00 $0.00 $0.00 $81.00 $128.30 $129.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRD250 SUP Custom 27203010 IRD250 - DISPOSABLE IRD250 IRRIGATION TUBING SET BOTH IP/OP $200.00 $148.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.44 $148.44 $0.00 $0.00 $41.68 $0.00 $0.00 $0.00 $0.00 $100.00 $158.40 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRD300 SUP Custom 27203010 IRD300 - TUBING IRRIGATION MIDAS REX LEGEND EHS DISPOSABLE BOTH IP/OP $196.40 $145.34 $0.00 $157.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.77 $145.77 $0.00 $0.00 $40.93 $0.00 $0.00 $0.00 $0.00 $98.20 $155.55 $157.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IRD350 SUP Custom 27203010 IRD350 - TUBING IRRIGATION BURR TRANSNASAL BOTH IP/OP $322.00 $238.28 $0.00 $257.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.99 $238.99 $0.00 $0.00 $67.10 $0.00 $0.00 $0.00 $0.00 $161.00 $255.02 $257.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 IST2 SUP Custom 27203010 "IST2 - INDIGO SYSTEM, ASPIRATION TUBING" BOTH IP/OP $912.50 $675.25 $0.00 $730.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $677.26 $677.26 $0.00 $0.00 $190.17 $0.00 $0.00 $0.00 $0.00 $456.25 $722.70 $730.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J3053-20 SUP Custom 27203010 INDICATOR ANAER GSPK DISP BOTH IP/OP $90.98 $67.33 $0.00 $72.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.49 $72.06 $72.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J3053-21 SUP Custom 27203010 INDICATOR ANAER DRY STRP GSPK BOTH IP/OP $107.10 $79.25 $0.00 $85.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.55 $84.82 $85.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J408G SUP Custom 27203010 J408G - SUTURE VCL 8-0 5-130-4 9IN BRAID COAT VIOL ABS BOTH IP/OP $48.93 $36.21 $0.00 $39.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.32 $36.32 $0.00 $0.00 $10.20 $0.00 $0.00 $0.00 $0.00 $24.47 $38.75 $39.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J494H SUP Custom 27203010 J494H - SUTURE ABSORBABLE 4-0 P-3 18IN BRAID COATED VICRYL MULTIPASS BOTH IP/OP $411.38 $304.42 $0.00 $334.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.32 $305.32 $0.00 $0.00 $85.73 $0.00 $0.00 $0.00 $0.00 $208.77 $330.70 $334.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J546G SUP Custom 27203010 J546G - SUTURE ABS 7-0 TG140-8 18IN VIOL VC MCRPT 2 ARM BRD COAT BOTH IP/OP $35.56 $26.31 $0.00 $28.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.39 $26.39 $0.00 $0.00 $7.41 $0.00 $0.00 $0.00 $0.00 $18.05 $28.58 $28.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J548G SUP Custom 27203010 J548G - SUTURE ABSORBABLE 8-0 TG140-8 12IN 2 ARM BRAID COATED VICRYL BOTH IP/OP $36.05 $26.68 $0.00 $29.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.76 $26.76 $0.00 $0.00 $7.51 $0.00 $0.00 $0.00 $0.00 $18.30 $28.98 $29.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J555G SUP Custom 27203010 J555G - SUTURE ABS 6-0 S-29 18IN VIOL VC SBRLC 2 ARM BRD COAT BOTH IP/OP $37.20 $27.53 $0.00 $30.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.61 $27.61 $0.00 $0.00 $7.75 $0.00 $0.00 $0.00 $0.00 $18.88 $29.91 $30.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J570G SUP Custom 27203010 J570G - SUTURE ABSORBABLE 6-0 S-14 18IN 2 ARM BRAID COATED VICRYL BOTH IP/OP $37.29 $27.59 $0.00 $30.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.68 $27.68 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $18.92 $29.98 $30.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J6054-0610 SUP HCPCS C1776 J6054-0610 - SYSTEM THR SCRFT+ 6-10 BOTH IP/OP "$7,204.00 " "$5,330.96" $0.00 "$5,763.20" "$3,241.80" "$3,241.80" $0.00 $0.00 $0.00 "$1,501.49" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,501.31" $0.00 "$3,551.57" "$3,551.57" $0.00 "$3,602.00" "$5,705.57" "$5,763.20" $0.00 $0.00 "$1,127.43" $0.00 $0.00 "$1,146.88" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-0711 SUP HCPCS C1776 J6054-0711 - STEM FEM 130MM 11MM PRIM SECFIT PLUS HYDRXAPT 7 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-0713 SUP HCPCS C1776 J6054-0713 - STEM FEM 130MM 13MM PRIM SECFIT PLUS HYDRXAPT 7 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-0812 SUP HCPCS C1776 J6054-0812 - STEM FEM 130MM 12MM PRIM SECFIT PLUS HYDRXAPT 8 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-0814 SUP HCPCS C1776 J6054-0814 - STEM FEM 130MM 14MM PRIM SECFIT PLUS HYDRXAPT 8 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-0913 SUP HCPCS C1776 J6054-0913 - STEM FEM 130MM 13MM PRIM SECFIT PLUS HYDRXAPT 9 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-0915 SUP HCPCS C1776 J6054-0915 - STEM FEM 130MM 15MM PRIM SECFIT PLUS HYDRXAPT 9 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-1014 SUP HCPCS C1776 J6054-1014 - STEM FEM 130MM 14MM PRIM SECFIT PLUS HYDRXAPT 10 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-1016 SUP HCPCS C1776 J6054-1016 - STEM FEM 130MM 16MM PRIM SECFIT PLUS HYDRXAPT 10 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-1115 SUP HCPCS C1776 J6054-1115 - STEM FEM 170MM 15MM PRIM SECFIT PLUS HYDRXAPT 11 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-1117 SUP HCPCS C1776 J6054-1117 - STEM FEM 170MM 17MM PRIM SECFIT PLUS HYDRXAPT 11 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J6054-1216 SUP HCPCS C1776 J6054-1216 - STEM FEM 170MM 16MM PRIM SECFIT PLUS HYDRXAPT 12 HIP BOTH IP/OP "$6,865.00 " "$5,080.10" $0.00 "$5,492.00" "$3,089.25" "$3,089.25" $0.00 $0.00 $0.00 "$1,430.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,430.67" $0.00 "$3,384.45" "$3,384.45" $0.00 "$3,432.50" "$5,437.08" "$5,492.00" $0.00 $0.00 "$1,074.37" $0.00 $0.00 "$1,092.91" $0.00 $0.00 $0.00 $0.00 $0.00 J634H SUP Custom 27203010 J634H - SUTURE ABS VIOL 18IN VCL 3-0 TIE BRAID COAT BOTH IP/OP $5.29 $3.91 $0.00 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.93 $3.93 $0.00 $0.00 $1.10 $0.00 $0.00 $0.00 $0.00 $2.65 $4.19 $4.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J671G SUP Custom 27203010 J671G - SUTURE ABSORBABLE 5-0 S-14 18IN 2 ARM BRAID COATED VICRYL BOTH IP/OP $31.41 $23.24 $0.00 $25.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.31 $23.31 $0.00 $0.00 $6.55 $0.00 $0.00 $0.00 $0.00 $15.71 $24.88 $25.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J726D SUP Custom 27203010 J726D - SUTURE VCL 2-0 CT2 8-18IN CR BRAID COAT VIOL ABS BOTH IP/OP $47.20 $34.93 $0.00 $37.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.03 $35.03 $0.00 $0.00 $9.84 $0.00 $0.00 $0.00 $0.00 $23.60 $37.38 $37.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J727D SUP Custom 27203010 J727D - SUTURE ABSORBABLE 0 CT-2 8-18IN TAPER POINT BRAID 8 STRAND BOTH IP/OP $29.89 $22.12 $0.00 $24.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.19 $22.19 $0.00 $0.00 $6.23 $0.00 $0.00 $0.00 $0.00 $15.17 $24.03 $24.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J739D SUP Custom 27203010 J739D - SUTURE ABSORBABLE 2-0 CT-1 18IN CONTROL RELEASE BRAIDED 8 BOTH IP/OP $29.86 $22.10 $0.00 $24.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.16 $22.16 $0.00 $0.00 $6.22 $0.00 $0.00 $0.00 $0.00 $15.15 $24.00 $24.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J740D SUP Custom 27203010 J740D - SUTURE ABSORBABLE 0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND BOTH IP/OP $29.96 $22.17 $0.00 $24.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.24 $22.24 $0.00 $0.00 $6.24 $0.00 $0.00 $0.00 $0.00 $15.20 $24.08 $24.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J741D SUP Custom 27203010 J741D - SUTURE ABSORBABLE 1 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND BOTH IP/OP $361.24 $267.32 $0.00 $288.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.11 $268.11 $0.00 $0.00 $75.28 $0.00 $0.00 $0.00 $0.00 $180.62 $286.10 $288.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J754T CR SUP Custom 27203010 J754T CR - NEEDLE 0 VICRYL 18 OS-6 BOTH IP/OP $465.23 $344.27 $0.00 $372.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.29 $345.29 $0.00 $0.00 $96.95 $0.00 $0.00 $0.00 $0.00 $232.61 $368.46 $372.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J761D SUP Custom 27203010 J761D - SUTURE ABSORBABLE 3-0 CP-2 18IN CONTROL RELEASE BRAID 8 BOTH IP/OP $37.30 $27.60 $0.00 $30.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.69 $27.69 $0.00 $0.00 $7.77 $0.00 $0.00 $0.00 $0.00 $18.93 $29.99 $30.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J762D SUP Custom 27203010 J762D - SUTURE ABSORBABLE 2-0 CP-2 18IN CONTROL RELEASE BRAID 8 BOTH IP/OP $37.49 $27.74 $0.00 $29.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.04 $27.04 $0.00 $0.00 $7.59 $0.00 $0.00 $0.00 $0.00 $18.49 $29.29 $29.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J764D SUP Custom 27203010 J764D - SUTURE ABSORBABLE 0 CTX 18IN CONTROL RELEASE BRAID 8 STRAND BOTH IP/OP $29.82 $22.07 $0.00 $24.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.13 $22.13 $0.00 $0.00 $6.22 $0.00 $0.00 $0.00 $0.00 $15.14 $23.97 $24.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J765D SUP Custom 27203010 J765D - SUTURE ABSORBABLE 1 CTX 18IN CONTROL RELEASE BRAID 8 STRAND BOTH IP/OP $29.82 $22.07 $0.00 $24.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.13 $22.13 $0.00 $0.00 $6.22 $0.00 $0.00 $0.00 $0.00 $15.14 $23.97 $24.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J774D SUP Custom 27203010 J774D - SUTURE ABS 3-0 SH 18IN VIOL VCL CR BRD 8 STRN COAT BOTH IP/OP $29.45 $21.79 $0.00 $23.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.86 $21.86 $0.00 $0.00 $6.14 $0.00 $0.00 $0.00 $0.00 $14.94 $23.67 $23.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J775D SUP Custom 27203010 J775D - SUTURE ABS 2-0 SH 18IN VIOL VCL CR BRD 8 STRN COAT BOTH IP/OP $28.82 $21.33 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.39 $21.39 $0.00 $0.00 $6.01 $0.00 $0.00 $0.00 $0.00 $14.63 $23.17 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J790D SUP Custom 27203010 J790D - SUTURE ABSORBABLE 3-0 X-1 18IN CONTROL RELEASE BRAID 8 BOTH IP/OP $43.68 $32.32 $0.00 $35.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.42 $32.42 $0.00 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $22.17 $35.12 $35.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J840D SUP Custom 27203010 J840D - SUTURE ABSORBABLE 0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND BOTH IP/OP $30.02 $22.21 $0.00 $24.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $0.00 $0.00 $0.00 $15.24 $24.13 $24.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J841D SUP Custom 27203010 J841D - SUTURE ABSORBABLE 1 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND BOTH IP/OP $29.80 $22.05 $0.00 $24.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.11 $22.11 $0.00 $0.00 $6.21 $0.00 $0.00 $0.00 $0.00 $15.12 $23.95 $24.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J841D CR SUP Custom 27203010 J841D CR - NEEDLE 1VICRYL 18 CT1 BOTH IP/OP $355.23 $262.87 $0.00 $284.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.65 $263.65 $0.00 $0.00 $74.03 $0.00 $0.00 $0.00 $0.00 $177.61 $281.34 $284.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 J864D SUP Custom 27203010 J864D - SUTURE ABS 3-0 SH 18IN UD VCL CR BRD 8 STRN COAT BOTH IP/OP $361.08 $267.20 $0.00 $293.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $267.99 $267.99 $0.00 $0.00 $75.25 $0.00 $0.00 $0.00 $0.00 $183.25 $290.26 $293.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JA-DLVT35L SUP Custom 27203010 JA-DLVT35L - TUBE VIVASIGHT DL DOUBLE LUMEN ENDOTRACHEAL 35 FR LEFT SIDED BOTH IP/OP $442.50 $327.45 $0.00 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.42 $328.42 $0.00 $0.00 $92.22 $0.00 $0.00 $0.00 $0.00 $221.25 $350.46 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JA-DLVT37L SUP Custom 27203010 JA-DLVT37L - TUBE VIVASIGHT DL DOUBLE LUMEN ENDOTRACHEAL 37 FR LEFT SIDED BOTH IP/OP $442.50 $327.45 $0.00 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.42 $328.42 $0.00 $0.00 $92.22 $0.00 $0.00 $0.00 $0.00 $221.25 $350.46 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JA-DLVT39L SUP Custom 27203010 JA-DLVT39L - TUBE VIVASIGHT DL DOUBLE LUMEN ENDOTRACHEAL 39 FR LEFT SIDED BOTH IP/OP $442.50 $327.45 $0.00 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.42 $328.42 $0.00 $0.00 $92.22 $0.00 $0.00 $0.00 $0.00 $221.25 $350.46 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JA-DLVT41L SUP Custom 27203010 JA-DLVT41L - TUBE VIVASIGHT DL DOUBLE LUMEN ENDOTRACHEAL 41 FR LEFT SIDED BOTH IP/OP $442.50 $327.45 $0.00 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.42 $328.42 $0.00 $0.00 $92.22 $0.00 $0.00 $0.00 $0.00 $221.25 $350.46 $354.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JA-TVT70100 SUP Custom 27203010 JA-TVT70100 - TUBE ENDOTRACHEAL VIVASIGHT SL SINGLE LUMEN 7.0MM BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JA-TVT75105 SUP Custom 27203010 JA-TVT75105 - TUBE ENDOTRACHEAL VIVASIGHT SL SINGLE LUMEN 7.5MM BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JA-TVT80110 SUP Custom 27203010 JA-TVT80110 - TUBE ENDOTRACHEAL VIVASIGHT SL SINGLE LUMEN 8.0MM BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.52 $224.52 $0.00 $0.00 $63.04 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JB840 SUP Custom 27203010 JB840 - SUTURE ABS 0 CTB-1 18IN UD VCL ETHGRD CR BRD 8 STRN COAT BOTH IP/OP $37.53 $27.77 $0.00 $30.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.85 $27.85 $0.00 $0.00 $7.82 $0.00 $0.00 $0.00 $0.00 $19.04 $30.17 $30.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JCDS-1618-EDS-HC SUP Custom 27203010 SET DILATOR 16 AND 18 FR BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JCDS-2022-EDS-HC SUP Custom 27203010 SET DILATOR 20 AND 22 FR BOTH IP/OP $427.50 $316.35 $0.00 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.75 $338.58 $342.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JEM 330 SUP HCPCS A7521 JEM 330 - TUBE ENDOTRAC 3MM CHGR SMTH RND TIP PE LATEX FREE DISP 3MM BOTH IP/OP $23.75 $17.58 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.63 $17.63 $0.00 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $11.88 $18.81 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JEM 365 SUP HCPCS A7520 JEM 365 - CATHETER AIRWAY EXCHANGE SMOOTH ROUNDED TIP LATEX FREE JEM BOTH IP/OP $26.15 $19.35 $0.00 $20.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.41 $19.41 $0.00 $0.00 $5.45 $0.00 $0.00 $0.00 $0.00 $13.08 $20.71 $20.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JEM 400 SUP Custom 27203010 JEM 400 - CATHETER AIRWAY EXCHANGE SMOOTH ROUNDED TIP LATEX FREE JEM BOTH IP/OP $27.50 $20.35 $0.00 $20.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.41 $20.41 $0.00 $0.00 $5.73 $0.00 $0.00 $0.00 $0.00 $13.08 $20.71 $20.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JEM370 SUP Custom 27203010 JEM370 - CATHETER ARWYEX SMPL RPD TCHQ PE DISP 7MM BOTH IP/OP $22.55 $16.69 $0.00 $18.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.74 $16.74 $0.00 $0.00 $4.70 $0.00 $0.00 $0.00 $0.00 $11.28 $17.86 $18.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JJ1952 SUP Custom 27203010 JJ1952 - HEMOSTAT ABSORBABLE 8X4IN ORIGINAL FLEXIBLE SHEER WEAVE BOTH IP/OP $147.91 $109.45 $0.00 $118.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.78 $109.78 $0.00 $0.00 $30.82 $0.00 $0.00 $0.00 $0.00 $73.95 $117.14 $118.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JJ4055 SUP HCPCS C1729 CATHETER IV 18GA 1.25IN RADIOPQ GRN JELCO TFLN STRL LF BOTH IP/OP $327.60 $242.42 $0.00 $262.08 $177.89 $177.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.80 $259.46 $262.08 $0.00 $0.00 $51.27 $0.00 $0.00 $52.15 $0.00 $0.00 $0.00 $0.00 $0.00 J-NCS-504070 SUP HCPCS C1887 J-NCS-504070 - CATH IU NOVY 5FR 40CM SET CVD CANNULATION 55CM DISP BOTH IP/OP $246.25 $182.23 $0.00 $197.00 $133.71 $133.71 $0.00 $0.00 $0.00 $51.32 $182.77 $182.77 $0.00 $0.00 $51.32 $0.00 $145.66 $145.66 $0.00 $123.13 $195.03 $197.00 $0.00 $0.00 $38.54 $0.00 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 JP-2230 SUP Custom 27203010 JP-2230 - DRAIN INCS 19FR JP SIL RND HBLS CHNL STRL LATEX BOTH IP/OP $40.63 $30.07 $0.00 $34.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.15 $30.15 $0.00 $0.00 $8.47 $0.00 $0.00 $0.00 $0.00 $20.31 $34.10 $32.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JP-HUF071 SUP Custom 27203010 JP-HUF071 - DRAIN INCISION 20CMX7MM 10FR FULL DUCT TROCAR LATEX FREE BOTH IP/OP $55.14 $40.80 $0.00 $44.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.92 $40.92 $0.00 $0.00 $11.49 $0.00 $0.00 $0.00 $0.00 $27.57 $43.67 $44.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 JW31U SUP HCPCS C1898 JW31U - LEAD PCNG OTW LT VNTRC SIN BOTH IP/OP "$4,750.00 " "$3,515.00" $0.00 "$3,800.00" "$2,137.50" "$2,137.50" $0.00 $0.00 $0.00 $990.02 "$3,525.45" "$3,525.45" $0.00 $0.00 $989.90 $0.00 "$2,341.75" "$2,341.75" $0.00 "$2,375.00" "$3,762.00" "$3,800.00" $0.00 $0.00 $743.38 $0.00 $0.00 $756.20 $0.00 $0.00 $0.00 $0.00 $0.00 K0675 SUP Custom 27203010 REAGENT RBT MS AB LSAB 2 110ML UNV SYS HRP CNJG IMMUN BOTH IP/OP "$1,382.93 " "$1,023.37" $0.00 "$1,106.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $691.46 "$1,095.28" "$1,106.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 K20-2154 SUP Custom 27203010 K20-2154 - BLADE OPTH 7MM CRNL SS TRPHN HNDL STRL DISP BOTH IP/OP $92.50 $68.45 $0.00 $74.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.65 $68.65 $0.00 $0.00 $19.28 $0.00 $0.00 $0.00 $0.00 $46.25 $73.26 $74.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 K3468 SUP Custom 27203010 REAGENT DAB PLUS 110ML LQ CHRMGN 1100 TST IMMUN BOTH IP/OP $366.93 $271.53 $0.00 $293.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.46 $290.61 $293.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 K4061 SUP Custom 27203010 REAGENT HRP ENVSN PLUS 11ML RBT MS DUAL LNK 1100 TST IMMUN BOTH IP/OP "$4,024.85 " "$2,978.39" $0.00 "$3,219.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,012.43" "$3,187.68" "$3,219.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 K5204 SUP Custom 27203010 KIT IMMUN TST HERCEPTEST SLD REAGENT HER 2 35 TST BOTH IP/OP "$3,781.18 " "$2,798.07" $0.00 "$3,024.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,890.59" "$2,994.69" "$3,024.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 K581H SUP Custom 27203010 K581H - SUTURE NONABSORBABLE 4-0 BB 24IN 2 ARM BRAID PERMA-HAND BOTH IP/OP $391.58 $289.77 $0.00 $317.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.63 $290.63 $0.00 $0.00 $81.60 $0.00 $0.00 $0.00 $0.00 $198.72 $314.78 $317.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 K8-6180 SUP Custom 27203010 K8-6180 - SPHERE EYE 18MM PLST SLD CLR BOTH IP/OP $62.78 $46.46 $0.00 $46.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.59 $46.59 $0.00 $0.00 $13.08 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 K8-6200 SUP HCPCS L8610 K8-6200 - SPHERE EYE 20MM PLST SLD CLR BOTH IP/OP $62.78 $46.46 $0.00 $50.22 $28.25 $28.25 $0.00 $0.00 $0.00 $13.08 $46.59 $46.59 $0.00 $0.00 $13.08 $0.00 $37.13 $37.13 $0.00 $31.39 $49.72 $50.22 $0.00 $0.00 $9.82 $0.00 $0.00 $9.99 $0.00 $0.00 $0.00 $0.00 $0.00 K8-6220 SUP HCPCS L8610 K8-6220 - SPHERE EYE 22MM PLST SLD CLR BOTH IP/OP $62.78 $46.46 $0.00 $54.00 $30.38 $30.38 $0.00 $0.00 $0.00 $13.08 $46.59 $46.59 $0.00 $0.00 $13.08 $0.00 $37.13 $37.13 $0.00 $33.75 $53.46 $54.00 $0.00 $0.00 $10.56 $0.00 $0.00 $10.75 $0.00 $0.00 $0.00 $0.00 $0.00 K8-6330 SUP HCPCS L8610 K8-6330 - CNFRMR OPTH LG UNV PLST CLR BOTH IP/OP $62.78 $46.46 $0.00 $46.59 $15.75 $15.75 $0.00 $0.00 $0.00 $0.00 $46.59 $46.59 $0.00 $0.00 $13.08 $0.00 $0.00 $0.00 $0.00 $17.50 $27.72 $28.00 $0.00 $0.00 $5.48 $0.00 $0.00 $5.57 $0.00 $0.00 $0.00 $0.00 $0.00 KC9529 SUP Custom 27203010 KC9529 - SLEEVES KNEE MEDIUM LENGTH BOTH IP/OP $73.60 $54.46 $0.00 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.63 $54.63 $0.00 $0.00 $15.34 $0.00 $0.00 $0.00 $0.00 $36.80 $58.29 $58.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 KCFW-6.0-35-70-RB-HFANL1-HC SUP HCPCS C1894 KCFW-6.0-35-70-RB-HFANL1-HC - INTROD SHTH 6FR .087IN 70CM ANL1 CURVE MULTPUR TIP ANSEL BOTH IP/OP $210.00 $155.40 $0.00 $168.00 $114.03 $114.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.00 $166.32 $168.00 $0.00 $0.00 $32.87 $0.00 $0.00 $33.43 $0.00 $0.00 $0.00 $0.00 $0.00 KC-RUMI-35 SUP HCPCS C1713 KC-RUMI-35 - MANIPULATOR ESCP 3.5CM STRL LF KOH-EFCT RUMI II K CP EZ LD BOTH IP/OP $223.26 $165.21 $0.00 $178.61 $100.47 $100.47 $0.00 $0.00 $0.00 $46.53 $165.70 $165.70 $0.00 $0.00 $46.53 $0.00 $132.06 $132.06 $0.00 $111.63 $176.82 $178.61 $0.00 $0.00 $34.94 $0.00 $0.00 $35.54 $0.00 $0.00 $0.00 $0.00 $0.00 KLIPPEN SUP HCPCS C1879 KLIPPEN - MARKER BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 KLTSD403 SUP Custom 27203010 AIRWAY ESPH 3 KLT-D SCT MGMT PORT BOTH IP/OP $80.58 $59.63 $0.00 $64.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.29 $63.82 $64.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 KLTSD424 SUP Custom 27203010 KLTSD424 - AIRWAY ESPH 4 KLT-D SCT MGMT PORT BOTH IP/OP $90.67 $67.10 $0.00 $67.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.30 $67.30 $0.00 $0.00 $18.90 $0.00 $0.00 $0.00 $0.00 $40.29 $63.82 $64.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 KLTSD425 SUP Custom 27203010 KLTSD425 - AIRWAY ESPH 5 KLT-D SCT MGMT PORT BOTH IP/OP $85.44 $63.23 $0.00 $63.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.41 $63.41 $0.00 $0.00 $17.81 $0.00 $0.00 $0.00 $0.00 $38.93 $61.66 $62.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 KM172-14-54 SUP Custom 27203010 KM172-14-54 - WIRE .054IN 4IN KWIRE SS SMTH TROCAR PNT 1 END ORTH NONSTRL BOTH IP/OP $5.70 $4.22 $0.00 $4.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.23 $4.23 $0.00 $0.00 $1.19 $0.00 $0.00 $0.00 $0.00 $2.85 $4.51 $4.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 KT1835C SUP HCPCS C1753 KT1835C - KIT CATH ER-REBOA BOTH IP/OP $467.50 $345.95 $0.00 $346.98 $203.63 $203.63 $0.00 $0.00 $0.00 $97.44 $346.98 $346.98 $0.00 $0.00 $97.43 $0.00 $276.53 $276.53 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 KW-062 SUP HCPCS C1769 KW-062 - WIRE FIX .062IN KWIRE SS BOTH IP/OP $181.25 $134.13 $0.00 $145.00 $98.42 $98.42 $0.00 $0.00 $0.00 $37.78 $134.52 $134.52 $0.00 $0.00 $37.77 $0.00 $107.21 $107.21 $0.00 $90.63 $143.55 $145.00 $0.00 $0.00 $28.37 $0.00 $0.00 $28.86 $0.00 $0.00 $0.00 $0.00 $0.00 KW062SS SUP HCPCS C1769 KW062SS - WIRE FIX 1.6MM KWIRE SS BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $33.94 $33.94 $0.00 $0.00 $0.00 $13.03 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $36.97 $36.97 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 KWIR-STD-09152 SUP Custom 27203010 KWIR-STD-09152 - WIRE FX STD .9MM 152MM KRSH TIP SS BOTH IP/OP $60.00 $44.40 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.53 $44.53 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $30.00 $47.52 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 KWIR-STD-15127 SUP HCPCS C1713 KWIR-STD-15127 - WIRE FX 1.5MM 127MM KRSH STD TIP SS BOTH IP/OP $70.00 $51.80 $0.00 $56.00 $31.50 $31.50 $0.00 $0.00 $0.00 $14.59 $51.95 $51.95 $0.00 $0.00 $14.59 $0.00 $41.41 $41.41 $0.00 $35.00 $55.44 $56.00 $0.00 $0.00 $10.96 $0.00 $0.00 $11.14 $0.00 $0.00 $0.00 $0.00 $0.00 L270309B SUP Custom 27203010 KIT BBL RPR CRD SERTST 3ML BOTH IP/OP $131.50 $97.31 $0.00 $105.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.75 $104.15 $105.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 L3030 SUP HCPCS C1713 L3030 - PIN SKL STRL MYFLD WNG GRV PLS ADLT CRNM DISP BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $405.00 $405.00 $0.00 $0.00 $0.00 $187.58 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $532.35 $532.35 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $140.85 $0.00 $0.00 $143.28 $0.00 $0.00 $0.00 $0.00 $0.00 L-70 SUP Custom 27203010 SYSTEM BLOOD WRM ADM SET INJEC PORT LVL 1 HTLN DISP STRL LF BOTH IP/OP $31.10 $23.01 $0.00 $24.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.55 $24.63 $24.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LA6EBU30 SUP HCPCS C1887 CATHETER GUID EBU3 CURVE 6FR 100CM CORON LNCHR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 LA6EBU40 SUP HCPCS C1887 CATHETER GUID EBU4 CURVE 6FR 100CM LNCHR BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 LAG3.2-24 SUP HCPCS C1713 LAG3.2-24 - SCREW BN 3.2MM 24MM LG CORT BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LAG3.2-26 SUP HCPCS C1713 LAG3.2-26 - SCREW BN 3.2MM 26MM LG CORT BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-4300 SUP HCPCS C1713 LAG-4300 - SCREW BONE 30MM MLR LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-4350 SUP HCPCS C1713 LAG-4350 - SCREW BONE 35MM MLR LAG NONSTRL BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-4400 SUP HCPCS C1713 LAG-4400 - SCREW BONE 40MM MLR LAG STRL BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-4450 SUP HCPCS C1713 LAG-4450 - SCREW BONE 45MM MLR LAG NONSTRL BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-4500 SUP HCPCS C1713 LAG-4500 - SCREW BONE 4MM 50MM TI MLR LAG NONSTRL BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5036 SUP HCPCS C1713 LAG-5036 - SCREW BONE 36MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5038 SUP HCPCS C1713 LAG-5038 - SCREW BONE 38MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5040 SUP HCPCS C1713 LAG-5040 - SCREW BONE 40MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5042 SUP HCPCS C1713 LAG-5042 - SCREW BONE 42MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5044 SUP HCPCS C1713 LAG-5044 - SCREW BONE 44MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5046 SUP HCPCS C1713 LAG-5046 - SCREW BONE 46MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5048 SUP HCPCS C1713 LAG-5048 - SCREW BONE 48MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5050 SUP HCPCS C1713 LAG-5050 - SCREW BONE 50MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5052 SUP HCPCS C1713 LAG-5052 - SCREW BONE 52MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5054 SUP HCPCS C1713 LAG-5054 - SCREW BONE 54MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5056 SUP HCPCS C1713 LAG-5056 - SCREW BONE 56MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5058 SUP HCPCS C1713 LAG-5058 - SCREW BONE 58MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5060 SUP HCPCS C1713 LAG-5060 - SCREW BONE 60MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5062 SUP HCPCS C1713 LAG-5062 - SCREW BONE 62MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5064 SUP HCPCS C1713 LAG-5064 - SCREW BONE 64MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5066 SUP HCPCS C1713 LAG-5066 - SCREW BONE 66MM ANKL SYNDESMOSIS LAG NONSTRL BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5068 SUP HCPCS C1713 LAG-5068 - SCREW BONE 68MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5070 SUP HCPCS C1713 LAG-5070 - SCREW BONE 70MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5072 SUP HCPCS C1713 LAG-5072 - SCREW BONE 72MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LAG-5074 SUP HCPCS C1713 LAG-5074 - SCREW BONE 74MM UPR/LWR XTRMT SYNDESMOSIS LAG BOTH IP/OP $460.00 $340.40 $0.00 $368.00 $207.00 $207.00 $0.00 $0.00 $0.00 $95.88 $341.41 $341.41 $0.00 $0.00 $95.86 $0.00 $272.09 $272.09 $0.00 $230.00 $364.32 $368.00 $0.00 $0.00 $71.99 $0.00 $0.00 $73.23 $0.00 $0.00 $0.00 $0.00 $0.00 LC3006 SUP Custom 27203010 LC3006 - KIT SRG STRL LF SPY PAQ DISP BOTH IP/OP "$1,374.25 " "$1,016.95" $0.00 "$1,099.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,019.97" "$1,019.97" $0.00 $0.00 $286.39 $0.00 $0.00 $0.00 $0.00 $687.13 "$1,088.41" "$1,099.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LCB002 SUP Custom 27203010 KIT INDCTR VRF MONITR STRP MEDIA VL LF BOTH IP/OP $6.83 $5.05 $0.00 $5.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.41 $5.41 $5.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS2.7-10 SUP HCPCS C1713 LCBS2.7-10 - SCREW BN 2.7MM 10MM LCK SS CORT TRIMED CLVCL FX SYS BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS2.7-16 SUP HCPCS C1713 LCBS2.7-16 - SCREW BN 2.7MM 16MM LCK SS CORT TRIMED CLVCL FX SYS BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS3.2-08 SUP HCPCS C1713 LCBS3.2-08 - SCREW BONE 3.2MM 8MM FRARM ELB CORT LOCK BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS3.2-12 SUP HCPCS C1713 LCBS3.2-12 - SCREW BONE 3.2MM 12MM LOCK FOREARM ELBOW CORTICAL BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS3.2-14 SUP HCPCS C1713 LCBS3.2-14 - SCREW BONE 3.2MM 14MM LOCK OLECRANON HOOK PLATE FOREARM BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS3.2-16 SUP HCPCS C1713 LCBS3.2-16 - SCREW BONE 3.2MM 16MM LOCK FOREARM ELBOW CORTICAL BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS3.2-18 SUP HCPCS C1713 LCBS3.2-18 - SCREW BONE 3.2MM 18MM LOCK FOREARM ELBOW CORTICAL BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS3.2-22 SUP HCPCS C1713 LCBS3.2-22 - SCREW BONE 3.2MM 22MM LOCK FOREARM ELBOW CORTICAL BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LCBS32-24 SUP HCPCS C1713 LCBS32-24 - SCREW BONE 24MM LOCK 3.2MM FOREARM ELBOW CORTICAL BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 LCC008 SUP Custom 27203010 STRIP INDCTR CHM MONITR VRF S1 PRC BOTH IP/OP $4.40 $3.26 $0.00 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.20 $3.48 $3.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LF1737 SUP Custom 27203010 LF1737 - SEALER/DIVIDER LAPSCP 350D 5MM 37CM LGSR MD 1 STP SL MLFNC BOTH IP/OP "$1,318.35 " $975.58 $0.00 "$1,054.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $978.48 $978.48 $0.00 $0.00 $274.74 $0.00 $0.00 $0.00 $0.00 $659.18 "$1,044.13" "$1,054.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LF4318 SUP Custom 27203010 LF4318 - SEALER/DIVIDER BP 180D 34MM LG 13.5MM 7.1IN STRL LF 36MM BOTH IP/OP "$8,795.55 " "$6,508.71" $0.00 "$7,036.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,832.99" $0.00 $0.00 $0.00 $0.00 "$4,397.78" "$6,966.08" "$7,036.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LF4418 SUP Custom 27203010 LF4418 - SEALER/DIVIDER BP 14D 180D 34MM 13.5MM 18CM STRL LF 36MM BOTH IP/OP "$1,465.93 " "$1,084.79" $0.00 "$1,172.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,088.01" "$1,088.01" $0.00 $0.00 $305.50 $0.00 $0.00 $0.00 $0.00 $732.96 "$1,161.02" "$1,172.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LFC002 SUP Custom 27203010 LFC002 - TIP APL LIQUIBAND ADH TISS FLW CNTRL BOTH IP/OP $92.98 $68.81 $0.00 $74.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.01 $69.01 $0.00 $0.00 $19.38 $0.00 $0.00 $0.00 $0.00 $46.49 $73.64 $74.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LHEX3.2-12 SUP HCPCS C1713 LHEX3.2-12 - SCREW BN 3.2MM 12MM LCK SS CORT TRIMED CLVCL FX SYS BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 LIG101 SUP Custom 27203010 LIQUIMMUNE IMMUNOASSAY LV 1 6X5ML BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LIG-101 SUP Custom 27203010 CONTROL IMAS MAS LIQUIMMUNE LVL 1 LQ 5ML IMMUN BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LIG202 SUP Custom 27203010 LIQUIMMUNE IMMUNOASSAY LV 2 6X5ML BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LIG-202 SUP Custom 27203010 CONTROL MLANLT 3-PNT LIQUIMMUNE LVL 2 ASY 5ML IMMUN BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LIG303 SUP Custom 27203010 LIQUIMMUNE IMMUNOASSAY LV 3 6X5ML BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LIG-303 SUP Custom 27203010 CONTROL IMAS MAS LIQUIMMUNE LVL 3 LQ 5ML IMMUN BOTH IP/OP $150.00 $111.00 $0.00 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $118.80 $120.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LL0004 SUP Custom 27203010 LL0004 - SET TBG 250 MILLIBAR STRL LTX 1 LUM INFL 2 OFLW DISP BOTH IP/OP $362.50 $268.25 $0.00 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.25 $287.10 $290.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LN205 SUP Custom 27203010 LN205 - RESERVOIR CARDIOTOMY 3L UNFILTERED BOTH IP/OP $77.00 $56.98 $0.00 $61.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.15 $57.15 $0.00 $0.00 $16.05 $0.00 $0.00 $0.00 $0.00 $38.50 $60.98 $61.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LPG1510 SUP HCPCS C1781 LPG1510 - MESH SURG 15X10CM SELF FIXATE FLAT SHEET LATEX FREE PROGRIP BOTH IP/OP $886.40 $655.94 $0.00 $838.60 $471.71 $471.71 $0.00 $0.00 $0.00 $184.75 $657.89 $657.89 $0.00 $0.00 $184.73 $0.00 $524.31 $524.31 $0.00 $524.13 $830.21 $838.60 $0.00 $0.00 $164.05 $0.00 $0.00 $166.88 $0.00 $0.00 $0.00 $0.00 $0.00 LPP11 SUP Custom 27803010 LPP11 - EXPANDER TISSUE P5CM 11X9CM TEXTURED LP PLUS LATERAL EXTN BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 $0.00 $0.00 $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LPP12 SUP HCPCS C1789 LPP12 - EXPANDER TISSUE P5.2CM 9.8X12CM TEXTURED LOW POLE PLUS BOTH IP/OP "$3,025.00 " "$2,238.50" $0.00 "$2,420.00" "$1,361.25" "$1,361.25" $0.00 $0.00 $0.00 $630.49 "$2,245.16" "$2,245.16" $0.00 $0.00 $630.41 $0.00 "$1,491.33" "$1,491.33" $0.00 "$1,512.50" "$2,395.80" "$2,420.00" $0.00 $0.00 $473.41 $0.00 $0.00 $481.58 $0.00 $0.00 $0.00 $0.00 $0.00 LPP13 SUP HCPCS C1789 LPP13 - XPD TISS 380-450ML TXTR LP PLUS LAT EXTN MID HT DERMASPAN BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 LPP14 SUP HCPCS C1789 LPP14 - EXPANDER TISSUE P6CM 14X11.2CM TEXTURED LP PLUS LATERAL EXTN BOTH IP/OP "$3,025.00 " "$2,238.50" $0.00 "$2,420.00" "$1,361.25" "$1,361.25" $0.00 $0.00 $0.00 $630.49 "$2,245.16" "$2,245.16" $0.00 $0.00 $630.41 $0.00 "$1,491.33" "$1,491.33" $0.00 "$1,512.50" "$2,395.80" "$2,420.00" $0.00 $0.00 $473.41 $0.00 $0.00 $481.58 $0.00 $0.00 $0.00 $0.00 $0.00 LPP15 SUP HCPCS C1789 LPP15 - EXPANDER TISS P6.4-7.9CM MID HT 15X11.5CM 500-600CC BOTH IP/OP "$3,025.00 " "$2,238.50" $0.00 "$2,420.00" "$1,361.25" "$1,361.25" $0.00 $0.00 $0.00 $630.49 "$2,245.16" "$2,245.16" $0.00 $0.00 $630.41 $0.00 "$1,491.33" "$1,491.33" $0.00 "$1,512.50" "$2,395.80" "$2,420.00" $0.00 $0.00 $473.41 $0.00 $0.00 $481.58 $0.00 $0.00 $0.00 $0.00 $0.00 LPP16 SUP HCPCS C1789 LPP16 - EXPANDER TISS P6.6-8.2CM MID HT 16X12CM 580-690CC DERMASPAN BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 LQB001 SUP Custom 27203010 LQB001 - LIQUIBAND SKIN ADHESIVE DOME TIP BOTH IP/OP $127.22 $94.14 $0.00 $101.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.43 $94.43 $0.00 $0.00 $26.51 $0.00 $0.00 $0.00 $0.00 $63.61 $100.76 $101.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LS1500 SUP Custom 27203010 LS1500 - SEALER/DIVIDER LAPSCP 179D 12MM 5MM 37CM STRL 18X2.6MM LGSR BOTH IP/OP "$1,215.66 " $899.59 $0.00 $972.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $902.26 $902.26 $0.00 $0.00 $253.34 $0.00 $0.00 $0.00 $0.00 $607.83 $962.80 $972.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LS3111 SUP Custom 27203010 ELECTRODE ESURG LG XTD SNP IN RDG GR SRFC CORD BOTH IP/OP $102.05 $75.52 $0.00 $81.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.03 $80.82 $81.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LT200 SUP HCPCS C1760 LT200 - CLIP MED 3.2MM INTNL LGCLP EX TI ENDSCP LIGAT STRL DISP LF BOTH IP/OP $30.60 $22.64 $0.00 $24.48 $13.77 $13.77 $0.00 $0.00 $0.00 $6.38 $22.71 $22.71 $0.00 $0.00 $6.38 $0.00 $18.10 $18.10 $0.00 $15.30 $24.24 $24.48 $0.00 $0.00 $4.79 $0.00 $0.00 $4.87 $0.00 $0.00 $0.00 $0.00 $0.00 LT400 SUP HCPCS C1760 LT400 - CLIP LG 6.2MM INTNL LGCLP EX TI ENDSCP LIGAT STRL DISP LF BOTH IP/OP $56.10 $41.51 $0.00 $44.88 $25.25 $25.25 $0.00 $0.00 $0.00 $11.69 $41.64 $41.64 $0.00 $0.00 $11.69 $0.00 $33.18 $33.18 $0.00 $28.05 $44.43 $44.88 $0.00 $0.00 $8.78 $0.00 $0.00 $8.93 $0.00 $0.00 $0.00 $0.00 $0.00 LUB07030 SUP HCPCS C2625 LUB07030 - STENT BIL 7MM 6FR 30MM 80CM .035IN CATH GWIRE E-LMNX BOTH IP/OP "$3,883.20 " "$2,873.57" $0.00 "$3,106.56" "$1,747.44" "$1,747.44" $0.00 $0.00 $0.00 $809.36 "$2,882.11" "$2,882.11" $0.00 $0.00 $809.26 $0.00 "$1,914.42" "$1,914.42" $0.00 "$1,941.60" "$3,075.49" "$3,106.56" $0.00 $0.00 $607.72 $0.00 $0.00 $618.21 $0.00 $0.00 $0.00 $0.00 $0.00 LUB07040 SUP HCPCS C2625 LUB07040 - STENT BIL .035IN 7MM 6FR 40MM 80CM LMNX SLF XPD DLV SYS NTNL BOTH IP/OP "$3,883.19 " "$2,873.56" $0.00 "$3,106.55" "$1,747.44" "$1,747.44" $0.00 $0.00 $0.00 $809.35 "$2,882.10" "$2,882.10" $0.00 $0.00 $809.26 $0.00 "$1,914.41" "$1,914.41" $0.00 "$1,941.60" "$3,075.49" "$3,106.55" $0.00 $0.00 $607.72 $0.00 $0.00 $618.20 $0.00 $0.00 $0.00 $0.00 $0.00 LUB08030 SUP HCPCS C2625 LUB08030 - STENT BIL .035IN 8MM 6FR 30MM 80CM LMNX SLF XPD DLV SYS NTNL BOTH IP/OP "$3,883.19 " "$2,873.56" $0.00 "$3,106.55" "$1,747.44" "$1,747.44" $0.00 $0.00 $0.00 $809.35 "$2,882.10" "$2,882.10" $0.00 $0.00 $809.26 $0.00 "$1,914.41" "$1,914.41" $0.00 "$1,941.60" "$3,075.49" "$3,106.55" $0.00 $0.00 $607.72 $0.00 $0.00 $618.20 $0.00 $0.00 $0.00 $0.00 $0.00 LUB08060 SUP HCPCS C2625 LUB08060 - STENT BIL .035IN 8MM 6FR 60MM 80CM LMNX SLF XPD DLV SYS NTNL BOTH IP/OP "$3,883.19 " "$2,873.56" $0.00 "$3,106.55" "$1,747.44" "$1,747.44" $0.00 $0.00 $0.00 $809.35 "$2,882.10" "$2,882.10" $0.00 $0.00 $809.26 $0.00 "$1,914.41" "$1,914.41" $0.00 "$1,941.60" "$3,075.49" "$3,106.55" $0.00 $0.00 $607.72 $0.00 $0.00 $618.20 $0.00 $0.00 $0.00 $0.00 $0.00 LUB10040 SUP HCPCS C2625 LUB10040 - STENT VASC .035IN 10MM 6FR 40MM 80CM E-LMNX SAFE PERFORMAXX BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" "$1,012.50" "$1,012.50" $0.00 $0.00 $0.00 $468.96 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 "$1,330.88" "$1,330.88" $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $352.13 $0.00 $0.00 $358.20 $0.00 $0.00 $0.00 $0.00 $0.00 LUB10060 SUP HCPCS C2625 LUB10060 - STENT BIL 10MM 60MM 80CM PERFORMAXX GRP E-LMNX BOTH IP/OP "$3,883.20 " "$2,873.57" $0.00 "$3,106.56" "$1,747.44" "$1,747.44" $0.00 $0.00 $0.00 $809.36 "$2,882.11" "$2,882.11" $0.00 $0.00 $809.26 $0.00 "$1,914.42" "$1,914.42" $0.00 "$1,941.60" "$3,075.49" "$3,106.56" $0.00 $0.00 $607.72 $0.00 $0.00 $618.21 $0.00 $0.00 $0.00 $0.00 $0.00 LUB12080 SUP HCPCS C2625 LUB12080 - STENT BIL 12MM 6FR 80MM 80CM .035IN SLF XPD DLV SYS LMNX BOTH IP/OP "$4,686.61 " "$3,468.09" $0.00 "$3,749.29" "$2,108.97" "$2,108.97" $0.00 $0.00 $0.00 $976.81 "$3,478.40" "$3,478.40" $0.00 $0.00 $976.69 $0.00 "$2,310.50" "$2,310.50" $0.00 "$2,343.30" "$3,711.80" "$3,749.29" $0.00 $0.00 $733.45 $0.00 $0.00 $746.11 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.100 SUP HCPCS V2632 LX10BD.100 - LENS IOL 5 D +10 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.105 SUP HCPCS V2632 LX10BD.105 - LENS IOL 5 D +10.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.110 SUP HCPCS V2632 LX10BD.110 - LENS IOL 5 D +11 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.115 SUP HCPCS V2632 LX10BD.115 - LENS IOL 5 D +11.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.120 SUP HCPCS V2632 LX10BD.120 - LENS IOL 5 D +12 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.125 SUP HCPCS V2632 LX10BD.125 - LENS IOL 5 D +12.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.130 SUP HCPCS V2632 LX10BD.130 - LENS IOL 5 D +13 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.135 SUP HCPCS V2632 LX10BD.135 - LENS IOL 5 D +13.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.140 SUP HCPCS V2632 LX10BD.140 - LENS IOL 5 D +14 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.145 SUP HCPCS V2632 LX10BD.145 - LENS IOL 5 D +14.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.150 SUP HCPCS V2632 LX10BD.150 - LENS IOL 5 D +15 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.155 SUP HCPCS V2632 LX10BD.155 - LENS IOL 5 D +15.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.160 SUP HCPCS V2632 LX10BD.160 - LENS IOL 5 D +16 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.165 SUP HCPCS V2632 LX10BD.165 - LENS IOL 5 D +16.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.170 SUP HCPCS V2632 LX10BD.170 - LENS IOL 5 D +17 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.175 SUP HCPCS V2632 LX10BD.175 - LENS IOL 5 D +17.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.180 SUP HCPCS V2632 LX10BD.180 - LENS IOL 5 D +18 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.185 SUP HCPCS V2632 LX10BD.185 - LENS IOL 5 D +18.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.190 SUP HCPCS V2632 LX10BD.190 - LENS IOL 5 D +19 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.195 SUP HCPCS V2632 LX10BD.195 - LENS IOL 5 D +19.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.200 SUP HCPCS V2632 LX10BD.200 - LENS IOL 5 D +20 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.205 SUP HCPCS V2632 LX10BD.205 - LENS IOL 5 D +20.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.210 SUP HCPCS V2632 LX10BD.210 - LENS IOL 5 D +21 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.215 SUP HCPCS V2632 LX10BD.215 - LENS IOL 5 D +21.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.220 SUP HCPCS V2632 LX10BD.220 - LENS IOL 5 D +22 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.225 SUP HCPCS V2632 LX10BD.225 - LENS IOL 5 D +22.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.230 SUP HCPCS V2632 LX10BD.230 - LENS IOL 5 D +23 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.235 SUP HCPCS V2632 LX10BD.235 - LENS IOL 5 D +23.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.240 SUP HCPCS V2632 LX10BD.240 - LENS IOL 5 D +24 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.245 SUP HCPCS V2632 LX10BD.245 - LENS IOL 5 D +24.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.250 SUP HCPCS V2632 LX10BD.250 - LENS IOL 5 D +25 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.255 SUP HCPCS V2632 LX10BD.255 - LENS IOL 5 D +25.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.260 SUP HCPCS V2632 LX10BD.260 - LENS IOL 5 D +26 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.265 SUP HCPCS V2632 LX10BD.265 - LENS IOL 5 D +26.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.270 SUP HCPCS V2632 LX10BD.270 - LENS IOL 5 D +27 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.275 SUP HCPCS V2632 LX10BD.275 - LENS IOL 5 D +27.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.280 SUP HCPCS V2632 LX10BD.280 - LENS IOL 5 D +28 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.285 SUP HCPCS V2632 LX10BD.285 - LENS IOL 5 D +28.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.290 SUP HCPCS V2632 LX10BD.290 - LENS IOL 5 D +29 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.295 SUP HCPCS V2632 LX10BD.295 - LENS IOL 5 D +29.5 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX10BD.300 SUP HCPCS V2632 LX10BD.300 - LENS IOL 5 D +30 DIOP MOD C BCNVX 5.25MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.100 SUP HCPCS V2632 LX90BD.100 - LENS IOL 5 D +10 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.105 SUP HCPCS V2632 LX90BD.105 - LENS IOL 5 D +10.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.110 SUP HCPCS V2632 LX90BD.110 - LENS IOL 5 D +11 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.115 SUP HCPCS V2632 LX90BD.115 - LENS IOL 5 D +11.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.120 SUP HCPCS V2632 LX90BD.120 - LENS IOL 5 D +12 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.125 SUP HCPCS V2632 LX90BD.125 - LENS IOL 5 D +12.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.130 SUP HCPCS V2632 LX90BD.130 - LENS IOL 5 D +13 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.135 SUP HCPCS V2632 LX90BD.135 - LENS IOL 5 D +13.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.140 SUP HCPCS V2632 LX90BD.140 - LENS IOL 5 D +14 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.145 SUP HCPCS V2632 LX90BD.145 - LENS IOL 5 D +14.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.150 SUP HCPCS V2632 LX90BD.150 - LENS IOL 5 D +15 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.155 SUP HCPCS V2632 LX90BD.155 - LENS IOL 5 D +15.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.160 SUP HCPCS V2632 LX90BD.160 - LENS IOL 5 D +16 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.165 SUP HCPCS V2632 LX90BD.165 - LENS IOL 5 D +16.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.170 SUP HCPCS V2632 LX90BD.170 - LENS IOL 5 D +17 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.175 SUP HCPCS V2632 LX90BD.175 - LENS IOL 5 D +17.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.180 SUP HCPCS V2632 LX90BD.180 - LENS IOL 5 D +18 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.185 SUP HCPCS V2632 LX90BD.185 - LENS IOL 5 D +18.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.190 SUP HCPCS V2632 LX90BD.190 - LENS IOL 5 D +19 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.195 SUP HCPCS V2632 LX90BD.195 - LENS IOL 5 D +19.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.200 SUP HCPCS V2632 LX90BD.200 - LENS IOL 5 D +20 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.205 SUP HCPCS V2632 LX90BD.205 - LENS IOL 5 D +20.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.210 SUP HCPCS V2632 LX90BD.210 - LENS IOL 5 D +21 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.215 SUP HCPCS V2632 LX90BD.215 - LENS IOL 5 D +21.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.220 SUP HCPCS V2632 LX90BD.220 - LENS IOL 5 D +22 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.225 SUP HCPCS V2632 LX90BD.225 - LENS IOL 5 D +22.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.230 SUP HCPCS V2632 LX90BD.230 - LENS IOL 5 D +23 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.235 SUP HCPCS V2632 LX90BD.235 - LENS IOL 5 D +23.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.240 SUP HCPCS V2632 LX90BD.240 - LENS IOL 5 D +24 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.245 SUP HCPCS V2632 LX90BD.245 - LENS IOL 5 D +24.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.250 SUP HCPCS V2632 LX90BD.250 - LENS IOL 5 D +25 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.255 SUP HCPCS V2632 LX90BD.255 - LENS IOL 5 D +25.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.260 SUP HCPCS V2632 LX90BD.260 - LENS IOL 5 D +26 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.265 SUP HCPCS V2632 LX90BD.265 - LENS IOL 5 D +26.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.270 SUP HCPCS V2632 LX90BD.270 - LENS IOL 5 D +27 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.275 SUP HCPCS V2632 LX90BD.275 - LENS IOL 5 D +27.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.280 SUP HCPCS V2632 LX90BD.280 - LENS IOL 5 D +28 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.285 SUP HCPCS V2632 LX90BD.285 - LENS IOL 5 D +28.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.290 SUP HCPCS V2632 LX90BD.290 - LENS IOL 5 D +29 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.295 SUP HCPCS V2632 LX90BD.295 - LENS IOL 5 D +29.5 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LX90BD.300 SUP HCPCS V2632 LX90BD.300 - LENS IOL 5 D +30 DIOP MOD C BCNVX 5.75MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 LXA19 SUP Custom 27803010 LXA19 - VALVE AORTIC 19MM MITROFLOW BVN PRICRD BOTH IP/OP "$12,500.00 " "$9,250.00" $0.00 "$10,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,605.00" $0.00 $0.00 $0.00 $0.00 "$6,250.00" "$9,900.00" "$10,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 LXA21 SUP Custom 27803010 LXA21 - VALVE AORTIC 21MM MITROFLOW BVN PRICRD BOTH IP/OP "$12,500.00 " "$9,250.00" $0.00 "$10,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,605.00" $0.00 $0.00 $0.00 $0.00 "$6,250.00" "$9,900.00" "$10,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001102200 SUP HCPCS C1726 M001102200 - CATHETER BLNDIL 9FR 15MM 100CM 3CM LV ANGPLSTY BOTH IP/OP $998.00 $738.52 $0.00 $798.40 $541.91 $541.91 $0.00 $0.00 $0.00 $208.01 $740.72 $740.72 $0.00 $0.00 $207.98 $0.00 $590.32 $590.32 $0.00 $499.00 $790.42 $798.40 $0.00 $0.00 $156.19 $0.00 $0.00 $158.88 $0.00 $0.00 $0.00 $0.00 $0.00 M001102240 SUP HCPCS C1726 M001102240 - CATHETER BLNDIL 9FR 20MM 100CM 3CM BLU MAX 20 OTW NC HI-PRS BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $373.31 $373.31 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 M0011031020 SUP HCPCS C1751 M0011031020 - CATHETER INFS .014-.016IN 3-2.7FR .021-.022IN 150CM 12CM BOTH IP/OP "$1,225.00 " $906.50 $0.00 $980.00 $665.18 $665.18 $0.00 $0.00 $0.00 $255.32 $909.20 $909.20 $0.00 $0.00 $255.29 $0.00 $724.59 $724.59 $0.00 $612.50 $970.20 $980.00 $0.00 $0.00 $191.71 $0.00 $0.00 $195.02 $0.00 $0.00 $0.00 $0.00 $0.00 M001125000 SUP HCPCS C1753 M001125000 - CATHETER BLNDIL 4MM 40CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125010 SUP HCPCS C1753 M001125010 - CATHETER BLNDIL 4MM 75CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125020 SUP HCPCS C1753 M001125020 - CATHETER BLNDIL 4MM 120CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125030 SUP HCPCS C1753 M001125030 - CATHETER BLNDIL 4MM 40CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125040 SUP HCPCS C1753 M001125040 - CATHETER BLNDIL 4MM 75CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125050 SUP HCPCS C1753 M001125050 - CATHETER BLNDIL 4MM 120CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125060 SUP HCPCS C1753 M001125060 - CATHETER BLNDIL 4MM 40CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125070 SUP HCPCS C1753 M001125070 - CATHETER BLNDIL 4MM 75CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125080 SUP HCPCS C1753 M001125080 - CATHETER BLNDIL 4MM 120CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125090 SUP HCPCS C1753 M001125090 - CATHETER BLNDIL 4MM 40CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125100 SUP HCPCS C1753 M001125100 - CATHETER BLNDIL 4MM 75CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125110 SUP HCPCS C1753 M001125110 - CATHETER BLNDIL 4MM 120CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $447.98 $447.98 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 M001125120 SUP HCPCS C1753 M001125120 - CATHETER BLNDIL 5MM 40CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125130 SUP HCPCS C1753 M001125130 - CATHETER BLNDIL 5MM 75CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125140 SUP HCPCS C1753 M001125140 - CATHETER BLNDIL 5MM 120CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125150 SUP HCPCS C1753 M001125150 - CATHETER BLNDIL 5MM 40CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125160 SUP HCPCS C1753 M001125160 - CATHETER BLNDIL 5MM 75CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125170 SUP HCPCS C1753 M001125170 - CATHETER BLNDIL 5MM 120CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125180 SUP HCPCS C1753 M001125180 - CATHETER BLNDIL 5MM 40CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125190 SUP HCPCS C1753 M001125190 - CATHETER BLNDIL 5MM 75CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125200 SUP HCPCS C1753 M001125200 - CATHETER BLNDIL 5MM 120CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125210 SUP HCPCS C1753 M001125210 - CATHETER BLNDIL 5MM 40CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125220 SUP HCPCS C1753 M001125220 - CATHETER BLNDIL 5MM 75CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125230 SUP HCPCS C1753 M001125230 - CATHETER BLNDIL 5MM 120CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125240 SUP HCPCS C1753 M001125240 - CATHETER BLNDIL 6MM 40CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125250 SUP HCPCS C1753 M001125250 - CATHETER BLNDIL 6MM 75CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125260 SUP HCPCS C1753 M001125260 - CATHETER BLNDIL 6MM 120CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125270 SUP HCPCS C1753 M001125270 - CATHETER BLNDIL 6MM 40CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125280 SUP HCPCS C1753 M001125280 - CATHETER BLNDIL 6MM 75CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125290 SUP HCPCS C1753 M001125290 - CATHETER BLNDIL 6MM 120CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125300 SUP HCPCS C1753 M001125300 - CATHETER BLNDIL 6MM 40CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125310 SUP HCPCS C1753 M001125310 - CATHETER BLNDIL 6MM 75CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125320 SUP HCPCS C1753 M001125320 - CATHETER BLNDIL 6MM 120CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125330 SUP HCPCS C1753 M001125330 - CATHETER BLNDIL 6MM 40CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125340 SUP HCPCS C1753 M001125340 - CATHETER BLNDIL 6MM 75CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125350 SUP HCPCS C1753 M001125350 - CATHETER BLNDIL 6MM 120CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125360 SUP HCPCS C1753 M001125360 - CATHETER BLNDIL 7MM 40CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125370 SUP HCPCS C1753 M001125370 - CATHETER BLNDIL 7MM 75CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125380 SUP HCPCS C1753 M001125380 - CATHETER BLNDIL 7MM 120CM 20MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125390 SUP HCPCS C1753 M001125390 - CATHETER BLNDIL 7MM 40CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125400 SUP HCPCS C1753 M001125400 - CATHETER BLNDIL 7MM 75CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125410 SUP HCPCS C1753 M001125410 - CATHETER BLNDIL 7MM 120CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125420 SUP HCPCS C1753 M001125420 - CATHETER BLNDIL 7MM 40CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125430 SUP HCPCS C1753 M001125430 - CATHETER BLNDIL 7MM 75CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125440 SUP HCPCS C1753 M001125440 - CATHETER BLNDIL 7MM 120CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125450 SUP HCPCS C1753 M001125450 - CATHETER BLNDIL 7MM 40CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125460 SUP HCPCS C1753 M001125460 - CATHETER BLNDIL 7MM 75CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125470 SUP HCPCS C1753 M001125470 - CATHETER BLNDIL 7MM 120CM 100MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $447.98 $447.98 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 M001125480 SUP HCPCS C1753 M001125480 - CATHETER BLNDIL 8MM 40CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125490 SUP HCPCS C1726 M001125490 - CATHETER BLNDIL 8MM 75CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125500 SUP HCPCS C1753 M001125500 - CATHETER BLNDIL 8MM 120CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125510 SUP HCPCS C1753 M001125510 - CATHETER BLNDIL 8MM 40CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125520 SUP HCPCS C1753 M001125520 - CATHETER BLNDIL 8MM 75CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125530 SUP HCPCS C1753 M001125530 - CATHETER BLNDIL 8MM 120CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125540 SUP HCPCS C1753 M001125540 - CATHETER BLNDIL 8MM 40CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125550 SUP HCPCS C1753 M001125550 - CATHETER BLNDIL 8MM 75CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125560 SUP HCPCS C1753 M001125560 - CATHETER BLNDIL 8MM 120CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125580 SUP HCPCS C1753 M001125580 - CATHETER BLNDIL 9MM 75CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125590 SUP HCPCS C1753 M001125590 - CATHETER BLNDIL 9MM 120CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125600 SUP HCPCS C1753 M001125600 - CATHETER BLNDIL 9MM 40CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125610 SUP HCPCS C1753 M001125610 - CATHETER BLNDIL 9MM 75CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125620 SUP HCPCS C1753 M001125620 - CATHETER BLNDIL 9MM 120CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125630 SUP HCPCS C1753 M001125630 - CATHETER BLNDIL 9MM 40CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125640 SUP HCPCS C1753 M001125640 - CATHETER BLNDIL 9MM 75CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125650 SUP HCPCS C1753 M001125650 - CATHETER BLNDIL 9MM 120CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125660 SUP HCPCS C1753 M001125660 - CATHETER BLNDIL 10MM 40CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125670 SUP HCPCS C1753 M001125670 - CATHETER BLNDIL 10MM 75CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125680 SUP HCPCS C1753 M001125680 - CATHETER BLNDIL 10MM 120CM 30MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125690 SUP HCPCS C1753 M001125690 - CATHETER BLNDIL 10MM 40CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125700 SUP HCPCS C1726 M001125700 - CATHETER BLNDIL 10MM 75CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125710 SUP HCPCS C1753 M001125710 - CATHETER BLNDIL 10MM 120CM 40MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125720 SUP HCPCS C1753 M001125720 - CATHETER BLNDIL 10MM 40CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125730 SUP HCPCS C1753 M001125730 - CATHETER BLNDIL 10MM 75CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M001125740 SUP HCPCS C1753 M001125740 - CATHETER BLNDIL 10MM 120CM 80MM BLU MAX 20 OTW HI-PRS PERI BOTH IP/OP $463.05 $342.66 $0.00 $370.44 $251.44 $251.44 $0.00 $0.00 $0.00 $96.51 $343.68 $343.68 $0.00 $0.00 $96.50 $0.00 $273.89 $273.89 $0.00 $231.53 $366.74 $370.44 $0.00 $0.00 $72.47 $0.00 $0.00 $73.72 $0.00 $0.00 $0.00 $0.00 $0.00 M0011341080 SUP HCPCS C1751 M0011341080 - CATH INFUS .014-.016IN 3-2.5FR .022-.021IN 150CM 20CM MCTH 1 BOTH IP/OP "$1,437.50 " "$1,063.75" $0.00 "$1,150.00" $780.56 $780.56 $0.00 $0.00 $0.00 $299.61 "$1,066.91" "$1,066.91" $0.00 $0.00 $299.58 $0.00 $850.28 $850.28 $0.00 $718.75 "$1,138.50" "$1,150.00" $0.00 $0.00 $224.97 $0.00 $0.00 $228.85 $0.00 $0.00 $0.00 $0.00 $0.00 M001145080 SUP HCPCS C1753 M001145080 - CATHETER BLNDIL 12MM 75CM 20MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145090 SUP HCPCS C1753 M001145090 - CATHETER BLNDIL 12MM 120CM 20MM XXL SCRCH RST HI STRTH SHFT BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145100 SUP HCPCS C1726 M001145100 - CATHETER BLNDIL 12MM 75CM 40MM XXL SCRCH RST HI STRTH SHFT BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145110 SUP HCPCS C1726 M001145110 - CATHETER BLNDIL 12MM 120CM 40MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145120 SUP HCPCS C1753 M001145120 - CATHETER BLNDIL 14MM 75CM 20MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145130 SUP HCPCS C1753 M001145130 - CATHETER BLNDIL 14MM 120CM 20MM XXL SCRCH RST HI STRTH SHFT BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145140 SUP HCPCS C1753 M001145140 - CATHETER BLNDIL 14MM 75CM 40MM XXL SCRCH RST HI STRTH SHFT BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145150 SUP HCPCS C1726 M001145150 - CATHETER BLNDIL 14MM 120CM 40MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145300 SUP HCPCS C1753 M001145300 - CATHETER BLNDIL 12MM 75CM 60MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145320 SUP HCPCS C1753 M001145320 - CATHETER BLNDIL 14MM 75CM 60MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145500 SUP HCPCS C1753 M001145500 - CATHETER BLNDIL 16MM 75CM 20MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145510 SUP HCPCS C1753 M001145510 - CATHETER BLNDIL 16MM 120CM 20MM XXL SCRCH RST HI STRTH SHFT BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145520 SUP HCPCS C1753 M001145520 - CATHETER BLNDIL 16MM 75CM 40MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145530 SUP HCPCS C1726 M001145530 - CATHETER BLNDIL 16MM 120CM 40MM XXL SCRCH RST HI STRTH SHFT BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145540 SUP HCPCS C1753 M001145540 - CATHETER BLNDIL 16MM 75CM 60MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145550 SUP HCPCS C1753 M001145550 - CATHETER BLNDIL 18MM 75CM 20MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145560 SUP HCPCS C1753 M001145560 - CATHETER BLNDIL 18MM 120CM 20MM XXL SCRCH RST HI STRTH SHFT BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145570 SUP HCPCS C1753 M001145570 - CATHETER BLNDIL 18MM 75CM 40MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145580 SUP HCPCS C1726 M001145580 - CATHETER BLNDIL 18MM 120CM 40MM XXL SCRCH RST HI STRTH SHFT BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001145590 SUP HCPCS C1753 M001145590 - CATHETER BLNDIL 18MM 75CM 60MM XXL QD-FOLD SCRCH RST HI BOTH IP/OP $505.00 $373.70 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $105.25 $374.81 $374.81 $0.00 $0.00 $105.24 $0.00 $298.71 $298.71 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001163980 SUP HCPCS C1753 M001163980 - CATHETER BLNDIL 3MM 120CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164000 SUP HCPCS C1753 M001164000 - CATHETER BLNDIL 3MM 40CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164010 SUP HCPCS C1753 M001164010 - CATHETER BLNDIL 3MM 75CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164020 SUP HCPCS C1753 M001164020 - CATHETER BLNDIL 3MM 120CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164030 SUP HCPCS C1753 M001164030 - CATHETER BLNDIL 3MM 150CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164040 SUP HCPCS C1753 M001164040 - CATHETER BLNDIL 3MM 40CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164050 SUP HCPCS C1753 M001164050 - CATHETER BLNDIL 3MM 75CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164060 SUP HCPCS C1753 M001164060 - CATHETER BLNDIL 3MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164070 SUP HCPCS C1753 M001164070 - CATHETER BLNDIL 3MM 150CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164080 SUP HCPCS C1753 M001164080 - CATHETER BLNDIL 3MM 40CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164090 SUP HCPCS C1753 M001164090 - CATHETER BLNDIL 3MM 75CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164100 SUP HCPCS C1753 M001164100 - CATHETER BLNDIL 3MM 120CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164110 SUP HCPCS C1753 M001164110 - CATHETER BLNDIL 3MM 150CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164120 SUP HCPCS C1753 M001164120 - CATHETER BLNDIL 4MM 40CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164130 SUP HCPCS C1753 M001164130 - CATHETER BLNDIL 4MM 75CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164140 SUP HCPCS C1753 M001164140 - CATHETER BLNDIL 4MM 120CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164150 SUP HCPCS C1753 M001164150 - CATHETER BLNDIL 4MM 150CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164160 SUP HCPCS C1753 M001164160 - CATHETER BLNDIL 4MM 40CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164170 SUP HCPCS C1726 M001164170 - CATHETER BLNDIL 4MM 75CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164180 SUP HCPCS C1726 M001164180 - CATHETER BLNDIL 4MM 120CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164190 SUP HCPCS C1753 M001164190 - CATHETER BLNDIL 4MM 150CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164200 SUP HCPCS C1753 M001164200 - CATHETER BLNDIL 4MM 75CM 30MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164210 SUP HCPCS C1753 M001164210 - CATHETER BLNDIL 4MM 120CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164220 SUP HCPCS C1753 M001164220 - CATHETER BLNDIL 4MM 40CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164230 SUP HCPCS C1726 M001164230 - CATHETER BLNDIL 4MM 75CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164240 SUP HCPCS C1726 M001164240 - CATHETER BLNDIL 4MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164250 SUP HCPCS C1753 M001164250 - CATHETER BLNDIL 4MM 150CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164280 SUP HCPCS C1753 M001164280 - CATHETER BLNDIL 4MM 40CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164290 SUP HCPCS C1726 M001164290 - CATHETER BLNDIL 4MM 75CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164300 SUP HCPCS C1726 M001164300 - CATH BALDILAT 5FR 4MM 120CM 10CM PERI PTA OTW TPR SHFT LP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164310 SUP HCPCS C1753 M001164310 - CATHETER BLNDIL 4MM 150CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164320 SUP HCPCS C1753 M001164320 - CATHETER BLNDIL 5MM 40CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164330 SUP HCPCS C1753 M001164330 - CATHETER BLNDIL 5MM 75CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164340 SUP HCPCS C1753 M001164340 - CATHETER BLNDIL 5MM 120CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164350 SUP HCPCS C1753 M001164350 - CATHETER BLNDIL 5MM 150CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164360 SUP HCPCS C1753 M001164360 - CATHETER BLNDIL 5MM 40CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164370 SUP HCPCS C1753 M001164370 - CATHETER BLNDIL 5MM 75CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164380 SUP HCPCS C1753 M001164380 - CATHETER BLNDIL 5MM 120CM 50MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164390 SUP HCPCS C1753 M001164390 - CATHETER BLNDIL 5MM 150CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164400 SUP HCPCS C1753 M001164400 - CATHETER BLNDIL 5MM 75CM 30MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164410 SUP HCPCS C1753 M001164410 - CATHETER BLNDIL 5MM 120CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164420 SUP HCPCS C1753 M001164420 - CATHETER BLNDIL 5MM 40CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164430 SUP HCPCS C1753 M001164430 - CATHETER BLNDIL 5MM 75CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164440 SUP HCPCS C1753 M001164440 - CATHETER BLNDIL 5MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164450 SUP HCPCS C1753 M001164450 - CATHETER BLNDIL 5MM 150CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164480 SUP HCPCS C1753 M001164480 - CATHETER BLNDIL 5MM 40CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164490 SUP HCPCS C1726 M001164490 - CATHETER BLNDIL 5MM 75CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164500 SUP HCPCS C1726 M001164500 - CATH BALDILAT 5FR 5MM 120CM 10CM PERI PTA OTW TPR SHFT LP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164510 SUP HCPCS C1753 M001164510 - CATHETER BLNDIL 5MM 150CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164520 SUP HCPCS C1753 M001164520 - CATHETER BLNDIL 6MM 40CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164530 SUP HCPCS C1753 M001164530 - CATHETER BLNDIL 6MM 75CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164540 SUP HCPCS C1753 M001164540 - CATHETER BLNDIL 6MM 120CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164550 SUP HCPCS C1753 M001164550 - CATHETER BLNDIL 6MM 150CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164560 SUP HCPCS C1753 M001164560 - CATHETER BLNDIL 6MM 40CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164570 SUP HCPCS C1753 M001164570 - CATHETER BLNDIL 6MM 75CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164580 SUP HCPCS C1753 M001164580 - CATHETER BLNDIL 6MM 120CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164590 SUP HCPCS C1753 M001164590 - CATHETER BLNDIL 6MM 150CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164600 SUP HCPCS C1753 M001164600 - CATHETER BLNDIL 6MM 75CM 30MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164610 SUP HCPCS C1753 M001164610 - CATHETER BLNDIL 6MM 120CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164620 SUP HCPCS C1753 M001164620 - CATHETER BLNDIL TPR 6MM 40CM 40MM U-T D OTW NC HDRPH PERI BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164630 SUP HCPCS C1753 M001164630 - CATHETER BLNDIL 6MM 75CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164640 SUP HCPCS C1753 M001164640 - CATHETER BLNDIL 6MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164650 SUP HCPCS C1753 M001164650 - CATHETER BLNDIL 6MM 150CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164680 SUP HCPCS C1753 M001164680 - CATHETER BLNDIL 6MM 40CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164690 SUP HCPCS C1726 M001164690 - CATHETER BLNDIL TPR 6MM 75CM 100MM U-T D OTW NC HDRPH PERI BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164700 SUP HCPCS C1726 M001164700 - CATHETER BLNDIL 6MM 120CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164710 SUP HCPCS C1753 M001164710 - CATHETER BLNDIL 6MM 150CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164720 SUP HCPCS C1753 M001164720 - CATHETER BLNDIL 7MM 40CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $509.93 $377.35 $0.00 $407.94 $276.89 $276.89 $0.00 $0.00 $0.00 $106.28 $378.47 $378.47 $0.00 $0.00 $106.27 $0.00 $301.62 $301.62 $0.00 $254.96 $403.86 $407.94 $0.00 $0.00 $79.80 $0.00 $0.00 $81.18 $0.00 $0.00 $0.00 $0.00 $0.00 M001164730 SUP HCPCS C1753 M001164730 - CATHETER BLNDIL 7MM 75CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164740 SUP HCPCS C1753 M001164740 - CATHETER BLNDIL 7MM 120CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164750 SUP HCPCS C1753 M001164750 - CATHETER BLNDIL 7MM 150CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164760 SUP HCPCS C1753 M001164760 - CATHETER BLNDIL 7MM 40CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164770 SUP HCPCS C1753 M001164770 - CATHETER BLNDIL 7MM 75CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164780 SUP HCPCS C1753 M001164780 - CATHETER BLNDIL 7MM 120CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164790 SUP HCPCS C1753 M001164790 - CATHETER BLNDIL 7MM 150CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164800 SUP HCPCS C1753 M001164800 - CATHETER BLNDIL 7MM 75CM 30MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164810 SUP HCPCS C1753 M001164810 - CATHETER BLNDIL 7MM 120CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164820 SUP HCPCS C1753 M001164820 - CATHETER BLNDIL TPR 7MM 40CM 40MM U-T D OTW NC HDRPH PERI BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164830 SUP HCPCS C1753 M001164830 - CATHETER BLNDIL 7MM 75CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164840 SUP HCPCS C1753 M001164840 - CATHETER BLNDIL 7MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164850 SUP HCPCS C1753 M001164850 - CATHETER BLNDIL 7MM 150CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164880 SUP HCPCS C1753 M001164880 - CATHETER BLNDIL 7MM 40CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164890 SUP HCPCS C1753 M001164890 - CATHETER BLNDIL TPR 7MM 75CM 100MM U-T D OTW NC HDRPH PERI BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164900 SUP HCPCS C1753 M001164900 - CATHETER BLNDIL 7MM 120CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164910 SUP HCPCS C1753 M001164910 - CATHETER BLNDIL 7MM 150CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164920 SUP HCPCS C1753 M001164920 - CATHETER BLNDIL 8MM 40CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164930 SUP HCPCS C1753 M001164930 - CATHETER BLNDIL 8MM 75CM 15MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164940 SUP HCPCS C1753 M001164940 - CATHETER BLNDIL 8MM 120CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164950 SUP HCPCS C1753 M001164950 - CATHETER BLNDIL 8MM 150CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164960 SUP HCPCS C1753 M001164960 - CATHETER BLNDIL 8MM 40CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164970 SUP HCPCS C1753 M001164970 - CATHETER BLNDIL 8MM 75CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164980 SUP HCPCS C1753 M001164980 - CATHETER BLNDIL 8MM 120CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001164990 SUP HCPCS C1753 M001164990 - CATHETER BLNDIL 8MM 150CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165000 SUP HCPCS C1753 M001165000 - CATHETER BLNDIL 8MM 40CM 30MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165010 SUP HCPCS C1726 M001165010 - CATHETER BLNDIL 8MM 75CM 30MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165020 SUP HCPCS C1753 M001165020 - CATHETER BLNDIL 8MM 120CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165030 SUP HCPCS C1753 M001165030 - CATHETER BLNDIL 8MM 150CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165040 SUP HCPCS C1753 M001165040 - CATHETER BLNDIL TPR 8MM 40CM 40MM U-T D OTW NC HDRPH PERI BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165050 SUP HCPCS C1753 M001165050 - CATHETER BLNDIL 8MM 75CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165060 SUP HCPCS C1753 M001165060 - CATHETER BLNDIL 8MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165070 SUP HCPCS C1753 M001165070 - CATHETER BLNDIL 8MM 150CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165080 SUP HCPCS C1753 M001165080 - CATHETER BLNDIL 8MM 40CM 80MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165090 SUP HCPCS C1753 M001165090 - CATHETER BLNDIL 8MM 75CM 80MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165100 SUP HCPCS C1753 M001165100 - CATHETER BLNDIL 8MM 120CM 80MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165110 SUP HCPCS C1753 M001165110 - CATHETER BLNDIL 8MM 150CM 80MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165120 SUP HCPCS C1753 M001165120 - CATHETER BLNDIL 9MM 40CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165130 SUP HCPCS C1753 M001165130 - CATHETER BLNDIL 9MM 75CM 20MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165140 SUP HCPCS C1753 M001165140 - CATHETER BLNDIL 9MM 120CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165150 SUP HCPCS C1753 M001165150 - CATHETER BLNDIL 9MM 150CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165160 SUP HCPCS C1753 M001165160 - CATHETER BLNDIL 9MM 40CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165170 SUP HCPCS C1753 M001165170 - CATHETER BLNDIL 9MM 75CM 40MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165180 SUP HCPCS C1753 M001165180 - CATHETER BLNDIL 9MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165190 SUP HCPCS C1753 M001165190 - CATHETER BLNDIL 9MM 150CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165200 SUP HCPCS C1753 M001165200 - CATHETER BLNDIL 10MM 40CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165210 SUP HCPCS C1753 M001165210 - CATHETER BLNDIL 10MM 75CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165220 SUP HCPCS C1753 M001165220 - CATHETER BLNDIL 10MM 120CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165230 SUP HCPCS C1753 M001165230 - CATHETER BLNDIL 10MM 150CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165240 SUP HCPCS C1753 M001165240 - CATHETER BLNDIL TPR 10MM 40CM 40MM U-T D OTW NC HDRPH PERI BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165250 SUP HCPCS C1753 M001165250 - CATHETER BLNDIL 10MM 75CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165260 SUP HCPCS C1753 M001165260 - CATHETER BLNDIL 10MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165270 SUP HCPCS C1753 M001165270 - CATHETER BLNDIL 10MM 150CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165290 SUP HCPCS C1726 M001165290 - CATHETER BLNDIL 12MM 75CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165300 SUP HCPCS C1753 M001165300 - CATHETER BLNDIL 12MM 120CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165330 SUP HCPCS C1753 M001165330 - CATHETER BLNDIL 12MM 75CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165340 SUP HCPCS C1753 M001165340 - CATHETER BLNDIL 12MM 120CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165550 SUP HCPCS C1753 M001165550 - CATHETER BLNDIL 4MM 75CM 60MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165560 SUP HCPCS C1753 M001165560 - CATHETER BLNDIL 4MM 120CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165590 SUP HCPCS C1753 M001165590 - CATHETER BLNDIL 5MM 75CM 60MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165600 SUP HCPCS C1753 M001165600 - CATHETER BLNDIL 5MM 120CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165630 SUP HCPCS C1753 M001165630 - CATHETER BLNDIL 6MM 75CM 60MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165640 SUP HCPCS C1753 M001165640 - CATHETER BLNDIL 6MM 120CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165670 SUP HCPCS C1753 M001165670 - CATHETER BLNDIL 7MM 75CM 60MM U-T D OTW 2 LUM TPR TIP HI-PRS BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001165680 SUP HCPCS C1753 M001165680 - CATHETER BLNDIL 7MM 120CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169410 SUP HCPCS C1753 M001169410 - CATHETER BLNDIL 3MM 135CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169420 SUP HCPCS C1753 M001169420 - CATHETER BLNDIL 3MM 135CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169430 SUP HCPCS C1753 M001169430 - CATHETER BLNDIL 3MM 135CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169440 SUP HCPCS C1753 M001169440 - CATHETER BLNDIL 4MM 135CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169450 SUP HCPCS C1753 M001169450 - CATHETER BLNDIL 4MM 135CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169460 SUP HCPCS C1753 M001169460 - CATHETER BLNDIL 4MM 135CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169470 SUP HCPCS C1753 M001169470 - CATHETER BLNDIL 4MM 135CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169480 SUP HCPCS C1753 M001169480 - CATHETER BLNDIL 4MM 135CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169490 SUP HCPCS C1753 M001169490 - CATHETER BLNDIL 4MM 135CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169510 SUP HCPCS C1753 M001169510 - CATHETER BLNDIL 5MM 135CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169520 SUP HCPCS C1753 M001169520 - CATHETER BLNDIL 5MM 135CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169530 SUP HCPCS C1753 M001169530 - CATHETER BLNDIL 5MM 135CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169540 SUP HCPCS C1753 M001169540 - CATHETER BLNDIL 5MM 135CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169550 SUP HCPCS C1753 M001169550 - CATHETER BLNDIL 5MM 135CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169570 SUP HCPCS C1753 M001169570 - CATHETER BLNDIL 6MM 135CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169580 SUP HCPCS C1753 M001169580 - CATHETER BLNDIL 6MM 135CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169590 SUP HCPCS C1753 M001169590 - CATHETER BLNDIL 6MM 135CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169600 SUP HCPCS C1753 M001169600 - CATHETER BLNDIL 6MM 135CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169610 SUP HCPCS C1753 M001169610 - CATHETER BLNDIL 6MM 135CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169620 SUP HCPCS C1753 M001169620 - CATHETER BLNDIL 7MM 135CM 15MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169630 SUP HCPCS C1753 M001169630 - CATHETER BLNDIL 7MM 135CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169640 SUP HCPCS C1753 M001169640 - CATHETER BLNDIL 7MM 135CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169650 SUP HCPCS C1753 M001169650 - CATHETER BLNDIL 7MM 135CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169660 SUP HCPCS C1753 M001169660 - CATHETER BLNDIL 7MM 135CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169670 SUP HCPCS C1753 M001169670 - CATHETER BLNDIL 7MM 135CM 100MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169690 SUP HCPCS C1753 M001169690 - CATHETER BLNDIL 8MM 135CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169700 SUP HCPCS C1753 M001169700 - CATHETER BLNDIL 8MM 135CM 30MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169710 SUP HCPCS C1753 M001169710 - CATHETER BLNDIL 8MM 135CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169720 SUP HCPCS C1753 M001169720 - CATHETER BLNDIL 8MM 135CM 60MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169730 SUP HCPCS C1753 M001169730 - CATHETER BLNDIL 8MM 135CM 80MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169740 SUP HCPCS C1753 M001169740 - CATHETER BLNDIL 9MM 135CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169750 SUP HCPCS C1753 M001169750 - CATHETER BLNDIL 9MM 135CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169760 SUP HCPCS C1753 M001169760 - CATHETER BLNDIL 10MM 135CM 20MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001169770 SUP HCPCS C1753 M001169770 - CATHETER BLNDIL 10MM 135CM 40MM U-T D OTW 2 LUM TPR TIP BOTH IP/OP $415.25 $307.29 $0.00 $332.20 $225.48 $225.48 $0.00 $0.00 $0.00 $86.55 $308.20 $308.20 $0.00 $0.00 $86.54 $0.00 $245.62 $245.62 $0.00 $207.63 $328.88 $332.20 $0.00 $0.00 $64.99 $0.00 $0.00 $66.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001171020 SUP Custom 27203010 M001171020 - CATHETER BALLOON OCCLUSION STANDARD 7FR 110.5MM 65CM 2 LUMEN BOTH IP/OP $471.45 $348.87 $0.00 $377.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $349.91 $349.91 $0.00 $0.00 $98.25 $0.00 $0.00 $0.00 $0.00 $235.73 $373.39 $377.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001171030 SUP HCPCS C2628 M001171030 - CATHETER BALLOON OCCLUSION STANDARD 7FR 110.5MM 100CM 2 BOTH IP/OP $471.45 $348.87 $0.00 $377.16 $0.00 $0.00 $0.00 $0.00 $0.00 $98.26 $349.91 $349.91 $0.00 $0.00 $98.25 $0.00 $278.86 $278.86 $0.00 $235.73 $373.39 $377.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001171050 SUP HCPCS C1726 M001171050 - CATHETER BALLOON OCCLUSION 14FR 20MM 65CM 2 LUMEN RADIOPQ BOTH IP/OP $605.65 $448.18 $0.00 $484.52 $328.87 $328.87 $0.00 $0.00 $0.00 $126.23 $449.51 $449.51 $0.00 $0.00 $126.22 $0.00 $358.24 $358.24 $0.00 $302.83 $479.67 $484.52 $0.00 $0.00 $94.78 $0.00 $0.00 $96.42 $0.00 $0.00 $0.00 $0.00 $0.00 M001171060 SUP HCPCS C1726 M001171060 - CATHETER BALLOON OCCLUSION 14FR 20MM 100CM 2 LUMEN GWIRE BOTH IP/OP $605.65 $448.18 $0.00 $484.52 $328.87 $328.87 $0.00 $0.00 $0.00 $126.23 $449.51 $449.51 $0.00 $0.00 $126.22 $0.00 $358.24 $358.24 $0.00 $302.83 $479.67 $484.52 $0.00 $0.00 $94.78 $0.00 $0.00 $96.42 $0.00 $0.00 $0.00 $0.00 $0.00 M001171070 SUP HCPCS C1726 M001171070 - CATHETER BALLOON OCCLUSION 7FR 27MM 65CM 2 LUMEN RADIOPQ BOTH IP/OP $605.65 $448.18 $0.00 $484.52 $328.87 $328.87 $0.00 $0.00 $0.00 $126.23 $449.51 $449.51 $0.00 $0.00 $126.22 $0.00 $358.24 $358.24 $0.00 $302.83 $479.67 $484.52 $0.00 $0.00 $94.78 $0.00 $0.00 $96.42 $0.00 $0.00 $0.00 $0.00 $0.00 M001171080 SUP HCPCS C1726 M001171080 - CATH BLNOCC .038IN 7FR 27MM 100CM 2 LUM EQLZR 10ML BOTH IP/OP $575.93 $426.19 $0.00 $460.74 $312.73 $312.73 $0.00 $0.00 $0.00 $120.04 $427.45 $427.45 $0.00 $0.00 $120.02 $0.00 $340.66 $340.66 $0.00 $287.96 $456.14 $460.74 $0.00 $0.00 $90.13 $0.00 $0.00 $91.69 $0.00 $0.00 $0.00 $0.00 $0.00 M001171090 SUP HCPCS C1726 M001171090 - CATHETER BALLOON OCCLUSION 7FR 33MM 65CM 2 LUMEN RADIOPQ BOTH IP/OP $605.65 $448.18 $0.00 $484.52 $328.87 $328.87 $0.00 $0.00 $0.00 $126.23 $449.51 $449.51 $0.00 $0.00 $126.22 $0.00 $358.24 $358.24 $0.00 $302.83 $479.67 $484.52 $0.00 $0.00 $94.78 $0.00 $0.00 $96.42 $0.00 $0.00 $0.00 $0.00 $0.00 M001171100 SUP HCPCS C1726 M001171100 - CATHETER BALLOON OCCLUSION 16FR 33MM 100CM 2 LUMEN RADIOPQ BOTH IP/OP $605.65 $448.18 $0.00 $484.52 $328.87 $328.87 $0.00 $0.00 $0.00 $126.23 $449.51 $449.51 $0.00 $0.00 $126.22 $0.00 $358.24 $358.24 $0.00 $302.83 $479.67 $484.52 $0.00 $0.00 $94.78 $0.00 $0.00 $96.42 $0.00 $0.00 $0.00 $0.00 $0.00 M001171110 SUP HCPCS C1726 M001171110 - CATHETER BALLOON OCCLUSION 7FR 40MM 65CM 2 LUMEN RADIOPQ BOTH IP/OP $605.65 $448.18 $0.00 $484.52 $328.87 $328.87 $0.00 $0.00 $0.00 $126.23 $449.51 $449.51 $0.00 $0.00 $126.22 $0.00 $358.24 $358.24 $0.00 $302.83 $479.67 $484.52 $0.00 $0.00 $94.78 $0.00 $0.00 $96.42 $0.00 $0.00 $0.00 $0.00 $0.00 M001171120 SUP HCPCS C1726 M001171120 - CATHETER BALLOON OCCLUSION 7FR 40MM 100CM 2 LUMEN RADIOPQ BOTH IP/OP $605.65 $448.18 $0.00 $484.52 $328.87 $328.87 $0.00 $0.00 $0.00 $126.23 $449.51 $449.51 $0.00 $0.00 $126.22 $0.00 $358.24 $358.24 $0.00 $302.83 $479.67 $484.52 $0.00 $0.00 $94.78 $0.00 $0.00 $96.42 $0.00 $0.00 $0.00 $0.00 $0.00 M001173010 SUP HCPCS C2628 M001173010 - CATHETER BALLOON OCCLUSION 6FR 11.5MM 80CM 2 LUMEN RADIOPQ BOTH IP/OP $471.45 $348.87 $0.00 $377.16 $0.00 $0.00 $0.00 $0.00 $0.00 $98.26 $349.91 $349.91 $0.00 $0.00 $98.25 $0.00 $278.86 $278.86 $0.00 $235.73 $373.39 $377.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001175000 SUP Custom 27203010 M001175000 - CATHETER BLNOCC .035IN 5FR 8.5MM 65CM EQLZR 2 LUM BOTH IP/OP $551.13 $407.84 $0.00 $440.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $409.04 $409.04 $0.00 $0.00 $114.85 $0.00 $0.00 $0.00 $0.00 $275.56 $436.49 $440.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001181250 SUP HCPCS C1887 M001181250 - MICROCATHETER INFS STRG 3-2.4FR 105CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,008.00 " $745.92 $0.00 $806.40 $547.34 $547.34 $0.00 $0.00 $0.00 $210.09 $748.14 $748.14 $0.00 $0.00 $210.07 $0.00 $596.23 $596.23 $0.00 $504.00 $798.34 $806.40 $0.00 $0.00 $157.75 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $0.00 M001181260 SUP HCPCS C1887 M001181260 - MICROCATHETER INFS STRG 3-2.4FR 105CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,008.00 " $745.92 $0.00 $806.40 $547.34 $547.34 $0.00 $0.00 $0.00 $210.09 $748.14 $748.14 $0.00 $0.00 $210.07 $0.00 $596.23 $596.23 $0.00 $504.00 $798.34 $806.40 $0.00 $0.00 $157.75 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $0.00 M001181270 SUP HCPCS C1887 M001181270 - MICROCATHETER INFS 90D 3-2.4FR 105CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,055.25 " $780.89 $0.00 $844.20 $573.00 $573.00 $0.00 $0.00 $0.00 $219.94 $783.21 $783.21 $0.00 $0.00 $219.91 $0.00 $624.18 $624.18 $0.00 $527.63 $835.76 $844.20 $0.00 $0.00 $165.15 $0.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001181280 SUP HCPCS C1887 M001181280 - MICROCATHETER INFS 90D 3-2.4FR 105CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,055.25 " $780.89 $0.00 $844.20 $573.00 $573.00 $0.00 $0.00 $0.00 $219.94 $783.21 $783.21 $0.00 $0.00 $219.91 $0.00 $624.18 $624.18 $0.00 $527.63 $835.76 $844.20 $0.00 $0.00 $165.15 $0.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001181310 SUP HCPCS C1887 M001181310 - MICROCATHETER INFS STRG 3-2.4FR 130CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,008.00 " $745.92 $0.00 $806.40 $547.34 $547.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $504.00 $798.34 $806.40 $0.00 $0.00 $157.75 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $0.00 M001181320 SUP HCPCS C1887 M001181320 - MICROCATHETER INFS STRG 3-2.4FR 130CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,008.00 " $745.92 $0.00 $806.40 $547.34 $547.34 $0.00 $0.00 $0.00 $210.09 $748.14 $748.14 $0.00 $0.00 $210.07 $0.00 $596.23 $596.23 $0.00 $504.00 $798.34 $806.40 $0.00 $0.00 $157.75 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $0.00 M001181330 SUP HCPCS C1887 M001181330 - MICROCATHETER INFS 90D 3-2.4FR 130CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,055.25 " $780.89 $0.00 $844.20 $573.00 $573.00 $0.00 $0.00 $0.00 $219.94 $783.21 $783.21 $0.00 $0.00 $219.91 $0.00 $624.18 $624.18 $0.00 $527.63 $835.76 $844.20 $0.00 $0.00 $165.15 $0.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001181340 SUP HCPCS C1887 M001181340 - MICROCATHETER INFS 90D 3-2.4FR 130CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,055.25 " $780.89 $0.00 $844.20 $573.00 $573.00 $0.00 $0.00 $0.00 $219.94 $783.21 $783.21 $0.00 $0.00 $219.91 $0.00 $624.18 $624.18 $0.00 $527.63 $835.76 $844.20 $0.00 $0.00 $165.15 $0.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001181370 SUP HCPCS C1887 M001181370 - MICROCATHETER INFS STRG 3-2.4FR 150CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,008.00 " $745.92 $0.00 $806.40 $547.34 $547.34 $0.00 $0.00 $0.00 $210.09 $748.14 $748.14 $0.00 $0.00 $210.07 $0.00 $596.23 $596.23 $0.00 $504.00 $798.34 $806.40 $0.00 $0.00 $157.75 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $0.00 M001181380 SUP HCPCS C1887 M001181380 - MICROCATHETER INFS STRG 3-2.4FR 150CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,008.00 " $745.92 $0.00 $806.40 $547.34 $547.34 $0.00 $0.00 $0.00 $210.09 $748.14 $748.14 $0.00 $0.00 $210.07 $0.00 $596.23 $596.23 $0.00 $504.00 $798.34 $806.40 $0.00 $0.00 $157.75 $0.00 $0.00 $160.47 $0.00 $0.00 $0.00 $0.00 $0.00 M001181390 SUP HCPCS C1887 M001181390 - MICROCATHETER INFS 90D 3-2.4FR 150CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,055.25 " $780.89 $0.00 $844.20 $573.00 $573.00 $0.00 $0.00 $0.00 $219.94 $783.21 $783.21 $0.00 $0.00 $219.91 $0.00 $624.18 $624.18 $0.00 $527.63 $835.76 $844.20 $0.00 $0.00 $165.15 $0.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001181400 SUP HCPCS C1887 M001181400 - MICROCATHETER INFS 90D 3-2.4FR 150CM RNGD STC 18 RADOPQ BOTH IP/OP "$1,055.25 " $780.89 $0.00 $844.20 $573.00 $573.00 $0.00 $0.00 $0.00 $219.94 $783.21 $783.21 $0.00 $0.00 $219.91 $0.00 $624.18 $624.18 $0.00 $527.63 $835.76 $844.20 $0.00 $0.00 $165.15 $0.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001182590 SUP HCPCS C1887 M001182590 - MICROCATHETER INFS 3-2.5FR 150CM RNGD RADOPQ BRD DIST TIP BOTH IP/OP "$1,959.90 " "$1,450.33" $0.00 "$1,454.64" $902.74 $902.74 $0.00 $0.00 $0.00 $408.49 "$1,454.64" "$1,454.64" $0.00 $0.00 $408.44 $0.00 "$1,159.28" "$1,159.28" $0.00 $831.25 "$1,316.70" "$1,330.00" $0.00 $0.00 $260.18 $0.00 $0.00 $264.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001182830 SUP HCPCS C1751 M001182830 - CATHETER INFUS MICRO 3-2.8FR .027IN 80CM 20CM KIT RADIOPQ BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182840 SUP HCPCS C1751 M001182840 - CATHETER INFUS STR 20.8-30FR .027IN 105CM 10CM RENEGADE BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182850 SUP HCPCS C1751 M001182850 - CATHETER INFUS MICRO 3-2.8FR .027IN 105CM 20CM KIT RADIOPQ BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182860 SUP HCPCS C1751 M001182860 - CATHETER INFUS MICRO 3-2.8FR .027IN 115CM 10CM KIT RADIOPQ BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182870 SUP HCPCS C1751 M001182870 - CATHETER INFUS MICRO 3-2.8FR .027IN 115CM 20CM KIT RADIOPQ BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182880 SUP HCPCS C1751 M001182880 - CATHETER INFUS MICRO 3-2.8FR .027IN 135CM 10CM KIT RADIOPQ BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182890 SUP HCPCS C1751 M001182890 - CATHETER INFUS MICRO 3-2.8FR .027IN 135CM 20CM KIT RADIOPQ BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182900 SUP HCPCS C1751 M001182900 - CATHETER INFUS MICRO 3-2.8FR .027IN 150CM 10CM KIT RADIOPQ BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182910 SUP HCPCS C1751 M001182910 - CATHETER INFUS MICRO 3-2.8FR .027IN 150CM 20CM KIT RADIOPQ BOTH IP/OP $899.60 $665.70 $0.00 $719.68 $488.48 $488.48 $0.00 $0.00 $0.00 $187.50 $667.68 $667.68 $0.00 $0.00 $187.48 $0.00 $532.11 $532.11 $0.00 $449.80 $712.48 $719.68 $0.00 $0.00 $140.79 $0.00 $0.00 $143.22 $0.00 $0.00 $0.00 $0.00 $0.00 M001182920 SUP HCPCS C1887 M001182920 - CATHETER INFUS 105CM KIT MICROCATHETER RADIOPQ MARKER BOTH IP/OP "$1,193.53 " $883.21 $0.00 $954.82 $648.08 $648.08 $0.00 $0.00 $0.00 $248.76 $885.83 $885.83 $0.00 $0.00 $248.73 $0.00 $705.97 $705.97 $0.00 $596.76 $945.28 $954.82 $0.00 $0.00 $186.79 $0.00 $0.00 $190.01 $0.00 $0.00 $0.00 $0.00 $0.00 M001182930 SUP HCPCS C1887 M001182930 - CATHETER INFUS 105CM KIT RADIOPQ BRAID HI-FLO RENEGADE MICRO BOTH IP/OP "$1,193.53 " $883.21 $0.00 $954.82 $648.08 $648.08 $0.00 $0.00 $0.00 $248.76 $885.83 $885.83 $0.00 $0.00 $248.73 $0.00 $705.97 $705.97 $0.00 $596.76 $945.28 $954.82 $0.00 $0.00 $186.79 $0.00 $0.00 $190.01 $0.00 $0.00 $0.00 $0.00 $0.00 M001182940 SUP HCPCS C1887 M001182940 - CATHETER INFUS 115CM KIT RADIOPQ BRAID HI-FLO RENEGADE MICRO BOTH IP/OP "$1,193.53 " $883.21 $0.00 $954.82 $648.08 $648.08 $0.00 $0.00 $0.00 $248.76 $885.83 $885.83 $0.00 $0.00 $248.73 $0.00 $705.97 $705.97 $0.00 $596.76 $945.28 $954.82 $0.00 $0.00 $186.79 $0.00 $0.00 $190.01 $0.00 $0.00 $0.00 $0.00 $0.00 M001182950 SUP HCPCS C1887 M001182950 - CATHETER INFUS 115CM KIT RADIOPQ BRAID HI-FLO RENEGADE MICRO BOTH IP/OP "$1,193.53 " $883.21 $0.00 $954.82 $648.08 $648.08 $0.00 $0.00 $0.00 $248.76 $885.83 $885.83 $0.00 $0.00 $248.73 $0.00 $705.97 $705.97 $0.00 $596.76 $945.28 $954.82 $0.00 $0.00 $186.79 $0.00 $0.00 $190.01 $0.00 $0.00 $0.00 $0.00 $0.00 M001182960 SUP HCPCS C1887 M001182960 - CATHETER INFUS 135CM KIT RADIOPQ BRAID HI-FLO RENEGADE MICRO BOTH IP/OP "$1,193.53 " $883.21 $0.00 $954.82 $648.08 $648.08 $0.00 $0.00 $0.00 $248.76 $885.83 $885.83 $0.00 $0.00 $248.73 $0.00 $705.97 $705.97 $0.00 $596.76 $945.28 $954.82 $0.00 $0.00 $186.79 $0.00 $0.00 $190.01 $0.00 $0.00 $0.00 $0.00 $0.00 M001182970 SUP HCPCS C1887 M001182970 - CATHETER INFUS 135CM KIT RADIOPQ BRAID HI-FLO RENEGADE MICRO BOTH IP/OP "$1,193.53 " $883.21 $0.00 $954.82 $648.08 $648.08 $0.00 $0.00 $0.00 $248.76 $885.83 $885.83 $0.00 $0.00 $248.73 $0.00 $705.97 $705.97 $0.00 $596.76 $945.28 $954.82 $0.00 $0.00 $186.79 $0.00 $0.00 $190.01 $0.00 $0.00 $0.00 $0.00 $0.00 M001184500 SUP HCPCS C1887 M001184500 - GUIDEWIRE VASCULAR .016IN 105CM 10CM PRELOAD HI-FLO RENEGADE BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $836.22 $836.22 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 M001184510 SUP HCPCS C1887 M001184510 - GUIDEWIRE VASCULAR .016IN 105CM 20CM PRELOAD HI-FLO RENEGADE BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $836.22 $836.22 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 M001184520 SUP HCPCS C1887 M001184520 - GUIDEWIRE VASCULAR .016IN 115CM 10CM PRELOAD HI-FLO RENEGADE BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $836.22 $836.22 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 M001184530 SUP HCPCS C1887 M001184530 - GUIDEWIRE VASCULAR .016IN 115CM 20CM PRELOAD HI-FLO RENEGADE BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $836.22 $836.22 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 M001184540 SUP HCPCS C1887 M001184540 - CATHETER GUID 10CM MICRO 2.8-3FR 180CM 135CM KIT STEERABLE BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $836.22 $836.22 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 M001184550 SUP HCPCS C1887 M001184550 - MICROCATHETER INFS .016IN 3-2.8FR 180CM RNGD HFL FATHOM BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $836.22 $836.22 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 M001184560 SUP HCPCS C1887 M001184560 - MICROCATHETER INFS .016IN 3-2.8FR 180CM RNGD HFL FATHOM BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $836.22 $836.22 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 M001184570 SUP HCPCS C1887 M001184570 - MICROCATHETER INFS .016IN 3-2.8FR 180CM RNGD HFL FATHOM BOTH IP/OP "$1,540.00 " "$1,139.60" $0.00 "$1,232.00" $836.22 $836.22 $0.00 $0.00 $0.00 $320.97 "$1,142.99" "$1,142.99" $0.00 $0.00 $320.94 $0.00 $910.91 $910.91 $0.00 $770.00 "$1,219.68" "$1,232.00" $0.00 $0.00 $241.01 $0.00 $0.00 $245.17 $0.00 $0.00 $0.00 $0.00 $0.00 M001196000 SUP HCPCS C1887 M001196000 - CATHETER GD HS CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196040 SUP HCPCS C1887 M001196040 - CATHETER GD RE S 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196080 SUP HCPCS C1887 M001196080 - CATHETER GD RE SS CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196120 SUP HCPCS C1887 M001196120 - CATHETER GD RE1 CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196160 SUP HCPCS C1887 M001196160 - CATHETER GD C1 CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196200 SUP HCPCS C1887 M001196200 - CATHETER GD C2 CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196230 SUP HCPCS C1887 M001196230 - CATHETER GD MP CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196260 SUP HCPCS C1887 M001196260 - CATHETER GD MP CRV 6FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196300 SUP HCPCS C1887 M001196300 - CATHETER GD MP2 CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196330 SUP HCPCS C1887 M001196330 - CATHETER GD MP2 CRV 6FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196380 SUP HCPCS C1887 M001196380 - CATHETER GD 40D 6FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 RND BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196450 SUP HCPCS C1887 M001196450 - CATHETER GD ST CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196480 SUP HCPCS C1887 M001196480 - CATHETER GD ST CRV 6FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196530 SUP HCPCS C1887 M001196530 - CATHETER GD XVR 1 CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196560 SUP HCPCS C1887 M001196560 - CATHETER GD XVR 2 CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196620 SUP HCPCS C1887 M001196620 - CATHETER GD LIMA CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196660 SUP HCPCS C1887 M001196660 - CATHETER GD RDC CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196700 SUP HCPCS C1887 M001196700 - CATHETER GD BATES 1 CRV 6FR 55CM STRL LF MACH1 LG LUM SH BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196800 SUP HCPCS C1887 M001196800 - CATHETER GD BATES 2 CRV 6FR 55CM STRL LF MACH1 LG LUM SH BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001196960 SUP HCPCS C1887 M001196960 - CATHETER GD RDC1 CRV 6FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197000 SUP HCPCS C1887 M001197000 - CATHETER GD HS CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197040 SUP HCPCS C1887 M001197040 - CATHETER GD RE S 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197080 SUP HCPCS C1887 M001197080 - CATHETER GD RE SS CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197120 SUP HCPCS C1887 M001197120 - CATHETER GD RE L CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197160 SUP HCPCS C1887 M001197160 - CATHETER GD C1 CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197200 SUP HCPCS C1887 M001197200 - CATHETER GD C2 CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197230 SUP HCPCS C1887 M001197230 - CATHETER GD MP CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197260 SUP HCPCS C1887 M001197260 - CATHETER GD MP CRV 7FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197300 SUP HCPCS C1887 M001197300 - CATHETER GD MP2 CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197330 SUP HCPCS C1887 M001197330 - CATHETER GD MP2 CRV 7FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197380 SUP HCPCS C1887 M001197380 - CATHETER GD 40D 7FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 RND BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197450 SUP HCPCS C1887 M001197450 - CATHETER GD ST CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197480 SUP HCPCS C1887 M001197480 - CATHETER GD ST CRV 7FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197530 SUP HCPCS C1887 M001197530 - CATHETER GD XVR 1 CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197560 SUP HCPCS C1887 M001197560 - CATHETER GD XVR 2 CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197620 SUP HCPCS C1887 M001197620 - CATHETER GD LIMA CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197660 SUP HCPCS C1887 M001197660 - CATHETER GD RDC CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197700 SUP HCPCS C1887 M001197700 - CATHETER GD BATES 1 CRV 7FR 55CM STRL LF MACH1 LG LUM SH BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197800 SUP HCPCS C1887 M001197800 - CATHETER GD BATES 2 CRV 7FR 55CM STRL LF MACH1 LG LUM SH BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001197960 SUP HCPCS C1887 M001197960 - CATHETER GD RDC1 CRV 7FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198000 SUP HCPCS C1887 M001198000 - CATHETER GD HS CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198040 SUP HCPCS C1887 M001198040 - CATHETER GD RE S 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198080 SUP HCPCS C1887 M001198080 - CATHETER GD RE SS CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198120 SUP HCPCS C1887 M001198120 - CATHETER GD RE L CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198160 SUP HCPCS C1887 M001198160 - CATHETER GD C1 CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198200 SUP HCPCS C1887 M001198200 - CATHETER GD C2 CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198230 SUP HCPCS C1887 M001198230 - CATHETER GD MP CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198260 SUP HCPCS C1887 M001198260 - CATHETER GD MP CRV 8FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198300 SUP HCPCS C1887 M001198300 - CATHETER GD MP2 CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198330 SUP HCPCS C1887 M001198330 - CATHETER GD MP2 CRV 8FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198380 SUP HCPCS C1887 M001198380 - CATHETER GD 40D 8FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 RND BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198450 SUP HCPCS C1887 M001198450 - CATHETER GD ST CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198480 SUP HCPCS C1887 M001198480 - CATHETER GD ST CRV 8FR 90CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198530 SUP HCPCS C1887 M001198530 - CATHETER GD XVR 1 CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198560 SUP HCPCS C1887 M001198560 - CATHETER GD XVR 2 CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198620 SUP HCPCS C1887 M001198620 - CATHETER GD LIMA CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198660 SUP HCPCS C1887 M001198660 - CATHETER GD RDC CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2X2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198700 SUP HCPCS C1887 M001198700 - CATHETER GD BATES 1 CRV 8FR 55CM STRL LF MACH1 LG LUM SH BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198800 SUP HCPCS C1887 M001198800 - CATHETER GD BATES 2 CRV 8FR 55CM STRL LF MACH1 LG LUM SH BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001198960 SUP HCPCS C1887 M001198960 - CATHETER GD RDC1 CRV 8FR 55CM STRL LF MACH1 LG LUM RADOPQ 2 BOTH IP/OP $214.50 $158.73 $0.00 $171.60 $116.47 $116.47 $0.00 $0.00 $0.00 $44.71 $159.20 $159.20 $0.00 $0.00 $44.70 $0.00 $126.88 $126.88 $0.00 $107.25 $169.88 $171.60 $0.00 $0.00 $33.57 $0.00 $0.00 $34.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001206130 SUP HCPCS C1892 M001206130 - INTRODUCER SHTH 11FR 30CM BNA PL PLWY COAX LCK TPR PE BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $73.31 $73.31 $0.00 $0.00 $0.00 $28.14 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $79.85 $79.85 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $21.13 $0.00 $0.00 $21.49 $0.00 $0.00 $0.00 $0.00 $0.00 M001207020 SUP HCPCS C1894 M001207020 - INTROD SHTH 6FR 4FR 20CM COAX DILAT JTP HVDTY FLPY XSTIF BOTH IP/OP $63.13 $46.72 $0.00 $186.50 $126.59 $126.59 $0.00 $0.00 $0.00 $13.16 $46.85 $46.85 $0.00 $0.00 $13.16 $0.00 $37.34 $37.34 $0.00 $116.56 $184.64 $186.50 $0.00 $0.00 $36.48 $0.00 $0.00 $37.11 $0.00 $0.00 $0.00 $0.00 $0.00 M001207030 SUP HCPCS C1894 M001207030 - SYSTEM INTROD .018IN .038IN FLOPPY STR 6FR 4FR 60CM 145CM 2 BOTH IP/OP $189.38 $140.14 $0.00 $151.50 $102.83 $102.83 $0.00 $0.00 $0.00 $39.47 $140.55 $140.55 $0.00 $0.00 $39.47 $0.00 $112.02 $112.02 $0.00 $94.69 $149.99 $151.50 $0.00 $0.00 $29.64 $0.00 $0.00 $30.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001207040 SUP HCPCS C1892 M001207040 - SYSTEM INTROD .038IN FLOPPY 6FR 4FR 60CM 20CM DILAT RADIOPQ BOTH IP/OP $151.88 $112.39 $0.00 $121.50 $82.47 $82.47 $0.00 $0.00 $0.00 $31.65 $112.72 $112.72 $0.00 $0.00 $31.65 $0.00 $89.83 $89.83 $0.00 $75.94 $120.29 $121.50 $0.00 $0.00 $23.77 $0.00 $0.00 $24.18 $0.00 $0.00 $0.00 $0.00 $0.00 M001207050 SUP HCPCS C1894 M001207050 - SYSTEM INTROD 6FR ACCUSTICK II STERILE DISPOSABLE BOTH IP/OP $120.00 $88.80 $0.00 $96.00 $65.16 $65.16 $0.00 $0.00 $0.00 $25.01 $89.06 $89.06 $0.00 $0.00 $25.01 $0.00 $70.98 $70.98 $0.00 $60.00 $95.04 $96.00 $0.00 $0.00 $18.78 $0.00 $0.00 $19.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001207111 SUP HCPCS C1729 M001207111 - INTRODUCER SHEATH .018IN FLOPPY 60CM 6CM RADIOPQ GWIRE BOTH IP/OP $451.88 $334.39 $0.00 $361.50 $245.37 $245.37 $0.00 $0.00 $0.00 $94.18 $335.38 $335.38 $0.00 $0.00 $94.17 $0.00 $267.28 $267.28 $0.00 $225.94 $357.89 $361.50 $0.00 $0.00 $70.72 $0.00 $0.00 $71.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001208500 SUP Custom 27203010 M001208500 - SET GSTRM 18GA BVL NDL AFFIXATION DEV BR-MLR TFSTNR SET BOTH IP/OP $131.25 $97.13 $0.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.41 $97.41 $0.00 $0.00 $27.35 $0.00 $0.00 $0.00 $0.00 $65.63 $103.95 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001221000 SUP HCPCS C1729 M001221000 - CATHETER DRAIN 8FR 30CM LOCK STIFFEN CANNU AMPLATZ ANCHOR BOTH IP/OP $189.38 $140.14 $0.00 $151.50 $102.83 $102.83 $0.00 $0.00 $0.00 $39.47 $140.55 $140.55 $0.00 $0.00 $39.47 $0.00 $112.02 $112.02 $0.00 $94.69 $149.99 $151.50 $0.00 $0.00 $29.64 $0.00 $0.00 $30.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001221010 SUP HCPCS C1729 M001221010 - CATHETER DRAIN 10FR 30CM LOCK STIFFEN CANNU AMPLATZ ANCHOR BOTH IP/OP $189.38 $140.14 $0.00 $151.50 $102.83 $102.83 $0.00 $0.00 $0.00 $39.47 $140.55 $140.55 $0.00 $0.00 $39.47 $0.00 $112.02 $112.02 $0.00 $94.69 $149.99 $151.50 $0.00 $0.00 $29.64 $0.00 $0.00 $30.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001221020 SUP HCPCS C2617 M001221020 - CATHETER DRAIN 12FR 30CM LOCK STIFFEN CANNU LATEX FREE BOTH IP/OP $189.38 $140.14 $0.00 $151.50 $85.22 $85.22 $0.00 $0.00 $0.00 $39.47 $140.55 $140.55 $0.00 $0.00 $39.47 $0.00 $112.02 $112.02 $0.00 $94.69 $149.99 $151.50 $0.00 $0.00 $29.64 $0.00 $0.00 $30.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001221360 SUP HCPCS C2617 M001221360 - STENT URETERAL LARGE REGULAR PROXIMAL PIGTAIL CURVE 2.66MM BOTH IP/OP $245.63 $181.77 $0.00 $196.50 $110.53 $110.53 $0.00 $0.00 $0.00 $51.19 $182.30 $182.30 $0.00 $0.00 $51.19 $0.00 $145.29 $145.29 $0.00 $122.81 $194.54 $196.50 $0.00 $0.00 $38.44 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001221370 SUP HCPCS C2617 M001221370 - STENT URETERAL LARGE REGULAR PROXIMAL PIGTAIL CURVE 2.66MM BOTH IP/OP $245.63 $181.77 $0.00 $196.50 $110.53 $110.53 $0.00 $0.00 $0.00 $51.19 $182.30 $182.30 $0.00 $0.00 $51.19 $0.00 $145.29 $145.29 $0.00 $122.81 $194.54 $196.50 $0.00 $0.00 $38.44 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001221380 SUP HCPCS C2617 M001221380 - STENT NEPHROURETERAL 2.66MM 26CM STIFFENING CANNU INTERNAL BOTH IP/OP $245.63 $181.77 $0.00 $196.50 $110.53 $110.53 $0.00 $0.00 $0.00 $51.19 $182.30 $182.30 $0.00 $0.00 $51.19 $0.00 $145.29 $145.29 $0.00 $122.81 $194.54 $196.50 $0.00 $0.00 $38.44 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001221390 SUP HCPCS C2617 M001221390 - STENT URETERAL LARGE REGULAR PROXIMAL PIGTAIL CURVE 2.66MM BOTH IP/OP $245.63 $181.77 $0.00 $196.50 $110.53 $110.53 $0.00 $0.00 $0.00 $51.19 $182.30 $182.30 $0.00 $0.00 $51.19 $0.00 $145.29 $145.29 $0.00 $122.81 $194.54 $196.50 $0.00 $0.00 $38.44 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001221400 SUP HCPCS C2617 M001221400 - STENT URETERAL LARGE REGULAR PROXIMAL PIGTAIL CURVE 3.33MM BOTH IP/OP $245.63 $181.77 $0.00 $196.50 $110.53 $110.53 $0.00 $0.00 $0.00 $51.19 $182.30 $182.30 $0.00 $0.00 $51.19 $0.00 $145.29 $145.29 $0.00 $122.81 $194.54 $196.50 $0.00 $0.00 $38.44 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001221410 SUP HCPCS C2617 M001221410 - STENT URETERAL LARGE REGULAR PROXIMAL PIGTAIL CURVE 3.33MM BOTH IP/OP $245.63 $181.77 $0.00 $196.50 $110.53 $110.53 $0.00 $0.00 $0.00 $51.19 $182.30 $182.30 $0.00 $0.00 $51.19 $0.00 $145.29 $145.29 $0.00 $122.81 $194.54 $196.50 $0.00 $0.00 $38.44 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001221420 SUP HCPCS C2617 M001221420 - STENT URETERAL LARGE REGULAR PROXIMAL PIGTAIL CURVE 3.33MM BOTH IP/OP $245.63 $181.77 $0.00 $196.50 $110.53 $110.53 $0.00 $0.00 $0.00 $51.19 $182.30 $182.30 $0.00 $0.00 $51.19 $0.00 $145.29 $145.29 $0.00 $122.81 $194.54 $196.50 $0.00 $0.00 $38.44 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001221430 SUP HCPCS C2617 M001221430 - STENT URETERAL LARGE REGULAR PROXIMAL PIGTAIL CURVE 3.33MM BOTH IP/OP $245.63 $181.77 $0.00 $196.50 $110.53 $110.53 $0.00 $0.00 $0.00 $51.19 $182.30 $182.30 $0.00 $0.00 $51.19 $0.00 $145.29 $145.29 $0.00 $122.81 $194.54 $196.50 $0.00 $0.00 $38.44 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001225140 SUP HCPCS C1729 M001225140 - SET NEPHROSTOMY PIGTAIL CURVE 8FR FIRM DUROMETER LOCK VTC BOTH IP/OP $176.25 $130.43 $0.00 $141.00 $95.70 $95.70 $0.00 $0.00 $0.00 $36.73 $130.81 $130.81 $0.00 $0.00 $36.73 $0.00 $104.25 $104.25 $0.00 $88.13 $139.59 $141.00 $0.00 $0.00 $27.58 $0.00 $0.00 $28.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001225510 SUP HCPCS C2617 M001225510 - STENT URET .038IN LG REG PGTL CRV 8FR 24CM DRMTR RADOPQ DRN BOTH IP/OP $313.50 $231.99 $0.00 $250.80 $141.08 $141.08 $0.00 $0.00 $0.00 $65.34 $232.68 $232.68 $0.00 $0.00 $65.33 $0.00 $185.44 $185.44 $0.00 $156.75 $248.29 $250.80 $0.00 $0.00 $49.06 $0.00 $0.00 $49.91 $0.00 $0.00 $0.00 $0.00 $0.00 M001225520 SUP HCPCS C1768 STENT URET 8FR 26CM REG DRMTR LG DRAIN HOLE PROX PGTL LCK BOTH IP/OP $303.28 $224.43 $0.00 $242.62 $136.47 $136.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.64 $240.20 $242.62 $0.00 $0.00 $47.46 $0.00 $0.00 $48.28 $0.00 $0.00 $0.00 $0.00 $0.00 M001262160 SUP Custom 27203010 M001262160 - NEEDLE ELECTROSURGICAL STANDARD UMBRELLA 5CM 15CM ARRAY TIP BOTH IP/OP "$5,362.50 " "$3,968.25" $0.00 "$4,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,980.05" "$3,980.05" $0.00 $0.00 "$1,117.55" $0.00 $0.00 $0.00 $0.00 "$2,681.25" "$4,247.10" "$4,290.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001271460 SUP HCPCS C1729 M001271460 - CATHETER DRAIN LOOP 8FR 25CM QUICKSTICK FLEXIMA HYDPHI BOTH IP/OP $170.18 $125.93 $0.00 $136.14 $92.41 $92.41 $0.00 $0.00 $0.00 $35.47 $126.30 $126.30 $0.00 $0.00 $35.46 $0.00 $100.66 $100.66 $0.00 $85.09 $134.78 $136.14 $0.00 $0.00 $26.63 $0.00 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $0.00 M001271470 SUP HCPCS C1729 M001271470 - CATHETER DRAIN LOOP 10FR 25CM QUICKSTICK FLEXIMA HYDPHI BOTH IP/OP $170.18 $125.93 $0.00 $136.14 $92.41 $92.41 $0.00 $0.00 $0.00 $35.47 $126.30 $126.30 $0.00 $0.00 $35.46 $0.00 $100.66 $100.66 $0.00 $85.09 $134.78 $136.14 $0.00 $0.00 $26.63 $0.00 $0.00 $27.09 $0.00 $0.00 $0.00 $0.00 $0.00 M001271540 SUP HCPCS C1729 M001271540 - CATHETER DRAIN PIGTAIL CURVE 8FR 35CM FLEXIBLE STIFF CANNU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271550 SUP HCPCS C1729 M001271550 - CATHETER DRAIN 10FR 35CM METAL AND FLEXIBLE STIFFENING CANNU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271560 SUP HCPCS C1729 M001271560 - CATHETER DRAIN PIGTAIL CURVE 8FR 35CM FLEXIBLE STIFF CANNU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271570 SUP HCPCS C1729 M001271570 - CATHETER DRAIN PIGTAIL CURVE 10FR 35CM FLEXIBLE STIFF CANNU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271580 SUP HCPCS C1729 M001271580 - CATHETER DRAIN PIGTAIL CURVE 12FR 35CM FLEXIBLE STIFF CANNU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271590 SUP HCPCS C1729 M001271590 - CATHETER DRAIN PIGTAIL CURVE 14FR 35CM FLEXIBLE STIFF CANNU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271600 SUP HCPCS C1729 M001271600 - CATHETER DRAIN PIGTAIL CURVE 10FR 35CM FLEXIBLE STIFF CANNU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271610 SUP HCPCS C1729 M001271610 - CATHETER DRN PGTL CRV 12FR 35CM FLXB STF CNN LCK DRMTR SFT BOTH IP/OP $235.25 $174.09 $0.00 $188.20 $127.74 $127.74 $0.00 $0.00 $0.00 $49.03 $174.60 $174.60 $0.00 $0.00 $49.03 $0.00 $139.15 $139.15 $0.00 $117.63 $186.32 $188.20 $0.00 $0.00 $36.82 $0.00 $0.00 $37.45 $0.00 $0.00 $0.00 $0.00 $0.00 M001271620 SUP HCPCS C1729 M001271620 - CATHETER DRAIN PIGTAIL CURVE 14FR 35CM FLEXIBLE STIFF CANNU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271630 SUP HCPCS C1729 M001271630 - KIT DRAIN 8FR 35CM FIRM DUROMETER LARGE HOLE FLEXIMA BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $186.79 $186.79 $0.00 $0.00 $0.00 $71.70 $255.32 $255.32 $0.00 $0.00 $71.69 $0.00 $203.48 $203.48 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $53.84 $0.00 $0.00 $54.76 $0.00 $0.00 $0.00 $0.00 $0.00 M001271640 SUP HCPCS C1729 M001271640 - KIT DRAIN 10FR 35CM FIRM DUROMETER LARGE HOLE FLEXIMA BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $186.79 $186.79 $0.00 $0.00 $0.00 $71.70 $255.32 $255.32 $0.00 $0.00 $71.69 $0.00 $203.48 $203.48 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $53.84 $0.00 $0.00 $54.76 $0.00 $0.00 $0.00 $0.00 $0.00 M001271650 SUP HCPCS C1729 M001271650 - CATHETER DRAIN REGULAR PIGTAIL CURVE 8FR 35CM KIT LOCK BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $186.79 $186.79 $0.00 $0.00 $0.00 $71.70 $255.32 $255.32 $0.00 $0.00 $71.69 $0.00 $203.48 $203.48 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $53.84 $0.00 $0.00 $54.76 $0.00 $0.00 $0.00 $0.00 $0.00 M001271660 SUP HCPCS C1729 M001271660 - KIT DRAIN REGULAR 10FR 35CM DUROMETER LARGE HOLE FLEXIMA BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $186.79 $186.79 $0.00 $0.00 $0.00 $71.70 $255.32 $255.32 $0.00 $0.00 $71.69 $0.00 $203.48 $203.48 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $53.84 $0.00 $0.00 $54.76 $0.00 $0.00 $0.00 $0.00 $0.00 M001271770 SUP HCPCS C1729 M001271770 - CATHETER NEPHROSTOMY PIGTAIL CURVE 8FR 25CM LOCK DUROMETER BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271780 SUP HCPCS C1729 M001271780 - CATHETER NEPHROSTOMY PIGTAIL CURVE 10FR 25CM LOCK DUROMETER BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271790 SUP HCPCS C1729 M001271790 - CATHETER NEPHROSTOMY REGULAR PIGTAIL CURVE 8FR 25CM LOCK BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271800 SUP HCPCS C1729 M001271800 - CATHETER NEPHROSTOMY REGULAR PIGTAIL CURVE 10FR 25CM LOCK BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271810 SUP HCPCS C1729 M001271810 - CATHETER NEPHROSTOMY PIGTAIL CURVE 12FR 25CM LOCK DUROMETER BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271820 SUP Custom 27203010 M001271820 - CATHETER NEPHROSTOMY PIGTAIL CURVE 14FR 25CM LOCK DUROMETER BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $0.00 $0.00 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001271830 SUP HCPCS C1726 M001271830 - CATHETER NEPHROSTOMY PIGTAIL CURVE 10FR 25CM LOCK DUROMETER BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271840 SUP HCPCS C1729 M001271840 - CATHETER DRAIN 12FR 25CM RADIOPQ SOFT DUROMETER TEMP TIP BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271850 SUP HCPCS C1729 M001271850 - CATHETER NPHSTM PGTL CRV 14FR 25CM LCK SFT DRMTR FLXM PU BOTH IP/OP $190.30 $140.82 $0.00 $152.24 $103.33 $103.33 $0.00 $0.00 $0.00 $39.66 $141.24 $141.24 $0.00 $0.00 $39.66 $0.00 $112.56 $112.56 $0.00 $95.15 $150.72 $152.24 $0.00 $0.00 $29.78 $0.00 $0.00 $30.30 $0.00 $0.00 $0.00 $0.00 $0.00 M001271860 SUP Custom 27203010 M001271860 - SET NEPHROSTOMY PIGTAIL CURVE 8FR 25CM LOCK REGULAR BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.32 $255.32 $0.00 $0.00 $71.69 $0.00 $0.00 $0.00 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001271870 SUP Custom 27203010 M001271870 - KIT NEPHROSTOMY PIGTAIL CURVE 10FR 25CM LOCK REGULAR BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.32 $255.32 $0.00 $0.00 $71.69 $0.00 $0.00 $0.00 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001271880 SUP Custom 27203010 M001271880 - KIT NEPHROSTOMY PIGTAIL CURVE 12FR 25CM LOCK REGULAR BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.32 $255.32 $0.00 $0.00 $71.69 $0.00 $0.00 $0.00 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001271900 SUP Custom 27203010 M001271900 - KIT NEPHROSTOMY J PIGTAIL CURVE 18FR 21GA 25CM DUROMETER BOTH IP/OP $344.00 $254.56 $0.00 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.32 $255.32 $0.00 $0.00 $71.69 $0.00 $0.00 $0.00 $0.00 $172.00 $272.45 $275.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001272600 SUP HCPCS C1729 M001272600 - CATH DRAIN 8FR 35CM LCK PGTL REG DRMTR RADIOPQ BIL PU HYDPHI BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001272610 SUP HCPCS C1729 M001272610 - CATH DRAIN 10FR 35CM LCK REG DRMTR RADIOPQ BIL PU HYDPHI BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001272620 SUP HCPCS C1729 M001272620 - CATH DRAIN 12FR 35CM LCK REG DRMTR RADIOPQ BIL PU HYDPHI BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001272630 SUP HCPCS C1729 M001272630 - CATH DRAIN 14FR 35CM LCK PGTL REG DRMTR RADIOPQ BIL PU FLXM BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001272640 SUP HCPCS C1729 M001272640 - CATH DRAIN 8FR 35CM LCK FIRM DRMTR RADIOPQ BIL PU HYDPHI BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001272650 SUP HCPCS C1729 M001272650 - CATH DRAIN 10FR 35CM LCK REG DRMTR RADIOPQ BIL PU HYDPHI BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001272660 SUP HCPCS C1729 M001272660 - CATH DRAIN 10FR 35CM LCK SFT DRMTR RADIOPQ BIL PU HYDPHI BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001272670 SUP HCPCS C1729 M001272670 - CATH DRAIN 12FR 35CM LCK SFT DRMTR RADIOPQ BIL PU HYDPHI BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001273130 SUP HCPCS C1729 M001273130 - CATHETER DRAIN 30CM 2 LUMEN REGULAR DUROMETER VANSONNENBERG BOTH IP/OP $364.25 $269.55 $0.00 $291.40 $197.79 $197.79 $0.00 $0.00 $0.00 $75.92 $270.35 $270.35 $0.00 $0.00 $75.91 $0.00 $215.45 $215.45 $0.00 $182.13 $288.49 $291.40 $0.00 $0.00 $57.01 $0.00 $0.00 $57.99 $0.00 $0.00 $0.00 $0.00 $0.00 M001274000 SUP HCPCS C2617 M001274000 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 2.66MM 20CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274010 SUP HCPCS C2617 M001274010 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 2.66MM 22CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274020 SUP HCPCS C2617 M001274020 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 2.66MM 24CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274030 SUP HCPCS C2617 M001274030 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 2.66MM 26CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274040 SUP HCPCS C2617 M001274040 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 2.66MM 28CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274050 SUP HCPCS C2617 M001274050 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 3.33MM 20CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274060 SUP HCPCS C2617 M001274060 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 3.33MM 22CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274070 SUP HCPCS C2617 M001274070 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 3.33MM 24CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274080 SUP HCPCS C2617 M001274080 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 3.33MM 26CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274090 SUP HCPCS C2617 M001274090 - STENT URETERAL LARGE REGULAR PIGTAIL CURVE 3.33MM 28CM BOTH IP/OP $266.25 $197.03 $0.00 $213.00 $119.81 $119.81 $0.00 $0.00 $0.00 $55.49 $197.61 $197.61 $0.00 $0.00 $55.49 $0.00 $157.49 $157.49 $0.00 $133.13 $210.87 $213.00 $0.00 $0.00 $41.67 $0.00 $0.00 $42.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001274110 SUP HCPCS C2617 M001274110 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 6FR 22CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001274120 SUP HCPCS C2617 M001274120 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 6FR 24CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001274130 SUP HCPCS C2617 M001274130 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 6FR 26CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001274140 SUP HCPCS C2617 M001274140 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 6FR 28CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001274150 SUP HCPCS C2617 M001274150 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 8FR 20CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001274160 SUP HCPCS C2617 M001274160 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 8FR 22CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001274170 SUP HCPCS C2617 M001274170 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 8FR 24CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001274180 SUP HCPCS C2617 M001274180 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 8FR 26CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001274190 SUP HCPCS C2617 M001274190 - KIT STENT .038IN LARGE REGULAR PIGTAIL CURVE 8FR 28CM DRAIN BOTH IP/OP $423.75 $313.58 $0.00 $339.00 $190.69 $190.69 $0.00 $0.00 $0.00 $88.32 $314.51 $314.51 $0.00 $0.00 $88.31 $0.00 $250.65 $250.65 $0.00 $211.88 $335.61 $339.00 $0.00 $0.00 $66.32 $0.00 $0.00 $67.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001281560 SUP HCPCS C1729 M001281560 - CATHETER DRAIN 8FR 35CM 1 LUMEN REGULAR DUROMETER FLEXIBLE BOTH IP/OP $197.63 $146.25 $0.00 $158.10 $107.31 $107.31 $0.00 $0.00 $0.00 $41.19 $146.68 $146.68 $0.00 $0.00 $41.19 $0.00 $116.90 $116.90 $0.00 $98.81 $156.52 $158.10 $0.00 $0.00 $30.93 $0.00 $0.00 $31.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001281570 SUP HCPCS C1729 M001281570 - CATHETER DRAIN 10FR 35CM REGULAR DUROMETER DISSOLVABLE TIP BOTH IP/OP $197.63 $146.25 $0.00 $158.10 $107.31 $107.31 $0.00 $0.00 $0.00 $41.19 $146.68 $146.68 $0.00 $0.00 $41.19 $0.00 $116.90 $116.90 $0.00 $98.81 $156.52 $158.10 $0.00 $0.00 $30.93 $0.00 $0.00 $31.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001281580 SUP HCPCS C1729 M001281580 - CATHETER DRAIN REGULAR 12FR 35CM TEMP TIP FLEXIMA HYDPHI BOTH IP/OP $197.63 $146.25 $0.00 $158.10 $107.31 $107.31 $0.00 $0.00 $0.00 $41.19 $146.68 $146.68 $0.00 $0.00 $41.19 $0.00 $116.90 $116.90 $0.00 $98.81 $156.52 $158.10 $0.00 $0.00 $30.93 $0.00 $0.00 $31.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001281590 SUP HCPCS C1729 M001281590 - CATHETER DRAIN 14FR 35CM REGULAR DUROMETER DISSOLVABLE TIP BOTH IP/OP $197.63 $146.25 $0.00 $158.10 $107.31 $107.31 $0.00 $0.00 $0.00 $41.19 $146.68 $146.68 $0.00 $0.00 $41.19 $0.00 $116.90 $116.90 $0.00 $98.81 $156.52 $158.10 $0.00 $0.00 $30.93 $0.00 $0.00 $31.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001281660 SUP Custom 27203010 M001281660 - KIT NEPHROSTOMY .018IN PIGTAIL CURVE FLOPPY 10FR 21GA 25CM BOTH IP/OP $364.13 $269.46 $0.00 $291.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.25 $270.25 $0.00 $0.00 $75.88 $0.00 $0.00 $0.00 $0.00 $182.06 $288.39 $291.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001281790 SUP HCPCS C1726 M001281790 - CATHETER NEPHROSTOMY PIGTAIL CURVE 8FR 25CM LOCK REGULAR BOTH IP/OP $197.63 $146.25 $0.00 $158.10 $107.31 $107.31 $0.00 $0.00 $0.00 $41.19 $146.68 $146.68 $0.00 $0.00 $41.19 $0.00 $116.90 $116.90 $0.00 $98.81 $156.52 $158.10 $0.00 $0.00 $30.93 $0.00 $0.00 $31.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001281800 SUP HCPCS C1729 M001281800 - CATHETER NEPHROSTOMY PIGTAIL CURVE 10FR 25CM LOCK SOFT BOTH IP/OP $197.63 $146.25 $0.00 $158.10 $107.31 $107.31 $0.00 $0.00 $0.00 $41.19 $146.68 $146.68 $0.00 $0.00 $41.19 $0.00 $116.90 $116.90 $0.00 $98.81 $156.52 $158.10 $0.00 $0.00 $30.93 $0.00 $0.00 $31.46 $0.00 $0.00 $0.00 $0.00 $0.00 M001281810 SUP Custom 27203010 M001281810 - CATHETER NEPHROSTOMY 12FR 25CM REGULAR DUROMETER DRAIN HOLE BOTH IP/OP $197.63 $146.25 $0.00 $158.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.68 $146.68 $0.00 $0.00 $41.19 $0.00 $0.00 $0.00 $0.00 $98.81 $156.52 $158.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001281820 SUP Custom 27203010 M001281820 - CATHETER NEPHROSTOMY PIGTAIL CURVE 14FR 25CM LOCK REGULAR BOTH IP/OP $197.63 $146.25 $0.00 $158.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.68 $146.68 $0.00 $0.00 $41.19 $0.00 $0.00 $0.00 $0.00 $98.81 $156.52 $158.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001282600 SUP HCPCS C1729 M001282600 - CATH DRAIN 8FR 35CM LCK REG DRMTR TMPTP RADIOPQ BIL PU BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001282610 SUP HCPCS C1729 M001282610 - CATH DRAIN 10FR 35CM LCK TEMP TIP RADIOPQ BIL PU HYDPHI FLXM BOTH IP/OP $200.63 $148.47 $0.00 $160.50 $108.94 $108.94 $0.00 $0.00 $0.00 $41.82 $148.90 $148.90 $0.00 $0.00 $41.81 $0.00 $118.67 $118.67 $0.00 $100.31 $158.90 $160.50 $0.00 $0.00 $31.40 $0.00 $0.00 $31.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001291650 SUP HCPCS C1729 M001291650 - KIT DRAIN 35CM 8FR PU HYDPHI FLXM BIL REG DRMTR STRL DISP BOTH IP/OP $402.85 $298.11 $0.00 $322.28 $218.75 $218.75 $0.00 $0.00 $0.00 $83.96 $299.00 $299.00 $0.00 $0.00 $83.95 $0.00 $238.29 $238.29 $0.00 $201.43 $319.06 $322.28 $0.00 $0.00 $63.05 $0.00 $0.00 $64.13 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120021 SUP Custom 27803010 M0013120021 - COIL EMBOLIZATION .018IN HELIX STR 2MM PLATINUM FIBER BOTH IP/OP $136.50 $101.01 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.31 $101.31 $0.00 $0.00 $28.45 $0.00 $0.00 $0.00 $0.00 $68.25 $108.11 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120051 SUP Custom 27803010 M0013120051 - COIL EMBOLIZATION STR 2MM 50MM 5MM 18 COIL PLATINUM FIBER BOTH IP/OP $136.50 $101.01 $0.00 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.31 $101.31 $0.00 $0.00 $28.45 $0.00 $0.00 $0.00 $0.00 $68.25 $108.11 $109.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120211 SUP Custom 27803010 M0013120211 - COIL EMBOLIZATION 2MM 5MM 10MM 8-18 COIL FIBERED PLATINUM BOTH IP/OP $198.83 $147.13 $0.00 $159.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.57 $147.57 $0.00 $0.00 $41.44 $0.00 $0.00 $0.00 $0.00 $99.42 $157.47 $159.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120221 SUP Custom 27803010 M0013120221 - COIL EMBOLIZATION .018IN HELIX 4MM 4MM COMPLEX PLATINUM BOTH IP/OP $994.15 $735.67 $0.00 $795.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $737.86 $737.86 $0.00 $0.00 $207.18 $0.00 $0.00 $0.00 $0.00 $497.08 $787.37 $795.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120331 SUP Custom 27803010 M0013120331 - COIL EMBOLIZATION .018IN HELIX 6MM 6MM COMPLEX PLATINUM BOTH IP/OP $198.83 $147.13 $0.00 $159.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.57 $147.57 $0.00 $0.00 $41.44 $0.00 $0.00 $0.00 $0.00 $99.42 $157.47 $159.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120431 SUP Custom 27803010 M0013120431 - COIL EMBOLIZATION .018IN HELIX 4MM 30MM COMPLEX PLATINUM BOTH IP/OP "$1,025.05 " $758.54 $0.00 $820.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.79 $760.79 $0.00 $0.00 $213.62 $0.00 $0.00 $0.00 $0.00 $512.53 $811.84 $820.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120441 SUP Custom 27803010 M0013120441 - COIL EMBOLIZATION .018IN HELIX 7MM 10MM COMPLEX PLATINUM BOTH IP/OP $205.01 $151.71 $0.00 $164.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.16 $152.16 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.51 $162.37 $164.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120551 SUP Custom 27803010 M0013120551 - COIL EMBOLIZATION .018IN HELICAL 8MM 12MM FIBERED COMPLEX BOTH IP/OP "$1,025.05 " $758.54 $0.00 $820.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.79 $760.79 $0.00 $0.00 $213.62 $0.00 $0.00 $0.00 $0.00 $512.53 $811.84 $820.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120661 SUP Custom 27803010 M0013120661 - COIL EMBOLIZATION .018IN HELICAL COMPLEX 10MM 14MM 60MM BOTH IP/OP $205.01 $151.71 $0.00 $164.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.16 $152.16 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.51 $162.37 $164.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0013120771 SUP Custom 27803010 M0013120771 - COIL EMBOLIZATION .018IN HELIX 11MM 17MM COMPLEX PLATINUM BOTH IP/OP $205.01 $151.71 $0.00 $164.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.16 $152.16 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.51 $162.37 $164.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001314001 SUP HCPCS C1725 M001314001 - CATHETER ANGIOGRAPHIC MULTPUR SHORT TIP CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314011 SUP HCPCS C1725 M001314011 - CATHETER ANGIOGRAPHIC MULTPUR SHORT TIP CURVE 5FR 100CM BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314021 SUP HCPCS C1725 M001314021 - CATHETER ANGIOGRAPHIC MULTPUR SHORT TIP CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314031 SUP HCPCS C1725 M001314031 - CATHETER ANGIOGRAPHIC STR 5FR 100CM BRAID TORQUE SELECTIVE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314041 SUP HCPCS C1725 M001314041 - CATHETER ANGIOGRAPHIC BERN CURVE FLUTE TAPER 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314051 SUP HCPCS C1725 M001314051 - CATHETER ANGIOGRAPHIC BERENSTEIN CURVE 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314061 SUP HCPCS C1725 M001314061 - CATHETER ANGIOGRAPHIC BERENSTEIN CURVE 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314071 SUP HCPCS C1725 M001314071 - CATHETER ANGIOGRAPHIC BERENSTEIN CURVE 5FR 40CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314081 SUP HCPCS C1887 M001314081 - CATHETER ANGIOGRAPHIC BERENSTEIN CURVE 5FR 40CM BRAID TORQUE BOTH IP/OP $127.40 $94.28 $0.00 $101.92 $69.18 $69.18 $0.00 $0.00 $0.00 $26.55 $94.56 $94.56 $0.00 $0.00 $26.55 $0.00 $75.36 $75.36 $0.00 $63.70 $100.90 $101.92 $0.00 $0.00 $19.94 $0.00 $0.00 $20.28 $0.00 $0.00 $0.00 $0.00 $0.00 M001314101 SUP HCPCS C1725 M001314101 - CATHETER ANGIOGRAPHIC BERENSTEIN CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314111 SUP HCPCS C1725 M001314111 - CATHETER ANGIOGRAPHIC WEIN CURVE FLUTE TAPER 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314121 SUP HCPCS C1725 M001314121 - CATHETER ANGIOGRAPHIC WEIN CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314131 SUP HCPCS C1725 M001314131 - CATHETER ANGIOGRAPHIC HEADHUNTER 1 CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314141 SUP HCPCS C1725 M001314141 - CATHETER ANGIOGRAPHIC HEADHUNTER 1 CURVE 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314151 SUP HCPCS C1725 M001314151 - CATHETER ANGIO HDHNTR 1 CRV 5FR 100CM IMGR2 BRD TRQ SLCT BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314161 SUP HCPCS C1725 M001314161 - CATHETER ANGIOGRAPHIC HEADHUNTER 3 CURVE 5FR 100CM TAPER TIP BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314171 SUP HCPCS C1725 M001314171 - CATHETER ANGIOGRAPHIC HEADHUNTER 3 CURVE 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314181 SUP HCPCS C1725 M001314181 - CATHETER ANGIOGRAPHIC HEADHUNTER 1 HEADHUNTER CURVE 5FR 100 BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314191 SUP HCPCS C1725 M001314191 - CATHETER ANGIOGRAPHIC HEADHUNTER 1 HEADHUNTER CURVE 5FR 100 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314201 SUP HCPCS C1725 M001314201 - CATHETER ANGIOGRAPHIC HEADHUNTER 3 HEADHUNTER CURVE 5FR 100 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314211 SUP HCPCS C1725 M001314211 - CATHETER ANGIOGRAPHIC BENTSON 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314221 SUP HCPCS C1725 M001314221 - CATHETER ANGIOGRAPHIC BENTSON 1 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314231 SUP HCPCS C1725 M001314231 - CATHETER ANGIOGRAPHIC BENTSON 1 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314241 SUP HCPCS C1725 M001314241 - CATHETER ANGIOGRAPHIC BENTSON 2 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314251 SUP HCPCS C1725 M001314251 - CATHETER ANGIOGRAPHIC BENTSON 2 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314261 SUP HCPCS C1725 M001314261 - CATHETER ANGIOGRAPHIC BENTSON 3 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314271 SUP HCPCS C1725 M001314271 - CATHETER ANGIOGRAPHIC BENTSON 3 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314281 SUP HCPCS C1725 M001314281 - CATHETER ANGIOGRAPHIC MANN CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314291 SUP HCPCS C1725 M001314291 - CATHETER ANGIOGRAPHIC MANN CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314301 SUP HCPCS C1725 M001314301 - CATHETER ANGIOGRAPHIC SIMMONS 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314311 SUP HCPCS C1725 M001314311 - CATHETER ANGIOGRAPHIC SIMMONS 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314321 SUP HCPCS C1725 M001314321 - CATHETER ANGIOGRAPHIC SIMMONS 1 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314331 SUP HCPCS C1725 M001314331 - CATHETER ANGIOGRAPHIC SIMMONS 1 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314341 SUP HCPCS C1725 M001314341 - CATHETER ANGIOGRAPHIC SIMMONS 2 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314351 SUP HCPCS C1725 M001314351 - CATHETER ANGIOGRAPHIC SIMMONS 2 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314361 SUP HCPCS C1725 M001314361 - CATHETER ANGIOGRAPHIC SIMMONS 3 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314371 SUP HCPCS C1725 M001314371 - CATHETER ANGIOGRAPHIC SIMMONS 3 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314381 SUP HCPCS C1725 M001314381 - CATHETER ANGIOGRAPHIC SIMMONS 4 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314391 SUP HCPCS C1725 M001314391 - CATHETER ANGIOGRAPHIC NEWTON 1 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314401 SUP HCPCS C1725 M001314401 - CATHETER ANGIOGRAPHIC NEWTON 1 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314411 SUP HCPCS C1725 M001314411 - CATHETER ANGIOGRAPHIC NEWTON 2 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314421 SUP HCPCS C1725 M001314421 - CATHETER ANGIOGRAPHIC NEWTON 2 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314431 SUP HCPCS C1725 M001314431 - CATHETER ANGIOGRAPHIC NEWTON 3 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314441 SUP HCPCS C1725 M001314441 - CATHETER ANGIOGRAPHIC NEWTON 3 CURVE 5FR 100CM TAPER TIP BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314451 SUP HCPCS C1725 M001314451 - CATHETER ANGIOGRAPHIC NEWTON 4 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314461 SUP HCPCS C1725 M001314461 - CATHETER ANGIOGRAPHIC NEWTON 4 CURVE 5FR 100CM TAPER TIP BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314471 SUP HCPCS C1725 M001314471 - CATHETER ANGIOGRAPHIC NEWTON 5 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314481 SUP HCPCS C1725 M001314481 - CATHETER ANGIOGRAPHIC NEWTON 5 CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314491 SUP HCPCS C1725 M001314491 - CATHETER ANGIOGRAPHIC CK CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314501 SUP HCPCS C1725 M001314501 - CATHETER ANGIOGRAPHIC MULTPUR GEN CURVE 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314511 SUP HCPCS C1725 M001314511 - CATHETER ANGIOGRAPHIC MULTPUR GEN CURVE 5FR 100CM BRAID BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314521 SUP HCPCS C1725 M001314521 - CATHETER ANGIOGRAPHIC CHUANG B CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314531 SUP HCPCS C1725 M001314531 - CATHETER ANGIOGRAPHIC CHUANG B CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314541 SUP HCPCS C1725 M001314541 - CATHETER ANGIOGRAPHIC CHUANG C CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314551 SUP HCPCS C1725 M001314551 - CATHETER ANGIOGRAPHIC CHUANG C CURVE 5FR 65CM TAPER TIP BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314561 SUP HCPCS C1725 M001314561 - CATHETER ANGIOGRAPHIC CHUANG 2.5 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314571 SUP HCPCS C1725 M001314571 - CATHETER ANGIOGRAPHIC CHUANG 2.5 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314581 SUP HCPCS C1725 M001314581 - CATHETER ANGIOGRAPHIC CONTRALATERAL 2 CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314591 SUP HCPCS C1726 M001314591 - CATHETER ANGIOGRAPHIC CONTRALATERAL 2 CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314601 SUP HCPCS C1725 M001314601 - CATHETER ANGIOGRAPHIC DUCK CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314611 SUP HCPCS C1725 M001314611 - CATHETER ANGIOGRAPHIC DUCK CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314621 SUP HCPCS C1725 M001314621 - CATHETER ANGIOGRAPHIC COBRA 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314631 SUP HCPCS C1725 M001314631 - CATHETER ANGIOGRAPHIC COBRA 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314641 SUP HCPCS C1725 M001314641 - CATHETER ANGIOGRAPHIC COBRA 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314651 SUP HCPCS C1725 M001314651 - CATHETER ANGIOGRAPHIC COBRA 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314661 SUP HCPCS C1725 M001314661 - CATHETER ANGIOGRAPHIC COBRA 2 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314671 SUP HCPCS C1725 M001314671 - CATHETER ANGIOGRAPHIC COBRA 2 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314681 SUP HCPCS C1725 M001314681 - CATHETER ANGIOGRAPHIC COBRA 2 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314691 SUP HCPCS C1725 M001314691 - CATHETER ANGIOGRAPHIC COBRA 2 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314701 SUP HCPCS C1725 M001314701 - CATHETER ANGIOGRAPHIC COBRA 3 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314711 SUP HCPCS C1725 M001314711 - CATHETER ANGIOGRAPHIC COBRA 3 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314721 SUP HCPCS C1725 M001314721 - CATHETER ANGIOGRAPHIC COBRA 3 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314731 SUP HCPCS C1725 M001314731 - CATHETER ANGIOGRAPHIC COBRA 3 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314741 SUP HCPCS C1725 M001314741 - CATHETER ANGIOGRAPHIC VAN ANDEL 2 CURVE 5FR 65CM BRAID BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314751 SUP HCPCS C1725 M001314751 - CATHETER ANGIOGRAPHIC TRAIN CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314761 SUP HCPCS C1725 M001314761 - CATHETER ANGIOGRAPHIC MIKELSON CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314771 SUP HCPCS C1725 M001314771 - CATHETER ANGIOGRAPHIC MIKELSON CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314781 SUP HCPCS C1725 M001314781 - CATHETER ANGIOGRAPHIC HK 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314791 SUP HCPCS C1725 M001314791 - CATHETER ANGIOGRAPHIC HK 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314801 SUP HCPCS C1725 M001314801 - CATHETER ANGIOGRAPHIC SHEPHERD HOOK .8 CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314811 SUP HCPCS C1725 M001314811 - CATHETER ANGIOGRAPHIC SHEPHERD HOOK .8 CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314821 SUP HCPCS C1725 M001314821 - CATHETER ANGIOGRAPHIC SHEPHERD HOOK 1 CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314831 SUP HCPCS C1725 M001314831 - CATHETER ANGIOGRAPHIC SHEPHERD HOOK 1 CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314841 SUP HCPCS C1725 M001314841 - CATHETER ANGIOGRAPHIC ROSCH 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314851 SUP HCPCS C1725 M001314851 - CATHETER ANGIOGRAPHIC ROSCH 1 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314861 SUP HCPCS C1725 M001314861 - CATHETER ANGIOGRAPHIC ROSCH 2 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314871 SUP HCPCS C1725 M001314871 - CATHETER ANGIOGRAPHIC ROSCH 2 CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314881 SUP HCPCS C1725 M001314881 - CATHETER ANGIOGRAPHIC RENAL DOUBLE CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314891 SUP HCPCS C1725 M001314891 - CATHETER ANGIOGRAPHIC RENAL DOUBLE CURVE 5FR 65CM BRAID BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001314901 SUP HCPCS C1725 M001314901 - CATHETER ANGIOGRAPHIC RENAL DOUBLE CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001314911 SUP HCPCS C1725 M001314911 - CATHETER ANGIOGRAPHIC RENAL DOUBLE CURVE 5FR 65CM BRAID BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001315001 SUP HCPCS C1725 M001315001 - CATHETER ANGIOGRAPHIC TENNIS RACQUET CURVE 4FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315011 SUP HCPCS C1725 M001315011 - CATHETER ANGIOGRAPHIC .035IN TENNIS RACQUET CURVE 4FR 90CM BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315021 SUP HCPCS C1725 M001315021 - CATHETER ANGIOGRAPHIC TENNIS RACQUET CURVE 4FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315031 SUP HCPCS C1725 M001315031 - CATHETER ANGIOGRAPHIC TENNIS RACQUET CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315041 SUP HCPCS C1725 M001315041 - CATHETER ANGIOGRAPHIC TENNIS RACQUET CURVE 5FR 90CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315051 SUP HCPCS C1725 M001315051 - CATHETER ANGIOGRAPHIC .035IN TENNIS RACQUET CURVE 5FR 100CM BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315061 SUP HCPCS C1725 M001315061 - CATHETER ANGIOGRAPHIC TENNIS RACQUET CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315071 SUP HCPCS C1725 M001315071 - CATHETER ANGIOGRAPHIC .038IN TENNIS RACQUET CURVE 5FR 90CM BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315081 SUP HCPCS C1725 M001315081 - CATHETER ANGIOGRAPHIC TENNIS RACQUET CURVE 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315091 SUP HCPCS C1725 M001315091 - CATHETER ANGIOGRAPHIC PIGTAIL CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315101 SUP HCPCS C1725 M001315101 - CATHETER ANGIOGRAPHIC STR FLUSH CURVE 4FR 65CM HIGH FLOW BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315111 SUP HCPCS C1725 M001315111 - CATHETER ANGIOGRAPHIC .035IN 4FR 90CM PIGTAIL IMAGER II BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315121 SUP HCPCS C1725 M001315121 - CATHETER ANGIOGRAPHIC STR 4FR 90CM BRAID TORQUE SELECTIVE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315131 SUP HCPCS C1726 M001315131 - CATHETER ANGIOGRAPHIC PIGTAIL FLUSH CURVE 5FR 65CM HIGH FLOW BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315141 SUP HCPCS C1725 M001315141 - CATHETER ANGIOGRAPHIC PIGTAIL CURVE 5FR 90CM TAPER TIP FLUTE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315151 SUP HCPCS C1725 M001315151 - CATHETER ANGIOGRAPHIC PIGTAIL CURVE 5FR 100CM TAPER TIP BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315161 SUP HCPCS C1725 M001315161 - CATHETER ANGIOGRAPHIC STR FLUSH CURVE 5FR 65CM HIGH FLOW BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315171 SUP HCPCS C1725 M001315171 - CATHETER ANGIOGRAPHIC STR FLUSH CURVE 5FR 90CM HIGH FLOW BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315181 SUP HCPCS C1725 M001315181 - CATHETER ANGIOGRAPHIC STR 5FR 100CM BRAID TORQUE SELECTIVE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315191 SUP HCPCS C1725 M001315191 - CATHETER ANGIOGRAPHIC PIGTAIL CURVE 5FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M00131520 SUP HCPCS C1725 M00131520 - CATHETER ANGIOGRAPHIC STR 5FR 65CM BRAID TORQUE SELECTIVE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315201 SUP HCPCS C1725 M001315201 - CATHETER ANGIOGRAPHIC STR 5FR 65CM BRAID TORQUE SELECTIVE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315211 SUP HCPCS C1725 M001315211 - CATHETER ANGIOGRAPHIC PIGTAIL CURVE 5FR 90CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315221 SUP HCPCS C1725 M001315221 - CATHETER ANGIOGRAPHIC STR 5FR 90CM TAPER TIP FLUTE HUB BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315231 SUP HCPCS C1725 M001315231 - CATHETER ANGIOGRAPHIC PIGTAIL CURVE 5FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315241 SUP HCPCS C1725 M001315241 - CATHETER ANGIOGRAPHIC STR 5FR 100CM BRAID TORQUE SELECTIVE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315251 SUP HCPCS C1725 M001315251 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 4FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315261 SUP HCPCS C1725 M001315261 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 4FR 90CM IMAGER II BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315271 SUP HCPCS C1725 M001315271 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 4FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315281 SUP HCPCS C1726 M001315281 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 5FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315291 SUP HCPCS C1725 M001315291 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 5FR 90CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315301 SUP HCPCS C1725 M001315301 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315311 SUP HCPCS C1725 M001315311 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 5FR 65CM TAPER TIP BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315321 SUP HCPCS C1725 M001315321 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 5FR 90CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001315331 SUP HCPCS C1725 M001315331 - CATHETER ANGIOGRAPHIC CONTRALATERAL CURVE 5FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316021 SUP HCPCS C1725 M001316021 - CATHETER ANGIOGRAPHIC MULTPUR SHORT TIP CURVE 4FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316031 SUP HCPCS C1725 M001316031 - CATHETER ANGIOGRAPHIC SHORT TIP CURVE 4FR 100CM TAPER TIP BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316041 SUP HCPCS C1725 M001316041 - CATHETER ANGIOGRAPHIC BARNH CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316061 SUP HCPCS C1725 M001316061 - CATHETER ANGIOGRAPHIC .035IN BERN CURVE 4FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316071 SUP HCPCS C1725 M001316071 - CATHETER ANGIOGRAPHIC BERNSTEIN CURVE 4FR 40CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316091 SUP HCPCS C1725 M001316091 - CATHETER ANGIOGRAPHIC BERENSTEIN CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316121 SUP HCPCS C1725 M001316121 - CATHETER ANGIOGRAPHIC WEINBERG CEREBRAL CURVE 4FR 100CM BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316131 SUP HCPCS C1725 M001316131 - CATHETER ANGIOGRAPHIC HEADHUNTER 1 CURVE 4FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316151 SUP HCPCS C1725 M001316151 - CATHETER ANGIOGRAPHIC HEADHUNTER 1 CURVE 4FR 100CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316171 SUP HCPCS C1725 M001316171 - CATHETER ANGIOGRAPHIC HEADHUNTER 3 CURVE 4FR 100CM BRAID BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316191 SUP HCPCS C1725 M001316191 - CATHETER ANGIOGRAPHIC HEADHUNTER 1 HEADHUNTER CURVE 4FR 100 BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316201 SUP HCPCS C1725 M001316201 - CATHETER ANGIOGRAPHIC HEADHUNTER 3 HEADHUNTER CURVE 4FR 100 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316211 SUP HCPCS C1725 M001316211 - CATHETER ANGIOGRAPHIC BENTSON 1 CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316231 SUP HCPCS C1725 M001316231 - CATHETER ANGIOGRAPHIC BENTSON 1 CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316251 SUP HCPCS C1725 M001316251 - CATHETER ANGIOGRAPHIC BENTSON 2 CURVE 4FR 100CM TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316271 SUP HCPCS C1725 M001316271 - CATHETER ANGIOGRAPHIC BENTSON 3 CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316291 SUP HCPCS C1725 M001316291 - CATHETER ANGIOGRAPHIC MANI CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316311 SUP HCPCS C1725 M001316311 - CATHETER ANGIOGRAPHIC SIMMONS 1 CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316331 SUP HCPCS C1725 M001316331 - CATHETER ANGIOGRAPHIC SIMMONS 1 CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316351 SUP HCPCS C1725 M001316351 - CATHETER ANGIOGRAPHIC SIMMONS 2 CURVE 4FR 100CM TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316371 SUP HCPCS C1725 M001316371 - CATHETER ANGIOGRAPHIC SIM3 CURVE 4FR 100CM BRAID IMAGER II BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316381 SUP HCPCS C1725 M001316381 - CATHETER ANGIOGRAPHIC SIMMONS 4 CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316401 SUP HCPCS C1725 M001316401 - CATHETER ANGIOGRAPHIC NEWTON 1 CURVE 4FR 100CM TORQUE SELECT BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316421 SUP HCPCS C1725 M001316421 - CATHETER ANGIOGRAPHIC NEWTON 2 CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316441 SUP HCPCS C1725 M001316441 - CATHETER ANGIOGRAPHIC NEWTON 3 CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316461 SUP HCPCS C1725 M001316461 - CATHETER ANGIOGRAPHIC NEWTON 4 CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316481 SUP HCPCS C1725 M001316481 - CATHETER ANGIOGRAPHIC NEWTON 5 CURVE 4FR 100CM BRAID IMAGER BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316491 SUP HCPCS C1725 M001316491 - CATHETER ANGIOGRAPHIC CK CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316511 SUP HCPCS C1725 M001316511 - CATHETER ANGIOGRAPHIC GEN CURVE 4FR 100CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316531 SUP HCPCS C1725 M001316531 - CATHETER ANGIOGRAPHIC CHUANG B CURVE 4FR 65CM TORQUE SELECT BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316551 SUP HCPCS C1725 M001316551 - CATHETER ANGIOGRAPHIC CHUANG C CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316571 SUP HCPCS C1725 M001316571 - CATHETER ANGIOGRAPHIC CHUANG 2 CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316581 SUP HCPCS C1725 M001316581 - CATHETER ANGIOGRAPHIC CONTRALATERAL 2 CURVE 4FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316611 SUP HCPCS C1725 M001316611 - CATHETER ANGIOGRAPHIC DUCK CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316631 SUP HCPCS C1725 M001316631 - CATHETER ANGIOGRAPHIC COBRA 1 CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316651 SUP HCPCS C1725 M001316651 - CATHETER ANGIOGRAPHIC COBRA 1 CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316671 SUP HCPCS C1725 M001316671 - CATHETER ANGIOGRAPHIC COBRA 2 CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316691 SUP HCPCS C1725 M001316691 - CATHETER ANGIOGRAPHIC COBRA 2 CURVE 4FR 65CM TAPER TIP FLUTE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316711 SUP HCPCS C1725 M001316711 - CATHETER ANGIOGRAPHIC COBRA 3 CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316731 SUP HCPCS C1725 M001316731 - CATHETER ANGIOGRAPHIC COBRA 3 CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316741 SUP HCPCS C1725 M001316741 - CATHETER ANGIOGRAPHIC VAN CURVE 4FR 65CM BRAID TORQUE BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001316751 SUP HCPCS C1725 M001316751 - CATHETER ANGIOGRAPHIC TRAIN CURVE FLUTE TAPER 4FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316771 SUP HCPCS C1725 M001316771 - CATHETER ANGIOGRAPHIC MIKELSON CURVE FLUTE TAPER 4FR 65CM BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316791 SUP HCPCS C1725 M001316791 - CATHETER ANGIOGRAPHIC HK 1 CURVE FLUTE TAPER 4FR 65CM BRAID BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316811 SUP HCPCS C1725 M001316811 - CATHETER ANGIOGRAPHIC SHK .8 CURVE FLUTE TAPER 4FR 65CM BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316831 SUP HCPCS C1725 M001316831 - CATHETER ANGIOGRAPHIC SHEPHERD HOOK 1 CURVE 4FR 65CM TAPER BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316851 SUP HCPCS C1725 M001316851 - CATHETER ANGIOGRAPHIC RIGHT CORON 1 CURVE 4FR 65CM TAPER TIP BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316871 SUP HCPCS C1725 M001316871 - CATHETER ANGIOGRAPHIC RIGHT CORON SHEPHERDS CROOK 2 CURVE BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316891 SUP HCPCS C1725 M001316891 - CATHETER ANGIOGRAPHIC RENAL DOUBLE CURVE FLUTE TAPER 4FR 65 BOTH IP/OP $25.48 $18.86 $0.00 $20.38 $13.84 $13.84 $0.00 $0.00 $0.00 $5.31 $18.91 $18.91 $0.00 $0.00 $5.31 $0.00 $15.07 $15.07 $0.00 $12.74 $20.18 $20.38 $0.00 $0.00 $3.99 $0.00 $0.00 $4.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001316911 SUP HCPCS C1725 M001316911 - CATHETER ANGIOGRAPHIC RENAL DOUBLE CURVE FLUTE TAPER 4FR 65 BOTH IP/OP $30.00 $22.20 $0.00 $24.00 $16.29 $16.29 $0.00 $0.00 $0.00 $6.25 $22.27 $22.27 $0.00 $0.00 $6.25 $0.00 $17.75 $17.75 $0.00 $15.00 $23.76 $24.00 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M001321751 SUP HCPCS C1887 M001321751 - CATHETER ANGIO .038IN C2 4FR 65CM GLDCATH TIP HDRPH BOTH IP/OP $139.50 $103.23 $0.00 $111.60 $75.75 $75.75 $0.00 $0.00 $0.00 $29.08 $103.54 $103.54 $0.00 $0.00 $29.07 $0.00 $82.51 $82.51 $0.00 $69.75 $110.48 $111.60 $0.00 $0.00 $21.83 $0.00 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $0.00 M001361480 SUP HCPCS C1895 M001361480 - COIL EMBOLIZATION .018IN STANDARD LENGTH 2D 2MM 4CM BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 M001361490 SUP HCPCS C1895 M001361490 - COIL EMBOLIZATION .018IN STANDARD LENGTH 2D 2MM 6CM BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 M001361500 SUP Custom 27803010 M001361500 - COIL EMBOLIZATION 2D HELIX 3MM 6CM 18 COIL OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361510 SUP Custom 27803010 M001361510 - COIL EMBOLIZATION 2D HELIX 3MM 12CM 18 COIL OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361520 SUP Custom 27803010 M001361520 - COIL EMBOLIZATION 2D HELIX 4MM 8CM 18 COIL OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361530 SUP Custom 27803010 M001361530 - COIL EMBOLIZATION 2D HELIX 4MM 15CM 8 COIL OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361540 SUP Custom 27203010 M001361540 - COIL EMBL 8CM 5MM INTLK 2D HLCL FBR OCL DTCH BOTH IP/OP "$1,022.48 " $756.64 $0.00 $758.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $471.44 $746.76 $754.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361550 SUP Custom 27803010 M001361550 - COIL EMBOLIZATION 2D HELIX 5MM 15CM 8 COIL OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361560 SUP Custom 27803010 M001361560 - COIL EMBOLIZATION 2D HELIX 6MM 10CM 18 COIL OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361570 SUP Custom 27803010 M001361570 - COIL EMBOLIZATION 2D HELIX 6MM 20CM 18 COIL OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361580 SUP Custom 27803010 M001361580 - COIL EMBOLIZATION 2D HELIX 8MM 20CM OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361590 SUP Custom 27803010 M001361590 - COIL EMBOLIZATION 2D HELIX 10MM 20CM DETACHABLE OCCLUSION BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361600 SUP Custom 27803010 M001361600 - COIL EMBOLIZATION .018IN 2D HELIX BUCK 10MM 30CM OCCLUSION BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361610 SUP Custom 27803010 M001361610 - COIL EMBOLIZATION 2D HELIX 12MM 20CM OCCLUSION INTERLOCK BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361620 SUP Custom 27803010 M001361620 - COIL EMBOLIZATION .018IN 2D HELIX TAPER 12MM 30CM 18 COIL BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361630 SUP Custom 27803010 M001361630 - COIL EMBOLIZATION .018IN 2D HELIX TAPER 14MM 20CM 18 COIL BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361640 SUP Custom 27803010 M001361640 - COIL EMBOLIZATION .018IN 2D HELIX 14MM 30CM INTERLOCK IDC BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361740 SUP Custom 27803010 M001361740 - COIL EMBOLIZATION DIAMOND 2/3MM 2.3CM 18 COIL RETRACTABLE BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361750 SUP Custom 27803010 M001361750 - COIL EMBOLIZATION DIAMOND 2/4MM 4.1CM 18 COIL RETRACTABLE BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361760 SUP Custom 27803010 M001361760 - COIL EMBOLIZATION DIAMOND 2/5MM 5.8CM 18 COIL RETRACTABLE BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361770 SUP Custom 27803010 M001361770 - COIL EMBOLIZATION DIAMOND 2/6MM 8CM OCCLUSION SYSTEM BOTH IP/OP "$1,022.48 " $756.64 $0.00 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $758.88 $758.88 $0.00 $0.00 $213.08 $0.00 $0.00 $0.00 $0.00 $511.24 $809.80 $817.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001361920 SUP HCPCS C1895 M001361920 - COIL EMBOLIZATION 2D LONG LENGTH 10MM 50CM 18 COIL BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 M001361930 SUP HCPCS C1895 M001361930 - COIL EMBOLIZATION .018IN 2D LONG 14CM 50CM 18 COIL BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 M001361940 SUP HCPCS C1895 M001361940 - COIL EMBOLIZATION .018IN LONG LENGTH 2D HELIX 18CM 50CM BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 M001361950 SUP HCPCS C1895 M001361950 - COIL EMBOLIZATION .018IN LONG LENGTH 2D HELIX 20MM 50CM BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 M001361960 SUP HCPCS C1895 M001361960 - COIL EMBOLIZATION .018IN LONG LENGTH 2D HELIX 20MM 50CM BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 M001363500 SUP Custom 27803010 M001363500 - COIL EMBOLIZATION .035IN 2D 3MM 4CM OCCLUSION INTERLOCK IDC BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $0.00 $0.00 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363520 SUP Custom 27803010 M001363520 - COIL EMBOLIZATION .035IN 2D HELICAL 4MM 10CM 35 COIL BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $0.00 $0.00 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363530 SUP Custom 27803010 M001363530 - COIL EMBL 20CM 4MM INTLK .035IN BOTH IP/OP "$1,755.00 " "$1,298.70" $0.00 "$1,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,302.56" "$1,302.56" $0.00 $0.00 $365.74 $0.00 $0.00 $0.00 $0.00 $877.50 "$1,389.96" "$1,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363540 SUP Custom 27803010 M001363540 - COIL EMBOLIZATION .035IN 2D 6MM 10CM OCCLUSION DETACHABLE BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $0.00 $0.00 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363550 SUP Custom 27803010 M001363550 - COIL EMBOLIZATION .035IN 2D 6MM 20CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363560 SUP Custom 27803010 M001363560 - COIL EMBL 40CM 6MM INTLK .035IN BOTH IP/OP "$2,340.00 " "$1,731.60" $0.00 "$1,872.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,736.75" "$1,736.75" $0.00 $0.00 $487.66 $0.00 $0.00 $0.00 $0.00 "$1,170.00" "$1,853.28" "$1,872.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363570 SUP HCPCS C1895 M001363570 - COIL EMBOLIZATION .018IN 2D HELIX 8MM 10CM OCCLUSION SYSTEM BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $529.71 $529.71 $0.00 $0.00 $0.00 $245.34 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $696.27 $696.27 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $184.22 $0.00 $0.00 $187.40 $0.00 $0.00 $0.00 $0.00 $0.00 M001363580 SUP Custom 27803010 M001363580 - COIL EMBOLIZATION .035IN 2D 8MM 20CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363590 SUP Custom 27803010 M001363590 - COIL EMBOLIZATION .035IN 2D 8MM 40CM OCCLUSION SYSTEM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363600 SUP Custom 27803010 M001363600 - COIL EMBOLIZATION .035IN 2D 10MM 20CM OCCLUSION INTERLOCK BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363610 SUP Custom 27803010 M001363610 - COIL EMBOLIZATION .035IN 2D 10MM 40CM OCCLUSION SYSTEM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363620 SUP Custom 27803010 M001363620 - COIL EMBOLIZATION .035IN 2D 12MM 20CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363630 SUP Custom 27803010 M001363630 - COIL EMBOLIZATION .035IN 2D 12MM 40CM FIBER OCCLUSION SYSTEM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363640 SUP Custom 27803010 M001363640 - COIL EMBOLIZATION .035IN 2D 15MM 20CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363650 SUP Custom 27803010 M001363650 - COIL EMBOLIZATION .035IN 2D 15MM 40CM OCCLUSION SYSTEM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363660 SUP HCPCS C1895 M001363660 - COIL EMBOLIZATION .018IN 2D 18MM 20CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $792.63 $792.63 $0.00 $0.00 $0.00 $367.12 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 "$1,041.87" "$1,041.87" $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $275.66 $0.00 $0.00 $280.41 $0.00 $0.00 $0.00 $0.00 $0.00 M001363670 SUP Custom 27803010 M001363670 - COIL EMBOLIZATION .035IN 2D 18MM 40CM OCCLUSION SYSTEM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363700 SUP Custom 27803010 M001363700 - COIL EMBOLIZATION .035IN CUBE 4MM 6CM OCCLUSION SYSTEM BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $0.00 $0.00 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363710 SUP Custom 27803010 M001363710 - COIL EMBL 17CM 4MM INTLK 360D BOTH IP/OP "$1,755.00 " "$1,298.70" $0.00 "$1,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,302.56" "$1,302.56" $0.00 $0.00 $365.74 $0.00 $0.00 $0.00 $0.00 $877.50 "$1,389.96" "$1,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363720 SUP Custom 27803010 M001363720 - COIL EMBOLIZATION .035IN CUBE 6MM 10CM OCCLUSION SYSTEM BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $0.00 $0.00 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363730 SUP Custom 27803010 M001363730 - COIL EMBOLIZATION .035IN CUBE 6MM 20CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363760 SUP Custom 27803010 M001363760 - COIL EMBOLIZATION .035IN CUBE 8MM 20CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363770 SUP Custom 27803010 M001363770 - COIL EMBL 40CM 8MM INTLK 360D BOTH IP/OP "$2,340.00 " "$1,731.60" $0.00 "$1,872.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,736.75" "$1,736.75" $0.00 $0.00 $487.66 $0.00 $0.00 $0.00 $0.00 "$1,170.00" "$1,853.28" "$1,872.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363790 SUP Custom 27803010 M001363790 - COIL EMBOLIZATION .035IN CUBE 10MM 25CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363800 SUP Custom 27803010 M001363800 - COIL EMBOLIZATION .035IN CUBE 10MM 40CM OCCLUSION SYSTEM BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363810 SUP Custom 27803010 M001363810 - COIL EMBOLIZATION .035IN CUBE 15MM 25CM OCCLUSION SYSTEM BOTH IP/OP "$1,761.40 " "$1,303.44" $0.00 "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,307.31" "$1,307.31" $0.00 $0.00 $367.08 $0.00 $0.00 $0.00 $0.00 $880.70 "$1,395.03" "$1,409.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363820 SUP Custom 27803010 M001363820 - COIL EMBOLIZATION .035IN CUBE 15MM 40CM FIBER OCCLUSION BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363830 SUP Custom 27803010 M001363830 - COIL EMBOLIZATION .035IN CUBE 20MM 40CM FIBER OCCLUSION BOTH IP/OP "$2,250.00 " "$1,665.00" $0.00 "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,669.95" "$1,669.95" $0.00 $0.00 $468.90 $0.00 $0.00 $0.00 $0.00 "$1,125.00" "$1,782.00" "$1,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363910 SUP Custom 27803010 M001363910 - COIL EMBOLIZATION .035IN DIAMOND 4MM 4.5CM OCCLUSION SYSTEM BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $0.00 $0.00 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363920 SUP Custom 27803010 M001363920 - COIL EMBOLIZATION .035IN DIAMOND 6MM 9CM OCCLUSION INTERLOCK BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $0.00 $0.00 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363930 SUP Custom 27803010 M001363930 - COIL EMBOLIZATION .035IN DIAMOND 8MM 14CM OCCLUSION BOTH IP/OP "$1,177.13 " $871.08 $0.00 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $873.66 $873.66 $0.00 $0.00 $245.31 $0.00 $0.00 $0.00 $0.00 $588.56 $932.29 $941.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363940 SUP Custom 27803010 M001363940 - COIL EMBL 10MM INTLK .035IN BOTH IP/OP "$1,755.00 " "$1,298.70" $0.00 "$1,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,302.56" "$1,302.56" $0.00 $0.00 $365.74 $0.00 $0.00 $0.00 $0.00 $877.50 "$1,389.96" "$1,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001363950 SUP Custom 27803010 M001363950 - COIL EMBL 12MM INTLK .035IN BOTH IP/OP "$1,755.00 " "$1,298.70" $0.00 "$1,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,302.56" "$1,302.56" $0.00 $0.00 $365.74 $0.00 $0.00 $0.00 $0.00 $877.50 "$1,389.96" "$1,404.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001391260 SUP HCPCS C1769 M001391260 - GUIDEWIRE VASCULAR STR .014IN 185CM JOURNEY NITINOL HYDPHI BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 M001391270 SUP HCPCS C1769 M001391270 - GUIDEWIRE VASCULAR .014IN 185CM 7CM NAVIGATE RADIOPQ ANGLE BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 M001391280 SUP HCPCS C1769 M001391280 - GUIDEWIRE VASCULAR .014IN 300CM 2CM FLEXIBLE CONVENTION STR BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 M001391290 SUP HCPCS C1769 M001391290 - GUIDEWIRE VASCULAR .014IN 300CM 7CM NAVIGATE RADIOPQ ANGLE BOTH IP/OP $318.50 $235.69 $0.00 $254.80 $172.95 $172.95 $0.00 $0.00 $0.00 $66.38 $236.39 $236.39 $0.00 $0.00 $66.38 $0.00 $188.39 $188.39 $0.00 $159.25 $252.25 $254.80 $0.00 $0.00 $49.85 $0.00 $0.00 $50.71 $0.00 $0.00 $0.00 $0.00 $0.00 M0014012160 SUP Custom 27803010 M0014012160 - PUSHER SURG .016FR .018IN 177CM EMBOLIZATION COIL BOTH IP/OP $419.80 $310.65 $0.00 $335.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.58 $311.58 $0.00 $0.00 $87.49 $0.00 $0.00 $0.00 $0.00 $209.90 $332.48 $335.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001442001 SUP Custom 27203010 M001442001 - DEVICE FLOW CONTROL 1050 PSI 1 WAY HIGH PRESSURE FLOSWITCH BOTH IP/OP $11.43 $8.46 $0.00 $9.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.48 $8.48 $0.00 $0.00 $2.38 $0.00 $0.00 $0.00 $0.00 $5.71 $9.05 $9.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001461541 SUP HCPCS C1769 M001461541 - GUIDEWIRE VASC .035IN 260CM 3CM GLDWR ANG TIP FLXB COR STD BOTH IP/OP $712.50 $527.25 $0.00 $570.00 $386.89 $386.89 $0.00 $0.00 $0.00 $148.50 $528.82 $528.82 $0.00 $0.00 $148.49 $0.00 $421.44 $421.44 $0.00 $356.25 $564.30 $570.00 $0.00 $0.00 $111.51 $0.00 $0.00 $113.43 $0.00 $0.00 $0.00 $0.00 $0.00 M001461940 SUP HCPCS C1769 M001461940 - GWIRE VASC .035IN 145CM 9CM INFUS KTZN PERI BOTH IP/OP $473.28 $350.23 $0.00 $378.62 $256.99 $256.99 $0.00 $0.00 $0.00 $98.64 $351.26 $351.26 $0.00 $0.00 $98.63 $0.00 $279.94 $279.94 $0.00 $236.64 $374.84 $378.62 $0.00 $0.00 $74.07 $0.00 $0.00 $75.35 $0.00 $0.00 $0.00 $0.00 $0.00 M001461960 SUP HCPCS C1769 M001461960 - GWIRE VASC .035IN 145CM 12CM INFUS KTZN BOTH IP/OP $473.28 $350.23 $0.00 $378.62 $256.99 $256.99 $0.00 $0.00 $0.00 $98.64 $351.26 $351.26 $0.00 $0.00 $98.63 $0.00 $279.94 $279.94 $0.00 $236.64 $374.84 $378.62 $0.00 $0.00 $74.07 $0.00 $0.00 $75.35 $0.00 $0.00 $0.00 $0.00 $0.00 M001465001 SUP HCPCS C1769 M001465001 - GUIDEWIRE VASCULAR 6CM J .035IN 145CM 3MM FLEXIBLE TIP BOTH IP/OP $75.95 $56.20 $0.00 $60.76 $41.24 $41.24 $0.00 $0.00 $0.00 $15.83 $56.37 $56.37 $0.00 $0.00 $15.83 $0.00 $44.92 $44.92 $0.00 $37.98 $60.15 $60.76 $0.00 $0.00 $11.89 $0.00 $0.00 $12.09 $0.00 $0.00 $0.00 $0.00 $0.00 M001465011 SUP HCPCS C1769 M001465011 - GUIDEWIRE VASCULAR SHORT LARGE J FLAT SPRING COIL .035IN 180 BOTH IP/OP $103.81 $76.82 $0.00 $83.04 $56.37 $56.37 $0.00 $0.00 $0.00 $21.64 $77.04 $77.04 $0.00 $0.00 $21.63 $0.00 $61.40 $61.40 $0.00 $51.90 $82.22 $83.04 $0.00 $0.00 $16.25 $0.00 $0.00 $16.53 $0.00 $0.00 $0.00 $0.00 $0.00 M001465021 SUP HCPCS C1769 M001465021 - GUIDEWIRE VASCULAR J .035IN 260CM 3MM FLEXIBLE TIP AMPLATZ BOTH IP/OP $108.46 $80.26 $0.00 $86.77 $58.89 $58.89 $0.00 $0.00 $0.00 $22.61 $80.50 $80.50 $0.00 $0.00 $22.60 $0.00 $64.15 $64.15 $0.00 $54.23 $85.90 $86.77 $0.00 $0.00 $16.97 $0.00 $0.00 $17.27 $0.00 $0.00 $0.00 $0.00 $0.00 M001465031 SUP HCPCS C1769 M001465031 - GUIDEWIRE VASCULAR J .035IN 145CM 3MM FLEXIBLE TIP AMPLATZ BOTH IP/OP $75.95 $56.20 $0.00 $60.76 $41.24 $41.24 $0.00 $0.00 $0.00 $15.83 $56.37 $56.37 $0.00 $0.00 $15.83 $0.00 $44.92 $44.92 $0.00 $37.98 $60.15 $60.76 $0.00 $0.00 $11.89 $0.00 $0.00 $12.09 $0.00 $0.00 $0.00 $0.00 $0.00 M001465041 SUP HCPCS C1769 M001465041 - GUIDEWIRE VASCULAR 6CM LARGE J .035IN 180CM 3MM FLEXIBLE TIP BOTH IP/OP $103.81 $76.82 $0.00 $83.04 $56.37 $56.37 $0.00 $0.00 $0.00 $21.64 $77.04 $77.04 $0.00 $0.00 $21.63 $0.00 $61.40 $61.40 $0.00 $51.90 $82.22 $83.04 $0.00 $0.00 $16.25 $0.00 $0.00 $16.53 $0.00 $0.00 $0.00 $0.00 $0.00 M001465091 SUP HCPCS C1769 M001465091 - GUIDEWIRE VASCULAR SHORT STR .035IN 260CM FLEXIBLE TIP BOTH IP/OP $110.79 $81.98 $0.00 $88.63 $60.16 $60.16 $0.00 $0.00 $0.00 $23.09 $82.23 $82.23 $0.00 $0.00 $23.09 $0.00 $65.53 $65.53 $0.00 $55.40 $87.75 $88.63 $0.00 $0.00 $17.34 $0.00 $0.00 $17.64 $0.00 $0.00 $0.00 $0.00 $0.00 M001465101 SUP HCPCS C1769 M001465101 - GUIDEWIRE VASCULAR .038IN 260CM 1CM FLEXIBLE TIP AMPLATZ BOTH IP/OP $110.79 $81.98 $0.00 $88.63 $60.16 $60.16 $0.00 $0.00 $0.00 $23.09 $82.23 $82.23 $0.00 $0.00 $23.09 $0.00 $65.53 $65.53 $0.00 $55.40 $87.75 $88.63 $0.00 $0.00 $17.34 $0.00 $0.00 $17.64 $0.00 $0.00 $0.00 $0.00 $0.00 M001465171 SUP HCPCS C1769 M001465171 - GUIDEWIRE VASCULAR TAPER .038IN 145CM 6CM STR TIP AMPLATZ BOTH IP/OP $66.57 $49.26 $0.00 $53.25 $36.14 $36.14 $0.00 $0.00 $0.00 $13.87 $49.40 $49.40 $0.00 $0.00 $13.87 $0.00 $39.37 $39.37 $0.00 $33.28 $52.72 $53.25 $0.00 $0.00 $10.42 $0.00 $0.00 $10.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001465181 SUP HCPCS C1769 M001465181 - GUIDEWIRE VASCULAR SHORT J .038IN 145CM 4CM FLEXIBLE TIP BOTH IP/OP $69.58 $51.49 $0.00 $55.66 $37.78 $37.78 $0.00 $0.00 $0.00 $14.50 $51.64 $51.64 $0.00 $0.00 $14.50 $0.00 $41.16 $41.16 $0.00 $34.79 $55.11 $55.66 $0.00 $0.00 $10.89 $0.00 $0.00 $11.08 $0.00 $0.00 $0.00 $0.00 $0.00 M001465191 SUP HCPCS C1769 M001465191 - GUIDEWIRE VASCULAR STR .038IN 180CM 6CM FLEXIBLE TIP AMPLATZ BOTH IP/OP $101.48 $75.10 $0.00 $81.18 $55.10 $55.10 $0.00 $0.00 $0.00 $21.15 $75.32 $75.32 $0.00 $0.00 $21.15 $0.00 $60.03 $60.03 $0.00 $50.74 $80.37 $81.18 $0.00 $0.00 $15.88 $0.00 $0.00 $16.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001465201 SUP HCPCS C1769 M001465201 - GUIDEWIRE VASCULAR STR .038IN 260CM 6CM FLEXIBLE TIP AMPLATZ BOTH IP/OP $106.14 $78.54 $0.00 $84.91 $57.63 $57.63 $0.00 $0.00 $0.00 $22.12 $78.77 $78.77 $0.00 $0.00 $22.12 $0.00 $62.78 $62.78 $0.00 $53.07 $84.06 $84.91 $0.00 $0.00 $16.61 $0.00 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 M001465231 SUP HCPCS C1769 M001465231 - GUIDEWIRE VASCULAR STR .035IN 145CM 7CM FLEXIBLE TIP AMPLATZ BOTH IP/OP $66.15 $48.95 $0.00 $52.92 $35.92 $35.92 $0.00 $0.00 $0.00 $13.79 $49.10 $49.10 $0.00 $0.00 $13.79 $0.00 $39.13 $39.13 $0.00 $33.08 $52.39 $52.92 $0.00 $0.00 $10.35 $0.00 $0.00 $10.53 $0.00 $0.00 $0.00 $0.00 $0.00 M001465241 SUP HCPCS C1769 M001465241 - GUIDEWIRE VASCULAR STR .035IN 145CM 3.5CM SUPER STIFF SHAFT BOTH IP/OP $66.15 $48.95 $0.00 $52.92 $35.92 $35.92 $0.00 $0.00 $0.00 $13.79 $49.10 $49.10 $0.00 $0.00 $13.79 $0.00 $39.13 $39.13 $0.00 $33.08 $52.39 $52.92 $0.00 $0.00 $10.35 $0.00 $0.00 $10.53 $0.00 $0.00 $0.00 $0.00 $0.00 M001465251 SUP HCPCS C1769 M001465251 - GUIDEWIRE VASCULAR TAPER .035IN 180CM 7CM STR TIP AMPLATZ BOTH IP/OP $101.48 $75.10 $0.00 $81.18 $55.10 $55.10 $0.00 $0.00 $0.00 $21.15 $75.32 $75.32 $0.00 $0.00 $21.15 $0.00 $60.03 $60.03 $0.00 $50.74 $80.37 $81.18 $0.00 $0.00 $15.88 $0.00 $0.00 $16.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001465261 SUP HCPCS C1769 M001465261 - GUIDEWIRE VASCULAR STR .035IN 260CM 7CM FLEXIBLE TIP AMPLATZ BOTH IP/OP $106.14 $78.54 $0.00 $84.91 $57.63 $57.63 $0.00 $0.00 $0.00 $22.12 $78.77 $78.77 $0.00 $0.00 $22.12 $0.00 $62.78 $62.78 $0.00 $53.07 $84.06 $84.91 $0.00 $0.00 $16.61 $0.00 $0.00 $16.90 $0.00 $0.00 $0.00 $0.00 $0.00 M001465501 SUP Custom 27203010 M001465501 - VISE TORQUE ACCEPTS .025-.038 IN GWIRE BOTH IP/OP $155.95 $115.40 $0.00 $124.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.75 $115.75 $0.00 $0.00 $32.50 $0.00 $0.00 $0.00 $0.00 $77.98 $123.51 $124.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001465631 SUP HCPCS C1769 M001465631 - GUIDEWIRE VASCULAR .035IN 75CM 7CM DISTAL STR TIP ATRAUMATIC BOTH IP/OP $66.15 $48.95 $0.00 $52.92 $35.92 $35.92 $0.00 $0.00 $0.00 $13.79 $49.10 $49.10 $0.00 $0.00 $13.79 $0.00 $39.13 $39.13 $0.00 $33.08 $52.39 $52.92 $0.00 $0.00 $10.35 $0.00 $0.00 $10.53 $0.00 $0.00 $0.00 $0.00 $0.00 M001465641 SUP HCPCS C1769 M001465641 - GUIDEWIRE VASCULAR STR .038IN 75CM 6CM FLOPPY TIP AMPLATZ BOTH IP/OP $66.15 $48.95 $0.00 $52.92 $35.92 $35.92 $0.00 $0.00 $0.00 $13.79 $49.10 $49.10 $0.00 $0.00 $13.79 $0.00 $39.13 $39.13 $0.00 $33.08 $52.39 $52.92 $0.00 $0.00 $10.35 $0.00 $0.00 $10.53 $0.00 $0.00 $0.00 $0.00 $0.00 M001465911 SUP HCPCS C1769 M001465911 - GUIDEWIRE VASCULAR SHAPEABLE CURVE .035IN 180CM 5CM STR TIP BOTH IP/OP $126.58 $93.67 $0.00 $101.27 $68.73 $68.73 $0.00 $0.00 $0.00 $26.38 $93.95 $93.95 $0.00 $0.00 $26.38 $0.00 $74.87 $74.87 $0.00 $63.29 $100.25 $101.27 $0.00 $0.00 $19.81 $0.00 $0.00 $20.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001465921 SUP HCPCS C1769 M001465921 - GUIDEWIRE VASCULAR SHAPEABLE CURVE .035IN 260CM 5CM STR TIP BOTH IP/OP $126.58 $93.67 $0.00 $101.27 $68.73 $68.73 $0.00 $0.00 $0.00 $26.38 $93.95 $93.95 $0.00 $0.00 $26.38 $0.00 $74.87 $74.87 $0.00 $63.29 $100.25 $101.27 $0.00 $0.00 $19.81 $0.00 $0.00 $20.15 $0.00 $0.00 $0.00 $0.00 $0.00 M001466000 SUP HCPCS C1769 M001466000 - GUIDEWIRE VASCULAR LONG .018IN 145CM 10CM RADIOPQ PLATINUM BOTH IP/OP $194.35 $143.82 $0.00 $155.48 $105.53 $105.53 $0.00 $0.00 $0.00 $40.51 $144.25 $144.25 $0.00 $0.00 $40.50 $0.00 $114.96 $114.96 $0.00 $97.18 $153.93 $155.48 $0.00 $0.00 $30.42 $0.00 $0.00 $30.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001466010 SUP HCPCS C1769 M001466010 - GUIDEWIRE VASCULAR LONG .018IN 180CM 10CM RADIOPQ PLATINUM BOTH IP/OP $194.35 $143.82 $0.00 $155.48 $105.53 $105.53 $0.00 $0.00 $0.00 $40.51 $144.25 $144.25 $0.00 $0.00 $40.50 $0.00 $114.96 $114.96 $0.00 $97.18 $153.93 $155.48 $0.00 $0.00 $30.42 $0.00 $0.00 $30.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001466020 SUP HCPCS C1769 M001466020 - GUIDEWIRE VASCULAR LONG .018IN 260CM 8CM RADIOPQ PLATINUM BOTH IP/OP $203.35 $150.48 $0.00 $162.68 $110.42 $110.42 $0.00 $0.00 $0.00 $42.38 $150.93 $150.93 $0.00 $0.00 $42.38 $0.00 $120.28 $120.28 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $31.82 $0.00 $0.00 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 M001466040 SUP HCPCS C1769 M001466040 - GUIDEWIRE VASCULAR SHORT .018IN 180CM 3CM RADIOPQ PLATINUM BOTH IP/OP $194.35 $143.82 $0.00 $155.48 $105.53 $105.53 $0.00 $0.00 $0.00 $40.51 $144.25 $144.25 $0.00 $0.00 $40.50 $0.00 $114.96 $114.96 $0.00 $97.18 $153.93 $155.48 $0.00 $0.00 $30.42 $0.00 $0.00 $30.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001466050 SUP HCPCS C1769 M001466050 - GUIDEWIRE VASC .018IN 260CM 3CM PLTN + SHRT TPR TIP RADOPQ BOTH IP/OP $203.35 $150.48 $0.00 $162.68 $110.42 $110.42 $0.00 $0.00 $0.00 $42.38 $150.93 $150.93 $0.00 $0.00 $42.38 $0.00 $120.28 $120.28 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $31.82 $0.00 $0.00 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 M001466100 SUP HCPCS C1769 M001466100 - GUIDEWIRE VASCULAR SHORT .025IN 180CM 3CM RADIOPQ PLATINUM BOTH IP/OP $194.35 $143.82 $0.00 $155.48 $105.53 $105.53 $0.00 $0.00 $0.00 $40.51 $144.25 $144.25 $0.00 $0.00 $40.50 $0.00 $114.96 $114.96 $0.00 $97.18 $153.93 $155.48 $0.00 $0.00 $30.42 $0.00 $0.00 $30.94 $0.00 $0.00 $0.00 $0.00 $0.00 M001466110 SUP HCPCS C1769 M001466110 - GUIDEWIRE VASCULAR SHORT .025IN 260CM 3CM RADIOPQ PLATINUM BOTH IP/OP $202.33 $149.72 $0.00 $161.86 $109.86 $109.86 $0.00 $0.00 $0.00 $42.17 $150.17 $150.17 $0.00 $0.00 $42.16 $0.00 $119.68 $119.68 $0.00 $101.16 $160.25 $161.86 $0.00 $0.00 $31.66 $0.00 $0.00 $32.21 $0.00 $0.00 $0.00 $0.00 $0.00 M001467120 SUP HCPCS C1769 M001467120 - GUIDEWIRE VASCULAR .014IN 300CM 7CM SHORT TAPER STR TIP BOTH IP/OP $203.35 $150.48 $0.00 $162.68 $110.42 $110.42 $0.00 $0.00 $0.00 $42.38 $150.93 $150.93 $0.00 $0.00 $42.38 $0.00 $120.28 $120.28 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $31.82 $0.00 $0.00 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 M001467300 SUP HCPCS C1769 M001467300 - GUIDEWIRE VASCULAR STR .018IN 60CM 3CM RADIOPQ PLATINUM PLUS BOTH IP/OP $203.35 $150.48 $0.00 $162.68 $110.42 $110.42 $0.00 $0.00 $0.00 $42.38 $150.93 $150.93 $0.00 $0.00 $42.38 $0.00 $120.28 $120.28 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $31.82 $0.00 $0.00 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 M001467310 SUP HCPCS C1769 M001467310 - GUIDEWIRE VASCULAR STR .018IN 180CM 3CM RADIOPQ PLATINUM BOTH IP/OP $203.35 $150.48 $0.00 $162.68 $110.42 $110.42 $0.00 $0.00 $0.00 $42.38 $150.93 $150.93 $0.00 $0.00 $42.38 $0.00 $120.28 $120.28 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $31.82 $0.00 $0.00 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 M001467320 SUP HCPCS C1769 M001467320 - GUIDEWIRE VASCULAR STR .018IN 260CM 3CM RADIOPQ PLATINUM BOTH IP/OP $203.35 $150.48 $0.00 $162.68 $110.42 $110.42 $0.00 $0.00 $0.00 $42.38 $150.93 $150.93 $0.00 $0.00 $42.38 $0.00 $120.28 $120.28 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $31.82 $0.00 $0.00 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 M001467400 SUP HCPCS C1769 M001467400 - GUIDEWIRE VASCULAR .014IN 180CM 3CM RADIOPQ PLATINUM PLUS BOTH IP/OP $203.35 $150.48 $0.00 $162.68 $110.42 $110.42 $0.00 $0.00 $0.00 $42.38 $150.93 $150.93 $0.00 $0.00 $42.38 $0.00 $120.28 $120.28 $0.00 $101.68 $161.05 $162.68 $0.00 $0.00 $31.82 $0.00 $0.00 $32.37 $0.00 $0.00 $0.00 $0.00 $0.00 M001468010 SUP HCPCS C1769 M001468010 - GUIDEWIRE VASCULAR STR .014IN 190CM 2CM STEERABLE TRANSEND BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $296.48 $296.48 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 M001468050 SUP HCPCS C1769 M001468050 - GUIDEWIRE VASC .014IN 182CM 2CM TRNSD EX RADOPQ HDRPH PLTN BOTH IP/OP "$1,116.25 " $826.03 $0.00 $893.00 $606.12 $606.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $558.13 $884.07 $893.00 $0.00 $0.00 $174.69 $0.00 $0.00 $177.71 $0.00 $0.00 $0.00 $0.00 $0.00 M001468070 SUP HCPCS C1769 M001468070 - GUIDEWIRE VASC .014IN 205CM 2CM TRNSD EX SHP FLPY BOTH IP/OP "$1,116.25 " $826.03 $0.00 $893.00 $606.12 $606.12 $0.00 $0.00 $0.00 $232.65 $828.48 $828.48 $0.00 $0.00 $232.63 $0.00 $660.26 $660.26 $0.00 $558.13 $884.07 $893.00 $0.00 $0.00 $174.69 $0.00 $0.00 $177.71 $0.00 $0.00 $0.00 $0.00 $0.00 M001468100 SUP HCPCS C1769 M001468100 - GUIDEWIRE VASCULAR STR .014IN 135CM 2CM STEERABLE TRANSEND BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $296.48 $296.48 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 M001468110 SUP HCPCS C1769 M001468110 - GUIDEWIRE VASCULAR STR .014IN 165CM 2CM STEERABLE TRANSEND BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $296.48 $296.48 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 M001468120 SUP HCPCS C1769 M001468120 - GUIDEWIRE VASCULAR STR .018IN 135CM 2CM STEERABLE TRANSEND BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $296.48 $296.48 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 M001468130 SUP HCPCS C1769 M001468130 - GUIDEWIRE VASCULAR STR .018IN 165CM 2CM STEERABLE TRANSEND BOTH IP/OP $546.00 $404.04 $0.00 $436.80 $296.48 $296.48 $0.00 $0.00 $0.00 $113.80 $405.24 $405.24 $0.00 $0.00 $113.79 $0.00 $322.96 $322.96 $0.00 $273.00 $432.43 $436.80 $0.00 $0.00 $85.45 $0.00 $0.00 $86.92 $0.00 $0.00 $0.00 $0.00 $0.00 M001468480 SUP HCPCS C1769 M001468480 - GUIDEWIRE VASCULAR STR .018IN 110CM 8CM RADIOPQ V-18 BOTH IP/OP $211.00 $156.14 $0.00 $168.80 $114.57 $114.57 $0.00 $0.00 $0.00 $43.98 $156.60 $156.60 $0.00 $0.00 $43.97 $0.00 $124.81 $124.81 $0.00 $105.50 $167.11 $168.80 $0.00 $0.00 $33.02 $0.00 $0.00 $33.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001468500 SUP HCPCS C1769 M001468500 - GUIDEWIRE VASCULAR STR .018IN 150CM 8CM RADIOPQ V-18 BOTH IP/OP $178.95 $132.42 $0.00 $143.16 $97.17 $97.17 $0.00 $0.00 $0.00 $37.30 $132.82 $132.82 $0.00 $0.00 $37.29 $0.00 $105.85 $105.85 $0.00 $89.48 $141.73 $143.16 $0.00 $0.00 $28.01 $0.00 $0.00 $28.49 $0.00 $0.00 $0.00 $0.00 $0.00 M001468520 SUP HCPCS C1769 M001468520 - GUIDEWIRE VASCULAR TAPER .018IN 200CM 8CM RADIOPQ STR TIP BOTH IP/OP $188.53 $139.51 $0.00 $150.82 $102.37 $102.37 $0.00 $0.00 $0.00 $39.29 $139.92 $139.92 $0.00 $0.00 $39.29 $0.00 $111.51 $111.51 $0.00 $94.26 $149.32 $150.82 $0.00 $0.00 $29.50 $0.00 $0.00 $30.01 $0.00 $0.00 $0.00 $0.00 $0.00 M001468540 SUP HCPCS C1769 M001468540 - GUIDEWIRE VASCULAR TAPER .018IN 300CM 8CM RADIOPQ STR TIP BOTH IP/OP $197.25 $145.97 $0.00 $157.80 $107.11 $107.11 $0.00 $0.00 $0.00 $41.11 $146.40 $146.40 $0.00 $0.00 $41.11 $0.00 $116.67 $116.67 $0.00 $98.63 $156.22 $157.80 $0.00 $0.00 $30.87 $0.00 $0.00 $31.40 $0.00 $0.00 $0.00 $0.00 $0.00 M001468560 SUP HCPCS C1769 M001468560 - GUIDEWIRE VASCULAR STR .018IN 150CM 12CM RADIOPQ V-18 BOTH IP/OP $213.15 $157.73 $0.00 $170.52 $115.74 $115.74 $0.00 $0.00 $0.00 $44.43 $158.20 $158.20 $0.00 $0.00 $44.42 $0.00 $126.08 $126.08 $0.00 $106.58 $168.81 $170.52 $0.00 $0.00 $33.36 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 M001468580 SUP HCPCS C1769 M001468580 - GUIDEWIRE VASCULAR STR .018IN 200CM 12CM RADIOPQ V-18 BOTH IP/OP $213.15 $157.73 $0.00 $170.52 $115.74 $115.74 $0.00 $0.00 $0.00 $44.43 $158.20 $158.20 $0.00 $0.00 $44.42 $0.00 $126.08 $126.08 $0.00 $106.58 $168.81 $170.52 $0.00 $0.00 $33.36 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 M001468600 SUP HCPCS C1769 M001468600 - GUIDEWIRE VASCULAR STR .018IN 300CM 12CM RADIOPQ V-18 BOTH IP/OP $213.15 $157.73 $0.00 $170.52 $115.74 $115.74 $0.00 $0.00 $0.00 $44.43 $158.20 $158.20 $0.00 $0.00 $44.42 $0.00 $126.08 $126.08 $0.00 $106.58 $168.81 $170.52 $0.00 $0.00 $33.36 $0.00 $0.00 $33.93 $0.00 $0.00 $0.00 $0.00 $0.00 M001491001 SUP HCPCS C1769 M001491001 - GUIDEWIRE VASCULAR STANDARD TAPER .025IN 150CM 3CM FIX CORE BOTH IP/OP $15.28 $11.31 $0.00 $12.22 $8.29 $8.29 $0.00 $0.00 $0.00 $3.18 $11.34 $11.34 $0.00 $0.00 $3.18 $0.00 $9.04 $9.04 $0.00 $7.64 $12.10 $12.22 $0.00 $0.00 $2.39 $0.00 $0.00 $2.43 $0.00 $0.00 $0.00 $0.00 $0.00 M001491011 SUP HCPCS C1769 M001491011 - GUIDEWIRE STAR SFC .035 150CM PTFE BOTH IP/OP $15.28 $11.31 $0.00 $15.60 $10.59 $10.59 $0.00 $0.00 $0.00 $3.18 $11.34 $11.34 $0.00 $0.00 $3.18 $0.00 $9.04 $9.04 $0.00 $9.75 $15.44 $15.60 $0.00 $0.00 $3.05 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001491021 SUP HCPCS C1769 M001491021 - GUIDEWIRE VASCULAR STANDARD STR SPRING COIL .038IN 150CM 3CM BOTH IP/OP $15.28 $11.31 $0.00 $12.22 $8.29 $8.29 $0.00 $0.00 $0.00 $3.18 $11.34 $11.34 $0.00 $0.00 $3.18 $0.00 $9.04 $9.04 $0.00 $7.64 $12.10 $12.22 $0.00 $0.00 $2.39 $0.00 $0.00 $2.43 $0.00 $0.00 $0.00 $0.00 $0.00 M001491031 SUP HCPCS C1769 M001491031 - GUIDEWIRE VASCULAR STR .035IN 260CM 3CM FIX CORE FLEXIBLE BOTH IP/OP $34.94 $25.86 $0.00 $27.95 $18.97 $18.97 $0.00 $0.00 $0.00 $7.28 $25.93 $25.93 $0.00 $0.00 $7.28 $0.00 $20.66 $20.66 $0.00 $17.47 $27.67 $27.95 $0.00 $0.00 $5.47 $0.00 $0.00 $5.56 $0.00 $0.00 $0.00 $0.00 $0.00 M001491451 SUP HCPCS C1769 M001491451 - GUIDEWIRE VASCULAR STR SPRING COIL .035IN 150CM 15CM STARTER BOTH IP/OP $24.71 $18.29 $0.00 $19.76 $13.41 $13.41 $0.00 $0.00 $0.00 $5.15 $18.34 $18.34 $0.00 $0.00 $5.15 $0.00 $14.61 $14.61 $0.00 $12.35 $19.57 $19.76 $0.00 $0.00 $3.87 $0.00 $0.00 $3.93 $0.00 $0.00 $0.00 $0.00 $0.00 M001491471 SUP HCPCS C1769 M001491471 - GUIDEWIRE VASCULAR STANDARD TAPER .035IN 180CM 15CM STR TIP BOTH IP/OP $195.50 $144.67 $0.00 $156.40 $106.16 $106.16 $0.00 $0.00 $0.00 $40.75 $145.10 $145.10 $0.00 $0.00 $40.74 $0.00 $115.64 $115.64 $0.00 $97.75 $154.84 $156.40 $0.00 $0.00 $30.60 $0.00 $0.00 $31.12 $0.00 $0.00 $0.00 $0.00 $0.00 M001491481 SUP HCPCS C1769 M001491481 - GUIDEWIRE VASCULAR STANDARD TAPER .035IN 260CM 15CM STR TIP BOTH IP/OP $251.38 $186.02 $0.00 $201.10 $136.50 $136.50 $0.00 $0.00 $0.00 $52.39 $186.57 $186.57 $0.00 $0.00 $52.39 $0.00 $148.69 $148.69 $0.00 $125.69 $199.09 $201.10 $0.00 $0.00 $39.34 $0.00 $0.00 $40.02 $0.00 $0.00 $0.00 $0.00 $0.00 M001491561 SUP HCPCS C1769 M001491561 - GUIDEWIRE VASCULAR 1.5MM STANDARD ROSEN CURVE TAPER .035IN BOTH IP/OP $129.88 $96.11 $0.00 $103.90 $70.52 $70.52 $0.00 $0.00 $0.00 $27.07 $96.39 $96.39 $0.00 $0.00 $27.07 $0.00 $76.82 $76.82 $0.00 $64.94 $102.86 $103.90 $0.00 $0.00 $20.33 $0.00 $0.00 $20.68 $0.00 $0.00 $0.00 $0.00 $0.00 M001491571 SUP HCPCS C1769 M001491571 - GUIDEWIRE VASCULAR 1.5MM STANDARD ROSEN CURVE TAPER .035IN BOTH IP/OP $208.95 $154.62 $0.00 $167.16 $113.46 $113.46 $0.00 $0.00 $0.00 $43.55 $155.08 $155.08 $0.00 $0.00 $43.55 $0.00 $123.59 $123.59 $0.00 $104.48 $165.49 $167.16 $0.00 $0.00 $32.70 $0.00 $0.00 $33.26 $0.00 $0.00 $0.00 $0.00 $0.00 M001491601 SUP HCPCS C1769 M001491601 - GUIDEWIRE VASCULAR STANDARD STR .035IN 150CM 3CM FIX CORE BOTH IP/OP $18.62 $13.78 $0.00 $14.90 $10.11 $10.11 $0.00 $0.00 $0.00 $3.88 $13.82 $13.82 $0.00 $0.00 $3.88 $0.00 $11.01 $11.01 $0.00 $9.31 $14.75 $14.90 $0.00 $0.00 $2.91 $0.00 $0.00 $2.96 $0.00 $0.00 $0.00 $0.00 $0.00 M001491611 SUP HCPCS C1769 M001491611 - GUIDEWIRE VASCULAR STANDARD STR .035IN 260CM 3CM FIX CORE BOTH IP/OP $37.24 $27.56 $0.00 $29.79 $20.22 $20.22 $0.00 $0.00 $0.00 $7.76 $27.64 $27.64 $0.00 $0.00 $7.76 $0.00 $22.03 $22.03 $0.00 $18.62 $29.49 $29.79 $0.00 $0.00 $5.83 $0.00 $0.00 $5.93 $0.00 $0.00 $0.00 $0.00 $0.00 M001491771 SUP HCPCS C1769 M001491771 - GUIDEWIRE VASCULAR BENTSON STANDARD .035IN 180CM 15CM SPRING BOTH IP/OP $216.00 $159.84 $0.00 $172.80 $117.29 $117.29 $0.00 $0.00 $0.00 $45.02 $160.32 $160.32 $0.00 $0.00 $45.01 $0.00 $127.76 $127.76 $0.00 $108.00 $171.07 $172.80 $0.00 $0.00 $33.80 $0.00 $0.00 $34.39 $0.00 $0.00 $0.00 $0.00 $0.00 M001491851 SUP HCPCS C1769 M001491851 - GUIDEWIRE VASCULAR J ROSEN CURVE SPRING COIL .035IN 180CM BOTH IP/OP $180.63 $133.67 $0.00 $144.50 $98.08 $98.08 $0.00 $0.00 $0.00 $37.65 $134.06 $134.06 $0.00 $0.00 $37.64 $0.00 $106.84 $106.84 $0.00 $90.31 $143.06 $144.50 $0.00 $0.00 $28.27 $0.00 $0.00 $28.76 $0.00 $0.00 $0.00 $0.00 $0.00 M001492031 SUP HCPCS C1769 M001492031 - GWIRE VASC 125CM .025IN STR FIX CORE 3CM TIP 10MM STRT PTFE BOTH IP/OP $19.50 $14.43 $0.00 $15.60 $10.59 $10.59 $0.00 $0.00 $0.00 $4.06 $14.47 $14.47 $0.00 $0.00 $4.06 $0.00 $11.53 $11.53 $0.00 $9.75 $15.44 $15.60 $0.00 $0.00 $3.05 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001492061 SUP HCPCS C1769 M001492061 - GWIRE VASC 150CM .028IN STR FIX CORE 3CM TIP 10MM STRT PTFE BOTH IP/OP $19.50 $14.43 $0.00 $15.60 $10.59 $10.59 $0.00 $0.00 $0.00 $4.06 $14.47 $14.47 $0.00 $0.00 $4.06 $0.00 $11.53 $11.53 $0.00 $9.75 $15.44 $15.60 $0.00 $0.00 $3.05 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001492081 SUP HCPCS C1769 M001492081 - GWIRE VASC 150CM .032IN STR FIX CORE 3CM TIP 10MM STRT PTFE BOTH IP/OP $28.75 $21.28 $0.00 $23.00 $15.61 $15.61 $0.00 $0.00 $0.00 $5.99 $21.34 $21.34 $0.00 $0.00 $5.99 $0.00 $17.01 $17.01 $0.00 $14.38 $22.77 $23.00 $0.00 $0.00 $4.50 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 M001492111 SUP HCPCS C1769 M001492111 - GWIRE VASC 125CM .035IN STR FIX CORE 3CM TIP 10MM STRT PTFE BOTH IP/OP $19.50 $14.43 $0.00 $15.60 $10.59 $10.59 $0.00 $0.00 $0.00 $4.06 $14.47 $14.47 $0.00 $0.00 $4.06 $0.00 $11.53 $11.53 $0.00 $9.75 $15.44 $15.60 $0.00 $0.00 $3.05 $0.00 $0.00 $3.10 $0.00 $0.00 $0.00 $0.00 $0.00 M001492121 SUP HCPCS C1769 M001492121 - GUIDEWIRE VASCULAR STR .035IN 180CM 3CM FIX CORE STARTER BOTH IP/OP $38.45 $28.45 $0.00 $30.76 $20.88 $20.88 $0.00 $0.00 $0.00 $8.01 $28.54 $28.54 $0.00 $0.00 $8.01 $0.00 $22.74 $22.74 $0.00 $19.23 $30.45 $30.76 $0.00 $0.00 $6.02 $0.00 $0.00 $6.12 $0.00 $0.00 $0.00 $0.00 $0.00 M001492311 SUP HCPCS C1769 M001492311 - GUIDEWIRE VASCULAR STR .035IN 80CM 3MM FIX CORE STARTER PTFE BOTH IP/OP $15.28 $11.31 $0.00 $12.22 $8.29 $8.29 $0.00 $0.00 $0.00 $3.18 $11.34 $11.34 $0.00 $0.00 $3.18 $0.00 $9.04 $9.04 $0.00 $7.64 $12.10 $12.22 $0.00 $0.00 $2.39 $0.00 $0.00 $2.43 $0.00 $0.00 $0.00 $0.00 $0.00 M001492751 SUP HCPCS C1769 M001492751 - GUIDEWIRE VASCULAR .018IN 130CM 3CM SHORT TAPER STR TIP BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492761 SUP HCPCS C1769 M001492761 - GUIDEWIRE VASCULAR J SHORT TAPER .018IN 130CM 3CM THRUWAY BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492771 SUP HCPCS C1769 M001492771 - GUIDEWIRE VASCULAR STR LONG TAPER .018IN 130CM 3CM SHAPEABLE BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492781 SUP HCPCS C1769 M001492781 - GUIDEWIRE VASCULAR J LONG TAPER .018IN 130CM 3CM THRUWAY BOTH IP/OP $210.10 $155.47 $0.00 $168.08 $114.08 $114.08 $0.00 $0.00 $0.00 $43.79 $155.94 $155.94 $0.00 $0.00 $43.78 $0.00 $124.27 $124.27 $0.00 $105.05 $166.40 $168.08 $0.00 $0.00 $32.88 $0.00 $0.00 $33.45 $0.00 $0.00 $0.00 $0.00 $0.00 M001492791 SUP HCPCS C1769 M001492791 - GUIDEWIRE VASCULAR STR SHORT TAPER .018IN 190CM 3CM BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492801 SUP HCPCS C1769 M001492801 - GUIDEWIRE VASCULAR .018IN 190CM 3CM SHORT TAPER J TIP DISTAL BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492811 SUP HCPCS C1769 M001492811 - GUIDEWIRE VASCULAR STR LONG TAPER .018IN 190CM 3CM SHAPEABLE BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492821 SUP HCPCS C1769 M001492821 - GUIDEWIRE VASCULAR J LONG TAPER .018IN 190CM 3CM THRUWAY BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492831 SUP HCPCS C1769 M001492831 - GUIDEWIRE VASCULAR STR SHORT TAPER .018IN 300CM 3CM BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492841 SUP HCPCS C1769 M001492841 - GUIDEWIRE VASCULAR J SHORT TAPER .018IN 300CM 3CM THRUWAY BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492851 SUP HCPCS C1769 M001492851 - GUIDEWIRE VASCULAR STR LONG TAPER .018IN 300CM 3CM SHAPEABLE BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001492861 SUP HCPCS C1769 M001492861 - GUIDEWIRE VASCULAR J LONG TAPER .018IN 300CM 3CM THRUWAY BOTH IP/OP $196.00 $145.04 $0.00 $156.80 $106.43 $106.43 $0.00 $0.00 $0.00 $40.85 $145.47 $145.47 $0.00 $0.00 $40.85 $0.00 $115.93 $115.93 $0.00 $98.00 $155.23 $156.80 $0.00 $0.00 $30.67 $0.00 $0.00 $31.20 $0.00 $0.00 $0.00 $0.00 $0.00 M001503000 SUP HCPCS C1884 M001503000 - SYSTEM EMBL PRTC 47MM VC JUG INTROD 12FR TI 38MM GRNFLD BOTH IP/OP "$2,497.25 " "$1,847.97" $0.00 "$1,997.80" "$1,123.76" "$1,123.76" $0.00 $0.00 $0.00 $520.49 "$1,853.46" "$1,853.46" $0.00 $0.00 $520.43 $0.00 "$1,477.12" "$1,477.12" $0.00 "$1,248.63" "$1,977.82" "$1,997.80" $0.00 $0.00 $390.82 $0.00 $0.00 $397.56 $0.00 $0.00 $0.00 $0.00 $0.00 M001503010 SUP HCPCS C1884 M001503010 - SYSTEM EMBL PRTC 47MM VC FEM INTROD 15FR TI 38MM GRNFLD BOTH IP/OP "$2,497.25 " "$1,847.97" $0.00 "$1,997.80" "$1,123.76" "$1,123.76" $0.00 $0.00 $0.00 $520.49 "$1,853.46" "$1,853.46" $0.00 $0.00 $520.43 $0.00 "$1,477.12" "$1,477.12" $0.00 "$1,248.63" "$1,977.82" "$1,997.80" $0.00 $0.00 $390.82 $0.00 $0.00 $397.56 $0.00 $0.00 $0.00 $0.00 $0.00 M001503350 SUP Custom 27803010 M001503350 - DILATOR VASC 12FR INTRO 6-14FR GRNFLD RADOPQ TI VC BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001503500 SUP HCPCS C1884 M001503500 - SYSTEM EMBL PRTC 47MM VC NDL SYR ACC INTROD 12FR TI 38MM BOTH IP/OP $332.50 $246.05 $0.00 $266.00 $149.63 $149.63 $0.00 $0.00 $0.00 $69.30 $246.78 $246.78 $0.00 $0.00 $69.29 $0.00 $196.67 $196.67 $0.00 $166.25 $263.34 $266.00 $0.00 $0.00 $52.04 $0.00 $0.00 $52.93 $0.00 $0.00 $0.00 $0.00 $0.00 M001504000 SUP Custom 27803010 M001504000 - FILTER VASCULAR .035IN 12FR 46MM 32MM OTW REINFORCE SHEATH BOTH IP/OP "$2,363.53 " "$1,749.01" $0.00 "$1,890.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,754.21" "$1,754.21" $0.00 $0.00 $492.56 $0.00 $0.00 $0.00 $0.00 "$1,181.76" "$1,871.92" "$1,890.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001505010 SUP Custom 27803010 M001505010 - FILTER VASCULAR 12FR OTW CAPSULE GREENFIELD FEMORAL SYSTEM BOTH IP/OP "$2,363.53 " "$1,749.01" $0.00 "$1,890.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,754.21" "$1,754.21" $0.00 $0.00 $492.56 $0.00 $0.00 $0.00 $0.00 "$1,181.76" "$1,871.92" "$1,890.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001509000 SUP HCPCS C1769 M001509000 - GUIDEWIRE VASCULAR STR .016IN 140CM 25CM STEERABLE FATHOM BOTH IP/OP $744.33 $550.80 $0.00 $595.46 $404.17 $404.17 $0.00 $0.00 $0.00 $155.14 $552.44 $552.44 $0.00 $0.00 $155.12 $0.00 $440.27 $440.27 $0.00 $372.16 $589.51 $595.46 $0.00 $0.00 $116.49 $0.00 $0.00 $118.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001509010 SUP HCPCS C1769 M001509010 - GUIDEWIRE VASCULAR STR .016IN 140CM 35CM STEERABLE FATHOM BOTH IP/OP $744.33 $550.80 $0.00 $595.46 $404.17 $404.17 $0.00 $0.00 $0.00 $155.14 $552.44 $552.44 $0.00 $0.00 $155.12 $0.00 $440.27 $440.27 $0.00 $372.16 $589.51 $595.46 $0.00 $0.00 $116.49 $0.00 $0.00 $118.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001509100 SUP HCPCS C1769 M001509100 - GUIDEWIRE VASCULAR .016IN 180CM 25CM STEERABLE STR TIP BOTH IP/OP $744.33 $550.80 $0.00 $595.46 $404.17 $404.17 $0.00 $0.00 $0.00 $155.14 $552.44 $552.44 $0.00 $0.00 $155.12 $0.00 $440.27 $440.27 $0.00 $372.16 $589.51 $595.46 $0.00 $0.00 $116.49 $0.00 $0.00 $118.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001509110 SUP HCPCS C1769 M001509110 - GUIDEWIRE VASCULAR .016IN 180CM 35CM STEERABLE STR TIP BOTH IP/OP $744.33 $550.80 $0.00 $595.46 $404.17 $404.17 $0.00 $0.00 $0.00 $155.14 $552.44 $552.44 $0.00 $0.00 $155.12 $0.00 $440.27 $440.27 $0.00 $372.16 $589.51 $595.46 $0.00 $0.00 $116.49 $0.00 $0.00 $118.50 $0.00 $0.00 $0.00 $0.00 $0.00 M0015501010 SUP HCPCS C1887 M0015501010 - CATHETER INFUS .014IN MICRO TAPER 14 FLEX 3-2.8FR .024IN 105 BOTH IP/OP "$1,157.13 " $856.28 $0.00 $925.70 $628.32 $628.32 $0.00 $0.00 $0.00 $241.17 $858.82 $858.82 $0.00 $0.00 $241.14 $0.00 $684.44 $684.44 $0.00 $578.56 $916.45 $925.70 $0.00 $0.00 $181.09 $0.00 $0.00 $184.21 $0.00 $0.00 $0.00 $0.00 $0.00 M0015501030 SUP HCPCS C1887 M0015501030 - CATHETER INFUS .038IN MICRO TAPER-14 FLEX 3-2.8FR .024IN 125 BOTH IP/OP "$1,157.13 " $856.28 $0.00 $925.70 $628.32 $628.32 $0.00 $0.00 $0.00 $241.17 $858.82 $858.82 $0.00 $0.00 $241.14 $0.00 $684.44 $684.44 $0.00 $578.56 $916.45 $925.70 $0.00 $0.00 $181.09 $0.00 $0.00 $184.21 $0.00 $0.00 $0.00 $0.00 $0.00 M0015501040 SUP HCPCS C1887 M0015501040 - CATHETER INFUS .014IN MICRO TAPER-14 FLEX 3-2.8FR .024IN 135 BOTH IP/OP "$1,157.13 " $856.28 $0.00 $925.70 $628.32 $628.32 $0.00 $0.00 $0.00 $241.17 $858.82 $858.82 $0.00 $0.00 $241.14 $0.00 $684.44 $684.44 $0.00 $578.56 $916.45 $925.70 $0.00 $0.00 $181.09 $0.00 $0.00 $184.21 $0.00 $0.00 $0.00 $0.00 $0.00 M0015502030 SUP HCPCS C1887 M0015502030 - CATHETER INFUS .016IN MICRO TAPER 14 FLEX 3-2.8FR .024IN 125 BOTH IP/OP "$1,157.13 " $856.28 $0.00 $925.70 $628.32 $628.32 $0.00 $0.00 $0.00 $241.17 $858.82 $858.82 $0.00 $0.00 $241.14 $0.00 $684.44 $684.44 $0.00 $578.56 $916.45 $925.70 $0.00 $0.00 $181.09 $0.00 $0.00 $184.21 $0.00 $0.00 $0.00 $0.00 $0.00 M0015502040 SUP HCPCS C1887 M0015502040 - CATHETER INFUS .038IN MICRO TAPER 14 FLEX 3-2.8FR .024IN 135 BOTH IP/OP "$1,157.13 " $856.28 $0.00 $925.70 $628.32 $628.32 $0.00 $0.00 $0.00 $241.17 $858.82 $858.82 $0.00 $0.00 $241.14 $0.00 $684.44 $684.44 $0.00 $578.56 $916.45 $925.70 $0.00 $0.00 $181.09 $0.00 $0.00 $184.21 $0.00 $0.00 $0.00 $0.00 $0.00 M001705020 SUP HCPCS C1874 M001705020 - STENT ENDOPRSTH 116CM 10MM 10FR 20MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705030 SUP HCPCS C2628 M001705030 - STENT ENDOPRSTH 116CM 10MM 10FR 30MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$2,318.68" "$2,318.68" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001705050 SUP HCPCS C1874 M001705050 - STENT ENDOPRSTH 116CM 10MM 10FR 50MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705070 SUP HCPCS C1874 M001705070 - STENT ENDOPRSTH 116CM 10MM 10FR 70MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705230 SUP HCPCS C2628 M001705230 - STENT ENDOPRSTH 116CM 12MM 11FR 30MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$2,318.68" "$2,318.68" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001705250 SUP HCPCS C2628 M001705250 - STENT ENDOPRSTH 116CM 12MM 11FR 50MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$2,318.68" "$2,318.68" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001705270 SUP HCPCS C1874 M001705270 - STENT ENDOPRSTH 116CM 12MM 11FR 70MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705450 SUP HCPCS C1874 M001705450 - STENT ENDOPRSTH 116CM 14MM 12FR 50MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705470 SUP HCPCS C1874 M001705470 - STENT ENDOPRSTH 116CM 14MM 12FR 70MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705620 SUP HCPCS C1874 M001705620 - STENT ENDOPRSTH 116CM 6MM 20MM 90CM DELIVERY SYSTEM BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705630 SUP HCPCS C1874 M001705630 - STENT ENDOPRSTH 116CM 6MM 9FR 30MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705650 SUP HCPCS C2617 M001705650 - STENT ENDOPRSTH 116CM 6MM 9FR 50MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705670 SUP HCPCS C1874 M001705670 - STENT ENDOPRSTH 116CM 6MM 9FR 70MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705720 SUP HCPCS C1874 M001705720 - STENT ENDOPRSTH 116CM 7MM 9FR 20MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705730 SUP HCPCS C1874 M001705730 - STENT ENDOPRSTH 116CM 7MM 9FR 30MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705750 SUP HCPCS C1874 M001705750 - STENT ENDOPRSTH 116CM 7MM 9FR 50MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705770 SUP HCPCS C1874 M001705770 - STENT ENDOPRSTH 116CM 7MM 9FR 90MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705820 SUP HCPCS C1874 M001705820 - STENT ENDOPRSTH 116CM 8MM 9FR 20MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705830 SUP HCPCS C1874 M001705830 - STENT ENDOPRSTH 116CM 8MM 9FR 30MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705850 SUP HCPCS C1874 M001705850 - STENT ENDOPRSTH 116CM 8MM 9FR 50MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705870 SUP HCPCS C1874 M001705870 - STENT ENDOPRSTH 116CM 8MM 9FR 70MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705920 SUP HCPCS C1874 M001705920 - STENT ENDOPRSTH 116CM 9MM 10FR 20MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705930 SUP HCPCS C1874 M001705930 - STENT ENDOPRSTH 116CM 9MM 10FR 30MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705950 SUP HCPCS C1874 M001705950 - STENT ENDOPRSTH 116CM 9MM 10FR 50MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001705970 SUP HCPCS C1874 M001705970 - STENT ENDOPRSTH 116CM 9MM 10FR 70MM 90CM COVER COATED BOTH IP/OP "$3,920.00 " "$2,900.80" $0.00 "$3,136.00" "$1,764.00" "$1,764.00" $0.00 $0.00 $0.00 $817.03 "$2,909.42" "$2,909.42" $0.00 $0.00 $816.93 $0.00 "$1,932.56" "$1,932.56" $0.00 "$1,960.00" "$3,104.64" "$3,136.00" $0.00 $0.00 $613.48 $0.00 $0.00 $624.06 $0.00 $0.00 $0.00 $0.00 $0.00 M001711000 SUP HCPCS C1877 M001711000 - STENT ENDOPRSTH 100CM 5MM 20MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711010 SUP HCPCS C1877 M001711010 - STENT ENDOPRSTH 5MM 6FR 20MM 135CM FLEXIBLE RECONSTRAINABLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711020 SUP HCPCS C1877 M001711020 - STENT ENDOPRSTH 100CM 5MM 40MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711030 SUP HCPCS C1877 M001711030 - STENT ENDOPRSTH 160CM 5MM 40MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711040 SUP HCPCS C1877 M001711040 - STENT ENDOPRSTH 100CM 5MM 55MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711050 SUP HCPCS C1877 M001711050 - STENT ENDOPRSTH 160CM 5MM 55MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711060 SUP HCPCS C1877 M001711060 - STENT ENDOPRSTH 100CM 5MM 80MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711070 SUP HCPCS C1877 M001711070 - STENT ENDOPRSTH 160CM 5MM 80MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711080 SUP HCPCS C1877 M001711080 - STENT ENDOPRSTH 100CM 6MM 20MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711090 SUP HCPCS C1877 M001711090 - STENT ENDOPRSTH 5MM 6FR 20MM 160CM FLEXIBLE RECONSTRAINABLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711100 SUP HCPCS C1877 M001711100 - STENT ENDOPRSTH 100CM 6MM 45MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711110 SUP HCPCS C1877 M001711110 - STENT ENDOPRSTH 160CM 6MM 45MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711120 SUP HCPCS C1877 M001711120 - STENT ENDOPRSTH 100CM 6MM 60MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711130 SUP HCPCS C1877 M001711130 - STENT ENDOPRSTH 160CM 6MM 60MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711140 SUP HCPCS C1877 M001711140 - STENT ENDOPRSTH 100CM 6MM 90MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711150 SUP HCPCS C1877 M001711150 - STENT ENDOPRSTH 160CM 6MM 90MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711160 SUP HCPCS C1877 M001711160 - STENT ENDOPRSTH 100CM 7MM 20MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711170 SUP HCPCS C1877 M001711170 - STENT ENDOPRSTH 7MM 6FR 20MM 160CM FLEXIBLE RECONSTRAINABLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711180 SUP HCPCS C1877 M001711180 - STENT ENDOPRSTH 100CM 7MM 40MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711190 SUP HCPCS C1877 M001711190 - STENT ENDOPRSTH 160CM 7MM 40MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711200 SUP HCPCS C1877 M001711200 - STENT ENDOPRSTH STENT 100CM 7MM 6FR 60MM 75CM SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711210 SUP HCPCS C1877 M001711210 - STENT ENDOPRSTH 160CM 7MM 60MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711220 SUP HCPCS C1877 M001711220 - STENT ENDOPRSTH 100CM 7MM 90MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711230 SUP HCPCS C1877 M001711230 - STENT ENDOPRSTH 160CM 7MM 90MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711240 SUP HCPCS C1877 M001711240 - STENT ENDOPRSTH 8MM 6FR 20MM 100CM FLEXIBLE RECONSTRAINABLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711250 SUP HCPCS C1877 M001711250 - STENT ENDOPRSTH 160CM 8MM 20MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711260 SUP HCPCS C2617 M001711260 - STENT ENDOPRSTH 8MM 6FR 40MM 100CM FLEXIBLE RECONSTRAINABLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711270 SUP HCPCS C1877 M001711270 - STENT TRACHEOBRONCHIAL 8MM 6FR 40MM 135CM ENDOPRSTH UNISTEP BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711280 SUP HCPCS C2617 M001711280 - STENT ENDOPRSTH 8MM 6FR 60MM 100CM FLEXIBLE RECONSTRAINABLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711290 SUP HCPCS C2617 M001711290 - STENT ENDOPRSTH 160CM 8MM 60MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711300 SUP HCPCS C2617 M001711300 - STENT ENDOPRSTH 100CM 8MM 80MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711310 SUP HCPCS C2617 M001711310 - STENT ENDOPRSTH 160CM 8MM 80MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711320 SUP HCPCS C1877 M001711320 - STENT ENDOPRSTH 10MM 6FR 20MM 100CM FLEXIBLE RECONSTRAINABLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711330 SUP HCPCS C1877 M001711330 - STENT ENDOPRSTH 160CM 10MM 20MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711340 SUP HCPCS C1877 M001711340 - STENT ENDOPRSTH 10MM 7FR 42MM 75CM ENDOPRSTH UNCOVERED BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711350 SUP HCPCS C1877 M001711350 - STENT ENDOPRSTH 160CM 10MM 42MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711360 SUP HCPCS C1877 M001711360 - STENT ENDOPRSTH 10MM 68MM 100CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711370 SUP HCPCS C1877 M001711370 - STENT ENDOPRSTH 160CM 10MM 68MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711380 SUP HCPCS C2617 M001711380 - STENT ENDOPRSTH 100CM 10MM 94MM 75CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001711390 SUP HCPCS C1877 M001711390 - STENT ENDOPRSTH 160CM 10MM 94MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712000 SUP HCPCS C1877 M001712000 - STENT ENDOPRSTH 100CM 6MM 24MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712010 SUP HCPCS C1877 M001712010 - STENT ENDOPRSTH 160CM 6MM 24MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712020 SUP HCPCS C1877 M001712020 - STENT ENDOPRSTH 100CM 6MM 6FR 36MM 75CM SYSTEM NONCOVERED BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712030 SUP HCPCS C1877 M001712030 - STENT ENDOPRSTH 160CM 6MM 36MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712040 SUP HCPCS C1877 M001712040 - STENT ENDOPRSTH 100CM 6MM 46MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712050 SUP HCPCS C1877 M001712050 - STENT ENDOPRSTH 160CM 6MM 46MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712060 SUP HCPCS C1877 M001712060 - STENT ENDOPRSTH 100CM 6MM 59MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712070 SUP HCPCS C1877 M001712070 - STENT ENDOPRSTH 160CM 6MM 59MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712080 SUP HCPCS C1877 M001712080 - STENT ENDOPRSTH 100CM 7MM 23MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712090 SUP HCPCS C1877 M001712090 - STENT ENDOPRSTH 160CM 7MM 6FR 23MM 135CM SYSTEM NONCOVERED BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712100 SUP HCPCS C1877 M001712100 - STENT ENDOPRSTH 100CM 7MM 34MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712110 SUP HCPCS C1877 M001712110 - STENT ENDOPRSTH 160CM 7MM 34MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712120 SUP HCPCS C1877 M001712120 - STENT ENDOPRSTH 100CM 7MM 6FR 55MM 75CM SYSTEM NONCOVERED BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712130 SUP HCPCS C1877 M001712130 - STENT ENDOPRSTH 160CM 7MM 55MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712140 SUP HCPCS C1877 M001712140 - STENT ENDOPRSTH 100CM 7MM 67MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712150 SUP HCPCS C1877 M001712150 - STENT ENDOPRSTH 160CM 7MM 67MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712160 SUP HCPCS C1877 M001712160 - STENT ENDOPRSTH 100CM 8MM 20MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712170 SUP HCPCS C1877 M001712170 - STENT ENDOPRSTH 160CM 8MM 20MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712180 SUP HCPCS C1877 M001712180 - STENT ENDOPRSTH 100CM 8MM 38MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712190 SUP HCPCS C1877 M001712190 - STENT ENDOPRSTH 160CM 8MM 38MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712200 SUP HCPCS C1877 M001712200 - STENT ENDOPRSTH 100CM 8MM 47MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712210 SUP HCPCS C1877 M001712210 - STENT ENDOPRSTH 160CM 8MM 47MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712220 SUP HCPCS C1877 M001712220 - STENT ENDOPRSTH 100CM 8MM 6FR 66MM 75CM SYSTEM NONCOVERED BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712230 SUP HCPCS C1877 M001712230 - STENT ENDOPRSTH 160CM 8MM 66MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712240 SUP HCPCS C1877 M001712240 - STENT ENDOPRSTH 100CM 9MM 6FR 18MM 75CM SYSTEM NONCOVERED BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712250 SUP HCPCS C1877 M001712250 - STENT ENDOPRSTH 160CM 9MM 6FR 18MM 135CM SYSTEM NONCOVERED BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712260 SUP HCPCS C1877 M001712260 - STENT ENDOPRSTH 100CM 9MM 35MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712270 SUP HCPCS C1877 M001712270 - STENT ENDOPRSTH 9MM 35MM 160CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712280 SUP HCPCS C1877 M001712280 - STENT ENDOPRSTH 100CM 9MM 52MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712290 SUP HCPCS C1877 M001712290 - STENT ENDOPRSTH 9MM 52MM 160CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712300 SUP HCPCS C1877 M001712300 - STENT ENDOPRSTH 100CM 9MM 61MM 75CM DELIVERY SYSTEM FLEXIBLE BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712310 SUP HCPCS C1877 M001712310 - STENT ENDOPRSTH 160CM 9MM 61MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712320 SUP HCPCS C1877 M001712320 - STENT ENDOPRSTH 100CM 10MM 20MM 75CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712330 SUP HCPCS C1877 M001712330 - STENT ENDOPRSTH 160CM 10MM 20MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712340 SUP HCPCS C1877 M001712340 - STENT ENDOPRSTH 100CM 10MM 39MM 75CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712350 SUP HCPCS C1877 M001712350 - STENT ENDOPRSTH 160CM 10MM 39MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712360 SUP HCPCS C2617 M001712360 - STENT ENDOPRSTH 10MM 6FR 49MM 75CM UNCOVERED UNISTEP PLUS BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712370 SUP HCPCS C1877 M001712370 - STENT ENDOPRSTH 160CM 10MM 49MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712380 SUP HCPCS C2617 M001712380 - STENT ENDOPRSTH 100CM 10MM 69MM 75CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001712390 SUP HCPCS C1877 M001712390 - STENT ENDOPRSTH 160CM 10MM 69MM 135CM DELIVERY SYSTEM BOTH IP/OP "$2,200.00 " "$1,628.00" $0.00 "$1,760.00" $990.00 $990.00 $0.00 $0.00 $0.00 $458.54 "$1,632.84" "$1,632.84" $0.00 $0.00 $458.48 $0.00 "$1,301.30" "$1,301.30" $0.00 "$1,100.00" "$1,742.40" "$1,760.00" $0.00 $0.00 $344.30 $0.00 $0.00 $350.24 $0.00 $0.00 $0.00 $0.00 $0.00 M001719000 SUP HCPCS C1876 M001719000 - STENT ENDOPRSTH 6MM 22MM CLOSE CELL DESIGN HIGH DELIVERABLE BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 M001719010 SUP HCPCS C1876 M001719010 - STENT ENDOPRSTH 8MM 21MM CLOSE CELL DESIGN HIGH DELIVERABLE BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 M001719020 SUP HCPCS C1876 M001719020 - STENT ENDOPRSTH 8MM 29MM CLOSE CELL DESIGN HIGH DELIVERABLE BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 M001719030 SUP HCPCS C1876 M001719030 - STENT ENDOPRSTH 8MM 22MM CLOSE CELL DESIGN HIGH DELIVERABLE BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 M001719040 SUP HCPCS C1876 M001719040 - STENT ENDOPRSTH 10MM 24MM CLOSE CELL DESIGN HIGH DELIVERABLE BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 M001719050 SUP HCPCS C1876 M001719050 - STENT ENDOPRSTH 10MM 31MM CLOSE CELL DESIGN HIGH DELIVERABLE BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 M001719060 SUP HCPCS C1876 M001719060 - STENT ENDOPRSTH 10MM 37MM CLOSE CELL DESIGN HIGH DELIVERABLE BOTH IP/OP "$4,500.00 " "$3,330.00" $0.00 "$3,600.00" "$2,025.00" "$2,025.00" $0.00 $0.00 $0.00 $937.91 "$3,339.90" "$3,339.90" $0.00 $0.00 $937.80 $0.00 "$2,218.50" "$2,218.50" $0.00 "$2,250.00" "$3,564.00" "$3,600.00" $0.00 $0.00 $704.25 $0.00 $0.00 $716.40 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600121 SUP HCPCS C1884 M0017600121 - PARTICLES EMBOLIZATION 45-150UM 2 VIAL CNTOUR-PVA PVA BOTH IP/OP $367.01 $271.59 $0.00 $293.61 $165.16 $165.16 $0.00 $0.00 $0.00 $76.49 $272.40 $272.40 $0.00 $0.00 $76.49 $0.00 $217.09 $217.09 $0.00 $183.51 $290.67 $293.61 $0.00 $0.00 $57.44 $0.00 $0.00 $58.43 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600151 SUP HCPCS C1884 M0017600151 - PARTICLES EMBOLIZATION 45-150UM 5 VIAL CNTOUR PVA BOTH IP/OP $358.51 $265.30 $0.00 $286.81 $161.33 $161.33 $0.00 $0.00 $0.00 $74.72 $266.09 $266.09 $0.00 $0.00 $74.71 $0.00 $212.06 $212.06 $0.00 $179.26 $283.94 $286.81 $0.00 $0.00 $56.11 $0.00 $0.00 $57.07 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600221 SUP HCPCS C1884 M0017600221 - PARTICLES EMBOLIZATION 150-250UM 2 VIAL CNTOUR PVA BOTH IP/OP $367.01 $271.59 $0.00 $293.61 $165.16 $165.16 $0.00 $0.00 $0.00 $76.49 $272.40 $272.40 $0.00 $0.00 $76.49 $0.00 $217.09 $217.09 $0.00 $183.51 $290.67 $293.61 $0.00 $0.00 $57.44 $0.00 $0.00 $58.43 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600251 SUP HCPCS C1884 M0017600251 - PARTICLES EMBOLIZATION 150-250UM 5 VIAL CNTOUR PVA BOTH IP/OP $358.51 $265.30 $0.00 $286.81 $161.33 $161.33 $0.00 $0.00 $0.00 $74.72 $266.09 $266.09 $0.00 $0.00 $74.71 $0.00 $212.06 $212.06 $0.00 $179.26 $283.94 $286.81 $0.00 $0.00 $56.11 $0.00 $0.00 $57.07 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600321 SUP HCPCS C1884 M0017600321 - PARTICLES EMBOLIZATION 250-355UM 2 VIAL CNTOUR PVA BOTH IP/OP $367.01 $271.59 $0.00 $293.61 $165.16 $165.16 $0.00 $0.00 $0.00 $76.49 $272.40 $272.40 $0.00 $0.00 $76.49 $0.00 $217.09 $217.09 $0.00 $183.51 $290.67 $293.61 $0.00 $0.00 $57.44 $0.00 $0.00 $58.43 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600351 SUP HCPCS C1884 M0017600351 - PARTICLES EMBOLIZATION 250-355UM 5 VIAL CNTOUR PVA BOTH IP/OP $358.51 $265.30 $0.00 $286.81 $161.33 $161.33 $0.00 $0.00 $0.00 $74.72 $266.09 $266.09 $0.00 $0.00 $74.71 $0.00 $212.06 $212.06 $0.00 $179.26 $283.94 $286.81 $0.00 $0.00 $56.11 $0.00 $0.00 $57.07 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600421 SUP HCPCS C1884 M0017600421 - PARTICLES EMBOLIZATION 355-500UM 2 VIAL CNTOUR PVA BOTH IP/OP $367.01 $271.59 $0.00 $293.61 $165.16 $165.16 $0.00 $0.00 $0.00 $76.49 $272.40 $272.40 $0.00 $0.00 $76.49 $0.00 $217.09 $217.09 $0.00 $183.51 $290.67 $293.61 $0.00 $0.00 $57.44 $0.00 $0.00 $58.43 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600451 SUP Custom 27203010 M0017600451 - PARTICLES EMBL 355-500UM 5 VL CNTOUR PVA BOTH IP/OP $348.00 $257.52 $0.00 $278.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $174.00 $275.62 $278.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600621 SUP Custom 27203010 PARTICLES EMBL 500-710UM 2 VL CNTOUR-PVA BOTH IP/OP $356.25 $263.63 $0.00 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.13 $282.15 $285.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600651 SUP HCPCS C1884 M0017600651 - PARTICLES EMBOLIZATION 500-710UM 5 VIAL CNTOUR PVA BOTH IP/OP $358.51 $265.30 $0.00 $286.81 $161.33 $161.33 $0.00 $0.00 $0.00 $74.72 $266.09 $266.09 $0.00 $0.00 $74.71 $0.00 $212.06 $212.06 $0.00 $179.26 $283.94 $286.81 $0.00 $0.00 $56.11 $0.00 $0.00 $57.07 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600821 SUP Custom 27203010 PARTICLES EMBL 710-1000UM 2 VL CNTOUR-PVA BOTH IP/OP $367.01 $271.59 $0.00 $399.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.49 $272.40 $272.40 $0.00 $0.00 $76.49 $0.00 $217.09 $217.09 $0.00 $249.38 $395.01 $399.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0017600851 SUP HCPCS C1884 M0017600851 - PARTICLES EMBOLIZATION 710-1000UM 5 VIAL CNTOUR PVA BOTH IP/OP $358.51 $265.30 $0.00 $286.81 $161.33 $161.33 $0.00 $0.00 $0.00 $74.72 $266.09 $266.09 $0.00 $0.00 $74.71 $0.00 $212.06 $212.06 $0.00 $179.26 $283.94 $286.81 $0.00 $0.00 $56.11 $0.00 $0.00 $57.07 $0.00 $0.00 $0.00 $0.00 $0.00 M0017601151 SUP HCPCS C1884 M0017601151 - PARTICLES EMBOLIZATION 1000-1180UM 5 VIAL CNTOUR PVA BOTH IP/OP $358.51 $265.30 $0.00 $286.81 $161.33 $161.33 $0.00 $0.00 $0.00 $74.72 $266.09 $266.09 $0.00 $0.00 $74.71 $0.00 $212.06 $212.06 $0.00 $179.26 $283.94 $286.81 $0.00 $0.00 $56.11 $0.00 $0.00 $57.07 $0.00 $0.00 $0.00 $0.00 $0.00 M001BATR111000 SUP HCPCS C1753 M001BATR111000 - MODULE CATH POLARCATH PWR SYS PERI CRYOPLASTY BOTH IP/OP "$1,415.95 " "$1,047.80" $0.00 "$1,132.76" $768.86 $768.86 $0.00 $0.00 $0.00 $295.12 "$1,050.92" "$1,050.92" $0.00 $0.00 $295.08 $0.00 $837.53 $837.53 $0.00 $707.98 "$1,121.43" "$1,132.76" $0.00 $0.00 $221.60 $0.00 $0.00 $225.42 $0.00 $0.00 $0.00 $0.00 $0.00 M001NC20000001 SUP Custom 27203010 M001NC20000001 - CARTRIDGE CATH POLARCATH N2O PERI BOTH IP/OP "$1,354.38 " "$1,002.24" $0.00 "$1,083.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,005.22" "$1,005.22" $0.00 $0.00 $282.25 $0.00 $0.00 $0.00 $0.00 $677.19 "$1,072.67" "$1,083.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001P4100080010 SUP HCPCS C1753 M001P4100080010 - CATHETER BLNDIL 4MM 80CM 100MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P4100120010 SUP HCPCS C1753 M001P4100120010 - CATHETER BLNDIL 4MM 120CM 100MM POLARCATH PERI ACPT .035IN BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P420080010 SUP HCPCS C1753 M001P420080010 - CATHETER BLNDIL 4MM 80CM 20MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P420120010 SUP HCPCS C1753 M001P420120010 - CATHETER BLNDIL 4MM 120CM 20MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P440080010 SUP HCPCS C1753 M001P440080010 - CATHETER BLNDIL 4MM 80CM 40MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P440120010 SUP HCPCS C1753 M001P440120010 - CATHETER BLNDIL 4MM 120CM 40MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P460080010 SUP HCPCS C1753 M001P460080010 - CATHETER BLNDIL 4MM 80CM 60MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P460120010 SUP HCPCS C1726 M001P460120010 - CATHETER BLNDIL 4MM 120CM 60MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P480080010 SUP HCPCS C1753 M001P480080010 - CATHETER BLNDIL 4MM 80CM 80MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P480120010 SUP HCPCS C1726 M001P480120010 - CATHETER BLNDIL 4MM 120CM 80MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P5100080010 SUP HCPCS C1753 M001P5100080010 - CATHETER BLNDIL 5MM 80CM 100MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P5100120010 SUP HCPCS C1753 M001P5100120010 - CATHETER BLNDIL 5MM 120CM 100MM POLARCATH PERI ACPT .035IN BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P5120120010 SUP HCPCS C1725 M001P5120120010 - CATHETER BLNDIL 5MM 120CM 120MM POLARCATH PERI ACPT .035IN BOTH IP/OP "$2,228.58 " "$1,649.15" $0.00 "$1,782.86" "$1,210.12" "$1,210.12" $0.00 $0.00 $0.00 $464.49 "$1,654.05" "$1,654.05" $0.00 $0.00 $464.44 $0.00 "$1,318.20" "$1,318.20" $0.00 "$1,114.29" "$1,765.04" "$1,782.86" $0.00 $0.00 $348.77 $0.00 $0.00 $354.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001P5150120010 SUP HCPCS C1725 M001P5150120010 - CATHETER BLNDIL 5MM 150CM 120MM POLARCATH PERI ACPT .035IN BOTH IP/OP "$2,487.13 " "$1,840.48" $0.00 "$1,989.70" "$1,350.51" "$1,350.51" $0.00 $0.00 $0.00 $518.38 "$1,845.94" "$1,845.94" $0.00 $0.00 $518.32 $0.00 "$1,471.13" "$1,471.13" $0.00 "$1,243.56" "$1,969.81" "$1,989.70" $0.00 $0.00 $389.24 $0.00 $0.00 $395.95 $0.00 $0.00 $0.00 $0.00 $0.00 M001P520080010 SUP HCPCS C1753 M001P520080010 - CATHETER BLNDIL 5MM 80CM 20MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P520120010 SUP HCPCS C1753 M001P520120010 - CATHETER BLNDIL 5MM 120CM 20MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P540080010 SUP HCPCS C1753 M001P540080010 - CATHETER BLNDIL 5MM 80CM 40MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P540120010 SUP HCPCS C1726 M001P540120010 - CATHETER BLNDIL 5MM 120CM 40MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P560080010 SUP HCPCS C1753 M001P560080010 - CATHETER BLNDIL 5MM 80CM 60MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P560120010 SUP HCPCS C1726 M001P560120010 - CATHETER BLNDIL 5MM 120CM 60MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P580080010 SUP HCPCS C1753 M001P580080010 - CATHETER BLNDIL 5MM 80CM 80MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P580120010 SUP HCPCS C1726 M001P580120010 - CATHETER BLNDIL 5MM 120CM 80MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P6100080010 SUP HCPCS C1753 M001P6100080010 - CATHETER BLNDIL 6MM 80CM 100MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P6100120010 SUP HCPCS C1753 M001P6100120010 - CATHETER BLNDIL 6MM 120CM 100MM POLARCATH PERI ACPT .035IN BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P6120120010 SUP HCPCS C1725 M001P6120120010 - CATHETER BLNDIL 6MM 120CM 120MM POLARCATH PERI ACPT .035IN BOTH IP/OP "$2,228.58 " "$1,649.15" $0.00 "$1,782.86" "$1,210.12" "$1,210.12" $0.00 $0.00 $0.00 $464.49 "$1,654.05" "$1,654.05" $0.00 $0.00 $464.44 $0.00 "$1,318.20" "$1,318.20" $0.00 "$1,114.29" "$1,765.04" "$1,782.86" $0.00 $0.00 $348.77 $0.00 $0.00 $354.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001P6150120010 SUP HCPCS C1725 M001P6150120010 - CATHETER BLNDIL 6MM 120CM 150MM POLARCATH PERI ACPT .035IN BOTH IP/OP "$2,487.13 " "$1,840.48" $0.00 "$1,989.70" "$1,350.51" "$1,350.51" $0.00 $0.00 $0.00 $518.38 "$1,845.94" "$1,845.94" $0.00 $0.00 $518.32 $0.00 "$1,471.13" "$1,471.13" $0.00 "$1,243.56" "$1,969.81" "$1,989.70" $0.00 $0.00 $389.24 $0.00 $0.00 $395.95 $0.00 $0.00 $0.00 $0.00 $0.00 M001P620080010 SUP HCPCS C1753 M001P620080010 - CATHETER BLNDIL 6MM 80CM 20MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P620120010 SUP HCPCS C1753 M001P620120010 - CATHETER BLNDIL 6MM 120CM 20MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P640080010 SUP HCPCS C1726 M001P640080010 - CATHETER BLNDIL 6MM 80CM 40MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P640120010 SUP HCPCS C1726 M001P640120010 - CATHETER BLNDIL 6MM 120CM 40MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P660080010 SUP HCPCS C1753 M001P660080010 - CATHETER BLNDIL 6MM 80CM 60MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P660120010 SUP HCPCS C1726 M001P660120010 - CATHETER BLNDIL 6MM 120CM 60MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P680080010 SUP HCPCS C1753 M001P680080010 - CATHETER BLNDIL 6MM 80CM 80MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P680120010 SUP HCPCS C1753 M001P680120010 - CATHETER BLNDIL 6MM 120CM 80MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P720080010 SUP HCPCS C1753 M001P720080010 - CATHETER BLNDIL 7MM 80CM 20MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P720120010 SUP HCPCS C1726 M001P720120010 - CATHETER BLNDIL 7MM 120CM 20MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P740080010 SUP HCPCS C1753 M001P740080010 - CATHETER BLNDIL 7MM 80CM 40MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P740120010 SUP HCPCS C1726 M001P740120010 - CATHETER BLNDIL 7MM 120CM 40MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P760080010 SUP HCPCS C2618 M001P760080010 - CATHETER BLNDIL 7MM 80CM 60MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 $0.00 $0.00 $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001P760120010 SUP HCPCS C1753 M001P760120010 - CATHETER BLNDIL 7MM 120CM 60MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P780080010 SUP HCPCS C1753 M001P780080010 - CATHETER BLNDIL 7MM 80CM 80MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P780120010 SUP HCPCS C1726 M001P780120010 - CATHETER BLNDIL 7MM 120CM 80MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,982.33 " "$1,466.92" $0.00 "$1,585.86" "$1,076.40" "$1,076.40" $0.00 $0.00 $0.00 $413.17 "$1,471.28" "$1,471.28" $0.00 $0.00 $413.12 $0.00 "$1,172.55" "$1,172.55" $0.00 $991.16 "$1,570.01" "$1,585.86" $0.00 $0.00 $310.23 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 M001P820080010 SUP HCPCS C1725 M001P820080010 - CATHETER BLNDIL 8MM 80CM 20MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P840080010 SUP HCPCS C1725 M001P840080010 - CATHETER BLNDIL 8MM 80CM 40MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001P840120010 SUP HCPCS C1726 M001P840120010 - CATHETER BLNDIL 8MM 120CM 40MM POLARCATH PERI ACPT .035IN GW BOTH IP/OP "$1,699.13 " "$1,257.36" $0.00 "$1,359.30" $922.62 $922.62 $0.00 $0.00 $0.00 $354.14 "$1,261.09" "$1,261.09" $0.00 $0.00 $354.10 $0.00 "$1,005.03" "$1,005.03" $0.00 $849.56 "$1,345.71" "$1,359.30" $0.00 $0.00 $265.91 $0.00 $0.00 $270.50 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB50201350 SUP HCPCS C1726 M001PCB50201350 - CATHETER BLNDIL 5MM 135CM 20MM PR CTBLN OTW TPR TIP INFL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB5020500 SUP HCPCS C1753 M001PCB5020500 - CATHETER BALDILAT 5MM 50CM 2CM OTW PERIPHERAL CUTTING BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB5020900 SUP HCPCS C1726 M001PCB5020900 - CATHETER BALDILAT 5MM 90CM 20MM OTW PLAQUE MODIFICATION BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB60201350 SUP HCPCS C1726 M001PCB60201350 - CATHETER BLNDIL 5MM 135CM 20MM PR CTBLN OTW TPR TIP INFL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB6020500 SUP HCPCS C1753 M001PCB6020500 - CATHETER BLNDIL 6MM 50CM 20MM PR CTBLN OTW TPR TIP INFL PORT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB6020900 SUP HCPCS C1726 M001PCB6020900 - CATHETER BLNDIL 6MM 90CM 20MM PR CTBLN OTW INFL PORT TPR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB70201350 SUP HCPCS C1753 M001PCB70201350 - CATHETER BLNDIL 7MM 135CM 20MM PR CTBLN OTW TPR TIP INFL BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB7020500 SUP HCPCS C1753 M001PCB7020500 - CATHETER BLNDIL 7MM 50CM 20MM PR CTBLN OTW TPR TIP INFL PORT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB7020900 SUP HCPCS C1753 M001PCB7020900 - CATHETER BLNDIL 7MM 90CM 20MM PR CTBLN OTW TPR TIP INFL PORT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB80201350 SUP HCPCS C1753 M001PCB80201350 - CATHETER BALDILAT 8MM 135CM 2CM OTW PLAQUE MODIFICATION BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB8020500 SUP HCPCS C1753 M001PCB8020500 - CATHETER BLNDIL 8MM 50CM 20MM PR CTBLN OTW INFL PORT TPR TIP BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCB8020900 SUP HCPCS C1753 M001PCB8020900 - CATHETER BLNDIL 8MM 90CM 20MM PR CTBLN OTW TPR TIP INFL PORT BOTH IP/OP "$1,750.00 " "$1,295.00" $0.00 "$1,400.00" $950.25 $950.25 $0.00 $0.00 $0.00 $364.74 "$1,298.85" "$1,298.85" $0.00 $0.00 $364.70 $0.00 "$1,035.13" "$1,035.13" $0.00 $875.00 "$1,386.00" "$1,400.00" $0.00 $0.00 $273.88 $0.00 $0.00 $278.60 $0.00 $0.00 $0.00 $0.00 $0.00 M001PCIU400000 SUP HCPCS C2618 M001PCIU400000 - UNIT CATH POLARCATH PERI CRYOPLASTY BOTH IP/OP "$2,561.00 " "$1,895.14" $0.00 "$2,048.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,900.77" "$1,900.77" $0.00 $0.00 $533.71 $0.00 $0.00 $0.00 $0.00 "$1,280.50" "$2,028.31" "$2,048.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M001T20100135010 SUP HCPCS C1725 M001T20100135010 - CATHETER BLNDIL 2MM 135CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T20100150010 SUP HCPCS C1725 M001T20100150010 - CATHETER BLNDIL 2MM 150CM 100MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T20120150010 SUP HCPCS C1725 M001T20120150010 - CATHETER BLNDIL 2MM 150CM 120MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,794.95 " "$2,068.26" $0.00 "$2,235.96" "$1,517.66" "$1,517.66" $0.00 $0.00 $0.00 $582.54 "$2,074.41" "$2,074.41" $0.00 $0.00 $582.47 $0.00 "$1,653.21" "$1,653.21" $0.00 "$1,397.48" "$2,213.60" "$2,235.96" $0.00 $0.00 $437.41 $0.00 $0.00 $444.96 $0.00 $0.00 $0.00 $0.00 $0.00 M001T20150150010 SUP HCPCS C1725 M001T20150150010 - CATHETER BLNDIL 2MM 150CM 150MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$3,041.20 " "$2,250.49" $0.00 "$2,432.96" "$1,651.37" "$1,651.37" $0.00 $0.00 $0.00 $633.86 "$2,257.18" "$2,257.18" $0.00 $0.00 $633.79 $0.00 "$1,798.87" "$1,798.87" $0.00 "$1,520.60" "$2,408.63" "$2,432.96" $0.00 $0.00 $475.95 $0.00 $0.00 $484.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2020135010 SUP HCPCS C1725 M001T2020135010 - CATHETER BLNDIL 2MM 135CM 20MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2020150010 SUP HCPCS C1725 M001T2020150010 - CATHETER BLNDIL 2MM 150CM 20MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2040135010 SUP HCPCS C1725 M001T2040135010 - CATHETER BLNDIL 2MM 135CM 40MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2040150010 SUP HCPCS C1725 M001T2040150010 - CATHETER BLNDIL 2MM 150CM 40MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2060135010 SUP HCPCS C1725 M001T2060135010 - CATHETER BLNDIL 2MM 135CM 60MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2060150010 SUP HCPCS C1725 M001T2060150010 - CATHETER BLNDIL 2MM 150CM 60MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T25100135010 SUP HCPCS C1725 M001T25100135010 - CATHETER BLNDIL 2.5MM 135CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T25100150010 SUP HCPCS C1725 M001T25100150010 - CATHETER BLNDIL 2.5MM 150CM 100MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T25120150010 SUP HCPCS C1725 M001T25120150010 - CATHETER BLNDIL 2.5MM 150CM 120MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,794.95 " "$2,068.26" $0.00 "$2,235.96" "$1,517.66" "$1,517.66" $0.00 $0.00 $0.00 $582.54 "$2,074.41" "$2,074.41" $0.00 $0.00 $582.47 $0.00 "$1,653.21" "$1,653.21" $0.00 "$1,397.48" "$2,213.60" "$2,235.96" $0.00 $0.00 $437.41 $0.00 $0.00 $444.96 $0.00 $0.00 $0.00 $0.00 $0.00 M001T25150150010 SUP HCPCS C1725 M001T25150150010 - CATHETER BLNDIL 2.5MM 150CM 150MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$3,041.20 " "$2,250.49" $0.00 "$2,432.96" "$1,651.37" "$1,651.37" $0.00 $0.00 $0.00 $633.86 "$2,257.18" "$2,257.18" $0.00 $0.00 $633.79 $0.00 "$1,798.87" "$1,798.87" $0.00 "$1,520.60" "$2,408.63" "$2,432.96" $0.00 $0.00 $475.95 $0.00 $0.00 $484.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2520135010 SUP HCPCS C1725 M001T2520135010 - CATHETER BLNDIL 2.5MM 135CM 20MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2520150010 SUP HCPCS C1725 M001T2520150010 - CATHETER BLNDIL 2.5MM 150CM 20MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2540135010 SUP HCPCS C1725 M001T2540135010 - CATHETER BLNDIL 2.5MM 135CM 40MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2540150010 SUP HCPCS C1725 M001T2540150010 - CATHETER BLNDIL 2.5MM 150CM 40MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2560135010 SUP HCPCS C1725 M001T2560135010 - CATHETER BLNDIL 2.5MM 135CM 60MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T2560150010 SUP HCPCS C1725 M001T2560150010 - CATHETER BLNDIL 2.5MM 150CM 60MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T30100135010 SUP HCPCS C1725 M001T30100135010 - CATHETER BLNDIL 3MM 135CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T30100150010 SUP HCPCS C1725 M001T30100150010 - CATHETER BLNDIL 3MM 150CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T30120150010 SUP HCPCS C1725 M001T30120150010 - CATHETER BLNDIL 3MM 150CM 120MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,794.95 " "$2,068.26" $0.00 "$2,235.96" "$1,517.66" "$1,517.66" $0.00 $0.00 $0.00 $582.54 "$2,074.41" "$2,074.41" $0.00 $0.00 $582.47 $0.00 "$1,653.21" "$1,653.21" $0.00 "$1,397.48" "$2,213.60" "$2,235.96" $0.00 $0.00 $437.41 $0.00 $0.00 $444.96 $0.00 $0.00 $0.00 $0.00 $0.00 M001T30150150010 SUP HCPCS C1725 M001T30150150010 - CATHETER BLNDIL 3MM 150CM 150MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$3,041.20 " "$2,250.49" $0.00 "$2,432.96" "$1,651.37" "$1,651.37" $0.00 $0.00 $0.00 $633.86 "$2,257.18" "$2,257.18" $0.00 $0.00 $633.79 $0.00 "$1,798.87" "$1,798.87" $0.00 "$1,520.60" "$2,408.63" "$2,432.96" $0.00 $0.00 $475.95 $0.00 $0.00 $484.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3020135010 SUP HCPCS C1725 M001T3020135010 - CATHETER BLNDIL 3MM 135CM 20MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3020150010 SUP HCPCS C1725 M001T3020150010 - CATHETER BLNDIL 3MM 150CM 20MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3040135010 SUP HCPCS C1725 M001T3040135010 - CATHETER BLNDIL 3MM 135CM 40MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3040150010 SUP HCPCS C1725 M001T3040150010 - CATHETER BLNDIL 3MM 150CM 40MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3060135010 SUP HCPCS C1725 M001T3060135010 - CATHETER BLNDIL 3MM 135CM 60MM POLARCATH COAX RADOPQ MRKNG BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3060150010 SUP HCPCS C1725 M001T3060150010 - CATHETER BLNDIL 3MM 150CM 60MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T35100135010 SUP HCPCS C1725 M001T35100135010 - CATHETER BLNDIL 3.5MM 135CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T35100150010 SUP HCPCS C1725 M001T35100150010 - CATHETER BLNDIL 3.5MM 150CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T35120150010 SUP HCPCS C1725 M001T35120150010 - CATHETER BLNDIL 3.5MM 150CM 120MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,794.95 " "$2,068.26" $0.00 "$2,235.96" "$1,517.66" "$1,517.66" $0.00 $0.00 $0.00 $582.54 "$2,074.41" "$2,074.41" $0.00 $0.00 $582.47 $0.00 "$1,653.21" "$1,653.21" $0.00 "$1,397.48" "$2,213.60" "$2,235.96" $0.00 $0.00 $437.41 $0.00 $0.00 $444.96 $0.00 $0.00 $0.00 $0.00 $0.00 M001T35150150010 SUP HCPCS C1725 M001T35150150010 - CATHETER BLNDIL 3.5MM 150CM 150MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$3,041.20 " "$2,250.49" $0.00 "$2,432.96" "$1,651.37" "$1,651.37" $0.00 $0.00 $0.00 $633.86 "$2,257.18" "$2,257.18" $0.00 $0.00 $633.79 $0.00 "$1,798.87" "$1,798.87" $0.00 "$1,520.60" "$2,408.63" "$2,432.96" $0.00 $0.00 $475.95 $0.00 $0.00 $484.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3520135010 SUP HCPCS C1725 M001T3520135010 - CATHETER BLNDIL 3.5MM 135CM 20MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3520150010 SUP HCPCS C1725 M001T3520150010 - CATHETER BLNDIL 3.5MM 150CM 20MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3540135010 SUP HCPCS C1725 M001T3540135010 - CATHETER BLNDIL 3.5MM 135CM 40MM POLARCATH COAX RADOPQ MRKNG BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3540150010 SUP HCPCS C1725 M001T3540150010 - CATHETER BLNDIL 3.5MM 150CM 40MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3560135010 SUP HCPCS C1725 M001T3560135010 - CATHETER BLNDIL 3.5MM 135CM 60MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T3560150010 SUP HCPCS C1725 M001T3560150010 - CATHETER BLNDIL 3.5MM 150CM 60MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T40100135010 SUP HCPCS C1725 M001T40100135010 - CATHETER BLNDIL 4MM 135CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T40100150010 SUP HCPCS C1725 M001T40100150010 - CATHETER BLNDIL 4MM 150CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T40120150010 SUP HCPCS C1725 M001T40120150010 - CATHETER BLNDIL 4MM 150CM 120MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,794.95 " "$2,068.26" $0.00 "$2,235.96" "$1,517.66" "$1,517.66" $0.00 $0.00 $0.00 $582.54 "$2,074.41" "$2,074.41" $0.00 $0.00 $582.47 $0.00 "$1,653.21" "$1,653.21" $0.00 "$1,397.48" "$2,213.60" "$2,235.96" $0.00 $0.00 $437.41 $0.00 $0.00 $444.96 $0.00 $0.00 $0.00 $0.00 $0.00 M001T40150150010 SUP HCPCS C1725 M001T40150150010 - CATHETER BLNDIL 4MM 150CM 150MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$3,041.20 " "$2,250.49" $0.00 "$2,432.96" "$1,651.37" "$1,651.37" $0.00 $0.00 $0.00 $633.86 "$2,257.18" "$2,257.18" $0.00 $0.00 $633.79 $0.00 "$1,798.87" "$1,798.87" $0.00 "$1,520.60" "$2,408.63" "$2,432.96" $0.00 $0.00 $475.95 $0.00 $0.00 $484.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001T4020135010 SUP HCPCS C1725 M001T4020135010 - CATHETER BLNDIL 5FR 4MM 135CM 20MM POLARCATH SHTH PERI ACPT BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T4020150010 SUP HCPCS C1725 M001T4020150010 - CATHETER BLNDIL 4MM 150CM 20MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T4040135010 SUP HCPCS C1725 M001T4040135010 - CATHETER BLNDIL 4MM 135CM 40MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T4040150010 SUP HCPCS C1725 M001T4040150010 - CATHETER BLNDIL 4MM 150CM 40MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T4060135010 SUP HCPCS C1725 M001T4060135010 - CATHETER BLNDIL 4MM 135CM 60MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T4060150010 SUP HCPCS C1725 M001T4060150010 - CATHETER BLNDIL 4MM 150CM 60MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T50100135010 SUP HCPCS C1725 M001T50100135010 - CATHETER BLNDIL 5MM 135CM 100MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T50120135010 SUP HCPCS C1725 M001T50120135010 - CATHETER BLNDIL 5MM 135CM 120MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$2,794.95 " "$2,068.26" $0.00 "$2,235.96" "$1,517.66" "$1,517.66" $0.00 $0.00 $0.00 $582.54 "$2,074.41" "$2,074.41" $0.00 $0.00 $582.47 $0.00 "$1,653.21" "$1,653.21" $0.00 "$1,397.48" "$2,213.60" "$2,235.96" $0.00 $0.00 $437.41 $0.00 $0.00 $444.96 $0.00 $0.00 $0.00 $0.00 $0.00 M001T50150135010 SUP HCPCS C1725 M001T50150135010 - CATHETER BLNDIL 5MM 135CM 150MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$3,041.20 " "$2,250.49" $0.00 "$2,432.96" "$1,651.37" "$1,651.37" $0.00 $0.00 $0.00 $633.86 "$2,257.18" "$2,257.18" $0.00 $0.00 $633.79 $0.00 "$1,798.87" "$1,798.87" $0.00 "$1,520.60" "$2,408.63" "$2,432.96" $0.00 $0.00 $475.95 $0.00 $0.00 $484.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001T5020135010 SUP HCPCS C1725 M001T5020135010 - CATHETER BLNDIL 5MM 135CM 20MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T5040135010 SUP HCPCS C1725 M001T5040135010 - CATHETER BLNDIL 5MM 135CM 40MM POLARCATH COAX RADOPQ PERI BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T5060135010 SUP HCPCS C1725 M001T5060135010 - CATHETER BLNDIL 5MM 135CM 60MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T60100135010 SUP HCPCS C1725 M001T60100135010 - CATHETER BLNDIL 6MM 135CM 100MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,536.38 " "$1,876.92" $0.00 "$2,029.10" "$1,377.25" "$1,377.25" $0.00 $0.00 $0.00 $528.64 "$1,882.50" "$1,882.50" $0.00 $0.00 $528.58 $0.00 "$1,500.27" "$1,500.27" $0.00 "$1,268.19" "$2,008.81" "$2,029.10" $0.00 $0.00 $396.94 $0.00 $0.00 $403.79 $0.00 $0.00 $0.00 $0.00 $0.00 M001T60120135010 SUP HCPCS C1725 M001T60120135010 - CATHETER BLNDIL 6MM 135CM 120MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$2,794.95 " "$2,068.26" $0.00 "$2,235.96" "$1,517.66" "$1,517.66" $0.00 $0.00 $0.00 $582.54 "$2,074.41" "$2,074.41" $0.00 $0.00 $582.47 $0.00 "$1,653.21" "$1,653.21" $0.00 "$1,397.48" "$2,213.60" "$2,235.96" $0.00 $0.00 $437.41 $0.00 $0.00 $444.96 $0.00 $0.00 $0.00 $0.00 $0.00 M001T60150135010 SUP HCPCS C1725 M001T60150135010 - CATHETER BLNDIL 6MM 135CM 150MM POLARCATH PERI ACPT .014IN BOTH IP/OP "$3,041.20 " "$2,250.49" $0.00 "$2,432.96" "$1,651.37" "$1,651.37" $0.00 $0.00 $0.00 $633.86 "$2,257.18" "$2,257.18" $0.00 $0.00 $633.79 $0.00 "$1,798.87" "$1,798.87" $0.00 "$1,520.60" "$2,408.63" "$2,432.96" $0.00 $0.00 $475.95 $0.00 $0.00 $484.16 $0.00 $0.00 $0.00 $0.00 $0.00 M001T6020135010 SUP HCPCS C1725 M001T6020135010 - CATHETER BLNDIL 6MM 135CM 20MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T6040135010 SUP HCPCS C1725 M001T6040135010 - CATHETER BLNDIL 6MM 135CM 40MM POLARCATH RADOPQ PERI ACPT BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M001T6060135010 SUP HCPCS C1725 M001T6060135010 - CATHETER BLNDIL 6MM 135CM 60MM POLARCATH PERI ACPT .014IN GW BOTH IP/OP "$2,265.50 " "$1,676.47" $0.00 "$1,812.40" "$1,230.17" "$1,230.17" $0.00 $0.00 $0.00 $472.19 "$1,681.45" "$1,681.45" $0.00 $0.00 $472.13 $0.00 "$1,340.04" "$1,340.04" $0.00 "$1,132.75" "$1,794.28" "$1,812.40" $0.00 $0.00 $354.55 $0.00 $0.00 $360.67 $0.00 $0.00 $0.00 $0.00 $0.00 M002002231680 SUP HCPCS C1768 M002002231680 - GRAFT CARDIO 40CM 16X8MM WVN BFUR NONSEALED CLY VRSFT EPTFE BOTH IP/OP "$1,337.50 " $989.75 $0.00 "$1,070.00" $601.88 $601.88 $0.00 $0.00 $0.00 $278.77 $992.69 $992.69 $0.00 $0.00 $278.74 $0.00 $791.13 $791.13 $0.00 $668.75 "$1,059.30" "$1,070.00" $0.00 $0.00 $209.32 $0.00 $0.00 $212.93 $0.00 $0.00 $0.00 $0.00 $0.00 M002020195300 SUP HCPCS C1768 M002020195300 - PATCH CARDIO THK.36MM 3X1IN KNTD ULTHN HMSH FNS BOTH IP/OP $278.93 $206.41 $0.00 $223.14 $125.52 $125.52 $0.00 $0.00 $0.00 $58.13 $207.02 $207.02 $0.00 $0.00 $58.13 $0.00 $164.98 $164.98 $0.00 $139.46 $220.91 $223.14 $0.00 $0.00 $43.65 $0.00 $0.00 $44.40 $0.00 $0.00 $0.00 $0.00 $0.00 M00202019530P0 SUP HCPCS C1768 M00202019530P0 - PATCH CV THK.36MM ULTHN TPR 3X1IN HMSH PL FNS KNIT PRETRIM BOTH IP/OP $321.70 $238.06 $0.00 $248.28 $139.66 $139.66 $0.00 $0.00 $0.00 $67.05 $238.77 $238.77 $0.00 $0.00 $67.04 $0.00 $190.29 $190.29 $0.00 $155.18 $245.80 $248.28 $0.00 $0.00 $48.57 $0.00 $0.00 $49.41 $0.00 $0.00 $0.00 $0.00 $0.00 M002020851470 SUP HCPCS C1768 M002020851470 - GRAFT CV 2 BRCH THN 14MM 7MM 40CM STRL HMSH G2 VLR MCVL SFT BOTH IP/OP "$1,772.45 " "$1,311.61" $0.00 "$1,467.64" $825.55 $825.55 $0.00 $0.00 $0.00 $369.42 "$1,315.51" "$1,315.51" $0.00 $0.00 $369.38 $0.00 "$1,048.40" "$1,048.40" $0.00 $917.28 "$1,452.96" "$1,467.64" $0.00 $0.00 $287.11 $0.00 $0.00 $292.06 $0.00 $0.00 $0.00 $0.00 $0.00 M002020851680 SUP HCPCS C1768 M002020851680 - GRAFT VASC 2 BRCH 16MM 8MM 40CM STRL HMSH GMCVL 2 VLR CLGN BOTH IP/OP "$1,834.55 " "$1,357.57" $0.00 "$1,467.64" $825.55 $825.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $917.28 "$1,452.96" "$1,467.64" $0.00 $0.00 $287.11 $0.00 $0.00 $292.06 $0.00 $0.00 $0.00 $0.00 $0.00 M002020952080 SUP HCPCS C1768 M002020952080 - GRAFT CV 8MM 60CM STRL HMSH GMCVL 2 VLR STRG TUBE KNIT SFT BOTH IP/OP "$1,308.00 " $967.92 $0.00 $996.58 $560.58 $560.58 $0.00 $0.00 $0.00 $272.62 $970.80 $970.80 $0.00 $0.00 $272.59 $0.00 $773.68 $773.68 $0.00 $622.86 $986.62 $996.58 $0.00 $0.00 $194.96 $0.00 $0.00 $198.32 $0.00 $0.00 $0.00 $0.00 $0.00 M002020952160 SUP HCPCS C1768 M002020952160 - GRAFT VASC 16MM 30CM STRL HMSH GMCVL PLSTR 2 VLR STRG TUBE BOTH IP/OP "$1,239.88 " $917.51 $0.00 "$1,026.64" $577.49 $577.49 $0.00 $0.00 $0.00 $258.42 $920.24 $920.24 $0.00 $0.00 $258.39 $0.00 $733.39 $733.39 $0.00 $641.65 "$1,016.37" "$1,026.64" $0.00 $0.00 $200.84 $0.00 $0.00 $204.30 $0.00 $0.00 $0.00 $0.00 $0.00 M00202175416P0 SUP HCPCS C1768 M00202175416P0 - GRAFT CARDIO 30CM 16MM 2 VLR WVN STR TUBE HMSH PL PLSTR STRL BOTH IP/OP "$1,384.73 " "$1,024.70" $0.00 "$1,043.02" $586.70 $586.70 $0.00 $0.00 $0.00 $288.61 "$1,027.74" "$1,027.74" $0.00 $0.00 $288.58 $0.00 $819.06 $819.06 $0.00 $651.89 "$1,032.59" "$1,043.02" $0.00 $0.00 $204.04 $0.00 $0.00 $207.56 $0.00 $0.00 $0.00 $0.00 $0.00 M002021754180 SUP HCPCS C1768 M002021754180 - GRAFT VASC 30CM 18MM HMSHLD MCVL WVN STR BOTH IP/OP "$1,235.50 " $914.27 $0.00 $988.40 $555.98 $555.98 $0.00 $0.00 $0.00 $257.51 $916.99 $916.99 $0.00 $0.00 $257.48 $0.00 $730.80 $730.80 $0.00 $617.75 $978.52 $988.40 $0.00 $0.00 $193.36 $0.00 $0.00 $196.69 $0.00 $0.00 $0.00 $0.00 $0.00 M00202175420P0 SUP HCPCS C1768 M00202175420P0 - GRAFT VASC 30CM 20MM HMSH PL EPTFE 2 VLR WVN STR TUBE SFT BOTH IP/OP "$1,384.73 " "$1,024.70" $0.00 "$1,055.02" $593.45 $593.45 $0.00 $0.00 $0.00 $288.61 "$1,027.74" "$1,027.74" $0.00 $0.00 $288.58 $0.00 $819.06 $819.06 $0.00 $659.39 "$1,044.47" "$1,055.02" $0.00 $0.00 $206.39 $0.00 $0.00 $209.95 $0.00 $0.00 $0.00 $0.00 $0.00 M00202175426P0 SUP HCPCS C1768 M00202175426P0 - GRAFT CARDIO 30CM 36MM 2 VLR SL TXTL STR TUBE WVN HMSH PL BOTH IP/OP "$1,371.55 " "$1,014.95" $0.00 "$1,097.24" $617.20 $617.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $685.78 "$1,086.27" "$1,097.24" $0.00 $0.00 $214.65 $0.00 $0.00 $218.35 $0.00 $0.00 $0.00 $0.00 $0.00 M00202175428P0 SUP HCPCS C1768 M00202175428P0 - GRAFT CV STRG TUBE 28MM 30CM HMSH PL WVN SMTH NDL PSG SUT BOTH IP/OP "$1,440.13 " "$1,065.70" $0.00 "$1,564.50" $880.03 $880.03 $0.00 $0.00 $0.00 $300.16 "$1,068.86" "$1,068.86" $0.00 $0.00 $300.12 $0.00 $851.83 $851.83 $0.00 $977.81 "$1,548.86" "$1,564.50" $0.00 $0.00 $306.06 $0.00 $0.00 $311.34 $0.00 $0.00 $0.00 $0.00 $0.00 M00202175430P0 SUP HCPCS C1768 M00202175430P0 - GRAFT CARDIO 30CM 30MM 2 VLR WVN STR TUBE HMSH PL PLSTR STRL BOTH IP/OP "$1,440.13 " "$1,065.70" $0.00 "$1,097.24" $617.20 $617.20 $0.00 $0.00 $0.00 $300.16 "$1,068.86" "$1,068.86" $0.00 $0.00 $300.12 $0.00 $851.83 $851.83 $0.00 $685.78 "$1,086.27" "$1,097.24" $0.00 $0.00 $214.65 $0.00 $0.00 $218.35 $0.00 $0.00 $0.00 $0.00 $0.00 M00202175434P0 SUP HCPCS C1768 M00202175434P0 - GRAFT VASC 30CM 34MM HMSH PL WVN STR BOTH IP/OP "$1,440.13 " "$1,065.70" $0.00 "$1,097.24" $617.20 $617.20 $0.00 $0.00 $0.00 $300.16 "$1,068.86" "$1,068.86" $0.00 $0.00 $300.12 $0.00 $851.83 $851.83 $0.00 $685.78 "$1,086.27" "$1,097.24" $0.00 $0.00 $214.65 $0.00 $0.00 $218.35 $0.00 $0.00 $0.00 $0.00 $0.00 M002363200201 SUP HCPCS C1768 M002363200201 - GRAFT SIZER 5-24MM BOTH IP/OP $26.00 $19.24 $0.00 $19.86 $11.17 $11.17 $0.00 $0.00 $0.00 $5.42 $19.30 $19.30 $0.00 $0.00 $5.42 $0.00 $15.38 $15.38 $0.00 $12.41 $19.67 $19.86 $0.00 $0.00 $3.89 $0.00 $0.00 $3.95 $0.00 $0.00 $0.00 $0.00 $0.00 M002363200211 SUP HCPCS C1768 M002363200211 - TMPLT SZ 24-38MM VASC GFT BOTH IP/OP $26.00 $19.24 $0.00 $19.86 $11.17 $11.17 $0.00 $0.00 $0.00 $5.42 $19.30 $19.30 $0.00 $0.00 $5.42 $0.00 $15.38 $15.38 $0.00 $12.41 $19.67 $19.86 $0.00 $0.00 $3.89 $0.00 $0.00 $3.95 $0.00 $0.00 $0.00 $0.00 $0.00 M0031351020 SUP HCPCS C1757 M0031351020 - CATHETER INFS MIC 155CM 15CM FRCKR10 BOTH IP/OP "$2,303.00 " "$1,704.22" $0.00 "$1,842.40" $0.00 $0.00 $0.00 $0.00 $0.00 $480.00 "$1,709.29" "$1,709.29" $0.00 $0.00 $479.95 $0.00 "$1,362.22" "$1,362.22" $0.00 "$1,151.50" "$1,823.98" "$1,842.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0031441890 SUP HCPCS C1751 M0031441890 - MICROCATHETER CRBRVASC .014-.016IN STRG 2.6-2FR .019IN 150CM BOTH IP/OP "$2,138.50 " "$1,582.49" $0.00 "$1,710.80" "$1,161.21" "$1,161.21" $0.00 $0.00 $0.00 $445.72 "$1,587.19" "$1,587.19" $0.00 $0.00 $445.66 $0.00 "$1,264.92" "$1,264.92" $0.00 "$1,069.25" "$1,693.69" "$1,710.80" $0.00 $0.00 $334.68 $0.00 $0.00 $340.45 $0.00 $0.00 $0.00 $0.00 $0.00 M0031681890 SUP HCPCS C1751 M0031681890 - CATHETER INFS .038IN 2.4-1.7FR .014IN 150CM 6CM EXCLS SL-10 BOTH IP/OP "$2,162.00 " "$1,599.88" $0.00 "$1,729.60" "$1,173.97" "$1,173.97" $0.00 $0.00 $0.00 $450.61 "$1,604.64" "$1,604.64" $0.00 $0.00 $450.56 $0.00 "$1,278.82" "$1,278.82" $0.00 "$1,081.00" "$1,712.30" "$1,729.60" $0.00 $0.00 $338.35 $0.00 $0.00 $344.19 $0.00 $0.00 $0.00 $0.00 $0.00 M0031681900 SUP HCPCS C1751 M0031681900 - MICROCATHETER CRBRVASC 45D .014IN PSHP 2.4-1.7FR .0165IN 150 BOTH IP/OP "$2,326.50 " "$1,721.61" $0.00 "$1,861.20" "$1,263.29" "$1,263.29" $0.00 $0.00 $0.00 $484.90 "$1,726.73" "$1,726.73" $0.00 $0.00 $484.84 $0.00 "$1,376.12" "$1,376.12" $0.00 "$1,163.25" "$1,842.59" "$1,861.20" $0.00 $0.00 $364.10 $0.00 $0.00 $370.38 $0.00 $0.00 $0.00 $0.00 $0.00 M003182880US0 SUP HCPCS C1887 M003182880US0 - MICROCATHETER INFS 135CM RNGD HFL RADOPQ DIST TIP VORTEC + BOTH IP/OP "$1,774.25 " "$1,312.95" $0.00 "$1,419.40" $963.42 $963.42 $0.00 $0.00 $0.00 $369.80 "$1,316.85" "$1,316.85" $0.00 $0.00 $369.75 $0.00 "$1,049.47" "$1,049.47" $0.00 $887.13 "$1,405.21" "$1,419.40" $0.00 $0.00 $277.67 $0.00 $0.00 $282.46 $0.00 $0.00 $0.00 $0.00 $0.00 M003182900US0 SUP HCPCS C1751 M003182900US0 - CATHETER INFS 150CM 10CM RNGD HF KT MCTH RADOPQ BRAID HDRPH BOTH IP/OP "$1,774.25 " "$1,312.95" $0.00 "$1,419.40" $963.42 $963.42 $0.00 $0.00 $0.00 $369.80 "$1,316.85" "$1,316.85" $0.00 $0.00 $369.75 $0.00 "$1,049.47" "$1,049.47" $0.00 $887.13 "$1,405.21" "$1,419.40" $0.00 $0.00 $277.67 $0.00 $0.00 $282.46 $0.00 $0.00 $0.00 $0.00 $0.00 M0032072209150 SUP HCPCS C1726 M0032072209150 - CATHETER BLNDIL 1.5MM 135CM LF 9MM GTWY OTW 2 LUM HDRPH ACPT BOTH IP/OP "$2,643.75 " "$1,956.38" $0.00 "$2,115.00" "$1,435.56" "$1,435.56" $0.00 $0.00 $0.00 $551.02 "$1,962.19" "$1,962.19" $0.00 $0.00 $550.96 $0.00 "$1,563.78" "$1,563.78" $0.00 "$1,321.88" "$2,093.85" "$2,115.00" $0.00 $0.00 $413.75 $0.00 $0.00 $420.89 $0.00 $0.00 $0.00 $0.00 $0.00 M0032072209200 SUP HCPCS C1726 M0032072209200 - CATHETER BLNDIL 2MM 135CM LF 9MM GTWY OTW 2 LUM HDRPH ACPT BOTH IP/OP "$2,643.75 " "$1,956.38" $0.00 "$2,115.00" "$1,435.56" "$1,435.56" $0.00 $0.00 $0.00 $551.02 "$1,962.19" "$1,962.19" $0.00 $0.00 $550.96 $0.00 "$1,563.78" "$1,563.78" $0.00 "$1,321.88" "$2,093.85" "$2,115.00" $0.00 $0.00 $413.75 $0.00 $0.00 $420.89 $0.00 $0.00 $0.00 $0.00 $0.00 M0032072209250 SUP HCPCS C1726 M0032072209250 - CATHETER BLNDIL 2.5MM 135CM LF 9MM GTWY OTW 2 LUM HDRPH ACPT BOTH IP/OP "$2,643.75 " "$1,956.38" $0.00 "$2,115.00" "$1,435.56" "$1,435.56" $0.00 $0.00 $0.00 $551.02 "$1,962.19" "$1,962.19" $0.00 $0.00 $550.96 $0.00 "$1,563.78" "$1,563.78" $0.00 "$1,321.88" "$2,093.85" "$2,115.00" $0.00 $0.00 $413.75 $0.00 $0.00 $420.89 $0.00 $0.00 $0.00 $0.00 $0.00 M0032072209300 SUP HCPCS C1726 M0032072209300 - CATHETER BLNDIL 3MM 135CM LF 9MM GTWY OTW 2 LUM HDRPH ACPT BOTH IP/OP "$2,643.75 " "$1,956.38" $0.00 "$2,115.00" "$1,435.56" "$1,435.56" $0.00 $0.00 $0.00 $551.02 "$1,962.19" "$1,962.19" $0.00 $0.00 $550.96 $0.00 "$1,563.78" "$1,563.78" $0.00 "$1,321.88" "$2,093.85" "$2,115.00" $0.00 $0.00 $413.75 $0.00 $0.00 $420.89 $0.00 $0.00 $0.00 $0.00 $0.00 M0032072209350 SUP HCPCS C1726 M0032072209350 - CATHETER BLNDIL 3.5MM 135CM LF 9MM GTWY OTW 2 LUM HDRPH ACPT BOTH IP/OP "$2,643.75 " "$1,956.38" $0.00 "$2,115.00" "$1,435.56" "$1,435.56" $0.00 $0.00 $0.00 $551.02 "$1,962.19" "$1,962.19" $0.00 $0.00 $550.96 $0.00 "$1,563.78" "$1,563.78" $0.00 "$1,321.88" "$2,093.85" "$2,115.00" $0.00 $0.00 $413.75 $0.00 $0.00 $420.89 $0.00 $0.00 $0.00 $0.00 $0.00 M0032072215250 SUP HCPCS C1726 M0032072215250 - CATHETER BLNDIL 2.5MM 135CM LF 15MM GTWY OTW 2 LUM HDRPH BOTH IP/OP "$2,643.75 " "$1,956.38" $0.00 "$2,115.00" "$1,435.56" "$1,435.56" $0.00 $0.00 $0.00 $551.02 "$1,962.19" "$1,962.19" $0.00 $0.00 $550.96 $0.00 "$1,563.78" "$1,563.78" $0.00 "$1,321.88" "$2,093.85" "$2,115.00" $0.00 $0.00 $413.75 $0.00 $0.00 $420.89 $0.00 $0.00 $0.00 $0.00 $0.00 M0032072215300 SUP HCPCS C1726 M0032072215300 - CATHETER BLNDIL 3MM 135CM LF 15MM GTWY OTW 2 LUM HDRPH ACPT BOTH IP/OP "$2,643.75 " "$1,956.38" $0.00 "$2,115.00" "$1,435.56" "$1,435.56" $0.00 $0.00 $0.00 $551.02 "$1,962.19" "$1,962.19" $0.00 $0.00 $550.96 $0.00 "$1,563.78" "$1,563.78" $0.00 "$1,321.88" "$2,093.85" "$2,115.00" $0.00 $0.00 $413.75 $0.00 $0.00 $420.89 $0.00 $0.00 $0.00 $0.00 $0.00 M0032072215350 SUP HCPCS C1726 M0032072215350 - CATHETER BLNDIL 3.5MM 135CM LF 15MM GTWY OTW 2 LUM HDRPH BOTH IP/OP "$2,643.75 " "$1,956.38" $0.00 "$2,115.00" "$1,435.56" "$1,435.56" $0.00 $0.00 $0.00 $551.02 "$1,962.19" "$1,962.19" $0.00 $0.00 $550.96 $0.00 "$1,563.78" "$1,563.78" $0.00 "$1,321.88" "$2,093.85" "$2,115.00" $0.00 $0.00 $413.75 $0.00 $0.00 $420.89 $0.00 $0.00 $0.00 $0.00 $0.00 M00326110 SUP HCPCS C1769 M00326110 - GUIDEWIRE VASCULAR .014IN 200CM 35CM SOFT TIP ATRAUMATIC BOTH IP/OP "$1,386.50 " "$1,026.01" $0.00 "$1,109.20" $752.87 $752.87 $0.00 $0.00 $0.00 $288.98 "$1,029.06" "$1,029.06" $0.00 $0.00 $288.95 $0.00 $820.11 $820.11 $0.00 $693.25 "$1,098.11" "$1,109.20" $0.00 $0.00 $216.99 $0.00 $0.00 $220.73 $0.00 $0.00 $0.00 $0.00 $0.00 M00326410 SUP HCPCS C1769 M00326410 - GUIDEWIRE VASC .014IN 200CM 35CM SYNCHRO2 STD ATRM RBN TIP BOTH IP/OP "$1,316.00 " $973.84 $0.00 "$1,052.80" $714.59 $714.59 $0.00 $0.00 $0.00 $274.29 $976.74 $976.74 $0.00 $0.00 $274.25 $0.00 $778.41 $778.41 $0.00 $658.00 "$1,042.27" "$1,052.80" $0.00 $0.00 $205.95 $0.00 $0.00 $209.51 $0.00 $0.00 $0.00 $0.00 $0.00 M00326420 SUP HCPCS C1769 M00326420 - GUIDEWIRE VASCULAR STANDARD .014IN 200CM 35CM PRESHAPED BOTH IP/OP "$1,386.50 " "$1,026.01" $0.00 "$1,109.20" $752.87 $752.87 $0.00 $0.00 $0.00 $288.98 "$1,029.06" "$1,029.06" $0.00 $0.00 $288.95 $0.00 $820.11 $820.11 $0.00 $693.25 "$1,098.11" "$1,109.20" $0.00 $0.00 $216.99 $0.00 $0.00 $220.73 $0.00 $0.00 $0.00 $0.00 $0.00 M00326520 SUP HCPCS C1769 M00326520 - GUIDEWIRE VASC .014IN 300CM 35CM SYNCHRO2 STD ATRM RBN TIP BOTH IP/OP "$1,715.50 " "$1,269.47" $0.00 "$1,372.40" $931.52 $931.52 $0.00 $0.00 $0.00 $357.55 "$1,273.24" "$1,273.24" $0.00 $0.00 $357.51 $0.00 "$1,014.72" "$1,014.72" $0.00 $857.75 "$1,358.68" "$1,372.40" $0.00 $0.00 $268.48 $0.00 $0.00 $273.11 $0.00 $0.00 $0.00 $0.00 $0.00 M003468140 SUP HCPCS C1769 M003468140 - GUIDEWIRE VASC .014IN 300CM STRL LF 2CM TRNSD X SPRT ICE BOTH IP/OP "$1,351.25 " $999.93 $0.00 "$1,081.00" $733.73 $733.73 $0.00 $0.00 $0.00 $281.63 "$1,002.90" "$1,002.90" $0.00 $0.00 $281.60 $0.00 $799.26 $799.26 $0.00 $675.63 "$1,070.19" "$1,081.00" $0.00 $0.00 $211.47 $0.00 $0.00 $215.12 $0.00 $0.00 $0.00 $0.00 $0.00 M0035503010 SUP HCPCS C1887 M0035503010 - CATHETER INFUS .038IN MICRO 3FR .024IN 105CM 12CM KIT GWIRE BOTH IP/OP "$1,157.13 " $856.28 $0.00 $925.70 $628.32 $628.32 $0.00 $0.00 $0.00 $241.17 $858.82 $858.82 $0.00 $0.00 $241.14 $0.00 $684.44 $684.44 $0.00 $578.56 $916.45 $925.70 $0.00 $0.00 $181.09 $0.00 $0.00 $184.21 $0.00 $0.00 $0.00 $0.00 $0.00 M0035503040 SUP HCPCS C1887 M0035503040 - CATHETER INFUS .018IN MICRO 3-2.8FR .024-.018IN 135CM 12CM BOTH IP/OP "$1,157.13 " $856.28 $0.00 $925.70 $628.32 $628.32 $0.00 $0.00 $0.00 $241.17 $858.82 $858.82 $0.00 $0.00 $241.14 $0.00 $684.44 $684.44 $0.00 $578.56 $916.45 $925.70 $0.00 $0.00 $181.09 $0.00 $0.00 $184.21 $0.00 $0.00 $0.00 $0.00 $0.00 M003N3EZ25200 SUP HCPCS C2617 M003N3EZ25200 - STENT INTRCRAN 2.5MM 20MM NRFRM EZ 3 BOTH IP/OP "$15,745.00 " "$11,651.30" $0.00 "$12,596.00" "$7,085.25" "$7,085.25" $0.00 $0.00 $0.00 "$3,281.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,281.26" $0.00 "$7,762.29" "$7,762.29" $0.00 "$7,872.50" "$12,470.04" "$12,596.00" $0.00 $0.00 "$2,464.09" $0.00 $0.00 "$2,506.60" $0.00 $0.00 $0.00 $0.00 $0.00 M003N3EZ30200 SUP HCPCS C2617 M003N3EZ30200 - STENT INTRCRAN 3MM 20MM NRFRM EZ NRFRM3 BOTH IP/OP "$15,745.00 " "$11,651.30" $0.00 "$12,596.00" "$7,085.25" "$7,085.25" $0.00 $0.00 $0.00 "$3,281.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,281.26" $0.00 "$7,762.29" "$7,762.29" $0.00 "$7,872.50" "$12,470.04" "$12,596.00" $0.00 $0.00 "$2,464.09" $0.00 $0.00 "$2,506.60" $0.00 $0.00 $0.00 $0.00 $0.00 M003N3EZ35200 SUP HCPCS C2617 M003N3EZ35200 - STENT INTRCRAN 3.5MM 20MM NRFRM EZ NRFRM3 BOTH IP/OP "$15,745.00 " "$11,651.30" $0.00 "$12,596.00" "$7,085.25" "$7,085.25" $0.00 $0.00 $0.00 "$3,281.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,281.26" $0.00 "$7,762.29" "$7,762.29" $0.00 "$7,872.50" "$12,470.04" "$12,596.00" $0.00 $0.00 "$2,464.09" $0.00 $0.00 "$2,506.60" $0.00 $0.00 $0.00 $0.00 $0.00 M003N3EZ40200 SUP HCPCS C2617 M003N3EZ40200 - STENT INTRCRAN 4MM 20MM NRFRM EZ 3 BOTH IP/OP "$15,745.00 " "$11,651.30" $0.00 "$12,596.00" "$7,085.25" "$7,085.25" $0.00 $0.00 $0.00 "$3,281.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,281.26" $0.00 "$7,762.29" "$7,762.29" $0.00 "$7,872.50" "$12,470.04" "$12,596.00" $0.00 $0.00 "$2,464.09" $0.00 $0.00 "$2,506.60" $0.00 $0.00 $0.00 $0.00 $0.00 M003N3EZ45200 SUP HCPCS C2617 M003N3EZ45200 - STENT INTRCRAN 4.5MM 20MM NRFRM EZ PRELD SLF XPD RADOPQ NTNL BOTH IP/OP "$15,745.00 " "$11,651.30" $0.00 "$12,596.00" "$7,085.25" "$7,085.25" $0.00 $0.00 $0.00 "$3,281.65" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,281.26" $0.00 "$7,762.29" "$7,762.29" $0.00 "$7,872.50" "$12,470.04" "$12,596.00" $0.00 $0.00 "$2,464.09" $0.00 $0.00 "$2,506.60" $0.00 $0.00 $0.00 $0.00 $0.00 M003N3EZ45300 SUP Custom 27803010 M003N3EZ45300 - STENT INTRCRAN 4.5MM 30MM NRFRM EZ PRELD SLF XPD RADOPQ NTNL BOTH IP/OP "$15,745.00 " "$11,651.30" $0.00 "$12,596.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,281.26" $0.00 $0.00 $0.00 $0.00 "$7,872.50" "$12,470.04" "$12,596.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003SNF3STA0 SUP Custom 27203010 M003SNF3STA0 - STENT INTRCRAN 2FR NRFRM3 STAB CATH BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,133.83" "$2,133.83" $0.00 $0.00 $599.15 $0.00 $0.00 $0.00 $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003UZAS30150 SUP Custom 27803010 M003UZAS30150 - STENT 3.0MM 15MM 3.5MM NEUROFORM ATLAS BOTH IP/OP "$18,125.00 " "$13,412.50" $0.00 "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,777.25" $0.00 $0.00 $0.00 $0.00 "$9,062.50" "$14,355.00" "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003UZAS30210 SUP Custom 27803010 M003UZAS30210 - STENT 3.0MM 21MM 3.5MM NEUROFORM ATLAS BOTH IP/OP "$18,125.00 " "$13,412.50" $0.00 "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,777.25" $0.00 $0.00 $0.00 $0.00 "$9,062.50" "$14,355.00" "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003UZAS30240 SUP Custom 27803010 M003UZAS30240 - STENT 3.0MM 24MM 3.5MM NEUROFORM ATLAS BOTH IP/OP "$18,125.00 " "$13,412.50" $0.00 "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,777.25" $0.00 $0.00 $0.00 $0.00 "$9,062.50" "$14,355.00" "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003UZAS40210 SUP Custom 27803010 M003UZAS40210 - STENT 4.0MM 21MM 4.5MM NEUROFORM ATLAS BOTH IP/OP "$18,125.00 " "$13,412.50" $0.00 "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,777.25" $0.00 $0.00 $0.00 $0.00 "$9,062.50" "$14,355.00" "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003UZAS40240 SUP Custom 27803010 M003UZAS40240 - STENT 4.0MM 24MM 4.5MM NEUROFORM ATLAS BOTH IP/OP "$18,125.00 " "$13,412.50" $0.00 "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,777.25" $0.00 $0.00 $0.00 $0.00 "$9,062.50" "$14,355.00" "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003UZAS45210 SUP Custom 27803010 M003UZAS45210 - STENT 4.5MM 21MM 5.0MM NEUROFORM ATLAS BOTH IP/OP "$18,125.00 " "$13,412.50" $0.00 "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,777.25" $0.00 $0.00 $0.00 $0.00 "$9,062.50" "$14,355.00" "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003UZAS45300 SUP Custom 27803010 M003UZAS45300 - STENT 4.5MM 30MM 5.0MM NEUROFORM ATLAS BOTH IP/OP "$18,125.00 " "$13,412.50" $0.00 "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,777.25" $0.00 $0.00 $0.00 $0.00 "$9,062.50" "$14,355.00" "$14,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003WS0250090 SUP HCPCS C2617 M003WS0250090 - STENT INTRCRAN 2.5MM 3.5FR 9MM STRL WINGSPAN GTWY SLF XPD BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" "$7,191.00" "$7,191.00" $0.00 $0.00 $0.00 "$3,330.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 "$7,878.14" "$7,878.14" $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 "$2,500.87" $0.00 $0.00 "$2,544.02" $0.00 $0.00 $0.00 $0.00 $0.00 M003WS0250150 SUP HCPCS C2617 M003WS0250150 - STENT INTRACRANIAL .014IN 2.5MM 15MM OTW FLEXIBLE TRACKABLE BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" "$7,191.00" "$7,191.00" $0.00 $0.00 $0.00 "$3,330.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 "$7,878.14" "$7,878.14" $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 "$2,500.87" $0.00 $0.00 "$2,544.02" $0.00 $0.00 $0.00 $0.00 $0.00 M003WS0300090 SUP HCPCS C2617 M003WS0300090 - STENT INTRCRAN 3MM 3.5FR 9MM STRL WINGSPAN GTWY SLF XPD OTW BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" "$7,191.00" "$7,191.00" $0.00 $0.00 $0.00 "$3,330.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 "$7,878.14" "$7,878.14" $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 "$2,500.87" $0.00 $0.00 "$2,544.02" $0.00 $0.00 $0.00 $0.00 $0.00 M003WS0300150 SUP Custom 27803010 M003WS0300150 - STENT INTRCRAN 3MM 3.5FR 15MM STRL WINGSPAN GTWY SLF XPD OTW BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 $0.00 $0.00 $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003WS0350090 SUP HCPCS C2617 M003WS0350090 - STENT INTRCRAN 3.5MM 3.5FR 9MM STRL WINGSPAN GTWY SLF XPD BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" "$7,191.00" "$7,191.00" $0.00 $0.00 $0.00 "$3,330.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 "$7,878.14" "$7,878.14" $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 "$2,500.87" $0.00 $0.00 "$2,544.02" $0.00 $0.00 $0.00 $0.00 $0.00 M003WS0350150 SUP Custom 27803010 M003WS0350150 - STENT INTRCRAN 3.5MM 3.5FR 15MM STRL WINGSPAN GTWY SLF XPD BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 $0.00 $0.00 $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M003WS0400090 SUP HCPCS C2617 M003WS0400090 - STENT INTRCRAN 4MM 3.5FR 9MM STRL WINGSPAN GTWY SLF XPD OTW BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" "$7,191.00" "$7,191.00" $0.00 $0.00 $0.00 "$3,330.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 "$7,878.14" "$7,878.14" $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 "$2,500.87" $0.00 $0.00 "$2,544.02" $0.00 $0.00 $0.00 $0.00 $0.00 M003WS0400150 SUP Custom 27803010 M003WS0400150 - STENT INTRCRAN 4MM 3.5FR 15MM STRL WINGSPAN GTWY SLF XPD OTW BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 $0.00 $0.00 $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00510860 SUP Custom 27203010 M00510860 - BASKET SPEC RTRVL 1.5CM 3.2MM STRL 3CM TRPZD RX LTHTRP DIST BOTH IP/OP $645.18 $477.43 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.85 $478.85 $0.00 $0.00 $134.45 $0.00 $0.00 $0.00 $0.00 $355.00 $529.02 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00510860 SUP Custom 27203592 RX LITHOTRIPTER COMPATABLE BASKET 3 BOTH IP/OP $645.18 $477.43 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.85 $478.85 $0.00 $0.00 $134.45 $0.00 $0.00 $0.00 $0.00 $355.00 $562.32 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00510870 SUP Custom 27203010 M00510870 - BASKET SPEC RTRVL 2MM 3.2MM STRL 4CM TRPZD RX LTHTRP DIST BOTH IP/OP $645.18 $477.43 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.85 $478.85 $0.00 $0.00 $134.45 $0.00 $0.00 $0.00 $0.00 $355.00 $529.02 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00510870 SUP Custom 27203593 RX LITHOTRIPTER COMPATABLE BASKET 4 BOTH IP/OP $645.18 $477.43 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.85 $478.85 $0.00 $0.00 $134.45 $0.00 $0.00 $0.00 $0.00 $355.00 $562.32 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00510880 SUP Custom 27203010 M00510880 - BASKET SPEC RTRVL 2.5CM 3.2MM STRL 5CM TRPZD RX LTHTRP DIST BOTH IP/OP $645.18 $477.43 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.85 $478.85 $0.00 $0.00 $134.45 $0.00 $0.00 $0.00 $0.00 $355.00 $529.02 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00510880 SUP Custom 27203594 RX LITHOTRIPTER COMPATABLE BASKET 5 BOTH IP/OP $645.18 $477.43 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.85 $478.85 $0.00 $0.00 $134.45 $0.00 $0.00 $0.00 $0.00 $355.00 $562.32 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00510890 SUP Custom 27203010 M00510890 - BASKET SPEC RTRVL 3CM 3.2MM STRL 3CM TRPZD RX LTHTRP DIST BOTH IP/OP $645.18 $477.43 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.85 $478.85 $0.00 $0.00 $134.45 $0.00 $0.00 $0.00 $0.00 $355.00 $529.02 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00510890 SUP Custom 27203595 RX LITHOTRIPTER COMPATABLE BASKET 6 BOTH IP/OP $645.18 $477.43 $0.00 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.85 $478.85 $0.00 $0.00 $134.45 $0.00 $0.00 $0.00 $0.00 $355.00 $562.32 $568.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00513210 SUP Custom 27203010 M00513210 - BASKET SPECIMEN RETRIEVAL 16MM 1MM 120CM AIRWAY ZERO TIP BOTH IP/OP $622.40 $460.58 $0.00 $501.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $461.95 $461.95 $0.00 $0.00 $129.71 $0.00 $0.00 $0.00 $0.00 $313.26 $496.21 $501.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00513740 SUP HCPCS C1874 M00513740 - STENT ESOPHAGEAL 18-23MM 12CM 9CM COVER DISTAL RELEASE NEXT BOTH IP/OP "$4,137.50 " "$3,061.75" $0.00 "$3,314.14" "$1,864.20" "$1,864.20" $0.00 $0.00 $0.00 $862.36 "$3,070.85" "$3,070.85" $0.00 $0.00 $862.26 $0.00 "$2,039.79" "$2,039.79" $0.00 "$2,071.34" "$3,281.00" "$3,314.14" $0.00 $0.00 $648.33 $0.00 $0.00 $659.51 $0.00 $0.00 $0.00 $0.00 $0.00 M00516720 SUP HCPCS C1874 M00516720 - STENT ESOPHAGEAL FLARE LP 18MM 18.5FR 15CM 120CM SELF EXPAND BOTH IP/OP "$5,892.90 " "$4,360.75" $0.00 "$4,778.42" "$2,687.86" "$2,687.86" $0.00 $0.00 $0.00 "$1,228.23" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,228.08" $0.00 "$2,905.20" "$2,905.20" $0.00 "$2,986.51" "$4,730.64" "$4,778.42" $0.00 $0.00 $934.78 $0.00 $0.00 $950.91 $0.00 $0.00 $0.00 $0.00 $0.00 M00516900 SUP HCPCS C1874 M00516900 - STENT ESOPHAGEAL LP 18MM 18.5FR 10CM 7CM PRTL COVER COAXIAL BOTH IP/OP "$5,772.58 " "$4,271.71" $0.00 "$4,729.78" "$2,660.50" "$2,660.50" $0.00 $0.00 $0.00 "$1,203.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.00" $0.00 "$2,845.88" "$2,845.88" $0.00 "$2,956.11" "$4,682.49" "$4,729.78" $0.00 $0.00 $925.26 $0.00 $0.00 $941.23 $0.00 $0.00 $0.00 $0.00 $0.00 M00516910 SUP HCPCS C1874 M00516910 - STENT ESOPHAGEAL LP 18MM 18.5FR 12CM 9CM PRTL COVER COAXIAL BOTH IP/OP "$5,772.58 " "$4,271.71" $0.00 "$4,729.78" "$2,660.50" "$2,660.50" $0.00 $0.00 $0.00 "$1,203.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.00" $0.00 "$2,845.88" "$2,845.88" $0.00 "$2,956.11" "$4,682.49" "$4,729.78" $0.00 $0.00 $925.26 $0.00 $0.00 $941.23 $0.00 $0.00 $0.00 $0.00 $0.00 M00516920 SUP HCPCS C1874 M00516920 - STENT ESOPHAGEAL LP 23MM 18MM 153MM 12CM PRTL COVER COAXIAL BOTH IP/OP "$5,772.58 " "$4,271.71" $0.00 "$4,729.78" "$2,660.50" "$2,660.50" $0.00 $0.00 $0.00 "$1,203.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.00" $0.00 "$2,845.88" "$2,845.88" $0.00 "$2,956.11" "$4,682.49" "$4,729.78" $0.00 $0.00 $925.26 $0.00 $0.00 $941.23 $0.00 $0.00 $0.00 $0.00 $0.00 M00516930 SUP HCPCS C1874 M00516930 - STENT ESOPHAGEAL LP 23MM 18.5MM 10CM 7CM BRAID DELIVERY BOTH IP/OP "$5,772.58 " "$4,271.71" $0.00 "$4,729.78" "$2,660.50" "$2,660.50" $0.00 $0.00 $0.00 "$1,203.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.00" $0.00 "$2,845.88" "$2,845.88" $0.00 "$2,956.11" "$4,682.49" "$4,729.78" $0.00 $0.00 $925.26 $0.00 $0.00 $941.23 $0.00 $0.00 $0.00 $0.00 $0.00 M00516950 SUP HCPCS C1874 M00516950 - STENT ESOPHAGEAL LP 23MM 18.5FR 15CM 12CM BRAID DELIVERY BOTH IP/OP "$5,772.58 " "$4,271.71" $0.00 "$4,729.78" "$2,660.50" "$2,660.50" $0.00 $0.00 $0.00 "$1,203.15" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,203.00" $0.00 "$2,845.88" "$2,845.88" $0.00 "$2,956.11" "$4,682.49" "$4,729.78" $0.00 $0.00 $925.26 $0.00 $0.00 $941.23 $0.00 $0.00 $0.00 $0.00 $0.00 M00522611 SUP Custom 27203591 RESOLUTION 235CM BOTH IP/OP $392.29 $290.29 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $291.16 $291.16 $0.00 $0.00 $81.75 $0.00 $0.00 $0.00 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00522611 SUP Custom 27803010 M00522611 - CLIP INTERNAL 11MM 235CM 2.8MM SECURE LOCK RADIOPQ USER BOTH IP/OP $392.29 $290.29 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $291.16 $291.16 $0.00 $0.00 $81.75 $0.00 $0.00 $0.00 $0.00 $212.50 $314.53 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00522612 SUP Custom 27803010 M00522612 - CLIP INTERNAL 11MM OPEN 235CM 2.8MM HEMOSTASIS RESOLUTION BOTH IP/OP $380.74 $281.75 $0.00 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.59 $282.59 $0.00 $0.00 $79.35 $0.00 $0.00 $0.00 $0.00 $192.38 $304.73 $307.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00530850 SUP HCPCS C1769 M00530850 - CANNULA ERCP STANDARD 5FR 210CM GWIRE CNTOUR BILIARY STERILE BOTH IP/OP $112.50 $83.25 $0.00 $91.50 $62.11 $62.11 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $57.19 $90.59 $91.50 $0.00 $0.00 $17.90 $0.00 $0.00 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 M00530860 SUP HCPCS C1769 M00530860 - CANNULA ERCP TAPER 5FR 210CM CNTOUR BILIARY DISPOSABLE BOTH IP/OP $112.50 $83.25 $0.00 $91.50 $62.11 $62.11 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $57.19 $90.59 $91.50 $0.00 $0.00 $17.90 $0.00 $0.00 $18.21 $0.00 $0.00 $0.00 $0.00 $0.00 M00530960 SUP HCPCS C1769 M00530960 - CANNU ERCP .025IN STD TIP GWIRE FLRTP 210CM 5FR BIL STRL BOTH IP/OP $81.93 $60.63 $0.00 $65.54 $44.49 $44.49 $0.00 $0.00 $0.00 $17.08 $60.81 $60.81 $0.00 $0.00 $17.07 $0.00 $48.46 $48.46 $0.00 $40.96 $64.89 $65.54 $0.00 $0.00 $12.82 $0.00 $0.00 $13.04 $0.00 $0.00 $0.00 $0.00 $0.00 M00530970 SUP HCPCS C1769 M00530970 - CANNU ERCP .035IN TPR TIP GWIRE FLRTP 210CM 5FR BIL STRL BOTH IP/OP $81.93 $60.63 $0.00 $65.54 $44.49 $44.49 $0.00 $0.00 $0.00 $17.08 $60.81 $60.81 $0.00 $0.00 $17.07 $0.00 $48.46 $48.46 $0.00 $40.96 $64.89 $65.54 $0.00 $0.00 $12.82 $0.00 $0.00 $13.04 $0.00 $0.00 $0.00 $0.00 $0.00 M00530980 SUP HCPCS C1769 M00530980 - CANNU ERCP .025IN TPR TIP FLRTP 210CM 5FR BIL STRL DISP BOTH IP/OP $81.93 $60.63 $0.00 $65.54 $44.49 $44.49 $0.00 $0.00 $0.00 $17.08 $60.81 $60.81 $0.00 $0.00 $17.07 $0.00 $48.46 $48.46 $0.00 $40.96 $64.89 $65.54 $0.00 $0.00 $12.82 $0.00 $0.00 $13.04 $0.00 $0.00 $0.00 $0.00 $0.00 M00532240 SUP HCPCS C2617 M00532240 - STENT BILIARY 2 PIGTAIL CURVE 10FR 3CM RAPEX TEMPORARY BOTH IP/OP $133.55 $98.83 $0.00 $108.70 $61.14 $61.14 $0.00 $0.00 $0.00 $27.84 $99.12 $99.12 $0.00 $0.00 $27.83 $0.00 $78.99 $78.99 $0.00 $67.94 $107.62 $108.70 $0.00 $0.00 $21.26 $0.00 $0.00 $21.63 $0.00 $0.00 $0.00 $0.00 $0.00 M00532260 SUP HCPCS C2617 M00532260 - STENT BILIARY 2 PIGTAIL CURVE 3.3MM 5CM TEMPORARY RAPEX BOTH IP/OP $133.55 $98.83 $0.00 $108.70 $61.14 $61.14 $0.00 $0.00 $0.00 $27.84 $99.12 $99.12 $0.00 $0.00 $27.83 $0.00 $78.99 $78.99 $0.00 $67.94 $107.62 $108.70 $0.00 $0.00 $21.26 $0.00 $0.00 $21.63 $0.00 $0.00 $0.00 $0.00 $0.00 M00532270 SUP HCPCS C2617 M00532270 - STENT BILIARY 2 PIGTAIL CURVE 10FR 7CM RAPEX TEMPORARY BOTH IP/OP $133.55 $98.83 $0.00 $108.70 $61.14 $61.14 $0.00 $0.00 $0.00 $27.84 $99.12 $99.12 $0.00 $0.00 $27.83 $0.00 $78.99 $78.99 $0.00 $67.94 $107.62 $108.70 $0.00 $0.00 $21.26 $0.00 $0.00 $21.63 $0.00 $0.00 $0.00 $0.00 $0.00 M00533580 SUP HCPCS C2617 M00533580 - STENT BILIARY 10FR 202.5CM DELIVERY SYSTEM RAPEX ADVANIX BOTH IP/OP $198.93 $147.21 $0.00 $161.16 $90.65 $90.65 $0.00 $0.00 $0.00 $41.46 $147.64 $147.64 $0.00 $0.00 $41.46 $0.00 $117.66 $117.66 $0.00 $100.73 $159.55 $161.16 $0.00 $0.00 $31.53 $0.00 $0.00 $32.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00534200 SUP HCPCS C2617 M00534200 - STENT BILIARY DUODENAL BEND 7FR 5CM RAPEX PRELOAD DELIVERY BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534210 SUP HCPCS C2617 M00534210 - STENT BILIARY DUODENAL BEND 7FR 7CM PRELOAD TEMPORARY RAPEX BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534220 SUP HCPCS C2617 M00534220 - STENT BILIARY DUODENAL BEND 7FR 9CM RAPEX PRELOAD ADVANIX BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534230 SUP HCPCS C2617 M00534230 - STENT BILIARY DUODENAL BEND 7FR 12CM RAPEX PRELOAD ADVANIX BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534260 SUP HCPCS C2617 M00534260 - STENT BILIARY DUODENAL BEND 2.83MM 5CM PRELOAD RAPEX BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534270 SUP HCPCS C2617 M00534270 - STENT BILIARY DUODENAL BEND 2.83MM 7CM PRELOAD RAPEX BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534320 SUP HCPCS C2617 M00534320 - STENT BILIARY DUODENAL BEND 10FR 5CM PRELOAD RAPEX DELIVERY BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534330 SUP HCPCS C2617 M00534330 - STENT BILIARY DUODENAL BEND 10FR 7CM PRELOAD RADIOPQ MARKER BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534340 SUP HCPCS C2617 M00534340 - STENT BILIARY DUODENAL BEND 10FR 9CM PRELOAD RADIOPQ MARKER BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534350 SUP HCPCS C2617 M00534350 - STENT BILIARY DUODENAL BEND 10FR 12CM PRELOAD TEMPORARY BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $148.83 $148.83 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00534360 SUP HCPCS C1726 M00534360 - STENT BILIARY DUODENAL BEND 10FR 15CM PRELOAD TEMPORARY BOTH IP/OP $324.83 $240.37 $0.00 $264.58 $179.58 $179.58 $0.00 $0.00 $0.00 $67.70 $241.09 $241.09 $0.00 $0.00 $67.69 $0.00 $192.13 $192.13 $0.00 $165.36 $261.94 $264.58 $0.00 $0.00 $51.76 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 M00545170 SUP Custom 27203596 AUTOTOME RX 44-20MM BOTH IP/OP $518.20 $383.47 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.01 $384.61 $384.61 $0.00 $0.00 $107.99 $0.00 $306.52 $306.52 $0.00 $555.00 $879.12 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545170 SUP HCPCS C1769 M00545170 - SPHINCTEROTOME ESCP 4.4FR 20MM STRL 5MM ATME RX CANNULATE BOTH IP/OP $518.20 $383.47 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.01 $384.61 $384.61 $0.00 $0.00 $107.99 $0.00 $306.52 $306.52 $0.00 $555.00 $418.60 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545190 SUP Custom 27203597 AUTOTOME RX 39-20MM BOTH IP/OP $518.20 $383.47 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.01 $384.61 $384.61 $0.00 $0.00 $107.99 $0.00 $306.52 $306.52 $0.00 $555.00 $879.12 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545190 SUP HCPCS C1769 M00545190 - SPHINCTEROTOME ESCP 3.9FR 20MM STRL 5MM ATME RX CANNULATE BOTH IP/OP $518.20 $383.47 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.01 $384.61 $384.61 $0.00 $0.00 $107.99 $0.00 $306.52 $306.52 $0.00 $555.00 $418.60 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545261 SUP Custom 27203010 M00545261 - SYSTEM CHLGM RX LCK DEV BX CAP DISP OLMPS FUJIFILM G5 SER BOTH IP/OP $22.58 $16.71 $0.00 $18.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.76 $16.76 $0.00 $0.00 $4.71 $0.00 $0.00 $0.00 $0.00 $11.53 $18.26 $18.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545550 SUP Custom 27803070 RX STENT / 7 X 5CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545550 SUP HCPCS C2617 M00545550 - STENT BIL DDNL BND 7FR 5CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545560 SUP HCPCS C2617 M00545560 - STENT BIL DDNL BND 7FR 7CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $205.22 $115.44 $115.44 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $128.26 $203.17 $205.22 $0.00 $0.00 $40.15 $0.00 $0.00 $40.84 $0.00 $0.00 $0.00 $0.00 $0.00 M00545570 SUP Custom 27803081 RX STENT / 7 X 10CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545570 SUP HCPCS C2617 M00545570 - STENT BIL DDNL BND 7FR 10CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545580 SUP Custom 27803072 RX STENT / 7 X 12CM BOTH IP/OP $254.25 $188.15 $0.00 $198.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545580 SUP HCPCS C2617 M00545580 - STENT BIL DDNL BND 7FR 12CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $123.75 $203.17 $198.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545610 SUP Custom 27803074 RX STENT / 10 X 7CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545610 SUP HCPCS C2617 M00545610 - STENT BIL DDNL BND 10FR 7CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545620 SUP Custom 27803075 RX STENT / 10 X 10CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545620 SUP HCPCS C2617 M00545620 - STENT BIL DDNL BND 10FR 10CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545630 SUP Custom 27803076 RX STENT / 10 X 12CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545630 SUP HCPCS C2617 M00545630 - STENT BIL DDNL BND 10FR 12CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545650 SUP Custom 27803077 RX STENT / 8.5 X 5CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545650 SUP HCPCS C2617 M00545650 - STENT BIL DDNL BND 8.5FR 5CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545660 SUP Custom 27803078 RX STENT / 8.5 X 7CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545660 SUP HCPCS C2617 M00545660 - STENT BIL DDNL BND 8.5FR 7CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545670 SUP Custom 27803079 RX STENT / 8.5 X 10CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545670 SUP HCPCS C2617 M00545670 - STENT BIL DDNL BND 8.5FR 10CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545680 SUP Custom 27803080 RX STENT / 8.5 X 12CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545680 SUP HCPCS C2617 M00545680 - STENT BIL DDNL BND 8.5FR 12CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $0.00 $0.00 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545700 SUP HCPCS C2617 M00545700 - STENT BIL DDNL BND 11.5FR 5CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545700 SUP HCPCS C2625 RX STENT / 11.5 X 5 BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545710 SUP HCPCS C2617 M00545710 - STENT BIL DDNL BND 11.5FR 7CM RX DLV SYS DISP ACPT .035IN GW BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545710 SUP HCPCS C2625 RX STENT / 11.5 X 7CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545720 SUP HCPCS C2617 M00545720 - STENT BIL DDNL BND 11.5FR 10CM RX DLV SYS DISP ACPT .035IN BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545720 SUP HCPCS C2625 RX STENT / 11.5 X 10CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545730 SUP HCPCS C2617 M00545730 - STENT BIL DDNL BND 11.5FR 12CM RX DLV SYS DISP ACPT .035IN BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545730 SUP HCPCS C2625 RX STENT / 11.5 X 12CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545740 SUP HCPCS C1876 M00545740 - STENT BIL DDNL BND 11.5FR 15CM RX DLV SYS DISP ACPT .035IN BOTH IP/OP $254.25 $188.15 $0.00 $203.17 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $203.17 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545740 SUP HCPCS C2625 RX STENT / 11.5 X 15CM BOTH IP/OP $254.25 $188.15 $0.00 $188.70 $54.45 $54.45 $0.00 $0.00 $0.00 $52.99 $188.70 $188.70 $0.00 $0.00 $52.99 $0.00 $150.39 $150.39 $0.00 $60.50 $95.83 $96.80 $0.00 $0.00 $18.94 $0.00 $0.00 $19.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00545840 SUP Custom 27203599 NEEDLEKNIFE RX BOTH IP/OP $487.50 $360.75 $0.00 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $243.75 $386.10 $390.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545900 SUP Custom 27203112 RX DILATATION BLN 4-4/5.8/180 BOTH IP/OP $595.55 $440.71 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.13 $442.02 $442.02 $0.00 $0.00 $124.11 $0.00 $352.27 $352.27 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545900 SUP HCPCS C1726 M00545900 - CATHETER BLNDIL 12 ATM 4MM 180CM 4CM HRCN RX LOPRFL RADOPQ BOTH IP/OP $595.55 $440.71 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.13 $442.02 $442.02 $0.00 $0.00 $124.11 $0.00 $352.27 $352.27 $0.00 $361.25 $477.62 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545920 SUP Custom 27203113 RX DILATATION BLN 6-4/5.8/180 BOTH IP/OP $595.55 $440.71 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.13 $442.02 $442.02 $0.00 $0.00 $124.11 $0.00 $352.27 $352.27 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545920 SUP HCPCS C1726 M00545920 - CATHETER BLNDIL 11 ATM 6MM 180CM 4CM HRCN RX LOPRFL RADOPQ BOTH IP/OP $595.55 $440.71 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.13 $442.02 $442.02 $0.00 $0.00 $124.11 $0.00 $352.27 $352.27 $0.00 $361.25 $477.62 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545960 SUP Custom 27203115 RX DILATATION BALLOON 10-5.8/180 BOTH IP/OP $595.55 $440.71 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.13 $442.02 $442.02 $0.00 $0.00 $124.11 $0.00 $352.27 $352.27 $0.00 $361.25 $572.22 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00545960 SUP HCPCS C1726 M00545960 - CATHETER BLNDIL 8 ATM 10MM 180CM 4CM HRCN RX LOPRFL RADOPQ BOTH IP/OP $595.55 $440.71 $0.00 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.13 $442.02 $442.02 $0.00 $0.00 $124.11 $0.00 $352.27 $352.27 $0.00 $361.25 $477.62 $578.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00546900 SUP HCPCS C1726 M00546900 - CATHETER SPEC RTRVL .035IN 6-7FR 9-12MM 200CM STRL LTX XTRT BOTH IP/OP $395.06 $292.34 $0.00 $316.05 $214.52 $214.52 $0.00 $0.00 $0.00 $82.34 $293.22 $293.22 $0.00 $0.00 $82.33 $0.00 $233.68 $233.68 $0.00 $197.53 $312.89 $316.05 $0.00 $0.00 $61.83 $0.00 $0.00 $62.89 $0.00 $0.00 $0.00 $0.00 $0.00 M00546910 SUP HCPCS C1726 M00546910 - CATHETER SPEC RTRVL .035IN 7-6FR 12-15MM 200CM STRL LTX XTRT BOTH IP/OP $395.06 $292.34 $0.00 $316.05 $214.52 $214.52 $0.00 $0.00 $0.00 $82.34 $293.22 $293.22 $0.00 $0.00 $82.33 $0.00 $233.68 $233.68 $0.00 $197.53 $312.89 $316.05 $0.00 $0.00 $61.83 $0.00 $0.00 $62.89 $0.00 $0.00 $0.00 $0.00 $0.00 M00546920 SUP Custom 27203101 EXTRACTOR RX 15-18MM ABOVE BOTH IP/OP $395.06 $292.34 $0.00 $318.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.34 $293.22 $293.22 $0.00 $0.00 $82.33 $0.00 $233.68 $233.68 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00546920 SUP HCPCS C1769 M00546920 - CATHETER SPEC RTRVL .035IN 7-6FR 15-18MM 200CM STRL LTX XTRT BOTH IP/OP $395.06 $292.34 $0.00 $318.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.34 $293.22 $293.22 $0.00 $0.00 $82.33 $0.00 $233.68 $233.68 $0.00 $198.75 $312.89 $318.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00547000 SUP Custom 27203010 M00547000 - CATHETER BALDILAT 7-6FR 9-12MM 200CM 3 LUMEN SPECIMEN BOTH IP/OP $356.55 $263.85 $0.00 $293.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.63 $264.63 $0.00 $0.00 $74.31 $0.00 $0.00 $0.00 $0.00 $183.13 $290.07 $293.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00547010 SUP Custom 27203010 M00547010 - CATHETER BALDILAT 7-6FR 12-15MM 200CM 3 LUMEN SPECIMEN BOTH IP/OP $356.55 $263.85 $0.00 $293.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.63 $264.63 $0.00 $0.00 $74.31 $0.00 $0.00 $0.00 $0.00 $183.13 $290.07 $293.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00547020 SUP Custom 27203010 M00547020 - CATHETER BALDILAT 7-6FR 15-18MM 200CM 3 LUMEN SPECIMEN BOTH IP/OP $356.55 $263.85 $0.00 $293.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.63 $264.63 $0.00 $0.00 $74.31 $0.00 $0.00 $0.00 $0.00 $183.13 $290.07 $293.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00551591 SUP HCPCS C1769 M00551591 - GWIRE ENDSCP .018IN 450CM EXCH SHP PTHFND BIL STRL DISP BOTH IP/OP $317.83 $235.19 $0.00 $254.26 $172.58 $172.58 $0.00 $0.00 $0.00 $66.24 $235.89 $235.89 $0.00 $0.00 $66.24 $0.00 $188.00 $188.00 $0.00 $158.92 $251.72 $254.26 $0.00 $0.00 $49.74 $0.00 $0.00 $50.60 $0.00 $0.00 $0.00 $0.00 $0.00 M00553650 SUP HCPCS C1874 M00553650 - STENT PNCR 15MM 24MM 10MM 146MM 138MM 10.8FR CAUT BOTH IP/OP "$11,000.00 " "$8,140.00" $0.00 "$8,950.00" "$5,034.38" "$5,034.38" $0.00 $0.00 $0.00 "$2,292.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,292.40" $0.00 "$5,423.00" "$5,423.00" $0.00 "$5,593.75" "$8,860.50" "$8,950.00" $0.00 $0.00 "$1,750.84" $0.00 $0.00 "$1,781.05" $0.00 $0.00 $0.00 $0.00 $0.00 M00553750 SUP HCPCS C1874 M00553750 - STENT BIL 10MM 10.8FR 146CM 10MM 21MM LUM SDL AXS BOTH IP/OP "$9,500.00 " "$7,030.00" $0.00 "$7,750.00" "$4,359.38" "$4,359.38" $0.00 $0.00 $0.00 "$1,980.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,979.80" $0.00 "$4,683.50" "$4,683.50" $0.00 "$4,843.75" "$7,672.50" "$7,750.00" $0.00 $0.00 "$1,516.09" $0.00 $0.00 "$1,542.25" $0.00 $0.00 $0.00 $0.00 $0.00 M00556021 SUP HCPCS C1769 M00556021 - GUIDEWIRE ENDSCP STR .035IN 260CM HIGH PERFORMANCE RAPEX BOTH IP/OP $423.74 $313.57 $0.00 $342.99 $232.80 $232.80 $0.00 $0.00 $0.00 $88.32 $314.50 $314.50 $0.00 $0.00 $88.31 $0.00 $250.64 $250.64 $0.00 $214.37 $339.56 $342.99 $0.00 $0.00 $67.10 $0.00 $0.00 $68.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00556041 SUP HCPCS C1769 M00556041 - GUIDEWIRE ENDSCP STR .035IN 450CM HIGH PERFORMANCE RAPEX BOTH IP/OP $423.74 $313.57 $0.00 $342.99 $232.80 $232.80 $0.00 $0.00 $0.00 $88.32 $314.50 $314.50 $0.00 $0.00 $88.31 $0.00 $250.64 $250.64 $0.00 $214.37 $339.56 $342.99 $0.00 $0.00 $67.10 $0.00 $0.00 $68.26 $0.00 $0.00 $0.00 $0.00 $0.00 M00556621 SUP HCPCS C1769 M00556621 - GUIDEWIRE ENDSCP STANDARD STR TRIM .038IN 260CM HIGH BOTH IP/OP $240.35 $177.86 $0.00 $195.71 $132.84 $132.84 $0.00 $0.00 $0.00 $50.09 $178.39 $178.39 $0.00 $0.00 $50.09 $0.00 $142.17 $142.17 $0.00 $122.32 $193.75 $195.71 $0.00 $0.00 $38.29 $0.00 $0.00 $38.95 $0.00 $0.00 $0.00 $0.00 $0.00 M00558330 SUP Custom 27203090 CRE DILATION BALLOON CRE 6-8MM 8CM F/G BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $272.12 $272.12 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00558340 SUP Custom 27203091 CRE DILATION BALLOON 8-10MM 8CM F/G BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00558350 SUP Custom 27203092 CRE DILATION BALLOON 10-12MM 8CM F/G BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00558360 SUP Custom 27203094 CRE DILATION BALLOON 15-18MM 8CM F/G BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00558370 SUP HCPCS C1726 M00558370 - CATHETER BALDILAT 6FR 15-18MM 180CM 8CM FIX WIRE HIGH BOTH IP/OP $460.05 $340.44 $0.00 $375.16 $254.64 $254.64 $0.00 $0.00 $0.00 $95.89 $341.45 $341.45 $0.00 $0.00 $95.87 $0.00 $272.12 $272.12 $0.00 $234.48 $371.41 $375.16 $0.00 $0.00 $73.39 $0.00 $0.00 $74.66 $0.00 $0.00 $0.00 $0.00 $0.00 M00558380 SUP Custom 27203095 CRE DILATION BALLOON 18-20MM 8CM F/G BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $272.12 $272.12 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00558380 SUP HCPCS C1726 M00558380 - CATHETER BALDILAT 6FR 18-20MM 180CM 8CM FIX WIRE HIGH BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $272.12 $272.12 $0.00 $281.25 $371.41 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00558410 SUP HCPCS C1726 M00558410 - DILATOR ENDSCP 7.5FR 10-12MM 180CM 5.5CM CRE PEBAX ESOPHAGUS BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558420 SUP HCPCS C1726 M00558420 - DILATOR ENDSCP 7.5FR 12-15MM 180CM 5.5CM CRE PEBAX ESOPHAGUS BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558450 SUP HCPCS C1769 M00558450 - DILATOR ENDSCP 7.5FR 6-8MM 240CM 5.5CM INFLATE CRE PEBAX BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558480 SUP HCPCS C1769 M00558480 - DILATOR ENDSCP 7.5FR 12-15MM 240CM 5.5CM INFLATE CRE PEBAX BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558500 SUP HCPCS C1726 M00558500 - CATHETER BALDILAT 7.5FR 18-20MM 240CM 5.5CM WIRE GUIDE CRE BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558660 SUP HCPCS C1726 M00558660 - DILATOR ESCP 7.5FR 6-8MM 240CM STRL LF 5.5CM CRE INFL BLN BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558670 SUP HCPCS C1726 M00558670 - DILATOR ESCP 7.5FR 8-10MM 240CM STRL LF 5.5CM CRE INFL BLN BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558680 SUP HCPCS C1726 M00558680 - DILATOR ESCP 7.5FR 10-12MM 240CM STRL LF 5.5CM CRE INFL BLN BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558690 SUP HCPCS C1726 M00558690 - DILATOR ESCP 7.5FR 12-13.5-15MM 240CM STRL LF 5.5CM CRE INFL BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558700 SUP HCPCS C1726 M00558700 - DILATOR ESCP 7.5FR 15-16.5-18MM 240CM STRL LF 5.5CM CRE INFL BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00558710 SUP HCPCS C1726 M00558710 - DILATOR ESCP 7.5FR 18-20MM 240CM STRL LF 5.5CM CRE INFL BOTH IP/OP $530.33 $392.44 $0.00 $427.48 $290.15 $290.15 $0.00 $0.00 $0.00 $110.53 $393.61 $393.61 $0.00 $0.00 $110.52 $0.00 $313.69 $313.69 $0.00 $267.18 $423.21 $427.48 $0.00 $0.00 $83.63 $0.00 $0.00 $85.07 $0.00 $0.00 $0.00 $0.00 $0.00 M00560071 SUP HCPCS C1726 M00560071 - CATHETER ELHMST 7FR 300CM STRL GLDPRB BP RND DIST TIP FIRM BOTH IP/OP $303.35 $224.48 $0.00 $246.26 $167.15 $167.15 $0.00 $0.00 $0.00 $63.23 $225.15 $225.15 $0.00 $0.00 $63.22 $0.00 $179.43 $179.43 $0.00 $153.91 $243.80 $246.26 $0.00 $0.00 $48.17 $0.00 $0.00 $49.01 $0.00 $0.00 $0.00 $0.00 $0.00 M00560150 SUP Custom 27203010 M00560150 - CATHETER ELHMST 7FR 25GA .24MM 210CM INJ GLDPRB BP RND DIST BOTH IP/OP $557.75 $412.74 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.96 $413.96 $0.00 $0.00 $116.24 $0.00 $0.00 $0.00 $0.00 $375.00 $420.81 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00560150 SUP Custom 27203118 INJECTION GOLD PROBE 7FR BOTH IP/OP $557.75 $412.74 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.96 $413.96 $0.00 $0.00 $116.24 $0.00 $0.00 $0.00 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00560160 SUP Custom 27203117 INJECTION GOLD PROBE 10FR BOTH IP/OP $557.75 $412.74 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.25 $413.96 $413.96 $0.00 $0.00 $116.24 $0.00 $329.91 $329.91 $0.00 $375.00 $594.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00560160 SUP HCPCS C1726 M00560160 - CATHETER ELECTROHEMOSTASIS 10FR 210CM BIPOL STANDARD PLUG BOTH IP/OP $557.75 $412.74 $0.00 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.25 $413.96 $413.96 $0.00 $0.00 $116.24 $0.00 $329.91 $329.91 $0.00 $375.00 $420.81 $600.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00561831 SUP Custom 27203010 M00561831 - SNARE ENDSCP MINI STANDARD OVAL 2.4MM 195CMX20MM POLYPECTOMY BOTH IP/OP $46.48 $34.40 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.50 $34.50 $0.00 $0.00 $9.69 $0.00 $0.00 $0.00 $0.00 $23.50 $37.22 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00562321 SUP Custom 27203010 M00562321 - SNARE ESCP MED OVL 2.4MM 240CM 27MM CPTVTR STF DISP PLYP BOTH IP/OP $33.68 $24.92 $0.00 $27.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $25.00 $0.00 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $17.03 $26.97 $27.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00562391 SUP Custom 27203010 M00562391 - SNARE ENDSCP THIN JUMBO OVAL 2.4MM 240CM 30MM FLEXIBLE WIRE BOTH IP/OP $33.68 $24.92 $0.00 $27.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $25.00 $0.00 $0.00 $7.02 $0.00 $0.00 $0.00 $0.00 $17.03 $26.97 $27.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00562401 SUP Custom 27203010 M00562401 - SNARE ENDSCP MEDIUM OVAL 2.4MM 240CM 27MM LOOP FLEXIBLE BOTH IP/OP $32.88 $24.33 $0.00 $26.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.40 $24.40 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $16.46 $26.07 $26.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00562402 SUP Custom 27203010 M00562402 - SNARE ENDSCP STANDARD OVAL 2.4MM 240CMX27MM FLEXIBLE BOTH IP/OP $21.19 $15.68 $0.00 $17.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.72 $15.72 $0.00 $0.00 $4.42 $0.00 $0.00 $0.00 $0.00 $10.82 $17.13 $17.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00562671 SUP Custom 27203010 M00562671 - INTRODUCER SHTH 9.5FR HMSTS VLV SDPRT BOTH IP/OP $61.41 $45.44 $0.00 $45.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.58 $45.58 $0.00 $0.00 $12.80 $0.00 $0.00 $0.00 $0.00 $22.50 $35.64 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00565020 SUP HCPCS C1876 M00565020 - STENT DUODENAL 22-27MM 10FR 9CM 230CM DELIVERY SYSTEM BOTH IP/OP "$6,159.53 " "$4,558.05" $0.00 "$5,006.54" "$2,816.18" "$2,816.18" $0.00 $0.00 $0.00 "$1,283.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,283.65" $0.00 "$3,036.65" "$3,036.65" $0.00 "$3,129.09" "$4,956.48" "$5,006.54" $0.00 $0.00 $979.40 $0.00 $0.00 $996.30 $0.00 $0.00 $0.00 $0.00 $0.00 M00565040 SUP HCPCS C1874 M00565040 - STENT COLONIC 25-30MM 10FR 60CM 230CM DELIVERY SYSTEM BOTH IP/OP "$6,159.53 " "$4,558.05" $0.00 "$5,006.54" "$2,816.18" "$2,816.18" $0.00 $0.00 $0.00 "$1,283.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,283.65" $0.00 "$3,036.65" "$3,036.65" $0.00 "$3,129.09" "$4,956.48" "$5,006.54" $0.00 $0.00 $979.40 $0.00 $0.00 $996.30 $0.00 $0.00 $0.00 $0.00 $0.00 M00565050 SUP HCPCS C1874 M00565050 - STENT COLONIC 25-30MM 10FR 90CM 230CM DELIVERY SYSTEM BOTH IP/OP "$6,159.53 " "$4,558.05" $0.00 "$5,006.54" "$2,816.18" "$2,816.18" $0.00 $0.00 $0.00 "$1,283.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,283.65" $0.00 "$3,036.65" "$3,036.65" $0.00 "$3,129.09" "$4,956.48" "$5,006.54" $0.00 $0.00 $979.40 $0.00 $0.00 $996.30 $0.00 $0.00 $0.00 $0.00 $0.00 M00565060 SUP HCPCS C1874 M00565060 - STENT COLONIC 25-30MM 10FR 120CM 230CM DELIVERY SYSTEM BOTH IP/OP "$6,159.53 " "$4,558.05" $0.00 "$5,006.54" "$2,816.18" "$2,816.18" $0.00 $0.00 $0.00 "$1,283.80" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,283.65" $0.00 "$3,036.65" "$3,036.65" $0.00 "$3,129.09" "$4,956.48" "$5,006.54" $0.00 $0.00 $979.40 $0.00 $0.00 $996.30 $0.00 $0.00 $0.00 $0.00 $0.00 M00566461 SUP Custom 27203010 M00566461 - KIT PG 20FR 5ML STRL LF EVV PUL METH AMP TROC CNN RND XTRN BOTH IP/OP $219.16 $162.18 $0.00 $194.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.66 $162.66 $0.00 $0.00 $45.67 $0.00 $0.00 $0.00 $0.00 $121.43 $192.35 $194.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00566471 SUP HCPCS C1769 M00566471 - KIT PG 11 20FR 22GA 1.5IN STRL LF EVV SFGLD CHLRPRP PUSH BOTH IP/OP $219.16 $162.18 $0.00 $194.29 $131.88 $131.88 $0.00 $0.00 $0.00 $45.68 $162.66 $162.66 $0.00 $0.00 $45.67 $0.00 $129.63 $129.63 $0.00 $121.43 $192.35 $194.29 $0.00 $0.00 $38.01 $0.00 $0.00 $38.66 $0.00 $0.00 $0.00 $0.00 $0.00 M00566481 SUP Custom 27203010 M00566481 - KIT PG 24FR 5ML STRL LF EVV PUL METH AMP TROC CNN RND XTRN BOTH IP/OP $219.16 $162.18 $0.00 $194.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.66 $162.66 $0.00 $0.00 $45.67 $0.00 $0.00 $0.00 $0.00 $121.43 $192.35 $194.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00566670 SUP Custom 27203116 ENCORE 26 SINGLE BOTH IP/OP $182.50 $135.05 $0.00 $146.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.25 $144.54 $146.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0056820 SUP Custom 27203010 M0056820 - KIT PG 20FR SIL PUL METH FENST DRP STD CLMP EVV 5ML BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00568201 SUP Custom 27203010 M00568201 - KIT PG 20FR SIL PUL METH FENST DRP STD CLMP EVV 5ML BOTH IP/OP $147.75 $109.34 $0.00 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.66 $109.66 $0.00 $0.00 $30.79 $0.00 $0.00 $0.00 $0.00 $101.00 $159.98 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0056824 SUP Custom 27203010 KIT PG 24FR PUL METH STD EVV BOTH IP/OP $137.50 $101.75 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.75 $108.90 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00568241 SUP Custom 27203010 M00568241 - KIT PG 24FR 6824 BOTH IP/OP $147.75 $109.34 $0.00 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.66 $109.66 $0.00 $0.00 $30.79 $0.00 $0.00 $0.00 $0.00 $101.00 $159.98 $161.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00570360 SUP HCPCS C1874 M00570360 - STENT BIL .035IN 10MM 8.5FR 40MM 194CM WALLFLEX RMLM FLLY BOTH IP/OP "$6,198.75 " "$4,587.08" $0.00 "$5,038.32" "$2,834.06" "$2,834.06" $0.00 $0.00 $0.00 "$1,291.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,291.82" $0.00 "$3,055.98" "$3,055.98" $0.00 "$3,148.95" "$4,987.94" "$5,038.32" $0.00 $0.00 $985.62 $0.00 $0.00 "$1,002.63" $0.00 $0.00 $0.00 $0.00 $0.00 M00570370 SUP HCPCS C1874 M00570370 - STENT BIL .035IN 10MM 8.5FR 60MM 194CM WALLFLEX RMLM FLLY BOTH IP/OP "$6,198.75 " "$4,587.08" $0.00 "$5,038.32" "$2,834.06" "$2,834.06" $0.00 $0.00 $0.00 "$1,291.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,291.82" $0.00 "$3,055.98" "$3,055.98" $0.00 "$3,148.95" "$4,987.94" "$5,038.32" $0.00 $0.00 $985.62 $0.00 $0.00 "$1,002.63" $0.00 $0.00 $0.00 $0.00 $0.00 M00570380 SUP HCPCS C1874 M00570380 - STENT BIL .035IN 10MM 8.5FR 80MM 194CM WALLFLEX RMLM FLLY BOTH IP/OP "$6,198.75 " "$4,587.08" $0.00 "$5,038.32" "$2,834.06" "$2,834.06" $0.00 $0.00 $0.00 "$1,291.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,291.82" $0.00 "$3,055.98" "$3,055.98" $0.00 "$3,148.95" "$4,987.94" "$5,038.32" $0.00 $0.00 $985.62 $0.00 $0.00 "$1,002.63" $0.00 $0.00 $0.00 $0.00 $0.00 M00570520 SUP HCPCS C1874 M00570520 - STENT BILIARY 10MM 8.5FR 40MM RAPEX WALLFLEX PERMALUME BOTH IP/OP "$6,297.90 " "$4,660.45" $0.00 "$5,038.32" "$2,834.06" "$2,834.06" $0.00 $0.00 $0.00 "$1,312.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.48" $0.00 "$3,104.86" "$3,104.86" $0.00 "$3,148.95" "$4,987.94" "$5,038.32" $0.00 $0.00 $985.62 $0.00 $0.00 "$1,002.63" $0.00 $0.00 $0.00 $0.00 $0.00 M00570530 SUP HCPCS C1769 M00570530 - STENT BILIARY 10MM 8.5FR 60MM RAPEX SELF EXPAND WALLFLEX BOTH IP/OP "$6,297.90 " "$4,660.45" $0.00 "$5,038.32" "$3,419.76" "$3,419.76" $0.00 $0.00 $0.00 "$1,312.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.48" $0.00 "$3,094.73" "$3,094.73" $0.00 "$3,148.95" "$4,987.94" "$5,038.32" $0.00 $0.00 $985.62 $0.00 $0.00 "$1,002.63" $0.00 $0.00 $0.00 $0.00 $0.00 M00570540 SUP HCPCS C1874 M00570540 - STENT BILIARY 10MM 8.5FR 80MM RAPEX SELF EXPAND WALLFLEX BOTH IP/OP "$6,297.90 " "$4,660.45" $0.00 "$5,038.32" "$2,834.06" "$2,834.06" $0.00 $0.00 $0.00 "$1,312.64" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,312.48" $0.00 "$3,104.86" "$3,104.86" $0.00 "$3,148.95" "$4,987.94" "$5,038.32" $0.00 $0.00 $985.62 $0.00 $0.00 "$1,002.63" $0.00 $0.00 $0.00 $0.00 $0.00 M00570640 SUP HCPCS C1769 M00570640 - STENT BIL 10MM 8FR 60MM 194CM WLSTNT UNCOVER INTGR RTRVL BOTH IP/OP "$4,133.58 " "$3,058.85" $0.00 "$3,372.50" "$2,289.08" "$2,289.08" $0.00 $0.00 $0.00 $861.54 "$3,067.94" "$3,067.94" $0.00 $0.00 $861.44 $0.00 "$2,445.01" "$2,445.01" $0.00 "$2,107.81" "$3,338.78" "$3,372.50" $0.00 $0.00 $659.75 $0.00 $0.00 $671.13 $0.00 $0.00 $0.00 $0.00 $0.00 M00570650 SUP HCPCS C1769 M00570650 - STENT BILIARY 10MM 8FR 80MM RAPEX DELIVERY SYSTEM WALLFLEX BOTH IP/OP "$4,133.58 " "$3,058.85" $0.00 "$3,372.50" "$2,289.08" "$2,289.08" $0.00 $0.00 $0.00 $861.54 "$3,067.94" "$3,067.94" $0.00 $0.00 $861.44 $0.00 "$2,445.01" "$2,445.01" $0.00 "$2,107.81" "$3,338.78" "$3,372.50" $0.00 $0.00 $659.75 $0.00 $0.00 $671.13 $0.00 $0.00 $0.00 $0.00 $0.00 M00570660 SUP HCPCS C1769 M00570660 - STENT BILIARY .035IN 10MM 8.5FR 100MM UNCOVERED RAPEX GWIRE BOTH IP/OP "$4,133.58 " "$3,058.85" $0.00 "$3,372.50" "$2,289.08" "$2,289.08" $0.00 $0.00 $0.00 $861.54 "$3,067.94" "$3,067.94" $0.00 $0.00 $861.44 $0.00 "$2,445.01" "$2,445.01" $0.00 "$2,107.81" "$3,338.78" "$3,372.50" $0.00 $0.00 $659.75 $0.00 $0.00 $671.13 $0.00 $0.00 $0.00 $0.00 $0.00 M00570720 SUP HCPCS C1874 M00570720 - STENT BILIARY .035IN 10MM 8.5FR 40MM 3.2MM RAPEX PARTIALLY BOTH IP/OP "$6,123.15 " "$4,531.13" $0.00 "$5,010.82" "$2,818.59" "$2,818.59" $0.00 $0.00 $0.00 "$1,276.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,276.06" $0.00 "$3,018.71" "$3,018.71" $0.00 "$3,131.76" "$4,960.72" "$5,010.82" $0.00 $0.00 $980.24 $0.00 $0.00 $997.15 $0.00 $0.00 $0.00 $0.00 $0.00 M00570730 SUP HCPCS C1874 M00570730 - STENT BIL .035IN 10MM 8.5FR 60MM 3.2MM WALLFLEX FLRSCP MRKR BOTH IP/OP "$6,123.15 " "$4,531.13" $0.00 "$5,010.82" "$2,818.59" "$2,818.59" $0.00 $0.00 $0.00 "$1,276.22" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,276.06" $0.00 "$3,018.71" "$3,018.71" $0.00 "$3,131.76" "$4,960.72" "$5,010.82" $0.00 $0.00 $980.24 $0.00 $0.00 $997.15 $0.00 $0.00 $0.00 $0.00 $0.00 M00573080 SUP HCPCS C1769 M00573080 - SPHINCTEROTOME ENDSCP .035IN 3.9FR 20MM 260CM CHOLANGIOGRAM BOTH IP/OP $750.00 $555.00 $0.00 $605.66 $411.09 $411.09 $0.00 $0.00 $0.00 $156.32 $556.65 $556.65 $0.00 $0.00 $156.30 $0.00 $443.63 $443.63 $0.00 $378.54 $599.61 $605.66 $0.00 $0.00 $118.48 $0.00 $0.00 $120.53 $0.00 $0.00 $0.00 $0.00 $0.00 M00582120 SUP Custom 27203010 M00582120 - TUBE GSTRM STD RT ANG 14FR EVV BLN REPL BLSTR BOTH IP/OP $77.78 $57.56 $0.00 $70.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.72 $57.72 $0.00 $0.00 $16.21 $0.00 $0.00 $0.00 $0.00 $43.79 $69.36 $70.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00582130 SUP Custom 27203010 M00582130 - TUBE GSTRM STD RT ANG 16FR EVV BLN REPL BLSTR BOTH IP/OP $77.78 $57.56 $0.00 $70.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.72 $57.72 $0.00 $0.00 $16.21 $0.00 $0.00 $0.00 $0.00 $43.79 $69.36 $70.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00582160 SUP Custom 27203010 M00582160 - TUBE GSTRM STD RT ANG 24FR EVV BLN REPL BLSTR BOTH IP/OP $77.78 $57.56 $0.00 $70.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.72 $57.72 $0.00 $0.00 $16.21 $0.00 $0.00 $0.00 $0.00 $43.79 $69.36 $70.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00583040 SUP HCPCS C1769 M00583040 - SPHINCTEROTOME ENDSCP .035IN 4.4FR 20MM 260CM CANN PRELOAD BOTH IP/OP "$1,002.23 " $741.65 $0.00 $808.86 $549.01 $549.01 $0.00 $0.00 $0.00 $208.89 $743.85 $743.85 $0.00 $0.00 $208.86 $0.00 $592.82 $592.82 $0.00 $505.54 $800.78 $808.86 $0.00 $0.00 $158.23 $0.00 $0.00 $160.96 $0.00 $0.00 $0.00 $0.00 $0.00 M00583060 SUP Custom 27203598 HYDRATOME RX 44-20MM / 450CM BOTH IP/OP "$1,002.23 " $741.65 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.89 $743.85 $743.85 $0.00 $0.00 $208.86 $0.00 $592.82 $592.82 $0.00 $555.00 $879.12 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00583060 SUP HCPCS C1769 M00583060 - SPHINCTEROTOME ENDSCP .035IN 4.4FR 20MM 450CM CANN PRELOAD BOTH IP/OP "$1,002.23 " $741.65 $0.00 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.89 $743.85 $743.85 $0.00 $0.00 $208.86 $0.00 $592.82 $592.82 $0.00 $555.00 $800.78 $888.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M00584040 SUP HCPCS C1769 M00584040 - SPHINCTEROTOME ENDSCP .035IN STR 4.4FR 260CM 20MM CANN BOTH IP/OP "$1,002.23 " $741.65 $0.00 $808.86 $549.01 $549.01 $0.00 $0.00 $0.00 $208.89 $743.85 $743.85 $0.00 $0.00 $208.86 $0.00 $592.82 $592.82 $0.00 $505.54 $800.78 $808.86 $0.00 $0.00 $158.23 $0.00 $0.00 $160.96 $0.00 $0.00 $0.00 $0.00 $0.00 M0061453500 SUP HCPCS C2617 M0061453500 - STENT URETERAL PIGTAIL CURVE LP TAPER 4.8FR 22CM ATTACH BOTH IP/OP $524.30 $387.98 $0.00 $419.44 $235.94 $235.94 $0.00 $0.00 $0.00 $109.28 $389.14 $389.14 $0.00 $0.00 $109.26 $0.00 $310.12 $310.12 $0.00 $262.15 $415.25 $419.44 $0.00 $0.00 $82.05 $0.00 $0.00 $83.47 $0.00 $0.00 $0.00 $0.00 $0.00 M0061453510 SUP HCPCS C2617 M0061453510 - STENT URETERAL PIGTAIL CURVE LP TAPER 4.8FR 24CM ATTACH BOTH IP/OP $524.30 $387.98 $0.00 $419.44 $235.94 $235.94 $0.00 $0.00 $0.00 $109.28 $389.14 $389.14 $0.00 $0.00 $109.26 $0.00 $310.12 $310.12 $0.00 $262.15 $415.25 $419.44 $0.00 $0.00 $82.05 $0.00 $0.00 $83.47 $0.00 $0.00 $0.00 $0.00 $0.00 M0061453520 SUP HCPCS C2617 M0061453520 - STENT URETERAL PIGTAIL CURVE LP 4.8FR 26CM TAPER TIP BLADDER BOTH IP/OP $524.30 $387.98 $0.00 $419.44 $235.94 $235.94 $0.00 $0.00 $0.00 $109.28 $389.14 $389.14 $0.00 $0.00 $109.26 $0.00 $310.12 $310.12 $0.00 $262.15 $415.25 $419.44 $0.00 $0.00 $82.05 $0.00 $0.00 $83.47 $0.00 $0.00 $0.00 $0.00 $0.00 M0061453530 SUP HCPCS C2617 M0061453530 - STENT URETERAL PIGTAIL CURVE LP TAPER 4.8FR 28CM ATTACH BOTH IP/OP $524.30 $387.98 $0.00 $419.44 $235.94 $235.94 $0.00 $0.00 $0.00 $109.28 $389.14 $389.14 $0.00 $0.00 $109.26 $0.00 $310.12 $310.12 $0.00 $262.15 $415.25 $419.44 $0.00 $0.00 $82.05 $0.00 $0.00 $83.47 $0.00 $0.00 $0.00 $0.00 $0.00 M0061453610 SUP HCPCS C2617 M0061453610 - STENT URETERAL PIGTAIL CURVE LP TAPER 6FR 24CM ATTACH SUTURE BOTH IP/OP $524.30 $387.98 $0.00 $419.44 $235.94 $235.94 $0.00 $0.00 $0.00 $109.28 $389.14 $389.14 $0.00 $0.00 $109.26 $0.00 $310.12 $310.12 $0.00 $262.15 $415.25 $419.44 $0.00 $0.00 $82.05 $0.00 $0.00 $83.47 $0.00 $0.00 $0.00 $0.00 $0.00 M0061752500 SUP HCPCS C2617 M0061752500 - STENT URETERAL TAPER 4.8FR 20CM BLADDER MARK HIGH COIL BOTH IP/OP $581.43 $430.26 $0.00 $465.14 $261.64 $261.64 $0.00 $0.00 $0.00 $121.18 $431.53 $431.53 $0.00 $0.00 $121.17 $0.00 $343.91 $343.91 $0.00 $290.71 $460.49 $465.14 $0.00 $0.00 $90.99 $0.00 $0.00 $92.56 $0.00 $0.00 $0.00 $0.00 $0.00 M0061901340 SUP HCPCS C2617 M0061901340 - STENT URET 6FR 28CM W/O GWIRE DUAL DRMTR PLRS HDR+ BOTH IP/OP $356.40 $263.74 $0.00 $285.12 $160.38 $160.38 $0.00 $0.00 $0.00 $74.28 $264.52 $264.52 $0.00 $0.00 $74.27 $0.00 $210.81 $210.81 $0.00 $178.20 $282.27 $285.12 $0.00 $0.00 $55.78 $0.00 $0.00 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 M0061901440 SUP HCPCS C2617 M0061901440 - STENT URET 7FR 28CM W/O GWIRE DUAL DRMTR PLRS HDR+ BOTH IP/OP $306.25 $226.63 $0.00 $245.00 $137.81 $137.81 $0.00 $0.00 $0.00 $63.83 $227.30 $227.30 $0.00 $0.00 $63.82 $0.00 $181.15 $181.15 $0.00 $153.13 $242.55 $245.00 $0.00 $0.00 $47.93 $0.00 $0.00 $48.76 $0.00 $0.00 $0.00 $0.00 $0.00 M0061901520 SUP HCPCS C2617 M0061901520 - STENT URET 8FR 24CM W/O GWIRE PLRS HDR+ BOTH IP/OP $306.25 $226.63 $0.00 $245.00 $137.81 $137.81 $0.00 $0.00 $0.00 $63.83 $227.30 $227.30 $0.00 $0.00 $63.82 $0.00 $181.15 $181.15 $0.00 $153.13 $242.55 $245.00 $0.00 $0.00 $47.93 $0.00 $0.00 $48.76 $0.00 $0.00 $0.00 $0.00 $0.00 M0061901530 SUP HCPCS C2617 M0061901530 - STENT URET 8FR 26CM W/O GWIRE PLRS HDR+ BOTH IP/OP $356.40 $263.74 $0.00 $285.12 $160.38 $160.38 $0.00 $0.00 $0.00 $74.28 $264.52 $264.52 $0.00 $0.00 $74.27 $0.00 $210.81 $210.81 $0.00 $178.20 $282.27 $285.12 $0.00 $0.00 $55.78 $0.00 $0.00 $56.74 $0.00 $0.00 $0.00 $0.00 $0.00 M0061901540 SUP HCPCS C2617 M0061901540 - STENT URET 8FR 28CM W/O GWIRE PLRS HDR+ BOTH IP/OP $359.98 $266.39 $0.00 $287.98 $161.99 $161.99 $0.00 $0.00 $0.00 $75.03 $267.17 $267.17 $0.00 $0.00 $75.02 $0.00 $212.93 $212.93 $0.00 $179.99 $285.10 $287.98 $0.00 $0.00 $56.34 $0.00 $0.00 $57.31 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921300 SUP HCPCS C2617 M0061921300 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 6FR 2.1FR 20CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921310 SUP HCPCS C1768 M0061921310 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 6FR 2.1FR 22CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921320 SUP HCPCS C1768 M0061921320 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 6FR 2.1FR 24CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921330 SUP HCPCS C1768 M0061921330 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 6FR 2.1FR 26CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921340 SUP HCPCS C2617 M0061921340 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 6FR 2.1FR 28CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921410 SUP HCPCS C2617 M0061921410 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 7FR 2.1FR 22CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921420 SUP HCPCS C2617 M0061921420 - STENT URETERAL 2 PIGTAIL CURVE TAPER 7FR 2.1FR 24CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921430 SUP HCPCS C2617 M0061921430 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 7FR 2.1FR 26CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921440 SUP HCPCS C2617 M0061921440 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 7FR 2.1FR 28CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921510 SUP HCPCS C2617 M0061921510 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 8FR 2.1FR 22CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921520 SUP HCPCS C2617 M0061921520 - STENT URETERAL 2 PIGTAIL CURVE LP TAPER 8FR 2.1FR 24CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0061921530 SUP HCPCS C2617 M0061921530 - STENT URETERAL 2 PIGTAIL CURVE TAPER 8FR 2.1FR 26CM 2 BOTH IP/OP $658.50 $487.29 $0.00 $526.80 $296.33 $296.33 $0.00 $0.00 $0.00 $137.25 $488.74 $488.74 $0.00 $0.00 $137.23 $0.00 $389.50 $389.50 $0.00 $329.25 $521.53 $526.80 $0.00 $0.00 $103.06 $0.00 $0.00 $104.83 $0.00 $0.00 $0.00 $0.00 $0.00 M0062101170 SUP HCPCS C1726 M0062101170 - CATHETER BLNDIL 17CM 30FR 55CM LF 12CM NPHRMX AMPTZ LOPRFL BOTH IP/OP "$1,077.18 " $797.11 $0.00 $861.74 $584.91 $584.91 $0.00 $0.00 $0.00 $224.51 $799.48 $799.48 $0.00 $0.00 $224.48 $0.00 $637.15 $637.15 $0.00 $538.59 $853.13 $861.74 $0.00 $0.00 $168.58 $0.00 $0.00 $171.49 $0.00 $0.00 $0.00 $0.00 $0.00 M0062251020 SUP HCPCS C1758 M0062251020 - CATHETER BLNDIL 6MM 75CM LF 4CM URMT U QD-FOLD HI-PRS KINK BOTH IP/OP "$1,131.68 " $837.44 $0.00 $905.34 $614.50 $614.50 $0.00 $0.00 $0.00 $235.87 $839.93 $839.93 $0.00 $0.00 $235.84 $0.00 $669.39 $669.39 $0.00 $565.84 $896.29 $905.34 $0.00 $0.00 $177.11 $0.00 $0.00 $180.16 $0.00 $0.00 $0.00 $0.00 $0.00 M0062251170 SUP HCPCS C1758 M0062251170 - CATHETER BALDILAT SHORT TAPER 5.8FR 18FR 75CM 10CM KINK BOTH IP/OP "$1,131.68 " $837.44 $0.00 $905.34 $614.50 $614.50 $0.00 $0.00 $0.00 $235.87 $839.93 $839.93 $0.00 $0.00 $235.84 $0.00 $669.39 $669.39 $0.00 $565.84 $896.29 $905.34 $0.00 $0.00 $177.11 $0.00 $0.00 $180.16 $0.00 $0.00 $0.00 $0.00 $0.00 M0062502091 SUP HCPCS C1894 M0062502091 - SHEATH ACCES 2 TAPER 15FR 13FR 36CM KINK RESISTANT RADIOPQ BOTH IP/OP $94.17 $69.69 $0.00 $75.33 $51.13 $51.13 $0.00 $0.00 $0.00 $19.63 $69.89 $69.89 $0.00 $0.00 $19.62 $0.00 $55.70 $55.70 $0.00 $47.08 $74.58 $75.33 $0.00 $0.00 $14.74 $0.00 $0.00 $14.99 $0.00 $0.00 $0.00 $0.00 $0.00 M0062601200 SUP HCPCS C1769 M0062601200 - DILATOR SURG 8-10FR 70CM 30CM KINK RESISTANT STYLET SHEATH BOTH IP/OP $236.20 $174.79 $0.00 $188.96 $128.26 $128.26 $0.00 $0.00 $0.00 $49.23 $175.31 $175.31 $0.00 $0.00 $49.22 $0.00 $139.71 $139.71 $0.00 $118.10 $187.07 $188.96 $0.00 $0.00 $36.97 $0.00 $0.00 $37.60 $0.00 $0.00 $0.00 $0.00 $0.00 M0062602500 SUP Custom 27203010 M0062602500 - DILATOR SURG SHEATH SET AMPLATZ RENAL STERILE BOTH IP/OP "$1,131.68 " $837.44 $0.00 $905.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $839.93 $839.93 $0.00 $0.00 $235.84 $0.00 $0.00 $0.00 $0.00 $565.84 $896.29 $905.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063201020 SUP Custom 27203010 M0063201020 - BASKET SPEC RTRVL 20MM 7FR 70CM SGR 4WR 0 TIP OVR GW BOTH IP/OP $528.75 $391.28 $0.00 $423.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $392.44 $392.44 $0.00 $0.00 $110.19 $0.00 $0.00 $0.00 $0.00 $264.38 $418.77 $423.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063201040 SUP Custom 27203010 M0063201040 - BASKET SPEC RTRVL 3FR 16MM 90CM S-D 4WR STON LSR BOTH IP/OP $649.00 $480.26 $0.00 $519.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $481.69 $481.69 $0.00 $0.00 $135.25 $0.00 $0.00 $0.00 $0.00 $324.50 $514.01 $519.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063301060 SUP Custom 27203010 M0063301060 - BASKET STON RTRVL HLCL 11MM 3FR 120CM STRL GMN 3 PR WRE SCR BOTH IP/OP $853.95 $631.92 $0.00 $683.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.80 $633.80 $0.00 $0.00 $177.96 $0.00 $0.00 $0.00 $0.00 $426.98 $676.33 $683.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063311060 SUP Custom 27203010 M0063311060 - BASKET SPEC RTRVL 120CM 3FR 11MM STON 3WR HLCL 0 TIP PR GMN BOTH IP/OP $473.00 $350.02 $0.00 $378.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.06 $351.06 $0.00 $0.00 $98.57 $0.00 $0.00 $0.00 $0.00 $236.50 $374.62 $378.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063401220 SUP Custom 27203010 M0063401220 - BASKET STON RTRVL HLCL 10MM 1.9FR 120CM STRL BGLY 3WR DISP BOTH IP/OP $853.95 $631.92 $0.00 $683.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.80 $633.80 $0.00 $0.00 $177.96 $0.00 $0.00 $0.00 $0.00 $426.98 $676.33 $683.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063601000 SUP HCPCS C1726 M0063601000 - CATHETER SPEC RTRVL 3FR 120CM 60CM OVL LOOP BOTH IP/OP $455.50 $337.07 $0.00 $364.40 $247.34 $247.34 $0.00 $0.00 $0.00 $94.94 $338.07 $338.07 $0.00 $0.00 $94.93 $0.00 $269.43 $269.43 $0.00 $227.75 $360.76 $364.40 $0.00 $0.00 $71.29 $0.00 $0.00 $72.52 $0.00 $0.00 $0.00 $0.00 $0.00 M0063801100 SUP Custom 27203010 M0063801100 - BASKET STON RTRVL 20MM 3FR 120CM STRL LF SGR HEMI PERMAFORM BOTH IP/OP $853.95 $631.92 $0.00 $683.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $426.98 $676.33 $683.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063901010 SUP Custom 27203010 M0063901010 - BASKET STON RTRVL 12MM 2.4FR 120CM STRL LF 0TP 4WR FLT DIST BOTH IP/OP $921.93 $682.23 $0.00 $737.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $684.25 $684.25 $0.00 $0.00 $192.13 $0.00 $0.00 $0.00 $0.00 $460.96 $730.17 $737.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063901020 SUP Custom 27203010 M0063901020 - BASKET STON RTRVL 16MM 3FR 90CM STRL LF 0TP 4WR FLT DIST BOTH IP/OP $921.93 $682.23 $0.00 $737.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $684.25 $684.25 $0.00 $0.00 $192.13 $0.00 $0.00 $0.00 $0.00 $460.96 $730.17 $737.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063901050 SUP Custom 27203010 M0063901050 - BASKET STON RTRVL 12MM 1.9FR 120CM STRL LF 0TP 4WR FLT DIST BOTH IP/OP $939.48 $695.22 $0.00 $751.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $697.28 $697.28 $0.00 $0.00 $195.79 $0.00 $0.00 $0.00 $0.00 $469.74 $744.07 $751.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063902000 SUP Custom 27203010 M0063902000 - BASKET STON RTRVL 1.9FR 90CM STRL LF ESCAPE SGR STD 4WR NTNL BOTH IP/OP "$1,158.53 " $857.31 $0.00 $926.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $859.86 $859.86 $0.00 $0.00 $241.44 $0.00 $0.00 $0.00 $0.00 $579.26 $917.56 $926.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063902010 SUP Custom 27203010 M0063902010 - BASKET STON RTRVL 1.9FR 120CM STRL LF ESCAPE SGR STD 4WR BOTH IP/OP "$1,158.53 " $857.31 $0.00 $926.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $859.86 $859.86 $0.00 $0.00 $241.44 $0.00 $0.00 $0.00 $0.00 $579.26 $917.56 $926.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063903100 SUP Custom 27203010 M0063903100 - COIL SPECIMEN RETRIEVAL 7MM 3FR 115CM LATEX FREE STONE CONE BOTH IP/OP "$1,112.15 " $822.99 $0.00 $889.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.44 $825.44 $0.00 $0.00 $231.77 $0.00 $0.00 $0.00 $0.00 $556.08 $880.82 $889.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0063903200 SUP Custom 27803010 M0063903200 - COIL SPECIMEN RETRIEVAL 3FR 10MM 115CM SHEAQTH QUICK RELEASE BOTH IP/OP "$1,112.15 " $822.99 $0.00 $889.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.44 $825.44 $0.00 $0.00 $231.77 $0.00 $0.00 $0.00 $0.00 $556.08 $880.82 $889.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0064002011 SUP HCPCS C1758 M0064002011 - CATHETER URETERAL 5FR 70CM 1 LUMEN OPEN END INJEC HUB LATEX BOTH IP/OP $921.45 $681.87 $0.00 $737.16 $500.35 $500.35 $0.00 $0.00 $0.00 $192.05 $683.90 $683.90 $0.00 $0.00 $192.03 $0.00 $545.04 $545.04 $0.00 $460.73 $729.79 $737.16 $0.00 $0.00 $144.21 $0.00 $0.00 $146.69 $0.00 $0.00 $0.00 $0.00 $0.00 M0064201000 SUP Custom 27203010 M0064201000 - CATH SPBC FDRTP 14FR 15CM KIT BLN PNCT 5ML BOTH IP/OP $198.00 $146.52 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.96 $146.96 $0.00 $0.00 $41.26 $0.00 $0.00 $0.00 $0.00 $99.00 $156.82 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M006580211 SUP Custom 27203010 M006580211 - UNIT ELECTROSURGICAL PROCEDURE SET GENESYS HTA BOTH IP/OP "$4,209.12 " "$3,114.75" $0.00 "$3,367.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,124.01" "$3,124.01" $0.00 $0.00 $877.18 $0.00 $0.00 $0.00 $0.00 "$2,104.56" "$3,333.62" "$3,367.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0066301001 SUP HCPCS C1769 M0066301001 - GWIRE ENDSCP .035IN 150CM STR FLX TP STF SHFT GLDWR HYDPHI 3 BOTH IP/OP $137.89 $102.04 $0.00 $110.31 $74.87 $74.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.95 $109.21 $110.31 $0.00 $0.00 $21.58 $0.00 $0.00 $21.95 $0.00 $0.00 $0.00 $0.00 $0.00 M0066301011 SUP HCPCS C1769 M0066301011 - GUIDEWIRE URO STD .038IN 150CM STRL 3CM GLDWR SFT FLXB STRG BOTH IP/OP $137.89 $102.04 $0.00 $110.31 $74.87 $74.87 $0.00 $0.00 $0.00 $28.74 $102.34 $102.34 $0.00 $0.00 $28.74 $0.00 $81.56 $81.56 $0.00 $68.95 $109.21 $110.31 $0.00 $0.00 $21.58 $0.00 $0.00 $21.95 $0.00 $0.00 $0.00 $0.00 $0.00 M0066301101 SUP HCPCS C1769 M0066301101 - GWIRE ENDSCP .035IN 150CM ANG TIP FLX TP STF SHFT GLDWR PU 3 BOTH IP/OP $201.16 $148.86 $0.00 $160.93 $109.23 $109.23 $0.00 $0.00 $0.00 $41.93 $149.30 $149.30 $0.00 $0.00 $41.92 $0.00 $118.99 $118.99 $0.00 $100.58 $159.32 $160.93 $0.00 $0.00 $31.48 $0.00 $0.00 $32.02 $0.00 $0.00 $0.00 $0.00 $0.00 M0066301121 SUP HCPCS C1769 M0066301121 - GWIRE ENDSCP .038IN 150CM ANG TIP FLX TP STF SHFT GLDWR PU 3 BOTH IP/OP $201.16 $148.86 $0.00 $160.93 $109.23 $109.23 $0.00 $0.00 $0.00 $41.93 $149.30 $149.30 $0.00 $0.00 $41.92 $0.00 $118.99 $118.99 $0.00 $100.58 $159.32 $160.93 $0.00 $0.00 $31.48 $0.00 $0.00 $32.02 $0.00 $0.00 $0.00 $0.00 $0.00 M0066401041 SUP HCPCS C1769 M0066401041 - GUIDEWIRE URO STRG .035IN 145CM LF 7CM AMP SPST BNTSN FLX TP BOTH IP/OP $120.44 $89.13 $0.00 $96.35 $65.40 $65.40 $0.00 $0.00 $0.00 $25.10 $89.39 $89.39 $0.00 $0.00 $25.10 $0.00 $71.24 $71.24 $0.00 $60.22 $95.39 $96.35 $0.00 $0.00 $18.85 $0.00 $0.00 $19.17 $0.00 $0.00 $0.00 $0.00 $0.00 M0066703051 SUP HCPCS C1769 M0066703051 - GUIDEWIRE ENDSCP STR FLOPPY .035IN 150CM 3CM HIGH BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $526.03 $526.03 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 M0066703061 SUP HCPCS C1769 M0066703061 - GUIDEWIRE ENDSCP ANGLE FLOPPY .035IN 150CM 3CM HIGH BOTH IP/OP $193.75 $143.38 $0.00 $155.00 $105.21 $105.21 $0.00 $0.00 $0.00 $40.38 $143.80 $143.80 $0.00 $0.00 $40.38 $0.00 $114.60 $114.60 $0.00 $96.88 $153.45 $155.00 $0.00 $0.00 $30.32 $0.00 $0.00 $30.85 $0.00 $0.00 $0.00 $0.00 $0.00 M0066703091 SUP HCPCS C1769 M0066703091 - GUIDEWIRE ENDSCP STR .038IN 150CM 3CM RADIOPQ FLEXIBLE TIP BOTH IP/OP $193.75 $143.38 $0.00 $155.00 $105.21 $105.21 $0.00 $0.00 $0.00 $40.38 $143.80 $143.80 $0.00 $0.00 $40.38 $0.00 $114.60 $114.60 $0.00 $96.88 $153.45 $155.00 $0.00 $0.00 $30.32 $0.00 $0.00 $30.85 $0.00 $0.00 $0.00 $0.00 $0.00 M0066703101 SUP HCPCS C1769 M0066703101 - GUIDEWIRE ENDSCP ANGLE .038IN 150CM 3CM 2 FLEXIBLE TIP BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $526.03 $526.03 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 M0067201001 SUP Custom 27203010 M0067201001 - SYSTEM PUMP IRRIGATION 1 HAND ACTION 1 WAY VALVE VACUUM BOTH IP/OP $212.74 $157.43 $0.00 $170.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.90 $157.90 $0.00 $0.00 $44.34 $0.00 $0.00 $0.00 $0.00 $106.37 $168.49 $170.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0067301251 SUP Custom 27203010 M0067301251 - EVACUATOR UROLOGY UROVAC BLADDER BOTH IP/OP $107.98 $79.91 $0.00 $86.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.14 $80.14 $0.00 $0.00 $22.50 $0.00 $0.00 $0.00 $0.00 $53.99 $85.52 $86.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0068318170 SUP HCPCS C1781 M0068318170 - MESH TRANSVAGINAL UPHOLD CAPIO BOTH IP/OP "$7,046.25 " "$5,214.23" $0.00 "$5,637.00" "$3,170.81" "$3,170.81" $0.00 $0.00 $0.00 "$1,468.61" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,468.44" $0.00 "$3,473.80" "$3,473.80" $0.00 "$3,523.13" "$5,580.63" "$5,637.00" $0.00 $0.00 "$1,102.74" $0.00 $0.00 "$1,121.76" $0.00 $0.00 $0.00 $0.00 $0.00 M0068502110 SUP HCPCS C1771 M0068502110 - SLING TRANSVAGINAL 2.7MM CURVE SYSTEM DELIVERY DEVICE MESH BOTH IP/OP "$3,940.00 " "$2,915.60" $0.00 "$3,152.00" "$1,773.00" "$1,773.00" $0.00 $0.00 $0.00 $821.19 "$2,924.27" "$2,924.27" $0.00 $0.00 $821.10 $0.00 "$1,942.42" "$1,942.42" $0.00 "$1,970.00" "$3,120.48" "$3,152.00" $0.00 $0.00 $616.61 $0.00 $0.00 $627.25 $0.00 $0.00 $0.00 $0.00 $0.00 M0068503000 SUP HCPCS C1771 M0068503000 - SLING PUBOVAGINAL SLING SYSTEM LYNX FMALE SUPRAPUBIC BOTH IP/OP "$3,753.08 " "$2,777.28" $0.00 "$3,002.46" "$1,688.88" "$1,688.88" $0.00 $0.00 $0.00 $782.23 "$2,785.53" "$2,785.53" $0.00 $0.00 $782.14 $0.00 "$1,850.27" "$1,850.27" $0.00 "$1,876.54" "$2,972.44" "$3,002.46" $0.00 $0.00 $587.36 $0.00 $0.00 $597.49 $0.00 $0.00 $0.00 $0.00 $0.00 M0068505000 SUP HCPCS C1771 M0068505000 - SLING PUBOVAGINAL SLING SYSTEM NEEDLE OBTRYX HALO FMALE BOTH IP/OP "$3,187.50 " "$2,358.75" $0.00 "$2,550.00" "$1,434.38" "$1,434.38" $0.00 $0.00 $0.00 $664.35 "$2,365.76" "$2,365.76" $0.00 $0.00 $664.28 $0.00 "$1,571.44" "$1,571.44" $0.00 "$1,593.75" "$2,524.50" "$2,550.00" $0.00 $0.00 $498.84 $0.00 $0.00 $507.45 $0.00 $0.00 $0.00 $0.00 $0.00 M0068505110 SUP HCPCS C1771 M0068505110 - SLING PUBOVAGINAL NEEDLE OBTRYX II HALO MIDURETHRAL BOTH IP/OP "$3,500.00 " "$2,590.00" $0.00 "$2,800.00" "$1,575.00" "$1,575.00" $0.00 $0.00 $0.00 $729.49 "$2,597.70" "$2,597.70" $0.00 $0.00 $729.40 $0.00 "$1,725.50" "$1,725.50" $0.00 "$1,750.00" "$2,772.00" "$2,800.00" $0.00 $0.00 $547.75 $0.00 $0.00 $557.20 $0.00 $0.00 $0.00 $0.00 $0.00 M0613 SUP Custom 25003010 ANTIBODY EMA CLONE E29 MS ANHMN .2ML LAB BOTH IP/OP $569.13 $421.16 $0.00 $455.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $284.56 $450.75 $455.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0630 SUP Custom 25003010 ANTIBODY CYKRTN CLONE 34BETAE12 MS IGG1 KAPPA MNCLN ANHMN .2 BOTH IP/OP "$1,016.33 " $752.08 $0.00 $813.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $508.16 $804.93 $813.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0634 SUP Custom 25003010 ANTIBODY MLNSM CLONE HMB45 MS ANHMN .2ML LAB BOTH IP/OP "$1,900.00 " "$1,406.00" $0.00 "$1,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $950.00 "$1,504.80" "$1,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0701 SUP Custom 25003010 ANTIBODY CD45 LCA CLONE 2B11 PD7/26 MS IGG1 KAPPA ANHMN 1ML BOTH IP/OP $817.85 $605.21 $0.00 $654.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.93 $647.74 $654.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0725 SUP Custom 25003010 ANTIBODY VM CLONE V9 MS ANHMN 1ML LAB BOTH IP/OP "$1,187.50 " $878.75 $0.00 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $593.75 $940.50 $950.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0733 SUP Custom 25003010 ANTIBODY CD15 CLONE C3D-1 MS IGM KAPPA ANHMN 1ML LAB BOTH IP/OP $861.60 $637.58 $0.00 $689.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $430.80 $682.39 $689.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0750 SUP Custom 25003010 ANTIBODY PSA CLONE ER-PR8 MS ANHMN 1ML LAB BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0751 SUP Custom 25003010 ANTIBODY CD30 CLONE BER H2 MS IGG1 KAPPA ANHMN 1ML LAB BOTH IP/OP "$1,101.68 " $815.24 $0.00 $881.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $550.84 $872.53 $881.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0755 SUP Custom 25003010 ANTIBODY CD20CY CLONE L26 MS IGG2A KAPPA ANHMN 1ML LAB BOTH IP/OP "$1,213.70 " $898.14 $0.00 $970.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $606.85 $961.25 $970.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0776 SUP Custom 25003010 ANTIBODY SNPTSN CLONE SY38 MS IGG1 KAPPA ANHMN 1ML LAB BOTH IP/OP "$1,252.00 " $926.48 $0.00 "$1,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $626.00 $991.58 "$1,001.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0781 SUP Custom 25003010 ANTIBODY IGG1 KAPPA DAK-TG6 CLONE MS ANHMN MNCLN CULT SPRNT BOTH IP/OP $877.60 $649.42 $0.00 $702.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $438.80 $695.06 $702.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0823 SUP Custom 25003010 ANTIBODY CD31 CLONE JC/70A MS IGG1 .2ML 1ML LAB BOTH IP/OP "$1,072.33 " $793.52 $0.00 $857.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $536.16 $849.29 $857.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M085401 SUP Custom 25003010 ANTIBODY CMV CLONE CCH2 DDG9 MS ANHMN 1ML LAB BOTH IP/OP "$1,091.25 " $807.53 $0.00 $873.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.63 $864.27 $873.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M0873 SUP Custom 25003010 ANTIBODY NSE CLONE BBS/NC/6-H14 MS ANHMN .2ML LAB BOTH IP/OP "$1,556.85 " "$1,152.07" $0.00 "$1,245.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $778.43 "$1,233.03" "$1,245.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M1599B SUP Custom 27203010 CABLE NIBP INTERCONNECT 3.0M BOTH IP/OP $115.50 $85.47 $0.00 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.75 $91.48 $92.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M1900B SUP Custom 27203010 CABLE OXM 3MR 12TO 9 PIN D-SUB INPT CONNCTR SPO2 ADPR LF BOTH IP/OP $339.60 $251.30 $0.00 $271.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.80 $268.96 $271.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M3526A SUP Custom 27203010 WIRE 3 LEAD SET SNAP BOTH IP/OP $340.00 $251.60 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.00 $269.28 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M3556 SUP Custom 25003010 ANTIBODY CALPONIN CLONE CALP MS IGG1 KAPPA ANHMN 1ML LAB BOTH IP/OP "$1,900.00 " "$1,406.00" $0.00 "$1,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $950.00 "$1,504.80" "$1,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M3569 SUP Custom 25003010 ANTIBODY PR CLONE PGR 636 MS IGG1 KAPPA MNCLN ANHMN .2ML 1ML BOTH IP/OP "$3,115.03 " "$2,305.12" $0.00 "$2,492.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,557.51" "$2,467.10" "$2,492.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M3609 SUP Custom 25003010 ANTIBODY INHIBIN ALPHA CLONE R1 MS ANHMN 1ML LAB BOTH IP/OP "$1,193.10 " $882.89 $0.00 $954.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $596.55 $944.94 $954.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M365SC550040 SUP HCPCS C1787 M365SC550040 - KIT STIMULATOR PRECISION SPECTRA SPINE CORD CASE REMOTE CONT BOTH IP/OP "$2,000.00 " "$1,480.00" $0.00 "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,484.40" "$1,484.40" $0.00 $0.00 $416.80 $0.00 $0.00 $0.00 $0.00 "$1,000.00" "$1,584.00" "$1,600.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M3717A SUP Custom 27203010 M3717A - PAD DFBR HRTSTRT MLFNC XTRN PLUG CONCTR PED LATEX FREE DISP BOTH IP/OP $60.16 $44.52 $0.00 $48.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.65 $44.65 $0.00 $0.00 $12.54 $0.00 $0.00 $0.00 $0.00 $30.08 $47.65 $48.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M6275033/10.S SUP HCPCS A6209 M6275033/10.S - DRSG THK1CM LG 15X10CM NADH CMFT VRSTL PVA VAC WHITEFOAM BOTH IP/OP $23.48 $17.38 $0.00 $18.78 $12.75 $12.75 $0.00 $0.00 $0.00 $4.89 $17.43 $17.43 $0.00 $0.00 $4.89 $0.00 $13.89 $13.89 $0.00 $11.74 $18.60 $18.78 $0.00 $0.00 $3.67 $0.00 $0.00 $3.74 $0.00 $0.00 $0.00 $0.00 $0.00 M6275034/10.S SUP HCPCS A6209 M6275034/10.S - DRSG THK1CM LG 15X10CM NADH CMFT VRSTL PVA VAC WHITEFOAM BOTH IP/OP $30.02 $22.21 $0.00 $24.01 $16.30 $16.30 $0.00 $0.00 $0.00 $6.26 $22.28 $22.28 $0.00 $0.00 $6.26 $0.00 $17.76 $17.76 $0.00 $15.01 $23.78 $24.01 $0.00 $0.00 $4.70 $0.00 $0.00 $4.78 $0.00 $0.00 $0.00 $0.00 $0.00 M6275053/10.S SUP HCPCS A6209 M6275053/10.S - DRSG THK3.3CM MED 18X12.5CM NADH CMFT VRSTL PU VAC GFM FOAM BOTH IP/OP $135.29 $100.11 $0.00 $108.23 $73.46 $73.46 $0.00 $0.00 $0.00 $28.20 $100.41 $100.41 $0.00 $0.00 $28.19 $0.00 $80.02 $80.02 $0.00 $67.64 $107.15 $108.23 $0.00 $0.00 $21.17 $0.00 $0.00 $21.54 $0.00 $0.00 $0.00 $0.00 $0.00 M6275096/10 SUP Custom 27203010 DRESSING THK3.3CM MED 18X12.5CM 2 ADH DRP KT PU VAC GFM SLVR BOTH IP/OP $148.16 $109.64 $0.00 $118.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.08 $117.34 $118.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M6275096/10.S SUP HCPCS A6209 M6275096/10.S - DRSG MED 18X12.5CM OPN PORE HDRPHB NEG PRSS KIT PU VAC GFM BOTH IP/OP $155.06 $114.74 $0.00 $124.04 $84.19 $84.19 $0.00 $0.00 $0.00 $32.32 $115.08 $115.08 $0.00 $0.00 $32.31 $0.00 $91.72 $91.72 $0.00 $77.53 $122.81 $124.04 $0.00 $0.00 $24.27 $0.00 $0.00 $24.68 $0.00 $0.00 $0.00 $0.00 $0.00 M6275098/10 SUP Custom 27203010 DRESSING THK3.3CM SM VAC GFM SLVR BLK 10X7.5CM M6275098/10 BOTH IP/OP "$1,180.45 " $873.53 $0.00 $944.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.23 $934.92 $944.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M6275098/10.S SUP HCPCS A6209 M6275098/10.S - DRSG SM 10X7.5CM 1 DRP PAD CONCTR PU VAC GFM SLVR FOAM BLK BOTH IP/OP $123.77 $91.59 $0.00 $99.01 $67.20 $67.20 $0.00 $0.00 $0.00 $25.80 $91.86 $91.86 $0.00 $0.00 $25.79 $0.00 $73.21 $73.21 $0.00 $61.88 $98.03 $99.01 $0.00 $0.00 $19.37 $0.00 $0.00 $19.70 $0.00 $0.00 $0.00 $0.00 $0.00 M6275099/10 SUP Custom 27203010 DRESSING THK3.3CM LG VAC GFM SLVR BLK 26X15CM M6275099/10 BOTH IP/OP $179.29 $132.67 $0.00 $143.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.65 $142.00 $143.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M6275099/10.S SUP HCPCS A6209 M6275099/10.S - DRSG LG 26X15CM 2 DRP SENSATRAC PAD CONCTR PU VAC GFM SLVR BOTH IP/OP $17.36 $12.85 $0.00 $13.89 $9.43 $9.43 $0.00 $0.00 $0.00 $3.62 $12.89 $12.89 $0.00 $0.00 $3.62 $0.00 $10.27 $10.27 $0.00 $8.68 $13.75 $13.89 $0.00 $0.00 $2.72 $0.00 $0.00 $2.76 $0.00 $0.00 $0.00 $0.00 $0.00 M653G SUP Custom 27203010 M653G - SUTURE SS 5 CCS 18IN MFL NABSB BOTH IP/OP $133.64 $98.89 $0.00 $99.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.19 $99.19 $0.00 $0.00 $27.85 $0.00 $0.00 $0.00 $0.00 $19.85 $31.45 $31.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M7001 SUP Custom 27803010 M7001 - CATHETER DRN SYS ASPT PLR BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M7019 SUP Custom 25003010 ANTIBODY CYKRTN 20 CLONE KS20.8 MS IGG2A KAPPA ANHMN 1ML LAB BOTH IP/OP "$1,013.43 " $749.94 $0.00 $810.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $506.71 $802.64 $810.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M7047 SUP Custom 25003010 ANTIBODY ER CLONE 1D5 MS IGG1 KAPPA MNCLN ANHMN .2ML 1ML LAB BOTH IP/OP "$2,638.43 " "$1,952.44" $0.00 "$2,110.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,319.21" "$2,089.64" "$2,110.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M7165 SUP Custom 25003010 ANTIBODY CD34 CLONE QBEND MS IGG1 KAPPA ANHMN 1ML LAB BOTH IP/OP "$1,173.58 " $868.45 $0.00 $938.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.79 $929.48 $938.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M7191 SUP Custom 25003010 ANTIBODY PLAP CLONE 8A9 MS ANHMN .2ML LAB BOTH IP/OP "$1,018.50 " $753.69 $0.00 $814.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.25 $806.65 $814.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M7240 SUP Custom 25003010 ANTIBODY KI-67 CLONE MIB-1 MS IGG1 KAPPA ANHMN 1ML LAB BOTH IP/OP "$1,193.03 " $882.84 $0.00 $954.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $596.51 $944.88 $954.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M7630-1A SUP Custom 27203010 MEDIA CYSL 60 LVISC CLR MOUNT BOTH IP/OP $319.08 $236.12 $0.00 $255.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.54 $252.71 $255.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275040/10.S SUP Custom 27203010 DRESSING MED SPIRAL FOAM V.A.C. SIMPLACE BOTH IP/OP $129.88 $96.11 $0.00 $103.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.94 $102.86 $103.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275041/5.S SUP HCPCS A6209 M8275041/5.S - KIT DRESSING THK1.75CM MEDIUM 7.5X11.5CM DRAPE PAD CONCTR BOTH IP/OP $93.58 $69.25 $0.00 $74.86 $50.81 $50.81 $0.00 $0.00 $0.00 $19.50 $69.46 $69.46 $0.00 $0.00 $19.50 $0.00 $55.35 $55.35 $0.00 $46.79 $74.12 $74.86 $0.00 $0.00 $14.65 $0.00 $0.00 $14.90 $0.00 $0.00 $0.00 $0.00 $0.00 M8275051/10 SUP HCPCS A6209 M8275051/10 - DRSG THK3.3CM SM 10X7.5CM SENSATRAC PAD DRP HDRPHB FLXB OPN BOTH IP/OP $80.69 $59.71 $0.00 $64.55 $43.81 $43.81 $0.00 $0.00 $0.00 $16.82 $59.89 $59.89 $0.00 $0.00 $16.82 $0.00 $47.73 $47.73 $0.00 $40.34 $63.91 $64.55 $0.00 $0.00 $12.63 $0.00 $0.00 $12.85 $0.00 $0.00 $0.00 $0.00 $0.00 M8275052/10 SUP Custom 27203010 DRESSING THK3.3CM LG 18X12.5CM OPN PORE HDRPHB NEG PRSS KT BOTH IP/OP $109.07 $80.71 $0.00 $87.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.54 $86.38 $87.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275052/10.S SUP HCPCS A6209 M8275052/10.S - KIT DRESSING THK3.3CM MEDIUM STANDARD 18X12.5CM 2 ADHESIVE BOTH IP/OP $99.71 $73.79 $0.00 $79.76 $54.14 $54.14 $0.00 $0.00 $0.00 $20.78 $74.00 $74.00 $0.00 $0.00 $20.78 $0.00 $58.98 $58.98 $0.00 $49.85 $78.97 $79.76 $0.00 $0.00 $15.60 $0.00 $0.00 $15.87 $0.00 $0.00 $0.00 $0.00 $0.00 M8275053/10 SUP Custom 27203010 DRESSING THK3.3CM LG VAC GFM WHT 26X15CM HDRPHB KT PU STRL BOTH IP/OP $135.28 $100.11 $0.00 $108.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.64 $107.14 $108.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275053/10.S SUP HCPCS A6209 M8275053/10.S - KIT VAC GFM DRSG SENSATRAC PAD DRP HDRPHB FLXB OPN PORE PU BOTH IP/OP $122.79 $90.86 $0.00 $98.23 $66.67 $66.67 $0.00 $0.00 $0.00 $25.59 $91.13 $91.13 $0.00 $0.00 $25.59 $0.00 $72.63 $72.63 $0.00 $61.39 $97.25 $98.23 $0.00 $0.00 $19.22 $0.00 $0.00 $19.55 $0.00 $0.00 $0.00 $0.00 $0.00 M8275057 SUP Custom 27203010 CANISTER WND DRAIN PAD TBG CLMP CONNCTR SENSATRAC STRL LF BOTH IP/OP $48.03 $35.54 $0.00 $38.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.64 $35.64 $0.00 $0.00 $10.01 $0.00 $0.00 $0.00 $0.00 $24.01 $38.04 $38.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275057/10.S SUP Custom 27203010 M8275057/10.S - PAD WOUND DRAIN TUBE CLMP CONCTR SENSATRAC VAC STERILE BOTH IP/OP $42.59 $31.52 $0.00 $34.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.61 $31.61 $0.00 $0.00 $8.87 $0.00 $0.00 $0.00 $0.00 $21.29 $33.73 $34.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275063/10.S SUP Custom 27203010 M8275063/10.S - CANISTER WOUND DRAIN C500ML GEL TUBE CLMP CONCTR CHARCOAL BOTH IP/OP $82.68 $61.18 $0.00 $66.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.37 $61.37 $0.00 $0.00 $17.23 $0.00 $0.00 $0.00 $0.00 $41.34 $65.48 $66.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275065/5 SUP HCPCS A6209 M8275065/5 - DRSG THK1.5CM XL 60X30CM OPN PORE HDRPHB NEG PRSS KIT PU VAC BOTH IP/OP $253.80 $187.81 $0.00 $203.04 $137.81 $137.81 $0.00 $0.00 $0.00 $52.90 $188.37 $188.37 $0.00 $0.00 $52.89 $0.00 $150.12 $150.12 $0.00 $126.90 $201.01 $203.04 $0.00 $0.00 $39.72 $0.00 $0.00 $40.40 $0.00 $0.00 $0.00 $0.00 $0.00 M8275080/5 SUP Custom 27203010 KCI V.A.C. GRANU FOAM DRESSING ABDOMINAL BOTH IP/OP $801.14 $592.84 $0.00 $640.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $400.57 $634.50 $640.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275080/5.S SUP Custom 27203010 M8275080/5.S - DRSG NADH LYR SENSATRAC PAD TBG PU VAC GFM FOAM ABD BOTH IP/OP $793.52 $587.20 $0.00 $634.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.76 $628.47 $634.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275096/10 SUP HCPCS A6209 M8275096/10 - KIT DRESSING THK3.2CM MEDIUM 18X12.5CM 2 ADHESIVE DRAPE 1 BOTH IP/OP $140.73 $104.14 $0.00 $112.58 $76.42 $76.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.36 $111.46 $112.58 $0.00 $0.00 $22.02 $0.00 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 M8275096/10.S SUP HCPCS A6209 M8275096/10.S - DRSG THK3.3CM MED 18X12.5CM SENSATRAC PAD DRP FLXB CNTOUR BOTH IP/OP $140.73 $104.14 $0.00 $112.58 $76.42 $76.42 $0.00 $0.00 $0.00 $29.33 $104.45 $104.45 $0.00 $0.00 $29.33 $0.00 $83.24 $83.24 $0.00 $70.36 $111.46 $112.58 $0.00 $0.00 $22.02 $0.00 $0.00 $22.40 $0.00 $0.00 $0.00 $0.00 $0.00 M8275096/5.S SUP Custom 27203010 M8275096/5.S - DRSG THK3.3CM MED 18X12.5CM SENSATRAC PAD DRP FLXB CNTOUR BOTH IP/OP $172.74 $127.83 $0.00 $138.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.21 $128.21 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $86.37 $136.81 $138.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275098/10 SUP HCPCS A6209 M8275098/10 - DRESSING FOAM THK3.3CM SMALL 10X7.5CM SENSATRAC PAD DRAPE BOTH IP/OP $112.33 $83.12 $0.00 $89.86 $60.99 $60.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.16 $88.97 $89.86 $0.00 $0.00 $17.58 $0.00 $0.00 $17.88 $0.00 $0.00 $0.00 $0.00 $0.00 M8275098/10.S SUP HCPCS A6209 M8275098/10.S - DRSG THK3.3CM SM 10X7.5CM SENSATRAC PAD DRP FLXB CNTOUR BOTH IP/OP $112.33 $83.12 $0.00 $89.86 $60.99 $60.99 $0.00 $0.00 $0.00 $23.41 $83.37 $83.37 $0.00 $0.00 $23.41 $0.00 $66.44 $66.44 $0.00 $56.16 $88.97 $89.86 $0.00 $0.00 $17.58 $0.00 $0.00 $17.88 $0.00 $0.00 $0.00 $0.00 $0.00 M8275099/10 SUP HCPCS A6209 M8275099/10 - DRESSING FOAM THK3.3CM LARGE 26X15CM ADHESIVE DRAPE BOTH IP/OP $170.41 $126.10 $0.00 $136.33 $92.53 $92.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.20 $134.96 $136.33 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 M8275099/10.S SUP HCPCS A6209 M8275099/10.S - DRSG THK3.3CM LG 26X15CM DRP SENSATRAC PAD PU VAC GFM SLVR BOTH IP/OP $170.41 $126.10 $0.00 $136.33 $92.53 $92.53 $0.00 $0.00 $0.00 $35.52 $126.48 $126.48 $0.00 $0.00 $35.51 $0.00 $100.80 $100.80 $0.00 $85.20 $134.96 $136.33 $0.00 $0.00 $26.67 $0.00 $0.00 $27.13 $0.00 $0.00 $0.00 $0.00 $0.00 M8275099/5 SUP Custom 27203010 DRESSING THK3.3CM LG VAC GFM SLVR BLK 26X15CM M8275099/5 BOTH IP/OP $199.48 $147.62 $0.00 $159.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.74 $157.99 $159.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8275099/5.S SUP Custom 27203010 M8275099/5.S - DRSG THK3.3CM LG 26X15CM DRP SENSATRAC PAD PU VAC GFM SLVR BOTH IP/OP $206.04 $152.47 $0.00 $164.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.92 $152.92 $0.00 $0.00 $42.94 $0.00 $0.00 $0.00 $0.00 $103.02 $163.18 $164.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8730 SUP Custom 27203010 M8730 - SUTURE NONABSORBABLE 8-0 BV130-5 18IN 2 ARM MONOFILAMENT BOTH IP/OP $202.54 $149.88 $0.00 $164.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.32 $150.32 $0.00 $0.00 $42.21 $0.00 $0.00 $0.00 $0.00 $102.79 $162.82 $164.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8747 SUP Custom 27203010 M8747 - SUTURE PRLN 7-0 BV175-8 24IN MFL DBL ARM BLUE NABSB ETM8747 BOTH IP/OP $137.60 $101.82 $0.00 $110.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.80 $108.98 $110.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 M8805 SUP Custom 27203010 SUTURE PRLN 6-0 BV-1 24IN MFL DBL ARM BLUE NABSB ET8805H BOTH IP/OP "$1,166.83 " $863.45 $0.00 $933.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $583.41 $924.13 $933.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC SUP HCPCS V2632 MA30AC - LENS IOL 5 D +1 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.100 SUP HCPCS V2632 MA30AC.100 - LENS IOL 5 D +10 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.105 SUP HCPCS V2632 MA30AC.105 - LENS IOL 5 D +10.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.110 SUP HCPCS V2632 MA30AC.110 - LENS IOL 5 D +11 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.115 SUP HCPCS V2632 MA30AC.115 - LENS IOL 5 D +11.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.120 SUP HCPCS V2632 MA30AC.120 - LENS IOL 5 D +12 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.125 SUP HCPCS V2632 MA30AC.125 - LENS IOL 5 D +12.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.130 SUP HCPCS V2632 MA30AC.130 - LENS IOL 5 D +13 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.135 SUP HCPCS V2632 MA30AC.135 - LENS IOL 5 D +13.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.140 SUP HCPCS V2632 MA30AC.140 - LENS IOL 5 D +14 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.145 SUP HCPCS V2632 MA30AC.145 - LENS IOL 5 D +14.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.150 SUP HCPCS V2632 MA30AC.150 - LENS IOL 5 D +15 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.155 SUP HCPCS V2632 MA30AC.155 - LENS IOL 5 D +15.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.160 SUP HCPCS V2632 MA30AC.160 - LENS IOL 5 D +16 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.165 SUP HCPCS V2632 MA30AC.165 - LENS IOL 5 D +16.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.170 SUP HCPCS V2632 MA30AC.170 - LENS IOL 5 D +17 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.175 SUP HCPCS V2632 MA30AC.175 - LENS IOL 5 D +17.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.180 SUP HCPCS V2632 MA30AC.180 - LENS IOL 5 D +18 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.185 SUP HCPCS V2632 MA30AC.185 - LENS IOL 5 D +18.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.190 SUP HCPCS V2632 MA30AC.190 - LENS IOL 5 D +19 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.195 SUP HCPCS V2632 MA30AC.195 - LENS IOL 5 D +19.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.200 SUP HCPCS V2632 MA30AC.200 - LENS IOL 5 D +20 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.205 SUP HCPCS V2632 MA30AC.205 - LENS IOL 5 D +20.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.210 SUP HCPCS V2632 MA30AC.210 - LENS IOL 5 D +21 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.215 SUP HCPCS V2632 MA30AC.215 - LENS IOL 5 D +21.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.220 SUP HCPCS V2632 MA30AC.220 - LENS IOL 5 D +22 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.225 SUP HCPCS V2632 MA30AC.225 - LENS IOL 5 D +22.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.230 SUP HCPCS V2632 MA30AC.230 - LENS IOL 5 D +23 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.235 SUP HCPCS V2632 MA30AC.235 - LENS IOL 5 D +23.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.240 SUP HCPCS V2632 MA30AC.240 - LENS IOL 5 D +24 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.245 SUP HCPCS V2632 MA30AC.245 - LENS IOL 5 D +24.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.250 SUP HCPCS V2632 MA30AC.250 - LENS IOL 5 D +25 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.255 SUP HCPCS V2632 MA30AC.255 - LENS IOL 5 D +25.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.260 SUP HCPCS V2632 MA30AC.260 - LENS IOL 5 D +26 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.265 SUP HCPCS V2632 MA30AC.265 - LENS IOL 5 D +26.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.270 SUP HCPCS V2632 MA30AC.270 - LENS IOL 5 D +27 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.275 SUP HCPCS V2632 MA30AC.275 - LENS IOL 5 D +27.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.280 SUP HCPCS V2632 MA30AC.280 - LENS IOL 5 D +28 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.285 SUP HCPCS V2632 MA30AC.285 - LENS IOL 5 D +28.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.290 SUP HCPCS V2632 MA30AC.290 - LENS IOL 5 D +29 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.295 SUP HCPCS V2632 MA30AC.295 - LENS IOL 5 D +29.5 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA30AC.300 SUP HCPCS V2632 MA30AC.300 - LENS IOL 5 D +30 DIOP MOD C BCNVX 5.5MM 12.5MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM SUP HCPCS V2632 MA50BM - LENS IOL 10 D +19.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.060 SUP HCPCS V2632 MA50BM.060 - LENS IOL 10 D +6 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.065 SUP HCPCS V2632 MA50BM.065 - LENS IOL 10 D +6.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.070 SUP HCPCS V2632 MA50BM.070 - LENS IOL 10 D +7 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.075 SUP HCPCS V2632 MA50BM.075 - LENS IOL 10 D +7.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.080 SUP HCPCS V2632 MA50BM.080 - LENS IOL 10 D +8 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.085 SUP HCPCS V2632 MA50BM.085 - LENS IOL 10 D +8.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.090 SUP HCPCS V2632 MA50BM.090 - LENS IOL 10 D +9 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.095 SUP HCPCS V2632 MA50BM.095 - LENS IOL 10 D +9.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.100 SUP HCPCS V2632 MA50BM.100 - LENS IOL 10 D +10 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.105 SUP HCPCS V2632 MA50BM.105 - LENS IOL 10 D +10.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.110 SUP HCPCS V2632 MA50BM.110 - LENS IOL 10 D +11 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.115 SUP HCPCS V2632 MA50BM.115 - LENS IOL 10 D +11.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.120 SUP HCPCS V2632 MA50BM.120 - LENS IOL 10 D +12 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.125 SUP HCPCS V2632 MA50BM.125 - LENS IOL 10 D +12.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.130 SUP HCPCS V2632 MA50BM.130 - LENS IOL 10 D +13 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.135 SUP HCPCS V2632 MA50BM.135 - LENS IOL 10 D +13.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.140 SUP HCPCS V2632 MA50BM.140 - LENS IOL 10 D +14 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.145 SUP HCPCS V2632 MA50BM.145 - LENS IOL 10 D +14.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.150 SUP HCPCS V2632 MA50BM.150 - LENS IOL 10 D +15 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.155 SUP HCPCS V2632 MA50BM.155 - LENS IOL 10 D +15.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.160 SUP HCPCS V2632 MA50BM.160 - LENS IOL 10 D +16 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.165 SUP HCPCS V2632 MA50BM.165 - LENS IOL 10 D +16.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.170 SUP HCPCS V2632 MA50BM.170 - LENS IOL 10 D +17 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.175 SUP HCPCS V2632 MA50BM.175 - LENS IOL 10 D +17.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.180 SUP HCPCS V2632 MA50BM.180 - LENS IOL 10 D +18 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.185 SUP HCPCS V2632 MA50BM.185 - LENS IOL 10 D +18.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.190 SUP HCPCS V2632 MA50BM.190 - LENS IOL 10 D +19 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.195 SUP HCPCS V2632 MA50BM.195 - LENS IOL 10 D +19.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.200 SUP HCPCS V2632 MA50BM.200 - LENS IOL 10 D +20 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.205 SUP HCPCS V2632 MA50BM.205 - LENS IOL 10 D +20.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.210 SUP HCPCS V2632 MA50BM.210 - LENS IOL 10 D +21 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.215 SUP HCPCS V2632 MA50BM.215 - LENS IOL 10 D +21.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.220 SUP HCPCS V2632 MA50BM.220 - LENS IOL 10 D +22 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.225 SUP HCPCS V2632 MA50BM.225 - LENS IOL 10 D +22.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.230 SUP HCPCS V2632 MA50BM.230 - LENS IOL 10 D +23 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.235 SUP HCPCS V2632 MA50BM.235 - LENS IOL 10 D +23.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.240 SUP HCPCS V2632 MA50BM.240 - LENS IOL 10 D +24 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.245 SUP HCPCS V2632 MA50BM.245 - LENS IOL 10 D +24.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.250 SUP HCPCS V2632 MA50BM.250 - LENS IOL 10 D +25 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.255 SUP HCPCS V2632 MA50BM.255 - LENS IOL 10 D +25.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.260 SUP HCPCS V2632 MA50BM.260 - LENS IOL 10 D +26 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.265 SUP HCPCS V2632 MA50BM.265 - LENS IOL 10 D +26.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.270 SUP HCPCS V2632 MA50BM.270 - LENS IOL 10 D +27 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.275 SUP HCPCS V2632 MA50BM.275 - LENS IOL 10 D +27.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.280 SUP HCPCS V2632 MA50BM.280 - LENS IOL 10 D +28 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.285 SUP HCPCS V2632 MA50BM.285 - LENS IOL 10 D +28.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.290 SUP HCPCS V2632 MA50BM.290 - LENS IOL 10 D +29 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.295 SUP HCPCS V2632 MA50BM.295 - LENS IOL 10 D +29.5 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA50BM.300 SUP HCPCS V2632 MA50BM.300 - LENS IOL 10 D +30 DIOP MOD C BCNVX 6.5MM 13MM BLU STRL ACRSF BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.060 SUP HCPCS V2630 MA60AC.060 - LENS IOL 10 D +6 DIOPTER BICNVX 6MM 13MM MULTIPIECE FOLDABLE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.065 SUP HCPCS V2632 MA60AC.065 - LENS IOL +6.5 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.070 SUP HCPCS V2632 MA60AC.070 - LENS IOL 10 D +7 DIOPTER BICNVX 6MM 13MM MULTIPIECE FOLDABLE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.075 SUP HCPCS V2632 MA60AC.075 - LENS IOL +7.5 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.080 SUP HCPCS V2632 MA60AC.080 - LENS IOL +8 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD ASYM BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.085 SUP HCPCS V2632 MA60AC.085 - LENS IOL 10 D +8.5 DIOPTER BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.090 SUP HCPCS V2632 MA60AC.090 - LENS IOL 10 D +9 DIOPTER BICNVX 6MM 13MM MULTIPIECE FOLDABLE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.095 SUP HCPCS V2632 MA60AC.095 - LENS IOL 10 D +9.5 DIOPTER BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.100 SUP HCPCS V2632 MA60AC.100 - LENS IOL +10 DIOP 13MM 6MM PSTCHBR BICNVX MLPC FLD ASYM BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.105 SUP HCPCS V2632 MA60AC.105 - LENS IOL +10.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.110 SUP HCPCS V2632 MA60AC.110 - LENS IOL 10 D +11 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.115 SUP HCPCS V2632 MA60AC.115 - LENS IOL +11.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.120 SUP HCPCS V2632 MA60AC.120 - LENS IOL +12 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD ASYM BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.125 SUP HCPCS V2632 MA60AC.125 - LENS IOL +12.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.130 SUP HCPCS V2632 MA60AC.130 - LENS IOL 10 D +13 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.135 SUP HCPCS V2632 MA60AC.135 - LENS IOL +13.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.140 SUP HCPCS V2630 MA60AC.140 - LENS IOL 10 D +14 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.145 SUP HCPCS V2632 MA60AC.145 - LENS IOL +14.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.150 SUP HCPCS V2630 MA60AC.150 - LENS IOL 10 D +15 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.155 SUP HCPCS V2630 MA60AC.155 - LENS IOL +15.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.160 SUP HCPCS V2632 MA60AC.160 - LENS IOL 10 D +16 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.165 SUP HCPCS V2632 MA60AC.165 - LENS IOL +16.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.170 SUP HCPCS V2632 MA60AC.170 - LENS IOL 10 D +17 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.175 SUP HCPCS V2632 MA60AC.175 - LENS IOL +17.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.180 SUP HCPCS V2630 MA60AC.180 - LENS IOL 10 D +18 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.185 SUP HCPCS V2630 MA60AC.185 - LENS IOL +18.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.190 SUP HCPCS V2630 MA60AC.190 - LENS IOL 10 D +19 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.195 SUP HCPCS V2630 MA60AC.195 - LENS IOL +19.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.200 SUP HCPCS V2630 MA60AC.200 - LENS IOL 10 D +20 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.205 SUP HCPCS V2630 MA60AC.205 - LENS IOL +20.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.210 SUP HCPCS V2630 MA60AC.210 - LENS IOL 10 D +21 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.215 SUP HCPCS V2630 MA60AC.215 - LENS IOL +21.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.220 SUP HCPCS V2630 MA60AC.220 - LENS IOL 10 D +22 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.225 SUP HCPCS V2630 MA60AC.225 - LENS IOL +22.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.230 SUP HCPCS V2632 MA60AC.230 - LENS IOL 10 D +23 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.235 SUP HCPCS V2632 MA60AC.235 - LENS IOL +23.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.240 SUP HCPCS V2630 MA60AC.240 - LENS IOL 10 D +24 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.245 SUP HCPCS V2632 MA60AC.245 - LENS IOL 10 D +24.5 DIOPTER BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.250 SUP HCPCS V2632 MA60AC.250 - LENS IOL 10 D +25 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.255 SUP HCPCS V2632 MA60AC.255 - LENS IOL +25.5 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.260 SUP HCPCS V2632 MA60AC.260 - LENS IOL +26 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD ASYM BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.265 SUP HCPCS V2632 MA60AC.265 - LENS IOL 10 D +26.5 DIOPTER BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.270 SUP HCPCS V2632 MA60AC.270 - LENS IOL +27 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD ASYM BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.275 SUP HCPCS V2632 MA60AC.275 - LENS IOL +27.5 DIOPTER 10 D BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.280 SUP HCPCS V2632 MA60AC.280 - LENS IOL +28 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD ASYM BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.285 SUP HCPCS V2632 MA60AC.285 - LENS IOL +28.5 DIOP 10 D 13MM 6MM PSTCHBR BICNVX MLPC FLD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.290 SUP HCPCS V2632 MA60AC.290 - LENS IOL 10 D +29 DIOPTER BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.295 SUP HCPCS V2632 MA60AC.295 - LENS IOL 10 D +29.5 DIOPTER BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60AC.300 SUP HCPCS V2632 MA60AC.300 - LENS IOL 10 D +30 DIOPTER BICNVX 6MM 13MM MULTIPIECE BOTH IP/OP $372.50 $275.65 $0.00 $298.00 $167.63 $167.63 $0.00 $0.00 $0.00 $77.64 $276.47 $276.47 $0.00 $0.00 $77.63 $0.00 $220.33 $220.33 $0.00 $186.25 $295.02 $298.00 $0.00 $0.00 $58.30 $0.00 $0.00 $59.30 $0.00 $0.00 $0.00 $0.00 $0.00 MA60MA.000 SUP HCPCS V2632 MA60MA.000 - LENS IOL 5 D +0 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF XPD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60MA.010 SUP HCPCS V2632 MA60MA.010 - LENS IOL 5 D +1 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF XPD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60MA.030 SUP HCPCS V2632 MA60MA.030 - INTRAOUCLAR LENS MA60MA 3.0D BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60MAN010 SUP HCPCS V2632 MA60MAN010 - LENS IOL 5 D -1 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF XPD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60MAN020 SUP HCPCS V2632 MA60MAN020 - LENS IOL 5 D -2 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF XPD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60MAN030 SUP HCPCS V2632 MA60MAN030 - LENS IOL 5 D -3 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF XPD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60MAN040 SUP HCPCS V2632 MA60MAN040 - LENS IOL 5 D -4 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF XPD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MA60MAN050 SUP HCPCS V2632 MA60MAN050 - LENS IOL 5 D -5 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF XPD BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 MAJ-210 SUP Custom 27203010 VALVE BIOP BSCP NOMENCLATURE DISP BOTH IP/OP $166.85 $123.47 $0.00 $133.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.84 $123.84 $0.00 $0.00 $34.77 $0.00 $0.00 $0.00 $0.00 $83.43 $132.15 $133.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MAL-0002 SUP Custom 27803010 MAL-0002 - EXPANDER OPHTHALMIC 7MM SAVES CONSIDERABLE TIME DISPOSABLE BOTH IP/OP "$1,937.50 " "$1,433.75" $0.00 "$1,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,438.01" "$1,438.01" $0.00 $0.00 $403.78 $0.00 $0.00 $0.00 $0.00 $968.75 "$1,534.50" "$1,550.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MAP111 SUP HCPCS C1725 MAP111 - VALVE HEMOSTASIS 9FR MAP INSERTION TOOL ACCES-9 METAL BOTH IP/OP $33.25 $24.61 $0.00 $26.60 $18.05 $18.05 $0.00 $0.00 $0.00 $6.93 $24.68 $24.68 $0.00 $0.00 $6.93 $0.00 $19.67 $19.67 $0.00 $16.63 $26.33 $26.60 $0.00 $0.00 $5.20 $0.00 $0.00 $5.29 $0.00 $0.00 $0.00 $0.00 $0.00 MAP500 SUP HCPCS C1769 MAP500 - DEVICE TORQUE LATEX FREE PIN VISE SALMON PTFE HYDPHI ACCEPTS BOTH IP/OP $0.44 $0.33 $0.00 $0.36 $0.24 $0.24 $0.00 $0.00 $0.00 $0.09 $0.33 $0.33 $0.00 $0.00 $0.09 $0.00 $0.26 $0.26 $0.00 $0.22 $0.35 $0.36 $0.00 $0.00 $0.07 $0.00 $0.00 $0.07 $0.00 $0.00 $0.00 $0.00 $0.00 MAXA SUP Custom 27203010 SENSOR ADLT OXMX OXM ADH STRAP CBL LF DISP 18IN BOTH IP/OP $34.93 $25.85 $0.00 $27.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.46 $27.66 $27.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MAXIICRTDMMAM SUP HCPCS C1882 MAXIICRTDMMAM - MAXIMO II CRT-D ADVANCED SYSTEM BOTH IP/OP "$60,500.00 " "$44,770.00" $0.00 "$48,400.00" "$27,225.00" "$27,225.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$12,608.20" $0.00 "$29,826.50" "$29,826.50" $0.00 "$30,250.00" "$47,916.00" "$48,400.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 MAXIIDRMMEM SUP HCPCS C1882 MAXIIDRMMEM - MAXIMO II DR SYSTEM BOTH IP/OP "$49,812.50 " "$36,861.25" $0.00 "$39,850.00" "$22,415.63" "$22,415.63" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,380.93" $0.00 "$24,557.56" "$24,557.56" $0.00 "$24,906.25" "$39,451.50" "$39,850.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,930.15" $0.00 $0.00 $0.00 $0.00 $0.00 MAXIIVREMEM SUP HCPCS C1882 MAXIIVREMEM - MAXIMO II VR SYSTEM BOTH IP/OP "$43,750.00 " "$32,375.00" $0.00 "$35,000.00" "$19,687.50" "$19,687.50" $0.00 $0.00 $0.00 "$9,118.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,117.50" $0.00 "$21,568.75" "$21,568.75" $0.00 "$21,875.00" "$34,650.00" "$35,000.00" $0.00 $0.00 "$6,846.88" $0.00 $0.00 "$6,965.00" $0.00 $0.00 $0.00 $0.00 $0.00 MAX-N SUP Custom 27203010 SENSOR NEO 18IN OXM ADH SPO2 BOTH IP/OP $30.80 $22.79 $0.00 $24.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.40 $24.39 $24.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MAX-P SUP Custom 27203010 SENSOR PED OXMX OXM ADH STRAP CBL LF DISP 18IN BOTH IP/OP $34.93 $25.85 $0.00 $27.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.46 $27.66 $27.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MAXR SUP Custom 27203010 CABLE SENSOR PULSE OXIMETRY DISPOSABLE ADULT NASAL 18IN F/O BOTH IP/OP $30.80 $22.79 $0.00 $24.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.40 $24.39 $24.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MAXX-1915 SUP HCPCS C1874 MAXX-1915 - STENT ESPH 19MM 24FR 150MM 90CM ENDOMAXX OTW FLLY COVERED BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,458.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 "$3,451.00" "$3,451.00" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 MAXX-197 SUP HCPCS C1874 MAXX-197 - STENT ESPH 19MM 24MM 70MM ENDOMAXX FLLY COVERED BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,458.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 "$3,451.00" "$3,451.00" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 MAXX-2310 SUP HCPCS C1874 MAXX-2310 - STENT ESOPHAGEAL 23MM 24FR 90CM 100CM FULLY COVERED OTW LP BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,458.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 "$3,451.00" "$3,451.00" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 MAXX-237 SUP HCPCS C1874 MAXX-237 - STENT ESPH 28MM 23MM 24FR 70MM 90CM ENDOMAXX OTW FLLY CVR BOTH IP/OP "$7,000.00 " "$5,180.00" $0.00 "$4,600.00" "$2,587.50" "$2,587.50" $0.00 $0.00 $0.00 "$1,458.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,458.80" $0.00 "$3,451.00" "$3,451.00" $0.00 "$2,875.00" "$4,554.00" "$4,600.00" $0.00 $0.00 $899.88 $0.00 $0.00 $915.40 $0.00 $0.00 $0.00 $0.00 $0.00 MB3555 SUP HCPCS C1713 MB3555 - DISC INTVRTB 15MM 15X5MM STRL MOBI-C FLT SPHRCL PLT MBL INS BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 MB3556 SUP HCPCS C1713 MB3556 - DISC INTVRTB 15MM 15X6MM STRL MOBI-C FLT SPHRCL PLT MBL INS BOTH IP/OP "$13,750.00 " "$10,175.00" $0.00 "$11,000.00" "$6,187.50" "$6,187.50" $0.00 $0.00 $0.00 "$2,865.84" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,865.50" $0.00 "$6,778.75" "$6,778.75" $0.00 "$6,875.00" "$10,890.00" "$11,000.00" $0.00 $0.00 "$2,151.88" $0.00 $0.00 "$2,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 MB3575 SUP HCPCS C1713 MB3575 - DISC INTVRTB 15MM 17X5MM STRL MOBI-C FLT SPHRCL PLT MBL INS BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 MB3595 SUP HCPCS C1713 MB3595 - DISC INTVRTB 15MM 19X5MM STRL MOBI-C FLT SPHRCL PLT MBL INS BOTH IP/OP "$11,250.00 " "$8,325.00" $0.00 "$9,000.00" "$5,062.50" "$5,062.50" $0.00 $0.00 $0.00 "$2,344.78" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,344.50" $0.00 "$5,546.25" "$5,546.25" $0.00 "$5,625.00" "$8,910.00" "$9,000.00" $0.00 $0.00 "$1,760.63" $0.00 $0.00 "$1,791.00" $0.00 $0.00 $0.00 $0.00 $0.00 MB46G SUP Custom 27203010 MB46G - SUTURE NONABSORBABLE 5 V-40 30IN 4 STRAND BRAID ETHIBOND BOTH IP/OP $45.35 $33.56 $0.00 $36.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.66 $33.66 $0.00 $0.00 $9.45 $0.00 $0.00 $0.00 $0.00 $23.02 $36.46 $36.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MC*PE28131YB SUP HCPCS C1725 MC*PE28131YB - CATH INTVN .021IN 2.8FR .027IN 130CM MCTH HYDPHI PROGREAT BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,080.00" $705.90 $705.90 $0.00 $0.00 $0.00 $291.80 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $828.10 $828.10 $0.00 $675.00 "$1,069.20" "$1,080.00" $0.00 $0.00 $211.28 $0.00 $0.00 $214.92 $0.00 $0.00 $0.00 $0.00 $0.00 MC011502 SUP HCPCS C1751 MC011502 - CATHETER TRIPLE LUMEN SIZE 20 BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 MC011503 SUP HCPCS C1751 MC011503 - CATHETER CV 24CM 3 LUM BOTH IP/OP $287.50 $212.75 $0.00 $230.00 $129.38 $129.38 $0.00 $0.00 $0.00 $59.92 $213.38 $213.38 $0.00 $0.00 $59.92 $0.00 $170.06 $170.06 $0.00 $143.75 $227.70 $230.00 $0.00 $0.00 $44.99 $0.00 $0.00 $45.77 $0.00 $0.00 $0.00 $0.00 $0.00 MC011505 SUP HCPCS C1750 MC011505 - SET CATH 15.5FR 32CM 3 LUM BSC GW DIL SCPL HMDIAL BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 MC061402 SUP HCPCS C1752 MC061402 - SET CATH 14FR 15CM SLX 2 LUM BSC INTRO NDL GW DIL BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MC061404 SUP HCPCS C1752 MC061404 - SET CATH 14FR 24CM SLX 2 LUM BSC INTRO NDL GW DIL BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MC061405 SUP HCPCS C1751 MC061405 - SET CATH 14FR 30CM SLX 2 LUM BSC STY INTRO NDL DIL BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 MC-125 SUP Custom 27203010 FILTER BCTR/VIR DISP BOTH IP/OP $6.20 $4.59 $0.00 $4.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.10 $4.91 $4.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MC172150SX SUP HCPCS C1725 MC172150SX - CATHETER BLNOCC MIC STRG 2.4-1.7FR .017IN 150CM HEADWAY SMTH BOTH IP/OP "$1,911.55 " "$1,414.55" $0.00 "$1,529.24" "$1,037.97" "$1,037.97" $0.00 $0.00 $0.00 $398.41 "$1,418.75" "$1,418.75" $0.00 $0.00 $398.37 $0.00 "$1,130.68" "$1,130.68" $0.00 $955.78 "$1,513.95" "$1,529.24" $0.00 $0.00 $299.16 $0.00 $0.00 $304.32 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.100 SUP HCPCS V2632 MC40BD.100 - LENS IOL 5 D +10 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.105 SUP HCPCS V2632 MC40BD.105 - LENS IOL 5 D +10.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.110 SUP HCPCS V2632 MC40BD.110 - LENS IOL 5 D +11 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.115 SUP HCPCS V2632 MC40BD.115 - LENS IOL 5 D +11.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.120 SUP HCPCS V2632 MC40BD.120 - LENS IOL 5 D +12 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.125 SUP HCPCS V2632 MC40BD.125 - LENS IOL 5 D +12.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.130 SUP HCPCS V2632 MC40BD.130 - LENS IOL 5 D +13 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.135 SUP HCPCS V2632 MC40BD.135 - LENS IOL 5 D +13.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.140 SUP HCPCS V2632 MC40BD.140 - LENS IOL 5 D +14 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.145 SUP HCPCS V2632 MC40BD.145 - LENS IOL 5 D +14.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.150 SUP HCPCS V2632 MC40BD.150 - LENS IOL 5 D +15 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.155 SUP HCPCS V2632 MC40BD.155 - LENS IOL 5 D +15.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.160 SUP HCPCS V2632 MC40BD.160 - LENS IOL 5 D +16 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.165 SUP HCPCS V2632 MC40BD.165 - LENS IOL 5 D +16.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.170 SUP HCPCS V2632 MC40BD.170 - LENS IOL 5 D +17 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.175 SUP HCPCS V2632 MC40BD.175 - LENS IOL 5 D +17.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.180 SUP HCPCS V2632 MC40BD.180 - LENS IOL 5 D +18 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.185 SUP HCPCS V2632 MC40BD.185 - LENS IOL 5 D +18.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.190 SUP HCPCS V2632 MC40BD.190 - LENS IOL 5 D +19 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.195 SUP HCPCS V2632 MC40BD.195 - LENS IOL 5 D +19.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.200 SUP HCPCS V2632 MC40BD.200 - LENS IOL 5 D +20 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.205 SUP HCPCS V2632 MC40BD.205 - LENS IOL 5 D +20.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.210 SUP HCPCS V2632 MC40BD.210 - LENS IOL 5 D +21 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.215 SUP HCPCS V2632 MC40BD.215 - LENS IOL 5 D +21.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.220 SUP HCPCS V2632 MC40BD.220 - LENS IOL 5 D +22 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.225 SUP HCPCS V2632 MC40BD.225 - LENS IOL 5 D +22.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.230 SUP HCPCS V2632 MC40BD.230 - LENS IOL 5 D +23 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.235 SUP HCPCS V2632 MC40BD.235 - LENS IOL 5 D +23.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.240 SUP HCPCS V2632 MC40BD.240 - LENS IOL 5 D +24 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.245 SUP HCPCS V2632 MC40BD.245 - LENS IOL 5 D +24.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.250 SUP HCPCS V2632 MC40BD.250 - LENS IOL 5 D +25 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.255 SUP HCPCS V2632 MC40BD.255 - LENS IOL 5 D +25.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.260 SUP HCPCS V2632 MC40BD.260 - LENS IOL 5 D +26 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.265 SUP HCPCS V2632 MC40BD.265 - LENS IOL 5 D +26.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.270 SUP HCPCS V2632 MC40BD.270 - LENS IOL 5 D +27 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.275 SUP HCPCS V2632 MC40BD.275 - LENS IOL 5 D +27.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.280 SUP HCPCS V2632 MC40BD.280 - LENS IOL 5 D +28 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.285 SUP HCPCS V2632 MC40BD.285 - LENS IOL 5 D +28.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.290 SUP HCPCS V2632 MC40BD.290 - LENS IOL 5 D +29 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.295 SUP HCPCS V2632 MC40BD.295 - LENS IOL 5 D +29.5 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC40BD.300 SUP HCPCS V2632 MC40BD.300 - LENS IOL 5 D +30 DIOP BCNVX 5MM 12.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD SUP HCPCS V2632 MC50BD - LENS IOL 5 D +17 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.100 SUP HCPCS V2632 MC50BD.100 - LENS IOL 5 D +10 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.110 SUP HCPCS V2632 MC50BD.110 - LENS IOL 5 D +11 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.120 SUP HCPCS V2632 MC50BD.120 - LENS IOL 5 D +12 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.130 SUP HCPCS V2632 MC50BD.130 - LENS IOL 5 D +13 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.140 SUP HCPCS V2632 MC50BD.140 - LENS IOL 5 D +14 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.150 SUP HCPCS V2632 MC50BD.150 - LENS IOL 5 D +15 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.160 SUP HCPCS V2632 MC50BD.160 - LENS IOL 5 D +16 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.170 SUP HCPCS V2632 MC50BD.170 - LENS IOL 5 D +17 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.180 SUP HCPCS V2632 MC50BD.180 - LENS IOL 5 D +18 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.190 SUP HCPCS V2632 MC50BD.190 - LENS IOL 5 D +19 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.200 SUP HCPCS V2632 MC50BD.200 - LENS IOL 5 D +20 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.210 SUP HCPCS V2632 MC50BD.210 - LENS IOL 5 D +21 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.220 SUP HCPCS V2632 MC50BD.220 - LENS IOL 5 D +22 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.230 SUP HCPCS V2632 MC50BD.230 - LENS IOL 5 D +23 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.240 SUP HCPCS V2632 MC50BD.240 - LENS IOL 5 D +24 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.250 SUP HCPCS V2632 MC50BD.250 - LENS IOL 5 D +25 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.260 SUP HCPCS V2632 MC50BD.260 - LENS IOL 5 D +26 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.270 SUP HCPCS V2632 MC50BD.270 - LENS IOL 5 D +27 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.280 SUP HCPCS V2632 MC50BD.280 - LENS IOL 5 D +28 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.285 SUP HCPCS V2632 MC50BD.285 - LENS IOL 5 D +28.5 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.290 SUP HCPCS V2632 MC50BD.290 - LENS IOL 5 D +29 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC50BD.295 SUP HCPCS V2632 MC50BD.295 - LENS IOL 5 D +29.5 DIOP MOD C BCNVX 6.5MM 13.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD SUP HCPCS V2632 MC60BD - LENS IOL 5D BCNVX 6MM 13.5MM STRL SLANT 1 PC UV ABS PMMA PC BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.100 SUP HCPCS V2632 MC60BD.100 - LENS IOL 5 D +10 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.105 SUP HCPCS V2632 MC60BD.105 - LENS IOL 5 D +10.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.110 SUP HCPCS V2632 MC60BD.110 - LENS IOL 5 D +11 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.115 SUP HCPCS V2632 MC60BD.115 - LENS IOL 5 D +11.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.120 SUP HCPCS V2632 MC60BD.120 - LENS IOL 5 D +12 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.125 SUP HCPCS V2632 MC60BD.125 - LENS IOL 5 D +12.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.130 SUP HCPCS V2632 MC60BD.130 - LENS IOL 5 D +13 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.135 SUP HCPCS V2632 MC60BD.135 - LENS IOL 5 D +13.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.140 SUP HCPCS V2632 MC60BD.140 - LENS IOL 5 D +14 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.145 SUP HCPCS V2632 MC60BD.145 - LENS IOL 5 D +14.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.150 SUP HCPCS V2632 MC60BD.150 - LENS IOL 5 D +15 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.155 SUP HCPCS V2632 MC60BD.155 - LENS IOL 5 D +15.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.160 SUP HCPCS V2632 MC60BD.160 - LENS IOL 5 D +16 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.165 SUP HCPCS V2632 MC60BD.165 - LENS IOL 5 D +16.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.170 SUP HCPCS V2632 MC60BD.170 - LENS IOL 5 D +17 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.175 SUP HCPCS V2632 MC60BD.175 - LENS IOL 5 D +17.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.180 SUP HCPCS V2632 MC60BD.180 - LENS IOL 5 D +18 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.185 SUP HCPCS V2632 MC60BD.185 - LENS IOL 5 D +18.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.190 SUP HCPCS V2632 MC60BD.190 - LENS IOL 5 D +19 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.195 SUP HCPCS V2632 MC60BD.195 - LENS IOL 5 D +19.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.200 SUP HCPCS V2632 MC60BD.200 - LENS IOL 5 D +20 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.205 SUP HCPCS V2632 MC60BD.205 - LENS IOL 5 D +20.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.210 SUP HCPCS V2632 MC60BD.210 - LENS IOL 5 D +21 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.215 SUP HCPCS V2632 MC60BD.215 - LENS IOL 5 D +21.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.220 SUP HCPCS V2632 MC60BD.220 - LENS IOL 5 D +22 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.225 SUP HCPCS V2632 MC60BD.225 - LENS IOL 5 D +22.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.230 SUP HCPCS V2632 MC60BD.230 - LENS IOL 5 D +23 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.235 SUP HCPCS V2632 MC60BD.235 - LENS IOL 5 D +23.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.240 SUP HCPCS V2632 MC60BD.240 - LENS IOL 5 D +24 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.245 SUP HCPCS V2632 MC60BD.245 - LENS IOL 5 D +24.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.250 SUP HCPCS V2632 MC60BD.250 - LENS IOL 5 D +25 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.255 SUP HCPCS V2632 MC60BD.255 - LENS IOL 5 D +25.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.260 SUP HCPCS V2632 MC60BD.260 - LENS IOL 5 D +26 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.265 SUP HCPCS V2632 MC60BD.265 - LENS IOL 5 D +26.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.270 SUP HCPCS V2632 MC60BD.270 - LENS IOL 5 D +27 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.275 SUP HCPCS V2632 MC60BD.275 - LENS IOL 5 D +27.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.280 SUP HCPCS V2632 MC60BD.280 - LENS IOL 5 D +28 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.285 SUP HCPCS V2632 MC60BD.285 - LENS IOL 5 D +28.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.290 SUP HCPCS V2632 MC60BD.290 - LENS IOL 5 D +29 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.295 SUP HCPCS V2632 MC60BD.295 - LENS IOL 5 D +29.5 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MC60BD.300 SUP HCPCS V2632 MC60BD.300 - LENS IOL 5 D +30 DIOP BCNVX 6MM 13.5MM STRL SLANT 1 PC UV BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MCEN133 SUP Custom 27203010 ELEVATOR SURG 11CM 2MM 2.5MM WORMALD BLNT SCT MLBL FRNTL SIN BOTH IP/OP "$1,332.50 " $986.05 $0.00 "$1,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $666.25 "$1,055.34" "$1,066.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MCPE28131YB SUP HCPCS C1725 MCPE28131YB - CATHETER INTERVENTIONAL MICRO 2.8FR .027IN 130CM MARKER BAND BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,040.00" $705.90 $705.90 $0.00 $0.00 $0.00 $291.80 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $828.10 $828.10 $0.00 $650.00 "$1,029.60" "$1,040.00" $0.00 $0.00 $203.45 $0.00 $0.00 $206.96 $0.00 $0.00 $0.00 $0.00 $0.00 MCR-0007 SUP Custom 27203010 MCR-0007 - RETRACTOR SRG STRL MST CPSL RTRCTR BOTH IP/OP $283.33 $209.66 $0.00 $226.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.29 $210.29 $0.00 $0.00 $59.05 $0.00 $0.00 $0.00 $0.00 $141.67 $224.40 $226.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MCSK3 SUP Custom 27203010 HOOK 152MM RTRCT VRT MLBL KNDY BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MCSK5 SUP Custom 27203010 TIP SCT MCFR KN 6FR MLBL BOTH IP/OP $380.00 $281.20 $0.00 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.00 $300.96 $304.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MD800F SUP HCPCS C1880 MD800F - FILTER CARDIO MRDN VC FEM DLV KIT BOTH IP/OP "$4,151.00 " "$3,071.74" $0.00 "$3,320.80" "$1,867.95" "$1,867.95" $0.00 $0.00 $0.00 $865.17 "$3,080.87" "$3,080.87" $0.00 $0.00 $865.07 $0.00 "$2,046.44" "$2,046.44" $0.00 "$2,075.50" "$3,287.59" "$3,320.80" $0.00 $0.00 $649.63 $0.00 $0.00 $660.84 $0.00 $0.00 $0.00 $0.00 $0.00 MD800J SUP HCPCS C1880 MD800J - FILTER CARDIO MRDN VC JUG DLV KIT BOTH IP/OP "$4,151.00 " "$3,071.74" $0.00 "$3,320.80" "$1,867.95" "$1,867.95" $0.00 $0.00 $0.00 $865.17 "$3,080.87" "$3,080.87" $0.00 $0.00 $865.07 $0.00 "$2,046.44" "$2,046.44" $0.00 "$2,075.50" "$3,287.59" "$3,320.80" $0.00 $0.00 $649.63 $0.00 $0.00 $660.84 $0.00 $0.00 $0.00 $0.00 $0.00 MDRT4101 SUP HCPCS Q4105 MDRT4101 - GRAFT SKIN 10X4IN MESHED DERMAL REGENERATION TEMPLATE BOVINE BOTH IP/OP "$17,768.95 " "$13,149.02" $0.00 "$16,153.60" "$9,086.40" "$9,086.40" $0.00 $0.00 $0.00 "$3,703.49" "$13,188.11" "$13,188.11" $0.00 $0.00 $25.37 $0.00 "$8,760.09" "$8,760.09" $0.00 "$10,096.00" "$15,992.06" "$16,153.60" $0.00 $0.00 $24.15 $0.00 $0.00 "$3,214.57" $0.00 $0.00 $0.00 $0.00 $0.00 MDRT8101 SUP HCPCS Q4105 MDRT8101 - GRAFT SKIN 25X20CM MESH DERMAL REGENERATION TEMPLATE BOTH IP/OP "$28,137.80 " "$20,821.97" $0.00 "$25,579.82" "$14,388.65" "$14,388.65" $0.00 $0.00 $0.00 "$5,864.62" "$20,883.88" "$20,883.88" $0.00 $0.00 $25.37 $0.00 "$13,871.94" "$13,871.94" $0.00 "$15,987.39" "$25,324.03" "$25,579.82" $0.00 $0.00 $24.15 $0.00 $0.00 "$5,090.38" $0.00 $0.00 $0.00 $0.00 $0.00 MH443 SUP Custom 27011340 MH443 - VALVE SCT RED BTN EVIS 140 VID IMG SYS STRL DISP BOTH IP/OP $183.78 $136.00 $0.00 $147.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.40 $136.40 $0.00 $0.00 $38.30 $0.00 $0.00 $0.00 $0.00 $91.89 $145.55 $147.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MHC1434 SUP Custom 27203010 RETAINER TBGRP E 10MR NTR DRSG BOTH IP/OP $93.33 $69.06 $0.00 $74.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.66 $73.92 $74.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MHC1439 SUP Custom 27203010 RETAINER TBGRP G 10MR NTR DRSG STRL BOTH IP/OP $117.60 $87.02 $0.00 $94.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.80 $93.14 $94.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MIS-7F11 SUP HCPCS C1894 MIS-7F11 - SET INTROD .018IN MICRO STR 7FR 21GA 11CM 2.75IN 1 END GWIRE BOTH IP/OP $152.50 $112.85 $0.00 $122.00 $82.81 $82.81 $0.00 $0.00 $0.00 $31.78 $113.19 $113.19 $0.00 $0.00 $31.78 $0.00 $90.20 $90.20 $0.00 $76.25 $120.78 $122.00 $0.00 $0.00 $23.87 $0.00 $0.00 $24.28 $0.00 $0.00 $0.00 $0.00 $0.00 MMSLED-42 SUP HCPCS C1713 MMSLED-42 - WIRE FIX 42MM SLED MEDIAL MALLEOLAR BOTH IP/OP "$1,887.50 " "$1,396.75" $0.00 "$1,510.00" $849.38 $849.38 $0.00 $0.00 $0.00 $393.40 "$1,400.90" "$1,400.90" $0.00 $0.00 $393.36 $0.00 "$1,116.46" "$1,116.46" $0.00 $943.75 "$1,494.90" "$1,510.00" $0.00 $0.00 $295.39 $0.00 $0.00 $300.49 $0.00 $0.00 $0.00 $0.00 $0.00 MMSLEDW SUP HCPCS C1713 MMSLEDW - WASHER ORTHOPEDIC SLED MEDIAL MALLEOLAR BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $185.63 $185.63 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.060 SUP HCPCS V2632 MN60AC.060 - LENS IOL 10 D +6 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.065 SUP HCPCS V2632 MN60AC.065 - LENS IOL 10 D +6.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.075 SUP HCPCS V2632 MN60AC.075 - LENS IOL 10 D +7.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.085 SUP HCPCS V2632 MN60AC.085 - LENS IOL 10 D +8.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.095 SUP HCPCS V2632 MN60AC.095 - LENS IOL 10 D +9.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.100 SUP HCPCS V2632 MN60AC.100 - LENS IOL 10 D +10 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.105 SUP HCPCS V2632 MN60AC.105 - LENS IOL 10 D +10.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.110 SUP HCPCS V2632 MN60AC.110 - LENS IOL 10 D +11 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.115 SUP HCPCS V2632 MN60AC.115 - LENS IOL 10 D +11.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.120 SUP HCPCS V2632 MN60AC.120 - LENS IOL 10 D +12 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.125 SUP HCPCS V2632 MN60AC.125 - LENS IOL 10 D +12.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.130 SUP HCPCS V2632 MN60AC.130 - LENS IOL 10 D +13 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.135 SUP HCPCS V2632 MN60AC.135 - LENS IOL 10 D +13.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.140 SUP HCPCS V2632 MN60AC.140 - LENS IOL 10 D +14 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.145 SUP HCPCS V2632 MN60AC.145 - LENS IOL 10 D +14.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.150 SUP HCPCS V2632 MN60AC.150 - LENS IOL 10 D +15 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.155 SUP HCPCS V2632 MN60AC.155 - LENS IOL 10 D +15.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.160 SUP HCPCS V2632 MN60AC.160 - LENS IOL 10 D +16 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.165 SUP HCPCS V2632 MN60AC.165 - LENS IOL 10 D +16.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.170 SUP HCPCS V2632 MN60AC.170 - LENS IOL 10 D +17 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.175 SUP HCPCS V2632 MN60AC.175 - LENS IOL 10 D +17.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.180 SUP HCPCS V2632 MN60AC.180 - LENS IOL 10 D +18 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.185 SUP HCPCS V2632 MN60AC.185 - LENS IOL 10 D +18.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.190 SUP HCPCS V2632 MN60AC.190 - LENS IOL 10 D +19 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.195 SUP HCPCS V2632 MN60AC.195 - LENS IOL 10 D +19.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.200 SUP HCPCS V2632 MN60AC.200 - LENS IOL 10 D +20 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.205 SUP HCPCS V2632 MN60AC.205 - LENS IOL 10 D +20.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.210 SUP HCPCS V2632 MN60AC.210 - LENS IOL 10 D +21 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.215 SUP HCPCS V2632 MN60AC.215 - LENS IOL 10 D +21.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.220 SUP HCPCS V2632 MN60AC.220 - LENS IOL 10 D +22 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.225 SUP HCPCS V2632 MN60AC.225 - LENS IOL 10 D +22.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.230 SUP HCPCS V2632 MN60AC.230 - LENS IOL 10 D +23 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.235 SUP HCPCS V2632 MN60AC.235 - LENS IOL 10 D +23.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.240 SUP HCPCS V2632 MN60AC.240 - LENS IOL 10 D +24 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.245 SUP HCPCS V2632 MN60AC.245 - LENS IOL 10 D +24.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.250 SUP HCPCS V2632 MN60AC.250 - LENS IOL 10 D +25 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.255 SUP HCPCS V2632 MN60AC.255 - LENS IOL 10 D +25.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.260 SUP HCPCS V2632 MN60AC.260 - LENS IOL 10 D +26 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.265 SUP HCPCS V2632 MN60AC.265 - LENS IOL 10 D +26.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.270 SUP HCPCS V2632 MN60AC.270 - LENS IOL 10 D +27 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.275 SUP HCPCS V2632 MN60AC.275 - LENS IOL 10 D +27.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.280 SUP HCPCS V2632 MN60AC.280 - LENS IOL 10 D +28 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.285 SUP HCPCS V2632 MN60AC.285 - LENS IOL 10 D +28.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.290 SUP HCPCS V2632 MN60AC.290 - LENS IOL 10 D +29 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.295 SUP HCPCS V2632 MN60AC.295 - LENS IOL 10 D +29.5 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60AC.300 SUP HCPCS V2632 MN60AC.300 - LENS IOL 10 D +30 DIOP MOD C BCNVX 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MA.000 SUP HCPCS V2632 MN60MA.000 - LENS IOL 5 D +0 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MA.010 SUP HCPCS V2632 MN60MA.010 - LENS IOL 5 D +1 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MA.030 SUP HCPCS V2632 MN60MA.030 - LENS IOL 5 D +30 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MA.040 SUP HCPCS V2632 MN60MA.040 - LENS IOL 5 D +4 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MA.050 SUP HCPCS V2632 MN60MA.050 - LENS IOL 5 D +5 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MAN010 SUP HCPCS V2632 MN60MAN010 - LENS IOL 5 D -1 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MAN020 SUP HCPCS V2632 MN60MAN020 - LENS IOL 5 D -2 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MAN030 SUP HCPCS V2632 MN60MAN030 - LENS IOL 5 D -3 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MAN040 SUP HCPCS V2632 MN60MAN040 - LENS IOL 5 D -4 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MN60MAN050 SUP HCPCS V2632 MN60MAN050 - LENS IOL 5 D -5 DIOP MOD C MNSCS 6MM 13MM BLU STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 MPIS-501-NT-SST SUP HCPCS C1894 MPIS-501-NT-SST - SET INTROD 40CM 5FR MPNCH .018IN NTNL GWIRE 10CM VLNK STRL BOTH IP/OP $47.50 $35.15 $0.00 $38.00 $25.79 $25.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $7.43 $0.00 $0.00 $7.56 $0.00 $0.00 $0.00 $0.00 $0.00 MPQ-2.5 SUP HCPCS L8603 MPQ-2.5 - AGENT BULKING MACROPLASTIQUE SILICONE ELASTOMER 2.5 ML BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MR17035101 SUP HCPCS C1751 MR17035101 - SET CATHETER 5FR 60CM 1 LUMEN PICC BASIC GWIRE INTROD NEEDLE BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 MR17035201 SUP HCPCS C1751 MR17035201 - SET CATHETER 5FR 55CM PICC 2 LUMEN BASIC GWIRE INTROD NEEDLE BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 MRCT15004M SUP HCPCS C1750 MRCT15004M - 5F MINI ATTACHABLE CATHETER BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 MRDP50ASN SUP HCPCS C1750 MRDP50ASN - 5F MINI ATTACHABLE CATHETER BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 MRDP66AMN SUP HCPCS C1788 MRDP66AMN - 6.6F DIGNITY PORT BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 MRN-420 SUP HCPCS L8606 MRN-420 - NEEDLE ESCP 3.8FR MACROPLASTIQUE URTH BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MRPP80AFS SUP HCPCS C1751 MRPP80AFS - CATHETER CENTRAL VENOUS PRO-FUSE TRINIFLEX OD8 FR ATTACHABLE BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $225.00 $225.00 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 MS DC5020 SUP Custom 27203010 MS DC5020 - BIT DRILL 5IN 2MM QRLSE STRL BOTH IP/OP $66.30 $49.06 $0.00 $53.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.21 $49.21 $0.00 $0.00 $13.82 $0.00 $0.00 $0.00 $0.00 $33.15 $52.51 $53.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS03 SUP Custom 27203010 MS03 - STOCKINETTE CAST 25YDX3IN WATER REPELLENT 3M SYNTH BOTH IP/OP $24.00 $17.76 $0.00 $42.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.81 $17.81 $0.00 $0.00 $5.00 $0.00 $0.00 $0.00 $0.00 $13.68 $42.49 $21.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-1106ST SUP HCPCS C1769 MS-1106ST - WIRE FIX .045IN KWIRE BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $3.65 $12.99 $12.99 $0.00 $0.00 $3.65 $0.00 $10.35 $10.35 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 MS-2213 SUP Custom 27203010 MS-2213 - TIP SCRDRVR CRCIFRM BOTH IP/OP $470.00 $347.80 $0.00 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.83 $348.83 $0.00 $0.00 $97.95 $0.00 $0.00 $0.00 $0.00 $235.00 $372.24 $376.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSC9023Z SUP HCPCS A6196 MSC9023Z - DRESSING GRMCDL 3.125X2.375IN LF ARGLS ANMC FLM TRNS IONIC BOTH IP/OP $26.69 $19.75 $0.00 $21.35 $14.49 $14.49 $0.00 $0.00 $0.00 $0.00 $19.81 $19.81 $0.00 $0.00 $5.56 $0.00 $0.00 $0.00 $0.00 $13.35 $21.14 $21.35 $0.00 $0.00 $4.18 $0.00 $0.00 $4.25 $0.00 $0.00 $0.00 $0.00 $0.00 MSC97310 SUP Custom 27203010 MSC97310 - DRESSING FOAM 10X3.5IN GENTLE POSTOPERATIVE STRIP BOTH IP/OP $58.60 $43.36 $0.00 $46.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.49 $43.49 $0.00 $0.00 $12.21 $0.00 $0.00 $0.00 $0.00 $29.30 $46.41 $46.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSC9736 SUP Custom 27203010 MSC9736 - DRESSING FOAM 6X3.5IN 7 DAY ADHESIVE ANTIMICROBIAL FLEXIBLE BOTH IP/OP $45.48 $33.66 $0.00 $50.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.75 $33.75 $0.00 $0.00 $9.48 $0.00 $0.00 $0.00 $0.00 $22.74 $50.59 $36.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-CT21 SUP Custom 27203010 MS-CT21 - TAP 2.1MM SURG BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-CT27 SUP Custom 27203010 MS-CT27 - TAP 2.7MM SURG BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-CTL21 SUP Custom 27100030 MS-CTL21 - TAP 2.7MM LNG BONE TIP SURG ELB ACUMED BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-CTL27 SUP Custom 27100030 MS-CTL27 - TAP 2.7MM LNG BONE TIP SURG ELB ACUMED BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-D761 SUP Custom 27203010 MS-D761 - BIT DRL 6.1MM BOTH IP/OP $215.00 $159.10 $0.00 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.57 $159.57 $0.00 $0.00 $44.81 $0.00 $0.00 $0.00 $0.00 $107.50 $170.28 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DC15 SUP Custom 27203010 MS-DC15 - BIT DRL 1.5MM BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSDC-20 SUP Custom 27203010 MSDC-20 - BIT DRILL 5IN 2MM LNG QRLSE STRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DC28 SUP Custom 27203010 MS-DC28 - DRILL SRG 2.8MM 5IN QRLSE BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSDC-35 SUP Custom 27203010 MSDC-35 - BIT DRILL 5IN 3.5MM ACTRK2 ORTH QRLSE STRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DC35 SUP Custom 27203010 MS-DC35 - DRILL SRG 3.5MM 5IN QRLSE BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSDC-5020 SUP Custom 27203010 BIT DRILL 5IN 2MM QRLSE STRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DC5020 SUP Custom 27203010 MS-DC5020 - DRILL SRG 2MM 5IN QRLSE BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSDCL15 SUP Custom 27203010 DRILL SURG QRLSE 1.5MM BOTH IP/OP $95.00 $70.30 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.50 $75.24 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSDCL20 SUP Custom 27203010 BIT DRILL 2MM RADL ELB BOTH IP/OP $80.00 $59.20 $0.00 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.00 $63.36 $64.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DCL28 SUP Custom 27203010 MS-DCL28 - BIT DRILL 2-8MM 2.8MM LNG QRLSE STRL BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DCR20 SUP Custom 27203010 MS-DCR20 - BIT DRILL 5IN 2MM QRLSE STRL BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DCSB32 SUP Custom 27203010 MS-DCSB32 - DRILL SURG SURGIBIT 3.2MM NONSTRL BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DG23 SUP Custom 27203010 MS-DG23 - GUIDE 2MM DRILL DEPTH GA SURG BOTH IP/OP $842.50 $623.45 $0.00 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.30 $625.30 $0.00 $0.00 $175.58 $0.00 $0.00 $0.00 $0.00 $421.25 $667.26 $674.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DG28 SUP Custom 27203010 MS-DG28 - GUIDE DRILL 2.8MM ASMBLY NONSTRL BOTH IP/OP $890.00 $658.60 $0.00 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $660.56 $660.56 $0.00 $0.00 $185.48 $0.00 $0.00 $0.00 $0.00 $445.00 $704.88 $712.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DG40 SUP Custom 27203010 MS-DG40 - GUIDE DRILL 4MM ASMBLY NONSTRL BOTH IP/OP $925.00 $684.50 $0.00 $740.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $686.54 $686.54 $0.00 $0.00 $192.77 $0.00 $0.00 $0.00 $0.00 $462.50 $732.60 $740.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DG46 SUP Custom 27203010 MS-DG46 - GUIDE DRILL 4.6MM ASMBLY NONSTRL BOTH IP/OP "$1,185.00 " $876.90 $0.00 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $879.51 $879.51 $0.00 $0.00 $246.95 $0.00 $0.00 $0.00 $0.00 $592.50 $938.52 $948.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-DS2835 SUP Custom 27203010 MS-DS2835 - SLEEVE DRILL 2.8/3.5MM LAG SCR BOTH IP/OP $277.50 $205.35 $0.00 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.96 $205.96 $0.00 $0.00 $57.83 $0.00 $0.00 $0.00 $0.00 $138.75 $219.78 $222.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-LDC20 SUP Custom 27203010 MS-LDC20 - DRILL SRG LNG 2MM QRLSE BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSLDC28 SUP Custom 27203010 BIT DRILL 2.8MM LNG QC STRL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-LDC28 SUP Custom 27203010 MS-LDC28 - DRILL SRG LNG 2.8MM QRLSE BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-LTT27 SUP Custom 27203010 MS-LTT27 - DRILL SRG LNG 2.7MM TPR BOTH IP/OP $565.00 $418.10 $0.00 $452.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $419.34 $419.34 $0.00 $0.00 $117.75 $0.00 $0.00 $0.00 $0.00 $282.50 $447.48 $452.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSLTT35 SUP HCPCS C1713 MSLTT35 - SCREW BONE 3.5MM ORTH TPR BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $84.38 $84.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 MS-LTT35 SUP HCPCS C1713 MS-LTT35 - SCREW BONE 2.7MM 35MM LNG CORT LNG TAP QCK CPLR NONSTRL 3.5 BOTH IP/OP $565.00 $418.10 $0.00 $452.00 $254.25 $254.25 $0.00 $0.00 $0.00 $117.76 $419.34 $419.34 $0.00 $0.00 $117.75 $0.00 $334.20 $334.20 $0.00 $282.50 $447.48 $452.00 $0.00 $0.00 $88.42 $0.00 $0.00 $89.95 $0.00 $0.00 $0.00 $0.00 $0.00 MS-PH28 SUP Custom 27203010 MS-PH28 - BIT DRL 2.8MM BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-PH40 SUP Custom 27203010 MS-PH40 - BIT DRL 4MM CANC BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-PH46 SUP Custom 27203010 MS-PH46 - DRILL SURG 4.6MM CANC CANC SCR STRL BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-PHBCD SUP Custom 27203010 MS-PHBCD - BIT DRILL CLRNC BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-PIN20 SUP Custom 27203010 MS-PIN20 - PIN FIX 2MM STNM QCK CPLR BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-PIN28 SUP Custom 27203010 MS-PIN28 - PIN DRILL 2.8MM LNG HUM ELB QRLSE DRILL GUIDE CLMP NONSTRL BOTH IP/OP $202.50 $149.85 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.30 $150.30 $0.00 $0.00 $42.20 $0.00 $0.00 $0.00 $0.00 $101.25 $160.38 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MSS4022 SUP Custom 27203010 MSS4022 - DRESSING HYALOMATRIX 5X5CM BILAYER FLXB SEMIPERM BOTH IP/OP $686.93 $508.33 $0.00 $549.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.84 $509.84 $0.00 $0.00 $143.16 $0.00 $0.00 $0.00 $0.00 $343.46 $544.05 $549.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MS-T35S SUP HCPCS C1713 MS-T35S - SCREW BONE 3.5MM SHRT CORT SLFTAP BOTH IP/OP $330.00 $244.20 $0.00 $264.00 $148.50 $148.50 $0.00 $0.00 $0.00 $68.78 $244.93 $244.93 $0.00 $0.00 $68.77 $0.00 $195.20 $195.20 $0.00 $165.00 $261.36 $264.00 $0.00 $0.00 $51.65 $0.00 $0.00 $52.54 $0.00 $0.00 $0.00 $0.00 $0.00 MT-1000 SUP Custom 27203010 MT-1000 - MINNIE TIE BOTH IP/OP $379.79 $281.04 $0.00 "$3,646.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.88 $281.88 $0.00 $0.00 $79.15 $0.00 $0.00 $0.00 $0.00 "$2,278.75" "$3,609.54" "$3,646.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MT2000 SUP Custom 27203010 LENS IRR MRGN MDGL THRP BOTH IP/OP $49.95 $36.96 $0.00 $39.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.98 $39.56 $39.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0 SUP HCPCS V2630 MTA3U0 - LENS IOL +21 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.050 SUP HCPCS V2630 MTA3U0.050 - LENS IOL +5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.060 SUP HCPCS V2630 MTA3U0.060 - LENS IOL +6 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.070 SUP HCPCS V2630 MTA3U0.070 - LENS IOL +7 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.080 SUP HCPCS V2630 MTA3U0.080 - LENS IOL +8 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.090 SUP HCPCS V2630 MTA3U0.090 - LENS IOL +9 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.100 SUP HCPCS V2630 MTA3U0.100 - LENS IOL +10 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.105 SUP HCPCS V2630 MTA3U0.105 - LENS IOL +10.5 DIOP 12.5MM 5.5MM ANTER CHAM 1 PC CNVXPLN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.110 SUP HCPCS V2630 MTA3U0.110 - LENS IOL +11 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.115 SUP HCPCS V2630 MTA3U0.115 - LENS IOL +11.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.120 SUP HCPCS V2630 MTA3U0.120 - LENS IOL +12 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.125 SUP HCPCS V2630 MTA3U0.125 - LENS IOL +12.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.130 SUP HCPCS V2630 MTA3U0.130 - LENS IOL +13 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.135 SUP HCPCS V2630 MTA3U0.135 - LENS IOL +13.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.145 SUP HCPCS V2630 MTA3U0.145 - LENS IOL +14.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.150 SUP HCPCS V2630 MTA3U0.150 - LENS IOL +15 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.155 SUP HCPCS V2630 MTA3U0.155 - LENS IOL +15.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.160 SUP HCPCS V2630 MTA3U0.160 - LENS IOL +16 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.165 SUP HCPCS V2630 MTA3U0.165 - LENS IOL +16.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.170 SUP HCPCS V2630 MTA3U0.170 - LENS IOL +17 DIOP 12.5MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.180 SUP HCPCS V2630 MTA3U0.180 - LENS IOL +18 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.185 SUP HCPCS V2630 MTA3U0.185 - LENS IOL +18.5 DIOP 12.5MM 5.5MM ANTER CHAM 1 PC CNVXPLN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.190 SUP HCPCS V2632 MTA3U0.190 - INTRAOCULAR LENS MTA3U0 19.0D BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.200 SUP HCPCS V2632 MTA3U0.200 - INTRAOUCLAR LENS MTA3U0 20.0D BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.205 SUP HCPCS V2630 MTA3U0.205 - LENS IOL +20.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.210 SUP HCPCS V2630 MTA3U0.210 - LENS IOL +21 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.215 SUP HCPCS V2630 MTA3U0.215 - LENS IOL +21.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.220 SUP HCPCS V2630 MTA3U0.220 - LENS IOL +22 DIOP 12.5MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.230 SUP HCPCS V2630 MTA3U0.230 - LENS IOL +23 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.235 SUP HCPCS V2630 MTA3U0.235 - LENS IOL +23.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.240 SUP HCPCS V2630 MTA3U0.240 - LENS IOL +24 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.245 SUP HCPCS V2630 MTA3U0.245 - LENS IOL +24.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.250 SUP HCPCS V2630 MTA3U0.250 - LENS IOL +25 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.255 SUP HCPCS V2630 MTA3U0.255 - LENS IOL +25.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.260 SUP HCPCS V2630 MTA3U0.260 - LENS IOL +26 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.265 SUP HCPCS V2630 MTA3U0.265 - LENS IOL +26.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.270 SUP HCPCS V2630 MTA3U0.270 - LENS IOL +27 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.275 SUP HCPCS V2630 MTA3U0.275 - LENS IOL +27.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.280 SUP HCPCS V2630 MTA3U0.280 - LENS IOL +28 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.285 SUP HCPCS V2630 MTA3U0.285 - LENS IOL +28.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.290 SUP HCPCS V2630 MTA3U0.290 - LENS IOL +29 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.295 SUP HCPCS V2630 MTA3U0.295 - LENS IOL +29.5 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA3U0.300 SUP HCPCS V2630 MTA3U0.300 - LENS IOL +30 DIOP CNVXPLN 5.5MM 12.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0 SUP HCPCS V2630 MTA4U0 - LENS IOL +6.5 DIOP CNVXPLN 5.5MM 13MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.015 SUP HCPCS V2630 MTA4U0.015 - LENS IOL +15 DIOP 13MM 5.5MM ANTER CHAM CNVXPLN 1 PC PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.050 SUP HCPCS V2630 MTA4U0.050 - LENS IOL +5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.055 SUP HCPCS V2630 MTA4U0.055 - LENS IOL +5.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.060 SUP HCPCS V2630 MTA4U0.060 - LENS IOL +6 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.065 SUP HCPCS V2630 MTA4U0.065 - LENS IOL +6.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.070 SUP HCPCS V2630 MTA4U0.070 - LENS IOL +7 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.075 SUP HCPCS V2630 MTA4U0.075 - LENS IOL +7.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.080 SUP HCPCS V2630 MTA4U0.080 - LENS IOL +8 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.085 SUP HCPCS V2630 MTA4U0.085 - LENS IOL +8.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.090 SUP HCPCS V2630 MTA4U0.090 - LENS IOL +9 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.095 SUP HCPCS V2630 MTA4U0.095 - LENS IOL +9.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.100 SUP HCPCS V2630 MTA4U0.100 - LENS IOL +10 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.105 SUP HCPCS V2630 MTA4U0.105 - LENS IOL +10.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.110 SUP HCPCS V2630 MTA4U0.110 - LENS IOL +11 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.115 SUP HCPCS V2630 MTA4U0.115 - LENS IOL +11.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.120 SUP HCPCS V2630 MTA4U0.120 - LENS IOL +12 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.125 SUP HCPCS V2630 MTA4U0.125 - LENS IOL +12.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.130 SUP HCPCS V2630 MTA4U0.130 - LENS IOL +13 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.135 SUP HCPCS V2630 MTA4U0.135 - LENS IOL +13.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.140 SUP HCPCS V2630 MTA4U0.140 - LENS IOL +14 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.145 SUP HCPCS V2630 MTA4U0.145 - LENS IOL +14.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.155 SUP HCPCS V2630 MTA4U0.155 - LENS IOL +15.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.160 SUP HCPCS V2630 MTA4U0.160 - LENS IOL +16 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.165 SUP HCPCS V2632 MTA4U0.165 - INTRAOCULAR LENS MTA4U0 16.5 D BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.170 SUP HCPCS V2632 MTA4U0.170 - INTRAOCULAR LENS MTA4UO 17.0D BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.175 SUP HCPCS V2630 MTA4U0.175 - LENS IOL +17.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.180 SUP HCPCS V2630 MTA4U0.180 - LENS IOL +18 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.185 SUP HCPCS V2630 MTA4U0.185 - LENS IOL +18.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.190 SUP HCPCS V2630 MTA4U0.190 - LENS IOL +19 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.195 SUP HCPCS V2632 MTA4U0.195 - INTRAOCULAR LENS MTA4U0 19.5D BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.200 SUP HCPCS V2630 MTA4U0.200 - LENS IOL +20 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.205 SUP HCPCS V2632 MTA4U0.205 - INTRAOCULAR LENS MTA4U0 20.5D BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.210 SUP HCPCS V2630 MTA4U0.210 - LENS IOL +21 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.215 SUP HCPCS V2630 MTA4U0.215 - LENS IOL +21.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.220 SUP HCPCS V2630 MTA4U0.220 - LENS IOL +22.0 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.225 SUP HCPCS V2630 MTA4U0.225 - LENS IOL +22.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.230 SUP HCPCS V2630 MTA4U0.230 - LENS IOL +23 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.235 SUP HCPCS V2630 MTA4U0.235 - LENS IOL +23.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.240 SUP HCPCS V2630 MTA4U0.240 - LENS IOL +24 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.245 SUP HCPCS V2630 MTA4U0.245 - LENS IOL +24.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.250 SUP HCPCS V2630 MTA4U0.250 - LENS IOL +25 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.255 SUP HCPCS V2630 MTA4U0.255 - LENS IOL +25.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.260 SUP HCPCS V2630 MTA4U0.260 - LENS IOL +26 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.265 SUP HCPCS V2630 MTA4U0.265 - LENS IOL +26.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.270 SUP HCPCS V2630 MTA4U0.270 - LENS IOL +27 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.275 SUP HCPCS V2630 MTA4U0.275 - LENS IOL +27.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.280 SUP HCPCS V2630 MTA4U0.280 - LENS IOL +28 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.285 SUP HCPCS V2630 MTA4U0.285 - LENS IOL +28.5 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.290 SUP HCPCS V2630 MTA4U0.290 - LENS IOL +29 DIOP 13MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA4U0.300 SUP HCPCS V2630 MTA4U0.300 - LENS IOL +30 DIOP CNVXPLN 5.5MM 13MM CLR STRL KLMN MULTIFLEX BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0 SUP HCPCS V2630 MTA5U0 - LENS IOL +13.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.050 SUP HCPCS V2630 MTA5U0.050 - LENS IOL +5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.060 SUP HCPCS V2630 MTA5U0.060 - LENS IOL +6 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.070 SUP HCPCS V2630 MTA5U0.070 - LENS IOL +7 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.080 SUP HCPCS V2630 MTA5U0.080 - LENS IOL +8 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.085 SUP HCPCS V2630 MTA5U0.085 - LENS IOL +8.5 DIOP CNVXPLN 13.5MM 5.5MM ANTER CHAM BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.095 SUP HCPCS V2630 MTA5U0.095 - LENS IOL +9.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.100 SUP HCPCS V2630 MTA5U0.100 - LENS IOL +10 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.105 SUP HCPCS V2630 MTA5U0.105 - LENS IOL +10.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.115 SUP HCPCS V2630 MTA5U0.115 - LENS IOL +11.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.125 SUP HCPCS V2630 MTA5U0.125 - LENS IOL +12.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.135 SUP HCPCS V2630 MTA5U0.135 - LENS IOL +13.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.140 SUP HCPCS V2630 MTA5U0.140 - LENS IOL +14 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.145 SUP HCPCS V2630 MTA5U0.145 - LENS IOL +14.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.150 SUP HCPCS V2630 MTA5U0.150 - LENS IOL +15 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.155 SUP HCPCS V2630 MTA5U0.155 - LENS IOL +15.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.160 SUP HCPCS V2630 MTA5U0.160 - LENS IOL +16 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.165 SUP HCPCS V2632 MTA5U0.165 - LENS IOL +16.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.170 SUP HCPCS V2630 MTA5U0.170 - LENS IOL +17 DIOP 13.5MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.175 SUP HCPCS V2630 MTA5U0.175 - LENS IOL +17.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.180 SUP HCPCS V2630 MTA5U0.180 - LENS IOL +18 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.185 SUP HCPCS V2630 MTA5U0.185 - LENS IOL +18.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.190 SUP HCPCS V2630 MTA5U0.190 - LENS IOL +19 DIOP 13.5MM 5.5MM ANTER CHAM 1 PC CNVXPLN PMMA BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.195 SUP HCPCS V2630 MTA5U0.195 - LENS IOL +19.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.200 SUP HCPCS V2630 MTA5U0.200 - LENS IOL +20 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.210 SUP HCPCS V2630 MTA5U0.210 - LENS IOL +21 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.215 SUP HCPCS V2630 MTA5U0.215 - LENS IOL +21.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.220 SUP HCPCS V2630 MTA5U0.220 - LENS IOL +22 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.225 SUP HCPCS V2630 MTA5U0.225 - LENS IOL +22.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.230 SUP HCPCS V2630 MTA5U0.230 - LENS IOL +23 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.235 SUP HCPCS V2630 MTA5U0.235 - LENS IOL +23.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.240 SUP HCPCS V2630 MTA5U0.240 - LENS IOL +24 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.250 SUP HCPCS V2630 MTA5U0.250 - LENS IOL +25 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.260 SUP HCPCS V2630 MTA5U0.260 - LENS IOL +26 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.270 SUP HCPCS V2630 MTA5U0.270 - LENS IOL +27 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.280 SUP HCPCS V2630 MTA5U0.280 - LENS IOL +28 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.285 SUP HCPCS V2630 MTA5U0.285 - LENS IOL +28.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.290 SUP HCPCS V2630 MTA5U0.290 - LENS IOL +29 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.295 SUP HCPCS V2630 MTA5U0.295 - LENS IOL +29.5 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTA5U0.300 SUP HCPCS V2630 MTA5U0.300 - LENS IOL +30 DIOP CNVXPLN 5.5MM 13.5MM CLR STRL KLMN BOTH IP/OP $212.50 $157.25 $0.00 $170.00 $95.63 $95.63 $0.00 $0.00 $0.00 $44.29 $157.72 $157.72 $0.00 $0.00 $44.29 $0.00 $125.69 $125.69 $0.00 $106.25 $168.30 $170.00 $0.00 $0.00 $33.26 $0.00 $0.00 $33.83 $0.00 $0.00 $0.00 $0.00 $0.00 MTLS-30060-TS SUP HCPCS C1713 MTLS-30060-TS - SCREW BN 3MM 6MM NS MULTITHREAD LCK TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTLS-30080-TS SUP HCPCS C1713 MTLS-30080-TS - SCREW BN 3MM 8MM NS MULTITHREAD LCK TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTLS-30100-TS SUP HCPCS C1713 MTLS-30100-TS - SCREW BN 3MM 10MM NS MULTITHREAD LCK TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTLS-30120-TS SUP HCPCS C1713 MTLS-30120-TS - SCREW BN 3MM 12MM NS MULTITHREAD LCK TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTLS-30140-TS SUP HCPCS C1713 MTLS-30140-TS - SCREW BN 3MM 14MM NS MULTITHREAD LCK TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTLS-30160-TS SUP HCPCS C1713 MTLS-30160-TS - SCREW BN 3MM 16MM NS MULTITHREAD LCK TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTLS-30180-TS SUP HCPCS C1713 MTLS-30180-TS - SCREW BN 3MM 18MM NS MULTITHREAD LCK TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTNL-30060-TS SUP HCPCS C1713 MTNL-30060-TS - SCREW BN 3MM 6MM NS LF CMPR MULTITHREAD TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTNL-30080-TS SUP HCPCS C1713 MTNL-30080-TS - SCREW BN 3MM 8MM NS LF CMPR MULTITHREAD TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTNL-30100-TS SUP HCPCS C1713 MTNL-30100-TS - SCREW BN 3MM 10MM NS LF CMPR MULTITHREAD TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTNL-30120-TS SUP HCPCS C1713 MTNL-30120-TS - SCREW BN 3MM 12MM NS LF CMPR MULTITHREAD TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTNL-30140-TS SUP HCPCS C1713 MTNL-30140-TS - SCREW BN 3MM 14MM NS LF CMPR MULTITHREAD TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTNL-30160-TS SUP HCPCS C1713 MTNL-30160-TS - SCREW BN 3MM 16MM NS LF CMPR MULTITHREAD TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTNL-30180-TS SUP HCPCS C1713 MTNL-30180-TS - SCREW BN 3MM 18MM NS LF CMPR MULTITHREAD TI DRSL SPAN PLT BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-F010 SUP Custom 27203010 MTP-F010 - REAMER SURG CNCV JNT BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-F012 SUP Custom 27203010 MTP-F012 - REAMER SURG 12MM CNCV MTP BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-F014 SUP Custom 27203010 MTP-F014 - REAMER SRG 14MM CNCV BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-F016 SUP Custom 27203010 MTP-F016 - REAMER SURG 16MM CNCV MTP BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-F020 SUP Custom 27203010 MTP-F020 - REAMER SRG 20MM CNCV BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-F024 SUP Custom 27203010 MTP-F024 - REAMER SURG 24MM CNCV MTP BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-M010 SUP Custom 27203010 MTP-M010 - REAMER SURG 10MM CNVX MTP BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-M012 SUP Custom 27203010 MTP-M012 - REAMER SURG 12MM CNVX MTP BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-M014 SUP Custom 27203010 MTP-M014 - REAMER SURG 14MM CNVX MTP BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-M016 SUP Custom 27203010 MTP-M016 - REAMER SURG 16MM CNVX MTP BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-M020 SUP Custom 27203010 MTP-M020 - REAMER SURG 20MM CNVX MTP FRFT MIDFT LG BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MTP-M024 SUP Custom 27203010 MTP-M024 - REAMER SURG 24MM CNVX MTP BOTH IP/OP "$1,120.00 " $828.80 $0.00 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.26 $831.26 $0.00 $0.00 $233.41 $0.00 $0.00 $0.00 $0.00 $560.00 $887.04 $896.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MWCE-35-5/3-TORNADO SUP Custom 27803010 MWCE-35-5/3-TORNADO - COIL EMBOLIZATION TORNADO .035IN PLATINUM 5-3MM BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MWM4051 SUP HCPCS C9363 MWM4051 - DRESSING BIOLOGICAL 5X4IN MESHED ADHERENT BILAYER MATRIX BOTH IP/OP "$11,030.65 " "$8,162.68" $0.00 "$10,027.86" "$5,640.67" "$5,640.67" $0.00 $0.00 $0.00 $0.00 "$8,186.95" "$8,186.95" $0.00 $0.00 "$2,298.79" $0.00 $0.00 $0.00 $0.00 "$6,267.41" "$9,927.59" "$10,027.86" $0.00 $0.00 "$1,961.70" $0.00 $0.00 "$1,995.54" $0.00 $0.00 $0.00 $0.00 $0.00 MX0100 SUP HCPCS C1782 MX0100 - TISSUE MORCELLATOR BOTH IP/OP "$3,567.27 " "$2,639.78" $0.00 "$2,853.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,647.63" "$2,647.63" $0.00 $0.00 $743.42 $0.00 $0.00 $0.00 $0.00 "$1,783.64" "$2,825.28" "$2,853.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MX563 SUP Custom 27203010 MX563 - SUTURE NONABSORBABLE 2-0 SH 30IN 2 ARM 4 STRAND BRAID BOTH IP/OP $124.00 $91.76 $0.00 $92.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.04 $92.04 $0.00 $0.00 $25.84 $0.00 $0.00 $0.00 $0.00 $21.40 $33.90 $34.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 MX6740 SUP HCPCS C1760 MX6740 - DEVICE CLSR BLK GRN 6-7FR MYNX ACE .035IN VASC LCK SYR BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD SUP HCPCS V2632 MZ30BD - LENS IOL 5 D +10 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.100 SUP HCPCS V2632 MZ30BD.100 - LENS IOL 5 D +10 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.110 SUP HCPCS V2632 MZ30BD.110 - LENS IOL 5 D +11 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.120 SUP HCPCS V2632 MZ30BD.120 - LENS IOL 5 D +12 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.130 SUP HCPCS V2632 MZ30BD.130 - LENS IOL 5 D +13 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.140 SUP HCPCS V2632 MZ30BD.140 - LENS IOL 5 D +14 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.150 SUP HCPCS V2632 MZ30BD.150 - LENS IOL 5 D +15 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.160 SUP HCPCS V2632 MZ30BD.160 - LENS IOL 5 D +16 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.170 SUP HCPCS V2632 MZ30BD.170 - LENS IOL 5 D +17 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.180 SUP HCPCS V2632 MZ30BD.180 - LENS IOL 5 D +18 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.190 SUP HCPCS V2632 MZ30BD.190 - LENS IOL 5 D +19 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.200 SUP HCPCS V2632 MZ30BD.200 - LENS IOL 5 D +20 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.210 SUP HCPCS V2632 MZ30BD.210 - LENS IOL 5 D +21 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.220 SUP HCPCS V2632 MZ30BD.220 - LENS IOL 5 D +22 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.225 SUP HCPCS V2632 MZ30BD.225 - LENS IOL 5 D +22.5 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.235 SUP HCPCS V2632 MZ30BD.235 - LENS IOL 5 D +23.5 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.245 SUP HCPCS V2632 MZ30BD.245 - LENS IOL 5 D +24.5 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.255 SUP HCPCS V2632 MZ30BD.255 - LENS IOL 5 D +25.5 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.265 SUP HCPCS V2632 MZ30BD.265 - LENS IOL 5 D +26.5 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.275 SUP HCPCS V2632 MZ30BD.275 - LENS IOL 5 D +27.5 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.285 SUP HCPCS V2632 MZ30BD.285 - LENS IOL 5 D +28.5 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ30BD.295 SUP HCPCS V2632 MZ30BD.295 - LENS IOL 5 D +29.5 DIOP MOD C BCNVX 5.5MM 12MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.100 SUP HCPCS V2632 MZ40BD.100 - LENS IOL 5 D +10 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.105 SUP HCPCS V2632 MZ40BD.105 - LENS IOL 5 D +10.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.110 SUP HCPCS V2632 MZ40BD.110 - LENS IOL 5 D +11 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.115 SUP HCPCS V2632 MZ40BD.115 - LENS IOL 5 D +11.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.120 SUP HCPCS V2632 MZ40BD.120 - LENS IOL 5 D +12 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.125 SUP HCPCS V2632 MZ40BD.125 - LENS IOL 5 D +12.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.130 SUP HCPCS V2632 MZ40BD.130 - LENS IOL 5 D +13 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.135 SUP HCPCS V2632 MZ40BD.135 - LENS IOL 5 D +13.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.140 SUP HCPCS V2632 MZ40BD.140 - LENS IOL 5 D +14 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.145 SUP HCPCS V2632 MZ40BD.145 - LENS IOL 5 D +14.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.150 SUP HCPCS V2632 MZ40BD.150 - LENS IOL 5 D +15 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.155 SUP HCPCS V2632 MZ40BD.155 - LENS IOL 5 D +15.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.160 SUP HCPCS V2632 MZ40BD.160 - LENS IOL 5 D +16 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.165 SUP HCPCS V2632 MZ40BD.165 - LENS IOL 5 D +16.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.170 SUP HCPCS V2632 MZ40BD.170 - LENS IOL 5 D +17 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.175 SUP HCPCS V2632 MZ40BD.175 - LENS IOL 5 D +17.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.180 SUP HCPCS V2632 MZ40BD.180 - LENS IOL 5 D +18 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.185 SUP HCPCS V2632 MZ40BD.185 - LENS IOL 5 D +18.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.190 SUP HCPCS V2632 MZ40BD.190 - LENS IOL 5 D +19 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.195 SUP HCPCS V2632 MZ40BD.195 - LENS IOL 5 D +19.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.200 SUP HCPCS V2632 MZ40BD.200 - LENS IOL 5 D +20 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.205 SUP HCPCS V2632 MZ40BD.205 - LENS IOL 5 D +20.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.210 SUP HCPCS V2632 MZ40BD.210 - LENS IOL 5 D +21 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.215 SUP HCPCS V2632 MZ40BD.215 - LENS IOL 5 D +21.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.220 SUP HCPCS V2632 MZ40BD.220 - LENS IOL 5 D +22 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.225 SUP HCPCS V2632 MZ40BD.225 - LENS IOL 5 D +22.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.230 SUP HCPCS V2632 MZ40BD.230 - LENS IOL 5 D +23 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.235 SUP HCPCS V2632 MZ40BD.235 - LENS IOL 5 D +23.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.240 SUP HCPCS V2632 MZ40BD.240 - LENS IOL 5 D +24 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.245 SUP HCPCS V2632 MZ40BD.245 - LENS IOL 5 D +24.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.250 SUP HCPCS V2632 MZ40BD.250 - LENS IOL 5 D +25 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.255 SUP HCPCS V2632 MZ40BD.255 - LENS IOL 5 D +25.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.260 SUP HCPCS V2632 MZ40BD.260 - LENS IOL 5 D +26 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.265 SUP HCPCS V2632 MZ40BD.265 - LENS IOL 5 D +26.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.270 SUP HCPCS V2632 MZ40BD.270 - LENS IOL 5 D +27 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.275 SUP HCPCS V2632 MZ40BD.275 - LENS IOL 5 D +27.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.280 SUP HCPCS V2632 MZ40BD.280 - LENS IOL 5 D +28 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.285 SUP HCPCS V2632 MZ40BD.285 - LENS IOL 5 D +28.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.290 SUP HCPCS V2632 MZ40BD.290 - LENS IOL 5 D +29 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.295 SUP HCPCS V2632 MZ40BD.295 - LENS IOL 5 D +29.5 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ40BD.300 SUP HCPCS V2632 MZ40BD.300 - LENS IOL 5 D +30 DIOP MOD C BCNVX 5MM 11.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD SUP HCPCS V2632 MZ60BD - LENS IOL 5 D +25.5 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.040 SUP HCPCS V2632 MZ60BD.040 - LENS IOL 5 D +4 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT 1 BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.050 SUP HCPCS V2632 MZ60BD.050 - LENS IOL 5 D +5 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT 1 BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.060 SUP HCPCS V2632 MZ60BD.060 - LENS IOL 5 D +6 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT 1 BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.070 SUP HCPCS V2632 MZ60BD.070 - LENS IOL 5 D +7 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT 1 BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.080 SUP HCPCS V2632 MZ60BD.080 - LENS IOL 5 D +8 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT 1 BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.090 SUP HCPCS V2632 MZ60BD.090 - LENS IOL 5 D +9 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT 1 BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.100 SUP HCPCS V2632 MZ60BD.100 - LENS IOL 5 D +10 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.110 SUP HCPCS V2632 MZ60BD.110 - LENS IOL 5 D +11 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.120 SUP HCPCS V2632 MZ60BD.120 - LENS IOL 5 D +12 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.130 SUP HCPCS V2632 MZ60BD.130 - LENS IOL 5 D +13 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.140 SUP HCPCS V2632 MZ60BD.140 - LENS IOL 5 D +14 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.150 SUP HCPCS V2632 MZ60BD.150 - LENS IOL 5 D +15 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.160 SUP HCPCS V2632 MZ60BD.160 - LENS IOL 5 D +16 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.170 SUP HCPCS V2632 MZ60BD.170 - LENS IOL 5 D +17 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.180 SUP HCPCS V2632 MZ60BD.180 - LENS IOL 5 D +18 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.190 SUP HCPCS V2632 MZ60BD.190 - LENS IOL 5 D +19 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.200 SUP HCPCS V2632 MZ60BD.200 - LENS IOL 5 D +20 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.210 SUP HCPCS V2632 MZ60BD.210 - LENS IOL 5 D +21 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.220 SUP HCPCS V2632 MZ60BD.220 - LENS IOL 5 D +22 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.230 SUP HCPCS V2632 MZ60BD.230 - LENS IOL 5 D +23 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.240 SUP HCPCS V2632 MZ60BD.240 - LENS IOL 5 D +24 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.245 SUP HCPCS V2632 MZ60BD.245 - LENS IOL 5 D +24.5 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.250 SUP HCPCS V2632 MZ60BD.250 - LENS IOL 5 D +25 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.260 SUP HCPCS V2632 MZ60BD.260 - LENS IOL 5 D +26 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.270 SUP HCPCS V2632 MZ60BD.270 - LENS IOL 5 D +27 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.280 SUP HCPCS V2632 MZ60BD.280 - LENS IOL 5 D +28 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.290 SUP HCPCS V2632 MZ60BD.290 - LENS IOL 5 D +29 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.300 SUP HCPCS V2632 MZ60BD.300 - LENS IOL 5 D +30 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.320 SUP HCPCS V2632 MZ60BD.320 - LENS IOL 5 D +32 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60BD.340 SUP HCPCS V2632 MZ60BD.340 - LENS IOL 5 D +34 DIOP MOD C BCNVX 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60MD SUP HCPCS V2632 MZ60MD - LENS IOL 5 D -1 DIOP MOD C MNSCS 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60MD.000 SUP HCPCS V2632 MZ60MD.000 - LENS IOL 5 D +0 DIOP MOD C MNSCS 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60MD.010 SUP HCPCS V2632 MZ60MD.010 - LENS IOL 5 D +1 DIOP MOD C MNSCS 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60MD.020 SUP HCPCS V2632 MZ60MD.020 - LENS IOL 5 D +2 DIOP MOD C MNSCS 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60MD.030 SUP HCPCS V2632 MZ60MD.030 - LENS IOL 5 D +3 DIOP MOD C MNSCS 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60MDN010 SUP HCPCS V2632 MZ60MDN010 - LENS IOL 5 D -1 DIOP MOD C MNSCS 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60MDN020 SUP HCPCS V2632 MZ60MDN020 - LENS IOL 5 D -2 DIOP MOD C MNSCS 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60MDN030 SUP HCPCS V2632 MZ60MDN030 - LENS IOL 5 D -3 DIOP MOD C MNSCS 6MM 12.5MM CLR STRL SLANT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60PDN040 SUP HCPCS V2632 MZ60PDN040 - LENS IOL 5 D -4 DIOP MOD C PLANO CNCV 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60PDN050 SUP HCPCS V2632 MZ60PDN050 - LENS IOL 5 D -5 DIOP MOD C PLANO CNCV 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60PDN060 SUP HCPCS V2632 MZ60PDN060 - LENS IOL 5 D -6 DIOP MOD C PLANO CNCV 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60PDN070 SUP HCPCS V2632 MZ60PDN070 - LENS IOL 5 D -7 DIOP MOD C PLANO CNCV 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60PDN080 SUP HCPCS V2632 MZ60PDN080 - LENS IOL 5 D -8 DIOP MOD C PLANO CNCV 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60PDN090 SUP HCPCS V2632 MZ60PDN090 - LENS IOL 5 D -9 DIOP MOD C PLANO CNCV 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 MZ60PDN100 SUP HCPCS V2632 MZ60PDN100 - LENS IOL 5 D -10 DIOP MOD C PLANO CNCV 6MM 12.5MM CLR STRL BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $73.13 $73.13 $0.00 $0.00 $0.00 $33.87 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $96.12 $96.12 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $25.43 $0.00 $0.00 $25.87 $0.00 $0.00 $0.00 $0.00 $0.00 N103A SUP Custom 27203010 N103A - NEEDLE DSCT MIC STRG 3CM LF CO HEAT RST TIP UL SHRP TUNG BOTH IP/OP $90.13 $66.70 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.89 $66.89 $0.00 $0.00 $18.78 $0.00 $0.00 $0.00 $0.00 $122.50 $194.04 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 N143001 SUP HCPCS C1769 N143001 - GWIRE VASC 15D .014IN 300CM 5CM INT STY A SHP TIP NTRX NTNL BOTH IP/OP $281.67 $208.44 $0.00 $225.33 $152.94 $152.94 $0.00 $0.00 $0.00 $58.71 $209.05 $209.05 $0.00 $0.00 $58.70 $0.00 $166.61 $166.61 $0.00 $140.83 $223.08 $225.33 $0.00 $0.00 $44.08 $0.00 $0.00 $44.84 $0.00 $0.00 $0.00 $0.00 $0.00 N1526 SUP Custom 25003010 ANTIBODY DESMIN CLONE D33 MS ANHMN 11ML LAB BOTH IP/OP "$1,320.00 " $976.80 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 N1580 SUP Custom 25003010 ANTIBODY CD3 RBT PLYCLN ANHMN 7ML LAB BOTH IP/OP "$1,320.00 " $976.80 $0.00 "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $660.00 "$1,045.44" "$1,056.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 N181805 SUP HCPCS C1769 N181805 - GWIRE ENDSCP .018IN 180CM HPRFR STF ANG TIP FLXB EXC TRQ BOTH IP/OP $216.67 $160.34 $0.00 $173.33 $117.65 $117.65 $0.00 $0.00 $0.00 $45.16 $160.81 $160.81 $0.00 $0.00 $45.15 $0.00 $128.16 $128.16 $0.00 $108.33 $171.60 $173.33 $0.00 $0.00 $33.91 $0.00 $0.00 $34.49 $0.00 $0.00 $0.00 $0.00 $0.00 N2031-3 SUP Custom 27203010 HOLDER LOOP BRSS INSL HNDL 8IN BOTH IP/OP $56.90 $42.11 $0.00 $45.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.45 $45.06 $45.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 N7695 SUP HCPCS A7520 N7695 - TUBE ET SYR CK BOTH IP/OP $11.13 $8.24 $0.00 $8.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.26 $8.26 $0.00 $0.00 $2.32 $0.00 $0.00 $0.00 $0.00 $5.56 $8.81 $8.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 N8254 SUP Custom 27203010 CANNULA CPAP NEO BN ARWY RDC IRRIT SIL LF DISP 4CM 2.5MM BOTH IP/OP $28.25 $20.91 $0.00 $22.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.13 $22.37 $22.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 N8304 SUP Custom 27203010 CANNULA CPAP NEO BN ARWY RDC IRRIT SIL LF DISP 4CM 3MM BOTH IP/OP $28.25 $20.91 $0.00 $22.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.13 $22.37 $22.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NAV2076 SUP Custom 27203010 NAV2076 - BIT DRL 2.9MM STRL VRTX DISP BOTH IP/OP "$1,950.00 " "$1,443.00" $0.00 "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,447.29" "$1,447.29" $0.00 $0.00 $406.38 $0.00 $0.00 $0.00 $0.00 $975.00 "$1,544.40" "$1,560.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NB5STFLP SUP Custom 27203010 NB5STFLP - TROCAR LAPSCOP STANDARD LP 5MM FIX SMOOTH ENTRY DIRECTIONAL BOTH IP/OP $50.75 $37.56 $0.00 $40.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.67 $37.67 $0.00 $0.00 $10.58 $0.00 $0.00 $0.00 $0.00 $25.38 $40.19 $40.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NC9822012 SUP Custom 27203010 KIT FTL CELL STN BLOOD BANK 300 TST BOTH IP/OP $505.00 $373.70 $0.00 $404.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.50 $399.96 $404.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2009X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2012X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2015X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2021X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP22506X SUP HCPCS C1725 CATHETER BALDILAT 2.25MM 6MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP22512X SUP HCPCS C1725 CATHETER BALDILAT 2.25MM 12MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP22521X SUP HCPCS C1725 CATHETER BALDILAT 2.25MM 21MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2506X SUP HCPCS C1725 CATHETER BALDILAT 2.5MM 6MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2509X SUP HCPCS C1725 CATHETER BALDILAT 2.5MM 9MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2512X SUP HCPCS C1725 CATHETER BALDILAT 2.5MM 12MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2515X SUP HCPCS C1725 CATHETER BALDILAT 2.5MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2521X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP2527X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP27506X SUP HCPCS C1725 CATHETER BALDILAT 2.7MM 6MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP27509X SUP HCPCS C1725 CATHETER BALDILAT 2.75MM 9MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP27512X SUP HCPCS C1725 CATHETER BALDILAT 2.75MM 12MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP27515X SUP HCPCS C1725 CATHETER BALDILAT 2.75MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP27521X SUP HCPCS C1725 CATHETER BALDILAT 2.75MM 21MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3006X SUP HCPCS C1725 CATHETER BALDILAT 3MM 6MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3009X SUP HCPCS C1725 CATHETER BALDILAT 3MM 9MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3012X SUP HCPCS C1725 CATHETER BALDILAT 3MM 12MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3015X SUP HCPCS C1725 CATHETER BALDILAT 3MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3021X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3027X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP32506X SUP HCPCS C1725 CATHETER BALDILAT 3.25MM 6MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP32509X SUP HCPCS C1725 CATHETER BALDILAT 3.25MM 9MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP32512X SUP HCPCS C1725 CATHETER BALDILAT 3.25MM 12MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP32515X SUP HCPCS C1725 CATHETER BALDILAT 3.25MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP32521X SUP HCPCS C1725 CATHETER BALDILAT 3.25MM 21MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3506X SUP HCPCS C1725 CATHETER BALDILAT 3.5MM 6MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3509X SUP HCPCS C1725 CATHETER BALDILAT 3.5MM 9MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3512X SUP HCPCS C1725 CATHETER BALDILAT 3.5MM 12MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3515X SUP HCPCS C1725 CATHETER BALDILAT 3.5MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3521X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP3527X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP37506X SUP HCPCS C1725 CATHETER BALDILAT 3.75MM 6MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP37509X SUP HCPCS C1725 CATHETER BALDILAT 3.75MM 9MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP37512X SUP HCPCS C1725 CATHETER BALDILAT 3.75MM 12MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP37515X SUP HCPCS C1725 CATHETER BALDILAT 3.75MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP37521X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP4006X SUP HCPCS C1725 CATHETER BALDILAT 4MM 6MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP4009X SUP HCPCS C1725 CATHETER BALDILAT 4MM 9MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP4012X SUP HCPCS C1725 CATHETER BALDILAT 4MM 12MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP4015X SUP HCPCS C1725 CATHETER BALDILAT 4MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP4021X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP4027X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP4515X SUP HCPCS C1725 CATHETER BALDILAT 4.5MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP4521X SUP HCPCS C1725 BALLON SPRINTER NC RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 NCSP5015X SUP HCPCS C1725 CATHETER BALDILAT 5MM 15MM RAPEX NC NC SPNTR ANGIOPLST BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 NL8505061 SUP Custom 27203010 NL8505061 - SHUNT CARDIO 5MM 3.5MM SUNDT CRTD INTNL LOOP CONICAL SPRG BOTH IP/OP "$1,035.00 " $765.90 $0.00 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.18 $768.18 $0.00 $0.00 $215.69 $0.00 $0.00 $0.00 $0.00 $517.50 $819.72 $828.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL850-5063 SUP Custom 27803010 NL850-5063 - SHUNT CARDIO 10CM 3.5-4MM SUNDT CRTD XTRN NREIN SEG SIL STRL BOTH IP/OP "$1,120.13 " $828.90 $0.00 $896.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $831.36 $831.36 $0.00 $0.00 $233.43 $0.00 $0.00 $0.00 $0.00 $560.06 $887.14 $896.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL8505065 SUP Custom 27803010 NL8505065 - SHUNT CARDIO 10CM 3X4MM SUNDT CRTD INTNL LOOP SFT CONICAL BOTH IP/OP $867.78 $642.16 $0.00 $694.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $644.06 $644.06 $0.00 $0.00 $180.84 $0.00 $0.00 $0.00 $0.00 $433.89 $687.28 $694.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL850-5067 SUP Custom 27803010 NL850-5067 - SHUNT CARDIO 10CM 4X5MM SUNDT CRTD INTNL LOOP SFT CONICAL BOTH IP/OP $867.78 $642.16 $0.00 $694.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $644.06 $644.06 $0.00 $0.00 $180.84 $0.00 $0.00 $0.00 $0.00 $433.89 $687.28 $694.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL8505070 SUP Custom 27803010 NL8505070 - SHUNT CARDIO 30CM 4X3MM SUNDT CRTD XTRN LOOP SFT CONICAL BOTH IP/OP $965.63 $714.57 $0.00 $772.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.69 $716.69 $0.00 $0.00 $201.24 $0.00 $0.00 $0.00 $0.00 $482.81 $764.78 $772.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL8505071 SUP Custom 27803010 NL8505071 - SHUNT CARDIO 30CM 3X5MM SUNDT CRTD XTRN LOOP SFT CONICAL BOTH IP/OP "$1,221.03 " $903.56 $0.00 $906.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $906.24 $906.24 $0.00 $0.00 $254.46 $0.00 $0.00 $0.00 $0.00 $482.81 $764.78 $772.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL850-5072 SUP Custom 27803010 NL850-5072 - SHUNT CARDIO 30CM 5X4MM SUNDT CRTD XTRN LOOP SFT CONICAL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL850-5076 SUP Custom 27803010 NL850-5076 - SHUNT NS SUNDT CRTD 30CM NREIN XTRN LOOP SIL 4MM 3MM STRL BOTH IP/OP $1.00 $0.74 $0.00 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.74 $0.74 $0.00 $0.00 $0.21 $0.00 $0.00 $0.00 $0.00 $0.50 $0.79 $0.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL8505078 SUP Custom 27803010 NL8505078 - SHUNT CARDIO 30CM 4MM 5MM SUNDT CRTD XTRN LOOP NREIN CNTR BOTH IP/OP "$1,507.68 " "$1,115.68" $0.00 "$1,119.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,119.00" "$1,119.00" $0.00 $0.00 $314.20 $0.00 $0.00 $0.00 $0.00 $594.83 $942.20 $951.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NL865 SUP Custom 27203010 NL865 - BLADE WIRE SAW 12IN ROUND SPIRAL LOOPED END LATEX FREE GIGLI BOTH IP/OP $121.50 $89.91 $0.00 $97.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.18 $90.18 $0.00 $0.00 $25.32 $0.00 $0.00 $0.00 $0.00 $60.75 $96.23 $97.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NN-8004 SUP Custom 27011340 NN-8004 - HANDPIECE ELECTROSURGICAL 13GA 13CM MYRIAD BOTH IP/OP "$8,235.00 " "$6,093.90" $0.00 "$5,922.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,716.17" $0.00 $0.00 $0.00 $0.00 "$3,701.25" "$5,862.78" "$5,922.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NN-8011 SUP HCPCS C1894 NN-8011 - SHEATH ENDSCP 13.5MM 50MM GROUNDBREAK ACCES TECHNOLOGY BOTH IP/OP "$5,535.00 " "$4,095.90" $0.00 "$4,108.08" "$2,701.43" "$2,701.43" $0.00 $0.00 $0.00 "$1,153.63" "$4,108.08" "$4,108.08" $0.00 $0.00 "$1,153.49" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,487.50" "$3,940.20" "$3,980.00" $0.00 $0.00 $778.59 $0.00 $0.00 $792.02 $0.00 $0.00 $0.00 $0.00 $0.00 NN-8012 SUP HCPCS C1894 NN-8012 - SHEATH ENDSCP 13.5MM 60MM GROUNDBREAK ACCES TECHNOLOGY BOTH IP/OP "$2,767.50 " "$2,047.95" $0.00 "$2,054.04" "$1,350.71" "$1,350.71" $0.00 $0.00 $0.00 $576.82 "$2,054.04" "$2,054.04" $0.00 $0.00 $576.75 $0.00 "$1,636.98" "$1,636.98" $0.00 "$1,243.75" "$1,970.10" "$1,990.00" $0.00 $0.00 $389.29 $0.00 $0.00 $396.01 $0.00 $0.00 $0.00 $0.00 $0.00 NN-8013 SUP HCPCS C1894 NN-8013 - SHEATH ENDSCP 13.5MM 75MM GROUNDBREAK ACCES TECHNOLOGY BOTH IP/OP "$5,125.00 " "$3,792.50" $0.00 "$4,108.08" "$2,701.43" "$2,701.43" $0.00 $0.00 $0.00 "$1,153.63" "$4,108.08" "$4,108.08" $0.00 $0.00 "$1,153.49" $0.00 "$3,094.73" "$3,094.73" $0.00 "$2,487.50" "$3,940.20" "$3,980.00" $0.00 $0.00 $778.59 $0.00 $0.00 $792.02 $0.00 $0.00 $0.00 $0.00 $0.00 NN-8016 SUP Custom 27203010 NN-8016 - VALVE MRCLTR .5MM STRL LF NICO MYRIAD INFS MTR LN DISP BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NN-8030 SUP Custom 27203010 NN-8030 - SHEATH ESCP 13.5MM 95MM STRL BRAINPATH ATRM TIP LCK FRST BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$1,901.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 $0.00 $0.00 $0.00 $621.88 $985.05 $995.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NON28226 SUP HCPCS C1713 NON28226 - CAP BOUF REG LG 24IN FLG LF PR MULTIPLY ELC CLSR LTWT LINT BOTH IP/OP $0.22 $0.16 $0.00 $0.17 $0.10 $0.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.11 $0.17 $0.17 $0.00 $0.00 $0.03 $0.00 $0.00 $0.03 $0.00 $0.00 $0.00 $0.00 $0.00 NON28234P SUP HCPCS C1713 NON28234P - CAP BOUF REG LG 24IN LF PR MULTIPLY ELC CLSR LTWT LINT FR PP BOTH IP/OP $150.88 $111.65 $0.00 $347.88 $195.68 $195.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.43 $119.50 $347.88 $0.00 $0.00 $23.61 $0.00 $0.00 $69.23 $0.00 $0.00 $0.00 $0.00 $0.00 NONB12STF SUP Custom 27203010 NONB12STF - TROCAR LAPSCP STD 12MM STRL VPRT+ FX CNN BLDLS INS TIP TISS BOTH IP/OP $68.08 $50.38 $0.00 $54.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.04 $53.92 $54.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NPAS-100 SUP HCPCS C1894 NPAS-100 - GWIRE VASC .018IN 7FR 22GA 20CM 15CM INTROD NDL NEFF SS PERC BOTH IP/OP $170.84 $126.42 $0.00 $136.67 $92.76 $92.76 $0.00 $0.00 $0.00 $35.61 $126.79 $126.79 $0.00 $0.00 $35.60 $0.00 $101.05 $101.05 $0.00 $85.42 $135.31 $136.67 $0.00 $0.00 $26.74 $0.00 $0.00 $27.20 $0.00 $0.00 $0.00 $0.00 $0.00 NR-09903-S SUP HCPCS C1894 INTRODUCER SHTH 9FR 10CM INTGR HMSTS VLV SDPRT TISS DILAT BOTH IP/OP $75.38 $55.78 $0.00 $60.30 $40.93 $40.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.69 $59.70 $60.30 $0.00 $0.00 $11.80 $0.00 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 NSLX120L SUP Custom 27203010 NSLX120L - SEALER BP 13MM 20CM ENSEAL X1 CRV LG JAW BOTH IP/OP "$2,180.86 " "$1,613.84" $0.00 "$1,744.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,618.64" "$1,618.64" $0.00 $0.00 $454.49 $0.00 $0.00 $0.00 $0.00 "$1,090.43" "$1,727.24" "$1,744.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NTSE-030115-UDH-MB SUP Custom 27203010 NTSE-030115-UDH-MB - XTRT STON 115CM 3FR 1.8CM TPLS MOD BSKT NCRCL NTNL BOTH IP/OP $458.25 $339.11 $0.00 $366.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.11 $340.11 $0.00 $0.00 $95.50 $0.00 $0.00 $0.00 $0.00 $229.13 $362.93 $366.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 N-VVDC-01-ABRM SUP Custom 27803010 N-VVDC-01-ABRM - CATHETER XTRN DRN 3MM 33CM EVM VNTRC BOTH IP/OP $144.00 $106.56 $0.00 $115.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.88 $106.88 $0.00 $0.00 $30.01 $0.00 $0.00 $0.00 $0.00 $72.00 $114.05 $115.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 NWL214066H SUP HCPCS C1785 NWL214066H - PACEMAKER SENSIA DR CARD SEDR01 NWL214066H BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" "$3,825.00" "$3,825.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 "$1,330.25" $0.00 $0.00 "$1,353.20" $0.00 $0.00 $0.00 $0.00 $0.00 OHOOKR-8 SUP HCPCS C1713 OHOOKR-8 - PLATE BN RT OFST OLCRN HK PLT CORT BOTH IP/OP "$2,212.50 " "$1,637.25" $0.00 "$1,770.00" $995.63 $995.63 $0.00 $0.00 $0.00 $461.14 "$1,642.12" "$1,642.12" $0.00 $0.00 $461.09 $0.00 "$1,308.69" "$1,308.69" $0.00 "$1,106.25" "$1,752.30" "$1,770.00" $0.00 $0.00 $346.26 $0.00 $0.00 $352.23 $0.00 $0.00 $0.00 $0.00 $0.00 OM-10000 SUP Custom 27203010 OM-10000 - STABILIZER SURGICAL ACROBAT I SUCTION POD MALLEABLE FOOT BOTH IP/OP "$4,092.50 " "$3,028.45" $0.00 "$3,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,046.25" "$3,241.26" "$3,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 OMST12BT SUP Custom 27203010 OMST12BT - TROCAR LAPSCOP 5-10MM 12MM BLUNT TIP BUILT IN CONVERTER BOTH IP/OP "$1,089.22 " $806.02 $0.00 $871.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $808.42 $808.42 $0.00 $0.00 $226.99 $0.00 $0.00 $0.00 $0.00 $544.61 $862.66 $871.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 OMS-T12BT SUP Custom 27203010 OMS-T12BT - TROCAR LAPSCOP 12MM SPCMKR BLNT TIP BLN STRL DISP PRPERITN BOTH IP/OP $318.05 $235.36 $0.00 $254.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.06 $236.06 $0.00 $0.00 $66.28 $0.00 $0.00 $0.00 $0.00 $159.03 $251.90 $254.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 OMST12T SUP Custom 27203010 OMST12T - BALLON TIP TROCAR BOTH IP/OP "$1,645.90 " "$1,217.97" $0.00 "$1,316.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,221.59" "$1,221.59" $0.00 $0.00 $343.01 $0.00 $0.00 $0.00 $0.00 $822.95 "$1,303.55" "$1,316.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ONB12LGF SUP Custom 27203010 ONB12LGF - TROCAR LAPSCP LNG 12MM 150MM STRL LF VRSPRT V2 FX CNN BLDLS BOTH IP/OP $450.75 $333.56 $0.00 $360.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.55 $334.55 $0.00 $0.00 $93.94 $0.00 $0.00 $0.00 $0.00 $225.38 $356.99 $360.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ONXACE-19 SUP Custom 27803010 ONXACE-19 - VALVE AOR 19MM ONX BOTH IP/OP "$14,875.00 " "$11,007.50" $0.00 "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,099.95" $0.00 $0.00 $0.00 $0.00 "$7,437.50" "$11,781.00" "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ONXACE-21 SUP Custom 27803010 ONXACE-21 - VALVE AOR 21MM ONX BOTH IP/OP "$14,875.00 " "$11,007.50" $0.00 "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,099.95" $0.00 $0.00 $0.00 $0.00 "$7,437.50" "$11,781.00" "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ONXACE-23 SUP Custom 27803010 ONXACE-23 - VALVE AOR 23MM ONX BOTH IP/OP "$14,875.00 " "$11,007.50" $0.00 "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,099.95" $0.00 $0.00 $0.00 $0.00 "$7,437.50" "$11,781.00" "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ONXACE-25 SUP Custom 27803010 ONXACE-25 - VALVE AOR 23.4MM 25MM 17.4MM ONX CNFRM-X SW RING PROS BOTH IP/OP "$14,875.00 " "$11,007.50" $0.00 "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,099.95" $0.00 $0.00 $0.00 $0.00 "$7,437.50" "$11,781.00" "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ONXACE-25/33 SUP Custom 27803010 ONXACE-25/33 - ON-X AORTIC VALVE SIZE 25/33 BOTH IP/OP "$14,875.00 " "$11,007.50" $0.00 "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,099.95" $0.00 $0.00 $0.00 $0.00 "$7,437.50" "$11,781.00" "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ONXACE-27/29 SUP Custom 27803010 ONXACE-27/29 - VALVE AOR 23.4MM 27/29MM 17.4MM ONX CNFRM-X SW RING PROS BOTH IP/OP "$14,875.00 " "$11,007.50" $0.00 "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,099.95" $0.00 $0.00 $0.00 $0.00 "$7,437.50" "$11,781.00" "$11,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 OS-401 SUP Custom 27804086 OS-401 - FILLER BN VOID 4CC BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 OSN-50 SUP HCPCS C1713 OSN-50 - WIRE FX 50MM SLED NTRL OLCRN BOTH IP/OP "$2,150.00 " "$1,591.00" $0.00 "$1,720.00" $967.50 $967.50 $0.00 $0.00 $0.00 $448.11 "$1,595.73" "$1,595.73" $0.00 $0.00 $448.06 $0.00 "$1,271.73" "$1,271.73" $0.00 "$1,075.00" "$1,702.80" "$1,720.00" $0.00 $0.00 $336.48 $0.00 $0.00 $342.28 $0.00 $0.00 $0.00 $0.00 $0.00 OSN-70 SUP HCPCS C1713 OSN-70 - WIRE FIX 70MM SLED NEUTRAL OLECRANON BOTH IP/OP "$2,412.50 " "$1,785.25" $0.00 "$1,930.00" "$1,085.63" "$1,085.63" $0.00 $0.00 $0.00 $502.83 "$1,790.56" "$1,790.56" $0.00 $0.00 $502.77 $0.00 "$1,426.99" "$1,426.99" $0.00 "$1,206.25" "$1,910.70" "$1,930.00" $0.00 $0.00 $377.56 $0.00 $0.00 $384.07 $0.00 $0.00 $0.00 $0.00 $0.00 OSW SUP HCPCS C1713 OSW - WASHER ORTHOPEDIC LP FIX OLECRANON STERILE BOTH IP/OP $687.50 $508.75 $0.00 $550.00 $309.38 $309.38 $0.00 $0.00 $0.00 $143.29 $510.26 $510.26 $0.00 $0.00 $143.28 $0.00 $406.66 $406.66 $0.00 $343.75 $544.50 $550.00 $0.00 $0.00 $107.59 $0.00 $0.00 $109.45 $0.00 $0.00 $0.00 $0.00 $0.00 P100510 SUP HCPCS C1781 P100510 - GRAFT SFT TIS THK1MM 10X5CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $22.05 $22.05 $0.00 $0.00 $0.00 $10.21 $36.37 $36.37 $0.00 $0.00 $10.21 $0.00 $28.98 $28.98 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $7.67 $0.00 $0.00 $7.80 $0.00 $0.00 $0.00 $0.00 $0.00 P101010 SUP HCPCS C9364 P101010 - GRAFT SFT TIS THK1MM 10X10CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P101015 SUP HCPCS C9364 P101015 - GRAFT SFT TIS THK1MM 15X10CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP "$7,500.00 " "$5,550.00" $0.00 "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,563.00" $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$5,940.00" "$6,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P101828 SUP HCPCS C9364 P101828 - GRAFT SFT TIS THK1MM 28X18CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP "$27,720.00 " "$20,512.80" $0.00 "$22,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,776.85" $0.00 $0.00 $0.00 $0.00 "$13,860.00" "$21,954.24" "$22,176.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P151015 SUP HCPCS C9364 P151015 - GRAFT SFT TIS THK1.5MM 15X10CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P151020 SUP HCPCS C9364 P151020 - GRAFT SFT TIS THK1.5MM 10X20CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP $73.50 $54.39 $0.00 $58.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.55 $54.55 $0.00 $0.00 $15.32 $0.00 $0.00 $0.00 $0.00 $36.75 $58.21 $58.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P151520 SUP HCPCS C9364 P151520 - GRAFT SFT TIS THK1.5MM 20X15CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP $49.00 $36.26 $0.00 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.37 $36.37 $0.00 $0.00 $10.21 $0.00 $0.00 $0.00 $0.00 $24.50 $38.81 $39.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P152030 SUP HCPCS C9364 P152030 - GRAFT SFT TIS THK1.5MM 30X20CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP $53.90 $39.89 $0.00 $43.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.00 $40.00 $0.00 $0.00 $11.23 $0.00 $0.00 $0.00 $0.00 $26.95 $42.69 $43.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P152040 SUP HCPCS C9364 P152040 - GRAFT SFT TIS THK1.5MM 40X20CM STRL PERMACOL PRCN DRML CLGN BOTH IP/OP "$43,120.00 " "$31,908.80" $0.00 "$34,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,986.21" $0.00 $0.00 $0.00 $0.00 "$21,560.00" "$34,151.04" "$34,496.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P224PC8T SUP HCPCS C1725 P224PC8T - CATHETER CENTRAL VENOUS BOTH IP/OP $124.88 $92.41 $0.00 $99.90 $67.81 $67.81 $0.00 $0.00 $0.00 $26.03 $92.68 $92.68 $0.00 $0.00 $26.02 $0.00 $73.86 $73.86 $0.00 $62.44 $98.90 $99.90 $0.00 $0.00 $19.54 $0.00 $0.00 $19.88 $0.00 $0.00 $0.00 $0.00 $0.00 P350 SUP Custom 27203010 P350 - PUNCH SURG 3MM SS DRML BIOP RZR SHRP RB HNDL ACPNCH STRL BOTH IP/OP $7.56 $5.59 $0.00 $6.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.78 $5.99 $6.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P4676-110 SUP Custom 27203010 PIPETTE SERO PLST 10ML GRAD PLG MOLD TIP STRL DISP .1ML BOTH IP/OP $33.00 $24.42 $0.00 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.50 $26.14 $26.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 P82012001 SUP HCPCS C1725 CATHETER POLAR DILATOR BALLOON 8X20X120 BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $814.50 $814.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25100-CC SUP HCPCS C1713 PALS-25100-CC - SCREW BN 2.5MM 10MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25120-CC SUP HCPCS C1713 PALS-25120-CC - SCREW BN 2.5MM 12MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25140-CC SUP HCPCS C1713 PALS-25140-CC - SCREW BN 2.5MM 14MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25160-CC SUP HCPCS C1713 PALS-25160-CC - SCREW BN 2.5MM 16MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25180-CC SUP HCPCS C1713 PALS-25180-CC - SCREW BN 2.5MM 18MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25200-CC SUP HCPCS C1713 PALS-25200-CC - SCREW BN 2.5MM 20MM GEMINUS CNN LCK PA COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25220-CC SUP HCPCS C1713 PALS-25220-CC - SCREW BN 2.5MM 22MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25240-CC SUP HCPCS C1713 PALS-25240-CC - SCREW BN 2.5MM 24MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25260-CC SUP HCPCS C1713 PALS-25260-CC - SCREW BN 2.5MM 26MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25280-CC SUP HCPCS C1713 PALS-25280-CC - SCREW BN 2.5MM 28MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PALS-25300-CC SUP HCPCS C1713 PALS-25300-CC - SCREW BN 2.5MM 30MM NS GEMINUS PA LCK CNN COCR DIST VOLR RDS BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $157.50 $157.50 $0.00 $0.00 $0.00 $72.95 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $207.03 $207.03 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $54.78 $0.00 $0.00 $55.72 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35080-TS SUP HCPCS C1713 PANL-35080-TS - SCREW BN 3.5MM 8MM NLCKG TI CORT BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35090-TS SUP HCPCS C1713 PANL-35090-TS - SCREW BN 3.5MM 9MM NLCKG TI CORT BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35100-TS SUP HCPCS C1713 PANL-35100-TS - SCREW BN 3.5MM 10MM BLU NS GEMINUS PA TI CORT VOLR DIST RDS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35110-TS SUP HCPCS C1713 PANL-35110-TS - SCREW BN 3.5MM 11MM BLU NS GEMINUS PA TI CORT VOLR DIST RDS BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35120-TS SUP HCPCS C1713 PANL-35120-TS - SCREW BN 3.5MM 12MM NS GEMINUS PA NLCKG TI CORT DIST VOLR BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35130-TS SUP HCPCS C1713 PANL-35130-TS - SCREW BN 3.5MM 13MM NS GEMINUS PA NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35140-TS SUP HCPCS C1713 PANL-35140-TS - SCREW BN 3.5MM 14MM NS GEMINUS PA NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35150-TS SUP HCPCS C1713 PANL-35150-TS - SCREW BN 3.5MM 15MM NS GEMINUS PA NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35160-TS SUP HCPCS C1713 PANL-35160-TS - SCREW BN 3.5MM 16MM NS GEMINUS PA NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35170-TS SUP HCPCS C1713 PANL-35170-TS - SCREW BN 3.5MM 17MM NS GEMINUS PA NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PANL-35180-TS SUP HCPCS C1713 PANL-35180-TS - SCREW BN 3.5MM 18MM NS GEMINUS PA NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 PAPS1 SUP Custom 27203010 PUMP SCT PK BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PC02520OS SUP HCPCS C1781 PC02520OS - MESH SURG PARIETEX 10X8IN VNTRL HERN OPN SKRT RECT PLSTR BOTH IP/OP "$3,925.00 " "$2,904.50" $0.00 "$3,140.00" "$1,766.25" "$1,766.25" $0.00 $0.00 $0.00 $818.07 "$2,913.14" "$2,913.14" $0.00 $0.00 $817.97 $0.00 "$1,935.03" "$1,935.03" $0.00 "$1,962.50" "$3,108.60" "$3,140.00" $0.00 $0.00 $614.26 $0.00 $0.00 $624.86 $0.00 $0.00 $0.00 $0.00 $0.00 PC1016SN SUP HCPCS C1768 PC1016SN - PATCH CARDIO 16X10CM APEX PROCESSING SUPPLE PERI-GUARD BOTH IP/OP "$1,767.10 " "$1,307.65" $0.00 "$1,413.68" $795.19 $795.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.55 "$1,399.54" "$1,413.68" $0.00 $0.00 $276.55 $0.00 $0.00 $281.32 $0.00 $0.00 $0.00 $0.00 $0.00 PC-1016SN SUP HCPCS C1768 PC-1016SN - PATCH CV 16X10CM SP PRGRD APX PRC BVN PRICRD BOTH IP/OP "$2,027.50 " "$1,500.35" $0.00 "$1,504.81" $795.19 $795.19 $0.00 $0.00 $0.00 $422.58 "$1,504.81" "$1,504.81" $0.00 $0.00 $422.53 $0.00 "$1,199.27" "$1,199.27" $0.00 $883.55 "$1,399.54" "$1,413.68" $0.00 $0.00 $276.55 $0.00 $0.00 $281.32 $0.00 $0.00 $0.00 $0.00 $0.00 PC111 SUP Custom 27803010 PC111 - LEGEND FN2-DISS TO M-SCHR(UK) BOTH IP/OP $405.90 $300.37 $0.00 $324.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.26 $301.26 $0.00 $0.00 $84.59 $0.00 $0.00 $0.00 $0.00 $202.95 $321.47 $324.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PCA-15 SUP HCPCS C1713 "PCA-15 - LOCKING PLATE, CURVED A, 15-HOLE" BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 PCB10 SUP HCPCS C1713 PCB10 - PLATE BN CRV B NS 10 HL LCK BOTH IP/OP "$2,587.50 " "$1,914.75" $0.00 "$2,070.00" "$1,164.38" "$1,164.38" $0.00 $0.00 $0.00 $539.30 "$1,920.44" "$1,920.44" $0.00 $0.00 $539.24 $0.00 "$1,275.64" "$1,275.64" $0.00 "$1,293.75" "$2,049.30" "$2,070.00" $0.00 $0.00 $404.94 $0.00 $0.00 $411.93 $0.00 $0.00 $0.00 $0.00 $0.00 PCB15 SUP HCPCS C1713 PCB15 - PLATE BN CRV B NS 15 HL LCK BOTH IP/OP "$3,375.00 " "$2,497.50" $0.00 "$2,700.00" "$1,518.75" "$1,518.75" $0.00 $0.00 $0.00 $703.43 "$2,504.93" "$2,504.93" $0.00 $0.00 $703.35 $0.00 "$1,663.88" "$1,663.88" $0.00 "$1,687.50" "$2,673.00" "$2,700.00" $0.00 $0.00 $528.19 $0.00 $0.00 $537.30 $0.00 $0.00 $0.00 $0.00 $0.00 PCDT1 SUP HCPCS C1781 PCDT1 - MESH SRG OVL 13X10IN STRL PRC FLXB TISS SEP LTWT MFL PRLN BOTH IP/OP "$6,122.25 " "$4,530.47" $0.00 "$4,897.80" "$2,755.01" "$2,755.01" $0.00 $0.00 $0.00 "$1,276.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,275.88" $0.00 "$3,018.27" "$3,018.27" $0.00 "$3,061.13" "$4,848.82" "$4,897.80" $0.00 $0.00 $958.13 $0.00 $0.00 $974.66 $0.00 $0.00 $0.00 $0.00 $0.00 PCO12 SUP HCPCS C1781 PCO12 - MESH SRG RND 4.8IN PARIETEX COMP 3D WV RND PLSTR VNTRL HRN BOTH IP/OP "$1,322.03 " $978.30 $0.00 "$1,057.62" $594.91 $594.91 $0.00 $0.00 $0.00 $275.54 $981.21 $981.21 $0.00 $0.00 $275.51 $0.00 $781.98 $781.98 $0.00 $661.01 "$1,047.05" "$1,057.62" $0.00 $0.00 $206.90 $0.00 $0.00 $210.47 $0.00 $0.00 $0.00 $0.00 $0.00 PCO12X SUP HCPCS C1781 PCO12X - MESH SURG ROUND 12CM 2X4.8IN 2 SIDE OPTIMIZE COMPOSITE LARGE BOTH IP/OP $951.10 $703.81 $0.00 $966.20 $543.49 $543.49 $0.00 $0.00 $0.00 $198.23 $705.91 $705.91 $0.00 $0.00 $198.21 $0.00 $562.58 $562.58 $0.00 $603.88 $956.54 $966.20 $0.00 $0.00 $189.01 $0.00 $0.00 $192.27 $0.00 $0.00 $0.00 $0.00 $0.00 PCO1510OS SUP HCPCS C1781 PCO1510OS - MESH SRG RECT 6X4IN PARIETEX RSRB COMP PLSTR VNTRL HRN BOTH IP/OP "$1,704.65 " "$1,261.44" $0.00 "$1,363.72" $767.09 $767.09 $0.00 $0.00 $0.00 $355.29 "$1,265.19" "$1,265.19" $0.00 $0.00 $355.25 $0.00 "$1,008.30" "$1,008.30" $0.00 $852.33 "$1,350.08" "$1,363.72" $0.00 $0.00 $266.78 $0.00 $0.00 $271.38 $0.00 $0.00 $0.00 $0.00 $0.00 PCO15X SUP HCPCS C1781 PCO15X - MESH SURG ROUND 15CM OPTIMIZE COMPOSITE PROPRIETARY TEXTILE BOTH IP/OP "$1,244.88 " $921.21 $0.00 "$1,264.40" $711.23 $711.23 $0.00 $0.00 $0.00 $259.46 $923.95 $923.95 $0.00 $0.00 $259.43 $0.00 $736.34 $736.34 $0.00 $790.25 "$1,251.76" "$1,264.40" $0.00 $0.00 $247.35 $0.00 $0.00 $251.62 $0.00 $0.00 $0.00 $0.00 $0.00 PCO2015X SUP HCPCS C1781 PCO2015X - MESH SURG RECTANGLE OVAL 20X15CM OPTIMIZE COMPOSITE 2 SIDE BOTH IP/OP "$1,525.73 " "$1,129.04" $0.00 "$1,549.94" $871.84 $871.84 $0.00 $0.00 $0.00 $318.00 "$1,132.39" "$1,132.39" $0.00 $0.00 $317.96 $0.00 $902.47 $902.47 $0.00 $968.71 "$1,534.44" "$1,549.94" $0.00 $0.00 $303.21 $0.00 $0.00 $308.44 $0.00 $0.00 $0.00 $0.00 $0.00 PCO20X SUP HCPCS C1781 PCO20X - MESH SURG ROUND 20CM 8IN COMPOSITE OPTIMIZE PROPRIETARY BOTH IP/OP "$1,830.70 " "$1,354.72" $0.00 "$2,564.92" "$1,442.77" "$1,442.77" $0.00 $0.00 $0.00 $381.56 "$1,358.75" "$1,358.75" $0.00 $0.00 $381.52 $0.00 "$1,082.86" "$1,082.86" $0.00 "$1,603.08" "$2,539.27" "$2,564.92" $0.00 $0.00 $501.76 $0.00 $0.00 $510.42 $0.00 $0.00 $0.00 $0.00 $0.00 PCO2520OS SUP HCPCS C1781 PCO2520OS - MESH SRG RECT RND 10X8IN STRL LF PARIETEX OPN SKRT OPTIMIZE BOTH IP/OP "$4,387.38 " "$3,246.66" $0.00 "$3,509.90" "$1,974.32" "$1,974.32" $0.00 $0.00 $0.00 $914.44 "$3,256.31" "$3,256.31" $0.00 $0.00 $914.33 $0.00 "$2,162.98" "$2,162.98" $0.00 "$2,193.69" "$3,474.80" "$3,509.90" $0.00 $0.00 $686.62 $0.00 $0.00 $698.47 $0.00 $0.00 $0.00 $0.00 $0.00 PCO2520X SUP HCPCS C1781 PCO2520X - MESH SURG RECTANGLE OVAL 25X20CM 2 SIDE OPTIMIZE COMPOSITE BOTH IP/OP "$2,318.93 " "$1,716.01" $0.00 "$2,355.72" "$1,325.09" "$1,325.09" $0.00 $0.00 $0.00 $483.32 "$1,721.11" "$1,721.11" $0.00 $0.00 $483.26 $0.00 "$1,371.64" "$1,371.64" $0.00 "$1,472.33" "$2,332.16" "$2,355.72" $0.00 $0.00 $460.84 $0.00 $0.00 $468.79 $0.00 $0.00 $0.00 $0.00 $0.00 PCO3020 SUP HCPCS C1781 PCO3020 - MESH SRG RECT 12X8IN PARIETEX RSRB COMP SKRT RECT PLSTR BOTH IP/OP "$4,471.20 " "$3,308.69" $0.00 "$3,576.96" "$2,012.04" "$2,012.04" $0.00 $0.00 $0.00 $931.91 "$3,318.52" "$3,318.52" $0.00 $0.00 $931.80 $0.00 "$2,204.30" "$2,204.30" $0.00 "$2,235.60" "$3,541.19" "$3,576.96" $0.00 $0.00 $699.74 $0.00 $0.00 $711.82 $0.00 $0.00 $0.00 $0.00 $0.00 PCO3020X SUP HCPCS C1781 PCO3020X - MESH SURG RECTANGLE OVAL 30X20CM OPTIMIZE COMPOSITE TEXTILE BOTH IP/OP "$3,170.33 " "$2,346.04" $0.00 "$3,220.64" "$1,811.61" "$1,811.61" $0.00 $0.00 $0.00 $660.77 "$2,353.02" "$2,353.02" $0.00 $0.00 $660.70 $0.00 "$1,562.97" "$1,562.97" $0.00 "$2,012.90" "$3,188.43" "$3,220.64" $0.00 $0.00 $630.04 $0.00 $0.00 $640.91 $0.00 $0.00 $0.00 $0.00 $0.00 PCO3728 SUP HCPCS C1781 PCO3728 - MESH SRG RECT 14.5X11IN LF PARIETEX 3D WV RSRB COMP PLSTR BOTH IP/OP "$5,309.55 " "$3,929.07" $0.00 "$4,247.64" "$2,389.30" "$2,389.30" $0.00 $0.00 $0.00 "$1,106.64" "$3,940.75" "$3,940.75" $0.00 $0.00 "$1,106.51" $0.00 "$2,617.61" "$2,617.61" $0.00 "$2,654.78" "$4,205.16" "$4,247.64" $0.00 $0.00 $830.94 $0.00 $0.00 $845.28 $0.00 $0.00 $0.00 $0.00 $0.00 PCO8OSX SUP HCPCS C1781 PCO8OSX - PARIETEX DUAL MESH POLYESTER SKIRTED 8 CM ROUND BOTH IP/OP "$1,147.35 " $849.04 $0.00 $917.88 $516.31 $516.31 $0.00 $0.00 $0.00 $239.14 $851.56 $851.56 $0.00 $0.00 $239.11 $0.00 $678.66 $678.66 $0.00 $573.68 $908.70 $917.88 $0.00 $0.00 $179.56 $0.00 $0.00 $182.66 $0.00 $0.00 $0.00 $0.00 $0.00 PCO9 SUP HCPCS C1781 PCO9 - MESH SRG RND 3.6IN STRL PARIETEX RND RSRB 3D WV PLSTR VNTRL BOTH IP/OP $958.53 $709.31 $0.00 $766.82 $431.34 $431.34 $0.00 $0.00 $0.00 $199.78 $711.42 $711.42 $0.00 $0.00 $199.76 $0.00 $566.97 $566.97 $0.00 $479.26 $759.16 $766.82 $0.00 $0.00 $150.01 $0.00 $0.00 $152.60 $0.00 $0.00 $0.00 $0.00 $0.00 PCO9X SUP HCPCS C1781 PCO9X - MESH SURG ROUND 9CM OPTIMIZE COMPOSITE PROPRIETARY TEXTILE BOTH IP/OP $231.17 $171.07 $0.00 $234.84 $132.10 $132.10 $0.00 $0.00 $0.00 $48.18 $171.57 $171.57 $0.00 $0.00 $48.18 $0.00 $136.74 $136.74 $0.00 $146.78 $232.49 $234.84 $0.00 $0.00 $45.94 $0.00 $0.00 $46.73 $0.00 $0.00 $0.00 $0.00 $0.00 PCP 050 120 130 SUP HCPCS C1725 PCP 050 120 130 - CATHETER BLNDIL 5MM 130CM 120MM PCFC + OTW LOPRFL COAX BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $305.44 $305.44 $0.00 $0.00 $0.00 $117.24 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $332.72 $332.72 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $88.03 $0.00 $0.00 $89.55 $0.00 $0.00 $0.00 $0.00 $0.00 PD0606 SUP Custom 27803010 PD0606 - PATCH BIOLOGICAL L6 CM X W6 CM W PORCINE DERMIS SOFT TISSUE BOTH IP/OP "$1,566.00 " "$1,158.84" $0.00 "$1,252.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,162.29" "$1,162.29" $0.00 $0.00 $326.35 $0.00 $0.00 $0.00 $0.00 $783.00 "$1,240.27" "$1,252.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD0808 SUP Custom 27803010 PD0808 - PATCH BIOLOGICAL L8 CM X W8 CM W PORCINE DERMIS SOFT TISSUE BOTH IP/OP "$2,784.00 " "$2,060.16" $0.00 "$2,227.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,066.28" "$2,066.28" $0.00 $0.00 $580.19 $0.00 $0.00 $0.00 $0.00 "$1,392.00" "$2,204.93" "$2,227.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD0822 SUP Custom 27803010 PD0822 - PATCH BIOLOGICAL L22 CM X W8 CM W PORCINE DERMIS SOFT TISSUE BOTH IP/OP "$7,656.00 " "$5,665.44" $0.00 "$6,124.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,595.51" $0.00 $0.00 $0.00 $0.00 "$3,828.00" "$6,063.55" "$6,124.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD1010 SUP Custom 27803010 PD1010 - PATCH BIOLOGICAL L10 CM X W10 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$4,350.00 " "$3,219.00" $0.00 "$3,480.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,228.57" "$3,228.57" $0.00 $0.00 $906.54 $0.00 $0.00 $0.00 $0.00 "$2,175.00" "$3,445.20" "$3,480.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD1016 SUP Custom 27803010 PD1016 - PATCH BIOLOGICAL L10 CM X W16 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$6,960.00 " "$5,150.40" $0.00 "$5,568.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,450.46" $0.00 $0.00 $0.00 $0.00 "$3,480.00" "$5,512.32" "$5,568.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD1025 SUP Custom 27803010 PD1025 - PATCH BIOLOGICAL L10 CM X W25 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$10,875.00 " "$8,047.50" $0.00 "$8,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,266.35" $0.00 $0.00 $0.00 $0.00 "$5,437.50" "$8,613.00" "$8,700.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD1620 SUP Custom 27803010 PD1620 - PATCH BIOLOGICAL L16 CM X W20 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$13,920.00 " "$10,300.80" $0.00 "$11,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,900.93" $0.00 $0.00 $0.00 $0.00 "$6,960.00" "$11,024.64" "$11,136.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD2020 SUP Custom 27803010 PD2020 - PATCH BIOLOGICAL L20 CM X W20 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$17,400.00 " "$12,876.00" $0.00 "$13,920.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,626.16" $0.00 $0.00 $0.00 $0.00 "$8,700.00" "$13,780.80" "$13,920.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD2025 SUP Custom 27803010 PD2025 - PATCH BIOLOGICAL L25 CM X W20 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$21,750.00 " "$16,095.00" $0.00 "$17,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,532.70" $0.00 $0.00 $0.00 $0.00 "$10,875.00" "$17,226.00" "$17,400.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD2035 SUP Custom 27803010 PD2035 - PATCH BIOLOGICAL L35 CM X W20 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$30,450.00 " "$22,533.00" $0.00 "$24,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,345.78" $0.00 $0.00 $0.00 $0.00 "$15,225.00" "$24,116.40" "$24,360.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD3030 SUP Custom 27803010 PD3030 - PATCH BIOLOGICAL L30 CM X W30 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$39,150.00 " "$28,971.00" $0.00 "$31,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,158.86" $0.00 $0.00 $0.00 $0.00 "$19,575.00" "$31,006.80" "$31,320.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PD-31-200 SUP HCPCS C1713 PD-31-200 - CAGE SPNL B STRL DTRAX TI CRV BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 PD-31-201 SUP HCPCS C1713 PD-31-201 - CAVUX CERVICAL CAGE B 5MM BOTH IP/OP "$4,375.00 " "$3,237.50" $0.00 "$3,500.00" "$1,968.75" "$1,968.75" $0.00 $0.00 $0.00 $911.86 "$3,247.13" "$3,247.13" $0.00 $0.00 $911.75 $0.00 "$2,156.88" "$2,156.88" $0.00 "$2,187.50" "$3,465.00" "$3,500.00" $0.00 $0.00 $684.69 $0.00 $0.00 $696.50 $0.00 $0.00 $0.00 $0.00 $0.00 PD-32-301 SUP HCPCS C1713 PD-32-301 - DTRAX BONE SCREW BOTH IP/OP "$1,000.00 " $740.00 $0.00 $800.00 $450.00 $450.00 $0.00 $0.00 $0.00 $208.43 $742.20 $742.20 $0.00 $0.00 $208.40 $0.00 $591.50 $591.50 $0.00 $500.00 $792.00 $800.00 $0.00 $0.00 $156.50 $0.00 $0.00 $159.20 $0.00 $0.00 $0.00 $0.00 $0.00 PD3535 SUP Custom 27803010 PD3535 - PATCH BIOLOGICAL L35 CM X W35 CM W PORCINE DERMIS SOFT TISSU BOTH IP/OP "$52,925.00 " "$39,164.50" $0.00 "$42,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$11,029.57" $0.00 $0.00 $0.00 $0.00 "$26,462.50" "$41,916.60" "$42,340.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PDG-AIM-015 SUP HCPCS C1713 PDG-AIM-015 - GUIDE SURG 1.5MM AIMING GEMINUS VOLAR DISTAL RAD BOTH IP/OP $75.00 $55.50 $0.00 $60.00 $33.75 $33.75 $0.00 $0.00 $0.00 $15.63 $55.67 $55.67 $0.00 $0.00 $15.63 $0.00 $44.36 $44.36 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 PF-20 SUP HCPCS C1729 PF-20 - CATHETER DRN 20FR STRL ACT CLRNC TCH PLEURAFLOW CHST TUBE BOTH IP/OP $968.75 $716.88 $0.00 $775.00 $526.03 $526.03 $0.00 $0.00 $0.00 $201.91 $719.01 $719.01 $0.00 $0.00 $201.89 $0.00 $573.02 $573.02 $0.00 $484.38 $767.25 $775.00 $0.00 $0.00 $151.61 $0.00 $0.00 $154.23 $0.00 $0.00 $0.00 $0.00 $0.00 PF-24 SUP HCPCS C1729 PF-24 - CATHETER DRN 24FR STRL PLEURAFLOW ACT CLRNC TCH CHST TUBE BOTH IP/OP $912.50 $675.25 $0.00 $730.00 $495.49 $495.49 $0.00 $0.00 $0.00 $190.19 $677.26 $677.26 $0.00 $0.00 $190.17 $0.00 $539.74 $539.74 $0.00 $456.25 $722.70 $730.00 $0.00 $0.00 $142.81 $0.00 $0.00 $145.27 $0.00 $0.00 $0.00 $0.00 $0.00 PF-28 SUP HCPCS C1729 PF-28 - CATHETER DRN 28FR STRL ACT CLRNC TCH PLEURAFLOW CHST TUBE BOTH IP/OP $912.50 $675.25 $0.00 $730.00 $495.49 $495.49 $0.00 $0.00 $0.00 $190.19 $677.26 $677.26 $0.00 $0.00 $190.17 $0.00 $539.74 $539.74 $0.00 $456.25 $722.70 $730.00 $0.00 $0.00 $142.81 $0.00 $0.00 $145.27 $0.00 $0.00 $0.00 $0.00 $0.00 PF-32 SUP HCPCS C1729 PF-32 - CATHETER DRN 32FR PLEURAFLOW ACT CLRNC TCH BOTH IP/OP $912.50 $675.25 $0.00 $730.00 $495.49 $495.49 $0.00 $0.00 $0.00 $190.19 $677.26 $677.26 $0.00 $0.00 $190.17 $0.00 $539.74 $539.74 $0.00 $456.25 $722.70 $730.00 $0.00 $0.00 $142.81 $0.00 $0.00 $145.27 $0.00 $0.00 $0.00 $0.00 $0.00 PFF0025 SUP HCPCS C1713 PFF0025 - SCREW PFF0025 25MM FACET FIXATION ANCHOR BOTH IP/OP "$5,940.00 " "$4,395.60" $0.00 "$4,752.00" "$2,673.00" "$2,673.00" $0.00 $0.00 $0.00 "$1,238.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,237.90" $0.00 "$2,928.42" "$2,928.42" $0.00 "$2,970.00" "$4,704.48" "$4,752.00" $0.00 $0.00 $929.61 $0.00 $0.00 $945.65 $0.00 $0.00 $0.00 $0.00 $0.00 PFF0030 SUP HCPCS C1713 PFF0030 - SCREW PFF0030 30MM FACET FIXATION ANCHOR BOTH IP/OP "$5,940.00 " "$4,395.60" $0.00 "$4,752.00" "$2,673.00" "$2,673.00" $0.00 $0.00 $0.00 "$1,238.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,237.90" $0.00 "$2,928.42" "$2,928.42" $0.00 "$2,970.00" "$4,704.48" "$4,752.00" $0.00 $0.00 $929.61 $0.00 $0.00 $945.65 $0.00 $0.00 $0.00 $0.00 $0.00 PFF0035 SUP HCPCS C1713 PFF0035 - SCREW PFF0035 35MM FACET FIXATION ANCHOR BOTH IP/OP "$5,940.00 " "$4,395.60" $0.00 "$4,752.00" "$2,673.00" "$2,673.00" $0.00 $0.00 $0.00 "$1,238.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,237.90" $0.00 "$2,928.42" "$2,928.42" $0.00 "$2,970.00" "$4,704.48" "$4,752.00" $0.00 $0.00 $929.61 $0.00 $0.00 $945.65 $0.00 $0.00 $0.00 $0.00 $0.00 PFF0040 SUP HCPCS C1713 PFF0040 - SCREW PFF0040 40MM FACET FIXATION ANCHOR BOTH IP/OP "$5,940.00 " "$4,395.60" $0.00 "$4,752.00" "$2,673.00" "$2,673.00" $0.00 $0.00 $0.00 "$1,238.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,237.90" $0.00 "$2,928.42" "$2,928.42" $0.00 "$2,970.00" "$4,704.48" "$4,752.00" $0.00 $0.00 $929.61 $0.00 $0.00 $945.65 $0.00 $0.00 $0.00 $0.00 $0.00 PGEN00506 SUP Custom 27203010 PGEN00506 - TIP APPLICATOR 6IN SPRAY EXTENDED ERGONOMIC APPLICATOR BOTH IP/OP "$1,390.00 " "$1,028.60" $0.00 "$1,031.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,031.66" "$1,031.66" $0.00 $0.00 $289.68 $0.00 $0.00 $0.00 $0.00 $425.00 $673.20 $680.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PGPS002 SUP Custom 27203010 PGPS002 - SEALANT PROGEL PLEURAL AIR LEAK BOTH IP/OP "$2,453.75 " "$1,815.78" $0.00 "$1,821.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,821.17" "$1,821.17" $0.00 $0.00 $511.36 $0.00 $0.00 $0.00 $0.00 "$1,037.50" "$1,643.40" "$1,660.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PHSE6 SUP HCPCS C1781 PHSE6 - MESH HERN POLYPRO 4 15/16INX2 5/32INX.5IN NABSB SFT KNTD BOTH IP/OP "$1,704.02 " "$1,260.97" $0.00 "$1,363.22" $766.81 $766.81 $0.00 $0.00 $0.00 $355.16 "$1,264.72" "$1,264.72" $0.00 $0.00 $355.12 $0.00 "$1,007.93" "$1,007.93" $0.00 $852.01 "$1,349.58" "$1,363.22" $0.00 $0.00 $266.68 $0.00 $0.00 $271.28 $0.00 $0.00 $0.00 $0.00 $0.00 PHSM SUP HCPCS C1781 PHSM - MESH SURG 3IN 3D MEDIUM 2 15/16IN .75IN 3 15/16INX1.75INX.5 BOTH IP/OP $882.48 $653.04 $0.00 $705.99 $397.12 $397.12 $0.00 $0.00 $0.00 $183.93 $654.98 $654.98 $0.00 $0.00 $183.91 $0.00 $521.99 $521.99 $0.00 $441.24 $698.92 $705.99 $0.00 $0.00 $138.11 $0.00 $0.00 $140.49 $0.00 $0.00 $0.00 $0.00 $0.00 PHSM6 SUP HCPCS C1781 PHSM6 - MESH HERN POLYPRO 3 15/16INX1.75INX.5IN NABSB SFT KNTD PRLN BOTH IP/OP "$1,704.02 " "$1,260.97" $0.00 "$1,363.22" $766.81 $766.81 $0.00 $0.00 $0.00 $355.16 "$1,264.72" "$1,264.72" $0.00 $0.00 $355.12 $0.00 "$1,007.93" "$1,007.93" $0.00 $852.01 "$1,349.58" "$1,363.22" $0.00 $0.00 $266.68 $0.00 $0.00 $271.28 $0.00 $0.00 $0.00 $0.00 $0.00 PHY1015V SUP HCPCS C1781 PHY1015V - MESH SURG 15X10CM FLEXIBLE COMPOSITE TISSUE SEPARATE LP BOTH IP/OP "$1,856.93 " "$1,374.13" $0.00 "$1,485.54" $835.62 $835.62 $0.00 $0.00 $0.00 $387.03 "$1,378.21" "$1,378.21" $0.00 $0.00 $386.98 $0.00 "$1,098.37" "$1,098.37" $0.00 $928.46 "$1,470.69" "$1,485.54" $0.00 $0.00 $290.61 $0.00 $0.00 $295.62 $0.00 $0.00 $0.00 $0.00 $0.00 PHY1520V SUP HCPCS C1781 PHY1520V - MESH SURG 20X15CM FLEXIBLE COMPOSITE TISSUE SEPARATE LP OVAL BOTH IP/OP "$3,372.53 " "$2,495.67" $0.00 "$2,698.02" "$1,517.64" "$1,517.64" $0.00 $0.00 $0.00 $702.92 "$2,503.09" "$2,503.09" $0.00 $0.00 $702.83 $0.00 "$1,662.65" "$1,662.65" $0.00 "$1,686.26" "$2,671.04" "$2,698.02" $0.00 $0.00 $527.80 $0.00 $0.00 $536.91 $0.00 $0.00 $0.00 $0.00 $0.00 PHY2025V SUP HCPCS C1781 PHY2025V - MESH SURG 25X20CM FLEXIBLE COMPOSITE TISSUE SEPARATE LP BOTH IP/OP "$5,461.58 " "$4,041.57" $0.00 "$4,369.26" "$2,457.71" "$2,457.71" $0.00 $0.00 $0.00 "$1,138.33" "$4,053.58" "$4,053.58" $0.00 $0.00 "$1,138.19" $0.00 "$2,692.56" "$2,692.56" $0.00 "$2,730.79" "$4,325.57" "$4,369.26" $0.00 $0.00 $854.74 $0.00 $0.00 $869.48 $0.00 $0.00 $0.00 $0.00 $0.00 PHY2030R SUP HCPCS C1781 PHY2030R - MESH SURG 30X20CM FLEXIBLE COMPOSITE TISSUE SEPARATE BOTH IP/OP "$5,891.08 " "$4,359.40" $0.00 "$4,712.86" "$2,650.98" "$2,650.98" $0.00 $0.00 $0.00 "$1,227.85" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,227.70" $0.00 "$2,904.30" "$2,904.30" $0.00 "$2,945.54" "$4,665.74" "$4,712.86" $0.00 $0.00 $921.95 $0.00 $0.00 $937.86 $0.00 $0.00 $0.00 $0.00 $0.00 PIC-301-IK SUP HCPCS C1729 PIC LINE 3FR BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 PIKA SUP Custom 27203010 PIKA - PERCUTANEOUS INSERTION KIT ARTERIAL BOTH IP/OP $157.63 $116.65 $0.00 $126.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.99 $116.99 $0.00 $0.00 $32.85 $0.00 $0.00 $0.00 $0.00 $78.81 $124.84 $126.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PIKV SUP Custom 27203010 PIKV - KIT CATH INS .038IN 18GA 11 SCPL INS NDL SYR GW DIL VN PERC BOTH IP/OP $159.99 $118.39 $0.00 $127.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.74 $118.74 $0.00 $0.00 $33.34 $0.00 $0.00 $0.00 $0.00 $79.99 $126.71 $127.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PJN1976284 SUP HCPCS C1898 PJN1976284 - LEAD PCMKR 58CM CP NV AV STRD-ELUT SIL BIPOL ACT PJN1976284 BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $675.00 $675.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $234.75 $0.00 $0.00 $238.80 $0.00 $0.00 $0.00 $0.00 $0.00 PK-16 SUP HCPCS V2790 PK-16 - GRAFT SFT TIS THK50-100UM 16MM AMNIOGRAFT PROKERA AMNIO BOTH IP/OP "$2,372.50 " "$1,755.65" $0.00 "$1,790.00" "$1,006.88" "$1,006.88" $0.00 $0.00 $0.00 $494.49 "$1,760.87" "$1,760.87" $0.00 $0.00 $494.43 $0.00 "$1,403.33" "$1,403.33" $0.00 "$1,118.75" "$1,772.10" "$1,790.00" $0.00 $0.00 $350.17 $0.00 $0.00 $356.21 $0.00 $0.00 $0.00 $0.00 $0.00 PL-2080 SUP HCPCS C1713 PL-2080 - SCREW BN CNTRSNK CO CA BOTH IP/OP $352.50 $260.85 $0.00 $282.00 $158.63 $158.63 $0.00 $0.00 $0.00 $73.47 $261.63 $261.63 $0.00 $0.00 $73.46 $0.00 $208.50 $208.50 $0.00 $176.25 $279.18 $282.00 $0.00 $0.00 $55.17 $0.00 $0.00 $56.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLA230300 SUP Custom 27806190 PLA230300 - GRAFT EVAS 23MM 19-21MM 3.3CM AORTA BOTH IP/OP "$8,932.50 " "$6,610.05" $0.00 "$6,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,861.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,861.53" $0.00 "$4,403.72" "$4,403.72" $0.00 "$3,968.75" "$6,286.50" "$6,350.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PLA320400 SUP HCPCS C1874 PLA320400 - GRAFT EVAS 32MM 27-29MM 4.5CM XCLDR STNT XTD ABRSN RST BOTH IP/OP "$8,932.50 " "$6,610.05" $0.00 "$6,508.00" "$3,660.75" "$3,660.75" $0.00 $0.00 $0.00 "$1,861.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,861.53" $0.00 "$4,403.72" "$4,403.72" $0.00 "$4,067.50" "$6,442.92" "$6,508.00" $0.00 $0.00 "$1,273.13" $0.00 $0.00 "$1,295.09" $0.00 $0.00 $0.00 $0.00 $0.00 PL-BG07 SUP Custom 27203010 PL-BG07 - BIT DRILL 7MM BNGFT HRVT BOTH IP/OP $852.50 $630.85 $0.00 $682.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.73 $632.73 $0.00 $0.00 $177.66 $0.00 $0.00 $0.00 $0.00 $426.25 $675.18 $682.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PL-BSWDL SUP HCPCS C1713 PL-BSWDL - PLATE BN NS WDG LT 1ST MTP BOTH IP/OP "$1,592.50 " "$1,178.45" $0.00 "$1,274.00" $716.63 $716.63 $0.00 $0.00 $0.00 $331.92 "$1,181.95" "$1,181.95" $0.00 $0.00 $331.88 $0.00 $941.96 $941.96 $0.00 $796.25 "$1,261.26" "$1,274.00" $0.00 $0.00 $249.23 $0.00 $0.00 $253.53 $0.00 $0.00 $0.00 $0.00 $0.00 PL-BSWDR SUP HCPCS C1713 PL-BSWDR - PLATE BN NS WDG TI RT MTRSL OSTM BOTH IP/OP "$1,592.50 " "$1,178.45" $0.00 "$1,274.00" $716.63 $716.63 $0.00 $0.00 $0.00 $331.92 "$1,181.95" "$1,181.95" $0.00 $0.00 $331.88 $0.00 $941.96 $941.96 $0.00 $796.25 "$1,261.26" "$1,274.00" $0.00 $0.00 $249.23 $0.00 $0.00 $253.53 $0.00 $0.00 $0.00 $0.00 $0.00 PLC141400 SUP HCPCS C1874 PLC141400 - GRAFT EVAS 14.5MM 12-13.5MM 14CM GORE XCLDR CNTRLT LG AAA BOTH IP/OP "$12,695.00 " "$9,394.30" $0.00 "$9,246.00" "$5,200.88" "$5,200.88" $0.00 $0.00 $0.00 "$2,645.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,645.64" $0.00 "$6,258.64" "$6,258.64" $0.00 "$5,778.75" "$9,153.54" "$9,246.00" $0.00 $0.00 "$1,808.75" $0.00 $0.00 "$1,839.95" $0.00 $0.00 $0.00 $0.00 $0.00 PLC161000 SUP HCPCS C1876 PLC161000 - GRAFT EVAS 16MM 13.5-14.5MM 9.5CM XCLDR STNT ABRSN RST BOTH IP/OP "$12,695.00 " "$9,394.30" $0.00 "$9,020.00" "$5,073.75" "$5,073.75" $0.00 $0.00 $0.00 "$2,645.96" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,645.64" $0.00 "$6,258.64" "$6,258.64" $0.00 "$5,637.50" "$8,929.80" "$9,020.00" $0.00 $0.00 "$1,764.54" $0.00 $0.00 "$1,794.98" $0.00 $0.00 $0.00 $0.00 $0.00 PL-CL6SL SUP HCPCS C1713 PL-CL6SL - PLATE SM TI 6 HOLE LCK BONE LEFT CLVCL NONSTRL BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 PL-CL6SR SUP HCPCS C1713 PL-CL6SR - PLATE SM 5MM TI 6 HOLE LCK ACUMED BONE RIGHT CLVCL NONSTRL BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 PL-CL8JR SUP HCPCS C1713 PL-CL8JR - PLATE TI 8 HOLE J LCK SYS BONE RIGHT CLVCL SHLDR STRL BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 PL-CL8LL SUP HCPCS C1713 PL-CL8LL - PLATE LG TI 8 HOLE LCK BONE CLVCL STRL BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 PL-CL8LR SUP HCPCS C1713 PL-CL8LR - PLATE LG TI 8 HOLE LCK ACUMED BONE RIGHT CLVCL SHLDR STRL BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DL26 SUP HCPCS C1713 PL-DL26 - PLATE BN 26MM LT DRSL RADL BOTH IP/OP "$1,115.00 " $825.10 $0.00 $892.00 $501.75 $501.75 $0.00 $0.00 $0.00 $232.39 $827.55 $827.55 $0.00 $0.00 $232.37 $0.00 $659.52 $659.52 $0.00 $557.50 $883.08 $892.00 $0.00 $0.00 $174.50 $0.00 $0.00 $177.51 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DMTPL SUP HCPCS C1713 PL-DMTPL - PLATE TI FSN BONE LEFT DORSAL MTP NONSTRL BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DMTPR SUP HCPCS C1713 PL-DMTPR - PLATE TI BONE RIGHT DORSAL 1ST MTP NONSTRL BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR26 SUP HCPCS C1713 PL-DR26 - PLATE BN 26MM NS TI RT DIST DRSL RADL BOTH IP/OP "$1,115.00 " $825.10 $0.00 $892.00 $501.75 $501.75 $0.00 $0.00 $0.00 $232.39 $827.55 $827.55 $0.00 $0.00 $232.37 $0.00 $659.52 $659.52 $0.00 $557.50 $883.08 $892.00 $0.00 $0.00 $174.50 $0.00 $0.00 $177.51 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR30L SUP HCPCS C1713 PL-DR30L - PLATE BN NAR ACLC RDS LT DIST VOLR BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR30R SUP HCPCS C1713 PL-DR30R - PLATE BN NAR ACLC RDS RT DIST VOLR BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR50L SUP HCPCS C1713 PL-DR50L - PLATE BN STD ACLC RDS LT DIST VOLR BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR50R SUP HCPCS C1713 PL-DR50R - PLATE BN STD ACLC RDS RT DIST VOLR BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PLDR60L SUP HCPCS C1713 PLDR60L - PLATE LNG STD BONE LEFT DISTAL RADL BOTH IP/OP "$1,737.50 " "$1,285.75" $0.00 "$1,390.00" $781.88 $781.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $868.75 "$1,376.10" "$1,390.00" $0.00 $0.00 $271.92 $0.00 $0.00 $276.61 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR60L SUP HCPCS C1713 PL-DR60L - PLATE LNG 60MM TI 6 HOLE ACLC BONE LEFT DISTAL VOLR RADL BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR60R SUP HCPCS C1713 PL-DR60R - PLATE BN LNG ACLC RDS RT DIST VOLR BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR65L SUP HCPCS C1713 PL-DR65L - PLATE XL ACLC BONE LEFT RADL DISTAL WR HND NONSTRL BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR65R SUP HCPCS C1713 PL-DR65R - PLATE XLNG TI ACLC BONE RIGHT DISTAL RADL WR HND STRL BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR70L SUP HCPCS C1713 PL-DR70L - PLATE W ACLC BONE LEFT DISTAL RADL WR HND STRL BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-DR70R SUP HCPCS C1713 PL-DR70R - PLATE BN W ACLC RDS RT DIST VOLR BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PLDS15 SUP Custom 27203010 PLDS15 - STAPLER INTNL ANG RT 15MM STRL LF LDS LNR CUT LKOUT PRELD TI BOTH IP/OP "$1,015.55 " $751.51 $0.00 $812.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.74 $753.74 $0.00 $0.00 $211.64 $0.00 $0.00 $0.00 $0.00 $507.78 $804.32 $812.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELCLL SUP HCPCS C1713 PL-ELCLL - PLATE TI XTD BONE LEFT CORONOID NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELCLR SUP HCPCS C1713 PL-ELCLR - PLATE BN NS XTD LCK TI ELB RT CORONOID BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELCOL SUP HCPCS C1713 PL-ELCOL - PLATE BN SM NS TI ELB LT CORONOID BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELCOR SUP HCPCS C1713 PL-ELCOR - PLATE BN NS TI ELB RT CORONOID BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELLXL SUP HCPCS C1713 PL-ELLXL - PLATE XLNG TI BONE L/L EPCND ELB BOTH IP/OP "$1,847.35 " "$1,367.04" $0.00 "$1,477.88" $831.31 $831.31 $0.00 $0.00 $0.00 $385.03 "$1,371.10" "$1,371.10" $0.00 $0.00 $384.99 $0.00 "$1,092.71" "$1,092.71" $0.00 $923.68 "$1,463.10" "$1,477.88" $0.00 $0.00 $289.11 $0.00 $0.00 $294.10 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELPO SUP HCPCS C1713 PL-ELPO - PLATE BN POST ELB BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELRD SUP HCPCS C1713 PL-ELRD - PLATE TI 7 HOLE BONE RADL HEAD NONSTRL BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELT1027 SUP Custom 27100030 PL-ELT1027 - TAP 2.7MM 2.7MM QRLSE SURG ELB ACUMED 2MM SCR BOTH IP/OP $565.00 $418.10 $0.00 $452.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $419.34 $419.34 $0.00 $0.00 $117.75 $0.00 $0.00 $0.00 $0.00 $282.50 $447.48 $452.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PL-ELT1035 SUP HCPCS C1713 PL-ELT1035 - PLATE TI 3.5MM SCR TAP BONE 3.5MM ELB NONSTRL DISP BOTH IP/OP $565.00 $418.10 $0.00 $452.00 $254.25 $254.25 $0.00 $0.00 $0.00 $117.76 $419.34 $419.34 $0.00 $0.00 $117.75 $0.00 $334.20 $334.20 $0.00 $282.50 $447.48 $452.00 $0.00 $0.00 $88.42 $0.00 $0.00 $89.95 $0.00 $0.00 $0.00 $0.00 $0.00 PL-FIB11 SUP HCPCS C1713 PL-FIB11 - PLATE TI 11 HOLE BONE LAT MLR FIB NONSTRL BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-FIB5 SUP HCPCS C1713 PL-FIB5 - PLATE TI 5 HOLE BONE FIB NONSTRL BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-FIB7 SUP HCPCS C1713 PL-FIB7 - PLATE TI 7 HOLE BONE FIB NONSTRL BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-FIB9 SUP HCPCS C1713 PL-FIB9 - PLATE TI 9 HOLE BONE LAT MLR FIB NONSTRL BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-GLD3 SUP HCPCS C1713 PL-GLD3 - PLATE TI 3 HOLE GLD BONE MLR NONSTRL BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-GLD5 SUP HCPCS C1713 PL-GLD5 - PLATE 5 HOLE GLD BONE BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-GLD7 SUP HCPCS C1713 PL-GLD7 - PLATE TI 7 HOLE GLD BONE MLR NONSTRL BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LE011 SUP HCPCS C1713 PL-LE011 - PLATE 11 HOLE LCK BONE OLCRN ELB BOTH IP/OP "$2,125.00 " "$1,572.50" $0.00 "$1,700.00" $956.25 $956.25 $0.00 $0.00 $0.00 $442.90 "$1,577.18" "$1,577.18" $0.00 $0.00 $442.85 $0.00 "$1,256.94" "$1,256.94" $0.00 "$1,062.50" "$1,683.00" "$1,700.00" $0.00 $0.00 $332.56 $0.00 $0.00 $338.30 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LE013 SUP HCPCS C1713 PL-LE013 - PLATE TI 13 HOLE LCK SYS BONE OLCRN ELB STRL BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LE09 SUP HCPCS C1713 PL-LE09 - PLATE STD TI 9 HOLE LCK BONE OLCRN NONSTRL BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL10L SUP HCPCS C1713 PL-LEL10L - PLATE BN 100MM NS 10 HL LCK TI ELB L/L BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL10R SUP HCPCS C1713 PL-LEL10R - PLATE BN 100MM NS 10 HL LCK TI ELB RL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL14 SUP HCPCS C1713 PL-LEL14 - PLATE 14 HOLE SYS BONE RL ELB STRL BOTH IP/OP "$1,875.00 " "$1,387.50" $0.00 "$1,500.00" $843.75 $843.75 $0.00 $0.00 $0.00 $390.80 "$1,391.63" "$1,391.63" $0.00 $0.00 $390.75 $0.00 "$1,109.06" "$1,109.06" $0.00 $937.50 "$1,485.00" "$1,500.00" $0.00 $0.00 $293.44 $0.00 $0.00 $298.50 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL14L SUP HCPCS C1713 PL-LEL14L - PLATE TI 14 HOLE LCK BONE L/L ELB STRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL14R SUP HCPCS C1713 PL-LEL14R - PLATE XLNG TI 14 HOLE BONE RL EPCND NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL20L SUP HCPCS C1713 PL-LEL20L - PLATE TI 20 HOLE LCK BONE L/L EPCND NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL20R SUP HCPCS C1713 PL-LEL20R - PLATE TI 20 HOLE LCK BONE RL ELB NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL6L SUP HCPCS C1713 PL-LEL6L - PLATE TI 6 HOLE LCK BONE L/L ELB NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEL6R SUP HCPCS C1713 PL-LEL6R - PLATE TI 6 HOLE LCK BONE RL ELB NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEM12 SUP HCPCS C1713 PL-LEM12 - PLATE TI 12 HOLE LCK ACUMED BONE MDL ELB NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEM16 SUP HCPCS C1713 PL-LEM16 - PLATE BN 16 HL LCK BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEM7 SUP HCPCS C1713 PL-LEM7 - PLATE 84MM TI 7 HOLE LCK ACUMED BONE MDL ELB NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEM8 SUP HCPCS C1713 PL-LEM8 - PLATE 88MM TITANIUIM 8 HOLE LCK BONE MDL ELB NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEM9L SUP HCPCS C1713 PL-LEM9L - PLATE LNG TITANIUIM 9 HOLE LCK SYS BONE MDL ELB STRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEM9S SUP HCPCS C1713 PL-LEM9S - PLATE SHRT TI 9 HOLE LCK BONE MDL ELB STRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEO11 SUP HCPCS C1713 PL-LEO11 - PLATE BN NS 11 HL LCK PRECONTOUR TI ELB OLCRN BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEO13 SUP HCPCS C1713 PL-LEO13 - PLATE TI 13 HOLE LCK SYS BONE OLCRN ELB STRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEO13E SUP HCPCS C1713 PL-LEO13E - PLATE BN 13 HL XTD ELB BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEO17L SUP HCPCS C1713 PL-LEO17L - PLATE BN NS 17 HL LCK PRECONTOUR TI ELB LT OLCRN BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$2,050.00" "$1,153.13" "$1,153.13" $0.00 $0.00 $0.00 $534.09 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 "$1,263.31" "$1,263.31" $0.00 "$1,281.25" "$2,029.50" "$2,050.00" $0.00 $0.00 $401.03 $0.00 $0.00 $407.95 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEO17R SUP HCPCS C1713 PL-LEO17R - PLATE BN NS 17 HL LCK PRECONTOUR TI OLCRN RT BOTH IP/OP "$2,562.50 " "$1,896.25" $0.00 "$2,050.00" "$1,153.13" "$1,153.13" $0.00 $0.00 $0.00 $534.09 "$1,901.89" "$1,901.89" $0.00 $0.00 $534.03 $0.00 "$1,263.31" "$1,263.31" $0.00 "$1,281.25" "$2,029.50" "$2,050.00" $0.00 $0.00 $401.03 $0.00 $0.00 $407.95 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LEO9 SUP HCPCS C1713 PL-LEO9 - PLATE STD TI 9 HOLE LCK BONE OLCRN NONSTRL BOTH IP/OP "$2,252.50 " "$1,666.85" $0.00 "$1,802.00" "$1,013.63" "$1,013.63" $0.00 $0.00 $0.00 $469.48 "$1,671.81" "$1,671.81" $0.00 $0.00 $469.42 $0.00 "$1,332.35" "$1,332.35" $0.00 "$1,126.25" "$1,783.98" "$1,802.00" $0.00 $0.00 $352.52 $0.00 $0.00 $358.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-LL8LR SUP HCPCS C1713 PL-LL8LR - PLATE LNG 8 HOLE BONE RIGHT CLVCL BOTH IP/OP "$1,862.50 " "$1,378.25" $0.00 "$1,490.00" $838.13 $838.13 $0.00 $0.00 $0.00 $388.19 "$1,382.35" "$1,382.35" $0.00 $0.00 $388.15 $0.00 "$1,101.67" "$1,101.67" $0.00 $931.25 "$1,475.10" "$1,490.00" $0.00 $0.00 $291.48 $0.00 $0.00 $296.51 $0.00 $0.00 $0.00 $0.00 $0.00 PL-MCPL SUP HCPCS C1713 PL-MCPL - PLATE BN RND NS FSN TI 1ST MCP LT BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-MCPR SUP HCPCS C1713 PL-MCPR - PLATE TI BONE RIGHT MCP BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-MPJL SUP HCPCS C1713 PL-MPJL - PLATE BN NS 4 HL FSN TI 1ST MTP LT BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 PL-MPJR SUP HCPCS C1713 PL-MPJR - PLATE SHRT BONE RIGHT MTP BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 PL-MTPL SUP HCPCS C1713 PL-MTPL - PLATE TI FSN BONE LEFT 1ST MTP NONSTRL BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 PL-MTPLR SUP HCPCS C1713 PL-MTPLR - PLATE BN NS 6 HL REV FSN TI 1ST MTP LT BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 PL-MTPR SUP HCPCS C1713 PL-MTPR - PLATE BN NS 4 HL FSN TI 1ST MTP RT BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 PL-MTPRR SUP HCPCS C1713 PL-MTPRR - PLATE TI FSN BONE RIGHT GRT TOE BOTH IP/OP "$1,275.00 " $943.50 $0.00 "$1,020.00" $573.75 $573.75 $0.00 $0.00 $0.00 $265.74 $946.31 $946.31 $0.00 $0.00 $265.71 $0.00 $754.16 $754.16 $0.00 $637.50 "$1,009.80" "$1,020.00" $0.00 $0.00 $199.54 $0.00 $0.00 $202.98 $0.00 $0.00 $0.00 $0.00 $0.00 PLP10342 SUP HCPCS C1713 PLP10342 - PLATE BN 1.3MM NS ANCHORAGE 6 HL LOPRFL PIN FX HL VRSN V1 TI BOTH IP/OP "$2,760.75 " "$2,042.96" $0.00 "$2,940.60" "$1,654.09" "$1,654.09" $0.00 $0.00 $0.00 $575.41 "$2,049.03" "$2,049.03" $0.00 $0.00 $575.34 $0.00 "$1,361.05" "$1,361.05" $0.00 "$1,837.88" "$2,911.19" "$2,940.60" $0.00 $0.00 $575.25 $0.00 $0.00 $585.18 $0.00 $0.00 $0.00 $0.00 $0.00 PLP10462 SUP HCPCS C1713 PLP10462 - PLATE BN LNG 1.3MM NS ANCHORAGE 8 HL LOPRFL PIN FX HL VRSN V BOTH IP/OP "$2,760.75 " "$2,042.96" $0.00 "$2,940.60" "$1,654.09" "$1,654.09" $0.00 $0.00 $0.00 $575.41 "$2,049.03" "$2,049.03" $0.00 $0.00 $575.34 $0.00 "$1,361.05" "$1,361.05" $0.00 "$1,837.88" "$2,911.19" "$2,940.60" $0.00 $0.00 $575.25 $0.00 $0.00 $585.18 $0.00 $0.00 $0.00 $0.00 $0.00 PLP20342 SUP HCPCS C1713 PLP20342 - PLATE BN 0MM STP 1.5MM NS ANCHORAGE LOPRFL PIN FX THRD HL TI BOTH IP/OP "$2,760.75 " "$2,042.96" $0.00 "$2,940.60" "$1,654.09" "$1,654.09" $0.00 $0.00 $0.00 $575.41 "$2,049.03" "$2,049.03" $0.00 $0.00 $575.34 $0.00 "$1,361.05" "$1,361.05" $0.00 "$1,837.88" "$2,911.19" "$2,940.60" $0.00 $0.00 $575.25 $0.00 $0.00 $585.18 $0.00 $0.00 $0.00 $0.00 $0.00 PLP30201 SUP HCPCS C1713 PLP30201 - PLATE BN LG 1.5MM NS ANCHORAGE LOPRFL PIN FX THRD HL TI LT 3 BOTH IP/OP "$2,760.75 " "$2,042.96" $0.00 "$2,940.60" "$1,654.09" "$1,654.09" $0.00 $0.00 $0.00 $575.41 "$2,049.03" "$2,049.03" $0.00 $0.00 $575.34 $0.00 "$1,361.05" "$1,361.05" $0.00 "$1,837.88" "$2,911.19" "$2,940.60" $0.00 $0.00 $575.25 $0.00 $0.00 $585.18 $0.00 $0.00 $0.00 $0.00 $0.00 PLP40160 SUP HCPCS C1713 PLP40160 - PLATE BN STRG 16MMX1.5MM NS ANCHORAGE 2 HL LOPRFL UTL SMTR BOTH IP/OP "$2,300.63 " "$1,702.47" $0.00 "$2,449.20" "$1,377.68" "$1,377.68" $0.00 $0.00 $0.00 $479.51 "$1,707.52" "$1,707.52" $0.00 $0.00 $479.45 $0.00 "$1,360.82" "$1,360.82" $0.00 "$1,530.75" "$2,424.71" "$2,449.20" $0.00 $0.00 $479.12 $0.00 $0.00 $487.39 $0.00 $0.00 $0.00 $0.00 $0.00 PLP40220 SUP HCPCS C1713 PLP40220 - PLATE BN STRG 22MMX1.5MM NS ANCHORAGE 3 HL LOPRFL UTL SMTR BOTH IP/OP "$2,300.63 " "$1,702.47" $0.00 "$2,449.20" "$1,377.68" "$1,377.68" $0.00 $0.00 $0.00 $479.51 "$1,707.52" "$1,707.52" $0.00 $0.00 $479.45 $0.00 "$1,360.82" "$1,360.82" $0.00 "$1,530.75" "$2,424.71" "$2,449.20" $0.00 $0.00 $479.12 $0.00 $0.00 $487.39 $0.00 $0.00 $0.00 $0.00 $0.00 PL-PHGL SUP HCPCS C1713 PL-PHGL - PLATE LG TI PLRS BONE LEFT PROX HUM NONSTRL BOTH IP/OP "$3,747.50 " "$2,773.15" $0.00 "$2,998.00" "$1,686.38" "$1,686.38" $0.00 $0.00 $0.00 $781.07 "$2,781.39" "$2,781.39" $0.00 $0.00 $780.98 $0.00 "$1,847.52" "$1,847.52" $0.00 "$1,873.75" "$2,968.02" "$2,998.00" $0.00 $0.00 $586.48 $0.00 $0.00 $596.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-PHGR SUP HCPCS C1713 PL-PHGR - PLATE BN LG HUM RT BOTH IP/OP "$3,747.50 " "$2,773.15" $0.00 "$2,998.00" "$1,686.38" "$1,686.38" $0.00 $0.00 $0.00 $781.07 "$2,781.39" "$2,781.39" $0.00 $0.00 $780.98 $0.00 "$1,847.52" "$1,847.52" $0.00 "$1,873.75" "$2,968.02" "$2,998.00" $0.00 $0.00 $586.48 $0.00 $0.00 $596.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-PHSL SUP HCPCS C1713 PL-PHSL - PLATE BN SM HUM LT PROX BOTH IP/OP "$3,747.50 " "$2,773.15" $0.00 "$2,998.00" "$1,686.38" "$1,686.38" $0.00 $0.00 $0.00 $781.07 "$2,781.39" "$2,781.39" $0.00 $0.00 $780.98 $0.00 "$1,847.52" "$1,847.52" $0.00 "$1,873.75" "$2,968.02" "$2,998.00" $0.00 $0.00 $586.48 $0.00 $0.00 $596.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-PHSR SUP HCPCS C1713 PL-PHSR - PLATE SM TI PLRS BONE RIGHT PROX HUM NONSTRL BOTH IP/OP "$3,747.50 " "$2,773.15" $0.00 "$2,998.00" "$1,686.38" "$1,686.38" $0.00 $0.00 $0.00 $781.07 "$2,781.39" "$2,781.39" $0.00 $0.00 $780.98 $0.00 "$1,847.52" "$1,847.52" $0.00 "$1,873.75" "$2,968.02" "$2,998.00" $0.00 $0.00 $586.48 $0.00 $0.00 $596.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-PHXGL SUP HCPCS C1713 PL-PHXGL - PLATE XLNG TI PLRS BONE LEFT PROX HUM NONSTRL BOTH IP/OP "$3,747.50 " "$2,773.15" $0.00 "$2,998.00" "$1,686.38" "$1,686.38" $0.00 $0.00 $0.00 $781.07 "$2,781.39" "$2,781.39" $0.00 $0.00 $780.98 $0.00 "$1,847.52" "$1,847.52" $0.00 "$1,873.75" "$2,968.02" "$2,998.00" $0.00 $0.00 $586.48 $0.00 $0.00 $596.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-PHXGR SUP HCPCS C1713 PL-PHXGR - PLATE XLNG TI PLRS BONE RIGHT PROX HUM BOTH IP/OP "$3,747.50 " "$2,773.15" $0.00 "$2,998.00" "$1,686.38" "$1,686.38" $0.00 $0.00 $0.00 $781.07 "$2,781.39" "$2,781.39" $0.00 $0.00 $780.98 $0.00 "$1,847.52" "$1,847.52" $0.00 "$1,873.75" "$2,968.02" "$2,998.00" $0.00 $0.00 $586.48 $0.00 $0.00 $596.60 $0.00 $0.00 $0.00 $0.00 $0.00 PL-PTACK SUP Custom 27803010 PL-PTACK - HOLDER IMPL FRFT MIDFT TEMP FIX TACK PLT BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.80 $66.80 $0.00 $0.00 $18.76 $0.00 $0.00 $0.00 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SA06L SUP HCPCS C1713 PL-SA06L - PLATE BN NS 6 HL TI SCAPULAR LT ACROMION BOTH IP/OP "$3,592.50 " "$2,658.45" $0.00 "$2,874.00" "$1,616.63" "$1,616.63" $0.00 $0.00 $0.00 $748.77 "$2,666.35" "$2,666.35" $0.00 $0.00 $748.68 $0.00 "$1,771.10" "$1,771.10" $0.00 "$1,796.25" "$2,845.26" "$2,874.00" $0.00 $0.00 $562.23 $0.00 $0.00 $571.93 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SA06R SUP HCPCS C1713 PL-SA06R - PLATE BONE RIGHT ACROMION BOTH IP/OP "$3,592.50 " "$2,658.45" $0.00 "$2,874.00" "$1,616.63" "$1,616.63" $0.00 $0.00 $0.00 $748.77 "$2,666.35" "$2,666.35" $0.00 $0.00 $748.68 $0.00 "$1,771.10" "$1,771.10" $0.00 "$1,796.25" "$2,845.26" "$2,874.00" $0.00 $0.00 $562.23 $0.00 $0.00 $571.93 $0.00 $0.00 $0.00 $0.00 $0.00 PLS-AIM-0910 SUP Custom 27203010 "PLS-AIM-0910 - GUIDE PLS AIMING, .9MM X 10?" BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.64 $81.64 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SG04L SUP HCPCS C1713 PL-SG04L - PLATE 4 HOLE BONE LEFT GLND SCAPULA STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SG04R SUP HCPCS C1713 PL-SG04R - PLATE 4 HOLE BONE RIGHT GLND SCAPULA NONSTRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 PLSL3012 SUP HCPCS C1713 PLSL3012 - SCREW BN T8 3MM 12MM BLU NS ANCHORAGE TX HD LCK TI FT/ANKL BOTH IP/OP $392.63 $290.55 $0.00 $418.08 $235.17 $235.17 $0.00 $0.00 $0.00 $81.83 $291.41 $291.41 $0.00 $0.00 $81.82 $0.00 $232.24 $232.24 $0.00 $261.30 $413.90 $418.08 $0.00 $0.00 $81.79 $0.00 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 PLSL3016 SUP HCPCS C1713 PLSL3016 - SCREW BN T8 3MM 16MM BLU NS ANCHORAGE TX HD LCK TI FT/ANKL BOTH IP/OP $392.63 $290.55 $0.00 $418.08 $235.17 $235.17 $0.00 $0.00 $0.00 $81.83 $291.41 $291.41 $0.00 $0.00 $81.82 $0.00 $232.24 $232.24 $0.00 $261.30 $413.90 $418.08 $0.00 $0.00 $81.79 $0.00 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 PLSL3516 SUP HCPCS C1713 PLSL3516 - SCREW BN T8 3.5MM 16MM YLW NS ANCHORAGE TX HD LCK TI FT/ANKL BOTH IP/OP $392.63 $290.55 $0.00 $418.08 $235.17 $235.17 $0.00 $0.00 $0.00 $81.83 $291.41 $291.41 $0.00 $0.00 $81.82 $0.00 $232.24 $232.24 $0.00 $261.30 $413.90 $418.08 $0.00 $0.00 $81.79 $0.00 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 PLSL3518 SUP HCPCS C1713 PLSL3518 - SCREW BN T8 3.5MM 18MM YLW NS ANCHORAGE TX HD LCK TI FT/ANKL BOTH IP/OP $392.63 $290.55 $0.00 $418.08 $235.17 $235.17 $0.00 $0.00 $0.00 $81.83 $291.41 $291.41 $0.00 $0.00 $81.82 $0.00 $232.24 $232.24 $0.00 $261.30 $413.90 $418.08 $0.00 $0.00 $81.79 $0.00 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 PLSL3530 SUP HCPCS C1713 PLSL3530 - SCREW BN T8 3.5MM 30MM YLW NS ANCHORAGE TX HD LCK TI FT/ANKL BOTH IP/OP $384.75 $284.72 $0.00 $418.08 $235.17 $235.17 $0.00 $0.00 $0.00 $80.19 $285.56 $285.56 $0.00 $0.00 $80.18 $0.00 $227.58 $227.58 $0.00 $261.30 $413.90 $418.08 $0.00 $0.00 $81.79 $0.00 $0.00 $83.20 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SLB10L SUP HCPCS C1713 PL-SLB10L - PLATE BN 10 HL LT SCAPULA LAT BOTH IP/OP "$4,570.00 " "$3,381.80" $0.00 "$3,656.00" "$2,056.50" "$2,056.50" $0.00 $0.00 $0.00 $952.50 "$3,391.85" "$3,391.85" $0.00 $0.00 $952.39 $0.00 "$2,253.01" "$2,253.01" $0.00 "$2,285.00" "$3,619.44" "$3,656.00" $0.00 $0.00 $715.21 $0.00 $0.00 $727.54 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SLB10R SUP HCPCS C1713 PL-SLB10R - PLATE 10 HOLE BONE SCAPULAR BOTH IP/OP "$4,570.00 " "$3,381.80" $0.00 "$3,656.00" "$2,056.50" "$2,056.50" $0.00 $0.00 $0.00 $952.50 "$3,391.85" "$3,391.85" $0.00 $0.00 $952.39 $0.00 "$2,253.01" "$2,253.01" $0.00 "$2,285.00" "$3,619.44" "$3,656.00" $0.00 $0.00 $715.21 $0.00 $0.00 $727.54 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SMB09L SUP HCPCS C1713 PL-SMB09L - PLATE BN 9 HL MED LT SCAPULA BOTH IP/OP "$4,235.00 " "$3,133.90" $0.00 "$3,388.00" "$1,905.75" "$1,905.75" $0.00 $0.00 $0.00 $882.68 "$3,143.22" "$3,143.22" $0.00 $0.00 $882.57 $0.00 "$2,087.86" "$2,087.86" $0.00 "$2,117.50" "$3,354.12" "$3,388.00" $0.00 $0.00 $662.78 $0.00 $0.00 $674.21 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SMB09R SUP HCPCS C1713 PL-SMB09R - PLATE 9 HOLE BRDR BONE RIGHT MDL SCAPULA NONSTRL BOTH IP/OP "$4,235.00 " "$3,133.90" $0.00 "$3,388.00" "$1,905.75" "$1,905.75" $0.00 $0.00 $0.00 $882.68 "$3,143.22" "$3,143.22" $0.00 $0.00 $882.57 $0.00 "$2,087.86" "$2,087.86" $0.00 "$2,117.50" "$3,354.12" "$3,388.00" $0.00 $0.00 $662.78 $0.00 $0.00 $674.21 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SMB13L SUP HCPCS C1713 PL-SMB13L - PLATE 13 HOLE BRDR BONE LEFT MDL SCAPULA BOTH IP/OP "$4,570.00 " "$3,381.80" $0.00 "$3,656.00" "$2,056.50" "$2,056.50" $0.00 $0.00 $0.00 $952.50 "$3,391.85" "$3,391.85" $0.00 $0.00 $952.39 $0.00 "$2,253.01" "$2,253.01" $0.00 "$2,285.00" "$3,619.44" "$3,656.00" $0.00 $0.00 $715.21 $0.00 $0.00 $727.54 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SMB13R SUP HCPCS C1713 PL-SMB13R - PLATE 13 HOLE BRDR LCK BONE RIGHT MDL SCAPULAR NONSTRL BOTH IP/OP "$4,570.00 " "$3,381.80" $0.00 "$3,656.00" "$2,056.50" "$2,056.50" $0.00 $0.00 $0.00 $952.50 "$3,391.85" "$3,391.85" $0.00 $0.00 $952.39 $0.00 "$2,253.01" "$2,253.01" $0.00 "$2,285.00" "$3,619.44" "$3,656.00" $0.00 $0.00 $715.21 $0.00 $0.00 $727.54 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SR27 SUP Custom 27203010 PL-SR27 - REAMER SRG MN FSN PLT SLV WRST BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SR29 SUP HCPCS C1776 PL-SR29 - HEAD RMR MN WRST FSN PLT BOTH IP/OP $552.50 $408.85 $0.00 $442.00 $248.63 $248.63 $0.00 $0.00 $0.00 $115.15 $410.07 $410.07 $0.00 $0.00 $115.14 $0.00 $326.80 $326.80 $0.00 $276.25 $437.58 $442.00 $0.00 $0.00 $86.47 $0.00 $0.00 $87.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SR30 SUP Custom 27203010 PL-SR30 - REAMER SRG MN ASMB BOTH IP/OP "$1,690.00 " "$1,250.60" $0.00 "$1,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,254.32" "$1,254.32" $0.00 $0.00 $352.20 $0.00 $0.00 $0.00 $0.00 $845.00 "$1,338.48" "$1,352.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SR38 SUP HCPCS C1776 PL-SR38 - HEAD RMR NS HBCP SHFT HND WRST BOTH IP/OP $587.50 $434.75 $0.00 $470.00 $264.38 $264.38 $0.00 $0.00 $0.00 $122.45 $436.04 $436.04 $0.00 $0.00 $122.44 $0.00 $347.51 $347.51 $0.00 $293.75 $465.30 $470.00 $0.00 $0.00 $91.94 $0.00 $0.00 $93.53 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SR39 SUP HCPCS C1776 PL-SR39 - HEAD RMR HBCP WRST FSN PLT BOTH IP/OP $630.00 $466.20 $0.00 $504.00 $283.50 $283.50 $0.00 $0.00 $0.00 $131.31 $467.59 $467.59 $0.00 $0.00 $131.29 $0.00 $372.65 $372.65 $0.00 $315.00 $498.96 $504.00 $0.00 $0.00 $98.60 $0.00 $0.00 $100.30 $0.00 $0.00 $0.00 $0.00 $0.00 PL-SR41 SUP Custom 27203010 PL-SR41 - WRENCH SRG RMR HD HUB CAP BOTH IP/OP $270.00 $199.80 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.39 $200.39 $0.00 $0.00 $56.27 $0.00 $0.00 $0.00 $0.00 $135.00 $213.84 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3016 SUP HCPCS C1713 PLSS3016 - SCREW BN STD T8 3MM 16MM BLU NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $271.13 $200.64 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $56.51 $201.23 $201.23 $0.00 $0.00 $56.50 $0.00 $160.37 $160.37 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3018 SUP HCPCS C1713 PLSS3018 - SCREW BN STD T8 3MM 18MM BLU NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $271.13 $200.64 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $56.51 $201.23 $201.23 $0.00 $0.00 $56.50 $0.00 $160.37 $160.37 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3020 SUP HCPCS C1713 PLSS3020 - SCREW BN STD T8 3MM 20MM BLU NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $420.00 $236.25 $236.25 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $262.50 $415.80 $420.00 $0.00 $0.00 $82.16 $0.00 $0.00 $83.58 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3022 SUP HCPCS C1713 PLSS3022 - SCREW BN STD T8 3MM 22MM BLU NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3024 SUP HCPCS C1713 PLSS3024 - SCREW BN STD T8 3MM 24MM BLU NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3026 SUP HCPCS C1713 PLSS3026 - SCREW BN STD T8 3MM 26MM BLU NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3028 SUP HCPCS C1713 PLSS3028 - SCREW BN STD T8 3MM 28MM BLU NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3514 SUP HCPCS C1713 PLSS3514 - SCREW BN STD T8 3.5MM 14MM YLW NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3516 SUP HCPCS C1713 PLSS3516 - SCREW BN STD T8 3.5MM 16MM YLW NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3520 SUP HCPCS C1713 PLSS3520 - SCREW BN STD T8 3.5MM 20MM YLW NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3522 SUP HCPCS C1713 PLSS3522 - SCREW BN STD T8 3.5MM 22MM YLW NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3526 SUP HCPCS C1713 PLSS3526 - SCREW BN STD T8 3.5MM 26MM YLW NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLSS3532 SUP HCPCS C1713 PLSS3532 - SCREW BN STD T8 3.5MM 32MM YLW NS ANCHORAGE TX HD TI FT/ANKL BOTH IP/OP $265.50 $196.47 $0.00 $287.04 $161.46 $161.46 $0.00 $0.00 $0.00 $55.34 $197.05 $197.05 $0.00 $0.00 $55.33 $0.00 $157.04 $157.04 $0.00 $179.40 $284.17 $287.04 $0.00 $0.00 $56.15 $0.00 $0.00 $57.12 $0.00 $0.00 $0.00 $0.00 $0.00 PLT-1030 SUP HCPCS C1713 PLT-1030 - PLATE MAXFACL 7X7 HOLE MESH BIODEG 1.5 MM SCR BONE CPS TI BOTH IP/OP "$2,833.13 " "$2,096.52" $0.00 "$2,266.50" "$1,274.91" "$1,274.91" $0.00 $0.00 $0.00 $590.49 "$2,102.75" "$2,102.75" $0.00 $0.00 $590.42 $0.00 "$1,396.73" "$1,396.73" $0.00 "$1,416.56" "$2,243.84" "$2,266.50" $0.00 $0.00 $443.38 $0.00 $0.00 $451.03 $0.00 $0.00 $0.00 $0.00 $0.00 PL-TACK2 SUP HCPCS C1713 PL-TACK2 - PLATE BN 3.75IN TEMP BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $40.50 $40.50 $0.00 $0.00 $0.00 $18.76 $66.80 $66.80 $0.00 $0.00 $18.76 $0.00 $53.24 $53.24 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $14.09 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 PL-TIBAM SUP HCPCS C1713 PL-TIBAM - PLATE TI BONE ANT MLR NONSTRL BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-TIBMM SUP HCPCS C1713 PL-TIBMM - PLATE TI BONE MDL MLR NONSTRL BOTH IP/OP "$1,017.50 " $752.95 $0.00 $814.00 $457.88 $457.88 $0.00 $0.00 $0.00 $212.07 $755.19 $755.19 $0.00 $0.00 $212.05 $0.00 $601.85 $601.85 $0.00 $508.75 $805.86 $814.00 $0.00 $0.00 $159.24 $0.00 $0.00 $161.99 $0.00 $0.00 $0.00 $0.00 $0.00 PL-TMT14 SUP HCPCS C1713 PL-TMT14 - PLATE TI 4 HOLE CNGR BONE MIDFT NONSTRL BOTH IP/OP "$1,222.50 " $904.65 $0.00 $978.00 $550.13 $550.13 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $611.25 $968.22 $978.00 $0.00 $0.00 $191.32 $0.00 $0.00 $194.62 $0.00 $0.00 $0.00 $0.00 $0.00 PL-TMT24 SUP HCPCS C1713 PL-TMT24 - PLATE CNGR BONE MIDFT NONSTRL BOTH IP/OP "$1,222.50 " $904.65 $0.00 $978.00 $550.13 $550.13 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $611.25 $968.22 $978.00 $0.00 $0.00 $191.32 $0.00 $0.00 $194.62 $0.00 $0.00 $0.00 $0.00 $0.00 PL-TMT5 SUP HCPCS C1713 PL-TMT5 - PLATE TI 5 HOLE BONE TARSOMETATARSAL NONSTRL BOTH IP/OP "$1,222.50 " $904.65 $0.00 $978.00 $550.13 $550.13 $0.00 $0.00 $0.00 $254.80 $907.34 $907.34 $0.00 $0.00 $254.77 $0.00 $723.11 $723.11 $0.00 $611.25 $968.22 $978.00 $0.00 $0.00 $191.32 $0.00 $0.00 $194.62 $0.00 $0.00 $0.00 $0.00 $0.00 PL-UL06 SUP HCPCS C1713 PL-UL06 - PLATE BN SHRT STRL 6 HL TI ULNA OSTM BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 PL-UL06-S SUP HCPCS C1713 PL-UL06-S - PLATE TI 6 HOLE SHTNG ACUMED BONE WRST ULN HAND STRL BOTH IP/OP "$1,790.00 " "$1,324.60" $0.00 "$1,432.00" $805.50 $805.50 $0.00 $0.00 $0.00 $373.08 "$1,328.54" "$1,328.54" $0.00 $0.00 $373.04 $0.00 "$1,058.79" "$1,058.79" $0.00 $895.00 "$1,417.68" "$1,432.00" $0.00 $0.00 $280.14 $0.00 $0.00 $284.97 $0.00 $0.00 $0.00 $0.00 $0.00 PL-VO47 SUP HCPCS C1713 PL-VO47 - PLATE 47MM TI BONE VOLR RADL NONSTRL BOTH IP/OP "$1,020.00 " $754.80 $0.00 $816.00 $459.00 $459.00 $0.00 $0.00 $0.00 $212.59 $757.04 $757.04 $0.00 $0.00 $212.57 $0.00 $603.33 $603.33 $0.00 $510.00 $807.84 $816.00 $0.00 $0.00 $159.63 $0.00 $0.00 $162.38 $0.00 $0.00 $0.00 $0.00 $0.00 PL-VO60 SUP HCPCS C1713 PL-VO60 - PLATE 60MM TI BONE VOLR RADL NONSTRL BOTH IP/OP "$1,020.00 " $754.80 $0.00 $816.00 $459.00 $459.00 $0.00 $0.00 $0.00 $212.59 $757.04 $757.04 $0.00 $0.00 $212.57 $0.00 $603.33 $603.33 $0.00 $510.00 $807.84 $816.00 $0.00 $0.00 $159.63 $0.00 $0.00 $162.38 $0.00 $0.00 $0.00 $0.00 $0.00 PLVW-14.0-38 SUP HCPCS C1892 PLVW-14.0-38 - SET INTROD 15.5CM 14FR PLWY PERC STRL DISP BOTH IP/OP $104.40 $77.26 $0.00 $83.52 $56.69 $56.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.20 $82.68 $83.52 $0.00 $0.00 $16.34 $0.00 $0.00 $16.62 $0.00 $0.00 $0.00 $0.00 $0.00 PL-WF33 SUP HCPCS C1713 PL-WF33 - PLATE BN MN NS HBCP 3 CRNR FSN TI WRST BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-WF40 SUP HCPCS C1713 PL-WF40 - PLATE BN NS HBCP TI WRST BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-WF44 SUP HCPCS C1713 PL-WF44 - PLATE MINI TI 4 CRNR FSN HBCP BONE WRST NONSTRL BOTH IP/OP "$2,047.50 " "$1,515.15" $0.00 "$1,638.00" $921.38 $921.38 $0.00 $0.00 $0.00 $426.75 "$1,519.65" "$1,519.65" $0.00 $0.00 $426.70 $0.00 "$1,211.10" "$1,211.10" $0.00 "$1,023.75" "$1,621.62" "$1,638.00" $0.00 $0.00 $320.43 $0.00 $0.00 $325.96 $0.00 $0.00 $0.00 $0.00 $0.00 PL-WF50 SUP HCPCS C1713 PL-WF50 - PLATE TI FSN POST HBCP BONE WRST BOTH IP/OP $82.50 $61.05 $0.00 $66.00 $37.13 $37.13 $0.00 $0.00 $0.00 $17.20 $61.23 $61.23 $0.00 $0.00 $17.19 $0.00 $48.80 $48.80 $0.00 $41.25 $65.34 $66.00 $0.00 $0.00 $12.91 $0.00 $0.00 $13.13 $0.00 $0.00 $0.00 $0.00 $0.00 PL-WF60 SUP HCPCS C1713 PL-WF60 - PLATE TI SCR HBCP BONE WRST NONSTRL BOTH IP/OP $237.50 $175.75 $0.00 $190.00 $106.88 $106.88 $0.00 $0.00 $0.00 $49.50 $176.27 $176.27 $0.00 $0.00 $49.50 $0.00 $140.48 $140.48 $0.00 $118.75 $188.10 $190.00 $0.00 $0.00 $37.17 $0.00 $0.00 $37.81 $0.00 $0.00 $0.00 $0.00 $0.00 PM010-A SUP Custom 27200555 PM010-A - KIT DRUG DELIVERY 3.5IN 2.5IN CATHETER ANTIMICROBIAL NEEDLE BOTH IP/OP $89.00 $65.86 $0.00 $66.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.06 $66.06 $0.00 $0.00 $18.55 $0.00 $0.00 $0.00 $0.00 $11.50 $18.22 $18.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PM020 SUP Custom 27200555 PM020 - SYSTEM DRG DLV ONQ PNBSTR SKR XPD KIT CATH TPL NDL 5IN 6IN BOTH IP/OP $116.00 $85.84 $0.00 $123.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.10 $86.10 $0.00 $0.00 $24.17 $0.00 $0.00 $0.00 $0.00 $77.25 $122.36 $123.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PM020-A SUP Custom 27200555 PM020-A - SYSTEM DRG DLV T 5IN 6IN ONQ PNBSTR SLSKR TPL XPD CATH NDL BOTH IP/OP $116.00 $85.84 $0.00 $86.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.10 $86.10 $0.00 $0.00 $24.17 $0.00 $0.00 $0.00 $0.00 $14.75 $23.36 $23.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PM040-A SUP Custom 27200555 PM040-A - SYSTEM DRG DLV ONQ SLSKR CATH XPD KIT TPL NDL 10IN 8IN BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $0.00 $0.00 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PM1110 SUP HCPCS C1786 PM1110 - PACEMAKER CRD THK6MM 52X42MM 9.5ML ACT 1 CHMBR IS-1 CNCT PLS BOTH IP/OP "$7,425.00 " "$5,494.50" $0.00 "$5,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,547.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,547.37" $0.00 "$3,660.53" "$3,660.53" $0.00 "$3,712.50" "$5,880.60" "$5,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PM1210 SUP HCPCS C1785 PM1210 - PACEMAKER CRD THK6MM 52X52MM 12.8ML ACT 1 CHMBR IS-1 CNCT RF BOTH IP/OP "$8,775.00 " "$6,493.50" $0.00 "$7,020.00" "$3,948.75" "$3,948.75" $0.00 $0.00 $0.00 "$1,828.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,828.71" $0.00 "$4,326.08" "$4,326.08" $0.00 "$4,387.50" "$6,949.80" "$7,020.00" $0.00 $0.00 "$1,373.29" $0.00 $0.00 "$1,396.98" $0.00 $0.00 $0.00 $0.00 $0.00 PM2110 SUP HCPCS C1785 PM2110 - PACEMAKER CRD THK6MM 52X46MM 10.5CC ACT 2 CHMBR IS-1 CNCT BOTH IP/OP "$8,550.00 " "$6,327.00" $0.00 "$6,840.00" "$3,847.50" "$3,847.50" $0.00 $0.00 $0.00 "$1,782.03" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,781.82" $0.00 "$4,215.15" "$4,215.15" $0.00 "$4,275.00" "$6,771.60" "$6,840.00" $0.00 $0.00 "$1,338.08" $0.00 $0.00 "$1,361.16" $0.00 $0.00 $0.00 $0.00 $0.00 PM2210 SUP HCPCS C1785 PM2210 - PACEMAKER CARDIAC THK6MM 52X52MM 2 CHAMBER INDUCTIVE BOTH IP/OP "$10,575.00 " "$7,825.50" $0.00 "$8,460.00" "$4,758.75" "$4,758.75" $0.00 $0.00 $0.00 "$2,204.09" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,203.83" $0.00 "$5,213.48" "$5,213.48" $0.00 "$5,287.50" "$8,375.40" "$8,460.00" $0.00 $0.00 "$1,654.99" $0.00 $0.00 "$1,683.54" $0.00 $0.00 $0.00 $0.00 $0.00 PM3210 SUP HCPCS C2621 PM3210 - PACEMAKER CRD THK6MM 58X52MM 13.7ML ANTHEM RF 2 CHMBR IS-1 BOTH IP/OP "$14,750.00 " "$10,915.00" $0.00 "$11,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,073.90" $0.00 $0.00 $0.00 $0.00 "$7,375.00" "$11,682.00" "$11,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PMG-18SP-60-COPE SUP HCPCS C1769 PMG-18SP-60-COPE - GWIRE VASC .018IN 60CM 7CM ANG SFT CP MDRL SS STRL DISP BOTH IP/OP $82.39 $60.97 $0.00 $65.91 $44.74 $44.74 $0.00 $0.00 $0.00 $17.17 $61.15 $61.15 $0.00 $0.00 $17.17 $0.00 $48.73 $48.73 $0.00 $41.19 $65.25 $65.91 $0.00 $0.00 $12.89 $0.00 $0.00 $13.12 $0.00 $0.00 $0.00 $0.00 $0.00 PMH SUP HCPCS C1781 PMH - MESH SURG FLAT 6X6IN KNIT NONABSORBABLE NONREACTIVE PROLENE BOTH IP/OP $164.86 $122.00 $0.00 $133.87 $75.30 $75.30 $0.00 $0.00 $0.00 $34.36 $122.36 $122.36 $0.00 $0.00 $34.36 $0.00 $97.52 $97.52 $0.00 $83.67 $132.53 $133.87 $0.00 $0.00 $26.19 $0.00 $0.00 $26.64 $0.00 $0.00 $0.00 $0.00 $0.00 PMII SUP HCPCS C1781 PMII - MESH SURG FLAT 6X3IN KNIT NONABSORBABLE NONREACTIVE LATEX BOTH IP/OP $149.00 $110.26 $0.00 $120.98 $68.05 $68.05 $0.00 $0.00 $0.00 $31.06 $110.59 $110.59 $0.00 $0.00 $31.05 $0.00 $88.13 $88.13 $0.00 $75.61 $119.77 $120.98 $0.00 $0.00 $23.67 $0.00 $0.00 $24.07 $0.00 $0.00 $0.00 $0.00 $0.00 PML SUP HCPCS C1781 PML - MESH SURG FLAT 12X12IN KNIT MONOFILAMENT SOFT PROLENE BOTH IP/OP $374.24 $276.94 $0.00 $303.88 $170.93 $170.93 $0.00 $0.00 $0.00 $78.00 $277.76 $277.76 $0.00 $0.00 $77.99 $0.00 $221.36 $221.36 $0.00 $189.93 $300.85 $303.88 $0.00 $0.00 $59.45 $0.00 $0.00 $60.47 $0.00 $0.00 $0.00 $0.00 $0.00 PMXS SUP HCPCS C1781 PMXS - MESH SURG FLAT 4X1IN KNIT NONABSORBABLE NONREACTIVE PROLENE BOTH IP/OP $117.33 $86.82 $0.00 $93.86 $52.80 $52.80 $0.00 $0.00 $0.00 $24.45 $87.08 $87.08 $0.00 $0.00 $24.45 $0.00 $69.40 $69.40 $0.00 $58.66 $92.93 $93.86 $0.00 $0.00 $18.36 $0.00 $0.00 $18.68 $0.00 $0.00 $0.00 $0.00 $0.00 PN-152836002 SUP Custom 27203010 PN-152836002 - CONCTR EKG ATR VNTRC ASMBLY BOTH IP/OP $45.05 $33.34 $0.00 $36.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.44 $33.44 $0.00 $0.00 $9.39 $0.00 $0.00 $0.00 $0.00 $22.53 $35.68 $36.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PND6F070956 SUP HCPCS C1757 PND6F070956 - CATHETER DELIVERY SYSTEM STR 6FR .07IN 95CM 6CM LUMEN BOTH IP/OP "$1,587.50 " "$1,174.75" $0.00 "$1,270.00" $0.00 $0.00 $0.00 $0.00 $0.00 $330.87 "$1,178.24" "$1,178.24" $0.00 $0.00 $330.84 $0.00 $939.01 $939.01 $0.00 $793.75 "$1,257.30" "$1,270.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PND6F1056 SUP HCPCS C1757 PND6F1056 - CATHETER DELIVERY SYSTEM .035IN .038IN 6FR .053IN 105CM 6CM BOTH IP/OP "$1,587.50 " "$1,174.75" $0.00 "$1,270.00" $0.00 $0.00 $0.00 $0.00 $0.00 $330.87 "$1,178.24" "$1,178.24" $0.00 $0.00 $330.84 $0.00 $939.01 $939.01 $0.00 $793.75 "$1,257.30" "$1,270.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PND6F1156 SUP HCPCS C1757 PND6F1156 - CATHETER DELIVERY SYSTEM .035IN .038IN STR 6FR .053IN 115CM BOTH IP/OP "$1,587.50 " "$1,174.75" $0.00 "$1,270.00" $0.00 $0.00 $0.00 $0.00 $0.00 $330.87 "$1,178.24" "$1,178.24" $0.00 $0.00 $330.84 $0.00 $939.01 $939.01 $0.00 $793.75 "$1,257.30" "$1,270.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG220 SUP HCPCS C9352 PNG220 - GUIDE NERVE 2MM 2CM RESORB BIOCOMPATIBLE SEMIPERMEABLE TUBE BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $651.47 "$2,319.88" "$2,319.88" $0.00 $0.00 $651.39 $0.00 "$1,540.96" "$1,540.96" $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG230 SUP HCPCS C9352 PNG230 - GUIDE NERVE 2MM 3CM SEMIPERMEABLE NEURAGEN COLLAGEN MATRIX BOTH IP/OP "$4,202.28 " "$3,109.69" $0.00 "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $875.86 "$3,118.93" "$3,118.93" $0.00 $0.00 $875.75 $0.00 "$2,071.72" "$2,071.72" $0.00 "$2,101.14" "$3,328.21" "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG320 SUP HCPCS C9352 PNG320 - GUIDE NERVE 3MM 2CM RESORB BIOCOMPATIBLE SEMIPERMEABLE TUBE BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG-320 SUP HCPCS C9352 PNG-320 - GUIDE NERVE 3MM 2CM RESORB BIOCOMPATIBLE SEMIPERMEABLE TUBE BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $651.47 "$2,319.88" "$2,319.88" $0.00 $0.00 $651.39 $0.00 "$1,540.96" "$1,540.96" $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG330 SUP HCPCS C9352 PNG330 - GUIDE NERVE 3MM 3CM FLEXIBLE ABSORBABLE TUBE BIOCOMPATIBLE BOTH IP/OP "$4,202.28 " "$3,109.69" $0.00 "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $875.86 "$3,118.93" "$3,118.93" $0.00 $0.00 $875.75 $0.00 "$2,071.72" "$2,071.72" $0.00 "$2,101.14" "$3,328.21" "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG420 SUP HCPCS C9352 PNG420 - GUIDE NERVE 4MM 2CM RESORB BIOCOMPATIBLE SEMIPERMEABLE TUBE BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $651.47 "$2,319.88" "$2,319.88" $0.00 $0.00 $651.39 $0.00 "$1,540.96" "$1,540.96" $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG430 SUP HCPCS C9352 PNG430 - GUIDE NERVE 4MM 3CM FLEXIBLE ABSORBABLE TUBE BIOCOMPATIBLE BOTH IP/OP "$4,202.28 " "$3,109.69" $0.00 "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $875.86 "$3,118.93" "$3,118.93" $0.00 $0.00 $875.75 $0.00 "$2,071.72" "$2,071.72" $0.00 "$2,101.14" "$3,328.21" "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG520 SUP HCPCS C9352 PNG520 - GUIDE NERVE 5MM 2CM RESORB BIOCOMPATIBLE SEMIPERMEABLE TUBE BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG-520 SUP HCPCS C9352 PNG-520 - GUIDE NERVE 5MM 2CM RESORB BIOCOMPATIBLE SEMIPERMEABLE TUBE BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $651.47 "$2,319.88" "$2,319.88" $0.00 $0.00 $651.39 $0.00 "$1,540.96" "$1,540.96" $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG530 SUP HCPCS C9352 PNG530 - GUIDE NERVE 5MM 3CM FLEXIBLE ABSORBABLE TUBE NEURAGEN BOTH IP/OP "$4,202.28 " "$3,109.69" $0.00 "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $875.86 "$3,118.93" "$3,118.93" $0.00 $0.00 $875.75 $0.00 "$2,071.72" "$2,071.72" $0.00 "$2,101.14" "$3,328.21" "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG620 SUP HCPCS C9352 PNG620 - GUIDE NERVE 6MM 2CM NEURAGEN PERIPHERAL BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG-620 SUP HCPCS C9352 PNG-620 - GUIDE NERVE 6MM 2CM NEURAGEN PERIPHERAL BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $651.47 "$2,319.88" "$2,319.88" $0.00 $0.00 $651.39 $0.00 "$1,540.96" "$1,540.96" $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG630 SUP HCPCS C9352 PNG630 - GUIDE NERVE 6MM 3CM FLEXIBLE ABSORBABLE TUBE BIOCOMPATIBLE BOTH IP/OP "$4,202.28 " "$3,109.69" $0.00 "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $875.86 "$3,118.93" "$3,118.93" $0.00 $0.00 $875.75 $0.00 "$2,071.72" "$2,071.72" $0.00 "$2,101.14" "$3,328.21" "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG720 SUP HCPCS C9352 PNG720 - GUIDE NERVE 7MM 2CM RESORB BIOCOMPATIBLE SEMIPERMEABLE TUBE BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG-720 SUP HCPCS C9352 PNG-720 - GUIDE NERVE 7MM 2CM RESORB BIOCOMPATIBLE SEMIPERMEABLE TUBE BOTH IP/OP "$3,125.68 " "$2,313.00" $0.00 "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $651.47 "$2,319.88" "$2,319.88" $0.00 $0.00 $651.39 $0.00 "$1,540.96" "$1,540.96" $0.00 "$1,562.84" "$2,475.54" "$2,500.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNG730 SUP HCPCS C9352 PNG730 - GUIDE NERVE 7MM 3CM EXCELLENT HANDLING SEMIPERMEABLE SIMPLE BOTH IP/OP "$4,202.28 " "$3,109.69" $0.00 "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $875.86 "$3,118.93" "$3,118.93" $0.00 $0.00 $875.75 $0.00 "$2,071.72" "$2,071.72" $0.00 "$2,101.14" "$3,328.21" "$3,361.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PNML6F088904M SUP HCPCS C1892 PNML6F088904M - SHEATH INTRO LNG MP CRV 6FR 8FR .088IN 90CM 4CM NEURON MXSS BOTH IP/OP "$1,137.50 " $841.75 $0.00 $910.00 $617.66 $617.66 $0.00 $0.00 $0.00 $237.08 $844.25 $844.25 $0.00 $0.00 $237.06 $0.00 $672.83 $672.83 $0.00 $568.75 $900.90 $910.00 $0.00 $0.00 $178.02 $0.00 $0.00 $181.09 $0.00 $0.00 $0.00 $0.00 $0.00 PNS5F120BER SUP HCPCS C1757 PNS5F120BER - CATH THRMB 120CM 5FR .4IN NEURON SLCT .035IN .038IN BER BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PP17/10 SUP HCPCS C1894 DEVICE 17GA 10CM ECHTP COAX THNWL PP INTROD BIOP BOTH IP/OP $33.88 $25.07 $0.00 $27.10 $18.39 $18.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.94 $26.83 $27.10 $0.00 $0.00 $5.30 $0.00 $0.00 $5.39 $0.00 $0.00 $0.00 $0.00 $0.00 PP1715 SUP HCPCS C1894 DEVICE 17GA 15CM ECHTP COAX THNWL PP INTROD BIOP BOTH IP/OP $40.50 $29.97 $0.00 $32.40 $21.99 $21.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.25 $32.08 $32.40 $0.00 $0.00 $6.34 $0.00 $0.00 $6.45 $0.00 $0.00 $0.00 $0.00 $0.00 PP19/10 SUP HCPCS C1894 DEVICE 19GA 10CM ECHTP COAX THNWL PP INTROD BIOP BOTH IP/OP $33.75 $24.98 $0.00 $27.00 $18.33 $18.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.88 $26.73 $27.00 $0.00 $0.00 $5.28 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 PP1915 SUP HCPCS C1894 DEVICE 19GA 15CM ECHTP COAX THNWL PP INTROD BIOP BOTH IP/OP $33.75 $24.98 $0.00 $27.00 $18.33 $18.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $16.88 $26.73 $27.00 $0.00 $0.00 $5.28 $0.00 $0.00 $5.37 $0.00 $0.00 $0.00 $0.00 $0.00 PP196 SUP Custom 27203010 NEEDLE BIOP 19GA 6CM ECHTP COAX THNWL PP INTROD BOTH IP/OP $32.38 $23.96 $0.00 $29.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.03 $24.03 $0.00 $0.00 $6.75 $0.00 $0.00 $0.00 $0.00 $18.71 $29.64 $29.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PP9031 SUP Custom 27203010 PP9031 - KIT ESCP STRL LF PNPT PAQ DISP BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PRE1001US.S SUP HCPCS A6212 PRE1001US.S - UNIT THERAPEUTIC INCISION MANAGEMENT SYSTEM PEEL PLACE KIT BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $671.96 $671.96 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 PRE1101US SUP Custom 27011340 PRE1101US - SYSTEM NEG PRSS 13CM PREVENA PEEL AND PLC PTCH BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PRE2001US SUP Custom 27203010 PRE2001US - KIT DRESSING 125 THERAPY UNIT CARRYING CASE CANISTER BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PRE4001US SUP HCPCS C1713 PRE4001US - SYSTEM NEG PRSS -125 MMHG 150ML PREVENA + VIS ADBL ALRM REPL BOTH IP/OP "$1,625.00 " "$1,202.50" $0.00 "$1,300.00" $731.25 $731.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $812.50 "$1,287.00" "$1,300.00" $0.00 $0.00 $254.31 $0.00 $0.00 $258.70 $0.00 $0.00 $0.00 $0.00 $0.00 PROTECTACRTDMMAM SUP HCPCS C1721 PROTECTACRTDMMAM - PROTECTA CRT-D ADVANCED SYSTEM BOTH IP/OP "$60,500.00 " "$44,770.00" $0.00 "$48,400.00" "$27,225.00" "$27,225.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$12,608.20" $0.00 "$29,826.50" "$29,826.50" $0.00 "$30,250.00" "$47,916.00" "$48,400.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 PROTECTADRMMEM SUP HCPCS C1721 PROTECTADRMMEM - PROTECTA DR SYSTEM (INCLUDING DF4 HEADER) BOTH IP/OP "$49,812.50 " "$36,861.25" $0.00 "$39,850.00" "$22,415.63" "$22,415.63" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,380.93" $0.00 "$24,557.56" "$24,557.56" $0.00 "$24,906.25" "$39,451.50" "$39,850.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,930.15" $0.00 $0.00 $0.00 $0.00 $0.00 PROTECTAVREMEM SUP HCPCS C1721 PROTECTAVREMEM - PROTECTA VR SYSTEM (INCLUDING DF4 HEADER) BOTH IP/OP "$43,750.00 " "$32,375.00" $0.00 "$35,000.00" "$19,687.50" "$19,687.50" $0.00 $0.00 $0.00 "$9,118.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,117.50" $0.00 "$21,568.75" "$21,568.75" $0.00 "$21,875.00" "$34,650.00" "$35,000.00" $0.00 $0.00 "$6,846.88" $0.00 $0.00 "$6,965.00" $0.00 $0.00 $0.00 $0.00 $0.00 PRT-FSP-DU SUP HCPCS C1713 PRT-FSP-DU - PLATE BN PRTN FRAG ULNA DISTAL BOTH IP/OP "$2,190.00 " "$1,620.60" $0.00 "$1,752.00" $985.50 $985.50 $0.00 $0.00 $0.00 $456.45 "$1,625.42" "$1,625.42" $0.00 $0.00 $456.40 $0.00 "$1,295.39" "$1,295.39" $0.00 "$1,095.00" "$1,734.48" "$1,752.00" $0.00 $0.00 $342.74 $0.00 $0.00 $348.65 $0.00 $0.00 $0.00 $0.00 $0.00 PRT-FSP-LR SUP HCPCS C1713 PRT-FSP-LR - PLATE BN PRTN FRAG ULNA DIST DOUBLE HOCKEY STICK BOTH IP/OP "$1,970.00 " "$1,457.80" $0.00 "$1,576.00" $886.50 $886.50 $0.00 $0.00 $0.00 $410.60 "$1,462.13" "$1,462.13" $0.00 $0.00 $410.55 $0.00 "$1,165.26" "$1,165.26" $0.00 $985.00 "$1,560.24" "$1,576.00" $0.00 $0.00 $308.31 $0.00 $0.00 $313.62 $0.00 $0.00 $0.00 $0.00 $0.00 PRT-FSP-YS SUP HCPCS C1713 PRT-FSP-YS - PLATE BN PRTN FRAG ULNA DIST Y BOTH IP/OP "$1,970.00 " "$1,457.80" $0.00 "$1,576.00" $886.50 $886.50 $0.00 $0.00 $0.00 $410.60 "$1,462.13" "$1,462.13" $0.00 $0.00 $410.55 $0.00 "$1,165.26" "$1,165.26" $0.00 $985.00 "$1,560.24" "$1,576.00" $0.00 $0.00 $308.31 $0.00 $0.00 $313.62 $0.00 $0.00 $0.00 $0.00 $0.00 PS11055 SUP Custom 27803010 PS11055 - GRAFT SFT TIS 5X5CM GRFX PRM ALGRF PLCNT MEMBR BOTH IP/OP "$6,875.00 " "$5,087.50" $0.00 "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,432.75" $0.00 $0.00 $0.00 $0.00 "$3,437.50" "$5,445.00" "$5,500.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PS12055 SUP Custom 27803010 PS12055 - GRAFT SFT TIS 5X5CM GRFX COR PLCNT MEMBR ALGRF BOTH IP/OP "$6,900.00 " "$5,106.00" $0.00 "$5,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,437.96" $0.00 $0.00 $0.00 $0.00 "$3,450.00" "$5,464.80" "$5,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PS60005 SUP Custom 27803010 PS60005 - GRAFT SFT TIS 4X2CM STRAVIX ALGRF PLCNT TISS BOTH IP/OP "$4,512.50 " "$3,339.25" $0.00 "$3,610.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,349.18" "$3,349.18" $0.00 $0.00 $940.41 $0.00 $0.00 $0.00 $0.00 "$2,256.25" "$3,573.90" "$3,610.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PS60008 SUP Custom 27803010 PS60008 - GRAFT SFT TIS 6X3CM STRAVIX ALGRF PLCNT TISS BOTH IP/OP "$7,956.25 " "$5,887.63" $0.00 "$6,365.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,658.08" $0.00 $0.00 $0.00 $0.00 "$3,978.13" "$6,301.35" "$6,365.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSC026 SUP HCPCS C1757 PSC026 - CATHETER THROMBECTOMY 3.9-2.8FR .026IN 154CM 150CM BOTH IP/OP "$3,725.00 " "$2,756.50" $0.00 "$2,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $776.38 "$2,764.70" "$2,764.70" $0.00 $0.00 $776.29 $0.00 "$2,203.34" "$2,203.34" $0.00 "$1,862.50" "$2,950.20" "$2,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSC041 SUP HCPCS C1757 PSC041 - CATHETER THROMBECTOMY 4.1FR .041IN 141CM REPERFUSION BOTH IP/OP "$3,725.00 " "$2,756.50" $0.00 "$2,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $776.38 "$2,764.70" "$2,764.70" $0.00 $0.00 $776.29 $0.00 "$2,203.34" "$2,203.34" $0.00 "$1,862.50" "$2,950.20" "$2,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSC054 SUP HCPCS C1757 PSC054 - CATHETER THROMBECTOMY 6-5FR .054IN 132CM 136CM REPERFUSION BOTH IP/OP "$3,725.00 " "$2,756.50" $0.00 "$2,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $776.38 "$2,764.70" "$2,764.70" $0.00 $0.00 $776.29 $0.00 "$2,203.34" "$2,203.34" $0.00 "$1,862.50" "$2,950.20" "$2,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSD 6002-UN SUP Custom 27203010 PSD 6002-UN - STAPLER INTNL 60MM UNV 2 FRNG 1 GEL TUBE STRL LF DISP PRSTRP BOTH IP/OP $368.75 $272.88 $0.00 $273.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.69 $273.69 $0.00 $0.00 $76.85 $0.00 $0.00 $0.00 $0.00 $61.46 $97.35 $98.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSD 6006-UV SUP Custom 27203010 PSD 6006-UV - STAPLER INTNL STRL LF PRSTRP DR 6 FRNG GEL TUBE LNR VRTS BOTH IP/OP $67.99 $50.31 $0.00 $54.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.46 $50.46 $0.00 $0.00 $14.17 $0.00 $0.00 $0.00 $0.00 $33.99 $53.85 $54.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSD 8006-UN SUP Custom 27203010 PSD 8006-UN - STAPLER INTNL ENDSCP LNR CTR 6 FRNG PRSTRP DR BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSE45A SUP Custom 27203010 PSE45A - STAPLER INTERNAL 45MM 340MM LINEAR CUTTER ARTICULATION BOTH IP/OP "$8,484.68 " "$6,278.66" $0.00 "$6,787.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,768.21" $0.00 $0.00 $0.00 $0.00 "$4,242.34" "$6,719.87" "$6,787.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSEE45A SUP Custom 27203010 PSEE45A - STAPLER INTNL STD 340MM 45MM ECHLN FLX PWR + LNR CTR ESCP BOTH IP/OP "$1,661.12 " "$1,229.23" $0.00 "$1,328.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,232.88" "$1,232.88" $0.00 $0.00 $346.18 $0.00 $0.00 $0.00 $0.00 $830.56 "$1,315.61" "$1,328.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSEE60A SUP Custom 27203010 PSEE60A - STAPLER INTERNAL BENT 60MM 440MM RIDGE ASYMMETRICAL LEG LINE BOTH IP/OP "$1,993.34 " "$1,475.07" $0.00 "$2,700.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,505.39" "$2,505.39" $0.00 $0.00 $703.48 $0.00 $0.00 $0.00 $0.00 "$1,687.81" "$2,673.50" "$2,700.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PSS-6F-4MT SUP HCPCS C1894 PSS-6F-4MT - INTRODUCER SHEATH SHORT 6FR 4CM NO WIRE PRELUDE GREEN BOTH IP/OP $47.50 $35.15 $0.00 $35.25 $23.08 $23.08 $0.00 $0.00 $0.00 $9.90 $35.25 $35.25 $0.00 $0.00 $9.90 $0.00 $28.10 $28.10 $0.00 $21.25 $33.66 $34.00 $0.00 $0.00 $6.65 $0.00 $0.00 $6.77 $0.00 $0.00 $0.00 $0.00 $0.00 PSS-7F-4MT SUP HCPCS C1894 PSS-7F-4MT - INTRODUCER SHEATH SHORT 7FR 21GA 4CM ORANGE HUB TUBING BOTH IP/OP $47.50 $35.15 $0.00 $35.25 $4.62 $4.62 $0.00 $0.00 $0.00 $9.90 $35.25 $35.25 $0.00 $0.00 $9.90 $0.00 $28.10 $28.10 $0.00 $4.25 $6.73 $6.80 $0.00 $0.00 $1.33 $0.00 $0.00 $1.35 $0.00 $0.00 $0.00 $0.00 $0.00 PTA5-35-135-7-14.0 SUP HCPCS C1725 PTA5-35-135-7-14.0 - CATH BALDILAT .035IN 5FR 7MM 135CM 14CM 2 LUM PTA LP GWIRE BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $278.29 $278.29 $0.00 $0.00 $0.00 $106.82 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $303.14 $303.14 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $80.21 $0.00 $0.00 $81.59 $0.00 $0.00 $0.00 $0.00 $0.00 PTB124275 SUP HCPCS C1874 PTB124275 - GORE VIATORR TIPS ENDOPROSTHESIS BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 PTB126275 SUP HCPCS C1874 PTB126275 - GORE VIATORR TIPS ENDOPROSTHESIS BOTH IP/OP "$10,500.00 " "$7,770.00" $0.00 "$8,400.00" "$4,725.00" "$4,725.00" $0.00 $0.00 $0.00 "$2,188.46" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,188.20" $0.00 "$5,176.50" "$5,176.50" $0.00 "$5,250.00" "$8,316.00" "$8,400.00" $0.00 $0.00 "$1,643.25" $0.00 $0.00 "$1,671.60" $0.00 $0.00 $0.00 $0.00 $0.00 PTB128275 SUP HCPCS C1874 PTB128275 - GORE VIATORR TIPS ENDOPROSTHESIS BOTH IP/OP "$9,750.00 " "$7,215.00" $0.00 "$7,800.00" "$4,387.50" "$4,387.50" $0.00 $0.00 $0.00 "$2,032.14" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,031.90" $0.00 "$4,806.75" "$4,806.75" $0.00 "$4,875.00" "$7,722.00" "$7,800.00" $0.00 $0.00 "$1,525.88" $0.00 $0.00 "$1,552.20" $0.00 $0.00 $0.00 $0.00 $0.00 PTB8106275 SUP HCPCS C1874 PTB8106275 - STENT EPRSTH 10MM 6CM STRL 2CM GORE VTR SLF XPD RADOPQ 2 LUM BOTH IP/OP "$12,855.00 " "$9,512.70" $0.00 "$9,888.00" "$5,562.00" "$5,562.00" $0.00 $0.00 $0.00 "$2,679.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,678.98" $0.00 "$6,337.52" "$6,337.52" $0.00 "$6,180.00" "$9,789.12" "$9,888.00" $0.00 $0.00 "$1,934.34" $0.00 $0.00 "$1,967.71" $0.00 $0.00 $0.00 $0.00 $0.00 PTB8108275 SUP HCPCS C1874 PTB8108275 - STENT EPRSTH 10MM 8CM STRL 2CM GORE VTR SLF XPD RADOPQ 2 LUM BOTH IP/OP "$12,855.00 " "$9,512.70" $0.00 "$9,888.00" "$5,562.00" "$5,562.00" $0.00 $0.00 $0.00 "$2,679.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,678.98" $0.00 "$6,337.52" "$6,337.52" $0.00 "$6,180.00" "$9,789.12" "$9,888.00" $0.00 $0.00 "$1,934.34" $0.00 $0.00 "$1,967.71" $0.00 $0.00 $0.00 $0.00 $0.00 PTH-MP SUP Custom 27203010 MAS PTH TRI-LEVEL CONTROL 6X3ML BOTH IP/OP $275.00 $203.50 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.50 $217.80 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PV014300 SUP HCPCS C1769 PV014300 - JETWIRE JETSTREAM BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,696.88" "$1,696.88" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,848.44" "$1,848.44" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 PV2014L016N SUP HCPCS C1751 PV2014L016N - CATHETER ART LN 4FR 16CM PICCO GW NTNL BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 PV2014L022N SUP HCPCS C1751 PV2014L022N - CATHETER ART LN 4FR 22CM PICCO GW ADLT FEM ART BRACHIA BOTH IP/OP $62.50 $46.25 $0.00 $50.00 $28.13 $28.13 $0.00 $0.00 $0.00 $13.03 $46.39 $46.39 $0.00 $0.00 $13.03 $0.00 $36.97 $36.97 $0.00 $31.25 $49.50 $50.00 $0.00 $0.00 $9.78 $0.00 $0.00 $9.95 $0.00 $0.00 $0.00 $0.00 $0.00 PV2015L20N SUP HCPCS C1751 PV2015L20N - CATH ART 5FR .028IN 7.78IN FEM PICCO ADLT STD BOTH IP/OP "$3,125.00 " "$2,312.50" $0.00 "$2,500.00" "$1,406.25" "$1,406.25" $0.00 $0.00 $0.00 $651.33 "$2,319.38" "$2,319.38" $0.00 $0.00 $651.25 $0.00 "$1,540.63" "$1,540.63" $0.00 "$1,562.50" "$2,475.00" "$2,500.00" $0.00 $0.00 $489.06 $0.00 $0.00 $497.50 $0.00 $0.00 $0.00 $0.00 $0.00 PV3116F SUP HCPCS C1714 PV3116F - CATHETER ATHRCM JETSTREAM NAVITUS ROT BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" "$4,615.50" "$4,615.50" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,771.40" $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 "$1,330.25" $0.00 $0.00 "$1,353.20" $0.00 $0.00 $0.00 $0.00 $0.00 PV3118F SUP HCPCS C1714 PV3118F - CATHETER ATHRCM .014IN 7FR 2.4/3.4MM 120CM JETSTREAM NAVITUS BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" "$4,615.50" "$4,615.50" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,771.40" $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 "$1,330.25" $0.00 $0.00 "$1,353.20" $0.00 $0.00 $0.00 $0.00 $0.00 PV31300 SUP HCPCS C1714 PV31300 - CATHETER ATHRCM JETSTREAM NAVITUS ROT BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" "$4,615.50" "$4,615.50" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,771.40" $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 "$1,330.25" $0.00 $0.00 "$1,353.20" $0.00 $0.00 $0.00 $0.00 $0.00 PV4046 SUP HCPCS C1751 PV4046 - KIT ART LN INJECTATE TEMP SNSR HSNG PICCO BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $371.25 $371.25 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 PV41340 SUP HCPCS C1714 PV41340 - CATHETER ATHRCM .014IN 7FR 2.4/3.4MM 120CM LF JETSTREAM BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" "$4,615.50" "$4,615.50" $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,771.40" $0.00 $0.00 $0.00 $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 "$1,330.25" $0.00 $0.00 "$1,353.20" $0.00 $0.00 $0.00 $0.00 $0.00 PVE35A SUP Custom 27203010 PVE35A - STAPLER INTERNAL 320MM 35MM POWER ADVANCE PLACEMENT TIP BOTH IP/OP $990.33 $732.84 $0.00 $792.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $735.02 $735.02 $0.00 $0.00 $206.38 $0.00 $0.00 $0.00 $0.00 $495.16 $784.34 $792.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PVPS SUP HCPCS C1781 PVPS - MESH SURG 4.3X4.3CM SELF EXPAND PRTL ABSORBABLE FLEXIBLE BOTH IP/OP "$1,462.90 " "$1,082.55" $0.00 "$1,170.32" $658.31 $658.31 $0.00 $0.00 $0.00 $304.90 "$1,085.76" "$1,085.76" $0.00 $0.00 $304.87 $0.00 $865.31 $865.31 $0.00 $731.45 "$1,158.62" "$1,170.32" $0.00 $0.00 $228.94 $0.00 $0.00 $232.89 $0.00 $0.00 $0.00 $0.00 $0.00 PWL229997H SUP HCPCS C1785 PWL229997H - PACEMAKER SENSIA DR CARD SEDR01 PWL229997H BOTH IP/OP "$22,500.00 " "$16,650.00" $0.00 "$18,000.00" "$10,125.00" "$10,125.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$11,250.00" "$17,820.00" "$18,000.00" $0.00 $0.00 "$3,521.25" $0.00 $0.00 "$3,582.00" $0.00 $0.00 $0.00 $0.00 $0.00 PWL242945H SUP HCPCS C1785 PWL242945H - PACEMAKER SENSIA 2CH CARD PWL242945H BOTH IP/OP "$19,655.00 " "$14,544.70" $0.00 "$15,724.00" "$8,844.75" "$8,844.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,827.50" "$15,566.76" "$15,724.00" $0.00 $0.00 "$3,076.01" $0.00 $0.00 "$3,129.08" $0.00 $0.00 $0.00 $0.00 $0.00 PWL243503H SUP HCPCS C1785 PWL243503H - PACEMAKER SENSIA 2CH CARD PWL243503H BOTH IP/OP "$19,207.50 " "$14,213.55" $0.00 "$15,366.00" "$8,643.38" "$8,643.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,603.75" "$15,212.34" "$15,366.00" $0.00 $0.00 "$3,005.97" $0.00 $0.00 "$3,057.83" $0.00 $0.00 $0.00 $0.00 $0.00 PWR224751H SUP HCPCS C1785 PWR224751H - PACEMAKER SENSIA 2CH CARD PWR224751H BOTH IP/OP "$18,900.00 " "$13,986.00" $0.00 "$15,120.00" "$8,505.00" "$8,505.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,450.00" "$14,968.80" "$15,120.00" $0.00 $0.00 "$2,957.85" $0.00 $0.00 "$3,008.88" $0.00 $0.00 $0.00 $0.00 $0.00 PWR230180H SUP HCPCS C1785 PWR230180H - PACEMAKER SENSIA DR CARD SEDR01 PWR230180H BOTH IP/OP "$7,237.50 " "$5,355.75" $0.00 "$5,790.00" "$3,256.88" "$3,256.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,618.75" "$5,732.10" "$5,790.00" $0.00 $0.00 "$1,132.67" $0.00 $0.00 "$1,152.21" $0.00 $0.00 $0.00 $0.00 $0.00 PXC121000 SUP Custom 27806189 PXC121000 - GRAFT EVAS LOPRFL 12MM 10CM XCLDR STNT XTD DLV SYS SL CUF BOTH IP/OP "$11,275.00 " "$8,343.50" $0.00 "$9,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,349.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,349.71" $0.00 "$5,558.58" "$5,558.58" $0.00 "$5,637.50" "$8,929.80" "$9,020.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PXSLIM045 SUP HCPCS C1757 PXSLIM045 - CATHETER DELIVERY SYSTEM 45D MICRO 2.95FR .025IN 150CM 2 TIP BOTH IP/OP "$2,210.00 " "$1,635.40" $0.00 "$1,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $460.62 "$1,640.26" "$1,640.26" $0.00 $0.00 $460.56 $0.00 "$1,307.22" "$1,307.22" $0.00 "$1,105.00" "$1,750.32" "$1,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PXSLIM090 SUP HCPCS C1757 PXSLIM090 - CATHETER DLV SYS 90D 0-.025IN MIC 2.6-2.95FR 150CM PX SLIM 2 BOTH IP/OP "$2,210.00 " "$1,635.40" $0.00 "$1,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $460.62 "$1,640.26" "$1,640.26" $0.00 $0.00 $460.56 $0.00 "$1,307.22" "$1,307.22" $0.00 "$1,105.00" "$1,750.32" "$1,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PXSLIM130 SUP HCPCS C1757 PXSLIM130 - CATHETER DELIVERY SYSTEM 130D 0-.025IN MICRO 2.6-2.95FR 150 BOTH IP/OP "$2,210.00 " "$1,635.40" $0.00 "$1,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $460.62 "$1,640.26" "$1,640.26" $0.00 $0.00 $460.56 $0.00 "$1,307.22" "$1,307.22" $0.00 "$1,105.00" "$1,750.32" "$1,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PXSLIMSTR SUP HCPCS C1757 PXSLIMSTR - CATHETER DLV SYS 0-.02IN MIC STRG 2.6-2.95FR .025IN 150CM PX BOTH IP/OP "$2,210.00 " "$1,635.40" $0.00 "$1,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $460.62 "$1,640.26" "$1,640.26" $0.00 $0.00 $460.56 $0.00 "$1,307.22" "$1,307.22" $0.00 "$1,105.00" "$1,750.32" "$1,768.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PXX52 SUP Custom 27203010 PXX52 - SUTURE NONABSORBABLE THK1/16IN 2-0 V-5 30IN .25X1/8IN 2 ARM BOTH IP/OP $195.26 $144.49 $0.00 $158.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.93 $144.93 $0.00 $0.00 $40.69 $0.00 $0.00 $0.00 $0.00 $99.10 $156.97 $158.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 PXX77 SUP Custom 27203010 PXX77 - SUTURE NONABSORBABLE THK1/16IN 2-0 V-7 30IN .25X1/8IN 2 ARM BOTH IP/OP $211.39 $156.43 $0.00 $169.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.90 $156.90 $0.00 $0.00 $44.05 $0.00 $0.00 $0.00 $0.00 $105.70 $167.42 $169.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Q50-65P SUP Custom 27204833 Q50-65P - CATHETER OCL 10-50MM 65CM Q50 + BLN STNT GFT DLV FLX TP BOTH IP/OP "$1,212.50 " $897.25 $0.00 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $899.92 $899.92 $0.00 $0.00 $252.69 $0.00 $0.00 $0.00 $0.00 $606.25 $960.30 $970.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 QC-12-30-HELIX SUP HCPCS C2628 QC-12-30-HELIX - COIL EMBL .3683MM HLX 12MM .0145IN 30CM AXIUM DTCH PLTN BOTH IP/OP "$1,802.50 " "$1,333.85" $0.00 "$1,442.00" $0.00 $0.00 $0.00 $0.00 $0.00 $375.69 "$1,337.82" "$1,337.82" $0.00 $0.00 $375.64 $0.00 "$1,066.18" "$1,066.18" $0.00 $901.25 "$1,427.58" "$1,442.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 QC-12-40-3D SUP Custom 27803010 QC-12-40-3D - COIL EMBL .3683MM 3D 12MM .0145IN 40CM AXIUM DTCH PLTN BOTH IP/OP "$2,432.50 " "$1,800.05" $0.00 "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,805.40" "$1,805.40" $0.00 $0.00 $506.93 $0.00 $0.00 $0.00 $0.00 "$1,216.25" "$1,926.54" "$1,946.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 QS70406 SUP Custom 27203010 QS70406 - ADHESIVE SKIN DERMA FLEX QS BOTH IP/OP $40.63 $30.07 $0.00 $32.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.15 $30.15 $0.00 $0.00 $8.47 $0.00 $0.00 $0.00 $0.00 $20.31 $32.18 $32.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 QTX321256 SUP Custom 27203010 QTX321256 - ROPE TRC 10FT STRL LF BOTH IP/OP $203.10 $150.29 $0.00 $156.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.74 $150.74 $0.00 $0.00 $42.33 $0.00 $0.00 $0.00 $0.00 $97.89 $155.06 $156.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R020 SUP HCPCS C1768 R020 - GRAFT SFT TIS CRYOARTERY FEM POPLT ART BOTH IP/OP "$16,250.00 " "$12,025.00" $0.00 "$13,000.00" "$7,312.50" "$7,312.50" $0.00 $0.00 $0.00 "$3,386.91" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,386.50" $0.00 "$8,011.25" "$8,011.25" $0.00 "$8,125.00" "$12,870.00" "$13,000.00" $0.00 $0.00 "$2,543.13" $0.00 $0.00 "$2,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 R0450 SUP Custom 27203010 CURETTE 4MM ADSP DRML LOOP TIP SURG SS STRL DISP BOTH IP/OP $3.75 $2.78 $0.00 $3.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.88 $2.97 $3.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R1212 SUP Custom 27203010 DRESSING WOUND PROCELLERA ANTIMICROBIAL 12X12 BOTH IP/OP $562.50 $416.25 $0.00 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R21121 SUP Custom 27203010 DISK BTYRT ESTRS M CATRRHL ID BOTH IP/OP $148.80 $110.11 $0.00 $119.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.40 $117.85 $119.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R30859602 SUP Custom 27203010 KIT WLCGN BCTR AG RPD LTX AGGL MCBLTST 30 TST BOTH IP/OP $59.03 $43.68 $0.00 $47.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.51 $46.75 $47.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R30950801 SUP Custom 27203010 REAGENT MCBL STRP GRP C LTX AGGL STREPTEX 50 TST BOTH IP/OP $4.05 $3.00 $0.00 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $2.03 $3.21 $3.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R30951001 SUP Custom 27203010 REAGENT MCBL XTRT ENZM SPL VL STREPTEX 25 TST BOTH IP/OP $3.85 $2.85 $0.00 $3.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.93 $3.05 $3.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R30951201 SUP Custom 27203010 REAGENT MCBL STRP GRP G LTX AGGL STREPTEX 50 TST BOTH IP/OP $3.98 $2.95 $0.00 $3.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.99 $3.15 $3.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R314II SUP Custom 27203010 CABLE EKG 3 LEAD SHLD CONNCTR .059IN BOTH IP/OP $172.08 $127.34 $0.00 $137.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.04 $136.29 $137.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R324II SUP Custom 27203010 CABLE EKG 3 LEAD CONNCTR 3 SHLD .059IN BOTH IP/OP $186.63 $138.11 $0.00 $149.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.31 $147.81 $149.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R32611 SUP Custom 27203010 CABLE ECG/PATIENT LIFEPACK .059IN 3 LEAD CONFIGURATION 3B C BOTH IP/OP $164.63 $121.83 $0.00 $131.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.31 $130.39 $131.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R390.003 SUP Custom 27203010 R390.003 - DEVICE EXFIX ROD ATTCH LG EXFIX 4-6 MM SCHNZ SCR NONSTRL BOTH IP/OP $632.50 $468.05 $0.00 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $469.44 $469.44 $0.00 $0.00 $131.81 $0.00 $0.00 $0.00 $0.00 $316.25 $500.94 $506.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R390.005 SUP HCPCS C1713 CLAMP COMBO MR CONDITIONAL CNTRL EXFIXA LG NSTRL BOTH IP/OP $0.03 $0.02 $0.00 $0.02 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.02 $0.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R390.008 SUP HCPCS C1713 CLAMP OPN ADJ MR CONDITIONAL CNTRL EXFIXA LG NSTRL BOTH IP/OP $0.03 $0.02 $0.00 $0.02 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.02 $0.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R390.009 SUP HCPCS C1713 PIN CLMP ROD 4 PSTN ADJ CNTRL EXFIXA LG NSTRL BOTH IP/OP $0.03 $0.02 $0.00 $0.02 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.02 $0.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R390.010 SUP Custom 27203010 R390.010 - CLAMP EXFIX LG 6 PSTN PIN NONSTRL BOTH IP/OP $705.00 $521.70 $0.00 $564.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.25 $523.25 $0.00 $0.00 $146.92 $0.00 $0.00 $0.00 $0.00 $352.50 $558.36 $564.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R390.012 SUP HCPCS C1713 PIN 11MM ADJ CNTRL ROD POST OTRGR EXFIXA 30D NSTRL BOTH IP/OP $0.03 $0.02 $0.00 $0.02 $0.01 $0.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.01 $0.02 $0.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R390.051 SUP Custom 27203010 R390.051 - CLAMP EXFIX 4MM DISTAL RADL ADJ NONSTRL BOTH IP/OP "$1,127.50 " $834.35 $0.00 $902.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $836.83 $836.83 $0.00 $0.00 $234.97 $0.00 $0.00 $0.00 $0.00 $563.75 $892.98 $902.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R394.85 SUP Custom 27203010 R394.85 - ROD EXFIX 300MM 11MM CARFBR SLFDRILL MR CONDITIONAL SET BOTH IP/OP $355.00 $262.70 $0.00 $284.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.48 $263.48 $0.00 $0.00 $73.98 $0.00 $0.00 $0.00 $0.00 $177.50 $281.16 $284.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R395.786 SUP Custom 27203010 R395.786 - ROD EXFIX 240MM 8MM DISTAL RADL CARFBR NONSTRL BOTH IP/OP $232.50 $172.05 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.56 $172.56 $0.00 $0.00 $48.45 $0.00 $0.00 $0.00 $0.00 $116.25 $184.14 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 R6515-01 SUP Custom 25803010 R6515-01 - SOLUTION IRR 2L LTX PHYSIOLYTE PIC 5% MNTL BOTH IP/OP $30.61 $22.65 $0.00 $24.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.72 $22.72 $0.00 $0.00 $6.38 $0.00 $0.00 $0.00 $0.00 $15.31 $24.24 $24.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RA-04020 SUP HCPCS C1729 RA-04020 - KIT ARTERIAL LINE .018IN 20GA 22GA 1.75IN CATHETER RADIOPQ BOTH IP/OP $39.45 $29.19 $0.00 $29.28 $15.64 $15.64 $0.00 $0.00 $0.00 $8.22 $29.28 $29.28 $0.00 $0.00 $8.22 $0.00 $23.33 $23.33 $0.00 $14.40 $22.81 $23.04 $0.00 $0.00 $4.51 $0.00 $0.00 $4.58 $0.00 $0.00 $0.00 $0.00 $0.00 RAN-811-OT SUP Custom 27203010 RAN-811-OT - NEEDLE IO 8GA 11CM DLV OPN TIP BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $0.00 $0.00 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RBY2C0725 SUP Custom 27803010 RBY2C0725 - COIL EMBL STD .02IN 7MM 25CM PENUMBRA COIL 400 RUBY CMPLX LG BOTH IP/OP "$2,475.00 " "$1,831.50" $0.00 "$1,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,836.95" "$1,836.95" $0.00 $0.00 $515.79 $0.00 $0.00 $0.00 $0.00 "$1,237.50" "$1,960.20" "$1,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RBY2C0825 SUP Custom 27803010 RBY2C0825 - COIL EMBL STD .02IN 8MM 25CM PENUMBRA COIL 400 RUBY CMPLX LG BOTH IP/OP "$2,475.00 " "$1,831.50" $0.00 "$1,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,836.95" "$1,836.95" $0.00 $0.00 $515.79 $0.00 $0.00 $0.00 $0.00 "$1,237.50" "$1,960.20" "$1,980.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RBY2C0840 SUP Custom 27803010 RBY2C0840 - COIL EMBL STD .02IN 8MM 40CM PENUMBRA COIL 400 RUBY CMPLX LG BOTH IP/OP "$3,225.00 " "$2,386.50" $0.00 "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,393.60" "$2,393.60" $0.00 $0.00 $672.09 $0.00 $0.00 $0.00 $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RBYPOD8 SUP Custom 27803010 RBYPOD8 - COIL EMBL 8MM 60CM RUBY POD CMPLX OCCULUSION DEV BOTH IP/OP "$4,475.00 " "$3,311.50" $0.00 "$3,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,321.35" "$3,321.35" $0.00 $0.00 $932.59 $0.00 $0.00 $0.00 $0.00 "$2,237.50" "$3,544.20" "$3,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RBYPODJ60 SUP Custom 27803010 RBYPODJ60 - COIL EMBL J-SFT 60CM STRL LF POD PK BOTH IP/OP "$3,225.00 " "$2,386.50" $0.00 "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,393.60" "$2,393.60" $0.00 $0.00 $672.09 $0.00 $0.00 $0.00 $0.00 "$1,612.50" "$2,554.20" "$2,580.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RC-15 SUP HCPCS C1760 SYSTEM EMBL PRTC VC FLTR 2LVL REM 12FR RCVR CN BOTH IP/OP "$1,312.50 " $971.25 $0.00 "$1,050.00" $590.63 $590.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $205.41 $0.00 $0.00 $208.95 $0.00 $0.00 $0.00 $0.00 $0.00 RC41-12027 SUP Custom 27203010 RC41-12027 - CIRCUIT BRTHG ANES HEAT WIRE 40IN NEO INF BOTH IP/OP $66.67 $49.34 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.48 $49.48 $0.00 $0.00 $13.89 $0.00 $0.00 $0.00 $0.00 $33.33 $52.80 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RCFW-5.0-35 SUP HCPCS C1894 RCFW-5.0-35 - SET INTROD 13CM 5FR CHK-FLO PRFRMR SDARM FIT SIDE CONNECT LN BOTH IP/OP $47.15 $34.89 $0.00 $37.72 $25.60 $25.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.58 $37.34 $37.72 $0.00 $0.00 $7.38 $0.00 $0.00 $7.51 $0.00 $0.00 $0.00 $0.00 $0.00 RCP3 SUP HCPCS C1713 RCP3 - PLATE BN NS RADL CLMN PIN PLT 3 HL PIN CLMN RADL BOTH IP/OP "$1,550.00 " "$1,147.00" $0.00 "$1,240.00" $697.50 $697.50 $0.00 $0.00 $0.00 $323.06 "$1,150.41" "$1,150.41" $0.00 $0.00 $323.02 $0.00 $916.83 $916.83 $0.00 $775.00 "$1,227.60" "$1,240.00" $0.00 $0.00 $242.58 $0.00 $0.00 $246.76 $0.00 $0.00 $0.00 $0.00 $0.00 RCP5 SUP HCPCS C1713 RCP5 - PLATE BN NS RADL CLMN PIN PLT 5 HL PIN CLMN RADL BOTH IP/OP "$1,550.00 " "$1,147.00" $0.00 "$1,240.00" $697.50 $697.50 $0.00 $0.00 $0.00 $323.06 "$1,150.41" "$1,150.41" $0.00 $0.00 $323.02 $0.00 $916.83 $916.83 $0.00 $775.00 "$1,227.60" "$1,240.00" $0.00 $0.00 $242.58 $0.00 $0.00 $246.76 $0.00 $0.00 $0.00 $0.00 $0.00 RF-310F SUP HCPCS C1760 SYSTEM EMBL PRTC 48CM VC FLTR FEM DLV KT 7FR G2 BOTH IP/OP "$2,750.00 " "$2,035.00" $0.00 "$2,200.00" "$1,237.50" "$1,237.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,375.00" "$2,178.00" "$2,200.00" $0.00 $0.00 $430.38 $0.00 $0.00 $437.80 $0.00 $0.00 $0.00 $0.00 $0.00 RFP-400 SUP Custom 25003010 SOLUTION DLYST 140 MEQ NA 2 MEQ K 3 MEQ CALCIUM 1 MEQ MG 111 BOTH IP/OP $118.75 $87.88 $0.00 $95.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $94.05 $95.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RFP-401 SUP Custom 25003010 SOLUTION DLYST 140 MEQ NA 4 MEQ K 3 MEQ CALCIUM 1 MEQ MG 113 BOTH IP/OP $118.75 $87.88 $0.00 $95.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.38 $94.05 $95.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RG*ES1818SP SUP HCPCS C1769 RG*ES1818SP - GUIDEWIRE VASCULAR STR .018IN 180CM 25CM SHAPEABLE SHAFT BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $215.84 $215.84 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 RG*GA1818SP SUP HCPCS C1769 RG*GA1818SP - GUIDEWIRE VASCULAR 45D .018IN 180CM 25CM GLIDEWIRE GT HYDPHI BOTH IP/OP $46.50 $34.41 $0.00 $34.51 $23.35 $23.35 $0.00 $0.00 $0.00 $9.69 $34.51 $34.51 $0.00 $0.00 $9.69 $0.00 $27.50 $27.50 $0.00 $21.50 $34.06 $34.40 $0.00 $0.00 $6.73 $0.00 $0.00 $6.85 $0.00 $0.00 $0.00 $0.00 $0.00 RH1 SUP Custom 27203010 RH1 - HANDLE INST RUBY DTCH COIL BOTH IP/OP $595.00 $440.30 $0.00 $476.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $441.61 $441.61 $0.00 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $297.50 $471.24 $476.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RL-3019-S SUP HCPCS C1713 RL-3019-S - ROD ORTH 190MM 3MM LEFT RADL WR HND RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RL-3021-S SUP HCPCS C1713 RL-3021-S - ROD ORTH 210MM 3MM LEFT RADL WR HND RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RL-3023-S SUP HCPCS C1713 RL-3023-S - ROD ORTH 230MM 3MM LEFT RADL WR HND TI RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RL-3619-S SUP HCPCS C1713 RL-3619-S - ROD ORTH 190MM 3.6MM LEFT RADL FRARM RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RL-3621-S SUP HCPCS C1713 RL-3621-S - ROD ORTH 210MM 3.6MM LEFT DISTAL RADL FRARM RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RL-3623-S SUP HCPCS C1713 RL-3623-S - ROD ORTH 230MM 3.6MM LEFT RADL FRARM RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RMT3130 SUP Custom 27203010 RMT3130 - REAMER SURG 3.1MM THDL ROD SYS WR HND 300MM STRL BOTH IP/OP $497.50 $368.15 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.75 $394.02 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RMT-3130 SUP Custom 27203010 RMT-3130 - REAMER SURG 3.1MM THDL ROD SYS WR HND 300MM STRL BOTH IP/OP $497.50 $368.15 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $369.24 $369.24 $0.00 $0.00 $103.68 $0.00 $0.00 $0.00 $0.00 $248.75 $394.02 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RMT-3137 SUP Custom 27203010 RMT-3137 - REAMER SRG 3.7MM THDL DISP FRARM ROD SYS BOTH IP/OP $497.50 $368.15 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $369.24 $369.24 $0.00 $0.00 $103.68 $0.00 $0.00 $0.00 $0.00 $248.75 $394.02 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RMT3730 SUP Custom 27203010 RMT3730 - REAMER SURG 3.7MM THDL WR HND DISP BOTH IP/OP $497.50 $368.15 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $369.24 $369.24 $0.00 $0.00 $103.68 $0.00 $0.00 $0.00 $0.00 $248.75 $394.02 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RMT7340 SUP Custom 27203010 RMT7340 - REAMER SURG 7.3MM THDL 400MM BOTH IP/OP $497.50 $368.15 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $369.24 $369.24 $0.00 $0.00 $103.68 $0.00 $0.00 $0.00 $0.00 $248.75 $394.02 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RMT8340 SUP Custom 27203010 RMT8340 - REAMER SURG 8.3MM THDL 400MM BOTH IP/OP $497.50 $368.15 $0.00 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $369.24 $369.24 $0.00 $0.00 $103.68 $0.00 $0.00 $0.00 $0.00 $248.75 $394.02 $398.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RPC-35-260 SUP HCPCS C1769 RPC-35-260 - GWIRE VASC .035IN 260CM ANG STD TPR STF SHFT EXCH RDRR PC BOTH IP/OP $81.40 $60.24 $0.00 $65.12 $44.20 $44.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.70 $64.47 $65.12 $0.00 $0.00 $12.74 $0.00 $0.00 $12.96 $0.00 $0.00 $0.00 $0.00 $0.00 RR-3019-S SUP HCPCS C1713 RR-3019-S - ROD ORTH 190MM 3MM RIGHT RADL WR HND RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RR-3021-S SUP HCPCS C1713 RR-3021-S - ROD ORTH 210MM 3MM RIGHT RADL WR HND RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RR-3023-S SUP HCPCS C1713 RR-3023-S - ROD ORTH 230MM 3MM RIGHT RADL FRARM RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RR-3619-S SUP HCPCS C1713 RR-3619-S - ROD RADIUS 3.6MM 90MM RIGHT BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RR-3621-S SUP HCPCS C1713 RR-3621-S - ROD RADIUS 3.6MM 210MM RIGHT BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RR-3623-S SUP HCPCS C1713 RR-3623-S - ROD ORTH 230MM 3.6MM RIGHT RADL WR HND RAD IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 RRT08030040L SUP HCPCS C1768 RRT08030040L - GRAFT VASCULAR THIN WALL RING STANDARD 8MM 40CM 30CM BOTH IP/OP "$1,830.00 " "$1,354.20" $0.00 "$1,464.00" $823.50 $823.50 $0.00 $0.00 $0.00 $381.42 "$1,358.23" "$1,358.23" $0.00 $0.00 $381.37 $0.00 "$1,082.45" "$1,082.45" $0.00 $915.00 "$1,449.36" "$1,464.00" $0.00 $0.00 $286.40 $0.00 $0.00 $291.34 $0.00 $0.00 $0.00 $0.00 $0.00 RRT08070070L SUP HCPCS C1768 RRT08070070L - GRAFT VASCULAR THIN WALL RING 8MM 70CM 70CM GORE-TEX BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 RRT10030030L SUP HCPCS C1768 RRT10030030L - GRAFT VASCULAR THIN WALL 10MM 30CM 30CM REMOVABLE RING LINE BOTH IP/OP "$2,302.50 " "$1,703.85" $0.00 "$1,842.00" "$1,036.13" "$1,036.13" $0.00 $0.00 $0.00 $479.90 "$1,708.92" "$1,708.92" $0.00 $0.00 $479.84 $0.00 "$1,361.93" "$1,361.93" $0.00 "$1,151.25" "$1,823.58" "$1,842.00" $0.00 $0.00 $360.34 $0.00 $0.00 $366.56 $0.00 $0.00 $0.00 $0.00 $0.00 RRT10070070L SUP HCPCS C1768 RRT10070070L - GRAFT VASCULAR THIN WALL 10MM 70CM 70CM REMOVABLE RING LINE BOTH IP/OP "$3,002.50 " "$2,221.85" $0.00 "$2,402.00" "$1,351.13" "$1,351.13" $0.00 $0.00 $0.00 $625.80 "$2,228.46" "$2,228.46" $0.00 $0.00 $625.72 $0.00 "$1,480.23" "$1,480.23" $0.00 "$1,501.25" "$2,377.98" "$2,402.00" $0.00 $0.00 $469.89 $0.00 $0.00 $478.00 $0.00 $0.00 $0.00 $0.00 $0.00 RS22 SUP Custom 27203010 RS22 - SUTURE NONABSORBABLE 5MM CTX 12IN 2 ARM MERSILENE WHITE BOTH IP/OP $80.02 $59.21 $0.00 $64.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.39 $59.39 $0.00 $0.00 $16.68 $0.00 $0.00 $0.00 $0.00 $40.61 $64.33 $64.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RS317 SUP Custom 27203010 CABLE ECG/PATIENT 3 LEAD FOR SRS SERIES HP 345P BOTH IP/OP $93.75 $69.38 $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.88 $74.25 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RSB501 SUP HCPCS C1894 RSB501 - INTRODUCER SHTH 5FR 6CM 2.5CM PNCL RADOPQ DIL NO MN GW BOTH IP/OP $62.88 $46.53 $0.00 $46.67 $25.45 $25.45 $0.00 $0.00 $0.00 $13.10 $46.67 $46.67 $0.00 $0.00 $13.10 $0.00 $37.19 $37.19 $0.00 $23.44 $37.13 $37.50 $0.00 $0.00 $7.34 $0.00 $0.00 $7.46 $0.00 $0.00 $0.00 $0.00 $0.00 RSB502 SUP HCPCS C1894 RSB502 - INTRODUCER SHTH 5FR 10CM 2.5CM PNCL RADOPQ DIL NO MN GW BOTH IP/OP $68.50 $50.69 $0.00 $50.84 $29.05 $29.05 $0.00 $0.00 $0.00 $14.28 $50.84 $50.84 $0.00 $0.00 $14.28 $0.00 $40.52 $40.52 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 RSB503 SUP HCPCS C1894 RSB503 - INTRODUCER SHTH 5FR 25CM 2.5CM PN RO2 DIL RADOPQ KINK RST BOTH IP/OP $87.15 $64.49 $0.00 $64.68 $35.30 $35.30 $0.00 $0.00 $0.00 $18.16 $64.68 $64.68 $0.00 $0.00 $18.16 $0.00 $51.55 $51.55 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 RSB602 SUP HCPCS C1894 RSB602 - INTRODUCER SHTH 6FR 10CM 2.5CM PN RO2 DIL RADOPQ KINK RST BOTH IP/OP $68.50 $50.69 $0.00 $50.84 $29.05 $29.05 $0.00 $0.00 $0.00 $14.28 $50.84 $50.84 $0.00 $0.00 $14.28 $0.00 $40.52 $40.52 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 RSB603 SUP HCPCS C1894 RSB603 - INTRODUCER SHTH 6FR 25CM 2.5CM PN RO2 DIL RADOPQ KINK RST BOTH IP/OP $87.15 $64.49 $0.00 $64.68 $35.30 $35.30 $0.00 $0.00 $0.00 $18.16 $64.68 $64.68 $0.00 $0.00 $18.16 $0.00 $51.55 $51.55 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 RSB702 SUP HCPCS C1894 RSB702 - INTRODUCER SHTH 7FR 2.5CM 10CM DILAT RADIOPQ MRKR BOTH IP/OP $68.50 $50.69 $0.00 $50.84 $29.05 $29.05 $0.00 $0.00 $0.00 $14.28 $50.84 $50.84 $0.00 $0.00 $14.28 $0.00 $40.52 $40.52 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 RSB703 SUP HCPCS C1894 RSB703 - INTRODUCER SHTH 7FR 2.5CM 25CM DILAT RADIOPQ MRKR BOTH IP/OP $87.15 $64.49 $0.00 $64.68 $35.30 $35.30 $0.00 $0.00 $0.00 $18.16 $64.68 $64.68 $0.00 $0.00 $18.16 $0.00 $51.55 $51.55 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 RSB802 SUP HCPCS C1894 RSB802 - INTRODUCER SHTH 8FR 2.5CM 10CM GWIRE DILAT RADIOPQ BOTH IP/OP $68.50 $50.69 $0.00 $50.84 $29.05 $29.05 $0.00 $0.00 $0.00 $14.28 $50.84 $50.84 $0.00 $0.00 $14.28 $0.00 $40.52 $40.52 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 RSB803 SUP HCPCS C1894 RSB803 - INTRODUCER SHTH 8FR 2.5CM 25CM DILAT RADIOPQ MRKR BOTH IP/OP $87.15 $64.49 $0.00 $64.68 $35.30 $35.30 $0.00 $0.00 $0.00 $18.16 $64.68 $64.68 $0.00 $0.00 $18.16 $0.00 $51.55 $51.55 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 RSB902 SUP HCPCS C1894 RSB902 - INTRODUCER SHTH 9FR 10CM 2.5CM PN RO2 DIL RADOPQ KINK RST BOTH IP/OP $68.50 $50.69 $0.00 $50.84 $29.05 $29.05 $0.00 $0.00 $0.00 $14.28 $50.84 $50.84 $0.00 $0.00 $14.28 $0.00 $40.52 $40.52 $0.00 $26.75 $42.37 $42.80 $0.00 $0.00 $8.37 $0.00 $0.00 $8.52 $0.00 $0.00 $0.00 $0.00 $0.00 RSB903 SUP HCPCS C1894 RSB903 - INTRODUCER SHTH 9FR 25CM 2.5CM PN RO2 DIL RADOPQ KINK RST BOTH IP/OP $87.15 $64.49 $0.00 $64.68 $35.30 $35.30 $0.00 $0.00 $0.00 $18.16 $64.68 $64.68 $0.00 $0.00 $18.16 $0.00 $51.55 $51.55 $0.00 $32.50 $51.48 $52.00 $0.00 $0.00 $10.17 $0.00 $0.00 $10.35 $0.00 $0.00 $0.00 $0.00 $0.00 RSR01 SUP HCPCS C1887 RSR01 - INTROD SHTH 6FR 45CM GUID STR XCUT VLV PN DSTN HYDPHI PTFE BOTH IP/OP $261.25 $193.33 $0.00 $193.90 $112.24 $112.24 $0.00 $0.00 $0.00 $54.45 $193.90 $193.90 $0.00 $0.00 $54.44 $0.00 $154.53 $154.53 $0.00 $103.35 $163.71 $165.36 $0.00 $0.00 $32.35 $0.00 $0.00 $32.91 $0.00 $0.00 $0.00 $0.00 $0.00 RSR02 SUP HCPCS C1887 RSR02 - SHEATH GD HS CRV 6FR 45CM 5CM PN DSTN XCUT VLV RADOPQ SS NYL BOTH IP/OP $261.25 $193.33 $0.00 $193.90 $111.32 $111.32 $0.00 $0.00 $0.00 $54.45 $193.90 $193.90 $0.00 $0.00 $54.44 $0.00 $154.53 $154.53 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 RSR14 SUP HCPCS C1894 RSR14 - SHEATH GD LIMA CRV 6FR 45CM 5CM PN DSTN XCUT VLV RADOPQ SS BOTH IP/OP $261.25 $193.33 $0.00 $193.90 $111.32 $111.32 $0.00 $0.00 $0.00 $54.45 $193.90 $193.90 $0.00 $0.00 $54.44 $0.00 $154.53 $154.53 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 RSS001 SUP HCPCS C1894 RSS001 - INTRODUCER SHEATH .035IN 10FR 10CM 2.5CM GWIRE DILAT KINK BOTH IP/OP $27.18 $20.11 $0.00 $20.17 $11.88 $11.88 $0.00 $0.00 $0.00 $5.66 $20.17 $20.17 $0.00 $0.00 $5.66 $0.00 $16.07 $16.07 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 RSS005 SUP HCPCS C1894 RSS005 - INTRODUCER SHEATH 10FR 25CM 2.5CM DILAT KINK RESISTANT BOTH IP/OP $59.38 $43.94 $0.00 $44.07 $27.08 $27.08 $0.00 $0.00 $0.00 $12.38 $44.07 $44.07 $0.00 $0.00 $12.37 $0.00 $35.12 $35.12 $0.00 $24.94 $39.50 $39.90 $0.00 $0.00 $7.81 $0.00 $0.00 $7.94 $0.00 $0.00 $0.00 $0.00 $0.00 RSS503 SUP HCPCS C1894 RSS503 - SHEATH INTRO 5FR 10CM 2.5CM PNCL DIL KINK RST PERI ACPT .038 BOTH IP/OP $27.18 $20.11 $0.00 $20.17 $11.88 $11.88 $0.00 $0.00 $0.00 $5.66 $20.17 $20.17 $0.00 $0.00 $5.66 $0.00 $16.07 $16.07 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 RSS505 SUP HCPCS C1894 RSS505 - SHEATH INTRO 5FR 25CM 2.5CM PNCL DIL KINK RST SS HDRPH PTFE BOTH IP/OP $59.38 $43.94 $0.00 $44.07 $27.08 $27.08 $0.00 $0.00 $0.00 $12.38 $44.07 $44.07 $0.00 $0.00 $12.37 $0.00 $35.12 $35.12 $0.00 $24.94 $39.50 $39.90 $0.00 $0.00 $7.81 $0.00 $0.00 $7.94 $0.00 $0.00 $0.00 $0.00 $0.00 RSS601 SUP HCPCS C1894 RSS601 - INTRODUCER SHEATH .035IN 6FR 10CM 2.5CM MINI GWIRE DILAT BOTH IP/OP $27.18 $20.11 $0.00 $20.17 $11.88 $11.88 $0.00 $0.00 $0.00 $5.66 $20.17 $20.17 $0.00 $0.00 $5.66 $0.00 $16.07 $16.07 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 RSS603 SUP HCPCS C1894 RSS603 - SHEATH INTRO 6FR 10CM 2.5CM PNCL DIL KINK RST PERI ACPT .038 BOTH IP/OP $271.75 $201.10 $0.00 $201.69 $118.78 $118.78 $0.00 $0.00 $0.00 $56.64 $201.69 $201.69 $0.00 $0.00 $56.63 $0.00 $160.74 $160.74 $0.00 $109.38 $173.25 $175.00 $0.00 $0.00 $34.23 $0.00 $0.00 $34.83 $0.00 $0.00 $0.00 $0.00 $0.00 RSS605 SUP HCPCS C1894 RSS605 - INTRODUCER SHEATH .035IN 6FR 25CM 2.5CM GWIRE DILAT KINK BOTH IP/OP $59.38 $43.94 $0.00 $44.07 $27.08 $27.08 $0.00 $0.00 $0.00 $12.38 $44.07 $44.07 $0.00 $0.00 $12.37 $0.00 $35.12 $35.12 $0.00 $24.94 $39.50 $39.90 $0.00 $0.00 $7.81 $0.00 $0.00 $7.94 $0.00 $0.00 $0.00 $0.00 $0.00 RSS606 SUP HCPCS C1894 RSS606 - INTRODUCER SHEATH 6FR 25CM 2.5CM DILAT KINK RESISTANT BOTH IP/OP $42.88 $31.73 $0.00 $34.30 $23.28 $23.28 $0.00 $0.00 $0.00 $8.94 $31.82 $31.82 $0.00 $0.00 $8.94 $0.00 $25.36 $25.36 $0.00 $21.44 $33.96 $34.30 $0.00 $0.00 $6.71 $0.00 $0.00 $6.83 $0.00 $0.00 $0.00 $0.00 $0.00 RSS705 SUP HCPCS C1894 RSS705 - SHEATH INTRO 7FR 25CM 2.5CM PNCL DIL KINK RST SS HDRPH PTFE BOTH IP/OP $593.75 $439.38 $0.00 $440.68 $270.82 $270.82 $0.00 $0.00 $0.00 $123.75 $440.68 $440.68 $0.00 $0.00 $123.74 $0.00 $351.20 $351.20 $0.00 $249.38 $395.01 $399.00 $0.00 $0.00 $78.05 $0.00 $0.00 $79.40 $0.00 $0.00 $0.00 $0.00 $0.00 RSS706 SUP HCPCS C1894 RSS706 - INTRODUCER SHEATH 7FR 25CM 2.5CM DILAT KINK RESISTANT SMOOTH BOTH IP/OP $42.88 $31.73 $0.00 $34.30 $23.28 $23.28 $0.00 $0.00 $0.00 $8.94 $31.82 $31.82 $0.00 $0.00 $8.94 $0.00 $25.36 $25.36 $0.00 $21.44 $33.96 $34.30 $0.00 $0.00 $6.71 $0.00 $0.00 $6.83 $0.00 $0.00 $0.00 $0.00 $0.00 RSS803 SUP HCPCS C1894 RSS803 - INTRODUCER SHEATH .035IN 8FR 10CM 2.5CM DILAT KINK RESISTANT BOTH IP/OP $27.18 $20.11 $0.00 $20.17 $11.88 $11.88 $0.00 $0.00 $0.00 $5.66 $20.17 $20.17 $0.00 $0.00 $5.66 $0.00 $16.07 $16.07 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 RSS805 SUP HCPCS C1894 RSS805 - INTRODUCER SHTH 8FR 25CM 2.5CM PNCL DIL MN GW KINK RST PERI BOTH IP/OP $59.38 $43.94 $0.00 $44.07 $27.08 $27.08 $0.00 $0.00 $0.00 $12.38 $44.07 $44.07 $0.00 $0.00 $12.37 $0.00 $35.12 $35.12 $0.00 $24.94 $39.50 $39.90 $0.00 $0.00 $7.81 $0.00 $0.00 $7.94 $0.00 $0.00 $0.00 $0.00 $0.00 RSS903 SUP HCPCS C1894 RSS903 - SHEATH INTROD .038IN 9FR 10CM 2.5CM GWIRE DILAT KINK BOTH IP/OP $27.18 $20.11 $0.00 $20.17 $11.88 $11.88 $0.00 $0.00 $0.00 $5.66 $20.17 $20.17 $0.00 $0.00 $5.66 $0.00 $16.07 $16.07 $0.00 $10.94 $17.33 $17.50 $0.00 $0.00 $3.42 $0.00 $0.00 $3.48 $0.00 $0.00 $0.00 $0.00 $0.00 RSZ-3004 SUP Custom 27203010 RSZ-3004 - SIZER IMPL P4.5CM HI PRFL RND 11.1CM 300ML STRL MEMORYGEL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RSZ-3504 SUP Custom 27203010 RSZ-3504 - SIZER IMPL P4.8CM HI PRFL RND 11.7CM 350ML STRL MEMORYGEL BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $0.00 $0.00 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RSZ-8004 SUP Custom 27803010 RSZ-8004 - SIZER IMPL P6CM HI PRFL RND 15.5CM 800ML STRL MEMORYGEL GEL BOTH IP/OP "$2,325.00 " "$1,720.50" $0.00 "$1,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,725.62" "$1,725.62" $0.00 $0.00 $484.53 $0.00 $0.00 $0.00 $0.00 "$1,162.50" "$1,841.40" "$1,860.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RT500-853 SUP Custom 27203010 CIRCUIT BRTHG HEAT RESP PORTLESS WYE PRLL WIRE CSTM 5FT ADLT BOTH IP/OP $31.25 $23.13 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.63 $24.75 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 RU510418 SUP HCPCS C1758 RU510418 - CATHETER URETHERAL SZ 18 BOTH IP/OP $7.51 $5.56 $0.00 $6.01 $4.08 $4.08 $0.00 $0.00 $0.00 $1.57 $5.57 $5.57 $0.00 $0.00 $1.57 $0.00 $4.44 $4.44 $0.00 $3.76 $5.95 $6.01 $0.00 $0.00 $1.18 $0.00 $0.00 $1.20 $0.00 $0.00 $0.00 $0.00 $0.00 RU510420 SUP HCPCS C1729 RU510420 - CATHETER ROBINSON URETHERAL SZ 20 BOTH IP/OP $7.81 $5.78 $0.00 $6.25 $4.24 $4.24 $0.00 $0.00 $0.00 $1.63 $5.80 $5.80 $0.00 $0.00 $1.63 $0.00 $4.62 $4.62 $0.00 $3.90 $6.19 $6.25 $0.00 $0.00 $1.22 $0.00 $0.00 $1.24 $0.00 $0.00 $0.00 $0.00 $0.00 RV80510 SUP HCPCS C1725 RV80510 - CATHETER BLNDIL 5MM 80CM 10CM RIVAL CK 2 LUM TPR TIP LOPRFL BOTH IP/OP $575.00 $425.50 $0.00 $460.00 $312.23 $312.23 $0.00 $0.00 $0.00 $119.84 $426.77 $426.77 $0.00 $0.00 $119.83 $0.00 $340.11 $340.11 $0.00 $287.50 $455.40 $460.00 $0.00 $0.00 $89.99 $0.00 $0.00 $91.54 $0.00 $0.00 $0.00 $0.00 $0.00 S0412-00 SUP Custom 27203010 KIT FTL MTRN BLOOD HMTLTST 950ML 300 TST BOTH IP/OP $625.25 $462.69 $0.00 $500.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.63 $495.20 $500.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-0793-HA42 SUP Custom 27803010 S-0793-HA42 - CUP ACETAB 42MM 22MM CEMENTED ODC ALL POLY HIP BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-0793-HA46 SUP Custom 27803010 S-0793-HA46 - CUP ACETAB 46MM 22MM CEMENTED ODC ALL POLY HIP BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-0793-HA50 SUP Custom 27803010 S-0793-HA50 - CUP ACETAB 50MM 22MM CEMENTED ODC ALL POLY HIP BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-0793-HA54 SUP Custom 27803010 S-0793-HA54 - CUP ACETAB 54MM 22MM CEMENTED ODC ALL POLY HIP BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-0793-HA58 SUP Custom 27803010 S-0793-HA58 - CUP ACETAB 58MM 22MM CEMENTED ODC ALL POLY HIP BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S0809 SUP Custom 27203010 REAGENT AB DILU DAKO 125ML INVIT DX IMMUN BOTH IP/OP $162.20 $120.03 $0.00 $129.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.10 $128.46 $129.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S100000 SUP Custom 27203010 S100000 - NEEDLE INSFL 14GA 100MM STP TROC BLDLS RADL EXPANDABLE SLV BOTH IP/OP $111.14 $82.24 $0.00 $82.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.49 $82.49 $0.00 $0.00 $23.16 $0.00 $0.00 $0.00 $0.00 $20.19 $31.97 $32.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-101 SUP HCPCS C1763 S-101 - GRAFT SFT TIS 3X3IN MEDISKIN PIG DRML CLGN MTRX SHT BOTH IP/OP $321.00 $237.54 $0.00 $256.80 $144.45 $144.45 $0.00 $0.00 $0.00 $66.90 $238.25 $238.25 $0.00 $0.00 $66.90 $0.00 $189.87 $189.87 $0.00 $160.50 $254.23 $256.80 $0.00 $0.00 $50.24 $0.00 $0.00 $51.10 $0.00 $0.00 $0.00 $0.00 $0.00 S1020GH SUP HCPCS C1884 S1020GH - PARTICLES EMBL 900-1200UM MCSPH 1ML PUR EMBSPH PREFL SYR BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 S-104 SUP HCPCS C1763 S-104 - DRESSING WND .25SQ FT PRCN BOTH IP/OP $175.78 $130.08 $0.00 $140.62 $79.10 $79.10 $0.00 $0.00 $0.00 $36.64 $130.46 $130.46 $0.00 $0.00 $36.63 $0.00 $103.97 $103.97 $0.00 $87.89 $139.22 $140.62 $0.00 $0.00 $27.51 $0.00 $0.00 $27.98 $0.00 $0.00 $0.00 $0.00 $0.00 S1-1500U SUP Custom 27803010 S1-1500U - STENT LCRML DCT .64MM 40MM STRL MN MNK DIL PLG INSRTR SIL BOTH IP/OP $145.83 $107.91 $0.00 $116.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.24 $108.24 $0.00 $0.00 $30.39 $0.00 $0.00 $0.00 $0.00 $72.92 $115.50 $116.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH22 SUP Custom 27803010 S-1399-HH22 - HEAD FEM HIP MRS TPR INTLK ION BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH31 SUP Custom 27803010 S-1399-HH31 - HEAD FEM HIP MRS TPR INTLK ION BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH32 SUP Custom 27803010 S-1399-HH32 - HEAD FEM HIP MRS TPR INTLK ION BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH34 SUP Custom 27803010 S-1399-HH34 - HEAD FEM 34MM HIP MRS TPR INTLK BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH62 SUP Custom 27803010 S-1399-HH62 - HEAD FEM 62MM HIP MRS TPR INTLK BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH64 SUP Custom 27803010 S-1399-HH64 - HEAD FEM 64MM HIP MRS TPR INTLK BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH82 SUP Custom 27803010 S-1399-HH82 - HEAD FEM 82MM HIP MRS TPR INTLK BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH83 SUP Custom 27803010 S-1399-HH83 - HEAD FEM 83MM HIP MRS TPR INTLK ION BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1399-HH84 SUP Custom 27803010 S-1399-HH84 - HEAD FEM 84MM HIP MRS TPR INTLK BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1400-HH22 SUP Custom 27803010 S-1400-HH22 - HEAD FEMORAL +2.5MM C TAPER 22MM LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1400-HH31 SUP Custom 27803010 S-1400-HH31 - HEAD FEM -2.5MM OFST CTPR 32MM STRL LFIT INTMD NK COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1400-HH32 SUP Custom 27803010 S-1400-HH32 - HEAD FEMORAL +2.5MM 32MM C TAPER NECK PRIM LFIT TRIDENT COCR BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1400-HH34 SUP Custom 27803010 S-1400-HH34 - HEAD FEM +7.5MM OFST CTPR 32MM STRL LFIT INTMD NK COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1400-HH62 SUP Custom 27803010 S-1400-HH62 - HEAD FEMORAL +2.5MM 26MM C TAPER INTERLOK LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1400-HH64 SUP Custom 27803010 S-1400-HH64 - HEAD FEMORAL +7.5MM 26MM C TAPER INTERLOK LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1400-HH82 SUP Custom 27803010 S-1400-HH82 - HEAD FEMORAL +2.5MM OFFST C TAPER 28MM LFIT TRIDENT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1400-HH84 SUP Custom 27803010 S-1400-HH84 - HEAD FEMORAL C TAPER INTERLOCK LFIT COCR HIP BOTH IP/OP $862.50 $638.25 $0.00 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $640.15 $640.15 $0.00 $0.00 $179.75 $0.00 $0.00 $0.00 $0.00 $431.25 $683.10 $690.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1539-HA46 SUP Custom 27803010 S-1539-HA46 - CUP ACETAB 26MM ODC ALPLY BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1539-HA50 SUP Custom 27803010 S-1539-HA50 - CUP ACETAB 50MM 26MM ODC ALL POLY HIP BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1539-HA54 SUP Custom 27803010 S-1539-HA54 - CUP ACETAB 54MM 26MM ODC ALL POLY HIP BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1539-HA58 SUP Custom 27803010 S-1539-HA58 - CUP ACETAB 58MM 26MM ODC ALL POLY HIP BOTH IP/OP $822.00 $608.28 $0.00 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.09 $610.09 $0.00 $0.00 $171.30 $0.00 $0.00 $0.00 $0.00 $411.00 $651.02 $657.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-1645-HF01 SUP HCPCS C1776 S-1645-HF01 - STEM FEM MOD HYDRXAPT 1 HIP BOTH IP/OP "$5,300.00 " "$3,922.00" $0.00 "$4,240.00" "$2,385.00" "$2,385.00" $0.00 $0.00 $0.00 "$1,104.65" "$3,933.66" "$3,933.66" $0.00 $0.00 "$1,104.52" $0.00 "$2,612.90" "$2,612.90" $0.00 "$2,650.00" "$4,197.60" "$4,240.00" $0.00 $0.00 $829.45 $0.00 $0.00 $843.76 $0.00 $0.00 $0.00 $0.00 $0.00 S1699 SUP Custom 27203010 REAGENT TRGT RTRVL SOL 500ML CONCEN IMMUN BOTH IP/OP $773.05 $572.06 $0.00 $618.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $386.53 $612.26 $618.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S17-45 SUP Custom 27803010 S17-45 - GRAFT ENDOVASCULAR SHEATH ABDOMINAL AORTIC ANEURYSM BOTH IP/OP "$1,247.50 " $923.15 $0.00 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $925.89 $925.89 $0.00 $0.00 $259.98 $0.00 $0.00 $0.00 $0.00 $623.75 $988.02 $998.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S195 SUP Custom 27203010 STAIN GMS 8OZ STK SOL HMTL BOTH IP/OP $246.25 $182.23 $0.00 $197.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.13 $195.03 $197.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S1967 SUP Custom 27203010 REAGENT CLEAN SOL DAB-AWAY 1.25L HMTL BOTH IP/OP $347.30 $257.00 $0.00 $277.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.65 $275.06 $277.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S20SFRN8 SUP Custom 27803010 S20SFRN8 - CLIP SHRT INTNL UCLP FLXB REG NDL BOTH IP/OP "$6,210.00 " "$4,595.40" $0.00 "$4,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,294.16" $0.00 $0.00 $0.00 $0.00 "$3,105.00" "$4,918.32" "$4,968.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2646 SUP Custom 27803010 S-2301-2646 - INSERT ACETAB 46-48MM 26MM 10D KNEE ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2648 SUP Custom 27803010 S-2301-2648 - INSERT ACETAB 48MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2650 SUP Custom 27803010 S-2301-2650 - INSERT ACETAB 50-52MM 26MM 10D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2652 SUP Custom 27803010 S-2301-2652 - INSERT ACETAB 52MM 26MM 10D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2654 SUP Custom 27803010 S-2301-2654 - INSERT ACETAB 54-56MM 26MM 10D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2656 SUP Custom 27803010 S-2301-2656 - INSERT ACETAB 56MM 26MM 10D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2658 SUP Custom 27803010 S-2301-2658 - INSERT ACETAB 58-60MM 26MM 10D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2662 SUP Custom 27803010 S-2301-2662 - INSERT ACETAB 61-72MM 26MM 10D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2846 SUP Custom 27803010 S-2301-2846 - INSERT ACETAB 46-48MM 28MM 10D ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2848 SUP Custom 27803010 S-2301-2848 - INSERT ACETAB 48MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2850 SUP Custom 27803010 S-2301-2850 - INSERT ACETAB 50MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2852 SUP Custom 27803010 S-2301-2852 - INSERT ACETAB 52MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2854 SUP Custom 27803010 S-2301-2854 - INSERT ACETAB 54MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2856 SUP Custom 27803010 S-2301-2856 - INSERT ACETAB 56MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2858 SUP Custom 27803010 S-2301-2858 - INSERT ACETAB 58-60MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2862 SUP Custom 27803010 S-2301-2862 - INSERT ACETAB 61-72MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2866 SUP Custom 27803010 S-2301-2866 - INSERT ACETAB 66-68MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2870 SUP Custom 27803010 S-2301-2870 - INSERT ACETAB 70-72MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-2874 SUP Custom 27803010 S-2301-2874 - INSERT ACETAB 74MM 28MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3250 SUP Custom 27803010 S-2301-3250 - INSERT ACETAB 50-52MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3252 SUP Custom 27803010 S-2301-3252 - INSERT ACETAB 52MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3254 SUP Custom 27803010 S-2301-3254 - INSERT ACETAB 54-56MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3256 SUP Custom 27803010 S-2301-3256 - INSERT ACETAB 56MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3258 SUP Custom 27803010 S-2301-3258 - INSERT ACETAB 58-60MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3262 SUP Custom 27803010 S-2301-3262 - INSERT ACETAB 61-72MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3266 SUP Custom 27803010 S-2301-3266 - INSERT ACETAB 66-68MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3270 SUP Custom 27803010 S-2301-3270 - INSERT ACETAB 70-72MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301-3274 SUP Custom 27803010 S-2301-3274 - INSERT ACETAB 74MM 32MM 10D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2846 SUP Custom 27803010 S-2301C-2846 - INSERT ACETAB 10D 46MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2848 SUP Custom 27803010 S-2301C-2848 - INSERT ACETAB 10D 48MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2850 SUP Custom 27803010 S-2301C-2850 - INSERT ACETAB 10D 50MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2852 SUP Custom 27803010 S-2301C-2852 - INSERT ACETAB 10D 52MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2854 SUP Custom 27803010 S-2301C-2854 - INSERT ACETAB 10D 54MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2856 SUP Custom 27803010 S-2301C-2856 - INSERT ACETAB 10D 56MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2858 SUP Custom 27803010 S-2301C-2858 - INSERT ACETAB 10D 58-60MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2862 SUP Custom 27803010 S-2301C-2862 - INSERT ACETAB 10D 62MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2866 SUP Custom 27803010 S-2301C-2866 - INSERT ACETAB 10D 66MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2870 SUP Custom 27803010 S-2301C-2870 - INSERT ACETAB 10D 70MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-2874 SUP Custom 27803010 S-2301C-2874 - INSERT ACETAB 10D 74MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3250 SUP Custom 27803010 S-2301C-3250 - INSERT ACETAB 10D 50MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3252 SUP Custom 27803010 S-2301C-3252 - INSERT ACETAB 10D 52MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3254 SUP Custom 27803010 S-2301C-3254 - INSERT ACETAB 10D 54MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3256 SUP Custom 27803010 S-2301C-3256 - INSERT ACETAB 10D 56MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3258 SUP Custom 27803010 S-2301C-3258 - INSERT ACETAB 10D 58-60MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3262 SUP Custom 27803010 S-2301C-3262 - INSERT ACETAB 10D 62MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3266 SUP Custom 27803010 S-2301C-3266 - INSERT ACETAB 10D 66MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3270 SUP Custom 27803010 S-2301C-3270 - INSERT ACETAB 10D 70MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2301C-3274 SUP Custom 27803010 S-2301C-3274 - INSERT ACETAB 74MM 32MM 10D HIP ECNTRC OMFT BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2646 SUP Custom 27803010 S-2302-2646 - INSERT ACETAB 46-48MM 26MM 20D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2648 SUP Custom 27803010 S-2302-2648 - INSERT ACETAB 48MM 26MM 20D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2650 SUP Custom 27803010 S-2302-2650 - INSERT ACETAB 50-52MM 26MM 20D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2652 SUP Custom 27803010 S-2302-2652 - INSERT ACETAB 52MM 26MM 20D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2654 SUP Custom 27803010 S-2302-2654 - INSERT ACETAB 54-56MM 26MM 20D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2656 SUP Custom 27803010 S-2302-2656 - INSERT ACETAB 56MM 26MM 20D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2658 SUP Custom 27803010 S-2302-2658 - INSERT ACETAB 58-60MM 26MM 20D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2662 SUP Custom 27803010 S-2302-2662 - INSERT ACETAB 61-72MM 26MM 20D HIP ECNTRC BOTH IP/OP "$2,299.38 " "$1,701.54" $0.00 "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.60" "$1,706.60" $0.00 $0.00 $479.19 $0.00 $0.00 $0.00 $0.00 "$1,149.69" "$1,821.11" "$1,839.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2846 SUP Custom 27803010 S-2302-2846 - INSERT ACETAB 46-48MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2848 SUP Custom 27803010 S-2302-2848 - INSERT ACETAB 48MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2850 SUP Custom 27803010 S-2302-2850 - INSERT ACETAB 50-52MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2852 SUP Custom 27803010 S-2302-2852 - INSERT ACETAB 52MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2854 SUP Custom 27803010 S-2302-2854 - INSERT ACETAB 54-56MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2856 SUP Custom 27803010 S-2302-2856 - INSERT ACETAB 56MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2858 SUP Custom 27803010 S-2302-2858 - INSERT ACETAB 58-60MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2862 SUP Custom 27803010 S-2302-2862 - INSERT ACETAB 61-72MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2866 SUP Custom 27803010 S-2302-2866 - INSERT ACETAB 66-68MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2870 SUP Custom 27803010 S-2302-2870 - INSERT ACETAB 70-72MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-2874 SUP Custom 27803010 S-2302-2874 - INSERT ACETAB 74MM 28MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3250 SUP Custom 27803010 S-2302-3250 - INSERT ACETAB 50-52MM 32MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3252 SUP Custom 27803010 S-2302-3252 - INSERT ACETAB 52MM 32MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3254 SUP Custom 27803010 S-2302-3254 - INSERT ACETAB 54-56MM 32MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3256 SUP Custom 27803010 S-2302-3256 - INSERT ACETAB 56MM 32MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3258 SUP Custom 27803010 S-2302-3258 - INSERT ACETAB 58-60MM 32MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3262 SUP Custom 27803010 S-2302-3262 - INSERT ACETAB 61-72MM 32MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3266 SUP Custom 27803010 S-2302-3266 - INSERT ACETAB 66-68MM 32MM 20D HIP ECNTRC BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3270 SUP Custom 27803010 S-2302-3270 - INSERT ACETAB 70-72MM 32MM 20D ECNTRC 8MM BOTH IP/OP "$2,125.50 " "$1,572.87" $0.00 "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,577.55" "$1,577.55" $0.00 $0.00 $442.95 $0.00 $0.00 $0.00 $0.00 "$1,062.75" "$1,683.40" "$1,700.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302-3274 SUP Custom 27803010 S-2302-3274 - INSERT ACETAB 74MM 32MM HIP ECNTRC BOTH IP/OP "$1,421.88 " "$1,052.19" $0.00 "$1,137.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,055.32" "$1,055.32" $0.00 $0.00 $296.32 $0.00 $0.00 $0.00 $0.00 $710.94 "$1,126.13" "$1,137.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2846 SUP Custom 27803010 S-2302C-2846 - INSERT ACETAB 20D 46MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2848 SUP Custom 27803010 S-2302C-2848 - INSERT ACETAB 20D 48MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2850 SUP Custom 27803010 S-2302C-2850 - INSERT ACETAB 20D 50MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2852 SUP Custom 27803010 S-2302C-2852 - INSERT ACETAB 20D 52MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2854 SUP Custom 27803010 S-2302C-2854 - INSERT ACETAB 20D 54MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2856 SUP Custom 27803010 S-2302C-2856 - INSERT ACETAB 20D 56MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2858 SUP Custom 27803010 S-2302C-2858 - INSERT ACETAB 20D 58MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2862 SUP Custom 27803010 S-2302C-2862 - INSERT ACETAB 20D 62MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2866 SUP Custom 27803010 S-2302C-2866 - INSERT ACETAB 20D 66MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2870 SUP Custom 27803010 S-2302C-2870 - INSERT ACETAB 20D 70MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-2874 SUP Custom 27803010 S-2302C-2874 - INSERT ACETAB 20D 74MM 28MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3250 SUP Custom 27803010 S-2302C-3250 - INSERT ACETAB 20D 50MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3252 SUP Custom 27803010 S-2302C-3252 - INSERT ACETAB 20D 52MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3254 SUP Custom 27803010 S-2302C-3254 - INSERT ACETAB 20D 54MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3256 SUP Custom 27803010 S-2302C-3256 - INSERT ACETAB 20D 56MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3258 SUP Custom 27803010 S-2302C-3258 - INSERT ACETAB 20D 58MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3262 SUP Custom 27803010 S-2302C-3262 - INSERT ACETAB 20D 62MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3266 SUP Custom 27803010 S-2302C-3266 - INSERT ACETAB 20D 66MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3270 SUP Custom 27803010 S-2302C-3270 - INSERT ACETAB 20D 70MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2302C-3274 SUP Custom 27803010 S-2302C-3274 - INSERT ACETAB 20D 74MM 32MM ECCENTRIC XFIRE HIP BOTH IP/OP "$3,105.00 " "$2,297.70" $0.00 "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,304.53" "$2,304.53" $0.00 $0.00 $647.08 $0.00 $0.00 $0.00 $0.00 "$1,552.50" "$2,459.16" "$2,484.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF04 SUP HCPCS C1776 S-2337-HF04 - STEM FEMORAL 4 100MM COLLAR ARC PRESS FIT SECFIT HA TITANIUM BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF05 SUP HCPCS C1776 S-2337-HF05 - STEM FEMORAL 5 110MM COLLAR ARC PRESS FIT SECFIT HA TITANIUM BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF06 SUP HCPCS C1776 S-2337-HF06 - STEM FEMORAL 6 COLLARED SECFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF07 SUP HCPCS C1776 S-2337-HF07 - STEM FEMORAL 7 COLLARED SECFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF08 SUP HCPCS C1776 S-2337-HF08 - STEM FEMORAL 8 COLLARED SECFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF09 SUP HCPCS C1776 S-2337-HF09 - STEM FEMORAL COLLARED ARC DEPOSITED SECFIT HYDRXAPT BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF10 SUP HCPCS C1776 S-2337-HF10 - STEM FEMORAL 10 COLLARED SECFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF11 SUP HCPCS C1776 S-2337-HF11 - STEM FEMORAL 11 COLLARED SECFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF12 SUP HCPCS C1776 S-2337-HF12 - STEM FEMORAL 12 COLLAR ARC DEPOSITED SECFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF13 SUP HCPCS C1776 S-2337-HF13 - STEM FEMORAL 13 COLLARED ARC DEPOSITED SECFIT HYDRXAPT HIP BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S-2337-HF14 SUP HCPCS C1776 S-2337-HF14 - STEM FEMORAL 14 180MM COLLAR ARC PRESS FIT SECFIT HA BOTH IP/OP "$5,180.00 " "$3,833.20" $0.00 "$4,144.00" "$2,331.00" "$2,331.00" $0.00 $0.00 $0.00 "$1,079.64" "$3,844.60" "$3,844.60" $0.00 $0.00 "$1,079.51" $0.00 "$2,553.74" "$2,553.74" $0.00 "$2,590.00" "$4,102.56" "$4,144.00" $0.00 $0.00 $810.67 $0.00 $0.00 $824.66 $0.00 $0.00 $0.00 $0.00 $0.00 S2368 SUP Custom 27203010 REAGENT TRIS EDTA BUFF 500ML PH 9 TRGT RTRVL SOL HISTOLGY BOTH IP/OP $243.68 $180.32 $0.00 $194.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.84 $192.99 $194.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S2369 SUP Custom 27203010 REAGENT TRGT RTRVL SOL CITR 500ML PH 6 CONCEN HISTOLGY BOTH IP/OP "$1,109.15 " $820.77 $0.00 $887.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.58 $878.45 $887.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-0711 SUP HCPCS C1776 S-2651-0711 - NECK FEMORAL 7 -5MM STR 11MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-0713 SUP HCPCS C1776 S-2651-0713 - NECK FEMORAL 7 -5MM STR 13MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-0812 SUP HCPCS C1776 S-2651-0812 - NECK FEMORAL 8 -5MM STR 12MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-0814 SUP HCPCS C1776 S-2651-0814 - NECK FEMORAL 8 -5MM STR 14MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-0913 SUP HCPCS C1776 S-2651-0913 - NECK FEMORAL 9 -5MM STR 13MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-0915 SUP HCPCS C1776 S-2651-0915 - STEM FEMORAL 9 -5MM STR 15MM 155MM REDUCE NECK RSTOR HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-1014 SUP HCPCS C1776 S-2651-1014 - NECK FEMORAL 10 -5MM STR 14MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-1016 SUP HCPCS C1776 S-2651-1016 - NECK FEMORAL 10 -5MM STR 16MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-1115 SUP HCPCS C1776 S-2651-1115 - NECK FEMORAL 11 -5MM STR 15MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-1117 SUP HCPCS C1776 S-2651-1117 - NECK FEMORAL 11 -5MM STR 17MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-1216 SUP HCPCS C1776 S-2651-1216 - NECK FEMORAL 12 -5MM STR 16MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2651-1218 SUP HCPCS C1776 S-2651-1218 - NECK FEMORAL 12 -5MM STR 18MM 155MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$11,937.50 " "$8,833.75" $0.00 "$9,550.00" "$5,371.88" "$5,371.88" $0.00 $0.00 $0.00 "$2,488.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,487.78" $0.00 "$5,885.19" "$5,885.19" $0.00 "$5,968.75" "$9,454.50" "$9,550.00" $0.00 $0.00 "$1,868.22" $0.00 $0.00 "$1,900.45" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-0812 SUP HCPCS C1776 S-2652-0812 - NECK FEMORAL 8 -5MM STR 12MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-0814 SUP HCPCS C1776 S-2652-0814 - NECK FEMORAL 8 -5MM STR 14MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-0913 SUP HCPCS C1776 S-2652-0913 - NECK FEMORAL 9 -5MM STR 13MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-0915 SUP HCPCS C1776 S-2652-0915 - NECK FEMORAL 9 -5MM STR 15MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1014 SUP HCPCS C1776 S-2652-1014 - NECK FEMORAL 10 -5MM STR 14MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1016 SUP HCPCS C1776 S-2652-1016 - NECK FEMORAL 10 -5MM STR 16MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1115 SUP HCPCS C1776 S-2652-1115 - NECK FEMORAL 11 -5MM STR 15MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1117 SUP HCPCS C1776 S-2652-1117 - STEM FEMORAL 11 -5MM STR 17MM 205MM REDUCE NECK RSTOR HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1216 SUP HCPCS C1776 S-2652-1216 - NECK FEMORAL 12 -5MM STR 16MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1218 SUP HCPCS C1776 S-2652-1218 - STEM FEMORAL 12 -5MM STR 18MM 205MM REDUCE NECK RSTOR HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1317 SUP HCPCS C1776 S-2652-1317 - NECK FEMORAL 17 -5MM STR 13MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1319 SUP HCPCS C1776 S-2652-1319 - NECK FEMORAL 13 -5MM STR 19MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1418 SUP HCPCS C1776 S-2652-1418 - NECK FEMORAL 14 -5MM STR 18MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1420 SUP HCPCS C1776 S-2652-1420 - NECK FEMORAL 14 -5MM STR 20MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2652-1422 SUP HCPCS C1776 S-2652-1422 - NECK FEMORAL 14 -5MM STR 22MM 205MM REDUCE RSTOR TITANIUM HA BOTH IP/OP "$12,645.00 " "$9,357.30" $0.00 "$10,116.00" "$5,690.25" "$5,690.25" $0.00 $0.00 $0.00 "$2,635.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,635.22" $0.00 "$6,233.99" "$6,233.99" $0.00 "$6,322.50" "$10,014.84" "$10,116.00" $0.00 $0.00 "$1,978.94" $0.00 $0.00 "$2,013.08" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-0812-L SUP HCPCS C1776 S-2653-0812-L - STEM FEM LEFT HIP 255MM 12-8MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-0812-R SUP HCPCS C1776 S-2653-0812-R - STEM FEM RIGHT HIP 255MM 12-8MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-0913-L SUP HCPCS C1776 S-2653-0913-L - STEM FEM LEFT HIP 255MM 13-9MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-0913-R SUP HCPCS C1776 S-2653-0913-R - STEM FEM RIGHT HIP 255MM 13-9MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1014-L SUP HCPCS C1776 S-2653-1014-L - STEM FEM LEFT HIP 255MM 14-10MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1014-R SUP HCPCS C1776 S-2653-1014-R - STEM FEM RIGHT HIP 255MM 14-10MM STR DISTAL SLOT RED NECK BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1115-L SUP HCPCS C1776 S-2653-1115-L - STEM FEM LEFT HIP 255MM 15-11MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1115-R SUP HCPCS C1776 S-2653-1115-R - STEM FEM RIGHT HIP 255MM 15-11MM STR DISTAL SLOT RED NECK BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1216-L SUP HCPCS C1776 S-2653-1216-L - STEM FEM LEFT HIP 255MM 16-12MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1216-R SUP HCPCS C1776 S-2653-1216-R - STEM FEM RIGHT HIP 255MM 16-12MM STR DISTAL SLOT RED NECK BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1317-L SUP HCPCS C1776 S-2653-1317-L - STEM FEM LEFT HIP 255MM 17-13MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1317-R SUP HCPCS C1776 S-2653-1317-R - STEM FEM RIGHT HIP 255MM 17-13MM STR DISTAL SLOT RED NECK BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1418-L SUP HCPCS C1776 S-2653-1418-L - STEM FEM LEFT HIP 255MM 18-14MM STR DISTAL SLOT RED NECK REV BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2653-1418-R SUP HCPCS C1776 S-2653-1418-R - STEM FEM RIGHT HIP 255MM 18-14MM STR DISTAL SLOT RED NECK BOTH IP/OP "$13,222.63 " "$9,784.75" $0.00 "$10,578.10" "$5,950.18" "$5,950.18" $0.00 $0.00 $0.00 "$2,755.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,755.60" $0.00 "$6,518.75" "$6,518.75" $0.00 "$6,611.31" "$10,472.32" "$10,578.10" $0.00 $0.00 "$2,069.34" $0.00 $0.00 "$2,105.04" $0.00 $0.00 $0.00 $0.00 $0.00 S-2722-2210 SUP Custom 27803010 S-2722-2210 - HEAD FEM HIP MRS TPR COCR LFIT BOTH IP/OP "$1,147.00 " $848.78 $0.00 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $851.30 $851.30 $0.00 $0.00 $239.03 $0.00 $0.00 $0.00 $0.00 $573.50 $908.42 $917.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S2801 SUP Custom 27203010 CONTROL PASCAL QUAL STRP HISTOLGY BOTH IP/OP $302.50 $223.85 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.25 $239.58 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S3006 SUP Custom 27203010 REAGENT WSH BUFF DUOCISH 1L IMMUN 10X BOTH IP/OP $192.45 $142.41 $0.00 $153.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.23 $152.42 $153.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S302030-2 SUP Custom 27203010 ENZYME LAB PRTNS K PREDIL 110ML BOTH IP/OP $890.68 $659.10 $0.00 $712.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.34 $705.42 $712.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S3417 SUP Custom 27203010 LABEL SLD RL RBN CLEAN PEN KT SEYMOUR BOTH IP/OP "$1,058.50 " $783.29 $0.00 $846.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $785.62 $785.62 $0.00 $0.00 $220.59 $0.00 $0.00 $0.00 $0.00 $529.25 $838.33 $846.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S3425 SUP Custom 27203010 VIAL STN REAGENT BOTH IP/OP $156.73 $115.98 $0.00 $125.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.36 $124.13 $125.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S420GH SUP HCPCS C1884 S420GH - PARTICLES EMBOLIZATION 300-500UM MICROSPHERE .038IN PREFILL BOTH IP/OP $607.50 $449.55 $0.00 $486.00 $273.38 $273.38 $0.00 $0.00 $0.00 $126.62 $450.89 $450.89 $0.00 $0.00 $126.60 $0.00 $359.34 $359.34 $0.00 $303.75 $481.14 $486.00 $0.00 $0.00 $95.07 $0.00 $0.00 $96.71 $0.00 $0.00 $0.00 $0.00 $0.00 S-55-150-120-P6 SUP HCPCS C1876 S-55-150-120-P6 - STENT VASCULAR 5.5MM 6FR 150MM 120CM OTW SELF EXPANDABLE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 S620GH/C SUP HCPCS C1884 S620GH/C - PARTICLES EMBL 500-700UM RND 2ML 20ML RD STRL EMBSPH SAL SYR BOTH IP/OP $515.00 $381.10 $0.00 $412.00 $231.75 $231.75 $0.00 $0.00 $0.00 $107.34 $382.23 $382.23 $0.00 $0.00 $107.33 $0.00 $304.62 $304.62 $0.00 $257.50 $407.88 $412.00 $0.00 $0.00 $80.60 $0.00 $0.00 $81.99 $0.00 $0.00 $0.00 $0.00 $0.00 S-65-080-120-P6 SUP HCPCS C1876 S-65-080-120-P6 - STENT VASCULAR 6.5MM 6FR 80MM 120CM OTW SELF EXPANDABLE BOTH IP/OP "$2,062.50 " "$1,526.25" $0.00 "$1,650.00" $928.13 $928.13 $0.00 $0.00 $0.00 $429.88 "$1,530.79" "$1,530.79" $0.00 $0.00 $429.83 $0.00 "$1,219.97" "$1,219.97" $0.00 "$1,031.25" "$1,633.50" "$1,650.00" $0.00 $0.00 $322.78 $0.00 $0.00 $328.35 $0.00 $0.00 $0.00 $0.00 $0.00 S7150 SUP Custom 27203010 REAGENT TSTK XP FRML 3 SET HISTOLGY BOTH IP/OP $660.00 $488.40 $0.00 $528.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.00 $522.72 $528.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S7439-12 SUP Custom 27203010 STAIN CLRFR 2 4GL HPRFR WKG SOL RA HEMATOX CYTO BOTH IP/OP $58.28 $43.13 $0.00 $46.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.14 $46.16 $46.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S7439-3 SUP Custom 27203010 STAIN HMTX 2 4PT HPRFR HISTOLGY BOTH IP/OP $67.03 $49.60 $0.00 $53.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.51 $53.09 $53.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S7439-33 SUP Custom 27203010 STAIN MOD HRS HMTX 1GL HG FR WKG SOL HISTOLGY BOTH IP/OP $209.35 $154.92 $0.00 $167.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.68 $165.81 $167.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S7439-39 SUP Custom 27203010 STAIN MOD PAP OG-6 1GL CYTO BOTH IP/OP $187.10 $138.45 $0.00 $149.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.55 $148.18 $149.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S7439-4 SUP Custom 27203010 STAIN EOSIN Y 4PT HPRFR WKG SOL HISTOLGY BOTH IP/OP $242.15 $179.19 $0.00 $193.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.08 $191.78 $193.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S7439-7A SUP Custom 27203010 STAIN BLUING SGNTR 1GL WKG SOL REAGENT HMTL BOTH IP/OP $99.58 $73.69 $0.00 $79.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.79 $78.87 $79.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S820GH SUP HCPCS C1884 S820GH - PARTICLES EMBL 700-900UM MCSPH 2ML GRN EMBSPH PREFL SYR BOTH IP/OP $607.50 $449.55 $0.00 $450.89 $231.75 $231.75 $0.00 $0.00 $0.00 $126.62 $450.89 $450.89 $0.00 $0.00 $126.60 $0.00 $359.34 $359.34 $0.00 $257.50 $407.88 $412.00 $0.00 $0.00 $80.60 $0.00 $0.00 $81.99 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.100 SUP HCPCS V2632 SA30AT.100 - LENS IOL 0 D +10 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.105 SUP HCPCS V2632 SA30AT.105 - LENS IOL 0 D +10.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.110 SUP HCPCS V2632 SA30AT.110 - LENS IOL 0 D +11 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.115 SUP HCPCS V2632 SA30AT.115 - LENS IOL 0 D +11.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.120 SUP HCPCS V2632 SA30AT.120 - LENS IOL 0 D +12 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.125 SUP HCPCS V2632 SA30AT.125 - LENS IOL 0 D +12.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.130 SUP HCPCS V2632 SA30AT.130 - LENS IOL 0 D +13 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.135 SUP HCPCS V2632 SA30AT.135 - LENS IOL 0 D +13.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.140 SUP HCPCS V2632 SA30AT.140 - LENS IOL 0 D +14 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.145 SUP HCPCS V2632 SA30AT.145 - LENS IOL 0 D +14.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.150 SUP HCPCS V2632 SA30AT.150 - LENS IOL 0 D +15 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.155 SUP HCPCS V2632 SA30AT.155 - LENS IOL 0 D +15.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.160 SUP HCPCS V2632 SA30AT.160 - LENS IOL 0 D +16 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.165 SUP HCPCS V2632 SA30AT.165 - LENS IOL 0 D +16.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.170 SUP HCPCS V2632 SA30AT.170 - LENS IOL 0 D +17 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.175 SUP HCPCS V2632 SA30AT.175 - LENS IOL 0 D +17.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.180 SUP HCPCS V2632 SA30AT.180 - LENS IOL 0 D +18 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.185 SUP HCPCS V2632 SA30AT.185 - LENS IOL 0 D +18.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.190 SUP HCPCS V2632 SA30AT.190 - LENS IOL 0 D +19 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.195 SUP HCPCS V2632 SA30AT.195 - LENS IOL 0 D +19.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.200 SUP HCPCS V2632 SA30AT.200 - LENS IOL 0 D +20 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.205 SUP HCPCS V2632 SA30AT.205 - LENS IOL 0 D +20.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.210 SUP HCPCS V2632 SA30AT.210 - LENS IOL 0 D +21 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.215 SUP HCPCS V2632 SA30AT.215 - LENS IOL 0 D +21.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.220 SUP HCPCS V2632 SA30AT.220 - LENS IOL 0 D +22 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.225 SUP HCPCS V2632 SA30AT.225 - LENS IOL 0 D +22.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.230 SUP HCPCS V2632 SA30AT.230 - LENS IOL 0 D +23 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.235 SUP HCPCS V2632 SA30AT.235 - LENS IOL 0 D +23.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.240 SUP HCPCS V2632 SA30AT.240 - LENS IOL 0 D +24 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.245 SUP HCPCS V2632 SA30AT.245 - LENS IOL 0 D +24.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.250 SUP HCPCS V2632 SA30AT.250 - LENS IOL 0 D +25 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.255 SUP HCPCS V2632 SA30AT.255 - LENS IOL 0 D +25.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.260 SUP HCPCS V2632 SA30AT.260 - LENS IOL 0 D +26 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.265 SUP HCPCS V2632 SA30AT.265 - LENS IOL 0 D +26.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.270 SUP HCPCS V2632 SA30AT.270 - LENS IOL 0 D +27 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.275 SUP HCPCS V2632 SA30AT.275 - LENS IOL 0 D +27.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.280 SUP HCPCS V2632 SA30AT.280 - LENS IOL 0 D +28 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.285 SUP HCPCS V2632 SA30AT.285 - LENS IOL 0 D +28.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.290 SUP HCPCS V2632 SA30AT.290 - LENS IOL 0 D +29 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.295 SUP HCPCS V2632 SA30AT.295 - LENS IOL 0 D +29.5 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA30AT.300 SUP HCPCS V2632 SA30AT.300 - LENS IOL 0 D +30 DIOP BCNVX 5.5MM 13MM STRL ACRSF 1 PC FLD BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA4644 SUP Custom 27203010 BLADDER TOP CCB SA4694 BOTH IP/OP $716.08 $529.90 $0.00 $572.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.04 $567.14 $572.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SA4645 SUP Custom 27203010 BLADDER BOTTOM CCB SA4645 BOTH IP/OP $733.23 $542.59 $0.00 $586.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $366.61 $580.72 $586.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SA4901 SUP Custom 27203010 FOAM CCB #SA4901 BOTH IP/OP $171.38 $126.82 $0.00 $137.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.69 $135.73 $137.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SA60AT.290 SUP HCPCS V2632 SA60AT.290 - LENS IOL 0 D +29 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA60AT.310 SUP HCPCS V2632 SA60AT.310 - LENS IOL 0 D +31 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60AT.350 SUP HCPCS V2632 SA60AT.350 - LENS IOL 0 D +35 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA60AT.360 SUP HCPCS V2632 SA60AT.360 - LENS IOL 0 D +36 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA60AT.370 SUP HCPCS V2632 SA60AT.370 - LENS IOL 0 D +37 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA60AT.380 SUP HCPCS V2632 SA60AT.380 - LENS IOL 0 D +38 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA60AT.390 SUP HCPCS V2632 SA60AT.390 - LENS IOL 0 D +39 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA60AT.400 SUP HCPCS V2632 SA60AT.400 - LENS IOL 0 D +40 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $375.00 $277.50 $0.00 $300.00 $168.75 $168.75 $0.00 $0.00 $0.00 $78.16 $278.33 $278.33 $0.00 $0.00 $78.15 $0.00 $221.81 $221.81 $0.00 $187.50 $297.00 $300.00 $0.00 $0.00 $58.69 $0.00 $0.00 $59.70 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF SUP HCPCS V2632 SA60WF - LENS IOL 0 D +22.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.060 SUP HCPCS V2632 SA60WF.060 - LENS IOL 0 D +6 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.065 SUP HCPCS V2632 SA60WF.065 - LENS IOL 0 D +6.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.070 SUP HCPCS V2632 SA60WF.070 - LENS IOL 0 D +7 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.075 SUP HCPCS V2632 SA60WF.075 - LENS IOL 0 D +7.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.080 SUP HCPCS V2632 SA60WF.080 - LENS IOL 0 D +8 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.085 SUP HCPCS V2632 SA60WF.085 - LENS IOL 0 D +8.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.090 SUP HCPCS V2632 SA60WF.090 - LENS IOL 0 D +9 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.095 SUP HCPCS V2632 SA60WF.095 - LENS IOL 0 D +9.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.100 SUP HCPCS V2632 SA60WF.100 - LENS IOL 0 D +10 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.105 SUP HCPCS V2632 SA60WF.105 - LENS IOL 0 D +10.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.110 SUP HCPCS V2632 SA60WF.110 - LENS IOL 0 D +11 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.115 SUP HCPCS V2632 SA60WF.115 - LENS IOL 0 D +11.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.120 SUP HCPCS V2632 SA60WF.120 - LENS IOL 0 D +12 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.125 SUP HCPCS V2632 SA60WF.125 - LENS IOL 0 D +12.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.130 SUP HCPCS V2632 SA60WF.130 - LENS IOL 0 D +13 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.135 SUP HCPCS V2632 SA60WF.135 - LENS IOL 0 D +13.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.140 SUP HCPCS V2632 SA60WF.140 - LENS IOL 0 D +14 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.145 SUP HCPCS V2632 SA60WF.145 - LENS IOL 0 D +14.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.150 SUP HCPCS V2632 SA60WF.150 - LENS IOL 0 D +15 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.155 SUP HCPCS V2632 SA60WF.155 - LENS IOL 0 D +15.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.160 SUP HCPCS V2632 SA60WF.160 - LENS IOL 0 D +16 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.165 SUP HCPCS V2632 SA60WF.165 - LENS IOL 0 D +16.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.170 SUP HCPCS V2632 SA60WF.170 - LENS IOL 0 D +17 DIOP MOD L BCNVX 6MM 13MM CLR STRL LF ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.175 SUP HCPCS V2632 SA60WF.175 - LENS IOL 0 D +17.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.180 SUP HCPCS V2632 SA60WF.180 - LENS IOL 0 D +18 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.185 SUP HCPCS V2632 SA60WF.185 - LENS IOL 0 D +18.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.190 SUP HCPCS V2632 SA60WF.190 - LENS IOL 0 D +19 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.195 SUP HCPCS V2632 SA60WF.195 - LENS IOL 0 D +19.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.200 SUP HCPCS V2632 SA60WF.200 - LENS IOL 0 D +20 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM 1 BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.205 SUP HCPCS V2632 SA60WF.205 - LENS IOL 0 D +20.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.210 SUP HCPCS V2632 SA60WF.210 - LENS IOL 0 D +21 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.215 SUP HCPCS V2632 SA60WF.215 - LENS IOL 0 D +21.5 DIOPTER BICNVX 118.4 A-CONSTANT 6MM 13MM BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.220 SUP HCPCS V2632 SA60WF.220 - LENS IOL 0 D +22 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.225 SUP HCPCS V2632 SA60WF.225 - LENS IOL 0 D +22.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.230 SUP HCPCS V2632 SA60WF.230 - LENS IOL 0 D +23 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.235 SUP HCPCS V2632 SA60WF.235 - LENS IOL 0 D +23.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.240 SUP HCPCS V2632 SA60WF.240 - LENS IOL 0 D +24 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.245 SUP HCPCS V2632 SA60WF.245 - LENS IOL 0 D +24.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.250 SUP HCPCS V2632 SA60WF.250 - LENS IOL 0 D +25 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.255 SUP HCPCS V2632 SA60WF.255 - LENS IOL 0 D +25.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.260 SUP HCPCS V2632 SA60WF.260 - LENS IOL 0 D +26 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.265 SUP HCPCS V2632 SA60WF.265 - LENS IOL 0 D +26.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.270 SUP HCPCS V2632 SA60WF.270 - LENS IOL 0 D +27 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.275 SUP HCPCS V2632 SA60WF.275 - LENS IOL 0 D +27.5 DIOP MOD L BCNVX 6MM 13MM CLR ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.280 SUP HCPCS V2632 SA60WF.280 - LENS IOL 0 D +28 DIOP ASYM BCNVX 6MM 13MM ACRSF STABLEFORCE BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.285 SUP HCPCS V2632 SA60WF.285 - LENS IOL 0 D +28.5 DIOP BCNVX 118.4 A-CNST 6MM 13MM ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.290 SUP HCPCS V2632 SA60WF.290 - LENS IOL 0 D +29 DIOP ASYM BCNVX 6MM 13MM ACRSF STABLEFORCE BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.295 SUP HCPCS V2632 SA60WF.295 - LENS IOL 0 D +29.5 DIOP MOD L BCNVX 6MM 13MM CLR STRL ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA60WF.300 SUP HCPCS V2632 SA60WF.300 - LENS IOL 0 D +30 DIOP BCNVX 118.4 A-CNST 6MM 13MM ACRSF BOTH IP/OP $335.00 $247.90 $0.00 $268.00 $150.75 $150.75 $0.00 $0.00 $0.00 $69.82 $248.64 $248.64 $0.00 $0.00 $69.81 $0.00 $198.15 $198.15 $0.00 $167.50 $265.32 $268.00 $0.00 $0.00 $52.43 $0.00 $0.00 $53.33 $0.00 $0.00 $0.00 $0.00 $0.00 SA8630 SUP Custom 27203010 COVER MATTRESS /5J:4K BOTH IP/OP $919.10 $680.13 $0.00 $735.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $459.55 $727.93 $735.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SAK 4689 SUP Custom 27203010 BLADE MCTM ACED LOW PROFILE BOTH IP/OP $580.05 $429.24 $0.00 $464.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.03 $459.40 $464.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SAX02D SUP HCPCS C1768 SAX02D - GRAFT VASC 90CM 8MM GRTX AXLBFM STRCH REM RING THNWL INTGR BOTH IP/OP "$6,235.00 " "$4,613.90" $0.00 "$4,988.00" "$2,805.75" "$2,805.75" $0.00 $0.00 $0.00 "$1,299.53" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,299.37" $0.00 "$3,073.86" "$3,073.86" $0.00 "$3,117.50" "$4,938.12" "$4,988.00" $0.00 $0.00 $975.78 $0.00 $0.00 $992.61 $0.00 $0.00 $0.00 $0.00 $0.00 SB6AL10 SUP HCPCS C1887 CATHETER GUID AL1 CURVE 6FR SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6AL10SH SUP HCPCS C1887 CATHETER GUID AL1 CURVE 6FR SH SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6AL20 SUP HCPCS C1887 CATHETER GUID AL2 CURVE 6FR SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6AL20SH SUP HCPCS C1887 CATHETER GUID AL2 CURVE 6FR SH SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6AL75 SUP HCPCS C1887 CATHETER GUID AL7.5 CURVE 6FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6AR10 SUP HCPCS C1887 CATHETER GUID AR1 CURVE 6FR SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6EBU35 SUP HCPCS C1887 CATHETER GUID XB3.5 CURVE 6FR SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6HS1 SUP HCPCS C1887 CATHETER GUID HS1 CURVE 6FR SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6HS1SH SUP HCPCS C1887 "SA6MP1 - CATHETER GUIDING SHERPA NX, 6FRX 100CM MP1" BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $23.45 $83.50 $83.50 $0.00 $0.00 $23.45 $0.00 $66.54 $66.54 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6JL35 SUP HCPCS C1887 CATHETER GUID JL3.5 CURVE 6FR SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6JL40 SUP HCPCS C1887 CATHETER GUID JL4 CURVE 6FR SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6JL40SH SUP HCPCS C1887 CATHETER GUID JL4 CURVE 6FR 100CM SH SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6JR35 SUP HCPCS C1887 CATHETER GUID JR3.5 CURVE 6FR SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB6JR40 SUP HCPCS C1887 CATHETER GUID JR4 CURVE 6FR SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB6JR40SH SUP HCPCS C1887 CATHETER GUID JR4 CURVE 6FR SH SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7AL10 SUP HCPCS C1887 CATHETER GUID AL1 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7AL20 SUP HCPCS C1887 CATHETER GUID AL2 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7AL75 SUP HCPCS C1887 CATHETER GUID AL.75 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7AR10 SUP HCPCS C1887 CATHETER GUID AR1 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7AR10SH SUP HCPCS C1887 CATHETER GUID AR1 CURVE 7FR 100CM SH SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB7EBU30 SUP HCPCS C1887 CATHETER GUID XB3 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7EBU35 SUP HCPCS C1887 CATHETER GUID XB3.5 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7EBU40 SUP HCPCS C1887 CATHETER GUID XB4 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7HS1 SUP HCPCS C1887 CATHETER GUIDING VISTA BRITE TIP 7FR X .078IN HS BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB7HS1SH SUP HCPCS C1887 CATHETER GUID HS1 CURVE 7FR SH SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB7IMA SUP HCPCS C1887 CATHETER GUID IM CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB7IMASH SUP HCPCS C1887 CATHETER GUID IM CURVE 7FR 100CM SH SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB7JL35 SUP HCPCS C1887 CATHETER GUID JL3.5 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB7JL40 SUP HCPCS C1887 CATHETER GUID JL4 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7JL40SH SUP HCPCS C1887 CATHETER GUID JL4 CURVE 7FR 100CM SH SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7JL50 SUP HCPCS C1887 CATHETER GUID JL5 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7JR35 SUP HCPCS C1887 CATHETER GUID JR3.5 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB7JR40 SUP HCPCS C1887 CATHETER GUID JR4 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7JR4SH SUP HCPCS C1887 CATHETER GUIDING VISTA BRITE TIP 7FR X 100CM JR4 SH BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7JR50 SUP HCPCS C1887 CATHETER GUID JR5 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7LCB SUP HCPCS C1887 CATHETER GUID LCB CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB7MP1 SUP HCPCS C1887 CATHETER GUID MP1 CURVE 7FR 100CM SHR NX BAL BOTH IP/OP $112.50 $83.25 $0.00 $90.00 $61.09 $61.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.25 $89.10 $90.00 $0.00 $0.00 $17.61 $0.00 $0.00 $17.91 $0.00 $0.00 $0.00 $0.00 $0.00 SB8AL20 SUP HCPCS C1887 CATHETER GUID AL2 CURVE 8FR 100CM CORON SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SB8EBU40 SUP HCPCS C1887 CATHETER GUID XB4 CURVE 8FR 100CM CORON SHR NX BAL BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SBFS045 SUP Custom 27203010 SBFS045 - KIT TRMA FX 1.1MM .045IN SBFS BOTH IP/OP "$1,015.00 " $751.10 $0.00 $812.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.33 $753.33 $0.00 $0.00 $211.53 $0.00 $0.00 $0.00 $0.00 $507.50 $803.88 $812.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SBFS062 SUP Custom 27203010 SBFS062 - KIT IM NL .062IN SLT AWL LK DV BNDRG TL CAP SM BN FX SYS BOTH IP/OP "$1,015.00 " $751.10 $0.00 $812.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.33 $753.33 $0.00 $0.00 $211.53 $0.00 $0.00 $0.00 $0.00 $507.50 $803.88 $812.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SBM-4963 SUP HCPCS C1765 "SBM-4963 - BLANKET SECTION MED (MUST ORDER MIN 4 BX, MED OR SM)" BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $0.00 $0.00 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SBRAR20 SUP HCPCS C1887 CATHETER GUIDING VISTA BRITE TIP 7FR X 100CM AR2 BOTH IP/OP $125.00 $92.50 $0.00 $100.00 $67.88 $67.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.50 $99.00 $100.00 $0.00 $0.00 $19.56 $0.00 $0.00 $19.90 $0.00 $0.00 $0.00 $0.00 $0.00 SBT1602D SUP HCPCS C1768 SBT1602D - GRAFT VASCULAR STANDARD WALL THIN WALL 2 BRANCH 16MM 8MM 50 BOTH IP/OP "$2,852.50 " "$2,110.85" $0.00 "$2,282.00" "$1,283.63" "$1,283.63" $0.00 $0.00 $0.00 $594.53 "$2,117.13" "$2,117.13" $0.00 $0.00 $594.46 $0.00 "$1,406.28" "$1,406.28" $0.00 "$1,426.25" "$2,259.18" "$2,282.00" $0.00 $0.00 $446.42 $0.00 $0.00 $454.12 $0.00 $0.00 $0.00 $0.00 $0.00 SBT1802D SUP HCPCS C1768 SBT1802D - GRAFT VASC STD WL THNWL 2 BRCH 18MM 9MM 50CM STRL STRCH GRTX BOTH IP/OP "$2,852.50 " "$2,110.85" $0.00 "$2,282.00" "$1,283.63" "$1,283.63" $0.00 $0.00 $0.00 $594.53 "$2,117.13" "$2,117.13" $0.00 $0.00 $594.46 $0.00 "$1,406.28" "$1,406.28" $0.00 "$1,426.25" "$2,259.18" "$2,282.00" $0.00 $0.00 $446.42 $0.00 $0.00 $454.12 $0.00 $0.00 $0.00 $0.00 $0.00 SBT2002D SUP HCPCS C1768 SBT2002D - GRAFT VASCULAR STANDARD WALL THIN WALL 2 BRANCH 20MM 10MM 50 BOTH IP/OP "$2,852.50 " "$2,110.85" $0.00 "$2,282.00" "$1,283.63" "$1,283.63" $0.00 $0.00 $0.00 $594.53 "$2,117.13" "$2,117.13" $0.00 $0.00 $594.46 $0.00 "$1,406.28" "$1,406.28" $0.00 "$1,426.25" "$2,259.18" "$2,282.00" $0.00 $0.00 $446.42 $0.00 $0.00 $454.12 $0.00 $0.00 $0.00 $0.00 $0.00 SC-1110-02 SUP HCPCS L8688 SC-1110-02 - NEUROSTIMULATOR IMPLTABLE PRCS PLS GNTR SC-1110 BOTH IP/OP "$36,900.00 " "$27,306.00" $0.00 "$29,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$18,450.00" "$29,224.80" "$29,520.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SC-2218-50 SUP Custom 27203010 KIT STM 50CM LINEAR 8 CNTCT LEAD BOTH IP/OP "$4,780.00 " "$3,537.20" $0.00 "$3,824.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,390.00" "$3,785.76" "$3,824.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SC-4385-50 SUP Custom 27203010 SC-4385-50 - KIT STM 50CM STY CAP BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SC-4400 SUP HCPCS L8688 SC-4400 - NEUROSTIMULATOR IMPLTABLE PLS GNTR PLG PORT BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SC-5500-2 SUP Custom 27203010 KIT STM PRCS LINEAR PT PRGMR NEUROMASCULAR BOTH IP/OP "$2,380.00 " "$1,761.20" $0.00 "$1,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,190.00" "$1,884.96" "$1,904.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SC-6412 SUP Custom 27203010 KIT STM SPNL CORD CHRGR ONLY BOTH IP/OP "$5,980.00 " "$4,425.20" $0.00 "$4,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,990.00" "$4,736.16" "$4,784.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SCD13 SUP Custom 27011340 SCD13 - DISSECTOR LAPSCOP US HNDPC 13CM SONICISION DISP BOTH IP/OP "$4,777.50 " "$3,535.35" $0.00 "$3,822.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,545.86" "$3,545.86" $0.00 $0.00 $995.63 $0.00 $0.00 $0.00 $0.00 "$2,388.75" "$3,783.78" "$3,822.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SCD26 SUP Custom 27011340 SCD26 - DISSECTOR ENDSCP STR JAW HND SWCH CRDLS US 26CM 5 BOTH IP/OP "$4,777.50 " "$3,535.35" $0.00 "$3,822.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,545.86" "$3,545.86" $0.00 $0.00 $995.63 $0.00 $0.00 $0.00 $0.00 "$2,388.75" "$3,783.78" "$3,822.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SCREWTEST SUP HCPCS C1713 SCREWTEST - SCREW SUPPLY TEST NEW ITEM BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $22.50 $22.50 $0.00 $0.00 $0.00 $10.42 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $29.58 $29.58 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $7.83 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $0.00 SD242.003 SUP HCPCS C1713 SD242.003 - PLATE BN STRG 170MM NS LCP SS WRST 2.4MM SCR BOTH IP/OP "$7,192.50 " "$5,322.45" $0.00 "$5,754.00" "$3,236.63" "$3,236.63" $0.00 $0.00 $0.00 "$1,499.10" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,498.92" $0.00 "$3,545.90" "$3,545.90" $0.00 "$3,596.25" "$5,696.46" "$5,754.00" $0.00 $0.00 "$1,125.63" $0.00 $0.00 "$1,145.05" $0.00 $0.00 $0.00 $0.00 $0.00 SE5423WV SUP Custom 27203010 SE5423WV - PACK 23 GA POSTERIOR WIDE-FIELD ELITE BOTH IP/OP $887.50 $656.75 $0.00 $710.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $658.70 $658.70 $0.00 $0.00 $184.96 $0.00 $0.00 $0.00 $0.00 $443.75 $702.90 $710.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SE5425WVB SUP Custom 27203010 SE5425WVB - PACK VITRTM 25GA STRL LF STELLARIS ELT 2 BLDE CTR W FLD POST BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SE5427MVB SUP Custom 27203010 SE5427MVB - PACK 27 GA. BI-BLADE VITREOUS CUTTER POSTERIOR MID-FIELD STE BOTH IP/OP $987.50 $730.75 $0.00 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $732.92 $732.92 $0.00 $0.00 $205.80 $0.00 $0.00 $0.00 $0.00 $493.75 $782.10 $790.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SECOC 28/28 SUP Custom 27803010 SECOC 28/28 - OUTER SMALL FRAGMENT CLAMP BOTH IP/OP $537.50 $397.75 $0.00 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $398.93 $398.93 $0.00 $0.00 $112.02 $0.00 $0.00 $0.00 $0.00 $268.75 $425.70 $430.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SECURADRMMEM SUP HCPCS C1721 SECURADRMMEM - SECURA DR SYSTEM (INCLUDING DF4 HEADER) BOTH IP/OP "$49,812.50 " "$36,861.25" $0.00 "$39,850.00" "$22,415.63" "$22,415.63" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,380.93" $0.00 "$24,557.56" "$24,557.56" $0.00 "$24,906.25" "$39,451.50" "$39,850.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$7,930.15" $0.00 $0.00 $0.00 $0.00 $0.00 SECURAVREMEM SUP HCPCS C1721 SECURAVREMEM - SECURA VR SYSTEM (INCLUDING DF4 HEADER) BOTH IP/OP "$43,750.00 " "$32,375.00" $0.00 "$35,000.00" "$19,687.50" "$19,687.50" $0.00 $0.00 $0.00 "$9,118.59" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,117.50" $0.00 "$21,568.75" "$21,568.75" $0.00 "$21,875.00" "$34,650.00" "$35,000.00" $0.00 $0.00 "$6,846.88" $0.00 $0.00 "$6,965.00" $0.00 $0.00 $0.00 $0.00 $0.00 SECX-10-7-30-135 SUP HCPCS C1876 SECX-10-7-30-135 - STENT VASC 30MM 10/7MM 6FR PRTG .014IN 8.5-9.5MM PERI CRTD BOTH IP/OP "$5,127.50 " "$3,794.35" $0.00 "$4,102.00" "$2,307.38" "$2,307.38" $0.00 $0.00 $0.00 "$1,068.70" "$3,805.63" "$3,805.63" $0.00 $0.00 "$1,068.57" $0.00 "$2,527.86" "$2,527.86" $0.00 "$2,563.75" "$4,060.98" "$4,102.00" $0.00 $0.00 $802.45 $0.00 $0.00 $816.30 $0.00 $0.00 $0.00 $0.00 $0.00 SECX-10-7-40-135 SUP HCPCS C1876 SECX-10-7-40-135 - STENT VASC 40MM 10/7MM 6FR PRTG .014IN 8.5-9.5MM PERI CRTD BOTH IP/OP "$5,127.50 " "$3,794.35" $0.00 "$4,102.00" "$2,307.38" "$2,307.38" $0.00 $0.00 $0.00 "$1,068.70" "$3,805.63" "$3,805.63" $0.00 $0.00 "$1,068.57" $0.00 "$2,527.86" "$2,527.86" $0.00 "$2,563.75" "$4,060.98" "$4,102.00" $0.00 $0.00 $802.45 $0.00 $0.00 $816.30 $0.00 $0.00 $0.00 $0.00 $0.00 SECX-8-6-30-135 SUP HCPCS C1876 SECX-8-6-30-135 - STENT VASC 8/6MM 6/8FR 30MM 135CM .014IN RAPEX TPR EXPRT BOTH IP/OP "$5,127.50 " "$3,794.35" $0.00 "$4,102.00" "$2,307.38" "$2,307.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,563.75" "$4,060.98" "$4,102.00" $0.00 $0.00 $802.45 $0.00 $0.00 $816.30 $0.00 $0.00 $0.00 $0.00 $0.00 SECX-8-6-40-135 SUP HCPCS C1876 SECX-8-6-40-135 - STENT VASC 40MM 8/6MM 6FR PRTG .014IN 6.5-7.5MM PERI CRTD BOTH IP/OP "$5,127.50 " "$3,794.35" $0.00 "$4,102.00" "$2,307.38" "$2,307.38" $0.00 $0.00 $0.00 "$1,068.70" "$3,805.63" "$3,805.63" $0.00 $0.00 "$1,068.57" $0.00 "$2,527.86" "$2,527.86" $0.00 "$2,563.75" "$4,060.98" "$4,102.00" $0.00 $0.00 $802.45 $0.00 $0.00 $816.30 $0.00 $0.00 $0.00 $0.00 $0.00 SEDR01 SUP HCPCS C1786 SEDR01 - PACEMAKER CARDIAC 2.8V 1.2AH 7.5MM 47.9X44.7MM IMPLTABLE 2 BOTH IP/OP "$8,500.00 " "$6,290.00" $0.00 "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,771.61" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,771.40" $0.00 "$4,190.50" "$4,190.50" $0.00 "$4,250.00" "$6,732.00" "$6,800.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SEG1411 SUP HCPCS C1769 SEG1411 - GWIRE VASC .014IN 190CM 8CM ANG SEGWAY HYDPHI BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $169.69 $169.69 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 SEG1412 SUP HCPCS C1769 SEG1412 - STR GUIDEWIRE .014X180 SEGWAY GT BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $169.69 $169.69 $0.00 $0.00 $0.00 $65.13 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $184.84 $184.84 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $48.91 $0.00 $0.00 $49.75 $0.00 $0.00 $0.00 $0.00 $0.00 SENSH1428W SUP HCPCS C1894 SENSH1428W - SHEATH INTROD 28CM GWIRE FLEXIBILITY REINFORCED COIL RADIOPQ BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 SENSH1628W SUP HCPCS C1894 SENSH1628W - SHEATH INTRO .035IN 16FR 28CM SENTRANT RADOPQ REINF COIL DIL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 SENSH1828W SUP HCPCS C1894 SENSH1828W - SHEATH INTRO .035IN 18FR 28CM SENTRANT RADOPQ REINF COIL DIL BOTH IP/OP $500.00 $370.00 $0.00 $400.00 $271.50 $271.50 $0.00 $0.00 $0.00 $104.21 $371.10 $371.10 $0.00 $0.00 $104.20 $0.00 $295.75 $295.75 $0.00 $250.00 $396.00 $400.00 $0.00 $0.00 $78.25 $0.00 $0.00 $79.60 $0.00 $0.00 $0.00 $0.00 $0.00 SENSH2028W SUP HCPCS C1894 SENSH2028W - SHEATH INTROD 28CM RADIOPQ MARKER BAND REINFORCED COIL DILAT BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $339.38 $339.38 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 SENSH2228W SUP HCPCS C1894 SENSH2228W - SHEATH INTRO 22FR 28CM SENTRANT HDRPH AAA BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $339.38 $339.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 SENSIADRK2 SUP HCPCS C2619 SENSIADRK2 - SENSIA DR SYSTEM BOTH IP/OP "$12,500.00 " "$9,250.00" $0.00 "$10,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,605.00" $0.00 $0.00 $0.00 $0.00 "$6,250.00" "$9,900.00" "$10,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SENSIASRK2 SUP HCPCS C2620 SENSIASRK2 - PACEMAKER CARDIAC THK7.5MM 42.9X40.2MM IMPLTABLE 1 CHAMBER BOTH IP/OP "$5,992.50 " "$4,434.45" $0.00 "$4,810.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,248.84" $0.00 $0.00 $0.00 $0.00 "$3,006.25" "$4,761.90" "$4,810.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SESR01 SUP HCPCS C1786 SESR01 - PACEMAKER CARDIAC 2.8V .97AH 7.5MM 42.9MMX40.2MM 1 CHAMBER BOTH IP/OP "$5,000.00 " "$3,700.00" $0.00 "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,042.13" "$3,711.00" "$3,711.00" $0.00 $0.00 "$1,042.00" $0.00 "$2,465.00" "$2,465.00" $0.00 "$2,500.00" "$3,960.00" "$4,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SF-2500-6101 SUP HCPCS C1713 SF-2500-6101 - PIN HALF 500MM NONSTRL DISPOSABLE BOTH IP/OP "$5,250.00 " "$3,885.00" $0.00 "$4,200.00" "$2,362.50" "$2,362.50" $0.00 $0.00 $0.00 "$1,094.23" "$3,896.55" "$3,896.55" $0.00 $0.00 "$1,094.10" $0.00 "$2,588.25" "$2,588.25" $0.00 "$2,625.00" "$4,158.00" "$4,200.00" $0.00 $0.00 $821.63 $0.00 $0.00 $835.80 $0.00 $0.00 $0.00 $0.00 $0.00 SFR-4-15 SUP Custom 27203010 SFR-4-15 - DEVICE THROMBECTOMY SOLITARE FR 4X15 BOTH IP/OP "$15,250.00 " "$11,285.00" $0.00 "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,178.10" $0.00 $0.00 $0.00 $0.00 "$7,625.00" "$12,078.00" "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SFR-4-20 SUP Custom 27203010 SFR-4-20 - DEVICE THRMB 31MM 4MM SOLITAIRE FR REVSC BOTH IP/OP "$15,250.00 " "$11,285.00" $0.00 "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,178.10" $0.00 $0.00 $0.00 $0.00 "$7,625.00" "$12,078.00" "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SFR-6-20 SUP Custom 27203010 SFR-6-20 - DEVICE THRMB 31MM 6MM SOLITAIRE FR REVSC BOTH IP/OP "$15,250.00 " "$11,285.00" $0.00 "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,178.10" $0.00 $0.00 $0.00 $0.00 "$7,625.00" "$12,078.00" "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SFR-6-30 SUP Custom 27203010 SFR-6-30 - DEVICE THRMB 42MM 6MM SOLITAIRE FR REVSC BOTH IP/OP "$15,250.00 " "$11,285.00" $0.00 "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,178.10" $0.00 $0.00 $0.00 $0.00 "$7,625.00" "$12,078.00" "$12,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SGL-1 SUP Custom 27203010 SGL-1 - SUTURE CR SURGITIE 0 21IN LGT LOOP DLV SYS ABS BOTH IP/OP $607.98 $449.91 $0.00 $486.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $303.99 $481.52 $486.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 S-H00703 SUP HCPCS C1776 S-H00703 - STEM FEM HDNK OMFT LNG HIP BOTH IP/OP "$3,866.00 " "$2,860.84" $0.00 "$3,092.80" "$1,739.70" "$1,739.70" $0.00 $0.00 $0.00 $805.77 "$2,869.35" "$2,869.35" $0.00 $0.00 $805.67 $0.00 "$1,905.94" "$1,905.94" $0.00 "$1,933.00" "$3,061.87" "$3,092.80" $0.00 $0.00 $605.03 $0.00 $0.00 $615.47 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0713-S SUP HCPCS C1776 SH-0713-S - STEM HUM 130MM 7MM MDLR SHRT SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0813-S SUP HCPCS C1776 SH-0813-S - STEM HUM 130MM 8MM MDLR SHRT SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0818-S SUP HCPCS C1776 SH-0818-S - STEM HUM 180MM 8MM LNG SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0820 SUP HCPCS C1776 SH-0820 - STEM HUM 200MM 8MM PLRS LNG SHLDR STRL BOTH IP/OP "$4,987.50 " "$3,690.75" $0.00 "$3,990.00" "$2,244.38" "$2,244.38" $0.00 $0.00 $0.00 "$1,039.52" "$3,701.72" "$3,701.72" $0.00 $0.00 "$1,039.40" $0.00 "$2,458.84" "$2,458.84" $0.00 "$2,493.75" "$3,950.10" "$3,990.00" $0.00 $0.00 $780.54 $0.00 $0.00 $794.01 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0820-S SUP HCPCS C1776 SH-0820-S - STEM HUM 200MM 8MM PLRS LNG SHLDR STRL BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0822-S SUP HCPCS C1776 SH-0822-S - STEM HUM 220MM 8MM MDLR LNG SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0824-S SUP HCPCS C1776 SH-0824-S - STEM HUM 240MM 8MM MDLR PLRS LNG SHLDR STRL BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0826-S SUP HCPCS C1776 SH-0826-S - STEM HUM 8MM 260MM STRL MDLR SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0828-S SUP HCPCS C1776 SH-0828-S - STEM HUM 280MM 8MM MDLR LNG SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-0913-S SUP HCPCS C1776 SH-0913-S - STEM HUM 130MM 9MM TI SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1013-S SUP HCPCS C1776 SH-1013-S - STEM HUM 130MM 10MM PLRS TI SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1018-S SUP HCPCS C1776 SH-1018-S - STEM HUM 180MM 10MM MDLR LNG SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1020-S SUP HCPCS C1776 SH-1020-S - STEM HUM 200MM 10MM MDLR LNG SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1022-S SUP HCPCS C1776 SH-1022-S - STEM HUM 220MM 10MM MDLR LNG SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1024-S SUP HCPCS C1776 SH-1024-S - STEM HUM 240MM 10MM MDLR LNG SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1026-S SUP HCPCS C1776 SH-1026-S - STEM HUM 260MM 10MM MDLR SHLDR STRL BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1028-S SUP HCPCS C1776 SH-1028-S - STEM HUM 280MM 10MM MDLR LNG SHLDR STRL BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1213-S SUP HCPCS C1776 SH-1213-S - STEM HUM 130MM 12MM MDLR SHRT SHLDR STRL BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1313-S SUP HCPCS C1776 SH-1313-S - STEM HUM 130MM 13MM MDLR SHRT SHLDR STRL BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1340L-S SUP HCPCS C1776 SH-1340L-S - HEAD HUM 13MM LEFT SHLDR BODY ASMBLY MDLR PLRS STRL BOTH IP/OP "$5,910.00 " "$4,373.40" $0.00 "$4,728.00" "$2,659.50" "$2,659.50" $0.00 $0.00 $0.00 "$1,231.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,231.64" $0.00 "$2,913.63" "$2,913.63" $0.00 "$2,955.00" "$4,680.72" "$4,728.00" $0.00 $0.00 $924.92 $0.00 $0.00 $940.87 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1340R-S SUP HCPCS C1776 SH-1340R-S - STEM HUM 13MM ASMBLY TI RIGHT SHLDR BOTH IP/OP "$5,910.00 " "$4,373.40" $0.00 "$4,728.00" "$2,659.50" "$2,659.50" $0.00 $0.00 $0.00 "$1,231.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,231.64" $0.00 "$2,913.63" "$2,913.63" $0.00 "$2,955.00" "$4,680.72" "$4,728.00" $0.00 $0.00 $924.92 $0.00 $0.00 $940.87 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1413-S SUP HCPCS C1776 SH-1413-S - STEM HUM 130MM 14MM MDLR SHRT SHLDR BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1513-S SUP HCPCS C1776 SH-1513-S - STEM HUM 130MM 15MM MDLR SHRT SHLDR STRL BOTH IP/OP "$4,055.00 " "$3,000.70" $0.00 "$3,244.00" "$1,824.75" "$1,824.75" $0.00 $0.00 $0.00 $845.16 "$3,009.62" "$3,009.62" $0.00 $0.00 $845.06 $0.00 "$1,999.12" "$1,999.12" $0.00 "$2,027.50" "$3,211.56" "$3,244.00" $0.00 $0.00 $634.61 $0.00 $0.00 $645.56 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1540L-S SUP HCPCS C1776 SH-1540L-S - STEM HUM 15MM MDLR BODY ASMBLY LEFT SHLDR STRL BOTH IP/OP "$5,910.00 " "$4,373.40" $0.00 "$4,728.00" "$2,659.50" "$2,659.50" $0.00 $0.00 $0.00 "$1,231.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,231.64" $0.00 "$2,913.63" "$2,913.63" $0.00 "$2,955.00" "$4,680.72" "$4,728.00" $0.00 $0.00 $924.92 $0.00 $0.00 $940.87 $0.00 $0.00 $0.00 $0.00 $0.00 SH-1540R-S SUP HCPCS C1776 SH-1540R-S - STEM HUM 15MM MDLR BODY ASMBLY RIGHT SHLDR BOTH IP/OP "$5,910.00 " "$4,373.40" $0.00 "$4,728.00" "$2,659.50" "$2,659.50" $0.00 $0.00 $0.00 "$1,231.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,231.64" $0.00 "$2,913.63" "$2,913.63" $0.00 "$2,955.00" "$4,680.72" "$4,728.00" $0.00 $0.00 $924.92 $0.00 $0.00 $940.87 $0.00 $0.00 $0.00 $0.00 $0.00 SH-3916-S SUP HCPCS C1776 SH-3916-S - HEAD HUM 39MM 16MM SHLDR MDLR PLRS STRL BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" "$1,558.13" "$1,558.13" $0.00 $0.00 $0.00 $721.67 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 "$1,707.01" "$1,707.01" $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $541.88 $0.00 $0.00 $551.23 $0.00 $0.00 $0.00 $0.00 $0.00 SH-3920-S SUP HCPCS C1776 SH-3920-S - HEAD HUM 39MM 20MM SHLDR MDLR STRL BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" "$1,558.13" "$1,558.13" $0.00 $0.00 $0.00 $721.67 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 "$1,707.01" "$1,707.01" $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $541.88 $0.00 $0.00 $551.23 $0.00 $0.00 $0.00 $0.00 $0.00 SH-4317-S SUP HCPCS C1776 SH-4317-S - HEAD HUM 43MM 17MM SHLDR TI BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" "$1,558.13" "$1,558.13" $0.00 $0.00 $0.00 $721.67 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 "$1,707.01" "$1,707.01" $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $541.88 $0.00 $0.00 $551.23 $0.00 $0.00 $0.00 $0.00 $0.00 SH-4321-S SUP HCPCS C1776 SH-4321-S - HEAD HUM 21MM 43MM SHLDR BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" "$1,558.13" "$1,558.13" $0.00 $0.00 $0.00 $721.67 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 "$1,707.01" "$1,707.01" $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $541.88 $0.00 $0.00 $551.23 $0.00 $0.00 $0.00 $0.00 $0.00 SH-4718-S SUP HCPCS C1776 SH-4718-S - HEAD HUM 47MM 18MM SHLDR PLRS TI BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" "$1,558.13" "$1,558.13" $0.00 $0.00 $0.00 $721.67 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 "$1,707.01" "$1,707.01" $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $541.88 $0.00 $0.00 $551.23 $0.00 $0.00 $0.00 $0.00 $0.00 SH-4722-S SUP HCPCS C1776 SH-4722-S - HEAD HUM 47MM 22MM STRL MDLR SHLDR BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" "$1,558.13" "$1,558.13" $0.00 $0.00 $0.00 $721.67 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 "$1,707.01" "$1,707.01" $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $541.88 $0.00 $0.00 $551.23 $0.00 $0.00 $0.00 $0.00 $0.00 SH-5119-S SUP HCPCS C1776 SH-5119-S - HEAD HUM 19MM 51MM SHLDR MDLR STRL BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" "$1,558.13" "$1,558.13" $0.00 $0.00 $0.00 $721.67 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 "$1,707.01" "$1,707.01" $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $541.88 $0.00 $0.00 $551.23 $0.00 $0.00 $0.00 $0.00 $0.00 SH-5123-S SUP HCPCS C1776 SH-5123-S - HEAD HUM 51MM 23MM SHLDR MDLR PLRS BOTH IP/OP "$3,462.50 " "$2,562.25" $0.00 "$2,770.00" "$1,558.13" "$1,558.13" $0.00 $0.00 $0.00 $721.67 "$2,569.87" "$2,569.87" $0.00 $0.00 $721.59 $0.00 "$1,707.01" "$1,707.01" $0.00 "$1,731.25" "$2,742.30" "$2,770.00" $0.00 $0.00 $541.88 $0.00 $0.00 $551.23 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1307 SUP Custom 27203010 SH-R1307 - REAMER SURG 13MM 7MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1308 SUP Custom 27203010 SH-R1308 - REAMER SURG 13MM 8MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1309 SUP Custom 27203010 SH-R1309 - REAMER SURG 13MM 9MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1310 SUP Custom 27203010 SH-R1310 - REAMER SURG 13MM 10MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1311 SUP Custom 27203010 SH-R1311 - REAMER SURG 13MM 11MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1312 SUP Custom 27203010 SH-R1312 - REAMER SURG 13MM 12MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1313 SUP Custom 27203010 SH-R1313 - REAMER SURG 13MM 13MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1514 SUP Custom 27203010 SH-R1514 - REAMER SURG 15MM 14MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1515 SUP Custom 27203010 SH-R1515 - REAMER SURG 15MM 15MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1716 SUP Custom 27203010 SH-R1716 - REAMER SURG 17MM 16MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SH-R1717 SUP Custom 27203010 SH-R1717 - REAMER SURG 17MM 17MM SHLDR BOTH IP/OP $735.00 $543.90 $0.00 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.52 $545.52 $0.00 $0.00 $153.17 $0.00 $0.00 $0.00 $0.00 $367.50 $582.12 $588.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SIG-3616 SUP Custom 25003010 ANTIBODY CA 19-9 PRF MNCLN LAB BOTH IP/OP "$1,827.50 " "$1,352.35" $0.00 "$1,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $913.75 "$1,447.38" "$1,462.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SIG45CTAVM SUP Custom 27203010 SIG45CTAVM - RELOAD STPLR 2MM 2.5MM 3MM 45MM TN STRL LF EGIA ARTC KNF BOTH IP/OP "$3,073.20 " "$2,274.17" $0.00 "$2,458.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,536.60" "$2,433.97" "$2,458.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SILSPT12 SUP Custom 27203010 SILSPT12 - PORT ENDSCP 5MM 12MM FLEXIBLE CANNU OBTURATOR LATEX FREE BOTH IP/OP "$1,205.31 " $891.93 $0.00 $964.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $894.58 $894.58 $0.00 $0.00 $251.19 $0.00 $0.00 $0.00 $0.00 $602.66 $954.61 $964.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SK-0480-C SUP Custom 27203010 STAIN KT COMBO 480 TST HISTOLGY BOTH IP/OP $106.25 $78.63 $0.00 $85.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.13 $84.15 $85.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SK200 SUP Custom 27203010 SK200 - KIT VASC 175CM 2MM 2.3-3FR AGN MIC NTNL INTROD TRQ DEV CATH BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SK400 SUP Custom 27203010 SK400 - SNARE VASC 175CM 4MM 2.3-3FR AGN MIC NTNL MCTH KIT 150CM BOTH IP/OP "$1,400.00 " "$1,036.00" $0.00 "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.08" "$1,039.08" $0.00 $0.00 $291.76 $0.00 $0.00 $0.00 $0.00 $700.00 "$1,108.80" "$1,120.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SMC-5060 SUP Custom 27203010 SMC-5060 - SHAFT SM 60MM FXTR BONE BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $0.00 $0.00 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SMC-5090 SUP HCPCS C1713 SMC-5090 - SCREW BONE 90MM SM SHFT FXTR BOTH IP/OP $205.00 $151.70 $0.00 $164.00 $92.25 $92.25 $0.00 $0.00 $0.00 $42.73 $152.15 $152.15 $0.00 $0.00 $42.72 $0.00 $121.26 $121.26 $0.00 $102.50 $162.36 $164.00 $0.00 $0.00 $32.08 $0.00 $0.00 $32.64 $0.00 $0.00 $0.00 $0.00 $0.00 SMT-5060 SUP Custom 27203010 SMT-5060 - ROD EXFIX STABLELOC RADL SS SM BONE FIX SYS STRL BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SMT-5090 SUP Custom 27203010 SMT-5090 - ROD EXFIX 90MM STABLELOC SS SM BONE FIX SYS STRL BOTH IP/OP $387.50 $286.75 $0.00 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.60 $287.60 $0.00 $0.00 $80.76 $0.00 $0.00 $0.00 $0.00 $193.75 $306.90 $310.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN 7016X SUP Custom 27203010 SN 7016X - DEVICE BIOP 10CM 14GA MNPTY 22MM INSTR AUTO STRL DISP BOTH IP/OP $85.00 $62.90 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.50 $67.32 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT SUP HCPCS V2632 SN60AT - LENS IOL 0D MOD L BCNVX 6MM 13MM STRL ACRSF N STABLEFORCE 1 BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.060 SUP HCPCS V2632 SN60AT.060 - LENS IOL 0 D +6 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.070 SUP HCPCS V2632 SN60AT.070 - LENS IOL 0 D +7 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.075 SUP HCPCS V2632 SN60AT.075 - LENS IOL 0 D +7.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.080 SUP HCPCS V2632 SN60AT.080 - LENS IOL 0 D +8 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.085 SUP HCPCS V2632 SN60AT.085 - LENS IOL 0 D +8.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.090 SUP HCPCS V2632 SN60AT.090 - LENS IOL 0 D +9 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.095 SUP HCPCS V2632 SN60AT.095 - LENS IOL 0 D +9.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.100 SUP HCPCS V2632 SN60AT.100 - LENS IOL 0 D +10 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.105 SUP HCPCS V2632 SN60AT.105 - LENS IOL 0 D +10.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.110 SUP HCPCS V2632 SN60AT.110 - LENS IOL 0 D +11 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.115 SUP HCPCS V2632 SN60AT.115 - LENS IOL 0 D +11.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.120 SUP HCPCS V2632 SN60AT.120 - LENS IOL 0 D +12 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.125 SUP HCPCS V2632 SN60AT.125 - LENS IOL 0 D +12.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.130 SUP HCPCS V2632 SN60AT.130 - LENS IOL 0 D +13 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.135 SUP HCPCS V2632 SN60AT.135 - LENS IOL 0 D +13.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.140 SUP HCPCS V2632 SN60AT.140 - LENS IOL 0 D +14 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.145 SUP HCPCS V2632 SN60AT.145 - LENS IOL 0 D +14.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.150 SUP HCPCS V2632 SN60AT.150 - LENS IOL 0 D +15 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.155 SUP HCPCS V2632 SN60AT.155 - LENS IOL 0 D +15.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.160 SUP HCPCS V2632 SN60AT.160 - LENS IOL 0 D +16 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.165 SUP HCPCS V2632 SN60AT.165 - LENS IOL 0 D +16.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.170 SUP HCPCS V2632 SN60AT.170 - LENS IOL 0 D +17 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.175 SUP HCPCS V2632 SN60AT.175 - LENS IOL 0 D +17.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.180 SUP HCPCS V2632 SN60AT.180 - LENS IOL 0 D +18 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.185 SUP HCPCS V2632 SN60AT.185 - LENS IOL 0 D +18.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.190 SUP HCPCS V2632 SN60AT.190 - LENS IOL 0 D +19 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.195 SUP HCPCS V2632 SN60AT.195 - LENS IOL 0 D +19.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.200 SUP HCPCS V2632 SN60AT.200 - LENS IOL 0 D +20 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.205 SUP HCPCS V2632 SN60AT.205 - LENS IOL 0 D +20.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.210 SUP HCPCS V2632 SN60AT.210 - LENS IOL 0 D +21 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.215 SUP HCPCS V2632 SN60AT.215 - LENS IOL 0 D +21.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.220 SUP HCPCS V2632 SN60AT.220 - LENS IOL 0 D +22 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.225 SUP HCPCS V2632 SN60AT.225 - LENS IOL 0 D +22.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.230 SUP HCPCS V2632 SN60AT.230 - LENS IOL 0 D +23 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.235 SUP HCPCS V2632 SN60AT.235 - LENS IOL 0 D +23.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.240 SUP HCPCS V2632 SN60AT.240 - LENS IOL 0 D +24 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.245 SUP HCPCS V2632 SN60AT.245 - LENS IOL 0 D +24.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.250 SUP HCPCS V2632 SN60AT.250 - LENS IOL 0 D +25 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.255 SUP HCPCS V2632 SN60AT.255 - LENS IOL 0 D +25.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.260 SUP HCPCS V2632 SN60AT.260 - LENS IOL 0 D +26 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.265 SUP HCPCS V2632 SN60AT.265 - LENS IOL 0 D +26.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.270 SUP HCPCS V2632 SN60AT.270 - LENS IOL 0 D +27 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.275 SUP HCPCS V2632 SN60AT.275 - LENS IOL 0 D +27.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.280 SUP HCPCS V2632 SN60AT.280 - LENS IOL 0 D +28 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.285 SUP HCPCS V2632 SN60AT.285 - LENS IOL 0 D +28.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.295 SUP HCPCS V2632 SN60AT.295 - LENS IOL 0 D +29.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.300 SUP HCPCS V2632 SN60AT.300 - LENS IOL 0 D +30 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.310 SUP HCPCS V2632 SN60AT.310 - LENS IOL 0 D +31 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.320 SUP HCPCS V2632 SN60AT.320 - LENS IOL 0 D +32 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.330 SUP HCPCS V2632 SN60AT.330 - LENS IOL 0 D +33 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.340 SUP HCPCS V2632 SN60AT.340 - LENS IOL 0 D +34 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.350 SUP HCPCS V2632 SN60AT.350 - LENS IOL 0 D +35 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.360 SUP HCPCS V2632 SN60AT.360 - LENS IOL 0 D +36 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.370 SUP HCPCS V2632 SN60AT.370 - LENS IOL 0 D +37 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.380 SUP HCPCS V2632 SN60AT.380 - LENS IOL 0 D +38 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.390 SUP HCPCS V2632 SN60AT.390 - LENS IOL 0 D +39 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60AT.400 SUP HCPCS V2632 SN60AT.400 - LENS IOL 0 D +40 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF N BOTH IP/OP $472.50 $349.65 $0.00 $378.00 $212.63 $212.63 $0.00 $0.00 $0.00 $98.48 $350.69 $350.69 $0.00 $0.00 $98.47 $0.00 $279.48 $279.48 $0.00 $236.25 $374.22 $378.00 $0.00 $0.00 $73.95 $0.00 $0.00 $75.22 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF SUP HCPCS V2632 SN60WF - LENS IOL 0D MOD L BCNVX 6MM 13MM STRL ACRSF IQ 1 PC FLD ANT BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.065 SUP HCPCS V2632 SN60WF.065 - LENS IOL 0 D +6.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.075 SUP HCPCS V2632 SN60WF.075 - LENS IOL 0 D +7.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.085 SUP HCPCS V2632 SN60WF.085 - LENS IOL 0 D +8.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.090 SUP HCPCS V2632 SN60WF.090 - LENS IOL 0 D +9 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.095 SUP HCPCS V2632 SN60WF.095 - LENS IOL 0 D +9.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.100 SUP HCPCS V2632 SN60WF.100 - LENS IOL 0 D +10 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.105 SUP HCPCS V2632 SN60WF.105 - LENS IOL 0 D +10.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.110 SUP HCPCS V2632 SN60WF.110 - LENS IOL 0 D +11 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.115 SUP HCPCS V2632 SN60WF.115 - LENS IOL 0 D +11.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.120 SUP HCPCS V2632 SN60WF.120 - LENS IOL 0 D +12 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.125 SUP HCPCS V2632 SN60WF.125 - LENS IOL 0 D +12.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.135 SUP HCPCS V2632 SN60WF.135 - LENS IOL 0 D +13.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.145 SUP HCPCS V2632 SN60WF.145 - LENS IOL 0 D +14.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.155 SUP HCPCS V2632 SN60WF.155 - LENS IOL 0 D +15.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.160 SUP HCPCS V2632 SN60WF.160 - LENS IOL 0 D +16 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.165 SUP HCPCS V2632 SN60WF.165 - LENS IOL 0 D +16.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.170 SUP HCPCS V2632 SN60WF.170 - LENS IOL 0 D +17 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.185 SUP HCPCS V2632 SN60WF.185 - LENS IOL 0 D +18.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.215 SUP HCPCS V2632 SN60WF.215 - LENS IOL 0 D +21.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.220 SUP HCPCS V2632 SN60WF.220 - LENS IOL 0 D +22 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.225 SUP HCPCS V2632 SN60WF.225 - LENS IOL 0 D +22.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.230 SUP HCPCS V2632 SN60WF.230 - LENS IOL 0 D +23 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.240 SUP HCPCS V2632 SN60WF.240 - LENS IOL 0 D +24 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.245 SUP HCPCS V2632 SN60WF.245 - LENS IOL 0 D +24.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.250 SUP HCPCS V2632 SN60WF.250 - LENS IOL 0 D +25 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.260 SUP HCPCS V2632 SN60WF.260 - LENS IOL 0 D +26 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.270 SUP HCPCS V2632 SN60WF.270 - LENS IOL 0 D +27 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.275 SUP HCPCS V2632 SN60WF.275 - LENS IOL 0 D +27.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.280 SUP HCPCS V2632 SN60WF.280 - LENS IOL 0 D +28 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.290 SUP HCPCS V2632 SN60WF.290 - LENS IOL 0 D +29 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.295 SUP HCPCS V2632 SN60WF.295 - LENS IOL 0 D +29.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WF.300 SUP HCPCS V2632 SN60WF.300 - LENS IOL 0 D +30 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS SUP HCPCS V2632 SN60WS - LENS IOL 0D BCNVX 6MM 13MM STRL ACRSF IQ NTR STABLEFORCE BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.060 SUP HCPCS V2632 SN60WS.060 - LENS IOL 0 D +6 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.065 SUP HCPCS V2632 SN60WS.065 - LENS IOL 0 D +6.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.070 SUP HCPCS V2632 SN60WS.070 - LENS IOL 0 D +7 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.075 SUP HCPCS V2632 SN60WS.075 - LENS IOL 0 D +7.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.080 SUP HCPCS V2632 SN60WS.080 - LENS IOL 0 D +8 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.085 SUP HCPCS V2632 SN60WS.085 - LENS IOL 0 D +8.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.090 SUP HCPCS V2632 SN60WS.090 - LENS IOL 0 D +9 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.095 SUP HCPCS V2632 SN60WS.095 - LENS IOL 0 D +9.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.100 SUP HCPCS V2632 SN60WS.100 - LENS IOL 0 D +10 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.105 SUP HCPCS V2632 SN60WS.105 - LENS IOL 0 D +10.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.110 SUP HCPCS V2632 SN60WS.110 - LENS IOL 0 D +11 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.115 SUP HCPCS V2632 SN60WS.115 - LENS IOL 0 D +11.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.120 SUP HCPCS V2632 SN60WS.120 - LENS IOL 0 D +12 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.125 SUP HCPCS V2632 SN60WS.125 - LENS IOL 0 D +12.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.130 SUP HCPCS V2632 SN60WS.130 - LENS IOL 0 D +13 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.135 SUP HCPCS V2632 SN60WS.135 - LENS IOL 0 D +13.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.140 SUP HCPCS V2632 SN60WS.140 - LENS IOL 0 D +14 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.145 SUP HCPCS V2632 SN60WS.145 - LENS IOL 0 D +14.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.150 SUP HCPCS V2632 SN60WS.150 - LENS IOL 0 D +15 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.155 SUP HCPCS V2632 SN60WS.155 - LENS IOL 0 D +15.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.160 SUP HCPCS V2632 SN60WS.160 - LENS IOL 0 D +16 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.165 SUP HCPCS V2632 SN60WS.165 - LENS IOL 0 D +16.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.170 SUP HCPCS V2632 SN60WS.170 - LENS IOL 0 D +17 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.175 SUP HCPCS V2632 SN60WS.175 - LENS IOL 0 D +17.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.180 SUP HCPCS V2632 SN60WS.180 - LENS IOL 0 D +18 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.185 SUP HCPCS V2632 SN60WS.185 - LENS IOL 0 D +18.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.190 SUP HCPCS V2632 SN60WS.190 - LENS IOL 0 D +19 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.195 SUP HCPCS V2632 SN60WS.195 - LENS IOL 0 D +19.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.200 SUP HCPCS V2632 SN60WS.200 - LENS IOL 0 D +20 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.205 SUP HCPCS V2632 SN60WS.205 - LENS IOL 0 D +20.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.210 SUP HCPCS V2632 SN60WS.210 - LENS IOL 0 D +21 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.215 SUP HCPCS V2632 SN60WS.215 - LENS IOL 0 D +21.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.220 SUP HCPCS V2632 SN60WS.220 - LENS IOL 0 D +22 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.225 SUP HCPCS V2632 SN60WS.225 - LENS IOL 0 D +22.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.230 SUP HCPCS V2632 SN60WS.230 - LENS IOL 0 D +23 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.235 SUP HCPCS V2632 SN60WS.235 - LENS IOL 0 D +23.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.240 SUP HCPCS V2632 SN60WS.240 - LENS IOL 0 D +24 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.245 SUP HCPCS V2632 SN60WS.245 - LENS IOL 0 D +24.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.250 SUP HCPCS V2632 SN60WS.250 - LENS IOL 0 D +25 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.255 SUP HCPCS V2632 SN60WS.255 - LENS IOL 0 D +25.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.260 SUP HCPCS V2632 SN60WS.260 - LENS IOL 0 D +26 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.265 SUP HCPCS V2632 SN60WS.265 - LENS IOL 0 D +26.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.270 SUP HCPCS V2632 SN60WS.270 - LENS IOL 0 D +27 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.275 SUP HCPCS V2632 SN60WS.275 - LENS IOL 0 D +27.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.280 SUP HCPCS V2632 SN60WS.280 - LENS IOL 0 D +28 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.285 SUP HCPCS V2632 SN60WS.285 - LENS IOL 0 D +28.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.290 SUP HCPCS V2632 SN60WS.290 - LENS IOL 0 D +29 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.295 SUP HCPCS V2632 SN60WS.295 - LENS IOL 0 D +29.5 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN60WS.300 SUP HCPCS V2632 SN60WS.300 - LENS IOL 0 D +30 DIOP BCNVX 6MM 13MM STRL ACRSF IQ NTR BOTH IP/OP "$1,202.50 " $889.85 $0.00 $962.00 $541.13 $541.13 $0.00 $0.00 $0.00 $250.63 $892.50 $892.50 $0.00 $0.00 $250.60 $0.00 $711.28 $711.28 $0.00 $601.25 $952.38 $962.00 $0.00 $0.00 $188.19 $0.00 $0.00 $191.44 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT3.150 SUP HCPCS V2787 SN6AT3.150 - DRILL SRG 2.1MM 110MM CNN TI BOTH IP/OP $995.00 $736.30 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $738.49 $738.49 $0.00 $0.00 $207.36 $0.00 $0.00 $0.00 $0.00 $497.50 $788.04 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT3.210 SUP HCPCS V2787 SN6AT3.210 - LENS INTRAOCULAR ACRYSOF IQ TORIC STABLEFORCE NATURAL ACRYLI BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT3.215 SUP HCPCS V2787 SN6AT3.215 - LENS IOL 0 D +21.5 DIOP +1.5 CYL BCNVX 6MM 13MM STRL ACRSF BOTH IP/OP $995.00 $736.30 $0.00 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $738.49 $738.49 $0.00 $0.00 $207.36 $0.00 $0.00 $0.00 $0.00 $497.50 $788.04 $796.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT5.145 SUP HCPCS V2632 SN6AT5.145 - LENS IOL 0 D +14.5 DIOP +3 CYL BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $310.03 "$1,104.02" "$1,104.02" $0.00 $0.00 $310.00 $0.00 $879.86 $879.86 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT5.150 SUP HCPCS V2632 SN6AT5.150 - LENS IOL 0 D +15 DIOP +3 CYL BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP "$1,487.50 " "$1,100.75" $0.00 "$1,190.00" $669.38 $669.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $743.75 "$1,178.10" "$1,190.00" $0.00 $0.00 $232.79 $0.00 $0.00 $236.81 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT5.165 SUP HCPCS V2787 SN6AT5.165 - LENS IOL 0 D +16.5 DIOP +3 CYL BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT5.185 SUP HCPCS V2787 SN6AT5.185 - LENS IOL 0 D +18.5 DIOP +3 CYL BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT5.220 SUP HCPCS V2787 SN6AT5.220 - LENS INTRAOCULAR ACRYSOF IQ TORIC STABLEFORCE NATURAL ACRYLI BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT5.225 SUP HCPCS V2787 SN6AT5.225 - LENS INTRAOCULAR ACRYSOF IQ TORIC STABLEFORCE NATURAL ACRYLI BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT6.175 SUP HCPCS V2787 SN6AT6.175 - LENS IOL 0 D +17.5 DIOP +3.75 CYL BCNVX 6MM 13MM STRL ACRSF BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT6.195 SUP HCPCS V2632 SN6AT6.195 - LENS IOL 0 D +19.5 DIOP +3.75 CYL BCNVX 6MM 13MM STRL ACRSF BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT6.205 SUP HCPCS V2632 SN6AT6.205 - LENS IOL 0 D +20.5 DIOP +3.75 CYL BCNVX 6MM 13MM STRL ACRSF BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT6.215 SUP HCPCS V2787 SN6AT6.215 - LENS IOL 0 D +21.5 DIOP +3.75 CYL BCNVX 6MM 13MM STRL ACRSF BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT6.245 SUP HCPCS V2632 SN6AT6.245 - LENS IOL 0 D +24.5 DIOP +3.75 CYL BCNVX 6MM 13MM STRL ACRSF BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT6.250 SUP HCPCS V2632 SN6AT6.250 - LENS IOL +25 DIOPTER +3.75 CYLINDER 0 D BICNVX 6MM 13MM 1 BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $257.93 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $731.98 $731.98 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT7.115 SUP HCPCS V2632 SN6AT7.115 - LENS IOL 0 D +11.5 DIOP +4.5 CYL BCNVX 6MM 13MM STRL ACRSF BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT7.205 SUP HCPCS V2632 SN6AT7.205 - LENS IOL 0 D +20.5 DIOP +4.5 CYL BCNVX 6MM 13MM STRL ACRSF BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $556.88 $556.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $193.67 $0.00 $0.00 $197.01 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT7U230 SUP HCPCS V2787 SN6AT7U230 - LENS IOL 0 D +23 DIOP +4.5 CYL BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT8.160 SUP HCPCS V2787 SN6AT8.160 - LENS INTRAOCULAR ACRYSOF IQ TORIC STABLEFORCE NATURAL ACRYLI BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT8U150 SUP HCPCS V2787 SN6AT8U150 - LENS INTRAOCULAR ACRYSOF IQ TORIC STABLEFORCE ACRYLIC 0 D +1 BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT9.165 SUP HCPCS V2787 SN6AT9.165 - LENS IOL 0 D +16.5 DIOP +6 CYL BICNVX 13MM 6MM BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT9.170 SUP HCPCS V2787 SN6AT9.170 - LENS IOL 0 D +17 DIOP +6 CYL BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP "$1,237.50 " $915.75 $0.00 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.47 $918.47 $0.00 $0.00 $257.90 $0.00 $0.00 $0.00 $0.00 $618.75 $980.10 $990.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SN6AT9U210 SUP HCPCS V2632 SN6AT9U210 - LENS IOL 0 D +21 DIOP +6 CYL BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $995.00 $736.30 $0.00 $796.00 $447.75 $447.75 $0.00 $0.00 $0.00 $207.38 $738.49 $738.49 $0.00 $0.00 $207.36 $0.00 $588.54 $588.54 $0.00 $497.50 $788.04 $796.00 $0.00 $0.00 $155.72 $0.00 $0.00 $158.40 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS SUP HCPCS V2632 SN6CWS - LENS IOL 0 D +16 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.060 SUP HCPCS V2632 SN6CWS.060 - LENS IOL 0 D +6 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.065 SUP HCPCS V2632 SN6CWS.065 - LENS IOL 0 D +6.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.070 SUP HCPCS V2632 SN6CWS.070 - LENS IOL 0 D +7 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.075 SUP HCPCS V2632 SN6CWS.075 - LENS IOL 0 D +7.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.080 SUP HCPCS V2632 SN6CWS.080 - LENS IOL 0 D +8 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.085 SUP HCPCS V2632 SN6CWS.085 - LENS IOL 0 D +8.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.090 SUP HCPCS V2632 SN6CWS.090 - LENS IOL 0 D +9 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.095 SUP HCPCS V2632 SN6CWS.095 - LENS IOL 0 D +9.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.100 SUP HCPCS V2632 SN6CWS.100 - LENS IOL 0 D +10 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.105 SUP HCPCS V2632 SN6CWS.105 - LENS IOL 0 D +10.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.110 SUP HCPCS V2632 SN6CWS.110 - LENS IOL 0 D +11 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.115 SUP HCPCS V2632 SN6CWS.115 - LENS IOL 0 D +11.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.120 SUP HCPCS V2632 SN6CWS.120 - LENS IOL 0 D +12 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.125 SUP HCPCS V2632 SN6CWS.125 - LENS IOL 0 D +12.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.130 SUP HCPCS V2632 SN6CWS.130 - LENS IOL 0 D +13 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.135 SUP HCPCS V2632 SN6CWS.135 - LENS IOL 0 D +13.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.140 SUP HCPCS V2632 SN6CWS.140 - LENS IOL 0 D +14 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.145 SUP HCPCS V2632 SN6CWS.145 - LENS IOL 0 D +14.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.150 SUP HCPCS V2632 SN6CWS.150 - LENS IOL 0 D +15 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.155 SUP HCPCS V2632 SN6CWS.155 - LENS IOL 0 D +15.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.160 SUP HCPCS V2632 SN6CWS.160 - LENS IOL 0 D +16 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.165 SUP HCPCS V2632 SN6CWS.165 - LENS IOL 0 D +16.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.170 SUP HCPCS V2632 SN6CWS.170 - LENS IOL 0 D +17 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.175 SUP HCPCS V2632 SN6CWS.175 - LENS IOL 0 D +17.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.180 SUP HCPCS V2632 SN6CWS.180 - LENS IOL 0 D +18 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.185 SUP HCPCS V2632 SN6CWS.185 - LENS IOL 0 D +18.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.190 SUP HCPCS V2632 SN6CWS.190 - LENS IOL 0 D +19 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.195 SUP HCPCS V2632 SN6CWS.195 - LENS IOL 0 D +19.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.200 SUP HCPCS V2632 SN6CWS.200 - LENS IOL 0 D +20 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.205 SUP HCPCS V2632 SN6CWS.205 - LENS IOL 0 D +20.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.210 SUP HCPCS V2632 SN6CWS.210 - LENS IOL 0 D +21 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.215 SUP HCPCS V2632 SN6CWS.215 - LENS IOL 0 D +21.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.220 SUP HCPCS V2632 SN6CWS.220 - LENS IOL 0 D +22 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.225 SUP HCPCS V2632 SN6CWS.225 - LENS IOL 0 D +22.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.230 SUP HCPCS V2632 SN6CWS.230 - LENS IOL 0 D +23 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.235 SUP HCPCS V2632 SN6CWS.235 - LENS IOL 0 D +23.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.240 SUP HCPCS V2632 SN6CWS.240 - LENS IOL 0 D +24 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.245 SUP HCPCS V2632 SN6CWS.245 - LENS IOL 0 D +24.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.250 SUP HCPCS V2632 SN6CWS.250 - LENS IOL 0 D +25 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.255 SUP HCPCS V2632 SN6CWS.255 - LENS IOL 0 D +25.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.260 SUP HCPCS V2632 SN6CWS.260 - LENS IOL 0 D +26 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.265 SUP HCPCS V2632 SN6CWS.265 - LENS IOL 0 D +26.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.270 SUP HCPCS V2632 SN6CWS.270 - LENS IOL 0 D +27 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.275 SUP HCPCS V2632 SN6CWS.275 - LENS IOL 0 D +27.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.280 SUP HCPCS V2632 SN6CWS.280 - LENS IOL 0 D +28 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.295 SUP HCPCS V2632 SN6CWS.295 - LENS IOL 0 D +29.5 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SN6CWS.300 SUP HCPCS V2632 SN6CWS.300 - LENS IOL 0 D +30 DIOP MOD L BCNVX 6MM 13MM STRL ACRSF IQ BOTH IP/OP $397.50 $294.15 $0.00 $318.00 $178.88 $178.88 $0.00 $0.00 $0.00 $82.85 $295.02 $295.02 $0.00 $0.00 $82.84 $0.00 $235.12 $235.12 $0.00 $198.75 $314.82 $318.00 $0.00 $0.00 $62.21 $0.00 $0.00 $63.28 $0.00 $0.00 $0.00 $0.00 $0.00 SOFT33 SUP Custom 27203010 SOFT33 - INSERT CLMP 33MM SOFTJAW SET ATRAUMATIC OCCLUSION HIGH FLOW BOTH IP/OP $32.50 $24.05 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.12 $24.12 $0.00 $0.00 $6.77 $0.00 $0.00 $0.00 $0.00 $16.25 $25.74 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SOFT61 SUP Custom 27203010 SOFT61 - INSERT CLMP 61MM SOFTJAW SET ATRAUMATIC OCCLUSION HIGH FLOW BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $0.00 $0.00 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SOFT86 SUP Custom 27203010 SOFT86 - INSERT CLMP FGRTY SFJW 86MM ATRM OCL HFLO RBR STRL LATEX BOTH IP/OP $40.00 $29.60 $0.00 $29.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $29.69 $0.00 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $16.38 $25.94 $26.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SP-1863 SUP HCPCS C1713 SP-1863 - COVER BURR HOLE 18.5MM SLOT TEFLON PI BOTH IP/OP $835.00 $617.90 $0.00 $668.00 $375.75 $375.75 $0.00 $0.00 $0.00 $174.03 $619.74 $619.74 $0.00 $0.00 $174.01 $0.00 $493.90 $493.90 $0.00 $417.50 $661.32 $668.00 $0.00 $0.00 $130.68 $0.00 $0.00 $132.93 $0.00 $0.00 $0.00 $0.00 $0.00 SP-1864 SUP HCPCS C1713 SP-1864 - PLATE BONE 26MM 2X4 HOLE MATRIX ORAL CRANIOMAXILLOFACIAL BOTH IP/OP $870.00 $643.80 $0.00 $696.00 $391.50 $391.50 $0.00 $0.00 $0.00 $181.33 $645.71 $645.71 $0.00 $0.00 $181.31 $0.00 $514.61 $514.61 $0.00 $435.00 $689.04 $696.00 $0.00 $0.00 $136.16 $0.00 $0.00 $138.50 $0.00 $0.00 $0.00 $0.00 $0.00 SP-1865 SUP HCPCS C1713 SP-1865 - MESH CRNL .2MM NS LORENZ TRAUMAONE MDFC ORBT FLR 1.5MM SCR BOTH IP/OP "$3,670.00 " "$2,715.80" $0.00 "$2,936.00" "$1,651.50" "$1,651.50" $0.00 $0.00 $0.00 $764.92 "$2,723.87" "$2,723.87" $0.00 $0.00 $764.83 $0.00 "$1,809.31" "$1,809.31" $0.00 "$1,835.00" "$2,906.64" "$2,936.00" $0.00 $0.00 $574.36 $0.00 $0.00 $584.26 $0.00 $0.00 $0.00 $0.00 $0.00 SP-1889 SUP Custom 27203010 SP-1889 - BLADE SURG 7X2MM REDX BOTH IP/OP $757.50 $560.55 $0.00 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.22 $562.22 $0.00 $0.00 $157.86 $0.00 $0.00 $0.00 $0.00 $378.75 $599.94 $606.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SP-1942 SUP HCPCS C1713 SP-1942 - PLATE SHUNT MEDIUM 18.5MM SPECIALTY X-DRIVE THINFLAP BOTH IP/OP $847.50 $627.15 $0.00 $678.00 $381.38 $381.38 $0.00 $0.00 $0.00 $176.64 $629.01 $629.01 $0.00 $0.00 $176.62 $0.00 $501.30 $501.30 $0.00 $423.75 $671.22 $678.00 $0.00 $0.00 $132.63 $0.00 $0.00 $134.92 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2032 SUP HCPCS C1713 SP-2032 - SCREW BONE 2.5MM 6MM SLFDRILL REDX BLADE BYRD LORENZ BOTH IP/OP "$1,032.50 " $764.05 $0.00 $826.00 $464.63 $464.63 $0.00 $0.00 $0.00 $215.20 $766.32 $766.32 $0.00 $0.00 $215.17 $0.00 $610.72 $610.72 $0.00 $516.25 $817.74 $826.00 $0.00 $0.00 $161.59 $0.00 $0.00 $164.37 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2256 SUP HCPCS C1713 SP-2256 - PLATE BONE 1MM SPECIALTY TRAUMAONE MANDIB BOTH IP/OP "$1,847.50 " "$1,367.15" $0.00 "$1,478.00" $831.38 $831.38 $0.00 $0.00 $0.00 $385.07 "$1,371.21" "$1,371.21" $0.00 $0.00 $385.02 $0.00 "$1,092.80" "$1,092.80" $0.00 $923.75 "$1,463.22" "$1,478.00" $0.00 $0.00 $289.13 $0.00 $0.00 $294.12 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2258 SUP Custom 27203010 SP-2258 - TAP SURG 2.3MM BOTH IP/OP "$1,592.50 " "$1,178.45" $0.00 "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,181.95" "$1,181.95" $0.00 $0.00 $331.88 $0.00 $0.00 $0.00 $0.00 $796.25 "$1,261.26" "$1,274.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2276 SUP HCPCS C1713 SP-2276 - PLATE BONE THK2.6MM SMALL SPECIALTY SYSTEM LORENZ BOTH IP/OP "$9,147.50 " "$6,769.15" $0.00 "$7,318.00" "$4,116.38" "$4,116.38" $0.00 $0.00 $0.00 "$1,906.57" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,906.34" $0.00 "$4,509.72" "$4,509.72" $0.00 "$4,573.75" "$7,244.82" "$7,318.00" $0.00 $0.00 "$1,431.58" $0.00 $0.00 "$1,456.28" $0.00 $0.00 $0.00 $0.00 $0.00 SP-2277 SUP HCPCS C1713 SP-2277 - PLATE BONE THK2.6MM MEDIUM SPECIALTY SYSTEM LORENZ BOTH IP/OP "$9,945.00 " "$7,359.30" $0.00 "$7,956.00" "$4,475.25" "$4,475.25" $0.00 $0.00 $0.00 "$2,072.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,072.54" $0.00 "$4,902.89" "$4,902.89" $0.00 "$4,972.50" "$7,876.44" "$7,956.00" $0.00 $0.00 "$1,556.39" $0.00 $0.00 "$1,583.24" $0.00 $0.00 $0.00 $0.00 $0.00 SP-2284 SUP HCPCS C1713 SP-2284 - PLATE BONE 1MM 4 HOLE STR LORENZ TRAUMAONE TITANIUM MANDIB BOTH IP/OP "$1,582.50 " "$1,171.05" $0.00 "$1,266.00" $712.13 $712.13 $0.00 $0.00 $0.00 $329.83 "$1,174.53" "$1,174.53" $0.00 $0.00 $329.79 $0.00 $936.05 $936.05 $0.00 $791.25 "$1,253.34" "$1,266.00" $0.00 $0.00 $247.66 $0.00 $0.00 $251.93 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2292 SUP HCPCS C1713 SP-2292 - PLATE BONE 2MM SPECIALTY TRAUMAONE MANDIB BOTH IP/OP "$2,492.50 " "$1,844.45" $0.00 "$1,994.00" "$1,121.63" "$1,121.63" $0.00 $0.00 $0.00 $519.50 "$1,849.93" "$1,849.93" $0.00 $0.00 $519.44 $0.00 "$1,474.31" "$1,474.31" $0.00 "$1,246.25" "$1,974.06" "$1,994.00" $0.00 $0.00 $390.08 $0.00 $0.00 $396.81 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2371 SUP HCPCS C1713 SP-2371 - PLATE BONE SPECIALTY LORENZ MIDFAC BOTH IP/OP $910.00 $673.40 $0.00 $728.00 $409.50 $409.50 $0.00 $0.00 $0.00 $189.67 $675.40 $675.40 $0.00 $0.00 $189.64 $0.00 $538.27 $538.27 $0.00 $455.00 $720.72 $728.00 $0.00 $0.00 $142.42 $0.00 $0.00 $144.87 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2375 SUP HCPCS C1713 SP-2375 - PLATE BONE 1MM LORENZ MANDIB BOTH IP/OP "$1,677.50 " "$1,241.35" $0.00 "$1,342.00" $754.88 $754.88 $0.00 $0.00 $0.00 $349.63 "$1,245.04" "$1,245.04" $0.00 $0.00 $349.59 $0.00 $992.24 $992.24 $0.00 $838.75 "$1,328.58" "$1,342.00" $0.00 $0.00 $262.53 $0.00 $0.00 $267.06 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2376 SUP HCPCS C1713 SP-2376 - PLATE BONE 1MM LORENZ MANDIB BOTH IP/OP "$1,677.50 " "$1,241.35" $0.00 "$1,342.00" $754.88 $754.88 $0.00 $0.00 $0.00 $349.63 "$1,245.04" "$1,245.04" $0.00 $0.00 $349.59 $0.00 $992.24 $992.24 $0.00 $838.75 "$1,328.58" "$1,342.00" $0.00 $0.00 $262.53 $0.00 $0.00 $267.06 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2377 SUP HCPCS C1713 SP-2377 - PLATE BONE 2MM LORENZ TRAUMAONE MIDFAC BOTH IP/OP "$2,450.00 " "$1,813.00" $0.00 "$1,960.00" "$1,102.50" "$1,102.50" $0.00 $0.00 $0.00 $510.64 "$1,818.39" "$1,818.39" $0.00 $0.00 $510.58 $0.00 "$1,449.18" "$1,449.18" $0.00 "$1,225.00" "$1,940.40" "$1,960.00" $0.00 $0.00 $383.43 $0.00 $0.00 $390.04 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2465 SUP HCPCS C1713 SP-2465 - PLATE BONE THK1.6MM LONG Y GRADE II TRAUMAONE LORENZ GOLD BOTH IP/OP "$2,017.50 " "$1,492.95" $0.00 "$1,614.00" $907.88 $907.88 $0.00 $0.00 $0.00 $420.50 "$1,497.39" "$1,497.39" $0.00 $0.00 $420.45 $0.00 "$1,193.35" "$1,193.35" $0.00 "$1,008.75" "$1,597.86" "$1,614.00" $0.00 $0.00 $315.74 $0.00 $0.00 $321.19 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2467 SUP HCPCS C1713 SP-2467 - PLATE BONE THK2.6MM SMALL STR ANGLED LORENZ MAGENTA MANDIB BOTH IP/OP "$4,520.00 " "$3,344.80" $0.00 "$3,616.00" "$2,034.00" "$2,034.00" $0.00 $0.00 $0.00 $942.08 "$3,354.74" "$3,354.74" $0.00 $0.00 $941.97 $0.00 "$2,228.36" "$2,228.36" $0.00 "$2,260.00" "$3,579.84" "$3,616.00" $0.00 $0.00 $707.38 $0.00 $0.00 $719.58 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2468 SUP HCPCS C1713 SP-2468 - PLATE BONE THK2.6MM 7 HOLE TRAUMAONE LORENZ MAGENTA MANDIB BOTH IP/OP "$4,075.00 " "$3,015.50" $0.00 "$3,260.00" "$1,833.75" "$1,833.75" $0.00 $0.00 $0.00 $849.33 "$3,024.47" "$3,024.47" $0.00 $0.00 $849.23 $0.00 "$2,008.98" "$2,008.98" $0.00 "$2,037.50" "$3,227.40" "$3,260.00" $0.00 $0.00 $637.74 $0.00 $0.00 $648.74 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2469 SUP HCPCS C1713 SP-2469 - PLATE BONE THK2.6MM 16 HOLE STR TRAUMAONE LORENZ MAGENTA BOTH IP/OP "$6,870.00 " "$5,083.80" $0.00 "$5,496.00" "$3,091.50" "$3,091.50" $0.00 $0.00 $0.00 "$1,431.88" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,431.71" $0.00 "$3,386.91" "$3,386.91" $0.00 "$3,435.00" "$5,441.04" "$5,496.00" $0.00 $0.00 "$1,075.16" $0.00 $0.00 "$1,093.70" $0.00 $0.00 $0.00 $0.00 $0.00 SP-2470 SUP HCPCS C1713 SP-2470 - PLATE BONE THK2.6MM SMALL 7 HOLE CVD LORENZ MAGENTA MANDIB BOTH IP/OP "$4,075.00 " "$3,015.50" $0.00 "$3,260.00" "$1,833.75" "$1,833.75" $0.00 $0.00 $0.00 $849.33 "$3,024.47" "$3,024.47" $0.00 $0.00 $849.23 $0.00 "$2,008.98" "$2,008.98" $0.00 "$2,037.50" "$3,227.40" "$3,260.00" $0.00 $0.00 $637.74 $0.00 $0.00 $648.74 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2472 SUP HCPCS C1713 SP-2472 - PLATE BONE L CRNMXF LEFT 8X10 HOLE XRIGID 1.5/1MM BOTH IP/OP $737.50 $545.75 $0.00 $590.00 $331.88 $331.88 $0.00 $0.00 $0.00 $153.71 $547.37 $547.37 $0.00 $0.00 $153.70 $0.00 $436.23 $436.23 $0.00 $368.75 $584.10 $590.00 $0.00 $0.00 $115.42 $0.00 $0.00 $117.41 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2473 SUP HCPCS C1713 SP-2473 - PLATE BN L 8X10 HL XRIGID CRNMXF RT 1.5/1MM SCR BOTH IP/OP "$1,242.50 " $919.45 $0.00 $994.00 $559.13 $559.13 $0.00 $0.00 $0.00 $258.97 $922.18 $922.18 $0.00 $0.00 $258.94 $0.00 $734.94 $734.94 $0.00 $621.25 $984.06 $994.00 $0.00 $0.00 $194.45 $0.00 $0.00 $197.81 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2526 SUP HCPCS C1713 SP-2526 - PLATE BONE CURVE CRNMXF 5 HOLE 1MM SCR BOTH IP/OP "$2,892.50 " "$2,140.45" $0.00 "$2,314.00" "$1,301.63" "$1,301.63" $0.00 $0.00 $0.00 $602.87 "$2,146.81" "$2,146.81" $0.00 $0.00 $602.80 $0.00 "$1,426.00" "$1,426.00" $0.00 "$1,446.25" "$2,290.86" "$2,314.00" $0.00 $0.00 $452.68 $0.00 $0.00 $460.49 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2566 SUP HCPCS C1713 SP-2566 - PLATE BONE STR 2MM 6 HOLE TRAUMAONE BLUE TITANIUM MANDIB BOTH IP/OP "$2,290.00 " "$1,694.60" $0.00 "$1,832.00" "$1,030.50" "$1,030.50" $0.00 $0.00 $0.00 $477.29 "$1,699.64" "$1,699.64" $0.00 $0.00 $477.24 $0.00 "$1,354.54" "$1,354.54" $0.00 "$1,145.00" "$1,813.68" "$1,832.00" $0.00 $0.00 $358.39 $0.00 $0.00 $364.57 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2575 SUP HCPCS C1713 SP-2575 - PLATE BONE 100D MEDIUM 3X3 HOLE L RIGID TRAUMAONE LORENZ BOTH IP/OP $877.50 $649.35 $0.00 $702.00 $394.88 $394.88 $0.00 $0.00 $0.00 $182.89 $651.28 $651.28 $0.00 $0.00 $182.87 $0.00 $519.04 $519.04 $0.00 $438.75 $694.98 $702.00 $0.00 $0.00 $137.33 $0.00 $0.00 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2576 SUP HCPCS C1713 SP-2576 - PLATE BONE 100D MEDIUM 3X3 HOLE L RIGID TRAUMAONE LORENZ BOTH IP/OP $877.50 $649.35 $0.00 $702.00 $394.88 $394.88 $0.00 $0.00 $0.00 $182.89 $651.28 $651.28 $0.00 $0.00 $182.87 $0.00 $519.04 $519.04 $0.00 $438.75 $694.98 $702.00 $0.00 $0.00 $137.33 $0.00 $0.00 $139.70 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2585 SUP HCPCS C1713 SP-2585 - PLATE .6MM MANDIB 4 HOLE STR 2/2.3MM SCR BONE BOTH IP/OP "$1,817.50 " "$1,344.95" $0.00 "$1,454.00" $817.88 $817.88 $0.00 $0.00 $0.00 $378.81 "$1,348.95" "$1,348.95" $0.00 $0.00 $378.77 $0.00 "$1,075.05" "$1,075.05" $0.00 $908.75 "$1,439.46" "$1,454.00" $0.00 $0.00 $284.44 $0.00 $0.00 $289.35 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2630 SUP HCPCS C1713 SP-2630 - PLATE BONE THK1.6MM STR 2X7 HOLE MATRIX GRADE II TRAUMAONE BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2631 SUP HCPCS C1713 SP-2631 - PLATE BONE THK1.6MM 7X2MM CVD MATRIX GOLD MANDIB 2/2.3MM BOTH IP/OP "$2,625.00 " "$1,942.50" $0.00 "$2,100.00" "$1,181.25" "$1,181.25" $0.00 $0.00 $0.00 $547.12 "$1,948.28" "$1,948.28" $0.00 $0.00 $547.05 $0.00 "$1,294.13" "$1,294.13" $0.00 "$1,312.50" "$2,079.00" "$2,100.00" $0.00 $0.00 $410.81 $0.00 $0.00 $417.90 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2665 SUP HCPCS C1713 SP-2665 - PLATE BONE THK1.6MM 7 HOLE 2Y GRADE II TRAUMAONE LORENZ BOTH IP/OP "$1,515.00 " "$1,121.10" $0.00 "$1,212.00" $681.75 $681.75 $0.00 $0.00 $0.00 $315.76 "$1,124.43" "$1,124.43" $0.00 $0.00 $315.73 $0.00 $896.12 $896.12 $0.00 $757.50 "$1,199.88" "$1,212.00" $0.00 $0.00 $237.10 $0.00 $0.00 $241.19 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2703 SUP HCPCS C1713 SP-2703 - PLATE STR 1.6MM 6 HOLE GAP BONE BOTH IP/OP "$2,450.00 " "$1,813.00" $0.00 "$1,960.00" "$1,102.50" "$1,102.50" $0.00 $0.00 $0.00 $510.64 "$1,818.39" "$1,818.39" $0.00 $0.00 $510.58 $0.00 "$1,449.18" "$1,449.18" $0.00 "$1,225.00" "$1,940.40" "$1,960.00" $0.00 $0.00 $383.43 $0.00 $0.00 $390.04 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2834 SUP HCPCS C1713 SP-2834 - SCREW BONE L8 MM OD2.4 MM RIB SELF DRILL LOCK BOTH IP/OP $625.00 $462.50 $0.00 $500.00 $281.25 $281.25 $0.00 $0.00 $0.00 $130.27 $463.88 $463.88 $0.00 $0.00 $130.25 $0.00 $369.69 $369.69 $0.00 $312.50 $495.00 $500.00 $0.00 $0.00 $97.81 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2889 SUP HCPCS C1713 SP-2889 - PLATE BN STRG STERNALOCK BLU 24 HL STRNM PRM CLSR SYS BOTH IP/OP "$3,760.00 " "$2,782.40" $0.00 "$3,008.00" "$1,692.00" "$1,692.00" $0.00 $0.00 $0.00 $783.68 "$2,790.67" "$2,790.67" $0.00 $0.00 $783.58 $0.00 "$1,853.68" "$1,853.68" $0.00 "$1,880.00" "$2,977.92" "$3,008.00" $0.00 $0.00 $588.44 $0.00 $0.00 $598.59 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2890 SUP HCPCS C1713 SP-2890 - PLATE BN HEX STERNALOCK BLU 6 HL STRNM PRM CLSR SYS BOTH IP/OP "$2,210.00 " "$1,635.40" $0.00 "$1,768.00" $994.50 $994.50 $0.00 $0.00 $0.00 $460.62 "$1,640.26" "$1,640.26" $0.00 $0.00 $460.56 $0.00 "$1,307.22" "$1,307.22" $0.00 "$1,105.00" "$1,750.32" "$1,768.00" $0.00 $0.00 $345.87 $0.00 $0.00 $351.83 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2891 SUP HCPCS C1713 SP-2891 - PLATE BN JL STRG STERNALOCK BLU 8 HL STRNM PRM CLSR SYS BOTH IP/OP "$1,945.00 " "$1,439.30" $0.00 "$1,556.00" $875.25 $875.25 $0.00 $0.00 $0.00 $405.39 "$1,443.58" "$1,443.58" $0.00 $0.00 $405.34 $0.00 "$1,150.47" "$1,150.47" $0.00 $972.50 "$1,540.44" "$1,556.00" $0.00 $0.00 $304.39 $0.00 $0.00 $309.64 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2899 SUP HCPCS C1713 SP-2899 - PLATE BN STRG STERNALOCK BLU 6 HL STRNM PRM CLSR SYS BOTH IP/OP "$1,962.50 " "$1,452.25" $0.00 "$1,570.00" $883.13 $883.13 $0.00 $0.00 $0.00 $409.03 "$1,456.57" "$1,456.57" $0.00 $0.00 $408.99 $0.00 "$1,160.82" "$1,160.82" $0.00 $981.25 "$1,554.30" "$1,570.00" $0.00 $0.00 $307.13 $0.00 $0.00 $312.43 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2913 SUP HCPCS C1713 SP-2913 - PLATE BN 70D L STERNALOCK BLU 8 HL STRNM PRM CLSR SYS BOTH IP/OP "$1,692.50 " "$1,252.45" $0.00 "$1,354.00" $761.63 $761.63 $0.00 $0.00 $0.00 $352.76 "$1,256.17" "$1,256.17" $0.00 $0.00 $352.72 $0.00 "$1,001.11" "$1,001.11" $0.00 $846.25 "$1,340.46" "$1,354.00" $0.00 $0.00 $264.88 $0.00 $0.00 $269.45 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2914 SUP HCPCS C1713 SP-2914 - PLATE BN Y STERNALOCK BLU 12 HL STRNM PRM CLSR SYS BOTH IP/OP "$3,332.50 " "$2,466.05" $0.00 "$2,666.00" "$1,499.63" "$1,499.63" $0.00 $0.00 $0.00 $694.58 "$2,473.38" "$2,473.38" $0.00 $0.00 $694.49 $0.00 "$1,642.92" "$1,642.92" $0.00 "$1,666.25" "$2,639.34" "$2,666.00" $0.00 $0.00 $521.54 $0.00 $0.00 $530.53 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2927 SUP HCPCS C1713 SP-2927 - PLATE BN STRG 1.6MM STERNALOCK BLU 16 HL STRNM PRM CLSR SYS BOTH IP/OP "$2,870.00 " "$2,123.80" $0.00 "$2,296.00" "$1,291.50" "$1,291.50" $0.00 $0.00 $0.00 $598.18 "$2,130.11" "$2,130.11" $0.00 $0.00 $598.11 $0.00 "$1,414.91" "$1,414.91" $0.00 "$1,435.00" "$2,273.04" "$2,296.00" $0.00 $0.00 $449.16 $0.00 $0.00 $456.90 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2984 SUP HCPCS C1713 SP-2984 - PLATE BN 100D X STERNALOCK BLU 8 HL STRNM BOTH IP/OP "$2,445.00 " "$1,809.30" $0.00 "$1,956.00" "$1,100.25" "$1,100.25" $0.00 $0.00 $0.00 $509.60 "$1,814.68" "$1,814.68" $0.00 $0.00 $509.54 $0.00 "$1,446.22" "$1,446.22" $0.00 "$1,222.50" "$1,936.44" "$1,956.00" $0.00 $0.00 $382.64 $0.00 $0.00 $389.24 $0.00 $0.00 $0.00 $0.00 $0.00 SP-2985 SUP HCPCS C1713 SP-2985 - PLATE BN 100D Y STERNALOCK BLU 6 HL STRNM BOTH IP/OP "$2,445.00 " "$1,809.30" $0.00 "$1,956.00" "$1,100.25" "$1,100.25" $0.00 $0.00 $0.00 $509.60 "$1,814.68" "$1,814.68" $0.00 $0.00 $509.54 $0.00 "$1,446.22" "$1,446.22" $0.00 "$1,222.50" "$1,936.44" "$1,956.00" $0.00 $0.00 $382.64 $0.00 $0.00 $389.24 $0.00 $0.00 $0.00 $0.00 $0.00 SP-3001 SUP HCPCS C1713 SP-3001 - PLATE BN 13MM STERNALOCK BLU STRNM JL G BOTH IP/OP "$2,070.00 " "$1,531.80" $0.00 "$1,656.00" $931.50 $931.50 $0.00 $0.00 $0.00 $431.44 "$1,536.35" "$1,536.35" $0.00 $0.00 $431.39 $0.00 "$1,224.41" "$1,224.41" $0.00 "$1,035.00" "$1,639.44" "$1,656.00" $0.00 $0.00 $323.96 $0.00 $0.00 $329.54 $0.00 $0.00 $0.00 $0.00 $0.00 SP-3022 SUP HCPCS C1713 SP-3022 - PLATE BN LG .6MM 4 HL CNTR MESH STRNL 1.5MM SCR EZ BOTH IP/OP "$1,677.50 " "$1,241.35" $0.00 "$1,342.00" $754.88 $754.88 $0.00 $0.00 $0.00 $349.63 "$1,245.04" "$1,245.04" $0.00 $0.00 $349.59 $0.00 $992.24 $992.24 $0.00 $838.75 "$1,328.58" "$1,342.00" $0.00 $0.00 $262.53 $0.00 $0.00 $267.06 $0.00 $0.00 $0.00 $0.00 $0.00 SP-3060 SUP HCPCS C1713 SP-3060 - SCREW BN 2MM 9MM OMNIMAX MXLMNDB SD XD BOTH IP/OP "$2,172.50 " "$1,607.65" $0.00 "$1,738.00" $977.63 $977.63 $0.00 $0.00 $0.00 $452.80 "$1,612.43" "$1,612.43" $0.00 $0.00 $452.75 $0.00 "$1,285.03" "$1,285.03" $0.00 "$1,086.25" "$1,720.62" "$1,738.00" $0.00 $0.00 $340.00 $0.00 $0.00 $345.86 $0.00 $0.00 $0.00 $0.00 $0.00 SP-3142 SUP HCPCS C1713 SP-3142 - PLATE BN 60D JL STERNALOCK BLU STRNM BOTH IP/OP "$2,977.50 " "$2,203.35" $0.00 "$2,382.00" "$1,339.88" "$1,339.88" $0.00 $0.00 $0.00 $620.59 "$2,209.90" "$2,209.90" $0.00 $0.00 $620.51 $0.00 "$1,467.91" "$1,467.91" $0.00 "$1,488.75" "$2,358.18" "$2,382.00" $0.00 $0.00 $465.98 $0.00 $0.00 $474.02 $0.00 $0.00 $0.00 $0.00 $0.00 SP-3192 SUP HCPCS C1713 SP-3192 - PLATE BN W STERNALOCK BLU 8 HL STRNL BOTH IP/OP "$3,537.50 " "$2,617.75" $0.00 "$2,830.00" "$1,591.88" "$1,591.88" $0.00 $0.00 $0.00 $737.30 "$2,625.53" "$2,625.53" $0.00 $0.00 $737.22 $0.00 "$1,743.99" "$1,743.99" $0.00 "$1,768.75" "$2,801.70" "$2,830.00" $0.00 $0.00 $553.62 $0.00 $0.00 $563.17 $0.00 $0.00 $0.00 $0.00 $0.00 SP-3215 SUP HCPCS C1713 SP-3215 - PLATE BN XW 80MM MESH CRNM CHIARI BOTH IP/OP "$2,977.50 " "$2,203.35" $0.00 "$2,382.00" "$1,339.88" "$1,339.88" $0.00 $0.00 $0.00 $620.59 "$2,209.90" "$2,209.90" $0.00 $0.00 $620.51 $0.00 "$1,467.91" "$1,467.91" $0.00 "$1,488.75" "$2,358.18" "$2,382.00" $0.00 $0.00 $465.98 $0.00 $0.00 $474.02 $0.00 $0.00 $0.00 $0.00 $0.00 SP719521 SUP Custom 27203010 REAGENT .8% RBC RSLV 3ML PNL B BLOOD BANK BOTH IP/OP $391.75 $289.90 $0.00 $313.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.88 $310.27 $313.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SP721380 SUP Custom 27203010 REAGENT ANTI-JK LTTL A BCLN 3ML MNCLN RARE GRP BLOOD BANK BOTH IP/OP $47.50 $35.15 $0.00 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.75 $37.62 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPD2-US-040-320 SUP HCPCS C1884 SPD2-US-040-320 - SYSTEM EMBL PRTC 320CM .014IN FLTR CPTR WIRE GUID CATH 4MM BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 SPD2-US-050-320 SUP HCPCS C1884 SPD2-US-050-320 - SYSTEM EMBL PRTC 320CM .014IN FLTR CPTR WIRE GUID CATH 5MM BOTH IP/OP "$2,875.00 " "$2,127.50" $0.00 "$2,300.00" "$1,293.75" "$1,293.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,437.50" "$2,277.00" "$2,300.00" $0.00 $0.00 $449.94 $0.00 $0.00 $457.70 $0.00 $0.00 $0.00 $0.00 $0.00 SPD2-US-060-320 SUP HCPCS C1773 SPD2-US-060-320 - SYSTEM EMBL PRTC 3.2-4.2FR 6MM 320CM 190CM SPIDERFX CPTR WRE BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" "$1,893.71" "$1,893.71" $0.00 $0.00 $0.00 $726.88 "$2,588.42" "$2,588.42" $0.00 $0.00 $726.80 $0.00 "$2,062.86" "$2,062.86" $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $545.79 $0.00 $0.00 $555.21 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100200-20 SUP Custom 27803010 SPH100200-20 - COIL EMBL 2MM 2.5CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,497.15 " "$1,847.89" $0.00 "$1,997.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,853.38" "$1,853.38" $0.00 $0.00 $520.41 $0.00 $0.00 $0.00 $0.00 "$1,248.58" "$1,977.74" "$1,997.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100250-20 SUP Custom 27803010 SPH100250-20 - COIL EMBL 2.5MM 3.3CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,530.45 " "$1,872.53" $0.00 "$2,024.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,878.10" "$1,878.10" $0.00 $0.00 $527.35 $0.00 $0.00 $0.00 $0.00 "$1,265.23" "$2,004.12" "$2,024.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100300-20 SUP Custom 27803010 SPH100300-20 - COIL EMBL 3MM 5.4CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,530.45 " "$1,872.53" $0.00 "$2,024.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,878.10" "$1,878.10" $0.00 $0.00 $527.35 $0.00 $0.00 $0.00 $0.00 "$1,265.23" "$2,004.12" "$2,024.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100350-20 SUP Custom 27803010 SPH100350-20 - COIL EMBL 3.5MM 6.6CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,530.45 " "$1,872.53" $0.00 "$2,024.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,878.10" "$1,878.10" $0.00 $0.00 $527.35 $0.00 $0.00 $0.00 $0.00 "$1,265.23" "$2,004.12" "$2,024.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100500-20 SUP Custom 27803010 SPH100500-20 - COIL EMBL 5MM 9.7CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,563.73 " "$1,897.16" $0.00 "$2,050.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,902.80" "$1,902.80" $0.00 $0.00 $534.28 $0.00 $0.00 $0.00 $0.00 "$1,281.86" "$2,030.47" "$2,050.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100600-20 SUP Custom 27803010 SPH100600-20 - COIL EMBL 6MM 11.9CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,597.03 " "$1,921.80" $0.00 "$2,077.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,927.51" "$1,927.51" $0.00 $0.00 $541.22 $0.00 $0.00 $0.00 $0.00 "$1,298.51" "$2,056.85" "$2,077.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100620-20 SUP Custom 27803010 SPH100620-20 - COIL EMBL 6MM 20CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH SFT BOTH IP/OP "$2,730.20 " "$2,020.35" $0.00 "$2,184.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,026.35" "$2,026.35" $0.00 $0.00 $568.97 $0.00 $0.00 $0.00 $0.00 "$1,365.10" "$2,162.32" "$2,184.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100700-20 SUP Custom 27803010 SPH100700-20 - COIL EMBL 7MM 13.9CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,630.33 " "$1,946.44" $0.00 "$2,104.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,952.23" "$1,952.23" $0.00 $0.00 $548.16 $0.00 $0.00 $0.00 $0.00 "$1,315.16" "$2,083.22" "$2,104.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100720-20 SUP Custom 27803010 SPH100720-20 - COIL EMBL 7MM 20CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH SFT BOTH IP/OP "$2,730.20 " "$2,020.35" $0.00 "$2,184.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,026.35" "$2,026.35" $0.00 $0.00 $568.97 $0.00 $0.00 $0.00 $0.00 "$1,365.10" "$2,162.32" "$2,184.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100800-20 SUP Custom 27803010 SPH100800-20 - COIL EMBL 8MM 16.1CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,663.63 " "$1,971.09" $0.00 "$2,130.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,976.94" "$1,976.94" $0.00 $0.00 $555.10 $0.00 $0.00 $0.00 $0.00 "$1,331.81" "$2,109.59" "$2,130.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100825-20 SUP Custom 27803010 SPH100825-20 - COIL EMBL 8MM 25CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH SFT BOTH IP/OP "$2,796.80 " "$2,069.63" $0.00 "$2,237.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,075.78" "$2,075.78" $0.00 $0.00 $582.85 $0.00 $0.00 $0.00 $0.00 "$1,398.40" "$2,215.07" "$2,237.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100900-20 SUP Custom 27803010 SPH100900-20 - COIL EMBL 9MM 18.4CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,696.93 " "$1,995.73" $0.00 "$2,157.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,001.66" "$2,001.66" $0.00 $0.00 $562.04 $0.00 $0.00 $0.00 $0.00 "$1,348.46" "$2,135.97" "$2,157.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH100925-20 SUP Custom 27803010 SPH100925-20 - COIL EMBL 9MM 25CM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH SFT BOTH IP/OP "$2,796.80 " "$2,069.63" $0.00 "$2,237.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,075.78" "$2,075.78" $0.00 $0.00 $582.85 $0.00 $0.00 $0.00 $0.00 "$1,398.40" "$2,215.07" "$2,237.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH101000-20 SUP Custom 27803010 SPH101000-20 - COIL EMBL SPHR 10MM 20.3CM MICRUSPHERE 10 MCIOL SPHRCL LOOP BOTH IP/OP "$2,730.20 " "$2,020.35" $0.00 "$2,184.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,026.35" "$2,026.35" $0.00 $0.00 $568.97 $0.00 $0.00 $0.00 $0.00 "$1,365.10" "$2,162.32" "$2,184.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH10103020 SUP Custom 27803010 SPH10103020 - COIL EMBL SPHR 10MM 30CM MICRUSPHERE 10 MCIOL SPHRCL LOOP BOTH IP/OP "$2,830.10 " "$2,094.27" $0.00 "$2,264.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,415.05" "$2,241.44" "$2,264.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH101030-20 SUP Custom 27803010 SPH101030-20 - COIL EMBL 30CM 10MM MICRUSPHERE 10 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,830.10 " "$2,094.27" $0.00 "$2,264.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,100.50" "$2,100.50" $0.00 $0.00 $589.79 $0.00 $0.00 $0.00 $0.00 "$1,415.05" "$2,241.44" "$2,264.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH181100-20 SUP Custom 27803010 SPH181100-20 - COIL EMBL 11MM 18.9CM MICRUSPHERE 18 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,725.80 " "$2,017.09" $0.00 "$2,180.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,023.09" "$2,023.09" $0.00 $0.00 $568.06 $0.00 $0.00 $0.00 $0.00 "$1,362.90" "$2,158.83" "$2,180.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH181200-20 SUP Custom 27803010 SPH181200-20 - COIL EMBL 12MM 20.7CM MICRUSPHERE 18 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,725.80 " "$2,017.09" $0.00 "$2,180.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,023.09" "$2,023.09" $0.00 $0.00 $568.06 $0.00 $0.00 $0.00 $0.00 "$1,362.90" "$2,158.83" "$2,180.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH181300-20 SUP Custom 27803010 SPH181300-20 - COIL EMBL 13MM 22.6CM MICRUSPHERE 18 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,725.80 " "$2,017.09" $0.00 "$2,180.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,023.09" "$2,023.09" $0.00 $0.00 $568.06 $0.00 $0.00 $0.00 $0.00 "$1,362.90" "$2,158.83" "$2,180.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH181400-20 SUP Custom 27803010 SPH181400-20 - COIL EMBL 14MM 24.3CM MICRUSPHERE 18 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,761.68 " "$2,043.64" $0.00 "$2,209.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,049.72" "$2,049.72" $0.00 $0.00 $575.53 $0.00 $0.00 $0.00 $0.00 "$1,380.84" "$2,187.25" "$2,209.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH181500-20 SUP Custom 27803010 SPH181500-20 - COIL EMBL 15MM 26CM MICRUSPHERE 18 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,797.53 " "$2,070.17" $0.00 "$2,238.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,076.32" "$2,076.32" $0.00 $0.00 $583.00 $0.00 $0.00 $0.00 $0.00 "$1,398.76" "$2,215.64" "$2,238.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH181600-20 SUP Custom 27803010 SPH181600-20 - COIL EMBL 16MM 27.9CM MICRUSPHERE 18 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,797.53 " "$2,070.17" $0.00 "$2,238.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,076.32" "$2,076.32" $0.00 $0.00 $583.00 $0.00 $0.00 $0.00 $0.00 "$1,398.76" "$2,215.64" "$2,238.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH181700-20 SUP Custom 27803010 SPH181700-20 - COIL EMBL 17MM 30CM MICRUSPHERE 18 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,833.40 " "$2,096.72" $0.00 "$2,266.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,102.95" "$2,102.95" $0.00 $0.00 $590.48 $0.00 $0.00 $0.00 $0.00 "$1,416.70" "$2,244.05" "$2,266.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPH181800-20 SUP Custom 27803010 SPH181800-20 - COIL EMBL 18MM 30CM MICRUSPHERE 18 MCIOL SPHRCL LOOP DTCH BOTH IP/OP "$2,833.40 " "$2,096.72" $0.00 "$2,266.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,102.95" "$2,102.95" $0.00 $0.00 $590.48 $0.00 $0.00 $0.00 $0.00 "$1,416.70" "$2,244.05" "$2,266.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPL15006X SUP HCPCS C1725 SPL15006X - CATH BALDILAT 1.5MM 6MM RAPEX SMCPNT SPNTR LGND BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL15010X SUP HCPCS C1726 SPL15010X - CATHETER BLNDIL 21CM .02IN 1.5MM 142CM LF 10MM SPNTR LGND BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $223.99 $223.99 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 SPL15012X SUP HCPCS C1725 CATHETER BLN 1.5MM 12MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL15015X SUP HCPCS C1725 CATHETER BLN 1.5MM 15MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL15020X SUP HCPCS C1725 CATHETER BLN 1.5MM 20MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL20006X SUP HCPCS C1726 SPL20006X - CATHETER BLNDIL 21CM .022IN 2MM 142CM LF 6MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL20010X SUP HCPCS C1726 SPL20010X - CATHETER BLNDIL 21CM .022IN 2MM 142CM LF 10MM SPNTR LGND BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $223.99 $223.99 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 SPL20012X SUP HCPCS C1725 CATHETER BLN 2MM 12MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL20015X SUP HCPCS C1725 CATHETER BLN 2MM 15MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL20020X SUP HCPCS C1725 CATHETER BLN 2MM 20MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL20025X SUP HCPCS C1726 SPL20025X - CATHETER BLNDIL 21CM .022IN 2MM 142CM LF 25MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL20030X SUP HCPCS C1726 SPL20030X - CATHETER BLNDIL 21CM .022IN 2MM 142CM LF 30MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL22506X SUP HCPCS C1726 SPL22506X - CATHETER BLNDIL 21CM .022IN 2.25MM 142CM LF 6MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL22510X SUP HCPCS C1726 SPL22510X - CATHETER BLNDIL 21CM .022IN 2.25MM 142CM LF 10MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL22512X SUP HCPCS C1726 SPL22512X - CATHETER BLNDIL 21CM .022IN 2.25MM 142CM LF 12MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL22515X SUP HCPCS C1726 SPL22515X - CATHETER BLNDIL 21CM .022IN 2.25MM 142CM LF 15MM SPNTR LGND BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $223.99 $223.99 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 SPL22520X SUP HCPCS C1726 SPL22520X - CATHETER BLNDIL 21CM .022IN 2.25MM 142CM LF 20MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL22525X SUP HCPCS C1726 SPL22525X - CATHETER BLNDIL 21CM .022IN 2.25MM 142CM LF 25MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL250010X SUP HCPCS C1726 SPL250010X - CATHETER BLNDIL 21CM .022IN 2.5MM 142CM LF 10MM SPNTR LGND BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $223.99 $223.99 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 SPL25006X SUP HCPCS C1726 SPL25006X - CATHETER BLNDIL 21CM .022IN 2.5MM 142CM LF 6MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL25012X SUP HCPCS C1725 CATHETER BLN 2.5MM 12MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL25015X SUP HCPCS C1725 CATHETER BLN 2.5MM 15MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL25020X SUP HCPCS C1725 CATHETER BLN 2.5MM 20MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL25025X SUP HCPCS C1726 SPL25025X - CATHETER BLNDIL 21CM .022IN 2.5MM 142CM LF 25MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL25030X SUP HCPCS C1726 SPL25030X - CATHETER BLNDIL 21CM .022IN 2.5MM 142CM LF 30MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL27506X SUP HCPCS C1726 SPL27506X - CATHETER BLNDIL 21CM .023IN 2.75MM 142CM LF 6MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL27512X SUP HCPCS C1726 SPL27512X - CATHETER BLNDIL 21CM .023IN 2.75MM 142CM LF 12MM SPNTR LGND BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $223.99 $223.99 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 SPL27515X SUP HCPCS C1726 SPL27515X - CATHETER BLNDIL 21CM .023IN 2.75MM 142CM LF 15MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL27520X SUP HCPCS C1726 SPL27520X - CATHETER BLNDIL 21CM .023IN 2.75MM 142CM LF 20MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL27525X SUP HCPCS C1726 SPL27525X - CATHETER BLNDIL 21CM .023IN 2.75MM 142CM LF 25MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL30006X SUP HCPCS C1726 SPL30006X - CATHETER BLNDIL 21CM .023IN 3MM 142CM LF 6MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL30010X SUP HCPCS C1726 SPL30010X - CATHETER BLNDIL 21CM .023IN 3MM 142CM LF 10MM SPNTR LGND BOTH IP/OP $412.50 $305.25 $0.00 $330.00 $223.99 $223.99 $0.00 $0.00 $0.00 $85.98 $306.16 $306.16 $0.00 $0.00 $85.97 $0.00 $243.99 $243.99 $0.00 $206.25 $326.70 $330.00 $0.00 $0.00 $64.56 $0.00 $0.00 $65.67 $0.00 $0.00 $0.00 $0.00 $0.00 SPL30012X SUP HCPCS C1725 CATHETER BLN 3MM 12MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL30015X SUP HCPCS C1725 CATHETER BLN 3MM 15MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL30020X SUP HCPCS C1725 CATHETER BLN 3MM 20MM RAPEX LGND SPNTR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $237.56 $237.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 SPL30025X SUP HCPCS C1726 SPL30025X - CATHETER BLNDIL 21CM .023IN 3MM 142CM LF 25MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL30030X SUP HCPCS C1726 SPL30030X - CATHETER BLNDIL 21CM .023IN 3MM 142CM LF 30MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL32512X SUP HCPCS C1726 SPL32512X - CATHETER BLNDIL 21CM .023IN 3.25MM 142CM LF 12MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL32515X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL32520X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL35006X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL35010X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL35012X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL35015X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL35020X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL35025X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL35030X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL37512X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL37515X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL37520X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL40006X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL40010X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL40012X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL40015X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL40020X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPL40025X SUP HCPCS C1726 SPL40025X - CATHETER BLNDIL 21CM .024IN 4MM 142CM LF 25MM SPNTR LGND BOTH IP/OP $425.00 $314.50 $0.00 $340.00 $230.78 $230.78 $0.00 $0.00 $0.00 $88.58 $315.44 $315.44 $0.00 $0.00 $88.57 $0.00 $251.39 $251.39 $0.00 $212.50 $336.60 $340.00 $0.00 $0.00 $66.51 $0.00 $0.00 $67.66 $0.00 $0.00 $0.00 $0.00 $0.00 SPL40030X SUP HCPCS C1725 BALLON SPRINTER LEGEND RX BOTH IP/OP $12.50 $9.25 $0.00 $10.00 $6.79 $6.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.25 $9.90 $10.00 $0.00 $0.00 $1.96 $0.00 $0.00 $1.99 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20100-TS SUP HCPCS C1713 SPLS-20100-TS - PEG FX 2MM 10MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20120-TS SUP HCPCS C1713 SPLS-20120-TS - PEG FX 2MM 12MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20140-TS SUP HCPCS C1713 SPLS-20140-TS - PEG FX 2MM 14MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20160-TS SUP HCPCS C1713 SPLS-20160-TS - PEG FX 2MM 16MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20170-TS SUP HCPCS C1713 SPLS-20170-TS - PEG FX 2MM 17MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20180-TS SUP HCPCS C1713 SPLS-20180-TS - PEG FX 2MM 18MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20190-TS SUP HCPCS C1713 SPLS-20190-TS - PEG FX 2MM 19MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20200-TS SUP HCPCS C1713 SPLS-20200-TS - PEG FX 2MM 20MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20210-TS SUP HCPCS C1713 SPLS-20210-TS - PEG FX 2MM 21MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20220-TS SUP HCPCS C1713 SPLS-20220-TS - PEG FX 2MM 22MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20230-TS SUP HCPCS C1713 SPLS-20230-TS - PEG FX 2MM 23MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20240-TS SUP HCPCS C1713 SPLS-20240-TS - PEG FX 2MM 24MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20260-TS SUP HCPCS C1713 SPLS-20260-TS - PEG FX 2MM 26MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20280-TS SUP HCPCS C1713 SPLS-20280-TS - PEG FX 2MM 28MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20300-TS SUP HCPCS C1713 SPLS-20300-TS - PEG FX 2MM 30MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPLS-20320-TS SUP HCPCS C1713 SPLS-20320-TS - PEG FX 2MM 32MM NS GEMINUS SMTH LCK SCR CADDY TI FOSSA RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 SPMTS4014 SUP Custom 27203010 REAGENT ANTI-IGG C3D ID MTS GEL CRD 6 TST ANALY BOTH IP/OP $160.70 $118.92 $0.00 $128.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.35 $127.27 $128.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPMTS4024 SUP Custom 27203010 REAGENT ANTI-IGG ID MTS GEL CRD PLYCLN 6 TST ANALY BOTH IP/OP $494.85 $366.19 $0.00 $395.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.43 $391.92 $395.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SPS0121K SUP HCPCS C1713 SPS0121K - SPACER HUM 99MMX16MM 41MM 7MM INTSPC SM SHLDR PMMA BOTH IP/OP "$9,975.00 " "$7,381.50" $0.00 "$7,980.00" "$4,488.75" "$4,488.75" $0.00 $0.00 $0.00 "$2,079.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,078.79" $0.00 "$4,917.68" "$4,917.68" $0.00 "$4,987.50" "$7,900.20" "$7,980.00" $0.00 $0.00 "$1,561.09" $0.00 $0.00 "$1,588.02" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0620-CS SUP HCPCS C1876 SR-0620-CS - STENT VASC STRG 6MM 20MM 57CM ENROUTE UBER FLX DLV SYS ANG BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0630-CS SUP HCPCS C1876 SR-0630-CS - STENT VASC 6MM .065IN 30MM 57CM ENROUTE UBER FLX DLV SYS ANG BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0640-CS SUP HCPCS C1876 SR-0640-CS - STENT VASC 6MM 40MM 57CM ENROUTE UBER FLX DLV SYS ANG TIP BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0730-CS SUP HCPCS C1876 SR-0730-CS - STENT VASC 7MM .065IN 30MM 57CM ENROUTE UBER FLX DLV SYS ANG BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0740-CS SUP HCPCS C1876 SR-0740-CS - STENT VASC 7MM .065IN 40MM 57CM ENROUTE UBER FLX DLV SYS ANG BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0830-CS SUP HCPCS C1876 SR-0830-CS - STENT VASC 8MM .065IN 30MM 57CM ENROUTE UBER FLX DLV SYS ANG BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0840-CS SUP HCPCS C1876 SR-0840-CS - STENT VASC 8MM .065IN 40MM 57CM ENROUTE UBER FLX DLV SYS ANG BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0930-CS SUP HCPCS C1876 SR-0930-CS - STENT VASC 9MM 30MM 57CM ENROUTE UBER FLX DLV SYS ANG TIP BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-0940-CS SUP HCPCS C1876 SR-0940-CS - STENT VASC 9MM .078IN 40MM 57CM ENROUTE UBER FLX DLV SYS ANG BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-1030-CS SUP HCPCS C1876 SR-1030-CS - STENT VASC SHRT STRG 10MM 6FR 30MM 57CM ENROUTE UBER FLX BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SR-1040-CS SUP HCPCS C1876 SR-1040-CS - STENT VASC 10MM .078IN 40MM 57CM ENROUTE UBER FLX DLV SYS BOTH IP/OP "$6,750.00 " "$4,995.00" $0.00 "$5,400.00" "$3,037.50" "$3,037.50" $0.00 $0.00 $0.00 "$1,406.87" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,406.70" $0.00 "$3,327.75" "$3,327.75" $0.00 "$3,375.00" "$5,346.00" "$5,400.00" $0.00 $0.00 "$1,056.38" $0.00 $0.00 "$1,074.60" $0.00 $0.00 $0.00 $0.00 $0.00 SRC140306-20 SUP Custom 27803010 SRC140306-20 - COIL EMBL 3MM 6CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,785.85 " "$2,061.53" $0.00 "$2,228.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,067.66" "$2,067.66" $0.00 $0.00 $580.57 $0.00 $0.00 $0.00 $0.00 "$1,392.93" "$2,206.39" "$2,228.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140406-20 SUP Custom 27803010 SRC140406-20 - COIL EMBL 4MM 6CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,785.85 " "$2,061.53" $0.00 "$2,228.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,067.66" "$2,067.66" $0.00 $0.00 $580.57 $0.00 $0.00 $0.00 $0.00 "$1,392.93" "$2,206.39" "$2,228.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140408-20 SUP Custom 27803010 SRC140408-20 - COIL EMBL 4MM 8CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,829.38 " "$2,093.74" $0.00 "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,099.96" "$2,099.96" $0.00 $0.00 $589.64 $0.00 $0.00 $0.00 $0.00 "$1,414.69" "$2,240.87" "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140445-20 SUP Custom 27803010 SRC140445-20 - COIL EMBL 4MM 4.5CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,785.85 " "$2,061.53" $0.00 "$2,228.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,067.66" "$2,067.66" $0.00 $0.00 $580.57 $0.00 $0.00 $0.00 $0.00 "$1,392.93" "$2,206.39" "$2,228.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140507-20 SUP Custom 27803010 SRC140507-20 - COIL EMBL 5MM 7CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,829.38 " "$2,093.74" $0.00 "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,099.96" "$2,099.96" $0.00 $0.00 $589.64 $0.00 $0.00 $0.00 $0.00 "$1,414.69" "$2,240.87" "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140512-20 SUP Custom 27803010 SRC140512-20 - COIL EMBL 5MM 12CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,829.38 " "$2,093.74" $0.00 "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,099.96" "$2,099.96" $0.00 $0.00 $589.64 $0.00 $0.00 $0.00 $0.00 "$1,414.69" "$2,240.87" "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140609-20 SUP Custom 27803010 SRC140609-20 - COIL EMBL 6MM 9CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,829.38 " "$2,093.74" $0.00 "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,099.96" "$2,099.96" $0.00 $0.00 $589.64 $0.00 $0.00 $0.00 $0.00 "$1,414.69" "$2,240.87" "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140615-20 SUP Custom 27803010 SRC140615-20 - COIL EMBL 6MM 15CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,872.90 " "$2,125.95" $0.00 "$2,298.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,132.27" "$2,132.27" $0.00 $0.00 $598.71 $0.00 $0.00 $0.00 $0.00 "$1,436.45" "$2,275.34" "$2,298.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140711-20 SUP Custom 27803010 SRC140711-20 - COIL EMBL 7MM 11CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,829.38 " "$2,093.74" $0.00 "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,099.96" "$2,099.96" $0.00 $0.00 $589.64 $0.00 $0.00 $0.00 $0.00 "$1,414.69" "$2,240.87" "$2,263.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140717-20 SUP Custom 27803010 SRC140717-20 - COIL EMBL 7MM 17CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,959.95 " "$2,190.36" $0.00 "$2,367.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,196.87" "$2,196.87" $0.00 $0.00 $616.85 $0.00 $0.00 $0.00 $0.00 "$1,479.98" "$2,344.28" "$2,367.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140812-20 SUP Custom 27803010 SRC140812-20 - COIL EMBL 8MM 12CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,872.90 " "$2,125.95" $0.00 "$2,298.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,132.27" "$2,132.27" $0.00 $0.00 $598.71 $0.00 $0.00 $0.00 $0.00 "$1,436.45" "$2,275.34" "$2,298.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140820-20 SUP Custom 27803010 SRC140820-20 - COIL EMBL 8MM 20CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$3,003.48 " "$2,222.58" $0.00 "$2,402.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,229.18" "$2,229.18" $0.00 $0.00 $625.92 $0.00 $0.00 $0.00 $0.00 "$1,501.74" "$2,378.76" "$2,402.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140914-20 SUP Custom 27803010 SRC140914-20 - COIL EMBL 9MM 14CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,959.95 " "$2,190.36" $0.00 "$2,367.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,196.87" "$2,196.87" $0.00 $0.00 $616.85 $0.00 $0.00 $0.00 $0.00 "$1,479.98" "$2,344.28" "$2,367.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC140922-20 SUP Custom 27803010 SRC140922-20 - COIL EMBL 9MM 22CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$3,003.48 " "$2,222.58" $0.00 "$2,402.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,229.18" "$2,229.18" $0.00 $0.00 $625.92 $0.00 $0.00 $0.00 $0.00 "$1,501.74" "$2,378.76" "$2,402.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC141016-20 SUP Custom 27803010 SRC141016-20 - COIL EMBL 10MM 16CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$2,959.95 " "$2,190.36" $0.00 "$2,367.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,196.87" "$2,196.87" $0.00 $0.00 $616.85 $0.00 $0.00 $0.00 $0.00 "$1,479.98" "$2,344.28" "$2,367.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC141025-20 SUP Custom 27803010 SRC141025-20 - COIL EMBL 10MM 25CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$3,047.03 " "$2,254.80" $0.00 "$2,437.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,261.50" "$2,261.50" $0.00 $0.00 $635.00 $0.00 $0.00 $0.00 $0.00 "$1,523.51" "$2,413.25" "$2,437.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC141118-20 SUP Custom 27803010 SRC141118-20 - COIL EMBL 11MM 18CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$3,003.48 " "$2,222.58" $0.00 "$2,402.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,229.18" "$2,229.18" $0.00 $0.00 $625.92 $0.00 $0.00 $0.00 $0.00 "$1,501.74" "$2,378.76" "$2,402.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC141127-20 SUP Custom 27803010 SRC141127-20 - COIL EMBL 11MM 27CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$3,090.55 " "$2,287.01" $0.00 "$2,472.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,293.81" "$2,293.81" $0.00 $0.00 $644.07 $0.00 $0.00 $0.00 $0.00 "$1,545.28" "$2,447.72" "$2,472.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC141219-20 SUP Custom 27803010 SRC141219-20 - COIL EMBL 12MM 19CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$3,003.48 " "$2,222.58" $0.00 "$2,402.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,229.18" "$2,229.18" $0.00 $0.00 $625.92 $0.00 $0.00 $0.00 $0.00 "$1,501.74" "$2,378.76" "$2,402.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRC141230-20 SUP Custom 27803010 SRC141230-20 - COIL EMBL 12MM 30CM CSMR 14 MCIOL 2 HLCL MLT INFNT LOOP DTCH BOTH IP/OP "$3,134.08 " "$2,319.22" $0.00 "$2,507.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,326.11" "$2,326.11" $0.00 $0.00 $653.14 $0.00 $0.00 $0.00 $0.00 "$1,567.04" "$2,482.19" "$2,507.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRE-CV-320S SUP Custom 27803010 SRE-CV-320S - EXPANDER TISSUE WALL CHART CURVILINEAR EXTREMITY SOFTSPAN BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 $0.00 $0.00 $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRE-CV-720S SUP Custom 27803010 SRE-CV-720S - EXPANDER TISSUE CURVILINEAR 26.2X9CM WALL CHART EXTREMITY BOTH IP/OP "$1,825.00 " "$1,350.50" $0.00 "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,354.52" "$1,354.52" $0.00 $0.00 $380.33 $0.00 $0.00 $0.00 $0.00 $912.50 "$1,445.40" "$1,460.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SRS-003-FSP SUP HCPCS C1713 SRS-003-FSP - CEMENT BONE NRN SRS FST ST 3ML PTTY STRL BOTH IP/OP "$2,018.60 " "$1,493.76" $0.00 "$1,614.88" $908.37 $908.37 $0.00 $0.00 $0.00 $420.73 "$1,498.20" "$1,498.20" $0.00 $0.00 $420.68 $0.00 "$1,194.00" "$1,194.00" $0.00 "$1,009.30" "$1,598.73" "$1,614.88" $0.00 $0.00 $315.91 $0.00 $0.00 $321.36 $0.00 $0.00 $0.00 $0.00 $0.00 SRS-005-FSP SUP HCPCS C1713 SRS-005-FSP - CEMENT BONE NRN SRS FST ST 5ML PTTY STRL BOTH IP/OP "$3,315.05 " "$2,453.14" $0.00 "$2,652.04" "$1,491.77" "$1,491.77" $0.00 $0.00 $0.00 $690.94 "$2,460.43" "$2,460.43" $0.00 $0.00 $690.86 $0.00 "$1,634.32" "$1,634.32" $0.00 "$1,657.53" "$2,625.52" "$2,652.04" $0.00 $0.00 $518.81 $0.00 $0.00 $527.76 $0.00 $0.00 $0.00 $0.00 $0.00 SRS-010-FSP SUP HCPCS C1713 SRS-010-FSP - CEMENT BONE NRN SRS FST ST 10ML PTTY STRL BOTH IP/OP "$6,518.20 " "$4,823.47" $0.00 "$5,214.56" "$2,933.19" "$2,933.19" $0.00 $0.00 $0.00 "$1,358.56" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,358.39" $0.00 "$3,213.47" "$3,213.47" $0.00 "$3,259.10" "$5,162.41" "$5,214.56" $0.00 $0.00 "$1,020.10" $0.00 $0.00 "$1,037.70" $0.00 $0.00 $0.00 $0.00 $0.00 SRS-015-FSP SUP HCPCS C1713 SRS-015-FSP - CEMENT BONE NRN SRS FST ST 15ML PTTY STRL BOTH IP/OP "$9,567.20 " "$7,079.73" $0.00 "$7,653.76" "$4,305.24" "$4,305.24" $0.00 $0.00 $0.00 "$1,994.04" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,993.80" $0.00 "$4,716.63" "$4,716.63" $0.00 "$4,783.60" "$7,577.22" "$7,653.76" $0.00 $0.00 "$1,497.27" $0.00 $0.00 "$1,523.10" $0.00 $0.00 $0.00 $0.00 $0.00 SSSA-EW-09 SUP Custom 27203010 SSSA-EW-09 - ADAPTER INTRO LNG 9FR SFSHTH SL XTD WNG VASC ATN BOTH IP/OP $110.00 $81.40 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.64 $81.64 $0.00 $0.00 $22.92 $0.00 $0.00 $0.00 $0.00 $55.00 $87.12 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ST-030 SUP Custom 27203010 BLANKET 30X24IN MED WT PED THRMPLST HPR/HPO H2O CIRC LMNT BOTH IP/OP $107.00 $79.18 $0.00 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.50 $84.74 $85.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ST09875 SUP HCPCS C1729 CATHETER TWIST LOCK CATH-GUARD CONTAMINATION SHIELD BOTH IP/OP $38.93 $28.81 $0.00 $31.14 $21.14 $21.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.46 $30.83 $31.14 $0.00 $0.00 $6.09 $0.00 $0.00 $6.20 $0.00 $0.00 $0.00 $0.00 $0.00 ST5678 SUP HCPCS C1713 ST5678 - SET SCREW BOTH IP/OP $250.00 $185.00 $0.00 $200.00 $112.50 $112.50 $0.00 $0.00 $0.00 $52.11 $185.55 $185.55 $0.00 $0.00 $52.10 $0.00 $147.88 $147.88 $0.00 $125.00 $198.00 $200.00 $0.00 $0.00 $39.13 $0.00 $0.00 $39.80 $0.00 $0.00 $0.00 $0.00 $0.00 STRAP25 SUP HCPCS C1781 STRAP25 - DEVICE FX 5MM SECURESTRAP 25 ABS STRAP MESH DISP HRN REPR BOTH IP/OP "$1,527.95 " "$1,130.68" $0.00 "$1,222.36" $687.58 $687.58 $0.00 $0.00 $0.00 $318.46 "$1,134.04" "$1,134.04" $0.00 $0.00 $318.42 $0.00 $903.78 $903.78 $0.00 $763.98 "$1,210.14" "$1,222.36" $0.00 $0.00 $239.12 $0.00 $0.00 $243.25 $0.00 $0.00 $0.00 $0.00 $0.00 SU16030 SUP Custom 27203010 HOLDER 8IN HGR NDL NAR BOTH IP/OP $84.63 $62.63 $0.00 $67.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.31 $67.03 $67.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SW46 SUP Custom 27203010 SOCK ABS 46X3IN SPC UNV APL BOTH IP/OP $200.60 $148.44 $0.00 $160.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.30 $158.88 $160.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SXP77 SUP Custom 27203010 SXP77 - SUTURE NONABSORBABLE THK1.5MM 2-0 V-7 30IN 7X3MM 2 ARM BRAID BOTH IP/OP $197.33 $146.02 $0.00 $160.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.46 $146.46 $0.00 $0.00 $41.12 $0.00 $0.00 $0.00 $0.00 $100.15 $158.63 $160.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 SYNCRACRTPMEAM SUP HCPCS C2621 SYNCRACRTPMEAM - SYNCRA CRT-P ADVANCED SYSTEM BOTH IP/OP "$20,177.50 " "$14,931.35" $0.00 "$16,470.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,204.99" $0.00 $0.00 $0.00 $0.00 "$10,293.75" "$16,305.30" "$16,470.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T1002 SUP Custom 27203010 T1002 - RETRACTOR SRG 10IN 30MM POST GLND NK TTH SHLDR OSTM BOTH IP/OP $653.13 $483.32 $0.00 $522.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $484.75 $484.75 $0.00 $0.00 $136.11 $0.00 $0.00 $0.00 $0.00 $326.56 $517.28 $522.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12BA20D SUP Custom 27203010 T12BA20D - TOOL LGD T12CM 2MM BALL DIAM BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12BA30D SUP Custom 27203010 T12BA30D - TOOL LGD T12CM 3MM BALL DIAM BOTH IP/OP $412.25 $305.07 $0.00 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $305.97 $305.97 $0.00 $0.00 $85.91 $0.00 $0.00 $0.00 $0.00 $206.13 $326.50 $329.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12MH15 SUP Custom 27203010 T12MH15 - TOOL LEGEND 12CM 1.5MM MH BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12MH20 SUP Custom 27203010 T12MH20 - TOOL LEGEND 12CM 2MM MH BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12MH20D SUP Custom 27203010 T12MH20D - TOOL LEGEND 12CM 2MM DIAM BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12MH25 SUP Custom 27203010 T12MH25 - TOOL LEGEND 12CM 2.5MM MH BOTH IP/OP $320.88 $237.45 $0.00 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.15 $238.15 $0.00 $0.00 $66.87 $0.00 $0.00 $0.00 $0.00 $160.44 $254.14 $256.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12MH25D SUP Custom 27203010 T12MH25D - TOOL LEGEND 12CM 2.5MM DIAM BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12MH30D SUP Custom 27203010 T12MH30D - TOOL LEGEND 12CM 3MM DIAM BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12MH35D SUP Custom 27203010 T12MH35D - TOOL LEGEND 12CM 3.5MM DIAM BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T12MH45D SUP Custom 27203010 T12MH45D - TOOL LEGEND 12CM 4.5MM DIAM BOTH IP/OP $348.50 $257.89 $0.00 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $258.66 $258.66 $0.00 $0.00 $72.63 $0.00 $0.00 $0.00 $0.00 $174.25 $276.01 $278.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T1415A SUP Custom 27203010 T1415A - NEEDLE BIOP STANDARD 14GA 15CM COAXIAL HANDLE TEMNO BOTH IP/OP $227.32 $168.22 $0.00 $168.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.71 $168.71 $0.00 $0.00 $47.37 $0.00 $0.00 $0.00 $0.00 $81.15 $128.54 $129.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T14BA20 SUP Custom 27203010 T14BA20 - TOOL LEGD 14CM TELESC 2MM BALL BOTH IP/OP $331.50 $245.31 $0.00 $265.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $246.04 $246.04 $0.00 $0.00 $69.08 $0.00 $0.00 $0.00 $0.00 $165.75 $262.55 $265.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T14BA30 SUP Custom 27203010 T14BA30 - TOOL LEGD 14CM TELESC 3MM BALL BOTH IP/OP $331.50 $245.31 $0.00 $265.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $246.04 $246.04 $0.00 $0.00 $69.08 $0.00 $0.00 $0.00 $0.00 $165.75 $262.55 $265.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T14BA40 SUP Custom 27203010 T14BA40 - TOOL LEGEND 14CM TELESC 4MM BALL BOTH IP/OP $331.50 $245.31 $0.00 $265.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $246.04 $246.04 $0.00 $0.00 $69.08 $0.00 $0.00 $0.00 $0.00 $165.75 $262.55 $265.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T14MH25 SUP Custom 27203010 T14MH25 - TOOL LEGEND 14CM 2.5MM MH BOTH IP/OP $357.00 $264.18 $0.00 $285.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.97 $264.97 $0.00 $0.00 $74.40 $0.00 $0.00 $0.00 $0.00 $178.50 $282.74 $285.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T14MH30D SUP Custom 27203010 T14MH30D - TOOL LEGEND 14CM 3MM MH DIAM BOTH IP/OP $391.00 $289.34 $0.00 $312.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.20 $290.20 $0.00 $0.00 $81.48 $0.00 $0.00 $0.00 $0.00 $195.50 $309.67 $312.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T15MH25 SUP Custom 27203010 T15MH25 - TOOL LEGEND 15CM 2.5MM MH BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T15MH30D SUP Custom 27203010 T15MH30D - TOOL LEGEND 15CM 3MM DIAM BOTH IP/OP $367.63 $272.05 $0.00 $294.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.85 $272.85 $0.00 $0.00 $76.61 $0.00 $0.00 $0.00 $0.00 $183.81 $291.16 $294.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T16X12 SUP HCPCS C1894 T16X12 - SHEATH DLV ONQ TNL SYS 12IN 16GA DISP BOTH IP/OP $69.00 $51.06 $0.00 $140.00 $95.03 $95.03 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $0.00 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 T17MH30D SUP Custom 27203010 T17MH30D - TOOL LEGEND 17CM 3MM DIAM BOTH IP/OP $365.50 $270.47 $0.00 $292.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.27 $271.27 $0.00 $0.00 $76.17 $0.00 $0.00 $0.00 $0.00 $182.75 $289.48 $292.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T17X8 SUP HCPCS C1894 T17X8 - TUNNELER SRG 17GA 8IN STRL LF ONQ SHTH DISP BOTH IP/OP $69.00 $51.06 $0.00 $60.00 $40.73 $40.73 $0.00 $0.00 $0.00 $14.38 $51.21 $51.21 $0.00 $0.00 $14.38 $0.00 $40.81 $40.81 $0.00 $37.50 $59.40 $60.00 $0.00 $0.00 $11.74 $0.00 $0.00 $11.94 $0.00 $0.00 $0.00 $0.00 $0.00 T18MH25 SUP Custom 27203010 T18MH25 - TOOL MATCH HEAD 2.5 MM 18 CM BOTH IP/OP $333.63 $246.89 $0.00 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.62 $247.62 $0.00 $0.00 $69.53 $0.00 $0.00 $0.00 $0.00 $166.81 $264.23 $266.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T18MH30D SUP Custom 27203010 T18MH30D - TOOL MATCH HEAD 3.0 MM DIAMOND BOTH IP/OP $367.63 $272.05 $0.00 $294.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.85 $272.85 $0.00 $0.00 $76.61 $0.00 $0.00 $0.00 $0.00 $183.81 $291.16 $294.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T4031 SUP Custom 27203010 GRINDER TISS LG 50ML CNTRF TUBE PCTV SLV PEEL PCH STRL DISP BOTH IP/OP $28.70 $21.24 $0.00 $22.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.35 $22.73 $22.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T43101 SUP Custom 27804086 T43101 - GRAFT BN .5ML GRFTN PTTY JR DBM BOTH IP/OP $312.50 $231.25 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.94 $231.94 $0.00 $0.00 $65.13 $0.00 $0.00 $0.00 $0.00 $156.25 $247.50 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T43102 SUP Custom 27804086 T43102 - GRAFT BONE PUTTY JAR GRAFTON DEMINERALIZED BONE MATRIX 1ML BOTH IP/OP $350.00 $259.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.77 $259.77 $0.00 $0.00 $72.94 $0.00 $0.00 $0.00 $0.00 $175.00 $277.20 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T43103 SUP Custom 27804086 T43103 - GRAFT BN 2.5ML GRFTN PTTY JR DBM BOTH IP/OP "$1,190.00 " $880.60 $0.00 $952.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.22 $883.22 $0.00 $0.00 $248.00 $0.00 $0.00 $0.00 $0.00 $595.00 $942.48 $952.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T43105 SUP Custom 27804086 T43105 - GRAFT BONE PUTTY JAR GRAFTON DEMINERALIZED BONE MATRIX 5ML BOTH IP/OP "$2,162.50 " "$1,600.25" $0.00 "$1,730.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,605.01" "$1,605.01" $0.00 $0.00 $450.67 $0.00 $0.00 $0.00 $0.00 "$1,081.25" "$1,712.70" "$1,730.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T9MH15 SUP Custom 27203010 T9MH15 - TOOL LEGEND 9CM 1.5MM MH BOTH IP/OP $318.75 $235.88 $0.00 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.58 $236.58 $0.00 $0.00 $66.43 $0.00 $0.00 $0.00 $0.00 $159.38 $252.45 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T9MH20 SUP Custom 27203010 T9MH20 - TOOL LEGEND 9CM 2MM MH BOTH IP/OP $318.75 $235.88 $0.00 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.58 $236.58 $0.00 $0.00 $66.43 $0.00 $0.00 $0.00 $0.00 $159.38 $252.45 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T9MH25 SUP Custom 27203010 T9MH25 - TOOL LEGEND 9CM 2.5MM MH BOTH IP/OP $318.75 $235.88 $0.00 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.58 $236.58 $0.00 $0.00 $66.43 $0.00 $0.00 $0.00 $0.00 $159.38 $252.45 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T9MH25D SUP Custom 27203010 T9MH25D - TOOL LEGEND 9CM 2.5MM DIAM BOTH IP/OP $361.25 $267.33 $0.00 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.12 $268.12 $0.00 $0.00 $75.28 $0.00 $0.00 $0.00 $0.00 $180.63 $286.11 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T9MH30D SUP Custom 27203010 T9MH30D - TOOL LEGEND 9CM 3MM MH DIAM BOTH IP/OP $361.25 $267.33 $0.00 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.12 $268.12 $0.00 $0.00 $75.28 $0.00 $0.00 $0.00 $0.00 $180.63 $286.11 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T9MH35D SUP Custom 27203010 T9MH35D - TOOL LEGEND 9CM 3.5MM DIAM BOTH IP/OP $361.25 $267.33 $0.00 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.12 $268.12 $0.00 $0.00 $75.28 $0.00 $0.00 $0.00 $0.00 $180.63 $286.11 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 T9MH45D SUP Custom 27203010 T9MH45D - TOOL LEGEND 9CM 4.5MM DIAM BOTH IP/OP $361.25 $267.33 $0.00 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.12 $268.12 $0.00 $0.00 $75.28 $0.00 $0.00 $0.00 $0.00 $180.63 $286.11 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA3035L SUP Custom 27203010 TA3035L - RELOAD STPLR 30MMX3.5MM BLU STRL LF 1.5MM DST TA 2 ROW LNR BOTH IP/OP $89.75 $66.42 $0.00 $72.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.61 $66.61 $0.00 $0.00 $18.70 $0.00 $0.00 $0.00 $0.00 $45.55 $72.15 $72.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA3035S SUP Custom 27203010 TA3035S - STAPLER INTERNAL 30MMX3.5MM 1.5MM 2 ROW 2 ACTION HANDLE BOTH IP/OP $204.93 $151.65 $0.00 $166.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.10 $152.10 $0.00 $0.00 $42.71 $0.00 $0.00 $0.00 $0.00 $104.00 $164.74 $166.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA3048S SUP Custom 27203010 TA3048S - STAPLER INTERNAL 30MMX4.8MM 2MM 2 ROW 2 ACTION HANDLE LINEAR BOTH IP/OP $216.93 $160.53 $0.00 $173.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.01 $161.01 $0.00 $0.00 $45.21 $0.00 $0.00 $0.00 $0.00 $108.47 $171.81 $173.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA30V3L SUP Custom 27203010 TA30V3L - RELOAD STPLR 30MMX2.5MM WHT STRL LF 1MM DST TA 3 ROW LNR CTR BOTH IP/OP $102.77 $76.05 $0.00 $82.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $76.27 $76.27 $0.00 $0.00 $21.42 $0.00 $0.00 $0.00 $0.00 $51.38 $81.39 $82.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA30V3S SUP Custom 27203010 TA30V3S - STAPLER INTERNAL 30MM 3 ROW 2 ACTION HANDLE LINEAR CUTTER BOTH IP/OP $249.36 $184.53 $0.00 $199.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.68 $197.49 $199.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA6035L SUP Custom 27203010 TA6035L - RELOAD STPLR 60MMX3.5MM BLU STRL LF 1.5MM DST TA 2 ROW LNR BOTH IP/OP $100.93 $74.69 $0.00 $81.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.91 $74.91 $0.00 $0.00 $21.03 $0.00 $0.00 $0.00 $0.00 $51.22 $81.13 $81.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA6035S SUP Custom 27203010 TA6035S - STAPLER INTERNAL 60X3.5MM STAPLE 2 ACTION HANDLE LINEAR BOTH IP/OP $211.95 $156.84 $0.00 $172.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.31 $157.31 $0.00 $0.00 $44.17 $0.00 $0.00 $0.00 $0.00 $107.56 $170.38 $172.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA6048S SUP Custom 27203010 TA6048S - STAPLER INTERNAL 60X4.8MM STAPLE 2 ACTION HANDLE LINEAR BOTH IP/OP $217.44 $160.91 $0.00 $173.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.72 $172.21 $173.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA9035L SUP Custom 27203010 TA9035L - RELOAD STPLR 90MMX3.5MM BLU STRL LF 1.5MM DST TA 2 ROW LNR BOTH IP/OP $106.55 $78.85 $0.00 $86.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.08 $79.08 $0.00 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $54.07 $85.65 $86.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA9035S SUP Custom 27203010 TA9035S - STAPLER INTERNAL 90X3.5MM STAPLE 2 ACTION HANDLE LINEAR BOTH IP/OP $223.78 $165.60 $0.00 $181.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.09 $166.09 $0.00 $0.00 $46.63 $0.00 $0.00 $0.00 $0.00 $113.57 $179.89 $181.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA9048L SUP Custom 27203010 TA9048L - RELOAD STPLR 90MMX4.8MM GRN STRL LF 2MM DST TA 2 ROW LNR CTR BOTH IP/OP $109.32 $80.90 $0.00 $87.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.66 $86.58 $87.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TA9048S SUP Custom 27203010 TA9048S - STAPLER INTERNAL 90X4.8MM STAPLE 2 ACTION HANDLE LINEAR BOTH IP/OP $263.98 $195.35 $0.00 $211.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.92 $195.92 $0.00 $0.00 $55.01 $0.00 $0.00 $0.00 $0.00 $131.99 $209.07 $211.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TB-1550K-S SUP HCPCS C1713 TB-1550K-S - PIN TNSNBND SYS 50MM ORTH SS STRL BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 TB-1570K-S SUP HCPCS C1713 TB-1570K-S - PIN TNSNBND KIT 70MM ORTH SS STRL BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 TB-1590K-S SUP HCPCS C1713 TB-1590K-S - PIN TNSNBND SYS 90MM ORTH SS STRL BOTH IP/OP $510.00 $377.40 $0.00 $408.00 $229.50 $229.50 $0.00 $0.00 $0.00 $106.30 $378.52 $378.52 $0.00 $0.00 $106.28 $0.00 $301.67 $301.67 $0.00 $255.00 $403.92 $408.00 $0.00 $0.00 $79.82 $0.00 $0.00 $81.19 $0.00 $0.00 $0.00 $0.00 $0.00 TC003 SUP HCPCS C1729 TC003 - CATH IU THRMCH BLN ABLT EXCESSIVE MENSTRUAL BLD BOTH IP/OP "$2,472.50 " "$1,829.65" $0.00 "$1,978.00" "$1,342.57" "$1,342.57" $0.00 $0.00 $0.00 $515.33 "$1,835.09" "$1,835.09" $0.00 $0.00 $515.27 $0.00 "$1,462.48" "$1,462.48" $0.00 "$1,236.25" "$1,958.22" "$1,978.00" $0.00 $0.00 $386.95 $0.00 $0.00 $393.62 $0.00 $0.00 $0.00 $0.00 $0.00 TC7465 SUP Custom 27203010 TRACHEOSTOMY TRAY BOTH IP/OP $255.98 $189.43 $0.00 $204.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.99 $202.74 $204.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TDF010U SUP HCPCS C1721 TDF010U - PARADYM 9550 RF DR BOTH IP/OP "$38,750.00 " "$28,675.00" $0.00 "$31,000.00" "$17,437.50" "$17,437.50" $0.00 $0.00 $0.00 "$8,076.47" "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,075.50" $0.00 "$19,103.75" "$19,103.75" $0.00 "$19,375.00" "$30,690.00" "$31,000.00" $0.00 $0.00 "$6,064.38" $0.00 $0.00 "$6,169.00" $0.00 $0.00 $0.00 $0.00 $0.00 TDF011U SUP HCPCS C1722 TDF011U - PARADYM 9250 RF VR BOTH IP/OP "$33,750.00 " "$24,975.00" $0.00 "$27,000.00" "$15,187.50" "$15,187.50" $0.00 $0.00 $0.00 "$7,034.34" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,033.50" $0.00 "$16,638.75" "$16,638.75" $0.00 "$16,875.00" "$26,730.00" "$27,000.00" $0.00 $0.00 "$5,281.88" $0.00 $0.00 "$5,373.00" $0.00 $0.00 $0.00 $0.00 $0.00 TDF012U SUP HCPCS C1882 TDF012U - PARADYM RF CRT 9750 BOTH IP/OP "$45,500.00 " "$33,670.00" $0.00 "$36,400.00" "$20,475.00" "$20,475.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,482.20" $0.00 "$22,431.50" "$22,431.50" $0.00 "$22,750.00" "$36,036.00" "$36,400.00" $0.00 $0.00 "$7,120.75" $0.00 $0.00 "$7,243.60" $0.00 $0.00 $0.00 $0.00 $0.00 TDF012U SYSTEM SUP HCPCS C1882 TDF012U SYSTEM - PARADYM RF CRT 9750 SYSTEM BOTH IP/OP "$60,500.00 " "$44,770.00" $0.00 "$48,400.00" "$27,225.00" "$27,225.00" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$12,608.20" $0.00 "$29,826.50" "$29,826.50" $0.00 "$30,250.00" "$47,916.00" "$48,400.00" $0.00 $0.00 "$7,751.33" $0.00 $0.00 "$8,138.89" $0.00 $0.00 $0.00 $0.00 $0.00 TE-1000 SUP Custom 27203010 TE-1000 - TOOL INSERTION EMBEDDING CURVED PLASTIC HANDLE TITANIUM TIP BOTH IP/OP $332.50 $246.05 $0.00 $266.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $246.78 $246.78 $0.00 $0.00 $69.29 $0.00 $0.00 $0.00 $0.00 $166.25 $263.34 $266.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TECR1510 SUP HCPCS C1781 TECR1510 - MESH SRG RECT 6X4IN PARIETEX 2D FLT SHT RGD PLSTR HRN BOTH IP/OP $179.68 $132.96 $0.00 $143.74 $80.85 $80.85 $0.00 $0.00 $0.00 $37.45 $133.35 $133.35 $0.00 $0.00 $37.44 $0.00 $106.28 $106.28 $0.00 $89.84 $142.31 $143.74 $0.00 $0.00 $28.12 $0.00 $0.00 $28.60 $0.00 $0.00 $0.00 $0.00 $0.00 TECT1510AL SUP HCPCS C1781 TECT1510AL - MESH SRG 6X4IN PARIETEX FLXB ANTM PLSTR LT HRN BOTH IP/OP $294.83 $218.17 $0.00 $314.48 $176.90 $176.90 $0.00 $0.00 $0.00 $61.45 $218.82 $218.82 $0.00 $0.00 $61.44 $0.00 $174.39 $174.39 $0.00 $196.55 $311.34 $314.48 $0.00 $0.00 $61.52 $0.00 $0.00 $62.58 $0.00 $0.00 $0.00 $0.00 $0.00 TECT1510AR SUP HCPCS C1781 TECT1510AR - MESH SURG PARIETEX 6X4IN RIGHT HERN 3D FLXB LTWT ANTM BOTH IP/OP $294.83 $218.17 $0.00 $340.10 $191.31 $191.31 $0.00 $0.00 $0.00 $61.45 $218.82 $218.82 $0.00 $0.00 $61.44 $0.00 $174.39 $174.39 $0.00 $212.56 $336.70 $340.10 $0.00 $0.00 $66.53 $0.00 $0.00 $67.68 $0.00 $0.00 $0.00 $0.00 $0.00 TEM1208GL SUP HCPCS C1781 TEM1208GL - MESH SURG 4.7X3IN LEFT FLAP SELF FIXATING ANATOMIC BOTH IP/OP $613.08 $453.68 $0.00 $591.52 $332.73 $332.73 $0.00 $0.00 $0.00 $127.78 $455.02 $455.02 $0.00 $0.00 $127.76 $0.00 $362.63 $362.63 $0.00 $369.70 $585.60 $591.52 $0.00 $0.00 $115.72 $0.00 $0.00 $117.71 $0.00 $0.00 $0.00 $0.00 $0.00 TEM1208GR SUP HCPCS C1781 TEM1208GR - MESH SURG 4.7X3IN RIGHT FLAP SELF FIXATING ANATOMIC BOTH IP/OP $613.08 $453.68 $0.00 $591.52 $332.73 $332.73 $0.00 $0.00 $0.00 $127.78 $455.02 $455.02 $0.00 $0.00 $127.76 $0.00 $362.63 $362.63 $0.00 $369.70 $585.60 $591.52 $0.00 $0.00 $115.72 $0.00 $0.00 $117.71 $0.00 $0.00 $0.00 $0.00 $0.00 TEST SUP Custom 27203010 STENT URETERAL RESONANCE METALLIC 6.0 X 26CM BOTH IP/OP "$2,425.00 " "$1,794.50" $0.00 "$1,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,212.50" "$1,920.60" "$1,940.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TET1309 SUP HCPCS C1781 TET1309 - MESH SRG RECT 5.2X3.6IN LF PARIETEX 3D HCMB WV KNIT FLT SHT BOTH IP/OP $206.50 $152.81 $0.00 $220.26 $123.90 $123.90 $0.00 $0.00 $0.00 $43.04 $153.26 $153.26 $0.00 $0.00 $43.03 $0.00 $122.14 $122.14 $0.00 $137.66 $218.06 $220.26 $0.00 $0.00 $43.09 $0.00 $0.00 $43.83 $0.00 $0.00 $0.00 $0.00 $0.00 TF-19A SUP Custom 27803010 TF-19A - VALVE AORTIC 15MM 24MM 19MM TRIFECTA 12MM TISS ANNULUS LTRM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TF-21A SUP Custom 27803010 TF-21A - VALVE AORTIC 16MM 21MM 26MM TRIFECTA 13MM TISS ANNULUS LTRM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TF-23A SUP Custom 27803010 TF-23A - VALVE AOR 13MM 23MM 38IN 17MM TRIFECTA LINX AC BPRTH STNT BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TF-25A SUP Custom 27803010 TF-25A - VALVE AORTIC 18MM 25MM 31MM TRIFECTA 14MM TISS ANNULUS LTRM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TF-27A SUP Custom 27803010 TF-27A - VALVE AOR 27MM 27MM 33MM 19MM TRIFECTA LINX FTG RST STNT BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TF-29A SUP Custom 27803010 TF-29A - VALVE AORTIC 20MM 29MM 35MM TRIFECTA 16MM TISS ANNULUS LTRM BOTH IP/OP "$15,000.00 " "$11,100.00" $0.00 "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,126.00" $0.00 $0.00 $0.00 $0.00 "$7,500.00" "$11,880.00" "$12,000.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TH90G01 SUP HCPCS C1787 TH90G01 - KIT STM NS LF PRX HNDST GU REUSE BOTH IP/OP "$4,875.00 " "$3,607.50" $0.00 "$3,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,437.50" "$3,861.00" "$3,900.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 THD155024/2 SUP HCPCS C1751 THD155024/2 - CATHETER CV STD 14.5FR 19CM HMGLD PRMCTH STAR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 THD155028/3 SUP HCPCS C1751 THD155028/3 - CATHETER CV STD 14.5FR 23CM HMGLD PRMCTH STAR BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $196.88 $196.88 $0.00 $0.00 $0.00 $91.19 $324.71 $324.71 $0.00 $0.00 $91.18 $0.00 $258.78 $258.78 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $68.47 $0.00 $0.00 $69.65 $0.00 $0.00 $0.00 $0.00 $0.00 THD155032 SUP HCPCS C1750 THD155032 - SET CATH 32CM 15.5FR TTN HD 2 LUM HMDIAL BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 THD155036 SUP HCPCS C1750 THD155036 - SET CATH 90D STRG 15.5FR 36CM TTN HD INTRO NDL GW DIL SCPL BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 THD155040 SUP HCPCS C1750 THD155040 - SET CATH 90D STRG 15.5FR 40CM TTN HD INTRO NDL GW DIL SCPL BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 THD155055 SUP HCPCS C1750 THD155055 - SET CATH 55CM 15.5FR TTN HD 2 LUM LTRM HMDIAL BOTH IP/OP $475.00 $351.50 $0.00 $380.00 $213.75 $213.75 $0.00 $0.00 $0.00 $99.00 $352.55 $352.55 $0.00 $0.00 $98.99 $0.00 $280.96 $280.96 $0.00 $237.50 $376.20 $380.00 $0.00 $0.00 $74.34 $0.00 $0.00 $75.62 $0.00 $0.00 $0.00 $0.00 $0.00 THSF-35-145-AUS SUP HCPCS C1769 THSF-35-145-AUS - GWIRE VASC .035IN 145CM 8CM STR FLX TP AMPTZ ULT STF SS PTFE BOTH IP/OP $59.45 $43.99 $0.00 $47.56 $32.28 $32.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.73 $47.08 $47.56 $0.00 $0.00 $9.30 $0.00 $0.00 $9.46 $0.00 $0.00 $0.00 $0.00 $0.00 TKFV-2 SUP Custom 27203010 TKFV-2 - CLAMP SURG MIC 2 DISP 15GM GRN .2-1MM VN BOTH IP/OP $178.75 $132.28 $0.00 "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.67 $132.67 $0.00 $0.00 $37.25 $0.00 $0.00 $0.00 $0.00 $893.75 "$1,415.70" "$1,430.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TKMV-1 SUP Custom 27203010 TKMV-1 - CLAMP SURG 30GM/SQ MM MEDIUM HEMISPHERE BIOVER POLYCARBONATE BOTH IP/OP $87.50 $64.75 $0.00 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.94 $64.94 $0.00 $0.00 $18.24 $0.00 $0.00 $0.00 $0.00 $43.75 $69.30 $70.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TKMV-2 SUP Custom 27203010 TKMV-2 - CLAMP SRG 30GM/SQ MM MED HMSPHR BIOVER 2 PLYCRB VN BOTH IP/OP $162.50 $120.25 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.61 $120.61 $0.00 $0.00 $33.87 $0.00 $0.00 $0.00 $0.00 $81.25 $128.70 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TKS100 SUP Custom 27203010 TKS100 - TUBING SCT STRL NEURO BOTH IP/OP $23.76 $17.58 $0.00 $19.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.63 $17.63 $0.00 $0.00 $4.95 $0.00 $0.00 $0.00 $0.00 $11.88 $18.00 $19.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TN30MCD SUP Custom 27203010 TN30MCD - BURR SURG 3MM MATCH FLUTED DIAMOND COARSE TRANSNASAL STERILE BOTH IP/OP $904.50 $669.33 $0.00 $723.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $671.32 $671.32 $0.00 $0.00 $188.50 $0.00 $0.00 $0.00 $0.00 $452.25 $716.36 $723.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TN30MFL SUP Custom 27203010 TN30MFL - BURR SURG 3MM MATCH FLUTED TRANSNASAL STERILE BOTH IP/OP $904.50 $669.33 $0.00 $723.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $671.32 $671.32 $0.00 $0.00 $188.50 $0.00 $0.00 $0.00 $0.00 $452.25 $716.36 $723.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TN7115 SUP Custom 27203010 PROCESSOR TISS PREPRC SOL TSTK XP BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TN7120 SUP Custom 27203010 FIXATIVE TSTK XP 3.8L MOL HISTOLGY BOTH IP/OP $111.25 $82.33 $0.00 $89.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.63 $88.11 $89.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TO-FTRT SUP Custom 27203010 TO-FTRT - RTRCTR TOBY 2.5MM 4MM SM LG FNL SHOHN TNDN SHTH SURG BOTH IP/OP $908.38 $672.20 $0.00 $726.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $674.20 $674.20 $0.00 $0.00 $189.31 $0.00 $0.00 $0.00 $0.00 $454.19 $719.44 $726.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP-14 SUP HCPCS C1713 TP-14 - PEG FIX 2.5MM 14MM PTHRD BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 TP-16 SUP HCPCS C1713 TP-16 - PEG 2.5MM 16MM LNG THRD BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $36.47 $129.89 $129.89 $0.00 $0.00 $36.47 $0.00 $103.51 $103.51 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 TP20 SUP HCPCS C1713 TP20 - PEG FIXAT 2.5MM 20MM ORTH THRD BOTH IP/OP $175.00 $129.50 $0.00 $140.00 $78.75 $78.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $138.60 $140.00 $0.00 $0.00 $27.39 $0.00 $0.00 $27.86 $0.00 $0.00 $0.00 $0.00 $0.00 TP341-M01 SUP Custom 27203010 TP341-M01 - 2.0-2.5MM BROKEN SCREW HEAD BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP342-M01 SUP Custom 27203010 TP342-M01 - TIP XTRT 2.5-4 MM BRKN SCR BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP343-M01 SUP Custom 27203010 TP343-M01 - 3.5-5.0MM BROKEN SCREW HEAD BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP344-M01 SUP Custom 27203010 TP344-M01 - 4.5-6.0MM BROKEN SCREW HEAD BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP345-M01 SUP Custom 27203010 TP345-M01 - 5.5-7.0MM BROKEN SCREW HEAD BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP346-M01 SUP Custom 27203010 TP346-M01 - 7.0-8.0MM BROKEN SCREW HEAD BOTH IP/OP $562.50 $416.25 $0.00 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.49 $417.49 $0.00 $0.00 $117.23 $0.00 $0.00 $0.00 $0.00 $281.25 $445.50 $450.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP347-M01 SUP Custom 27203010 TP347-M01 - 2.0-2.5MM STRIPPED SCREW HEAD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP348-M01 SUP Custom 27203010 TP348-M01 - 2.5-3.5MM STRIPPED SCREW HEAD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP349-M01 SUP Custom 27203010 TP349-M01 - 3.5-4.5MM STRIPPED SCREW HEAD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP350-M01 SUP Custom 27203010 TP350-M01 - 4.5-5.5MM STRIPPED SCREW HEAD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP351-M01 SUP Custom 27203010 TP351-M01 - 5.0-6.5MM STRIPPED SCREW HEAD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TP352-M01 SUP Custom 27203010 TP352-M01 - 6.0-7.0MM STRIPPED SCREW HEAD BOTH IP/OP $512.50 $379.25 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.38 $380.38 $0.00 $0.00 $106.81 $0.00 $0.00 $0.00 $0.00 $256.25 $405.90 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TPEG-14 SUP HCPCS C1713 TPEG-14 - PEG FIX 14MM THREAD LOCK TORX WRIST VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 TPEG-16 SUP HCPCS C1713 TPEG-16 - PEG FIX 16MM THREAD LOCK TORX WRIST VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 TPEG-18 SUP HCPCS C1713 TPEG-18 - PEG FIX 18MM THREAD LOCK TORX WRIST VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 TPEG-20 SUP HCPCS C1713 TPEG-20 - PEG FIX 20MM THREAD LOCK TORX WRIST VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 TPEG-22 SUP HCPCS C1713 TPEG-22 - PEG FIX 22MM THREAD LOCK TORX WRIST VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 TPEG-24 SUP HCPCS C1713 TPEG-24 - PEG FIX 24MM THREAD LOCK TORX WRIST VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 TPEG-28 SUP HCPCS C1713 TPEG-28 - PEG FIX 28MM THREAD LOCK TORX WRIST VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23100-TS SUP HCPCS C1713 TPLS-23100-TS - PEG FX 2.3MM 10MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23120-TS SUP HCPCS C1713 TPLS-23120-TS - PEG FX 2.3MM 12MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23140-TS SUP HCPCS C1713 TPLS-23140-TS - PEG FX 2.3MM 14MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23160-TS SUP HCPCS C1713 TPLS-23160-TS - PEG FX 2.3MM 16MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23170-TS SUP HCPCS C1713 TPLS-23170-TS - PEG FX 2.3MM 17MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23180-TS SUP HCPCS C1713 TPLS-23180-TS - PEG FIX 2.3MM 18MM THREADED LOCKING GEMINUS TITANIUM DISTAL BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23190-TS SUP HCPCS C1713 TPLS-23190-TS - PEG FX 2.3MM 19MM NS THRDLK TI GEMINUS VOLR PLT SYS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23200-TS SUP HCPCS C1713 TPLS-23200-TS - PEG FX 2.3MM 20MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23210-TS SUP HCPCS C1713 TPLS-23210-TS - PEG FX 2.3MM 21MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23220-TS SUP HCPCS C1713 TPLS-23220-TS - PEG FX 2.3MM 22MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23230-TS SUP HCPCS C1713 TPLS-23230-TS - PEG FX 2.3MM 23MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23240-TS SUP HCPCS C1713 TPLS-23240-TS - PEG FX 2.3MM 24MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23260-TS SUP HCPCS C1713 TPLS-23260-TS - PEG FX 2.3MM 26MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23280-TS SUP HCPCS C1713 TPLS-23280-TS - PEG FX 2.3MM 28MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23300-TS SUP HCPCS C1713 TPLS-23300-TS - PEG FX 2.3MM 30MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPLS-23320-TS SUP HCPCS C1713 TPLS-23320-TS - PEG FX 2.3MM 32MM NS GEMINUS THRD LCK TI DIST VOLR RDS FOSSA BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPM002U SUP HCPCS C1786 TPM002U - REPLY SR BOTH IP/OP "$6,962.50 " "$5,152.25" $0.00 "$5,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,451.16" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,450.99" $0.00 "$3,432.51" "$3,432.51" $0.00 "$3,481.25" "$5,514.30" "$5,570.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TPM002U SYSTEM SUP HCPCS C1786 TPM002U SYSTEM - REPLY SR SYSTEM BOTH IP/OP "$8,205.00 " "$6,071.70" $0.00 "$6,564.00" $0.00 $0.00 $0.00 $0.00 $0.00 "$1,710.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,709.92" $0.00 "$4,045.07" "$4,045.07" $0.00 "$4,102.50" "$6,498.36" "$6,564.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27100-TS SUP HCPCS C1713 TPNL-27100-TS - PEG FX 2.7MM 10MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27120-TS SUP HCPCS C1713 TPNL-27120-TS - PEG FX 2.7MM 12MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27140-TS SUP HCPCS C1713 TPNL-27140-TS - PEG FX 2.7MM 14MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27160-TS SUP HCPCS C1713 TPNL-27160-TS - PEG FX 2.7MM 16MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27180-TS SUP HCPCS C1713 TPNL-27180-TS - PEG FX 2.7MM 18MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27200-TS SUP HCPCS C1713 TPNL-27200-TS - PEG FIX 2.7MM 20MM THREADED NONLOCKING GEMINUS TITANIUM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27220-TS SUP HCPCS C1713 TPNL-27220-TS - PEG FIX 2.7MM 22MM THREADED NONLOCKING GEMINUS TITANIUM BOTH IP/OP $247.50 $183.15 $0.00 $198.00 $111.38 $111.38 $0.00 $0.00 $0.00 $51.59 $183.69 $183.69 $0.00 $0.00 $51.58 $0.00 $146.40 $146.40 $0.00 $123.75 $196.02 $198.00 $0.00 $0.00 $38.73 $0.00 $0.00 $39.40 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27240-TS SUP HCPCS C1713 TPNL-27240-TS - PEG FX 2.7MM 24MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27260-TS SUP HCPCS C1713 TPNL-27260-TS - PEG FX 2.7MM 26MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27280-TS SUP HCPCS C1713 TPNL-27280-TS - PEG FX 2.7MM 28MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27300-TS SUP HCPCS C1713 TPNL-27300-TS - PEG FX 2.7MM 30MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPNL-27320-TS SUP HCPCS C1713 TPNL-27320-TS - PEG FX 2.7MM 32MM NS GEMINUS THRD NLCKG TI DIST VOLR RDS BOTH IP/OP $217.50 $160.95 $0.00 $174.00 $97.88 $97.88 $0.00 $0.00 $0.00 $45.33 $161.43 $161.43 $0.00 $0.00 $45.33 $0.00 $128.65 $128.65 $0.00 $108.75 $172.26 $174.00 $0.00 $0.00 $34.04 $0.00 $0.00 $34.63 $0.00 $0.00 $0.00 $0.00 $0.00 TPT1000 SUP Custom 27203010 TRAY DRAIN 4.75IN 8FR 15GA PU NDL THOR PARA 1.5IN STRL LTX BOTH IP/OP $75.25 $55.69 $0.00 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.63 $59.60 $60.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H200L-S SUP HCPCS C1776 TR-H200L-S - HEAD RADL 20MM LEFT ELB BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H200R-S SUP HCPCS C1776 TR-H200R-S - HEAD RADL 4D 20MM RT ELB BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H220L-S SUP HCPCS C1776 TR-H220L-S - HEAD RADL ANG 22MM STRL ACUMED ARH ANTM ELB LT BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H220R-S SUP HCPCS C1776 TR-H220R-S - HEAD RADL 22MM RT BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H240R-S SUP HCPCS C1776 TR-H240R-S - HEAD RADL ANG 24MM STRL ACUMED ARH ANTM ELB RT BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H260L-S SUP HCPCS C1776 TR-H260L-S - HEAD RADL ANG 26MM STRL ACUMED ARH ANTM ELB LT BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H260R-S SUP HCPCS C1776 TR-H260R-S - HEAD RADL 26MM 4D RIGHT ANTM STRL BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H280L-S SUP HCPCS C1776 TR-H280L-S - HEAD RADL 28MM ACUMED LEFT ELB TOT STRL BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-H280R-S SUP HCPCS C1776 TR-H280R-S - HEAD RADL 28MM STRL RT BOTH IP/OP "$6,015.00 " "$4,451.10" $0.00 "$4,812.00" "$2,706.75" "$2,706.75" $0.00 $0.00 $0.00 "$1,253.68" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,253.53" $0.00 "$2,965.40" "$2,965.40" $0.00 "$3,007.50" "$4,763.88" "$4,812.00" $0.00 $0.00 $941.35 $0.00 $0.00 $957.59 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0600-S SUP HCPCS C1776 TR-S0600-S - STEM RADL 0MM 6MM STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0602-S SUP HCPCS C1776 TR-S0602-S - STEM RADL 2MM 6MM STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0604-S SUP HCPCS C1776 TR-S0604-S - STEM RADL 4MM 6MM STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0606-S SUP Custom 27203010 TR-S0606-S - BNDG NUSTIMWRAP 36X2.5IN CMPR BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 $0.00 $0.00 $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0608-S SUP HCPCS C1776 TR-S0608-S - STEM RADL 6MM 8MM STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0700-S SUP HCPCS C1776 TR-S0700-S - STEM RADL 0MM 7MM ELB BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0702-S SUP HCPCS C1776 TR-S0702-S - STEM RADL 2MM 7MM STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0704-S SUP HCPCS C1776 TR-S0704-S - STEM RADL 7MM 4MM ELB TOT STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0706-S SUP HCPCS C1776 TR-S0706-S - STEM RADL 7MM 6MM BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0708-S SUP HCPCS C1776 TR-S0708-S - STEM RADL 8MM 7MM ELB TOT STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0800-S SUP HCPCS C1776 TR-S0800-S - STEM RADL 8MM 4MM ELB TI HEAD TOT STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0802-S SUP HCPCS C1776 TR-S0802-S - STEM RADL 8MM 2MM ELB HEAD STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0804-S SUP HCPCS C1776 TR-S0804-S - STEM RADL 4MM 8MM ELB TI HEAD STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0806-S SUP HCPCS C1776 TR-S0806-S - STEM RADL 6MM 8MM HEAD BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0808-S SUP HCPCS C1776 TR-S0808-S - STEM RADL 8MM 8MM ELB TOT STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0900-S SUP HCPCS C1776 TR-S0900-S - STEM RADL 0MM 9MM STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0902-S SUP HCPCS C1776 TR-S0902-S - STEM RADL 9MM 2MM ELB SYS STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0904-S SUP HCPCS C1776 TR-S0904-S - STEM RADL 9MM 4MM ELB TOT STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0906-S SUP HCPCS C1776 TR-S0906-S - STEM RADL 9MM 6MM TI STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S0908-S SUP HCPCS C1776 TR-S0908-S - STEM RADL 9MM 8MM ELB STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S1000-S SUP HCPCS C1776 TR-S1000-S - STEM RADL 0MM 10MM STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S1002-S SUP HCPCS C1776 TR-S1002-S - STEM RADL 2MM 10MM STRL ELB BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S1004-S SUP HCPCS C1776 TR-S1004-S - STEM RADL 4MM 10MM STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S1006-S SUP Custom 27203010 TR-S1006-S - BNDG NUSTIMWRAP 36X6IN CMPR BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 $0.00 $0.00 $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TR-S1008-S SUP HCPCS C1776 TR-S1008-S - STEM RADL 10MM 8MM 8MM TR ELB TI STRL BOTH IP/OP "$3,610.00 " "$2,671.40" $0.00 "$2,888.00" "$1,624.50" "$1,624.50" $0.00 $0.00 $0.00 $752.41 "$2,679.34" "$2,679.34" $0.00 $0.00 $752.32 $0.00 "$1,779.73" "$1,779.73" $0.00 "$1,805.00" "$2,859.12" "$2,888.00" $0.00 $0.00 $564.97 $0.00 $0.00 $574.71 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-10 SUP HCPCS C1713 TRX2.3-10 - SCREW BONE 2.3MM 10MM ANKLE CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-12 SUP HCPCS C1713 TRX2.3-12 - SCREW BONE 2.3MM 12MM ANKLE CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-14 SUP HCPCS C1713 TRX2.3-14 - SCREW BONE 2.3MM 14MM ANKLE CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-16 SUP HCPCS C1713 TRX2.3-16 - SCREW BONE 2.3MM 16MM ANKLE CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-18 SUP HCPCS C1713 TRX2.3-18 - SCREW BONE 2.3MM 18MM ANKLE CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-20 SUP HCPCS C1713 TRX2.3-20 - SCREW BONE 2.3MM 20MM CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-22 SUP HCPCS C1713 TRX2.3-22 - SCREW BONE 2.3MM 22MM ANKLE CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-24 SUP HCPCS C1713 TRX2.3-24 - SCREW BONE 2.3MM 24MM ANKLE CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-26 SUP HCPCS C1713 TRX2.3-26 - SCREW BONE 2.3MM 26MM ANKLE CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-28 SUP HCPCS C1713 TRX2.3-28 - SCREW BONE 2.3MM 28MM CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TRX2.3-30 SUP HCPCS C1713 TRX2.3-30 - SCREW BONE 2.3MM 30MM CORTICAL BOTH IP/OP $225.00 $166.50 $0.00 $180.00 $101.25 $101.25 $0.00 $0.00 $0.00 $46.90 $167.00 $167.00 $0.00 $0.00 $46.89 $0.00 $133.09 $133.09 $0.00 $112.50 $178.20 $180.00 $0.00 $0.00 $35.21 $0.00 $0.00 $35.82 $0.00 $0.00 $0.00 $0.00 $0.00 TS101DC SUP Custom 27203010 TS101DC - SET TBG DIEGO ELT DECLOG BOTH IP/OP $117.64 $87.05 $0.00 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.31 $87.31 $0.00 $0.00 $24.52 $0.00 $0.00 $0.00 $0.00 $58.82 $93.17 $94.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT12 SUP Custom 27203010 TT12 - TUBE LEGEND 12CM T12 TELE STRAIGHT BOTH IP/OP "$1,486.25 " "$1,099.83" $0.00 "$1,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,103.09" "$1,103.09" $0.00 $0.00 $309.73 $0.00 $0.00 $0.00 $0.00 $743.13 "$1,177.11" "$1,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT12A SUP Custom 27203010 TT12A - TUBE LEGEND 12CM T12 TELE ANGLED BOTH IP/OP "$1,486.25 " "$1,099.83" $0.00 "$1,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,103.09" "$1,103.09" $0.00 $0.00 $309.73 $0.00 $0.00 $0.00 $0.00 $743.13 "$1,177.11" "$1,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT12C SUP Custom 27203010 TT12C - TUBE LEGEND 12CM T12 TELE CURVED BOTH IP/OP "$1,486.25 " "$1,099.83" $0.00 "$1,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,103.09" "$1,103.09" $0.00 $0.00 $309.73 $0.00 $0.00 $0.00 $0.00 $743.13 "$1,177.11" "$1,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT12F SUP Custom 27203010 TT12F - TUBE LEGEND 12CM T12 TELE CURVED BOTH IP/OP "$1,486.25 " "$1,099.83" $0.00 "$1,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,103.09" "$1,103.09" $0.00 $0.00 $309.73 $0.00 $0.00 $0.00 $0.00 $743.13 "$1,177.11" "$1,189.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT14A SUP Custom 27203010 TT14A - TUBE LEGEND 14CM T14 TELE ANGLED BOTH IP/OP "$1,590.80 " "$1,177.19" $0.00 "$1,272.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,180.69" "$1,180.69" $0.00 $0.00 $331.52 $0.00 $0.00 $0.00 $0.00 $795.40 "$1,259.91" "$1,272.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT15 SUP Custom 27203010 TT15 - TUBE LEGEND 15CM T15 TELE STRAIGHT BOTH IP/OP "$1,521.10 " "$1,125.61" $0.00 "$1,216.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,128.96" "$1,128.96" $0.00 $0.00 $317.00 $0.00 $0.00 $0.00 $0.00 $760.55 "$1,204.71" "$1,216.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT15H SUP Custom 27203010 TT15H - TUBE LEGEND 15CM T15 TELE HOODED BOTH IP/OP "$2,144.30 " "$1,586.78" $0.00 "$1,715.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,591.50" "$1,591.50" $0.00 $0.00 $446.87 $0.00 $0.00 $0.00 $0.00 "$1,072.15" "$1,698.29" "$1,715.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT17 SUP Custom 27203010 TT17 - TUBE LEGEND 17CM T17 TELE STRAIGHT BOTH IP/OP "$1,596.95 " "$1,181.74" $0.00 "$1,277.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,185.26" "$1,185.26" $0.00 $0.00 $332.80 $0.00 $0.00 $0.00 $0.00 $798.48 "$1,264.78" "$1,277.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT18H SUP Custom 27203010 TT18H - TUBE LEGEND 18CM T18 TELE HOODED BOTH IP/OP "$2,207.85 " "$1,633.81" $0.00 "$1,766.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,638.67" "$1,638.67" $0.00 $0.00 $460.12 $0.00 $0.00 $0.00 $0.00 "$1,103.93" "$1,748.62" "$1,766.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT9 SUP Custom 27203010 TT9 - TUBE LEGEND 9CM T9 TELE STRAIGHT BOTH IP/OP "$1,250.50 " $925.37 $0.00 "$1,000.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $928.12 $928.12 $0.00 $0.00 $260.60 $0.00 $0.00 $0.00 $0.00 $625.25 $990.40 "$1,000.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TT9C SUP Custom 27203010 TT9C - TUBE LEGEND 9CM T9 TELE CURVED BOTH IP/OP "$1,330.45 " $984.53 $0.00 "$1,064.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $987.46 $987.46 $0.00 $0.00 $277.27 $0.00 $0.00 $0.00 $0.00 $665.23 "$1,053.72" "$1,064.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TU1101 SUP Custom 27203010 CONTROL MLANLT TMKR LVL 1 ASY 3ML IMMUN BOTH IP/OP $83.33 $61.66 $0.00 $66.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.66 $66.00 $66.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TU2202 SUP Custom 27203010 CONTROL MLANLT TMKR LVL 2 ASY 3ML IMMUN BOTH IP/OP $83.33 $61.66 $0.00 $66.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.66 $66.00 $66.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TU3303 SUP Custom 27203010 CONTROL MLANLT TMKR LVL 3 ASY 3ML IMMUN BOTH IP/OP $83.33 $61.66 $0.00 $66.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.66 $66.00 $66.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TVI07 SUP HCPCS C1894 TVI07 - TOOL INSERTION 7FR TRANSVALVULAR BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $4.89 $4.89 $0.00 $0.00 $0.00 $1.88 $6.68 $6.68 $0.00 $0.00 $1.88 $0.00 $5.32 $5.32 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $1.41 $0.00 $0.00 $1.43 $0.00 $0.00 $0.00 $0.00 $0.00 TVI-07 SUP HCPCS C1894 TVI-07 - TOOL INSERTION 7FR TRANSVALVULAR BOTH IP/OP $9.00 $6.66 $0.00 $7.20 $4.89 $4.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.50 $7.13 $7.20 $0.00 $0.00 $1.41 $0.00 $0.00 $1.43 $0.00 $0.00 $0.00 $0.00 $0.00 TVTRL SUP HCPCS C1771 TVTRL - SLING GYNECOLOGICAL GYNECARE TVT SECUR STRESS URINARY BOTH IP/OP "$2,262.00 " "$1,673.88" $0.00 "$1,809.60" "$1,017.90" "$1,017.90" $0.00 $0.00 $0.00 $471.46 "$1,678.86" "$1,678.86" $0.00 $0.00 $471.40 $0.00 "$1,337.97" "$1,337.97" $0.00 "$1,131.00" "$1,791.50" "$1,809.60" $0.00 $0.00 $354.00 $0.00 $0.00 $360.11 $0.00 $0.00 $0.00 $0.00 $0.00 TW173016 SUP Custom 27203010 TW173016 - ENDO STITCH 10 MM SUTURING DEVICE BOTH IP/OP $836.10 $618.71 $0.00 $668.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $620.55 $620.55 $0.00 $0.00 $174.24 $0.00 $0.00 $0.00 $0.00 $418.05 $662.19 $668.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 TYPE 14C SUP HCPCS L8610 RING FIXAT 24-28MM MORCHER 11-13MM CPSLR TNSN EXPANDABLE BOTH IP/OP $447.50 $331.15 $0.00 $358.00 $201.38 $201.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.75 $354.42 $358.00 $0.00 $0.00 $70.03 $0.00 $0.00 $71.24 $0.00 $0.00 $0.00 $0.00 $0.00 U202H SUP Custom 27203010 U202H - SUTURE ABSORBABLE 5-0 RB-1 27IN MONOFILAMENT CHROMIC BOTH IP/OP $294.60 $218.00 $0.00 $239.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.65 $218.65 $0.00 $0.00 $61.39 $0.00 $0.00 $0.00 $0.00 $149.51 $236.82 $239.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 U2295-40 SUP Custom 27203010 STAIN TCHRM BLUE PRPK 500ML BHOSPHATE BUFF PRSTLGY BOTH IP/OP $537.15 $397.49 $0.00 $429.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.58 $425.42 $429.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 U2295-5 SUP Custom 27203010 STAIN TCHRM PRPK WHEATLEY 500ML PRSTLGY BOTH IP/OP $369.73 $273.60 $0.00 $295.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.86 $292.83 $295.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 U2316-2 SUP Custom 27203010 SLIDE GSTCLT GCB HMTLTST BOTH IP/OP $332.45 $246.01 $0.00 $265.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.23 $263.30 $265.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UA1329-S SUP Custom 27203010 UA1329-S - GUIDE NEEDLE DUAL READY TO USE INDIVIDUALLY STERILE BOTH IP/OP $900.00 $666.00 $0.00 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $667.98 $667.98 $0.00 $0.00 $187.56 $0.00 $0.00 $0.00 $0.00 $450.00 $712.80 $720.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UAB-260 SUP Custom 27203010 CONTROL MAS LVL 2 ABN 60ML UA BOTH IP/OP $56.25 $41.63 $0.00 $45.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.13 $44.55 $45.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UFH-624-R SUP HCPCS C2617 UFH-624-R - STENT URET 6FR 24CM W/O GWIRE SET TETH STRAIGHTENER RADIOPQ BOTH IP/OP $281.25 $208.13 $0.00 $225.00 $152.72 $152.72 $0.00 $0.00 $0.00 $58.62 $208.74 $208.74 $0.00 $0.00 $58.61 $0.00 $166.36 $166.36 $0.00 $140.63 $222.75 $225.00 $0.00 $0.00 $44.02 $0.00 $0.00 $44.78 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-36-22 SUP Custom 27803010 UH1-36-22 - HEAD BIPOL 36MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-38-22 SUP Custom 27803010 UH1-38-22 - HEAD BIPOL 38MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-40-22 SUP Custom 27803010 UH1-40-22 - HEAD BIPOL UNIVERSAL 40MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-41-22 SUP Custom 27803010 UH1-41-22 - HEAD BIPOL UNIVERSAL 41MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-41-26 SUP Custom 27803010 UH1-41-26 - HEAD BIPOL UNIVERSAL 41MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-42-22 SUP Custom 27803010 UH1-42-22 - HEAD BP UNV 42MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-42-26 SUP Custom 27803010 UH1-42-26 - HEAD BIPOL UNIVERSAL 42MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-42-28 SUP Custom 27803010 UH1-42-28 - HEAD BIPOL UNIVERSAL 42MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-43-22 SUP Custom 27803010 UH1-43-22 - HEAD BIPOL UNIVERSAL 43MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-43-26 SUP Custom 27803010 UH1-43-26 - HEAD BIPOL UNIVERSAL 43MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-44-22 SUP Custom 27803010 UH1-44-22 - HEAD BIPOL UNIVERSAL 44MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-44-26 SUP Custom 27803010 UH1-44-26 - HEAD BIPOL UNIVERSAL 44MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-44-28 SUP Custom 27803010 UH1-44-28 - HEAD BIPOL UNIVERSAL 44MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-45-22 SUP Custom 27803010 UH1-45-22 - HEAD BIPOL UNIVERSAL 45MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-45-26 SUP Custom 27803010 UH1-45-26 - HEAD BIPOL UNIVERSAL 45MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-45-28 SUP Custom 27803010 UH1-45-28 - HEAD BP 45MM 28MM UHR HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-46-22 SUP Custom 27803010 UH1-46-22 - HEAD BIPOL UNIVERSAL 46MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-46-26 SUP Custom 27803010 UH1-46-26 - HEAD BIPOL UNIVERSAL 46MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-46-28 SUP Custom 27803010 UH1-46-28 - HEAD BIPOL UNIVERSAL 46MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-47-22 SUP Custom 27803010 UH1-47-22 - HEAD BIPOL UNIVERSAL 47MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-47-26 SUP Custom 27803010 UH1-47-26 - HEAD BIPOL UNIVERSAL 47MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-47-28 SUP Custom 27803010 UH1-47-28 - HEAD BP UNV 47MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-48-22 SUP Custom 27803010 UH1-48-22 - HEAD BIPOL UNIVERSAL 48MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-48-26 SUP Custom 27803010 UH1-48-26 - HEAD BIPOL UNIVERSAL 48MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-48-28 SUP Custom 27803010 UH1-48-28 - HEAD BP 48MM 28MM UHR HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-48-32 SUP Custom 27803010 UH1-48-32 - HEAD BIPOL UNIVERSAL 48MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-49-22 SUP Custom 27803010 UH1-49-22 - HEAD BIPOL UNIVERSAL 49MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-49-26 SUP Custom 27803010 UH1-49-26 - HEAD BIPOL UNIVERSAL 49MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-49-28 SUP Custom 27803010 UH1-49-28 - HEAD BIPOL UNIVERSAL 49MM 28MM UHR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-49-32 SUP Custom 27803010 UH1-49-32 - HEAD BIPOL UNIVERSAL 49MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-50-22 SUP Custom 27803010 UH1-50-22 - HEAD BIPOL UNIVERSAL 50MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-50-26 SUP Custom 27803010 UH1-50-26 - HEAD BIPOL UNIVERSAL 50MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-50-28 SUP Custom 27803010 UH1-50-28 - HEAD BIPOL UNIVERSAL 50MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-50-32 SUP Custom 27803010 UH1-50-32 - HEAD BIPOL UNIVERSAL 50MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-51-22 SUP Custom 27803010 UH1-51-22 - HEAD BIPOL UNIVERSAL 51MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-51-26 SUP Custom 27803010 UH1-51-26 - HEAD BIPOL UNIVERSAL 51MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-51-28 SUP Custom 27803010 UH1-51-28 - HEAD BIPOL UNIVERSAL 51MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-51-32 SUP Custom 27803010 UH1-51-32 - HEAD BIPOL UNIVERSAL 51MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-52-22 SUP Custom 27803010 UH1-52-22 - HEAD BIPOL UNIVERSAL 52MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-52-26 SUP Custom 27803010 UH1-52-26 - HEAD BIPOL UNIVERSAL 52MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-52-28 SUP Custom 27803010 UH1-52-28 - HEAD BP 52MM 28MM UHR HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-52-32 SUP Custom 27803010 UH1-52-32 - HEAD BIPOL UNIVERSAL 52MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-53-22 SUP Custom 27803010 UH1-53-22 - HEAD BIPOL UNIVERSAL 53MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-53-26 SUP Custom 27803010 UH1-53-26 - HEAD BIPOL UNIVERSAL 53MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-53-28 SUP Custom 27803010 UH1-53-28 - HEAD BP 53MM 28MM UHR HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-53-32 SUP Custom 27803010 UH1-53-32 - HEAD BIPOL UNIVERSAL 53MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-54-22 SUP Custom 27803010 UH1-54-22 - HEAD BIPOL UNIVERSAL 54MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-54-26 SUP Custom 27803010 UH1-54-26 - HEAD BIPOL UNIVERSAL 54MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-54-28 SUP Custom 27803010 UH1-54-28 - HEAD BIPOL UNIVERSAL 54MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-54-32 SUP Custom 27803010 UH1-54-32 - HEAD BIPOL UNIVERSAL 54MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-55-22 SUP Custom 27803010 UH1-55-22 - HEAD BIPOL UNIVERSAL 55MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-55-26 SUP Custom 27803010 UH1-55-26 - HEAD BIPOL UNIVERSAL 55MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-55-28 SUP Custom 27803010 UH1-55-28 - HEAD BP 55MM 28MM UHR HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-55-32 SUP Custom 27803010 UH1-55-32 - HEAD BIPOL UNIVERSAL 55MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-56-22 SUP Custom 27803010 UH1-56-22 - HEAD BIPOL UNIVERSAL 56MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-56-26 SUP Custom 27803010 UH1-56-26 - HEAD BIPOL UNIVERSAL 56MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-56-28 SUP Custom 27803010 UH1-56-28 - HEAD BIPOL UNIVERSAL 56MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-56-32 SUP Custom 27803010 UH1-56-32 - HEAD BIPOL UNIVERSAL 56MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-58-22 SUP Custom 27803010 UH1-58-22 - HEAD BIPOL UNIVERSAL 58MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-58-26 SUP Custom 27803010 UH1-58-26 - HEAD BIPOL UNIVERSAL 58MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-58-28 SUP Custom 27803010 UH1-58-28 - HEAD BIPOL UNIVERSAL 58MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-58-32 SUP Custom 27803010 UH1-58-32 - HEAD BIPOL UNIVERSAL 58MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-61-22 SUP Custom 27803010 UH1-61-22 - HEAD BIPOL UNIVERSAL 61MM 22MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-61-26 SUP Custom 27803010 UH1-61-26 - HEAD BIPOL UNIVERSAL 61MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-61-28 SUP Custom 27803010 UH1-61-28 - HEAD BIPOL UNIVERSAL 61MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-61-32 SUP Custom 27803010 UH1-61-32 - HEAD BIPOL UNIVERSAL 61MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-64-26 SUP Custom 27803010 UH1-64-26 - HEAD BIPOL UNIVERSAL 64MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-64-28 SUP Custom 27803010 UH1-64-28 - HEAD BIPOL UNIVERSAL 64MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-64-32 SUP Custom 27803010 UH1-64-32 - HEAD BIPOL UNIVERSAL 64MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-68-26 SUP Custom 27803010 UH1-68-26 - HEAD BIPOL UNIVERSAL 68MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-68-28 SUP Custom 27803010 UH1-68-28 - HEAD BIPOL UNIVERSAL 68MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-68-32 SUP Custom 27803010 UH1-68-32 - HEAD BIPOL UNIVERSAL 68MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-72-26 SUP Custom 27803010 UH1-72-26 - HEAD BIPOL UNIVERSAL 72MM 26MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-72-28 SUP Custom 27803010 UH1-72-28 - HEAD BIPOL UNIVERSAL 72MM 28MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UH1-72-32 SUP Custom 27803010 UH1-72-32 - HEAD BIPOL UNIVERSAL 72MM 32MM UHR COCR UHMWPE HIP BOTH IP/OP "$1,150.00 " $851.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $853.53 $853.53 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $575.00 $910.80 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UL-3021-S SUP HCPCS C1713 UL-3021-S - ROD ORTH 210MM 3MM ULN WR HND ULNA IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 UL-3023-S SUP HCPCS C1713 UL-3023-S - ROD ORTH 230MM 3MM ULN ULNA IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 UL-3025-S SUP HCPCS C1713 UL-3025-S - ROD OTHOPEDIC 250MM 3MM ULN WR HND ULNA IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 UL-3027-S SUP HCPCS C1713 UL-3027-S - NAIL 3MM 27CM ULN IM TI NONSTRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 UL-3621-S SUP HCPCS C1713 UL-3621-S - NAIL 3.6MM 21CM ULN IM STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 UL-3623-S SUP HCPCS C1713 UL-3623-S - ROD ORTH 230MM ULN ULNA IM IMPL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 UL-3625-S SUP HCPCS C1713 UL-3625-S - ROD ORTH 250MM 3.6MM ULN WR HND ULNA IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 UL-3627-S SUP HCPCS C1713 UL-3627-S - ROD OTHOPEDIC 270MM 3.6MM ULN WR HND ULNA IM IMPL STRL BOTH IP/OP "$2,690.00 " "$1,990.60" $0.00 "$2,152.00" "$1,210.50" "$1,210.50" $0.00 $0.00 $0.00 $560.66 "$1,996.52" "$1,996.52" $0.00 $0.00 $560.60 $0.00 "$1,326.17" "$1,326.17" $0.00 "$1,345.00" "$2,130.48" "$2,152.00" $0.00 $0.00 $420.99 $0.00 $0.00 $428.25 $0.00 $0.00 $0.00 $0.00 $0.00 ULTRA O-RNG RPL SUP Custom 27803010 ULTRA O-RNG RPL - O RING OPTH BLK ULFL REPL SIL BOTH IP/OP $135.00 $99.90 $0.00 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.20 $100.20 $0.00 $0.00 $28.13 $0.00 $0.00 $0.00 $0.00 $67.50 $106.92 $108.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UM-04018 SUP Custom 27203010 UM-04018 - KIT ARTERIAL LINE 18GA 20GA 16CM 1.5IN INDWELL CATHETER BOTH IP/OP $75.50 $55.87 $0.00 $104.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.04 $56.04 $0.00 $0.00 $15.73 $0.00 $0.00 $0.00 $0.00 $65.61 $103.93 $104.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UOCP SUP HCPCS C1713 UOCP - PLATE BN SHTNG ULNA BOTH IP/OP "$2,150.00 " "$1,591.00" $0.00 "$1,720.00" $967.50 $967.50 $0.00 $0.00 $0.00 $448.11 "$1,595.73" "$1,595.73" $0.00 $0.00 $448.06 $0.00 "$1,271.73" "$1,271.73" $0.00 "$1,075.00" "$1,702.80" "$1,720.00" $0.00 $0.00 $336.48 $0.00 $0.00 $342.28 $0.00 $0.00 $0.00 $0.00 $0.00 UPA3030 SUP HCPCS C1781 UPA3030 - MESH SURG ULTRAPRO ADV 30X30CM PRTL ABS LTWT BOTH IP/OP $619.33 $458.30 $0.00 $495.46 $278.70 $278.70 $0.00 $0.00 $0.00 $129.08 $459.66 $459.66 $0.00 $0.00 $129.07 $0.00 $366.33 $366.33 $0.00 $309.66 $490.51 $495.46 $0.00 $0.00 $96.92 $0.00 $0.00 $98.60 $0.00 $0.00 $0.00 $0.00 $0.00 UPA31015 SUP HCPCS C1781 UPA31015 - MESH SRG RECT 15X10CM BLU STRP ULTRAPRO ADV PRT ABS LTWT HI BOTH IP/OP $310.66 $229.89 $0.00 $248.53 $139.80 $139.80 $0.00 $0.00 $0.00 $64.75 $230.57 $230.57 $0.00 $0.00 $64.74 $0.00 $183.75 $183.75 $0.00 $155.33 $246.04 $248.53 $0.00 $0.00 $48.62 $0.00 $0.00 $49.46 $0.00 $0.00 $0.00 $0.00 $0.00 UPC510 SUP Custom 27203010 PACK PRNTR 5 7/8INX8 3/8IN SNY COLOR INK RBN UP-50 UP-50 BOTH IP/OP $2.25 $1.67 $0.00 $1.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.13 $1.78 $1.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 UPEG-14 SUP HCPCS C1713 UPEG-14 - PEG FIX 14MM UNTHREADED VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 UPEG-16 SUP HCPCS C1713 UPEG-16 - PEG FIX 14MM UNTHREADED VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 UPEG-18 SUP HCPCS C1713 UPEG-18 - PEG FIX 18MM UNTHREADED VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 UPEG-20 SUP HCPCS C1713 UPEG-20 - SCREW BONE 20MM PEG UNTHREADED TRX BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 UPEG-22 SUP HCPCS C1713 UPEG-22 - PEG FIX 22MM UNTHREADED VOLAR BOTH IP/OP $262.50 $194.25 $0.00 $210.00 $118.13 $118.13 $0.00 $0.00 $0.00 $54.71 $194.83 $194.83 $0.00 $0.00 $54.71 $0.00 $155.27 $155.27 $0.00 $131.25 $207.90 $210.00 $0.00 $0.00 $41.08 $0.00 $0.00 $41.79 $0.00 $0.00 $0.00 $0.00 $0.00 UPLUG403 SUP HCPCS C1781 UPLUG403 - MESH SURG 14X7CM ONLAY PLUG ULTRAPRO 40MM BOTH IP/OP $674.33 $499.00 $0.00 $539.46 $303.45 $303.45 $0.00 $0.00 $0.00 $140.55 $500.48 $500.48 $0.00 $0.00 $140.53 $0.00 $398.86 $398.86 $0.00 $337.16 $534.07 $539.46 $0.00 $0.00 $105.53 $0.00 $0.00 $107.35 $0.00 $0.00 $0.00 $0.00 $0.00 UPLUG553 SUP HCPCS C1781 UPLUG553 - MESH SURG 14X7CM ONLAY PLUG ULTRAPRO 55MM BOTH IP/OP $674.33 $499.00 $0.00 $539.46 $303.45 $303.45 $0.00 $0.00 $0.00 $140.55 $500.48 $500.48 $0.00 $0.00 $140.53 $0.00 $398.86 $398.86 $0.00 $337.16 $534.07 $539.46 $0.00 $0.00 $105.53 $0.00 $0.00 $107.35 $0.00 $0.00 $0.00 $0.00 $0.00 USA-FDX SUP Custom 27203010 USA-FDX - ASPIRATOR SCT 72IN LF FLD DMD TUBE DISP BOTH IP/OP "$1,350.00 " $999.00 $0.00 "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,001.97" "$1,001.97" $0.00 $0.00 $281.34 $0.00 $0.00 $0.00 $0.00 $675.00 "$1,069.20" "$1,080.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 V1205 SUP Custom 27203010 REAGENT .45% NA CHLOR BTL 1L ANALY BOTH IP/OP $12.08 $8.94 $0.00 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $6.04 $9.57 $9.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 V402G SUP Custom 27203010 V402G - SUTURE ABS 9-0 BV100-3 5IN VIOL VCL MFL COAT BOTH IP/OP $46.45 $34.37 $0.00 $37.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.48 $34.48 $0.00 $0.00 $9.68 $0.00 $0.00 $0.00 $0.00 $23.57 $37.34 $37.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 V4900 SUP HCPCS C1729 CATHETER DLYS PRTNL TROCATH ADLT BOTH IP/OP $125.75 $93.06 $0.00 $100.60 $68.28 $68.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.88 $99.59 $100.60 $0.00 $0.00 $19.68 $0.00 $0.00 $20.02 $0.00 $0.00 $0.00 $0.00 $0.00 V4908(SUB) SUP Custom 27203010 V4908(SUB) - SET PERITONEAL DIALYSIS BOTH IP/OP $201.93 $149.43 $0.00 $161.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.87 $149.87 $0.00 $0.00 $42.08 $0.00 $0.00 $0.00 $0.00 $100.96 $159.93 $161.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAC6000M SUP Custom 27203010 VAC6000M - VACUUM EXTRACTION 6MM CUP MUSHROOM TRACTION FORCE INDICATOR BOTH IP/OP $139.98 $103.59 $0.00 $111.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.99 $110.86 $111.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAC-6000M SUP Custom 27203010 VAC-6000M - VACUUM EXTRACTION 6MM CUP MUSHROOM TRACTION FORCE INDICATOR BOTH IP/OP $61.48 $45.50 $0.00 $49.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.74 $48.69 $49.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF2626C100TU SUP Custom 27803010 VAMF2626C100TU - GRAFT STNT 26MM 100MM VALIANT PROX MAIN SECT FREEFLO CLS WEB BOTH IP/OP "$42,487.50 " "$31,440.75" $0.00 "$33,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,854.40" $0.00 $0.00 $0.00 $0.00 "$21,243.75" "$33,650.10" "$33,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF2824C150TU SUP Custom 27803010 VAMF2824C150TU - GRAFT STNT STRG TPR SINUSOIDAL 25FR 24MM 112MM 100MM VALIANT BOTH IP/OP "$46,237.50 " "$34,215.75" $0.00 "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,635.90" $0.00 $0.00 $0.00 $0.00 "$23,118.75" "$36,620.10" "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3026C150TU SUP Custom 27803010 VAMF3026C150TU - GRAFT STNT TPR 30MM 26MM 150MM VALIANT CAPTIVIA THRX BOTH IP/OP "$46,237.50 " "$34,215.75" $0.00 "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,118.75" "$36,620.10" "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3228C150TU SUP Custom 27803010 VAMF3228C150TU - GRAFT STNT TPR 28MM 150MM VALIANT CAPTIVIA DLV SYS BOTH IP/OP "$46,237.50 " "$34,215.75" $0.00 "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$23,118.75" "$36,620.10" "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3430C150TU SUP Custom 27803010 VAMF3430C150TU - GRAFT STNT TPR 34MM 30MM 150MM VALIANT CAPTIVIA EVAS BOTH IP/OP "$46,237.50 " "$34,215.75" $0.00 "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,635.90" $0.00 $0.00 $0.00 $0.00 "$23,118.75" "$36,620.10" "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3434C150TU SUP Custom 27803010 VAMF3434C150TU - GRAFT STNT STRG 34MM 150MM VALIANT PROX MAIN SECT CLS WEB BOTH IP/OP "$46,237.50 " "$34,215.75" $0.00 "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,635.90" $0.00 $0.00 $0.00 $0.00 "$23,118.75" "$36,620.10" "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3434C200TU SUP Custom 27803010 VAMF3434C200TU - GRAFT STNT STRG SINUSOIDAL 34MM 24FR 200MM 212MM VALIANT SYS BOTH IP/OP "$48,737.50 " "$36,065.75" $0.00 "$38,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,156.90" $0.00 $0.00 $0.00 $0.00 "$24,368.75" "$38,600.10" "$38,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3632C150TU SUP Custom 27803010 VAMF3632C150TU - GRAFT STNT STRG TPR 32MM 36MM 150MM STRL LF VALIANT CAPTIVIA BOTH IP/OP "$46,237.50 " "$34,215.75" $0.00 "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,635.90" $0.00 $0.00 $0.00 $0.00 "$23,118.75" "$36,620.10" "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3636C150TU SUP Custom 27803010 VAMF3636C150TU - GRAFT STNT SINUSOIDAL STRG 36MM 24FR 167MM 150MM VALIANT BOTH IP/OP "$46,237.50 " "$34,215.75" $0.00 "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,635.90" $0.00 $0.00 $0.00 $0.00 "$23,118.75" "$36,620.10" "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3636C200TU SUP Custom 27803010 VAMF3636C200TU - GRAFT STNT STRG 36MM 200MM 207MM VALIANT PROX FREEFLO EVAS BOTH IP/OP "$48,737.50 " "$36,065.75" $0.00 "$38,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,156.90" $0.00 $0.00 $0.00 $0.00 "$24,368.75" "$38,600.10" "$38,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF3838C200TU SUP HCPCS C2625 VAMF3838C200TU - GRAFT STNT SINUSOIDAL STRG 38MM 24FR 207MM 200MM VALIANT BOTH IP/OP "$48,737.50 " "$36,065.75" $0.00 "$38,990.00" "$21,931.88" "$21,931.88" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,156.90" $0.00 "$24,027.59" "$24,027.59" $0.00 "$24,368.75" "$38,600.10" "$38,990.00" $0.00 $0.00 "$7,627.42" $0.00 $0.00 "$7,759.01" $0.00 $0.00 $0.00 $0.00 $0.00 VAMF4242C150TU SUP Custom 27803010 VAMF4242C150TU - GRAFT STNT SINUSOIDAL STRG 42MM 25FR 157MM 150MM VALIANT BOTH IP/OP "$46,237.50 " "$34,215.75" $0.00 "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$9,635.90" $0.00 $0.00 $0.00 $0.00 "$23,118.75" "$36,620.10" "$36,990.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VAMF4242C200TU SUP HCPCS C1768 VAMF4242C200TU - GRAFT STNT SINUSOIDAL STRG 42MM 25FR 207MM 200MM VALIANT BOTH IP/OP "$48,737.50 " "$36,065.75" $0.00 "$38,990.00" "$21,931.88" "$21,931.88" $0.00 $0.00 $0.00 "$9,417.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$10,156.90" $0.00 "$24,027.59" "$24,027.59" $0.00 "$24,368.75" "$38,600.10" "$38,990.00" $0.00 $0.00 "$7,627.42" $0.00 $0.00 "$7,759.01" $0.00 $0.00 $0.00 $0.00 $0.00 VBH060502 SUP HCPCS C1874 VBH060502 - STENT ENDOPRSTH 6MM 7FR 5CM 120CM .035IN HEP BIOACTIVE SRFC BOTH IP/OP "$7,097.50 " "$5,252.15" $0.00 "$5,678.00" "$3,193.88" "$3,193.88" $0.00 $0.00 $0.00 "$1,479.30" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,479.12" $0.00 "$3,499.07" "$3,499.07" $0.00 "$3,548.75" "$5,621.22" "$5,678.00" $0.00 $0.00 "$1,110.76" $0.00 $0.00 "$1,129.92" $0.00 $0.00 $0.00 $0.00 $0.00 VBH061002 SUP HCPCS C1874 VBH061002 - STENT ENDOPRSTH 6MM 10CM 120CM .035IN DLV SYS TIP TO HUB DPL BOTH IP/OP "$8,122.50 " "$6,010.65" $0.00 "$6,498.00" "$3,655.13" "$3,655.13" $0.00 $0.00 $0.00 "$1,692.93" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,692.73" $0.00 "$4,004.39" "$4,004.39" $0.00 "$4,061.25" "$6,433.02" "$6,498.00" $0.00 $0.00 "$1,271.17" $0.00 $0.00 "$1,293.10" $0.00 $0.00 $0.00 $0.00 $0.00 VBH080502 SUP HCPCS C1874 VBH080502 - STENT ENDOPRSTH 8MM 5CM 120CM .035IN DLV SYS TIP TO HUB DPL BOTH IP/OP "$6,737.50 " "$4,985.75" $0.00 "$5,390.00" "$3,031.88" "$3,031.88" $0.00 $0.00 $0.00 "$1,404.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,404.10" $0.00 "$3,321.59" "$3,321.59" $0.00 "$3,368.75" "$5,336.10" "$5,390.00" $0.00 $0.00 "$1,054.42" $0.00 $0.00 "$1,072.61" $0.00 $0.00 $0.00 $0.00 $0.00 VBH081002 SUP HCPCS C1874 VBH081002 - STENT ENDOPRSTH 8MM 10CM 120CM .035IN DLV SYS TIP TO HUB DPL BOTH IP/OP "$7,737.50 " "$5,725.75" $0.00 "$6,190.00" "$3,481.88" "$3,481.88" $0.00 $0.00 $0.00 "$1,612.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,612.50" $0.00 "$3,814.59" "$3,814.59" $0.00 "$3,868.75" "$6,128.10" "$6,190.00" $0.00 $0.00 "$1,210.92" $0.00 $0.00 "$1,231.81" $0.00 $0.00 $0.00 $0.00 $0.00 VBH081502 SUP HCPCS C1874 VBH081502 - STENT ENDOPRSTH 8MM 15CM 120CM .035IN DLV SYS TIP TO HUB DPL BOTH IP/OP "$8,900.00 " "$6,586.00" $0.00 "$7,120.00" "$4,005.00" "$4,005.00" $0.00 $0.00 $0.00 "$1,854.98" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,854.76" $0.00 "$4,387.70" "$4,387.70" $0.00 "$4,450.00" "$7,048.80" "$7,120.00" $0.00 $0.00 "$1,392.85" $0.00 $0.00 "$1,416.88" $0.00 $0.00 $0.00 $0.00 $0.00 VBH090502 SUP HCPCS C1874 VBH090502 - STENT ENDOPRSTH 5CM DELIVERY SYSTEM TIP TO HUB DEPLOYMENT BOTH IP/OP "$7,487.50 " "$5,540.75" $0.00 "$5,990.00" "$3,369.38" "$3,369.38" $0.00 $0.00 $0.00 "$1,560.58" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,560.40" $0.00 "$3,691.34" "$3,691.34" $0.00 "$3,743.75" "$5,930.10" "$5,990.00" $0.00 $0.00 "$1,171.79" $0.00 $0.00 "$1,192.01" $0.00 $0.00 $0.00 $0.00 $0.00 VBH091002 SUP HCPCS C1874 VBH091002 - STENT ENDOPRSTH 10CM DELIVERY SYSTEM TIP TO HUB DEPLOYMENT BOTH IP/OP "$8,237.50 " "$6,095.75" $0.00 "$6,590.00" "$3,706.88" "$3,706.88" $0.00 $0.00 $0.00 "$1,716.90" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,716.70" $0.00 "$4,061.09" "$4,061.09" $0.00 "$4,118.75" "$6,524.10" "$6,590.00" $0.00 $0.00 "$1,289.17" $0.00 $0.00 "$1,311.41" $0.00 $0.00 $0.00 $0.00 $0.00 VBH100502 SUP HCPCS C1874 VBH100502 - STENT EPRSTH 10MM 11FR 5CM 120CM VBHN DLV SYS TIP TO HUB DPL BOTH IP/OP "$6,737.50 " "$4,985.75" $0.00 "$5,390.00" "$3,031.88" "$3,031.88" $0.00 $0.00 $0.00 "$1,404.26" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,404.10" $0.00 "$3,321.59" "$3,321.59" $0.00 "$3,368.75" "$5,336.10" "$5,390.00" $0.00 $0.00 "$1,054.42" $0.00 $0.00 "$1,072.61" $0.00 $0.00 $0.00 $0.00 $0.00 VBH101002 SUP HCPCS C1874 VBH101002 - STENT ENDOPRSTH 10MM 10CM 120CM .035IN DLV SYS TIP TO HUB BOTH IP/OP "$7,737.50 " "$5,725.75" $0.00 "$6,190.00" "$3,481.88" "$3,481.88" $0.00 $0.00 $0.00 "$1,612.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,612.50" $0.00 "$3,814.59" "$3,814.59" $0.00 "$3,868.75" "$6,128.10" "$6,190.00" $0.00 $0.00 "$1,210.92" $0.00 $0.00 "$1,231.81" $0.00 $0.00 $0.00 $0.00 $0.00 VBH101002A SUP HCPCS C1874 VBH101002A - STENT EPRSTH 10MM 11FR 10CM 120CM VBHN DLV SYS TIP TO HUB BOTH IP/OP "$9,807.50 " "$7,257.55" $0.00 "$7,692.00" "$4,326.75" "$4,326.75" $0.00 $0.00 $0.00 "$2,044.13" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,043.88" $0.00 "$4,835.10" "$4,835.10" $0.00 "$4,807.50" "$7,615.08" "$7,692.00" $0.00 $0.00 "$1,504.75" $0.00 $0.00 "$1,530.71" $0.00 $0.00 $0.00 $0.00 $0.00 VBHR080502A SUP HCPCS C1874 "VBHR080502A - VIABAHN ENDOPROSTHESIS , 8X5" BOTH IP/OP "$8,940.00 " "$6,615.60" $0.00 "$7,012.00" "$3,944.25" "$3,944.25" $0.00 $0.00 $0.00 "$1,863.32" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,863.10" $0.00 "$4,407.42" "$4,407.42" $0.00 "$4,382.50" "$6,941.88" "$7,012.00" $0.00 $0.00 "$1,371.72" $0.00 $0.00 "$1,395.39" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ050502 SUP HCPCS C1874 VBJ050502 - STENT ENDOPRSTH 5CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 5 BOTH IP/OP "$7,737.50 " "$5,725.75" $0.00 "$6,190.00" "$3,481.88" "$3,481.88" $0.00 $0.00 $0.00 "$1,612.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,612.50" $0.00 "$3,814.59" "$3,814.59" $0.00 "$3,868.75" "$6,128.10" "$6,190.00" $0.00 $0.00 "$1,210.92" $0.00 $0.00 "$1,231.81" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ051002 SUP HCPCS C1874 VBJ051002 - STENT ENDOPRSTH 10CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 5 BOTH IP/OP "$8,487.50 " "$6,280.75" $0.00 "$6,790.00" "$3,819.38" "$3,819.38" $0.00 $0.00 $0.00 "$1,769.01" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,768.80" $0.00 "$4,184.34" "$4,184.34" $0.00 "$4,243.75" "$6,722.10" "$6,790.00" $0.00 $0.00 "$1,328.29" $0.00 $0.00 "$1,351.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ051502 SUP HCPCS C1874 VBJ051502 - STENT ENDOPRSTH 15CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 5 BOTH IP/OP "$9,737.50 " "$7,205.75" $0.00 "$7,790.00" "$4,381.88" "$4,381.88" $0.00 $0.00 $0.00 "$2,029.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,029.30" $0.00 "$4,800.59" "$4,800.59" $0.00 "$4,868.75" "$7,712.10" "$7,790.00" $0.00 $0.00 "$1,523.92" $0.00 $0.00 "$1,550.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ052502 SUP HCPCS C1874 VBJ052502 - STENT ENDOPRSTH 25CM BIOACTIVE SURFACE CATHETER LOWER BOTH IP/OP "$15,987.50 " "$11,830.75" $0.00 "$12,790.00" "$7,194.38" "$7,194.38" $0.00 $0.00 $0.00 "$3,332.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,331.80" $0.00 "$7,881.84" "$7,881.84" $0.00 "$7,993.75" "$12,662.10" "$12,790.00" $0.00 $0.00 "$2,502.04" $0.00 $0.00 "$2,545.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ060502 SUP HCPCS C1874 VBJ060502 - STENT ENDOPRSTH 5CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 6 BOTH IP/OP "$7,737.50 " "$5,725.75" $0.00 "$6,190.00" "$3,481.88" "$3,481.88" $0.00 $0.00 $0.00 "$1,612.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,612.50" $0.00 "$3,814.59" "$3,814.59" $0.00 "$3,868.75" "$6,128.10" "$6,190.00" $0.00 $0.00 "$1,210.92" $0.00 $0.00 "$1,231.81" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ061002 SUP HCPCS C1874 VBJ061002 - STENT EPRSTH 6MM 6FR 10CM 120CM VBHN DLV SYS HEP SPRFC FEM BOTH IP/OP "$8,487.50 " "$6,280.75" $0.00 "$6,790.00" "$3,819.38" "$3,819.38" $0.00 $0.00 $0.00 "$1,769.01" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,768.80" $0.00 "$4,184.34" "$4,184.34" $0.00 "$4,243.75" "$6,722.10" "$6,790.00" $0.00 $0.00 "$1,328.29" $0.00 $0.00 "$1,351.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ061502 SUP HCPCS C1874 VBJ061502 - STENT ENDOPRSTH 15CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 6 BOTH IP/OP "$9,737.50 " "$7,205.75" $0.00 "$7,790.00" "$4,381.88" "$4,381.88" $0.00 $0.00 $0.00 "$2,029.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,029.30" $0.00 "$4,800.59" "$4,800.59" $0.00 "$4,868.75" "$7,712.10" "$7,790.00" $0.00 $0.00 "$1,523.92" $0.00 $0.00 "$1,550.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ062502 SUP HCPCS C1874 VBJ062502 - STENT ENDOPRSTH 25CM BIOACTIVE SURFACE CATHETER LOWER BOTH IP/OP "$15,987.50 " "$11,830.75" $0.00 "$12,790.00" "$7,194.38" "$7,194.38" $0.00 $0.00 $0.00 "$3,332.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,331.80" $0.00 "$7,881.84" "$7,881.84" $0.00 "$7,993.75" "$12,662.10" "$12,790.00" $0.00 $0.00 "$2,502.04" $0.00 $0.00 "$2,545.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ070502 SUP HCPCS C1874 VBJ070502 - STENT ENDOPRSTH 5CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 7 BOTH IP/OP "$7,737.50 " "$5,725.75" $0.00 "$6,190.00" "$3,481.88" "$3,481.88" $0.00 $0.00 $0.00 "$1,612.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,612.50" $0.00 "$3,814.59" "$3,814.59" $0.00 "$3,868.75" "$6,128.10" "$6,190.00" $0.00 $0.00 "$1,210.92" $0.00 $0.00 "$1,231.81" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ071002 SUP HCPCS C1874 VBJ071002 - STENT ENDOPRSTH 10CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 7 BOTH IP/OP "$8,487.50 " "$6,280.75" $0.00 "$6,790.00" "$3,819.38" "$3,819.38" $0.00 $0.00 $0.00 "$1,769.01" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,768.80" $0.00 "$4,184.34" "$4,184.34" $0.00 "$4,243.75" "$6,722.10" "$6,790.00" $0.00 $0.00 "$1,328.29" $0.00 $0.00 "$1,351.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ071502 SUP HCPCS C1874 VBJ071502 - STENT ENDOPRSTH 15CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 7 BOTH IP/OP "$9,737.50 " "$7,205.75" $0.00 "$7,790.00" "$4,381.88" "$4,381.88" $0.00 $0.00 $0.00 "$2,029.54" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,029.30" $0.00 "$4,800.59" "$4,800.59" $0.00 "$4,868.75" "$7,712.10" "$7,790.00" $0.00 $0.00 "$1,523.92" $0.00 $0.00 "$1,550.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ072502 SUP HCPCS C1874 VBJ072502 - STENT ENDOPRSTH 25CM BIOACTIVE SURFACE CATHETER DELIVERY BOTH IP/OP "$15,987.50 " "$11,830.75" $0.00 "$12,790.00" "$7,194.38" "$7,194.38" $0.00 $0.00 $0.00 "$3,332.19" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,331.80" $0.00 "$7,881.84" "$7,881.84" $0.00 "$7,993.75" "$12,662.10" "$12,790.00" $0.00 $0.00 "$2,502.04" $0.00 $0.00 "$2,545.21" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ080202 SUP HCPCS C1874 VBJ080202 - STENT ENDOPRSTH 2.5CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM BOTH IP/OP "$7,355.00 " "$5,442.70" $0.00 "$5,884.00" "$3,309.75" "$3,309.75" $0.00 $0.00 $0.00 "$1,532.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,532.78" $0.00 "$3,626.02" "$3,626.02" $0.00 "$3,677.50" "$5,825.16" "$5,884.00" $0.00 $0.00 "$1,151.06" $0.00 $0.00 "$1,170.92" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ080502 SUP HCPCS C1874 VBJ080502 - STENT ENDOPRSTH 8MM 7FR 5CM 120CM DELIVERY SYSTEM VIABAHN BOTH IP/OP "$7,737.50 " "$5,725.75" $0.00 "$6,190.00" "$3,481.88" "$3,481.88" $0.00 $0.00 $0.00 "$1,612.69" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,612.50" $0.00 "$3,814.59" "$3,814.59" $0.00 "$3,868.75" "$6,128.10" "$6,190.00" $0.00 $0.00 "$1,210.92" $0.00 $0.00 "$1,231.81" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ081002 SUP HCPCS C1874 VBJ081002 - STENT ENDOPRSTH 8MM 7FR 10CM 120CM DELIVERY SYSTEM VIABAHN BOTH IP/OP "$8,950.00 " "$6,623.00" $0.00 "$7,160.00" "$4,027.50" "$4,027.50" $0.00 $0.00 $0.00 "$1,865.40" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,865.18" $0.00 "$4,412.35" "$4,412.35" $0.00 "$4,475.00" "$7,088.40" "$7,160.00" $0.00 $0.00 "$1,400.68" $0.00 $0.00 "$1,424.84" $0.00 $0.00 $0.00 $0.00 $0.00 VBJ081502 SUP HCPCS C1874 VBJ081502 - STENT ENDOPRSTH 15CM DELIVERY SYSTEM VIABAHN HEPARIN 120CM 8 BOTH IP/OP "$9,660.00 " "$7,148.40" $0.00 "$7,728.00" "$4,347.00" "$4,347.00" $0.00 $0.00 $0.00 "$2,013.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,013.14" $0.00 "$4,762.38" "$4,762.38" $0.00 "$4,830.00" "$7,650.72" "$7,728.00" $0.00 $0.00 "$1,511.79" $0.00 $0.00 "$1,537.87" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR050502A SUP HCPCS C1874 VBJR050502A - STENT EPRSTH 5MM 5CM STRL 120CM VBHN FLXB SLF XPD RADOPQ HEP BOTH IP/OP "$9,207.50 " "$6,813.55" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,919.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,918.84" $0.00 "$4,539.30" "$4,539.30" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR051002A SUP HCPCS C1874 VBJR051002A - STENT ENDOPRSTH 5MM 10CM 120CM FLEXIBLE SELF EXPAND RADIOPQ BOTH IP/OP "$10,072.50 " "$7,453.65" $0.00 "$7,900.00" "$4,443.75" "$4,443.75" $0.00 $0.00 $0.00 "$2,099.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,099.11" $0.00 "$4,965.74" "$4,965.74" $0.00 "$4,937.50" "$7,821.00" "$7,900.00" $0.00 $0.00 "$1,545.44" $0.00 $0.00 "$1,572.10" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR060502A SUP HCPCS C1874 VBJR060502A - STENT EPRSTH 6MM 6FR 5CM 120CM VBHN DLV SYS HEP SPRFC FEM BOTH IP/OP "$9,207.50 " "$6,813.55" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,919.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,918.84" $0.00 "$4,539.30" "$4,539.30" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR061002A SUP HCPCS C1874 VBJR061002A - STENT EPRSTH 6MM 6FR 10CM 120CM VBHN DLV SYS HEP SPRFC BOTH IP/OP "$10,072.50 " "$7,453.65" $0.00 "$7,900.00" "$4,443.75" "$4,443.75" $0.00 $0.00 $0.00 "$2,099.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,099.11" $0.00 "$4,965.74" "$4,965.74" $0.00 "$4,937.50" "$7,821.00" "$7,900.00" $0.00 $0.00 "$1,545.44" $0.00 $0.00 "$1,572.10" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR061502A SUP HCPCS C1874 "VBJR061502A - VIABAHN ENDOPROSTHESIS, 6MMX 15CM" BOTH IP/OP "$11,225.00 " "$8,306.50" $0.00 "$8,804.00" "$4,952.25" "$4,952.25" $0.00 $0.00 $0.00 "$2,339.57" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,339.29" $0.00 "$5,533.93" "$5,533.93" $0.00 "$5,502.50" "$8,715.96" "$8,804.00" $0.00 $0.00 "$1,722.28" $0.00 $0.00 "$1,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR062502A SUP HCPCS C1874 VBJR062502A - STENT ENDOPRSTH 6MM 25CM 120CM FLEXIBLE SELF EXPAND RADIOPQ BOTH IP/OP "$18,450.00 " "$13,653.00" $0.00 "$14,470.00" "$8,139.38" "$8,139.38" $0.00 $0.00 $0.00 "$3,845.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,844.98" $0.00 "$9,095.85" "$9,095.85" $0.00 "$9,043.75" "$14,325.30" "$14,470.00" $0.00 $0.00 "$2,830.69" $0.00 $0.00 "$2,879.53" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR070202A SUP HCPCS C1874 VBJR070202A - STENT EPRSTH 7MM 2.5CM STRL 120CM VBHN FLXB SLF XPD RADOPQ BOTH IP/OP "$9,207.50 " "$6,813.55" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,919.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,918.84" $0.00 "$4,539.30" "$4,539.30" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR070502A SUP HCPCS C1874 "VBJR070502A - LOW-PROFILE, VIABAHN 7MMX 5CM" BOTH IP/OP "$9,207.50 " "$6,813.55" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,919.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,918.84" $0.00 "$4,539.30" "$4,539.30" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR071002A SUP HCPCS C1874 VBJR071002A - STENT ENDOPRSTH SPRFC FEM ART ILIUM 10CM 7MM 7FR BOTH IP/OP "$10,072.50 " "$7,453.65" $0.00 "$7,900.00" "$4,443.75" "$4,443.75" $0.00 $0.00 $0.00 "$2,099.36" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,099.11" $0.00 "$4,965.74" "$4,965.74" $0.00 "$4,937.50" "$7,821.00" "$7,900.00" $0.00 $0.00 "$1,545.44" $0.00 $0.00 "$1,572.10" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR071502A SUP HCPCS C1874 VBJR071502A - STENT ENDOPRSTH 7MM 7FR 15CM 120CM DELIVERY SYSTEM VIABAHN BOTH IP/OP "$11,225.00 " "$8,306.50" $0.00 "$8,804.00" "$4,952.25" "$4,952.25" $0.00 $0.00 $0.00 "$2,339.57" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,339.29" $0.00 "$5,533.93" "$5,533.93" $0.00 "$5,502.50" "$8,715.96" "$8,804.00" $0.00 $0.00 "$1,722.28" $0.00 $0.00 "$1,752.00" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR072502A SUP HCPCS C1874 VBJR072502A - STENT ENDOPRSTH 7MM 25CM 120CM FLEXIBLE SELF EXPAND RADIOPQ BOTH IP/OP "$18,450.00 " "$13,653.00" $0.00 "$14,470.00" "$8,139.38" "$8,139.38" $0.00 $0.00 $0.00 "$3,845.44" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,844.98" $0.00 "$9,095.85" "$9,095.85" $0.00 "$9,043.75" "$14,325.30" "$14,470.00" $0.00 $0.00 "$2,830.69" $0.00 $0.00 "$2,879.53" $0.00 $0.00 $0.00 $0.00 $0.00 VBJR080502A SUP HCPCS C1874 "VBJR080502A - VIABAHN ENDOPROSTHESIS, 8MMX 5CM" BOTH IP/OP "$9,207.50 " "$6,813.55" $0.00 "$7,222.00" "$4,062.38" "$4,062.38" $0.00 $0.00 $0.00 "$1,919.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,918.84" $0.00 "$4,539.30" "$4,539.30" $0.00 "$4,513.75" "$7,149.78" "$7,222.00" $0.00 $0.00 "$1,412.80" $0.00 $0.00 "$1,437.18" $0.00 $0.00 $0.00 $0.00 $0.00 VBP32 SUP HCPCS C1713 VBP32 - PIN FIX 32MM BUTTRESS TITANIUM VOLAR BOTH IP/OP $937.50 $693.75 $0.00 $750.00 $421.88 $421.88 $0.00 $0.00 $0.00 $195.40 $695.81 $695.81 $0.00 $0.00 $195.38 $0.00 $554.53 $554.53 $0.00 $468.75 $742.50 $750.00 $0.00 $0.00 $146.72 $0.00 $0.00 $149.25 $0.00 $0.00 $0.00 $0.00 $0.00 VCP740D SUP Custom 27203010 VCP740D - SUTURE ABSORBABLE 0 CT-1 18IN CONTROL RELEASE BRAID 8 STRAND BOTH IP/OP $32.80 $24.27 $0.00 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.34 $24.34 $0.00 $0.00 $6.83 $0.00 $0.00 $0.00 $0.00 $16.40 $25.98 $26.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VE220GS SUP HCPCS C1884 VE220GS - PARTICLES EMBL 100-300UM 2ML YLW LC BEAD VL BOTH IP/OP "$4,237.50 " "$3,135.75" $0.00 "$3,390.00" "$1,906.88" "$1,906.88" $0.00 $0.00 $0.00 $883.20 "$3,145.07" "$3,145.07" $0.00 $0.00 $883.10 $0.00 "$2,089.09" "$2,089.09" $0.00 "$2,118.75" "$3,356.10" "$3,390.00" $0.00 $0.00 $663.17 $0.00 $0.00 $674.61 $0.00 $0.00 $0.00 $0.00 $0.00 VE420GS SUP HCPCS C1884 VE420GS - PARTICLES EMBL 300-500UM 2ML BLU LC BEAD LBL BOTH IP/OP "$4,037.50 " "$2,987.75" $0.00 "$3,230.00" "$1,816.88" "$1,816.88" $0.00 $0.00 $0.00 $841.52 "$2,996.63" "$2,996.63" $0.00 $0.00 $841.42 $0.00 "$1,990.49" "$1,990.49" $0.00 "$2,018.75" "$3,197.70" "$3,230.00" $0.00 $0.00 $631.87 $0.00 $0.00 $642.77 $0.00 $0.00 $0.00 $0.00 $0.00 VE620GS SUP Custom 27203010 PARTICLES EMBL 500-700UM 2ML LBL LC BEAD RD BOTH IP/OP "$3,487.50 " "$2,580.75" $0.00 "$2,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,743.75" "$2,762.10" "$2,790.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VEDR01 SUP HCPCS C1785 VEDR01 - PACEMAKER CARDIAC 2.8V 1.3AH 7.5MM 47.9X7.5X44.7MM IMPLTABLE BOTH IP/OP "$6,002.50 " "$4,441.85" $0.00 "$4,900.00" "$2,756.25" "$2,756.25" $0.00 $0.00 $0.00 "$1,251.07" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,250.92" $0.00 "$2,959.23" "$2,959.23" $0.00 "$3,062.50" "$4,851.00" "$4,900.00" $0.00 $0.00 $958.56 $0.00 $0.00 $975.10 $0.00 $0.00 $0.00 $0.00 $0.00 VERSADRK2 SUP HCPCS C1785 VERSADRK2 - PACEMAKER CARDIAC THK7.5MM 47.9X44.7MM IMPLTABLE 2 CHAMBER BOTH IP/OP "$7,987.50 " "$5,910.75" $0.00 "$6,520.00" "$3,667.50" "$3,667.50" $0.00 $0.00 $0.00 "$1,664.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,664.60" $0.00 "$3,937.84" "$3,937.84" $0.00 "$4,075.00" "$6,454.80" "$6,520.00" $0.00 $0.00 "$1,275.48" $0.00 $0.00 "$1,297.48" $0.00 $0.00 $0.00 $0.00 $0.00 VG-0108N SUP HCPCS C1768 VG-0108N - PATCH CARDIO TAPER 8X.8CM APEX PROCESS VASCU-GUARD BOVINE BOTH IP/OP $525.28 $388.71 $0.00 $396.08 $222.80 $222.80 $0.00 $0.00 $0.00 $109.48 $389.86 $389.86 $0.00 $0.00 $109.47 $0.00 $310.70 $310.70 $0.00 $247.55 $392.12 $396.08 $0.00 $0.00 $77.48 $0.00 $0.00 $78.82 $0.00 $0.00 $0.00 $0.00 $0.00 VG-0209N SUP HCPCS C1768 VG-0209N - PATCH CARDIO 9X2CM TPR VSGRD BVN PRICRD PERI BOTH IP/OP $532.50 $394.05 $0.00 $426.00 $239.63 $239.63 $0.00 $0.00 $0.00 $110.99 $395.22 $395.22 $0.00 $0.00 $110.97 $0.00 $314.97 $314.97 $0.00 $266.25 $421.74 $426.00 $0.00 $0.00 $83.34 $0.00 $0.00 $84.77 $0.00 $0.00 $0.00 $0.00 $0.00 VG1CPAR10P SUP HCPCS C1762 VG1CPAR10P - GRAFT BONE 12X14.5X10MM ANTERIOR CERV FUSION PARALLEL SOLID BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,497.50" "$2,372.04" "$2,396.00" $0.00 $0.00 $468.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1CPAR5P SUP HCPCS C1762 VG1CPAR5P - GRAFT BONE VG1 CERV BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,497.50" "$2,372.04" "$2,396.00" $0.00 $0.00 $468.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1CPAR6P SUP HCPCS C1762 VG1CPAR6P - GRAFT BONE 12X14.5X6MM ANTERIOR CERV FUSION PARALLEL SOLID BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,497.50" "$2,372.04" "$2,396.00" $0.00 $0.00 $468.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1CPAR7P SUP HCPCS C1762 VG1CPAR7P - GRAFT BONE 12X14.5X7MM ANTERIOR CERV FUSION PARALLEL SOLID BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,497.50" "$2,372.04" "$2,396.00" $0.00 $0.00 $468.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1CPAR8P SUP HCPCS C1762 VG1CPAR8P - GRAFT BONE 12X14.5X8MM ANTERIOR CERV FUSION PARALLEL BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,497.50" "$2,372.04" "$2,396.00" $0.00 $0.00 $468.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1CPAR9P SUP HCPCS C1762 VG1CPAR9P - GRAFT BONE 12X14.5X9MM ANTERIOR CERV FUSION PARALLEL SOLID BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,497.50" "$2,372.04" "$2,396.00" $0.00 $0.00 $468.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1C-T46P SUP HCPCS C1762 VG1C-T46P - GRAFT BONE 7D 6MM 4MM 1 PIECE LORDOSIS SOLID CENTRL VOID BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,662.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,663.75" "$2,635.38" "$2,662.00" $0.00 $0.00 $520.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1C-T57P SUP HCPCS C1762 VG1C-T57P - GRAFT BONE 7D 7MM 5MM 1 PIECE LORDOSIS SOLID CENTRL VOID BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,497.50" "$2,372.04" "$2,396.00" $0.00 $0.00 $468.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1C-T68P SUP HCPCS C1762 VG1C-T68P - GRAFT BONE 7D 12X14.5X8MM 6MM ANTERIOR CERV FUSION PRESERVON BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,662.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,663.75" "$2,635.38" "$2,662.00" $0.00 $0.00 $520.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1C-T79P SUP HCPCS C1762 VG1C-T79P - GRAFT BONE 7D 12X14.5X9MM 7MM ANTERIOR CERV FUSION PRESERVON BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,598.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,623.75" "$2,572.02" "$2,598.00" $0.00 $0.00 $508.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG1C-T810P SUP HCPCS C1762 VG1C-T810P - GRAFT BONE 7D 12X14.5X10MM 8MM ANTERIOR CERV FUSION BOTH IP/OP "$2,495.63 " "$1,846.77" $0.00 "$2,396.00" $0.00 $0.00 $0.00 $0.00 $0.00 $520.15 "$1,852.25" "$1,852.25" $0.00 $0.00 $520.09 $0.00 "$1,476.16" "$1,476.16" $0.00 "$1,497.50" "$2,372.04" "$2,396.00" $0.00 $0.00 $468.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG2C-T57P SUP Custom 27803010 VG2C-T57P - LIFENET HEALTH 5.75 X 7.22MM CERVICAL LORDOTIC BOTH IP/OP "$2,630.63 " "$1,946.67" $0.00 "$2,598.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,952.45" "$1,952.45" $0.00 $0.00 $548.22 $0.00 $0.00 $0.00 $0.00 "$1,623.75" "$2,572.02" "$2,598.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VG501 SUP Custom 27203010 "CONTROLLER, V-GRIP DETACHMENT" BOTH IP/OP $437.50 $323.75 $0.00 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.75 $346.50 $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VH - 2004 SUP Custom 27203010 VH - 2004 - SYSTEM VSL HRVT SHRT BLNT CONE 30ML VSVW TROC ESCP CNN SL BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,113.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $656.25 "$1,039.50" "$1,050.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VKML SUP HCPCS C1781 VKML - MESH SURG FLAT 12X12IN KNIT VICRYL POLYGLACTIN 910 WOVEN BOTH IP/OP "$1,899.22 " "$1,405.42" $0.00 "$1,542.16" $867.47 $867.47 $0.00 $0.00 $0.00 $395.84 "$1,409.60" "$1,409.60" $0.00 $0.00 $395.80 $0.00 "$1,123.39" "$1,123.39" $0.00 $963.85 "$1,526.75" "$1,542.16" $0.00 $0.00 $301.69 $0.00 $0.00 $306.89 $0.00 $0.00 $0.00 $0.00 $0.00 VL1060031 SUP Custom 27203010 KIT OC VAP GRD PKG BOTH IP/OP $3.03 $2.24 $0.00 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $1.51 $2.40 $2.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPL-11-7 SUP HCPCS C1713 VLBPL-11-7 - PLATE BONE 11 HOLE 7 PEG LOCKING VOLAR BEARING PLATE BOTH IP/OP "$5,187.50 " "$3,838.75" $0.00 "$4,150.00" "$2,334.38" "$2,334.38" $0.00 $0.00 $0.00 "$1,081.20" "$3,850.16" "$3,850.16" $0.00 $0.00 "$1,081.08" $0.00 "$2,557.44" "$2,557.44" $0.00 "$2,593.75" "$4,108.50" "$4,150.00" $0.00 $0.00 $811.84 $0.00 $0.00 $825.85 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPL-3-7 SUP HCPCS C1713 VLBPL-3-7 - PLATE BONE 3 HOLE 7 PEG LOCKING VOLAR BEARING PLATE TITANIUM BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$2,160.00" "$1,215.00" "$1,215.00" $0.00 $0.00 $0.00 $562.75 "$2,003.94" "$2,003.94" $0.00 $0.00 $562.68 $0.00 "$1,331.10" "$1,331.10" $0.00 "$1,350.00" "$2,138.40" "$2,160.00" $0.00 $0.00 $422.55 $0.00 $0.00 $429.84 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPL-5-5 SUP HCPCS C1713 VLBPL-5-5 - PLATE BONE 5 HOLE 5 PEG LOCKING VOLAR BEARING PLATE TITANIUM BOTH IP/OP "$2,962.50 " "$2,192.25" $0.00 "$2,370.00" "$1,333.13" "$1,333.13" $0.00 $0.00 $0.00 $617.46 "$2,198.77" "$2,198.77" $0.00 $0.00 $617.39 $0.00 "$1,460.51" "$1,460.51" $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $463.63 $0.00 $0.00 $471.63 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPL-5-7 SUP HCPCS C1713 VLBPL-5-7 - PLATE BONE 5 HOLE EDGE FREE CNTOUR VOLAR BEARING PLATE LEFT BOTH IP/OP "$2,962.50 " "$2,192.25" $0.00 "$2,370.00" "$1,333.13" "$1,333.13" $0.00 $0.00 $0.00 $617.46 "$2,198.77" "$2,198.77" $0.00 $0.00 $617.39 $0.00 "$1,460.51" "$1,460.51" $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $463.63 $0.00 $0.00 $471.63 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPL-7-7 SUP HCPCS C1713 VLBPL-7-7 - PLATE BONE 7 HOLE EDGE FREE CNTOUR VOLAR BEARING PLATE LEFT BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPL-9-7 SUP HCPCS C1713 VLBPL-9-7 - PLATE BN VOLR BRNG PLT 9 HL 7 PG LCK TI LT WRST BOTH IP/OP "$4,225.00 " "$3,126.50" $0.00 "$3,380.00" "$1,901.25" "$1,901.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,112.50" "$3,346.20" "$3,380.00" $0.00 $0.00 $661.21 $0.00 $0.00 $672.62 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPR-11-7 SUP HCPCS C1713 VLBPR-11-7 - PLATE BONE VOLAR BEARING PLATE TITANIUM RIGHT WRIST 11 HOLE BOTH IP/OP "$5,187.50 " "$3,838.75" $0.00 "$4,150.00" "$2,334.38" "$2,334.38" $0.00 $0.00 $0.00 "$1,081.20" "$3,850.16" "$3,850.16" $0.00 $0.00 "$1,081.08" $0.00 "$2,557.44" "$2,557.44" $0.00 "$2,593.75" "$4,108.50" "$4,150.00" $0.00 $0.00 $811.84 $0.00 $0.00 $825.85 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPR-3-7 SUP HCPCS C1713 VLBPR-3-7 - PLATE BONE 3 HOLE 7 PEG LOCKING VOLAR BEARING PLATE TITANIUM BOTH IP/OP "$2,700.00 " "$1,998.00" $0.00 "$2,160.00" "$1,215.00" "$1,215.00" $0.00 $0.00 $0.00 $562.75 "$2,003.94" "$2,003.94" $0.00 $0.00 $562.68 $0.00 "$1,331.10" "$1,331.10" $0.00 "$1,350.00" "$2,138.40" "$2,160.00" $0.00 $0.00 $422.55 $0.00 $0.00 $429.84 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPR-5-5 SUP HCPCS C1713 VLBPR-5-5 - PLATE TI 5 HOLE 5 PG LCK VOLR BRNG PLT BONE RIGHT BOTH IP/OP "$2,962.50 " "$2,192.25" $0.00 "$2,370.00" "$1,333.13" "$1,333.13" $0.00 $0.00 $0.00 $617.46 "$2,198.77" "$2,198.77" $0.00 $0.00 $617.39 $0.00 "$1,460.51" "$1,460.51" $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $463.63 $0.00 $0.00 $471.63 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPR-5-7 SUP HCPCS C1713 VLBPR-5-7 - PLATE BONE STANDARD 5 HOLE PEG VOLAR BEARING PLATE RIGHT BOTH IP/OP "$2,962.50 " "$2,192.25" $0.00 "$2,370.00" "$1,333.13" "$1,333.13" $0.00 $0.00 $0.00 $617.46 "$2,198.77" "$2,198.77" $0.00 $0.00 $617.39 $0.00 "$1,460.51" "$1,460.51" $0.00 "$1,481.25" "$2,346.30" "$2,370.00" $0.00 $0.00 $463.63 $0.00 $0.00 $471.63 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPR-7-7 SUP HCPCS C1713 VLBPR-7-7 - PLATE BONE STANDARD 7 HOLE PEG VOLAR BEARING PLATE RIGHT BOTH IP/OP "$3,237.50 " "$2,395.75" $0.00 "$2,590.00" "$1,456.88" "$1,456.88" $0.00 $0.00 $0.00 $674.78 "$2,402.87" "$2,402.87" $0.00 $0.00 $674.70 $0.00 "$1,596.09" "$1,596.09" $0.00 "$1,618.75" "$2,564.10" "$2,590.00" $0.00 $0.00 $506.67 $0.00 $0.00 $515.41 $0.00 $0.00 $0.00 $0.00 $0.00 VLBPR-9-7 SUP HCPCS C1713 VLBPR-9-7 - PLATE BONE 9 HOLE 7 PEG LOCKING VOLAR BEARING PLATE TITANIUM BOTH IP/OP "$4,225.00 " "$3,126.50" $0.00 "$3,380.00" "$1,901.25" "$1,901.25" $0.00 $0.00 $0.00 $880.60 "$3,135.80" "$3,135.80" $0.00 $0.00 $880.49 $0.00 "$2,082.93" "$2,082.93" $0.00 "$2,112.50" "$3,346.20" "$3,380.00" $0.00 $0.00 $661.21 $0.00 $0.00 $672.62 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCL0315 SUP Custom 27203010 VLOCL0315 - DEVICE CLSR 2-0 GS-21 .5 CRC 12IN GRN 37MM V-LOC 180 TPR PNT BOTH IP/OP $65.75 $48.66 $0.00 $52.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.80 $48.80 $0.00 $0.00 $13.70 $0.00 $0.00 $0.00 $0.00 $32.88 $52.07 $52.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCL0316 SUP Custom 27203010 VLOCL0316 - DEVICE CLOSURE 0 GS-21 .5 CIR 12IN 37MM TAPER POINT BOTH IP/OP $7.89 $5.84 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.86 $5.86 $0.00 $0.00 $1.64 $0.00 $0.00 $0.00 $0.00 $3.95 $6.25 $6.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCL0325 SUP Custom 27203010 VLOCL0325 - DEVICE CLOSURE 2-0 GS-21 .5 CIR 18IN 37MM TAPER POINT BOTH IP/OP $72.53 $53.67 $0.00 $58.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.83 $53.83 $0.00 $0.00 $15.11 $0.00 $0.00 $0.00 $0.00 $36.26 $57.44 $58.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCL0346 SUP Custom 27203010 VLOCL0346 - DEVICE CLSR 0 GS-21 9IN GRN V-LOC 180 ABS TPR PNT BOTH IP/OP $75.89 $56.16 $0.00 $728.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.32 $56.32 $0.00 $0.00 $15.81 $0.00 $0.00 $0.00 $0.00 $455.31 $721.22 $728.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCL0604 SUP Custom 27203010 VLOCL0604 - DEVICE CLSR 3-0 V-20 6IN GRN V-LOC 180 SURGALLOY ABS TPR PNT BOTH IP/OP $62.63 $46.35 $0.00 $50.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.48 $46.48 $0.00 $0.00 $13.05 $0.00 $0.00 $0.00 $0.00 $31.31 $49.60 $50.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCL0614 SUP Custom 27203010 VLOCL0614 - DEVICE CLOSURE 3-0 V-20 .5 CIR 12IN 26MM TAPER POINT BOTH IP/OP $789.00 $583.86 $0.00 $631.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $585.60 $585.60 $0.00 $0.00 $164.43 $0.00 $0.00 $0.00 $0.00 $394.50 $624.89 $631.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCL0615 SUP Custom 27203010 VLOCL0615 - DEVICE CLSR 2-0 V-20 12IN GRN V-LOC 180 TPR PNT ABS 2 ANG BOTH IP/OP $65.75 $48.66 $0.00 $52.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.80 $48.80 $0.00 $0.00 $13.70 $0.00 $0.00 $0.00 $0.00 $32.88 $52.07 $52.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCM0315 SUP Custom 27203010 VLOCM0315 - DEVICE CLOSURE 2-0 GS-21 .5 CIR 12IN 37MM TAPER POINT BOTH IP/OP $7.89 $5.84 $0.00 $6.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.86 $5.86 $0.00 $0.00 $1.64 $0.00 $0.00 $0.00 $0.00 $3.95 $6.25 $6.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCM0345 SUP HCPCS C1760 VLOCM0345 - WOUND CLOSURE DEVICE ABSORB V LOC 90 2-0 GS-21 BOTH IP/OP $73.68 $54.52 $0.00 $58.94 $33.15 $33.15 $0.00 $0.00 $0.00 $15.36 $54.68 $54.68 $0.00 $0.00 $15.35 $0.00 $43.58 $43.58 $0.00 $36.84 $58.35 $58.94 $0.00 $0.00 $11.53 $0.00 $0.00 $11.73 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCM0604 SUP Custom 27203010 VLOCM0604 - DEVICE CLSR 3-0 V-20 6IN VIOL V-LOC 90 SURGALLOY ABS TPR PNT BOTH IP/OP $62.63 $46.35 $0.00 $50.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.48 $46.48 $0.00 $0.00 $13.05 $0.00 $0.00 $0.00 $0.00 $31.31 $49.60 $50.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCM0804 SUP Custom 27203010 VLOCM0804 - DEVICE CLSR 3-0 CV-23 6IN VIOL V-LOC 90 ABS BOTH IP/OP $753.48 $557.58 $0.00 $602.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $559.23 $559.23 $0.00 $0.00 $157.02 $0.00 $0.00 $0.00 $0.00 $376.74 $596.76 $602.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCM1904 SUP Custom 27203010 VLOCM1904 - DEVICE CLSR 3-0 CV-23 6IN UD 17MM V-LOC 90 SURGALLOY ABS BOTH IP/OP $62.63 $46.35 $0.00 $50.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.48 $46.48 $0.00 $0.00 $13.05 $0.00 $0.00 $0.00 $0.00 $31.31 $49.60 $50.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLOCM1944 SUP Custom 27203010 VLOCM1944 - DEVICE CLSR 3-0 CV-23 .5 CRC 9IN UD 17MM V-LOC 90 SURGALLOY BOTH IP/OP $62.63 $46.35 $0.00 $50.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.48 $46.48 $0.00 $0.00 $13.05 $0.00 $0.00 $0.00 $0.00 $31.31 $49.60 $50.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLS03AF SUP Custom 27011340 VLS03AF - LINER TRC AIRFLO SHRT HEAD SYNTH BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $0.00 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VLS05AF SUP Custom 27011340 VLS05AF - HALTER TRC BREMER AIRFLO TALL CERV LINR LTWT VAC FRM BOTH IP/OP $255.00 $188.70 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.26 $189.26 $0.00 $0.00 $53.14 $0.00 $0.00 $0.00 $0.00 $127.50 $201.96 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VN1004040 SUP HCPCS C1874 VN1004040 - STENT ENDOPRSTH 10MM 4CM 40CM EXPANDABLE PULL LINE SOLID BOTH IP/OP "$7,695.00 " "$5,694.30" $0.00 "$6,156.00" "$3,462.75" "$3,462.75" $0.00 $0.00 $0.00 "$1,603.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,603.64" $0.00 "$3,793.64" "$3,793.64" $0.00 "$3,847.50" "$6,094.44" "$6,156.00" $0.00 $0.00 "$1,204.27" $0.00 $0.00 "$1,225.04" $0.00 $0.00 $0.00 $0.00 $0.00 VN1006040 SUP HCPCS C1874 VN1006040 - STENT ENDOPRSTH 10MM 6CM 40CM EXPANDABLE PULL LINE SOLID BOTH IP/OP "$7,695.00 " "$5,694.30" $0.00 "$6,156.00" "$3,462.75" "$3,462.75" $0.00 $0.00 $0.00 "$1,603.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,603.64" $0.00 "$3,793.64" "$3,793.64" $0.00 "$3,847.50" "$6,094.44" "$6,156.00" $0.00 $0.00 "$1,204.27" $0.00 $0.00 "$1,225.04" $0.00 $0.00 $0.00 $0.00 $0.00 VN1008040 SUP HCPCS C1874 VN1008040 - STENT ENDOPRSTH 10MM 8CM 40CM EXPANDABLE PULL LINE HOLE BOTH IP/OP "$7,695.00 " "$5,694.30" $0.00 "$6,156.00" "$3,462.75" "$3,462.75" $0.00 $0.00 $0.00 "$1,603.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,603.64" $0.00 "$3,793.64" "$3,793.64" $0.00 "$3,847.50" "$6,094.44" "$6,156.00" $0.00 $0.00 "$1,204.27" $0.00 $0.00 "$1,225.04" $0.00 $0.00 $0.00 $0.00 $0.00 VN1010040 SUP HCPCS C1874 VN1010040 - STENT ENDOPRSTH 10MM 10CM 40CM EXPANDABLE PULL LINE HOLE BOTH IP/OP "$7,695.00 " "$5,694.30" $0.00 "$6,156.00" "$3,462.75" "$3,462.75" $0.00 $0.00 $0.00 "$1,603.83" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,603.64" $0.00 "$3,793.64" "$3,793.64" $0.00 "$3,847.50" "$6,094.44" "$6,156.00" $0.00 $0.00 "$1,204.27" $0.00 $0.00 "$1,225.04" $0.00 $0.00 $0.00 $0.00 $0.00 VP40101-070 SUP Custom 27011340 VP40101-070 - IMMOBILIZER ORTH UNV 24IN QCK WRP REINF POST STAY ELC HKLP BOTH IP/OP $37.45 $27.71 $0.00 $31.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.80 $27.80 $0.00 $0.00 $7.80 $0.00 $0.00 $0.00 $0.00 $19.85 $31.44 $31.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VP-C328 SUP Custom 25003010 ANTIBODY CD10 CLONE 56C6 MS IGG1 KAPPA ANHMN 1ML LAB BOTH IP/OP "$1,512.50 " "$1,119.25" $0.00 "$1,210.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $756.25 "$1,197.90" "$1,210.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VPPL-5-7 SUP HCPCS C1713 VPPL-5-7 - PLATE BN NS VOLR FA PLT 5 HL 7 PG WRST LT VOLR BOTH IP/OP "$1,950.00 " "$1,443.00" $0.00 "$1,560.00" $877.50 $877.50 $0.00 $0.00 $0.00 $406.43 "$1,447.29" "$1,447.29" $0.00 $0.00 $406.38 $0.00 "$1,153.43" "$1,153.43" $0.00 $975.00 "$1,544.40" "$1,560.00" $0.00 $0.00 $305.18 $0.00 $0.00 $310.44 $0.00 $0.00 $0.00 $0.00 $0.00 VR702 SUP Custom 27203010 VR702 - REG PRFSN PMP KIT EXTN BOTH IP/OP "$1,500.00 " "$1,110.00" $0.00 "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.30" "$1,113.30" $0.00 $0.00 $312.60 $0.00 $0.00 $0.00 $0.00 $750.00 "$1,188.00" "$1,200.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VS0602 SUP Custom 27203010 "VIVASPIN 6 @ 10,000 MWCO" BOTH IP/OP $877.50 $649.35 $0.00 $702.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $438.75 $694.98 $702.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VS101000 SUP Custom 27203010 VS101000 - SLEEVE LAPSCOP 12MM 100MM RADIAL EXPAND BLADELESS TROCAR BOTH IP/OP $112.30 $83.10 $0.00 $91.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.35 $83.35 $0.00 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $56.99 $90.27 $91.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VS101005 SUP Custom 27203010 VS101005 - CANNULA ESCP 5MM BLU STRL LF VRSTP BLDLS TROC DIL RADL XPD BOTH IP/OP $106.55 $78.85 $0.00 $85.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.08 $79.08 $0.00 $0.00 $22.21 $0.00 $0.00 $0.00 $0.00 $53.28 $84.39 $85.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VS150000 SUP Custom 27203010 VS150000 - NEEDLE INSFL LNG 14GA 150MM VRSTP BLDLS TROC EXPANDABLE SLV BOTH IP/OP $39.95 $29.56 $0.00 $31.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.65 $29.65 $0.00 $0.00 $8.33 $0.00 $0.00 $0.00 $0.00 $19.98 $31.64 $31.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VTP2201 SUP HCPCS C9356 VTP2201 - PROTECTOR TENDON VERAWRAP HYALURONIC ACID ALGINATE 2X2 TENDO BOTH IP/OP "$4,900.00 " "$3,626.00" $0.00 "$3,920.00" "$2,205.00" "$2,205.00" $0.00 $0.00 $0.00 "$1,021.28" "$3,636.78" "$3,636.78" $0.00 $0.00 "$1,021.16" $0.00 "$2,415.70" "$2,415.70" $0.00 "$2,450.00" "$3,880.80" "$3,920.00" $0.00 $0.00 $766.85 $0.00 $0.00 $780.08 $0.00 $0.00 $0.00 $0.00 $0.00 VU-CTE-520 SUP HCPCS C1789 VU-CTE-520 - XPD TISS 520-780ML TXTR CNTER PRFL DERMASPAN P4.5-7CM BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $894.38 $894.38 $0.00 $0.00 $0.00 $414.24 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 "$1,175.61" "$1,175.61" $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $311.04 $0.00 $0.00 $316.41 $0.00 $0.00 $0.00 $0.00 $0.00 VU-CTE-720 SUP Custom 27803010 VU-CTE-720 - EXPANDER TISS P4.7-7.5CM CURVILINEAR 26.2X9CM 720-1080CC BOTH IP/OP "$1,987.50 " "$1,470.75" $0.00 "$1,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,475.12" "$1,475.12" $0.00 $0.00 $414.20 $0.00 $0.00 $0.00 $0.00 $993.75 "$1,574.10" "$1,590.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 VXH13300 SUP HCPCS C1874 VXH13300 - STENT CORON 3MM 13MM 137CM .014IN RAPEX RPTRL DLV SYS BX VLC BOTH IP/OP $2.50 $1.85 $0.00 $2.00 $1.13 $1.13 $0.00 $0.00 $0.00 $0.52 $1.86 $1.86 $0.00 $0.00 $0.52 $0.00 $1.48 $1.48 $0.00 $1.25 $1.98 $2.00 $0.00 $0.00 $0.39 $0.00 $0.00 $0.40 $0.00 $0.00 $0.00 $0.00 $0.00 W0400D SUP Custom 27203010 BRACE WLK S/MED LOW PROFILE ANKL LEG HTOP RCKR SOLE HK/LOP BOTH IP/OP $163.13 $120.72 $0.00 $130.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.56 $129.20 $130.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 W4200 SUP HCPCS C1760 W4200 - CLIP LG INTNL HRZN TI ENDSCP LIGAT STRL DISP LATEX FREE ORNG BOTH IP/OP $15.59 $11.54 $0.00 $12.47 $7.02 $7.02 $0.00 $0.00 $0.00 $3.25 $11.57 $11.57 $0.00 $0.00 $3.25 $0.00 $9.22 $9.22 $0.00 $7.80 $12.35 $12.47 $0.00 $0.00 $2.44 $0.00 $0.00 $2.48 $0.00 $0.00 $0.00 $0.00 $0.00 WA22706S SUP Custom 27203010 WA22706S - ELECTRODE ELECTROSURGICAL OLYMPUS PLASMA LOOP 30 D MEDIUM DI BOTH IP/OP "$1,157.59 " $856.62 $0.00 $859.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $859.16 $859.16 $0.00 $0.00 $241.24 $0.00 $0.00 $0.00 $0.00 $535.92 $848.91 $857.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 WA22760S SUP Custom 27203010 WA22760S - ELECTRODE ELECTROSURGICAL OLYMPUS PLASMA BUTTON MEDIUM DISPO BOTH IP/OP "$1,209.74 " $895.21 $0.00 $897.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $897.87 $897.87 $0.00 $0.00 $252.11 $0.00 $0.00 $0.00 $0.00 $560.06 $887.14 $896.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 WA425600 SUP Custom 27203010 KIT IMMUN TST CNTRL CLBRT ELISA VZV IGG 2 96 TST BOTH IP/OP $779.73 $577.00 $0.00 $623.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.86 $617.55 $623.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 WBTN-2750-T SUP HCPCS C1713 WBTN-2750-T - WASHER ORTH 5MM 27MM NS GEMINUS TI DIST VOLR RDS FOSSA BOTH IP/OP $100.00 $74.00 $0.00 $80.00 $45.00 $45.00 $0.00 $0.00 $0.00 $20.84 $74.22 $74.22 $0.00 $0.00 $20.84 $0.00 $59.15 $59.15 $0.00 $50.00 $79.20 $80.00 $0.00 $0.00 $15.65 $0.00 $0.00 $15.92 $0.00 $0.00 $0.00 $0.00 $0.00 WHV-4 SUP HCPCS C1713 WHV-4 - VOLAR HOOK PLATE BOTH IP/OP "$1,812.50 " "$1,341.25" $0.00 "$1,450.00" $815.63 $815.63 $0.00 $0.00 $0.00 $377.77 "$1,345.24" "$1,345.24" $0.00 $0.00 $377.73 $0.00 "$1,072.09" "$1,072.09" $0.00 $906.25 "$1,435.50" "$1,450.00" $0.00 $0.00 $283.66 $0.00 $0.00 $288.55 $0.00 $0.00 $0.00 $0.00 $0.00 WHV-6 SUP HCPCS C1713 WHV-6 - VOLAR HOOK PLATE BOTH IP/OP "$2,075.00 " "$1,535.50" $0.00 "$1,660.00" $933.75 $933.75 $0.00 $0.00 $0.00 $432.48 "$1,540.07" "$1,540.07" $0.00 $0.00 $432.43 $0.00 "$1,227.36" "$1,227.36" $0.00 "$1,037.50" "$1,643.40" "$1,660.00" $0.00 $0.00 $324.74 $0.00 $0.00 $330.34 $0.00 $0.00 $0.00 $0.00 $0.00 WIRE-0.7/080 SUP HCPCS C1713 WIRE-0.7/080 - WIRE FX .7MM 80MM KRSH SS BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $22.50 $22.50 $0.00 $0.00 $0.00 $10.42 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $29.58 $29.58 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $7.83 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $0.00 WIRE-0.8/120 SUP HCPCS C1713 WIRE-0.8/120 - WIRE FX .8MM 120MM KRSH SS BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $22.50 $22.50 $0.00 $0.00 $0.00 $10.42 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $29.58 $29.58 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $7.83 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $0.00 WIRE-0.9 SUP HCPCS C1713 WIRE-0.9 - WIRE FIX .9MM KWIRE STAINLESS STEEL BOTH IP/OP $37.50 $27.75 $0.00 $30.00 $16.88 $16.88 $0.00 $0.00 $0.00 $7.82 $27.83 $27.83 $0.00 $0.00 $7.82 $0.00 $22.18 $22.18 $0.00 $18.75 $29.70 $30.00 $0.00 $0.00 $5.87 $0.00 $0.00 $5.97 $0.00 $0.00 $0.00 $0.00 $0.00 WIRE-0.9/100 SUP HCPCS C1713 WIRE-0.9/100 - WIRE FX .9MM 100MM NS KRSH BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $22.50 $22.50 $0.00 $0.00 $0.00 $10.42 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $29.58 $29.58 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $7.83 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $0.00 WIRE-1.1 SUP HCPCS C1713 WIRE-1.1 - WIRE FX 1.1MM NS KRSH BOTH IP/OP $40.00 $29.60 $0.00 $32.00 $18.00 $18.00 $0.00 $0.00 $0.00 $8.34 $29.69 $29.69 $0.00 $0.00 $8.34 $0.00 $23.66 $23.66 $0.00 $20.00 $31.68 $32.00 $0.00 $0.00 $6.26 $0.00 $0.00 $6.37 $0.00 $0.00 $0.00 $0.00 $0.00 WIRE-1.6/100 SUP HCPCS C1713 WIRE-1.6/100 - WIRE FX 1.6MM 100MM NS KRSH BOTH IP/OP $50.00 $37.00 $0.00 $40.00 $22.50 $22.50 $0.00 $0.00 $0.00 $10.42 $37.11 $37.11 $0.00 $0.00 $10.42 $0.00 $29.58 $29.58 $0.00 $25.00 $39.60 $40.00 $0.00 $0.00 $7.83 $0.00 $0.00 $7.96 $0.00 $0.00 $0.00 $0.00 $0.00 WN-1104ST SUP HCPCS C1769 WN-1104ST - GUIDEWIRE ORTH .045IN 4IN SS BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $48.87 $48.87 $0.00 $0.00 $0.00 $18.76 $66.80 $66.80 $0.00 $0.00 $18.76 $0.00 $53.24 $53.24 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $14.09 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 WN-2020 SUP HCPCS C1769 WN-2020 - GWIRE ORTH 20IN 2MM SGL TROCAR TIP BOTH IP/OP $187.50 $138.75 $0.00 $150.00 $101.81 $101.81 $0.00 $0.00 $0.00 $39.08 $139.16 $139.16 $0.00 $0.00 $39.08 $0.00 $110.91 $110.91 $0.00 $93.75 $148.50 $150.00 $0.00 $0.00 $29.34 $0.00 $0.00 $29.85 $0.00 $0.00 $0.00 $0.00 $0.00 WN-2020ST SUP HCPCS C1769 WN-2020ST - GUIDEWIRE ORTH 2MM 20IN TROC TIP NTNL BOTH IP/OP $230.00 $170.20 $0.00 $184.00 $124.89 $124.89 $0.00 $0.00 $0.00 $47.94 $170.71 $170.71 $0.00 $0.00 $47.93 $0.00 $136.05 $136.05 $0.00 $115.00 $182.16 $184.00 $0.00 $0.00 $36.00 $0.00 $0.00 $36.62 $0.00 $0.00 $0.00 $0.00 $0.00 WS0450090 SUP HCPCS C1876 WS0450090 - STENT INTRCRAN 4.5MM 9MM WINGSPAN BOTH IP/OP "$15,980.00 " "$11,825.20" $0.00 "$12,784.00" "$7,191.00" "$7,191.00" $0.00 $0.00 $0.00 "$3,330.63" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,330.23" $0.00 "$7,878.14" "$7,878.14" $0.00 "$7,990.00" "$12,656.16" "$12,784.00" $0.00 $0.00 "$2,500.87" $0.00 $0.00 "$2,544.02" $0.00 $0.00 $0.00 $0.00 $0.00 WS1406ST SUP HCPCS C1769 WS1406ST - GUIDEWIRE ORTH 6IN .054IN ACTRK SS 1 TROC TIP BOTH IP/OP $25.00 $18.50 $0.00 $20.00 $13.58 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.50 $19.80 $20.00 $0.00 $0.00 $3.91 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $0.00 WS-1504STT SUP HCPCS C1769 WS-1504STT - GWIRE ORTH 4IN .054IN SS THRD BOTH IP/OP $122.50 $90.65 $0.00 $98.00 $66.52 $66.52 $0.00 $0.00 $0.00 $25.53 $90.92 $90.92 $0.00 $0.00 $25.53 $0.00 $72.46 $72.46 $0.00 $61.25 $97.02 $98.00 $0.00 $0.00 $19.17 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 WS1505-DT SUP HCPCS C1769 WS1505-DT - WIRE FIX .062IN KWIRE FSN BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $9.50 $9.50 $0.00 $0.00 $0.00 $3.65 $12.99 $12.99 $0.00 $0.00 $3.65 $0.00 $10.35 $10.35 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 WS-1606 SUP HCPCS C1771 WS-1606 - GWIRE ORTH 6IN .062IN SS BOTH IP/OP $17.50 $12.95 $0.00 $14.00 $7.88 $7.88 $0.00 $0.00 $0.00 $3.65 $12.99 $12.99 $0.00 $0.00 $3.65 $0.00 $10.35 $10.35 $0.00 $8.75 $13.86 $14.00 $0.00 $0.00 $2.74 $0.00 $0.00 $2.79 $0.00 $0.00 $0.00 $0.00 $0.00 WS2009ST SUP HCPCS C1769 WS2009ST - GUIDEWIRE ORTH 9IN 2IN SHLDR ELB SS BOTH IP/OP $25.00 $18.50 $0.00 $20.00 $13.58 $13.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.50 $19.80 $20.00 $0.00 $0.00 $3.91 $0.00 $0.00 $3.98 $0.00 $0.00 $0.00 $0.00 $0.00 WS-2020 SUP HCPCS C1769 WS-2020 - GWIRE ORTH 20IN .078IN PLRS HUM SHLDR SS BOTH IP/OP $147.50 $109.15 $0.00 $118.00 $80.09 $80.09 $0.00 $0.00 $0.00 $30.74 $109.47 $109.47 $0.00 $0.00 $30.74 $0.00 $87.25 $87.25 $0.00 $73.75 $116.82 $118.00 $0.00 $0.00 $23.08 $0.00 $0.00 $23.48 $0.00 $0.00 $0.00 $0.00 $0.00 WS-2409STT SUP HCPCS C1769 WS-2409STT - GWIRE ORTH 9IN .094IN 1 TROCAR THRD BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $48.87 $48.87 $0.00 $0.00 $0.00 $18.76 $66.80 $66.80 $0.00 $0.00 $18.76 $0.00 $53.24 $53.24 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $14.09 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 WT-0906STT SUP HCPCS C1769 WT-0906STT - GWIRE ORTH 6IN .035IN TI THRD BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $48.87 $48.87 $0.00 $0.00 $0.00 $18.76 $66.80 $66.80 $0.00 $0.00 $18.76 $0.00 $53.24 $53.24 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $14.09 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 WT-1606STT SUP HCPCS C1769 WT-1606STT - GWIRE ORTH 5.75IN .062IN ACTRK TI 1 TROCAR TIP THRD BOTH IP/OP $90.00 $66.60 $0.00 $72.00 $48.87 $48.87 $0.00 $0.00 $0.00 $18.76 $66.80 $66.80 $0.00 $0.00 $18.76 $0.00 $53.24 $53.24 $0.00 $45.00 $71.28 $72.00 $0.00 $0.00 $14.09 $0.00 $0.00 $14.33 $0.00 $0.00 $0.00 $0.00 $0.00 X0411407 SUP HCPCS C1713 X0411407 - CONNECTOR ROD 10MM CD HORIZON CROSSLINK GDLH LIBERTY SEXTANT BOTH IP/OP "$4,822.50 " "$3,568.65" $0.00 "$3,858.00" "$2,170.13" "$2,170.13" $0.00 $0.00 $0.00 "$1,005.13" "$3,579.26" "$3,579.26" $0.00 $0.00 "$1,005.01" $0.00 "$2,377.49" "$2,377.49" $0.00 "$2,411.25" "$3,819.42" "$3,858.00" $0.00 $0.00 $754.72 $0.00 $0.00 $767.74 $0.00 $0.00 $0.00 $0.00 $0.00 X0590 SUP Custom 27203010 BLOTTER EPHRS BIOTN 15ML BOTH IP/OP $386.53 $286.03 $0.00 $309.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.26 $306.13 $309.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 X42200 SUP HCPCS C1713 X42200 - SUB BNGFT 10X2.5CM GRFTN DBM PLIF BOTH IP/OP "$4,926.25 " "$3,645.43" $0.00 "$3,941.00" "$2,216.81" "$2,216.81" $0.00 $0.00 $0.00 "$1,026.75" "$3,656.26" "$3,656.26" $0.00 $0.00 "$1,026.63" $0.00 "$2,428.64" "$2,428.64" $0.00 "$2,463.13" "$3,901.59" "$3,941.00" $0.00 $0.00 $770.96 $0.00 $0.00 $784.26 $0.00 $0.00 $0.00 $0.00 $0.00 X42210 SUP HCPCS C1713 X42210 - SUB BNGFT 5X2.5CM GRFTN DBM PLIF BOTH IP/OP "$3,053.75 " "$2,259.78" $0.00 "$2,266.49" $765.62 $765.62 $0.00 $0.00 $0.00 $636.48 "$2,266.49" "$2,266.49" $0.00 $0.00 $636.40 $0.00 "$1,505.50" "$1,505.50" $0.00 $850.69 "$1,347.49" "$1,361.10" $0.00 $0.00 $266.27 $0.00 $0.00 $270.86 $0.00 $0.00 $0.00 $0.00 $0.00 X44135 SUP HCPCS C1713 X44135 - SUB BNGFT GRFTN LG DFCT DBM OTHBLND JAR 15ML BOTH IP/OP "$3,080.00 " "$2,279.20" $0.00 "$2,745.60" "$1,544.40" "$1,544.40" $0.00 $0.00 $0.00 $641.95 "$2,285.98" "$2,285.98" $0.00 $0.00 $641.87 $0.00 "$1,518.44" "$1,518.44" $0.00 "$1,716.00" "$2,718.14" "$2,745.60" $0.00 $0.00 $537.11 $0.00 $0.00 $546.37 $0.00 $0.00 $0.00 $0.00 $0.00 X44145 SUP HCPCS C1713 X44145 - SUB BNGFT GRFTN SM DFCT DBM OTHBLND JAR 5ML BOTH IP/OP "$2,340.00 " "$1,731.60" $0.00 "$1,872.00" "$1,053.00" "$1,053.00" $0.00 $0.00 $0.00 $487.71 "$1,736.75" "$1,736.75" $0.00 $0.00 $487.66 $0.00 "$1,384.11" "$1,384.11" $0.00 "$1,170.00" "$1,853.28" "$1,872.00" $0.00 $0.00 $366.21 $0.00 $0.00 $372.53 $0.00 $0.00 $0.00 $0.00 $0.00 X523H SUP Custom 27203010 X523H - SUTURE NABSB 2-0 SH 36IN GRN EBND 2 ARM BRD BOTH IP/OP $387.23 $286.55 $0.00 $314.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.40 $287.40 $0.00 $0.00 $80.70 $0.00 $0.00 $0.00 $0.00 $196.52 $311.28 $314.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 X559H SUP Custom 27203010 X559H - SUTURE NONABSORBABLE 2-0 SH-2 36IN 2 ARM BRAID ETHIBOND BOTH IP/OP $416.10 $307.91 $0.00 $337.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.83 $308.83 $0.00 $0.00 $86.72 $0.00 $0.00 $0.00 $0.00 $211.17 $334.49 $337.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 X833H SUP Custom 27203010 X833H - SUTURE NABSB 2-0 SH 30IN GRN EBND BRD BOTH IP/OP $5.31 $3.93 $0.00 $153.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.94 $3.94 $0.00 $0.00 $1.11 $0.00 $0.00 $0.00 $0.00 $95.66 $151.53 $153.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XA3816KT SUP HCPCS C1751 XA3816KT - KIT CATHETER 8.5FR 16CM 3 LUMEN EXPAND CHLORAPREP SAFETY BOTH IP/OP $825.00 $610.50 $0.00 $660.00 $371.25 $371.25 $0.00 $0.00 $0.00 $171.95 $612.32 $612.32 $0.00 $0.00 $171.93 $0.00 $487.99 $487.99 $0.00 $412.50 $653.40 $660.00 $0.00 $0.00 $129.11 $0.00 $0.00 $131.34 $0.00 $0.00 $0.00 $0.00 $0.00 XA3820KT SUP HCPCS C1751 XA3820KT - CATHETER CV 20CM PEDIASAT 3 LUM OXM CNT SCVO2 MNTR PED BOTH IP/OP "$1,125.00 " $832.50 $0.00 $900.00 $506.25 $506.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $562.50 $891.00 $900.00 $0.00 $0.00 $176.06 $0.00 $0.00 $179.10 $0.00 $0.00 $0.00 $0.00 $0.00 XBR001002 SUP HCPCS C1713 XBR001002 - WIRE FX OLV 1.2MM 65MM KRSH SMTH TROC TIP BOTH IP/OP $209.95 $155.36 $0.00 $280.04 $157.52 $157.52 $0.00 $0.00 $0.00 $43.76 $155.82 $155.82 $0.00 $0.00 $43.75 $0.00 $124.19 $124.19 $0.00 $175.03 $277.24 $280.04 $0.00 $0.00 $54.78 $0.00 $0.00 $55.73 $0.00 $0.00 $0.00 $0.00 $0.00 XC200 SUP Custom 27803010 XC200 - CLIP SUT STRL LF LPR TY VCL 1 PC ABS POLY BOTH IP/OP $352.00 $260.48 $0.00 $489.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $261.25 $261.25 $0.00 $0.00 $73.36 $0.00 $0.00 $0.00 $0.00 $176.00 $489.50 $281.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XF0012002 SUP Custom 27203010 XF0012002 - BIT DRL 2MM AO BOTH IP/OP $490.85 $363.23 $0.00 $392.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $364.31 $364.31 $0.00 $0.00 $102.29 $0.00 $0.00 $0.00 $0.00 $245.43 $388.75 $392.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XFO082001 SUP Custom 27203010 XFO082001 - BIT DRL 2MM 3MM SCR BOTH IP/OP $287.30 $212.60 $0.00 $392.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.23 $213.23 $0.00 $0.00 $59.87 $0.00 $0.00 $0.00 $0.00 $245.43 $388.75 $392.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XFO082501 SUP Custom 27203010 XFO082501 - BIT DRL 2.5MM 3.5MM SCR BOTH IP/OP $287.30 $212.60 $0.00 $392.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.23 $213.23 $0.00 $0.00 $59.87 $0.00 $0.00 $0.00 $0.00 $245.43 $388.75 $392.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XHAT45 SUP Custom 27203010 KIT IMMUN TST ELISA ANTI-PF4 45 TST BOTH IP/OP "$1,181.73 " $874.48 $0.00 $945.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.86 $935.93 $945.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XL-105914 SUP HCPCS C1776 XL-105914 - LINER ACETAB 24 36MM HIGH WALL RINGLOC ARCOMXL HIP BOTH IP/OP "$6,575.00 " "$4,865.50" $0.00 "$5,260.00" "$2,958.75" "$2,958.75" $0.00 $0.00 $0.00 "$1,370.39" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,370.23" $0.00 "$3,241.48" "$3,241.48" $0.00 "$3,287.50" "$5,207.40" "$5,260.00" $0.00 $0.00 "$1,028.99" $0.00 $0.00 "$1,046.74" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0204S SUP HCPCS C1763 XM106.0204S - GRAFT SFT TIS 4X2CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP $485.00 $358.90 $0.00 $388.00 $218.25 $218.25 $0.00 $0.00 $0.00 $101.09 $359.97 $359.97 $0.00 $0.00 $101.07 $0.00 $286.88 $286.88 $0.00 $242.50 $384.12 $388.00 $0.00 $0.00 $75.90 $0.00 $0.00 $77.21 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0407S SUP HCPCS C1763 XM106.0407S - GRAFT SFT TIS 7X4CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$1,732.50 " "$1,282.05" $0.00 "$1,386.00" $779.63 $779.63 $0.00 $0.00 $0.00 $361.10 "$1,285.86" "$1,285.86" $0.00 $0.00 $361.05 $0.00 "$1,024.77" "$1,024.77" $0.00 $866.25 "$1,372.14" "$1,386.00" $0.00 $0.00 $271.14 $0.00 $0.00 $275.81 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0416S SUP HCPCS C1763 XM106.0416S - GRAFT SFT TIS 16X4CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$4,790.00 " "$3,544.60" $0.00 "$3,832.00" "$2,155.50" "$2,155.50" $0.00 $0.00 $0.00 $998.36 "$3,555.14" "$3,555.14" $0.00 $0.00 $998.24 $0.00 "$2,361.47" "$2,361.47" $0.00 "$2,395.00" "$3,793.68" "$3,832.00" $0.00 $0.00 $749.64 $0.00 $0.00 $762.57 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0516S SUP HCPCS C1763 XM106.0516S - GRAFT SFT TIS 16X5CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$5,985.00 " "$4,428.90" $0.00 "$4,788.00" "$2,693.25" "$2,693.25" $0.00 $0.00 $0.00 "$1,247.42" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,247.27" $0.00 "$2,950.61" "$2,950.61" $0.00 "$2,992.50" "$4,740.12" "$4,788.00" $0.00 $0.00 $936.65 $0.00 $0.00 $952.81 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0612S SUP HCPCS C1763 XM106.0612S - GRAFT SFT TIS 12X6CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$4,455.30 " "$3,296.92" $0.00 "$3,564.24" "$2,004.89" "$2,004.89" $0.00 $0.00 $0.00 $928.60 "$3,306.72" "$3,306.72" $0.00 $0.00 $928.48 $0.00 "$2,196.46" "$2,196.46" $0.00 "$2,227.65" "$3,528.60" "$3,564.24" $0.00 $0.00 $697.25 $0.00 $0.00 $709.28 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0616S SUP HCPCS C1763 XM106.0616S - GRAFT SFT TIS 16X6CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$5,939.73 " "$4,395.40" $0.00 "$4,751.78" "$2,672.88" "$2,672.88" $0.00 $0.00 $0.00 "$1,237.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,237.84" $0.00 "$2,928.28" "$2,928.28" $0.00 "$2,969.86" "$4,704.27" "$4,751.78" $0.00 $0.00 $929.57 $0.00 $0.00 $945.60 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0620S SUP HCPCS C1763 XM106.0620S - GRAFT SFT TIS 20X6CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$8,977.50 " "$6,643.35" $0.00 "$7,182.00" "$4,039.88" "$4,039.88" $0.00 $0.00 $0.00 "$1,871.14" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,870.91" $0.00 "$4,425.91" "$4,425.91" $0.00 "$4,488.75" "$7,110.18" "$7,182.00" $0.00 $0.00 "$1,404.98" $0.00 $0.00 "$1,429.22" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0812S SUP HCPCS C1763 XM106.0812S - GRAFT SFT TIS 12X8CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$5,939.73 " "$4,395.40" $0.00 "$4,751.78" "$2,672.88" "$2,672.88" $0.00 $0.00 $0.00 "$1,237.99" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,237.84" $0.00 "$2,928.28" "$2,928.28" $0.00 "$2,969.86" "$4,704.27" "$4,751.78" $0.00 $0.00 $929.57 $0.00 $0.00 $945.60 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0816S SUP HCPCS C1763 XM106.0816S - GRAFT SFT TIS 16X8CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$7,920.30 " "$5,861.02" $0.00 "$6,336.24" "$3,564.14" "$3,564.14" $0.00 $0.00 $0.00 "$1,650.79" "$4,181.12" "$4,181.12" $0.00 $0.00 "$1,650.59" $0.00 "$3,904.71" "$3,904.71" $0.00 "$3,960.15" "$6,272.88" "$6,336.24" $0.00 $0.00 "$1,239.53" $0.00 $0.00 "$1,260.91" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.0820S SUP HCPCS C1763 XM106.0820S - GRAFT SFT TIS 20X8CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$9,898.88 " "$7,325.17" $0.00 "$7,919.10" "$4,454.49" "$4,454.49" $0.00 $0.00 $0.00 "$2,063.17" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,062.93" $0.00 "$4,880.15" "$4,880.15" $0.00 "$4,949.44" "$7,839.91" "$7,919.10" $0.00 $0.00 "$1,549.17" $0.00 $0.00 "$1,575.90" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.1016S SUP HCPCS C1763 XM106.1016S - GRAFT SFT TIS 16X10CM XCM BIOLOGIC THK PIG DERM XCLR MTRX BOTH IP/OP "$9,898.88 " "$7,325.17" $0.00 "$7,919.10" "$4,454.49" "$4,454.49" $0.00 $0.00 $0.00 "$2,063.17" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,062.93" $0.00 "$4,880.15" "$4,880.15" $0.00 "$4,949.44" "$7,839.91" "$7,919.10" $0.00 $0.00 "$1,549.17" $0.00 $0.00 "$1,575.90" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.1020S SUP HCPCS C1762 XM106.1020S - DD-XCM BIOLOGIC TISSUE MATRIX 10CM X 20CM/THICK-STERILE BOTH IP/OP "$12,373.60 " "$9,156.46" $0.00 "$9,898.88" $0.00 $0.00 $0.00 $0.00 $0.00 "$2,578.97" "$4,181.12" "$4,181.12" $0.00 $0.00 "$2,578.66" $0.00 "$6,100.18" "$6,100.18" $0.00 "$6,186.80" "$9,799.89" "$9,898.88" $0.00 $0.00 "$1,936.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.1220S SUP HCPCS C1763 XM106.1220S - GRAFT SFT TIS 20X12CM XCM BIOLOGIC THK PIG DERM NONCROSS LNK BOTH IP/OP "$14,848.33 " "$10,987.76" $0.00 "$11,878.66" "$6,681.75" "$6,681.75" $0.00 $0.00 $0.00 "$3,094.76" "$4,181.12" "$4,181.12" $0.00 $0.00 "$3,094.39" $0.00 "$7,320.22" "$7,320.22" $0.00 "$7,424.16" "$11,759.88" "$11,878.66" $0.00 $0.00 "$2,323.76" $0.00 $0.00 "$2,363.85" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.1620S SUP HCPCS C1762 XM106.1620S - DD-XCM BIOLOGIC TISSUE MATRIX 16CM X 20CM/THICK-STERILE BOTH IP/OP "$19,795.80 " "$14,648.89" $0.00 "$15,836.64" $0.00 $0.00 $0.00 $0.00 $0.00 "$4,125.94" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,125.44" $0.00 "$9,759.33" "$9,759.33" $0.00 "$9,897.90" "$15,678.27" "$15,836.64" $0.00 $0.00 "$3,098.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XM106.1625S SUP HCPCS C1763 XM106.1625S - GRAFT SFT TIS 25X16CM XCM BIOLOGIC THK PIG DERM HDRT XCLR BOTH IP/OP "$23,201.73 " "$17,169.28" $0.00 "$18,561.38" "$10,440.78" "$10,440.78" $0.00 $0.00 $0.00 "$4,835.82" "$4,181.12" "$4,181.12" $0.00 $0.00 "$4,835.24" $0.00 "$11,438.45" "$11,438.45" $0.00 "$11,600.86" "$18,375.77" "$18,561.38" $0.00 $0.00 "$3,631.07" $0.00 $0.00 "$3,693.71" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.2020S SUP HCPCS C1763 XM106.2020S - GRAFT SFT TIS 20X20CM XCM BIOLOGIC THK PIG DERM XCLR MTRX BOTH IP/OP "$24,745.23 " "$18,311.47" $0.00 "$19,796.18" "$11,135.35" "$11,135.35" $0.00 $0.00 $0.00 "$5,157.52" "$4,181.12" "$4,181.12" $0.00 $0.00 "$5,156.90" $0.00 "$12,199.40" "$12,199.40" $0.00 "$12,372.61" "$19,598.22" "$19,796.18" $0.00 $0.00 "$3,872.63" $0.00 $0.00 "$3,939.44" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.2025S SUP HCPCS C1763 XM106.2025S - GRAFT SFT TIS 25X20CM XCM BIOLOGIC THK PIG DERM MTRX STRL BOTH IP/OP "$30,933.00 " "$22,890.42" $0.00 "$24,746.40" "$13,919.85" "$13,919.85" $0.00 $0.00 $0.00 "$6,447.21" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,446.44" $0.00 "$15,249.97" "$15,249.97" $0.00 "$15,466.50" "$24,498.94" "$24,746.40" $0.00 $0.00 "$4,841.01" $0.00 $0.00 "$4,924.53" $0.00 $0.00 $0.00 $0.00 $0.00 XM106.2030S SUP HCPCS C1763 XM106.2030S - GRAFT SFT TIS 30X20CM XCM BIOLOGIC THK PIG DERM HDRT XCLR BOTH IP/OP "$37,116.85 " "$27,466.47" $0.00 "$29,693.48" "$16,702.58" "$16,702.58" $0.00 $0.00 $0.00 "$7,736.08" "$4,181.12" "$4,181.12" $0.00 $0.00 "$7,735.15" $0.00 "$18,298.61" "$18,298.61" $0.00 "$18,558.43" "$29,396.55" "$29,693.48" $0.00 $0.00 "$5,808.79" $0.00 $0.00 "$5,909.00" $0.00 $0.00 $0.00 $0.00 $0.00 XP-5000 SUP Custom 27203010 XP-5000 - STABILIZER SRG YLW ACRB-I VAC PSTNR BOTH IP/OP "$2,467.50 " "$1,825.95" $0.00 "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,233.75" "$1,954.26" "$1,974.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 XT-7542 SUP HCPCS C1725 XT-7542 - CATHETER BLNDIL .035IN 5FR 4MM 75CM 2CM OPTPLST XT 2 LUM BOTH IP/OP $497.50 $368.15 $0.00 $398.00 $270.14 $270.14 $0.00 $0.00 $0.00 $103.69 $369.24 $369.24 $0.00 $0.00 $103.68 $0.00 $294.27 $294.27 $0.00 $248.75 $394.02 $398.00 $0.00 $0.00 $77.86 $0.00 $0.00 $79.20 $0.00 $0.00 $0.00 $0.00 $0.00 Y3462 SUP Custom 27203010 MEDIA CULT YST BROTH SENSITITRE BOTH IP/OP $65.20 $48.25 $0.00 $52.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.60 $51.64 $52.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 YO-9 SUP Custom 27203010 KIT MYCTST YEASTONE ANIDULAFUNGIN MICAFUNGIN PLT BOTH IP/OP $791.78 $585.92 $0.00 $633.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $395.89 $627.09 $633.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Z117H SUP Custom 27203010 Z117H - SUTURE ABSORBABLE 6-0 BV-1 30IN 2 ARM MONOFILAMENT PDS II BOTH IP/OP $39.65 $29.34 $0.00 $31.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.43 $29.43 $0.00 $0.00 $8.26 $0.00 $0.00 $0.00 $0.00 $19.83 $31.40 $31.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Z126H SUP Custom 27203010 Z126H - SUTURE ABSORBABLE 5-0 C-1 30IN 2 ARM MONOFILAMENT PDS II BOTH IP/OP $46.32 $34.28 $0.00 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.38 $34.38 $0.00 $0.00 $9.65 $0.00 $0.00 $0.00 $0.00 $23.51 $37.23 $37.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Z135H SUP Custom 27203010 Z135H - SUTURE ABSORBABLE 7-0 BV-1 30IN 2 ARM MONOFILAMENT PDS II BOTH IP/OP $40.04 $29.63 $0.00 $32.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.72 $29.72 $0.00 $0.00 $8.34 $0.00 $0.00 $0.00 $0.00 $20.02 $31.71 $32.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Z137H SUP Custom 27203010 Z137H - SUTURE ABSORBABLE 4-0 V-5 36IN 2 ARM MONOFILAMENT PDS II BOTH IP/OP $25.17 $18.63 $0.00 $20.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.68 $18.68 $0.00 $0.00 $5.25 $0.00 $0.00 $0.00 $0.00 $12.58 $19.93 $20.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Z60353 SUP HCPCS L8614 Z60353 - IMPLANT COCHLEAR FREEDOM CNTOUR ADVANCE NUCLEUS CI24RE BOTH IP/OP "$39,847.50 " "$29,487.15" $0.00 "$31,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,181.12" "$4,181.12" $0.00 $0.00 "$8,304.22" $0.00 $0.00 $0.00 $0.00 "$19,923.75" "$31,559.22" "$31,878.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 ZBM12060 SUP HCPCS C2625 ZBM12060 - STENT BIL 12MM 6FR 60MM 80CM .035IN SLF XPD DLV SYS LMNX BOTH IP/OP "$3,883.20 " "$2,873.57" $0.00 "$3,106.56" "$1,747.44" "$1,747.44" $0.00 $0.00 $0.00 $809.36 "$2,882.11" "$2,882.11" $0.00 $0.00 $809.26 $0.00 "$1,914.42" "$1,914.42" $0.00 "$1,941.60" "$3,075.49" "$3,106.56" $0.00 $0.00 $607.72 $0.00 $0.00 $618.21 $0.00 $0.00 $0.00 $0.00 $0.00 ZTEG-2P-28-120-PF-US SUP HCPCS C1874 ZTEG-2P-28-120-PF-US - GRAFT EVAS 120MM 28MM 22FR ZNTH TX2 THOR AORTIC ANRSM PROX BOTH IP/OP "$30,235.00 " "$22,373.90" $0.00 "$24,188.00" "$13,605.75" "$13,605.75" $0.00 $0.00 $0.00 "$6,301.73" "$4,181.12" "$4,181.12" $0.00 $0.00 "$6,300.97" $0.00 "$14,905.86" "$14,905.86" $0.00 "$15,117.50" "$23,946.12" "$24,188.00" $0.00 $0.00 "$4,731.78" $0.00 $0.00 "$4,813.41" $0.00 $0.00 $0.00 $0.00 $0.00 100 EAP CPT® 00100 "PR ANESTH,SALIVARY GLAND W/BX" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 103 EAP CPT® 00103 "PR ANESTH,BLEPHAROPLASTY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 120 EAP CPT® 00120 "ANESTH,EAR SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 124 EAP CPT® 00124 "ANESTH,EAR EXAM" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 140 EAP CPT® 00140 "PR ANESTH,PROCEDURES ON EYE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 142 EAP CPT® 00142 "ANESTH, LENS SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 144 EAP CPT® 00144 "PR ANESTH,CORNEAL TRANSPLANT" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 145 EAP CPT® 00145 "ANESTH, VITREORETINAL SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 160 EAP CPT® 00160 "PR ANESTH,NOSE,SINUS SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 162 EAP CPT® 00162 "PR ANESTH,NOSE,RADICAL SINUS SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 170 EAP CPT® 00170 "PR ANESTH,PROCEDURE ON MOUTH" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 190 EAP CPT® 00190 "PR ANESTH,FACIAL BONE SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 192 EAP CPT® 00192 "PR ANESTH,RADICAL FACIAL BONE SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 210 EAP CPT® 00210 "PR ANESTH,OPEN HEAD SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 211 EAP CPT® 00211 "PR ANESTH, INTRACRANIAL HEMATOMA EVACUATION" OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 214 EAP CPT® 00214 "PR ANESTH,SKULL SURG BURR HOLE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 215 EAP CPT® 00215 "PR ANESTH, CRANIOPLASTY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 216 EAP CPT® 00216 "PR ANESTH,HEAD VESSEL SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 220 EAP CPT® 00220 "PR ANESTH,INTRACRAN PROC; CSF SHUNT PROC" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 300 EAP CPT® 00300 "PR ANESTH,SKIN SURG HEAD/NECK" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 320 EAP CPT® 00320 "PR ANESTH,NECK ORG PROC; NOS, AGE 1 YR/OLD" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 326 EAP CPT® 00326 "PR ANESTH,LARYNX/TRACH PROC; CHILDREN <1 YR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 350 EAP CPT® 00350 "PR ANESTH,NECK VESSEL SURGERY NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 352 EAP CPT® 00352 "PR ANESTH,NECK VESSEL SURG SIMPL LIGAT" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 400 EAP CPT® 00400 "PR ANESTH,SKIN SURG THORAX/EXTR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 402 EAP CPT® 00402 "PR ANESTH,SURG BREAST RECONSTRUCTIVE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 404 EAP CPT® 00404 "PR ANESTH,SURG BREAST RAD MASTEC" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 410 EAP CPT® 00410 "PR ANESTH,CORRECT HEART RHYTHM" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 450 EAP CPT® 00450 "PR ANESTH,SURG CLAVICLE/SCAPULA" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 470 EAP CPT® 00470 "PR ANESTH,PARTIAL RIB RESECTN" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 500 EAP CPT® 00500 "PR ANESTH,ESOPHAGEAL SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 520 EAP CPT® 00520 "PR ANESTH,CHEST PROC CLOSED,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 528 EAP CPT® 00528 "PR ANESTH,MEDIASTINOSCOPY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 529 EAP CPT® 00529 "PR ANESTH, CHEST PARTITION VIEW" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 532 EAP CPT® 00532 "PR ANESTH,CENTRL VASCULAR ACCESS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 534 EAP CPT® 00534 "PR ANESTH,CARDIOVERTER/DEFIB" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 540 EAP CPT® 00540 "PR ANESTH,CHEST SURGERY,THORACOTOMY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 541 EAP CPT® 00541 "PR ANESTH,THORACOTOMY PROC, W/1 LUNG VENT" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 542 EAP CPT® 00542 "PR ANESTH,CHEST DECORTICATION" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 560 EAP CPT® 00560 "PR ANESTH,OPEN HEART; W/O PUMP OXYEGENATOR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 562 EAP CPT® 00562 "PR ANESTH,OPEN HEART SURGERY+PUMP" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 566 EAP CPT® 00566 "PR ANESTH,DIRECT CABG W/O PUMP OXYGENATOR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 567 EAP CPT® 00567 "PR ANESTH, DIRECT CABG W PUMP OXYGENATOR" OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 600 EAP CPT® 00600 "PR ANESTH,CERV SPINE,CORD SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 620 EAP CPT® 00620 "PR ANESTH,THOR SPINE,CORD SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 630 EAP CPT® 00630 "PR ANESTH,LUMBAR SPINE,CORD SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 635 EAP CPT® 00635 "PR ANESTH,LUMBAR PUNCTURE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 670 EAP CPT® 00670 "PR ANESTH,EXTENSIVE SPINE,CORD PROCED" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 700 EAP CPT® 00700 "PR ANESTH,ABD WALL,UPER ANTER,SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 702 EAP CPT® 00702 "PR ANESTH,FOR LIVER BIOPSY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 731 EAP CPT® 00731 PR ANESTHESIA UPPER GI ENDOSCOPIC PX NOS OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 732 EAP CPT® 00732 PR ANESTHESIA UPPER GI ENDOSCOPIC PX ERCP OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 750 EAP CPT® 00750 "PR ANESTH,REPAIR UPPER ABD HERNIA NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 752 EAP CPT® 00752 "PR ANESTH,REPAIR UP HERNIA LUMBAR/VENTR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 770 EAP CPT® 00770 "PR ANESTH,MAJOR ABD BLOOD VESSEL REPAIR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 790 EAP CPT® 00790 "PR ANESTH,SURG UPPER ABDOMEN" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 792 EAP CPT® 00792 "PR ANESTH,PARTIAL LIVER REMOVAL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 794 EAP CPT® 00794 "PR ANESTH,PANCREAS REMOVAL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 800 EAP CPT® 00800 "PR ANESTH,ABD WALL,LOWER ANT,SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 802 EAP CPT® 00802 "PR ANESTH,FAT LAYER REMOVAL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 811 EAP CPT® 00811 PR ANESTHESIA LOWER INTST ENDOSCOPIC PX NOS OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 812 EAP CPT® 00812 PR ANESTHESIA LOWER INTST ENDOSCOPIC PX SCR COLSC OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 813 EAP CPT® 00813 PR ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 830 EAP CPT® 00830 "PR ANESTH,REPAIR LO ABD HERNIA NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 832 EAP CPT® 00832 "PR ANESTH,REPAIR LO HERNIA VENTR/INCIS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 840 EAP CPT® 00840 "PR ANESTH,SURG LOWER ABDOMEN" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 851 EAP CPT® 00851 "PR ANESTH,TUBAL LIGATION/TRANSECTION" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 860 EAP CPT® 00860 "PR ANESTH,SURG LOW ABD,EXTRAPERINTONEAL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 862 EAP CPT® 00862 "PR ANESTH,KIDNEY,PROX URETER SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 864 EAP CPT® 00864 "PR ANESTH,REMOVAL OF BLADDER" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 865 EAP CPT® 00865 "PR ANESTH,REMOVAL OF PROSTATE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 866 EAP CPT® 00866 "PR ANESTH,REMOVAL OF ADRENAL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 902 EAP CPT® 00902 "PR ANESTH,ANORECTAL SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 904 EAP CPT® 00904 "PR ANESTH,RADICAL PERINEAL SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 906 EAP CPT® 00906 "PR ANESTH,REMOVAL OF VULVA" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 910 EAP CPT® 00910 "PR ANESTH,TRANSURETHRAL SURG,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 912 EAP CPT® 00912 "PR ANESTH,XURETHRAL BLADDER TUMOR SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 914 EAP CPT® 00914 "PR ANESTH,XURETHRAL REMOVAL OF PROSTATE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 918 EAP CPT® 00918 "PR ANESTH,STONE RMVOVAL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 920 EAP CPT® 00920 "PR ANESTH,MALE GENITALIA SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 926 EAP CPT® 00926 "PR ANESTH,RADICAL REMV TESTIS,INGUINAL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 930 EAP CPT® 00930 "PR ANESTH,TESTIS SUSPENSION" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 940 EAP CPT® 00940 "PR ANESTH,VAGINAL PROCEDURES" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 942 EAP CPT® 00942 "PR ANESTH,COLPOT,VAGINECT,COLPORR,URETH PRO" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 944 EAP CPT® 00944 "PR ANESTH,VAGINAL HYSTERECTOMY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 948 EAP CPT® 00948 "PR ANESTH,REPAIR OF CERVIX" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 952 EAP CPT® 00952 "PR ANESTH,HYSTEROSCOPY/VAG BX" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1112 EAP CPT® 01112 "PR ANESTH,BONE MARROW ASP/BX ILIAC CRST" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1120 EAP CPT® 01120 "PR ANESTH,BONY PELVIS SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1160 EAP CPT® 01160 "PR ANESTH,PUBIS,SACROILIAC OPEN PROC" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1170 EAP CPT® 01170 "PR ANESTH,PUBIS,SACROILIAC CLOSED PROC" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1173 EAP CPT® 01173 "PR ANESTH, FX REPAIR, PELVIS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1200 EAP CPT® 01200 "PR ANESTH,HIP JOINT PROCEDURE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1202 EAP CPT® 01202 "PR ANESTH,ARTHROSCOPY OF HIP" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1210 EAP CPT® 01210 "PR ANESTH,HIP JOINT SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1214 EAP CPT® 01214 "PR ANESTH,TOTAL HIP ARTHROPLASTY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1215 EAP CPT® 01215 "PR ANESTH,REVISE TOTAL HIP ARTHROPLASTY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1220 EAP CPT® 01220 "PR ANESTH,CLOSED PROC UPPER 2/3 FEMUR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1230 EAP CPT® 01230 "PR ANESTH,OPEN PROC UPPER 2/3 FEMUR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1232 EAP CPT® 01232 "PR ANESTH,AMPUTATION OF FEMUR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1250 EAP CPT® 01250 "PR ANESTH,UPPER LEG SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1260 EAP CPT® 01260 "PR ANESTH,UPPER LEG VEINS SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1270 EAP CPT® 01270 "PR ANESTH,THIGH ARTERIES SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1320 EAP CPT® 01320 "PR ANESTH,KNEE AREA SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1360 EAP CPT® 01360 "PR ANESTH,LOWER 1/3 FEMUR,OPEN PROC" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1380 EAP CPT® 01380 "PR ANESTH,KNEE JOINT,CLOSED PROCEDURE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1390 EAP CPT® 01390 "PR ANESTH,UPPER LEG,CLOSED PROCEDURE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1392 EAP CPT® 01392 "PR ANESTH,UPPER LEG,OPEN PROCEDURE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1400 EAP CPT® 01400 "PR ANESTH,KNEE JOINT; NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1402 EAP CPT® 01402 "PR ANESTH,TOTAL KNEE ARTHROPLASTY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1430 EAP CPT® 01430 "PR ANESTH,KNEE VEINS SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1440 EAP CPT® 01440 "PR ANESTH,KNEE ARTERIES SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1462 EAP CPT® 01462 "PR ANESTH,LOWER LEG,CLOSED PROCEDURE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1470 EAP CPT® 01470 "PR ANESTH,LOWER LEG,OPEN SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1472 EAP CPT® 01472 "PR ANESTH,ACHILLES TENDON SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1480 EAP CPT® 01480 "PR ANESTH,LOWER LEG BONE SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1482 EAP CPT® 01482 "PR ANESTH,RADICAL LEG RESECTION" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1500 EAP CPT® 01500 "PR ANESTH,LOWER LEG ARTERIES SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1502 EAP CPT® 01502 "PR ANESTH,LOWER LEG EMBOLECTOMY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1520 EAP CPT® 01520 "PR ANESTH,LOWER LEG VEIN SURG,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1610 EAP CPT® 01610 "PR ANESTH,SURGERY OF SHOULDER" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1620 EAP CPT® 01620 "PR ANESTH,SHOULDER,CLOSED PROCEDURE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1630 EAP CPT® 01630 "PR ANESTH,SHOULDER JOINT,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1638 EAP CPT® 01638 "PR ANESTH,SHOULDER REPLACEMENT" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1650 EAP CPT® 01650 "PR ANESTH,SHOULDER ARTERY SURG,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1656 EAP CPT® 01656 "PR ANESTH,AXILL-FEM BYPASS GRFT SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1710 EAP CPT® 01710 "PR ANESTH,ELBOW AREA SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1712 EAP CPT® 01712 "PR ANESTH,UPPERARM TENDON SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1716 EAP CPT® 01716 "PR ANESTH,BICEPS TENDON REPAIR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1740 EAP CPT® 01740 "PR ANESTH,ELBOW,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1744 EAP CPT® 01744 "PR ANESTH,HUMERUS REPAIR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1770 EAP CPT® 01770 "PR ANESTH,UPPERARM ARTERY SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1772 EAP CPT® 01772 "PR ANESTH,UPPERARM EMBOLECTOMY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1810 EAP CPT® 01810 "PR ANESTH,LOWER ARM SURGERY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1820 EAP CPT® 01820 "PR ANESTH,FOREARM BONES,CLOSED PROC" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1830 EAP CPT® 01830 "PR ANESTH,DISTAL RADIUS/ULNA WRIST/HAND,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1840 EAP CPT® 01840 "PR ANESTH,LOWER ARM ARTERY SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1844 EAP CPT® 01844 "PR ANESTH,LOWER ARM,VASC SHUNT SURG" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1916 EAP CPT® 01916 "PR ANESTH,DX ARTERIOGRAPHY/VENOGRAPHY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1920 EAP CPT® 01920 "PR ANESTH,CARDIAC CATH W/CORON ART & VENT" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1922 EAP CPT® 01922 "PR ANESTH,CAT/MRI SCAN,RADIATN THERAPY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1924 EAP CPT® 01924 "PR ANESTH,INTER RAD,ARTERIAL SYS,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1925 EAP CPT® 01925 "ANESTH,INTER RAD, ARTERIAL, CAROTID/CORONARY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1926 EAP CPT® 01926 "ANESTH,INTER RAD,ARTERIAL, INTRACRA/INTRACAR/AORT" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1930 EAP CPT® 01930 "PR ANESTH,INTER RAD,VENOUS/LYMPH SYS,NOS" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1931 EAP CPT® 01931 "ANESTH,INTER RAD,VENOUS/LYMPH,INTRAHEPAT/PORTAL CIRC" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1932 EAP CPT® 01932 "ANESTH,INTER RAD,VENOUS/LYMPH,INTRATHORACIC/JUGULAR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1933 EAP CPT® 01933 "ANESTH,INTER RAD,VENOUS/LYMPH,INTRACRANIAL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1941 EAP CPT® 01941 PR ANES PERQ IMG NEUROMD/NTRVRT PX SPI/SP CRV/THRC OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1942 EAP CPT® 01942 PR ANES PERQ IMG NEUROMD/NTRVRT PX SPI/SP LMBR/SAC OP $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 1951 EAP CPT® 01951 "PR ANESTH,BURN TX, <4% TBSA" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1952 EAP CPT® 01952 "PR ANESTH,BURN TX, 4-9% TBSA" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1958 EAP CPT® 01958 "PR ANESTH, ANTEPARTUM MANIPUL" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1960 EAP CPT® 01960 "PR ANESTH,VAGINAL DELIVERY ONLY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $90.00 $0.00 $90.00 1961 EAP CPT® 01961 "PR ANESTH,CESAREAN DELIVERY ONLY" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $90.00 $0.00 $90.00 1965 EAP CPT® 01965 "PR ANESTH, INCOMP/MISSED AB PROC" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1966 EAP CPT® 01966 "PR ANESTH, INDUCED AB PROCEDURE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1967 EAP CPT® 01967 "ANESTH, NEURAXIAL LABOR, PLAN VAG DEL" OP $480.00 $0.00 $0.00 $480.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $480.00 $94.50 $0.00 $94.50 1968 EAP CPT® 01968 "ANESTH,CES DEL AFTER NEURAXIAL ANESTH" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $90.00 $0.00 $90.00 1990 EAP CPT® 01990 "PR PHYS SUPPORT,BRAIN-DEAD ORGAN DONOR" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1991 EAP CPT® 01991 PR ANES DX/THER NRV BLK/NJX OTH/THN PRONE POS OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 1992 EAP CPT® 01992 PR ANES DX/THER NERVE BLOCK/INJECTION PRONE POS OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $0.00 $90.00 10005 EAP CPT® 10005 PR FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION OP $224.00 $0.00 $0.00 $168.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.69 $0.00 $26.87 $0.00 10006 EAP CPT® 10006 PR FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL OP $154.00 $0.00 $0.00 $114.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.87 $0.00 $36.67 $0.00 10021 EAP CPT® 10021 PR FINE NEEDLE ASP;W/O IMAGING GUIDANCE OP $173.00 $0.00 $0.00 $160.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.56 $126.80 $58.42 $126.80 10030 EAP CPT® 10030 PR IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE OP $431.00 $0.00 $0.00 $389.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.58 $0.00 $431.00 $0.00 10035 EAP CPT® 10035 PR PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE OP $266.00 $0.00 $0.00 $200.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.87 $0.00 $266.00 $0.00 10060 EAP CPT® 10060 PR DRAIN SKIN ABSCESS SIMPLE OP $325.00 $0.00 $0.00 $222.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.32 $93.51 $46.70 $93.51 10061 EAP CPT® 10061 PR DRAIN SKIN ABSCESS COMPLIC OP $563.00 $0.00 $0.00 $412.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $412.05 $163.98 $85.09 $163.98 10080 EAP CPT® 10080 PR DRAIN PILONIDAL CYST SIMPL OP $319.00 $0.00 $0.00 $235.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.83 $155.44 $55.43 $155.44 10081 EAP CPT® 10081 PR DRAIN PILONIDAL CYST COMPLIC OP $533.00 $0.00 $0.00 $389.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.91 $239.26 $101.56 $239.26 10120 EAP CPT® 10120 PR REMOVE FOREIGN BODY SIMPLE OP $318.00 $0.00 $0.00 $237.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.65 $125.50 $53.59 $125.50 10121 EAP CPT® 10121 PR REMOVE FOREIGN BODY COMPLIC OP $576.00 $0.00 $0.00 $426.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $426.81 $235.80 $105.61 $235.80 10140 EAP CPT® 10140 PR DRAINAGE OF HEMATOMA/FLUID OP $369.00 $0.00 $0.00 $272.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.03 $130.38 $56.30 $130.38 10160 EAP CPT® 10160 PR PUNCTURE DRAINAGE OF LESION OP $293.00 $0.00 $0.00 $220.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.53 $108.87 $49.13 $108.87 10180 EAP CPT® 10180 "PR COMPLEX DRAINAGE, WOUND" OP $688.00 $0.00 $0.00 $411.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.92 $204.03 $81.67 $204.03 11004 EAP CPT® 11004 "PR DEBRIDE NECROTIC SKIN/ TISSUE, GENIT & PERINM" OP "$1,804.00 " $0.00 $0.00 "$1,342.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,342.44" $543.65 $341.95 $543.65 11005 EAP CPT® 11005 "PR DEBRIDE NECROTIC SKIN/ TISSUE, ABD WALL" OP "$2,457.00 " $0.00 $0.00 "$1,815.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,815.23" $730.88 $466.14 $730.88 11008 EAP CPT® 11008 REMOVE MESH FROM ABD WALL FOR INFECTION OP $864.00 $0.00 $0.00 $638.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.33 $266.02 $175.12 $266.02 11010 EAP CPT® 11010 PR DEBRIDE ASSOC OPEN FX/DISLOC SKIN/SUBQ OP $861.00 $0.00 $0.00 $645.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $645.45 $420.46 $174.46 $420.46 11011 EAP CPT® 11011 PR DEBRIDE ASSOC OPEN FX/DISLOC SKIN/MUSCLE OP $940.00 $0.00 $0.00 $691.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $691.01 $488.04 $216.41 $488.04 11012 EAP CPT® 11012 PR DEBRIDE ASSOC OPEN FX/DISLO SKIN/MUS/BONE OP "$1,308.00 " $0.00 $0.00 $986.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $986.84 $696.19 $298.94 $696.19 11042 EAP CPT® 11042 "PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,=<20 SQ CM" OP $334.00 $0.00 $0.00 $142.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.29 $68.18 $43.80 $68.18 11043 EAP CPT® 11043 "PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,=<20 SQ CM" OP $601.00 $0.00 $0.00 $358.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.82 $244.83 $105.38 $244.83 11044 EAP CPT® 11044 "PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,=<20 SQ CM" OP $737.00 $0.00 $0.00 $534.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $534.26 $328.20 $142.06 $328.20 11045 EAP CPT® 11045 "PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,EACH ADD 20 SQ CM" OP $83.00 $0.00 $0.00 $60.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.17 $0.00 $18.27 $0.00 11046 EAP CPT® 11046 "PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,EACH ADD 20 SQ CM" OP $175.00 $0.00 $0.00 $129.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.03 $0.00 $31.72 $0.00 11047 EAP CPT® 11047 "PR DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,EACH ADD 20 SQ CM" OP $309.00 $0.00 $0.00 $229.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.94 $0.00 $52.14 $0.00 11055 EAP CPT® 11055 "PR TRIM HYPERKERATOTIC SKIN LESION, ONE" OP $56.00 $0.00 $0.00 $40.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.01 $40.13 $13.27 $40.13 11056 EAP CPT® 11056 "TRIM BENIGN HYPERKERATOTIC SKIN LESION,2-4" OP $72.00 $0.00 $0.00 $52.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.28 $49.68 $17.66 $49.68 11057 EAP CPT® 11057 "TRIM BENIGN HYPERKERATOTIC SKIN LESION,>4" OP $112.00 $0.00 $0.00 $68.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.36 $60.99 $19.61 $60.99 11102 EAP CPT® 11102 PR TANGENTIAL BIOPSY SKIN SINGLE LESION OP $121.00 $0.00 $0.00 $91.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.58 $0.00 $59.83 $0.00 11103 EAP CPT® 11103 PR TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION OP $70.00 $0.00 $0.00 $53.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.03 $0.00 $32.27 $0.00 11104 EAP CPT® 11104 PR PUNCH BIOPSY SKIN SINGLE LESION OP $151.00 $0.00 $0.00 $114.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.90 $0.00 $75.21 $0.00 11105 EAP CPT® 11105 PR PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION OP $82.00 $0.00 $0.00 $62.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.67 $0.00 $36.98 $0.00 11106 EAP CPT® 11106 PR INCISIONAL BIOPSY SKIN SINGLE LESION OP $183.00 $0.00 $0.00 $139.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.77 $0.00 $91.03 $0.00 11200 EAP CPT® 11200 "PR REMOVAL OF SKIN TAGS, UP TO 15" OP $227.00 $0.00 $0.00 $168.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.33 $69.39 $34.68 $69.39 11301 EAP CPT® 11301 "PR SHAV SKIN LES 6-10MM TRUNK,ARM,LEG" OP $162.00 $0.00 $0.00 $123.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.72 $75.78 $40.01 $75.78 11310 EAP CPT® 11310 "PR SHAV SKIN LES <5MM FACE,FACIAL" OP $145.00 $0.00 $0.00 $109.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.23 $70.70 $37.62 $70.70 11312 EAP CPT® 11312 "PR SHAV SKIN LES 11-20MM FACE,FACIAL" OP $235.00 $0.00 $0.00 $180.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.69 $101.58 $55.26 $101.58 11313 EAP CPT® 11313 "PR SHAV SKIN LES >21MM FACE,FACIAL" OP $305.00 $0.00 $0.00 $232.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.05 $130.75 $72.22 $130.75 11400 EAP CPT® 11400 "PR EXC SKIN BENIG <5MM TRUNK,ARM,LEG" OP $297.00 $0.00 $0.00 $184.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.40 $104.64 $54.50 $104.64 11401 EAP CPT® 11401 "PR EXC SKIN BENIG 0.6-1CM TRUNK,ARM,LEG" OP $320.00 $0.00 $0.00 $238.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.19 $123.81 $65.86 $123.81 11402 EAP CPT® 11402 "PR EXC SKIN BENIG 1.1-2CM TRUNK,ARM,LEG" OP $354.00 $0.00 $0.00 $262.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.20 $137.69 $76.22 $137.69 11403 EAP CPT® 11403 "PR EXC SKIN BENIG 2.1-3CM TRUNK,ARM,LEG" OP $457.00 $0.00 $0.00 $339.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.32 $159.08 $89.41 $159.08 11404 EAP CPT® 11404 "PR EXC SKIN BENIG 3.1-4CM TRUNK,ARM,LEG" OP $504.00 $0.00 $0.00 $373.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $373.68 $181.21 $100.41 $181.21 11406 EAP CPT® 11406 "PR EXC SKIN BENIG >4CM TRUNK,ARM,LEG" OP $767.00 $0.00 $0.00 $568.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $568.25 $250.10 $123.49 $250.10 11420 EAP CPT® 11420 PR EXC SKIN BENIG <5MM REMAINDR BODY OP $253.00 $0.00 $0.00 $187.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.64 $103.76 $53.05 $103.76 11421 EAP CPT® 11421 PR EXC SKIN BENIG 0.6-1CM REMAINDR BODY OP $338.00 $0.00 $0.00 $252.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.63 $132.63 $69.99 $132.63 11422 EAP CPT® 11422 PR EXC SKIN BENIG 1.1-2CM REMAINDR BODY OP $420.00 $0.00 $0.00 $311.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.40 $147.67 $79.92 $147.67 11423 EAP CPT® 11423 PR EXC SKIN BENIG 2.1-3CM REMAINDR BODY OP $481.00 $0.00 $0.00 $361.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.86 $174.18 $97.74 $174.18 11424 EAP CPT® 11424 PR EXC SKIN BENIG 3.1-4CM REMAINDR BODY OP $553.00 $0.00 $0.00 $413.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.87 $199.24 $110.88 $199.24 11426 EAP CPT® 11426 PR EXC SKIN BENIG >4CM REMAINDR BODY OP $853.00 $0.00 $0.00 $633.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.41 $286.55 $151.46 $286.55 11440 EAP CPT® 11440 "PR EXC SKIN BENIG <5MM FACE,FACIAL" OP $318.00 $0.00 $0.00 $236.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.96 $117.79 $63.31 $117.79 11441 EAP CPT® 11441 "PR EXC SKIN BENIG 0.6-1CM FACE,FACIAL" OP $403.00 $0.00 $0.00 $302.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.66 $143.77 $77.11 $143.77 11442 EAP CPT® 11442 "PR EXC SKIN BENIG 1.1-2CM FACE,FACIAL" OP $448.00 $0.00 $0.00 $334.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.70 $160.74 $87.24 $160.74 11443 EAP CPT® 11443 "PR EXC SKIN BENIG 2.1-3CM FACE,FACIAL" OP $549.00 $0.00 $0.00 $410.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.88 $195.74 $111.00 $195.74 11444 EAP CPT® 11444 "PR EXC SKIN BENIG 3.1-4CM FACE,FACIAL" OP $702.00 $0.00 $0.00 $523.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $523.19 $247.49 $138.12 $247.49 11446 EAP CPT® 11446 "PR EXC SKIN BENIG >4CM FACE,FACIAL" OP "$1,001.00 " $0.00 $0.00 $750.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $750.36 $331.47 $171.89 $331.47 11450 EAP CPT® 11450 "PR EXC SWEAT GLAND LESN AXILL,SIMPL" OP $870.00 $0.00 $0.00 $580.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $580.56 $307.97 $141.47 $307.97 11462 EAP CPT® 11462 "PR EXC SWEAT GLAND LESN INGUIN,SIMPL" OP $758.00 $0.00 $0.00 $554.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.28 $303.45 $132.65 $303.45 11602 EAP CPT® 11602 "PR EXC SKIN MALIG 1.1-2CM TRUNK,ARM,LEG" OP $501.00 $0.00 $0.00 $377.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $377.10 $196.05 $100.13 $196.05 11603 EAP CPT® 11603 "PR EXC SKIN MALIG 2.1-3CM TRUNK,ARM,LEG" OP $599.00 $0.00 $0.00 $451.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $451.68 $225.57 $113.39 $225.57 11621 EAP CPT® 11621 PR EXC SKIN MALIG 0.6-1CM REMAINDR BODY OP $462.00 $0.00 $0.00 $346.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.52 $182.70 $96.19 $182.70 11622 EAP CPT® 11622 PR EXC SKIN MALIG 1.1-2CM REMAINDR BODY OP $525.00 $0.00 $0.00 $396.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.33 $205.84 $112.06 $205.84 11623 EAP CPT® 11623 PR EXC SKIN MALIG 2.1-3CM REMAINDR BODY OP $652.00 $0.00 $0.00 $490.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $490.94 $244.84 $129.99 $244.84 11719 EAP CPT® 11719 PR TRIM NAIL(S) OP $42.00 $0.00 $0.00 $17.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.70 $16.84 $10.91 $16.84 11720 EAP CPT® 11720 "PR DEBRIDEMENT OF NAIL(S), 1-5" OP $45.00 $0.00 $0.00 $33.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.78 $26.32 $15.92 $26.32 11721 EAP CPT® 11721 "PR DEBRIDEMENT OF NAILS, 6 OR MORE" OP $78.00 $0.00 $0.00 $57.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.06 $38.87 $24.95 $38.87 11730 EAP CPT® 11730 PR REMOVAL OF NAIL PLATE OP $170.00 $0.00 $0.00 $117.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.36 $84.36 $39.56 $84.36 11740 EAP CPT® 11740 PR DRAIN BLOOD FROM UNDER NAIL OP $97.00 $0.00 $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $36.70 $20.59 $36.70 11750 EAP CPT® 11750 PR REMOVAL OF NAIL BED OP $315.00 $0.00 $0.00 $315.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.00 $179.52 $85.23 $179.52 11760 EAP CPT® 11760 PR RECONSTRUC OF NAIL BED OP $356.00 $0.00 $0.00 $268.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.76 $167.40 $65.44 $167.40 11765 EAP CPT® 11765 "PR EXCISION OF NAIL FOLD, TOE" OP $286.00 $0.00 $0.00 $216.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.05 $101.52 $32.69 $101.52 11771 EAP CPT® 11771 PR REMV PILONIDAL LESION EXTENS OP "$1,378.00 " $0.00 $0.00 "$1,000.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,000.31" $452.96 $248.56 $452.96 11772 EAP CPT® 11772 PR REMV PILONIDAL LESION COMPLIC OP "$1,804.00 " $0.00 $0.00 "$1,327.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,327.97" $565.13 $292.85 $565.13 11900 EAP CPT® 11900 "INJECTION INTO SKIN LESIONS, UP TO 7" OP $94.00 $0.00 $0.00 $72.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.30 $45.68 $22.75 $45.68 11901 EAP CPT® 11901 "INJECTION INTO SKIN LESIONS, 8 OR MORE" OP $147.00 $0.00 $0.00 $111.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.66 $57.04 $32.44 $57.04 11920 EAP CPT® 11920 PR CORRECT SKIN COLR DEFCT <6SQ CM OP $466.00 $0.00 $0.00 $261.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $261.99 $188.85 $73.42 $188.85 11970 EAP CPT® 11970 PR REPLACEMENT TISSUE EXPANDER W/PERMANENT IMPLANT OP "$1,905.00 " $0.00 $0.00 "$1,401.87" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,401.87" $540.40 $316.48 $540.40 11971 EAP CPT® 11971 PR REMOVAL TISSUE EXPANDER W/O INSERTION IMPLANT OP "$1,295.00 " $0.00 $0.00 $733.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $733.35 $443.39 $141.20 $443.39 11976 EAP CPT® 11976 PR REMOVAL OF CONTRACEPTIVE CAPSUL OP $295.00 $0.00 $0.00 $216.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.03 $133.13 $74.28 $133.13 11981 EAP CPT® 11981 PR INSERTION DRUG DELIVERY IMPLANT OP $365.00 $0.00 $0.00 $189.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.99 $121.07 $70.63 $121.07 11982 EAP CPT® 11982 PR REMOVAL DRUG IMPLANT DEVICE OP $405.00 $0.00 $0.00 $230.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.91 $141.05 $80.43 $141.05 11983 EAP CPT® 11983 PR REMOVAL W/ REINSERT DRUG IMPLANT DEVICE OP $600.00 $0.00 $0.00 $400.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $402.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $400.47 $212.43 $129.89 $212.43 12001 EAP CPT® 12001 PR REPR SUPERF WND BODY <2.5CM OP $222.00 $0.00 $0.00 $136.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.94 $136.61 $72.72 $136.61 12002 EAP CPT® 12002 PR REPR SUP NPTERF WND BODY 2.6-7.5 OP $269.00 $0.00 $0.00 $144.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.00 $144.99 $80.01 $144.99 12004 EAP CPT® 12004 PR REPR SUPERF WND BODY 7.6-12.5 OP $334.00 $0.00 $0.00 $170.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.64 $170.01 $95.41 $170.01 12005 EAP CPT® 12005 PR REPR SUPERF WND BODY 12.6-20 OP $352.00 $0.00 $0.00 $218.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $218.03 $212.09 $118.48 $212.09 12007 EAP CPT® 12007 PR REPR SUPERF WND BODY >30CM OP $500.00 $0.00 $0.00 $338.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $338.15 $297.36 $169.54 $297.36 12011 EAP CPT® 12011 PR REPR SUPERF WND FACE <2.5CM OP $269.00 $0.00 $0.00 $144.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.74 $144.40 $77.38 $144.40 12013 EAP CPT® 12013 PR REPR SUPERF WND FACE 2.6-5 OP $315.00 $0.00 $0.00 $158.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.05 $158.87 $87.75 $158.87 12014 EAP CPT® 12014 PR REPR SUPERF WND FACE 5.1-7.5 OP $362.00 $0.00 $0.00 $187.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.53 $187.37 $103.99 $187.37 12015 EAP CPT® 12015 PR REPR SUPERF WND FACE 7.6-12.5 OP $473.00 $0.00 $0.00 $235.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.60 $235.25 $131.45 $235.25 12020 EAP CPT® 12020 PR CLOSURE SUPERF WND DEHIS SIMPLE OP $587.00 $0.00 $0.00 $448.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.76 $242.70 $105.67 $242.70 12031 EAP CPT® 12031 "PR LAYR CLOS WND TRUNK,ARM,LEG <2.5 CM" OP $471.00 $0.00 $0.00 $353.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $353.07 $181.32 $88.61 $181.32 12032 EAP CPT® 12032 "PR LAYR CLOS WND TRUNK,ARM,LEG 2.6-7.5 CM" OP $640.00 $0.00 $0.00 $450.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $450.48 $247.47 $100.96 $247.47 12034 EAP CPT® 12034 "PR LAYR CLOS WND TRUNK,ARM,LEG 7.6-12.5 CM" OP $639.00 $0.00 $0.00 $477.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $477.33 $242.38 $120.27 $242.38 12035 EAP CPT® 12035 "PR LAYR CLOS WND TRUNK,ARM,LEG 12.6-20 CM" OP $751.00 $0.00 $0.00 $555.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $555.05 $325.75 $138.44 $325.75 12036 EAP CPT® 12036 "PR LAYR CLOS WND TRUNK,ARM,LEG 20.1-30 CM" OP $881.00 $0.00 $0.00 $644.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $644.48 $363.96 $179.63 $363.96 12041 EAP CPT® 12041 PR LAYR CLOS WND REST BODY <2.5 CM OP $456.00 $0.00 $0.00 $347.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.37 $196.50 $98.74 $196.50 12042 EAP CPT® 12042 PR LAYR CLOS WND REST BODY 2.6-7.5 CM OP $610.00 $0.00 $0.00 $463.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $463.13 $234.63 $111.07 $234.63 12044 EAP CPT® 12044 PR LAYR CLOS WND REST BODY 7.6-12.5 CM OP $666.00 $0.00 $0.00 $495.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.86 $258.28 $127.50 $258.28 12045 EAP CPT® 12045 PR LAYR CLOS WND REST BODY 12.6-20 CM OP $839.00 $0.00 $0.00 $624.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $624.57 $333.93 $149.53 $333.93 12046 EAP CPT® 12046 PR LAYR CLOS WND REST BODY 20.1-30 CM OP $982.00 $0.00 $0.00 $716.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.22 $399.01 $189.89 $399.01 12051 EAP CPT® 12051 "PR LAYR CLOS WND FACE,FACIAL <2.5 CM" OP $524.00 $0.00 $0.00 $396.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.41 $222.72 $102.28 $222.72 12052 EAP CPT® 12052 "PR LAYR CLOS WND FACE,FACIAL 2.5-5 CM" OP $621.00 $0.00 $0.00 $471.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.14 $239.19 $114.65 $239.19 12053 EAP CPT® 12053 "PR LAYR CLOS WND FACE,FACIAL 5.1-7.5 CM" OP $671.00 $0.00 $0.00 $503.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $503.15 $257.34 $128.25 $257.34 12054 EAP CPT® 12054 "PR LAYR CLOS WND FACE,FACIAL 7.6-12.5 CM" OP $687.00 $0.00 $0.00 $514.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $514.11 $280.59 $150.59 $280.59 13101 EAP CPT® 13101 PR REPR CMPL WND TRUNK 2.6-7.5CM OP $772.00 $0.00 $0.00 $586.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.92 $331.18 $155.13 $331.18 13102 EAP CPT® 13102 "PR REP,SKIN,TRUNK,CMPLX,+5CM/<" OP $227.00 $0.00 $0.00 $172.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.47 $93.25 $44.65 $93.25 13120 EAP CPT® 13120 "PR REPR CMPL WND SCALP,EXTR 1.1-2.5" OP $722.00 $0.00 $0.00 $546.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.75 $282.98 $131.02 $282.98 13121 EAP CPT® 13121 "PR REPR CMPL WND SCALP,EXTR 2.6-7.5" OP $811.00 $0.00 $0.00 $619.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.56 $358.48 $174.55 $358.48 13122 EAP CPT® 13122 "PR REP,SKIN,SCALP/EXTREM+5CM/<" OP $262.00 $0.00 $0.00 $198.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.20 $110.54 $51.91 $110.54 13131 EAP CPT® 13131 "PR REPR CMPL WND HEAD,FAC,HAND 1.1-2.5" OP $761.00 $0.00 $0.00 $578.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $578.63 $309.97 $152.46 $309.97 13132 EAP CPT® 13132 "PR REPR CMPL WND HEAD,FAC,HAND 2.6-7.5" OP $953.00 $0.00 $0.00 $729.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $729.62 $476.91 $242.75 $476.91 13133 EAP CPT® 13133 "PR REP,FACE,GENITAL,HAND,FT+5CM/<" OP $399.00 $0.00 $0.00 $304.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.26 $146.93 $76.74 $146.93 13152 EAP CPT® 13152 "PR REPR CMPL WND LID,NOS,EAR 2.5-7.5" OP "$1,139.00 " $0.00 $0.00 $807.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $807.42 $474.21 $271.80 $474.21 13160 EAP CPT® 13160 PR SECD CLOS SURG WND EXTEN/COMPLIC OP "$2,486.00 " $0.00 $0.00 "$1,860.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,860.77" $733.16 $361.36 $733.16 14020 EAP CPT® 14020 "PR ADJ TISS XFER SCALP,EXTREM <10SQCM" OP "$1,736.00 " $0.00 $0.00 "$1,312.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,312.56" $622.70 $295.67 $622.70 14040 EAP CPT® 14040 "PR ADJ TISS XFER HEAD,FAC,HAND <10SQCM" OP "$1,928.00 " $0.00 $0.00 "$1,461.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.95" $656.90 $351.83 $656.90 14041 EAP CPT® 14041 "PR ADJ TISS XFER HEAD,FAC,HAND 10.1-30" OP "$2,364.00 " $0.00 $0.00 "$1,799.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,799.34" $892.45 $468.91 $892.45 14301 EAP CPT® 14301 "PR ADJ TISS XFER ANY AREA,30.1-60 SQCM" OP "$2,705.00 " $0.00 $0.00 "$2,040.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,040.92" $0.00 $480.82 $0.00 14302 EAP CPT® 14302 "PR ADJ TISS XFER ANY AREA,EA ADD 30.0 SQCM" OP $682.00 $0.00 $0.00 $513.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $513.41 $0.00 $105.11 $0.00 14350 EAP CPT® 14350 PR FILLET FINGR/TOE FLAP W PREP OP "$2,134.00 " $0.00 $0.00 "$1,604.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,604.61" $689.26 $366.93 $689.26 15002 EAP CPT® 15002 "PR WOUND PREP, PED, TRK/ARM/LG 1ST 100 CM" OP $717.00 $0.00 $0.00 $524.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $524.84 $296.50 $176.46 $296.50 15003 EAP CPT® 15003 "PR WOUND PREP, PED, TRK/ARM/LG ADDL 100 CM" OP $157.00 $0.00 $0.00 $105.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.80 $65.73 $39.12 $65.73 15004 EAP CPT® 15004 "PR WND PREP PED, FACE/NCK/HND/FT/GEN" OP $827.00 $0.00 $0.00 $625.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $625.71 $357.74 $212.23 $357.74 15005 EAP CPT® 15005 "PR WND PREP,PED, FACE/NCK/HND/FT/GEN ADD 100 CM" OP $288.00 $0.00 $0.00 $210.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.84 $110.96 $65.22 $110.96 15050 EAP CPT® 15050 PR SKIN PINCH GRAFT PROCEDURE <2CM OP "$1,415.00 " $0.00 $0.00 "$1,026.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,026.44" $470.11 $176.55 $470.11 15100 EAP CPT® 15100 "PR SPLIT GRFT TRUNK,ARM,LEG <100SQCM" OP "$2,227.00 " $0.00 $0.00 "$1,651.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,651.88" $824.17 $339.15 $824.17 15101 EAP CPT® 15101 "PR SPLIT GRFT,TRUNK,ARM,LEG EA 100SQCM" OP $501.00 $0.00 $0.00 $257.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.40 $194.67 $73.11 $194.67 15110 EAP CPT® 15110 PR EPIDRM AUTOGRFT TRNK/ARM/LEG <100SQCM OP "$2,158.00 " $0.00 $0.00 "$1,606.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,606.10" $805.68 $482.57 $805.68 15115 EAP CPT® 15115 PR EPI AUTOGRFT FACE/NCK/HND/FT/GEN <100SQCM OP "$2,130.00 " $0.00 $0.00 "$1,653.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.42" $774.13 $452.12 $774.13 15120 EAP CPT® 15120 "PR SPLIT GRFT,HEAD,FAC,HAND,FEET <100SQCM" OP "$2,157.00 " $0.00 $0.00 "$1,613.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,613.85" $826.16 $394.12 $826.16 15121 EAP CPT® 15121 "PR SPLIT GRFT,HEAD,FAC,HAND,FEET EA 100SQCM" OP $716.00 $0.00 $0.00 $307.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.34 $261.86 $117.47 $261.86 15260 EAP CPT® 15260 "PR FULL THICK GRFT NOS,EAR,LID <20SQCM" OP "$2,615.00 " $0.00 $0.00 "$1,987.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,987.35" $828.94 $421.39 $828.94 15271 EAP CPT® 15271 PR APP SKN SUB GRFT T/A/L AREA/<100SCM /<1ST 25 SCM OP $289.00 $0.00 $0.00 $195.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.90 $0.00 $86.07 $0.00 15272 EAP CPT® 15272 PR APP SKN SUB GRFT T/A/L AREA/<100SCM EA ADL 25SCM OP $55.00 $0.00 $0.00 $40.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.10 $0.00 $16.23 $0.00 15273 EAP CPT® 15273 PR APP SKN SUB GRFT T/A/L AREA/>100SCM 1ST 100SCM OP $629.00 $0.00 $0.00 $468.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.21 $0.00 $176.55 $0.00 15274 EAP CPT® 15274 PR APP SKN SUB GRFT T/A/L AREA/>100SCM ADL 100SCM OP $143.00 $0.00 $0.00 $106.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.52 $0.00 $41.62 $0.00 15275 EAP CPT® 15275 PR SUB GRFT F/S/N/H/F/G/M/D /<100SCM /<1ST 25 SCM OP $310.00 $0.00 $0.00 $221.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.01 $0.00 $92.25 $0.00 15276 EAP CPT® 15276 PR SUB GRFT F/S/N/H/F/G/M/D /<100SCM EA ADL 25SCM OP $81.00 $0.00 $0.00 $57.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.80 $0.00 $20.06 $0.00 15277 EAP CPT® 15277 PR SUB GRFT F/S/N/H/F/G/M/D />100SCM 1ST 100SCM OP $714.00 $0.00 $0.00 $520.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $520.59 $0.00 $177.49 $0.00 15278 EAP CPT® 15278 PR SUB GRFT F/S/N/H/F/G/M/D />100SCM ADL 100SCM OP $181.00 $0.00 $0.00 $132.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.18 $0.00 $50.68 $0.00 15650 EAP CPT® 15650 PR TRANSFER SKIN PEDICLE FLAP OP "$1,433.00 " $0.00 $0.00 $881.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $881.63 $440.31 $214.59 $440.31 15734 EAP CPT® 15734 "PR MUSCLE-SKIN FLAP,TRUNK" OP "$4,836.00 " $0.00 $0.00 "$3,046.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,046.37" "$1,426.93" $779.44 "$1,426.93" 15736 EAP CPT® 15736 "PR MUSCLE-SKIN FLAP,ARM" OP "$4,048.00 " $0.00 $0.00 "$2,630.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,630.75" "$1,310.27" $701.25 "$1,310.27" 15738 EAP CPT® 15738 "PR MUSCLE-SKIN FLAP,LEG" OP "$4,227.00 " $0.00 $0.00 "$2,844.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,844.98" "$1,383.32" $707.30 "$1,383.32" 15757 EAP CPT® 15757 PR FREE SKIN FLAP W MICROVASC ANAST OP "$8,489.00 " $0.00 $0.00 "$5,317.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,317.20" "$2,191.91" "$1,446.97" "$2,191.91" 15760 EAP CPT® 15760 PR COMPOSITE SKIN GRAFT OP "$2,221.00 " $0.00 $0.00 "$1,638.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,638.75" $742.62 $384.16 $742.62 15771 EAP CPT® 15771 PR GRAFTING OF AUTOLOGOUS FAT BY LIPO 50 CC OR LESS OP "$1,495.00 " $0.00 $0.00 "$1,105.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,105.59" $0.00 $353.43 $0.00 15772 EAP CPT® 15772 PR GRAFTING OF AUTOLOGOUS FAT BY LIPO EA ADDL 50 CC OP $475.00 $0.00 $0.00 $326.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.37 $0.00 $111.49 $0.00 15777 EAP CPT® 15777 PR IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT OP $676.00 $0.00 $0.00 $493.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.82 $0.00 $126.78 $0.00 15821 EAP CPT® 15821 PR REV LOWER EYELID EXTEN FAT PAD OP "$1,679.00 " $0.00 $0.00 "$1,246.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,246.55" $516.22 $305.31 $516.22 15830 EAP CPT® 15830 "PR EXCISE EXCESS SKIN TISSUE,ABDOMEN" OP "$3,675.00 " $0.00 $0.00 "$2,703.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,703.23" "$1,067.02" $622.78 "$1,067.02" 15839 EAP CPT® 15839 "PR EXCISE EXCESS SKIN TISSUE,OTHER" OP "$2,297.00 " $0.00 $0.00 "$1,701.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,701.42" $735.38 $320.59 $735.38 15850 EAP CPT® 15850 PR REM SUTURES W ANESTH SAME SURGEON OP $210.00 $0.00 $0.00 $95.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.48 $0.00 $0.00 $0.00 15852 EAP CPT® 15852 "PR DRESSING CHANGE,NOT FOR BURN" OP $145.00 $0.00 $0.00 $108.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.26 $44.77 $44.21 $44.77 15860 EAP CPT® 15860 PR IV INJ TO TEST BLOOD FLOW IN FLAP/GRAFT OP $339.00 $0.00 $0.00 $255.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.74 $105.81 $75.42 $105.81 16000 EAP CPT® 16000 PR INITIAL RX BURN(S) 1ST DEGREE OP $144.00 $0.00 $0.00 $105.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.96 $64.69 $35.67 $64.69 16020 EAP CPT® 16020 PR DRESS/DEBRID SMALL BURN NO ANES OP $169.00 $0.00 $0.00 $124.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.76 $76.88 $34.17 $76.88 16025 EAP CPT® 16025 PR DRESS/DEBRID MED BURN NO ANESTH OP $344.00 $0.00 $0.00 $256.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.32 $134.89 $67.00 $134.89 16030 EAP CPT® 16030 PR DRESS/DEBRID LARGE BURN NO ANESTH OP $415.00 $0.00 $0.00 $308.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.36 $159.44 $84.08 $159.44 16035 EAP CPT® 16035 PR ESCHAROTOMY OP $866.00 $0.00 $0.00 $450.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $450.15 $203.21 $170.05 $203.21 16036 EAP CPT® 16036 "PR INCISION OF BURN SCAB, EACH ADDNTL" OP $433.00 $0.00 $0.00 $186.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.74 $80.77 $59.15 $80.77 17000 EAP CPT® 17000 "PR DESTRUC PREMALIGNANT, FIRST LESION" OP $165.00 $0.00 $0.00 $122.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.37 $62.75 $30.31 $62.75 17003 EAP CPT® 17003 "PR DESTRUC PREMALIGNANT,2-14 LESIONS" OP $27.00 $0.00 $0.00 $6.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.60 $6.72 $7.97 $6.72 17110 EAP CPT® 17110 PR DESTRUCTION BENIGN LESIONS UP TO 14 OP $207.00 $0.00 $0.00 $160.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.38 $86.19 $30.72 $86.19 17111 EAP CPT® 17111 DESTRUCTION BENIGN LESIONS 15 OR MORE OP $253.00 $0.00 $0.00 $197.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.33 $102.36 $41.52 $102.36 17250 EAP CPT® 17250 PR CHEM CAUTERY GRANULATN TISSUE OP $165.00 $0.00 $0.00 $85.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.28 $65.52 $23.18 $65.52 17261 EAP CPT® 17261 "PR DESTR MALIG TRUNK,EXTREM 0.6-1 CM" OP $269.00 $0.00 $0.00 $210.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.74 $111.49 $58.87 $111.49 17262 EAP CPT® 17262 "PR DESTR MALIG TRUNK,EXTREM 1.1-2 CM" OP $345.00 $0.00 $0.00 $268.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.56 $137.13 $75.43 $137.13 19000 EAP CPT® 19000 PR PUNC/ASPIR BREAST CYST OP $170.00 $0.00 $0.00 $103.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.13 $103.74 $37.28 $103.74 19020 EAP CPT® 19020 PR EXPLO/DRAIN BREAST ABSCESS OP $966.00 $0.00 $0.00 $704.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $704.21 $381.55 $172.41 $381.55 19081 EAP CPT® 19081 PR BX BREAST W DEVICE 1ST LESION STEREOTACTIC GUIDE OP $521.00 $0.00 $0.00 $393.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.45 $0.00 $406.55 $0.00 19082 EAP CPT® 19082 PR BX BREAST W DEVICE ADDL LESION STEREOTACT GUIDE OP $262.00 $0.00 $0.00 $196.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.74 $0.00 $262.00 $0.00 19083 EAP CPT® 19083 PR BX BREAST W DEVICE 1ST LESION ULTRASOUND GUIDE OP $493.00 $0.00 $0.00 $368.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $368.67 $0.00 $403.90 $0.00 19084 EAP CPT® 19084 PR BX BREAST W DEVICE ADDL LESION ULTRASOUND GUIDE OP $243.00 $0.00 $0.00 $184.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.74 $0.00 $243.00 $0.00 19100 EAP CPT® 19100 "PR BIOPSY OF BREAST, NEEDLE CORE" OP $343.00 $0.00 $0.00 $161.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.58 $126.09 $71.30 $126.09 19110 EAP CPT® 19110 PR NIPPLE EXPLORATION OP "$1,098.00 " $0.00 $0.00 $788.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.03 $390.31 $214.89 $390.31 19120 EAP CPT® 19120 PR REMOVAL OF BREAST LESION OP "$1,298.00 " $0.00 $0.00 $953.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $953.27 $402.44 $214.35 $402.44 19125 EAP CPT® 19125 PR EXCISE BREAST LES W XRAY MARKER OP "$1,441.00 " $0.00 $0.00 "$1,059.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,059.59" $442.65 $233.91 $442.65 19281 EAP CPT® 19281 PR PERQ DEVICE PLACEMT BREAST LOC 1ST LES W GUIDNCE OP $494.00 $0.00 $0.00 $235.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.52 $0.00 $146.42 $0.00 19285 EAP CPT® 19285 PR PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG OP $269.00 $0.00 $0.00 $200.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.87 $0.00 $269.00 $0.00 19286 EAP CPT® 19286 PR PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE OP $136.00 $0.00 $0.00 $101.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.22 $0.00 $136.00 $0.00 19301 EAP CPT® 19301 "PR MASTECTOMY, PARTIAL" OP "$2,061.00 " $0.00 $0.00 "$1,506.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,506.78" $367.13 $213.51 $367.13 19302 EAP CPT® 19302 "PR MASTECTOMY,PARTIAL, WITH AXILLARY LYMPHADENECTOMY" OP "$2,833.00 " $0.00 $0.00 "$2,076.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,076.18" $782.53 $451.61 $782.53 19303 EAP CPT® 19303 "PR MASTECTOMY, SIMPLE, COMPLETE" OP "$3,011.00 " $0.00 $0.00 "$2,333.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,333.18" $799.24 $455.81 $799.24 19307 EAP CPT® 19307 "PR MASTECTOMY, MODIFIED RADICAL" OP "$3,783.00 " $0.00 $0.00 "$2,763.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,763.27" "$1,013.43" $584.82 "$1,013.43" 19316 EAP CPT® 19316 PR SUSPENSION OF BREAST OP "$2,845.00 " $0.00 $0.00 "$1,773.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,773.90" $716.59 $478.02 $716.59 19318 EAP CPT® 19318 PR BREAST REDUCTION OP "$4,322.00 " $0.00 $0.00 "$2,540.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,540.70" "$1,060.52" $656.68 "$1,060.52" 19328 EAP CPT® 19328 PR REMOVAL INTACT BREAST IMPLANT OP "$1,560.00 " $0.00 $0.00 "$1,141.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,141.32" $440.22 $228.54 $440.22 19342 EAP CPT® 19342 PR INSJ/RPLCMT BREAST IMPLANT SEP DAY MASTECTOMY OP "$2,896.00 " $0.00 $0.00 "$2,125.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,125.73" $830.06 $482.09 $830.06 19350 EAP CPT® 19350 PR NIPPLE/AREOLA RECONSTRUCTION OP "$3,313.00 " $0.00 $0.00 "$1,551.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,551.02" $837.77 $427.60 $837.77 19357 EAP CPT® 19357 PR TISSUE EXPANDER PLACEMENT BREAST RECONSTRUCTION OP "$4,690.00 " $0.00 $0.00 "$3,470.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,470.19" "$1,401.46" $724.19 "$1,401.46" 19370 EAP CPT® 19370 PR REVISION PERI-IMPLANT CAPSULE BREAST OP "$2,161.00 " $0.00 $0.00 "$1,580.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.09" $615.51 $330.94 $615.51 19380 EAP CPT® 19380 PR REVISION OF RECONSTRUCTED BREAST OP "$2,521.00 " $0.00 $0.00 "$1,780.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,780.95" $693.17 $390.19 $693.17 20100 EAP CPT® 20100 "PR EXPLORE WOUND,NECK" OP "$1,889.00 " $0.00 $0.00 "$1,406.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,406.03" $563.04 $362.99 $563.04 20101 EAP CPT® 20101 "PR EXPLORE WOUND,CHEST" OP "$1,684.00 " $0.00 $0.00 $482.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $482.25 $349.76 $130.75 $349.76 20102 EAP CPT® 20102 "PR EXPLORE WOUND,ABDOMEN/FLANK/BACK" OP "$1,946.00 " $0.00 $0.00 $592.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $592.17 $424.39 $156.85 $424.39 20103 EAP CPT® 20103 "PR EXPLORE WOUND,EXTREMITY" OP "$1,684.00 " $0.00 $0.00 $804.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.41 $519.45 $202.42 $519.45 20200 EAP CPT® 20200 PR MUSCLE BIOPSY OP $449.00 $0.00 $0.00 $221.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.03 $171.27 $67.00 $171.27 20205 EAP CPT® 20205 PR DEEP MUSCLE BIOPSY OP $636.00 $0.00 $0.00 $361.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.01 $235.84 $122.12 $235.84 20206 EAP CPT® 20206 "PR NEEDLE BIOPSY,MUSCLE" OP $561.00 $0.00 $0.00 $261.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.55 $261.63 $65.24 $261.63 20220 EAP CPT® 20220 "PR BONE BIOPSY,TROCAR/NEEDLE SUPERF" OP $561.00 $0.00 $0.00 $196.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.92 $196.83 $84.82 $196.83 20225 EAP CPT® 20225 "PR BONE BIOPSY,TROCAR/NEEDLE DEEP" OP "$1,123.00 " $0.00 $0.00 $860.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.53 $860.38 $79.21 $860.38 20240 EAP CPT® 20240 PR BIOPSY BONE OPEN SUPERFICIAL OP $618.00 $0.00 $0.00 $357.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $357.33 $219.12 $139.99 $219.12 20245 EAP CPT® 20245 PR BIOPSY BONE OPEN DEEP OP "$1,572.00 " $0.00 $0.00 "$1,197.57" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,197.57" $588.03 $182.69 $588.03 20520 EAP CPT® 20520 PR REMOVAL OF FOREIGN BODY OP $456.00 $0.00 $0.00 $337.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.13 $176.95 $102.69 $176.95 20526 EAP CPT® 20526 PR INJECT CARPAL TUNNEL OP $178.00 $0.00 $0.00 $132.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.41 $71.89 $0.00 $71.89 20550 EAP CPT® 20550 PR INJECT TENDON SHEATH/LIGAMENT OP $159.00 $0.00 $0.00 $96.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $162.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.41 $54.71 $44.01 $54.71 20551 EAP CPT® 20551 PR INJECT TENDON ORIGIN/INSERT OP $159.00 $0.00 $0.00 $98.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.07 $53.67 $41.64 $53.67 20552 EAP CPT® 20552 "PR INJECT TRIGGER POINT, 1 OR 2" OP $168.00 $0.00 $0.00 $87.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.63 $50.28 $41.64 $50.28 20553 EAP CPT® 20553 "PR INJECT TRIGGER POINTS, > 3" OP $175.00 $0.00 $0.00 $99.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.69 $56.45 $41.64 $56.45 20560 EAP CPT® 20560 PR NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES OP $50.00 $0.00 $0.00 $37.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.77 $0.00 $0.00 $0.00 20600 EAP CPT® 20600 PR ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US OP $150.00 $0.00 $0.00 $81.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.96 $50.12 $34.28 $50.12 20604 EAP CPT® 20604 PR ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT OP $143.00 $0.00 $0.00 $106.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.02 $0.00 $43.42 $0.00 20605 EAP CPT® 20605 PR ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US OP $159.00 $0.00 $0.00 $85.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.95 $54.57 $37.86 $54.57 20606 EAP CPT® 20606 PR ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US OP $164.00 $0.00 $0.00 $121.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $121.25 $0.00 $48.06 $0.00 20610 EAP CPT® 20610 PR ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US OP $178.00 $0.00 $0.00 $105.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.96 $67.53 $44.28 $67.53 20611 EAP CPT® 20611 PR ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US OP $187.00 $0.00 $0.00 $142.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.07 $0.00 $55.44 $0.00 20612 EAP CPT® 20612 PR ASPIRAT/INJECTION GANGLION CYST(S) OP $129.00 $0.00 $0.00 $96.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.42 $54.15 $34.34 $54.15 20650 EAP CPT® 20650 PR INSERT AND REMOVE BONE PIN OP $491.00 $0.00 $0.00 $361.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.05 $177.83 $106.69 $177.83 20670 EAP CPT® 20670 PR REMOVAL SUPERFICIAL IMPLANT OP $452.00 $0.00 $0.00 $449.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.54 $449.34 $104.06 $449.34 20680 EAP CPT® 20680 PR REMOVAL DEEP IMPLANT OP "$1,312.00 " $0.00 $0.00 $978.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $978.63 $544.55 $166.73 $544.55 20690 EAP CPT® 20690 "PR APPLY BONE UNIPLANE,EXT FIX DEV" OP "$1,862.00 " $0.00 $0.00 "$1,372.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,372.38" $239.61 $149.35 $239.61 20692 EAP CPT® 20692 "PR APPLY BONE MULTIPLAN,EXT FIX DEV" OP "$3,491.00 " $0.00 $0.00 "$2,584.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,584.64" $395.29 $258.08 $395.29 20693 EAP CPT® 20693 PR ADJUST EXTERN BONE FIX DEV W ANESTH OP "$1,380.00 " $0.00 $0.00 "$1,029.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,029.65" $435.09 $283.50 $435.09 20694 EAP CPT® 20694 PR REMOVE EXTERN BONE FIX DEV W ANESTH OP "$1,051.00 " $0.00 $0.00 $781.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $781.29 $417.28 $211.37 $417.28 20696 EAP CPT® 20696 "PR COMP ASSIST MULTIPLANE EXT FIXATION, INITIAL" OP "$3,713.00 " $0.00 $0.00 "$2,781.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,781.60" $0.00 $597.04 $0.00 20700 EAP CPT® 20700 PR MANUAL PREP AND INSERTION DEEP DRUG DELIVERY DEV OP $264.00 $0.00 $0.00 $195.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.60 $0.00 $52.12 $0.00 20702 EAP CPT® 20702 PR MANUAL PREP&INSJ INTRAMEDULLARY DRUG DLVR DEVICE OP $439.00 $0.00 $0.00 $325.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $325.41 $0.00 $86.73 $0.00 20703 EAP CPT® 20703 PR REMOVAL INTRAMEDULLARY DRUG DELIVERY DEVICE OP $315.00 $0.00 $0.00 $233.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $233.33 $0.00 $62.17 $0.00 20822 EAP CPT® 20822 "PR REPLANTATION DIGIT DISTAL, COMPLT" OP "$5,541.00 " $0.00 $0.00 "$4,142.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,142.82" "$2,231.12" "$1,259.66" "$2,231.12" 20827 EAP CPT® 20827 "PR REPLANTATION THUMB DISTAL,COMPLETE" OP "$5,693.00 " $0.00 $0.00 "$4,225.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,225.61" "$2,310.39" "$1,325.42" "$2,310.39" 20900 EAP CPT® 20900 PR REMV BONE FOR GRAFT MINOR OP $711.00 $0.00 $0.00 $552.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $439.73 $552.26 $227.12 $552.26 20902 EAP CPT® 20902 PR REMV BONE FOR GRAFT MAJOR OP "$1,422.00 " $0.00 $0.00 $662.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $662.51 $568.62 $329.36 $568.62 20910 EAP CPT® 20910 PR REMV CARTILAGE FOR GRAFT COSTOCH OP "$1,460.00 " $0.00 $0.00 $949.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $949.89 $400.98 $210.20 $400.98 20930 EAP CPT® 20930 ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED OP $430.00 $0.00 $0.00 $280.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.94 $0.00 $0.00 $0.00 20936 EAP CPT® 20936 AUTOGRAFT SPINE SURGERY LOCAL FROM SAME INCISION OP $655.00 $0.00 $0.00 $294.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $294.57 $0.00 $0.00 $0.00 20937 EAP CPT® 20937 AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION OP "$1,142.00 " $0.00 $0.00 $391.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $391.14 $166.73 $117.03 $166.73 20938 EAP CPT® 20938 AUTOGRAFT SPINE SURGERY BICORT/TRICORT SEP INCISION OP "$1,422.00 " $0.00 $0.00 $431.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $431.39 $181.84 $128.15 $181.84 20969 EAP CPT® 20969 "PR BONE-SKIN GRAFT, MICROVASCULAR" OP "$8,502.00 " $0.00 $0.00 "$6,423.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,423.39" "$2,684.23" "$1,860.27" "$2,684.23" 20982 EAP CPT® 20982 PR ABLATION BONE TUMOR RF PERQ W/IMG GDN WHEN DONE OP "$1,142.00 " $0.00 $0.00 "$1,142.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.80 "$1,142.00" "$1,142.00" "$1,142.00" 21011 EAP CPT® 21011 PR EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ < 2CM OP $798.00 $0.00 $0.00 $599.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $599.22 $0.00 $143.61 $0.00 21012 EAP CPT® 21012 PR EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2+CM OP "$1,051.00 " $0.00 $0.00 $783.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $783.05 $0.00 $153.11 $0.00 21014 EAP CPT® 21014 PR EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL 2+CM OP "$1,622.00 " $0.00 $0.00 "$1,204.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,204.88" $0.00 $236.42 $0.00 21025 EAP CPT® 21025 "PR EXCISION OF BONE, LOWER JAW" OP "$2,418.00 " $0.00 $0.00 "$1,757.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,757.42" $888.16 $406.34 $888.16 21030 EAP CPT® 21030 "PR EXCISION,BENIGN TUMOR,MAXILLA/ZYGOMA" OP "$1,624.00 " $0.00 $0.00 $977.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $977.57 $428.39 $248.26 $428.39 21031 EAP CPT® 21031 "PR EXCISION,TORUS MANDIBULARIS" OP $868.00 $0.00 $0.00 $691.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $691.34 $328.02 $0.00 $328.02 21032 EAP CPT® 21032 "PR EXCISION,MAXILLARY TORUS PALATINUS" OP $864.00 $0.00 $0.00 $684.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $684.80 $334.01 $157.98 $334.01 21040 EAP CPT® 21040 "PR EXCISION,BENIGN TUMOR,MANDIBLE" OP "$1,624.00 " $0.00 $0.00 $979.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $979.19 $430.58 $114.40 $430.58 21044 EAP CPT® 21044 PR REMV MALIG JAW BONE LESION OP "$2,867.00 " $0.00 $0.00 "$2,039.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,039.93" $812.79 $478.86 $812.79 21070 EAP CPT® 21070 PR REMV CORONOID PROCESS OP "$3,420.00 " $0.00 $0.00 "$1,420.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,420.13" $595.15 $339.86 $595.15 21244 EAP CPT® 21244 "PR RECONSTR MANDIBLE,BONE PLATE" OP "$4,836.00 " $0.00 $0.00 "$2,485.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,485.52" $950.01 $532.36 $950.01 21320 EAP CPT® 21320 PR CLOSED TX NASAL BONE FX W/MNPJ W/STABILIZATION OP $898.00 $0.00 $0.00 $313.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.61 $216.63 $118.18 $216.63 21338 EAP CPT® 21338 PR REPAIR NASOETHMOID FRACTURE OP "$2,418.00 " $0.00 $0.00 "$1,673.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,673.60" $741.37 $275.52 $741.37 21345 EAP CPT® 21345 PR CLOSED RX NOSE/JAW FRAC+WIRES OP "$3,247.00 " $0.00 $0.00 "$1,516.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,516.56" $705.48 $0.00 $705.48 21347 EAP CPT® 21347 PR OPEN RX NOSE/JAW FRACT/COMPLX OP "$4,940.00 " $0.00 $0.00 "$2,633.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,633.73" "$1,075.82" $524.45 "$1,075.82" 21360 EAP CPT® 21360 PR OPEN RX DEPRESS MALAR FRAC OP "$2,349.00 " $0.00 $0.00 "$1,249.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,249.62" $486.33 $295.95 $486.33 21365 EAP CPT® 21365 PR OPEN RX COMPLX CHEEK BONE FRAC OP "$3,800.00 " $0.00 $0.00 "$2,580.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,580.42" "$1,024.61" $620.07 "$1,024.61" 21386 EAP CPT® 21386 "PR REPAIR EYE BLOWOUT,PERIORBITAL" OP "$2,902.00 " $0.00 $0.00 "$1,605.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,605.78" $616.47 $407.18 $616.47 21390 EAP CPT® 21390 "PR REPAIR EYE BLOWOUT,PERIORB+IMPLNT" OP "$3,316.00 " $0.00 $0.00 "$1,837.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,837.98" $703.85 $461.79 $703.85 21407 EAP CPT® 21407 PR OPEN RX FX ORBIT W IMPLANT OP "$3,040.00 " $0.00 $0.00 "$1,494.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,494.26" $590.89 $368.80 $590.89 21421 EAP CPT® 21421 PR CLOSED RX LEFORTE I+WIRES OP "$2,073.00 " $0.00 $0.00 "$1,483.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,483.76" $597.47 $0.00 $597.47 21422 EAP CPT® 21422 PR OPEN RX LEFORTE I OP "$2,764.00 " $0.00 $0.00 "$1,564.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,564.97" $623.82 $381.78 $623.82 21440 EAP CPT® 21440 PR CLOSED RX DENTAL RIDGE FX OP "$1,562.00 " $0.00 $0.00 "$1,095.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,095.20" $418.35 $154.80 $418.35 21453 EAP CPT® 21453 PR CLOSED RX MANDIBLE FX+DENTAL FIX OP "$2,651.00 " $0.00 $0.00 "$1,828.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,828.88" $682.24 $283.19 $682.24 21454 EAP CPT® 21454 PR OPEN RX MANDIBLE FX+EXTERN FIX OP "$2,867.00 " $0.00 $0.00 "$1,380.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,380.11" $506.79 $292.66 $506.79 21461 EAP CPT® 21461 PR OPEN RX MANDIBLE FX OP "$3,119.00 " $0.00 $0.00 "$2,195.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,195.75" "$1,403.48" $386.03 "$1,403.48" 21462 EAP CPT® 21462 PR OPEN RX MANDIBLE FX+DENTAL FIX OP "$5,611.00 " $0.00 $0.00 "$2,445.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,445.36" "$1,570.72" $458.37 "$1,570.72" 21465 EAP CPT® 21465 PR OPEN RX MANDIBLE CONDYLE FX OP "$4,145.00 " $0.00 $0.00 "$2,230.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,230.34" $853.49 $461.67 $853.49 21470 EAP CPT® 21470 "PR OPEN RX MANDIBLE CONDYLE FX,COMPL" OP "$4,698.00 " $0.00 $0.00 "$2,805.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,805.71" "$1,102.02" $667.07 "$1,102.02" 21480 EAP CPT® 21480 PR REDUCE TEMPOROMANDIBL DISLOC OP $345.00 $0.00 $0.00 $85.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.79 $85.97 $0.00 $85.97 21499 EAP CPT® 21499 PR HEAD SURGERY PROC UNLISTED OP "$4,638.00 " $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 21501 EAP CPT® 21501 PR I&D DEEP ABSC/HEMATOMA NECK/CHEST OP "$1,013.00 " $0.00 $0.00 $744.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $744.98 $386.43 $157.40 $386.43 21552 EAP CPT® 21552 PR EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ 3+CM OP "$1,394.00 " $0.00 $0.00 "$1,033.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,033.70" $0.00 $203.80 $0.00 21554 EAP CPT® 21554 PR EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBFASCIAL 5+CM OP "$2,285.00 " $0.00 $0.00 "$1,695.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,695.27" $0.00 $334.68 $0.00 21555 EAP CPT® 21555 "PR EXCISE LESN NECK/CHEST,SUBCUTAN" OP $950.00 $0.00 $0.00 $708.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.41 $378.81 $168.71 $378.81 21600 EAP CPT® 21600 PR PARTIAL REMOVAL OF RIB OP "$1,724.00 " $0.00 $0.00 "$1,292.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,292.07" $496.58 $315.85 $496.58 21601 EAP CPT® 21601 PR EXCISION CHEST WALL TUMOR INCLUDING RIBS OP "$3,695.00 " $0.00 $0.00 "$2,738.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,738.60" $0.00 $729.80 $0.00 21620 EAP CPT® 21620 PR PARTIAL REMOVAL OF STERNUM OP "$3,110.00 " $0.00 $0.00 "$1,167.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,167.95" $495.23 $345.75 $495.23 21685 EAP CPT® 21685 PR HYOID MYOTOMY & SUSPENSION OP "$3,047.00 " $0.00 $0.00 "$2,326.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,326.64" $912.65 $557.25 $912.65 21750 EAP CPT® 21750 "PR CLOSE MED STERNOTOMY SEP, W/WO DEBRIDE" OP "$2,304.00 " $0.00 $0.00 "$1,587.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,587.00" $674.13 $505.39 $674.13 21811 EAP CPT® 21811 PR OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 1-3 RIBS OP "$1,865.00 " $0.00 $0.00 "$1,417.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,417.88" $0.00 $368.18 $0.00 21812 EAP CPT® 21812 PR OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 4-6 RIBS OP "$2,275.00 " $0.00 $0.00 "$1,700.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,700.13" $0.00 $441.41 $0.00 21825 EAP CPT® 21825 PR OPEN RX STERNUM FRACTURE OP "$1,920.00 " $0.00 $0.00 "$1,253.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,253.52" $533.60 $406.76 $533.60 21931 EAP CPT® 21931 PR EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ 3+CM OP "$1,473.00 " $0.00 $0.00 "$1,087.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,087.19" $0.00 $213.19 $0.00 21936 EAP CPT® 21936 PR RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK 5CM/> OP "$4,434.00 " $0.00 $0.00 "$3,267.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,267.03" $0.00 $653.27 $0.00 22015 EAP CPT® 22015 "PR I&D, POST SPINE, LUMB/SACR/LUMBOSAC" OP "$2,950.00 " $0.00 $0.00 "$2,138.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,138.31" $812.99 $478.84 $812.99 22318 EAP CPT® 22318 "PR ODONTOID FX,W/O GRAFT,OPEN" OP "$8,352.00 " $0.00 $0.00 "$3,830.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,830.40" "$1,460.66" $874.74 "$1,460.66" 22325 EAP CPT® 22325 "PR OPEN POST RX LUMB VERT FX,1 LVL" OP "$4,540.00 " $0.00 $0.00 "$3,343.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,343.68" "$1,264.54" $701.90 "$1,264.54" 22326 EAP CPT® 22326 "PR OPEN POST RX CERV VERT FX,1 LVL" OP "$4,800.00 " $0.00 $0.00 "$3,472.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,472.14" "$1,336.42" $854.08 "$1,336.42" 22327 EAP CPT® 22327 "PR OPEN POST RX THOR VERT FX,1 LVL" OP "$4,728.00 " $0.00 $0.00 "$3,496.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,496.07" "$1,310.42" $829.94 "$1,310.42" 22328 EAP CPT® 22328 PR OPEN POST REPAIR EA ADDN VERT FX OP "$1,382.00 " $0.00 $0.00 $660.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $660.42 $272.52 $195.39 $272.52 22513 EAP CPT® 22513 PR PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION OP "$1,604.00 " $0.00 $0.00 "$1,251.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,251.65" $0.00 "$1,604.00" $0.00 22515 EAP CPT® 22515 PR PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ EACH OP $691.00 $0.00 $0.00 $527.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $527.73 $0.00 $691.00 $0.00 22533 EAP CPT® 22533 PR LAT LUMBAR SPINE FUSION OP "$7,234.00 " $0.00 $0.00 "$3,843.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,843.41" "$1,475.09" $910.49 "$1,475.09" 22534 EAP CPT® 22534 "PR LAT THOR/LUMB, ADDL SEG" OP "$3,596.00 " $0.00 $0.00 $841.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $841.94 $357.83 $229.36 $357.83 22551 EAP CPT® 22551 "PR ARTHRODESIS ANT INTERBODY INC DISCECTOMY, CERVICAL BELOW C2" OP "$5,339.00 " $0.00 $0.00 "$3,997.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,997.10" $0.00 "$1,018.02" $0.00 22552 EAP CPT® 22552 "ARTHRODESIS ANT INTERBODY INC DISCECTOMY, CERVICAL BELOL" OP "$1,249.00 " $0.00 $0.00 $935.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $935.73 $0.00 $237.25 $0.00 22554 EAP CPT® 22554 "PR CERV SPINE FUSN,ANTER,BELOW C2" OP "$6,283.00 " $0.00 $0.00 "$2,925.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,925.44" "$1,204.04" $863.71 "$1,204.04" 22556 EAP CPT® 22556 "PR THORAX SPINE FUSION,ANTER APPRCH" OP "$7,647.00 " $0.00 $0.00 "$3,880.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,880.88" "$1,536.50" "$1,027.33" "$1,536.50" 22558 EAP CPT® 22558 "PR LUMBAR SPINE FUSION,ANTER APPRCH" OP "$7,027.00 " $0.00 $0.00 "$3,584.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,584.04" "$1,403.34" $953.72 "$1,403.34" 22585 EAP CPT® 22585 "PR SPINAL FUSION,ANT,EA ADNL LEVEL" OP "$1,767.00 " $0.00 $0.00 $770.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $770.52 $331.94 $236.48 $331.94 22590 EAP CPT® 22590 "PR CRANIOCERV FUSN,POST TECHNIQUE" OP "$6,820.00 " $0.00 $0.00 "$3,687.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,687.84" "$1,406.57" $947.59 "$1,406.57" 22595 EAP CPT® 22595 "PR CERV C1-2 FUSN,POSTER TECH" OP "$6,614.00 " $0.00 $0.00 "$3,518.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,518.19" "$1,336.69" $906.37 "$1,336.69" 22600 EAP CPT® 22600 PR ARTHRD PST/PSTLAT TQ 1NTRSPC CRV BELW C2 SEGMENT OP "$5,580.00 " $0.00 $0.00 "$3,003.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,003.41" "$1,142.40" $758.86 "$1,142.40" 22610 EAP CPT® 22610 PR ARTHRODESIS POSTERIOR/PSTLAT TQ 1NTRSPC THORACIC OP "$5,477.00 " $0.00 $0.00 "$2,941.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,941.74" "$1,134.03" $747.83 "$1,134.03" 22612 EAP CPT® 22612 PR ARTHRODESIS POSTERIOR/PSTLAT TQ 1NTRSPC LUMBAR OP "$7,027.00 " $0.00 $0.00 "$3,700.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,700.10" "$1,481.34" $931.40 "$1,481.34" 22614 EAP CPT® 22614 PR ARTHRODESIS PST/PSTLAT TQ 1NTRSPC EA ADDL NTRSPC OP "$1,984.00 " $0.00 $0.00 $916.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $916.41 $387.99 $264.69 $387.99 22630 EAP CPT® 22630 "PR LUMBAR SPINE FUSN,POST INTRBDY" OP "$7,027.00 " $0.00 $0.00 "$3,654.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,654.42" "$1,419.95" $916.59 "$1,419.95" 22633 EAP CPT® 22633 PR ARTHRODESIS COMBINED TQ 1NTRSPC LUMBAR OP "$5,803.00 " $0.00 $0.00 "$4,319.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,319.13" $0.00 "$1,104.51" $0.00 22634 EAP CPT® 22634 PR ARTHRODESIS CMBN TQ 1NTRSPC EACH ADDITIONAL OP "$1,558.00 " $0.00 $0.00 "$1,163.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,163.24" $0.00 $297.42 $0.00 22840 EAP CPT® 22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION OP "$3,823.00 " $0.00 $0.00 "$1,781.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,781.03" $757.64 $470.20 $757.64 22842 EAP CPT® 22842 POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG OP "$4,340.00 " $0.00 $0.00 "$1,786.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,786.68" $758.36 $466.54 $758.36 22843 EAP CPT® 22843 POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG OP "$4,754.00 " $0.00 $0.00 "$1,909.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,909.16" $799.42 $512.88 $799.42 22845 EAP CPT® 22845 ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS OP "$4,134.00 " $0.00 $0.00 "$1,713.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,713.62" $724.84 $458.28 $724.84 22846 EAP CPT® 22846 ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS OP "$4,340.00 " $0.00 $0.00 "$1,779.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,779.93" $753.03 $499.18 $753.03 22848 EAP CPT® 22848 PELVIC FIXATION OTHER THAN SACRUM OP "$1,984.00 " $0.00 $0.00 $840.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $840.66 $359.13 $264.82 $359.13 22853 EAP CPT® 22853 PR INSJ BIOMCHN DEV INTERVERTEBRAL DSC SPC W/ARTHRD OP $813.00 $0.00 $0.00 $610.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $610.05 $0.00 $162.97 $0.00 22854 EAP CPT® 22854 PR INSJ BIOMCHN DEV VRT CORPECTOMY DEFECT W/ARTHRD OP "$1,053.00 " $0.00 $0.00 $789.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $789.72 $0.00 $210.96 $0.00 22864 EAP CPT® 22864 "PR REMOVE TOTAL DISC ARTHROPLASTY, CERVICAL, SINGLE" OP "$6,459.00 " $0.00 $0.00 "$4,810.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,810.98" $0.00 "$1,021.27" $0.00 23030 EAP CPT® 23030 "PR INCIS/DRAIN SHLDR ABSC/HEMA,DEEP" OP $776.00 $0.00 $0.00 $590.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.94 $400.87 $165.11 $400.87 23040 EAP CPT® 23040 PR DEEP INCIS SHLDR BONE CORTEX OP "$2,239.00 " $0.00 $0.00 "$1,659.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,659.78" $672.30 $450.76 $672.30 23071 EAP CPT® 23071 PR EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3+CM OP "$1,314.00 " $0.00 $0.00 $970.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $970.53 $0.00 $189.50 $0.00 23073 EAP CPT® 23073 PR EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5+CM OP "$2,176.00 " $0.00 $0.00 "$1,603.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,603.28" $0.00 $314.01 $0.00 23107 EAP CPT® 23107 PR EXPLORE SHOULDER JOINT OP "$2,304.00 " $0.00 $0.00 "$1,519.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,519.65" $619.89 $427.24 $619.89 23180 EAP CPT® 23180 PR PART EXCIS CLAVICLE OP "$2,075.00 " $0.00 $0.00 "$1,537.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,537.37" $674.11 $406.43 $674.11 23335 EAP CPT® 23335 PR PROSTHESIS REMOVAL HUMERAL AND GLENOID COMPONENT OP "$3,974.00 " $0.00 $0.00 "$2,959.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,959.92" $0.00 $776.60 $0.00 23350 EAP CPT® 23350 PR INJ PROC SHOULDER ARTHROGRAPHY/CT/MRI OP $209.00 $0.00 $0.00 $155.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.17 $155.91 $126.50 $155.91 23395 EAP CPT® 23395 "PR MUSCLE TRANSFER,SHOULDER/ARM,SINGLE" OP "$4,010.00 " $0.00 $0.00 "$2,969.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,969.97" "$1,202.37" $683.14 "$1,202.37" 23430 EAP CPT® 23430 PR REPAIR BICEPS LONG TENDON OP "$2,373.00 " $0.00 $0.00 "$1,721.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,721.04" $698.34 $442.98 $698.34 23472 EAP CPT® 23472 PR RECONSTR TOTAL SHOULDER IMPLANT OP "$4,607.00 " $0.00 $0.00 "$3,370.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,370.08" "$1,426.17" $787.19 "$1,426.17" 23473 EAP CPT® 23473 PR REVIS SHOULDER ARTHRPLSTY HUMERAL/GLENOID COMPNT OP "$5,064.00 " $0.00 $0.00 "$3,763.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,763.56" $0.00 $974.63 $0.00 23485 EAP CPT® 23485 PR OSTEOTOMY CLAVICLE W BONE GRAFT OP "$2,989.00 " $0.00 $0.00 "$2,203.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,203.94" $913.93 $591.67 $913.93 23500 EAP CPT® 23500 PR CLOSED RX CLAVICLE FRACTURE OP $697.00 $0.00 $0.00 $509.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $509.66 $188.55 $105.36 $188.55 23525 EAP CPT® 23525 "PR CLOSED RX STERN-CLAV DISLOC,MANIP" OP "$1,116.00 " $0.00 $0.00 $797.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $797.93 $311.38 $160.23 $311.38 23550 EAP CPT® 23550 PR OPEN RX A-C JT DISLOC OP "$2,853.00 " $0.00 $0.00 "$1,299.87" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,299.87" $531.96 $351.63 $531.96 23552 EAP CPT® 23552 "PR OPEN RX A-C JT DISLOC,FASCIAL GRFT" OP "$3,718.00 " $0.00 $0.00 "$1,509.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,509.95" $614.78 $377.39 $614.78 23570 EAP CPT® 23570 PR CLOSED RX SCAPULA FX OP $745.00 $0.00 $0.00 $548.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $548.16 $201.06 $109.72 $201.06 23585 EAP CPT® 23585 PR OPEN RX SCAPULA FRACTURE OP "$3,059.00 " $0.00 $0.00 "$2,265.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,265.15" $644.91 $405.43 $644.91 23600 EAP CPT® 23600 PR CLOSED RX PROX HUMERUS FRACTURE OP $964.00 $0.00 $0.00 $705.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $705.23 $284.46 $159.64 $284.46 23615 EAP CPT® 23615 OPEN TREATMENT PROX HUMERAL FRACTURE OP "$3,026.00 " $0.00 $0.00 "$2,041.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,041.79" $760.12 $451.32 $760.12 23620 EAP CPT® 23620 PR CLOSED RX GR TUBEROSITY HUM FX OP $800.00 $0.00 $0.00 $587.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $587.60 $230.63 $143.68 $230.63 23650 EAP CPT® 23650 PR CLOSED RX SHLDR DISLOCATION OP $904.00 $0.00 $0.00 $658.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $658.97 $265.86 $157.08 $265.86 23675 EAP CPT® 23675 "PR CLOSED RX SHLDR DISLOC,PROX HUM FX" OP "$1,564.00 " $0.00 $0.00 "$1,152.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,152.44" $494.30 $275.62 $494.30 23700 EAP CPT® 23700 PR MANIPULATN SHLDR JT W ANESTHESIA OP $811.00 $0.00 $0.00 $453.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $453.00 $181.58 $118.69 $181.58 24000 EAP CPT® 24000 PR EXPLORE/DRAIN ELBOW FOR INFECT OP "$2,104.00 " $0.00 $0.00 "$1,097.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,097.66" $437.03 $275.59 $437.03 24006 EAP CPT® 24006 PR ARTHROTOMY/CAPULE RELEASE ELBOW JT OP "$2,220.00 " $0.00 $0.00 "$1,628.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,628.00" $664.79 $397.07 $664.79 24071 EAP CPT® 24071 PR EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 3+CM OP "$1,268.00 " $0.00 $0.00 $938.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $938.63 $0.00 $184.01 $0.00 24075 EAP CPT® 24075 "PR EXCIS TUMOR,SOFT TISS UP ARM/ELBOW,SUBQ" OP "$1,024.00 " $0.00 $0.00 $762.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $762.08 $426.22 $192.77 $426.22 24076 EAP CPT® 24076 "PR EXCIS TUMOR,SOFT TISS UP ARM/ELBOW,DEEP" OP "$1,697.00 " $0.00 $0.00 "$1,253.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,253.81" $432.71 $264.65 $432.71 24100 EAP CPT® 24100 PR BIOPSY SYNOVIUM ELBOW JOINT OP "$1,721.00 " $0.00 $0.00 $962.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $962.64 $367.83 $234.41 $367.83 24102 EAP CPT® 24102 PR EXPLOR ELBOW JT/REMOV SYNOVIUM OP "$2,754.00 " $0.00 $0.00 "$1,420.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,420.16" $574.78 $378.56 $574.78 24149 EAP CPT® 24149 "PR RADICAL RESECT ELBOW, CONTRAC RELEAS" OP "$3,664.00 " $0.00 $0.00 "$2,711.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,711.37" "$1,061.66" $612.80 "$1,061.66" 24201 EAP CPT® 24201 "PR REMOVAL ARM/ELBOW F.B.,DEEP" OP "$1,130.00 " $0.00 $0.00 $832.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $832.74 $528.59 $225.84 $528.59 24300 EAP CPT® 24300 PR MANIPULATE ELBOW W/ANESTH OP "$1,324.00 " $0.00 $0.00 $961.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $961.22 $362.46 $219.86 $362.46 24341 EAP CPT® 24341 PR MUSC/TENDON REPAIR EACH; ARM/ELBOW OP "$2,601.00 " $0.00 $0.00 "$1,721.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,721.10" $659.37 $351.51 $659.37 24342 EAP CPT® 24342 "PR REINSERT BI/TRICEPS TENDON,DISTAL" OP "$2,716.00 " $0.00 $0.00 "$1,789.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,789.04" $741.36 $475.64 $741.36 24343 EAP CPT® 24343 PR REPR ELBOW LAT LIGMNT W/TISS OP "$2,601.00 " $0.00 $0.00 "$1,627.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,627.07" $654.61 $394.81 $654.61 24345 EAP CPT® 24345 PR REPR ELBW MED LIGMNT W/TISS OP "$2,601.00 " $0.00 $0.00 "$1,621.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,621.29" $650.90 $394.81 $650.90 24359 EAP CPT® 24359 PR TENOTOMY ELBOW LATERAL/MEDIAL DEBRIDE REPAIR OP "$2,064.00 " $0.00 $0.00 "$1,518.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,518.95" $0.00 $315.81 $0.00 24430 EAP CPT® 24430 PR REPAIR NON/MALUNION HUMERUS OP "$3,298.00 " $0.00 $0.00 "$2,439.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,439.42" $960.74 $606.05 $960.74 24500 EAP CPT® 24500 PR CLOSED RX MID HUMERUS FRACTURE OP "$1,023.00 " $0.00 $0.00 $747.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $747.62 $307.14 $183.43 $307.14 24515 EAP CPT® 24515 PR OPEN FIXATN MID HUMERUS FRACTURE OP "$2,998.00 " $0.00 $0.00 "$2,021.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,021.82" $823.37 $509.91 $823.37 24516 EAP CPT® 24516 PR OPEN ROD FIXATN HUMERAL SHAFT FX OP "$3,634.00 " $0.00 $0.00 "$1,985.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,985.91" $815.98 $515.45 $815.98 24530 EAP CPT® 24530 PR CLOSED RX HUMERAL SUPRACONDYLAR FX OP "$1,077.00 " $0.00 $0.00 $790.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $790.07 $331.33 $203.17 $331.33 24535 EAP CPT® 24535 "PR CLOSED RX HUM SUPRACONDYLR FX,MANIPU" OP "$1,767.00 " $0.00 $0.00 "$1,302.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,302.54" $563.45 $336.84 $563.45 24545 EAP CPT® 24545 OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/O XTN OP "$3,179.00 " $0.00 $0.00 "$2,145.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,145.09" $744.88 $473.76 $744.88 24546 EAP CPT® 24546 OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W XTN OP "$3,861.00 " $0.00 $0.00 "$2,399.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,399.33" "$1,055.24" $636.51 "$1,055.24" 24575 EAP CPT® 24575 OPEN TX HUMERAL EPICONDYLAR FRACTURE OP "$2,362.00 " $0.00 $0.00 "$1,683.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,683.62" $749.79 $436.14 $749.79 24579 EAP CPT® 24579 OPEN TX HUMERAL CONDYLAR FRACTURE OP "$2,771.00 " $0.00 $0.00 "$1,928.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,928.07" $805.77 $482.07 $805.77 24586 EAP CPT® 24586 PR OPEN RX PERIARTIC FX/DISLOC ELBOW OP "$3,634.00 " $0.00 $0.00 "$2,501.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,501.15" "$1,036.46" $657.76 "$1,036.46" 24600 EAP CPT® 24600 PR CLOSED RX ELBOW DISLOCATION OP "$1,050.00 " $0.00 $0.00 $763.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $763.13 $337.43 $217.41 $337.43 24605 EAP CPT® 24605 "PR CLOSED RX ELBOW DISLOCATN,ANESTHESIA" OP "$1,475.00 " $0.00 $0.00 "$1,081.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,081.08" $417.05 $206.78 $417.05 24635 EAP CPT® 24635 OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW OP "$3,338.00 " $0.00 $0.00 "$1,551.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,551.20" "$1,035.85" $666.96 "$1,035.85" 24640 EAP CPT® 24640 "PR CLOSED RX RADIAL HEAD DISLOC,CHILD" OP $302.00 $0.00 $0.00 $211.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.43 $111.55 $98.90 $111.55 24650 EAP CPT® 24650 PR CLOSED RX RADIAL HEAD/NECK FX OP $752.00 $0.00 $0.00 $549.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.99 $225.50 $149.04 $225.50 24665 EAP CPT® 24665 OPEN TX RADIAL HEAD/NECK FRACTURE OP "$2,294.00 " $0.00 $0.00 "$1,501.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,501.73" $603.81 $375.56 $603.81 24666 EAP CPT® 24666 OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC OP "$2,930.00 " $0.00 $0.00 "$1,689.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,689.89" $684.59 $453.66 $684.59 24675 EAP CPT® 24675 CLOSED TX ULNAR FRACTURE PROX END W MANIPULATION OP "$1,296.00 " $0.00 $0.00 $949.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $949.65 $409.98 $254.23 $409.98 24685 EAP CPT® 24685 OPEN TX ULNAR FRACTURE PROX END OP "$2,453.00 " $0.00 $0.00 "$1,507.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,507.25" $632.28 $410.70 $632.28 24802 EAP CPT® 24802 PR FUSION/GRAFT OF ELBOW JOINT OP "$4,542.00 " $0.00 $0.00 "$2,259.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,259.89" $944.83 $591.29 $944.83 25000 EAP CPT® 25000 "PR INCIS TENDON SHEATH,RADIAL STYLOID" OP "$1,053.00 " $0.00 $0.00 $774.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $980.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $774.03 $375.00 $191.35 $375.00 25024 EAP CPT® 25024 "PR DECOMP FOREARM,2 COMPART,W/O DEBRIDE" OP "$2,441.00 " $0.00 $0.00 "$1,781.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,781.37" $693.70 $460.69 $693.70 25071 EAP CPT® 25071 PR EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3+CM OP "$1,325.00 " $0.00 $0.00 $983.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $983.07 $0.00 $192.83 $0.00 25075 EAP CPT® 25075 "PR EXCIS TUMOR,SOFT TISS FOREARM/WRIST,SUBQ" OP "$1,087.00 " $0.00 $0.00 $730.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $730.26 $358.77 $185.50 $358.77 25111 EAP CPT® 25111 PR EXCIS PRIMARY GANGLION WRIST OP $999.00 $0.00 $0.00 $735.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $735.95 $305.92 $178.80 $305.92 25150 EAP CPT® 25150 "PR PART REMOVAL BONE,ULNA" OP "$1,824.00 " $0.00 $0.00 "$1,302.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,302.99" $579.58 $361.38 $579.58 25240 EAP CPT® 25240 "PR EXCIS DISTAL ULNA,PART/COMPLETE" OP "$1,403.00 " $0.00 $0.00 $982.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $982.62 $451.09 $284.83 $451.09 25260 EAP CPT® 25260 "PR REPR FOREARM TEND/MUSC,FLEX,PRIM,EA" OP "$1,966.00 " $0.00 $0.00 "$1,449.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,449.08" $769.61 $391.51 $769.61 25270 EAP CPT® 25270 "PR REPR FOREARM TEND/MUSC,EXTEN,PRIM,EA" OP "$1,534.00 " $0.00 $0.00 "$1,124.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,124.69" $648.94 $322.74 $648.94 25290 EAP CPT® 25290 PR INCISE WRIST/FOREARM TENDON OP "$1,356.00 " $0.00 $0.00 "$1,003.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,003.23" $711.68 $312.09 $711.68 25310 EAP CPT® 25310 PR TRANSPLANT FOREARM/WRIST TENDON OP "$2,279.00 " $0.00 $0.00 "$1,425.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,425.68" $772.01 $434.78 $772.01 25312 EAP CPT® 25312 "PR XPLANT FOREARM TENDON,W TENDON GRFT" OP "$2,455.00 " $0.00 $0.00 "$1,646.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,646.13" $861.75 $486.15 $861.75 25320 EAP CPT® 25320 "PR REVISE WRIST JOINT,CARPAL INSTABIL" OP "$3,064.00 " $0.00 $0.00 "$2,271.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,271.93" $901.23 $477.55 $901.23 25405 EAP CPT® 25405 PR REPAIR NONUNION RADIUS OR ULNAW/GRAFT OP "$3,239.00 " $0.00 $0.00 "$2,390.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,390.93" "$1,187.61" $696.10 "$1,187.61" 25447 EAP CPT® 25447 PR REPAIR INTERCARP/CARP-METACARP JT OP "$2,630.00 " $0.00 $0.00 "$1,905.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,905.00" $752.18 $476.97 $752.18 25500 EAP CPT® 25500 PR CLOSED RX RADIAL SHAFT FX OP $784.00 $0.00 $0.00 $574.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $574.77 $229.25 $152.65 $229.25 25505 EAP CPT® 25505 "PR CLOSED RX RADIAL SHAFT FX,MANIPULATN" OP "$1,428.00 " $0.00 $0.00 "$1,056.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,056.71" $450.84 $268.65 $450.84 25515 EAP CPT® 25515 OPEN TREATMENT RADIAL SHAFT FRACTURE OP "$2,087.00 " $0.00 $0.00 "$1,541.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,541.49" $651.49 $411.00 $651.49 25525 EAP CPT® 25525 OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE OP "$2,639.00 " $0.00 $0.00 "$1,807.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,807.98" $874.63 $549.71 $874.63 25530 EAP CPT® 25530 PR CLOSED RX ULNA SHAFT FX OP $744.00 $0.00 $0.00 $544.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $544.35 $222.40 $146.18 $222.40 25535 EAP CPT® 25535 "PR CLOSED RX ULNA SHAFT FX,MANIPULATN" OP "$1,410.00 " $0.00 $0.00 "$1,038.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,038.78" $431.24 $264.92 $431.24 25545 EAP CPT® 25545 OPEN TREATMENT OF ULNAR SHAFT FRACTURE OP "$1,989.00 " $0.00 $0.00 "$1,434.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,434.29" $644.08 $402.54 $644.08 25560 EAP CPT® 25560 PR CLOSED RX RAD/ULNA SHAFT FX OP $790.00 $0.00 $0.00 $574.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $574.83 $232.51 $152.44 $232.51 25565 EAP CPT® 25565 "PR CLOSED RX RAD/ULNA SHAFT FX,MANIP" OP "$1,462.00 " $0.00 $0.00 "$1,078.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,078.01" $471.98 $296.36 $471.98 25575 EAP CPT® 25575 OPEN TX RADIAL & ULNAR SHAFT FX FIX RADIUS AND ULNA OP "$2,812.00 " $0.00 $0.00 "$2,077.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,077.41" $830.18 $488.12 $830.18 25600 EAP CPT® 25600 PR CLOSED RX DIST RAD/ULNA FX OP $979.00 $0.00 $0.00 $710.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $710.48 $255.35 $167.28 $255.35 25605 EAP CPT® 25605 "PR CLOSED RX DIST RAD/ULNA FX,MANIPUL" OP "$1,665.00 " $0.00 $0.00 "$1,177.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,177.85" $543.76 $293.51 $543.76 25606 EAP CPT® 25606 "PR PERCUT SKELETAL FIX, DISTAL RADIUS FX" OP "$2,066.00 " $0.00 $0.00 "$1,526.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,526.51" $636.93 $378.04 $636.93 25607 EAP CPT® 25607 "PR OPEN RX DISTAL RADIUS FX, EXTRA-ARTICULAR" OP "$2,292.00 " $0.00 $0.00 "$1,692.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,692.74" $642.48 $377.52 $642.48 25608 EAP CPT® 25608 "PR OPEN RX DISTAL RADIUS FX, INTRA-ARTICULAR, 2 FRAG" OP "$2,571.00 " $0.00 $0.00 "$1,898.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,898.00" $734.14 $430.91 $734.14 25609 EAP CPT® 25609 "PR OPEN RX DISTAL RADIUS FX, INTRA-ARTICULAR, 3+ FRAG" OP "$3,272.00 " $0.00 $0.00 "$2,413.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,413.40" $936.62 $548.96 $936.62 25622 EAP CPT® 25622 PR CLOSED RX NAVICULAR FX OP $872.00 $0.00 $0.00 $634.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $634.47 $261.60 $159.66 $261.60 25628 EAP CPT® 25628 OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE OP "$2,242.00 " $0.00 $0.00 "$1,659.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,659.75" $664.44 $383.36 $664.44 25630 EAP CPT® 25630 PR CLOSED RX CARPAL FX OP $879.00 $0.00 $0.00 $642.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $642.21 $268.33 $166.64 $268.33 25635 EAP CPT® 25635 "PR CLOSED RX CARPAL FX,MAIPULATN" OP "$1,301.00 " $0.00 $0.00 $872.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $872.90 $395.18 $242.38 $395.18 25650 EAP CPT® 25650 PR CLOSED RX ULNA STYLOID FX OP $941.00 $0.00 $0.00 $687.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $687.38 $279.49 $176.60 $279.49 25670 EAP CPT® 25670 PR OPEN REPAIR WRIST DISLOCATION OP "$1,896.00 " $0.00 $0.00 "$1,395.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,395.42" $572.40 $366.53 $572.40 25671 EAP CPT® 25671 "PR PERCUT SKELETAL FIX,DIST RADIOULN DISLOC" OP "$1,654.00 " $0.00 $0.00 "$1,219.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,219.92" $476.60 $418.56 $476.60 25695 EAP CPT® 25695 PR OPEN REPAIR LUNATE DISLOCATION OP "$1,979.00 " $0.00 $0.00 "$1,459.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,459.79" $593.11 $379.64 $593.11 25810 EAP CPT® 25810 PR FUSION/GRAFT WRIST JOINT OP "$3,492.00 " $0.00 $0.00 "$1,997.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,997.94" $823.26 $505.32 $823.26 25920 EAP CPT® 25920 PR AMPUTATE THRU WRIST OP "$2,436.00 " $0.00 $0.00 "$1,598.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,598.99" $638.37 $386.08 $638.37 26010 EAP CPT® 26010 "PR DRAIN FINGER ABSCESS,SIMPLE" OP $429.00 $0.00 $0.00 $315.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.59 $250.54 $90.83 $250.54 26020 EAP CPT® 26020 PR DRAIN HAND TENDON SHEATH OP "$1,726.00 " $0.00 $0.00 $997.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $997.10 $391.18 $266.59 $391.18 26025 EAP CPT® 26025 "PR DRAINAGE PALM BURSA,SINGLE" OP "$1,310.00 " $0.00 $0.00 $971.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $971.19 $383.74 $280.61 $383.74 26035 EAP CPT® 26035 "PR DECOMPRESS FINGERS/HAND,INJECT INJ" OP "$2,766.00 " $0.00 $0.00 "$1,966.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,966.94" $734.48 $442.24 $734.48 26037 EAP CPT® 26037 PR DECOMPRESS FASCIOTOMY FINGR/HAND OP "$1,765.00 " $0.00 $0.00 "$1,304.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,304.75" $527.15 $366.39 $527.15 26055 EAP CPT® 26055 PR INCISE FINGER TENDON SHEATH OP "$1,027.00 " $0.00 $0.00 $712.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,711.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $712.32 $597.39 $172.83 $597.39 26075 EAP CPT® 26075 PR EXPLORE & TREAT METACARPO-PHAL JT OP "$1,185.00 " $0.00 $0.00 $764.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $764.03 $288.36 $241.79 $288.36 26080 EAP CPT® 26080 "PR EXPLORE/TREAT INTERPHALANGEAL JT,EA" OP "$1,223.00 " $0.00 $0.00 $896.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $896.79 $349.56 $251.48 $349.56 26115 EAP CPT® 26115 PR EXCIS SOFT TISSUE LESION HAND SUBCUT OP "$1,028.00 " $0.00 $0.00 $765.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $765.47 $607.90 $186.06 $607.90 26116 EAP CPT® 26116 PR EXCIS SOFT TISSUE LESION HAND DEEP OP "$1,636.00 " $0.00 $0.00 "$1,212.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,212.77" $440.72 $296.88 $440.72 26145 EAP CPT® 26145 "PR RAD EXCIS JT LINING,FLEXOR,EACH" OP "$1,601.00 " $0.00 $0.00 "$1,175.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,175.78" $472.56 $350.97 $472.56 26160 EAP CPT® 26160 "PR EXCIS TENDON SHEATH LESION, HAND/FINGER" OP $977.00 $0.00 $0.00 $766.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $766.79 $561.00 $172.03 $561.00 26235 EAP CPT® 26235 "PR PART REMV BONE,PROX/MID PHALANX" OP "$1,535.00 " $0.00 $0.00 "$1,134.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,134.14" $457.99 $310.01 $457.99 26350 EAP CPT® 26350 "PR REPAIR FLEXOR TENDON,HAND,W/O GRAFT,EA" OP "$2,250.00 " $0.00 $0.00 "$1,612.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,612.62" $734.02 $383.54 $734.02 26356 EAP CPT® 26356 "PR REPAIR FLEX TENDON,ZONE 2,HAND" OP "$2,530.00 " $0.00 $0.00 "$2,012.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,012.28" "$1,033.52" $464.19 "$1,033.52" 26370 EAP CPT® 26370 "PR REPAIR PROFUNDUS TENDON,PRIMARY" OP "$2,376.00 " $0.00 $0.00 "$1,715.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,715.79" $793.20 $428.18 $793.20 26410 EAP CPT® 26410 "PR REPAIR EXTEN TENDON,DORSUM HAND,EA" OP "$1,790.00 " $0.00 $0.00 "$1,281.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,281.69" $587.31 $287.27 $587.31 26418 EAP CPT® 26418 "PR REPAIR EXTEN TENDON,DORSUM FINGR,EA" OP "$1,841.00 " $0.00 $0.00 "$1,308.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,308.08" $587.73 $282.40 $587.73 26442 EAP CPT® 26442 "PR TENOLYSIS FLEX TENDON,PALM & FINGER,EA" OP "$3,002.00 " $0.00 $0.00 "$2,186.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,186.94" $921.30 $412.55 $921.30 26445 EAP CPT® 26445 "PR TENOLYSIS EXT TENDON,HAND/FINGER,EA" OP "$1,817.00 " $0.00 $0.00 "$1,304.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,304.90" $611.00 $298.50 $611.00 26485 EAP CPT® 26485 PR TRANSPLANT PALM TENDON OP "$2,534.00 " $0.00 $0.00 "$1,829.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,829.96" $826.60 $448.37 $826.60 26492 EAP CPT® 26492 "PR THUMB TENDON TRANSFER,GRAFT" OP "$2,832.00 " $0.00 $0.00 "$1,978.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,978.86" $853.74 $487.29 $853.74 26541 EAP CPT® 26541 "PR FIX COLLAT LIG,MC-P JT,GRAFT" OP "$2,526.00 " $0.00 $0.00 "$1,816.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,816.59" $801.41 $465.37 $801.41 26560 EAP CPT® 26560 "PR REPAIR OF WEB FINGER,EACH" OP "$1,888.00 " $0.00 $0.00 "$1,269.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,269.92" $554.70 $289.64 $554.70 26591 EAP CPT® 26591 PR REPAIR MUSCLES OF HAND OP "$1,410.00 " $0.00 $0.00 $985.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $985.86 $454.82 $217.25 $454.82 26600 EAP CPT® 26600 PR CLOSED RX METACARPAL FX OP $871.00 $0.00 $0.00 $633.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.89 $232.37 $131.24 $232.37 26605 EAP CPT® 26605 "PR CLOSED RX METACARPAL FX,MANIP" OP $914.00 $0.00 $0.00 $671.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $671.27 $282.35 $179.88 $282.35 26608 EAP CPT® 26608 "PR CLOSED RX METACARPAL FX,PERCUT" OP "$1,762.00 " $0.00 $0.00 "$1,094.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,094.48" $441.42 $249.22 $441.42 26615 EAP CPT® 26615 OPEN TX METACARPAL FRACTURE SINGLE EA BONE OP "$1,938.00 " $0.00 $0.00 "$1,325.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,325.54" $408.45 $261.14 $408.45 26676 EAP CPT® 26676 "PR PERCUT FIX CARPOMETACAR DISLOC,NON-THUMB" OP "$1,572.00 " $0.00 $0.00 "$1,149.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,149.24" $463.72 $275.79 $463.72 26685 EAP CPT® 26685 OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB OP "$2,064.00 " $0.00 $0.00 "$1,325.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,325.63" $506.13 $320.40 $506.13 26706 EAP CPT® 26706 PR PERCUT RX MC-P DISLOC OP "$1,374.00 " $0.00 $0.00 "$1,010.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,010.67" $393.92 $235.28 $393.92 26715 EAP CPT® 26715 OPEN TREATMENT METACARPOPHALANGEAL DISLOCATION 1 OP "$1,888.00 " $0.00 $0.00 "$1,315.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,315.32" $432.04 $263.49 $432.04 26720 EAP CPT® 26720 PR CLOSE RX PROX/MID FING SHFT FX OP $575.00 $0.00 $0.00 $421.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.28 $168.24 $81.03 $168.24 26725 EAP CPT® 26725 "PR CLOSE RX PROX/MID FING SHFT FX,MANIP" OP $944.00 $0.00 $0.00 $695.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $695.07 $306.16 $146.76 $306.16 26727 EAP CPT® 26727 PR PERCUT RX PROX/MID FING SHFT FX OP "$1,466.00 " $0.00 $0.00 "$1,076.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,076.81" $434.70 $234.53 $434.70 26735 EAP CPT® 26735 OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA OP "$1,850.00 " $0.00 $0.00 "$1,372.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,372.05" $443.47 $266.69 $443.47 26742 EAP CPT® 26742 "PR CLOSE RX FINGR ARTICULAR FX,MANIP" OP "$1,042.00 " $0.00 $0.00 $765.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $765.62 $334.43 $208.72 $334.43 26746 EAP CPT® 26746 OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA OP "$2,312.00 " $0.00 $0.00 "$1,706.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,706.61" $436.26 $274.88 $436.26 26750 EAP CPT® 26750 PR CLOSE RX DIST FINGR FX OP $578.00 $0.00 $0.00 $421.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $421.31 $157.47 $83.25 $157.47 26755 EAP CPT® 26755 "PR CLOSE RX DIST FINGR FX,MANIPULATN" OP $851.00 $0.00 $0.00 $623.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $623.57 $281.91 $133.49 $281.91 26765 EAP CPT® 26765 OPEN TX DISTAL PHALANGEAL FRACTURE EACH OP "$1,559.00 " $0.00 $0.00 "$1,151.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,151.58" $328.64 $199.71 $328.64 26770 EAP CPT® 26770 PR CLOSED RX IP JT DISLOCATION OP $801.00 $0.00 $0.00 $581.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $581.84 $238.98 $126.41 $238.98 26775 EAP CPT® 26775 "PR CLOSED RX IP JT DISLOCATION,ANESTH" OP "$1,077.00 " $0.00 $0.00 $792.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $792.51 $336.14 $182.82 $336.14 26785 EAP CPT® 26785 OPEN TX INTERPHALANGEAL JOINT DISLOCATION 1 OP "$1,699.00 " $0.00 $0.00 "$1,259.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,259.03" $334.85 $204.81 $334.85 26860 EAP CPT® 26860 PR FUSION FINGER JOINT OP "$1,888.00 " $0.00 $0.00 "$1,278.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,278.42" $569.23 $279.58 $569.23 26910 EAP CPT® 26910 PR AMPUTATE METACARPAL+FINGER OP "$2,286.00 " $0.00 $0.00 "$1,633.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,633.73" $694.83 $374.63 $694.83 26951 EAP CPT® 26951 PR AMPUTATION FINGER/THUMB OP "$2,070.00 " $0.00 $0.00 "$1,482.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,482.29" $586.73 $258.35 $586.73 26952 EAP CPT® 26952 PR AMPUTATION FINGER/THUMB+FLAPS OP "$2,044.00 " $0.00 $0.00 "$1,461.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.78" $650.56 $325.62 $650.56 26989 EAP CPT® 26989 PR HAND/FINGER SURGERY UNLISTED OP $965.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27071 EAP CPT® 27071 PR PARTIAL EXCISION DEEP PELVIS OP "$3,849.00 " $0.00 $0.00 "$2,115.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,115.12" $854.40 $557.78 $854.40 27086 EAP CPT® 27086 "PR REMOVE PELV/HIP F.B.,SUBCUTANEOUS" OP $521.00 $0.00 $0.00 $382.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $382.67 $234.62 $98.64 $234.62 27096 EAP CPT® 27096 PR INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMAGE OP $592.00 $0.00 $0.00 $195.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.50 $194.66 $249.29 $194.66 27125 EAP CPT® 27125 PR PARTIAL HIP REPLACEMENT OP "$7,993.00 " $0.00 $0.00 "$2,621.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,621.66" "$1,048.50" $687.58 "$1,048.50" 27130 EAP CPT® 27130 PR TOTAL HIP ARTHROPLASTY OP "$11,250.00 " $0.00 $0.00 "$3,138.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,138.59" "$1,356.54" $928.69 "$1,356.54" 27132 EAP CPT® 27132 PR CONV PREV HIP SURG TO TOT HIP ARTHROPLAS OP "$13,322.00 " $0.00 $0.00 "$3,876.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,876.54" "$1,591.56" "$1,066.58" "$1,591.56" 27134 EAP CPT® 27134 PR REVISE TOTAL HIP REPLACEMENT OP "$14,506.00 " $0.00 $0.00 "$4,438.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,438.61" "$1,856.70" "$1,290.58" "$1,856.70" 27137 EAP CPT® 27137 PR REVISE ACETABULAR PART OF TOTAL HIP OP "$11,546.00 " $0.00 $0.00 "$3,410.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,410.25" "$1,412.06" $975.17 "$1,412.06" 27187 EAP CPT® 27187 PR REINFORCE HIP BONES OP "$6,513.00 " $0.00 $0.00 "$2,290.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,290.70" $941.28 $642.06 $941.28 27197 EAP CPT® 27197 PR CLSD TX PELVIC RING FX W/O MANIPULATION OP $398.00 $0.00 $0.00 $269.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.57 $0.00 $71.34 $0.00 27215 EAP CPT® 27215 "PR OPEN FIX ILIAC FX,INTERN FIXATN" OP "$3,611.00 " $0.00 $0.00 "$1,441.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.92" $689.70 $478.64 $689.70 27216 EAP CPT® 27216 PR PERCUT FIX POST PELV RING FX OP "$2,869.00 " $0.00 $0.00 "$2,136.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,136.53" $993.21 $540.91 $993.21 27217 EAP CPT® 27217 PR OPEN INTERN FIX ANTER PELV RING FX OP "$3,789.00 " $0.00 $0.00 "$2,004.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,004.93" $957.68 $643.85 $957.68 27218 EAP CPT® 27218 PR OPEN INTERN FIX POST PELV RING FX OP "$4,164.00 " $0.00 $0.00 "$2,770.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,770.49" "$1,274.51" $784.82 "$1,274.51" 27220 EAP CPT® 27220 PR CLOSED RX ACETABULAR FX OP "$1,322.00 " $0.00 $0.00 "$1,211.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,211.37" $478.81 $275.04 $478.81 27226 EAP CPT® 27226 PR OPEN INTERN FIX ACETABULAR WALL FX OP "$3,302.00 " $0.00 $0.00 "$2,442.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,442.80" $927.37 $677.15 $927.37 27227 EAP CPT® 27227 PR OPEN INTERN FIX ACETABULAR FX OP "$5,175.00 " $0.00 $0.00 "$3,840.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,840.78" "$1,574.19" $983.91 "$1,574.19" 27228 EAP CPT® 27228 PR OPEN INTERN FIX COMPLEX ACETABUL FX OP "$7,498.00 " $0.00 $0.00 "$4,379.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,379.33" "$1,808.94" "$1,097.38" "$1,808.94" 27235 EAP CPT® 27235 PR PERCUT FIX PROX/NECK FEMUR FX OP "$4,233.00 " $0.00 $0.00 "$2,101.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,101.89" $859.86 $565.30 $859.86 27236 EAP CPT® 27236 "PR FEMORAL FX, OPEN TX" OP "$4,381.00 " $0.00 $0.00 "$2,767.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,767.73" "$1,105.25" $711.98 "$1,105.25" 27244 EAP CPT® 27244 "PR TREAT INTER/SUBTROCH FX,W/PLATE/SCREW" OP "$4,085.00 " $0.00 $0.00 "$2,848.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,848.62" "$1,096.57" $714.62 "$1,096.57" 27245 EAP CPT® 27245 "PR OPEN FIX INTER/SUBTROCH FX,IMPLNT" OP "$4,479.00 " $0.00 $0.00 "$2,847.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,847.86" "$1,346.88" $846.17 "$1,346.88" 27252 EAP CPT® 27252 "PR CLOSED RX TRAUMA HIP DISLOC,ANESTH" OP "$2,360.00 " $0.00 $0.00 "$1,751.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,751.33" $706.04 $385.64 $706.04 27254 EAP CPT® 27254 PR OPEN RX HIP DISLOC/ACETABULAR FX OP "$3,981.00 " $0.00 $0.00 "$2,931.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,931.20" "$1,198.44" $738.87 "$1,198.44" 27275 EAP CPT® 27275 PR MANIPULATION HIP JOINT W ANESTHESIA OP $878.00 $0.00 $0.00 $418.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $418.68 $169.08 $110.36 $169.08 27299 EAP CPT® 27299 PR PELVIS/HIP JOINT SURGERY UNLISTED OP "$2,870.00 " $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 27301 EAP CPT® 27301 "PR INCIS/DRAIN THIGH/KNEE ABSCESS,DEEP" OP "$1,573.00 " $0.00 $0.00 "$1,156.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,156.80" $622.36 $334.92 $622.36 27310 EAP CPT® 27310 "PR EXPLOR/DRAIN KNEE,INFECTN" OP "$2,309.00 " $0.00 $0.00 "$1,687.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,687.01" $674.44 $439.73 $674.44 27331 EAP CPT® 27331 PR ARTHROTOMY/EXPLORE/TREAT KNEE JOINT OP "$2,040.00 " $0.00 $0.00 "$1,094.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,094.30" $439.49 $293.46 $439.49 27334 EAP CPT® 27334 "PR RMV KNEE SYNOVIUM,ANT/POST" OP "$2,810.00 " $0.00 $0.00 "$1,575.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,575.69" $634.61 $421.54 $634.61 27337 EAP CPT® 27337 PR EXCISON TUMOR SOFT TISSUE THIGH/KNEE SUBQ 3+CM OP "$1,310.00 " $0.00 $0.00 $967.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $967.34 $0.00 $190.01 $0.00 27360 EAP CPT® 27360 PR PART REMV FEMUR/PROX TIB/FIB OP "$2,739.00 " $0.00 $0.00 "$1,962.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,962.72" $799.58 $531.82 $799.58 27364 EAP CPT® 27364 PR RAD RESECTION TUMOR SOFT TIS THIGH/KNEE 5 CM/> OP "$4,890.00 " $0.00 $0.00 "$3,617.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,617.24" $0.00 $713.73 $0.00 27372 EAP CPT® 27372 "PR REMV FOREIGN BODY,KNEE/THIGH,DEEP" OP "$1,253.00 " $0.00 $0.00 $930.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $930.30 $560.83 $239.61 $560.83 27380 EAP CPT® 27380 "PR FIX INFRAPATELLA TENDON,PRIMARY" OP "$1,895.00 " $0.00 $0.00 "$1,368.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.41" $556.50 $350.32 $556.50 27381 EAP CPT® 27381 "PR FIX PATELLA TENDN,SECONDARY" OP "$2,525.00 " $0.00 $0.00 "$1,836.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,836.74" $755.33 $487.76 $755.33 27385 EAP CPT® 27385 "PR FIX QUAD/HAMSTR MUSC RUPT,PRIMARY" OP "$2,247.00 " $0.00 $0.00 "$1,324.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,324.62" $596.54 $377.90 $596.54 27403 EAP CPT® 27403 "PR ARTHROTOMY,OPEN REPAIR MENISCUS" OP "$2,765.00 " $0.00 $0.00 "$1,476.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,476.08" $601.90 $397.16 $601.90 27405 EAP CPT® 27405 "PR REPAIR COLLAT LIGAMT/CAPSULE,KNEE" OP "$2,713.00 " $0.00 $0.00 "$1,554.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,554.89" $632.10 $422.26 $632.10 27407 EAP CPT® 27407 "PR REPAIR CRUCIATE LIGAMENT,KNEE" OP "$3,111.00 " $0.00 $0.00 "$1,792.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,792.74" $728.49 $460.07 $728.49 27416 EAP CPT® 27416 PR OSTEOCHONDRAL KNEE AUTOGRAFT OP "$3,064.00 " $0.00 $0.00 "$2,260.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,260.83" $0.00 $470.88 $0.00 27427 EAP CPT® 27427 "PR LIGMT REVISION,KNEE,EXTRA-ARTIC" OP "$4,147.00 " $0.00 $0.00 "$1,642.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,642.25" $672.25 $447.08 $672.25 27430 EAP CPT® 27430 PR REVISION QUADRICEPS OP "$2,419.00 " $0.00 $0.00 "$1,705.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,705.61" $694.88 $443.04 $694.88 27447 EAP CPT® 27447 PR TOTAL KNEE ARTHROPLASTY OP "$6,498.00 " $0.00 $0.00 "$3,137.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,137.78" "$1,459.64" $982.35 "$1,459.64" 27457 EAP CPT® 27457 "PR OSTEOTOMY PROX TIB,AFTR EPIPHY CLOS" OP "$3,214.00 " $0.00 $0.00 "$2,186.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,186.58" $919.01 $605.56 $919.01 27466 EAP CPT® 27466 PR LENGTHENING OF FEMUR OP "$4,839.00 " $0.00 $0.00 "$2,724.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,724.08" "$1,117.23" $721.72 "$1,117.23" 27470 EAP CPT® 27470 PR FIX NON/MALUNION FEMUR BELOW NECK OP "$3,681.00 " $0.00 $0.00 "$2,717.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,717.55" "$1,111.51" $752.66 "$1,111.51" 27472 EAP CPT® 27472 "PR FIX NON/MALUNION FEMUR,W GRAFT" OP "$3,975.00 " $0.00 $0.00 "$2,920.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,920.11" "$1,206.39" $834.99 "$1,206.39" 27487 EAP CPT® 27487 "PR REVISE KNEE JOINT REPLACE,ALL PARTS" OP "$7,604.00 " $0.00 $0.00 "$4,070.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,070.55" "$1,683.66" "$1,146.70" "$1,683.66" 27488 EAP CPT® 27488 PR REMOVAL OF KNEE PROSTHESIS OP "$4,147.00 " $0.00 $0.00 "$2,776.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,776.83" "$1,124.03" $720.61 "$1,124.03" 27495 EAP CPT® 27495 PR REINFORCE FEMUR OP "$3,525.00 " $0.00 $0.00 "$2,607.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,607.23" "$1,073.37" $740.73 "$1,073.37" 27500 EAP CPT® 27500 PR CLOSED RX FEMUR SHAFT FX OP "$1,498.00 " $0.00 $0.00 "$1,105.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,105.37" $471.80 $358.92 $471.80 27503 EAP CPT® 27503 PR CLOSED RX CONDYLAR FX+MANIP OP "$2,500.00 " $0.00 $0.00 "$1,852.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,852.79" $749.86 $456.15 $749.86 27506 EAP CPT® 27506 PR OPEN RX FEMUR FX+INTRAMED ROD OP "$4,179.00 " $0.00 $0.00 "$3,094.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,094.37" "$1,243.12" $761.87 "$1,243.12" 27507 EAP CPT® 27507 PR OPEN RX FEMUR FX+PLATE/SCREW OP "$3,813.00 " $0.00 $0.00 "$2,249.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,249.16" $935.63 $650.22 $935.63 27508 EAP CPT® 27508 "PR CLOSED RX FEMUR,DISTAL" OP "$1,546.00 " $0.00 $0.00 "$1,137.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,137.18" $477.19 $288.34 $477.19 27509 EAP CPT® 27509 PR PERCUT FIX DISTAL FEMUR OP "$2,215.00 " $0.00 $0.00 "$1,480.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,480.22" $606.93 $324.52 $606.93 27511 EAP CPT® 27511 OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O EXTENSION OP "$3,813.00 " $0.00 $0.00 "$2,305.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,305.74" $963.56 $642.40 $963.56 27513 EAP CPT® 27513 OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W EXTENSION OP "$4,358.00 " $0.00 $0.00 "$2,871.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,871.48" "$1,282.58" $782.38 "$1,282.58" 27514 EAP CPT® 27514 OPEN TX FEMORAL FRACTURE DISTAL MED/LAT CONDYLE OP "$3,886.00 " $0.00 $0.00 "$2,236.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,236.01" "$1,252.95" $755.03 "$1,252.95" 27524 EAP CPT® 27524 PR OPEN RX PATELLA FX OP "$2,488.00 " $0.00 $0.00 "$1,736.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,736.70" $710.93 $455.96 $710.93 27530 EAP CPT® 27530 PR CLOSED RX TIBIAL PLATEAU FX OP $881.00 $0.00 $0.00 $644.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $644.09 $352.16 $216.60 $352.16 27532 EAP CPT® 27532 PR CLOSED RX TIB PLAT FX+MANIP OP "$1,798.00 " $0.00 $0.00 "$1,329.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,329.30" $565.79 $320.81 $565.79 27535 EAP CPT® 27535 OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR OP "$2,807.00 " $0.00 $0.00 "$2,074.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,074.91" $837.62 $538.90 $837.62 27536 EAP CPT® 27536 PR OPEN RX BILAT TIB PLAT FX OP "$3,714.00 " $0.00 $0.00 "$2,752.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,752.62" "$1,113.22" $641.03 "$1,113.22" 27540 EAP CPT® 27540 OPEN TX INTERCONDYLAR SPINE/TUBRST FRACTURE KNEE OP "$2,724.00 " $0.00 $0.00 "$1,869.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,869.17" $886.96 $553.36 $886.96 27560 EAP CPT® 27560 PR CLOSED RX KNEECAP DISLOCATN OP "$1,068.00 " $0.00 $0.00 $765.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $765.00 $320.01 $192.86 $320.01 27562 EAP CPT® 27562 PR CLOSED RX KNEECAP DISLOC+ANESTH OP "$1,515.00 " $0.00 $0.00 "$1,079.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.22" $410.47 $257.43 $410.47 27570 EAP CPT® 27570 PR MANIPULATN KNEE JT+ANESTHESIA OP $663.00 $0.00 $0.00 $348.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.81 $135.48 $92.39 $135.48 27590 EAP CPT® 27590 "PR AMPUTATE THIGH,THRU FEMUR" OP "$2,651.00 " $0.00 $0.00 "$1,874.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,874.63" $771.07 $530.28 $771.07 27594 EAP CPT® 27594 "PR AMPUTATE THIGH,SECONDRY CLOSUR" OP "$1,599.00 " $0.00 $0.00 "$1,180.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,180.74" $473.80 $300.20 $473.80 27598 EAP CPT® 27598 PR AMPUTATE LOWER LEG AT KNEE OP "$2,905.00 " $0.00 $0.00 "$1,684.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,684.17" $698.51 $489.15 $698.51 27600 EAP CPT® 27600 PR DECOMPRESS ANT/LAT LEG CMPART OP "$1,266.00 " $0.00 $0.00 $953.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $953.97 $398.70 $260.55 $398.70 27602 EAP CPT® 27602 PR DECOMPRESS ANT/LAT+POST LEG CMPART OP "$1,811.00 " $0.00 $0.00 "$1,145.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,145.07" $490.62 $310.72 $490.62 27603 EAP CPT® 27603 PR DRAIN LOWER LEG DEEP ABSC/HEMATOMA OP "$1,214.00 " $0.00 $0.00 $898.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $898.67 $475.73 $294.89 $475.73 27606 EAP CPT® 27606 PR INCIS ACHILLES TENDON+GEN ANESTH OP $864.00 $0.00 $0.00 $654.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $654.72 $286.55 $216.34 $286.55 27610 EAP CPT® 27610 PR EXPLORE/TREAT ANKLE JOINT OP "$2,099.00 " $0.00 $0.00 "$1,504.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,504.52" $614.54 $389.57 $614.54 27620 EAP CPT® 27620 PR EXPLOR ANKLE JOINT OP "$2,222.00 " $0.00 $0.00 "$1,049.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,049.09" $438.26 $294.57 $438.26 27640 EAP CPT® 27640 PR PARTIAL REMOVAL OF TIBIA OP "$2,757.00 " $0.00 $0.00 "$1,927.85" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,927.85" $849.78 $562.82 $849.78 27641 EAP CPT® 27641 PR PARTIAL REMOVAL OF FIBULA OP "$2,469.00 " $0.00 $0.00 "$1,545.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,545.51" $684.74 $462.67 $684.74 27650 EAP CPT® 27650 "PR REPAIR ACHILLES TENDON,PRIMARY" OP "$2,552.00 " $0.00 $0.00 "$1,522.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,522.58" $669.22 $435.65 $669.22 27652 EAP CPT® 27652 PR REPAIR/GRAFT ACHILLES TENDON OP "$3,045.00 " $0.00 $0.00 "$1,580.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,580.30" $714.05 $468.42 $714.05 27658 EAP CPT® 27658 "PR REPAIR FLEX LEG TENDON,PRIM,EA" OP "$1,440.00 " $0.00 $0.00 $862.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $862.22 $365.37 $293.59 $365.37 27659 EAP CPT® 27659 "PR REPAIR FLEX LEG TENDON,SECOND,EA" OP "$1,852.00 " $0.00 $0.00 "$1,113.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,113.63" $483.88 $364.43 $483.88 27680 EAP CPT® 27680 "PR RELEASE TIB/FIB/ANKLE FLEX TENDON,EA" OP "$1,321.00 " $0.00 $0.00 $992.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $992.73 $416.56 $262.26 $416.56 27685 EAP CPT® 27685 "PR LENGTH/SHORT LEG/ANKL TENDON,SINGLE" OP "$1,482.00 " $0.00 $0.00 "$1,073.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,073.72" $546.33 $283.30 $546.33 27695 EAP CPT® 27695 "PR REPAIR 1 COLLAT ANKLE LIGMNT,PRIMARY" OP "$2,346.00 " $0.00 $0.00 "$1,098.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,098.41" $475.24 $330.49 $475.24 27698 EAP CPT® 27698 "PR REPAIR COLLAT ANKLE LIGMNT,SECONDARY" OP "$3,087.00 " $0.00 $0.00 "$1,482.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,482.60" $630.56 $442.11 $630.56 27705 EAP CPT® 27705 PR OSTEOTOMY TIBIA OP "$2,881.00 " $0.00 $0.00 "$1,754.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,754.61" $728.47 $493.81 $728.47 27715 EAP CPT® 27715 PR LENGTHENING TIBIA/FIBULA OP "$4,939.00 " $0.00 $0.00 "$2,475.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,475.62" "$1,005.36" $643.85 "$1,005.36" 27720 EAP CPT® 27720 RPR NON/MALUNION TIBIA OP "$3,704.00 " $0.00 $0.00 "$2,021.57" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,021.57" $832.01 $575.24 $832.01 27724 EAP CPT® 27724 RPR NON/MALUNION TIBIA+AUTOGRAFT OP "$4,321.00 " $0.00 $0.00 "$2,925.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,925.90" "$1,218.98" $703.02 "$1,218.98" 27726 EAP CPT® 27726 PR RPR FIBULA NONUNION/MALUNION W INT FIXATION OP "$2,991.00 " $0.00 $0.00 "$2,236.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,236.56" $0.00 $0.00 $0.00 27750 EAP CPT® 27750 PR CLOSED RX TIBIA SHAFT FX OP "$1,001.00 " $0.00 $0.00 $729.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $729.83 $303.83 $199.15 $303.83 27752 EAP CPT® 27752 "PR CLOSED RX TIBIA SHAFT FX,MANIPULATN" OP "$1,646.00 " $0.00 $0.00 "$1,141.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,141.82" $488.50 $308.50 $488.50 27758 EAP CPT® 27758 "PR OPEN RX TIBIA SHAFT FX,SCREWS" OP "$3,781.00 " $0.00 $0.00 "$2,057.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,057.54" $832.94 $559.19 $832.94 27759 EAP CPT® 27759 "PR TREAT TIBIAL SHAFT FX, INTRAMED IMPLANT" OP "$4,048.00 " $0.00 $0.00 "$2,308.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,308.98" $949.19 $632.67 $949.19 27760 EAP CPT® 27760 PR CLOSED RX MED MALLEOLUS FX OP $953.00 $0.00 $0.00 $698.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $698.76 $293.13 $181.34 $293.13 27766 EAP CPT® 27766 OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE OP "$2,135.00 " $0.00 $0.00 "$1,409.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,409.97" $612.79 $380.32 $612.79 27769 EAP CPT® 27769 PR OPEN TREATMENT POSTERIOR MALLEOLUS FRACTURE OP "$2,276.00 " $0.00 $0.00 "$1,685.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,685.99" $0.00 $334.54 $0.00 27780 EAP CPT® 27780 PR CLOSED RX PROX/SHAFT FIBULA FX OP $874.00 $0.00 $0.00 $639.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $639.96 $260.63 $139.92 $260.63 27784 EAP CPT® 27784 OPEN TREATMENT PROXIMAL FIBULA/SHAFT FRACTURE OP "$2,218.00 " $0.00 $0.00 "$1,653.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,653.59" $532.22 $322.10 $532.22 27786 EAP CPT® 27786 PR CLOSED RX DIST FIBULA FX OP $892.00 $0.00 $0.00 $656.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $656.84 $278.09 $176.54 $278.09 27788 EAP CPT® 27788 "PR CLOSED RX DIST FIBULA FX,MANIP" OP "$1,200.00 " $0.00 $0.00 $883.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.82 $385.46 $235.82 $385.46 27792 EAP CPT® 27792 OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS OP "$2,269.00 " $0.00 $0.00 "$1,507.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,507.70" $569.38 $353.98 $569.38 27808 EAP CPT® 27808 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANIP OP $941.00 $0.00 $0.00 $689.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $689.12 $290.55 $189.33 $290.55 27810 EAP CPT® 27810 CLOSED TX BIMALLEOLAR ANKLE FRACTURE W MANIP OP "$1,557.00 " $0.00 $0.00 $973.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $973.67 $433.06 $285.08 $433.06 27814 EAP CPT® 27814 OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE OP "$2,936.00 " $0.00 $0.00 "$1,783.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,783.56" $756.66 $486.83 $756.66 27822 EAP CPT® 27822 OPEN TX TRIMALLEOLAR ANKLE FX W/O FIX PST LIP OP "$3,425.00 " $0.00 $0.00 "$1,942.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,942.32" $866.88 $734.97 $866.88 27823 EAP CPT® 27823 OPEN TX TRIMALLEOLAR ANKLE FX W FIX PST LIP OP "$4,048.00 " $0.00 $0.00 "$2,206.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,206.01" $982.75 $835.43 $982.75 27824 EAP CPT® 27824 PR CLOSED RX WEIGHT BEAR DIST TIBIA OP $946.00 $0.00 $0.00 $700.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $700.05 $274.22 $198.71 $274.22 27825 EAP CPT® 27825 "PR CLOSED RX WEIGHT BEAR DIST TIB,MANIP" OP "$1,779.00 " $0.00 $0.00 "$1,136.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,136.69" $502.93 $336.50 $502.93 27826 EAP CPT® 27826 OPEN TREATMENT FRACTURE DISTAL TIBIA FIBULA OP "$3,559.00 " $0.00 $0.00 "$1,920.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,920.75" $672.99 $690.85 $672.99 27827 EAP CPT® 27827 OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY OP "$3,692.00 " $0.00 $0.00 "$2,496.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,496.68" "$1,088.86" $891.52 "$1,088.86" 27828 EAP CPT® 27828 OPEN TREATMENT FRACTURE DISTAL TIBIA & FIBULA OP "$4,226.00 " $0.00 $0.00 "$2,993.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,993.58" "$1,234.24" $971.22 "$1,234.24" 27829 EAP CPT® 27829 OPEN TX DISTAL TIBIOFIBULAR JOINT DISRUPTION OP "$2,184.00 " $0.00 $0.00 "$1,578.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,578.98" $469.57 $487.14 $469.57 27831 EAP CPT® 27831 PR CLOSED RX PROX TIB/FIB DISLOC+ANESTH OP "$1,257.00 " $0.00 $0.00 $902.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $902.46 $347.36 $207.94 $347.36 27842 EAP CPT® 27842 "PR CLOSED RX ANKLE DISLOCATN,ANESTH" OP "$1,535.00 " $0.00 $0.00 "$1,142.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,142.54" $443.34 $227.70 $443.34 27846 EAP CPT® 27846 PR OPEN RX ANKLE DISLOCATN OP "$2,669.00 " $0.00 $0.00 "$1,676.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,676.91" $697.37 $439.39 $697.37 27860 EAP CPT® 27860 PR MANIPULATION ANKLE JT W ANESTHESIA OP $656.00 $0.00 $0.00 $404.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $404.28 $166.34 $105.83 $166.34 27870 EAP CPT® 27870 "PR ARTHRODESIS,ANKLE,OPEN" OP "$4,226.00 " $0.00 $0.00 "$2,383.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,383.89" $991.05 $635.96 $991.05 27880 EAP CPT® 27880 PR AMPUTATION LOW LEG THRU TIB/FIB OP "$3,003.00 " $0.00 $0.00 "$2,145.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,145.62" $857.69 $508.02 $857.69 27882 EAP CPT® 27882 "PR AMPUTATION LOW LEG,CIRCULAR" OP "$2,447.00 " $0.00 $0.00 "$1,406.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,406.78" $614.52 $427.98 $614.52 27884 EAP CPT® 27884 "PR AMPUTATION LOW LEG,SECOND CLOSURE" OP "$1,792.00 " $0.00 $0.00 "$1,347.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,347.66" $551.55 $344.92 $551.55 27886 EAP CPT® 27886 PR RE-AMPUTATION LOWER LEG OP "$2,980.00 " $0.00 $0.00 "$1,539.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,539.30" $628.40 $418.05 $628.40 27894 EAP CPT® 27894 "PR DECOMPRESS LEG,ANT/LAT & POST" OP "$2,630.00 " $0.00 $0.00 "$1,978.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,978.40" $776.29 $397.40 $776.29 28039 EAP CPT® 28039 PR EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ 1.5+CM OP "$1,075.00 " $0.00 $0.00 $813.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $813.11 $0.00 $217.53 $0.00 28046 EAP CPT® 28046 PR RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE <3CM OP "$2,236.00 " $0.00 $0.00 "$1,691.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,691.48" $756.48 $407.33 $756.48 28060 EAP CPT® 28060 PR PART EXCIS PLANTAR FASCIA OP "$1,204.00 " $0.00 $0.00 $826.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $826.61 $427.05 $248.27 $427.05 28100 EAP CPT® 28100 PR REMV TALUS/HEEL BENIGN BONE LESN OP "$1,480.00 " $0.00 $0.00 $955.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.59 $523.86 $286.85 $523.86 28104 EAP CPT® 28104 PR REMV TARSAL/METATARSAL BENIGN BONE LESN OP "$1,204.00 " $0.00 $0.00 $817.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $817.56 $424.14 $246.32 $424.14 28111 EAP CPT® 28111 PR FULL EXCIS 1ST METATARSAL HEAD OP "$1,239.00 " $0.00 $0.00 $756.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $756.18 $441.56 $269.86 $441.56 28112 EAP CPT® 28112 "PR FULL EXCIS 2,3 OR 4TH METATAR HEAD" OP "$1,170.00 " $0.00 $0.00 $725.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $725.97 $407.45 $229.71 $407.45 28113 EAP CPT® 28113 PR FULL EXCIS 5TH METATARSAL HEAD OP "$1,317.00 " $0.00 $0.00 $984.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $984.87 $473.79 $241.85 $473.79 28120 EAP CPT® 28120 PR PART REMV TALUS OR CALCANEUS OP "$1,550.00 " $0.00 $0.00 "$1,154.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,154.12" $500.13 $303.86 $500.13 28126 EAP CPT® 28126 "PR RESEC ONE TOE PHALANGEAL BASE,EA" OP $860.00 $0.00 $0.00 $575.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $575.82 $311.85 $197.97 $311.85 28190 EAP CPT® 28190 "PR REMV FOOT FOREIGN BODY,SUBCUTANEOUS" OP $508.00 $0.00 $0.00 $309.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $309.99 $207.60 $108.49 $207.60 28192 EAP CPT® 28192 "PR REMV FOOT FOREIGN BODY,DEEP" OP $974.00 $0.00 $0.00 $728.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $728.49 $399.12 $206.05 $399.12 28272 EAP CPT® 28272 "PR CAPSULOTOMY I-P JT,FOOT,EA" OP $784.00 $0.00 $0.00 $589.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $589.62 $320.27 $175.82 $320.27 28285 EAP CPT® 28285 "PR REPAIR OF HAMMERTOE,ONE" OP "$1,183.00 " $0.00 $0.00 $874.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $874.40 $380.07 $232.62 $380.07 28400 EAP CPT® 28400 PR CLOSED RX HEEL FX OP $805.00 $0.00 $0.00 $525.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.15 $221.10 $160.72 $221.10 28405 EAP CPT® 28405 "PR CLOSED RX HEEL FX,MANIPULATN" OP "$1,309.00 " $0.00 $0.00 $824.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $824.57 $362.37 $237.57 $362.37 28406 EAP CPT® 28406 PR PERCUT RX HEEL FX OP "$1,762.00 " $0.00 $0.00 "$1,207.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,207.62" $503.41 $309.27 $503.41 28415 EAP CPT® 28415 OPEN TREATMENT CALCANEAL FRACTURE OP "$3,491.00 " $0.00 $0.00 "$2,558.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,558.36" "$1,175.78" $892.58 "$1,175.78" 28430 EAP CPT® 28430 PR CLOSED RX TALUS FX OP $652.00 $0.00 $0.00 $486.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $486.38 $207.89 $153.38 $207.89 28435 EAP CPT® 28435 "PR CLOSED RX TALUS FX,MANIPULATN" OP "$1,007.00 " $0.00 $0.00 $655.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $655.92 $281.67 $197.93 $281.67 28445 EAP CPT® 28445 OPEN TREATMENT TALUS FRACTURE OP "$3,235.00 " $0.00 $0.00 "$2,457.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,457.47" "$1,083.34" $438.43 "$1,083.34" 28450 EAP CPT® 28450 "PR CLOSED RX TARSAL FX,EACH" OP $743.00 $0.00 $0.00 $444.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $444.65 $190.68 $137.83 $190.68 28465 EAP CPT® 28465 OPEN TX TARSAL FRACTURE XCP TALUS &CALCANEUS EA OP "$2,190.00 " $0.00 $0.00 "$1,441.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,441.52" $509.10 $465.19 $509.10 28470 EAP CPT® 28470 PR CLOSED RX METATARSAL FX OP $632.00 $0.00 $0.00 $472.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $472.94 $192.16 $134.39 $192.16 28476 EAP CPT® 28476 PR PERCUT RX METATARSAL FX OP "$1,510.00 " $0.00 $0.00 $814.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $814.14 $317.27 $183.11 $317.27 28485 EAP CPT® 28485 OPEN TREATMENT METATARSAL FRACTURE EACH OP "$1,963.00 " $0.00 $0.00 "$1,214.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,214.99" $423.65 $423.89 $423.65 28510 EAP CPT® 28510 PR CLOSED RX TOE FX OP $369.00 $0.00 $0.00 $278.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.96 $102.00 $57.72 $102.00 28525 EAP CPT® 28525 OPEN TX FRACTURE PHALANX/PHALANGES NOT GREAT TOE OP "$1,256.00 " $0.00 $0.00 $923.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $923.18 $405.16 $287.27 $405.16 28576 EAP CPT® 28576 PR PERCUT RX TALOTARSAL DISLOCATION OP "$1,208.00 " $0.00 $0.00 $900.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $900.38 $333.26 $191.44 $333.26 28605 EAP CPT® 28605 "PR CLOSED RX TAR-METATAR DISLOC,ANESTH" OP $927.00 $0.00 $0.00 $676.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $676.79 $231.92 $159.40 $231.92 28606 EAP CPT® 28606 PR PERCUT RX TAR-METATAR FOOT DISLOC OP "$1,334.00 " $0.00 $0.00 $913.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $913.44 $371.63 $310.17 $371.63 28615 EAP CPT® 28615 OPEN TREATMENT TARSOMETATARSAL JOINT DISLOCATION OP "$2,534.00 " $0.00 $0.00 "$1,826.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,826.31" $646.11 $516.11 $646.11 28635 EAP CPT® 28635 "PR CLOSED RX MT-PHAL TOE DISLOC,ANESTH" OP $667.00 $0.00 $0.00 $303.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $303.44 $153.79 $94.80 $153.79 28660 EAP CPT® 28660 "PR CLOSED RX I-P JT,TOE DISLOCATION" OP $315.00 $0.00 $0.00 $205.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $205.10 $95.08 $79.81 $95.08 28665 EAP CPT® 28665 "PR CLOSED RX I-P JT,TOE DISLOC,ANESTH" OP $440.00 $0.00 $0.00 $302.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $302.63 $133.65 $92.34 $133.65 28675 EAP CPT® 28675 OPEN TREATMENT INTERPHALANGEAL JOINT DISLOCATION OP "$1,257.00 " $0.00 $0.00 $953.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $953.55 $377.52 $231.46 $377.52 28725 EAP CPT® 28725 "PR FUSION FOOT BONES,SUBTALAR" OP "$3,675.00 " $0.00 $0.00 "$1,799.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,799.96" $776.70 $508.31 $776.70 28730 EAP CPT® 28730 "PR FUSION FOOT BONES,MIDTARSAL,MULTI" OP "$3,121.00 " $0.00 $0.00 "$1,695.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,695.90" $794.38 $473.27 $794.38 28740 EAP CPT® 28740 "PR FUSION FOOT BONE,MIDTARSAL,1 JT" OP "$2,416.00 " $0.00 $0.00 "$1,442.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,442.48" $761.89 $360.40 $761.89 28805 EAP CPT® 28805 "PR AMPUTATION FOOT,TRANSMETATARSAL" OP "$2,256.00 " $0.00 $0.00 "$1,702.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,702.80" $695.88 $366.11 $695.88 28810 EAP CPT® 28810 "PR AMPUTATION METATARSAL+TOE,SINGLE" OP "$1,611.00 " $0.00 $0.00 "$1,004.57" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,004.57" $420.48 $271.64 $420.48 28820 EAP CPT® 28820 "PR AMPUTATION TOE,MT-P JT" OP "$1,762.00 " $0.00 $0.00 $920.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $920.78 $472.17 $231.39 $472.17 28825 EAP CPT® 28825 "PR AMPUTATION TOE,I-P JT" OP "$1,510.00 " $0.00 $0.00 $863.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $863.07 $406.10 $202.43 $406.10 29075 EAP CPT® 29075 PR APPLY FOREARM CAST OP $190.00 $0.00 $0.00 $143.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.91 $77.24 $69.38 $77.24 29105 EAP CPT® 29105 PR APPLY LONG ARM SPLINT OP $145.00 $0.00 $0.00 $136.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.64 $78.68 $58.98 $78.68 29125 EAP CPT® 29125 "PR APPLY FOREARM SPLINT,STATIC" OP $124.00 $0.00 $0.00 $90.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.93 $60.23 $45.30 $60.23 29130 EAP CPT® 29130 "PR APPLY FINGER SPLINT,STATIC" OP $92.00 $0.00 $0.00 $65.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.84 $36.60 $22.72 $36.60 29445 EAP CPT® 29445 PR APPLY RIGID LEG CAST OP $537.00 $0.00 $0.00 $240.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.36 $136.45 $128.96 $136.45 29505 EAP CPT® 29505 PR APPLY LONG LEG SPLINT OP $207.00 $0.00 $0.00 $115.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.01 $69.25 $59.12 $69.25 29515 EAP CPT® 29515 PR APPLY LOWER LEG SPLINT OP $154.00 $0.00 $0.00 $114.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.23 $61.62 $50.37 $61.62 29580 EAP CPT® 29580 PR APPLY OF PASTE BOOT OP $116.00 $0.00 $0.00 $82.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $82.01 $46.19 $34.11 $46.19 29700 EAP CPT® 29700 PR REMV/REVISN BOOT/BODY CAST OP $104.00 $0.00 $0.00 $77.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.04 $56.08 $25.80 $56.08 29806 EAP CPT® 29806 "PR SHLDR ARTHROSCOP,SURG,CAPSULORRHAPHY" OP "$3,415.00 " $0.00 $0.00 "$2,455.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,455.16" "$1,005.32" $675.25 "$1,005.32" 29822 EAP CPT® 29822 PR SURGICAL ARTHROSCOPY SHOULDER LMTD DBRDMT 1/2 OP "$2,244.00 " $0.00 $0.00 "$1,310.19" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,310.19" $543.18 $375.91 $543.18 29824 EAP CPT® 29824 "PR SHLDR ARTHROSCOP,SURG,DIS CLAVICULECTOMY" OP "$2,104.00 " $0.00 $0.00 "$1,541.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,541.70" $626.70 $411.10 $626.70 29826 EAP CPT® 29826 PR SHOULDER SCOPE BONE SHAVING OP "$2,903.00 " $0.00 $0.00 $635.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.94 $635.79 $442.62 $635.79 29827 EAP CPT® 29827 "PR SHLDR ARTHROSCOP,SURG,W/ROTAT CUFF REPR" OP "$3,343.00 " $0.00 $0.00 "$2,442.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,442.81" "$1,038.33" $641.30 "$1,038.33" 29828 EAP CPT® 29828 PR ARTHROSCOPY SHOULDER SURGICAL BICEPS TENODESIS OP "$2,868.00 " $0.00 $0.00 "$2,107.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,107.82" $0.00 $445.82 $0.00 29870 EAP CPT® 29870 "PR KNEE SCOPE,DIAGNOSTIC" OP "$1,277.00 " $0.00 $0.00 $952.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $952.88 $382.12 $230.39 $382.12 29874 EAP CPT® 29874 "PR KNEE SCOPE,REMV LOOSE BODY" OP "$2,508.00 " $0.00 $0.00 "$1,241.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,241.75" $502.75 $339.05 $502.75 29875 EAP CPT® 29875 "PR KNEE SCOPE,PART SYNOVECT" OP "$2,475.00 " $0.00 $0.00 "$1,144.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,144.73" $467.06 $309.25 $467.06 29877 EAP CPT® 29877 "PR KNEE SCOPE,SHAVE ARTICULAR CART" OP "$2,640.00 " $0.00 $0.00 "$1,438.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,438.50" $571.41 $354.65 $571.41 29880 EAP CPT® 29880 PR ARTHRS KNEE W/MENISCECTOMY MED&LAT W/SHAVING OP "$3,629.00 " $0.00 $0.00 "$1,299.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,299.75" $639.50 $404.86 $639.50 29881 EAP CPT® 29881 PR ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG OP "$3,002.00 " $0.00 $0.00 "$1,252.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,252.43" $595.68 $372.49 $595.68 29882 EAP CPT® 29882 "PR KNEE SCOPE,MED OR LAT MENIS REPAIR" OP "$3,250.00 " $0.00 $0.00 "$1,620.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,620.12" $643.07 $410.59 $643.07 29883 EAP CPT® 29883 "PR KNEE SCOPE,MED+LAT MENIS REPAIR" OP "$4,223.00 " $0.00 $0.00 "$1,946.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,946.06" $793.97 $446.06 $793.97 29884 EAP CPT® 29884 "PR KNEE SCOPE,LYSIS OF ADHESNS" OP "$2,475.00 " $0.00 $0.00 "$1,421.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,421.51" $569.21 $361.86 $569.21 29888 EAP CPT® 29888 "PR KNEE SCOPE,AID ANT CRUCIATE REPAIR" OP "$5,312.00 " $0.00 $0.00 "$2,281.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,281.11" $937.92 $649.63 $937.92 29889 EAP CPT® 29889 "PR KNEE SCOPE,AID POST CRUC REPAIR" OP "$5,312.00 " $0.00 $0.00 "$2,826.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,826.81" "$1,139.90" $627.98 "$1,139.90" 29916 EAP CPT® 29916 PR ARTHROSCOPY HIP W/LABRAL REPAIR OP "$3,199.00 " $0.00 $0.00 "$2,344.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,344.56" $0.00 $618.58 $0.00 30117 EAP CPT® 30117 PR EXCIS/DEST INTRANAS LESION; INT APP OP "$1,024.00 " $0.00 $0.00 $787.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $787.35 $638.46 $150.88 $638.46 30118 EAP CPT® 30118 PR EXCIS/DEST INTRANAS LESION; EXT APP OP "$2,389.00 " $0.00 $0.00 "$1,773.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,773.12" $699.44 $410.29 $699.44 30130 EAP CPT® 30130 PR EXCISION TURBINATE OP "$1,219.00 " $0.00 $0.00 $878.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $878.70 $333.83 $137.96 $333.83 30140 EAP CPT® 30140 "PR EXCISION TURBINATE,SUBMUCOUS" OP "$1,251.00 " $0.00 $0.00 "$1,017.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,017.71" $365.64 $180.29 $365.64 30300 EAP CPT® 30300 PR REMOVE NASAL FOREIGN BODY OP $349.00 $0.00 $0.00 $244.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.19 $205.38 $54.18 $205.38 30420 EAP CPT® 30420 PR RECONSTR NOSE+MAJ SEPTAL REPAIR OP "$4,594.00 " $0.00 $0.00 "$3,158.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,158.34" "$1,268.24" $713.99 "$1,268.24" 30465 EAP CPT® 30465 PR REPAIR NASAL CAVITY STENOSIS OP "$3,229.00 " $0.00 $0.00 "$2,259.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,259.26" $893.22 $554.69 $893.22 30520 EAP CPT® 30520 PR REPAIR OF NASAL SEPTUM OP "$2,497.00 " $0.00 $0.00 "$1,437.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,437.32" $510.11 $267.67 $510.11 30580 EAP CPT® 30580 PR REPAIR ORO-MAXILLARY FISTULA OP "$1,665.00 " $0.00 $0.00 "$1,185.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,185.74" $557.94 $283.75 $557.94 30801 EAP CPT® 30801 "PR CAUTER TURBINATE MUCOSA,SUPERFICIAL" OP $443.00 $0.00 $0.00 $315.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.36 $192.68 $55.27 $192.68 30901 EAP CPT® 30901 "PR CTRL NOSEBLEED,ANTER,SIMPLE" OP $208.00 $0.00 $0.00 $130.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.73 $95.10 $56.51 $95.10 30903 EAP CPT® 30903 "PR CTRL NOSEBLEED,ANTER,COMPLEX" OP $308.00 $0.00 $0.00 $186.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.12 $161.84 $71.31 $161.84 30920 EAP CPT® 30920 PR LIGATE INTERN MAXILL ARTERY OP "$2,830.00 " $0.00 $0.00 "$1,925.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,925.61" $741.27 $432.43 $741.27 30930 EAP CPT® 30930 PR THERAPEUTIC FRACTURE INFER TURBINATE OP $364.00 $0.00 $0.00 $284.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $284.37 $108.05 $57.63 $108.05 31225 EAP CPT® 31225 PR REMV UPPER JAW-MAXILLECTOMY OP "$5,641.00 " $0.00 $0.00 "$4,326.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,326.92" "$1,636.08" $843.79 "$1,636.08" 31231 EAP CPT® 31231 "PR NASAL ENDOSCOPY,DX" OP $270.00 $0.00 $0.00 $165.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.21 $165.55 $61.55 $165.55 31237 EAP CPT® 31237 "PR NASAL SCOPE,BX/RMV POLYP/DEBRID" OP $970.00 $0.00 $0.00 $374.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.39 $299.44 $141.60 $299.44 31238 EAP CPT® 31238 "PR NASAL/SINUS SCOPY,W/CONTROL NASAL HEM" OP $629.00 $0.00 $0.00 $392.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $392.04 $309.45 $156.20 $309.45 31240 EAP CPT® 31240 "PR NASAL/SINUS SCOPY,RMV CONCHA BULL" OP $719.00 $0.00 $0.00 $373.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $373.53 $159.14 $112.27 $159.14 31253 EAP CPT® 31253 PR NASAL/SINUS NDSC TOT W/FRNT SINS EXPL TISS RMVL OP "$1,558.00 " $0.00 $0.00 "$1,154.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,154.12" $0.00 $308.53 $0.00 31254 EAP CPT® 31254 "PR NASAL SCOPY,REMV PART ETHMOID" OP "$1,276.00 " $0.00 $0.00 $632.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $632.78 $273.93 $201.18 $273.93 31255 EAP CPT® 31255 "PR NASAL SCOPY,REMV TOTL ETHMOID" OP "$1,743.00 " $0.00 $0.00 $927.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $927.32 $406.36 $301.51 $406.36 31256 EAP CPT® 31256 "PR NASAL SCOPY,OPEN MAXILL SINUS" OP "$1,006.00 " $0.00 $0.00 $458.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $458.63 $198.28 $142.50 $198.28 31257 EAP CPT® 31257 PR NASAL/SINUS NDSC TOTAL WITH SPHENOIDOTOMY OP "$1,387.00 " $0.00 $0.00 "$1,027.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,027.41" $0.00 $274.60 $0.00 31267 EAP CPT® 31267 "PR NASAL SCOPY,RMV TISS MAXILL SINUS" OP "$1,509.00 " $0.00 $0.00 $736.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $736.29 $320.36 $227.03 $320.36 31276 EAP CPT® 31276 "PR NASAL SCOPY,EXPLOR FRONTAL SINUS" OP "$1,509.00 " $0.00 $0.00 "$1,170.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,170.48" $512.46 $345.44 $512.46 31287 EAP CPT® 31287 "PR NASAL SCOPY,SPHENOIDOTOMY" OP "$1,258.00 " $0.00 $0.00 $538.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $538.08 $233.40 $169.84 $233.40 31288 EAP CPT® 31288 "PR NASAL SCOPY,REMV TISS SPHENOID" OP "$1,384.00 " $0.00 $0.00 $623.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $623.13 $270.75 $198.30 $270.75 31297 EAP CPT® 31297 PR NASAL/SINUS NDSC SURG W/DILATION SPHENOID SINUS OP $446.00 $0.00 $0.00 $372.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $372.71 $0.00 $446.00 $0.00 31500 EAP CPT® 31500 PR INSERT EMERGENCY ENDOTRACH AIRWAY OP $448.00 $0.00 $0.00 $253.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.50 $107.86 $74.55 $107.86 31502 EAP CPT® 31502 PR TRACH TUBE CHANGE OP $274.00 $0.00 $0.00 $81.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.11 $34.15 $39.91 $34.15 31525 EAP CPT® 31525 "PR LARYNGOSCOPY,DIRECT,DIAGNOSTIC" OP $629.00 $0.00 $0.00 $373.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $373.52 $230.40 $117.19 $230.40 31535 EAP CPT® 31535 "PR LARYNGOSCOPY,DIRCT,OP,BIOPSY" OP $916.00 $0.00 $0.00 $442.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $442.53 $187.68 $136.52 $187.68 31536 EAP CPT® 31536 "PR LARYNGOSCOPY,DIRCT,OP SCOPE,BIOPSY" OP "$1,102.00 " $0.00 $0.00 $492.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $492.33 $210.59 $154.16 $210.59 31541 EAP CPT® 31541 "PR LARYNGOSCOPY,DIRCT,OP SCOP,EXC TUMR" OP "$1,316.00 " $0.00 $0.00 $616.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $616.73 $265.28 $190.70 $265.28 31545 EAP CPT® 31545 "PR LARYNGOSCOPY,DIR,OP,EXC TUMR,LCL FLAP" OP "$1,545.00 " $0.00 $0.00 $846.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $846.32 $353.12 $234.30 $353.12 31571 EAP CPT® 31571 "PR LARYNGOSCOPY,DIRECT,SCOPE,INJ CORDS" OP "$1,202.00 " $0.00 $0.00 $583.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $583.79 $249.63 $182.13 $249.63 31573 EAP CPT® 31573 PR LARYNGOSCOPY FLEXIBLE THERAPEUTIC INJECTION UNI OP $456.00 $0.00 $0.00 $345.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $345.41 $0.00 $160.34 $0.00 31575 EAP CPT® 31575 PR LARYNGOSCOPY FLEXIBLE DIAGNOSTIC OP $300.00 $0.00 $0.00 $177.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.74 $108.80 $64.69 $108.80 31600 EAP CPT® 31600 "PR TRACHEOSTOMY, PLANNED" OP "$1,018.00 " $0.00 $0.00 $922.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $922.14 $389.39 $153.09 $389.39 31610 EAP CPT® 31610 "PR TRACHEOSTOMY,FENESTRATN+FLAPS" OP "$2,950.00 " $0.00 $0.00 "$1,656.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,656.00" $649.59 $398.08 $649.59 31611 EAP CPT® 31611 PR CREATE T-E FISTULA+SPEECH PROSTHESIS OP "$1,891.00 " $0.00 $0.00 "$1,250.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,250.58" $479.25 $308.76 $479.25 31613 EAP CPT® 31613 "PR TRACH REVISION,SIMPLE" OP "$1,346.00 " $0.00 $0.00 "$1,053.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,053.20" $395.98 $226.25 $395.98 31615 EAP CPT® 31615 PR TRACHEOBRNCHSC THRU EST TRACHS INC OP $582.00 $0.00 $0.00 $298.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $298.13 $171.28 $107.05 $171.28 31622 EAP CPT® 31622 PR BRNCHSC INCL FLUOR GDNCE DX W/CELL WASHG SPX OP $735.00 $0.00 $0.00 $334.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.14 $308.23 $137.38 $308.23 31623 EAP CPT® 31623 PR BRNCHSC BRUSHING/PROTECTED BRUSHINGS OP $771.00 $0.00 $0.00 $339.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.26 $338.45 $140.42 $338.45 31624 EAP CPT® 31624 PR BRNCHSC W/BRNCL ALVEOLAR LAVAGE OP $771.00 $0.00 $0.00 $342.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.50 $314.65 $135.93 $314.65 31625 EAP CPT® 31625 PR BRONCHOSCOPY BRONCHIAL/ENDOBRNCL BX 1+ SITES OP $786.00 $0.00 $0.00 $392.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $392.19 $335.51 $154.46 $335.51 31626 EAP CPT® 31626 PR BRONCHOSCOPY W/PLMT FIDUCIAL MARKERS SINGLE/MULT OP "$1,854.00 " $0.00 $0.00 $489.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.86 $0.00 $198.86 $0.00 31627 EAP CPT® 31627 PR BRONCHOSCOPY W/CPTR-ASST IMAGE-GUIDED NAVIGATION OP "$2,878.00 " $0.00 $0.00 $225.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.65 $0.00 $550.26 $0.00 31628 EAP CPT® 31628 PR BRONCHOSCOPY W/TRANSBRONCHIAL LUNG BX 1 LOBE OP $873.00 $0.00 $0.00 $436.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $436.59 $398.65 $174.43 $398.65 31629 EAP CPT® 31629 PR BRONCHOSCOPY NEEDLE BX TRACHEA MAIN STEM&/BRON OP "$1,018.00 " $0.00 $0.00 $652.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $462.12 $652.92 $132.57 $652.92 31630 EAP CPT® 31630 "PR BRONCHOSCOPY,TRACH/BRONCH DILATN" OP $931.00 $0.00 $0.00 $464.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $464.09 $205.33 $153.87 $205.33 31632 EAP CPT® 31632 PR BRONCHOSCOPY W/TRANSBRONCHIAL LUNG BX EACH LOBE OP $436.00 $0.00 $0.00 $114.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.15 $72.95 $44.31 $72.95 31633 EAP CPT® 31633 PR BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE OP $436.00 $0.00 $0.00 $147.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $147.08 $86.71 $54.27 $86.71 31634 EAP CPT® 31634 PR BRONCHOSCOPY BALLOON OCCLUSION OP $597.00 $0.00 $0.00 $478.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $478.43 $0.00 $597.00 $0.00 31635 EAP CPT® 31635 PR BRONCHOSCOPY W/REMOVAL FOREIGN BODY OP "$1,455.00 " $0.00 $0.00 $436.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $436.97 $354.00 $149.44 $354.00 31640 EAP CPT® 31640 "PR BRONCHOSCOPY,EXCIS LESN" OP "$1,455.00 " $0.00 $0.00 $590.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $590.09 $261.52 $199.79 $261.52 31641 EAP CPT® 31641 "PR BRONCHOSCOPY,RX STENOSIS" OP "$1,891.00 " $0.00 $0.00 $598.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $598.35 $255.81 $202.81 $255.81 31645 EAP CPT® 31645 "PR BRONCHOSCOPY,RX ASPIR PULM TREE" OP $786.00 $0.00 $0.00 $373.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $373.80 $302.83 $125.03 $302.83 31646 EAP CPT® 31646 PR BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE SBSQ OP $786.00 $0.00 $0.00 $323.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $323.18 $276.08 $107.82 $276.08 31652 EAP CPT® 31652 PR BRNCHSC EBUS GUIDED SAMPL 1/2 NODE STATION/STRUX OP "$1,690.00 " $0.00 $0.00 $542.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $542.45 $0.00 $547.09 $0.00 31653 EAP CPT® 31653 PR BRNCHSC EBUS GUIDED SAMPL 3/> NODE STATION/STRUX OP "$1,798.00 " $0.00 $0.00 $598.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $598.68 $0.00 $581.51 $0.00 31654 EAP CPT® 31654 PR BRNSCHSC TNDSC EBUS DX/TX INTERVENTION PERPH LES OP $275.00 $0.00 $0.00 $156.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.66 $0.00 $87.09 $0.00 31730 EAP CPT® 31730 PR INTRO WINDPIPE WIRE/TUBE OP $468.00 $0.00 $0.00 $400.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $343.64 $400.50 $122.27 $400.50 31785 EAP CPT® 31785 "PR EXCIS TRACH LESN,CERVICAL" OP "$3,346.00 " $0.00 $0.00 "$2,522.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,522.43" "$1,034.69" $660.28 "$1,034.69" 31820 EAP CPT® 31820 PR SURG CLOSURE TRACH/FISTULA OP "$1,010.00 " $0.00 $0.00 $761.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $761.30 $381.07 $230.17 $381.07 32100 EAP CPT® 32100 PR THORACOTOMY WITH EXPLORATION OP "$2,922.00 " $0.00 $0.00 "$1,879.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,879.58" $923.98 $561.09 $923.98 32110 EAP CPT® 32110 PR THORCOM CTRL TRAUMTC HEMRRG&/RPR LNG TEAR OP "$4,586.00 " $0.00 $0.00 "$3,396.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,396.18" "$1,385.88" $612.33 "$1,385.88" 32120 EAP CPT® 32120 PR THORACOTOMY POSTOPERATIVE COMPLICATIONS OP "$3,653.00 " $0.00 $0.00 "$2,022.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,022.84" $817.93 $539.51 $817.93 32160 EAP CPT® 32160 PR THORACOTOMY W/CARDIAC MASSAGE OP "$3,653.00 " $0.00 $0.00 "$1,832.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,832.61" $704.53 $421.55 $704.53 32408 EAP CPT® 32408 PR CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG OP $459.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 32480 EAP CPT® 32480 PR RMVL LUNG OTHER THAN PNEUMONECTOMY 1 LOBE LOBECT OP "$4,932.00 " $0.00 $0.00 "$3,434.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,434.79" "$1,453.98" $811.66 "$1,453.98" 32484 EAP CPT® 32484 PR RMVL LUNG OTHER THAN PNEUMONECT 1 SEGMENTECTOMY OP "$4,481.00 " $0.00 $0.00 "$3,340.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,340.49" "$1,400.13" $885.74 "$1,400.13" 32550 EAP CPT® 32550 PR INSERTION INDWELLING TUNNELED PLEURAL CATHETER OP $646.00 $0.00 $0.00 $515.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $515.76 $0.00 $453.26 $0.00 32551 EAP CPT® 32551 PR TUBE THORACOSTOMY INCLUDES WATER SEAL OP $493.00 $0.00 $0.00 $394.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $394.37 $0.00 $91.41 $0.00 32554 EAP CPT® 32554 PR THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING OP $280.00 $0.00 $0.00 $208.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.07 $0.00 $280.00 $0.00 32555 EAP CPT® 32555 PR THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING OP $348.00 $0.00 $0.00 $261.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $261.21 $0.00 $348.00 $0.00 32557 EAP CPT® 32557 PR PERQ DRAINAGE PLEURA INSERT CATH W/IMAGING OP $476.00 $0.00 $0.00 $357.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $357.59 $0.00 $476.00 $0.00 32561 EAP CPT® 32561 "PR INSTILL VIA CHEST TUBE AGENT FOR FIBRINOLYSIS, 1ST DAY" OP $211.00 $0.00 $0.00 $158.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.94 $0.00 $43.86 $0.00 32601 EAP CPT® 32601 PR THORSC DX LUNGS/PERICAR/MED/PLEURAL SPACE W/O BX OP "$1,096.00 " $0.00 $0.00 $717.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $717.87 $303.56 $227.86 $303.56 32607 EAP CPT® 32607 PR THORACOSCOPY W/DX BX OF LUNG INFILTRATE UNILATRL OP $965.00 $0.00 $0.00 $718.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $718.59 $0.00 $187.02 $0.00 32608 EAP CPT® 32608 PR THORACOSCOPY W/DX BX OF LUNG NODULES UNILATRL OP "$1,185.00 " $0.00 $0.00 $880.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $880.91 $0.00 $229.64 $0.00 32650 EAP CPT® 32650 PR THORACOSCOPY SURG W/PLEURODESIS OP "$2,995.00 " $0.00 $0.00 "$1,547.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,547.55" $668.37 $479.09 $668.37 32651 EAP CPT® 32651 PR THORACOSCOPY SURG PART PULM DECORT OP "$3,421.00 " $0.00 $0.00 "$2,548.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,548.46" $996.57 $583.81 $996.57 32652 EAP CPT® 32652 PR THORACOSCOPY SURG TOT PULM DECORT OP "$5,191.00 " $0.00 $0.00 "$3,865.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,865.70" "$1,503.30" $807.77 "$1,503.30" 32653 EAP CPT® 32653 PR THORACOSCOPY SURG REMOV FB INTRAPLEU OP "$3,317.00 " $0.00 $0.00 "$2,462.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,462.27" $965.78 $572.85 $965.78 32655 EAP CPT® 32655 PR THORACOSCOPY W/RESECTION BULLAE W/WO PLEURAL PX OP "$3,470.00 " $0.00 $0.00 "$2,223.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,223.09" $897.76 $607.49 $897.76 32662 EAP CPT® 32662 PR THORACOSCOPY SURG EXC MEDIAST MASS OP "$4,201.00 " $0.00 $0.00 "$2,075.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,075.18" $904.51 $730.42 $904.51 32663 EAP CPT® 32663 PR THORACOSCOPY W/LOBECTOMY SINGLE LOBE OP "$4,749.00 " $0.00 $0.00 "$3,259.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,259.11" "$1,345.62" $818.75 "$1,345.62" 32666 EAP CPT® 32666 PR THORACOSCOPY W/THERA WEDGE RESEXN INITIAL UNILAT OP "$2,712.00 " $0.00 $0.00 "$2,025.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,025.68" $0.00 $527.19 $0.00 32667 EAP CPT® 32667 PR THORACOSCOPY W/THERA WEDGE RESEXN ADDL IPSILATRL OP $490.00 $0.00 $0.00 $366.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $366.11 $0.00 $94.89 $0.00 32669 EAP CPT® 32669 PR THORACOSCOPY W/SEGMENTECTOMY OP "$4,200.00 " $0.00 $0.00 "$3,132.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,132.68" $0.00 $811.49 $0.00 32674 EAP CPT® 32674 PR THORCOSCPY W/MEDIASTINL ®IONL LYMPHADENECTOMY OP $674.00 $0.00 $0.00 $502.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.80 $0.00 $130.09 $0.00 33016 EAP CPT® 33016 PR PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED OP $741.00 $0.00 $0.00 $548.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $548.22 $0.00 $146.34 $0.00 33020 EAP CPT® 33020 PR INCIS HEART SAC REMV CLOT/FB OP "$3,421.00 " $0.00 $0.00 "$2,044.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,044.64" $833.32 $590.12 $833.32 33025 EAP CPT® 33025 PR INCIS HEART SAC WINDW FOR DRAIN OP "$3,497.00 " $0.00 $0.00 "$1,856.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,856.27" $773.42 $583.63 $773.42 33120 EAP CPT® 33120 PR REMOVAL HEART LESION INTERN OP "$8,553.00 " $0.00 $0.00 "$4,882.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,882.67" "$1,508.75" "$1,181.24" "$1,508.75" 33207 EAP CPT® 33207 PR INS NEW/RPLC PRM PACEMAKER W/TRANSV ELTRD VENTR OP "$1,505.00 " $0.00 $0.00 "$1,143.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,143.56" $523.36 $377.29 $523.36 33208 EAP CPT® 33208 PR INS NEW/RPLCMT PRM PM W/TRANSV ELTRD ATRIAL&VENT OP "$2,091.00 " $0.00 $0.00 "$1,237.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,237.97" $489.02 $382.78 $489.02 33210 EAP CPT® 33210 PR INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH OP $760.00 $0.00 $0.00 $415.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $415.98 $173.90 $135.87 $173.90 33212 EAP CPT® 33212 PR INS PM PLS GEN W/EXIST SINGLE LEAD OP "$1,406.00 " $0.00 $0.00 $774.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $774.69 $337.33 $256.03 $337.33 33213 EAP CPT® 33213 PR INS PACEMAKER PULSE GEN ONLY W/EXIST DUAL LEADS OP "$1,597.00 " $0.00 $0.00 $807.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $807.48 $383.20 $280.43 $383.20 33225 EAP CPT® 33225 PR INSJ ELTRD CAR VEN SYS TM INSJ DFB/PM PLS GEN OP "$1,863.00 " $0.00 $0.00 "$1,087.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,087.23" $442.65 $262.00 $442.65 33227 EAP CPT® 33227 PR REMVL PERM PM PLSE GEN W/REPL PLSE GEN SNGL LEAD OP "$1,062.00 " $0.00 $0.00 $813.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $813.98 $0.00 $202.45 $0.00 33241 EAP CPT® 33241 PR REMOVAL IMPLANTABLE DEFIB PULSE GENERATOR ONLY OP $798.00 $0.00 $0.00 $530.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $530.00 $231.62 $150.46 $231.62 33244 EAP CPT® 33244 PR RMVL1/DUAL CHMBR IMPLTBL DFB ELTRD TRANSVNS XTRJ OP "$3,649.00 " $0.00 $0.00 "$2,018.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.34" $858.44 $551.38 $858.44 33249 EAP CPT® 33249 PR INSJ/RPLCMT PERM DFB W/TRNSVNS LDS 1/DUAL CHMBR OP "$3,725.00 " $0.00 $0.00 "$2,152.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,152.53" $886.85 $636.20 $886.85 33259 EAP CPT® 33259 "PR ABLATE/ RECONSTUCT ATRIA, W OTHER PROCED EXTENS W/ BYPASS" OP "$2,637.00 " $0.00 $0.00 "$1,964.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,964.28" $0.00 $451.12 $0.00 33262 EAP CPT® 33262 PR RMVL IMPLTBL DFB PLSE GEN W/REPL PLSE GEN 1 LEAD OP "$1,171.00 " $0.00 $0.00 $894.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $894.06 $0.00 $219.95 $0.00 33263 EAP CPT® 33263 PR RMVL IMPLTBL DFB PLSE GEN W/RPLCMT PLSE GEN 2 LD OP "$1,218.00 " $0.00 $0.00 $929.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $929.28 $0.00 $228.60 $0.00 33270 EAP CPT® 33270 PR INS/RPLCMNT PERM SUBQ IMPLTBL DFB W/SUBQ ELTRD OP "$1,777.00 " $0.00 $0.00 "$1,373.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,373.25" $0.00 $359.53 $0.00 33274 EAP CPT® 33274 PR TCAT INSJ/RPL PERM LEADLESS PACEMAKER RV W/IMG OP "$1,527.00 " $0.00 $0.00 "$1,138.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,138.29" $0.00 $306.54 $0.00 33286 EAP CPT® 33286 PR REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR OP $274.00 $0.00 $0.00 $203.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.30 $0.00 $81.68 $0.00 33300 EAP CPT® 33300 PR REPAIR HEART WOUND OP "$7,686.00 " $0.00 $0.00 "$5,702.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,702.72" "$2,085.13" $788.20 "$2,085.13" 33405 EAP CPT® 33405 PR RPLCMT PROST AORTIC VALVE OPEN XCP HOMOGRF/STENT OP "$8,209.00 " $0.00 $0.00 "$5,283.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,283.98" "$2,282.69" "$1,373.55" "$2,282.69" 33427 EAP CPT® 33427 PR MITRALPLASTY W RADICAL RECONSTR OP "$7,654.00 " $0.00 $0.00 "$5,690.87" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,690.87" "$2,466.31" "$1,514.42" "$2,466.31" 33430 EAP CPT® 33430 PR REPLACEMENT OF MITRAL VALVE OP "$8,777.00 " $0.00 $0.00 "$6,514.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,514.37" "$2,622.15" "$1,447.31" "$2,622.15" 33464 EAP CPT® 33464 PR VALVULOPLAS TRICUS W RING INSERT OP "$8,175.00 " $0.00 $0.00 "$5,685.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,685.27" "$2,240.25" "$1,275.55" "$2,240.25" 33508 EAP CPT® 33508 "PR ENDOSCOPY W/VIDEO-ASST VEIN HARVEST,CABG" OP $349.00 $0.00 $0.00 $37.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.58 $16.04 $9.95 $16.04 33517 EAP CPT® 33517 "PR CABG, ARTERY-VEIN, SINGLE" OP $629.00 $0.00 $0.00 $436.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $436.50 $174.70 $109.56 $174.70 33518 EAP CPT® 33518 "PR CABG, ARTERY-VEIN, TWO" OP "$1,293.00 " $0.00 $0.00 $959.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.37 $371.82 $206.77 $371.82 33519 EAP CPT® 33519 "PR CABG, ARTERY-VEIN, THREE" OP "$1,747.00 " $0.00 $0.00 "$1,268.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,268.76" $500.39 $303.35 $500.39 33533 EAP CPT® 33533 "PR CABG, ARTERIAL, SINGLE" OP "$7,493.00 " $0.00 $0.00 "$4,350.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,350.89" "$1,914.38" "$1,209.37" "$1,914.38" 33641 EAP CPT® 33641 PR REPR ASD W BYPASS OP "$5,764.00 " $0.00 $0.00 "$3,841.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,841.50" "$1,519.09" $992.10 "$1,519.09" 33880 EAP CPT® 33880 PR ENDOVASC TAA REPR INCL SUBCL OP "$5,631.00 " $0.00 $0.00 "$4,234.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,234.28" "$1,785.02" "$1,086.54" "$1,785.02" 33947 EAP CPT® 33947 PR ECMO/ECLS INITIATION VENO-ARTERIAL OP "$1,076.00 " $0.00 $0.00 $788.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $788.61 $0.00 $209.08 $0.00 33952 EAP CPT® 33952 PR ECMO/ECLS INSJ OF PRPH CANNULA 6 YRS&OLDER PERQ OP "$1,343.00 " $0.00 $0.00 "$1,001.69" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,001.69" $0.00 $263.65 $0.00 33954 EAP CPT® 33954 PR ECMO/ECLS INSJ OF PRPH CANNULA 6 YRS&OLDER OPEN OP "$1,495.00 " $0.00 $0.00 "$1,119.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,119.98" $0.00 $294.54 $0.00 33967 EAP CPT® 33967 PR INSERT INTRA-AORTIC BALLOON ASST DEVICE OP $812.00 $0.00 $0.00 $604.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $604.59 $257.13 $173.02 $257.13 33984 EAP CPT® 33984 PR ECMO/ECLS RMVL PRPH CANNULA OPEN 6 YRS & OLDER OP $892.00 $0.00 $0.00 $666.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $666.08 $0.00 $175.35 $0.00 34101 EAP CPT® 34101 "PR REMV ART CLOT AXILL-BRACH,ARM INCIS" OP "$1,880.00 " $0.00 $0.00 "$1,422.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,422.42" $619.04 $399.72 $619.04 34111 EAP CPT® 34111 "PR REMV ART CLOT ARM,ARM INCIS" OP "$3,715.00 " $0.00 $0.00 "$1,417.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,417.71" $619.47 $334.77 $619.47 34201 EAP CPT® 34201 "PR REMV ART CLOT ILIAC-POP,LEG INCIS" OP "$3,225.00 " $0.00 $0.00 "$2,438.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,438.99" $948.92 $388.47 $948.92 34502 EAP CPT® 34502 "PR RECONSTRUCT, VENA CAVA" OP "$5,386.00 " $0.00 $0.00 "$3,602.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,602.76" "$1,545.44" "$1,020.24" "$1,545.44" 34705 EAP CPT® 34705 PR EVASC RPR DPLMNT AORTO-BI-ILIAC NDGFT OP "$4,817.00 " $0.00 $0.00 "$3,546.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,546.99" $0.00 $955.61 $0.00 34713 EAP CPT® 34713 PR PERQ ACCESS & CLOSURE FEM ART FOR DELIVERY NDGFT OP $393.00 $0.00 $0.00 $299.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $299.25 $0.00 $80.58 $0.00 35045 EAP CPT® 35045 "PR REPR ANEURYSM/GRFT INS,RADIAL/ULNAR" OP "$3,076.00 " $0.00 $0.00 "$2,346.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,346.90" $983.78 $498.08 $983.78 35206 EAP CPT® 35206 "PR REPR BL VES DIRECT,UP EXTREM" OP "$2,453.00 " $0.00 $0.00 "$1,829.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,829.55" $779.63 $418.00 $779.63 35207 EAP CPT® 35207 "PR REPR BL VES DIRECT,HAND/FINGR" OP "$2,353.00 " $0.00 $0.00 "$1,755.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,755.65" $697.35 $468.83 $697.35 35216 EAP CPT® 35216 "PR REPR BL VES DIRECT,CHEST" OP "$6,499.00 " $0.00 $0.00 "$4,794.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,794.27" "$1,760.54" $746.36 "$1,760.54" 35221 EAP CPT® 35221 "PR REPR BL VES DIRECT,ABD" OP "$4,612.00 " $0.00 $0.00 "$3,420.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,420.32" "$1,404.75" $620.47 "$1,404.75" 35226 EAP CPT® 35226 "PR REPR BL VES DIRECT,LOW EXTREM" OP "$2,614.00 " $0.00 $0.00 "$1,967.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,967.07" $865.31 $421.09 $865.31 35231 EAP CPT® 35231 "PR REPR BL VES VEIN GRFT,NECK" OP "$3,936.00 " $0.00 $0.00 "$2,862.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,862.62" "$1,182.45" $527.02 "$1,182.45" 35236 EAP CPT® 35236 "PR REPR BL VES VEIN GRFT,UP EXTREM" OP "$3,156.00 " $0.00 $0.00 "$2,314.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,314.05" $993.42 $474.34 $993.42 35256 EAP CPT® 35256 "PR REPR BL VES VEIN GRFT,LOW EXTREM" OP "$3,221.00 " $0.00 $0.00 "$2,408.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,408.33" "$1,050.51" $509.01 "$1,050.51" 35261 EAP CPT® 35261 "PR REPR BL VES GRAFT,NECK" OP "$3,075.00 " $0.00 $0.00 "$2,500.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,500.02" "$1,042.29" $504.59 "$1,042.29" 35266 EAP CPT® 35266 "PR REPR BL VES GRAFT,UP EXTREM" OP "$2,717.00 " $0.00 $0.00 "$2,058.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,058.36" $873.34 $461.01 $873.34 35281 EAP CPT® 35281 "PR REPR BL VES GRAFT,ABDOMEN" OP "$5,117.00 " $0.00 $0.00 "$3,816.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,816.47" "$1,604.72" $698.44 "$1,604.72" 35286 EAP CPT® 35286 "PR REPR BL VES GRAFT,LOW EXTREM" OP "$4,024.00 " $0.00 $0.00 "$2,212.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,212.62" $963.13 $518.34 $963.13 35355 EAP CPT® 35355 PR THROMBOENDARTECTMY ILIOFEMORAL OP "$3,250.00 " $0.00 $0.00 "$2,453.87" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,453.87" "$1,071.99" $667.91 "$1,071.99" 35371 EAP CPT® 35371 PR THROMBOENDARTECTMY FEMORAL COMMON OP "$2,569.00 " $0.00 $0.00 "$1,941.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,941.11" $852.21 $503.26 $852.21 35518 EAP CPT® 35518 "PR VEIN BYPASS GRAFT,AXILL-AXILL" OP "$3,653.00 " $0.00 $0.00 "$2,745.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,745.42" "$1,216.31" $657.08 "$1,216.31" 35556 EAP CPT® 35556 "PR VEIN BYPASS GRAFT,FEM-POP" OP "$4,405.00 " $0.00 $0.00 "$3,322.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,322.55" "$1,396.63" $871.57 "$1,396.63" 35566 EAP CPT® 35566 "PR VEIN BYPASS GRAFT,FEM-TIBIAL" OP "$5,257.00 " $0.00 $0.00 "$3,964.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,964.70" "$1,676.86" "$1,079.48" "$1,676.86" 35583 EAP CPT® 35583 "PR VEIN IN SITU BYPASS GRAFT,FEM-POP" OP "$4,543.00 " $0.00 $0.00 "$3,433.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,433.53" "$1,447.06" $921.12 "$1,447.06" 35587 EAP CPT® 35587 "PR VEIN IN SITU BYPASS GRAFT,POP-TIB" OP "$4,289.00 " $0.00 $0.00 "$3,238.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,238.56" "$1,435.91" $850.28 "$1,435.91" 35656 EAP CPT® 35656 "PR BYPASS GRAFT OTHR,FEM-POP" OP "$3,397.00 " $0.00 $0.00 "$2,573.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,573.55" "$1,116.93" $794.07 "$1,116.93" 35661 EAP CPT® 35661 "PR BYPASS GRAFT OTHR,FEM-FEM" OP "$3,408.00 " $0.00 $0.00 "$2,574.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,574.56" "$1,119.47" $573.11 "$1,119.47" 35666 EAP CPT® 35666 "PR BYPASS GRAFT OTHR,FEM-TIBIAL" OP "$4,004.00 " $0.00 $0.00 "$3,007.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,007.44" "$1,311.66" $843.83 "$1,311.66" 35685 EAP CPT® 35685 "PR BYPASS GRAFT VEIN PATCH/CUFF,SYNTHETIC" OP $929.00 $0.00 $0.00 $470.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $470.60 $208.51 $0.00 $208.51 35800 EAP CPT® 35800 "PR EXPLOR POSTOP BLEED,INFEC,CLOT-NECK" OP "$2,252.00 " $0.00 $0.00 "$1,677.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,677.42" $479.49 $283.19 $479.49 35820 EAP CPT® 35820 "PR EXPLOR POSTOP BLEED,INFEC,CLOT-CHST" OP "$6,303.00 " $0.00 $0.00 "$4,689.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,689.26" "$1,696.32" $473.87 "$1,696.32" 35903 EAP CPT® 35903 "PR EXCISION, INFEC GRAFT, EXTREMITY" OP "$1,775.00 " $0.00 $0.00 "$1,337.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,337.96" $590.00 $409.35 $590.00 36000 EAP CPT® 36000 PR PLACE NEEDLE IN VEIN OP $146.00 $0.00 $0.00 $26.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.69 $26.45 $13.11 $26.45 36002 EAP CPT® 36002 PR INJECTION RX EXTREMITY PSEUDOANEURYSM OP $366.00 $0.00 $0.00 $248.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.79 $173.41 $0.00 $173.41 36005 EAP CPT® 36005 "PR INJECTION PROC,EXTREMITY,VENOGRAPHY" OP $214.00 $0.00 $0.00 $214.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $113.03 $214.00 $197.41 $214.00 36010 EAP CPT® 36010 PR INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA OP $549.00 $0.00 $0.00 $549.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.07 $549.00 $90.88 $549.00 36011 EAP CPT® 36011 "PR PLACE CATH IN VEIN,SELECT" OP $610.00 $0.00 $0.00 $610.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $367.20 $610.00 $106.97 $610.00 36012 EAP CPT® 36012 "PR PLACE CATH IN VEIN,SUBSELECT" OP $732.00 $0.00 $0.00 $732.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.39 $732.00 $123.88 $732.00 36014 EAP CPT® 36014 PR PLACE CATH IN LT/RT PULM ART OP $732.00 $0.00 $0.00 $732.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.69 $732.00 $106.08 $732.00 36015 EAP CPT® 36015 PR PLACE CATH IN SUBSEGMT PULM ART OP $854.00 $0.00 $0.00 $854.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $401.55 $854.00 $124.10 $854.00 36140 EAP CPT® 36140 PR INTRO NEEDLE/INTRACATH EXTREMITY ARTERY OP $458.00 $0.00 $0.00 $458.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $240.89 $458.00 $70.78 $458.00 36200 EAP CPT® 36200 PR INTRODUCTION CATHETER AORTA OP $687.00 $0.00 $0.00 $687.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.31 $687.00 $112.50 $687.00 36215 EAP CPT® 36215 "PR PLACE CATH SELECTIVE ART,NECK" OP $732.00 $0.00 $0.00 $732.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.21 $732.00 $157.71 $732.00 36216 EAP CPT® 36216 "PR PLACE CATH SUBSELECT ART,NECK" OP $946.00 $0.00 $0.00 $946.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $643.67 $946.00 $177.81 $946.00 36217 EAP CPT® 36217 "PR PLACE CATH SUBSUBSELECT ART,NECK" OP "$1,099.00 " $0.00 $0.00 "$1,099.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $765.42 "$1,099.00" $214.24 "$1,099.00" 36218 EAP CPT® 36218 "PR PLACE CATH ADDN SUBSELEC ART,NECK" OP $244.00 $0.00 $0.00 $211.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.14 $211.17 $34.73 $211.17 36222 EAP CPT® 36222 PR SLCTV CATH CAROTID/INNOM ART ANGIO XTRCRANL ART OP $886.00 $0.00 $0.00 $689.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $689.78 $0.00 $865.63 $0.00 36223 EAP CPT® 36223 PR SLCTV CATH CAROTID/INNOM ART ANGIO INTRCRANL ART OP $993.00 $0.00 $0.00 $753.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.86 $0.00 $947.04 $0.00 36224 EAP CPT® 36224 PR SLCTV CATH INTRNL CAROTID ART ANGIO INTRCRNL ART OP "$1,128.00 " $0.00 $0.00 $839.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $839.34 $0.00 "$1,028.71" $0.00 36225 EAP CPT® 36225 PR SLCTV CATH SUBCLAVIAN ART ANGIO VERTEBRAL ARTERY OP $990.00 $0.00 $0.00 $742.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.82 $0.00 $940.10 $0.00 36226 EAP CPT® 36226 PR SLCTV CATH VERTEBRAL ART ANGIO VERTEBRAL ARTERY OP "$1,112.00 " $0.00 $0.00 $841.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $841.67 $0.00 "$1,048.75" $0.00 36227 EAP CPT® 36227 PR SLCTV CATH XTRNL CAROTID ANGIO XTRNL CAROTD CIRC OP $369.00 $0.00 $0.00 $265.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $265.65 $0.00 $150.43 $0.00 36228 EAP CPT® 36228 PR SLCTV CATH INTRCRNL BRNCH ANGIO INTRL CAROT/VERT OP $755.00 $0.00 $0.00 $543.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.29 $0.00 $720.08 $0.00 36245 EAP CPT® 36245 PR SLCTV CATHJ EA 1ST ORD ABDL PEL/LXTR ART BRNCH OP $763.00 $0.00 $0.00 $763.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $591.29 $763.00 $165.66 $763.00 36246 EAP CPT® 36246 PR SLCTV CATHJ 2ND ORDER ABDL PEL/LXTR ART BRNCH OP $854.00 $0.00 $0.00 $854.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $629.15 $854.00 $180.81 $854.00 36247 EAP CPT® 36247 PR SLCTV CATHJ 3RD+ ORD SLCTV ABDL PEL/LXTR BRNCH OP "$1,068.00 " $0.00 $0.00 "$1,068.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $744.06 "$1,068.00" $213.80 "$1,068.00" 36248 EAP CPT® 36248 PR SLCTV CATHJ EA 2ND+ ORD ABDL PEL/LXTR ART BRNCH OP $198.00 $0.00 $0.00 $177.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $116.39 $177.86 $35.15 $177.86 36251 EAP CPT® 36251 PR SLCTV CATH 1STORD W/WO ART PUNCT/FLUORO/S&I UN OP $812.00 $0.00 $0.00 $658.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $658.01 $0.00 $812.00 $0.00 36253 EAP CPT® 36253 PR SUPSLCTV CATH 2ND+ORD RENAL&ACCESSORY ARTERY/S&I OP "$1,120.00 " $0.00 $0.00 $883.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.67 $0.00 "$1,120.00" $0.00 36410 EAP CPT® 36410 PR VNPNXR 3 YEARS/> PHYS/QHP SKILL OP $89.00 $0.00 $0.00 $21.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.69 $17.66 $11.76 $17.66 36415 EAP CPT® 36415 ROUTINE VENIPUNCTURE OP $18.00 $0.00 $0.00 $4.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $4.32 $0.00 $0.00 $0.00 36430 EAP CPT® 36430 PR BLOOD TRANSFUSION SERVICE OP $123.00 $0.00 $0.00 $79.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.25 $38.09 $24.14 $38.09 36465 EAP CPT® 36465 PR NJX NONCMPND SCLEROSANT SINGLE INCMPTNT VEIN OP $376.00 $0.00 $0.00 $276.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.78 $0.00 $376.00 $0.00 36473 EAP CPT® 36473 PR ENDOVEN ABLTJ INCMPTNT VEIN MCHNCHEM 1ST VEIN OP $560.00 $0.00 $0.00 $401.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $401.42 $0.00 $560.00 $0.00 36475 EAP CPT® 36475 "PR ENDOVENOUS RF, 1ST VEIN" OP "$3,422.00 " $0.00 $0.00 "$1,993.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $657.08 "$1,993.28" "$1,399.48" "$1,993.28" 36478 EAP CPT® 36478 "PR ENDOVENOUS LASER, 1ST VEIN" OP "$2,726.00 " $0.00 $0.00 "$1,820.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $653.28 "$1,820.48" "$1,288.06" "$1,820.48" 36500 EAP CPT® 36500 PR VENOUS SELECT SAMPLING W CATH OP $572.00 $0.00 $0.00 $424.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.79 $180.25 $94.25 $180.25 36555 EAP CPT® 36555 PR INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE < 5 Y OP $675.00 $0.00 $0.00 $294.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $273.90 $294.79 $204.63 $294.79 36556 EAP CPT® 36556 PR INSERT NON-TUNNEL CV CATH OP $591.00 $0.00 $0.00 $280.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.11 $275.89 $194.80 $275.89 36558 EAP CPT® 36558 PR INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> OP "$1,841.00 " $0.00 $0.00 $899.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $645.69 $899.04 $434.13 $899.04 36561 EAP CPT® 36561 PR INSJ TUNNELED CTR VAD W/SUBQ PORT AGE 5 YR/> OP "$3,007.00 " $0.00 $0.00 "$1,244.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $825.38 "$1,244.41" $827.72 "$1,244.41" 36569 EAP CPT® 36569 PR INSERTION PICC W/O IMG GDN 5 YR/> OP $706.00 $0.00 $0.00 $310.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.02 $310.93 $217.01 $310.93 36571 EAP CPT® 36571 PR INSJ PRPH CTR VAD W/SUBQ PORT AGE 5 YR/> OP "$3,222.00 " $0.00 $0.00 "$1,342.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $752.90 "$1,342.71" $965.13 "$1,342.71" 36573 EAP CPT® 36573 PR INSERTION PICC W/RS&I 5 YR/> OP $265.00 $0.00 $0.00 $196.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.77 $0.00 $0.00 $0.00 36581 EAP CPT® 36581 PR RPLCMT COMPL TUN CVC W/O SUBQ PORT/PMP OP "$1,688.00 " $0.00 $0.00 $800.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $457.98 $800.28 $399.64 $800.28 36582 EAP CPT® 36582 PR RPLCMT COMPL TUN CTR VAD W/SUBQ PORT OP "$2,618.00 " $0.00 $0.00 "$1,089.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $713.91 "$1,089.78" $751.81 "$1,089.78" 36589 EAP CPT® 36589 PR REMOVAL TUNNELED CV CATH OP $429.00 $0.00 $0.00 $320.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.48 $166.57 $107.32 $166.57 36590 EAP CPT® 36590 PR RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ OP $596.00 $0.00 $0.00 $477.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $477.29 $257.79 $232.24 $257.79 36595 EAP CPT® 36595 PR MECH REMOV TUNNELED CV CATH OP "$1,657.00 " $0.00 $0.00 $702.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $429.75 $702.46 $547.56 $702.46 36598 EAP CPT® 36598 "PR CONTRAST INJ CENT VEN CATH, INC FLOURO" OP $116.00 $0.00 $0.00 $116.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.98 $116.00 $78.92 $116.00 36600 EAP CPT® 36600 PR WITHDRAWAL OF ARTERIAL BLOOD OP $136.00 $0.00 $0.00 $36.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.15 $30.09 $15.25 $30.09 36620 EAP CPT® 36620 "PR INSERT CATH,ART,PERCUT,SHORTTERM" OP $308.00 $0.00 $0.00 $118.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.05 $51.21 $37.52 $51.21 36625 EAP CPT® 36625 "PR INSERT CATH,ART,CUTDOWN,SHORTTERM" OP $331.00 $0.00 $0.00 $241.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $241.91 $102.68 $65.93 $102.68 36680 EAP CPT® 36680 "PR INSERT NEEDLE,INTRAOSSEOUS INFUSN" OP $188.00 $0.00 $0.00 $135.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.45 $62.85 $48.21 $62.85 36819 EAP CPT® 36819 "PR AV ANAST,UP ARM BASILIC VEIN TRANSPOSIT" OP "$2,300.00 " $0.00 $0.00 "$1,733.67" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,733.67" $798.09 $486.69 $798.09 36820 EAP CPT® 36820 "PR AV ANAST,FOREARM VEIN TRANSPOSITION" OP "$2,293.00 " $0.00 $0.00 "$1,729.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,729.10" $798.88 $535.30 $798.88 36821 EAP CPT® 36821 "PR ANASTOMOSIS,AV,ANY SITE" OP "$2,088.00 " $0.00 $0.00 "$1,571.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.52" $529.89 $360.45 $529.89 36825 EAP CPT® 36825 "PR CREAT AV FISTULA,AUTOGENOUS GRAFT" OP "$2,579.00 " $0.00 $0.00 "$1,895.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,895.06" $577.76 $434.17 $577.76 36830 EAP CPT® 36830 "PR CREAT AV FISTULA,NON-AUTOGENOUS GRAFT" OP "$2,595.00 " $0.00 $0.00 "$1,581.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,581.05" $663.00 $483.09 $663.00 36831 EAP CPT® 36831 "PR THROMBECTOMY,AV FISTULA DIALYS GRFT" OP "$1,936.00 " $0.00 $0.00 "$1,461.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,461.11" $458.22 $242.16 $458.22 36832 EAP CPT® 36832 "PR REVISE AV FISTULA,W/O THROMBECTOMY" OP "$2,376.00 " $0.00 $0.00 "$1,793.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,793.25" $584.90 $404.28 $584.90 36901 EAP CPT® 36901 PR INTRO CATH DIALYSIS CIRCUIT DX ANGRPH FLUOR S&I OP $530.00 $0.00 $0.00 $337.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.37 $0.00 $344.49 $0.00 36902 EAP CPT® 36902 PR INTRO CATH DIALYSIS CIRCUIT W/TRLUML BALO ANGIOP OP $751.00 $0.00 $0.00 $502.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $502.43 $0.00 $732.58 $0.00 36903 EAP CPT® 36903 PR INTRO CATH DIALYSIS CIRCUIT W/TCAT PLMT IV STENT OP $995.00 $0.00 $0.00 $687.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $687.51 $0.00 $995.00 $0.00 36904 EAP CPT® 36904 PR PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH OP "$1,162.00 " $0.00 $0.00 $791.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $791.66 $0.00 "$1,068.12" $0.00 36905 EAP CPT® 36905 PR PERQ THRMBC/NFS DIAL CIRCUIT TRLUML BALO ANGIOP OP "$1,393.00 " $0.00 $0.00 $993.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $993.54 $0.00 "$1,366.82" $0.00 36906 EAP CPT® 36906 PR PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT OP "$1,609.00 " $0.00 $0.00 "$1,159.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,159.35" $0.00 "$1,609.00" $0.00 36907 EAP CPT® 36907 PR TRLUML BALO ANGIOP CTR DIALYSIS SEG W/IMG S&I OP $460.00 $0.00 $0.00 $289.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.23 $0.00 $438.35 $0.00 36909 EAP CPT® 36909 PR DIALYIS CIRCUIT VASC EMBOLI OCCLS EVASC IMG S&I OP $631.00 $0.00 $0.00 $411.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.86 $0.00 $631.00 $0.00 37182 EAP CPT® 37182 PR INSERT TRANSVEN INTRAHEP PORTOSYS SHUNT OP "$2,569.00 " $0.00 $0.00 "$1,949.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,949.12" $851.21 $550.15 $851.21 37184 EAP CPT® 37184 PR PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA 1ST OP "$4,860.00 " $0.00 $0.00 "$2,729.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.04" "$2,729.27" "$1,966.53" "$2,729.27" 37187 EAP CPT® 37187 PR PRQ TRANSLUMINAL MECHANICAL THROMBECTOMY VEIN OP "$4,493.00 " $0.00 $0.00 "$2,653.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $955.29 "$2,653.73" "$1,914.21" "$2,653.73" 37191 EAP CPT® 37191 PR INS INTRVAS VC FILTR W/WO VAS ACS VSL SELXN RS&I OP "$5,669.00 " $0.00 $0.00 $559.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $559.02 $0.00 "$1,605.38" $0.00 37193 EAP CPT® 37193 PR RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I OP "$1,096.00 " $0.00 $0.00 $857.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $857.34 $0.00 "$1,025.68" $0.00 37197 EAP CPT® 37197 PR PRQ TRANSCATHETER RTRVL INTRVAS FB WITH IMAGING OP $945.00 $0.00 $0.00 $740.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $740.57 $0.00 $945.00 $0.00 37200 EAP CPT® 37200 PR TRANSCATHETER BIOPSY OP $903.00 $0.00 $0.00 $514.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $514.34 $224.55 $138.78 $224.55 37211 EAP CPT® 37211 PR THROMBOLYSIS ARTERIAL INFUSION ICRA RS&I INIT TX OP "$1,214.00 " $0.00 $0.00 $936.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $936.39 $0.00 $240.57 $0.00 37212 EAP CPT® 37212 PR THROMBOLYSIS VENOUS INFUSION W/IMAGING INIT TX OP "$1,061.00 " $0.00 $0.00 $823.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $823.65 $0.00 $212.38 $0.00 37214 EAP CPT® 37214 PR CESSATION THROMBOLYTIC THER W/CATHETER REMOVAL OP $386.00 $0.00 $0.00 $317.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.51 $0.00 $87.24 $0.00 37215 EAP CPT® 37215 PR TCAT IV STENT CRV CRTD ART EMBOLIC PROTECJ OP "$3,141.00 " $0.00 $0.00 "$2,353.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,353.94" "$1,076.38" $666.35 "$1,076.38" 37217 EAP CPT® 37217 PR TCATH STENT PLACEMT RETROGRAD CAROTID/INNOMINATE OP "$3,393.00 " $0.00 $0.00 "$2,576.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,576.40" $0.00 $687.20 $0.00 37218 EAP CPT® 37218 PR TCATH STENT PLACEMT ANTEGRADE CAROTID/INNOMINATE OP "$2,570.00 " $0.00 $0.00 "$1,926.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,926.74" $0.00 $506.58 $0.00 37221 EAP CPT® 37221 PR REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOPLSTY OP "$9,986.00 " $0.00 $0.00 "$1,201.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,201.49" $0.00 "$2,788.99" $0.00 37222 EAP CPT® 37222 PR REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL OP $586.00 $0.00 $0.00 $440.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $440.55 $0.00 $543.42 $0.00 37224 EAP CPT® 37224 PR REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI OP "$7,903.00 " $0.00 $0.00 "$1,076.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,076.13" $0.00 "$2,267.07" $0.00 37226 EAP CPT® 37226 PR REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL OP "$1,638.00 " $0.00 $0.00 "$1,264.56" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,264.56" $0.00 "$1,638.00" $0.00 37228 EAP CPT® 37228 PR REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI OP "$11,232.00 " $0.00 $0.00 "$1,314.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,314.24" $0.00 "$3,227.81" $0.00 37230 EAP CPT® 37230 PR REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL OP "$5,769.00 " $0.00 $0.00 "$1,675.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,675.62" $0.00 "$4,988.73" $0.00 37232 EAP CPT® 37232 PR REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL OP $631.00 $0.00 $0.00 $477.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $477.54 $0.00 $631.00 $0.00 37236 EAP CPT® 37236 PR OPEN/PERQ PLACEMENT INTRAVASCULAR STENT INITIAL OP "$1,399.00 " $0.00 $0.00 "$1,065.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,065.44" $0.00 "$1,399.00" $0.00 37238 EAP CPT® 37238 PR OPEN/PERQ PLACEMENT INTRAVASCULAR STENT SAME 1ST OP $961.00 $0.00 $0.00 $738.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $738.24 $0.00 $961.00 $0.00 37239 EAP CPT® 37239 PR OPEN/PERQ PLACEMENT INTRAVASC STENT SAME EA ADDL OP $479.00 $0.00 $0.00 $351.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.33 $0.00 $479.00 $0.00 37241 EAP CPT® 37241 PR VASCULAR EMBOLIZATION OR OCCLUSION VENOUS RS&I OP "$9,350.00 " $0.00 $0.00 "$1,058.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,058.09" $0.00 "$2,770.05" $0.00 37242 EAP CPT® 37242 PR VASCULAR EMBOLIZATION OR OCCLUSION ARTERIAL RS&I OP "$15,755.00 " $0.00 $0.00 "$1,158.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,158.86" $0.00 "$4,667.57" $0.00 37243 EAP CPT® 37243 PR VASCULAR EMBOLIZE/OCCLUDE ORGAN TUMOR INFARCT OP "$1,764.00 " $0.00 $0.00 "$1,368.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,368.78" $0.00 "$1,764.00" $0.00 37244 EAP CPT® 37244 PR VASCULAR EMBOLIZATION OR OCCLUSION HEMORRHAGE OP "$2,088.00 " $0.00 $0.00 "$1,602.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,602.27" $0.00 "$2,088.00" $0.00 37248 EAP CPT® 37248 PR TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I 1ST VEIN OP $935.00 $0.00 $0.00 $708.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $708.96 $0.00 $893.78 $0.00 37249 EAP CPT® 37249 PR TRLML BALO ANGIOP OPEN/PERQ W/IMG S&I ADDL VEIN OP $459.00 $0.00 $0.00 $347.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $347.64 $0.00 $383.03 $0.00 37252 EAP CPT® 37252 PR INTRAVASCULAR US NONCORONARY RS&I INTIAL VESSEL OP $284.00 $0.00 $0.00 $215.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.88 $0.00 $284.00 $0.00 37253 EAP CPT® 37253 PR INTRAVASCULAR US NONCORONARY RS&I ADDL VESSEL OP $228.00 $0.00 $0.00 $172.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.65 $0.00 $131.39 $0.00 37565 EAP CPT® 37565 PR LIGATN NECK VEIN OP "$2,264.00 " $0.00 $0.00 "$1,696.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,696.92" $670.67 $182.02 $670.67 37605 EAP CPT® 37605 "PR LIGATN NECK ARTERY,ICA,CCA" OP "$2,318.00 " $0.00 $0.00 "$1,873.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,873.05" $810.20 $260.71 $810.20 37607 EAP CPT® 37607 PR LIGATN ANGIOACCESS AV FISTULA OP "$1,175.00 " $0.00 $0.00 $886.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $886.55 $373.86 $227.41 $373.86 37609 EAP CPT® 37609 PR TEMPORAL ARTERY LIGATN OR BX OP $742.00 $0.00 $0.00 $483.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.83 $281.55 $151.42 $281.55 37616 EAP CPT® 37616 PR LIGATN OF CHEST ARTERY OP "$3,463.00 " $0.00 $0.00 "$2,570.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,570.13" "$1,042.45" $596.18 "$1,042.45" 37617 EAP CPT® 37617 PR LIGATN OF ABDOMEN ARTERY OP "$4,177.00 " $0.00 $0.00 "$3,123.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,123.81" "$1,264.50" $564.36 "$1,264.50" 37618 EAP CPT® 37618 PR LIGATN OF EXTREMITY ARTERY OP "$1,214.00 " $0.00 $0.00 $900.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $900.03 $363.56 $216.83 $363.56 37650 EAP CPT® 37650 PR LIGATN FEMORAL VEIN OP "$1,437.00 " $0.00 $0.00 "$1,193.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,193.90" $498.99 $215.19 $498.99 37660 EAP CPT® 37660 PR LIGATN COMMON ILIAC VEIN OP "$4,145.00 " $0.00 $0.00 "$2,721.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,721.72" "$1,193.43" $393.61 "$1,193.43" 37700 EAP CPT® 37700 PR LIGATN LONG SAPHENOUS VEIN AT SEPH-FEM JUNC OP $838.00 $0.00 $0.00 $587.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $587.52 $249.73 $168.15 $249.73 37765 EAP CPT® 37765 PR PHLEB VEINS - EXTREM - TO 20 OP "$1,193.00 " $0.00 $0.00 "$1,057.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,057.61" $447.44 $280.05 $447.44 37766 EAP CPT® 37766 PR PHLEB VEINS - EXTREM 20+ OP "$1,612.00 " $0.00 $0.00 "$1,292.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,292.10" $541.26 $340.09 $541.26 37780 EAP CPT® 37780 PR LIGATN SHORT SAPHEN OP $871.00 $0.00 $0.00 $598.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $598.67 $255.91 $150.10 $255.91 38100 EAP CPT® 38100 "PR REMOVAL SPLEEN, TOTAL" OP "$4,392.00 " $0.00 $0.00 "$2,680.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,680.74" $988.60 $486.17 $988.60 38102 EAP CPT® 38102 "PR REMOVAL SPLEEN, TOTAL W OTHR PROC" OP "$2,196.00 " $0.00 $0.00 $609.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $609.56 $247.73 $165.59 $247.73 38115 EAP CPT® 38115 PR REPAIR OF RUPTURED SPLEEN OP "$4,148.00 " $0.00 $0.00 "$2,942.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,942.58" "$1,096.45" $508.77 "$1,096.45" 38222 EAP CPT® 38222 PR DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS OP $242.00 $0.00 $0.00 $180.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.27 $0.00 $103.15 $0.00 38500 EAP CPT® 38500 "PR BIOPSY/EXCISION, LYMPH NODE(S)" OP $878.00 $0.00 $0.00 $589.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $589.16 $285.11 $116.87 $285.11 38505 EAP CPT® 38505 "PR NEEDLE BIOPSY, LYMPH NODE(S)" OP $488.00 $0.00 $0.00 $165.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.78 $118.45 $72.50 $118.45 38510 EAP CPT® 38510 "PR BX/REMV,LYMPH NODE,DEEP CERV" OP "$1,464.00 " $0.00 $0.00 $976.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $976.82 $461.70 $174.69 $461.70 38525 EAP CPT® 38525 "PR BX/REMV,LYMPH NODE,DEEP AXILL" OP "$1,373.00 " $0.00 $0.00 "$1,012.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,012.23" $373.85 $184.53 $373.85 38531 EAP CPT® 38531 PR OPEN BIOPSY/EXCISION INGUINOFEMORAL NODES OP "$1,354.00 " $0.00 $0.00 "$1,011.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.12" $0.00 $0.00 $0.00 38572 EAP CPT® 38572 "PR LAP,PELVIC LYMPHADENECTOMY/BX" OP "$4,636.00 " $0.00 $0.00 "$2,154.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,154.60" $913.45 $524.43 $913.45 38724 EAP CPT® 38724 "PR REMOVAL NODES, NECK,CERV MOD RAD" OP "$5,856.00 " $0.00 $0.00 "$3,383.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.73" "$1,249.68" $685.68 "$1,249.68" 38746 EAP CPT® 38746 PR REMOVE THOR LYMPH NODES RAD REGNL OP "$1,244.00 " $0.00 $0.00 $501.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $501.23 $254.43 $155.37 $254.43 38790 EAP CPT® 38790 PR INJECTION FOR LYMPHATIC XRAY OP $830.00 $0.00 $0.00 $192.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.69 $77.64 $319.60 $77.64 38792 EAP CPT® 38792 PR INJ RADIOACTIVE TRACER FOR ID OF SENTINEL NODE OP $732.00 $0.00 $0.00 $92.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.55 $37.03 $0.00 $37.03 38900 EAP CPT® 38900 PR INTRAOPERATIVE SENTINEL LYMPH NODE ID W DYE INJECTION OP $436.00 $0.00 $0.00 $320.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.66 $0.00 $80.58 $0.00 39501 EAP CPT® 39501 PR REPAIR DIAPHRAGM LACERATION OP "$4,392.00 " $0.00 $0.00 "$1,969.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,969.50" $783.42 $541.60 $783.42 39540 EAP CPT® 39540 PR REPAIR DIAPHR HERNIA TRAUMA ACUTE OP "$5,563.00 " $0.00 $0.00 "$2,009.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,009.76" $797.16 $567.25 $797.16 40490 EAP CPT® 40490 PR BIOPSY OF LIP OP $220.00 $0.00 $0.00 $170.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.30 $109.38 $54.33 $109.38 40650 EAP CPT® 40650 "PR REPAIR LIP,FULL THICK,VERMILION" OP $969.00 $0.00 $0.00 $698.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $698.39 $384.75 $184.97 $384.75 40652 EAP CPT® 40652 "PR REPAIR LIP,<1/2 VERT HEIGHT" OP "$1,279.00 " $0.00 $0.00 $819.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $819.72 $448.00 $220.57 $448.00 40800 EAP CPT® 40800 "PR DRAIN MOUTH ABSC/CYST/HEMATOMA,SIMPL" OP $385.00 $0.00 $0.00 $311.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $311.84 $163.01 $54.98 $163.01 40801 EAP CPT® 40801 "PR DRAIN MOUTH ABSC/CYST/HEMAT,COMPLX" OP "$1,047.00 " $0.00 $0.00 $526.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.25 $256.36 $104.24 $256.36 40804 EAP CPT® 40804 "PR REMOVAL FOREIGN BODY,MOUTH,SIMPLE" OP $367.00 $0.00 $0.00 $276.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.23 $174.67 $61.00 $174.67 40808 EAP CPT® 40808 PR BIOPSY OF MOUTH LESION OP $310.00 $0.00 $0.00 $257.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $257.07 $143.18 $51.11 $143.18 40818 EAP CPT® 40818 PR EXCISE ORAL MUCOSA FOR GRAFT OP $841.00 $0.00 $0.00 $643.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $643.14 $298.75 $0.00 $298.75 40820 EAP CPT® 40820 PR DESTRUC MOUTH LESION/SCAR OP $517.00 $0.00 $0.00 $408.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $408.14 $204.81 $0.00 $204.81 40830 EAP CPT® 40830 "PR REPAIR MOUTH LACERATION,<2.5CM" OP $523.00 $0.00 $0.00 $389.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.82 $209.02 $73.58 $209.02 40845 EAP CPT® 40845 PR RECONSTRUC MOUTH COMPLEX OP "$3,768.00 " $0.00 $0.00 "$2,867.93" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,867.93" "$1,356.15" $798.15 "$1,356.15" 41005 EAP CPT® 41005 "PR I&D MOUTH/TONG INTRA,SUBLING,SUPERF" OP $401.00 $0.00 $0.00 $295.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.65 $179.43 $57.38 $179.43 41007 EAP CPT® 41007 "PR I&D MOUTH/TONG INTRA,SUBMENTAL" OP $977.00 $0.00 $0.00 $572.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.91 $311.80 $142.07 $311.80 41008 EAP CPT® 41008 "PR I&D MOUTH/TONG INTRA,SUBMANDIBULAR" OP $977.00 $0.00 $0.00 $638.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $638.60 $313.04 $0.00 $313.04 41009 EAP CPT® 41009 "PR I&D MOUTH/TONG INTRA,MASTICATOR" OP $886.00 $0.00 $0.00 $692.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $692.55 $333.89 $160.19 $333.89 41015 EAP CPT® 41015 "PR I&D MOUTH/TONG EXTRA,SUBLING" OP $965.00 $0.00 $0.00 $829.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $829.64 $362.85 $144.45 $362.85 41016 EAP CPT® 41016 "PR I&D MOUTH/TONG EXTRA,SUBMENTAL" OP "$1,073.00 " $0.00 $0.00 $833.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $833.64 $374.13 $0.00 $374.13 41017 EAP CPT® 41017 "PR I&D MOUTH/TONG EXTRA,SUBMANDIBUL" OP "$1,066.00 " $0.00 $0.00 $837.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $837.63 $376.32 $153.76 $376.32 41018 EAP CPT® 41018 "PR I&D MOUTH/TONG EXTRA,MASTICATOR" OP "$1,239.00 " $0.00 $0.00 $978.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $978.87 $433.30 $212.31 $433.30 41100 EAP CPT® 41100 "PR BIOPSY TONGUE,ANTER 2/3" OP $327.00 $0.00 $0.00 $254.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.18 $144.44 $72.62 $144.44 41116 EAP CPT® 41116 PR EXCIS FLOOR MOUTH LESION OP "$1,172.00 " $0.00 $0.00 $521.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $521.67 $263.49 $121.35 $263.49 41120 EAP CPT® 41120 "PR PART REMOVAL TONGUE,<1/2" OP "$3,286.00 " $0.00 $0.00 "$2,558.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,558.60" $956.97 $407.06 $956.97 41153 EAP CPT® 41153 "PR EXCIS TONGUE,MOUTH,NECK" OP "$7,399.00 " $0.00 $0.00 "$5,692.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,692.43" "$2,142.74" "$1,048.30" "$2,142.74" 41252 EAP CPT® 41252 "PR REPAIR TONGUE LACER,2.6CM+/COMPLX" OP "$1,456.00 " $0.00 $0.00 $494.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $494.40 $262.82 $130.79 $262.82 41800 EAP CPT® 41800 PR DRAINAGE OF GUM LESION OP $472.00 $0.00 $0.00 $346.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.73 $161.67 $54.75 $161.67 41823 EAP CPT® 41823 "PR EXCIS OSSEOUS TUBER,DENTOALV" OP "$1,110.00 " $0.00 $0.00 $768.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $768.48 $356.59 $156.63 $356.59 41825 EAP CPT® 41825 PR EXCIS DENTOALVEOLAR LESION OP $391.00 $0.00 $0.00 $289.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.76 $169.93 $72.38 $169.93 41874 EAP CPT® 41874 PR REPAIR TOOTH SOCKET OP $821.00 $0.00 $0.00 $608.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $608.91 $311.73 $142.84 $311.73 41899 EAP CPT® 41899 PR DENTAL SURGERY PROCEDURE OP $350.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 42000 EAP CPT® 42000 PR DRAINAGE ABSCESS PALATE/UVULA OP $401.00 $0.00 $0.00 $244.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $244.67 $140.16 $59.44 $140.16 42100 EAP CPT® 42100 PR BIOPSY PALATE/UVULA OP $391.00 $0.00 $0.00 $259.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.10 $129.01 $62.73 $129.01 42140 EAP CPT® 42140 PR EXCISION OF UVULA OP $821.00 $0.00 $0.00 $364.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $364.83 $203.86 $87.65 $203.86 42330 EAP CPT® 42330 "PR REMOVAL SALIVARY STONE,UNCOMPLIC" OP $586.00 $0.00 $0.00 $387.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $387.68 $201.54 $92.14 $201.54 42409 EAP CPT® 42409 PR DRAINAGE SUBLING SALIVARY CYST OP $977.00 $0.00 $0.00 $519.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $519.80 $280.81 $133.64 $280.81 42415 EAP CPT® 42415 "PR EXC PAROTD,LAT LOBE,DISSECT 5TH NERV" OP "$3,712.00 " $0.00 $0.00 "$2,465.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,465.15" "$1,058.17" $682.79 "$1,058.17" 42440 EAP CPT® 42440 PR EXCISION SUBMAXILLARY GLAND OP "$2,989.00 " $0.00 $0.00 $963.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.68 $434.53 $318.06 $434.53 42505 EAP CPT® 42505 PR REPAIR SALIVARY DUCT COMPLICATED OP "$2,345.00 " $0.00 $0.00 "$1,063.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,063.95" $497.57 $0.00 $497.57 42650 EAP CPT® 42650 PR DILATION OF SALIVARY DUCT OP $178.00 $0.00 $0.00 $137.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.58 $70.99 $0.00 $70.99 42700 EAP CPT® 42700 PR INC/DRAIN PERITONSIL ABSCESS OP $417.00 $0.00 $0.00 $317.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.93 $161.03 $76.43 $161.03 42720 EAP CPT® 42720 "PR INC/DRAIN RETROPHARYNG ABSCESS,ORAL" OP "$1,206.00 " $0.00 $0.00 $918.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $918.21 $412.05 $199.91 $412.05 42800 EAP CPT® 42800 PR BIOPSY OROPHARYNX OP $348.00 $0.00 $0.00 $262.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.31 $134.84 $68.07 $134.84 42826 EAP CPT® 42826 "PR REMOVAL OF TONSILS,12+ Y/O" OP $957.00 $0.00 $0.00 $588.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $588.77 $235.91 $160.60 $235.91 42831 EAP CPT® 42831 "PR REMOVAL ADENOIDS,PRIMARY,12+ Y/O" OP $713.00 $0.00 $0.00 $524.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $524.70 $205.40 $117.80 $205.40 42900 EAP CPT® 42900 PR SUTURE INJURY/WND PHARYNX OP "$1,034.00 " $0.00 $0.00 $789.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $789.18 $329.25 $214.82 $329.25 42962 EAP CPT® 42962 "PR CONTROL THROAT BLEED,SURG INTERVENTN" OP "$1,590.00 " $0.00 $0.00 "$1,213.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,213.40" $485.48 $301.60 $485.48 43191 EAP CPT® 43191 PR ESOPHAGOSCOPY RIGID TRANSORAL DIAGNOSTIC BRUSH OP $479.00 $0.00 $0.00 $359.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.87 $0.00 $77.36 $0.00 43197 EAP CPT® 43197 PR ESOPHAGOSCOPY FLEXIBLE TRANSNASAL DIAGNOSTIC OP $498.00 $0.00 $0.00 $193.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.37 $0.00 $111.85 $0.00 43198 EAP CPT® 43198 PR ESOPHAGOSCOPY FLEXIBLE TRANSNASAL WITH BIOPSY OP $436.00 $0.00 $0.00 $231.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.86 $0.00 $124.82 $0.00 43200 EAP CPT® 43200 PR ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC OP $630.00 $0.00 $0.00 $219.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.27 $206.63 $116.83 $206.63 43202 EAP CPT® 43202 PR ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY OP $687.00 $0.00 $0.00 $271.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.38 $271.44 $123.34 $271.44 43205 EAP CPT® 43205 PR ESPHGOSCOPY FLEX W/BAND LIGATION ESOPHGL VARICES OP $945.00 $0.00 $0.00 $344.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $344.66 $204.72 $135.02 $204.72 43213 EAP CPT® 43213 PR ESOPHAGOSCOPY RETROGRADE DILATE BALLOON/OTHER OP $809.00 $0.00 $0.00 $620.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $620.75 $0.00 $747.87 $0.00 43220 EAP CPT® 43220 PR ESOPHAGOSCOPY FLEX BALLOON DILAT <30 MM DIAM OP $773.00 $0.00 $0.00 $290.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.75 $117.44 $85.30 $117.44 43227 EAP CPT® 43227 PR ESOPHAGOSCOPY FLEXIBLE W/BLEEDING CONTROL OP $945.00 $0.00 $0.00 $402.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $402.38 $193.94 $145.67 $193.94 43235 EAP CPT® 43235 PR ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC OP $630.00 $0.00 $0.00 $301.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.23 $281.43 $142.74 $281.43 43239 EAP CPT® 43239 PR EGD TRANSORAL BIOPSY SINGLE/MULTIPLE OP $730.00 $0.00 $0.00 $339.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.77 $321.44 $147.69 $321.44 43242 EAP CPT® 43242 PR EGD INTRMURAL NEEDLE ASPIR/BIOP ALTERED ANATOMY OP $887.00 $0.00 $0.00 $633.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $633.80 $386.91 $199.85 $386.91 43244 EAP CPT® 43244 PR EGD BAND LIGATION ESOPHGEAL/GASTRIC VARICES OP $973.00 $0.00 $0.00 $592.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $592.04 $270.04 $166.08 $270.04 43245 EAP CPT® 43245 PR EGD DILATION GASTRIC/DUODENAL STRICTURE OP $859.00 $0.00 $0.00 $427.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $427.04 $172.74 $137.30 $172.74 43246 EAP CPT® 43246 PR EGD PERCUTANEOUS PLACEMENT GASTROSTOMY TUBE OP "$1,260.00 " $0.00 $0.00 $483.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $483.93 $231.20 $175.61 $231.20 43247 EAP CPT® 43247 PR EGD FLEXIBLE FOREIGN BODY REMOVAL OP $859.00 $0.00 $0.00 $430.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $430.43 $183.50 $137.30 $183.50 43248 EAP CPT® 43248 PR EGD INSERT GUIDE WIRE DILATOR PASSAGE ESOPHAGUS OP $759.00 $0.00 $0.00 $404.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $404.90 $172.07 $127.39 $172.07 43249 EAP CPT® 43249 PR EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM OP $830.00 $0.00 $0.00 $374.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $374.33 $158.98 $117.03 $158.98 43250 EAP CPT® 43250 PR EGD FLEX REMOVAL LESION(S) BY HOT BIOPSY FORCEPS OP $945.00 $0.00 $0.00 $413.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.37 $173.89 $129.58 $173.89 43251 EAP CPT® 43251 PR EGD REMOVAL TUMOR POLYP/OTHER LESION SNARE TECH OP $612.00 $0.00 $0.00 $475.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $475.46 $199.65 $149.64 $199.65 43255 EAP CPT® 43255 PR EGD TRANSORAL CONTROL BLEEDING ANY METHOD OP $626.00 $0.00 $0.00 $486.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $486.00 $258.17 $177.42 $258.17 43259 EAP CPT® 43259 PR EDG US EXAM SURGICAL ALTER STOM DUODENUM/JEJUNUM OP $759.00 $0.00 $0.00 $546.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.29 $276.10 $180.43 $276.10 43260 EAP CPT® 43260 PR ERCP DX COLLECTION SPECIMEN BRUSHING/WASHING OP "$1,059.00 " $0.00 $0.00 $773.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $773.52 $317.34 $233.29 $317.34 43262 EAP CPT® 43262 PR ERCP W/SPHINCTEROTOMY/PAPILLOTOMY OP "$1,660.00 " $0.00 $0.00 $856.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $856.20 $391.84 $298.41 $391.84 43264 EAP CPT® 43264 PR ERCP REMOVE CALCULI/DEBRIS BILIARY/PANCREAS DUCT OP "$1,135.00 " $0.00 $0.00 $872.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $872.30 $470.60 $348.50 $470.60 43270 EAP CPT® 43270 PR EGD ABLATE TUMOR POLYP/LESION W/DILATION& WIRE OP $701.00 $0.00 $0.00 $561.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $561.47 $0.00 $439.15 $0.00 43273 EAP CPT® 43273 PR ENDOSCOPIC PAPILLA CANNULATION BILE/PANCREATIC OP $375.00 $0.00 $0.00 $281.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $281.84 $0.00 $74.56 $0.00 43274 EAP CPT® 43274 PR ERCP STENT PLACEMENT BILIARY/PANCREATIC DUCT OP "$1,445.00 " $0.00 $0.00 "$1,105.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,105.14" $0.00 $294.95 $0.00 43275 EAP CPT® 43275 PR ERCP REMOVE FOREIGN BODY/STENT BILIARY/PANC DUCT OP "$1,175.00 " $0.00 $0.00 $901.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $901.97 $0.00 $243.22 $0.00 43276 EAP CPT® 43276 PR ERCP BILIARY/PANC DUCT STENT EXCHANGE W/DIL&WIRE OP "$1,504.00 " $0.00 $0.00 "$1,150.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,150.89" $0.00 $306.83 $0.00 43277 EAP CPT® 43277 PR ERCP BALLOON DILATE BILIARY/PANC DUCT/AMPULLA EA OP "$1,181.00 " $0.00 $0.00 $906.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $906.80 $0.00 $244.71 $0.00 43280 EAP CPT® 43280 "PR LAP,ESOPHAGOGAST FUNDOPLASTY" OP "$6,794.00 " $0.00 $0.00 "$2,513.55" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,513.55" $975.75 $656.46 $975.75 43282 EAP CPT® 43282 "PR LAP, REPAIR PARAESOPHAGEAL HERNIA, INCL FUNDOPLASTY W/ MESH" OP "$5,475.00 " $0.00 $0.00 "$4,037.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,037.03" $0.00 $803.04 $0.00 43288 EAP CPT® 43288 PR ESOPHAGECTOMY TOTAL NEAR TOTAL W/THRSC MOBLJ OP "$11,876.00 " $0.00 $0.00 "$8,694.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$8,694.90" $0.00 "$2,333.73" $0.00 43410 EAP CPT® 43410 "PR SUTURE ESOPHAGUS WOUND,CERV APPRCH" OP "$3,177.00 " $0.00 $0.00 "$2,446.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,446.46" $914.34 $473.82 $914.34 43450 EAP CPT® 43450 PR DILATE ESOPHAGUS OP $263.00 $0.00 $0.00 $199.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.34 $149.39 $54.63 $149.39 43611 EAP CPT® 43611 PR EXCIS STOAMCH MALIG OP "$3,853.00 " $0.00 $0.00 "$2,840.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,840.27" "$1,074.35" $499.88 "$1,074.35" 43631 EAP CPT® 43631 "PR REMV STOMACH,PART,DISTAL,GASTRODUOD" OP "$4,575.00 " $0.00 $0.00 "$3,366.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,366.54" "$1,295.31" $720.97 "$1,295.31" 43653 EAP CPT® 43653 "PR LAP,GASTROSTOMY,W/O TUBE CONSTR" OP "$1,963.00 " $0.00 $0.00 "$1,329.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,329.66" $486.12 $308.69 $486.12 43752 EAP CPT® 43752 PR PLACEMENT NG/OG TUBE BY PHYSICIAN OP $207.00 $0.00 $0.00 $94.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.82 $38.82 $0.00 $38.82 43761 EAP CPT® 43761 REPOSITION GASTRIC FEEDING TUBE THRU DUODENUM OP $344.00 $0.00 $0.00 $238.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $238.61 $116.68 $65.45 $116.68 43762 EAP CPT® 43762 PR PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC OP $119.00 $0.00 $0.00 $87.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.41 $0.00 $119.00 $0.00 43820 EAP CPT® 43820 PR GASTROJEJUNOSTOMY OP "$4,237.00 " $0.00 $0.00 "$3,114.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,114.60" "$1,115.30" $447.50 "$1,115.30" 43830 EAP CPT® 43830 "PR GASTROSTOMY,OPEN,W/O TUBE CNSTR" OP "$2,210.00 " $0.00 $0.00 "$1,624.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,624.16" $603.92 $296.25 $603.92 43840 EAP CPT® 43840 PR REPAIR PERF DUOD/GAST ULC-WND/INJ OP "$4,290.00 " $0.00 $0.00 "$3,155.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,155.48" "$1,137.28" $446.02 "$1,137.28" 43870 EAP CPT® 43870 "PR CLOSURE OF GASTROSTOMY,SURGICAL" OP "$2,236.00 " $0.00 $0.00 "$1,652.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,652.46" $615.81 $295.02 $615.81 43999 EAP CPT® 43999 PR STOMACH SURGERY PROCEDURE UNLISTED OP "$1,500.00 " $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 44005 EAP CPT® 44005 "PR FREEING BOWEL ADHESION,ENTEROLYSIS" OP "$3,445.00 " $0.00 $0.00 "$2,540.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,540.13" $969.16 $505.51 $969.16 44015 EAP CPT® 44015 "PR INSERT TUBE-BOWEL,ENTERAL ALIMENT" OP "$1,243.00 " $0.00 $0.00 $331.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.04 $135.11 $108.33 $135.11 44120 EAP CPT® 44120 "PR RESECT SMALL INTEST,SINGL RESEC/ANAS" OP "$3,853.00 " $0.00 $0.00 "$2,841.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,841.71" "$1,071.99" $537.97 "$1,071.99" 44121 EAP CPT® 44121 "PR RESECT SMALL INTEST,EACH ADDNL" OP "$1,261.00 " $0.00 $0.00 $563.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $563.90 $229.06 $153.30 $229.06 44130 EAP CPT® 44130 PR BOWEL TO BOWEL ANASTOMOSIS OP "$4,140.00 " $0.00 $0.00 "$3,049.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,049.79" "$1,088.64" $468.32 "$1,088.64" 44139 EAP CPT® 44139 PR MOBILIZE SPLENIC FLEX OP $381.00 $0.00 $0.00 $282.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $282.41 $114.63 $76.99 $114.63 44140 EAP CPT® 44140 PR PART REMOVAL COLON W ANASTOMOSIS OP "$4,225.00 " $0.00 $0.00 "$3,116.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,116.15" "$1,199.50" $674.02 "$1,199.50" 44141 EAP CPT® 44141 PR PART REMOVAL COLON W COLOSTOMY OP "$5,736.00 " $0.00 $0.00 "$4,244.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,244.00" "$1,527.82" $743.30 "$1,527.82" 44143 EAP CPT® 44143 PR PART REMOVAL COLON W END COLOSTOMY OP "$5,235.00 " $0.00 $0.00 "$3,869.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,869.15" "$1,471.20" $767.24 "$1,471.20" 44145 EAP CPT® 44145 PR PART REMOVAL COLON W COLOPROCTOSTOMY OP "$5,198.00 " $0.00 $0.00 "$3,853.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,853.49" "$1,504.41" $837.10 "$1,504.41" 44150 EAP CPT® 44150 PR REMOVAL COLON/ILEOSTOMY OP "$5,857.00 " $0.00 $0.00 "$4,347.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,347.51" "$1,613.46" $830.24 "$1,613.46" 44160 EAP CPT® 44160 PR REMVL COLON & TERM ILEUM W/ILEOCOLOSTOMY OP "$6,255.00 " $0.00 $0.00 "$2,885.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,885.09" "$1,098.89" $617.84 "$1,098.89" 44180 EAP CPT® 44180 "PR LAP, SURG ENTEROLYSIS" OP "$2,897.00 " $0.00 $0.00 "$2,133.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,133.32" $824.02 $496.39 $824.02 44188 EAP CPT® 44188 "PR LAP, SURG COLOSTOMY" OP "$3,833.00 " $0.00 $0.00 "$2,849.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,849.45" "$1,079.37" $634.48 "$1,079.37" 44202 EAP CPT® 44202 "PR LAP,SURG,ENTERECTOMY,RESECT & ANAST" OP "$4,363.00 " $0.00 $0.00 "$3,223.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,223.31" "$1,242.00" $800.12 "$1,242.00" 44204 EAP CPT® 44204 "PR LAP,SURG,COLECTOMY, PARTIAL, W/ANAST" OP "$4,834.00 " $0.00 $0.00 "$3,575.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,575.97" "$1,392.72" $906.06 "$1,392.72" 44205 EAP CPT® 44205 "PR LAP,SURG,COLECTOMY,W/REMVL TERM ILEUM" OP "$4,199.00 " $0.00 $0.00 "$3,110.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,110.16" "$1,218.00" $802.47 "$1,218.00" 44207 EAP CPT® 44207 "PR LAP,SURG,COLECTOMY,W/ANAST" OP "$5,699.00 " $0.00 $0.00 "$4,232.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,232.73" "$1,660.06" $975.87 "$1,660.06" 44213 EAP CPT® 44213 "PR LAP, SURG MOBIL SPLENIC FL DUR PTL COLECTOMY" OP $587.00 $0.00 $0.00 $437.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $437.87 $180.68 $113.37 $180.68 44300 EAP CPT® 44300 PLACEMENT ENTEROSTOMY/CECOSTOMY TUBE OPEN OP "$2,654.00 " $0.00 $0.00 "$1,955.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,955.48" $739.84 $348.34 $739.84 44320 EAP CPT® 44320 PR COLOSTOMY OP "$3,775.00 " $0.00 $0.00 "$2,790.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,790.54" "$1,056.65" $514.29 "$1,056.65" 44360 EAP CPT® 44360 PR ENDOSCOPY UPPER SMALL INTESTINE OP $999.00 $0.00 $0.00 $351.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.12 $142.88 $117.91 $142.88 44366 EAP CPT® 44366 PR ENTEROSCOPY > 2ND PRTN W/CONTROL BLEEDING OP "$1,427.00 " $0.00 $0.00 $579.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $579.98 $237.03 $200.56 $237.03 44372 EAP CPT® 44372 PR ENTEROSCOPY > 2ND PRTN W/PLMT PRQ TUBE OP $999.00 $0.00 $0.00 $578.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $578.87 $235.76 $201.19 $235.76 44378 EAP CPT® 44378 PR ENTEROSCOPY > 2ND PRTN ILEUM CONTROL BLEEDING OP "$1,676.00 " $0.00 $0.00 $921.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $921.27 $377.64 $272.79 $377.64 44384 EAP CPT® 44384 PR ILEOSCOPY STOMA W/PLMT OF ENDOSCOPIC STENT OP $480.00 $0.00 $0.00 $368.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $368.69 $0.00 $0.00 $0.00 44388 EAP CPT® 44388 PR COLONOSCOPY STOMA DX INCLUDING COLLJ SPEC SPX OP "$1,070.00 " $0.00 $0.00 $380.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.39 $304.61 $163.88 $304.61 44389 EAP CPT® 44389 PR COLONOSCOPY STOMA W/BIOPSY SINGLE/MULTIPLE OP "$1,248.00 " $0.00 $0.00 $417.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $417.50 $366.94 $180.29 $366.94 44392 EAP CPT® 44392 PR COLONOSCOPY STOMA RMVL LES BY HOT BIOPSY FORCEPS OP "$1,462.00 " $0.00 $0.00 $479.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.94 $395.21 $214.76 $395.21 44394 EAP CPT® 44394 PR COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNARE OP "$1,462.00 " $0.00 $0.00 $545.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $545.07 $461.90 $236.08 $461.90 44602 EAP CPT® 44602 "PR SUTURE SM INTEST,SINGLE PERF" OP "$4,444.00 " $0.00 $0.00 "$3,281.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,281.04" "$1,193.36" $407.09 "$1,193.36" 44603 EAP CPT® 44603 "PR SUTURE SM INTEST,MULTPL PERF" OP "$5,099.00 " $0.00 $0.00 "$3,762.84" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,762.84" "$1,360.61" $519.74 "$1,360.61" 44604 EAP CPT® 44604 PR SUTURE LRG INTEST OP "$3,329.00 " $0.00 $0.00 "$2,456.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,456.09" $944.98 $512.16 $944.98 44605 EAP CPT® 44605 PR SUTURE LRG INTEST W COLOSTOMY OP "$4,102.00 " $0.00 $0.00 "$3,033.05" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,033.05" "$1,168.52" $565.14 "$1,168.52" 44620 EAP CPT® 44620 PR CLOSE ENTEROSTOMY OP "$2,721.00 " $0.00 $0.00 "$2,017.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,017.34" $757.37 $393.20 $757.37 44625 EAP CPT® 44625 "PR CLOSE ENTEROSTOMY,RESEC+ANAST" OP "$3,178.00 " $0.00 $0.00 "$2,362.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,362.89" $903.00 $508.53 $903.00 44626 EAP CPT® 44626 "PR CLOSE ENTEROSTOMY,RESEC+COLOREC ANAS" OP "$5,032.00 " $0.00 $0.00 "$3,726.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,726.50" "$1,448.52" $788.46 "$1,448.52" 44650 EAP CPT® 44650 PR REPAIR BOWEL-BOWEL FISTULA OP "$4,549.00 " $0.00 $0.00 "$3,369.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,369.41" "$1,307.41" $536.49 "$1,307.41" 44700 EAP CPT® 44700 "PR EXCLUSION,SMALL BOWEL FROM PELVIS" OP "$3,143.00 " $0.00 $0.00 "$2,370.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,370.29" $920.16 $557.24 $920.16 44850 EAP CPT® 44850 PR SUTURE OF MESENTERY OP "$2,345.00 " $0.00 $0.00 "$1,745.31" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,745.31" $656.94 $353.18 $656.94 44955 EAP CPT® 44955 "PR APPENDECTOMY,W OTHR PROC" OP "$1,029.00 " $0.00 $0.00 $195.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.24 $79.77 $63.20 $79.77 44970 EAP CPT® 44970 "PR LAP,APPENDECTOMY" OP "$1,900.00 " $0.00 $0.00 "$1,395.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,395.38" $520.36 $315.06 $520.36 45100 EAP CPT® 45100 PR BIOPSY OF RECTUM OP $935.00 $0.00 $0.00 $693.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $693.99 $246.06 $161.79 $246.06 45300 EAP CPT® 45300 "PR PROCTOSIGMOIDOSCOPY,RIGID,DIAGNOS" OP $149.00 $0.00 $0.00 $125.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.33 $74.43 $38.28 $74.43 45305 EAP CPT® 45305 PR PROCTOSGMDSC RIGID W/BX SINGLE/MULTIPLE OP $227.00 $0.00 $0.00 $182.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $182.94 $141.38 $51.25 $141.38 45330 EAP CPT® 45330 PR SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD OP $228.00 $0.00 $0.00 $131.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.03 $121.99 $52.46 $121.99 45331 EAP CPT® 45331 "PR SIGMOIDOSCOPY,BIOPSY" OP $531.00 $0.00 $0.00 $168.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.81 $157.63 $71.53 $157.63 45334 EAP CPT® 45334 PR SIGMOIDOSCOPY FLX CONTROL BLEEDING OP $623.00 $0.00 $0.00 $290.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.03 $149.47 $114.02 $149.47 45335 EAP CPT® 45335 PR SGMDSC FLX DIRED SBMCSL NJX ANY SBST OP $699.00 $0.00 $0.00 $192.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.77 $192.44 $88.49 $192.44 45338 EAP CPT® 45338 PR SGMDSC FLX RMVL TUM POLYP/OTH LES SNARE TQ OP $720.00 $0.00 $0.00 $295.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.58 $286.03 $126.88 $286.03 45340 EAP CPT® 45340 PR SIGMOIDOSCOPY FLX TNDSC BALO DILAT OP $242.00 $0.00 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $195.20 $242.00 $0.00 $242.00 45349 EAP CPT® 45349 PR SGMDSC FLX WITH ENDOSCOPIC MUCOSAL RESECTION OP $620.00 $0.00 $0.00 $479.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $479.24 $0.00 $0.00 $0.00 45378 EAP CPT® 45378 PR COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD OP $862.00 $0.00 $0.00 $448.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.02 $368.36 $203.67 $368.36 45379 EAP CPT® 45379 PR COLONOSCOPY FLX W/REMOVAL OF FOREIGN BODY(S) OP $884.00 $0.00 $0.00 $576.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $576.50 $464.40 $247.98 $464.40 45380 EAP CPT® 45380 PR COLONOSCOPY W/BIOPSY SINGLE/MULTIPLE OP "$1,070.00 " $0.00 $0.00 $485.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $485.90 $437.54 $220.97 $437.54 45381 EAP CPT® 45381 PR COLSC FLX WITH DIRECTED SUBMUCOSAL NJX ANY SBST OP "$2,829.00 " $0.00 $0.00 $485.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $485.96 $425.07 $238.33 $425.07 45382 EAP CPT® 45382 PR COLSC FLEXIBLE W/CONTROL BLEEDING ANY METHOD OP "$1,010.00 " $0.00 $0.00 $624.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $624.87 $583.57 $287.26 $583.57 45384 EAP CPT® 45384 PR COLSC FLX W/REMOVAL LESION BY HOT BX FORCEPS OP "$1,073.00 " $0.00 $0.00 $550.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $550.58 $432.27 $248.03 $432.27 45385 EAP CPT® 45385 PR COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ OP "$1,073.00 " $0.00 $0.00 $613.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $613.53 $493.47 $282.15 $493.47 45388 EAP CPT® 45388 PR COLONOSCOPY FLX ABLATION TUMOR POLYP/OTHER LES OP "$1,126.52 " $0.00 $0.00 $651.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $651.06 $0.00 $0.00 $0.00 45390 EAP CPT® 45390 PR COLONOSCOPY FLX W/ENDOSCOPIC MUCOSAL RESECTION OP "$1,037.00 " $0.00 $0.00 $795.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $795.38 $0.00 $0.00 $0.00 45393 EAP CPT® 45393 PR COLONOSCOPY FLEXIBLE WITH DECOMPRESSION OP $791.00 $0.00 $0.00 $608.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $608.33 $0.00 $0.00 $0.00 45395 EAP CPT® 45395 "PR LAP, SURG PROCTECTOMY W COLOSTOMY" OP "$6,152.00 " $0.00 $0.00 "$4,597.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,597.52" "$1,780.30" "$1,055.31" "$1,780.30" 45562 EAP CPT® 45562 PR EXPLOR/REPAIR RECTUM INJURY OP "$3,539.00 " $0.00 $0.00 "$2,598.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,598.83" $961.28 $457.11 $961.28 45990 EAP CPT® 45990 "PR SURG DIAGNOSTIC EXAM, ANORECTAL" OP $332.00 $0.00 $0.00 $249.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.38 $98.64 $63.83 $98.64 46020 EAP CPT® 46020 "PR PLACEMENT,SETON" OP $737.00 $0.00 $0.00 $543.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $543.20 $208.35 $152.42 $208.35 46030 EAP CPT® 46030 PR REMOVAL OF RECTAL MARKER OP $280.00 $0.00 $0.00 $208.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.85 $103.08 $64.99 $103.08 46040 EAP CPT® 46040 PR I&D PERIRECTAL ABSCESS OP "$1,315.00 " $0.00 $0.00 $959.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $959.70 $417.89 $196.63 $417.89 46050 EAP CPT® 46050 "PR I&D PERIANAL ABSCESS,SUPERFICIAL" OP $375.00 $0.00 $0.00 $225.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.05 $146.55 $72.44 $146.55 46220 EAP CPT® 46220 PR REMOVAL OF ANAL TAB OP $444.00 $0.00 $0.00 $274.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $274.70 $151.82 $58.90 $151.82 46221 EAP CPT® 46221 PR LIGATION OF HEMORRHOID(S) OP $597.00 $0.00 $0.00 $440.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $440.07 $196.41 $74.93 $196.41 46250 EAP CPT® 46250 "PR HEMORRHOIDECTOMY,EXTERNAL" OP $994.00 $0.00 $0.00 $730.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $730.65 $363.95 $200.59 $363.95 46260 EAP CPT® 46260 "PR HEMORRHOIDECTOMY,INT/EXT,COMPLX" OP "$1,500.00 " $0.00 $0.00 "$1,101.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,101.26" $385.93 $298.78 $385.93 46270 EAP CPT® 46270 "PR REMOVAL ANAL FISTULA,SUBCUTANEOUS" OP "$1,236.00 " $0.00 $0.00 $907.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $907.76 $380.92 $165.09 $380.92 46280 EAP CPT® 46280 "PR REMOVAL ANAL FISTULA,COMPLEX/MULTI" OP "$1,483.00 " $0.00 $0.00 "$1,086.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,086.24" $373.73 $257.50 $373.73 46288 EAP CPT® 46288 "PR REPAIR ANAL FISTULA,RECT ADV FLAP" OP "$1,724.00 " $0.00 $0.00 "$1,273.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,273.77" $443.27 $260.21 $443.27 46505 EAP CPT® 46505 PR CHEMODENERVATION ANAL SPHINCTER OP $764.00 $0.00 $0.00 $552.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $552.84 $230.03 $136.01 $230.03 46600 EAP CPT® 46600 PR ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD OP $174.00 $0.00 $0.00 $94.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.86 $75.46 $23.41 $75.46 46601 EAP CPT® 46601 PR ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT OP $293.00 $0.00 $0.00 $217.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $217.35 $0.00 $0.00 $0.00 46606 EAP CPT® 46606 PR ANOSCOPY AND BIOPSY OP $235.00 $0.00 $0.00 $176.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.64 $171.31 $33.01 $171.31 46607 EAP CPT® 46607 PR ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT W/BX OP $395.00 $0.00 $0.00 $292.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.77 $0.00 $0.00 $0.00 46612 EAP CPT® 46612 "PR ANOSCOPY,REMOVE LESIONS" OP $459.00 $0.00 $0.00 $282.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.39 $282.59 $98.26 $282.59 46900 EAP CPT® 46900 "PR DESTRUCT,ANAL LESN(S),SIMPLE,CHEM" OP $424.00 $0.00 $0.00 $317.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $317.64 $177.67 $86.26 $177.67 46910 EAP CPT® 46910 "PR ELECTRODESSICATN,ANAL LESN(S)" OP $415.00 $0.00 $0.00 $310.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.05 $188.44 $90.57 $188.44 46916 EAP CPT® 46916 "PR CRYOSURGERY, ANAL LESION(S)" OP $439.00 $0.00 $0.00 $331.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $331.50 $191.82 $86.86 $191.82 46922 EAP CPT® 46922 PR SURG EXCISION OF ANAL LESION(S) OP $502.00 $0.00 $0.00 $313.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.14 $201.45 $99.27 $201.45 46924 EAP CPT® 46924 "PR DESTRUCTION,ANAL LESION(S),EXTENSIVE" OP "$2,401.00 " $0.00 $0.00 $433.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $424.86 $433.70 $149.11 $433.70 46945 EAP CPT® 46945 PR INT HRHC BY LIGATION SINGLE HROID W/O IMG GDN OP "$1,041.00 " $0.00 $0.00 $522.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $522.47 $215.90 $99.74 $215.90 46946 EAP CPT® 46946 PR INT HRHC BY LIGATION 2+ HROID W/O IMG GDN OP "$1,174.00 " $0.00 $0.00 $521.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $521.24 $246.07 $135.20 $246.07 46948 EAP CPT® 46948 PR INT HRHC TRANSANAL HROID DARTLZJ 2+ W/US GDN OP "$1,374.00 " $0.00 $0.00 "$1,021.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,021.35" $0.00 $271.43 $0.00 47000 EAP CPT® 47000 PR BIOPSY LIVER NEEDLE PERCUTANEOUS OP $456.00 $0.00 $0.00 $239.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $239.66 $222.58 $145.84 $222.58 47015 EAP CPT® 47015 PR INJECT/ASPIRATE LIVER CYST/ABSCESS OP "$3,674.00 " $0.00 $0.00 "$2,659.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,659.32" $991.02 $377.29 $991.02 47350 EAP CPT® 47350 PR REPAIR BLEED LIVER/SUTURE WOUND OP "$4,313.00 " $0.00 $0.00 "$3,180.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,180.71" "$1,205.02" $470.65 "$1,205.02" 47360 EAP CPT® 47360 PR REPR BLEED LIVER/COMPLX SUTURE WND OP "$5,926.00 " $0.00 $0.00 "$4,318.40" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,318.40" "$1,642.02" $651.77 "$1,642.02" 47361 EAP CPT® 47361 "PR EXPLOR LIVER WOUND,EXTENSIV DEBRIDE" OP "$9,553.00 " $0.00 $0.00 "$7,019.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,019.58" "$2,721.55" "$1,061.54" "$2,721.55" 47362 EAP CPT® 47362 "PR RE-EXPLORE LIVER WOUND,REMV PACKING" OP "$4,578.00 " $0.00 $0.00 "$3,365.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,365.72" "$1,239.59" $423.48 "$1,239.59" 47531 EAP CPT® 47531 PR NJX CHOLANGIO PRQ W/IMG GID RS&I EXISTING ACCESS OP $221.00 $0.00 $0.00 $221.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.00 $0.00 $221.00 $0.00 47534 EAP CPT® 47534 PR PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I INT-EXT OP "$1,165.00 " $0.00 $0.00 $945.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $945.81 $0.00 $997.21 $0.00 47536 EAP CPT® 47536 PR EXCHANGE BILIARY DRG CATHETER PRQ W/IMG GID RS&I OP $415.00 $0.00 $0.00 $344.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $344.06 $0.00 $415.00 $0.00 47542 EAP CPT® 47542 PR BALLOON DILAT BILIARY DUCT/AMPULLA PRQ EACH DUCT OP $428.00 $0.00 $0.00 $310.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.19 $0.00 $312.38 $0.00 47543 EAP CPT® 47543 PR ENDOLUMINAL BX BILIARY TREE PRQ ANY METH 1/MLT OP $455.00 $0.00 $0.00 $390.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $390.21 $0.00 $455.00 $0.00 47562 EAP CPT® 47562 "PR LAP,CHOLECYSTECTOMY" OP "$2,964.00 " $0.00 $0.00 "$1,526.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,526.54" $646.61 $417.96 $646.61 47563 EAP CPT® 47563 "PR LAP,CHOLECYSTECTOMY/GRAPH" OP "$3,162.00 " $0.00 $0.00 "$1,658.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,658.48" $671.23 $449.60 $671.23 47564 EAP CPT® 47564 "PR LAP,CHOLECYSTECTOMY/EXPLORE" OP "$3,513.00 " $0.00 $0.00 "$2,584.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,584.79" $780.05 $533.76 $780.05 47600 EAP CPT® 47600 PR REMOVAL GALLBLADDER OP "$3,371.00 " $0.00 $0.00 "$2,478.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,478.12" $910.71 $433.59 $910.71 48000 EAP CPT® 48000 PR PLACE DRAIN ABD FOR PANCREATITIS OP "$5,951.00 " $0.00 $0.00 "$4,344.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,344.06" "$1,661.60" $525.36 "$1,661.60" 48140 EAP CPT® 48140 "PR PART REMV PANCREAS,DISTAL SUBTOTAL" OP "$4,929.00 " $0.00 $0.00 "$3,629.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,629.03" "$1,378.61" $771.72 "$1,378.61" 48150 EAP CPT® 48150 "PR PART REMV PANC,PROX+REMV DUOD+ANAST" OP "$9,830.00 " $0.00 $0.00 "$7,228.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,228.58" "$2,779.88" "$1,546.87" "$2,779.88" 49000 EAP CPT® 49000 PR EXPLORATORY OF ABDOMEN OP "$2,420.00 " $0.00 $0.00 "$1,789.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,789.41" $687.40 $430.51 $687.40 49002 EAP CPT® 49002 PR REOPEN RECENT ABD EXPLORATORY OP "$3,292.00 " $0.00 $0.00 "$2,428.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,428.37" $866.87 $391.50 $866.87 49010 EAP CPT® 49010 PR EXPLORATORY RETROPERITONEAL OP "$2,908.00 " $0.00 $0.00 "$2,167.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,167.71" $838.16 $456.69 $838.16 49013 EAP CPT® 49013 PR PREPERITONEAL PEL PACK F/HEMRRG ASSOC PEL TRMA OP "$1,375.00 " $0.00 $0.00 "$1,018.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,018.53" $0.00 $271.54 $0.00 49020 EAP CPT® 49020 PR DRAIN ABD ABSCESS OPEN OP "$5,014.00 " $0.00 $0.00 "$3,694.61" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,694.61" "$1,404.93" $544.99 "$1,404.93" 49082 EAP CPT® 49082 PR ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE OP $365.00 $0.00 $0.00 $172.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.77 $0.00 $98.20 $0.00 49083 EAP CPT® 49083 PR ABDOM PARACENTESIS DX/THER W IMAGING GUIDANCE OP $336.00 $0.00 $0.00 $253.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.32 $0.00 $185.31 $0.00 49084 EAP CPT® 49084 PR PERITONEAL LAVAGE W/WO IMAGING GUIDANCE OP $342.00 $0.00 $0.00 $252.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.08 $0.00 $58.39 $0.00 49180 EAP CPT® 49180 "PR PERCUT BIOPSY, ABDOMINAL MASS" OP $623.00 $0.00 $0.00 $199.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.34 $170.97 $127.56 $170.97 49203 EAP CPT® 49203 PR EXCISION/DESTRUCTION OPEN ABDOMINAL TUMORS 5 CM OP "$3,751.00 " $0.00 $0.00 "$2,778.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,778.71" $0.00 $562.03 $0.00 49255 EAP CPT® 49255 PR REMOVAL OF OMENTUM OP "$2,472.00 " $0.00 $0.00 "$1,835.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,835.25" $693.67 $398.05 $693.67 49320 EAP CPT® 49320 "PR LAP,DIAGNOSTIC ABDOMEN" OP "$1,418.00 " $0.00 $0.00 $754.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $754.55 $297.16 $207.81 $297.16 49322 EAP CPT® 49322 "PR LAP,ABDOMEN,ASPIRATE CYST" OP "$1,609.00 " $0.00 $0.00 $852.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $852.47 $341.41 $230.06 $341.41 49324 EAP CPT® 49324 PR LAP INSERTION TUNNELED INTRAPERITONEAL CATHETER OP "$1,226.00 " $0.00 $0.00 $905.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $905.96 $349.50 $0.00 $349.50 49326 EAP CPT® 49326 PR LAP OMENTOPEXY ADD-ON OP $597.00 $0.00 $0.00 $440.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $440.55 $172.63 $0.00 $172.63 49402 EAP CPT® 49402 PR REMOVE PERITONEAL FOREIGN BODY OP "$2,696.00 " $0.00 $0.00 "$1,987.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,987.53" $753.19 $432.33 $753.19 49405 EAP CPT® 49405 PR IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ OP $618.00 $0.00 $0.00 $493.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.55 $0.00 $529.06 $0.00 49406 EAP CPT® 49406 PR IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ OP $617.00 $0.00 $0.00 $493.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $493.55 $0.00 $528.84 $0.00 49422 EAP CPT® 49422 PR REMOVAL TUNNELED INTRAPERITONEAL CATHETER OP "$1,149.00 " $0.00 $0.00 $883.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $883.40 $352.93 $233.52 $352.93 49423 EAP CPT® 49423 PR DRAINAGE CATHETER EXCHANGE OP "$1,801.00 " $0.00 $0.00 $555.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.97 $555.36 $52.90 $555.36 49424 EAP CPT® 49424 "PR CONTRAST INJ,ABSCESS/CYST VIA CATH TUBE" OP $498.00 $0.00 $0.00 $156.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.22 $156.80 $27.03 $156.80 49428 EAP CPT® 49428 PR LIGATION OF ABD-VENOUS SHUNT OP "$1,360.00 " $0.00 $0.00 "$1,001.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,001.78" $403.68 $92.02 $403.68 49440 EAP CPT® 49440 PR INSERT GASTROSTOMY TUBE PERCUTANEOUS OP $807.00 $0.00 $0.00 $516.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $516.90 $0.00 $0.00 $0.00 49441 EAP CPT® 49441 PR INSERT DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ OP $756.00 $0.00 $0.00 $598.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $598.25 $0.00 $730.57 $0.00 49446 EAP CPT® 49446 PR CONVERT GASTROSTOMY-GASTRO-JEJUNOSTOMY TUBE PERQ OP $574.00 $0.00 $0.00 $379.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.31 $0.00 $574.00 $0.00 49450 EAP CPT® 49450 PR REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS OP $207.00 $0.00 $0.00 $156.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $156.68 $0.00 $207.00 $0.00 49452 EAP CPT® 49452 PR REPLACEMENT GASTRO-JEJUNOSTOMY TUBE PERCUTANEOUS OP "$2,572.00 " $0.00 $0.00 $326.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.31 $0.00 $553.80 $0.00 49465 EAP CPT® 49465 PR CONTRAST INJECTION PERCUTANEOUOS RADIOLOGIC EVAL GI TUBE OP $96.00 $0.00 $0.00 $72.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.36 $0.00 $94.35 $0.00 49505 EAP CPT® 49505 "PR REPAIR ING HERNIA,5+Y/O,REDUCIBL" OP "$1,640.00 " $0.00 $0.00 "$1,207.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,207.52" $452.36 $254.67 $452.36 49507 EAP CPT® 49507 "PR REPAIR ING HERNIA,5+Y/O,STRANG" OP "$1,855.00 " $0.00 $0.00 "$1,357.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,357.11" $559.48 $317.72 $559.48 49520 EAP CPT® 49520 "PR REPAIR RECURR INGUIN HERN,REDUCIBL" OP "$1,990.00 " $0.00 $0.00 "$1,465.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,465.76" $555.93 $314.98 $555.93 49521 EAP CPT® 49521 "PR REPAIR RECURR INGUIN HERN,STRANG" OP "$2,259.00 " $0.00 $0.00 "$1,660.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,660.95" $681.28 $363.87 $681.28 49525 EAP CPT® 49525 PR REPAIR SLIDING INGUINAL HERNIA OP "$1,807.00 " $0.00 $0.00 "$1,328.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,328.27" $501.42 $291.91 $501.42 49540 EAP CPT® 49540 PR REPAIR LUMBAR HERNIA OP "$2,124.00 " $0.00 $0.00 "$1,556.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,556.39" $596.76 $333.75 $596.76 49550 EAP CPT® 49550 "PR REPAIR FEMORAL HERNIA,REDUCIBLE" OP "$1,819.00 " $0.00 $0.00 "$1,333.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,333.82" $504.81 $277.96 $504.81 49553 EAP CPT® 49553 "PR REPAIR FEMORAL HERNIA,STRANG" OP "$2,102.00 " $0.00 $0.00 "$1,463.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,463.45" $551.94 $298.29 $551.94 49560 EAP CPT® 49560 "PR REPAIR INCISIONAL HERNIA,REDUCIBLE" OP "$2,425.00 " $0.00 $0.00 "$1,710.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,710.68" $656.75 $366.38 $656.75 49561 EAP CPT® 49561 "PR REPAIR INCISIONAL HERNIA,STRANG" OP "$2,930.00 " $0.00 $0.00 "$2,157.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,157.66" $825.64 $426.73 $825.64 49565 EAP CPT® 49565 "PR REPAIR RECURR INCIS HERNIA,REDUC" OP "$2,789.00 " $0.00 $0.00 "$1,781.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,781.30" $676.70 $376.71 $676.70 49568 EAP CPT® 49568 PR IMPLANT MESH HERNIA REPAIR/DEBRIDEMENT CLOSURE OP $844.00 $0.00 $0.00 $621.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $621.42 $251.95 $168.88 $251.95 49585 EAP CPT® 49585 "REPAIR UMBILICAL HERN,5+Y/O,REDUC" OP "$1,819.00 " $0.00 $0.00 "$1,030.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,030.79" $381.18 $221.93 $381.18 49587 EAP CPT® 49587 "REPAIR UMBILICAL HERN,5+Y/O,STRANG" OP "$2,102.00 " $0.00 $0.00 "$1,102.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,102.80" $453.54 $250.43 $453.54 49650 EAP CPT® 49650 "PR LAP,INGUINAL HERNIA REPR,INITIAL" OP "$1,940.00 " $0.00 $0.00 $993.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $993.08 $372.62 $242.05 $372.62 49652 EAP CPT® 49652 "PR LAP, VENTRAL HERNIA REPAIR,REDUCIBLE" OP "$2,346.00 " $0.00 $0.00 "$1,726.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,726.71" $0.00 $422.96 $0.00 49653 EAP CPT® 49653 "PR LAP, VENTRAL HERNIA REPAIR,INCARCERATED" OP "$2,929.00 " $0.00 $0.00 "$2,153.43" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,153.43" $0.00 $528.11 $0.00 49654 EAP CPT® 49654 "PR LAP, INCISIONAL HERNIA REPAIR,REDUCIBLE" OP "$2,664.00 " $0.00 $0.00 "$1,961.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,961.81" $0.00 $485.50 $0.00 49905 EAP CPT® 49905 "PR OMENTAL FLAP,INTRA-ABDOMINAL" OP "$1,617.00 " $0.00 $0.00 $821.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $821.10 $336.24 $226.37 $336.24 49999 EAP CPT® 49999 PR ABDOMEN SURGERY PROC UNLISTED OP "$1,000.00 " $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 50045 EAP CPT® 50045 PR EXPLORATION OF KIDNEY OP "$3,409.00 " $0.00 $0.00 "$2,222.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,222.39" $894.02 $568.20 $894.02 50080 EAP CPT® 50080 PR PERQ NL/PL LITHOTRP SIMPLE UP TO 2 CM 1 LOCATION OP "$3,674.00 " $0.00 $0.00 "$2,008.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,008.94" $842.71 $594.36 $842.71 50081 EAP CPT® 50081 PR PERQ NL/PL LITHOTRP COMPLEX >2 CM MLT LOCATIONS OP "$4,224.00 " $0.00 $0.00 "$2,948.78" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,948.78" "$1,236.44" $817.88 "$1,236.44" 50200 EAP CPT® 50200 PR RENAL BIOPSY PRQ TROCAR/NEEDLE OP $606.00 $0.00 $0.00 $330.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.41 $144.65 $101.12 $144.65 50220 EAP CPT® 50220 "PR REMV KIDNEY,W/RIB RESECTION" OP "$3,334.00 " $0.00 $0.00 "$2,418.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,418.99" $992.83 $658.17 $992.83 50230 EAP CPT® 50230 "PR REMV KIDNEY,RADICAL" OP "$4,167.00 " $0.00 $0.00 "$2,960.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,960.60" "$1,240.35" $848.42 "$1,240.35" 50240 EAP CPT® 50240 PR PARTIAL REMOVAL OF KIDNEY OP "$4,205.00 " $0.00 $0.00 "$3,058.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,058.65" "$1,272.40" $840.39 "$1,272.40" 50382 EAP CPT® 50382 PR RMVL & RPLCMT INTLY DWELLING URETERAL STENT PRQ OP $804.00 $0.00 $0.00 $804.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $630.03 $804.00 $804.00 $804.00 50384 EAP CPT® 50384 PR REMOVAL INDWELLING URETERAL STENT PRQ OP $719.00 $0.00 $0.00 $719.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $572.15 $719.00 $719.00 $719.00 50387 EAP CPT® 50387 PR RMVL & RPLCMT XTRNL ACCESSIBLE NEPHROURTRL CATH OP $263.00 $0.00 $0.00 $263.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $226.67 $263.00 $263.00 $263.00 50389 EAP CPT® 50389 PR REMOVE RENAL TUBE W/FLUORO OP $168.00 $0.00 $0.00 $168.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.17 $168.00 $168.00 $168.00 50390 EAP CPT® 50390 PR PERCUT DRAIN/INJECT RENAL CYST OP $436.00 $0.00 $0.00 $225.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.06 $96.44 $71.13 $96.44 50430 EAP CPT® 50430 PR NJX PX ANTEGRDE NFROSGRM &/URTRGRM NEW ACCESS OP $482.00 $0.00 $0.00 $389.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $389.19 $0.00 $315.27 $0.00 50431 EAP CPT® 50431 PR NJX PX ANTEGRDE NFROSGRM &/URTRGRM EXSTNG ACESS OP $203.00 $0.00 $0.00 $154.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.50 $0.00 $98.04 $0.00 50432 EAP CPT® 50432 PR PLMT NEPHROSTOMY CATH PRQ NEW ACCESS RS&I OP $645.00 $0.00 $0.00 $514.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $514.61 $0.00 $511.40 $0.00 50433 EAP CPT® 50433 PR PLMT NEPHROURETERAL CATH PRQ NEW ACCESS RS&I OP $801.00 $0.00 $0.00 $634.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $634.31 $0.00 $688.33 $0.00 50434 EAP CPT® 50434 PR CONVERT NEPHROSTOMY CATH TO NEPHROURTRL CATH PRQ OP $602.00 $0.00 $0.00 $486.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $486.42 $0.00 $544.70 $0.00 50435 EAP CPT® 50435 PR EXCHANGE NEPHROSTOMY CATHETER PRQ W/IMG GID RS&I OP $312.00 $0.00 $0.00 $236.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.49 $0.00 $285.94 $0.00 50436 EAP CPT® 50436 PR PERQ DILATION XST TRC ENDOUROLOGIC PX W/IMG OP $471.00 $0.00 $0.00 $351.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.35 $0.00 $93.74 $0.00 50500 EAP CPT® 50500 PR REPAIR OF KIDNEY WOUND OP "$3,884.00 " $0.00 $0.00 "$2,952.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,952.83" "$1,132.09" $735.46 "$1,132.09" 50543 EAP CPT® 50543 "PR LAP,PARTIAL NEPHRECTOMY" OP "$4,652.00 " $0.00 $0.00 "$3,435.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,435.63" "$1,440.37" $828.75 "$1,440.37" 50545 EAP CPT® 50545 "PR LAP, RADICAL NEPHRECTOMY" OP "$5,171.00 " $0.00 $0.00 "$3,096.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,096.02" "$1,311.47" $899.02 "$1,311.47" 50546 EAP CPT® 50546 PR NEPHRECTOMY OP "$3,762.00 " $0.00 $0.00 "$2,780.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,780.01" "$1,159.86" $660.67 "$1,159.86" 50600 EAP CPT® 50600 PR EXPLORATION OF URETER OP "$2,932.00 " $0.00 $0.00 "$2,179.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,179.01" $907.44 $574.97 $907.44 50693 EAP CPT® 50693 PR PLMT URTRL STENT PRQ PRE-EXISTING NFROS TRACT OP $640.00 $0.00 $0.00 $508.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $508.95 $0.00 $640.00 $0.00 50785 EAP CPT® 50785 "PR REIMPLANT URETER,VESICOPSOAS HITCH" OP "$3,791.00 " $0.00 $0.00 "$2,803.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,803.46" "$1,166.42" $774.35 "$1,166.42" 51040 EAP CPT® 51040 PR INCISE/DRAIN BLADDER OP "$3,867.00 " $0.00 $0.00 $667.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $667.64 $278.16 $203.21 $278.16 51050 EAP CPT® 51050 "PR OPEN BLADDER,REMV CALCULUS" OP "$4,640.00 " $0.00 $0.00 "$1,090.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,090.20" $446.61 $298.78 $446.61 51065 EAP CPT® 51065 "PR CYSTOTOMY,EXTRACT &/OR FRAG URETER CALC" OP "$5,413.00 " $0.00 $0.00 "$1,335.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,335.24" $549.13 $352.59 $549.13 51565 EAP CPT® 51565 "PR PART REMV BLADDER,REIMPLNT URETER" OP "$8,506.00 " $0.00 $0.00 "$3,003.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,003.98" "$1,249.28" $812.58 "$1,249.28" 51600 EAP CPT® 51600 PR INJECTION FOR BLADDER X-RAY OP $290.00 $0.00 $0.00 $209.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.83 $209.38 $175.26 $209.38 51610 EAP CPT® 51610 PR INJECT FOR RETROGRADE URETHOCYSTO OP $348.00 $0.00 $0.00 $148.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.86 $119.37 $188.59 $119.37 51700 EAP CPT® 51700 PR IRRIGATION OF BLADDER OP $155.00 $0.00 $0.00 $103.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.59 $91.13 $62.86 $91.13 51701 EAP CPT® 51701 "PR INSERT,NON-INDWELLING BLADDER CATHETER" OP $147.00 $0.00 $0.00 $72.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.28 $72.23 $36.05 $72.23 51702 EAP CPT® 51702 "PR INSERT,TEMP INDWELLING BLAD CATH,SIMPLE" OP $147.00 $0.00 $0.00 $90.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.93 $90.16 $57.05 $90.16 51703 EAP CPT® 51703 "PR INSERT,TEMP INDWELLING BLAD CATH,COMP" OP $241.00 $0.00 $0.00 $188.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.06 $151.54 $106.48 $151.54 51705 EAP CPT® 51705 "PR CHANGE OF BLADDER TUBE,SIMPLE" OP $329.00 $0.00 $0.00 $120.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.78 $120.08 $54.01 $120.08 51710 EAP CPT® 51710 "PR CHANGE OF BLADDER TUBE,COMPLICATED" OP "$1,025.00 " $0.00 $0.00 $184.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.92 $173.53 $91.13 $173.53 51720 EAP CPT® 51720 PR INSTILL ANTICANCER AGENT IN BLADDER OP "$1,005.00 " $0.00 $0.00 $184.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.82 $121.01 $92.38 $121.01 51729 EAP CPT® 51729 COMPLEX CYSTOMETROGRAM W/ VOIDING PRESSURE STUDIES OP $980.00 $0.00 $0.00 $775.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $775.89 $0.00 $147.43 $0.00 51741 EAP CPT® 51741 PR COMPLEX UROFLOWMETRY OP $217.00 $0.00 $0.00 $77.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.27 $77.70 $40.65 $77.70 51785 EAP CPT® 51785 "PR ANAL/URINARY MUSCLE STUDY,NEEDLE" OP "$1,085.00 " $0.00 $0.00 $603.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $603.03 $222.83 $59.20 $222.83 51797 EAP CPT® 51797 PR VOIDING PRESS STUDY INTRA-ABDOMINAL VOID OP $475.00 $0.00 $0.00 $265.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.17 $265.73 $61.13 $265.73 51798 EAP CPT® 51798 "PR MEAS,POST-VOID RES,US,NON-IMAGING" OP $35.00 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $17.12 $12.51 $17.12 51860 EAP CPT® 51860 "PR REPAIR BLADDER WOUND/INJ,SIMPLE" OP "$3,044.00 " $0.00 $0.00 "$1,722.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,722.23" $703.49 $455.81 $703.49 51865 EAP CPT® 51865 "PR REPAIR BLADDER WOUND/INJ,COMPLIC" OP "$3,913.00 " $0.00 $0.00 "$2,067.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,067.32" $860.88 $575.11 $860.88 51992 EAP CPT® 51992 "PR LAP,SLING OPERATION" OP "$3,348.00 " $0.00 $0.00 "$1,940.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,940.42" $803.41 $461.46 $803.41 52000 EAP CPT® 52000 PR CYSTOURETHROSCOPY OP $478.00 $0.00 $0.00 $291.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $291.75 $208.78 $95.49 $208.78 52001 EAP CPT® 52001 PR CYSTOURETHROSCOPY W/IRRIG & EVAC CLOTS OP $895.00 $0.00 $0.00 $665.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $665.13 $392.98 $88.69 $392.98 52005 EAP CPT® 52005 "PR CYSTOURETHROSCOPY,URETER CATHETER" OP $783.00 $0.00 $0.00 $307.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.79 $295.39 $133.59 $295.39 52007 EAP CPT® 52007 "PR CYSTOURETHROSCOPY,URETERAL BIOPSY" OP $870.00 $0.00 $0.00 $664.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $383.28 $664.53 $115.19 $664.53 52204 EAP CPT® 52204 "PR CYSTOURETHROSCOPY,BIOPSIES" OP $700.00 $0.00 $0.00 $572.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $327.84 $572.80 $143.91 $572.80 52214 EAP CPT® 52214 "PR CYSTOURETHROSCOPY,FULGURATN" OP $700.00 $0.00 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $407.93 $700.00 $184.23 $700.00 52224 EAP CPT® 52224 "PR CYSTOURETHROSCOPY,FULGUR <.5CM LESN" OP $737.00 $0.00 $0.00 $737.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.38 $737.00 $170.72 $737.00 52234 EAP CPT® 52234 "PR CYSTOURETHROSCOPY,FULGUR .5-2CM LESN" OP "$1,106.00 " $0.00 $0.00 $569.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $569.57 $242.74 $236.74 $242.74 52235 EAP CPT® 52235 "PR CYSTOURETHROSCOPY,FULGUR 2-5CM LESN" OP "$1,843.00 " $0.00 $0.00 $668.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $668.37 $284.62 $274.51 $284.62 52240 EAP CPT® 52240 "PR CYSTOURETHROSCOPY,FULGUR >5CM LESN" OP "$2,580.00 " $0.00 $0.00 $907.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $907.67 $500.51 $445.55 $500.51 52260 EAP CPT® 52260 "PR CYSTOSCOPY,DIL BLADDER,GEN ANESTH" OP $663.00 $0.00 $0.00 $486.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $486.86 $206.20 $130.69 $206.20 52276 EAP CPT® 52276 "PR CYSTOSCOPY,DIR VIS INT URETHROTOMY" OP "$1,364.00 " $0.00 $0.00 $612.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $612.93 $261.24 $246.11 $261.24 52281 EAP CPT® 52281 "PR CYSTOSCOPY,DIL URETHRAL STRICTURE" OP $663.00 $0.00 $0.00 $351.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.96 $349.91 $130.14 $349.91 52282 EAP CPT® 52282 "PR CYSTOSCOPY,INSERT URETHRAL STENT" OP "$1,054.00 " $0.00 $0.00 $779.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $779.12 $332.04 $280.80 $332.04 52287 EAP CPT® 52287 PR CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER OP $529.00 $0.00 $0.00 $391.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $391.20 $0.00 $184.72 $0.00 52300 EAP CPT® 52300 "PR CYSTOSCOPY,RESECT ORTHO URETEROCELE" OP $872.00 $0.00 $0.00 $649.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $649.91 $278.44 $184.65 $278.44 52310 EAP CPT® 52310 "PR CYSTOSCOPY,REMV CALCULUS,SIMPLE" OP $756.02 $0.00 $0.00 $351.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $351.08 $272.70 $255.98 $272.70 52317 EAP CPT® 52317 "PR REMOVE BLADDER STONE,<2.5CM" OP "$1,511.00 " $0.00 $0.00 "$1,206.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $804.80 "$1,206.26" $482.01 "$1,206.26" 52332 EAP CPT® 52332 "PR CYSTOSCOPY,INSERT URETERAL STENT" OP "$1,238.30 " $0.00 $0.00 $379.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.99 $379.61 $419.27 $379.61 52351 EAP CPT® 52351 "PR CYSTO/URETERO/PYELOSCOPY, DX" OP "$1,500.00 " $0.00 $0.00 $701.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $701.30 $308.39 $228.27 $308.39 52352 EAP CPT® 52352 "PR CYSTO/URETERO/PYELOSCOPY, CALCULUS TX" OP "$2,667.00 " $0.00 $0.00 $820.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $820.16 $362.47 $282.94 $362.47 52353 EAP CPT® 52353 PR CYSTO/URETERO/PYELOSCOPY W/LITHOTRIPSY OP "$3,334.00 " $0.00 $0.00 $907.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $907.67 $417.49 $327.79 $417.49 52354 EAP CPT® 52354 "PR CYSTO/URETERO/PYELOSC,BX &/OR FULG LESN" OP "$1,800.00 " $0.00 $0.00 $965.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $965.51 $385.94 $286.36 $385.94 52355 EAP CPT® 52355 "PR CYSTO/URETERO/PYELOSCOPY,W/RESECT TUMOR" OP "$2,134.00 " $0.00 $0.00 "$1,081.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,081.95" $460.57 $336.00 $460.57 52356 EAP CPT® 52356 PR CYSTO/URETERO W/LITHOTRIPSY &INDWELL STENT INSRT OP "$1,296.00 " $0.00 $0.00 $963.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $963.08 $0.00 $251.08 $0.00 52601 EAP CPT® 52601 PR TRANSURETHRAL ELEC-SURG PROSTATECTOM OP "$2,767.00 " $0.00 $0.00 "$1,953.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,953.51" $787.76 $511.87 $787.76 52630 EAP CPT® 52630 "PR REMV RESID OBSTRUC PROSTATE,>1 YR" OP "$3,000.00 " $0.00 $0.00 $923.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $923.16 $422.07 $327.96 $422.07 53020 EAP CPT® 53020 PR INCISION OF URETHRAL MEATUS OP $561.00 $0.00 $0.00 $224.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.18 $94.74 $94.29 $94.74 53405 EAP CPT® 53405 "PR REVISE URETHRA, 2ND STAGE" OP "$3,929.00 " $0.00 $0.00 "$2,017.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,017.16" $845.38 $544.47 $845.38 53410 EAP CPT® 53410 PR RECONSTRUC ANT MALE URETHRA OP "$4,490.00 " $0.00 $0.00 "$2,258.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,258.90" $948.21 $575.12 $948.21 53415 EAP CPT® 53415 PR RECONSTRUC PROSTATIC URETHRA OP "$5,052.00 " $0.00 $0.00 "$2,610.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,610.54" "$1,080.85" $690.20 "$1,080.85" 53440 EAP CPT® 53440 "PR SLING OPERATION,CORRECTION,MALE INCONT" OP "$5,052.00 " $0.00 $0.00 "$1,737.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,737.63" $828.86 $530.24 $828.86 53446 EAP CPT® 53446 "PR REMOVAL,INFLATABLE SPHINCTER" OP "$3,536.00 " $0.00 $0.00 "$1,483.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,483.13" $620.50 $472.37 $620.50 54015 EAP CPT® 54015 "PR INCIS/DRAIN PENIS,DEEP" OP $955.00 $0.00 $0.00 $716.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $716.03 $301.93 $214.46 $301.93 54050 EAP CPT® 54050 "PR DESTR PENIS LESN,SIMPL,CHEMICAL" OP $323.00 $0.00 $0.00 $242.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.33 $112.23 $57.90 $112.23 54056 EAP CPT® 54056 "PR DESTR PENIS LESN,SIMPL,CRYOSURG" OP $337.00 $0.00 $0.00 $256.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.04 $114.91 $65.33 $114.91 54060 EAP CPT® 54060 "PR DESTR PENIS LESN,SIMPL,SURG EXCIS" OP $545.00 $0.00 $0.00 $300.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.86 $187.14 $113.93 $187.14 54065 EAP CPT® 54065 "PR DESTR PENIS LESN,EXTENSIVE" OP "$1,133.00 " $0.00 $0.00 $399.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $399.74 $193.67 $141.41 $193.67 54100 EAP CPT® 54100 "PR BX,PENIS (SEPARATE PROCEDURE)" OP $379.00 $0.00 $0.00 $291.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $291.02 $178.76 $89.52 $178.76 54150 EAP CPT® 54150 "PR CIRCUMCISION,CLAMP,NEWBORN W/ ANESTH" OP $417.00 $0.00 $0.00 $225.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.59 $127.90 $108.37 $127.90 54160 EAP CPT® 54160 "PR CIRCUMCISION,OTHER,<28 D/O" OP $471.00 $0.00 $0.00 $336.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $336.72 $242.94 $139.06 $242.94 54161 EAP CPT® 54161 "PR CIRCUMCISION, OLDER THAN 28 DAYS OLD" OP "$1,396.00 " $0.00 $0.00 $454.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $454.20 $188.23 $122.62 $188.23 54220 EAP CPT® 54220 "PR IRRIGAT CORPUS CAVERN,PRIAPISM" OP $577.00 $0.00 $0.00 $310.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.04 $228.19 $94.74 $228.19 54235 EAP CPT® 54235 "PR INJECT CORPORA CAVERN,PHARM AGNT" OP $227.00 $0.00 $0.00 $169.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.70 $84.22 $44.02 $84.22 54300 EAP CPT® 54300 PR STRAIGHTEN PENIS OP "$2,354.00 " $0.00 $0.00 "$1,479.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,479.81" $635.46 $415.65 $635.46 54400 EAP CPT® 54400 PR INSERT SEMI-RIGID PENILE PROSTHESIS OP "$2,265.00 " $0.00 $0.00 "$1,223.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,223.42" $518.08 $0.00 $518.08 54405 EAP CPT® 54405 "PR INSERT,INFLATABLE PENILE PROSTHESIS" OP "$3,287.00 " $0.00 $0.00 "$1,866.87" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,866.87" $782.61 $0.00 $782.61 54415 EAP CPT® 54415 "PR REMOVAL,PENILE PROSTHESIS W/O REPLACMT" OP "$2,043.00 " $0.00 $0.00 "$1,219.64" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,219.64" $502.07 $0.00 $502.07 54430 EAP CPT® 54430 PR CORPORA CAVER-SPONGIOSA SHUNT OP "$2,665.00 " $0.00 $0.00 "$1,478.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,478.30" $618.06 $400.34 $618.06 54437 EAP CPT® 54437 PR REPAIR OF TRAUMATIC CORPOREAL TEAR(S) OP "$2,106.00 " $0.00 $0.00 "$1,573.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,573.47" $0.00 $414.36 $0.00 54440 EAP CPT® 54440 PR REPAIR PENIS POST INJURY OP "$2,792.00 " $0.00 $0.00 "$1,311.62" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,311.62" $0.00 $335.97 $0.00 54450 EAP CPT® 54450 PR PREPUTIAL STRETCHING OP $222.00 $0.00 $0.00 $133.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.29 $76.71 $44.28 $76.71 54520 EAP CPT® 54520 "PR REMOVAL TESTIS,SIMPLE" OP "$1,271.00 " $0.00 $0.00 $753.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $753.18 $314.20 $223.03 $314.20 54530 EAP CPT® 54530 "PR REMOVAL TESTIS,RADICAL" OP "$1,816.00 " $0.00 $0.00 "$1,167.27" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,167.27" $526.26 $342.20 $526.26 54620 EAP CPT® 54620 PR FIXATN OF TESTIS OPP TORSN OP $935.00 $0.00 $0.00 $696.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $696.90 $293.09 $186.73 $293.09 54640 EAP CPT® 54640 PR ORCHIOPEXY INGUINAL OR SCROTAL APPROACH OP "$2,070.00 " $0.00 $0.00 "$1,107.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,107.66" $443.18 $297.79 $443.18 54690 EAP CPT® 54690 "PR LAP,ORCHIECTOMY" OP "$2,070.00 " $0.00 $0.00 "$1,707.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,707.72" $639.14 $412.92 $639.14 54700 EAP CPT® 54700 "PR INCIS/DRAIN SCROTUM/TESTIS,EPIDIDYM" OP $668.00 $0.00 $0.00 $495.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.09 $206.66 $178.10 $206.66 54830 EAP CPT® 54830 PR EXCIS EPIDIDYMIS LOCAL LESION OP "$1,235.00 " $0.00 $0.00 $861.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $861.20 $348.47 $205.43 $348.47 54840 EAP CPT® 54840 PR EXCIS SPERMATOCELE OP "$1,126.00 " $0.00 $0.00 $742.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.17 $309.72 $216.34 $309.72 55000 EAP CPT® 55000 "PR DRAINAGE OF HYDROCELE,TUNICA" OP $264.00 $0.00 $0.00 $196.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.94 $128.32 $57.95 $128.32 55040 EAP CPT® 55040 "PR REMOVAL OF HYDROCELE,TUNICA,UNILAT" OP "$1,452.00 " $0.00 $0.00 $781.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $781.47 $322.34 $219.98 $322.34 55041 EAP CPT® 55041 "PR REMOVAL OF HYDROCELE,TUNICA,BILAT" OP "$2,251.00 " $0.00 $0.00 "$1,176.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,176.90" $481.19 $317.64 $481.19 55100 EAP CPT® 55100 PR DRAINAGE SCROTAL WALL ABSCESS OP $519.00 $0.00 $0.00 $384.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.42 $224.10 $156.39 $224.10 55110 EAP CPT® 55110 PR EXPLORE SCROTUM OP "$1,210.00 " $0.00 $0.00 $895.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $895.58 $363.53 $211.69 $363.53 55175 EAP CPT® 55175 "PR REVISION OF SCROTUM,SIMPLE" OP "$1,452.00 " $0.00 $0.00 $837.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $837.17 $340.60 $213.40 $340.60 55250 EAP CPT® 55250 PR REMOVAL OF SPERM DUCT(S) OP $745.00 $0.00 $0.00 $524.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $524.63 $512.20 $201.32 $512.20 55500 EAP CPT® 55500 "PR REMV HYDROCELE,SPERM CORD,UNILAT" OP "$1,228.00 " $0.00 $0.00 $916.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $916.58 $359.60 $222.84 $359.60 55700 EAP CPT® 55700 "PR BIOPSY OF PROSTATE,NEEDLE/PUNCH" OP $448.00 $0.00 $0.00 $322.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $322.17 $245.08 $92.43 $245.08 55706 EAP CPT® 55706 "PR BIOPSY OF PROSTATE,NEEDLE,TRANSPERINEAL" OP "$1,163.00 " $0.00 $0.00 $862.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $862.65 $0.00 $234.70 $0.00 55821 EAP CPT® 55821 "PR REMV PROSTATE,SUPRAPUBIC,SUBTOTAL" OP "$3,583.00 " $0.00 $0.00 "$2,018.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,018.60" $842.22 $577.75 $842.22 55866 EAP CPT® 55866 "PR LAP,PROSTATECTOMY,RADICAL,W/NERVE SPARE,INCL ROBOTIC" OP "$4,510.00 " $0.00 $0.00 "$3,242.34" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,242.34" "$1,692.63" $974.09 "$1,692.63" 55874 EAP CPT® 55874 PR TRANSPERINEAL PLMT BIODEGRADABLE MATRL 1/MLT NJX OP $516.00 $0.00 $0.00 $386.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $386.27 $0.00 $516.00 $0.00 55876 EAP CPT® 55876 "PR PLACE RADIOTHER DEVICE/MARKER, PROSTATE" OP $315.00 $0.00 $0.00 $232.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.38 $145.41 $86.63 $145.41 56405 EAP CPT® 56405 PR I&D OF VULVA/PERINEUM ABSCESS OP $371.00 $0.00 $0.00 $247.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.01 $104.61 $67.34 $104.61 56420 EAP CPT® 56420 PR I&D BARTHOLIN GLAND ABSCESS OP $328.00 $0.00 $0.00 $208.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.22 $131.63 $66.70 $131.63 56440 EAP CPT® 56440 PR MARSUP BARTHOLIN GLAND CYST OP $656.00 $0.00 $0.00 $415.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $415.62 $174.28 $136.06 $174.28 56501 EAP CPT® 56501 "PR DESTRUCTION,LESION(S),VULVA,SIMPLE" OP $389.00 $0.00 $0.00 $262.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $262.31 $124.57 $66.40 $124.57 56515 EAP CPT® 56515 "PR DESTRUCTION,LESION(S),VULVA;EXTENSIVE" OP $864.00 $0.00 $0.00 $460.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $460.47 $210.36 $100.69 $210.36 56605 EAP CPT® 56605 "PR BIOPSY VULVA/PERINEUM,ONE LESN" OP $231.00 $0.00 $0.00 $138.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.12 $81.12 $52.78 $81.12 56620 EAP CPT® 56620 PR PART SIMPLE REMV VULVA OP "$1,729.00 " $0.00 $0.00 "$1,193.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,193.99" $501.91 $304.01 $501.91 56820 EAP CPT® 56820 "PR COLPOSCOPY,VULVA" OP $267.00 $0.00 $0.00 $198.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.99 $106.14 $72.79 $106.14 56821 EAP CPT® 56821 "PR COLPOSCOPY,VULVA,W/BIOPSY(S)" OP $357.00 $0.00 $0.00 $264.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.86 $142.82 $94.23 $142.82 57100 EAP CPT® 57100 "PR BIOPSY OF VAGINA,SIMPLE" OP $255.00 $0.00 $0.00 $153.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.26 $85.38 $45.02 $85.38 57107 EAP CPT® 57107 PR REMOVE VAGINA TISSUE/PARTIAL OP "$4,492.00 " $0.00 $0.00 "$3,338.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,338.66" "$1,328.82" $730.53 "$1,328.82" 57135 EAP CPT® 57135 PR EXCIS VAGINAL CYST/TUMOR OP $705.00 $0.00 $0.00 $395.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $395.45 $186.03 $116.01 $186.03 57150 EAP CPT® 57150 PR TREAT VAGINA INFECTION OP $106.00 $0.00 $0.00 $65.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.87 $57.17 $25.17 $57.17 57155 EAP CPT® 57155 PR INSERTION UTERINE TANDEM&/VAGINAL OVOIDS OP "$1,656.00 " $0.00 $0.00 $669.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $669.03 $413.85 $256.98 $413.85 57156 EAP CPT® 57156 PR INSERT VAGINAL RADIATION DEVICE OP $465.00 $0.00 $0.00 $337.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.16 $0.00 $88.94 $0.00 57160 EAP CPT® 57160 PR FIT/INSERT INTRAVAG SUPPORT DEVICE OP $146.00 $0.00 $0.00 $106.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.82 $72.27 $37.91 $72.27 57200 EAP CPT® 57200 PR REPAIR OF VAGINA OP "$1,026.00 " $0.00 $0.00 $690.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $690.50 $275.58 $156.76 $275.58 57210 EAP CPT® 57210 PR REPAIR VAGINA/PERINEUM OP "$1,197.00 " $0.00 $0.00 $837.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $837.69 $344.62 $197.58 $344.62 57240 EAP CPT® 57240 "PR ANTER COLPORRHAPHY,BLAD/VAGINA" OP "$1,892.00 " $0.00 $0.00 "$1,530.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,530.96" $582.33 $268.74 $582.33 57250 EAP CPT® 57250 "PR POST COLPORRHAPHY,RECTUM/VAGINA" OP "$1,904.00 " $0.00 $0.00 "$1,539.77" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,539.77" $572.64 $243.31 $572.64 57260 EAP CPT® 57260 PR COMBINED ANT/POST COLPORRHAPHY OP "$2,426.00 " $0.00 $0.00 "$1,897.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,897.11" $730.09 $350.74 $730.09 57282 EAP CPT® 57282 "PR REPR VAGINAL PROLAPSE,SACROSP LIG" OP "$1,748.00 " $0.00 $0.00 "$1,141.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,141.76" $476.08 $367.80 $476.08 57283 EAP CPT® 57283 "PR REPR VAGINAL PROLAPSE,UTEROSACRAL" OP "$2,190.00 " $0.00 $0.00 "$1,569.47" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,569.47" $656.31 $410.00 $656.31 57288 EAP CPT® 57288 PR SLING OPER STRES INCONTINENCE OP "$2,660.00 " $0.00 $0.00 "$1,634.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,634.90" $763.35 $505.24 $763.35 57410 EAP CPT® 57410 PR PELVIC EXAMINATION W ANESTH OP $389.00 $0.00 $0.00 $246.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $246.65 $100.99 $72.98 $100.99 57415 EAP CPT® 57415 PR REMOVAL VAGINAL FOR.BODY W ANESTH OP $529.00 $0.00 $0.00 $365.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.88 $147.28 $91.04 $147.28 57420 EAP CPT® 57420 "PR COLPOSCOPY,ENTIRE VAGINA" OP $285.00 $0.00 $0.00 $210.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.23 $111.50 $75.90 $111.50 57421 EAP CPT® 57421 "PR COLPOSCOPY,ENTIRE VAGINA,W/BIOPSY(S)" OP $427.00 $0.00 $0.00 $285.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $285.65 $152.30 $98.90 $152.30 57425 EAP CPT® 57425 "PR LAPAROSCOPY, SURG, COLPOPEXY" OP "$3,062.00 " $0.00 $0.00 "$2,210.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,210.24" $906.10 $543.42 $906.10 57452 EAP CPT® 57452 "PR COLPOSCOPY,CERVIX W/ADJ VAGINA" OP $286.00 $0.00 $0.00 $211.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.34 $105.04 $48.38 $105.04 57454 EAP CPT® 57454 "PR COLPOSC,CERVIX W/ADJ VAG,W/BX & CURRETAG" OP $650.00 $0.00 $0.00 $310.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $310.19 $150.07 $62.53 $150.07 57455 EAP CPT® 57455 "PR COLPOSCOPY,CERVIX W/ADJ VAGINA,W/BX" OP $450.00 $0.00 $0.00 $252.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.98 $139.42 $91.06 $139.42 57456 EAP CPT® 57456 "PR COLPOSCOPY,CERVIX W/ADJ VAGINA, CURETTAG" OP $342.00 $0.00 $0.00 $235.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.32 $131.43 $86.15 $131.43 57460 EAP CPT® 57460 "PR COLPOSCOPY,CERVIX W/ADJ VAG,W/LOOP BX" OP "$1,015.00 " $0.00 $0.00 $371.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $371.97 $311.50 $111.63 $311.50 57461 EAP CPT® 57461 "PR COLPOSCOPY,CERVIX W/ADJ VAG,W/LOOP CONIZ" OP "$1,015.00 " $0.00 $0.00 $428.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $428.81 $344.27 $203.93 $344.27 57500 EAP CPT® 57500 "PR BIOPSY CERVIX, 1 OR MORE, OR EXCISION OF LESION" OP $397.00 $0.00 $0.00 $173.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $448.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.64 $134.55 $44.58 $134.55 57505 EAP CPT® 57505 PR ENDOCERVICAL CURETTAGE OP $314.00 $0.00 $0.00 $210.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $210.84 $97.70 $54.10 $97.70 57520 EAP CPT® 57520 "PR CONIZATION CERVIX,KNIFE/LASER" OP $890.00 $0.00 $0.00 $629.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $629.34 $299.15 $179.80 $299.15 57522 EAP CPT® 57522 "PR CONIZATION CERVIX,LOOP ELECTRD" OP $850.00 $0.00 $0.00 $555.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $555.63 $254.06 $160.13 $254.06 58100 EAP CPT® 58100 PR BIOPSY OF UTERUS LINING OP $252.00 $0.00 $0.00 $200.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.03 $106.97 $37.37 $106.97 58110 EAP CPT® 58110 PR ENDOMET BIOPSY DONE W/COLPOSCOPY OP $149.00 $0.00 $0.00 $93.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $93.15 $48.91 $31.37 $48.91 58120 EAP CPT® 58120 "PR DILATION/CURETTAGE,DIAGNOSTIC" OP $709.00 $0.00 $0.00 $499.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $499.74 $226.46 $149.21 $226.46 58140 EAP CPT® 58140 "PR MYOMECTOMY 1-4,W/TOT 250GMS/<,ABD APPRCH" OP "$2,912.00 " $0.00 $0.00 "$2,104.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,104.53" $869.61 $522.56 $869.61 58145 EAP CPT® 58145 "PR EXCIS UTERINE FIBROID,VAG APPRCH" OP "$1,756.00 " $0.00 $0.00 "$1,250.96" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,250.96" $515.38 $339.04 $515.38 58146 EAP CPT® 58146 "PR MYOMECTOMY 5/>,TOT>250 GMS,ABD APPRCH" OP "$3,632.00 " $0.00 $0.00 "$2,616.83" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,616.83" "$1,110.36" $657.56 "$1,110.36" 58150 EAP CPT® 58150 PR TOTAL ABDOM HYSTERECTOMY OP "$3,445.00 " $0.00 $0.00 "$2,316.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,316.42" $938.61 $554.33 $938.61 58180 EAP CPT® 58180 PR SUPRACERV ABD HYSTERECTOMY OP "$3,336.00 " $0.00 $0.00 "$2,197.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,197.92" $903.71 $558.49 $903.71 58200 EAP CPT® 58200 PR TOTAL ABD HYSTEREC+LTD NODES OP "$4,860.00 " $0.00 $0.00 "$3,143.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,143.10" "$1,251.40" $780.25 "$1,251.40" 58260 EAP CPT® 58260 "PR VAGINAL HYSTERECTOMY,UTERUS 250 GMS/<" OP "$3,083.00 " $0.00 $0.00 "$1,879.52" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,879.52" $786.82 $463.09 $786.82 58262 EAP CPT® 58262 "PR VAG HYST,RMV TUBE/OVARY" OP "$3,264.00 " $0.00 $0.00 "$2,098.58" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,098.58" $881.42 $512.70 $881.42 58300 EAP CPT® 58300 PR INSERT INTRAUTERINE DEVICE OP $269.00 $0.00 $0.00 $123.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $265.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.57 $0.00 $43.74 $0.00 58301 EAP CPT® 58301 PR REMOVE INTRAUTERINE DEVICE OP $240.00 $0.00 $0.00 $154.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $316.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.19 $95.76 $51.09 $95.76 58340 EAP CPT® 58340 PR CATH/INJECT HYSTEROSALPINGOGRAM OP "$2,343.00 " $0.00 $0.00 $140.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.55 $140.39 $134.18 $140.39 58350 EAP CPT® 58350 "PR REOPEN FALLOPIAN TUBE,CHROMOTUBATION" OP $324.00 $0.00 $0.00 $178.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $178.71 $93.80 $0.00 $93.80 58353 EAP CPT® 58353 "PR ENDOMETRIAL ABLATION, THERMAL" OP "$1,487.00 " $0.00 $0.00 "$1,327.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $498.38 "$1,327.53" $937.98 "$1,327.53" 58543 EAP CPT® 58543 "PR LAP, SUPRACERVIAL HYSTERECTOMY, >250G" OP "$2,635.00 " $0.00 $0.00 "$1,886.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,886.66" $899.14 $0.00 $899.14 58544 EAP CPT® 58544 "PR LAP, SUPRACERVIAL HYSTERECTOMY W/ TUBE&OV, >250G" OP "$2,837.00 " $0.00 $0.00 "$2,058.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,058.45" $973.55 $0.00 $973.55 58545 EAP CPT® 58545 "PR LAP,MYOMECTOMY 1-4,TOT WT 250 GMS" OP "$2,820.00 " $0.00 $0.00 "$2,059.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,059.44" $859.66 $528.79 $859.66 58546 EAP CPT® 58546 "PR LAP,MYOMECTOMY 5/>,TOTAL WT >250 GMS" OP "$3,516.00 " $0.00 $0.00 "$2,552.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,552.46" "$1,091.03" $666.60 "$1,091.03" 58550 EAP CPT® 58550 "PR LAP,VAG HYST,UTERUS 250GMS/<" OP "$2,768.00 " $0.00 $0.00 "$2,007.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,007.23" $845.72 $518.55 $845.72 58552 EAP CPT® 58552 "PR LAP,VAG HYST,UTERUS 250GMS/<,SALP-OOPH" OP "$3,085.00 " $0.00 $0.00 "$2,253.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,253.26" $934.38 $514.99 $934.38 58553 EAP CPT® 58553 "PR LAP,VAG HYST,UTERUS >250GMS" OP "$3,537.00 " $0.00 $0.00 "$2,587.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,587.74" "$1,095.77" $662.57 "$1,095.77" 58555 EAP CPT® 58555 "PR HYSTEROSCOPY,DX,SEP PROC" OP $728.00 $0.00 $0.00 $431.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $431.43 $216.68 $130.53 $216.68 58558 EAP CPT® 58558 "PR HYSTEROSCOPY,W/ENDO BX" OP "$3,500.00 " $0.00 $0.00 $607.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $607.22 $279.39 $169.86 $279.39 58559 EAP CPT® 58559 "PR HYSTEROSCOPY,LYSIS ADHESIONS" OP "$1,424.00 " $0.00 $0.00 $777.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.50 $337.05 $217.47 $337.05 58561 EAP CPT® 58561 "PR HYSTEROSCOPY,RMV MYOMA" OP "$4,427.00 " $0.00 $0.00 "$1,243.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,243.28" $541.58 $337.77 $541.58 58562 EAP CPT® 58562 "PR HYSTEROSCOPY,RMV FB" OP "$1,424.00 " $0.00 $0.00 $659.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $659.46 $301.99 $168.84 $301.99 58563 EAP CPT® 58563 "PR HYSTEROSCOPY,W/ENDOMETRIAL ABLATION" OP "$10,220.00 " $0.00 $0.00 "$2,124.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $776.78 "$2,124.30" $224.64 "$2,124.30" 58570 EAP CPT® 58570 PR LAPAROSCOPY W TOT HYSTERECT UTERUS 250 GRAM OR LESS OP "$2,487.00 " $0.00 $0.00 "$1,773.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,773.89" $0.00 $452.31 $0.00 58571 EAP CPT® 58571 PR LAPAROSCOPY W TOT HYSTERECTUTERUS <=250 GRAM W TUBE/OVARY OP "$2,805.00 " $0.00 $0.00 "$2,052.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,052.09" $0.00 $494.91 $0.00 58573 EAP CPT® 58573 PR LAPAROSCOPY TOT HYSTERECTOMY UTERUS >250 GRAM W TUBE/OVARY OP "$3,789.00 " $0.00 $0.00 "$2,777.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,777.16" $0.00 $631.91 $0.00 58600 EAP CPT® 58600 PR LIGATE FALLOPIAN TUBE OP "$1,631.00 " $0.00 $0.00 $827.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $827.33 $348.36 $168.96 $348.36 58605 EAP CPT® 58605 "PR LIGATE FALLOPIAN TUBE,POSTPARTUM" OP "$1,631.00 " $0.00 $0.00 $749.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $749.45 $315.89 $159.05 $315.89 58611 EAP CPT® 58611 "PR LIGATION,FALLOPIAN TUBE W/C-SECTION" OP $816.00 $0.00 $0.00 $175.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.88 $76.70 $24.78 $76.70 58660 EAP CPT® 58660 "PR LAP,LYSIS OF ADHESIONS" OP "$2,646.00 " $0.00 $0.00 "$1,536.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,536.20" $641.94 $395.49 $641.94 58661 EAP CPT® 58661 "PR LAP,RMV ADNEXAL STRUCTURE" OP "$2,538.00 " $0.00 $0.00 "$1,482.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,482.66" $622.91 $401.77 $622.91 58662 EAP CPT® 58662 "PR LAP,FULGURATE/EXCISE LESIONS" OP "$2,900.00 " $0.00 $0.00 "$1,617.41" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,617.41" $678.80 $402.32 $678.80 58671 EAP CPT® 58671 "PR LAP,TUBAL BLOCK BY DEVICE" OP "$1,631.00 " $0.00 $0.00 $829.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $829.61 $347.51 $231.81 $347.51 58700 EAP CPT® 58700 PR REMOVAL OF FALLOPIAN TUBE OP "$2,477.00 " $0.00 $0.00 "$1,784.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,784.90" $721.18 $272.27 $721.18 58720 EAP CPT® 58720 PR REMOVAL OF OVARY/TUBE(S) OP "$2,538.00 " $0.00 $0.00 "$1,684.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,684.37" $680.14 $421.85 $680.14 58740 EAP CPT® 58740 PR LYSIS ADNEXAL ADHESIONS OP "$2,808.00 " $0.00 $0.00 "$2,016.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,016.54" $833.92 $254.49 $833.92 58925 EAP CPT® 58925 PR REMOVAL OF OVARIAN CYST(S) OP "$2,377.00 " $0.00 $0.00 "$1,705.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,705.86" $689.17 $410.77 $689.17 58950 EAP CPT® 58950 PR RESEC OVAR MALIG+BILAT OVAR+OMENTUM OP "$3,534.00 " $0.00 $0.00 "$2,595.99" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,595.99" "$1,014.01" $585.18 "$1,014.01" 58960 EAP CPT® 58960 PR LAPAROTOMY FOR STAGING OVAR MALIG OP "$3,263.00 " $0.00 $0.00 "$2,237.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,237.54" $876.29 $587.71 $876.29 59000 EAP CPT® 59000 "PR AMNIOCENTESIS,DIAGNOSTIC" OP $285.00 $0.00 $0.00 $142.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.50 $128.63 $59.60 $128.63 59025 EAP CPT® 59025 PR FETAL NON-STRESS TEST OP $99.00 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.50 $41.67 $25.35 $41.67 59120 EAP CPT® 59120 "PR TREAT ECTOPIC PREG,RMV TUBE/OVARY" OP "$2,540.00 " $0.00 $0.00 "$1,270.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,270.00" $755.18 $428.44 $755.18 59121 EAP CPT® 59121 "PR TREAT ECTOPIC PREG,NON REMVAL" OP "$2,543.00 " $0.00 $0.00 "$1,271.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,271.50" $761.28 $403.84 $761.28 59151 EAP CPT® 59151 "PR RX ECTOP PREG BY SCOPE,RMV TUBE/OVRY" OP "$2,406.00 " $0.00 $0.00 "$1,203.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,203.00" $725.34 $333.56 $725.34 59160 EAP CPT® 59160 PR D&C AFTER DELIVERY OP $659.00 $0.00 $0.00 $329.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $329.50 $226.04 $135.95 $226.04 59300 EAP CPT® 59300 PR EPISIOTOMY/VAG RPR OTH/THN ATTENDING OP $475.00 $0.00 $0.00 $237.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.50 $183.78 $85.93 $183.78 59320 EAP CPT® 59320 "PR REVISION CERVIX W PREG,VAG APPRCH" OP $709.00 $0.00 $0.00 $354.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.50 $150.18 $94.38 $150.18 59400 EAP CPT® 59400 "PR FULL ROUT OBSTE CARE,VAGINAL DELIV" OP "$6,654.00 " $0.00 $0.00 "$3,327.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,327.00" "$1,680.38" "$1,522.91" "$1,680.38" 59409 EAP CPT® 59409 "PR OBSTETRICAL CARE,VAG DELIV ONLY" OP "$2,545.00 " $0.00 $0.00 "$1,272.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,272.50" $761.60 $558.20 $761.60 59410 EAP CPT® 59410 "PR OBSTE CARE,VAG DELIV+POSTPARTUM" OP "$3,276.00 " $0.00 $0.00 "$1,638.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,638.00" $874.17 $630.70 $874.17 59412 EAP CPT® 59412 PR ANTEPARTUM HEAD MANIPULATION OP $591.00 $0.00 $0.00 $295.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $295.50 $101.84 $67.82 $101.84 59414 EAP CPT® 59414 PR DELIVER PLACENTA OP $473.00 $0.00 $0.00 $236.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.50 $91.05 $64.31 $91.05 59425 EAP CPT® 59425 "PR ANTEPARTUM CARE ONLY, 4-6 VISITS" OP "$1,400.00 " $0.00 $0.00 $700.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $700.00 $411.81 $330.48 $411.81 59426 EAP CPT® 59426 "PR ANTEPARTUM CARE ONLY, >7 VISITS" OP "$2,500.00 " $0.00 $0.00 "$1,250.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,250.00" $734.59 $591.33 $734.59 59430 EAP CPT® 59430 PR CARE AFTER DELIVERY ONLY OP $600.00 $0.00 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.00 $135.43 $67.28 $135.43 59510 EAP CPT® 59510 "PR FULL ROUT OBSTE CARE,CESAREAN DELIV" OP "$7,500.00 " $0.00 $0.00 "$3,750.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,750.00" "$1,898.60" "$1,683.65" "$1,898.60" 59514 EAP CPT® 59514 PR CESAREAN DELIVERY ONLY OP "$2,876.00 " $0.00 $0.00 "$1,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,438.00" $900.11 $767.50 $900.11 59515 EAP CPT® 59515 PR CESAREAN DELIVERY+POSTPARTUM CARE OP "$3,989.00 " $0.00 $0.00 "$1,994.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,994.50" "$1,053.09" $840.00 "$1,053.09" 59525 EAP CPT® 59525 PR REMOVE UTERUS AFTER CESAREAN OP "$1,525.00 " $0.00 $0.00 $762.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $762.50 $477.89 $282.31 $477.89 59610 EAP CPT® 59610 "PR ROUT OB CARE,VAG DELIV,PREV C-SEC" OP "$7,001.00 " $0.00 $0.00 "$3,500.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,500.50" "$1,759.20" "$1,596.28" "$1,759.20" 59612 EAP CPT® 59612 "PR VAG DELIV ONLY,PREV C-SECTN" OP "$2,876.00 " $0.00 $0.00 "$1,438.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,438.00" $854.40 $574.03 $854.40 59614 EAP CPT® 59614 "PR VAG DELIV+POSTPARTUM CARE,PREV C-SEC" OP "$3,574.00 " $0.00 $0.00 "$1,787.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,787.00" $951.57 $630.70 $951.57 59622 EAP CPT® 59622 "PR C-SEC+POSTPARTUM CARE,PREV C-SEC" OP "$4,122.00 " $0.00 $0.00 "$2,061.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,061.00" "$1,142.25" $840.00 "$1,142.25" 59812 EAP CPT® 59812 PR SURG RX INCOMPLETE ABORTN OP $950.00 $0.00 $0.00 $475.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $475.00 $284.67 $167.39 $284.67 59820 EAP CPT® 59820 "PR SURG RX MISSED ABORTN,1ST TRI" OP "$1,163.00 " $0.00 $0.00 $581.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $581.50 $355.41 $189.03 $355.41 59821 EAP CPT® 59821 "PR SURG RX MISSED ABORTN,2ND TRI" OP "$1,153.00 " $0.00 $0.00 $576.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $576.50 $362.58 $192.07 $362.58 59830 EAP CPT® 59830 PR SURG RX SEPTIC ABORTN OP "$1,419.00 " $0.00 $0.00 $709.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $709.50 $418.66 $238.84 $418.66 59840 EAP CPT® 59840 PR INDUCED ABORTN BY D&C OP $978.00 $0.00 $0.00 $489.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $489.00 $206.30 $161.73 $206.30 59870 EAP CPT® 59870 PR EVACUATE MOLE OF UTERUS OP "$1,590.00 " $0.00 $0.00 $795.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $795.00 $435.29 $167.53 $435.29 59871 EAP CPT® 59871 PR REMOVE CERCLAGE SUTURE OP $416.00 $0.00 $0.00 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.00 $131.40 $92.01 $131.40 60100 EAP CPT® 60100 "PR BIOPSY OF THYROID,PERCUT" OP $309.00 $0.00 $0.00 $183.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.21 $108.22 $58.30 $108.22 60220 EAP CPT® 60220 "PR THYROID LOBECTOMY,UNILAT" OP "$2,435.00 " $0.00 $0.00 "$1,641.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,641.54" $698.71 $425.69 $698.71 60240 EAP CPT® 60240 PR THYROIDECTOMY OP "$3,002.00 " $0.00 $0.00 "$2,133.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,133.53" $901.17 $613.41 $901.17 60252 EAP CPT® 60252 "PR THYROIDECTOMY,MALIG,LTD NECK SURG" OP "$4,337.00 " $0.00 $0.00 "$3,066.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,066.38" "$1,208.60" $713.45 "$1,208.60" 60260 EAP CPT® 60260 PR THYROIDECTOMY POST PREV THYR SURG OP "$3,401.00 " $0.00 $0.00 "$2,538.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,538.03" "$1,012.24" $508.92 "$1,012.24" 60271 EAP CPT® 60271 "PR THYROIDECTOMY=SUBSTERNAL,TRANSCERV" OP "$3,297.00 " $0.00 $0.00 "$2,455.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,455.29" $980.03 $605.55 $980.03 60500 EAP CPT® 60500 PR EXPLORE PARATHYROID GLANDS OP "$3,069.00 " $0.00 $0.00 "$2,238.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,238.00" $924.12 $615.61 $924.12 60540 EAP CPT® 60540 PR EXCISE ADRENAL GLAND OP "$3,355.00 " $0.00 $0.00 "$2,456.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,456.25" $977.78 $635.87 $977.78 60600 EAP CPT® 60600 PR EXCISE CAROTID BODY LESION OP "$4,294.00 " $0.00 $0.00 "$3,242.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,242.15" "$1,343.65" $738.42 "$1,343.65" 60650 EAP CPT® 60650 "PR LAP,ADRENALECTOMY" OP "$3,744.00 " $0.00 $0.00 "$2,765.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,765.70" "$1,103.29" $702.33 "$1,103.29" 61020 EAP CPT® 61020 PR VENTRICULAR PUCTURE OP $440.00 $0.00 $0.00 $235.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.28 $115.88 $75.29 $115.88 61070 EAP CPT® 61070 PR BRAIN SHUNT TUBE/RESERV INJECTN OP $368.00 $0.00 $0.00 $134.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.06 $75.53 $99.58 $75.53 61105 EAP CPT® 61105 PR TWIST DRILL HOLE SUBDURAL/VENT PUNC OP "$1,842.00 " $0.00 $0.00 "$1,066.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,066.29" $387.23 $242.22 $387.23 61107 EAP CPT® 61107 "PR TWIST HOLE SKULL,IMPLANT CATH/DEVICE" OP "$2,381.00 " $0.00 $0.00 $742.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $742.58 $305.32 $230.02 $305.32 61140 EAP CPT® 61140 PR BURR HOLE FOR BIOPSY OP "$3,953.00 " $0.00 $0.00 "$2,966.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,966.15" "$1,106.94" $692.78 "$1,106.94" 61154 EAP CPT® 61154 PR BURR HOLE EVAC SUBDUR/EXTRA HEMATOMA OP "$4,493.00 " $0.00 $0.00 "$2,978.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,978.00" "$1,095.68" $695.79 "$1,095.68" 61210 EAP CPT® 61210 PR BURR HOLE IMPLANT CATH/DEVICE OP "$2,453.00 " $0.00 $0.00 $869.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $869.88 $355.19 $263.12 $355.19 61304 EAP CPT® 61304 PR OPEN SKULL SUPRATENT EXPLORE OP "$5,247.00 " $0.00 $0.00 "$3,859.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,859.37" "$1,477.84" "$1,001.08" "$1,477.84" 61312 EAP CPT® 61312 PR OPEN SKULL EVAC SUB/EXTRADUR BLOOD OP "$6,484.00 " $0.00 $0.00 "$4,883.73" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,883.73" "$1,827.99" "$1,091.35" "$1,827.99" 61313 EAP CPT® 61313 PR OPEN SKULL EVAC INTRACEREBR BLOOD OP "$6,469.00 " $0.00 $0.00 "$4,658.79" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,658.79" "$1,749.64" "$1,101.37" "$1,749.64" 61320 EAP CPT® 61320 PR OPEN SKULL DRAIN SUPRATENT ABSC OP "$6,290.00 " $0.00 $0.00 "$4,463.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,463.51" "$1,720.16" "$1,055.26" "$1,720.16" 61322 EAP CPT® 61322 "PR OPEN SKULL,DECOMPRES,W/DURAPLASTY" OP "$7,430.00 " $0.00 $0.00 "$5,582.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,582.63" "$2,050.81" "$1,068.91" "$2,050.81" 61323 EAP CPT® 61323 "PR OPEN SKULL,DECOMP,W/LOBECTOMY" OP "$7,487.00 " $0.00 $0.00 "$5,649.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,649.50" "$2,098.20" "$1,106.41" "$2,098.20" 61460 EAP CPT® 61460 PR CRANIECT SECTN 1+ CRAN NERVES OP "$6,936.00 " $0.00 $0.00 "$4,962.38" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,962.38" "$1,855.56" "$1,211.13" "$1,855.56" 61510 EAP CPT® 61510 PR EXCIS SUPRATENT BRAIN TUMOR OP "$8,087.00 " $0.00 $0.00 "$5,125.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,125.20" "$1,940.39" "$1,250.24" "$1,940.39" 61512 EAP CPT® 61512 PR EXCIS SUPRATENT MENINGIOMA OP "$8,087.00 " $0.00 $0.00 "$5,978.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,978.30" "$2,317.41" "$1,486.14" "$2,317.41" 61514 EAP CPT® 61514 PR EXCIS SUPRATENT BRAIN ABSCESS OP "$6,829.00 " $0.00 $0.00 "$4,454.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,454.72" "$1,703.14" "$1,128.97" "$1,703.14" 61519 EAP CPT® 61519 PR EXCIS INFRATENT MENINGIOMA OP "$9,239.00 " $0.00 $0.00 "$6,872.42" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,872.42" "$2,693.06" "$1,719.30" "$2,693.06" 61570 EAP CPT® 61570 PR REMOVE BRAIN FOREIGN BODY OP "$8,051.00 " $0.00 $0.00 "$4,378.14" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,378.14" "$1,639.70" $983.79 "$1,639.70" 61580 EAP CPT® 61580 "PR CRANIOFACIAL APPROACH,EXTRADURAL" OP "$7,628.00 " $0.00 $0.00 "$5,843.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,843.48" "$2,228.11" "$1,191.11" "$2,228.11" 61590 EAP CPT® 61590 PR INFRATEMPORAL APPROACH/PREAURICULAR OP "$9,482.00 " $0.00 $0.00 "$7,097.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$7,097.45" "$2,843.05" "$1,647.80" "$2,843.05" 61619 EAP CPT® 61619 PR REPAIR DURA POSTOP SK BASE-PEDICLE OP "$8,626.00 " $0.00 $0.00 "$3,373.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,373.16" "$1,348.23" $838.86 "$1,348.23" 61624 EAP CPT® 61624 "PR PERM OCCLUSION/EMBOLIZATION,PERCUT,CNS" OP "$5,750.00 " $0.00 $0.00 "$2,659.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,659.80" "$1,027.58" $715.13 "$1,027.58" 61635 EAP CPT® 61635 PR INTRACRANIAL BALLOON ANGIOPLSTY W/STENT OP "$4,543.00 " $0.00 $0.00 "$3,326.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,326.36" $0.00 $793.36 $0.00 61645 EAP CPT® 61645 PR PERQ ART TRLUML M-THROMBEC &/NFS INTRACRANIAL OP "$2,616.00 " $0.00 $0.00 "$1,807.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,807.71" $0.00 $476.04 $0.00 61650 EAP CPT® 61650 PR EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART 1ST OP "$1,786.00 " $0.00 $0.00 "$1,207.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,207.04" $0.00 $317.86 $0.00 61651 EAP CPT® 61651 PR EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART ADDL OP $765.00 $0.00 $0.00 $512.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $512.60 $0.00 $134.99 $0.00 61682 EAP CPT® 61682 "PR BRAIN AVM SURG,SUPRATENT,COMPLX" OP "$13,377.00 " $0.00 $0.00 "$9,767.70" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$9,767.70" "$3,896.29" "$2,401.82" "$3,896.29" 61711 EAP CPT® 61711 PR INTRA-EXTRACRANIAL ART ANASTOM OP "$8,103.00 " $0.00 $0.00 "$6,088.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$6,088.89" "$2,371.37" "$1,571.14" "$2,371.37" 61781 EAP CPT® 61781 "PR STEREOTACTIC COMP ASSIST PROC,CRANIAL,INTRADURAL" OP $736.00 $0.00 $0.00 $554.64 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $554.64 $0.00 $141.48 $0.00 61782 EAP CPT® 61782 "PR STEREOTACTIC COMP ASSIST PROC,CRANIAL,EXTRADURAL" OP $542.00 $0.00 $0.00 $410.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.00 $0.00 $116.45 $0.00 61783 EAP CPT® 61783 "PR STEREOTACTIC COMP ASSIST PROC,SPINAL" OP $731.00 $0.00 $0.00 $546.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $546.44 $0.00 $141.48 $0.00 62000 EAP CPT® 62000 PR FIX SIMPL DEPRESS SKULL FX OP "$3,810.00 " $0.00 $0.00 "$2,425.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,425.07" $745.62 $423.02 $745.62 62010 EAP CPT® 62010 "PR FIX DEPRESS SKULL FX,REPR DURA" OP "$5,894.00 " $0.00 $0.00 "$3,588.24" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,588.24" "$1,353.33" $875.63 "$1,353.33" 62117 EAP CPT® 62117 PR REDUCTN CRANIOMEG W RECONSTRUC OP "$6,138.00 " $0.00 $0.00 "$3,797.10" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,797.10" "$1,710.24" "$1,101.35" "$1,710.24" 62120 EAP CPT® 62120 "PR REPAIR ENCEPHALOCELE,VAULT" OP "$6,555.00 " $0.00 $0.00 "$3,884.33" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,884.33" "$1,618.90" $947.30 "$1,618.90" 62141 EAP CPT® 62141 "PR REPAIR SKULL DEFECT,>5CM" OP "$5,643.00 " $0.00 $0.00 "$2,662.28" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,662.28" "$1,022.28" $692.50 "$1,022.28" 62143 EAP CPT® 62143 PR REPLACE SKULL PLATE/FLAP OP "$4,313.00 " $0.00 $0.00 "$2,431.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,431.89" $909.20 $546.18 $909.20 62161 EAP CPT® 62161 "PR NEUROENDOSCOP,DISS ADHESION/FENESTRATION" OP "$4,719.00 " $0.00 $0.00 "$3,568.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,568.98" "$1,360.16" $738.07 "$1,360.16" 62165 EAP CPT® 62165 "PR NEUROENDOSCOP,EXC,PIT TUM,TRANSNAS/SPHEN" OP "$4,747.00 " $0.00 $0.00 "$3,614.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,614.39" "$1,394.03" $802.89 "$1,394.03" 62223 EAP CPT® 62223 PR CREATE SHUNT:VENTRIC-PERITONEAL OP "$4,852.00 " $0.00 $0.00 "$2,455.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,455.50" $907.86 $598.85 $907.86 62225 EAP CPT® 62225 PR REPLACE/IRRIGATE VENTRIC CATH OP "$2,336.00 " $0.00 $0.00 "$1,228.46" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,228.46" $424.75 $243.78 $424.75 62230 EAP CPT® 62230 "PR REPLACEMENT/REVISION,CSF SHUNT" OP "$3,414.00 " $0.00 $0.00 "$1,973.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,973.75" $735.35 $466.64 $735.35 62256 EAP CPT® 62256 "PR REMOVAL,COMPLETE CSF SHUNT,W/O REPLACE" OP "$2,120.00 " $0.00 $0.00 "$1,399.89" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,399.89" $497.66 $307.92 $497.66 62267 EAP CPT® 62267 PR PERCUT ASPIRATION VERTEBRAL DISC OP $491.00 $0.00 $0.00 $370.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.68 $0.00 $142.04 $0.00 62270 EAP CPT® 62270 PR DIAGNOSTIC LUMBAR SPINAL PUNCTURE OP $263.00 $0.00 $0.00 $180.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $180.66 $154.65 $75.10 $154.65 62272 EAP CPT® 62272 PR THERAPEUTIC SPINAL PUNCTURE DRAINAGE CSF OP $342.00 $0.00 $0.00 $193.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.89 $180.75 $82.28 $180.75 62273 EAP CPT® 62273 "PR INJ,LUMB EPIDUR,BLOOD/CLOT PATCH" OP $575.00 $0.00 $0.00 $263.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $263.75 $170.51 $77.18 $170.51 62284 EAP CPT® 62284 PR INJECTION PROCEDURE MYELOGRAPHY/CT LUMBAR OP $675.00 $0.00 $0.00 $228.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.37 $228.47 $98.92 $228.47 62321 EAP CPT® 62321 PR NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN OP $334.00 $0.00 $0.00 $254.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.67 $0.00 $150.32 $0.00 62323 EAP CPT® 62323 PR NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN OP $309.00 $0.00 $0.00 $232.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.26 $0.00 $147.54 $0.00 62328 EAP CPT® 62328 PR DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT OP $280.00 $0.00 $0.00 $207.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.80 $0.00 $157.99 $0.00 62361 EAP CPT® 62361 "INSERT/ PREPLACE INFUSN PUMP,NONPROGRAM" OP "$1,734.00 " $0.00 $0.00 $836.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $836.84 $404.94 $194.71 $404.94 63001 EAP CPT® 63001 "LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG, CERVICAL" OP "$4,761.00 " $0.00 $0.00 "$2,903.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,903.16" "$1,096.20" $740.05 "$1,096.20" 63005 EAP CPT® 63005 "LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG, LUMBAR" OP "$4,591.00 " $0.00 $0.00 "$2,757.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,757.86" "$1,050.03" $695.66 "$1,050.03" 63015 EAP CPT® 63015 "PR LAMINECTOMY,>2 SGMT,CERVICAL" OP "$5,849.00 " $0.00 $0.00 "$3,471.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,471.68" "$1,325.22" $903.95 "$1,325.22" 63030 EAP CPT® 63030 PR LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR OP "$5,203.00 " $0.00 $0.00 "$2,256.65" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,256.65" $870.61 $571.08 $870.61 63042 EAP CPT® 63042 PR REDO EXCIS LUMBAR DISC OP "$5,849.00 " $0.00 $0.00 "$3,018.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,018.51" "$1,207.86" $810.26 "$1,207.86" 63045 EAP CPT® 63045 "LAMINEC/FACETECT/FORAMIN,CERVICAL 1 SEG" OP "$4,021.00 " $0.00 $0.00 "$3,011.16" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,011.16" "$1,141.97" $774.11 "$1,141.97" 63046 EAP CPT® 63046 "LAMINEC/FACETECT/FORAMIN,THORACIC 1 SEG" OP "$3,837.00 " $0.00 $0.00 "$2,848.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,848.20" "$1,093.72" $740.73 "$1,093.72" 63047 EAP CPT® 63047 "LAMINEC/FACETECT/FORAMIN,LUMBAR 1 SEG" OP "$3,449.00 " $0.00 $0.00 "$2,571.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,571.32" "$1,003.34" $682.96 "$1,003.34" 63048 EAP CPT® 63048 PR LAM FACETECTOMY&FORAMOT 1 VRT SGM EA ADDL SGM OP "$2,040.00 " $0.00 $0.00 $495.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.27 $204.26 $144.70 $204.26 63051 EAP CPT® 63051 "PR C-LAMINOPLASTY W/GRAFT/PLATE, 2 OR MORE" OP "$5,339.00 " $0.00 $0.00 "$3,989.97" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,989.97" "$1,530.60" $974.39 "$1,530.60" 63052 EAP CPT® 63052 PR LAM FACETEC/FORAMOT DRG ARTHRD LUMBAR 1 VRT SGM OP $778.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63053 EAP CPT® 63053 PR LAM FACETEC/FORAMOT DRG ARTHRD LMBR EA ADDL SGM OP $582.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 63081 EAP CPT® 63081 "PR REMV VERT BODY,CERV,ONE SGMT" OP "$6,019.00 " $0.00 $0.00 "$4,102.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,102.86" "$1,620.94" "$1,101.40" "$1,620.94" 63101 EAP CPT® 63101 PR REMOVAL OF VERTEBRAL BODY OP "$7,822.00 " $0.00 $0.00 "$5,406.03" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,406.03" "$2,078.86" "$1,283.88" "$2,078.86" 63102 EAP CPT® 63102 PR REMOVAL OF VERTEBRAL BODY OP "$7,822.00 " $0.00 $0.00 "$5,298.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$5,298.72" "$2,076.30" "$1,283.88" "$2,076.30" 63266 EAP CPT® 63266 "PR EXCIS INTRASP LESN,XDURAL,THORACIC" OP "$5,441.00 " $0.00 $0.00 "$4,018.44" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,018.44" "$1,535.23" $782.68 "$1,535.23" 63276 EAP CPT® 63276 "PR BX/EXCIS SPINAL TUMOR,XDURAL,THOR" OP "$6,257.00 " $0.00 $0.00 "$4,176.95" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,176.95" "$1,598.34" "$1,066.65" "$1,598.34" 63300 EAP CPT® 63300 "PR REMV VERT,EXDUR,CERV TUMOR" OP "$5,747.00 " $0.00 $0.00 "$4,297.08" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$4,297.08" "$1,657.83" $999.77 "$1,657.83" 63308 EAP CPT® 63308 "PR REMV VERT,EACH ADDNL SEGMENT" OP "$1,462.00 " $0.00 $0.00 $760.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.28 $316.64 $211.96 $316.64 63707 EAP CPT® 63707 "PR REPR,DURAL/CSF LEAK,NOT REQ LAMINECTOMY" OP "$5,101.00 " $0.00 $0.00 "$2,142.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,142.54" $810.43 $520.46 $810.43 63710 EAP CPT® 63710 "PR DURAL GRAFT REPAIR,SPINE DEFECT" OP "$4,761.00 " $0.00 $0.00 "$2,526.71" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,526.71" $985.29 $580.97 $985.29 63741 EAP CPT® 63741 "PR INSTALL SPINAL SHUNT,PERCUT" OP "$2,211.00 " $0.00 $0.00 "$1,579.04" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,579.04" $549.03 $370.21 $549.03 63744 EAP CPT® 63744 PR REVISION OF SPINAL SHUNT OP "$2,123.00 " $0.00 $0.00 "$1,571.09" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,571.09" $576.15 $368.95 $576.15 64400 EAP CPT® 64400 PR INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH OP $508.00 $0.00 $0.00 $163.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.62 $106.75 $55.47 $106.75 64405 EAP CPT® 64405 PR INJECTION AA&/STRD GREATER OCCIPITAL NERVE OP $476.00 $0.00 $0.00 $146.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.03 $100.72 $64.03 $100.72 64415 EAP CPT® 64415 PR INJECTION AA&/STRD BRACHIAL PLEXUS W/IMG GDN OP $198.17 $0.00 $0.00 $150.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.21 $146.13 $67.10 $146.13 64417 EAP CPT® 64417 PR INJECTION AA&/STRD AXILLARY NERVE W/IMG GDN OP $196.91 $0.00 $0.00 $163.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.94 $152.15 $66.67 $152.15 64418 EAP CPT® 64418 PR INJECTION AA&/STRD SUPRASCAPULAR NERVE OP $192.55 $0.00 $0.00 $176.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.07 $138.47 $65.20 $138.47 64420 EAP CPT® 64420 PR INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL OP $186.00 $0.00 $0.00 $172.79 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.67 $172.79 $59.93 $172.79 64421 EAP CPT® 64421 PR INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL OP $229.62 $0.00 $0.00 $229.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.37 $229.62 $77.74 $229.62 64425 EAP CPT® 64425 PR INJECTION AA&/STRD ILIOINGUINAL IH NERVES OP $212.87 $0.00 $0.00 $212.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.87 $123.97 $72.07 $123.97 64445 EAP CPT® 64445 PR INJECTION AA&/STRD SCIATIC NERVE W/IMG GDN OP $217.44 $0.00 $0.00 $167.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.01 $144.61 $73.63 $144.61 64447 EAP CPT® 64447 PR INJECTION AA&/STRD FEMORAL NERVE W/IMG GDN OP $166.00 $0.00 $0.00 $152.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.63 $70.41 $46.52 $70.41 64450 EAP CPT® 64450 PR INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH OP $157.57 $0.00 $0.00 $105.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $216.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.41 $95.14 $53.35 $95.14 64451 EAP CPT® 64451 PR INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG OP $248.00 $0.00 $0.00 $184.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.05 $0.00 $127.89 $0.00 64454 EAP CPT® 64454 PR INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG OP $255.00 $0.00 $0.00 $189.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $189.71 $0.00 $129.17 $0.00 64455 EAP CPT® 64455 PR NJX AA&/STRD PLANTAR COMMON DIGITAL NERVES OP $108.00 $0.00 $0.00 $80.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.36 $0.00 $29.04 $0.00 64461 EAP CPT® 64461 PR PVB THORACIC SINGLE INJECTION SITE W/IMG GID OP $240.00 $0.00 $0.00 $200.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.10 $0.00 $89.58 $0.00 64463 EAP CPT® 64463 PR PVB THORACIC CONT CATHETER INFUSION W/IMG GID OP $259.00 $0.00 $0.00 $193.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.70 $0.00 $97.49 $0.00 64483 EAP CPT® 64483 PR NJX AA&/STRD TFRML EPI LUMBAR/SACRAL 1 LEVEL OP $794.00 $0.00 $0.00 $322.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $261.57 $322.58 $123.84 $322.58 64484 EAP CPT® 64484 PR NJX AA&/STRD TFRML EPI LUMBAR/SACRAL EA ADDL OP $397.00 $0.00 $0.00 $154.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.65 $154.93 $114.53 $154.93 64486 EAP CPT® 64486 PR TAP BLOCK UNILATERAL BY INJECTION(S) OP $175.00 $0.00 $0.00 $146.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $146.24 $0.00 $74.89 $0.00 64488 EAP CPT® 64488 PR TAP BLOCK BILATERAL BY INJECTION(S) OP $216.00 $0.00 $0.00 $184.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.77 $0.00 $92.08 $0.00 64490 EAP CPT® 64490 "CERVICAL/THORACIC FACET JT INJ, SINGLE LEVEL, INC CT/FL GUIDANCE" OP $329.00 $0.00 $0.00 $247.02 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.02 $0.00 $76.69 $0.00 64491 EAP CPT® 64491 "CERVICAL/THORACIC FACET JT INJ,2ND LEVEL, INC CT/FL GUIDANCE" OP $187.00 $0.00 $0.00 $139.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.91 $0.00 $37.67 $0.00 64493 EAP CPT® 64493 "LUMBAR FACET JT INJ, SINGLE LEVEL INC CT/FL GUIDANCE" OP $279.00 $0.00 $0.00 $211.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.62 $0.00 $69.48 $0.00 64494 EAP CPT® 64494 "LUMBAR FACET JT INJ, 2ND LEVEL, INC CT/FL GUIDANCE AKA ANE ARTERIAL LINE" OP $161.00 $0.00 $0.00 $120.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.59 $0.00 $33.82 $0.00 64495 EAP CPT® 64495 "LUMBAR FACET JT INJ, 3RD,ADDL LEVELS, INC CT/FL GIDANCE" OP $163.00 $0.00 $0.00 $122.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.21 $0.00 $34.33 $0.00 64505 EAP CPT® 64505 "PR INJECT NERV BLCK,SPHENOPALAT GANGLN" OP $302.00 $0.00 $0.00 $201.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.11 $95.94 $62.49 $95.94 64510 EAP CPT® 64510 "PR INJECT NERV BLCK,STELLATE GANGLION" OP $234.00 $0.00 $0.00 $170.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.66 $157.96 $61.92 $157.96 64520 EAP CPT® 64520 "PR INJECT NERV BLCK,PARAVERT SYMPATH" OP $257.00 $0.00 $0.00 $215.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.50 $215.37 $78.41 $215.37 64530 EAP CPT® 64530 "PR INJECT NERV BLCK,CELIAC PLEXUS" OP "$1,879.00 " $0.00 $0.00 $213.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.27 $205.30 $81.40 $205.30 64566 EAP CPT® 64566 "PR POST TIBIAL NEUROSTIMULATION,PERC NEEDLE ELECTRODE" OP $400.00 $0.00 $0.00 $70.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.65 $0.00 $76.85 $0.00 64581 EAP CPT® 64581 PR OPEN IMPLANTATION NEA SACRAL NERVE OP "$2,074.00 " $0.00 $0.00 "$1,530.29" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,530.29" $748.79 $501.50 $748.79 64590 EAP CPT® 64590 PR IMPLANT GASTRIC NEUROSTIM/RECEIVER OP $542.00 $0.00 $0.00 $370.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.70 $347.06 $0.00 $347.06 64600 EAP CPT® 64600 "PR INJECT TRIGEM NERV,1ST BRANCH" OP $923.00 $0.00 $0.00 $507.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $507.14 $438.86 $136.14 $438.86 64612 EAP CPT® 64612 PR CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL OP $362.00 $0.00 $0.00 $270.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.72 $157.33 $94.57 $157.33 64615 EAP CPT® 64615 PR CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE OP $385.00 $0.00 $0.00 $287.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $287.63 $0.00 $85.27 $0.00 64616 EAP CPT® 64616 PR CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA OP $340.00 $0.00 $0.00 $251.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.87 $0.00 $73.72 $0.00 64624 EAP CPT® 64624 PR DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG OP $458.00 $0.00 $0.00 $340.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $340.26 $0.00 $247.01 $0.00 64625 EAP CPT® 64625 PR RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN OP $605.00 $0.00 $0.00 $449.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $449.61 $0.00 $301.89 $0.00 64630 EAP CPT® 64630 PR DESTRUCT BY NEURO AGENT; PUDENDAL OP $588.00 $0.00 $0.00 $445.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.82 $215.34 $120.88 $215.34 64633 EAP CPT® 64633 PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA OP $699.00 $0.00 $0.00 $526.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $526.40 $0.00 $270.60 $0.00 64634 EAP CPT® 64634 PR DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA OP $212.00 $0.00 $0.00 $159.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.23 $0.00 $124.17 $0.00 64635 EAP CPT® 64635 PR DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL OP $689.00 $0.00 $0.00 $519.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $519.18 $0.00 $265.93 $0.00 64636 EAP CPT® 64636 PR DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL OP $186.00 $0.00 $0.00 $139.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.16 $0.00 $111.76 $0.00 64640 EAP CPT® 64640 PR INJECT RX OTHER PERIPH NERVE OP $367.66 $0.00 $0.00 $245.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.18 $245.73 $124.48 $245.73 64642 EAP CPT® 64642 PR CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE OP $334.00 $0.00 $0.00 $250.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.85 $0.00 $83.94 $0.00 64643 EAP CPT® 64643 PR CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE OP $223.00 $0.00 $0.00 $168.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.23 $0.00 $55.20 $0.00 64644 EAP CPT® 64644 PR CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES OP $364.00 $0.00 $0.00 $274.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $274.92 $0.00 $95.89 $0.00 64645 EAP CPT® 64645 PR CHEMODENERVATION 1 EXTREMITY EA ADDL 5/< MUSCLES OP $256.00 $0.00 $0.00 $192.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.96 $0.00 $67.55 $0.00 64646 EAP CPT® 64646 PR CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES OP $359.00 $0.00 $0.00 $270.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.78 $0.00 $90.31 $0.00 64680 EAP CPT® 64680 PR INJECT RX CELIAC PLEXUS NERVE OP $769.00 $0.00 $0.00 $384.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $384.63 $320.26 $107.36 $320.26 64708 EAP CPT® 64708 "PR NEUROPLASTY OTHER ARM/LEG NERVE,OPEN" OP "$2,307.00 " $0.00 $0.00 "$1,146.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,146.74" $425.28 $281.77 $425.28 64712 EAP CPT® 64712 "PR NEUROPLASTY SCIATIC NERVE,OPEN" OP "$2,691.00 " $0.00 $0.00 "$1,325.75" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,325.75" $493.01 $339.63 $493.01 64718 EAP CPT® 64718 PR REVISE ULNAR NERVE AT ELBOW OP "$2,499.00 " $0.00 $0.00 "$1,364.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,364.48" $506.99 $279.46 $506.99 64719 EAP CPT® 64719 PR REVISE ULNAR NERVE AT WRIST OP "$1,672.00 " $0.00 $0.00 $922.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $922.55 $361.44 $223.34 $361.44 64721 EAP CPT® 64721 PR REVISE MEDIAN N/CARPAL TUNNEL SURG OP "$1,769.00 " $0.00 $0.00 $983.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $983.07 $386.40 $220.39 $386.40 64772 EAP CPT® 64772 "PR TRANSECT OTHR SPINAL N,XTRADURAL" OP "$1,759.00 " $0.00 $0.00 "$1,295.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,295.49" $504.39 $317.93 $504.39 64782 EAP CPT® 64782 PR EXCISE HAND/FOOT NEUROMA OP "$1,420.00 " $0.00 $0.00 "$1,045.20" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,045.20" $409.84 $241.04 $409.84 64820 EAP CPT® 64820 "PR SYMPATHECTOMY,DIGITAL ARTERIES, EA" OP "$2,275.00 " $0.00 $0.00 "$1,672.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,672.82" $687.91 $418.86 $687.91 64831 EAP CPT® 64831 PR REPAIR OF DIGIT NERVE OP "$2,148.00 " $0.00 $0.00 "$1,582.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,582.17" $665.95 $341.08 $665.95 64832 EAP CPT® 64832 PR REPAIR EACH ADDNL DIGIT NERVE OP "$1,052.00 " $0.00 $0.00 $782.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $782.88 $330.93 $186.40 $330.93 64835 EAP CPT® 64835 SUTURE 1 NERVE MEDIAN MOTOR THENAR OP "$2,551.00 " $0.00 $0.00 "$1,866.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,866.02" $747.79 $416.61 $747.79 64857 EAP CPT® 64857 PR REPAIR MAJOR PERIPHERAL NERVE OP "$3,292.00 " $0.00 $0.00 "$2,439.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,439.39" $977.53 $567.84 $977.53 64859 EAP CPT® 64859 PR REPAIR ADDNL MAJ PERIPH NERVE OP "$1,192.00 " $0.00 $0.00 $586.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $586.73 $250.70 $170.22 $250.70 64864 EAP CPT® 64864 "PR REPR FACIAL NERVE,EXTRACRANIAL" OP "$2,685.00 " $0.00 $0.00 "$2,039.90" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,039.90" $821.69 $484.76 $821.69 64876 EAP CPT® 64876 "PR REPAIR NERVE DELAY,SHORTEN BONE" OP $618.00 $0.00 $0.00 $410.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $410.88 $190.02 $126.04 $190.02 64897 EAP CPT® 64897 "PR NERV GRFT,ARM/LEG,MULT,=<4CM" OP "$3,967.00 " $0.00 $0.00 "$2,879.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,879.76" "$1,158.27" $709.13 "$1,158.27" 64898 EAP CPT® 64898 "PR NERV GRFT,ARM/LEG,MULT,>4CM" OP "$4,295.00 " $0.00 $0.00 "$3,161.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,161.37" "$1,260.33" $774.21 "$1,260.33" 64902 EAP CPT® 64902 "PR EA ADDNL NERVE GRAFT,MULTPL STRANDS" OP "$2,172.00 " $0.00 $0.00 "$1,530.30" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,530.30" $674.44 $491.56 $674.44 64905 EAP CPT® 64905 "PR NERVE PEDICLE XFER,FIRST STAGE" OP "$3,191.00 " $0.00 $0.00 "$2,379.35" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,379.35" $895.42 $529.35 $895.42 64910 EAP CPT® 64910 PR NERVE REPAIR W/ALLOGRAFT OR SYNTH OP "$2,458.00 " $0.00 $0.00 "$1,905.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,905.60" $645.63 $393.36 $645.63 64912 EAP CPT® 64912 PR NERVE REPAIR W/NERVE ALLOGRAFT FIRST STRAND OP "$2,849.00 " $0.00 $0.00 "$1,799.13" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,799.13" $0.00 $479.82 $0.00 64999 EAP CPT® 64999 PR NERVOUS SYSTEM SURGERY UNLISTED OP "$6,000.00 " $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65093 EAP CPT® 65093 PR REMOVE OCULAR CONTENTS W IMPLANT OP "$3,182.00 " $0.00 $0.00 "$1,431.60" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,431.60" $561.91 $358.27 $561.91 65101 EAP CPT® 65101 PR REMOVAL OF EYE OP "$2,917.00 " $0.00 $0.00 "$1,681.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,681.68" $637.34 $365.32 $637.34 65103 EAP CPT® 65103 PR REMOVE EYE W IMPLANT OP "$3,182.00 " $0.00 $0.00 "$1,755.80" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,755.80" $664.76 $386.97 $664.76 65105 EAP CPT® 65105 PR REMOVE EYE W MUSC TO IMPLANT OP "$3,977.00 " $0.00 $0.00 "$1,935.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,935.45" $730.82 $425.39 $730.82 65205 EAP CPT® 65205 "PR REMV F.B.,EYE,SUPERF CONJUNC" OP $220.00 $0.00 $0.00 $100.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.71 $49.46 $83.16 $49.46 65220 EAP CPT® 65220 "PR REMV F.B.,EYE,CORNEA,NO SLIT" OP $257.00 $0.00 $0.00 $96.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.47 $50.07 $105.56 $50.07 65222 EAP CPT® 65222 "PR REMV F.B.,EYE,CORNEA,SLIT LAMP" OP $271.74 $0.00 $0.00 $119.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.24 $66.51 $92.00 $66.51 65235 EAP CPT® 65235 "PR REMOVAL,FB,INTRAOCULAR,ANT CHAMBER/LENS" OP "$2,200.00 " $0.00 $0.00 "$1,623.66" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,623.66" $575.47 $314.48 $575.47 65265 EAP CPT® 65265 "PR REMV F.B.,EYE,POST SGMT,NONMAGNETIC" OP "$3,977.00 " $0.00 $0.00 "$2,469.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,469.68" $905.84 $554.04 $905.84 65280 EAP CPT® 65280 "PR REPAIR CORNEA LAC,PERF,NO UVEAL" OP "$3,182.00 " $0.00 $0.00 "$1,532.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,532.94" $556.27 $357.31 $556.27 65285 EAP CPT® 65285 "PR REPAIR CORNEA LAC,PERF,RESEC UVEAL" OP "$4,243.00 " $0.00 $0.00 "$2,531.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,531.25" $870.17 $591.30 $870.17 65420 EAP CPT® 65420 PR EXCIS PTERYGIUM OP "$1,153.00 " $0.00 $0.00 $862.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $862.95 $465.62 $225.53 $465.62 65426 EAP CPT® 65426 "PR EXCIS PTERYGIUM,W GRAFT" OP "$1,463.00 " $0.00 $0.00 "$1,093.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,093.22" $576.40 $268.75 $576.40 65710 EAP CPT® 65710 "PR CORNEAL TRANSPLANT,LAMELLAR" OP "$3,444.00 " $0.00 $0.00 "$2,525.49" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,525.49" $927.56 $564.75 $927.56 65730 EAP CPT® 65730 "PR CORNEAL TRANSPLANT,PENETRATING" OP "$3,810.00 " $0.00 $0.00 "$2,800.92" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,800.92" "$1,028.40" $660.39 "$1,028.40" 65755 EAP CPT® 65755 "PR CORNEAL TRANSPLANT,PEN,PSEUDOAPHAK" OP "$3,813.00 " $0.00 $0.00 "$2,800.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,800.59" "$1,040.66" $690.01 "$1,040.66" 65756 EAP CPT® 65756 "PR CORNEAL TRANSPLANT,ENDOTHELIAL" OP "$3,617.00 " $0.00 $0.00 "$2,704.98" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,704.98" $0.00 $590.88 $0.00 65757 EAP CPT® 65757 PR PREP CORNEAL ENDOTHEL ALLOGRAFT OP $353.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 65778 EAP CPT® 65778 PR PLACE AMNIOTIC MEMBRA OCULAR SURFACE W/O SUTURES OP $168.00 $0.00 $0.00 $133.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.65 $0.00 $0.00 $0.00 65800 EAP CPT® 65800 PR PARACENTSIS ANT CHAMB EYE ASPIR AQUEOUS SPX OP $279.00 $0.00 $0.00 $209.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $209.34 $133.82 $88.65 $133.82 65855 EAP CPT® 65855 PR LASER SURGERY OF EYE OP "$1,406.00 " $0.00 $0.00 $549.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $549.33 $297.11 $221.85 $297.11 65920 EAP CPT® 65920 "PR REMVL,IMPLANT MATERIAL,ANT SEGMENT,EYE" OP "$2,419.00 " $0.00 $0.00 "$1,800.23" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,800.23" $657.06 $377.44 $657.06 66170 EAP CPT® 66170 "PR GLAUCOMA SURG,TRABECU AB EXTERNO" OP "$3,346.00 " $0.00 $0.00 "$2,216.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,216.22" $985.36 $547.16 $985.36 66172 EAP CPT® 66172 "PR GLAUCOMA SURG,TRAB AB EXT,PREV SCAR" OP "$3,644.00 " $0.00 $0.00 "$2,796.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,796.50" "$1,233.09" $634.26 "$1,233.09" 66180 EAP CPT® 66180 PR AQUEOUS SHUNT EXTRAOC EQUAT PLATE RSVR W/GRAFT OP "$3,486.00 " $0.00 $0.00 "$2,596.32" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,596.32" $984.14 $659.51 $984.14 66710 EAP CPT® 66710 "PR DESTRUC,CILIARY BODY,CYCLOPHOTOCOAG" OP "$1,341.00 " $0.00 $0.00 $897.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $897.20 $373.78 $258.08 $373.78 66761 EAP CPT® 66761 "PR IRIDOTOMY/IRIDECTOMY BY LASER, PER SESSION" OP "$1,341.00 " $0.00 $0.00 $539.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $539.33 $381.45 $197.11 $381.45 66762 EAP CPT® 66762 PR IRIDOPLASTY BY PHOTOCOAG OP "$1,368.00 " $0.00 $0.00 $973.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $973.91 $398.48 $217.84 $398.48 66821 EAP CPT® 66821 "PR DISCISSION,2ND CATARACT,LASER" OP $953.00 $0.00 $0.00 $710.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $710.66 $270.65 $117.73 $270.65 66850 EAP CPT® 66850 "PR REMV LENS MATERIAL,PHACOFRAGMT" OP "$2,645.00 " $0.00 $0.00 "$1,809.51" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,809.51" $660.68 $404.32 $660.68 66852 EAP CPT® 66852 "PR REMV LENS MATERIAL,PARS PLANAR APPRC" OP "$3,174.00 " $0.00 $0.00 "$1,927.88" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,927.88" $708.70 $440.99 $708.70 66982 EAP CPT® 66982 PR XCAPSL CTRC RMVL INSJ IO LENS PROSTH CPLX WO ECP OP "$3,307.00 " $0.00 $0.00 "$1,814.82" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,814.82" $907.24 $594.62 $907.24 66984 EAP CPT® 66984 PR XCAPSL CTRC RMVL INSJ IO LENS PROSTH W/O ECP OP "$2,751.00 " $0.00 $0.00 "$1,459.76" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,459.76" $647.98 $451.05 $647.98 66985 EAP CPT® 66985 PR INSERT LENS PROSTHESIS ONLY OP "$2,349.00 " $0.00 $0.00 "$1,758.18" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,758.18" $631.68 $373.61 $631.68 67005 EAP CPT® 67005 "PR PART REMV VITREOUS,ANT APPRCH" OP "$2,417.00 " $0.00 $0.00 "$1,079.57" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,079.57" $392.36 $237.51 $392.36 67028 EAP CPT® 67028 PR INJECT INTRAVITREAL PHARMCOLOGIC OP $524.00 $0.00 $0.00 $228.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.81 $188.85 $192.54 $188.85 67036 EAP CPT® 67036 "PR VITRECTOMY,MECHANICAL" OP "$3,894.00 " $0.00 $0.00 "$2,058.45" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,058.45" $814.31 $524.69 $814.31 67039 EAP CPT® 67039 "PR VITRECTOMY,FOCAL LASER RX RETINA" OP "$4,297.00 " $0.00 $0.00 "$2,204.21" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,204.21" "$1,045.60" $653.48 "$1,045.60" 67040 EAP CPT® 67040 "PR VITRECTOMY,PANRETINAL LASER RX" OP "$4,566.00 " $0.00 $0.00 "$2,382.12" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,382.12" "$1,205.62" $766.92 "$1,205.62" 67042 EAP CPT® 67042 PR VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA OP "$3,518.00 " $0.00 $0.00 "$2,632.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,632.53" $0.00 $658.89 $0.00 67107 EAP CPT® 67107 "PR REPAIR DETACH RETINA,SCLERAL BUCKLE" OP "$3,458.00 " $0.00 $0.00 "$2,322.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,322.53" "$1,017.58" $678.37 "$1,017.58" 67108 EAP CPT® 67108 "PR REPAIR DETACH RETINA,W VITRECTOMY" OP "$5,372.00 " $0.00 $0.00 "$2,963.72" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,963.72" "$1,357.11" $943.29 "$1,357.11" 67113 EAP CPT® 67113 PR REPAIR COMPLEX RETINA DETACH VITRECTOMY & MEMB PEEL OP "$4,094.00 " $0.00 $0.00 "$3,219.86" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,219.86" $0.00 $694.72 $0.00 67145 EAP CPT® 67145 PR PROPH RETINAL DTCHMNT W/O DRG PHOTOCOAGULATION OP "$1,565.00 " $0.00 $0.00 "$1,137.54" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,137.54" $437.14 $258.36 $437.14 67210 EAP CPT® 67210 "PR DESTRUC RETINAL LESN,PHOTOCOAG" OP "$1,622.00 " $0.00 $0.00 "$1,142.39" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,142.39" $585.48 $391.08 $585.48 67228 EAP CPT® 67228 "PR TX EXTENSIVE RETINOPATHY, PHOTOCOAGULATION" OP "$1,736.00 " $0.00 $0.00 $918.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $701.82 $918.55 $514.02 $918.55 67311 EAP CPT® 67311 "PR STABISMUS SURG,ONE HORIZ MUSCLE" OP "$1,894.00 " $0.00 $0.00 "$1,365.53" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,365.53" $501.05 $309.52 $501.05 67332 EAP CPT® 67332 "PR STRABISMUS SURG,SCAR EXTRAOCUL MUSC" OP "$1,208.00 " $0.00 $0.00 $760.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $760.01 $281.12 $284.97 $281.12 67400 EAP CPT® 67400 PR EXPLORE EYE SOCKET OP "$3,014.00 " $0.00 $0.00 "$2,121.36" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,121.36" $808.74 $482.76 $808.74 67412 EAP CPT® 67412 "PR EXPLORE EYE SOCKET,REMV LESN" OP "$2,823.00 " $0.00 $0.00 "$1,941.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,941.48" $760.41 $491.04 $760.41 67414 EAP CPT® 67414 "PR EXPLORE EYE SOCKET,DECOMPRESS" OP "$4,280.00 " $0.00 $0.00 "$3,024.26" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,024.26" "$1,097.88" $513.62 "$1,097.88" 67715 EAP CPT® 67715 PR INCISION OF EYELID FOLD OP $328.00 $0.00 $0.00 $248.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $248.25 $229.47 $51.00 $229.47 67800 EAP CPT® 67800 "PR EXCIS CHALAZION,SINGLE" OP $315.00 $0.00 $0.00 $236.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.16 $109.75 $109.19 $109.75 67805 EAP CPT® 67805 "PR EXCIS CHALAZION,MULT,BOTH LIDS" OP $501.00 $0.00 $0.00 $376.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $376.34 $173.44 $138.92 $173.44 67810 EAP CPT® 67810 PR INCISIONAL BIOPSY EYELID SKIN & LID MARGIN OP $294.00 $0.00 $0.00 $182.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.75 $182.54 $95.68 $182.54 67825 EAP CPT® 67825 PR REVISE EYELASHES OP $371.00 $0.00 $0.00 $277.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.44 $113.07 $125.79 $113.07 67840 EAP CPT® 67840 PR REMOVE EYELID LESN (NOT CHALAZION) OP $482.00 $0.00 $0.00 $361.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $361.88 $263.41 $130.95 $263.41 67875 EAP CPT® 67875 PR TEMP CLOSURE EYELID BY SUTURE OP $405.00 $0.00 $0.00 $222.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $222.36 $163.43 $147.80 $163.43 67900 EAP CPT® 67900 PR REPAIR BROW PTOSIS OP "$2,432.00 " $0.00 $0.00 "$1,164.17" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,164.17" $569.44 $287.12 $569.44 67901 EAP CPT® 67901 "PR FIX LID PTOSIS,FRONTALIS MUSC,SUT" OP "$2,006.00 " $0.00 $0.00 "$1,317.68" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,317.68" $517.30 $324.45 $517.30 67911 EAP CPT® 67911 PR CORRECT LID RETRACTN OP "$1,715.00 " $0.00 $0.00 "$1,284.63" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,284.63" $453.56 $260.16 $453.56 67912 EAP CPT® 67912 PR CORRECTION EYELID W/ IMPLANT OP "$3,243.00 " $0.00 $0.00 "$1,122.11" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,122.11" $871.78 $609.55 $871.78 67914 EAP CPT® 67914 "PR FIX ECTROPION,SUTURE" OP "$1,581.00 " $0.00 $0.00 $748.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $748.38 $357.30 $245.81 $357.30 67917 EAP CPT® 67917 "PR FIX ECTROPION,ENTENSV LID REPAIR" OP "$2,310.00 " $0.00 $0.00 "$1,047.02" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,047.02" $524.59 $317.77 $524.59 67921 EAP CPT® 67921 "PR FIX ENTROPION,SUTURE" OP $947.00 $0.00 $0.00 $709.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $709.77 $341.25 $233.91 $341.25 67924 EAP CPT® 67924 "PR FIX ENTROPION,EXTENSV LID REPAIR" OP "$2,351.00 " $0.00 $0.00 "$1,047.06" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,047.06" $528.63 $304.26 $528.63 67930 EAP CPT® 67930 "PR SUTURE EYELID WOUND,PARTIAL THICK" OP $750.00 $0.00 $0.00 $548.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $548.49 $333.65 $212.42 $333.65 67935 EAP CPT® 67935 "PR SUTURE EYELID WOUND,FULL THICK" OP "$1,354.00 " $0.00 $0.00 "$1,011.48" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,011.48" $534.48 $340.68 $534.48 67961 EAP CPT® 67961 "PR REVISION OF EYELID,< 1/4 LID MARGIN" OP "$2,229.00 " $0.00 $0.00 "$1,039.01" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,039.01" $518.69 $287.01 $518.69 68020 EAP CPT® 68020 PR INCISE/DRAIN CONJUNCTIVA OP $336.00 $0.00 $0.00 $252.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.35 $102.11 $102.47 $102.11 68110 EAP CPT® 68110 "PR EXCIS CONJUNC LESN,=<1 CM" OP $452.00 $0.00 $0.00 $339.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $339.47 $208.16 $130.70 $208.16 68115 EAP CPT® 68115 "PR EXCIS CONJUNC LESN,>1 CM" OP $608.00 $0.00 $0.00 $420.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $420.75 $293.14 $149.81 $293.14 68320 EAP CPT® 68320 "PR REVISE CONJUNC,CONJUNC GRFT" OP "$2,432.00 " $0.00 $0.00 "$1,231.94" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,231.94" $634.85 $252.51 $634.85 68510 EAP CPT® 68510 PR BIOPSY OF TEAR GLAND OP $893.00 $0.00 $0.00 $668.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $668.39 $422.26 $267.62 $422.26 68700 EAP CPT® 68700 PR REPAIR TEAR DUCTS OP "$2,711.00 " $0.00 $0.00 "$1,379.15" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,379.15" $501.92 $251.22 $501.92 68705 EAP CPT® 68705 PR REVISE TEAR DUCT OPENING OP $506.00 $0.00 $0.00 $380.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $380.49 $220.65 $131.38 $220.65 68720 EAP CPT® 68720 PR CREATE TEAR SAC-NASAL FISTULA OP "$4,190.00 " $0.00 $0.00 "$1,727.22" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,727.22" $645.30 $405.27 $645.30 68761 EAP CPT® 68761 "PR CLOSE TEAR DUCT OPENING BY PLUG,EA" OP $359.00 $0.00 $0.00 $271.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.83 $130.64 $106.72 $130.64 69000 EAP CPT® 69000 "PR DRAIN EXT EAR ABSC/BLOOD,SIMPLE" OP $375.00 $0.00 $0.00 $275.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.34 $160.21 $57.93 $160.21 69020 EAP CPT® 69020 PR DRAIN EXT AUD CANAL ABSCESS OP $434.00 $0.00 $0.00 $330.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.23 $202.40 $61.05 $202.40 69105 EAP CPT® 69105 PR BIOPSY OF EXT AUDITORY CANAL OP $302.00 $0.00 $0.00 $148.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.04 $119.53 $43.57 $119.53 69200 EAP CPT® 69200 PR REMV EXT CANAL FOREIGN BODY OP $221.00 $0.00 $0.00 $113.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.31 $113.15 $36.65 $113.15 69205 EAP CPT® 69205 "PR REMV EXT CANAL F.B.,GEN ANESTH" OP $886.00 $0.00 $0.00 $235.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $235.89 $94.03 $55.20 $94.03 69209 EAP CPT® 69209 PR REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT OP $43.00 $0.00 $0.00 $29.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.10 $0.00 $7.66 $0.00 69210 EAP CPT® 69210 PR REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT OP $106.00 $0.00 $0.00 $75.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $134.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.51 $45.76 $29.62 $45.76 69222 EAP CPT® 69222 "PR DEBRIDE MASTOID CAVITY,COMPLEX" OP $544.00 $0.00 $0.00 $318.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $318.17 $194.12 $62.00 $194.12 69320 EAP CPT® 69320 "PR REBUILD EXT AUD CANAL,CONG ANOMALY" OP "$4,700.00 " $0.00 $0.00 "$3,593.91" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,593.91" "$1,419.31" $718.57 "$1,419.31" 69421 EAP CPT® 69421 "PR INCISION EARDRUM,ASPIR,GEN ANESTH" OP $455.00 $0.00 $0.00 $346.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $346.13 $142.16 $77.92 $142.16 69433 EAP CPT® 69433 "PR CREATE EARDRUM OPENING,LOCAL ANESTH" OP $433.00 $0.00 $0.00 $308.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $308.31 $172.45 $72.91 $172.45 69502 EAP CPT® 69502 "PR MASTOIDECTOMY,COMPLETE" OP "$2,932.00 " $0.00 $0.00 "$2,260.74" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,260.74" $887.31 $561.09 $887.31 69631 EAP CPT® 69631 PR TYMPANOPLASTY OP "$2,878.00 " $0.00 $0.00 "$2,057.25" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,057.25" $784.61 $455.07 $784.61 69645 EAP CPT® 69645 "PR TYMPANOPLAS/MASTOIDEC,RADICAL/COMPLE" OP "$4,472.00 " $0.00 $0.00 "$3,383.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$3,383.07" "$1,340.94" $742.12 "$1,340.94" 69661 EAP CPT® 69661 "PR STAPEDECTOMY,FOOTPLATE DRILL OUT" OP "$3,708.00 " $0.00 $0.00 "$2,811.59" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,811.59" "$1,121.27" $708.23 "$1,121.27" 69990 EAP CPT® 69990 "PR MICROSURG TECHNIQUES,REQ OPER MICROSCOPE" OP $681.00 $0.00 $0.00 $513.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $513.98 $212.40 $130.21 $212.40 70100 EAP CPT® 70100 CHG X-RAY JAW <4 VW OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $28.00 $18.23 $28.00 70110 EAP CPT® 70110 CHG X-RAY JAW 4+ VW OP $41.00 $0.00 $0.00 $41.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.00 $36.66 $22.66 $36.66 70160 EAP CPT® 70160 PR X-RAY NASAL BONES OP $27.00 $0.00 $0.00 $27.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.00 $27.00 $17.79 $27.00 70250 EAP CPT® 70250 CHG X-RAY SKULL <4 VW OP $36.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $35.93 $22.44 $35.93 70330 EAP CPT® 70330 PR X-RAY TMJ BILAT OP $45.00 $0.00 $0.00 $45.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.00 $44.66 $27.81 $44.66 70336 EAP CPT® 70336 "PR MRI, TMJ" OP $227.00 $0.00 $0.00 $227.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.00 $227.00 $0.00 $227.00 70355 EAP CPT® 70355 PR ORTHOPANTOGRAM OP $32.00 $0.00 $0.00 $29.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.46 $29.21 $20.00 $29.21 70360 EAP CPT® 70360 PR X-RAY NECK SOFT TISSUE OP $32.00 $0.00 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.00 $25.20 $15.55 $25.20 70450 EAP CPT® 70450 "PR CT SCAN,HEAD/BRAIN,W/O CONTRAST MATL" OP $142.00 $0.00 $0.00 $142.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $313.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.00 $142.00 $138.79 $142.00 70460 EAP CPT® 70460 PR CT SCAN HEAD CONTRAST OP $187.00 $0.00 $0.00 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.00 $187.00 $170.14 $187.00 70470 EAP CPT® 70470 PR CT SCAN HEAD COMBO OP $211.00 $0.00 $0.00 $211.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.00 $211.00 $207.85 $211.00 70480 EAP CPT® 70480 "PR CT SCAN,ORBIT/SELLA/POST FOSSA/EAR,W/O" OP $223.00 $0.00 $0.00 $223.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $223.00 $223.00 $152.39 $223.00 70481 EAP CPT® 70481 PR CT SCAN SKULL CONTRAST OP $227.00 $0.00 $0.00 $227.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $227.00 $227.00 $177.61 $227.00 70482 EAP CPT® 70482 PR CT SCAN SKULL COMBO OP $237.00 $0.00 $0.00 $237.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.00 $237.00 $213.56 $237.00 70486 EAP CPT® 70486 "PR CT SCAN,MAXILLOFACIAL AREA,W/O CONTRAST" OP $195.00 $0.00 $0.00 $195.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $379.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.12 $195.00 $147.99 $195.00 70487 EAP CPT® 70487 "PR CT SCAN, FACE/JAW CONTRAST" OP $212.00 $0.00 $0.00 $212.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $212.00 $212.00 $175.19 $212.00 70488 EAP CPT® 70488 PR CT SCANS FACE/JAW COMBO OP $234.00 $0.00 $0.00 $234.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.00 $234.00 $212.68 $234.00 70490 EAP CPT® 70490 "PR CT SCAN,SOFT TISSUE NECK,W/O CONTRAST" OP $220.00 $0.00 $0.00 $220.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $445.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $220.00 $220.00 $152.39 $220.00 70491 EAP CPT® 70491 PR CT NECK TISSUE CONTRAST OP $224.00 $0.00 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.00 $224.00 $177.61 $224.00 70492 EAP CPT® 70492 PR CT NECK TISSUE COMBO OP $250.00 $0.00 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $250.00 $213.33 $250.00 70496 EAP CPT® 70496 "PR CT ANGIO,HEAD COMBO,INCL IMAGE PROCESS" OP $268.00 $0.00 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.00 $268.00 $260.29 $268.00 70498 EAP CPT® 70498 "PR CT ANGIO,NECK COMBO,INCL IMAGE PROCESS" OP $268.00 $0.00 $0.00 $268.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.00 $268.00 $260.29 $268.00 70540 EAP CPT® 70540 "PR MRI, FACE, NECK" OP $249.00 $0.00 $0.00 $249.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $249.00 $249.00 $249.00 $249.00 70543 EAP CPT® 70543 "PR MRI, FACE, NECK, COMBO" OP $328.00 $0.00 $0.00 $328.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.00 $328.00 $328.00 $328.00 70544 EAP CPT® 70544 "PR MR ANGIO, HEAD" OP $188.00 $0.00 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.00 $188.00 $188.00 $188.00 70545 EAP CPT® 70545 "PR MR ANGIO, HEAD W/CONTRAST" OP $209.00 $0.00 $0.00 $209.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $209.00 $209.00 $209.00 $209.00 70546 EAP CPT® 70546 "PR MR ANGIO, HEAD, COMBO" OP $228.00 $0.00 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.00 $228.00 $228.00 $228.00 70547 EAP CPT® 70547 "PR MR ANGIO, NECK" OP $185.00 $0.00 $0.00 $185.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.00 $185.00 $185.00 $185.00 70548 EAP CPT® 70548 "PR MR ANGIO, NECK W/CONTRAST" OP $230.00 $0.00 $0.00 $230.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.00 $230.00 $230.00 $230.00 70549 EAP CPT® 70549 "PR MR ANGIO, NECK, COMBO" OP $277.00 $0.00 $0.00 $277.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $277.00 $277.00 $277.00 $277.00 70551 EAP CPT® 70551 PR MRI BRAIN OP $256.00 $0.00 $0.00 $256.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.00 $256.00 $256.00 $256.00 70553 EAP CPT® 70553 PR MRI BRAIN COMBO OP $352.00 $0.00 $0.00 $352.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.00 $352.00 $352.00 $352.00 71045 EAP CPT® 71045 CHG RADIOLOGIC EXAM CHEST SINGLE VIEW OP $28.00 $0.00 $0.00 $26.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.55 $0.00 $11.95 $0.00 71046 EAP CPT® 71046 CHG RADIOLOGIC EXAM CHEST 2 VIEWS OP $34.00 $0.00 $0.00 $34.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.00 $0.00 $18.33 $0.00 71048 EAP CPT® 71048 CHG RADIOLOGIC EXAM CHEST 4+ VIEWS OP $50.00 $0.00 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.00 $0.00 $25.14 $0.00 71101 EAP CPT® 71101 "CHG X-RAY RIBS, CHEST 3+ VW" OP $46.00 $0.00 $0.00 $46.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.00 $38.56 $24.44 $38.56 71110 EAP CPT® 71110 CHG X-RAY RIBS 3 VW BILAT OP $47.00 $0.00 $0.00 $47.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.00 $42.16 $27.34 $42.16 71111 EAP CPT® 71111 "CHG X-RAY RIBS, CHEST 4+ VW" OP $54.00 $0.00 $0.00 $54.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.00 $50.32 $31.56 $50.32 71120 EAP CPT® 71120 CHG X-RAY STERNUM 2+ VW OP $34.00 $0.00 $0.00 $34.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.00 $33.97 $21.78 $33.97 71250 EAP CPT® 71250 CHG DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST OP $192.00 $0.00 $0.00 $192.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $393.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.00 $192.00 $177.05 $192.00 71260 EAP CPT® 71260 CHG DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/CONTRAST OP $202.00 $0.00 $0.00 $202.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.00 $202.00 $202.00 $202.00 71270 EAP CPT® 71270 CHG DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX C-/C+ OP $224.00 $0.00 $0.00 $224.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.00 $224.00 $224.00 $224.00 71271 EAP CPT® 71271 CHG COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C- OP $157.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 71275 EAP CPT® 71275 "PR CT ANGIO, CHEST (NON-CORON), COMBO, INCL IMG PROC" OP $279.00 $0.00 $0.00 $279.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $279.00 $279.00 $279.00 $279.00 71550 EAP CPT® 71550 "PR MRI, CHEST" OP $289.00 $0.00 $0.00 $289.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.00 $289.00 $289.00 $289.00 71552 EAP CPT® 71552 "PR MRI, CHEST, COMBO" OP $344.00 $0.00 $0.00 $344.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $344.00 $344.00 $344.00 $344.00 72020 EAP CPT® 72020 PR X-RAY SPINE ONE VIEW OP $25.00 $0.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $22.94 $14.89 $22.94 72040 EAP CPT® 72040 CHG RADEX SPINE CERVICAL 2 OR 3 VIEWS OP $36.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $34.77 $21.33 $34.77 72050 EAP CPT® 72050 CHG RADEX SPINE CERVICAL 4 OR 5 VIEWS OP $48.00 $0.00 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.00 $48.00 $31.11 $48.00 72052 EAP CPT® 72052 CHG RADEX SPINE CERVICAL 6 OR MORE VIEWS OP $55.00 $0.00 $0.00 $55.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.00 $55.00 $38.26 $55.00 72070 EAP CPT® 72070 CHG X-RAY THORACIC SPINE 2 VW OP $34.00 $0.00 $0.00 $34.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.00 $34.00 $22.45 $34.00 72074 EAP CPT® 72074 CHG X-RAY THORACIC SPINE 4 VW OP $38.00 $0.00 $0.00 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.00 $38.00 $28.92 $38.00 72080 EAP CPT® 72080 CHG X-RAY THOR-LUMB SP 2 VW OP $36.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $35.87 $22.90 $35.87 72081 EAP CPT® 72081 CHG RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW OP $41.00 $0.00 $0.00 $41.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.00 $0.00 $23.17 $0.00 72082 EAP CPT® 72082 CHG RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW OP $50.00 $0.00 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.00 $0.00 $37.24 $0.00 72100 EAP CPT® 72100 CHG X-RAY LUMBAR SPINE 2/3 VW OP $35.00 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $35.00 $22.90 $35.00 72110 EAP CPT® 72110 CHG X-RAY LUMBAR SPINE 4 VW OP $50.00 $0.00 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.00 $50.00 $31.56 $50.00 72114 EAP CPT® 72114 PR RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 OP $59.00 $0.00 $0.00 $59.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.00 $59.00 $39.81 $59.00 72120 EAP CPT® 72120 PR RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS OP $35.00 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $35.00 $28.48 $35.00 72125 EAP CPT® 72125 "PR CT SCAN,CERVICAL SPINE,W/O CONTRAST" OP $177.00 $0.00 $0.00 $177.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.00 $177.00 $177.00 $177.00 72126 EAP CPT® 72126 PR CT SCAN CERV SPINE CONTRAST OP $188.00 $0.00 $0.00 $188.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $188.00 $188.00 $188.00 $188.00 72127 EAP CPT® 72127 PR CT SCAN CERV SP COMBO OP $201.00 $0.00 $0.00 $201.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.00 $201.00 $201.00 $201.00 72128 EAP CPT® 72128 "PR CT SCAN,THORACIC SPINE,W/O CONTRAST" OP $177.00 $0.00 $0.00 $177.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.00 $177.00 $177.00 $177.00 72129 EAP CPT® 72129 PR CT SCAN DORSAL SP CONTRAST OP $187.00 $0.00 $0.00 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.00 $187.00 $187.00 $187.00 72131 EAP CPT® 72131 "PR CT SCAN,LUMBAR SPINE,W/O CONTRAST" OP $176.00 $0.00 $0.00 $176.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $383.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.00 $176.00 $176.00 $176.00 72132 EAP CPT® 72132 PR CT SCAN LUMBAR SP CONTRAST OP $187.00 $0.00 $0.00 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.00 $187.00 $187.00 $187.00 72133 EAP CPT® 72133 PR CT SCAN LUMBAR SP COMBO OP $194.00 $0.00 $0.00 $194.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.00 $194.00 $194.00 $194.00 72141 EAP CPT® 72141 "PR MRI, CERV SPINE" OP $253.00 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $253.00 $253.00 $253.00 $253.00 72146 EAP CPT® 72146 "PR MRI, DORSAL SPINE" OP $236.00 $0.00 $0.00 $236.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.00 $236.00 $236.00 $236.00 72147 EAP CPT® 72147 "PR MRI, DORSAL SPINE CONTRAST" OP $301.00 $0.00 $0.00 $301.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $301.00 $301.00 $301.00 $301.00 72148 EAP CPT® 72148 "PR MRI, LUMBAR SPINE" OP $228.00 $0.00 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.00 $228.00 $228.00 $228.00 72156 EAP CPT® 72156 "PR MRI, CERV SPINE COMBO" OP $352.00 $0.00 $0.00 $352.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.00 $352.00 $352.00 $352.00 72157 EAP CPT® 72157 "PR MRI, DORSAL SPINE COMBO" OP $352.00 $0.00 $0.00 $352.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.00 $352.00 $352.00 $352.00 72158 EAP CPT® 72158 "PR MRI, LUMBAR SPINE COMBO" OP $352.00 $0.00 $0.00 $352.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $352.00 $352.00 $352.00 $352.00 72170 EAP CPT® 72170 CHG X-RAY PELVIS 1/2 VW OP $31.00 $0.00 $0.00 $31.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.00 $27.39 $17.79 $27.39 72190 EAP CPT® 72190 CHG X-RAY PELVIS 3+ VW OP $39.00 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.00 $36.93 $22.69 $36.93 72192 EAP CPT® 72192 "PR CT SCAN,PELVIS,W/O CONTRAST" OP $167.00 $0.00 $0.00 $167.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $167.00 $167.00 $167.00 72193 EAP CPT® 72193 PR CT SCAN OF PELVIS CONTRAST OP $177.00 $0.00 $0.00 $177.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $286.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.00 $177.00 $177.00 $177.00 72194 EAP CPT® 72194 PR CT SCAN OF PELVIS COMBO OP $187.00 $0.00 $0.00 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.00 $187.00 $187.00 $187.00 72195 EAP CPT® 72195 "PR MRI, PELVIS, W/O CONTRAST" OP $237.00 $0.00 $0.00 $237.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $237.00 $237.00 $237.00 $237.00 72196 EAP CPT® 72196 "PR MRI, PELVIS W/CONTRAST" OP $274.00 $0.00 $0.00 $274.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $274.00 $274.00 $274.00 $274.00 72197 EAP CPT® 72197 "PR MRI, PELVIS, COMBO" OP $335.00 $0.00 $0.00 $335.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $335.00 $335.00 $335.00 $335.00 72200 EAP CPT® 72200 CHG X-RAY SACROILIAC JTS <3 VW OP $29.00 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.00 $28.13 $17.79 $28.13 72220 EAP CPT® 72220 CHG X-RAY SACRUM/COCCYX 2+ VW OP $30.00 $0.00 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.00 $29.85 $19.12 $29.85 73000 EAP CPT® 73000 PR X-RAY CLAVICLE OP $26.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $26.00 $17.35 $26.00 73010 EAP CPT® 73010 PR X-RAY SCAPULA OP $32.00 $0.00 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.00 $28.13 $17.79 $28.13 73020 EAP CPT® 73020 CHG X-RAY SHOULDER 1 VW OP $24.00 $0.00 $0.00 $24.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.00 $24.00 $16.23 $24.00 73030 EAP CPT® 73030 CHG X-RAY SHOULDER 2+ VW OP $32.00 $0.00 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.00 $30.24 $19.33 $30.24 73060 EAP CPT® 73060 CHG X-RAY HUMERUS OP $29.00 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.00 $29.00 $19.12 $29.00 73070 EAP CPT® 73070 CHG X-RAY ELBOW 2 VW OP $26.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $26.00 $17.13 $26.00 73080 EAP CPT® 73080 CHG X-RAY ELBOW 3+ VW OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $28.00 $19.12 $28.00 73090 EAP CPT® 73090 CHG X-RAY FOREARM 2 VW OP $26.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $26.00 $17.35 $26.00 73100 EAP CPT® 73100 CHG X-RAY WRIST 2 VW OP $26.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $26.00 $17.12 $26.00 73110 EAP CPT® 73110 CHG X-RAY WRIST 3+ VW OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $28.00 $18.01 $28.00 73120 EAP CPT® 73120 CHG X-RAY HAND 2 VW OP $26.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $26.00 $17.12 $26.00 73130 EAP CPT® 73130 CHG X-RAY HAND 3+ VW OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $28.00 $18.01 $28.00 73140 EAP CPT® 73140 CHG X-RAY EXAM OF FINGER(S) OP $22.00 $0.00 $0.00 $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.00 $22.00 $14.45 $22.00 73200 EAP CPT® 73200 "PR CT SCAN,UPPER EXTREMITY,W/O CONTRAST" OP $154.00 $0.00 $0.00 $154.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.00 $154.00 $151.85 $154.00 73201 EAP CPT® 73201 PR CT SCAN OF ARM CONTRAST OP $177.00 $0.00 $0.00 $177.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.00 $177.00 $177.00 $177.00 73202 EAP CPT® 73202 PR CT SCAN OF ARM COMBO OP $187.00 $0.00 $0.00 $187.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.00 $187.00 $187.00 $187.00 73206 EAP CPT® 73206 "PR CT ANGIO,UPPER EXTREM,COMBO" OP $275.00 $0.00 $0.00 $275.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $275.00 $275.00 $246.00 $275.00 73218 EAP CPT® 73218 "PR MRI, UPPER EXTREM" OP $208.00 $0.00 $0.00 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.00 $208.00 $208.00 $208.00 73220 EAP CPT® 73220 "PR MRI UPPER EXTR, W/CONTRAST" OP $329.00 $0.00 $0.00 $329.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $329.00 $329.00 $313.04 $329.00 73221 EAP CPT® 73221 "PR MRI, JOINT UPPER EXTREM" OP $211.00 $0.00 $0.00 $211.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $211.00 $211.00 $211.00 $211.00 73222 EAP CPT® 73222 "PR MRI, JOINT UPPER EXTREM W/CONTRAST" OP $251.00 $0.00 $0.00 $251.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.00 $251.00 $251.00 $251.00 73223 EAP CPT® 73223 "PR MRI, JOINT UPPER EXTREM COMBO" OP $329.00 $0.00 $0.00 $329.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $329.00 $329.00 $329.00 $329.00 73501 EAP CPT® 73501 CHG RADEX HIP UNILATERAL WITH PELVIS 1 VIEW OP $29.00 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.00 $0.00 $17.65 $0.00 73502 EAP CPT® 73502 CHG RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS OP $35.00 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $0.00 $24.68 $0.00 73503 EAP CPT® 73503 CHG RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS OP $42.00 $0.00 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.00 $0.00 $30.85 $0.00 73521 EAP CPT® 73521 CHG RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS OP $35.00 $0.00 $0.00 $35.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $0.00 $23.62 $0.00 73522 EAP CPT® 73522 CHG RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS OP $45.00 $0.00 $0.00 $45.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.00 $0.00 $29.14 $0.00 73523 EAP CPT® 73523 CHG RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS OP $49.00 $0.00 $0.00 $49.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.00 $0.00 $33.82 $0.00 73551 EAP CPT® 73551 CHG RADIOLOGIC EXAMINATION FEMUR 1 VIEW OP $26.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $0.00 $16.37 $0.00 73552 EAP CPT® 73552 CHG RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $0.00 $19.36 $0.00 73560 EAP CPT® 73560 CHG X-RAY KNEE 1 OR 2 VIEW OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $28.00 $17.79 $28.00 73562 EAP CPT® 73562 CHG X-RAY KNEE 3 VIEW OP $29.00 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.00 $29.00 $19.56 $29.00 73564 EAP CPT® 73564 CHG X-RAY KNEE 4+ VIEW OP $37.00 $0.00 $0.00 $37.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.00 $36.23 $21.78 $36.23 73590 EAP CPT® 73590 "CHG X-RAY TIB + FIB, 2VW" OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $27.76 $17.79 $27.76 73592 EAP CPT® 73592 "CHG X-RAY LEG, INFANT" OP $25.00 $0.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $25.00 $17.12 $25.00 73600 EAP CPT® 73600 CHG X-RAY ANKLE 2 VW OP $26.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $26.00 $17.12 $26.00 73610 EAP CPT® 73610 CHG X-RAY ANKLE 3+ VW OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $28.00 $18.01 $28.00 73620 EAP CPT® 73620 CHG X-RAY FOOT 2 VW OP $25.00 $0.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $25.00 $17.12 $25.00 73630 EAP CPT® 73630 CHG X-RAY FOOT 3+ VW OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $28.00 $18.01 $28.00 73650 EAP CPT® 73650 CHG X-RAY HEEL OP $25.00 $0.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $25.00 $16.68 $25.00 73660 EAP CPT® 73660 CHG X-RAY TOE(S) OP $22.00 $0.00 $0.00 $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.00 $22.00 $14.45 $22.00 73700 EAP CPT® 73700 "PR CT SCAN,LOWER EXTREMITY,W/O CONTRAST" OP $154.00 $0.00 $0.00 $154.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.00 $154.00 $151.85 $154.00 73701 EAP CPT® 73701 PR CT SCAN OF LEG CONTRAST OP $177.00 $0.00 $0.00 $177.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.00 $177.00 $177.00 $177.00 73702 EAP CPT® 73702 PR CT SCAN OF LEG COMBO OP $186.00 $0.00 $0.00 $186.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $186.00 $186.00 $186.00 $186.00 73706 EAP CPT® 73706 "PR CT ANGIO,LOWER EXTREM,COMBO,IMAGE PRC" OP $288.00 $0.00 $0.00 $288.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $288.00 $288.00 $246.00 $288.00 73718 EAP CPT® 73718 "PR MRI, LOWER EXTREM" OP $207.00 $0.00 $0.00 $207.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $207.00 $207.00 $207.00 $207.00 73719 EAP CPT® 73719 "PR MRI, LOWER EXTREM W/CONTRAST" OP $250.00 $0.00 $0.00 $250.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $250.00 $250.00 $250.00 $250.00 73720 EAP CPT® 73720 "PR MRI, LOWER EXTR, W/O CONTRAST F/U BY CONTRAST" OP $328.00 $0.00 $0.00 $328.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.00 $328.00 $313.04 $328.00 73721 EAP CPT® 73721 "PR MRI LOWER EXTREM JT, W/O CONTRAST" OP $208.00 $0.00 $0.00 $208.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $208.00 $208.00 $208.00 $208.00 73723 EAP CPT® 73723 "PR MRI, JOINT OF LEG. COMBO" OP $329.00 $0.00 $0.00 $329.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $329.00 $329.00 $329.00 $329.00 74018 EAP CPT® 74018 CHG RADIOLOGIC EXAM ABDOMEN 1 VIEW OP $28.00 $0.00 $0.00 $28.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.00 $0.00 $16.42 $0.00 74019 EAP CPT® 74019 CHG RADIOLOGIC EXAM ABDOMEN 2 VIEWS OP $36.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $0.00 $20.03 $0.00 74022 EAP CPT® 74022 CHG RADIOLOGIC EXAM COMPLETE ACUTE ABDOMEN SERIES OP $51.00 $0.00 $0.00 $51.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.00 $44.51 $27.76 $44.51 74150 EAP CPT® 74150 "PR CT SCAN,ABDOMEN,W/O CONTRAST" OP $196.00 $0.00 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $406.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.00 $196.00 $171.89 $196.00 74160 EAP CPT® 74160 PR CT SCAN OF ABDOMEN CONTRAST OP $219.00 $0.00 $0.00 $219.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $540.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.00 $219.00 $202.49 $219.00 74170 EAP CPT® 74170 PR CT SCAN OF ABDOMEN COMBO OP $236.00 $0.00 $0.00 $236.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.00 $236.00 $236.00 $236.00 74174 EAP CPT® 74174 PR CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMGES OP $335.00 $0.00 $0.00 $335.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $335.00 $0.00 $335.00 $0.00 74175 EAP CPT® 74175 "PR CT ANGIO, ABD, COMBO,INCL IMAGE PROC" OP $278.00 $0.00 $0.00 $278.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.00 $278.00 $273.93 $278.00 74176 EAP CPT® 74176 "CHG CT SCAN,ABDOMENT AND PELVIS,W/O CONTRAST" OP $267.00 $0.00 $0.00 $267.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $370.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $267.00 $0.00 $128.75 $0.00 74177 EAP CPT® 74177 "CHG CT SCAN,ABDOMENT AND PELVIS,W CONTRAST" OP $280.00 $0.00 $0.00 $280.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $920.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $280.00 $0.00 $202.47 $0.00 74178 EAP CPT® 74178 "CHG CT SCAN,ABDOMENT AND PELVIS,COMBO" OP $307.00 $0.00 $0.00 $307.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,030.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.00 $0.00 $256.29 $0.00 74181 EAP CPT® 74181 "PR MRI, ABDOMEN (MRI)" OP $271.00 $0.00 $0.00 $271.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.00 $271.00 $271.00 $271.00 74183 EAP CPT® 74183 "PR MRI, ABDOMEN, COMBO" OP $335.00 $0.00 $0.00 $335.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $335.00 $335.00 $335.00 $335.00 74220 EAP CPT® 74220 CHG RADIOLOGIC EXAM ESOPHAGUS SINGLE CONTRAST STUDY OP $92.00 $0.00 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.00 $72.96 $42.89 $72.96 74221 EAP CPT® 74221 CHG RADIOLOGIC EXAM ESOPHAGUS DOUBLE CONTRAST STUDY OP $107.00 $0.00 $0.00 $107.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.00 $0.00 $65.33 $0.00 74240 EAP CPT® 74240 CHG RADIOLOGIC EXAM UPR GI TRC SINGLE CONTRAST STUDY OP $124.00 $0.00 $0.00 $124.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.00 $93.96 $56.60 $93.96 74246 EAP CPT® 74246 CHG RADIOLOGIC EXAM UPR GI TRC DOUBLE CONTRAST STUDY OP $138.00 $0.00 $0.00 $138.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.00 $104.11 $61.07 $104.11 74248 EAP CPT® 74248 CHG RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY OP $107.00 $0.00 $0.00 $107.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.00 $0.00 $49.54 $0.00 74250 EAP CPT® 74250 CHG RADIOLOGIC EXAM SMALL INT SINGLE CONTRAST STUDY OP $126.00 $0.00 $0.00 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.00 $81.00 $45.78 $81.00 74270 EAP CPT® 74270 CHG RADIOLOGIC EXAM COLON SINGLE CONTRAST STUDY OP $159.00 $0.00 $0.00 $159.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.00 $112.83 $62.62 $112.83 74420 EAP CPT® 74420 PR X-RAY RETROGRADE PYELOGRAM OP $217.91 $0.00 $0.00 $157.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.94 $0.00 $73.78 $0.00 74430 EAP CPT® 74430 "X-RAY CYSTOGRAM, MIN 3 VIEW" OP $58.00 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.28 $58.00 $35.36 $58.00 74450 EAP CPT® 74450 PR X-RAY URETHROCYSTOGRAM OP $61.00 $0.00 $0.00 $61.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.00 $0.00 $45.19 $0.00 74455 EAP CPT® 74455 PR X-RAY URETHROCYSTOGRAM+VOIDING OP $63.00 $0.00 $0.00 $63.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.00 $63.00 $48.09 $63.00 74740 EAP CPT® 74740 PR X-RAY HYSTEROSALPINGOGRAM OP $73.00 $0.00 $0.00 $73.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.00 $71.22 $43.14 $71.22 75561 EAP CPT® 75561 PR CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ OP $391.00 $0.00 $0.00 $391.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $391.00 $0.00 $391.00 $0.00 75565 EAP CPT® 75565 CHG CARDIAC MRI FOR VELOCITY FLOW MAPPING OP $38.00 $0.00 $0.00 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.00 $0.00 $38.00 $0.00 75571 EAP CPT® 75571 PR CT HRT W/O DYE W/CA TEST OP $89.00 $0.00 $0.00 $89.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.00 $0.00 $40.15 $0.00 75572 EAP CPT® 75572 PR CT HEART W 3D IMAGE OP $266.00 $0.00 $0.00 $266.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $266.00 $0.00 $124.05 $0.00 75574 EAP CPT® 75574 PR CT ANGIOGRAM HEART W 3D IMAGE OP $362.00 $0.00 $0.00 $362.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $362.00 $0.00 $216.24 $0.00 75605 EAP CPT® 75605 PR ANGIO AORTOGRAM THOR SERIAL OP $203.00 $0.00 $0.00 $203.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.96 $203.00 $203.00 $203.00 75625 EAP CPT® 75625 PR ANGIO AORTOGRAM ABD SERIAL OP $215.00 $0.00 $0.00 $215.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.39 $215.00 $215.00 $215.00 75630 EAP CPT® 75630 PR ANGIO AORTOBIFEMORAL W CATH OP $338.00 $0.00 $0.00 $338.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.87 $338.00 $338.00 $338.00 75635 EAP CPT® 75635 "PR CT ANGIO AORTOBIFEMORAL, COMBO" OP $471.00 $0.00 $0.00 $471.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.00 $420.20 $298.80 $420.20 75705 EAP CPT® 75705 PR ANGIO SPINAL SELECTV OP $422.00 $0.00 $0.00 $422.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.93 $422.00 $368.07 $422.00 75710 EAP CPT® 75710 PR ANGIO EXTREMITY UNILAT OP $265.00 $0.00 $0.00 $265.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $219.63 $265.00 $265.00 $265.00 75716 EAP CPT® 75716 PR ANGIO EXTERMITY BILAT OP $293.00 $0.00 $0.00 $293.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.88 $293.00 $293.00 $293.00 75726 EAP CPT® 75726 PR ANGIO VISCERAL SELECTV/SUBSELEC OP $301.00 $0.00 $0.00 $301.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.77 $301.00 $301.00 $301.00 75736 EAP CPT® 75736 PR ANGIO PELVIS OP $202.00 $0.00 $0.00 $202.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $202.00 $202.00 $202.00 $202.00 75741 EAP CPT® 75741 PR ANGIO PULMON UNILAT SELECT OP $253.00 $0.00 $0.00 $253.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.10 $253.00 $253.00 $253.00 75756 EAP CPT® 75756 PR ANGIO INTERN MAMMARY OP $203.00 $0.00 $0.00 $203.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.00 $203.00 $203.00 $203.00 75774 EAP CPT® 75774 PR ANGIO EA ADDNL SELECTV VESSEL OP $149.00 $0.00 $0.00 $149.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.82 $149.00 $149.00 $149.00 75805 EAP CPT® 75805 PR LYMPHANGIO ABD/PELV UNILAT OP $137.00 $0.00 $0.00 $137.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.00 $0.00 $137.00 $0.00 75820 EAP CPT® 75820 PR VENOGRAM EXTREM UNILAT OP $161.00 $0.00 $0.00 $154.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.77 $87.16 $44.74 $87.16 75822 EAP CPT® 75822 PR VENOGRAM EXTREM BILAT OP $201.00 $0.00 $0.00 $184.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.58 $119.44 $68.24 $119.44 75825 EAP CPT® 75825 PR VENOGRAM INFER VENA CAVA OP $170.00 $0.00 $0.00 $170.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $170.00 $170.00 $170.00 $170.00 75827 EAP CPT® 75827 PR VENOGRAM SUPER VENA CAVA OP $171.00 $0.00 $0.00 $171.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.00 $171.00 $171.00 $171.00 75860 EAP CPT® 75860 PR VENOGRAM SINUS/JUGULAR OP $172.00 $0.00 $0.00 $172.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.00 $172.00 $172.00 $172.00 75889 EAP CPT® 75889 PR VENOGRAM HEPATIC W HEMODYNAMICS OP $166.00 $0.00 $0.00 $166.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.00 $166.00 $166.00 $166.00 75891 EAP CPT® 75891 PR VENOGRAM HEPATIC OP $169.00 $0.00 $0.00 $169.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.00 $169.00 $169.00 $169.00 75893 EAP CPT® 75893 PR VENOUS SAMPLING BY CATHETER OP $83.00 $0.00 $0.00 $83.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.00 $83.00 $83.00 $83.00 75894 EAP CPT® 75894 PR TRANSCATHETER RX EMBOLIZATN OP $221.00 $0.00 $0.00 $221.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.00 $0.00 $221.00 $0.00 75898 EAP CPT® 75898 CHG ANGRPH CATH F-UP STD TCAT OTHER THAN THROMBYLSIS OP $336.00 $0.00 $0.00 $169.27 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.27 $0.00 $77.06 $0.00 75901 EAP CPT® 75901 "PR REMOVE,OBST MATL,CVA DEV VIA SEP VEN ACC" OP $72.00 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.00 $72.00 $0.00 $72.00 75956 EAP CPT® 75956 PR ENDOVASC REPAIR THOR AORTA INCL SUBCLAVIAN OP "$1,060.00 " $0.00 $0.00 $470.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $470.07 $0.00 $0.00 $0.00 75957 EAP CPT® 75957 PR ENDOVASC REPAIR THOR AORTA EXCL SUBCLAVIAN OP $908.00 $0.00 $0.00 $403.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $403.68 $0.00 $0.00 $0.00 75970 EAP CPT® 75970 PR VASCULAR BIOPSY OP $133.00 $0.00 $0.00 $133.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.00 $0.00 $0.00 $0.00 75984 EAP CPT® 75984 CHANGE PERCUT TUBE/DRAIN CATH W CONTRAST MONIT OP $146.00 $0.00 $0.00 $142.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.45 $110.00 $69.11 $110.00 76000 EAP CPT® 76000 CHG FLUOROSCOPY SPX UP TO 1 HOUR PHYS/QHP TIME OP $48.00 $0.00 $0.00 $48.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.00 $48.00 $36.56 $48.00 76080 EAP CPT® 76080 "PR X-RAY FISTULA,ABSCESS,SINUS TRACT" OP $80.00 $0.00 $0.00 $73.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $73.99 $65.17 $42.16 $65.17 76098 EAP CPT® 76098 "PR X-RAY EXAM, BREAST SPECIMEN" OP $49.00 $0.00 $0.00 $22.26 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.26 $22.24 $0.00 $22.24 76376 EAP CPT® 76376 CHG 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION OP $30.00 $0.00 $0.00 $30.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.00 $30.00 $30.00 $30.00 76377 EAP CPT® 76377 CHG 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION OP $122.00 $0.00 $0.00 $122.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.29 $122.00 $116.86 $122.00 76506 EAP CPT® 76506 "PR US, HEAD, REAL TIME" OP $110.00 $0.00 $0.00 $110.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $110.00 $94.74 $54.17 $94.74 76512 EAP CPT® 76512 "US, EYE B-SCAN" OP $147.00 $0.00 $0.00 $124.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.40 $109.65 $58.64 $109.65 76514 EAP CPT® 76514 "US, EYE, FOR CORNEAL THICKNESS" OP $30.00 $0.00 $0.00 $20.37 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.37 $12.08 $7.48 $12.08 76516 EAP CPT® 76516 "US, EYE BIOMETRY" OP $98.00 $0.00 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.00 $72.86 $47.98 $72.86 76519 EAP CPT® 76519 "US, EYE BIOMETRY W LENS CALC" OP $96.00 $0.00 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.00 $76.52 $47.98 $76.52 76536 EAP CPT® 76536 "US, HEAD/NECK TISSUES,REAL TIME" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $89.99 $51.53 $89.99 76604 EAP CPT® 76604 "PR US, CHEST,REAL TIME" OP $160.00 $0.00 $0.00 $118.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.24 $78.66 $48.43 $78.66 76641 EAP CPT® 76641 CHG US BREAST UNI REAL TIME WITH IMAGE COMPLETE OP $111.00 $0.00 $0.00 $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.00 $0.00 $65.00 $0.00 76642 EAP CPT® 76642 CHG US BREAST UNI REAL TIME WITH IMAGE LIMITED OP $104.00 $0.00 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.00 $0.00 $53.50 $0.00 76700 EAP CPT® 76700 "PR US, ABDOM,B-SCAN &/OR REAL TIME,COMPLETE" OP $132.00 $0.00 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.00 $121.18 $72.20 $121.18 76705 EAP CPT® 76705 "PR US, ABDOMEN LIMITED" OP $220.00 $0.00 $0.00 $122.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $183.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $122.99 $89.29 $52.42 $89.29 76706 EAP CPT® 76706 CHG US ABDOMINAL AORTA REAL TIME SCREEN STUDY AAA OP $84.00 $0.00 $0.00 $84.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.00 $0.00 $56.62 $0.00 76770 EAP CPT® 76770 "PR US,RETROPERIT,REAL TIME,COMPLETE" OP $275.00 $0.00 $0.00 $152.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $152.43 $117.39 $70.22 $117.39 76775 EAP CPT® 76775 "US, RETROPERITNL ABD, LTD" OP $140.00 $0.00 $0.00 $88.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.79 $88.89 $52.20 $88.89 76776 EAP CPT® 76776 "PR US,TRANSPLANTED KIDNEY, REAL TIME/ DOPPLER" OP $118.00 $0.00 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.00 $118.00 $74.54 $118.00 76801 EAP CPT® 76801 "CHG US, OB < 14 WKS, SINGLE FETUS" OP $153.00 $0.00 $0.00 $153.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.00 $129.32 $56.88 $129.32 76802 EAP CPT® 76802 "CHG US, OB < 14 WKS, ADD'L FETUS" OP $127.00 $0.00 $0.00 $87.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.19 $80.19 $44.37 $80.19 76805 EAP CPT® 76805 "CHG US, OB >/= 14 WKS, SNGL FETUS" OP $345.00 $0.00 $0.00 $191.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.31 $134.09 $81.47 $134.09 76810 EAP CPT® 76810 "CHG US, OB >/= 14 WKS, ADDL FETUS" OP $151.00 $0.00 $0.00 $125.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.67 $95.77 $151.00 $95.77 76811 EAP CPT® 76811 "CHG US,PREG UTER,FET & MAT,+ DETL FET EXM" OP $290.00 $0.00 $0.00 $245.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $245.05 $228.00 $148.76 $228.00 76812 EAP CPT® 76812 "CHG US,PREG UTER,FET & MAT,+ DETL FET,ADDL" OP $272.00 $0.00 $0.00 $272.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $272.00 $148.77 $87.42 $148.77 76813 EAP CPT® 76813 "CHG US,PREG UTER,NUCHAL MEAS, 1ST TRIMEST, SINGLETON" OP $181.00 $0.00 $0.00 $163.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $163.10 $123.47 $74.24 $123.47 76815 EAP CPT® 76815 "CHG US,PREGNANT UTERUS,LIMITED, 1/> FETUSES" OP $100.00 $0.00 $0.00 $100.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $100.00 $87.62 $54.62 $87.62 76816 EAP CPT® 76816 "CHG US,PREGNANT UTERUS,F/U,TRANSABD APP" OP $130.00 $0.00 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.00 $94.10 $44.84 $94.10 76817 EAP CPT® 76817 "CHG US,PREGNANT UTERUS,TRANSVAGINAL" OP $235.00 $0.00 $0.00 $130.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.99 $96.08 $59.19 $96.08 76818 EAP CPT® 76818 CHG FETAL BIOPHYSICAL PROFILE OP $160.00 $0.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.00 $116.73 $63.26 $116.73 76819 EAP CPT® 76819 "CHG FETAL BIOPHYS PROF,W/O NST" OP $118.00 $0.00 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.00 $97.73 $60.35 $97.73 76820 EAP CPT® 76820 CHG DOPPLER FETAL UMBILICAL ARTERY OP $77.00 $0.00 $0.00 $77.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.50 $77.00 $57.99 $77.00 76821 EAP CPT® 76821 CHG DOPPLER FETAL MID CEREBRAL ARTERY OP $106.00 $0.00 $0.00 $106.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.00 $98.16 $64.44 $98.16 76825 EAP CPT® 76825 CHG SONO FETAL HEART OP $252.00 $0.00 $0.00 $252.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $252.00 $175.08 $95.84 $175.08 76826 EAP CPT® 76826 CHG SONO FETAL HEART F/U OP $126.00 $0.00 $0.00 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.00 $84.67 $47.37 $84.67 76827 EAP CPT® 76827 PR SONO FETAL HEART DOPPLER OP $88.00 $0.00 $0.00 $88.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.00 $87.62 $64.71 $87.62 76828 EAP CPT® 76828 PR SONO FETAL HRT DOPPL F/U OP $85.00 $0.00 $0.00 $72.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.06 $65.76 $45.48 $65.76 76830 EAP CPT® 76830 "CHG ECHOGRAPHY,TRANSVAGINAL" OP $118.00 $0.00 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.00 $100.81 $58.16 $100.81 76831 EAP CPT® 76831 "PR SONO EXAM, HYSTEROSONOGRAPHY" OP $131.00 $0.00 $0.00 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.00 $103.10 $59.26 $103.10 76856 EAP CPT® 76856 "PR US,PELVIC (NONOBSTETRIC),REAL TIME,COMPLETE" OP $105.00 $0.00 $0.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.00 $101.55 $58.16 $101.55 76857 EAP CPT® 76857 "PR US,PELVIC (NONOBSTETRIC),REAL TIME,LIMITED" OP $76.00 $0.00 $0.00 $76.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.01 $76.00 $37.33 $76.00 76870 EAP CPT® 76870 "PR ECHO,SCROTUM & CONTENTS" OP $97.00 $0.00 $0.00 $97.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.60 $97.00 $56.62 $97.00 76872 EAP CPT® 76872 "PR ECHO,TRANSRECTAL" OP $103.00 $0.00 $0.00 $103.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.00 $103.00 $58.38 $103.00 76873 EAP CPT® 76873 "PR ECHO,TRANSRECTAL,PROSTATE VOL" OP $240.00 $0.00 $0.00 $225.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.47 $165.91 $91.22 $165.91 76881 EAP CPT® 76881 "CHG US,EXTREMITY,NONVASCULAR,REAL-TIME IMAGE,COMPLETE" OP $96.00 $0.00 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.00 $0.00 $68.54 $0.00 76882 EAP CPT® 76882 CHG US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG OP $75.00 $0.00 $0.00 $48.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $104.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.31 $0.00 $17.93 $0.00 76937 EAP CPT® 76937 "CHG US GUIDE, VASCULAR ACCESS" OP $95.00 $0.00 $0.00 $42.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.23 $33.43 $20.85 $33.43 76942 EAP CPT® 76942 PR SONO GUIDE NEEDLE BIOPSY OP $126.00 $0.00 $0.00 $106.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $81.55 $106.83 $57.72 $106.83 76946 EAP CPT® 76946 PR SONO GUIDE AMNIOCENTESIS OP $87.00 $0.00 $0.00 $66.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.05 $66.66 $48.50 $66.66 76975 EAP CPT® 76975 PR GI ENDOSCOPIC ULTRASOUND OP $259.00 $0.00 $0.00 $139.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.73 $0.00 $61.89 $0.00 76998 EAP CPT® 76998 "PR ULTRASONIC GUIDANCE, INTRAOPERATIVE" OP $195.00 $0.00 $0.00 $85.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.20 $0.00 $0.00 $0.00 77001 EAP CPT® 77001 "PR FLUOROGUIDE CNTRL VEN ACCESS,PLACE,REPLACE,REMOVE" OP $162.00 $0.00 $0.00 $94.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $94.05 $80.26 $49.83 $80.26 77002 EAP CPT® 77002 CHG FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT ADD ON OP $105.00 $0.00 $0.00 $105.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $334.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $105.00 $73.53 $44.85 $73.53 77003 EAP CPT® 77003 CHG FLUOR NEEDLE/CATH SPINE/PARASPINAL DX/THER ADDON OP $322.00 $0.00 $0.00 $114.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.43 $71.44 $43.42 $71.44 77012 EAP CPT® 77012 PR CT GUIDANCE NEEDLE PLACEMENT OP $227.00 $0.00 $0.00 $227.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $167.00 $227.00 $195.29 $227.00 77014 EAP CPT® 77014 PR CT GUIDANCE PLACEMENT RAD THERAPY FIELDS OP $138.00 $0.00 $0.00 $138.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.00 $136.96 $102.63 $136.96 77047 EAP CPT® 77047 CHG MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL OP $246.00 $0.00 $0.00 $246.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $246.00 $0.00 $153.79 $0.00 77049 EAP CPT® 77049 CHG MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERAL OP $353.00 $0.00 $0.00 $353.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $353.00 $0.00 $242.93 $0.00 77061 EAP CPT® 77061 CHG DIGITAL BREAST TOMOSYNTHESIS UNILATERAL OP $472.00 $0.00 $0.00 $171.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $171.96 $0.00 $0.00 $0.00 77063 EAP CPT® 77063 CHG SCREENING DIGITAL BREAST TOMOSYNTHESIS BI OP $92.00 $0.00 $0.00 $74.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $149.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.00 $0.00 $33.31 $0.00 77065 EAP CPT® 77065 CHG DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI OP $126.00 $0.00 $0.00 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.00 $0.00 $81.59 $0.00 77066 EAP CPT® 77066 CHG DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ BI OP $154.00 $0.00 $0.00 $154.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.00 $0.00 $102.24 $0.00 77067 EAP CPT® 77067 CHG SCREENING MAMMOGRAPHY BI 2-VIEW BREAST INC CAD OP $118.00 $0.00 $0.00 $118.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.00 $0.00 $83.06 $0.00 77071 EAP CPT® 77071 CHG MANUAL APPL STRESS PFRMD PHYS/QHP JOINT FILMS OP $162.00 $0.00 $0.00 $64.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $64.41 $28.65 $16.84 $28.65 77073 EAP CPT® 77073 "PR X-RAYS, BONE LENGTH STUDIES" OP $42.00 $0.00 $0.00 $42.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $42.00 $41.06 $25.29 $41.06 77074 EAP CPT® 77074 "PR X-RAYS, BONE SURVEY, LIMITED" OP $68.00 $0.00 $0.00 $68.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.00 $62.32 $38.26 $62.32 77075 EAP CPT® 77075 "PR X-RAYS, BONE SURVEY COMPLETE" OP $85.00 $0.00 $0.00 $85.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.00 $85.00 $53.42 $85.00 77077 EAP CPT® 77077 "PR JOINT SURVEY, SINGLE VIEW" OP $53.00 $0.00 $0.00 $52.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.81 $52.78 $32.52 $52.78 77080 EAP CPT® 77080 "PR DEXA,BONE DENSITY,AXIAL SKELETON" OP $41.00 $0.00 $0.00 $41.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.00 $41.00 $41.00 $41.00 77263 EAP CPT® 77263 CHG RADIATION THERAPY PLAN COMPLEX OP $811.00 $0.00 $0.00 $221.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.29 $157.43 $100.84 $157.43 77280 EAP CPT® 77280 CHG SET RADN THERAPY FIELD SIMPLE OP $173.00 $0.00 $0.00 $173.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $173.00 $173.00 $104.91 $173.00 77285 EAP CPT® 77285 CHG SET RADN THERAPY FIELD INTERME OP $270.00 $0.00 $0.00 $270.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.00 $270.00 $165.94 $270.00 77290 EAP CPT® 77290 CHG SET RADN THERAPY FIELD COMPLEX OP $395.00 $0.00 $0.00 $395.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $395.00 $384.94 $204.79 $384.94 77293 EAP CPT® 77293 CHG RESPIRATORY MOTION MANAGEMENT SIMULATION OP $328.00 $0.00 $0.00 $328.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $328.00 $0.00 $258.22 $0.00 77295 EAP CPT® 77295 CHG 3-D RADIOTHERAPY PLAN DOSE-VOLUME HISTOGRAMS OP $742.00 $0.00 $0.00 $742.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $657.40 $742.00 $742.00 $742.00 77300 EAP CPT® 77300 "CHG RADIATION THERAPY,DOSIMETRY PLAN" OP $101.00 $0.00 $0.00 $89.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.21 $78.46 $51.52 $78.46 77301 EAP CPT® 77301 CHG INTEN MOD RADIOTHER PLAN W/DOSE VOL HIST OP "$1,297.00 " $0.00 $0.00 "$1,297.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,297.00" "$1,297.00" $973.28 "$1,297.00" 77306 EAP CPT® 77306 CHG TELETHX ISODOSE PLN SMPL W/DOSIMETRY CALCULATION OP $228.00 $0.00 $0.00 $200.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.25 $0.00 $86.42 $0.00 77307 EAP CPT® 77307 CHG TELETHX ISODOSE PLN CPLX W/BASIC DOSIMETRY OP $472.00 $0.00 $0.00 $386.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $386.71 $168.68 $169.16 $168.68 77316 EAP CPT® 77316 CHG BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL OP $228.00 $0.00 $0.00 $228.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.00 $0.00 $110.87 $0.00 77317 EAP CPT® 77317 CHG BRACHYTX ISODOSE PLN INTERMED W/DOSIMETRY CAL OP $300.00 $0.00 $0.00 $300.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.00 $0.00 $145.05 $0.00 77321 EAP CPT® 77321 CHG TELETHER ISO-PORT PLAN OP $157.00 $0.00 $0.00 $157.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.30 $157.00 $126.44 $157.00 77332 EAP CPT® 77332 CHG RADN TREATMENT AID(S) SIMPLE OP $75.00 $0.00 $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $75.00 $49.10 $75.00 77334 EAP CPT® 77334 CHG RADN TREATMENT AID(S) COMPLX OP $196.00 $0.00 $0.00 $196.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.00 $177.25 $116.45 $177.25 77338 EAP CPT® 77338 CHG MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN OP $697.00 $0.00 $0.00 $680.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $680.70 $0.00 $224.85 $0.00 77427 EAP CPT® 77427 "CHG RADIATION,MANGEMENT,5 TX'S" OP $811.00 $0.00 $0.00 $247.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $247.86 $179.87 $98.74 $179.87 77470 EAP CPT® 77470 PR SPECIAL TREATMENT PROCEDURE OP $510.00 $0.00 $0.00 $438.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $209.05 $438.74 $331.70 $438.74 77770 EAP CPT® 77770 CHG HDR RDNCL NTRSTL/INTRCAV BRACHYTX 1 CHANNEL OP $318.00 $0.00 $0.00 $318.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $318.00 $0.00 $192.80 $0.00 77771 EAP CPT® 77771 CHG HDR RDNCL NTRSTL/INTRCAV BRACHYTX 2-12 CHANNEL OP $617.00 $0.00 $0.00 $617.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $617.00 $0.00 $358.76 $0.00 78012 EAP CPT® 78012 CHG THYROID UPTAKE SINGLE/MULTIPLE QUANT MEASUREMENT OP $29.00 $0.00 $0.00 $29.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.00 $0.00 $29.00 $0.00 78014 EAP CPT® 78014 CHG THYROID UPTAKE W/BLOOD FLOW SNGLE/MULT QUAN MEAS OP $75.00 $0.00 $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $0.00 $75.00 $0.00 78018 EAP CPT® 78018 PR THYROID MET IMAGING BODY OP $141.00 $0.00 $0.00 $141.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.00 $141.00 $141.00 $141.00 78070 EAP CPT® 78070 CHG PARATHYROID PLANAR IMAGING OP $133.00 $0.00 $0.00 $133.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.00 $133.00 $67.47 $133.00 78072 EAP CPT® 78072 CHG PARATHYROID IMAGING W/TOMOGRAPHIC SPECT & CT OP $236.00 $0.00 $0.00 $236.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.00 $0.00 $46.58 $0.00 78201 EAP CPT® 78201 PR LIVER IMAGING OP $98.00 $0.00 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.00 $98.00 $70.16 $98.00 78215 EAP CPT® 78215 PR LIVER AND SPLEEN IMAGING OP $92.00 $0.00 $0.00 $92.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.00 $92.00 $85.14 $92.00 78226 EAP CPT® 78226 PR HEPATOBILIARY SYST IMAGING INCLUDING GALLBLADDER OP $111.00 $0.00 $0.00 $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.00 $0.00 $111.00 $0.00 78227 EAP CPT® 78227 PR HEPATOBIL SYST IMAG INC GB W/PHARMA INTERVENJ OP $137.00 $0.00 $0.00 $137.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $137.00 $0.00 $137.00 $0.00 78264 EAP CPT® 78264 PR GASTRIC EMPTYING STUDY OP $130.00 $0.00 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.00 $130.00 $122.95 $130.00 78278 EAP CPT® 78278 PR ACUTE GI BLOOD LOSS IMAGING OP $159.00 $0.00 $0.00 $159.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.00 $159.00 $147.21 $159.00 78306 EAP CPT® 78306 "PR BONE IMAGING, WHOLE BODY" OP $135.00 $0.00 $0.00 $135.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.00 $135.00 $128.51 $135.00 78315 EAP CPT® 78315 "CHG BONE IMAGING, 3 PHASE" OP $155.00 $0.00 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.00 $155.00 $145.61 $155.00 78451 EAP CPT® 78451 PR NM CARDIAC PERFUSION SINGLE OP $206.00 $0.00 $0.00 $206.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.00 $0.00 $104.80 $0.00 78452 EAP CPT® 78452 PR NM CARDIAC SCAN OP $242.00 $0.00 $0.00 $242.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $242.00 $0.00 $179.12 $0.00 78453 EAP CPT® 78453 CHG MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS OP $153.00 $0.00 $0.00 $153.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $153.00 $0.00 $91.22 $0.00 78472 EAP CPT® 78472 "PR GATED HEART, PLANAR SINGLE" OP $148.00 $0.00 $0.00 $148.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $148.00 $148.00 $148.00 $148.00 78580 EAP CPT® 78580 PR PULMONARY PERFUSION IMAGING PARTICULATE OP $127.00 $0.00 $0.00 $127.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.00 $127.00 $104.88 $127.00 78582 EAP CPT® 78582 PR PULMONARY VENTILATION & PERFUSION IMAGING OP $161.00 $0.00 $0.00 $161.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.00 $0.00 $161.00 $0.00 78606 EAP CPT® 78606 BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW OP $130.00 $0.00 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.00 $130.00 $112.11 $130.00 78610 EAP CPT® 78610 PR BRAIN FLOW IMAGING ONLY OP $58.00 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.00 $58.00 $47.21 $58.00 78707 EAP CPT® 78707 "PR RENAL IMAGING, MORPH W/ FLOW/FUNC" OP $145.00 $0.00 $0.00 $145.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.00 $145.00 $136.49 $145.00 78708 EAP CPT® 78708 "PR RENAL IMAGING, MORPH W/ FLOW/FUNC, PHARM, SINGLE" OP $197.00 $0.00 $0.00 $197.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $197.00 $197.00 $142.84 $197.00 78803 EAP CPT® 78803 CHG RP LOCLZJ TUM SPECT 1 AREA/ACQUISJ 1 DAY IMG OP $161.00 $0.00 $0.00 $161.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.00 $161.00 $161.00 $161.00 78814 EAP CPT® 78814 PET IMAGING CT FOR ATTENUATION LIMITED AREA OP $326.00 $0.00 $0.00 $326.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $326.00 $0.00 $0.00 $0.00 78815 EAP CPT® 78815 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH OP $365.00 $0.00 $0.00 $365.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $365.00 $0.00 $365.00 $0.00 78816 EAP CPT® 78816 PET IMAGING FOR CT ATTENUATION WHOLE BODY OP $368.00 $0.00 $0.00 $368.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $368.00 $0.00 $368.00 $0.00 78830 EAP CPT® 78830 CHG RP LOCLZJ TUM SPECT W/CT 1 AREA/ACQUISJ 1DAY IMG OP $221.00 $0.00 $0.00 $221.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.00 $0.00 $221.00 $0.00 78832 EAP CPT® 78832 PR RP LOCLZJ TUM SPECT CT 2AREA/SEP ACQUISJ IMG OP $314.00 $0.00 $0.00 $314.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $314.00 $0.00 $314.00 $0.00 79005 EAP CPT® 79005 CHG NUC THERAPY INTRACAVITARY RADIOCOLLOID OP $271.00 $0.00 $0.00 $184.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.40 $175.60 $123.17 $175.60 79101 EAP CPT® 79101 CHG NUC THERAPY INTRA-ARTERIAL OP $302.00 $0.00 $0.00 $192.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.48 $185.93 $128.48 $185.93 80299 EAP CPT® 80299 CHG QUANTITATION DRUG NOT ELSEWHERE SPECIFIED OP $88.00 $0.00 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.00 $0.00 $0.00 $0.00 81025 EAP CPT® 81025 URINE PREGNANCY TEST OP $29.00 $0.00 $0.00 $14.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.50 $0.00 $0.00 $0.00 82355 EAP CPT® 82355 "CHG CALCULUS,QUALITATIVE ANALYSIS" OP $104.00 $0.00 $0.00 $52.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.00 $0.00 $0.00 $0.00 82365 EAP CPT® 82365 CALCULUS SPECTROSCOPY OP $107.00 $0.00 $0.00 $53.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.50 $0.00 $0.00 $0.00 82668 EAP CPT® 82668 ASSAY OF ERYTHROPOIETIN OP $127.00 $0.00 $0.00 $63.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.50 $0.00 $0.00 $0.00 83020 EAP CPT® 83020 HEMOGLOBIN ELECTROPHORESIS OP $92.00 $0.00 $0.00 $46.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.00 $0.00 $0.00 $0.00 83021 EAP CPT® 83021 HEMOGLOBIN CHROMOTOGRAPHY OP $118.00 $0.00 $0.00 $59.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.00 $0.00 $0.00 $0.00 83026 EAP CPT® 83026 "CHG HEMOGLOBIN, COPPER SULFATE" OP $18.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.00 $0.00 $0.00 $0.00 84165 EAP CPT® 84165 PROTEIN ELECTROPHORESIS SERUM OP $91.00 $0.00 $0.00 $45.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.50 $0.00 $0.00 $0.00 84443 EAP CPT® 84443 ASSAY THYROID STIM HORMONE OP $92.00 $0.00 $0.00 $46.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.00 $0.00 $0.00 $0.00 85018 EAP CPT® 85018 HEMOGLOBIN OP $17.00 $0.00 $0.00 $8.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $3.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.50 $0.00 $0.00 $0.00 85060 EAP CPT® 85060 CHG BLOOD SMEAR INTERPRETATION OP $76.00 $0.00 $0.00 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $38.00 $22.76 $0.00 $22.76 85097 EAP CPT® 85097 BONE MARROW EXAM OP $160.00 $0.00 $0.00 $99.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $80.00 $99.49 $0.00 $99.49 85347 EAP CPT® 85347 "CHG COAGULATION TIME, ACTIVATED" OP $27.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 86077 EAP CPT® 86077 "CHG PHYS BLD BANK SERV,DIFF XMTCH" OP $158.00 $0.00 $0.00 $79.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.00 $49.02 $0.00 $49.02 86078 EAP CPT® 86078 TRANSFUSION REACTION OP $158.00 $0.00 $0.00 $79.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $79.00 $50.86 $0.00 $50.86 86334 EAP CPT® 86334 IMMUNOFIX E-PHORESIS SERUM OP $57.00 $0.00 $0.00 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $0.00 $0.00 $0.00 86335 EAP CPT® 86335 IMMUNOFIX E-PHORESIS/URINE/CSF OP $57.00 $0.00 $0.00 $28.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $28.50 $0.00 $0.00 $0.00 86850 EAP CPT® 86850 PRENATAL ANTIBODY SCREEN OP $37.00 $0.00 $0.00 $18.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.50 $0.00 $0.00 $0.00 87070 EAP CPT® 87070 CULTURE OTHER SPECIMEN AEROBIC OP $41.00 $0.00 $0.00 $20.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.50 $0.00 $0.00 $0.00 87075 EAP CPT® 87075 CULTURE BACTERIA EXCEPT BLOOD OP $46.00 $0.00 $0.00 $23.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.00 $0.00 $0.00 $0.00 87101 EAP CPT® 87101 FUNGUS CULTURE DERM OP $38.00 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.00 $0.00 $0.00 $0.00 87102 EAP CPT® 87102 FUNGUS ISOLATION CULTURE OP $40.00 $0.00 $0.00 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $0.00 $0.00 $0.00 87116 EAP CPT® 87116 MYCOBACTERIA CULTURE OP $46.00 $0.00 $0.00 $23.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.00 $0.00 $0.00 $0.00 87210 EAP CPT® 87210 SMEAR WET MOUNT SALINE/INK OP $20.00 $0.00 $0.00 $10.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $10.00 $0.00 $0.00 $0.00 87220 EAP CPT® 87220 CHG TISSUE EXAM BY KOH OP $24.00 $0.00 $0.00 $12.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.00 $0.00 $0.00 $0.00 87430 EAP CPT® 87430 CHG IAAD IA STREPTOCOCCUS GROUP A OP $28.00 $0.00 $0.00 $14.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.00 $0.00 $0.00 $0.00 88020 EAP CPT® 88020 "CHG AUTOPSY COMPL,W/O CNS" OP $824.00 $0.00 $0.00 $412.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $412.00 $0.00 $0.00 $0.00 88104 EAP CPT® 88104 "CHG CYTOPATH FLUIDS,SMEAR,INTERP" OP $89.00 $0.00 $0.00 $55.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.50 $55.18 $0.00 $55.18 88108 EAP CPT® 88108 "CHG CYTOPATH FLUIDS,CONCENTRATN,INTERP" OP $78.00 $0.00 $0.00 $67.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.00 $67.63 $0.00 $67.63 88112 EAP CPT® 88112 "CHG CYTOPATH, CELL ENHANCE TECH" OP $87.00 $0.00 $0.00 $87.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.50 $87.00 $0.00 $87.00 88141 EAP CPT® 88141 CHG CYTOPATH CERV/VAG INTERPRET OP $79.00 $0.00 $0.00 $39.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.50 $23.43 $0.00 $23.43 88172 EAP CPT® 88172 "CHG EVALUATION OF FNA SMEAR TO DETERMINE ADEQUACY, FIRST EVAL" OP $113.00 $0.00 $0.00 $56.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.50 $50.55 $0.00 $50.55 88173 EAP CPT® 88173 CHG INTERPRETATION OF FNA SMEAR OP $222.00 $0.00 $0.00 $131.71 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $111.00 $131.71 $0.00 $131.71 88177 EAP CPT® 88177 "CHG EVALUATION OF FNA SMEAR TO DETERMINE ADEQUACY, EA ADD EVAL" OP $69.00 $0.00 $0.00 $34.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $34.50 $0.00 $0.00 $0.00 88187 EAP CPT® 88187 FLOW CYTOMETRY READ OP $118.00 $0.00 $0.00 $64.96 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.00 $64.96 $0.00 $64.96 88188 EAP CPT® 88188 FLOW CYTOMETRY INTERP OP $198.00 $0.00 $0.00 $99.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.00 $80.57 $0.00 $80.57 88189 EAP CPT® 88189 FLOWCYTOMETRY READ 16 OR MORE OP $266.00 $0.00 $0.00 $133.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $133.00 $105.19 $0.00 $105.19 88241 EAP CPT® 88241 CHG FROZEN CELL PREPARATION OP $199.00 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.50 $0.00 $0.00 $0.00 88302 EAP CPT® 88302 "CHG SURG PATH,LEVEL II" OP $22.00 $0.00 $0.00 $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.00 $22.00 $22.00 $22.00 88304 EAP CPT® 88304 "CHG SURG PATH, LEVEL III" OP $36.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $18.00 $36.00 $21.13 $36.00 88305 EAP CPT® 88305 "CHG SURG PATH, LEVEL IV" OP $118.00 $0.00 $0.00 $100.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.00 $100.95 $46.12 $100.95 88307 EAP CPT® 88307 "CHG SURG PATH,LEVEL V" OP $685.00 $0.00 $0.00 $342.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $342.50 $188.01 $93.31 $188.01 88309 EAP CPT® 88309 "CHG SURG PATH,LEVEL VI" OP $458.00 $0.00 $0.00 $282.52 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $229.00 $282.52 $131.45 $282.52 88311 EAP CPT® 88311 DECALCIFY TISSUE OP $43.00 $0.00 $0.00 $21.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.50 $17.80 $10.82 $17.80 88312 EAP CPT® 88312 STAIN MISC OP $83.00 $0.00 $0.00 $83.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.50 $83.00 $30.37 $83.00 88313 EAP CPT® 88313 STAIN MISC OP $38.00 $0.00 $0.00 $38.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.00 $38.00 $31.44 $38.00 88331 EAP CPT® 88331 "CHG PATH CONSULT IN SURG,W FRZ SEC" OP $196.00 $0.00 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.00 $86.78 $52.33 $86.78 88332 EAP CPT® 88332 "CHG PATH CONSULT IN SURG,W ADDN FRZ SEC" OP $100.00 $0.00 $0.00 $50.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $50.00 $39.17 $26.27 $39.17 88333 EAP CPT® 88333 "PR INTRAOPERATIVE CYTO PATH CONSULT, INITIAL SITE" OP $196.00 $0.00 $0.00 $98.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $98.00 $87.55 $52.84 $87.55 88334 EAP CPT® 88334 "CHG INTRAOPERATIVE CYTO PATH CONSULT, ADD SITES" OP $119.00 $0.00 $0.00 $59.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.50 $51.29 $27.61 $51.29 88341 EAP CPT® 88341 CHG IMHISTOCHEM/CYTCHM EA ADDL ANTIBODY SLIDE OP $89.00 $0.00 $0.00 $44.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.50 $0.00 $40.17 $0.00 88342 EAP CPT® 88342 CHG IMHISTOCHEM/CYTCHM INIT ANTIBODY STAIN PROCEDURE OP $110.00 $0.00 $0.00 $90.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.00 $90.36 $50.11 $90.36 88344 EAP CPT® 88344 CHG IMHISTOCHEM/CYTCHM EA MULTIPLEX ANTIBODY SLIDE OP $120.00 $0.00 $0.00 $60.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.00 $0.00 $0.00 $0.00 88356 EAP CPT® 88356 "CHG ANALYSIS, NERVE" OP $401.00 $0.00 $0.00 $289.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.50 $289.46 $142.13 $289.46 88360 EAP CPT® 88360 CHG M/PHMTRC ALYS TUMOR IMHCHEM EA ANTIBODY MANUAL OP $132.00 $0.00 $0.00 $110.32 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.00 $110.32 $0.00 $110.32 88361 EAP CPT® 88361 CHG M/PHMTRC ALYS TUMOR IMHCHEM EA ANTBDY CMPTR ASST OP $140.00 $0.00 $0.00 $140.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $70.00 $140.00 $0.00 $140.00 88364 EAP CPT® 88364 CHG IN SITU HYBRIDIZATION EA ADDL PROBE STAIN OP $108.00 $0.00 $0.00 $54.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.00 $0.00 $0.00 $0.00 88365 EAP CPT® 88365 CHG IN SITU HYBRIDIZATION 1ST PROBE STAIN OP $142.00 $0.00 $0.00 $129.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.00 $129.45 $61.73 $129.45 90371 EAP CPT® 90371 "PR HEPB IG, IM" OP $180.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 90471 EAP CPT® 90471 "PR IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOXOID" OP $64.00 $0.00 $0.00 $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.00 $0.00 $0.00 $0.00 90472 EAP CPT® 90472 "PR IMMUNIZ,ADMIN,EACH ADDL" OP $39.00 $0.00 $0.00 $19.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.50 $10.24 $0.00 $10.24 90632 EAP CPT® 90632 PR HEPA VACCINE ADULT IM OP $127.00 $0.00 $0.00 $63.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.50 $0.00 $0.00 $0.00 90651 EAP CPT® 90651 PR HUMAN PAPILLOMA VIRUS NONAVALENT HPV 3 DOSE IM OP $400.00 $0.00 $0.00 $200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.00 $0.00 $0.00 $0.00 90680 EAP CPT® 90680 "PR ROTOVIRUS VACCINE, PENTAVAL, 3 DOSE, ORAL" OP $156.00 $0.00 $0.00 $78.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.00 $0.00 $0.00 $0.00 90686 EAP CPT® 90686 BPR IIV4 VACC PRESRV FREE 0.5 ML DOS FOR IM USE OP $50.00 $0.00 $0.00 $25.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $25.00 $0.00 $0.00 $0.00 90715 EAP CPT® 90715 "PR TDAP VACCINE >7 YO, IM" OP $90.00 $0.00 $0.00 $45.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $45.00 $0.00 $0.00 $0.00 90734 EAP CPT® 90734 PR MENACWYD/MENACWY-CRM CONJ VACC GRPS ACWY IM USE OP $202.00 $0.00 $0.00 $101.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.00 $0.00 $0.00 $0.00 90740 EAP CPT® 90740 "PR HEP B VACCINE,DIAL/IMMUNOSUP, IM" OP $262.00 $0.00 $0.00 $131.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $131.00 $0.00 $0.00 $0.00 90746 EAP CPT® 90746 PR HEPATITIS B VACCINE ADULT 3 DOSE IM OP $175.00 $0.00 $0.00 $87.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.50 $0.00 $0.00 $0.00 90791 EAP CPT® 90791 PR PSYCHIATRIC DIAGNOSTIC EVALUATION OP $383.00 $0.00 $0.00 $200.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $321.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $200.06 $0.00 $89.77 $0.00 90792 EAP CPT® 90792 PR PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES OP $429.00 $0.00 $0.00 $221.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $359.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.81 $0.00 $73.76 $0.00 90832 EAP CPT® 90832 PR PSYCHOTHERAPY W/PATIENT 30 MINUTES OP $192.00 $0.00 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $139.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.00 $0.00 $37.25 $0.00 90833 EAP CPT® 90833 PR PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 30 MIN OP $264.00 $0.00 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.00 $0.00 $24.65 $0.00 90834 EAP CPT® 90834 PR PSYCHOTHERAPY W/PATIENT 45 MINUTES OP $255.00 $0.00 $0.00 $127.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $184.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.50 $0.00 $0.00 $0.00 90836 EAP CPT® 90836 PR PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 45 MIN OP $252.00 $0.00 $0.00 $126.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.00 $0.00 $0.00 $0.00 90837 EAP CPT® 90837 PR PSYCHOTHERAPY W/PATIENT 60 MINUTES OP $382.00 $0.00 $0.00 $191.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $271.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $191.00 $0.00 $37.25 $0.00 90839 EAP CPT® 90839 PR PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES OP $399.00 $0.00 $0.00 $199.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $199.50 $0.00 $0.00 $0.00 90847 EAP CPT® 90847 PR FAMILY PSYCHOTHERAPY W/PATIENT PRESENT 50 MINS OP $320.00 $0.00 $0.00 $160.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.00 $110.02 $66.07 $110.02 90853 EAP CPT® 90853 PR GROUP PSYCHOTHERAPY OP $78.00 $0.00 $0.00 $39.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.00 $30.92 $21.52 $30.92 90887 EAP CPT® 90887 PR CONSULTATION WITH FAMILY OP $231.00 $0.00 $0.00 $115.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $115.50 $0.00 $0.00 $0.00 90935 EAP CPT® 90935 PR HEMODIALYSIS PROCEDURE W/ PHYS/QHP EVALUATION OP "$1,231.00 " $0.00 $0.00 $114.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $114.56 $68.44 $0.00 $68.44 90937 EAP CPT® 90937 "PR HEMODIALYSIS, REPEATED EVAL." OP "$1,970.00 " $0.00 $0.00 $164.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.29 $111.81 $0.00 $111.81 90945 EAP CPT® 90945 PR DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL OP "$1,293.00 " $0.00 $0.00 $135.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.88 $71.16 $0.00 $71.16 90947 EAP CPT® 90947 PR DIALYSIS OTH/THN HEMODIALY REPEAT PHYS/QHP EVALS OP "$1,970.00 " $0.00 $0.00 $196.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $196.13 $113.78 $0.00 $113.78 90969 EAP CPT® 90969 "PR ESRD SERVICES, PER DAY, 12-19 YR OLD" OP $47.00 $0.00 $0.00 $24.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.03 $0.00 $0.00 $0.00 91010 EAP CPT® 91010 PR ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT OP $206.00 $0.00 $0.00 $206.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.00 $202.77 $69.74 $202.77 91035 EAP CPT® 91035 PR GERD TST W/ MUCOS PH ELECTROD OP $256.00 $0.00 $0.00 $256.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.00 $256.00 $256.00 $256.00 91037 EAP CPT® 91037 PR GERD TST W/ NASAL IMPEDENCE ELECTROD OP $155.00 $0.00 $0.00 $155.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.00 $149.63 $95.22 $149.63 91110 EAP CPT® 91110 PR GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R OP $396.00 $0.00 $0.00 $396.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $396.00 $396.00 $396.00 $396.00 91111 EAP CPT® 91111 PR GASTROINTESTINAL TRACT IMAGING ESOPHAGUS W/I&R OP $185.00 $0.00 $0.00 $185.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$2,479.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.00 $185.00 $0.00 $185.00 91120 EAP CPT® 91120 "PR RECTAL SENSATION TEST, BALLOON" OP $813.00 $0.00 $0.00 $673.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $673.01 $422.05 $289.14 $422.05 91122 EAP CPT® 91122 PR ANAL PRESSURE RECORD OP $309.00 $0.00 $0.00 $309.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $309.00 $244.02 $78.46 $244.02 91200 EAP CPT® 91200 PR LIVER ELASTOGRAPHY W/O IMAG W/I&R OP $80.00 $0.00 $0.00 $49.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.90 $0.00 $21.44 $0.00 92002 EAP CPT® 92002 "PR EYE EXAM, NEW PATIENT,INTERMED" OP $145.00 $0.00 $0.00 $75.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.55 $67.57 $38.00 $67.57 92004 EAP CPT® 92004 "PR EYE EXAM, NEW PATIENT,COMPREHESV" OP $300.00 $0.00 $0.00 $157.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.80 $122.06 $63.48 $122.06 92012 EAP CPT® 92012 "PR EYE EXAM ESTABLISHED PT, INTERMED" OP $159.00 $0.00 $0.00 $83.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $83.38 $61.47 $32.31 $61.47 92014 EAP CPT® 92014 "PR EYE EXAM, EST PATIENT,COMPREHESV" OP $241.00 $0.00 $0.00 $126.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $126.46 $91.21 $46.59 $91.21 92015 EAP CPT® 92015 PR REFRACTION OP $59.00 $0.00 $0.00 $30.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.75 $0.00 $0.00 $0.00 92018 EAP CPT® 92018 PR NEW EYE EXAM & TREATMENT OP $439.00 $0.00 $0.00 $230.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.04 $129.77 $47.90 $129.77 92020 EAP CPT® 92020 "PR SPECIAL EYE EVAL,GONISCOPY" OP $64.00 $0.00 $0.00 $33.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.04 $25.16 $21.20 $25.16 92025 EAP CPT® 92025 PR CORNEAL TOPOGRAPHY OP $61.00 $0.00 $0.00 $59.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.99 $29.06 $0.00 $29.06 92071 EAP CPT® 92071 PR FIT CONTACT LENS TX OCULAR SURFACE DISEASE OP $102.00 $0.00 $0.00 $53.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.18 $0.00 $22.32 $0.00 92083 EAP CPT® 92083 "PR VISUAL FIELD EXAM,EXTENDED" OP $150.00 $0.00 $0.00 $101.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.55 $71.98 $35.53 $71.98 92133 EAP CPT® 92133 PR COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE OP $90.00 $0.00 $0.00 $69.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $69.51 $0.00 $26.44 $0.00 92134 EAP CPT® 92134 PR COMPUTERIZED OPHTHALMIC IMAGING RETINA OP $100.00 $0.00 $0.00 $71.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.20 $0.00 $26.44 $0.00 92136 EAP CPT® 92136 "PR OPHTHAL BIOMETRY,INTRAOC LENS POW CALC" OP $95.00 $0.00 $0.00 $95.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.00 $80.55 $56.67 $80.55 92201 EAP CPT® 92201 PR OPSCPY EXTND RTA DRAWING & SCL DEPRSN I&R UNI/BI OP $70.00 $0.00 $0.00 $36.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.36 $0.00 $15.17 $0.00 92235 EAP CPT® 92235 PR FLUORESCEIN ANGRPH W/MULTIFRAME I&R UNI/BI OP $132.00 $0.00 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.00 $124.51 $62.85 $124.51 92285 EAP CPT® 92285 PR EYE PHOTOGRAPHY OP $22.00 $0.00 $0.00 $22.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.00 $22.00 $22.00 $22.00 92511 EAP CPT® 92511 PR NASOPHARYNGOSCOPY OP $218.00 $0.00 $0.00 $148.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.66 $148.68 $40.26 $148.68 92538 EAP CPT® 92538 PR CALORIC VESTIBULAR TEST W/REC BI MONOTHERMAL OP $50.00 $0.00 $0.00 $32.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.46 $0.00 $12.31 $0.00 92540 EAP CPT® 92540 PR VESTIBULAR EVAL NYSTAG FOVL&PERPH STIM OSCIL TRACKING OP $245.00 $0.00 $0.00 $160.74 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.74 $0.00 $44.61 $0.00 92551 EAP CPT® 92551 "PR PURE TONE HEARING TEST, AIR" OP $37.00 $0.00 $0.00 $19.09 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.09 $0.00 $5.64 $0.00 92552 EAP CPT® 92552 "PR PURE TONE AUDIOMETRY, AIR" OP $96.00 $0.00 $0.00 $49.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.44 $18.44 $10.93 $18.44 92553 EAP CPT® 92553 "PR AUDIOMETRY, AIR & BONE" OP $117.00 $0.00 $0.00 $59.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $59.00 $26.39 $16.07 $26.39 92557 EAP CPT® 92557 PR COMPREHENSIVE HEARING TEST OP $101.00 $0.00 $0.00 $52.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.01 $48.01 $29.43 $48.01 92567 EAP CPT® 92567 PR TYMPANOMETRY OP $48.00 $0.00 $0.00 $20.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.34 $20.53 $12.93 $20.53 92590 EAP CPT® 92590 "PR HEARING AID EXAM, ONE EAR" OP $105.00 $0.00 $0.00 $85.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $85.11 $0.00 $0.00 $0.00 92591 EAP CPT® 92591 "PR HEARING AID EXAM, BOTH EARS" OP $134.00 $0.00 $0.00 $108.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $108.06 $0.00 $0.00 $0.00 92592 EAP CPT® 92592 "PR HEARING AID CHECK, ONE EAR" OP $42.00 $0.00 $0.00 $33.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.61 $0.00 $0.00 $0.00 92593 EAP CPT® 92593 "PR HEARING AID CHECK, BOTH EARS" OP $69.00 $0.00 $0.00 $55.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.44 $0.00 $0.00 $0.00 92603 EAP CPT® 92603 "PR DX ANAL COCHLEAR IMP,PT >7 YRS,W/PROG" OP $377.00 $0.00 $0.00 $194.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.13 $90.03 $55.24 $90.03 92928 EAP CPT® 92928 PR PRQ TRLUML CORONARY STENT W/ANGIO ONE ART/BRNCH OP "$1,854.00 " $0.00 $0.00 $978.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $978.55 $0.00 $416.40 $0.00 92941 EAP CPT® 92941 PR PRQ TRLUML CORONRY TOT OCCLUS REVASC MI ONE VSL OP "$2,084.00 " $0.00 $0.00 "$1,096.81" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,096.81" $0.00 $400.23 $0.00 92950 EAP CPT® 92950 PR HEART/LUNG RESUSCITATION (CPR) OP $580.00 $0.00 $0.00 $297.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $297.30 $289.32 $132.58 $289.32 92960 EAP CPT® 92960 PR CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL OP $462.00 $0.00 $0.00 $295.97 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $194.51 $295.97 $96.74 $295.97 92961 EAP CPT® 92961 PR CARDIOVERSION ELECTIVE ARRHYTHMIA INTERNAL SPX OP "$1,439.00 " $0.00 $0.00 $419.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $419.25 $253.48 $141.33 $253.48 92978 EAP CPT® 92978 PR ENDOLUMINAL CORONARY IVUS OCT I&R INITIAL VESSEL OP $503.00 $0.00 $0.00 $443.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $443.76 $0.00 $170.92 $0.00 93000 EAP CPT® 93000 PR ELECTROCARDIOGRAM COMPLETE OP $80.00 $0.00 $0.00 $26.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.88 $24.10 $17.56 $24.10 93005 EAP CPT® 93005 "PR ELECTROCARDIOGRAM, TRACING" OP $50.00 $0.00 $0.00 $15.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.46 $15.62 $10.96 $15.62 93010 EAP CPT® 93010 PR ELECTROCARDIOGRAM REPORT OP $30.00 $0.00 $0.00 $13.41 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.41 $8.47 $6.61 $8.47 93015 EAP CPT® 93015 PR CV STRS TST XERS&/OR RX CONT ECG W/SI&R OP $410.00 $0.00 $0.00 $120.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $130.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.54 $102.38 $69.34 $102.38 93016 EAP CPT® 93016 PR CV STRS TST XERS&/OR RX CONT ECG W/O I&R OP $90.00 $0.00 $0.00 $35.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.23 $23.49 $16.76 $23.49 93017 EAP CPT® 93017 "PR CARDIAC STRESS TST,TRACING ONLY" OP $230.00 $0.00 $0.00 $63.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.38 $63.44 $40.45 $63.44 93018 EAP CPT® 93018 "PR CARDIAC STRESS TST,INTERP/REPT ONLY" OP $90.00 $0.00 $0.00 $22.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.94 $15.45 $12.14 $15.45 93024 EAP CPT® 93024 PR CARDIAC DRUG STRESS TEST OP $186.00 $0.00 $0.00 $177.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.14 $111.03 $74.69 $111.03 93042 EAP CPT® 93042 "PR RHYTHM ECG, REPORT" OP $32.00 $0.00 $0.00 $11.16 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $11.16 $7.71 $5.72 $7.71 93224 EAP CPT® 93224 PR XTRNL ECG & 48 HR RECORD SCAN STOR W/R&I OP $474.00 $0.00 $0.00 $146.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $138.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $144.21 $146.57 $103.17 $146.57 93227 EAP CPT® 93227 PR XTRNL ECG CONTINUOUS RHYTHM W/I&R UP TO 48 HRS OP $84.00 $0.00 $0.00 $41.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $41.95 $27.01 $20.96 $27.01 93244 EAP CPT® 93244 PR EXTERNAL ECG REC>48HR<7D REVIEW & INTERPRETATION OP $73.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $47.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93248 EAP CPT® 93248 PR EXTERNAL ECG REC>7D<15D REVIEW & INTERPRETATION OP $81.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 93261 EAP CPT® 93261 PR INTERROGATION EVAL F2F IMPLANT SUBQ LEAD DEFIB OP $115.00 $0.00 $0.00 $95.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.84 $0.00 $36.70 $0.00 93270 EAP CPT® 93270 "PR EXT ECG,PT DEMAND EVENT, SYMPT MEMORY LOOP, RECORD" OP $140.00 $0.00 $0.00 $39.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.59 $39.08 $29.72 $39.08 93271 EAP CPT® 93271 "PR EXT ECG,PT DEMAND EVENT, SYMPT MEMORY LOOP, TRANSMIT" OP $660.00 $0.00 $0.00 $270.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $270.40 $218.63 $57.16 $218.63 93279 EAP CPT® 93279 PR PRGRMG DEV EVAL 1 LEAD PM/LDLS PM 1 CAR CHMBR IP OP $100.00 $0.00 $0.00 $78.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $78.43 $0.00 $33.29 $0.00 93280 EAP CPT® 93280 PR PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER OP $119.00 $0.00 $0.00 $91.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $91.85 $0.00 $39.38 $0.00 93281 EAP CPT® 93281 PR PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER OP $132.00 $0.00 $0.00 $107.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.56 $0.00 $46.05 $0.00 93282 EAP CPT® 93282 PR PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB OP $132.00 $0.00 $0.00 $99.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $99.14 $0.00 $42.55 $0.00 93283 EAP CPT® 93283 PR PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB OP $180.00 $0.00 $0.00 $128.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $128.83 $0.00 $51.81 $0.00 93284 EAP CPT® 93284 PR PRGRMG EVAL IMPLANTABLE IN PERSON MULTI LEAD DFB OP $195.00 $0.00 $0.00 $142.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.25 $0.00 $60.67 $0.00 93285 EAP CPT® 93285 PR PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON OP $145.00 $0.00 $0.00 $66.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.66 $0.00 $28.76 $0.00 93288 EAP CPT® 93288 PR INTERROG DEV EVAL PM/LDLS PM PHYS/QHP IN PERSON OP $65.00 $0.00 $0.00 $58.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.25 $0.00 $25.77 $0.00 93289 EAP CPT® 93289 PR INTERROG EVAL F2F 1/DUAL/MLT LEADS IMPLTBL DFB OP $116.00 $0.00 $0.00 $103.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $103.05 $0.00 $39.60 $0.00 93294 EAP CPT® 93294 PR REM INTERROG PM/LDLS PM <90 D PHYS/QHP OP $96.00 $0.00 $0.00 $53.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.65 $0.00 $21.92 $0.00 93295 EAP CPT® 93295 PR INTERROGATION EVAL REMOTE 12HR<26HR AFTER 24HR WO VID OP $487.00 $0.00 $0.00 $251.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $251.44 $0.00 $97.22 $0.00 95720 EAP CPT® 95720 PR EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG OP $638.00 $0.00 $0.00 $329.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $329.68 $0.00 $127.98 $0.00 95721 EAP CPT® 95721 PR EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/O VIDEO OP $640.00 $0.00 $0.00 $330.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $330.80 $0.00 $129.05 $0.00 95723 EAP CPT® 95723 PR EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/O VIDEO OP $793.00 $0.00 $0.00 $409.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $409.51 $0.00 $160.03 $0.00 95810 EAP CPT® 95810 PR POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND OP $495.00 $0.00 $0.00 $495.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $495.00 $495.00 $371.84 $495.00 95811 EAP CPT® 95811 PR POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND OP $525.00 $0.00 $0.00 $525.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.00 $525.00 $386.68 $525.00 95812 EAP CPT® 95812 "PR EEG,EXTENDED MONITORING,41-60 MINUTES" OP $177.00 $0.00 $0.00 $177.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.00 $177.00 $82.78 $177.00 95813 EAP CPT® 95813 PR EEG EXTENDED MONITORING 61-119 MINUTES OP $269.00 $0.00 $0.00 $269.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.00 $265.94 $114.63 $265.94 95816 EAP CPT® 95816 "PR EEG,W/AWAKE & DROWSY RECORD" OP $177.00 $0.00 $0.00 $177.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $177.00 $177.00 $80.33 $177.00 95819 EAP CPT® 95819 "PR EEG,W/AWAKE & ASLEEP RECORD" OP $179.00 $0.00 $0.00 $179.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.00 $179.00 $68.89 $179.00 95822 EAP CPT® 95822 "PR EEG,COMA/SLEEP RECORD ONLY" OP $179.00 $0.00 $0.00 $179.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.00 $179.00 $77.59 $179.00 95829 EAP CPT® 95829 PR SURGERY ELECTROCORTICOGRAM OP "$1,042.00 " $0.00 $0.00 "$1,042.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,042.00" "$1,042.00" $222.33 "$1,042.00" 95860 EAP CPT® 95860 EMG 1 EXT OP $161.00 $0.00 $0.00 $161.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $161.00 $86.17 $44.40 $86.17 95861 EAP CPT® 95861 EMG 2 EXT OP $255.00 $0.00 $0.00 $255.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $255.00 $113.52 $75.58 $113.52 95867 EAP CPT® 95867 "PR EMG,NEEDLE,CRANIAL NERVE SUPP MUS,UNILAT" OP $132.00 $0.00 $0.00 $132.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.00 $66.30 $42.70 $66.30 95874 EAP CPT® 95874 PR NEEDLE EMG GUIDANCE FOR CHEMODENERVATION OP $61.00 $0.00 $0.00 $61.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.00 $33.40 $17.47 $33.40 95885 EAP CPT® 95885 NCS/EMG <=4 LIMB OP $57.00 $0.00 $0.00 $57.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.00 $0.00 $33.45 $0.00 95886 EAP CPT® 95886 NCS/EMG 5+ LIMB OP $142.00 $0.00 $0.00 $142.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $142.00 $0.00 $52.31 $0.00 95887 EAP CPT® 95887 EMG/NCS NON-EXT OP $117.00 $0.00 $0.00 $117.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $117.00 $0.00 $46.64 $0.00 95907 EAP CPT® 95907 NCS 1-2 NERVES OP $167.00 $0.00 $0.00 $151.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $151.31 $0.00 $56.55 $0.00 95908 EAP CPT® 95908 NCS 3-4 NERVES OP $208.00 $0.00 $0.00 $187.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.76 $0.00 $69.76 $0.00 95909 EAP CPT® 95909 NCS 5-6 NERVES OP $249.00 $0.00 $0.00 $228.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $228.70 $0.00 $83.59 $0.00 95910 EAP CPT® 95910 NCS 7-8 NERVES OP $333.00 $0.00 $0.00 $304.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.91 $0.00 $110.01 $0.00 95911 EAP CPT® 95911 NCS 9-10 NERVES OP $412.00 $0.00 $0.00 $368.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $368.24 $0.00 $133.17 $0.00 95912 EAP CPT® 95912 NCS 11-12 NERVES OP $491.00 $0.00 $0.00 $411.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $411.85 $0.00 $155.91 $0.00 95913 EAP CPT® 95913 NCS 13+ NERVES OP $583.00 $0.00 $0.00 $471.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $471.19 $0.00 $180.69 $0.00 95937 EAP CPT® 95937 RNS OP $142.00 $0.00 $0.00 $129.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.00 $51.06 $31.37 $51.06 95938 EAP CPT® 95938 PR SHORT-LATENCY SOMATOSENS EP STD UPR & LOW LIMBS OP $143.00 $0.00 $0.00 $143.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $143.00 $0.00 $143.00 $0.00 95939 EAP CPT® 95939 PR CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LIMB OP $369.00 $0.00 $0.00 $369.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $369.00 $0.00 $277.61 $0.00 95940 EAP CPT® 95940 PR IONM 1 ON 1 IN OR W/ATTENDANCE EACH 15 MINUTES OP $102.00 $0.00 $0.00 $51.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.95 $0.00 $19.04 $0.00 95941 EAP CPT® 95941 PR IONM REMOTE/NEARBY/>1 PATIENT IN OR PER HOUR OP $138.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 95992 EAP CPT® 95992 "PR CANALITH REPOSITIONING PROCEDURE, PER DAY" OP $117.00 $0.00 $0.00 $54.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.51 $0.00 $0.00 $0.00 96110 EAP CPT® 96110 PR DEVELOPMENTAL SCREEN W/SCORING & DOC STD INSTRM OP $73.00 $0.00 $0.00 $14.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $14.03 $12.16 $8.24 $12.16 96112 EAP CPT® 96112 PR DEVELOPMENTAL TST ADMIN PHYS/QHP 1ST HOUR OP $394.00 $0.00 $0.00 $201.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $201.76 $0.00 $81.98 $0.00 96113 EAP CPT® 96113 PR DEVELOPMENTAL TST ADMIN PHYS/QHP EA ADDL 30 MIN OP $179.00 $0.00 $0.00 $92.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $92.20 $0.00 $36.62 $0.00 96127 EAP CPT® 96127 PR BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT OP $15.00 $0.00 $0.00 $8.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $9.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $8.40 $0.00 $3.19 $0.00 96132 EAP CPT® 96132 PR NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP 1ST HOUR OP $329.00 $0.00 $0.00 $169.89 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.89 $0.00 $79.32 $0.00 96136 EAP CPT® 96136 PR PSYL/NRPSYCL TST PHYS/QHP 2+ TST 1ST 30 MIN OP $76.00 $0.00 $0.00 $39.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.10 $0.00 $28.41 $0.00 96137 EAP CPT® 96137 PR PSYCL/NRPSYCL TST PHYS/QHP 2+ TST EA ADDL 30 MIN OP $60.00 $0.00 $0.00 $30.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $30.73 $0.00 $26.26 $0.00 96138 EAP CPT® 96138 PR PSYCL/NRPSYCL TST TECH 2+ TST 1ST 30 MIN OP $116.00 $0.00 $0.00 $60.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $0.00 $23.02 $0.00 96139 EAP CPT® 96139 PR PSYCL/NRPSYCL TST TECH 2+ TST EA ADDL 30 MIN OP $116.00 $0.00 $0.00 $60.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.69 $0.00 $23.02 $0.00 96156 EAP CPT® 96156 PR HEALTH BEHAVIOR ASSESSMENT/RE-ASSESSMENT OP $272.00 $0.00 $0.00 $140.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $140.23 $0.00 $59.20 $0.00 96160 EAP CPT® 96160 PR PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM OP $25.00 $0.00 $0.00 $7.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.31 $0.00 $0.00 $0.00 96161 EAP CPT® 96161 PR CAREGIVER HLTH RISK ASSMT SCORE DOC STND INSTRM OP $35.00 $0.00 $0.00 $7.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.31 $0.00 $0.00 $0.00 96360 EAP CPT® 96360 "PR IV INFUSION, HYDRATION, 31-60 MIN" OP $114.00 $0.00 $0.00 $90.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.38 $0.00 $33.74 $0.00 96361 EAP CPT® 96361 "PR IV INFUSION, HYDRATION, EA ADD HOUR" OP $41.00 $0.00 $0.00 $24.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.11 $0.00 $9.81 $0.00 96365 EAP CPT® 96365 "PR IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR" OP $216.00 $0.00 $0.00 $109.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.44 $0.00 $41.10 $0.00 96370 EAP CPT® 96370 "PR SUBCUT INFUSION, THERAP/PROPH/DIAGNOST,EA ADD HOUR" OP $47.00 $0.00 $0.00 $23.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $23.53 $0.00 $9.36 $0.00 96372 EAP CPT® 96372 "PR INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT" OP $64.00 $0.00 $0.00 $39.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.65 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.84 $0.00 $12.52 $0.00 96374 EAP CPT® 96374 "PR INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG" OP $120.00 $0.00 $0.00 $89.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $89.78 $0.00 $32.55 $0.00 96900 EAP CPT® 96900 PR ULTRAVIOLET LIGHT THERAPY OP $68.00 $0.00 $0.00 $32.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $32.58 $17.83 $9.61 $17.83 97597 EAP CPT® 97597 PR DEBRIDEMENT OPEN WOUND 20 SQ CM< OP $114.00 $0.00 $0.00 $50.43 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.95 $50.43 $30.13 $50.43 97598 EAP CPT® 97598 PR DEBRIDEMENT OPEN WOUND EA ADDL 20 SQ CM OP $80.00 $0.00 $0.00 $63.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.94 $63.51 $38.25 $63.51 97602 EAP CPT® 97602 PR RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS OP $118.00 $0.00 $0.00 $53.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $53.59 $0.00 $23.88 $0.00 97605 EAP CPT® 97605 PR NEGATIVE PRESSURE WOUND THERAPY DME 50 SQ CM OP $87.00 $0.00 $0.00 $39.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.61 $35.96 $22.82 $35.96 97607 EAP CPT® 97607 PR NEG PRESSURE WOUND THERAPY NON DME 50 SQ CM OP $79.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 97802 EAP CPT® 97802 "PR MED NUTR THER, 1ST, INDIV, EA 15 MIN" OP $104.00 $0.00 $0.00 $51.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $67.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $51.51 $30.50 $0.00 $30.50 97803 EAP CPT® 97803 "PR MED NUTR THER, SUBSQ, INDIV, EA 15 MIN" OP $88.00 $0.00 $0.00 $43.66 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $58.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.66 $27.35 $0.00 $27.35 97804 EAP CPT® 97804 "PR MED NUTR THER, GROUP, EA 30 MIN" OP $49.00 $0.00 $0.00 $24.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.08 $14.55 $0.00 $14.55 98960 EAP CPT® 98960 "PR SELF-MGMT EDUC & TRAIN, 1 PT, EA 30 MIN" OP $85.00 $0.00 $0.00 $44.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.35 $0.00 $0.00 $0.00 98966 EAP CPT® 98966 PR NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 MIN OP $45.00 $0.00 $0.00 $20.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $24.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.14 $0.00 $0.00 $0.00 98967 EAP CPT® 98967 PR NONPHYSICIAN TELEPHONE ASSESSMENT 11-20 MIN OP $85.00 $0.00 $0.00 $40.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $40.24 $0.00 $0.00 $0.00 98968 EAP CPT® 98968 PR NONPHYSICIAN TELEPHONE ASSESSMENT 21-30 MIN OP $130.00 $0.00 $0.00 $60.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $61.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $60.38 $0.00 $0.00 $0.00 99050 EAP CPT® 99050 PR MEDICAL SERVICES AFTER HRS OP $57.00 $0.00 $0.00 $29.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.69 $0.00 $14.00 $0.00 99080 EAP CPT® 99080 PR SPECIAL REPORTS OR FORMS OP $53.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99140 EAP CPT® 99140 PR EMERGENCY ANESTHESIA OP $16.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99152 EAP CPT® 99152 PR MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS OP $330.00 $0.00 $0.00 $19.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $19.54 $0.00 $30.86 $0.00 99153 EAP CPT® 99153 PR MOD SED SAME PHYS/QHP EACH ADDL 15 MINS OP $32.00 $0.00 $0.00 $17.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.40 $0.00 $6.60 $0.00 99156 EAP CPT® 99156 PR MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS OP $240.00 $0.00 $0.00 $119.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.90 $0.00 $45.78 $0.00 99157 EAP CPT® 99157 PR MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS OP $196.00 $0.00 $0.00 $90.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.91 $0.00 $34.71 $0.00 99170 EAP CPT® 99170 PR ANOGENITAL XM MAGNIFY CHILD/SUSPECT TRAUMA W IMG OP $266.00 $0.00 $0.00 $141.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.38 $127.19 $81.28 $127.19 99173 EAP CPT® 99173 "PR VISUAL SCREENING TEST, BILAT" OP $20.00 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $7.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $5.03 $0.00 $0.00 $0.00 99184 EAP CPT® 99184 PR INITIAT SELECTIVE HEAD/BODY HYPOTHERMIA NEONATE OP $685.00 $0.00 $0.00 $362.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $362.70 $0.00 $139.94 $0.00 99188 EAP CPT® 99188 PR APPLICATION TOPICAL FLUORIDE VARNISH BY PHS/QHP OP $32.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.31 $0.00 99195 EAP CPT® 99195 PR PHLEBOTOMY OP $308.00 $0.00 $0.00 $158.34 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.34 $36.50 $10.73 $36.50 99202 EAP CPT® 99202 PR OFFICE/OUTPATIENT NEW SF MDM 15-29 MINUTES OP $189.00 $0.00 $0.00 $87.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $204.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $87.10 $62.27 $90.40 $62.27 99203 EAP CPT® 99203 PR OFFICE/OUTPATIENT NEW LOW MDM 30-44 MINUTES OP $273.00 $0.00 $0.00 $132.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $314.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.99 $92.30 $90.40 $92.30 99204 EAP CPT® 99204 PR OFFICE/OUTPATIENT NEW MODERATE MDM 45-59 MINUTES OP $416.00 $0.00 $0.00 $225.04 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $467.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $225.04 $140.99 $90.40 $140.99 99205 EAP CPT® 99205 PR OFFICE/OUTPATIENT NEW HIGH MDM 60-74 MINUTES OP $527.00 $0.00 $0.00 $292.47 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $618.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.47 $177.24 $90.40 $177.24 99211 EAP CPT® 99211 PR OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP OP $46.00 $0.00 $0.00 $19.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $65.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $15.96 $19.82 $46.00 $19.82 99212 EAP CPT® 99212 PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10-19 MIN OP $116.00 $0.00 $0.00 $43.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $159.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $43.54 $36.61 $90.40 $36.61 99213 EAP CPT® 99213 PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20-29 MIN OP $184.00 $0.00 $0.00 $88.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $254.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $88.36 $59.94 $90.40 $59.94 99214 EAP CPT® 99214 PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30-39 MIN OP $271.00 $0.00 $0.00 $135.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $358.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $135.62 $90.92 $90.40 $90.92 99215 EAP CPT® 99215 PR OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40-54 MIN OP $365.00 $0.00 $0.00 $192.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $505.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $192.06 $123.15 $90.40 $123.15 99217 EAP CPT® 99217 PR OBSERVATION CARE DISCHARGE MANAGEMENT OP $222.00 $0.00 $0.00 $125.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.85 $67.02 $0.00 $67.02 99218 EAP CPT® 99218 PR INITIAL OBSERVATION CARE/DAY 30 MINUTES OP $305.00 $0.00 $0.00 $172.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $172.36 $63.36 $0.00 $63.36 99219 EAP CPT® 99219 PR INITIAL OBSERVATION CARE/DAY 50 MINUTES OP $414.00 $0.00 $0.00 $234.40 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.40 $104.76 $0.00 $104.76 99220 EAP CPT® 99220 PR INITIAL OBSERVATION CARE/DAY 70 MINUTES OP $565.00 $0.00 $0.00 $320.33 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $320.33 $147.61 $0.00 $147.61 99221 EAP CPT® 99221 PR 1ST HOSPITAL IP/OBS CARE SF/LOW MDM 40 MINUTES OP $312.00 $0.00 $0.00 $175.29 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.29 $86.98 $0.00 $86.98 99222 EAP CPT® 99222 PR 1ST HOSPITAL IP/OBS CARE MODERATE MDM 55 MINUTES OP $421.00 $0.00 $0.00 $236.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.76 $121.71 $0.00 $121.71 99223 EAP CPT® 99223 PR 1ST HOSPITAL IP/OBS CARE HIGH MDM 75 MINUTES OP $618.00 $0.00 $0.00 $350.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $350.31 $177.75 $0.00 $177.75 99224 EAP CPT® 99224 PR SBSQ OBSERVATION CARE/DAY 15 MINUTES OP $150.00 $0.00 $0.00 $68.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.70 $0.00 $0.00 $0.00 99225 EAP CPT® 99225 PR SBSQ OBSERVATION CARE/DAY 25 MINUTES OP $222.00 $0.00 $0.00 $125.83 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.83 $0.00 $0.00 $0.00 99226 EAP CPT® 99226 PR SBSQ OBSERVATION CARE/DAY 35 MINUTES OP $319.00 $0.00 $0.00 $181.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $181.67 $0.00 $0.00 $0.00 99231 EAP CPT® 99231 PR SBSQ HOSPITAL IP/OBS CARE SF/LOW MDM 25 MINUTES OP $120.00 $0.00 $0.00 $68.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $68.08 $36.40 $0.00 $36.40 99232 EAP CPT® 99232 PR SBSQ HOSPITAL IP/OBS CARE MOD MDM 35 MINUTES OP $221.00 $0.00 $0.00 $124.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $124.58 $65.26 $0.00 $65.26 99233 EAP CPT® 99233 PR SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES OP $318.00 $0.00 $0.00 $179.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.78 $93.25 $0.00 $93.25 99234 EAP CPT® 99234 PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MIN OP $408.00 $0.00 $0.00 $231.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $231.25 $127.40 $0.00 $127.40 99235 EAP CPT® 99235 PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MIN OP $516.00 $0.00 $0.00 $292.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.06 $168.12 $0.00 $168.12 99236 EAP CPT® 99236 PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MIN OP $664.00 $0.00 $0.00 $376.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $376.14 $209.53 $0.00 $209.53 99238 EAP CPT® 99238 PR HOSPITAL IP/OBS DISCHARGE DAY MGMT 30 MIN/< OP $223.00 $0.00 $0.00 $125.28 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $125.28 $66.71 $0.00 $66.71 99239 EAP CPT® 99239 PR HOSPITAL IP/OBS DISCHARGE DAY MGMT > 30 MIN OP $438.00 $0.00 $0.00 $185.44 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $185.44 $96.57 $0.00 $96.57 99241 EAP CPT® 99241 PR OFFICE CONSULTATION NEW/ESTAB PATIENT 15 MIN OP $127.00 $0.00 $0.00 $56.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $56.46 $48.43 $0.00 $48.43 99242 EAP CPT® 99242 PR OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES OP $208.00 $0.00 $0.00 $118.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.46 $89.68 $0.00 $89.68 99243 EAP CPT® 99243 PR OFFICE/OP CONSLTJ NEW/EST PT LOW MDM 30 MINUTES OP $291.00 $0.00 $0.00 $165.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $165.73 $122.89 $0.00 $122.89 99244 EAP CPT® 99244 PR OFFICE/OP CONSLTJ NEW/EST PT MOD MDM 40 MINUTES OP $468.00 $0.00 $0.00 $266.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $423.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $266.39 $181.27 $0.00 $181.27 99245 EAP CPT® 99245 PR OFFICE/OP CONSLTJ NEW/EST PT HIGH MDM 55 MINUTES OP $579.00 $0.00 $0.00 $329.61 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $329.61 $224.86 $0.00 $224.86 99251 EAP CPT® 99251 PR INITL INPATIENT CONSULT NEW/ESTAB PT 20 MIN OP $149.00 $0.00 $0.00 $84.68 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $84.68 $46.88 $0.00 $46.88 99252 EAP CPT® 99252 PR IP/OBS CONSLTJ NEW/EST PT SF MDM 35 MINUTES OP $227.00 $0.00 $0.00 $129.49 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $129.49 $74.80 $0.00 $74.80 99253 EAP CPT® 99253 PR IP/OBS CONSLTJ NEW/EST PT LOW MDM 45 MINUTES OP $349.00 $0.00 $0.00 $198.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $198.88 $110.93 $0.00 $110.93 99254 EAP CPT® 99254 PR IP/OBS CONSLTJ NEW/EST PT MOD MDM 60 MINUTES OP $508.00 $0.00 $0.00 $289.12 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $289.12 $159.87 $0.00 $159.87 99255 EAP CPT® 99255 PR IP/OBS CONSLTJ NEW/EST PT HIGH MDM 80 MINUTES OP $612.00 $0.00 $0.00 $348.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $348.60 $198.98 $0.00 $198.98 99281 EAP CPT® 99281 LEVEL 1-ED VISIT LIMITED/MINOR PROB OP $94.00 $0.00 $0.00 $36.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.76 $19.83 $0.00 $19.83 99282 EAP CPT® 99282 LEVEL 2-ED VISIT LOW/MODER SEVERITY OP $133.00 $0.00 $0.00 $71.67 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $71.67 $38.17 $0.00 $38.17 99283 EAP CPT® 99283 LEVEL 3-ED VISIT MODERATE SEVERITY OP $199.00 $0.00 $0.00 $107.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $107.20 $61.92 $0.00 $61.92 99284 EAP CPT® 99284 LEVEL 4-ED VISIT HIGH/URGENT SEVERITY OP $366.00 $0.00 $0.00 $203.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $203.35 $113.05 $0.00 $113.05 99285 EAP CPT® 99285 LEVEL 5-ED VISIT HIGH SEVERITY&THREAT OP $531.00 $0.00 $0.00 $300.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.08 $169.20 $0.00 $169.20 99291 EAP CPT® 99291 "PR CRITICAL CARE, E/M 30-74 MINUTES" OP $704.00 $0.00 $0.00 $386.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $386.78 $259.17 $0.00 $259.17 99292 EAP CPT® 99292 "PR CRITICAL CARE, ADDL 30 MIN" OP $352.00 $0.00 $0.00 $193.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $193.72 $116.36 $0.00 $116.36 99307 EAP CPT® 99307 PR SBSQ NURSING FACILITY CARE SF MDM 10 MINUTES OP $134.00 $0.00 $0.00 $77.38 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $77.38 $32.30 $0.00 $32.30 99308 EAP CPT® 99308 PR SBSQ NURSING FACILITY CARE LOW MDM 15 MINUTES OP $211.00 $0.00 $0.00 $119.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $119.75 $53.53 $0.00 $53.53 99309 EAP CPT® 99309 PR SBSQ NURSING FACILITY CARE MOD MDM 30 MINUTES OP $278.00 $0.00 $0.00 $157.84 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.84 $75.12 $0.00 $75.12 99310 EAP CPT® 99310 PR SBSQ NURSING FACILITY CARE HIGH MDM 45 MINUTES OP $410.00 $0.00 $0.00 $234.56 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $234.56 $93.93 $0.00 $93.93 99335 EAP CPT® 99335 PR DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES OP $291.00 $0.00 $0.00 $164.55 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.55 $67.33 $0.00 $67.33 99341 EAP CPT® 99341 PR HOME/RES VISIT NEW PATIENT SF MDM 15 MINUTES OP $167.00 $0.00 $0.00 $95.13 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.13 $54.97 $0.00 $54.97 99342 EAP CPT® 99342 PR HOME/RES VISIT NEW PATIENT LOW MDM 30 MINUTES OP $239.00 $0.00 $0.00 $136.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.86 $80.84 $0.00 $80.84 99343 EAP CPT® 99343 PR HOME VST NEW PATIENT MOD-HI SEVERITY 45 MINUTES OP $393.00 $0.00 $0.00 $224.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $224.59 $117.21 $0.00 $117.21 99344 EAP CPT® 99344 PR HOME/RES VISIT NEW PATIENT MOD MDM 60 MINUTES OP $557.00 $0.00 $0.00 $314.87 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $314.87 $153.66 $0.00 $153.66 99345 EAP CPT® 99345 PR HOME/RES VISIT NEW PATIENT HIGH MDM 75 MINUTES OP $678.00 $0.00 $0.00 $381.73 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $381.73 $189.66 $0.00 $189.66 99347 EAP CPT® 99347 PR HOME/RES VISIT EST PATIENT SF MDM 20 MINUTES OP $167.00 $0.00 $0.00 $95.76 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $95.76 $42.58 $0.00 $42.58 99348 EAP CPT® 99348 PR HOME/RES VISIT EST PATIENT LOW MDM 30 MINUTES OP $256.00 $0.00 $0.00 $145.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $145.45 $67.33 $0.00 $67.33 99349 EAP CPT® 99349 PR HOME/RES VISIT EST PATIENT MOD MDM 40 MINUTES OP $393.00 $0.00 $0.00 $221.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.60 $104.13 $0.00 $104.13 99350 EAP CPT® 99350 PR HOME/RES VISIT EST PATIENT HIGH MDM 60 MINUTES OP $547.00 $0.00 $0.00 $307.48 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $307.48 $153.66 $0.00 $153.66 99354 EAP CPT® 99354 PR PROLONGED SVC OUTPATIENT SETTING 1ST HOUR OP $372.00 $0.00 $0.00 $160.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $160.75 $92.83 $0.00 $92.83 99355 EAP CPT® 99355 PR PROLONGED SVC OUTPATIENT SETTING EA ADDL 30 MIN OP $280.00 $0.00 $0.00 $155.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $155.85 $92.16 $0.00 $92.16 99356 EAP CPT® 99356 PR PROLONGED SVC I/P OR OBS SETTING 1ST HOUR OP $282.00 $0.00 $0.00 $158.99 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $158.99 $85.41 $0.00 $85.41 99357 EAP CPT® 99357 PR PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA 30 MIN OP $285.00 $0.00 $0.00 $157.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $157.75 $85.72 $0.00 $85.72 99358 EAP CPT® 99358 PR PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR OP $341.00 $0.00 $0.00 $187.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $187.85 $0.00 $0.00 $0.00 99360 EAP CPT® 99360 PR PHYS STANDBY SVC PROLNG PHYS ATTN EA 30 MINUTES OP $186.00 $0.00 $0.00 $106.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $106.19 $0.00 $0.00 $0.00 99367 EAP CPT® 99367 PR TEAM CONFERENCE NON-FACE-TO-FACE PHYSICIAN OP $171.00 $0.00 $0.00 $97.58 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $97.58 $0.00 $0.00 $0.00 99381 EAP CPT® 99381 "PR PREVENTIVE VISIT,NEW,INFANT < 1 YR" OP $278.00 $0.00 $0.00 $132.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $256.75 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.57 $0.00 $0.00 $0.00 99382 EAP CPT® 99382 "PR PREVENTIVE VISIT,NEW,AGE 1-4" OP $248.00 $0.00 $0.00 $141.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $268.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $141.19 $0.00 $0.00 $0.00 99383 EAP CPT® 99383 "PR PREVENTIVE VISIT,NEW,AGE5-11" OP $264.00 $0.00 $0.00 $150.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $278.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.39 $0.00 $0.00 $0.00 99384 EAP CPT® 99384 "PR PREVENTIVE VISIT,NEW,12-17" OP $311.00 $0.00 $0.00 $176.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.77 $0.00 $0.00 $0.00 99385 EAP CPT® 99385 "PR PREVENTIVE VISIT,NEW,18-39" OP $331.00 $0.00 $0.00 $169.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.85 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $169.42 $0.00 $0.00 $0.00 99386 EAP CPT® 99386 "PR PREVENTIVE VISIT,NEW,40-64" OP $363.00 $0.00 $0.00 $206.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $354.25 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.23 $0.00 $0.00 $0.00 99387 EAP CPT® 99387 "PR PREVENTIVE VISIT,NEW,65 & OVER" OP $389.00 $0.00 $0.00 $221.59 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $221.59 $0.00 $0.00 $0.00 99391 EAP CPT® 99391 "PR PREVENTIVE VISIT,EST, INFANT < 1 YR" OP $250.00 $0.00 $0.00 $120.93 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $230.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $120.93 $0.00 $0.00 $0.00 99392 EAP CPT® 99392 "PR PREVENTIVE VISIT,EST,AGE 1-4" OP $267.00 $0.00 $0.00 $132.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $245.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.57 $0.00 $0.00 $0.00 99393 EAP CPT® 99393 "PR PREVENTIVE VISIT,EST,AGE5-11" OP $267.00 $0.00 $0.00 $132.57 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $245.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $132.57 $0.00 $0.00 $0.00 99394 EAP CPT® 99394 "PR PREVENTIVE VISIT,EST,12-17" OP $292.00 $0.00 $0.00 $150.39 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $269.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.39 $0.00 $0.00 $0.00 99395 EAP CPT® 99395 "PR PREVENTIVE VISIT,EST,18-39" OP $299.00 $0.00 $0.00 $154.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $274.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $154.70 $0.00 $0.00 $0.00 99396 EAP CPT® 99396 "PR PREVENTIVE VISIT,EST,40-64" OP $321.00 $0.00 $0.00 $168.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $292.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $168.19 $0.00 $0.00 $0.00 99397 EAP CPT® 99397 "PR PREVENTIVE VISIT,EST,65 & OVER" OP $350.00 $0.00 $0.00 $176.77 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $315.90 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $176.77 $0.00 $0.00 $0.00 99402 EAP CPT® 99402 "PR PREVENT COUNSEL,INDIV,30 MIN" OP $153.00 $0.00 $0.00 $86.54 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $86.54 $0.00 $0.00 $0.00 99406 EAP CPT® 99406 PR TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES OP $38.00 $0.00 $0.00 $21.46 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $27.95 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $21.46 $0.00 $0.00 $0.00 99407 EAP CPT® 99407 PR TOBACCO USE CESSATION INTENSIVE >10 MINUTES OP $80.00 $0.00 $0.00 $44.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.78 $0.00 $0.00 $0.00 99408 EAP CPT® 99408 PR ALCOHOL/SUBSTANCE SCREEN & INTERVEN 15-30 MIN OP $101.00 $0.00 $0.00 $57.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $57.69 $0.00 $0.00 $0.00 99411 EAP CPT® 99411 "PR PREVENT COUNSEL,GROUP,30 MIN" OP $86.00 $0.00 $0.00 $13.51 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.51 $0.00 $0.00 $0.00 99417 EAP CPT® 99417 PR PROLONGED OUTPATIENT E/M SERVICE EACH 15 MINUTES OP $113.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99421 EAP CPT® 99421 PR ONLINE DIGITAL E/M SVC EST PT <7 D 5-10 MINUTES OP $50.00 $0.00 $0.00 $22.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.69 $0.00 $0.00 $0.00 99423 EAP CPT® 99423 PR ONLINE DIGITAL E/M SVC EST PT <7 D 21+ MINUTES OP $150.00 $0.00 $0.00 $74.17 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $74.17 $0.00 $0.00 $0.00 99441 EAP CPT® 99441 PR PHYS/QHP TELEPHONE EVALUATION 5-10 MIN OP $120.00 $0.00 $0.00 $22.11 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $102.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $22.11 $0.00 $0.00 $0.00 99442 EAP CPT® 99442 PR PHYS/QHP TELEPHONE EVALUATION 11-20 MIN OP $225.00 $0.00 $0.00 $44.19 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $164.45 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.19 $0.00 $0.00 $0.00 99443 EAP CPT® 99443 PR PHYS/QHP TELEPHONE EVALUATION 21-30 MIN OP $330.00 $0.00 $0.00 $66.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $232.70 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $66.31 $0.00 $0.00 $0.00 99447 EAP CPT® 99447 PR NTRPROF PHONE/NTRNET/EHR ASSMT&MGMT 11-20 MIN OP $111.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99448 EAP CPT® 99448 PR NTRPROF PHONE/NTRNET/EHR ASSMT&MGMT 21-30 MIN OP $167.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 99451 EAP CPT® 99451 PR NTRPROF PHONE/NTRNET/EHR ASSMT&MGMT 5/> MIN OP $113.00 $0.00 $0.00 $63.81 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $63.81 $0.00 $0.00 $0.00 99453 EAP CPT® 99453 PR REM MNTR PHYSIOL PARAM 1ST SET UP PT EDUCAJ EQP OP $70.00 $0.00 $0.00 $33.31 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.31 $0.00 $0.00 $0.00 99454 EAP CPT® 99454 PR REM MNTR PHYSIOL PARAM 1ST DEV SUPPLY EA 30 D OP $220.00 $0.00 $0.00 $109.88 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $109.88 $0.00 $0.00 $0.00 99457 EAP CPT® 99457 PR REMOTE PHYSIOLOGIC MONITORING 1ST 20 MIN MONTH OP $105.00 $0.00 $0.00 $55.23 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.23 $0.00 $0.00 $0.00 99458 EAP CPT® 99458 PR REMOTE PHYSIOLOGIC MONITORING EA ADDL 20 MIN MO OP $105.00 $0.00 $0.00 $55.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $55.82 $0.00 $0.00 $0.00 99460 EAP CPT® 99460 "PR INITIAL NORMAL NEWBORN CARE, HOSPITAL OR BIRTH CENTER" OP $325.00 $0.00 $0.00 $166.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $166.92 $0.00 $0.00 $0.00 99462 EAP CPT® 99462 "PR SUBSEQUENT HOSPITAL CARE, NORMAL NEWBORN" OP $150.00 $0.00 $0.00 $72.42 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.42 $0.00 $0.00 $0.00 99463 EAP CPT® 99463 "PR INITIAL NORMAL NEWBORN CARE, SAME DAY DISCHARGE" OP $340.00 $0.00 $0.00 $206.30 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.30 $0.00 $0.00 $0.00 99464 EAP CPT® 99464 PR ATTN AT DELIVERY 1ST STABILIZATION OF NEWBORN OP $228.00 $0.00 $0.00 $123.86 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $123.86 $0.00 $0.00 $0.00 99465 EAP CPT® 99465 PR DELIVERY/BIRTHING ROOM RESUSCITATION OP $447.00 $0.00 $0.00 $264.53 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $264.53 $0.00 $0.00 $0.00 99468 EAP CPT® 99468 "PR INITIAL HOSP NEONATE 28 DAY OR LESS, CRITICALLY ILL" OP "$2,811.00 " $0.00 $0.00 "$1,633.37" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,633.37" $0.00 $0.00 $0.00 99469 EAP CPT® 99469 "PR SUBSEQUENT HOSP NEONATE 28 DAY OR LESS, CRITICALLY ILL" OP "$1,217.00 " $0.00 $0.00 $689.69 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $689.69 $0.00 $0.00 $0.00 99471 EAP CPT® 99471 PR INITIAL PED CRITICAL CARE 29 DAY THRU 24 MO OP "$2,433.00 " $0.00 $0.00 "$1,517.07" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,517.07" $0.00 $0.00 $0.00 99472 EAP CPT® 99472 PR SUBSEQUENT PED CRITICAL CARE 29 DAY THRU 24 MO OP "$1,230.00 " $0.00 $0.00 $709.06 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $709.06 $0.00 $0.00 $0.00 99477 EAP CPT® 99477 "PR INITIAL HOSP NEONATE 28 DAY OR LESS, NOT CRITICALLY ILL" OP "$1,068.00 " $0.00 $0.00 $619.35 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $619.35 $0.00 $0.00 $0.00 99478 EAP CPT® 99478 PR SUBSEQUENT INTENSIVE CARE INFANT < 1500 GRAMS OP $420.00 $0.00 $0.00 $236.82 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.82 $0.00 $0.00 $0.00 99479 EAP CPT® 99479 PR SUBSEQUENT INTENSIVE CARE INFANT 1500-2500 GRAMS OP $381.00 $0.00 $0.00 $215.98 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $215.98 $0.00 $0.00 $0.00 99480 EAP CPT® 99480 PR SUBSEQUENT INTENSIVE CARE INFANT 2501-5000 GRAMS OP $366.00 $0.00 $0.00 $206.80 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $206.80 $0.00 $0.00 $0.00 99490 EAP CPT® 99490 PR CHRONIC CARE MGMT SVCS STAFF 1ST 20 MIN CAL MO OP $115.00 $0.00 $0.00 $54.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $54.00 $0.00 $0.00 $0.00 99495 EAP CPT® 99495 PR TRANSJ CARE MGMT MOD MDM F2F 14 CAL D DISCHARGE OP $377.00 $0.00 $0.00 $190.91 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $576.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $190.91 $0.00 $0.00 $0.00 99496 EAP CPT® 99496 PR TRANSJ CARE MGMT HIGH MDM F2F 7 CAL D DISCHARGE OP $497.00 $0.00 $0.00 $276.21 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $777.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $276.21 $0.00 $0.00 $0.00 99497 EAP CPT® 99497 PR ADVANCE CARE PLANNING FIRST 30 MINS OP $241.00 $0.00 $0.00 $136.24 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $236.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $136.24 $0.00 $0.00 $0.00 99498 EAP CPT® 99498 PR ADVANCE CARE PLANNING EA ADDL 30 MINS OP $227.00 $0.00 $0.00 $127.63 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $127.63 $0.00 $0.00 $0.00 0042T EAP CPT® 0042T "CEREBRAL PERFUS ANALYSIS, CT W/CONTRAST" OP $600.00 $0.00 $0.00 $525.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $525.00 $0.00 $0.00 $0.00 01967SA EAP CPT® 01967SA "ANESTH, NEURAXIAL LABOR, PLAN VAG DEL; STANDALONE" OP $90.00 $0.00 $0.00 $90.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $90.00 $90.00 $0.00 $90.00 0479T EAP CPT® 0479T PR FRACTIONAL ABL LSR FENESTRATION FIRST 100 SQCM OP "$1,579.00 " $0.00 $0.00 $789.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $789.50 $0.00 $0.00 $0.00 0480T EAP CPT® 0480T PR FRACTIONAL ABL LSR FENESTRATION EA ADDL 100 SQCM OP $827.00 $0.00 $0.00 $413.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $413.50 $0.00 $0.00 $0.00 A4649 EAP HCPCS A4649 PR SURGICAL SUPPLIES OP $40.00 $0.00 $0.00 $20.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $20.00 $0.00 $0.00 $0.00 D7140 EAP HCPCS D7140 PR EXTRACTION ERUPTED TOOTH/EXR OP $150.00 $0.00 $0.00 $75.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $75.00 $0.00 $0.00 $0.00 D7210 EAP HCPCS D7210 PR REM IMP TOOTH W MUCOPER FLP OP $350.00 $0.00 $0.00 $175.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.00 $0.00 $0.00 $0.00 D7220 EAP HCPCS D7220 PR IMPACT TOOTH REMOV SOFT TISS OP $192.00 $0.00 $0.00 $96.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $96.00 $0.00 $0.00 $0.00 D7230 EAP HCPCS D7230 PR IMPACT TOOTH REMOV PART BONY OP $144.00 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.00 $0.00 $0.00 $0.00 D7240 EAP HCPCS D7240 PR IMPACT TOOTH REMOV COMP BONY OP $203.00 $0.00 $0.00 $101.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $101.50 $0.00 $0.00 $0.00 D7241 EAP HCPCS D7241 PR IMPACT TOOTH REM BONY W/COMP OP $300.00 $0.00 $0.00 $150.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $150.00 $0.00 $0.00 $0.00 D7521 EAP HCPCS D7521 INCISION/DRAIN ABSCESS EXTRA OP $237.00 $0.00 $0.00 $118.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.50 $0.00 $0.00 $0.00 D8040 EAP HCPCS D8040 PR LIMITED DENTAL TX ADULT OP $237.00 $0.00 $0.00 $118.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $118.50 $0.00 $0.00 $0.00 D9239 EAP HCPCS D9239 "PR IV SEDATION PER UNIT, 1ST 15 MIN MAC BILLING" OP $75.00 $0.00 $0.00 $37.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.50 $0.00 $0.00 $0.00 D9243 EAP HCPCS D9243 PR IV SEDATION EA AD 15 MIN MAC BILLING OP $75.00 $0.00 $0.00 $37.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $37.50 $0.00 $0.00 $0.00 G0101 EAP HCPCS G0101 PR CA SCREEN;PELVIC/BREAST EXAM OP $88.00 $0.00 $0.00 $44.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $72.15 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.00 $35.21 $0.00 $35.21 G0105 EAP HCPCS G0105 PR COLORECTAL SCRN; HI RISK IND OP $600.00 $0.00 $0.00 $368.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $300.00 $368.36 $213.45 $368.36 G0121 EAP HCPCS G0121 PR COLON CA SCRN NOT HI RSK IND OP $580.00 $0.00 $0.00 $368.36 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $290.00 $368.36 $0.00 $368.36 G0168 EAP HCPCS G0168 PR WOUND CLOSURE BY ADHESIVE OP $58.00 $0.00 $0.00 $58.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $29.00 $58.00 $0.00 $58.00 G0179 EAP HCPCS G0179 PR MD RECERTIFICATION HHA PT OP $124.00 $0.00 $0.00 $62.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $62.00 $49.12 $0.00 $49.12 G0259 EAP HCPCS G0259 PR INJECT FOR SACROILIAC JOINT OP $592.00 $0.00 $0.00 $296.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $296.00 $0.00 $0.00 $0.00 G0279 EAP HCPCS G0279 PR DIAGNOSTIC DIGITAL BREAST TOMOSYNTHESIS OP $89.00 $0.00 $0.00 $44.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $44.50 $0.00 $0.00 $0.00 G0402 EAP HCPCS G0402 WELCOME TO MEDICARE -PREVENTIVE VISIT OP $426.00 $0.00 $0.00 $213.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $304.20 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $213.00 $0.00 $0.00 $0.00 G0403 EAP HCPCS G0403 EKG FOR INITIAL PREVENT EXAM OP $52.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $26.00 $0.00 $0.00 $0.00 G0405 EAP HCPCS G0405 EKG INTERPRET & REPORT PREVE OP $26.00 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $13.00 $0.00 $0.00 $0.00 G0413 EAP HCPCS G0413 PERCUTANEOUS SKELETAL FIXATION OP "$3,322.00 " $0.00 $0.00 "$1,661.00" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,661.00" $0.00 $0.00 $0.00 G0414 EAP HCPCS G0414 PELVIC RING FX TREAT INT FIX OP "$3,137.00 " $0.00 $0.00 "$1,568.50" $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 "$1,568.50" $0.00 $0.00 $0.00 G0438 EAP HCPCS G0438 FIRST ANNUAL WELLNESS VISIT-MEDICARE OP $518.00 $0.00 $0.00 $259.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $468.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $259.00 $0.00 $0.00 $0.00 G0439 EAP HCPCS G0439 SUBSEQUENT ANNUAL WELLNESS VIST-MEDICARE OP $351.00 $0.00 $0.00 $175.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $366.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $175.50 $0.00 $0.00 $0.00 G0442 EAP HCPCS G0442 "ANNUAL ALCOHOL MISUSE SCREENING, 15 MINUTES" OP $35.00 $0.00 $0.00 $17.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.50 $0.00 $0.00 $0.00 G0443 EAP HCPCS G0443 "BRIEF FACE-TO-FACE BEHAVIORAL COUNSELING FOR ALCOHOL MISUSE, 15 MINUTE" OP $72.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 G0444 EAP HCPCS G0444 "PR ANNUAL DEPRESSION SCREENING, 5 TO 15 MINUTES" OP $35.00 $0.00 $0.00 $17.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $17.50 $0.00 $0.00 $0.00 G0447 EAP HCPCS G0447 "FACE-TO-FACE BEHAVIORAL COUNSELING FOR OBESITY, 15 MINUS" OP $72.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $48.10 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $36.00 $0.00 $0.00 $0.00 G0453 EAP HCPCS G0453 PR CONT INTRAOPERATIVE NEURO MONITORING EA 15M OP $99.00 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $49.50 $0.00 $0.00 $0.00 G2212 EAP HCPCS G2212 PR PROLONGED OUTPT/OFFICE VISIT; EA ADDL 15 MIN OP $92.00 $0.00 $0.00 $46.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $46.00 $0.00 $0.00 $0.00 G6002 EAP CPT® G6002 CHG GUIDANCE FOR LOC OP $63.00 $0.00 $0.00 $31.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $31.50 $0.00 $44.63 $0.00 G6017 EAP HCPCS G6017 PR INTRA-FRACTION LOCALIZATION AND TRACKING OF TARGET OP $359.00 $0.00 $0.00 $179.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $179.50 $0.00 $0.00 $0.00 M0201 EAP HCPCS M0201 PR COVID-19 VACCINE HOME ADMIN ADD-ON OP $105.00 $0.00 $0.00 $52.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $52.50 $0.00 $0.00 $0.00 P3001 EAP HCPCS P3001 PR SCREENING PAP SMEAR BY PHYS OP $79.00 $0.00 $0.00 $39.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $39.50 $23.43 $0.00 $23.43 Q0091 EAP HCPCS Q0091 PR OBTAINING SCREEN PAP SMEAR OP $70.00 $0.00 $0.00 $39.01 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $35.00 $39.01 $0.00 $39.01 Q0111 EAP HCPCS Q0111 PR WET MOUNTS/ W PREPARATIONS OP $25.00 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $12.50 $0.00 $0.00 $0.00 S2900 EAP HCPCS S2900 PR ROBOTIC SURGICAL SYSTEM OP $675.00 $0.00 $0.00 $337.50 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $337.50 $0.00 $0.00 $0.00